局部麻醉透皮技术与整形美容手术

术中麻醉根据麻醉药物分布范围可分为全身麻醉和局部麻醉,其中局部麻醉在整形美容手术中的应用较为广泛。传统剂型经皮递送局麻药作用时间较短,且脂溶性差,限制了其在体表透皮方面的应用。近年来,随着麻醉技术的发展,新型体表镇痛局麻药递送系统可将涂抹于皮肤的药物递送至真皮层以阻滞神经末梢痛觉传入,从而达到镇痛的效果,提高了药物递送效率。此外,透皮给药相较于注射给药可显著增加给药安全性和患者舒适度。本文概述了常用的局麻药透皮吸收促进方法以及目前已上市的透皮局麻药物,并结合研究进展对局部麻醉透皮技术在整形美容手术中的应用和发展作一展望。     

胸部手术后吗啡不同途径术后镇痛的临床研究

目的评价吗啡不同使用方法对胸部手术术后镇痛的临床效果，并探讨其临床意义。方法选择117例开胸手术患者分成硬膜外吗啡镇痛组和肌内注射吗啡镇痛组，比较两组患者心、肺功能指标及术后并发症。结果两组术后血压心率较术前均增高，肺功能较术前均降低，但肌内注射吗啡镇痛组术后24h收缩压、舒张压明显高于硬膜外吗啡镇痛组（P〈0．05），两组术后24h之间心率无显著差异（P〉0．05），肌内注射吗啡镇痛组肺功能术后24h明显低于硬膜外吗啡镇痛组（P〈0．05），肌内注射吗啡镇痛组并发症总发生率明显高于硬膜外吗啡镇痛组（P〈0．05）。结论硬膜外吗啡持续泵入方法用于胸部手术术后镇痛的安全、有效，各项术后指标更接近生理水平，并发症明显少于吗啡肌内注射。     

Systemic local anesthetics in pain control

Analgesia has been reported as a potential effect of systemically administered local anesthetics for over four decades. Interest in the use of these drugs as analgesics has been stimulated by the advent of oral formulations and the findings of several controlled studies that suggest efficacy of these preparations in neuropathic pain syndromes. We review the pharmacology of local anesthetics and critically evaluate the medical literature describing the analgesic consequences of systemic administration. The data extant support their analgesic effect in selected pain syndromes.     

两种不同镇痛方法对开胸手术术后恢复的影响

目的:比较经静脉自控镇痛、肋间神经冷冻术两种镇痛方法对开胸手术患者术后恢复的影响。方法:60例开胸手术患者随机分为肋间神经冷冻组(INC组)和患者静脉自控镇痛组(PCA组)。疼痛强度评分法(NRS)评估术后疼痛程度。结果:(1)两组比较,术后并发症、下床时间、正常活动时间差异无统计学意义(P>0.05)。而术后副反应比较,PCA组较INC组严重(P<0.05);INC组较PCA组术后胸引管引流量大,胸引管拔除时间长(均P<0.05)。INC组术后肺功能恢复明显好于PCA组(P<0.05)。(2)术后前2d内,疼痛指数及镇痛药物使用方面两组差异无统计学意义(P>0.05);术后第3～7天,INC组较PCA组疼痛明显减轻(P<0.05),但药物使用方面差异无统计学意义(P>0.05)。结论:肋间神经冷冻术是比较好的胸部手术术后镇痛治疗方法,副作用小,但术后胸引管引流量增加,拔除胸引管时间延长。     

Analgesic efficacy of modified thoracoabdominal nerves block through the perichondrial approach in laparoscopic cholecystectomy: A retrospective study with propensity analysis

Modified thoracoabdominal nerves block through the perichondral approach (M-TAPA) was recently reported to provide broad analgesia with only a single injection of local anesthetics (LA) on each side. However, the effectiveness of M-TAPA in laparoscopic cholecystectomy (LC) is not often reported. We retrospectively evaluated the analgesic efficacy of M-TAPA in patients who underwent LC and compared it with conventional LA infiltration (LAI) by calculating the propensity score. The primary outcome was the frequency of analgesic use after surgery. Although there was no difference in the frequency of analgesic use within 48 hours (P = .063), there was significantly less analgesic use 24–48 hours after surgery in the TAPA group (P = .02). Intraoperative remifentanil administration also significantly decreased in the TAPA group (P < .001). We found that pre-incisional M-TAPA may have an advantage over LAI with respect to analgesia on postoperative day 1.     

电视胸腔镜在胸部外伤中的应用

目的 探讨电视胸腔镜在诊断和治疗胸部外伤中的应用情况.方法 回顾性分析2005年10月～2010年10月应用电视胸腔镜治疗胸部外伤患者50例的临床资料.其中诊断肺挫裂伤38例,肋间血管出血6例,心包填塞1例,膈肌破裂、胸腹贯通伤5例,除2例辅助小切口进胸外,余均在VATS 下缝合修补及止血完成手术,手术时间（80±30.1）min.结果 术后患者全部治愈,住院时间5～14d,平均8d,未发生并发症及死亡.结论 电视胸腔镜用于探查诊断治疗胸部外伤的患者,具有安全、手术创伤小、术后恢复快、住院时间短的优点,减少胸外伤术前观察时间,改变了传统经胸腔闭式引流观察漏气、出血量,再决定手术与否的模式.     

Chest X-rays in detecting injuries caused by blunt trauma

BACKGROUND: The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma.METHODS: A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009-2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists.RESULTS: Of the 447 patients, 309 (69.1%) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3%) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95%CI 78.3 (63.6-89)] but the lowest in pneuomediastinum [95%CI 11.8 (1.5-36.4)]. The specificity of CXR was close to 100% in detecting a wide array of entities.CONCLUSION: CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.     

PCA评价体表电刺激对心外科术后疼痛疗效的对照研究

心外科术后疼痛不仅给病人带来痛苦，也会影响全身各系统的功能，甚至会导致肺不张、心衰等严重的并发症。临床上通常采用麻醉性镇痛药或局麻药区域阻滞缓解术后疼痛，但这两类药物均存在一定的副作用及并发症。近年来，体表神经电刺激（transcutaneouselectricnervestimulation，TENS）开始用于心脏外科术后镇痛，但有关研究常得出相互矛盾的结果。本工作以病人自控镇痛（patientcontrolledanalgrsia，PCA）法作为评价指标，以电极安慰组作为对照，对33例心脏外科术后疼痛患者进行了TENS术后镇痛的疗效观察。结果表明，在PCA存在的条件下，TENS能够显著降低疼痛评分，减少PCA的用药次数和用药量（ANOVA，P＜0．01）。本工作为心脏外科术后常规应用：TENS镇痛提供了依据。     

右美托咪定对带状疱疹患者免疫功能的影响

目的探讨右美托咪定对带状疱疹免疫功能的影响。方法将40例带状疱疹后遗神经痛患者随机分为2组,每组20例。观察组给予右美托咪定联合局麻药皮内注射,对照组给予单纯局麻药皮内注射。比较2组不同时段CD4、CD8、CD4/CD8,以及视觉模拟评分(VAS)的变化。结果观察组治疗24、48 h时CD8水平显著低于对照组,CD4/CD8水平显著高于对照组。治疗后5、10、30 d观察组VAS显著低于对照组。结论右美托咪定联合局麻药组治疗带状疱疹后神经疼痛,能增加患者的免疫力,并延长局麻药的镇痛时间,减少治疗次数,缩短疗程,且后期疗效明显,优于单纯局麻药治疗,值得临床推广。     

The perineural administration of opiates during regional conduction block of nerve trunks and plexuses

The effect of perineural administration of narcotic analgesics on the efficacy of nerve trunk and plexus blockade has been studied in 290 patients with traumas and surgical diseases. It has been established that combined administration of a local anesthetic and narcotic analgesic into a brachial fascia and sciatic nerve ensures a more even, adequate and durable analgesia during and after surgery on the upper and lower extremities. Similarly, the results of paravertebral analgesia after abdominal surgery are improved. It is also concluded that thermographic registration of infrared irradiation intensity in a "pain" dermatome zone gives an objective information on the efficacy and duration of postoperative analgesia.     

纤维支气管镜在胸外科疾病诊疗中的应用

目的：探讨纤维支气管镜（简称纤支镜）在胸外科疾病诊疗中的应用效果。方法：回顾性分析2009年7月—2013年9月胸外科采用常规纤支镜或床旁纤支镜及术中经气管导管纤支镜检查患者的临床资料,镜下直视活组织检查和刷检找脱落细胞、床旁吸痰及术中明确大咯血出血部位。结果：366例胸外科门诊及住院肺占位患者中经纤支镜检查、活组织检查或刷检,明确诊断肺癌182例（50%）、良性病变26例（7.1%）,良性病变中经支气管复查4例,提示为癌;胸部手术后或胸部外伤排痰困难并发肺不张患者,经床旁纤支镜吸痰,所有患者症状明显改善,其中2例胸部外伤患者经过2次床旁吸痰治疗,血氧饱和度（SpO2）、心率及动脉血氧分压（PaO2）均高于治疗前（P〈0.01）;33例大咯血患者行术中纤支镜出血部位定位,其中32例术中经纤支镜明确定位出血部位,有1例患者因气管内出血凶猛,纤支镜无法准确定位,终止手术,患者死亡。结论：支气管镜检查在胸外科疾病诊疗中发挥着重大的作用。     

Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma

Objectives: Supine anteroposterior (AP) chest radiographs in patients with blunt trauma have poor sensitivity for the identification of pneumothorax. Ultrasound (US) has been proposed as an alternative screening test for pneumothorax in this population. The authors conducted an evidence‐based review of the medical literature to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. Methods: MEDLINE and EMBASE databases were searched for trials from 1965 through June 2009 using a search strategy derived from the following PICO formulation of our clinical question: patients included adult (18 + years) emergency department (ED) patients in whom pneumothorax was suspected after blunt trauma. The intervention was thoracic ultrasonography for the detection of pneumothorax. The comparator was the supine AP chest radiograph during the initial evaluation of the patient. The outcome was the diagnostic performance of US in identifying the presence of pneumothorax in the study population. The criterion standard for the presence or absence of pneumothorax was computed tomography (CT) of the chest or a rush of air during thoracostomy tube placement (in unstable patients). Prospective, observational trials of emergency physician (EP)‐performed thoracic US were included. Trials in which the exams were performed by radiologists or surgeons, or trials that investigated patients suffering penetrating trauma or with spontaneous or iatrogenic pneumothoraces, were excluded. The methodologic quality of the studies was assessed. Qualitative methods were used to summarize the study results. Data analysis consisted of test performance (sensitivity and specificity, with 95% confidence intervals [CIs]) of thoracic US and supine AP chest radiography. Results: Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. Conclusions: This evidence‐based review suggests that bedside thoracic US is a more sensitive screening test than supine AP chest radiography for the detection of pneumothorax in adult patients with blunt chest trauma. ACADEMIC EMERGENCY MEDICINE 2010; 17:11–17 © 2010 by the Society for Academic Emergency Medicine     

Chest physical therapy: comparative efficacy of preoperative and postoperative in the elderly

Although chest physical therapy (PT) immediately after surgery lowers the risk of postoperative pulmonary complications, several reports indicate preoperative chest PT results in further improvement. This study compares the effects of initiating chest PT either before and/or after chest surgery in patients over age 65. We studied two groups: 130 patients (the PRE group) undergoing both pre- and postoperative therapy and 150 patients (the POST group) undergoing only postoperative therapy, dividing them into four surgical subgroups: lung, cardiac and other thoracic surgery, upper abdominal, and lower abdominal (considered low risk compared with the other three). Overall complication rates and atelectasis rates were significantly lower in the PRE high-risk subgroups. PRE and POST pneumonia rates, however, were statistically equivalent in all surgical subgroups. Since the low rate of pulmonary complications for PRE-group patients undergoing thoracic or upper abdominal procedures is comparable to that for PRE-group therapy in much younger populations, advanced age alone does not appear to be a significant risk factor. The lack of effect on incidence of pneumonia indicates that preoperative chest PT only counters the altered pulmonary mechanics responsible for atelectasis, but has no effect on pulmonary complications due to infection.     

Preemptive analgesia: Moving beyond conventional strategies and confusing terminology

Trials of preemptive analgesia compare the effect of drugs administered before injury with the same treatment administered after injury, whereas studies of perioperative analgesia include comparisons of preinjury administration with no particular analgesic treatment at all. In contrast to earlier reports, recent animal behavioral studies of persistent nociception and clinical trials of preemptive analgesia using randomized, controlled protocols strongly indicate that conventional treatments such as local anesthetics and opioids do not exhibit significant preemptive analgesic effects for postoperative pain. The direction of perioperative medicine must be shifted away from conventional preemptive analgesia studies, and towards (1) preemptive analgesia studies using novel treatment strategies; (2) perioperative analgesic strategies involving continuous administration of analgesics and anesthetics; and (3) a focus on clinical outcomes involving hospital stay, cost, and patient satisfaction.     

连枷胸伴肺挫伤92例外科治疗体会

[目的]总结重症胸外伤连枷胸伴肺挫伤的临床经验.[方法] 回顾分析2006年1月至2011年6月期间在本院诊治的连枷胸伴肺挫伤92例,其中通过手术进行肺修补,胸腔血肿清除,同时应用记忆合金环抱式接骨板对重点肋骨骨折行内固定等治疗的52例,与同期非手术组40例比较,比较其临床疗效.[结果] 随访3～6个月,所有病例均治愈,全组无死亡病例.手术组胸廓畸形率、住院时间、抗生素使用时间、ICU住院时间、中度以上的疼痛、呼吸支持天数、肺部感染率均明显低于非手术组（P〈0.05,P〈0.01）.[结论]应用记忆合金环抱式接骨板行重点部位肋骨骨折内固定治疗连枷胸伴肺挫伤,可以减少并发症,有利于患者的快速康复.     

Intrapleural alteplase in a patient with complicated pleural effusion

OBJECTIVE: To report the intrapleural use of alteplase in a patient diagnosed with complicated pleural effusion (CPE). CASE SUMMARY: A 62-year-old white woman admitted with respiratory distress and hypotension developed a right-sided multi-loculated pleural effusion. Thoracentesis and chest tube drainage were not successful in resolving the effusion. In an attempt to increase the drainage of the pleural effusion, alteplase 16 mg was administered into the pleural cavity via the chest tube on 6 consecutive days. As a result, the volume drained from the patient's chest tube increased, there was improvement on the chest X-ray, and she did not require surgical intervention. DISCUSSION: While streptokinase and urokinase have been shown to be useful adjuncts to chest tube drainage in the treatment of complicated pleural effusion and empyema, there have been no reports on the use of intrapleural alteplase. This report demonstrates that intrapleural administration of alteplase is a useful adjunct to tube drainage in resolving CPE. CONCLUSIONS: This patient's CPE resolved when intrapleural alteplase was used as an adjunct to chest tube drainage and antibiotics. Controlled trials need to be conducted to investigate fully the efficacy, dosing, and safety of intrapleural alteplase in the treatment of patients with CPE and empyema.     

Open pneumothorax resulting from blunt thoracic trauma: a case report

Cases of open pneumothorax have been documented as early as 326 BC. Until the last 50 years, understanding of the epidemiology and treatment of penetrating chest trauma has arisen from military surgery. A better understanding of cardiopulmonary dynamics, advances in ventilatory support, and improvement in surgical technique have drastically improved treatment and increased the survival rate of patients with penetrating thoracic trauma. Open pneumothorax is rare in blunt chest trauma, but can occur when injury results in a substantial loss of the chest wall. This case study presents an adolescent who sustained a large open pneumothorax as a result of being run over by a car. Early and appropriate surgical intervention coupled with coordinated efforts by all members of the trauma team resulted in a positive outcome for this patient.     

Präemptive Analgesie: Klinische Realität oder wissenschaftliche Hypothese?

Numerous experimental studies have shown that systemic or regional administration of analgesics prior to a nociceptive stimulus results in a significant reduction of analgesic requirements compared with the administration of the same analgesic dose given after the nociceptive stimulus. This phenomenon is called "preemptive analgesia". Recently several clinical studies have been conducted to determine whether "preemptive analgesia" also occurs in humans. Regional and systemic opioids, local anesthetics and non-steroidal anti-inflammatory drugs have been investigated so far. Most studies have failed to show a significant reduction in postoperative analgesic requirements with preemptive analgesia. Even in studies with positive results the reduction in analgesic requirements was limited and without clinical relevance. Further studies should focus on the questions which analgesics and which administration routes might provide clinically significant "preemptive analgesia" and how long analgesia should be prolonged into the postoperative period.     

Sonographic septation: a useful prognostic indicator of acute thoracic empyema.

The aim of this study was to identify sonographic predictors of patient outcomes or need for surgical intervention of acute thoracic empyema. All patients with a clinical diagnosis of thoracic empyema underwent transthoracic ultrasonographic examination and thoracentesis at admission. According to the presence or absence of septa in sonographic images, the patients were classified into two groups: septated and nonseptated. Sonographic findings were analyzed with respect to duration of hospital stay, chest tube drainage, and treatment efficacy. A total of 163 consecutive patients were included in the study (83 patients with septated and 80 with nonseptated sonographic images). The mean duration of hospital stay (35.4 versus 27.0 days, P = 0.009) and chest tube drainage (13.1 versus 7.6 days, P < 0.001) for the patients with septa were significantly longer than for those without septa. The patients with septa were more likely to undergo intrapleural fibrinolytic therapy (63.8% versus 38.8%, odds ratio 2.79, P = 0.001) and surgical intervention (24.3% versus 7.5%, odds ratio 3.92, P = 0.004). We concluded that sonographic septation is a useful sign to predict the need for subsequent intrapleural fibrinolytic therapy and surgical intervention in cases of acute thoracic empyema. Early fibrinolytic therapy or even surgical intervention may be indicated in patients with sonographic septations.