0．75％罗哌卡因用于小儿蛛网膜下腔阻滞中的临床研究

目的探讨0．75％罗哌卡因用于小儿蛛网膜下腔阻滞的合适剂量。方法选择ASAⅠ-Ⅱ级择期手术的小儿患者60例．随机分为三组，每组20例。A组0．75％罗哌卡因2ml（按每厘米椎管长0．15mg给药）、B组0．75％罗哌卡因2ml（按每厘米椎管长0．3mg给药）、C组0．5％布比卡因2ml（按每厘米椎管长0．15mg给药）。用药后观察最高感觉阻滞平面等蛛网膜下腔阻滞运动和感觉参数、监测不同时间段的MAP、HR值和不良反应和并发症。结果A组最高阻滞平面、T10感觉平面阻滞持续时间、平面固定时间、运动起效时间、运动恢复时间，与C组比较，差异有统计学意义（F分别=0．16、7．03、0．57、19．23、1．17，P均〈0．05），与B组比较，差异有统计学意义（F分别=0．21、6．78、0．78、17．98、1．23，P均〈0．05）；A组下肢运动阻滞程度弱于C组，差异有统计学意义（x^2分别=40．83、21．16、10．42，P均〈0．05），与B组比较，差异有统计学意义（x^2分别=36．01、21．16、9．60，P均〈0．05）：B组运动恢复快于C组，差异有统计学意义（F=1．23，P〈0．05）；B组感觉阻滞起效时间与A组、C组比较，差异无统计学意义（F分别=4．13、4．54，P均〉0．05）。结论0．75％罗哌卡因每厘米椎长0．3mg用于小儿脊麻能达到安全麻醉：而0．75％罗哌卡因每厘米椎长0．15mg用于小儿脊麻，运动、感觉阻滞较布比卡因差。     

An alternative method of wound pain control following hepatic resection: a preliminary study

BackgroundEpidural analgesia is considered one of the optimal methods for provision of postoperative pain relief in patients recovering from major upper abdominal operations. Concerns regarding the potential risk of neurological complications prompted an evaluation of an alternative strategy using a continuous intermuscular bupivacaine (CIB) infusion combined with patient-controlled analgesia (PCA).MethodsTwo fine-bore catheters are inserted in the deep intermuscular intercostal neuronal plane during abdominal wound closure, and a continuous infusion of bupivacaine 0.25% is commenced for 72 h postoperatively. Simultaneously, patient-controlled analgesia provided intravenous morphine on demand. The study comprised 10 consecutive patients undergoing liver resection in whom CIB infusion and PCA were employed. The feasibility, safety and efficacy of the technique were investigated, analysing postoperative pain scores, morphine requirements, spirometry and oxygen saturation.ResultsThere were no postoperative deaths. Postoperative morbidity included one urinary tract infection, one minor chest infection and acute confusional episodes in two patients. Median pain scores and morphine requirements at 12, 24, 48 and 72 h postoperatively were satisfactory. Spirometry and oxygen saturation values also remained within the normal range.DiscussionPreliminary experience with CIB infusion/PCA in the aftermath of major liver resection has demonstrated its simplicity and safety as an alternative method of postoperative pain control. Further study is required to investigate the role of CIB infusion/PCA as a practical alternative to epidural analgesia or PCA alone.     

轻比重布比卡因蛛网膜下腔麻醉联合脊椎麻醉对行防旋股骨近端髓内钉术老年患者的麻醉效果及影响

目的探究轻比重布比卡因蛛网膜下腔麻醉联合脊椎麻醉对行防旋股骨近端髓内钉(PFNA)术老年患者的麻醉效果及其对循环呼吸系统的影响。方法选取2015年8月至2018年8月在青海省人民医院行PFNA术的60例老年患者为研究对象。分为2组:轻比重组和重比重组,每组30例。重比重组使用3 ml含0.5%布比卡因的葡萄糖溶液麻醉,轻比重组使用6 ml含0.25%布比卡因的蒸馏水溶液麻醉。检测并比较2组麻醉前(T_0)、麻醉平面固定后(T_1)、用药后5 min(T_2)、15 min(T_3)、30 min(T_4)和60 min(T_5)的镇静程度及循环呼吸系统变化。使用简易精神状态量表(MMSE)评估患者认知情况。比较2组麻醉效果和不良反应发生情况。采用SPSS 20.0软件进行数据处理。结果 2组患者麻醉起效时间、T_0～T_5时间点的Ramsay评分基本一致(P0.05)。与重比重组相比,轻比重组中麻醉阻滞平面≥T_(10)者的比例(20.00%vs 43.33%)、以及麻黄碱(3.33%vs 43.33%)和阿托品(6.67%vs 36.67%)的使用率均显著降低(P0.05)。与T_0时间点相比,2组患者T_2～T_5时间点的平均动脉压(MAP)、心率、收缩压、舒张压、呼吸频率和脉搏血氧饱和度(SpO_2)均有降低趋势。与轻比重组比较,重比重组患者T_1～T_5时间点的MAP和SpO_2显著降低(P0.05),T_2～T_5时间点的心率、收缩压、舒张压和呼吸频率显著降低(P0.05)。轻比重组患者麻醉后24 h的MMSE评分显著高于重比重组[(24.14±2.14)vs(26.83±2.34)分,P0.05]。轻比重组认知功能障碍发生率(3.33%vs 16.67%)和不良反应发生率(23.33%vs 46.67%)均显著低于重比重组(P0.05)。结论对行PFNA术的老年患者采用轻比重布比卡因蛛网膜下腔麻醉联合脊椎麻醉阻滞能够获得满意的麻醉效果,且对循环呼吸系统影响较小、安全性较高,值得在临床推广。     

Randomized clinical trial of local infiltration plus patient-controlled opiate analgesia vs. epidural analgesia following liver resection surgery

Objectives

Epidural analgesia is recommended for the provision of analgesia following major abdominal surgery. Continuous local anaesthetic wound infiltration may be an effective alternative. A prospective randomized trial was undertaken to compare these two methods following open liver resection. The primary outcome was length of time required to fulfil criteria for discharge from hospital.

Methods

Patients undergoing open liver resection were randomized to receive either epidural (EP group) or local anaesthetic wound infiltration plus patient-controlled opiate analgesia (WI group) for the first 2 days postoperatively. All other care followed a standardized enhanced recovery protocol. Time to fulfil discharge criteria, pain scores, physical activity measurements and complications were recorded.

Results

Between August 2009 and July 2010, 65 patients were randomized to EP (n= 32) or WI (n= 33). The mean time required to fulfil discharge criteria was 4.5 days (range: 2.5–63.5 days) in the WI group and 6.0 days (range: 3.0–42.5 days) in the EP group (P= 0.044). During the first 48 h following surgery, pain scores were significantly lower in the EP group both at rest and on movement. Resting pain scores within both groups were rated as mild (range: 0–3). There was no significant difference between the groups in time to first mobilization or overall complication rate (48.5% in the WI group vs. 58.1% in the EP group; P= 0.443).

Conclusions

Local anaesthetic wound infiltration combined with patient-controlled opiate analgesia reduces the length of time required to fulfil criteria for discharge from hospital compared with epidural analgesia following open liver resection. Epidural analgesia provides superior analgesia, but does not confer benefits in terms of faster mobilization or recovery.     

布比卡因对肌梭的损害作用

用 54只健康成年家兔 ,观察肌注布比卡因对腓肠肌肌梭的作用。组织学结果显示 ,肌注布比卡因后12 h,肌梭即可出现轻度的变性 ;2～ 3d受损最严重 ,可出现肌梭的广泛坏死 ;1周后受损肌梭可自行修复改善 ,至 3周末可完全修复正常。提示布比卡因能引起肌梭发生可逆性的变性及坏死改变。     

The influence of intraperitoneal bupivacaine on pain following major laparoscopic gynaecological procedures

We present the results of a randomised, double-blind controlled trial to determine the effect of adding bupivacaine to intraperitoneal Hartmann's solution, used to reduce the incidence of postoperative adhesions, on postoperative pain and on analgesic consumption in patients presenting for major laparoscopic gynaecological procedures. Fifty-six women were studied and postoperative analgesic requirements and visual analogue scores were used to assess the pain experienced by the treatment group when compared with the control group. There was no statistical difference in the pain scores between the two groups at any time during the study period (Student's t-test; p = 0.29-0.74) nor was there any difference in analgesic consumption (Mann-Whitney U-test; p = 0.34-0.79).     

Unilateral spinal anaesthesia with hyperbaric bupivacaine

Background: The dosage of local anaesthetic and the time the patient must be kept in the lateral decubitus position for a unilateral spinal anaesthesia is not known. The aim of this study was to determine the ideal dosage of hyperbaric bupivacaine and the time required for the lateral decubitus position for a unilateral spinal block. Methods: Ninety patients who were scheduled to receive spinal block for surgery in the lower extremity were randomised into 9 groups (n=10). The spinal block was performed through the L₄–L₅ intervertebral space with the patient in the lateral decubitus position. Patients in groups Ia, Ib, Ic; IIa, IIb, IIc; IIIa, IIIb, IIIc received 1.5 ml of 0.5%, 2 ml of 0.5%, and 2.5 ml of 0.5% hyperbaric bupivacaine solutions, respectively. The patients were turned to the supine position for 5 min after the injection in groups Ia, IIa, IIIa, 10 min after the injection in groups Ib, IIb, IIIb, and 15 min after the injection in groups Ic, IIc, IIIc. The onset and regression of sensory and motor block were checked and compared between the dependent and non-dependent sides in each group. Results: The rate of block progression of the non-dependent side was higher in the groups receiving 2.5 ml 0.5% hyperbaric bupivacaine solution than in the other groups; at the same time the level of block was higher and the duration of block was longer. The incidence of hypotension was 10–20% in these groups. In the 2 ml 0.5% hyperbaric bupivacaine solution groups, a satisfactory block level and duration of anaesthesia for surgery was obtained. The rate of block progression to non-dependent side in the groups receiving 1.5 ml of 0.5% hyperbaric bupivacaine solution was lower than the other groups, but the duration of block was shorter and the level of block was lower than the other groups. Conclusion: For unilateral spinal anaesthesia in lower extremity operations, 2ml 0.5% hyperbaric bupivacaine solution for operations above the knee and 1.5 ml 0.5% hyperbaric bupivacaine solution for operations below the knee and keeping the patients for 10 min in the lateral decubitus position were found to be appropriate.     

ACUTE TOXICITY OF BUPIVACAINE METABOLITES IN MICE

1. This study was designed to document the acute toxicity of two metabolites of bupivacaine, desbutylbupivacaine (2,6, desbutylbupivacaine; PPX) and pipecolic acid in mice. All the compounds were administered by the intraperitoneal (i.p.) route. 2. The mean convulsant activity was 100% for controls, 30, 100, 100, 100 and 90% for 400, 200, 150, 125 and 112.5 mg/kg i.p. of PPX, respectively, and 0% for the animals receiving pipecolic acid. 3. The acute induced mortality was 60% for bupivacaine control group (50 mg/kg/i.p.), 60, 30 and 0% for 800, 400 and 200 mg/kg of pipecolic acid, respectively, and 100, 90, 60, 80 and 10% for 400, 200, 150, 125 and 112.5 mg/kg i.p. of PPX, respectively. 4. The time to convulse was 158 ± 16 s for bupivacaine, 230 ± 30, 270 ± 24, 255 ± 21, 442 ± 84 and 418 ± 32 s for 200, 150, 125, 112.5 and 100 mg/kg i.p. of PPX, respectively; any pipecolic acid treated animal have convulsed. 5. In conclusion, the present study demonstrated that PPX is more toxic than expected since we found that its induced mortality was approximately three times that found for bupivacaine and its CNS toxicity was about two times that of bupivacaine.     

Wound infiltration with liposomal bupivacaine prolongs analgesia in rats

Background: Wound infiltration with local anesthetics does not reliably produce satisfactory postoperative analgesia, and the dose of local anesthetic which may be safely administered is limited by the potential for systemic toxicity. This study evaluated the efficacy of a slow-release liposomal bupivacaine formulation on duration of wound analgesia.
Methods: Multilammelar liposomes containing bupivacaine were assessed using a rat paw wound model. Twenty-four hours after surgical incision, paw wounds determined to be hyperalgesic to graded force testing with von Frey hairs were infiltrated with 0.3 ml of 2% liposomal bupivacaine, 0.5% plain bupivacaine, saline, or 'empty' (normal saline) liposomes (n=6/group). The duration of analgesia was measured. The 0.5% plain concentration was chosen because, in preliminary experiments, larger doses were often fatal. Analgesia duration was compared using Mann-Whitney U test at P < 0.05. In other rats, plasma bupivacaine levels after wound infiltration with either 2% liposomal formulation or 0.5% plain formulation were assessed (n=8/group).
Results: The mean duration of analgesia was 23+/-3 (SD) min for plain bupivacaine and 180+/-30 min for liposomal bupivacaine. No wound analgesia was detected in animals given normal saline or 'empty' liposomes. Plasma bupivacaine levels tended to be lower after liposomal than plain bupivacaine.
Conclusions: The 8-fold increase in duration of wound analgesia and the lower plasma levels seen with the liposomal formulation are explained by gradual drug release from the liposomal depot. These results may have important implications for achieving safe and effective analgesia with wound infiltration techniques in humans.