Anesthesia & Analgesia

July 2002

Table of Content

伴和不伴有術後認知障礙的CABG術病人中的血清肌酐變化
(周潔   王祥瑞校)
Serum Creatinine Patterns in Coronary Bypass Surgery Patients With and Without Postoperative Cognitive Dysfunction
Madhav Swaminathan, Brian J. McCreath, Barbara G. Phillips-Bute, Mark F. Newman, Joseph P.

Departments of *Anesthesiology, Surgery (Cardiothoracic Division), and Medicine and Psychiatry, Duke University Medical Center , Durham , North Carolina

Anesth & Analg July 2002 95:1-8.

 

心肌缺血和細胞因子與非心臟手術後的感染相關
 (周潔   王祥瑞校)

Myocardial Ischemia and Cytokine Response Are Associated with Subsequent Onset of Infections After Noncardiac Surgery

laudia D. Spies, MD*, Hartmut Kern, MD*, Torsten Schröder, MD*, Michael Sander, MD*, Henning Sepold, MD*, Philip Lang, MD*, Karl Stangl, MD, Steffen Behrens, MD, Pranav Sinha, MD, Walter Schaffartzik, MD||, Klaus-Dieter Wernecke, PhD¶, Wolfgang J. Kox, MD, PhD*, and Uday Jain, MSIT, PhD, MD#

Departments of *Anesthesiology and Intensive Care Medicine and Cardiology and Institute of Clinical Chemistry and Pathological Biochemistry, University Hospital

Anesth & Analg July 2002 95:9-18.

七氟醚對健康和心肌病倉鼠交替性正性肌力作用

王士雷譯  庄心良校)

The Paradoxical Positive Inotropic Effect of Sevoflurane in Healthy and Cardiomyopathic Hamsters

Benoît Vivien, MD*, Jean-Stéphane David, MD, Jean-Luc Hanouz, MD, PhD, Julien Amour, MD*, Yves Lecarpentier, MD, PhD, Pierre Coriat, MD*, and Bruno Riou, MD, PhD*||

 

*Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Centre Hospitalier Universitaire (CHU) Pitié-Salpêtrière, Université Paris VI, Paris, France; Department of Anesthesiology, CHU Edouard Herriot, Lyon, France; Department of Anesthesiology, CHU Côte de Nacre, Caen, France; Department of Physiology, CHU de Bicêtre, and Institut National de la Santé et de la Recherche Médicale, Palaiseau, France; and ||Department of Emergency Medicine, CHU Pitié-Salpêtrière, Université Paris VI, Paris, France

Anesth & Analg July 2002 95:31-38

 

Rapacuronium對麻醉儿童肺机械的影響:与美維松比較

(趙雪蓮譯  庄心良校)

The Effect on Lung Mechanics in Anesthetized Children with Rapacuronium: A Comparative Study with Mivacurium

Gavin F. Fine, MB, BCh*{ddagger}, Etsuro K. Motoyama, MD*{dagger}{ddagger}§, Barbara W. Brandom, MD*{ddagger}, Kathleen M. Fertal, BSN*, Rebecca Mutich, RRT{dagger}, and Peter J. Davis, MD*{ddagger}§

*Department of Anesthesiology and {dagger}Division of Pulmonology, Children’s Hospital of Pittsburgh; and the Departments of {ddagger}Anesthesiology and §Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Anesth & Analg July 2002 95:56-61                                

 

可彎曲支氣管鏡模擬器氣道模擬器的的評估
 (周潔   王祥瑞校)

An Evaluation of a Virtual Reality Airway Simulator

Richard Rowe, MD, MPH*, and Ronald A. Cohen, MD

Departments of *Anesthesiology and Diagnostic Imaging, Children’s Hospital Oakland, Oakland; and Departments of Anesthesiology and Radiology, University of California, San Francisco School of Medicine, San Francisco, California

Anesth & Analg July 2002 95:62-66.

 

門診病人麻醉的知曉和回憶

(王士雷譯  庄心良校)

Awareness and Recall in Outpatient Anesthesia

Johanna Wennervirta, MD*, Seppo O.-V. Ranta, MD*, and Markku Hynynen, MD, PhD{dagger}

*Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Children’s Hospital, Helsinki, Finland; and {dagger}Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

 Anesth & Analg July 2002 95:72-77

 

α-7煙鹼型乙H膽鹼受體對异氟醚的敏感性有賴受體失活態

(楊保仲譯   庄心良校)

Sensitivity of the α-7 Nicotinic Acetylcholine Receptor to Isoflurane May Depend on Receptor Inactivation

Pamela Flood, MD, FACA, and Kristen M. Coates, BS

Department of Anesthesiology, Columbia University, New York

Anesth & Analg July 2002 95:83-87

 

小劑量氯胺酮可改善術後病人抑鬱狀態
(忻紀華譯 王祥瑞校)

Small-Dose Ketamine Improves the Postoperative State of Depressed Patients

Akira Kudoh, MD*,Yoko Takahira, Hiroshi Katagai, MD, Tomoko Takazawa, MD

*Department of Anesthesiology, Hakodate Watanabe Hospital; and department of Anesthesiology, Hirosaki National Hospital, Hirosaki, Aomori, Japan

Anesth & Analg July 2002 95:114-118.

 

琥珀膽鹼能安全用于高鉀血症的病人嗎﹖

(顏濤譯  莊心良校)

Can Succinylcholine Be Used Safely in Hyperkalemic Patients?

Adam J. Schow, MD*, David A. Lubarsky, MD, MBA{dagger}, Ronald P. Olson, MD*, and Tong J. Gan, MB*

 

*Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; and {dagger}Department of Anesthesiology, University of Miami/Jackson Medical Center, Florida Anesth & Analg July 2002 95:119-122

對婦科術前和術後疼痛評估的一種有效可靠的新方法
(忻紀華   王祥瑞校)

A New Highly Reliable Instrument for the Assessment of Pre- and Postoperative Gynecological Pain

Elisabet Stener-Victorin,RPT,PhD*, Jan Kowalski, BS, and Thomas Lundeberg,MD,PhD

瑞典歌德堡大學婦產科學系﹔斯德哥爾摩Karolinska學會生理學和藥理學分會﹔瑞典斯德哥爾摩Karolinska醫院藥劑

Anesth & Analg July 20002 95:151-157.

 

腹式全子宮切除術後于腹膜內和切口應用布比卡因加腎上腺素的鎮痛效應
 (齊波   王祥瑞校)

The Analgesic Effects of Intraperitoneal and Incisional Bupivacaine with Epinephrine After Total Abdominal Hysterectomy

A.Ng, FRCA*, A. Swami, FFARCSI*, G. Smith, MD, FRCA*, A.C. Davidson, FRCOG, and J. Emembolu, FRCOG

*University Department of Anaesthesia, Critical Care, and Pain Management, and Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester LE1 5WW, United Kingdom

Anesth & Analg July 2002 95:158-162

 

單極和雙極气管內電極用于電刺激通气

(葛圣金譯  庄心良校)

Electroventilation with Monopolar and Bipolar Intratracheal Electrodes

Zachary W. Sopcak, MSBME, L. A. Geddes, PhD, Kirk S. Foster, BSEE, William E. Schoenlein, BS, and Joe D. Bourland, PhD

Purdue University Department of Biomedical Engineering, West Lafayette, Indiana

 Anesth & Analg July 2002 95:189-191

 

建立壓力-控制模式時气管導管逐漸阻塞時潮气量變化的模型

(趙雪蓮譯  庄心良校)

Modeling the Effect of Progressive Endotracheal Tube Occlusion on Tidal Volume in Pressure-Control Mode

Avery Tung, MD*, and Sherwin E. Morgan, RRT{dagger}

Departments of *Anesthesia and Critical Care and {dagger}Respiratory Therapy, University of Chicago, Chicago, Illinois

Anesth & Analg July 2002 95:192-197

硬膜外應用布比卡因和羅磪d因分娩鎮痛的相對運動神經阻滯效能
(齊波   王祥瑞校)

The Relative Motor Blocking Potencies of Epidural Bupivacaine and Ropivacaine in Labor

Héctor J. Lacassie, MD*, Malachy O. Columb, FRCA, Héctor P. Lacassie, MD, and Rodrigo A. Lantadilla, MD*

*Anesthesiology Department, Pontificia Universidad Católica de Chile; and Anesthesiology Service, Clínica Alemana, Santiago, Chile; and South Manchester University Hospital, Withington, United Kingdom

Anesth & Analg July 2002 95:204-208.

 

坐骨神經阻滯前路法的新標志:影像學和臨床研究

(焦志華譯  庄心良校)

New Landmarks for the Anterior Approach to the Sciatic Nerve Block: Imaging and Clinical Study

Alain C. Van Elstraete, MD*, Claude Poey, MD, Thierry Lebrun, MD*, and Frédéric Pastureau, MD*

Departments of *Anesthesiology and Radiology, Saint-Paul Medical Center, Fort de France, Martinique, France

Anesth & Analg July 2002 95:214-218

降低吸入笑氣濃度後對雙腔管支氣管套囊迅速放氣的研究
(忻紀華   王祥瑞校)

Rapid Deflation of the Bronchial Cuff of the Double-Lumen Tube After Decreasing the Concentration of Inspired Nitrous Oxide

Fujio Karasawa, MD, Akira Takita, MD, Isao Takamatsu, MD, Tomohisa Mori, MD, Takashi Oshima, MD, and Yasushi Kawatani, MD

Department of Anesthesiology, National Defense Medical College, Saitama, Japan

Anesth & Analg July 2002 95:238-242.

 

N2O麻醉時氣管套囊重複放氣以穩定套囊內壓力

(焦志華譯  莊心良校)

Repeated Deflation of a Gas-Barrier Cuff to Stabilize Cuff Pressure During Nitrous Oxide Anesthesia

Fujio Karasawa, MD, Nobuhiro Matsuoka, MD, Mitsuyoshi Kodama, MD, Tomohiro Okuda, MD, Tomohisa Mori, MD, and Yasushi Kawatani, MD

Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan

Anesth & Analg July 2002 95:243-248

Abstracts

 

伴和不伴有術後認知障礙的CABG術病人中的血清肌酐變化

Serum Creatinine Patterns in Coronary Bypass Surgery Patients With and Without Postoperative Cognitive Dysfunction

Madhav Swaminathan, Brian J. McCreath, Barbara G. Phillips-Bute, Mark F. Newman, Joseph P.

Departments of *Anesthesiology, Surgery (Cardiothoracic Division), and Medicine and Psychiatry, Duke University Medical Center , Durham , North Carolina

Anesth & Analg July 2002 95:1-8.

 

  目的 CABG術後腎功能障礙較為常見。我們早就發現CABG術中伴有腦卒中的病人其血清肌酐為未伴有腦卒中者的三倍。但是﹐術後肌酐變化是否合併認知障礙還未得知。因此﹐我們假設CABG術後的圍術期急性腎功能損傷與術後認知障礙有關。方法 選擇282例擇期CABG術病人,于術前和術後6周進行心理測量試驗並行資料統計。認知功能障礙定義為受兩分變量認知缺陷[CD])和連續變量認知指數)。結果 40%的病人在術後6周有CD。但是﹐對術後肌酐和CD(相關性=-0.41P=0.91)或認知指數(相關性=-1.29P=0.46)之間的百分比峰變化的相關研究表明﹕兩者無明顯相關。結論 心臟術後的認知障礙與腦卒中不同﹐與術後腎功能障礙的增加無關。

                                                 (周潔   王祥瑞校)

Renal dysfunction is common after coronary artery bypass graft (CABG) surgery. We have previously shown that CABG procedures complicated by stroke have a threefold greater peak serum creatinine level relative to uncomplicated surgery. However, postoperative creatinine patterns for procedures complicated by cognitive dysfunction are unknown. Therefore, we tested the hypothesis that postoperative cognitive dysfunction is associated with acute perioperative renal injury after CABG surgery. Data were prospectively gathered for 282 elective CABG surgery patients. Psychometric tests were performed at baseline and 6 wk after surgery. Cognitive dysfunction was defined both as a dichotomous variable (cognitive deficit [CD]) and as a continuous variable (cognitive index). Forty percent of patients had CD at 6 wk. However, the association between peak percentage change in postoperative creatinine and CD (parameter estimate = -0.41; P = 0.91) or cognitive index (parameter estimate = -1.29; P = 0.46) was not significant. These data indicate that postcardiac surgery cognitive dysfunction, unlike stroke, is not associated with major increases in postoperative renal dysfunction.

                                                

心肌缺血和細胞因子與非心臟手術後的感染相關

Myocardial Ischemia and Cytokine Response Are Associated with Subsequent Onset of Infections After Noncardiac Surgery

laudia D. Spies, MD*, Hartmut Kern, MD*, Torsten Schröder, MD*, Michael Sander, MD*, Henning Sepold, MD*, Philip Lang, MD*, Karl Stangl, MD, Steffen Behrens, MD, Pranav Sinha, MD, Walter Schaffartzik, MD||, Klaus-Dieter Wernecke, PhD¶, Wolfgang J. Kox, MD, PhD*, and Uday Jain, MSIT, PhD, MD#

Departments of *Anesthesiology and Intensive Care Medicine and Cardiology and Institute of Clinical Chemistry and Pathological Biochemistry, University Hospital

Anesth & Analg July 2002 95:9-18.

 

目的 在多數非心臟手術術後普遍存在心肌缺血(POMI)。手術和POMI可能影響免疫力﹐使患者預後惡化。我們通過研究由POMI調節有關的白介素─6IL6)和IL10及其與術後感染率相關性。方法 選擇的203例腹部﹐血管和整形外科手術病人。圍術期處理方法一致。血流動力學改變維持在基礎值的20%范圍內。從麻醉誘導前8小時開始至術後96小時行Holter心動電流描記器來判斷POMI。在入院﹐手術前﹐麻醉誘導前﹐手術後﹐入監護室﹐和術後612182436487296120144﹐和168小時檢查12導聯心電圖﹐心肌脢譜和免疫指標測定。根據疾病控制中心所定規則診斷感染。結果 POMI發生率為27%﹐多數病例(76%)發生在術後24小時內。IL6IL10水平在手術中顯著昇高﹐但在POMI和非POMI組中無區別。術後出現嚴重感染或敗血症(n=47)平均為3天(范圍從18天)﹐在此類病人中﹐POMI組病人術中IL6IL10較非POMI組昇高3─10倍。在這些嚴重感染病人中用多因素分析法分析發現﹐外科創傷的類型與IL6的昇高相關﹐而IL─10的昇高與POMI有關。結論 這些發現提示由POMI引起的細胞因子的即刻反應和手術類型與嚴重感染和敗血症的發生相關。

                                              (周潔   王祥瑞校)

Postoperative myocardial ischemia (POMI) is prevalent among patients after major noncardiac surgery. Surgery, as well as POMI, may modulate the immune system, potentially worsening patient outcome. We sought to investigate the modulation of soluble interleukin (IL)-6 and IL-10 by POMI and its association with increased postoperative infection rates. Two-hundred-three patients undergoing elective major abdominal, vascular, and orthopedic surgery participated in this prospective observational study. Perioperative management was standardized. Hemodynamic variables were kept within 20% of baseline. POMI was assessed by Holter electrocardiography starting at least 8 h before the induction of anesthesia and continued until 96 h after surgery. Twelve-lead electrocardiograms, cardiac enzymes, and immune variables were obtained at the time of admission to the hospital, before surgery, before the induction of anesthesia, after surgery, at the time of admission to the intensive care unit, and 6, 12, 18, 24, 36, 48, 72, 96, 120, 144, and 168 h after surgery. Infections were diagnosed according to the Centers for Disease Control criteria. The incidence of POMI was 27%, and the majority of cases (76%) occurred within the first 24 h after surgery. IL-6 and IL-10 levels significantly increased during surgery but did not differ between the POMI and Non-POMI groups. However, in the subset of patients who developed severe infections or sepsis (n = 47) a median of 3 days (range, 1每8 days) after surgery, the intraoperative increases of IL-6 and IL-10 in the POMI group were, respectively, 3 and 10 times higher compared with the increase in the Non-POMI group. By using a multifactorial analysis in these patients with severe infections, the type of surgical trauma was associated with an increased IL-6 response, whereas the increase in IL-10 was attributed to POMI. These findings suggest that immediate cytokine responses due to POMI and type of surgery might be relevant for the later onset of severe infections and sepsis.

                                                  

七氟醚對健康和心肌病倉鼠交替性正性肌力作用

The Paradoxical Positive Inotropic Effect of Sevoflurane in Healthy and Cardiomyopathic Hamsters

Benoît Vivien, MD*, Jean-Stéphane David, MD, Jean-Luc Hanouz, MD, PhD, Julien Amour, MD*, Yves Lecarpentier, MD, PhD, Pierre Coriat, MD*, and Bruno Riou, MD, PhD*||

 

*Laboratory of Experimental Anesthesiology, Department of Anesthesiology, Centre Hospitalier Universitaire (CHU) Pitié-Salpêtrière, Université Paris VI, Paris, France; Department of Anesthesiology, CHU Edouard Herriot, Lyon, France; Department of Anesthesiology, CHU Côte de Nacre, Caen, France; Department of Physiology, CHU de Bicêtre, and Institut National de la Santé et de la Recherche Médicale, Palaiseau, France; and ||Department of Emergency Medicine, CHU Pitié-Salpêtrière, Université Paris VI, Paris, France

Anesth & Analg July 2002 95:31-38

 

目的  比較七氟醚(0.7~3.6vol%)對健康和基因誘發心肌病倉鼠左室乳頭肌的變力作用。方法  在體外(29oC,pH7.40,Ca2+2.5mM,刺激頻率3/)低負荷(等張)和高負荷(等容)條件下,研究七氟醚對健康和基因誘發心肌病倉鼠左室乳頭肌的變力作用。結果 七氟醚對健康倉鼠和心肌病倉鼠均產生中度正性肌力作用(3.6vol%七氟醚對健康倉鼠心肌產生的等張和等容最大縮短速率分別為115%±12%128%±21%P<0.01;而對心肌病倉鼠心肌產生的等張和等容最大縮短速率分別為115%±20%124%±31%P<0.05 。七氟醚產生的正性肌力作用在健康和心肌病倉鼠之間無差异。在應用α-腎上腺受體阻滯劑和β-腎上腺受體阻滯劑的情況下,七氟醚產生的正性肌力作用在二類倉鼠之間也無不同。在應用鈣通道阻滯劑的情況下,七氟醚產生的正性肌力作用在健康倉鼠消失,而在心肌病倉鼠增強。而在低負荷和高負荷情況下,七氟醚對二种倉鼠均產生中度負性舒張作用。結論 七氟醚對健康和心肌病倉鼠產生矛盾的正性肌力作用。

王士雷譯  庄心良校)

We investigated the effects of sevoflurane (0.7 to 3.6 vol%) on inotropy and lusitropy in left ventricular papillary muscles of healthy hamsters and genetically induced cardiomyopathic (strain BIO 14.6) hamsters in vitro (29°C, pH 7.40, Ca2+ 2.5 mM, stimulation frequency three per minute) under low (isotony) and high (isometry) loads. Sevoflurane induced a moderate positive inotropic effect in healthy hamsters (maximum unloaded shortening velocity and isometric active force at 3.6 vol%: 115% ± 12% and 128% ± 21% of baseline values, respectively; P < 0.01) and in cardiomyopathic hamsters (maximum unloaded shortening velocity and isometric active force at 3.6 vol%: 115% ± 20% and 124% ± 31% of baseline values, respectively; P < 0.05). This positive inotropic effect did not differ between healthy and cardiomyopathic hamsters, even when sevoflurane concentrations were corrected for minimum alveolar anesthetic concentration values in each strain, and was unchanged after {alpha}- and ß-adrenoceptor blockade. After calcium-channel blockade, this positive inotropic effect was abolished in healthy hamsters but enhanced in cardiomyopathic hamsters. In both strains, sevoflurane induced a moderate negative lusitropic effect under low and high loads.

 

Rapacuronium對麻醉儿童肺机械的影響:与美維松比較

The Effect on Lung Mechanics in Anesthetized Children with Rapacuronium: A Comparative Study with Mivacurium

Gavin F. Fine, MB, BCh*{ddagger}, Etsuro K. Motoyama, MD*{dagger}{ddagger}§, Barbara W. Brandom, MD*{ddagger}, Kathleen M. Fertal, BSN*, Rebecca Mutich, RRT{dagger}, and Peter J. Davis, MD*{ddagger}§

*Department of Anesthesiology and {dagger}Division of Pulmonology, Children’s Hospital of Pittsburgh; and the Departments of {ddagger}Anesthesiology and §Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Anesth & Analg July 2002 95:56-61

 

目的  使用Rapacuronium可增加急性支气管痙攣發生的危險。本文通過測定肺功能來直接證明應用Rapacuronium的儿童是否會出現气道收縮。方法  本實驗選取10ASA-患者(2-6歲),隨机均分為兩組,分別給予Rapacuronium和美維松。用七氟醚進行麻醉誘導,持續輸入雷米芬太尼(0.2-0.3ug.kg-1.min-1)和异丙酚(200-250 ug.kg-1.min-1)維持麻醉。每組進行三個階段的肺功能測試:肺功能基線數据測定;應用肌松藥后和應用β2-激動劑后肺功能的測定。兩組相較,靜息狀態呼吸順應性沒有發生變化。應用Rapacuronium使總呼吸系統阻力增加,但沒有統計學上的意義(為基線數值的214.4%±122.65%P≈0.1)。相反10%用力肺活量的最大呼气流量(MEF10)和由用力通气技術測定的流量-容積曲線中的MEF功能余气量(MEFFRC)均明顯降低(分別為53.4%±18.49%P0.0141.3%±27.42%P0.001〉。美維松組中呼吸系統阻力沒有發生變化(109.5%±30.28%)。MEF10輕微降低(77.0%±9.03%P0.005〉但是MEFFRC沒有發生明顯改變(81.2%±29.85%,無統計學意義)。給予?/span>2-激動劑后,所有的監測指標均回到基線水平。結論 与美維松相較,使用Rapacuronium可引起較輕的气道阻塞同時對靜態呼吸順應性沒有影響。

                                (趙雪蓮譯  庄心良校)

The administration of rapacuronium increases the risk of severe bronchospasm. There have been no studies of pulmonary function directly demonstrating airway constriction with rapacuronium in children. In this study, 10 ASA physical status I or II patients (aged 2-6 yr) were randomly divided into 2 equal groups, receiving either rapacuronium or mivacurium. Anesthesia was induced with sevoflurane and maintained with remifentanil (0.2~0.3 µg·kg-1·min-1)and propofol (200~250 µg·kg-1·min-1)infusions. We performed three sets of pulmonary function tests: baseline, after the administration of muscle relaxant, and after the administration of a ß2 agonist. In both groups, there were no changes in static respiratory compliance. The increase in total respiratory system resistance after the administration of rapacuronium did not reach statistical significance (214.4% ± 122.65% of baseline, P ≈0.1), whereas maximal expiratory flow at 10% of forced vital capacity (MEF)10 and MEFfunctional residual capacity on partial flow-volume curves by the forced deflation technique decreased markedly (53.4% ± 18.49%, P < 0.01 and 41.3% ± 27.42%, P < 0.001, respectively). With the administration of mivacurium, no changes were observed in respiratory system resistance (109.5% ± 30.28%). MEF10 decreased slightly (77.0% ± 9.03%, P < 0.005) whereas MEFFRC did not (81.2% ± 29.85%, not significant). After the administration of a ?sub>2 agonist, all measurements returned to baseline. Thus, the administration of rapacuronium consistently results in lower airway obstruction with minimal changes in static respiratory compliance when compared with mivacurium.

 

 

可彎曲支氣管鏡模擬器氣道模擬器的的評估

An Evaluation of a Virtual Reality Airway Simulator

Richard Rowe, MD, MPH*, and Ronald A. Cohen, MD

Departments of *Anesthesiology and Diagnostic Imaging, Children’s Hospital Oakland, Oakland; and Departments of Anesthesiology and Radiology, University of California, San Francisco School of Medicine, San Francisco, California

Anesth & Analg July 2002 95:62-66.

 

   目的 在本研究中﹐我們測試AccuTough®可彎曲支氣管鏡模擬器(模擬器)的使用對臨床醫生掌握小兒纖支鏡氣管插管是否有用。方法 選擇以往未用過纖支鏡的小兒科住院醫生。住院醫生在全麻下對小兒行纖支鏡插管。對插管錄象帶做以下分析研究﹕看到氣管隆突的時間﹐支氣管鏡頭端觸及黏膜的次數和時間。然後在模擬器對住院醫生進行訓練。與下一個小兒的纖支鏡插管進行比較。在兩次間僅接受模擬器的訓練。結果 對照組在兩次插管間不接受模擬器的訓練。住院醫生使用模擬器練習了平均17次﹐耗時39分鐘。在使用模擬器後操作明顯改善。由支氣管鏡成功完成插管的時間從5.15分鐘減少至0.88分鐘(P<0.001)。支氣管鏡頭端觸及黏膜的次數由21.4減至3.0P<0.001)。看見黏膜的時間由2.29降至0.19分鐘(P<0.001)。看見氣道的次數百分比從58.5%增加至80.4%P=0.004)。結論 支氣管鏡模擬器對住院醫生掌握纖支鏡插管是有效的。它可顯著提高完成氣管插管和其他操作性能指標。

                                                   (周潔   王祥瑞校)

In this research, we sought to test the hypothesis that the AccuTouch® Flexible Bronchoscopy Simulator (Simulator) is an effective way to teach clinicians the psychomotor skills necessary to use the fiberoptic bronchoscope as an instrument for intubating the trachea of a pediatric patient. Pediatric residents with no prior experience in fiberoptic bronchoscopy were studied. Residents performed fiberoptic intubation on children undergoing general anesthesia. Tapes of these intubations were analyzed for: time to visualization of the carina, and number and time that the bronchoscope tip hit the mucosa. Residents were then trained on the Simulator. Performance of fiberoptic intubation on a subsequent child was compared. Training on the Simulator was the only instruction that the residents received between the two cases. A control group of residents performed two consecutive intubations without training on the Simulator between cases. Residents studied an average of 17 cases, and spent 39 min on the Simulator. Performance was markedly improved after the Simulator. Time to completion of successful intubation with a bronchoscope was reduced from 5.15 to 0.88 min (P < 0.001). The number of times that the tip of the bronchoscope hit the mucosa was reduced from 21.4 to 3.0 (P < 0.001). The amount of time that the resident spent viewing the mucosa decreased from 2.24 to 0.19 min (P < 0.001). The percent of time viewing the channel of the airway increased from 58.5% to 80.4% (P = 0.004). This bronchoscopy simulator was very effective in teaching residents the psychomotor skills necessary for fiberoptic intubation. Significant improvement was seen in time to completion of endotracheal intubation, as well as other performance indicators.

                                                

門診病人麻醉的知曉和回憶

Awareness and Recall in Outpatient Anesthesia

Johanna Wennervirta, MD*, Seppo O.-V. Ranta, MD*, and Markku Hynynen, MD, PhD{dagger}

*Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Children’s Hospital, Helsinki, Finland; and {dagger}Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

 Anesth & Analg July 2002 95:72-77

目的  研究門診病人麻醉知曉和回憶的發生率,并与住院病人進行比較。方法  14.5個月期間,我們調查了1500例門診病人和2343例住院病人麻醉知曉和回憶的發生情況。結果  5例門診病人出現麻醉知曉和回憶,其中1例為清晰回憶,另外4例為模糊回憶。而在住院病人中有6例出現麻醉知曉和回憶,其中清晰回憶和模糊回憶各占3例。門診病人和住院病人清晰回憶的發生率分別為0.07%0.13%,經統計學處理無顯著性差异。出現麻醉知曉和回憶的門診病人應用七氟醚的量較無知曉和回憶者少(p0.05〉。結論  麻醉知曉和回憶是全麻期間少見的并發症,而門診病人和住院病人相比,出現麻醉知曉和回憶的危險性并無增加。

(王士雷譯  庄心良校)

We studied the incidence of awareness and explicit recall during general anesthesia in outpatients versus inpatients undergoing surgery. During a 14.5-mo period, we structurally interviewed 1500 outpatients and 2343 inpatients. Among outpatients, there were five cases of awareness and recall (one with clear intraoperative recollections and four with doubtful intraoperative recollections). Of the inpatients, six reported awareness and recall (three with clear and three with doubtful intraoperative recollections). The incidence of clear intraoperative recollections was 0.07% in outpatients and 0.13% in inpatients. The difference in the incidence was not significant. Among outpatients, those with awareness and recall were given smaller doses of sevoflurane than those without awareness and recall (P < 0.05). In conclusion, awareness and recall are rare complications of general anesthesia, and outpatients are not at increased risk for this event compared with inpatients undergoing general anesthesia.

 

 

α-7煙鹼型乙H膽鹼受體對异氟醚的敏感性有賴受體失活態

Sensitivity of the α-7 Nicotinic Acetylcholine Receptor to Isoflurane May Depend on Receptor Inactivation

Pamela Flood, MD, FACA, and Kristen M. Coates, BS

Department of Anesthesiology, Columbia University, New York

Anesth & Analg July 2002 95:83-87

 

目的  我們曾經證實,當异氟醚的濃度達到640µM2倍的MAC)時,將會影響α-7煙鹼型乙H膽鹼受體(α-7 nAChR)功能,而α-7nAChR廣泛分布于中樞和外周神經系統,通過突触前和突触后方式影響突触信號傳遞,這樣,异氟醚對α-7 nAChR 活性的調制可能是其主要麻醉机制之一。本次實驗中,我們進一步研究异氟醚對α-7 nAChR 的藥理作用特征。方法   應用分子生物學技術,利用爪蛙卵母細胞表達系統表達雞和人的α-7 nAChR,用雙電極電壓鉗技術,研究了不同的异氟醚預灌注時間、不同的激動劑濃度和不同的膜電位水平下异氟醚對α-7 nAChR 的抑制作用。結果   在一定的電生理條件下,臨床相關濃度的异氟醚可抑制α-7 nAChR 活性。當激動劑濃度增高以及异氟醚預灌注時間延長時,抑制作用增強。在用异氟醚預灌注,用100µM乙H膽鹼激動受體的條件下,异氟醚對雞nAChR 的半數最大抑制濃度為938± 26µM,而用1 mM乙H膽鹼濃度時,异氟醚對雞nAChR  的半數最大抑制濃度為408±51µM結論  激動劑濃度增高以及异氟醚預灌注時間延長時,异氟醚對之抑制增強,此現象提示,异氟醚主要作用于nAChR  的通道關閉態或關閉-脫敏態。

(楊保仲譯   庄心良校)

In previous studies, we demonstrated that nicotinic acetylcholine receptors (nAChRs) composed of the α-7 subunit are unaffected by the co-application of isoflurane with agonists at concentrations up to 640 µM(two times the minimum alveolar anesthetic concentration). Modulation of α-7-nAChR activity by isoflurane might have important behavioral ramifications because these receptors are expressed diffusely in the central and peripheral nervous systems and play pre- and postsynaptic roles in synaptic transmission. Here we have demonstrated that under some potentially physiologically relevant circumstances, the activation of α-7 nAChRs may be inhibited by clinically relevant concentrations of isoflurane. We evaluated isoflurane inhibition of α-7 nAChRs from chicks and humans expressed in Xenopus oocytes using two-electrode voltage clamp methodology. We determined the influence of time of preperfusion of isoflurane, agonist concentration, and membrane potential on inhibition by isoflurane. Both activation by a large concentration of agonist and isoflurane preperfusion increased inhibition. The half-maximal inhibitory concentration for isoflurane inhibition of chick α-7 nAChR with isoflurane preperfusion and activation by 100 µM of acetylcholine was 938 ± 26, and when activated by 1 mM of acetylcholine, it was 408 ± 51 µM. The increase in inhibition with isoflurane preexposure and large agonist concentration raises the possibility that isoflurane interacts preferentially with a closed or closed-desensitized state of the channel.

 

 

 

電針刺激足三里﹐陽陵泉﹐昆侖三穴位並不減少麻醉藥用量

Electro-Acupuncture at the Zusanli, Yanglingquan, and Kunlun Points Does Not Reduce Anesthetic Requirement

Nobutada Morioka, MD*,Ozan Akca, MD*, Anthony  G. Doufas, MD, PhD*, Gregory Chernyak, MD*, and Daniel I. Sessler, MD#

*Department of Anesthesiology, University Louisville, Kentueky. #Ludwig Boltzmann Institute,University of Vienna, Austria.

Anesth & Analg July 2002 95:98-102

 

     目的  本文試圖驗證電針刺激足三里﹐陽陵泉﹐昆侖三穴位可以減少麻醉藥得用量。方法14位年輕﹐健康的志願者﹐在不同兩天內分別使用地氟醚麻醉。針狀電極置于腿上此三穴位處﹐試圖獲得全身性的鎮靜和鎮痛效應。在試驗期內﹐電針穿透皮膚刺入此三穴位﹐而在對照期內則拔出。在受試期中經電極給予電刺激﹐ 2秒的間隙交替給予強度為2Hz100Hz的刺激。當呼氣末地氟醚濃度達到5.5%並穩定15分鐘時﹐在雙腿上由25號針給予持續1070mA100Hz的刺激。如受試者有動作則將地氟醚濃度昇高0.5%﹐如試驗者不動則將地氟醚濃度減少0.5%。判定受試者是否移動的調查者對治療情況並不知情。這一上下調節濃度的試驗將持續直至受試者從動到不動反復輪回4次。結果 經回歸分析﹐將在電刺激時50%有移動的地氟醚濃度確認為地氟醚麻醉最低肺泡濃度。在電刺激組(4.6%±0.6%)與對照組(4.6%±0.8%)間﹐最低地氟醚肺泡麻醉濃度無明顯差異(P=0.8)。結論 這些數據提示可檢出組間差別為0.35容積百分比的概率為80%

                                               (忻紀華   王祥瑞校)

We tested the hypothesis that electro-acupuncture at the Zusanli, Yanglingquan, and Kunlun acupuncture points on the legs decreases anesthetic requirement. Fourteen young, healthy volunteers were anesthetized with desflurane on two separate days. Needle electrodes were positioned at the three acupuncture points thought to produce a generalized sedative and analgesic effect. Needles were percutaneously placed on treatment days; on control days, they were insulated and taped near the insertion points. The electrodes were stimulated on the treatment day. Stimulation consisted of 2-Hz and 100-Hz currents alternated at 2-s intervals. When the end-tidal desflurane concentration of 5.5% was stable for 15 min, noxious electrical stimuli were administered via 25-gauge needles on both thighs (70 mA at 100 Hz for 10 s). Desflurane concentration was increased 0.5% when movement occurred and decreased 0.5% when it did not. An investigator, blinded to treatment, determined movement. These up-and-down sequences were continued until volunteers crossed from movement to no movement four times. A logistic regression determined the partial pressure of desflurane that produced a 50% likelihood of movement in response to noxious stimulation and consequently identified the minimum alveolar anesthetic concentration equivalent for desflurane. There was no significant difference in minimum alveolar anesthetic concentration equivalents between the electro-acupuncture (4.6% ± 0.6%, mean ± SD) and control (4.6% ± 0.8%) days (P = 0.8). These data provided an 80% power for detecting a difference of 0.35 volume-percent between the groups.

                                             

 

小劑量氯胺酮可改善術後病人抑鬱狀態

Small-Dose Ketamine Improves the Postoperative State of Depressed Patients

Akira Kudoh, MD*,Yoko Takahira, Hiroshi Katagai, MD, Tomoko Takazawa, MD

*Department of Anesthesiology, Hakodate Watanabe Hospital; and department of Anesthesiology, Hirosaki National Hospital, Hirosaki, Aomori, Japan

Anesth & Analg July 2002 95:114-118.

 

目的 本研究探討氯胺酮是否適宜于有抑鬱狀態整形外科手術病人。方法70名有抑鬱情緒的成年病人和25名對照組(C組)。抑鬱病人隨機分為2組﹐麻醉誘導A組(n=35)用異丙酚﹐芬太尼及氯胺酮﹐B組(n=35)用異丙酚及芬太尼。所有病人吸入1.5%-2.0%異氟醚及笑氣維持麻醉。結果 術前2Hamilton Depressed Rating(HDR)平均評分在A組為12.7±5.4B組為12.3±6.0。術後1AHDR評分為9.9±4.1B組為14.4±3.8。術後1AHDR評分顯著低于B組(P<0.05)。CHDR評分在術前2天為4.2±1.7﹐術後1天為4.8±1.6。與B組相比﹐A組病人的抑鬱情緒﹐自殺傾向﹐焦慮不安等有明顯降低。A組病人麻醉後8小時(26.6±8.7)和16小時(24.9±8.2)的疼痛評分要顯著低于B組病人8小時(34.3±12.0)和16小時(31.1±8.8)的疼痛評分(P<0.05)。結論 小劑量氯胺酮可以改善抑鬱病人術後的抑鬱狀態﹐並減輕其術後疼痛。

                                            (忻紀華譯 王祥瑞校)

We investigated whether ketamine is suitable for depressed patients who had undergone orthopedic surgery. We studied 70 patients with major depression and 25 patients as the control (Group C). The depressed patients were divided randomly into two groups; patients in Group A (n = 35) were induced with propofol, fentanyl, and ketamine and patients in Group B (n = 35) were induced with propofol and fentanyl, and all patients were maintained with 1.5%–2.0% isoflurane plus nitrous oxide. The mean Hamilton Depression Rating (HDR) score was 12.7 ± 5.4 for Group A and 12.3 ± 6.0 for Group B 2 days before surgery and 9.9 ± 4.1 for Group A and 14.4 ± 3.8 for Group B 1 day after surgery. The HDR score in Group A 1 day after surgery was significantly (P < 0.05) lower than that in Group B. The HDR score in Group C was 4.2 ± 1.7 2 days before surgery and 4.8 ± 1.6 1 day after surgery. Depressed mood, suicidal tendencies, somatic anxiety, and hypochondriasis significantly decreased in Group A as compared with Group B. Postoperative pain scores in Group A at 8 and 16 h after the end of anesthesia were 26.6 ± 8.7 and 24.9 ± 8.2, respectively, which were significantly (P < 0.05) lower than 34.3 ± 12.0 and 31.1 ± 8.8 in Group B. In conclusion, small-dose ketamine improved the postoperative depressive state and relieved postoperative pain in depressed patients.

                                                     

琥珀膽鹼能安全用于高鉀血症的病人嗎﹖

Can Succinylcholine Be Used Safely in Hyperkalemic Patients?

Adam J. Schow, MD*, David A. Lubarsky, MD, MBA{dagger}, Ronald P. Olson, MD*, and Tong J. Gan, MB*

 

*Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; and {dagger}Department of Anesthesiology, University of Miami/Jackson Medical Center, Florida Anesth & Analg July 2002 95:119-122

 

背景 盡管現在還沒有系統的資料确定血鉀處于何种水平是安全的,高鉀血症常被認為是琥珀膽鹼的相對禁忌證。目的 研究在患有高鉀血症的病人中應用琥珀膽鹼是否安全。方法  回顧性地調查了超過四萬例誘導時使用了琥珀膽鹼的全麻病人﹐時間跨度超過70個月。結果  其中38人術前血清鉀濃度超過5.6 mEq/L。這些病人的麻醉生存率是100%。通過人工調查以及檢查術中自動生成的麻醉記錄和術後病程記錄均未發現有心律不齊或其它嚴重併發症的記載。經過統計處理﹐95%可信區間最大風險率是7.9%。當然這個比例是不容忽視的。但是這個數據幾乎可以肯定高估了中等程度的高鉀血症的危險。結論  欲通過前瞻性研究確定高鉀血症的安全範圍是困難的。所以現有的這些數據表明﹐在需要緊急插管又不能有長時間肌肉痲痺的情況下﹐對於中等高鉀血症的病人﹐應用琥珀膽鹼還是安全的。

                                       (顏濤譯  莊心良校)

 

The use of succinylcholine in hyperkalemic patients (serum potassium >5.5 mEq/L) is often viewed as relatively contraindicated, although there are no systematic data to define what preoperative potassium level is safe. We retrospectively reviewed more than 40,000 general anesthetics administered over 70 mo in which succinylcholine was given at the induction. This search yielded 38 patients with a preoperative potassium of 5.6 mEq/L or greater. Survival of the anesthetic was 100%, and no dysrhythmias or other major morbidity were documented upon manual review of the intraoperative automated record keeper charts or the patient medical records. These data allow a 95% confidence interval assessment of maximal risk for an event of 7.9%, which is not negligible, but which almost certainly grossly overestimates the risk for patients with moderately increased potassium levels. A prospective trial to definitively assess the safety margin for succinylcholine use in hyperkalemic patients would be difficult. Therefore, these data, taken in the context of a compelling case for rapid intubating conditions without long-term paralysis, suggest safety in succinylcholine use in patients with modest hyperkalemia.

 

對婦科術前和術後疼痛評估的一種有效可靠的新方法

A New Highly Reliable Instrument for the Assessment of Pre- and Postoperative Gynecological Pain

Elisabet Stener-Victorin,RPT,PhD*, Jan Kowalski, BS, and Thomas Lundeberg,MD,PhD

瑞典歌德堡大學婦產科學系﹔斯德哥爾摩Karolinska學會生理學和藥理學分會﹔瑞典斯德哥爾摩Karolinska醫院藥劑

Anesth & Analg July 20002 95:151-157.

    目的  在本文中我們在短小婦科手術中對一項新的疼痛評估方法的可靠性進行驗證。方法這一方法建立在疼痛匹配對知覺匹配比較基礎上。另外﹐對使用兩種不同麻醉方法──電刺激或快速阿片類藥物如阿芬太尼﹐兩組同時合用宮頸旁阻滯﹐在術前和術後2小時使用疼痛匹配和VAS評分進行疼痛評估。有223名女病人(22-38歲)參與了這一測試。結果 疼痛匹配是一種可靠的疼痛評估方法。有個別病人不願意參加此項測試﹐但這並不影響本文結果的統計學意義。擴大的階梯程序(rank-order coefficient,ra)系數值十分理想(0.95-1.00)。當刻度用于探知疼痛狀態的改變時﹐並沒有明顯的跡象顯示有何反應。這可能主要是由於數據統計時無法顧及個別的情況。由於個別情況導致的差異在疼痛匹配測量時要小於VAS評分。總而言之﹐我們發現疼痛匹配是一種很好的測量疼痛的方法﹐其結果可靠﹐反復測量時差異比VAS評分小。結論 病人能很好地接受疼痛匹配測量﹐這在測量急性術前和術後疼痛時是非常有用的。

                                                   (忻紀華   王祥瑞校)

In this study, we evaluated the reliability of a newly developed method for pain assessment, which is based on perceptual matching by Pain Matcher® Cefar Medical AB, Lund, Sweden, during minor gynecological surgery. In addition, the responsiveness to two different anesthetic methods─electro-acupuncture or a fast-acting opiate, alfentanil, both in combination with a paracervical block─was estimated by using Pain Matcher and visual analog scale (VAS) assessments before and 2 h after surgery. Two hundred-twenty-three women (aged 22–38 yr) participated. The results show that Pain Matcher is a reliable method for pain assessments, with lack of random individual disagreement and with no statistical evidence of systematic disagreement in position or in concentration. The augmented rank-order coefficient (ra) values were excellent (0.95–1.00). When scales were used to detect true changes over time, there was no clear indication of responsiveness, mostly because of statistically significant random individual changes. However, the individual changes were much smaller for magnitude matching than for VAS. In conclusion, we would recommend the use of perceptual matching by Pain Matcher for pain assessment, because in this study it was a reliable and powerful in test-retest situations and had smaller individual changes than VAS after intervention. The Pain Matcher procedure was well accepted by the patients, and the results suggest that it may be useful when evaluating acute pre- and postoperative pain.

 

 

腹式全子宮切除術後于腹膜內和切口應用布比卡因加腎上腺素的鎮痛效應

The Analgesic Effects of Intraperitoneal and Incisional Bupivacaine with Epinephrine After Total Abdominal Hysterectomy

A.Ng, FRCA*, A. Swami, FFARCSI*, G. Smith, MD, FRCA*, A.C. Davidson, FRCOG, and J. Emembolu, FRCOG

*University Department of Anaesthesia, Critical Care, and Pain Management, and Department of Obstetrics and Gynaecology, Leicester Royal Infirmary, Leicester LE1 5WW, United Kingdom

Anesth & Analg July 2002 95:158-162

 

目的 本研究觀察腹式全子宮切除術後于腹膜內和切口應用布比卡因加腎上腺素產生的鎮痛效應。方法 46ASAI-II級的病人接受常規麻醉﹐術畢行病人自控嗎啡以及每6小時經直腸給予扑熱息痛1g鎮痛。病人被隨機分為兩組﹐一組給予50ml 0.25%布比卡因複合5ug/ml腎上腺素﹔另一組給予50ml生理鹽水作為對照組。在關閉傷口前將其中30ml應用于腹膜內﹐另外20ml應用于切口。結果 安慰劑組的17例病人和布比卡因組的16例病人分別完成了本研究。部份病人沒有完成本研究是因為PCA故障、PCA中止太早、惡心、胸部感染、放置了腹腔內引流管以及違反協議。兩組病人在年齡、身高、體重或手術時間方面無明顯差異。清醒狀態下安慰劑組的病人活動後疼痛明顯比布比卡因組病人強烈。安慰劑組病人24小時嗎啡用量為62mg (53-85mg)﹐而布比卡因組為44mg (33-56mg) (p<0.01)討論 兩組24h嗎啡用量明顯差異主要是因為安慰劑組病人在術後第一個4小時內的嗎啡用量較大。結論 腹式全子宮切除術後于腹膜內和切口應用布比卡因加腎上腺素﹐在第一個4小時具有明顯鎮痛效果﹐可明顯減少嗎啡用量。

                                                         (齊波   王祥瑞校)

The objective of our study was to see if incisional and intraperitoneal bupivacaine with epinephrine produces analgesia after total abdominal hysterectomy. Forty-six ASA physical status I and II patients received a standardized anesthetic, patient-controlled analgesia (PCA) morphine, and rectal paracetamol 1 g every 6 h. Patients were randomized to receive 50 mL of bupivacaine 0.25% with epinephrine 5 µg/mL or 50 mL of normal saline. Thirty milliliters and 20 mL of treatment solution were administered into the peritoneum and incision, respectively, before wound closure. Seventeen and 16 patients in the Placebo and Bupivacaine groups, respectively, completed the study. The reasons for withdrawal were PCA malfunction, PCA discontinued too early, nausea, chest infection, intraabdominal drain insertion, and protocol violation. There were no significant differences between the Bupivacaine and Placebo groups in age, height, weight, or duration of surgery. Pain on movement was significantly more intense in the Placebo group than in the Bupivacaine group on awakening. Morphine consumption (interquartile range) over 24 h was 62 mg (53-85 mg) in the Placebo group compared with 44 mg (33-56 mg) in the Bupivacaine group (P < 0.01). This significant difference was attributable to the larger morphine consumption in the Placebo group in the first 4 postoperative h. We conclude that a combination of intraperitoneal and incisional bupivacaine with epinephrine provides significant morphine-sparing analgesia for 4 h after total abdominal hysterectomy.

                                                       

單極和雙極气管內電極用于電刺激通气

Electroventilation with Monopolar and Bipolar Intratracheal Electrodes

Zachary W. Sopcak, MSBME, L. A. Geddes, PhD, Kirk S. Foster, BSEE, William E. Schoenlein, BS, and Joe D. Bourland, PhD

Purdue University Department of Biomedical Engineering, West Lafayette, Indiana

 Anesth & Analg July 2002 95:189-191

 

目的 電刺激通气(electroventilation)是一种通過精心放置于體表或體內的電極給予吸气肌電刺激以產生吸气動作的技術。本研究分析使用單極和雙極气管內電極進行電刺激通气的有效性。方法 選擇7只狗為實驗對象。置放單極和雙極气管內電極進行電刺激通气,記錄自發的潮气量和刺激所需電流及吸气量。結果 使用雙極電極可以使所有7只狗的吸气量均大于自發的潮气量,但是使用單極電極僅能使其中3只吸气量增大。使用气管內電極產生單次潮气量所需電流比體表電極小,且電極置放比使用食道內電極方便。實驗結果顯示雙極電極可以被用來進行電刺激通气。結論 本研究說明電刺激通气可以使用气管內電極,所需刺激電流比使用體表電極減小。气管內電極通气有兩种方式:一种是單極式,其返回電極位于體表;另一种是雙極式,其返回電極位于气管內。

(葛圣金譯  庄心良校)

Electroventilation is the technique of producing inspiration with stimuli applied to inspiratory muscles by using strategically placed electrodes on or within the body. We conducted studies using the dog to determine the efficacy of monopolar and bipolar intratracheal electrodes for electroventilation. Bipolar electrodes were able to produce an inspired volume greater than a spontaneous tidal volume in all seven dogs, but monopolar electrodes were able to in only three of seven dogs. The intratracheal electrode has the advantage over body-surface electrodes that less current is required to produce a single tidal volume, and it has the advantage over intraesophageal electrodes that anatomical placement of the electrode is simplified. These experiments demonstrated that a bipolar electrode can be used for electroventilation.

 

建立壓力-控制模式時气管導管逐漸阻塞時潮气量變化的模型

Modeling the Effect of Progressive Endotracheal Tube Occlusion on Tidal Volume in Pressure-Control Mode

Avery Tung, MD*, and Sherwin E. Morgan, RRT{dagger}

Departments of *Anesthesia and Critical Care and {dagger}Respiratory Therapy, University of Chicago, Chicago, Illinois

Anesth & Analg July 2002 95:192-197

 

目的  因气道分泌物可在气管導管(ETT)內的沉積,長期使用气管插管的主要的危險是气道逐漸阻塞。在使用容積-控制的呼吸机時,監測峰值和平台期的气道壓差有助于查覺ETT阻塞的形成。然而在壓力-控制的呼吸机,吸气時的气道壓是預先設定的,因此不能作為報警指標,取而代之是以潮气量的變化幫助判斷ETT的堵塞。本文采用數學方式模擬在逐漸增加气道阻力時壓力-控制模式呼吸机的反應,進而驗證監測潮气量是否能有效的發現進展中的气道阻塞。方法 為了确證作者的模型,作者采用實驗肺和內徑由9.0mm3.5mm的气管導管(模擬逐漸阻塞的气道)檢測西門子 300型和Puritan-Bennett 7200型呼吸机。結果 作者發現當使用壓力-控制模式時,直到气道几近完全阻塞,潮气量才降低。結論 作者認為長期使用壓力-控制呼吸模式,會導致ETT發生明顯阻塞而不能發覺,有發生气管完全阻塞的危險,同時用此通气模式使患者圍術期的處理變复雜。

                                          (趙雪蓮譯  庄心良校)

A recognized hazard of prolonged endotracheal intubation is progressive airway occlusion resulting from deposition of secretions on the inner surface of the endotracheal tube (ETT). When volume-controlled ventilation is used, progressive ETT occlusion may be detected by monitoring the difference between peak and plateau airway pressures. In pressure-controlled modes, however, inspiratory airway pressures are preset and thus cannot act as a warning indicator. Instead, changes in delivered tidal volumes may aid the diagnosis of ETT occlusion. To determine whether tidal volume monitoring effectively de-tects progressive ETT occlusion, we mathematically modeled the response of a ventilator operating in pressure-controlled mode to increasing airway resistance. To corroborate our model, we then bench-tested the Siemens 300 and Puritan-Bennett 7200 ventilators by using a test lung and a series of ETTs ranging in size from 9.0 to 3.5 mm inner diameter to simulate progressive occlusion. We found that when pressure-controlled mode was used, progressive ETT occlusion did not reduce delivered tidal volumes until occlusion was nearly complete. We conclude that prolonged use of pressure-controlled mode may allow significant ETT obstruction to build up undetected, risking complete ETT occlusion and complicating the perioperative care of patients ventilated with this mode.

 

硬膜外應用布比卡因和羅磪d因分娩鎮痛的相對運動神經阻滯效能

The Relative Motor Blocking Potencies of Epidural Bupivacaine and Ropivacaine in Labor

Héctor J. Lacassie, MD*, Malachy O. Columb, FRCA, Héctor P. Lacassie, MD, and Rodrigo A. Lantadilla, MD*

*Anesthesiology Department, Pontificia Universidad Católica de Chile; and Anesthesiology Service, Clínica Alemana, Santiago, Chile; and South Manchester University Hospital, Withington, United Kingdom

Anesth & Analg July 20002 95:204-208.

 

目的 最小局麻藥濃度(MLAC)已用于評價硬膜外應用布比卡因和羅磪d因的鎮痛效能。目前尚無此類藥物運動神經阻滯效能的報道。本研究主要觀察兩種藥物在MLAC時的運動神經阻滯效能和兩種藥物的相對效能比。方法 60ASA I-II 級的產婦被隨機分為兩組﹐在第一產程分別給予兩組產婦布比卡因或羅磪d因20ml單次劑量。每一組第一個產婦所給藥物的濃度為0.35%﹐其餘產婦的藥物濃度在0.35%的基礎上依次遞增或遞減一個實驗間隔劑量0.025%。在30分鐘內Bromage評分<4則認為是有效的運動神經阻滯。結果 應用DixonMassey分析產婦藥物濃度的上-下順序﹐並用概率回歸量化運動神經阻滯的最小局麻藥濃度。兩方面均于P<0.05時有明顯差異。結果 布比卡因的運動神經阻滯的最小局麻藥濃度為0.326%(95%可靠區間[CI]0.285-0.367)﹐羅磪d因為0.497%(95%CI0.431-0.563) (p=0.0008)。布比卡因/羅磪d因效能比為0.66 (95%CI0.52-0.82)結論 本文首次評估布比卡因和羅磪d因運動神經阻滯效能MLAC﹐羅磪d因的運動神經阻滯效能較低﹐僅為布比卡因的66%

                                                 (齊波   王祥瑞校)

Minimal local analgesic concentrations (MLAC) have been used to determine the epidural analgesic potencies of bupivacaine and ropivacaine. There are no reports of the motor blocking potencies of these drugs. We sought to determine the motor block MLAC of both drugs and their relative potency ratio. Sixty ASA physical status I and II parturients were randomized to one of two groups, during the first stage of labor. Each received a 20-mL bolus of epidural bupivacaine or ropivacaine. The first woman in each group received 0.35%. Up-down sequential allocation was used to determine subsequent concentrations at a testing interval of 0.025%. Effective motor block was defined as a Bromage score <4 within 30 min. The up-down sequences were analyzed by using the Dixon and Massey method and probit regression to quantify the motor block minimal local analgesic concentration. Two-sided P < 0.05 defined significance. The motor block minimal local analgesic concentration for bupivacaine was 0.326% (95% confidence interval [CI], 0.285-0.367) and for ropivacaine was 0.497% (95% CI, 0.431-0.563) (P = 0.0008). The ropivacaine/bupivacaine potency ratio was 0.66 (95% CI, 0.52-0.82). This is the first MLAC study to estimate the motor blocking potencies of bupivacaine and ropivacaine. Ropivacaine was significantly less potent for motor block, at 66% that of bupivacaine.

                                                    

 

坐骨神經阻滯前路法的新標志:影像學和臨床研究

New Landmarks for the Anterior Approach to the Sciatic Nerve Block: Imaging and Clinical Study

Alain C. Van Elstraete, MD*, Claude Poey, MD{dagger}, Thierry Lebrun, MD*, and Frédéric Pastureau, MD*

Departments of *Anesthesiology and {dagger}Radiology, Saint-Paul Medical Center, Fort de France, Martinique, France

Anesth & Analg July 2002 95:214-218

 

目的 評价腹股溝褶皺和股動脈作為前路坐骨神經阻滯解剖標志的可靠性并确定此路徑時腿的理想位置。方法 臨床研究前先進行一項影像學研究,以兩种定位方法對20例行腳踝和足部手術的病人行坐骨神經阻滯:一為腿中間位,一為腿外旋位,病人均為仰臥位。使用一支連接神經刺激器的22150mm長斜角針從离腹股溝褶皺2.5cm遠,距股動脈2.5cm遠處向后側方向与垂直面成10~15度角方向進針。結果 腿在中間位時,所有病人的坐骨神經阻滯點定位于10.6±1.8cm深度,而腿外旋位時則是10.4±1.5cm(無顯著差別)。腿中間位和外旋位時,确定解剖標志的時間分別是28±15s26±14s(無顯著差別)。确定坐骨神經阻滯的時間分別為79±53s46±25s (p<0.006)。我們确定腹股溝褶皺和股動脈是前路坐骨神經阻滯的可靠及有效的解剖標志,理想的體位是腿外旋位。結論 以腹股溝褶皺和股動脈作為進行坐骨神經阻滯的標志是一項簡便和可靠的技術。

                                            (焦志華譯  庄心良校)

In this study, we assessed the reliability of the inguinal crease and femoral artery as anatomic landmarks for the anterior approach to the sciatic nerve and determined the optimal position of the leg during this approach. An imaging study was conducted before the clinical study. The sciatic nerve was located twice in 20 patients undergoing ankle or foot surgery, once with the leg in the neutral position and once with the leg in the externally rotated position. The patient was lying supine. A 22-gauge, 150-mm insulated b-beveled needle connected to a nerve stimulator was inserted 2.5 cm distal to the inguinal crease and 2.5 cm medial to the femoral artery and was directed posteriorly and laterally with a 10∼每15∼ angle relative to the vertical plane. The sciatic nerve was located in all patients at a depth of 10.6 ± 1.8 cm when the leg was in the neutral position and 10.4 ± 1.5 cm when the leg was in the externally rotated position (not significant). In the neutral position and in the externally rotated position, the time needed to identify anatomic landmarks was 28 ± 15 s and 26 ± 14 s, respectively (not significant), and the time needed to locate the sciatic nerve was 79 ± 53 s and 46 ± 25 s (P < 0.006), respectively. We conclude that the inguinal crease and femoral artery are reliable and effective anatomic landmarks for the anterior approach to the sciatic nerve and that the optimal position of the leg is the externally rotated position.

 

 

降低吸入笑氣濃度後對雙腔管支氣管套囊迅速放氣的研究

Rapid Deflation of the Bronchial Cuff of the Double-Lumen Tube After Decreasing the Concentration of Inspired Nitrous Oxide

Fujio Karasawa, MD, Akira Takita, MD, Isao Takamatsu, MD, Tomohisa Mori, MD, Takashi Oshima, MD, and Yasushi Kawatani, MD

Department of Anesthesiology, National Defense Medical College, Saitama, Japan

Anesth & Analg July 2002 95:238-242.

 

目的 麻醉中吸入笑氣(N2O)濃度減小後氣管內套囊可發生放氣現象﹐本文研究雙腔管(DLT)套囊的放氣現象。方法 隨機挑選24例行胸外科手術的病人﹐並隨機分為三組﹐採用Mallinckrodt雙腔管(Athlone, Ireland)﹐在雙腔管的氣管套囊和左支氣管套囊內分別充滿空氣、40%N2O67%N2O(分別命名為空氣組、N40組和N67)40分鐘後﹐將N40組部份病人套囊內的N2O改為O2(命名為N40-c)。測定套囊內氣體容積、N2O濃度和套囊順應性。結果空氣組病人的氣管和支氣管套囊的壓力明顯增大﹐而N67組減小。N40組無明顯改變﹐但N40-c組病人在笑氣麻醉結束後﹐氣管和支氣管套囊的壓力均降低。支氣管套囊壓力減小一半所需時間(12.0+_5.5min)要短于氣管套囊壓力減小一半所需時間(31.2+_11.0min , P<0.01)N40-c組病人的氣管套囊和支氣管套囊的容積變化無顯著差異﹐但氣管套囊的順應性明顯高于支氣管套囊。結論 在應用67%N2O進行麻醉時﹐如採用40%N2O充填DLT套囊可穩定套囊壓力﹐在終止應用N2O後﹐因為支氣管套囊的順應性小﹐因此比氣管套囊放氣更加快。

                                              (忻紀華   王祥瑞校)

Deflationary phenomena of the endotracheal tube cuff may occur after inspired nitrous oxide (N2O) concentrations are reduced, but deflationary phenomena of the double-lumen tube (DLT) cuff have not been investigated. In this study, tracheal and bronchial cuffs of left-sided Mallinckrodt (Athlone, Ireland) DLTs were inflated with air, 40% N2O, or 67% N2O (Air, N40, or N67 groups, respectively) in 24 patients undergoing thoracic surgery; 40 min later, O2 was substituted for N2O in some of the patients in the N40 group (N40-c group). Intracuff gas volumes, N2O concentrations, and cuff compliance were also measured. Both tracheal and bronchial cuff pressures significantly increased in the Air group but decreased in the N67 group. Neither pressure significantly changed in the N40 group, but both decreased in the N40-c group after terminating N2O anesthesia; the time required for bronchial cuff pressures to decrease by half (12.0 ± 5.5 min) was less than that for tracheal cuff pressures (31.2 ± 11.0 min, P < 0.01). The volume change in the N40-c group was not significantly different between the tracheal and bronchial cuffs, but tracheal cuff compliance was significantly higher than bronchial compliance. Therefore, filling DLT cuffs with 40% N2O stabilizes cuff pressure during anesthesia with 67% N2O, but bronchial cuffs deflate more quickly than tracheal cuffs after cessation of N2O administration through smaller compliance.

                                                  

N2O麻醉時氣管套囊重複放氣以穩定套囊內壓力

Repeated Deflation of a Gas-Barrier Cuff to Stabilize Cuff Pressure During Nitrous Oxide Anesthesia

Fujio Karasawa, MD, Nobuhiro Matsuoka, MD, Mitsuyoshi Kodama, MD, Tomohiro Okuda, MD, Tomohisa Mori, MD, and Yasushi Kawatani, MD

Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan

Anesth & Analg July 2002 95:243-248

 

目的 評价N2O麻醉中氣管套囊重複放氣時裝有N2O阻擋器的氣管導管套囊是否較標準的氣管導管套囊能更有效地穩定套囊內壓力。方法 分別測量67%N2O麻醉(每組8人)中充滿氣體的標準型氣管套囊和裝有N2O阻擋裝置的軟塞形氣管內套囊(PSSC)壓力。起初的3-4小時內﹐氣囊每隔3060分鐘放氣一次。結果 吸气3小時後﹐兩組中半數以上病人的氣管套囊壓力超過22mmHg。而兩組中吸氣4小時的氣管套囊在放氣間隔期的最大壓力已經降低(p<0.01)﹐氣管套囊內N2O濃度增高(p<0.001)。重複放氣4小時後﹐兩組病人在接下來的3小時中氣管套囊壓力再也不超過22mmHg﹐套囊內N2O濃度也無明顯變化。因此﹐N2O麻醉時4小時內重複放氣可有效穩定兩組氣囊壓力和平衡氣囊內N2O濃度。但是PSSC沒有減少放氣時間去穩定壓力。結論 N2O麻醉中氣管套囊從2小時充氣到4小時時﹐裝有N2O阻擋器的軟塞氣囊中N2O濃度和壓力逐漸穩定﹐且因為需要放氣的次數較少﹐軟塞形氣管套囊將比標準氣管套囊更方便應用于臨床。

(焦志華譯  莊心良校)

Although a nitrous oxide (N2O) gas-barrier cuff effectively limits the increase of cuff pressure during N2O anesthesia, there are few data assessing whether an N2O gas-barrier cuff is more beneficial for stabilizing intracuff pressure than standard endotracheal tubes when cuffs are repeatedly deflated to stabilize pressure during N2O anesthesia. In the present study, the pressure of air-filled standard-type cuffs (Trachelon; Terumo, Tokyo, Japan) and N2O gas-barrier type endotracheal tube cuffs (Profile Soft-Seal Cuff [PSSC]; Sims Portex, Kent, UK) was measured during 67% N2O anesthesia (n = 8 in each), during which the cuffs were repeatedly deflated every 30 min (Trachelon) or 60 min (PSSC) for the first 3 or 4 h. After aspirating the cuffs for 3 h, the cuff pressure exceeded 22 mm Hg in more than half of the patients in both groups. However, aspiration of the cuffs for 4 h decreased the maximal cuff pressure between deflation intervals in both groups (P < 0.01 for each), and increased the intracuff N2O concentration (P < 0.0001 for each). After deflating the cuffs over 4 h, the cuff pressure in both groups never exceeded 22 mm Hg during the subsequent 3 h, and intracuff N2O concentrations did not significantly change. Therefore, deflation of cuffs for 4 h during N2O anesthesia sufficiently stabilized cuff pressure and equilibrated the intracuff N2O concentrations in both groups. The use of the PSSC endotracheal tube might be more practical because of the smaller number of cuff deflations required, but the PSSC does not reduce the duration of cuff deflations to stabilize the pressure.