Anesthesia & Analgesia

December 2002

Table of Content

CARDIOVASCULAR ANESTHESIA:

圍術期經食道超聲心動圖新考查方法應用的前景分析

(趙延華 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.  

住院病人冠狀動脈搭橋術後心率和死亡率間的關係

(唐   莊心良 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.

體外迴圈後48小時內高熱

( 薛張綱 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復蘇法可改善豬的低溫心臟停跳模型中血管收縮反應

(趙延華 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.  

實驗檢測家兔肝素活性變化:抗Xa活性與血栓彈性圖、活化部分凝血活酶時間、啟動凝血時間的比較

(唐   莊心良 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.

有嚴重左室收縮功能障礙的患者行冠脈搭橋術預後與術前右室功能有關

( 薛張綱 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.

中心靜脈徑路:患者體位、偏側、頭轉向對頸內靜脈橫切面積的影響

(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.  

心臟保護措施對腹主動脈手術後心臟併發症發生率的影響

(嵇富海 薛張綱 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.

全國郵政調查對成年心臟手術患者神經肌肉阻滯藥使用情況報告

(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.

麻醉藥預處理減輕豚鼠離體完整心臟缺血時的線粒體鈣超載

(   莊心良 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.

在綿羊輸注速率及輸入容量對0.9%生理鹽水和7.5%鹽水/6.0%右旋糖酐動力學的影響

 (   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.  

小劑量氧化氮增進單肺通氣時的氧合:實驗研究

(唐   莊心良 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.

術前臨床評估的變化對減少心臟科會診次數和提高心臟科會診質量的影響

( 懿譯 薛張綱 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:

小兒氟烷麻醉影響血壓和術前禁食時間相關

(   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.  

小兒和成人在異丙酚和異氟醚麻醉下經導管射頻消融術後噁心和嘔吐發生率較

(楊保仲 莊心良 )

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.  

雙頻譜指數監測:正常兒童和Quadrplegic腦癱兒童之間對照

( 薛張綱 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異丙酚抑制患兒喉罩刺激的比較:雙盲隨機化實驗研究

 ( 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:

三種預防術後噁心和嘔吐方案比較

(楊保仲 莊心良 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.

門診手術小劑量利多卡因-芬太尼蛛網膜下腔麻醉:比較預防性應用

(李懿 薛張綱 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.

術前使用阿普唑侖減少門診外科患者的焦慮:和口服咪唑安定的比較

( 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:

靜脈全麻藥對中國倉鼠卵母細胞重組人M1-M3毒蕈堿受體的影響

(趙雪蓮    莊心良  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.

乙酰膽鹼受體與三氟乙醚及12-二氯乙氟環丁烷致驚厥閾值的關係

(梁雅芬 薛張綱 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.

揮發性麻醉劑攝取模型的預測精確度

(殷文淵 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.  

抑制超強有害刺激引起撤退反應的異氟醚可減少大鼠脊髓C-Fos表達而氟烷無此作用

(趙雪蓮    莊心良 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竇狀隙頸部吸引用於評價壓力感受器敏感性

(梁雅芬 薛張綱 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.

咪唑安定和安定對成年老鼠心室肌細胞收縮和細胞內瞬間Ca2+的不同影響

(殷文淵 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

.

剖胸體位的胃食管返流與氣管吸入:術前應該常規應用雷尼替丁嗎?

(      莊心良  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.

離體豚鼠支氣管平滑肌細胞中揮發性麻醉藥和膽鹼能藥、速激酶和白三烯的相互作用

(梁雅芬 薛張綱 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.

溴吡斯的明拮抗維庫溴安和羅庫溴安後的殘餘肌松作用

( 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.

神經甾體類麻醉藥Alphaxalone抑制牛腎上腺髓質細胞去甲腎上腺素轉運體的功能

(王士雷   莊心良 )

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:

圍手術期患者狀態指數與腦雙頻指數的比較

(潘志浩 薛張綱 )

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:

硬膜外腔注射類固醇激素的門診疼痛治療病人使用非甾體抗炎藥的出血併發症風險評估

(張俊峰譯 薛張綱校)

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.

硬膜外注射嗎啡和新斯的明用於骨科術後鎮痛

( 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.

 

腹式子宮切除術後活動所致的疼痛及自發性疼痛與呼氣流量峰值間的關係

(   莊心良 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.

 

鞘內應用前列腺E受體亞型EP1拮抗劑對術後疼痛模型鼠機械和溫度的痛覺過敏的影響研究

(張俊峰 薛張綱 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.

成人腹部手術後應用嗎啡和曲馬多自控鎮痛:一項雙盲,安慰劑對照隨機試驗

 (忻紀華 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.

 

加巴噴丁在格林-巴厘綜合征疼痛治療中的應用——雙盲、對照的交叉研究

(朱慧   莊心良  )

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:

知道在哪間手術室手術的不確定性對手術室的分配或提高其效率影響不大

(張俊峰 薛張綱 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:

應用單純擴張技術行經皮氣管切開:Criglia Blue Rhino Griggs’ 的前瞻性和隨機性比較

(忻紀華 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:

持續過度通氣對硫噴妥鈉麻醉下的兔局部腦血容量的影響

(      莊心良  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. 

 

在神經外科病人上使用一種新型熱交換導管的初步經驗

(潘志浩 薛張綱 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:

脊麻下行髖關節置換術中氨基酸灌注可以引起產熱和減少失血

(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.

預防性給予奧丹西龍能減少椎管內注射芬太尼後病人瘙癢的發生率

(王士雷   莊心良 校)

Prophylactic Ondansetron Reduces the Incidence of Intrathecal Fentanyl-Induced Pruritus

Yavuz Gürkan and Kamil Toker

Anesth Analg 2002 95: 1763-1766.  

術後硬膜外鎮痛目前的實踐:德國調查

(潘志浩 薛張綱 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:

在豬模型上氣管插管拔管前吸氧使全麻後的氣體交換惡化

 (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.

 

氣管拔管前增加吸入氧濃度對術後肺不張的影響

(張 莊心良 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喉罩的最大分鐘通氣量的測試

(潘志浩 薛張綱 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.

病態肥胖和術後肺不張:一個被低估的問題

(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.

 

 

圍術期經食道超聲心動圖新考查方法應用的前景分析

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

 

促進圍術期超聲心動圖的知識和能力應用的主要因素在於考試,本文報導對應用超聲心動圖的考查方法的發展。另外,還證明一種假設,即考試成績與應用超聲心動圖的臨床經驗有關。1995年來,參加超聲心動圖檢查考試的超過1200人,通過率大於70%。考試成績與是否接受培訓有關,接受過3個月以上培訓且每週檢查次數至少6次者成績較好。我們認為這種考試對於檢查受試者有關圍術期超聲心動圖的應用知識是有效的。提示:本文描述了建立經食道超聲心動圖應用知識考查方法的過程,證明考試成績能反映實際應用能力。

                                              (趙延華 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復蘇法可改善豬的低溫心臟停跳模型中血管收縮反應

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

 

常溫心臟停跳後進行積極心臟按壓(ACD)心肺復蘇和inspiratory threshold valveITV)可顯著改善重要器官的血流,但在低溫心臟停跳中未見應用。因此,本文應用豬的低溫心臟停跳模型,評價抗利尿激素對ACD+ITV心肺復蘇前後血流動力學的效應。14只受試豬隨機分為ACD+ITV復蘇組(n=7)和標準復蘇組(n=7),經體表降溫至中心溫度為26°C,出現室顫,14min後進行復蘇。復蘇8min後,經靜脈注入0.4U/kg抗利尿激素,繼續復蘇10min,心跳驟停28min後進行除顫。注入抗利尿激素前,ACD+ITV復蘇組頸總動脈血流顯著高於標準復蘇組(分別為67 ± 13 26 ± 5 mL/minP < 0.025);注入抗利尿激素後冠狀動脈灌注壓在ACD+ITV復蘇組顯著升高,而在標準復蘇組沒有變化(12min時分別為29±315±2 mmHg18min時分別為25±114±1 mmHgP < 0.001)。相應時間的頸總動脈血流在ACD+ITV復蘇組高於標準復蘇組(12min時分別為33±810±3 mL/min18min時分別為31±77±3 mL/minP < 0.01)。兩組均未主動升溫,ACD + ITV組有3只動物迴圈自發恢復並維持穩定,而在標準組沒有,但結果沒有統計學差異。在低溫心跳驟停中,與標準復蘇相比,ACD + ITV復蘇能改善頸總動脈血流;而且應用抗利尿激素後,冠狀動脈灌注壓明顯升高。為了改善低溫心跳驟停後心肺復蘇的有效性需要新的措施,ACDITV復蘇可改善頸總動脈血流以及應用抗利尿激素後升高冠脈灌注壓。

                                                (趙延華 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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中心靜脈徑路:患者體位、偏側、頭轉向對頸內靜脈橫切面積的影響

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

 

我們研究了在進行右側頸內靜脈穿刺置管時,穿刺途徑(側路法或前路法),不同體位(仰臥或頭低腳高),頭方位(頭側轉20°或最大角度)對穿刺的影響。24名志願者先採取仰臥位後改為25°頭低腳高位,分別在側路或前路時頭旋轉0°, 20°或最大角度後測量頸內靜脈橫切面積。研究發現當患者採取頭低腳高位,側路時頸內靜脈橫切面積最大,在這一體位頭轉動時差異不大,都可獲得最大橫切面積。該實驗顯示若不能採取頭低腳高位則前路可獲最大穿刺橫切面積。

                                               (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.

 

全國郵政調查對成年心臟手術患者神經肌肉阻滯藥使用情況報告

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

 

現有資料顯示選擇性神經肌肉阻滯藥可能影響快心率心臟手術患者的初期癒合。此次實驗目的是要通過某些實驗工具測定臨床麻醉醫師在應用神經肌肉阻滯藥(NMBDs)時對心臟手術患者的影響。我們向《心臟麻醉學》上曾刊登過的3295位患者中的1/3發出了徵詢信件,並對未回復者再次發出信函,其後共有459位患者(43%)回函。Pancuronium作為基本的神經肌肉阻滯藥被用於大多數心臟手術患者,體外迴圈(69%)和非體外迴圈(41%)下進行。僅有28%的患者在術中使用神經刺激監測瞭解神經肌肉阻滯情況。另有9%的患者在拔管前仍使用神經肌肉阻滯藥。這一測試表明長效神經肌肉阻滯劑常被用於快心率心臟手術患者,在手術室或加護病房中很少運用末稍神經監測系統,術後患者也很少使用拮抗藥物(抗膽鹼酯酶)。

                                               (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.

 

在綿羊輸注速率及輸入容量對0.9%生理鹽水和7.5%鹽水/6.0%右旋糖酐動力學的影響

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

 

短時間輸注0.9%的生理鹽水(NS)和7.5%的鹽水/6.0%的右旋糖酐(HSD)通常是20分鐘,其血容量的動力學變化是否能夠預示一時間-稀釋曲線。本研究選擇6只平均體重36±3kg,清醒並脾切除的綿羊,在不同的四天,任意選擇4只綿羊靜脈輸注:NS1.2ml/kg/min持續5min20min或使用HSD4.0ml/kg持續2min20min123個血容量動力學模型符合動脈血紅蛋白濃度的稀釋,且我們在180分鐘內留取了尿樣。輸注NS的綿羊在5分鐘末和20分鐘末其血漿蛋白最大稀釋度分別為10%22%,而輸注HSD的綿羊在2分鐘末和20分鐘末其血漿蛋白最大稀釋度分別為24%21%。輸注NS5分鐘和20分鐘所預示的時間-稀釋曲線實際上是一樣的,其平均稀釋度都為0.027單位,而輸注HSD2分鐘和20分鐘其平均稀釋度分別為0.0500.047。電腦模擬提示如果輸注NSHSD的時間越長兩者的擴容作用差異就越顯著。我們得出結論:短時間輸注液體其血容量動力學的變化能夠預示長時間輸注後的預後,即使輸注時間越長其血容量也就越大。

                                                                                       

                                                (   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.

 

小兒氟烷麻醉影響血壓和術前禁食時間相關

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

 

本研究中確定術前禁食時間是否會影響嬰兒和兒童在氟烷麻醉期間血壓下降的程度。研究250個小兒患者將他們分成5個年齡組:新生兒組(n=50),1-6mon=50),6-24mon=50),2-6yrn=50),以及6-12yrn=50),每組患者又再根據術前禁食時間分成四組(0-4h,4-8h,8-12h,>12h)。在使用氟烷誘導後我們使呼氣末氟烷濃度保持在2MAC濃度並維持10分鐘以便心肌攝取。我們觀察患者誘導前到氟烷濃度達2MAC這段時間內的心率、收縮壓(SAP)及平均動脈壓(MAP)的變化並對不同禁食時間組間的患者作比較。結果顯示1-6mo年齡組禁食時間為8-12h的患者其收縮壓和平均動脈壓變化幅度明顯大於那些0-4h的患者(SAP-51 mmHg  vs –31mmHg MAP-48mmHg vs -32mmHgP0.05)。在其他年齡組統計學上沒有顯著性差異。這項結果表明嬰兒術前延長禁食時間與麻醉期間患者血壓大幅度下降有關。因此我們應強調遵守術前禁食原則的重要性。

                                                (   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異丙酚抑制患兒喉罩刺激的比較:雙盲隨機化實驗研究

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

 

喉罩作為通氣設備和氣管內插管導管已被成功運用於臨床。在這個隨機化、雙盲實驗中,我們想確定保持患兒自主呼吸情況下,術前利多卡因合用氯胺酮,然後置喉罩作為一種氣道管理方法是否可行。術前靜脈給予0.05mg/kg咪唑安定和0.005mg/kg胃長寧,90位患者隨機分配到異丙酚組和氯胺酮組之一。40位患者給予2.5mg/kg,3.0 mg/kg,3.5 mg/kg,4.0 mg/kg異丙酚靜注(n = 10),而另外50位患者給予2.0, 2.5, 3.0, 3.5, 4.0 mg/kg氯胺酮靜注(n = 10)。氯胺酮組在麻醉誘導前1分鐘口咽部應用利多卡因噴霧。應用指定藥物後,評價自主呼吸、下頜鬆弛,呼吸道梗阻。喉罩插入後,自主呼吸、喉痙攣性咳嗽、嘔吐、吞咽、咬牙或舌頭運動、分泌物和頭或肢體運動被分級。所有的變數分為滿意、可接受、不滿意三個等級。假如所有的指標是滿意的可以認為整體效果是滿意的。假如至少一個指標是可接受的,其他各指標優於可接受,則可以認為整體效果是可接受的。假如至少一個指標是不滿意的,則可以認為整體效果是不滿意的。氯胺酮的劑量3.0 3.5 mg/kg才能取得滿意或可接受的整體效果。異丙酚所有劑量都不能取得滿意效果,大多數病例有呼吸暫停和呼吸道梗阻的症狀。氯胺酮合用利多卡因噴霧對喉罩置入來說是合適的,在困難呼吸道患兒中是一種安全的管理方法。

                                                 ( 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.

 

術前使用阿普唑侖減少門診外科患者的焦慮:和口服咪唑安定的比較

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

 

由於咪唑安定口服製劑在某些國家沒有獲得批准,我們將阿普唑侖作為替代物來評估。為比較阿普唑侖0.5 mg和咪唑安定7.5 mg的效果和副作用,選擇45例婦科腹腔鏡門診手術患者參與雙盲實驗。我們通過Trieger Dot 試驗 (TDT) Digit-Symbol Substitution 試驗來評價精神運動。同時我們也進行簡單記憶測試。資料處理根據適用性用團體T檢驗、配對T檢驗 SNK單因素方差分析或KW單因素方差分析,P < 0.05為有統計學意義。和安慰劑相比,阿普唑侖和咪唑安定都減少焦慮評分(P < 0.05)。術前給藥後一小時,Digit- Symbol Substitution試驗評分在所有組都是相似的,而TDT評分(表明功能抑制)阿普唑侖組比安慰劑組要高。鎮靜評分、拔管時間、出院時間藥物組均和安慰劑組不同。離開麻醉後恢復室時間、TDT評分藥物組均比安慰劑組要大(P < 0.05)。有健忘症的5為患者均發生在咪唑安定組。我們認為在減少焦慮而無健忘方面,阿普唑侖是咪唑安定的有效替代物,但是阿普唑侖在術後早期能引起更大的精神運動損害。

結論:口服阿普唑侖0.5 mg和咪唑安定7.5 mg同樣減少門診外科手術患者的焦慮。儘管有早期精神運動損害的作用,兩種藥物都不延長麻醉後拔管時間,同樣不延長離開術後麻醉監護室的時間。

..                                                ( 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.

 

揮發性麻醉劑攝取模型的預測精確度

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

 

一個模擬麻醉劑攝取和分佈的電腦程式作為一種教學工具在我們科室已經使用了20年。新的電動測量新鮮氣體流速和揮發罐刻度的麻醉機使得我們能夠在臨床麻醉期間評定這個模型的性能。在30個選擇性麻醉期間每隔10 s從麻醉機(Datex S/5 ADU)收集氣體流速,揮發罐刻度和呼氣末CO2濃度。這些資料都被輸入攝取模型。計算呼出麻醉氣體濃度與實際從病人監護儀(Datex AS/3)上測量出的數值相比較。16名病人使用七氟醚,14名病人使用異氟醚。在所有病人中,性能誤差中間值為-0.24%,絕對性能誤差中間值為13.7%,分歧為2.3%/h,擺動為3.1%。七氟醚和異氟醚之間沒有顯著差別。這個模型在這些病人中預測的呼出濃度很準確。這些結果看上去與丙泊酚輸注系統中計算和實際丙泊酚濃度相比較的結果相類似,且符合出版的指導手冊中規定的在靶控麻醉系統中使用的模型精確度。這個模型也許在預測對新鮮氣體和揮發罐刻度變化的反應方面有用。

                                                (殷文淵 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.

 

咪唑安定和安定對成年老鼠心室肌細胞收縮和細胞內瞬間Ca2+的不同影響

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

 

我們研究了咪唑安定和安定對成年老鼠心室肌細胞激動-收縮藕連作用的直接影響。新鮮分離的心室肌細胞存放於fura-2/AM中,在28℃下進行域刺激。單個細胞內瞬間Ca2+和肌細胞縮短都被同步監測。咪唑安定(3-100μM)會劑量依賴性地降低細胞內Ca2+峰值和細胞縮短。安定(30-100μM)則會增加肌細胞縮短和Ca2+峰值且伴隨達到Ca2+峰值的時間縮短。更大濃度的咪唑安定(>300μM)差不多停止了細胞內Ca2+瞬間變化和細胞縮短。咪唑安定(100μM)和安定(300μM)減少了因咖啡因刺激而釋放的細胞內儲存的Ca2+數量。安定(30μM),但沒有咪唑安定(10μM),會引起縮短有關的劑量依賴性細胞外Ca2+曲線向下變化,但對細胞內Ca2+峰值瞬間沒有影響。這些結果說明咪唑安定和安定對心臟激動-收縮藕連在細胞水平有不同的變力影響,這是通過改變細胞內游離Ca2+實用性所介導的。可是,苯二氮卓對老鼠心室肌細胞的激動-收縮藕連沒有直接影響,除非非常大的劑量。抑制咖啡因敏感的細胞內Ca2+儲備的釋放也許在較大劑量的苯二氮卓產生的心肌抑制中起部分作用。安定,而沒有咪唑安定,降低了肌絲對Ca2+的反應性。

                                                (殷文淵 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+.

 

溴吡斯的明拮抗維庫溴安和羅庫溴安後的殘餘肌松作用

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

 

我們連續調查了602例由於使用了維庫溴安或羅庫溴安而引起術後殘餘筒箭毒樣癱瘓的患者,他們術後均以溴吡斯的明拮抗肌松劑但沒有使用神經肌肉監測。患者到達恢復室後,神經肌肉功能同時由TOF方式的肌松監測儀和臨床上持續抬頭>5秒及壓舌試驗來評價,術後殘餘筒箭毒樣癱瘓定義為TOF比率<0.7602例患者中五分之一在恢復室中TOF0.7(其中維庫溴安24.7%;羅庫溴安,14.7%)。使用10mg20mg溴吡斯的明TOF無顯著差異。引起殘餘肌松作用與下列因素相關:缺乏術後神經肌肉監測,使用溴吡斯的明(沒有新斯的明有效),大劑量的維庫溴安,最後一次神經肌肉阻滯至TOF監測的時間太短,或周圍環境寒冷。我們總結認為使用大劑量溴吡斯的明拮抗維庫溴安和羅庫溴安後,顯著的殘餘神經肌肉阻滯作用仍沒有減少。

                                                 ( 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.

 

硬膜外注射嗎啡和新斯的明用於骨科術後鎮痛

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

 

在本調查中,我們研究了骨科手術後硬膜外聯合使用嗎啡和新斯的明的副作用和鎮痛效果。60例接受膝關節手術的患者分成4組。椎管內麻醉使用15mg布比卡因。硬膜外試驗藥物用生理鹽水稀釋至10ml。對比組使用單純生理鹽水。嗎啡組硬膜外注入0.6mg嗎啡,新斯的明組注入60ug新斯的明,嗎啡新斯的明聯合組同時注入以上劑量的兩種藥物。各組在統計學上和手術中情況均無顯著差異。組間首次需要追加鎮痛藥物時視覺疼痛評分和副作用也相似(p0.05)。新斯的明組的一例患者抱怨術中噁心,與椎管內麻醉引起的低血壓緊密相關,術後新斯的明組有兩例患者嘔吐一次。追加鎮痛藥物的時間在嗎啡新斯的明聯合組(11小時)與其他組比較較長(p0.05〉。鎮痛藥物的總量(24h)在對比組較其他組更大(p0.05

提示:硬膜外聯合應用嗎啡和新斯的明產生術後鎮痛效果並且避免了副作用,是人群中的替代鎮痛技術。

                                                 ( 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).

 

成人腹部手術後應用嗎啡和曲馬多自控鎮痛:一項雙盲,安慰劑對照隨機試驗

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

 

在本雙盲,隨機對照試驗中,我們檢驗了以嗎啡附加曲馬多行PCA與單獨用嗎啡行PCA相比是否可改善成人腹部手術後的鎮痛效果,並減少嗎啡的用量。69例病人被隨機分為兩組,每組術後以PCA注入嗎啡1mg/ml。曲馬多組術中給予負荷劑量1mg/kg的曲馬多,術後予0.2mg/kg的曲馬多。對照組術中和術後給予等容量的生理鹽水。曲馬多可改善術後主觀鎮痛效果(p=0.031),且曲馬多組PCA中的嗎啡用量明顯減少(p=0.023)。兩組中噁心,止吐藥,鎮靜或恢復程度(所有p>0.05)無差異。我們得出結論:曲馬多與嗎啡合用行PCA治療與單獨用嗎啡相比可以改善鎮痛效果並減少嗎啡的用量。

提示:本試驗的目的在於判斷加入第二種止痛藥,曲馬多是否可以緩解大手術後嗎啡自控鎮痛病人的疼痛。我們發現接受曲馬多的病人主觀疼痛明顯改善,且在未增加副作用的情況下使嗎啡的用量明顯減少。

                                                (忻紀華 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.

 

應用單純擴張技術行經皮氣管切開:Criglia Blue Rhino Griggs’ 的前瞻性和隨機性比較

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

 

應用Griggs’ guidewire dialating forceps (GWDF)以單步擴張技術行氣管切開已廣泛開展。近來,Ciaglia提出應用一種彎曲的,漸細的擴張器,Ciaglia Blue Rhino (CBR) 行單步擴張技術。在一項前瞻性隨機試驗中,我們連續在60例病人中以CBRGWDF方法行經皮氣管切開。術後所有病人均由不知情的專家行支氣管鏡檢查,並觀察穿刺口特徵和氣管損傷。兩種方法平均氣管切開時間(切開皮膚到插入導管的時間)無差異(CBR7.5分鐘,GWDF6.5分鐘)。GWDF方法有三分之一的病人穿刺口擴張不全和過度擴張。在CBR組中,所有病人的氣道峰壓明顯升高(p<0.05)。有9例病人氣管軟骨損傷,3例病人氣管縱向擦傷,一例病人氣胸。3例病人在拔管後疤痕處氣管內陷聲音嘶啞8周;但是,沒有人發生呼吸困難。結論:這兩種技術在經皮氣管切開時的作用相同。但是,GWDF使穿刺處氣管過度擴張和CBR使氣道峰壓升高和氣管環的損傷仍不可避免。

                                                (忻紀華 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.

 

脊麻下行髖關節置換術中氨基酸灌注可以引起產熱和減少失血

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        

 

氨基酸的熱效應在全麻下增大,能對抗低溫。輕度低溫能減少術中出血。我們研究在脊麻時氨基酸是否引起產熱以及這種內源性產熱是否能減少髖關節置換術中的出血。22名患者在脊麻前1小時和脊麻中給予氨基酸IV混合劑(vamin 18®, 240 kJ/h)對他們的直腸溫度,氧攝取,圍術期出血測定,對照患者24人,給予酸處理過的林格氏液。通過對用過的紗布稱重和對吸引瓶中出去生理鹽水的液體的估計來計算術中的失血量。在氨基酸組,比術前溫度上升了0.4°C ± 0.2°C (P < 0.01),對照組沒有變化。在術畢時,對照組中心溫度降低了0.9°C ± 0.4°C,而在氨基酸組患者中心溫度降低了0.4°C ± 0.3°Cp<0.01)。在氨基酸組患者的氧攝取比基礎水平提高了26 ± 7 mL/min, or 16% ± 5% (P < 0.05),在對照病人中卻沒有改變。術中失血量在對照患者中(702 ± 344 mL)比在用氨基酸患者中(516 ± 272 mL)更加明顯(P < 0.05)。術後血容量的下降量組患者並沒有明顯差異。總之,氨基酸灌注在脊麻時能引起產熱反應。而且防止脊麻時溫度下降似乎對術中失血有積極作用。

                                                (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.

 

在豬模型上氣管插管拔管前吸氧使全麻後的氣體交換惡化

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

 

在氣管插管拔管前給予100%氧是臨床常見的方法。 我們在豬模型上採用複合惰性氣體排除法測定這種方法對術後氣體交換的影響。全麻機械通氣30min後(吸氧30%)停止麻醉,豬隨機給予30%100%的氧,直到能安全拔管。拔管後30min吸空氣,結果:100%氧的豬到達通氣不足部分的血流量比吸30%氧的豬明顯增加(17% ± 15%7% ± 5%; P = 0.009).。我們認為拔管前吸100%氧可能引起氣體交換的不利影響。

                                                (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.

 

病態肥胖和術後肺不張:一個被低估的問題

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

 

在病態肥胖患者(MO)中由於全麻和手術產生的呼吸機的干擾更加明顯。因為全麻引起非肥胖患者的肺不張,所以我們推測在MO患者中肺不張都是很特殊的。我們研究MO和非肥胖患者在全麻後肺不張的重要性和吸收。為20 MO患者在腹腔鏡下行胃成型術和10個非肥胖患者腹腔鏡下膽囊切除麻醉。我們用CT在不同階段評估肺不張:全麻誘導前,插管即刻,和24小時後。在麻醉誘導前,MO患者比非肥胖患者有更多的肺不張(2.1% 1.0%, 各自的 P < 0.01).,用在全肺中的百分比來表示。氣管拔管後,兩組患者肺不張均增加,但在MO患者出現中仍比較多(MO 患者7.6% 肺肥胖患者2.8% ; P < 0.05)24小時後在MO患者中肺不張的數量沒變,但在非肥胖患者中我們觀察到完全吸收(9.7% 1.9%, 各自的 P < 0.01)。在MO患者全麻引起的肺不張要多於非肥胖患者, 而且肺不張在MO患者至少維持24小時,這時肺不張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.

 

剖胸體位的胃食管返流與氣管吸入:術前應該常規應用雷尼替丁嗎?

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:氣管內吸入胃內容物可以造成剖胸手術後的肺部併發症。病人在側臥位行剖胸手術時的胃食管返流以及氣管內吸入胃內容物的發病率仍未知。雷尼替丁作為術前用藥可以減少胃內容量、提高胃內PH,可能減少胃食管返流。目的:研究雷尼替丁對於剖胸手術病人的胃食管返流和氣管內吸入的影響。方法:本研究採用安慰劑對照、隨機、雙盲。使用氣管和食管腔內連續PH監測探頭,研究雷尼替丁對於80位接受剖胸手術的成年病人的胃食管返流和氣管內吸入的影響。具有胃食管返流高危因素的病人被排除出本研究。結果:在安慰劑組和雷尼替丁組酸性胃食管返流的發生率分別是28.2%和2.5%(P0.006),只有在安慰劑組有幾位元病人發生了多次胃食管返流。安慰劑組和雷尼替丁組總的胃食管返流事件分別是161P0.002)。安慰劑組和雷尼替丁組氣管內酸性物質吸入的發生率分別是7.7%和2.5%(無統計學顯著意義)。結論:接受剖胸手術的病人屬於胃食管返流的高危人群,導致氣管內酸性物質的吸入發生率較高。採用雷尼替丁作為術前藥能夠明顯減少但是不能完全防止這種具潛在致命危險的併發症。

                                   (顏      莊心良  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.

 

持續過度通氣對硫噴妥鈉麻醉下的兔局部腦血容量的影響

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:探討持續過度通氣對不同腦區的血容量是否存在時間限制性的影響。方法:對9只硫噴妥鈉麻醉的兔,持續過度通氣3小時,採用穩態敏感對照磁共振成像技術,每30分鐘測定新皮層背側壁、紋狀體和小腦的腦血容量。結果:紋狀體是唯一在低碳酸血症(PaCO2, 24 ± 3 mm Hg)期間表現出穩定的血容量減少的腦區。相反,新皮層和小腦(程度比較輕)表現出進行性的恢復到正常腦血容量的趨勢。三個腦區的腦血容量在恢復到正常通氣時都沒有發現反跳跡象。結論:持續過度通氣可以導致腦血容量的不均衡減少,其原因可能是由不同的腦血管對於細胞外PH的敏感性不同造成的。我們的研究結果證實,持續過度通氣對於腦血流動力學影響是短暫的。

(顏      莊心良  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.

神經甾體類麻醉藥Alphaxalone抑制牛腎上腺髓質細胞去甲腎上腺素轉運體的功能

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

本文研究神經甾體類麻醉藥alphaxalone 對牛腎上腺髓質細胞去甲腎上腺素轉運體(NET)功能以及麻醉條件下大鼠血壓和血漿腎上腺素濃度的影響。結果顯示Alphaxalone (10–100 µM)以濃度依賴性的方式抑制對地昔帕明敏感的牛腎上腺髓質細胞攝取去甲腎上腺素。Eadie-Hofstee 分析顯示Alphaxalone 明顯增加凱米利斯常數(酶反應常數)而不增加最大反應速度,表明這種抑制作用是通過和NET競爭引起的。Alphaxalone 可能抑制牛腎上腺素細胞質膜[3H]- 地昔帕明的特殊結合部位。[3H]- 地昔帕明結合的Scatchard分析顯示alphaxalone顯著增加地昔帕明與受體結合的解離常數而不增加最大結合程度,也表明這種抑制作用是競爭性抑制。靜脈單次給予 alphaxalone 對麻醉大鼠血壓無顯著影響,但是顯著增加血漿去甲腎上腺素的濃度。結論是, alphaxalone競爭性抑制腎上腺髓質細胞NET的功能,提示其對交感神經功能可能產生影響。

                                      (王士雷   莊心良 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.

 

預防性給予奧丹西龍能減少椎管內注射芬太尼後病人瘙癢的發生率

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:研究預防性靜脈給予奧丹西龍對蛛網膜下腔給予芬太尼後病人瘙癢的發生率。方法:150ASA I–II在蛛網膜下腔神經阻滯麻醉(用藥:重比重布比卡因 7–10 mg,芬太尼 25 µg )的病人隨機分為麻醉開始前靜脈注射奧丹西龍 8 mg 組和生理鹽水組。在用藥後1h內的每 15 min和隨後的12, 3, 4, 5, and 6 h 對瘙癢的情況進行評估。用 {chi}2 t檢驗進行統計學處理。結果:空白對照組瘙癢的發生率明顯高於奧丹西龍組 (68% versus 39%) (P = 0.001)。二組病人開始出現瘙癢的時間無顯著差異 (對照組55 ± 32 min,奧丹西龍組 50 ± 31 min) 二組病人瘙癢持續時間無差異 (空白對照組 98 ± 60 min,奧丹西龍組 103 ± 58 min)。結論:預防性應用奧丹西龍能明顯減少鞘內應用芬太尼後瘙癢的發生率。

                                      (王士雷   莊心良 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.

 

小兒和成人在異丙酚和異氟醚麻醉下經導管射頻消融術後噁心和嘔吐發生率較

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

對兒科病人施行經導管射頻消融術,一般需全身麻醉,這樣,術後噁心和嘔吐現象很普遍,在用吸入麻醉藥時,噁心和嘔吐的發生率可達60%。與吸入麻醉藥相比,異丙酚全麻後,其噁心和嘔吐發生率較低。我們對此作進一步的研究。病人隨機分為異丙酚麻醉組和異氟醚麻醉組,所有病人在麻醉前均預防性地給予止吐藥奧丹西龍,在術後18小時的觀察期內,發生噁心和嘔吐的病人用氟呱利多止吐。記錄和比較各組發生噁心次數、嘔吐次數、用氟呱利多止吐次數、鎮靜程度積分以及麻醉藥費用。噁心和嘔吐的發生率在異氟醚麻醉組(63% 噁心/55% 嘔吐)明顯高於異丙酚麻醉組(21% 噁心/6%嘔吐);噁心和嘔吐病人應用氟呱利多無效者在異氟醚麻醉組(70%)明顯高於異丙酚麻醉組(0%)。結果表明,在異氟醚麻醉下經導管射頻消融術的兒科病人,有很高的術後噁心和嘔吐發生率,而且,奧丹西龍的預防效果以及氟呱利多的治療效果均不佳。而應用異丙酚麻醉後,噁心和嘔吐的發生率低,奧丹西龍的預防效果和氟呱利多的治療效果均較好。

(楊保仲 莊心良 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.


三種預防術後噁心和嘔吐方案比較

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

我們用前瞻、隨機、雙盲的方法,對三種預防術後噁心和嘔吐的方案作一比較。婦科手術病人90例,ASA分級I-II級,年齡18-65歲,所有病人均用統一的麻醉方法(全麻)和鎮痛方法(嗎啡鎮痛)。病人隨機分為三組,第一組:麻醉誘導後給予奧丹西龍 4 mg 氟呱利多 1.25 mg12小時後給予氟呱利多 1.25 mg  (n = 30);第二組:麻醉誘導後給予地塞米松 8 mg 氟呱利多 1.25 mg12小時後給予氟呱利多 1.25 mg  (n = 30);第三組:麻醉誘導後給予奧丹西龍 4 mg 地塞米松8 mg 12小時後再給安慰劑 (n = 30)。完全有效率(48小時內無噁心和嘔吐),第一組為80%,第二組為40%,第三組為70%(第二組明顯低於第一組和第三組, P = 0.004)。三組不良反應的發生率相似。結果表明,在婦科手術病人,奧丹西龍複合 氟呱利多或地塞米松,其預防噁心和嘔吐的效果優於地塞米松複合氟呱利多

(楊保仲 莊心良 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.

靜脈全麻藥對中國倉鼠卵母細胞重組人M1-M3毒蕈堿受體的影響

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:先前研究表明異丙酚、氯氨酮和硫賁妥鈉通過作用於副交感神經使氣道張力增加。本實驗研究靜脈全麻藥異丙酚、氯氨酮和硫賁妥鈉是否對中國倉鼠卵細胞重組的M1-M3CHO-M1M2M3)毒蕈堿受體發生作用。方法:作者應用0.4nM1-N甲基-3H甲基氯化東莨菪堿([3H]NMS)作為置換劑研究這些全麻藥與中國倉鼠卵母細胞重組人M1-M3毒蕈堿受體的作用。另外採用螢光分光光度計檢測由1mM乙酰甲膽鹼激發的細胞鈣內流,進而檢測受體的功能。結果:氯氨酮呈濃度依賴置換[3H]NMS 結合的CHO-M1M2M3細胞,其親和力pKi平均值分別為4.34 ± 0.14 (45 µM), 3.53 ± 0.10 (294 µM), and 3.61 ± 0.02 (246 µM)。臨床相關濃度的氯氨酮即可影響M1受體。氯氨酮在乙酰甲膽鹼存在和不存在時都不增加CHO-M1細胞的鈣內流。硫賁妥鈉可替換結合於CHO-M3[3H]NMS ,有統計學意義, pKi平均值為 4.12 ± 0.06 [75 µM],但對M1M2無作用。10-5–10-3 M 的硫賁妥鈉呈濃度依賴性抑制乙酰甲膽鹼引起CHO-M3細胞 的鈣內流。異丙酚和巴比妥酸對任何一種毒蕈堿受體亞型均無作用。結論:本實驗表明在細胞內鈣離子水平,硫賁妥鈉M3受體有拮抗作用,但氯氨酮對M1受體無功能性影響。

                                          (趙雪蓮    莊心良  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.


 

抑制超強有害刺激引起撤退反應的異氟醚可減少大鼠脊髓C-Fos表達而氟烷無此作用

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:作者研究大鼠後爪受到超強有害機械刺激時異氟醚和氟烷對腰骶脊髓fos樣免疫反應(FLI)產生的影響。方法:本實驗採用不同濃度的異氟醚和氟烷,並設立對照組。結果:與無刺激的對照組(0.9%異氟醚)相比較,0.9-1.5%的異氟醚下有害刺激能增加雙側的FLIFLI主要分佈於背角的表層(Ⅰ-Ⅲ層),較少分佈於背角的深層(IV–VI 層)中間帶(VII 層),3-5倍以上單側標記。在1.8%異氟醚時所有層的FLI均數都明顯降低(1.7 ± 1.3每層),其他濃度的數值分別為0.9%-11.4 ± 9.5, 1.2%-7.5 ± 6.8, 1.5%-9.7 ± 6.6 ,但是與無刺激的對照阻相比無區別。在骶骨水平,作者發現無刺激對照組首先出現在骶骨水平脊髓表層的雙側分佈的FLI與其他濃度異氟醚組相比無明顯差異。不同濃度的氟烷的FLI數無明顯不同。只有在能抑制有力、有意向和撤退反射濃度的異氟醚可減少FLI,但是氟烷即使達到抑制撤退反射濃度時也不降低FLI。結論:異氟醚和氟烷對有害刺激的伸肌功能和神經反應有不同的作用。

                                    (趙雪蓮    莊心良 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.


腹式子宮切除術後活動所致的疼痛及自發性疼痛與呼氣流量峰值間的關係

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:術後肺功能障礙的發病機制在活動導致疼痛中起了一定的作用(例如避免疼痛而引起的夾板效應和通氣不足)。然而,活動所致的疼痛和呼吸生理學間的交互作用還未被瞭解。目的:研究活動所致疼痛和自發性疼痛與一項肺功能指標(PEF)之間的關係。方法:25例行子宮切除術的患者,在術後第一、二天內的八個時點記錄其自發疼痛、坐位疼痛、被迫呼氣及咳嗽時的視覺疼痛評分和呼氣流量峰值(PEF),其次觀察其氧飽和度和需氧量。結果:咳嗽、坐位、被迫呼氣時的疼痛和自發性疼痛在八個時點中分別有八個、七個、四個、二個時點與PEF明顯相關。咳嗽及坐位時的視覺疼痛評分(26.1 mm [1.7]21.5 mm [1.5])高於自發性疼痛(10.5 mm [0.8]),(P<0.05)。咳嗽時高於被迫呼氣時的評分(16.8 mm [1.3]),(P<0.05)。研究過程中,所有的疼痛均得到緩解(P<0.05),PEF也有所恢復。可以假設咳嗽引起的疼痛與PEF之間存在負相關,部分是因為回避咳嗽,最終限制了深吸氣、肺複張和分泌物的清除。結論:活動引起的疼痛可能是導致術後併發症的重要因素,但其機制尚未被瞭解。此研究提供了術後疼痛與肺功能間關係的第一手證據,並指出了今後需要繼續研究此現象機制和意義。

                                               (   莊心良 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.


加巴噴丁在格林-巴厘綜合征疼痛治療中的應用——雙盲、對照的交叉研究

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:評價加巴噴丁對緩解格林-巴厘綜合征疼痛的雙峰特性的療效。方法:對18名重症監護病房給予通氣支援的患者進行了隨機、雙盲、對照的交互研究。在最初7天裏,分別給予患者加巴噴丁15 mg · kg-1 · d-1(三次劑量)或用於對照的安慰劑,經過2天的清除期後,先前用加巴噴丁的患者改用安慰劑,用安慰劑的患者改用加巴噴丁。在患者需要時或在疼痛評分〉5分(評分為0-10分)時給芬太尼2 µg/kg。記錄疼痛評分、鎮靜評分、芬太尼用量及副作用,並比較這些變數。結果:加巴噴丁治療開始後第二天疼痛評分從7.22 ± 0.83 降至 2.33 ± 1.67,並在加巴噴丁治療期間保持低水平(2.06 ± 0.63) (P < 0.001)。加巴噴丁治療期間第一天至第七天的芬太尼用量(211.11 ± 21.39 µg 65.53 ± 16.17 µg)較安慰劑治療期間(319.44 ± 25.08µg 316.67 ± 24.25 µg)明顯減少(P < 0.001)。結論:加巴噴丁已經用於治療各種類型的疼痛。其副作用小,是除阿片類藥物和非甾體類抗炎藥外治療格林-巴厘綜合征雙峰性疼痛的又一選擇。

                                            (朱慧   莊心良  )

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).

 

氣管拔管前增加吸入氧濃度對術後肺不張的影響

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

全麻導致的肺不張可為肺活量手法(膨脹肺至40 cm H2O 15 s)消除 。高濃度氧吸入導致肺不張的再發生。因此,在拔管前吸入100%氧可能引起肺不張。為評價在拔管前使用100%氧是否增加術後肺不張的數量,我們研究了30位擇期行四肢手術的病人。在預計手術結束前10分鐘,病人隨機分成(a)吸入氧FIO2 = 1.0 (n = 10)組;(b)肺活量手法+ FIO2 = 1.0 (n = 10)組;或(c)肺活量手法+ FIO2 = 0.4(n = 10)。以CT片測定肺不張發生的病例數,動脈血氣分析檢查氧合情況。以單側方差分析,Bonferroni 法校正進行資料分析。結果以平均數± SD表示; P < 0.05為統計學有意義。在肺活量手法+ FIO2 = 0.4(總肺表面的2.6% ± 1.1%, P < 0.05),術後肺不張比 FIO2 = 1.0組(8.3% ± 6.2%)少。在全麻結束時吸入100%導致術後肺不張。從氧合的觀點而言,氣管拔管時的安全界限是必要的,因此進一步的研究應評價儘管應用了100%氧是否仍能防止肺不張的形成。

                                       (張 莊心良 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.

 

住院病人冠狀動脈搭橋術後心率和死亡率間的關係

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:避免心動過速是冠脈搭橋術(CABG)麻醉管理的共識。然而,術中心率增快和死亡率間的關係還未曾有所描述。方法:我們設計了一個觀察性研究,來評估誘導前心率(到達手術室時的心率)和CABG手術住院死亡率之間的關係。結果:總共收集了5934CABG病人的資料。15%的病人有誘導前的心率增快(>80bpm)。這些病人初步計算的死亡率明顯較高(P=0.002)。經過把病人間的差異以基線標準化後,誘導前的心率增快仍然與高死亡率密切相關(P<0.001)。心率的增快可能是被觀察到的死亡率一個原因。快速的心率可能是不可逆心肌損害的標誌,或者有進一步損害危險時心臟儲備能力有限的標誌,再就是ß阻滯劑用量不足。因為術前使用ß阻滯劑可以提高住院病人生存率,深入研究關於ß阻滯劑治療術中心率增快對CABG術後死亡率的作用顯得很有必要。結論:經基線差異調整後,誘導前心率>80bpmCABG術後死亡率增加有關。

                     (唐   莊心良 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.

 

實驗檢測家兔肝素活性變化:抗Xa活性與血栓彈性圖、活化部分凝血活酶時間、啟動凝血時間的比較

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:血栓彈性圖(Thrombelastography®TEG®)在臨床和實驗室中被用來檢測外源和內源性迴圈肝素活性。在本研究中,給家兔以小劑量肝素,以期比較TEG®、活化部分凝血活酶時間(aPTT)和啟動凝血時間(ACT)各值對抗Xa活性變化的敏感性。方法:靜脈給與11只清醒家兔0102030u/kg肝素,從其耳動脈抽取血樣用於血液學分析。結果:不同劑量下,抗Xa活性分別是38 ± 9 mU/mL74 ± 15 mU/mL105 ± 14 mU/mL134 ± 17 mU/mL,所有數值間的差異均有統計學意義。TEG® 參數R和α在01020 u/kg組間有顯著改變(P<0.05),而2030 u/kg組間由於可看清的凝血塊丟失而未能判別。aPTT 01020 u/kg組間有顯著改變(P<0.05)。ACT在對照組與其他組間均有顯著變化,但在各用藥組間卻未發現有明顯差異。抗Xa活性與各參數間的線性關係:R (r = 0.81P < 0.0001),α(r = -0.85P < 0.0001),aPTTr = 0.74P < 0.0001),和ACTr = 0.41P = 0.005)。在本小劑量肝素模型中,TEG®對肝素活性的敏感性比的敏感性都要高。結論:在家兔的小劑量肝素模型中,TEG®aPTTACT更加敏感地反映迴圈肝素活性的變化。因此,無論在實驗室還是臨床對凝血病實施肝素治療中,檢測肝素活性用TEG®aPTTACT都更有幫助。

                     (唐   莊心良 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.

 

 

麻醉藥預處理減輕豚鼠離體完整心臟缺血時的線粒體鈣超載

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:心臟缺血再灌注損傷(IR)與線粒體鈣超載有關。預先使用麻醉藥可以減輕IR損傷。本文假定麻醉藥減輕線粒體鈣超載與線粒體腺苷酸敏感性鉀通道(mKATP)開放有關。方法:使用吲哚-1indo-1)螢光,在40Langendorff灌注的豚鼠心臟中測量線粒體鈣濃度(m[Ca2+])。對照組(CON)為接受IR50分鐘未加處理的心臟,麻醉藥預處理組(APC)則暴露在1.2 mM 8.8 vol%)七氟醚中15分鐘。APC5-羥基癸酸(5-hydroxydecanoate5-HD)組(APC+5HD)在暴露於七氟醚的5分鐘前到15分鐘後時接受200 µM 5-HD5-HD組接受35分鐘5-HD。在30分鐘的完全缺血和120分鐘的再灌注之前,洗脫七氟醚30分鐘,洗脫5-HD 15分鐘。結果:缺血中,APC組的m[Ca2+]峰值累計從489 ± 37 nMCON)降低到355 ± 28 nM P < 0.05),並可被5-HD消除(475 ± 38 nM m[Ca2+])。APC可增強心臟功能,並減少再灌注時的梗死面積,此作用可以被5-HD所阻斷。而5-HD單獨預處理則對m[Ca2+]470 ± 34 nM)和IR損傷沒有影響。再灌注時功能和形態學上的保護與缺血時的m[Ca2+]累計值相關。5-HD的翻轉作用提示APC可能為mKATP通道開放所觸發。結論:心肌缺血再灌注損傷與線粒體鈣超載有關。豚鼠離體心臟中測得的線粒體鈣濃度和功能說明,麻醉藥預處理減輕了缺血時的鈣超載,增強了心功能,減小了梗死面積。5-HD的翻轉作用則提示麻醉藥的預防作用可能由線粒體腺苷酸敏感性鉀通道開放觸發。

(唐   莊心良 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.


小劑量氧化氮增進單肺通氣時的氧合:實驗研究

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)不能增進單肺通氣(OLV)時的動脈氧合。作者假定更低濃度的NO可能有助於氧合。方法:十二頭26-32kg的小豬被用於試驗。OLV中,當PaO2達到平臺期時,隨機吸入481632ppmNO30分鐘。有創監測血液動力學資料。用動脈血液分析和通氣血流分析(6頭動物進行了複合惰性氣體清除法)瞭解肺氣體交換功能。結果:481632ppmNO均可增加PaO2,其中4ppm的作用最為明顯(ΔPaO2分別為42 ± 35 mm Hg22 ± 20 mm Hg13 ± 18 mm Hg15 ± 16 mm HgP < 0.05)。4ppmNO可減少肺內分流,而更大濃度並沒有表現出更有意義的結果。結論:NO在低濃度,即4ppm時比高濃度更加有助於提高動脈氧合,其原因是減少了肺內分流,其量效關係還有待於OLV急性低氧實驗證實。

                       (唐   莊心良 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.

 

體外迴圈後48小時內高熱

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 圍手術期低溫引起的不良後果已被重視。然而,由於高熱增加氧供需求和潛在的神經損傷同樣能對患者構成危險。方法 為了了解體外迴圈後出現高熱(膀胱溫度≥38.5℃)的幾率,術後48小時內在監護室305例病患每小時記錄一次膀胱溫度,40例記錄鼻咽腔溫度,20例記錄頸靜脈球溫度。結果 雖然不是所有患者都在監護室觀察48小時,但是至少38%的患者出現術後高熱。幾率呈現雙峰值分佈,分別在術後9.1±4.0小時(26%)和27.7±6.326%)。其中有14%的患者在二個時間點上均出現高熱。在術後前5小時內,頸靜脈球溫度比膀胱溫度高0.4℃(P0.05=。膀胱溫度和鼻咽腔溫度則沒有差別。監護室環境溫度較高和年齡小於60歲與高熱的出現無關。結論 總之,在心臟手術體外迴圈後48小時內早或晚出現高熱是普遍現象。體外迴圈後腦性高熱可能引起嚴重腦部損傷。

(李 薛張綱 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.

 

有嚴重左室收縮功能障礙的患者行冠脈搭橋術預後與術前右室功能有關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 有嚴重左室收縮功能障礙的患者行冠狀動脈搭橋手術後併發症發生率和死亡率都上升。本研究的目的在於評價術前右室功能和術前具有左室收縮功能障礙患者行冠脈搭橋術的預後的相關性。方法 我們回顧性研究了41名患者(左室射血分數≤25%)。資料獲取來自醫療記錄、經食道超聲記錄和電話採訪。體外迴圈前後的左室射血分數和右室射血分數的測定採用術中經食道超聲。第一組患者右室射血分數≤35%(7例),第二組右室射血分數>35%(34例)。機械通氣、ICU入住時間和總住院時間取中位數。術前左室射血分數在兩組患者是相似的(15.8±3.3%和17.8% ± 3.9%)。結果 與第二組相比,第一組患者需要更多機械通氣的時間(12天比1天,P < 0.01),ICU監護時間更長(14天比2天,P < 0.01),出現更多更嚴重的左室舒張功能障礙,體外迴圈後左室收縮壓的改變更小(4.1% ± 8.3% 12.5% ± 9.2% P < 0.01)。所有第一組患者術後2年死於心臟原因,其中5例在當次住院期間死亡。第二組有3例病人死亡(1例於術後18個月死於結腸癌,2例分別在術後2448個月死於心臟問題),1例患者于術後4年等待心臟移植,其餘患者心功能Ⅰ-Ⅱ級(紐約心臟協會)。結論 對嚴重左室手術功能不全的患者來說,體外迴圈前伴有右室功能不全者預後差。患者右室射血分數>35%者能相對平穩度過圍手術期並能較好長期生存,而右室射血分數≤35%的患者早期和晚期預後均較差。進行右室功能的評估對進一步評價冠脈搭橋手術的風險有一定幫助。

(李 薛張綱 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.

心臟保護措施對腹主動脈手術後心臟併發症發生率的影響

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 我們分析了研究所8年來468例擇期行腹主動脈手術的病人的病案資料。在19971月一個新的心臟保護措施被採用,我們想探討是否應用美國心臟大學/心臟病協會指南來一步一步的圍術期評價和應用腎上腺受體的拮抗藥對心臟有利影響。手術中給可樂定,手術後給β-受體的拮抗劑使心率小於80/分。方法 我們比較19931996(控制期)年和19972000年(幹預期)兩組四年的數據。結果 應用美國心臟大學/心臟病協會指南來一步一步的圍術期評價和增加圍術期心臟的檢查是一致的(44.3%20.6,p<0.05)也和冠狀血管的再血管化一致的。(7.7%0.8% p<0.05)。在幹預期心臟併發症的發生率降低(從11..3%4.5%)。手術後一年生存律增加從91..3%98.2%)多變數回歸分析顯示聯合應用可樂定和β-受體的拮抗劑降低心臟不良事件的發生(0..3,95%的可信區間0.1-0.8),而大出血、腎功能不全、慢阻肺預示心臟併發症。結論 心臟試驗對一小部分得益於再血管化的高危病人有益。連續和選擇性的應用腎上腺受體的拮抗藥可改善手術後心臟功能。

(嵇富海 薛張綱 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.

 

術前臨床評估的變化對減少心臟科會診次數和提高心臟科會診質量的影響

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 雖然術前臨床實驗評估(preoperative assessment testing clinics  PATCs)能有效得評估擇期手術的患者,但是它對會診的影響還未被研究。我們假設改變PTCA的操作程式,教育方式和工作人員能影響心臟科醫生會診的次數和效率。方法 1993年至1999年回顧性研究了所有擇期非心臟手術的患者(麻醉科要求心臟科會診)的 PATC。該時期覆蓋了PATC改變的前後3年,而改變表現擇更嚴格的諮詢方式、心臟評估、心電圖解釋、麻醉師和輔助人員的變更。一位高級心臟科醫生完成了所有的會診。速率包括年齡、性別、會診的原因、測試結果及結論、手術取消及手術過程和結果。結果 PATC改變前後的兩組分別有917次和279次會診(1.46%比.49%,P = 0.00010 非心臟手術)。PATC改變後的一組患者儘管外科夾雜症有所增加,但是心臟科會診和要求進一步評估心功能狀態的情況明顯減少。結論 我們認為PATC的改變(包括諮詢方式、教育、人員等)顯著減少了術前心臟科會診的次數,提高了會診的效率。

(李 懿譯 薛張綱 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.

 

雙頻譜指數監測:正常兒童和Quadrplegic腦癱兒童之間對照

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 我們進行該項研究來比較正常兒童和那些精神發育阻滯的Ouadrplegic腦癱兒童在不同七氟醚濃度時雙頻譜指數數值得相關程度。方法 214歲的20名精神發育阻滯的腦癱兒童(組)和21名正常兒童(組)作為研究物件。以七氟醚和66N2O/O2進行麻醉誘導和維持。應用Aspect Medical Systems (Natick, MA)監測儀記錄雙頻譜指數,Ohmeda (Hanover, MA)吸入麻醉氣體監測儀測算七氟醚的濃度。分別在應用術前藥咪達唑倫後,麻醉誘導後,呼氣末七氟醚濃度達到1%、3%、再次降至1%時和麻醉蘇醒後記錄雙頻譜指數。兩組病人在年齡和性別上均衡性好。但是組的患兒體重明顯低於組正常兒童(P0.05=。結果 組患兒在鎮靜後,七氟醚濃度1%和蘇醒後的雙頻譜指數顯著低於組正常兒童。兩組在麻醉誘導後(8%)和七氟醚濃度為3%時沒有差別。結論 雖然在蘇醒後和不同的七氟醚濃度下那些腦癱兒童的雙頻譜指數絕對值低於正常兒童,但整體上雙頻譜指數的變化模式在兩組兒童間是相似的。

(李 薛張綱 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.

 

門診手術小劑量利多卡因-芬太尼蛛網膜下腔麻醉:比較預防性應用NalbuphineNalbuphine加氟呱啶

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 小劑量利多卡因-芬太尼蛛網膜下腔阻滯對於門診手術是一種安全、有效和經濟的麻醉方法。但遺憾的是它常常會引起瘙癢和噁心嘔吐等併發症。Nalbuphine能有效地治療和預防鞘內或硬膜外應用嗎啡引起的瘙癢,但對噁心嘔吐沒有作用。而氟呱啶有拮抗鴉片類藥物對神經系統的作用。該研究比較了小劑量利多卡因-芬太尼蛛網膜下腔麻醉後單用Nalbuphine和聯合應用Nalbuphine加氟呱啶的預防作用。方法 124例門診膝關節鏡手術的病人行小劑量利多卡因-芬太尼蛛網膜下腔麻醉,應用0.5%利多卡因20mg和芬太尼20μg,隨機在術後注射Nalbuphine 4mgN組)或Nalbuphine 4mg聯合氟呱啶0.625mgND組)。結果 早期(未離院時)和後期出現的併發症噁心分別是N18%相對於ND5%和N32%相對於ND13%。術後瘙癢N61%而ND組為40%,19%的N組病人要求止癢而只有2%的ND組病人要求處理瘙癢。ND組病人痛覺評分低,首次止痛後間隔週期較長。兩組病人評價的離院時間沒有差別。ND組唯一的藥物副作用是引起嗜睡。結論 小劑量利多卡因-芬太尼蛛網膜下腔麻醉聯合應用氟呱啶0.625mgNalbuphine 4mg作為預防性用藥優於單獨使用Nalbuphine。能夠減少術後噁心、瘙癢和疼痛,並在離院後持續作用。同時也沒有出現極端延擱離院的個別病例。

(李懿 薛張綱 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.

 

圍手術期患者狀態指數與腦雙頻指數的比較

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 患者狀態指數(PSI),作為一種量化腦電圖指數,最近被引用到臨床實踐用來監測評價鎮靜和全麻中意識狀態(清醒程度)。方法 我們設計了這個觀察性研究,比較PSIBIS在設計神志喪失和麻醉清醒能力上的敏感性和特異性以及評估麻醉維持期間靜脈麻醉藥(異丙酚)和吸入麻醉藥(地氟醚)的變化。這一前瞻性臨床研究收錄了二十位擇期行腹腔鏡手術的知情同意患者。麻醉誘導用異丙酚2mg/kg,芬太尼1µgcisatracurium 0.3 mg/kg,麻醉維持用4%地氟醚複合一氧化二氮。結果 logistic回歸模型分析,BISPSI均能有效地預計神志喪失(如對語言刺激無反應性)(P < 0.01)而且在全麻的誘導和蘇醒階段,BISPSI均表現為相關性(r 分別為 0.780.73)。然而用來檢測神志狀態的接受器運行特徵性曲線下面積表明PSI0.95 ± 0.04)優於BIS對異丙酚(0.79 ± 0.04)。在麻醉維持階段,BISPSI對異丙酚和地氟醚變化的反應具有可比性,但PSI的病人間變異率更大。最後BISPSI相比在術中受電灼器的干擾更小(16%65%)。結論 PSI被證明可作為全麻誘導和蘇醒階段評價意識狀態的可行性替代選擇,也可認為麻醉維持階段異丙酚和地氟醚劑量調整的一個指標。然而,我們仍需用PSA裝置對PSI在麻醉中的地位作進一步的研究。

(潘志浩 薛張綱 )

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.

 

乙酰膽鹼受體與三氟乙醚及12-二氯乙氟環丁烷致驚厥閾值的關係

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 乙酰膽鹼受體遍佈整個中樞神經系統,它們可能介導了某些方式的驚厥或驚厥的某些方面。在大腦中,結合煙鹼、胞苷和epibatidine的煙鹼乙酰膽鹼受體上的大部分高親和力結合位點都含有β2亞基。過渡型吸入複合物(指那些效能低於其親脂性和Meyer-Overton假說系統的值得複合物)和非制動劑(指那些儘管根據Meyer-Overton假說預計應具有親脂性應有的麻醉效能卻不能產生不動性的複合物)可導致驚厥。非制動劑三氟乙醚(雙三氟乙基醚)在γ-氨基丁酸-AGABA-A受體上阻滯了GABA的作用。而另一種非制動劑12-二氯乙氟環丁烷(2N;也稱F6)並沒有此中作用。2N可認為在煙鹼乙酰膽鹼受體上阻斷乙酰膽鹼作用。方法 我們觀察了在乙酰膽鹼受體β2亞基正常或缺失小鼠重這些複合物致驚厥的相對能力。結果 發現使半數小鼠致驚厥的氣體分壓(即半數有效濃度EC50)試驗組與對照組相同。在β2亞基缺失的小鼠,三氟乙醚的EC500.00170±0.00030 atm(平均數±標準差),2NEC500.0345 ± 0.0041 atm。對照組的EC50分別為0.00172 ± 0.00057 atm 0.0341 ± 0.0048 atm。缺失組比值,2N/三氟乙醚為20.8 ± 3.5,對照組為2N/三氟乙醚為21.7 ± 7.0。結論 這些結果並不支持乙酰膽鹼受體是2N或三氟乙醚致驚厥能力的重要介體的說法。然而,我們還發現兩種非制動劑在EC50分壓時都抑制了大鼠{alpha}4ß2神經元煙鹼乙酰膽鹼受體(EC50分壓:三氟乙醚0.00094 atm2N 0.062 atm)這些分壓值與致驚厥的分壓值相似(0.0015 atm and 0.04 atm)。

(梁雅芬 薛張綱 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).

 

硬膜外腔注射類固醇激素的門診疼痛治療病人使用非甾體抗炎藥的出血併發症風險評估

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.

我們前瞻性研究了1214例硬膜外注射類固醇激素中的1035例病人以明確出血併發症的風險。存在出血或淤斑病史的患者有176例(占15%)。有77例在硬膜外注射類固醇激素前進行了血小板計數,其中無一例低於100 x 109/L383例(占32%)報導使用了非甾體抗炎藥(NASID,包括34例複合用藥的病人。阿斯匹林是最為常用的NASID,其中有158例病人使用阿斯匹林,包括104例每天劑量在325 mg或以下的病人。沒有一例發生脊髓血腫(嚴重併發症),在穿刺或置管時明顯出血(輕度併發症)的病人有63例(占5.2%)。NSAIDs 不增加輕度出血併發症的發生率。但是,增加的年齡、穿刺針號、穿刺入路、多間隙穿刺、穿刺次數、注入藥物的容量及意外硬膜穿透則都是發生輕度出血併發症的顯著風險因素。有42 例病人出現新的神經症狀或原有的主訴惡化,這些表現在注入後持續超過24小時,症狀平均持續3(range, 1–20 days)。我們的結果證實了以前在產科和外科病人中進行的研究結論:在接受NSAIDS治療的這類病人中進行神經阻滯是安全的。我們推論在接受阿斯匹林類抗血小板藥物治療的病人中進行硬膜外注射類固醇激素是安全的,在硬膜外注射類固醇激素後可能發生神經功能輕度惡化,應注意與其它的需要干預治療的病因鑒別。結論:以前在產科和外科病人中進行的研究表明抗血小板治療不增加發生脊麻或硬膜外麻醉和止痛相關的脊髓血腫的發生率。我們證實了接受阿司匹林類抗血小板藥物治療的病人硬膜外注射類固醇激素的安全性。

(張俊峰譯 薛張綱校)

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.

 

在神經外科病人上使用一種新型熱交換導管的初步經驗

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 雖然輕度低溫在動物模型上對腦缺血提供了顯著的保護作用,低溫在腦外科手術中可能有治療價值。然而,目前的冷卻系統常不能在硬腦膜切開前誘發足夠的低溫。而且,這些系統常常未能在手術結束時恢復常溫,因此會延遲拔管。我們對一種新型內部熱交換導管進行了評價。方法 8 ASA II–IV級的開顱病人(29–72)列入研究。在全麻誘導後,我們將SetPoint導管通過股靜脈放置到下腔靜脈。目標核心體溫34°C–34.5°C。在達到目標溫度後,核心溫度維持直到硬腦膜關閉。目標核心溫度然後設定到37.0°C,病人盡可能快速複溫。結果 病人中7例是腫瘤切除,1例是動脈瘤夾閉。核心溫的冷卻速度為3.9°C ± 1.6°C/h, 複溫速度是 2.0°C ± 0.5°C/h; 手術結束時核心溫度是 35.9°C ± 0.2°C。病人然後在導管拔出前保持常溫3小時。在拔出的導管上沒有血栓或其他微粒物質。沒有一個病人出現與SetPoint系統或熱處理有關的併發症。結論 因為目前的系統誘導治療性低溫的速度太慢,我們對一種內部逆流熱處理系統在低溫神經外科手術上進行了測試。SetPoint導管以3.9°C ± 1.6°C/h速度冷卻 ,以2.0°C ± 0.5°C/h的速度複溫。導管為基礎的內部熱處理系統看來是快速而有效的。

(潘志浩 薛張綱 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.

 

知道在哪間手術室手術的不確定性對手術室的分配或提高其效率影響不大

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 在美國的許多外科組織,採用原來公佈的發揮手術室最大使用時間的方法是一種優化手術室時間分配的有效途徑,其效果卻與已記錄的手術時間中的小差錯有矛盾。然而,有些外科組織的資訊系統資料中有10%的差錯,這些差錯降低了屬於每個人員的手術室時間,手術室時間是該分配方法的基礎。這些差錯會導致不正確的手術室分配,增加手術室費用。這可能需要使用昂貴的耗時的資料清除步驟(data-cleaning steps)解決實際的手術室的分配問題。方法 我們使用來自一個大型教學醫院1年的資料通過類比方法研究差錯水平的增加如何影響手術室分配及使用的效率。為了製造資料的干擾,實際的手術室隨機的被改變為唯一的未知的手術間。結果 30%的差錯水平上,與知道每個手術室的位置相比,手術室的分配降低了4.8%,費用增加了1.4%。在11個外科組中只有1個分配降低,其手術室錯誤率低於25%。結論 我們推論為解決手術室分配的不確定性的data-cleaning steps在大多數情況下不必作準確的手術室分配。知道手術室位置的不確定性在達到30%時對為達到手術室使用的最大效率及相應的費用而進行的手術室的分配影響不大,因此,大多外科組織在此差錯水平上一般能夠使用其存在的資訊系統資料進行準確的手術室分配。

(張俊峰 薛張綱 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.

 

術後硬膜外鎮痛目前的實踐:德國調查

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 我們對當前德國的術後硬膜外鎮痛的實踐進行調查。方法 調查共發出300份不具名的調查表, 147 (49%)份調查表完全完成後返還。結果 41%的德國醫院中有24小時急性疼痛服務(APS)70%大的教學醫院 (>1000張床) APS,而只有 9% <500張床的醫院提供APS。小型醫院(<200 張床) 常用羅呱卡因作為局麻藥,而更大的教學醫院則更多使用布比卡因。在普通病房中,36% 的回應者只用局麻藥,另外64%結合使用局麻藥和阿片。如果使用羅呱卡因, 0.2% 是最常用的濃度 (78%), 常與嗎啡結合使用(17%),或與芬太尼結合使用(14%), 或與蘇芬太尼結合使用 (75%)。如果使用布比卡因, 0.25%是常用的濃度(30%),它可結合嗎啡使用(40%), 結合芬太尼使用(8%),或結合蘇芬太尼使用(60%)。在病房中, 58% 德國麻醉科應用持續的硬膜外輸注, 57%使用衝擊劑量, 20%使用病人自控硬膜外模式。結論 在德國醫院中提供24小時APS (41%)的比例與國際上的資料相當 。在病房中用局麻藥和阿片結合硬膜外內使用是最常見的模式。

(潘志浩 薛張綱 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竇狀隙頸部吸引用於評價壓力感受器敏感性

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過不同機制調整自主神經活力。我們檢驗了關於這些麻醉藥對動脈血壓的短效壓力感受器反射有不同效果的假說。方法 40ASAⅠ的病人,年齡2042歲。隨機接受1.0MAC濃度的七氟醚或足以維持麻醉的濃度的地氟醚,固定呼吸頻率在0.25HZ以上。研究病人清醒狀態,誘導後20分鐘0.2HZ功率竇狀隙頸部吸引(壓力感受器反射主要由迷走神經介導),0.1HZ功率(壓力感受器反射由迷走神經、交感神經介導)吸引時的變化。R-R間期和動脈壓變化用放大光譜分析法和複合傳導功能分析法評價。結果 從信號的平方連貫性,即光譜相關係數的平衡看,七氟醚和地氟醚並未影響壓力感受器刺激與效應器反應的一致性,和七氟醚、地氟醚不影響壓力感受器刺激於迷走神經介導心臟反應的延時性相似,他們抑制了心率對頸部吸引得反應。使用七氟醚和地氟醚的病人,0.1HZ功率頸部吸引和動脈血壓波動之間的傳導速度減慢了相當一段數值。兩種藥物都對壓力感受器刺激引發的收縮壓變化延遲約3.54.3秒。靜息狀態下,地氟醚和七氟醚所致的壓力感受器介導的短時動脈壓控制相似。結論 儘管七氟醚和地氟醚對自主神經活性有不同的影響,他們在抑制壓力感受器的心率和血壓短時的控制是相似的。

(梁雅芬 薛張綱 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喉罩的最大分鐘通氣量的測試

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喉罩一個特點是它可以導致上呼吸道的阻塞,即使在在環狀軟骨後準確插入時也會出現。方法 我們應用一種過度通氣試驗,最大分鐘通氣測試 (MMV test), 來幫助診斷ProSeal喉罩插入後上呼吸道梗阻。病人過度通氣15秒產生 MMV=4 x (呼吸次數/15) x (呼出的潮氣量)。在6個月內317例成人上採集 MMV 值。結果  臨界 MMV值在317例成人中的17例病人中獲得,其中的15(4.7%) ProSeal喉罩的插入有關。317病人中7 (2.2%)拔除了ProSeal喉罩。最常見的ProSeal喉罩導致上呼吸道阻塞的原因是喉阻塞 。這是指對聲門上和聲門的壓迫而導致氣道的狹窄。另一個更少見的形成氣道狹窄的原因是雙側氣囊向內夾閉形成狹窄或夾閉會厭的低部。結論 我們討論了分鐘通氣的安全限, MMV過度超過或低於基礎分鐘通氣量。在臨界 MMV, 安全限顯著下降或不存在。ProSeal喉罩一個特點是它會導致上呼吸道阻塞,即使在它準確插入環狀軟骨後也會發生。我們應用一種過度通氣試驗去幫助診斷插入ProSeal喉罩後的上呼吸道阻塞。

(潘志浩 薛張綱 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.

 

鞘內應用前列腺E受體亞型EP1拮抗劑對術後疼痛模型鼠機械和溫度的痛覺過敏的影響研究

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 儘管對急性疼痛的機制的瞭解及疼痛的治療已有了很大的進展,但是術後疼痛,尤其是機械激發性疼痛(incident pain)還不能得到有效治療。組織損傷和炎症增加了脊髓前列腺E2的釋放,它促使痛覺過敏的產生。方法 我們設計該試驗以明確鞘內應用前列腺E受體亞型EP1拮抗劑ONO-8711對切割引起的機械的和溫度的痛覺過敏是否具有鎮痛效應。在鼠腳底作一1釐米的縱向切口,切口附近予以機械刺激和溫度刺激,記錄對刺激的閾值和潛伏期。在切皮後2小時和24小時觀察到機械性和溫度性痛覺過敏。鞘內分別使用 ONO-8711 (50, 80, 100 µg)或生理鹽水。結果 ONO-8711劑量和時間依賴性的顯著增加對機械刺激的閾值,但並不增加對溫度刺激的閾值。我們推論EP1 受體介導的脊髓角敏感化可能導致機械性而非溫度性的痛覺過敏的產生,並且鞘內使用前列腺EP1 受體拮抗劑是術後疼痛(尤其是機械激發的疼痛)的一種有潛力的治療方法。結論 我們研究了在術後疼痛模型鞘內使用選擇性前列腺EP1受體拮抗劑對機械性和溫度性痛覺過敏的影響,鞘內使用的前列腺EP1受體拮抗劑抑制機械性而非溫度性痛覺過敏,這表明前列腺EP1受體拮抗劑可被用於治療術後疼痛(尤其是incident pain)。

(張俊峰 薛張綱 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.

 

離體豚鼠支氣管平滑肌細胞中揮發性麻醉藥和膽鹼能藥、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 我們研究七氟醚、地氟醚和氟烷對離體豚鼠支氣管平滑肌的鬆弛作用。方法 環狀標本放置於充滿生理鹽水的組織浴中,並持續給予含5%二氧化碳的氧氣。電流刺激誘發了對河豚毒素敏感的收縮,即神經介導的反應。這包括了對阿托品敏感的膽鹼能期和對SR48968(一種神經肽-2受體拮抗劑)敏感的非腎上腺素非膽鹼能(NANC)期。麻醉氣體通入到充氧的組織浴中。結果 七氟醚、地氟醚在1.0MAC,氟烷在1.0-2.0MAC均抑制了對電流刺激的膽鹼能和NANC收縮,但沒有一種麻醉藥影響了外源性物質,也就是提示另外它具有NANC神經傳導的突觸前抑制作用。麻醉藥並不影響對哮喘支氣管收縮介質白三烯4的收縮反應。然而七氟醚和地氟醚都可以鬆弛白三烯4引導的穩態收縮。奇怪的是,氟烷並沒有鬆弛白三烯4的收縮。關於白三烯引發的支氣管收縮,七氟醚和地氟醚對離體氣道平滑肌細胞是更強的鬆弛劑。結論 氟烷、七氟醚和地氟醚通過抑制膽鹼能和NANC神經傳導降低了氣道平滑肌張力。七氟醚和地氟醚降低了白三烯4誘發的支氣管收縮,而氟烷不具備這種能力。這表明在哮喘病人選用七氟醚和地氟醚更加優越。

(梁雅芬 薛張綱 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.