Anesthesia & Analgesia

August 2002

Table of Content

CARDIOVASCULAR ANESTHESIA

正常體溫和淺低溫心肺轉流使肝和內臟氧合受損以及血漿透明質增加

(顏濤   莊心良校)

Impairment of Hepatosplanchnic Oxygenation and Increase of Serum Hyaluronate During Normothermic and Mild Hypothermic Cardiopulmonary Bypass

Nobuhiro Okano, MD*, Sotaro Miyoshi, MD*, Ryoichi Owada, MD*, Nao Fujita, MD*, Yuji Kadoi, MD, Shigeru Saito, MD, Fumio Goto, MD, and Toshihiro Morita, MD*

*Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center, Saitama, Japan; and Department of Anesthesiology and Reanimatology, Gunma University, School of Medicine, Gunma, Japan

Anesth Analg 2002;95:278-286

骨科大手術中抑肽酶對安慰劑:一項隨機,雙盲,劑量範圍研究

(張俊峰譯 薛張剛校)

Aprotinin Versus Placebo in Major Orthopedic Surgery: A Randomized, Double-Blinded, Dose-Ranging Study

Charles Marc Samama, MD PhD*, Olivier Langeron, MD, Nadia Rosencher, MD, Xavier Capdevila, MD PhD, Patricia Rouche, MD||, Michel Pegoix, MD, Josée Bernière, MD#, and Pierre Coriat, MD for the Hémorragies et Aprotinine en Chirurgie Orthopédique Lourde Study Group

常溫體外迴圈時平均動脈壓增加不影響胰島素依賴病人的頸靜脈氧飽和度

(張俊峰譯 薛張剛校)

Increasing Mean Arterial Blood Pressure Has No Effect on Jugular Venous Oxygen Saturation in Insulin-Dependent Patients During Tepid Cardiopulmonary Bypass

Yuji Kadoi, MD*, Shigeru Saito, MD*, Daisuke Yoshikawa, MD*, Fumio Goto, MD*, Nao Fujita, MD, and Fumio Kunimoto, MD

術中心動過速和高血壓與非心臟手術後的長期預後獨立影響因素

(忻紀華     王祥瑞 )

Intraoperative Tachycardia and Hypertension Are Independently Associated with Adverse Outcome in Noncardiac Surgery of Long Duration

David L. Reich, MD, Elliott Bennett-Guerrero, MD, Carol A. Bodian, DrPH, Sabera Hossain, MSc, Wanda Winfree, RN, and Marina Krol, PhD

Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York

Anesth Analg 2002;95:273-277

成人脊柱手術中,乳酸林格氏液大量靜脈內灌注後的術後早期呼吸性酸中毒

(忻紀華     王祥瑞 )

Early Postoperative Respiratory Acidosis After Large Intravascular Volume Infusion of Lactated Ringers Solution During Major Spine Surgery

Arzu Takil, MD, Zeynep Eti, MD, Pinar Irmak, MD, and F. Yilmaz Göü, MD

Department of Anesthesiology, Medical Faculty of Marmara University, Istanbul, Turkey

Anesth Analg 2002;95:294-298

PEDIATRIC ANESTHESIA:

心電圖指導下嬰幼兒經尾入路胸部硬膜外置管

(王士雷   莊心良校)

Thoracic Epidural Catheter Placement Via the Caudal Approach in Infants by Using Electrocardiographic Guidance

Ban C. H. Tsui, MSC MD, FRCP(C), R. Seal, MD FRCP(C), and J. Koller, MD FRCP(C)

Department of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Walter Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada

Anesth & Analg August 2002 95:326-330

 

AMBULATORY ANESTHESIA:

腕部神經阻滯可增加門診腕管手術病人術中心血管穩定性並提早出院時間

(潘志浩譯薛張剛校)

Distal Nerve Blocks at the Wrist for Outpatient Carpal Tunnel Surgery Offer Intraoperative Cardiovascular Stability and Reduce Discharge Time

Ralf E. Gebhard, MD, Tameem Al-Samsam, MD, Jennifer Greger, MD, Ahmad Khan, MD, and Jacques E. Chelly, MD PhD, MBA

ANESTHETIC PHARMACOLOGY:

吸入麻醉藥和非去極化類肌肉鬆弛藥在神經肌肉接頭部位的相互作用特徵

(楊保仲   莊心良校)

Characterization of the Interactions Between Volatile Anesthetics and Neuromuscular Blockers at the Muscle Nicotinic Acetylcholine Receptor

Matthias Paul, MD DEAA*, Ralf M. Fokt*, Christoph H. Kindler, MD DEAA, Natalie C. J. Dipp, and C. Spencer Yost, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; Department of Anesthesia, Kantonsspital, Basel, Switzerland; and University of Cologne, Germany

Anesth Analg 2002;95:362-367

 

高血壓患者應用美維松的心血管效應

(趙雪蓮    莊心良校)

The Cardiovascular Effects of Mivacurium in Hypertensive Patients

Benoît Plaud, MD*, Jean Marty, MD, Bertrand Debaene, MD, Claude Meistelman, MD, Daniel Pellissier, MD||, Jean-Yves LePage, MD, Pierre Feiss, MD#, Philippe Scherpereel, MD**, Marie-Noëlle Bouverne, MSc, and Sandrine Fosse, MSc

*Department of Anesthesiology and Intensive Care, Fondation Adolphe de Rothschild, Paris, France; Department of Anesthesiology and Intensive Care, Hôpital Beaujon, Université Paris VII, Clichy, France; Department of Anesthesiology and Intensive Care, Centre Hospitalier Regional Universitaire de Poitiers, Poitiers, France; Department of Anesthesiology and Intensive Care, Hôpitaux de Brabois, Centre Hospitalo-Universitaire de Nancy, Nancy, France; ||Department of Anesthesiology and Intensive Care, Hôpital La Timone, Marseille, France; Department of Anesthesiology and Intensive Care, CHRU de Nantes, Nantes, France; #Department of Anesthesiology and Intensive Care, CHRU de Limoges, Limoges, France; **Department of Anesthesiology and Intensive Care, CHRU de Lille, Lille, France; and GlaxoSmithKline Laboratories, Marly-le-Roi, France

Anesth Analg 2002;95:379-384

口服α2受體激動劑Tizannidine降低成人七氟醚的最小肺泡濃度

(張軍   莊心良 )

Oral Tizanidine, an 2-Adrenoceptor Agonist, Reduces the Minimum Alveolar Concentration of Sevoflurane in Human Adults

Zenichiro Wajima, MD PhD, Tatsusuke Yoshikawa, MD PhD, Akira Ogura, MD PhD, Kazuyuki Imanaga, MD, Toshiya Shiga, MD PhD, Tetsuo Inoue, MD PhD, and Ryo Ogawa

Department of Anesthesia, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan; Department of Anesthesia, Hakujikai Memorial Hospital, Tokyo, Japan; Department of Anesthesiology, Tokyo Jikeikai Medical School, Tokyo, Japan; Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and ||Department of Anesthesiology, Nippon Medical School, Tokyo, Japan

Anesth Analg 2002;95:393-396

第二代血液替代品Perflubron Emulsion增加體外試驗中現代吸入麻醉藥的血溶性

(潘志浩譯薛張剛校)

A Second-Generation Blood Substitute (Perflubron Emulsion) Increases the Blood Solubility of Modern Volatile Anesthetics In Vitro

Olivier Y. Cuignet, MD*, Philippe M. Baele, MD, and Luc J. Van Obbergh, MD PhD

確定乳腺癌前哨淋巴結時的Isosulfan Blue Dye反應

(嵇富海譯  薛張剛校)

Isosulfan Blue Dye Reactions During Sentinel Lymph Node Mapping for Breast Cancer

Leslie L. Montgomery, MD*, Alisa C. Thorne, MD, Kimberly J. Van Zee, MS MD*, Jane Fey, MPH*, Alexandra S. Heerdt, MD MPH*, Mary Gemignani, MD*, Elisa Port, MD*, Jeanne Petrek, MD*, Hiram S. Cody, III, MD*, and Patrick I. Borgen, MD*

*Breast Service, Department of Surgery, and Department of Anesthesia, Memorial Sloan-Kettering Cancer Center, New York, New York

Anesth Analg 2002;95:385-388

氟化物和低溫對體內咪庫溴胺代謝影響

嵇富海譯  薛張剛校)

The Effect of Fluoride and Hypothermia on the In Vitro Metabolism of Mivacurium

Michael Gruber, PhD, Regina Lindner, Christopher Prasser, MD, and Gunther Wiesner, MD

Department of Anesthesiology, University of Regensburg, Regensburg, Germany

Anesth Analg 2002;95:397-399

麻醉藥的靜電相互作用對N-乙酰膽鹼受體的影響

(朱輝       王祥瑞 )

The Role of Electrostatic Interactions in Governing Anesthetic Action on the Torpedo Nicotinic Acetylcholine Receptor

Douglas E. Raines, MD*, and Robert J. Claycomb, BS

*Department of Anesthesia, Harvard Medical School; and Massachusetts General Hospital, Boston, Massachusetts

Anesth Analg 2002;95:356-361

咪唑安定的非γ-氨基丁酸介導的促使c-FosEGR-1的表達

(朱輝       王祥瑞 )

Midazolam Induces Expression of c-Fos and EGR-1 by a Non-GABAergic Mechanism

Kazuhiko Fukuda, MD, Takehiro Shoda, MD, Hiroyuki Mima, MD, and Hisatoshi Uga, MD

Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan

Anesth Analg 2002;95:373-378

 

在異丙酚麻醉中使用阿托品對心率的影響

(周潔       王祥瑞 )

Heart Rate Response to Intravenous Atropine During Propofol Anesthesia

Takashi Horiguchi, MD, and Toshiaki Nishikawa, MD

Department of Anesthesia, Akita University School of Medicine, Akita, Japan

Anesth Analg 2002;95:389-392

PAIN MEDICINE:

硬膜外類固醇藥物的注入技術:一項全國性問卷調查

(周潔       王祥瑞 )

The Technical Aspects of Epidural Steroid Injections: A National Survey

Robert Cluff, MD, Abdel-Kader Mehio, MD, Steven P. Cohen, MD, Yuchiao Chang, PhD, Christine N. Sang, MD MPH*, and Milan P. Stojanovic, MD

*Clinical Trials Program and Interventional Pain Program, MGH Pain Center; and Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Anesth Analg 2002;95:403-408

CRITICAL CARE AND TRAUMA:

咪噠唑侖對模擬急救醫療運輸服務過程中應激水平的影響:安慰劑對照的、劑量效應研究

(焦志華譯 莊心良校)

The Effect of Midazolam on Stress Levels During Simulated Emergency Medical Service Transport: A Placebo-Controlled, Dose-Response Study

Volker Dörges, MD*, Volker Wenzel, MD, Susanne Dix, BS, Alexander Kühl, BSThomas Schumann, BS, Michael Hüppe, PhD,Heiko Iven, PhD,  and Klaus Gerlach, MD

*Department of Anesthesiology and Intensive Care Medicine, University Hospital of Kiel; Departments of Anesthesiology, and Pharmacology, Medical University of Lübeck, Germany; and Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria

Anesth Analg 2002;95:417-422

比較0.1%0.2%羅比卡因和布比卡因加嗎啡用於大的腹部手術後的術後鎮痛。

(張德林譯 薛張剛校)

A Comparison of 0.1% and 0.2% Ropivacaine and Bupivacaine Combined with Morphine for Postoperative Patient-Controlled Epidural Analgesia After Major Abdominal Surgery

Marc Senard, MD, Jean L. Joris, MD PhD, Didier Ledoux, MD, Pierre J. Toussaint, MD, Benoît Lahaye-Goffart, MD, and Maurice L. Lamy, MD

Department of Anesthesia and Intensive Care Medicine, CHU de Liège, D Anesth Analg 2002;95

omaine du Sart-Tilman, Belgium

 

比較異丙酚和右美托咪定在術中鎮靜中的作用、副作用和恢復特性

(李懿   薛張剛校)

The Efficacy, Side Effects, and Recovery Characteristics of Dexmedetomidine Versus Propofol When Used for Intraoperative Sedation

Shahbaz R. Arain, MD, and Thomas J. Ebert, MD PhD

Department of Anesthesiology, Medical College of Wisconsin and VA Medical Center, Milwaukee, Wisconsin

Anesth Analg 2002;95:461-466

NEUROSURGICAL ANESTHESIA:

硬膜外穿刺後鼠模型觀察硬膜外注射血液和其他藥液時顱內血流調節機制

(張德林譯 薛張剛校)

The Mechanisms of Intracranial Pressure Modulation by Epidural Blood and Other Injectates in a Postdural Puncture Rat Model

Jeffrey S. Kroin, PhD, Subhash K.S. Nagalla, MD, Asokumar Buvanendran, MD

Department of Anesthesiology, Rush Medical College at Rush-Presbyterian-St. Lukes Medical Center, Chicago, Illinois

Anesth Analg 2002;95

 

三種麻醉技術應用於幕上顱內手術病人的比較

(齊波    王祥瑞 )

A Comparison of Three Anesthetic Techniques in Patients Undergoing Craniotomy for Supratentorial Intracranial Surgery

Pekka Talke, MD, James E. Caldwell, MBChB, Ronald Brown, BS, Barbara Dodson, MD, Joan Howley, MD, and Charles A. Richardson, PhD

Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, California

Anesth Analg 2002;95:430-435

OBSTETRIC ANESTHESIA:

鞘內和硬膜外注射嗎啡用於擇期剖宮產術後鎮痛的對比研究

(王士雷   莊心良 )

A Double-Blinded, Randomized Comparison of Intrathecal and Epidural Morphine for Elective Cesarean Delivery

J. Sarvela, MD PhD, P. Halonen, MD, A. Soikkeli, MD, and K. Korttila, MD PhD, FRCA

Department of Anaesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland

Anesth & Analg August 2002 95: 436-440

REGIONAL ANESTHESIA:

應用前臂或上臂止血帶實施利多卡因-酮咯酸靜脈局部麻醉鎮痛效能的對比研究

(葛聖金譯  莊心良校)

An Evaluation of the Analgesic Efficacy of Intravenous Regional Anesthesia with Lidocaine and Ketorolac Using a Forearm Versus Upper Arm Tourniquet

Scott S. Reuben, MD*, Robert B. Steinberg, MD PhD*, Holly Maciolek, RN*, and Poornachandran Manikantan, MD*

 

Department of Anesthesiology, *Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts

Anesth & Analg August 2002 95: 457-460

腹腔鏡膽囊切除術後通過導管向膽囊窩內間斷注射0.5%布比卡因的鎮痛研究

(齊波    王祥瑞 )

Postoperative Pain Relief Using Intermittent Injections of 0.5% Ropivacaine Through a Catheter After Laparoscopic Cholecystectomy

Anil Gupta, MD FRCA, PhD*, Sven E. Thörn, MD PhD*, Kjell Axelsson, MD PhD*, Lars G. Larsson, MD, Göran Ågren, MD, Björn Holmström, MD PhD*, and Narinder Rawal, MD PhD*

Departments of *Anesthesiology and Intensive Care, Surgery, and Division for Ambulatory Surgery, University Hospital, Örebro, Sweden

Anesth Analg 2002;95:450-456

硬膜外/全麻複合麻醉和硬膜外術後鎮痛對腹腔鏡或開腹結直腸手術病人的腸道功能恢復和體溫調節的影響

(殷文淵    王祥瑞 )

Temperature Control and Recovery of Bowel Function After Laparoscopic or Laparotomic Colorectal Surgery in Patients Receiving Combined Epidural/General Anesthesia and Postoperative Epidural Analgesia

Giorgio Danelli, MD*, Marco Berti, MD*, Valeria Perotti, MD*, Andrea Albertin, MD*, Paolo Baccari, MD, Francesco Deni, MD*, Guido Fanelli, MD*, and Andrea Casati, MD*

*Department of Anesthesiology and Emergency Surgery, Vita-Salute University of Milano, IRCCS H.S. Raffaele, Milano, Italy

Anesth Analg 2002;95:467-471

GENERAL ARTICLES:

圍術期胃排空不能預測經腹腔鏡膽囊切除術後早期噁心嘔吐的發生

(顏濤   莊心良 )

Perioperative Gastric Emptying Is Not a Predictor of Early Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Cholecystectomy

M. Wattwil, MD PhD*, S.-E. Thörn, MD PhD*, A Lövqvist*, L. Wattwil*, H. Klockhoff, MD, L.-G. Larsson, MD, and I. Näslund, MD PhD

Departments of *Anesthesiology and Intensive Care and Surgery, Örebro University Hospital, Örebro; and Department of Medicine and Care, Faculty of Health Sciences, Linköping, Sweden

Anesth Analg 2002;95:476-479

比較應用喉鏡和Lightwand氣管插管裝置 (Trachlight®)兩者行成人正常氣道氣管內插管的血流動力學反應

(李懿 薛張剛校)

Hemodynamic Responses to Tracheal Intubation with Laryngoscope Versus Lightwand Intubating Device (Trachlight®) in Adults with Normal Airway

Shinji Takahashi, MD*, Taro Mizutani, MD, Masayuki Miyabe, MD*, and Hidenori Toyooka, MD*

Departments of *Anesthesiology and Critical Care Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan

Anesth Analg 2002;95:480-484

Abstracts

 

正常體溫和淺低溫心肺轉流使肝和內臟氧合受損以及血漿透明質增加

Impairment of Hepatosplanchnic Oxygenation and Increase of Serum Hyaluronate During Normothermic and Mild Hypothermic Cardiopulmonary Bypass

Nobuhiro Okano, MD*, Sotaro Miyoshi, MD*, Ryoichi Owada, MD*, Nao Fujita, MD*, Yuji Kadoi, MD, Shigeru Saito, MD, Fumio Goto, MD, and Toshihiro Morita, MD*

*Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center, Saitama, Japan; and Department of Anesthesiology and Reanimatology, Gunma University, School of Medicine, Gunma, Japan

Anesth Analg 2002;95:278-286

目的  研究心肺轉流期間和轉流後內源性透明質酸(一種敏感的反映SEC功能的指示劑)的血漿動力學以及肝-內臟的氧合情況。方法  在心肺轉流下行擇期冠狀動脈搭橋手術的25病人,其中15位為正常體溫心肺轉流(>35℃),10位為淺低溫心肺轉流(32)。每例病人都放置肝靜脈導管以監測肝-內臟氧合情況及血漿透明質酸濃度。結果  正常體溫或淺低溫體外迴圈下肝靜脈血氧飽和度的下降程度相似。在正常體溫心肺轉流期間肝-內臟氧耗和氧的提取量都增加(P<0.05),但是在淺低溫心肺轉流期間則沒有變化。兩組病人的動脈和肝靜脈血透明質酸濃度在心肺轉流中和轉流後都升高了3倍。結論  在心肺轉流期間,動脈血透明質酸濃度和肝-內臟氧耗量之間存在正相關,提示肝-內臟氧代謝在血漿透明質酸濃度升高的機制中起作用。肝臟喪失了提高對透明質酸的提取能力強烈提示肝血竇內皮細胞功能損害可能是血漿透明質酸濃度升高的原因                  

                                       (顏濤   莊心良 )

Hepatic sinusoidal endothelial cells (SECs) are more vulnerable to hypoxia or hypothermia than hepatocytes. To test the hypothesis that hepatic venous desaturation during cardiopulmonary bypass (CPB) leads to impairment of SEC function, we studied the plasma kinetics of endogenous hyaluronate (HA), a sensitive indicator of SEC function, and hepatosplanchnic oxygenation during and after CPB. Twenty-five consecutive patients scheduled for elective coronary artery bypass graft surgery, who underwent normothermic (>35°C; n = 15) or mild hypothermic (32°C; n = 10) CPB participated in this study. A hepatic venous catheter was inserted into each patient to monitor hepatosplanchnic oxygenation and serum levels of HA concentration. Hepatic venous oxygen saturation decreased essentially to a similar degree during normothermic and mild hypothermic CPB. Hepatosplanchnic oxygen consumption and extraction increased during normothermic (P < 0.05), but not mild hypothermic, CPB. Both arterial and hepatic venous HA concentrations showed threefold increases during and after CPB in both groups. A positive correlation was found between hepatosplanchnic oxygen consumption and arterial HA concentrations during CPB, suggesting a role of changes in hepatosplanchnic oxygen metabolism in the mechanisms of increases in serum HA concentrations. The failure of the liver to increase HA extraction to a great degree suggests that a functional impairment of the SEC may contribute to the observed increase of serum HA.

 

骨科大手術中抑肽酶對安慰劑:一項隨機,雙盲,劑量範圍研究

Aprotinin Versus Placebo in Major Orthopedic Surgery: A Randomized, Double-Blinded, Dose-Ranging Study

Charles Marc Samama, MD PhD*, Olivier Langeron, MD, Nadia Rosencher, MD, Xavier Capdevila, MD PhD, Patricia Rouche, MD||, Michel Pegoix, MD, Josée Bernière, MD#, and Pierre Coriat, MD for the Hémorragies et Aprotinine en Chirurgie Orthopédique Lourde Study Group

    我們進行的前瞻性,多中心,雙盲,劑量範圍研究比較了骨科大手術後大劑量和小劑量抑肽酶以及安慰劑的風險/效益比。58例病人隨機分為三組: 大劑量抑肽酶組(術前4 百萬KIU負荷劑量隨後持續輸注1百萬KIU/小時直到手術結束),小劑量組(2百萬 KIU 負荷 0.5 百萬 KIU/小時),以及安慰劑組。測量和計算出血量。雙側順行靜脈造影在術後第三天系統地進行。大劑量抑肽酶組測定和計算的血液喪失減少(計算出血量,全血量, 壓積 30%, 均數 [範圍], 2,023 mL [6334,113];安慰劑組, 3,577 mL [1,67021,758 mL])。異體和自體輸血的總量在大劑量抑肽酶組也顯著減少 (2 U [05 U]; 安慰劑組, 4 U [042 U]) 抑肽酶組觀察到的深靜脈血栓和肺栓塞沒有增加。大劑量抑肽酶在骨科大手術後安全、有效地顯著減少了測定和計算的出血量和輸用的紅細胞單位。結論:大劑量抑肽酶在骨科大手術後減少了失血和輸血量。(張俊峰譯 薛張剛校)

We conducted a prospective, multicenter, double-blinded, dose-ranging study to compare the risk/benefit ratio of large- and small-dose aprotinin with placebo after major orthopedic surgery. Fifty-eight patients were randomized into three groups: Large-Dose Aprotinin (4 M kallikrein inactivator unit [KIU] bolus before surgery followed by a continuous infusion of 1 M KIU/h until the end of surgery), Small-Dose Aprotinin (2 M KIU bolus plus 0.5 M KIU/h), and Placebo. Bleeding was measured and calculated. Bilateral ascending venography was systematically performed on the third postoperative day. Measured and calculated blood loss decreased in the Large-Dose Aprotinin group (calculated bleeding, whole blood, hematocrit 30%, median [range], 2,023 mL [6334,113] as compared with placebo, 3,577 mL [1,67021,758 mL]). The total number of homologous and autologous units was also significantly decreased in the Large-Dose Aprotinin group (2 U [05 U] as compared with placebo, 4 U [042 U]). No increase in deep vein thrombosis or pulmonary embolism was observed in the aprotinin groups. Large-dose aprotinin was safe and effective in dramatically reducing the measured and calculated bleeding and the amount of transfused red blood cell units after major orthopedic surgery.

IMPLICATIONS: Large doses of aprotinin decrease blood loss and transfusion amount in major orthopedic surgery.

 

常溫體外迴圈時平均動脈壓增加不影響胰島素依賴病人的頸靜脈氧飽和度

Increasing Mean Arterial Blood Pressure Has No Effect on Jugular Venous Oxygen Saturation in Insulin-Dependent Patients During Tepid Cardiopulmonary Bypass

Yuji Kadoi, MD*, Shigeru Saito, MD*, Daisuke Yoshikawa, MD*, Fumio Goto, MD*, Nao Fujita, MD, and Fumio Kunimoto, MD

    術前存在的糖尿病是一個與心臟手術後不良神經功能紊亂相關的重要因素。在以前的報告中,我們發現在常溫體外迴圈時糖尿病病人與非糖尿病病人相比腦去飽和更多見。本研究的目的在於檢測在糖尿病病人常溫體外迴圈時應用新福林提高平均動脈壓對頸靜脈氧飽和度的影響。我們研究了20例擇期冠脈搭橋手術的糖尿病病人,20例年齡相當的非糖尿病病人作為對照。在麻醉誘導後,光纖氧飽和度導管置入右頸靜脈球監測SjvO2。在測定動脈和頸靜脈血氣分壓和心血管血流動力學參數的基礎值後,重複應用10-µg衝擊劑量的新福林增加平均動脈壓直到基礎值的100%。在應用新福林後糖尿病組和對照組SjvO2 值有顯著差異 (糖尿病組, 56% ± 6%; 對照組: 60% ± 4%) (P < 0.05)。在應用新福林後糖尿病組和對照組 的動脈-頸靜脈氧含量差值也有顯著差異 (糖尿病組, 4.9% ± 0.6%;對照組, 4.5% ± 0.4%) (P < 0.05)。我們將糖尿病組又分為三個小組 (飲食治療組 [n = 4], 優降糖組 [n = 10],和胰島素依賴組 [n = 6])。胰島素依賴組和其他組之間SjvO2對腦灌注壓的平均斜率也有顯著差異 (Dunnett 檢驗: P = 0.04)。胰島素依賴病人在常溫體外迴圈平均動脈壓增加對SjvO2 值無影響。結論: 我們檢測了糖尿病病人常溫體外迴圈時應用新福林增加平均動脈壓對頸內靜脈氧飽和度的效應,發現胰島素依賴病人平均動脈壓的增加對SjvO2 值無影響。(張俊峰譯 薛張剛校)

Preexisting diabetes mellitus is one of the major factors related to adverse postoperative neurological disorders after cardiac surgery. In previous reports, we found that diabetic patients more often experienced cerebral desaturation than nondiabetic patients during normothermic cardiopulmonary bypass (CPB). The purpose of this study was to examine the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen hemoglobin saturation (SjvO2) during tepid CPB in diabetic patients. We studied 20 diabetic patients scheduled for elective coronary artery bypass graft surgery and, as a control, 20 age-matched nondiabetic patients. After the induction of anesthesia, a fiberoptic oximetry catheter was inserted into the right jugular bulb to monitor SjvO2. After measuring the baseline partial pressure of the arterial and jugular venous blood gases and cardiovascular hemodynamic values, MAP was increased by the repeated administration of a 10-µg bolus of phenylephrine until it reached 100% of baseline values. There was a significant difference in SjvO2 value between the Diabetic and Control groups after the administration of phenylephrine (Diabetic group, 56% ± 6%; Control group: 60% ± 4%) (P < 0.05). There was a significant difference in the arterial-jugular oxygen content difference value between the Diabetic and Control groups after the administration of phenylephrine (diabetic group, 4.9% ± 0.6%; Control group, 4.5% ± 0.4%) (P < 0.05). We subdivided the Diabetic group into three groups (Diet Therapy group [n = 4], Glibenclamide group [n = 10], and Insulin-Dependent group [n = 6]). There was a significant difference in the mean slopes of SjvO2 versus cerebral perfusion pressure for increasing cerebral perfusion pressure between the Insulin-Dependent group and the other groups (Dunnett test: P = 0.04). Increasing MAP had no effects on the SjvO2 value in insulin-dependent patients during tepid CPB.

IMPLICATIONS: We examined the effects of increasing mean arterial blood pressure (MAP) by the administration of phenylephrine on internal jugular venous oxygen saturation (SjvO2) during tepid cardiopulmonary bypass in diabetic patients and found that increasing MAP had no effect on the SjvO2 value in insulin-dependent patients

 

術中心動過速和高血壓與非心臟手術後的長期預後獨立影響因素

Intraoperative Tachycardia and Hypertension Are Independently Associated with Adverse Outcome in Noncardiac Surgery of Long Duration

David L. Reich, MD, Elliott Bennett-Guerrero, MD, Carol A. Bodian, DrPH, Sabera Hossain, MSc, Wanda Winfree, RN, and Marina Krol, PhD

Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York

Anesth Analg 2002;95:273-277

已知術中血流動力學改變對外科預後的影響幾乎無關。我們從一項非心臟手術病人的研究中取樣(n=797)。以生理學的POSSUM(生理學和手術的標準誤分數計算死亡率)作為手術危險分級指數,並且從電腦的麻醉記錄中取得術中的測量值,包括心率(HR)、平均動脈壓、收縮壓(SAP)。術中每5分鐘記錄一次,HR、平均動脈壓、SAP各自被分為低、正常和高組。手術預後不良(NSO)指住院天數大於10天且病情不好轉,或於住院期間死亡。統計學分析包括Mantel Haenszel核對總和多項邏輯回歸分析。對於短小手術,血流動力學改變和NSO無明顯相關。在133例手術時間長於平均手術時間(220分鐘)的病人中,NSO的發生率為15.6%。對照POSSUM評分和手術時間大於220分鐘,心率加快(差率,2.704p=0.001)和SAP升高(差率,2.095p=0.009)和長時間手術後的NSO有關。因此,術中心動過速和高血壓與多數非心臟手術後的長期預後不良有關。

                              (忻紀華     王祥瑞 )

Relatively little is known about the influence of intraoperative hemodynamic variables on surgical outcomes. We drew subjects (n = 797) from a study of patients undergoing major noncardiac surgery. The physiological component of the POSSUM (Physiological and Operative Se- verity Score for the enUmeration of Mortality) operative risk stratification index was determined, and intraoperative measurements of heart rate (HR), mean arterial blood pressure, and systolic arterial blood pressure (SAP) were retrieved from computerized anesthesia records. For every 5-min epoch during the surgery, HR, mean arterial blood pressure, and SAP were each classified as low, normal, or high. Negative surgical outcome (NSO) was defined as a hospital stay of >10 days with a morbid condition or death during the hospital stay. Statistical analyses included Mantel-Haenszel tests and multiple logistic regression. There was no significant association between hemodynamic variables and NSO with short operations. In 388 patients with operations longer than the median time of 220 min, NSO occurred in 15.6%. Controlling for POSSUM score and operation time beyond 220 min, both high HR (odds ratio, 2.704; P = 0.01) and high SAP (odds ratio, 2.095; P = 0.009) were associated with NSO in longer operations. Thus, intraoperative tachycardia and hypertension were associated independently with adverse outcomes after major noncardiac surgery of long duration, over and above the risk imparted by underlying medical conditions.

成人脊柱手術中,乳酸林格氏液大量靜脈內灌注後的術後早期呼吸性酸中毒

Early Postoperative Respiratory Acidosis After Large Intravascular Volume Infusion of Lactated Ringers Solution During Major Spine Surgery

Arzu Takil, MD, Zeynep Eti, MD, Pinar Irmak, MD, and F. Yilmaz Göü, MD

Anesth Analg 2002;95:294-298

Department of Anesthesiology, Medical Faculty of Marmara University, Istanbul, Turkey

本研究在30(年齡為1870)成人脊柱手術病人比較0.9%鹽溶液(NS)或乳酸林格氏液(LR)大量靜脈輸注對術中電解質和酸堿平衡的影響,同時估價其術後作用。全麻誘導5mg/kg硫賁妥和0.1mg/kg維庫溴胺。麻醉維持吸入70%笑氣和1.52%的七氟醚。I組輸注NS溶液,II組輸注LR溶液,術中以20ml/kg/hr ,術後以2.5ml/kg/hr 滴注。於術前,術中每隔一小時,術後第1246小時測量電解質(Na+,K+,Cl-)和動脈血氣。NS組,pHa,HCO3-和堿剩餘(BE)下降,Cl-濃度在術中第2小時,Na+濃度在術中第4小時明顯增高(p<0.001,術後12小時,濃度降至正常。LR組,血氣分析和電解質濃度在術中無明顯改變,但在術後1小時PaCO2明顯升高,血清Na+pHa降低。儘管術中20ml/kg/hrLR輸注沒有象NS組引起高氯性代謝性酸中毒,但LR可導致術後呼吸性酸中毒和輕度低鈉血症。                 (忻紀華     王祥瑞 )

In this study, we compared the effects of large intravascular volume infusion of 0.9% saline (NS) or lactated Ringers (LR) solution on electrolytes and acid base balance during major spine surgery and evaluated the postoperative effects. Thirty patients aged 1870 yr were included in the study. General anesthesia was induced with 5 mg/kg thiopental and 0.1 mg/kg vecuronium IV. Anesthesia was maintained with oxygen in 70% nitrous oxide and 1.5%2% sevoflurane. In Group I, the NS solution, and in Group II, the LR solution were infused 20 mL · kg-1 · h-1 during the operation and 2.5 mL · kg-1 · h-1, postoperatively. Electrolytes (Na+, K+, Cl-) and arterial blood gases were measured preoperatively, every hour intraoperatively and at the 1st, 2nd, 4th, 6th, and 12th hours postoperatively. In the NS group, pHa, HCO3 and base excess decreased, and Cl- values increased significantly at the 2nd hour and Na+ values increased at the 4th hour intraoperatively (P < 0.001). The values returned to normal ranges at the 12th hour postoperatively. In the LR group, blood gas analysis and electrolyte values did not show any significant difference intraoperatively, but the increase in PaCO2 and the decrease in pHa and serum Na+ was significant at the 1st hour postoperatively. Although intraoperative 20 mL · kg-1 · h-1 LR infusion does not cause hyperchloremic metabolic acidosis as does NS infusion, it leads to postoperative respiratory acidosis and mild hyponatremia.

心電圖指導下嬰幼兒經尾入路胸部硬膜外置管

Thoracic Epidural Catheter Placement Via the Caudal Approach in Infants by Using Electrocardiographic Guidance

Ban C. H. Tsui, MSC MD, FRCP(C), R. Seal, MD FRCP(C), and J. Koller, MD FRCP(C)

Department of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Walter Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada

Anesth & Analg August 2002 95:326-330

目的 探討在心電圖監測指導下嬰幼兒經尾入路胸部硬膜外置管的成功率。方法 在病人(20例)全麻誘導後,用18號穿刺針經尾穿刺,置入20號硬膜外導管。同時記錄經硬膜外導管5導聯心電圖和仰臥位體表5導聯心電圖,二者波形相同時,停止置入導管。通過術後X線檢查確認導管尖端的位置。結果 所有患兒均獲得滿意的硬膜外麻醉效果,硬膜外導管尖端位於目的平面2個椎間隙內。結論 經硬膜外導管監測心電圖可以指導嬰幼兒經尾入路胸部硬膜外置管。

                                     (王士雷   莊心良 )

We examined the success of inserting epidural catheters via the caudal route in infants by using electrocardiographic guidance. A case series of 20 patients with thoracic epidural analgesia was studied. After the induction of general anesthesia, an 18-gauge IV catheter was inserted into the caudal space to allow threading of a 20-gauge epidural catheter. The electrocardiogram (ECG) tracings via the epidural catheter, as well as the surface ECG at the target spine level, were recorded simultaneously with a modified two-channel five-lead ECG system. The epidural catheter was advanced from the caudal space until the tip reached the target level as demonstrated by a match in the configuration of the epidural ECG tracing to that of the surface ECG tracing at the target level. The catheter tip location was verified by postoperative radiographs. All catheter tips were located within two vertebrae of the target level, and satisfactory intraoperative epidural anesthesia was achieved in all subjects.

 

腕部神經阻滯可增加門診腕管手術病人術中心血管穩定性並提早出院時間Distal Nerve Blocks at the Wrist for Outpatient Carpal Tunnel Surgery Offer Intraoperative Cardiovascular Stability and Reduce Discharge Time

Ralf E. Gebhard, MD, Tameem Al-Samsam, MD, Jennifer Greger, MD, Ahmad Khan, MD, and Jacques E. Chelly, MD PhD, MBA

    腕管松解術是一個常在門診施行的手術。我們設計該回顧性研究以評價不同麻醉方法對術中心血管穩定性和出院時間的影響。根據所使用的麻醉方法不同,62例病人依次分為靜脈局部麻醉組BIER (IV regional anesthesia)、神經阻滯組BLOCK (distal nerve blocks)和全身麻醉組GENERAL (general anesthesia),研究其術中心動過緩、心動過速、高血壓及低血壓的發生率,上止血帶時間,手術時間,手術室停留時間及出院時間。BLOCK組的心血管穩定性較佳,與 BIER組相比其高血壓的發生率較低(5%對25%),與GENERAL組相比其低血壓的發生率也較低(14%42)。術後醫院停留時間明顯短於BIER組(6588分鐘)和GENERAL組(65133分鐘)。因此,我們認為,對於門診行腕管松解術的病人,神經阻滯麻醉可提供比全身麻醉更佳的術中心血管穩定性。在術後,BLOCK組的病人比BIER組或GENERAL組的病人較早出院,可能與神經阻滯具有卓越的術後鎮痛效應有關。結論:該項關於門診腕管松解術三種麻醉方法的回顧性研究顯示腕部神經阻滯麻醉可提供較佳的術中心血管穩定性並可提早出院時間。(潘志浩譯薛張剛校)

 

Carpal tunnel release is often performed as an outpatient procedure. We designed this retrospective study to assess the effect of different anesthesia techniques on intraoperative cardiovascular stability and discharge time. According to the anesthesia technique received, 62 consecutive patients were categorized in Group BIER (IV regional anesthesia), Group BLOCK (distal nerve blocks), and Group GENERAL (general anesthesia). Incidences of intraoperative periods of tachycardia or bradycardia and hyper- or hypotension were studied, as were tourniquet, surgical, operating room, and discharge times. Cardiovascular stability was better achieved in Group BLOCK, as indicated by a significantly smaller incidence of periods of hypertension compared with Group BIER (5% vs 25%) and a significantly less frequent incidence of periods of hypotension compared with Group GENERAL (14% vs 42%). Patients in Group BLOCK spent significantly less time in the hospital after surgery than patients in Group BIER (65 vs 88 min) or patients in Group GENERAL (65 vs 133 min). We conclude that distal nerve blocks for outpatient carpal tunnel surgery are associated with greater intraoperative cardiovascular stability than general anesthesia. After surgery, patients in Group BLOCK could be discharged earlier than patients who received IV regional anesthesia or general anesthesia; this could be related to the superior postoperative analgesia provided by this technique. IMPLICATIONS: This retrospective analysis of three different anesthetic techniques for ambulatory carpal tunnel surgery shows that nerve blocks performed at the wrist provided excellent intraoperative cardiovascular stability and allowed for earlier discharge.

 

吸入麻醉藥和非去極化類肌肉鬆弛藥在神經肌肉接頭部位的相互作用特徵

Characterization of the Interactions Between Volatile Anesthetics and Neuromuscular Blockers at the Muscle Nicotinic Acetylcholine Receptor

Matthias Paul, MD DEAA*, Ralf M. Fokt*, Christoph H. Kindler, MD DEAA, Natalie C. J. Dipp, and C. Spencer Yost, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; Department of Anesthesia, Kantonsspital, Basel, Switzerland; and University of Cologne, Germany

Anesth Analg 2002;95:362-367

目的  吸入麻醉藥可以強化非去極化類肌肉鬆弛藥(NDMRs)的肌松效應。這兩種藥物相互影響的作用位點被認為是在神經肌肉接頭部位,即兩種藥物共同作用於神經肌肉接頭部位的乙酰膽鹼受體(m-nAChRs)之結果。本試驗擬對此假說作驗證。方法  應用異種組織表達系統爪蟾卵母細胞表達大鼠肌肉成年型乙酰膽鹼受體m-nAChRs2α、β、δ、ε),首先建立維庫溴銨、筒箭毒堿、異氟醚和七氟醚對該受體由乙酰膽鹼所激發的電流之抑制效應的濃度—效應曲線,求得單獨應用維庫溴銨、筒箭毒堿、異氟醚和七氟醚時對該受體的半數(或半效)抑制劑量(ID50)。接著研究了在同時給予ID50的異氟醚或七氟醚時NDMRsm-nAChRs的抑制效應。結果  四種藥物均產生可逆的濃度依賴性的抑制效應,維庫溴銨、筒箭毒堿、異氟醚和七氟醚的ID50值分別為9.9nM(95%可信區間為8.4-11.4nM)43.4nM(95%可信區間為33.6-53.3nM)897μM(95%可信區間為699-1150μM)818μM(95%可信區間為685-1001μM)。同時應用異氟醚或七氟醚可大大加強維庫溴銨或筒箭毒堿對m-nAChRs之抑制效應,尤以使用低濃度的NDMRs時為最。結論  吸入麻醉藥可以強化非去極化類肌肉鬆弛藥的效能,此現象的可能機制是吸入麻醉藥增加拮抗劑和受體的親和力。

                                    (楊保仲   莊心良 校)

Volatile anesthetics enhance the neuromuscular blockade produced by nondepolarizing muscle relaxants (NDMRs). The neuromuscular junction is a postulated site of this interaction. We tested the hypothesis that volatile anesthetic enhancement of muscle relaxation is the result of combined drug effects on the nicotinic acetylcholine receptor. The adult mouse muscle nicotinic acetylcholine receptor (2, ß, , ) was heterologously expressed in Xenopus laevis oocytes. Concentration-effect curves for the inhibition of acetylcholine-induced currents were established for vecuronium, d-tubocurarine, isoflurane, and sevoflurane. Subsequently, inhibitory effects of NDMRs were studied in the presence of the volatile anesthetics at a concentration equivalent to half the concentration producing a 50% inhibition alone. All individually tested compounds produced rapid and readily reversible concentration-dependent inhibition. The calculated 50% inhibitory concentration values were 9.9 nM (95% confidence interval [CI], 8.411.4 nM), 43.4 nM (95% CI, 33.653.3 nM), 897 µM (95% CI, 6991150 µM), and 818 µM (95% CI, 6851001 µM) for vecuronium, d-tubocurarine, isoflurane, and sevoflurane, respectively. Coapplication of either isoflurane or sevoflurane significantly enhanced the inhibitory effects of vecuronium and d-tubocurarine, especially so at small concentrations of NDMRs. Volatile anesthetics increase the potency of NDMRs, possibly by enhancing antagonist affinity at the receptor site. This effect may contribute to the clinically observable enhancement of neuromuscular blockade by volatile anesthetics.

 

高血壓患者應用美維松的心血管效應

The Cardiovascular Effects of Mivacurium in Hypertensive Patients

Benoît Plaud, MD*, Jean Marty, MD, Bertrand Debaene, MD, Claude Meistelman, MD, Daniel Pellissier, MD||, Jean-Yves LePage, MD, Pierre Feiss, MD#, Philippe Scherpereel, MD**, Marie-Noëlle Bouverne, MSc, and Sandrine Fosse, MSc

*Department of Anesthesiology and Intensive Care, Fondation Adolphe de Rothschild, Paris, France; Department of Anesthesiology and Intensive Care, Hôpital Beaujon, Université Paris VII, Clichy, France; {ddagger}Department of Anesthesiology and Intensive Care, Centre Hospitalier Regional Universitaire de Poitiers, Poitiers, France; Department of Anesthesiology and Intensive Care, Hôpitaux de Brabois, Centre Hospitalo-Universitaire de Nancy, Nancy, France; ||Department of Anesthesiology and Intensive Care, Hôpital La Timone, Marseille, France; Department of Anesthesiology and Intensive Care, CHRU de Nantes, Nantes, France; #Department of Anesthesiology and Intensive Care, CHRU de Limoges, Limoges, France; **Department of Anesthesiology and Intensive Care, CHRU de Lille, Lille, France; and GlaxoSmithKline Laboratories, Marly-le-Roi, France

AAnesth Analg 2002;95:379-384

目的:健康患者應用美維松通常會出現低血壓。本文研究高血壓患者應用美維松後的血流動力學變化。方法:本文為採用開放式、多中心研究。以芬太尼和依託米酯進行麻醉誘導後,血壓正常組(n=149)和高血壓組(n=57)患者分別在10秒或30秒靜注0.2mgKg-1的美維松。用電子血壓計記錄HRMAP結果:血壓正常組和高血壓組患者10秒靜注組低血壓(血壓低於給美維松前對照MAP20%為低血壓)的發生率分別為21%36% 30秒靜注組低血壓的發生率分別為11%10%。在高血壓組30秒靜注組MAP的降低幅度明顯高於10秒靜注組(20%10% p=0.002),而在血壓正常組未見這種差異。結論:高血壓患者與正常血壓患者相比,快速靜注美維松(10秒注射完)後低血壓的發生率更多,降低幅度更大。

 

                  (趙雪蓮      莊心良校)

Hypotension is common after mivacurium injection in healthy patients. This hemodynamic event had not been investigated in hypertensive patients characterized by more intense hemodynamic instability. In this open-label, multicenter, randomized, and controlled study, we sought to determine whether mean arterial blood pressure (MAP) and heart rate variations were larger in hypertensive versus normotensive patients after a bolus dose of mivacurium injected over 10 or 30 s. After the induction of anesthesia with fentanyl and etomidate, normotensive (n = 149) and hypertensive (n = 57) patients received a single dose of mivacurium 0.2 mg/kg injected over 10 or 30 s by random allocation. Heart rate and MAP were recorded electronically. The incidence of hypotension (defined as a 20% MAP decrease from the control value before mivacurium injection) was 21% and 36% (10-s injection) or 11% and 10% (30-s injection) in the Normotensive and Hypertensive groups, respectively. In Hypertensive patients, the maximum decrease in MAP was significantly greater when mivacurium was injected over 10 s compared with 30 s: 20% vs 11%, respectively (P = 0.002). This difference was not observed in Normotensive patients. Hypotension after rapid (e.g., 10 s) mivacurium injection was more frequent and more pronounced in Hypertensive than in Normotensive patients.

 

口服α2受體激動劑Tizannidine降低成人七氟醚的最小肺泡濃度

Oral Tizanidine, an 2-Adrenoceptor Agonist, Reduces the Minimum Alveolar Concentration of Sevoflurane in Human Adults

Zenichiro Wajima, MD PhD, Tatsusuke Yoshikawa, MD PhD, Akira Ogura, MD PhD, Kazuyuki Imanaga, MD, Toshiya Shiga, MD PhD, Tetsuo Inoue, MD PhD, and Ryo Ogawa

 

Department of Anesthesia, Chiba Hokusoh Hospital, Nippon Medical School, Chiba, Japan; Department of Anesthesia, Hakujikai Memorial Hospital, Tokyo, Japan; Department of Anesthesiology, Tokyo Jikeikai Medical School, Tokyo, Japan; Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; and ||Department of Anesthesiology, Nippon Medical School, Tokyo, Japan

Anesth Analg 2002;95:393-396

 

目的  α2受體激動劑Tizannidine對動物具有抗傷害作用。術前口服Tizannidine,可減輕與放置咽喉鏡及插管相關的血壓升高,令意識消失所需的咪唑安定劑量顯著減少。我們推測口服Tizannidine可能降低七氟醚的最小肺泡麻醉濃度(MAC)方法  52ASAⅠ∼Ⅱ級的病人,年齡2456歲,隨機分成兩組:對照組(n=26)和Tizannidine組(n=26),分別在手術切皮前90分鐘口服安慰劑和Tizannidin 4毫克。所有病人使用肺活量吸入七氟醚(5%)進行誘導。意識消失定義為眼瞼反射消失及對語言命令反應的喪失。採用傳統的上∼下(up-down)法進行可數性反應來測定。結果  對照組七氟醚的MAC2.2%±0.2%,Tizannidine組為1.8%±0.2%p=0.0004)。意識消失的時間Tizannidine組(60.2±22.5秒)顯著短於對照組(73.7±26.3秒)(p=0.03)。結論  口服4毫克Tizannidine可以降低成人七氟醚18%的最小肺泡濃度。               (張軍   莊心良 )

 

Tizanidine, an 2-adrenoceptor agonist, has an antinociceptive effect in animals. In humans premedicated with oral tizanidine, the increase in blood pressure associated with laryngoscopy and intubation was attenuated, and the amount of midazolam required for loss of consciousness was significantly reduced. We speculated that the oral administration of tizanidine might reduce the minimum alveolar anesthetic concentration (MAC) of sevoflurane. Fifty-two ASA physical status III patients, aged 2456 yr, were randomly allocated into two groups: a Control group (n = 26) and a Tizanidine group (n = 26). As premedication, the Control group received a placebo, and the Tizanidine group received 4 mg of oral tizanidine 90 min before surgical skin incision. Anesthesia was induced in all patients by using vital capacity rapid inhaled induction with sevoflurane (5%). Loss of consciousness was defined as both the loss of the eyelid reflex and the lack of a response to a verbal command. MAC was determined by a technique adapted from the conventional up-down method for quantal responses. The MAC of sevoflurane was 2.2% ± 0.2% in the Control group and 1.8% ± 0.2% in the Tizanidine group (P = 0.0004). The time to loss of consciousness in the Tizanidine group (60.2 ± 22.5 s) was significantly shorter than that in the Control group (73.7 ± 26.3 s) (P = 0.03). The oral administration of tizanidine 4 mg successfully reduced the MAC of sevoflurane by 18% in human adults.

 

第二代血液替代品Perflubron Emulsion增加體外試驗中現代吸入麻醉藥的血溶性

A Second-Generation Blood Substitute (Perflubron Emulsion) Increases the Blood Solubility of Modern Volatile Anesthetics In Vitro

Olivier Y. Cuignet, MD*, Philippe M. Baele, MD, and Luc J. Van Obbergh, MD PhD

    全氟碳乳劑可增加異氟醚、氨氟醚、氟烷的血溶性,據報導對溶解性較低的異氟醚具有最大的效應。目前的吸入麻醉藥的血溶性都較低並且較易受此現象影響。Perflubron (OxygentTM)是一種正接受後期臨床試驗的全氟碳類乳劑,它用於外科病人作為暫時的氧載體。該研究事先假設perflubron可增加異氟醚、七氟醚、地氟醚的溶解性,其溶解度以其血氣分配係數Bl:g作為反映。從8位志願者中採集新鮮全血標本並與perflubron混合使其容積百分比濃度分別達到1.2%1.8%3.6%,相當於體內1.8-5.4g/kg的劑量,該劑量是臨床期望劑量的兩倍。採用雙重提取技術我們證實異氟醚、七氟醚、地氟醚的Bl:g增加了,但是其血溶性沒有真正變化,因為實際上吸入麻醉藥部分溶入到perflubron中,增加血液中乳膠的容量自然就增加了氣體的攜帶量,並反映在三種吸入麻醉藥的Bl:g值和perflubron劑量線性相關性上。 儘管增加量是正常值的0.9(地氟醚)到2.6倍(七氟醚),目前的許多perflubron試驗缺乏明顯的臨床意義,這還有待於進一步的體外實驗研究。結論:血液中臨床濃度水平的perflubron可增加吸入麻醉藥的溶解度。實際上吸入麻醉藥部分溶入到perflubron,但其血中溶解度並無變化。有待進一步研究明確perflubron是否影響體內吸入麻醉藥的藥代動力學。(潘志浩譯薛張剛校)

 Perfluorocarbon-based emulsions increase the blood solubility of isoflurane, enflurane, and halothane, with a maximal effect Bl:g reported for the less soluble isoflurane. Current volatile anesthetics are less soluble and may be more affected by this phenomenon. Perflubron (OxygentTM) is a perfluorocarbon-based emulsion in late-stage clinical testing in surgical patients for use as a temporary oxygen carrier. We tested the hypothesis that perflubron increases the solubility of isoflurane, sevoflurane, and desflurane, as reflected by their blood/gas partition coefficient (Bl:g). Fresh whole-blood samples were drawn from eight volunteers and mixed with perflubron to obtain concentrations of 1.2%, 1.8%, and 3.6% by volume (equivalent to in vivo doses of 1.8 to 5.4 g/kg, which represent up to twice the intended clinical dose range). By using the double-extraction method, we demonstrated increased Bl:g for isoflurane, sevoflurane, and desflurane. However, the solubility in blood does not really change, because volatile anesthetics are actually partitioning into perflubron. Increasing the amount of emulsion in the blood consequently increases the amount of gas carried, as reflected by the measured linear correlation between the Bl:g values of all three volatile anesthetics and perflubron doses. Even though the increase ranges from 0.9 (desflurane) to 2.6 (sevoflurane) times the normal value, the apparent lack of clinical implications in current trials with perflubron may trigger further in vivo experiments. IMPLICATIONS: Perflubron increases the in vitro solubility of volatile anesthetics when present in the blood at clinically relevant concentrations. Volatile anesthetics actually partition into the emulsion, but the solubility in the blood does not change. Further studies are needed to assess whether perflubron will affect the pharmacokinetics of volatile anesthetics in vivo.

 

確定乳腺癌前哨淋巴結時的Isosulfan Blue Dye反應

Isosulfan Blue Dye Reactions During Sentinel Lymph Node Mapping for Breast Cancer

Leslie L. Montgomery, MD*, Alisa C. Thorne, MD, Kimberly J. Van Zee, MS MD*, Jane Fey, MPH*, Alexandra S. Heerdt, MD MPH*, Mary Gemignani, MD*, Elisa Port, MD*, Jeanne Petrek, MD*, Hiram S. Cody, III, MD*, and Patrick I. Borgen, MD*

*Breast Service, Department of Surgery, and Department of Anesthesia, Memorial Sloan-Kettering Cancer Center, New York, New York

Anesth Analg 2002;95:385-388

     在美國,確定前哨淋巴結(SLN)需要99mTc標誌的膠體,1% isosulfan blue dye,或者示蹤一個新生物的淋巴通路。我們報導在確定乳腺癌前哨淋巴結時的Isosulfan Blue Dye副反應的臨床經驗。我們總結回顧了1996912-2000816日在Memorial Sloan-Kettering癌症中心乳腺癌SLN的病史,有2392個病人用isosulfan blue dye行組織檢查。2392病人中有39個有過敏反應(1.6%,大多數反應(69%)產生蕁麻疹,藍色蕁麻疹,形成一片,搔癢。低血壓的發生率0.5%。儘管在注射isosulfan blue dye後發生過敏反應很少,但本文強調在注射sosulfan blue dye後血流動力學不穩定,應懷疑是過敏反應。我們的經驗表明發生支氣管痙攣、呼吸不好並不常見,大多數病人不需要緊急氣管插管,而只需短期的壓力支持。而且我們的資料也表明對磺胺藥過敏的病人對isosulfan blue dye無交叉過敏反應。(嵇富海譯  薛張剛校)

 

In the United States, identification of the sentinel lymph node (SLN) requires the use of 99mTc-labeled colloid, 1% isosulfan blue dye, or both to trace the lymphatic drainage of a given neoplasm. We report our experience with adverse reactions to isosulfan blue dye during SLN mapping in breast cancer. A chart review of the breast cancer SLN database was performed; it included 2392 sequential patients who underwent SLN biopsy involving isosulfan blue dye at Memorial Sloan-Kettering Cancer Center from September 12, 1996, to August 17, 2000. Thirty-nine of 2392 patients (1.6%) had a documented allergic reaction during the mapping procedure. Most reactions (69%) produced urticaria, blue hives, a generalized rash, or pruritus. The incidence of hypotensive reactions was 0.5%. Although anaphylaxis after the injection of isosulfan blue dye is rare, this article highlights the need to suspect anaphylaxis when hemodynamic instability occurs after the injection of this compound. Our experience indicates that bronchospasm and respiratory compromise are unusual and that most patients do not require emergent intubation and can be managed with short-term pressor support. In addition, our data indicate that patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye.

IMPLICATIONS: We report the largest single-institution review of adverse reactions to injection of isosulfan blue dye during sentinel lymph node mapping in breast cancer. Bronchospasm and respiratory compromise are unusual, and most patients can be treated with short-term pressor support. Patients with a sulfa allergy do not display a cross-sensitivity to isosulfan blue dye.

 

氟化物和低溫對體內咪庫溴胺代謝影響

The Effect of Fluoride and Hypothermia on the In Vitro Metabolism of Mivacurium

Michael Gruber, PhD, Regina Lindner, Christopher Prasser, MD, and Gunther Wiesner, MD

Department of Anesthesiology, University of Regensburg, Regensburg, Germany

Anesth Analg 2002;95:397-399

                                                嵇富海譯  薛張剛校)

 

IMPLICATIONS: The fluoride inhibition of mivacurium hydrolysis by pseudocholinesterase increases in hypothermia, but it will very rarely occur in clinical practice because it requires rather large fluoride concentrations (>50 µmol/L) and very low temperatures (<28°C).

 

麻醉藥的靜電相互作用對N-乙酰膽鹼受體的影響

The Role of Electrostatic Interactions in Governing Anesthetic Action on the Torpedo Nicotinic Acetylcholine Receptor

Douglas E. Raines, MD*, and Robert J. Claycomb, BS

*Department of Anesthesia, Harvard Medical School; and Massachusetts General Hospital, Boston, Massachusetts

Anesth Analg 2002;95:356-361

臨床使用濃度的異氟醚和正鏈烷醇能降低N-乙酰膽鹼受體表面興奮劑的離解常數,而環丙烷和丁烷無此作用。這就提示本受體模型系統中麻醉劑的靜電相互作用(氫鍵和/偶極)調節麻醉強度,進一步明確這些相互作用的特性,將不同全身麻醉劑降低N-乙酰膽鹼受體表面興奮劑離解常數的強度量化,以評估麻醉劑分子容量、提供酸性氫鍵或接受鹼性氫鍵的能力及偶極距的重要性。結果發現麻醉劑的水容性隨分子量增加而增強,隨鹼性氫鍵減少而降低,但不受偶極矩和酸性氫鍵的影響。這就提示麻醉劑像水分子一樣,通過偶極和結合氫鍵來降低N-乙酰膽鹼受體表面興奮劑的離解常數,但提供氫鍵的能力弱于水分子。

                                (朱輝       王祥瑞 )

Isoflurane and normal alkanols reduce the apparent agonist dissociation constant (Kd) of the nicotinic acetylcholine receptor (nAChR) at clinically relevant concentrations, whereas cyclopropane and butane do not. This suggests that electrostatic (hydrogen bonding and/or dipolar) interactions modulate anesthetic potency in this model receptor system. To further define the nature of these interactions, we quantified the potencies with which a heterologous group of general anesthetics reduces the nAChRs apparent Kd for acetylcholine. We assessed the importance that an anesthetics molecular volume, ability to donate a hydrogen bond (hydrogen bond acidity), ability to accept a hydrogen bond (hydrogen bond basicity), and dipole moment play in determining aqueous potency. We found that aqueous anesthetic potency increases with molecular volume and decreases with hydrogen bond basicity but is unaffected by dipole moment and hydrogen bond acidity. These results suggest that anesthetics reduce the apparent agonist Kd of the nAChR by binding to a site that has a dipolarity and ability to accept hydrogen bonds that are similar to those of water, but a hydrogen bond-donating capacity that is less.

 

咪唑安定的非γ-氨基丁酸介導的促使c-FosEGR-1的表達

Midazolam Induces Expression of c-Fos and EGR-1 by a Non-GABAergic Mechanism

Kazuhiko Fukuda, MD, Takehiro Shoda, MD, Hiroyuki Mima, MD, and Hisatoshi Uga, MD

Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan

Anesth Analg 2002;95:373-378

由全身麻醉藥誘發的基因表達的變化還沒有被廣泛研究。本研究在含有嗜鉻細胞瘤PC12細胞的老鼠體內注射靜脈麻醉藥,通過免疫印跡分析法以評估早期基因產物c-FosEGR-1的表達。戊硫代巴比妥,氯氨酮,異丙酚及安定沒有使c-FosEGR-1的量顯著變化,與此相反,咪唑安定促進c-FosEGR-1的表達且受時間-劑量依賴的影響,但不受苯二氮受體拮抗劑flumazenilPK11195的影響。咪唑安定促發的c-FosEGR-1的表達可被促細胞分裂活化蛋白酶/細胞外信號調控酶(ERKs)抑制劑PD98059終止。免疫印跡分析法證明咪唑安定促使ERKs磷酸化並啟動。結果表明咪唑安定促使PC12細胞內c-FosEGR-1的表達並非依賴γ-氨基丁酸受體介導的機制而是通過啟動ERKs,這就說明咪唑安定可以通過改變基因表達來長時間的改變神經中樞功能。

                                (朱輝       王祥瑞 )

Gene expression changes induced by general anesthetics have not been extensively examined. In this investigation, we treated rat pheochromocytoma PC12 cells with IV anesthetics, and assessed expression of immediate early gene products, c-Fos and EGR-1, by immunoblot analysis. Thiopental, ketamine, propofol, and diazepam did not significantly change the expression level of c-Fos and EGR-1. In contrast, midazolam dose- and time-dependently induced expression of c-Fos and EGR-1, which was not affected by antagonists of the benzodiazepine receptors, flumazenil and PK11195. The midazolam-induced c-Fos and EGR-1 expression was abolished by PD98059, an inhibitor for mitogen- activated protein kinase/extracellular signal-regulated kinase kinase, suggesting the involvement of extracellular signal-regulated kinases (ERKs). Immunoblot analysis demonstrated that midazolam induces phosphorylation and activation of ERKs. These results indicate that midazolam induces the expression of c-Fos and EGR-1, by activation of ERKs through a mechanism independent from -aminobutyric acidA receptors, in PC12 cells, and suggest the possibility that midazolam can induce long-term changes of neural functions by changing gene expression.

 

在異丙酚麻醉中使用阿托品對心率的影響

Heart Rate Response to Intravenous Atropine During Propofol Anesthesia

Takashi Horiguchi, MD, and Toshiaki Nishikawa, MD

Department of Anesthesia, Akita University School of Medicine, Akita, Japan

Anesth Analg 2002;95:389-392

61例異丙酚麻醉的病人中研究靜注阿托品與心率改變的劑量—反應關係。對照組(n=15)不用異丙酚。P-5組(n=22)在1分鐘內靜注異丙酚1.25mg/kg後使用異丙酚5mg/kg/h維持。插管後,麻醉維持異丙酚5mg/kg/h和吸入67%笑氣。P-10組(n=24)先靜注異丙酚2.5 mg/kg後使用異丙酚10mg/kg/h維持,其餘用藥均相等。所有病人每2分鐘以5秒的速度靜注阿托品5μg/kg劑量遞增直至心率增加超過基礎心率20bpm。靜注阿托品10μg/kg後,P-5組心率增加12±7 bpmP-10組心率增加9±6 bpm,而對照組心率增加28±13 bpm,與前兩組相比,差異有顯著意義(P<0.05)。靜注異丙酚劑量達到20μg/kg時,對照組所有病人的心率均增加>20bpm,而在P-5組和P-10組心率均增加>20bpm的病人僅為43%13%P<0.05)。上述結果顯示,在使用異丙酚的病人中,阿托品對心率的影響明顯減少,即使加大阿托品的劑量也無法克服異丙酚對其的影響,可能與異丙酚引起交感神經系統的抑制有關。

                                       (周潔       王祥瑞 )

We studied the dose-response relationships for atropine-induced heart rate (HR) changes in 61 patients during propofol anesthesia. The control group (n = 15) received no propofol. Group P-5 (n = 22) received IV propofol 1.25 mg/kg over 1 min followed by propofol at 5 mg · kg-1 · h-1. After tracheal intubation, anesthesia was maintained with propofol 5 mg · kg-1 · h-1 and 67% nitrous oxide in oxygen. Group P-10 (n = 24) received IV propofol 2.5 mg/kg over 1 min followed by propofol at 10 mg · kg-1 · h-1. The P-10 protocol was otherwise identical. All patients received incremental doses of IV atropine 5 µg/kg over 5 s at 2-min intervals until HR increased >20 bpm from baseline values. Heart rate response to atropine 10 µg/kg was attenuated in Groups P-5 (12 ± 7 bpm) and P-10 (9 ± 6 bpm) compared with the control group (28 ± 13 bpm, P<0.05). When atropine 20 µg/kg was administered, HR increased >20 bpm in all patients of the control group, but in only 43% and 13% of patients in Groups P-5 and P-10, respectively (P<0.05). These results indicate the decreased HR responsiveness to IV atropine in patients receiving propofol, which cannot be effectively overcome by a large dose of atropine, is possibly attributable to propofol-induced suppression of the sympathetic nervous system.

 

硬膜外類固醇藥物的注入技術:一項全國性問卷調查

The Technical Aspects of Epidural Steroid Injections: A National Survey

Robert Cluff, MD, Abdel-Kader Mehio, MD, Steven P. Cohen, MD, Yuchiao Chang, PhD, Christine N. Sang, MD MPH*, and Milan P. Stojanovic, MD*

*Clinical Trials Program and Interventional Pain Program, MGH Pain Center; and Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts

Anesth Analg 2002;95:403-408

儘管在慢性疼痛治療中硬膜外類固醇藥物注射(ESI)是一項常用的治療方法,但臨床操作醫生的操作方法是否正確一致尚無定論。近來的文獻報導顯示,操作技術的不同將明顯影響ESI的效果。本研究的目的在於提供制定ESI標準方法的參考。對美國68所醫學院和28所私立診所的麻醉科問捲進行分析調查。結果發現目前臨床上並無一致可靠的ESI實施方法。被調查者ESI操作方法的個體差異非常大。私立診所與醫學院麻醉科相比,更多地使用了X線透視的技術。最明顯的差別是在子宮頸阻滯的病人中,依靠X線透視的引導進行ESI的病人比例在私立診所為73%而在學院附屬醫院則為39%P=0.005)。類似的差異也發生在椎板切除術後的病人中,在私立診所有61%的病人使用微孔針進行ESI,而在學院附屬醫院這一比例僅為15%。上述結果表明,目前並無一致有效的方法用於ESI,臨床上的操作差異非常大。                     (周潔       王祥瑞 )

Although epidural steroid injections (ESIs) are a common treatment for chronic pain conditions, it is not clear whether there is consensus on their technical aspects. The current literature suggests that variations in technical aspects may affect ESI outcomes. The goal of the survey was to help establish a standard frame of reference for the performance of ESIs. We analyzed survey results from 68 academic anesthesia programs and 28 private practices in the United States. The main finding in this survey is that there is no clear-cut consensus as to the ideal method to perform ESI. There is a wide variation among individual practices in almost every technical aspect of ESI. Private practices use significantly more fluoroscopy than academic centers. The large difference was found in the cervical region where 73% of private practices and only 39% of academic institutions polled perform the ESIs with fluoroscopic guidance (P = 0.005). A similar discrepancy was found in approaches to the epidural space after laminectomy where 61% of private practices, but only 15% of academic centers, use the transforaminal approach. The study results indicate that there is no consensus, and that there is a wide variation in current practices.

 

咪噠唑侖對模擬急救醫療運輸服務過程中應激水平的影響:安慰劑對照的、劑量效應研究

The Effect of Midazolam on Stress Levels During Simulated Emergency Medical Service Transport: A Placebo-Controlled, Dose-Response Study

Volker Dörges, MD*, Volker Wenzel, MD, Susanne Dix, BS, Alexander Kühl, BSThomas Schumann, BS, Michael Hüppe, PhD,Heiko Iven, PhD,  and Klaus Gerlach, MD

*Department of Anesthesiology and Intensive Care Medicine, University Hospital of Kiel; Departments of Anesthesiology, and Pharmacology, Medical University of Lübeck, Germany; and Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria

Anesth Analg 2002;95:417-422

 

目的 比較幾組進行急救醫療服務(EMS)的病人血清兒茶酚胺含量,探討預先給予鎮靜劑的作用。方法 在模擬EMS的求救的場景中,72名健康男性志願者中的一半被護理人員通過樓梯從三層樓上抬下來,然後送上帶有警報的急救服務車中(3個應激組,每組n=12,總數n=36)。另一半則坐在椅子上5分鐘或躺在擔架上15分鐘(3個對照組n=12,總n=36)。測量各基礎血清兒茶酚胺含量以及給予IV組安慰劑(n=12)、25µg/kg(n=12)50µg/kgn=12)的咪噠唑侖後的血清兒茶酚胺值,IV組安慰劑應用於全部的實驗過程。統計學處理採用方差分析,p<0.05認為差別有顯著意義。結果 經過樓梯運輸以後,安慰劑應激組和對照組相比明顯增加血清腎上腺素(73±5pg/ml VS 45±5pg/ml; p<0.001)和去甲腎上腺素含量(398±34pg/ml VS 278±23pg/mlp<0.01),而50µg/kg咪噠唑侖組血清腎上腺素和去甲腎上腺素含量無明顯增加。經過急救車運輸後,安慰劑應激組和對照阻相比,腎上腺素含量明顯增加(51±4pg/ml VS 37±4pg/mlp<0.05),而去甲腎上腺素含量無明顯變化(216±24pg/ml VS 237±18pg/ml);而在2550µg/kg咪噠唑侖組血清兒茶酚胺含量與對照阻相比無明顯差別。結論 模擬EMS的病人在樓梯運輸過程中的應激水平高於救護車運輸的過程。加入咪噠唑侖能明顯降低內源性兒茶酚胺的水平,對心率無明顯影響。

(焦志華譯 莊心良校)

Patients in the emergency medical service (EMS) may have increased endogenous catecholamines because of pain or fear and may benefit from sedation similar to premedication in the hospital. During a simulated EMS scene call, 72 healthy male volunteers were either transported by paramedics from a third-floor apartment through a staircase with subsequent EMS transport with sirens (three stress groups of n = 12; total, n = 36) or asked to sit on a chair for 5 min and lie down on a stretcher for 15 min (three control groups of n = 12; total, n = 36). Catecholamine plasma samples were measured in the respective stress and control groups at baseline and after placebo IV (n = 12) or 25 (n = 12) or 50 (n = 12) µg/kg of midazolam IV throughout the experiment, respectively. Statistical analysis was performed with analysis of variance; P < 0.05 was considered significant. The Placebo Stress versus Control group, but not the 50 µg/kg Stress Midazolam group, had both significantly increased epinephrine (73 ± 5 pg/mL versus 45 ± 5 pg/mL; P < 0.001) and norepinephrine (398 ± 34 pg/mL versus 278 ± 23 pg/mL; P < 0.01) plasma levels after staircase transport. After EMS transport, the Placebo Stress versus Control group had significantly increased epinephrine (51 ± 4 pg/mL versus 37 ± 4 pg/mL; P < 0.05) but not norepinephrine (216 ± 24 pg/mL versus 237 ± 18 pg/mL) plasma levels, whereas no significant differences in catecholamine plasma levels occurred between groups after either 25 or 50 µg/kg of midazolam. In conclusion, simulated EMS patients may be subject to more stress during staircase transport than during transport in an EMS vehicle. Titrating sedation with 25 µg/kg of midazolam significantly reduced endogenous catecholamines but not heart rate.

 

比較0.1%0.2%羅比卡因和布比卡因加嗎啡用於大的腹部手術後的術後鎮痛。

A Comparison of 0.1% and 0.2% Ropivacaine and Bupivacaine Combined with Morphine for Postoperative Patient-Controlled Epidural Analgesia After Major Abdominal Surgery

Anesth Analg 2002;95

Marc Senard, MD, Jean L. Joris, MD PhD, Didier Ledoux, MD, Pierre J. Toussaint, MD, Benoît Lahaye-Goffart, MD, and Maurice L. Lamy, MD

Department of Anesthesia and Intensive Care Medicine, CHU de Liège, Domaine du Sart-Tilman, Belgium

羅比卡因與布比卡因相比由於用於硬膜外鎮痛時具有較少的毒性和較小的運動阻滯而似乎更具有吸引力。關於羅比卡因加嗎啡用於硬膜外鎮痛時的劑量的文章很少。本研究中,我們比較羅比卡因和布比卡因加小劑量嗎啡用於大的腹部手術後的術後鎮痛的劑量和副作用,60個病人隨機分為4組:0.1%0.2%羅比卡因和布比卡因加0.1mg/kg嗎啡用於術後病人自控鎮痛。觀察60小時的疼痛評分、副作用、運動阻滯和局麻藥用量。組間的疼痛評分和副作用無差別。兩0.1%組的羅比卡因和布比卡因用量相似。劑量加倍後可減少布比卡因用量(P>0.05)但羅比卡因用量無減少。因此,用0.%羅比卡因與0.1%羅比卡因用量相比用量顯著增加(ROPI 0.1% = 314 ± 151 mg ROPI 0.2% = 573 ± 304 mg at Hour 48; P < 0.05. 0.1%0.2%羅比卡因和布比卡因加嗎啡用於術後病人自控鎮痛效果相似。與0.1%羅比卡因相比,0.2%羅比卡因用量增加但沒有改善鎮壓痛效果。(張德林譯 薛張剛校)

Ropivacaine (ROPI), which is less toxic and produces less motor block than bupivacaine (BUPI), seems attractive for epidural analgesia. Few data are available concerning dose requirements of epidural ROPI when combined with morphine. In this study, we compared the dose requirements and side effects of ROPI and BUPI combined with small-dose morphine after major abdominal surgery. Postoperatively, 60 patients were randomly allocated (double-blinded manner) to four groups: patient-controlled epidural analgesia with the same settings using 0.1% or 0.2% solution of ROPI or BUPI combined with an epidural infusion of 0.1 mg/h of morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores and the incidence of side effects did not differ among the groups. Consumption of ROPI and BUPI were similar in both 0.1% groups. Doubling the concentration significantly reduced the consumption (milliliters) of BUPI (P < 0.05) but not of ROPI. Consequently, using ROPI 0.2% significantly increased the dose administered as compared with ROPI 0.1% (ROPI 0.1% = 314 ± 151 mg and ROPI 0.2% = 573 ± 304 mg at Hour 48; P < 0.05). Patient-controlled epidural analgesia with the 0.1% or 0.2% solution of ROPI or BUPI combined with epidural morphine resulted in comparable analgesia. As compared with ROPI 0.1%, the use of ROPI 0.2% increased consumption of local anesthetic without improving analgesia.

 

比較異丙酚和右美托咪定在術中鎮靜中的作用、副作用和恢復特性

The Efficacy, Side Effects, and Recovery Characteristics of Dexmedetomidine Versus Propofol When Used for Intraoperative Sedation

Shahbaz R. Arain, MD, and Thomas J. Ebert, MD PhD

Department of Anesthesiology, Medical College of Wisconsin and VA Medical Center, Milwaukee, Wisconsin

Anesth Analg 2002;95:461-466

目的 我們評價在術中鎮靜中異丙酚和右美托咪定達到相同鎮靜效果的劑量對心肺功能的影響。其次,比較兩者達到鎮靜和從鎮靜中恢復的時間以及術後鎮痛和精神運動方面的表現。方法 40例擇期手術的病人在知情同意的情況下被隨機分為兩組,術中分別給予右美托咪定(初始10分鐘,1 µg/kg 維持,0.40.7 µg · kg-1 · h-1)異丙酚(初始10分鐘,75 µg · kg-1 · min-1;維持,12.575 µg · kg-1 · min-1)。術中及術後95分鐘內監測血流動力學指標(心率和平均動脈壓)、鎮靜的程度(visual analog scale和觀察者對患者覺醒或鎮靜的評估)、腦電雙頻譜指數、通氣指標(呼吸頻率、O2 sat ETCO2)、精神運動表現(digital symbol substitution test)和疼痛程度(visual analog scale)。術中鎮靜的程度要求達到腦電雙頻譜指數評分70-80。兩組病人的人口統計學指標、ASA評分等級、手術操作過程和基礎心肺功能都相似。結果 使用異丙酚組出現鎮靜較迅速,但是在注射初始劑量後25分鐘兩組間鎮靜程度無差別。右美托咪定平均注射速度為0.7 µg · kg-1 · h-1,異丙酚平均注射速度為38 µg · kg-1 · min-1。在恢復階段,兩組精神運動表現和呼吸頻率沒有差別。右美托咪定組在恢復期間遺留較強的鎮靜作用,導致低血壓和協助鎮痛作用(減少嗎啡用量)。結論 右美托咪定適用於圍手術期鎮靜,相對於異丙酚其達到鎮靜和從鎮靜恢復都延緩。並且右美托咪定在術後有促進鎮痛的作用,減少嗎啡的用量。

                                               (李懿   薛張剛校)

We evaluated the cardio-respiratory effects of equi-sedative doses of dexmedetomidine and propofol for intraoperative sedation. Secondary comparison end points were time to achieve and terminate sedation and postoperative analgesia and psychomotor performance. Forty patients scheduled for elective surgery provided informed consent and were randomized equally to receive either dexmedetomidine (1 µg/kg initial loading dose for 10 min; maintenance, 0.40.7 µg · kg-1 · h-1) or propofol (75 µg · kg-1 · min-1 x 10 min; maintenance, 12.575 µg · kg-1 · min-1). Hemodynamic variables (heart rate and mean arterial blood pressure), sedation (visual analog scale and Observer Assessment of Alertness/Sedation), bispectral index score of sedation, ventilation (respiratory rate, O2 sat, and ETCO2), psychomotor performance (digital symbol substitution test), and pain (visual analog scale) were determined during surgery and up to 95 min after surgery. Intraoperative sedation levels were targeted to achieve a bispectral index score of 7080. Patient demographics, ASA class, surgical procedure, and baseline cardio-respiratory variables were similar between groups. Sedation was achieved more rapidly with propofol but was similar between groups 25 min after initiating infusions. The average infusion rate for dexmedetomidine was 0.7 µg · kg-1 · h-1 and 38 µg · kg-1 · min-1 for propofol. There were no differences between groups in psychomotor performance and respiratory rate during recovery. The previous use of dexmedetomidine resulted in more sedation, lower blood pressure, and improved analgesia (less morphine use) in recovery. Dexmedetomidine may be useful for perioperative sedation. It has a slower onset and offset of sedation compared with propofol. Dexmedetomidine was associated with improved analgesia and less morphine use in the postoperative period.

 

硬膜外穿刺後鼠模型觀察硬膜外注射血液和其他藥液時顱內血流調節機制

The Mechanisms of Intracranial Pressure Modulation by Epidural Blood and Other Injectates in a Postdural Puncture Rat Model

Jeffrey S. Kroin, PhD, Subhash K.S. Nagalla, MD, Asokumar Buvanendran, MD

epartment of Anesthesiology, Rush Medical College at Rush-Presbyterian-St. Lukes Medical Center, Chicago, Illinois

Anesth Analg 2002;95

硬膜外血液填補被認為是治療硬膜外穿刺後頭痛的有效的方法。我們硬膜外穿刺後鼠模型來定量評價硬膜外注射血液和其他藥液時顱內血流(CSF)變化的程度和時間。這種模型用來比較硬膜外注射不同藥物恢復和維持CSF壓力達240分鐘。腰部硬膜外穿刺後CSF壓力下降3.6 ± 0.2 mm Hg,在硬膜外穿刺點注射鹽水100 µL,最初壓力增加7.2 ± 0.7 mm Hg,但迅速7.8 ± 0.6 min下降到基線。注射其他藥物可觀察到類似最初壓力增加的變化,但持續時間有很大的不同,賀斯和低佑40結果與鹽水相似。僅全血和纖維凝膠持續增加CSF壓力達240分鐘,距穿刺點向頭端20mm注射全血加凝劑不能維持壓力。在椎板切開後在硬膜外直用或粘合劑不能維持壓力。注射初量後持續輸注鹽水能維持壓力增加達180分鐘,但停止輸注後壓力回到基線。這結果證明硬膜外注射全血和纖維凝膠糾正硬膜外穿刺後CSF低壓是有效的,且提供瞭解顱內壓的調節機制。除非硬膜外填塞是持續的,否則對糾正CSF壓力無效。(張德林譯 薛張剛校)

The epidural blood patch is considered effective in treating postdural puncture headache. We have developed a postdural puncture model in rats for quantitative evaluation of the magnitude and duration of changes in cerebrospinal fluid (CSF) pressure in the cisterna magna in response to the administration of epidural blood or other moieties. This model was used to compare the efficacy of various methods of epidural injection for restoring and maintaining CSF pressure for up to 240 min. After lumbar dural puncture, CSF pressure declined 3.6 ± 0.2 mm Hg. Epidural saline (100 µL) injected at the puncture site initially increased pressure by 7.2 ± 0.7 mm Hg, but it rapidly (7.8 ± 0.6 min) returned to postdural puncture baseline. A similar initial increase of CSF pressure was observed with equal volumes of all other epidural injectates, but the duration of pressure increase varied greatly. Hetastarch and dextran 40 produced results similar to saline. Only whole blood or fibrin glue consistently increased CSF pressure for the entire 240-min observation period. Whole blood mixed with anticoagulant or injected 20-mm cephalad to the puncture site did not sustain pressure. After laminectomy, direct application of blood or adhesive to the dural defect caused no pressure increase. Continuous infusion of saline after bolus could maintain pressure increase for 180 min, but within 60 min of stopping infusion, pressure returned to baseline. These results confirm the efficacy of the epidural administration of blood or fibrin glue to correct CSF hypotension after dural puncture and also provide insight into the mechanisms of intracranial pressure modulation. Sealing the dural defect does not effectively correct CSF pressure unless an epidural tamponade effect is also maintained.

 

.三種麻醉技術應用於幕上顱內手術病人的比較

A Comparison of Three Anesthetic Techniques in Patients Undergoing Craniotomy for Supratentorial Intracranial Surgery

Pekka Talke, MD, James E. Caldwell, MBChB, Ronald Brown, BS, Barbara Dodson, MD, Joan Howley, MD, and Charles A. Richardson, PhD

Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, California

Anesth Analg 2002;95:430-435

 

幾種麻醉技術已成功用於顱內幕上腫塊切除手術的麻醉,其中之一為在關顱時將吸入麻醉更改為異丙酚麻醉促進病人儘快恢復的方法。然而,目前尚無臨床資料證明該種方法對顱腦手術病人術後恢復的臨床優點。在本研究中選擇60例擇期行顱內幕上腫塊切除手術的病人,對三種麻醉技術進行了評估。將病人隨機分為三組:異丙酚麻醉組、異氟醚麻醉組以及異丙酚和異氟醚複合麻醉組。在複合麻醉組,當硬腦膜關閉後停止吸入異氟醚,同時改用異丙酚麻醉。觀察術中和術後病人的血流動力學參數以及麻醉後2小時內的幾個神志恢復變數。各組病人術中的基礎血壓、平均壓及心率無明顯差異。各組病人的心率和血壓在氣管插管、探針放置及術後恢復階段均有同樣幅度的升高。各恢復事件的時間(如睜眼、拔管、指令動作、方向識別和Aldrete評分)或精神運動測試均無明顯差異。因此我們認為與單獨應用異氟醚麻醉相比,術中按次序複合應用異氟醚和異丙酚並不能促進病人意識和認識能力的早期恢復。

                                                (齊波    王祥瑞 )

Several anesthetic techniques have been used successfully to provide anesthesia for resection of intracranial supratentorial mass lesions. One technique used to enhance recovery involves changing anesthesia from vapor-based to propofol-based for cranial closure. However, there are no data to support a beneficial effect of this approach in the immediate postoperative period after craniotomy. We evaluated 3 anesthetic techniques in 60 patients undergoing elective surgery for supratentorial mass lesions. Patients were randomly assigned to three anesthesia study groups: propofol infusion, isoflurane inhalation, and these two techniques combined. In the combination group, once the dura was closed, isoflurane was discontinued and propofol infusion simultaneously started. We studied intra- and postoperative hemodynamics and several recovery variables for 2 h after the end of anesthesia. Baseline and average intraoperative blood pressure and heart rate values did not differ among the groups. Heart rate and blood pressure increased similarly in all groups in response to intubation and pin placement and postoperatively. None of the recovery event times (open eyes, extubation, follow commands, oriented, Aldrete score) or psychomotor test performance differed significantly. We conclude that the sequential administration of isoflurane and propofol did not provide earlier recovery and cognition than the intraoperative use of isoflurane alone.

 

鞘內和硬膜外注射嗎啡用於擇期剖宮產術後鎮痛的對比研究

A Double-Blinded, Randomized Comparison of Intrathecal and Epidural Morphine for Elective Cesarean Delivery

J. Sarvela, MD PhD, P. Halonen, MD, A. Soikkeli, MD, and K. Korttila, MD PhD, FRCA

Department of Anaesthesia and Intensive Care, Helsinki University Central Hospital, Helsinki, Finland

Anesth & Analg August 2002 95: 436-440

目的 比較鞘內和硬膜外注射嗎啡的鎮痛效果和副作用的發生率。方法 在腰-硬聯合麻醉下行剖宮產手術的病人共150例,按術後鎮痛方式隨機分為鞘內嗎啡100ug組、鞘內嗎啡 200 ug組和硬膜外嗎啡3mg組。另外,病人每天服用酮洛酚300mg。術後24h內每3h記錄術後疼痛程度和副作用發生率。結果 各組病人的術後疼痛得到了有效控制(優良率90%),但鞘內嗎啡100ug組與另外二組比較,產婦需要更多的額外鎮痛藥物。瘙癢是三組病人術後鎮痛最常見的併發症,硬膜外嗎啡3mg組、鞘內嗎啡 100 ug組和鞘內嗎啡 200 ug組的發生率分別為74% 65% 91%,其中需藥物治療的病人比例分別為44% 24%45%。各組病人術後噁心嘔吐的發生率無差別。結論 由於鞘內嗎啡100ug組瘙癢發生率低,需治療者少,因此,術後鎮痛推薦鞘內注射嗎啡100ug配合應用酮洛酚,但仍應按需輔助其他鎮痛藥物。

 

                                     (王士雷   莊心良 )

 

We randomized 150 parturients into a double-blinded trial to receive intrathecal (IT) 100 µg (IT 100 group) or 200 µg (IT 200 group) or epidural 3 mg (Epidural group) of morphine for elective cesarean delivery with a combined spinal/epidural technique. The patients additionally received ketoprofen 300 mg/d. Postoperative pain relief and side effects were registered every 3 h up to 24 h, and all patients were interviewed on the first postoperative day. Pain control was equally good, but the parturients in the IT 100 group requested rescue analgesics more often compared with the other groups (P < 0.05). Itching was a common complaint and was reported by 74% of the parturients in the Epidural group and 65% and 91% in the IT 100 and IT 200 groups, respectively (P < 0.01). Medication for itching was requested by 44%, 24%, and 45% of the patients, respectively (P < 0.05). There was no difference in postoperative nausea or vomiting. The pain relief was perceived as good by >90% of the patients in all groups. In conclusion, because of the decreased incidence of and lesser requirements of medication for itching, IT morphine 100 µg with ketoprofen is recommended in cesarean deliveries. Rescue analgesics nevertheless need to be prescribed.

 

應用前臂或上臂止血帶實施利多卡因-酮咯酸靜脈局部麻醉鎮痛效能的對比研究

An Evaluation of the Analgesic Efficacy of Intravenous Regional Anesthesia with Lidocaine and Ketorolac Using a Forearm Versus Upper Arm Tourniquet

 

Scott S. Reuben, MD*, Robert B. Steinberg, MD PhD*, Holly Maciolek, RN*, and Poornachandran Manikantan, MD*

 

Department of Anesthesiology, *Baystate Medical Center and Tufts University School of Medicine, Springfield, Massachusetts

Anesth & Analg August 2002 95: 457-460

 

目的 評估門診手部手術時應用前臂以及上臂止血帶實施利多卡因-酮咯酸經靜脈局部麻醉(IVRA)的鎮痛效能。方法 將所選的在IVRA下行門診手部手術的病人隨機分為上臂IVRA組和前臂IVRA上臂IVRA組的藥物配方是利多卡因200 mg酮咯酸20 mg (0.5 mg/mL) 稀釋至40 mL。前臂IVRA組的藥物配方是利多卡因100 mg酮咯酸10 mg (0.5 mg/mL) 稀釋至20 mL。記錄感覺阻滯的起效和持續時間以及術後鎮痛和使用鎮痛藥的情況。結果 前臂IVRA組的病人無需鎮痛藥鎮痛的時間 (701 ± 133 min) 顯著長於上臂IVRA (624 ± 80 min) (P = 0.032)。兩組感覺阻滯起效時間相似,但前臂IVRA組感覺恢復時間 (22 ± 5 min) 顯著長於上臂IVRA (13 ± 3 min) (P < 0.05)。兩組之間術後鎮痛藥的使用和鎮痛評分無差異。由此可見,門診手部手術時實施利多卡因-酮咯酸前臂IVRA能提供安全有效的圍術期鎮痛,其與上臂IVRA相比感覺阻滯和術後鎮痛時間延長,且利多卡因和酮咯酸用量減少一半。結論 使用上臂IVRA所需利多卡因和酮咯酸的50%劑量實施前臂IVRA能提供更長時間感覺阻滯和術後鎮痛。

 

(葛聖金譯  莊心良校)

 

Intravenous regional anesthesia (IVRA) using a forearm tourniquet may be a potentially safer technique compared with using an upper arm tourniquet. Ketorolac is a useful adjuvant to lidocaine for IVRA. In this study, we assessed the analgesic efficacy of administering IVRA lidocaine and ketorolac with either a forearm or upper arm tourniquet for outpatient hand surgery. Upper arm IVRA was established using 40 mL of a solution containing 200 mg of lidocaine and ketorolac 20 mg (0.5 mg/mL). Forearm IVRA was established using 20 mL of a solution containing 100 mg of lidocaine and ketorolac 10 mg (0.5 mg/mL). Onset and duration of sensory block as well as postoperative pain and analgesic use were recorded. The patients who received forearm IVRA had a significantly longer period during which they required no analgesics (701 ± 133 min) compared with 624 ± 80 min for the upper arm IVRA ketorolac patients (P = 0.032). Onset of sensory block was similar between the two groups; however, recovery of sensation was significantly longer in the Forearm IVRA (22 ± 5 min) group compared with the Upper Arm IVRA (13 ± 3 min) group (P < 0.05). There were no differences in postoperative analgesic use or pain scores between the two groups. We conclude that forearm IVRA with lidocaine and ketorolac provides safe and effective perioperative analgesia for patients undergoing ambulatory hand surgery. This technique results in a longer duration of sensory block and prolonged postoperative analgesia compared with upper arm IVRA while using one-half the doses of both lidocaine and ketorolac.

 

腹腔鏡膽囊切除術後通過導管向膽囊窩內間斷注射0.5%布比卡因的鎮痛研究

Postoperative Pain Relief Using Intermittent Injections of 0.5% Ropivacaine Through a Catheter After Laparoscopic Cholecystectomy

Anil Gupta, MD FRCA, PhD*, Sven E. Thörn, MD PhD*, Kjell Axelsson, MD PhD*, Lars G. Larsson, MD, Göran Ågren, MD, Björn Holmström, MD PhD*, and Narinder Rawal, MD PhD*

Departments of *Anesthesiology and Intensive Care, Surgery, and Division for Ambulatory Surgery, University Hospital, Örebro, Sweden

Anesth Analg 2002;95:450-456

 

術後疼痛是限制日間腹腔鏡膽囊切除開展的一個重要因素。選擇40ASA I-II的病人,採用異丙酚誘導,七氟醚、空氧混合氣維持麻醉。在麻醉結束時,將病人隨機分為兩組:P(安慰劑組)R(0.5羅呱卡因)。術畢通過放置於膽囊窩內的一個導管將20ml生理鹽水或布比卡因分別注射入腹腔內。術後當病人感到疼痛時,間斷注射10ml的研究藥物,並靜脈注射1-2mg 凱托米酮。在術後12348121620小時,以及術後第一周內每隔一天應用視覺類比疼痛評分評估病人休息時(深疼痛)、肩部和切口以及咳嗽時的疼痛程度。在病人從第一階段到第二階段期間,評估病人行走、喝水、進食以及排泄的能力。並測定了8例病人的血漿羅呱卡因濃度。有關病人恢復行走、排便、駕車以及正常日常活動能力的時間,我們通過調查問卷的形式進行調查。在術後第一個4小時,R組病人深疼痛和咳嗽後疼痛的評分比P組病人低(P<0.05)。兩組病人術後Ketobemidone 的用量無明顯差異。兩組病人在家中恢復的中位時間是相似的。在術後第七天時93%的病人恢復了正常的日常生活能力。因此我們認為於膽囊窩內間斷0.5%羅呱卡因可緩解行走腹腔鏡膽囊切除病人術後早期疼痛。

                                             (齊波    王祥瑞 )

Postoperative pain has been an important limiting factor for ambulatory laparoscopic cholecystectomy. We anesthetized 40 ASA physical status III patients using propofol for the induction and sevoflurane in oxygen and air for the maintenance of anesthesia. At the end of the anesthesia, the patients were randomized into one of two groups: Group P (Placebo) and Group R (0.5% Ropivacaine). Twenty milliliters of normal saline or ropivacaine, respectively, were injected intraperitoneally at the end of surgery via a catheter placed in the bed of the gall bladder. Postoperatively, intermittent injections (10 mL) of the study solution were given when required for pain. Ketobemidone 12 mg was given IV as rescue medication. Pain was assessed using a visual analog scale at 1, 2, 3, 4, 8, 12, 16, and 20 h after surgery and once each day for 1 wk at rest (deep pain), shoulder and incision sites, and pain during coughing. Recovery was assessed by the time to transfer from Phase 1 to 2, the ability to walk, drink, and eat, and the ability to void. Plasma concentrations of ropivacaine were measured in eight patients. Time to ability to walk, defecation, driving a car, and return to normal activities were also recorded through a questionnaire sent home with the patient. During the first 4 postoperative h, patients in Group R had lower scores for deep pain and during coughing compared with Group P (P < 0.05). No differences were found in the postoperative consumption of ketobemidone. Median times to recovery at home were similar between the groups. By the seventh day, 93% of the patients had returned to normal activities of daily living. We conclude that the early postoperative pain after ambulatory laparoscopic cholecystectomy could be relieved using intermittent injections of ropivacaine 0.5% into the bed of the gall bladder.

 

硬膜外/全麻複合麻醉和硬膜外術後鎮痛對腹腔鏡或開腹結直腸手術病人的腸道功能恢復和體溫調節的影響

Temperature Control and Recovery of Bowel Function After Laparoscopic or Laparotomic Colorectal Surgery in Patients Receiving Combined Epidural/General Anesthesia and Postoperative Epidural Analgesia

Giorgio Danelli, MD*, Marco Berti, MD*, Valeria Perotti, MD*, Andrea Albertin, MD*, Paolo Baccari, MD, Francesco Deni, MD*, Guido Fanelli, MD*, and Andrea Casati, MD*

*Department of Anesthesiology and Emergency Surgery, Vita-Salute University of Milano, IRCCS H.S. Raffaele, Milano, Italy

Anesth Analg 2002;95:467-471

 

比較44名硬膜外/全麻複合麻醉下開腹(n=21)和腹腔鏡(n=23)成人結直腸手術病人體溫調節的影響。胸段硬膜外阻滯,給予0.75%羅呱卡因6-10ml,麻醉平面最高到T4, 全麻誘導靜注硫噴妥鈉,芬太尼,和卡肌寧;異氟醚吸入維持麻醉。通過膀胱探針測量中心體溫,誘導後每15分鐘記錄一次。手術結束後兩組病人的中心體溫都下降到35.2℃(範圍,34-36℃)。手術後,腹腔鏡組病人在75分鐘後(60-120分鐘)體溫恢復正常;開腹組病人在60分鐘後(45-180分鐘)體溫恢復正常(P = 0.56)。術後24h72h內腹腔鏡手術病人咳嗽引起疼痛的程度要小於開腹組病人(P < 0.01)。開腹組病人術後鎮痛嗎啡用量為 22 mg2-65mg),腹腔鏡組病人嗎啡用量為5 mg0-45mg)(P = 0.02)。腹腔鏡組病人第一次排氣的時間(24h[16-72h])短於開腹組病人(72h[26-96h])(P =0.0005),腹腔鏡組病人在術後48h24-72h)首次進食無渣流質;開腹組病人在術後96h90-96h)首次進食無渣流質(P = 0.0005)。雖然腹腔鏡手術對術後疼痛程度和腸道功能恢復有積極的影響,但腹腔鏡手術中最少地暴露腸管所減少的熱量損失並不能補償麻醉等相關因素的對體溫調節的影響,因此腹腔鏡手術時也必須積極地對病人進行保溫。

                                    (殷文淵    王祥瑞 )

We compared the effects of a laparoscopic (n = 23) versus laparotomic (n = 21) technique for major abdominal surgery on temperature control in 44 patients undergoing colorectal surgery during a combined epidural/general anesthesia. A thoracic epidural block up to T4 was induced with 610 mL of 0.75% ropivacaine; general anesthesia was induced with thiopental, fentanyl, and atracurium IV and maintained with isoflurane. Core temperature was measured with a bladder probe and recorded every 15 min after the induction. In both groups, core temperature decreased to 35.2°C (range, 34°C36°C) at the end of surgery. After surgery, normothermia returned after 75 min (60120 min) in the Laparoscopy group and 60 min (45180 min) in the Laparotomy group (P = 0.56). No differences in postanesthesia care unit discharge time were reported between the two groups. The degree of pain during coughing was smaller after laparoscopy than laparotomy from the 24th to the 72nd observation times (P < 0.01). Morphine consumption was 22 mg (265 mg) in the Laparotomy group and 5 mg (045 mg) in the Laparoscopy group (P = 0.02). The time to first flatus was shorter after laparoscopy (24 h [1672 h]) than laparotomy (72 h [2696 h]) (P = 0.0005), and the first intake of clear liquid occurred after 48 h (2472 h) in the Laparoscopy group and after 96 h (9096 h) in the Laparotomy group (P = 0.0005). Although laparoscopic surgery provides positive effects on the degree of postoperative pain and recovery of bowel function, the reduction in heat loss produced by minimizing bowel exposure with laparoscopic surgery does not compensate for the anesthesia-related effects on temperature control, and active patient warming must also be used with laparoscopic techniques.

 

圍術期胃排空不能預測經腹腔鏡膽囊切除術後早期噁心嘔吐的發生

Perioperative Gastric Emptying Is Not a Predictor of Early Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Cholecystectomy

M. Wattwil, MD PhD*, S.-E. Thörn, MD PhD*, A Lövqvist*, L. Wattwil*, H. Klockhoff, MD, L.-G. Larsson, MD, and I. Näslund, MD PhD

Departments of *Anesthesiology and Intensive Care and Surgery, Örebro University Hospital, Örebro; and Department of Medicine and Care, Faculty of Health Sciences, Linköping, Sweden

 

Anesth Analg 2002;95:476-479

 

目的  比較在鏡腹腔下膽囊切除術術後即刻發生術後噁心嘔吐與未發生噁心嘔吐的病人的胃排空率。 方法  採用對乙酰氨基酚法研究胃的排空率。40ASA-Ⅱ級的病人,在麻醉誘導後放置胃管,從中注入用200ml水稀釋的對乙酰氨基酚1.5克。在注入前和注入後180分鐘內每15分鐘抽靜脈血測定血漿對乙酰氨基酚濃度。結果  26例病人在術後4小時內發生噁心,而其他14例病人沒有噁心。二者血漿對乙酰氨基酚峰濃度、達峰時間、在用藥後0-60分鐘、0-120分鐘、0-180分鐘內血漿藥物濃度曲線下面積無統計學顯著差異。結論 術後胃排空速度和噁心嘔吐間存在任何聯繫,故胃排空速率不是術後噁心嘔吐的預測因素。

                      (顏濤   莊心良 )

It is not known whether patients with postoperative nausea and vomiting (PONV) have delayed gastric emptying compared with patients without PONV. We compared the perioperative rate of gastric emptying in patients experiencing PONV with the rate in those without PONV immediately after laparoscopic cholecystectomy. Gastric emptying was studied by the acetaminophen method. Acetaminophen is not absorbed from the stomach but is rapidly absorbed from the small intestine, and the rate of gastric emptying therefore determines the rate of absorption of acetaminophen administered into the stomach. Forty patients (ASA physical status I and II) were included in the study. After the induction of anesthesia, a gastric tube was positioned in the stomach and 1.5 g of acetaminophen dissolved in 200 mL of water was administered. Venous blood samples for the determination of serum acetaminophen concentrations were taken before and at 15-min intervals during a period of 180 min after the administration of acetaminophen. Twenty-six patients experienced nausea during the first 4 h postoperatively. The other 14 patients had no nausea. There were no statistically significant differences in the maximal acetaminophen concentration, the time taken to reach the maximal concentration, or the area under the serum acetaminophen concentration time curves from 0 to 60, 0120, and 0180 min between the groups of patients with or without PONV. We did not find any relationship between postoperative gastric emptying and PONV, and therefore gastric emptying is not a predictor of PONV.

 

比較應用喉鏡和Lightwand氣管插管裝置 (Trachlight®)兩者行成人正常氣道氣管內插管的血流動力學反應

Hemodynamic Responses to Tracheal Intubation with Laryngoscope Versus Lightwand Intubating Device (Trachlight®) in Adults with Normal Airway

Shinji Takahashi, MD*, Taro Mizutani, MD, Masayuki Miyabe, MD*, and Hidenori Toyooka, MD*

Departments of *Anesthesiology and Critical Care Medicine, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan

Anesth Analg 2002;95:480-484

目的 使用Lightwand 輔助進行氣管插管是一種有效而且安全的措施。理論上,避免行直視下喉鏡氣管插管相對于傳統的用喉鏡氣管插管法能夠減少氣管插管引起的刺激。我們設計了一個前瞻性隨機化研究來評價正常成人在七氟醚麻醉下行Lightwand或直接喉鏡氣管插管後心血管系統的變化。方法 60例健康、正常氣道的成人根據插管方式的不同隨機分為三組,三組均使用七氟醚混合笑氣麻醉(吸入氧濃度為0.33)(每組20例)。Lightwand 組使用Trachlight®裝置完成氣管內插管,喉鏡氣管插管組使用直視喉鏡(Macintosh 喉鏡片)進行氣管插管,而第三組僅行喉鏡檢查。在從容地行氣管內插管後或喉鏡檢查5分鐘內持續記錄心率和收縮壓。所有的操作均一次成功。結果 使用Trachlight®裝置行氣管內插管組出現的最快心率和最高收縮壓(分別是114 ± 20 bpm 143 ± 30 mm Hg)與使用Macintosh喉鏡插管組(分別是114 ± 20 bpm 138 ± 23 mm Hg)沒有差別,但是兩組的最快心率和最高收縮壓都顯著大於僅行喉鏡檢查組(分別是94 ± 19 bpm 112 ± 21 mm Hg)(P < 0.05)。結論 氣管插管術中對氣管的直接刺激是引起血流動力學改變的一個主要因素。

                                                  (李懿 薛張剛校)

Lightwand devices are effective and safe as an aid to tracheal intubation. Theoretically, avoiding direct-vision laryngoscopy could allow for less stimulation by intubation than the conventional laryngoscopic procedure. We designed this prospective randomized study to assess the cardiovascular changes after either lightwand or direct laryngoscopic tracheal intubation in adult patients anesthetized with sevoflurane. Sixty healthy adult patients with normal airways were randomly assigned to one of three groups according to intubating procedure under sevoflurane/nitrous oxide anesthesia (fraction of inspired oxygen = 0.33) (n = 20 each). The lightwand group received tracheal intubation with Trachlight®, the laryngoscope-intubation group received tracheal intubation with a direct-vision laryngoscope (Macintosh blade), and the laryngoscopy-alone group received the laryngoscope alone. Heart rate and systolic blood pressure were recorded continuously for 5 min after tracheal intubation or laryngoscopy with enough time to intubate. All procedures were successful on the first attempt. The maximum heart rate and systolic blood pressure values obtained after intubation with Trachlight (114 ± 20 bpm and 143 ± 30 mm Hg, respectively) did not differ from those with the Macintosh laryngoscope (114 ± 20 bpm and 138 ± 23 mm Hg), but they were significantly larger than those in the laryngoscopy-alone group (94 ± 19 bpm and 112 ± 21 mm Hg) (P < 0.05). Direct stimulation of the trachea appears to be a major cause of the hemodynamic changes associated with tracheal intubation..