不插管单孔胸腔镜右肺中叶袖式切除术一例

目的评估不插管单孔胸腔镜肺叶袖式切除术的安全性及可行性。 方法对所在科室首例监护麻醉下不插管右肺中叶袖式切除术的成功案例进行报道并对此类手术进行文献回顾。 结果不插管单孔胸腔镜右肺中下叶袖式切除术成功,患者恢复良好。 结论不插管单孔胸腔镜肺叶袖式切除术是一种更微创的支气管重建手术,具有进一步开展的价值。     

Bispectral Index and the incidence of apnea during monitored anesthesia care

Purpose:

The Bispectral Index (BIS) provides an estimate of depth of consciousness during sedation. If apnea can be shown to correlate with BIS, then a potential improvement in safety during MAC/sedation may be achieved.

Scope:

Ninety-nine patients undergoing MAC anesthesia were monitored with BIS for level of consciousness, and capnography for apnea detection. The anesthesia provider was blinded to BIS and capnography data. Forty-nine percent of subjects experienced apnea independent of medical history, procedure, or medication. BIS immediately preceding apneic episodes (55 ± 18) was frequently lower than that recommended for an upper limit during general anesthetics (<60). The incidence increased as depth of consciousness decreased with a 50% likelihood of developing apnea at a BIS of 56.

Conclusions:

The incidence of apnea during MAC is high, and incidence increases as BIS decreases.     

Hypothermia during herniorrhaphy using local anesthesia with sedation

Summary General, spinal and epidural anesthesia disrupt the thermoregulatory response. The resultant decrease in core temperature places increased demands on the cardiovascular system. Virtually all of our groin hernia repairs are performed using local anesthesia. The study was designed to ascertain the impact of local anesthesia with intravenous sedation on thermo-regulation and to evaluate the efficacy of perioperative warming in these cases. Tympanic membrane temperatures were monitored in 50 consecutive inguinal herniorrhaphies performed under local anesthesia with intravenous sedation. The first group (n = 45) were not warmed. An upper body warming cover was applied in the last five cases. In the non-warmed group, a decrease in body temperature of –0.81 °C ± 0.38 was recorded. In the five warmed cases, the change in body temperature was –0.12 °C ± 0.18 °C. The results indicate that the hypothermic response during hernia repair under local anesthesia with intravenous sedation is small but significant. The perioperative use of an upper body warming cover is protective.     

Comparative study between dexmedetomidine/nalbuphine and midazolam/nalbuphine in monitored anesthesia care during ear surgery

BackgroundMonitored anesthesia care (MAC) is the practice of administrating local anesthesia in combination with IV sedatives, anxiolytics and/or analgesic drugs during certain surgical procedures. Most of ear surgeries can be done under monitored anesthesia care.MethodologyThis is a randomized, double blind, prospective study and 100 patients undergoing ear surgery under MAC were divided into two groups of 50 patients each. The patients in group (D) received dexmedetomidine 1 μg/kg IV over 10 min followed by 0.7 μg/kg/h + nalbuphine 100 μg/kg IV and in group (M) received midazolam 20 μg/kg IV followed by 20 μg/kg/h + nalbuphine 100 μg/kg over 10 min. Assessment of sedation by Ramsay sedation score, requirement of intraoperative rescue sedation, intraoperative VAS, intraoperative rescue analgesia, intraoperative hemodynamics, intraoperative bleeding, intraoperative complications, postoperative visual analogue score and postoperative rescue analgesia requirement, time to achieve full recovery and satisfaction scores of patients and surgeon were recorded.ResultsGroup (D) showed more sedation by Ramsay sedation score than the midazolam (M) group. Fifty percent in group (M) needed more rescue sedation than 26% in group (D) (p < 0.05). Intraoperative VAS was significantly higher in group (M) than in group (D) that led to the use of more rescue analgesia in 60% of group (M). Intraoperative heart rate and mean blood pressure were significantly lower in group (D) than in group (M) (p < 0.05). There was no statistical difference between the two groups as regards respiratory rate or SpO₂. Intraoperative bleeding is less significantly less in group (D). Intraoperative hypotension was significantly higher in group (D) (30%) than in group (M) (20%). Bradycardia was insignificantly higher in group (D). As regards postoperative VAS, group (D) was significantly lower than group (M). This led to the use of more rescue analgesia in 94% of group (M). There was no statistically significant difference between the two groups as regards recovery time. Patient’s satisfaction was significantly higher in group (D) (80%) compared with group (M) (60%) (p >0.05). The same as regards doctor’s satisfaction where satisfaction was significantly higher in group (D) (76%) than in group (M) (54%).ConclusionWe concluded that the combination of dexmedetomidine/nalbuphine is a better alternative to midazolam/nalbuphine in MAC since it provides analgesia, amnesia and sedation with better intraoperative and postoperative patient satisfaction with better surgical field exposure.     

脑电双频指数指导下监测麻醉在老年患者慢性硬膜下血肿手术中的应用

目的探讨脑电双频指数(bispectral index,BIS)指导下的监测麻醉(monitored anesthesia care,MAC)在老年患者慢性硬膜下血肿钻孔引流手术中的应用。方法选择2014年3月至2015年5月择期行慢性硬膜下血肿钻孔引流手术患者60例,男33例,女27例,年龄65~85岁,ASAⅡ~Ⅳ级,随机分为BIS指导下监测麻醉组(M组)和局部麻醉组(C组),每组30例。M组静脉应用丙泊酚和瑞芬太尼;C组仅采用局部麻醉,未给予任何静脉麻醉药,始终处于清醒状态。记录患者局麻药和血管活性药追加次数。采用Likert 7点量表法分别由患者和术者评估手术镇静/镇痛满意度。记录患者体动、恶心呕吐、反流误吸、呼吸抑制、呼吸道梗阻等不良反应发生情况。结果M组局麻药和艾司洛尔追加例数明显少于C组,镇静/镇痛满意度明显高于C组(P0.05)。M组体动发生率明显低于C组(P0.05)。两组呼吸抑制和呼吸道梗阻发生率差异无统计学意义,均未发生恶心呕吐和反流误吸。结论脑电双频指数作为反馈控制变量调控镇静麻醉技术可以达到较精确的控制麻醉深度,可安全用于老年患者慢性硬膜下血肿手术。     

Preemptive analgesia and local anesthesia as a supplement to general anesthesia: a review

General anesthesia (GA) and local anesthesia (LA) evolved on separate tracks. Procedures that could not be performed under LA were typically conducted under GA. Decoding of afferent linkage of peripheral noxious stimuli has provided important understanding that may change the way we traditionally treat surgical pain. In the 1980s, animal studies suggested that preemptive peripheral blocking of painful (nociceptive) stimuli to the central nervous system with regional anesthesia or LA and nonsteroidal analgesics could be beneficial in attenuating postoperative pain. Clinical studies based on this knowledge suggest combining LA with GA, and perhaps non-steroidal analgesics with or without narcotics, to reduce the severity of postoperative pain. General anesthetics can be given in lower minimal alveolar concentration when combined with LA, and recovery characteristics are superior. Increasing evidence suggests that the combined use of GA and LA may reduce the afferent barrage of surgery, and that preemptive analgesia may reduce postoperative pain and should be used in patient care. This article reviews the evidence supporting the combined use of LA or analgesics with GA or sedation to provide improved pain management after surgery.     

Pre-emptive analgesia with local anaesthetic for herniorrhaphy

There is little evidence that local anaesthetics produce pre-emptive analgesia and one reason may be the short duration of action of the drugs studied. We examined the pre-emptive analgesic effect of a bupivacaine field block on postoperative pain in 40 patients following herniorrhaphy in a double-blind, randomised trial. Patients received the block either after induction but before surgery, or after surgery but before the end of anaesthesia. There was no difference in pain scores or analgesic consumption up to 7 days after surgery between the two groups. We have demonstrated that bupivacaine does not appear to provide significant pre-emptive analgesia following a field block for herniorrhaphy. This study does not support the hypothesis that pre-emptive analgesia with local anaesthetic depends upon the duration of action of the drug.     

Postoperative pain and return to activity after five different types of inguinal herniorrhaphy

Summary The purpose of this study was to determine postoperative pain following inguinal herniorrhaphy dependent of technical factors such as: minimal access surgery, open transinguinal and preperitoneal tension-free repair, reduced suture line tension, type of anesthesia. 240 consecutive unilateral groin hernia repairs were prospectively allocated to one of five groups: Lichtenstein patch under local anesthesia, and the following under general anesthesia, Lichtenstein patch, laparoscopic TAPP repair, a modified Shouldice technique with omission of the third and fourth row of sutures and open preperitoneal prosthethic repair [Wantz 1989]. Using a visual pain analogue score, no significant differences were found for pain intensity between the groups on days 0, 1, 2, 3, 21. There was also no significant difference for return to work. Analgesic requirements were lower than in previous studies and this is attributed to immediate resumption of physical activity on a home-trainer bicycle. The percentage of patients who did not require any pain medication after the first postoperative day was 85% for Wantz, 81% for Shouldice, 86% for TAPP, 77% for Lichtenstein under general anesthesia and 89% for Lichtenstein under local anesthesia. Local anesthesia was the only technical factor for significantly reducing analgesic requirements during the three perioperative days. With local anesthesia and immediate resumption of physical activity early postoperative pain becomes a limited outcome measure for comparing open versus laparoscopic groin hernia repair techniques.     

监测麻醉在老年青光眼患者手术中的应用

目的比较监测麻醉和气管内插管全麻在老年青光眼患者手术中的麻醉效果。方法50例ASAⅠ-Ⅲ级老年青光眼患者随机分为A、B两组：A组23例采用监测麻醉法;B组27例采用气管内插管全麻法．观察两组的麻醉效果及各时点患者的心率、呼吸、平均动脉压、血氧饱和度变化情况。结果两组的麻醉效果满意,A组患者呼吸、心率、平均动脉压等监测指标波动不大,患者恢复时间快,麻醉费用少,与B组比较差异有显著性（P〈0．05）。结论对于老年青光眼手术患者,监测麻醉法是一种安全、有效的麻醉方法,优于传统的气管内插管全麻法。     

Study of unilateral postherniorraphy analgesia with local anaesthetic and monitored anaesthesia care

Local anaesthetic with monitored anaesthetic care (MAC) is a very good technique for unilateral-inguinal herniorraphy. We looked at the analgesia produced by the infiltration with local anaesthetic, the intensity of pain in the immediate postsurgery period; the efficiency of oral analgesics and the satisfaction of the patients. Between January and July 1997, 63 patients underwent unilateral-inguinal herniorraphy (Shouldice type) using local anaesthetic (300 mg of mepivacain 1% and 50 mg of bupivacain 0.25%) and MAC (fentanyl, mydazolan and propofol). The intensity of pain was measured using two evaluation scales: visual analogue scale (EV) and verbal scale (Eve). When the patients asked for an analgesic they were given magnesic metamizol (Nolotil), every 6 h. Five patients (8%) felt no pain and 58 felt pain 4 h 36 min after local anaesthetic infiltration (EV=2.5; Eve=1.45) of these 58 patients, 49 took a first dose of ‘Nolotil’ 6 h 40 min after local anaesthetic induction (EV=4; Eve=1.97), 43 received a second dose of ‘Nolotil’ at 13 h 40 min (EV=3; Eve=1.49) and 22 a third dose at 17 h 40 min (EV=3.2; Eve=1.7). Every patient that was very satisfied with the anaesthetic technique, said that the postsurgery pain was bearable and they would be happy to be operated on again with the same anaesthetic-surgery technique. The efficacy of the anaesthetic technique (local anaesthetic with conscious sedation) was very good, 8% of the patients never felt pain and 21% never received any analgesic. The time passed until the first analgesic dose was 6 h 40 min, and the tolerance of the pain was excellent.     

局麻下Modified Kugel^TM疝补片在老年腹股沟疝修补术中的应用

目的 探讨局麻下Modified Kugel^TM疝补片在老年腹股沟疝无张力修补术中的应用效果。方法回顾分析2005年4月至2007年5月我科使用巴德公司Kugel^TM疝补片在局麻下修补老年腹股沟疝87例的临床资料（包括手术时间、手术出血量、术后并发症及住院时间）。结果平均手术时间42min，术中平均出血量37．5ml，86例切口甲级愈合，术后下床活动时间平均6．5h，切口疼痛7例，术后出现皮下血肿1例，阴囊水肿3例，局部有异物感2例。随访时间最长39个月，最短3个月，无一例复发。结论局麻下Modified Kuzel^TM疝补片存老年腹股沟疝的应用中优点明显、安全可靠。     

Cervicofacial subcutaneous emphysema and pneumomediastinum after retinal detachment surgery: just another monitored anesthesia eye case

Repair of a retinal detachment was performed during a retrobulbar block with monitored anesthesia care and intravenous conscious sedation. Following the procedure and after removal of the sterile drapes, the patient exhibited significant swelling of the bilateral orbits, face, neck, and chest. Subcutaneous emphysema and pneumomediastinum were confirmed on postoperative chest radiographs and computed tomographic scans. Possible mechanisms and potential sequelae of this intraoperative event are discussed.     

Colostomy closure using local anesthesia

The feasibility of performing colostomy closures using local anesthesia was evaluated. The subjects comprised 14 patients: 2 with colostomies involving a mucous fistula and 12 with loop colostomies. Patients who had colostomies with mucous fistulas separated by 10 cm or more were excluded from this study. All patients were graded as ASA 1 (according to the American Society of Anesthesiologists). The bowel was evaluated by colonoscopy in 6 patients and by barium enema in 8 patients. Bowel preparation was performed with Colayte and all patients were given prophylactic antibiotics. Closure of the colostomy was extraperitoneal and the time taken to perform the operation ranged from 40 to 120 min. Tolerance was regarded as excellent in 9 patients, good in 3, and average in 2. There were 3 anastomotic leaks that resolved without further surgical treatment, 2 wound infections, and 1 bowel obstruction that was successfully treated with medication. Patients were discharged 2–22 days postoperatively, after a mean period of 9 days. Local anesthesia offers a safe and effective alternative to general or regional anesthesia for surgical closure of colostomies. Received: May 29, 2000 / Accepted: January 9, 2001     

Use of an anesthetic cream before infiltration with local anesthesia in aesthetic surgery

The use of local anesthesia in aesthetic surgery must be provided to the patient based on its risk/benefit ratio, effective control of postoperative pain, and lower incidence of postoperative disorders. The use of a new anesthetic cream before infiltration with a local anesthetic may cause reduction or elimination of the pain provoked by the needle during the infiltration, increasing the compliance of local anesthesia. Here we describe the modalities and the advantages of using anesthetic cream.     

舒芬太尼-丙泊酚用于视网膜脱离复位术的镇静止痛

目的：本文观察视网膜脱离复位术中应用舒芬太尼-丙泊酚的锁静止痛效果。 方法：40例患者随机分为纯局麻组（对照组）和舒芬太尼-丙泊酚镇静止痛组（实验组）。对照两组患者的血流动力学改变和疼痛评分以及满意度，观察实验组是否出现过度镇静和呼吸，循环抑制。 结果：实验组患者术中和术后1小时的疼痛评分明显低于对照组（0.9±0.7 vs 3.2±1.1;0.9±0.6vs 2.6±1.0）,满意度明显高于对照组（95%vs 50%）,P〈0.05。实验组患者无过度镇静和明显的呼吸和循环抑制。 结论：舒芬太尼-丙泊酚联合应用可为网脱复位术提供良好的镇静止痛，适当的用药方法和剂量不会导致严重的呼吸，循环抑制。     

局部浸润麻醉在隆乳术中的应用

目的 探讨局部浸润麻醉方法在隆乳术中的应用效果。方法 将2％利多卡因20ml加0．5％布匹卡因5ml配制成120ml局部麻醉液，采用局部浸润麻醉方法为568例受术者行隆乳手术，根据胸部神经、肌肉的解剖特点，行合理的分布药量和准确有效的注射。结果 568例隆乳术者，局部浸润麻醉方法均有效，且麻醉效果良好。无一例受术者因分离腔穴时产生疼痛而影响手术操作或停止手术。结论 局部麻醉效果理想可靠，方法简单易行，适用于任何术式的隆乳术。而在分离腔穴时产生的疼痛主要是因注射层次不当和药量分布不均所致。与麻醉方法无关；其麻醉效果与假体置入层次或乳腺胸大肌是否发达无因果关系。     

门诊局麻下抽脂89例报告

为探索简单、安全、可靠的麻醉方法和完美的手术效果。选择合适的门诊病人,在改良的局部肿胀麻醉方法下,进行常规脂肪抽吸术。结果：均取得满意手术效果,无严重并发症发生。结论：１．本文介绍的局部肿胀麻醉方法是一种简便、安全、有效的麻醉方法;２．恰当掌握手术适应证,限制抽吸部位和抽吸量,选择肿胀局麻技术、注意抽吸技巧和术中、术后的塑形及护理等是降低手术并发症,取得更好手术效果的保证。     

中老年腹股沟疝局麻与硬膜外麻醉手术的比较

目的比较中老年人在局麻与硬膜外麻醉下行腹股沟疝修补术的疗效、住院时间、平均费用、恢复正常生活的时间及手术并发症等.方法采用随机对照方法,将223例病人分为局麻组(男,113人)和硬膜外阻滞麻组(男110人).结果局麻组病人平均手术时间(44min)、住院时间(2.1d)、恢复正常生活时间(5.4d)和手术并发症等均明显小于硬膜外阻滞组(P＜0.01～0.05).结论中老年人局麻下进行疝修补,可明显减少手术费用,术后并发症的发生率,是一安全而有效的方法,值得推广.     

Postoperative care and analgesia in vascular surgery

Patients undergoing major vascular surgery are high risk for myocardial infarction, renal failure, respiratory complications and death. Invasive procedures confer greater risk of complication, with patients undergoing open aortic surgery being at highest risk. Endovascular procedures are less invasive, yet not devoid of potentially serious complications. Reduction of myocardial oxygen demand is key: stabilizing cardiovascular parameters, maintaining normothermia, adequate volume resuscitation and effective analgesia. Continuation of preoperative risk-reduction strategies including aspirin, beta-blockers and statin therapies are critical, and should be continued in the postoperative period. Maintaining a high index of suspicion for procedure-specific complications is essential in order to reduce morbidity and mortality in these patients.     

Postoperative care and analgesia in vascular surgery

Patients undergoing major vascular surgery are high risk for myocardial infarction, renal failure, respiratory complications and death. Invasive procedures confer greater risk of complication, with patients undergoing open aortic surgery being at highest risk. Endovascular procedures are less invasive, yet not devoid of potentially serious complications. Reduction of myocardial oxygen demand is key, as is stabilizing cardiovascular parameters, maintaining normothermia, adequate volume resuscitation and effective analgesia. Continuation of preoperative risk-reduction strategies including aspirin, beta-blockers and statin therapies are critical, and should be continued in the postoperative period. Maintaining a high index of suspicion for procedure-specific complications is essential in order to reduce morbidity and mortality in these patients.