Anesthesia & Analgesia

September 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

多巴胺應激性心臟超聲檢查對非心臟擇期手術室病人術前評估的低效性

(忻紀華     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.

 

體外迴圈下冠脈搭橋術中應用低劑量多巴酚丁胺負荷的超聲心動圖監測是否具有遠期預測價值?

(張俊峰    薛張綱 )

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.

 

氯胺酮減弱體外迴圈後中性粒細胞作用

(陳湧明        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.

 

非心臟胸科手術後室性心律失常的發生率及其後果

(張俊峰    薛張綱 )

The Incidence and Outcome of Ventricular Arrhythmias After Noncardiac Thoracic Surgery

David Amar, Hao Zhang, and Nancy Roistacher

Anesth Analg 2002 95: 537-543.

 

中重度腎功能損害患者靜脈輸注新型羥乙基澱粉130/0.46%500ML)的藥代動力學和耐受性研究

(張俊峰    薛張綱 )

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:

非鹵化鏈烷和鹵化鏈烷抑制α4β2神經型乙酰膽鹼受體

(楊保仲    莊心良 )

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.

 

甘氨酸受體亞單位變異鼠對揮發性麻醉藥均敏感和有抵抗性

(陳湧明        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.

 

異氟醚對中性粒細胞選擇蛋白和β2 -整合蛋白在體外啟動的影響

(李紹清    薛張綱 )

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.

 

重視重症肌無力患者未結合的乙酰膽鹼受體數量可改良羅庫溴銨在其體內的藥物代謝動力學和藥物效應動力學的模式

(趙雪蓮     莊心良  )

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.

 

甲狀腺切除術中異丙酚及舒芬太尼麻醉--確保術中迴圈及腦電圖穩定,術後恢復快的最佳濃度

(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:

小兒七氟醚麻醉而不用肌松藥的情況下氣管插管成功率的影響因素

(王士雷    莊心良  )

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---影響日間手術出院及術後恢復的因素

(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:

靶控和手控輸注異丙酚中的雙頻指數

(李紹清    薛張綱 )   

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. 

 

用聲音反射計預測困難氣管插管的臨床研究

(楊保仲    莊心良 )

Clinical Application of Acoustic Reflectometry in Predicting the Difficult Airway

E. Andrew Ochroch and David M. Eckmann

Anesth Analg 2002 95: 645-649.  

 

吸附劑中小劑量一氧化碳形成與少量二氧化碳吸收無關

(陳潔       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.

 

全麻時減少手術室麻醉氣體污染的麻醉氣排出櫥的使用

(李紹清    薛張綱 )

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:

鞘內注射鎂鹽延長芬太尼鎮痛時間:一個前瞻性、隨機化、對照研究

(葛聖金   莊心良 )

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——腸道外環氧化酶-2抑制劑對咪達唑侖藥代動力學和臨床效果的影響

(陳潔         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:

聯合應用平均頻率和振幅對豬心跳驟停模型除顫結局的預測能力

(張鴻    薛張綱 )

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:

羅呱卡因硬膜外分娩鎮痛時加用壓寧定的藥理效應研究

(齊波       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.

 

可樂定對分娩時硬膜外羅吡卡因最低局部鎮痛濃度的影響

(張鴻    薛張綱 )

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.

 

檢驗萘普生用於剖腹產術後第二天鎮痛效果的一項試驗

(焦志華譯  莊心良校)

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:

全麻前行雙側頸深叢及淺叢阻滯對甲狀腺手術病人的鎮痛效果

(周潔      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.

 

老年人髖關節骨折手術中預防性肌注小劑量苯腎上腺素緩解脊髓麻醉導致的低血壓反應

(唐俊    莊心良 )

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:

通過氣管-肺模型,用不同方法比較高頻噴射通氣(HFJV)

(張軍     莊心良 )

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況下行壓力控制通氣時Proseal™喉罩氣道和喉管氣道的比較

( 顏濤譯    莊心良校)

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.

 

重視重症肌無力患者未結合的乙酰膽鹼受體數量可改良羅庫溴銨在其體內的藥物代謝動力學和藥物效應動力學的模式

 

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:重症肌無力患者對非去極化肌松藥敏感性強于健康患者。方法:我們研究8名重症肌無力患者和8名對照組患者的羅庫溴銨的藥物代謝動力學和藥物效應動力學模式。以異丙酚,蘇芬太尼及笑氣和氧氣的混合氣麻醉患者。施行拇內收肌的肌收縮的機械效應圖。重症肌無力患者的羅庫溴銨輸注速度為25ug.Kg-1.min-1,對照組患者為116.7 ug.Kg-1.min-1。至70%神經肌肉阻滯時停止輸注。在神經阻滯開始、結束以及羅庫溴銨停藥後4小時,分別採集動脈血樣。用高效液相測定羅庫溴銨的濃度。羅庫溴銨的藥物代謝動力學和藥物效應動力學模式研究採用雪納模式(Sheiner model)和未結合受體模式(URM),因為這兩種模式均考慮到未結合的乙酰膽鹼受體數量。結果:羅庫溴銨50%效應濃度和濃度-效應曲線的斜率,在重症肌無力患者組明顯降低。結論:雪納模式(Sheiner model)和未結合受體模式(URM)均適合重症肌無力患者。重症肌無力患者的乙酰膽鹼受體濃度明顯減少。未結合受體模式(URM)可以解釋觀察到的兩組間的時間效應和藥物效應強度的不同,但是雪納模式(Sheiner model 模式解釋不了。

                                (趙雪蓮     莊心良  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.

 

                         

非鹵化鏈烷和鹵化鏈烷抑制α4β2神經型乙酰膽鹼受體

非鹵化的有麻醉作用的鏈烷如環丙烷和丁烷,對中樞抑制性遞質γ-氨基丁酸(GABA)及其相應受體無強化作用,說明其通過其他機制發揮麻醉作用。鹵化的非制動性鏈烷如12-雙氯六氟環丁烷和23-雙氯八氟丁烷同樣不能強化γ-氨基丁酸能電流,其對行為能力有特殊的影響,這一點不同於其結構相似的非鹵化鏈烷,後者因有制動效應而用作麻醉藥。在一定濃度時12-雙氯六氟環丁烷和23-雙氯八氟丁烷只產生遺忘效應而不產生制動效應。神經型乙酰膽鹼受體對許多麻醉藥敏感,而且在學習和記憶過程中發揮重要作用。我們假定神經型乙酰膽鹼受體介導非鹵化鏈烷和鹵化鏈烷遺忘作用。為驗證神經型乙酰膽鹼受體介導的麻醉藥和非制動藥的行為效應,我們定量研究了非鹵化的麻醉性鏈烷和鹵化的非制動性的鏈烷對α4β2神經型乙酰膽鹼受體的抑制效應。結果顯示二者在達到能夠抑制學習的濃度時顯著抑制α4β2神經型乙酰膽鹼受體,其效能與其疏水性相關。證明α4β2神經型乙酰膽鹼受體介導鏈烷的遺忘效應而非制動效應。       (楊保仲    莊心良 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.

用聲音反射計預測困難氣管插管的臨床研究

本研究通過用聲音反射計測量病人氣道長度和氣道截面積,計算出氣道容積,進而預測給病人作氣管內插管的難易程度。第一部分是回顧性研究,總結臨床氣管插管病例,結果發現在氣管內插管容易的病人和氣管內插管困難的病人之間似乎是以氣道容積為40.2毫升為界限。第二部分是前瞻性研究,根據第一部分研究結果得出假設,即當氣道容積小於40.2毫升時氣管內插管困難,將此結論用於預測臨床氣管內插管的難易程度。但是,結果表明,氣道容積小和氣管內插管失敗、聲門顯露困難及喉檢困難之間沒有明顯相關性。  

(楊保仲    莊心良 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.

 

老年人髖關節骨折手術中預防性肌注小劑量苯腎上腺素緩解脊髓麻醉導致的低血壓反應

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:評估1.5mg3mg苯腎上腺素肌注對高滲丁卡因脊髓麻醉所誘發的低血壓反應的預防效果。方法: 65歲以上行髖關節骨折手術的病人共90例,其中正常血壓和高血壓病人各45例,均隨機等分為三組分別給予生理鹽水對照、苯腎上腺素1.5mg3mg肌注(分別為N/CN/P-1.5N/P-3.0組和H/CH/P-1.5H/P-3.0組)。結果:所有組最高感覺阻滯平面均為T9左右(範圍在T8T10之間)。以平均動脈壓(MAP)下降大於基礎值的25%為標準,無論正常血壓組或高血壓組,接受1.5mg3mg苯腎上腺素的病人低血壓的發生率均低於對照組(P<0.01)。N/P-3.0N/P-1.5H/P-3.0組與N/CH/C組相比,MAP下降的幅度較小(P<0.05),需要腎上腺素靜脈注射的劑量也明顯減小(P<0.05)。肌注苯腎上腺素的各組均未出現心動過緩(心律<50次每分)。在N/P-3.0H/P-3.0組,可見MAP大於基礎值20%的高血壓,而N/P-1.5H/P-1.5組未見。結論:在正常血壓或高血壓的老年病人,預防性肌注苯腎上腺素1.5mg可以減少脊髓麻醉相關性低血壓,並可以避免心動過緩和高血壓的發生。

                                (唐俊    莊心良 校)

 

(II)在一項90位正常血壓和高血壓、年齡>65歲行髖關節骨折手術患者的雙盲、安慰劑對照、隨機研究中,我們評估了預防性肌注1.53mg新福林對重比重丁卡因蛛網膜下腔麻醉誘發低血壓的影響。30位正常血壓患者分別肌注新福林1.5mg3mg(N/P-1.5 N/P-3.0組;每組n = 15),對照組給予生理鹽水(N/C組;n = 15)45位高血壓患者行相似的處理(H/P-1.5, H/P-3.0,H/C組;每組n = 15)。各組的高位感覺阻滯平面為T9,範圍T8T10。在正常血壓和高血壓組,給予新福林1.5mg3mg的患者低血壓(平均動脈壓[MAP]由基礎值下降>25%)的發生均較對照組有顯著降低。與N/C組或H/C組相比,N/P-3.0N/P-1.5組以及H/P-3.0MAP下降的百分比顯著降低(P < 0.05),所需靜注麻黃堿的量顯著減少(P < 0.05)。儘管與H/C組比, H/P-1.5組未能顯著減少MAP下降的百分比,但其所需靜注麻黃堿的量也顯著降低(P < 0.05)。各組均未觀察到作為肌注新福林不良反應的心動過緩發生。在N/P-3.0H/P-3.0組,給藥後發生高血壓(MAP由基礎值上升20%),而N/P-1.5H/P-1.5組未發生。我們認為預防性肌注1.5mg新福林是安全的(就抑制心動過緩和高血壓的發生而言),並且是減少正常血壓和高血壓的老年患者蛛網膜下腔麻醉時發生低血壓的有效方法。

結論 我們認為對正常血壓和高血壓的老年患者,針對蛛網膜下腔麻醉所致的低血壓,小劑量新福林預防性使用是有效和安全的。1.5mg新福林肌注對於減少低血壓的發生和避免不良反應是有效的。

                                                     (張鴻    薛張綱 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.

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

通過氣管-肺模型,用不同方法比較高頻噴射通氣(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

 

利用內徑為2.5-8.5mm的連接管制成氣管-肺模型進行高頻噴射通氣(HFJV)以模擬通過不同程度狹窄的喉氣管通氣。隨著連接管直徑的縮小,呼氣末壓力(EEP)和吸氣峰壓(PIP)增加。分別經聲門上、喉和氣管進行HFJV,當連接管直徑小於5.5,4.0,3.5cm 時, EEP 10 mm Hg;當連接管直徑小於5.5,3.5,3.0cm時,PIP>20 mm Hg。經聲門上進行HFJV時的EEPPIP大於經喉和經氣管 (P < 0.01)。當連接管直徑小於3.5 4.0 cm時,EEPPIP增加,而且經喉HFJV大於經氣管HFJV (P < 0.01)。在第二個實驗中,應用笑氣4 L/min來評價通氣和氣體摻雜的程度。在聲門上進行HFJV時的笑氣濃度顯著小於經喉或經氣管 HFJV (P < 0.01),而氮氣濃度顯著大於經喉或經氣管HFJV (P < 0.01)。同經喉和經氣管HFJV相比,聲門上進行HFJVEEPPIP的增加可歸因於通氣和摻氣的增加。

                                (張軍     莊心良 )

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

檢驗萘普生用於剖腹產術後第二天鎮痛效果的一項試驗

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 檢驗非類固醇類抗炎藥和常用口服鎮痛藥物聯合應用對手術後第二天鎮痛的效果。方法 80例行擇期剖腹產手術的女性病人隨機分為術後每12小時椎管內注射嗎啡合併應用萘普生或安慰劑組。兩組病人都給以常用的治療方法如對乙酰氨基酚和可待因(必需)及輔助肌注鴉片類。通過視覺類比評分(0—100)來評估坐立時切口痛(IPS)、休息時切口痛、子宮收縮痛及呼吸痛的程度,並對術後72小時內最劇烈的間歇痛(0—10)程度及使用鎮靜劑以及發生不良反應的情況進行評價。結果 36小時時,合用萘普生減輕IPS38.2±26.0 VS 51.4±25.7; P=0.05)、休息時的切口痛、子宮收縮痛和間歇痛的評分。整個過程發現其在臨床上中等、統計學上則明顯減輕IPSP=0.0001)和鴉片的使用(P<0.01)。第一天可以降低鎮靜不全的發生率,減輕整體痛覺(P=0.0006),但不能持續到第二天(整體痛覺減輕,P=0.057鎮靜不全,24%萘普生 VS 27%對照;P=1.00)。結論 剖腹產手術後加入常用量的萘普生和口服止痛藥可以減輕36小時時的IPS及第二天的疼痛,在36小時疼痛高峰時效果最強,但不能減少鎮靜不全的發生率。

                                (焦志華譯  莊心良校)

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.

小兒七氟醚麻醉而不用肌松藥的情況下氣管插管成功率的影響因素

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:探討小兒七氟醚麻醉而不用肌松藥的情況下氣管插管成功率的影響因素。方法:153ASA-Ⅱ級病人,用8%七氟醚和60%笑氣行麻醉誘導,1min後停用笑氣。將每組最初5例病人80%成功氣管插管的時間確定為麻醉誘導後放置喉鏡的時間。分析病人80%成功氣管插管的時間和影響因素。結果:小兒80%成功氣管插管的時間在1-4y4-8y二個年齡段分別為137s95%可信區間94.6-159s)和187s95%可信區間153-230s)。通過概率分析發現年齡和誘導時間是預測氣管插管成功率的主要因素。如果放置喉鏡時病人有自主呼吸,則預示氣管插管條件較差。結論:在七氟醚麻醉不用肌松藥的情況下,小兒80%成功氣管插管的時間在1-4y4-8y二個年齡段分別為137s187s,年齡和誘導時間是預測氣管插管成功率的主要因素。

                                  (王士雷    莊心良  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

鞘內注射鎂鹽延長芬太尼鎮痛時間:一個前瞻性、隨機化、對照研究

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:鎂是一種非競爭性NMDA受體拮抗劑,但經靜脈注射不能有效通過血腦屏障。在大鼠鞘內注射鎂鹽能增強阿片類藥物的抗傷害性刺激作用,且在動物鞘內注射鎂鹽的安全性已得到證實。本研究探討在人體鞘內注射鎂鹽能否延長阿片類藥物脊髓鎮痛的持續時間。方法52例要求分娩鎮痛的病人,隨機接受以鞘內注射芬太尼25 µg加生理鹽水或芬太尼25 µg加硫酸鎂50 mg為鎮痛藥物的脊-硬聯合阻滯鎮痛技術。由於坐位時鞘內注射重比重溶液向頭側擴散受限,本研究中未使用更大劑量的鎂鹽。自注藥至病人要求額外鎮痛藥物為止,為鞘內藥物鎮痛的持續時間。結果:鎂鹽加芬太尼組的鎮痛持續時間(75 min)明顯長於單用芬太尼組(60 min)。鞘內注射鎂鹽未見有相關的不良反應的增加。資料顯示鞘內注射鎂鹽能延長人體阿片類藥物脊髓鎮痛作用時間,且提示如能鞘內使用NMDA拮抗劑將對臨床疼痛治療有重要意義。結論:鎂能在脊髓中自然產生,阻斷NMDA谷氨酸通路。在動物研究中,鞘內注射硫酸鎂能增強嗎啡脊髓鎮痛效果。對於接受分娩脊髓鎮痛的病人,聯合應用硫酸鎂和阿片類藥物芬太尼延長了鎮痛時間,但副作用未見增加。

                                    (葛聖金   莊心良 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況下行壓力控制通氣時Proseal™喉罩氣道和喉管氣道的比較

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:比較成年病人在壓力控制通氣狀態下兩種聲門外通氣裝置的使用情況。方法:120ASA I-II級的成年病人被隨機分配到PLMATM組或LTA組。由兩位元對這些氣道裝置都很有經驗的醫生按照標準方案進行麻醉。對以下方面進行比較:1)放置所需的時間和成功率;2)氣道的密閉性;3)在壓力控制通氣狀態下的通氣參數;4)不同頭/頸位置時的潮氣量;5)需要對通氣道進行干預的情況。有效的通氣道的標準是:在壓力控制模式下,設定壓力是17 cm H2O時,最小呼出潮氣量潮過7ml/kg,無口咽部反流和胃脹氣。結果:在試圖建立有效通氣道時的一次成功率兩者相似(PLMATM: 85%; LTA: 87%);但是在三次嘗試以後,PLMATM 的成功率明顯高於LTA (100% versus 92%, P = 0.02)。在最大推薦氣囊容量的50%時,PLMATM口咽部反流壓高於LTA29 ± 7 versus 21 ± 6 cm H2O, P < 0.0001),但是在最大推薦氣囊容量時兩者的口咽部反流壓力相同(33 ± 7 versus 31 ± 8 cm H2O)。PLMATM的潮氣量較大(614 ± 173 versus 456 ± 207 mL, P < 0.0001),呼氣末二氧化碳較低(33 ± 9 versus 40 ± 11 mm Hg, P = 0.0001)。PLMATM需要對通氣道進行干預的次數明顯較少。而LTA發生氣道阻塞的情況更常見。通過對不同頭/頸位時的潮氣量進行比較發現,PLMATM組維持高質量氣道的人數比 LTA 組多(PLMATM56/60 93%LTA: 42/ 5576% P = 0.01)。結論:對於在肌松情況下接受壓力控制通氣的病人,在絕大多數氣道管理的技術問題上PLMATM都優於LTA

                                    顏濤譯    莊心良校)

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.

 

 

多巴胺應激性心臟超聲檢查對非心臟擇期手術室病人術前評估的低效性

   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

 

本研究根據ACCAmerican College of Cardiologe)和AHAAmerican Heart Association)頒佈的標準,觀察85例病人了術前多巴胺應激性心臟超聲檢查(DSE)的效果。回顧每一例病人的醫療記錄以確認是否符合術前行多巴胺應激性心臟超聲檢查臨床標準,以確定DSE結果的有效干預和預測圍手術期心臟事件的發生。85例病人中,4例陽性為缺血性改變(占4.7%);74例陰性(占87.1%);7例為非特異性改變(占8.2%)。48例由於合併糖尿病,輕度心絞痛,或“輕度臨床影響因素”而行DSE的病人結果為陰性。4例陽性病例中3例曾行冠狀血管造影術,且其中1人曾行CABG術。另外29例病人亦于術前接受DSE,但因為DSE的改變未達到ACC/AHA的標準,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費共為US$104635。利用ACC/AHA標準作為術前DSE的指標似乎並不有效。但是,可通過改變目前術前DSE的標準來提高顯著性。

                                               ( 忻紀華     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.

 

氯胺酮減弱體外迴圈後中性粒細胞作用

 

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.

 

外科手術與啟動中性粒細胞以及對受影響組織的趨化作用密切相關。被啟動的中性粒細胞所產生的過氧化物的病理作用已被多次報導。在試管實驗中,氯胺酮抑制中性粒細胞含氧基產物。本研究CABG術全麻誘導期間,在阿片類藥中加入小劑量的氯胺酮,比較它們對中性粒細胞過氧化物的影響。35例選擇性CABG術患者隨機分成兩組行前瞻性雙盲實驗。患者在大劑量芬太尼麻醉中加入氯胺酮0.25mg/kg或相似容量的生理鹽水。分別在手術前、CPB後即刻、術後2448小時、和術後3~6天內抽取血標本。以12-肉豆蔻酸13-醋酸氟波醇,調理化酵母聚糖或甲酰基蛋氨亮氨苯丙氨酸刺激後的過氧化產物來評估中性粒細胞功能。在術後4~6天,沒有化學無刺激和以12-肉豆蔻酸13-醋酸氟波醇,調理化酵母聚糖或甲酰基蛋氨亮氨苯丙氨酸刺激各組在全麻中加入小劑量氯胺酮均減弱了中性粒細胞過氧化陰離子的增加。另外,氯胺酮降低了術後2~6內中性粒細胞的百分比。與基值相比,對照組的過氧化物顯著增高。相反,氯胺酮組則無顯著差異。

                                                       ( 陳湧明        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.

 

   甘氨酸受體亞單位變異鼠對揮發性麻醉藥均敏感和有抵抗性

 

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

 

我們利用兩種甘氨酸受體變異鼠來證實是否甘氨酸受體對在體麻醉反應中起重要作用。在loss-of-righting反射分析中,痙攣突變體對安氟醚輕度較敏感(P=0.02)。對照組50%有效濃度(EC50=1.17±0.06atm而痙攣突變體組(spA)0.97±0.06atm。但是,在夾尾分析中對安氟醚仍具有較強抵抗性(P=0.01)。(對照組EC50=1.96±0.10atm,spA2.58±0.25atm)spA組在loss-of-righting反射分析中對氟烷敏感(P<0.001)。(對照組EC50=0.81±0.03atm,spA0.57±0.04atm)。但是在存在氟烷時和對照組相比夾尾反應相似。痙攣調節和變異鼠對兩種藥物的反應無差異。注射三種催眠藥(咪唑安定、硫賁妥鈉、乙醇)後變異鼠睡眠時間根本性地延長。結論提示在調節麻醉反應時牽涉到一個複雜的甘氨酸通道。由於變異鼠縮小了甘氨酸容量而加大了對安氟醚、氟烷、咪唑安定、硫賁妥鈉、乙醇催眠效果的敏感性,提示甘氨酸活力和催眠藥呈反比關係。然而對安氟醚抵抗力夾尾分析提示甘氨酸活力加強肺泡最小麻醉藥濃度反應。氟烷的作用機制似乎與安氟醚不盡相同,提示不是每一種揮發性麻醉藥相同地調節甘氨酸通道。

( 陳湧明        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.

 

甲狀腺切除術中異丙酚及舒芬太尼麻醉--確保術中迴圈及腦電圖穩定,術後恢復快的最佳濃度

 

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.

 

  催眠鎮靜藥和阿片類的相互協同作用可減輕外科併發症,且不同的組合劑量可提供不同的麻醉需要。本研究通過控制藥物的輸注量確定異丙酚及舒芬太尼的最佳濃度,以保證術中迴圈穩定,鎮靜適當(通過腦電圖分析評估),術後恢復快。45名行甲狀腺切除術的患者(ASA I-II, 隨機分為三組,術中輸注舒芬太尼濃度分別為0.10.20.3ng/ml。同時調節異丙酚的濃度(STC)以控制動脈血壓在30%參考值及bispectral 指數40-60之間。所有組的麻醉效果都較滿意,但STC(目標濃度)較低組的高血壓的發生率較高,STC較高組的低血壓發生率較高。同時術中異丙酚的目標濃度(STC)若遞減(5.04.02.5 g/ml)其用量也隨之遞減(740668474 mg/h)。研究顯示0.3ng/ml STC 大大延遲了自主呼吸的恢復。

                                                            (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---影響日間手術出院及術後恢復的因素

 

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.

 

 

     疼痛會影響日間手術術後的恢復。調查175例日間手術病例以區分疼痛的嚴重程度,鎮痛藥的使用,恢復期相關疼痛及其它相關因素對疼痛的影響。多元化回歸 分析對研究各類可變因素有其獨特的作用。日間手術病例主要包括膝關節鏡檢查(n=50),疝手術(n=25),陰宮術(n=25),胸部手術(n=25),整形術(n=25). 研究顯示最大疼痛值(標準為0-10)變異在2.3+-0.55.1+-0.5之間,24%的患者疼痛值大於7,同時也有24%的患者由於疼痛致使第一恢復期延長。如果術中使用了局麻藥或酮咯酸則疼痛值較低(分別為22%26%)。恢復期的芬太尼劑量與最大疼痛值有關,若術中使用了酮咯酸則芬太尼的用量可減少42%。對於女性患者來說,恢復期的芬太尼劑量要高於術中用量。最大疼痛得分取決於總恢復時間(恢復時間為135172212分鐘;其最大疼痛得分分別為0-34-6,和7-10P0.001)。綜上所述,為了改善疼痛治療的療效,就需要提高患者的舒適度,加快其恢復。

                                               (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.

 

吸附劑中小劑量一氧化碳形成與少量二氧化碳吸收無關

 

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.

 

 本研究探討吸附劑中形成的少量CO是否與CO2的吸收存在可能的相關。各種吸附劑均徹底乾燥,重量600g:氫氧化鋇(A,Dr gersorb 800 (B), A+B (C) ,  Intersorb (D) , Spherasorb (E), LoFloSorb (F)  , Superia (G)Amsorb (H)。將其置於5I/min的純氧中60分鐘,異氟醚濃度分別為0.5% A-Hn=4,5)和4%F-H; n=3)。每60秒鐘記錄下游的一氧化碳濃度、溫度和異氟醚濃度以計算一氧化碳的生成量和異氟醚的損失量。各組二氧化碳的吸收能力通過以下方法測算:在30g樣品(n=5)中吹入5.1%的二氧化碳(流量250ml/min)直至呼出濃度為0.5%。一氧化碳在含有氫氧化鉀的吸附劑組中生成最多(AB),在不含氫氧化堿的吸附劑中沒有生成(F-H)。下游溫度與一氧化碳形成相關,但異氟醚丟失與之無關。二氧化碳的持續吸收也與一氧化碳的形成無關。研究結果表明產生小劑量的一氧化碳的吸附劑不一定是二氧化碳的吸附劑。

                                                        (陳潔       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——腸道外環氧化酶-2抑制劑對咪達唑侖藥代動力學和臨床效果的影響

 

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,腸道外環氧化酶-2抑制劑,在臨床作為 解熱鎮痛藥物用於圍術期。它本身是無活性的前體,在體內水解後成為valdecoxib,是肝細胞色素酶P450 CYP3A4的底物。這就使之與其他CYP3A4的底物存在潛在的相互作用。本研究探討ParecoxibCYP3A4作用底物——咪達唑侖對志願者的藥代動力學和臨床效果的影響。  通過隨機雙盲、平衡交叉、安慰劑對照的臨床調查。1223-41歲的健康志願者,靜注安慰劑或40mg Parecoxib 後靜注0.07mg咪達唑侖。靜脈咪達唑侖血藥濃度用液相色譜儀-質譜儀分析。藥效動力學變化採用連續分析:包括病人清醒,認知能力(記憶力、數位記號替換實驗),自我清醒評估(視覺疼痛評分)和腦電雙頻指數。安慰劑組和Parecoxib 治療組的血漿濃度相似,咪達唑侖的藥代動力學(最大血漿濃度、清除率、半衰期、分佈容積)和藥效動力學(臨床終點、數位記號替換實驗、記憶力、視覺疼痛評分、腦電雙頻指數)亦無差別。單次劑量的       Parecoxib沒有改變咪達唑侖的藥代動力學和藥效動力學。使用咪達唑侖清除率作為體內試驗指標,結果表明Parecoxib並沒有影響CYP3A4活性。

(陳潔         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.

 

 

 

羅呱卡因硬膜外分娩鎮痛時加用壓寧定的藥理效應研究

 

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.

 

   為研究羅呱卡因硬膜外分娩鎮痛過程中加用壓寧定的藥理效應, 66例處於分娩活躍期早期的未經產婦隨機分為三組:組1 0.1%羅呱卡因8ml,並加用壓寧定75mg;組2  0.2%羅呱卡因8ml,並加用0.5mlNS;組3 先給予75mg腎上腺素化的布比卡因作為試驗劑量,5分鐘後再給予0.2%羅呱卡因8ml並加用壓寧定75mg。分娩過程中持續應用0.2%羅呱卡因8ml/h,根據病情需要,如患者疼痛可追加0.2%羅呱卡因8ml。結果表明:複合壓甯定組的病人鎮痛維持時間延長(132±48min[1]154±42min[3],而組291±44minP0.05〉,而第一個4h內總的羅呱卡因的用量明顯減少(40.5±15mg[1]47.0±16[3],而組272.5±18mgP0.01〉。組2病人的深運動神經阻滯較組13深(P0.05〉。雖然接受壓甯定的產婦在分娩過程中常需給予麻黃素處理低血壓,但並無證據顯示應用壓寧定可產生嚴重後果,或增加了剖宮產率。研究表明羅呱卡因加用壓寧定可減少羅呱卡因的用量。

(齊波       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.

 

全麻前行雙側頸深叢及淺叢阻滯對甲狀腺手術病人的鎮痛效果

 

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

 

       觀察甲狀腺切除術的病人在施行全身麻醉前使用頸深淺叢複合神經阻滯的鎮痛效果。39例擇期甲狀腺手術的病人,所有病人在麻醉前都進行雙側頸深淺叢複合神經阻滯(每側14ml)。組1(n=13),使用生理鹽水,組2(n=13),使用0.5%的羅呱卡因,組3(n=13),使用的是0.5%的羅呱卡因加可樂定7.5g/mL。頸深叢阻滯都在C3水平進行8ml單次注射。頸淺叢注射採用胸鎖乳突肌後緣注射6ml。在術中,組2和組3的阿芬太尼追加劑量明顯低於組1(分別為1.3±1.01.1±1.02.6±1.0P<0.05)。2和組3術後24小時內阿片類和非阿片類鎮痛藥的需求量明顯減少(P<0.05)。除了組3中有一名病人在注射後發生短暫的臂叢阻滯外,各組病人均未發現有其他副反應。結果表明頸深淺叢複合神經阻滯在甲狀腺切除術中和術後早期有確切良好的鎮痛效果。

                                                (周潔      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.

 


體外迴圈下冠脈搭橋術中應用低劑量多巴酚丁胺負荷的超聲心動圖監測是否具有遠期預測價值?

 

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.

冠心病患者靜息狀態下的慢性左室局部收縮功能障礙可能與心肌冬眠或心肌梗死有關,術中低劑量的多巴酚丁胺負荷的超聲心動圖監測能可靠的預測CABG術後即刻的局部心肌功能恢復情況。該研究旨在明確術中LDD超聲心動圖監測是否對CABG術後一年的局部心肌功能恢復也具預測價值。25CABG術中使用LDD超聲心動圖監測的冠心病患者術後一年使用經胸超聲心動圖隨訪評價其心肌功能。室壁運動功能分析(RWM)中考慮了左室射血分數(EF)、陳舊性心肌梗死、糖尿病等協變數,16節段模型和1-5分評分系統被用於評價350個心肌節段,使用多元LOGISTIC回歸分析方法分析術中LDD超聲心動圖(5 µg · kg-1 · min-1)監測的反應是否能夠預測術後1年局部心肌功能的變化。CABG術中CPB後在LDD輸注過程中RWM評分惡化但是在術後1年的超聲心動圖隨訪功能恢復的心肌節段定義為頓抑心肌(STUNNED MYIOCAIOL INGENT),術中LDD反應陽性的心肌功能改善的機會是反應陰性的心肌節段的2.22倍(95%可信區間:1.29,3.82;P=0.0039,術中LDD超聲心動圖監測的心肌功能改善的陽性預測值為0.81,陰性預測值為0.43,預測值不因協變數的不同而變化。在CPB後即刻RWM評分惡化的心肌節段中有87%1年後的心超隨訪時心肌功能得到改善。術中LDD超聲心動圖監測顯示的心肌收縮功能儲備可以預測1年後的局部心肌功能,但是多巴芬丁胺試驗不能預測哪些心肌節段不會恢復。大多數CABG術後即刻的局部心肌收縮功能障礙是心肌頓抑所致。結論 CABG術中LDD超聲心動圖監測對於術後1年的局部心肌功能變化的預測價值有限。對於術中應用小劑量的多巴酚丁胺後局部室壁運動障礙得到改善的心肌節段術中LDD超聲心動圖監測可預測術後1年的心肌功能變化,但是它不能預測哪些心肌節段在1年後的心超隨訪不會得到改善。

                                            (張俊峰    薛張綱 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.

 

非心臟胸科手術後室性心律失常的發生率及其後果

 

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.

胸科手術後常發生房性心律失常,但胸科術後早期室性心律失常的發生率及其意義尚不十分明確。該研究的目的在於明確連續的前瞻性的412例胸科手術(肺葉切除術243例,全肺切除術169例)後併發室性心律失常的發生率及其後果(應用Holter記錄儀術後72-96內小時連續監測),該研究中室性心動過速(VT)的發生定義為連續的3個及以上的寬QRS波。412例中有61例(占15%)發生1次或多次VT,每次發作都沒超過30秒並且沒有患者因血流動力障礙需要治療。與沒有發生VT的患者相比,VT發生者術前常合併左束支傳導阻滯(P=0.01),但在其他臨床資料、手術資料及到達麻醉後恢復室的中心體溫並無差異。發生VT患者比未發生VT者更易發生房性期前收(P< 0.001)、室性期前收縮(P< 0.001 、室早二聯律(P< 0.001)及術後房顫(61例中有21例房顫占34%351例中有58 例房顫占17%P=0.001)。多元LOGISTIC回歸分析提示只有術後房顫的發生與VT的發生獨立相關(相對風險指數為2.695%可信區間為1.4-4.8,P=0.002)。因此我們認為非心臟胸科手術後VT的發生較為常見,但並無不良後果,與VT強烈相關的房性和室性心律失常的發生提示去迷走神經作用和或腎上腺能高反應性對促使術後早期發生這些心律失常事件可能具有重要作用。結論 通過412例病例研究,我們明確了胸科大手術後非持續性VT的發生率為15%並且無不良後果。

                                        (張俊峰    薛張綱 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.

 

中重度腎功能損害患者靜脈輸注新型羥乙基澱粉130/0.46%500ML)的藥代動力學和耐受性研究

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.

羥乙基澱粉(HES)在澱粉酶水解後幾乎完全經腎小球排泌。HES 130/0.4 (Voluven®; Fresenius Kabi Deutschland GmbH, Bad Homburg, Germany)是一種新開發的HES,在保留HES容量效應的同時提高了其藥代動力學特性。我們研究其藥代動力學對腎功能的依賴性。19例穩定的非少尿性腎功能不全自願者(肌肝清除率CLcr從基本正常到嚴重的腎功能損害,其平均CLcr50.6 mL · min-1 · 1.73 m-2)接受了研究,每人在大於30分鐘內靜注500 mL 6% HES 130/0.4,靜注72小時測定血漿HES濃度,7296小時測定尿液中分泌量,在靜注前後至少分別測定2CLcr,然後進行標準的藥代動力學計算和回歸分析。與CLcr50者相比, CLcr <50者的時間濃度曲線下的面積(AUC0–inf)明顯依賴於腎功能。峰值濃度(Cmax, 4.34 mg/mL)和終末半衰期(16.1小時)則不受腎功能損害的影響。CLcr 30者中有59%的藥物在尿中可測到,而CLcr15–<30者只有51%30分鐘時血漿HES的平均分子量為62704d顯示腎功能損害者的值較低(P=0.04)。靜注前的血澱粉酶濃度與基礎CLcr 負相關。在所有的受試者中24小時時的滯留HES血漿濃度很小(0.6 mg/mL)。我們認為只要保持一定尿量HES 130/0.4 (500 mL 6%)可安全地應用於腎功能嚴重損害的患者而且不會在血漿內蓄積。結論 我們研究了HES 130/0.4的藥代動力學是否與腎功能存在依賴關係,結果顯示時間濃度曲線下面積在重度腎功能不全患者中輕度增加,而靜注24小時後血漿HES 130/0.4濃度很低,終末半衰期和峰值濃度則不受腎功能損害的影響。

(張俊峰    薛張綱 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.

 

異氟醚對中性粒細胞選擇蛋白和β2 -整合蛋白在體外啟動的影響

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.

異氟醚減弱缺血再灌注損傷。CD11b低表達可能減弱缺血後中性粒細胞粘附到內皮細胞的能力。但是,中性粒細胞粘附到血管內皮是包括一些選擇蛋白和 β2 -整合蛋白在內的多步反應。所以,我們的目的是評估異氟醚是否影響P-選擇性糖蛋白的配基-1PSGL1)、L-選擇蛋白和 β2 -整合蛋白CD11aCD11b的啟動。所有人血標本均在0.5MAC的異氟醚中孵化60分。孵化後,中性粒細胞用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。粘附細胞啟動通過流式細胞分析儀測定。在無活化樣本中,1MAC異氟醚減少了CD11a的表達。用FMLPPMA活化後,在異氟醚環境下,L-選擇蛋白的脫落是低的。另外,同未被暴露的樣本相比,1MAC的異氟醚減少了FMLP誘導CD11aCD11b啟動。這些結果證明,異氟醚影響參與中性粒細胞募集反應的3個粘附分子的啟動。首先,異氟醚抑制L-選擇蛋白在血管內皮上對中性粒細胞圈合和滾動的調節;其次,異氟醚抑制β2 -整合蛋白的CD11aCD11b的啟動,從而抑制了CD11aCD11b對中性粒細胞的加固粘附和跨膜移動的調節。

結論 中性粒細胞粘附內皮細胞損傷受多種粘附分子調節。這個試驗表明,異氟醚對中性粒細胞募集的抑制可能是通過減少L-選擇蛋白、β2 -整合蛋白的CD11aCD11b的啟動作用而調節的。

                                            (李紹清    薛張綱 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.

 

靶控和手控輸注異丙酚中的雙頻指數

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.

在這個預期、隨即試驗中,我們比較了雙頻指數(BIS),血流動力學,拔管時間,靶控輸注(TCI)和手控輸注(MAC)異丙酚的費用。40例進行心電除顫器植入的病人被研究。麻醉用雷米芬太尼(0.20.3µg · kg-1 · min-1)和異丙酚(TCI,血漿靶控濃度:2.5–3.5 µg/mL; n = 20)MCI (3.0–4.0 mg · kg-1 · h-1; n = 20). BIS, 心率,動脈血壓在6個時間點測量:T1,麻醉前;T2,插管後;T3,切皮後;T4,首次去纖顫後;T5,第三次去纖顫後;T6,拔管後。兩組血流動力學無明顯差異。TCI組較MCI組在T3T4BIS明顯低。TCI病人異丙酚平均用量大於MCI病人 (5.8 ± 1.4 mg · kg-1 · h-13.7 ± 0.6 mg · kg-1 · h-1),雷米芬太尼劑量無差別。

兩組拔管時間不同(TCI, 13.7 ± 5.3 min; MCI, 12.3± 3.5 min)。MCI組一個病人在第一次去纖顫術中有知曉(除顫前BIS49;除顫後,83)。MCI組費用明顯少於TCI(US$34.83US$39.73)。對下次疼痛刺激,BIS不能預測麻醉是否足夠。

 

   結論 在這個預期、隨即試驗中,我們比較了雙頻指數(BIS),血流動力學,拔管時間,靶控輸注(TCI)和手控輸注(MAC)異丙酚的費用。對下次疼痛刺激,BIS不能預測麻醉是否足夠。

(李紹清    薛張綱 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.


 

全麻時減少手術室麻醉氣體污染的麻醉氣排出櫥的使用

 

 

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.

   許多研究證明,長期暴露于一定濃度水平的麻醉氣體中對手術室(OR)工作人員是有害的。在嬰兒分娩全麻中,常用無套口的氣管導管(ETT),可導至相當夠的麻醉氣體或NO污染手術室。這個報告中,我們展示了一個通過麻醉氣體排出櫥(ASH)減少OR中麻醉氣體的方法。ASH用於6個用無套口的ETT麻醉的兒科患者,測量周圍不同水平面不同點的麻醉氣體濃度水平。應用ASH真空源,周圍麻醉氣體明顯低,沒有發現通氣變數改變,患者體溫也無變化。停用ASH真空源,周圍麻醉氣體明顯高。我們的結論是,ASH在用無套口的ETT麻醉中明顯減少麻醉氣體污染,也可保存患者體溫,而且費用低。

 

    結論 長期暴露于一定濃度水平的麻醉氣體中對手術室(OR)工作人員是有害的,特別是在常用無套口的氣管導管(ETT)嬰兒分娩全麻中。麻醉氣體排出櫥(ASH)在減少麻醉氣體和保存患者體溫都是有效的而且費用低。

                                    (李紹清    薛張綱 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.

 

 

聯合應用平均頻率和振幅對豬心跳驟停模型除顫結局的預測能力

                                          

 

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.

我們評價了室顫(VF)的平均頻率(FREQ)、平均峰穀振幅(AMPL)及其聯合,對除顫結局的預測能力。我們檢測了四個不同的心跳驟停組64頭豬的室顫心電圖信號,四個組有不同的無處理室顫間期,不同的心肺復蘇間期,應用不同藥物(腎上腺素,血管加壓素,N-硝基-L-精氨酸甲基酯,或生理鹽水對照)。頻率範圍限定於4.33-30 Hz。在第一次除顫前的20秒至10秒的間期(10秒間期)記錄FREQAMPL。我們通過應用多元logistic回歸,引入生存指數(SI0.68 Hz-1 · FREQ + 12.69 mV-1 · AMPL)。應用Kruskal-Wallis非參數單因素分析來分析不同豬模型間的顯著差異。運用單因素logistic回歸分析和受試者工作特性曲線來比較變數FREQAMPLSI和除顫結局的關係。與單一的FREQAMPL相比,SI增加了預測力,達到了89%的敏感度和86%的特異度。FREQAMPLSI預測除顫結局的概率分別為0.850.890.90FREQAMPLSI值就四組不同的心跳驟停模型而言並不敏感,但對應用血管加壓素和腎上腺素的動物有明顯的不同。

結論 我們作了回顧性的資料分析,來評估豬的不同室顫心電圖變數對除顫結局的預測力。研究提示變數的聯合改善了預測力,因而可有助於減少有害的、不成功的除顫嘗試。

                                              (張鴻    薛張綱 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.

 

可樂定對分娩時硬膜外羅吡卡因最低局部鎮痛濃度的影響

 

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.

以最低局部鎮痛濃度(MLAC)為判定標準,羅吡卡因在分娩第一產程期間的作用強度不如布比卡因。本研究評估了可樂定對羅吡卡因MLAC的影響。77名要求分娩(宮頸擴張,3-7cm)硬膜外鎮痛的不同產次孕婦進入本研究。分別給予硬膜外單次注射羅吡卡因(n=30),羅吡卡因和可樂定30 µgn28),或在研究第二部分給予羅吡卡因和可樂定60 µgn19)。根據上下順序分配法,羅吡卡因給藥濃度由該組上一位孕婦的反應而定。硬膜外單次注射後30分鐘內,模擬疼痛評分10 mm被認為有效反應。有效反應使下一位患者的濃度下降0.01% wt/vol。無效反應使濃度增加0.01% wt/vol。羅吡卡因的MLAC0.097% wt/vol (95% 可信區間, 0.085%–0.108%)MLAC30-µg硬膜外可樂定時,不受影響(0.081% [0.045%–0.117%]);但60-µg時,顯著降低(0.035% [0.024%–0.046%]) (P < 0.001)。本研究顯示60-µg可樂定能顯著降低羅吡卡因的MLAC

結論 在分娩期,硬膜外加用可樂定可增強硬膜外羅吡卡因的效能。該研究顯示,在第一產程期間,硬膜外可樂定可顯著降低羅吡卡因的最低局部鎮痛濃度,但可引起鎮靜。

                                           (張鴻    薛張綱 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.

 

老年髖關節骨折手術時預防性肌注小劑量新福林減弱蛛網膜下腔麻醉誘發低血壓的作用

 

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.

 

在一項90位正常血壓和高血壓、年齡>65歲行髖關節骨折手術患者的雙盲、安慰劑對照、隨機研究中,我們評估了預防性肌注1.53mg新福林對重比重丁卡因蛛網膜下腔麻醉誘發低血壓的影響。30位正常血壓患者分別肌注新福林1.5mg3mg(N/P-1.5 N/P-3.0組;每組n = 15),對照組給予生理鹽水(N/C組;n = 15)45位高血壓患者行相似的處理(H/P-1.5, H/P-3.0,H/C組;每組n = 15)。各組的高位感覺阻滯平面為T9,範圍T8T10。在正常血壓和高血壓組,給予新福林1.5mg3mg的患者低血壓(平均動脈壓[MAP]由基礎值下降>25%)的發生均較對照組有顯著降低。與N/C組或H/C組相比,N/P-3.0N/P-1.5組以及H/P-3.0MAP下降的百分比顯著降低(P < 0.05),所需靜注麻黃堿的量顯著減少(P < 0.05)。儘管與H/C組比, H/P-1.5組未能顯著減少MAP下降的百分比,但其所需靜注麻黃堿的量也顯著降低(P < 0.05)。各組均未觀察到作為肌注新福林不良反應的心動過緩發生。在N/P-3.0H/P-3.0組,給藥後發生高血壓(MAP由基礎值上升20%),而N/P-1.5H/P-1.5組未發生。我們認為預防性肌注1.5mg新福林是安全的(就抑制心動過緩和高血壓的發生而言),並且是減少正常血壓和高血壓的老年患者蛛網膜下腔麻醉時發生低血壓的有效方法。

結論 我們認為對正常血壓和高血壓的老年患者,針對蛛網膜下腔麻醉所致的低血壓,小劑量新福林預防性使用是有效和安全的。1.5mg新福林肌注對於減少低血壓的發生和避免不良反應是有效的。

                                                     (張鴻    薛張綱 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.