硬膜外麻醉分娩镇痛临床分析

目的:观察硬膜外麻醉用于分娩镇痛的效果及对产程、母婴的影响.方法:选择300例足月单胎、产前检查无阴道分娩禁忌、无椎管内硬膜穿刺禁忌的初产妇.ASA Ⅰ-Ⅱ级,随机分为硬膜外麻醉作为观察组,自然分娩组作为对照组,每组150例.观察产妇的生命体征,镇痛效果、产程时间、产后出血量、分娩方式、新生儿Apgar评分.结果:观察组产妇镇痛有效率为95.33%,活跃期与对照组相比明显缩短(p＜0.01),第二产程时间及产后出血量与对照组相比无显著差异(P＞0.05),剖宫产率明显低于对照组的剖宫产率(P＜0.05);两组新生儿Apgar评分均无统计学差异(P＞0.05).结论:硬膜外麻醉镇痛效果确切,相对安全,是目前分娩镇痛的理想方法.     

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.     

Comparison of Transversus Abdominis Plane Infiltration with Liposomal Bupivacaine versus Continuous Epidural Analgesia versus Intravenous Opioid Analgesia

Epidural analgesia is considered the standard of care but cannot be provided to all patients Liposomal bupivacaine has been approved for field blocks such as transversus abdominis plane (TAP) blocks but has not been clinically compared against other modalities. In this retrospective propensity matched cohort study we thus tested the primary hypothesis that TAP infiltration are noninferior (not worse) to continuous epidural analgesia and superior (better) to intravenous opioid analgesia in patients recovering from major lower abdominal surgery. 318 patients were propensity matched on 18 potential factors among three groups (106 per group): 1) TAP infiltration with bupivacaine liposome; 2) continuous Epidural analgesia with plain bupivacaine; and; 3) intravenous patient-controlled analgesia (IV PCA). We claimed TAP noninferior (not worse) over Epidural if TAP was noninferior (not worse) on total morphine-equivalent opioid and time-weighted average pain score (10-point scale) within first 72 hours after surgery with noninferiority deltas of 1 (10-point scale) for pain and an increase less of 20% in the mean morphine equivalent opioid consumption. We claimed TAP or Epidural groups superior (better) over IV PCA if TAP or Epidural was superior on opioid consumption and at least noninferior on pain outcome. Multivariable linear regressions within the propensity-matched cohorts were used to model total morphine-equivalent opioid dose and time-weighted average pain score within first 72 hours after surgery; joint hypothesis framework was used for formal testing. TAP infiltration were noninferior to Epidural on both primary outcomes (p<0.001). TAP infiltration were noninferior to IV PCA on pain scores (p = 0.001) but we did not find superiority on opioid consumption (p = 0.37). We did not find noninferiority of Epidural over IV PCA on pain scores (P = 0.13) and nor did we find superiority on opioid consumption (P = 0.98). TAP infiltration with liposomal bupivacaine and continuous epidural analgesia were similar in terms of pain and opioid consumption, and not worse in pain compared with IV PCA. TAP infiltrations might be a reasonable alternative to epidural analgesia in abdominal surgical patients. A large randomized trial comparing these techniques is justified.     

Differential Effects of Epidural Analgesia on Modes of Delivery and Perinatal Outcomes between Nulliparous and Multiparous Women: A Retrospective Cohort Study

Background

Epidural analgesia is considered one of the most effective methods for pain relief during labor. However, it is not clear whether similar effects of epidural analgesia on the progression of labor, modes of delivery, and perinatal outcomes exist between nulliparous and multiparous women.

Methodology/Principal Findings

A retrospective cohort study was conducted to analyze all deliveries after 37 weeks of gestation, with the exclusion of pregnancies complicated by multiple gestations and fetal anomalies and deliveries without trials of labor; these criteria produced a study population of n=16,852. A multivariable logistic regression model was constructed to control for confounders. In total, 7260 of 10,175 (71.4%) nulliparous and 2987 of 6677 (44.7%) multiparous parturients were administered epidural analgesia. The independent factors for intrapartum epidural analgesia included a low prepregnancy body mass index, genetic amniocentesis, group B streptococcal colonization of the genito-rectal tract, and augmentation and induction of labor. In the nulliparous women, epidural analgesia was a significant risk factor for operative vaginal delivery (adjusted odds ratio [OR] 2.14, 95% confidence interval [CI] 1.80-2.54); however, it was a protective factor against Caesarean delivery (adjusted OR 0.62, 95% CI 0.55-0.69). Epidural analgesia remained a significant risk factor for operative vaginal delivery (adjusted OR 2.17, 95% CI 1.58-2.97) but not for Caesarean delivery (adjusted OR 1.09, 95% CI 0.77-1.55) in the multiparous women. Furthermore, the women who were administered epidural analgesia during the trials of labor had similar rates of adverse perinatal outcomes compared with the women who were not administered epidural analgesia, except that a higher rate of 1-minute Apgar scores less than 7 was noted in the nulliparous women who were administered epidural analgesia.

Conclusions/Significance

Intrapartum epidural analgesia has differential effects on the modes of delivery between nulliparous and multiparous women, and it is not associated with adverse perinatal outcomes.     

硬膜外阻滞用于多发性痔、瘘手术及术后镇痛观察（附76例报告）

目的 观察硬膜外阻滞用于多发性痔、瘘手术麻醉效果及硬膜外注入布比卡因混合液术后镇痛研究。方法 于L3－4椎间隙进行硬膜外穿刺管,阻滞应用1．6％－2％利用多卡因8－11ml,术中必须时辅助用氟芬合剂,术后经硬膜外导管一次性汪入布比卡因混合液一个单位进行术后镇痛。结果 全组麻醉效果良好,术后镇痛优良率达100％。而且全组术后在无刺激的情况下始终无明显疼痛。结论 硬膜外阻滞用于痔、痔手术效果,而且较安全。硬膜外注入布比卡因混合液达到长时间术后镇痛作用,认为地塞米松能显著延长布比卡因止痛时间,维生素B12也具有局麻药协同作用及镇痛效果。     

腰硬联合麻醉下术中静脉右美托咪啶对术后硬膜外镇痛的影响

目的：观察腰硬联合麻醉下术中静脉持续输注0．5μg·kg-1．h-1的右关托咪啶对腹式全子宫切除术病人术后吗啡硬膜外自控镇痛（PCEA）的影响及相关不良反应发生的情况。方法：选择ASAI或II级、择期行腹式全子宫切除术病人50例,腰硬联合麻醉成功后,随机分为Ⅰ组（右关托咪啶组）和Ⅱ组（盐水对照组）,每组25例,术后镇痛采用硬膜外镇痛。观察患者术后第一疼痛出现时间,术后24h和术后24--48h吗啡用量、PCEA泵按压次数和有效次数,VAS评分法评估患者术后不同时点的疼痛程度;记录围术期血流动力学的变化和血管活性药物的使用情况;记录镇痛期间恶心呕吐及皮肤瘙痒等不良反应的发生情况。结果：患者术后第一疼痛时间Ⅰ组较Ⅱ组延长（P〈0．05）;术后24小时吗啡用量、PCEA泵按压次数及有效按压次数Ⅰ组较Ⅱ组显著减少（P〈0．05）,24---48小时两组病人无差异（P〉0．05）;病人术后0．5小时、6小时静息和运动VAS评分Ⅰ组较Ⅱ组显著减低（P〈0．05）,其余时点无差异（P〉0．05）;麻醉后15min时Ⅰ组较Ⅱ组心率下降（P〈0．05）,其余各时点比较无差异（P〉0．05）,各时点平均动脉压两组无差异（P〉0．05）;阿托品和麻黄碱Ⅰ组使用量较Ⅱ组增多（P〈0．05）;恶心的发生率Ⅰ组较Ⅱ组降低（P〈0．05）。结论：腰硬联合麻醉下行腹式全子宫切除术,术中静脉持续输注0．5μg·kg-1．h-1的右美托咪啶可在术后24小时内减轻患者的疼痛反应,减少硬膜外镇痛吗啡的用量,且无明显不良反应。     

硬膜外分娩镇痛转行硬膜外剖宫产麻醉失败的相关因素分析

目的：探讨采用硬膜外分娩镇痛中途转行硬膜外剖宫产麻醉失败的相关因素并对其进行分析。方法：选择来我院进行硬膜外分娩镇痛转而形硬膜外剖宫产麻醉的产妇218例,根据硬膜外麻醉失败的定义将其划分为成功组和失败组,对两组的一般资料、产程中的平均动脉压、硬膜外分娩镇痛情况分别进行比较分析。结果：成功组192例,失败组26例,两组产妇在一般资料上无差异（P〉0．05）。在转行剖宫产前成功组平均动脉压显著低于失败组（P〈O．05）,补救给药的次数上成功组显著低于失败组（P〈0．05）,在镇痛持续时间上成功组显著少于失败组（P〈0．05）。结论：影响硬膜外剖宫产麻醉失败的危险因素是分娩镇痛时需要补救给药的次数增加以及镇痛所持续的时间延长,对于出现此类危险因素的产妇,应改变剖宫产麻醉方式,以最大限度地降低剖宫产麻醉的失败率,这对于母婴并发症的减少起着积极的作用。     

舒芬太尼-罗哌卡因术后硬膜外镇痛的临床效果观察

目的:比较舒芬太尼-罗哌卡因与芬太尼-罗哌卡因混合液用于术后硬膜外镇痛的临床效果。方法:选择下肢择期手术病人60例,随机分为Ⅰ组(芬太尼组:芬太尼0．5mg 罗哌卡因200mg 氟哌利多2．5mg 生理盐水,总量为100ml)和Ⅱ组(舒芬太尼组:舒芬太尼0．05mg 罗哌卡因200mg 氟哌利多2．5mg 生理盐水,总量为100ml),以2ml/h硬膜外自控镇痛。以VAS评分比较两组镇痛效果,以Ramesay评分比较两组镇静程度,比较两组PCEA有效与实际按压次数比、镇痛药液用量和恶心呕吐等不良反应的差异。结果:术后6、12、24、48hVAS评分Ⅱ组显著高于Ⅰ组,PCA有效与实际按压次数比Ⅱ组较Ⅰ组明显减少,两组其它指标两组间无显著差异。结论:舒芬太尼0．05mg 罗哌卡因200mg 氟哌利多2．5mg 生理盐水(总量为100ml)应用于术后硬膜外镇痛是安全有效的组合,适于临床应用。     

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。     

Oral Delivery of Lactoferrin: A Review

Lactoferrin (Lf), as a therapeutic protein drug, has attracted much interest due to its many important roles in human and animal health and development. Oral delivery offers the most convenient way for supplementing Lf. However, the bioavailability of orally administered Lf is limited by a number of barriers associated with protein absorption. During the past decade, several oral delivery systems have been developed to preserve Lf stability in order to enhance gastric residence time and improve its bioavailability. This review summarizes various pharmaceutical strategies currently under investigation including: PEGylation, absorption enhancers, enzymatic inhibitors and advanced drug carrier systems.     

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.     

先天性尿道下裂的矫治(附1 000例报告)

目的:总结先天性尿道下裂的矫治经验.方法:尿道下裂患者1000例,年龄1～26岁,平均4岁.冠状沟型118例,阴茎体型593例.阴茎阴囊型189例,会阴型100例.791例采用尿道板切开卷管成形法(TIP),117例采用Duckett+Duplay术,92例采用二期手术,一期行阴茎伸直及皮辩转移,二期行尿道成形术(TIP).术中遵循微创原则,使用显微器械,尽量保留原有的正常组织结构.结果:随访6月至2年,TIP术741例手术一次成功,Duckett+Duplay术99例一次成功,分期手术二期成功86例.并发尿道皮肤瘘51例,尿道狭窄17例,尿道憩室6例,均经再次手术治愈.结论:尿道下裂矫治手术中,首先保留尿道板手术,并发症少,成功率高,值得推广,阴茎严重弯曲者或重度尿道下裂患者可选Duckett+Duplay术或者分期手术.     

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.