硬膜外自控镇痛对全髋置换术患者血液流变学的影响

目的　观察术后硬膜外自控镇痛 (PCEA)对全髋置换术患者的血液流变学的影响。方法　ASAⅠ～Ⅱ级行择期全髋置换手术患者 2 6例 ,随机分为PCEA组和对照组 ,每组均为 13例。 2 6例均行连续硬膜外麻醉。PCEA组于手术结束后经硬膜外腔注入吗啡 0 5mg ;后接PCA泵 ,镇痛液配方用吗啡 5mg +布比卡因 12 5mg +氟哌利多 2 5mg ,以生理盐水稀释至 10 0ml。背景速度2ml/h ,PCA剂量 0 5ml,锁定时间 15min。对照组病人则视术后疼痛情况间断肌注哌替啶。结果(1)术后 1、12、2 4、4 8hVAS评分PCEA组均显著低于对照组 (P <0 0 1)。 (2 )两组病人血浆粘度和纤维蛋白原麻醉后 1h及术毕时均显著降低 (P <0 0 5 ) ;术后 4 8h ,PCEA组恢复至术前水平 ;而对照组仍升高 (P <0 0 5 ) ,并显著高于PCEA组 (P <0 0 5 )。两组病人全血粘度各切变率麻醉后 1h及术毕各值均下降 ,PCEA组术后 2 4、4 8h各值逐渐恢复至麻醉前水平 ,而对照组则进行性升高 ,术后 4 8h显著高于麻醉前水平 (P <0 0 1) ,与PCEA组比较有显著性差异 (P <0 0 1)。结论　PCEA改善了全髋置换术患者术后血液流变学指标 ,可作为减少术后血栓性并发症的有效措施之一。     

Postoperative pancreatitis after total hip replacement under general anesthesia

A 61 year old male patient developed postoperative pancreatitis after total hip replacement under general anesthesia with sevoflurane. The patient had chronic renal failure and was receiving hemodialysis. The estimated intraoperative blood loss was 1500 ml, and 1200 ml of blood was administered. The intraoperative mean blood pressure was 60 to 70 mmHg and the central venous pressure at the end of anesthesia was 0 mmHg. Postoperatively he complained of severe upper abdominal pain. On the 1st postoperative day serum amylase level increased to fifteen times of the normal level. He complained again of severe abdominal pain on hemodialysis. From these episodes, we estimate that the circulatory disturbance of pancreas is the cause of this postoperative pancreatitis.     

Unusual complication after hip surgery under spinal anesthesia

The development of an acute respiratory distress syndrome following hip surgery in elderly patients is suggestive of thromboembolism in most instances. However, we must keep in mind the possibility of rarer complications, which can remain undiagnosed because they are hidden by prominent abnormal behaviours, which can develop following any type of anaesthesia. We report the case of a patient who developed a confusion following an orthopaedic surgery under spinal anaesthesia; this confusion concealed a penetration syndrome resulting from accidental inhalation of a dental crown. Because this patient was old and had previously developed chronic lung disorders, we selected a spinal anaesthesia for performing the surgery; these underlying respiratory disorders worsened the clinical consequences of the inhalation. The dental crown was removed under general anaesthesia with spontaneous ventilation using a bronchoscope after an unsuccessful attempt with a fibrescope due to the size of the foreign body.     

Thromboembolism after total hip replacement: role of epidural and general anesthesia

The effects of continuous epidural anesthesia and of general anesthesia on the incidence of thromboembolism following total hip replacement were studied. Sixty patients were randomly allotted to one of two groups receiving either epidural or general anesthesia. Epidural anesthesia (N = 30) consisted of 0.5% bupivacaine with epinephrine intraoperatively; for pain relief in the postoperative period (24 h), 0.25% bupivacaine with epinephrine was given every 3 h. General anesthesia (N = 30) consisted of controlled ventilation with N2O-O2 and intravenous fentanyl and pancuronium bromide; postoperatively, narcotic analgesics were given intramuscularly on demand for pain relief. Significantly lower frequencies were found following epidural anesthesia than after general anesthesia in deep venous thrombosis involving the popliteal and femoral veins (13% and 67%, respectively), deep venous thrombosis involving both calf and thigh veins (40% and 77%), and pulmonary embolism (10% and 33%). Possible explanations for these differences include increased circulation in the lower extremities, less tendency for intravascular clotting to occur, and more efficient fibrinolysis in association with continuous epidural anesthesia. The decrease in blood loss associated with epidural anesthesia with lower transfusion requirements also might play a role. Epidural analgesia prolonged into the postoperative period, in addition to other appropriate thromboprophylactic measures, should be of value in patients undergoing operations associated with a high risk of thromboembolic complications.     

Bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia

The gluteal compartment syndrome is uncommon and is discussed in only a few published case reports. The simultaneous bilateral gluteal compartment syndrome is exceptionally rare and is tackled in only 4 case reports to date. We report a case of bilateral gluteal compartment syndrome after total hip arthroplasty under epidural anesthesia and discuss its management.     

Comparison of hypotensive epidural anesthesia and hypotensive total intravenous anesthesia on intraoperative blood loss during total hip replacement

STUDY OBJECTIVE: To compare hypotensive epidural anesthesia (HEA) and hypotensive total intravenous anesthesia (HTIVA) with propofol and remifentanil on blood loss during primary total hip replacement. DESIGN: Prospective, randomized clinical study. SETTING: University hospital. PATIENTS: Forty ASA physical status I, II, and III patients presenting for primary total hip replacement. INTERVENTIONS: Patients received either HEA with bupivacaine (HEA group, n = 20) or HTIVA with propofol and remifentanil (HTIVA group, n = 20) to maintain mean arterial pressure between 50 and 60 mm Hg. MEASUREMENTS: Duration of hypotension, blood loss, blood transfusions, hemodynamics, and coagulation studies were recorded in both groups. MAIN RESULTS: Intraoperative blood loss, percentage of patients receiving blood substitution, and total packed red blood cells transfused were less in those patients receiving HEA than those receiving HTIVA (P = .001, .04, and .015, respectively). Mean central venous pressure was lower in the HEA group than in the HTIVA group intraoperatively (P = .019). Mean hemoglobin concentrations and coagulation studies were similar between the groups. Neurologic examinations of all patients were intact in the postoperative period. CONCLUSIONS: In spite the similar mean arterial pressure levels noted between groups, HEA results in less intraoperative blood loss than HTIVA during primary total hip replacement. This outcome may be associated with non-positive pressure ventilation, distribution of blood flow, and lower mean intraoperative central venous pressure in the HEA group.     

硬膜外麻醉联合腰麻腹腔镜下完全腹膜外疝修补治疗腹股沟斜疝15例体会

目的:总结硬膜外麻醉联合腰麻腹腔镜完全腹膜外疝修补术的优点。方法:对15例腹股沟斜疝行腹腔镜完全腹膜外疝修补手术(TEP)的临床资料进行回顾性分析。结果:手术顺利,无中转开腹。手术时间60-180m in,平均85m in,术后平均4d出院,平均节省费用4 000元。随访至今无复发。结论:硬膜外麻醉联合腰麻行完全腹膜外腹腔镜疝修补术安全有效,具有患者创伤小,术后疼痛轻、康复快。复发率、并发症发生率低等优点,并可降低手术费用。     

Delayed hypoxemia after bone cement insertion during total hip replacement under spinal anesthesia--a case report

We report a case of delayed hypoxemia in an aged healthy male patient, which developed 2 hours after cementation of the prosthesis in total hip replacement (THR) under spinal anesthesia. The patient was doing well throughout the operation but unfortunately, progressive tachypnea was noted 1 h after he was transferred to the recovery room (i.e. 2 h after the application of bone cement into the femur). An hour further, distinct wheeze was heard bilaterally on auscultation, which signified bronchospasm. Arterial blood gases analysis revealed a low PaO2 of 71 mmHg and a decrease of oxygen saturation to 91% with supplement of fractional oxygen of 35%. Aerosolization of bronchodilator with terbutaline was administered and supplemental fractional oxygen was increased to 50%. Although wheezing soon subsided, tachypnea and desaturation persisted. He was then transferred to the surgical intensive care unit for further management. Ventilation-perfusion lung scan was performed, which was suggestive of multiple pulmonary embolism.     

Leg blood flow during total hip replacement under spinal or general anaesthesia

Calf blood flow was studied using venous occlusion impedance plethysmography during 122 total hip arthroplasties. Patients were randomly allocated to receive spinal or general anaesthesia. Blood flow was measured nine times perioperatively. In the non-surgical leg, mean blood flow rose by over 50% in both groups following anaesthetic induction, remaining significantly elevated with spinal but falling back gradually to baseline with general anaesthesia. In the surgical leg, surgical manipulations produced marked falls in flow in many patients, particularly with femoral component insertion. If this occurred, hyperaemia was commonly seen with spinal anaesthesia but rarely with general anaesthesia once the joint was relocated. Venous outflow resistance rose slightly during anaesthesia in both groups, more so with general anaesthesia. In the surgical leg, marked rises occurred with surgical manipulations, but resistance fell abruptly once the joint was relocated. No clear relationship between these observations and the occurrence of deep vein thrombosis postoperatively was established.     

Frequency of hypotension and bradycardia during general anesthesia, epidural anesthesia, or integrated epidural-general anesthesia for total hip replacement

STUDY OBJECTIVE: To evaluate the frequency of hypotension and bradycardia during integrated epidural-general anesthesia as compared with general anesthesia or epidural anesthesia alone. DESIGN: Prospective, randomized, open, multicenter study. SETTING: Inpatient anesthesia at 7 University or Hospital Departments of anesthesia. PATIENTS: 210 ASA physical status I, II, and III patients undergoing elective total hip replacement. INTERVENTIONS: Using a balanced randomization method, each hospital enrolled 30 consecutive patients who received integrated epidural-general anesthesia, epidural anesthesia, or general anesthesia. MEASUREMENTS AND MAIN RESULTS: Occurrence of clinically relevant hypotension (systolic arterial blood pressure (BP) decrease >30% from baseline), or bradycardia (heart rate (HR) <45 bpm) requiring pharmacologic treatment were recorded, as well as routine cardiovascular parameters. Clinically relevant hypotension during induction of nerve block was reported in 13 patients receiving epidural block (18%) and 16 patients receiving epidural-general anesthesia (22%) (p = 0.67). Subsequently, 22 of the remaining 54 patients in the epidural-general anesthesia group (41%) developed hypotension after the induction of general anesthesia, as compared with 16 patients of the general anesthesia group (23%) (p = 0.049). No differences in HR or in frequency of bradycardia were observed in the three groups. CONCLUSIONS: The induction of general anesthesia in patients with an epidural block up to T10 increased the odds of developing clinically relevant hypotension as compared with those patients who received no epidural block, and was associated with a twofold increase of the odds of hypotension as compared with the use of epidural anesthesia alone.     

Hypotension during thoracic surgery under combined general and high thoracic epidural anesthesia

High thoracic epidural anesthesia (TEA) is increasingly often used in combination with general anesthesia for major thoracic and abdominal surgery. TEA leads to sympatholysis of cardiac efferences leading to improved myocardial oxygen balance, which is in part due to vasodilation of atherosclerotic coronary vessels. To provide the full benefit of TEA, it is important to extend it as patient-controlled epidural analgesia in the postoperative period. If adequate vascular volume is maintained, hypotension is less frequent after TEA than after lumbar epidural anesthesia. However, in combination with general anesthesia, it may be more frequent and more severe. Treatment of hypotension is sometimes difficult and may require the use of nonadrenergic vasoconstrictors (eg, vasopressin). Copyright © 2000 by W.B. Saunders Company     

Effects of sympathetic blockade on the efficiency of forced-air warming during combined spinal-epidural anesthesia for total hip arthroplasty.

STUDY OBJECTIVE: To evaluate if active cutaneous warming of the two upper limbs with reflex vasoconstriction is less effective in maintaining intraoperative normothermia than warming the vasodilated unoperated lower limb during combined spinal-epidural anesthesia (CSE). DESIGN: Prospective, randomized study. SETTING: Inpatient anesthesia at university departments of orthopedic surgery. PATIENTS: 48 ASA physical status I, II, and III patients, who were scheduled for elective total hip arthroplasty. INTERVENTIONS: Patients received CSE with intrathecal injection of 15 mg of 0.5% hyperbaric bupivacaine. All procedures started 8 to 10 AM, and operating room temperature was maintained between 21 degrees and 23 degrees C, with relative humidity ranging between 40% and 45%. For warming therapy, patients received active forced-air warming of either the two upper limbs (Group Upper body, n = 24), or the unoperated lower limb (Group Lower extremity, n = 24). Core temperature was measured before CSE placement (baseline), and then every 30 minutes until completion of surgery. Time for fulfillment of clinical discharging criteria from the recovery area was evaluated by a blinded observer. MEASUREMENTS AND MAIN RESULTS: Demographic data, duration of surgery, intraoperative blood losses, crystalloid infusion, and hemodynamic variables were similar in the two groups. Core temperature slightly decreased in both groups, but at the end of surgery the mean core temperature was 36.2 degrees +/- 0.5 degree C in Group Upper body and 36.3 +/- 0.5 in Group Lower extremity (NS). At recovery room arrival, seven patients in Group Upper body (29%) and three patients in Group Lower extremity (12.5%) had a core temperature less than 36 degrees C (NS). Shivering was observed in one patient in Group Upper body and in two patients in Group Lower extremity (NS). Clinical discharging criteria were fulfilled after 37 +/- 16 minutes in Group Upper body and 30 +/- 32 minutes in Group Lower extremity (NS). CONCLUSIONS: Forced-air cutaneous warming allows the anesthesiologist to maintain normothermia during CSE for total hip replacement even if the convective blanket is placed on a relatively small skin surface with reflex vasoconstriction. Placing the forced-air warming system on the vasodilated unoperated lower limb may be troublesome to the surgeons and does not offer clinically relevant advantages in warming efficiency.     

Epidural hematoma unrelated to combined spinal-epidural anesthesia in a patient with ankylosing spondylitis receiving aspirin after total hip replacement

Although rare, major complications after spinal and epidural anesthesia do occur. The safety of spinal and epidural anesthesia has been well established. This is a report of an epidural hematoma in a patient with ankylosing spondylitis who received aspirin for thromboprophylaxis after total hip replacement that was unrelated to the combined spinal-epidural anesthetic. Most epidural hematomas are spontaneous and idiopathic.     

Effect of tranexamic acid on reducing postoperative blood loss in combined hypotensive epidural anesthesia and general anesthesia for total hip replacement

Study ObjectiveTo determine whether the use of tranexamic acid in the setting of hypotension induced by hypotensive epidural anesthesia (HEA) has any additional beneficial effects in reducing perioperative blood loss and transfusion requirements in total hip replacement.DesignProspective, randomized, double-blinded trial.SettingUniversity-affiliated hospital.Patients68 adult, ASA physical status 1 and 2 patients undergoing primary unilateral cementless total hip replacement with general anesthesia and HEA.InterventionsThe HEATA group received a bolus dose of 15 mg/kg of tranexamic acid before surgical incision, followed by a continuous 15 mg/kg infusion until skin closure. The HEA group received normal saline instead of tranexamic acid in the same manner.MeasurementsIntraoperative blood loss was measured using the difference between the weights of used gauze and the original unused gauze, in addition to the blood volume accumulated in suction bottles. Postoperative blood loss was considered to be the amount of blood accumulated in drainage bags.Main ResultsThere was no significant difference in intraoperative blood loss between the HEA and HEATA groups (251.8 ± 109.9 mL vs 234.9 ± 93.9 mL), but postoperative blood loss was significantly less in the HEATA group than the HEA group (439.3 ± 171. 6 mL vs 1074.4 ± 287.1 mL), as was total cumulative blood loss (674.2 ± 216.4 mL vs 1326.2 ± 347.8 mL). There was no significant difference in intraoperative transfusion incidences, but postoperative transfusion was greater in the HEA group than the HEATA group.ConclusionsAdministration of tranexamic acid combined with hypotensive epidural anesthesia reduced postoperative and total accumulative blood loss and transfusion requirements more than did hypotensive epidural anesthesia alone.     

Isoflurane requirements during combined general/epidural anesthesia for major abdominal surgery

We evaluated the effects of bupivacaine on the requirements for thiopental and isoflurane during combined general/epidural anesthesia. Sixty patients scheduled for colon resection were randomly distributed into six groups that received, before the induction of anesthesia, an epidural (T9-10) bolus (8 mL) followed by an infusion (8 mL/h) of saline (Groups 1 and 4), bupivacaine 0.0625% plus fentanyl 2 microg/mL (Groups 2 and 5), or bupivacaine 0.125% plus fentanyl 2 microg/mL (Groups 3 and 6). We evaluated the amount of thiopental needed to abolish the eyelid reflex and the percentage of isoflurane required to maintain the bispectral index (BIS) between 50 and 60 (Groups 1-3) or the mean arterial blood pressure (MAP) within 20% of basal values (Groups 4-6). All groups required similar doses of thiopental (5 mg/kg); the time of evaluation, but not epidural treatment, had a significant effect (P < 0.0001) on BIS and MAP. After tracheal intubation, MAP and BIS increased by 18% and 49%, respectively (P < 0.05). In the bupivacaine groups, isoflurane requirements similarly decreased by 35% (P < 0.03). For BIS and MAP, the epidural treatment (P < 0.02) and type of evaluation (P < 0.03) had a significant effect; MAP was lower (P < 0.05) with 0.125% bupivacaine. We conclude that epidural bupivacaine does not alter the thiopental dose, but it decreases isoflurane requirements by 35%. This study demonstrates that both doses of bupivacaine and fentanyl induce similar isoflurane-sparing effects. However, patients receiving 0.125% bupivacaine showed lower values of MAP when compared with controls, and thus bupivacaine 0.0625% should be favored during combined anesthesia. IMPLICATIONS: In patients undergoing colon resection under combined anesthesia, isoflurane requirements were assessed by changes in blood pressure or bispectral index. Epidural bupivacaine at concentrations of 0.125% or 0.0625% (each with 2 mg/mL of fentanyl) induced the same sparing of isoflurane (35%). The smaller dose produced less hypotension and should be favored.     

右美托咪定对全麻下髋关节置换术术后认知功能的影响

目的：探讨右美托咪定对全身麻醉下髋关节置换术术后老年患者认知功能的影响,为全身麻醉下髋关节置换术辅助用药的选择提供依据。方法选择于我院择期行髋关节置换手术的老年患者72例,分为观察组和对照组,每组36例。观察组在术前给予右美托咪定辅助全身麻醉患者的镇静,然后两组皆给予全身麻醉下髋关节置换术和相应常规处理,并通过简易精神状态量表（mini-mental state examination,MMSE）评估患者认知功能的改变以及认知功能障碍的发生率。结果观察组与对照组患者在体液量、手术时间、麻醉时间等方面无显著统计学差异（P＞0.05）。在术后S100蛋白含量方面差异有统计学意义（P＜0.05）。在术后第1天、第7天的MMSE评分存在统计学差异。术后第3天,对照组认识功能障碍的发生率为27.78%（10/36）,观察组认识功能障碍的发生率为19.45%（7/36）,两组间存在统计学差异（P＜0.05）。术后第9天,两组患者认知能力均有部分恢复,对照组发生率为16.67%（6/36）,观察组发生率为8.3%（3/36）,两组间存在统计学差异（P＜0.05）。结论研究发现右美托咪定具有明显的镇静作用,能够帮助改善老年患者全身麻醉下髋关节置换术后的认知功能障碍。     

Ultrasound guided single injection caudal epidural anesthesia of isobaric bupivacaine with/without dexamethasone for geriatric patients undergoing total hip replacement surgery

BackgroundDexamethasone has anti-inflammatory properties that can affect postoperative analgesia when added to caudal bupivacaine.MethodsSeventy-two geriatric patients scheduled for elective total hip replacement under ultrasound guided caudal anesthesia were randomized blindly into two groups: Group BD received caudal isobaric bupivacaine 0.25% (20 ml) and dexamethasone 8 mg (2 ml) and Group BS received caudal isobaric bupivacaine 0.25% (20 ml) and normal saline (2 ml). Postoperative analgesia was assessed by recording time to first rescue analgesia and the analgesic doses (paracetamol and meperidine hydrochloride) required during the first 24 h postoperatively as a primary outcome. Secondary outcomes were the time taken to the onset of sensory analgesia at T10, time to the onset of complete motor block, VAS pain score at rest and on movement at 1, 2, 4, 6, 8, 12 and 24 h, and postoperative adverse events.ResultsGroup BD had a significantly longer time to first rescue analgesia [402 (63) vs 213 (53)] min and significantly lower doses of paracetamol [3389 (728) vs 2833 (697)] mg meperidine hydrochloride [78 (30) vs 142 (28)] mg than Group BS. VAS scores were significantly lower in Group BD than Group BS both at rest and on movement respectively at 4, 6, 8, 12 and 24 h.ConclusionAdding dexamethasone with isobaric bupivacaine caudal anesthesia prolongs the duration of postoperative analgesia and decreased postoperative analgesic requirement in geriatric patients undergoing total hip replacement surgery in comparison isobaric bupivacaine alone.     

Antagonism of diazepam-induced sedative effects by flumazenil in patients after surgery under lumbar spinal or epidural anesthesia

The efficacy and general safety of flumazenil (YM684), a specific benzodiazepine antagonist, have been evaluated. Forty-seven patients scheduled for surgery under lumbar spinal or epidural anesthesia with diazepam sedation received flumazenil at the end of the procedure. Criteria of efficacy were the degree of sedation and antegrade amnesia. Before injection all patients were heavily sedated with the mean dose of 27 mg of diazepam (range 10-50 mg). After the mean dose of 0.21 mg of flumazenil (range 0.2-0.4 mg), all patients were awake or drowsy within 1-6 min but sedation recurred in one patient 1 hour later. The amnesia was eliminated by flumazenil in 34 patients (72%). No serious side-effects or hemodynamic changes were observed after flumazenil. It is concluded that flumazenil is an effective antagonist of sedation induced by diazepam.