不同方式超声引导连续髂筋膜阻滞在髋关节置换术后镇痛效果

目的 对两种不同方式超声引导连续髂筋膜间隙阻滞在髋关节置换术后镇痛效果进行评价。方法 采用前瞻性随机对照研究,纳入新疆医科大学第六附属医院于2016年3月至2017年10月收治的腰-硬联合阻滞麻醉下人工全髋关节置换术（total hip arthroplasty, THA）术后病人60例,男29例,女31例,年龄为65~83岁,平均（66.78±9.32）岁。按照数字随机法分为：①腹股沟韧带上髂筋膜阻滞组（上髂筋膜组）30例,男17例,女13例,年龄为65~84岁,平均（66.13±9.16）岁;②腹股沟韧带下髂筋膜阻滞组（下髂筋膜组）30例,男12例,女18例,年龄为65~82岁,平均（65.80±8.13）岁。在超声引导下行髂筋膜连续神经阻滞后镇痛,设置两组镇痛泵的局部麻醉药物均为0.2%的罗哌卡因200 ml,负荷量20 ml,置管成功后注入,背景量为0。病人自控镇痛（patient controlled analgesia, PCA）10 ml/次,锁定时间为1 h。对病人的静息疼痛、持续性被动疼痛和主观性疼痛等疼痛视觉模拟量表（visual analogue scale, VAS）评分进行记录,对病人的阻滞效果、曲马多用量以及病人满意度进行评价。结果 上髂筋膜组的手术时间为（70.4±12.1） min,下髂筋膜组为（70.8±10.3） min,两组比较差异无统计学意义（P＞0.05）。在静息状态、主被动VAS评分方面,上髂筋膜组均优于下髂筋膜组;上髂筋膜组病人阻滞后各时间点股外侧皮神经支配区的感觉阻滞程度和曲马多使用量优于下髂筋膜组,以上指标比较,两组差异均有统计学意义（均P＜0.05）。两组病人阻滞后各时间点股神经阻滞率和术后镇痛满意度比较,差异均无统计学意义（均P＞0.05）。结论 THA术后采用超声引导下浓度为0.2%罗哌卡因,在THA术后镇痛效果上,腹股沟韧带上连续髂筋膜阻滞明显优于腹股沟韧带下连续髂筋膜神经阻滞。     

肌松程度对腹腔镜胆囊切除术中患者肺功能的影响

目的：探讨肌松程度对腹腔镜胆囊切除术（laparoscopic cholecystectomy，LC）中患者肺功能的影响。方法：选取2018年9月到2020年1月复旦大学附属上海市第五人民医院收治的择期LC患者90例，采用随机数字表法分为3组（n=30）：浅度肌松组（S组）、中度肌松组（M组）和深度肌松组（D组），3组均在肌松监测下采用罗库溴铵维持目标肌松程度，S组、M组和D组目标肌松程度分别为TOF计数4、TOF计数1~3、PTC计数≤2，分别于插管后（T₁）、气腹10 min（T₂）、气腹结束后（T₃）和术毕（T₄）时记录气道峰压（P_peak）、气道平台压（P_plat）和肺顺应性（lung compliance，CL），在T₁、T₂、T₄时采集桡动脉血样行血气分析，计算氧合指数（oxygenation index，OI）、呼吸指数（respiratory index，RI）和肺内分流率（Qs/Qt），术后进行手术条件满意度评级，并记录拔管时间和罗库溴铵用量。结果：与S组相比，M组和D组T₂时CL和OI较高、RI和Qs/Qt较低（P<0.01），T₄时各指标差异无统计学意义，M组和D组手术条件满意度较高，但拔管时间明显延长（P<0.01），罗库溴铵用量增加（M组P<0.05，D组P<0.01）。D组与M组相比，拔管时间延长11 min，罗库溴铵用量增加（P<0.01），其余指标无统计学意义。3组各时间点P_peak和P_plat差异均无统计学意义。结论：中度肌松能够提供与深度肌松相似的手术条件，在改善气腹期间肺功能的同时，拔管时间较短，是腹腔镜胆囊切除术中较为适宜的肌松程度。     

Nitroglycerin-induced nNOS increase in rat trigeminal nucleus caudalis is inhibited by systemic administration of lysine acetylsalicylate but not of sumatriptan

Systemic administration of nitroglycerin (NTG), a nitric oxide (NO) donor, in migraineurs triggers after several hours an attack of which the precise mechanisms are unknown. We found previously in rats that nitroglycerin (10 mg/kg s.c.) is able to increase significantly after 4 h the number of neuronal nitric oxide synthase (nNOS)-immunoreactive neurones in the cervical part of trigeminal nucleus caudalis. In the present experiments, we demonstrate that the 5-HT1B/D agonist sumatriptan (0.6 mg/kg s.c.) does not alter this phenomenon when given before NTG. By contrast, pretreatment with lysine acetylsalicylate (50 mg/kg i.m.) attenuates the NTG-induced nNOS expression in the superficial laminae of trigeminal nucleus caudalis. These findings suggest that effect of NTG on nNOS at a high dosage may involve the cycloxygenase pathway and that activation of the peripheral 5-HT1B/D receptors is not able to modify this effect. These data could help to better understand the role of NO in the pathogenesis of headaches and the action of antimigraine drugs.     

超声引导下腰方肌阻滞与髂筋膜间隙阻滞在老年髋关节术后镇痛的比较

目的比较腰方肌阻滞(quadratus lumborum block,QLB)和髂筋膜间隙阻滞(fasciailiaca compartment block,FICB)在老年髋关节置换术的镇痛效果。方法选择择期拟行腰麻下全髋关节置换术的老年患者55例,男22例,女33例,年龄65～85岁,ASAⅠ或Ⅱ级,随机分为QLB组(n=28)和FICB组(n=27)。术后分别于超声引导下行QLB和FICB,予0.375%罗哌卡因30ml。所有患者术后行舒芬太尼静脉自控镇痛。记录术后6、12、24、48h镇痛泵按压次数及舒芬太尼用量;记录静息及运动时VAS疼痛评分;记录术后恶心呕吐、眩晕等不良反应情况。结果术后12、24、48h QLB组镇痛泵按压次数及舒芬太尼用量明显少于FICB组(P0.05);术后12、24、48hQLB组运动时VAS评分明显低于FICB组(P0.05),两组不同时点静息时VAS评分差异无统计学意义;QLB组恶心呕吐发生率明显低于FICB组[2(7.1%)vs 9(33.3%),P0.05]。结论腰方肌阻滞较髂筋膜间隙阻滞更能明显减轻髋关节置换术后活动痛,减少阿片类药物的使用及不良反应发生率。     

超声引导下肋锁间隙和喙突入路锁骨下臂丛神经阻滞在前臂或手部术中效果的比较

目的比较超声引导下肋锁间隙(CCS)臂丛神经阻滞与超声引导下喙突入路锁骨下臂丛神经阻滞在前臂或手部术中临床麻醉效果。方法选取拟行前臂或手部手术患者58例,男33例,女25例,年龄18~70岁,ASAⅠ~Ⅲ级,随机分为超声引导下CCS臂丛神经阻滞组(A组)和超声引导下喙突入路锁骨下臂丛神经阻滞组(B组)。分别给予0.5%罗哌卡因20 ml,记录臂丛神经深度,神经阻滞操作时间,注射局麻药后5、10、20、30 min臂丛神经分支(正中神经、尺神经、桡神经、肌皮神经)感觉阻滞和运动阻滞情况,神经阻滞持续时间,以及麻醉相关不良反应等。结果 A组臂丛神经深度(2.0±1.2)cm,明显浅于B组(3.5±1.8)cm(P0.05);A组神经阻滞操作时间(2.0±1.5)min,明显短于B组(4.0±1.5)min(P0.05);注射局麻药后5、10 min A组正中神经、尺神经、桡神经、肌皮神经的感觉阻滞率均明显高于B组(P0.05);注药后10 min A组尺神经、桡神经、肌皮神经的运动阻滞率明显高于B组(P0.05),其余时点两组运动阻滞率差异无统计学意义。两组无一例呼吸困难、恶心呕吐、耳鸣等不良反应。结论超声引导下肋锁间隙臂丛神经阻滞较喙突入路锁骨下臂丛神经阻滞深度浅,神经阻滞穿刺操作时间更短,其感觉阻滞和运动阻滞起效更快。     

Sonographically guided ilioinguinal nerve block.

OBJECTIVE: The aim of this study was to describe a sonographically guided ilioinguinal nerve block in adults. METHODS: We developed a useful step-by-step technique of sonographically guided ilioinguinal nerve block based on visualization of abdominal muscles, fascial planes, and the branch of the deep circumflex iliac artery. RESULTS: We performed 9 sonographic examinations with subsequent blockade of the ilioinguinal nerve. All injections resulted in a clinically successful sensory block. CONCLUSIONS: This technique is reliable and reproducible. The block is achievable by a low-volume local anesthetic injection. Visualization of the intestines and blood vessels in the abdominal wall may help prevent an inadvertent injury.     

Catheter-induced A-V Nodal Block Occurring during Electrophysiologic Study

We describe a patienl who underwent electrophysiologic study for evaluation of recurrent syncope. No abnormalities were found but high-grade A-V block proximal to the A-V bundle depolarization developed abruptly as the coronary sinus electrode catheter was being withdrawn. The A-V block disappeared gradually over a 12-hour period, progressing to type I second-degree A-V block, and then to first-degree A-V block (due to prolonged A-V nodal conduction), prior to resuming normal conduction. We postulate that A-V block was induced by direct contact between the electrode catheter and the A-V node or very proximal His bundle. Catheter-induced A-V block at this site has been described only rarely, possibly because of the relatively protected location and the configuration of the A-V node.     

综合治疗腰椎间盘突出症的疗效分析

目的探讨综合治疗腰椎间盘突出症（LIDP）的临床疗效。方法回顾性分析2002年1月-2007年12月经综合治疗的117例LIDP患者的临床资料。结果治愈84例,显效16例,好转11例,总有效率94.87%,未发现并发症。结论硬膜外麻醉、牵引、药物和手法推拿等综合治疗LIDP疗效满意,且安全、痛苦小、见效快,是一种理想且安全的治疗方法。     

Adult Acute Rheumatic Fever: A Rare Case Presenting with Left Bundle Branch Block

In contrast to the more common electrocardiographic patterns seen in acute rheumatic fever, such as first-degree heart block, the appearance of left bundle branch block is rare. An adult patient with acute rheumatic fever presented with left bundle branch block on admission, subsequently had sudden cardiac arrest. She was resuscitated successfully and required temporary pacing. An echocardiogram and radionuclide ventriculography were compatible with interventricular septal involvement in the rheumatic carditis. After 20 days of steroid therapy, the left bundle branch block pattern of the electrocardiogram disappeared. A possible mechanism for the development of complete heart block in acute rheumatic fever is discussed. It is suggested that patients with acute rheumatic carditis who have electrocardiographic manifestations of prolonged P-R interval and left bundle branch block should be managed with prophylactic pacing.     

Focal atrial tachycardia from the fossa ovalis in a patient with Bachmann's bundle block

We report the case of a patient with tracings during sinus rhythm compatible with block of the Bachmann's bundle and presenting with focal atrial tachycardia arising from the fossa ovalis with successful ablation on the right side of the septum. Upward activation of the left atrium has been related in this case to the block of the Bachmann's bundle and to the lack of transseptal conduction.