Anesthesia & Analgesia

October 2002

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

高位胸段硬膜外麻醉用于两种方式的冠状动脉旁路移植术

(   王祥瑞 )

High Thoracic Epidural Anesthesia for Coronary Artery Bypass Grafting Using Two Different Surgical Approaches in Conscious Patients

Paul Kessler, MD*, Gerd Neidhart, MD*, Dorothee H. Bremerich, MD*, Tayfun Aybek, MD, Selami Dogan, MD, Volker Lischke, MD*, and Christian Byhahn, MD*

Departments of *Anesthesiology, Intensive Care Medicine and Pain Control and Thoracic and Cardiovascular Surgery, J. W. Goethe University Hospital Center, Frankfurt, Germany

Anesth & Analg Oct. 2002;95:791-797

前负荷调整最大功率作为右室收缩力指数的局限性

( 鸿   薛张纲 )

The Limitations of Preload-Adjusted Maximal Power as an Index of Right Ventricular Contractility

H. Alex Leather, MD*, Patrick Segers, PhD{dagger}, Yuan-Yuan Sun, MD*, Hendrik A. De Ruyter, MD*, Eugène Vandermeersch, MD PhD*, and Patrick F. Wouters, MD PhD*

*Center for Experimental Surgery and Anesthesiology, Anesthesiology Department, Katholieke Universiteit Leuven, Belgium; and {dagger}Hydraulics Laboratory, Institute Biomedical Technology, Ghent University, Belgium

Anesth Analg 2002 95: 798-804.

丙帕他莫用于心脏手术患者术后辅助镇痛

Propacetamol as Adjunctive Treatment for Postoperative Pain After Cardiac Surgery

Pasi Lahtinen, MD*, Hannu Kokki, MD PhD*, Heikki Hendolin, MD PhD*, Tapio Hakala, MD{dagger}, and Markku Hynynen, MD PhD{ddagger}

*Department of Anesthesia and Intensive Care and {dagger}Department of Surgery, Kuopio University Hospital, Kuopio; and {ddagger}Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

Anesth Analg Oct. 2002;95:828-834

心脏手术后的持续性疼痛:一项关于高位胸段硬膜外和阿片类药物镇痛治疗的调查

( 鸿   薛张纲 校)

Persistent Pain After Cardiac Surgery: An Audit of High Thoracic Epidural and Primary Opioid Analgesia Therapies

Sue C. Ho, MBBS FANZCA*, Colin F. Royse, MBBS MD, FANZCA{dagger}{ddagger}, Alistair G. Royse, MBBS MD, FRACS{dagger}§, Arthur Penberthy, MBBS FANZCA*, and Roderick McRae, MBBS FANZCA, FFIANZCA{ddagger}

*Department of Anaesthesia, Monash Medical Centre; {dagger}Department of Pharmacology, University of Melbourne; and Departments of {ddagger}Anaesthesia and Pain Management and §Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, Australia

Anesth Analg 2002 95: 835-843.

体外循环期间纠正血浆内镁离子浓度可降低术后心律失常的风险

(殷文渊   王祥瑞 )

Correction of Ionized Plasma Magnesium During Cardiopulmonary Bypass Reduces the Risk of  Postoperative Cardiac Arrhythmia

Nicholas  J. Wilkes,  FRCA,Susan  V.  Mallett,  FRCA,  Tim  Peachey,  FRCA,  Carmelo  Di  Salvo,  MD,  and  Robin  Walesby,  MSc  FRCS

Departments of Anaesthesia and Cardiothoracic Surgery, Royal Free Hospital, London, United Kingdom

Anesth & Analg Oct. 2002;95:828-834

 

前负荷指数:肺移植术中监测肺动脉阻塞压和胸腔内血容量的对比

(张 鸿 译  薛张纲 校)

Preload Index: Pulmonary Artery Occlusion Pressure Versus Intrathoracic Blood Volume Monitoring During Lung Transplantation

Giorgio Della Rocca, Gabriella M. Costa, Cecilia Coccia, Livia Pompei, Pierangelo Di Marco, and Paolo Pietropaoli

Istituto di Anestesiologia e Rianimazione, University of Rome "La Sapienza," Azienda Ospedaliera Policlinico Umberto I, Rome, Italy

Anesth & Analg Oct.2002; 95: 835-843.

急性等容血液稀释期间使用β-肾上腺素激动剂可恢复氧摄取的储备力

(殷文渊 译  王祥瑞 校)

β-Adrenergic  Stimulation  Restores  Oxygen  Extraction  Reserve  During  Acute  Normvolemic  Hemodilution

George J. Crystal , PhD ,  and  M. Ramez Salem, MD

Department  of  Anesthesiology,  Advocate  Illinois  Masonic  Medical  Center,  Chicago,  Illinois;  and  Department  of  Anesthesiology  and  Physiology  and  Biophysics,  University  of  Illinois  College  of  Medicine,  Chicago,  Illinois

Anesth & Analg Oct. 2002:95:851-857

围术期晶胶体输注对血小板介导的止血及凝血的影响

(李绍清 译  薛张纲 校)

The Effects of Perioperatively Administered Colloids and Crystalloids on Primary Platelet-Mediated Hemostasis and Clot Formation

Petra Innerhofer, MD*, Dietmar Fries, MD*, Josef Margreiter, MD*, Anton Klingler, PhD{dagger}, Gabriele Kühbacher, MD*, Bernhard Wachter, MD*, Elgar Oswald, MD*, Erwin Salner, MD*, Bernhard Frischhut, MD{ddagger}, and Wolfgang Schobersberger, MD*

*Department of Anesthesia and Critical Care Medicine, {dagger}Theoretical Surgery Unit, Department of General Surgery, and {ddagger}Department of Orthopedics, The Leopold-Franzens University of Innsbruck, Innsbruck, Austria

Anesth & Analg Oct. 2002; 95: 889-892

HemoCue 血浆/ 低血红蛋白系统能准确测量血浆中三个不同的低浓度血红蛋白氧载体(HBOCs):

(  辉 译   王祥瑞 校)

Hemoglobin Glutamer-200(Boving)(Oxyglobin), Hemoglobin Glutamer-250(Boving)(Hemoglobin), Hemoglobin-Raffimer(Hemolink)

The Novel HemoCue Plasma/Low Hemoglovin System Accurately Measures Small Concentrations of Three Different Hemoglobin-Based Oxygren Carriers in Plasma: Hemoglobin Glutamer-200(Boving)(Oxyglobin),HemoglobinGlutamer-250(Boving)(Hemoglobin), Hemoglobin-Raffimer(Hemolink)

Fedor Lurie, MD PhD*, Jonathan S. Jahr, MD{dagger}, and Bernd Driessen, DVM PhD{ddagger}

*Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; {dagger}Department of Anesthesiology, University of California-Los Angeles School of Medicine, Los Angeles, California, and Department of Anesthesiology, Charles R. Drew University of Medicine and Science, Martin Luther King, Jr./Drew Medical Center, Los Angeles, California; and {ddagger}Department of Clinical Studies, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania

Anesth & Analg Oct. 2002;95;870-873 

PEDIATRIC ANESTHESIA:

从先心病婴幼儿获得的胶质蛋白,S100B:神经损伤的预先证明

(李绍清 译  薛张纲 校)

A Glial-Derived Protein, S100B, in Neonates and Infants with Congenital Heart Disease: Evidence for Preexisting Neurologic Injury

Paula M. Bokesch, MD*, Elumalai Appachi, MD{dagger}, Marco Cavaglia, MD*, Emad Mossad, MD*, and Roger B.B. Mee, MB ChB, FRACS{ddagger}

Departments of *Cardiothoracic Anesthesia, {dagger}Pediatric Critical Care, and the {ddagger}Center for Congenital Heart Disease and Surgery, The Cleveland Clinic Foundation, Ohio

Anesth & Analg Oct. 2002; 95: 907-914.

 

ANESTHETIC PHARMACOLOGY:

神经类固醇麻醉剂Alphaxalone)抑制牛肾上腺素嗜铬细胞的烟碱酸乙酰胆碱受体

(朱慧琛 译 王祥瑞 校)

A Neurosteroid Anesthetic, Alphaxalone, Inphaxalone, Inhibits Nicotinic Acetylcholine Receptors in Cultured Boving Adrenal Chromaffin Cells

Munehiro Shiraishi, MD, Izumi Shibuya, PhD, Kouichiro Minami, MD PhD, Yasuhito Uezono, MD PhD, Takashi Okamoto, MD, Nobuyuki Yanagihara, PhD, Susumu Ueno, MD PhD, Yoidhi Ueta, MD PhD, and Akio Shigematsu, MD PhD

Departments of Anesthesiology, Physiology, and Pharmacology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu; and Department of Second Pharmacology, Nagasaki University, School of Medicine, Nagasaki, Japan

Anesth & Analg Oct. 2002;95:900 906

 

异丙酚对急性分离的大鼠脊髓背角神经元γ-氨基丁酸-A和甘氨酸受体的作用

(张俊峰 译    薛张纲 校)

The Actions of Propofol on {gamma}-Aminobutyric Acid-A and Glycine Receptors in Acutely Dissociated Spinal Dorsal Horn Neurons of the Rat

Xian-Ping Dong, MS, and Tian-Le Xu, PhD MD

Laboratory of Receptor Pharmacology, Department of Neurobiology and Biophysics, University of Science and Technology of China, Hefei, People’s Republic of China

Anesth &Analg Oct.2002; 95: 907-914

TECHNOLOGY, COMPUTING, AND SIMULATION:

入院前创伤监护过程中积极升温对脉搏血氧定量法信号质量的影响

(朱慧琛 译 王祥瑞 校)

The Influence of Active Warming on Signal Quality of Pulse Oximetry in Prehospital Trauma Care

Alexander Kober , MD ,  Thomas Scheck, MD , Frank Lieba, BS , Renate, MD , Wolfgang Vlach, MD , Wolfgang Schram, MD , and Klaus Hoerauf, MD

Department of Anesthesia and Intensive , University if Vienna ; Vienna Red Cross, Van Swieten; and Research Institute of the Vienna Red Cross, Vienna, Austria

Anesh & Analg Oct. 2002;95:979-984

PAIN MEDICINE:

阿片类物质戒断期间的痛觉过敏:谷氨酸和P物质介导

(忻纪华 译  王祥瑞 校)

Hyperalgesia During Opioid Abstinence:Mediation by Glutamate and Substance P

Xiangqi Li, MD and J.David Clark, MD PhD

Veterans Affairs Palo Alto Health Care System and Stanford University Department of Anesthesiology, Palo Alto, California

Anesh & Analg Oct. 2002;95:997-1001

乳癌手术后GabapentinMexiletine的镇痛效应

(张俊峰 译    薛张纲 校)

The Analgesic Effect of Gabapentin and Mexiletine After Breast Surgery for Cancer

Argyro Fassoulaki, MD PhD, DEAA*, Konstantinos Patris, MD{dagger}, Costantine Sarantopoulos, MD DEAA{ddagger}, and Quinn Hogan, MD{ddagger}

*Department of Anesthesiology, Aretaieion Hospital, Medical School, University of Athens; {dagger}Department of Anesthesiology, St Savas Hospital, Athens, Greece; and {ddagger}Department of Anesthesiology, Medical College of Wisconsin, Milwaukee

Anesth & Analg Oct.2002; 95: 985-991.

在鼠的鞘内注射离子变异的谷氨酰胺受体激动剂后的发声反应

(忻纪华 译  王祥瑞 校)

Vocalization Responses After Intrathecal Administration of Ionotropic Glutamate Receptor Agonists in Rats

Vesa K. Kontinen, MD PhD, and Theo F. Meert, PhD

Pain and Analgesia, Discovery Research, Johnson & Johnson Pharmaceutical Research & Development, Beerse, Belgium

Anesth & Analg Oct.2002; 95: 997-1001

 

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

Cochrane Anesthesia Review Group的使命:准备和发布系统的麻醉学中关于卫生保健效果的综述文献

(潘志浩 译    薛张纲 校)

The Mission of the Cochrane Anesthesia Review Group: Preparing and Disseminating Systematic Reviews of the Effect of Health Care in Anesthesiology

Tom Pedersen, MD PhD, Ann M. Møller, MD, and Jane Cracknell, RN BA

Department of Anesthesiology, Bispebjerg University Hospital, Copenhagen, Denmark

Anesth & Analg Oct.2002; 95: 1012-1018.

CRITICAL CARE AND TRAUMA:

肺复苏成功的猪模型中 高渗高张溶液减少心脏肌钙蛋白IS—100 的释放的研究

(忻纪华 译  王祥瑞 校)

Hypertonic-Hyperoncotic solutions Reduce the Release of Cardiac Troponin I and S-100 After Successful Cardiopulmonary Resuscitation in Pigs

Heiner Krieter, MD DEAA*, Christof Denz, MD*, Christonph Janke, Thomas Bertsch, MD*, Thomas Luiz, MD*, Klaus Ellinger, MD*,and Klaus van Ackern, MD*

* Institutes of *Anesthesiology and Intensive Care Medicine and {dagger}Clinical Chemistry, Faculty of Clinical Medicine Mannheim, University of Heidelberg, Mannheim, Germany

Anesth & Analg Oct. 2002; 95: 1031-1036

 

气管内肾上腺素:提倡更大的剂量

(潘志浩 译    薛张纲 校)

Endotracheal Epinephrine: A Call for Larger Doses

Yossi Manisterski, MD, Zvi Vaknin, MD, Ron Ben-Abraham, MD, Ori Efrati, MD, Danny Lotan, MD, Mati Berkovitch, MD, Asher Barak, MD, Zohar Barzilay, MD FCCM, and Gideon Paret, MD

Department of Pediatric Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, Israel

Anesth & Analg Oct.2002; 95: 1037-1041.

NEUROSURGICAL ANESTHESIA:

高碳酸血症对收缩期Sylvius导水管内脑脊液流速峰值的影响

(周 洁   王祥瑞 校)

The impact of Hypercapnia on Systolic Cerebrospinal Fluid Peak Velocity in the Aqueduct of Sylvius

Christian Kolbitsch, MD DEAA, Iorenz, MD, Christoph H rmann, MD, Michael F. Schocke, MD, Christian Kremser, PHD, Patrizial L. Moser, MD, Karl P. Pfeiffer, PhD, and Arnulf Benzer, MD DEAA

Departments of Anaesthesia and Intensive Care Medicine, Magnetic Resonance Imaging, Pathology, and Bilstatistics and Documentation, University of Innsbruck, Austria

Anesth & Analg Oct. 2002; 95: 1049-1051

自愿者中Dexmedetomidine 诱导的镇静会降低脑局部和全脑的血流量

(潘志浩     薛张纲 校)

Dexmedetomidine-Induced Sedation in Volunteers Decreases Regional and Global Cerebral Blood Flow

Richard C. Prielipp, MD FCCM*, Michael H. Wall, MD*, Joseph R. Tobin, MD FCCM*, Leanne Groban, MD*, Mark A. Cannon, MD*, Frederic H. Fahey, DSc{dagger}, H. Donald Gage, PhD{dagger}, David A. Stump, PhD*, Robert L. James, MS*, Judy Bennett, RN*, and John Butterworth, MD*

Departments of *Anesthesiology (Sections of Critical Care and Cardiothoracic Anesthesiology) and {dagger}Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth & AnalgOct.2002; 95: 1052-1059.

REGIONAL ANESTHESIA:

正中径路经骶孔硬膜外阻滞

(周 洁 译  王祥瑞 校)

The Median Approach to Transsacral Edural Blook

Tomoki Nishiyama, MD PhD, Kazuo Hanaoka, MD PhD, and Youji Ochiai, MD PhD

Surgical Center, The Institute of Medical Science, Department of Anesthesiology, The University of Tolyo; and Department of Anesthesiology, Matsuda Hospital, Kurashili, Japan

Anesth & Analg Oct. 2002; 95:1067-1070

坐骨神经与小转子关系:关联坐骨神经前方阻滞

(李绍清   薛张刚校)

The anatomic Relationship of the Sciatic Nerve to the Lesser Trochanter: Implications for Anterior Sciatic Nerve Block

 

Marty L. Ericksen, MD, Jeffrey D. Swenson, MD, and Nathan L. Pace, MD Mstat

Department of Anesthesiology, University of Utah, Salt Lake City

Anesth & Analg Oct. 2002; 95: 1090-1093.

使用外周神经刺激仪定位的臂丛神经阻滞四点法:腋路和肩部入路的比较

(潘志浩 译    薛张纲 校)

Four-Injection Brachial Plexus Block Using Peripheral Nerve Stimulator: A Comparison Between Axillary and Humeral Approaches

Salvatore Sia, MD, Antonella Lepri, MD, Maria Consolata Campolo, MD, and Rossana Fiaschi, MD

Department of Anesthesiology, Centro Traumatologico Ortopedico, Azienda Ospedaliera Careggi, Firenze, Italy

Anesth & Analg Oct.2002; 95: 1075-1079

利多卡因和拟肾上腺素收缩药物对鼠坐骨神经和骨骼肌血流的影响

(   王祥瑞 )

The effect of lidocaine and adrenergic agonists on rat sciatec nerve and skelital muscle blood flow in vive

Greta M. Palmer, MBBS FANZCA, FFPMANZCA*, Brian E. Cairns, PhD*, Steven L. Berkes, MD*, Patricia S. Dunning, BSc RT(R){dagger}, George A. Taylor, MD{dagger}, and Charles B. Berde, MD PhD*

Departments of *Anesthesia and {dagger}Radiology, Children’s Hospital, and Harvard Medical School, Boston, Massachusetts

Anesth & Analg Oct. 2002; 95:1080-1086

GENERAL ARTICLES:

使用弹性橡胶管芯以盲插法或间接喉镜法在非预期困难插管病人中进行气管内插管的比较

(陈 智 译    薛张纲 校)

Endotracheal Intubation with a Gum-Elastic Bougie in Unanticipated Difficult Direct Laryngoscopy: Comparison of a Blind Technique Versus Indirect Laryngoscopy with a Laryngeal Mirror

Marian Weisenberg, MD*, R. David Warters, MD{dagger}, Benjamin Medalion, MD{ddagger}, Peter Szmuk, MD{dagger}, Yehuda Roth, MD§, and Tiberiu Ezri, MD*

From the Departments of *Anesthesia, {ddagger}Cardiothoracic Surgery, and §Otorhynolaryngology, Wolfson Medical Center, Holon, affiliated with Sackler School of Medicine, Tel Aviv, Israel; and {dagger}Department of Anesthesiology, University of Texas Medical School at Houston, Texas

Anesth & Analg Oct.2002; 95: 1090-1093.

睡眠呼吸暂停综合征病人与困难气管内插管

(齐 波 译  王祥瑞 校)

Difficult Endotracheal Intubation in Patients with Sleep Apnea Syndrome

Mohammad A. Siyam, and Dan Benhamou

Département d’Anesthésie-Réanimation, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Bicêtre Cedex, France

Anesth & Analg Oct. 2002; 95:1098-1102

韩国针刺穴位使用辣椒贴可以降低经腹子宫切除术病人术后恶心呕吐发生率

(陈 智  薛张纲 校)

Capsicum Plaster at the Korean Hand Acupuncture Point Reduces Postoperative Nausea and Vomiting After Abdominal Hysterectomy

Kyo S. Kim, MD PhD*, Min S. Koo, MD*, Jeong W. Jeon, MD*, Hahck S. Park, MD{dagger}, and Ik S. Seung, MD PhD*

*Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea; and {dagger}Department of Anesthesiology, College of Medicine, In Je University, Seoul, Korea

 Anesth & Analg Oct.2002;95(4):1103-7

 

 

 

高位胸段硬膜外麻醉用于两种方式的冠状动脉旁路移植术

High Thoracic Epidural Anesthesia for Coronary Artery Bypass Grafting Using Two Different Surgical Approaches in Conscious Patients

 

Paul Kessler, MD*, Gerd Neidhart, MD*, Dorothee H. Bremerich, MD*, Tayfun Aybek, MD, Selami Dogan, MD, Volker Lischke, MD*, and Christian Byhahn, MD*

Departments of *Anesthesiology, Intensive Care Medicine and Pain Control and Thoracic and Cardiovascular Surgery, J. W. Goethe University Hospital Center, Frankfurt, Germany

 

Anesth & Analg Oct. 2002;95:791-797

 

随着非人工心肺机的冠脉搭桥手术(OPCAB)的开展,该类病人采用高位胸段硬膜外麻醉(TEA,手术中病人保持清醒。以往, TEA仅报道用于经外侧胸廓切开后单支血管搭桥手术。20例患者分为下段部分胸骨切开后接受不停跳单支血管搭桥术患者(微创冠脉搭桥术[MIDCAB]n=10),和完全中段胸骨切开多根血管疾病患者(不停跳冠脉搭桥术[OPCAB]; n=10)。硬膜外导管置于胸1-22-3间隙。硬膜外注入0.5%罗哌卡因和1.66g/ml的舒芬太尼至麻醉平面到达颈5-6用于OPCAB或胸1-2用于MIDCAB9OPCAB8MIDCAB患者在整个手术过程中保持清醒并且自主呼吸。由于手术过程中产生气胸(OPCAB),麻醉不充分以及膈神经麻痹(两组),三例患者要求术中转为全麻。术中两组10-15%的患者心率显著下降,与基础值(B)相比,平均动脉压仅在冠脉吻合(CA)时显著下降(BOPCAB, 95±11; CAOPCAB, 68±9;BMIDCAB, 86±10; CAMIDCAB, 73±10;两组间无显著差异。术中OPCABPaCO242±2mmHg上升至46±7mmHg(p<0.05),而在MIDCAB组基本保持不变。所有患者均评价TEA“好”“很好”。结论 高位胸段连硬麻醉用于MIDCAB OPCAB手术是可行的,且患者满意率较高。

                                              (   王祥瑞 )

Recent developments in coronary artery bypass graft surgery (CABG) without cardiopulmonary bypass made the sole use of high thoracic epidural anesthesia (TEA) in conscious patients feasible. Previously, TEA has been reported only for single-vessel CABG via lateral thoracotomy. We investigated the feasibility and complications of sole TEA in 20 patients undergoing beating-heart arterial revascularization via partial lower sternotomy for single-vessel disease (minimally invasive direct coronary artery bypass grafting [MIDCAB] technique; n = 10) or complete median sternotomy for multivessel disease (off-pump coronary artery bypass grafting [OPCAB] technique; n = 10). An epidural catheter was inserted at the T1-2 or T2-3 interspace. An epidural infusion of ropivacaine 0.5% and sufentanil 1.66 µg/mL was started to establish anesthetic levels at C5-6 for OPCAB and at T1-2 for MIDCAB. Nine OPCAB and eight MIDCAB procedures were completed while patients were awake and spontaneously breathing during the entire procedure. Because of surgical pneumothorax (OPCAB), insufficient anesthesia, or phrenic nerve palsy (both MIDCAB), three patients required intraoperative conversion to general anesthesia. The heart rate decreased significantly (P < 0.05) by 10%–15% in both groups during the procedure. Compared with baseline (B), mean arterial blood pressure (mm Hg) was decreased significantly only during coronary anastomosis (CA) (BOPCAB, 95 ± 11; CAOPCAB, 68 ± 9; BMIDCAB, 86 ± 10; CAMIDCAB, 73 ± 10; P not significant between groups). PaCO2 increased from 42 ± 2 mm Hg to 46 ± 7 mm Hg (P < 0.05) throughout the perioperative course during OPCAB, whereas it remained almost unaltered during MIDCAB procedures. All patients rated TEA as "good" or "excellent." In conclusion, we demonstrated that the sole use of TEA for MIDCAB and OPCAB procedures was feasible and provided a high degree of patient satisfaction in our small and highly selected cohorts.

丙帕他莫用于心脏手术患者术后辅助镇痛

Propacetamol as Adjunctive Treatment for Postoperative Pain After Cardiac Surgery

 

Pasi Lahtinen, MD*, Hannu Kokki, MD PhD*, Heikki Hendolin, MD PhD*, Tapio Hakala, MD{dagger}, and Markku Hynynen, MD PhD{ddagger}

*Department of Anesthesia and Intensive Care and {dagger}Department of Surgery, Kuopio University Hospital, Kuopio; and {ddagger}Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

Anesth Analg Oct. 2002;95:828-834

 

心脏手术后镇痛主要使用肠道外阿片类药物,由于阿片类药物有诸多副作用,推荐同时服用非阿片类镇痛药用以减少阿片类药物的剂量。本研究采用随机双盲前瞻性方法评价丙帕他莫——静脉使用的对乙酰氨基酚(扑热息痛)前体,对心脏术后辅助镇痛的疗效。随机选择79例择期冠脉搭桥手术的患者,分为两组:术后72小时内每隔6小时静脉注射2g丙帕他莫n=40)或安慰剂(n=39)。从拔管后,病人通过患者自控装置接受阿片类药物(氧化可代因)。每天4次使用视觉疼痛评分表来评价镇痛效果,同时每日评价呼吸功能(用力肺容量、1秒用力呼气量,呼气峰值流量和动脉血气测量)。基本有效量(72小时氧化可代因的累计消耗量)在丙帕他莫组为123.5±51.3mg;安慰剂组为141.8mg±57.5mg。睡眠组(p=0.65)和深呼吸组(p=0.72)的疼痛评分无显著差异。两组在肺功能检查、术后出血、肝脏功能、副反应的发生率方面均无显著差异。并采用apost hoc分析法研究第一个24小时内每6小时内的数据,发现24小时氧化可代因的消耗在丙帕他莫组显著低于对照组(47.1±20.7mg比较57.9±23.9mg p=0.036)。结果表明丙帕他莫没有加强冠脉搭桥手术后阿片类药物的镇痛效果,也没有减少术后三天阿片类药物的消耗量和副作用。然而,apost hoc分析发现第一个24小时内丙帕他莫组氧化可代因的用量减少。

 

(   王祥瑞 )

 

Postoperative pain management after cardiac surgery has been mainly based on parenteral opioids. However, because opioids have numerous side effects, coadministration of non-opioid analgesics has been introduced as a method of reducing opioid dose. In this prospective, randomized, double-blinded study, we evaluated the efficacy of propacetamol, an IV administered prodrug of acetaminophen (paracetamol), as an adjunctive analgesic after cardiac surgery. Seventy-nine patients scheduled for elective coronary artery bypass grafting were randomized to receive either propacetamol 2 g (n = 40) or placebo (n = 39) IV in 6-h intervals for 72 h. From the time of extubation, patients had access to an opioid (oxycodone) via a patient-controlled analgesia device. Pain was evaluated on a visual analog scale four times daily, whereas respiratory function tests (forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow, and arterial blood gas measurements) were performed once a day. The prespecified primary efficacy variable (cumulative oxycodone consumption at the end of the 72-h postoperative period) was 123.5 mg (51.3 mg) (mean [SD]) in the propacetamol group and 141.8 mg (57.5 mg) in the placebo group (difference in mean, 18.3 mg = 13%; 95% confidence interval, 6.1–42.7 mg; P = 0.15). Pain scores did not differ between the groups at rest (P = 0.65) or during a deep breath (P = 0.72). The groups were also similar in terms of pulmonary function tests, postoperative bleeding, and hepatic function tests, and no significant differences were noted in the incidences of adverse effects. After completion of the study, apost hoc analysis was also performed analyzing the first 24 h as split into 6-h intervals. This analysis showed a significantly (P = 0.036) smaller consumption of oxycodone in the propacetamol group at 24 h (47.1 mg [20.7 mg] versus 57.9 mg [23.9 mg]; difference in mean, 10.8 mg; 95% confidence interval, 0.7–20.9 mg). In conclusion, propacetamol did not enhance opioid-based analgesia in coronary artery bypass grafting patients, nor did it decrease cumulative opioid consumption or reduce adverse effects within 3 days after surgery. However, post hoc analysis showed that oxycodone requirement was reduced within the first 24 h in the propacetamol group.

 

 

 

体外循环期间纠正血浆内镁离子浓度可降低术后心律失常的风险

Correction of Ionized Plasma Magnesium During Cardiopulmonary Bypass Reduces the Risk of  Postoperative Cardiac Arrhythmia

 

Nicholas  J. Wilkes,  FRCA,Susan  V.  Mallett,  FRCA,  Tim  Peachey,  FRCA,  Carmelo  Di  Salvo,  MD,  and  Robin  Walesby,  MSc  FRCS

Departments of Anaesthesia and Cardiothoracic Surgery, Royal Free Hospital, London, United Kingdom

 

Anesth & Analg Oct. 2002;95:828-834

 

我们随机抽取病例进行对照试验以确定术中测量和纠正血浆内镁离子是否可以降低体外循环后心律失常的风险。我们选择了85例进行冠状动脉搭桥的患者,随机分成两组,一组是根据血浆内镁离子浓度给以硫酸镁的患者(n=43),另一组是知道镁离子浓度但不予纠正的对照组(n=42)。我们利用离子选择电极在最短时间内计算镁离子浓度然后将样本带入实验室测定血浆内镁浓度。所有的病人在术后72小时内带上Holter以监测心电图。在体外循环之前总的血镁浓度下降比镁离子下降的发生机率更高,前者有45个病人发生血镁下降,占总病人数的53%,后者有11个病人发生离子镁下降,占总病人数 11%。对照组的患者在体外循环过程中血镁和离子镁浓度进一步下降。在起初的24小时内纠正镁离子的一组患者室性心动过速发生率比对照组低,前者3,7%,后者12,30%,(P0.01〉,且前者窦性心律患者高于后者,分别是14个(30%)和2个(5%P0.01。结果表明术中纠正镁离子浓度可以减少心脏手术后室性心律失常的发生。

                                             (殷文渊 译  王祥瑞 校)

 

We conducted this randomized controlled trial to determine whether the intraoperative measurement and correction of ionized plasma magnesium can reduce the risk of cardiac arrhythmia after cardiopulmonary bypass. Eighty-five patients presenting for coronary artery bypass grafting were randomly assigned either to the magnesium-corrected group, which received magnesium sulfate on the basis of measured levels of ionized plasma magnesium (n = 43), or to the control group, in which magnesium levels were identified but not corrected (n = 42). Ionized magnesium was determined with an ion-selective electrode with minimal delay, and further samples were taken for laboratory analysis of total plasma magnesium. All patients had Holter electrocardiogram monitoring for 72 h after surgery. Total hypomagnesemia (45 patients; 53% of all patients) was more common than ionized hypomagnesemia (11 patients; 13%) before cardiopulmonary bypass. Both total and ionized magnesium levels declined further during the course of cardiopulmonary bypass in the control group. The incidence of ventricular tachycardia in the first 24 h was less frequent in the magnesium-corrected group (3 patients; 7%) than the control group (12 patients, 30%; P < 0.01). Patients in the magnesium-corrected group were more likely to display continuous sinus rhythm (Lown Grade 0) in the first 24 h (14 patients; 34%) than patients in the control group (2 patients, 5%; P < 0.001). Our results suggest that the intraoperative correction of ionized magnesium is associated with a reduction in postoperative ventricular arrhythmia in cardiac surgical patients.

      

急性等容血液稀释期间使用β-肾上腺素激动剂可恢复氧摄取的储备力

β-Adrenergic  Stimulation  Restores  Oxygen  Extraction  Reserve  During  Acute  Normvolemic  Hemodilution

 

George J. Crystal , PhD ,  and  M. Ramez Salem, MD

Department  of  Anesthesiology,  Advocate  Illinois  Masonic  Medical  Center,  Chicago,  Illinois;  and  Department  of  Anesthesiology  and  Physiology  and  Biophysics,  University  of  Illinois  College  of  Medicine,  Chicago,  Illinois

 

Anesth & Analg Oct. 2002:95:851-857

 

在急性等容血液稀释(ANH)期间由于氧分压降低导致摄取分数(EO2)的代偿性增加,从而增加组织缺氧的风险。假定在急性等容血液稀释期间应用β-肾上腺素激动剂异丙肾上腺素(ISOP)增加心排血量,从而扭转氧摄取的代偿性增加并恢复组织氧供的安全系数。本研究在选择7只麻醉的狗,通过温度稀释发法测量心排血量,通过放射性微球体测量局部血流(RBF)。我们计算出全身氧输送量(DO2),氧耗量(VO2),氧摄取(EO2)以及局部氧输送量(DO2)。每只狗的所有数据都在以下条件下测定:1)基准-12ISOP0.1g·kg-1·min-1IV),3)基准-24ANH,和5)在ANH期间使用ISOP。实验狗的基础血球压积为45%±3%ANH后为18%。在ANH前,ISOP导致心排血量和全身氧输送量增加,而氧耗量不变氧摄取减少,同时心肌和脾脏血流增加,胰腺血流减少,而大脑、脊髓和其它组织血流没有变化。在急性等容血液稀释期间心排血量增加以代偿动脉氧含量降低所致的全身氧输送下降;而氧摄取增加以保持全身氧耗量稳定。急性等容血液稀释期间心肌、大脑、十二指肠和胰腺血流增加以维持这些脏器的氧输送量,而肾脏和脾脏的氧输送降低。ISOPANH期间可增加心排血量和全身氧输送量,这就可以使全身的氧摄取恢复到原来水平,并可以增加心肌,肾脏,十二指肠以及脾脏的血流。结论  1. ANH期间使用β-肾上腺素激动剂异丙肾上腺素可以恢复氧摄取的储备力且对身体组织无副作用,2. ANH期间使用促心肌收缩的药物如ISOP,或许可以扩大血球压积下降的界限。

                                             (殷文渊   王祥瑞 )

Compensatory increases in oxygen extraction (EO2) during acute normovolemic hemodilution (ANH) have the effect of decreasing tissue oxygen tension values, thus increasing the threat of tissue hypoxia. We hypothesized that if the ß-adrenergic agonist isoproterenol (ISOP) could augment cardiac output (CO) during ANH, it could reverse the increases in EO2 and restore the margin of safety for tissue oxygenation. Studies were performed in seven anesthetized (isoflurane) dogs. CO was measured by using thermodilution, and regional blood flow (RBF) was measured by using radioactive microspheres. Systemic oxygen delivery (DO2), oxygen consumption ({image}O2), and EO2, as well as regional DO2, were calculated. Measurements were obtained under the following conditions in each dog: 1) baseline-1, 2) ISOP (0.1 µg · kg-1 · min-1 IV), 3) baseline-2, 4) ANH, and 5) ISOP during ANH. Hematocrit was 45% ± 3% under baseline conditions and 18% ± 3% during ANH. Before ANH, ISOP caused parallel increases in CO and systemic DO2, which, in the presence of an unchanged {image}O2, reduced EO2. RBF increased in myocardium and spleen, decreased in pancreas, and did not change in brain, spinal cord, or other tissues. ANH caused increases in CO, which were insufficient to offset the decrease in arterial oxygen content, and thus systemic DO2 declined; systemic {image}O2 was maintained by an increase in EO2. ANH-related increases in RBF maintained DO2 in myocardium, brain, duodenum, and pancreas, whereas DO2 declined in kidney and spleen. ISOP during ANH increased CO and systemic DO2, which returned systemic EO2 to baseline, and it increased RBF in myocardium, kidney, duodenum, and spleen. We conclude that 1) ß-adrenergic stimulation with ISOP restored the systemic EO2 reserve during ANH, without apparent adverse effects in the individual body tissues, and that 2) the use of inotropic drugs, such as ISOP, may extend the limit to which hematocrit can be reduced safely during ANH.

HemoCue 血浆/ 低血红蛋白系统能准确测量血浆中三个不同的低浓度血红蛋白氧载体(HBOCs):

Hemoglobin Glutamer-200(Boving)(Oxyglobin), Hemoglobin Glutamer-250(Boving)(Hemoglobin), Hemoglobin-Raffimer(Hemolink)

The Novel HemoCue Plasma/Low Hemoglovin System Accurately Measures Small Concentrations of Three Different Hemoglobin-Based Oxygren Carriers in Plasma: Hemoglobin Glutamer-200(Boving)(Oxyglobin),HemoglobinGlutamer-250(Boving)(Hemoglobin), Hemoglobin-Raffimer(Hemolink)

 

Fedor Lurie, MD PhD*, Jonathan S. Jahr, MD{dagger}, and Bernd Driessen, DVM PhD{ddagger}

*Department of Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; {dagger}Department of Anesthesiology, University of California-Los Angeles School of Medicine, Los Angeles, California, and Department of Anesthesiology, Charles R. Drew University of Medicine and Science, Martin Luther King, Jr./Drew Medical Center, Los Angeles, California; and {ddagger}Department of Clinical Studies, University of Pennsylvania, School of Veterinary Medicine, Philadelphia, Pennsylvania

Anesth & Analg Oct. 2002;95;870-873

 

为证实HemoCue 血浆/ 低血红蛋白系统在测定基础血红蛋白氧载体(HBOCs)的准确性。本实验反复测试50例犬类的血浆标本,发现每一例都混合有三个不同的HBOCs。两个技术人员对每一例样本都进行了10次随机测试,同时分析其相关性及差异性,并评估统计学意义,P<<0.05。与床边光度计测量的血红蛋白浓度与已知的样本浓度无太大区别,且两位研究员对相同的标本进行的单独测试结果也未存在重大的不同之处。所有的HBOCs测试及测试浓度都是真实的。主要的测试数据偏差以样品浓度的百分比表示。0.1%为血色素glutamer-200()0.58%为血色素glutamer-250()0.19%为血色素raffimer。三个HBOCs的主要偏差都〈8%。这些检测都具有很高的可信度及统计学意义。HemoCue 血浆/ 低血红蛋白系统是探测和测量血浆低浓度HBOCs的可靠工具。

                                            (     王祥瑞 )

The accuracy of the HemoCue® Plasma/Low Hemoglobin System was validated in vitr. with low levels of hemoglobin-based oxygen carriers (HBOCs). Repeated measurements were performed on 50 samples of canine plasma, each mixed with three different HBOCs at varying small concentrations (a total of 150 samples), by using plasma samples without HBOCs as controls. Two technicians performed the measurements and randomly tested each sample 10 times. The results were analyzed for correlation, and analysis of variance was used to evaluate statistical significance, with a P value of <=0.05 considered significant. Hemoglobin concentrations determined with the bedside photometer were not significantly different from known values of hemoglobin concentration in the samples. There was no significant difference between values obtained by two independent observers for the same samples. This was true for all three tested HBOCs and for all tested concentrations. The mean bias of the measurement expressed as a percentage of sample concentration was 0.1% for hemoglobin glutamer-200 (bovine), 0.58% for hemoglobin glutamer-250 (bovine), and 0.19% for hemoglobin-raffimer. The mean error was <8% for all three HBOCs. Both intraobserver and interobserver reliabilities were high and statistically significant. The HemoCue® Plasma/Low Hemoglobin System is a reliable instrument for detecting and measuring small concentrations of three different HBOCs in plasma.

神经类固醇麻醉剂(Alphaxalone)抑制牛肾上腺素嗜铬细胞的烟碱酸乙酰胆碱受体

A Neurosteroid Anesthetic, Alphaxalone, Inphaxalone, Inhibits Nicotinic Acetylcholine Receptors in Cultured Boving Adrenal Chromaffin Cells

Munehiro Shiraishi, MD, Izumi Shibuya, PhD, Kouichiro Minami, MD PhD, Yasuhito Uezono, MD PhD, Takashi Okamoto, MD, Nobuyuki Yanagihara, PhD, Susumu Ueno, MD PhD, Yoidhi Ueta, MD PhD, and Akio Shigematsu, MD PhD

Departments of Anesthesiology, Physiology, and Pharmacology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu; and Department of Second Pharmacology, Nagasaki University, School of Medicine, Nagasaki, Japan

Anesth & Analg Oct. 2002;95:900 906

 

有证据显示全身麻醉剂作用于烟碱酸乙酰胆碱受体(nAChRs)。Alphaxalone (5 σ-pregnan-3σ-ol-11, 20-dion) 是应用于临床麻醉一类神经类固醇,nAChRs的作用尚未进行过很好的调查研究。本研究观察alphaxalone 对牛肾上腺素嗜铬细胞nAChRs的作用,同时采用钙离子成像和全细胞修补术观察alphaxalone对烟碱递质的增加及胞浆钙离子浓度和膜电流的影响及其对同一细胞上7-胺基丁酸受体的作用,比较了其对nAChRs的不同作用。Alphaxalone (0.1-100 M)抑制了浓度依赖的钙离子介导的烟碱递质的增长,Alphaxalone 抑制了高K+-Ca2+的增长,但其抑制作用只能在100M时被观测到。在voltage-clamp实验中运用负电压alphaxalone (0.1-100 M) 本身即可引发内向电流, 且其能被木防己苦毒素(picrotoxin)的7-胺基丁酸受体解除。Alghaxalone也抑制了烟碱递质的内向电流,其抑制作用可被苦味毒(picrotoxin)解除。结果表明麻醉浓度的alphaxalone可抑制肾上腺素嗜铬细胞的nAChRsAlphaxalone通过抑制nAChRs而作用于迷走神经和其它神经系统。

                                              (朱慧琛 王祥瑞 )

 

Several lines of evidence suggest that nicotinic acetylcholine receptors (nAChRs) are a target of general anesthetics. Alphaxalone (5{alpha}-pregnan-3{alpha}-ol-11, 20-dion) is a neurosteroid, which was used clinically for anesthesia, but its effects on the function of nAChRs have not been well investigated. We examined the effects of alphaxalone on nAChRs in cultured bovine adrenal chromaffin cells. We studied the effects of alphaxalone on nicotine-induced increases in the cytosolic Ca2+ concentration ([Ca2+]i) and on membrane currents using Ca2+-imaging and whole-cell patch-clamp techniques, respectively, in these cells. We also examined the effects of alphaxalone on {gamma}-aminobutyric acid A receptors in the same cells and compared them with the effects on nAChRs. Alphaxalone (0.1–100 µM) inhibited nicotine-induced [Ca2+]i increases in a concentration-dependent manner. Alphaxalone inhibited high K+-induced [Ca2+]i increases, but the inhibition was observed only at 100 µM. In voltage-clamp experiments using negative holding potentials, alphaxalone (0.1–100 µM) itself induced inward currents, which were abolished by the {gamma}-aminobutyric acid A receptor antagonist picrotoxin. Alphaxalone also inhibited nicotine-induced inward currents, and the inhibition was unaffected by picrotoxin. We conclude that alphaxalone, at anesthetic concentrations, inhibits nAChRs in adrenal chromaffin cells. Alphaxalone may affect the sympathetic and other nervous systems via inhibition of nAChRs.

 

入院前创伤监护过程中积极升温对脉搏血氧定量法信号质量的影响

The Influence of Active Warming on Signal Quality of Pulse Oximetry in Prehospital Trauma Care

Alexander Kober , MD ,  Thomas Scheck, MD , Frank Lieba, BS , Renate, MD , Wolfgang Vlach, MD , Wolfgang Schram, MD , and Klaus Hoerauf, MD

Department of Anesthesia and Intensive , University if Vienna ; Vienna Red Cross, Van Swieten; and Research Institute of the Vienna Red Cross, Vienna, Austria

Anesh & Analg Oct. 2002;95:979-984

类似挫伤和单纯骨折这类创伤的受害者通常为医务辅助人员所运送。许多病人由于喝酒或其他毒品的缘故往往处于醉酒状态,因而易于发生通气不充分。所以他们的氧合情况依靠无创脉搏血氧定量法来监测。我们测试了在运送医院途中对全身进行积极升温能提高动脉血氧饱和度监测(SpO2)的可靠性的假设。在这个研究中,24名运送至医院的创伤病人随机分为两组:一组(n=12)覆盖普通的羊毛毯,而另一组(n=12)则在运输途中使用热毯。我们记录中心温度,颤抖,前臂和手指的皮肤温度,SpO2和血液动力学变化。在随机选择前,两组都是具有可比性的。到达医院后,积极升温的病人明显具有较高的中心温度(36.1±0.3 35.5±0.3;P<0.001)和皮肤温度(34.1±1.5 24.9±1.4;P<0.001)。在积极升温组中,脉搏血氧饱和度仪的报警次数明显减少(3158),发生故障的时间明显减少(146±42s 420±256s),提供了更加稳定的测量数据(P<0.001)。在本研究中,我们发现在创伤病人运送至医院的途中对其进行积极升温可以提高脉搏血氧饱和度仪的监测质量。

                                              (朱慧琛 王祥瑞 )

Victims of trauma such as contusions and simple fractures are usually transported by paramedics. Because many victims are intoxicated with alcohol or other drugs, they are vulnerable to some risk of inadequate respiration. Thus, their oxygenation is monitored by noninvasive pulse oximetry. We tested the hypothesis that active warming of the whole body during transport to the hospital can improve the reliability of arterial oxygen saturation (SpO2) monitoring. Twenty-four trauma patients transported to hospital were included in the study and randomly assigned to two groups: one group (n = 12) was covered with normal wool blankets, and the other group (n = 12) was treated with resistive heating blankets during transport. We recorded core temperature, shivering, skin temperature at the forearm and finger, SpO2, and hemodynamic variables. Before randomization, both groups were comparable. On arrival at the hospital, the actively warmed patients had significantly warmer core (36.1 ± 0.3°C versus 35.5 ± 0.3°C; P < 0.001) and skin (34.1 ± 1.5°C versus 24.9 ± 1.4°C; P < 0.001) temperatures. In the actively warmed group, the pulse oximeter had significantly fewer alerts (31 versus 58) and a significantly less time of malfunction (146 ± 42 s versus 420 ± 256 s) and provided more constant measurements in the actively warmed group (P < 0.001). In this study we showed that active warming improves pulse oximeter monitoring quality in trauma patients during transport to the hospital.

阿片类物质戒断期间的痛觉过敏:谷氨酸和P物质介导

Hyperalgesia During Opioid Abstinence:Mediation by Glutamate and Substance P

Xiangqi Li, MD and J.David Clark, MD PhD

Veterans Affairs Palo Alto Health Care System and Stanford University Department of Anesthesiology, Palo Alto, California

Anesh & Analg Oct. 2002;95:997-1001

 

阿片类物质戒断痛觉过敏(OAH)是一种以热和机械性痛觉过敏为特征的现象,发生于间歇应用阿片类物质或在长期应用这些药物时突然停药。本研究试图确定在患有OAH的小鼠和对照小鼠的鞘内使用初级神经递质谷氨酸和P物质,前者的活化作用是否大于后者。设定方案是在小鼠中移植吗啡药丸,六天后去除,根据热板和哈格理夫斯热爪撤离测试评估,小鼠出现了痛觉过敏。机械性异常性疼痛也证实存在。在OAH小鼠和对照组小鼠鞘内注射谷氨酸(5-25g)或P物质(0.02-0.1nmol),前者引起的疼痛行为大于后者。同样观察到应用谷氨酸或P物质后在OAH小鼠的脊髓前角区域中的Fos-positive细胞核多于对照组小鼠。本研究表明与对照组小鼠相比较,在鞘内应用谷氨酸和P物质的OAH小鼠显示出痛觉行为增强和Fos-positive细胞核增多。因而脊柱对初级神经递质的感受性增强可能与OAH的表现部分相关。

                                             (忻纪华   王祥瑞 )

Opioid-abstinence hyperalgesia (OAH) is a phenomenon characterized by thermal and mechanical hyperalgesia that occurs between intermittent doses of opioids or after the chronic administration of these drugs when administration is abruptly stopped. In these studies we attempted to determine whether the activation of spinal cord dorsal horn neurons was greater in mice with OAH than in control mice in response to the intrathecal administration of the primary neurotransmitters glutamate and substance P. After mice were treated with an established protocol consisting of the implantation of morphine pellets followed by removal after 6 days, the mice were hyperalgesic as assessed with the hotplate and Hargreaves thermal paw withdrawal assays. Mechanical allodynia was also demonstrated. The intrathecal injection of either glutamate (5–25 µg) or substance P (0.02–0.1 nmol) caused greater pain behaviors in mice with OAH than in control mice. Likewise, it was observed that the dorsal horn regions of OAH mice had more Fos-positive nuclei after either glutamate or substance P administration than did control mice. We conclude that mice with OAH exhibit increased pain behaviors and have increased numbers of Fos-positive nuclei in response to intrathecal glutamate and substance P administration when compared with control mice. Thus, spinal sensitization to primary neurotransmitters may be responsible in part for the manifestation of OAH.

在鼠的鞘内注射离子变异的谷氨酰胺受体激动剂后的发声反应

Vocalization Responses After Intrathecal Administration of Ionotropic Glutamate Receptor Agonists in Rats

Vesa K. Kontinen, MD PhD, and Theo F. Meert, PhD

Pain and Analgesia, Discovery Research, Johnson & Johnson Pharmaceutical Research & Development, Beerse, Belgium

Anesth & Analg Oct.2002; 95: 997-1001

 

脊髓中离子变异的谷氨酰胺受体(N—甲基—D—天冬氨酸[NMDA],或天冬氨酸—3—羟基—5—甲基—4—isoxazolepropionic  zcid[AMPA] ,和Kainate受体似乎在急性疼痛的传递和慢性疼痛的神经元的适应性中起关键作用。疼痛传导路径上这些受体活化后产生的发声反应能够半自动定量,并且因此可作为一种研究工具。我们研究在正常的鼠和存在外部感染及慢性压缩损伤引起神经性疼痛的模型鼠的鞘内注射各种谷氨酰胺受体激动剂后引起的发声反应。非选择性内源性激动剂,谷氨酰胺,和NMDA受体甘氨酸位点激动剂D—丝氨酸不产生发声反应,而选择性作用于AMPANMDAKainate受体的激动剂产生剂量相关性发声反应。总结:鞘内注射离子型谷氨酰胺受体激动剂可产生短效的,剂量相关性的发声反应可作为镇痛的基础研究和审查的工具。然而,外部感染或神经损伤根本不改变发声反应,可能提示在这些病理性疼痛的条件下,发声试验不能作为研究这些氨基酸的手段。

(忻纪华   王祥瑞 )

Ionotropic glutamate receptors in the spinal cord (N-methyl-D-aspartic acid [NMDA], {alpha}-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid [AMPA], and kainate receptors) seem to play a key role in acute pain transmission and the neuronal plasticity in chronic pain states. Vocalization responses produced by activation of these receptors on the pain pathways can be quantified semiautomatically and thus could be used as a research tool. We studied vocalization responses induced by intrathecal administration of various agonists acting at the glutamate receptors in normal rats and in the presence of peripheral inflammation and a chronic constriction injury model of neuropathic pain. The nonselective endogenous agonist, glutamate, and the NMDA receptor glycine site agonist D-serine did not produce vocalization, whereas selective agonists acting at AMPA, NMDA, and kainate receptors produced dose-related vocalization responses. The vocalization response evoked by the administration of AMPA was significantly increased in the neuropathic pain model. In conclusion, spinal administration of ionotropic glutamate receptor agonists produce short-lasting, dose-related vocalization responses that can be used as a basic research and screening tool for analgesic studies. However, peripheral inflammation or nerve injury did not substantially alter vocalization responses overall, possibly indicating that the vocalization test is not a good tool for studying the role of excitatory amino acids in these pathological pain conditions.

肺复苏成功的猪模型中 高渗高张溶液减少心脏肌钙蛋白IS—100 的释放的研究

Hypertonic-Hyperoncotic solutions Reduce the Release of Cardiac Troponin I and S-100 After Successful Cardiopulmonary Resuscitation in Pigs

Heiner Krieter, MD DEAA*, Christof Denz, MD*, Christonph Janke, Thomas Bertsch, MD*, Thomas Luiz, MD*, Klaus Ellinger, MD*,and Klaus van Ackern, MD*

* Institutes of *Anesthesiology and Intensive Care Medicine and {dagger}Clinical Chemistry, Faculty of Clinical Medicine Mannheim, University of Heidelberg, Mannheim, Germany

Anesth & Analg Oct. 2002; 95: 1031-1036

 

某些病人中,心肺复苏(CPR)可恢复自主循环(ROSC)。但是,神经系统的预后差。高渗高张溶液(HHS)可改善局部或全身缺血后的微血管传导性。我们研究了猪CPR模型的HHS灌注效应。由于室颤引起心跳骤停。上述的心脏支持在停跳未加干预后4分钟,基本生命支持后1分钟。在ROSC基础上,动物随机给予125ml的正常生理盐水(安慰剂,n=8)或7.2%NaCl10%羟乙基淀粉200000/0.5HHS n=7)。至ROSC后,各自用肌钙蛋白IS—100的血清浓度来评估心肌和脑损伤。所有动物模型中,肌钙蛋白IS—100水平在ROSC后升高(p<0.0.1)。而HHS组的升高明显低于安慰剂组。因此在CPR初期有了一个新的选择,即在心肌和脑缺血后使用HHS可减少细胞损伤。

(忻纪华   王祥瑞 )

 

In some patients, cardiopulmonary resuscitation (CPR) can revive spontaneous circulation (ROSC). However, neurological outcome often remains poor. Hypertonic-hyperoncotic solutions (HHS) have been shown to improve microvascular conductivity after regional and global ischemia. We investigated the effect of infusion of HHS in a porcine CPR model. Cardiac arrest was induced by ventricular fibrillation. Advanced cardiac life support was begun after 4 min of nonintervention and 1 min of basic life support. Upon ROSC, the animals randomly received 125 mL of either normal saline (placebo, n = 8) or 7.2% NaCl and 10% hydroxyethyl starch 200,000/0.5 (HHS, n = 7). Myocardial and cerebral damage were assessed by serum concentrations of cardiac troponin I and astroglial protein S-100, respectively, up to 240 min after ROSC. In all animals, the levels of cardiac troponin I and S-100 increased after ROSC (P < 0.01). This increase was significantly blunted in animals that received HHS instead of placebo. The use of HHS in the setting of CPR may provide a new option in reducing cell damage in postischemic myocardial and cerebral tissues.

                                  

高碳酸血症对收缩期Sylvius导水管内脑脊液流速峰值的影响

The impact of Hypercapnia on Systolic Cerebrospinal Fluid Peak Velocity in the Aqueduct of Sylvius

Christian Kolbitsch, MD DEAA, Iorenz, MD, Christoph H rmann, MD, Michael F. Schocke, MD, Christian Kremser, PHD, Patrizial L. Moser, MD, Karl P. Pfeiffer, PhD, and Arnulf Benzer, MD DEAA

Departments of Anaesthesia and Intensive Care Medicine, Magnetic Resonance Imaging, Pathology, and Bilstatistics and Documentation, University of Innsbruck, Austria

Anesth & Analg Oct. 2002; 95: 1049-1051

 

 使用核磁共振可以发现Sylvius导水管内脑脊液流速峰值的变化,并且这一检查极其敏感,足以发现脑顺应性的微小变化。颅内血容量(CBV)改变可以引起脑顺应性改变。呼气末二氧化碳浓度(ETCO2)可以直接影响动脉血二氧化碳分压,后者可以引起CBV改变。本实验中,我们在麻醉的病人n=8中研究了高碳酸血症对CBV及收缩期CSFV峰值的影响。与正常血碳酸值的病人(ETCO2=40mmHg)相比,高碳酸血症的病人(ETCO2=60mmHg)其收缩期Sylvius导水管内脑脊液流速峰值明显减小(高碳酸血症的病人:—5.67±0.74cm/s正常血碳酸值的病人:—3.54±0.98cm/s。除了上述数值外,脑顺应性的数值改变也提示了收缩期CSFV峰值的下降。

                                                 (   王祥瑞 )

Phase-contrast magnetic resonance imaging measurements of systolic cerebrospinal fluid peak velocity (CSFVPeak) in the aqueduct of Sylvius have been shown to be sensitive enough to detect even minor changes in cerebral compliance. Clinically relevant changes in cerebral compliance can be caused by changes in cerebral blood volume (CBV). Changes in arterial carbon dioxide partial pressure, which correlate well with end-tidal carbon dioxide concentration (ETCO2), cause changes in CBV. In this study, we investigated the effect of hypercapnia-induced changes in CBV on systolic CSFVPeak in anesthetized patients (n = 8). Hypercapnia (ETCO2 = 60 mm Hg) increased systolic CSFVPeak in the aqueduct of Sylvius as compared with normocapnia (ETCO2 = 40 mm Hg) (hypercapnia: -5.67 ± 0.74 cm/s versus normocapnia: -3.54 ± 0.98 cm/s). In addition to the already known decrease in systolic CSFVPeak, changes in cerebral compliance can also prompt an increase in systolic CSFVPeak.

正中径路经骶孔硬膜外阻滞

The Median Approach to Transsacral Edural Blook

Tomoki Nishiyama, MD PhD, Kazuo Hanaoka, MD PhD, and Youji Ochiai, MD PhD

Surgical Center, The Institute of Medical Science, Department of Anesthesiology, The University of Tolyo; and Department of Anesthesiology, Matsuda Hospital, Kurashili, Japan

Anesth & Analg Oct. 2002; 95:1067-1070

 

正中径路经骶孔硬膜外阻滞对于直肠,肛门及尿道附近区域的手术或肿瘤疼痛是十分有效的。由于注射径路较长,经脊柱骶孔穿刺十分困难。我们发现正中径路经骶孔硬膜外阻滞比侧路穿刺更简单易行。共有30名膀胱肿瘤病人参加了这一实验,使用19号穿刺针经正中径路穿刺。15名病人在S2-3穿刺向头端置管5cm15名病人向尾端置管。麻醉用药为2%利多卡因15ml。对两组病人的麻醉平面,血流动力学情况及副反应进行比较。麻醉有效率(麻醉平面高于T10)为87%,两组病人骶神经阻滞效果(S1-5)均为100%。注药后20min时两组病人的最高麻醉平面分别为头端组T8,尾端组T9结论 正中径路经骶孔硬膜外阻滞在操作上可行,而且对骶尾部阻滞效果确切。

                                                (   王祥瑞 )

                                                       

Transsacral epidural block may be useful for surgery or cancer pain affecting the rectal, anal, or urethral region. The procedure through the dorsal sacral foramen is difficult because of the long insertion route. We investigated whether the transsacral epidural block could be simplified by using a median approach instead of a lateral approach through the foramen. Thirty patients for transurethral resection of bladder tumor had a catheter placed 5 cm cephalad at S2-3 (15 patients) or caudal (15 patients) epidural space using a 19-gauge Tuohy needle by the median approach. Lidocaine 2% 15 mL was administered for anesthesia. Anesthesia level (sensory block to cold), hemodynamics, and side effects were compared between the two approaches. The success rate of anesthesia was 87% for transurethral resection of bladder tumor (proximal anesthesia level higher than T10) and 100% for the sacral region (S1-5) in both groups. The highest level of anesthesia (median, T8 in the S2-3 group and T9 in the caudal group) was obtained in 20 min in both groups. No side effects were observed. We conclude that the median transsacral epidural approach is technically feasible in adults and presents an alternative to caudal block.

      

利多卡因和拟肾上腺素收缩药物对鼠坐骨神经和骨骼肌血流的影响

The effect of lidocaine and adrenergic agonists on rat sciatec nerve and skelital muscle blood flow in vive

Greta M. Palmer, MBBS FANZCA, FFPMANZCA*, Brian E. Cairns, PhD*, Steven L. Berkes, MD*, Patricia S. Dunning, BSc RT(R){dagger}, George A. Taylor, MD{dagger}, and Charles B. Berde, MD PhD*

Departments of *Anesthesia and {dagger}Radiology, Children’s Hospital, and Harvard Medical School, Boston, Massachusetts

Anesth & Analg Oct. 2002; 95:1080-1086

 

已知肾上腺素与利多卡因合用,可以收缩注射部位组织的局部血管,延缓利多卡因的清除,从而延长利多卡因神经阻滞持续的时间。然而,先前的研究并没有证明单独和联合应用利多卡因和肾上腺素对血管特性或局部血流的持续影响。为重新研究,在这个实验中,分别在坐骨神经和咬肌内注射利多卡因、肾上腺素、选择性α1受体收缩剂去氧肾上腺素,或联合应用利多卡因和这些肾上腺素受体收缩剂,在注射及注射后的几个时间点,应用X射线引导的微球技术测定组织内血流量。通过重复测定分析研究中的变量来评估实验中有意义的血流变化,发现单独注射利多卡因(21020mg/ml)和肾上腺素(10g/ml1100000)没有改变坐骨神经、坐骨神经周围肌肉或咬肌的血流量。联合应用利多卡因(10mg/ml)和肾上腺素(10g/ml)对临近肌肉血流量没有影响,但引起坐骨神经血流量明显减少,这在注射后30分钟最明显。然而,利多卡因复合应用去氧肾上腺素可明显减少所有实验组织的血流量。我们的研究提示除肾上腺素的局部血管收缩效应可延长利多卡因神经阻滞持续时间外还有其它作用机理。

(   王祥瑞 )                                                                                    

It has been proposed that epinephrine prolongs lidocaine nerve blockade duration by exerting a local vasoconstrictive effect on tissues at the injection site, slowing lidocaine’s local clearance. However, previous studies have failed to demonstrate consistent effects of lidocaine and epinephrine, injected alone and in combination, on vascular tone or regional blood flow. To reinvestigate this idea, in this study we used the radiolabeled microsphere technique to measure in vivo tissue blood flow before and at several time points after perisciatic nerve and intramasseter muscle injection of lidocaine alone, epinephrine, the selective {alpha}1-adrenergic receptor agonist phenylephrine, or lidocaine combined with these adrenergic receptor agonists. Repeated-measures analyses of variance were used to assess significant changes in blood flow over time. Lidocaine (2, 10, and 20 mg/mL) and epinephrine (10 µg/mL or 1:100,000) injected alone did not alter blood flow in sciatic nerve, perisciatic muscle, or masseter muscle. Injections of lidocaine (10 mg/mL) combined with epinephrine (10 µg/mL) did not affect adjacent muscle blood flow but caused a mild reduction in sciatic nerve blood flow, which was significant 30 min after injection. However, phenylephrine (10 µg/mL), a potent vasoconstrictor, combined with lidocaine (10 mg/mL) significantly reduced blood flow in all three tissues. Our findings suggest that mechanisms other than local vasoconstriction may contribute to the prolongation of lidocaine nerve blocks by epinephrine.

睡眠呼吸暂停综合征病人与困难气管内插管

Difficult Endotracheal Intubation in Patients with Sleep Apnea Syndrome

Mohammad A. Siyam, and Dan Benhamou

Département d’Anesthésie-Réanimation, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Bicêtre Cedex, France

Anesth & Analg Oct. 2002; 95:1098-1102

 

虽然睡眠呼吸暂停综合征(SAS)病人是常见的,但通过实验研究来评估此类病人的麻醉管理却非常少,且主要是个案报道研究。我们进行了回顾性病例对照研究来研究SAS病人困难气管内插管的发生率,以及SAS的严重程度与困难气管内插管之间的关系。在113例病人中包括36SAS病人和77例对照组病人,结果发现SAS病人困难气管内插管明显多于对照组(SAS组为21.9%,而对照组为2.6%P<0.05)。SAS严重程度与困难气管内插管没有关系。令人失望的是没有发现哪一个独立的因素与SAS病人的困难气管内插管有关系。结论  SAS是困难气管内插管的危险因素。

                                             (   王祥瑞 )

                                                             

Although sleep apnea syndrome (SAS) is common, studies assessing the anesthetic management of these patients are rare and consist mainly of case studies. We performed a retrospective case-control study to determine the incidence of difficult intubation in SAS patients and to determine the relationship between the severity of SAS and the occurrence of difficult intubation. Among 113 patients included (36 and 77 in the SAS and control groups, respectively), difficult intubation occurred more often in SAS patients than in controls (21.9% versus 2.6%, respectively; P < 0.05). No relationship was found between the severity of SAS and the occurrence of difficult intubation. Disappointingly, no single factor was associated with the occurrence of difficult intubation in SAS patients. We conclude that SAS is a risk factor for difficult intubation.

                              

前负荷调整最大功率作为右室收缩力指数的局限性

The Limitations of Preload-Adjusted Maximal Power as an Index of Right Ventricular Contractility

H. Alex Leather, MD*, Patrick Segers, PhD{dagger}, Yuan-Yuan Sun, MD*, Hendrik A. De Ruyter, MD*, Eugène Vandermeersch, MD PhD*, and Patrick F. Wouters, MD PhD*

*Center for Experimental Surgery and Anesthesiology, Anesthesiology Department, Katholieke Universiteit Leuven, Belgium; and {dagger}Hydraulics Laboratory, Institute Biomedical Technology, Ghent University, Belgium

Anesth Analg 2002 95: 798-804.

右室功能障碍是围术期,特别是在心脏外科围术期发病和死亡的重要原因。然而右室收缩力评估在临床实践中仍然较为困难。本研究的目的是决定作为右室收缩力指数的前负荷调整最大功率(PWRmax/舒张末期容量 [EDV]2; PAMP)的价值,这一指数是除压力-容量-来源指数外的另一个与负荷无关的指数。应用电导技术,研究已麻醉狗作为金标准的右室收缩末期弹性阻力和前负荷可增加的搏出功。PAMP由肺动脉血流和右室压力来计算。这些指数的改变与变力状态(多巴酚丁胺输注,n=12)和负荷条件(肺动脉和下腔静脉闭塞,n=14)改变后的情况作比较。所有指数均随多巴酚丁胺剂量的增加而增加。前负荷下降轻度影响PAMPPAMPEDV相关的斜率为0.00397 ± 0.01026 W · mL-3 · 0.10-4;均数±标准差)。肺动脉闭塞期间PAMP显著下降(从1.1 ± 0.70.7 ± 0.5 W · mL-2 · 0.10-4;均数±标准差),而收缩末期弹性阻力和前负荷可增加的搏出功不变。我们认为在开胸/开心包的情况下,PAMP作为右室收缩力指数的价值是有限的,主要是因为它对后负荷改变较敏感。结论前负荷调整最大功率(PAMP),一个与负荷无关的左室收缩力指数,在临床实践中可提供一个解决测量右室收缩力问题的方法。然而,用开胸狗所做的这个研究提示,由于PAMP对后负荷改变较敏感,因而在右室收缩力评估中并不可靠。

                                               (张 鸿   薛张纲 校)

Right ventricular (RV) dysfunction is an important cause of perioperative morbidity and mortality, particularly in cardiac surgery. However, assessment of                  
contractility remains difficult in clinical practice. Our goal in this study was to examine the value of preload-adjusted maximal power (PWRmax/end-diastolic volume [EDV]2; PAMP) as an alternative to the load-independent pressure-volume-derived indices of contractility in the RV. In anesthetized dogs, RV end-systolic elastance and preload-recruitable stroke work were studied as "gold standards" by using the conductance technique. PAMP was calculated with pulmonary artery flow and RV pressure measurements. Changes in these indices were compared after modulation of the inotropic state (dobutamine infusion; n = 12) and loading conditions (pulmonary artery and inferior caval vein occlusion; n = 14). All indices increased dose-dependently with dobutamine. PAMP was slightly influenced by preload reduction (the slope of the relation between PAMP and EDV was 0.00397 ± 0.01026 W · mL-3 · 0.10-4; mean ± SD). PAMP decreased significantly during pulmonary artery banding (from 1.1 ± 0.7 to 0.7 ± 0.5 W · mL-2 · 0.10-4; mean ± SD), whereas end-systolic elastance and preload-recruitable stroke work did not change. We conclude that the value of PAMP as an index of RV contractility is limited in the open-chest/open-pericardium setting, primarily by its sensitivity to alterations in afterload.

 

心脏手术后的持续性疼痛:一项关于高位胸段硬膜外和阿片类药物镇痛治疗的调查

Persistent Pain After Cardiac Surgery: An Audit of High Thoracic Epidural and Primary Opioid Analgesia Therapies

Sue C. Ho, MBBS FANZCA*, Colin F. Royse, MBBS MD, FANZCA{dagger}{ddagger}, Alistair G. Royse, MBBS MD, FRACS{dagger}§, Arthur Penberthy, MBBS FANZCA*, and Roderick McRae, MBBS FANZCA, FFIANZCA{ddagger}

*Department of Anaesthesia, Monash Medical Centre; {dagger}Department of Pharmacology, University of Melbourne; and Departments of {ddagger}Anaesthesia and Pain Management and §Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, Australia

Anesth Analg 2002 95: 835-843.

 

心脏手术后持续性疼痛报道的发病率较低。我们对单一手术医生在19971999年间所做的冠状动脉旁路移植术的所有病人进行疼痛调查。应用了两种镇痛策略:手术后4872小时,予高位胸段硬膜外(HTEA)镇痛或静脉注射和口服阿片类药物(OPIOID)镇痛。持续性疼痛的定义为术后疼痛持续2个月以上。所有问题只是指调查当时的情况。365份问卷中,305位患者有反馈信息,其中61位不同意调查,剩下的244位患者完成了调查(HTEA组,150[69%]OPIOID组,94[68%])。任意切口的持续性疼痛发生率为29%而胸骨切开者为25%。所述的疼痛程度较轻,仅7%患者的疼痛影响其日常生活。其他常见的疼痛部位是肩(17.4%)、背(15.9%)、颈(5.8%)。20位患者(8%)描述了内乳动脉综合症的症状。尽管OPIOID组在调查时距离手术的时间较长,两组在疼痛的频率和程度上无显著性差异。胸骨切开后,轻度的持续性胸痛是常见的,但不经常影响日常生活。

结论:冠状动脉旁路移植术后的持续性伤口疼痛是常见的,但通常较轻,不经常影响日常生活。调查显示,两种镇痛策略在持续性疼痛的发生上并无差异。

(张 鸿   薛张纲 校)

Persistent pain is an underreported morbidity after cardiac surgery. We sent pain surveys to all patients who underwent coronary artery bypass graft surgery from 1997 to 1999 from a single surgeon’s experience. Two analgesia strategies were used: high thoracic epidural (HTEA) or IV and oral opiates (OPIOID) for 48–72 h after surgery. Persistent pain was defined as pain still present two or more months after surgery, and all questions referred to the time of survey only. From 356 questionnaires, 305 patients responded, and 61 of them refused consent, leaving 244 patients with complete surveys (HTEA, 150 patients [69%]; OPIOID, 94 patients [68%]). The incidence of persistent pain at any site was 29% and for sternotomy was 25%. The intensity of pain reported was mild, with only 7% reporting interference with daily living. Other common locations of persistent pain were the shoulders (17.4%), back (15.9%), and neck (5.8%). Twenty patients (8%) described symptoms suggestive of the internal mammary artery syndrome. A comparative audit of the HTEA and OPIOID groups showed no significant differences in the frequency or intensity of pain, although the time of survey from operation was longer in the OPIOID group. Mild persistent chest pain after sternotomy is common but infrequently interferes with daily life.

前负荷指数:肺移植术中监测肺动脉阻塞压和胸腔内血容量的对比

Preload Index: Pulmonary Artery Occlusion Pressure Versus Intrathoracic Blood Volume Monitoring During Lung Transplantation

Giorgio Della Rocca, Gabriella M. Costa, Cecilia Coccia, Livia Pompei, Pierangelo Di Marco, and Paolo Pietropaoli

Istituto di Anestesiologia e Rianimazione, University of Rome "La Sapienza," Azienda Ospedaliera Policlinico Umberto I, Rome, Italy

Anesth & Analg Oct.2002; 95: 835-843.

在本研究中,我们分析了肺移植术中传统的前负荷指数:肺动脉阻塞压(PAOP)和新的前负荷指数:胸腔内血容量指数(ITBVI),后者来源于单一指示剂经肺稀释技术(PiCCO系统),与每搏量指数(SVIpa)相关。我们也评价了肺移植术中ITBVIPAOP的变化({Delta})与每搏量的变化{Delta}SVIpa之间的关系。由经肺单一指示剂稀释技术(CIart)和肺动脉温度稀释技术(CIpa)所得到的心脏参数测量值,其可重复性和精确性得到了判定。对50位患者用肺动脉导管和PiCCO系统监测,在整个研究的6个阶段进行测量。变量值的改变由第二个测量值减去第一个测量值计算所得({Delta}1),并以此类推({Delta}1{Delta}5)ITBVISVIpa间的线性相关显著(r2=0.41; P < 0.0001),而PAOPSVIpa间的线性相关较差(r2 = -0.01)ITBVI的变化和SVIpa的变化相关({Delta}1, r2 = 0.30; {Delta}2, r2 = 0.57; {Delta}4, r2 = 0.26; and {Delta}5, r2 = 0.67),而PAOP的变化则无关。CiartCipa间的平均偏倚为0.15 l · min-1 · m-2 (1.37)。总之,ITBVI是衡量心脏前负荷的有效参数,在行肺移植术的患者中可能优于PAOP

结论 在肺移植患者中,由经肺单一指示剂技术测定胸腔内血容量指数是个有用的方法,可提供一个反应心脏前负荷的有效参数,可能优于肺动脉阻塞压。然而,这一技术的作用和局限性还需要前瞻性随机临床试验来评价。

(张 鸿   薛张纲 校)

In this study, during lung transplantation, we analyzed a conventional preload index, the pulmonary artery occlusion pressure (PAOP), and a new preload index, the intrathoracic blood volume index (ITBVI), derived from the single-indicator transpulmonary dilution technique (PiCCO System), with respect to stroke volume index (SVIpa). We also evaluated the relationships between changes ({Delta}) in ITBVI and PAOP and {Delta}SVIpa during lung transplantation. The reproducibility and precision of all cardiac index measurements obtained with the transpulmonary single-indicator dilution technique (CIart) and with the pulmonary artery thermodilution technique (CIpa) were also determined. Measurements were made in 50 patients monitored with a pulmonary artery catheter and with a PiCCO System at six stages throughout the study. Changes in the variables were calculated by subtracting the first from the second measurement ({Delta}1) and so on ({Delta}1 to {Delta}5). The linear correlation between ITBVI and SVIpa was significant (r2=0.41; P < 0.0001), whereas PAOP poorly correlated with SVIpa (r2 = -0.01). Changes in ITBVI correlated with changes in SVIpa ({Delta}1, r2 = 0.30; {Delta}2, r2 = 0.57; {Delta}4, r2 = 0.26; and {Delta}5, r2 = 0.67), whereas PAOP failed. The mean bias between CIart and CIpa was 0.15 l · min-1 · m-2 (1.37). In conclusion, ITBVI is a valid indicator of cardiac preload and may be superior to PAOP in patients undergoing lung transplantation.

 

围术期晶胶体输注对血小板介导的止血及凝血的影响

The Effects of Perioperatively Administered Colloids and Crystalloids on Primary Platelet-Mediated Hemostasis and Clot Formation

Petra Innerhofer, MD*, Dietmar Fries, MD*, Josef Margreiter, MD*, Anton Klingler, PhD{dagger}, Gabriele Kühbacher, MD*, Bernhard Wachter, MD*, Elgar Oswald, MD*, Erwin Salner, MD*, Bernhard Frischhut, MD{ddagger}, and Wolfgang Schobersberger, MD*

*Department of Anesthesia and Critical Care Medicine, {dagger}Theoretical Surgery Unit, Department of General Surgery, and {ddagger}Department of Orthopedics, The Leopold-Franzens University of Innsbruck, Innsbruck, Austria

Anesth & Analg Oct. 2002; 95: 889-892

 

为了探讨常规输注晶胶体是否影响凝血系统,我们研究了60例膝关节置换术的患者,在基础林格氏液(RL)基础上,随即血管内输注6%羟乙基淀粉200/0.5HES)或4%明胶(GEL)。进行常规凝血试验,测凝血功能用血小板功能分析法(PFA-100®)ROTEG®分析法进行体外出血时间功能测定。所有参量均用方差分析组间差异用曲线下计算面积(AUCA–D)检验。所有时间变量,除了非固有凝血时间(ExCT,非固有血凝块形成时间(ExCFT,固有血凝块形成时间(InCFT)外,均证明有明显时间依赖性,即静脉输注液体,减弱了血小板介导的止血和凝血功能。胶体组与晶体组相比,总的血凝快强度、纤维蛋白原和血凝块弹性均降低(InA20: HES, -13.0 mm; GEL, -11.5 mm; RL, -1.3 mm; P = 0.042; FibA20: HES, -10.5 mm; GEL, -6.0 mm; RL, -1.3 mm: P < 0.0001; MCE: HES, -48; GEL, -35; RL, -15.8; P < 0.0001)GEL组与HES组相比,纤维蛋白浓度明显低,然而,两胶体组均有蛋白浓度下降趋势。

 结论 输注胶体比单纯晶体更明显减弱了血凝块强度,虽然对血凝系统影响不大。总血凝块强度降低是由于消弱了纤维蛋白聚合作用,从而导致血凝块纤维蛋白原和血凝快弹性降低。

                                               (李绍清   薛张纲 )

To explore whether routinely administered colloids and crystalloids influence the hemostatic system, we studied 60 patients undergoing knee replacement surgery during randomized intravascular fluid administration using 6% hydroxyethyl starch 200/0.5 (HES) or 4% modified gelatin (GEL) in addition to a basal infusion of lactated Ringer’s solution (RL), or exclusively RL. In addition to routine coagulation tests, measurements of coagulation factors were performed. Also, functional measurements of the in vitro bleeding time by use of the platelet function analyzer (PFA-100®) and ROTEG® analysis (ROTEG®; extrinsically and intrinsically [Ex; In] activated measurements of clotting time, CT [s]; clot formation time, CFT [s]; clot strength, A20 [mm]; fibrinogen component of the clot, FibA20 [mm]; and maximal clot elasticity) were used. Time dependency of variables was analyzed with a repeated-measures analysis of variance (all groups pooled); differences between groups were detected by comparing the calculated area under the curve (AUCA–D). For all variables, except ExCT, ExCFT, and InCFT, a significant time dependency was demonstrated, indicating that impaired platelet-mediated hemostasis and clot formation occurred with IV administration of fluids. Total clot strength, fibrinogen part, and clot elasticity decreased significantly more in the colloid groups than in the RL group (InA20: HES, -13.0 mm; GEL, -11.5 mm; RL, -1.3 mm; P = 0.042; FibA20: HES, -10.5 mm; GEL, -6.0 mm; RL, -1.3 mm: P < 0.0001; MCE: HES, -48; GEL, -35; RL, -15.8; P < 0.0001). The decrease in fibronectin concentrations was significantly smaller with GEL as compared with HES, whereas a weak trend toward a larger decrease in fibrinogen concentrations was observed with both colloids. Results show that colloid administration reduces final clot strength more than does RL alone, which also exhibited effects, albeit minor, on the coagulation system. The reduction in total clot strength was due to impaired fibrinogen polymerization, resulting in a decreased fibrinogen part of the clot and reduced clot elasticity.

 


从先心病婴幼儿获得的胶质蛋白,S100B:神经损伤的预先证明

A Glial-Derived Protein, S100B, in Neonates and Infants with Congenital Heart Disease: Evidence for Preexisting Neurologic Injury

Paula M. Bokesch, MD*, Elumalai Appachi, MD{dagger}, Marco Cavaglia, MD*, Emad Mossad, MD*, and Roger B.B. Mee, MB ChB, FRACS{ddagger}

Departments of *Cardiothoracic Anesthesia, {dagger}Pediatric Critical Care, and the {ddagger}Center for Congenital Heart Disease and Surgery, The Cleveland Clinic Foundation, Ohio

Anesth & Analg Oct. 2002; 95: 907-914.

神经胶质蛋白S100B是脑缺血的标记物和成人心肺转流术后神经损伤相关物。我们旨在证明心肺转流术(CPB)后S100B的释放特征及其同死亡率的相关性。109例有先心病婴幼儿,在术前和术后24h收集血样本,所有病儿术前均行超声心动图检查,术中行低温或无低温转流,双点位免疫测定法测量S100B浓度,并观察30d外科死亡率。术前所有S100B浓度升高的婴儿,术后24h均下降。在32例伴有左室发育不良综合症的婴儿,S100B浓度与血流、主动脉大小和术后死亡率变法一致(r2 = -0.63; P = 0.03)。婴幼儿中,增加肺血流时测得S100B比紫绀时的S100B高,但并不与术后S100BCPB时间、低温循环、30d外科死亡率相一致。结论 术前S100B浓度与左室发育不良综合症、升主动脉大小相一致,S100B可能作为预先存在脑损伤和脑细胞死亡的指示剂。

                                              (李绍清   薛张纲 )

The glial-derived protein S100B is a serum marker of cerebral ischemia and correlates with negative neurological outcome after cardiopulmonary bypass (CPB) in adults. We sought to characterize the S100B release pattern before and after CPB in neonates and infants with congenital heart disease and correlate it with surgical mortality. Serum was collected before surgery and at 24 postoperative h from 109 neonates and infants with congenital heart disease. All patients had presurgical transthoracic echocardiograms and CPB with or without hypothermic circulatory arrest. S100B concentrations were determined using a two-site immunoluminometric assay (Sangtec 100TM). Thirty-day surgical mortality was observed. All neonates had significantly increased S100B concentrations before surgery that decreased by 24 postoperative h. Preoperative S100B concentrations in 32 neonates with hypoplastic left heart syndrome correlated inversely with the forward flow and size of the ascending aorta and postoperative mortality (r2 = -0.63; P = 0.03). Among infants, increased pulmonary blood flow was associated with higher S100B levels before surgery than cyanosis. There was no correlation with postoperative S100B and time on CPB, hypothermic circulatory arrest, or 30-day surgical mortality. In conclusion, preoperative S100B concentrations correlate inversely with the size of the ascending aorta in hypoplastic left heart syndrome and may serve as a marker for preexisting brain injury and mortality.

 

异丙酚对急性分离的大鼠脊髓背角神经元γ-氨基丁酸-A和甘氨酸受体的作用

The Actions of Propofol on {gamma}-Aminobutyric Acid-A and Glycine Receptors in Acutely Dissociated Spinal Dorsal Horn Neurons of the Rat

Xian-Ping Dong, MS, and Tian-Le Xu, PhD MD

Laboratory of Receptor Pharmacology, Department of Neurobiology and Biophysics, University of Science and Technology of China, Hefei, People’s Republic of China

Anesth &Analg Oct.2002; 95: 907-914

脊髓在调节麻醉药诱导的伤害性传递的抑制中发挥重要作用。为了解异丙酚在脊髓水平的麻醉机制,我们用整体细胞的斑片钳电生理技术对异丙酚在急性分离大鼠背角神经元以及对γ-氨基丁酸-A和甘氨酸受体的调节进行研究。异丙酚诱导对bicuculline敏感而对strychnine敏感较差的氯离子电流。异丙酚诱导的氯离子电流在激活,脱敏,灭活上较GABA和甘氨酸诱导的氯离子电流为慢。另外,本研究显示异丙酚对GABA受体和甘氨酸受体有相同的调节作用。异丙酚在低浓度时增强GABA和甘氨酸诱导的氯离子电流,而在高浓度时则抑制。异丙酚对氯离子电流的增强是由缓慢电流的脱敏和灭活引起,而抑制作用则可能包含GABA和异丙酚诱导的氯离子电流之间的交叉脱敏以及GABA受体和甘氨酸受体之间的交叉抑制。结果显示异丙酚在脊髓水平对GABA受体和甘氨酸受体的易化显著利于全身麻醉药诱导的镇痛和麻醉的产生。.

(张俊峰 译    薛张纲 校)

 

 The spinal cord plays an important role in modulating anesthetic-induced suppression of nociceptive transmission. To gain some insight into the anesthetic mechanisms of propofol at the spinal level, we investigated the direct action of propofol and its modulation on the {gamma}-aminobutyric acid-A receptor (GABAAR) and the glycine receptor (GlyR) in acutely dissociated rat spinal dorsal horn neurons by using whole-cell patch-clamp electrophysiology. Propofol induced Cl- currents (ICl), which were sensitive to bicuculline and, to a lesser extent, to strychnine. The activation, desensitization, and deactivation of propofol-induced ICl were slower than those of GABA- and glycine-induced ICl. In addition, this study revealed similar modulatory actions of propofol on GABAAR and GlyR. Propofol potentiated both GABA- and glycine-induced ICl at small con-centrations and inhibited both GABA- and glycine-induced ICl at large concentrations. The potentiation of propofol on ICl was caused by slowing current desensitization and deactivation, whereas the inhibition actions might be involved in the cross-desensitization between GABA- and propofol-induced ICl and the cross-inhibition between the GABAAR and GlyR. The results suggest that propofol facilitation of GABAAR and GlyR at the spinal level could contribute significantly to general anesthetic-induced analgesia and anesthesia

乳癌手术后GabapentinMexiletine的镇痛效应

The Analgesic Effect of Gabapentin and Mexiletine After Breast Surgery for Cancer

Argyro Fassoulaki, MD PhD, DEAA*, Konstantinos Patris, MD{dagger}, Costantine Sarantopoulos, MD DEAA{ddagger}, and Quinn Hogan, MD{ddagger}

*Department of Anesthesiology, Aretaieion Hospital, Medical School, University of Athens; {dagger}Department of Anesthesiology, St Savas Hospital, Athens, Greece; and {ddagger}Department of Anesthesiology, Medical College of Wisconsin, Milwaukee

Anesth & Analg Oct.2002; 95: 985-991.

我们研究了mexiletinegabapentin75例乳癌手术后伴随的急性慢性疼痛病人上镇痛效应。病人以双盲方式,随机分为接受mexiletine 600 mg/d, gabapentin 1200 mg/d,或安慰剂治疗10天。麻醉过程标准化,所有病人常规按需接受术后镇痛药。VAS在静息和运动后评定。三个月后,所有都随访确定慢性疼痛的强度和镇痛药的需要量。从第二到第十天, Mexiletine gabapentin减少可待因的消耗50%同时,总的扑热息痛的消耗也减少了,两种药物应用静息和运动后疼痛在术后第三天都减少。运动后疼痛应用gabapentin后在术后第二和第五天也减轻。各治疗组慢性疼痛发生率,强度,镇痛药物的需要都不受影响。然而,烧灼痛在对照组发生更多。

(张俊峰 译    薛张纲 校)

 

We investigated the analgesic efficacy of mexiletine and gabapentin on acute and chronic pain associated with cancer breast surgery in 75 patients. They were randomized to receive, in a double-blinded manner, mexiletine 600 mg/d, gabapentin 1200 mg/d, or placebo for 10 days. Anesthesia was standardized, and all patients had access to routine postoperative analgesics on demand. The visual analog scale score assessed pain at rest and after movement. Three months later, all patients were interviewed to identify intensity of chronic pain and analgesic requirements. Mexiletine and gabapentin reduced codeine consumed from the second to tenth day by 50% (P = 0.029; P = 0.018 and P = 0.035 for mexiletine versus control and gabapentin versus control comparisons, respectively). Total paracetamol consumption was also reduced during the same time (P = 0.0085; P = 0.007 and P = 0.011 for the mexiletine and gabapentin groups when compared with the control, respectively). Pain at rest and after movement was reduced by both drugs on the third postoperative day. Pain after movement also was reduced by gabapentin between the second and fifth postoperative day. Three months later, the incidence of chronic pain, its intensity, and need for analgesics were not affected by either treatment. However, burning pain was more frequent in the control group (P = 0.033).

Cochrane Anesthesia Review Group的使命:准备和发布系统的麻醉学中关于卫生保健效果的综述文献

The Mission of the Cochrane Anesthesia Review Group: Preparing and Disseminating Systematic Reviews of the Effect of Health Care in Anesthesiology

Tom Pedersen, MD PhD, Ann M. Møller, MD, and Jane Cracknell, RN BA

Department of Anesthesiology, Bispebjerg University Hospital, Copenhagen, Denmark

Anesth & Analg Oct.2002; 95: 1012-1018.

结论 该论文阐述了循证医学(EBM)的基本原则及Cochrane Collaboration Cochrane Anesthesia Review Group的工作范围,描述了随机控制试验和系统的综述文献在为解决临床相关问题提供最佳的证据时的非常重要。

(潘志浩 译    薛张纲 校)

IMPLICATIONS: This article illustrates the basic principles of evidence-based medicine and the work within the Cochrane Collaboration and the Cochrane Anesthesia Review Group. It describes how important randomized controlled trials and systematic reviews are in providing the best evidence to answer clinically relevant questions

气管内肾上腺素:提倡更大的剂量

Endotracheal Epinephrine: A Call for Larger Doses

Yossi Manisterski, MD, Zvi Vaknin, MD, Ron Ben-Abraham, MD, Ori Efrati, MD, Danny Lotan, MD, Mati Berkovitch, MD, Asher Barak, MD, Zohar Barzilay, MD FCCM, and Gideon Paret, MD

Department of Pediatric Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer and the Sackler Faculty of Medicine, Tel Aviv University, Israel

Anesth & Analg Oct.2002; 95: 1037-1041.

心肺复苏当静脉通路还未建立时推荐气管内应用肾上腺素0.02 mg/kg(两倍于静注剂量)。标准的静注剂量用作气管途径给药被认为是太小,因可造成有害的动脉血压的下降,这可能是通过未被α肾上腺素能血管收缩作用所抵消的β受体发生作用。我们进行了一个前瞻,随机实验比较递增的气管内应用肾上腺素的剂量以明确尚未确定的可以增加血压的气管内肾上腺素的最佳剂量。在注射生理盐水(对照)后,盐水稀释的肾上腺素(0.02, 0.035, 0.1, 0.2, 0.3 mg/kg)至少一周间隔分别注入五条麻醉犬的气管插管内。动脉血气分析的血样在用药前,以及在用药后14个时间点直至60分钟。心率和动脉血压用多导记录仪连续监测。只有0.3 mg/kg剂量成功地增加了血压,这在用药后2分钟观察到,持续达10分钟。早期血压的降低只有在剂量等同于目前推荐剂量的10倍时才能避免。结论 我们进行的一个前瞻,随机实验比较递增的气管内肾上腺素的剂量,以明确尚未确定的可以增加血压的气管内肾上腺素的最佳剂量。血压的降低只有在剂量等同于目前推荐剂量的10倍时才能避免。需要有应用更大剂量的气管内肾上腺素以及将他们用作心跳骤停一线治疗的临床研究。

(潘志浩 译    薛张纲 校)

Endotracheal administration of epinephrine 0.02 mg/kg (twice the IV dose) is recommended when IV access is unavailable during cardiopulmonary resuscitation. The standard IV dose has been considered too small for the endotracheal route by causing a detrimental decrease of arterial blood pressure (BP), presumably mediated by the ß-adrenergic receptor unopposed by {alpha}adrenergic vasoconstriction. We conducted a prospective, randomized, laboratory comparison of increasing doses of endotracheal epinephrine to ascertain the yet undetermined optimal dose of endotracheal epinephrine that would increase BP. After injecting normal saline (control), saline-diluted epinephrine (0.02, 0.035, 0.1, 0.2, and 0.3 mg/kg) was injected into the endotracheal tube of five anesthetized dogs at least 1 wk apart. Arterial blood samples for blood gases were collected before and at 14 time points up to 60 min after the drug administration. Heart rate and arterial BP were continuously monitored with a polygraph recorder. Only the 0.3 mg/kg dose successfully caused an increase in BP, observed 2 min after administration, and lasting for 10 min. An early decrease in BP was obviated only at a dose equivalent to 10-fold the currently recommended one.

使用外周神经刺激仪定位的臂丛神经阻滞四点法:腋路和肩部入路的比较

Four-Injection Brachial Plexus Block Using Peripheral Nerve Stimulator: A Comparison Between Axillary and Humeral Approaches

Salvatore Sia, MD, Antonella Lepri, MD, Maria Consolata Campolo, MD, and Rossana Fiaschi, MD

Department of Anesthesiology, Centro Traumatologico Ortopedico, Azienda Ospedaliera Careggi, Firenze, Italy

Anesth & Analg Oct.2002; 95: 1075-1079

我们设计该前瞻性、随机试验比较神经刺激仪定位的臂从阻滞四点法分别在腋路(腋路组,50例)和肩部(肩部组,50例)水平两种方法在麻醉成功率、操作时间及麻醉起效时间上的差异。所有病人均予以0.5% bupivacaine 2% lidocaine等量混合液40ml。由于未在规定时间内准确定位,有6例患者(其中腋路组4例,肩部组2例)被排除于该研究。完全阻滞定义为肘部以下的所有感觉区域被阻滞,两组在完全阻滞率(91%89%)和感觉阻滞起效时间(15 ± 6 min 16 ± 7 min)并无差异。肩部组的操作时间则相对较短(7 ± 2 min 8 ± 2 min; P < 0.005),但腋路组的阻滞操作疼痛时间则较短(16 ± 9 min versus 23 ± 12 min; P < 0.005)。因此,我们认为腋路和肩部入路臂丛阻滞都可获得高的成功率及迅速的感觉阻滞效果,本试验中发现的差异并无临床意义。

(潘志浩 译    薛张纲 校)

We conducted this prospective, randomized study to compare the success 7 ± 2 min versus 8 ± 2 min; P < 0.005)rate, performance time, and onset time of surgical anesthesia of a four-injection brachial plexus block performed at the axillary (Group Axillary; n = 50) or at the humeral (Group Humeral; n = 50) level using a peripheral nerve stimulator. All patients received 40 mL of a mixture of equal parts of 0.5% bupivacaine and 2% lidocaine. Four patients in Group Axillary and two in Group Humeral were excluded from the study because all of the four nerves were not localized in the allotted time. The incidence of complete block (91% versus 89%), defined as block of all the sensory areas below the elbow, and the onset time of sensory block (15 ± 6 min versus 16 ± 7 min) were not different between the groups. The performance time was shorter in Group Humeral (7 ± 2 min versus 8 ± 2 min; P < 0.005). Block performance pain was lower in Group Axillary patients (16 ± 9 min versus 23 ± 12 min; P < 0.005). For four-injection brachial plexus block, we conclude that both the axillary and the humeral approaches provide a high success rate and a rapid onset of sensory anesthesia; the differences found between the groups could be considered clinically unimportant.

自愿者中Dexmedetomidine 诱导的镇静会降低脑局部和全脑的血流量

Dexmedetomidine-Induced Sedation in Volunteers Decreases Regional and Global Cerebral Blood Flow

Richard C. Prielipp, MD FCCM*, Michael H. Wall, MD*, Joseph R. Tobin, MD FCCM*, Leanne Groban, MD*, Mark A. Cannon, MD*, Frederic H. Fahey, DSc{dagger}, H. Donald Gage, PhD{dagger}, David A. Stump, PhD*, Robert L. James, MS*, Judy Bennett, RN*, and John Butterworth, MD*

Departments of *Anesthesiology (Sections of Critical Care and Cardiothoracic Anesthesiology) and {dagger}Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth & AnalgOct.2002; 95: 1052-1059.

Dexmedetomidine 是一种可用于危重病人镇静的选择性的α2受体激动剂,目前对其药效学特性已有相当多的了解,但其对脑血流动力学的影响却知之甚少。我们假定治疗剂量的Dexmedetomidine会降低脑血流(CBF)。9位年龄在2448岁的自愿者接受了研究,仰卧位下予以负荷剂量的Dexmedetomidine1 µg/kg IV,然后予以维持量:低剂量组(0.2 µg · kg-1 · h-1 )和高剂量组(0.6 µg · kg-1 · h-1 ),采用PET测定各时间点的血流动力学参数和CBF。结果显示两组的心输出量(CO)及心率(HR)在药物输注中和输注后30分钟均降低,血压在输注中和输注后降低12%到16%,CBF从基线(91 mL · 100 g-1 · min-1 [95%可信区间, 72–114] 分别降低到64 mL · 100 g-1 · min-1 [51–81] (低剂量组)和 61 mL · 100 g-1 · min-1 [48–76] (高剂量组)。这种CBF的降低在停止输注至少30分钟后仍持续存在,尽管在这期间其血浆浓度已降低了40(628 pg/mL [524–732] 380 pg/mL [253–507])

(潘志浩 译    薛张纲 校)

Dexmedetomidine is a selective {alpha}2-agonist approved for sedation of critically ill patients. There is little information on the effects of dexmedetomidine on cerebral blood flow (CBF) or intracranial hemodynamics, despite considerable other pharmacodynamic data. We hypothesized that therapeutic doses of dexmedetomidine would decrease CBF. Therefore, nine supine volunteers, aged 24–48 yr, were infused with a 1 µg/kg IV loading dose of dexmedetomidine, followed by an infusion of 0.2 µg · kg-1 · h-1 (LOW DEX) and 0.6 µg · kg-1 · h-1 (HIGH DEX). Hemodynamic and CBF (via positron emission tomography) measurements were determined at each experimental time point. Dexmedetomidine decreased both cardiac output and heart rate during and 30 min after drug administration. Blood pressure decreased from 12% to 16% during and after the dexmedetomidine administration. Global CBF was decreased significantly from baseline (91 mL · 100 g-1 · min-1 [95% confidence interval, 72–114] to 64 mL · 100 g-1 · min-1 [51–81] LOW DEX and 61 mL · 100 g-1 · min-1 [48–76] HIGH DEX). This decrease in CBF remained constant for at least 30 min after the dexmedetomidine infusion was discontinued, despite the plasma dexmedetomidine concentration decreasing 40% during this same time period (628 pg/mL [524–732] to 380 pg/mL [253–507]).

坐骨神经与小转子关系:关联坐骨神经前方阻滞

The natomic Relationship of the Sciatic Nerve to the Lesser Trochanter: Implications for Anterior Sciatic Nerve Block

Marty L. Ericksen, MD, Jeffrey D. Swenson, MD, and Nathan L. Pace, MD Mstat

Department of Anesthesiology, University of Utah, Salt Lake City

Anesth & Analg Oct. 2002; 95: 1090-1093

经典坐骨神经阻滞要求在小转子水平进针。最近研究证明,在小转子水平,坐骨神经并不容易阻滞。为了更准确定位坐骨神经与小转子关系,我们分析了20例仰卧位髋和股骨近端磁共振扫描影像,从五个轴面分析,特别是小转子和小转子下4cm1cm厚平面。在每轴上,从中间和侧面两点测失状位上股骨边缘到坐骨神经的距离:如果坐骨神经从侧位走向失状位,值计为负值(不易阻滞),从中位到失状位,计为正值(易阻滞)。股骨前缘和坐骨神经冠状平面间距离在每一观察轴,均记录。小转子平面,坐骨神经相对股骨缘,20例中13例在侧面,平均距离为-4.0 ± 7.7 mm。小转子下4cm处,20例有19例在中位,平均距离7.8 ± 5.8 mm。小转子平面,坐骨神经距股骨前缘42.9 ± 5.8 mm;小转子下4cm处,45.7 ± 9.5 mm。经典的坐骨神经前路阻滞证明小转子平面是中等远离的。我们的数据与最近大多数报道的小转子平面坐骨神经前路阻滞不易成功相一致的。但,小转子下4cm处,20例有19例坐骨神经在中位。结论:在股骨近端,小转子下4cm处,中间位行坐骨神经阻滞更易成功。

                                           (李绍清 译  薛张刚校)

Classic descriptions of the anterior sciatic nerve block suggest needle placement at the level of the lesser trochanter of the femur. Recently, investigators have reported that the sciatic nerve is not accessible at this level. To define more accurately the anatomic relationship of the sciatic nerve to the lesser trochanter, we analyzed magnetic resonance scans performed on 20 patients in the supine position. After IRB approval, magnetic resonance scans of the hip and proximal femur were reviewed in 20 supine patients in the neutral position. Images from five axial levels were studied, specifically, at the level of the lesser trochanter and at 1-cm intervals inferior to the lesser trochanter for 4 cm. In each axial image, the medial or lateral distance was measured from the sciatic nerve to a sagittal plane at the medial border of the femur. If the sciatic nerve was lateral to this sagittal plane (inaccessible), the distance was assigned a negative value, and if the sciatic nerve was medial to the sagittal plane (accessible), the distance was assigned a positive value. The distance between the coronal plane at the anterior border of the femur and the coronal plane through the sciatic nerve was also recorded for each level. At the level of the lesser trochanter, the sciatic nerve was lateral to the femoral border (inaccessible) in 13 of 20 patients with a mean distance of -4.0 ± 7.7 mm. At 4 cm below the lesser trochanter, the sciatic nerve was medial to the femoral border (accessible) in 19 of 20 patients with a mean distance 7.8 ± 5.8 mm. The distance from the anterior border of the femur to the sciatic nerve was 42.9 ± 5.8 mm at the level of the lesser trochanter and 45.7 ± 9.5 mm at 4 cm below the lesser trochanter. The classic description of the anterior approach to the sciatic nerve suggests that the needle be walked off medially at the level of the lesser trochanter. Our data are consistent with recent reports suggesting that in the majority of subjects, the position of the sciatic nerve relative to lesser trochanter made it inaccessible from an anterior approach at this level. In contrast, at 4 cm below the lesser trochanter, the sciatic nerve was medial to the femur in 19 of 20 subjects. We conclude that needle insertion medial to the proximal femur, 4 cm below the lesser trochanter, is a more direct anatomical approach to the anterior sciatic nerve block.

使用弹性橡胶管芯以盲插法或间接喉镜法在非预期困难插管病人中进行气管内插管的比较

Endotracheal Intubation with a Gum-Elastic Bougie in Unanticipated Difficult Direct Laryngoscopy: Comparison of a Blind Technique Versus Indirect Laryngoscopy with a Laryngeal Mirror

Marian Weisenberg, MD*, R. David Warters, MD{dagger}, Benjamin Medalion, MD{ddagger}, Peter Szmuk, MD{dagger}, Yehuda Roth, MD§, and Tiberiu Ezri, MD*

From the Departments of *Anesthesia, {ddagger}Cardiothoracic Surgery, and §Otorhynolaryngology, Wolfson Medical Center, Holon, affiliated with Sackler School of Medicine, Tel Aviv, Israel; and {dagger}Department of Anesthesiology, University of Texas Medical School at Houston, Texas

Anesth & Analg Oct.2002; 95: 1090-1093.

我们比较了使用弹性橡胶管芯以盲插法或间接喉镜法在非预期困难插管病人中进行气管内插管的效果。在一个前瞻研究中,连续60名非预期直接喉镜困难插管III-IV级病人随机分为两组:盲插法(组1)和间接喉镜法,评估其插管失败率、并发症及插管所需时间。在两个月的研究过程中,725名病人中的60名非预期直接喉镜困难插管III级病人随机分入两组,每组30名。组18例插管失败,组21例,盲插法组的8例失败均为气管导管进入食道。插管时间两组无明显差异,分别为45+/-10s44+/-11s;两组均未见其他并发症。因此可知使用弹性橡胶管芯间接喉镜法气管插管与传统的盲插法相比有较低的失败率。提示:我们评估了使用弹性橡胶管芯以盲插法或间接喉镜法在非预期困难插管病人中进行气管内插管的效果,间接喉镜法气管插管与传统的盲插法相比有较低的失败率(P<0.05)。

                                           (陈     薛张纲 校)                                                                                                   

We evaluated the efficacy of intubation over a gum-elastic bougie by using either a blind technique or indirect laryngoscopy with a laryngeal mirror in patients with unexpected difficult direct laryngoscopy. In a prospective study, 60 consecutive patients with an unexpected Grade III or IV direct laryngoscopy were randomly allocated for intubation with a gum-elastic bougie either blindly (Group 1) or by indirect laryngoscopy with a laryngeal mirror (Group 2). We evaluated the failure rate of each method of intubation, complications related to either method, and the time required for intubation. Out of 725 patients evaluated over a 2-mo period, 60 patients (8.3%) had a Grade III laryngoscopy, and 30 of these were randomized into each group. There were 8 failed intubations in Group 1 compared with 1 failed intubation in Group 2 (P < 0.05). All eight failures in the blind intubation group ended with esophageal intubation. No additional complications were noted in either group. The time required for endotracheal intubation with each group was not significantly different (45 ± 10 s versus 44 ± 11 s). We conclude that intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror than a traditional blind technique.

 

韩国针刺穴位使用辣椒贴可以降低经腹子宫切除术病人术后恶心呕吐发生率

Capsicum Plaster at the Korean Hand Acupuncture Point Reduces Postoperative Nausea and Vomiting After Abdominal Hysterectomy

 

Kyo S. Kim, MD PhD*, Min S. Koo, MD*, Jeong W. Jeon, MD*, Hahck S. Park, MD{dagger}, and Ik S. Seung, MD PhD*

*Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea; and {dagger}Department of Anesthesiology, College of Medicine, In Je University, Seoul, Korea

Anesth & Analg Oct.2002;95(4):1103-7

全麻术后恶心呕吐(PONV)仍是一个常见的困绕我们的问题,尤其是那些经腹子宫切除术病人。我们研究了PONV的非药物治疗方法,即在双手韩国针刺穴位K-D2或中国心包针刺穴位P6上敷贴辣椒贴(PAS)。160名病人参加该随机双盲实验,对照组60名,K-D250名,P650名。K-D2组在K-D2点上使用PAS,组在P6点上使用PAS,对照组则在K-D2点使用无活性贴,使用时间为麻醉诱导前至术后8小时,并在一定时间间隔记录恶心呕吐发生率和相关治疗。术后24小时治疗组的恶心发生率(K-D222%P626%)明显低于对照组(56.7%),P<0.001;镇吐治疗的需要亦明显低于对照组。因此,在韩国手法针刺穴位使用PAS是一种减少PONV的有效方法。提示:无论韩国手法针刺穴位K-D2还是在中国心包针刺穴位P6上敷贴辣椒贴均可减少经腹子宫切除术病人术后恶心呕吐发生率。

  薛张纲 校)

 

Postoperative nausea and vomiting (PONV) are still common and distressing problems after general anesthesia, especially in patients undergoing abdominal hysterectomy. We studied a nonpharmacological therapy of PONV—capsicum plaster (PAS)—at either the Korean hand acupuncture point K-D2 or the Chinese acupuncture point Pericardium 6 (P6) of both hands. One-hundred-sixty healthy patients were included in a randomized, double-blinded study: 60 patients were in the control group, 50 patients were in the K-D2 group, and 50 patients were in the P6 group. PAS was applied at the K-D2 point in the K-D2 group and at the P6 point in the P6 group, whereas in the control group, an inactive tape was fixed at the K-D2 point of both hands. The PAS was applied before the induction of anesthesia and removed at 8 h after surgery. The incidence of PONV and the need for rescue medication were evaluated at predetermined time intervals. In the treatment group, the incidence of vomiting was significantly less (22% for the K-D2 group and 26% for the P6 group) than in the control group (56.7%) at 24 h after surgery (P < 0.001). The need for rescue antiemetics was significantly less in the treatment groups compared with the control group (P < 0.001). We conclude that PAS at the Korean hand acupuncture point K-D2 was an effective method for reducing PONV, as was PAS at the P6 acupoint, after abdominal hysterectomy.