不同镇痛方式对胸导管颈外静脉吻合术患者血浆皮质醇和血糖的影响

目的 观察不同镇痛方式对胸导管颈外静脉吻合术患者血浆皮质醇(Cor)和血糖(Glu)的影响.方法 选择ASA Ⅰ或Ⅱ级行择期胸导管颈外静脉吻合术患者60例,随机均分为盐酸罗哌卡因组(R组)、氟比洛芬酯预处理组(F1组)和氟比洛芬酯后处理组(F2组).R组于手术结束前向切口内喷洒0.75%盐酸罗哌卡因4 ml,并在切口两侧注入0.75%盐酸罗哌卡因6 m1.F1组和F2组分别于麻醉诱导前5 min和手术结束前5 min静注氟比洛芬酯1.0 mg/kg.观察三组患者在麻醉前5 min(T0)、术后6 h(T1)、24 h(T2)、48 h(T3)、72 h(T4)的血浆Cor和Glu水平.记录T2～T4时使用镇痛药的患者比例和VAS.结果 与T0时比较,T1、T2时三组血浆Cor和Glu均显著升高(P＜0.05或P＜0.01),但R组和F2组升高幅度显著低于F1组(P＜0.05).T2时R组、T4时R组和F2组需要使用镇痛药的患者显著少于F1组(P＜0.05或P＜0.01).T2～T4时VAS差异无统计学意义.结论 胸导管颈外静脉吻合术患者使用罗哌卡因封闭治疗,能取得较好的镇痛效果,并能有效地抑制围术期应激反应.     

Changes in plasma immunoreactive beta-endorphin in burn and its clinical significance]

The plasma immunoreactive beta-endorphin (ir-beta-EP) contents in 20 healthy volunteers and 30 burned patients (average age: 36 years, average burn area: 38.1% +/- 30.0% of TBSA) were determined by radioimmunoassay (RIA). Results showed that there were significant increases of plasma ir-beta-EP in burned patients, which correlated to the extents of the burn areas positively (r = 0.576). Raised ir-beta-EP contents were also observed in the complications of operation, wound infection, septicaemic shock, heart failure and brain edema, which reached as high as 3,000pg/ml before death. The above findings suggested that the determination of plasma beta-EP might be helpful in understanding injury extent and evaluating prognosis.     

Stimulation-produced analgesia: acupuncture,TENS and alternative techniques

Counter-irritant techniques are available in almost all pain clinics and physiotherapy departments. While these methods of pain suppression have been used for thousands of years, it is only in the last few decades, that we have begun to understand the basic neurophysiology of the body's pain modulatory system. Traditional Chinese acupuncture is based on concepts such as Yin and Yang and the flow of life energy along meridians on the body surface. Modern practitioners largely ignore the ancient ideas but continue to use the powerful needling areas discovered by the Chinese. The Western approach places particular emphasis on the comparative innervation (segments) of skin, muscles and internal organs, and the influence of descending pathways on pain transmission in the dorsal horn of the spinal cord. Common techniques include muscular trigger point therapy, segmental acupuncture and microsystem needling (e.g. auriculotherapy). Electrical irritation allows a more powerful stimulus to be applied in a controlled and predictable way. Electroanalgesia is usually given through acupuncture needles and is partially mediated by the central release of endogenous opioids. TENS is given through adhesive skin electrodes and is applied as either high-frequency low-intensity pulses that work via gating mechanisms at spinal cord level, or in a low-frequency, high-intensity mode that functions in a similar way to electroanalgesia. Numerous related complementary methods (e.g. massage, manipulation, heat, vibration) have a similar rationale and stimulate receptors in joints, muscles and skin.     

Stimulation-produced analgesia: acupuncture,TENS and related techniques

Stimulation-produced analgesia (SPA) is a term that describes many techniques, both non-invasive and invasive. These techniques relieve pain via both peripheral and central mechanisms. Simple antidromic conduction of non-painful stimuli (electrical or physical) and gate control of noxious impulses typically produce rapid analgesia of short duration. Longer-term effects are dependent on production of endogenous opioids at spinal cord and brain level and activation of non-opioid transmitter systems in the limbic system and at the spinal gate. There is no scientific evidence that metaphysical (without form or substance) energy pathways play any role in SPA. Methods of producing analgesia by nerve stimulation include non-invasive or minimally invasive techniques such as acupuncture, transcutaneous electrical nerve stimulation (TENS) and acupressure. Good evidence indicates that they are useful as a sole or supplementary analgesic technique for many painful conditions, both acute and chronic. Electronic stimulators may also be permanently implanted at peripheral nerves, into the epidural space or into the brain. These invasive techniques are useful for refractory pain conditions, mostly of neuropathic origin.     

Immunoreactive ACTH, beta-endorphin, and cortisol levels in plasma following spinal manipulative therapy

This study examines the possibility of a humorally mediated analgesic response to spinal manipulative therapy by determination of plasma levels of beta-endorphin, adrenocorticotropic hormone (ACTH), and cortisol before and after intervention. Forty male subjects (20 symptomatic, 20 asymptomatic) were allocated into four equal groups. Two treatment groups were given spinal manipulative therapy, and two groups underwent a sham procedure. Blood samples were taken via indwelling butterfly needles pre- and postintervention in all four groups, and levels of immunoreactive ACTH, immunoreactive beta-endorphin, and cortisol determined by radioimmunoassay. No differences in ACTH or beta-endorphin were found between sham and treated groups, or between pre- and postintervention in any group; cortisol levels fell over the course of the study in all groups. The findings thus appear to exclude a humoral role for beta-endorphin in mediating the analgesic response to spinal manipulative therapy; in addition, they suggest that such therapy is not a stressor that activates the hypothalamo-pituitary-adrenal axis.     

Diabetes induced by streptozocin results in a decrease in immunoreactive beta-endorphin levels in the pituitary and hypothalamus of female rats

Immunoreactive beta-endorphin (IR-BE) was measured by radioimmunoassay in the anterior pituitary (AP), neurointermediate lobe of the pituitary (NIL), and hypothalamus of female rats 4 wk after being made diabetic by a single injection of streptozocin (STZ). STZ-induced diabetes resulted in a significant reduction in the content and concentration of IR-BE in the AP and the content of IR-BE in the hypothalamus. Total hypothalamic protein was also significantly diminished. IR-BE levels in the NIL were unchanged. Column chromatography indicated that the reduction in IR-BE in the AP of the diabetic female rats represented a decrease in peptides that co-eluted with beta-endorphin and beta-lipotropin. In the hypothalamus, the reduction in IR-BE was represented solely by a decrease in a peptide co-eluting with beta-endorphin. Beta-lipotropin was not detectable in the hypothalami of control or diabetic female rats. These results suggest that, in the rat, diabetes may produce alterations in the mechanism(s) that regulate endogenous opiate levels in the pituitary and hypothalamus.     

不同麻醉深度指标在全麻镇静和镇痛监测中的比较

目的评价脑电双频指数(BIS)和电刺激-循环反应在全麻镇静和镇痛监测中的价值。方法20例择期手术全麻病人,将丙泊酚血浆靶浓度依次设定为1、2、3、4和5μg/ml,记录每一靶浓度下的BIS、SBP、DBP和HR值。维持意识消失时的效应室靶浓度,给予一次60mA强直电刺激,随后将雷米芬太尼效应室靶浓度依次设定为1、2、3、4和5ng/ml,达到每一靶浓度后给予一次同样电刺激,计算每次电刺激前后各指标的变化值(△BIS、△SBP、△DBP和△HR)。结果丙泊酚靶浓度依次增加,BIS值依次减少(P<0.05),两者之间呈负相关(r=-0.789,P<0.01)。不同雷米芬太尼靶浓度时,电刺激均未引起BIS的变化,但引起SBP、DBP和HR增加(P<0.05或P<0.01)。随着雷米芬太尼靶浓度增加,△SBP、△DBP和△HR呈下降趋势。雷米芬太尼靶浓度与△SBP和△HR之间呈负相关(r=-0.386和-0.302,P<0.05)。结论BIS对镇静药浓度变化敏感,对疼痛刺激反应差,电刺激-循环反应能够灵敏地反映镇痛水平,所以麻醉深度监测应该针对不同成分进行多指标、多方法的综合监测。     

Inhibition of plasma cyclic AMP, glucose and cortisol response to surgery by epidural analgesia.

Cyclic AMP, glucose and cortisol in plasma were measured in three groups of patients undergoing hysterectomy. The operations were performed under general anaesthesia, under general anaesthesia combined with epidural analgesia and under epidural analgesia alone. Surgery elicited a significant rise in plasma cyclic AMP, glucose and cortisol when performed under general anaesthesia alone. Epidural analgesia extending from T4-6 to S5 combined with general anaesthesia abolished the rise in cyclic AMP and reduced the increase in glucose and cortisol and epidural analgesia alone extending from T4 to S5 blocked the rise in glucose and cortisol as well as that in cyclic AMP. The results support the theory that afferent nerve impulses from the area of trauma are of major importance for the catabolic state induced by surgical procedures and indicate that anaesthetic management which includes blockade of afferent nerve impulses which includes blockade of afferent nerve impulses from the area of trauma can be reduce the catabolic response to surgery. These observations could be of value in the operative management of patients with diabetes mellitus and possibly in other groups by patients with a high surgical morbidity.     

镇静镇痛技术在危重新生儿的应用

新生儿即能感知记忆疼痛,其疼痛传导的特点包括外周痛觉感受器发育不成熟,主要由无髓鞘神经纤维传导、疼痛调节系统发育不完善以及存在着内源性止痛机制。目前适用于危重新生儿的镇痛药物和技术有阿片类药物和非甾体类抗炎药的使用、非药物性镇痛技术、局部麻醉技术。镇静药物如苯二氮卓类、丙泊酚、巴比妥类和水合氯醛。     

The effects of three different analgesia techniques on long-term postthoracotomy pain.

In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain. IMPLICATIONS: Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%.     

锁孔技术胸(腹)腔镜下脊柱内固定的难点及对策

目的探讨标准锁孔技术行胸(腹)腔镜下脊柱内固定的技术难点及对策。方法2004年7月~2005年9月,我院对6例T5~L1椎体病变采用单肺通气、胸腔镜锁孔技术,行病灶椎体切除减压、髂骨或钛网植骨、Z-p late钢板或CD-Horizon固定,其中结核2例。2例L2~L3结核采用腹膜后不充气入路腹腔镜锁孔技术,行病灶椎体切除、髂骨植骨、Z-p late钢板固定。结核病变术前抗结核治疗3周,术后继续抗结核治疗半年。结果8例施行病灶清除及椎管前壁减压,7例行Z-p late钢板内固定,1例行CD-Horizon内固定。髂骨植骨5例,钛网植骨3例。手术时间6.5~12.6 h,平均8.7 h。术中出血量250~1 800 m l,平均950 m l。Cobb角矫正5°~18°,平均12°。8例随访时间2~13个月,平均7.4月,5例伴神经损伤者功能恢复1~2级(Frankel分级),1例T7转移性腺癌术后6个月钛网植骨未愈合,Cobb角丢失4°。结论采用标准锁孔腔镜技术进行T5~L3椎体内固定是可行的,手术关键是入口准确定位,节段血管处理,椎管前壁切除等技术难点的对策。     

不同麻醉法对血浆肾素、血管紧张素Ⅱ、醛固酮、皮质醇水平的影响

观察全麻复合硬膜外阻滞和全麻两种麻醉时血浆肾素、血管紧张素Ⅱ、醛固酮、皮质醇变化。２５例择期上腹部手术患者，随机分两组：Ａ组为全麻复合硬膜外阻滞１２例，Ｂ组为全麻１３例。分别于麻醉前、麻醉插管后２分钟、进腹探查时、术中２小时、拔管后即刻抽取中心静脉血测肾素、血管紧张素Ⅱ、醛固酮、皮质醇的浓度。结果示Ａ组麻醉前后无明显变化（Ｐ＞０．０５）；Ｂ组术中肾素活性和皮质醇显著增高（Ｐ＜０．０１）。此外，手术期间Ａ组比Ｂ组心率慢，血压低（Ｐ＜０．０１）。表明全麻复合硬膜外阻滞是一种应激反应较轻的麻醉方法。     

Patient-controlled epidural analgesia or continuous infusion: advantages and disadvantages of different modes of delivering epidural analgesia for labour

Patient-controlled epidural analgesia, intermittent top-up and continuous infusion are equally effective in providing epidural pain relief during labour. Patient-controlled epidural analgesia is associated with a significant reduction in hourly dose requirements when compared with continuous infusion, and by transferring the responsibility for epidural top-up, it offers the parturient the psychological benefit of being in control. For these reasons, patient-controlled epidural analgesia may become the method of choice for epidural pain relief during labour. However, the safety of the method needs to be documented more extensively, and the advantage of a reduction in hourly dose requirements needs to be visualized in terms of an improvement in labour or neonatal outcome. Moreover, the optimal dose, drug combination and settings still remain to be determined.     

Effects of transcutaneous nerve stimulation on the plasma and CSF concentrations of beta-endorphin and the plasma concentrations of ACTH, cortisol and prolactin in hysterectomized women with postoperative pain]

Plasmatic and cerebrospinal fluid levels of beta-endorphin and plasmatic concentration of ACTH, cortisol, and prolactin were investigated in 10 healthy volunteers free of pain and in a group of 38 patients who presented moderate or intense postoperative pain. The analgesic technique was transcutaneous neural stimulation. In 28 patients the stimulation was delivered at 40-80 Hz (high frequency) whereas in the remaining 10 patients it was administered in a placebo form. Measurements of hormone concentrations were performed using radioimmunoassay techniques. In patients free of pain hormone analysis was done at once, whereas in patients with pain this analysis was performed before and one hour after transcutaneous neural stimulation. We compared data obtained in control subjects with data collected in patients before and one hour after high frequency and placebo transcutaneous neural stimulation. Levels of beta-endorphin were comparable in patients with and without pain. However, ACTH, cortisol, and prolactin were increased in patients with pain. High frequency stimulation induced greater beta-endorphin levels than placebo neural stimulation and slightly lower concentration of prolactin. There were no significant differences in ACTH and cortisol levels.     

硬膜外超前镇痛对胃切除病人血糖、皮质醇和一氧化氮的影响

目的 探讨超前镇痛对病人血糖（Glu）、皮质醇（Cor）和一氧化氮（NO）的影响及其部分作用机制。方法 选择ASAⅠ或Ⅱ级在全麻下行胃切除病人30例,随机均分为两组。A组,切皮前45min经硬膜外导管注入吗啡0．05mg／kg,随后以0．02mg·kg^-1·h^-1维持;B组,不予以硬膜外镇痛。术后6、12、24h随访记录镇痛效果、镇静程度及不良反应,分别于麻醉前、术中90min和术后6h抽血检测Glu、Cor和NO。结果A组术后6、12、24h镇痛评分及哌替啶的消耗量明显低于B组（P〈0．05）;与A组同时点相比,B组术中90min时Glu水平明显升高（P〈0．05）,术中90min和术后6hCor含量明显增高（P〈0．05）;A组各时点NO含量无明显变化,B组术中90min和术后6hNO显著高于A组同时点（P〈0．05）。结论 硬膜外吗啡的合理应用可发挥超前镇痛效应,同时可缓解手术的应激反应;脊髓水平的吗啡镇痛可能通过抑制NO的生成,影响脊髓的可塑性形成, 达到超前镇痛效果。     

胸段硬膜外镇痛对开胸手术病人血糖、胰岛素和皮质醇水平的影响

目的　观察胸段硬膜外镇痛 (TEA)对开胸手术病人血糖、胰岛素和皮质醇水平的影响。方法　 2 0例在地氟醚麻醉下行开胸手术病人 ,随机分为TEA组和对照组。于麻醉前、术中 90分钟、术毕 6 0分钟和术后第 1、2、3天测定血糖、胰岛素及皮质醇浓度 ,计算胰岛素敏感性指数。结果　两组病人血糖均自术中 90分钟时明显升高 ,术毕 6 0分钟达峰值 ,术后第 1、2天仍居高不下 (P<0 0 5或P <0 0 1)。TEA组术中及术后胰岛素水平无明显改变 ;对照组术后第 1、2天胰岛素水平升高明显 (P <0 0 5或P <0 0 1)。TEA组病人皮质醇仅术毕 6 0分钟时明显升高 (P <0 0 5 ) ,而对照组于手术中 90分钟明显升高 ,并持续到术后第 1、2天 (P <0 0 5 )。两组胰岛素敏感性指数均明显下降 (P <0 0 5 ) ,于术后第 3天TEA组恢复接近麻醉前水平 (P >0 0 5 ) ;而对照组至术后第 3天仍低于麻醉前值 (P <0 0 5 )。结论　TEA可缓解开胸手术应激反应 ,减轻术后糖代谢紊乱。     

氟比洛芬酯术后镇痛对血浆皮质醇、白细胞介素10和肿瘤坏死因子α的影响

目的 观察氟比洛芬酯用于髋关节置换术后患者静脉自控镇痛(patient-controlled intravenous analgesia,PCIA)的临床效果及其对机体血浆皮质醇(cortisol,Cor)、白细胞介素10(interleukin 10,IL-10)和肿瘤坏死因子α(tumor necrosis factor α,TNF-α)的影响.方法 选择40例单侧髋关节置换术患者,ASA Ⅰ级～Ⅱ级,按抽签方法随机分为两组,每组20例,Ⅰ组为枸橼酸芬太尼1.2mg/24ml+0.9%生理盐水76ml,负荷量为枸橼酸芬太尼0.001 mg/kg;Ⅱ组为氟比洛芬酯300mg/30ml+0.9%生理盐水70 ml,负荷量为氟比洛芬酯1 mg/kg.分别于麻醉前(T1)、术后第4 h(T2)、24 h(T3)、36 h(T4)和48 h(T5)5个时点抽取静脉血测定血浆Cor、IL-10和TNF-α浓度,于术后4、24、36、48 h用视觉模拟评分法(visual analogue scales,VAS)行静止和活动评分,均由同一麻醉医生在不知道到具体镇痛方式情况下进行.结果 术后各时点VAS评分两组间比较差异无统计学意义(P＞0.05),但Ⅰ组尿潴留、恶心和呕吐发生率40%高于Ⅱ组(P＜0.01).两组在T2时血浆Cor值(275±28.6)μg/I和(276±30.5)μg/L均升高,与T1(203.5±22.3)μg/L和(192.3±21.3)比较差异有统计学意义(P＜0.01),Ⅰ组在T3时血浆Cor水平(256±28.3)μg/L仍明显高于T1值(203.5±22.3)μg/L(P<0.05),在T3(256±28.3)μg/L和T4(235±23.3)μg/L时均高于Ⅱ组水平(176±22.3)μg/L和(172±20.5)μg/L(P＜0.05);两组T3(60.23±3.65)ng/L和(62.35±5.02)ng/L和T4(60.12±3.31)ng/L和(61.34±4.23)ng/L时血浆IL-10水平均高于T1值(55.32±2.61)ng/L和(55.65±2.53)ng/L(P<0.05),组间比较差异无统计学意义(P＞0.05);Ⅱ组在T3、T4和T5时血浆TNF-α浓度(52.56±4.31 ng/L,58.42±5.64 ng/L和59.53±6.02ng/L)均比T1(43.31±1.52)ng/L明显升高(P＜0.01),同时明显高于Ⅰ组(45.12±2.32)ng/L,(42.23±2.21)ng/L和(42.52±2.35)ng/L(P＜0.01).结论 髋关节置换术患者术后行PCIA,氟比洛芬酯与芬太尼的镇痛效果相似,副作用明显减少,且在一定程度上改善机体免疫力.     

Incidence of vomiting in susceptible children under regional analgesia with two different anaesthetic techniques

BACKGROUND: Postoperative vomiting (POV) is a frequent side-effect of paediatric surgery and a leading cause of unplanned admission. Many antiemetic drugs have been studied, but less attention has been given to the effects on POV of the anaesthetic technique adopted. The aim of this study was to compare two different anaesthetic techniques in children under regional analgesia at risk for POV. METHODS: We studied 135 children suffering from motion sickness or with a previous history of POV. The patients were randomized to receive inhalation anaesthesia (group S) with sevoflurane by LMA or intravenous (i.v.) anaesthesia with ketamine and propofol (group P). All the patients were treated with an ilio-inguinal block after induction of anaesthesia. Postoperatively, the children were followed by the nursing staff and by their parents, none of whom were aware of the anaesthesia technique used. RESULTS: A significant decrease was observed in the incidence of early (0-6 h) and delayed (6-24 h) POV in those children who received i.v. sedation. There was no difference between the two groups in the level of analgesia either at the end of surgery or 2 h postoperatively. CONCLUSIONS: Anaesthesia based on propofol and ketamine is better than inhalation anaesthesia with sevoflurane by LMA for reducing POV in children at risk under an ilio-inguinal block. Tailoring the anaesthetic to the specific needs of children susceptible to POV should be considered before resorting to the routine use of expensive antiemetic prophylaxis.