Заключение

Цель данной главы заключалась в клиническом обосновании рацио­нального использования эпидуральных инфузий комбинацией локальных анестетиков и опиоидов. Продолжительная эпидуральная инфузия одними локальными анестетиками сопряжена с частым развитием тахифилаксии. Присоединение опиоидов не только предупреждает развитие тахифилаксии, но и усиливает действие локальных анестетиков (синергизм). Одновремен­ное эпидуральное введение локальных анестетиков и опиоидов, когда оно применяется как составная часть метода балансированной аналгезии, под­держивает подавление центральной гиперсенсибилизации, достигнутое уже во время операции благодаря региональной анестезии. (Аналогичное воз­действие комбинированное эпидуральное введение локальных анестетиков и опиоидов оказывает и на нейроэндокринные реакции, см. гл. 4.)

Таким образом, аналгезия представляет собой продолжительный про­цесс, который не ограничивается только послеоперационным периодом. Восприятие аналгезии как единого продолжающегося процесса, исполь­зование метода балансированной аналгезии и подавление нежелательных патофизиологических реакций должно сократить время выздоровления. Центральную роль в этом играет комбинированное эпидуральное введение локальных анестетиков и опиоидов.

Список литературы

1. Dahl JB, Rosenberg J, Dirkes W E et al: Prevention of postoperative pain by balanced analgesia. BrJ Anaesth 64:518, 1990

2. Schuize S, Roikjaer 0. Hasselstr^m L et al: Epidural bupivacaine and morphine plus systemic indomethacin eliminates pain but not systemic response and convalescence after cholecystectomy. Surgery 103:321, 1987

3. Dahl JB, Rosenberg J. Hansen BL et al: Differential analgesic effects of low-dose epidural morphine and morphine-bupivacaine at rest and during mobilization after major abdominal surgery. Anesth Analg 74:362, 1992

4. Mogensen T, Vegger P. Jonsson Т et al: Systemic piroxicam as an adjunct to combined epidural bupivacaine and morphine for postoperative pain relief- a doubleblind study. Anesth Analg 74:366, 1992

5. Tverskoy M, Cozacov С, Ayache M et al: Postoperative pain after inguinal herniorrhaphy with different types of anesthesia. Anesth Analg 70:29, 1990

6. Kehlet H: Surgical stress: the role of pain and analgesia. Br J Anaesth 63: 189, 1989

7. Cullen ML, Staren ED, El-Ganzouri A et al: Continuous epidural infusion for analgesia after major abdominal operations: a randomized, prospective, double-blind study. Surgery 98:718, 1985

8. Lee A, Simpson D, Whitfield A, Scott DB: Postoperative analgesia by continuous extradural infusion of bupivacaine and diamorphone. Br J Anaesth 60:845, 1988

9. Hjortsf» N-C, Luna C, Mogensen T et al: Epidural morphine improves pain relief and maintains sensory analgesia during continuous epidural bupivacaine after abdominal surgery. Anesth Analg 65:1033, 1986

10. Scott NB, Mogensen T, Bigler D et al: Continuous thoracic extradural 0.5% bupivacaine with or without morphine: effect on quality of blockade, lung function and the surgical stress response. Br J Anaesth 62:253, 1989

11. Miller IV, Dinesen К, S^ndergard S et al: Effect of patient-controlled analgesia on plasma catecholamine, cortisol and glucose concentrations after cholecystectomy. Br J Anaesth 61 :160, 1988

12. Kehlet H: Modification of responses to surgery by neural blockade: clinical implications, p. 145. In Cousins MJ, Bridenbaugh PO (eds): Neural Blockade in Clinical Anesthesia and Management of Pain. 2nd Ed. Lippincott, Philadelphia, 1988

13. Matthews PJ, Govenden V: Comparison of continuous paravertebral and extradural infusions of bupivacaine for pain relief after thoracotomy. Br J Anaesth 62:204, 1989

14. Griffiths DPG, Diamond AW, Cameron JD: Postoperative extradural analgesia following thoracic surgery: a feasibility study. Br J Anaesth 47:48, 1975

15. Conacher ID, Paes ML. Jacohson L et al: Epidural analgesia following thoracic surgery. A review of two years' experience. Anaesthesia 38:546, 1983

16. Logas WG, El-Baz N, El-Ganzouri A et al: Continuous thoracic epidural analgesia for post­operative pain relief following thoracotomy: a randomized prospective study. Anesthesiology 67:787, 1987

17. James EC, Kolherg HL, Iwen GW, Gellatly ТА: Epidural analgesia for post-thoracotomy patients. J Thorac Cardiovasc Surg 82:898, 1981

18. Miller L, Gertel M, Fox GS, MacLean LD: Comparison of effect of narcotic and epidural analgesia on postoperative respiratory function. Am J Surg 131:291, 1976

19. Hendolin H, Lahtinen J, Lansimies E et al: The effect of thoracic epidural analgesia on respiratory function after cholecystectomy. Acta Anaesthesiol Scand 31 :645, 1987

20. Hendolin H, Lahtinen J, Lanimies E, Tuppurainen T: The effect of thoracic epidural analgesia on postoperative stress and morbidity. Ann Chir Gynaecol 76:234, 1987

21. Raj PP. Knarr DC, Vigdorth E et al: Comparison of continuous epidural infusion of local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement. Anesth Analg 66:401, 1987

22. Pettine KA, Wedel DJ, Cabanela ME, Weeks JL: The use of epidural bupivacaine following total knee arthroplasty. Orthop Rev 18:894, 1989

23. Ulrich С, Burri С, Worsdorfer 0: Continuous passive motion after knee-joint arthrolysis under catheter peridural anesthesia. Arch Orthop Trauma Surg 104:346, 1986

24. Covino BG: Pharmacology of local anaesthetic agents. Br J Anaesth 58:701, 1986

25. Gissen AJ, Covino BG, Gregus J: Differential sensitivity of fast and slow fibers in mammalian nerve. III. Effect of etidocaine and bupivacaine on fast/slow fibers. Anesth Analg 61 :570, 1892

26. Cousins MJ, Bromage PR: Epidural neural blockade, p. 253. In Cousins MJ, Bridenbaugh PO (eds): Neural Blockade in Clinical Anesthesia and Management of Pain. 2nd Ed. JB Lippincott, Philadelphia, 1988

27. Brock-way MS, Bannister J, McClure JH el al: Comparison of extradural ropivacaine and bupivacaine. Br J Anaesth 66:31, 1991

28. Conception M, Arthur GR. Steele SM et al: A new local anesthetic, ropivacaine. Its epidural effects in humans. Anesth Analg 70:80, 1990

29. Bonica JJ, Berges PU, Morikawa K: Circulatory effects of peridural block. I. Effects of level of analgesia and dose of lidocaine. Anesthesiology 33:619, 1970

30. Shimosato S, Etsten BE: The role of the venous system in cardiocirculatory dynamics during spinal and epidural anesthesia in man. Anesthesiology 30:619, 1969

31. Bromaqe PR: Continuous epidural analgesia. p. 215. In Epidural Analgesia. WB Saunders, Philadelphia, 1978

32. Raj PP, Denson DD: Prolonged analgesia technique with local anesthetics, p. 687. In Raj PP (ed):

Practical Management of Pain. 1st Ed. Year Book, Chicago, 1986

33. Tucker GT, Cooper S, Litllewood D et al: Observed and predicted accumulation of local anaesthetic agents during continuous extradural analgesia. Br J Anaesth 49:237, 1977

34. Green R, Dawkins CJM: Postoperative analgesia: the use of a continuous drip epidural block. Anaesthesia 21:372, 1967

35. Denson DD, Raj PP. Saldahna F et al: Continuous perineural infusion of bupivacaine for prolonged analgesia: pharmacokinetic considerations. Int J Clin Pharmacol Ther Toxicol 21 :591, 1983

36. Denson DD, Thompson GA, Raj PP et al: Continuous perineural infusions of bupivacaine for prolonged analgesia-a rapid two-point method for estimating individual pharmacokinetic parameters. Int J Clin Pharmacol Ther Toxicol 22:512, 1984

37. Ball WD: Unstructured two-point estimation of one-compartment linear pharmacokinetic para­meters. J Clin Pharmacol 22:326, 1982

38. Tucker GT. Cooper S, Littlewood D et al: Observed and predicted accumulation of local anaesthetic agents during continuous extradural analgesia. Br J Anaesth 49:237, 1977

39. Ross RA, Clarke JE, Armitage EN: Postoperative pain prevention by continuous epidural infusion. A study of the clinical effects and the plasma concentrations obtained. Anaesthesia 35:663, 1980

40. Holmdahl MH, Sjogren S, Strom G, Wright B: Clinical aspects of continuous epidural blockade for postoperative pain relief. Upps J Med Sci 77:47, 1972

41. Sjogren S, Wright B: Blood concentration of lidocaine during continuous epidural blockade. Acta Anesthesiol Scand, suppl. 46:51, 1972

42. Scott DB, Schweitzer S, Thorn J: Epidural block in postoperative pain relief. Reg Anesth 7:135, 1982

43. Bromage PR. Pettigrew RT, Crowell DE: Tachyphlaxis in epidural analgesia: 1. Augmentation and decay of local anesthesia. J Clin Pharmacol J New Drugs 9:30, 1969

44. Renck H, Edstnjun H: Thoracic epidural analgesia III. Prolongation in the early postoperative period by intermittent injections of etidocainc with adrenaline. Acta Anesthesiol Scand 20:104, 1976

45. Renck H. Edstn^m H, Kinnberger B, Brandt G: Thoracic epidural analgesia II. Prolongation in the early postoperative period by continuous injection of I % bupivacaine. Acta Anaesthesiol Scand 20:47, 1976

46. Wiist HJ, Liehau U, Richter 0, Strasser K: Tachuphylaxis in continuous epidural anaesthesia with bupivacaine 0.125% and 0.25%. Anasth Intensivther Notf Med 15:159, 1980

47. Mogensen T, Hjortss^ N-C, Bigler D et al: Unpredictability of regression of analgesia during the continuous postoperative extradural infusion of bupivacaine. Br J Anaesth 60:515, 1988

48. Mogensen T, Scott NB. Hjort'4 N-C et al: The influence of volume and concentration of bupivacaine on regression of analgesia during continuous postoperative epidural infusion. Reg Anesth 13:122, 1988

49. Mogensen T, Dirkes W, Bigler D et al: No tachypylaxis during postoperative continuous epidural 0.125% bupivacaine infusion. Reg Anesth 13:117, 1988

50. Moir DD, Slater PJ, Thorhurn J et al: Extradural analgesia in obstetrics: a controlled trial of carbonated lignocaine and bupivacaine hydrochloride with and without adrenaline. Br J Anaesth 48:129, 1976

51. Tucker G T, Mather LE: Pharmacology of local anaesthetic agents: pharmacokinetics of local anaesthetic agents. Br J Anaesth, suppl. 47:213, 1975

52. Bigler D, Lund C, Mogensen Tet al: Tachyphylaxis during postoperative epidural analgesia - new insights (editorial). Acta Anaesthesiol Scand 31:664, 1987

53. Renck H: Tachyphlaxis during postoperative peridural analgesia of long action, p. 188. In Wii'st HJ, Zindler M (eds): New Aspects in Regional Anesthesia. Vol. 1. Springer-Verlag, Berlin, 1980

54. Mather LE: Tachyphylaxis in regional anesthesia. Can we reconcile clinical observations and laboratory measurements? p. 3. In Wust HJ, Stanton-Hicks M (eds): New Aspects in Regional Anesthesia. Vol. 4. Springer-Verlag, Berlin, 1986

55. Lipfert P, Holthusen H, Arndt JO: Tachyphylaxis to local anesthetics does not result from reduced drug effectiveness at the nerve itself. Anaesthesiology 70:71, 1989

56. Myers RR, Kalichman MW, Reisner LS, Powell HC: Neurotoxicity of local anesthetics: altered perineurial permeability, edema, and nerve fiber injury. Anesthesiology 64:29, 1986

57. Cohen EN, Levine DA, Collins JE, Gunther RE: The role of pH in the development of tachy-phylaxis to local anesthetic agents. Anesthesiology 29:994, 1968

58. Robin ED, Whaley RD, Crump CH et al: Acid-base relations between spinal fluid and arterial blood with special reference to control of ventilation. J Appi Physiol 13:385, 1958

59. Baker СЕ, Berry RL, Elston RC: Effect of pH bupivacaine on duration of repeated sciatic nerve blocks in the albino rat. Local anesthetics for neuralgia study group. Anesth Analg 72:773, 1991

60. Mogensen T, H^jgaard L, Scott NB et al: Epidural blood flow and regression of sensory analgesia during continuous postoperative epidural infusion of bupivacaine. Anesth Analg 67:809, 1988

61. Mogensen T, Simonsen L, Scott NB et al: Tachyphylaxis associated with repeated epidural injections of lidocaine is not related to changes in distribution or rate of elimination from the epidural space. Anesth Analg 69:180, 1989

62. Kraynack BJ, Gintautas J: Reversal of procaine conduction blockade by adenine nucleotides in vivo and in vitro. Acta Anaesthesiol Scand 26:334, 1982

63. Coderre TJ. Melzack R: Cutaneous hyperalgesia: contributions of the peripheral and central nervous systems to the increase in pain sensitivity after injury. Brain Res 404:95, 1987

64. Woolj CJ: Evidence for a central component of postinjury pain hypersensitivity. Nature 306:686, 1983

65. Cook AJ, WoolfCJ, Wall PD, McMahon SB: Dynamic receptive field plasticity in rat spinal cord dorsal horn following C-primary afferent input. Nature 325:151, 1987

66. Wall PD, Woolf CJ: The brief and prolonged facilitatory effects of unmyelinated afferent input on the rat spinal cord are independently influenced by peripheral nerve section. Neuroscience 17:1199, 1986

67. Wall PD, WoolfCJ: Muscle but not cutaneous C-afferent input produces prolonged increases in the excitability of the flexion reflex in the rat. J Physiol (Lond) 356:443, 1984

68. Mogensen T, Scott NB, Lund С et al: The roles of acute and chronic pain in regression of sensory analgesia during continuous epidural bupivacaine infusion. Anesth Analg 67:737, 1988

69. Akerman В, Arwestn^m E, Post С: Local anesthetics potentiate spinal morphine antinociception. Anesth Analg 67:943, 1988

70. Tejwuni GA. Rattan AK, McDonald JS: Role of spinal opioid receptors in the antinociceptive interactions between intrathecal morphine and bupivacaine. Anesth Analg 74:726, 1992

71. Shapiro LA, Hoffman S, Jedeikin R, Kaplan R: Single-injection epidural anesthesia with bupi­vacaine and morphine for prostatectomy. Anesth Analg 60:818, 1981

72. Lanz E, Kehrberger E, Theiss D: Epidural morphine: a clinical double-blind study of dosage. Anesth Analg 64:786, 1985

73. Rattan AK. McDonald JS, Tejwani GA: Antinociceptive interactions between morphine and bupivacaine given epidurally, abstracted. Anesthesiology 75:A760, 1991

74. Chestnut DH, Owen CL, Bates JN et al: Continuous infusion epidural analgesia during labor:

a randomized double-blind comparison of 0.0625% bupivacaine, 0.0002% fentanyl versus 0.125% bupivacaine. Anesthesiology 68:754, 1988

75. Hunt CO, Naulty JS, Malinow AM et al: Epidural butorphanol-bupivacaine for analgesia during labor and delivery. Anesth Analg 68:323, 1989

76. King MJ, Bowden Ml, Cooper GM: Epidural fentanyl and 0.5% bupivacaine for elective cesarean section. Anaesthesia 45:285, 1990

77. Bisgaard С, Mowisden P, Dahl JB: Continuous lumbar epidural bupivacaine plus morphine versus epidural morphine after major abdominal surgery. Eur J Anaesthesiol 7:219, 1990

78. Douglas MJ, McMorland GH, Janzen JA: Influence of bupivacaine as an adjuvant to epidural morphine for analgesia after cesarean section. Anesth Analg 67: 1138, 1988

79. Badner NH, Reimer EJ, Komar WE, Moote С A: Low-dose bupivacaine does not improve postoperative epidural fentanyl analgesia in orthopedic patients. Anesth Analg 72:337, 1991

80. Parker RK, Baron M, Heifer DL et al: Use of epidural PCA for post-operative pain management:

effect of local anesthetic on the opioid requirement, abstracted. Anesth Analg 70:S297, 1990

81. Lund С, Mogensen T, Hjortsd» N-C, Kehlet H: Systemic morphine enhances spread of sensory analgesia during postoperative epidural bupivacaine infusion. Lancet ii:1156, 1985

82. Fields HL, Vanegas H, Hentall ID, Zorman G: Evidence that disinhibition of brain stem neurones contributes to morphine analgesia. Nature 306:684, 1983

83. Fields HL, Heinricher MM: Anatomy and physiology of a nociceptive modulatory system. Phil Trans R Soc Lond [Biol] 308:361, 1985

84. Sugimoto T, Takemura M, Sakai A, Ishimuru M: Rapid transneuronal destruction following peripheral nerve transection. Pain 30:385, 1987

85. Bach S. Noreng MF, Tjellden NV: Phantom limb pain in amputees during the First 12 months following limb amputation, after preoperative lumbar epidural blockade. Pain 33:297, 1988

86. Wall PD: The prevention of postoperative pain (editorial). Pain 33:289, 1988

87. WoolfCJ, Wall PD: Morphine-sensitive and morphine- insensitive actions of C-fibre input on the rat spinal cord. Neurosci Lett 64:221, 1986

88. McQuay HJ, Carroll D, Moore RA: Postoperative orthopedic pain-the effect of opiate premedi-cation and local anaesthetic blocks. Pain 33:291, 1988

89. Bromage PR. Camporesi EM, Durant PA, Nielson CH: Influence ofepinephrine as an adjuvant to epidural morphine. Anesthesiology 58:257, 1983

90. Sfostrom S, Hartvig D, Tamsen A: Patient-controlled analgesia with extradural morphine or pethidine. Br J Anaesth 60:358, 1988

91. Loper К A, Ready LB, Downey M et al: Epidural and intravenous fentanyl infusions are clinically equivalent after knee surgery. Anesth Analg 70:72, 1990

13

Паховый параваскулярный доступ

при аналгезии поясничного сплетения (блок «З-в-1»)

Леонард Дж. Линд (Leonard J. Lind)

Посредством пахового параваскулярного доступа можно достигнуть либо блокады бедренного нерва, либо получить полную невральную бло­каду всего поясничного сплетения [I]. Локальный анестетик, введенный в малом количестве в бедренную оболочку, остается на месте введения, вызывая анестезию только бедренного нерва. При инъекции больших количеств локального анестетика под бедренную оболочку раствор «вы­давливается» проксимально в направлении поясничного сплетения. Анесте­зия при этом наступает в области бедренного, бокового кожного нерва бедра и запирательного нерва.