【摘要】 目的 探討腰硬聯合麻醉復合丙泊酚恒速輸注清醒鎮靜的可行性、理想的藥物劑量、術中知曉情況以及麻醉質量和效果。 方法 收集2009年3-12月480例美國麻醉醫師協會（ASA）Ⅰ～Ⅲ級擬在腰硬聯合麻醉下行下腹部、會陰部、下肢手術的患者480例，隨機分為咪達唑侖組（M組）、丙泊酚Ⅰ組（PA組）、丙泊酚Ⅱ組（PB組）、丙泊酚Ⅲ組（PC組），每組各120例。四組患者均于腰2-3或腰3-4行腰硬聯合麻醉，蛛網膜下腔注入輕比重0.2 %布比卡因12～15 mg，麻醉平面確切后，M組予以咪達唑侖0.04~0.06 mg/kg，PA組先予以負荷量丙泊酚0.50 mg/kg再以2.00 mg/（kg?h）劑量持續泵注，PB組予以負荷量丙泊酚0.75 mg/kg再以3.00 mg/（kg?h）劑量持續泵注，PC組予以負荷量丙泊酚1.00 mg/kg再以3.75 mg/（kg?h）劑量持續泵注。觀察患者給藥前（T0）、給藥1（T1）、3（T2）、5（T3）、10（T4）、30（T5）、60 min（T6）各時點血流動力學平均動脈血壓（MAP）、心率（HR）的變化、腦電雙頻指數（BIS）值及鎮靜評分、術中所看到的圖片的回憶及不良反應。 結果 各組在給予鎮靜藥后MAP、HR均有所下降，但測量值的變化在正常范圍內；在T3時間點，各組BIS值及鎮靜/警醒OAA/S評分降低，與T0比較，差異有統計學意義（Plt;0.05）；與其他3組比較，在T4、T5、T6時點PC組BIS值與OAA/S評分降低，差異有統計學意義（Plt;0.05），PC組的鎮靜遺忘滿意率高于其他3組；各組間未見發生嚴重的舌后墜、呼吸暫停和血氧飽和度（SpO2）lt;90%。 結論 在下腹部、下肢手術中，應用腰硬聯合麻醉復合1.00 mg/kg負荷量的丙泊酚繼而以3.75 mg/（kg?h）劑量持續泵注，可取得良好的鎮靜效果，不良反應小。【Abstract】 Objective To investigate the feasibility, ideal dose, intra-operative awareness as well as the quality and effectiveness of constant infusion of propofol under combined spinal-epidural anesthesia (CSEA) for conscious sedation. Methods A total of 480 patients at ASA grade Ⅰ-Ⅲ to be operated in the lower abdomen, perineum and lower limbs under CSEA from March to December 2009 were randomly divided into four groups: midazolam group (M group), propofol group Ⅰ (PA group), propofol group Ⅱ (PB group), and propofol group Ⅲ (PC group), with 120 patients in each group. All four groups of patients underwent CSEA at L2-3 or L3-4 and accepted pinal injection of 12-15 mg of 0.2% hypobaric bupivacaine. After the anesthetic plane was confirmed, patients in M group accepted 0.04-0.06 mg/kg of midazolam; patients in PA group accepted propofol at a loading dose of 0.50 mg/kg followed by continuous infusion at a dose of 2.00 mg/(kg?h); patients in PB group accepted propofol at a loading dose of 0.75 mg/kg followed by continuous infusion at a dose of 3.00 mg/(kg?h); patients in PC group accepted propofol at a loading dose of 1.00 mg/kg followed by continuous infusion at a dose of 3.75 mg/(kg?h). The change of hemodynamics including the mean arterial pressure (MAP) and the heart rate (HR), bispectral index (BIS) values, sedation scores, memory of pictures seen during operation and adverse effects before drug administration (T0), at minute 1 (T1), 3 (T2), 5 (T3), 10 (T4), 30 (T5) and 60 (T6) after drug administration were observed. Results MAP and HR decreased in all the four groups after administration of sedatives, but the changes of measured values were within normal ranges. BIS value and the Observer’s Assessment of Alertness and Sedation (OAA/S) scale decreased in all groups at T3, compared with those at T0 (Plt;0.05). Compared with the other 3 groups, BIS valueand OAA/S scale were significantly lower in PC group at T4, T5 and T6 (Plt;0.05), and the satisfaction rate of sedation and amnesia was much higher. No serious glossocoma, apnea and SpO2 below 90% was observed in all the four groups. Conclusion During the surgery of lower abdomen and lower limbs, application of CSEA combined with propofol at a loading dose of 1.00 mg/kg followed by continuous infusion at a dose of 3.75 mg/(kg?h) can achieve a good sedative effect, with little side effect.
ObjectiveTo review the clinical research progress of spinal epidural lipomatosis (SEL). Methods The clinical studies on SEL at home and abroad in recent years were extensively reviewed, and the pathogenesis, clinical and imaging manifestations, and treatment status of SEL were summarized and analyzed. ResultsSEL is a disease characterized by compression of the spinal cord and nerve roots due to abnormal accumulation of epidural adipose tissue in the spinal canal. Its prevalence and diagnosis rate are low and the pathogenesis is not fully understood. MRI is the most sensitive and specific diagnostic test for SEL. Surgical decompression and removal of excess adipose tissue are the only options for patients with acute SEL or those who have failed conservative management, and conservative management should be considered for other patients. ConclusionSEL is a rare disease and related research still needs to be improved. In the future, high-quality, multi-center and large-sample studies will be of great significance for evaluating the choice of treatment methods and effectiveness of SEL patients.
Objective To evaluate the effectiveness of intravenous patient-controlled analgesia versus epidural patient-controlled analgesia for postoperative analgesia, sedation, and the incidence of side effects. Methods We searched the specialized trials registered in the Cochrane anesthesia group, The Cochrane Library (CCTR), MEDLINE (1966 to Sept. 2008), EMbase (1966 to Sept. 2008), PubMed (1966 to Sept. 2008), and handsearched some Chinese anesthesia Journals and Clinical anesthesia journals. Randomized controlled trials (RCTs) and quasi-RCTs of intravenous versus epidural analgesia for post-operation were included. The quality of the trials was critically assessed. RevMan 4.2.8 software was used for meta-analyses. Results Thirteen RCTs involving 580 patients of intravenous versus epidural analgesia for post-operation were included. The results of meta-analyses showed that there were no significant differences in postoperative analgesia and sedation at the hour-points of 2nd, 4th, 8th, 12th, and 24th hours after operation. There were no significant differences in plasma fentanyl concentration in the two groups on the same analgesia effects. There were also no significant differences in side effects. Conclusion Both intravenous patient-controlled analgesia and epidural patient-controlled analgesia have the same clinical effects. Compared with epidural patient-controlled analgesia, intravenous patient-controlled analgesia has fewer side effects and is more convenient. At the same time, it can reduce more costs of hospitalization. But because of the low quality and small sample size of the included studies, more well-designed, large scale, randomized controlled trials are needed.
【摘要】 目的 比較術后芬太尼皮下鎮痛（PCSA）與硬膜外鎮痛（PCEA）的臨床效果，以及對胃腸功能的影響。 方法 2009年1-6月間觀察擇期硬膜外麻醉下經腹子宮切除術患者120例，術后分別實施PCSA與PCEA，觀察術后第4、8、12、24、48 h的鎮痛、鎮靜情況，呼吸循環、惡心嘔吐及其他不良事件，記錄術后首次肛門排氣時間，測評術后鎮痛滿意度。 結果 術后兩組患者鎮痛優良率均在90%以上，各時點鎮痛評分、鎮靜評分、惡心嘔吐發生率、首次肛門排氣時間以及患者鎮痛優良率差異均無統計學意義（Pgt;0.05）。 結論 術后芬太尼PCSA與PCEA一樣，效果確切，對術后胃腸功能無明顯影響，患者滿意，是一種安全、有效的鎮痛方法。【Abstract】 Objective To compare clinical efficiency and gastrointestinal reaction of subcutaneous patient-controlled analgesia (PCSA) and epidural patient-controlled analgesia (PCEA) with fentanyl analgesic for patients after operation. Methods A total of 120 patients having undergone transabdominal hysterectomy under epidural anesthesia between January and June 2009 accepted PCSA or PCEA after operation. We evaluated the state of analgesia and sedation at the 4th, 8th, 12th, 24th and 48th hour after operation. We also looked into the respiration, blood circulation, nausea, vomiting and other abnormal events of the patients during the first 48 hours after operation. At the same time, we recorded the first time of anal exsufflation after operation and the degree of patients’ satisfaction. Results The analgesic effective rate was higher than 90% in both groups. There were no significant differences in analgesia and sedation scores at above-mentioned points after operation, incidence of nausea and vomiting, first time of anal exsufflation or analgesic effective rate between the two groups. Conclusion PCSA with fentanyl can be as effective in relieving postoperative pain as PCEA with fentanyl without obvious adverse effect in the gastrointestinal function. Therefore, PCSA is a safe and effective method to alleviate postoperative pain.
Objective To determine the ability of the polyactic acid glue (PLA-G) in preventing epidural adhesion after laminectomy. Methods Each of the 24 randomly selected rats was done laminectomyof L2 and L5. The PLA-G, which would change from liquid to solid when meets with serum, was used in the epidural site of L5 to become a half-solid membrane(the experimental group, EG). The PLA-G was not used in the same site of L2(the control group, CG) .The gross anatomical, histological, and microscopical evaluation were made 2，4，6，8，10 and 12 weeks after operation; electron microscope observation was also made on two rats 4 weeks after operation(both EG and CG). Results Obvious epidural space was observed between dura mater and scar tissue(ST), but no cells in the epidural space were observed inEG 2 weeks after operation. Corps of the red cells between dura mater and ST and proliferation of fibroblast cell(FB) were observed in CG 2 weeks after operation. Some remaining glue shiver in the epidural space with lightly increasing fibroblast and smooth dura mater were observed in EG 4 weeks after operation. However, fragile scar conglutinated with dura mater diffusely and more FB were observed in CG. From the 6th week to the 12th week, a potential interspace between scar and dura mater was observed and PLA glue was absorbed completely in EG. However, tougher scar, which was very difficult to dissect from dura mater and surrounding tissues, was observed. According to the fibroblast ultrastructure observation, bigger nucleus and more plentiful rough endoplasmic reticulum were observed in CG. Conclusion The PLA-G can effectively reduce the epidural scar and adhesion in animal experiment.
【摘要】 目的 比較舒芬太尼與等效劑量芬太尼在髖關節置換術后患者硬膜外鎮痛的臨床效果。 方法 2006年11月-2008年9月收治的50例硬膜外麻醉下髖關節置換術患者，隨機分為兩組（n=25）。芬太尼組（A組）:芬太尼0.75 mg加0.894%甲磺酸哌卡因20 mL加生理鹽水至100 mL；舒芬太尼組（B組），舒芬太尼75 μg加0.894%甲磺酸哌卡因20 mL加生理鹽水至100 mL硬膜外鎮痛。其中，A組患者于手術結束時，靜脈滴注格拉司瓊3 mg。持續劑量2 mL/h，單次給藥量（PCA）0.5 mL/次，鎖定時間15 min。觀察兩組的鎮痛效果，惡心、嘔吐次數，記錄脈搏血氧飽和度、心率、呼吸的變化。 結果 鎮痛泵開機后，B組各時段鎮靜評分，2分以上者明顯多于A組，鎮痛評分明顯低于A組，有統計學意義（Plt;0.05），兩組術后惡心、嘔吐發生率都較低，組間差異無統計學意義（Pgt;0.05）。兩組4、12、24 h的呼吸頻率和脈搏血氧飽和度差異有統計學意義（Plt;0.05），但48 h的呼吸頻率和脈搏血氧飽和度無統計學意義（Pgt;0.05）。 結論 在等效劑量下，髖關節置換術后患者硬膜外鎮痛，舒芬太尼明顯優于芬太尼。【Abstract】 Objective To compare the clinical effect of epidural analgesia with sufentanil and fentanyl in an equivalent dose after hip replacement. Methods From December 2006 to September 2008, fifty cases of epidural anesthesia after hip replacement were randomly divided into two groups, each group had 25 cases. Group A (fentanyl group): fentanyl mesylate 0.75 mg+0.894% ropivacaine 20 mL+0.9% sodium chloride solution to 100 mL; group B (sufentanil group): sufentanil 75 μg+0.894% ropivacaine mesylate 20 mL+0.9% sodium chloride solution to 100 mL epidural analgesia. Patients in group A received intravenous infusion of granisetron 3 mg at the end of surgery. Continuous dose was 2 mL/h, with the volume of single dose (PCA) 0.5 mL per time and lockout time of 15 minutes. The analgesic effect, nausea, and vomiting frequency were observed, and the pulse oxygen saturation, heart rate, and breathing changes were recorded. Results After boot analgesia, S sedation scores for each phase and pain score in group B were significantly different compared with those in group A (Plt;0.05). Both groups had low incidence of nausea and vomiting, and the difference was not statistically significant (Pgt;0.05). The difference of respiratory rate and pulse oxygen saturation at 4 h, 12 h, 24 h was statistically significant between two groups (Plt;0.05), but at 48 h the difference was not significant (Pgt;0.05). Conclusion In the equivalent dose, epidural analgesia with sufentanil in the patients with hip replacement is superior to fentanyl.
Objective To study the effect of the allogeneic bone sheet that has been treated by the freezedrying and radiation sterilization in preventing the epidural adhesion after laminectomy in sheep. Methods Laminectomy was performed on L3,4and L4,5 of 12 adult male sheep. Afteroperation, one site of L3,4 or L4,5was covered by the allogeneicbone sheet in “H” shape after the freeze-drying and radiation sterilization treatment; and the other site was used as a control. The sheep were killed and the specimens were retrieved at 4，8，12，16，20 and 24 weeks after operation to observe the scar formation process. X-ray andCT scan were performed in the segments of L3,4and L4,5at 4 and 24weeks. Results Four weeks after operation, the position and the shape of the allogeneic bone sheet were good in condition, and no lumbar spinal stenosis or compression of the dura was found in the experimental sections. Twentyfour weeks after operation theexamination on the experimental sections revealed that the vertebral canal reconstruction was completed, the allograft was absorbed almost completely, and inosculation with the lamina of the vertebra and the shape of the lumbar spine were good, with no fibroid tissues found in the epidural area. Compared with the control segment, the dura adhesion degree in the laminoplasty segment was significantly decreased (Plt;0.01), and the dura sac remained in a good shape. There was no obvious compression on the dura. Conclusion The allogeneic bone sheet after the treatment of freeze-drying and radiation sterilization can effectively reduce the scar formation after laminectomy and prevent postoperative recurrence of the spinal stenosis.
Objective To investigate the clinical effect of polylactic acid membrane in prevention of epidural scar and adhesion. Methods From July 1998 to April 2000, 62 patients with lumbar disc herniation were randomly assigned into two groups. All were treated surgically with discectomy by fenestration or laminectomy.One group were placed with a thin of polylactic acid membrane covering the interlaminar space(n=32). The thickness of the film was 0.1mm. The other group was blank control(n=30). After 2 weeks of operation, we observed the local and systemic reactions. After 6 months clinical symptoms were revaluated and the degrees of epidural scar and adhesion were determined by CT scans. Results After 2 weeks, we found no adverse systemic reactions in all patients. Wound healing was excellent. No abnormalities of hepatic and renal functions as well as blood for routine were found. Temperature after operation was normal. After 6 months, the curative effects were as follows in experimental group and in control group: excellent in 27 patients and in 24 patients, good in 4 patients and in 4 patients, fair in 1 patient and in 1 patient, and poor in 0 patient and in 1 patient, respectively. There are no significant difference between two groups. The CT scans showed no adhesion between the epidural scar and the dural sac in all patients of experimental group. There existed various extents of adhesion in control group. Conclusion The results demonstrate that the polylactic acidmembrane can effectively prevent the epidural scar adhesion with a good biocompatibility and no toxity. Its clinical application was promising.