Ultrasound-Guided Transversus Abdominis Plane Block versus Continuous Wound Infusion for Post-Caesarean Analgesia: A Randomized Trial

Objective

To compare the analgesic effect of ultrasound-guided Transversus Abdominis Plane (TAP) block versus Continuous Wound Infusion (CWI) with levobupivacaine after caesarean delivery.

Methods

We recruited parturients undergoing elective caesareans for this multicenter study. Following written informed consent, they received a spinal anaesthetic without intrathecal morphine for their caesarean section. The postoperative analgesia was randomized to either a bilateral ultrasound guided TAP block (levobupivicaine = 150 mg) or a CWI through an elastomeric pump for 48 hours (levobupivacaine = 150 mg the first day and 12.5 mg/h thereafter). Every woman received regular analgesics along with oral morphine if required. The primary outcome was comparison of the 48-hour area under the curve (AUC) pain scores. Secondary outcomes included morphine consumption, adverse events, and persistent pain one month postoperatively.

Results

Recruitment of 120 women was planned but the study was prematurely terminated due to the occurrence of generalized seizures in one patient of the TAP group. By then, 36 patients with TAP and 29 with CWI had completed the study. AUC of pain at rest and during mobilization were not significantly different: 50 [22.5–80] in TAP versus 50 [27.5–130] in CWI (P = 0.4) and 190 [130–240] versus 160 [112.5–247.5] (P = 0.5), respectively. Morphine consumption (0 [0–20] mg in the TAP group and 10 [0–32.5] mg in the CWI group (P = 0.09)) and persistent pain at one month were similar in both groups (respectively 29.6% and 26.6% (P = 0.73)).

Conclusion

In cases of morphine-free spinal anesthesia for cesarean delivery, no difference between TAP block and CWI for postoperative analgesia was suggested. TAP block may induce seizures in this specific context. Consequently, such a technique after a caesarean section cannot be recommended.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01151943","term_id":"NCT01151943"}}NCT01151943     

超声引导下腹横肌平面阻滞与静脉镇痛在腹股沟疝气手术中的应用价值

摘要 目的：分析超声引导下腹横肌平面阻滞与静脉镇痛在腹股沟疝气手术中的应用价值。方法：选择2019年1月～2020年12月我院的120例腹股沟疝气手术患者为研究对象,按照麻醉镇痛方法的差异分为两组,对照组采用静脉镇痛,观察组采用腹横肌平面阻滞。记录两组患者术中丙泊酚、麻黄碱以及芬太尼的使用剂量以及手术后不同时间的VAS评分和芬太尼追加次数;比较两组术后恶心呕吐的发生率,并比较进食时间、肠道功能恢复时间以及下床活动时间。结果：观察组患者丙泊酚、麻黄碱以及芬太尼的使用剂量均显著少于对照组(P<0.05);观察组疝气手术后1 h(T0)、5 h(T1)、10 h(T2)、1d (T3)、2 d(T4)的VAS评分均明显低于对照组(P<0.05);观察组的芬太尼追加次数为4次/人,明显低于对照组的11次(P<0.05);观察组疝气手术后恶心呕吐的发生率（6.67%）、进食时间、肠道功能恢复时间以及下床活动时间均明显低于对照组(P<0.05)。结论：腹横肌平面阻滞对腹股沟疝气手术后患者的镇痛效果明显优于静脉镇痛,且更有助于促进术后恢复。     

患者静脉自控镇痛与患者硬膜外自控镇痛的比较

术后自控镇痛方法有：患者静脉自控镇痛（Patient-controlled Intravenous Analgesia, PCIA）、患者硬膜外自控镇痛 (Patient-controlled Epidural Analgesia, PCEA）、患者区域自控镇痛（Patient-controlled Regional Analgesia, PCRA)、患者皮下自控镇痛 (Patient-controlled Subcutaneous Analgesia, PCSA)、患者自控鼻内镇痛（Patient-controlled intranasal analgesia, PCINA)、芬太尼HCI 电离子渗入疗法经皮系统（Fentanyl Iontophoretic Transdermal System, ITS)和连续椎旁阻滞（Continuous Paravertebral block, CPVB） 等。目前在临床工作中较常使用的主要是PCIA 和PCEA。有研究报道,与PCIA 比较,PCEA 镇痛效果更确切,恶心、呕吐及嗜睡发 生率低;但也有报道认为,与PCEA 相比,PCIA 实施相对方便,同时也可以提供令患者满意的镇痛效果,适用范围更广。目前对于 这两种镇痛方法的效果优劣尚无确切的定论,在此就PCIA 和PCEA的镇痛药物特点、镇痛效果、副反应及对免疫功能和肿瘤患 者远期生存率的影响作一综述。     

Intravenous Remifentanil versus Epidural Ropivacaine with Sufentanil for Labour Analgesia: A Retrospective Study

Remifentanil with appropriate pharmacological properties seems to be an ideal alternative to epidural analgesia during labour. A retrospective cohort study was undertaken to assess the efficacy and safety of remifentanil intravenous patient-controlled analgesia (IVPCA) compared with epidural analgesia. Medical records of 370 primiparas who received remifentanil IVPCA or epidural analgesia were reviewed. Pain and sedation scores, overall satisfaction, the extent of pain control, maternal side effects and neonatal outcome as primary observational indicators were collected. There was a significant decline of pain scores in both groups. Pain reduction was greater in the epidural group throughout the whole study period (0∼180 min) (P<0.0001), and pain scores in the remifentanil group showed an increasing trend one hour later. The remifentanil group had a lower SpO₂ (P<0.0001) and a higher sedation score (P<0.0001) within 30 min after treatment. The epidural group had a higher overall satisfaction score (3.8±0.4 vs. 3.7±0.6, P = 0.007) and pain relief score (2.9±0.3 vs. 2.8±0.4, P<0.0001) compared with the remifentanil group. There was no significant difference on side effects between the two groups, except that a higher rate of dizziness (1% vs. 21.8%, P<0.0001) was observed during remifentanil analgesia. And logistic regression analysis demonstrated that nausea, vomiting were associated with oxytocin usage and instrumental delivery, and dizziness was associated to the type and duration of analgesia. Neonatal outcomes such as Apgar scores and umbilical-cord blood gas analysis were within the normal range, but umbilical pH and base excess of neonatus in the remifentanil group were significantly lower. Remifentanil IVPCA provides poorer efficacy on labor analgesia than epidural analgesia, with more sedation on parturients and a trend of newborn acidosis. Despite these adverse effects, remifentanil IVPCA can still be an alternative option for labor analgesia under the condition of one-to-one bedside care, continuous monitoring, oxygen supply and preparation for neonatal resuscitation.     

Continuous Epidural Analgesia for Labour and Delivery: Review of 1000 Cases

In six years in London, Ontario, the use of continuous lumbar epidural analgesia in deliveries increased from 5% to over 50%. Its effect was assessed in 1000 consecutive cases, all vertex presentations. In established labour, epidural analgesia was started for pain relief and was maintained with intermittent injections until delivery; in 34% the duration exceeded four hours. Labour was not retarded, but there was an inadvertent selection of patients with slow and painful progress. Forceps delivery was used in 89%, mid-forceps in 11.8% and forceps rotation in 17.7%; 2.4% required Cesarean section. Fetal condition was excellent (Apgar rating of 7 or greater in 96.7%). Postpartum complications could not be directly related to the technique. Continuous epidural analgesia gives superior relief of pain but calls for experienced anesthetists and adjustments in obstetrical management and nursing care.     

静脉与硬膜外注射地塞米松对吗啡硬膜外术后镇痛的影响

目的:比较两种不同途径注射地塞米松磷酸钠对吗啡硬膜外术后镇痛的影响。方法:选择200例(ASAⅠ-Ⅱ)在腰硬联合麻醉下行腹式子宫切除术的患者,随机分为A、B、C、D四组(n=50),各组均给以硬膜外注射2.5 mg吗啡作为术后镇痛治疗的同时,A组静脉注射安慰剂(生理盐水),B组静脉注射地塞米松磷酸钠10 mg,C组静脉注射地塞米松磷酸钠5 mg,D组硬膜外注射地塞米松磷酸钠5 mg及静脉注射安慰剂(生理盐水),以上均以5 mL作为注射容积。观察和比较术后24 h内各组恶心和呕吐(PONV)、皮肤瘙痒、补救镇痛、呼吸抑制的发生率、排气时间和补救镇痛时间。结果:B、C、D三组的PONV总发生率显著低于A组(P0.0083),而B、C、D三组之间比较无显著差异(P0.0083);A、B、C、D四组间恶心的发生率无显著差异(P0.05),而D组呕吐的发生率明显低于A组(P0.0083);B组皮肤瘙痒的发生率明显低于A组(P0.0083);四组患者的VAS评分比较无显著差异,均达到满意的镇痛效果(P0.05)。四组患者补救镇痛的发生率、补救镇痛药量和排气时间比较无明显差异(P0.05),而C、D组的补救镇痛时间明显比A组延长(P0.0083),四组患者均未出现呼吸抑制。结论:地塞米松磷酸钠可降低吗啡硬膜外术后恶心和呕吐的发生率,延长补救镇痛时间;硬膜外注射地塞米松磷酸钠对降低呕吐的发生率更有效;静脉注射地塞米松磷酸钠10 mg可降低瘙痒的发生率,且无明显的不良反应。     

Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study

MethodsFrom January 2010 to December 2012, 587 consecutive cases undergoing McKeown-type esohpageactomy were retrospectively identified from a prospectively maintained database.ResultsAfter propensity-matching, incorporating baseline characteristics, 178 cases were included in each group, and patients characteristics distributions were well-balanced between two groups. Compared with intravenous analgesia, the use of EDA significantly decreased the incidence of pneumonia from 32% to 19.7% (P = 0.008), and anastomotic leakage from 23.0% to 14.0% (P = 0.029). The change in CRP level of EDA group was significantly decreased (preoperative, 6.2 vs. 6.2; POD 1, 108.1 vs. 121.3; POD 3, 131.5 vs. 137.8; POD 7, 69.3 vs. 82.1 mg/L; P = 0.044). EDA patients had a significantly longer duration of indwelling urinary catheter (P<0.001), and lower levels in both systolic (P = 0.001) and diastolic blood pressure (P<0.001). There weren''t significant differences in overall survival (log-rank P = 0.47) and recurrence (Gray-test P = 0.46) between two groups.ConclusionsThese findings revealed that EDA could attenuate inflammatory response and reduce the incidence of pneumonia and anastomotic leakage after esophagectomy, at the price of delayed urinary catheter removal and lower blood pressure. EDA remains an important component of multimodal perioperative management after esophagectomy.     

罗哌卡因切口浸润联合静脉自控镇痛对肝癌肝切除术患者术后镇痛镇静效果及肝功能的影响

摘要 目的：探讨静脉自控镇痛（PCIA）联合罗哌卡因切口浸润对肝癌肝切除术患者术后的镇痛镇静效果及肝功能的影响。方法：选取2017年2月~2019年4月期间我院收治的119例行肝切除术的肝癌患者,根据随机数字表法分为对照组（n=59）和研究组（n=60）,对照组患者术后给予生理盐水联合 PCIA,研究组患者术后给予罗哌卡因切口浸润联合PCIA。比较两组患者术后指标、镇痛镇静效果、肝功能及不良反应。结果：研究组腹腔引流管拔出时间、术后首次下床活动时间、术后住院时间较对照组更短（P<0.05）,术后 PCIA 药物使用量少于对照组（P<0.05）。两组患者术后4 h~术后48 h视觉模拟疼痛评分量表（VAS）评分均呈先升高后降低趋势,且术后12 h、术后24 h、术后48 h研究组VAS评分均低于对照组（P<0.05）;研究组术后12 h、术后24 h、术后48 h Ramsay镇静评分均高于对照组（P<0.05）。两组患者术后3 d丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBIL)水平均升高（P<0.05）。两组患者不良反应发生率比较无统计学差异（P>0.05）。结论：罗哌卡因切口浸润联合PCIA应用于肝癌肝切除术患者术后镇痛,镇静镇痛效果确切,可有效改善术后指标,且不增加肝功能损害,不良反应发生率较低。     

舒芬太尼复合吗啡硬膜外术后镇痛的最佳剂量配伍

目的：观察腹式子宫全切术后硬膜外镇痛应用舒芬太尼复合吗啡时两种药物不同剂量的镇痛效果和不良反应,以寻找其最佳剂量配伍。方法：选择90例美国麻醉医师协会（ASA）标准Ⅰ-Ⅱ级、年龄20-60岁拟行腹式子宫全切术的病人,均实施腰硬联合麻醉。随机分成3组,每组30例：Ⅰ组：舒芬太尼10μg＋吗啡2 mg＋氟哌利多1 mg＋1%罗哌卡因20 mg;Ⅱ组：舒芬太尼15μg＋吗啡1.5 mg＋氟哌利多1 mg＋1%罗哌卡因20 mg;Ⅲ组：舒芬太尼20μg＋吗啡1 mg＋氟哌利多1 mg＋1%罗哌卡因20mg。术中监测生命体征,记录术后24小时内的镇痛效果、不良反应及辅助镇痛药物的使用情况。镇痛效果评价采用视觉模拟评分（visual analogue scale,VAS）标准。结果：2组各个时间点VAS评分均明显低于1组（P〈0.05）,在术后6 h,8 h,12 h,18 h,24 h与3组有统计学差异（P〈0.05）,3组在2 h,4 h,6 h的VAS评分低于1组（P〈0.05）;2组恶心评分与3组相比明显较低（P〈0.05）,其他不良反应三组间没有统计学差异;各组患者在术后24h内辅助镇痛药物使用情况比较无统计学差异（P〉0.05）。结论：舒芬太尼15μg复合吗啡1.5 mg用于腹式子宫全切术后硬膜外镇痛效果优于其他常用剂量配伍,镇痛效果平稳确切且不良反应少,具有临床应用价值。     

硬膜外阻滞复合静脉麻醉与气管插管全身麻醉在腹腔镜胆囊摘除中的护理比较

目的:观察腹腔镜胆囊摘除术(LC)两种不同麻醉方式下患者的不同生理变化用于指导临床护理.方法:LC患者50例,随机均分为两组.Ⅰ组,硬膜外阻滞复合静脉麻醉;Ⅱ组气管插管全身麻醉.观察各时段患者血流动力学变化,术后恶心、呕吐及术后疼痛与镇静情况.结果:Ⅰ组在手术开始后半小时内血流动力学波动较Ⅱ组大(P＜0.01),Ⅱ组在术毕后半小时内血流动力学波动较Ⅰ组大(P＜0.01).且术后恶心、呕吐发生率较Ⅰ组高(P＜0.01),疼痛与镇静效果较Ⅰ组差(P＜0.01).结论:硬膜外阻滞复合静脉麻醉用于腹腔镜的胆囊摘除术,因其术后苏醒期血流动力学改变轻,术后恶心、呕吐发生率低,术后止痛、镇静较完善.在护理上优于气管插管全身麻醉患者.     

吗啡与氢吗啡酮在小儿静脉自控镇痛中的应用效果比较

目的:比较吗啡与氢吗啡酮在小儿静脉自控镇痛(PCIA)应用中的镇痛效果及副作用。方法:选取40名6~10岁择期行下肢骨科手术的患儿,术毕即予PCIA,随机分为两组:M组(吗啡背景剂量15μg/kg/h,PCA剂量15μg/kg)和H组(氢吗啡酮背景剂量3μg/kg/h,PCA剂量3μg/kg),每组20例。记录患儿PCIA后3、6、12、24和48h的FLACC疼痛评分、Ramsay镇静评分、PCA次数及不良反应的发生情况(恶心呕吐、皮肤瘙痒、尿潴留、过度镇静、呼吸抑制)。结果:两组患儿各时间点FLACC疼痛评分、Ramsay镇静评分比较均无统计学差异(P均0.05)。术后第二天,M组PCA次数少于H组,差异存在统计学意义(P0.05)。M组皮肤瘙痒发生率(15%)显著高于H组(0%)(P0.05),两组其余不良反应的发生情况比较均无统计学差异(P均0.05)。结论:氢吗啡酮与吗啡用于小儿术后PCIA的镇痛效果和安全性相当。     

A Comparison of the Analgesia Efficacy and Side Effects of Paravertebral Compared with Epidural Blockade for Thoracotomy: An Updated Meta-Analysis

Objective

The most recent systematic review and meta-analysis comparing the analgesic efficacy and side effects of paravertebral and epidural blockade for thoracotomy was published in 2006. Nine well-designed randomized trials with controversial results have been published since then. The present report constitutes an updated meta-analysis of this issue.

Summary of Background

Thoracotomy is a major surgical procedure and is associated with severe postoperative pain. Epidural analgesia is the gold standard for post-thoracotomy pain management, but has its limitations and contraindications, and paravertebral blockade is increasingly popular. However, it has not been decided whether the analgesic effect of the two methods is comparable, or whether paravertebral blockade leads to a lower incidence of adverse side effects after thoracotomy.

Methods

Two reviewers independently searched the databases PubMed, EMBASE, and the Cochrane Library (last performed on 1 February, 2013) for reports of studies comparing post-thoracotomy epidural analgesia and paravertebral blockade. The same individuals independently extracted data from the appropriate studies.

Result

Eighteen trials involving 777 patients were included in the current analysis. There was no significant difference in pain scores between paravertebral blockade and epidural analgesia at 4–8, 24, 48 hours, and the rates of pulmonary complications and morphine usage during the first 24 hours were also similar. However, paravertebral blockade was better than epidural analgesia in reducing the incidence of urinary retention (p<0.0001), nausea and vomiting (p = 0.01), hypotension (p<0.00001), and rates of failed block were lower in the paravertebral blockade group (p = 0.01).

Conclusions

This meta-analysis showed that PVB can provide comparable pain relief to traditional EPI, and may have a better side-effect profile for pain relief after thoracic surgery. Further high-powered randomized trials are to need to determine whether PVB truly offers any advantages over EPI.     

小剂量纳洛酮硬膜外应用对胃癌术后芬太尼静脉自控镇痛效果及胃肠功能的影响

目的:探讨小剂量纳洛酮硬膜外应用对胃癌术后芬太尼静脉自控镇痛效果及胃肠功能的影响。方法:选取我院2010年7月-2015年7月收治的110例胃癌患者为研究对象,将所有患者随机分为试验组和对照组各55例,两组患者均行根治性肿瘤切除术,术后采用芬太尼静脉自控镇痛,试验组于术后硬膜外注入小剂量纳洛酮,对照组注入等量的生理盐水,对两组术后不同时间点(4 h、8 h、12 h、24 h)疼痛程度进行评分,对比两组肠鸣音恢复时间、肛门排气时间、肛门排便时间、胃动力恢复时间,镇痛泵药物消耗量及并发症发生率。结果:术后4 h,试验组疼痛评分明显低于对照组(P0.05),术后8 h、12 h两组患者的疼痛评分均有显著上升(P0.05),且试验组患者的疼痛评分均远低于对照组(均P0.05),术后24 h,试验组与术后12 h比较差异无统计学意义(P0.05),对照组术后24 h疼痛评分与术后12 h分相比有显著差异(P0.01);试验组患者肠鸣音恢复时间、肛门排气时间、肛门排便时间、胃动力恢复时间、镇痛泵药物消耗量、芬太尼用量均远远低于对照组(P0.05);试验组并发症总发生率(7.27%)远远低于对照组(23.64%),差异具有统计学意义(P0.05)。结论:采用小剂量纳洛酮硬膜外应用方法辅助术后镇痛可以有效的减轻患者的疼痛,降低并发症的发生率,促进胃肠功能恢复,疗效显著,值得在临床上推广使用。     

超前镇痛对VATS肺叶切除患者阿片类药物使用的影响

目的:探讨术前应用对乙酰氨基酚和加巴喷丁对电视辅助胸腔镜肺叶切除患者术后阿片类药物使用、恶心呕吐的影响。方法:收集2016年1月至2018年12月因非小细胞肺癌就诊于我科行电视辅助胸腔镜肺叶切除的患者,收集患者临床资料包括年龄、性别、BMI、合并症、美国麻醉医师协会麻醉分级、肿瘤分级、肿瘤部位、手术时间,术中和术后阿片类药物使用情况、术后止吐药使用情况,阿片类药物使用均换算为口服吗啡当量,根据术前是否采用对乙酰氨基酚和加巴喷丁超前镇痛方案将患者分为两组,比较两组患者术前基本情况及术中术后阿片类药物使用情况,分析对乙酰氨基酚和加巴喷丁超前镇痛方案对阿片类药物使用情况的影响。结果:共有241例患者纳入研究,有78例患者术前采用对乙酰氨基酚和加巴喷丁超前镇痛方案,163例患者没有采用该镇痛方案,超前镇痛组患者术中及术后阿片类药物使用剂量、术后24小时呕吐次数、术后止吐药使用剂量均低于没有采用超前镇痛方案的患者,两组患者术后NSAIDs使用和镇静状态没有统计学差异。结论:术前采用对乙酰氨基酚和加巴喷丁超前镇痛方案可减少行电视辅助胸腔镜肺叶切除患者术中及术后阿片类药物使用剂量,降低术后恶心呕吐的发生。     

中药穴位贴敷联合硬膜外镇痛泵对老年髋关节骨折患者镇痛效果的影响

目的:探讨中药穴位贴敷联合硬膜外镇痛泵对老年髋关节骨折患者镇痛效果的影响。方法:选取2012年2月至2019年2月西安交通大学附属红会医院中医骨科80例老年髋关节骨折患者为研究对象,根据入院顺序,随机化原则将受试者分为对照组和研究组,每组40例,对照组患者术后均给予硬膜外镇痛泵止痛,研究组患者在对照组的基础上联合中药穴位贴敷止痛,比较两组患者术后的疼痛程度、疼痛相关指标、手术前后血清β-内啡肽水平变化及术后镇痛不良反应发生率。结果:研究组患者在术后1 d、3 d、7 d静息状态及活动状态的近期视觉模拟评分(Visual analogue scale, VAS)均显著低于对照组(P0.05),研究组患者疼痛时间、爆发痛次数、术后24 h按压镇痛泵次数、睡眠时间及止痛剂用量均显著少于对照组(P0.05),术后首次按压镇痛泵时间显著长于对照组(P0.05),术前两组患者的血清β-内啡肽水平比较无统计学差异(P0.05),术后24 h及48 h研究组患者的血清β-内啡肽水平均显著高于对照组(P0.05),两组术后镇痛不良反应发生率比较无统计学差异(P0.05)。结论:中药穴位贴敷联合硬膜外镇痛泵可有效缓解术后疼痛,减少止痛剂用量,提高患者睡眠质量及血清β-内啡肽水平,对促进髋关节骨折患者术后康复具有积极意义。     

连续股神经阻滞与静脉自控镇痛对全膝关节置换术后患者凝血功能的影响

目的:比较连续股神经阻滞(CFNB)与静脉自控镇痛(PCIA)在全膝关节置换术中的应用效果及对患者凝血功能的影响。方法:选取2014年1月至2015年12月间我院行单侧全膝关节置换术的患者80例,按照随机数字表法分为CFNB组和PCIA组,每组各40例,两组患者分别接受CFNB和PCIA治疗。观察两组患者术后6 h、12 h、24 h、48 h视觉模拟疼痛评分(VAS),两组患者分别于麻醉前(T1)、术毕(T2)、术后1 d(T3)、术后2 d(T4)进行血栓弹力图检查,观察两组凝血功能变化。并于术后随访1年,比较两组患者膝关节功能。结果:术后6 h、12 h、24 h、48 h CFNB组患者VAS评分显著低于PCIA组患者(P0.05)。T2、T3、T4时点CFNB组患者凝血反应时间(R)、血凝块形成时间(K)较T1升高,血凝块聚合形成速率(α角)、血凝块最大振幅(MA)较T1降低,PCIA组患者R、K较T1降低,α角、MA较T1升高,T2、T3、T4时点CFNB组患者R、K高于PCIA组患者,α角、MA低于PCIA组患者,差异均有统计学意义(P0.05)。两组患者术后均完成1年的随访,两组患者KSS评分、膝关节最大屈曲度、膝关节最大伸直度比较无统计学差异(P0.05)。结论:CFNB对于全膝关节置换术术后患者镇痛效果优于PCIA,有利于改善患者凝血功能,不影响术后患者膝关节功能的恢复。