经皮穴位电刺激对开颅手术安氟醚麻醉的强化作用

选择８０例颅脑手术患者，随机分组观察用 Ｈａｎ’ｓ电刺激仪经皮电刺激开颅侧合谷、风池和鱼腰三个穴位对安氟醚的临床麻醉效果及血流动力学变化的影响。结果表明，穴位电刺激明显减少手术期间安氟醚的吸入浓度和用量，维持相似麻醉深度时所需ＭＡＣ较单纯吸入安氟醚减少３７．８％～４７．０％，心血管抑制也明显减轻，患者恢复快而平稳。     

开颅手术后疼痛管理的研究进展

开颅手术是最常见的神经外科手术之一。开颅术后中重度疼痛发生率高达75%,术后疼痛可增加术后并发症,延长ICU停留时间和住院时间,严重影响患者术后康复。部分镇痛方法和镇痛药物导致的恶心、呕吐、呼吸抑制等不良反应可能会影响患者术后的神经功能,掩盖神经系统症状,干扰病情判断,目前尚无针对开颅患者的确切镇痛方案。如何实施开颅患者术后镇痛,改善患者转归,成为临床亟待解决的问题。本文就开颅术后疼痛特点、疼痛机制、疼痛评估、镇痛策略与管理进行综述,以期为开颅手术的术后镇痛提供参考。     

The effects of preoperative rofecoxib,metoclopramide, dexamethasone,and ondansetron on postoperative pain and nausea in patients undergoing elective laparoscopic cholecystectomy

Background No trial to date has evaluated the combined effect of preoperative Rofecoxib, Metoclopramide, Dexamethasone, and Ondansetron on postoperative pain and nausea in patients undergoing laparoscopic cholecystectomy (LC). Methods A prospective randomized double-blinded placebo-controlled trial was conducted on patients undergoing elective LC. The patients in the intervention group received Rofecoxib 25 mg PO. Additionally the study group received Metoclopramide 10 mg and Dexamethasone 4 mg; and Ondansetron 4 mg intravenously. Pain and nausea were rated preoperatively, on arrival at the postanesthesia care unit (PACU), at points until discharge, and at 24 hours. Results 97 patients were in the control group, and 108 received intervention. The intervention group had a smaller proportion of men (10% vs. 23%; p < 0.015). There were differences in: length of stay (LOS) until discharge criteria met (12.88 vs. 9.85 hours, p = 0.0006), pain rating on arrival to floor (3.55 vs. 2.48, p = 0.003); highest pain rating (4.38 vs. 3.56, p = 0.032), highest nausea rating (2.99 vs. 1.47, p = 0.001), worst nausea since discharge (2.58 vs. 1.26, p = 0.005), and the use of postoperative anti-emetics in women (64% vs. 37.1%, p = 0.001). Conclusions The use of this preoperative regimen resulted in decreased LOS, maximum pain, and nausea ratings. Patients in the intervention group required less postoperative anti-emetics.     

围手术期地塞米松对全膝关节置换术后恶心呕吐和疼痛的影响

目的:探讨围手术期应用地塞米松对于单侧全膝关节置换术后恶心呕吐和疼痛的影响及安全性评估。方法:2014年2月至2016年6月采用全膝关节置换治疗的单侧晚期骨性关节炎患者100例,分为2组,每组50例:其中地塞米松组,男27例,女23例,年龄(72.30±7.02)岁,术前给予地塞米松10 mg静脉滴注;生理盐水组,男26例,女24例,年龄(71.30±6.08)岁,相应时间给予等量生理盐水静滴。观察记录术后2、4、6、8、12、24、36、48 h时休息时和屈膝45°时疼痛VAS评分,记录术后0～24 h和24～48 h发生呕吐情况、使用止吐药及阿片类药情况。并记录术后患者药物副作用及并发症。结果:100例患者均获得随访,平均随访时间14.5个月。休息时疼痛VAS评分地塞米松组术后8、24、48 h时低于生理盐水组(P0.05);屈膝45°时VAS评分地塞米松组术后8、48 h时低于生理盐水组(P0.05);地塞米松组休息时和屈膝45°时VAS评分总体低于生理盐水组(P0.05)。术后0～24 h、24～48 h阿片类药用量及总阿片类药用量地塞米松组均低于生理盐水组(P0.05)。两组患者术后0～24 h和24～48 h发生恶心呕吐比例,术后0～24 h要求使用止吐药比例差异均有统计学意义(P0.05)。总止吐药用量地塞米松组少于生理盐水组(P0.05)。截止末次随访,两组患者未出现术后感染、消化道溃疡、出血等并发症。结论:术前全身应用地塞米松可有效减少TKA术后疼痛和恶心呕吐,且并不增加术后并发症。     

The effect of diclofenac and nefopam on postoperative dental pain

Eighty-two outpatients who received general anaesthesia for surgical removal of maxillary or mandibular third molars were given either diclofenac 75 mg or nefopam 20 mg intramuscularly for postoperative pain control. They and the control group were also allowed oral paracetamol as required. The results showed that there was no significant pain relief from these single intramuscular injections.     

不同用药方式对昂丹司琼预防术后镇痛后恶心、呕吐疗效的影响

目的比较不同用药方式对中枢性镇吐药昂丹司琼预防术后镇痛治疗后发生恶心、呕吐的疗效差异。方法择期妇科手术患者120例按昂丹司琼用药方式不同分为四组镇痛泵联合静脉用药组(A组)、镇痛泵用药组(B组)、静脉用药组(C组)和对照组(D组),每组30例。记录手术结束后的不同时间点(0、1、3、6、12和24h)疼痛视觉模拟评分(VAS)以及不同时间段内(0~1h、1~3h、3~6h、6~12h、12~24h)恶心、呕吐发生例数。结果不同时间点组内和组间VAS差异无显著意义。恶心、呕吐发生率在A组和C组间以及B组和D组间差别无显著意义。而A组和B组间以及C组和D组间差异有显著意义(P<0·05)。结论术后静脉注射昂丹司琼较其他用药方式可明显减少术后镇痛后恶心、呕吐的发生率。     

后腹腔镜肾癌根治术对患者术后疼痛及相关血液指标的影响研究

目的 观察后腹腔镜肾癌根治术与开放性肾癌根治术对患者术后疼痛及相关血液指标影响的差异.方法 以2012年5月至2015年5月在本院接受肾癌根治术的80例患者为研究对象,并随机分为对照组和观察组,每组各40例患者.其中对照组采取开放性肾癌根治术,观察组则给予后腹腔镜肾癌根治术.比较两组患者手术前后VAS得分和疼痛因子水平;比较两组患者手术前后血清中应激相关指标[白细胞数、血清皮质醇、甲状腺素和C-反应蛋白(CRP)]、肿瘤标志物(CA50、CEA、CA125)和炎症相关细胞因子水平的差异.结果 手术前两组患者VAS得分和5-HT水平无明显差异,术后第3天,由于手术创伤两组患者的VAS得分和5-HT水平均较术前明显升高,但观察组低于对照组(P＜0.05);术前两组患者的应激指标无明显差异,术后第3天,对照组白细胞数、皮质醇、CRP水平均高于观察组,而FT3和FT4水平低于观察组;观察组患者抑炎因子中IL-2高于对照组,IL-10和IL-13低于对照组,促炎因子IL-1β、IL-6和IL-12均低于对照组(P＜0.05).结论 与开放性肾癌根治术相比,后腹腔镜肾癌根治术在确保癌肿清除的同时,对机体炎性平衡状态的影响较小,并可减轻机体的氧化应激反应,对减轻患者术后疼痛、促进机体早日恢复有重要意义.     

Retrospective analysis of postoperative nausea and vomiting after craniotomy

BACKGROUND: Postoperative nausea and vomiting are important complications after craniotomy. METHODS: One hundred and seventy eight patients who had undergone brain tumor resection at Nara Medical University were retrospectively divided to one of two groups; with or without PONV within 24 hours postoperatively. Variables compared between the groups include gender, age, weight, height, site of surgery (supratentorial versus infratentorial craniotomy), size of brain tumor, type of anesthesia (inhalation versus intravenous anesthesia with nitrous oxide), intraoperative fentanyl dose, duration of surgery as well as anesthesia, and intraoperative posture. RESULTS: PONV occurred in 87 patients (49%). The incidence of PONV in patients undergoing infratentorial craniotomy was significantly higher than that in patients undergoing supratentorial craniotomy (75% vs 45%, P = 0.0011). There were no significant associations between PONV and other variables analyzed. CONCLUSIONS: These results indicate that the incidence of PONV after brain tumor resection is high and infratentorial surgery is a risk factor for PONV. Strategies for the prevention of PONV after craniotomy are required.     

Effect of premedication with mirtazapine versus ondansetron on postoperative nausea and vomiting in breast surgery

Background

Mirtazapine is a specific serotonergic antidepressant drug. The aim of this study was to compare the efficacy of mirtazapine as PONV prophylaxis with a classic 5HT3 receptor antagonist; ondansetron.

Methods

Eighty female patients with high PONV risk undergoing prophylactic mastectomy with a standardized anesthetic were randomized to receive either an oral disintegrating tablet (ODT) of mirtazapine 30 mg (group M) or ondansetron 16 mg (group O) 1 h before surgery. Preoperative anxiety level was assessed by state and trait anxiety inventory before taking the study drug and 1 h after. Vital sign variables, the incidence of PONV, the use of rescue antiemetic, complete response, postoperative VAS pain scores, the inverted observer’s assessment of alertness/sedation scale and side effects were compared.

Results

Mirtazapine premedication reduced preoperative state anxiety inventory scores (P < 0.01) and the incidence of early nausea and late vomiting (P < 0.05). The percentage of patient having complete responses during the first 24 h after anesthesia was 75% after mirtazapine and 65% after ondansetron prophylaxis. Anesthetic requirements, postoperative pain, sedation scores, and side effects were similar between the two groups.

Conclusion

Mirtazapine prophylaxis reduces preoperative anxiety and the incidence of postoperative early nausea and late vomiting compared with ondansetron, without untoward sedative or cardiovascular effects.     

开颅手术对脑脊液中药物浓度的影响

目的通过测定开颅术后周围静脉血、皮下引流液及脑脊液中药物浓度,来评价开颅手术对脑脊液药物浓度的影响.方法开颅手术前半小时静脉滴注硫酸庆大霉素8万单位,6小时后分别测定周围静脉血、皮下引流液及脑脊液中庆大霉素浓度,分别对无需切开硬脑膜及需要切开硬脑膜的病例各20例进行对照观察.结果硬脑膜完整组:周围静脉血为0.47±0.15,皮下引流液为1.41±0.46,脑脊液0.27±0.18,以皮下引流液中浓度最高,周围静脉血其次,脑脊液最低,三者比较均有显著差异(P＜0.01);硬脑膜开放组:周围静脉血为0.56±0.19,皮下引流液为1.28±0.75,脑脊液为0.52±0.15,亦是皮下引流液中浓度最高,但周围静脉血与脑脊液无显著差异(P＞0.05).两组之间周围静脉血以及皮下引流液无显著差异(P＞0.05),而脑脊液有显著差异(P＜0.01).结论开颅术后的皮下引流液中含有较高的药物浓度,与脑脊液间存在着明显的浓度差,药物能通过脑脊液与皮下渗出液的交换而进入颅内,使脑脊液中的药物浓度上升.     

Routine use of postoperative ICU care for elective craniotomy: a cost-benefit analysis

OBJECTIVE: Postoperative monitoring in an intensive care unit (ICU) setting following elective craniotomy is routine at many institutions, as it is believed that this reduces the incidence and potential seriousness of early postoperative complications. This is unproven, however, and ICU resources are scarce and costly. At our institution, one surgeon began to routinely transfer elective craniotomy patients directly to the floor following an uneventful postanesthesia care unit (PACU) recovery. This study was undertaken to see whether that practice was safe and cost-effective. METHODS: A retrospective cohort of 430 consecutive, elective adult craniotomies, from February, 2000 to September, 2001 were analyzed. Variables were divided into 12 major groups: attending surgeon, age, sex, diagnosis, Current Procedural Terminology (CPT) code, length of stay, preoperative deficit, medical co-morbidities, postop floor, medical complications, neurological complications, and total hospitalization cost. RESULTS: Patients admitted to the surgical intensive care unit (SICU) did not have fewer complications than patients transferred directly to the floor. Patients admitted to the SICU did not have more preoperative neurological deficits or medical co-morbidities. Age was not a significant predictor of either medical or neurological complications. In patients without initial postop complications, only length of stay and postop floor assignment correlated with cost (p < 0.001). Immediate transfer to the floor decreased average hospitalization length by 3 days, and provided cost savings of $4,026 per patient. CONCLUSIONS: Selective, rather than routine use of postoperative ICU care in elective craniotomy patients is safe, resulting in no greater incidence of medical or neurological complications, and may provide significant reductions in average hospitalization length and cost.     

低龄儿童颅脑手术术后疼痛情况的评估

目的 观察低龄儿童(1岁～6岁)开颅术后的疼痛现状,并探讨影响其术后疼痛的相关因素. 方法 应用前瞻性队列研究,入选择期开颅肿瘤切除术1岁～6岁患儿135例,其中15例因为术后不能即刻拔除气管导管被排除,11例因为术后1h内未清醒不能配合术后评分也被排除,另有1例因术后2日血肿行二次手术也被排除.最终共108例能够配合术后疼痛评分的患儿纳入研究.美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级.测量和记录每名患儿的人口统计学资料、手术的变量及术后疼痛及相关变量,术后分别采用Face、Legs、Activity、Cry and Consolability(FLACC)评分和Wong-Baker Faces Scale (WBFS)评分两种方法进行疼痛评分. 结果 108名患儿中大部分的患儿(FLACC法62％、WBFS法82％)在术后1h的疼痛评分超过4分.开颅部位(PFLACC=0.035;PWBS=0.039)、手术结束前末次镇痛药的使用(PFLACC=0.026,PWBFS=0.015)、手术结束后患儿的去向(PW肝S=0.022)及术后是否使用静脉镇痛泵(PFLACC=0.000,PWBFS=0.002)均为术后疼痛的相关因素. 结论 大部分低龄儿童在行开颅肿瘤切除术后48 h内经历了中到重度的疼痛,尤其是某些1岁～2岁小儿.在可以控制的因素中手术,手术结束前镇痛药的使用,术后及时得到父母的安抚与关怀,术后使用静脉镇痛泵等可以明显减轻患儿的术后疼痛.     

The effect of glycopyrrolate on postoperative pain and analgesic requirements following laparoscopic sterilisation

In order to evaluate the contribution of tubal spasm to pelvic pain following laparoscopic sterilisation, we have studied the effect of glycopyrrolate, an anticholinergic agent with antispasmodic properties, on 60 ASA 1 and 2 patients presenting as day-cases for laparoscopic sterilisation using Filshie clips. In a randomised, double-blind, controlled trial, patients received either glycopyrrolate 0.3mg or saline intravenously prior to induction of anaesthesia. Compared with the control group, patients receiving glycopyrrolate had significantly reduced immediate postoperative pain scores (p < 0.02) and required significantly less postoperative morphine (p < 0.01). Nausea, vomiting and anti-emetic requirements were also reduced though not significantly. We conclude that glycopyrrolate 0.3mg at induction of anaesthesia is an effective method of improving the quality of recovery after day-case laparoscopic sterilisation using clips.     

The effect of buffering on pain and duration of local anesthetic in the face: A double-blind,randomized controlled trial

BACKGROUND:

The acidity of lidocaine preparations is believed to contribute to the pain of local anesthetic injection.

OBJECTIVE:

To investigate the effect of buffering lidocaine on the pain of injection and duration of anesthetic effect.

METHODS:

A double-blind, randomized trial involving 44 healthy volunteers was conducted. The upper lip was injected with a solution of: lidocaine 1% (Xylocaine, AstraZeneca, Canada, Inc) with epinephrine; and lidocaine 1% with epinephrine and 8.4% sodium bicarbonate. Volunteers reported pain of injection and duration of anesthetic effect.

RESULTS:

Twenty-six participants found the unbuffered solution to be more painful. Fifteen participants found the buffered solution to be more painful; the difference was not statistically significant. Twenty-one volunteers reported duration of anesthetic effect. The buffered solution provided longer anesthetic effect than the unbuffered solution (P=0.004).

CONCLUSION:

Although buffering increased the duration of lidocaine’s anesthetic effect in this particular model, a decrease in the pain of the injection was not demonstrated, likely due to limitations of the study.     

The effect of smoking on postoperative nausea and vomiting

In an attempt to quantify the postoperative effects of smoking, 327 consecutive patients undergoing arthroscopic day case knee surgery were given a standard anaesthetic consisting of an intravenous induction with propofol and fentanyl followed by inhalational maintenance using isoflurane in an oxygen and nitrous oxide mixture. Pre-operatively, patients were asked inter alia to give details of social smoking habits. Postoperatively, patients were given standard analgesic and anti-emetic drugs. Prior to discharge patients were asked to give details of postoperative nausea and vomiting together with details of the severity of postoperative pain. There were 85 smokers and 242 nonsmokers. Of the 327 patients, a total of 42 (13%) complained of postoperative nausea and vomiting. Of the smokers, only 6% complained of postoperative nausea and vomiting in contrast to 15% of the nonsmokers (p < 0.05). It is postulated that enzyme induction is the most likely reason for this anti-emetic effect. Possible ways in which this clinically beneficial mechanism can be utilised to improve outcome after anaesthesia are discussed.     

疼痛灾难化预测术后疼痛的研究进展

疼痛灾难化是患者对疼痛产生的夸大且消极的思维定势。作为与疼痛相关的主要负面心理情绪之一,疼痛灾难化可以通过多种机制调控疼痛体验。因此,疼痛灾难化可能是各种疼痛相关疾病的潜在发病机制和治疗靶点。近年来,由于相对统一的量表出现,越来越多的研究将疼痛灾难化作为术前心理评估项目,探讨术前疼痛灾难化强度预测术后疼痛发生的可能性。全文对疼痛灾难化的相关概念、发生机制、评估手段以及疼痛灾难化对术后急慢性疼痛的预测能力的研究进展进行综述。     

术前使用罗哌卡因对腹腔镜胆囊切除术后镇痛效应的临床研究

目的:观察腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)术前应用罗哌卡因切口浸润结合术中腹腔喷洒对术后疼痛的缓解效应。方法:随机将择期行LC的90例患者分为3组(n=30),A组术前用0.75%罗哌卡因13.3 ml(100 mg)逐层浸润切口并喷洒腹腔;B组术后使用静脉镇痛泵;C组为对照组,使用生理盐水,方法同A组。分别于麻醉苏醒后2 h、6 h、12 h、24 h记录镇痛模拟评分(visual analogue scale,VAS),并记录3组患者使用镇痛药情况。结果:3组患者术后均无并发症发生及相应毒副反应。术后2 h、6 h、12 h,A、B两组患者VAS评分差异无统计学意义(P>0.05),均明显低于C组(P<0.05)。A、B两组各有2例(6.7%)患者应用非甾体类抗炎药,C组11例(36.7%)应用非甾体类抗炎药,差异有统计学意义(P<0.05)。结论:术前罗哌卡因切口浸润结合腹腔内喷洒可明显降低LC术后早期VAS评分,具有良好的镇痛效果,可减少其他镇痛药物的使用量。