Regional anesthesia最新文献

英文中文

Not everything that can be done should be done 不是所有能做的事都应该做

Regional anesthesia

Pub Date : 2016-02-24 DOI: 10.2147/LRA.S102366

C. Slagt

Dear editor After reading the article, “Thoracic combined spinal epidural anesthesia for laparoscopic cholecystectomy in a geriatric patient with ischemic heart disease and renal insufficiency” by Mehta et al,1 I have the following considerations. Laparoscopic cholecystectomy was performed under spinal anesthesia in healthy patients.2 Perioperative hemodynamic instability (59%) and discomfort (43%) were noticed in this group of 49 patients. From the gastroenterology literature, we know that a combination of lumbar spinal and thoracic epidural anesthesia can be used as a monotherapy for high-risk patients undergoing gastrointestinal and colorectal surgery.3 Perioperative hemodynamics and discomfort were not observed in 12 patients. Is this a stress-free environment? Preventing general anesthesia should not be a goal on its own. From an oxygen delivery-consumption point of view, general anesthesia reduces oxygen consumption and can promote oxygen delivery, theoretically preventing organ failure, especially in high-risk surgical patients with diseases that involve multiple organs.4 Our body has protected the delicate spinal cord by the vertebral column. Damaging the spinal cord during anesthesia, for instance, during epidural procedures, is one of the greatest fears of our patients and anesthesiologists.5,6 New techniques should be thoroughly tested on healthy patients before they are used on high-risk surgical patients. A combined thoracic spinal epidural anesthesia is, in the light of the above, an undesirable technique, especially combined with pneumoperitoneum when hemodynamic and respiratory homeostasis and patient comfort can be compromised. Although there is the possibility to place a thoracic combined spinal epidural anesthesia, I strongly like to emphasize that especially in the view of patient safety, this procedure is undesirable. A thoracic epidural combined with general anesthesia is in the most cases (if not all cases) a safe alternative.

在阅读了Mehta等人的文章《胸腔联合脊髓硬膜外麻醉在老年缺血性心脏病肾功能不全患者腹腔镜胆囊切除术中的应用》后，我有以下几点考虑。健康患者在脊髓麻醉下行腹腔镜胆囊切除术本组49例患者围手术期血流动力学不稳定(59%)和不适(43%)。从胃肠病学文献中，我们知道腰椎和胸椎硬膜外联合麻醉可以作为高危患者接受胃肠道和结肠直肠手术的单一疗法12例患者围手术期无血流动力学及不适。这是一个没有压力的环境吗?预防全身麻醉本身不应该是一个目标。从供氧耗氧量的角度来看，全身麻醉可以减少耗氧量，促进供氧，理论上可以预防器官衰竭，特别是对于多器官疾病的高危手术患者我们的身体通过脊柱保护着脆弱的脊髓。在麻醉过程中损伤脊髓，例如，在硬膜外手术中，是我们的病人和麻醉师最害怕的事情之一。5,6新技术应用于高危外科患者前，应在健康患者身上进行彻底的试验。综上所述，胸椎硬膜外联合麻醉是一种不可取的技术，特别是当血液动力学和呼吸稳态及患者舒适度可能受到损害时，与气腹联合麻醉。虽然有可能放置胸椎联合硬膜外麻醉，但我强烈强调，特别是从患者安全的角度来看，这种手术是不可取的。在大多数情况下(如果不是所有情况)，胸腔硬膜外联合全身麻醉是一种安全的选择。

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引用次数: 0

Thoracic combined spinal epidural anesthesia for laparoscopic cholecystectomy in a geriatric patient with ischemic heart disease and renal insufficiency 胸椎联合硬膜外麻醉在老年缺血性心脏病伴肾功能不全的腹腔镜胆囊切除术中的应用

Regional anesthesia

Pub Date : 2015-12-02 DOI: 10.2147/LRA.S86390

N. Mehta, Sunana Gupta, A. Sharma, M. Dar

Older people undergoing any surgery have a higher incidence of morbidity and mortality, resulting from a decline in physiological reserves, associated comorbidities, polypharmacy, cognitive dysfunction, and frailty. Most of the clinical trials comparing regional versus general anesthesia in elderly have failed to establish superiority of any single technique. However, the ideal approach in elderly is to be least invasive, thus minimizing alterations in homeostasis. The goal of anesthetic management in laparoscopic procedures includes management of pneumoperitoneum, achieving an adequate level of sensory blockade without any respiratory compromise, management of shoulder tip pain, provision of adequate postoperative pain relief, and early ambulation. Regional anesthesia fulfills all the aforementioned criteria and aids in quick recovery and thus has been suggested to be a suitable alternative to general anesthesia for laparoscopic surgeries, particularly in patients who are at high risk while under general anesthesia or for patients unwilling to undergo general anesthesia. In conclusion, we report results of successful management with thoracic combined spinal epidural for laparoscopic cholecystectomy of a geriatric patient with ischemic heart disease with chronic obstructive pulmonary disease and renal insufficiency.

由于生理储备下降、相关合并症、多药、认知功能障碍和虚弱，接受任何手术的老年人的发病率和死亡率都较高。大多数比较老年人局部麻醉与全身麻醉的临床试验都未能确定任何一种技术的优越性。然而，对于老年人来说，理想的方法是侵入性最小，从而最大限度地减少对体内平衡的改变。腹腔镜手术麻醉管理的目标包括气腹管理，在不损害呼吸的情况下实现足够程度的感觉封锁，肩尖疼痛的管理，提供足够的术后疼痛缓解和早期下床。区域麻醉符合上述所有标准，有助于快速恢复，因此被认为是腹腔镜手术中全身麻醉的合适替代方案，特别是对于全麻下高危患者或不愿接受全身麻醉的患者。综上所述，我们报告了一例老年缺血性心脏病合并慢性阻塞性肺疾病和肾功能不全的腹腔镜胆囊切除术中胸椎硬膜外联合手术的成功治疗结果。

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引用次数: 8

Comparative evaluation of continuous intercostal nerve block or epidural analgesia on the rate of respiratory complications, intensive care unit, and hospital stay following traumatic rib fractures: a retrospective review 连续肋间神经阻滞或硬膜外镇痛对外伤性肋骨骨折后呼吸并发症发生率、重症监护病房和住院时间的比较评价:回顾性回顾

Regional anesthesia

Pub Date : 2015-10-27 DOI: 10.2147/LRA.S80498

T. Britt, Ryan Sturm, R. Ricardi, V. LaBond

Background Thoracic trauma accounts for 10%–15% of all trauma admissions. Rib fractures are the most common injury following blunt thoracic trauma. Epidural analgesia improves patient outcomes but is not without problems. The use of continuous intercostal nerve blockade (CINB) may offer superior pain control with fewer side effects. This study’s objective was to compare the rate of pulmonary complications when traumatic rib fractures were treated with CINB vs epidurals. Methods A hospital trauma registry provided retrospective data from 2008 to 2013 for patients with 2 or more traumatic rib fractures. All subjects were admitted and were treated with either an epidural or a subcutaneously placed catheter for continuous intercostal nerve blockade. Our primary outcome was a composite of either pneumonia or respiratory failure. Secondary outcomes included total hospital days, total ICU days, and days on the ventilator. Results 12.5% (N=8) of the CINB group developed pneumonia or had respiratory failure compared to 16.3% (N=7) in the epidural group. No statistical difference (P=0.58) in the incidence of pneumonia or vent dependent respiratory failure was observed. There was a significant reduction (P=0.05) in hospital days from 9.72 (SD 9.98) in the epidural compared to 6.98 (SD 4.67) in the CINB group. The rest of our secondary outcomes showed no significant difference. Conclusion This study did not show a difference in the rate of pneumonia or ventilator-dependent respiratory failure in the CINB vs epidural groups. It was not sufficiently powered. Our data supports a reduction in hospital days when CINB is used vs epidural. CINB may have advantages over epidurals such as fewer complications, fewer contraindications, and a shorter time to placement. Further studies are needed to confirm these statements.

背景:胸部创伤占所有入院创伤的10%-15%。肋骨骨折是钝性胸外伤后最常见的损伤。硬膜外镇痛改善了患者的预后，但并非没有问题。使用连续肋间神经阻滞(CINB)可以提供更好的疼痛控制和更少的副作用。本研究的目的是比较外伤性肋骨骨折采用CINB和硬膜外治疗时肺部并发症的发生率。方法回顾性分析2008 - 2013年2例及以上外伤性肋骨骨折患者的创伤登记资料。所有受试者入院并接受硬膜外或皮下置管持续肋间神经阻滞治疗。我们的主要结局是肺炎或呼吸衰竭的复合结局。次要结局包括总住院天数、ICU总天数和使用呼吸机天数。结果12.5% (N=8) CINB组发生肺炎或呼吸衰竭，而硬膜外组为16.3% (N=7)。肺炎和通气依赖性呼吸衰竭的发生率比较，差异无统计学意义(P=0.58)。硬膜外组的住院天数为9.72天(SD 9.98)，而CINB组为6.98天(SD 4.67)，显著减少(P=0.05)。其余次要结果无显著差异。结论:本研究未显示CINB组与硬膜外组在肺炎或呼吸机依赖性呼吸衰竭发生率上存在差异。它的动力不足。我们的数据支持使用CINB与硬膜外相比减少住院天数。CINB可能比硬膜外有优势，如更少的并发症，更少的禁忌症，更短的放置时间。需要进一步的研究来证实这些说法。

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引用次数: 32

External ventilation monitoring system in nonintubated subjects: the noninvasive apnea monitor. 非插管受试者体外通气监测系统:无创呼吸暂停监测。

Regional anesthesia

Pub Date : 1997-11-01

E Zarzur

引用次数: 0

Response to Dr. Neal's comments and to paper by Dr. Rathmell et al. 对Neal博士的评论和Rathmell博士等人的论文的回应。

Regional anesthesia

Pub Date : 1997-11-01

E I Abouleish

引用次数: 0

Asystole during trigger point injections in a patient with panic disorder. 恐慌症患者在触发点注射时心脏骤停。

Regional anesthesia

Pub Date : 1997-11-01

C Spevak

引用次数: 0

A low-dose hypobaric bupivacaine spinal anesthesia for knee arthroscopies. 低剂量低压布比卡因脊柱麻醉用于膝关节镜检查。

Regional anesthesia

Pub Date : 1997-11-01

K S Kuusniemi, K K Pihlajamäki, M T Pitkänen, J E Korkeila

Background and objectives: Ambulatory surgery requires anesthesia methods that allow rapid recovery and safe discharge of the patient. Spinal anesthesia is easy and quick to perform, and the use of noncutting small gauge needles reduces the occurrence of postdural puncture headache. For minimal hemodynamic consequences and faster recovery and discharge it would be optimal to limit the spread of spinal anesthesia only to the area which is necessary for surgery. In this study, the possibility in achieving unilateral spinal anesthesia with 0.18% hypobaric bupivacaine was studied.

Methods: Spinal anesthesia with 3.4 mL of hypobaric 0.18% bupivacaine (6.12 mg), without any intravenous infusion or prophylactic vasopressors, was administered with 27-gauge Whitacre unidirectional needle to 70 ASA I and II patients undergoing knee arthroscopies. The patients were allocated randomly to be kept either 20 (group I) or 30 (group II) minutes in the lateral position operation side uppermost. Sensory and motor block (pinprick/modified Bromage scale) were compared between the operation and the contralateral side.

Results: The motor and sensory block between operation and contralateral sides were significantly different at all testing times in both groups (P < .001, Mann-Whitney U test). The motor block was completely unilateral in 14 patients (39%) in group I and in 22 patients (65%) in group II. The hemodynamics were stable in all 70 patients.

Conclusions: Approximately three and a half milliliters hypobaric 0.18% bupivacaine (6.12 mg) provides a predominantly unilateral spinal block. Thirty minutes spent in the lateral position does not provide benefits over 20 minutes. The main advantages of our method are the hemodynamic stability and the patient satisfaction.

背景和目的:门诊手术需要麻醉方法，使患者快速恢复和安全出院。脊髓麻醉操作简单、快捷，且使用非切割小径针可减少硬脊膜穿刺后头痛的发生。为了使血流动力学影响最小，恢复和出院更快，最好将脊髓麻醉的扩散限制在手术所需的区域。在本研究中，研究了0.18%低压布比卡因实现单侧脊髓麻醉的可能性。方法:采用27号Whitacre单向针对70例经膝关节镜检查的ASA I、II级患者进行腰麻麻醉，腰麻浓度为3.4 mL, 0.18%布比卡因(6.12 mg)，无静脉输注，无预防性血管加压药物。随机分配患者在侧位手术中保持20 (I组)或30 (II组)分钟。比较手术组和对侧组的感觉和运动阻滞(针刺/改良Bromage评分)。结果:两组手术侧与对侧的运动和感觉阻滞在所有测试时间均有显著差异(P < 0.001, Mann-Whitney U检验)。I组14例(39%)患者和II组22例(65%)患者出现完全单侧运动阻滞。70例患者血流动力学均稳定。结论:约3.5毫升0.18%的低压布比卡因(6.12 mg)主要提供单侧脊髓阻滞。30分钟的侧卧姿势并不能提供超过20分钟的好处。该方法的主要优点是血流动力学稳定性和患者满意度。

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引用次数: 0

Failed axillary brachial plexus block techniques result in high plasma concentrations of mepivacaine. 失败的腋窝臂丛阻滞技术导致高血浆浓度的甲哌卡因。

Regional anesthesia

Pub Date : 1997-11-01

K Yamamoto, T Nomura, K Shibata, S Ohmura

Background and objectives: Unintentional extrasheath injection causes failed axillary brachial plexus block. We wanted to find out if extrasheath injections produce higher plasma concentrations of local anesthetics compared to intrasheath injections. We also studied the incidence of extrasheath injection with radiographs.

Methods: Axillary brachial plexus blocks were established using a catheter technique. Fifty milliliters of 1.5% mepivacaine without epinephrine mixed with contrast medium was injected through the catheter. An anteroposterior radiograph was used to determine the distribution of contrast medium. Mepivacaine concentrations in arterial plasma were compared when local anesthetic solution was injected unintentionally outside of the axillary neurovascular sheath (n = 6) and when it was injected correctly into the sheath (n = 6). The incidence of extrasheath injection was studied in a different series of 109 patients.

Results: Arterial plasma mepivacaine concentrations were higher after extrasheath injection [8.0 (6.3-9.7) vs 5.8 (4.5-7.0), microg/mL, means (95% confidence intervals), P < .05]. Pharmacokinetic parameters such as mean residence time and total clearance did not differ between intra- and extrasheath injections. Extrasheath injection was observed in 3.7% (4/109) of cases.

Conclusion: Failed extrasheath injection of 50 mL 1.5% plain mepivacaine produces higher arterial plasma concentration in axillary brachial plexus block.

背景和目的:无意的鞘外注射导致腋窝臂丛阻滞失败。我们想知道与鞘内注射相比，鞘外注射是否会产生更高的局部麻醉药血浆浓度。我们还通过x线片研究了鞘外注射的发生率。方法:采用导管技术建立腋窝臂丛神经阻滞。经导管注射1.5%不含肾上腺素的甲哌卡因50毫升，与造影剂混合。用正位x线片确定造影剂的分布。比较了局麻溶液在腋神经血管鞘外非故意注射(n = 6)和正确注射(n = 6)时动脉血浆中甲哌卡因的浓度，并对109例不同系列患者的鞘外注射发生率进行了研究。结果:经皮外注射后动脉血浆甲哌卡因浓度较高[8.0 (6.3-9.7)vs 5.8 (4.5-7.0)， μ g/mL，平均值(95%可信区间)，P < 0.05]。药代动力学参数，如平均停留时间和总清除率在内注射和外注射之间没有差异。3.7%(4/109)的病例使用外鞘注射液。结论:50 mL 1.5%普通甲哌卡因在腋窝臂丛阻滞失败后可引起较高的动脉血药浓度。

{"title":"Failed axillary brachial plexus block techniques result in high plasma concentrations of mepivacaine.","authors":"K Yamamoto, T Nomura, K Shibata, S Ohmura","doi":"","DOIUrl":"","url":null,"abstract":"Background and objectives: Unintentional extrasheath injection causes failed axillary brachial plexus block. We wanted to find out if extrasheath injections produce higher plasma concentrations of local anesthetics compared to intrasheath injections. We also studied the incidence of extrasheath injection with radiographs.Methods: Axillary brachial plexus blocks were established using a catheter technique. Fifty milliliters of 1.5% mepivacaine without epinephrine mixed with contrast medium was injected through the catheter. An anteroposterior radiograph was used to determine the distribution of contrast medium. Mepivacaine concentrations in arterial plasma were compared when local anesthetic solution was injected unintentionally outside of the axillary neurovascular sheath (n = 6) and when it was injected correctly into the sheath (n = 6). The incidence of extrasheath injection was studied in a different series of 109 patients.Results: Arterial plasma mepivacaine concentrations were higher after extrasheath injection [8.0 (6.3-9.7) vs 5.8 (4.5-7.0), microg/mL, means (95% confidence intervals), P < .05]. Pharmacokinetic parameters such as mean residence time and total clearance did not differ between intra- and extrasheath injections. Extrasheath injection was observed in 3.7% (4/109) of cases.Conclusion: Failed extrasheath injection of 50 mL 1.5% plain mepivacaine produces higher arterial plasma concentration in axillary brachial plexus block.","PeriodicalId":77347,"journal":{"name":"Regional anesthesia","volume":"22 6","pages":"557-61"},"PeriodicalIF":0.0,"publicationDate":"1997-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20353493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Comments on articles by Carpenter et al. and Bromage. 对Carpenter等人和Bromage的文章的评论。

Regional anesthesia

Pub Date : 1997-11-01 DOI: 10.1136/RAPM-00115550-199722060-00019

Schweitzer Tw

引用次数: 1

Does epidural analgesia during labor affect the incidence of cesarean delivery? 分娩时硬膜外镇痛是否影响剖宫产的发生率?

Regional anesthesia

Pub Date : 1997-11-01

D H Chestnut

There is substantial evidence that there is an increased incidence of cesarean delivery among patients who receive epidural analgesia during labor. The controversy as to whether there is a causal relationship between epidural analgesia and cesarean delivery. Two prospective, randomized studies suggest that epidural analgesia may increase the incidence of operative delivery in laboring women. However, retrospective population-based studies suggest that the introduction of an epidural analgesia service, or the increased use of epidural analgesia, does not increase the cesarean delivery rate. It is possible that epidural analgesia during labor may increase the risk of cesarean delivery in selected patients. Such an effect--if it exists at all--appears to be small in contemporary practice. Furthermore, the availability and use of epidural analgesia may encourage other patients to undergo an adequate trial of labor or attempt vaginal birth after cesarean delivery. It is important to consider the impact of epidural analgesia on the total population of obstetric patients. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate. Finally, physicians should remember that pain relief is itself a worthy goal.

有大量证据表明，在分娩过程中接受硬膜外镇痛的患者中，剖宫产的发生率增加。关于硬膜外镇痛与剖宫产是否存在因果关系的争论。两项前瞻性随机研究表明，硬膜外镇痛可能会增加分娩妇女手术分娩的发生率。然而，基于人群的回顾性研究表明，引入硬膜外镇痛服务或增加硬膜外镇痛的使用并不会增加剖宫产率。分娩时硬膜外镇痛可能会增加某些患者剖宫产的风险。这种影响——如果存在的话——在当代实践中似乎很小。此外，硬膜外镇痛的可用性和使用可能会鼓励其他患者在剖宫产后接受充分的分娩试验或尝试阴道分娩。考虑硬膜外镇痛对产科患者总数的影响是很重要的。母胎因素和产科管理，而不是硬膜外镇痛，是剖宫产率的最重要决定因素。最后，医生应该记住，缓解疼痛本身就是一个有价值的目标。

{"title":"Does epidural analgesia during labor affect the incidence of cesarean delivery?","authors":"D H Chestnut","doi":"","DOIUrl":"","url":null,"abstract":"There is substantial evidence that there is an increased incidence of cesarean delivery among patients who receive epidural analgesia during labor. The controversy as to whether there is a causal relationship between epidural analgesia and cesarean delivery. Two prospective, randomized studies suggest that epidural analgesia may increase the incidence of operative delivery in laboring women. However, retrospective population-based studies suggest that the introduction of an epidural analgesia service, or the increased use of epidural analgesia, does not increase the cesarean delivery rate. It is possible that epidural analgesia during labor may increase the risk of cesarean delivery in selected patients. Such an effect--if it exists at all--appears to be small in contemporary practice. Furthermore, the availability and use of epidural analgesia may encourage other patients to undergo an adequate trial of labor or attempt vaginal birth after cesarean delivery. It is important to consider the impact of epidural analgesia on the total population of obstetric patients. Maternal-fetal factors and obstetric management, not epidural analgesia, are the most important determinants of the cesarean delivery rate. Finally, physicians should remember that pain relief is itself a worthy goal.","PeriodicalId":77347,"journal":{"name":"Regional anesthesia","volume":"22 6","pages":"495-9"},"PeriodicalIF":0.0,"publicationDate":"1997-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"20352881","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

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