堀田 訓久

Both single-injection transversus abdominis plane (TAP) block and continuous wound infiltration (CWI) provide postoperative analgesia, but no study has compared the two regional techniques. We tested the hypothesis that CWI is more effective for controlling postoperative pain compared with single-injection TAP block after laparotomy. We conducted a prospective randomized study of patients undergoing gynecologic laparotomy with midline incision through the umbilicus under general anesthesia. The patients were allocated to receive either single-injection TAP block (TAP group) or CWI (CWI group) for postoperative analgesia. All patients received intravenous patient-controlled analgesia with morphine and intravenous flurbiprofen twice daily after surgery. Postoperative pain at rest and on coughing, postoperative morphine consumption, incidence of postoperative nausea and vomiting (PONV), pruritus and urinary retention, ambulation, and satisfaction score were recorded. Patients were assessed at 3 h after surgery and twice daily on postoperative days (POD) 1 and 2. Data of 54 patients were analyzed. Compared to the TAP group (n = 27), pain score on coughing was significantly lower in the CWI group (n = 27) on POD1 and POD2 (P < 0.05). Pain score on coughing at 3 h after surgery, pain score at rest at all assessed time points, morphine consumption, incidence of PONV, pruritus and urinary retention, ambulation, and satisfaction score were not different between the two groups. CWI reduced pain on coughing after the day of surgery compared with single-injection TAP block when performed as part of multimodal analgesia in patients undergoing gynecologic laparotomy.

肺がんによる難治性胸部痛に対し，オピオイド，放射線治療にアルコールを用いた超音波ガイド下胸部傍脊椎ブロック（US-TPVB）を併用し，良好な除痛効果が得られた症例を経験した．症例は右下葉肺がんの61歳，女性．原発巣の増大，右肋骨転移，胸膜播種に伴う右胸部痛を認めた．オピオイドの増量，肋間神経ブロック，間欠的硬膜外ブロックでは対処困難であったため，アルコールを用いたUS-TPVBを行い，いったんは鎮痛が得られた．しかし，痛みが悪化し，病巣の拡大が判明したため，放射線照射と1回目より尾側でのアルコールによるUS-TPVBを行った．以後6カ月間，痛みとオピオイド投与量は減少し，患者の活動性は改善した．TPVBは，体幹片側を除痛でき，術後鎮痛では硬膜外ブロックと鎮痛効果が同等で，合併症が少ないことが示されている．これらの特徴を考慮すると，神経破壊薬を用いたUS-TPVBは適切な症例を選べば，がん性痛治療の選択肢になると考えられる．進行肺がんによる難治性がん性痛に対し，アルコールによるUS-TPVBを併用することで良好な除痛効果が得られた．

We report three cases of continuous wound infiltration (CWI) for postoperative analgesia in upper abdominal surgery using the multi-holed epidural catheter. Ropivacaine 0.2% at a rate of 8 ml·hr-1 was administered through the catheters after surgery. Intravenous-patient controlled analgesia was used as a rescue. The postoperative pain was well controlled, and all patients could walk the next day after surgery. The consumption of rescue morphine was little and no side effect of morphine was observed. CWI is an easy procedure and is indicated in the patients with hemostatic abnormality and a difficulty in the epidural anesthesia. CWI was an effective technique for postoperative pain control in the upper abdominal surgery patients.

Design: A prospective, randomized, open study. The regional technique used was not blinded. Setting: A university teaching hospital. Participants: Forty-eight patients undergoing video-assisted thoracoscopic surgery (VATS) for tumor resection. Interventions: Patients received either continuous extrapleural block or continuous epidural block using ropivacaine for a period of 60 hours after surgery. Measurements and Main Results: To evaluate postoperative pain control, the primary and secondary endpoints were the visual analog scale (VAS) on movement and the amount of rescue analgesia, respectively. There were no significant differences between the extrapleural and epidural block groups with regard to VAS at rest and during movement assessed at 4, 12, 24, 36, and 48 hours after surgery, dosage of intravenous morphine (extrapleural: 12.9 +/- 11.3, epidural: 10.2 +/- 6.9 mg), supplemental nonsteroidal anti-inflammatory drugs, incidence of postoperative nausea and vomiting (extrapleural: 12/20, epidural: 11/20), postoperative ambulation (extrapleural: 18 at postoperative day [POD] 1 and 20 at POD 2, epidural: 19 at POD 1 and 20 at POD 2) and hospital stay after surgery (extrapleural: 12.7 +/- 6.3, epidural: 12.6 +/- 4.7 days). Conclusions: Although this study did not show the superiority of continuous extrapleural block relative to continuous epidural in VATS patients, the results suggest that both methods provided effective analgesia with a relatively small dose of rescue morphine. Although the analgesic effects of these techniques were comparable, extrapleural block has the advantage of safety and precise placement of the catheter and can be considered an alternative to epidural block in VATS patients. (C) 2011 Published by Elsevier Inc.

Background: To evaluate obstetric and anesthetic problems relating to cesarean delivery, we investigated parturients who had undergone cesarean section at the Center for Perinatal and Neonatal Medicine in Jichi Medical University Hospital. Methods: Obstetric and anesthetic data were gathered from January 2007 to December 2007 for all cesarean sections. Results: In all, 607 parturients received cesarean section during the period. Of the 607 cesarean deliveries, 308 were performed in elective condition, and 299 were done in emergency situation. Of the 299 emergencies, 125 underwent cesarean section at nights and/or holidays. Population risk included maternal age (age&gt 35 year, 33.1%), preterm birth (31.5%), and obesity (BMI&gt 35kg·m-2, 3.3%). Complicated pregnancy included multifetal pregnancies (15.2%) and placenta previa(12.5%). Conclusions: At the center for perinatal and neonatal medicine, population risk is increasing because of increases in maternal age, obesity, placenta previa, and rates of multifetal pregnancies.

We report two cases of elderly patients who underwent ultrasound-guided combined femoral nerve and lateral femoral cutaneous nerve blocks for osteosynthesis of femur neck fracture. In both cases, neuraxial anesthesia was contraindicated due to coagulopathy, and severe restrictive ventilatory disorder was observed. The femoral nerve and lateral femoral cutaneous nerve blocks were performed with 20 ml of 0.375% ropivacaine under ultrasonographic visualization using a high frequency linear probe. Ultrasonographic visualization was useful to identify the needle tip and to observe the spread of local anesthetics. Supplemental local infiltration of anesthetics and intravenous low-dose sedative drugs were administered during surgery. The perioperative course was uneventful in both cases. This combined block technique could be a choice for osteosynthesis of femur neck fracture especially in high-risk patients.

Epidural block is performed with surface landmark guidance and loss of resistance technique. Ultrasound visualization of the spinal column and surrounding structures gives additional anatomical information, which could make the block easier and safer. Previous studies revealed that there is strong correlation between the depth of the epidural space measured using ultrasound and the depth of the needle inserted. In order to obtain an image of the spinal canal, the ultrasound probe is positioned at the interspace of spinous processes in transverse and longitudinal planes. The dura mater is identified as an echogenic structure inside the spinal canal. Prepuncture ultrasound examination offers useful information for epidural block such as puncture point and depth as well as angle to the epidural space.