永久起搏电极植入途径及起搏类型的探讨

目的评价起搏电极的植入途径及永久起搏器的类型.方法选择1987～1999年安置的80例永久起搏器患者.结果经颈外静脉植入电极6例,手术时间为256±75分;经头静脉植入电极48例,手术时间为247±65分(P＞0.05);经锁骨下静脉途径植入电极26例,手术时间为118±35分(P均＜0.01).其中,AAI型3例(4%),DDD型5例(6%),VVI型72例(90%).结论经锁骨下静脉植入起搏电极,方法简单,组织损伤小,手术时间短,优于其它途径.VVI型起搏器在我国仍然是主要使用的起搏器.     

急性心肌梗塞伴右束支传导阻滞的临床意义

目的 :评价急性心肌梗塞 (AMI)患者并发右束支传导阻滞 (RBBB)的临床特征及预后意义。方法 :观察了我院 1995年 1月至 2 0 0 0年 7月 339例住院AMI患者的心电图、血清磷酸肌酸激酶 (CK)及其同工酶 (CK MB)的峰值水平、严重并发症及死亡率。结果 :5 4例AMI并发RBBB患者 (占 15 .93% )预后明显差于无并发RBBB者 ,表现为血清CK及CK MB浓度更高 ,严重心脏事件发生率及死亡率增高 ,经统计学处理两组间比较有显著性差异 (P<0 .0 1)。结论 :AMI患者并发RBBB通常是心肌大面积梗死的表现 ,RBBB是一个独立的可判断预后的指标 ,冠脉的再灌注可影响传导的可逆性 ,可预防束支传导阻滞的发生或限制其持续时间 ,积极的心脏介入性治疗及血管重建可改善预后。     

左右侧星状神经节阻滞对冠脉循环影响的实验研究

目的探讨左右侧星状神经节阻滞(SGB)对左冠状动脉急性闭塞区域的心肌组织血流及心肌血氧供需关系的影响.方法取犬24只,急性闭塞左冠状动脉前降支后,随机分为三组.对照组不进行SGB(6只);右侧SGB组(9只);左侧SGB组(9只),观察血液流变学有关指标变化.结果①左冠状动脉前降支闭塞后,心率(HR)、左冠状动脉回旋支血流量(CoBF)、左心室舒张期终末压(EDP)、心肌氧摄取率(MOER)显著增加(P＜0.05);闭塞区域心肌组织血流量(CBF)、心率血压双乘积(RPP)显著减少(P＜0.05);但三组间差异无显著性.②左SGB后HR、舒张期动脉血压(dBP)、CoBF、CBF无显著变化;左颈动脉血流量(LCaBF)、EDP、MOER、RPP与阻滞前相比有意义增加(P＜0.05).③右SGB后,EDP阻滞前后相比有意义增加(P＜0.05);HR、CoBF、RPP显著减少(P＜0.05).④HR、LCaBF、RPP、CoBF左右不同侧变化差异有显著性(P＜0.05).对照组左冠状动脉前下支闭塞后15min和30min各项测定指标没有显著性变化.结论急性左冠状动脉前降支闭塞导致的MOER、RPP的增加,左SGB无改善作用,并使其进一步增加;而右侧SGB后引起HR、CoBF、RPP显著减少.提示急性心肌梗塞时,左SGB有可能使心肌缺血、缺氧恶化,而右侧SGB在解除心脏疼痛的同时可减少心肌的耗氧量,因而有治疗作用.     

Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThis study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA).MethodsPatients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications.ResultsCompared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates.ConclusionAdding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.     

Liposomal Bupivacaine vs Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty: A Prospective Randomized Trial

BackgroundThe purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty.MethodsPatients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status.ResultsOne hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome.ConclusionWe did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.     

A randomised trial of bilateral erector spinae plane block vs. no block for thoracolumbar decompressive spinal surgery

Major spinal surgery causes significant postoperative pain. We tested the efficacy and safety of bilateral erector spinae block on quality of recovery and pain after thoracolumbar decompression. We randomly allocated 60 adults to standard care or erector spinae block. Erector spinae block improved the mean (SD) quality of recovery-15 score at 24 postoperative hours, from 119 (20) to 132 (14), an increase (95%CI) of 13 (4–22), p = 0.0044. Median (IQR [range]) comprehensive complication index was 1 (0–3 [0–5]) in the control group vs. 1 (0–1 [0–4]) after block, p = 0.4. Erector spinae block reduced mean (SD) area under the curve pain during the first 24 postoperative hours: at rest, from 78 (49) to 50 (39), p = 0.018; and on sitting, from 125 (51) to 91 (50), p = 0.009. The cumulative mean (SD) oxycodone consumption to 24 h was 27 (18) mg in the control group and 19 (26) mg after block, p = 0.20. In conclusion, erector spinae block improved recovery and reduced pain for 24 h after thoracolumbar decompression surgery.     

Bloqueo del plano del músculo erector de la columna para analgesia de dolor lumbar crónico: serie de casos

BackgroundChronic low back pain (CLBP) is a frequent condition, poorly managed with conventional treatments. The ultrasound-guided erector spinae plane block has increasingly been used in the management of acute and chronic pain. We aimed to determine this technique's analgesic efficacy in patients with moderate to severe CLBP.MethodsTen consecutively selected patients: adults, regularly followed in our Pain Clinic with moderate/severe long-term CLBP refractory to pharmacological treatment, VAS > 4. Prospective data collection: before the intervention –demographical data, past medical history, current pain therapies, VAS pain level, Brief Pain Inventory– Short Form and Neuropathic Pain Questionnaire; 30 minutes after – VAS and satisfaction level; 24 and 72 hours, 7 days and 1 month after - complications and pain level.ResultsMajority of females (90%), mean age of 70.3 years-old. All had primary musculoskeletal CLBP. 90% experienced severe pain (VAS > = 7) in the last 24 hours. Half presented neuropathic characteristics. Patients were very satisfied with the technique (mean: 8.75) with immediate pain relief (VAS mean: 2.3). 24 and 72 hours, 7 days and 1 month after the treatment VAS means were 3.2, 3.1, 3.8 and 6.2. We report a 20.8 days duration mean. No short or long-term complications.Discussion and conclusionsUltrasound-guided erector spinae plane block has preliminary advantages in CLBP: easily performed with low complications risk, immediate discharge home with absence of motor block, 100% efficacy at short and medium-terms. Even though pain's relief was shorter than a month, it is a useful tool allowing patients’ well-being, physical rehabilitation and exercise during this period.