超声引导下不同入路臂丛神经阻滞在桡骨远端手术中效果的比较

目的 比较超声引导下不同入路臂丛神经阻滞(肌间沟、腋路、锁骨上)在桡骨远端手术中的麻醉效果. 方法 90例择期行“桡骨远端骨折切开复位内固定术”或“桡骨远端骨折术后内固定取出手术”的成年患者,在超声引导下行臂丛神经阻滞,按照随机数字表法分为3组(每组30例):肌间沟入路臂丛神经阻滞组(A组)、腋路臂丛神经阻滞组(B组)、锁骨上入路臂丛神经阻滞组(C组).记录操作时间、镇痛持续时间,测定桡神经、尺神经、正中神经、前臂外侧皮神经和前臂内侧皮神经分布区的痛觉消失时间,评价感觉阻滞效果、麻醉效果及并发症的发生情况. 结果 3组患者基本资料与操作时间比较,差异无统计学意义(P＞0.05).3组的镇痛持续时间差异无统计学意义(P＞0.05).3组桡神经、正中神经、前臂外侧皮神经痛觉消失时间差异均无统计学意义(P＞0.05).A组和C组患者尺神经痛觉消失时间比较[(21±6) min比(20±5) min],差异无统计学意义(P＞0.05),但均长于B组[(8±5)min](P＜0.05);A组和C组前臂内侧皮神经痛觉消失时间比较[(18±6) min比(17±6) min],差异亦无统计学意义(P＞0.05),但与B组[(10±6) min]比较,差异均有统计学意义(P＜0.05).B组麻醉效果优秀率最高(90％).A组和C组分别有2例和1例患者出现膈神经阻滞,B组有1例患者止血带不耐受. 结论 超声引导下腋路臂丛神经阻滞时尺神经及前臂内侧皮神经痛觉消失时间短,在桡骨远端手术中麻醉优秀率高、并发症少.     

The influence of native aortic valve calcium and transcatheter valve oversize on the need for pacemaker implantation after transcatheter aortic valve insertion

Objective

Native aortic valve calcium and transcatheter aortic valve oversize have been reported to predict pacemaker implantation after transcatheter aortic valve insertion. We reviewed our experience to better understand the association.

肋缘下腹横肌平面阻滞对胆道手术患者术后镇痛效果的影响

目的 观察全麻复合肋缘下腹横肌平面阻滞与单纯全麻对胆道手术患者术后镇痛效果的影响.方法 择期行胆道手术患者70例,随机分为全麻复合超声引导肋缘下腹横肌平面阻滞组(联合组35例)和全麻组35例.术后在恢复室给予静脉吗啡滴定至镇痛评分(VAS)≤3分后接静脉吗啡自控镇痛泵.记录术后VAS评分、镇静评分(Ramsay)、吗啡滴定用量、术后24h镇痛泵内吗啡总用量、不良反应及术后镇痛患者满意度.结果 联合组吗啡滴定量及术后24 h镇痛泵内吗啡总用量少于全麻组(P<0.01).患者术后12 h内VAS评分低于全麻组(P<0.05).联合组麻醉总体满意度高于全麻组(P<0.01).结论 胆道手术患者行超声引导肋缘下腹横肌平面阻滞可减少吗啡用量,降低术后疼痛,提高麻醉总体满意度.     

星状神经节阻滞对腹腔镜全子宫切除术患者术后睡眠质量和恶心呕吐的影响

目的 观察超声引导下右侧星状神经节阻滞（SGB）对腹腔镜全子宫切除术患者术后睡眠质量和恶心呕吐（PONV）的影响。
方法 选择择期行腹腔镜全子宫切除术患者98例,年龄42～74岁,BMI 19～25 kg/m ²,ASAⅠ或Ⅱ级。采用随机数字表法分为两组：全身麻醉联合SGB组（S组）和全身麻醉组（GA组）,每组49例。S组于麻醉诱导前在超声引导下行右侧SGB,注入 0.2%罗哌卡因5 ml,GA组不行SGB。两组采用相同的全身麻醉方法和麻醉药物。记录术前1 d、手术当日、术后1 d的匹兹堡睡眠质量指数（PSQI）。记录术后24 h PONV分级和止吐药补救情况。记录术后24 h活动时VAS疼痛评分、镇痛药补救情况、术后首次下床活动时间和术后住院时间。记录局麻药中毒、全脊髓麻醉、气胸、臂丛神经阻滞等SGB相关并发症发生情况。
结果 与GA组比较,S组手术当日、术后1 d PSQI评分、POSD发生率明显降低（P＜0.05）,PONV 0级、1级发生率明显升高,PONV 2级、3级、4级发生率、止吐药补救率明显降低（P＜0.05）,术后24 h活动时VAS疼痛评分明显降低（P＜0.05）,术后首次下床活动时间明显缩短（P＜0.05）。两组补救镇痛情况、术后住院时间差异无统计学意义。S组无一例出现局麻药中毒、全脊髓麻醉、气胸、臂丛神经阻滞等SGB相关并发症。
结论 右侧星状神经节阻滞可有效改善腹腔镜全子宫切除术患者的术后睡眠质量,降低术后恶心呕吐的发生率及严重程度,减轻术后疼痛。     

区域麻醉在心脏手术快速康复中的应用进展

正中劈开胸骨的心脏手术创伤大,术后加速康复一直是手术和麻醉的重点和难点。目前,由于区域麻醉可以阻断疼痛的传导通路,减少手术应激,有益于术后镇痛,因此已广泛应用于普通外科手术的辅助麻醉。由于心脏手术中心肺转流需要全身肝素化,区域麻醉的应用一直存在争议。本文对几种常见的应用于正中劈开胸骨的心脏手术的区域麻醉方式及其并发症等研究状况进行综述,为开胸心脏手术麻醉管理提供参考。     

A randomised controlled trial of intravenous dexmedetomidine added to dexamethasone for arthroscopic rotator cuff repair and duration of interscalene block

Prolongation of peripheral nerve blockade by intravenous dexamethasone may be extended by intravenous dexmedetomidine. We randomly allocated 122 participants who had intravenous dexamethasone 0.15 mg.kg⁻¹ before interscalene brachial plexus block for day-case arthroscopic rotator cuff repair to intravenous saline (62 participants) or intravenous dexmedetomidine 1 μg.kg⁻¹ (60 participants). The primary outcome was time from block to first oral morphine intake during the first 48 postoperative hours. Fifty-nine participants reported taking oral morphine, 25/62 after placebo and 34/60 after dexmedetomidine, p = 0.10. The time to morphine intake was shorter after dexmedetomidine, hazard ratio (95%CI) 1.68 (1.00–2.82), p = 0.049. Median (IQR [range]) morphine doses were 0 (0–12.5 [0–50]) mg after control vs. 10 (0–30 [0–50]) after dexmedetomidine, a difference (95%CI) of 7 (0–10) mg, p = 0.056. There was no effect of dexmedetomidine on pain at rest or on movement. Intra-operative hypotension was recorded for 27/62 and 50/60 participants after placebo vs. dexmedetomidine, respectively, p < 0.001. Other outcomes were similar, including durations of sensory and motor block. In conclusion, dexmedetomidine shortened the time to oral morphine consumption after interscalene block combined with dexamethasone and caused intra-operative hypotension.     

Patients' expectations,experience and acceptability of postoperative analgesia: a nested qualitative study within a randomised controlled trial comparing rectus sheath catheter and thoracic epidural analgesia

Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.     

超声引导下腹股沟韧带上髂筋膜阻滞对膝关节镜下交叉韧带重建术患者止血带相关反应的影响

目的 探讨超声引导下腹股沟韧带上髂筋膜阻滞对全麻下行膝关节镜下交叉韧带重建术（ACLR）患者术中止血带相关反应以及缺血-再灌注损伤的影响。

方法 选择行膝关节镜下交叉韧带重建术患者86例,男58例,女28例,年龄18～64岁,BMI 17～28 kg/m²,ASA Ⅰ或Ⅱ级。采用随机数字表法将患者分为两组：超声引导下腹股沟韧带上髂筋膜阻滞联合全麻组（B组）和单纯全麻组（C组）,每组43例。B组于超声引导下行腹股沟韧带上髂筋膜阻滞联合全麻,C组仅行全麻,术毕均行静脉自控镇痛。记录麻醉诱导时（T₀）、止血带充气即刻（T₁）、止血带充气后60 min（T₂）、止血带充气后90 min（T₃）、放松止血带即刻（T₄）、放松止血带后10 min（T₅）的HR和MAP,于T₁、T₅时抽取静脉血测定血清丙二醛（MDA）和乳酸（Lac）浓度。记录入PACU即刻（T₆）、术后6 h（T₇）、12 h（T₈）、24 h（T₉）静息和活动时VAS疼痛评分。记录术中丙泊酚和瑞芬太尼总用量、术后镇痛泵总按压次数、镇痛泵有效按压次数和氟比洛氛酯补救镇痛例数。记录术后神经损伤、寒颤、术后恶心呕吐等不良反应的发生情况。

结果 与T₁时比较,T₅时两组血清MDA和Lac浓度明显升高（P<0.05）。与C组比较,T₂—T₅时B组HR明显减慢,MAP明显降低（P<0.05）,T₅时B组MDA和Lac浓度明显降低（P<0.05）,T₆、T₇时B组静息和活动时VAS疼痛评分明显降低（P<0.05）,B组术中丙泊酚和瑞芬太尼总用总量明显减少（P<0.05）,B组术后镇痛泵总按压次数、有效按压次数明显减少、氟比洛氛酯补救镇痛率明显降低（P<0.05）。T₈、T₉时两组静息和活动时VAS疼痛评分、术后神经损伤、寒颤、术后恶心呕吐等不良反应发生率差异无统计学意义。

结论 腹股沟韧带上髂筋膜阻滞可减轻止血带相关反应,减轻肢体缺血-再灌注后脂质过氧化反应,减少MDA及Lac等生成,从而减轻缺血-再灌注损伤。     

地塞米松联合罗哌卡因用于老年髋部骨折患者术前镇痛的临床效果

目的：探讨地塞米松联合罗哌卡因用于超声引导下髋关节囊周围神经阻滞在术前老年髋部骨折患者镇痛中的应用。方法：选取2017年1月—2022年3月到我院就诊的老年髋部骨折患者103例,采用随机数字表法分为对照组（n=51）与治疗组（n=52）,两组患者在腰麻前均进行超声引导下髋关节囊周围神经阻滞,对照组注射0.5%的罗哌卡因,治疗组注射0.5%的罗哌卡因+8 mg地塞米松。观察比较术后6 h、12 h、24 h、48 h患者分别于静息状态、运动状态时的NRS疼痛评分、两组患者的术后情况（住院时间、下床时间、镇痛药物使用次数及首次按压镇痛泵时间）、两组患者术后并发症发生情况（心律失常、穿刺血肿、恶心呕吐、神经损伤等）。结果：治疗组静息状态和运动状态时6 h、12 h、24 h、48 h的NRS评分均低于对照组,差异有统计学意义（P <0.05）,术后治疗组患者住院时间、下床时间、镇痛药物使用次数均低于对照组,差异有统计学意义（P <0.05）,首次按压镇痛泵时间长于对照组,差异有统计学意义（P <0.05）。治疗组患者术后心律失常、穿刺血肿、恶心呕吐、神经损伤等并发症发生率为...     

区域阻滞麻醉与老年患者术后神经系统功能、病死率关系的研究进展

背景 区域阻滞麻醉应用于老年患者手术日益增多,其对老年患者术后神经系统功能、病死率的影响有待总结. 目的 通过文献综述,分析区域阻滞麻醉对老年患者术后神经系统、病死率的影响. 内容 讨论区域阻滞麻醉与老年患者术后神经系统功能,包括术后谵妄、认知功能障碍、脑卒中以及与病死率之间的关系. 趋向 区域阻滞麻醉可以减少老年患者术后肺部并发症,减少术后早期认知功能障碍,与全身麻醉相比,具有一定优势.区域阻滞麻醉是否能降低老年患者术后病死率、心血管并发症发生率、谵妄发生率、围手术期脑卒中发生率尚有待于进一步研究.