腰硬联合镇痛及患者自控镇痛对产程及分娩结局的影响

目的 探讨腰硬联合(CSEA)及患者自控镇痛(PCEA)对产程及分娩结局的影响。方法 随机选取2014年1~12月足月待产、无妊娠合并症和并发症初产妇996例,其中503例产妇于活跃期实施CSEA+PCEA镇痛(分娩镇痛组),493例未行分娩镇痛(对照组),分别记录并比较两组产妇各产程时间、子宫收缩、镇痛效果、运动神经阻滞程度、产程中缩宫素的使用率、产后出血率、羊水Ⅲ度污染率、新生儿Apgar评分、产钳助产和剖宫产率。结果 分娩镇痛组第一产程、第二产程较对照组有所延长,差异有统计学意义(P<0.05);第三产程无明显改变;子宫收缩力减弱;分娩镇痛组较对照组镇痛效果显著,差异有统计学意义(P<0.05);运动阻滞程度低;缩宫素使用率、产后出血率、羊水Ⅲ度污染率、及新生儿Apgar评分及产钳助产和剖宫产率两组比较,差异均无统计学意义(P>0.05)。结论 腰硬联合分娩镇痛可能会使第一产程、第二产程延长,对子宫收缩力有一定的影响,但并未增加缩宫素的使用率及产钳助产和剖宫产率,其镇痛效果显著,运动阻滞程度低,对分娩结局无不良影响。     

舒芬太尼联合氯诺昔康对术后静脉自控镇痛的效果观察

目的观察舒芬太尼与氯诺昔康联合用药在术后静脉自控镇痛治疗中的效果及不良反应。方法随机选取120例ASA分级为Ⅰ~Ⅱ级,在全身麻醉下进行择期根治性胃癌切除手术的患者,随机均分为舒芬太尼组(S组)、氯诺昔康联合舒芬太尼组(M组);S组以舒芬太尼+托烷司琼做术后静脉自控镇痛,M组以氯诺昔康联合舒芬太尼+托烷司琼做术后静脉自控镇痛。记录开始术后镇痛后4,8,12,24和48h2组的疼痛视觉模拟评分(VAS)、Prince-Henry疼痛评分(PHS)、Ramsay镇静评分(RSS)和治疗期间出现的不良反应,以及患者对镇痛治疗的总体满意度。结果 2组在术后镇痛治疗期间各时间点VAS、PHS及RSS的比较差异无统计学意义。S组与M组2组患者对镇痛治疗的总体满意度无明显差别。但镇痛治疗期间M组恶心、呕吐的发生率低于S组(6%vs 1.6%,8%vs 2%,P<0.05);不良反应的组间比较无统计学差异。结论氯诺昔康联合舒芬太尼用于普通外科术后静脉自控镇痛可以取得满意的镇痛效果。     

Novel developments with selective,non-peptidic kappa-opioid receptor agonists

Despite the recent introduction of a number of new compounds, there has of late been a cooling of interest by pharmaceutical companies in the development of centrally-active, selective kappa opioid agonists for therapeutic purposes. This is reflected in the discontinuation of a number of clinical trials, for reasons that are often not completely clear to outside observers. Spiradoline and enadoline have apparently been abandoned as potential analgesics because they induce dose-limiting central side-effects (i.e., dysphoria) in models of post-surgical pain. The development of niravoline as an aquaretic for the treatment of cirrhosis with ascites and other hyponatraemic disorders has also been halted. Enadoline may yet find some application against ischaemic stroke and severe head injury, presumably in comatose patients in whom psychiatric side-effects are taken to be immaterial, while apadoline and TRK 820 remain in Phase II clinical testing against cancer pain. The peripherally-selective kappa agonists, asimadoline, and the atypical compound, fedotozine, are well-tolerated in man. Results of Phase III trials of fedotozine against irritable bowel syndrome and dyspepsia have, however, ultimately been disappointing, whereas asimadoline is currently in Phase II clinical trials against pain of rheumatic and osteoarthritic origin. The results of these trials are eagerly awaited.     

Escitalopram 20 mg versus duloxetine 60 mg for the treatment of chronic low back pain

Background: Escitalopram has never been demonstrated to be useful in the treatment of chronic low back pain (CLBP), while duloxetine has demonstrated analgesic effect in chronic pain states. The aim of this trial was to examine the efficacy of escitalopram for the treatment of CLBP compared with duloxetine. Methods: A total of 85 adult patients with non-radicular CLBP entered a 13-week randomized study comparing escitalopram 20 mg with duloxetine 60 mg once daily. The primary measure was comparison of the two drugs on reduction in weekly mean 24-h average pain. Secondary measures included Clinical Global Impressions of Severity (CGI-S) and the 36-item Short-Form Health Survey (SF-36). Results: Eighty patients (n = 39 escitalopram, n = 41 duloxetine) completed the study. No significant differences existed between escitalopram and duloxetine on reduction in weekly mean 24-h average pain at end point. Both escitalopram and duloxetine demonstrated significant improvement on CGI-S and SF-36. Conclusions: Escitalopram and duloxetine demonstrated efficacy and safety in the management of CLBP, with no significant differences. Results of this study should be replicated in a larger sample of patients.     

Clinical efficacy of controlled-release oxycodone 20 mg administered on a 12-h dosing schedule on the management of postoperative pain after breast surgery for cancer

SUMMARY

Objective: To assess clinical efficacy of controlled-release oxycodone (CRO) 20?mg on a 12-h dosing schedule in this prospective, randomised, placebo-controlled, double-blinded study of 40 ASA physical status I-III women undergoing breast surgery for cancer.

Research design and methods: General anaesthesia using remifentanil and propofol was performed for surgery. Both groups received premedication with oral midazolam 7.5?mg 1?h before surgery. In the controlled-release oxycodone group, one tablet of 20?mg CRO was administered with the premedication, and 12?h after the premedication another 20?mg CRO. In the placebo (PL) group, a placebo tablet was administered with the premedication, and 12?h later another placebo tablet. All patients had access to opioid rescue medication via an IV patient-controlled analgesia (PCA) device.

Main outcome measures: Area under the curve (AUC), based on IV opioid rescue consumption over 24?h postoperatively.

Results: The AUC for IV PCA opioid consumption was significantly lower in the CRO group than in the PL group (p?=?0.01). The CRO group required less IV opioid loading dose (p?<?0.001), and consumed less opioid rescue medication 4h (p?=?0.036), 16h (p?=?0.01), and 24?h (p?=?0.005) postoperatively. AUC for VAS scores at rest was significantly lower in the CRO group than in the PL group (p?=?0.05). VAS scores at rest were lower in the CRO group 16?h (p?=?0.04) and 24h (p?=?0.03) postoperatively. There was no difference in AUC for pain scores on movement (p?=?0.103) and for quality of analgesia (p?=?0.139). There was no difference in nausea between groups (p?=?0.34). Pruritus, arterial hypotension or hypertension, bradycardia, and tachycardia were not observed in either treatment group. None of the patients showed signs of confusion, agitation, or respiratory depression.

Conclusion: The administration of CRO 20?mg on a 12-h dosing schedule halves postoperative IV PCA opioid consumption. CRO 20mg is effective in preventing pain after breast surgery for cancer with only mild side-effects.     

Considerations on the use of oxymorphone in geriatric patients

Background: Pain among the elderly is pervasive, under-treated and can be properly managed by judiciously using analgesics in the armamentarium. For severe pain, opioids generally provide the most effective pain relief, but concerns about safety and tolerability have limited, often unnecessarily, their utilization in the geriatric population. Objective: It is common for geriatric patients to be taking more than one medicine. Oxymorphone might be particularly well suited for use in geriatric patients, in that its metabolism is mainly through non-CYPP450 pathways, thereby posing less risk of interaction with the many drugs that are metabolized by the CYPP450 system. However, oxymorphone is not as familiar to clinicians as morphine or some other opioids. We review here the clinical studies on oxymorphone to outline the key considerations for use of oxymorphone in the geriatric population. Methods: Nine available clinical trials of oxymorphone alone or comparing oxymorphone with placebo or other active agents were analyzed with respect to the safety and tolerability findings. These studies included geriatric patients but were not designed to evaluate oxymorphone exclusively in this population. Results: Based on the results from nine published clinical studies, oxymorphone is an effective opioid analgesic with a safety profile at least comparable to other opioid drugs. At low starting doses and individual titration, oxymorphone should be considered for appropriate geriatric patients, particularly in whom there is concern about interaction with drugs that are metabolized by CYPP450 enzymes.     

Blocking sodium channels to treat neuropathic pain

Neuropathic pain remains a large unmet medical need. A number of therapeutic options exist, but efficacy and tolerability are less than satisfactory. Based on animal models and limited data from human patients, the pain and hypersensitivity that characterize neuropathic pain are associated with spontaneous discharges of normally quiescent nociceptors. Sodium channel blockers inhibit this spontaneous activity, reverse nerve injury-induced pain behavior in animals and alleviate neuropathic pain in humans. Several sodium channel subtypes are expressed primarily in sensory neurons and may contribute to the efficacy of sodium channel blockers. In this report, the authors review the current understanding of the role of sodium channels and of specific sodium channel subtypes in neuropathic pain signaling.     

多模式镇痛复合不同浓度罗哌卡因切口浸润在加速康复外科术后镇痛的效果

目的 探讨在多模式镇痛中复合不同浓度罗哌卡因切口浸润在加速康复外科(ERAS)行开腹结直肠手术术后镇痛的效果.方法 选择择期加速康复外科开腹结直肠手术患者62例,随机分为2组,每组31例.R1组:0.5％罗哌卡因20 mL术毕切口局部浸润;R2组:0.375％罗哌卡因20 mL术毕切口局部浸润.术后均行舒芬太尼静脉自控镇痛(PCIA).分别观察并记录手术结束0、2、4、6、24、48 h各组静息视觉模拟评分(VAS)、Prince-Henry疼痛评分;记录术后首次追加舒芬太尼时间,术后6、24、48 h舒芬太尼消耗量及患者实际按压PCIA泵次数;记录患者术后首次排气排便、离床活动时间及术后住院时长;记录患者术后48 h内不良反应的发生情况.结果 两组患者的一般情况、手术时间、切口长度、手术方式及术中补液量比较,差异均无统计学意义.两组术后备时间点VAS、Prince-Henry评分及不良反应发生情况比较,差异无统计学意义.R1组与R2组比较,首次追加舒芬太尼时间延长[(60.97±20.79) min vs.(37.74±33.14) min],6h舒芬太尼消耗量减少[(16.80±1.74) μg vs.(21.62±2.62) μg],6h镇痛泵按压次数减少[2(1 ～3)次vs.12(10～ 14)次];术后首次排气排便时间提前[(21.47±2.45)h vs.(27.47±3.10)h],差异均有统计学意义(P＜0.05).结论 在多模式镇痛中复合0.5％罗哌卡因20 mL术毕切口局部浸润,可为开腹行结直肠手术患者提供早期良好的术后镇痛,同时减少术后早期PCIA舒芬太尼使用量,加速胃肠功能恢复.     

盐酸羟考酮注射液复合酮咯酸氨丁三醇用于剖宫产术后镇痛的临床观察

目的：观察盐酸羟考酮注射液复合酮咯酸氨丁三醇用于剖宫产术后镇痛的效果及安全性。方法选择腰?硬联合麻醉下剖宫产手术患者75例,ASAⅠ或Ⅱ级,随机均分为盐酸羟考酮组（ O组）,盐酸羟考酮复合酮咯酸氨丁三醇组（ OT组）,酮咯酸氨丁三醇组（T组）。术后镇痛泵配方为O组羟考酮1 mg／kg ＋托烷司琼5 mg;OT组羟考酮0．5 mg／kg＋酮咯酸氨丁三醇1．5 mg／kg＋托烷司琼5 mg;T组酮咯酸氨丁三醇3 mg／kg＋托烷司琼5 mg,三组均以生理盐水稀释至100 mL。观察术后6、12、24、48 h的切口痛VAS评分、宫缩痛评分及BCS评分;记录麻醉前、术后12、24、36 h血清P物质（ SP ）浓度;记录术后48 h内的不良反应,术后12、36 h的缩宫素使用量和子宫底高度。结果与T组比较,术后6、12、24 h O组和OT组的切口痛VAS评分和宫缩痛评分明显降低、BCS评分明显升高（P＜0．05）,术后12、24、36 h O组和OT组SP浓度明显降低（P＜0．05）,O组和OT组胃绞痛发生率明显降低（P＜0．05）。与术前比较,三组患者术后12、24、36 h的SP浓度均明显升高（P＜0．05）。结论盐酸羟考酮复合酮咯酸氨丁三醇用于剖宫产术后镇痛,镇痛效果好,不影响子宫复旧,不良反应少。