Anesthesia & Analgesia

January 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

评价一种新型脉搏氧饱和度仪在浅低温心肺转流期间的工作性能

(颜 涛 译 庄心良 校)

Performance Evaluation of a New Pulse Oximeter During Mild Hypothermic Cardiopulmonary Bypass

Kazuo Irita, Yoichiro Kai, Kozaburo Akiyoshi, Yukako Tanaka, and Shosuke Takahashi

Anesth Analg 2003 96: 11-14.

 

体外循环时体外肝素酶处理后的血标本和体外循环鱼精蛋白给药后的血标本之间凝血酶原时间的一致性

(张 鸿 译    薛张刚 校)

Agreements Between the Prothrombin Times of Blood Treated In Vitro with Heparinase During Cardiopulmonary Bypass (CPB) and Blood Sampled After CPB and Systemic Protamine

Anthony M.-H. Ho, Anna Lee, Elizabeth Ling, Alan Daly, Kevin Teoh, and Theodore E. Warkentin

Anesth Analg 2003 96: 15-20.

 

微型食管探头心脏超声监测用于麻醉诱导期
 (忻纪华   王祥瑞 )

Echocardiographic Monitoring During Induction of General Anesthesia with a Miniaturized Esophageal Probe

Peter Zimmermann, Clemens Greim, Herbert Trautner, Ulrich Sagmeister, Katharina Kraemer, and Norbert Roewer

Anesth Analg 2003 96: 21-27.

 

血液稀释不改变麻醉狗影响心率的动脉压力反射

(赵雪莲  译 庄心良  )

Hemodilution Does Not Alter Arterial Baroreflex Control of Heart Rate in Anesthetized Dogs

Makoto Tanaka and Toshiaki Nishikawa

Anesth Analg 2003 96: 28-32.

 

血管手术患者靶控输注雷米芬太尼改善血流动力学并减少雷米芬太尼用量

(张 鸿 译    薛张刚 校)

Target-Controlled Infusion for Remifentanil in Vascular Patients Improves Hemodynamics and Decreases Remifentanil Requirement

Victor De Castro, Gilles Godet, Gonzalo Mencia, Mathieu Raux, and Pierre Coriat

Anesth Analg 2003 96: 33-38.

 

重度失血性休克和持续出血犬应用乳酸林格氏液和6%羟乙基淀粉的比较

(忻纪华   王祥瑞 )

A Comparison of Lactated Ringer’s Solution to Hydroxyethyl Starch 6% in a Model of Severe Hemorrhagic Shock and Continuous Bleeding in Dogs

Zeev Friedman, Haim Berkenstadt, Sergei Preisman, and Azriel Perel

Anesth Analg 2003 96: 39-45. 

 

用不同浓度血红蛋白氧载体进行失血犬模型复苏后动脉和混合静脉氧饱和度监测的价值

(唐 俊 译   庄心良  )

Validity of Arterial and Mixed Venous Oxygen Saturation Measurements in a Canine Hemorrhage Model After Resuscitation with Varying Concentrations of Hemoglobin-Based Oxygen Carrier

Fedor Lurie, Bernd Driessen, Jonathan S. Jahr, Rashell Reynoso, and Robert A. Gunther

Anesth Analg 2003 96: 46-50.

 

计算修正的血栓弹力图和血小板功能分析对常规心脏手术后失血的预测价值

(张鸿     薛张刚 校)

The Predictive Value of Modified Computerized Thromboelastography and Platelet Function Analysis for Postoperative Blood Loss in Routine Cardiac Surgery

Ursula Cammerer, Wulf Dietrich, Tobias Rampf, Siegmund L. Braun, and Josef A. Richter

Anesth Analg 2003 96: 51-57.

 

PEDIATRIC ANESTHESIA

非甾体类抗炎药与扁桃体切除术后手术野出血的风险:定量系统回顾

(朱 慧 译   庄心良  校)

Nonsteroidal Antiinflammatory Drugs and the Risk of Operative Site Bleeding After Tonsillectomy: A Quantitative Systematic Review

Steen Møiniche, Janne Rømsing, Jørgen B. Dahl, and Martin R. Tramèr

Anesth Analg 2003 96: 68-77.

 

AMBULATORY ANESTHESIA:

提高氧浓度不能减少妇科病人腹腔镜术后恶心呕吐的发生率

 (朱慧琛   王祥瑞 )

Supplemental Oxygen Does Not Reduce the Incidence of Postoperative Nausea and Vomiting After Ambulatory Gynecologic Laparoscopy

Sinikka Purhonen, Matti Turunen, Ulla-Maija Ruohoaho, Minna Niskanen, and Markku Hynynen

Anesth Analg 2003 96: 91-96.  

 

ANESTHETIC PHARMACOLOGY:

甘氨酸受体介导吸入麻醉药的制动效应

(杨保仲 译  庄心良 校)

Glycine Receptors Mediate Part of the Immobility Produced by Inhaled

Anesthetics

Yi Zhang, Michael J. Laster, Koji Hara, R. Adron Harris, Edmond I. Eger, II, Caroline R. Stabernack, and James M. Sonner

Anesth Analg 2003 96: 97-101.

 

脊髓N-甲基-d-天冬氨酸受体可能抑制异氟醚作用

(李绍清译 薛张纲校)

 Spinal N-Methyl-D-Aspartate Receptors May Contribute to the Immobilizing Action of Isoflurane

Caroline Stabernack, James M. Sonner, Michael Laster, Yi Zhang, Yilei Xing, Manohar Sharma, and Edmond I. Eger, II

Anesth Analg 2003 96: 102-107.

 

吸入性麻醉药减少脑组织乙酰胆碱烟碱样受体的亲和力

(   王祥瑞 )

Volatile Anesthetics Reduce Agonist Affinity at Nicotinic Acetylcholine Receptors in the Brain

Erin M. Rada, Elizabeth C. Tharakan, and Pamela Flood

Anesth Analg 2003 96: 108-111.

 

非卤素烷烃类麻醉药对GABAA受体功能的调制作用:激动剂增强作用,直接激活和抑制效应

(唐 俊 译   庄心良  校)

Modulation of GABAA Receptor Function by Nonhalogenated Alkane Anesthetics: The Effects on Agonist Enhancement, Direct Activation, and Inhibition

Douglas E. Raines, Robert J. Claycomb, and Stuart A. Forman

Anesth Analg 2003 96: 112-118.

 

异氟醚MAC与不同氙气浓度在猪身上的研究

(李绍清译 薛张纲校)

Minimum Alveolar Anesthetic Concentration of Isoflurane with Different Xenon Concentrations in Swine

Klaus E. Hecker, Matthias Reyle-Hahn, Jan H. Baumert, Nicola Horn, Nicole Heussen, and Rolf Rossaint

Anesth Analg 2003 96: 119-124.

 

吸入性麻醉药对大鼠非肾上腺能非胆碱能反应的作用

( 王祥瑞 )

The Effects of Volatile Anesthetics on Nonadrenergic, Noncholinergic Depressor Responses in Rats

Daisuke Yoshikawa, Masataka Kuroda, Hiroshi Tsukagoshi, Ken-ichiro Takahashi, Shigeru Saito, Koichi Nishikawa, and Fumio Goto

Anesth Analg 2003 96: 125-131.

 

异丙酚-氧化亚氮麻醉能提高静注异丙肾上腺素的心率反应

(赵雪莲  译 庄心良  )

Propofol-Nitrous Oxide Anesthesia Enhances the Heart Rate Response to Intravenous Isoproterenol Infusion

Takashi Horiguchi and Toshiaki Nishikawa

Anesth Analg 2003 96: 132-135. 

 

麻醉前使用可乐定对老年和青年患者异丙酚麻醉中麻黄素的血压和心动过速反应性的影响

(潘志浩译 薛张纲校)

The Effects of Clonidine Premedication on the Blood Pressure and Tachycardiac Responses to Ephedrine in Elderly and Young Patients During Propofol Anesthesia

Tadahiko Ishiyama, Satoshi Kashimoto, Takeshi Oguchi, Takashi Matsukawa, and Teruo Kumazawa

Anesth Analg 2003 96: 136-141.

 

异丙酚靶控输注的人工计算尺的研制和评估

( 王祥瑞 )

A Manual Slide Rule for Target-Controlled Infusion of Propofol: Development and Evaluation

Jörgen Bruhn, Thomas W. Bouillon, Heiko Röpcke, and Andreas Hoeft

Anesth Analg 2003 96: 142-147.  

 

用微透析法研究戊巴比妥对大鼠伏核氯胺酮诱导的多巴胺释放的抑制作用

(杨保仲 译  庄心良 校)

Pentobarbital Inhibits Ketamine-Induced Dopamine Release in the Rat Nucleus Accumbens: A Microdialysis Study

Munehiro Masuzawa, Shinichi Nakao, Etsuko Miyamoto, Makiko Yamada, Kouhei Murao, Kenichirou Nishi, and Koh Shingu

Anesth Analg 2003 96: 148-152.

 

在恶性高热试验中延长骨骼肌的生存期

(张俊峰 薛张纲 )

Extending the Skeletal Muscle Viability Period in the Malignant Hyperthermia Test

Saiid Bina, Stephen Holman, and Sheila M. Muldoon

Anesth Analg 2003 96: 153-158.

 

TECHNOLOGY, COMPUTING, AND SIMULATION:

比较三种保温方式以确定最有效的维持围术期体温正常

( 庄心良 校)

A Comparative Study of Three Warming Interventions to Determine the Most Effective in Maintaining Perioperative Normothermia

Siew-Fong Ng, Cheng-Sim Oo, Khiam-Hong Loh, Poh-Yan Lim, Yiong-Huak Chan, and Biauw-Chi Ong

Anesth Analg 2003 96: 171-176.

PAIN MEDICINE:

加强术后疼痛治疗的干涉研究

(张俊峰 薛张纲 )

Françoise M. Bardiau, Nicole F. Taviaux, Adelin Albert, Jean G. Boogaerts, and Michaela Stadler

An Intervention Study to Enhance Postoperative Pain Management
Anesth Analg 2003 96: 179-185.

 

鞘内镇痛治疗病人和导管有关的肿块

(殷文渊 王祥瑞 )

Catheter-Associated Masses in Patients Receiving Intrathecal Analgesic Therapy

Marion R. McMillan, Thomas Doud, and W. Nugent

Anesth Analg 2003 96: 186-190.

 

鞘内注射酮咯酸增强可乐定的抗伤害作用

(王士雷 译 庄心良 校)

Intrathecal Ketorolac Enhances Antinociception from Clonidine

Dawn R. Conklin and James C. Eisenach

Anesth Analg 2003 96: 191-194.  

 

Dexmedetomidine在慢性应用停止后不会造成痛觉过敏

(张俊峰 薛张纲 )

Dexmedetomidine Fails to Cause Hyperalgesia After Cessation of Chronic Administration

M. Frances Davies, Fawzi Haimor, Geoffrey Lighthall, and J. David Clark

Anesth Analg 2003 96: 195-200.

CRITICAL CARE AND TRAUMA:

离体兔肺模型中用大潮气量及零呼期末正压单肺通气是有害的

 ( 王祥瑞 )

One-Lung Ventilation with High Tidal Volumes and Zero Positive End-Expiratory Pressure Is Injurious in the Isolated Rabbit Lung Model

Marcelo Gama de Abreu, Manuel Heintz, Axel Heller, Roswitha Széchényi, Detlev Michael Albrecht, and Thea Koch

Anesth Analg 2003 96: 220-228.  

 

NEUROSURGICAL ANESTHESIA:

异氟醚预调通过激活KATP通道对大鼠局灶性脑缺血产生剂量依赖性的神经保护

(   庄心良  校)

Preconditioning with Isoflurane Produces Dose-Dependent Neuroprotection via Activation of Adenosine Triphosphate-Regulated Potassium Channels After Focal Cerebral Ischemia in Rats

Lize Xiong, Yu Zheng, Mingchun Wu, Lichao Hou, Zhenghua Zhu, Xijing Zhang, and Zhihong Lu

Anesth Analg 2003 96: 233-237. 

 

S(+)-氯胺酮在脊髓α运动神经元处或远程减弱了肌源性运动诱发位S(+)-

(潘志浩 薛张纲 )

S(+)-Ketamine Attenuates Myogenic Motor-Evoked Potentials at or Distal to the Spinal {alpha}-Motoneuron

Kai-Michael Scheufler, Christof Thees, Joachim Nadstawek, and Josef Zentner

Anesth Analg 2003 96: 238-244.

 

REGIONAL ANESTHESIA:

405次连续腋路臂丛阻滞的神经并发症

(殷文渊 王祥瑞 )

Neurologic Complications of 405 Consecutive Continuous Axillary Catheters

Bradley D. Bergman, James R. Hebl, Jay Kent, and Terese T. Horlocker

Anesth Analg 2003 96: 247-252.  

 

开放性肩部手术的肌间沟法臂丛麻醉和镇痛:左旋布比卡因和罗哌卡因随机双盲对照试验

(     庄心良 校)

Interscalene Brachial Plexus Anesthesia and Analgesia for Open Shoulder Surgery: A Randomized, Double-Blinded Comparison Between Levobupivacaine and Ropivacaine

Andrea Casati, Battista Borghi, Guido Fanelli, Nicoletta Montone, Roberto Rotini, Gianfranco Fraschini, Federico Vinciguerra, Giorgio Torri, and Jacques Chelly

Anesth Analg 2003 96: 253-259.  

 

可乐定作为肌间沟阻滞镇痛药用于肩关节镜时的镇痛作用

(潘志浩 薛张纲 )

The Analgesic Effect of Interscalene Block Using Clonidine as an Analgesic for Shoulder Arthroscopy

Henri Iskandar, Antoine Benard, Joelle Ruel-Raymond, Gyslaine Cochard, and Bertrand Manaud

Anesth Analg 2003 96: 260-262.

 

血液稀释不改变麻醉狗影响心率的动脉压力反射

Hemodilution Does Not Alter Arterial Baroreflex Control of Heart Rate in Anesthetized Dogs

Makoto Tanaka, MD, and Toshiaki Nishikawa, MD

Department of Anesthesia, Akita University School of Medicine, Japan

Anesth Analg Jan 2003 ;96:28-32

目的:急性等容量血液稀释(ANH)的心血管效应包括心输出量增加和血管张力降低。然而,ANH是否影响动脉压力反射,至今还无研究。故本文研究ANH对动脉压力反射的影响。方法:选用研究23只在麻醉下机械通气的狗为研究对象,对其实施中度ANH(血红蛋白,7-8g/dLn=11)或重度ANH(血红蛋白,4-5g/dLn=12)。对狗施行静脉切开和同时用乳酸林格氏液按13输入,维持稳定中心静脉压和肺动脉楔压。通过测定心电图RR间期和股动脉插管测平均动脉压评估压力反射灵敏度。通过静脉注苯福林(25-75ug)和硝普钠(50-100ug)诱发压力反射。通过与RR间期和MAP相关的压力反射曲线的直线直线部分反映压力反射敏感性。结果:与稀释前相较,两组心输量均有明显增高,总血管阻力明显下降(P <0.001)但MAP和心率无变化。但两组的ANH前后压力反射均无明显不同。结论:结果显示接受麻醉狗血红蛋白浓度4-5g/dL时与HR有关的动脉压力反射仍存在。

                                (赵雪莲  译 庄心良  校)

The cardiovascular effects of acute normovolemic hemodilution (ANH) are characterized by increased cardiac output and decreased systemic vascular resistance. However, whether arterial baroreflex function is altered by ANH remains undetermined. We assigned 23 anesthetized, mechanically ventilated dogs to mild ANH (hemoglobin, 7–8 g/dL; n = 11) or profound ANH (hemoglobin, 4–5 g/dL; n = 12) achieved by phlebotomy and simultaneous exchange with lactated Ringer’s solution at 1:3 ratio to maintain constant central venous pressure and pulmonary artery occluded pressure. Baroreflex sensitivity was assessed by measurements of RR intervals of the electrocardiogram and mean arterial blood pressure (MAP) through a femoral artery catheter. Baroreflex responses were triggered by bolus IV injections of phenylephrine (25–75 µg) and nitroprusside (50–100 µg). The linear portion of the baroreflex curves relating RR intervals and MAP were used to determine baroreflex sensitivities. Compared with the predilution period, both ANH groups had significant increases in cardiac output and decreases in systemic vascular resistance (P < 0.01), whereas MAP and heart rate (HR) remained unchanged. However, no significant difference was detected between pre-ANH and post-ANH baroreflex sensitivities in either group. Our results indicate that arterial baroreflex control of HR is preserved during ANH to a hemoglobin concentration of 4–5 g/dL in anesthetized dogs.

 

异丙酚-氧化亚氮麻醉能提高静注异丙肾上腺素的心率反应

Propofol-Nitrous Oxide Anesthesia Enhances the Heart Rate Response to Intravenous Isoproterenol Infusion

Takashi Horiguchi, MD, and Toshiaki Nishikawa, MD

Department of Anesthesia and Intensive Care, Akita University School of Medicine, Japan

Anesth Analg Jan. 2003;96:132-135

目的:异丙酚-N2O麻醉使对静注阿托品的心率反应减弱。作者研究异丙肾上腺素在异丙酚-N2O麻醉时的心率变化。方法:实验对照阻(n=15)不使用异丙酚和N2O。实验组(n=21)静脉注射2.5mg/kg异丙酚1分钟后持续输入异丙酚10mg.kg-1.h-1。气管插管后,麻醉维持用5 mg.kg-1.h-167%N2O-33%O2;两组患者均静脉持续输入异丙肾上腺素(2.55.7.51012.51517.5 ng.kg-1.min-1,每个剂量均输入2分钟)到HR超过基础心率20bpm。输注完成测定血液动力学指标。结果:输入7.5 ng.kg-1.min-1时实验组HR增加明显超过对照阻(20 ± 5 14 ± 4 bpm; P < 0.05)。异丙肾上腺素输注速率为10 ng.kg-1.min-1 时实验组所有成员HR增加都超过20bpm,对照阻只有31%患者HR超过基础值20bpm(P < 0.0001)。结论:异丙酚-N2O麻醉时,若大剂量阿托品不能维持正常HR,可采用静脉持续输注异丙肾上腺素。

                                        (赵雪莲  译 庄心良  校)

Heart rate (HR) response to IV atropine is attenuated during propofol-nitrous oxide (N2O) anesthesia. We studied the effects of propofol-N2O anesthesia on isoproterenol-induced HR changes. The control group (n = 15) received no propofol and no N2O. Patients in the propofol-N2O group (n = 21) received IV propofol 2.5 mg/kg over 1 min followed by a continuous infusion of propofol 10 mg · kg-1 · h-1. After tracheal intubation, anesthesia was maintained with propofol 5 mg · kg-1 · h-1 and 67% N2O in oxygen. All patients in both groups received IV isoproterenol at incremental infusion rates (2.5, 5, 7.5, 10, 12.5, 15, and 17.5 ng · kg-1 · min-1 for 2 min at each dose) until HR increased more than 20 bpm from baseline values. At the end of each infusion period, hemodynamic data were collected. The HR response to isoproterenol 7.5 ng · kg-1 · min-1 was increased more in the propofol group than in the control group (20 ± 5 versus 14 ± 4 bpm; P < 0.05). During the isoproterenol infusion at 10 ng · kg-1 · min-1, HR increased by more than 20 bpm in all patients in the propofol group but in only 31% of patients in the control group (P < 0.0001). These results suggest that continuous isoproterenol infusion might be useful when a large dose of atropine is ineffective in restoring normal HR during propofol-N2O anesthesia.

 

甘氨酸受体介导吸入麻醉药的制动效应

Glycine Receptors Mediate Part of the Immobility Produced by Inhaled Anesthetics

Yi Zhang, MD*, Michael J. Laster, DVM*, Koji Hara, MD, R. Adron Harris, PhD, Edmond I. Eger, II, MD*, Caroline R. Stabernack, MD*, and James M. Sonner, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; University of Texas, Austin

Anesth Analg Jan. 2003;96:97-101

在体外实验中,许多吸入麻醉药可以加强士的宁敏感的甘氨酸受体的功能,这与吸入麻醉药在低于MAC时,抑制伤害性刺激的体动反应是由甘氨酸受体介导的观点相一致。各种吸入麻醉药对甘氨酸受体的强化作用,在程度上是有差别的,氟烷强化作用最强,异氟醚有中等强度的强化作用,而环丙烷的强化作用最小。按此可以推论,在脊髓水平阻滞甘氨酸受体,将使吸入麻醉药之MAC 值增大,增大的程度与吸入麻醉药在体外对此受体功能的强化作用成正比例,其顺序依次为氟烷、异氟醚、环丙烷。对鞘内留置导管的大鼠行吸入麻醉,药物分别选用氟烷、异氟醚、环丙烷,经鞘内留置导管滴入含有士的宁的脑脊液,剂量分别为0,3, 12, 24, 48(异氟醚加到此剂量) µg/min,测出相应的MAC值。结果表明,鞘内应用士的宁,可增加吸入麻醉药的MAC值,增加的程度与在各麻醉药在体外对甘氨酸受体的强化作用成比例。在甘氨酸的应用剂量为12 µg/min时,此效应最大,在甘氨酸的应用剂量为12 24 µg/min时,MAC值的增加与麻醉药在体外对甘氨酸受体的强化作用相关(r2 = 0.82)。试验结果支持甘氨酸受体介导吸入麻醉药动作用的假说。

                                   (杨保仲 译  庄心良 校)

Many inhaled anesthetics potentiate the effect of glycine on inhibitory strychnine-sensitive glycine receptors in vitro, supporting the view that this receptor could mediate the immobility produced by inhaled anesthetics during noxious stimulation (i.e., would underlie minimum alveolar anesthetic concentration [MAC]). There are quantitative differences between anesthetics in their capacity to potentiate glycine’s effect in receptor expression systems: halothane (most potentiation), isoflurane (intermediate), and cyclopropane (minimal). If glycine receptors mediate MAC, then their blockade in the spinal cord should increase the MAC of halothane more than that of isoflurane and isoflurane MAC more than cyclopropane MAC; the increases in MAC should be proportional to the receptor potentiation produced in vitro. Rats with chronically implanted intrathecal catheters were anesthetized with halothane, isoflurane, or cyclopropane. During intrathecal infusion of artificial cerebrospinal fluid, MAC was determined. Then MAC was re-determined during an infusion of 3, 12, 24, or 48 (isoflurane only) µg/min of strychnine (strychnine blocks glycine receptors) in artificial cerebrospinal fluid. Strychnine infusion increased MAC in proportion to the enhancement of glycine receptors found in vitro. The maximum effect was with an infusion of 12 µg/min. For the combined results at 12 and 24 µg/min of strychnine, the increase in MAC correlated with the extent of in vitro potentiation (r2 = 0.82). These results support the hypothesis that glycine receptors mediate part of the immobilization produced by inhaled anesthetics.

 

用微透析法研究戊巴比妥对大鼠伏核氯胺酮诱导的多巴胺释放的抑制作用

Pentobarbital Inhibits Ketamine-Induced Dopamine Release in the Rat Nucleus Accumbens: A Microdialysis Study

Munehiro Masuzawa, MD, Shinichi Nakao, MD, PhD, Etsuko Miyamoto, MD, PhD, Makiko Yamada, MD, Kouhei Murao, MD, PhD, Kenichirou Nishi, MD, and Koh Shingu, MD, PhD

Department of Anesthesiology, Kansai Medical University, Osaka, Japan

Anesth Analg Jan. 2003;96:148-152

伏核多巴胺释放在某些药物所致的精神症状和成瘾性作用中起重要的作用。氯胺酮和巴比妥类药物有精神作用和成瘾性,而巴比妥类药物可以防止氯胺酮的精神症状。我们研究了氯胺酮和巴比妥类药物对伏核多巴胺释放的影响作用。给大鼠(n=35)植入微透析取样用探针,给药途径为腹膜腔内注射,大鼠随机分为七组:生理盐水组; 50 mg/kg氯胺酮组;100 mg/kg氯胺酮组;25 mg/kg戊巴比妥组; 50 mg/kg戊巴比妥组;生理盐水之后给50 mg/kg氯胺酮组;25 mg/kg戊巴比妥之后给50 mg/kg氯胺酮组。灌注液每20分钟取样一次,多巴胺浓度用高效液相色谱技术测量。50 mg/kg 100 mg/kg剂量的氯胺酮明显增加伏核多巴胺的释放。相反,戊巴比妥明显减少伏核多巴胺的释放,并且抑制氯胺酮诱导的多巴胺的释放。实验结果提示,伏核多巴胺的释放,主要介导氯胺酮导致的精神症状和成瘾作用中起作用,而非巴比妥类药物导致的精神症状和成瘾作用。巴比妥类药物可能通过抑制伏核多巴胺的释放而防止氯胺酮的精神症状。

(杨保仲 译  庄心良 校)

Dopamine release in the nucleus accumbens (NAC) plays a crucial role in the actions of various psychotropic and addictive drugs. Ketamine and barbiturates have psychotropic effects and addictive properties, but barbiturates prevent ketamine’s psychotomimetic effects. We investigated the effects of ketamine and pentobarbital on dopamine release in the NAC. A microdialysis probe was implanted in the NAC in 35 rats, which were randomly assigned to seven groups: a normal saline intraperitoneal injection (ip) group, 50 and 100 mg/kg of ketamine ip groups, 25 and 50 mg/kg of pentobarbital ip groups, and a normal saline or 25 mg/kg of pentobarbital ip followed by 50 mg/kg of ketamine ip groups. Perfusate samples were collected every 20 min, and dopamine concentration was measured by high-performance liquid chromatography. Ketamine at doses of 50 mg/kg and 100 mg/kg significantly increased dopamine release in the NAC. Conversely, pentobarbital significantly decreased dopamine release in the NAC and inhibited the ketamine-induced dopamine release. These data suggest that the dopamine release in the NAC may be involved in ketamine-induced, but not barbiturate-induced, psychotropic effects and addiction. Inhibition of ketamine-induced dopamine release by barbiturates may be a mechanism by which they prevent ketamine emergence reactions.

 

用不同浓度血红蛋白氧载体进行失血犬模型复苏后动脉和混合静脉氧饱和度监测的价值

Validity of Arterial and Mixed Venous Oxygen Saturation Measurements in a Canine Hemorrhage Model After Resuscitation with Varying Concentrations of Hemoglobin-Based Oxygen Carrier

Fedor Lurie, MD, PhD*, Bernd Driessen, DVM, PhD, Jonathan S. Jahr, MD, Rashell Reynoso, and Robert A. Gunther, PhD||

*John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology, UCLA, and King/Drew Medical Center, Los Angeles, California; University of California-Davis College of Letters and Science, Davis, California; and ||Department of Surgery, University of California-Davis, Davis, California

Anesth Analg Jan. 2003;96:46-50

 

目的:评估失血后使用不同浓度血红蛋白氧载体(Hemoglobin glutamer-200 []Oxyglobin® [Hb-200])复苏时动脉和静脉混合氧饱和度监测的价值。方法:19条脾切除后的杂种犬经麻醉后,行肺动脉插管(Abbott QVUE Oximetrix 3导管),股动脉放置18号导管,舌上安放Nellcor探头。LEXO2CON-K氧分析仪分析基础、失血40%(保持动脉压在50mmHg)以及用30 mL/kg的含6% 羟乙基淀粉的乳酸林格氏液(n = 4),10 mL/kg Hb-20020 mL/kg羟乙基淀粉(n = 6)或20 mL/kg Hb-20010 mL/kg羟乙基淀粉(n = 7)复苏后的静脉和动脉血氧含量,并且与监护仪计算所得的氧含量进行比较。结果:有两条犬未能从放血过程中生存下来而被排除,也证明了模型的可行性。计算所得和测量所得的血红蛋白氧饱和度值的基础值之间有很好的相关性(0.97 r 0.92)。复苏后两者的相关性都有统计学意义的减少。监护仪计算所得的氧含量值与肺动脉氧定量直接测定值偏差可达20%。结论:急性失血模型证明,血液替代品进行复苏可能干扰一部分监护仪的数据,而且呈剂量相关性。

                                        (唐 俊 译   庄心良  校)

In this study, we evaluated the validity of saturation measurements in mixed venous and arterial blood during posthemorrhagic anemia and resuscitation with varying levels of hemoglobin-based oxygen carrier (Hemoglobin glutamer-200 [bovine]; Oxyglobin® [Hb-200]). Nineteen anesthetized, splenectomized, mixed-breed dogs were anesthetized (two were excluded from the data because they did not survive the exsanguination, supporting the validity of the model). Their pulmonary arteries were cannulated with the Abbott QVUE Oximetrix 3 catheter. An 18-gauge catheter was placed in the femoral artery, and a reusable Nellcor probe was applied to the tongue. Mixed venous and arterial samples were drawn at baseline, after 40% hemorrhage (to keep arterial pressure at 50 mm Hg), and postresuscitation with 30 mL/kg of 6% hetastarch in lactated Ringer’s solution (n = 4), 10 mL/kg of Hb-200, 20 mL/kg of hetastarch (n = 6), 20 mL/kg of Hb-200, and 10 mL/kg of hetastarch (n = 7). Samples were compared with oxygen content from the LEXO2CON-K oxygen analyzer, and oxygen content was calculated for all values from the monitors. Results were compared by using analysis of variance. There was good correlation (0.97 r 0.92) for the measured versus calculated hemoglobin oxygen saturation values at baseline. After resuscitation, the correlation between calculated and measured values of oxygen content was significantly smaller for all tested instruments. The values of oxygen content calculated from the oxygen saturation monitor and from the oximetric pulmonary artery can deviate by as much as 20% from directly measured values. We conclude that the administration of this oxygen therapeutic may interfere with the values of some monitors.

 

非甾体类抗炎药与扁桃体切除术后手术野出血的风险:定量系统回顾

Nonsteroidal Antiinflammatory Drugs and the Risk of Operative Site Bleeding After Tonsillectomy: A Quantitative Systematic Review

Steen Møiniche, MD*, Janne Rømsing, MS, Pharm, PhD, Jørgen B. Dahl, MD, DMSc*, and Martin R. Tramèr, MD, DPhil

*Department of Anesthesiology and Intensive Care Medicine, Herlev University Hospital; Department of Pharmaceutics, The Royal Danish School of Pharmacy, Copenhagen, Denmark; and Division of Anesthesiology, Geneva University Hospitals, Switzerland

Anesth Analg Jan. 2003;96:68-77

 

目的:扁桃体术后用非甾体类抗炎药(NSAIDs)镇痛一直是一个有争议的问题。NSAIDs抑制血小板活性,因而可能会增加围术期出血。方法:本文系统地查阅了已报导的关于扁桃体切除术病人因使用NSAIDs而发生围术期出血的随机对照试验。另外,我们也分析了疼痛缓解的质量和术后恶心呕吐的发生率。对25篇研究中的共970名接受NSAID838名非NSAID或安慰剂治疗的病人进行了研究。数据组合使用固定效应模型(fixed-effect model)。结果:在四个出血指标(术中失血,术后出血,入院治疗和因出血进行再次手术)中,只有再次手术的发生率在NSAIDs组增多。Peto几率比值为2.3395%可信限[CI]1.124.83),需要治疗数60 (95% CI 34277)。与阿片类相比,镇痛效果相同,而呕吐风险明显下降(相对风险:0.7395% CI0.630.85;需要治疗数:995% CI519)。结论:非甾体类抗炎药增加扁桃体切除术后出血风险的证据不明确,风险效益比并不明显。有一些迹象表明可能增加因出血而再次手术的风险,但对此尚需进一步的研究证实。   

(朱 慧 译   庄心良  校)

The use of nonsteroidal antiinflammatory drugs (NSAIDs) for analgesia after tonsillectomy is controversial because NSAIDS,through platelet inhibition, may increase the risk of perioperative bleeding. We systematically searched for randomized,controlled trials that reported on the incidence of perioperative bleeding attributable to the use of NSAIDs in patients

undergoing tonsillectomy. As secondary outcome measures, we analyzed the quality of pain relief and the incidence ofpostoperative nausea and vomiting. Twenty-five studies with data from 970 patients receiving a NSAID and 883 receiving anon-NSAID treatment or a placebo were analyzed. Data were combined using a fixed-effect model. Of four bleeding endpoints (intraoperative blood loss, postoperative bleeding, hospital admission, and reoperationbecause of bleeding), only

reoperation happened significantly more often with NSAIDs: Peto-odds ratio, 2.33 (95% confidence interval [CI], 1.12–4.83)and number-needed-to-treat, 60 (95% CI, 34–277). Compared with opioids, NSAIDs were equianalgesic, and the risk ofemesis was significantly decreased (relative risk, 0.73; 95% CI, 0.63–0.85; numbers-needed-to-treat, 9; 95% CI, 5–19).

 

非卤素烷烃类麻醉药对GABAA受体功能的调制作用:激动剂增强作用,直接激活和抑制效应

Modulation of GABAA Receptor Function by Nonhalogenated Alkane Anesthetics: The Effects on Agonist Enhancement, Direct Activation, and Inhibition
Douglas E. Raines, MD*, Robert J. Claycomb, BS, andStuart A. Forman*

Department of Anesthesia, Harvard Medical School; and Department of Anesthesia, Massachusetts General Hospital, Boston

Anesth Analg 2003;96:112-118

 

目的:临床浓度下,乙醚、酒精、卤素类烷烃增强γ氨基丁酸GABAA受体作用,非卤素类烷烃则不然。许多麻醉药也直接激活和/或抑制GABAA受体,导致重要的行为效应,非卤素类烷烃对GABAA受体的直接激活和抑制作用仍未研究。方法:评估了两种有代表性的非卤素类烷烃,环丙烷和丁烷的作用。用电生理技术对表达的α1β2γ21GABAA受体研究了增强激动剂效应,直接激活和抑制效应。结果:环丙烷和丁烷在超过麻醉作用的浓度可以增强GABAA受体激动剂的作用。哪怕在接近水溶解饱和度时,两者也不直接激活和抑制GABAA受体作用。这个结果强烈说明非卤素类烷烃的麻醉作用不是增强激动剂作用、直接增强或抑制α1β2γ21GABAA受体,而与麻醉药与蛋白结合处的静电作用调节GABAA受体的假说一致。结论:将在体麻醉强度或疏水性标准化后,环丙烷和丁烷对α1β2γ21GABAA受体激动激增强作用比异氟醚低1-1.5个数量级。另外,环丙烷和丁烷甚至在其接近水饱和浓度时也不能直接激活或抑制受体。由此可见,环丙烷和丁烷对行为活动的影响并非增强或抑制脑内含量最多的GABAA受体亚型。

(唐 俊 译   庄心良  校)

At clinically relevant concentrations, ethers, alcohols, and halogenated alkanes enhance agonist action on the -aminobutyricacidA (GABAA) receptor, whereas nonhalogenated alkanes do not. Many anesthetics also directly activate and/or inhibitGABAA receptors, actions that may produce important behavioral effects; although, the effects of nonhalogenated alkaneanesthetics on GABAA receptor direct activation and inhibition have not been studied. In this study, we assessed the abilities oftwo representative nonhalogenated alkanes, cyclopropane and butane, to enhance agonist action, directly activate, and inhibitcurrents mediated by expressed 1ß22L GABAA receptors using electrophysiological techniques. Our studies reveal thatcyclopro- pane and butane enhance agonist action on the GABAA receptor at concentrations that exceed those required toproduce anesthesia. Neither nonhalogenated alkane directly activated nor inhibited GABAA receptors, even at concentrationsthat approach their aqueous saturated solubilities. These results strongly suggest that the behavioral actions of nonhalogenatedalkane anesthetics do not result from their abilities to enhance agonist actions, directly activate, or inhibit 1ß22L GABAAreceptors and are consistent with the hypothesis that electrostatic interactions between anesthetics and their protein binding sites

modulate GABAA receptor potency.

 

鞘内注射酮咯酸增强可乐定的抗伤害作用

Intrathecal Ketorolac Enhances Antinociception from Clonidine

Dawn R. Conklin, BA, and James C. Eisenach, MD

From the Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg Jan. 2003;96:191-194

 

目的:虽然α2肾上腺素能激动剂和环氧化酶抑制剂都有镇痛作用,但对它们的确切作用位点及其之间的相互作用并不清楚。曾有报道证明鞘内应用可乐定对大鼠的抗伤害作可被酮咯酸(ketorolac)所抑制。本文对两药单独使用和联合使用的效应进行了评价。方法:鞘内注射药物,观察热刺激引发的大鼠后肢的伤害性反应。结果:可乐定可以减轻热刺激引发的后肢的伤害性反应,而酮咯酸没有此作用。但是,酮咯酸可以显著增强可乐定的抗伤害作用,两者之间呈现协同作用。结论:鞘内注射α2肾上腺素能激动剂可乐定和环氧化酶抑制剂酮咯酸的抗伤害作用呈现协同效应,两者复合应用可以增强镇痛效果。

(王士雷 译 庄心良 校)

Although both 2-adrenergic agonists and cyclooxygenase inhibitors produce analgesia, their exact sites of action and interaction remain unclear. A previous report demonstrated a surprising inhibition of antinociception in rats from intrathecal clonidine by co-administered ketorolac. There are no other reports of interaction between these two classes of analgesics. We therefore reexamined this interaction, determining the effect of intrathecal clonidine and ketorolac alone and in combination in normal rats. Clonidine, but not ketorolac, produced antinociception to noxious hind paw thermal stimulation. The addition of ketorolac significantly enhanced the effect of clonidine, indicating a synergistic interaction for analgesia. Although the reasons for the discrepancy between this and the previous report are unclear, these results are consistent with previous studies that indicate an antinociceptive action of intrathecal 2-adrenergic agonists in the normal condition, a lack of such effect for cyclooxygenase inhibitors, and positive reinforcing effects of these two systems when co-stimulated.

 

开放性肩部手术的肌间沟法臂丛麻醉和镇痛:左旋布比卡因和罗哌卡因随机双盲对照试验

Interscalene Brachial Plexus Anesthesia and Analgesia for Open Shoulder Surgery: A Randomized, Double-Blinded Comparison Between Levobupivacaine and Ropivacaine

Andrea Casati, MD*, Battista Borghi, MD, Guido Fanelli, MD||, Nicoletta Montone, MD, Roberto Rotini, MD, Gianfranco Fraschini, MD, Federico Vinciguerra, MD*, Giorgio Torri, MD*, and Jacques Chelly, MD, PhD, MBA

*Department of Anesthesiology and Orthopedic Surgery, Vita-Salute University of Milano, IRCCS H. San Raffaele; Department of Anesthesia Research and Shoulder and Elbow Surgery, IRCCS Istituti Ortopedici Rizzoli, Bologna; ||Department of Anesthesiology, University of Parma, Azienda Ospedaliera di Parma, Italy; and ¶Department of Anesthesiology, The University of Texas Medical School at Houston, Texas

Anesth Analg Jan. 2003;96:253-259

 

目的:比较左旋布比卡因和罗哌卡因行肌间沟法臂丛阻滞时的起效时间和质量。方法:50名接受开放肩部手术的病人,随机均分成两组,分别接受30ml 0.5%左旋布比卡因和0.5%罗哌卡因。从经18号绝缘刺激鞘(Tuohy)置入的20号导管中注入药物。术后用PCA法延长阻滞时间,药物分别为0.125%布比卡因或0.2%罗哌卡因,背景速率6ml/h,快速注射每次2ml,锁定时间15min,最大每小时注射次数3次。结果:共3例病人(两名左旋布比卡因组8%,一名罗哌卡因组4%)因在45min内未能达到外科手术需要的阻滞效果而被排除。神经阻滞的起效时间:左旋布比卡因组20min 10-40min),罗哌卡因组20min 5-45min)(P=0.53)。术中需加用0.1mg芬太尼辅助镇痛者两组均为8名(34%)(P=0.99)。42名病人完成了24h术后输注(左旋布比卡因组22名,罗哌卡因组20名)。术后镇痛效果相似。总局麻药消耗量:左旋布比卡因组147ml144-196ml),罗哌卡因组162ml144-248ml)(P=0.019),外加注射药物的获得和需求比为0.80.4–1.0)和0.70.4–1.0)(P = 0.004)。开始术后镇痛时,左旋布比卡因组手术肢体的运动阻滞程度比罗哌卡因组重,两组运动功能没有进一步的差异。结论:本前瞻性随机双盲对照实验证实,用30ml 0.5%左旋布比卡因与相同浓度和容量的罗哌卡因行肌间沟臂丛阻滞,具有相似的起效时间和深度。术后用0.125%左旋布比卡因和0.2%罗哌卡因镇痛相比,疼痛缓解和运动功能恢复相似,前者所需容量较少。

(唐     庄心良 校)

We compared the onset time and quality of interscalene brachial plexus block produced with levobupivacaine and ropivacaine in 50 patients undergoing open shoulder surgery randomly allocated to receive 30 mL of 0.5% levobupivacaine (n = 25) or 0.5% ropivacaine (n = 25) injected through a 20-gauge catheter placed into the interscalene sheath using a 18-gauge insulated and stimulating Tuohy introducer. The block was also prolonged after surgery using a patient-controlled interscalene analgesia with 0.125% levobupivacaine or 0.2% ropivacaine, respectively (basal infusion rate, 6 mL/h; bolus, 2 mL; lockout period, 15 min; maximum boluses per hour, three). Three patients (two with levobupivacaine [8%] and one with ropivacaine [4%]) failed to achieve surgical block within 45 min after the injection and were excluded. The onset time of surgical block was 20 min (10–40 min) with levobupivacaine and 20 min (5–45 min) with ropivacaine (P = 0.53). Rescue intraoperative analgesia (0.1 mg of fentanyl IV) was required in eight patients in each group (34%) (P = 0.99). Forty-two patients completed the 24-h postoperative infusion (22 with levobupivacaine and 20 with ropivacaine). Postoperative analgesia was similarly effective in both groups. Total consumption of local anesthetic infused during the first 24 h was 147 mL (144–196 mL) with levobupivacaine and 162 mL (144–248 mL) with ropivacaine (P = 0.019), with a ratio between boluses received and requested of 0.8 (0.4–1.0) and 0.7 (0.4–1.0), respectively (P = 0.004). The degree of motor block of the operated limb was deeper with levobupivacaine than ropivacaine when starting postoperative analgesia; however, no further differences in degree of motor function were observed between the two groups. We conclude that 30 mL of levobupivacaine 0.5% induces an interscalene brachial plexus anesthesia of similar onset and intensity as the one produced by the same volume and concentration of ropivacaine. Postoperative interscalene analgesia with 0.125% levobupivacaine results in similar pain relief and recovery of motor function with less volume of local anesthetic than with 0.2% ropivacaine.

 

评价一种新型脉搏氧饱和度仪在浅低温心肺转流期间的工作性能

Performance Evaluation of a New Pulse Oximeter During Mild Hypothermic Cardiopulmonary Bypass

Kazuo Irita, MD, PhD, Yoichiro Kai, MD, PhD, Kozaburo Akiyoshi, MD, Yukako Tanaka, MD, and Shosuke Takahashi, MD, PhD

Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

Anesth Analg Jan. 2003;96:11-14

目的:比较新型的脉搏氧饱和度仪Masimo SET Radical(M)和传统的日本光电AY-900P(N)在低温心肺转流期间的性能。方法:分别观察18位患者使用这两种机器的结果。氧饱和度仪监测失败指显示不出氧饱和度的数值或者连续三分钟显示错误的数值。结果:MN监测失败的例数分别是414(P=0.0022),所有M监测失败的病人N检测也失败。在主动脉箝闭期间,M不能提供氧饱和度数值的机会是4%±12%N组是36%±39%P=0.002)。MN监测失败开始和结束时的皮肤温度和平均动脉压相似。N而不是M在病人存在术前利尿治疗或者手术中高乳酸血症时容易发生监测失败。与N相比,M在浅低温心肺转流期间非搏动性血流情况下准确显示脉搏氧饱和度的次数更多,时间更长。结论:M在低灌注情况下监测脉搏氧饱和度更加有用。

(颜 涛 译 庄心良 校)

Newly developed pulse oximeters (POs) are designed to display accurate SpO2 during motion and hypoperfusion. We compared the performance of a new PO, the Masimo SET Radical (M), with a conventional PO, the Nihon Kohden AY-900P (N), during hypothermic cardiopulmonary bypass. Eighteen patients were studied prospectively. PO failure was defined as failure to show no SpO2 value or show incorrect SpO2 values for longer than 3 min continuously. PO failure occurred in 4 and 14 patients with M and N, respectively (P = 0.0022). All 4 patients in whom PO failure developed with M were among the 14 patients with N. No SpO2 was provided for 4% ± 12% of the duration of aorta cross-clamping with M and 36% ± 39% with N (P = 0.002). Skin temperature and mean arterial blood pressure when PO failure started to occur and ended were similar between M and N. PO failure easily developed in patients with preoperative diuretic therapy or with intraoperative hyperlactatemia in N, but not in M. M was able to display accurate SpO2 values significantly more frequently and longer than N during mild hypothermic cardiopulmonary bypass with nonpulsatile flow, suggesting that M is more useful for monitoring SpO2 during hypoperfusion.

 

比较三种保温方式以确定最有效的维持围术期体温正常

A Comparative Study of Three Warming Interventions to Determine the Most Effective in Maintaining Perioperative Normothermia

Siew-Fong Ng, BHSN*, Cheng-Sim Oo, BHSN*, Khiam-Hong Loh, BHSN*, Poh-Yan Lim, BHSN*, Yiong-Huak Chan, PhD, and Biauw-Chi Ong, MD

*Block 3 Major Operating Theatre, Singapore General Hospital; Clinical Trials & Epidemiology Research Unit, Ministry of Health, Singapore; and Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Singapore

Anesth Analg Jan. 2003;96:171-176

目的:确定最有效的术中体温干预措施 方法:我们研究了300位接受单侧全膝关节置换术的病人,这些病人被随机平均分为三组:(a)两条棉毯组;(b)一条反射毯加一条棉毯组;(c)主动空气加温加一条棉毯组。术前在诱导室内、到达恢复室时以及在恢复室内每隔十分钟测量鼓膜温度。结果:在到达恢复室时,主动空气加温组体温(已经根据病人的性别、年龄和病人所在的诱导室的温度进行标准化)高于反射毯组 0.577°C ± 0.079°C (95% confidence interval [CI], 0.427–0.726; P < 0.001) ,高于两条棉毯组0.510°C ± 0.08°C (95% CI, 0.349–0.672; P < 0.001)。与反射毯组(41.78 min95% CI 36.86–46.58)和两条棉毯组(36.43 min 95% CI 31.23–41.62)相比,主动空气加温组病人体温回复到36.5°C的时间较短(18.75 min 95% CI 13.88–23.62 P < 0.001) 。结论:主动空气加温是维持围手术期正常体温最有效的方法,反射毯比两条棉被效果更差。

(颜 庄心良 校)

Perioperative hypothermia poses a challenge because of its deleterious effects on patient recovery. The current practice of applying two cotton blankets on patients during surgery is thought to be less ideal than using reflective insulation or forced-air warming. We studied 300 patients who underwent unilateral total knee replacement and were randomized equally to three groups: (a) the two-cotton-blanket group, (b) the one-reflective-blanket with one-cotton-blanket group, and (c) the forced-air-warming with one-cotton-blanket group. Tympanic temperature readings were taken before surgery in the induction room, on arrival at the recovery room, and at 10-min intervals until discharge from the recovery room. On arrival at the recovery room, the forced-air-warming group had significantly higher temperatures (adjusted for sex, age, and patient’s induction room temperature) of 0.577°C ± 0.079°C (95% confidence interval [CI], 0.427–0.726; P < 0.001) and 0.510°C ± 0.08°C (95% CI, 0.349–0.672; P < 0.001) more than the reflective-blanket and two-cot-ton-blanket groups, respectively. The forced-air-warming group took a significantly (P < 0.001) shorter time of 18.75 min (95% CI, 13.88–23.62) to achieve a temperature of 36.5°C in the recovery room as compared with 41.78 min (95% CI, 36.86–46.58) and 36.43 min (95% CI, 31.23–41.62) for the reflective-blanket and two-cotton-blanket groups, respectively. The reflective technology was less effective than using two cotton blankets, and the forced-air warming was most efficient in maintaining perioperative normothermia.

 

异氟醚预调通过激活KATP通道对大鼠局灶性脑缺血产生剂量依赖性的神经保护

Preconditioning with Isoflurane Produces Dose-Dependent Neuroprotection via Activation of Adenosine Triphosphate-Regulated Potassium Channels After Focal Cerebral Ischemia in Rats

Lize Xiong, MD, Yu Zheng, MD, Mingchun Wu, MD, Lichao Hou, MD, Zhenghua Zhu, MD, Xijing Zhang, MD, and Zhihong Lu, MD

Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China

 Anesth Analg Jan 2003 96: 233-237. [

本研究目的是评价反复短时间异氟醚麻醉诱导对局灶性脑缺血是否会产生剂量依赖性的耐受以及这种效应是否依赖于KATPATP调节的钾通道)。在实验1中,40只大鼠随机分成4组:对照组动物每天吸纯氧1小时,共5天。而异氟醚(Iso1Iso2Iso3组分别吸入含0.75%, 1.5%, 2.25% Iso的氧气,每天1小时共5天。实验2中,36只大鼠随机分成4组:对照组动物每天吸纯氧1小时,共5天。IsoI+GIso+优降糖)组动物吸入含2%Iso的氧气,每天1小时共5天。I+G组动物在每次Iso预处理前予以优降糖(5mg/kg腹腔用药)。优降糖(GLB)组动物予以优降糖(5mg/kg腹腔用药)每天一次共5天。在最后一次预处理后24小时,右大脑中动脉阻断120分钟。24小时后评定神经功能缺失评分(NDS)和脑梗死容积。Iso2Iso3组的NDS及梗死容积小于对照组(P < 0.05)。而Iso3组梗死容积小于Iso2组(P < 0.05)。Iso组的NDS和梗死容积小于对照组和I+G组(P < 0.05)。在对照组,I+G组及GLB组间没有统计学差异。此研究表明反复Iso麻醉以剂量依赖方式诱导大鼠缺血耐受。KATP通道阻滞剂- GLB,消除了由Iso诱导的耐受。

(张   庄心良  校)

In this study, we determined whether repeated brief isoflurane (Iso) anesthesia induces ischemic tolerance to focal cerebral ischemia in a dose-response manner and whether the effect is dependent on adenosine triphosphate-regulated potassium channels. In Experiment 1, 40 rats were randomly assigned to 4 groups: control animals received 100% oxygen 1 h/d for 5 days, whereas the isoflurane (Iso)1, Iso2, and Iso3 groups received 0.75%, 1.5%, or 2.25% Iso in oxygen 1 h/d for 5 days. In Experiment 2, 36 rats were randomly assigned to 4 groups: controls received 100% oxygen 1 h/d for 5 days; animals in the Iso and I+G (Iso+glibenclamide) groups received 2% Iso in oxygen 1 h/d for 5 days, and the I+G group received glibenclamide (GLB) (5 mg/kg intraperitoneally) before each Iso pretreatment. Animals in the GLB group received GLB (5 mg/kg intraperitoneally) once a day for 5 days. Twenty-four hours after the last pretreatment, the right middle cerebral artery was occluded for 120 min. Neurologic deficit scores (NDS) and brain infarct volumes were evaluated at 24 h. The NDS and infarct volumes of Iso2 and Iso3 were less than those of the controls (P < 0.05). The infarct volume in Iso3 was smaller than in Iso2 (P < 0.05). The NDS and infarct volume in the Iso group were less than in the control and I+G groups (P < 0.05). There was no statistical difference among the control, I+G, and GLB groups. The study demonstrated that repeated Iso anesthesia induces ischemic tolerance in rats in a dose-response manner. GLB, an adenosine triphosphate-regulated potassium channel blocker, abolished the tolerance induced by Iso.

 

微型食管探头心脏超声监测用于麻醉诱导期
Echocardiographic Monitoring During Induction of General Anesthesia with a Miniaturized Esophageal Probe

Peter Zimmermann, MD, DEAA, Clemens Greim, MD, PhD, Herbert Trautner, MD, Ulrich Sagmeister, MD, Katharina Kraemer, MD, and Norbert Roewer, MD, PhD

Department of Anesthesiology, University of Würzburg Medical Center, Würzburg, Germany

Anesth Analg Jan. 2003;96:21-27

麻醉诱导期间不能进行标准的经食管心脏超声(TEE)检查,因为标准的食管探头限制了口咽空间,并影响面罩通气和气管插管。我们假设标准的小型化TEE探头在麻醉诱导时,可以安全的经鼻进入清醒病人、行面罩通气和经口插管,同时进行左室功能监测(LV)。45名病人进行了前瞻性研究。将经鼻TEE探头经一侧鼻腔插入,直至可以显示左室乳头肌的横切面。诱导期间病人行面罩通气,TEE探头经过面罩的中央孔。12例病人仅在局麻下成功插入探头,31例病人局麻合并轻度镇静。两例病人未成功置入。在插入过程中所有病人的血流动力学未明显改变,也无明显的黏膜改变。1例病人发生胃内容物的反流但未影响预后。在麻醉诱导期间,95%的病人可成功显示二围心脏超声图象。我们得出结论,经鼻TEE探头可以是用于全麻诱导期间的有效监测。

                                                       (忻纪华   王祥瑞 )

Standard transesophageal echocardiography (TEE) does not allow cardiac monitoring during the induction of anesthesia because standard probes would limit the oropharyngeal space and impair mask ventilation and tracheal intubation. We hypothesized that a prototype, miniaturized TEE probe could be safely introduced transnasally in awake patients and that mask ventilation and orotracheal intubation could be performed while continuously monitoring left ventricular (LV) function during the induction of anesthesia. Forty-five patients were studied prospectively. The transnasal TEE probe was introduced through one of the nares and advanced until a transverse plane image of the LV at the level of the papillary muscles was seen. Anesthesia was induced, and the patients were ventilated with a mask that had previously been threaded over the TEE probe via a central perforation. Probe insertion was successful in 12 patients under local anesthesia alone and in an additional 31 patients with a combination of local anesthesia and mild sedation. In two cases, probe placement was unsuccessful. Overall, hemodynamic variables did not change significantly during insertion. No case of significant mucosal bleeding was seen. In one patient, regurgitation of gastric contents occurred without affecting the perioperative outcome. The two-dimensional echocardiogram image quality of the LV during the induction of anesthesia was good or acceptable in 95% of patients. We conclude that transnasal TEE can effectively be used for cardiac monitoring during the induction of general anesthesia.

 

重度失血性休克和持续出血犬应用乳酸林格氏液和6%羟乙基淀粉的比较

A Comparison of Lactated Ringer’s Solution to Hydroxyethyl Starch 6% in a Model of Severe Hemorrhagic Shock and Continuous Bleeding in Dogs

Zeev Friedman, MD, Haim Berkenstadt, MD, Sergei Preisman, MD, and Azriel Perel, MD

Department of Anesthesiology and Intensive Care, The Chaim Sheba Medical Center, Tel Hashomer, Israel (affiliated with the Sackler School of Medicine, Tel Aviv University)

 Anesth Analg Jan.2003, 96: 39-45

 

我们研究狗以晶体液或胶体液行体液复苏达到目标血压时,对全身氧供和血乳酸浓度的短期影响。在体液复苏时,以6%羟乙基淀粉(HES)使平均动脉压达到60mmHg,与使用乳酸林格氏液(LR)使平均动脉压分别达到6080mmHg(LR60,LR80)相对照。以动脉导管放血使平均动脉压达40mmHg,并在研究期间继续放血使动脉压不超过40mmHg。持续进行上述的体液置换使目标血压维持于60mmHg。全部15头犬(5头一组)存活的测量。血液丧失在LR80组(2980+/-503ml)(平均值+/-标准差)大于LR60组和HES60组(分别为1800+/-389ml1820+/-219)(p<0.001)。达到目标血压时,HES组补液共840+/-219mlLR60组为1880+/-425mlLR80组为4590+/-930mlp<0.001)。与LR60组和LR80组相比,HES60组的血乳酸浓度更低,氧供更佳。乳酸浓度和氧供在HES组分别为35+/-17ml/dl239+/-61ml/min,在LR80组分别为75+/-23ml/dl153+/-17ml/min,LR80组分别为89+/-18ml/dl140+/-48ml/min(p=0.02p=0.026)。结论,出血未控制时的体液复苏,为达到目标血压,HES60组与LR80LR60相比更利于氧供,全身乳酸浓度更低。

                                                  (忻纪华   王祥瑞 )

In this randomized, controlled study in dogs, we examined the short-term effects of blood pressure targeted fluid resuscitation with colloids or crystalloids solutions on systemic oxygen delivery, and lactate blood concentration. Fluid resuscitation using hydroxyethyl starch (HES) 6% to a mean arterial blood pressure (MAP) of 60 mm Hg was compared with lactated Ringer’s solution (LR) to a MAP of 60 or 80 mm Hg (LR60 and LR80, respectively). The model was one of withdrawal of blood to a MAP of 40 mm Hg through an arterial catheter that was then connected to a system allowing bleeding to occur throughout the study whenever MAP exceeded 40 mm Hg. Target MAP was maintained for 60 min with a continuous infusion of the designated fluid replacement. All 15 dogs (5 in each group) survived until the last measurement. Blood loss in the LR80 group (2980 ± 503 mL) (all values mean ± SD) was larger than in the LR60 and HES60 groups (1800 ± 389 mL, and 1820 ± 219 mL, respectively) (P < 0.001). Whereas 840 ± 219 mL of HES60 was needed to maintain target MAP, 1880 ± 425 mL of LR was needed in the LR60 group, and 4590 ± 930 mL in the LR80 group (P < 0.001). Lactate blood concentrations were smaller and delivered O2 higher in the HES60 group (35 ± 17 mg/dL and 239 ± 61 mL/min, respectively) in comparison to the LR60 group (89 ± 18 mg/dL and 140 ± 48 mL/min, respectively) and the LR80 group (75 ± 23 mg/dL and 153 ± 17 mL/min, respectively) (P = 0.02 and P = 0.026). In conclusion, fluid resuscitation during uncontrolled bleeding, to a target MAP of 60 mm Hg, using HES60 resulted in larger oxygen delivery and smaller systemic lactate A resuscitation to a target MAP of 60 or 80 mm Hg using LR.

 

提高氧浓度不能减少妇科病人腹腔镜术后恶心呕吐的发生率

Supplemental Oxygen Does Not Reduce the Incidence of Postoperative Nausea and Vomiting After Ambulatory Gynecologic Laparoscopy

Sinikka Purhonen, MD*, Matti Turunen, MD*, Ulla-Maija Ruohoaho, MD*, Minna Niskanen, MD, PhD*, and Markku Hynynen, MD, PhD

*Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland; and Department of Anesthesia and Intensive Care, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland

Anesth Analg Jan. 2003;96:91-96

 

吸入80%的氧可降低一半患者术后呕吐和恶心(PONV)发生率,但其机制现尚不十分明确。本研究观察非住院妇科腹腔镜手术病人吸入80%的氧减少术后恶心呕吐的效果。100例患者均吸入七 氟醚麻醉,并随机分为两组,A组在术中及术后一小时给予吸入30%的氧, B组则吸入80%的氧。测试结果表明两组发生术后恶心呕吐的几率并不存在很大差别,A组术后24小时内PONV的发生率为62%,B组为55%。实验结果表明增加供氧量并不能减少妇科腹腔镜手术病人PONV的发生率。

                                                  (朱慧琛   王祥瑞 )

Supplemental 80% oxygen administration halves the incidence of postoperative nausea and vomiting (PONV) in inpatients. Whether it prevents PONV after ambulatory surgery is unknown. We tested the efficacy of supplemental 80% oxygen in decreasing the incidence of PONV after ambulatory gynecologic laparoscopy. One hundred patients were given a standardized sevoflurane anesthetic. They were randomly assigned to two groups: routine oxygen administration with 30% oxygen, balance nitrogen (Group A); and supplemental oxygen with 80% oxygen, balance nitrogen (Group B). Oxygen was administered during surgery and up to 1 h after surgery. The incidence of nausea and vomiting and the need for rescue antiemetics did not differ between the groups in the postanesthesia care unit, in the Phase II unit, or during the 24-h follow-up. The overall incidence of nausea and vomiting during the first postoperative 24 h was 62% in Group A and 55% in Group B (P = 0.486). There were no differences in the recovery profiles and patient satisfaction between the groups. In this study, supplemental oxygen did not prevent PONV in patients undergoing ambulatory gynecologic laparoscopy.

 

吸入性麻醉药减少脑组织乙酰胆碱烟碱样受体的亲和力

Volatile Anesthetics Reduce Agonist Affinity at Nicotinic Acetylcholine Receptors in the Brain

Erin M. Rada*, Elizabeth C. Tharakan, and Pamela Flood, MD, FACA

*Columbia College, Hunter College High School, and Department of Anesthesiology, Columbia University, New York, New York

Anesth Analg Jan. 2003;108-111

 

在过去的研究中,我们认为乙酰胆碱烟碱样受体(nAChRs)的激活可以被亚麻醉浓度的吸入性麻醉药所抑制。究竟何种激活途径被抑制尚未明了。从电鱼TorpedonAChRs相关的进化方面的研究发现:吸入性麻醉药改变了受体激动剂的亲和力。我们研究了两种吸入麻醉药物的效果,将异氟醚和七氟醚作用于鼠脑,脑内烟碱样受体与高度亲和力的激动剂—— epibatidine结合处于平衡.我们分别研究了雌性和雄性的大脑,因为有报道烟碱反应存在性别差异。麻醉前两类大脑中有等量的epibatidine结合。异氟醚和七氟醚减少了[3H] epibatidine与烟碱样受体的结合,但仅在浓度等于或高于麻醉要求时。异氟醚抑制雄性大脑中[3H] epibatidine与烟碱样受体的结合达到50%时的浓度时 0.58±0.07mM,雌性为1.62±0.30mM。七氟醚的作用浓度在雄性为0.77±0.05 mM,雌性为0.77±0.04 mM。两种性别之间的药物作用无显著差异(p0.05)。虽然在麻醉浓度下存在激动剂 亲和力的轻微下降,但是nAChRs功能的显著下降不能完全有激动剂亲和力的改变来解释。                                                                                                                                          

                                                   (   王祥瑞 )

In previous studies we and others have demonstrated that the activation of nicotinic acetylcholine receptors (nAChRs) is inhibited by subanesthetic concentrations of volatile anesthetics. The mechanism by which activation is inhibited is unknown. Studies of the evolutionarily related nAChRs from the electric fish Torpedo have suggested that volatile anesthetics alter the affinity of the agonist for the receptor. We studied the effect of two volatile anesthetics, isoflurane and sevoflurane, on equilibrium binding of the high-affinity nicotinic agonist epibatidine to nicotinic receptors from mouse brain. We studied binding to male and female brain separately, because sex differences in nicotine responses have been reported. Male and female brains have equal epibatidine binding without anesthetic. Isoflurane and sevoflurane reduce the binding of [3H]epibatidine to male and female nicotinic receptors, but only at concentrations at and above those required for anesthesia. The 50% inhibitory concentration for isoflurane inhibition of [3H]epibatidine binding to male brain was 0.58 ± 0.07 mM and to female brain was 1.62 ± 0.30 mM. The 50% inhibitory concentration for sevoflurane inhibition of [3H]epibatidine binding to male brain was 0.77 ± 0.05 mM and to female brain was 0.77 ± 0.04 mM. There was no statistically significant difference in the effect of either drug between sexes (P > 0.05). Although there is a slight decrease in agonist affinity at anesthetic concentrations, the marked reductions in nAChR function at subanesthetic concentrations cannot be attributed to changes in agonist affinity.

 

吸入性麻醉药对大鼠非肾上腺能非胆碱能反应的作用

The Effects of Volatile Anesthetics on Nonadrenergic, Noncholinergic Depressor Responses in Rats

Daisuke Yoshikawa, MD*, Masataka Kuroda, MD*, Hiroshi Tsukagoshi, MD, Ken-ichiro Takahashi, MD*, Shigeru Saito, MD*, Koichi Nishikawa, MD*, and Fumio Goto, MD*

*Department of Anesthesiology and Reanimatology, Gunma University School of Medicine, Maebashi, Japan; and Department of Anesthesiology, Kameda General Hospital, Kamogawa, Japan

Anesth Analg Jan. 2003;96:125-131

 

吸入性麻醉药物对降钙素基因相关肽(CGRP)所介导的非肾上腺能非胆碱能(NANC)用尚未明了.我门研究了异氟醚,氟烷和七氟醚对电刺激脊髓大鼠NANC抑制反应的作用,实验过程中通过持续性输注甲氧胺以维持平均动脉压在120mmHg左右,自主性的流出由六甲铵所阻断.吸入30分钟不同浓度的麻醉药后,刺激低胸段的脊髓30(10 V 4Hz 持续1ms)以引起NANC抑制反应. 2%的异氟醚和1.5%的氟烷显著地减弱了NANC抑制反应,然而1%的异氟醚和0.75%的氟烷和2%4%的七氟醚未起作用. 吸入性麻醉药物没有减少脊髓刺激后CGRP的释放,2%的异氟醚 1.5%的七氟醚显著地抑制了当摄入外源性CGRP时的抑制反应.4%的七氟醚没有显著影响CGRP所介导的抑制反应.这样,高浓度的异氟醚和氟烷通过减少CGRP所介导的抑制反应而不是CGRP的释放减弱了NANC抑制反应.                                                                                                  

                                                   ( 王祥瑞 )

The effects of volatile anesthetics on nonadrenergic, noncholinergic (NANC) transmission mediated by calcitonin gene-related peptide (CGRP) are unclear. We studied the effects of isoflurane, halothane, and sevoflurane on NANC depressor responses to electrical spinal cord stimulation in pithed rats whose mean arterial blood pressure was maintained near 120 mm Hg by continuous infusion of methoxamine. Autonomic outflow was blocked by hexamethonium. After 30 min of inhalation of different concentrations of anesthetics, spinal cord stimulation at the lower thoracic level (10 V at 4 Hz; duration, 1 ms) was applied for 30 s to induce a NANC depressor response. Isoflurane at 2% and halothane at 1.5% attenuated NANC depressor responses significantly, whereas isoflurane at 1%, halothane at 0.75%, and sevoflurane at 2% or 4% did not. Volatile anesthetics did not attenuate the release of CGRP after spinal cord stimulation, whereas isoflurane at 2% and halothane at 1.5% significantly inhibited depressor responses to exogenously administered CGRP. Sevoflurane at 4% did not significantly affect CGRP-induced depressor responses. Thus, isoflurane and halothane at large concentrations attenuate NANC depressor responses by attenuating the depressor action of CGRP, not CGRP release.

 

异丙酚靶控输注的人工计算尺的研制和评估

A Manual Slide Rule for Target-Controlled Infusion of Propofol: Development and Evaluation

Jörgen Bruhn, MD*, Thomas W. Bouillon, MD, Heiko Röpcke, MD*, and Andreas Hoeft, MD, PhD*

*Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Germany; Department of Anesthesia, LUMC, Leiden, The Netherlands; and Inselspital, University of Bern, Switzerland

Anesth Analg Jan. 2003;96:142-147

 

我们在此阐述简易计算尺的研制并对其进行评估,它能够在床边确定异丙酚的输注速率以使异丙酚达到特定的血浆靶浓度。为使异丙酚准时达到靶浓度,其滴注速率是由所需的靶浓度,体重,以及开始时间决定的。我们的靶控制输注(TCI)计算尺,是按照乘法运算法则建立起来的,就如同经典的计算尺是按照指数加法构造的。我们通过STANPUMP计算使用TCI计算尺所达到的预期血浆浓度的偏差百分率。使用STANPUMP评估结果显示如果异丙酚的靶浓度 3µg/ml,在第一个15分钟平均偏差为4.05%(最大为6.97%),16300分钟之间平均偏差为0.5%(最大为2.03%)。当靶浓度从3µg/ml改为124,和5µg/ml时其平均偏差也相应从1.15%变至17.76%。这种口袋大小的TCI计算尺除了比较精确还有成本低的优点。

                                                 ( 王祥瑞 )

We describe the development and evaluation of a simple slide rule that enables the bedside determination of the infusion rate for a particular target plasma concentration of propofol. The infusion rate to reach this target concentration at time (t) is the product of the target concentration, body weight, and a correction factor that depends on the time elapsed from the start of the initial infusion. Our target-controlled infusion (TCI) slide rule, constructed along this principle, performs the multiplications, analogous to the principle of the classical slide rule, as addition of logarithms. We calculated the percentage deviation of the predicted concentration obtained by STANPUMP versus predicted concentrations obtained using the infusion rates determined from the TCI slide rule. The evaluation using STANPUMP simulations showed, for a constant target concentration of 3 µg/mL of propofol, a mean deviation of 4.05% (max, 6.97%) in the first 15 min and a mean deviation of 0.5% (max, 2.03%) between 16 and 300 min. The mean deviation after changing the target from 3 µg/mL to 1, 2, 4, or 5 µg/mL ranged from 1.15% to 17.76%. This pocket-sized TCI slide rule combines the advantages of minimal financial and technical cost with reasonable accuracy.

 

鞘内镇痛治疗病人和导管有关的肿块

Catheter-Associated Masses in Patients Receiving Intrathecal Analgesic Therapy

Marion R. McMillan, MD, Thomas Doud, MD, and W. Nugent, RN

Foothills Regional Pain Center and Mountainview Medical Imaging, Seneca, South Carolina

Anesth Analg Jan. 2003;96:186-190

 

七名接受鞘内镇痛药物治疗慢性难治性疼痛的病人接受放射对比鞘内摄影和CT检查来筛查导管相关鞘内肿块。七名检查病人中的三名病人在总共118个月的治疗后有与注射导管尖端想关的脊髓内肿块。索引患者存在神经痛恶化和左侧下肢麻痹。另外通过CT鞘内摄影检查出的两名患者没有症状。诊断出导管相关肿块前的平均治疗时间为11.6个月,范围为16-25个月。通过对有和没有导管相关肿块两组在统计学上和病人间治疗差异进行比较,发现有肿块的患者与没有的患者相比较,年龄较轻且接受的吗啡剂量较大。统计学上有显著差异(P=0.05)。一名没有症状的鞘内导管相关肿块病人,在停止治疗后发现肿块有所减小。第二个无症状的病人在用hydromorphone替代吗啡持续治疗后,肿块在一年多的时间里维持稳定。无症状的病人在发现鞘内导管相关肿块和进行临床干预后,没有人继发其他的神经系统发现和损伤。我们建议所有病人在接受长期鞘内麻醉患者都应接受定期的X光检查以进一步确定发生导管相关肿块的风险,在发生神经损伤前进行治疗。

                                                    (殷文渊 王祥瑞 )

A cohort of seven patients receiving intrathecal analgesic drug therapy for chronic intractable pain underwent radiocontrast myelography and computed tomography (CT) scanning to screen for catheter-associated intrathecal masses. Three of seven patients examined had intraspinal masses associated with the tip of the drug infusion catheter after a total of 118 mo of therapy. The index case presented with exacerbation of neuropathic pain and paralysis of the left lower extremity. The two additional cases detected by CT myelography were asymptomatic at the time the catheter-associated mass was assessed. The mean duration of therapy before diagnosis of the catheter-associated mass was 19.6 mo, with a range of 16–25 mo. An intergroup comparison of demographic and treatment variables between patients, with and without catheter-associated masses, demonstrated that patients with masses were younger and were receiving a larger morphine dose than patients without masses. The differences were statistically significant (P = 0.05). In one patient with an asymptomatic catheter-associated intrathecal mass, regression of the mass was observed after cessation of therapy. In a second asymptomatic patient, the mass remained stable over 1 yr of continued treatment after substitution of hydromorphone for morphine without interruption of therapy. Neither asymptomatic patient has subsequently developed additional neurologic findings or injury after detection of occult catheter-associated intrathecal masses and clinical intervention. We suggest that all patients receiving long-term intrathecal analgesia should undergo periodic radiographic surveillance to further define their risk of developing occult catheter-associated masses and to allow intervention before neurologic injury can develop.

 

离体兔肺模型中用大潮气量及零呼期末正压单肺通气是有害的

One-Lung Ventilation with High Tidal Volumes and Zero Positive End-Expiratory Pressure Is Injurious in the Isolated Rabbit Lung Model

Marcelo Gama de Abreu, PhD, MD, MSc, Manuel Heintz, MD, Axel Heller, PhD, MD, Roswitha Széchényi, Detlev Michael Albrecht, MD, PhD, and Thea Koch, MD, PhD

Clinic of Anesthesiology and Intensive Care Medicine, University Clinic Carl Gustav Carus, Technical University Dresden, Dresden, Germany

Anesth Analg Jan. 2003;96:220-228

我们验证了这样一个假设,在单肺通气中使用高潮气量及零呼期末正压可能会导致呼吸机引起的肺损伤。在一个独立的完好的兔子肺模型中,在持续的气流下实施双肺通气时设置适当的潮气量及呼期末正压以避免肺塌陷及过度膨胀。然后我们随机选择动物把它分成三组,I组为无保护性单肺通气(左肺)(n=6),并使呼期末正压为零及使潮气量与双肺通气前一样高;II组为保护性单肺通气(左肺)n=6),并使潮气量减少50%以及使呼期末正压同双肺通气前一样;III组为对照组(n=6),就与试验前一样实施双肺通气。在无保护性单肺通气组中,小程度地使肺塌陷使肺过度膨胀(P<0.01),气道峰压升高并在观察期间渐进性增高(P<0.01) ,肺动脉平均压和肺的重量以及凝血氧烷B2浓度都相对增高(P<0.05)。因此在临床中实施单肺通气使用高潮气量以及零呼气末正压会导致呼吸机引起的肺损伤,但这可以通过降低潮气量和呼气末正压来避免肺过度膨胀和肺塌陷。

                                                    ( 王祥瑞 )

We tested the hypothesis that one-lung ventilation (OLV) with high tidal volumes (VT) and zero positive end-expiratory pressure (PEEP) may lead to ventilator-induced lung injury. In an isolated, perfused rabbit lung model, VT and PEEP were set to avoid lung collapse and overdistension in both lungs, resulting in a straight pressure-time (P-vs-t) curve during constant flow. Animals were randomized to (a) nonprotective OLV (left lung) (n = 6), with VT values as high as before randomization and zero PEEP; (b) protective OLV (left lung) (n = 6), with 50% reduction of VT and maintenance of PEEP as before randomization; and (c) control group (n = 6), with ventilation of two lungs as before randomization. The nonprotective OLV was associated with significantly smaller degrees of collapse and overdistension in the ventilated lung (P < 0.001). Peak inspiratory pressure values were higher in the nonprotective OLV group (P < 0.001) and increased progressively throughout the observation period (P < 0.01). The mean pulmonary artery pressure and lung weight gain values, as well as the concentration of thromboxane B2, were comparatively higher in the nonprotective OLV group (P < 0.05). A ventilatory strategy with VT values as high as those used in the clinical setting and zero PEEP leads to ventilator-induced lung injury in this model of OLV, but this can be minimized with VT and PEEP values set to avoid lung overdistension and collapse.

 

405次连续腋路臂丛阻滞的神经并发症

Neurologic Complications of 405 Consecutive Continuous Axillary Catheters

Bradley D. Bergman, DO*, James R. Hebl, MD*, Jay Kent, MD, and Terese T. Horlocker, MD*

*Department of Anesthesiology, Mayo Clinic, Rochester; and Associated Anesthesiology, Saint Paul, Minnesota

Anesth Analg Jan. 2003;96:247-252

 

由于导管所致的机械损伤或局部麻醉药的毒性反应,持续腋路臂丛神经阻滞理论上会增加神经并发症的风险。本研究回顾了使用当前技术和设备发生并发症的频率。在368名病人使用了405根腋窝导管。41名病人先前就存在神经异常(10.1%),包括30名病人有术前尺神经病。305名病人(75.3%)在肘部手术后留置腋窝导管辅助恢复。导管常规在术后记录病人正常神经功能检查后放置。355名病人(88.7%)注射的局麻药为布比卡因而45名病人(11.1%)mepivacaine。平均注射速度为10±2ml/h。导管留置55±32h31名病人是由于技术问题或麻醉不充分而放置腋窝导管。有8名病人存在9种并发症,总发生率为2.2%。并发症包括下例之一:局部感染(除去导管和抗生素治疗),腋窝血肿,导管碎片残留需要手术取出。此外,有两名病人报道有全身局麻药中毒的症状和体征。四名病人(1.0%)报道术后有新的神经功能缺陷。在两名病人中,神经功能丧失与麻醉无关。所有四名病人都在肘部手术后持续放置导管。我们的结论是持续腋路臂丛阻滞神经并发症的风险与单次注射技术相似。

                                                    (殷文渊 王祥瑞 )

Continuous axillary brachial plexus block may theoretically increase the risk of neurologic complications because of catheter-induced mechanical trauma or local anesthetic toxicity. In this study, we retrospectively reviewed the frequency of complications using current techniques and applications. There were 405 continuous axillary catheters in 368 patients. A preexisting neurologic condition was present in 41 (10.1%) patients, including 30 patients with a preoperative ulnar neuropathy. In 305 (75.3%) cases, the axillary catheter was placed to facilitate rehabilitation after major elbow surgery. Catheters were typically placed postoperatively, after documentation of the patient’s normal neurologic examination. The local anesthetic infusion contained bupivacaine in 355 (88.7%) patients and mepivacaine in 45 (11.1%) patients. The mean infusion rate was 10 ± 2 mL/h. Catheters remained indwelling for 55 ± 32 h. In 31 patients, the axillary catheter was replaced because of technical problems or inadequate analgesia. There were 9 complications in 8 patients for an overall frequency of 2.2%. Complications included one each of the following: localized infection (treated with catheter removal and antibiotics), axillary hematoma, and retained catheter fragment requiring surgical excision. In addition, two patients reported signs and symptoms of systemic (preseizure) local anesthetic toxicity. Four (1.0%) patients reported new neurologic deficits postoperatively. In two patients, the neural dysfunction was non-anesthesia related. All four had continuous catheters placed after major elbow surgery. We conclude that the risk of neurologic complications associated with continuous axillary blockade is similar to that of single-dose techniques.

 

体外循环时体外肝素酶处理后的血标本和体外循环鱼精蛋白给药后的血标本之间凝血酶原时间的一致性

Agreements Between the Prothrombin Times of Blood Treated In Vitro with Heparinase During Cardiopulmonary Bypass (CPB) and Blood Sampled After CPB and Systemic Protamine

Anthony M.-H. Ho, MSc, MD, FRCPC, FCCP*, Anna Lee, MPH, PhD*, Elizabeth Ling, MSc, MD, FRCPC, Alan Daly, CCP, Kevin Teoh, MD, FRCSC, and Theodore E. Warkentin, MD, FRCPC||

*Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, People’s Republic of China; and Departments of Anaesthesia, Clinical Perfusion, Surgery, and ||Medicine, Hamilton Health Sciences Corporation, McMaster University, Hamilton, Ontario, Canada

Anesth Analg 2003 96: 15-20.

 

凝血酶原时间(PT)测定对确定体外循环(CPB)后凝血因子缺乏是有效的。然而,其测定和新鲜冰冻血浆(FFP)加热所需时间延误了凝血因子的替代治疗。我们假设,体外循环结束前采集的血标本用肝素酶处理后,能提供PT结果以决定CPBFFP的需要量。实时监测可弥补实验室的延迟。我们研究了158例成人非急诊心脏手术。脱离CPB前采得的血样与肝素酶混和,在实验室中用HemoTec测定PT。这些结果与用鱼精蛋白拮抗后采得血样测定的结果进行比较,应用阈值为±1.0 秒的Bland and Altman曲线。结果发现CPB中和CPB后的实验室PT值具有可比性,但其一致性的限值超越了这些阈值。同样,CPB前、中、后HemoTec和实验室测得的PT结果之间,一致性不满意。在CPB中测得的每个PT值,计算相应的鱼精蛋白拮抗后PT值的可信区间。CPB中实验室PT16秒或18秒,提示CPB83%的可能性不需要或93%的可能性需要FFP。我们的结论:大部分CPB停机前采得血样经肝素酶体外处理后测得的PT值与CPB后是否需要FFP的可能性高度相关。

结论:体外循环后凝血功能障碍可能会引起出血。获得凝血测定结果和新鲜冰冻血浆需要一定的时间,从而延迟对需要新鲜冰冻血浆患者的治疗。我们设计了一种早期估计体外循环后凝血功能状态的方法。                    

(张 鸿 译    薛张刚 校)

The prothrombin time (PT) is useful for identifying coagulation factor deficits after cardiopulmonary bypass (CPB). However, long processing times and the need for fresh frozen plasma (FFP) to be thawed cause delays in factor replacement. We hypothesized that, by treating with heparinase, blood sampled toward the end of CPB can provide PT results that help to determine the requirement for FFP after CPB. Laboratory delays can be eliminated with point-of-care monitors. We studied 158 adults undergoing nonemergent cardiac surgery. Blood taken before separation from CPB was mixed with heparinase, and PT was measured in the laboratory with a HemoTec timer. Agreements between these results and laboratory measurements of blood taken after systemic protamine were compared by using Bland and Altman plots with the threshold of ±1.0 s. We found that the laboratory PT measurements during CPB versus after CPB were compara-ble, but the limits of agreement exceeded these thresholds. Similarly, there was unsatisfactory agreement between the HemoTec and laboratory PT results measured before, during, and after CPB. For each PT measured during CPB, the corresponding confidence interval for the postprotamine PT was calculated. During CPB, a laboratory PT of 16 s or18 s suggests a 83% or 93% probability of not requiring or potentially requiring, respectively, FFP after CPB. We conclude that the majority of PT measurements obtained from blood taken before weaning from CPB and treated in vitro with heparinase was associated with a high probability of whether or not FFP would be needed after CPB

 

血管手术患者靶控输注雷米芬太尼改善血流动力学并减少雷米芬太尼用量

Target-Controlled Infusion for Remifentanil in Vascular Patients Improves Hemodynamics and Decreases Remifentanil Requirement

Victor De Castro, MD, Gilles Godet, MD, Gonzalo Mencia, MD, Mathieu Raux, MD, and Pierre Coriat, MD

Department of Anesthesiology, Pitié-Salpêtrière Hospital, Paris, France

Anesth Analg 2003 96: 33-38.

 

雷米芬太尼是一种强效、超短作用时间、快速苏醒的阿片类药物。然而,雷米芬太尼价格昂贵,过量时对血流动力学可能有不良影响。靶控输注可按药代动力学模型调整输注。在这个前瞻性随机研究中,我们比较了择期颈动脉手术患者,应用体重调整(RIVA)或靶控(TCIR)输注雷米芬太尼情况下,术中术后的血流动力学、麻醉期间雷米芬太尼的需要量、术后吗啡的需要量。46位患者进入本研究:均用异丙酚靶控输注麻醉。23位病人在麻醉诱导和气管内插管时应用RIVA(0.5 µg · kg-1 · min-1),插管后输注速率降至0.25 µg · kg-1 · min-1,然后根据血流动力学按照0.05 µg · kg-1 · min-1逐步调整输注速率。23位病人应用TCIR(Minto model, Rugloop),诱导时效应室浓度为4 ng/mL,然后根据血流动力学按照1 ng/mL逐步调整靶浓度。所有病人给予阿曲库铵和50%笑氧混合气体。每分钟记录血流动力学参数。两组病人均收集血流动力学事件发生次数和持续时间,麻醉药物(雷米芬太尼和异丙酚)和血管活性药物的总量。资料用非配对t检验进行分析。与TCIR相比,RIVA组发生更多术中低血压事件(166, P < 0.001)、更多需频繁应用ß肾上腺素能受体阻滞剂的术后高血压/心动过速事件(1610, P < 0.04)。两组间吗啡需要量无显着差异。TCIR组在异丙酚需要量无明显差异的情况下,雷米芬太尼需要量明显减少(700 ± 290 1390 ± 555 µg, P < 0.001)。这一前瞻性随机研究显示,在颈动脉内膜剥脱术中,与雷米芬太尼的持续RIVA给药相比,TCI给药在麻醉诱导期低血压事件较少,在苏醒期心动过速和/或高血压事件较少,且ß肾上腺素能受体阻滞剂需要量较少,以及苏醒期雷米芬太尼需要量减少。推荐在颈动脉剥脱术中应用雷米芬太尼靶控给药可能是合理的。

结论:雷米芬太尼用于颈动脉手术中镇痛时,靶控给药较之体重调整输注可提供更平稳的围术期血流动力学。这可能与靶控输注时需要量较少和给药方式平稳有关。

(张 鸿 译    薛张刚 校)

Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 µg · kg-1 · min-1) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 µg · kg-1 · min-1 after intubation, then adapted by step of 0.05 µg · kg-1 · min-1 according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N2O/O2. Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of ß-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 ± 290 versus 1390 ± 555 µg, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller ß-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remifentanil administration during carotid endarterectomy may be justified

 

计算修正的血栓弹力图和血小板功能分析对常规心脏手术后失血的预测价值

The Predictive Value of Modified ComputerizeThromboelastography and Platelet Function Analysis for Postoperative Blood Loss in Routine Cardiac Surgery

Ursula Cammerer, MD*, Wulf Dietrich, MD, PhD*, Tobias Rampf, MD*, Siegmund L. Braun, MD, and Josef A. Richter, MD*

Departments of *Anesthesiology and Laboratory Medicine, German Heart Center, Munich, Germany

Anesth Analg 2003 96: 51-57.

 

体外循环(CPB)后出血仍是一个临床问题。床旁用来判定凝血紊乱的实时检测方法是非常需要的。本研究评价了两种实时检测方法对常规心脏手术后出血的预测价值。前瞻性比较修正血栓弹力图(ROTEGTM)和血小板功能分析仪(PFA-100TM),对连续的255位病人术后失血的预测能力。在三个时点进行测量:术前、CPB过程中、鱼精蛋白给药后进行三次修正血栓弹力图和血小板功能分析测定。出血倾向增加的最佳预测值是CPB后做的测定。角是最佳预测因子(ROC曲线下面积为0.69),联合应用二磷酸腺酐-PFA监测时,预测的精确性增加(ROC曲线下面积为0.73)。尽管角的阳性预测值较小(41%),其阴性预测值为82%。血栓弹力图的预测能力比PFA强。在常规心脏手术中,由实时监测判定的凝血紊乱并不一定导致术后出血,但测定结果正常的患者不可能因凝血原因而出血。这些病人的出血可能由手术引起。高阴性预测值支持早期判定和针对性治疗手术出血,将手术出血与凝血异常区分开来。结论:常规心脏手术中的血栓弹力图和血小板功能分析显示了对术后出血的高阴性预测值,这支持早期判定和针对性治疗手术出血,将手术出血与凝血异常区分开来。阳性预测值较小。最佳预测值为体外循环后的血栓弹力图测定值。

(张鸿     薛张刚 校)

Hemorrhage after cardiopulmonary bypass (CPB) remains a clinical problem. Point-of-care tests to identify hemostatic disturbances at the bedside are desirable. In the present study, we evaluated the predictive value of two point-of-care tests on postoperative bleeding after routine cardiac surgery. Prospectively, 255 consecutive patients were studied to compare the ability of modified thromboelastography (ROTEGTM) as well as a platelet function analyzer (PFA-100TM) to predict postoperative blood loss. Measurements were performed at three time points: preoperatively, during CPB, and after protamine administration with three modified thromboelastography® and PFA tests. The best predictors of increased bleeding tendency were the tests performed after CPB. The anglis the best predictor (area under the receiver operating characteristic curve 0.69) and, in combination with the adenosine diphosphate-PFA test, the predictive accuracy is enhanced (area under the receiver operating characteristic curve 0.73). The negative predictive value for the angle is 82%, although the positive predictive value is small (41%). Thromboelastography® is a better predictor than PFA. In routine cardiac surgery, impaired hemostasis as identified by point-of-care tests does not inevitably lead to hemorrhage postoperatively. However, patients with normal test results are unlikely to bleed for hemostatic reasons. Bleeding in these patients is probably caused surgically. The high negative predictive value supports early identification and targeted treatment of surgical bleeding by distinguishing it from a significant coagulopathy

 

脊髓N-甲基-d-天冬氨酸受体可能抑制异氟醚作用

Spinal N-methyl-d-aspartate receptors may contribute to the immobilizing action of isoflurane.
Stabernack C, Sonner JM, Laster M, Zhang Y, Xing Y, Sharma M, Eger EI 2nd.
Department of Anesthesia and Perioperative Care, University of California, San Francisco.

Anesth Analg 2003 96: 102-107.

 

我们目的在于证实N-甲基-d-天冬氨酸(NMDA)受体是否通过脊髓或脊椎上影响异氟醚抑制和性。方法:通过鞘内(IT)、脑室内(ICV)和静脉(IV)注入MK801(一个非竞争的NMDA拮抗剂)对抗NMDA受体,同时测定异氟醚MAC下降变化和MK801脊索上下段、脑皮层和全脑组织匀浆浓度。结果:通过ITMK801减低异氟醚MAC比通过ICVIV给药效果强。低位脊髓索异氟醚MAC变化与MK801浓度有关(P < 0.01),而脊椎上与浓度无关。ITMK801最大可达到一个无麻醉效应平台;无异氟醚时,IT给药的270IV剂量也不能产生麻醉效果。这些结果表明MK801减低异氟醚MAC能力是因为主要对脊髓索影响,而NMDA受体通过异氟醚产生部分抑制调节作用。因为ITIVMK801均不能产生麻醉,引起了对NMDA独自可以在面对伤害性刺激起抑制作用而产生麻醉效果的定义的质疑。结论:脊髓索NMDA受体可调节部分异氟醚抑制作用;通过MK801在脊髓中的NMDA受体的阻滞可产生异氟醚MAC下降效应,但是MK801自己并不产生完善麻醉。                                                       (李绍清译 薛张纲校)
We examined whether N-methyl-D-aspartate (NMDA) receptors influence the immobilizing effect of isoflurane by a spinal or supraspinal action. We antagonized NMDA receptors by intrathecal (IT), intracerebroventricular (ICV), and IV administration of MK 801 (a noncompetitive NMDA antagonist) and measured the decrease in isoflurane minimum alveolar anesthetic concentration (MAC). We also measured MK 801 tissue concentrations in homogenates of upper and lower spinal cord, a slice of cerebral cortex, and the whole brain. IT infusion of MK 801 decreased isoflurane MAC more potently than ICV or IV infusions. The change in MAC correlated with the MK 801 concentration in the lower part of the spinal cord (P < 0.01) but not with concentrations in supraspinal tissue. The maximal effect of IT MK 801 reached a plateau without achieving anesthesia. IV doses 270-fold larger than the largest IT dose also did not produce anesthesia in the absence of isoflurane. These results suggest that the capacity of MK 801 to decrease the MAC of isoflurane results from an effect on the spinal cord but that spinal NMDA receptors provide only partial mediation of the immobility produced by isoflurane. Because neither IT nor IV MK 801 provide complete anesthesia, these findings also call into question the notion that NMDA blockade alone suffices to produce anesthesia as defined by immobility in the face of noxious stimulation. IMPLICATIONS: Spinal cord NMDA receptors may mediate a portion of the immobilizing effect of isoflurane. Blockade of NMDA receptors in the cord by MK 801 has a MAC-sparing effect, but MK 801 does not, by itself, produce complete anesthesia.

异氟醚MAC与不同氙气浓度在猪身上的研究

Minimum alveolar anesthetic concentration of isoflurane with different xenon concentrations in Swine.
Hecker KE, Reyle-Hahn M, Baumert JH, Horn N, Heussen N, Rossaint R.
Departments of Anesthesiology and Medical Statistics, Klinikum der RWTH Aachen, Aachen, Germany.

Anesth Analg 2003 96: 119-124.

 

对患者吸入氧浓度大于30%,而氙气MAC大到71%,故独自用氙气麻醉受限,这个试验研究氙气与其它麻醉气混合使用。因而我们研究了氙气对异氟醚MAC的影响。10只猪(重28-35 kg),与氧混合的氙气浓度分别为0%, 15%, 30%, 40%, 50%, 65%,每一氙气浓度,用智能方式给不同异氟醚浓度。每一混合浓度下给予大强度疼痛刺激,记录撤退反应。异氟醚MAC定义为50%无痛反应的呼气末浓度,每一氙气浓度下,痛反应均被分类,用逻辑回归模式分析异氟醚MAC值结果。吸入氙气后异氟醚MAC非线性减少,从1.92% (95% 可信区间, 1.70%-2.15%) 混合0% Xe 1.17% (95%可信区间, 0.75%-1.59%) 混合 65% Xe。虽然这表明两麻醉气体有部分对抗,但氙气与异氟醚混合对要求吸氧浓度大于30%的患者仍有价值。

结论:我们研究了氙气对异氟醚MAC的影响。这个试验用固定氙气与不同异氟醚浓10只猪上进行。吸入氙气后异氟醚MAC非线性减少。                                                     (李绍清译 薛张纲校)

 

For patients requiring a fraction of inspired oxygen more than 0.3, the use of xenon (Xe) as the sole anesthetic is limited because of its large minimum alveolar anesthetic concentration (MAC) of 71%. This warrants investigating the combination of Xe with other inhaled anesthetics. We therefore investigated the influence of Xe on the MAC of isoflurane. The study was performed in 10 swine (weight, 28-35 kg) ventilated with Xe 0%, 15%, 30%, 40%, 50%, and 65% in oxygen. For each Xe concentration, various concentrations of isoflurane were administered in a step-wise design. For each combination, a supramaximal pain stimulus (claw-clamp) was applied, and the appearance of a withdrawal reaction was recorded. The isoflurane MAC was defined as the end-tidal concentration required to produce a 50% response rate. At each Xe concentration, the responses to the pain stimulus were categorized, and a logistic regression model was fitted to the results to determine isoflurane MAC. Isoflurane MAC was decreased by inhalation of Xe in a nonlinear manner from 1.92% (95% confidence interval, 1.70%-2.15%) with 0% Xe to 1.17% (95% confidence interval, 0.75%-1.59%) with 65% Xe. Although this indicates partial antagonism of the two anesthetics, a combination of Xe with isoflurane may prove valuable for patients requiring a fraction of inspired oxygen more than 0.3. IMPLICATIONS: We investigated the influence of the anesthetic gas xenon on the minimum alveolar anesthetic concentration (MAC) for isoflurane (another anesthetic gas). The study was performed in 10 swine ventilated with fixed xenon and various concentrations of isoflurane. The isoflurane MAC is decreased by inhalation of xenon in a nonlinear relationship.

麻醉前使用可乐定对老年和青年患者异丙酚麻醉中麻黄素的血压和心动过速反应性的影响

The Effects of Clonidine Premedication on the Blood Pressure and Tachycardiac Responses to Ephedrine in Elderly and Young Patients During Propofol Anesthesia

Tadahiko Ishiyama, MD, PhD, Satoshi Kashimoto, MD, PhD, Takeshi Oguchi, MD, PhD, Takashi Matsukawa, MD, PhD, and Teruo Kumazawa, MD, PhD

Department of Anesthesiology, Yamanashi Medical University, Japan

 Anesth Analg 2003 96: 136-141.

我们研究了异丙酚麻醉麻醉前使用可乐定或咪唑安定的老年和青年患者对麻黄素的升压和心率增快反应。第一部分试验中,老年(>60 yr)和青年 (20–45 y )患者根据年龄和麻醉前用药方案随机分为四组(每组16例):老年可乐定组[EC], 老年咪唑安定组[EM],青年可乐定组[YC]和青年咪唑安定组[YM]。异丙酚麻醉下    注射麻黄素后观察血流动力学变化;第二部分试验中,麻醉前使用可乐定,老年(16例)予以较少剂量的异丙酚注射(EC-LP),青年(16例)予以增加剂量的异丙酚注射(YC-HP),然后注射麻黄素并观测血流动力学变化。结果在EC组中平均动脉压和心率的增加比EMYM EC-LP组明显(P < 0.05) 。与YC组相比YC-HP组的麻黄素升压反应增强但无统计学意义。该结果显示麻醉前使用可乐定(尤其在标准剂量异丙酚麻醉下的老年患者)增强麻黄素的升压和心动过速反应,并且可乐定、年龄及异丙酚都可能与此反应增强有关。结论: 可乐定麻醉前用药增强老年患者标准剂量或大剂量异丙酚麻醉下麻黄素的升压和心动过速反应,但并不增加小剂量异丙酚麻醉的麻黄素的反应性,可乐定、年龄及异丙酚都可能与此反应增强有关。

(潘志浩译 薛张纲校)

We studied the pressor and tachycardiac responses to ephedrine in elderly and young patients given either clonidine or midazolam during propofol anesthesia. In the first experiment, elderly (>60 yr) and young (20–45 yr) patients were randomly allocated to one of four groups according to age and premedicated regimens (n = 16 each; elderly-clonidine [EC], elderly-midazolam [EM], young-clonidine [YC], and young-midazolam [YM]). Under propofol anesthesia, ephedrine was injected, and hemodynamic measurements were made. In the second experiment, with clonidine premedication, elderly patients (n = 16) were given a reduced dose of propofol (EC-LP) and young patients (n = 16) were given an increased dose of propofol (YC-HP). Ephedrine was injected, and he- modynamic measurements were performed. The in-creases in mean blood pressure and heart rate were larger in the EC group than in the EM, YM, and EC-LP groups (P < 0.05). In the YC-HP group, the pressor response to ephedrine tended to be augmented as compared with the YC group but was not statistically significant. These results suggest that clonidine premedication augmented the pressor and tachycardiac responses to ephedrine, especially in elderly patients during a standard dose of propofol anesthesia, and that clonidine, age, and propofol could be involved in the augmentation of the blood pressure and tachycardiac responses to ephedrine.

可乐定作为肌间沟阻滞镇痛药用于肩关节镜时的镇痛作用

The Analgesic Effect of Interscalene Block Using Clonidine as an Analgesic for Shoulder Arthroscopy

Henri Iskandar, MD*, Antoine Benard, MD, Joelle Ruel-Raymond, MD*, Gyslaine Cochard, MD*, and Bertrand Manaud, MD*

*Clinique chirurgicale Bordeaux-Mérignac, Mérignac; and ISPED, Université Bordeaux 2, France

Anesth Analg 2003 96: 260-262.

 

作为一种单独的镇痛药,可乐定在中枢神经阻滞和关节内注射后产生镇痛作用,但在腋路阻滞时没有作用。在本研究中,我们要确定是否肌间沟内可乐定会在关节镜手术产生镇痛效果。40例要进行肩关节镜手术的病人包含在这一双盲的研究中。应用神经刺激器技术,置入一肌间沟导管。病人随机分为两组。肌间沟组 (n = 20)通过导管给溶于15毫升盐水的可乐定 150 µg以及1毫升皮下盐水;全身给药组(n = 20)通过导管给15毫升的盐水,皮下给150 µg (1 mL)的可乐定。所有病人均用全麻进行手术,在关节镜结束后,所有病人都接受自控镇痛,负荷剂量为8 mL0.2%的罗呱卡因(经导管),锁定时间为1小时。术后疼痛每隔4小时用视觉模拟评分测定共24小时。如果需要则用胃肠外给纳布啡作另外的术后镇痛直到VAS < 3。在苏醒室内全身给药组VAS与肌间沟组相比明显高(P < 0.0001)。镇痛时间也是肌间沟组较长 (P < 0.00001),而罗呱卡因的消耗量在全身给药组显着低 (P < 0.0001)。两组间纳布啡的消耗量并无差异,不良反应液相似。结论: 可乐定通过肌间沟导管给药与全身给药相比增强了镇痛效果。然而,可乐定在这一剂量的不良反应限制了它常规用于术后镇痛的处理。

(潘志浩 薛张纲 )

Used as the sole analgesic, clonidine produces analgesia after central neural blockade and intraarticular injection but not after axillary block. In this study, we sought to determine whether interscalene clonidine induces analgesia for shoulder arthroscopy. Forty patients scheduled for shoulder arthroscopy were prospectively included in this double-blinded study. Using a nerve stimulator technique, an interscalene catheter was inserted. The patients were randomly divided into two groups. The interscalene group (n = 20) received clonidine 150 µg in 15 mL of saline through the catheter and 1 mL of subcutaneous saline, and the systemic group (n = 20) received 15 mL of saline through the catheter and clonidine 150 µg (1 mL) subcutaneously. All patients underwent general anesthesia for surgery. On completion of arthroscopy, all patients received, via a patient-controlled analgesia, on demand a bolus of 8 mL of ropivacaine 0.2% through the catheter with a 1-h lockout period. Postoperative pain was measured every 4 h using the visual analog scale (VAS) for 24 h. Additional postoperative analgesia was available with parenteral nalbuphine if required until VAS < 3. VAS scores in the recovery room were significantly higher in the systemic group compared with the interscalene group (P < 0.0001). Analgesic duration was significantly longer in the interscalene group (P < 0.00001), and ropivacaine consumption was significantly less than in the systemic group (P < 0.0001). No significant difference was observed between groups for nalbuphine consumption. Side effects were comparable in the two groups.

 

S(+)-氯胺酮在脊髓α运动神经元处或远程减弱了肌源性运动诱发位S(+)-

Ketamine Attenuates Myogenic Motor-Evoked Potentials at or Distal to the Spinal -Motoneuron

Kai-Michael Scheufler, MD*, Christof Thees, MD, Joachim Nadstawek, MD, PhD, and Josef Zentner, MD, PhD*

 *Department of NeurosurgeryUniversity of Freiburg, Freiburg, Germany; and Department of Anesthesiology and Intensive Care MedicineUniversity of Bonn, Bonn, Germany

Anesth Analg 2003 96: 238-244.

我们在兔模型上电刺激运动皮质后S(+)-氯胺酮对脊髓诱发电位 (ESCPs)和肌源性运动诱发电位的影响进行了研究。设计这一研究是为了确定ESCP特征和前后肢衍生的混合肌电位的相应改变之间的关系。直接(D)和间接(I)的皮质脊髓电位(ESCP)用两个双极硬膜外电极在上胸段和低胸段脊髓处记录,16只新西兰白兔在用单个脉冲双极以50 (阈值), 6070伏电刺激运动皮质时评价静注 0.02, 0.05, 0.10.2 mg · kg-1 · min-1 S(+)-氯胺酮的影响,每一次都在神经肌肉阻滞前后 (0.4 mg/kgcisatracurium)进行评价。 在以0.10.2 mL · kg-1 · min-1 的速度输注时,CMAP在前后肢的振幅明显抑制 (P < 0.01), 而相应的D- I-波都没有改变。在刺激振幅变化(50–70 V)时也有同样的发现。对CMAP的振幅和不同的ESCP特征的多变量回归分析显示并无明显的参数间的相关。这些发现显示S(+)-氯胺酮影响CMAP与皮质脊髓D-I-波介导的脊髓α运动神经元或远程的易化作用无关。结论: S(+)-氯胺酮结合了几种麻醉药的特性适合全静脉神经外科麻醉,这其中包括了它对神经生理监测的影响极小。对电刺激运动皮质神经和肌源性反应的记录显示S(+)-氯胺酮依靠脊髓α运动神经元或其远程的外周机制影响肌源性的运动诱发电位。

(潘志浩 薛张纲 )

We investigated the effect of S(+)-ketamine on spinal cord evoked potentials (ESCPs) and myogenic motor-evoked potentials after electrical stimulation of the motor cortex in a rabbit model. This study was designed to characterize the relationship between ESCP characteristics and corresponding changes in compound muscle action potentials (CMAPs) derived from fore and hind limbs. Direct (D) and indirect (I) corticospinal volleys (ESCP) from the upper and lower thoracic spinal cord, recorded by two bipolar epidural electrodes, were assessed during IV administration of 0.02, 0.05, 0.1, and 0.2 mg · kg-1 · min-1 of S(+)-ketamine, each before and after neuromuscular blockade (0.4 mg/kg of cisatracurium), in 16 New Zealand White rabbits after single-pulse bipolar electrical stimulation of the motor cortex at 50 (threshold), 60, and 70 V. CMAP amplitudes at fore and hind limbs were significantly suppressed (P < 0.01) during infusion at 0.1 and 0.2 mL · kg-1 · min-1, whereas neither corresponding D- nor I-waves were altered. Similar findings were obtained during variation of stimulus amplitude (50–70 V). Multivariate regression analysis of CMAP amplitudes and various ESCP characteristics demonstrated no apparent interparametric association. These findings indicate that S(+)-ketamine modulates CMAP independent from corticospinal D- and I-wave-mediated facilitation at or distal to the spinal -motoneuron.

 

Dexmedetomidine在慢性应用停止后不会造成痛觉过敏

Dexmedetomidine Fails to Cause Hyperalgesia After Cessation of Chronic Administration

M. Frances Davies, PhD, Fawzi Haimor, Geoffrey Lighthall, MD, PhD, and J. David Clark, MD, PhD

Veterans Affairs Palo Alto Health Care System and Stanford University Department of Anesthesiology, Palo Alto, California

Anesth Analg 2003 96: 195-200.

人类慢性应用阿片中止后会出现痛觉过敏,在慢性全身和鞘内用药的啮齿类上复制模型。然而,现在不清楚这种镇痛后的痛觉过敏是否是阿片类药物所特有的。 2-肾上腺素能激动剂, dexmedetomidine (Dex),与阿片相类似,也是一种镇痛药,它与抑制腺苷酸环化酶相关联的细胞表面受体相互作用以及调节离子信道的活性 。在这些研究中,我们首先确立了 Dex和吗啡(MSO4)抗伤害性感受的量效曲线。C57Bl/6小鼠腹腔内用Dex MSO450%有效剂量分别为75 µg/kg5.2 mg/kg。用等效剂量,我们在不同组的小鼠上用Dex MSO4一天两次共5天。之后可以发现有对这些药物的耐受。在停药后16–72 小时, MSO4-治疗的小鼠显示出热和机械痛觉过敏。然而, Dex-治疗小鼠并未显示有撤药有热、机械阈值的改变。我们通过这一研究得出结论。阿片而非2-肾上腺素能激动剂在慢性应用停药后出现了痛觉过敏。 结论: 在人体和其它一些动物中止应用阿片会出现痛觉过敏。然而,抗伤害的 dexmedetomidine在停用期间没有出现这种痛觉过敏综合征。

(张俊峰 薛张纲 )

Hyperalgesia occurring after the cessation of chronic opioid administration occurs in humans and has been modeled in rodents with chronic systemic and intrathecal administration paradigms. It is, however, unclear if this type of postanalgesic hyperalgesia is unique to opioids. The 2-adrenergic receptor agonist, dexmedetomidine (Dex), is similar to opioids in that it is an analgesic that interacts with cell-surface receptors linked to the inhibition of adenylate cyclase and the modulation of ion channel activity. In these studies, we first constructed antinociceptive dose-response curves for Dex and morphine (MSO4). The 50% effective doses for Dex and MSO4 administered intraperitoneally to C57Bl/6 mice were 75 µg/kg and 5.2 mg/kg, respectively. Using equally effective doses, we treated separate groups of mice with twice-daily injections of Dex or MSO4 for 5 days. Tolerance to these drugs was documented after this period. In the 16–72 h after cessation of administration, MSO4-treated mice demonstrated both thermal hyperalgesia and mechanical allodynia. However, the Dex-treated mice showed no changes in their thermal or mechanical withdrawal thresholds. We conclude that using this experimental paradigm, opioids but not an 2-adrenergic agonist, cause hyperalgesia and allodynia after cessation of chronic administration.

 

加强术后疼痛治疗的干涉研究

An Intervention Study to Enhance Postoperative Pain Management

Françoise M. Bardiau, RN, PhD*, Nicole F. Taviaux, RN*, Adelin Albert, PhD, Jean G. Boogaerts, MD, PhD, and Michaela Stadler, MD, MSc

Departments of *Nursing and Anesthesiology, University Hospital Center of Charleroi, Charleroi, Belgium; and Department of Biostatistics, University of Liege, Liege, Belgium

Anesth Analg 2003;96:179-185

这一研究,在一家一千张病床的医院中急性疼痛服务执行的前后进行,描述了急性疼痛服务执行的过程。包含了护理、麻醉和手术科室。在这一研究,我们对用确定质量指针和应用质量工具的持续质量改善程序的结果进行评估。目前已经根据急性疼痛治疗(多模式)的标准制定的质量程序来强化所有外科病人的疼痛解除。一项对护士关于术后疼痛知识的调查已经进行,用视觉模拟评分来评价疼痛强度。护士和医生都对关于术后疼痛的循证指南熟悉。三个连续的调查监测了整个过程,包含了2383个手术病人。以VAS为基础的疼痛指针和镇痛药物的消耗在术后头72小时进行记录。在关于当前的镇痛实践的基础调查进行之后,一个护士为基础,麻醉师监控的APS进行。在两个进一步的研究中,对用VAS评分表达的镇痛的改善也进行了评价。完成了一本质量手册并执行。在APS开始后疼痛评分有了一个重大的改善。 结论: 急性疼痛服务的执行, 包括用视觉模拟评分进行疼痛评价,标准的多模式疼痛治疗,持续的质量评价,改善的术后镇痛。建立外科医生,麻醉师和护士的队伍是这一改善的先决条件。

(张俊峰 薛张纲 )

This study, conducted before and after the implementation of an acute pain service (APS) in a 1000-bed hospital, describes the process of the implementation of an APS. The nursing, anesthesia, and surgery departments were involved. In this study we sought to evaluate the results of a continuous quality improvement program by defining quality indicators and using quality tools. A quality program in accordance with current standards of acute pain treatment (multimodal) was worked out to enhance pain relief for all surgical inpatients. A survey of nurses’ knowledge with regard to postoperative pain was conducted, and a visual analog scale (VAS) was introduced to assess pain intensity. Both nurses and physicians became familiar with evidence-based guidelines concerning postoperative pain. The entire process was monitored in three consecutive surveys and enrolled 2383 surgical inpatients. Pain indicators based on VAS and analgesic consumption were recorded during the first 72 postoperative hours. After a baseline survey about current practices of pain treatment, a nurse-based, anesthesiologist-supervised APS was implemented. The improvement in pain relief, expressed as VAS scores, was assessed in two further surveys. A quality manual was written and implemented. A major improvement in pain scores was observed after the APS inception (P < 0.001).

 

在恶性高热试验中延长骨骼肌的生存期

Extending the Skeletal Muscle Viability Period in the Malignant Hyperthermia Test

Saiid Bina, PhD, Stephen Holman, MD, and Sheila M. Muldoon, MD

Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland

Anesth Analg 2003 96: 153-158

 

咖啡因氟烷挛缩试验是用于诊断恶性高热易感性和显性易感家族的唯一的有效试验。尽管大多数的实验室诊断试验可以通过使用标准的对照样品来检查实验室之间和实验室内部的一致性,但对于咖啡因氟烷挛缩试验来说这一方法不可行。诊断中心之间的距离和咖啡因氟烷挛缩试验程序的时间限制 (5 h) 使得诊断中心不能分享组织样品。在这一研究中,我们研究了不同的储存条件下将骨骼肌的标准生存期延长到24小时。20MHS病人根据北美方法进行检测。在标准的咖啡因氟烷挛缩试验后,剩余的肌肉样品放入四个治疗组其中之一。在组12, 肌肉在Krebs 缓冲液(pH 7.4)中在23°C–25°C (钳-热)4°C (钳-冷)张力下保存。在组3 4, 肌肉条被切开,末端用丝线系上,从钳上切下,放在23°C–25°C(游离-热)和4°C(游离-冷)的 Krebs缓冲液中。在切除后2226小时测定各治疗组对氟烷 (3%) 和咖啡因(0.5–32 mM) 的反应。在所有的病人中钳-热储存组都准确地诊断了MHS结论:本文研究了不同的肌肉储存条件在恶性高热试验中将肌肉生存期从5延长到24小时。在室温张力下保存24小时肌肉仍然存活并正确诊断了MH的易感性。

(张俊峰 薛张纲 )

The caffeine halothane contracture test (CHCT) is the only validated test for diagnosing malignant hyperthermia (MH) susceptibility (MHS) and phenotyping MHS families. Although most diagnostic laboratory tests can check intra- and interlaboratory consistency through the use of standard control samples, there has been no practical way to achieve this goal for the CHCT. The distances between diagnostic centers and time constraints of the CHCT protocol (5 h) prohibit centers from sharing tissue samples. In this study, we investigated varying storage conditions to extend the standard viability period of skeletal muscle to 24 h. Twenty MHS patients were tested according to the North America protocol. After standard CHCT, the surplus muscle samples were placed in one of the following four treatment groups. In Groups 1 and 2, muscles remained under tension and were stored in Krebs buffer (pH 7.4) at 23°C–25°C (clamped-warm) and 4°C (clamped-cold), respectively. In Groups 3 and 4, muscle strips were dissected, and the ends were tied with silk sutures, cut from the clamp, and placed in Krebs buffer at 23°C–25°C (free-warm) and 4°C (free-cold), respectively. The responses of the treatment groups to halothane (3%) and caffeine (0.5–32 mM) were tested at 22–26 h after excision. The clamped-warm storage group correctly diagnosed MHS in all patients.