Dahm P, Nitescu P, Appelgren L, Curelaru I
Department of Anaesthesia and Intensive Care, Göteborg University, Sahlgrenska Hospital, Gothenburg, Sweden.
Acta Anaesthesiol Scand. 1998 Sep;42(8):1010-7. doi: 10.1111/j.1399-6576.1998.tb05363.x.
There is no reliable treatment for "refractory" pain from unstable angina pectoris (UAP) when epidural infusion of bupivacaine has failed to relieve it. In two such cases we explored the potential of intrathecal (i.t.) bupivacaine infusion to provide pain relief.
Two female patients, 70 and 67 years. An 18-G nylon catheter was inserted intrathecally through a 17-G Tuohy needle via the T2-T3 interspace and its tip located at the height of C6-C7 vertebrae. The catheter was connected to a portable, programmable electronic pump filled with bupivacaine 5 mg/ml. The infusion started at rates of 0.1-0.2 ml/h, with optional bolus doses of 0.1-0.2 ml, 4-2 times/h, respectively, by PCA (Patients-Controlled Analgesia), and then adjusted to give the patients satisfactory (80%-100%) pain relief.
Pain relief was obtained with doses of i.t.-bupivacaine ranging from 17 to 45 (mean = 25) mg/d. The pain intensity decreased from VAS (Visual Analogue Score) 9-10 to 0-2 out of 10. The nocturnal sleep improved from 2-4 to 6-7 h. The patients could now ambulate, walking or in a wheel-chair. The i.t.-treatment lasted 700 and 437 d, of which 540 and 343 d (respectively) were spent at home, and was terminated by: (a) the patient's death due to intracranial bleeding (1st case); (b) progressive aggravation of the unstable angina that could not be fully countered by increasing the bupivacaine dose above 1.0 mg/h due to occurrence of cerebral transient ischemic attacks, usually not correlated with orthostatic arterial hypotension but apparently facilitated by microembolization of the cerebral arteries (2nd case).
I.t.-bupivacaine infusion may alleviate "refractory" pain in patients with unstable angina pectoris when epidural bupivacaine failed to do so. Its use is apparently limited by the IT-bupivacaine critical dosage (in these patients = 1.0-1.5 mg/h).
当硬膜外输注布比卡因未能缓解不稳定型心绞痛（UAP）所致的“难治性”疼痛时，尚无可靠的治疗方法。在两例此类病例中，我们探讨了鞘内注射布比卡因缓解疼痛的可能性。
两名女性患者，分别为70岁和67岁。通过17G的Tuohy针经T2 - T3椎间隙鞘内插入一根18G尼龙导管，其尖端位于C6 - C7椎体高度。导管连接至一个便携式、可编程电子泵，泵内装有5mg/ml的布比卡因。输注以0.1 - 0.2ml/h的速率开始，通过患者自控镇痛（PCA）分别可选推注剂量0.1 - 0.2ml，每小时4 - 2次，然后进行调整以使患者获得满意（80% - 100%）的疼痛缓解。
鞘内注射布比卡因剂量为17至45（平均 = 25）mg/d时获得了疼痛缓解。疼痛强度从视觉模拟评分（VAS）9 - 10降至0 - 2（满分10分）。夜间睡眠从2 - 4小时改善至6 - 7小时。患者现在能够行走，或坐轮椅活动。鞘内治疗持续了700天和437天，其中分别有540天和343天在家中进行，治疗终止原因如下：（a）第一例患者因颅内出血死亡；（b）第二例患者不稳定型心绞痛进行性加重，由于发生脑短暂性缺血发作，将布比卡因剂量增加至1.0mg/h以上也无法完全控制，脑短暂性缺血发作通常与体位性动脉低血压无关，但显然因脑动脉微栓塞而加重。
当硬膜外布比卡因未能缓解时，鞘内注射布比卡因可缓解不稳定型心绞痛患者的“难治性”疼痛。其应用显然受鞘内布比卡因临界剂量（在这些患者中 = 1.0 - 1.5mg/h）限制。
