硬膜外控自动镇痛泵用于剖宫产术后临床观察

目的 :观察硬膜外腔自动镇痛泵 (AFA)用于剖宫产术后镇痛效果及对产后各项生理指标的影响。方法 :选择剖宫产术后患者 10 0例 ,随机分为两组 ,每组各 5 0例。硬膜外腔自动镇痛泵内含有 0 75 %布比卡因 15ml,0 5 %布比卡因 0 5ml,氟哌啶醇 5mg ,吗啡 8mg ,麻黄素 15mg ,生理盐水 80ml,以每小时 2ml速度给药 ,持续给药 48小时 ,对照组则不给任何药物。采用视觉模拟评分法 ,分别观察 2组患者术后的疼痛情况 ,肠蠕动恢复时间 ,拔尿管后排尿情况 ,产后出血、子宫复旧、泌乳情况及下床活动早晚情况 ,以及是否有恶心、呕吐、呼吸抑制等。结果 :①术后镇痛泵组患者术后无明显疼痛感 ,镇痛效果好 ,而对照组患者术后有明显疼痛感 (P <0 0 1) ;②镇痛泵组患者术后肠蠕动恢复时间为 (16 68±9 3 2 )h ,对照组 (16 2 3± 10 1)h ,两者比较无明显差异 (P >0 0 5 ) ;③术后尿管拔除后尿潴留发生率 ,镇痛泵组 8例 ,对照组 2例 ,差异有显著性 (P <0 0 5 ) ;④镇痛泵组下床活动时间为 (19± 5 )h ,明显早于对照组 (2 7± 8)h ,两组比较差异有显著性 (P <0 0 5 ) ;⑤ 2组患者产后出血、泌乳情况、子宫复旧、术后恶心呕吐、呼吸抑制发生情况比较 ,差异均无显著性(P >0 0 5 )。结论 :硬膜外自动镇痛泵具有良好的镇痛     

2-chloroprocaine antagonism of epidural morphine analgesia

Background: 2-chloroprocaine (2-CP) used for lumbar epidural anesthesia (LEA) reportedly decreases the efficacy of epidural morphine (EM) administered for post-cesarean section (CS) analgesia. The amount of supplemental i.v. morphine self-administered by the patient via the patient-controlled analgesia device (PCA) is used to study the interaction between EM and 2-CP.
Methods: Forty-two patients scheduled for elective CS were randomly divided into 3 equal groups, and received 2-CP, 2-CP+epinephrine (Epi, 5 μg ml^-1) or 2% lidocaine (Lido) with Epi for LEA. All patients received 5 mg EM and i.v. PCA morphine for postoperative pain. Cumulative amount of i.v. morphine used in the first 24 hours as well as the amount of the drug used during each 2-h period were noted. Nonparametric analysis of variance and Chi-squared analysis were used for statistical comparisons.
Results: The mean cumulative 24-h i.v. PCA morphine requirement in the 2-CP, 2-CP+Epi and Lido+Epi groups respectively was 20.5±24, 33.1.5±27 and 4.07±6.3 (mean±SD). The Lido+Epi group used significantly less morphine ( P = 0.01) compared to either of the 2-CP groups with no significant difference between the 2-CP groups. The maximum i.v. PCA morphine use occurred in the first 4 hours following surgery in all three groups.
Conclusion: Analgesic efficacy of EM is decreased when 2-CP is used for LEA compared to when Lido+Epi is used.     

Retardation of pain development: a case of recovery from congenital insensitivity to pain

Congenital analgesia is a rare genetic disorder. We report here that a 12-year-old boy was able to recover from congenital insensitivity to pain. Neurological examinations revealed that there was a 'stocking' distribution of pain decrement on the lower extremities under the patient's knee joints. Magnetic Resonance Imaging (MRI) of his brain showed gyrus thinning with sulcus widening at both sides of the parietal lobe. Southern blot hybridization probed with cDNAs of various opioid receptors did not detect any significant abnormality. Our results suggest that this rare case may not be genetically determined.     

褪黑素和哌替啶对小鼠的镇痛作用比较

利用热板法或甩尾法测定小鼠痛阈，发现褪黑素１０～４０ｍｇ·ｋｇ－１ｉｐ后６０ｍｉｎ时镇痛作用最强，１５０ｍｉｎ时仍有镇痛作用。哌替啶１０～４０ｍｇ·ｋｇ－１ｉｐ后３０ｍｉｎ时镇痛作用最强，１２０ｍｉｎ时已无镇痛作用。在６０ｍｉｎ时两者镇痛作用相近。是示两者的作用特点不同。     

米索前列醇用于正常足月妊娠计划分娩临床效果分析

目的:研究米索前列醇促宫颈成熟、诱发临产的效果及用药量。方法:将200例正常足月孕妇随机分为催产素组(对照组)100例和米索前列醇组(观察组)100例。结果:①引产有效率观察组明显高于对照组;②米索前列醇用药1天有效率为91％,用药量为100.54±25.27μg;2天有效率为97％,用药量为108.76±63.53μg;③孕妇产后出血及剖宫产率两组无显著差异;④羊水混浊发生率,观察组高于对照组差异有显著性;新生儿窒息率,两组相同,差异无显著性。结论:米索前列醇促宫颈成熟及诱发临产效果明显好于催产素,用于正常足月妊娠进行计划分娩是一种安全、有效、方便的方法,值得推广。     

Preoperative metoprolol improves cardiovascular stability and reduces oxygen consumption after thoracotomy

Background : Increased sympathetic activity perioperatively and associated cardiovascular effects play a central role in cardiovascular complications. High thoracic epidural blockade attenuates the sympathetic response, but even with complete pain relief, haemodynamic and endocrine responses are still present. Beta–adrenoceptor blockade is effective in situations with increased sympathetic activity. This study was designed to evaluate the perioperative haemodynamic effect of preoperative βblockade and its influence on the haemodynamic aspects of the surgical stress response.
Methods : Thirty–six otherwise healthy patients undergoing elective thoracotomy for lung resection were randomised doubleblinded to receive either 100 mg metoprolol or placebo preoperatively. Anaesthesia was combined high thoracic epidural block and general anaesthesia. The epidural analgesia was continued during recovery. Patients were monitored with ECG, pulse oximetry, invasive haemodynamic monitoring, arterial blood gases and electrolytes.
Results : After induction of anaesthesia the mean arterial pressure (MAP) decreased in both groups, and decreased further in the placebo group after initiation of the epidural block. The heart rate (HR) was slightly less throughout the observation period after metoprolol. Peroperatively, the only difference in measured haemodynamics was a marginally higher MAP after metoprolol. Postoperative cardiac index (CI) was lower with a lower variability and cardiac filling pressures were slightly higher in the metoprolol group. The oxygen consumption index was higher after placebo throughout the observation period, with no difference in the oxygen delivery.
Conclusion. We found that preoperative β–blockade during combined general anaesthesia and high thoracic epidural blockade stabilised perioperative HR and CI and decreased total oxygen consumption.     

Effect of thoracic epidural etidocaine 1.5% on somatosensory evoked potentials, cortisol and glucose during cholecystectomy

The effect of thoracic (T7-8) epidural etidocaine 1.5%, 9 ml, and continuous per- and postoperative epidural infusion of etidocaine 1.5%, 4 ml/h, on early (less than 500 ms) somatosensory evoked potentials (SEPs), and cortisol and glucose in plasma during cholecystectomy, was examined in ten patients. Spread of analgesia (pin-prick) was T3 (T1-T3) to L2 (T11-L3) 35 min after injection of etidocaine, and T3 (T2-T4) to T12 (T8-L4) 3 h after surgical incision (median (range)). Before operation, epidural etidocaine had no significant effects on peak-to-peak amplitude of SEPs to electrical stimulation at the L1, T10 or T6 dermatomal level (P greater than 0.09). SEPs were abolished in only two patients at T6, and no patient had SEPs abolished at T10 or L1. The plasma concentrations of cortisol and glucose were significantly increased 20 min after surgical incision and remained increased throughout the study. No correlation was found between the block-induced decrease in the peak-to-peak amplitude at T6 or T10 and increase in plasma cortisol, except for a negative correlation at T10 and the initial increase in cortisol (Rs = 0.72, P = 0.03). In conclusion, thoracic epidural administration of 9 ml of etidocaine 1.5% does not provide total afferent somatic blockade assessed by SEP and the stress response to cholecystectomy.     

Ambulatory laparoscopic fundoplication

Background: Increasingly larger series of laparoscopic fundoplications (LF) are being reported. A well-documented advantage of the laparoscopic approach is shortened hospital stay. Most centers report typical lengths of stay (LOS) for LF of 2–3 days. Our success with LF with a LOS of 1 day led to an attempt at performing LF on an ambulatory basis. Methods: Sixty-one consecutive patients with appropriate criteria for LF underwent surgery at our institution. Patients were counseled by the authors as to the usual postop course and progression of diet. All patients received preemptive analgesia (PEA) consisting of perioperative ketorolac and preincisional local infiltration with bupivicaine. Anesthetic management included induction with propofol, high-dose inhalational anesthetics, minimizing administration of parenteral narcotics, and avoidance of reversal of neuromuscular blockade. Immediate postop pain management included parenteral ketorolac and oral hydro- or oxycodone. All patients were given oral fluids and soft solids after transfer from the recovery room to the postoperative observation unit. Two patients were excluded from ambulatory consideration due to excessive driving distance from our hospital. Another two were hospitalized for observation after experiencing intraoperative technical problems. Results: Of 57 patients in whom same-day discharge was attempted, there were three failures requiring overnight hospitalization: All were due to pain and nausea; one patient also suffered transient urinary retention. There were no adverse outcomes related to early discharge, and there were no readmissions. One patient returned to the emergency room after delayed development of urinary retention. Median time from conclusion of operation to discharge was less than 5 h. No patients expressed dissatisfaction with early discharge on follow-up interview. Conclusions: LF can be safely performed as an ambulatory procedure. Analgesic and anesthetic management should be tailored to minimize nausea and provide adequate pain control. Received: 1 April 1996/Accepted: 29 May 1997     

静注加肌注曲马多防治硬膜外麻醉期间寒战反应的研究

目的　观察曲马多防治硬膜外麻醉期间寒战反应时两种用药方法的临床效果。　方法硬膜外麻醉手术期间发生寒战的 6 0例成年患者 ,当出现寒战分级达 2～ 3级时 ,用室温下盐酸曲马多 1mg kg加氟哌啶 2 .5mg缓慢静脉推注 ,随机分成二组 :研究组 (R组 )与对照组 (C组 ) ,每组各 30例 ;R组在 5min内用上述同样药物和剂量予以肌内注射 ,C组以生理盐水 2ml肌内注射。观察寒战的治疗效果及 6h内寒战复发率。　结果　两组均于静注曲马多后 3min内起效 ,所有病人寒战反应均得到缓解 ,6h内R组均无寒战反应复发 ,C组有 5例再次出现寒战达 2级以上 ,给予追加首次量的 1 2后缓解 ,两组间差异有显著性 (P <0 .0 5 )。　结论　静注加肌注曲马多和氟哌啶可更有效地防治硬膜外麻醉期间的寒战反应。     

全麻复合硬膜外麻醉患者林格氏溶液的容量动力学

目的 通过确定全麻复合硬膜外时麻醉林格氏溶液的容量动力学模型参数，评价硬膜外复合全麻对晶体液扩容效应的影响。方法择期行肝癌切除术患者20例，随机分为2组：组Ⅰ麻醉诱导前行扩容治疗，组Ⅱ硬膜外复合全麻诱导后行扩容治疗。扩容采用30ml／kg乳酸钠林格氏溶液（LR）恒速输注，30min内输完，输注LR开始后90min内每5min测定血红蛋白（Hb）及红细胞压积（Hct），并记录总尿量及血液动力学数据。用容量动力学数学模型和物质守恒定律处理数据，获得结果。结果 组Ⅱ容量增加量、容量扩张效率、输注结束时液体保留率均高于组Ⅰ（P〈0．05）。一级容量动力学分析结果：组Ⅰ目标容积（V）和清除率（k1）均大于组Ⅱ（P〈0．05）。二级容量动力学分析结果：组Ⅱ的V1、k1、k1均高于组Ⅱ（P〈0．05）。扩容后组Ⅱ的平均动脉压、中心静脉压、心输出量均小于组Ⅰ（P〈0．05）。结论 全麻复合硬膜外麻醉可提高晶体液的容量扩张效率。