小剂量布比卡因复合芬太尼腰-硬联合麻醉用于急诊剖宫产的临床观察

目的 探讨小剂量布比卡因复合芬太尼腰-硬联合麻醉在急诊剖宫产手术中应用的可行性.方法 单胎急诊产妇108例,随机均分为布比卡因复合芬太尼组(BF组)和布比卡因组(B组).药物分别为0.75%布比卡因5 mg加芬太尼20μg和0.75%布比卡因7.5 mg.两组产妇均在右侧卧位下于L2～3间隙用针内针方法行腰麻,留置硬膜外导管备用.记录麻醉等待时间、最高平面、硬膜外追加药物的情况,术中心率、血压变化和麻黄碱的使用情况,并记录术中恶心呕吐、胸闷、呼吸困难等不良反应;记录手术医师和产妇对麻醉的评价以及术后下肢肌力完全恢复所需时间.结果 所有患者成功完成手术,无需改变麻醉方式或静脉辅助用药.BF组硬膜外腔追加药物率、低血压发生率和麻黄碱使用率明显少于B组(P＜0.01);麻黄碱平均用量明显少于B组(P＜0.05);恶心呕吐和胸闷的发生率明显低于B组(P＜0.05或P＜0.01);下肢肌力恢复到Bromage 0分的时间短于B组(P＜0.05).结论 0.75%布比卡因5 mg复合芬太尼20 μg腰-硬联合麻醉能为急诊剖宫产提供满意的麻醉.     

预先静注布托啡诺对腰硬联合麻醉后寒战反应的影响

目的 观察预先静脉注射布托啡诺对下腹部手术腰硬联合麻醉后寒战反应的影响.方法 选择60例ASA Ⅰ～Ⅱ级下腹部手术腰硬联合麻醉患者,随机分为两组A组(观察组)、B组(对照组),A组在腰硬联合麻醉前10 min静脉注射布托啡诺1 mg/5 ml,B组注射5 ml生理盐水.观察麻醉后两组患者寒战发生的情况及镇静评分.结果 观察组寒战反应发生率明显低于对照组(P<0.01),镇静评分满意率观察组显著高于对照组(P<0.05).结论 预先静脉注射布托啡诺能够有效地预防下腹部手术腰硬联合麻醉后寒战的发生,且镇静效果满意.     

Optimum dose of intravenous butorphanol as a supplemental drug during regional anesthesia

The optimum doses according to age of butorphanol tartrate as a supplemental drug during epidural and spinal anesthesia were investigated in 60 patients without complications. We classified patients into 4 groups by age as A, B, C and D-group. A-group consisting of patients between 20 to 40 years received 1.5mg of butorphanol. B-group 41-60, C-group 61-75 and D-group over 76 years received 1.0mg, 0.5mg and 0.25mg respectively. After operation was started without pain, and during the stable period, we determined by age, doses of butorphanol injected intravenously in one minute. HRs, mean BPs, respiratory rates (RRs) and so on were obtained at the preinjection point and 5 minutes after injection. In addition, in 15 patients, arterial blood gas analysis was performed at the same times. Butorphanol injections decreased HRs, mean BPs and RRs significantly. But there was no one whose PaCO2 increased more than 50 mmHg and no difference was found in degree of side effects between the groups. In conclusion, this study suggests that the decision to administer doses depending on the age is useful to decrease frequency of the grave side effects, especially respiratory depression which the elderly people frequently fall into.     

腰麻-硬膜外联合麻醉对老年患者血液动力学的影响

目的 观察腰麻-硬膜外联合麻醉对老年患者血液动力学的影响.方法 选择60例65岁及以上ASA Ⅱ～Ⅲ级,择期行单侧下肢全膝关节置换术的患者,随机分成腰麻-硬膜外联合麻醉组和连续硬膜外麻醉组,每组30例.记录患者一般情况,手术时间,术中出血量,液体输入量.观察腰麻或硬膜外给药前、给药后15 min和术毕时的MAP及HR.记录感觉阻滞平面和改良Bromage运动分级.观察需要给与麻黄碱或阿托品的病例数,以及出现止血带疼痛的人数.结果 2组患者一般情况、手术时间、术中出血量、液体输入量无差异,感觉阻滞平面无明显差异,运动阻滞程度有显著差异.各个时间点的MAP及HR无显著性差异.2组给予麻黄碱和阿托品的例数无显著性差异.2组出现止血带疼痛的例数相比有显著行差异.结论 对行全膝关节置换术的老年患者实施腰麻-硬膜外联合麻醉,引起的血液动力学改变与硬膜外麻醉相比无明显差异,且患者止血带反应较轻.     

布托啡诺与舒芬太尼对腰硬联合麻醉行单侧疝修补术患者寒战反应的观察

目的分析布托啡诺与舒芬太尼对腰硬联合麻醉行单侧疝修补术患者寒战反应的预防效果。 方法选取2019年1月至2021年1月于重庆市巴南区人民医院在腰硬联合麻醉下行单侧疝修补术的300例患者作为研究对象。依据麻醉方式不同分为A组和B组,各150例。A组患者进行布托啡诺静脉注射,B组患者进行舒芬太尼静脉注射。比较2组寒战的治疗效果;比较用药前,用药后1、5、10 min及术毕的血流动力学指标;术前（T0）,术后4 h（T1）、12 h（T2）、24 h（T3）及48 h（T4）的视觉模拟评分表（VAS）、Ramsay镇静评分（RSS）。 结果A组寒战的治疗总有效率（96.00%）显著高于B组（90.00%）,差异有统计学意义（P<0.05）;2组用药后1 min至术毕,相较于用药前平均动脉压、指血氧饱和度、心率均有不同程度的起伏（P<0.05）,但组间比较差异均无统计学意义（P>0.05）;T1~T4时刻,相较于T0时刻B组VAS评分显著低于A组（P<0.05）,B组RSS评分则显著高于A组（P<0.05）。 结论布托啡诺可以减轻腰硬联合麻醉行单侧疝修补术患者寒战反应的发生率,舒芬太尼则能够发挥较强的镇痛镇静作用,疗效较好。     

复合瑞芬太尼时艾司氯胺酮用于无痛胃镜诊疗麻醉诱导的半数有效剂量

目的 测定复合瑞芬太尼时艾司氯胺酮用于无痛胃镜诊疗麻醉诱导的半数有效剂量(ED₅₀)。方法 选择2021年10月于内镜中心行无痛胃镜诊疗的患者18例,男8例,女10例,年龄18～60岁,BMI 18～30 kg/m²,ASAⅠ或Ⅱ级。采用序贯法测定艾司氯胺酮用于无痛胃镜患者麻醉诱导的有效剂量,初始剂量为静脉推注艾司氯胺酮0.1 mg/kg复合瑞芬太尼0.3μg/kg,艾司氯胺酮相邻药物剂量比值为1∶1.2,若患者MOAA/S评分≤1分、诱导时间≤2 min,体动程度≤1级且围麻醉期未发生Ⅲ级以上不良事件为镇静成功(成功组),则下一例患者在上一例的给药剂量基础上降低一个梯度,若任意一项指标不达标则为镇静失败(失败组),下一例给药剂量升高一个梯度;直到出现第7个拐点终止研究。采用Probit法计算艾司氯胺酮的ED₅₀、95%有效剂量(ED₉₅)及其95%可信区间(CI)。记录诱导时间和苏醒时间。结果 艾司氯胺酮复合瑞芬太尼用于无痛胃镜诊疗麻醉诱导的ED₅₀为0.215 mg/kg ...     

Comparison of combined spinal-epidural and low dose epidural for labour analgesia

PURPOSE: To compare the combined spinal-epidural (CSE) technique with the epidural technique with regard to time to initiate and manage, motor block, onset of analgesia and satisfaction during labour. METHODS: Upon requesting analgesia, 50 healthy term parturients were randomized in a prospective, double-blind fashion to receive either CSE analgesia or lumbar epidural analgesia in the labour floor of a university hospital at an academic medical centre. The epidural group (n = 24) received bupivacaine 0.0625%-fentanyl 0.0002% with 0.05 ml in 10 ml local anesthetic sodium bicarbonate 8.4% and epinephrine 1:200,000. The CSE group (n = 26) received intrathecal 25 microg fentanyl and 2.5 mg bupivacaine. Additional analgesia was provided upon maternal request. RESULTS: There were no differences (P>0.05) in time to perform either technique, motor blockade, or parturient satisfaction or in the number of times that the anesthesiologist was called to perform any intervention. Although the first sign of analgesia was not different between the two groups, the onset of complete analgesia was more rapid with the CSE technique (Visual Analogue Pain Score (VAPS) at five minutes < three: 26/26 vs. 17/24, P+/-0.001). CONCLUSION: Although epidural analgesia with a low concentration of local anesthetic and opioid mixture takes longer to produce complete analgesia, it is a satisfactory alternative to CSE.     

舒芬太尼复合布托啡诺对依托咪酯全麻诱导肌震颤的影响

目的观察舒芬太尼复合布托啡诺对依托咪酯全麻诱导肌震颤的影响以及合适剂量。 方法选择2018年11月至2019年6月河北省保定市第一中心医院择期行全麻手术患者120例,ASA Ⅰ~Ⅱ级,随机分为S组、BS1组和BS2组。S组静注舒芬太尼0.4 μg/kg;BS1组预注布托啡诺10 μg/kg,3 min后静注舒芬太尼0.3 μg/kg;BS2组预注布托啡诺20 μg/kg,3 min后静注舒芬太尼0.2 μg/kg,三组患者均于1 min后静注依托咪酯0.3 mg/kg（推注时间10~15 s）。连续观察2 min,静注顺苯磺酸阿曲库铵0.25 mg/kg,2 min后行气管插管。记录呛咳反应发生率,肌震颤发生情况,给药前、插管前即刻及插管后即刻的心率（HR)、平均动脉压（MAP）,术后6 h内恶心呕吐的发生率。 结果三组患者肌震颤的发生率无明显差异,S组呛咳反应的发生率高（χ²=10.350,P=0.006）;S组给药前至插管前即刻MAP、HR降低较BS1、BS2组明显（F=25.910、22.057,均P<0.001）,BS1、BS2组间差异无统计学意义;插管前后BS1组HR、MAP升高最小,其次为S组,BS2升高最大（F=8.849、16.101,均P<0.001）。三组患者术中情况均稳定,术后均无严重的麻醉相关并发症。 结论舒芬太尼复合布托啡诺与等效镇痛剂量的单纯舒芬太尼对于依托咪酯所致肌震颤的抑制作用相同,布托啡诺对舒芬太尼所致的呛咳反应具有抑制作用。布托啡诺10 μg/kg复合舒芬太尼0.3 μg/kg更能维持全麻患者气管插管血流动力学的稳定,为比较合适的麻醉诱导复合剂量。     

The epidural "top-up" in combined spinal-epidural anesthesia: the effect of volume versus dose

The reinforcement of anesthesia by an epidural "top-up" in combined spinal-epidural anesthesia may be explained by a dual mechanism: a volume effect compressing the dural sac and a local anesthetic effect. The purpose of our study was to investigate the relative importance of each of these factors. Fifty patients scheduled for lower limb orthopedic surgery under combined spinal-epidural anesthesia were randomly allocated to one of five groups comprising 10 patients each. Using a needle-through-needle technique, all patients received a subarachnoid injection of 10 mg of plain bupivacaine and an epidural catheter. After the maximal level of sensory blockade as a result of the subarachnoid injection had been established, an epidural top-up was given according to the randomization code. Patients in Group 1 received 10 mL of bupivacaine 0.25%; patients in Group 2 received 10 mL of saline; patients in Group 3 received 5 mL of bupivacaine 0.5%; patients in Group 4 received 5 mL of saline; and patients in Group 5 received no epidural top-up. The maximal level of sensory blockade was then assessed for an additional 30 min. In Groups 1-4, the maximal level of sensory blockade increased significantly, whereas there was no significant increase in Group 5. There was no significant difference in the increase in the maximal level of sensory blockade among Groups 1-4. We conclude that, under the conditions of our study, there is no difference between 5 and 10 mL with regard to the volume effect of an epidural top-up in combined spinal-epidural anesthesia and that to produce an additional local anesthetic effect with bupivacaine, the dose must be larger than 25 mg. Implications: In combined spinal-epidural anesthesia, an epidural "top-up" may increase the maximal level of sensory blockade by means of a volume effect and a local anesthetic effect. In this study, volumes of 5 and 10 mL produced a similar increase, and 25 mg of bupivacaine was insufficient to produce an additional local anesthetic effect.     

Laparoscopic ovarian cystectomy with abdominal wall lift during pregnancy under combined spinal-epidural anesthesia

Abdominal wall lift laparoscopic surgery is often used for patients during pregnancy because it is physiologically superior to CO2 pneumoperitoneum laparoscopic surgery. Operation for adnexal cysts is performed in the 1st trimester. We report seven cases of ovarian cysts during pregnancy, resected using gassless laparoscopic method with a whole abdominal wall lift under combined spinal-epidural anesthesia (CSEA). Combined spinal-epidural anesthesia had several advantages in these cases; 1. In the 1 st trimester, general anesthesia should be avoided. We could manage these cases without general anesthesia nor sedative medications. 2. During pregnancy, it is difficult to estimate the level of sensory blockade by spinal anesthesia. Epidural top-up helped us to easily control the level of sensory blockade. 3. Differential diagnosis of pain related to uterine contraction and postoperative pain is difficult. Post-operative analgesia was established by epidural PCA, thus anti uterine contraction medicines were prophylactically administered in only one of seven cases. There was no particular trouble during the anesthesia and all the operative procedures were performed uneventfully. Based on our limited experiences, CSEA may be a safe and appropriate anesthetic technique for laparoscopic ovarian cystectomy with abdominal wall lift during pregnancy.     

Ultra-low dose combined spinal-epidural anesthesia with intrathecal bupivacaine 3.75 mg for cesarean delivery: a randomized controlled trial

BACKGROUND: We wished to investigate the feasibility of an ultra low-dose combined spinal-epidural technique in providing surgical anesthesia for uncomplicated cesarean deliveries in a randomized, double-blind controlled trial. METHOD: Forty-four normotensive, non-obese patients were randomized to receive either intrathecal hyperbaric bupivacaine 3.75 mg (low dose group, n=22) or 9 mg (conventional group, n=22), in addition to intrathecal fentanyl 25 microg, morphine 100 microg, and epidural 1.5% lidocaine 3 mL. Sensorimotor anesthesia and hemodynamic data were assessed at 2.5-min intervals for the first 15 min. RESULTS: The maximal sensory block achieved in the low-dose group was significantly lower than that in the conventional group (median T3, [range T2-T6] vs. T2 [C2-T6], P<0.001) with a longer time taken to reach maximal sensory block. The low-dose group had less motor block, faster sensory regression to T10 dermatome and faster motor recovery to Bromage 0 (all P<0.001). The block failed to reach T6 bilaterally within 10 min in one patient in the low-dose group and two in the conventional group, with no significant difference in the need for epidural supplementation before or after delivery of the baby. The low-dose group experienced less hypotension (14% vs. 73%, P<0.001) with less ephedrine usage (0.68 vs. 17.5 mg, P<0.001). There was no difference in operating conditions and other side effects (shivering, pruritus). CONCLUSION: We conclude that this technique results in a significantly lower incidence of maternal hypotension and has a role in high-risk parturients in whom maintenance of stable hemodynamics is imperative.     

不同小剂量低浓度罗哌卡因用于老年患者腰-硬联合麻醉的研究

目的 观察不同小剂量罗哌卡因用于老年患者腰-硬联合麻醉对下肢手术的可行性.方法 择期下肢手术的老年患者120例,随机分为三组,每组40例.A组:0.5%罗哌卡因5～7.5mg+10%葡萄糖0.5ml;B组:0.75%罗哌卡因5～7.5mg +10%葡萄糖0.5ml;C组:0.75%罗哌卡因8～10mg+10%葡萄糖0.5ml.观察感觉阻滞、运动阻滞起效时间和最高时间,最高麻醉阻滞平面,痛觉及运动阻滞维持时间,不良反应及血流动力学等.Bromage法评定运动神经阻滞程度.连续监测SBP、DBP、HR、SpO2、ECG.结果 随着罗哌卡因浓度剂量的降低,感觉、运动阻滞起效时间和最大阻滞时间延长,维持时间缩短;与C组比较,A、B组感觉、运动阻滞起效时间、最大时间、维持时间差异均有统计学意义(P＜0.05),A与B组比较差异无统计学意义(P＞0.05).三组运动阻滞的Bromage评分组差异无统计学意义(P＞0.05).术中低血压使用麻黄碱A组为0,B、C组均使用麻黄碱,但这两组比较差异无统计学意义(P＞0.05),三组均未发生呕吐、头痛和神经系统症状.结论 0.5%罗哌卡因5～7.5mg+10%葡萄糖0.5ml配方可安全应用于蛛网膜下腔阻滞,适应于老年患者下肢手术,是一种较安全有效的麻醉方法.     

Differing incidences of relevant hypotension with combined spinal-epidural anesthesia and spinal anesthesia

In this investigation we assessed whether patients receiving spinal anesthesia (SPA) as part of combined spinal-epidural anesthesia (CSE) more often experience relevant hypotension than patients receiving SPA alone. From January 1, 1997, until August 5, 2000, electronic anesthesia records from 1596 patients having received SPA and 1023 patients having received CSE for elective surgery were collected by using a computerized anesthesia record-keeping system. Relevant hypotension was defined as a decrease of mean arterial blood pressure of more than 30% within a 10-min interval and a therapeutic action of the attending anesthesiologist within 20 min after onset. Electronic patient charts were reviewed by using logistic regression with a forward stepwise algorithm to identify independent risk factors that were associated with an increased incidence of hypotension after CSE. Univariate analysis was performed to assess differences in biometric data and relevant risk factors for hypotension between the two procedures. The incidence of relevant hypotension was more frequent with CSE than with SPA alone (10.9% versus 5.0%; P < 0.001). In the multivariate analysis, arterial hypertension (odds ratio, 1.83; 95% confidence interval, 1.21-2.78) and sensory block height >T6 (odds ratio, 2.81; 95% confidence interval, 1.88-4.22) were found to be factors associated with hypotension in the CSE group. Compared with patients receiving SPA alone, patients undergoing CSE had a significantly more frequent prevalence of arterial hypertension and higher sensory block levels (P < 0.01) despite smaller amounts of local anesthetics. In this study, patients receiving CSE had an increased risk for relevant hypotension as compared with patients with SPA alone. Part of this effect seems to be due to the procedure alone and not only because this population is at higher risk. IMPLICATIONS: This study, based on a large number of patients with a retrospective design by using on-line recorded data, suggests that spinal anesthesia as part of combined spinal-epidural anesthesia may more often lead to relevant hypotension than spinal anesthesia alone. Preexisting arterial hypertension and a sensory block height exceeding T6 are major risk factors for the development of this complication.     

Vascular effects of ketamine during anesthesia with diazepam and fentanyl]

Twenty-six adults undergoing elective cardiac surgery were anaesthetized with diazepam and fentanyl (induction with 200 micrograms.kg-1 and 30 micrograms.kg-1 respectively, maintenance with incremental doses). Normothermic constant perfusion output cardiopulmonary bypass was carried out with a membrane oxygenator, haemodilution with Ringer's lactate solution, and cardioplegia with St. Thomas's Hospital solution. The patients were randomly assigned to two groups. They were given either 2 mg.kg-1 of ketamine (group 1) or placebo (5 ml of normal saline) (group 2) via the venous line of the oxygenator. The non pulsatile flow was then kept at a steady rate of 2.41 x min-1.m-2, and no other infusion or treatment was started during the study period (ten minutes). The mean arterial pressure and blood reservoir level were measured every min during this period. The systemic vascular resistances did not change significantly in either group, but remained 27% lower in the ketamine group than in the placebo group (p less than 0.01). The blood reservoir level was 37% higher in the ketamine group (p less than 0.01), suggesting a decreased venous capacitance. It is therefore concluded that ketamine leads to venous constriction, and probably arterial dilation, during fentanyl-diazepam anaesthesia and normothermic cardiopulmonary bypass. The venous effects of ketamine could explain why it is usually well tolerated in hypovolaemic states.     

妇科腹腔镜手术腰麻联合硬膜外麻醉的效果

目的:评价妇科腹腔镜手术腰麻联合硬膜外麻醉(combined spinal-epidural anesthesia,CSEA)的效果。方法:择期选择妇科腹腔镜手术患者1000例,ASAⅠ～Ⅱ,随机分为CSEA组和连续硬膜外麻醉组(epidural anesthesia,EA),每组500例,记录入室后(基础值)和注入首剂量局麻药后1min、5min、10min、15min时的SP、DP、MAP、HR、SpO2、PETCO2。观察麻醉前(T1)、气腹即刻(T2)、气腹后20min(T3)、气腹后30min(T4)、气腹后40min(T5)、气腹后50min(T6)两组各指标的变化。记录开始注入局麻药至出现满意阻滞平面的时间、肌松程度、局麻药总量、丙泊酚总量。结果:阻滞平面达T6时间两组有极显著差异(P<0.01)。局麻药总量,丙泊酚总量EA组明显增多(P<0.05),两组SP、DP、MAP、HR、SpO2、PETCO2比较差异无统计学意义(P>0.05)。镇痛效果及肌松程度CSEA组优于EA组。结论:与硬膜外阻滞相比,妇科腹腔镜手术患者腰麻联合硬膜外麻醉有较好的镇痛、肌松效果,且局麻药用量、丙泊酚用量较少。     

罗哌卡因腰硬联合麻醉在中下腹部手术中的应用

目的 观察罗哌卡因腰硬联合麻醉应用于中下腹部手术的安全性和麻醉效果。方法 择期和急诊的中下腹部手术病人90例,随机分为3组,Ⅰ、Ⅱ组行腰硬联合麻醉,分别采用罗哌卡因和布比卡因腰麻,Ⅲ组采用硬膜外麻醉。比较3组最大感觉阻滞平面、最大阻滞时间、麻醉效果、用药量以及麻醉前后呼吸循环的变化等。结果 Ⅰ组和Ⅱ组均较Ⅲ组起效快、用药量少、麻醉阻滞完善、对呼吸循环的影响小。结论 罗哌卡因腰硬联合麻醉可安全用于中下腹部手术,且效果确切。