Anesthesia & Analgesia

September 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

多巴胺应激性心脏超声检查对非心脏择期手术室病人术前评估的低效性

(忻纪华     王祥瑞校)

Low Utility of Dobutamine Stress Echocardiograms in the Preoperative Evaluation of Patients Scheduled for Noncardiac Surgery

Peter B. Morgan, Gregory E. Panomitros, Ana C. Nelson, Douglas F. Smith, Daneshvari R. Solanki, and Mark H. Zornow

Anesth Analg 2002 95: 512-516.

 

体外循环下冠脉搭桥术中应用低剂量多巴酚丁胺负荷的超声心动图监测是否具有远期预测价值?

(张俊峰    薛张纲 )

Is There a Long-Term Predictive Value of Intraoperative Low-Dose Dobutamine Echocardiography in Patients Who Have Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass?

Frank W. Dupont, Roberto M. Lang, Melinda L. Drum, and Solomon Aronson

Anesth Analg 2002 95: 517-523.

 

氯胺酮减弱体外循环后中性粒细胞作用

(陈涌明        王祥瑞 )

Ketamine Attenuates Neutrophil Activation After Cardiopulmonary Bypass

Genadi Zilberstein, Rachel Levy, Maxim Rachinsky, Allan Fisher, Lev Greemberg, Yoram Shapira, Azai Appelbaum, and Leonid Roytblat

Anesth Analg 2002 95: 531-536.

 

非心脏胸科手术后室性心律失常的发生率及其后果

(张俊峰    薛张纲 )

The Incidence and Outcome of Ventricular Arrhythmias After Noncardiac Thoracic Surgery

David Amar, Hao Zhang, and Nancy Roistacher

Anesth Analg 2002 95: 537-543.

 

中重度肾功能损害患者静脉输注新型羟乙基淀粉130/0.46%500ML)的药代动力学和耐受性研究

(张俊峰    薛张纲 )

The Pharmacokinetics and Tolerability of an Intravenous Infusion of the New Hydroxyethyl Starch 130/0.4 (6%, 500 mL) in Mild-to-Severe Renal Impairment

Cornelius Jungheinrich, Roland Scharpf, Manfred Wargenau, Frank Bepperling, and Jean-François Baron

Anesth Analg 2002 95: 544-551.

 

 

 

ANESTHETIC PHARMACOLOGY:

非卤化链烷和卤化链烷抑制α4β2神经型乙酰胆碱受体

(杨保仲    庄心良 )

Nonhalogenated Anesthetic Alkanes and Perhalogenated Nonimmobilizing Alkanes Inhibit 4ß2 Neuronal Nicotinic Acetylcholine Receptors

Douglas E. Raines, Robert J. Claycomb, and Stuart A. Forman

Anesth Analg 2002 95: 573-577.

 

甘氨酸受体亚单位变异鼠对挥发性麻醉药均敏感和有抵抗性

(陈涌明        王祥瑞 )

Mice with Glycine Receptor Subunit Mutations Are Both Sensitive and Resistant to Volatile Anesthetics

Joseph J. Quinlan, Carolyn Ferguson, Katherine Jester, Leonard L. Firestone, and Gregg E. Homanics

Anesth Analg 2002 95: 578-582.

 

异氟醚对中性粒细胞选择蛋白和β2 -整合蛋白在体外激活的影响

(李绍清    薛张纲 )

The Effect of Isoflurane on Neutrophil Selectin and ß2-Integrin Activation In Vitro
Lothar W. de Rossi, Nicola A. Horn, Wolfgang Buhre, Florian Gass, Gabriele Hutschenreuter, and Rolf Rossaint

Anesth Analg 2002 95: 583-587.

 

重视重症肌无力患者未结合的乙酰胆碱受体数量可改良罗库溴铵在其体内的药物代谢动力学和药物效应动力学的模式

(赵雪莲     庄心良  )

Pharmacokinetic/Pharmacodynamic Modeling of Rocuronium in Myasthenic Patients Is Improved by Taking into Account the Number of Unbound Acetylcholine Receptors

Ann De Haes, Johannes H. Proost, Jan B. M. Kuks, David C. van den Tol, and J. Mark K. H. Wierda

Anesth Analg 2002 95: 588-596.

 

甲状腺切除术中异丙酚及舒芬太尼麻醉--确保术中循环及脑电图稳定,术后恢复快的最佳浓度

(朱慧深       王祥瑞 )

Propofol-Sufentanil Anesthesia for Thyroid Surgery: Optimal Concentrations for Hemodynamic and Electroencephalogram Stability, and Recovery Features

Elisabeth Hentgen, Malik Houfani, Valérie Billard, Florent Capron, Jean-Marc Ropars, and Jean Paul Travagli

Anesth Analg 2002 95: 597-605.

 

PEDIATRIC ANESTHESIA:

小儿七氟醚麻醉而不用肌松药的情况下气管插管成功率的影响因素

(王士雷    庄心良  )

Factors Associated with Successful Tracheal Intubation of Children with Sevoflurane and No Muscle Relaxant

George D. Politis, Michael J. Frankland, Robert L. James, Jacland F. ReVille, Michael P. Rieker, and Betty C. Petree

Anesth Analg 2002 95: 615-620.

AMBULATORY ANESTHESIA:

疼痛---影响日间手术出院及术后恢复的因素

(朱慧深         王祥瑞 )

Pain as a Factor Complicating Recovery and Discharge After Ambulatory Surgery
D. Janet Pavlin, C. Chen, D. A. Penaloza, Nayak L. Polissar, and F. Peter Buckley

Anesth Analg 2002 95: 627-634.

TECHNOLOGY, COMPUTING, AND SIMULATION:

靶控和手控输注异丙酚中的双频指数

(李绍清    薛张纲 )   

Bispectral Index in Patients with Target-Controlled or Manually-Controlled Infusion of Propofol

Andreas Lehmann, Joachim Boldt, Elfi Thaler, Swen Piper, and Udo Weisse

Anesth Analg 2002 95: 639-644. 

 

用声音反射计预测困难气管插管的临床研究

(杨保仲    庄心良 )

Clinical Application of Acoustic Reflectometry in Predicting the Difficult Airway

E. Andrew Ochroch and David M. Eckmann

Anesth Analg 2002 95: 645-649.  

 

吸附剂中小剂量一氧化碳形成与少量二氧化碳吸收无关

(陈洁       王祥瑞 )

Small Carbon Monoxide Formation in Absorbents Does Not Correlate with Small Carbon Dioxide Absorption

Erich Knolle, Georg Heinze, and Hermann Gilly

Anesth Analg 2002 95: 650-655.

 

全麻时减少手术室麻醉气体污染的麻醉气排出橱的使用

(李绍清    薛张纲 )

The Use of a Uniquely Designed Anesthetic Scavenging Hood to Reduce Operating Room Anesthetic Gas Contamination During General Anesthesia
Moeen K. Panni and Stephen B. Corn

Anesth Analg 2002 95: 656-660.

PAIN MEDICINE:

鞘内注射镁盐延长芬太尼镇痛时间:一个前瞻性、随机化、对照研究

(葛圣金   庄心良 )

Intrathecal Magnesium Prolongs Fentanyl Analgesia: A Prospective, Randomized, Controlled Trial

Asokumar Buvanendran, Robert J. McCarthy, Jeffrey S. Kroin, Warren Leong, Patricia Perry, and Kenneth J. Tuman

Anesth Analg 2002 95: 661-666.

 

Parecoxib——肠道外环氧化酶-2抑制剂对咪达唑仑药代动力学和临床效果的影响

(陈洁         王祥瑞 )

The Influence of Parecoxib, a Parenteral Cyclooxygenase-2 Specific Inhibitor, on the Pharmacokinetics and Clinical Effects of Midazolam
Andra Ibrahim, Aziz Karim, Jennifer Feldman, and Evan Kharasch

Anesth Analg 2002 95: 667-673.

CRITICAL CARE AND TRAUMA:

联合应用平均频率和振幅对猪心跳骤停模型除颤结局的预测能力

(张鸿    薛张纲 )

The Prediction of Defibrillation Outcome Using a New Combination of Mean Frequency and Amplitude in Porcine Models of Cardiac Arrest

Anton Amann, Klaus Rheinberger, Ulrich Achleitner, Anette C. Krismer, Werner Lingnau, Karl H. Lindner, and Volker Wenzel

Anesth Analg 2002 95: 716-722.

OBSTETRIC ANESTHESIA:

罗哌卡因硬膜外分娩镇痛时加用压宁定的药理效应研究

(齐波       王祥瑞  )

The Dose-Sparing Effect of Clonidine Added to Ropivacaine for Labor Epidural Analgesia

Ruth Landau, Eduardo Schiffer, Michel Morales, Georges Savoldelli, and Christian Kern

Anesth Analg 2002 95: 728-734.

 

可乐定对分娩时硬膜外罗吡卡因最低局部镇痛浓度的影响

(张鸿    薛张纲 )

The Effect of Clonidine on the Minimum Local Analgesic Concentration of Epidural Ropivacaine During Labor

Chritophe Aveline, Sonia El Metaoua, Anis Masmoudi, Pierre-Yves Boelle, and Francis Bonnet

Anesth Analg 2002 95: 735-740.

 

检验萘普生用于剖腹产术后第二天镇痛效果的一项试验

(焦志华译  庄心良校)

A Randomized Controlled Trial Examining the Effect of Naproxen on Analgesia During the Second Day After Cesarean Delivery

Pamela J. Angle, Stephen H. Halpern, Barbara L. Leighton, J. P. Szalai, K. Gnanendran, and Jean E. Kronberg

Anesth Analg 2002 95: 741-745. 

REGIONAL ANESTHESIA:

全麻前行双侧颈深丛及浅丛阻滞对甲状腺手术病人的镇痛效果

(周洁      王祥瑞   )

The Analgesic Efficacy of Bilateral Combined Superficial and Deep Cervical Plexus Block Administered Before Thyroid Surgery Under General Anesthesia

Sophie Aunac, Marianne Carlier, Francois Singelyn, and Marc De Kock

Anesth Analg 2002 95: 746-750.

 

老年人髋关节骨折手术中预防性肌注小剂量苯肾上腺素缓解脊髓麻醉导致的低血压反应

(唐俊    庄心良 )

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Kohki Nishikawa, Michiaki Yamakage, Keiichi Omote, and Akiyoshi Namiki

Anesth Analg 2002 95: 751-756.   

GENERAL ARTICLES:

通过气管-肺模型,用不同方法比较高频喷射通气(HFJV)

(张军     庄心良 )

Comparing Methods of Administering High-Frequency Jet Ventilation in a Model of Laryngotracheal Stenosis

Alexander Ng, William C. Russell, Nicholas Harvey, and Jonathan P. Thompson

Anesth Analg 2002 95: 764-769. 

 

成人在麻醉和肌松情况下行压力控制通气时Proseal™喉罩气道和喉管气道的比较

( 颜涛译    庄心良校)

A Comparison of the Laryngeal Mask Airway ProSealTM and the Laryngeal Tube Airway in Paralyzed Anesthetized Adult Patients Undergoing Pressure-Controlled Ventilation

Joseph Brimacombe, Christian Keller, and Lawrence Brimacombe

Anesth Analg 2002 95: 770-776.

 

重视重症肌无力患者未结合的乙酰胆碱受体数量可改良罗库溴铵在其体内的药物代谢动力学和药物效应动力学的模式

 

Pharmacokinetic/Pharmacodynamic Modeling of Rocuronium in Myasthenic Patients Is Improved by Taking into Account the Number of Unbound Acetylcholine Receptors

Ann De Haes, MD*, Johannes H. Proost, PharmD PhD*, Jan B. M. Kuks, MD PhD, David C. van den Tol, MD, and J. Mark K. H. Wierda, MD PhD*

*Research Group for Experimental Anesthesiology and Clinical Pharmacology and Department of Neurology, University Hospital Groningen, Groningen, The Netherlands; and Department of Anesthesiology, Lievensberg General Hospital, Bergen op Zoom, The Netherlands

Anesth Analg 2002;95:588-596

 

目的:重症肌无力患者对非去极化肌松药敏感性强于健康患者。方法:我们研究8名重症肌无力患者和8名对照组患者的罗库溴铵的药物代谢动力学和药物效应动力学模式。以异丙酚,苏芬太尼及笑气和氧气的混合气麻醉患者。施行拇内收肌的肌收缩的机械效应图。重症肌无力患者的罗库溴铵输注速度为25ug.Kg-1.min-1,对照组患者为116.7 ug.Kg-1.min-1。至70%神经肌肉阻滞时停止输注。在神经阻滞开始、结束以及罗库溴铵停药后4小时,分别采集动脉血样。用高效液相测定罗库溴铵的浓度。罗库溴铵的药物代谢动力学和药物效应动力学模式研究采用雪纳模式(Sheiner model)和未结合受体模式(URM),因为这两种模式均考虑到未结合的乙酰胆碱受体数量。结果:罗库溴铵50%效应浓度和浓度-效应曲线的斜率,在重症肌无力患者组明显降低。结论:雪纳模式(Sheiner model)和未结合受体模式(URM)均适合重症肌无力患者。重症肌无力患者的乙酰胆碱受体浓度明显减少。未结合受体模式(URM)可以解释观察到的两组间的时间效应和药物效应强度的不同,但是雪纳模式(Sheiner model 模式解释不了。

                                (赵雪莲     庄心良  校)

 

Patients with myasthenia gravis are more sensitive than healthy patients to nondepolarizing neuromuscular blocking drugs. We performed a pharmacokinetic/pharmacodynamic modeling study of rocuronium in eight myasthenic patients and eight matched control patients. Patients were anesthetized with propofol and sufentanil and a mixture of nitrous oxide/oxygen. Mechanomyographical monitoring of the adductor pollicis was applied. Rocuronium was infused at a rate of 25 µg · kg-1 · min-1 in myasthenic patients and 116.7 µg · kg-1 · min-1 in control patients and was terminated at 70% neuromuscular block. Arterial blood samples were drawn during onset and offset of the block and for 4 h after the administration of rocuronium. Plasma concentrations were determined by high-performance liquid chromatography. Pharmacokinetic/pharmacodynamic modeling was performed by using the Sheiner model and the unbound receptor model (URM), which takes into account the number of unbound acetylcholine receptors. The effective concentration at 50% effect and the steepness of the concentration-effect relationship were significantly decreased in myasthenic patients. Both the URM and the Sheiner model provided an adequate fit in myasthenic patients. The acetylcholine receptor concentration was significantly decreased in myasthenic patients. The URM explains the observed differences in time course and potency, whereas the Sheiner model does not.

 

                         

非卤化链烷和卤化链烷抑制α4β2神经型乙酰胆碱受体

非卤化的有麻醉作用的链烷如环丙烷和丁烷,对中枢抑制性递质γ-氨基丁酸(GABA)及其相应受体无强化作用,说明其通过其它机制发挥麻醉作用。卤化的非制动性链烷如12-双氯六氟环丁烷和23-双氯八氟丁烷同样不能强化γ-氨基丁酸能电流,其对行为能力有特殊的影响,这一点不同于其结构相似的非卤化链烷,后者因有制动效应而用作麻醉药。在一定浓度时12-双氯六氟环丁烷和23-双氯八氟丁烷只产生遗忘效应而不产生制动效应。神经型乙酰胆碱受体对许多麻醉药敏感,而且在学习和记忆过程中发挥重要作用。我们假定神经型乙酰胆碱受体介导非卤化链烷和卤化链烷遗忘作用。为验证神经型乙酰胆碱受体介导的麻醉药和非制动药的行为效应,我们定量研究了非卤化的麻醉性链烷和卤化的非制动性的链烷对α4β2神经型乙酰胆碱受体的抑制效应。结果显示二者在达到能够抑制学习的浓度时显着抑制α4β2神经型乙酰胆碱受体,其效能与其疏水性相关。证明α4β2神经型乙酰胆碱受体介导链烷的遗忘效应而非制动效应。       (杨保仲    庄心良 校)

Nonhalogenated Anesthetic Alkanes and Perhalogenated Nonimmobilizing Alkanes Inhibit 4ß2 Neuronal Nicotinic Acetylcholine Receptors

Douglas E. Raines, MD, Robert J. Claycomb, BS, and Stuart A. Forman, MD PhD

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

 AnesthAnalg 2002;95:573-577
The nonhalogenated anesthetic alkanes, cyclopropane and butane, do not enhance -aminobutyric acid-elicited GABAergic currents, suggesting that these agents produce anesthesia via interactions with other molecular targets. Perhalogenated nonimmobilizing alkanes, such as 1,2-dichlorohexafluorocyclobutane and 2,3-dichlorooctafluorobutane, also fail to enhance GABAergic currents, but display specific behavioral effects that are distinct from those of structurally similar anesthetics. At concentrations predicted to be anesthetic, 1,2-dichlorohexafluorocyclobutane and 2,3-dichlorooctafluorobutane produce amnesia but fail to produce immobility. Neuronal nicotinic acetylcholine (nACh) receptors are sensitive to many anesthetics and are thought to have an important role in learning and memory. We postulated that neuronal nACh receptors might mediate the common amnestic action of nonhalogenated and perhalogenated alkanes. To test the hypothesis that neuronal nACh receptors have a role in mediating the behavioral effects of general anesthetics and nonimmobilizers, we quantified the inhibitory potencies of nonhalogenated anesthetic alkanes and perhalogenated nonimmobilizing alkanes on currents mediated by 4ß2 neuronal nACh receptors. Our studies reveal that anesthetics and nonimmobilizers significantly inhibit 4ß2 neuronal nACh receptors at concentrations that suppress learning and with potencies that correlate with their hydrophobicities. These results support the hypothesis that 4ß2 neuronal nACh receptors mediate the amnestic actions of alkanes but not their immobilizing actions.

用声音反射计预测困难气管插管的临床研究

本研究通过用声音反射计测量病人气道长度和气道截面积,计算出气道容积,进而预测给病人作气管内插管的难易程度。第一部分是回顾性研究,总结临床气管插管病例,结果发现在气管内插管容易的病人和气管内插管困难的病人之间似乎是以气道容积为40.2毫升为界限。第二部分是前瞻性研究,根据第一部分研究结果得出假设,即当气道容积小于40.2毫升时气管内插管困难,将此结论用于预测临床气管内插管的难易程度。但是,结果表明,气道容积小和气管内插管失败、声门显露困难及喉检困难之间没有明显相关性。  

(杨保仲    庄心良 校)

Clinical Application of Acoustic Reflectometry in Predicting the Difficult Airway

E. Andrew Ochroch, MD*, and David M. Eckmann, PhD MD

*Department of Anesthesiology, University of Pennsylvania Health System; and Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, PA

Anesth Analg 2002;95:645-649
 Acoustic reflectometry, a noninvasive test that produces a length versus cross-sectional area map of the airway, has been used to identify difficult-to-tracheally intubate patients in a small retrospective case-control study. A critical airway volume of 40.2 mL separated those patients whose tracheas were impossible to intubate from those who were easily intubated. To determine if this technology was applicable for prospectively predicting difficult intubation and difficult ventilation in routine clinical practice, we performed a double-blinded, prospective cohort study. Our a priori hypothesis was that small airway volumes in adults (<40.2 mL) would predict absolute inability to intubate. We conclude that by use of acoustic reflectometry, there was no relationship between inability to intubate, poor glottic visualization, and multiple laryngoscopies with airway volume.

 

老年人髋关节骨折手术中预防性肌注小剂量苯肾上腺素缓解脊髓麻醉导致的低血压反应

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Kohki Nishikawa, MD, Michiaki Yamakage, MD PhD, Keiichi Omote, MD PhD, and Akiyoshi Namiki, MD PhD

Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan

Anesth Analg 2002;95:751-756

(I)目的:评估1.5mg3mg苯肾上腺素肌注对高渗丁卡因脊髓麻醉所诱发的低血压反应的预防效果。方法: 65岁以上行髋关节骨折手术的病人共90例,其中正常血压和高血压病人各45例,均随机等分为三组分别给予生理盐水对照、苯肾上腺素1.5mg3mg肌注(分别为N/CN/P-1.5N/P-3.0组和H/CH/P-1.5H/P-3.0组)。结果:所有组最高感觉阻滞平面均为T9左右(范围在T8T10之间)。以平均动脉压(MAP)下降大于基础值的25%为标准,无论正常血压组或高血压组,接受1.5mg3mg苯肾上腺素的病人低血压的发生率均低于对照组(P<0.01)。N/P-3.0N/P-1.5H/P-3.0组与N/CH/C组相比,MAP下降的幅度较小(P<0.05),需要肾上腺素静脉注射的剂量也明显减小(P<0.05)。肌注苯肾上腺素的各组均未出现心动过缓(心律<50次每分)。在N/P-3.0H/P-3.0组,可见MAP大于基础值20%的高血压,而N/P-1.5H/P-1.5组未见。结论:在正常血压或高血压的老年病人,预防性肌注苯肾上腺素1.5mg可以减少脊髓麻醉相关性低血压,并可以避免心动过缓和高血压的发生。

                                (唐俊    庄心良 校)

 

(II)在一项90位正常血压和高血压、年龄>65岁行髋关节骨折手术患者的双盲、安慰剂对照、随机研究中,我们评估了预防性肌注1.53mg新福林对重比重丁卡因蛛网膜下腔麻醉诱发低血压的影响。30位正常血压患者分别肌注新福林1.5mg3mg(N/P-1.5 N/P-3.0组;每组n = 15),对照组给予生理盐水(N/C组;n = 15)45位高血压患者行相似的处理(H/P-1.5, H/P-3.0,H/C组;每组n = 15)。各组的高位感觉阻滞平面为T9,范围T8T10。在正常血压和高血压组,给予新福林1.5mg3mg的患者低血压(平均动脉压[MAP]由基础值下降>25%)的发生均较对照组有显著降低。与N/C组或H/C组相比,N/P-3.0N/P-1.5组以及H/P-3.0MAP下降的百分比显著降低(P < 0.05),所需静注麻黄碱的量显著减少(P < 0.05)。尽管与H/C组比, H/P-1.5组未能显著减少MAP下降的百分比,但其所需静注麻黄碱的量也显著降低(P < 0.05)。各组均未观察到作为肌注新福林不良反应的心动过缓发生。在N/P-3.0H/P-3.0组,给药后发生高血压(MAP由基础值上升20%),而N/P-1.5H/P-1.5组未发生。我们认为预防性肌注1.5mg新福林是安全的(就抑制心动过缓和高血压的发生而言),并且是减少正常血压和高血压的老年患者蛛网膜下腔麻醉时发生低血压的有效方法。

结论 我们认为对正常血压和高血压的老年患者,针对蛛网膜下腔麻醉所致的低血压,小剂量新福林预防性使用是有效和安全的。1.5mg新福林肌注对于减少低血压的发生和避免不良反应是有效的。

                                                     (张鸿    薛张纲

In a double-blinded, placebo-controlled, randomized study, we evaluated the effect of prophylactic IM phenylephrine at doses of 1.5 and 3 mg on hyperbaric tetracaine spinal anesthesia-induced hypotension in 90 normotensive and hypertensive patients aged >65 yr undergoing surgery for hip fracture. Thirty normotensive patients received 1.5 or 3 mg of phenylephrine IM (N/P-1.5 and N/P-3.0 groups; n = 15 in each), whereas controls received saline (N/C group; n = 15), and 45 hypertensive patients were treated in a similar manner (H/P-1.5, H/P-3.0, and H/C groups; n = 15 in each). All groups had a peak sensory block height of T9, with a range of T8 to T10. The incidence of hypotension (>25% decrease in mean arterial blood pressure [MAP] from baseline) was significantly lower in the patients who received phenylephrine 1.5 or 3 mg than in the controls, both in the normotensive and hypertensive groups (P < 0.01). The N/P-3.0 and N/P-1.5 groups and the H/P-3.0 group had significantly lower percentage reductions in MAP (P < 0.05) and required significantly smaller doses of rescue IV ephedrine (P < 0.05) than did the N/C group or the H/C group. The H/P-1.5 group also required significantly less rescue IV ephedrine (P < 0.05), although it was not sufficient to significantly attenuate the percentage decrease in MAP compared with that in the H/C group. Bradycardia (heart rate <50 bpm) as an adverse effect after IM administration of phenylephrine was not observed in any of the groups. Hypertension (MAP >20% increase from baseline) after medication occurred in the N/P-3.0 and H/P-3.0 groups, but not in the N/P-1.5 and H/P-1.5 groups. We conclude that prophylactic IM injection of 1.5 mg of phenylephrine is a safe (defined as the inhibition of bradycardia and hypertension) and effective means of reducing the incidence of hypotension associated with spinal anesthesia in normotensive and hypertensive elderly patients.

IMPLICATIONS: We evaluated the efficacy and safety of small-dose IM phenylephrine for prophylaxis against spinal anesthesia-induced hypotension in normotensive and hypertensive elderly patients. Phenylephrine 1.5 mg IM was effective for reducing the incidence of hypotension and avoided adverse effects.

Comparing Methods of Administering High-Frequency Jet Ventilation in a Model of Laryngotracheal Stenosis

通过气管-肺模型,用不同方法比较高频喷射通气(HFJV)

Alexander Ng, FRCA, William C. Russell, FANZCA, Nicholas Harvey, FRCA, and Jonathan P. Thompson, BSc MD, FRCA

University Department of Anaesthesia, Critical Care & Pain Management, Leicester Royal Infirmary, Leicester, United Kingdom

 

利用内径为2.5-8.5mm的连接管制成气管-肺模型进行高频喷射通气(HFJV)以模拟通过不同程度狭窄的喉气管通气。随着连接管直径的缩小,呼气末压力(EEP)和吸气峰压(PIP)增加。分别经声门上、喉和气管进行HFJV,当连接管直径小于5.5,4.0,3.5cm 时, EEP 10 mm Hg;当连接管直径小于5.5,3.5,3.0cm时,PIP>20 mm Hg。经声门上进行HFJV时的EEPPIP大于经喉和经气管 (P < 0.01)。当连接管直径小于3.5 4.0 cm时,EEPPIP增加,而且经喉HFJV大于经气管HFJV (P < 0.01)。在第二个实验中,应用笑气4 L/min来评价通气和气体掺杂的程度。在声门上进行HFJV时的笑气浓度显着小于经喉或经气管 HFJV (P < 0.01),而氮气浓度显着大于经喉或经气管HFJV (P < 0.01)。同经喉和经气管HFJV相比,声门上进行HFJVEEPPIP的增加可归因于通气和掺气的增加。

                                (张军     庄心良 )

We administered high-frequency jet ventilation (HFJV) to a tracheal-lung model with connectors of internal diameter 2.5–8.5 mm to simulate ventilation through varying degrees of laryngotracheal stenosis. With reductions in diameter, end-expiratory pressure (EEP) and peak inspiratory pressure (PIP) increased. During supraglottic, translaryngeal, and transtracheal HFJV, respectively, EEP was 10 mm Hg at diameters narrower than 5.5, 4.0, and 3.5 cm, and PIP was >20 mm Hg at diameters narrower than 5.5, 3.5, and 3.0 cm. EEP and PIP were greater during supraglottic HFJV than during translaryngeal and transtracheal HFJV (P < 0.01). At diameters of <3.5 and 4.0 cm, respectively, PIP and EEP increased and were significantly greater (P < 0.01) during translaryngeal HFJV than during transtracheal HFJV. In a second experiment, the degree of ventilation and air entrainment was assessed by administering nitrous oxide 4 L/min to the model. Nitrous oxide concentrations were significantly (P < 0.01) smaller and nitrogen concentrations were significantly (P < 0.01) larger during supraglottic HFJV than either translaryngeal or transtracheal HFJV. The larger EEP and PIP associated with supraglottic HFJV may be attributable to increased ventilation and air entrainment compared with translaryngeal and transtracheal HFJV.


A Randomized Controlled Trial Examining the Effect of Naproxen on Analgesia During the Second Day After Cesarean Delivery

检验萘普生用于剖腹产术后第二天镇痛效果的一项试验

Pamela J. Angle, MD FRCPC*, Stephen H. Halpern, MD FRCPC*, Barbara L. Leighton, MD,  J. P. Szalai, PhD,  K. Gnanendran, MD FRCPC*, and Jean E. Kronberg, MD PhD*

*Department of Anesthesia, Women’s College Hospital Campus, Sunnybrook and Women’s College Health Sciences Center, University of Toronto; Visiting Professor of Obstetric Anesthesia, University of Toronto; and Director, Research Design and Biostatistics, Sunnybrook and Women’s College Health Sciences Center, University of Toronto, Toronto, Ontario, Canada

目的 检验非类固醇类抗炎药和常用口服镇痛药物联合应用对手术后第二天镇痛的效果。方法 80例行择期剖腹产手术的女性病人随机分为术后每12小时椎管内注射吗啡合并应用萘普生或安慰剂组。两组病人都给以常用的治疗方法如对乙酰氨基酚和可待因(必需)及辅助肌注鸦片类。通过视觉模拟评分(0—100)来评估坐立时切口痛(IPS)、休息时切口痛、子宫收缩痛及呼吸痛的程度,并对术后72小时内最剧烈的间歇痛(0—10)程度及使用镇静剂以及发生不良反应的情况进行评价。结果 36小时时,合用萘普生减轻IPS38.2±26.0 VS 51.4±25.7; P=0.05)、休息时的切口痛、子宫收缩痛和间歇痛的评分。整个过程发现其在临床上中等、统计学上则明显减轻IPSP=0.0001)和鸦片的使用(P<0.01)。第一天可以降低镇静不全的发生率,减轻整体痛觉(P=0.0006),但不能持续到第二天(整体痛觉减轻,P=0.057镇静不全,24%萘普生 VS 27%对照;P=1.00)。结论 剖腹产手术后加入常用量的萘普生和口服止痛药可以减轻36小时时的IPS及第二天的疼痛,在36小时疼痛高峰时效果最强,但不能减少镇静不全的发生率。

                                (焦志华译  庄心良校)

Whereas nonsteroidal antiinflammatory drugs augment spinal morphine on Day l, the analgesia gained by simply combining these drugs with conventional "on request" oral regimens on Day 2 is less clear. In this trial, we randomized 80 women undergoing elective cesarean delivery with spinal morphine (0.2 mg) to receive naproxen (500 mg) or placebo every 12 h after surgery. Both groups received conventional therapy with acetaminophen with codeine (on request) and rescue IM opioids. Incision pain on sitting (IPS), incision pain at rest, uterine cramping, and gas pain were evaluated with visual analog scales (0–100). Worst interval pain (0–10), analgesic use, and side effects were measured over 72 h. At 36 h (primary outcome), naproxen use was associated with reductions in IPS (38.2 ± 26.0 versus 51.4 ± 25.7; P = 0.05), incision pain at rest, uterine cramping, and worst interval pain scores. Clinically modest, statistically significant reductions in IPS (P = 0.0001) and opioid use were found over time (P < 0.0l). Reductions in the incidence of inadequate analgesia and improvements in overall pain relief (P = 0.0006) on Day l did not persist on Day 2 (overall pain relief, P = 0.057; inadequate analgesia, 24% naproxen versus 27% controls; P = 1.00). The addition of regular doses of naproxen to conventional oral pain therapy after cesarean delivery leads to reductions in IPS at 36 h and pain over Day 2 but does not reduce the incidence of inadequate analgesia.

小儿七氟醚麻醉而不用肌松药的情况下气管插管成功率的影响因素

Factors Associated with Successful Tracheal Intubation of Children with Sevoflurane and No Muscle Relaxant

George D. Politis, MD MPH*, Michael J. Frankland, MD, Robert L. James, MS, Jacland F. ReVille, MD, Michael P. Rieker, CRNA, and Betty C. Petree, CRNA

*Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia; and Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2002;95:615-620

目的:探讨小儿七氟醚麻醉而不用肌松药的情况下气管插管成功率的影响因素。方法:153ASA-Ⅱ级病人,用8%七氟醚和60%笑气行麻醉诱导,1min后停用笑气。将每组最初5例病人80%成功气管插管的时间确定为麻醉诱导后放置喉镜的时间。分析病人80%成功气管插管的时间和影响因素。结果:小儿80%成功气管插管的时间在1-4y4-8y二个年龄段分别为137s95%可信区间94.6-159s)和187s95%可信区间153-230s)。通过概率分析发现年龄和诱导时间是预测气管插管成功率的主要因素。如果放置喉镜时病人有自主呼吸,则预示气管插管条件较差。结论:在七氟醚麻醉不用肌松药的情况下,小儿80%成功气管插管的时间在1-4y4-8y二个年龄段分别为137s187s,年龄和诱导时间是预测气管插管成功率的主要因素。

                                  (王士雷    庄心良  校)

Better definition of end points required to achieve successful tracheal intubation after induction with sevoflurane could improve patient care. The authors therefore designed a study that could determine, with meaningful confidence intervals, the time required to successfully intubate 80% of children by using 8% inspired sevoflurane and no muscle relaxant. We hypothesized that the time required could vary by age or body mass index. One-hundred fifty-three ASA physical status I or II patients received induction with 8% sevoflurane in 60% nitrous oxide with discontinuation of nitrous oxide 1 min after the start of the induction. The time until laryngoscopy remained close to the time required to achieve 80% successful intubation by varying induction time according to the success rate in each group of five patients. A probit model of induction time and age found that both were predictive of successful intubation (P values of 0.006 and 0.02, respectively). The induction times needed to achieve 80% successful intubation were 137 s (95% confidence interval, 94.6–159 s) and 187 s (153–230 s) for ages 1–4 yr and 4–8 yr, respectively. The persistence of spontaneous ventilation at the time of laryngoscopy, despite attempts to control ventilation, was associated with poor intubation conditions (P < 0.001).

IMPLICATIONS: To successfully intubate 80% of children by using sevoflurane and no muscle relaxant, induction times of 137 and 187 s were needed in children of 1–4 yr and 4–8 yr, respectively.



 

Intrathecal Magnesium Prolongs Fentanyl Analgesia: A Prospective, Randomized, Controlled Trial

鞘内注射镁盐延长芬太尼镇痛时间:一个前瞻性、随机化、对照研究

Asokumar Buvanendran, MD, Robert J. McCarthy, PharmD, Jeffrey S. Kroin, PhD, Warren Leong, MD, Patricia Perry, MD, and Kenneth J. Tuman, MD

 

Department of Anesthesiology, Rush Medical College at Rush-Presbyterian-St Luke’s Medical Center, Chicago, Illinois 

Anesth Analg 2002; 95:

 

目的:镁是一种非竞争性NMDA受体拮抗剂,但经静脉注射不能有效通过血脑屏障。在大鼠鞘内注射镁盐能增强阿片类药物的抗伤害性刺激作用,且在动物鞘内注射镁盐的安全性已得到证实。本研究探讨在人体鞘内注射镁盐能否延长阿片类药物脊髓镇痛的持续时间。方法52例要求分娩镇痛的病人,随机接受以鞘内注射芬太尼25 µg加生理盐水或芬太尼25 µg加硫酸镁50 mg为镇痛药物的脊-硬联合阻滞镇痛技术。由于坐位时鞘内注射重比重溶液向头侧扩散受限,本研究中未使用更大剂量的镁盐。自注药至病人要求额外镇痛药物为止,为鞘内药物镇痛的持续时间。结果:镁盐加芬太尼组的镇痛持续时间(75 min)明显长于单用芬太尼组(60 min)。鞘内注射镁盐未见有相关的不良反应的增加。数据显示鞘内注射镁盐能延长人体阿片类药物脊髓镇痛作用时间,且提示如能鞘内使用NMDA拮抗剂将对临床疼痛治疗有重要意义。结论:镁能在脊髓中自然产生,阻断NMDA谷氨酸通路。在动物研究中,鞘内注射硫酸镁能增强吗啡脊髓镇痛效果。对于接受分娩脊髓镇痛的病人,联合应用硫酸镁和阿片类药物芬太尼延长了镇痛时间,但副作用未见增加。

                                    (葛圣金   庄心良 校)

 

Magnesium is a noncompetitive, N-methyl-D-aspartate receptor antagonist that does not effectively cross the blood-brain barrier when given IV. Intrathecal magnesium potentiates opioid antinociception in rats, and the safety of intrathecal magnesium has been demonstrated in animals. This is the first prospective human study evaluating whether intrathecal magnesium could prolong spinal opioid analgesia. Fifty-two patients requesting analgesia for labor were randomized to receive either intrathecal fentanyl 25 µg plus saline or fentanyl 25 µg plus magnesium sulfate 50 mg as part of a combined spinal-epidural technique. The duration of analgesia of the intrathecal drug combination was defined by the time of patient request for additional analgesia. There was significant prolongation in the median duration of analgesia (75 min) in the magnesium plus fentanyl group compared with the fentanyl alone group (60 min). There was no associated increase in adverse events in the group that received intrathecal magnesium. Larger doses of intrathecal magnesium were not studied in this group of patients because of the limitations on cephalad spread when hyperbaric solutions are injected in the sitting position. Our data indicate that intrathecal magnesium prolongs spinal opioid analgesia in humans and suggest that the availability of an intrathecal N-methyl-D-aspartate antagonist could be of clinical importance for pain management.

IMPLICATIONS: Magnesium occurs naturally in the spinal cord and blocks the NMDA glutamate channel. In animal studies, intrathecal magnesium sulfate improves spinal morphine analgesia. For patients receiving spinal analgesia for labor, the addition of magnesium sulfate to the opioid fentanyl prolonged analgesia with no increase of side effects.

成人在麻醉和肌松情况下行压力控制通气时Proseal™喉罩气道和喉管气道的比较

A Comparison of the Laryngeal Mask Airway ProSealTM and the Laryngeal Tube Airway in Paralyzed Anesthetized Adult Patients Undergoing Pressure-Controlled Ventilation

Joseph Brimacombe, MB ChB, FRCA, MD*, Christian Keller, MD, and Lawrence Brimacombe, MB ChB*   *Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns, Australia; and Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens

University, Innsbruck, Austria Anesth Analg 2002;95:770-776

目的:比较成年病人在压力控制通气状态下两种声门外通气装置的使用情况。方法:120ASA I-II级的成年病人被随机分配到PLMATM组或LTA组。由两位对这些气道装置都很有经验的医生按照标准方案进行麻醉。对以下方面进行比较:1)放置所需的时间和成功率;2)气道的密闭性;3)在压力控制通气状态下的通气参数;4)不同头/颈位置时的潮气量;5)需要对通气道进行干预的情况。有效的通气道的标准是:在压力控制模式下,设定压力是17 cm H2O时,最小呼出潮气量潮过7ml/kg,无口咽部反流和胃胀气。结果:在试图建立有效通气道时的一次成功率两者相似(PLMATM: 85%; LTA: 87%);但是在三次尝试以后,PLMATM 的成功率明显高于LTA (100% versus 92%, P = 0.02)。在最大推荐气囊容量的50%时,PLMATM口咽部反流压高于LTA29 ± 7 versus 21 ± 6 cm H2O, P < 0.0001),但是在最大推荐气囊容量时两者的口咽部反流压力相同(33 ± 7 versus 31 ± 8 cm H2O)。PLMATM的潮气量较大(614 ± 173 versus 456 ± 207 mL, P < 0.0001),呼气末二氧化碳较低(33 ± 9 versus 40 ± 11 mm Hg, P = 0.0001)。PLMATM需要对通气道进行干预的次数明显较少。而LTA发生气道阻塞的情况更常见。通过对不同头/颈位时的潮气量进行比较发现,PLMATM组维持高质量气道的人数比 LTA 组多(PLMATM56/60 93%LTA: 42/ 5576% P = 0.01)。结论:对于在肌松情况下接受压力控制通气的病人,在绝大多数气道管理的技术问题上PLMATM都优于LTA

                                    颜涛译    庄心良校)

We compared the laryngeal mask airway ProSealTM (PLMATM) and the laryngeal tube airway (LTA), two new extraglottic airway devices, with respect to: 1) insertion success rates and times, 2) efficacy of seal, 3) ventilatory variables during pressure-controlled ventilation, 4) tidal volume in different head/neck positions, and 5) airway interventional requirements. One-hundred-twenty paralyzed anesthetized ASA physical status I and II adult patients were randomly allocated to the PLMATM or LTA for airway management. A standardized anesthesia protocol was followed by two anesthesiologists experienced with both devices. The criteria for an effective airway included a minimal expired tidal volume of 6 mL/kg during pressure-controlled ventilation at 17 cm H2O with no oropharyngeal leak or gastric insufflation. First attempt success rates at achieving an effective airway were similar (PLMATM: 85%; LTA: 87%), but after 3 attempts, success was more frequent for the PLMATM (100% versus 92%, P = 0.02). Effective airway time was similar. Oropharyngeal leak pressure was larger for PLMATM at 50% maximal recommended cuff volume (29 ± 7 versus 21 ± 6 cm H2O, P < 0.0001), but was similar at the maximal recommended cuff volume (33 ± 7 versus 31 ± 8 cm H2O). Tidal volumes (614 ± 173 versus 456 ± 207 mL, P < 0.0001) were larger and ETCO2 (33 ± 9 versus 40 ± 11 mm Hg, P = 0.0001) lower for the PLMATM. The number of airway interventions was significantly less frequent for the PLMATM. Airway obstruction was more common with the LTA. When comparing mean tidal volumes in different head/neck positions, the quality of airway was unchanged in 56 of 60 patients (93%) with the PLMATM and 42 of 55 (76%) with the LTA (P = 0.01). The PLMATM offers advantages over the LTA in most technical aspects of airway management in paralyzed patients undergoing pressure-controlled ventilation.

 


 

 

   

 

多巴胺应激性心脏超声检查对非心脏择期手术室病人术前评估的低效性

   Low Utility of Dobutamine Stress Echocardiograms in the Preoperative Evaluation of Patients Scheduled for Noncardiac Surgery

 

Peter B. Morgan, Gregory E. Panomitros, Ana C. Nelson, Douglas F.Smith, Daneshvari R. Solanki, and Mark H. Zornow

 

Department of Anesthesiology, The University of Texas Medical Branch, 301 University Blvd., Galveston

 

   Anaeth & Analg Sep.2002 95:512-516

 

本研究根据ACCAmerican College of Cardiologe)和AHAAmerican Heart Association)颁布的标准,观察85例病人了术前多巴胺应激性心脏超声检查(DSE)的效果。回顾每一例病人的医疗记录以确认是否符合术前行多巴胺应激性心脏超声检查临床标准,以确定DSE结果的有效干预和预测围手术期心脏事件的发生。85例病人中,4例阳性为缺血性改变(占4.7%);74例阴性(占87.1%);7例为非特异性改变(占8.2%)。48例由于合并糖尿病,轻度心绞痛,或“轻度临床影响因素”而行DSE的病人结果为阴性。4例阳性病例中3例曾行冠状血管造影术,且其中1人曾行CABG术。另外29例病人亦于术前接受DSE,但因为DSE的改变未达到ACC/AHA的标准,故未列入本研究中。全部85例病人行DSE的病人在本研究所的花费共为US$104635。利用ACC/AHA标准作为术前DSE的指标似乎并不有效。但是,可通过改变目前术前DSE的标准来提高显着性。

                                               ( 忻纪华     王祥瑞校)

In this study, we examined the utility of preoperative dopamine stress echocardiograms (DSE) obtained from 85 patients in according to guidelines published by the American College of Cardiology (ACC) and the American Heart Association (AHA). The medical record of each patient was reviewed to identify the clinical criteria that indicated the need for a DSE, the DSE results, therapeutic interventions rendered as a result of the DSE, and any perioperative cardiac morbidity. The DSE was positive for inducible ischemia in 4 patients (4.7%), negative in 74 (87.1%), and non-diffrential change in 7 (8.2%). DSEs that were obtained for 48 patients because of a history of diabetes mellitus, mild angina, or "minor clinical predictors" produced only negative results. In the four patients with positive DSE results, three underwent coronary angiography, and one of those three underwent bypass grafting before surgery. An additional 29 patients received a preoperative DSE but were excluded from the study because the criteria for ordering the DSE did not meet the ACC/AHA guidelines. No patient had any perioperative morbidity related to myocardial ischemia. The total patient charge for the 85 DSEs obtained at our institution was US$104,635. Use of the ACC/AHA guidelines for preoperative DSEs does not appear to be cost-effective. However, the current algorithm could be significantly improved by altering the criteria for obtaining preoperative DSEs.

 

氯胺酮减弱体外循环后中性粒细胞作用

 

Ketamine Attenuates Neutrophil Activation After Cardiopulmonary Bypass

 

Genaldi Zilberstein, Rachel Levy, Maxim Rachinsky, Allan Fisher, Lev Greenberg, Yoram Shapira, Azai Appelbaum, and Leonid Roytblat

 

*Division of Anesthesiology, Laboratory of Infectious Diseases, and Departments of Clinical Biochemistry and Cardiothoracic Surgery, Soroka Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

 

Anaesth & Analg Nov.2002 95:531-536.

 

外科手术与激活中性粒细胞以及对受影响组织的趋化作用密切相关。被激活的中性粒细胞所产生的过氧化物的病理作用已被多次报道。在试管实验中,氯胺酮抑制中性粒细胞含氧基产物。本研究CABG术全麻诱导期间,在阿片类药中加入小剂量的氯胺酮,比较它们对中性粒细胞过氧化物的影响。35例选择性CABG术患者随机分成两组行前瞻性双盲实验。患者在大剂量芬太尼麻醉中加入氯胺酮0.25mg/kg或相似容量的生理盐水。分别在手术前、CPB后即刻、术后2448小时、和术后3~6天内抽取血标本。以12-肉豆蔻酸13-醋酸氟波醇,调理化酵母聚糖或甲酰基蛋氨亮氨苯丙氨酸刺激后的过氧化产物来评估中性粒细胞功能。在术后4~6天,没有化学无刺激和以12-肉豆蔻酸13-醋酸氟波醇,调理化酵母聚糖或甲酰基蛋氨亮氨苯丙氨酸刺激各组在全麻中加入小剂量氯胺酮均减弱了中性粒细胞过氧化阴离子的增加。另外,氯胺酮降低了术后2~6内中性粒细胞的百分比。与基值相比,对照组的过氧化物显着增高。相反,氯胺酮组则无显着差异。

                                                       ( 陈涌明        王祥瑞 )

Surgery is associated with activation of neutrophils and their influx in affected tissue tendence. The pathogenic role of superoxide production generated by activated neutrophils has been documented repeatedly. Ketamine inhibited neutrophil oxygen radical production in vitro. In the present study, we compared the effect of adding small-dose ketamine to opioids during the induction of general anesthesia on superoxide production by neutrophils after coronary artery bypass grafting (CABG). Thirty-five patients undergoing elective CABG were randomized to one of two groups and prospectively studied in a double-blinded manner. The patients received either ketamine 0.25 mg/kg or a similar volume of saline in addition to large-dose fentanyl anesthesia. Blood samples were drawn before the operation, immediately after cardiopulmonary bypass, 24h and 48h postoperative , and on postoperative Days 36. Functional capacity of neutrophils was assessed by superoxide generation after stimulation with phorbol 12-myristate 13-acetate, opsonized zymosan, or formyl-methionyl-leucyl-phenylalanine. The addition of small-dose ketamine to general anesthesia attenuates increased production of the superoxide anion (O2-) by neutrophils without chemical stimulation and after stimulation with phorbol 12-myristate 13-acetate, formyl-methionyl-leucyl-phenylalanine, and opsonized zymosan for 46 days after CABG. In addition, ketamine attenuated the percentage of neutrophils on postoperative Days 26. In the Control group, superoxide production significantly increased compared with the baseline value. By contrast, in the Ketamine group, this difference was not significant.

 

   甘氨酸受体亚单位变异鼠对挥发性麻醉药均敏感和有抵抗性

 

Mice with Glycine Receptor Subunit Mutations Are Both Sensitive and Resistant to  Volatile Anesthetics

 

Joseph J. Quinlan, Carolyn Ferguson, Katherine Jester, Leonard L. Firestone, and Gregg E. Homanics

 

Departments of *Anesthesiology and Pharmacology, University of Pittsburgh, Pennsylvania

 

Anaeth &Analg Sep.2002  95:578-582

 

我们利用两种甘氨酸受体变异鼠来证实是否甘氨酸受体对在体麻醉反应中起重要作用。在loss-of-righting反射分析中,痉挛突变体对安氟醚轻度较敏感(P=0.02)。对照组50%有效浓度(EC50=1.17±0.06atm而痉挛突变体组(spA)0.97±0.06atm。但是,在夹尾分析中对安氟醚仍具有较强抵抗性(P=0.01)。(对照组EC50=1.96±0.10atm,spA2.58±0.25atm)spA组在loss-of-righting反射分析中对氟烷敏感(P<0.001)。(对照组EC50=0.81±0.03atm,spA0.57±0.04atm)。但是在存在氟烷时和对照组相比夹尾反应相似。痉挛调节和变异鼠对两种药物的反应无差异。注射三种催眠药(咪唑安定、硫贲妥钠、乙醇)后变异鼠睡眠时间根本性地延长。结论提示在调节麻醉反应时牵涉到一个复杂的甘氨酸通道。由于变异鼠缩小了甘氨酸容量而加大了对安氟醚、氟烷、咪唑安定、硫贲妥钠、乙醇催眠效果的敏感性,提示甘氨酸活力和催眠药呈反比关系。然而对安氟醚抵抗力夹尾分析提示甘氨酸活力加强肺泡最小麻醉药浓度反应。氟烷的作用机制似乎与安氟醚不尽相同,提示不是每一种挥发性麻醉药相同地调节甘氨酸通道。

( 陈涌明        王祥瑞 )

 

We used two mouse lines with glycine receptor mutations to determine whether glycine receptors might play an important role in anesthetic responses in vivo. Spastic (spA) mutants were slightly more sensitive (P = 0.02) to enflurane in the loss-of-righting reflex assay (50% effective concentration [EC50] = 1.17 ± 0.06 atm for controls versus 0.97 ± 0.06 atm for spA) but were also substantially more resistant (P = 0.01) to enflurane in the tail clamp assay (EC50 = 1.96 ± 0.10 atm for controls versus 2.58 ± 0.25 atm for spA). spA mice were also more sensitive to halothane (P < 0.001) in the loss-of-righting reflex assay (EC50 = 0.81 ± 0.03 atm for controls versus 0.57 ± 0.04 atm for spA), but the responses of mutant and control mice to tail clamp in the presence of halothane were similar. Spasmodic control and mutant mice did not differ in their responses to the two drugs. Sleep time was substantially longer in both mutant mouse lines after injection of three hypnotics (midazolam, pentobarbital, and ethanol). Our results suggest a complex involvement of glycinergic pathways in mediating anesthetic responses. Greater sensitivity to the hypnotic effect of enflurane, halothane, midazolam, pentobarbital, and ethanol in mutant mice with diminished glycinergic capacity suggests that glycinergic activity is inversely related to hypnosis, whereas resistance to enflurane in the tail clamp assay suggests that glycinergic activity potentiates the minimum alveolar anesthetic concentration response. Halothane seems to share some, but not all, of enfluranes mechanisms, indicating that not all volatile anesthetics modulate glycinergic pathways equally.

 

甲状腺切除术中异丙酚及舒芬太尼麻醉--确保术中循环及脑电图稳定,术后恢复快的最佳浓度

 

Propofol-Sufentanil Anesthesia for Thyroid Surgery: Optimal Concentrations for Hemodynamic and Electroencephalogram Stability, and Recovery Features

 

Elisabeth Hentgen, Malik Houfani, Valerie Billard, Florent Capron, Jean-Marc Ropars, and Jean Paul Travagli

 

 Departments of *Anesthesia and Surgery, Institut Gustave Roussy, Villejuif, France

 

Anaeth & Analg Sep. 2002 95:597-605.

 

  催眠镇静药和阿片类的相互协同作用可减轻外科并发症,且不同的组合剂量可提供不同的麻醉需要。本研究通过控制药物的输注量确定异丙酚及舒芬太尼的最佳浓度,以保证术中循环稳定,镇静适当(通过脑电图分析评估),术后恢复快。45名行甲状腺切除术的患者(ASA I-II, 随机分为三组,术中输注舒芬太尼浓度分别为0.10.20.3ng/ml。同时调节异丙酚的浓度(STC)以控制动脉血压在30%参考值及bispectral 指数40-60之间。所有组的麻醉效果都较满意,但STC(目标浓度)较低组的高血压的发生率较高,STC较高组的低血压发生率较高。同时术中异丙酚的目标浓度(STC)若递减(5.04.02.5 g/ml)其用量也随之递减(740668474 mg/h)。研究显示0.3ng/ml STC 大大延迟了自主呼吸的恢复。

                                                            (朱慧深       王祥瑞 )

  Hypnotics and opioids interact synergistically to block responses to surgery complications and different dose combinations may be used to provide adequate anesthesia. In this study, we sought to determine the optimal concentrations of propofol and sufentanil, given by target-controlled infusions, to ensure hemodynamic stability, adequate hypnosis (assessed by electroencephalogram bispectral indexTM), and fast recovery for a moderately painful operation. Forty-five patients, ASA physical status I or II, undergoing thyroidectomy, were randomly assigned to a sufentanil target concentration (STC) that was maintained throughout surgery (0.1, 0.2, or 0.3 ng/mL). The propofol target concentration was adjusted to keep mean arterial blood pressure within 30% of a reference value, and bispectral indexTM between 40 and 60. Adequate anesthesia was obtained in all groups. Hypertension and clinically dangerous movements were more frequent with the small STC, and hypotension requiring treatment was more frequent with the large STC. Propofol target concentration during surgery decreased significantly with increasing STC (median at thyroid removal 5.0, 4.0, and 2.5 µg/mL, respectively) as well as the propofol consumption (740, 668, 474 mg/h). The 0.3 ng/mL STC significantly delayed the return of spontaneous breathing.

 

疼痛---影响日间手术出院及术后恢复的因素

 

Pain as a Factor Complicating Recovery and Discharge After Ambulatory Surgery

 

   D. Janet Pavlin, C. Chen, D. A. Penaloza, Nayak L. Polissar, and F. Peter Buckley

 *Department of Anesthesiology, University of Washington, Seattle, Washington; Global Outcomes Research, Pharmacia, Skokie, Illinois; and The Mountain-Whisper-Light Statistical Consulting, Seattle, Washington

Departments of *Anesthesiology and General Intensive Care (B) and Medical Computer Sciences, University of Vienna; and Ludwig Boltzmann Institute for Experimental Anesthesiology and Research in Intensive Care Medicine, Vienna, Austria

 

  Anesth & Analg Sep.2002 95:627-634.

 

 

     疼痛会影响日间手术术后的恢复。调查175例日间手术病例以区分疼痛的严重程度,镇痛药的使用,恢复期相关疼痛及其它相关因素对疼痛的影响。多元化回归 分析对研究各类可变因素有其独特的作用。日间手术病例主要包括膝关节镜检查(n=50),疝手术(n=25),阴宫术(n=25),胸部手术(n=25),整形术(n=25). 研究显示最大疼痛值(标准为0-10)变异在2.3+-0.55.1+-0.5之间,24%的患者疼痛值大于7,同时也有24%的患者由于疼痛致使第一恢复期延长。如果术中使用了局麻药或酮咯酸则疼痛值较低(分别为22%26%)。恢复期的芬太尼剂量与最大疼痛值有关,若术中使用了酮咯酸则芬太尼的用量可减少42%。对于女性患者来说,恢复期的芬太尼剂量要高于术中用量。最大疼痛得分取决于总恢复时间(恢复时间为135172212分钟;其最大疼痛得分分别为0-34-6,和7-10P0.001)。综上所述,为了改善疼痛治疗的疗效,就需要提高患者的舒适度,加快其恢复。

                                               (朱慧深         王祥瑞 )

 

Pain complicates the recovery process after ambulatory surgery. We surveyed 175 ambulatory surgery patients to determine pain severity, analgesic use, relationship of pain to duration of recovery, and the relative importance of various factors to predicting these outcomes. Multivariate regression analysis was used to determine unique contributions of predictor variables to outcome. Surgical procedures included knee arthroscopy (n = 50), hernia surgery (n = 25), pelvic laparoscopy (n = 25), transvaginal uterine surgery (n = 25), surgery for breast disease (n = 25), and plastic surgery (n = 25). Maximum pain (on a scale of 010) varied from 2.3 ± 0.5 to 5.1 ± 0.5 (mean ± SE), depending on surgical procedure; 24% of patients had pain scores of 7, and 24% were delayed in Phase 1 recovery by pain. Pain scores were lower if local anesthetic or ketorolac was administered intraoperatively (22% and 26% respectively). Fentanyl dose during recovery correlated with maximum pain scores; fentanyl dose was 42% less if ketorolac was administered intraoperatively. In females, the recovery fentanyl dose increased in proportion to the intraoperative fentanyl dose. The maximum pain score was predictive of total recovery time (135, 172, and 212 min of recovery for maximum pain scores of 03, 46, and 710, respectively; P < 0.001). We conclude that improvements in pain therapy are warranted to improve patient comfort and to expedite recovery.

 

吸附剂中小剂量一氧化碳形成与少量二氧化碳吸收无关

 

Small Carbon Monoxide Formation in Absorbents Does Not Correlate with Small Carbon Dioxide Absorption

 

Erich Knolle, Georg Heinze, and Hermann Gilly

 

Departments of *Anesthesiology and General Intensive Care (B) and Medical Computer Sciences, University of Vienna; and Ludwig Boltzmann Institute for Experimental Anesthesiology and Research in Intensive Care Medicine, Vienna, Austria

Anaeth & Analg Sep.2002 95:650-655.

 

 本研究探讨吸附剂中形成的少量CO是否与CO2的吸收存在可能的相关。各种吸附剂均彻底干燥,重量600g:氢氧化钡(A,Dr gersorb 800 (B), A+B (C) ,  Intersorb (D) , Spherasorb (E), LoFloSorb (F)  , Superia (G)Amsorb (H)。将其置于5I/min的纯氧中60分钟,异氟醚浓度分别为0.5% A-Hn=4,5)和4%F-H; n=3)。每60秒钟记录下游的一氧化碳浓度、温度和异氟醚浓度以计算一氧化碳的生成量和异氟醚的损失量。各组二氧化碳的吸收能力通过以下方法测算:在30g样品(n=5)中吹入5.1%的二氧化碳(流量250ml/min)直至呼出浓度为0.5%。一氧化碳在含有氢氧化钾的吸附剂组中生成最多(AB),在不含氢氧化碱的吸附剂中没有生成(F-H)。下游温度与一氧化碳形成相关,但异氟醚丢失与之无关。二氧化碳的持续吸收也与一氧化碳的形成无关。研究结果表明产生小剂量的一氧化碳的吸附剂不一定是二氧化碳的吸附剂。

                                                        (陈洁       王祥瑞 )

 

In this study we sought to determine whether an absorbent in which little carbon monoxide (CO) forms has a correspondingly small capacity to absorb carbon dioxide (CO2). Completely dried samples (600 g) of Baralyme (A), Drägersorb 800 (B), Drägersorb 800 Plus (C), Intersorb (D), Spherasorb (E), LoFloSorb (F), Superia (G), and Amsorb (H) were exposed to a flow of 0.5% (AH; n = 45) and 4% isoflurane (FH; n = 3) in pure oxygen at 5 L/min for 60 min. Downstream CO concentration, temperature, and isoflurane concentration were recorded every 60 s to calculate CO formation and isoflurane loss. The CO2 absorption capacity of each brand was determined by passing 5.1% CO2 in oxygen (flow, 250 mL/min) through untreated samples (30 g; n = 5) until the outlet CO2 concentration reached 0.5%. CO formation was largest in absorbents containing potassium hydroxide (A and B) and negligible in absorbents not containing any alkali hydroxide (FH). The outlet temperature correlated with CO formation, but the isoflurane loss did not. The duration of CO2 absorption also did not correlate with CO formation. We conclude that absorbents that allow only very little CO formation are not necessarily poor CO2 absorbents.

 

 

 

Parecoxib——肠道外环氧化酶-2抑制剂对咪达唑仑药代动力学和临床效果的影响

 

The Influence of Parecoxib, a Parenteral Cyclooxygenase-2 Specific Inhibitor, on the Pharmacokinetics and Clinical Effects of Midazolam

 

Andra Ibrahim, Aziz Karim, Jennifer Feldman, and Evan Kharasch

 

Departments of *Anesthesiology and Medicinal Chemistry, University of Washington, Seattle, Washington; and Pharmacia, Inc., Skokie, Illinois

 

   Anaeth & Analg Sep.2002 95:667-673

 

      Parecoxib,肠道外环氧化酶-2抑制剂,在临床作为 解热镇痛药物用于围术期。它本身是无活性的前体,在体内水解后成为valdecoxib,是肝细胞色素酶P450 CYP3A4的底物。这就使之与其它CYP3A4的底物存在潜在的相互作用。本研究探讨ParecoxibCYP3A4作用底物——咪达唑仑对志愿者的药代动力学和临床效果的影响。  通过随机双盲、平衡交叉、安慰剂对照的临床调查。1223-41岁的健康志愿者,静注安慰剂或40mg Parecoxib 后静注0.07mg咪达唑仑。静脉咪达唑仑血药浓度用液相色谱仪-质谱仪分析。药效动力学变化采用连续分析:包括病人清醒,认知能力(记忆力、数字符号替换实验),自我清醒评估(视觉疼痛评分)和脑电双频指数。安慰剂组和Parecoxib 治疗组的血浆浓度相似,咪达唑仑的药代动力学(最大血浆浓度、清除率、半衰期、分布容积)和药效动力学(临床终点、数字符号替换实验、记忆力、视觉疼痛评分、脑电双频指数)亦无差别。单次剂量的       Parecoxib没有改变咪达唑仑的药代动力学和药效动力学。使用咪达唑仑清除率作为体内试验指针,结果表明Parecoxib并没有影响CYP3A4活性。

(陈洁         王祥瑞 )

 

Parecoxib, a parenteral cyclooxygenase-2 inhibitor, is undergoing clinical development as an analgesic/antiinflammatory drug for perioperative use. Parecoxib, an inactive prodrug, is hydrolyzed in vivo to valdecoxib, a substrate for hepatic cytochrome P450 (CYP) 3A4. Thus, potential exists for interactions with other CYP3A4 substrates. In this investigation, we determined the influence of parecoxib on the pharmacokinetics and clinical effects of midazolam, a CYP3A4 substrate, in volunteers. This was a randomized, balanced crossover, placebo-controlled, double-blinded clinical investigation. Twelve healthy subjects aged 2341 yr were studied after providing IRB-approved informed consent. Midazolam 0.07 mg/kg IV infusion was administered 1 h after placebo (control) or parecoxib 40 mg IV. Venous midazolam concentrations were determined by using liquid chromatography-mass spectrometry/mass spectrometry assay. Pharmacokinetic variables were determined by noncompartmental analysis. Pharmacodynamic measurements included clinical end-points, cognitive function (memory; digit symbol substitution tests), subjective self-assessment of recovery (visual analog scales), and bispectral index. Midazolam plasma concentrations were similar between placebo and parecoxib-treated subjects. No differences were found in midazolam pharmacokinetics (maximal observed plasma concentration, clearance, elimination half-life, volume of distribution) or pharmacodynamics (clinical end-points, digit symbol substitution tests, memory, visual analog scales, bispectral index). Single-bolus parecoxib does not alter the pharmacokinetics or pharmacodynamics of midazolam infusion. Parecoxib did not affect CYP3A4 activity as assessed using midazolam clearance as the in vivo probe.

 

 

 

罗哌卡因硬膜外分娩镇痛时加用压宁定的药理效应研究

 

The Dose-Sparing Effect of Clonidine Added to Ropivacaine for Labor Epidural Anesthesia

 

Ruth Landau, Eduardo Schiffer, Michel Morales, Georges Savoldelli, and Christian Kern

 

*Division d’Anesthésiologie, Département d’Anesthésiologie, Pharmacologie et Soins Intensifs de Chirurgie (APSIC), and Clinique d’Obstétrique, Département de Gynécologie et Obstétrique, Hôpitaux Universitaires de Genève (HUG), Genève, Suisse

 

Anaeth & Analg Sep.2002 95:728-734.

 

   为研究罗哌卡因硬膜外分娩镇痛过程中加用压宁定的药理效应, 66例处于分娩活跃期早期的未经产妇随机分为三组:组1 0.1%罗哌卡因8ml,并加用压宁定75mg;组2  0.2%罗哌卡因8ml,并加用0.5mlNS;组3 先给予75mg肾上腺素化的布比卡因作为试验剂量,5分钟后再给予0.2%罗哌卡因8ml并加用压宁定75mg。分娩过程中持续应用0.2%罗哌卡因8ml/h,根据病情需要,如患者疼痛可追加0.2%罗哌卡因8ml。结果表明:复合压宁定组的病人镇痛维持时间延长(132±48min[1]154±42min[3],而组291±44minP0.05〉,而第一个4h内总的罗哌卡因的用量明显减少(40.5±15mg[1]47.0±16[3],而组272.5±18mgP0.01〉。组2病人的深运动神经阻滞较组13深(P0.05〉。虽然接受压宁定的产妇在分娩过程中常需给予麻黄素处理低血压,但并无证据显示应用压宁定可产生严重后果,或增加了剖宫产率。研究表明罗哌卡因加用压宁定可减少罗哌卡因的用量。

(齐波       王祥瑞  )

 

To determine the effects of clonidine with ropivacaine during epidural labor analgesia, we studied 66 nulliparous women in early active labor. Women were randomized to receive ropivacaine 0.1% 8 mL plus 75 µg of clonidine (Group 1), ropivacaine 0.2% 8 mL plus 0.5 mL of NaCl 0.9% (Group 2), or ropivacaine 0.2% 8 mL plus 75 µg of clonidine (Group 3) 5 min after a bupivacaine 7.5 mg with epinephrine 15 µg test dose. Upon request, additional analgesia with ropivacaine 0.1% 8 mL followed by ropivacaine 0.2% 8 mL/h was administered. With clonidine, duration of analgesia was increased (132 ± 48 min [Group 1] and 154 ± 42 min [Group 3] versus 91 ± 44 min [Group 2]; P < 0.05), and total ropivacaine dose over the first 4 h was significantly reduced (40.5 ± 15 mg [Group 1] and 47.0 ± 16 mg [Group 3] versus 72.5 ± 18 mg [Group 2]; P < 0.01). The incidence of more profound motor block was more frequent in Group 2 (P < 0.05). Although there was a trend for more women receiving clonidine to require ephedrine for treatment of hypotension, this did not seem to have an impact on fetal outcome or incidence of cesarean deliveries for nonreassuring fetal heart rate tracings. This study demonstrates the dose-sparing effect of clonidine when added to ropivacaine.

 

全麻前行双侧颈深丛及浅丛阻滞对甲状腺手术病人的镇痛效果

 

The Analgesic Efficacy of Bilateral Combined Superficial and Deep Cervical Plexus Block Administered Before Thyroid Surgery Under General Anesthesia

 

Sophie Aunac, Marianne Carlier, Francois Singelyn, and Marc De Kock

 

Department of Anesthesiology, University of Louvain, St. Luc Hospital, Brussels, Belgium

 

Anaeth & Analg Sep.2002 95:746-750

 

       观察甲状腺切除术的病人在施行全身麻醉前使用颈深浅丛复合神经阻滞的镇痛效果。39例择期甲状腺手术的病人,所有病人在麻醉前都进行双侧颈深浅丛复合神经阻滞(每侧14ml)。组1(n=13),使用生理盐水,组2(n=13),使用0.5%的罗哌卡因,组3(n=13),使用的是0.5%的罗哌卡因加可乐定7.5g/mL。颈深丛阻滞都在C3水平进行8ml单次注射。颈浅丛注射采用胸锁乳突肌后缘注射6ml。在术中,组2和组3的阿芬太尼追加剂量明显低于组1(分别为1.3±1.01.1±1.02.6±1.0P<0.05)。2和组3术后24小时内阿片类和非阿片类镇痛药的需求量明显减少(P<0.05)。除了组3中有一名病人在注射后发生短暂的臂丛阻滞外,各组病人均未发现有其它副反应。结果表明颈深浅丛复合神经阻滞在甲状腺切除术中和术后早期有确切良好的镇痛效果。

                                                (周洁      王祥瑞   )

In this study we evaluated the analgesic efficacy of combined deep and superficial cervical plexus block in patients undergoing thyroidectomy under general anesthesia. For this purpose, 39 patients undergoing elective thyroid surgery were randomized to receive a bilateral combined deep and superficial cervical block (14 mL per side) with saline (Group 1; n = 13), ropivacaine 0.5% (Group 2; n = 13), or ropivacaine 0.5% plus clonidine 7.5 µg/mL (Group 3; n = 13). Deep cervical plexus block was performed with a single injection (8 mL) at the C3 level. Superficial cervical plexus block consisted of a subcutaneous injection (6 mL) behind the lateral border of the sternocleidomastoid muscle. During surgery, the number of additional alfentanil boluses was significantly reduced in Groups 2 and 3 compared with Group 1 (1.3 ± 1.0 and 1.1 ± 1.0 vs 2.6 ± 1.0; P < 0.05). After surgery, the opioid and non-opioid analgesic requirements were also significantly reduced in Groups 2 and 3 (P < 0.05) during the first 24 h. Except for one patient in Group 3, who experienced transient anesthesia of the brachial plexus, no side effect was noted in any group. We conclude that combined deep and superficial cervical plexus block is an effective technique to alleviate pain during and immediately after thyroidectomy.

 


体外循环下冠脉搭桥术中应用低剂量多巴酚丁胺负荷的超声心动图监测是否具有远期预测价值?

 

Is There a Long-Term Predictive Value of Intraoperative Low-Dose Dobutamine Echocardiography in Patients Who Have Coronary Artery Bypass Graft Surgery with Cardiopulmonary Bypass?

Frank W. Dupont, MD*, Roberto M. Lang, MD FACC, Melinda L. Drum, PhD, and Solomon Aronson, MD FACC, FACCP*

Departments of *Anesthesia and Critical Care, Cardiology, and Health Studies, University of Chicago, Chicago, Illinois

Anesth & Analg Sep. 2002 95: 517-523.

冠心病患者静息状态下的慢性左室局部收缩功能障碍可能与心肌冬眠或心肌梗死有关,术中低剂量的多巴酚丁胺负荷的超声心动图监测能可靠的预测CABG术后即刻的局部心肌功能恢复情况。该研究旨在明确术中LDD超声心动图监测是否对CABG术后一年的局部心肌功能恢复也具预测价值。25CABG术中使用LDD超声心动图监测的冠心病患者术后一年使用经胸超声心动图随访评价其心肌功能。室壁运动功能分析(RWM)中考虑了左室射血分数(EF)、陈旧性心肌梗死、糖尿病等协变量,16节段模型和1-5分评分系统被用于评价350个心肌节段,使用多元LOGISTIC回归分析方法分析术中LDD超声心动图(5 µg · kg-1 · min-1)监测的反应是否能够预测术后1年局部心肌功能的变化。CABG术中CPB后在LDD输注过程中RWM评分恶化但是在术后1年的超声心动图随访功能恢复的心肌节段定义为顿抑心肌(STUNNED MYIOCAIOL INGENT),术中LDD反应阳性的心肌功能改善的机会是反应阴性的心肌节段的2.22倍(95%可信区间:1.29,3.82;P=0.0039,术中LDD超声心动图监测的心肌功能改善的阳性预测值为0.81,阴性预测值为0.43,预测值不因协变量的不同而变化。在CPB后即刻RWM评分恶化的心肌节段中有87%1年后的心超随访时心肌功能得到改善。术中LDD超声心动图监测显示的心肌收缩功能储备可以预测1年后的局部心肌功能,但是多巴芬丁胺试验不能预测哪些心肌节段不会恢复。大多数CABG术后即刻的局部心肌收缩功能障碍是心肌顿抑所致。结论 CABG术中LDD超声心动图监测对于术后1年的局部心肌功能变化的预测价值有限。对于术中应用小剂量的多巴酚丁胺后局部室壁运动障碍得到改善的心肌节段术中LDD超声心动图监测可预测术后1年的心肌功能变化,但是它不能预测哪些心肌节段在1年后的心超随访不会得到改善。

                                            (张俊峰    薛张纲 校)

In patients with coronary artery disease, chronic regional left ventricular systolic dysfunction at rest may be caused by hibernating or by infarcted myocardium. Intraoperative low-dose dobutamine (LDD) echocardiography reliably predicts the immediate recovery of regional myocardial function after coronary artery bypass graft (CABG) surgery. We sought to determine whether intraoperative LDD echocardiography would also predict recovery of regional function after 1 yr. Twenty-five patients with coronary artery disease who underwent CABG surgery with intraoperative LDD echocardiography were evaluated 1 yr later with a follow-up transthoracic echocardiogram. The covariates of left ventricular ejection fraction, old myocardial infarction, and diabetes mellitus were considered in an analysis of regional wall motion (RWM). A 16-segment model and a 1–5-point scoring system were used to evaluate 350 myocardial segments. Multiple logistic regression analysis was performed to determine whether response to intraoperative LDD echocardiography (5 µg · kg-1 · min-1) predicted changes in regional function at 1 yr. A segment was defined as stunned if the RWM score obtained during LDD infusion deteriorated after cardiopulmonary bypass but recovered in the 1-yr follow-up echocardiogram. A response to intraoperative LDD predicted changes in regional function at 1 yr. The overall odds of improvement in regional function were 2.22 times greater (95% confidence interval = 1.29, 3.82; P = 0.0039) with a positive response to intraoperative LDD. The positive predictive value of intraoperative LDD echocardiography for improvement in myocardial function was 0.81 and the negative predictive value was 0.34. The predictive values did not vary with the examined covariates. Of segments with unexpected deterioration of RWM immediately after cardiopulmonary bypass, 87% recovered at the time of the 1-yr follow-up echocardiogram. Contractile reserve demonstrated by intraoperative LDD echocardiography predicts regional function at 1 yr; however, the test cannot predict which segment will not recover. Most of unexpected regional ventricular systolic dysfunction immediately after CABG surgery can be attributed to myocardial stunning.

 

非心脏胸科手术后室性心律失常的发生率及其后果

 

The Incidence and Outcome of Ventricular Arrhythmias After Noncardiac Thoracic Surgery

David Amar, MD*, Hao Zhang, MD*, and Nancy Roistacher, MD

Departments of *Anesthesiology and Critical Care Medicine, and Medicine, Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University, New York, New York

Anesth & Analg Sep. 2002 95: 537-543.

胸科手术后常发生房性心律失常,但胸科术后早期室性心律失常的发生率及其意义尚不十分明确。该研究的目的在于明确连续的前瞻性的412例胸科手术(肺叶切除术243例,全肺切除术169例)后并发室性心律失常的发生率及其后果(应用Holter记录仪术后72-96内小时连续监测),该研究中室性心动过速(VT)的发生定义为连续的3个及以上的宽QRS波。412例中有61例(占15%)发生1次或多次VT,每次发作都没超过30秒并且没有患者因血流动力障碍需要治疗。与没有发生VT的患者相比,VT发生者术前常合并左束支传导阻滞(P=0.01),但在其它临床资料、手术资料及到达麻醉后恢复室的中心体温并无差异。发生VT患者比未发生VT者更易发生房性期前收(P< 0.001)、室性期前收缩(P< 0.001 、室早二联律(P< 0.001)及术后房颤(61例中有21例房颤占34%351例中有58 例房颤占17%P=0.001)。多元LOGISTIC回归分析提示只有术后房颤的发生与VT的发生独立相关(相对风险指数为2.695%可信区间为1.4-4.8,P=0.002)。因此我们认为非心脏胸科手术后VT的发生较为常见,但并无不良后果,与VT强烈相关的房性和室性心律失常的发生提示去迷走神经作用和或肾上腺能高反应性对促使术后早期发生这些心律失常事件可能具有重要作用。结论 通过412例病例研究,我们明确了胸科大手术后非持续性VT的发生率为15%并且无不良后果。

                                        (张俊峰    薛张纲 校)

Atrial arrhythmias are common after thoracic surgery, but the incidence and significance of ventricular arrhythmias early after such surgery are not well established. Our goal was to determine the incidence and outcome of this complication from a continuing prospective database in 412 patients who had lobectomy (n = 243) or pneumonectomy (n = 169) and were continuously monitored with Holter recorders for 72–96 h postoperatively. The primary end point of the study was the occurrence of ventricular tachycardia (VT) defined as three or more consecutive wide complexes. Sixty-one of 412 patients (15%) developed 1 or more episode of VT. There were no episodes of sustained (>30 s) VT and no patient required treatment for hemodynamic compromise associated with any VT episode. Patients with VT had a more frequent incidence of a preoperative left bundle branch block (P = 0.01) but did not differ in other clinical characteristics, operative data, or core temperature on arrival to the postanesthesia care unit, when compared with those without VT. Patients who developed VT had significantly more atrial premature contractions (P < 0.001), ventricular premature contractions (P < 0.001), ventricular couplets (P < 0.001), and postoperative atrial fibrillation, 21 of 61 (34%) versus 58 of 351 (17%), P = 0.001, than those without VT, respectively. Multivariate logistic regression analysis revealed that only postoperative atrial fibrillation occurrence was independently associated with VT (relative risk 2.6, 95% confidence intervals 1.4 to 4.8, P = 0.002). We conclude that nonsustained VT after noncardiac thoracic surgery occurs frequently but is not associated with poor outcome. The strong association of atrial and ventricular arrhythmogenesis with VT suggests that vagal withdrawal and/or adrenergic hyperactivity may have a role in precipitating these events in the early postoperative period.

 

中重度肾功能损害患者静脉输注新型羟乙基淀粉130/0.46%500ML)的药代动力学和耐受性研究

The Pharmacokinetics and Tolerability of an Intravenous Infusion of the New Hydroxyethyl Starch 130/0.4 (6%, 500 mL) in Mild-to-Severe Renal Impairment

Cornelius Jungheinrich, MD*, Roland Scharpf, PhD*, Manfred Wargenau, PhD, Frank Bepperling, PhD*, and Jean-François Baron, MD PhD

*Clinical Research, Fresenius Kabi, Bad Homburg; M.A.R.C.O. Biostatistics Institute, Düsseldorf, Germany; and Medical Department, Fresenius Kabi France, formerly Anesthesia Department, Hôpital Pitié-Salpêtrière, Paris, France

Anesth & Analg Sep. 2002 95: 544-551.

羟乙基淀粉(HES)在淀粉酶水解后几乎完全经肾小球排泌。HES 130/0.4 (Voluven®; Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany)是一种新开发的HES,在保留HES容量效应的同时提高了其药代动力学特性。我们研究其药代动力学对肾功能的依赖性。19例稳定的非少尿性肾功能不全自愿者(肌肝清除率CLcr从基本正常到严重的肾功能损害,其平均CLcr50.6 mL · min-1 · 1.73 m-2)接受了研究,每人在大于30分钟内静注500 mL 6% HES 130/0.4,静注72小时测定血浆HES浓度,7296小时测定尿液中分泌量,在静注前后至少分别测定2CLcr,然后进行标准的药代动力学计算和回归分析。与CLcr50者相比, CLcr <50者的时间浓度曲线下的面积(AUC0–inf)明显依赖于肾功能。峰值浓度(Cmax, 4.34 mg/mL)和终末半衰期(16.1小时)则不受肾功能损害的影响。CLcr 30者中有59%的药物在尿中可测到,而CLcr15–<30者只有51%30分钟时血浆HES的平均分子量为62704d显示肾功能损害者的值较低(P=0.04)。静注前的血淀粉酶浓度与基础CLcr 负相关。在所有的受试者中24小时时的滞留HES血浆浓度很小(0.6 mg/mL)。我们认为只要保持一定尿量HES 130/0.4 (500 mL 6%)可安全地应用于肾功能严重损害的患者而且不会在血浆内蓄积。结论 我们研究了HES 130/0.4的药代动力学是否与肾功能存在依赖关系,结果显示时间浓度曲线下面积在重度肾功能不全患者中轻度增加,而静注24小时后血浆HES 130/0.4浓度很低,终末半衰期和峰值浓度则不受肾功能损害的影响。

(张俊峰    薛张纲 校)

Hydroxyethyl starches (HES) are almost exclusively excreted glomerularly, in part after hydrolysis by amylase. HES 130/0.4 (Voluven®; Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany) was developed to improve pharmacokinetics whereas preserving the efficacy of volume effect. We studied the dependency of pharmacokinetics of HES 130/0.4 on renal function. Nineteen volunteers with stable, non-anuric renal dysfunction, ranging from almost normal creatinine clearance (CLcr) to severe renal impairment (mean CLcr: 50.6 mL · min-1 · 1.73 m-2), were given a single infusion of 500 mL 6% HES 130/0.4 over 30 min. HES plasma concentrations were determined until 72 h, urinary excretion until 72–96 h. CLcr had been obtained at least twice before and twice after dosing. Standard pharmacokinetic calculations and regression analysis were performed. Area under the time concentration curve (AUC0–inf) clearly depended on renal function comparing subjects with CLcr <50 with those with CLcr 50 (ratio 1.73). Peak concentration (Cmax, 4.34 mg/mL) as well as terminal half-life (16.1 h, model independent) were not affected by renal impairment. At CLcr 30, 59% of the drug could be retrieved in urine, versus 51% at CLcr 15–<30. The mean molecular weight of HES in plasma was 62,704 d at 30 min, showing lower values with increased renal impairment (P = 0.04). Pre-dose amylase concentrations inversely correlated with baseline CLcr. Residual HES plasma concentrations after 24 h were small in all subjects. We conclude that HES 130/0.4 (500 mL 6%) can be safely administered to patients even with severe renal impairment, as long as urine flow is preserved, without plasma accumulation.

 

异氟醚对中性粒细胞选择蛋白和β2 -整合蛋白在体外激活的影响

The Effect of Isoflurane on Neutrophil Selectin and ß2-Integrin Activation In Vitro

Lothar W. de Rossi, MD*, Nicola A. Horn, MD*, Wolfgang Buhre, MD*, Florian Gass, Gabriele Hutschenreuter, MD, and Rolf Rossaint, MD*

*Department of Anesthesiology and Institute of Transfusion Medicine, University Hospital, Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany

Anesth & Analg Sep. 2002 95: 583-587.

异氟醚减弱缺血再灌注损伤。CD11b低表达可能减弱缺血后中性粒细胞粘附到内皮细胞的能力。但是,中性粒细胞粘附到血管内皮是包括一些选择蛋白和 β2 -整合蛋白在内的多步反应。所以,我们的目的是评估异氟醚是否影响P-选择性糖蛋白的配基-1PSGL1)、L-选择蛋白和 β2 -整合蛋白CD11aCD11b的激活。所有人血标本均在0.5MAC的异氟醚中孵化60分。孵化后,中性粒细胞用N-甲酰-甲硫醇-亮氨酸-苯丙氨酸(FMLP)或佛波醇-12-肉豆蔻酸-13-乙醇(PMA)活化。粘附细胞激活通过流式细胞分析仪测定。在无活化样本中,1MAC异氟醚减少了CD11a的表达。用FMLPPMA活化后,在异氟醚环境下,L-选择蛋白的脱落是低的。另外,同未被暴露的样本相比,1MAC的异氟醚减少了FMLP诱导CD11aCD11b激活。这些结果证明,异氟醚影响参与中性粒细胞募集反应的3个粘附分子的激活。首先,异氟醚抑制L-选择蛋白在血管内皮上对中性粒细胞圈合和滚动的调节;其次,异氟醚抑制β2 -整合蛋白的CD11aCD11b的激活,从而抑制了CD11aCD11b对中性粒细胞的加固粘附和跨膜移动的调节。

结论 中性粒细胞粘附内皮细胞损伤受多种粘附分子调节。这个试验表明,异氟醚对中性粒细胞募集的抑制可能是通过减少L-选择蛋白、β2 -整合蛋白的CD11aCD11b的激活作用而调节的。

                                            (李绍清    薛张纲 校)

Isoflurane is reported to reduce ischemia-reperfusion injury. Lower expression of CD11b may be responsible for attenuated postischemic neutrophil adhesion to vascular endothelium. However, neutrophil adhesion to vascular endothelium is a multistep process involving several selectins and ß2-integrins. Therefore, we assessed whether isoflurane affects the activation of the selectins P-selectin glycoprotein ligand-1 (PSGL-1) and L-selectin and the ß2-integrins CD11a and CD11b. Whole blood was incubated for 60 min with 0.5 or 1 minimum alveolar anesthetic concentration (MAC) isoflurane. After incubation, neutrophils were activated with N-formyl-methionyl-leucyl-phenylalanine (FMLP) or phorbol-12-myristate-13-acetate (PMA). Activation of adhesion molecules was evaluated via flow cytometry, and 1 MAC isoflurane reduced the expression of CD11a in the unstimulated samples. After stimulation with FMLP and PMA, shedding of L-selectin was lower in the presence of isoflurane. Furthermore, 1 MAC isoflurane reduced FMLP-induced activation of CD11a and CD11b compared with unexposed blood samples. These results demonstrate that isoflurane affects the activation of three adhesion molecules involved in the multistep process of neutrophil recruitment. First, isoflurane inhibits the activation of L-selectin, which mediates the neutrophil tethering and rolling on the vascular endothelium. Second, isoflurane attenuates the activation of both ß2-integrins—CD11a and CD11b—which mediate firm adhesion and transendothelial migration.

 

靶控和手控输注异丙酚中的双频指数

Bispectral Index in Patients with Target-Controlled or Manually-Controlled Infusion of Propofol

Andreas Lehmann, MD*, Joachim Boldt, MD*, Elfi Thaler, MD*, Swen Piper, MD*, and Udo Weisse, MD

Departments of *Anesthesiology and Intensive Care Medicine and Cardiac Surgery, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany

Anesth & Analg Sep. 2002 95: 639-644.

在这个预期、随即试验中,我们比较了双频指数(BIS),血流动力学,拔管时间,靶控输注(TCI)和手控输注(MAC)异丙酚的费用。40例进行心电除颤器植入的病人被研究。麻醉用雷米芬太尼(0.20.3µg · kg-1 · min-1)和异丙酚(TCI,血浆靶控浓度:2.5–3.5 µg/mL; n = 20)MCI (3.0–4.0 mg · kg-1 · h-1; n = 20). BIS, 心率,动脉血压在6个时间点测量:T1,麻醉前;T2,插管后;T3,切皮后;T4,首次去纤颤后;T5,第三次去纤颤后;T6,拔管后。两组血流动力学无明显差异。TCI组较MCI组在T3T4BIS明显低。TCI病人异丙酚平均用量大于MCI病人 (5.8 ± 1.4 mg · kg-1 · h-13.7 ± 0.6 mg · kg-1 · h-1),雷米芬太尼剂量无差别。

两组拔管时间不同(TCI, 13.7 ± 5.3 min; MCI, 12.3± 3.5 min)。MCI组一个病人在第一次去纤颤术中有知晓(除颤前BIS49;除颤后,83)。MCI组费用明显少于TCI(US$34.83US$39.73)。对下次疼痛刺激,BIS不能预测麻醉是否足够。

 

   结论 在这个预期、随即试验中,我们比较了双频指数(BIS),血流动力学,拔管时间,靶控输注(TCI)和手控输注(MAC)异丙酚的费用。对下次疼痛刺激,BIS不能预测麻醉是否足够。

(李绍清    薛张纲 校)   

 

In this prospective, randomized study we compared bispectral index (BIS), hemodynamics, time to extubation, and the costs of target-controlled infusion (TCI) and manually-controlled infusion (MCI) of propofol. Forty patients undergoing first-time implantation of a cardioverter-defibrillator were included. Anesthesia was performed with remifentanil (0.2–0.3 µg · kg-1 · min-1) and propofol. Propofol was used as TCI (plasma target concentration, 2.5–3.5 µg/mL; n = 20) or MCI (3.0–4.0 mg · kg-1 · h-1; n = 20). BIS, heart rate, and arterial blood pressure were measured at six data points: T1, before anesthesia; T2, after intubation; T3, after skin incision; T4, after first defibrillation; T5, after third defibrillation; and T6, after extubation. There were no significant hemodynamic differences between the two groups. BIS was significantly lower at T3 and T4 in the TCI group than in the MCI group. The mean dose of propofol was larger in TCI patients (5.8 ± 1.4 mg · kg-1 · h-1) than in the MCI patients (3.7 ± 0.6 mg · kg-1 · h-1) (P < 0.05), whereas doses of remifentanil did not differ. Time to extubation did not differ between the two groups (TCI, 13.7 ± 5.3 min; MCI, 12.3 ± 3.5 min). One patient in the MCI group had signs of intraoperative awareness without explicit memory after first defibrillation (BIS before shock, 49; after shock, 83). Costs were significantly less in the MCI group (US$34.83) than in the TCI group (US$39.73). BIS failed to predict the adequacy of anesthesia for the next painful stimulus.


 

全麻时减少手术室麻醉气体污染的麻醉气排出橱的使用

 

 

The Use of a Uniquely Designed Anesthetic Scavenging Hood to Reduce Operating Room Anesthetic Gas Contamination During General Anesthesia

Moeen K. Panni, MD PhD*, and Stephen B. Corn, MD*

*Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, and Department of Anesthesiology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts

Anesth & Analg Sep. 2002 95: 656-660.

   许多研究证明,长期暴露于一定浓度水平的麻醉气体中对手术室(OR)工作人员是有害的。在婴儿分娩全麻中,常用无套口的气管导管(ETT),可导至相当够的麻醉气体或NO污染手术室。这个报告中,我们展示了一个通过麻醉气体排出橱(ASH)减少OR中麻醉气体的方法。ASH用于6个用无套口的ETT麻醉的儿科患者,测量周围不同水平面不同点的麻醉气体浓度水平。应用ASH真空源,周围麻醉气体明显低,没有发现通气变量改变,患者体温也无变化。停用ASH真空源,周围麻醉气体明显高。我们的结论是,ASH在用无套口的ETT麻醉中明显减少麻醉气体污染,也可保存患者体温,而且费用低。

 

    结论 长期暴露于一定浓度水平的麻醉气体中对手术室(OR)工作人员是有害的,特别是在常用无套口的气管导管(ETT)婴儿分娩全麻中。麻醉气体排出橱(ASH)在减少麻醉气体和保存患者体温都是有效的而且费用低。

                                    (李绍清    薛张纲 校)

 

Numerous studies have suggested that chronic exposure to trace levels of anesthetic gas is harmful to operating room (OR) personnel. In the delivery of pediatric general anesthesia, an uncuffed endotracheal tube (ETT) is normally used which can result in considerable volatile anesthetic and nitrous oxide contamination of the OR. In this report, we present a method to reduce exposure to these anesthetic gases by means of an anesthetic scavenging hood (ASH). The ASH was used on six pediatric patients undergoing general endotracheal anesthesia via an uncuffed ETT. Measurements of all ambient gas levels were made 6 in. horizontally from the patient’s ear and 6 in. from the table surface. The application of the vacuum source to the ASH resulted in a very significant (P < 0.01, paired t-test) decrease in levels of ambient anesthetic gas, with no measurable change in ventilatory variables or changes in body temperature (P > 0.05, paired t-test). Discontinuation of the vacuum force to the ASH resulted in a marked increase in ambient levels of anesthetic gas. We conclude that the ASH is extremely effective in reducing waste anesthetic gas associated with anesthesia administered via an uncuffed ETT. The ASH may be a valuable and cost-effective addition in the OR for both reducing ambient anesthetic waste gas levels and conserving patient heat.

 

 

联合应用平均频率和振幅对猪心跳骤停模型除颤结局的预测能力

                                          

 

The Prediction of Defibrillation Outcome Using a New Combination of Mean Frequency and Amplitude in Porcine Models of Cardiac Arrest

Anton Amann, PhD, Klaus Rheinberger, MSc, Ulrich Achleitner, MSc, Anette C. Krismer, MD, Werner Lingnau, MD, Karl H. Lindner, MD, and Volker Wenzel, MD

Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University Innsbruck, Innsbruck, Austria

Anesth & Analg Sep. 2002 95: 716-722.

我们评价了室颤(VF)的平均频率(FREQ)、平均峰谷振幅(AMPL)及其联合,对除颤结局的预测能力。我们检测了四个不同的心跳骤停组64头猪的室颤心电图信号,四个组有不同的无处理室颤间期,不同的心肺复苏间期,应用不同药物(肾上腺素,血管加压素,N-硝基-L-精氨酸甲基酯,或生理盐水对照)。频率范围限定于4.33-30 Hz。在第一次除颤前的20秒至10秒的间期(10秒间期)记录FREQAMPL。我们通过应用多元logistic回归,引入生存指数(SI0.68 Hz-1 · FREQ + 12.69 mV-1 · AMPL)。应用Kruskal-Wallis非参数单因素分析来分析不同猪模型间的显著差异。运用单因素logistic回归分析和受试者工作特性曲线来比较变量FREQAMPLSI和除颤结局的关系。与单一的FREQAMPL相比,SI增加了预测力,达到了89%的敏感度和86%的特异度。FREQAMPLSI预测除颤结局的概率分别为0.850.890.90FREQAMPLSI值就四组不同的心跳骤停模型而言并不敏感,但对应用血管加压素和肾上腺素的动物有明显的不同。

结论 我们作了回顾性的数据分析,来评估猪的不同室颤心电图变量对除颤结局的预测力。研究提示变量的联合改善了预测力,因而可有助于减少有害的、不成功的除颤尝试。

                                              (张鸿    薛张纲 校)

 

 

We estimated the predictive power with respect to defibrillation outcome of ventricular fibrillation (VF) mean frequency (FREQ), mean peak-to-trough amplitude (AMPL), and their combination. We examined VF electrocardiogram signals of 64 pigs from 4 different cardiac arrest models with different durations of untreated VF, different durations of cardiopulmonary resuscitation, and use of different drugs (epinephrine, vasopressin, N-nitro-L-arginine methyl ester, or saline placebo). The frequency domain was restricted to the range from 4.33 to 30 Hz. In the 10-s epoch between 20 and 10 s before the first defibrillation shock, FREQ and AMPL were estimated. We introduced the survival index (SI; 0.68 Hz-1 · FREQ + 12.69 mV-1 · AMPL) by use of multiple logistic regression. Kruskal-Wallis nonparametric one-way analysis was used to analyze the different porcine models for significant difference. The variables FREQ, AMPL, and SI were compared with defibrillation outcome by means of univariate logistic regression and receiver operating characteristic curves. SI increased predictive power compared with AMPL or FREQ alone, resulting in 89% sensitivity and 86% specificity. The probabilities of predicting defibrillation outcome for FREQ, AMPL, and SI were 0.85, 0.89 and 0.90, respectively. FREQ, AMPL, and SI values were not sensitive in regard to the four different cardiac arrest models but were significantly different for vasopressin and epinephrine animals.

 

可乐定对分娩时硬膜外罗吡卡因最低局部镇痛浓度的影响

 

The Effect of Clonidine on the Minimum Local Analgesic Concentration of Epidural Ropivacaine During Labor

Chritophe Aveline, MD, Sonia El Metaoua, MD, Anis Masmoudi, MD, Pierre-Yves Boelle, PhD, and Francis Bonnet, MD

Département d’Anesthésie-Réanimation Chirurgicale, Hôpital TENON, Assistance Publique Hôpitaux de Paris, Paris, France

Anesth & Analg Sep. 2002 95: 735-740.

以最低局部镇痛浓度(MLAC)为判定标准,罗吡卡因在分娩第一产程期间的作用强度不如布比卡因。本研究评估了可乐定对罗吡卡因MLAC的影响。77名要求分娩(宫颈扩张,3-7cm)硬膜外镇痛的不同产次孕妇进入本研究。分别给予硬膜外单次注射罗吡卡因(n=30),罗吡卡因和可乐定30 µgn28),或在研究第二部分给予罗吡卡因和可乐定60 µgn19)。根据上下顺序分配法,罗吡卡因给药浓度由该组上一位孕妇的反应而定。硬膜外单次注射后30分钟内,模拟疼痛评分10 mm被认为有效反应。有效反应使下一位患者的浓度下降0.01% wt/vol。无效反应使浓度增加0.01% wt/vol。罗吡卡因的MLAC0.097% wt/vol (95% 可信区间, 0.085%–0.108%)MLAC30-µg硬膜外可乐定时,不受影响(0.081% [0.045%–0.117%]);但60-µg时,显著降低(0.035% [0.024%–0.046%]) (P < 0.001)。本研究显示60-µg可乐定能显著降低罗吡卡因的MLAC

结论 在分娩期,硬膜外加用可乐定可增强硬膜外罗吡卡因的效能。该研究显示,在第一产程期间,硬膜外可乐定可显著降低罗吡卡因的最低局部镇痛浓度,但可引起镇静。

                                           (张鸿    薛张纲 校)

 

On the basis of the determination of minimum local analgesic concentration (MLAC), ropivacaine has been demonstrated to be less potent than bupivacaine during the first stage of labor. In this study we assessed the effect of clonidine on the MLAC of ropivacaine. Seventy-seven parturients of mixed parity requesting epidural analgesia for labor (cervical dilation, 3–7 cm) were included in the study. They received an epidural bolus of either ropivacaine (n = 30), ropivacaine plus clonidine 30 µg (n = 28), or ropivacaine plus clonidine 60 µg (n = 19) in the second part of the study. The concentration of the ropivacaine solution was determined by the response of the previous parturient in that group by using an up-down sequential allocation. A visual analog pain score of 10 mm within 30 min after the epidural bolus (20 mL) was considered an effective response. An effective result directed a 0.01% wt/vol decrement for the next patient. An ineffective result directed a 0.01% wt/vol increment. The MLAC of ropivacaine was 0.097% wt/vol (95% confidence interval, 0.085%–0.108%). It was unaffected by a 30-µg dose of epidural clonidine (0.081% [0.045%–0.117%]) but was significantly decreased by a 60-µg clonidine dose (0.035% [0.024%–0.046%]) (P < 0.001). This study documents a decrease in the MLAC of ropivacaine by clonidine, significant for a 60-µg dose.

 

老年髋关节骨折手术时预防性肌注小剂量新福林减弱蛛网膜下腔麻醉诱发低血压的作用

 

Prophylactic IM Small-Dose Phenylephrine Blunts Spinal Anesthesia-Induced Hypotensive Response During Surgical Repair of Hip Fracture in the Elderly

Kohki Nishikawa, MD, Michiaki Yamakage, MD PhD, Keiichi Omote, MD PhD, and Akiyoshi Namiki, MD PhD

Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Japan

Anesth & Analg Sep. 2002 95: 751-756.

 

在一项90位正常血压和高血压、年龄>65岁行髋关节骨折手术患者的双盲、安慰剂对照、随机研究中,我们评估了预防性肌注1.53mg新福林对重比重丁卡因蛛网膜下腔麻醉诱发低血压的影响。30位正常血压患者分别肌注新福林1.5mg3mg(N/P-1.5 N/P-3.0组;每组n = 15),对照组给予生理盐水(N/C组;n = 15)45位高血压患者行相似的处理(H/P-1.5, H/P-3.0,H/C组;每组n = 15)。各组的高位感觉阻滞平面为T9,范围T8T10。在正常血压和高血压组,给予新福林1.5mg3mg的患者低血压(平均动脉压[MAP]由基础值下降>25%)的发生均较对照组有显著降低。与N/C组或H/C组相比,N/P-3.0N/P-1.5组以及H/P-3.0MAP下降的百分比显著降低(P < 0.05),所需静注麻黄碱的量显著减少(P < 0.05)。尽管与H/C组比, H/P-1.5组未能显著减少MAP下降的百分比,但其所需静注麻黄碱的量也显著降低(P < 0.05)。各组均未观察到作为肌注新福林不良反应的心动过缓发生。在N/P-3.0H/P-3.0组,给药后发生高血压(MAP由基础值上升20%),而N/P-1.5H/P-1.5组未发生。我们认为预防性肌注1.5mg新福林是安全的(就抑制心动过缓和高血压的发生而言),并且是减少正常血压和高血压的老年患者蛛网膜下腔麻醉时发生低血压的有效方法。

结论 我们认为对正常血压和高血压的老年患者,针对蛛网膜下腔麻醉所致的低血压,小剂量新福林预防性使用是有效和安全的。1.5mg新福林肌注对于减少低血压的发生和避免不良反应是有效的。

                                                     (张鸿    薛张纲 校)

 

In a double-blinded, placebo-controlled, randomized study, we evaluated the effect of prophylactic IM phenylephrine at doses of 1.5 and 3 mg on hyperbaric tetracaine spinal anesthesia-induced hypotension in 90 normotensive and hypertensive patients aged >65 yr undergoing surgery for hip fracture. Thirty normotensive patients received 1.5 or 3 mg of phenylephrine IM (N/P-1.5 and N/P-3.0 groups; n = 15 in each), whereas controls received saline (N/C group; n = 15), and 45 hypertensive patients were treated in a similar manner (H/P-1.5, H/P-3.0, and H/C groups; n = 15 in each). All groups had a peak sensory block height of T9, with a range of T8 to T10. The incidence of hypotension (>25% decrease in mean arterial blood pressure [MAP] from baseline) was significantly lower in the patients who received phenylephrine 1.5 or 3 mg than in the controls, both in the normotensive and hypertensive groups (P < 0.01). The N/P-3.0 and N/P-1.5 groups and the H/P-3.0 group had significantly lower percentage reductions in MAP (P < 0.05) and required significantly smaller doses of rescue IV ephedrine (P < 0.05) than did the N/C group or the H/C group. The H/P-1.5 group also required significantly less rescue IV ephedrine (P < 0.05), although it was not sufficient to significantly attenuate the percentage decrease in MAP compared with that in the H/C group. Bradycardia (heart rate <50 bpm) as an adverse effect after IM administration of phenylephrine was not observed in any of the groups. Hypertension (MAP >20% increase from baseline) after medication occurred in the N/P-3.0 and H/P-3.0 groups, but not in the N/P-1.5 and H/P-1.5 groups. We conclude that prophylactic IM injection of 1.5 mg of phenylephrine is a safe (defined as the inhibition of bradycardia and hypertension) and effective means of reducing the incidence of hypotension associated with spinal anesthesia in normotensive and hypertensive elderly patients.