左旋布比卡因复合舒芬太尼或芬太尼在分娩硬膜外自控镇痛的应用

目的探讨左旋布比卡因复合舒芬太尼硬膜外自控镇痛（PCEA）用于分娩镇痛的临床效果及安全性。方法随机选择120例美国标准协会（ASA）I-Ⅱ级初产妇，随机分为舒芬太尼组（A组）、芬太尼组（B组）、无镇痛组（C组），每组40例。A组和B组采用PCEA，C组不给予镇痛药物。观察各组不同时段视觉模拟评分（VAS）和不良反应的发生，同时记录3组产程时间、分娩方式、缩宫使用情况、产后出血量、新生儿Apgar评分。结果A、B2组和C组在PCEA20、60min及宫口开全时VAS差异有统计学意义（P〈0.05）；PCEA5min，A、B2组VAS差异有统计学意义（P〈0.05），2组Bromage评分、不良反应差异无统计学意义（P〉0.05）。3组产程时间、分娩方式、产后出血量、新生儿Apgar评分比较差异均无统计学意义（P〉0.05）。结论左旋布比卡因复合舒芬太尼或芬太尼用于分娩镇痛安全有效，对母婴无明显不良影响。     

术后镇痛10年后的质量控制探讨：1168例回顾性研究

目的 了解术后镇痛的现状，探讨术后镇痛的质量控制问题。方法 回顾近3个月1168例术后镇痛所采用的镇痛方法和预防术后恶心呕吐的方法，了解镇痛效果和副作用的发生情况，并分析影响镇痛效果和副作用发生率的有关因素，患者的满意度情况。结果 90％采用了连续硬膜外镇痛法，配方主要是小剂量吗啡复合低浓度布比卡因或罗比卡因，静脉镇痛主要采用吗啡复合氯诺昔康。预防术后恶心呕吐（PONV）的方法有5-HT3受体拮抗剂（昂丹司琼或阿扎司琼），氟哌啶，地塞米松等，单用或复合应用。连续硬膜外镇痛需要补救镇痛者约5％，静脉镇痛补救镇痛者约10％。PONV总体发生率低，妇科开腹手术低至20％，女性非妇科手术低至10％，剖宫产术低至1％，使用氟哌啶使妇科手术PONV降低约50％。1例高龄患者出现血氧饱和度下降至82％，经停药、吸氧等处理好转。硬膜外导管脱落0．5％。瘙痒、头晕等并发症小于5％。通过补救镇痛，及时处理并发症，患者满意度在90％以上。结论 硬膜外镇痛方法效果优于静脉镇痛方法，适度镇痛，减少镇痛药量，增加安全性，重视PONV的预防，及时处理镇痛不足和副作用，从而提高患者的满意度，是术后镇痛质量控制的可行的理念和方法。     

Post-surgical pain relief with zero-order intravenous infusions of meptazinol and morphine: a double-blind placebo-controlled evaluation of their effects on ventilation

Summary A double-blind, placebo-controlled study has been made of the analgesic and respiratory effects of constant rate infusions of meptazinol and morphine in 30 patients after abdominal surgery. Group I received meptazinol, loading dose 50 mg followed by i.v. infusion 0.5 mg · kg⁻¹ · h⁻¹, Group II received morphine, loading dose 5 mg and then an infusion of 0.05 mg · kg⁻¹ · h⁻¹, and Group III received saline. After recovery from inhalation anaesthesia (without opiates or a local anaesthetic) pain relief and chemoreceptor carbon dioxide tolerance were assessed before and at various times after starting the analgesic infusion. A similar degree of pain relief was found after 10 min in Groups I and II, which lasted until the end of observation period (20 h). Heart rate and systolic and diastolic blood pressures were lower in Group II than in Groups I and III, and respiratory rate fell in Groups I and II. After 6 h arterial carbon dioxide tensions (P_aCO₂) became significantly higher in Group II than Group III. The maximum percentage fall in mean tidal volume (V_T) and expired minute volume (0V_E) from the preinjection values was significant in Groups I and II. End-tidal carbon-dioxide (P_ETCO₂) and P_aCO₂ were significantly higher after 20 h of infusion in Group II compared to Group I. The slope of 0V_E/P_ETCO₂ (<S>) was increased in Group I and it was significantly reduced in Group II. Analysis of derived variables, such as the CO₂ intercept (CO₂I) and minute ventilation at 7 kPa (0V_E7), indicated a shift to the right of the slopes in Groups I and II, initially more so in Group I. It is concluded that constant rate infusions of meptazinol and morphine were effective in providing postoperative pain relief. However, their effects on the central regulation of respiration were different, as meptazinol did not impair CO₂ sensitivity whereas morphine did.     

Unusual course of an epidural rhabdomyosarcoma of the upper thoracic spine

Summary This report deals with a case of rhabdomyosarcoma in the upper thoracic spine. It is of particular interest, not only for the rarity of type and location of this tumour, but for its clinical course, which presented fluctuations of neurological status, included an acute demonstration of complete paraplegia followed by full recovery after conservative treatment, and gradual relapsing of neurological deficit, one year later.     

Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic MAO inhibitor therapy

We describe a patient in whom long-term monoamine oxidase (MAO) inhibitor therapy was discontinued 20 days before surgery with general anesthesia. This patient developed severe perioperative hypotension after administration of 10 mg of bupivacaine through an epidural catheter, which was corrected only after potent vasopressor therapy. We attribute this hemodynamic instability to attenuation of this patient's sympathetic tone based on several mechanisms: (1) residual effect of long-term administration of MAO inhibitor that caused a decrease in the number of β-adrenergic receptors (adrenergic subsensitivity due to receptor down-regulation), (2) recovered MAO activity causing effective degradation of sympathetic amines, and (3) combined attenuating effects of general and epidural anesthesia on sympathetic tone.     

分娩期子宫破裂64例分析

目的 分析分娩期子宫破裂的发病原因及预防措施。方法 回顾分析1985年8月至2001年12月，16a间64例分娩期子宫破裂的临床资料。结果 子宫收缩剂使用不当3l例，占48．4％；胎先露下降受阻13例，占20．3％；子宫疤痕16例，占25％；阴道助产4例，占6．3％。初产妇10例(10．9％)；经产妇54例(89．1％)。结论 降低分娩期子宫破裂发生率关键在于加强计划生育工作及围生期保健，严格掌握子宫收缩剂的适应证及剂量；严格首次剖宫产指征；严密观察产程，及时处理异常分娩。     

CO2 laser in cancer surgery of the breast: a comparative clinical study

Review of the literature reveals little to no data regarding the use of the CO2 laser as a surgical modality in the local treatment of breast cancer. This study was undertaken to determine if the CO2 laser is a surgical improvement over the scalpel, influencing patient care during the surgical and postsurgical period. In the author's series, a total of 209 procedures were performed. Within this group, 105 cases were performed with CO2 laser and 104 cases performed with the scalpel. Biopsies were always performed as a separate procedure prior to definitive surgery. This study was not designed to compare cure rates, the medical follow-up period being 1 year. The results of this study demonstrate a significant improvement in patients' postoperative care, surgical technique, and hospital cost-effectiveness.     

Treatment Outcomes in Spontaneous Intracranial Hypotension: Do Epidural Blood Patches Stop the Leaks?

Abstract:   Spontaneous intracranial hypotension (SIH) is a postural headache syndrome unrelated to dural puncture. Because of the increasing failure of epidural blood patch (EBP) to relieve headache in SIH, we retrospectively investigated the epidemiological features and treatment outcomes in 55 cases of SIH. The study population was stratified by age and sex; continuous variables were compared for differences by t -tests; categorical variables were compared by Chi-squared analysis or Fisher exact tests. Significant differences were identified by P values of 0.05 or less. The mean age of the study population was 44 ± 12 years with a female to male ratio of 1.3:1.0. Men presented with subdural hematomas ( P  = 0.001) more often than women. Meningeal enhancement on contrast magnetic resonance imaging (MRI) was the most consistent radiographic finding. Radionuclide cisternography (RC) demonstrated thoracolumbar dural leaks in 16 of 22 patients. EBP failures were more common in patients aged 40 and younger than in older patients ( P  = 0.003). Postural headache from SIH was not uniformly responsive to EBP, and had significant comorbidities, especially in men. The management of postural headache in SIH by other techniques to restore brain position and cerebrospinal fluid dynamics should be investigated.