Anesthesia & Analgesia

November 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

利多卡因冠脈搭橋手術術後早期充血性心力衰竭的影響

(趙雪蓮 譯    莊心良  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.

 

新發現的卵圓孔未閉對不停跳冠脈搭橋病人的影響:11例報導

(潘志浩譯 薛張剛校)

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、異氟醚和芬太尼提高植入性心內除顫器的最低有效閾值的首例報導

 (   慧 譯 王祥瑞 校)   

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.

 

圍術期兩種血液保護技術的前瞻性隨機對照研究:等容量和超容量血液稀釋

(張 軍 譯  莊心良 校)

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.

 

在體研究中異氟醚沒有產生保護心梗的預處理的第二窗

(潘志浩 譯 薛張剛 校)

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.

 

鼠高鈉血症對移植肝的影響

(朱慧琛譯   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.

 

突然阻斷腔靜脈血流的血流動力學和激素反應:通過肝大部切除手術中肝血管排空的前瞻性研究

(顏 濤    莊心良  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:

純氧合用七氟醚,異氟醚,氟烷,芬太尼/咪唑安定時對小兒先天性心臟病病人肺循環與體循環血流比影響

(潘志浩 譯 薛張剛 校)

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.

 

小兒心臟麻醉時靜脈注射和鞘內注射芬太尼的比較

 (周 潔譯 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.

 

骶管內注射新斯的明、 布比卡因及兩藥複合液用於小兒尿道下裂術後鎮痛

(王士雷 譯   莊心良 校)

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.

 

小兒骶麻:睾丸固定術阻滯精索牽拉反應中布比卡因的容量和濃度的比較

(張俊峰 譯 薛張剛 校)

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方法用於認知缺損兒童疼痛評估

(周 潔 譯   王祥瑞 校  

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 對施行扁桃體切除術的門診病人有等效的止吐功能

(楊保仲譯   莊心良校)

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.

 

門脈高壓患兒行診斷性腹腔鏡檢查時動脈二氧化碳分壓顯著增高

(張 鴻 譯 薛張剛 校)

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:

門診病人行肛門直腸手術時鞘內注射小劑量利多卡因和羅呱卡因的比較

(齊 波 譯  王祥瑞 校)

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:

利多卡因冠脈搭橋手術術後早期充血性心力衰竭的影響

(趙雪蓮 譯    莊心良  校)

利多卡因對谷氨酸轉運體EAAT3活性的影響:蛋白激酶C和磷脂酰肌醇3激酶的作用

(張 鴻 譯 薛張剛 校)

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. 

 

曲馬多對爪蟾卵母細胞克隆表達的M3受體的抑制作用研究

(齊 波 譯  王祥瑞 校)

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.

 

全麻藥對游離的鼠皮層神經末梢去甲腎上腺素釋放的影響

(張 軍 譯  莊心良 校)

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.  

 

異丙酚持續輸注時腦脊液濃度的變化

(張 鴻 譯 薛張剛 校)

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.

 

磷酸異丙酚,一種水溶性的異丙酚前體藥物:在體評估

(忻紀華 譯  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.

 

麻黃堿減少丙泊酚注射時的疼痛

(顏 濤     莊心良  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對防止安定注射疼痛的比較

(張 鴻 譯 薛張剛 校)

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.

 

田鼠福馬林試驗比較氙和笑氣的鎮痛效應

(忻紀華 譯  王祥瑞 校)

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.

 

離體雷米芬太尼代謝:全血和血漿假性膽鹼酯酶對其影響

(趙雪蓮      莊心良  )

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 應用於耳鼻喉科手術的鎮痛作用

(李 懿 譯 薛張剛 校)

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:

自體血液回收效果評價的資料模型

(  輝 譯 王祥瑞 校)

A Mathematical Model of Cell Salvage Efficiency

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

Anesth Analg 2002 95: 1312-1317.

 

聽覺穩態反應不是一個合適的麻醉監測方法

(張 軍譯  莊心良 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,腦雙頻譜指數和經典腦電圖在靜脈注射異丙酚聯合瑞芬太尼麻醉蘇醒時的變化

(李 懿 譯 薛張剛 校)

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.

 

攜帶型輸注泵持續區域鎮痛時推注速率準確性的研究

(  輝 譯 王祥瑞 校)

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:

胍乙啶和局麻藥對電刺激鼠輸精管反應的影響

(王士雷     莊心良  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.

 

隨機雙盲比較開胸後硬膜外用羅呱卡因、羅呱卡因/芬太尼、布比卡因/芬太尼鎮痛

(嵇富海 譯 薛張剛 校)

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.

 

術後早期抑制外周感受傷害活動減輕疼痛的隨機試驗

(殷文淵 譯 王祥瑞 校)

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:

評估術中治療和診斷干預

 (趙雪蓮      莊心良  校)

Evaluating Intraoperative Therapeutic and Diagnostic Interventions

Nava Klein and Charles Weissman

Anesth Analg 2002 95: 1373-1380.

 

全麻下施行大手術發生低體溫的原因分析

楊保仲 譯 莊心良 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:

長時間神經外科手術期間七氟醚比安氟醚提供更快的恢復和術後神經估價

(嵇富海 譯 薛張剛 校)

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-羥基丁酸(GABA)受體藥物對嗎啡誘導的無損傷脊髓缺血後鼠的痙攣性下肢輕癱的影響

(殷文淵 譯  王祥瑞 校)

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:

腰硬聯合分娩鎮痛時蛛網膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可樂定的隨機雙盲試驗研究。

(王士雷 譯   莊心良  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:

腎上腺素對羅呱卡因硬膜外應用時早期全身吸收的影響

(朱 慧    莊心良校)

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.

 

心電圖導聯的選擇是否影響其用於檢測試驗劑量中腎上腺素血管內注射的T波標準的功效

(潘志浩 譯 薛張剛 校)

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.

 

連硬及非連硬阻滯患者異氟醚對術中腦電抑制時的等效劑量

(陳 潔譯 王祥瑞 校)

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靜脈局部麻醉

(張俊峰 譯 薛張剛 校)

Intravenous Regional Anesthesia Using Prilocaine and Neostigmine

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

Anesth Analg 2002 95: 1419-1422.

 

一種住院醫師局部麻醉培訓的新模式

(張俊峰 譯 薛張剛 校)

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:

經鼻氣管插管:一種簡單而有效的減少鼻咽部創傷和導管污染的技術

(陳 潔 譯 王祥瑞 校)

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試驗評估寰枕關節伸展度的可靠性

(朱 慧 譯   莊心良 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可預防成人中耳整複術後的噁心和嘔吐

(張俊峰 譯 薛張剛 校)

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、異氟醚和芬太尼提高植入性心內除顫器的最低有效閾值的首例報導

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

置入植入性心內除顫器(ICD)包括感應性心室纖顫患者,其最低有效除顫閾值(DFT)的確定。對於置入植入性心內除顫器的患者我們分別研究不同的麻醉方式對其最低有效除顫閾值的影響,在全麻下分別給予患者吸入0.7%氟烷、1%異氟醚或靜注 1.5 µg/kg芬太尼,或單純皮下注射1.5%利多卡因並輔以 0.35 mg/kg 異丙酚靜注,此時進行第一次DFT值測定,30分鐘後關閉吸入麻醉,分別給予三個全麻組靜注1 µg/kg 芬太尼,並進行第二次DFT測量,30分鐘後又進行了第三次測定,此時患者尚未蘇醒且僅以N2O/O2吸入。而利多卡因輔以異丙酚組則在同一時間給予靜注異丙酚。第一次測量結果DFT分別為16.1 ± 2.2 J (氟烷), 17.7 ± 2.7 J (異氟醚), 16.4 ± 2.9 J (芬太尼) 12.9 ± 3.8 J (利多卡因+異丙酚) (P = 0.01).第二次測量時氟烷(P = 0.01)及異氟醚(P = 0.02)DFT值都明顯低於第一次。第三次測量值除利多卡因+異丙酚這組外其餘三組的DFT均明顯下降(P <0.01)。由此推斷氟烷、異氟醚、芬太尼都提高了ICD置入患者的DFT值,而利多卡因輔以間歇靜注異丙酚則可降低該值。

                                           (   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.

鼠高鈉血症對移植肝的影響

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

捐贈者出現的高鈉血症是引起常位肝移植(OLT)手術後肝功能缺損的主要危險因素之一。然而對於外傷後出現溶液高滲而誘發急性高鈉血症時的供體進行肝移植後,其移植肝的存活能力尚未進行過系統研究。在目前的研究中我們試圖評估使用存在高鈉血症(由溶液高滲引發)的供體鼠的肝臟時是否會影響肝移植手術結果。于高鈉血症(>160 mEq/L)出現30分鐘後,在麻醉狀態下九隻小鼠的肝臟被取下,其中的六個立即進行移植,其餘三個經4°C 低溫保存了六小時後也被移植入受體鼠體內,在其後的7天內我們將供體鼠和其受體鼠的肝功能變化與對照組進行了比較,同時還比較了移植後的肝臟含水量和受體鼠存活情況。實驗結果顯示供體及受體組的肝功能測試和肝臟含水量均無明顯差異, 所有的實驗鼠經過7天觀察期都存活。這項研究顯示非腦死亡供體鼠在注射了10%高滲鹽水後引起的高鈉血症不會導致常位肝移植術(OLT)後移植肝的功能衰竭現象。

                                                      (朱慧琛譯   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.

 

小兒心臟麻醉時靜脈注射和鞘內注射芬太尼的比較

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

大劑量阿片類藥物已廣泛應用于小兒心臟手術麻醉中,但是對於這類手術中使用鞘內注射阿片類藥物並無系統對照的研究。本實驗採用對照,前瞻性研究,對小兒心臟手術中鞘內(IT)和靜脈內(IV)注射芬太尼進行研究。共有306月至6歲的小兒在麻醉中IV芬太尼10μg/kg作負荷量,追加藥量分別為IV組使用芬太尼靜注10μg/·kg-1·h-1IV組,n=10),IT組使用2μg/kg芬太尼鞘內注射(IT組,n=10),IV+IT組混合使用上述劑量的芬太尼(IV+IT組,n=10)。在試驗中記錄心率,平均動脈壓,追加芬太尼的劑量,首次需要疼痛治療的時間,舒適程度,患兒住院時的疼痛評分和拔管時間。在術前,劈開胸骨後,體外轉流期間(CPB),術後6小時及24小時分別測定血中皮質醇,胰島素,血糖及血乳酸水平。並在術後第一天檢測病兒尿中皮質醇水平。三組病人的各項檢測結果相似,僅在體外轉流期間(CPBIT組血糖水平明顯高於IV組(P<0.004)。只有IV+IT組在術前及術後比較中未發現心率和平均動脈壓沒有明顯升高。在IVITIV+IT24小時尿皮質醇檢測結果分別為(61.51±39,92.54±67.55,40.15±29.69μg·kg-1·d-1)。從血流動力學和應激反應來說,單次IT注入芬太尼並不優於全身使用芬太尼(10μg/kg負荷量以及10μg/·kg-1·h-1維持)。混合使用上述兩種方法則可以在CPB前期獲得更穩定的血流動力學狀態,並且降低術後24小時尿中皮質醇水平。

                                                  ( 潔譯 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方法用於認知缺損兒童疼痛評估
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

 

由於在認知方面的欠缺(CI),兒童的疼痛評估常常顯得十分困難。本實驗通過面部表情,腿部動作,活動,哭泣,安慰性(FLACC)等方面來對有認知欠缺的兒童進行疼痛治療的有效性和可靠性進行評估。每一名兒童的發育水平和對疼痛的表述能力都被列入考慮。由護士負責對每一名兒童在疼痛治療前後使用FLACC進行疼痛觀察和評估。同時,對其父母使用疼痛刻度尺進行評分,並對部分有表述能力的兒童進行疼痛刻度評分。觀察過程由護士攝錄並播放,前者對疼痛治療和評分並不知情。一共對79名兒童進行了140次觀察。結果顯示,FLACC評分與父母的疼痛評分有良好的相關性(P<0.001),並且此評分在疼痛治療後明顯降低(P=0.001),說明了疼痛治療的有效性。所有評分的相關性(r=0.5-0.8;P<0.001)以及各類別的相關性(r=0.3-0.8;P<0.001)均顯示此方法有良好的可靠性。試驗的可重複性良好(r=0.8-0.883;P,0.001),各類別均具可重複性(r=0.617-0.935;P,0.001)。上述資料顯示,FLACC評分對於在認知方面有欠缺(CI)的兒童進行疼痛評估時非常有效。

                                                    (    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

 

門診病人行肛門直腸手術時鞘內注射小劑量利多卡因和羅呱卡因的比較

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

在應用利多卡因實施腰麻醉時應詳細檢查病人,因為可能導致病人出現短暫神經系統症狀(TNS)。我們設計了這樣的一個前瞻性實驗研究,比較門診病人擇期行肛門直腸手術時應用羅呱卡因和利多卡因麻醉時的效用。72個病人被隨機分為兩組,一組病人接受重比重的利多卡因25mg加芬太尼20ug(n=37),而另外一組病人接受重比重的羅呱卡因4mg加芬太尼20ug(n=35)。麻醉後檢查病人的運動神經阻滯、感覺神經阻滯和阻滯持續時間。術後24h48h72h168h隨訪病人,並詢問病人麻醉後有沒有疼痛感覺,以及有關TNS診斷的問題。兩組病人均沒有出現TNS症狀。且兩組病人無任何明顯差異。因此實驗總結認為:在肛門直腸手術時應用小劑量重比重的羅呱卡因複合芬太尼行蛛網膜下腔麻醉是一個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.

 

曲馬多對爪蟾卵母細胞克隆表達的M3受體的抑制作用研究

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

曲馬多是一種廣泛應用的鎮痛藥,但它的作用機理還不是完全清楚。由於M受體與大腦和自主神經系統的神經元功能有關,因此目前作為中樞神經系統內鎮痛藥的作用受體而被廣泛關注。在這個研究中,我們應用爪蟾卵母細胞表達系統來研究曲馬多對M3受體的效應。曲馬多(100nM-100uM)可以抑制乙酰膽鹼誘導的M3受體效應。雖然GF109203X,一種蛋白激酶C抑制劑,可以增加乙酰膽鹼的效應,但在曲馬多存在時沒有效果。而且,曲馬多抑制了{3H}quinuclidinyl benzilate的特殊結合部位。這些研究發現表明曲馬多在臨床相關劑量下可經過quinuclidinyl benzilate結合部位抑制M3受體。這可以解釋神經元功能調節和曲馬多的抗副交感神經作用。

(   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.

磷酸異丙酚,一種水溶性的異丙酚前體藥物:在體評估

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,家兔和豬中單次靜脈注射水溶性異丙酚前體藥物磷酸異丙酚(PP),1—15分鐘後轉化為異丙酚,產生劑量依賴性鎮靜效應。在家鼠中,半數催眠劑量(HD50),半數致死量(LD50),和安全指數(指LD50/HD50的比率)分別是165.4mg/kg ,600.6 mg/kg, 3.6。異丙酚轉化的半衰期在田鼠中為5.3+/0.6 min,在家兔中為2.1 +/-0.6 min,在豬中為4.4+/-2.4min。最大濃度為劑量和種族依賴性。清除半衰期在田鼠中為24+/-12min,家兔中為21+/-16min,在豬中為225+/-56min。從PP到異丙酚的產生藥理作用與獻報導類似。結果表明異丙酚的血藥濃度大於1.0ug/kg時,PP劑量和鎮靜時間相關,該劑量在鼠和豬中產生嗜睡和鎮靜作用。用PP後可產生充分的鎮靜,且當計量足夠大時可達到麻醉深度的鎮靜作用。總之,水溶性異丙酚的前體藥物可成為鎮靜和麻醉用藥的發展方向。

                                                    (忻紀華   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.

 

田鼠福馬林試驗比較氙和笑氣的鎮痛效應

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

為研究氙的鎮痛效應,以氙或笑氣的半數最低肺泡有效濃度在田鼠中進行了福馬林試驗,並通過抗生物素蛋白-輔酶R-過氧化物酶法(zaidin-biotin-peroxidase法)對腰神經根的c-fos(n=18)和磷酸化N—甲基—D—天冬氨酸(NMDA)受體(n=24)進行染色。在吸入79%的氙氣,68%的笑氣,或100%的氧氣後20min在實驗組的田鼠臀部注射10%的福馬林(100ul)。觀察1小時的感受傷害反應。福馬林注射2小時後殺死田鼠,對腰神經根經染色的c-fos和磷酸化NMDA進行免疫組化測定。氙和笑氣組的動物感受傷害的反應較氧氣組弱。笑氣組腰神經根中的c-fos染色陽性細胞沒有減少,但氙氣組減少。磷酸化NMDA受體陽性細胞在氙氣組較笑氣和氧氣組明顯減少。在田鼠福馬林試驗中氙的吸入可以抑制感受傷害反應,c-fos表達,和NMDA受體的活性。這些結果證實了氙的鎮痛效應通過抑制NMDA受體而實現。

                                                     (忻紀華 譯  王祥瑞 校)

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.

 

自體血液回收效果評價的資料模型

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)是降低手術期間同種異體輸血的一種方法。它不同于急性等容性血液稀釋, 其效果還沒有被精確模擬過。本文假定數學模型能夠在血液回收期間預計血球壓積的下降,以說明在容量相等的患者中由於紅細胞丟失引起血球壓積降低而再利用清洗過的紅細胞使血球壓積增高。血液回收的效果可通過“血液丟失最大允許量”(MABL)來確定。為了說明問題,假想的患者的血容量估計在5000ml,術前血球壓積為45%,而需輸血的血球壓積臨界值為21%。在典型的病例中,血液丟失最大允許量為9600ml,紅細胞的回收率為60%。病例記錄樣本顯示紅細胞平均回收率為57%,並有20%的誤差。這個資料模型說明當紅細胞收集理想的情況下血液回收是一種高效的節約用血的方法。

                                                     (  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. 
                                                 
攜帶型輸注泵持續區域鎮痛時推注速率準確性的研究

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

 

區域麻醉期間使用攜帶型泵來輸注局部麻醉劑已被逐漸接受。這些泵常常被用於在滴注期間無須照看的可以走動的患者。然而使用這些泵引起潛在的藥物中毒還未被專門地研究。我們對持續區域鎮痛期間使用滴注泵滴注麻醉劑的滴注速率的準確性,連貫性及各種泵的性能進行了研究。我們在實驗室內通過電腦/定標聯合的方法對6個泵的滴速調節器在預期溫度和升高的溫度的情況下進行測試並記錄了它們的滴速。結果顯示各個泵間的滴注速率大不相同,在整個輸注時間的18%-100%其滴注速率與預期速率相差±15%。溫度升高也不同程度地影響泵的滴注速率,滴速增快從0%25%不等。這些結果表明,當使用攜帶型泵滴注局部麻醉劑時應考慮這些因素比如滴速的準確性,連貫性及各種泵的滴注性能。

                                                       (  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.


術後早期抑制外周感受傷害活動減輕疼痛的隨機試驗

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

 

組織損傷所產生的外周神經元屏障會導致中樞神經系統發生改變,這是維持術後疼痛的原因所在。阻滯這些中樞變化的治療方法仍有爭議,因為以前的研究並沒有將術前干涉作用從組織損傷後的作用中區分出來,也就是疼痛發作前。本研究估計了在術中或術後早期組織感受傷害活動輸入對疼痛抑制的相對作用。研究物件被隨機地分入四組中的一組,術前2%利多卡因,術後0.5布比卡因,兩者都注射或注射安慰劑。全麻誘導後三次抽取血樣。分別於4h24h48h後評價疼痛。手術期間血樣本內的β-內啡肽增加兩倍。這提示外周感受傷害的屏障的活動對疼痛刺激產生反應。術後早期應用布比卡因組的病人疼痛減輕,然而利多卡因組則隨著時間的推移疼痛加重。布比卡因鎮痛組在術後48h內疼痛較輕,但是術前單獨應用利多卡因組則沒有效果。這些手術疼痛模型的結果說明術後早期最小化外周感受傷害的屏障可以在隨後的時間內減輕疼痛。相反地,在手術期間阻滯外周感受傷害的屏障似乎對減輕疼痛並沒有很大的作用。

                                                    (殷文淵 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-羥基丁酸(GABA)受體藥物對嗎啡誘導的無損傷脊髓缺血後鼠的痙攣性下肢輕癱的影響
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

 

作者曾經描述過齧齒動物模型在無損傷脊髓缺血後鞘內注射嗎啡引起痙攣性下身輕癱。但這種輕癱的機制不得而知。假設嗎啡抑制了控制強直性痙攣的脊髓α-運動神經元的γ-羥基丁酸(GABA)中間神經元,這種對脊髓中間神經元的抑制會引起痙攣性下身輕癱。本研究研究了嗎啡和GABA激動劑或拮抗劑之間對脊髓缺血後運動功能的相互影響從而闡明鞘內注射嗎啡引起痙攣性下身輕癱的機制。通過大動脈阻滯6分鐘來引起脊髓缺血。首先確定在這種模型中鞘內注射GABA激動劑(muscimolbaclofen)是否加重痙攣性下身輕癱。GABA激動劑並沒有加重痙攣性下身輕癱。接著觀察GABA拮抗劑(bicuculline5-aminovaleric acid)的影響,從而確定嗎啡和GABA拮抗劑之間的相互作用。通過同種輻射測熱分析,減輕痙攣的50%有效劑量在理論附加線以下,提示嗎啡和GABA拮抗劑之間存在協同作用。這些結果說明鞘內注射嗎啡引起的痙攣性下身癱瘓也許可以部分被GABA受體中止。

                                               (殷文淵   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.

 

連硬及非連硬阻滯患者異氟醚對術中腦電抑制時的等效劑量

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

採用隨機、前瞻性對比方法以探討在手術中要求達到相同的腦電圖(EEG)抑制程度時,硬膜外阻滯對異氟醚使用劑量的影響。試驗選取50例行腹式子宮切除術患者,麻醉方式為連硬複合全麻或者單獨使用異氟醚和阿芬太尼作為全麻。異氟醚吸入採用電腦控制的閉合迴圈反饋機制以保持EEG中95%的光譜移動頻率為17.5HZ, 此目標根據一項飛行員的研究設定。接受連硬麻醉的患者中,呼氣末異氟醚濃度較另一組低0.19%,(95%可信區間[CI]-0.32%-0.06%p0.01〉;平均動脈壓低17mmHg柱(95%[CI]-24-9mmHgp0.0001〉;體溫低0.4℃(95%[CI]-0.70℃;p0.05〉;腦電雙頻指數BIS4點(95%[CI]17p0.05〉。EEG的中等值和心率在兩組中類似。接受連硬麻醉的患者因為低血壓而需要間羥胺的比例高76%95%CI58%94%p0.001〉,另外,多28%的患者因為心動過緩而需要使用甘羅溴銨95%CI3%53%p0.05〉。術後,患者睜眼的時間短2.3分鐘(95%CI-4.2-0.5分鐘,p0.05〉。麻醉最後30秒呼氣末異氟醚濃度與睜眼時間的相關性優於BIS,(FEISO=0.07× 睜眼時間+0.31r2=0.59p0.0001〉,(BIS=64-1.25×睜眼時間;r2=0.22p0.001〉(p0.0001〉。為了達到相同的光譜移動頻率,患者接受全麻聯合連硬所需的異氟醚用量較單獨使用全麻患者少21%,較少的異氟醚用量也伴隨著麻醉後更快的蘇醒。

                                                  ( 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.

 

 經鼻氣管插管:一種簡單而有效的減少鼻咽部創傷和導管污染的技術

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

假設通過鼻咽導管(Wendl 管)作為“引導者”來幫助氣管內導管通過鼻咽部。採用相應的隨機對比雙盲實驗,以估計鼻咽部的出血和氣管內導管末端的污染程度。麻醉誘導後,將Wendl 管插入鼻孔。在對照組(n=30),Wendl 管在氣管內導管(內徑7.0mm)接觸鼻咽通路之前收回。在調查組(n=30),Wendl管保持位置固定僅取走調節凸緣。然後將氣管內導管的末端插入Wendl管的拖尾。最後,氣管內導管通過Wendl管引導到達口咽部。之後,Wendl管取走,插管完成。術後6小時評定患者的鼻部疼痛,“引導者”技術減少了出血的發生率(p0.001〉和嚴重程度(p=0.001)和減少了導管被血液和黏液的污染(p0.001〉,並且減少了術後的鼻部疼痛(p=0.036)。  

                                                      ( 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).

骶管內注射新斯的明、 布比卡因及兩藥複合液用於小兒尿道下裂術後鎮痛

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:研究小兒尿道下裂術後骶管內注射新斯的明布比卡因及兩藥複合液的鎮痛效果。方法:60例行尿道下裂手術的患兒,隨機分為三組,分別于全麻誘導後骶管內注射0.25% 布比卡因1 mL/kg、 新斯的明2µg/kg (用生理鹽水稀釋,1 mL/kg )和兩者複合組(0.25% 布比卡因1 mL/kg內含2 µg/kg) (n=20)。結果:骶管內注射布比卡因或布比卡因新斯的明複合液的患兒術中吸入麻醉藥的量較骶管內注射新斯的明組少,血流動力學也更穩定,而且全麻後蘇醒也更快。術後第一次追加鎮痛藥的時間,三者分別為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組術後24h需要的醋氨酚的量較複合組多。術後嘔吐的發生率分別為25%, 10%, 30% (P < 0.01)。結論:小兒尿道下裂術後骶管注射新斯的明的鎮痛效果和骶管注射布比卡因相當,兩藥複合時鎮痛作用增強。

(王士雷 譯   莊心良 校)

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.

 

胍乙啶和局麻藥對電刺激鼠輸精管反應的影響

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:複雜疼痛綜合症(CRPS)常用胍乙啶和局麻藥治療,但出現不同的效果。因為局麻藥抑制去甲腎上腺素轉運體的攝取,是否因為抑制胍乙啶的攝取而使作用顯著不同?本實驗用附帶交感神經的輸精管驗證此假說。方法:觀察丙胺卡因、普魯卡因、可卡因及其分別與胍乙啶複合對電刺激附帶交感神經的輸精管的作用。結果:丙胺卡因(1 mM)能即刻抑制電刺激鼠輸精管的顫搐反應(2 min後達100%),在1h時洗脫藥物顫搐反應能完全恢復。胍乙啶(3 µM)15min內抑制電刺激鼠輸精管的顫搐反應95% ± 3%,但1h時洗脫藥液顫搐反應僅部分恢復(33% ±12%)。聯合應用丙胺卡因和胍乙啶,1h時洗脫藥液顫搐反應可以恢復80% ± 13%。普魯卡因(300 µM)使顫搐反應短暫升高(152% ± 14%)。聯合應用胍乙啶(3µM),顫搐反應降為24% ± 4% 1h時洗脫藥液顫搐反應可以恢復77% ± 7%。可卡因(30 µM)抑制顫搐反應53% ± 8%,在1h時洗脫藥液顫搐反應可以完全恢復。聯合應用胍乙啶(3µM),顫搐反應降為39% ± 6%,在1h時洗脫藥液顫搐反應恢復86% ± 10%。所有複合用藥引起的反轉都比單用胍乙啶為強。結論:局麻藥能降低胍乙啶的交感活性,這可以解釋為什麼用胍乙啶治療區域疼痛綜合症時常出現不一樣的效果。

(王士雷     莊心良  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.

腰硬聯合分娩鎮痛時蛛網膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可樂定的隨機雙盲試驗研究。

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:蛛網膜下腔注射可樂定可能延長阿片藥的作用時間,增強局麻藥的鎮痛效果,但是,也可能引起低血壓和嗜睡等副作用。本文對腰硬聯合分娩鎮痛時蛛網膜下腔注射布比卡因-芬太尼或布比卡因-芬太尼-可樂定進行比較。方法:110例在腰硬聯合下分娩鎮痛的產婦,隨機分為4組,分別於蛛網膜下腔注射芬太尼(20 µg-布比卡因(2.5 mg-NS或芬太尼(20 µg-布比卡因(2.5 mg)複合可樂定15, 30, or 45 µg。結果:101例符合統計要求的產婦中,有22例在腰麻終止前娩出胎兒。各組病人在注藥後0-120分鐘期間的疼痛評分相同。各組病人腰麻鎮痛時間無顯著不同。所有複合可樂定的病人在腰麻期後40-90min時體循環血壓都低,且低血壓和需要應用麻黃素者隨可樂定用量的增加而增多,但組間低血壓的發生率無差別。結論:可樂定1545 µg不能延長蛛網膜下腔注射布比卡因-芬太尼的鎮痛時間,卻顯著降低血壓。

                               (王士雷 譯   莊心良  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 對施行扁桃體切除術的門診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

我們用前瞻、隨機、雙盲以及安慰劑對照的方法,以159例年齡在2-12歲、ASA分級為III級的施行扁桃體切除術的病人為研究物件,術前分別給予單次劑量的ondansetron dolasetron,比較其嘔吐發生率和術後48小時的恢復特徵。所有病人均給以相同的術中處理,包括術前用藥、鎮痛藥、手術和麻醉技術等。病人隨機分組如下,ondansetron組,ondansetron 0.15mg/kg,最大量不超過4 mgdolasetron組,dolasetron  0.5mg/kg, 最大量不超過25 mg;安慰劑組,靜脈注射生理鹽水。另外,所有病人術前均給以地塞米松1 mg/kg,最大量不超過25 mg。發生噁心/嘔吐超過2次的病人,即刻給以額外的止吐藥。在醫院,ondansetron dolasetron噁心/嘔吐發生率組間無差別,兩組均顯著低於安慰劑組(分別為10%8%30%)。在家裏(即術後24-48小時),也觀察到相似的結果(分別為6%, 6%18%)。在醫院,出現兩次噁心/嘔吐而需給以止吐藥的發生率,在ondansetron dolasetron顯著低於安慰劑組(分別為4%6%22%)。完全顯效率(即48小時內無噁心/嘔吐現象,未用止吐藥物),在ondansetron dolasetron組顯著低於安慰劑組(分別為76%74%44%)。所以預防性的應用ondansetron dolasetron具有相同的止吐效果。

(楊保仲譯   莊心良校)

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.


全麻下施行大手術發生低體溫的原因分析

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

許多因素,諸如病人的年齡和體質,會影響病人術中的體溫。本研究的第一部分,我們用回顧性方法,建立了如下數學模型:術中發生低體溫的可能性P=1/(1 + e-Z),其中Z= -15.014 + 0.097 x (年齡) + 0.263 x (身高) - 0.323 x (體重) - 0.055 x (術前收縮壓) - 0.121 x (術前心率)。當P>0.5,此方法的靈敏度為81.5%,特異度為 83%。本研究的第二部分,我們用前瞻性的方法,驗證此數學模型的有效性,在P>0.7的病人時,中心體溫明顯降低,其體溫調節性血管收縮反應的閾值也明顯降低;在P≤0.3的病人,術中體溫正常。本次研究結果表明,我們可以根據病人術前的年齡、身高、體重、收縮壓和心率等因素來預估病人術中發生低體溫的可能性,即年齡大、體型瘦小、血壓低和心率慢是術中低體溫發生的主要原因。

(楊保仲 莊心良 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.

 

全麻藥對游離的鼠皮層神經末梢去甲腎上腺素釋放的影響

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

靜脈和吸入麻醉藥抑制交感神經元和其他神經分泌細胞釋放去甲腎上腺素(NE)。然而,全麻藥對中樞神經系統去甲腎上腺素釋放的作用尚不清楚。作者研究了具有代表性的靜脈和吸入麻醉藥對游離鼠大腦皮層神經末梢(突觸體)釋放[3H]NE的影響。大鼠純化的大腦皮層突觸體預載[3H]NE,用含優降甯(一種單胺氧化酶抑制劑)和抗壞血酸(一種抗氧化劑)的緩衝液灌洗。在含或不含各種麻醉藥時檢測灌注液中基礎 (自發)和刺激誘發的[3H]NE 釋放量。採用高濃度的KCl(15–20 mM)4-氨基吡啶(0.5–1.0 mM)誘發鼠皮層突觸體濃度和Ca2+-依賴的[3H]NE釋放增加。靜脈麻醉藥依託米酯(5–40 µM),氯胺酮(5–30 µM),或戊巴比妥(25–100 µM)不影響基礎或刺激誘發的[3H]NE 釋放。異丙酚(5–40 µM)增加基礎[3H]NE 的釋放,在大劑量時減少刺激誘發的釋放。吸入麻醉藥氟烷(0.15–0.70 mM)增加基礎[3H]NE的釋放,但不影響刺激誘發的釋放。這些發現提示藥物特異性的刺激基礎去甲腎上腺素的釋放。去甲腎上腺素傳遞可能是中樞神經系統內全麻藥的一個突觸前靶位。如果從全麻藥對中樞神經系統其他遞質釋放的影響考慮,那麼全麻藥的突觸前作用是藥物和遞質特異性的。

(   莊心良 )

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.

 

圍術期兩種血液保護技術的前瞻性隨機對照研究:等容量和超容量血液稀釋

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

作者比較了標準情況下超容量(HVH)和等容量(IVH)血液稀釋作為圍術期血液保護方法的效果。30ASA I/II級,行骨科,耳--喉科或普外科手術的成年病人,預計失血>500 mL,入選IVH(n = 15)HVH (n = 15)。採用抽血和同時輸入多聚明膠(海脈素,Hemaccel)的方法(IVH)或輸入多聚明膠而不抽血產生高容量(HVH) 的方法把血液紅細胞壓積(Hct)稀釋至25%。在為維持術後24小時Hct >=25%而進行自體或異體輸血前允許失血達到Hct20%。在HVH 組,收縮壓(P = 0.0107)和中心靜脈壓(P = 0.0281)明顯高。稀釋後目標Hct 25% 和實際達到的Hct之間的均差(MD)在兩組沒有統計學意義。(MD [95% 可信區間; CI], IVH組, 0% [-0.7% to 0.7%] HVH 組,0.6% [-0.1% to 1.3%])實際異體輸血量在兩組間是相似的,MD (95% CI) –7 (-326 312)。並且顯著低於相應的預計失血量。(MD [95% CI], IVH 組,-581 mL [-753 -409 mL]; HVH 組,-376 mL [-531 to -221]) 兩種技術在用時(MD [95% CI] = 7 min [-0.5 to 14.5 min]),費用MD [95% CI] = $1.7 (-$4.10 $7.50))及所用多聚明膠的量(MD [95% CI] = -6 mL/kg 體重 [-16 to 4 mL/kg 體重])上是相似的。本研究發現IVH HVH 在顯著減少圍術期異體血用量,用時,費用方面具有可比性,而達到所需HVH 的方法似乎是有前途的。

(   莊心良 )

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.

 

聽覺穩態反應不是一個合適的麻醉監測方法

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.

 

 既往研究顯示人的40-Hz 聽覺穩態反應(ASSR)在麻醉誘導時消失,提示其可能是一種較好的麻醉監護方法。本研究的目的是瞭解是否所有的正常清醒成人的ASSR 具有足夠的信噪比。在35  70 Hz頻率間發出一系列的卡噠音並把在頭頂記錄的腦電圖進行傅裏葉(Fourier)轉換。在所發出卡噠音頻率的腦電圖頻譜上可觀察到ASSRs以尖峰形式出現。最初的結果顯示在研究所使用的任何卡噠音頻率由一半的研究物件不能獲得可辨認的ASSR 。進一步的研究顯示那些清醒狀態下得不到ASSR 的研究物件卻在進入昏睡狀態時出現了科觀察到的ASSR 。這是由於在昏睡狀態時信號強度增加的緣故,而不是噪音降低。結論是:由於研究物件存在明顯的比例 不能在清醒時容易地顯示可記錄的ASSR ,因此使用ASSR 消失作為麻醉是否足夠的常規實驗是不現實的。

(張 軍譯  莊心良 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.

腎上腺素對羅呱卡因硬膜外應用時早期全身吸收的影響

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

 

由於腎上腺素有收縮血管的特性,至今仍未被推薦和羅呱卡因聯合使用,然而,有一些藥物動力學方面的資料顯示人體硬膜外給羅呱卡因加用腎上腺素是可行的。在這個前瞻、雙盲的研究中,把行擇期腹部子宮切除術的患者隨機分為硬膜外注射羅呱卡因組(1.5mg/kg,稀釋至15ml)和羅呱卡因複合腎上腺素(5µg/mL)組(n=12)。在180分鐘內間隔測定動靜脈血漿中羅呱卡因的濃度。結果顯示,在給藥後60分鐘內,腎上腺素組的動靜脈內羅呱卡因的血漿濃度要比對空白組小(P<0.01)。腎上腺素組羅呱卡因最大血漿濃度的平均值(動脈 0.92± 0.32 µg/mL,靜脈 0.82 ± 0.33 µg/mL)小於空白組(動脈 1.31 ± 0.39 µg/mL 靜脈 1.31 ± 0.50 µg/mL)(P=0.01)。達到最大血漿濃度的時間沒有顯著的差異(腎上腺素組:動脈 16 ± 2 min,靜脈 23 ± 2 min;空白組:動脈  9 ± 2 min ,靜脈 12 ± 3 min )(P=0.08)。在1小時內動脈血羅呱卡因的濃度高於靜脈血(P<0.01);動靜脈血濃度的差值呈指數級下降,其下降的速率和程度不受腎上腺素的影響。結論:在羅呱卡因中加用腎上腺素5 µg/mL減少了硬膜外注射後早期羅呱卡因的血漿濃度,有助於減少硬膜外給羅呱卡因全身吸收而致的毒性。

(朱     莊心良校)

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試驗評估寰枕關節伸展度的可靠性

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等人描述的評估寰枕關節伸展度的可靠性。方法:20位頸椎正常的成人志願者,取坐位,頭保持正中。然後最大程度地伸展頭部,同時盡可能少的移動頸部。用量角器測量正中位到最大伸展位的角度。在相應的位置拍攝側位的頸椎X,包括寰枕關節伸展角。結果:用X線測得的寰枕關節伸展的角度和用Bellhouse試驗測得的頭部伸展的角度中位數分別為21.5°和30°。由於頸部表面輪廓的關係,有9.5°在軸下區域不能被檢測到。軸下區域的範圍幾乎和Bellhouse試驗過高估計寰枕關節伸展的角度一致。由於軸下區域不依賴於寰枕關節伸展的角度,用量角器測得的角度與X線測得的寰枕關節角度間就沒有明顯的相關了(P<0.01, r2 = 0.44)。結論:這些發現意味著Bellhouse試驗不總是正確地評估寰枕關節伸展度,如果軸下區域是正常存在的,那麼也未能找到寰枕關節的復位術。因此,由Bellhouse試驗所發現的問題使困難氣管插管的評估變得更難,因為寰枕關節伸展的減少是導致插管困難的一個重要因素。

(朱    莊心良 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.

 

利多卡因冠脈搭橋手術術後早期充血性心力衰竭的影響

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:研究利多卡因對心臟手術術後早期充血性心衰發生率的影響。方法:作者研究了108名行擇期冠脈搭橋手術患者,術中採用體外迴圈。此108名患者隨機給予利多卡因(術中單次1.5mg/kg,維持4mg/min。體外迴圈預充液注入4mg/kg)或安慰劑。患者術前和術後9天使用9項神經生理測試電池。術後其中任何測試值低於術前所有患者測試的平均值示為功能降低。如患者兩項或兩項以上的測定值降低示為發生術後充血性心力衰竭。88名患者完成術前和術後神經生理測試。轉機前10分鐘、轉機後10分鐘、30分鐘、60分鐘和術畢利多卡因的血漿濃度分別為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。利多卡因組的患者術後充血性心力衰竭發生率明顯低於安慰劑組(18.6%40.0P=0.0028)結論:術中給予患者利多卡因能降低術後早期充血性心力衰竭的發生。

(趙雪蓮     莊心良  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.

                          

評估術中治療和診斷干預

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:作者希望建立一種可以反映術中的資源利用情況的量化標準。方法:評估一個有成本-意識醫療保健制度要求詳細地評估各項行為,包括評估術中患者得到的關注。因為對術中護理做法程度沒有量化的記分規則,所以作者提出一種術中治療強度記分法(I-TIS)。把生理或生化檢查和治療干預所和或護理強度,在其基礎上被賦予1-4分。對目前的患者進行評分,其結果與ASA分級和手術複雜度對比。此體系含78項評分標準,實驗分兩組進行。第一組(n=307)患者是術後短時間在麻醉後恢復室停留的,其I-TIS7.3±5.0;第二組(n=443)患者術後進普外、心外和神經外科復蘇室或長時間在麻醉後恢復室停留的,其I-TIS值為25.2±12.4(與第一組對比P0.001〉。I-TIS與手術複雜度分級的相關係數是r=0.77,ASA基本相對值相關係數是r=0.75,與ASA生理狀態分級的相關係數是r=0.49。結論:此評分與手術複雜度有很好的相關性而且可反映不同的手術的不同護理需求。

                                           (趙雪蓮      莊心良  )

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.

    

離體雷米芬太尼代謝:全血和血漿假性膽鹼酯酶對其影響

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:作者以此離體實驗研究假性膽鹼酯酶缺乏病人應用雷米芬太尼時,其半衰期是否發生改變。方法:試管分別含克雷布斯緩衝液、全血、血漿或由正常和假性膽鹼酯酶缺乏患者分離的紅細胞,將它們與雷米芬太尼共同孵育。用氣相色譜分析法測定雷米芬太尼的濃度,其半衰期均數採用非線性回歸分析法。結果:正常和假性膽鹼酯酶缺乏的志願者的全血、紅細胞或血漿,藥物的半衰期沒有差異。正常和假性膽鹼酯酶缺乏的志願者的全血和血漿中的雷米芬太尼半衰期都明顯長於紅細胞的。結論:由此推斷雷米芬太尼在假性膽鹼酯酶缺乏患者體內的藥物代謝動力學不發生改變。

(趙雪蓮      莊心良  )

 

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.

麻黃堿減少丙泊酚注射時的疼痛

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級,接受擇期手術的病人被隨機分為六組以研究不同劑量的麻黃堿和利多卡因相比對於減少丙泊酚注射疼痛的效果。P組病人(n=30)使用生理鹽水作為對照;L組病人(n=30)使用2%利多卡因40mgE30組(n=28)使用30μg/kg麻黃堿;E70組(n=30)使用70μg/kg麻黃堿;E110組(n=30)使用110μg/kg麻黃堿;E150組(n=28)使用150μg/kg麻黃堿。各組分別在注射丙泊酚2.5mg/kg後注射。由一位不知情的麻醉醫生詢問病人的疼痛評分(口頭評分和表情疼痛評分)。利多卡因組和麻黃堿組的疼痛發生率和疼痛強度均小於對照組(P<0.01)。在氣管插管前,P組和L組動脈血壓均下降,E110組和E150組在插管後血流動力學均加強(P<0.05)。我們的結論是,預先注射小劑量的麻黃堿(3070μg/kg)可以減少注射丙泊酚導致的疼痛的發生率和嚴重程度,而且動脈血壓下降程度比單純採用利多卡因預處理時注射丙泊酚的下降程度輕。

(顏      莊心良  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.

 

突然阻斷腔靜脈血流的血流動力學和激素反應:通過肝大部切除手術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)包括肝門三支阻斷和下腔靜脈阻斷。儘管肝血管排空已經在上兩個世紀中用於肝大部切除手術,人們對該方法為什麼會取得滿意的血流動力學耐受性的機理所知甚少。所以我們對HVE的血流動力學和激素反應進行了研究。對22位元沒有肝硬化發生繼發性肝臟腫瘤的病人進行了前瞻性研究。採用經食管超聲心動圖記錄這些的心率、動脈血壓、肺動脈壓、混合靜脈血氧飽和度、心輸出量和左室尺度。在鉗閉前、鉗閉後51530分鐘後和開放鉗閉後15分鐘測血中精氨酸加壓素(AVP)、腎上腺素、去甲腎上腺素、多巴胺、心房利尿肽濃度和血漿腎素活性。血流動力學變化的特徵是左室尺度、面積分數(fractional area change)變化和肺動脈壓明顯下降(P<0.05)。我們還觀察到心輸出量顯著下降(50%)和心率及體循環血管阻力的增加。在鉗閉開放後,由體循環血管阻力比鉗閉前明顯下降可知外周血管擴張。我們還注意到,精氨酸加壓素和去甲腎上腺素濃度發生急性的和持續性的增高直至鉗閉開放,但是血漿腎素濃度沒有變化。HVE特徵性的回心血量顯著減少通過啟動精氨酸加壓素和交感神經系統使血管阻力增加得到代償。血漿腎素系統在維持HVE期間動脈血壓中不起重要作用。

(顏     莊心良  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.

長時間神經外科手術期間七氟醚比安氟醚提供更快的恢復和術後神經估價

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)提供更快的恢復。隨著吸入時間延長這個優點更突出。而且SEVO還有好幾個適合於神經外科麻醉的特點。我們設計一個前瞻性的、隨機的、雙盲的試驗來比較七氟醚(SEVO)和安氟醚用於神經外科手術中的恢復特徵。60個顱內手術病人,隨機分為兩組:SEVOISO,吸入氧40%,調節MAC0.5-1之間,維持平均動脈血壓降低在術前的20%以內。手術結束,拮抗肌松藥的作用,停止吸入,新鮮氣體流量調至10 L/min 。記錄恢復時間從關吸入麻醉藥開始,在兩組吸入麻醉藥時間都是4.7hSEVO組病人恢復明顯較快(P = 0.02),對握手(P = 0.03)、動腳(P = 0.01)指令反應恢復時間明顯短。Glasgow 評分>=10SEVO組比ISO組快 5 min(P = 0.04)。在神經外科病人獲得早期神經功能檢查很重要,因此使用SEVOISO恢復快有一定臨床意義。

(嵇富海 薛張剛 )

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.

 

隨機雙盲比較開胸後硬膜外用羅呱卡因、羅呱卡因/芬太尼、布比卡因/芬太尼鎮痛

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

開胸後硬膜外羅呱卡因鎮痛還沒有和布比卡因比較過。80個肺手術病人術後硬膜外鎮痛採用隨機、雙盲方法分成三組:持續輸注0.1 mL · kg-1 · h-10.2% 羅呱卡因、0.15%羅呱卡因/芬太尼5 µg/mL, 0.1% 布比卡因/芬太尼5 µg/mL。我們測定48小時的疼痛評分(休息和呼吸),靜脈嗎啡消耗量,呼吸量,握手力,PaCO2 ,心率,血壓,呼吸頻率,副作用(鎮靜、噁心、嘔吐、搔癢)。開胸後2天內硬膜外羅呱卡因/芬太尼和布比卡因/芬太尼鎮痛一樣有效。單純用0.2% 羅呱卡因鎮痛在呼吸時效果不好,靜脈嗎啡消耗量大,副作用多。嗎啡消耗量在羅呱卡因/芬太尼和布比卡因/芬太尼無差別。病人在羅呱卡因組比加芬太尼更痛呼吸時加重。在運動阻滯方面沒有不同。我們得出開胸後羅呱卡因/芬太尼硬膜外鎮痛並不比布比卡因/芬太尼更好。

(嵇富海 薛張剛 )

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.

 

小兒骶麻:睾丸固定術阻滯精索牽拉反應中布比卡因的容量和濃度的比較

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

  在這一研究中,我們對一定劑量的布比卡因兩種不同容量和不同濃度應用時骶麻的強度和水平的差異。50個小兒病人, 16 ,在誘導後應用2 mg/kg固定劑量布比卡因骶麻後行單側睾丸固定術。 1 (n = 23) 使用0.8 mL/kg0.25% 的布比卡因, 而組2 (n = 27)使用 1.0 mL/kg0.2% 布比卡因。 10ml局麻藥物中加用1:400,000的腎上腺素和0.1 mL的碳酸氫鈉。在兩組病人麻醉,手術,恢復,出院時間上都沒有顯著差異。1組中 15(65.2%)需要增加氟烷的吸入濃度已阻滯精索牽拉時的血流動力學和/或呼吸反應,而組2 中只有 8 (29.6%) (P = 0.022)。在恢復室中,組1中有4(17.4%)需要芬太尼治療,而組2只有2(7.4%) (P = 0.372)。在睾丸固定術小兒,用較大容量的稀釋的布比卡因骶麻與標準的較少容量的0.25%溶液相比,在阻斷精索牽拉時的腹膜反應上更加有效,而對術後的鎮痛質量沒有影響。

(張俊峰 薛張剛 )

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可預防成人中耳整複術後的噁心和嘔吐

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.

 

我們假定5-羥色胺-1A受體激動劑――tandospirone可減少術後噁心嘔吐(PONV)的發生。30例病人採用雙盲法隨機分為3組:1)安慰劑組(P組),2tandospirone 10 mg (T10)3) tandospirone 30 mg (T30),每組病人均在進入手術室前90分鐘分別口服各組藥物並同時口服famotidine 20 mg。每組病人均採用同樣的麻醉方法。 分別在全麻結束後03 h 324 h兩個時間間隔記錄所有噁心嘔吐情況,T30組完全有效(指無噁心嘔吐發生並且無需補充應用止吐藥)的發生率在024hP = 0.019),尤其在324 h (P = 0.007) 期間與P組相比有顯著性差異。因此,術前口服tandospirone可有效預防全麻下行中耳整複術後的PONV

(張俊峰 薛張剛 )

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: 03 h and 324 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 024 h (P = 0.019), especially during 324 h (P = 0.007) after general anesthesia. In conclusion, premedication with oral tandospirone is effective against PONV in patients undergoing tympanoplasty under general anesthesia.

 

一種住院醫師局部麻醉培訓的新模式

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

麻醉住院醫師局部麻醉培訓的充足性問題是全國性問題。1996Duke大學健康系統(Anesthesiology Residenc)制定了麻醉住院醫師培訓系統旨在提高住院醫師局部麻醉培訓質量。該培訓模式的主要特點在於使用CA-3住院醫師在圍術期訓練局部麻醉技術。為評價新模式的有效性,我們比較了分別由Anesthesiology Residency和麻醉住院醫師培訓回顧協會(Residency Review Committee)提供的在July 1992–June 1995 (pre-model)July 1998–June 2001 (post-model)培訓期間的數據。在3年培訓期間,re-model CA-3 住院醫師組 (n = 12)累積操作80 (58–105)外周神經阻滯(PNBs), 66 (59–74) 腰麻和133 (127–142) 硬膜外麻醉,CA-3 post-model 住院醫師組(n = 10)則累積操作 350 (237–408) PNBs, 107 (92–123) 腰麻和233 (221–241)硬膜外麻醉 (P < 0.0001),所有資料均採用中位數(四分位數間距)表示。由此我們推論採用我們的把CA-3住院醫師在圍術期作為阻滯住院醫師的新培訓模式可以增加他們接觸臨床PNBs的機會。

(張俊峰 薛張剛 )

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 1992June 1995 (pre-model) and the training period July 1998June 2001 (post-model). During the 3-yr training period, the pre-model CA-3 residents (n = 12) performed a cumulative total of 80 (58105) peripheral nerve blocks (PNBs), 66 (5974) spinal anesthetics, and 133 (127142) epidural anesthetics. The CA-3 post-model residents (n = 10) performed 350 (237408) PNBs, 107 (92123) spinal anesthetics, and 233 (221241) 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靜脈局部麻醉

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

在中樞和外周神經阻滯中局麻藥合用新斯的明可增強麻醉效果、延長麻醉時間並改善鎮痛效果。該研究的目的在於評價丙胺卡因靜脈局麻(IVRA)中合用新斯的明的效果。30例採用IVRA擬行手部手術的患者隨機分為兩組,控制組採用1 mL 生理鹽水加3 mg/kg of丙胺卡因然後稀釋到40 mL,研究組則採用 0.5 mg新斯的明加3 mg/kg 丙胺卡因然後稀釋到40 mL。感覺和運動組織起始和恢復時間、麻醉質量由麻醉醫師確定,麻醉質量也有外科醫師確定並同時記錄術野乾燥情況,分別在手術開始前和止血帶釋放後1, 5, 10, 20, and 40 min記錄心率、平均動脈壓及氧飽和度值和第一次需用鎮痛藥的時間。結果在新斯的明組中感覺和運動阻滯起始時間縮短,感覺和運動恢復時間延長,麻醉質量改善,首次需用鎮痛藥的時間也延長。因此,我們認為新斯的明是改善靜脈丙胺卡因麻醉質量的有效的輔助藥並且在IVRA中是有益的。

(張俊峰 薛張剛 )

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.

 

心電圖導聯的選擇是否影響其用於檢測試驗劑量中腎上腺素血管內注射的T波標準的功效

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

含有腎上腺素的試驗劑量意外血管內注射會降低心電圖 (EKG) II導聯的T-wave振幅,在以T波振幅降低>=25%為陽性的T-wave 標準的定義基礎上,心電圖具有100%的敏感性和特異性。該研究的目的在於驗證在麻醉病人中模擬注射試驗劑量時心電圖導聯的選擇是否會影響其檢測功效。8小時禁食並且不用術前用藥,35例健康患者氣管插管後採用呼氣末 2% 的七氟醚和笑氣麻醉維持,當血流動力學穩定後,所有患者先靜注3 mL生理鹽水,4分鐘後靜注1.5%利多卡因 3 mL15 µg腎上腺素(1:200,000),心率、收縮壓, II導聯 (n = 35) V5導聯(n = 35 I導聯 (n = 17) III導聯(這些導聯都有明顯的T波)分別在生理鹽水和試驗劑量靜注後持續監測4分鐘,在所有病人中靜注試驗劑量後心率和收縮壓明顯增加,所有導聯的T波振幅都降低,而靜注生理鹽水後這些變數無明顯變化,II導聯的T波振幅降低比例最大,I, IIIV5導聯則分別為 -87% ± 13%, -88% ± 8%, -94% ± 15%,-86% ± 16% (mean ± SD; P > 0.05)4導聯中T波的時限則無明顯差異,在T-wave標準定義的基礎上任一導聯都具有100%的敏感性和特異性,我們的結果顯示心電圖II, I, III,V5 導聯在檢測成人七氟醚麻醉中含有腎上腺素的試驗劑量血管內注射時具有同樣的功效。

(潘志浩 薛張剛 )

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.

純氧合用七氟醚,異氟醚,氟烷,芬太尼/咪唑安定時對小兒先天性心臟病病人肺循環與體循環血流比影響

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

對於吸入麻醉藥對先天性心臟病小兒的影響已有研究,但對於存在心內分流的病人麻醉藥對肺循環,體循環血流比的影響還知之甚少。在這一研究中,我們在房缺和室缺病人上比較了氟烷,異氟醚,七氟醚和芬太尼/咪唑安定對Qp:Qs和心肌收縮力的影響。4014 歲以下的準備行ASD VSD修補的病人隨機接受氟烷,異氟醚,七氟醚和芬太尼/咪唑安定。記錄心血管和心超資料的基礎值,隨機安排 1 1.5 MAC的麻醉藥或預測的等效芬太尼/咪唑安定水平應用的順序。計算射血分數 (用改良Simpson定律)。體循環 (Qs) 和肺循環(Qp)血流用心超流速-時間法進行評價。 在任何一種方案和任何濃度下Qp:Qs都沒有受影響。左室收縮功能在1.5 MAC的異氟醚和七氟醚以及11.5 MAC的氟烷應用時受輕度抑制。氟烷,異氟醚,七氟醚和芬太尼/咪唑安定在 1 1.5 MAC濃度或他們的等效濃度都沒有影響單純ASD VSD病人的 Qp:Qs

(潘志浩 薛張剛 )

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.


在體研究中異氟醚沒有產生保護心梗的預處理的第二窗

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

長期缺血發生前即刻吸入全麻藥具有與缺血預處理相似的保護心梗作用。保護心梗的預處理第二窗(SWOP)亦見於阻斷冠脈24h引起的短暫缺血。至於遙控吸入揮發性全麻藥是否具有延遲的心肌保護則尚不清楚。預處理的第二窗(SWOP)在缺血發生在延長的冠脈堵塞前24小時的情況下可以出現。是否長時間間隔前吸入麻醉藥的應用也會產生心肌保護作用還不清楚。我們對在缺血前24小時應用異氟醚會產生SWOP的假說進行了驗證。巴比妥麻醉犬 (n = 25)進行血流動力學測定,其中包括主動脈和左室壓力以及 LV +dP/dtmax, 這些試驗犬進行60分鐘的左前降枝冠脈阻塞,然後進行3小時的再灌注。心梗面積和冠脈側枝血流分別用 triphenyltetrazolium chloride染色和放射行微球進行評價。兩組犬分別在缺血,再灌注前30分鐘(急性)或24小時(慢性)吸入1.0MAC的異氟醚30分鐘或6小時。對照組不吸入異氟醚。在沒有用異氟醚預處理的心梗面積是高危左室面積的27% ± 3% 。急性應用,而非長時間間隔應用的異氟醚降低了心梗面積(分別為12% ± 1%31% ± 3%)。兩組在阻塞前後血流動力學或跨壁心肌灌注方面都沒有觀察到有差異。結果顯示體內研究中,在延長心肌缺血前24小時應用異氟醚沒有產生SWOP

(潘志浩 薛張剛 )

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.

 

新發現的卵圓孔未閉對不停跳冠脈搭橋病人的影響:11例報導

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

  麻醉師應用食道超聲的增加會導致術中發現先前為診斷的卵圓孔未閉的病人的增加。不停跳冠脈搭橋病人心臟操作對於通過未閉卵圓孔的房內反流的影響還沒有被研究。我們回顧了OPCABG11例操作卵圓孔未閉的病人。在基礎狀態,心臟抬高行遠端冠脈吻合時以及手術結束時行TEE 造影試驗和血氣分析測定。在基礎狀態,11例病人中5例操作左向右分流,2例存在右向左分流。心臟抬高沒有導致任何病人出現去氧飽和;然而,它導致了一例病人右向左分流的消失,一例病人分流持續以及兩例新的右向左分流的出現。心臟恢復到它的原始位置後TEE的表現都恢復到基礎狀態。這一序列的病人上的發現顯示OPCABG可以在大部分卵圓孔未閉的病人上安全進行; 然而, 還需要進一步研究來證實在存在卵圓孔未閉的行OPCABG 的一些特定的病人上有害效應也不會產生。

(潘志浩譯 薛張剛校)

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對防止安定注射疼痛的比較

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

我們比較了靜注利多卡因和甲氧氯普胺預處理對於防止安定注射痛的能力。在一項前瞻性、隨機、雙盲、安慰劑對照的臨床試驗中,159位元患者(ASA生理狀態Ⅰ-Ⅱ級),年齡20-70歲,分為三組。在手背靜脈注射安慰劑和研究藥物後,隨即注入0.1mg/Kg安定。組1、組2、組3的患者分別注射安慰劑2ml1%利多卡因2ml、甲氧氯普胺2ml10mg)。患者的反應以4分尺度來衡量。除了0分外的任一分值均判定為注射痛。我們發現在安慰劑組安定注射痛的發生率為83%,用甲氧氯普胺和利多卡因預處理後發生率分別降至70%39%。儘管當安定注射時,在疼痛的發生率上,組1和組3無明顯差異(P>0.05),但是組3的疼痛評分高的患者較之組1顯著減少(P<0.000)。當注射安定時,組2疼痛的發生率較生理鹽水組(P<0.000)和甲氧氯普胺組(P<0.002)顯著降低。組2的疼痛強度顯著低於組3P=0.012)。安定注射痛的強度在安慰劑組顯著高於其他組(P<0.000)。甲氧氯普胺,而不是利多卡因預處理,對於注射疼痛可能是一種理想的止痛選擇。

( 薛張剛 )

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 2070 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 patients 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.

 

異丙酚持續輸注時腦脊液濃度的變化

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位行擇期顱內手術的患者,以異丙酚持續靶控輸注麻醉,研究其腦脊液(CSF)內異丙酚濃度的變化。麻醉期間,芬太尼和cisatracurium按需給予。氣管插管後,以空氧混和氣體(FiO20.33)給患者通氣至血二氧化碳分壓正常。在麻醉誘導後90180分鐘期間,收集動脈血和腦脊液(由腦室內引流獲取)樣本。血異丙酚濃度穩定於5.0±1.894.5±1.7µg/mL(均數±標準差)之間。腦脊液的異丙酚濃度從90分鐘的52.2 ± 35.01 ng/mL降至150分鐘的28.6 ± 21.9 ng/mL,下降有顯著性差異(P<0.05)。在180分鐘時,CSF的異丙酚濃度(21.4 ± 14.0 ng/mL)150分鐘時的濃度無顯著性差異。本文討論了開始持續腦室內引流後,CSF內濃度下降的可能原因。

結論:異丙酚在神經外科患者腦脊液中出現。在被研究的患者中,開始腦室內引流後,儘管擁有相對穩定的血異丙酚濃度,但其腦脊液濃度顯著下降。這些結果擴充了有關異丙酚在人類中樞神經系統內的藥物代謝動力學資訊。

( 薛張剛 )

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 90180 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.

 

利多卡因對谷氨酸轉運體EAAT3活性的影響: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

應用雙極電壓鉗,我們研究了利多卡因對一種谷氨酸轉運體(EAAT3)的影響,以及蛋白激酶CPKC)和磷脂酰肌醇3激酶(PI3K)在介導利多卡因效應中的作用。EAAT3表達於爪蟾屬卵母細胞,應用左旋谷氨酸(30µM)後記錄膜電流。利多卡因只在兩種濃度(100 µM and 1 mM)下增加谷氨酸誘導的內向電流。與對照相比,利多卡因(100 µM)顯著增加谷氨酸和EAAT3結合的Vmax ,而非Km 。利多卡因對EAAT3的作用點似乎在細胞內,因為只有細胞內注射QX314(持久帶電的利多卡因擬似物)能增加反應。phorbol-12-myrisate-13-acetate(一種PKC激動劑)與利多卡因的聯合應用,與他們各自應用相比,並不能進一步增強反應,儘管這三組中的任一組與對照相比均顯示了更強的反應。三種PKC抑制劑(staurosporine, calphostin C, and chelerythrine)不影響EAAT3的基礎活性,但是消除了利多卡因增強的EAAT3活性。Wortmannin(一種特異的PI3K抑制劑)抑制了EAAT3的基礎活性和利多卡因增強的EAAT3活性。我們的結果顯示,利多卡因在特定的濃度下增強了EAAT3的活性,PKCPI3K可能介導了利多卡因的這些效應

( 薛張剛 )

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.

 

門脈高壓患兒行診斷性腹腔鏡檢查時動脈二氧化碳分壓顯著增高

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

腹腔鏡操作中幾個因素可導致高碳酸血症。我們進行本研究,是因為我們觀察到在門脈高壓(PHT)的患兒行腹腔鏡時PaCO2有驟然的增高,而這在正常小兒並不常見。57位小兒在全麻機械通氣下行腹腔鏡操作。插管後5分鐘(T0),二氧化碳氣腹後1530分鐘(T15 and T30),放氣後5分鐘(Tend),拔管後10分鐘(Text)分別收集動脈血標本行血氣分析。兩組研究期間PaCO2, pH, ETCO2的改變均有統計學意義(P<0.05)。在對照組和PHT組,T0 T15PaCO2上升的百分比分別為11.5% and 20.1%P<0.05)。在PHT組到T30時這一上升值達36.8%,而在對照組為17.2%P<0.05)。ETCO2呈現出相似的改變。各組堿剩餘,重碳酸鹽,PaO2,動脈氧飽和度,SpO2的變化均無顯著性(P>0.05)。PHT的患兒行腹腔鏡檢查時PaCO2顯著上升,肝內或肝外來源並無差異。對於這種病例,減少CO2氣腹時間和氣腹壓力,並調整通氣參數以適應高碳酸血症是至關重要的。

( 薛張剛 )

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,腦雙頻譜指數和經典腦電圖在靜脈注射異丙酚聯合瑞芬太尼麻醉蘇醒時的變化

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 是為研究現代和經典腦電圖在靜脈注射異丙酚-芬太尼中的變化。我們假設現代腦電圖改變能夠提示異丙酚的影響而不能揭示瑞芬太尼的作用。方法 研究物件是25位元elective spine 手術結束後沒有手術刺激的患者。瑞芬太尼的基礎量是0.3 µg · kg-1 · min-1,靶控輸注異丙酚3.0 µg/mL。在停用瑞芬太尼後13579分鐘監測腦電圖指標的變化,同時逐步減少靶控輸注異丙酚量(每3分鐘減少0.2 µg/mL)。每個時間點都記錄Narcotrend (NT; classifying EEG stages from awake to deep anesthesia),腦雙頻譜指數, EEG spectral frequency bands (%), 50% (Median) and 95% percentiles (spectral edge frequency),平均動脈壓,心電圖和血氧飽和度。結果 停用瑞芬太尼顯著增加了腦電圖中α波的百分比,spectral edge frequency,平均動脈壓和θ波的百分比,減少了δ波的百分比 (P < 0.05)。而NT, BIS, Median,心率和血氧飽和度沒有改變。降低異丙酚的濃度使NT, BIS上升並具有顯著的統計學意義(P < 0.05)結論 現代腦電圖指標能夠估計作為鎮靜-催眠的異丙酚的作用,但對作為鎮痛作用的瑞芬太尼卻沒有監測作用。因此無論有無手術刺激,如果仍靜脈輸注瑞芬太尼,NTBIS對麻醉深度均不能提供足夠良好的評估。

( 薛張剛 )

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

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Rofecoxib 應用於耳鼻喉科手術的鎮痛作用

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 評價 rofecoxib應用於耳鼻喉手術患者鎮痛和opioid-sparing作用。方法 進行鼻中隔或鼻竇手術的患者術前1小時隨機給予口服安慰劑或rofecoxib 50 mg。所有患者術中均給予異丙酚0.8 mg/kg, 芬太尼 1 µg/kg並在手術部位進行局部麻醉。持續靜脈輸注異丙酚維持患者鎮靜狀態在23級水平(Ramsey scale)。如果病人要求或verbal rating scale評分大於4,額外給予芬太尼0.51 µg/kg。術中515304560分鐘以及術後30分鐘,2461224小時對病人鎮靜和疼痛程度進行評分。術後如果病人要求或visual analog scale (VAS)痛覺評分大於4給予肌注diclofenac 75 mg鎮痛。結果 rofecoxib VAS痛覺評分,術中芬太尼用量和術後diclofenac需要量均顯著少於空白對照組(P < 0.001),而且首次鎮痛後再要求鎮痛的次數也明顯少於對照組。結論 術前應用rofecoxib——一種新型的環氧化酶-2抑制劑,對鼻中隔和鼻竇手術的病人能夠提供顯著的鎮痛作用並能減少阿片類藥物的應用。

( 薛張剛 )

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 23 level on the Ramsey scale. Additional fentanyl 0.51 µg/kg was administered at the patients 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 patients 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.