采用造影技术观察局麻药在老年患者硬膜外腔的扩散
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摘要
目的：老年人硬膜外腔解剖结构的改变，如老年人骨质增生、椎间盘突出、椎间孔闭锁、黄韧带和后纵韧带钙化、关节退化变性等导致的椎管狭窄；高血压，血管硬化，硬脊膜的通透性改变等降低局麻药的吸收，局麻药容易在硬膜外腔广泛扩散导致阻滞平面增宽。本研究目的通过硬膜外腔造影技术观察局麻药在老年患者硬膜外腔的扩散情况，探讨硬膜外麻醉的用药特点。
方法：本研究经河北医科大学第三医院伦理委员会批准。选择ASAⅠ-Ⅲ患者60例，根据年龄分为老年组（65-74岁）和青年组（25-34岁）。患者均取左侧卧位，L2～L3间隙穿刺，头侧置管3cm。回吸阴性以每分钟5毫升速度注入2%氯普鲁卡因5m（l5%盐酸氯普鲁卡因用灭菌注射用水稀释成10ml,取5%盐酸氯普鲁卡因2ml与3ml造影剂（非离子型碘海醇300mgI/ml）混合配成2%氯普鲁卡因）。以穿刺点为中心，患者左侧卧位躺在影像板上，球管与影像板的距离调整到101cm,调整焦距。5分钟后应用移动式数字摄影X线系统照相，观察2%氯普鲁卡因在硬膜外腔的扩散显影情况，记录含造影剂的2%氯普鲁卡因在硬膜外腔的显影长度及其扩散的相应椎体数，计算每个节段所需要局麻药的毫升数。用针刺法和酒精棉球测试皮肤痛觉、温度觉的阻滞平面。
结果：
1一般情况比较,两组患者性别、体重、身高比较无统计学差异（P>0.05）。
2老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为13.0±2.8cm;青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为9.0±2.1cm。两组比较，含碘海醇的2%氯普鲁卡因在老年组硬膜外腔的显影长度明显大于青年组（P<0.05）。
3老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为5.3±1.2个节段；青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为3.3±0.8个节段。两组比较,含碘海醇的2%氯普鲁卡因在老年人硬膜外腔扩散的椎体数明显大于青年组（P<0.05）。
4老年组中阻滞每个神经节段所需的局麻药容量为1.0±0.2ml;青年组中阻滞每个神经节段所需的局麻药容量为1.6±0.4ml。两组比较，老年组阻滞每个脊神经节段所需要的局麻药容量明显少于青年组（P<0.05）。
5老年组中温度觉阻滞平面为6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；青年组中温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段。两组比较，老年组的温度觉阻滞平面、痛觉阻滞平面明显高于青年组（P<0.05）。
6老年组内温度觉阻滞平面6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为5.3±1.2个节段。温度觉、痛觉阻滞平面与2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。老年患者的痛觉与温度觉阻滞平面比较无统计学差异（P>0.05）。
7青年组内温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为3.3±0.2个节段。温度觉、痛觉阻滞平面与含碘海醇的2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。青年患者的痛觉与温度觉阻滞平面比较有统计学差异（P<0.05）。
结论：
1相同容量的局麻药在老年人硬膜外腔的扩散范围明显大于青年人，老年人硬膜外麻醉用药量宜减少。
2老年人阻滞一个神经节段所需氯普鲁卡因的量为1.0（0.8-1.2）ml/节段；青壮年阻滞一个神经节段所需氯普鲁卡因的量为1.6（1.2-2.0）ml/节段。
Objective:The anatomic changes of epidural space with oldpeople,included bone hyperplasia, ligament calcification, degenerative joint,These lead to spinal canal stenosis.High blood pressure, vascularsclerosis,permeability reduce of endorhachis reduce the absorption of localanesthetics.Local anesthetics was easy to widely spread in the epiduralspace,lead to high block plane.The purpose of the research, through theepidural canvity imaging technology,observed the diffusion of localanesthetics in elderly patients’s epidural space, investigated the characteristicsof epidural anesthesia medication.
Methods：The study protocol was approved by Ethics Committee ofHebei Medical University Third Hospital. Written informed consent wasobtained from each patient after a detailed explanation of the protocol.Sixtypatients (ASA physical status Ⅰ to Ⅲ) were enrolled in this study.All patientsenrolled in this study were divided into two groups on the basis of age:(Ⅰ) the elderlygroup (65~74yr of age,13female and15male patients)(Ⅱ)the young group (25~34yr of age,12female and17male patients).They wereplaced in the left lateral position on a horizontal operating table. Epiduralpuncture was performed aseptically by an attending anesthetist at the L2-L3level of the lumbar intervertebral space using a reusable16G winged Tuohyneedle by a paramedian approach with the loss of resistance(LOR) to air using0.3ml.On entering the epidural space,the bevel of the needle was pointedcephalad.The epidural catheter was advanced3cm in the cephalad directioninto the epidural space.After confirming negative aspiration of cerebrospinalfluid and blood,5ml of2%chloroprocaine with3ml Omnipaque was injectedat the rate of5ml.min-1(5%chloroprocaine was diluted with sterilizationinjection water into10ml. Take2ml of (5%chloroprocaine and3ml of iohexol(nonionic300mgI/ml) made up with5ml of2%chloroprocaine) in theleft lateral position. Five minutes after injection of the anesthetic,the spreadwas studied by taking X-rays after both injections in the left lateral position.The spread of contrast medium were recorded by epidurograms after5mlinjection of2%chloroprocaine through the epidural catheter. Five minutesafter the anesthetics injection,assessment of the spread of hypesthesia to coldand pain on both sides of the body according to a dermatomal chart,usingcotton soaked in rubbing alcohol and pinprick,was performed by an individualblinded to determine the sensory blockade.The extent of the hypesthesia wascalculated as the average dermatome of both side.
Results:
1No statistically significant differences were found between the elderlygroup and the young group on sex, weight, height（P>0.05）.
2The total radiographic length of2%chloroprocaine in epidural canvitywere13.0±2.8cm in the elderly group. The total radiographic length of2%chloroprocaine were9.0±2.1cm in the young group.The total radiographiclength of2%chloroprocaine was significantly greater in the elderly groupthan in the young group.(P<0.05).
3The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments in the elderly group.The spread segments of2%chloroprocaine in epidural canvity were3.3±0.8segments in the younggroup.The spread segments of2%chloroprocaine was significantly greater inthe elderly group than in the young group.(P<0.05).
4The dose of one spinal segment were1.0±0.2ml in the elderly group,The dose of one spinal segment were1.6±0.4ml in the young group. The doseof one spinal segment was statistically lesser in the elderly group than in theyoung group (P<0.05).
5In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes. In the young group, thenumber of spinal segments with hypesthesia for prinprick were3.3±0.4 dermatomes, the number of spinal segments with hypesthesia for coldnesswere2.8±0.3dermatomes. the number of spinal segments with hypesthesia forprinprick and the number of spinal segments with hypesthesia for coldnesswas significantly greater in the elderly group than in the younggroup(p<0.05).
6In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes.The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments.There were nosignificant differences between the number of spinal segments withhypesthesia for coldness and prinprick (p>0.05). There were no significantdifferences between the number of spinal segments with hypesthesia forprinprick and the spread segments of2%chloroprocaine(p>0.05). There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05).
7In the young group, the number of spinal segments with hypesthesiafor prinprick were2.8±0.3dermatomes, the number of spinal segments withhypesthesia for coldness were3.3±0.4dermatomes, the spread segmentsofof2%chloroprocaine in epidural canvity were3.3±0.2segments. There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05). There were no significant differences between the number of spinalsegments with hypesthesia for prinprick and the spread segments of2%chloroprocaine (p>0.05). The number of spinal segments with hypesthesiafor coldness was significantly wider than the number of spinal segments withhypesthesia for prinprick in the young group(p<0.05).
Conclusion:
1The spread of local anesthetics in epidural space was significantlygreater in the elderly group than in the young group with the same volum ofanesthetic solution，the dosage of epidural anesthesia should reduce in the elderly patients.
2The dose of one spinal segment were1.0±0.2ml in the elderly patientsgroup, The dose of one spinal segment were1.6±0.4ml in the young paients.
方法：本研究经河北医科大学第三医院伦理委员会批准。选择ASAⅠ-Ⅲ患者60例，根据年龄分为老年组（65-74岁）和青年组（25-34岁）。患者均取左侧卧位，L2～L3间隙穿刺，头侧置管3cm。回吸阴性以每分钟5毫升速度注入2%氯普鲁卡因5m（l5%盐酸氯普鲁卡因用灭菌注射用水稀释成10ml,取5%盐酸氯普鲁卡因2ml与3ml造影剂（非离子型碘海醇300mgI/ml）混合配成2%氯普鲁卡因）。以穿刺点为中心，患者左侧卧位躺在影像板上，球管与影像板的距离调整到101cm,调整焦距。5分钟后应用移动式数字摄影X线系统照相，观察2%氯普鲁卡因在硬膜外腔的扩散显影情况，记录含造影剂的2%氯普鲁卡因在硬膜外腔的显影长度及其扩散的相应椎体数，计算每个节段所需要局麻药的毫升数。用针刺法和酒精棉球测试皮肤痛觉、温度觉的阻滞平面。
结果：
1一般情况比较,两组患者性别、体重、身高比较无统计学差异（P>0.05）。
2老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为13.0±2.8cm;青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔的显影长度为9.0±2.1cm。两组比较，含碘海醇的2%氯普鲁卡因在老年组硬膜外腔的显影长度明显大于青年组（P<0.05）。
3老年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为5.3±1.2个节段；青年组中含碘海醇的2%氯普鲁卡因在硬膜外腔扩散的椎体数为3.3±0.8个节段。两组比较,含碘海醇的2%氯普鲁卡因在老年人硬膜外腔扩散的椎体数明显大于青年组（P<0.05）。
4老年组中阻滞每个神经节段所需的局麻药容量为1.0±0.2ml;青年组中阻滞每个神经节段所需的局麻药容量为1.6±0.4ml。两组比较，老年组阻滞每个脊神经节段所需要的局麻药容量明显少于青年组（P<0.05）。
5老年组中温度觉阻滞平面为6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；青年组中温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段。两组比较，老年组的温度觉阻滞平面、痛觉阻滞平面明显高于青年组（P<0.05）。
6老年组内温度觉阻滞平面6.6±0.7个节段、痛觉阻滞平面6.3±0.7个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为5.3±1.2个节段。温度觉、痛觉阻滞平面与2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。老年患者的痛觉与温度觉阻滞平面比较无统计学差异（P>0.05）。
7青年组内温度觉阻滞平面3.3±0.4个节段、痛觉阻滞平面2.8±0.3个节段；含造影剂的2%氯普鲁卡因在硬膜外腔显影的节段数为3.3±0.2个节段。温度觉、痛觉阻滞平面与含碘海醇的2%氯普鲁卡因在硬膜外腔显影的节段数相一致，无统计学差异（P>0.05）。青年患者的痛觉与温度觉阻滞平面比较有统计学差异（P<0.05）。
结论：
1相同容量的局麻药在老年人硬膜外腔的扩散范围明显大于青年人，老年人硬膜外麻醉用药量宜减少。
2老年人阻滞一个神经节段所需氯普鲁卡因的量为1.0（0.8-1.2）ml/节段；青壮年阻滞一个神经节段所需氯普鲁卡因的量为1.6（1.2-2.0）ml/节段。
Objective:The anatomic changes of epidural space with oldpeople,included bone hyperplasia, ligament calcification, degenerative joint,These lead to spinal canal stenosis.High blood pressure, vascularsclerosis,permeability reduce of endorhachis reduce the absorption of localanesthetics.Local anesthetics was easy to widely spread in the epiduralspace,lead to high block plane.The purpose of the research, through theepidural canvity imaging technology,observed the diffusion of localanesthetics in elderly patients’s epidural space, investigated the characteristicsof epidural anesthesia medication.
Methods：The study protocol was approved by Ethics Committee ofHebei Medical University Third Hospital. Written informed consent wasobtained from each patient after a detailed explanation of the protocol.Sixtypatients (ASA physical status Ⅰ to Ⅲ) were enrolled in this study.All patientsenrolled in this study were divided into two groups on the basis of age:(Ⅰ) the elderlygroup (65~74yr of age,13female and15male patients)(Ⅱ)the young group (25~34yr of age,12female and17male patients).They wereplaced in the left lateral position on a horizontal operating table. Epiduralpuncture was performed aseptically by an attending anesthetist at the L2-L3level of the lumbar intervertebral space using a reusable16G winged Tuohyneedle by a paramedian approach with the loss of resistance(LOR) to air using0.3ml.On entering the epidural space,the bevel of the needle was pointedcephalad.The epidural catheter was advanced3cm in the cephalad directioninto the epidural space.After confirming negative aspiration of cerebrospinalfluid and blood,5ml of2%chloroprocaine with3ml Omnipaque was injectedat the rate of5ml.min-1(5%chloroprocaine was diluted with sterilizationinjection water into10ml. Take2ml of (5%chloroprocaine and3ml of iohexol(nonionic300mgI/ml) made up with5ml of2%chloroprocaine) in theleft lateral position. Five minutes after injection of the anesthetic,the spreadwas studied by taking X-rays after both injections in the left lateral position.The spread of contrast medium were recorded by epidurograms after5mlinjection of2%chloroprocaine through the epidural catheter. Five minutesafter the anesthetics injection,assessment of the spread of hypesthesia to coldand pain on both sides of the body according to a dermatomal chart,usingcotton soaked in rubbing alcohol and pinprick,was performed by an individualblinded to determine the sensory blockade.The extent of the hypesthesia wascalculated as the average dermatome of both side.
Results:
1No statistically significant differences were found between the elderlygroup and the young group on sex, weight, height（P>0.05）.
2The total radiographic length of2%chloroprocaine in epidural canvitywere13.0±2.8cm in the elderly group. The total radiographic length of2%chloroprocaine were9.0±2.1cm in the young group.The total radiographiclength of2%chloroprocaine was significantly greater in the elderly groupthan in the young group.(P<0.05).
3The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments in the elderly group.The spread segments of2%chloroprocaine in epidural canvity were3.3±0.8segments in the younggroup.The spread segments of2%chloroprocaine was significantly greater inthe elderly group than in the young group.(P<0.05).
4The dose of one spinal segment were1.0±0.2ml in the elderly group,The dose of one spinal segment were1.6±0.4ml in the young group. The doseof one spinal segment was statistically lesser in the elderly group than in theyoung group (P<0.05).
5In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes. In the young group, thenumber of spinal segments with hypesthesia for prinprick were3.3±0.4 dermatomes, the number of spinal segments with hypesthesia for coldnesswere2.8±0.3dermatomes. the number of spinal segments with hypesthesia forprinprick and the number of spinal segments with hypesthesia for coldnesswas significantly greater in the elderly group than in the younggroup(p<0.05).
6In the elderly group, the number of spinal segments with hypesthesiafor prinprick were6.6±0.7dermatomes, the number of spinal segments withhypesthesia for coldness were6.3±0.7dermatomes.The spread segments of2%chloroprocaine in epidural canvity were5.3±1.2segments.There were nosignificant differences between the number of spinal segments withhypesthesia for coldness and prinprick (p>0.05). There were no significantdifferences between the number of spinal segments with hypesthesia forprinprick and the spread segments of2%chloroprocaine(p>0.05). There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05).
7In the young group, the number of spinal segments with hypesthesiafor prinprick were2.8±0.3dermatomes, the number of spinal segments withhypesthesia for coldness were3.3±0.4dermatomes, the spread segmentsofof2%chloroprocaine in epidural canvity were3.3±0.2segments. There wereno significant differences between the number of spinal segments withhypesthesia for coldness and the spread segments of2%chloroprocaine(p>0.05). There were no significant differences between the number of spinalsegments with hypesthesia for prinprick and the spread segments of2%chloroprocaine (p>0.05). The number of spinal segments with hypesthesiafor coldness was significantly wider than the number of spinal segments withhypesthesia for prinprick in the young group(p<0.05).
Conclusion:
1The spread of local anesthetics in epidural space was significantlygreater in the elderly group than in the young group with the same volum ofanesthetic solution，the dosage of epidural anesthesia should reduce in the elderly patients.
2The dose of one spinal segment were1.0±0.2ml in the elderly patientsgroup, The dose of one spinal segment were1.6±0.4ml in the young paients.
引文
1Sadean MR,Glass PS.Pharmacokinetic in the elderly.Best Pract ResClin Anaesthesiol,2003,17:191-205
2Gassel HJ,Meyer D, Sailer M, et al. Nononcologic abdominal surgery inthe elderly. Chirurq,2005,76(1):35-42
3Simon MJ, Veering BT, Stienstra R, et al. Effect of age on theclinical profile and systemic absorption and disposition of levobupivacaineafter epidural administration. Br J Anaesth,2004,93:512-520
4Yokoyama M, Ohtomo N, Sonoda H, et al. The spread of contrast mediumin the epidural space and the analgesic area in epidural anesthesia inelderly patients.Masui,1996,45(9):1067-1067
5Simon MJ, Veering BT, Vletter AA, et al.The effect of age on the systemicabsorption and systemic disposition of ropivacaine after epiduraladministration.Anesth Analg,2006,102:276-282
6Blomberg RG,Olsson SS.The lumber epidural space in patients examinedwith epiduroscopy.Anesth Analg,1989,68:157-160
7Bromage PR.Mechanism of action of extradural analgesia. BrAnaesth,1975,47；199-211
8Hogan, Quinn M.D. Distribution of Solution in the Epidural Space:Examination by Cryomicrotome Section Regional Anesthesia&PainMedicine,2002,27(2):150-156
9Igarashi T, Hirabayashi Y, Shimizu R,et al.The lumbar extradural structurechanges with increasing age. Br J Anaesth,1997,78:149-152
10Watanabe S,Takeshima R, Asakura N, et al. The effect of age on retrievalof local anesthetic solution from the epidural space. AnesthAnalg,1997,85(5):1091-6
11Aogt MT. Lower extremity arterial disease and the aging process-review.JClin Epidermol,1992,45(3):529-529
12Bromage PR. Exaggerated spread of epidural analgesia in arterioscleroticpatients:dosage in relation to biological and chronological ageing. BMJ,1962,2:1634-8
13Tucker GT,Mather LE. Absorption and disposition of localanesthetics:pharmacokinetic. Neural blockade in clinical anesthesia andmanagement of pain. Philadelphia:JB lippincont,1980,45-58
14Brendan T, Finucane MD, Willian D,et al.Influence of age on vascularabsorption of lidocaine from the epidural space. Anesth Analg,1987,66:843-6
15Visser MD, Ruben A, Lee BE, et al. Factors affecting the distribution ofneural blockade by local anesthetics in epidural anesthesia and acomparison of lumber versus thoracic epidural anesthesia. Anesth Analg,2008,107(2):708-721
16Parkin IG, Harrison GR. The topographical anatomy of the lumbarextradural space. Journal of Anatomy,1985,141:211-217
17Iseri T, Nishimura R, Nagahama S, et al. Epidural spread of iohexolfollowing the use of air or saline in the 'loss of resistance' test. Vet AnaesthAnalg.2010,37(6):526-30
18Toshiyuki MD, Sumio MD.Saline-anesthetic interval and the spread ofepidural anesthesia.Can J Anesth,1999,46(10):935-938
19Alley DG, Amico JA, Rybicki LA,et al. The effect of posture on theinduction of epidural anesthesia for peripheral vascularsurgery.RegAnesth1995,20:407-11
20Ernest M, Grundy MD,Alon P,et al. Epidural anesthesia and the lateralposition. Anesth Analg1978,57:95-97
21Park WY, Hagins FM, Macnamara TE. Lateral position and epiduralanesthetic spread. Anesth Analg1983,62:278-9
22Hirabayashi Y,Sbimizu R, Masuda I,et al. Effect of extradural complianceand resistance on spread of extradural analgesia. Br J Anaeshth,1990,65:508-13
23Usubiaga JE, Wikinski JA,Usubiaga LE.Epidural pressure and its relationto spread of anesthetic solutions in epidural space.AnesthAnalg,1967,46:440-6
24Cardoso MMSC,Carvalbo JCA.Epidural pressures and spread of2%lidocaine in the epidural space:influence of volume and spread of injectionof the local anesthetic solution. Reg Anesth Pain Med,1998,23:14-9
25Yokoyama MD,Hanazakl MD, Fujii MD,et al.Correlation between thedistribution of contrast medium and the extent of blockade during epiduralanesthesia.Anesthesiology,2004,100:1504-10
26Mrcs K, Watson D, Campbell C,et al.Intra-articular injection composed ofseroid,iohexol and local anaesthetic-is it stable? TheBritish Journal ofRadiology,2009,82:109-11
27Oberts RE, Selcer BA. Myelography and epidurography. Vet Clin NorthAm Small Anim Pract,1993,23(2):307-29
28Fatone G, Lamagna F, Pasolini MP, et al. Myelography in the dog withnon-ionic contrast media at different iodine concentrations. J Small AnimPract,1997,38(7):292-4
29Shimizu J, Yamada K, Kishimoto M, et al.The difference of contrasteffects of myelography in normal dogs:comparison of iohexol(180mgI/ml), iohexol(240mgI/ml) and iotrolan(240mgI/ml). J Vet Med Sci,2008,70(7):659-63
30高秀梅，杨拔贤，顾健，等.氯普鲁卡因硬膜外阻滞时的药效学和药代动力学.临床麻醉学杂志,2007,23:379-381
31詹晓光，肖哲文.盐酸氯普鲁卡因硬膜外麻醉用于下腹部手术40例观察.福建医药杂志,2010,32（1）：131-132
32Cusick JF, Myklebust JB, Abram SE. Differential neural effects ofepidural local anesthetic. Anesthesiology,1980,53:299-306
33徐福涛，骆璇,林建.国产盐酸氯普鲁卡因硬膜外麻醉的临床试验[J].临床麻醉学杂志,2000,16（7）：358-359
1Gassel HJ,Meyer D, Sailer M, et al. Nononcologic abdominal surgery in theelderly. Chirurq,2005,76(1):35-42
2Pavelescu D, Mirea L,Paduraru M, et al. The role of multimodal analgesia inthe decrease of postoperative surgical stress responsein major neoplasticthoraco-abdominal surgery. Chirurqia(Bucur),2011,106(6):723-8
3Cohendy R,Brougere A,Cuvillon P. Anaesthesia in the older patient.CurrOpin Clin Nutr Metab Care,2005,8(1);17-21
4Simon MJ, Veering BT, Stienstra R, et al. Effect of age on the clinical profileand systemic absorption and disposition of levobupivacaine after epiduraladministration. Br J Anaesth,2004,93:512-520
5SSakura S, Saito Y, Kosaka Y. Effect of extradural anaesthesia on theventilatory response to hypoxaemia. Anaesthesia,1993,48:205-9
6Hulzebos EH, Helders PJ, Favie NJ, et al. Preoperative intensive inspiratorymuscle training to prevent postoperative pulmonary complications inhigh-risk patients undergoing CABG surgery: a randomized clinical trial.JAMA,2006,296(15):1851-1857
7Panaretou V, Toufektzian L,Siafaka I,et al. Postoperative pulmonaryfunction after open abdominal aortic aneurysm repair in patients withchronic obstructive pulmonary disease:epidural versus intravenousanalgesia. Ann Vasc Surg,2012,26(2):149-55
8Ozcan PE, Senturk M,Ulke ZS, et al. effects of thoracic epidural anaesthsiaon pulmonary venous admixture and oxygenation during one-lungventilation. Acta Anaesthesiol Scand,2007,51(8):1117-22
9Groeben H: Epidural anesthesia and pulmonary function. J Anesth,2006,20:290-299
10Kirow MY, Eremeev AV, Smetkin AA, et al. Epidural anesthesia andpostoperative analgesia with ropivacaine and fentanyl in off-pumpcoronary artery bypass grafting:a randomized,controlled study. BMCAnesthesiol,2011,18:11-17
11Daniel M, P pping MD, Nadia Elia MD, et al. Protective Effects ofEpidural Analgesia on Pulmonary Complications After Abdominal andThoracic Surgery。Arch Surg,2008,143(10):990-999
12Simeoforidou M,Vretzakis G, Bareka M, et al. Thoracic epidural analgesiawith levobupivacaine for6postoperative days attenuates sympatheticactivation after thoracic surgery. J Cardiothorac Vasc Anesth,2011,25(5):817-23
13Guo Z, Wang JP. Blockade of spinal nerves attenuates myocardialapoptosis in acute myocardial ischaemia/infarction in rats. Eur JAnaesthesiol,2010,27(2):146-52
14Kilickan L, Solak M, Bayindir O. Thoracic epidural anesthesia preservesmyocardial function during intraoperative and postoperative period incoronary artery bypass grafting operation. J Cardiovasc Surg,2005,46(6):559-67
15Yang SS, Han H, Cao Y, et al. Effects of high thoracic epidural anesthesiaon atrial electrophysiological characteristics and sympathetic nervesprouting in a canine model of artial fibrillation. Basic Res Cardiol,2011,106(3):495-506
16Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epiduralanesthesia on coronary arreries and arterioles in patients with coronaryartery disease. Anesthesiology,1990,73:840-847
17Casalino, Fabio M, Edmond S, et al. High thoracic epidural anesthesia incardiac surgery risk factors for arterial hypotension stefano.Tesler TexHeart Inst J，2006,33(2):148-153
18Chrousos GP,Gold PW.The concepts of stress and stress system disorders:Overview of physical and behavioral homeostasis.JAMA,1992,267(9):1244-1252
19Vuori A,Salo M,Viljanto J,et al. effects of postoperative pain treatmentusing non-steroidal anti-inflammatory analgesics, opioids or epiduralblockade oilsystemic and local immune responses in children. ActaAnaesthesiol Scand,2004,48(6):738-49
20Xing CY, Wu MY, Fan HP. Effects of different anesthetic and analgesicprotocols on cellular immune function and stress hormone level in patientsundergoing lobectomy for esophagus cancer. Nan Fang Yi Ke Da Xue XueBao,2010,30(2):284-7
21Taylor NM, Lacoumenta S, Hall GM.Fentanly and the interleukin-6response to surgery.Anaesthrsia,1997,52:112-115
22Segawn H,Mori K Kasai K,et al.The role of the phrenic nerves in stressresponse in upper abdominal surgery.Anesth Analg,1996,82(6):1215-1224
23Lewis K S,Whipple J K,Michael K A,et al. Effect of analgesic treatment onthe physiological consequences of acute pain.Am J Hosp pharm,1994,51(12):1539-1554
24Palomero Rodriquez MA, Suarez Gonzalo L, Villar Alvarez F, et al.Thoracic epidural anesthesia decreases C-reactive protein levels in patientsundergoing elective coronary artery bypass graft surgery withcardiopulmonary bypass. Minerva Anestesiol,2008,74(11):619-26
25addox TM. Preoperative cardiovascular evaluation for noncardiac surgery.Mt Sinai J Med,2005,72(3):185-192
26Sum JZ, Maguire D.How to prevent perioperative myocardial injury:theconundrum continues.Am Heart J,2007,154(6):1021-1028
27Gottschalk A. Regional anaesthesia and organ protection the role ofthoracic epidural anaesthesia. Anasthesiol Intensivmed NotfallmedSchmerzther,2010,45(4):264-9
28Choileain NN,Redmond HP. Cell response to surgery.Arch Surg,2006,141(11):1132-40
29Takada M, Fukusaki M,Terao Y.Preadministration of flurbiprofensuppersses prostaglandin prodaction and postoperative pain in orthopedicpatients undergoing tourniquet inflation.Journal of Clinical Anesthesia,2007,(2):1176-1177
30Volk T, Schenk M, Voigt K,et al. Postoperative epidural anesthesiapreserves lymphocyte,but not monocyte,immune function after major spinsurgey.Anesth Analg,2004,98(6):1086-92
31Gajdosz R. Evaluation of regional analgesia and surgical trauma onselected factor of the human immune system.Folia Med Cracov,1994,35(1-4):69-86
32Bonzion B, Shavit Y,Trabekin E,et al.The effect of postoperative painManagement on immune response to surgery.Anesth Analg,2003,97(9):822-827
33Roediger L,Joris J,Senard M, et al.The use of pre-operative intrathecalmorphine for analgesia following coronary artery bypasssurgery.Anaesthesia,2006,61(9):838-44
34Hendrik Freise,M D,Stefan Lauer,Soeren Anthonsen,et al. Tboracicepidural analgesia augments ileal mucosal capillary perfusion andimprovessurvival in severe acute pancreatitis in rat.Anesthesiology,2006,105:354-9
35Taqi A,Hong X,Mistraletti G,et al.Thoracic epidural analgesia facilitates therestoration of bowel function and dietary intake in patients undergoinglaparoscopic colon resection using a traditional, nonaccelerated,perioperative care progarm.Surg Endosc,2007,21(2):247-52
36Vagts, Iber, Szabo, et al.Effects of epidural anaesthesia on intestinaloxygenation in pigs. British Journal of Anaesthesia,2003,90(2):212-20
37Adolphs, Diego, Schmidt, et al. Thoracic epidural anesthesia attenuateshemorrbage-induced impairment of intestinal perfusion in rats.Anesthesiology,2003,99:685-92
38Davis FM, Medromott E,Hickton C, et al. Influence of spinaland generalanaesthesia on haemostasis during total hip arthroplasty. Br JAnaestg,1987,59(5):561-571
39Rosenfeld BA, Beattie C, Christopherson R, et al The effect of differentanesthetic regimens on fibronolysis and the development of postoperativearterial thrombosis.Anesthesiology,1993,79(3):435-443
40Hafezi F,Naqhibzadeh B,Nouhi AH, et al. Epidural anesthesia as athromboembolic prophylaxis modality in plastic surgery. Aesthet Surg J,2011,31(7):821-4
41孟琛，汤哲，方向华，等.北京老年人认知功能对对生存率影响的八年随访观察.中华老年医学杂志，2004,23:507-509
42Sauer AM, Kalkman C, et al.Postoperative cognitive decline.J Anesth,2009,23(2):256-9
43Steinmetz J，Rasmussen LS. Cognitive deterioration after surgery. UgeskrLaeger,2008,170:4032-4
44Rasmussen L, Brier JT, Silverstein T H,et al. Is peri-operative cortisolsecretion related to post-operative cognitive dysfunction? ActaAnaesthesiol Scand,2005,49(9):1225-1231
45Fujita Y,Nakamura K,Horiguchi Y, et al.Effect of different perioperativeanalgesic methods on postoperative cognitive dysfunction in elderlypatients undergoing upper abdominal surgery.Masui,2011,60(10):1153-8
46Olker AR, Hawes DW, Jordan WS, et al. Use of epidural anesthesia andspontaneous ventilation during transab-dominal colon and rectalprocedures in selected high-risk patient groups. Dis ColonRectum,1997,40(3):339-340
47朱谦,刘莎莎,贾乃光.单侧蛛网膜下腔阻滞对老年患者循环呼吸系统的影响.中国心血管病研究杂志,2005,9（3）：661
48Lzarena SD. Comparative study between thoracic epidural block andanesthesia for oncologic mastectomy. Rev Bras Anestesiol,2008,58(6):561-8
49Bedder MD. Epidural opioid therapy for chronic nonmalignant pain:critique of current experience. J Pain Symptom Manage,1996,11(6):353-6
50Lkersh MA, Simopoulus TT, Malik AB, et al. Epidural clonidine relievesintractable neuropathic itch associated with herpes zoster-related pain. RegAnesth Pain Med,2003,28(4):344-6
51Manabe H, Dan K, Hirata K, et al. Optimum pain relief with continuousepidural infusion of local anesthetics shortens the duration of zosterassociated pain. Clin J Pain,2004,20(5):302-8
52Uematsu H, Hiei K, Kawasaki H. Unknown fever and abnormal liverfunctions after repeated epidural blocks with lidocaine for management ofherpes zoster pain. Masui,1994,43(3):405-8
53Yokoyama MD, Ohashi MD, Nakatsuka MD, et al. Drug-induced liverDisease during continuous epidural block with bupivacaine.Anesthesiology,2001,95(1):259-61
54Grass JA. Sufentanil: clinical use as postoperative analgesic—epiduralintrathecal route. J Pain Symptom Manage,1992,7(5):271-86.
55Coda BA, Bromn MC, Schaffer R, et al. Pharmacology of epiduralfentanyI, alfentaniI,and sufentanil in volunteers. Anesthsiology,1994,81:1149-1161
56Decosterd I,Beggah AT,Durrer A, et al. Spinal opioids:mechanisms ofaction and chronic pain management. Rev Med Suisse,2006,2(71):1636-8
57Schenk MR, Putzier M, Kugler B,et al. Postoperative analgesia after majorspine surgery: patient-controlled epidural analgesia versuspatient-controlled intravenous analgesia. Anesth analg,2006,103(5):1311-17
58Bercovitch M, Adnnsky A, Pattems of high-dose morphine use in ahome-care hospice service:should we be afraid of it. Cancer,2004,101(6):1473-1477
59Candiotti KA, Gitlin MC. Review of the the effect of opioid-relatedside effects on the undertreatment of moderate to severe chronicnon-cancer pain: tapentadol, a step toward a solution? Curr Med ResOpin,2010,26(7):1677-84
60Valarucha S,Maboonvanon P, Napachoti T, et al. Cost-effectiveness ofthoracic patient-controlled epidural analgesia using bupivacaine withfentanyI vs bupivacaine with morphine after thoracotomy and upperabdominal surgery. J Med Assoc Thai,2005,88(7):921-927
61Iatrou CA,Dragoumanis CK, Vogiatzaki TD, et al. ProphylacticIntraven-ous ondansetron and dolasetron in intrathecal morphine=inducedpruritus:a randomized, double-blinded, placebo-controlled study. Anesthanalg,2005,101(5):1516-1520
62Radoslaw O, Mariusz S, Magdalena AW. Effects of thoracic epiduralanaesthesia on cardiac perolarization.Clinical and ExperimentalPharmacology and Physiology,2009,36:880-883
63Bloberg SG. Long-term home self-treament with high thoracic epiduralanesthesia in patients with severe coronary artery disease. AnesthAnalg,1994,79(2):413-414
64Kirno K, Friberg P,Grzegorczyk,et al. Thoracic epidural anesthesia duringcoronary artery bypass: Effects on cardial sympathetic activity, centralhemodynamic. Anesth Analg,1994,79(4):1075-1076
65Gramling-Babb P, miller MJ, Reeve ST,et al. Treatment of medically andsurgically refractory angina pectoris with high thoracic epiduralanalgesia:initial clinical experience. Am Heart J,1997,133(6):648-55
66Olausson K, Maqnusdottir H, Lurie L, et al. Anti-ischemic and anti-anginaleffect of thoracic epidural anesthesia versus those of conventional medialtherapy in the treatment of severe refractory unstable angina pectoris.Circulation,1997,96(7):2178-82
2Gassel HJ,Meyer D, Sailer M, et al. Nononcologic abdominal surgery inthe elderly. Chirurq,2005,76(1):35-42
3Simon MJ, Veering BT, Stienstra R, et al. Effect of age on theclinical profile and systemic absorption and disposition of levobupivacaineafter epidural administration. Br J Anaesth,2004,93:512-520
4Yokoyama M, Ohtomo N, Sonoda H, et al. The spread of contrast mediumin the epidural space and the analgesic area in epidural anesthesia inelderly patients.Masui,1996,45(9):1067-1067
5Simon MJ, Veering BT, Vletter AA, et al.The effect of age on the systemicabsorption and systemic disposition of ropivacaine after epiduraladministration.Anesth Analg,2006,102:276-282
6Blomberg RG,Olsson SS.The lumber epidural space in patients examinedwith epiduroscopy.Anesth Analg,1989,68:157-160
7Bromage PR.Mechanism of action of extradural analgesia. BrAnaesth,1975,47；199-211
8Hogan, Quinn M.D. Distribution of Solution in the Epidural Space:Examination by Cryomicrotome Section Regional Anesthesia&PainMedicine,2002,27(2):150-156
9Igarashi T, Hirabayashi Y, Shimizu R,et al.The lumbar extradural structurechanges with increasing age. Br J Anaesth,1997,78:149-152
10Watanabe S,Takeshima R, Asakura N, et al. The effect of age on retrievalof local anesthetic solution from the epidural space. AnesthAnalg,1997,85(5):1091-6
11Aogt MT. Lower extremity arterial disease and the aging process-review.JClin Epidermol,1992,45(3):529-529
12Bromage PR. Exaggerated spread of epidural analgesia in arterioscleroticpatients:dosage in relation to biological and chronological ageing. BMJ,1962,2:1634-8
13Tucker GT,Mather LE. Absorption and disposition of localanesthetics:pharmacokinetic. Neural blockade in clinical anesthesia andmanagement of pain. Philadelphia:JB lippincont,1980,45-58
14Brendan T, Finucane MD, Willian D,et al.Influence of age on vascularabsorption of lidocaine from the epidural space. Anesth Analg,1987,66:843-6
15Visser MD, Ruben A, Lee BE, et al. Factors affecting the distribution ofneural blockade by local anesthetics in epidural anesthesia and acomparison of lumber versus thoracic epidural anesthesia. Anesth Analg,2008,107(2):708-721
16Parkin IG, Harrison GR. The topographical anatomy of the lumbarextradural space. Journal of Anatomy,1985,141:211-217
17Iseri T, Nishimura R, Nagahama S, et al. Epidural spread of iohexolfollowing the use of air or saline in the 'loss of resistance' test. Vet AnaesthAnalg.2010,37(6):526-30
18Toshiyuki MD, Sumio MD.Saline-anesthetic interval and the spread ofepidural anesthesia.Can J Anesth,1999,46(10):935-938
19Alley DG, Amico JA, Rybicki LA,et al. The effect of posture on theinduction of epidural anesthesia for peripheral vascularsurgery.RegAnesth1995,20:407-11
20Ernest M, Grundy MD,Alon P,et al. Epidural anesthesia and the lateralposition. Anesth Analg1978,57:95-97
21Park WY, Hagins FM, Macnamara TE. Lateral position and epiduralanesthetic spread. Anesth Analg1983,62:278-9
22Hirabayashi Y,Sbimizu R, Masuda I,et al. Effect of extradural complianceand resistance on spread of extradural analgesia. Br J Anaeshth,1990,65:508-13
23Usubiaga JE, Wikinski JA,Usubiaga LE.Epidural pressure and its relationto spread of anesthetic solutions in epidural space.AnesthAnalg,1967,46:440-6
24Cardoso MMSC,Carvalbo JCA.Epidural pressures and spread of2%lidocaine in the epidural space:influence of volume and spread of injectionof the local anesthetic solution. Reg Anesth Pain Med,1998,23:14-9
25Yokoyama MD,Hanazakl MD, Fujii MD,et al.Correlation between thedistribution of contrast medium and the extent of blockade during epiduralanesthesia.Anesthesiology,2004,100:1504-10
26Mrcs K, Watson D, Campbell C,et al.Intra-articular injection composed ofseroid,iohexol and local anaesthetic-is it stable? TheBritish Journal ofRadiology,2009,82:109-11
27Oberts RE, Selcer BA. Myelography and epidurography. Vet Clin NorthAm Small Anim Pract,1993,23(2):307-29
28Fatone G, Lamagna F, Pasolini MP, et al. Myelography in the dog withnon-ionic contrast media at different iodine concentrations. J Small AnimPract,1997,38(7):292-4
29Shimizu J, Yamada K, Kishimoto M, et al.The difference of contrasteffects of myelography in normal dogs:comparison of iohexol(180mgI/ml), iohexol(240mgI/ml) and iotrolan(240mgI/ml). J Vet Med Sci,2008,70(7):659-63
30高秀梅，杨拔贤，顾健，等.氯普鲁卡因硬膜外阻滞时的药效学和药代动力学.临床麻醉学杂志,2007,23:379-381
31詹晓光，肖哲文.盐酸氯普鲁卡因硬膜外麻醉用于下腹部手术40例观察.福建医药杂志,2010,32（1）：131-132
32Cusick JF, Myklebust JB, Abram SE. Differential neural effects ofepidural local anesthetic. Anesthesiology,1980,53:299-306
33徐福涛，骆璇,林建.国产盐酸氯普鲁卡因硬膜外麻醉的临床试验[J].临床麻醉学杂志,2000,16（7）：358-359
1Gassel HJ,Meyer D, Sailer M, et al. Nononcologic abdominal surgery in theelderly. Chirurq,2005,76(1):35-42
2Pavelescu D, Mirea L,Paduraru M, et al. The role of multimodal analgesia inthe decrease of postoperative surgical stress responsein major neoplasticthoraco-abdominal surgery. Chirurqia(Bucur),2011,106(6):723-8
3Cohendy R,Brougere A,Cuvillon P. Anaesthesia in the older patient.CurrOpin Clin Nutr Metab Care,2005,8(1);17-21
4Simon MJ, Veering BT, Stienstra R, et al. Effect of age on the clinical profileand systemic absorption and disposition of levobupivacaine after epiduraladministration. Br J Anaesth,2004,93:512-520
5SSakura S, Saito Y, Kosaka Y. Effect of extradural anaesthesia on theventilatory response to hypoxaemia. Anaesthesia,1993,48:205-9
6Hulzebos EH, Helders PJ, Favie NJ, et al. Preoperative intensive inspiratorymuscle training to prevent postoperative pulmonary complications inhigh-risk patients undergoing CABG surgery: a randomized clinical trial.JAMA,2006,296(15):1851-1857
7Panaretou V, Toufektzian L,Siafaka I,et al. Postoperative pulmonaryfunction after open abdominal aortic aneurysm repair in patients withchronic obstructive pulmonary disease:epidural versus intravenousanalgesia. Ann Vasc Surg,2012,26(2):149-55
8Ozcan PE, Senturk M,Ulke ZS, et al. effects of thoracic epidural anaesthsiaon pulmonary venous admixture and oxygenation during one-lungventilation. Acta Anaesthesiol Scand,2007,51(8):1117-22
9Groeben H: Epidural anesthesia and pulmonary function. J Anesth,2006,20:290-299
10Kirow MY, Eremeev AV, Smetkin AA, et al. Epidural anesthesia andpostoperative analgesia with ropivacaine and fentanyl in off-pumpcoronary artery bypass grafting:a randomized,controlled study. BMCAnesthesiol,2011,18:11-17
11Daniel M, P pping MD, Nadia Elia MD, et al. Protective Effects ofEpidural Analgesia on Pulmonary Complications After Abdominal andThoracic Surgery。Arch Surg,2008,143(10):990-999
12Simeoforidou M,Vretzakis G, Bareka M, et al. Thoracic epidural analgesiawith levobupivacaine for6postoperative days attenuates sympatheticactivation after thoracic surgery. J Cardiothorac Vasc Anesth,2011,25(5):817-23
13Guo Z, Wang JP. Blockade of spinal nerves attenuates myocardialapoptosis in acute myocardial ischaemia/infarction in rats. Eur JAnaesthesiol,2010,27(2):146-52
14Kilickan L, Solak M, Bayindir O. Thoracic epidural anesthesia preservesmyocardial function during intraoperative and postoperative period incoronary artery bypass grafting operation. J Cardiovasc Surg,2005,46(6):559-67
15Yang SS, Han H, Cao Y, et al. Effects of high thoracic epidural anesthesiaon atrial electrophysiological characteristics and sympathetic nervesprouting in a canine model of artial fibrillation. Basic Res Cardiol,2011,106(3):495-506
16Blomberg S, Emanuelsson H, Kvist H, et al. Effects of thoracic epiduralanesthesia on coronary arreries and arterioles in patients with coronaryartery disease. Anesthesiology,1990,73:840-847
17Casalino, Fabio M, Edmond S, et al. High thoracic epidural anesthesia incardiac surgery risk factors for arterial hypotension stefano.Tesler TexHeart Inst J，2006,33(2):148-153
18Chrousos GP,Gold PW.The concepts of stress and stress system disorders:Overview of physical and behavioral homeostasis.JAMA,1992,267(9):1244-1252
19Vuori A,Salo M,Viljanto J,et al. effects of postoperative pain treatmentusing non-steroidal anti-inflammatory analgesics, opioids or epiduralblockade oilsystemic and local immune responses in children. ActaAnaesthesiol Scand,2004,48(6):738-49
20Xing CY, Wu MY, Fan HP. Effects of different anesthetic and analgesicprotocols on cellular immune function and stress hormone level in patientsundergoing lobectomy for esophagus cancer. Nan Fang Yi Ke Da Xue XueBao,2010,30(2):284-7
21Taylor NM, Lacoumenta S, Hall GM.Fentanly and the interleukin-6response to surgery.Anaesthrsia,1997,52:112-115
22Segawn H,Mori K Kasai K,et al.The role of the phrenic nerves in stressresponse in upper abdominal surgery.Anesth Analg,1996,82(6):1215-1224
23Lewis K S,Whipple J K,Michael K A,et al. Effect of analgesic treatment onthe physiological consequences of acute pain.Am J Hosp pharm,1994,51(12):1539-1554
24Palomero Rodriquez MA, Suarez Gonzalo L, Villar Alvarez F, et al.Thoracic epidural anesthesia decreases C-reactive protein levels in patientsundergoing elective coronary artery bypass graft surgery withcardiopulmonary bypass. Minerva Anestesiol,2008,74(11):619-26
25addox TM. Preoperative cardiovascular evaluation for noncardiac surgery.Mt Sinai J Med,2005,72(3):185-192
26Sum JZ, Maguire D.How to prevent perioperative myocardial injury:theconundrum continues.Am Heart J,2007,154(6):1021-1028
27Gottschalk A. Regional anaesthesia and organ protection the role ofthoracic epidural anaesthesia. Anasthesiol Intensivmed NotfallmedSchmerzther,2010,45(4):264-9
28Choileain NN,Redmond HP. Cell response to surgery.Arch Surg,2006,141(11):1132-40
29Takada M, Fukusaki M,Terao Y.Preadministration of flurbiprofensuppersses prostaglandin prodaction and postoperative pain in orthopedicpatients undergoing tourniquet inflation.Journal of Clinical Anesthesia,2007,(2):1176-1177
30Volk T, Schenk M, Voigt K,et al. Postoperative epidural anesthesiapreserves lymphocyte,but not monocyte,immune function after major spinsurgey.Anesth Analg,2004,98(6):1086-92
31Gajdosz R. Evaluation of regional analgesia and surgical trauma onselected factor of the human immune system.Folia Med Cracov,1994,35(1-4):69-86
32Bonzion B, Shavit Y,Trabekin E,et al.The effect of postoperative painManagement on immune response to surgery.Anesth Analg,2003,97(9):822-827
33Roediger L,Joris J,Senard M, et al.The use of pre-operative intrathecalmorphine for analgesia following coronary artery bypasssurgery.Anaesthesia,2006,61(9):838-44
34Hendrik Freise,M D,Stefan Lauer,Soeren Anthonsen,et al. Tboracicepidural analgesia augments ileal mucosal capillary perfusion andimprovessurvival in severe acute pancreatitis in rat.Anesthesiology,2006,105:354-9
35Taqi A,Hong X,Mistraletti G,et al.Thoracic epidural analgesia facilitates therestoration of bowel function and dietary intake in patients undergoinglaparoscopic colon resection using a traditional, nonaccelerated,perioperative care progarm.Surg Endosc,2007,21(2):247-52
36Vagts, Iber, Szabo, et al.Effects of epidural anaesthesia on intestinaloxygenation in pigs. British Journal of Anaesthesia,2003,90(2):212-20
37Adolphs, Diego, Schmidt, et al. Thoracic epidural anesthesia attenuateshemorrbage-induced impairment of intestinal perfusion in rats.Anesthesiology,2003,99:685-92
38Davis FM, Medromott E,Hickton C, et al. Influence of spinaland generalanaesthesia on haemostasis during total hip arthroplasty. Br JAnaestg,1987,59(5):561-571
39Rosenfeld BA, Beattie C, Christopherson R, et al The effect of differentanesthetic regimens on fibronolysis and the development of postoperativearterial thrombosis.Anesthesiology,1993,79(3):435-443
40Hafezi F,Naqhibzadeh B,Nouhi AH, et al. Epidural anesthesia as athromboembolic prophylaxis modality in plastic surgery. Aesthet Surg J,2011,31(7):821-4
41孟琛，汤哲，方向华，等.北京老年人认知功能对对生存率影响的八年随访观察.中华老年医学杂志，2004,23:507-509
42Sauer AM, Kalkman C, et al.Postoperative cognitive decline.J Anesth,2009,23(2):256-9
43Steinmetz J，Rasmussen LS. Cognitive deterioration after surgery. UgeskrLaeger,2008,170:4032-4
44Rasmussen L, Brier JT, Silverstein T H,et al. Is peri-operative cortisolsecretion related to post-operative cognitive dysfunction? ActaAnaesthesiol Scand,2005,49(9):1225-1231
45Fujita Y,Nakamura K,Horiguchi Y, et al.Effect of different perioperativeanalgesic methods on postoperative cognitive dysfunction in elderlypatients undergoing upper abdominal surgery.Masui,2011,60(10):1153-8
46Olker AR, Hawes DW, Jordan WS, et al. Use of epidural anesthesia andspontaneous ventilation during transab-dominal colon and rectalprocedures in selected high-risk patient groups. Dis ColonRectum,1997,40(3):339-340
47朱谦,刘莎莎,贾乃光.单侧蛛网膜下腔阻滞对老年患者循环呼吸系统的影响.中国心血管病研究杂志,2005,9（3）：661
48Lzarena SD. Comparative study between thoracic epidural block andanesthesia for oncologic mastectomy. Rev Bras Anestesiol,2008,58(6):561-8
49Bedder MD. Epidural opioid therapy for chronic nonmalignant pain:critique of current experience. J Pain Symptom Manage,1996,11(6):353-6
50Lkersh MA, Simopoulus TT, Malik AB, et al. Epidural clonidine relievesintractable neuropathic itch associated with herpes zoster-related pain. RegAnesth Pain Med,2003,28(4):344-6
51Manabe H, Dan K, Hirata K, et al. Optimum pain relief with continuousepidural infusion of local anesthetics shortens the duration of zosterassociated pain. Clin J Pain,2004,20(5):302-8
52Uematsu H, Hiei K, Kawasaki H. Unknown fever and abnormal liverfunctions after repeated epidural blocks with lidocaine for management ofherpes zoster pain. Masui,1994,43(3):405-8
53Yokoyama MD, Ohashi MD, Nakatsuka MD, et al. Drug-induced liverDisease during continuous epidural block with bupivacaine.Anesthesiology,2001,95(1):259-61
54Grass JA. Sufentanil: clinical use as postoperative analgesic—epiduralintrathecal route. J Pain Symptom Manage,1992,7(5):271-86.
55Coda BA, Bromn MC, Schaffer R, et al. Pharmacology of epiduralfentanyI, alfentaniI,and sufentanil in volunteers. Anesthsiology,1994,81:1149-1161
56Decosterd I,Beggah AT,Durrer A, et al. Spinal opioids:mechanisms ofaction and chronic pain management. Rev Med Suisse,2006,2(71):1636-8
57Schenk MR, Putzier M, Kugler B,et al. Postoperative analgesia after majorspine surgery: patient-controlled epidural analgesia versuspatient-controlled intravenous analgesia. Anesth analg,2006,103(5):1311-17
58Bercovitch M, Adnnsky A, Pattems of high-dose morphine use in ahome-care hospice service:should we be afraid of it. Cancer,2004,101(6):1473-1477
59Candiotti KA, Gitlin MC. Review of the the effect of opioid-relatedside effects on the undertreatment of moderate to severe chronicnon-cancer pain: tapentadol, a step toward a solution? Curr Med ResOpin,2010,26(7):1677-84
60Valarucha S,Maboonvanon P, Napachoti T, et al. Cost-effectiveness ofthoracic patient-controlled epidural analgesia using bupivacaine withfentanyI vs bupivacaine with morphine after thoracotomy and upperabdominal surgery. J Med Assoc Thai,2005,88(7):921-927
61Iatrou CA,Dragoumanis CK, Vogiatzaki TD, et al. ProphylacticIntraven-ous ondansetron and dolasetron in intrathecal morphine=inducedpruritus:a randomized, double-blinded, placebo-controlled study. Anesthanalg,2005,101(5):1516-1520
62Radoslaw O, Mariusz S, Magdalena AW. Effects of thoracic epiduralanaesthesia on cardiac perolarization.Clinical and ExperimentalPharmacology and Physiology,2009,36:880-883
63Bloberg SG. Long-term home self-treament with high thoracic epiduralanesthesia in patients with severe coronary artery disease. AnesthAnalg,1994,79(2):413-414
64Kirno K, Friberg P,Grzegorczyk,et al. Thoracic epidural anesthesia duringcoronary artery bypass: Effects on cardial sympathetic activity, centralhemodynamic. Anesth Analg,1994,79(4):1075-1076
65Gramling-Babb P, miller MJ, Reeve ST,et al. Treatment of medically andsurgically refractory angina pectoris with high thoracic epiduralanalgesia:initial clinical experience. Am Heart J,1997,133(6):648-55
66Olausson K, Maqnusdottir H, Lurie L, et al. Anti-ischemic and anti-anginaleffect of thoracic epidural anesthesia versus those of conventional medialtherapy in the treatment of severe refractory unstable angina pectoris.Circulation,1997,96(7):2178-82