Anesthesia & Analgesia

October 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

高位胸段硬膜外麻醉用於兩種方式的冠狀動脈旁路移植術

(   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

前負荷調整最大功率作為右室收縮力指數的局限性

(   薛張綱 )

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.

丙帕他莫用於心臟手術患者術後輔助鎮痛

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

心臟手術後的持續性疼痛:一項關於高位胸段硬膜外和阿片類藥物鎮痛治療的調查

(   薛張綱 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.

體外迴圈期間糾正血漿內鎂離子濃度可降低術後心律失常的風險

(殷文淵   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

 

前負荷指數:肺移植術中監測肺動脈阻塞壓和胸腔內血容量的對比

(張 鴻 譯  薛張綱 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.

急性等容血液稀釋期間使用β-腎上腺素激動劑可恢復氧攝取的儲備力

(殷文淵 譯  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

圍術期晶膠體輸注對血小板介導的止血及凝血的影響

(李紹清 譯  薛張綱 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 血漿/ 低血紅蛋白系統能準確測量血漿中三個不同的低濃度血紅蛋白氧載體(HBOCs):

(  輝 譯   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:

從先心病嬰幼兒獲得的膠質蛋白,S100B:神經損傷的預先證明

(李紹清 譯  薛張綱 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:

神經類固醇麻醉劑Alphaxalone)抑制牛腎上腺素嗜鉻細胞的煙鹼酸乙酰膽鹼受體

(朱慧琛 譯 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

 

異丙酚對急性分離的大鼠脊髓背角神經元γ-氨基丁酸-A和甘氨酸受體的作用

(張俊峰 譯    薛張綱 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:

入院前創傷監護過程中積極升溫對脈搏血氧定量法信號質量的影響

(朱慧琛 譯 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:

阿片類物質戒斷期間的痛覺過敏:谷氨酸和P物質介導

(忻紀華 譯  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

乳癌手術後GabapentinMexiletine的鎮痛效應

(張俊峰 譯    薛張綱 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.

在鼠的鞘內注射離子變異的穀氨酰胺受體激動劑後的發聲反應

(忻紀華 譯  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:準備和發佈系統的麻醉學中關於衛生保健效果的綜述文獻

(潘志浩 譯    薛張綱 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:

肺復蘇成功的豬模型中 高滲高張溶液減少心臟肌鈣蛋白IS—100 的釋放的研究

(忻紀華 譯  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 

氣管內腎上腺素:提倡更大的劑量

(潘志浩 譯    薛張綱 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:

高碳酸血症對收縮期Sylvius導水管內腦脊液流速峰值的影響

(周 潔   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

自願者中Dexmedetomidine 誘導的鎮靜會降低腦局部和全腦的血流量

(潘志浩     薛張綱 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:

正中徑路經骶孔硬膜外阻滯

(周 潔 譯  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

坐骨神經與小轉子關係:關聯坐骨神經前方阻滯

(李紹清   薛張剛校)

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.

使用外周神經刺激儀定位的臂叢神經阻滯四點法:腋路和肩部入路的比較

(潘志浩 譯    薛張綱 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

利多卡因和擬腎上腺素收縮藥物對鼠坐骨神經和骨骼肌血流的影響

(   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:

使用彈性橡膠管芯以盲插法或間接喉鏡法在非預期困難插管病人中進行氣管內插管的比較

(陳 智 譯    薛張綱 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.

睡眠呼吸暫停綜合征病人與困難氣管內插管

(齊 波 譯  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

韓國針刺穴位使用辣椒貼可以降低經腹子宮切除術病人術後噁心嘔吐發生率

(陳 智  薛張綱 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於兩種方式的冠狀動脈旁路移植術

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

 

隨著非人工心肺機的冠脈搭橋手術(OPCAB)的開展,該類病人採用高位胸段硬膜外麻醉(TEA,手術中病人保持清醒。以往, TEA僅報導用於經外側胸廓切開後單支血管搭橋手術。20例患者分為下段部分胸骨切開後接受不停跳單支血管搭橋術患者(微創冠脈搭橋術[MIDCAB]n=10),和完全中段胸骨切開多根血管疾病患者(不停跳冠脈搭橋術[OPCAB]; n=10)。硬膜外導管置於胸1-22-3間隙。硬膜外注入0.5%羅呱卡因和1.66g/ml的舒芬太尼至麻醉平面到達頸5-6用於OPCAB或胸1-2用於MIDCAB9OPCAB8MIDCAB患者在整個手術過程中保持清醒並且自主呼吸。由於手術過程中產生氣胸(OPCAB),麻醉不充分以及膈神經麻痹(兩組),三例患者要求術中轉為全麻。術中兩組10-15%的患者心率顯著下降,與基礎值(B)相比,平均動脈壓僅在冠脈吻合(CA)時顯著下降(BOPCAB, 95±11; CAOPCAB, 68±9;BMIDCAB, 86±10; CAMIDCAB, 73±10;兩組間無顯著差異。術中OPCABPaCO242±2mmHg上升至46±7mmHg(p<0.05),而在MIDCAB組基本保持不變。所有患者均評價TEA“好”“很好”。結論 高位胸段連硬麻醉用於MIDCAB OPCAB手術是可行的,且患者滿意率較高。

                                              (   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.

丙帕他莫用於心臟手術患者術後輔助鎮痛

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

 

心臟手術後鎮痛主要使用腸道外阿片類藥物,由於阿片類藥物有諸多副作用,推薦同時服用非阿片類鎮痛藥用以減少阿片類藥物的劑量。本研究採用隨機雙盲前瞻性方法評價丙帕他莫——靜脈使用的對乙酰氨基酚(撲熱息痛)前體,對心臟術後輔助鎮痛的療效。隨機選擇79例擇期冠脈搭橋手術的患者,分為兩組:術後72小時內每隔6小時靜脈注射2g丙帕他莫n=40)或安慰劑(n=39)。從拔管後,病人通過患者自控裝置接受阿片類藥物(氧化可代因)。每天4次使用視覺疼痛評分表來評價鎮痛效果,同時每日評價呼吸功能(用力肺容量、1秒用力呼氣量,呼氣峰值流量和動脈血氣測量)。基本有效量(72小時氧化可代因的累計消耗量)在丙帕他莫組為123.5±51.3mg;安慰劑組為141.8mg±57.5mg。睡眠組(p=0.65)和深呼吸組(p=0.72)的疼痛評分無顯著差異。兩組在肺功能檢查、術後出血、肝臟功能、副反應的發生率方面均無顯著差異。並採用apost hoc分析法研究第一個24小時內每6小時內的資料,發現24小時氧化可代因的消耗在丙帕他莫組顯著低於對照組(47.1±20.7mg比較57.9±23.9mg p=0.036)。結果表明丙帕他莫沒有加強冠脈搭橋手術後阿片類藥物的鎮痛效果,也沒有減少術後三天阿片類藥物的消耗量和副作用。然而,apost hoc分析發現第一個24小時內丙帕他莫組氧化可代因的用量減少。

 

(   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.

 

 

體外迴圈期間糾正血漿內鎂離子濃度可降低術後心律失常的風險

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

 

我們隨機抽取病例進行對照試驗以確定術中測量和糾正血漿內鎂離子是否可以降低體外迴圈後心律失常的風險。我們選擇了85例進行冠狀動脈搭橋的患者,隨機分成兩組,一組是根據血漿內鎂離子濃度給以硫酸鎂的患者(n=43),另一組是知道鎂離子濃度但不予糾正的對照組(n=42)。我們利用離子選擇電極在最短時間內計算鎂離子濃度然後將樣本帶入實驗室測定血漿內鎂濃度。所有的病人在術後72小時內帶上Holter以監測心電圖。在體外迴圈之前總的血鎂濃度下降比鎂離子下降的發生機率更高,前者有45個病人發生血鎂下降,占總病人數的53%,後者有11個病人發生離子鎂下降,占總病人數 11%。對照組的患者在體外迴圈過程中血鎂和離子鎂濃度進一步下降。在起初的24小時內糾正鎂離子的一組患者室性心動過速發生率比對照組低,前者3,7%,後者12,30%,(P0.01〉,且前者竇性心律患者高於後者,分別是14個(30%)和2個(5%P0.01。結果表明術中糾正鎂離子濃度可以減少心臟手術後室性心律失常的發生。

                                             (殷文淵 譯  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.

      

急性等容血液稀釋期間使用β-腎上腺素激動劑可恢復氧攝取的儲備力

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

 

在急性等容血液稀釋(ANH)期間由於氧分壓降低導致攝取分數(EO2)的代償性增加,從而增加組織缺氧的風險。假定在急性等容血液稀釋期間應用β-腎上腺素激動劑異丙腎上腺素(ISOP)增加心排血量,從而扭轉氧攝取的代償性增加並恢復組織氧供的安全係數。本研究在選擇7只麻醉的狗,通過溫度稀釋發法測量心排血量,通過放射性微球體測量局部血流(RBF)。我們計算出全身氧輸送量(DO2),氧耗量(VO2),氧攝取(EO2)以及局部氧輸送量(DO2)。每只狗的所有資料都在以下條件下測定:1)基準-12ISOP0.1g·kg-1·min-1IV),3)基準-24ANH,和5)在ANH期間使用ISOP。實驗狗的基礎血球壓積為45%±3%ANH後為18%。在ANH前,ISOP導致心排血量和全身氧輸送量增加,而氧耗量不變氧攝取減少,同時心肌和脾臟血流增加,胰腺血流減少,而大腦、脊髓和其他組織血流沒有變化。在急性等容血液稀釋期間心排血量增加以代償動脈氧含量降低所致的全身氧輸送下降;而氧攝取增加以保持全身氧耗量穩定。急性等容血液稀釋期間心肌、大腦、十二指腸和胰腺血流增加以維持這些臟器的氧輸送量,而腎臟和脾臟的氧輸送降低。ISOPANH期間可增加心排血量和全身氧輸送量,這就可以使全身的氧攝取恢復到原來水平,並可以增加心肌,腎臟,十二指腸以及脾臟的血流。結論  1. ANH期間使用β-腎上腺素激動劑異丙腎上腺素可以恢復氧攝取的儲備力且對身體組織無副作用,2. ANH期間使用促心肌收縮的藥物如ISOP,或許可以擴大血球壓積下降的界限。

                                             (殷文淵   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 血漿/ 低血紅蛋白系統能準確測量血漿中三個不同的低濃度血紅蛋白氧載體(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

 

為證實HemoCue 血漿/ 低血紅蛋白系統在測定基礎血紅蛋白氧載體(HBOCs)的準確性。本實驗反復測試50例犬類的血漿標本,發現每一例都混合有三個不同的HBOCs。兩個技術人員對每一例樣本都進行了10次隨機測試,同時分析其相關性及差異性,並評估統計學意義,P<<0.05。與床邊光度計測量的血紅蛋白濃度與已知的樣本濃度無太大區別,且兩位研究員對相同的標本進行的單獨測試結果也未存在重大的不同之處。所有的HBOCs測試及測試濃度都是真實的。主要的測試資料偏差以樣品濃度的百分比表示。0.1%為血色素glutamer-200()0.58%為血色素glutamer-250()0.19%為血色素raffimer。三個HBOCs的主要偏差都〈8%。這些檢測都具有很高的可信度及統計學意義。HemoCue 血漿/ 低血紅蛋白系統是探測和測量血漿低濃度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.

神經類固醇麻醉劑(Alphaxalone)抑制牛腎上腺素嗜鉻細胞的煙鹼酸乙酰膽鹼受體

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

 

有證據顯示全身麻醉劑作用於煙鹼酸乙酰膽鹼受體(nAChRs)。Alphaxalone (5 σ-pregnan-3σ-ol-11, 20-dion) 是應用於臨床麻醉一類神經類固醇,nAChRs的作用尚未進行過很好的調查研究。本研究觀察alphaxalone 對牛腎上腺素嗜鉻細胞nAChRs的作用,同時採用鈣離子成像和全細胞修補術觀察alphaxalone對煙鹼遞質的增加及胞漿鈣離子濃度和膜電流的影響及其對同一細胞上7-胺基丁酸受體的作用,比較了其對nAChRs的不同作用。Alphaxalone (0.1-100 M)抑制了濃度依賴的鈣離子介導的煙鹼遞質的增長,Alphaxalone 抑制了高K+-Ca2+的增長,但其抑制作用只能在100M時被觀測到。在voltage-clamp實驗中運用負電壓alphaxalone (0.1-100 M) 本身即可引發內向電流, 且其能被木防己苦毒素(picrotoxin)的7-胺基丁酸受體解除。Alghaxalone也抑制了煙鹼遞質的內向電流,其抑制作用可被苦味毒(picrotoxin)解除。結果表明麻醉濃度的alphaxalone可抑制腎上腺素嗜鉻細胞的nAChRsAlphaxalone通過抑制nAChRs而作用於迷走神經和其他神經系統。

                                              (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.

 

入院前創傷監護過程中積極升溫對脈搏血氧定量法信號質量的影響

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

類似挫傷和單純骨折這類創傷的受害者通常為醫務輔助人員所運送。許多病人由於喝酒或其他毒品的緣故往往處於醉酒狀態,因而易於發生通氣不充分。所以他們的氧合情況依靠無創脈搏血氧定量法來監測。我們測試了在運送醫院途中對全身進行積極升溫能提高動脈血氧飽和度監測(SpO2)的可靠性的假設。在這個研究中,24名運送至醫院的創傷病人隨機分為兩組:一組(n=12)覆蓋普通的羊毛毯,而另一組(n=12)則在運輸途中使用熱毯。我們記錄中心溫度,顫抖,前臂和手指的皮膚溫度,SpO2和血液動力學變化。在隨機選擇前,兩組都是具有可比性的。到達醫院後,積極升溫的病人明顯具有較高的中心溫度(36.1±0.3 35.5±0.3;P<0.001)和皮膚溫度(34.1±1.5 24.9±1.4;P<0.001)。在積極升溫組中,脈搏血氧飽和度儀的報警次數明顯減少(3158),發生故障的時間明顯減少(146±42s 420±256s),提供了更加穩定的測量資料(P<0.001)。在本研究中,我們發現在創傷病人運送至醫院的途中對其進行積極升溫可以提高脈搏血氧飽和度儀的監測質量。

                                              (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.

阿片類物質戒斷期間的痛覺過敏:谷氨酸和P物質介導

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

 

阿片類物質戒斷痛覺過敏(OAH)是一種以熱和機械性痛覺過敏為特徵的現象,發生于間歇應用阿片類物質或在長期應用這些藥物時突然停藥。本研究試圖確定在患有OAH的小鼠和對照小鼠的鞘內使用初級神經遞質谷氨酸和P物質,前者的活化作用是否大於後者。設定方案是在小鼠中移植嗎啡藥丸,六天後去除,根據熱板和哈格理夫斯熱爪撤離測試評估,小鼠出現了痛覺過敏。機械性異常性疼痛也證實存在。在OAH小鼠和對照組小鼠鞘內注射谷氨酸(5-25g)或P物質(0.02-0.1nmol),前者引起的疼痛行為大於後者。同樣觀察到應用谷氨酸或P物質後在OAH小鼠的脊髓前角區域中的Fos-positive細胞核多於對照組小鼠。本研究表明與對照組小鼠相比較,在鞘內應用谷氨酸和P物質的OAH小鼠顯示出痛覺行為增強和Fos-positive細胞核增多。因而脊柱對初級神經遞質的感受性增強可能與OAH的表現部分相關。

                                             (忻紀華   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.

在鼠的鞘內注射離子變異的穀氨酰胺受體激動劑後的發聲反應

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

 

脊髓中離子變異的穀氨酰胺受體(N—甲基—D—天冬氨酸[NMDA],或天冬氨酸—3—羥基—5—甲基—4—isoxazolepropionic  zcid[AMPA] ,和Kainate受體似乎在急性疼痛的傳遞和慢性疼痛的神經元的適應性中起關鍵作用。疼痛傳導路徑上這些受體活化後產生的發聲反應能夠半自動定量,並且因此可作為一種研究工具。我們研究在正常的鼠和存在外部感染及慢性壓縮損傷引起神經性疼痛的模型鼠的鞘內注射各種穀氨酰胺受體激動劑後引起的發聲反應。非選擇性內源性激動劑,穀氨酰胺,和NMDA受體甘氨酸位點激動劑D—絲氨酸不產生發聲反應,而選擇性作用於AMPANMDAKainate受體的激動劑產生劑量相關性發聲反應。總結:鞘內注射離子型穀氨酰胺受體激動劑可產生短效的,劑量相關性的發聲反應可作為鎮痛的基礎研究和審查的工具。然而,外部感染或神經損傷根本不改變發聲反應,可能提示在這些病理性疼痛的條件下,發聲試驗不能作為研究這些氨基酸的手段。

(忻紀華   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.

肺復蘇成功的豬模型中 高滲高張溶液減少心臟肌鈣蛋白IS—100 的釋放的研究

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,心肺復蘇(CPR)可恢復自主迴圈(ROSC)。但是,神經系統的預後差。高滲高張溶液(HHS)可改善局部或全身缺血後的微血管傳導性。我們研究了豬CPR模型的HHS灌注效應。由於室顫引起心跳驟停。上述的心臟支持在停跳未加干預後4分鐘,基本生命支持後1分鐘。在ROSC基礎上,動物隨機給予125ml的正常生理鹽水(安慰劑,n=8)或7.2%NaCl10%羥乙基澱粉200000/0.5HHS n=7)。至ROSC後,各自用肌鈣蛋白IS—100的血清濃度來評估心肌和腦損傷。所有動物模型中,肌鈣蛋白IS—100水平在ROSC後升高(p<0.0.1)。而HHS組的升高明顯低於安慰劑組。因此在CPR初期有了一個新的選擇,即在心肌和腦缺血後使用HHS可減少細胞損傷。

(忻紀華   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.

                                  

高碳酸血症對收縮期Sylvius導水管內腦脊液流速峰值的影響

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

 

 使用核磁共振可以發現Sylvius導水管內腦脊液流速峰值的變化,並且這一檢查極其敏感,足以發現腦順應性的微小變化。顱內血容量(CBV)改變可以引起腦順應性改變。呼氣末二氧化碳濃度(ETCO2)可以直接影響動脈血二氧化碳分壓,後者可以引起CBV改變。本實驗中,我們在麻醉的病人n=8中研究了高碳酸血症對CBV及收縮期CSFV峰值的影響。與正常血碳酸值的病人(ETCO2=40mmHg)相比,高碳酸血症的病人(ETCO2=60mmHg)其收縮期Sylvius導水管內腦脊液流速峰值明顯減小(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。除了上述數值外,腦順應性的數值改變也提示了收縮期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.

正中徑路經骶孔硬膜外阻滯

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

 

正中徑路經骶孔硬膜外阻滯對於直腸,肛門及尿道附近區域的手術或腫瘤疼痛是十分有效的。由於注射徑路較長,經脊柱骶孔穿刺十分困難。我們發現正中徑路經骶孔硬膜外阻滯比側路穿刺更簡單易行。共有30名膀胱腫瘤病人參加了這一實驗,使用19號穿刺針經正中徑路穿刺。15名病人在S2-3穿刺向頭端置管5cm15名病人向尾端置管。麻醉用藥為2%利多卡因15ml。對兩組病人的麻醉平面,血流動力學情況及副反應進行比較。麻醉有效率(麻醉平面高於T10)為87%,兩組病人骶神經阻滯效果(S1-5)均為100%。注藥後20min時兩組病人的最高麻醉平面分別為頭端組T8,尾端組T9結論 正中徑路經骶孔硬膜外阻滯在操作上可行,而且對骶尾部阻滯效果確切。

                                                (   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.

      

利多卡因和擬腎上腺素收縮藥物對鼠坐骨神經和骨骼肌血流的影響

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

 

已知腎上腺素與利多卡因合用,可以收縮注射部位組織的局部血管,延緩利多卡因的清除,從而延長利多卡因神經阻滯持續的時間。然而,先前的研究並沒有證明單獨和聯合應用利多卡因和腎上腺素對血管特性或局部血流的持續影響。為重新研究,在這個實驗中,分別在坐骨神經和咬肌內注射利多卡因、腎上腺素、選擇性α1受體收縮劑去氧腎上腺素,或聯合應用利多卡因和這些腎上腺素受體收縮劑,在注射及注射後的幾個時間點,應用X射線引導的微球技術測定組織內血流量。通過重複測定分析研究中的變數來評估實驗中有意義的血流變化,發現單獨注射利多卡因(21020mg/ml)和腎上腺素(10g/ml1100000)沒有改變坐骨神經、坐骨神經周圍肌肉或咬肌的血流量。聯合應用利多卡因(10mg/ml)和腎上腺素(10g/ml)對臨近肌肉血流量沒有影響,但引起坐骨神經血流量明顯減少,這在注射後30分鐘最明顯。然而,利多卡因複合應用去氧腎上腺素可明顯減少所有實驗組織的血流量。我們的研究提示除腎上腺素的局部血管收縮效應可延長利多卡因神經阻滯持續時間外還有其他作用機理。

(   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.

睡眠呼吸暫停綜合征病人與困難氣管內插管

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

 

雖然睡眠呼吸暫停綜合征(SAS)病人是常見的,但通過實驗研究來評估此類病人的麻醉管理卻非常少,且主要是個案報導研究。我們進行了回顧性病例對照研究來研究SAS病人困難氣管內插管的發生率,以及SAS的嚴重程度與困難氣管內插管之間的關係。在113例病人中包括36SAS病人和77例對照組病人,結果發現SAS病人困難氣管內插管明顯多於對照組(SAS組為21.9%,而對照組為2.6%P<0.05)。SAS嚴重程度與困難氣管內插管沒有關係。令人失望的是沒有發現哪一個獨立的因素與SAS病人的困難氣管內插管有關係。結論  SAS是困難氣管內插管的危險因素。

                                             (   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.

                              

前負荷調整最大功率作為右室收縮力指數的局限性

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.

右室功能障礙是圍術期,特別是在心臟外科圍術期發病和死亡的重要原因。然而右室收縮力評估在臨床實踐中仍然較為困難。本研究的目的是決定作為右室收縮力指數的前負荷調整最大功率(PWRmax/舒張末期容量 [EDV]2; PAMP)的價值,這一指數是除壓力-容量-來源指數外的另一個與負荷無關的指數。應用電導技術,研究已麻醉狗作為金標準的右室收縮末期彈性阻力和前負荷可增加的搏出功。PAMP由肺動脈血流和右室壓力來計算。這些指數的改變與變力狀態(多巴酚丁胺輸注,n=12)和負荷條件(肺動脈和下腔靜脈閉塞,n=14)改變後的情況作比較。所有指數均隨多巴酚丁胺劑量的增加而增加。前負荷下降輕度影響PAMPPAMPEDV相關的斜率為0.00397 ± 0.01026 W · mL-3 · 0.10-4;均數±標準差)。肺動脈閉塞期間PAMP顯著下降(從1.1 ± 0.70.7 ± 0.5 W · mL-2 · 0.10-4;均數±標準差),而收縮末期彈性阻力和前負荷可增加的搏出功不變。我們認為在開胸/開心包的情況下,PAMP作為右室收縮力指數的價值是有限的,主要是因為它對後負荷改變較敏感。結論前負荷調整最大功率(PAMP),一個與負荷無關的左室收縮力指數,在臨床實踐中可提供一個解決測量右室收縮力問題的方法。然而,用開胸狗所做的這個研究提示,由於PAMP對後負荷改變較敏感,因而在右室收縮力評估中並不可靠。

                                               (張   薛張綱 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.

 

心臟手術後的持續性疼痛:一項關於高位胸段硬膜外和阿片類藥物鎮痛治療的調查

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.

 

心臟手術後持續性疼痛報導的發病率較低。我們對單一手術醫生在19971999年間所做的冠狀動脈旁路移植術的所有病人進行疼痛調查。應用了兩種鎮痛策略:手術後4872小時,予高位胸段硬膜外(HTEA)鎮痛或靜脈注射和口服阿片類藥物(OPIOID)鎮痛。持續性疼痛的定義為術後疼痛持續2個月以上。所有問題只是指調查當時的情況。365份問卷中,305位元患者有反饋資訊,其中61位元不同意調查,剩下的244位患者完成了調查(HTEA組,150[69%]OPIOID組,94[68%])。任意切口的持續性疼痛發生率為29%而胸骨切開者為25%。所述的疼痛程度較輕,僅7%患者的疼痛影響其日常生活。其他常見的疼痛部位是肩(17.4%)、背(15.9%)、頸(5.8%)。20位患者(8%)描述了內乳動脈綜合症的症狀。儘管OPIOID組在調查時距離手術的時間較長,兩組在疼痛的頻率和程度上無顯著性差異。胸骨切開後,輕度的持續性胸痛是常見的,但不經常影響日常生活。

結論:冠狀動脈旁路移植術後的持續性傷口疼痛是常見的,但通常較輕,不經常影響日常生活。調查顯示,兩種鎮痛策略在持續性疼痛的發生上並無差異。

(張   薛張綱 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.

前負荷指數:肺移植術中監測肺動脈阻塞壓和胸腔內血容量的對比

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,我們分析了肺移植術中傳統的前負荷指數:肺動脈阻塞壓(PAOP)和新的前負荷指數:胸腔內血容量指數(ITBVI),後者來源於單一指示劑經肺稀釋技術(PiCCO系統),與每搏量指數(SVIpa)相關。我們也評價了肺移植術中ITBVIPAOP的變化({Delta})與每搏量的變化{Delta}SVIpa之間的關係。由經肺單一指示劑稀釋技術(CIart)和肺動脈溫度稀釋技術(CIpa)所得到的心臟參數測量值,其可重複性和精確性得到了判定。對50位元患者用肺動脈導管和PiCCO系統監測,在整個研究的6個階段進行測量。變數值的改變由第二個測量值減去第一個測量值計算所得({Delta}1),並以此類推({Delta}1{Delta}5)ITBVISVIpa間的線性相關顯著(r2=0.41; P < 0.0001),而PAOPSVIpa間的線性相關較差(r2 = -0.01)ITBVI的變化和SVIpa的變化相關({Delta}1, r2 = 0.30; {Delta}2, r2 = 0.57; {Delta}4, r2 = 0.26; and {Delta}5, r2 = 0.67),而PAOP的變化則無關。CiartCipa間的平均偏倚為0.15 l · min-1 · m-2 (1.37)。總之,ITBVI是衡量心臟前負荷的有效參數,在行肺移植術的患者中可能優於PAOP

結論 在肺移植患者中,由經肺單一指示劑技術測定胸腔內血容量指數是個有用的方法,可提供一個反應心臟前負荷的有效參數,可能優於肺動脈阻塞壓。然而,這一技術的作用和局限性還需要前瞻性隨機臨床試驗來評價。

(張   薛張綱 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.

 

圍術期晶膠體輸注對血小板介導的止血及凝血的影響

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

 

為了探討常規輸注晶膠體是否影響凝血系統,我們研究了60例膝關節置換術的患者,在基礎林格氏液(RL)基礎上,隨即血管內輸注6%羥乙基澱粉200/0.5HES)或4%明膠(GEL)。進行常規凝血試驗,測凝血功能用血小板功能分析法(PFA-100®)ROTEG®分析法進行體外出血時間功能測定。所有參量均用方差分析組間差異用曲線下計算面積(AUCA–D)檢驗。所有時間變數,除了非固有凝血時間(ExCT,非固有血凝塊形成時間(ExCFT,固有血凝塊形成時間(InCFT)外,均證明有明顯時間依賴性,即靜脈輸注液體,減弱了血小板介導的止血和凝血功能。膠體組與晶體組相比,總的血凝快強度、纖維蛋白原和血凝塊彈性均降低(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組與HES組相比,纖維蛋白濃度明顯低,然而,兩膠體組均有蛋白濃度下降趨勢。

 結論 輸注膠體比單純晶體更明顯減弱了血凝塊強度,雖然對血凝系統影響不大。總血凝塊強度降低是由於消弱了纖維蛋白聚合作用,從而導致血凝塊纖維蛋白原和血凝快彈性降低。

                                               (李紹清   薛張綱 )

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.

 


從先心病嬰幼兒獲得的膠質蛋白,S100B:神經損傷的預先證明

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.

神經膠質蛋白S100B是腦缺血的標記物和成人心肺轉流術後神經損傷相關物。我們旨在證明心肺轉流術(CPB)後S100B的釋放特徵及其同死亡率的相關性。109例有先心病嬰幼兒,在術前和術後24h收集血樣本,所有病兒術前均行超聲心動圖檢查,術中行低溫或無低溫轉流,雙點位免疫測定法測量S100B濃度,並觀察30d外科死亡率。術前所有S100B濃度升高的嬰兒,術後24h均下降。在32例伴有左室發育不良綜合症的嬰兒,S100B濃度與血流、主動脈大小和術後死亡率變法一致(r2 = -0.63; P = 0.03)。嬰幼兒中,增加肺血流時測得S100B比紫紺時的S100B高,但並不與術後S100BCPB時間、低溫迴圈、30d外科死亡率相一致。結論 術前S100B濃度與左室發育不良綜合症、升主動脈大小相一致,S100B可能作為預先存在腦損傷和腦細胞死亡的指示劑。

                                              (李紹清   薛張綱 )

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.

 

異丙酚對急性分離的大鼠脊髓背角神經元γ-氨基丁酸-A和甘氨酸受體的作用

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

脊髓在調節麻醉藥誘導的傷害性傳遞的抑制中發揮重要作用。為瞭解異丙酚在脊髓水平的麻醉機制,我們用整體細胞的斑片鉗電生理技術對異丙酚在急性分離大鼠背角神經元以及對γ-氨基丁酸-A和甘氨酸受體的調節進行研究。異丙酚誘導對bicuculline敏感而對strychnine敏感較差的氯離子電流。異丙酚誘導的氯離子電流在啟動,脫敏,滅活上較GABA和甘氨酸誘導的氯離子電流為慢。另外,本研究顯示異丙酚對GABA受體和甘氨酸受體有相同的調節作用。異丙酚在低濃度時增強GABA和甘氨酸誘導的氯離子電流,而在高濃度時則抑制。異丙酚對氯離子電流的增強是由緩慢電流的脫敏和滅活引起,而抑制作用則可能包含GABA和異丙酚誘導的氯離子電流之間的交叉脫敏以及GABA受體和甘氨酸受體之間的交叉抑制。結果顯示異丙酚在脊髓水平對GABA受體和甘氨酸受體的易化顯著利於全身麻醉藥誘導的鎮痛和麻醉的產生。.

(張俊峰 譯    薛張綱 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

乳癌手術後GabapentinMexiletine的鎮痛效應

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.

我們研究了mexiletinegabapentin75例乳癌手術後伴隨的急性慢性疼痛病人上鎮痛效應。病人以雙盲方式,隨機分為接受mexiletine 600 mg/d, gabapentin 1200 mg/d,或安慰劑治療10天。麻醉過程標準化,所有病人常規按需接受術後鎮痛藥。VAS在靜息和運動後評定。三個月後,所有都隨訪確定慢性疼痛的強度和鎮痛藥的需要量。從第二到第十天, Mexiletine gabapentin減少可待因的消耗50%同時,總的撲熱息痛的消耗也減少了,兩種藥物應用靜息和運動後疼痛在術後第三天都減少。運動後疼痛應用gabapentin後在術後第二和第五天也減輕。各治療組慢性疼痛發生率,強度,鎮痛藥物的需要都不受影響。然而,燒灼痛在對照組發生更多。

(張俊峰 譯    薛張綱 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:準備和發佈系統的麻醉學中關於衛生保健效果的綜述文獻

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.

結論 該論文闡述了循證醫學(EBM)的基本原則及Cochrane Collaboration Cochrane Anesthesia Review Group的工作範圍,描述了隨機控制試驗和系統的綜述文獻在為解決臨床相關問題提供最佳的證據時的非常重要。

(潘志浩 譯    薛張綱 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

氣管內腎上腺素:提倡更大的劑量

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.

心肺復蘇當靜脈通路還未建立時推薦氣管內應用腎上腺素0.02 mg/kg(兩倍於靜注劑量)。標準的靜注劑量用作氣管途徑給藥被認為是太小,因可造成有害的動脈血壓的下降,這可能是通過未被α腎上腺素能血管收縮作用所抵消的β受體發生作用。我們進行了一個前瞻,隨機實驗比較遞增的氣管內應用腎上腺素的劑量以明確尚未確定的可以增加血壓的氣管內腎上腺素的最佳劑量。在注射生理鹽水(對照)後,鹽水稀釋的腎上腺素(0.02, 0.035, 0.1, 0.2, 0.3 mg/kg)至少一周間隔分別注入五條麻醉犬的氣管插管內。動脈血氣分析的血樣在用藥前,以及在用藥後14個時間點直至60分鐘。心率和動脈血壓用多導記錄儀連續監測。只有0.3 mg/kg劑量成功地增加了血壓,這在用藥後2分鐘觀察到,持續達10分鐘。早期血壓的降低只有在劑量等同於目前推薦劑量的10倍時才能避免。結論 我們進行的一個前瞻,隨機實驗比較遞增的氣管內腎上腺素的劑量,以明確尚未確定的可以增加血壓的氣管內腎上腺素的最佳劑量。血壓的降低只有在劑量等同於目前推薦劑量的10倍時才能避免。需要有應用更大劑量的氣管內腎上腺素以及將他們用作心跳驟停一線治療的臨床研究。

(潘志浩 譯    薛張綱 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.

使用外周神經刺激儀定位的臂叢神經阻滯四點法:腋路和肩部入路的比較

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

我們設計該前瞻性、隨機試驗比較神經刺激儀定位的臂從阻滯四點法分別在腋路(腋路組,50例)和肩部(肩部組,50例)水平兩種方法在麻醉成功率、操作時間及麻醉起效時間上的差異。所有病人均予以0.5% bupivacaine 2% lidocaine等量混合液40ml。由於未在規定時間內準確定位,有6例患者(其中腋路組4例,肩部組2例)被排除於該研究。完全阻滯定義為肘部以下的所有感覺區域被阻滯,兩組在完全阻滯率(91%89%)和感覺阻滯起效時間(15 ± 6 min 16 ± 7 min)並無差異。肩部組的操作時間則相對較短(7 ± 2 min 8 ± 2 min; P < 0.005),但腋路組的阻滯操作疼痛時間則較短(16 ± 9 min versus 23 ± 12 min; P < 0.005)。因此,我們認為腋路和肩部入路臂叢阻滯都可獲得高的成功率及迅速的感覺阻滯效果,本試驗中發現的差異並無臨床意義。

(潘志浩 譯    薛張綱 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.

自願者中Dexmedetomidine 誘導的鎮靜會降低腦局部和全腦的血流量

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 是一種可用于危重病人鎮靜的選擇性的α2受體激動劑,目前對其藥效學特性已有相當多的瞭解,但其對腦血流動力學的影響卻知之甚少。我們假定治療劑量的Dexmedetomidine會降低腦血流(CBF)。9位年齡在2448歲的自願者接受了研究,仰臥位元下予以負荷劑量的Dexmedetomidine1 µg/kg IV,然後予以維持量:低劑量組(0.2 µg · kg-1 · h-1 )和高劑量組(0.6 µg · kg-1 · h-1 ),採用PET測定各時間點的血流動力學參數和CBF。結果顯示兩組的心輸出量(CO)及心率(HR)在藥物輸注中和輸注後30分鐘均降低,血壓在輸注中和輸注後降低12%到16%,CBF從基線(91 mL · 100 g-1 · min-1 [95%可信區間, 72–114] 分別降低到64 mL · 100 g-1 · min-1 [51–81] (低劑量組)和 61 mL · 100 g-1 · min-1 [48–76] (高劑量組)。這種CBF的降低在停止輸注至少30分鐘後仍持續存在,儘管在這期間其血漿濃度已降低了40(628 pg/mL [524–732] 380 pg/mL [253–507])

(潘志浩 譯    薛張綱 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]).

坐骨神經與小轉子關係:關聯坐骨神經前方阻滯

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

經典坐骨神經阻滯要求在小轉子水平進針。最近研究證明,在小轉子水平,坐骨神經並不容易阻滯。為了更準確定位坐骨神經與小轉子關係,我們分析了20例仰臥位髖和股骨近端磁共振掃描影像,從五個軸面分析,特別是小轉子和小轉子下4cm1cm厚平面。在每軸上,從中間和側面兩點測失狀位上股骨邊緣到坐骨神經的距離:如果坐骨神經從側位走向失狀位,值計為負值(不易阻滯),從中位到失狀位,計為正值(易阻滯)。股骨前緣和坐骨神經冠狀平面間距離在每一觀察軸,均記錄。小轉子平面,坐骨神經相對股骨緣,20例中13例在側面,平均距離為-4.0 ± 7.7 mm。小轉子下4cm處,20例有19例在中位,平均距離7.8 ± 5.8 mm。小轉子平面,坐骨神經距股骨前緣42.9 ± 5.8 mm;小轉子下4cm處,45.7 ± 9.5 mm。經典的坐骨神經前路阻滯證明小轉子平面是中等遠離的。我們的資料與最近大多數報導的小轉子平面坐骨神經前路阻滯不易成功相一致的。但,小轉子下4cm處,20例有19例坐骨神經在中位。結論:在股骨近端,小轉子下4cm處,中間位行坐骨神經阻滯更易成功。

                                           (李紹清 譯  薛張剛校)

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.

使用彈性橡膠管芯以盲插法或間接喉鏡法在非預期困難插管病人中進行氣管內插管的比較

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.

我們比較了使用彈性橡膠管芯以盲插法或間接喉鏡法在非預期困難插管病人中進行氣管內插管的效果。在一個前瞻研究中,連續60名非預期直接喉鏡困難插管III-IV級病人隨機分為兩組:盲插法(組1)和間接喉鏡法,評估其插管失敗率、併發症及插管所需時間。在兩個月的研究過程中,725名病人中的60名非預期直接喉鏡困難插管III級病人隨機分入兩組,每組30名。組18例插管失敗,組21例,盲插法組的8例失敗均為氣管導管進入食道。插管時間兩組無明顯差異,分別為45+/-10s44+/-11s;兩組均未見其他併發症。因此可知使用彈性橡膠管芯間接喉鏡法氣管插管與傳統的盲插法相比有較低的失敗率。提示:我們評估了使用彈性橡膠管芯以盲插法或間接喉鏡法在非預期困難插管病人中進行氣管內插管的效果,間接喉鏡法氣管插管與傳統的盲插法相比有較低的失敗率(P<0.05)。

                                           (陳     薛張綱 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.

 

韓國針刺穴位使用辣椒貼可以降低經腹子宮切除術病人術後噁心嘔吐發生率

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

全麻術後噁心嘔吐(PONV)仍是一個常見的困繞我們的問題,尤其是那些經腹子宮切除術病人。我們研究了PONV的非藥物治療方法,即在雙手韓國針刺穴位K-D2或中國心包針刺穴位P6上敷貼辣椒貼(PAS)。160名病人參加該隨機雙盲實驗,對照組60名,K-D250名,P650名。K-D2組在K-D2點上使用PAS,組在P6點上使用PAS,對照組則在K-D2點使用無活性貼,使用時間為麻醉誘導前至術後8小時,並在一定時間間隔記錄噁心嘔吐發生率和相關治療。術後24小時治療組的噁心發生率(K-D222%P626%)明顯低於對照組(56.7%),P<0.001;鎮吐治療的需要亦明顯低於對照組。因此,在韓國手法針刺穴位使用PAS是一種減少PONV的有效方法。提示:無論韓國手法針刺穴位K-D2還是在中國心包針刺穴位P6上敷貼辣椒貼均可減少經腹子宮切除術病人術後噁心嘔吐發生率。

  薛張綱 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.