Anesthesia & Analgesia

December 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

围术期经食道超声心动图新考查方法应用的前景分析

(赵延华 王祥瑞 )

Development and Analysis of a New Certifying Examination in Perioperative Transesophageal Echocardiography

Solomon Aronson, Aggie Butler, Raja Subhiyah, Richard E. Buckingham, Jr, Michael K. Cahalan, Steven Konstandt, Jonathan Mark, James Ramsay, Robert Savage, Joseph Savino, Jack S. Shanewise, John Smith, and Daniel Thys

Anesth Analg 2002 95: 1476-1482.  

住院病人冠状动脉搭桥术后心率和死亡率间的关系

(唐   庄心良 校)

The Association Between Heart Rate and In-Hospital Mortality After Coronary Artery Bypass Graft Surgery

Mary P. Fillinger, Stephen D. Surgenor, Gregg S. Hartman, Cantwell Clark, Thomas M. Dodds, Athos J. Rassias, William C. Paganelli, Peter Marshall, David Johnson, Dennis Kelly, Dean Galatis, Elaine M. Olmstead, Cathy S. Ross, and Gerald T. O’Connor

Anesth Analg 2002 95: 1483-1488.

体外循环后48小时内高热

( 薛张纲 校)

Hyperthermia in the Forty-Eight Hours After Cardiopulmonary Bypass

Weng Y. Thong, Andrew G. Strickler, Shu Li, Elester E. Stewart, Connie L. Collier, William K. Vaughn, and Nancy A. Nussmeier

Anesth Analg 2002 95: 1489-1495.

ACD+ITV复苏法可改善猪的低温心脏停跳模型中血管收缩反应

(赵延华 王祥瑞 )

Vasopressor Response in a Porcine Model of Hypothermic Cardiac Arrest Is Improved with Active Compression-Decompression Cardiopulmonary Resuscitation Using the Inspiratory Impedance Threshold Valve

Claus Raedler, Wolfgang G. Voelckel, Volker Wenzel, Ludger Bahlmann, Wolfgang Baumeier, Christian A. Schmittinger, Holger Herff, Anette C. Krismer, Karl H. Lindner, and Keith G. Lurie

Anesth Analg 2002 95: 1496-1502.  

实验检测家兔肝素活性变化:抗Xa活性与血栓弹性图、活化部分凝血活酶时间、激活凝血时间的比较

(唐   庄心良 校)

The Detection of Changes in Heparin Activity in the Rabbit: A Comparison of Anti-Xa Activity, Thrombelastography®, Activated Partial Thromboplastin Time, and Activated Coagulation Time

Vance G. Nielsen

Anesth Analg 2002 95: 1503-1506.

有严重左室收缩功能障碍的患者行冠脉搭桥术预后与术前右室功能有关

( 薛张纲 校)

Precardiopulmonary Bypass Right Ventricular Function Is Associated with Poor Outcome After Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Systolic Dysfunction

Andrew D. Maslow, Meredith M. Regan, Peter Panzica, Stephanie Heindel, John Mashikian, and Mark E. Comunale

Anesth Analg 2002 95: 1507-1518.

中心静脉径路:患者体位、偏侧、头转向对颈内静脉横切面积的影响

(朱慧琛   王祥瑞 )

Central Venous Access: The Effects of Approach, Position, and Head Rotation on Internal Jugular Vein Cross-Sectional Area

Thomas Suarez, Jeffrey P. Baerwald, and Chadd Kraus

Anesth Analg 2002 95: 1519-1524.  

心脏保护措施对腹主动脉手术后心脏并发症发生率的影响

(嵇富海 薛张纲 校)

The Impact of a Cardioprotective Protocol on the Incidence of Cardiac Complications After Aortic Abdominal Surgery

Marc Licker, Gregory Khatchatourian, Alexandre Schweizer, Marek Bednarkiewicz, Didier Tassaux, and Catherine Chevalley

Anesth Analg 2002 95: 1525-1533.

全国邮政调查对成年心脏手术患者神经肌肉阻滞药使用情况报告

(朱慧琛   王祥瑞 )

The Use of Neuromuscular Blocking Drugs in Adult Cardiac Surgery: Results of a National Postal Survey

Glenn S. Murphy, Joseph W. Szokol, Jeffery S. Vender, Jesse H. Marymont, and Michael J. Avram

Anesth Analg 2002 95: 1534-1539.

麻醉药预处理减轻豚鼠离体完整心脏缺血时的线粒体钙超载

(   庄心良 校)

Anesthetic Preconditioning Attenuates Mitochondrial Ca2+ Overload During Ischemia in Guinea Pig Intact Hearts: Reversal by 5-Hydroxydecanoic Acid

Matthias L. Riess, Amadou K. S. Camara, Enis Novalija, Qun Chen, Samhita S. Rhodes, and David F. Stowe

Anesth Analg 2002 95: 1540-1546.

在绵羊输注速率及输入容量对0.9%生理盐水和7.5%盐水/6.0%右旋糖酐动力学的影响

 (   王祥瑞 )

Influence of Rate and Volume of Infusion on the Kinetics of 0.9% Saline and 7.5% Saline/6.0% Dextran 70 in Sheep

Lance P. Brauer, Christer H. Svensén, Robert G. Hahn, Sadik Kilicturgay, George C. Kramer, and Donald S. Prough

Anesth Analg 2002 95: 1547-1556.  

小剂量氧化氮增进单肺通气时的氧合:实验研究

(唐   庄心良 校)

Small-Dose Nitric Oxide Improves Oxygenation During One-Lung Ventilation: An Experimental Study

Jochen Sticher, Stefan Scholz, Olav Böning, Ralph Theo Schermuly, Claudia Schumacher, Dieter Walmrath, and Gunter Hempelmann

Anesth Analg 2002 95: 1557-1562.

术前临床评估的变化对减少心脏科会诊次数和提高心脏科会诊质量的影响

( 懿译 薛张纲 校)

The Effect of Alterations in a Preoperative Assessment Clinic on Reducing the Number and Improving the Yield of Cardiology Consultations

Lawrence C. Tsen, Scott Segal, Margaret Pothier, L. Howard Hartley, and Angela M. Bader

Anesth Analg 2002 95: 1563-1568.

PEDIATRIC ANESTHESIA:

小儿氟烷麻醉影响血压和术前禁食时间相关

(   王祥瑞 )

Duration of Preoperative Fast Correlates with Arterial Blood Pressure Response to Halothane in Infants

Robert H. Friesen, Jonathan L. Wurl, and Richard M. Friesen

Anesth Analg 2002 95: 1572-1576.  

小儿和成人在异丙酚和异氟醚麻醉下经导管射频消融术后恶心和呕吐发生率较

(杨保仲 庄心良 )

Postoperative Nausea and Vomiting in Children and Adolescents Undergoing Radiofrequency Catheter Ablation: A Randomized Comparison of Propofol- and Isoflurane-Based Anesthetics

Thomas O. Erb, Janet M. Hall, Richard J. Ing, Ronald J. Kanter, Frank H. Kern, Scott R. Schulman, and Tong J. Gan

Anesth Analg 2002 95: 1577-1581.  

双频谱指数监测:正常儿童和Quadrplegic脑瘫儿童之间对照

( 薛张纲 校)

Bispectral Index Monitoring: A Comparison Between Normal Children and Children with Quadriplegic Cerebral Palsy

Dinesh K. Choudhry and B. Randall Brenn

Anesth Analg 2002 95: 1582-1585.

氯胺酮合用利多卡因和异丙酚抑制患儿喉罩刺激的比较:双盲随机化实验研究

 ( 王祥瑞 )

A Comparison of Ketamine and Lidocaine Spray with Propofol for the Insertion of Laryngeal Mask Airway in Children: A Double-Blinded Randomized Trial

Jae-Hyon Bahk, Joohon Sung, and In-Jin Jang

Anesth Analg 2002 95: 1586-1589.  

AMBULATORY ANESTHESIA:

三种预防术后恶心和呕吐方案比较

(杨保仲 庄心良 校)

A Comparison of Three Antiemetic Combinations for the Prevention of Postoperative Nausea and Vomiting

M. J. Sanchez-Ledesma, L. López-Olaondo, F. J. Pueyo, F. Carrascosa, and A. Ortega

Anesth Analg 2002 95: 1590-1595.

门诊手术小剂量利多卡因-芬太尼蛛网膜下腔麻醉:比较预防性应用

(李懿 薛张纲 校)

Minidose Lidocaine-Fentanyl Spinal Anesthesia in Ambulatory Surgery: Prophylactic Nalbuphine Versus Nalbuphine Plus Droperidol

Bruce Ben-David, Patrick J. DeMeo, Christen Lucyk, and David Solosko

Anesth Analg 2002 95: 1596-1600.

术前使用阿普唑仑减少门诊外科患者的焦虑:和口服咪唑安定的比较

( 王祥瑞 )

Preoperative Alprazolam Reduces Anxiety in Ambulatory Surgery Patients: A Comparison with Oral Midazolam

Jan L. De Witte, Carmen Alegret, Daniel I. Sessler, and Guy Cammu

Anesth Analg 2002 95: 1601-1606.  

ANESTHETIC PHARMACOLOGY:

静脉全麻药对中国仓鼠卵母细胞重组人M1-M3毒蕈碱受体的影响

(赵雪莲    庄心良  校)

Interaction of Intravenous Anesthetics with Recombinant Human M1-M3 Muscarinic Receptors Expressed in Chinese Hamster Ovary Cells

Kazuyoshi Hirota, Yoshio Hashimoto, and David G. Lambert

Anesth Analg 2002 95: 1607-1610.

乙酰胆碱受体与三氟乙醚及12-二氯乙氟环丁烷致惊厥阈值的关系

(梁雅芬 薛张纲 校)

Acetylcholine Receptors and Thresholds for Convulsions from Flurothyl and 1,2-Dichlorohexafluorocyclobutane

Edmond I Eger, II, Diane Gong, Yilei Xing, Douglas E. Raines, and Pamela Flood

Anesth Analg 2002 95: 1611-1615.

挥发性麻醉剂摄取模型的预测精确度

(殷文渊 王祥瑞 )

Predictive Accuracy of a Model of Volatile Anesthetic Uptake

R. Ross Kennedy, Richard A. French, and Christopher Spencer

Anesth Analg 2002 95: 1616-1621.  

抑制超强有害刺激引起撤退反应的异氟醚可减少大鼠脊髓C-Fos表达而氟烷无此作用

(赵雪莲    庄心良 校)

Isoflurane, but Not Halothane, Depresses C-Fos Expression in Rat Spinal Cord at Concentrations that Suppress Reflex Movement After Supramaximal Noxious Stimulation

Steven L. Jinks, Joseph F. Antognini, John T. Martin, S.- W. Jung, Earl Carstens, and Richard Atherley

Anesth Analg 2002 95: 1622-1628.

地氟醚和七氟醚麻醉中窦状隙颈部吸引用于评价压力感受器敏感性

(梁雅芬 薛张纲 校)

Sinusoidal Neck Suction for Evaluation of Baroreflex Sensitivity During Desflurane and Sevoflurane Anesthesia

Cornelius Keyl, Annette Schneider, Jonny Hobbhahn, and Luciano Bernardi

Anesth Analg 2002 95: 1629-1636.

咪唑安定和安定对成年老鼠心室肌细胞收缩和细胞内瞬间Ca2+的不同影响

(殷文渊 王祥瑞 )

The Differential Effects of Midazolam and Diazepam on Intracellular Ca2+ Transients and Contraction in Adult Rat Ventricular Myocytes

Noriaki Kanaya, Paul A. Murray, and Derek S. Damron

Anesth Analg 2002 95: 1637-1644

.

剖胸体位的胃食管返流与气管吸入:术前应该常规应用雷尼替丁吗?

(      庄心良  校)

Gastroesophageal Reflux and Tracheal Aspiration in the Thoracotomy Position: Should Ranitidine Premedication be Routine?

Neil M. Agnew, Jonathan B. Kendall, Maria Akrofi, Jane Tran, Ajaib S. Soorae, Richard Page, Glenn N. Russell, and Stephen H. Pennefather

Anesth Analg 2002 95: 1645-1649.

离体豚鼠支气管平滑肌细胞中挥发性麻醉药和胆碱能药、速激酶和白三烯的相互作用

(梁雅芬 薛张纲 校)

Interactions of Volatile Anesthetics with Cholinergic, Tachykinin, and Leukotriene Mechanisms in Isolated Guinea Pig Bronchial Smooth Muscle

C.U. Wiklund, U. Lindsten, S. Lim, and S.G.E. Lindahl

Anesth Analg 2002 95: 1650-1655.

溴吡斯的明拮抗维库溴安和罗库溴安后的残余肌松作用

( 王祥瑞 )

Residual Paralysis Induced by Either Vecuronium or Rocuronium After Reversal with Pyridostigmine

Kyo S. Kim, Se H. Lew, Hee Y. Cho, and Mi A. Cheong

Anesth Analg 2002 95: 1656-1660.

神经甾体类麻醉药Alphaxalone抑制牛肾上腺髓质细胞去甲肾上腺素转运体的功能

(王士雷   庄心良 )

Alphaxalone, a Neurosteroid Anesthetic, Inhibits Norepinephrine Transporter Function in Cultured Bovine Adrenal Medullary Cells

Takafumi Horishita, Kouichiro Minami, Nobuyuki Yanagihara, Munehiro Shiraishi, Takashi Okamoto, Yousuke Shiga, Susumu Ueno, and Akio Shigematsu

Anesth Analg 2002 95: 1661-1666.  

TECHNOLOGY, COMPUTING, AND SIMULATION:

围手术期患者状态指数与脑双频指数的比较

(潘志浩 薛张纲 )

A Comparison of Patient State Index and Bispectral Index Values During the Perioperative Period

Xiaoguang Chen, Jun Tang, Paul F. White, Ronald H. Wender, Hong Ma, Alexander Sloninsky, and Robert Kariger

Anesth Analg 2002 95: 1669-1674.

PAIN MEDICINE:

硬膜外腔注射类固醇激素的门诊疼痛治疗病人使用非甾体抗炎药的出血并发症风险评估

(张俊峰译 薛张纲校)

Risk Assessment of Hemorrhagic Complications Associated with Nonsteroidal Antiinflammatory Medications in Ambulatory Pain Clinic Patients Undergoing Epidural Steroid Injection

Terese T. Horlocker, Zahid H. Bajwa, Zubaira Ashraf, Sajid Khan, Jack L. Wilson, Naveed Sami, Christine Peeters-Asdourian, Christopher A. Powers, Darrell R. Schroeder, Paul A. Decker, and Carol A. Warfield

Anesth Analg 2002 95: 1691-1697.

硬膜外注射吗啡和新斯的明用于骨科术后镇痛

( 王祥瑞 )

Epidural Morphine and Neostigmine for Postoperative Analgesia After Orthopedic Surgery

Maruãn Omais, Gabriela R. Lauretti, and Cleber A.J. Paccola

Anesth Analg 2002 95: 1698-1701.

 

腹式子宫切除术后活动所致的疼痛及自发性疼痛与呼气流量峰值间的关系

(   庄心良 校)

The Relationship Between Movement-Evoked Versus Spontaneous Pain and Peak Expiratory Flow After Abdominal Hysterectomy

Ian Gilron, Debbie Tod, David H. Goldstein, Joel L. Parlow, and Elizabeth Orr

Anesth Analg 2002 95: 1702-1707.

 

鞘内应用前列腺E受体亚型EP1拮抗剂对术后疼痛模型鼠机械和温度的痛觉过敏的影响研究

(张俊峰 薛张纲 校)

The Effects of Intrathecal Administration of an Antagonist for Prostaglandin E Receptor Subtype EP1 on Mechanical and Thermal Hyperalgesia in a Rat Model of Postoperative Pain

 

Keiichi Omote, Hiroki Yamamoto, Tomoyuki Kawamata, Yoshito Nakayama, and Akiyoshi Namiki

Anesth Analg 2002 95: 1708-1712.

成人腹部手术后应用吗啡和曲马多自控镇痛:一项双盲,安慰剂对照随机试验

 (忻纪华 王祥瑞 )

The Addition of a Tramadol Infusion to Morphine Patient-Controlled Analgesia After Abdominal Surgery: A Double-Blinded, Placebo-Controlled Randomized Trial

Ashley R. Webb, Samuel Leong, Paul S. Myles, and Sara J. Burn

Anesth Analg 2002 95: 1713-1718.

 

加巴喷丁在格林-巴利综合征疼痛治疗中的应用——双盲、对照的交叉研究

(朱慧   庄心良  )

Gabapentin for the Treatment of Pain in Guillain-Barré Syndrome: A Double-Blinded, Placebo-Controlled, Crossover Study

Chandra K. Pandey, Neeta Bose, Garima Garg, Namita Singh, Arvind Baronia, Anil Agarwal, Prabhat K. Singh, and Uttam Singh

Anesth Analg 2002 95: 1719-1723.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

知道在哪间手术室手术的不确定性对手术室的分配或提高其效率影响不大

(张俊峰 薛张纲 校)

Uncertainty in Knowing the Operating Rooms in Which Cases Were Performed Has Little Effect on Operating Room Allocations or Efficiency

Richard H. Epstein and Franklin Dexter

Anesth Analg 2002 95: 1726-1730.

CRITICAL CARE AND TRAUMA:

应用单纯扩张技术行经皮气管切开:Criglia Blue Rhino Griggs’ 的前瞻性和随机性比较

(忻纪华 王祥瑞 )

Percutaneous Tracheostomy with Single Dilatation Technique: A Prospective, Randomized Comparison of Ciaglia Blue Rhino Versus Griggs’ Guidewire Dilating Forceps

Sushil P. Ambesh, Chandra K. Pandey, Shashi Srivastava, Anil Agarwal, and Dinesh K. Singh

Anesth Analg 2002 95: 1739-1745.

NEUROSURGICAL ANESTHESIA:

持续过度通气对硫喷妥钠麻醉下的兔局部脑血容量的影响

(      庄心良  校)

The Effects of Sustained Hyperventilation on Regional Cerebral Blood Volume in Thiopental-Anesthetized Rats

Christophe Broux, Irène Tropres, Olivier Montigon, Cécile Julien, Michel Decorps, and Jean-François Payen

Anesth Analg 2002 95: 1746-1751. 

 

在神经外科病人上使用一种新型热交换导管的初步经验

(潘志浩 薛张纲 校)

Initial Experience with a Novel Heat-Exchanging Catheter in Neurosurgical Patients

Anthony G. Doufas, Ozan Akça, Atul Barry, David A. Petrusca, Mohammad-Irfan Suleman, Nobutada Morioka, John J. Guarnaschelli, and Daniel I. Sessler

Anesth Analg 2002 95: 1752-1756.

REGIONAL ANESTHESIA:

脊麻下行髋关节置换术中氨基酸灌注可以引起产热和减少失血

(王震虹 王祥瑞 )

Amino Acid Infusion Induces Thermogenesis and Reduces Blood Loss During Hip Arthroplasty Under Spinal Anesthesia

Jan Widman, Folke Hammarqvist, and Eva Selldén

Anesth Analg 2002 95: 1757-1762.

预防性给予奥丹西龙能减少椎管内注射芬太尼后病人瘙痒的发生率

(王士雷   庄心良 校)

Prophylactic Ondansetron Reduces the Incidence of Intrathecal Fentanyl-Induced Pruritus

Yavuz Gürkan and Kamil Toker

Anesth Analg 2002 95: 1763-1766.  

术后硬膜外镇痛目前的实践:德国调查

(潘志浩 薛张纲 校)

Current Practice in Postoperative Epidural Analgesia: A German Survey

Sandra Kampe, Peter Kiencke, Jens Krombach, Karen Cranfield, Stefan Mario Kasper, and Christoph Diefenbach

Anesth Analg 2002 95: 1767-1769.

GENERAL ARTICLES:

在猪模型上气管插管拔管前吸氧使全麻后的气体交换恶化

 (王震虹 王祥瑞 )

Administration of Oxygen Before Tracheal Extubation Worsens Gas Exchange After General Anesthesia in a Pig Model

Alexander Loeckinger, Axel Kleinsasser, Christian Keller, Andreas Schaefer, Christian Kolbitsch, Karl H. Lindner, and Arnulf Benzer

Anesth Analg 2002 95: 1772-1776.

 

气管拔管前增加吸入氧浓度对术后肺不张的影响

(张 庄心良 校)

The Effect of Increased FIO2 Before Tracheal Extubation on Postoperative Atelectasis

Zilgia Benoît, Stephan Wicky, Jean-François Fischer, Philippe Frascarolo, Carine Chapuis, Donat R. Spahn, and Lennart Magnusson

Anesth Analg 2002 95: 1777-1781.

 

ProSeal喉罩的最大分钟通气量的测试

(潘志浩 薛张纲 校)

Maximum Minute Ventilation Test for the ProSealTM Laryngeal Mask Airway

Michael S. Stix and Cornelius J. O’Connor, Jr.

Anesth Analg 2002 95: 1782-1787.

病态肥胖和术后肺不张:一个被低估的问题

(王震虹 王祥瑞 )

Morbid Obesity and Postoperative Pulmonary Atelectasis: An Underestimated Problem

A.- S. Eichenberger, S. Proietti, S. Wicky, P. Frascarolo, M. Suter, D. R. Spahn, and L. Magnusson

Anesth Analg 2002 95: 1788-1792.

 

 

围术期经食道超声心动图新考查方法应用的前景分析

Development and Analysis of a New Certifying Examination in Perioperative Transesophageal Echocardiography

Solomon Aronson, MD FACC, FACCP, FAHA*, Aggie Butler, PhD, Raja Subhiyah, PhD, Richard E. Buckingham, Jr, MD, Michael K. Cahalan, MD, Steven Konstandt, MD MBA, FACC||, Jonathan Mark, MD¶, James Ramsay, MD#, Robert Savage, MD FACC, FCCP**, Joseph Savino, MD, Jack S. Shanewise, MD#, John Smith, MD, and Daniel Thys, MD FACC, FAHA***

*Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois; National Board of Medical Examiners, Philadelphia, Pennsylvania; Mercer Island, Washington; University of Utah Medical Center, Salt Lake City, Utah; ||Mt. Sinai Medical Center, New York, New York; ¶Duke University, Durham, North Carolina; #Emory University Hospital, Atlanta, Georgia; **Cleveland Clinic Foundation, Cleveland, Ohio; University of Pennsylvania, Philadelphia, Pennsylvania; Cardiovascular Surgery of Southern Nevada, Las Vegas, Nevada; and ***St. Luke’s/Roosevelt Hospital, New York, New York

Anesth Analg Dec. 2002;95:1476-1482

 

促进围术期超声心动图的知识和能力应用的主要因素在于考试,本文报道对应用超声心动图的考查方法的发展。另外,还证明一种假设,即考试成绩与应用超声心动图的临床经验有关。1995年来,参加超声心动图检查考试的超过1200人,通过率大于70%。考试成绩与是否接受培训有关,接受过3个月以上培训且每周检查次数至少6次者成绩较好。我们认为这种考试对于检查受试者有关围术期超声心动图的应用知识是有效的。提示:本文描述了建立经食道超声心动图应用知识考查方法的过程,证明考试成绩能反映实际应用能力。

                                              (赵延华 王祥瑞 )

A key element in developing a process to determine knowledge and ability in applying perioperative echocardiography has included an examination. We report on the development of a certifying examination in perioperative echocardiography. In addition, we tested the hypothesis that examination performance is related to clinical experience in echocardiography. Since 1995, more than 1200 participants have taken the examination, and more than 70% have passed. Overall examination performance was related positively to longer than 3 mo of training (or equivalent) in echocardiography and performance and interpretation of at least six examinations a week. We concluded that the certifying examination in perioperative echocardiography is a valid tool to help determine individual knowledge in perioperative echocardiography application.

 

ACD+ITV复苏法可改善猪的低温心脏停跳模型中血管收缩反应

Vasopressor Response in a Porcine Model of Hypothermic Cardiac Arrest Is Improved with Active Compression-Decompression Cardiopulmonary Resuscitation Using the Inspiratory Impedance Threshold Valve

Claus Raedler, MD*, Wolfgang G. Voelckel, MD*, Volker Wenzel, MD*, Ludger Bahlmann, MD, Wolfgang Baumeier, MD, Christian A. Schmittinger*, Holger Herff*, Anette C. Krismer, MD*, Karl H. Lindner, MD*, and Keith G. Lurie, MD

*Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria; Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and the Department of Anesthesiology, Medical University, Lübeck, Germany

 

Anesth Analg Dec. 2002;95:1496-1502

 

常温心脏停跳后进行积极心脏按压(ACD)心肺复苏和inspiratory threshold valveITV)可显著改善重要器官的血流,但在低温心脏停跳中未见应用。因此,本文应用猪的低温心脏停跳模型,评价抗利尿激素对ACD+ITV心肺复苏前后血流动力学的效应。14只受试猪随机分为ACD+ITV复苏组(n=7)和标准复苏组(n=7),经体表降温至中心温度为26°C,出现室颤,14min后进行复苏。复苏8min后,经静脉注入0.4U/kg抗利尿激素,继续复苏10min,心跳骤停28min后进行除颤。注入抗利尿激素前,ACD+ITV复苏组颈总动脉血流显著高于标准复苏组(分别为67 ± 13 26 ± 5 mL/minP < 0.025);注入抗利尿激素后冠状动脉灌注压在ACD+ITV复苏组显著升高,而在标准复苏组没有变化(12min时分别为29±315±2 mmHg18min时分别为25±114±1 mmHgP < 0.001)。相应时间的颈总动脉血流在ACD+ITV复苏组高于标准复苏组(12min时分别为33±810±3 mL/min18min时分别为31±77±3 mL/minP < 0.01)。两组均未主动升温,ACD + ITV组有3只动物循环自发恢复并维持稳定,而在标准组没有,但结果没有统计学差异。在低温心跳骤停中,与标准复苏相比,ACD + ITV复苏能改善颈总动脉血流;而且应用抗利尿激素后,冠状动脉灌注压明显升高。为了改善低温心跳骤停后心肺复苏的有效性需要新的措施,ACDITV复苏可改善颈总动脉血流以及应用抗利尿激素后升高冠脉灌注压。

                                                (赵延华 王祥瑞 )

During normothermic cardiac arrest, a combination of active compression-decompression (ACD) cardiopulmonary resuscitation (CPR) with the inspiratory threshold valve (ITV) significantly improves vital organ blood flow, but this technique has not been studied during hypothermic cardiac arrest. Accordingly, we evaluated the hemodynamic effects of ACD + ITV CPR before, and after, the administration of vasopressin in a porcine model of hypothermic cardiac arrest. Pigs were surface-cooled until their body core temperature was 26°C. After 10 min of untreated ventricular fibrillation, 14 animals were randomly assigned to either ACD CPR with the ITV (n = 7) or to standard (STD) CPR (n = 7). After 8 min of CPR, all animals received 0.4 U/kg vasopressin IV, and CPR was maintained for an additional 10 min in each group; defibrillation was attempted after 28 min of cardiac arrest, including 18 min of CPR. Before the administration of vasopressin, mean ± SEM common carotid blood flow was significantly higher in the ACD + ITV group com-pared with STD CPR (67 ± 13 versus 26 ± 5 mL/min, respectively; P < 0.025). After vasopressin was given at minute 8 during CPR, mean ± SEM coronary perfusion pressure was significantly higher in the ACD + ITV group, but did not increase in the STD group (29 ± 3 versus 15 ± 2 mm Hg, and 25 ± 1 versus 14 ± 1 mm Hg at minute 12 and 18, respectively; P < 0.001); mean ± SEM common carotid blood flow remained higher at respective time points (33 ± 8 versus 10 ± 3 mL/min, and 31 ± 7 versus 7 ± 3 mL/min, respectively; P < 0.01). Without active rewarming, spontaneous circulation was restored and maintained for 1 h in three of seven animals in the ACD + ITV group versus none of seven animals in the STD CPR group (not significant). During hypothermic cardiac arrest, ACD CPR with the ITV improved common carotid blood flow compared with STD CPR alone. Moreover, after the administration of vasopressin, coronary perfusion pressure was significantly higher during ACD + ITV CPR, but not during STD CPR.

New strategies are needed to improve the efficiency of cardiopulmonary resuscitation (CPR) in hypothermic cardiac arrest. Active compression-decompression CPR with the inspiratory threshold valve improved carotid blood flow (and coronary perfusion pressure with vasopressin) compared with standard CPR.

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中心静脉径路:患者体位、偏侧、头转向对颈内静脉横切面积的影响

Central Venous Access: The Effects of Approach, Position, and Head Rotation on Internal Jugular Vein Cross-Sectional Area

Thomas Suarez, MD*, Jeffrey P. Baerwald, PhD, and Chadd Kraus

*Sinai Hospital of Baltimore, Johns Hopkins University, Baltimore, Maryland; and Loyola College in Maryland, Baltimore, Maryland

Anesth Analg Dec. 2002;95:1519-1524

 

我们研究了在进行右侧颈内静脉穿刺置管时,穿刺途径(侧路法或前路法),不同体位(仰卧或头低脚高),头方位(头侧转20°或最大角度)对穿刺的影响。24名志愿者先采取仰卧位后改为25°头低脚高位,分别在侧路或前路时头旋转0°, 20°或最大角度后测量颈内静脉横切面积。研究发现当患者采取头低脚高位,侧路时颈内静脉横切面积最大,在这一体位头转动时差异不大,都可获得最大横切面积。该实验显示若不能采取头低脚高位则前路可获最大穿刺横切面积。

                                               (朱慧琛   王祥瑞 )

We investigated the effects of approach (lateral versus anterior), position (supine versus Trendelenburg), and head rotation (0°, 20°, and maximum) during central venous catheterization on the area of the right internal jugular vein. Twenty-four patients were placed in supine position, followed by 25° of Trendelenburg position. In each position, measurement of the anterior and lateral right internal jugular vein cross-sectional areas was obtained by using planimetry with the patient’s head oriented at 0°, 20°, and maximum rotation. The largest cross-sectional areas were achieved in the lateral approach with the Trendelenburg position. In this position, no differences were detected among head rotation conditions. Data suggest that for those patients who tolerate the Trendelenburg position, the lateral access approach yields the statistically largest target area regardless of head rotation. When the Trendelenburg position is contraindicated, the results of this study suggest other approaches, e.g., the anterior approach, for central venous catheter placement that maximize the internal jugular vein area.

 

全国邮政调查对成年心脏手术患者神经肌肉阻滞药使用情况报告

The Use of Neuromuscular Blocking Drugs in Adult Cardiac Surgery: Results of a National Postal Survey

Glenn S. Murphy, MD*, Joseph W. Szokol, MD*, Jeffery S. Vender, MD*, Jesse H. Marymont, MD*, and Michael J. Avram, PhD

*Department of Anesthesiology, Evanston Northwestern Healthcare, Illinois; and Department of Anesthesiology, Northwestern University Feinberg School of Medicine (get address)

Anesth Analg Dec. 2002;;95:1534-1539

 

现有数据显示选择性神经肌肉阻滞药可能影响快心率心脏手术患者的初期愈合。此次实验目的是要通过某些实验工具测定临床麻醉医师在应用神经肌肉阻滞药(NMBDs)时对心脏手术患者的影响。我们向《心脏麻醉学》上曾刊登过的3295位患者中的1/3发出了征询信件,并对未回复者再次发出信函,其后共有459位患者(43%)回函。Pancuronium作为基本的神经肌肉阻滞药被用于大多数心脏手术患者,体外循环(69%)和非体外循环(41%)下进行。仅有28%的患者在术中使用神经刺激监测了解神经肌肉阻滞情况。另有9%的患者在拔管前仍使用神经肌肉阻滞药。这一测试表明长效神经肌肉阻滞剂常被用于快心率心脏手术患者,在手术室或加护病房中很少运用末稍神经监测系统,术后患者也很少使用拮抗药物(抗胆碱酯酶)。

                                               (朱慧琛   王祥瑞 )

Available data suggest that the choice of neuromuscular blocking drugs (NMBDs) can influence early clinical recovery of the fast-track cardiac surgical patient. The aim of this study was to use a survey tool to determine practice patterns of anesthesiologists for the use of NMBDs in the cardiac surgical setting. We mailed a survey to one third of the 3295 active members of the Society of Cardiovascular Anesthesiologists. A follow-up letter and survey were sent to each individual who did not respond to the initial mailing. After the second mailing, 459 surveys were returned, yielding a response rate of 43%. Pancuronium was listed as the primary NMBD used in the majority of patients undergoing cardiopulmonary bypass (69%) and off-pump (41%) procedures. Only 28% of respondents routinely used a peripheral nerve stimulator to monitor neuromuscular blockade in the operating room. Residual neuromuscular blockade was routinely reversed before tracheal extubation by only 9% of cardiac anesthesiologists. This survey demonstrates that long-acting NMBDs are often administered to fast-track cardiac patients. Peripheral nerve stimulator monitoring is rarely used in the operating room or intensive care unit, and reversal drugs (anticholinesterases) are infrequently administered in the postoperative period.

 

在绵羊输注速率及输入容量对0.9%生理盐水和7.5%盐水/6.0%右旋糖酐动力学的影响

Influence of Rate and Volume of Infusion on the Kinetics of 0.9% Saline and 7.5% Saline/6.0% Dextran 70 in Sheep

Lance P. Brauer, MD*, Christer H. Svensén, MD PhD*, Robert G. Hahn, MD PhD, Sadik Kilicturgay, MD*, George C. Kramer, PhD*, and Donald S. Prough, MD*

*Department of Anesthesiology, University of Texas Medical Branch, Galveston; and Department of Anesthesiology and Intensive Care, Stockholm Söder Hospital and the Karolinska Institute, Sweden

Anesth Analg Dec. 2002;95:1547-1556

 

短时间输注0.9%的生理盐水(NS)和7.5%的盐水/6.0%的右旋糖酐(HSD)通常是20分钟,其血容量的动力学变化是否能够预示一时间-稀释曲线。本研究选择6只平均体重36±3kg,清醒并脾切除的绵羊,在不同的四天,任意选择4只绵羊静脉输注:NS1.2ml/kg/min持续5min20min或使用HSD4.0ml/kg持续2min20min123个血容量动力学模型符合动脉血红蛋白浓度的稀释,且我们在180分钟内留取了尿样。输注NS的绵羊在5分钟末和20分钟末其血浆蛋白最大稀释度分别为10%22%,而输注HSD的绵羊在2分钟末和20分钟末其血浆蛋白最大稀释度分别为24%21%。输注NS5分钟和20分钟所预示的时间-稀释曲线实际上是一样的,其平均稀释度都为0.027单位,而输注HSD2分钟和20分钟其平均稀释度分别为0.0500.047。电脑模拟提示如果输注NSHSD的时间越长两者的扩容作用差异就越显著。我们得出结论:短时间输注液体其血容量动力学的变化能够预示长时间输注后的预后,即使输注时间越长其血容量也就越大。

                                                                                       

                                                (   王祥瑞 )

We examined whether volume kinetic variables obtained during infusion of a short bolus of 0.9% saline (NS) or 7.5% saline/6.0% dextran 70 (HSD) predict the dilution-time curve resulting from a 20-min infusion of the same fluid. Each of six conscious, splenectomized sheep (mean body weight, 36 ± 3 kg), on 4 different days, in a random order, received each of 4 IV boluses: NS at a rate of 1.2 mL · kg-1 · min-1 over 5 min or 20 min or 4.0 mL/kg of HSD over 2 min or 20 min. One, 2, and 3-volume kinetic models were fitted to the dilution of the arterial hemoglobin concentration and the urinary excretion as sampled during 180 min. The maximum dilution of arterial plasma at the end of the 5-min and 20-min infusions of NS was approximately 10% and 22%, respectively, and after the 2-min and 20-min infusions of HSD, maximum dilution was 24% and 21%, respectively. The median absolute performance error was virtually identical when the mean variable estimates from the 5-min infusion of NS were used to predict the individual dilution-time curves of the 5-min (mean, 0.027 dilution units) and 20-min (mean, 0.027) infusions and when the 2-min infusion of HSD was used to predict the dilution during the individual 2-min (mean, 0.050) and 20-min infusions (mean, 0.047). Computer simulations indicated that the difference at the end of infusion between the volume effects of NS and HSD is larger after longer infusions. We concluded that the volume kinetic variables obtained during a short infusion can be used to predict the outcome of a longer one, even if the longer infusion also delivers a larger volume.

 

小儿氟烷麻醉影响血压和术前禁食时间相关

Duration of Preoperative Fast Correlates with Arterial Blood Pressure Response to Halothane in Infants

Robert H. Friesen, MD, Jonathan L. Wurl, MD, and Richard M. Friesen

Department of Anesthesiology, The Children’s Hospital and the University of Colorado School of Medicine, Denver, Colorado

Anesth Analg Dec. 2002;95:1572-1576

 

本研究中确定术前禁食时间是否会影响婴儿和儿童在氟烷麻醉期间血压下降的程度。研究250个小儿患者将他们分成5个年龄组:新生儿组(n=50),1-6mon=50),6-24mon=50),2-6yrn=50),以及6-12yrn=50),每组患者又再根据术前禁食时间分成四组(0-4h,4-8h,8-12h,>12h)。在使用氟烷诱导后我们使呼气末氟烷浓度保持在2MAC浓度并维持10分钟以便心肌摄取。我们观察患者诱导前到氟烷浓度达2MAC这段时间内的心率、收缩压(SAP)及平均动脉压(MAP)的变化并对不同禁食时间组间的患者作比较。结果显示1-6mo年龄组禁食时间为8-12h的患者其收缩压和平均动脉压变化幅度明显大于那些0-4h的患者(SAP-51 mmHg  vs –31mmHg MAP-48mmHg vs -32mmHgP0.05)。在其他年龄组统计学上没有显著性差异。这项结果表明婴儿术前延长禁食时间与麻醉期间患者血压大幅度下降有关。因此我们应强调遵守术前禁食原则的重要性。

                                                (   王祥瑞 )

In this study, we sought to determine whether the duration of preoperative fasting affects the decrease in blood pressure observed in infants and children during halothane anesthesia. Two-hundred-fifty pediatric patients were divided into 5 age groups: term neonates (n = 50), 1–6 mo (n = 50), 6–24 mo (n = 50), 2–6 yr (n = 50), and 6–12 yr (n = 50). After anesthetic induction with halothane, end-tidal halothane was maintained at 2 minimum alveolar anesthetic concentration (MAC) for 10 min to allow myocardial uptake. Patients were grouped by duration of preoperative fast (0–4 h, 4–8 h, 8–12 h, and >12 h). Changes in heart rate and systolic (SAP) and mean (MAP) arterial blood pressure from preinduction to 2 MAC were compared among fasting groups within each age group. In the 1- to 6-mo age group, the changes in SAP and MAP were significantly greater in infants fasting 8–12 h than in those fasting 0–4 h (SAP, -51 mm Hg versus -31 mm Hg, respectively; MAP, -48 mm Hg versus -32 mm Hg; P < 0.05). No statistically significant differences were noted in the older age groups. The results of this study demonstrate that prolonged preoperative fasting is associated with a greater decrease in blood pressure in infants. This exacerbation of the already significant hemodynamic depression observed in infants during halothane anesthesia underscores the importance of adherence to published fasting guidelines.

 

氯胺酮合用利多卡因和异丙酚抑制患儿喉罩刺激的比较:双盲随机化实验研究

A Comparison of Ketamine and Lidocaine Spray with Propofol for the Insertion of Laryngeal Mask Airway in Children: A Double-Blinded Randomized Trial

Jae-Hyon Bahk, MD*, Joohon Sung, MD PhD, and In-Jin Jang, MD PhD

*Department of Anesthesiology and Clinical Research Institute, Seoul National University Hospital, and Department of Pharmacology, Seoul National University College of Medicine, Seoul, Korea; and Department of Preventive Medicine, Kangwon National University College of Medicine, Chuncheon, Kangwon-Do, Korea

Anesth Analg Dec. 2002;95:1586-1589

 

喉罩作为通气设备和气管内插管导管已被成功运用于临床。在这个随机化、双盲实验中,我们想确定保持患儿自主呼吸情况下,术前利多卡因合用氯胺酮,然后置喉罩作为一种气道管理方法是否可行。术前静脉给予0.05mg/kg咪唑安定和0.005mg/kg胃长宁,90位患者随机分配到异丙酚组和氯胺酮组之一。40位患者给予2.5mg/kg,3.0 mg/kg,3.5 mg/kg,4.0 mg/kg异丙酚静注(n = 10),而另外50位患者给予2.0, 2.5, 3.0, 3.5, 4.0 mg/kg氯胺酮静注(n = 10)。氯胺酮组在麻醉诱导前1分钟口咽部应用利多卡因喷雾。应用指定药物后,评价自主呼吸、下颌松弛,呼吸道梗阻。喉罩插入后,自主呼吸、喉痉挛性咳嗽、呕吐、吞咽、咬牙或舌头运动、分泌物和头或肢体运动被分级。所有的变量分为满意、可接受、不满意三个等级。假如所有的指标是满意的可以认为整体效果是满意的。假如至少一个指标是可接受的,其他各指标优于可接受,则可以认为整体效果是可接受的。假如至少一个指标是不满意的,则可以认为整体效果是不满意的。氯胺酮的剂量3.0 3.5 mg/kg才能取得满意或可接受的整体效果。异丙酚所有剂量都不能取得满意效果,大多数病例有呼吸暂停和呼吸道梗阻的症状。氯胺酮合用利多卡因喷雾对喉罩置入来说是合适的,在困难呼吸道患儿中是一种安全的管理方法。

                                                 ( 王祥瑞 )

The laryngeal mask airway (LMA) has been used successfully as both a ventilatory device and a conduit for tracheal intubation. In this double-blinded, randomized study, we examined whether pretreatment with lidocaine spray, ketamine anesthesia, and LMA insertion could be used as airway management that could maintain spontaneous breathing in children. After IV premedication with midazolam 0.05 mg/kg and glycopyrrolate 0.005 mg/kg, 90 patients were randomly allocated to 1 of 2 main groups for the administration of either propofol or ketamine: 40 patients received 2.5, 3.0, 3.5, or 4.0 mg/kg of propofol IV (n = 10 each), whereas 50 patients received 2.0, 2.5, 3.0, 3.5, or 4.0 mg/kg of ketamine IV (n = 10 each). Only in the ketamine group was lidocaine spray applied to the oropharynx 1 min before anesthesia induction. After injection of the designated drug, self-respiration, airway obstruction, and jaw relaxation were checked. Self-respiration, laryngospasm coughing, gagging, swallowing, biting or tongue movements, secretions, and head or limb movements after LMA insertion were graded. All variables were graded as satisfactory, acceptable, or unsatisfactory. The overall result was considered satisfactory if all criteria were satisfactory; acceptable if all were better than acceptable, but at least one acceptable criterion was included; and unsatisfactory if at least one criterion was unsatisfactory. Overall satisfactory or acceptable results in every patient were achieved only in the ketamine 3.0 or 3.5 mg/kg subgroups. No propofol dose was completely satisfactory; most cases involved apnea or airway obstruction. Ketamine and lidocaine spray were appropriate for LMA insertion, which may be a safe method for management of difficult airway in children.

 

术前使用阿普唑仑减少门诊外科患者的焦虑:和口服咪唑安定的比较

Preoperative Alprazolam Reduces Anxiety in Ambulatory Surgery Patients: A Comparison with Oral Midazolam

Jan L. De Witte, MD*, Carmen Alegret, MD, Daniel I. Sessler, MD, and Guy Cammu, MD*

*Department of Anesthesiology and Intensive Care, OLV-Hospital, Aalst, Belgium; Department of Anesthesiology, AZ Groeninge, Kortrijk, Belgium; and Outcomes ResearchTM Institute, Department of Anesthesiology, University of Louisville, Louisville, Kentucky, and the Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria

Anesth Analg Dec. 2002;95:1601-1606

 

由于咪唑安定口服制剂在某些国家没有获得批准,我们将阿普唑仑作为替代物来评估。为比较阿普唑仑0.5 mg和咪唑安定7.5 mg的效果和副作用,选择45例妇科腹腔镜门诊手术患者参与双盲实验。我们通过Trieger Dot 试验 (TDT) Digit-Symbol Substitution 试验来评价精神运动。同时我们也进行简单记忆测试。数据处理根据适用性用团体T检验、配对T检验 SNK单因素方差分析或KW单因素方差分析,P < 0.05为有统计学意义。和安慰剂相比,阿普唑仑和咪唑安定都减少焦虑评分(P < 0.05)。术前给药后一小时,Digit- Symbol Substitution试验评分在所有组都是相似的,而TDT评分(表明功能抑制)阿普唑仑组比安慰剂组要高。镇静评分、拔管时间、出院时间药物组均和安慰剂组不同。离开麻醉后恢复室时间、TDT评分药物组均比安慰剂组要大(P < 0.05)。有健忘症的5为患者均发生在咪唑安定组。我们认为在减少焦虑而无健忘方面,阿普唑仑是咪唑安定的有效替代物,但是阿普唑仑在术后早期能引起更大的精神运动损害。

结论:口服阿普唑仑0.5 mg和咪唑安定7.5 mg同样减少门诊外科手术患者的焦虑。尽管有早期精神运动损害的作用,两种药物都不延长麻醉后拔管时间,同样不延长离开术后麻醉监护室的时间。

..                                                ( 王祥瑞 )

Because an oral formulation of midazolam is not approved in certain countries, we evaluated oral alprazolam as an alternative. Forty-five outpatients scheduled for gynecological laparoscopic surgery participated in a double-blinded study to compare the effectiveness and side effects of oral alprazolam 0.5 mg with midazolam 7.5 mg, as a reference drug, and placebo. We evaluated psychomotor function by means of the Trieger Dot Test (TDT) and the Digit-Symbol Substitution Test. Simple memory tests were performed. Data were analyzed with 2 or paired Student’s t-tests, or with one-way analysis of variance with the Student-Newman-Keuls or Kruskal-Wallis test, as appropriate; P < 0.05 was considered statistically significant. Alprazolam and midazolam both decreased anxiety scores more than placebo (P < 0.05). One hour after premedication, the Digit- Symbol Substitution Test score was similar in all groups, whereas the TDT score was greater (indicating impairment of performance) in the alprazolam group than in the placebo group (P < 0.05). Sedation scores, extubation time, and discharge times in the active drug groups did not differ from placebo. At discharge from the postanesthesia care unit, the TDT score was greater in both active drug groups compared with placebo (P < 0.05). Five patients, exclusively in the midazolam group, had amnesia (P < 0.05). We conclude that alprazolam may be an effective alternative to midazolam for anxiety reduction without causing amnesia. However, it may cause greater impairment of psychomotor function in the early postoperative period.

 

挥发性麻醉剂摄取模型的预测精确度

Predictive Accuracy of a Model of Volatile Anesthetic Uptake

R. Ross Kennedy, MB ChB, PhD, FANZCA, Richard A. French, MB BS, FANZCA, and Christopher Spencer

Department of Anaesthesia, Christchurch Hospital, and Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

Anesth Analg Dec. 2002;95:1616-1621

 

一个模拟麻醉剂摄取和分布的计算机程序作为一种教学工具在我们科室已经使用了20年。新的电动测量新鲜气体流速和挥发罐刻度的麻醉机使得我们能够在临床麻醉期间评定这个模型的性能。在30个选择性麻醉期间每隔10 s从麻醉机(Datex S/5 ADU)收集气体流速,挥发罐刻度和呼气末CO2浓度。这些数据都被输入摄取模型。计算呼出麻醉气体浓度与实际从病人监护仪(Datex AS/3)上测量出的数值相比较。16名病人使用七氟醚,14名病人使用异氟醚。在所有病人中,性能误差中间值为-0.24%,绝对性能误差中间值为13.7%,分歧为2.3%/h,摆动为3.1%。七氟醚和异氟醚之间没有显著差别。这个模型在这些病人中预测的呼出浓度很准确。这些结果看上去与丙泊酚输注系统中计算和实际丙泊酚浓度相比较的结果相类似,且符合出版的指导手册中规定的在靶控麻醉系统中使用的模型精确度。这个模型也许在预测对新鲜气体和挥发罐刻度变化的反应方面有用。

                                                (殷文渊 王祥瑞 )

A computer program that models anesthetic uptake and distribution has been in use in our department for 20 yr as a teaching tool. New anesthesia machines that electronically measure fresh gas flow rates and vaporizer settings allowed us to assess the performance of this model during clinical anesthesia. Gas flow, vaporizer settings, and end-tidal concentrations were collected from the anesthesia machine (Datex S/5 ADU) at 10-s intervals during 30 elective anesthetics. These were entered into the uptake model. Expired anesthetic vapor concentrations were calculated and compared with actual values as measured by the patient monitor (Datex AS/3). Sevoflurane was used in 16 patients and isoflurane in 14 patients. For all patients, the median performance error was -0.24%, the median absolute performance error was 13.7%, divergence was 2.3%/h, and wobble was 3.1%. There was no significant difference between sevoflurane and isoflurane. This model predicted expired concentrations well in these patients. These results are similar to those seen when comparing calculated and actual propofol concentrations in propofol infusion systems and meet published guidelines for the accuracy of models used in target-controlled anesthesia systems. This model may be useful for predicting responses to changes in fresh gas and vapor settings.

 

咪唑安定和安定对成年老鼠心室肌细胞收缩和细胞内瞬间Ca2+的不同影响

The Differential Effects of Midazolam and Diazepam on Intracellular Ca2+ Transients and Contraction in Adult Rat Ventricular Myocytes

Noriaki Kanaya, MD, Paul A. Murray, PhD, and Derek S. Damron, PhD

Center for Anesthesiology Research, The Cleveland Clinic Foundation, Ohio

Anesth Analg Dec. 2002;95:1637-1644

 

我们研究了咪唑安定和安定对成年老鼠心室肌细胞激动-收缩藕连作用的直接影响。新鲜分离的心室肌细胞存放于fura-2/AM中,在28℃下进行域刺激。单个细胞内瞬间Ca2+和肌细胞缩短都被同步监测。咪唑安定(3-100μM)会剂量依赖性地降低细胞内Ca2+峰值和细胞缩短。安定(30-100μM)则会增加肌细胞缩短和Ca2+峰值且伴随达到Ca2+峰值的时间缩短。更大浓度的咪唑安定(>300μM)差不多停止了细胞内Ca2+瞬间变化和细胞缩短。咪唑安定(100μM)和安定(300μM)减少了因咖啡因刺激而释放的细胞内储存的Ca2+数量。安定(30μM),但没有咪唑安定(10μM),会引起缩短有关的剂量依赖性细胞外Ca2+曲线向下变化,但对细胞内Ca2+峰值瞬间没有影响。这些结果说明咪唑安定和安定对心脏激动-收缩藕连在细胞水平有不同的变力影响,这是通过改变细胞内游离Ca2+实用性所介导的。可是,苯二氮卓对老鼠心室肌细胞的激动-收缩藕连没有直接影响,除非非常大的剂量。抑制咖啡因敏感的细胞内Ca2+储备的释放也许在较大剂量的苯二氮卓产生的心肌抑制中起部分作用。安定,而没有咪唑安定,降低了肌丝对Ca2+的反应性。

                                                (殷文渊 王祥瑞 )

We investigated the direct effects of midazolam and diazepam on cardiac excitation-contraction coupling in adult rat ventricular myocytes. Freshly isolated rat ventricular myocytes were loaded with fura-2/AM and field-stimulated at 28°C. Intracellular Ca2+ transients (340:380 ratio) and myocyte shortening (video edge detection) were simultaneously monitored in individual cells. Midazolam (3–100 µM) caused a dose-dependent decrease in both peak intracellular Ca2+ and cell shortening. Diazepam (30 and 100 µM) increased myocyte shortening and peak Ca2+ concomitant with a decrease in time to peak Ca2+. A larger concentration of diazepam (>300 µM) nearly abolished intracellular Ca2+ and cell shortening. Midazolam (100 µM) and diazepam (300 µM) decreased the amount of Ca2+ released from intracellular stores in response to caffeine. Diazepam (30 µM), but not midazolam (10 µM), caused a downward shift in the dose-response curve to extracellular Ca2+ for shortening, with no concomitant effect on peak intracellular Ca2+ transient. These results indicate that midazolam and diazepam have different inotropic effects on cardiac excitation-contraction coupling at the cellular level, which is mediated by altering the availability of intracellular-free Ca2+. However, the benzodiazepines have no direct influence on excitation-contraction coupling in rat ventricular myocytes, except at very large doses. Inhibition of Ca2+ release from caffeine-sensitive intracellular Ca2+ stores may play some part in myocardial depression at the larger concentrations of benzodiazepines. Diazepam, but not midazolam, decreased myofilament responsiveness to Ca2+.

 

溴吡斯的明拮抗维库溴安和罗库溴安后的残余肌松作用

Residual Paralysis Induced by Either Vecuronium or Rocuronium After Reversal with Pyridostigmine

Kyo S. Kim, MD PhD, Se H. Lew, MD, Hee Y. Cho, MD, and Mi A. Cheong, MD

Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea

Anesth Analg Dec. 2002;95:1656-1660

 

我们连续调查了602例由于使用了维库溴安或罗库溴安而引起术后残余筒箭毒样瘫痪的患者,他们术后均以溴吡斯的明拮抗肌松剂但没有使用神经肌肉监测。患者到达恢复室后,神经肌肉功能同时由TOF方式的肌松监测仪和临床上持续抬头>5秒及压舌试验来评价,术后残余筒箭毒样瘫痪定义为TOF比率<0.7602例患者中五分之一在恢复室中TOF0.7(其中维库溴安24.7%;罗库溴安,14.7%)。使用10mg20mg溴吡斯的明TOF无显著差异。引起残余肌松作用与下列因素相关:缺乏术后神经肌肉监测,使用溴吡斯的明(没有新斯的明有效),大剂量的维库溴安,最后一次神经肌肉阻滞至TOF监测的时间太短,或周围环境寒冷。我们总结认为使用大剂量溴吡斯的明拮抗维库溴安和罗库溴安后,显著的残余神经肌肉阻滞作用仍没有减少。

                                                 ( 王祥瑞 )

We investigated postoperative residual curarization after administration of either vecuronium or rocuronium with reversal by pyridostigmine in 602 consecutive patients without perioperative neuromuscular monitoring. On arrival in the recovery room, neuromuscular function was assessed both by acceleromyography in a train-of-four (TOF) pattern and also clinically by the ability to sustain a head-lift for >5 s and the tongue-depressor test. Postoperative residual curarization was defined as a TOF ratio <0.7. One fifth of 602 patients (vecuronium, 24.7%; rocuronium, 14.7%) had a TOF <0.7 in the recovery room. There were no significant differences in the TOF ratios between 10 mg and 20 mg of pyridostigmine. The patients with residual block had several associated factors: the absence of perioperative neuromuscular monitoring, the use of pyridostigmine, which is less potent than neostigmine, a larger dose of vecuronium, shorter time from the last neuromuscular blocker to TOF monitoring, or peripheral cooling. We conclude that significant residual neuromuscular block after vecuronium or rocuronium was not eliminated even with reversal by a large dose of pyridostigmine.

 

硬膜外注射吗啡和新斯的明用于骨科术后镇痛

Epidural Morphine and Neostigmine for Postoperative Analgesia After Orthopedic Surgery

Maruãn Omais, MD, Gabriela R. Lauretti, MD MSc, PhD, and Cleber A.J. Paccola, MD PhD

Teaching Hospital, Department of Biomechanics, Medicine, and Rehabilitation of Locomotor Members, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

Anesth Analg Dec. 2002;95:1698-1701

 

在本调查中,我们研究了骨科手术后硬膜外联合使用吗啡和新斯的明的副作用和镇痛效果。60例接受膝关节手术的患者分成4组。椎管内麻醉使用15mg布比卡因。硬膜外试验药物用生理盐水稀释至10ml。对比组使用单纯生理盐水。吗啡组硬膜外注入0.6mg吗啡,新斯的明组注入60ug新斯的明,吗啡新斯的明联合组同时注入以上剂量的两种药物。各组在统计学上和手术中情况均无显著差异。组间首次需要追加镇痛药物时视觉疼痛评分和副作用也相似(p0.05)。新斯的明组的一例患者抱怨术中恶心,与椎管内麻醉引起的低血压紧密相关,术后新斯的明组有两例患者呕吐一次。追加镇痛药物的时间在吗啡新斯的明联合组(11小时)与其他组比较较长(p0.05〉。镇痛药物的总量(24h)在对比组较其他组更大(p0.05

提示:硬膜外联合应用吗啡和新斯的明产生术后镇痛效果并且避免了副作用,是人群中的替代镇痛技术。

                                                 ( 王祥瑞 )

In this study, we examined the side effects and analgesia of the combination of epidural neostigmine and morphine in patients undergoing orthopedic surgery. Sixty patients undergoing knee surgery were divided into four groups. The intrathecal anesthetic was 15 mg of bupivacaine. The epidural test drug was diluted in saline to a final volume of 10 mL. The control group received saline as the epidural test drug. The morphine group received 0.6 mg of epidural morphine. The neostigmine group (NG) received 60 µg of epidural neostigmine. The morphine/neostigmine group received 0.6 mg of epidural morphine combined with 60 µg of epidural neostigmine. The groups were demographically the same and did not differ in intraop- erative characteristics. The visual analog scale score at first rescue analgesic and the incidence of adverse effects were similar among groups (P > 0.05). One patient from the NG complained of intraoperative nausea, closely related to spinal hypotension. Postoperatively, two patients from the NG had vomited once. The time (min) to first rescue analgesic was longer in the morphine/neostigmine group (11 h) compared with the other groups (P < 0.05). The analgesic consumption (number of analgesic administrations in 24 h) was larger in the control group compared with the other groups (P < 0.05).

 

成人腹部手术后应用吗啡和曲马多自控镇痛:一项双盲,安慰剂对照随机试验

The Addition of a Tramadol Infusion to Morphine Patient-Controlled Analgesia After Abdominal Surgery: A Double-Blinded, Placebo-Controlled Randomized Trial

Ashley R. Webb, MB BS, FANZCA*, Samuel Leong, MB BS, FANZCA*, Paul S. Myles, MB BS, MPH, MD, FFARCSI, FANZCA, and Sara J. Burn, BA RN*

*Department of Anaesthesia, Frankston Hospital, Frankston; and Department of Anaesthesia and Pain Management, Alfred Hospital, Prahran, Victoria, Australia

Anesth Analg Dec. 2002;95:1713-1718

 

在本双盲,随机对照试验中,我们检验了以吗啡附加曲马多行PCA与单独用吗啡行PCA相比是否可改善成人腹部手术后的镇痛效果,并减少吗啡的用量。69例病人被随机分为两组,每组术后以PCA注入吗啡1mg/ml。曲马多组术中给予负荷剂量1mg/kg的曲马多,术后予0.2mg/kg的曲马多。对照组术中和术后给予等容量的生理盐水。曲马多可改善术后主观镇痛效果(p=0.031),且曲马多组PCA中的吗啡用量明显减少(p=0.023)。两组中恶心,止吐药,镇静或恢复程度(所有p>0.05)无差异。我们得出结论:曲马多与吗啡合用行PCA治疗与单独用吗啡相比可以改善镇痛效果并减少吗啡的用量。

提示:本试验的目的在于判断加入第二种止痛药,曲马多是否可以缓解大手术后吗啡自控镇痛病人的疼痛。我们发现接受曲马多的病人主观疼痛明显改善,且在未增加副作用的情况下使吗啡的用量明显减少。

                                                (忻纪华 王祥瑞 )

In this double-blinded, randomized controlled trial, we tested whether the addition of tramadol to morphine for patient-controlled analgesia (PCA) resulted in improved analgesia efficacy and smaller morphine requirements compared with morphine PCA alone after abdominal surgery in adults. Sixty-nine patients were randomly allocated into two groups, each receiving morphine 1 mg/mL via PCA after surgery. The tramadol group received an intraoperative initial loading dose of tramadol (1 mg/kg) and a postoperative infusion of tramadol at 0.2 mg · kg-1 · h-1. The control group received an intraoperative equivalent volume of normal saline and a postoperative saline infusion. Postoperatively, tramadol was associated with improved subjective analgesic efficacy (P = 0.031) and there was significantly less PCA morphine use in the tramadol group (P = 0.023). No differences between the groups were found with regard to nausea, antiemetic use, sedation, or quality of recovery (all P > 0.05). We conclude that a tramadol infusion combined with PCA morphine improves analgesia and reduces morphine requirements after abdominal surgery compared with morphine PCA alone.

 

应用单纯扩张技术行经皮气管切开:Criglia Blue Rhino Griggs’ 的前瞻性和随机性比较

Percutaneous Tracheostomy with Single Dilatation Technique: A Prospective, Randomized Comparison of Ciaglia Blue Rhino Versus Griggs’ Guidewire Dilating Forceps

Sushil P. Ambesh, MD, Chandra K. Pandey, MD, Shashi Srivastava, MD, Anil Agarwal, MD, and Dinesh K. Singh, MD

Department of Anesthesiology and Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Anesth Analg Dec. 2002;95:1739-1745

 

应用Griggs’ guidewire dialating forceps (GWDF)以单步扩张技术行气管切开已广泛开展。近来,Ciaglia提出应用一种弯曲的,渐细的扩张器,Ciaglia Blue Rhino (CBR) 行单步扩张技术。在一项前瞻性随机试验中,我们连续在60例病人中以CBRGWDF方法行经皮气管切开。术后所有病人均由不知情的专家行支气管镜检查,并观察穿刺口特征和气管损伤。两种方法平均气管切开时间(切开皮肤到插入导管的时间)无差异(CBR7.5分钟,GWDF6.5分钟)。GWDF方法有三分之一的病人穿刺口扩张不全和过度扩张。在CBR组中,所有病人的气道峰压明显升高(p<0.05)。有9例病人气管软骨损伤,3例病人气管纵向擦伤,一例病人气胸。3例病人在拔管后疤痕处气管内陷声音嘶哑8周;但是,没有人发生呼吸困难。结论:这两种技术在经皮气管切开时的作用相同。但是,GWDF使穿刺处气管过度扩张和CBR使气道峰压升高和气管环的损伤仍不可避免。

                                                (忻纪华 王祥瑞 )

 

Percutaneous tracheostomy with single-step dilation technique using Griggs’ guidewire dilating forceps (GWDF) is a well-recognized procedure. Recently, Ciaglia has introduced a one-step dilation technique using a curved, gradually tapered dilator, the Ciaglia Blue Rhino (CBR). In a prospective, randomized study, we performed percutaneous tracheostomy in 60 consecutive patients, using either the CBR or the GWDF technique. Postoperatively, all patients had bronchoscopy by a blinded consultant, and stoma characteristics and injuries to the trachea were studied. Mean tracheostomy time (skin incision to insertion of tracheostomy tube) in the two procedures (CBR 7.5 min versus GWDF 6.5 min) was not different (P > 0.05). The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma, each in almost one-third of patients. In the CBR group, the procedure was associated with a significant increase in peak airway pressure (P < 0.05) in all patients. There were nine cases of tracheal cartilage rupture, three cases of longitudinal tracheal abrasion, and one pneumothorax. Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation; however, none had any breathing difficulty. We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy. However, tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns.

 

脊麻下行髋关节置换术中氨基酸灌注可以引起产热和减少失血

Amino Acid Infusion Induces Thermogenesis and Reduces Blood Loss During Hip Arthroplasty Under Spinal Anesthesia

Jan Widman, MD*, Folke Hammarqvist, MD PhD, and Eva Selldén, MD PhD

*Department of Orthopedics, St. Göran Hospital; Gastrocentrum, Department of Surgery, Huddinge University Hospital; and Department of Anesthesia and Intensive Care, Karolinska Hospital, Karolinska Institute, Stockholm, Sweden

Anesth Analg Dec. 2002;95:1757-1762        

 

氨基酸的热效应在全麻下增大,能对抗低温。轻度低温能减少术中出血。我们研究在脊麻时氨基酸是否引起产热以及这种内源性产热是否能减少髋关节置换术中的出血。22名患者在脊麻前1小时和脊麻中给予氨基酸IV混合剂(vamin 18®, 240 kJ/h)对他们的直肠温度,氧摄取,围术期出血测定,对照患者24人,给予酸处理过的林格氏液。通过对用过的纱布称重和对吸引瓶中出去生理盐水的液体的估计来计算术中的失血量。在氨基酸组,比术前温度上升了0.4°C ± 0.2°C (P < 0.01),对照组没有变化。在术毕时,对照组中心温度降低了0.9°C ± 0.4°C,而在氨基酸组患者中心温度降低了0.4°C ± 0.3°Cp<0.01)。在氨基酸组患者的氧摄取比基础水平提高了26 ± 7 mL/min, or 16% ± 5% (P < 0.05),在对照病人中却没有改变。术中失血量在对照患者中(702 ± 344 mL)比在用氨基酸患者中(516 ± 272 mL)更加明显(P < 0.05)。术后血容量的下降量组患者并没有明显差异。总之,氨基酸灌注在脊麻时能引起产热反应。而且防止脊麻时温度下降似乎对术中失血有积极作用。

                                                (王震虹 王祥瑞 )

The thermic effect of amino acids is augmented under general anesthesia and counteracts hypothermia. Mild hypothermia may increase surgical bleeding. We studied whether amino acids also induce thermogenesis under spinal anesthesia and whether this endogenous heat production reduces bleeding during hip arthroplasty. Rectal temperature, oxygen uptake, and perioperative bleeding were measured in 22 patients receiving an IV amino acid mixture (Vamin 18®, 240 kJ/h) for 1 h before and then during spinal anesthesia and in 24 control patients receiving acetated Ringer’s solution. Blood loss was calculated after surgery by weighing the swabs and the content of the suction tubes after subtraction of the saline used. After surgery, the closed drains were weighed after 24 h. In the amino acid group, the preanesthesia temperature increased by 0.4°C ± 0.2°C (P < 0.01) and was unchanged in controls. At end of surgery, core temperature had decreased by 0.9°C ± 0.4°C in controls and by 0.4°C ± 0.3°C in the amino acid patients (P < 0.01). Oxygen uptake increased by 26 ± 7 mL/min, or 16% ± 5% (P < 0.05), from baseline in the amino acid patients, whereas it was unchanged in the controls. Blood loss during surgery was significantly larger in the control patients (702 ± 344 mL) than in the amino acid patients (516 ± 272 mL) (P < 0.05). After surgery, there were no significant differences in shed blood volume. In conclusion, amino acid infusion also induced a thermogenic response under spinal anesthesia. In addition, the prevention of temperature decrease during spinal anesthesia seemed to have a positive effect on intraoperative blood loss.

 

在猪模型上气管插管拔管前吸氧使全麻后的气体交换恶化

Administration of Oxygen Before Tracheal Extubation Worsens Gas Exchange After General Anesthesia in a Pig Model

Alexander Loeckinger, MD, Axel Kleinsasser, MD, Christian Keller, MD, Andreas Schaefer, MD, Christian Kolbitsch, MD, Karl H. Lindner, MD, and Arnulf Benzer, MD

Department of Anesthesiology, Critical Care and Emergency Medicine, The Leopold-Franzens University Innsbruck, Austria

Anesth Analg Dec. 2002;95:1772-1776

 

在气管插管拔管前给予100%氧是临床常见的方法。 我们在猪模型上采用复合惰性气体排除法测定这种方法对术后气体交换的影响。全麻机械通气30min后(吸氧30%)停止麻醉,猪随机给予30%100%的氧,直到能安全拔管。拔管后30min吸空气,结果:100%氧的猪到达通气不足部分的血流量比吸30%氧的猪明显增加(17% ± 15%7% ± 5%; P = 0.009).。我们认为拔管前吸100%氧可能引起气体交换的不利影响。

                                                (王震虹 王祥瑞 )

Administration of 100% oxygen before tracheal extubation is common clinical practice. We determined the effect of this technique on postoperative gas exchange in a porcine model using the multiple inert gas elimination technique. After general anesthesia with mechanical ventilation for a period of 30 min (inspiratory fraction of oxygen of 0.3), anesthesia was discontinued, and the pigs were randomized to an inspiratory fraction of oxygen of 0.3 or 1.0 until they could be safely extubated. Thirty minutes after extubation while breathing air, blood flow to poorly ventilated units had significantly increased in pigs that had been administered 100% oxygen as compared with those receiving 30% oxygen (17% ± 15% versus 7% ± 5%; P = 0.009). We conclude that exposure to 100% oxygen before extubation may cause an undesirable alteration in gas exchange.

 

病态肥胖和术后肺不张:一个被低估的问题

Morbid Obesity and Postoperative Pulmonary Atelectasis: An Underestimated Problem

A.- S. Eichenberger, MD*, S. Proietti, MD, S. Wicky, MD, P. Frascarolo, PhD*, M. Suter, MD, D. R. Spahn, MD*, and L. Magnusson, MD PhD*

Departments of *Anesthesiology, Diagnostic Radiology, and General Surgery, University Hospital, Lausanne, Switzerland

Anesth Analg Dec. 2002;95:1788-1792

 

在病态肥胖患者(MO)中由于全麻和手术产生的呼吸机的干扰更加明显。因为全麻引起非肥胖患者的肺不张,所以我们推测在MO患者中肺不张都是很特殊的。我们研究MO和非肥胖患者在全麻后肺不张的重要性和吸收。为20 MO患者在腹腔镜下行胃成型术和10个非肥胖患者腹腔镜下胆囊切除麻醉。我们用CT在不同阶段评估肺不张:全麻诱导前,插管即刻,和24小时后。在麻醉诱导前,MO患者比非肥胖患者有更多的肺不张(2.1% 1.0%, 各自的 P < 0.01).,用在全肺中的百分比来表示。气管拔管后,两组患者肺不张均增加,但在MO患者出现中仍比较多(MO 患者7.6% 肺肥胖患者2.8% ; P < 0.05)24小时后在MO患者中肺不张的数量没变,但在非肥胖患者中我们观察到完全吸收(9.7% 1.9%, 各自的 P < 0.01)。在MO患者全麻引起的肺不张要多于非肥胖患者, 而且肺不张在MO患者至少维持24小时,这时肺不张在非肥胖患者已消失。

 

                                                    

(王震虹 王祥瑞 )

Perturbation of respiratory mechanics produced by general anesthesia and surgery is more pronounced in morbidly obese (MO) patients. Because general anesthesia induces pulmonary atelectasis in nonobese patients, we hypothesized that atelectasis formation would be particularly significant in MO patients. We investigated the importance and resorption of atelectasis after general anesthesia in MO and nonobese patients. Twenty MO patients were anesthetized for laparoscopic gastroplasty and 10 nonobese patients for laparoscopic cholecystectomy. We assessed pulmonary atelectasis by computed tomography at three different periods: before the induction of general anesthesia, immediately after tracheal extubation, and 24 h later. Already before the induction of anesthesia, MO patients had more atelectasis, expressed in the percentage of the total lung area, than nonobese patients (2.1% versus 1.0%, respectively; P < 0.01). After tracheal extubation, atelectasis had increased in both groups but remained significantly more so in the MO group (7.6% for MO patients versus 2.8% for the nonobese; P < 0.05). Twenty-four hours later, the amount of atelectasis remained unchanged in the MO patients, but we observed a complete resorption in nonobese patients (9.7% versus 1.9%, respectively; P < 0.01). General anesthesia in MO patients generated much more atelectasis than in nonobese patients. Moreover, atelectasis remained unchanged for at least 24 h in MO patients, whereas atelectasis disappeared in the nonobese.

 

剖胸体位的胃食管返流与气管吸入:术前应该常规应用雷尼替丁吗?

Gastroesophageal Reflux and Tracheal Aspiration in the Thoracotomy Position: Should Ranitidine Premedication be Routine?

Neil M. Agnew, FRCA*, Jonathan B. Kendall, FRCA*, Maria Akrofi, FRCA*, Jane Tran, BTech{dagger}, Ajaib S. Soorae, FRCS{ddagger}, Richard Page, FRCS{ddagger}, Glenn N. Russell, FRCA*, and Stephen H. Pennefather, FRCA*

Departments of *Anaesthesia, {dagger}Respiratory Measurement, and {ddagger}Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom

Anesth Anal Dec. 2002;95:1645-1649

背景:气管内吸入胃内容物可以造成剖胸手术后的肺部并发症。病人在侧卧位行剖胸手术时的胃食管返流以及气管内吸入胃内容物的发病率仍未知。雷尼替丁作为术前用药可以减少胃内容量、提高胃内PH,可能减少胃食管返流。目的:研究雷尼替丁对于剖胸手术病人的胃食管返流和气管内吸入的影响。方法:本研究采用安慰剂对照、随机、双盲。使用气管和食管腔内连续PH监测探头,研究雷尼替丁对于80位接受剖胸手术的成年病人的胃食管返流和气管内吸入的影响。具有胃食管返流高危因素的病人被排除出本研究。结果:在安慰剂组和雷尼替丁组酸性胃食管返流的发生率分别是28.2%和2.5%(P0.006),只有在安慰剂组有几位病人发生了多次胃食管返流。安慰剂组和雷尼替丁组总的胃食管返流事件分别是161P0.002)。安慰剂组和雷尼替丁组气管内酸性物质吸入的发生率分别是7.7%和2.5%(无统计学显著意义)。结论:接受剖胸手术的病人属于胃食管返流的高危人群,导致气管内酸性物质的吸入发生率较高。采用雷尼替丁作为术前药能够明显减少但是不能完全防止这种具潜在致命危险的并发症。

                                   (颜      庄心良  校)

Aspiration of gastric contents may contribute to pulmonary complications after thoracotomy. The incidence of gastroesophageal reflux (GER) and tracheal acid aspiration in patients undergoing thoracotomy in the lateral position is unknown. Ranitidine premedication reduces gastric volume, increases gastric pH, and may reduce GER. We used continuous intraluminal esophageal and tracheal pH monitoring probes to investigate the effect of ranitidine on the incidence of GER and tracheal aspiration in 80 adult patients undergoing thoracotomy. The study was placebo-controlled, randomized, and double-blinded. Patients at high risk of GER were excluded from the study. The incidence of acid GER in the placebo and ranitidine groups was 28.2% and 2.5%, respectively (P = 0.006). Multiple episodes of GER occurred in some patients in the placebo group only. The total number of episodes of GER in the placebo and ranitidine groups was 16 and 1, respectively (P = 0.002). The incidence of tracheal acid aspiration in the placebo and ranitidine groups was 7.7% and 2.5%, respectively (not significant). Patients undergoing thoracotomy are therefore at high risk of acid GER, which may lead to tracheal acid aspiration in an appreciable proportion. Premedication with ranitidine significantly reduces, but does not eliminate, the incidence of this potentially life-threatening complication.

 

持续过度通气对硫喷妥钠麻醉下的兔局部脑血容量的影响

The Effects of Sustained Hyperventilation on Regional Cerebral Blood Volume in Thiopental-Anesthetized Rats

Christophe Broux, MD*, Irène Tropres, PhD{dagger}, Olivier Montigon{dagger}, Cécile Julien, PhD{dagger}, Michel Decorps, PhD{dagger}, and Jean-François Payen, MD PhD*

*Department of Anesthesiology, and {dagger}INSERM, The University of Grenoble School of Medicine, Grenoble, France

Anesth Analg Dec. 2002;95:1746-1751

目的:探讨持续过度通气对不同脑区的血容量是否存在时间限制性的影响。方法:对9只硫喷妥钠麻醉的兔,持续过度通气3小时,采用稳态敏感对照磁共振成像技术,每30分钟测定新皮层背侧壁、纹状体和小脑的脑血容量。结果:纹状体是唯一在低碳酸血症(PaCO2, 24 ± 3 mm Hg)期间表现出稳定的血容量减少的脑区。相反,新皮层和小脑(程度比较轻)表现出进行性的恢复到正常脑血容量的趋势。三个脑区的脑血容量在恢复到正常通气时都没有发现反跳迹象。结论:持续过度通气可以导致脑血容量的不均衡减少,其原因可能是由不同的脑血管对于细胞外PH的敏感性不同造成的。我们的研究结果证实,持续过度通气对于脑血流动力学影响是短暂的。

(颜      庄心良  校)

Sustained hyperventilation has a time-limited effect on cerebrovascular dynamics. We investigated whether this effect was similar among brain regions by measuring regional cerebral blood volume (CBV) with steady-state susceptibility contrast magnetic resonance imaging during 3 h of hyperventilation. Regional CBV was determined in nine thiopental-anesthetized, mechanically-ventilated rats every 30 min in the dorsoparietal neocortex, the corpus striatum, and the cerebellum. The corpus striatum was the only brain region showing a stable reduction in CBV during the hypocapnic episode (PaCO2, 24 ± 3 mm Hg). In contrast, neocortex and, to a lesser extent, cerebellum exhibited a progressive return toward normal values despite continued hypocapnia. No evidence of a rebound in CBV was found on return to normal ventilation in the three brain regions. We conclude that sustained hyperventilation can lead to an uneven change in the reduction of CBV, possibly because of differences of brain vessels in their sensitivity to extracellular pH. Our results in neocortex confirm the transient effect of sustained hyperventilation on cerebral hemodynamics.

神经甾体类麻醉药Alphaxalone抑制牛肾上腺髓质细胞去甲肾上腺素转运体的功能

Alphaxalone, a Neurosteroid Anesthetic, Inhibits Norepinephrine Transporter Function in Cultured Bovine Adrenal Medullary Cells

Takafumi Horishita*, Kouichiro Minami*, Nobuyuki Yanagihara{dagger}, Munehiro Shiraishi*, Takashi Okamoto*, Yousuke Shiga*, Susumu Ueno{dagger}, and Akio Shigematsu*

Departments of *Anesthesiology and {dagger}Pharmacology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan

Anesth Analg Dec 2002;95:1661-1666

本文研究神经甾体类麻醉药alphaxalone 对牛肾上腺髓质细胞去甲肾上腺素转运体(NET)功能以及麻醉条件下大鼠血压和血浆肾上腺素浓度的影响。结果显示Alphaxalone (10–100 µM)以浓度依赖性的方式抑制对地昔帕明敏感的牛肾上腺髓质细胞摄取去甲肾上腺素。Eadie-Hofstee 分析显示Alphaxalone 明显增加凯米利斯常数(酶反应常数)而不增加最大反应速度,表明这种抑制作用是通过和NET竞争引起的。Alphaxalone 可能抑制牛肾上腺素细胞质膜[3H]- 地昔帕明的特殊结合部位。[3H]- 地昔帕明结合的Scatchard分析显示alphaxalone显著增加地昔帕明与受体结合的解离常数而不增加最大结合程度,也表明这种抑制作用是竞争性抑制。静脉单次给予 alphaxalone 对麻醉大鼠血压无显著影响,但是显著增加血浆去甲肾上腺素的浓度。结论是, alphaxalone竞争性抑制肾上腺髓质细胞NET的功能,提示其对交感神经功能可能产生影响。

                                      (王士雷   庄心良 校)                                                           

We studied the effects of alphaxalone, a neurosteroid anesthetic, on norepinephrine transporter (NET) function in cultured bovine adrenal medullary cells and the effect of a bolus injection of alphaxalone on blood pressure and serum norepinephrine (NE) levels in anesthetized rats. Alphaxalone (10–100 µM) inhibited the desipramine-sensitive uptake of [3H]-NE by bovine adrenal medullary cells in a concentration-dependent manner. Eadie-Hofstee analysis of [3H]-NE uptake showed that alphaxalone increased the apparent Michaelis constant without altering the maximal velocity, indicating that inhibition occurred via competition for the NET. Alphaxalone inhibited the specific binding of [3H]-desipramine to plasma membranes isolated from bovine adrenal medulla. Scatchard analysis of [3H]-desipramine binding revealed that alphaxalone increased the apparent dissociation constant for binding without altering maximal binding, indicating competitive inhibition. Bolus IV administration of alphaxalone had little effect on blood pressure but slightly, and significantly, increased the serum NE levels in anesthetized rats. These findings suggest that alphaxalone competitively inhibits NET function by interfering with both desipramine binding and NE recognition on the NET in adrenal medullary cells and probably in sympathetic neurons.

 

预防性给予奥丹西龙能减少椎管内注射芬太尼后病人瘙痒的发生率

Prophylactic Ondansetron Reduces the Incidence of Intrathecal Fentanyl-Induced Pruritus

Yavuz Gürkan and Kamil Toker

Kocaeli University School of Medicine, Department of Anesthesiology and Reanimation, Kocaeli, Turkey

Anesth Analg Dec 2002;95:1763-1766

目的:研究预防性静脉给予奥丹西龙对蛛网膜下腔给予芬太尼后病人瘙痒的发生率。方法:150ASA I–II在蛛网膜下腔神经阻滞麻醉(用药:重比重布比卡因 7–10 mg,芬太尼 25 µg )的病人随机分为麻醉开始前静脉注射奥丹西龙 8 mg 组和生理盐水组。在用药后1h内的每 15 min和随后的12, 3, 4, 5, and 6 h 对瘙痒的情况进行评估。用 {chi}2 t检验进行统计学处理。结果:空白对照组瘙痒的发生率明显高于奥丹西龙组 (68% versus 39%) (P = 0.001)。二组病人开始出现瘙痒的时间无显著差异 (对照组55 ± 32 min,奥丹西龙组 50 ± 31 min) 二组病人瘙痒持续时间无差异 (空白对照组 98 ± 60 min,奥丹西龙组 103 ± 58 min)。结论:预防性应用奥丹西龙能明显减少鞘内应用芬太尼后瘙痒的发生率。

                                      (王士雷   庄心良 校)

We investigated the effectiveness of prophylactic IV ondansetron in preventing intrathecal fentanyl-induced pruritus. One-hundred-fifty ASA status I–II patients undergoing spinal anesthesia with 7–10 mg of hyperbaric bupivacaine and 25 µg of fentanyl were randomized to receive ondansetron 8 mg IV or normal saline IV before the commencement of spinal anesthesia. Evaluations were performed every 15 min in the first hour after the injection of study drugs and at 1, 2, 3, 4, 5, and 6 h after the administration of the study drug. Statistical analysis was performed by using {chi}2 tests and Student’s t-test, as appropriate. The incidence of pruritus was significantly more frequent in the placebo group compared with the ondansetron group (68% versus 39%) (P = 0.001). Time to pruritus was similar in both groups (placebo group, 55 ± 32 min versus ondansetron group, 50 ± 31 min). Duration of pruritus was also similar in both groups (placebo group, 98 ± 60 min versus ondansetron group, 103 ± 58 min). Ondansetron prophylaxis significantly reduced the incidence of intrathecal fentanyl-induced pruritus in patients undergoing surgery under bupivacaine spinal anesthesia.

 

小儿和成人在异丙酚和异氟醚麻醉下经导管射频消融术后恶心和呕吐发生率较

Postoperative Nausea and Vomiting in Children and Adolescents Undergoing Radiofrequency Catheter Ablation: A Randomized Comparison of Propofol- and Isoflurane-Based Anesthetics

Thomas O. Erb, MD MHS*, Janet M. Hall, CRNA*, Richard J. Ing, MD*, Ronald J. Kanter, MD{dagger}, Frank H. Kern, MD*, Scott R. Schulman, MD*, and Tong J. Gan, MD*

Departments of *Anesthesiology and {dagger}Pediatric Cardiology, Duke University, Durham, North Carolina

Anesth Analg Dec 2002;95:1577-1581

对儿科病人施行经导管射频消融术,一般需全身麻醉,这样,术后恶心和呕吐现象很普遍,在用吸入麻醉药时,恶心和呕吐的发生率可达60%。与吸入麻醉药相比,异丙酚全麻后,其恶心和呕吐发生率较低。我们对此作进一步的研究。病人随机分为异丙酚麻醉组和异氟醚麻醉组,所有病人在麻醉前均预防性地给予止吐药奥丹西龙,在术后18小时的观察期内,发生恶心和呕吐的病人用氟哌利多止吐。记录和比较各组发生恶心次数、呕吐次数、用氟哌利多止吐次数、镇静程度积分以及麻醉药费用。恶心和呕吐的发生率在异氟醚麻醉组(63% 恶心/55% 呕吐)明显高于异丙酚麻醉组(21% 恶心/6%呕吐);恶心和呕吐病人应用氟哌利多无效者在异氟醚麻醉组(70%)明显高于异丙酚麻醉组(0%)。结果表明,在异氟醚麻醉下经导管射频消融术的儿科病人,有很高的术后恶心和呕吐发生率,而且,奥丹西龙的预防效果以及氟哌利多的治疗效果均不佳。而应用异丙酚麻醉后,恶心和呕吐的发生率低,奥丹西龙的预防效果和氟哌利多的治疗效果均较好。

(杨保仲 庄心良 校)

In children, radiofrequency catheter ablation (RFCA) is typically performed under general anesthesia. With the use of volatile anesthetics, postoperative nausea and vomiting (PONV) are common, with an incidence of emesis as frequent as 60%. We tested the hypothesis that a propofol (PRO)-based anesthetic would have a less frequent incidence of PONV than an isoflurane (ISO)-based anesthetic. Patients were randomly assigned to receive either an ISO- or PRO-based anesthetic. Prophylactic ondansetron was given to all patients and droperidol was used as a rescue antiemetic postoperatively while PONV was monitored postoperatively for 18 h. The incidence of nausea, vomiting, use of rescue antiemetic drugs, and sedation scores were recorded. The cost for the anesthetic was also calculated. Fifty-six subjects were included in this study. The cumulative incidence of PONV was significantly more frequent in group ISO (63% nausea/55% emesis) compared with group PRO (21% nausea/6% emesis). After the administration of droperidol, further vomiting occurred in 70% of the patients in group ISO versus 0% of the patients in group PRO. We conclude that RFCA using ISO has a high PONV risk and the prophylactic use of ondansetron as well as antiemetic therapy with droperidol are ineffective. In contrast, a PRO-based anesthetic is highly effective in preventing PONV in children undergoing RFCA.


三种预防术后恶心和呕吐方案比较

A Comparison of Three Antiemetic Combinations for the Prevention of Postoperative Nausea and Vomiting

M. J. Sanchez-Ledesma, MD PhD*, L. López-Olaondo, MD PhD*, F. J. Pueyo, MD PhD*, F. Carrascosa, MD PhD*, and A. Ortega, MD PhD{dagger}

Departments of *Anesthesiology and Critical Care and {dagger}Pharmacology, University Clinic, School of Medicine, University of Navarra, Pamplona, Spain

Anesth Analg Dec 2002;95:1590-1595

我们用前瞻、随机、双盲的方法,对三种预防术后恶心和呕吐的方案作一比较。妇科手术病人90例,ASA分级I-II级,年龄18-65岁,所有病人均用统一的麻醉方法(全麻)和镇痛方法(吗啡镇痛)。病人随机分为三组,第一组:麻醉诱导后给予奥丹西龙 4 mg 氟哌利多 1.25 mg12小时后给予氟哌利多 1.25 mg  (n = 30);第二组:麻醉诱导后给予地塞米松 8 mg 氟哌利多 1.25 mg12小时后给予氟哌利多 1.25 mg  (n = 30);第三组:麻醉诱导后给予奥丹西龙 4 mg 地塞米松8 mg 12小时后再给安慰剂 (n = 30)。完全有效率(48小时内无恶心和呕吐),第一组为80%,第二组为40%,第三组为70%(第二组明显低于第一组和第三组, P = 0.004)。三组不良反应的发生率相似。结果表明,在妇科手术病人,奥丹西龙复合 氟哌利多或地塞米松,其预防恶心和呕吐的效果优于地塞米松复合氟哌利多

(杨保仲 庄心良 校)

In this study we compared the efficacy and safety of three antiemetic combinations in the prevention of postoperative nausea and vomiting (PONV). Ninety ASA status I–II women, aged 18–65 yr, undergoing general anesthesia for major gynecological surgery, were included in a prospective, randomized, double-blinded study. A standardized anesthetic technique and postoperative analgesia (intrathecal morphine plus IV patient-controlled analgesia (PCA) with morphine) were used in all patients. Patients were randomly assigned to receive ondansetron 4 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 1, n = 30), dexamethasone 8 mg plus droperidol 1.25 mg after the induction of anesthesia and droperidol 1.25 mg 12 h later (Group 2, n = 30), or ondansetron 4 mg plus dexamethasone 8 mg after the induction of anesthesia and placebo 12 h later (Group 3, n = 30). A complete response, defined as no PONV in 48 h, occurred in 80% of patients in Group 1, 70% in Group 3, and 40% in Group 2 (P = 0.004 versus Groups 1 and 3). The incidences of side effects and other variables that could modify the incidence of PONV were similar among groups. In conclusion, ondansetron, in combination with droperidol or dexamethasone, is more effective than dexamethasone in combination with droperidol in women undergoing general anesthesia for major gynecological surgery with intrathecal morphine plus IV PCA with morphine for postoperative analgesia.

静脉全麻药对中国仓鼠卵母细胞重组人M1-M3毒蕈碱受体的影响

Interaction of Intravenous Anesthetics with Recombinant Human M1-M3 Muscarinic Receptors Expressed in Chinese Hamster Ovary Cells

Kazuyoshi Hirota, MD*, Yoshio Hashimoto, MD*, and David G. Lambert, PhD{dagger}

*Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki, Japan; and {dagger}University Department of Anaesthesia, Critical Care and Pain Management, Leicester Royal Infirmary, Leicester, United Kingdom

Anesth Analg Dec 2002;95:1607-1610

目的:先前研究表明异丙酚、氯氨酮和硫贲妥钠通过作用于副交感神经使气道张力增加。本实验研究静脉全麻药异丙酚、氯氨酮和硫贲妥钠是否对中国仓鼠卵细胞重组的M1-M3CHO-M1M2M3)毒蕈碱受体发生作用。方法:作者应用0.4nM1-N甲基-3H甲基氯化东莨菪碱([3H]NMS)作为置换剂研究这些全麻药与中国仓鼠卵母细胞重组人M1-M3毒蕈碱受体的作用。另外采用荧光分光光度计检测由1mM乙酰甲胆碱激发的细胞钙内流,进而检测受体的功能。结果:氯氨酮呈浓度依赖置换[3H]NMS 结合的CHO-M1M2M3细胞,其亲和力pKi平均值分别为4.34 ± 0.14 (45 µM), 3.53 ± 0.10 (294 µM), and 3.61 ± 0.02 (246 µM)。临床相关浓度的氯氨酮即可影响M1受体。氯氨酮在乙酰甲胆碱存在和不存在时都不增加CHO-M1细胞的钙内流。硫贲妥钠可替换结合于CHO-M3[3H]NMS ,有统计学意义, pKi平均值为 4.12 ± 0.06 [75 µM],但对M1M2无作用。10-5–10-3 M 的硫贲妥钠呈浓度依赖性抑制乙酰甲胆碱引起CHO-M3细胞 的钙内流。异丙酚和巴比妥酸对任何一种毒蕈碱受体亚型均无作用。结论:本实验表明在细胞内钙离子水平,硫贲妥钠M3受体有拮抗作用,但氯氨酮对M1受体无功能性影响。

                                          (赵雪莲    庄心良  校)                                                     

Previous reports suggest that the effects of propofol, ketamine, and thiopental on airway tone may be because of modulation of parasympathetic activity. We examined if these anesthetics interact with recombinant human M1-M3 muscarinic receptors expressed in Chinese hamster ovary cells (CHO-M1, M2, and M3) using the displacement of 0.4 nM of l-[N-methyl-3H]scopolamine methyl chloride([3H]NMS). In addition, functional studies were performed by fluorometrically monitoring methacholine (1 mM) stimulated intracellular Ca2+ ([Ca2+]i) responses. Ketamine concentration dependently displaced [3H]NMS binding to CHO-M1, M2, and M3 cells with affinity, pKi (mean Ki) values of 4.34 ± 0.14 (45 µM), 3.53 ± 0.10 (294 µM), and 3.61 ± 0.02 (246 µM), respectively. The effects at M1 were in the clinical range. Ketamine did not affect either basal or methacholine stimulated increase in [Ca2+]i in CHO-M1 cells. Thiopental significantly displaced [3H]NMS binding to M3 (pKi [mean Ki] = 4.12 ± 0.06 [75 µM]) but not M1 or M2 receptors. Thiopental (10-5–10-3 M) concentration dependently inhibited methacholine stimulated increase in [Ca2+]i in CHO-M3 cells. Propofol and barbituric acid did not interact with any muscarinic receptor subtype. We suggest that at the level of [Ca2+]I, thiopental may possess M3 antagonist activity, whereas there are no functional consequences of the interaction of ketamine with the M1 receptor.


 

抑制超强有害刺激引起撤退反应的异氟醚可减少大鼠脊髓C-Fos表达而氟烷无此作用

Isoflurane, but Not Halothane, Depresses C-Fos Expression in Rat Spinal Cord at Concentrations that Suppress Reflex Movement After Supramaximal Noxious Stimulation

Steven L. Jinks, PhD*, Joseph F. Antognini, MD*{dagger}, John T. Martin, MD*, S.- W. Jung, MD{ddagger}, Earl Carstens, PhD{dagger}, and Richard Atherley, BS*

*Department of Anesthesiology and Pain Medicine and {dagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis; and {ddagger}Department of Anesthesiology, Keimyung University, Daegu, Korea

Anesth Analg Dec 2002;95:1622-1628

目的:作者研究大鼠后爪受到超强有害机械刺激时异氟醚和氟烷对腰骶脊髓fos样免疫反应(FLI)产生的影响。方法:本实验采用不同浓度的异氟醚和氟烷,并设立对照组。结果:与无刺激的对照组(0.9%异氟醚)相比较,0.9-1.5%的异氟醚下有害刺激能增加双侧的FLIFLI主要分布于背角的表层(Ⅰ-Ⅲ层),较少分布于背角的深层(IV–VI 层)中间带(VII 层),3-5倍以上单侧标记。在1.8%异氟醚时所有层的FLI均数都明显降低(1.7 ± 1.3每层),其它浓度的数值分别为0.9%-11.4 ± 9.5, 1.2%-7.5 ± 6.8, 1.5%-9.7 ± 6.6 ,但是与无刺激的对照阻相比无区别。在骶骨水平,作者发现无刺激对照组首先出现在骶骨水平脊髓表层的双侧分布的FLI与其它浓度异氟醚组相比无明显差异。不同浓度的氟烷的FLI数无明显不同。只有在能抑制有力、有意向和撤退反射浓度的异氟醚可减少FLI,但是氟烷即使达到抑制撤退反射浓度时也不降低FLI。结论:异氟醚和氟烷对有害刺激的伸肌功能和神经反应有不同的作用。

                                    (赵雪莲    庄心良 校)

We investigated the effects of isoflurane and halothane on the induction of fos-like immunoreactivity (FLI) in the rat lumbosacral spinal cord after supramaximal noxious mechanical stimulation of the hindpaw. Compared with unstimulated controls (0.9% isoflurane), noxious stimulation at 0.9%–1.5% elicited significant (0.9%–1.5% isoflurane) `increases in FLI bilaterally. FLI was distributed mainly in the superficial dorsal horn (laminae I–III) and, to a lesser extent, in the deep dorsal horn (laminae IV–VI) and intermediate zone (lamina VII), with three- to fivefold greater labeling ipsilaterally. At 1.8% isoflurane, mean FLI counts in all laminar regions were significantly smaller (1.7 ± 1.3 per section) compared with the other concentrations (11.4 ± 9.5, 7.5 ± 6.8, and 9.7 ± 6.6 at 0.9%, 1.2%, and 1.5%, respectively) but were not different from unstimulated controls. At sacral levels, we observed a bilateral distribution of FLI primarily in superficial laminae in unstimulated controls that was not significantly different at any isoflurane concentration. FLI counts were not significantly different across groups receiving halothane (0.9%–1.5%). FLI was reduced only at isoflurane concentrations that depressed both gross, purposeful movement and reflex withdrawal, whereas halothane did not cause depression even at concentrations that depressed withdrawal reflexes. Isoflurane and halothane may have differing effects on neuronal function and responses to noxious stimulation.


腹式子宫切除术后活动所致的疼痛及自发性疼痛与呼气流量峰值间的关系

The Relationship Between Movement-Evoked Versus Spontaneous Pain and Peak Expiratory Flow After Abdominal Hysterectomy

Ian Gilron, MD MSc, FRCPC, Debbie Tod, RN, David H. Goldstein, MD MSc, FRCPC, Joel L. Parlow, MD MSc, FRCPC, and Elizabeth Orr, RN

Departments of Anesthesiology and Pharmacology & Toxicology, Queen’s University, Kingston, Ontario, Canada

Anesth Analg Dec 2002;95:1719-1723                                                                          


背景:术后肺功能障碍的发病机制在活动导致疼痛中起了一定的作用(例如避免疼痛而引起的夹板效应和通气不足)。然而,活动所致的疼痛和呼吸生理学间的交互作用还未被了解。目的:研究活动所致疼痛和自发性疼痛与一项肺功能指标(PEF)之间的关系。方法:25例行子宫切除术的患者,在术后第一、二天内的八个时点记录其自发疼痛、坐位疼痛、被迫呼气及咳嗽时的视觉疼痛评分和呼气流量峰值(PEF),其次观察其氧饱和度和需氧量。结果:咳嗽、坐位、被迫呼气时的疼痛和自发性疼痛在八个时点中分别有八个、七个、四个、二个时点与PEF明显相关。咳嗽及坐位时的视觉疼痛评分(26.1 mm [1.7]21.5 mm [1.5])高于自发性疼痛(10.5 mm [0.8]),(P<0.05)。咳嗽时高于被迫呼气时的评分(16.8 mm [1.3]),(P<0.05)。研究过程中,所有的疼痛均得到缓解(P<0.05),PEF也有所恢复。可以假设咳嗽引起的疼痛与PEF之间存在负相关,部分是因为回避咳嗽,最终限制了深吸气、肺复张和分泌物的清除。结论:活动引起的疼痛可能是导致术后并发症的重要因素,但其机制尚未被了解。此研究提供了术后疼痛与肺功能间关系的第一手证据,并指出了今后需要继续研究此现象机制和意义。

                                               (   庄心良 校)

 

The pathogenesis of postoperative lung dysfunction implies a role for movement-evoked pain (e.g., splinting/hypoventilation because of pain avoidance). However, interactions between evoked pain and respiratory physiology are poorly understood. Thus, we examined the relationship between evoked versus spontaneous pain and one index of pulmonary function. In 25 patients having undergone a hysterectomy, visual analog scale ratings (100 mm) for spontaneous pain (REST) and pain during sitting (SIT), forced expiration (BLOW), and coughing (COUGH) were measured together with peak expiratory flow (PEF) at eight time points during postoperative Days 1 and 2. Secondary outcome measures included oxygen saturation and oxygen requirements. Pain was significantly correlated with PEF for COUGH, SIT, BLOW, and REST at eight, seven, four, and two of the eight studied time points, respectively. Mean visual analog scale scores [SE] for COUGH (26.1 mm [1.7]) and SIT (21.5 mm [1.5]) were greater (P < 0.05) than REST (10.5 mm [0.8]), and COUGH was greater (P < 0.05) than BLOW (16.8 mm [1.3]). All pain measures diminished (P < 0.05), and PEF reductions improved (P < 0.05) across the study period. We hypothesize that the consistent negative correlation of COUGH-evoked pain with PEF is, in part, caused by avoidance of coughing, which ultimately limits deep inspiration, lung reexpansion, and clearance of secretions.


加巴喷丁在格林-巴利综合征疼痛治疗中的应用——双盲、对照的交叉研究

Gabapentin for the Treatment of Pain in Guillain-Barré Syndrome: A Double-Blinded, Placebo-Controlled, Crossover Study

Chandra K. Pandey, MD*, Neeta Bose, MD*, Garima Garg, MD*, Namita Singh, MD PDCC*, Arvind Baronia, MD*, Anil Agarwal, MD*, Prabhat K. Singh, MD*, and Uttam Singh, PhD{dagger}

Departments of *Anaesthesiology and Critical Care Medicine and {dagger}Bio-statistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Anesth Analg Dec 2002;95:1746-1751

目的:评价加巴喷丁对缓解格林-巴利综合征疼痛的双峰特性的疗效。方法:对18名重症监护病房给予通气支持的患者进行了随机、双盲、对照的交互研究。在最初7天里,分别给予患者加巴喷丁15 mg · kg-1 · d-1(三次剂量)或用于对照的安慰剂,经过2天的清除期后,先前用加巴喷丁的患者改用安慰剂,用安慰剂的患者改用加巴喷丁。在患者需要时或在疼痛评分〉5分(评分为0-10分)时给芬太尼2 µg/kg。记录疼痛评分、镇静评分、芬太尼用量及副作用,并比较这些变量。结果:加巴喷丁治疗开始后第二天疼痛评分从7.22 ± 0.83 降至 2.33 ± 1.67,并在加巴喷丁治疗期间保持低水平(2.06 ± 0.63) (P < 0.001)。加巴喷丁治疗期间第一天至第七天的芬太尼用量(211.11 ± 21.39 µg 65.53 ± 16.17 µg)较安慰剂治疗期间(319.44 ± 25.08µg 316.67 ± 24.25 µg)明显减少(P < 0.001)。结论:加巴喷丁已经用于治疗各种类型的疼痛。其副作用小,是除阿片类药物和非甾体类抗炎药外治疗格林-巴利综合征双峰性疼痛的又一选择。

                                            (朱慧   庄心良  )

Pain syndromes of Guillain-Barré are neuropathic as well as nociceptive in origin. We aimed to evaluate the therapeutic efficacy of gabapentin in relieving the bimodal nature of pain in Guillain-Barré syndrome in a randomized, double-blinded, placebo-controlled, crossover study in 18 patients admitted to the intensive care unit for ventilatory support. Patients were assigned to receive either gabapentin (15 mg · kg-1 · d-1 in 3 divided doses) or matching placebo as initial medication for 7 days. After a 2-day washout period, those who previously received gabapentin received placebo, and those previously receiving placebo received gabapentin as in the initial phase. Fentanyl 2 µg/kg was used as a rescue analgesic on patient demand or when the pain score was >5 on a numeric rating scale of 0–10. The numeric rating score, sedation score, consumption of fentanyl, and adverse effects were noted, and these observed variables were compared. The numeric pain score decreased from 7.22 ± 0.83 to 2.33 ± 1.67 on the second day after initiation of gabapentin therapy and remained low during the period of gabapentin therapy (2.06 ± 0.63) (P < 0.001). There was a significant decrease in the need for fentanyl from Day 1 to Day 7 during the gabapentin therapy period (211.11 ± 21.39 to 65.53 ± 16.17 [µg]) in comparison to the placebo therapy period (319.44 ± 25.08 to 316.67 ± 24.25 [µg]) (P < 0.001).

 

气管拔管前增加吸入氧浓度对术后肺不张的影响

The Effect of Increased FIO2 Before Tracheal Extubation on Postoperative Atelectasis

Zilgia Benoît, MD*, Stephan Wicky, MD{dagger}, Jean-François Fischer, MD{ddagger}, Philippe Frascarolo, PhD*, Carine Chapuis, MD*, Donat R. Spahn, MD*, and Lennart Magnusson, MD PhD*

Departments of *Anesthesiology, {dagger}Radiology, and {ddagger}Trauma and Orthopedic Surgery, Centre Hospitalier Universitaire Vaudois, Lausanne, Suisse

Anesth Analg Dec 2002;95:1777-1781

全麻导致的肺不张可为肺活量手法(膨胀肺至40 cm H2O 15 s)消除 。高浓度氧吸入导致肺不张的再发生。因此,在拔管前吸入100%氧可能引起肺不张。为评价在拔管前使用100%氧是否增加术后肺不张的数量,我们研究了30位择期行四肢手术的病人。在预计手术结束前10分钟,病人随机分成(a)吸入氧FIO2 = 1.0 (n = 10)组;(b)肺活量手法+ FIO2 = 1.0 (n = 10)组;或(c)肺活量手法+ FIO2 = 0.4(n = 10)。以CT片测定肺不张发生的病例数,动脉血气分析检查氧合情况。以单侧方差分析,Bonferroni 法校正进行数据分析。结果以平均数± SD表示; P < 0.05为统计学有意义。在肺活量手法+ FIO2 = 0.4(总肺表面的2.6% ± 1.1%, P < 0.05),术后肺不张比 FIO2 = 1.0组(8.3% ± 6.2%)少。在全麻结束时吸入100%导致术后肺不张。从氧合的观点而言,气管拔管时的安全界限是必要的,因此进一步的研究应评价尽管应用了100%氧是否仍能防止肺不张的形成。

                                       (张 庄心良 校)

General anesthesia promotes pulmonary atelectasis, which can be eliminated by a vital capacity (VC) maneuver (inflation of the lungs to 40 cm H2O for 15 s). High-inspired oxygen concentration favors recurrence of atelectasis. Therefore, 100% oxygen before tracheal extubation may contribute to atelectasis.To evaluate whether the use of 100% oxygen before extubation increases the amount of postoperative atelectasis, we studied 30 adults scheduled for elective surgery of the extremities. Ten minutes before the presumed end of surgery, patients were randomly assigned to (a) a fraction of inspired oxygen (FIO2) = 1.0 (n = 10), (b) VC maneuver + FIO2 = 1.0 (n = 10), or (c) VC maneuver + FIO2 = 0.4 (n = 10). The amount of atelectasis was measured by computed tomography scan, and oxygenation was studied by arterial blood gas analysis. Data were analyzed by one-way analysis of variance with Bonferroni correction. Results are presented as mean ± SD; P < 0.05 was considered significant. In the VC maneuver + FIO2 = 0.4 group, postoperative atelectasis was smaller (2.6% ± 1.1% of total lung surface, P < 0.05) than in the FIO2 = 1.0 group (8.3% ± 6.2%) and in the VC maneuver + FIO2 = 1.0 group (6.8% ± 3.4%). Oxygen 100% at the end of general anesthesia promotes postoperative atelectasis. A safety margin in terms of oxygenation during tracheal extubation is essential, and further studies should therefore evaluate whether atelectasis formation could be prevented despite the use of 100% oxygen.

 

住院病人冠状动脉搭桥术后心率和死亡率间的关系

The Association Between Heart Rate and In-Hospital Mortality After Coronary Artery Bypass Graft Surgery
Mary P. Fillinger, Stephen D. Surgenor, Gregg S. Hartman, Cantwell Clark, Thomas M. Dodds, Athos J. Rassias, William C. Paganelli, Peter Marshall, David Johnson, Dennis Kelly, Dean Galatis, Elaine M. Olmstead, Cathy S. Ross, and Gerald T. O’Connor

Departments of *Anesthesiology and {dagger}Medicine, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire; {ddagger}Department of Anesthesiology, Catholic Medical Center, Manchester, New Hampshire; Department of Anesthesiology, Concord Hospital, Concord, New Hampshire; &Verbar||Dartmouth Medical School, Hanover, New Hampshire; ¶Department of Anesthesiology, Maine Medical Center, Portland, Maine; #Department of Anesthesiology, Central Maine Medical Center, Lewiston, Maine; and **Department of Anesthesiology, Fletcher Allen Health Care, Burlington, Vermont

Anesth Analg DEC2002 95: 1483-1488.

 

目的:避免心动过速是冠脉搭桥术(CABG)麻醉管理的共识。然而,术中心率增快和死亡率间的关系还未曾有所描述。方法:我们设计了一个观察性研究,来评估诱导前心率(到达手术室时的心率)和CABG手术住院死亡率之间的关系。结果:总共收集了5934CABG病人的数据。15%的病人有诱导前的心率增快(>80bpm)。这些病人初步计算的死亡率明显较高(P=0.002)。经过把病人间的差异以基线标准化后,诱导前的心率增快仍然与高死亡率密切相关(P<0.001)。心率的增快可能是被观察到的死亡率一个原因。快速的心率可能是不可逆心肌损害的标志,或者有进一步损害危险时心脏储备能力有限的标志,再就是ß阻滞剂用量不足。因为术前使用ß阻滞剂可以提高住院病人生存率,深入研究关于ß阻滞剂治疗术中心率增快对CABG术后死亡率的作用显得很有必要。结论:经基线差异调整后,诱导前心率>80bpmCABG术后死亡率增加有关。

                     (唐   庄心良 校)

Avoidance of tachycardia is a commonly described goal for anesthetic management during coronary artery bypass graft (CABG) surgery. However, an association between increased intraoperative heart rate and mortality has not been described. We conducted an observational study to evaluate the association between preinduction heart rate (heart rate upon arrival to the operating room) and in-hospital mortality during CABG surgery. Data were collected on 5934 CABG patients. Fifteen percent of patients had an increased preinduction heart rate >=80 bpm. Crude mortality was significantly more frequent among patients with increased preinduction heart rate (Ptrend = 0.002). After adjustment for baseline differences among patients, preinduction heart rate >=80 bpm remained associated with increased mortality (Ptrend < 0.001). The increased heart rate may be a cause of the observed mortality. Alternatively, faster heart rate may be either a marker of patients with irreversible myocardial damage, or a marker of patients with limited cardiac reserve at risk for further injury. Lastly, faster heart rate may be a marker for under-use of ß-adrenergic blockade. Because the use of preoperative ß-adrenergic blockade in CABG patients is associated with improved in-hospital survival, further investigation concerning the effect of intraoperative treatment of increased heart rate with ß-adrenergic blockers on mortality after CABG surgery is warranted.

 

实验检测家兔肝素活性变化:抗Xa活性与血栓弹性图、活化部分凝血活酶时间、激活凝血时间的比较

The Detection of Changes in Heparin Activity in the Rabbit: A Comparison of Anti-Xa Activity, Thrombelastography®, Activated Partial Thromboplastin Time, and Activated Coagulation Time
Vance G. Nielsen

Department of Anesthesiology (Divisions of Cardiothoracic Anesthesia and Anesthesiology Research), The University of Alabama at Birmingham, Birmingham, Alabama

Anesth Analg Dec2002 95: 1503-1506.

目的:血栓弹性图(Thrombelastography®TEG®)在临床和实验室中被用来检测外源和内源性循环肝素活性。在本研究中,给家兔以小剂量肝素,以期比较TEG®、活化部分凝血活酶时间(aPTT)和激活凝血时间(ACT)各值对抗Xa活性变化的敏感性。方法:静脉给与11只清醒家兔0102030u/kg肝素,从其耳动脉抽取血样用于血液学分析。结果:不同剂量下,抗Xa活性分别是38 ± 9 mU/mL74 ± 15 mU/mL105 ± 14 mU/mL134 ± 17 mU/mL,所有数值间的差异均有统计学意义。TEG® 参数R和α在01020 u/kg组间有显著改变(P<0.05),而2030 u/kg组间由于可看清的凝血块丢失而未能判别。aPTT 01020 u/kg组间有显著改变(P<0.05)。ACT在对照组与其他组间均有显著变化,但在各用药组间却未发现有明显差异。抗Xa活性与各参数间的线性关系:R (r = 0.81P < 0.0001),α(r = -0.85P < 0.0001),aPTTr = 0.74P < 0.0001),和ACTr = 0.41P = 0.005)。在本小剂量肝素模型中,TEG®对肝素活性的敏感性比的敏感性都要高。结论:在家兔的小剂量肝素模型中,TEG®aPTTACT更加敏感地反映循环肝素活性的变化。因此,无论在实验室还是临床对凝血病实施肝素治疗中,检测肝素活性用TEG®aPTTACT都更有帮助。

                     (唐   庄心良 校)

Thrombelastography (TEG®) has been used to detect both exogenous and endogenous circulating heparin activity in clinical and laboratory settings. Thus, in this study I sought to compare the sensitivity of TEG®, activated partial thromboplastin time (aPTT), and activated coagulation time (ACT) values with changes in anti-Xa activity after small-dose heparin administration in rabbits. Conscious rabbits (n = 11) had blood obtained from ear arteries for hematological analyses after the administration of 0, 10, 20, and 30 U/kg of IV heparin. Anti-Xa activities after the administration of 0, 10, 20, and 30 U/kg of heparin were, respectively, 38 ± 9 mU/mL, 74 ± 15 mU/mL, 105 ± 14 mU/mL, and 134 ± 17 mU/mL; all values were significantly different from each other. TEG® variables (R and {alpha}) significantly (P < 0.05) changed between 0, 10, and 20 U/kg heparin doses, but a difference between 20 and 30 U/kg could not be discerned secondary to loss of a detectable clot. The aPTT was significantly (P < 0.05) different between 0, 20, and 30 U/kg doses. ACT values were significantly different between the 0 U/kg heparin dose and all other doses; however, there were no significant differences between the 10, 20, and 30 U/kg heparin doses. Changes in anti-Xa activity were significantly linearly related to R (r = 0.81, P < 0.0001), {alpha}(r = -0.85, P < 0.0001), aPTT (r = 0.74, P < 0.0001), and ACT (r = 0.41, P = 0.005). In this model of small-dose heparin administration, TEG® variables were more sensitive to changes in heparin activity than aPTT and ACT.

 

 

麻醉药预处理减轻豚鼠离体完整心脏缺血时的线粒体钙超载

Anesthetic Preconditioning Attenuates Mitochondrial Ca2+ Overload During Ischemia in Guinea Pig Intact Hearts: Reversal by 5-Hydroxydecanoic Acid
Matthias L. Riess, Amadou K. S. Camara, Enis Novalija, Qun Chen, Samhita S. Rhodes, and David F. Stowe

Anesthesiology Research Laboratory, Departments of *Anesthesiology and {dagger}Physiology, and &Verbar||Cardiovascular Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin; {ddagger}Department of Anesthesiology and Intensive Care Medicine, University Hospital Münster, Münster, Germany; Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin; and ¶Research Service, Veterans Affairs Medical Center, Milwaukee, Wisconsin

Anesth Analg Dec.2002; 95: 1540-1546.

 

目的:心脏缺血再灌注损伤(IR)与线粒体钙超载有关。预先使用麻醉药可以减轻IR损伤。本文假定麻醉药减轻线粒体钙超载与线粒体腺苷酸敏感性钾通道(mKATP)开放有关。方法:使用吲哚-1indo-1)荧光,在40Langendorff灌注的豚鼠心脏中测量线粒体钙浓度(m[Ca2+])。对照组(CON)为接受IR50分钟未加处理的心脏,麻醉药预处理组(APC)则暴露在1.2 mM 8.8 vol%)七氟醚中15分钟。APC5-羟基癸酸(5-hydroxydecanoate5-HD)组(APC+5HD)在暴露于七氟醚的5分钟前到15分钟后时接受200 µM 5-HD5-HD组接受35分钟5-HD。在30分钟的完全缺血和120分钟的再灌注之前,洗脱七氟醚30分钟,洗脱5-HD 15分钟。结果:缺血中,APC组的m[Ca2+]峰值累计从489 ± 37 nMCON)降低到355 ± 28 nM P < 0.05),并可被5-HD消除(475 ± 38 nM m[Ca2+])。APC可增强心脏功能,并减少再灌注时的梗死面积,此作用可以被5-HD所阻断。而5-HD单独预处理则对m[Ca2+]470 ± 34 nM)和IR损伤没有影响。再灌注时功能和形态学上的保护与缺血时的m[Ca2+]累计值相关。5-HD的翻转作用提示APC可能为mKATP通道开放所触发。结论:心肌缺血再灌注损伤与线粒体钙超载有关。豚鼠离体心脏中测得的线粒体钙浓度和功能说明,麻醉药预处理减轻了缺血时的钙超载,增强了心功能,减小了梗死面积。5-HD的翻转作用则提示麻醉药的预防作用可能由线粒体腺苷酸敏感性钾通道开放触发。

(唐   庄心良 校)

Cardiac ischemia/reperfusion (IR) injury is associated with mitochondrial (m)Ca2+ overload. Anesthetic preconditioning (APC) attenuates IR injury. We hypothesized that mCa2+ overload is decreased by APC in association with mitochondrial adenosine triphosphate-sensitive K+ (mKATP) channel opening. By use of indo-1 fluorescence, m[Ca2+] was measured in 40 guinea pig Langendorff-prepared hearts. Control (CON) hearts received no treatment for 50 min before IR; APC hearts were exposed to 1.2 mM (8.8 vol%) sevoflurane for 15 min; APC + 5-hydroxydecanoate (5-HD) hearts received 200 µM 5-HD from 5 min before to 15 min after sevoflurane exposure; and 5-HD hearts received 5-HD for 35 min. Sevoflurane was washed out for 30 min and 5-HD for 15 min before 30 min of global ischemia and 120 min of reperfusion. During ischemia, the peak m[Ca2+] accumulation was decreased by APC from 489 ± 37 nM (CON) to 355 ± 28 nM (P < 0.05); this was abolished by 5-HD (475 ± 38 nM m[Ca2+]). APC resulted in improved function and reduced infarct size on reperfusion, which also was blocked by 5-HD. 5-HD pretreatment alone did not affect m[Ca2+] (470 ± 34 nM) or IR injury. Thus, preservation of function and morphology on reperfusion is associated with attenuated mCa2+ accumulation during ischemia. Reversal by 5-HD suggests that APC may be triggered by opening mKATP channels.


小剂量氧化氮增进单肺通气时的氧合:实验研究

Small-Dose Nitric Oxide Improves Oxygenation During One-Lung Ventilation: An Experimental Study
Jochen Sticher, Stefan Scholz, Olav Böning, Ralph Theo Schermuly, Claudia Schumacher, Dieter Walmrath, and Gunter Hempelmann `

Departments of *Anaesthesiology and Intensive Care Medicine and {dagger}Internal Medicine, Justus-Liebig University, Giessen, Germany

Anesth Analg Dec2002 95: 1557-1562.

 

目的:吸入20-40ppm的氧化氮(NO)不能增进单肺通气(OLV)时的动脉氧合。作者假定更低浓度的NO可能有助于氧合。方法:十二头26-32kg的小猪被用于试验。OLV中,当PaO2达到平台期时,随机吸入481632ppmNO30分钟。有创监测血液动力学数据。用动脉血液分析和通气血流分析(6头动物进行了复合惰性气体清除法)了解肺气体交换功能。结果:481632ppmNO均可增加PaO2,其中4ppm的作用最为明显(ΔPaO2分别为42 ± 35 mm Hg22 ± 20 mm Hg13 ± 18 mm Hg15 ± 16 mm HgP < 0.05)。4ppmNO可减少肺内分流,而更大浓度并没有表现出更有意义的结果。结论:NO在低浓度,即4ppm时比高浓度更加有助于提高动脉氧合,其原因是减少了肺内分流,其量效关系还有待于OLV急性低氧实验证实。

                       (唐   庄心良 校)

Inhaled nitric oxide (NO) at 20 or 40 ppm does not improve arterial oxygenation during one-lung ventilation (OLV). The authors hypothesized that NO at smaller concentrations might improve oxygenation. Twelve piglets weighing 26 to 32 kg were studied. When PaO2 had reached a plateau during OLV, NO at doses of 4, 8, 16, and 32 ppm were randomly administered for 30 min. Hemodynamic data were determined by invasive monitoring. Blood gas analysis and, in six animals, ventilation-perfusion analysis by the multiple inert gas elimination technique were used to characterize pulmonary gas exchange. NO at 4, 8, 16, and 32 ppm improved PaO2 during OLV. NO at 4 ppm had a more intense effect on arterial oxygenation than doses of 8, 16, and 32 ppm ({Delta}PaO2, 42 ± 35 mm Hg versus 22 ± 20 mm Hg, 13 ± 18 mm Hg, and 15 ± 16 mm Hg; P < 0.05). NO at 4 ppm reduced intrapulmonary shunt flow, whereas a larger concentration exhibited no statistically significant effect. The authors conclude that NO improves arterial oxygenation more effectively at smaller doses than at larger doses. This dose-dependent effect remains to be confirmed in acute hypoxemia during OLV.

 

体外循环后48小时内高热

Hyperthermia in the Forty-Eight Hours After Cardiopulmonary Bypass

Weng Y. Thong, MD*, Andrew G. Strickler, MS*, Shu Li, MD*, Elester E. Stewart, RN*, Connie L. Collier, RN*, William K. Vaughn, PhD{dagger}, and Nancy A. Nussmeier, MD*

Departments of *Cardiovascular Anesthesiology and {dagger}Biostatistics and Epidemiology, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston

Anesth Analg Dec. 2002 95: 1489-1495

目的 围手术期低温引起的不良后果已被重视。然而,由于高热增加氧供需求和潜在的神经损伤同样能对患者构成危险。方法 为了了解体外循环后出现高热(膀胱温度≥38.5)的几率,术后48小时内在监护室305例病患每小时记录一次膀胱温度,40例记录鼻咽腔温度,20例记录颈静脉球温度。结果 虽然不是所有患者都在监护室观察48小时,但是至少38%的患者出现术后高热。几率呈现双峰值分布,分别在术后9.1±4.0小时(26%)和27.7±6.326%)。其中有14%的患者在二个时间点上均出现高热。在术后前5小时内,颈静脉球温度比膀胱温度高0.4P0.05=。膀胱温度和鼻咽腔温度则没有差别。监护室环境温度较高和年龄小于60岁与高热的出现无关。结论 总之,在心脏手术体外循环后48小时内早或晚出现高热是普遍现象。体外循环后脑性高热可能引起严重脑部损伤。

(李 薛张纲 校)

The adverse consequences of perioperative hypothermia have been emphasized. However, postoperative hyperthermia may be equally hazardous after cardiac surgery, owing to increased oxygen demand and potential exacerbation of neurologic injury. To determine the incidence of hyperthermia (bladder temperature [BT] >=38.5°C) after cardiopulmonary bypass, we recorded hourly postoperative BT (n = 305), nasopharyngeal (n = 40), and jugular venous bulb (n = 20) temperatures for up to 48 h after admission to the intensive care unit (ICU). At least 38% of the patients developed postoperative hyperthermia, although all patients did not remain in the ICU for 48 h. The incidence of hyperthermia peaked with a bimodal distribution at 9.1 ± 4.0 h (26%) and at 27.7 ± 6.3 h (26%). Of these, 14% of the patients were hyperthermic at both times. For the first 5 postoperative h, jugular venous bulb temperature was 0.4°C higher than the BT (P < 0.05). There was no difference between BT and nasopharyngeal temperature. Higher temperature on ICU entry and age <60 yr were independently associated with hyperthermia (P < 0.05). In summary, postoperative hyperthermia is common, with both early and late occurrences during the first 48 h after cardiac surgery with cardiopulmonary bypass.

 

有严重左室收缩功能障碍的患者行冠脉搭桥术预后与术前右室功能有关Precardiopulmonary Bypass Right Ventricular Function Is Associated with Poor Outcome After Coronary Artery Bypass Grafting in Patients with Severe Left Ventricular Systolic Dysfunction

 Andrew D. Maslow, MD*, Meredith M. Regan, ScD{dagger}, Peter Panzica, MD{dagger}, Stephanie Heindel, MD{dagger}, John Mashikian, MD{dagger}, and Mark E. Comunale, MD{dagger}

*Department of Anesthesiology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island; and {dagger}Beth Israel Deaconess Medical Center, Boston, Massachusetts

Anesth Analg Dec. 2002 95: 1507-1518.

目的 有严重左室收缩功能障碍的患者行冠状动脉搭桥手术后并发症发生率和死亡率都上升。本研究的目的在于评价术前右室功能和术前具有左室收缩功能障碍患者行冠脉搭桥术的预后的相关性。方法 我们回顾性研究了41名患者(左室射血分数≤25%)。数据采集来自医疗记录、经食道超声记录和电话采访。体外循环前后的左室射血分数和右室射血分数的测定采用术中经食道超声。第一组患者右室射血分数≤35%(7例),第二组右室射血分数>35%(34例)。机械通气、ICU入住时间和总住院时间取中位数。术前左室射血分数在两组患者是相似的(15.8±3.3%和17.8% ± 3.9%)。结果 与第二组相比,第一组患者需要更多机械通气的时间(12天比1天,P < 0.01),ICU监护时间更长(14天比2天,P < 0.01),出现更多更严重的左室舒张功能障碍,体外循环后左室收缩压的改变更小(4.1% ± 8.3% 12.5% ± 9.2% P < 0.01)。所有第一组患者术后2年死于心脏原因,其中5例在当次住院期间死亡。第二组有3例病人死亡(1例于术后18个月死于结肠癌,2例分别在术后2448个月死于心脏问题),1例患者于术后4年等待心脏移植,其余患者心功能级(纽约心脏协会)。结论 对严重左室手术功能不全的患者来说,体外循环前伴有右室功能不全者预后差。患者右室射血分数>35%者能相对平稳度过围手术期并能较好长期生存,而右室射血分数≤35%的患者早期和晚期预后均较差。进行右室功能的评估对进一步评价冠脉搭桥手术的风险有一定帮助。

(李 薛张纲 校)

Patients with severe left ventricular systolic dysfunction (LVSD) undergoing coronary artery bypass grafting (CABG) have an increased risk for morbidity and mortality. The purpose of this study was to assess the association of pre-CABG right ventricular (RV) function with outcome for patients with severe LVSD. We performed a retrospective evaluation of 41 patients with severe LVSD (left ventricular ejection fraction [LVEF] <=25%) scheduled for nonemergent CABG. Data were obtained from review of medical records, transesophageal echocardiography tapes, and phone interview. The pre- and post-cardiopulmonary bypass (CPB) LVEF and the RV fractional area of contraction (RVFAC) were calculated by using intraoperative transesophageal echocardiography. Group 1 patients had an RVFAC <=35% (n = 7), whereas Group 2 patients had RVFAC >35% (n = 34). The durations of mechanical ventilation and of intensive care unit and hospital stays are presented as the median. Pre-CABG LVEF was similar between Groups 1 and 2 (15.8% ± 3.3% versus 17.8% ± 3.9%). Compared with Group 2, Group 1 patients required greater duration of mechanical ventilation (12 days versus 1 day; P < 0.01), longer intensive care unit (14 versus 2 days; P < 0.01) and hospital (14 versus 7 days; P = 0.02) stays, had a more frequent incidence and severity of LV diastolic dysfunction, and had a smaller change in LVEF immediately after CPB (4.1% ± 8.3% versus 12.5% ± 9.2%; P = 0.03). All Group 1 patients died of cardiac causes within 2 yr of surgery; five died during the same hospital admission. Three Group 2 patients died: one of colon cancer at 18 mo after CABG and two of cardiac causes 24 and 48 mo after surgery. A fourth patient was awaiting cardiac transplantation 4 yr after surgery. The remaining Group 2 patients were New York Heart Association Classification I or II. For patients with severe LVSD undergoing CABG, pre-CPB RV dysfunction was associated with poor outcome. Patients with RVFAC >35% had a relatively uneventful perioperative course and good long-term survival, whereas patients with RVFAC <=35% had a poor early and late outcome. Assessment of RV function is useful to further assess the risk of CABG.

心脏保护措施对腹主动脉手术后心脏并发症发生率的影响

The Impact of a Cardioprotective Protocol on the Incidence of Cardiac Complications After Aortic Abdominal Surgery

Marc Licker, MD*, Gregory Khatchatourian, MD{dagger}, Alexandre Schweizer, MD*, Marek Bednarkiewicz, MD{dagger}, Didier Tassaux, MD*, and Catherine Chevalley, MD*

*Division of Anesthesiology and {dagger}Clinic of Cardiovascular Surgery, University Hospital, Geneva, Switzerland

Anesth Analg Dec. 2002; 95: 1525-1533.

目的 我们分析了研究所8年来468例择期行腹主动脉手术的病人的病案资料。在19971月一个新的心脏保护措施被采用,我们想探讨是否应用美国心脏大学/心脏病协会指南来一步一步的围术期评价和应用肾上腺受体的拮抗药对心脏有利影响。手术中给可乐定,手术后给β-受体的拮抗剂使心率小于80/分。方法 我们比较19931996(控制期)年和19972000年(干预期)两组四年的数据。结果 应用美国心脏大学/心脏病协会指南来一步一步的围术期评价和增加围术期心脏的检查是一致的(44.3%20.6,p<0.05)也和冠状血管的再血管化一致的。(7.7%0.8% p<0.05)。在干预期心脏并发症的发生率降低(从11..3%4.5%)。手术后一年生存律增加从91..3%98.2%)多变量回归分析显示联合应用可乐定和β-受体的拮抗剂降低心脏不良事件的发生(0..3,95%的可信区间0.1-0.8),而大出血、肾功能不全、慢阻肺预示心脏并发症。结论 心脏试验对一小部分得益于再血管化的高危病人有益。连续和选择性的应用肾上腺受体的拮抗药可改善手术后心脏功能。

(嵇富海 薛张纲 校)

We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and ß-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993–1996 [control period] versus 1997–2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and ß-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1–0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome.

 

术前临床评估的变化对减少心脏科会诊次数和提高心脏科会诊质量的影响

The Effect of Alterations in a Preoperative Assessment Clinic on Reducing the Number and Improving the Yield of Cardiology Consultations

Lawrence C. Tsen, MD*, Scott Segal, MD*, Margaret Pothier, CRNA*, L. Howard Hartley, MD{dagger}, and Angela M. Bader, MD*

*Departments of Anesthesiology, Perioperative and Pain Medicine and {dagger}Internal Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts

Anesth Analg Dec.2002; 95: 1563-1568.

目的 虽然术前临床实验评估(preoperative assessment testing clinics  PATCs)能有效得评估择期手术的患者,但是它对会诊的影响还未被研究。我们假设改变PTCA的操作程序,教育方式和工作人员能影响心脏科医生会诊的次数和效率。方法 1993年至1999年回顾性研究了所有择期非心脏手术的患者(麻醉科要求心脏科会诊)的 PATC。该时期覆盖了PATC改变的前后3年,而改变表现择更严格的咨询方式、心脏评估、心电图解释、麻醉师和辅助人员的变更。一位高级心脏科医生完成了所有的会诊。速率包括年龄、性别、会诊的原因、测试结果及结论、手术取消及手术过程和结果。结果 PATC改变前后的两组分别有917次和279次会诊(1.46%比.49%,P = 0.00010 非心脏手术)。PATC改变后的一组患者尽管外科夹杂症有所增加,但是心脏科会诊和要求进一步评估心功能状态的情况明显减少。结论 我们认为PATC的改变(包括咨询方式、教育、人员等)显著减少了术前心脏科会诊的次数,提高了会诊的效率。

(李 懿译 薛张纲 校)

Although preoperative assessment testing clinics (PATCs) can produce efficiency in the evaluation of surgical candidates, their effect on the use of consultants has not been studied. We hypothesized that changes in PATC procedures, education, and staffing could affect the use and yield of cardiology consultations. All PATC anesthesiologist-requested cardiology consultations for patients undergoing elective noncardiac surgery from 1993 to 1999 were reviewed. This period corresponded to 3 yr before and after a change in the PATC leadership, which resulted in more stringent consultation algorithms, a cardiac assessment and electrocardiogram interpretation educational program, and altered staffing of anesthesiologists and ancillary personnel. A single senior cardiologist completed all consultations. Data including age, sex, reason for consultation, resultant testing, consultant conclusions, cancellations, and surgical procedure and outcomes were collected. In the PRE and POST groups, respectively, 917 and 279 consultations (1.46% versus 0.49% [P = 0.0001] of noncardiovascular surgeries) were ordered despite an increase in the surgical case-mix acuity. In the POST group, significantly fewer consultations were ordered and significantly more required further testing to assess cardiac status. We conclude that changes in PATC consultation algorithms, education, and staffing can significantly decrease the use and yield of preoperative cardiology consultations.

 

双频谱指数监测:正常儿童和Quadrplegic脑瘫儿童之间对照

Bispectral Index Monitoring: A Comparison Between Normal Children and Children with Quadriplegic Cerebral Palsy

Dinesh K. Choudhry, MD FRCA, and B. Randall Brenn, MD

Department of Anesthesiology and Critical Care, Alfred I. duPont Hospital for Children, Wilmington, Delaware

Anesth Analg Dec2002 95: 1582-1585.

 

目的 我们进行该项研究来比较正常儿童和那些精神发育阻滞的Ouadrplegic脑瘫儿童在不同七氟醚浓度时双频谱指数数值得相关程度。方法 214岁的20名精神发育阻滞的脑瘫儿童(组)和21名正常儿童(组)作为研究对象。以七氟醚和66N2O/O2进行麻醉诱导和维持。应用Aspect Medical Systems (Natick, MA)监测仪记录双频谱指数,Ohmeda (Hanover, MA)吸入麻醉气体监测仪测算七氟醚的浓度。分别在应用术前药咪达唑伦后,麻醉诱导后,呼气末七氟醚浓度达到1%、3%、再次降至1%时和麻醉苏醒后记录双频谱指数。两组病人在年龄和性别上均衡性好。但是组的患儿体重明显低于组正常儿童(P0.05=。结果 组患儿在镇静后,七氟醚浓度1%和苏醒后的双频谱指数显著低于组正常儿童。两组在麻醉诱导后(8%)和七氟醚浓度为3%时没有差别。结论 虽然在苏醒后和不同的七氟醚浓度下那些脑瘫儿童的双频谱指数绝对值低于正常儿童,但整体上双频谱指数的变化模式在两组儿童间是相似的。

(李 薛张纲 校)

We performed this study to compare the correlation of bispectral index (BIS) values with different sevoflurane concentrations between normal children and those with quadriplegic cerebral palsy with mental retardation (CPMR). Twenty children with CPMR (Group I) and 21 normal children (Group II) between 2 and 14 yr of age were studied. Anesthesia was induced and maintained with sevoflurane and 66% N2O/O2. Bispectral values were recorded on an Aspect Medical Systems (Natick, MA) monitor, and sevoflurane concentrations were measured with an Ohmeda (Hanover, MA) inhaled anesthetic monitor. The BIS values were recorded after midazolam premedication; after the induction of anesthesia; at end-tidal sevoflurane concentrations of 1%, 3%, and again at 1%; and after emergence from the anesthetic. Both groups were similar in age and sex distribution, but children in Group I weighed less than those in Group II (P < 0.05). The BIS values were significantly lower in Group I compared with Group II after sedation, at 1% sevoflurane concentrations, and after emergence. No difference was observed between the two groups at anesthesia induction (8%) and at 3% sevoflurane concentration. We conclude that, in children with CPMR, BIS values exhibit a pattern of change similar to that observed in normal children. However, absolute BIS values obtained in such children are lower than those in normal children while awake and at different sevoflurane concentrations.

 

门诊手术小剂量利多卡因-芬太尼蛛网膜下腔麻醉:比较预防性应用NalbuphineNalbuphine加氟哌啶

Minidose Lidocaine-Fentanyl Spinal Anesthesia in Ambulatory Surgery: Prophylactic Nalbuphine Versus Nalbuphine Plus Droperidol

Bruce Ben-David, MD*, Patrick J. DeMeo, MD{dagger}, Christen Lucyk, RN ADN*, and David Solosko, MD*

Departments of *Anesthesiology and {dagger}Orthopedic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania

Anesth Analg Dec 2002 95: 1596-1600.

目的 小剂量利多卡因-芬太尼蛛网膜下腔阻滞对于门诊手术是一种安全、有效和经济的麻醉方法。但遗憾的是它常常会引起瘙痒和恶心呕吐等并发症。Nalbuphine能有效地治疗和预防鞘内或硬膜外应用吗啡引起的瘙痒,但对恶心呕吐没有作用。而氟哌啶有拮抗鸦片类药物对神经系统的作用。该研究比较了小剂量利多卡因-芬太尼蛛网膜下腔麻醉后单用Nalbuphine和联合应用Nalbuphine加氟哌啶的预防作用。方法 124例门诊膝关节镜手术的病人行小剂量利多卡因-芬太尼蛛网膜下腔麻醉,应用0.5%利多卡因20mg和芬太尼20μg,随机在术后注射Nalbuphine 4mgN组)或Nalbuphine 4mg联合氟哌啶0.625mgND组)。结果 早期(未离院时)和后期出现的并发症恶心分别是N18%相对于ND5%和N32%相对于ND13%。术后瘙痒N61%而ND组为40%,19%的N组病人要求止痒而只有2%的ND组病人要求处理瘙痒。ND组病人痛觉评分低,首次止痛后间隔周期较长。两组病人评价的离院时间没有差别。ND组唯一的药物副作用是引起嗜睡。结论 小剂量利多卡因-芬太尼蛛网膜下腔麻醉联合应用氟哌啶0.625mgNalbuphine 4mg作为预防性用药优于单独使用Nalbuphine。能够减少术后恶心、瘙痒和疼痛,并在离院后持续作用。同时也没有出现极端延搁离院的个别病例。

(李懿 薛张纲 校)

Minidose lidocaine-fentanyl spinal anesthesia (SABMLF) is a safe, effective, and efficient anesthetic for ambulatory surgery. Unfortunately, it has a frequent incidence of pruritus and a substantial incidence of nausea and vomiting. Nalbuphine is effective in treating or preventing pruritus after intrathecal or epidural morphine but may or may not have a beneficial effect on nausea and vomiting. Droperidol has demonstrated antiemetic efficacy with neuraxial opiates. In this study, we examined the prophylactic use of nalbuphine alone compared with nalbuphine with droperidol after SABMLF. One-hundred-twenty-four patients having outpatient knee arthroscopy under SABMLF with 20 mg of lidocaine 0.5% and 20 µg of fentanyl were randomized to receive IV at the end of surgery either 4 mg of nalbuphine (Group N) or droperidol 0.625 mg plus nalbuphine 4 mg (Group ND). The incidences of early (before discharge) and late onset nausea were, respectively, 18% versus 5% and 32% versus 13%. The postoperative incidences of pruritus were 61% versus 40%, whereas 19% of patients in Group N compared with 2% of patients in Group ND requested treatment for this. Group ND had lower pain scores and had a longer delay until first use of analgesic. There were no differences in average times to discharge. The only side effect of the medications was an increased drowsiness in Group ND. In conclusion, as prophylactic medication for use in conjunction with SABMLF, the addition of droperidol 0.625 mg to nalbuphine 4 mg was superior to nalbuphine alone. The combination provided for reduced postoperative nausea, pruritus, and pain—benefits that persisted after discharge home. The combination also avoided isolated cases of extreme delay in discharge.

 

围手术期患者状态指数与脑双频指数的比较

A Comparison of Patient State Index and Bispectral Index Values During the Perioperative Period

Xiaoguang Chen, MD*, Jun Tang, MD*, Paul F. White, PhD MD, FANZCA*, Ronald H. Wender, MD{dagger}, Hong Ma, MD{dagger}, Alexander Sloninsky, MD{dagger}, and Robert Kariger, MD{dagger}

*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas; and {dagger}Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California

Anesth Analg Dec 2002 95: 1669-1674.

目的 患者状态指数(PSI),作为一种量化脑电图指数,最近被引用到临床实践用来监测评价镇静和全麻中意识状态(清醒程度)。方法 我们设计了这个观察性研究,比较PSIBIS在设计神志丧失和麻醉清醒能力上的敏感性和特异性以及评估麻醉维持期间静脉麻醉药(异丙酚)和吸入麻醉药(地氟醚)的变化。这一前瞻性临床研究收录了二十位择期行腹腔镜手术的知情同意患者。麻醉诱导用异丙酚2mg/kg,芬太尼1µgcisatracurium 0.3 mg/kg,麻醉维持用4%地氟醚复合一氧化二氮。结果 logistic回归模型分析,BISPSI均能有效地预计神志丧失(如对语言刺激无反应性)(P < 0.01)而且在全麻的诱导和苏醒阶段,BISPSI均表现为相关性(r 分别为 0.780.73)。然而用来检测神志状态的接受器运行特征性曲线下面积表明PSI0.95 ± 0.04)优于BIS对异丙酚(0.79 ± 0.04)。在麻醉维持阶段,BISPSI对异丙酚和地氟醚变化的反应具有可比性,但PSI的病人间变异率更大。最后BISPSI相比在术中受电灼器的干扰更小(16%65%)。结论 PSI被证明可作为全麻诱导和苏醒阶段评价意识状态的可行性替代选择,也可认为麻醉维持阶段异丙酚和地氟醚剂量调整的一个指标。然而,我们仍需用PSA装置对PSI在麻醉中的地位作进一步的研究。

(潘志浩 薛张纲 )

The patient state index (PSI), a quantitative electroencephalographic index, has been recently introduced into clinical practice as a monitor for assessing consciousness during sedation and general anesthesia. We designed this observational study to compare the sensitivity and specificity of the PSI with that of the bispectral index (BIS) with respect to their ability to predict the loss of consciousness and emergence from anesthesia, as well as to assess changes in IV (propofol) and inhaled (desflurane) anesthetics during the maintenance period. Twenty consenting patients scheduled for elective laparoscopic surgical procedures were enrolled in this prospective clinical study. Anesthesia was induced with propofol 2 mg/kg IV and fentanyl 1 µg/kg IV, and tracheal intubation was facilitated with cisatracurium 0.3 mg/kg IV. Desflurane 4% in combination with nitrous oxide 60% in oxygen was administered for the maintenance of anesthesia. Comparative PSI and BIS values were obtained at specific time intervals during the induction, maintenance, and emergence periods. The changes in these indices were recorded after the administration of propofol (20 mg IV) or with 2% increases or decreases in the inspired concentration of desflurane during the maintenance period. With logistic regression models, both the BIS and PSI were found to be effective as predictors of unconsciousness (i.e., failed to respond to verbal stimuli) (P < 0.01). The PSI also correlated with the BIS during both the induction of (r = 0.78) and emergence from (r = 0.73) general anesthesia. However, the area under the receiver operating characteristic curve for detection of consciousness indicated a better performance with the PSI (0.95 ± 0.04) than the BIS (0.79 ± 0.04). During the maintenance period, the PSI values were comparable to the BIS in response to changes in propofol and desflurane but displayed greater interpatient variability. Finally, the PSI (versus BIS) values were less interfered with by the electrocautery unit during surgery (16% versus 65%, respectively). In conclusion, the PSI may prove to be a viable alternative to the BIS for evaluating consciousness during the induction of and emergence from general anesthesia, as well as for titrating the administration of propofol and desflurane during the maintenance period. However, further studies with the PSA device are needed to determine its role in anesthesia.

 

乙酰胆碱受体与三氟乙醚及12-二氯乙氟环丁烷致惊厥阈值的关系

Acetylcholine Receptors and Thresholds for Convulsions from Flurothyl and 1,2-Dichlorohexafluorocyclobutane

Edmond I Eger, II, MD*, Diane Gong, BS*, Yilei Xing, MD*, Douglas E. Raines, MD{dagger}, and Pamela Flood, MD{ddagger}

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; {dagger}Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts; and {ddagger}Department of Anesthesiology, Columbia University, New York

Anesth Analg Dec 2002 95: 1611-1615.

目的 乙酰胆碱受体遍布整个中枢神经系统,它们可能介导了某些方式的惊厥或惊厥的某些方面。在大脑中,结合烟碱、胞苷和epibatidine的烟碱乙酰胆碱受体上的大部分高亲和力结合位点都含有β2亚基。过渡型吸入复合物(指那些效能低于其亲脂性和Meyer-Overton假说系统的值得复合物)和非制动剂(指那些尽管根据Meyer-Overton假说预计应具有亲脂性应有的麻醉效能却不能产生不动性的复合物)可导致惊厥。非制动剂三氟乙醚(双三氟乙基醚)在γ-氨基丁酸-AGABA-A受体上阻滞了GABA的作用。而另一种非制动剂12-二氯乙氟环丁烷(2N;也称F6)并没有此中作用。2N可认为在烟碱乙酰胆碱受体上阻断乙酰胆碱作用。方法 我们观察了在乙酰胆碱受体β2亚基正常或缺失小鼠重这些复合物致惊厥的相对能力。结果 发现使半数小鼠致惊厥的气体分压(即半数有效浓度EC50)试验组与对照组相同。在β2亚基缺失的小鼠,三氟乙醚的EC500.00170±0.00030 atm(平均数±标准差),2NEC500.0345 ± 0.0041 atm。对照组的EC50分别为0.00172 ± 0.00057 atm 0.0341 ± 0.0048 atm。缺失组比值,2N/三氟乙醚为20.8 ± 3.5,对照组为2N/三氟乙醚为21.7 ± 7.0。结论 这些结果并不支持乙酰胆碱受体是2N或三氟乙醚致惊厥能力的重要介体的说法。然而,我们还发现两种非制动剂在EC50分压时都抑制了大鼠{alpha}4ß2神经元烟碱乙酰胆碱受体(EC50分压:三氟乙醚0.00094 atm2N 0.062 atm)这些分压值与致惊厥的分压值相似(0.0015 atm and 0.04 atm)。

(梁雅芬 薛张纲 校)

There are acetylcholine receptors throughout the central nervous system, and they may mediate some forms and aspects of convulsive activity. Most high-affinity binding sites on nicotinic acetylcholine receptors for nicotine, cytisine, and epibatidine in the brain contain the ß2 subunit of the receptor. Transitional inhaled compounds (compounds less potent than predicted from their lipophilicity and the Meyer-Overton hypothesis) and nonimmobilizers (compounds that do not produce immobility despite a lipophilicity that suggests anesthetic qualities as predicted from the Meyer-Overton hypothesis) can produce convulsions. The nonimmobilizer flurothyl [di-(2,2,2,-trifluoroethyl)ether] blocks the action of {gamma}-aminobutyric acid on {gamma}-aminobutyric acidA receptors, whereas the nonimmobilizer 1,2-dichlorohexafluorocyclobutane (2N, also called F6) does not. 2N can block the action of acetylcholine on nicotinic acetylcholine receptors. We examined the relative capacities of these compounds to cause convulsions in mice having and lacking the ß2 subunit of the acetylcholine receptor. The partial pressure causing convulsions in half the mice (the 50% effective concentration [EC50]) was the same as in control mice. For the knockout mice, the EC50 for flurothyl was 0.00170 ± 0.00030 atm (mean ± SD), and for 2N, it was 0.0345 ± 0.0041 atm. For the control mice, the respective values were 0.00172 ± 0.00057 atm and 0.0341 ± 0.0048 atm. The ratio of the 2N to flurothyl EC50 values was 20.8 ± 3.5 for the knockout mice and 21.7 ± 7.0 for the control mice. These results do not support the notion that acetylcholine receptors are important mediators of the capacity of 2N or flurothyl to cause convulsions. However, we also found that both nonimmobilizers inhibit rat {alpha}4ß2 neuronal nicotinic acetylcholine receptors at EC50 partial pressures (0.00091 atm and 0.062 atm for flurothyl and 2N, respectively) that approximate those that produce convulsions (0.0015 atm and 0.04 atm).

 

硬膜外腔注射类固醇激素的门诊疼痛治疗病人使用非甾体抗炎药的出血并发症风险评估

Risk Assessment of Hemorrhagic Complications Associated with Nonsteroidal Antiinflammatory Medications in Ambulatory Pain Clinic Patients Undergoing Epidural Steroid Injection

Terese T. Horlocker, MD*, Zahid H. Bajwa, MD{ddagger}, Zubaira Ashraf, MD{ddagger}, Sajid Khan, MD{ddagger}, Jack L. Wilson, MD*, Naveed Sami, MD{ddagger}, Christine Peeters-Asdourian, MD{ddagger}, Christopher A. Powers, MD*, Darrell R. Schroeder, MS{dagger}, Paul A. Decker, MS{dagger}, and Carol A. Warfield, MD{ddagger}

Departments of *Anesthesiology and {dagger}Health Sciences Research, Mayo Clinic, Rochester, Minnesota, and {ddagger}Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Anesth Analg Dec2002 95: 1691-1697.

我们前瞻性研究了1214例硬膜外注射类固醇激素中的1035例病人以明确出血并发症的风险。存在出血或淤斑病史的患者有176例(占15%)。有77例在硬膜外注射类固醇激素前进行了血小板计数,其中无一例低于100 x 109/L383例(占32%)报道使用了非甾体抗炎药(NASID,包括34例复合用药的病人。阿斯匹林是最为常用的NASID,其中有158例病人使用阿斯匹林,包括104例每天剂量在325 mg或以下的病人。没有一例发生脊髓血肿(严重并发症),在穿刺或置管时明显出血(轻度并发症)的病人有63例(占5.2%)。NSAIDs 不增加轻度出血并发症的发生率。但是,增加的年龄、穿刺针号、穿刺入路、多间隙穿刺、穿刺次数、注入药物的容量及意外硬膜穿透则都是发生轻度出血并发症的显著风险因素。有42 例病人出现新的神经症状或原有的主诉恶化,这些表现在注入后持续超过24小时,症状平均持续3(range, 1–20 days)。我们的结果证实了以前在产科和外科病人中进行的研究结论:在接受NSAIDS治疗的这类病人中进行神经阻滞是安全的。我们推论在接受阿斯匹林类抗血小板药物治疗的病人中进行硬膜外注射类固醇激素是安全的,在硬膜外注射类固醇激素后可能发生神经功能轻度恶化,应注意与其它的需要干预治疗的病因鉴别。结论:以前在产科和外科病人中进行的研究表明抗血小板治疗不增加发生脊麻或硬膜外麻醉和止痛相关的脊髓血肿的发生率。我们证实了接受阿司匹林类抗血小板药物治疗的病人硬膜外注射类固醇激素的安全性。

(张俊峰译 薛张纲校)

We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 109/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1–20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention. IMPLICATIONS: Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.

 

在神经外科病人上使用一种新型热交换导管的初步经验

Initial Experience with a Novel Heat-Exchanging Catheter in Neurosurgical Patients

Anthony G. Doufas, MD PhD*, Ozan Akça, MD*, Atul Barry, MD{dagger}, David A. Petrusca, MD{ddagger}, Mohammad-Irfan Suleman, MD*, Nobutada Morioka, MD*, John J. Guarnaschelli, MD{ddagger}, and Daniel I. Sessler, MD*

*Outcomes Research® Institute and Department of Anesthesiology, University of Louisville; {dagger}Department of Anesthesiology, Jewish Hospital Health Care Services, Louisville; {ddagger}Neurosurgical Group of Greater Louisville and Southern Indiana, Louisville, Kentucky; and Ludwig Boltzmann Institute, University of Vienna, Austria

Anesth Analg Dec 2002 95: 1752-1756.

目的 虽然轻度低温在动物模型上对脑缺血提供了显著的保护作用,低温在脑外科手术中可能有治疗价值。然而,目前的冷却系统常不能在硬脑膜切开前诱发足够的低温。而且,这些系统常常未能在手术结束时恢复常温,因此会延迟拔管。我们对一种新型内部热交换导管进行了评价。方法 8 ASA II–IV级的开颅病人(29–72)列入研究。在全麻诱导后,我们将SetPoint导管通过股静脉放置到下腔静脉。目标核心体温34°C–34.5°C。在达到目标温度后,核心温度维持直到硬脑膜关闭。目标核心温度然后设定到37.0°C,病人尽可能快速复温。结果 病人中7例是肿瘤切除,1例是动脉瘤夹闭。核心温的冷却速度为3.9°C ± 1.6°C/h, 复温速度是 2.0°C ± 0.5°C/h; 手术结束时核心温度是 35.9°C ± 0.2°C。病人然后在导管拔出前保持常温3小时。在拔出的导管上没有血栓或其他微粒物质。没有一个病人出现与SetPoint系统或热处理有关的并发症。结论 因为目前的系统诱导治疗性低温的速度太慢,我们对一种内部逆流热处理系统在低温神经外科手术上进行了测试。SetPoint导管以3.9°C ± 1.6°C/h速度冷却 ,以2.0°C ± 0.5°C/h的速度复温。导管为基础的内部热处理系统看来是快速而有效的。

(潘志浩 薛张纲 校)

Even mild hypothermia provides marked protection against cerebral ischemia in animal models. Hypothermia may be of therapeutic value during neurosurgical procedures. However, current cooling systems often fail to induce sufficient hypothermia before the dura is opened. Furthermore, they usually fail to restore normothermia by the end of surgery, thus delaying extubation. We evaluated a new internal heat-exchanging catheter. Eight ASA physical status II–IV patients (29–72 yr) undergoing craniotomy were enrolled. After the induction of general anesthesia, we introduced the SetPoint® catheter into the inferior vena cava via a femoral vein. The target core body temperature was 34°C–34.5°C. After reaching the target, core temperature was maintained until the dura was closed. Target core temperature was then set to 37.0°C, and the patient was rewarmed as quickly as possible. Seven patients had a tumor resection, and one had an aneurysm clipped. The core-cooling rate was 3.9°C ± 1.6°C/h, and the rewarming rate was 2.0°C ± 0.5°C/h; core temperature was 35.9°C ± 0.2°C by the end of surgery. Patients were subsequently kept normothermic for 3 h before the catheter was removed. No thrombus or other particulate material was identified on the extracted catheters. None of the patients suffered any complications that could be attributed to the SetPoint® system or thermal management.

 

知道在哪间手术室手术的不确定性对手术室的分配或提高其效率影响不大

Uncertainty in Knowing the Operating Rooms in Which Cases Were Performed Has Little Effect on Operating Room Allocations or Efficiency

Richard H. Epstein, MD*, and Franklin Dexter, MD PhD{dagger}

*Department of Anesthesiology, Jefferson Medical College, Philadelphia, Pennsylvania, and MDA Ltd., Jenkintown, Pennsylvania; and {dagger}Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa

Anesth Analg Dec 2002 95: 1726-1730.

目的 在美国的许多外科组织,采用原来公布的发挥手术室最大使用时间的方法是一种优化手术室时间分配的有效途径,其效果却与已记录的手术时间中的小差错有矛盾。然而,有些外科组织的信息系统数据中有10%的差错,这些差错降低了属于每个人员的手术室时间,手术室时间是该分配方法的基础。这些差错会导致不正确的手术室分配,增加手术室费用。这可能需要使用昂贵的耗时的数据清除步骤(data-cleaning steps)解决实际的手术室的分配问题。方法 我们使用来自一个大型教学医院1年的数据通过模拟方法研究差错水平的增加如何影响手术室分配及使用的效率。为了制造数据的干扰,实际的手术室随机的被改变为唯一的未知的手术间。结果 30%的差错水平上,与知道每个手术室的位置相比,手术室的分配降低了4.8%,费用增加了1.4%。在11个外科组中只有1个分配降低,其手术室错误率低于25%。结论 我们推论为解决手术室分配的不确定性的data-cleaning steps在大多数情况下不必作准确的手术室分配。知道手术室位置的不确定性在达到30%时对为达到手术室使用的最大效率及相应的费用而进行的手术室的分配影响不大,因此,大多外科组织在此差错水平上一般能够使用其存在的信息系统数据进行准确的手术室分配。

(张俊峰 薛张纲 校)

At many US surgical facilities, applying the previously published method that maximizes the efficiency of use of operating room (OR) time is an effective way to optimize the allocation of OR time. Results are resistant to small errors in recorded OR times. However, at some facilities, the OR information systems data have as much as a 10% error in the correct OR where each case took place. This decreases the total OR time attributed to each service, which is the basis for the allocation method. Such errors could result in incorrect OR allocations and increased OR staffing costs. Expensive and time-consuming data-cleaning steps may be required to resolve the actual OR allocation for each case. We used 1 yr of data from a large, tertiary academic hospital to investigate, through simulation, how increasing levels of error in the correct OR affect OR efficiency and allocations. To apply noise to the data, the actual ORs were changed randomly to unique, "unknown" rooms. At a 30% error level, OR allocations decreased by 4.8%, and costs increased by 1.4% relative to knowing the actual location of every case. Only 1 of 11 surgical services had an allocation decrease at room error rates of less than 25%. We conclude that, in most circumstances, data-cleaning steps to resolve uncertainty in OR locations are not necessary to make accurate OR allocations. IMPLICATIONS: Up to a 30% uncertainty in knowing the actual operating room (OR) in which cases were performed had a minor effect on OR allocations to maximize OR efficiency and on the resulting staffing costs. Thus, facilities with this common error in their OR information systems data will generally be able to use their existing data for accurate OR allocations.

 

术后硬膜外镇痛目前的实践:德国调查

Current Practice in Postoperative Epidural Analgesia: A German Survey

Sandra Kampe, MD*, Peter Kiencke, PhD{dagger}, Jens Krombach, MD{ddagger}, Karen Cranfield, FRCA, Stefan Mario Kasper, MD*, and Christoph Diefenbach, MD*

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Medical Statistics, University of Cologne, Cologne, Germany; {ddagger}Department of Anesthesiology, University of California-San Francisco, San Francisco, California; and Department of Anesthesiology, Aberdeen Royal Infirmary, Aberdeen, Scotland

Anesth Analg Dec 2002 95: 1767-1769.  

目的 我们对当前德国的术后硬膜外镇痛的实践进行调查。方法 调查共发出300份不具名的调查表, 147 (49%)份调查表完全完成后返还。结果 41%的德国医院中有24小时急性疼痛服务(APS)70%大的教学医院 (>1000张床) APS,而只有 9% <500张床的医院提供APS。小型医院(<200 张床) 常用罗哌卡因作为局麻药,而更大的教学医院则更多使用布比卡因。在普通病房中,36% 的回应者只用局麻药,另外64%结合使用局麻药和阿片。如果使用罗哌卡因, 0.2% 是最常用的浓度 (78%), 常与吗啡结合使用(17%),或与芬太尼结合使用(14%), 或与苏芬太尼结合使用 (75%)。如果使用布比卡因, 0.25%是常用的浓度(30%),它可结合吗啡使用(40%), 结合芬太尼使用(8%),或结合苏芬太尼使用(60%)。在病房中, 58% 德国麻醉科应用持续的硬膜外输注, 57%使用冲击剂量, 20%使用病人自控硬膜外模式。结论 在德国医院中提供24小时APS (41%)的比例与国际上的数据相当 。在病房中用局麻药和阿片结合硬膜外内使用是最常见的模式。

(潘志浩 薛张纲 校)

We surveyed current German practice in postoperative epidural analgesia (EA). Of 300 questionnaires sent anonymously, 147 (49%) were returned fully completed. A 24-h acute pain service (APS) was offered in 41% of German hospitals. Seventy percent of the large teaching hospitals (>1000 beds) offered an APS, whereas just 9% of the hospitals of <500 beds provided an APS. Small-size hospitals (<200 beds) preferred ropivacaine as the local anesthetic (LA) in contrast to large teaching hospitals using more bupivacaine than ropivacaine. In the general ward setting, 36% of the respondents used plain LA, and 64% combined the LA with an opioid. If ropivacaine was used, 0.2% was the most popular concentration (78%), combined with morphine (17%), fentanyl (14%), or sufentanil (75%). If bupivacaine was used, 0.25% was the preferred concentration (30%), combined with morphine (40%), fentanyl (8%), or sufentanil (60%). On wards, 58% of German anesthetic departments used continuous epidural infusion, 57% bolus doses, and 20% patient-controlled EA mode. We conclude that the availability of a 24-h APS (41%) in German hospitals corresponds favorably to international data. EA with the combination of LAs and opioids was the most common modality in the ward setting.

 

地氟醚和七氟醚麻醉中窦状隙颈部吸引用于评价压力感受器敏感性

Sinusoidal Neck Suction for Evaluation of Baroreflex Sensitivity During Desflurane and Sevoflurane Anesthesia

Cornelius Keyl, MD*, Annette Schneider, MD*, Jonny Hobbhahn, MD*, and Luciano Bernardi, MD{dagger}

*Department of Anesthesiology, University of Regensburg, Germany; {dagger}Department of Internal Medicine, University of Pavia, and Istituto di Ricovero e Cura a Carattere Scientifico S. Matteo, Pavia, Italy

Anesth Analg Dec 2002 95: 1629-1636.

目的 七氟醚和地氟醚可通过不同机制调整自主神经活力。我们检验了关于这些麻醉药对动脉血压的短效压力感受器反射有不同效果的假说。方法 40ASA的病人,年龄2042岁。随机接受1.0MAC浓度的七氟醚或足以维持麻醉的浓度的地氟醚,固定呼吸频率在0.25HZ以上。研究病人清醒状态,诱导后20分钟0.2HZ功率窦状隙颈部吸引(压力感受器反射主要由迷走神经介导),0.1HZ功率(压力感受器反射由迷走神经、交感神经介导)吸引时的变化。R-R间期和动脉压变化用放大光谱分析法和复合传导功能分析法评价。结果 从信号的平方连贯性,即光谱相关系数的平衡看,七氟醚和地氟醚并未影响压力感受器刺激与效应器反应的一致性,和七氟醚、地氟醚不影响压力感受器刺激于迷走神经介导心脏反应的延时性相似,他们抑制了心率对颈部吸引得反应。使用七氟醚和地氟醚的病人,0.1HZ功率颈部吸引和动脉血压波动之间的传导速度减慢了相当一段数值。两种药物都对压力感受器刺激引发的收缩压变化延迟约3.54.3秒。静息状态下,地氟醚和七氟醚所致的压力感受器介导的短时动脉压控制相似。结论 尽管七氟醚和地氟醚对自主神经活性有不同的影响,他们在抑制压力感受器的心率和血压短时的控制是相似的。

(梁雅芬 薛张纲 校)

Sevoflurane and desflurane modulate autonomic nervous activity by different mechanisms. We tested the hypothesis that these anesthetics also exhibit different effects on short-term baroreflex regulation of arterial blood pressure. Forty ASA physical status I patients, aged 20 to 42 yr, were randomly assigned to receive either 1.0 minimum alveolar anesthetic concentration of sevoflurane or desflurane for the maintenance of anesthesia. Patients were studied during awake conditions and 20 min after the anesthesia induction using sinusoidal neck suction at 0.2 Hz (baroreflex response mediated mainly by vagal activity) and 0.1 Hz (baroreflex response mediated by vagal and sympathetic activity), whereas respiratory frequency was fixed at 0.25 Hz. RR interval and arterial blood pressure responses were evaluated by power spectral analysis and complex transfer function analysis. Sevoflurane and desflurane did not disturb the linear relationship between baroreceptor stimulation and effector response, expressed as squared coherence of signals, i.e., the equivalent of the correlation coefficient of power spectra. Sevoflurane and desflurane depressed the response of the heart rate to neck suction in a similar way without affecting the time delay between baroreceptor stimulation and vagal-mediated cardiac response. The gain of the transfer function between neck suction and oscillation in arterial blood pressure at 0.1 Hz decreased with sevoflurane and desflurane to comparable values. Both anesthetics increased the delay of systolic blood pressure response to baroreceptor stimulation from approximately 3.5 to 4.3 s. Baroreflex-mediated short-term control of arterial blood pressure is similar between desflurane and sevoflurane during steady-state conditions.

 

ProSeal喉罩的最大分钟通气量的测试

Maximum Minute Ventilation Test for the ProSealTM Laryngeal Mask Airway

Michael S. Stix, MD PhD, and Cornelius J. O’Connor, Jr., MD

Department of Anesthesiology, Lahey Clinic, Burlington, Massachusetts

Anesth Analg Dec2002 95: 1629-1636.

目的 ProSeal喉罩一个特点是它可以导致上呼吸道的阻塞,即使在在环状软骨后准确插入时也会出现。方法 我们应用一种过度通气试验,最大分钟通气测试 (MMV test), 来帮助诊断ProSeal喉罩插入后上呼吸道梗阻。病人过度通气15秒产生 MMV=4 x (呼吸次数/15) x (呼出的潮气量)。在6个月内317例成人上采集 MMV 值。结果  临界 MMV值在317例成人中的17例病人中获得,其中的15(4.7%) ProSeal喉罩的插入有关。317病人中7 (2.2%)拔除了ProSeal喉罩。最常见的ProSeal喉罩导致上呼吸道阻塞的原因是喉阻塞 。这是指对声门上和声门的压迫而导致气道的狭窄。另一个更少见的形成气道狭窄的原因是双侧气囊向内夹闭形成狭窄或夹闭会厌的低部。结论 我们讨论了分钟通气的安全限, MMV过度超过或低于基础分钟通气量。在临界 MMV, 安全限显著下降或不存在。ProSeal喉罩一个特点是它会导致上呼吸道阻塞,即使在它准确插入环状软骨后也会发生。我们应用一种过度通气试验去帮助诊断插入ProSeal喉罩后的上呼吸道阻塞。

(潘志浩 薛张纲 校)

One of the distinguishing features of the ProSealTM laryngeal mask airway (PLMA) is that it can cause upper airway obstruction, even when it is correctly inserted behind the cricoid cartilage. We used a hyperventilation test, the maximum minute ventilation test (MMV test), to aid in the diagnosis of upper airway obstruction after PLMA insertion. The patient was briefly hyperventilated for 15 s yielding a MMV value equal to 4 x (breaths/15 s) x (exhaled tidal volume). MMV values were collected in 317 adult women and men over 6 mo. Critical MMV values were obtained in 17 of 317 patients, 15 of 317 (4.7%) of which were due to insertion of the PLMA. The PLMA was removed in seven of 317 (2.2%) patients. The most common cause of upper airway obstruction due to the PLMA was laryngeal obstruction. This refers to compression of supraglottic and glottic structures with resulting narrowing and compromise of the airway. A second, much less common, form of airway obstruction was bilateral cuff infolding with or without downfolding of the epiglottis. Finally, we discuss the margin of safety for minute ventilation, defined as the excess of the MMV over and above basal minute ventilation requirements for the patient. With critical MMV, the margin of safety is drastically reduced or nonexistent.

 

鞘内应用前列腺E受体亚型EP1拮抗剂对术后疼痛模型鼠机械和温度的痛觉过敏的影响研究

The Effects of Intrathecal Administration of an Antagonist for Prostaglandin E Receptor Subtype EP1 on Mechanical and Thermal Hyperalgesia in a Rat Model of Postoperative Pain

 

Keiichi Omote, MD, Hiroki Yamamoto, MD, Tomoyuki Kawamata, MD, Yoshito Nakayama, MD, and Akiyoshi Namiki, MD

Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan

Anesth Analg Dec. 2002; 95: 1708-1712.

目的 尽管对急性疼痛的机制的了解及疼痛的治疗已有了很大的进展,但是术后疼痛,尤其是机械激发性疼痛(incident pain)还不能得到有效治疗。组织损伤和炎症增加了脊髓前列腺E2的释放,它促使痛觉过敏的产生。方法 我们设计该试验以明确鞘内应用前列腺E受体亚型EP1拮抗剂ONO-8711对切割引起的机械的和温度的痛觉过敏是否具有镇痛效应。在鼠脚底作一1厘米的纵向切口,切口附近予以机械刺激和温度刺激,记录对刺激的阈值和潜伏期。在切皮后2小时和24小时观察到机械性和温度性痛觉过敏。鞘内分别使用 ONO-8711 (50, 80, 100 µg)或生理盐水。结果 ONO-8711剂量和时间依赖性的显著增加对机械刺激的阈值,但并不增加对温度刺激的阈值。我们推论EP1 受体介导的脊髓角敏感化可能导致机械性而非温度性的痛觉过敏的产生,并且鞘内使用前列腺EP1 受体拮抗剂是术后疼痛(尤其是机械激发的疼痛)的一种有潜力的治疗方法。结论 我们研究了在术后疼痛模型鞘内使用选择性前列腺EP1受体拮抗剂对机械性和温度性痛觉过敏的影响,鞘内使用的前列腺EP1受体拮抗剂抑制机械性而非温度性痛觉过敏,这表明前列腺EP1受体拮抗剂可被用于治疗术后疼痛(尤其是incident pain)。

(张俊峰 薛张纲 校)

Despite substantial advances in understanding acute pain mechanisms and in the treatment of pain, postoperative pain, especially mechanically evoked pain (incident pain), is generally not effectively treated. Tissue injury and inflammation increase the release of prostaglandin E2 in the spinal cord, contributing to the development of hyperalgesia. We designed the present study to determine whether the intrathecal administration of an antagonist for prostaglandin E2 receptor subtype EP1, ONO-8711, has an analgesic effect on incision-induced mechanical and thermal hyperalgesia. A 1-cm longitudinal skin incision was made in the plantar aspect of the rat foot. The withdrawal threshold to mechanical stimulation and the withdrawal latency to thermal stimulation applied adjacent to the wound of the hindpaw were investigated. Both mechanical and thermal hyperalgesia were observed at 2 h and 24 h after the incision had been made. ONO-8711 (50, 80, 100 µg) or saline was administered intrathecally. ONO-8711 significantly increased the withdrawal thresholds to mechanical stimulation, but not to thermal stimulation, in a dose- and time-dependent manner. We conclude that EP1 receptor-mediated sensitization of the spinal dorsal horn may contribute to the generation of mechanical, but not thermal, hyperalgesia and that an EP1 receptor antagonist administered intrathecally is a potential analgesic for postoperative pain, especially mechanically evoked pain (incident pain). IMPLICATIONS: We examined the effects of an intrathecally administered selective EP1 receptor antagonist on mechanical and thermal hyperalgesia in a postoperative pain model. The intrathecal EP1 receptor antagonist inhibited the mechanical, but not thermal, hyperalgesia, indicating the potential for an EP1 receptor antagonist to be used as an analgesic for postoperative pain, especially incident pain.

 

离体豚鼠支气管平滑肌细胞中挥发性麻醉药和胆碱能药、速激酶和白三烯的相互作用

Interactions of Volatile Anesthetics with Cholinergic, Tachykinin, and Leukotriene Mechanisms in Isolated Guinea Pig Bronchial Smooth Muscle

C.U. Wiklund, MD PhD*, U. Lindsten, MD*, S. Lim, MD{dagger}, and S.G.E. Lindahl, MD PhD*

*Department of Anesthesiology and Intensive Care Medicine, Karolinska Hospital and Institute, Stockholm, Sweden; and {dagger}Division of Pediatric Cardiology, University of Michigan, Ann Arbor

Anesth Analg Dec. 2002; 95: 1650-1655.

目的 我们研究七氟醚、地氟醚和氟烷对离体豚鼠支气管平滑肌的松弛作用。方法 环状标本放置于充满生理盐水的组织浴中,并持续给予含5%二氧化碳的氧气。电流刺激诱发了对河豚毒素敏感的收缩,即神经介导的反应。这包括了对阿托品敏感的胆碱能期和对SR48968(一种神经肽-2受体拮抗剂)敏感的非肾上腺素非胆碱能(NANC)期。麻醉气体通入到充氧的组织浴中。结果 七氟醚、地氟醚在1.0MAC,氟烷在1.0-2.0MAC均抑制了对电流刺激的胆碱能和NANC收缩,但没有一种麻醉药影响了外源性物质,也就是提示另外它具有NANC神经传导的突触前抑制作用。麻醉药并不影响对哮喘支气管收缩介质白三烯4的收缩反应。然而七氟醚和地氟醚都可以松弛白三烯4引导的稳态收缩。奇怪的是,氟烷并没有松弛白三烯4的收缩。关于白三烯引发的支气管收缩,七氟醚和地氟醚对离体气道平滑肌细胞是更强的松弛剂。结论 氟烷、七氟醚和地氟醚通过抑制胆碱能和NANC神经传导降低了气道平滑肌张力。七氟醚和地氟醚降低了白三烯4诱发的支气管收缩,而氟烷不具备这种能力。这表明在哮喘病人选用七氟醚和地氟醚更加优越。

(梁雅芬 薛张纲 校)

We studied relaxation of airway smooth muscle by sevoflurane, desflurane, and halothane in isolated guinea pig bronchi. Ring preparations were mounted in tissue baths filled with physiological salt solution and continuously aerated with 5% CO2 in oxygen. Electrical field stimulation induced contractions sensitive to tetrodotoxin, indicating nerve-mediated responses. These consisted of an atropine-sensitive cholinergic phase and a nonadrenergic noncholinergic (NANC) phase sensitive to SR48968, a neurokinin-2 receptor antagonist. Anesthetics were added to the gas aerating the tissue baths. Sevoflurane and desflurane at 1.0 minimum alveolar anesthetic concentration and halothane at 1.0–2.0 minimum alveolar anesthetic concentrations inhibited both cholinergic and NANC contractions to electrical field stimulation. None of the anesthetics affected responses to exogenously applied neurokinin A, a likely mediator of NANC contractions, suggesting prejunctional inhibition of NANC neurotransmission. The anesthetics did not affect the initiation of contractile responses to leukotriene C4 (LTC4), a mediator of asthmatic bronchoconstriction. However, sevoflurane and desflurane both relaxed bronchi in a steady-state contraction achieved by LTC4. Surprisingly, halothane did not relax LTC4 contractions. Concerning LTC4-elicited bronchoconstriction, sevoflurane and desflurane were more potent airway smooth muscle relaxants in vitro.