培训课件---局麻技术与术后镇痛管理.pptVIP

Needed – the complete picture ? ? Prevention of cancer recurrence? Perioperative EDA and outcome after major surgery Summary Perioperative EDA provides outstanding analgesia No major advantages in other outcomes As good or better alternatives now available (major knee,hip, abdominal,thoracic surgery) May have a role in:???????- high risk patients undergoing major surgery???????- reducing risk of persistent post-surgical pain???????- reducing risk of cancer recurrence Studies necessary to establish risk-benefit of this invasive and expensive technique Is bupivacaine passé? Indications for chiral “caines” Pediatric regional techniques Use of large doses of local anesthetics Administration of local anesthetics in anesthetized patients Administration of local anesthetics by non-experts (surgeons) Pregnant patients - more vulnerable if cardiac arrest Use of local anesthetics outside hospital (day-care surgery) Intravascular injection risk relatively high (1:500) (Kopacz 1999) Incidence of seizures 1:4500 (Auroy 1997) Prospective. PCEA (n = 14,223), iv PCA (n = 1591), brachial plexus cath. interscalene or axillary (n = 1737), femoral/ sciatic catheter (n = 1374) pain scores significantly better for regional techniques Complications : - epidural haematoma 1:4741 (0.02 %), risk greater with lumbar (vs thoracic) - epidural abscess 1:7142 (0.01 %) - severe neurological complications of perineural catheters 2: 3111 (0.06 %) - infection (perineural catheter) 3.7 % (no abscess) - respiratory depression PCEA 1.1 %, iv PCA 0.7 % PCEA, iv PCA and perineural catheter techniques --- are safe and efficient, --- close supervision of all these techniques by an acute pain service in the postoperative period is mandatory Rawal N et al. Eur J Anaesthesiol 1998;15:354–63 A range of reasons for this dissatisfaction with postoperative pain management Lack of organised APS Lack of qualified