β-endorphin in the brain. A role in nociception

We have known the endogenous opioid peptide β-endorphin for 20 years. Surprisingly, our knowledge of the physiological role of this peptide and its receptors in modulation of pain perception is still fragmentary. Whereas most studies have tried to elucidate the physiological role of β-endorphin by reversing evoked responses by the opioid antagonist naloxone, this review focuses on quantification of release of β-endorphin in the brain as the approach to define physiological and pathophysiological roles of β-endorphin in relation to nociception. Using a lateral ventricle-cisterna magna perfusion model in the anesthetized rat, it was shown that depolarization of neurons in the arcuate nucleus of the hypothalamus, where β-endorphin is produced, was followed by release of β-endorphin to the cerebrospinal fluid compartment. Intense activation of spinal nociceptive pathways by intrathecal capsaicin injections also led to β-endorphin release. It is concluded that there may still be good reason to quantify β-endorphin in human cerebrospinal fluid to elucidate the role of β-endorphin in pain perception.     

An epidural abscess due to resistant Staphylococcus aureus following epidural catheterisation

We report a case of abscess formation after epidural analgesia, a rare complication that developed in our patient 13 days after placement of a thoracic epidural catheter for patient controlled analgesia. Culture of the pus grew methicillin-resistant Staphylococcus aureus . Although early diagnosis and rapid management have been reported to yield a satisfactory outcome, the case we describe ended in severe sequelae.     

Long QT interval syndrome with increased QT dispersion

This case report describes the anaesthetic management of a patient with sporadic-type long QT interval syndrome (LQTS), and increased QT dispersion, who presented for removal of an ovarian cyst. Beta adrenergic blockade and adequate depth of anaesthesia for successful management is emphasized. The Successful use of epidural administration of lignocaine and opioids in addition to general anaesthesia is described.     

Decreased incidence of headache after accidental dural puncture in caesarean delivery patients receiving continuous postoperative intrathecal analgesia

To examine the effects of prolonged (> 24 h) intrathecal catheterization with the use of postoperative analgesia on the incidence of post–dural puncture headache (PDPH), charts of 45 obstetric patients who had accidental dural puncture following attempts at epidural block were reviewed retrospectively. Three groups were identified: Group I (n = 15) patients had a dural puncture on the first attempt at epidural block, but successful epidural block on a repeated attempt; Group II (n=17) patients had a dural puncture with immediate conversion to continuous spinal anaesthesia with catheterization lasting only for the duration of caesarean delivery; Group III (n= 13) patients had an immediate conversion to spinal anaesthesia and received post–caesarean section continuous intrathecal patient–controlled analgesia consisting of fentanyl 5 (ig'ml^-1 with bupivacaine 0.25 mg·ml^-1 and epinephrine 2 μg·ml^-1 with catheterization lasting >24 h. No parturient in group III developed a PDPH. This was substantially lower ( P < 0.009) than the 33% incidence for group I and the 47% incidence for group II. The incidence of a PDPH did not differ between group I and II. Similarly, there was no difference between group I and II with regard to requests for a blood patch. Patients receiving continuous intrathecal analgesia had excellent pain relief, could easily ambulate and none complained of pruritus, nausea, vomiting, sensory loss or weakness. In conclusion, indwelling spinal catheterization > 24 h with continuous intrathecal analgesia following accidental dural puncture in parturients may for some patients be a suitable method for providing PDPH prophylaxis and postoperative analgesia.     

硬膜外腔阻滞对胸部手术应激反应的影响

目的 观察硬膜外腔阻滞对胸部手术应激激素和细胞因子的影响。方法20例食管癌手术病人,随机分为两组,每组10例,即全麻复令硬膜外腔阻滞(GEA)组和全麻(GA)组,分别测定麻醉诱导前、手术2h、手术4h、术毕、术后1d及术后3d的血浆去甲肾上腺素、肾上腺素、血清促肾上腺皮质激素(ACTH)、皮质醇、C-反应蛋白、IL-6及IL-10的水平。结果 血浆去甲肾上腺素和血清皮质醇GEA组术中术后无显著改变,但GA组术毕和术后1d显著升高(P<0.05),术后3d恢复至术前水平,组间比较前者有显著差异(P<0.05)。两组血浆肾上腺素、IL-10术中术后均无显著变化。两组血清ACTH、IL-6及CRP术中术后均显著升高(P<0.05),组间比较无显著差异。结论 硬膜外腔阻滞可以减轻胸部手术的应激反应。IL-6是较CRP更灵敏的反映组织损伤的炎性指标。     

碳酸利多卡因硬膜外麻醉用于乳腺癌根治术的评价

40例乳腺癌根治术患者，美国麻醉医师协会（ASA）分级Ⅰ-Ⅱ级，随机分为2且，第1组硬膜外阻滞＋臂丛神经阻滞，应用1．33％盐酸利多卡因＋0．15％盐酸地卡因＋1：20万肾上腺素，硬膜外阻滞首量12ml，臂丛神经阻滞20ml;第2组硬膜外阻滞，应用1．73％碳酸利多卡因＋1：20万肾上腺素，首量15ml。两组硬膜外阻滞选为T4－5间隙穿刺。首量给完后测定麻醉药效，并监测患者心率（HR）、平均动脉压（MAP）、血氧饱和度（SpO2)，在麻醉前、后30、60、120min抽取动脉血作血气分析。结果显示：第2组麻醉的起效时间、阻滞完善时间要比第1组短（P＜0．01）。感觉神经阻滞分段数要比第1组多（P＜0．01）；两组病人的HR和MAP，麻醉手术中改变不明显。麻醉后面罩给氧。两组病人的SpO2、PaO2增加，PaCO2有所下降，两组比较无统计学意义，但组内前后对照有显著差异（P＜0．05）。结果提示碳酸利多卡因硬膜外麻醉下施行乳腺癌根治术具有良好的麻醉效果和更高的安全性。     

不同麻醉方法对28例胃癌手术患者红细胞醛糖还原酶及血浆一氧化氮的影响

目的:观察不同麻醉方法对胃癌手术患者红细胞醛糖还原酶(AR)活性及血浆一氧化氮(NO)浓度的影响。方法:28例胃癌手术患者随机分为两组,组1吸入1.5～2.0最小肺泡吸入有效浓度(MAC)的异氟醚,组2为0.5～1.0MAC异氟醚复合硬膜外麻醉。分别于麻醉前30min、手术90min、术后60min、术后1天和术后2天5个时间点抽取静脉血,测定血糖浓度、红细胞AR活性及血浆NO浓度。结果:与麻醉前值相比,组1病人血糖浓度于手术90min、术后60min、术后1天明显升高(P<0.05或P<0.01);术后1天红细胞AR活性明显升高(P<0.05),同时血浆NO浓度显著下降(P<0.05)。组2病人血糖浓度于手术90min、术后60min显著升高(P<0.01);红细胞AR活性及血浆NO浓度,虽有与组1病人相似的变化趋势,但与麻醉前值相比,各时间点无明显变化。术后1天组1病人红细胞AR活性明显高于组2(P<0.05),而血浆NO浓度则相反(P<0.05),两组间血糖无明显差异。结论:胃癌手术病人在应激高血糖状态下,红细胞多元醇途径被激活的同时血浆NO合成受抑制。全麻联合硬膜外阻滞能较好抑制这一改变。     

儿童硬膜外血肿的治疗

目的 探讨儿童硬膜外血肿的临床特点及其治疗方法。方法 回顾性分析我院2001年1月～2003年12月收治的儿童硬膜外血肿120例。结果 婴幼儿和学龄前儿童受伤原因以坠落伤及摔伤为主，7岁以上儿童以交通伤为主。65.8％(79/120)的患儿合并有颅骨骨折，格拉斯哥昏迷评分(GCS)平均13．6分。急性血肿除立即手术者外，其他于首次发现血肿1d后及3d左右再复查CT。手术者占57.5％(69/120)，术中发现血肿来源于板障出血的占44％(29/66)。结论 儿童硬膜外血肿的原发颅脑损伤相对较轻，颅骨骨折的发生率低于成人，板障出血为血肿形成的首要原因。有必要做多次CT检查，经恰当治疗预后良好。     

Rebound intracranial hypertension after treatment of spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is characterized by orthostatic headache and the cause is usually cerebrospinal fluid leaks in spine level. Most patients with SIH have a benign course. Epidural blood patch (EBP) is the treatment of choice when initial conservative managements are ineffective. We reported a patient with SIH diagnosed by using magnetic resonance imaging and radionuclide cisternography. Acute rebound intracranial hypertension developed after EBP and was successfully treated with intravenous osmotic agent.     

Misoprostol in preventing postpartum hemorrhage: a meta-analysis.

OBJECTIVE: To assess misoprostol's ability to prevent postpartum hemorrhage (PPH) where no alternatives exist. Comparison to oxytocics demonstrates how similarly misoprostol achieves a level of effectiveness-obtainable only in hospitals-in remote locations around the world. METHOD: Using the Mantel-Haenszel fixed-effects model and the DerSirmonian and Laird random-effects model, summary statistics indicated that misoprostol's excess risk of PPH was only 4% when compared to oxytocics. RESULT: This risk difference was well within the range of expected results for all uterotonic agents and does not warrant branding misoprostol as an inferior drug. CONCLUSION: Conventional uterotonic drugs should not be used to set the lowest-accepted level of effectiveness in settings where they are entirely unsuitable. Continuing to weigh the benefits of one effective drug against another only delays the distribution of misoprostol in countries where it is the only feasible choice and must be measured against no treatment at all.