Anesthesia & Analgesia

November 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

利多卡因冠脉搭桥手术术后早期充血性心力衰竭的影响

(赵雪莲     庄心良  校)

The Effect of Lidocaine on Early Postoperative Cognitive Dysfunction After Coronary Artery Bypass Surgery

Dongxin Wang, Xinmin Wu, Jun Li, Feng Xiao, Xiaoying Liu, and Meijin Meng

Anesth Analg 2002 95: 1134-1141.

 

新发现的卵圆孔未闭对不停跳冠脉搭桥病人的影响:11例报道

(潘志浩译 薛张刚校)

The Impact of Newly Diagnosed Patent Foramen Ovale in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: Case Series of Eleven Patients

M. R. Sukernik, B. Mets, B. Kachulis, M. C. Oz, and E. Bennett-Guerrero

Anesth Analg 2002 95: 1142-1146.

 

氟烷、异氟醚和芬太尼提高植入性心内除颤器的最低有效阈值的首例报道

 (   王祥瑞 )   

Halothane, Isoflurane, and Fentanyl Increase the Minimally Effective Defibrillation Threshold of an Implantable Cardioverter Defibrillator: First Report in Humans

Avi A. Weinbroum, Aharon Glick, Yitzchak Copperman, Tamar Yashar, Valery Rudick, and Ron Flaishon

Anesth Analg 2002 95: 1147-1153.

 

围术期两种血液保护技术的前瞻性随机对照研究:等容量和超容量血液稀释

(   庄心良 )

A Prospective Randomized Study Comparing Two Techniques of Perioperative Blood Conservation: Isovolemic Hemodilution and Hypervolemic Hemodilution

Rakesh Kumar, Indranil Chakraborty, and Raminder Sehgal

Anesth Analg 2002 95: 1154-1161.

 

在体研究中异氟醚没有产生保护心梗的预处理的第二窗

(潘志浩 薛张刚 )

Isoflurane Does Not Produce a Second Window of Preconditioning Against Myocardial Infarction In Vivo
Franz Kehl, Paul S. Pagel, John G. Krolikowski, Weidong Gu, Wolfgang Toller, David C. Warltier, and Judy R. Kersten

Anesth Analg 2002 95: 1162-1168.

 

鼠高钠血症对移植肝的影响

(朱慧琛译   王祥瑞校)

The Effect of Hypernatremia on Liver Allografts in Rats

Bruno Jawan, Shigeru Goto, Chia-Yun Lai, Vanessa H. de Villa, Hsiang-Ning Luk, Hock-Liew Eng, Yaw-Sen Chen, Chi-Chih Wang, Yu-Fen Cheng, and Chao-Long Chen

Anesth Analg 2002 95: 1169-1172.

 

突然阻断腔静脉血流的血流动力学和激素反应:通过肝大部切除手术中肝血管排空的前瞻性研究

(     庄心良  校)

Hemodynamic and Hormonal Responses to the Sudden Interruption of Caval Flow: Insights from a Prospective Study of Hepatic Vascular Exclusion During Major Liver Resections

Daniel Eyraud, Olivier Richard, Dominique C. Borie, Barbara Schaup, Alain Carayon, Corinne Vézinet, Marie Movschin, Jean-Christophe Vaillant, Pierre Coriat, and Laurent Hannoun

Anesth Analg 2002 95: 1173-1178.

PEDIATRIC ANESTHESIA:

纯氧合用七氟醚,异氟醚,氟烷,芬太尼/咪唑安定时对小儿先天性心脏病病人肺循环与体循环血流比影响

(潘志浩 薛张刚 )

Pulmonary-to-Systemic Blood Flow Ratio Effects of Sevoflurane, Isoflurane, Halothane, and Fentanyl/Midazolam with 100% Oxygen in Children with Congenital Heart Disease
Tracy H. Laird, Stephen A. Stayer, Shannon M. Rivenes, Mark B. Lewin, E. Dean McKenzie, Charles D. Fraser, and Dean B. Andropoulos

Anesth Analg 2002 95: 1200-1206.

 

小儿心脏麻醉时静脉注射和鞘内注射芬太尼的比较

 ( 洁译 王祥瑞校)   

Intrathecal Versus IV Fentanyl in Pediatric Cardiac Anesthesia

Arash Pirat, Elif Akpek, and Gülnaz Arslan

Anesth Analg 2002 95: 1207-1214.

 

骶管内注射新斯的明、 布比卡因及两药复合液用于小儿尿道下裂术后镇痛

(王士雷    庄心良 )

Caudal Neostigmine, Bupivacaine, and Their Combination for Postoperative Pain Management After Hypospadias Surgery in Children

Mohamed Abdulatif and Mohga El-Sanabary

Anesth Analg 2002 95: 1215-1218.

 

小儿骶麻:睾丸固定术阻滞精索牵拉反应中布比卡因的容量和浓度的比较

(张俊峰 薛张刚 )

Caudal Anesthesia in Children: Effect of Volume Versus Concentration of Bupivacaine on Blocking Spermatic Cord Traction Response During Orchidopexy

Susan T. Verghese, Raafat S. Hannallah, Linda Jo Rice, A. Barry Belman, and Kantilal M. Patel

Anesth Analg 2002 95: 1219-1223.

 

FLACC方法用于认知缺损儿童疼痛评估

(    王祥瑞 )    

The Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Observational Tool as a Measure of Pain in Children with Cognitive Impairment

Terri Voepel-Lewis, Sandy Merkel, Alan R. Tait, Agnieszka Trzcinka, and Shobha Malviya

Anesth Analg 2002 95: 1224-1229.

 

Ondansetron Dolasetron 对施行扁桃体切除术的门诊病人有等效的止吐功能

(杨保仲译   庄心良校)

Ondansetron and Dolasetron Provide Equivalent Postoperative Vomiting Control After Ambulatory Tonsillectomy in Dexamethasone-Pretreated Children

Radha Sukhani, Ana Lucia Pappas, Jordan Lurie, Andrew J. Hotaling, Albert Park, and Elaine Fluder

Anesth Analg 2002 95: 1230-1235.

 

门脉高压患儿行诊断性腹腔镜检查时动脉二氧化碳分压显着增高

( 鸿 薛张刚 )

Arterial Carbon Dioxide Markedly Increases During Diagnostic Laparoscopy in Portal Hypertensive Children

Pervin Bozkurt, Guner Kaya, Yuksel Yeker, Nuvit Sarimurat, Ebru Yesildag, Gonca Tekant, Haluk Emir, and Osman Faruk Senyuz

Anesth Analg 2002 95: 1236-1240.

AMBULATORY ANESTHESIA:

门诊病人行肛门直肠手术时鞘内注射小剂量利多卡因和罗哌卡因的比较

(   王祥瑞 )

Small-Dose Intrathecal Lidocaine Versus Ropivacaine for Anorectal Surgery in an Ambulatory Setting

Chester C. Buckenmaier, III, Karen C. Nielsen, Ricardo Pietrobon, Stephen M. Klein, Aliki H. Martin, Roy A. Greengrass, and Susan M. Steele

Anesth Analg 2002 95: 1253-1257.

ANESTHETIC PHARMACOLOGY:

利多卡因冠脉搭桥手术术后早期充血性心力衰竭的影响

(赵雪莲     庄心良  校)

利多卡因对谷氨酸转运体EAAT3活性的影响:蛋白激酶C和磷脂酰肌醇3激酶的作用

( 鸿 薛张刚 )

The Effects of Lidocaine on the Activity of Glutamate Transporter EAAT3: The Role of Protein Kinase C and Phosphatidylinositol 3-Kinase
Sang-Hwan Do, Hong-yu Fang, Byung-Moon Ham, and Zhiyi Zuo

Anesth Analg 2002 95: 1263-1268. 

 

曲马多对爪蟾卵母细胞克隆表达的M3受体的抑制作用研究

(   王祥瑞 )

The Inhibitory Effects of Tramadol on Muscarinic Receptor-Induced Responses in Xenopus Oocytes Expressing Cloned M3 Receptors

Yousuke Shiga, Kouichiro Minami, Munehiro Shiraishi, Yasuhito Uezono, Osamu Murasaki, Muneshige Kaibara, and Akio Shigematsu

Anesth Analg 2002 95: 1269-1273.

 

全麻药对游离的鼠皮层神经末梢去甲肾上腺素释放的影响

(   庄心良 )

The Effects of General Anesthetics on Norepinephrine Release from Isolated Rat Cortical Nerve Terminals

Victor N. Pashkov and Hugh C. Hemmings, Jr.
Anesth Analg 2002 95: 1274-1281.  

 

异丙酚持续输注时脑脊液浓度的变化

( 鸿 薛张刚 )

Changes of Propofol Concentration in Cerebrospinal Fluid During Continuous Infusion

Andrzej L. Dawidowicz, Rafal Kalitynski, Andrzej Nestorowicz, and Anna Fijalkowska
Anesth Analg 2002 95: 1282-1284.

 

磷酸异丙酚,一种水溶性的异丙酚前体药物:在体评估

(忻纪华   王祥瑞校)

Propofol Phosphate, a Water-Soluble Propofol Prodrug: In Vivo Evaluation

Mariusz G. Banaszczyk, Alison T. Carlo, Violeta Millan, Adam Lindsey, Ronald Moss, Dennis J. Carlo, and Sheldon S. Hendler

Anesth Analg 2002 95: 1285-1292.

 

麻黄碱减少丙泊酚注射时的疼痛

(      庄心良  校)

Ephedrine Reduces the Pain from Propofol Injection

Mi A. Cheong, Kyo S. Kim, and Won J. Choi
Anesth Analg 2002 95: 1293-1296.  

 

甲氧氯普胺和利多卡因对防止安定注射疼痛的比较

( 鸿 薛张刚 )

A Comparison of Metoclopramide and Lidocaine for Preventing Pain on Injection of Diazepam
Hossein Majedi, Mozaffar Rabiee, Zahid Hussain Khan, and Bahman Hassannasab

Anesth Analg 2002 95: 1297-1299.

 

田鼠福尔马林试验比较氙和笑气的镇痛效应

(忻纪华   王祥瑞 )

The Analgesic Effect of Xenon on the Formalin Test in Rats: A Comparison with Nitrous Oxide

Taeko Fukuda, Chikako Nishimoto, Setsuji Hisano, Masayuki Miyabe, and Hidenori Toyooka

Anesth Analg 2002 95: 1300-1304.

 

离体雷米芬太尼代谢:全血和血浆假性胆碱酯酶对其影响

(赵雪莲      庄心良  )

In Vitro Remifentanil Metabolism: The Effects of Whole Blood Constituents and Plasma Butyrylcholinesterase

Peter J. Davis, Richard L. Stiller, Annette S. Wilson, Francis X. McGowan, Talmage D. Egan, and Keith T. Muir

Anesth Analg 2002 95: 1305-1307.

 

Rofecoxib 应用于耳鼻喉科手术的镇痛作用

( 薛张刚 )

Analgesic Effects of Rofecoxib in Ear-Nose-Throat Surgery
A. Turan, S. Emet, B. Karamanlioglu, D. Memis, N. Turan, and Z. Pamukcu

Anesth Analg 2002 95: 1308-1311.  

TECHNOLOGY, COMPUTING, AND SIMULATION:

自体血液回收效果评价的数据模型

(  王祥瑞 )

A Mathematical Model of Cell Salvage Efficiency

Jonathan H. Waters, Julia ShinJung Lee, and Matthew T. Karafa

Anesth Analg 2002 95: 1312-1317.

 

听觉稳态反应不是一个合适的麻醉监测方法

( 军译  庄心良 校)

The Auditory Steady-State Response Is Not a Suitable Monitor of Anesthesia

S. Pockett and S. M. Tan

Anesth Analg 2002 95: 1318-1323.

 

Narcotrend,脑双频谱指数和经典脑电图在静脉注射异丙酚联合瑞芬太尼麻醉苏醒时的变化

( 薛张刚 )

Narcotrend, Bispectral Index, and Classical Electroencephalogram Variables During Emergence from Propofol/Remifentanil Anesthesia
Gunter N. Schmidt, Petra Bischoff, Thomas Standl, Moritz Voigt, Luca Papavero, and Jochen Schulte am Esch

Anesth Analg 2002 95: 1324-1330.

 

便携式输注泵持续区域镇痛时推注速率准确性的研究

(  王祥瑞 )

The Delivery Rate Accuracy of Portable Infusion Pumps Used for Continuous Regional Analgesia

Brian M. Ilfeld, Timothy E. Morey, and F. Kayser Enneking

Anesth Analg 2002 95: 1331-1336.

PAIN MEDICINE:

胍乙啶和局麻药对电刺激鼠输精管反应的影响

(王士雷     庄心良  校)

The Effect of Guanethidine and Local Anesthetics on the Electrically Stimulated Mouse Vas Deferens

Philip I. Joyce, Daniela Rizzi, Girolamo Caló, David J. Rowbotham, and David G. Lambert

Anesth Analg 2002 95: 1339-1343.

 

随机双盲比较开胸后硬膜外用罗哌卡因、罗哌卡因/芬太尼、布比卡因/芬太尼镇痛

(嵇富海 薛张刚 )

A Randomized, Double-Blinded Comparison of Thoracic Epidural Ropivacaine, Ropivacaine/Fentanyl, or Bupivacaine/Fentanyl for Postthoracotomy Analgesia

Antonio Macias, Pablo Monedero, María Adame, Wenceslao Torre, Isabel Fidalgo, and Francisco Hidalgo

Anesth Analg 2002 95: 1344-1350.

 

术后早期抑制外周感受伤害活动减轻疼痛的随机试验

(殷文渊 王祥瑞 )

Attenuation of Pain in a Randomized Trial by Suppression of Peripheral Nociceptive Activity in the Immediate Postoperative Period

Sharon M. Gordon, Jaime S. Brahim, Ronald Dubner, Linda M. McCullagh, Christine Sang, and Raymond A. Dionne

Anesth Analg 2002 95: 1351-1357.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

评估术中治疗和诊断干预

 (赵雪莲      庄心良  )

Evaluating Intraoperative Therapeutic and Diagnostic Interventions

Nava Klein and Charles Weissman

Anesth Analg 2002 95: 1373-1380.

 

全麻下施行大手术发生低体温的原因分析

杨保仲 庄心良 校)

Preoperative Risk Factors of Intraoperative Hypothermia in Major

Surgery Under General Anesthesia

T. Kasai, M. Hirose, K. Yaegashi, T. Matsukawa, A. Takamata, and Y. Tanaka

Anesth Analg 2002 95: 1381-1383.

NEUROSURGICAL ANESTHESIA:

长时间神经外科手术期间七氟醚比安氟醚提供更快的恢复和术后神经估价

(嵇富海 薛张刚 )

Sevoflurane Provides Faster Recovery and Postoperative Neurological Assessment Than Isoflurane in Long-Duration Neurosurgical Cases

Alain Gauthier, Francois Girard, Daniel Boudreault, Monique Ruel, and Alexandre Todorov

Anesth Analg 2002 95: 1384-1388.

 

γ-羟基丁酸(GABA)受体药物对吗啡诱导的无损伤脊髓缺血后鼠的痉挛性下肢轻瘫的影响

(殷文渊   王祥瑞 )

The Effect of Gamma-Aminobutyric Acid (GABA) Receptor Drugs on Morphine-Induced Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in Rats

Seiya Nakamura, Manabu Kakinohana, Yutaka Taira, Hiroshi Iha, and Kazuhiro Sugahara

Anesth Analg 2002 95: 1389-1395.

OBSTETRIC ANESTHESIA:

腰硬联合分娩镇痛时蛛网膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可乐定的随机双盲试验研究。

(王士雷    庄心良  校)

A Randomized, Double-Blinded Trial of Subarachnoid Bupivacaine and Fentanyl, With or Without Clonidine, for Combined Spinal/Epidural Analgesia During Labor

Michael J. Paech, Samantha L. Banks, Lyle C. Gurrin, Seng T. Yeo, and Timothy J. G. Pavy

Anesth Analg 2002 95: 1396-1401.

REGIONAL ANESTHESIA:

肾上腺素对罗哌卡因硬膜外应用时早期全身吸收的影响

(     庄心良校)

The Effect of the Addition of Epinephrine on Early Systemic Absorption of Epidural Ropivacaine in Humans

Bee B. Lee, Warwick D. Ngan Kee, John L. Plummer, Manoj K. Karmakar, and April S.Y. Wong

Anesth Analg 2002 95: 1402-1407.

 

心电图导联的选择是否影响其用于检测试验剂量中肾上腺素血管内注射的T波标准的功效

(潘志浩 薛张刚 )

Does the Choice of Electrocardiography Lead Affect the Efficacy of the T-Wave Criterion for Detecting Intravascular Injection of an Epinephrine Test Dose?
Makoto Tanaka and Toshiaki Nishikawa

Anesth Analg 2002 95: 1408-1411.

 

连硬及非连硬阻滞患者异氟醚对术中脑电抑制时的等效剂量

( 洁译 王祥瑞 )

Isoflurane Dosage for Equivalent Intraoperative Electroencephalographic Suppression in Patients With and Without Epidural Blockade

Andrew P. Morley, James Derrick, Paul T. Seed, Perpetua E. Tan, David C. Chung, and Timothy G. Short

Anesth Analg 2002 95: 1412-1418.

 

丙胺卡因和新斯的明静脉局部麻醉

(张俊峰 薛张刚 )

Intravenous Regional Anesthesia Using Prilocaine and Neostigmine

A. Turan, B. Karamanlyoglu, D. Memis, G. Kaya, and Z. Pamukçu

Anesth Analg 2002 95: 1419-1422.

 

一种住院医师局部麻醉培训的新模式

(张俊峰 薛张刚 )

A New Teaching Model for Resident Training in Regional Anesthesia
Gavin Martin, Catherine K. Lineberger, David B. MacLeod, Habib E. El-Moalem, Dara S. Breslin, David Hardman, and Francine D’Ercole

Anesth Analg 2002 95: 1423-1427.

GENERAL ARTICLES:

经鼻气管插管:一种简单而有效的减少鼻咽部创伤和导管污染的技术

( 王祥瑞 )

Nasotracheal Intubation: A Simple and Effective Technique to Reduce Nasopharyngeal Trauma and Tube Contamination

Dietmar Enk, Anne M. Palmes, Hugo Van Aken, and Martin Westphal

Anesth Analg 2002 95: 1432-1436.

 

Bellhouse试验评估寰枕关节伸展度的可靠性

(    庄心良 校)

The Reliability of the Bellhouse Test for Evaluating Extension Capacity of the Occipitoatlantoaxial Complex

Yasunari Urakami, Ichiro Takenaka, Motohiro Nakamura, Hiroshi Fukuyama, Kazuyoshi Aoyama, and Tatsuo Kadoya

Anesth Analg 2002 95: 1437-1441.

 

Tandospirone可预防成人中耳整复术后的恶心和呕吐

(张俊峰 薛张刚 )

Prevention of Nausea and Vomiting with Tandospirone in Adults After Tympanoplasty

Tsutomu Oshima, Yoshiko Kasuya, Yasuhisa Okumura, Etsuji Terazawa, and Shuji Dohi

Anesth Analg 2002 95: 1442-1445.

 

氟烷、异氟醚和芬太尼提高植入性心内除颤器的最低有效阈值的首例报道

Halothane, Isoflurane, and Fentanyl Increase the Minimally Effective Defibrillation Threshold of an Implantable Cardioverter Defibrillator: First Report in Humans

Avi A. Weinbroum, MD*{dagger}, Aharon Glick, MD{ddagger}, Yitzchak Copperman, MRCPI{ddagger}, Tamar Yashar, MD{dagger}, Valery Rudick, MD{dagger}, and Ron Flaishon, MD{dagger}

*Post-Anesthesia Care Unit and Departments of {dagger}Anesthesiology and Critical Care and {ddagger}Cardiology, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Israel

 Anesth & Analg Nov. 2002;95:1147-1153

置入植入性心内除颤器(ICD)包括感应性心室纤颤患者,其最低有效除颤阈值(DFT)的确定。对于置入植入性心内除颤器的患者我们分别研究不同的麻醉方式对其最低有效除颤阈值的影响,在全麻下分别给予患者吸入0.7%氟烷、1%异氟醚或静注 1.5 µg/kg芬太尼,或单纯皮下注射1.5%利多卡因并辅以 0.35 mg/kg 异丙酚静注,此时进行第一次DFT值测定,30分钟后关闭吸入麻醉,分别给予三个全麻组静注1 µg/kg 芬太尼,并进行第二次DFT测量,30分钟后又进行了第三次测定,此时患者尚未苏醒且仅以N2O/O2吸入。而利多卡因辅以异丙酚组则在同一时间给予静注异丙酚。第一次测量结果DFT分别为16.1 ± 2.2 J (氟烷), 17.7 ± 2.7 J (异氟醚), 16.4 ± 2.9 J (芬太尼) 12.9 ± 3.8 J (利多卡因+异丙酚) (P = 0.01).第二次测量时氟烷(P = 0.01)及异氟醚(P = 0.02)DFT值都明显低于第一次。第三次测量值除利多卡因+异丙酚这组外其余三组的DFT均明显下降(P <0.01)。由此推断氟烷、异氟醚、芬太尼都提高了ICD置入患者的DFT值,而利多卡因辅以间歇静注异丙酚则可降低该值。

                                           (   王祥瑞 )                                                                                                                        Placing an implantable cardioverter defibrillator (ICD) involves the induction of ventricular fibrillation, whereupon the minimally effective defibrillation energy threshold (DFT) is determined .We evaluated the effects of 0.7% halothane, 1% isoflurane, or 1.5 µg/kg of IV fentanyl during N2O/oxygen-based general anesthesia (GA) or those of subcutaneous 1.5% lidocaine plus IV 0.35 mg/kg of propofol on the DFT during ICD implantation in humans (n = 20 per group). Thirty minutes after the first set of DFT measurements under such conditions, the inhaled anesthetics were withdrawn, and all three GA groups received fentanyl 1 µg/kg IV (second set). A third set was taken 30 min later, before the GA patients awakened and when only N2O/oxygen was delivered for GA. The lidocaine plus propofol patients were given the same IV propofol bolus 1 min before each fibrillation/defibrillation trial and at the same time points as the three GA groups. The first DFTs were 16.1 ± 2.2 J (halothane), 17.7 ± 2.7 J (isoflurane), 16.4 ± 2.9 J (fentanyl), and 12.9 ± 3.8 J (lidocaine plus propofol) (P = 0.01). The second set of DFTs were significantly lower than the first sets for the halothane (P = 0.01) and isoflurane (P = 0.02), but not the fentanyl or lidocaine plus propofol, regimens. The third DFTs were significantly (P < 0.01) lower than the first ones for the three GA groups, but not for the lidocaine plus propofol patients. Thus, halothane, isoflurane, and fentanyl increased DFT values during ICD implantation in humans, whereas lidocaine plus intermittent small-dose IV propofol minimized these thresholds.

鼠高钠血症对移植肝的影响

The Effect of Hypernatremia on Liver Allografts in Rats

Bruno Jawan*, Shigeru Goto{dagger}, Chia-Yun Lai{dagger}, Vanessa H. de Villa{dagger}, Hsiang-Ning Luk*, Hock-Liew Eng{dagger}, Yaw-Sen Chen{dagger}, Chi-Chih Wang{dagger}, Yu-Fen Cheng{dagger}, and Chao-Long Chen{dagger}

*Department of Anesthesiology and {dagger}Liver Transplantation Program, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Chang Gung University, Taiwan

Anesth &Analg Nov. 2002;95:1169-1172

捐赠者出现的高钠血症是引起常位肝移植(OLT)手术后肝功能缺损的主要危险因素之一。然而对于外伤后出现溶液高渗而诱发急性高钠血症时的供体进行肝移植后,其移植肝的存活能力尚未进行过系统研究。在目前的研究中我们试图评估使用存在高钠血症(由溶液高渗引发)的供体鼠的肝脏时是否会影响肝移植手术结果。于高钠血症(>160 mEq/L)出现30分钟后,在麻醉状态下九只小鼠的肝脏被取下,其中的六个立即进行移植,其余三个经4°C 低温保存了六小时后也被移植入受体鼠体内,在其后的7天内我们将供体鼠和其受体鼠的肝功能变化与对照组进行了比较,同时还比较了移植后的肝脏含水量和受体鼠存活情况。实验结果显示供体及受体组的肝功能测试和肝脏含水量均无明显差异, 所有的实验鼠经过7天观察期都存活。这项研究显示非脑死亡供体鼠在注射了10%高渗盐水后引起的高钠血症不会导致常位肝移植术(OLT)后移植肝的功能衰竭现象。

                                                      (朱慧琛译   王祥瑞校)

Hypernatremia in the donor organ is one of the most dangerous risk factors that may cause primary graft loss after orthotopic liver transplantation (OLT).However, the viability of donor grafts from acute hypernatremic donors, which is likely to occur during resuscitation of trauma patients with hypertonic saline solution, has not been studied precisely. In the present study, we sought to evaluate whether the hypernatremia, per se, induced by hypertonic saline solution, affects the outcome of liver transplantation in the normal rat. Thirty minutes after the induction of hypernatremia (>160 mEq/L), the livers of nine Wistar rats were removed under ether anesthesia. Six livers were immediately transplanted into normal Wistar rats, whereas the other three were preserved in 4°C University of Wisconsin solution for 6 h before transplantation in the recipients. Liver function variables of the donor rats at graft procurement and of the recipients at Day 7 after OLT were compared with a control group. The water content of the graft at procurement and the survival of the recipients at 7 days after OLT were, likewise, compared with the untreated control group. Results showed that there were no significant differences in the liver function tests of the donors and recipients, as well as in the water content of the grafts, between groups. All the rats survived the observation period of 7 days. This study showed that acute hypernatremia induced by the infusion of 10% saline solution before graft procurement in a nonbrain-dead donor rat model did not lead to a deterioration of liver graft viability after OLT.

 

小儿心脏麻醉时静脉注射和鞘内注射芬太尼的比较

Intrathecal Versus IV Fentanyl in Pediatric Cardiac Anesthesia

Arash Pirat, MD, Elif Akpek, MD, and Gülnaz Arslan, MD

Department of Anesthesiology, Baskent University Faculty of Medicine, Ankara, Turkey

Anesth &Analg Nov. 2002;95:1207-1214

大剂量阿片类药物已广泛应用于小儿心脏手术麻醉中,但是对于这类手术中使用鞘内注射阿片类药物并无系统对照的研究。本实验采用对照,前瞻性研究,对小儿心脏手术中鞘内(IT)和静脉内(IV)注射芬太尼进行研究。共有306月至6岁的小儿在麻醉中IV芬太尼10μg/kg作负荷量,追加药量分别为IV组使用芬太尼静注10μg/·kg-1·h-1IV组,n=10),IT组使用2μg/kg芬太尼鞘内注射(IT组,n=10),IV+IT组混合使用上述剂量的芬太尼(IV+IT组,n=10)。在试验中记录心率,平均动脉压,追加芬太尼的剂量,首次需要疼痛治疗的时间,舒适程度,患儿住院时的疼痛评分和拔管时间。在术前,劈开胸骨后,体外转流期间(CPB),术后6小时及24小时分别测定血中皮质醇,胰岛素,血糖及血乳酸水平。并在术后第一天检测病儿尿中皮质醇水平。三组病人的各项检测结果相似,仅在体外转流期间(CPBIT组血糖水平明显高于IV组(P<0.004)。只有IV+IT组在术前及术后比较中未发现心率和平均动脉压没有明显升高。在IVITIV+IT24小时尿皮质醇检测结果分别为(61.51±39,92.54±67.55,40.15±29.69μg·kg-1·d-1)。从血流动力学和应激反应来说,单次IT注入芬太尼并不优于全身使用芬太尼(10μg/kg负荷量以及10μg/·kg-1·h-1维持)。混合使用上述两种方法则可以在CPB前期获得更稳定的血流动力学状态,并且降低术后24小时尿中皮质醇水平。

                                                  ( 洁译 王祥瑞校)                                                                                                     Systemic large-dose opioids are widely used in pediatric cardiac anesthesia, but there are no randomized, prospective studies regarding the use of intrathecal (IT) opioids for these procedures. In this randomized, prospective study, we compared cardiovascular and neurohumoral responses during IT or IV fentanyl anesthesia for pediatric cardiac surgery. Thirty children aged 6 mo to 6 yr were anesthetized with an IV fentanyl bolus of 10 µg/kg. This was followed by a fentanyl infusion of 10 µg · kg-1 · h-1 (Group IV; n = 10), 2 µg/kg of IT fentanyl (Group IT; n = 10), or combined IV and IT protocols (Group IV + IT; n = 10). Heart rate, mean arterial blood pressure, additional fentanyl doses, time to first analgesic requirement, COMFORT and Children’s Hospital of Eastern Ontario Pain Scale scores, and extubation time were recorded. Blood cortisol, insulin, glucose, and lactate levels were measured presurgery, poststernotomy, during the rewarming phase of cardiopulmonary bypass (CPB), and 6 and 24 h after surgery. The patients’ urinary cortisol excretion rates were also measured during the first postoperative day. The findings in all three groups were statistically similar, except for higher blood glucose levels during CPB in Group IT compared with Group IV (P < 0.004). Group IV + IT was the only group in which the increases in heart rate and mean arterial blood pressure from presurgery to poststernotomy were not significant. The 24-h urinary cortisol excretion rates (µg · kg-1 · d-1) were 61.51 ± 39, 92.54 ± 67.55, and 40.15 ± 29.69 for Groups IV, IT, and IV + IT, respectively (P > 0.05). A single IT injection of fentanyl 2 µg/kg offers no advantage over systemic fentanyl (10 µg/kg bolus and 10 µg · kg-1 · h-1) with regard to hemodynamic stability or suppression of stress response. The combination of these two regimens may provide better hemodynamic stability during the pre-CPB period and may be associated with a decreased 24-h urinary cortisol excretion rate.

FLACC方法用于认知缺损儿童疼痛评估
The Reliability and Validity of the Face, Legs, Activity, Cry, Consolability Observational Tool as a Measure of Pain in Children with Cognitive Impairment

Terri Voepel-Lewis, MSN RN, Sandy Merkel, MS RN, Alan R. Tait, PhD, Agnieszka Trzcinka, BS, and Shobha Malviya, MD

Department of Anesthesiology, Section of Pediatrics, C. S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan

Anesth Analg 2002;95:1224-1229

 

由于在认知方面的欠缺(CI),儿童的疼痛评估常常显得十分困难。本实验通过面部表情,腿部动作,活动,哭泣,安慰性(FLACC)等方面来对有认知欠缺的儿童进行疼痛治疗的有效性和可靠性进行评估。每一名儿童的发育水平和对疼痛的表述能力都被列入考虑。由护士负责对每一名儿童在疼痛治疗前后使用FLACC进行疼痛观察和评估。同时,对其父母使用疼痛刻度尺进行评分,并对部分有表述能力的儿童进行疼痛刻度评分。观察过程由护士摄录并播放,前者对疼痛治疗和评分并不知情。一共对79名儿童进行了140次观察。结果显示,FLACC评分与父母的疼痛评分有良好的相关性(P<0.001),并且此评分在疼痛治疗后明显降低(P=0.001),说明了疼痛治疗的有效性。所有评分的相关性(r=0.5-0.8;P<0.001)以及各类别的相关性(r=0.3-0.8;P<0.001)均显示此方法有良好的可靠性。试验的可重复性良好(r=0.8-0.883;P,0.001),各类别均具可重复性(r=0.617-0.935;P,0.001)。上述数据显示,FLACC评分对于在认知方面有欠缺(CI)的儿童进行疼痛评估时非常有效。

                                                    (    王祥瑞 )                                                                                                         

Pain assessment remains difficult in children with cognitive impairment (CI). In this study, we evaluated the validity and reliability of the Face, Legs, Activity, Cry, Consolability (FLACC) tool for assessing pain in children with CI. Each child’s developmental level and ability to self-report pain were evaluated. The child’s nurse observed and scored pain with the FLACC tool before and after analgesic administration. Simultaneously, parents scored pain with a visual analog scale, and scores were obtained from children who were able to self-report pain. Observations were videotaped and later viewed by nurses blinded to analgesics and pain scores. One-hundred-forty observations were recorded from 79 children. FLACC scores correlated with parent scores (P < 0.001) and decreased after analgesics (P = 0.001), suggesting good validity. Correlations of total scores (r = 0.5–0.8; P < 0.001) and of each category (r = 0.3–0.8; P < 0.001), as well as measures of exact agreement ({kappa} = 0.2–0.65), suggest good reliability. Test-retest reliability was supported by excellent correlations (r = 0.8–0.883; P < 0.001) and categorical agreement (r = 0.617–0.935; {kappa}= 0.400–0.881; P < 0.001). These data suggest that the FLACC tool may be useful as an objective measure of postoperative pain in children with CI

 

门诊病人行肛门直肠手术时鞘内注射小剂量利多卡因和罗哌卡因的比较

Small-Dose Intrathecal Lidocaine Versus Ropivacaine for Anorectal Surgery in an Ambulatory Setting

Chester C. Buckenmaier, III, MD*, Karen C. Nielsen, MD*, Ricardo Pietrobon, MD*{dagger}, Stephen M. Klein, MD*, Aliki H. Martin, RN*, Roy A. Greengrass, MD*, and Susan M. Steele, MD*

Departments of *Anesthesiology and {dagger}Surgery, Duke University Medical Center, Durham, North Carolina

 

Anesth & Analg Nov. 2002;95:1253-1257

在应用利多卡因实施腰麻醉时应详细检查病人,因为可能导致病人出现短暂神经系统症状(TNS)。我们设计了这样的一个前瞻性实验研究,比较门诊病人择期行肛门直肠手术时应用罗哌卡因和利多卡因麻醉时的效用。72个病人被随机分为两组,一组病人接受重比重的利多卡因25mg加芬太尼20ug(n=37),而另外一组病人接受重比重的罗哌卡因4mg加芬太尼20ug(n=35)。麻醉后检查病人的运动神经阻滞、感觉神经阻滞和阻滞持续时间。术后24h48h72h168h随访病人,并询问病人麻醉后有没有疼痛感觉,以及有关TNS诊断的问题。两组病人均没有出现TNS症状。且两组病人无任何明显差异。因此实验总结认为:在肛门直肠手术时应用小剂量重比重的罗哌卡因复合芬太尼行蛛网膜下腔麻醉是一个可以接受的麻醉方式。

(   王祥瑞 )

Spinal anesthesia with the local anesthetic lidocaine has come under scrutiny because it is associated with transient neurologic symptoms (TNS). We designed this study to prospectively compare the efficacy of ropivacaine as an alternative to lidocaine in patients undergoing elective outpatient anorectal procedures. Seventy-two patients were randomized to receive either hyperbaric lidocaine 25 mg with fentanyl 20 µg (n = 37) or hyperbaric ropivacaine 4 mg with fentanyl 20 µg (n = 35). Patients were examined for motor block, sensory block, and block duration. Patients were contacted at 24, 48, 72, and 168 h and questioned about their perceptions of pain after the spinal with specific questions designed to diagnose TNS. There were no patients with TNS in either group. There was no significant difference between the lidocaine and ropivacaine groups in any of the outcomes studied. In conclusion, intrathecal hyperbaric small-dose ropivacaine with fentanyl is an acceptable anesthetic for anorectal surgery.

 

曲马多对爪蟾卵母细胞克隆表达的M3受体的抑制作用研究

The Inhibitory Effects of Tramadol on Muscarinic Receptor-Induced Responses in Xenopus Oocytes Expressing Cloned M3 Receptors

Yousuke Shiga, MD*, Kouichiro Minami, MD PhD*, Munehiro Shiraishi, MD*, Yasuhito Uezono, MD PhD{dagger}, Osamu Murasaki, MD{dagger}, Muneshige Kaibara, MD PhD{dagger}, and Akio Shigematsu, MD PhD*

*Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu; and {dagger}Department of Pharmacology II, Nagasaki University, School of Medicine, Nagasaki, Japan

Anesth & Analg Nov. 2002;95:1269-1273

曲马多是一种广泛应用的镇痛药,但它的作用机理还不是完全清楚。由于M受体与大脑和自主神经系统的神经元功能有关,因此目前作为中枢神经系统内镇痛药的作用受体而被广泛关注。在这个研究中,我们应用爪蟾卵母细胞表达系统来研究曲马多对M3受体的效应。曲马多(100nM-100uM)可以抑制乙酰胆碱诱导的M3受体效应。虽然GF109203X,一种蛋白激酶C抑制剂,可以增加乙酰胆碱的效应,但在曲马多存在时没有效果。而且,曲马多抑制了{3H}quinuclidinyl benzilate的特殊结合部位。这些研究发现表明曲马多在临床相关剂量下可经过quinuclidinyl benzilate结合部位抑制M3受体。这可以解释神经元功能调节和曲马多的抗副交感神经作用。

(   王祥瑞 )

Tramadol is a widely used analgesic, but its mechanism of action is not completely understood. Muscarinic receptors are involved in neuronal function in the brain and autonomic nervous system, and much attention has been paid to these receptors as targets of analgesic drugs in the central nervous system. In this study, we investigated the effects of tramadol on type-3 muscarinic (M3) receptors using the Xenopus oocyte expression system. Tramadol (10 nM–100 µM) inhibited acetylcholine-induced currents in oocytes expressing M3 receptor. Although GF109203X, a protein kinase C inhibitor, increased the basal current, it had little effect on the inhibition of acetylcholine-induced currents by tramadol. Moreover, tramadol inhibited the specific binding sites of [3H]quinuclidinyl benzilate. These findings suggest that tramadol at clinically relevant concentrations inhibits M3 function via quinuclidinyl benzilate-binding sites. This may explain the modulation of neuronal function and the anticholinergic effects of tramadol.

磷酸异丙酚,一种水溶性的异丙酚前体药物:在体评估

Propofol Phosphate, a Water-Soluble Propofol Prodrug: In Vivo Evaluation

Mariusz G. Banaszczyk, PhD*, Alison T. Carlo*, Violeta Millan*, Adam Lindsey*, Ronald Moss, MD*, Dennis J. Carlo, PhD*, and Sheldon S. Hendler, MD PhD{dagger}

*The Immune Response Corporation, Carlsbad, California; and {dagger}Vyrex Corporation, La Jolla, California

Anesth & Analg Nov. 2002;95:1285-1292

在家鼠,田鼠,家兔和猪中单次静脉注射水溶性异丙酚前体药物磷酸异丙酚(PP),1—15分钟后转化为异丙酚,产生剂量依赖性镇静效应。在家鼠中,半数催眠剂量(HD50),半数致死量(LD50),和安全指数(指LD50/HD50的比率)分别是165.4mg/kg ,600.6 mg/kg, 3.6。异丙酚转化的半衰期在田鼠中为5.3+/0.6 min,在家兔中为2.1 +/-0.6 min,在猪中为4.4+/-2.4min。最大浓度为剂量和种族依赖性。清除半衰期在田鼠中为24+/-12min,家兔中为21+/-16min,在猪中为225+/-56min。从PP到异丙酚的产生药理作用与献报道类似。结果表明异丙酚的血药浓度大于1.0ug/kg时,PP剂量和镇静时间相关,该剂量在鼠和猪中产生嗜睡和镇静作用。用PP后可产生充分的镇静,且当计量足够大时可达到麻醉深度的镇静作用。总之,水溶性异丙酚的前体药物可成为镇静和麻醉用药的发展方向。

                                                    (忻纪华   王祥瑞校)

After a single IV injection of the water-soluble propofol prodrug propofol phosphate (PP) in mice, rats, rabbits, and pigs, propofol was produced rapidly (1–15 min), inducing dose-dependent sedative effects. In mice, the hypnotic dose (HD50), lethal dose (LD50), and safety index (defined as a ratio: LD50/HD50) were 165.4 mg/kg, 600.6 mg/kg, and 3.6, respectively. Propofol was produced with half-lives of 5.3 ± 0.6 min in rats, 2.1 ± 0.6 min in rabbits, and 4.4 ± 2.4 min in pigs. The maximal concentration was dose and species dependent. The elimination half-life was 24 ± 12 min in rats, 21 ± 16 min in rabbits, and 225 ± 56 min in pigs. Propofol generated from PP produced pharmacological effects similar to those described in the literature. We found a correlation between PP dose and duration of sedation with propofol concentrations larger than 1.0 µg/mL, which produced somnolence and sedation in rats and pigs. Adequate sedation and, at large enough doses, anesthetic-level sedation were produced after the administration of PP. Overall, PP, the water-soluble prodrug of propofol, seems to be a viable development candidate for sedative and anesthetic applications.

 

田鼠福尔马林试验比较氙和笑气的镇痛效应

The Analgesic Effect of Xenon on the Formalin Test in Rats: A Comparison with Nitrous Oxide

Taeko Fukuda, MD*, Chikako Nishimoto, MD*, Setsuji Hisano, PhD{dagger}, Masayuki Miyabe, MD*, and Hidenori Toyooka, MD*

*Department of Anesthesiology, Institute of Clinical Medicine; and {dagger}Laboratory of Neuroendocrinology, Institute of Basic Medical Sciences, Tsukuba University, Tsukuba-city, Japan

Anesth & Analg Nov. 2002;95:1300-1304

为研究氙的镇痛效应,以氙或笑气的半数最低肺泡有效浓度在田鼠中进行了福尔马林试验,并通过抗生物素蛋白-辅酶R-过氧化物酶法(zaidin-biotin-peroxidase法)对腰神经根的c-fos(n=18)和磷酸化N—甲基—D—天冬氨酸(NMDA)受体(n=24)进行染色。在吸入79%的氙气,68%的笑气,或100%的氧气后20min在实验组的田鼠臀部注射10%的福尔马林(100ul)。观察1小时的感受伤害反应。福尔马林注射2小时后杀死田鼠,对腰神经根经染色的c-fos和磷酸化NMDA进行免疫组化测定。氙和笑气组的动物感受伤害的反应较氧气组弱。笑气组腰神经根中的c-fos染色阳性细胞没有减少,但氙气组减少。磷酸化NMDA受体阳性细胞在氙气组较笑气和氧气组明显减少。在田鼠福尔马林试验中氙的吸入可以抑制感受伤害反应,c-fos表达,和NMDA受体的活性。这些结果证实了氙的镇痛效应通过抑制NMDA受体而实现。

                                                     (忻纪华   王祥瑞 )

To investigate the analgesic effects of xenon, we performed formalin tests in rats under 0.5 minimum alveolar anesthetic concentration xenon or nitrous oxide and stained the lumbar spinal cord for c-fos (n = 18) and the phosphorylated N-methyl-D-aspartate (NMDA) receptor (n = 24) by using the avidin-biotin-peroxidase method. After 20 min of 79% xenon, 68% nitrous oxide, or 100% inhaled oxygen, 10% formalin (100 µL) was injected into the left rear paw of the animals except for a control group. Nociceptive behavior was observed for 1 h. The rats were killed 2 h after the formalin injection, and the lumbar spinal cord was stained for c-fos or the phosphorylated NMDA receptor immunohistochemically. Animals in the xenon and nitrous oxide groups showed less nociceptive behavior than did the oxygen group. Although the number of c-fos-positive cells in the lumbar spinal cord in the nitrous oxide group was not decreased, that in the xenon group decreased. The number of phosphorylated NMDA receptor-positive cells in the xenon group was significantly less than in the nitrous oxide and oxygen groups. Inhaled xenon suppressed nociceptive behaviors, c-fos expression, and activation of the NMDA receptor during the formalin test in rats. These results confirm that xenon’s analgesic effects result from inhibition of the NMDA receptor.

 

自体血液回收效果评价的数据模型

A Mathematical Model of Cell Salvage Efficiency

Jonathan H. Waters, MD*, Julia ShinJung Lee, MPH MS{dagger}, and Matthew T. Karafa, MS{dagger}

Departments of *General Anesthesiology and {dagger}Biostatistics, Cleveland Clinic Foundation, Cleveland, Ohio

Anesth & Analg Nov. 2002;95:1312-1317

血液回收(CS)是降低手术期间同种异体输血的一种方法。它不同于急性等容性血液稀释, 其效果还没有被精确模拟过。本文假定数学模型能够在血液回收期间预计血球压积的下降,以说明在容量相等的患者中由于红细胞丢失引起血球压积降低而再利用清洗过的红细胞使血球压积增高。血液回收的效果可通过“血液丢失最大允许量”(MABL)来确定。为了说明问题,假想的患者的血容量估计在5000ml,术前血球压积为45%,而需输血的血球压积临界值为21%。在典型的病例中,血液丢失最大允许量为9600ml,红细胞的回收率为60%。病例记录样本显示红细胞平均回收率为57%,并有20%的误差。这个数据模型说明当红细胞收集理想的情况下血液回收是一种高效的节约用血的方法。

                                                     (  王祥瑞 )

Cell salvage (CS) is one of the modalities that can be used during surgery to decrease the use of allogeneic blood. Unlike acute normovolemic hemodilution, the efficiency of CS has not been mathematically modeled. In this article, we hypothesized that a mathematical model could predict the decline of hematocrit during CS. The model that was developed accounts for both the effect of decreasing the hematocrit because of blood loss and the effect of increasing hematocrit because of the readministration of washed blood in an isovolemic patient. The efficiency of CS is defined to be the maximum allowable blood loss (MABL) for a fixed blood volume and a fixed transfusion trigger. For demonstration purposes, variables used for a hypothetical patient included an estimated blood volume of 5000 mL, a presurgery hematocrit of 45%, and a transfusion trigger of 21%. The MABL in a typical case was 9600 mL, with a CS red cell recovery rate of 60%. Patient records from a convenience sample showed an average recovery rate of 57% with 20% variability. This mathematical model suggests that CS can be a highly effective blood conservation method when red blood cell collection is optimal. 
                                                 
便携式输注泵持续区域镇痛时推注速率准确性的研究

The Delivery Rate Accuracy of Portable Infusion Pumps Used for Continuous Regional Analgesia

Brian M. Ilfeld, MD*, Timothy E. Morey, MD*, and F. Kayser Enneking, MD*{dagger}

Departments of *Anesthesiology and {dagger}Orthopedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida

Anesth & Analg Nov. 2002;95:1331-1336

 

区域麻醉期间使用便携式泵来输注局部麻醉剂已被逐渐接受。这些泵常常被用于在滴注期间无须照看的可以走动的患者。然而使用这些泵引起潜在的药物中毒还未被专门地研究。我们对持续区域镇痛期间使用滴注泵滴注麻醉剂的滴注速率的准确性,连贯性及各种泵的性能进行了研究。我们在实验室内通过计算机/定标联合的方法对6个泵的滴速调节器在预期温度和升高的温度的情况下进行测试并记录了它们的滴速。结果显示各个泵间的滴注速率大不相同,在整个输注时间的18%-100%其滴注速率与预期速率相差±15%。温度升高也不同程度地影响泵的滴注速率,滴速增快从0%25%不等。这些结果表明,当使用便携式泵滴注局部麻醉剂时应考虑这些因素比如滴速的准确性,连贯性及各种泵的滴注性能。

                                                       (  王祥瑞 )

Portable pumps used for local anesthetic infusion during continuous regional analgesia are gaining acceptance. These pumps are often used for ambulatory patients who are medically unsupervised throughout most of the infusion. However, the performance of these pumps, which infuse potentially toxic medication, has not been independently investigated. We investigated the flow rate accuracy, consistency, and profiles of various portable pumps often used for local anesthetic infusion during continuous regional analgesia. By using a computer/scale combination within a laboratory to record infusion rates, 6 pumps were tested with their flow regulators at expected (30°–32°C) and increased (34°–36°C) temperatures. Infusion rate accuracy differed significantly among the pumps, exhibiting flow rates within ±15% of their expected rate for 18%–100% of their infusion duration. An increase in temperature also affected pumps to differing degrees, with infusion rates increasing from 0% to 25% for each model tested. These results suggest that factors such as flow rate accuracy and consistency, infusion profile, and temperature sensitivity should be considered when choosing and using a portable infusion pump for local anesthetic administration.


术后早期抑制外周感受伤害活动减轻疼痛的随机试验

Attenuation of Pain in a Randomized Trial by Suppression of Peripheral Nociceptive Activity in the Immediate Postoperative Period

Sharon M. Gordon, DDS MPH*, Jaime S. Brahim, DDS MS*, Ronald Dubner, DDS PhD{dagger}, Linda M. McCullagh, RN MPH{ddagger}, Christine Sang, MD MPH§, and Raymond A. Dionne, DDS PhD*

*National Institute of Dental and Craniofacial Research, Bethesda, Maryland; {dagger}University of Maryland, School of Dentistry, Baltimore, Maryland; {ddagger}Department of Nursing, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, Maryland; and §Department of Anesthesia, Massachusetts General Hospital, Boston, Massachusetts

Anesth & Analg Nov. 2002;95:1351-1357

 

组织损伤所产生的外周神经元屏障会导致中枢神经系统发生改变,这是维持术后疼痛的原因所在。阻滞这些中枢变化的治疗方法仍有争议,因为以前的研究并没有将术前干涉作用从组织损伤后的作用中区分出来,也就是疼痛发作前。本研究估计了在术中或术后早期组织感受伤害活动输入对疼痛抑制的相对作用。研究对象被随机地分入四组中的一组,术前2%利多卡因,术后0.5布比卡因,两者都注射或注射安慰剂。全麻诱导后三次抽取血样。分别于4h24h48h后评价疼痛。手术期间血样本内的β-内啡肽增加两倍。这提示外周感受伤害的屏障的活动对疼痛刺激产生反应。术后早期应用布比卡因组的病人疼痛减轻,然而利多卡因组则随着时间的推移疼痛加重。布比卡因镇痛组在术后48h内疼痛较轻,但是术前单独应用利多卡因组则没有效果。这些手术疼痛模型的结果说明术后早期最小化外周感受伤害的屏障可以在随后的时间内减轻疼痛。相反地,在手术期间阻滞外周感受伤害的屏障似乎对减轻疼痛并没有很大的作用。

                                                    (殷文渊 王祥瑞 )

Peripheral neuronal barrage from tissue injury produces central nervous system changes that contribute to the maintenance of postoperative pain. The therapeutic approaches to blocking these central changes remain controversial, because previous studies have not differentiated presurgical interventions from those administered after tissue injury, yet before pain onset. In this study, we evaluated the relative contributions of blockade of nociceptive input during surgery or during the immediate postoperative period on pain suppression. Subjects were randomly allocated to one of four groups: preoperative 2% lidocaine, postoperative 0.5% bupivacaine, both, or placebo injections. General anesthesia was induced and third molars extracted. Pain was assessed over 4 h and at 24 and 48 h. The ß-endorphin in blood samples increased twofold during surgery, which is indicative of activation of the peripheral nociceptive barrage in response to painful stimuli. Pain was decreased in the immediate postoperative period in the bupivacaine groups, whereas it increased in the lidocaine group over time. Pain intensity was less 48 h after surgery in the groups whose postoperative pain was blocked by the administration of bupivacaine, but no effect was demonstrated for the preoperative administration of lidocaine alone. These results in the oral surgery pain model suggest that minimizing the peripheral nociceptive barrage during the immediate postoperative period decreases pain at later time periods. In contrast, blocking the intraoperative nociceptive barrage does not appear to contribute significantly to the subsequent reduction in pain.

 

γ-羟基丁酸(GABA)受体药物对吗啡诱导的无损伤脊髓缺血后鼠的痉挛性下肢轻瘫的影响
The Effect of Gamma-Aminobutyric Acid (GABA) Receptor Drugs on Morphine-Induced Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in Rats

Seiya Nakamura, MD, Manabu Kakinohana, MD PhD, Yutaka Taira, MD PhD, Hiroshi Iha, MD PhD, and Kazuhiro Sugahara, MD PhD

Department of Anesthesiology, University of the Ryukyus, Okinawa, Japan

 

Anesth & Analg Nov. 2002;95:1389-1395

 

作者曾经描述过啮齿动物模型在无损伤脊髓缺血后鞘内注射吗啡引起痉挛性下身轻瘫。但这种轻瘫的机制不得而知。假设吗啡抑制了控制强直性痉挛的脊髓α-运动神经元的γ-羟基丁酸(GABA)中间神经元,这种对脊髓中间神经元的抑制会引起痉挛性下身轻瘫。本研究研究了吗啡和GABA激动剂或拮抗剂之间对脊髓缺血后运动功能的相互影响从而阐明鞘内注射吗啡引起痉挛性下身轻瘫的机制。通过大动脉阻滞6分钟来引起脊髓缺血。首先确定在这种模型中鞘内注射GABA激动剂(muscimolbaclofen)是否加重痉挛性下身轻瘫。GABA激动剂并没有加重痉挛性下身轻瘫。接着观察GABA拮抗剂(bicuculline5-aminovaleric acid)的影响,从而确定吗啡和GABA拮抗剂之间的相互作用。通过同种辐射测热分析,减轻痉挛的50%有效剂量在理论附加线以下,提示吗啡和GABA拮抗剂之间存在协同作用。这些结果说明鞘内注射吗啡引起的痉挛性下身瘫痪也许可以部分被GABA受体中止。

                                               (殷文渊   王祥瑞 )

We have previously demonstrated that intrathecal morphine given after a noninjurious interval of spinal cord ischemia induced transient spastic paraparesis in a rodent model. However, the mechanism of this paraparesis is unknown. We hypothesized that morphine inhibits {gamma}-aminobutyric acid (GABA)ergic interneurons that control the tonus of spinal cord {alpha}-motoneurons and that inhibition of spinal cord interneurons may cause spastic paraparesis. In this study, we investigate interactions between morphine and GABAergic agonists or antagonists on motor function after spinal cord ischemia and then clarified the mechanism of the spastic paraparesis induced by intrathecal morphine. Spinal cord ischemia was induced by aortic occlusion lasting 6 min. We first determined whether intrathecally administered GABA agonists (muscimol or baclofen) improve the spastic paraparesis in this model. GABA agonists did not improve the paraparesis. Next, we examined the effect of GABA antagonists (bicuculline or 5-aminovaleric acid) and determined the interaction between morphine and GABA antagonists. In an isobolographic analysis, the 50% effective dose decreased below the theoretical additive line, indicating a synergistic interaction between morphine and GABA antagonists. These results indicate that the spastic paraparesis induced by intrathecal morphine may be mediated in part by GABA receptors.

 

连硬及非连硬阻滞患者异氟醚对术中脑电抑制时的等效剂量

Isoflurane Dosage for Equivalent Intraoperative Electroencephalographic Suppression in Patients With and Without Epidural Blockade

Andrew P. Morley, FRCA*, James Derrick, FANZCA*, Paul T. Seed, MSc CStat{dagger}, Perpetua E. Tan, MPhil*, David C. Chung, MD FRCA, FRCPC*, and Timothy G. Short, MD FANZCA{ddagger}

*Department of Anaesthesia and Intensive Care, Faculty of Medicine, Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, New Territories, Hong Kong Special Administrative Region; {dagger}Maternal and Fetal Research Unit, Department of Obstetrics and Gynaecology, Guy’s, King’s and St. Thomas’ School of Medicine, King’s College, London, United Kingdom; and {ddagger}Department of Anaesthesia, Auckland Hospital, Grafton, Auckland, New Zealand

 

Anesth & Analg Nov.2002;95:1412-1418

采用随机、前瞻性对比方法以探讨在手术中要求达到相同的脑电图(EEG)抑制程度时,硬膜外阻滞对异氟醚使用剂量的影响。试验选取50例行腹式子宫切除术患者,麻醉方式为连硬复合全麻或者单独使用异氟醚和阿芬太尼作为全麻。异氟醚吸入采用计算机控制的闭合循环反馈机制以保持EEG中95%的光谱移动频率为17.5HZ, 此目标根据一项飞行员的研究设定。接受连硬麻醉的患者中,呼气末异氟醚浓度较另一组低0.19%,(95%可信区间[CI]-0.32%-0.06%p0.01〉;平均动脉压低17mmHg柱(95%[CI]-24-9mmHgp0.0001〉;体温低0.4℃(95%[CI]-0.70℃;p0.05〉;脑电双频指数BIS4点(95%[CI]17p0.05〉。EEG的中等值和心率在两组中类似。接受连硬麻醉的患者因为低血压而需要间羟胺的比例高76%95%CI58%94%p0.001〉,另外,多28%的患者因为心动过缓而需要使用甘罗溴铵95%CI3%53%p0.05〉。术后,患者睁眼的时间短2.3分钟(95%CI-4.2-0.5分钟,p0.05〉。麻醉最后30秒呼气末异氟醚浓度与睁眼时间的相关性优于BIS,(FE’ISO=0.07× 睁眼时间+0.31r2=0.59p0.0001〉,(BIS=64-1.25×睁眼时间;r2=0.22p0.001〉(p0.0001〉。为了达到相同的光谱移动频率,患者接受全麻联合连硬所需的异氟醚用量较单独使用全麻患者少21%,较少的异氟醚用量也伴随着麻醉后更快的苏醒。

                                                  (陈 洁 王祥瑞 )

We conducted a prospective, randomized, controlled trial to establish the effect of epidural blockade on isoflurane requirements for equivalent intraoperative electroencephalographic (EEG) suppression. Fifty patients undergoing abdominal hysterectomy received combined epidural and general anesthesia or general anesthesia alone with isoflurane and alfentanil. Isoflurane was administered by computer-controlled closed-loop feedback to maintain an EEG 95% spectral edge frequency of 17.5 Hz, a target chosen on the basis of a pilot study. In epidural patients, end-tidal isoflurane concentration (FE'ISO) was 0.19% smaller (95% confidence interval [CI], -0.32% to -0.06%; P < 0.01), mean arterial blood pressure was 17 mm Hg lower (95% CI, -24 to -9 mm Hg; P < 0.0001), and body temperature was 0.4°C lower (95% CI, -0.7 to 0°C; P < 0.05) than in controls. EEG bispectral index (BIS) was 4 points higher (95% CI, 1 to 7; P < 0.05). EEG median frequency and heart rate were similar in both groups. Epidural patients were 76% more likely (95% CI, 58% to 94%; P < 0.001) to require metaraminol for hypotension and were 28% more likely (95% CI, 3% to 53%; P < 0.05) to require glycopyrrolate for bradycardia. After surgery, the time to eye opening in epidural patients was 2.3 min shorter (95% CI, -4.2 to -0.5 min; P < 0.05). Time to eye opening correlated better with FE'ISO in the last 30 s of anesthesia (FE'ISO = 0.07 x time to eye opening + 0.31; r2 = 0.59; P < 0.0001) than with BIS from the same period (BIS = 64 - 1.25 x time to eye opening; r2 = 0.22; P < 0.001) (P < 0.0001). To maintain similar intraoperative spectral edge frequency, patients receiving combined epidural and general anesthesia require 21% less isoflurane than those receiving general anesthesia alone. This smaller isoflurane dose is associated with faster emergence from anesthesia.

 

 经鼻气管插管:一种简单而有效的减少鼻咽部创伤和导管污染的技术

Nasotracheal Intubation: A Simple and Effective Technique to Reduce Nasopharyngeal Trauma and Tube Contamination

Dietmar Enk, MD, Anne M. Palmes, MD, Hugo Van Aken, MD PhD, FRCA, FANZCA, and Martin Westphal, MD

Department of Anaesthesiology and Intensive Care, University of Münster, Münster, Germany

Anesth & Analg Nov. 2002;95:1432-1436

假设通过鼻咽导管(Wendl 管)作为引导者来帮助气管内导管通过鼻咽部。采用相应的随机对比双盲实验,以估计鼻咽部的出血和气管内导管末端的污染程度。麻醉诱导后,将Wendl 管插入鼻孔。在对照组(n=30),Wendl 管在气管内导管(内径7.0mm)接触鼻咽通路之前收回。在调查组(n=30),Wendl管保持位置固定仅取走调节凸缘。然后将气管内导管的末端插入Wendl管的拖尾。最后,气管内导管通过Wendl管引导到达口咽部。之后,Wendl管取走,插管完成。术后6小时评定患者的鼻部疼痛,引导者技术减少了出血的发生率(p0.001〉和严重程度(p=0.001)和减少了导管被血液和黏液的污染(p0.001〉,并且减少了术后的鼻部疼痛(p=0.036)。  

                                                      (陈 洁 王祥瑞 )

Our hypothesis was that nasopharyngeal passage of an endotracheal tube can be facilitated by a nasopharyngeal airway (Wendl tube) acting as a "pathfinder." Accordingly, we performed a randomized, controlled trial with blinded assessment of nasopharyngeal bleeding and contamination of the tip of the endotracheal tube. After the induction of anesthesia, a Wendl tube (28 Ch) was inserted into the more patent nostril. In the control group (n = 30), the Wendl tube was retrieved before nasopharyngeal passage was attempted with an endotracheal tube (inner diameter, 7.0 mm). In the intervention group (n = 30), the Wendl tube was kept in position and only its adjustable flange was removed. Then, we inserted the tip of the endotracheal tube into the trailing end of the Wendl tube. Subsequently, the endotracheal tube was advanced under visual control to the oropharynx guided by the Wendl tube. After the endotracheal tube was positioned in the oropharynx, the Wendl tube was removed and intubation completed. Six hours after surgery, we determined the patients’ nasal pain. The "pathfinder" technique reduced the incidence (P < 0.001) and severity (P = 0.001) of bleeding, decreased tube contamination with blood and mucus (P < 0.001), and diminished postoperative nasal pain (P = 0.036).

骶管内注射新斯的明、 布比卡因及两药复合液用于小儿尿道下裂术后镇痛

Caudal Neostigmine, Bupivacaine, and Their Combination for Postoperative Pain Management After Hypospadias Surgery in Children

Mohamed Abdulatif, MB BCH, MSc, MD, and Mohga El-Sanabary, MB BCH, MSc, MD

Department of Anesthesiology, Cairo University, Egypt

Anesth & Analg Nov. 2002;95:1215-1218

目的:研究小儿尿道下裂术后骶管内注射新斯的明布比卡因及两药复合液的镇痛效果。方法:60例行尿道下裂手术的患儿,随机分为三组,分别于全麻诱导后骶管内注射0.25% 布比卡因1 mL/kg 新斯的明2µg/kg (用生理盐水稀释,1 mL/kg )和两者复合组(0.25% 布比卡因1 mL/kg内含2 µg/kg n=20)。结果:骶管内注射布比卡因或布比卡因新斯的明复合液的患儿术中吸入麻醉药的量较骶管内注射新斯的明组少,血流动力学也更稳定,而且全麻后苏醒也更快。术后第一次追加镇痛药的时间,三者分别为22.8 ± 2.9 h, 8.1 ± 5.9 h 5.2 ± 2.1 h(P < 0.001) 。骶管注射布比卡因和新斯的明组术后24h需要的醋氨酚的量较复合组多。术后呕吐的发生率分别为25%, 10%, 30% (P < 0.01)。结论:小儿尿道下裂术后骶管注射新斯的明的镇痛效果和骶管注射布比卡因相当,两药复合时镇痛作用增强。

(王士雷    庄心良 )

In a randomized, double-blinded study, we examined the analgesic efficacy of caudal neostigmine, bupivacaine, or a mixture of both drugs in 60 children. After the induction of general anesthesia, children were allocated randomly into three groups (n = 20) to receive a caudal injection of either 0.25% bupivacaine 1 mL/kg, with or without neostigmine 2 µg/kg, or neostigmine 2 µg/kg in normal saline 1 mL/kg. Intraoperatively, children receiving caudal bupivacaine or a bupivacaine/neostigmine mixture maintained hemodynamic stability, required less inhaled anesthetics, and had a shorter recovery time compared with the caudal neostigmine alone. Postoperatively, the caudal bupivacaine/neostigmine mixture resulted in superior analgesia compared with the other two groups. Recovery to first rescue analgesic times were (mean ± SD) 22.8 ± 2.9 h, 8.1 ± 5.9 h, and 5.2 ± 2.1 h in the bupivacaine/neostigmine, bupivacaine, and neostigmine groups, respectively (P < 0.001). In addition, the bupivacaine and neostigmine groups received more doses of paracetamol than the bupivacaine/neostigmine group to maintain adequate analgesia in the first 24 postoperative h. Postoperative vomiting occurred in 25%, 10%, and 30% in the caudal bupivacaine/neostigmine, bupivacaine, and neostigmine groups, respectively (P < 0.01). We conclude that caudal neostigmine 2 µg/kg provides postoperative analgesia comparable to caudal bupivacaine in children undergoing hypospadias repair surgery.

 

胍乙啶和局麻药对电刺激鼠输精管反应的影响

The Effect of Guanethidine and Local Anesthetics on the Electrically Stimulated Mouse Vas Deferens

Philip I. Joyce, PhD*, Daniela Rizzi{dagger}, Girolamo Caló, MD PhD{dagger}, David J. Rowbotham, MD FRCA*, and David G. Lambert, PhD*

*University Department of Anaesthesia and Pain Management, Leicester Royal Infirmary, Leicester, United Kingdom; and {dagger}Department of Experimental and Clinical Medicine, Section of Pharmacology, and Neuroscience Center, University of Ferrara, Ferrara, Italy

Anesth & Analg Nov. 2002;95:1339-1343

目的:复杂疼痛综合症(CRPS)常用胍乙啶和局麻药治疗,但出现不同的效果。因为局麻药抑制去甲肾上腺素转运体的摄取,是否因为抑制胍乙啶的摄取而使作用显着不同?本实验用附带交感神经的输精管验证此假说。方法:观察丙胺卡因、普鲁卡因、可卡因及其分别与胍乙啶复合对电刺激附带交感神经的输精管的作用。结果:丙胺卡因(1 mM)能即刻抑制电刺激鼠输精管的颤搐反应(2 min后达100%),在1h时洗脱药物颤搐反应能完全恢复。胍乙啶(3 µM)15min内抑制电刺激鼠输精管的颤搐反应95% ± 3%,但1h时洗脱药液颤搐反应仅部分恢复(33% ±12%)。联合应用丙胺卡因和胍乙啶,1h时洗脱药液颤搐反应可以恢复80% ± 13%。普鲁卡因(300 µM)使颤搐反应短暂升高(152% ± 14%)。联合应用胍乙啶(3µM),颤搐反应降为24% ± 4% 1h时洗脱药液颤搐反应可以恢复77% ± 7%。可卡因(30 µM)抑制颤搐反应53% ± 8%,在1h时洗脱药液颤搐反应可以完全恢复。联合应用胍乙啶(3µM),颤搐反应降为39% ± 6%,在1h时洗脱药液颤搐反应恢复86% ± 10%。所有复合用药引起的反转都比单用胍乙啶为强。结论:局麻药能降低胍乙啶的交感活性,这可以解释为什么用胍乙啶治疗区域疼痛综合症时常出现不一样的效果。

(王士雷     庄心良  校)

Complex regional pain syndrome is often treated with the sympatholytic guanethidine and a local anesthetic in a Bier’s block. The efficacy of this treatment has been questioned. Because local anesthetics inhibit the norepinephrine uptake transporter, we hypothesized that this variable efficacy results from the local inhibiting the uptake of guanethidine. In this study, we tested this hypothesis by using a sympathetically innervated mouse vas deferens preparation. Organ bath-mounted mouse vasa deferentia were electrically stimulated in the absence and presence of guanethidine, prilocaine, procaine, and cocaine in various combinations. Prilocaine (1 mM) induced an immediate inhibition of twitch response (maximum 100% after 2 min) that fully reversed after washing. Guanethidine (3 µM) also inhibited twitching by 95% ± 3% in 15 min, but this effect was only partially reversed after 1 h of washing (33% ± 12% of control). When prilocaine and guanethidine were added in combination, a reversal of 80% ± 13% (at 1 h) was observed. Procaine (300 µM) produced a transient increase (152% ± 14%) in response. When co-incubated with guanethidine (3 µM), the twitch was reduced to 24% ± 4% of control and was reversed to 77% ± 7% after 1 h. Cocaine (30 µM) inhibited the twitch response to 53% ± 8%, which was fully reversed by 1 h of washing. When co-incubated with guanethidine, the response was reduced to 39% ± 6% of control and was reversed to 86% ± 10% after 1 h. In all cases, the reversal produced by the combination was significantly more intense (P < 0.05) than that produced by guanethidine alone. Local anesthetics reduce the sympatholytic actions of guanethidine, and this may explain the variable efficacy of guanethidine in the treatment of complex regional pain syndrome.

腰硬联合分娩镇痛时蛛网膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可乐定的随机双盲试验研究。

A Randomized, Double-Blinded Trial of Subarachnoid Bupivacaine and Fentanyl, With or Without Clonidine, for Combined Spinal/Epidural Analgesia During Labor

Michael J. Paech, FANZCA*, Samantha L. Banks, FRCA*, Lyle C. Gurrin, PhD{dagger}, Seng T. Yeo, FRCA*, and Timothy J. G. Pavy, FANZCA*

*Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Subiaco, Western Australia; and {dagger}the Women and Infants Research Foundation, Perth, Western Australia

Anesth & Analg Nov. 2002;95:1396-1401

目的:蛛网膜下腔注射可乐定可能延长阿片药的作用时间,增强局麻药的镇痛效果,但是,也可能引起低血压和嗜睡等副作用。本文对腰硬联合分娩镇痛时蛛网膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可乐定进行比较。方法:110例在腰硬联合下分娩镇痛的产妇,随机分为4组,分别于蛛网膜下腔注射芬太尼(20 µg-布比卡因(2.5 mg-NS或芬太尼(20 µg-布比卡因(2.5 mg)复合可乐定15, 30, or 45 µg。结果:101例符合统计要求的产妇中,有22例在腰麻终止前娩出胎儿。各组病人在注药后0-120分钟期间的疼痛评分相同。各组病人腰麻镇痛时间无显着不同。所有复合可乐定的病人在腰麻期后40-90min时体循环血压都低,且低血压和需要应用麻黄素者随可乐定用量的增加而增多,但组间低血压的发生率无差别。结论:可乐定15–45 µg不能延长蛛网膜下腔注射布比卡因-芬太尼的镇痛时间,却显着降低血压。

                               (王士雷    庄心良  校)

Subarachnoid clonidine may increase the duration of spinal opioid and local anesthetic analgesia during labor, but it may also increase hypotension and sedation, and the therapeutic range is unclear. We studied 110 term parturients of mixed parity having combined spinal/epidural analgesia during labor in this randomized, double-blinded trial. All received subarachnoid fentanyl 20 µg and bupivacaine 2.5 mg, plus either saline or clonidine (15, 30, or 45 µg). Of 101 per-protocol parturients (n = 25, 24, 26, and 26 in Groups C0, C15, C30, and C45, respectively), 22 delivered before the cessation of spinal analgesia. Group demographics and pain scores from Time 0 to 120 min were similar. There was no significant difference among groups in the duration of spinal analgesia (P = 0.09) or in the duration of clonidine groups combined compared with control (median, 120 min [interquartile range, 96–139 min] versus 98 min [80–120 min]; P = 0.07). Systolic blood pressure was significantly lower in all clonidine groups between 40 and 90 min (P = 0.001). Hypotension (P = 0.05) and the requirement for ephedrine (P = 0.02) were dose dependent, but groups had a similar incidence of hypotension. The addition of clonidine 15–45 µg to subarachnoid fentanyl and bupivacaine reduced blood pressure and did not significantly increase the duration of spinal analgesia.

 

Ondansetron Dolasetron 对施行扁桃体切除术的门诊病人有等效的止吐功能

Ondansetron and Dolasetron Provide Equivalent Postoperative Vomiting Control After Ambulatory Tonsillectomy in Dexamethasone-Pretreated Children

Radha Sukhani, MD, Ana Lucia Pappas, MD, Jordan Lurie, MD, Andrew J. Hotaling, MD, Albert Park, MD, and Elaine Fluder, RN MSN

Departments of *Anesthesiology and {dagger}Otolaryngology, Loyola University Medical Center, Maywood, Illinois

Anesth & Analg Nov. 2002;95:1230-1235

我们用前瞻、随机、双盲以及安慰剂对照的方法,以159例年龄在2-12岁、ASA分级为III级的施行扁桃体切除术的病人为研究对象,术前分别给予单次剂量的ondansetron dolasetron,比较其呕吐发生率和术后48小时的恢复特征。所有病人均给以相同的术中处理,包括术前用药、镇痛药、手术和麻醉技术等。病人随机分组如下,ondansetron组,ondansetron 0.15mg/kg,最大量不超过4 mgdolasetron组,dolasetron  0.5mg/kg, 最大量不超过25 mg;安慰剂组,静脉注射生理盐水。另外,所有病人术前均给以地塞米松1 mg/kg,最大量不超过25 mg。发生恶心/呕吐超过2次的病人,即刻给以额外的止吐药。在医院,ondansetron dolasetron恶心/呕吐发生率组间无差别,两组均显着低于安慰剂组(分别为10%8%30%)。在家里(即术后24-48小时),也观察到相似的结果(分别为6%, 6%18%)。在医院,出现两次恶心/呕吐而需给以止吐药的发生率,在ondansetron dolasetron显着低于安慰剂组(分别为4%6%22%)。完全显效率(即48小时内无恶心/呕吐现象,未用止吐药物),在ondansetron dolasetron组显着低于安慰剂组(分别为76%74%44%)。所以预防性的应用ondansetron dolasetron具有相同的止吐效果。

(杨保仲译   庄心良校)

In this prospective, randomized, double-blinded, placebo-controlled study, we compared the incidence of emesis and 48-h recovery profiles after a single dose of preoperative ondansetron versus dolasetron in dexamethasone-pretreated children undergoing ambulatory tonsillectomy. One-hundred-forty-nine children, 2–12 yr old, ASA physical status I and II, completed the study. All children received standardized perioperative care, including premedication, surgical and anesthetic techniques, IV fluids, analgesics, and rescue antiemetic medications. Patients were randomized to receive ondansetron 0.15 mg/kg, maximum 4 mg (Group 1); dolasetron 0.5 mg/kg, maximum 25 mg (Group 2); or saline placebo (Group 3) IV before the initiation of surgery. In addition, all patients received dexamethasone 1 mg/kg (maximum 25 mg). Rescue antiemetics were administered for two or more episodes of retching/vomiting. The incidence of retching/vomiting before home discharge did not differ between the ondansetron and dolasetron groups and was significantly less frequent compared with the placebo group (10%, Group 1; 8%, Group 2; 30%, Group 3). Similar results were obtained at 24–48 h after discharge (6%, Groups 1 and 2; 18%, Group 3). The need for rescue antiemetics administered after the second retching/vomiting episode was significantly less in Groups 1 (4%) and 2 (6%) compared with Group 3 (22%) before home discharge. The complete response rate, defined as no retching/vomiting and no antiemetic for 48 h, was significantly increased in Groups 1 (76%) and 2 (74%) compared with Group 3 (44%). The antiemetic efficacy of prophylactic ondansetron and dolasetron was comparable in dexamethasone-pretreated children undergoing ambulatory tonsillectomy.


全麻下施行大手术发生低体温的原因分析

Preoperative Risk Factors of Intraoperative Hypothermia in Major Surgery Under General Anesthesia

T. Kasai, MD*, M. Hirose, MD*, K. Yaegashi, MD*, T. Matsukawa, MD{ddagger}, A. Takamata, PhD{dagger}, and Y. Tanaka, MD*

Departments of *Anesthesiology and {dagger}Physiology, Kyoto Prefectural University of Medicine, Kyoto; and {ddagger}Department of Anesthesiology, Yamanashi Medical University, Yamanashi, Japan

Anesth & Analg Nov. 2002;95:1381-1383

许多因素,诸如病人的年龄和体质,会影响病人术中的体温。本研究的第一部分,我们用回顾性方法,建立了如下数学模型:术中发生低体温的可能性P=1/(1 + e-Z),其中Z= -15.014 + 0.097 x (年龄) + 0.263 x (身高) - 0.323 x (体重) - 0.055 x (术前收缩压) - 0.121 x (术前心率)。当P>0.5,此方法的灵敏度为81.5%,特异度为 83%。本研究的第二部分,我们用前瞻性的方法,验证此数学模型的有效性,在P>0.7的病人时,中心体温明显降低,其体温调节性血管收缩反应的阈值也明显降低;在P≤0.3的病人,术中体温正常。本次研究结果表明,我们可以根据病人术前的年龄、身高、体重、收缩压和心率等因素来预估病人术中发生低体温的可能性,即年龄大、体型瘦小、血压低和心率慢是术中低体温发生的主要原因。

(杨保仲 庄心良 校)

 Preoperative factors, such as age and body habitus, affect intraoperative hypothermia during general anesthesia. In a preliminary study, we developed a logistic model to retrospectively evaluate predictors of intraoperative hypothermia in patients who received major surgery. The following factors were selected to develop the model: Z = -15.014 + 0.097 x (Age) + 0.263 x (Height) - 0.323 x (Weight) - 0.055 x (Preoperative systolic blood pressure) - 0.121 x (Preoperative heart rate). By using this model, the probability of hypothermia can be estimated by applying the following for-mula: Probability = 1/(1 + e-Z). If an estimated probability of hypothermia was >0.5, the sensibility of prediction was 81.5% and the specificity was 83%. In the second study, the model was applied prospectively to other patients, and the validity of the logistic model was evaluated. The core temperature showed a significant decrease in patients with a probability >0.7, who were predicted to be hypothermic, and their thermoregulatory vasoconstriction threshold also showed a significant decrease, compared with the patients with a probability <=0.3, who were predicted to be normothermic. We concluded that intraoperative hypothermia could be predicted from preoperative characteristics such as age, height, weight, systolic blood pressure, and heart rate.

 

全麻药对游离的鼠皮层神经末梢去甲肾上腺素释放的影响

The Effects of General Anesthetics on Norepinephrine Release from Isolated Rat Cortical Nerve Terminals

Victor N. Pashkov, PhD, and Hugh C. Hemmings, Jr., MD PhD

Departments of Anesthesiology and Pharmacology, Weill Medical College of Cornell University, New York, New York

Anesth & Analg Nov. 2002;95:1274-1281

静脉和吸入麻醉药抑制交感神经元和其它神经分泌细胞释放去甲肾上腺素(NE)。然而,全麻药对中枢神经系统去甲肾上腺素释放的作用尚不清楚。作者研究了具有代表性的静脉和吸入麻醉药对游离鼠大脑皮层神经末梢(突触体)释放[3H]NE的影响。大鼠纯化的大脑皮层突触体预载[3H]NE,用含优降宁(一种单胺氧化酶抑制剂)和抗坏血酸(一种抗氧化剂)的缓冲液灌洗。在含或不含各种麻醉药时检测灌注液中基础 (自发)和刺激诱发的[3H]NE 释放量。采用高浓度的KCl(15–20 mM)4-氨基吡啶(0.5–1.0 mM)诱发鼠皮层突触体浓度和Ca2+-依赖的[3H]NE释放增加。静脉麻醉药依托米酯(5–40 µM),氯胺酮(5–30 µM),或戊巴比妥(25–100 µM)不影响基础或刺激诱发的[3H]NE 释放。异丙酚(5–40 µM)增加基础[3H]NE 的释放,在大剂量时减少刺激诱发的释放。吸入麻醉药氟烷(0.15–0.70 mM)增加基础[3H]NE的释放,但不影响刺激诱发的释放。这些发现提示药物特异性的刺激基础去甲肾上腺素的释放。去甲肾上腺素传递可能是中枢神经系统内全麻药的一个突触前靶位。如果从全麻药对中枢神经系统其它递质释放的影响考虑,那么全麻药的突触前作用是药物和递质特异性的。

(   庄心良 )

Intravenous and volatile general anesthetics inhibit norepinephrine (NE) release from sympathetic neurons and other neurosecretory cells. However, the actions of general anesthetics on NE release from central nervous system (CNS) neurons are unclear. We investigated the effects of representative IV and volatile anesthetics on [3H]NE release from isolated rat cortical nerve terminals (synaptosomes). Purified synaptosomes prepared from rat cerebral cortex were preloaded with [3H]NE and superfused with buffer containing pargyline (a monoamine oxidase inhibitor) and ascorbic acid (an antioxidant). Basal (spontaneous) and stimulus-evoked [3H]NE release was evaluated in the superfusate in the absence or presence of various anesthetics. Depolarization with increased concentrations of KCl (15–20 mM) or 4-aminopyridine (0.5–1.0 mM) evoked concentration- and Ca2+-dependent increases in [3H]NE release from rat cortical synaptosomes. The IV anesthetics etomidate (5–40 µM), ketamine (5–30 µM), or pentobarbital (25–100 µM) did not affect basal or stimulus-evoked [3H]NE release. Propofol (5–40 µM) increased basal [3H]NE release and, at larger concentrations, reduced stimulus-evoked release. The volatile anesthetic halothane (0.15–0.70 mM) increased basal [3H]NE release, but did not affect stimulus-evoked release. These findings demonstrate drug-specific stimulation of basal NE release. Noradrenergic transmission may represent a presynaptic target for selected general anesthetics in the CNS. Given the contrasting effects of general anesthetics on the release of other CNS transmitters, the presynaptic actions of general anesthetics are both drug- and transmitter-specific.

 

围术期两种血液保护技术的前瞻性随机对照研究:等容量和超容量血液稀释

A Prospective Randomized Study Comparing Two Techniques of Perioperative Blood Conservation: Isovolemic Hemodilution and Hypervolemic Hemodilution

 

Rakesh Kumar, MD, Indranil Chakraborty, MD, and Raminder Sehgal, MD

Department of Anesthesiology and Intensive Care, Maulana Azad Medical College and Associated Hospitals, New Delhi, India

Anesth & Analg Nov. 2002;95:1154-1161

作者比较了标准情况下超容量(HVH)和等容量(IVH)血液稀释作为围术期血液保护方法的效果。30ASA I/II级,行骨科,耳--喉科或普外科手术的成年病人,预计失血>500 mL,入选IVH(n = 15)HVH (n = 15)。采用抽血和同时输入多聚明胶(海脉素,Hemaccel)的方法(IVH)或输入多聚明胶而不抽血产生高容量(HVH) 的方法把血液红细胞压积(Hct)稀释至25%。在为维持术后24小时Hct >=25%而进行自体或异体输血前允许失血达到Hct20%。在HVH 组,收缩压(P = 0.0107)和中心静脉压(P = 0.0281)明显高。稀释后目标Hct 25% 和实际达到的Hct之间的均差(MD)在两组没有统计学意义。(MD [95% 可信区间; CI], IVH组, 0% [-0.7% to 0.7%] HVH 组,0.6% [-0.1% to 1.3%])实际异体输血量在两组间是相似的,MD (95% CI) –7 (-326 312)。并且显着低于相应的预计失血量。(MD [95% CI], IVH 组,-581 mL [-753 -409 mL]; HVH 组,-376 mL [-531 to -221]) 两种技术在用时(MD [95% CI] = 7 min [-0.5 to 14.5 min]),费用MD [95% CI] = $1.7 (-$4.10 $7.50))及所用多聚明胶的量(MD [95% CI] = -6 mL/kg 体重 [-16 to 4 mL/kg 体重])上是相似的。本研究发现IVH HVH 在显着减少围术期异体血用量,用时,费用方面具有可比性,而达到所需HVH 的方法似乎是有前途的。

(   庄心良 )

We compared hypervolemic hemodilution (HVH) and isovolemic hemodilution (IVH) as means of perioperative blood conservation under standardized conditions. Thirty ASA status I/II adults slated for orthopedic, ear-nose-throat, or general surgery with expected blood loss of >500 mL underwent either IVH (n = 15) or HVH (n = 15). They were hemodiluted to a hematocrit (Hct) of 25% by blood withdrawal and simultaneous polygeline (Hemaccel®) infusion (IVH) or by infusing polygeline without blood withdrawal, thus creating hypervolemia (HVH). Further blood loss to a Hct of 20% was allowed beforeautologous/allogeneic blood transfusion to aim for a 24-h postoperative Hct of >=25%. Systolic blood pressure (P = 0.0107) and central venous pressure (P = 0.0281) were significantly higher during HVH. The mean difference (MD) between the target postdilution Hct of 25% and the Hct achieved was not statistically significant in either group (MD [95% confidence interval; CI], 0% [-0.7% to 0.7%] for IVH and 0.6% [-0.1% to 1.3%] for HVH). The actual amount of allogeneic blood used was similar in the two groups, with an MD (95% CI) of -7 (-326 to 312), and was significantly less than the corresponding projected amount (MD [95% CI], -581 mL [-753 to -409 mL] in IVH; -376 mL [-531 to -221] in HVH). The two techniques were similar in time taken (MD [95% CI] = 7 min [-0.5 to 14.5 min]), cost incurred (MD [95% CI] = $1.7 (-$4.10 to $7.50)), and volumes of polygeline used (MD [95% CI] = -6 mL/kg body weight [-16 to 4 mL/kg body weight]). This study found IVH and HVH comparable in significantly reducing perioperative allogeneic blood requirements, time needed, and cost incurred. The formula used for achieving the desired HVH appears promising.

 

听觉稳态反应不是一个合适的麻醉监测方法

The Auditory Steady-State Response Is Not a Suitable Monitor of Anesthesia

S. Pockett, PhD, and S. M. Tan, PhD

Department of Physics, University of Auckland, Auckland, New Zealand

Anesth & Analg Nov. 2002 95: 1318-1323.

 

 既往研究显示人的40-Hz 听觉稳态反应(ASSR)在麻醉诱导时消失,提示其可能是一种较好的麻醉监护方法。本研究的目的是了解是否所有的正常清醒成人的ASSR 具有足够的信噪比。在35  70 Hz频率间发出一系列的卡哒音并把在头顶记录的脑电图进行傅里叶(Fourier)转换。在所发出卡哒音频率的脑电图频谱上可观察到ASSRs以尖峰形式出现。最初的结果显示在研究所使用的任何卡哒音频率由一半的研究对象不能获得可辨认的ASSR 。进一步的研究显示那些清醒状态下得不到ASSR 的研究对象却在进入昏睡状态时出现了科观察到的ASSR 。这是由于在昏睡状态时信号强度增加的缘故,而不是噪音降低。结论是:由于研究对象存在明显的比例 不能在清醒时容易地显示可记录的ASSR ,因此使用ASSR 消失作为麻醉是否足够的常规实验是不现实的。

(张 军译  庄心良 校)

Previous studies show that the human 40-Hz auditory steady-state response (ASSR) disappears on induction of general anesthesia, suggesting that it may be a good candidate for a monitor of anesthesia. In this study, we aimed to learn whether all normal alert adults display ASSRs with adequate signal-to-noise ratio. Clicks were presented at a series of frequencies between 35 and 70 Hz and electroencephalographic records taken at the vertex  were Fourier transformed. ASSRs were observable as sharp peaks in the electroencephalograph spectrum at the frequency of the clicks. Initial results showed that a discernible ASSR could not be obtained from about half the subjects studied at any click frequency used. Further investigation revealed that in subjects whose ASSR was undetectable in the alert state, induction of a drowsy mental state resulted in appearance of an observable ASSR. This was attributable to an increase in signal in the drowsy state, not to a decrease in noise. We conclude that, because a significant proportion of subjects do not display easily recordable ASSRs when alert, it is not practical to use disappearance of the ASSR as a routine test for adequacy of anesthesia.

肾上腺素对罗哌卡因硬膜外应用时早期全身吸收的影响

The Effect of the Addition of Epinephrine on Early Systemic Absorption of Epidural Ropivacaine in Humans

Bee B. Lee, FANZCA FHKCA, FHKAM, Warwick D. Ngan Kee, MD FANZCA, FHKCA, FHKAM, John L. Plummer, PhD AStat, Manoj K. Karmakar, FRCA FHKCA, and April S.Y. Wong, BSc

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; and Department of Anaesthesia, Flinders Medical Centre, Flinders University of South Australia, Bedford Park, South Australia, Australia

Anesth & Analg Nov. 2002;95:1402-1407

 

由于肾上腺素有收缩血管的特性,至今仍未被推荐和罗哌卡因联合使用,然而,有一些药物动力学方面的数据显示人体硬膜外给罗哌卡因加用肾上腺素是可行的。在这个前瞻、双盲的研究中,把行择期腹部子宫切除术的患者随机分为硬膜外注射罗哌卡因组(1.5mg/kg,稀释至15ml)和罗哌卡因复合肾上腺素(5µg/mL)组(n=12)。在180分钟内间隔测定动静脉血浆中罗哌卡因的浓度。结果显示,在给药后60分钟内,肾上腺素组的动静脉内罗哌卡因的血浆浓度要比对空白组小(P<0.01)。肾上腺素组罗哌卡因最大血浆浓度的平均值(动脉 0.92± 0.32 µg/mL,静脉 0.82 ± 0.33 µg/mL)小于空白组(动脉 1.31 ± 0.39 µg/mL 静脉 1.31 ± 0.50 µg/mL)(P=0.01)。达到最大血浆浓度的时间没有显着的差异(肾上腺素组:动脉 16 ± 2 min,静脉 23 ± 2 min;空白组:动脉  9 ± 2 min ,静脉 12 ± 3 min )(P=0.08)。在1小时内动脉血罗哌卡因的浓度高于静脉血(P<0.01);动静脉血浓度的差值呈指数级下降,其下降的速率和程度不受肾上腺素的影响。结论:在罗哌卡因中加用肾上腺素5 µg/mL减少了硬膜外注射后早期罗哌卡因的血浆浓度,有助于减少硬膜外给罗哌卡因全身吸收而致的毒性。

(朱     庄心良校)

The addition of epinephrine to ropivacaine has not been recommended because ropivacaine has intrinsic vasoconstrictor properties. However, few pharmacokinetic data are available on the addition of epinephrine to epidural ropivacaine in humans. In this prospective, double-blinded study, we randomized patients having elective abdominal hysterectomy to receive epidural ropivacaine 1.5 mg/kg, diluted in 15 mL, either with (epinephrine group, n = 12) or without (plain group, n = 12) epinephrine 5 µg/mL and then measured arterial and venous plasma concentrations of ropivacaine at intervals up to 180 min. We found that arterial and venous plasma ropivacaine concentrations were smaller in the epinephrine group compared with the plain group in the first 60 min after the drug administration (P < 0.01). Mean (± SD) maximum total plasma ropivacaine concentration was smaller in the epinephrine group (arterial, 0.92 ± 0.32 µg/mL; venous, 0.82 ± 0.33 µg/mL) compared with the plain group (1.31 ± 0.39 µg/mL and 1.31 ± 0.50 µg/mL, respectively; P = 0.01). Time to maximum total plasma ropivacaine concentration was not significantly different between groups (mean ± SD; arterial, 16 ± 2 min; venous, 23 ± 2 min in the epinephrine group versus 9 ± 2 min and 12 ± 3 min, respectively, in the plain group; P = 0.08). Arterial plasma ropivacaine concentrations were larger than venous concentrations during the first hour (P < 0.01); the arterio-venous difference decreased exponentially, and the rate and magnitude of this decrease was unaffected by epinephrine. We conclude that the addition of epinephrine 5 µg/mL to ropivacaine reduced the early systemic plasma concentrations of ropivacaine after epidural injection and may be useful for decreasing the risk of toxicity from systemic absorption of epidural ropivacaine.

 

Bellhouse试验评估寰枕关节伸展度的可靠性

The Reliability of the Bellhouse Test for Evaluating Extension Capacity of the Occipitoatlantoaxial Complex

Yasunari Urakami, MD, Ichiro Takenaka, MD, Motohiro Nakamura, MD, Hiroshi Fukuyama, MD, Kazuyoshi Aoyama, MD, and Tatsuo Kadoya, MD

Department of Anesthesia, Nippon Steel Yawata Memorial Hospital; and Department of Anesthesia, Moji Rosai Hospital, Kitakyushu, Japan

Anesth & Analg Nov. 2002;95:1437-1441

目的:研究Bellhouse等人描述的评估寰枕关节伸展度的可靠性。方法:20位颈椎正常的成人志愿者,取坐位,头保持正中。然后最大程度地伸展头部,同时尽可能少的移动颈部。用量角器测量正中位到最大伸展位的角度。在相应的位置拍摄侧位的颈椎X,包括寰枕关节伸展角。结果:用X线测得的寰枕关节伸展的角度和用Bellhouse试验测得的头部伸展的角度中位数分别为21.5°和30°。由于颈部表面轮廓的关系,有9.5°在轴下区域不能被检测到。轴下区域的范围几乎和Bellhouse试验过高估计寰枕关节伸展的角度一致。由于轴下区域不依赖于寰枕关节伸展的角度,用量角器测得的角度与X线测得的寰枕关节角度间就没有明显的相关了(P<0.01, r2 = 0.44)。结论:这些发现意味着Bellhouse试验不总是正确地评估寰枕关节伸展度,如果轴下区域是正常存在的,那么也未能找到寰枕关节的复位术。因此,由Bellhouse试验所发现的问题使困难气管插管的评估变得更难,因为寰枕关节伸展的减少是导致插管困难的一个重要因素。

(朱    庄心良 校)

We examined the reliability of an airway evaluation test to assess the occipitoatlantoaxial (OAA) extension capacity described by Bellhouse et al. (Bellhouse test) in 20 adult volunteers with normal cervical spines. Each subject sat upright with the head in the neutral position and was then asked to extend the head maximally while attempting to move the neck as little as possible. The angle from the neutral position to the extreme extension was measured using the goggle-goniometer. Lateral cervical radiographs were taken in these positions, and the OAA extension angle was radiographically measured. Median values for OAA extension measured radiographically and extension of the head measured with the Bellhouse test were 21.5° and 30°, respectively. Extension of 9.5° occurred at the subaxial regions, which could not be detected by inspecting surface contours of the neck. The extent of the subaxial extension was almost consistent with the degree of overestimation of the OAA extension capacity by the Bellhouse test. Because the subaxial extension occurred independent of the degree of the OAA extension, a strong relationship between the angle measured with the goggle-goniometer and the OAA extension angle measured radiographically was not established (P < 0.01, r2 = 0.44). These findings mean that the test is not always accurate to evaluate the OAA extension capacity and will fail to detect a reduction of the OAA extension capacity if the subaxial regions are normal. Therefore, these problems derived from the Bellhouse test offer a potential for missing a prediction of difficult tracheal intubations because reduced OAA extension is one of the important factors that make intubation difficult.

 

利多卡因冠脉搭桥手术术后早期充血性心力衰竭的影响

The Effect of Lidocaine on Early Postoperative Cognitive Dysfunction After Coronary Artery Bypass Surgery

Dongxin Wang, MD PhD*, Xinmin Wu, MD*, Jun Li, MD*, Feng Xiao, MD{dagger}, Xiaoying Liu, MD*, and Meijin Meng, MD*

Departments of *Anesthesiology and {dagger}Cardiac Surgery, First Hospital, Peking University, Beijing, China

Anesth & Analg Nov. 2002;95:1134-1141

目的:研究利多卡因对心脏手术术后早期充血性心衰发生率的影响。方法:作者研究了108名行择期冠脉搭桥手术患者,术中采用体外循环。此108名患者随机给予利多卡因(术中单次1.5mg/kg,维持4mg/min。体外循环预充液注入4mg/kg)或安慰剂。患者术前和术后9天使用9项神经生理测试电池。术后其中任何测试值低于术前所有患者测试的平均值示为功能降低。如患者两项或两项以上的测定值降低示为发生术后充血性心力衰竭。88名患者完成术前和术后神经生理测试。转机前10分钟、转机后10分钟、30分钟、60分钟和术毕利多卡因的血浆浓度分别为4.78±0.52ug/ml5.38±0.95 ug/ml4.52±0.39 ug/ml5.82±0.76 ug/ml 7.10±1.09 ug/ml。利多卡因组的患者术后充血性心力衰竭发生率明显低于安慰剂组(18.6%40.0P=0.0028)结论:术中给予患者利多卡因能降低术后早期充血性心力衰竭的发生。

(赵雪莲     庄心良  校)

We investigated the effect of lidocaine on the incidence of cognitive dysfunction in the early postoperative period after cardiac surgery. One-hundred-eighteen patients undergoing elective coronary artery bypass surgery with cardiopulmonary bypass (CPB) were randomized to receive either lidocaine (1.5 mg/kg bolus followed by a 4 mg/min infusion during operation and 4 mg/kg in the priming solution of CPB) or placebo. A battery of nine neuropsychological tests was administered before and 9 days after surgery. A postoperative deficit in any test was defined as a decline by more than or equal to the preoperative SD of that test in all patients. Any patient showing a deficit in two or more tests was defined as having postoperative cognitive dysfunction. Eighty-eight patients completed pre- and postoperative neuropsychological tests. Plasma lidocaine concentrations (µg/mL) were 4.78 ± 0.52 (mean ± SD), 5.38 ± 0.95, 4.52 ± 0.39, 5.82 ± 0.76, and 7.10 ± 1.09 at 10 min before CPB; 10, 30, and 60 min of CPB; and at the end of operation, respectively. The proportion of patients showing postoperative cognitive dysfunction was significantly reduced in the lidocaine group compared with that in the placebo group (18.6% versus 40.0%; P = 0.028). We conclude that intraoperative administration of lidocaine decreased the occurrence of cognitive dysfunction in the early postoperative period.

                          

评估术中治疗和诊断干预

Evaluating Intraoperative Therapeutic and Diagnostic Interventions

Nava Klein, BA RN, and Charles Weissman, MD

Department of Anesthesiology and Critical Care Medicine, Hebrew University, Hadassah School of Medicine, Jerusalem, Israel

Anesth & Analg Nov. 2002;95:1373-1380

目的:作者希望建立一种可以反映术中的资源利用情况的量化标准。方法:评估一个有成本-意识医疗保健制度要求详细地评估各项行为,包括评估术中患者得到的关注。因为对术中护理做法程度没有量化的记分规则,所以作者提出一种术中治疗强度记分法(I-TIS)。把生理或生化检查和治疗干预所和或护理强度,在其基础上被赋予1-4分。对目前的患者进行评分,其结果与ASA分级和手术复杂度对比。此体系含78项评分标准,实验分两组进行。第一组(n=307)患者是术后短时间在麻醉后恢复室停留的,其I-TIS7.3±5.0;第二组(n=443)患者术后进普外、心外和神经外科复苏室或长时间在麻醉后恢复室停留的,其I-TIS值为25.2±12.4(与第一组对比P0.001〉。I-TIS与手术复杂度分级的相关系数是r=0.77,ASA基本相对值相关系数是r=0.75,与ASA生理状态分级的相关系数是r=0.49。结论:此评分与手术复杂度有很好的相关性而且可反映不同的手术的不同护理需求。

                                           (赵雪莲      庄心良  )

A cost-conscious health care system requires detailed measures of its activities, including measurements of care provided to perioperative patients. Because there are no scoring systems that quantify the extent of intraoperative care interventions, we developed an intraoperative therapeutic intensity score (I-TIS). Physiological/biochemical monitoring and therapeutic interventions were assigned one to four points on the basis of the resource utilization and/or intensity of care they each reflect. Scoring was performed on actual patients, and the results were compared with ASA classification and surgical complexity. A 78-item scoring system was developed and assessed by using two patient groups. Group 1 (n = 307) entered the postanesthesia care unit (PACU) for short postoperative stays and had an I-TIS of 7.3 ± 5.0; Group 2 patients (n = 443) were either admitted to the surgical, cardiothoracic, or neurosurgical intensive care units or had extended PACU stays, and they had an I-TIS of 25.2 ± 12.4 (P < 0.001 versus Group 1). The correlation of I-TIS with the surgical complexity classification was r = 0.77, with ASA base relative value units was rs = 0.75, and with the ASA physical status classification was rs = 0.49. The score correlated well with surgical complexity and was able to differentiate between the intensity of care during various surgical procedures.

    

离体雷米芬太尼代谢:全血和血浆假性胆碱酯酶对其影响

Vitro Remifentanil Metabolism: The Effects of Whole Blood Constituents and Plasma Butyrylcholinesterase

Peter J. Davis, MD*{dagger}, Richard L. Stiller, PhD*{ddagger}, Annette S. Wilson, PhD, Francis X. McGowan, MD*{dagger}#, Talmage D. Egan, MD§, and Keith T. Muir, PhD||

Departments of *Anesthesiology, {dagger}Pediatrics, {ddagger}Pharmacology, and ¶Environmental and Occupational Health, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania; §Department of Anesthesiology, University of Utah, School of Medicine, Salt Lake City, Utah; ||Clinical Pharmacokinetics, Glaxo-SmithKline; and #Department of Anesthesia, Harvard Medical School, Boston, Massachusetts

Anesth & Analg Nov. 2002;95:1305-1307

目的:作者以此离体实验研究假性胆碱酯酶缺乏病人应用雷米芬太尼时,其半衰期是否发生改变。方法:试管分别含克雷布斯缓冲液、全血、血浆或由正常和假性胆碱酯酶缺乏患者分离的红细胞,将它们与雷米芬太尼共同孵育。用气相色谱分析法测定雷米芬太尼的浓度,其半衰期均数采用非线性回归分析法。结果:正常和假性胆碱酯酶缺乏的志愿者的全血、红细胞或血浆,药物的半衰期没有差异。正常和假性胆碱酯酶缺乏的志愿者的全血和血浆中的雷米芬太尼半衰期都明显长于红细胞的。结论:由此推断雷米芬太尼在假性胆碱酯酶缺乏患者体内的药物代谢动力学不发生改变。

(赵雪莲      庄心良  )

 

We designed this in vitro study to determine whether the half-life of remifentanil was altered in butyrylcholinesterase-deficient patients. Test tubes containing Krebs buffered solution, whole blood, plasma, or red cells from both normal and butyrylcholinesterase-deficient patients were incubated with remifentanil. Remifentanil concentrations were determined by using gas chromatography and mean half-lives were calculated by using a nonlinear regression analysis. There were no differences in whole blood, red cells, or plasma half-life between normal and butyrylcholinesterase-deficient volunteers. In both normal and butyrylcholinesterase-deficient volunteers, whole blood and plasma had a significantly longer half-life than the red cell component. Extrapolation to the in vivo setting would suggest that a butyrylcholinesterase-deficient patient should not have altered remifentanil kinetics.

麻黄碱减少丙泊酚注射时的疼痛

Ephedrine Reduces the Pain from Propofol Injection

Mi A. Cheong, MD, Kyo S. Kim, MD PhD, and Won J. Choi, MD

Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea

Anesth & Analg Nov. 2002;95:1293-1296
176ASA -Ⅱ级,接受择期手术的病人被随机分为六组以研究不同剂量的麻黄碱和利多卡因相比对于减少丙泊酚注射疼痛的效果。P组病人(n=30)使用生理盐水作为对照;L组病人(n=30)使用2%利多卡因40mgE30组(n=28)使用30μg/kg麻黄碱;E70组(n=30)使用70μg/kg麻黄碱;E110组(n=30)使用110μg/kg麻黄碱;E150组(n=28)使用150μg/kg麻黄碱。各组分别在注射丙泊酚2.5mg/kg后注射。由一位不知情的麻醉医生询问病人的疼痛评分(口头评分和表情疼痛评分)。利多卡因组和麻黄碱组的疼痛发生率和疼痛强度均小于对照组(P<0.01)。在气管插管前,P组和L组动脉血压均下降,E110组和E150组在插管后血流动力学均加强(P<0.05)。我们的结论是,预先注射小剂量的麻黄碱(3070μg/kg)可以减少注射丙泊酚导致的疼痛的发生率和严重程度,而且动脉血压下降程度比单纯采用利多卡因预处理时注射丙泊酚的下降程度轻。

(颜      庄心良  校)

One hundred seventy-six patients (ASA physical status I or II) presenting for elective surgery were randomly allocated into six study groups to compare the incidence of propofol-induced pain after pretreatment with different doses of ephedrine as compared with lidocaine. Patients in Group P (n = 30) received saline placebo; patients in Group L (n = 30) received 2% lidocaine 40 mg; patients received ephedrine 30 µg/kg (Group E30, n = 28), 70 µg/kg (Group E70, n = 30), 110 µg/kg (Group E110, n = 30), and 150 µg/kg (Group E150, n = 28), respectively, followed 30 s later by propofol 2.5 mg/kg. A blinded anesthesiologist asked the patient to evaluate the pain score (verbal rating scale and face pain scale). The incidence and intensity of pain was less in the lidocaine and ephedrine groups than in the placebo group (P < 0.01). Before tracheal intubation, the arterial blood pressure was decreased in the P and L groups, and after intubation, hemodynamics were increased in the E110 and E150 groups, respectively (P < 0.05). We concluded that pretreatment with a small dose of ephedrine (30 and 70 µg/kg) reduced the incidence and intensity of propofol-induced pain with a lesser decrease in arterial blood pressure than from propofol alone in lidocaine pretreatment.

 

突然阻断腔静脉血流的血流动力学和激素反应:通过肝大部切除手术中肝血管排空的前瞻性研究

Hemodynamic and Hormonal Responses to the Sudden Interruption of Caval Flow: Insights from a Prospective Study of Hepatic Vascular Exclusion During Major Liver Resections

Daniel Eyraud, MD*, Olivier Richard, MD*, Dominique C. Borie, MD PhD{dagger}, Barbara Schaup, MD*, Alain Carayon, MD PhD{ddagger}, Corinne Vézinet, MD*, Marie Movschin, MD*, Jean-Christophe Vaillant, MD{dagger}, Pierre Coriat, MD*, and Laurent Hannoun, MD

Departments of *Anesthesiology and Critical Care, {dagger}Hepato-Biliary Surgery and Liver Transplantation, and {ddagger}Biochemistry and Molecular Biology, Groupe Hospitalier Pitié-Salpętričre, Assistance Publique-Hôpitaux de Paris, University Pierre et Marie Curie, Paris, France

Anesth & Analg Nov. 2002;95:1173-1178

肝血管排空(HVE)包括肝门三支阻断和下腔静脉阻断。尽管肝血管排空已经在上两个世纪中用于肝大部切除手术,人们对该方法为什么会取得满意的血流动力学耐受性的机理所知甚少。所以我们对HVE的血流动力学和激素反应进行了研究。对22位没有肝硬化发生继发性肝脏肿瘤的病人进行了前瞻性研究。采用经食管超声心动图记录这些的心率、动脉血压、肺动脉压、混合静脉血氧饱和度、心输出量和左室尺度。在钳闭前、钳闭后51530分钟后和开放钳闭后15分钟测血中精氨酸加压素(AVP)、肾上腺素、去甲肾上腺素、多巴胺、心房利尿肽浓度和血浆肾素活性。血流动力学变化的特征是左室尺度、面积分数(fractional area change)变化和肺动脉压明显下降(P<0.05)。我们还观察到心输出量显着下降(50%)和心率及体循环血管阻力的增加。在钳闭开放后,由体循环血管阻力比钳闭前明显下降可知外周血管扩张。我们还注意到,精氨酸加压素和去甲肾上腺素浓度发生急性的和持续性的增高直至钳闭开放,但是血浆肾素浓度没有变化。HVE特征性的回心血量显着减少通过激活精氨酸加压素和交感神经系统使血管阻力增加得到代偿。血浆肾素系统在维持HVE期间动脉血压中不起重要作用。

(颜     庄心良  校)

Hepatic vascular exclusion (HVE) combines portal triad clamping and occlusion of the inferior vena cava. Although HVE has been performed for major liver resections during the last 2 decades, little is known about the mechanisms that explain its satisfactory hemodynamic tolerance. Consequently, we performed a comprehensive study of both hemodynamic and hormone responses to HVE. Twenty-two patients who underwent liver resection for secondary tumors developed in noncirrhotic livers were prospectively studied. Heart rate, arterial blood pressure, pulmonary artery pressure, mixed venous saturation, cardiac output, and left ventricular dimensions determined by transesophageal echocardiography were monitored in HVE patients. Blood concentrations of arginine vasopressin (AVP), epinephrine, norepinephrine, dopamine, and atrial natriuretic peptide and plasma renin activity (PRA) were measured before clamping; 5, 15, and 30 min after clamping; and 15 min after unclamping. Hemodynamic response to HVE was characterized by a significant (P < 0.05) decrease in left ventricular dimensions, fractional area change, and pulmonary artery pressure. We also observed a marked decrease in cardiac output (50%) and an increase in heart rate and systemic vascular resistance. After unclamping, there was peripheral vasodilation, assessed by a significant decrease in systemic vascular resistance from the preclamping value to unclamping. An acute and sustained increase in AVP and norepinephrine that returned to baseline after unclamping and the absence of modification in PRA concentrations were noted. The marked decrease in venous return that characterizes HVE is compensated for by an increase in vascular resistance secondary to an important activation of the AVP and sympathetic systems. The PRA system does not play an important role in maintaining arterial blood pressure during HVE.

长时间神经外科手术期间七氟醚比安氟醚提供更快的恢复和术后神经估价

Sevoflurane Provides Faster Recovery and Postoperative Neurological Assessment Than Isoflurane in Long-Duration Neurosurgical Cases

Alain Gauthier, MD*, Francois Girard, MD FRCPC*, Daniel Boudreault, MD FRCPC*, Monique Ruel, RN*, and Alexandre Todorov, PhD

{dagger}    

*Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal, Hopital Notre-Dame, Montréal, Canada; and {dagger}Department of Psychiatry, Washington University Medical Center, St. Louis, Missouri

Anesth Analg Nov. 2002;95:1408-1411
 

七氟醚(SEVO)比安氟醚(ISO)提供更快的恢复。随着吸入时间延长这个优点更突出。而且SEVO还有好几个适合于神经外科麻醉的特点。我们设计一个前瞻性的、随机的、双盲的试验来比较七氟醚(SEVO)和安氟醚用于神经外科手术中的恢复特征。60个颅内手术病人,随机分为两组:SEVOISO,吸入氧40%,调节MAC0.5-1之间,维持平均动脉血压降低在术前的20%以内。手术结束,拮抗肌松药的作用,停止吸入,新鲜气体流量调至10 L/min 。记录恢复时间从关吸入麻醉药开始,在两组吸入麻醉药时间都是4.7hSEVO组病人恢复明显较快(P = 0.02),对握手(P = 0.03)、动脚(P = 0.01)指令反应恢复时间明显短。Glasgow 评分>=10SEVO组比ISO组快 5 min(P = 0.04)。在神经外科病人获得早期神经功能检查很重要,因此使用SEVOISO恢复快有一定临床意义。

(嵇富海 译 薛张刚 校)

Sevoflurane (SEVO) provides faster emergence than isoflurane (ISO). This advantage is thought to magnify with increased duration of exposure. In addition, SEVO has several of the characteristics of an ideal neuroanesthetic. We designed a prospective, randomized, double-blinded study to compare the recovery profile of SEVO versus ISO in neurosurgery. Sixty patients undergoing intracranial surgery were enrolled. They were randomized to receive SEVO or ISO in 40% oxygen as part of a balanced anesthetic regimen. The anesthetic concentration (0.5 to 1.0 minimum alveolar anesthetic concentration [MAC]) was adjusted to maintain mean arterial blood pressure within 20% of the preinduction baseline. At the end of the surgery, neuromuscular blockade was reversed, anesthetics were discontinued without prior tapering, and fresh gas flow was increased to 10 L/min. Recovery end-points were measured as the time from closure of the anesthetic vaporizer. Mean MAC-hours were identical in both groups (4.7). Patients in the SEVO group demonstrated a shorter time to emergence (P = 0.02) and for response to command (squeeze hand, P = 0.03; move feet, P = 0.01). Patients in the SEVO group obtained a Glasgow coma scale score of >=10 5 min before patients in the ISO group (P = 0.04). Obtaining an early neurological examination can be critical in neurosurgical patients. The observed difference in emergence between SEVO and ISO could therefore be of clinical importance.

 

随机双盲比较开胸后硬膜外用罗哌卡因、罗哌卡因/芬太尼、布比卡因/芬太尼镇痛

A Randomized, Double-Blinded Comparison of Thoracic Epidural Ropivacaine, Ropivacaine/Fentanyl, or Bupivacaine/Fentanyl for Postthoracotomy Analgesia

Antonio Macias, MD*, Pablo Monedero, MD PhD*, María Adame, MD PhD*, Wenceslao Torre, MD PhD{dagger}, Isabel Fidalgo, MD*, and Francisco Hidalgo, MD PhD*

*Department of Anesthesia and Critical Care and {dagger}Thoracic Surgery Service, Clinica Universitaria, University of Navarra, Spain

Anesth Analg Nov. 2002;95:1384-1388

开胸后硬膜外罗哌卡因镇痛还没有和布比卡因比较过。80个肺手术病人术后硬膜外镇痛采用随机、双盲方法分成三组:持续输注0.1 mL · kg-1 · h-10.2% 罗哌卡因、0.15%罗哌卡因/芬太尼5 µg/mL, 0.1% 布比卡因/芬太尼5 µg/mL。我们测定48小时的疼痛评分(休息和呼吸),静脉吗啡消耗量,呼吸量,握手力,PaCO2 ,心率,血压,呼吸频率,副作用(镇静、恶心、呕吐、搔痒)。开胸后2天内硬膜外罗哌卡因/芬太尼和布比卡因/芬太尼镇痛一样有效。单纯用0.2% 罗哌卡因镇痛在呼吸时效果不好,静脉吗啡消耗量大,副作用多。吗啡消耗量在罗哌卡因/芬太尼和布比卡因/芬太尼无差别。病人在罗哌卡因组比加芬太尼更痛呼吸时加重。在运动阻滞方面没有不同。我们得出开胸后罗哌卡因/芬太尼硬膜外镇痛并不比布比卡因/芬太尼更好。

(嵇富海 译 薛张刚 校)

Epidural ropivacaine has not been compared with bupivacaine for postthoracotomy analgesia. Eighty patients undergoing elective lung surgery were randomized in a double-blinded manner to receive one of three solutions for high thoracic epidural analgesia. A continuous epidural infusion of 0.1 mL · kg-1 · h-1 of either 0.2% ropivacaine, 0.15% ropivacaine/fentanyl 5 µg/mL, or 0.1% bupivacaine/fentanyl 5 µg/mL was started at admission to the intensive care unit. We assessed pain scores (rest and spirometry), IV morphine consumption, spirometry, hand grip strength, PaCO2, heart rate, blood pressure, respiratory rate, and side effects (sedation, nausea, vomiting, and pruritus) for 48 h. Thoracic epidural ropivacaine/fentanyl provided adequate pain relief similar to bupivacaine/fentanyl during the first 2 postoperative days after posterolateral thoracotomy. The use of plain 0.2% ropivacaine was associated with worse pain control during spirometry, larger consumption of IV morphine, and increased incidence of postoperative nausea and vomiting. Morphine requirements were larger in the ropivacaine group, with no differences between bupivacaine/fentanyl and ropivacaine/fentanyl groups. Patients in the ropivacaine group experienced more pain and performed worse in spirometry than patients who received epidural fentanyl. There was no significant difference in motor block. We conclude that epidural ropivacaine/fentanyl offers no clinical advantage compared with bupivacaine/fentanyl for postthoracotomy analgesia.

 

小儿骶麻:睾丸固定术阻滞精索牵拉反应中布比卡因的容量和浓度的比较

Caudal Anesthesia in Children: Effect of Volume Versus Concentration of Bupivacaine on Blocking Spermatic Cord Traction Response During Orchidopexy

Susan T. Verghese, MD*{dagger}, Raafat S. Hannallah, MD*{dagger}, Linda Jo Rice, MD*{dagger}, A. Barry Belman, MD{dagger}{ddagger}, and Kantilal M. Patel, PhD{dagger}

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Pediatric Urology, Children’s National Medical Center and George Washington University, Washington, DC

Anesth Analg Nov. 2002;95:1236-1240

  在这一研究中,我们对一定剂量的布比卡因两种不同容量和不同浓度应用时骶麻的强度和水平的差异。50个小儿病人, 1–6 ,在诱导后应用2 mg/kg固定剂量布比卡因骶麻后行单侧睾丸固定术。 组1 (n = 23) 使用0.8 mL/kg0.25% 的布比卡因, 而组2 (n = 27)使用 1.0 mL/kg0.2% 布比卡因。 每10ml局麻药物中加用1:400,000的肾上腺素和0.1 mL的碳酸氢钠。在两组病人麻醉,手术,恢复,出院时间上都没有显着差异。1组中 15(65.2%)需要增加氟烷的吸入浓度已阻滞精索牵拉时的血流动力学和/或呼吸反应,而组2 中只有 8 (29.6%) (P = 0.022)。在恢复室中,组1中有4(17.4%)需要芬太尼治疗,而组2只有2(7.4%) (P = 0.372)。在睾丸固定术小儿,用较大容量的稀释的布比卡因骶麻与标准的较少容量的0.25%溶液相比,在阻断精索牵拉时的腹膜反应上更加有效,而对术后的镇痛质量没有影响。

(张俊峰 译 薛张刚 校)

In this study we compared the intensity and level of caudal blockade when two different volumes and concentrations of a fixed dose of bupivacaine were used. Fifty children, 1–6 yr old, undergoing unilateral orchidopexy received a caudal block with a fixed 2 mg/kg dose of bupivacaine immediately after the induction. Group 1 (n = 23) received 0.8 mL/kg of 0.25% bupivacaine, whereas Group 2 (n = 27) received 1.0 mL/kg of 0.2% bupivacaine. Epinephrine 1:400,000 and 0.1 mL of sodium bicarbonate per 10 mL of local anesthetic solution were added. There were no statistically significant differences between the two groups in their anesthesia, surgery, recovery, and discharge times. Fifteen patients (65.2%) in Group 1 required an increase in inspired halothane concentration to block hemodynamic and/or ventilatory response during spermatic cord traction, as compared with 8 patients (29.6%) in Group 2 (P = 0.022). In the recovery room, four (17.4%) patients in Group 1 required rescue treatment with fentanyl, versus two (7.4%) in Group 2 (P = 0.372). In children undergoing orchidopexy, a caudal block with a larger volume of dilute bupivacaine is more effective than a smaller volume of the standard 0.25% solution in blocking the peritoneal response during spermatic cord traction, with no change in the quality of postoperative analgesia.

 

Tandospirone可预防成人中耳整复术后的恶心和呕吐

Prevention of Nausea and Vomiting with Tandospirone in Adult After Tympanoplasty

Tsutomu Oshima, MD PhD, Yoshiko Kasuya, MD PhD, Yasuhisa Okumura, MD, Etsuji Terazawa, MD, and Shuji Dohi, MD PhD

Department of Anesthesiology and Critical Care Medicine, Gifu University School of Medicine, Gifu-City, Gifu, Japan

Anesth Analg Nov. 2002; 95: 1442-1445.

 

我们假定5-羟色胺-1A受体激动剂――tandospirone可减少术后恶心呕吐(PONV)的发生。30例病人采用双盲法随机分为3组:1)安慰剂组(P组),2tandospirone 10 mg (T10)3) tandospirone 30 mg (T30),每组病人均在进入手术室前90分钟分别口服各组药物并同时口服famotidine 20 mg。每组病人均采用同样的麻醉方法。 分别在全麻结束后0–3 h 3–24 h两个时间间隔记录所有恶心呕吐情况,T30组完全有效(指无恶心呕吐发生并且无需补充应用止吐药)的发生率在024hP = 0.019),尤其在3–24 h (P = 0.007) 期间与P组相比有显着性差异。因此,术前口服tandospirone可有效预防全麻下行中耳整复术后的PONV

(张俊峰 译 薛张刚 校)

We have hypothesized that the 5-hydroxytrypta-mine-1A receptor agonist tandospirone reduces postoperative nausea and vomiting (PONV). In a double-blinded, randomized design, 3 groups of 30 patients each received 1 of the following oral medications 90 min before arrival in the operating room, together with famotidine 20 mg: 1) placebo (P group), 2) tandospirone 10 mg (T10 group), or 3) tandospirone 30 mg (T30 group). Standard anesthetic regimens and techniques were applied for all patients. All episodes of PONV were recorded during the following time intervals: 0–3 h and 3–24 h after the end of general anesthesia. The incidence of a complete response, defined as no PONV and no need for other rescue antiemetics, was significantly more frequent in the T30 group than in the P group during 0–24 h (P = 0.019), especially during 3–24 h (P = 0.007) after general anesthesia. In conclusion, premedication with oral tandospirone is effective against PONV in patients undergoing tympanoplasty under general anesthesia.

 

一种住院医师局部麻醉培训的新模式

A New Teaching Model for Resident Training in Regional Anesthesia

Gavin Martin, MB ChB, FRCA*, Catherine K. Lineberger, MD*, David B. MacLeod, MBBS FRCA*, Habib E. El-Moalem, PhD{dagger}, Dara S. Breslin, MB FFARCSI*, David Hardman, MD*, and Francine D’Ercole, MD*

Departments of *Anesthesia and {dagger}Biostatistics and Bioinformatics, Duke University Health System, Durham, North Carolina

Anesth Analg Nov. 2002;95:1442-1445

麻醉住院医师局部麻醉培训的充足性问题是全国性问题。1996Duke大学健康系统(Anesthesiology Residenc)制定了麻醉住院医师培训系统旨在提高住院医师局部麻醉培训质量。该培训模式的主要特点在于使用CA-3住院医师在围术期训练局部麻醉技术。为评价新模式的有效性,我们比较了分别由Anesthesiology Residency和麻醉住院医师培训回顾协会(Residency Review Committee)提供的在July 1992–June 1995 (pre-model)July 1998–June 2001 (post-model)培训期间的数据。在3年培训期间,re-model CA-3 住院医师组 (n = 12)累积操作80 (58–105)外周神经阻滞(PNBs), 66 (59–74) 腰麻和133 (127–142) 硬膜外麻醉,CA-3 post-model 住院医师组(n = 10)则累积操作 350 (237–408) PNBs, 107 (92–123) 腰麻和233 (221–241)硬膜外麻醉 (P < 0.0001),所有数据均采用中位数(四分位数间距)表示。由此我们推论采用我们的把CA-3住院医师在围术期作为阻滞住院医师的新培训模式可以增加他们接触临床PNBs的机会。

(张俊峰 译 薛张刚 校)

The adequacy of resident education in regional anesthesia is of national concern. A teaching model to improve resident training in regional anesthesia was instituted in the Anesthesiology Residency in 1996 at Duke University Health System. The key feature of the model was the use of a CA-3 resident in the preoperative area to perform regional anesthesia techniques. We assessed the success of the new model by comparing the data supplied by the Anesthesiology Residency to the Residency Review Committee for Anesthesiology for the training period July 1992–June 1995 (pre-model) and the training period July 1998–June 2001 (post-model). During the 3-yr training period, the pre-model CA-3 residents (n = 12) performed a cumulative total of 80 (58–105) peripheral nerve blocks (PNBs), 66 (59–74) spinal anesthetics, and 133 (127–142) epidural anesthetics. The CA-3 post-model residents (n = 10) performed 350 (237–408) PNBs, 107 (92–123) spinal anesthetics, and 233 (221–241) epidural anesthetics (P < 0.0001). All results are reported as median (interquartile range). We conclude that our new teaching model using our CA-3 residents as block residents in the preoperative area has increased their clinical exposure to PNBs.

 

丙胺卡因和新斯的明静脉局部麻醉

Intravenous Regional Anesthesia Using Prilocaine and Neostigmine

A. Turan, B. Karamanlyoglu, D. Memis, G. Kaya, and Z. Pamukçu

Department of Anaesthesiology and Reanimation, Medical Faculty, Trakya University, Edirne, Turkey

Anesth Analg Nov. 2002;95:1423-1427

在中枢和外周神经阻滞中局麻药合用新斯的明可增强麻醉效果、延长麻醉时间并改善镇痛效果。该研究的目的在于评价丙胺卡因静脉局麻(IVRA)中合用新斯的明的效果。30例采用IVRA拟行手部手术的患者随机分为两组,控制组采用1 mL 生理盐水加3 mg/kg of丙胺卡因然后稀释到40 mL,研究组则采用 0.5 mg新斯的明加3 mg/kg 丙胺卡因然后稀释到40 mL。感觉和运动组织起始和恢复时间、麻醉质量由麻醉医师确定,麻醉质量也有外科医师确定并同时记录术野干燥情况,分别在手术开始前和止血带释放后1, 5, 10, 20, and 40 min记录心率、平均动脉压及氧饱和度值和第一次需用镇痛药的时间。结果在新斯的明组中感觉和运动阻滞起始时间缩短,感觉和运动恢复时间延长,麻醉质量改善,首次需用镇痛药的时间也延长。因此,我们认为新斯的明是改善静脉丙胺卡因麻醉质量的有效的辅助药并且在IVRA中是有益的。

(张俊峰 译 薛张刚 校)

Neostigmine has been added to local anesthetics for central and peripheral nerve blocks resulting in prolonged, increased anesthesia and improved analgesia. We conducted this study to evaluate the effects of neostigmine when added to prilocaine for IV regional anesthesia (IVRA). Thirty patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 1 mL of saline plus 3 mg/kg of prilocaine diluted with saline to a total dose of 40 mL; the study group received 0.5 mg of neostigmine plus 3 mg/kg of prilocaine diluted with saline to a total dose of 40 mL. Sensory and motor block onset and recovery, anesthesia quality determined by an anesthesiologist, anesthesia quality determined by a surgeon, and dryness of the operative field were noted. Heart rate, mean arterial blood pressure, and oxygen saturation values were noted at 1, 5, 10, 20, and 40 min before surgery and after tourniquet release. Time to first analgesic requirement was also noted. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, improved quality of anesthesia, and prolonged time to first analgesic requirement were found in the neostigmine group. We conclude that neostigmine as an adjunct to prilocaine improves quality of anesthesia and is beneficial in IVRA.

 

心电图导联的选择是否影响其用于检测试验剂量中肾上腺素血管内注射的T波标准的功效

Does the Choice of Electrocardiography Lead Affect the Efficacy of the T-Wave Criterion for Detecting Intravascular Injection of an Epinephrine Test Dose?

Makoto Tanaka, MD, and Toshiaki Nishikawa, MD

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

Anesth Analg Nov. 2002;95:1419-1422

含有肾上腺素的试验剂量意外血管内注射会降低心电图 (EKG) II导联的T-wave振幅,在以T波振幅降低>=25%为阳性的T-wave 标准的定义基础上,心电图具有100%的敏感性和特异性。该研究的目的在于验证在麻醉病人中模拟注射试验剂量时心电图导联的选择是否会影响其检测功效。8小时禁食并且不用术前用药,35例健康患者气管插管后采用呼气末 2% 的七氟醚和笑气麻醉维持,当血流动力学稳定后,所有患者先静注3 mL生理盐水,4分钟后静注1.5%利多卡因 3 mL15 µg肾上腺素(1:200,000),心率、收缩压, II导联 (n = 35) V5导联(n = 35 I导联 (n = 17) III导联(这些导联都有明显的T波)分别在生理盐水和试验剂量静注后持续监测4分钟,在所有病人中静注试验剂量后心率和收缩压明显增加,所有导联的T波振幅都降低,而静注生理盐水后这些变量无明显变化,II导联的T波振幅降低比例最大,I, IIIV5导联则分别为 -87% ± 13%, -88% ± 8%, -94% ± 15%,-86% ± 16% (mean ± SD; P > 0.05)4导联中T波的时限则无明显差异,在T-wave标准定义的基础上任一导联都具有100%的敏感性和特异性,我们的结果显示心电图II, I, III,V5 导联在检测成人七氟醚麻醉中含有肾上腺素的试验剂量血管内注射时具有同样的功效。

(潘志浩 译 薛张刚 校)

Accidental intravascular injection of an epinephrine-containing test dose decreases the T-wave amplitude of a Lead II electrocardiogram (EKG) with 100% sensitivity and specificity on the basis of the T-wave criterion (positive if there is a >=25% decrease in amplitude). We designed this study to test whether the choice of EKG lead would affect the efficacy of the simulated intravascular test dose in anesthetized patients. After an 8-h fast and no premedication, 35 healthy patients were anesthetized with end-tidal 2% sevoflurane and nitrous oxide after endotracheal intubation. When hemodynamic stability was obtained, all subjects received 3 mL of normal saline IV, followed 4 min later by 1.5% lidocaine 3 mL plus 15 µg of epinephrine (1:200,000) IV. Heart rate, systolic blood pressure, Leads II (n = 35) and V5 (n = 35), and either Lead I (n = 17) or III (n = 18), whichever had the greater T-wave amplitude, were continuously recorded for 4 min after the saline and test-dose injections. An IV test dose produced significant increases in heart rate and systolic blood pressure and produced decreases in the T-wave amplitude of all EKG leads studied in all subjects, whereas IV saline elicited no changes in these variables. The maximum percentage decreases in T-wave amplitude of Leads II, I, III, and V5 were -87% ± 13%, -88% ± 8%, -94% ± 15%, and -86% ± 16%, respectively (mean ± SD; P > 0.05). There was no significant difference in temporal changes in T-wave amplitude among the 4 leads, and sensitivity and specificity were 100% on the basis of the T-wave criterion, irrespective of the lead examined. Our results indicate that Leads II, I, III, and V5 of the EKG are equally effective for detecting intravascular injection of the epinephrine-containing test dose in sevoflurane-anesthetized adults.

纯氧合用七氟醚,异氟醚,氟烷,芬太尼/咪唑安定时对小儿先天性心脏病病人肺循环与体循环血流比影响

Pulmonary-to-Systemic Blood Flow Ratio Effects of Sevoflurane, Isoflurane, Halothane, and Fentanyl/Midazolam with 100% Oxygen in Children with Congenital Heart Disease

Tracy H. Laird, MD*, Stephen A. Stayer, MD{dagger}, Shannon M. Rivenes, MD*, Mark B. Lewin, MD§, E. Dean McKenzie, MD{ddagger}, Charles D. Fraser, MD{ddagger}, and Dean B. Andropoulos, MD{dagger}

Divisions of *Pediatric Cardiology, {dagger}Pediatric Cardiovascular Anesthesiology, and {ddagger}Congential Heart Surgery, Texas Children’s Hospital and Baylor College of Medicine, Houston; and §Division of Pediatric Cardiology, Children’s Hospital and Regional Medical Center and the University of Washington School of Medicine, Seattle, Washington

Anesth Analg Nov.2002;95:1219-1223

对于吸入麻醉药对先天性心脏病小儿的影响已有研究,但对于存在心内分流的病人麻醉药对肺循环,体循环血流比的影响还知之甚少。在这一研究中,我们在房缺和室缺病人上比较了氟烷,异氟醚,七氟醚和芬太尼/咪唑安定对Qp:Qs和心肌收缩力的影响。4014 岁以下的准备行ASD VSD修补的病人随机接受氟烷,异氟醚,七氟醚和芬太尼/咪唑安定。记录心血管和心超数据的基础值,随机安排 1 1.5 MAC的麻醉药或预测的等效芬太尼/咪唑安定水平应用的顺序。计算射血分数 (用改良Simpson定律)。体循环 (Qs) 和肺循环(Qp)血流用心超流速-时间法进行评价。 在任何一种方案和任何浓度下Qp:Qs都没有受影响。左室收缩功能在1.5 MAC的异氟醚和七氟醚以及11.5 MAC的氟烷应用时受轻度抑制。氟烷,异氟醚,七氟醚和芬太尼/咪唑安定在 1 1.5 MAC浓度或他们的等效浓度都没有影响单纯ASD VSD病人的 Qp:Qs

(潘志浩 译 薛张刚 校)

The cardiovascular effects of volatile anesthetics in children with congenital heart disease have been studied, but there are limited data on the effects of anesthetics on pulmonary-to-systemic blood flow ratio (Qp:Qs) in patients with intracardiac shunting. In this study, we compared the effects of halothane, isoflurane, sevoflurane, and fentanyl/midazolam on Qp:Qs and myocardial contractility in patients with atrial (ASD) or ventricular (VSD) septal defects. Forty patients younger than 14 yr old scheduled to undergo repair of ASD or VSD were randomized to receive halothane, sevoflurane, isoflurane, or fentanyl/midazolam. Cardiovascular and echocardiographic data were recorded at baseline, randomly ordered 1 and 1.5 mean alveolar anesthetic concentration (MAC) levels, or predicted equivalent fentanyl/midazolam plasma levels. Ejection fraction (using the modified Simpson’s rule) was calculated. Systemic (Qs) and pulmonary (Qp) blood flow was echocardiographically assessed by the velocity-time integral method. Qp:Qs was not significantly affected by any of the four regimens at either anesthetic level. Left ventricular systolic function was mildly depressed by isoflurane and sevoflurane at 1.5 MAC and depressed by halothane at 1 and 1.5 MAC. Sevoflurane, halothane, isoflurane, or fentanyl/midazolam in 1 or 1.5 MAC concentrations or their equivalent do not change Qp:Qs in patients with isolated ASD or VSD.


在体研究中异氟醚没有产生保护心梗的预处理的第二窗

Isoflurane Does Not Produce a Second Window of Preconditioning Against Myocardial Infarction In Vivo

 

Franz Kehl, MD DEAA*, Paul S. Pagel, MD PhD*{dagger}, John G. Krolikowski, BA*, Weidong Gu, MD*, Wolfgang Toller, MD DEAA{ddagger}, David C. Warltier, MD PhD*{dagger}§||, and Judy R. Kersten, MD*||

Departments of *Anesthesiology, §Medicine (Division of Cardiovascular Diseases), and ||Pharmacology and Toxicology, the Medical College of Wisconsin, Milwaukee, Wisconsin; the {dagger}Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; and the {ddagger}Department of Anesthesiology, University of Graz, Graz, Austria

Anesth Analg Nov 2002;95:1200-1206

长期缺血发生前即刻吸入全麻药具有与缺血预处理相似的保护心梗作用。保护心梗的预处理第二窗(SWOP)亦见于阻断冠脉24h引起的短暂缺血。至于遥控吸入挥发性全麻药是否具有延迟的心肌保护则尚不清楚。预处理的第二窗(SWOP)在缺血发生在延长的冠脉堵塞前24小时的情况下可以出现。是否长时间间隔前吸入麻醉药的应用也会产生心肌保护作用还不清楚。我们对在缺血前24小时应用异氟醚会产生SWOP的假说进行了验证。巴比妥麻醉犬 (n = 25)进行血流动力学测定,其中包括主动脉和左室压力以及 LV +dP/dtmax, 这些试验犬进行60分钟的左前降枝冠脉阻塞,然后进行3小时的再灌注。心梗面积和冠脉侧枝血流分别用 triphenyltetrazolium chloride染色和放射行微球进行评价。两组犬分别在缺血,再灌注前30分钟(急性)或24小时(慢性)吸入1.0MAC的异氟醚30分钟或6小时。对照组不吸入异氟醚。在没有用异氟醚预处理的心梗面积是高危左室面积的27% ± 3% 。急性应用,而非长时间间隔应用的异氟醚降低了心梗面积(分别为12% ± 1%31% ± 3%)。两组在阻塞前后血流动力学或跨壁心肌灌注方面都没有观察到有差异。结果显示体内研究中,在延长心肌缺血前24小时应用异氟醚没有产生SWOP

(潘志浩 译 薛张刚 校)

The administration of a volatile anesthetic shortly before a prolonged ischemic episode exerts protective effects against myocardial infarction similar to those of ischemic preconditioning. A second window of preconditioning (SWOP) against myocardial infarction can also be elicited by brief episodes of ischemia when this occurs 24 h before prolonged coronary artery occlusion. Whether remote exposure to a volatile anesthetic also causes delayed myocardial protection is unknown. We tested the hypothesis that the administration of isoflurane 24 h before ischemia produces a SWOP against infarction. Barbiturate-anesthetized dogs (n = 25) were instrumented for measurement of hemodynamics, including aortic and left ventricular (LV) pressures and LV +dP/dtmax, and subjected to a 60-min left anterior descending coronary artery occlusion followed by 3 h of reperfusion. Myocardial infarct size and coronary collateral blood flow were assessed with triphenyltetrazolium chloride staining and radioactive microspheres, respectively. Two groups of dogs received 1.0 minimum alveolar anesthetic concentration isoflurane for 30 min or 6 h that was discontinued 30 min (acute) or 24 h (delayed) before ischemia and reperfusion, respectively. A control group of dogs did not receive isoflurane. Infarct size was 27% ± 3% of the LV area at risk in the absence of pretreatment with isoflurane. Acute, but not remote, administration of isoflurane reduced infarct size (12% ± 1% and 31% ± 3%, respectively). No differences in hemodynamics or transmural myocardial perfusion during or after occlusion were observed between groups. The results indicate that isoflurane does not produce a SWOP when administered 24 h before prolonged myocardial ischemia in vivo.

 

新发现的卵圆孔未闭对不停跳冠脉搭桥病人的影响:11例报道

The Impact of Newly Diagnosed Patent Foramen Ovale in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting: Case Series of Eleven Patients

M. R. Sukernik, MD PhD*, B. Mets, MB ChB, PhD, FRCA*, B. Kachulis, MD*, M. C. Oz, MD{dagger}, and E. Bennett-Guerrero, MD*

Departments of *Anesthesiology and {dagger}Surgery, College of Physicians & Surgeons, Columbia University, New York, New York

Anesth Analg Nov. 2002;95:1162-1168

  麻醉师应用食道超声的增加会导致术中发现先前为诊断的卵圆孔未闭的病人的增加。不停跳冠脉搭桥病人心脏操作对于通过未闭卵圆孔的房内反流的影响还没有被研究。我们回顾了OPCABG11例操作卵圆孔未闭的病人。在基础状态,心脏抬高行远端冠脉吻合时以及手术结束时行TEE 造影试验和血气分析测定。在基础状态,11例病人中5例操作左向右分流,2例存在右向左分流。心脏抬高没有导致任何病人出现脱氧饱和;然而,它导致了一例病人右向左分流的消失,一例病人分流持续以及两例新的右向左分流的出现。心脏恢复到它的原始位置后TEE的表现都恢复到基础状态。这一序列的病人上的发现显示OPCABG可以在大部分卵圆孔未闭的病人上安全进行; 然而, 还需要进一步研究来证实在存在卵圆孔未闭的行OPCABG 的一些特定的病人上有害效应也不会产生。

(潘志浩译 薛张刚校)

The increased use of transesophageal echocardiography (TEE) by anesthesiologists may lead to an increase in the intraoperative detection of previously undiagnosed patent foramen ovale (PFO). The impact of heart manipulation on interatrial shunting through a PFO during off-pump coronary artery bypass graft (CABG) has not been studied. We retrospectively studied 11 patients with PFOs who underwent off-pump CABG. TEE contrast studies and blood gas analyses were performed at baseline, during heart elevation for distal coronary arteries anastomoses, and at the end of the surgery. At baseline, 5 of 11 patients had left-to-right shunting and 2 of 11 had right-to-left shunting. Heart elevation did not result in oxygen desaturation in any patient; however, it caused the disappearance of a right-to-left shunt (n = 1), persistence of this shunt (n = 1), and the development of a new right-to-left shunt (n = 2). Return of the heart to its original position resulted in a return of TEE findings to the baseline state in all patients. This series suggests that off-pump CABG can be performed safely in the majority of patients with PFOs; however, additional investigation is needed to assure that adverse effects do not occur in a subset of patients undergoing off-pump CABG in the presence of a PFO.

 

甲氧氯普胺和利多卡因对防止安定注射疼痛的比较

A Comparison of Metoclopramide and Lidocaine for Preventing Pain on Injection of Diazepam

Hossein Majedi, MD*, Mozaffar Rabiee, MD*, Zahid Hussain Khan, MD{dagger}, and Bahman Hassannasab, MD*

Department of Anesthesiology, Babol University of Medical Sciences, Babol, Iran; and {dagger}Department of Anesthesiology, Tehran University of Medical Sciences, Tehran, Iran.

Anesth Analg Nov. 2002;95:1308-1311

我们比较了静注利多卡因和甲氧氯普胺预处理对于防止安定注射痛的能力。在一项前瞻性、随机、双盲、安慰剂对照的临床试验中,159位患者(ASA生理状态Ⅰ-Ⅱ级),年龄20-70岁,分为三组。在手背静脉注射安慰剂和研究药物后,随即注入0.1mg/Kg安定。组1、组2、组3的患者分别注射安慰剂2ml1%利多卡因2ml、甲氧氯普胺2ml10mg)。患者的反应以4分尺度来衡量。除了0分外的任一分值均判定为注射痛。我们发现在安慰剂组安定注射痛的发生率为83%,用甲氧氯普胺和利多卡因预处理后发生率分别降至70%39%。尽管当安定注射时,在疼痛的发生率上,组1和组3无明显差异(P>0.05),但是组3的疼痛评分高的患者较之组1显着减少(P<0.000)。当注射安定时,组2疼痛的发生率较生理盐水组(P<0.000)和甲氧氯普胺组(P<0.002)显着降低。组2的疼痛强度显着低于组3P=0.012)。安定注射痛的强度在安慰剂组显着高于其它组(P<0.000)。甲氧氯普胺,而不是利多卡因预处理,对于注射疼痛可能是一种理想的止痛选择。

(张 鸿 译 薛张刚 校)

We compared the ability of metoclopramide with IV lidocaine pretreatment to abolish pain from a diazepam injection. In a randomized, prospective, double-blinded, placebo-controlled clinical trial, 159 patients (ASA physical status I and II), aged 20–70 yr old, were allocated to one of three groups. Placebo and study drugs were injected IV immediately before 0.1 mg/kg of diazepam into a dorsal hand vein. Patients in Groups 1, 2, and 3 received 2 mL of placebo, 2 mL of lidocaine 1%, and 2 mL of metoclopramide (10 mg), respectively. The patient’s response was graded using a 4-point scale. Any score other than 0 represented pain on injection. We observed that the incidence of pain on diazepam injection was 83% in the placebo group, which was decreased to 70% and 39% in patients pretreated with metoclopramide and lidocaine, respectively. Although there was no significant difference in the incidence of pain in Groups 1 and 3 (P > 0.05), Group 3 showed significantly less patients with severe pain scores than Group 1 as diazepam was injected (P < 0.000). Group 2 showed a significantly less frequent incidence of pain than the saline (P < 0.000) and the metoclopramide (P < 0.002) groups as diazepam was injected. The intensity of pain in Group 2 was significantly less than Group 3 (P = 0.012). The intensity of diazepam injection pain was intense with placebo as compared with other groups (P < 0.000). Metoclopramide, rather than lidocaine pretreatment, may be a reasonable analgesic alternative for painful injections.

 

异丙酚持续输注时脑脊液浓度的变化

Changes of Propofol Concentration in Cerebrospinal Fluid During Continuous Infusion

Andrzej L. Dawidowicz, PhD*, Rafal Kalitynski, MSc*, Andrzej Nestorowicz, MD PhD{dagger}, and Anna Fijalkowska, MD PhD{dagger}

*Department of Chemical Physics and Physicochemical Separation Methods, Maria Curie-Sklodowska University; and {dagger}Department of Anesthesiology and Intensive Therapy, University School of Medicine, Lublin, Poland

Anesth Analg Nov..2002;95:1297-1299

14位行择期颅内手术的患者,以异丙酚持续靶控输注麻醉,研究其脑脊液(CSF)内异丙酚浓度的变化。麻醉期间,芬太尼和cisatracurium按需给予。气管插管后,以空氧混和气体(FiO20.33)给患者通气至血二氧化碳分压正常。在麻醉诱导后90180分钟期间,收集动脉血和脑脊液(由脑室内引流获取)样本。血异丙酚浓度稳定于5.0±1.894.5±1.7µg/mL(均数±标准差)之间。脑脊液的异丙酚浓度从90分钟的52.2 ± 35.01 ng/mL降至150分钟的28.6 ± 21.9 ng/mL,下降有显着性差异(P<0.05)。在180分钟时,CSF的异丙酚浓度(21.4 ± 14.0 ng/mL)150分钟时的浓度无显着性差异。本文讨论了开始持续脑室内引流后,CSF内浓度下降的可能原因。

结论:异丙酚在神经外科患者脑脊液中出现。在被研究的患者中,开始脑室内引流后,尽管拥有相对稳定的血异丙酚浓度,但其脑脊液浓度显着下降。这些结果扩充了有关异丙酚在人类中枢神经系统内的药物代谢动力学信息。

(张 鸿 译 薛张刚 校)

We studied the changes in the propofol concentration in the cerebrospinal fluid (CSF) in 14 patients, undergoing elective intracranial procedures, who were anesthetized with propofol administered by target-controlled infusion. During anesthesia, fentanyl and cisatracurium were administered as required. After intubation of the trachea, the lungs of the patients were ventilated to normocapnia with an oxygen-air mixture (FIO2 = 0.33). Arterial blood and CSF samples (from an intraventricular drain) were collected between 90–180 min after the induction of anesthesia. Blood propofol concentrations were stable, between 5.0 ± 1.89 and 4.5 ± 1.7 µg/mL (mean ± SD). There was a significant decrease in the CSF propofol concentration, from 52.2 ± 35.01 ng/mL at 90 min to 28.6 ± 21.9 ng/mL at 150 min (P < 0.05). The CSF propofol concentration at 180 min (21.4 ± 14.0 ng/mL) was not significantly different from the concentration at 150 min. Some possible reasons for this decrease after commencing continuous intraventricular drainage are discussed.

 

利多卡因对谷氨酸转运体EAAT3活性的影响:蛋白激酶C和磷脂酰肌醇3激酶的作用

The Effects of Lidocaine on the Activity of Glutamate Transporter EAAT3: The Role of Protein Kinase C and Phosphatidylinositol 3-Kinase

Sang-Hwan Do, Hong-yu Fang, Byung-Moon Ham, and Zhiyi Zuo

*Department of Chemical Physics and Physicochemical Separation Methods, Maria Curie-Sklodowska University; and {dagger}Department of Anesthesiology and Intensive Therapy, University School of Medicine, Lublin, Poland

Anesth Analg Nov. 2002;95:1297-1299

应用双极电压钳,我们研究了利多卡因对一种谷氨酸转运体(EAAT3)的影响,以及蛋白激酶CPKC)和磷脂酰肌醇3激酶(PI3K)在介导利多卡因效应中的作用。EAAT3表达于爪蟾属卵母细胞,应用左旋谷氨酸(30µM)后记录膜电流。利多卡因只在两种浓度(100 µM and 1 mM)下增加谷氨酸诱导的内向电流。与对照相比,利多卡因(100 µM)显着增加谷氨酸和EAAT3结合的Vmax ,而非Km 。利多卡因对EAAT3的作用点似乎在细胞内,因为只有细胞内注射QX314(持久带电的利多卡因拟似物)能增加反应。phorbol-12-myrisate-13-acetate(一种PKC激动剂)与利多卡因的联合应用,与他们各自应用相比,并不能进一步增强反应,尽管这三组中的任一组与对照相比均显示了更强的反应。三种PKC抑制剂(staurosporine, calphostin C, and chelerythrine)不影响EAAT3的基础活性,但是消除了利多卡因增强的EAAT3活性。Wortmannin(一种特异的PI3K抑制剂)抑制了EAAT3的基础活性和利多卡因增强的EAAT3活性。我们的结果显示,利多卡因在特定的浓度下增强了EAAT3的活性,PKCPI3K可能介导了利多卡因的这些效应

(张 鸿 译 薛张刚 校)

Using two electrode voltage clamps, we investigated the effects of lidocaine on one type of glutamate transporter, EAAT3, and the role of protein kinase C (PKC) and phosphatidylinositol 3-kinase (PI3K) in mediating the lidocaine effects. EAAT3 was expressed in Xenopus oocytes, and membrane currents were recorded after the application of L-glutamate (30 µM). Lidocaine increased glutamate-induced inward currents significantly at 2 concentrations (100 µM and 1 mM), but not at other concentrations. Lidocaine (100 µM) significantly increased the Vmax, but not the Km, of EAAT3 for glutamate compared with control. The action sites of lidocaine on EAAT3 seem to be intracellular, because only intracellularly injected QX314 (permanently charged lidocaine analog) increased the response. The combination of phorbol-12-myrisate-13-acetate, an activator of PKC, and lidocaine did not further increase the responses compared with phorbol-12-myrisate-13-acetate or lidocaine alone, although each of these three groups showed significantly bigger responses than controls. Three PKC inhibitors (staurosporine, calphostin C, and chelerythrine) did not affect the basal EAAT3 activity but abolished lidocaine-enhanced EAAT3 activity. Wortmannin (a specific PI3K inhibitor) inhibited EAAT3 basal activity and lidocaine-enhanced EAAT3 activity. Our results suggest that lidocaine enhances EAAT3 activity at certain concentrations and that PKC and PI3K may mediate these lidocaine effects.

 

门脉高压患儿行诊断性腹腔镜检查时动脉二氧化碳分压显着增高

Arterial Carbon Dioxide Markedly Increases During Diagnostic Laparoscopy in Portal Hypertensive Children

Pervin Bozkurt, MD*, Guner Kaya, MD*, Yuksel Yeker, MD*, Nuvit Sarimurat, MD{dagger}, Ebru Yesildag, MD{dagger}, Gonca Tekant, MD{dagger}, Haluk Emir, MD{dagger}, and Osman Faruk Senyuz, MD{dagger}

Departments of *Anesthesiology and {dagger}Pediatric Surgery, Istanbul University, Cerrahpasa Medical Faculty, Istanbul, Turkey

Anesth Analg Nov.2002;95:1263-1268

腹腔镜操作中几个因素可导致高碳酸血症。我们进行本研究,是因为我们观察到在门脉高压(PHT)的患儿行腹腔镜时PaCO2有骤然的增高,而这在正常小儿并不常见。57位小儿在全麻机械通气下行腹腔镜操作。插管后5分钟(T0),二氧化碳气腹后1530分钟(T15 and T30),放气后5分钟(Tend),拔管后10分钟(Text)分别收集动脉血标本行血气分析。两组研究期间PaCO2, pH, ETCO2的改变均有统计学意义(P<0.05)。在对照组和PHT组,T0 T15PaCO2上升的百分比分别为11.5% and 20.1%P<0.05)。在PHT组到T30时这一上升值达36.8%,而在对照组为17.2%P<0.05)。ETCO2呈现出相似的改变。各组碱剩余,重碳酸盐,PaO2,动脉氧饱和度,SpO2的变化均无显着性(P>0.05)。PHT的患儿行腹腔镜检查时PaCO2显着上升,肝内或肝外来源并无差异。对于这种病例,减少CO2气腹时间和气腹压力,并调整通气参数以适应高碳酸血症是至关重要的。

(张 鸿 译 薛张刚 校)

Several factors are responsible for hypercarbia during laparoscopic procedures. This study was undertaken because we observed a sudden increase in PaCO2 in children with portal hypertension (PHT), which was unusual in healthy children undergoing laparoscopic procedures. Fifty-seven children underwent laparoscopic procedures under general anesthesia and were mechanically ventilated. Arterial blood samples were obtained 5 min after intubation (T0), 15 min and 30 min after CO2 pneumoperitoneum (T15 and T30), 5 min after desufflation (Tend), and 10 min after extubation (Text) for blood gas analysis. The changes in PaCO2, pH, and ETCO2 were statistically significant during the study periods in both groups (P < 0.05). The percentage of PaCO2 increase between T0 and T15 was 11.5% and 20.1%, respectively, in the control group and the PHT group (P < 0.05). This increase reached 36.8% at T30 in the PHT group, whereas the control group had a 17.2% increase (P < 0.05). ETCO2 presented similar changes. The variability in base excess, bicarbonate, PaO2, arterial oxygen saturation, and SpO2 was not significant in either group (P > 0.05). The PaCO2 increased remarkably in children with PHT undergoing laparoscopy, with no difference in intrahepatic or extrahepatic origin. Limiting the duration of CO2 pneumoperitoneum and intraabdominal pressure and adjusting ventilatory variables to accommodate hypercarbia are of the utmost importance for such cases.

 

Narcotrend,脑双频谱指数和经典脑电图在静脉注射异丙酚联合瑞芬太尼麻醉苏醒时的变化

Narcotrend, Bispectral Index, and Classical Electroencephalogram Variables During Emergence from Propofol/Remifentanil Anesthesia

Gunter N. Schmidt, MD*, Petra Bischoff, MD*, Thomas Standl, MD*, Moritz Voigt*, Luca Papavero, MD{dagger}, and Jochen Schulte am Esch, MD*

Departments of *Anesthesiology and {dagger}Neurosurgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Anesth Analg Nov. 2002;95:1344-1350

目的 是为研究现代和经典脑电图在静脉注射异丙酚-芬太尼中的变化。我们假设现代脑电图改变能够提示异丙酚的影响而不能揭示瑞芬太尼的作用。方法 研究对象是25elective spine 手术结束后没有手术刺激的患者。瑞芬太尼的基础量是0.3 µg · kg-1 · min-1,靶控输注异丙酚3.0 µg/mL。在停用瑞芬太尼后13579分钟监测脑电图指标的变化,同时逐步减少靶控输注异丙酚量(每3分钟减少0.2 µg/mL)。每个时间点都记录Narcotrend (NT; classifying EEG stages from awake to deep anesthesia),脑双频谱指数, EEG spectral frequency bands (%), 50% (Median) and 95% percentiles (spectral edge frequency),平均动脉压,心电图和血氧饱和度。结果 停用瑞芬太尼显着增加了脑电图中α波的百分比,spectral edge frequency,平均动脉压和θ波的百分比,减少了δ波的百分比 (P < 0.05)。而NT, BIS, Median,心率和血氧饱和度没有改变。降低异丙酚的浓度使NT, BIS上升并具有显着的统计学意义(P < 0.05)结论 现代脑电图指标能够估计作为镇静-催眠的异丙酚的作用,但对作为镇痛作用的瑞芬太尼却没有监测作用。因此无论有无手术刺激,如果仍静脉输注瑞芬太尼,NTBIS对麻醉深度均不能提供足够良好的评估。

(李 懿 译 薛张刚 校)

The aim of this study was to investigate modern and classical electroencephalographic (EEG) variables in response to remifentanil and propofol infusions. We hypothesized that modern EEG variables may indicate the effects of propofol but not of remifentanil. Twenty-five patients were included in the study after the end of elective spine surgery without any surgical stimulation. Baseline values were defined with remifentanil 0.3 µg · kg-1 · min-1 and target-controlled infusion of propofol 3.0 µg/mL. EEG changes were evaluated 1, 3, 5, 7, and 9 min after the stop of remifentanil infusion, followed by a step-by-step reduction (0.2 µg/mL) every 3 min of target-controlled infusion propofol. Narcotrend (NT; classifying EEG stages from awake to deep anesthesia), bispectral index (BIS), EEG spectral frequency bands (%), 50% (Median) and 95% percentiles (spectral edge frequency), mean arterial blood pres- sure, heart rate, and oxygen saturation were detected at every time point. The end of remifentanil application resulted in significant increases in %{alpha}, spectral edge frequency, mean arterial blood pressure, and %{theta} and decreases in %{delta} (P < 0.05). NT, BIS, Median, heart rate, and oxygen saturation were unchanged. Decreases in propofol concentration were associated with statistically significant increases in NT and BIS (P < 0.05). Thus, the sedative-hypnotic component of propofol could be estimated by modern EEG variables (NT and BIS), whereas the analgesic component provided by remifentanil was not indicated. However, during conditions without surgical stimulation, neither NT nor BIS provided an adequate assessment of the depth of anesthesia when a remifentanil infusion was used

.

Rofecoxib 应用于耳鼻喉科手术的镇痛作用

Analgesic Effects of Rofecoxib in Ear-Nose-Throat Surgery

A. Turan*, S. Emet*, B. Karamanlioglu*, D. Memis*, N. Turan{dagger}, and Z. Pamukcu*

Departments of *Anaesthesiology and {dagger}Biostatistics, Trakya University Medical Faculty, Edirne, Turkey

Anesth Analg Nov. 2002;95:1324-1330

目的 评价 rofecoxib应用于耳鼻喉手术患者镇痛和opioid-sparing作用。方法 进行鼻中隔或鼻窦手术的患者术前1小时随机给予口服安慰剂或rofecoxib 50 mg。所有患者术中均给予异丙酚0.8 mg/kg, 芬太尼 1 µg/kg并在手术部位进行局部麻醉。持续静脉输注异丙酚维持患者镇静状态在23级水平(Ramsey scale)。如果病人要求或verbal rating scale评分大于4,额外给予芬太尼0.5–1 µg/kg。术中515304560分钟以及术后30分钟,2461224小时对病人镇静和疼痛程度进行评分。术后如果病人要求或visual analog scale (VAS)痛觉评分大于4给予肌注diclofenac 75 mg镇痛。结果 rofecoxib VAS痛觉评分,术中芬太尼用量和术后diclofenac需要量均显着少于空白对照组(P < 0.001),而且首次镇痛后再要求镇痛的次数也明显少于对照组。结论 术前应用rofecoxib——一种新型的环氧化酶-2抑制剂,对鼻中隔和鼻窦手术的病人能够提供显着的镇痛作用并能减少阿片类药物的应用。

(李 懿 译 薛张刚 校)

In this study we evaluated the analgesic efficacy and the opioid-sparing effect of rofecoxib in ear-nose-throat surgery patients. Patients undergoing nasal septal or sinus surgery were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received propofol 0.8 mg/kg, fentanyl 1 µg/kg, and local anesthesia at the operative site. Sedation was maintained by a continuous infusion of propofol adjusted to maintain sedation at a 2–3 level on the Ramsey scale. Additional fentanyl 0.5–1 µg/kg was administered at the patient’s request or if the verbal rating scale score was >4. Patient sedation and pain scores were obtained at 5, 15, 30 45, and 60 min during surgery and 30 min and 2, 4, 6, 12, and 24 h after completion of the procedure. During the postoperative period, diclofenac 75 mg IM was administered for analgesia at the patient’s request or if the visual analog scale (VAS) rating for pain was more than 4. VAS pain scores, intraoperative fentanyl, and postoperative diclofenac requirements were significantly smaller in the rofecoxib group compared with the placebo group (P < 0.001). The times to first analgesic request were also significantly less in the rofecoxib group. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the need for opioids in patients undergoing nasal septal and nasal sinus surgery.