胆道手术全麻-硬膜外复合麻醉围拔管期心血管反应的临床观察

目的 探讨全麻-硬膜外复合麻醉对胆道手术病人围拔管期心血管反应的影响。方法 ASAⅠ-Ⅱ级择期胆道手术患者40例,随机分成两组：Ⅰ组20例,采用单纯全麻;Ⅱ组采用全麻复合硬膜外麻。观察并记录两组术前、拔管前5 m in、拔管、拔管后5 m in的SBP、DBP、HR。结果Ⅰ组在围拔管期各时点、Ⅱ组在拔管时SBP、DBP、HR较术前显著升高（P〈0.01）;组间比较,Ⅱ组围拔管期各时点SBP、DBP、HR均低于与Ⅰ组（P〈0.01）,全麻用药量也少于Ⅰ组（P〈0.05）。结论 全麻-硬膜外复合麻醉有利于维持胆道手术病人围拔管期血流动力学的相对稳定。     

Narcotrend监测下硬膜外阻滞复合全麻在老年病人腹部手术中的应用

目的比较Narcotrend监测下硬膜外阻滞复合全麻和单纯全麻用于老年病人腹部手术的临床效果,探讨老年腹部手术病人更安全合理的麻醉方式。方法 40例ASAⅡ～Ⅲ择期行腹部手术的老年病人,随机分为硬膜外阻滞复合全麻组(EGA)和单纯全麻组(GA),每组20例。两组全麻诱导用药为舒芬太尼0.4μg/kg、顺苯磺阿曲库铵0.15 mg/kg、依托咪酯0.2 mg/kg,气管插管后微泵持续输注丙泊酚、瑞芬太尼及间断静注顺苯磺阿曲库铵维持麻醉,术中行Narcotrend监测并使Narcotrend分级(NTS)维持在D0～D2之间。EGA组全麻诱导前先行硬膜外穿刺置管,注入试验剂量1.3%利多卡因3 ml,气管插管后硬膜外追加1.3%利多卡因6～8 ml,再以0.375%罗哌卡因5～8 ml/次维持硬膜外阻滞。术中监测血流动力学变化,术毕记录两组病人全麻维持用药量和病人睁眼时间、拔管时间及定位功能恢复时间等。结果 EGA组术中收缩压低于GA组(P<0.05);术中麻醉用药比较,EGA组丙泊酚及顺苯磺阿曲库铵用量少于GA组(P<0.05),EGA组瑞芬太尼用量明显少于GA组(P<0.01);恢复时间比较,EGA组病人睁眼时间、拔管时间、定位功能恢复时间均明显短于GA组(P<0.01);两组病人均无术中知晓发生。结论硬膜外阻滞复合全麻用于老年病人腹部手术血流动力学稳定,全麻药用量减少,病人恢复较快,是一种安全可行的麻醉方法,同时进行麻醉深度监测,有利于预防术中知晓。     

Regional versus general anesthesia in high-risk surgical patients: The need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

Combined use of neuraxial and general anesthesia during major abdominal procedures in neonates and infants

With the advent of ultrasound and improvements in equipment, the applications of regional anesthesia in the pediatric population have continued to expand. Although frequently used for postoperative analgesia or as a means of avoiding general anesthesia in patients with comorbid conditions, the adjunctive use of regional anesthesia during general anesthesia may effectively decrease the intraoperative requirements for intravenous and volatile agents, thereby providing a more rapid awakening and earlier tracheal extubation. More recently, the limitation of the requirements for volatile and other anesthetic agents may be desirable, given concerns regarding the potential impact of these agents on neurocognitive outcome in neonates and infants. Several authors have demonstrated the potential utility of combining a neuraxial technique (spinal or epidural anesthesia) with general anesthesia in neonates and infants undergoing intraabdominal procedures. We review the literature regarding the combined use of neuraxial and general anesthesia in neonates and infants during major abdominal surgery, discuss its potential applications in this population, and review the techniques of such practice.     

Changes in rapidly extracted auditory evoked potentials during tracheal intubation

BACKGROUND: One of the problems encountered in assessment of the hypnotic level during anesthesia is the extraction of a consistent and reliable measure online and close to real time. Hemodynamic parameters such as heart rate and blood pressure are not, at least with the traditional single parameter versus time presentation, adequate for ensuring an optimal level of anesthesia, especially when using neuromuscular blocking agents (NMBA). In the literature, it has been demonstrated that auditory evoked potentials (AEP) are able to provide two aspects relevant to determining level of anesthesia: firstly, they have identifiable anatomical significance and, secondly, their characteristics reflect the way the brain perceives a stimulus. METHODS: The aim of this study was to evaluate the AEP index based on a system identification model, the autoregressive model with exogenous input (ARX-model), and to compare it to the classical method, the moving time average (MTA). The ARX enables the extraction within 15-25 sweeps, depending on the signal-to-noise ratio (SNR), whereas MTA typically needs 250-500 sweeps. The hypothesis of the present study was that since the ARX-model extracts the AEP faster than the MTA-model, the former should be able to detect changes during the brief, intense stimulus of endotracheal intubation. Twelve female patients scheduled for gynecological surgery were included in the study. Anesthesia was initiated with thiopentone and maintained with isoflurane and alfentanil. The AEP was mapped into an index (AEP-index) normalized to 100 when the individual was awake and decreasing to an average of 25 during thiopentone induced anaesthesia. The results were compared to those obtained by MTA-extracted AEP. RESULTS: During tracheal intubation 9 patients showed an increase in the ARX-extracted AEP-index larger than 15, and 6 of these patients showed an increase larger than 25 (mean increase=33, SD=18). The MTA-extracted AEP-index showed only one patient with an increase larger than 15. The ARX-extracted AEP changed significantly faster than the MTA-extracted AEP. CONCLUSION: The ARX-extracted AEP-index increases during tracheal intubation. There is a significant difference between the ARX-extracted AEP and the traditional MTA-extracted AEP, in terms of response time. In order to trace short-lasting changes in the hypnotic level by AEP, the AEP should be extracted by a method with a fast response such as the ARX-model.     

Regional versus general anesthesia in high-risk surgical patients: the need for a clinical trial

Regional anesthesia is often preferred over general anesthesia for patients with cardiovascular disease because of presumed decreased risk of perioperative myocardial ischemia. However, few studies have addressed this issue directly. To determine whether the type of anesthesia is independently associated with myocardial ischemia, records of 134 patients undergoing peripheral vascular grafting under general or regional anesthesia were examined. There were no significant differences preoperatively between groups in ASA class, age, sex, or prevalence of angina, diabetes, or hypertension. Twelve patients developed myocardial ischemia or infarction within 7 days of operation; 11 of these 12 patients had received regional anesthesia (p < 0.015). The association between anesthetic approach and perioperative myocardial ischemia or infarction remained after adjustment for preoperative factors associated with ischemia or with type of anesthesia. General anesthesia does not appear to be associated with increased risk of myocardial ischemia, and stringent recommendations to avoid it in this population may be unfounded. A clinical trial is needed to define more clearly the risks and benefits of different types of anesthesia in high-risk patients.     

腰-硬联合阻滞复合浅全麻在妇科腹腔镜手术的临床应用研究

目的:探讨腰-硬联合阻滞(combined spinal epidural anesthesia,CSEA)技术辅以静脉浅全麻在妇科腹腔镜手术中的临床麻醉效果及安全性。方法:在腰-硬联合阻滞后分别予以力月西、杜氟合剂、异丙酚辅助麻醉施行腹腔镜妇科手术;回顾分析269例妇科腹腔镜手术的临床麻醉数据,进行统计分析,分析其麻醉效果、副作用。结果:术中麻醉效果良好,镇静充分,DBP、SBP、HR指标在CSEA后10min内有变化但平稳(P>0.05),均在正常范围;CO2气腹后10min与气腹前比较,HR增快,有统计学意义(P<0.05),RR加快、PETCO2升高,有统计学意义(P<0.01),两者变化最为显著,但仍可维持在正常范围,而SpO2变化幅度不显著(P>0.05),在气腹30min后,各项指标均有所改善,排气后10min各项指标与气腹前比较无统计学意义(P>0.05),269例患者均顺利完成妇科腹腔镜手术,无一例发生麻醉并发症及意外。结论:在妇科腹腔镜手术中,应用腰-硬联合阻滞辅以静脉浅全麻,在强化麻醉管理、充分吸氧的前提下能很好的控制血流动力学和呼吸功能的变化而维持正常的生命体征,麻醉效果良好,可在选择适应证的前提下推广应用。     

Topical wound anaesthesia in children--a temporary postoperative pain relief

BACKGROUND: Administration of local anaesthetics into the surgical wound may modulate pain at the peripheral level. A previous study in adults has shown good analgesic effects of topical lidocaine in wounds after herniorrhaphy. METHODS: Postoperative pain relief after topical administration of 10% lidocaine aerosol in the surgical wound was investigated in a randomised, double-blind study in children undergoing inguinal hernia repair. Forty-four patients aged between 9 months and 11 years were randomised into three groups. One group received active treatment with a lidocaine aerosol 2.5-4.7 mg kg-1, one group received a placebo aerosol and one control group was untreated. Postoperative pain was evaluated by nurse assessment, self-assessment and wound palpation 0, 1, 4 and 12 h after arrival in the recovery room. RESULTS: After 1 h the incidence of pain, as estimated by behavioural assessment and self-assessment, was significantly reduced in the lidocaine group in comparison to the placebo group, but not in comparison to the control group. The reaction on wound palpation was significantly reduced in the lidocaine group compared to both the placebo and control groups. At 0, 4 and 12 h no significant differences between the groups were observed. Plasma lidocaine concentrations were measured in six patients. Maximum individual concentrations were low, ranging from 0.17 to 0.86 microgram ml-1. CONCLUSION: A very short and clinically insignificant pain relief is obtained following the administration of a lidocaine aerosol in the surgical wound. A low pain level in this model may limit the possibility to detect an effect of lidocaine.     

The sevoflurane-sparing effect of nitrous oxide: a clinical study

BACKGROUND: We studied the sevoflurane-sparing effect of nitrous oxide in a prospective randomised study. METHODS: Forty-two ASA I-II patients scheduled for elective knee arthroscopy under general anaesthesia were randomly assigned to a fresh gas flow consisting of oxygen in air or oxygen in nitrous oxide 1:2. All patients received a standardised anaesthesia consisting of induction with fentanyl and propofol and maintenance with sevoflurane adjusted according to clinical signs. The sevoflurane consumption was studied by means of weighing the vaporiser before and after every anaesthesia. RESULTS: The mean sevoflurane consumption was reduced from 0.62 to 0.25 g/min, a 60% reduction, by the use of oxygen in nitrous oxide 1:2 in the fresh gas flow. The emergence was faster for the patients receiving nitrous oxide. No major differences were observed during recovery. CONCLUSION: Nitrous oxide was found to be cost-effective for use during short ambulatory knee arthroscopy.     

不同组成5g/L罗哌卡因10mg用于蛛网膜下腔阻滞的临床比较

目的观察不同组成的5 g/L罗哌卡因10 mg蛛网膜下腔阻滞时感觉、运动神经阻滞的效果。方法下腹部及以下手术患者36例,ASA分级Ⅰ~Ⅱ,随机分为3组（n=12）,腰硬联合麻醉下,蛛网膜下腔给药。A组注入10 g/L罗哌卡因1 ml＋生理盐水1 ml,B组注入10 g/L罗哌卡因1 ml＋注射用水1 ml,C组注入10 g/L罗哌卡因1 ml＋100 g/L葡萄糖1 ml。结果A、B组间感觉、运动神经阻滞无差异;A、B组感觉、运动神经阻滞的起效时间及最大运动阻滞时间均慢于C组,最高感觉阻滞平面与最大运动阻滞程度均低于C组（P〈0.05）。结论5 g/L罗哌卡因10 mg蛛网膜下腔阻滞时,加入100 g/L葡萄糖缩短了感觉与运动阻滞的起效时间,提高了感觉阻滞的平面及运动阻滞的程度。     

The effect of anesthetic technique on recovery after orthognathic surgery: a retrospective audit

We audited the recovery characteristics of 51 patients who had undergone orthognathic maxillofacial surgery at a single center. Patients whose anesthesia had been maintained with intravenous propofol and remifentanil (n  =  21) had significantly higher pain scores during the first 4 hours after surgery than those whose anesthesia was maintained with volatile inhalational agents and longer-acting opioids (n  =  30) (P  =  .016). There was a nonsignificant trend towards shorter recovery times in the former group, while there were no differences in early postoperative opioid usage, hemodynamic parameters, or postoperative nausea and vomiting . Given that our data were collected retrospectively and without the ability to control for potential confounders, we interpret the results with caution. Notwithstanding these limitations, we believe this is the first report comparing the effects of different opioid-based anesthetic regimens on early recovery from orthognathic surgery, and we believe this report may be used as the starting point for a controlled study.     

Millikan手术治疗腹股沟疝的临床应用价值

目的 评估Millikan手术治疗腹股沟疝的临床应用价值. 方法 用Millikan方法局麻下修补腹股沟疝52例,以同期行疝环充填式修补术的50例作为对照,观察两组手术效果、并发症、术后复发情况及生活质量等指标. 结果 Millikan方法同疝环充填式修补法在手术时间、麻醉药用量以及围手术期并发症发生率方面比较无差异(P＞0.05).术后住院期间Millikan组镇痛药使用率明显低于 对照组(38.5％ vs.70.0％,P＜0.01).所有病例至少随访1年以上,两组均无复发.Millikan组慢性疼痛3月内仅1例,3月后消失;对照组术后3月慢性疼痛9例,超过1年5例.Millikan组1例有异物感,3月后消失;对照组3月时8例有明显异物感,其中5例时间超过了1年.两组术后慢性疼痛和异物感比较均有统计学差异(P＜0.05). 结论 Millikan术式安全可靠,疗效确切,术后慢性疼痛轻,异物感更少,生活质量更佳.     

SBA 2020: Atualização na diretriz da anestesia regional em uso de anticoagulantes

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique‐associated complications; spinal hematoma‐associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.     

患者硬膜外注射不同浓度左旋布比卡因的药代动力学

Objective To investigate the pharmacokinetics of different concentrations of levobupivacaine for lumbar epidural anesthesia.Methods Twenty ASA Ⅰ or Ⅱ patients of both sexes, aged 35-59 years and scheduled for elective radical resection of rectal or colon carcinoma under general anesthesia combined with epidural block, were randomly divided into 2 groups (n=10 each):group Ⅰ (receiving 0.75% levobupivacaine) and group Ⅱ (receiving 0.5% levobupivacaine). Epidural block was performed at L1-2 interspace. Group Ⅰ and Ⅱ received epidural 0.75% and 0.5% levobupivacaine 2 mg/kg (containing adrenaline 5 μg/kg)injected slowly over 2 min, respectively. And 30 min later, general anesthesia was induced with y-hydroxybutyrate 60-80 mg/kg and remifentanil 1-2μg/kg. Tracheal intubation was facilitated with succinylcholine 1-1.5 mg/kg and the patients were mechanically ventilated. Anesthesia was maintained with inhalation of nitrous oxide (N2 O) and O2 (1:1) and continuous infusion of remifentanil 0.01-0.1μg·kg-1·min-1 and intermittent intravenous boluses of atracurium. Sensory and motor blocks were assessed after epidural levobupivacaine. Blood samples were taken from the central vein at 0, 10, 20, 30, 45, 60, 90, 120, 210, 300, 420,540, 660 and 840 min, respectively, after epidural administration for determination of plasma concentrations of levobupivacaine by high performance liquid chromatography.Results The plasma concentration-time curves of levobupivacaine were fitted to a two-compartment open model in the two groups and there were no significant differences in the pharmacokinetic profiles between the two groups. The onset time of sensory and motor blocks was shorter and the duration of the two blocks was longer with 0.75% levobupivacaine as compared with 0.5%levobupivacaine. The incidences of nausea and vomiting and hypotension were low and no severe cardiovascular and neurological side-effects developed.Conclusion The pharmacokinetic parameters do not differ significantly between epidural 0.75% and 0.5% levobupivacaine when the total doses are the same. And epidural anesthesia with either 0.75% or 0.5% levobupivacaine is safe.