正经皮肾镜钬激光碎石术(percutaneous nephrolithotomy,PNCL)是一种安全、高效的上尿路结石治疗方法。由于手术为微创,术后疼痛往往被忽视,一般较少使用术后镇痛装置。但术后疼痛是躯体痛与内脏痛的混合表现,皮肤小切口、皮下与肌肉组织的钝性分离、肾盂穿刺口的扩张等创伤,术后造瘘管的持续引流,以及膀胱阵

尿路结石是泌尿系统常见疾病,根据结石所在部位的不同,分为肾结石、输尿管结石、尿道结石、膀胱结石。临床医学上以肾结石最为多见,男性发病率高于女性,男女尿路结石发病率比例约为4~5∶1,肾和膀胱是尿路结石形成的主要区域。目前临床医学在治疗肾结石的手术方法上发生了变革,传统的手术方式具有开放性、创伤大、术后恢复时间长的缺陷,而现在的微创腔内经皮肾镜碎石取石具有创伤小、术后并发症少、术后住院时间短的优势,能够有效弥补传统手术的不足。

正近年来,经皮肾镜(PCNI)手术是治疗上尿路结石的较好方法,有创伤小、术后恢复快、结石清除率高等优点。但因术前准备不足、术中操作不当引起的感染性休克、结石残留、大出血、肾脏贯通伤等术后并发症也较常见,其中感染性休克是最危险的并发症之一。感染性休克起病急,进展快,往往尚未确定病因时,休克己经发生。2013年1月至2014年8月我科对泌尿系结石行经皮肾镜术后并发感染性休克12例,经积极抢救治疗及护理后恢复正常,现将护理

目的：为全麻术后患者使用静脉自控镇痛泵（PCIA）提高镇痛效果。方法对61例全麻术后行PCIA患者行健康教育后镇痛效果进行观察调查。结果健康教育组镇痛有效率为88.5%。结论健康教育能帮助患者更好的实施自控镇痛，更快更及时并安全的为患者减轻疼痛，为患者的术后康复保驾护航。

目的 观察不同剂量舒芬太尼复合氟比洛芬酯用于胃癌术后患者的镇痛效果.方法 选择择期行胃癌切除术患者90例,完全随机分为Ⅰ、Ⅱ、Ⅲ组,每组30例,术后均行静脉自控镇痛(PCIA).3组镇痛均使用氟比洛芬酯2 mg/kg与托烷司琼5 mg,以0.9％氯化钠注射液稀释至100 ml,Ⅰ组另加用舒芬太尼1.5 μg/kg,Ⅱ组为舒芬太尼2.0 μg/kg,Ⅲ组为舒芬太尼2.5 μg/kg.观察并记录术后2、4、8、12、24、48 h患者视觉模拟评分(VAS评分)和Ramsay评分,分别评价镇痛效果和镇静效果;记录0～2h、＞2 ～4 h、＞4～8 h、＞8～12h、＞12 ～24 h和＞24 ～ 48 h PCIA有效按压次数和不良反应发生情况.结果 ①Ⅱ组和Ⅲ组术后4、8、12 h VAS评分低于Ⅰ组,组间差异有统计学意义[术后4、8、12 h VAS评分:Ⅰ组分别为(3.53 ±0.62)、(3.01±0.32)、(2.60 ±0.85)分,Ⅱ组分别为(2.71±0.53)、(1.95±0.43)、(1.36±0.42)分,Ⅲ组分别为(2.65±0.42)、(1.82±0.35)、(1.29±0.36)分,P＜0.05];Ⅱ组和Ⅲ组术后2、24和48 h与Ⅰ组的差异无统计学意义(P＞0.05);术后各时点Ⅱ组和Ⅲ组VAS评分的差异无统计学意义(P＞0.05).②Ⅱ组和Ⅲ组术后4、8、12 h Ramsay评分高于Ⅰ组,组间差异有统计学意义[术后4、8、12 h Ramsay评分:Ⅰ组分别为(2.51±0.42)、(2.59±0.79)、(2.66±0.53)分,Ⅱ组分别为(3.32±0.52)、(3.48±0.72)、(3.51±0.43)分,Ⅲ组分别为(3.31±0.31)、(3.50±1.00)、(3.42±0.50)分,P＜0.05];Ⅱ组和Ⅲ组术后2、24和48 h与Ⅰ组的差异无统计学意义(P＞0.05);术后各时点Ⅱ组和Ⅲ组的Ramsay评分差异无统计学意义(P＞0.05).③术后0～2 h、＞2～4h、＞4～8h、＞8～12 h、＞12 ～24 h,Ⅱ组和Ⅲ组PCIA按压次数均明显少于Ⅰ组,差异均有统计学意义[术后0～2h、＞2 ～4 h、＞4～8 h、＞8～12 h、＞12～24 hPCIA按压次数:Ⅰ组分别为(2.81±0.61)、(3.32±0.91)、(4.65±0.38)、(5.37±0.78)、(4.87±0.92)次,Ⅱ组分别为(1.40±0.50)、(1.72±0.54)、(2.97±0.63)、(3.61±0.83)、(3.02±0.65)次,Ⅲ组分别为(1.37±0.65)、(1.69±0.38)、(2.89±0.42)、(3.42±0.25)、(2.95±0.43)次,P＜0.05];Ⅱ组和Ⅲ组PCIA按压次数比较,差异无统计学意义(P＞0.05).术后＞24～48 h,3组间PCIA按压次数差异无统计学意义(P＞0.05).④Ⅰ、Ⅱ和Ⅲ组恶心、呕吐发生率分别为6.7％(2例)、6.7％(2例)和40.0％(12例),Ⅲ组恶心、呕吐发生率高于Ⅰ组和Ⅱ组,差异有统计学意义(P＜0.05);仅Ⅲ组有1例患者(3.3％)发生皮肤瘙痒;3组均未发生呼吸抑制和尿潴留.结论 不同剂量舒芬太尼用于胃癌术后静脉自控镇痛均可满足镇痛需求,其中舒芬太尼2.0 μg/kg镇痛效果更确切,镇静效果适中,不良反应少.

目的 探讨氟比洛芬酯静脉镇痛联合舒芬太尼在全髋置换术后的镇痛效果.方法 选择择期全髋置换术患者54例,年龄63～80岁,ASAI或Ⅱ级,随机数字表法分成A、B两组,每组27例.A组:术后静脉自控镇痛采用150mg氟比洛芬酯+150μg舒芬太尼+10mg阿扎司琼+0.9％氯化钠溶液稀释至100 ml(1.5 mg/ml氟比洛芬酯+1.5 μg/ml舒芬太尼);B组:采用150 mg氟比洛芬酯+100μg舒芬太尼+10mg阿扎司琼+0.9％氯化钠溶液稀释至100ml(1.5 mg/ml氟比洛芬酯+1.0 μg/ml舒芬太尼).观察并记录两组患者术后24h内自控静脉镇痛(PCIA)泵有效按压次数及术后6、12、24及48h VAS评分、Ramsay镇静评分.结果 与A组比较,B组术6、12及24 h时VAS评分、Ramsay镇静评分降低,差异均有统计学意义(均P＜0.05);两组术后24 h内患者PCIA泵按压次数比较差异无统计学意义(P＞0.05).结论 氟比洛芬酯静脉镇痛联合舒芬太尼用于全髋关节置换术后镇痛效果显著,患者耐受少,且不良反应少,值得临床推广使用.

Epidural and intravenous patient-controlled analgesia (PCA) are established methods for pain relief after total hip arthroplasty (THA). Periarticular infiltration is an alternative method that is gaining ground due to its simplicity and safety. Our study aims to assess the efficacy of periarticular infiltration in pain relief after THA.Sixty-three patients undergoing THA under spinal anaesthesia were randomly assigned to receive postoperative analgesia with continuous epidural infusion with ropivacaine (epidural group), intraoperative periarticular infiltration with ropivacaine, clonidine, morphine, epinephrine and corticosteroids (infiltration group) or PCA with morphine (PCA group). PCA morphine provided rescue analgesia in all groups. We recorded morphine consumption, visual analog scale (VAS) scores at rest and movement, blood loss from wound drainage, mean arterial pressure (MAP) and adverse effects at 1, 6, 12, 24 h postoperatively.Morphine consumption at all time points, VAS scores at rest, 6, 12 and 24 h and at movement, 6 and 12 h postoperatively were lower in infiltration group compared to PCA group (p In our study periarticular infiltration was clearly superior to PCA with morphine after THA, providing better pain relief and lower opioid consumption postoperatively. Infiltration seems to be equally effective to epidural analgesia without having the potential side effects of the latter.

Sufficient acute pain therapy has been scientifically proven to be one of the therapeutic pillars for rapid patient convalescence, a low rate of pain chronification, and a high grade of patient satisfaction. This includes not only systemic pharmacological pain therapy, but also nonpharmaceutical measures, e.g., physical, psychological, locoregional, and adequate patient information. This requires a specific infrastructure, exact clinical control mechanisms, and fundamental knowledge about pain avoidance. The surgeon can responsibly contribute to this. The goal of the following article is to demonstrate and deepen this knowledge and to describe the newest scientific developments.

Abstract BACKGROUND: We tested the hypothesis that pain relief after total hip replacement (THR) can be obtained with a multimodal approach using oral controlled release (CR) oxycodone plus IV paracetamol. METHODS: Two hundred and sixty patients undergoing THR were randomized into two groups. A group of 130 patients (EPI) under epidural anesthesia followed by continuous infusion of levobupivacaine 0.125% and sufentanil 0.7 mcg/mL at 7 mL/h was compared with a group (OXY) of 130 patients under spinal anesthesia and oral CR oxycodone 10 mg/q12h plus IV paracetamol 1g/q6h. Pain intensity at rest and dynamic by visual analogue scores (VAS), rescue dose consumption and side effects of three postoperative days (POD) were collected and analyzed with Mann-Withney test (P<0.05 was considered significant). RESULTS: VAS values at rest were similar in both groups at POD#1, significantly lower in the OXY group either at POD#2 (P=0.018) and POD#3 (P=0.001). Dynamic VAS values were significantly lower in the EPI group at POD#1 (P=0.001), similar for both groups at POD#2 and significantly lower in the OXY group at POD#3 (P=0.026) than the comparing group. Rescue dose consumption was significantly lower in the EPI group during the POD#1 (P=0.009), similar for both groups at POD#2 and higher in the EPI at POD#3 (P=0.008). The incidence of vomiting was similar for the two groups. Nausea was more frequent in the OXY group at POD#3 and more hypotension events occurred in the OXY group at POD#2. CONCLUSION: Oral CR oxycodone plus IV paracetamol was as effective as epidural levobupivacaine and sufentanil for postoperative pain relief after THR.

氟比洛芬酯是近些年来被广泛应用于临床的一种非甾体类抗炎药，由氟比洛芬和包裹在外层的脂微球组成，常用于手术疼痛和癌症疼痛的治疗。本文对其在药理学、镇痛机制与临床应用等方面的国内外研究进行综述。

目的 观察氟比洛芬酯用于骨科手术时超前镇痛的作用效果.方法 50例美国麻醉师协会（ASA）Ⅰ～Ⅱ级行骨科手术的患者,随机分为实验组Ⅰ组和对照组Ⅱ组,每组25例.术前15 min实验组（Ⅰ组）进行氟比洛芬酯100 mg的静脉缓注,对照组（Ⅱ组）进行生理盐水20 ml静脉缓注.分别记录术后1 h、2 h、4 h、6 h、8 h、12 h、24 h的视觉模拟评分（VAS）、24 h曲马多用量和不良反应,并在镇痛结束后统计患者对镇痛治疗的总体满意度.结果 术后1 h、2 h、4 h、6 h VAS Ⅰ组均低于Ⅱ组（P〈0.05）,术后8 h、24 h两组VAS无显著差异;术后24 hⅠ组（275.8±45.5）mg的曲马多用量明显低于Ⅱ组的（310.5±57.2）mg（P〈0.05）,不良反应方面两组差异无显著性.Ⅰ组与Ⅱ组患者总体满意度在Ⅱ级和Ⅳ级上差异明显（P〈0.05）.结论 氟比洛芬酯在骨科手术镇痛中的超前应用,能够减少曲马多用量,对术后镇痛有显著效果.

目的:探讨不同剂量舒芬太尼复 合罗哌卡因腰硬联合麻醉用于分娩镇痛的临床效果。方法:将2014年7月~2015年7月我院收治的90例产妇随机分成三组,每组30例,均采用腰硬联合 麻醉,分别给予0μg(A组)、5μg(B组)、10μg(C组)的舒芬太尼和5mg的罗哌卡因复合进行腰硬联合麻醉分娩镇痛,记录、分析并比较三组镇痛 效果。结果:三组产妇采用不同剂量舒芬太尼复合罗哌卡因腰硬联合麻醉用于分娩镇痛,B、C两组产妇镇痛起效时间、感觉阻滞平面、PCA用药量、PCA给药 次数均无显著差异,但B组用药量明显减少,B、C两组对镇痛效果的满意程度明显高于A组,临床分娩镇痛效果显著。讨论:5μg舒芬太尼复合5mg罗哌卡因 在腰硬联合麻醉时分娩镇痛效果最佳,而且操作安全,临床效果显著。

目前,骨科围手术期镇痛的方法 比较多,如阿片类、非甾体类药物,硬膜外麻醉,局部麻醉,外周神经阻滞等,但是其使用及效果各有局限性.对于骨科患者来说,术后早期的功能锻炼是极其必要 的,但是术后疼痛极大地阻碍了患者功能锻炼及康复.国内外许多专家主张将术后疼痛作为与血压、心率、呼吸、体温等同起来的"第五生命体征",应予及时正确 的处理.良好的术后镇痛在骨科围手术期中起着关键的作用.围手术期的镇痛治疗可以减少术后并发症,减轻患者痛苦,并且让患者及早进行功能锻炼,这一点对于 骨科患者的康复尤为重要.目前的镇痛方法 有很多,而多模式镇痛已经得到公认.本文就多模式镇痛治疗在骨科围手术期中的应用进行综述.

目的观察骨科手术后患者联合应用氟比洛芬酯与舒芬太尼镇痛的效果。方法将沈阳市第五人民医院骨科手术患者320例随机分成治疗组和对照组,每组160例。治疗组给予生理盐水200 m L与氟比洛芬酯200 mg＋舒芬太尼50μg联合应用;对照组给予0.9%生理盐水200 m L与舒芬太尼150μg。观察两组患者治疗后2、6、12、24 h的疼痛视觉模拟评分（VAS）、镇静评分和药物不良反应发生率。结果治疗组的舒芬太尼用量仅为50μg,明显低于对照组（150μg）,两组比较差异有统计学意义（P〈0.05）。两组患者的VAS评分和镇静评分比较差异无统计学意义（P〉0.05）。治疗组的药物不良反应发生率为8.1%,明显低于对照组（18.1%）,两组比较差异有统计学意义（P〈0.05）。结论氟比洛芬酯与舒芬太尼联合用于骨科术后镇痛,疗效确切,可减少药物的用量,降低药物不良反应和并发症发生率,并增强患者舒适感和满意度,值得推广。

<br /><div>Thirty-six patients who underwent primary unilateral total hip arthroplasty (THA) were randomly allocated to 4 groups with different pain control protocols; continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group). Postoperative pain was assessed using the numerical rating scale (NRS) scores and the analgesic effect was compared among the groups. The NRS upon arrival at the recovery room and 6 hours after surgery in the FNB, EB, and IV-PCA groups were significantly lower than that in the NSAIDs group. The amount of additional analgesics requested by the patient was smaller in the FNB, EB, and IV-PCA groups as compared to the NSAIDs group. Regarding the complications related to the analgesia, 5 of the 9 patients in the IV-PCA group complained nausea and vomiting and received antiemetic drugs. Delay in the rehabilitation process due to drowsiness was encountered in 3 patients in this group, while no patient in the FNB and EB groups suffered from delayed rehabilitation. Considering both the analgesic effect and the potential risk of complications, continuous femoral nerve blocks and caudal epidural blocks for are recommended for postoperative pain control after THA procedure.

C-reactive protein is a marker of inflammation and vascular disease. It also seems to be associated with an increased risk of dementia. To better understand potential underlying mechanisms, we assessed microstructural brain integrity and cognitive performance relative to serum levels of high-sensitivity C-reactive protein (hs-CRP).We cross-sectionally examined 447 community-dwelling and stroke-free individuals from the Systematic Evaluation and Alteration of Risk Factors for Cognitive Health (SEARCH) Health Study (mean age 63 years, 248 female). High-field MRI was performed in 321 of these subjects. Imaging measures included fluid-attenuated inversion recovery sequences for assessment of white matter hyperintensities, automated quantification of brain parenchyma volumes, and diffusion tensor imaging for calculation of global and regional white matter integrity, quantified by fractional anisotropy (FA). Psychometric analyses covered verbal memory, word fluency, and executive functions.Higher levels of hs-CRP were associated with worse performance in executive function after adjustment for age, gender, education, and cardiovascular risk factors in multiple regression analysis (beta = -0.095, p = 0.02). Moreover, higher hs-CRP was related to reduced global fractional anisotropy (beta = -0.237, p < 0.001), as well as regional FA scores of the frontal lobes (beta = -0.246, p < 0.001), the corona radiata (beta = -0.222, p < 0.001), and the corpus callosum (beta = -0.141, p = 0.016), in particular the genu (beta = -0.174, p = 0.004). We did not observe a significant association of hs-CRP with measures of white matter hyperintensities or brain atrophy.These data suggest that low-grade inflammation as assessed by high-sensitivity C-reactive protein is associated with cerebral microstructural disintegration that predominantly affects frontal pathways and corresponding executive function.

围手术期的应激反应研究越来越受到重视，一定范围内的应激反应可以提高机体的适应能力，对体内的内环境起到稳定作用，而由于患者围手术期心理恐惧、各种麻醉及手术操作以及术后疼痛等一系列刺激容易导致机体造成强烈的应激反应[1，2]。应激反应的强度评定尚没有统一的标准，但临床普遍认为C反应蛋白主要是机体对组织损伤的一种保护性反应机制。当有组织创伤和炎症反应刺激时，激活单核细胞释放白细胞介素-2，从而刺激肝细胞加速合成C反应蛋白并使其上升并迅速达到峰值,随后随着损伤组织的愈合则迅速下降。大量研究表明C反应蛋白的水平与组织损伤后应激状态程度成正比，相同部位、相同损伤的手术后CRP变化时相曲线基本相似，组织破坏越重，C反应蛋白峰值越高，即C反应蛋白浓度变化只与组织损伤大小和损伤部位有关，，不同损伤部位及创伤、手术造成骨与软组织损伤的比例决定了C反应蛋白值，与麻醉方式、出血量、手术时间、投药、年龄以及性别等无相关性[3]。较多研究证明：术后感染发生时，血CRP会持续升高或先下降后再升高。若CRP恢复正常预示着疾病的康复。因此C反应蛋白值是反映麻醉及手术应激程度的可靠指标，其测定已广泛应用于目前临床疾病的早期诊断及鉴别诊断已广泛应用[4-6]。

目的 ：比较围手术期运用快速康复外科（FTS）方案与传统方案治疗结直肠癌患者的优越性。方法：选取安徽医科大学附属安庆医院2013年4月—2014年11月收治的53例结直肠癌患者,将53例患者简单随机分配分为实验组28例,围手术期采用快速康复处理措施;对照组25例,围手术期采用传统处理措施。比较两组患者术后首次排气时间、排便时间、术后住院时间、住院费用及术后并发症发生率,并比较患者手术当天、术后第1天及第5天清晨外周空腹血C-反应蛋白（CRP）、白细胞介素6（IL-6）及血清淀粉样蛋白A（SAA）的水平。结果：实验组28例患者,5例术中探查分期过晚,被排除,剩余23例;对照组患者25例,3例患者术中探查分期过晚,被排除,剩余22例。实验组患者术后首次排气时间、排便时间、术后住院时间、住院费用均低于对照组,差异有统计学意义（P〈0.05）;实验组术前CRP、IL-6、SAA浓度与对照组相比差异无统计学意义（P〉0.05）;实验组后第1天、第5天的CRP、IL-6及SAA浓度均低于对照组,差异有统计学意义（P〈0.05）;两组患者术后并发症发生率相比差异无统计学意义（P〉0.05）。结论：FTS处理措施运用于结直肠癌患者能显著降低术后机体应激反应,加速患者术后康复。