Anesthesia & Analgesia

January 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

評價一種新型脈搏氧飽和度儀在淺低溫心肺轉流期間的工作性能

(顏 濤 譯 莊心良 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.

 

體外迴圈時體外肝素酶處理後的血標本和體外迴圈魚精蛋白給藥後的血標本之間凝血酶原時間的一致性

(張 鴻 譯    薛張剛 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.

 

微型食管探頭心臟超聲監測用於麻醉誘導期
 (忻紀華   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.

 

血液稀釋不改變麻醉狗影響心率的動脈壓力反射

(趙雪蓮  譯 莊心良  )

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

Makoto Tanaka and Toshiaki Nishikawa

Anesth Analg 2003 96: 28-32.

 

血管手術患者靶控輸注雷米芬太尼改善血流動力學並減少雷米芬太尼用量

(張 鴻 譯    薛張剛 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續出血犬應用乳酸林格氏液和6%羥乙基澱粉的比較

(忻紀華   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. 

 

用不同濃度血紅蛋白氧載體進行失血犬模型復蘇後動脈和混合靜脈氧飽和度監測的價值

(唐 俊 譯   莊心良  )

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.

 

計算修正的血栓彈力圖和血小板功能分析對常規心臟手術後失血的預測價值

(張鴻     薛張剛 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

非甾體類抗炎藥與扁桃體切除術後手術野出血的風險:定量系統回顧

(朱 慧 譯   莊心良  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:

提高氧濃度不能減少婦科病人腹腔鏡術後噁心嘔吐的發生率

 (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:

甘氨酸受體介導吸入麻醉藥的制動效應

(楊保仲 譯  莊心良 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-天冬氨酸受體可能抑制異氟醚作用

(李紹清譯 薛張綱校)

 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.

吸入性麻醉藥減少腦組織乙酰膽鹼煙鹼樣受體的親和力

(   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.

 

非鹵素烷烴類麻醉藥對GABAA受體功能的調製作用:激動劑增強作用,直接啟動和抑制效應

(唐 俊 譯   莊心良  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.

 

異氟醚MAC與不同氙氣濃度在豬身上的研究

(李紹清譯 薛張綱校)

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.

 

吸入性麻醉藥對大鼠非腎上腺能非膽鹼能反應的作用

( 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.

 

異丙酚-氧化亞氮麻醉能提高靜注異丙腎上腺素的心率反應

(趙雪蓮  譯 莊心良  )

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

Takashi Horiguchi and Toshiaki Nishikawa

Anesth Analg 2003 96: 132-135. 

 

麻醉前使用可樂定對老年和青年患者異丙酚麻醉中麻黃素的血壓和心動過速反應性的影響

(潘志浩譯 薛張綱校)

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.

 

異丙酚靶控輸注的人工計算尺的研製和評估

( 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對大鼠伏核氯胺酮誘導的多巴胺釋放的抑制作用

(楊保仲 譯  莊心良 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.

 

在惡性高熱試驗中延長骨骼肌的生存期

(張俊峰 薛張綱 )

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:

比較三種保溫方式以確定最有效的維持圍術期體溫正常

( 莊心良 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:

加強術後疼痛治療的干涉研究

(張俊峰 薛張綱 )

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.

 

鞘內鎮痛治療病人和導管有關的腫塊

(殷文淵 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.

 

鞘內注射酮咯酸增強可樂定的抗傷害作用

(王士雷 譯 莊心良 校)

Intrathecal Ketorolac Enhances Antinociception from Clonidine

Dawn R. Conklin and James C. Eisenach

Anesth Analg 2003 96: 191-194.  

 

Dexmedetomidine在慢性應用停止後不會造成痛覺過敏

(張俊峰 薛張綱 )

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:

離體兔肺模型中用大潮氣量及零呼期末正壓單肺通氣是有害的

 ( 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:

異氟醚預調通過啟動KATP通道對大鼠局灶性腦缺血產生劑量依賴性的神經保護

(   莊心良  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運動神經元處或遠程減弱了肌源性運動誘發位S(+)-

(潘志浩 薛張綱 )

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次連續腋路臂叢阻滯的神經併發症

(殷文淵 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.  

 

開放性肩部手術的肌間溝法臂叢麻醉和鎮痛:左旋布比卡因和羅呱卡因隨機雙盲對照試驗

(     莊心良 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.  

 

可樂定作為肌間溝阻滯鎮痛藥用於肩關節鏡時的鎮痛作用

(潘志浩 薛張綱 )

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.

 

血液稀釋不改變麻醉狗影響心率的動脈壓力反射

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:急性等容量血液稀釋(ANH)的心血管效應包括心輸出量增加和血管張力降低。然而,ANH是否影響動脈壓力反射,至今還無研究。故本文研究ANH對動脈壓力反射的影響。方法:選用研究23只在麻醉下機械通氣的狗為研究物件,對其實施中度ANH(血紅蛋白,7-8g/dLn=11)或重度ANH(血紅蛋白,4-5g/dLn=12)。對狗施行靜脈切開和同時用乳酸林格氏液按13輸入,維持穩定中心靜脈壓和肺動脈楔壓。通過測定心電圖RR間期和股動脈插管測平均動脈壓評估壓力反射靈敏度。通過靜脈注苯福林(25-75ug)和硝普鈉(50-100ug)誘發壓力反射。通過與RR間期和MAP相關的壓力反射曲線的直線直線部分反映壓力反射敏感性。結果:與稀釋前相較,兩組心輸量均有明顯增高,總血管阻力明顯下降(P <0.001)但MAP和心率無變化。但兩組的ANH前後壓力反射均無明顯不同。結論:結果顯示接受麻醉狗血紅蛋白濃度4-5g/dL時與HR有關的動脈壓力反射仍存在。

                                (趙雪蓮  譯 莊心良  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.

 

異丙酚-氧化亞氮麻醉能提高靜注異丙腎上腺素的心率反應

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:異丙酚-N2O麻醉使對靜注阿托品的心率反應減弱。作者研究異丙腎上腺素在異丙酚-N2O麻醉時的心率變化。方法:實驗對照阻(n=15)不使用異丙酚和N2O。實驗組(n=21)靜脈注射2.5mg/kg異丙酚1分鐘後持續輸入異丙酚10mg.kg-1.h-1。氣管插管後,麻醉維持用5 mg.kg-1.h-167%N2O-33%O2;兩組患者均靜脈持續輸入異丙腎上腺素(2.55.7.51012.51517.5 ng.kg-1.min-1,每個劑量均輸入2分鐘)到HR超過基礎心率20bpm。輸注完成測定血液動力學指標。結果:輸入7.5 ng.kg-1.min-1時實驗組HR增加明顯超過對照阻(20 ± 5 14 ± 4 bpm; P < 0.05)。異丙腎上腺素輸注速率為10 ng.kg-1.min-1 時實驗組所有成員HR增加都超過20bpm,對照阻只有31%患者HR超過基礎值20bpm(P < 0.0001)。結論:異丙酚-N2O麻醉時,若大劑量阿托品不能維持正常HR,可採用靜脈持續輸注異丙腎上腺素。

                                        (趙雪蓮  譯 莊心良  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.

 

甘氨酸受體介導吸入麻醉藥的制動效應

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

在體外實驗中,許多吸入麻醉藥可以加強士的甯敏感的甘氨酸受體的功能,這與吸入麻醉藥在低於MAC時,抑制傷害性刺激的體動反應是由甘氨酸受體介導的觀點相一致。各種吸入麻醉藥對甘氨酸受體的強化作用,在程度上是有差別的,氟烷強化作用最強,異氟醚有中等強度的強化作用,而環丙烷的強化作用最小。按此可以推論,在脊髓水平阻滯甘氨酸受體,將使吸入麻醉藥之MAC 值增大,增大的程度與吸入麻醉藥在體外對此受體功能的強化作用成正比例,其順序依次為氟烷、異氟醚、環丙烷。對鞘內留置導管的大鼠行吸入麻醉,藥物分別選用氟烷、異氟醚、環丙烷,經鞘內留置導管滴入含有士的寧的腦脊液,劑量分別為0,3, 12, 24, 48(異氟醚加到此劑量) µg/min,測出相應的MAC值。結果表明,鞘內應用士的甯,可增加吸入麻醉藥的MAC值,增加的程度與在各麻醉藥在體外對甘氨酸受體的強化作用成比例。在甘氨酸的應用劑量為12 µg/min時,此效應最大,在甘氨酸的應用劑量為12 24 µg/min時,MAC值的增加與麻醉藥在體外對甘氨酸受體的強化作用相關(r2 = 0.82)。試驗結果支持甘氨酸受體介導吸入麻醉藥動作用的假說。

                                   (楊保仲 譯  莊心良 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對大鼠伏核氯胺酮誘導的多巴胺釋放的抑制作用

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

伏核多巴胺釋放在某些藥物所致的精神症狀和成癮性作用中起重要的作用。氯胺酮和巴比妥類藥物有精神作用和成癮性,而巴比妥類藥物可以防止氯胺酮的精神症狀。我們研究了氯胺酮和巴比妥類藥物對伏核多巴胺釋放的影響作用。給大鼠(n=35)植入微透析取樣用探針,給藥途徑為腹膜腔內注射,大鼠隨機分為七組:生理鹽水組; 50 mg/kg氯胺酮組;100 mg/kg氯胺酮組;25 mg/kg戊巴比妥組; 50 mg/kg戊巴比妥組;生理鹽水之後給50 mg/kg氯胺酮組;25 mg/kg戊巴比妥之後給50 mg/kg氯胺酮組。灌注液每20分鐘取樣一次,多巴胺濃度用高效液相色譜技術測量。50 mg/kg 100 mg/kg劑量的氯胺酮明顯增加伏核多巴胺的釋放。相反,戊巴比妥明顯減少伏核多巴胺的釋放,並且抑制氯胺酮誘導的多巴胺的釋放。實驗結果提示,伏核多巴胺的釋放,主要介導氯胺酮導致的精神症狀和成癮作用中起作用,而非巴比妥類藥物導致的精神症狀和成癮作用。巴比妥類藥物可能通過抑制伏核多巴胺的釋放而防止氯胺酮的精神症狀。

(楊保仲 譯  莊心良 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.

 

用不同濃度血紅蛋白氧載體進行失血犬模型復蘇後動脈和混合靜脈氧飽和度監測的價值

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:評估失血後使用不同濃度血紅蛋白氧載體(Hemoglobin glutamer-200 []Oxyglobin® [Hb-200])復蘇時動脈和靜脈混合氧飽和度監測的價值。方法:19條脾切除後的雜種犬經麻醉後,行肺動脈插管(Abbott QVUE Oximetrix 3導管),股動脈放置18號導管,舌上安放Nellcor探頭。用LEXO2CON-K氧分析儀分析基礎、失血40%(保持動脈壓在50mmHg)以及用30 mL/kg的含6% 羥乙基澱粉的乳酸林格氏液(n = 4),10 mL/kg Hb-20020 mL/kg羥乙基澱粉(n = 6)或20 mL/kg Hb-20010 mL/kg羥乙基澱粉(n = 7)復蘇後的靜脈和動脈血氧含量,並且與監護儀計算所得的氧含量進行比較。結果:有兩條犬未能從放血過程中生存下來而被排除,也證明了模型的可行性。計算所得和測量所得的血紅蛋白氧飽和度值的基礎值之間有很好的相關性(0.97 r 0.92)。復蘇後兩者的相關性都有統計學意義的減少。監護儀計算所得的氧含量值與肺動脈氧定量直接測定值偏差可達20%。結論:急性失血模型證明,血液替代品進行復蘇可能干擾一部分監護儀的資料,而且呈劑量相關性。

                                        (唐 俊 譯   莊心良  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.

 

非甾體類抗炎藥與扁桃體切除術後手術野出血的風險:定量系統回顧

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:扁桃體術後用非甾體類抗炎藥(NSAIDs)鎮痛一直是一個有爭議的問題。NSAIDs抑制血小板活性,因而可能會增加圍術期出血。方法:本文系統地查閱了已報導的關於扁桃體切除術病人因使用NSAIDs而發生圍術期出血的隨機對照試驗。另外,我們也分析了疼痛緩解的質量和術後噁心嘔吐的發生率。對25篇研究中的共970名接受NSAID838名非NSAID或安慰劑治療的病人進行了研究。資料組合使用固定效應模型(fixed-effect model)。結果:在四個出血指標(術中失血,術後出血,入院治療和因出血進行再次手術)中,只有再次手術的發生率在NSAIDs組增多。Peto幾率比值為2.3395%可信限[CI]1.124.83),需要治療數60 (95% CI 34277)。與阿片類相比,鎮痛效果相同,而嘔吐風險明顯下降(相對風險:0.7395% CI0.630.85;需要治療數:995% CI519)。結論:非甾體類抗炎藥增加扁桃體切除術後出血風險的證據不明確,風險效益比並不明顯。有一些跡象表明可能增加因出血而再次手術的風險,但對此尚需進一步的研究證實。   

(朱 慧 譯   莊心良  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).

 

非鹵素烷烴類麻醉藥對GABAA受體功能的調製作用:激動劑增強作用,直接啟動和抑制效應

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:臨床濃度下,乙醚、酒精、鹵素類烷烴增強γ氨基丁酸GABAA受體作用,非鹵素類烷烴則不然。許多麻醉藥也直接啟動和/或抑制GABAA受體,導致重要的行為效應,非鹵素類烷烴對GABAA受體的直接啟動和抑制作用仍未研究。方法:評估了兩種有代表性的非鹵素類烷烴,環丙烷和丁烷的作用。用電生理技術對表達的α1β2γ21GABAA受體研究了增強激動劑效應,直接啟動和抑制效應。結果:環丙烷和丁烷在超過麻醉作用的濃度可以增強GABAA受體激動劑的作用。哪怕在接近水溶解飽和度時,兩者也不直接啟動和抑制GABAA受體作用。這個結果強烈說明非鹵素類烷烴的麻醉作用不是增強激動劑作用、直接增強或抑制α1β2γ21GABAA受體,而與麻醉藥與蛋白結合處的靜電作用調節GABAA受體的假說一致。結論:將在體麻醉強度或疏水性標準化後,環丙烷和丁烷對α1β2γ21GABAA受體激動激增強作用比異氟醚低1-1.5個數量級。另外,環丙烷和丁烷甚至在其接近水飽和濃度時也不能直接啟動或抑制受體。由此可見,環丙烷和丁烷對行為活動的影響並非增強或抑制腦內含量最多的GABAA受體亞型。

(唐 俊 譯   莊心良  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.

 

 

鞘內注射酮咯酸增強可樂定的抗傷害作用

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:雖然α2腎上腺素能激動劑和環氧化酶抑制劑都有鎮痛作用,但對它們的確切作用位點及其之間的相互作用並不清楚。曾有報導證明鞘內應用可樂定對大鼠的抗傷害作可被酮咯酸(ketorolac)所抑制。本文對兩藥單獨使用和聯合使用的效應進行了評價。方法:鞘內注射藥物,觀察熱刺激引發的大鼠後肢的傷害性反應。結果:可樂定可以減輕熱刺激引發的後肢的傷害性反應,而酮咯酸沒有此作用。但是,酮咯酸可以顯著增強可樂定的抗傷害作用,兩者之間呈現協同作用。結論:鞘內注射α2腎上腺素能激動劑可樂定和環氧化酶抑制劑酮咯酸的抗傷害作用呈現協同效應,兩者複合應用可以增強鎮痛效果。

(王士雷 譯 莊心良 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.

 

開放性肩部手術的肌間溝法臂叢麻醉和鎮痛:左旋布比卡因和羅呱卡因隨機雙盲對照試驗

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:比較左旋布比卡因和羅呱卡因行肌間溝法臂叢阻滯時的起效時間和質量。方法:50名接受開放肩部手術的病人,隨機均分成兩組,分別接受30ml 0.5%左旋布比卡因和0.5%羅呱卡因。從經18號絕緣刺激鞘(Tuohy)置入的20號導管中注入藥物。術後用PCA法延長阻滯時間,藥物分別為0.125%布比卡因或0.2%羅呱卡因,背景速率6ml/h,快速注射每次2ml,鎖定時間15min,最大每小時注射次數3次。結果:共3例病人(兩名左旋布比卡因組8%,一名羅呱卡因組4%)因在45min內未能達到外科手術需要的阻滯效果而被排除。神經阻滯的起效時間:左旋布比卡因組20min 10-40min),羅呱卡因組20min 5-45min)(P=0.53)。術中需加用0.1mg芬太尼輔助鎮痛者兩組均為8名(34%)(P=0.99)。42名病人完成了24h術後輸注(左旋布比卡因組22名,羅呱卡因組20名)。術後鎮痛效果相似。總局麻藥消耗量:左旋布比卡因組147ml144-196ml),羅呱卡因組162ml144-248ml)(P=0.019),外加注射藥物的獲得和需求比為0.80.4–1.0)和0.70.4–1.0)(P = 0.004)。開始術後鎮痛時,左旋布比卡因組手術肢體的運動阻滯程度比羅呱卡因組重,兩組運動功能沒有進一步的差異。結論:本前瞻性隨機雙盲對照實驗證實,用30ml 0.5%左旋布比卡因與相同濃度和容量的羅呱卡因行肌間溝臂叢阻滯,具有相似的起效時間和深度。術後用0.125%左旋布比卡因和0.2%羅呱卡因鎮痛相比,疼痛緩解和運動功能恢復相似,前者所需容量較少。

(唐     莊心良 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.

評價一種新型脈搏氧飽和度儀在淺低溫心肺轉流期間的工作性能

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:比較新型的脈搏氧飽和度儀Masimo SET Radical(M)和傳統的日本光電AY-900P(N)在低溫心肺轉流期間的性能。方法:分別觀察18位患者使用這兩種機器的結果。氧飽和度儀監測失敗指顯示不出氧飽和度的數值或者連續三分鐘顯示錯誤的數值。結果:MN監測失敗的例數分別是414(P=0.0022),所有M監測失敗的病人N檢測也失敗。在主動脈箝閉期間,M不能提供氧飽和度數值的機會是4%±12%N組是36%±39%P=0.002)。MN監測失敗開始和結束時的皮膚溫度和平均動脈壓相似。N而不是M在病人存在術前利尿治療或者手術中高乳酸血症時容易發生監測失敗。與N相比,M在淺低溫心肺轉流期間非搏動性血流情況下準確顯示脈搏氧飽和度的次數更多,時間更長。結論:M在低灌注情況下監測脈搏氧飽和度更加有用。

(顏 濤 譯 莊心良 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.

 

比較三種保溫方式以確定最有效的維持圍術期體溫正常

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:確定最有效的術中體溫干預措施 方法:我們研究了300位接受單側全膝關節置換術的病人,這些病人被隨機平均分為三組:(a)兩條棉毯組;(b)一條反射毯加一條棉毯組;(c)主動空氣加溫加一條棉毯組。術前在誘導室內、到達恢復室時以及在恢復室內每隔十分鐘測量鼓膜溫度。結果:在到達恢復室時,主動空氣加溫組體溫(已經根據病人的性別、年齡和病人所在的誘導室的溫度進行標準化)高於反射毯組 0.577°C ± 0.079°C (95% confidence interval [CI], 0.427–0.726; P < 0.001) ,高於兩條棉毯組0.510°C ± 0.08°C (95% CI, 0.349–0.672; P < 0.001)。與反射毯組(41.78 min95% CI 36.86–46.58)和兩條棉毯組(36.43 min 95% CI 31.23–41.62)相比,主動空氣加溫組病人體溫回復到36.5°C的時間較短(18.75 min 95% CI 13.88–23.62 P < 0.001) 。結論:主動空氣加溫是維持圍手術期正常體溫最有效的方法,反射毯比兩條棉被效果更差。

(顏 莊心良 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.

 

異氟醚預調通過啟動KATP通道對大鼠局灶性腦缺血產生劑量依賴性的神經保護

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. [

本研究目的是評價反復短時間異氟醚麻醉誘導對局灶性腦缺血是否會產生劑量依賴性的耐受以及這種效應是否依賴於KATPATP調節的鉀通道)。在實驗1中,40只大鼠隨機分成4組:對照組動物每天吸純氧1小時,共5天。而異氟醚(Iso1Iso2Iso3組分別吸入含0.75%, 1.5%, 2.25% Iso的氧氣,每天1小時共5天。實驗2中,36只大鼠隨機分成4組:對照組動物每天吸純氧1小時,共5天。IsoI+GIso+優降糖)組動物吸入含2%Iso的氧氣,每天1小時共5天。I+G組動物在每次Iso預處理前予以優降糖(5mg/kg腹腔用藥)。優降糖(GLB)組動物予以優降糖(5mg/kg腹腔用藥)每天一次共5天。在最後一次預處理後24小時,右大腦中動脈阻斷120分鐘。24小時後評定神經功能缺失評分(NDS)和腦梗死容積。Iso2Iso3組的NDS及梗死容積小於對照組(P < 0.05)。而Iso3組梗死容積小於Iso2組(P < 0.05)。Iso組的NDS和梗死容積小於對照組和I+G組(P < 0.05)。在對照組,I+G組及GLB組間沒有統計學差異。此研究表明反復Iso麻醉以劑量依賴方式誘導大鼠缺血耐受。KATP通道阻滯劑- GLB,消除了由Iso誘導的耐受。

(張   莊心良  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.

 

微型食管探頭心臟超聲監測用於麻醉誘導期
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

麻醉誘導期間不能進行標準的經食管心臟超聲(TEE)檢查,因為標準的食管探頭限制了口咽空間,並影響面罩通氣和氣管插管。我們假設標準的小型化TEE探頭在麻醉誘導時,可以安全的經鼻進入清醒病人、行面罩通氣和經口插管,同時進行左室功能監測(LV)。45名病人進行了前瞻性研究。將經鼻TEE探頭經一側鼻腔插入,直至可以顯示左室乳頭肌的橫切面。誘導期間病人行面罩通氣,TEE探頭經過面罩的中央孔。12例病人僅在局麻下成功插入探頭,31例病人局麻合併輕度鎮靜。兩例病人未成功置入。在插入過程中所有病人的血流動力學未明顯改變,也無明顯的黏膜改變。1例病人發生胃內容物的反流但未影響預後。在麻醉誘導期間,95%的病人可成功顯示二圍心臟超聲圖像。我們得出結論,經鼻TEE探頭可以是用於全麻誘導期間的有效監測。

                                                       (忻紀華   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續出血犬應用乳酸林格氏液和6%羥乙基澱粉的比較

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

 

我們研究狗以晶體液或膠體液行體液復蘇達到目標血壓時,對全身氧供和血乳酸濃度的短期影響。在體液復蘇時,以6%羥乙基澱粉(HES)使平均動脈壓達到60mmHg,與使用乳酸林格氏液(LR)使平均動脈壓分別達到6080mmHg(LR60,LR80)相對照。以動脈導管放血使平均動脈壓達40mmHg,並在研究期間繼續放血使動脈壓不超過40mmHg。持續進行上述的體液置換使目標血壓維持於60mmHg。全部15頭犬(5頭一組)存活的測量。血液喪失在LR80組(2980+/-503ml)(平均值+/-標準差)大於LR60組和HES60組(分別為1800+/-389ml1820+/-219)(p<0.001)。達到目標血壓時,HES組補液共840+/-219mlLR60組為1880+/-425mlLR80組為4590+/-930mlp<0.001)。與LR60組和LR80組相比,HES60組的血乳酸濃度更低,氧供更佳。乳酸濃度和氧供在HES組分別為35+/-17ml/dl239+/-61ml/min,在LR80組分別為75+/-23ml/dl153+/-17ml/min,LR80組分別為89+/-18ml/dl140+/-48ml/min(p=0.02p=0.026)。結論,出血未控制時的體液復蘇,為達到目標血壓,HES60組與LR80LR60相比更利於氧供,全身乳酸濃度更低。

                                                  (忻紀華   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.

 

提高氧濃度不能減少婦科病人腹腔鏡術後噁心嘔吐的發生率

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術後嘔吐和噁心(PONV)發生率,但其機制現尚不十分明確。本研究觀察非住院婦科腹腔鏡手術病人吸入80%的氧減少術後噁心嘔吐的效果。100例患者均吸入七 氟醚麻醉,並隨機分為兩組,A組在術中及術後一小時給予吸入30%的氧, B組則吸入80%的氧。測試結果表明兩組發生術後噁心嘔吐的幾率並不存在很大差別,A組術後24小時內PONV的發生率為62%,B組為55%。實驗結果表明增加供氧量並不能減少婦科腹腔鏡手術病人PONV的發生率。

                                                  (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.

 

吸入性麻醉藥減少腦組織乙酰膽鹼煙鹼樣受體的親和力

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

 

在過去的研究中,我們認為乙酰膽鹼煙鹼樣受體(nAChRs)的啟動可以被亞麻醉濃度的吸入性麻醉藥所抑制。究竟何種啟動途徑被抑制尚未明瞭。從電魚TorpedonAChRs相關的進化方面的研究發現:吸入性麻醉藥改變了受體激動劑的親和力。我們研究了兩種吸入麻醉藥物的效果,將異氟醚和七氟醚作用於鼠腦,腦內煙鹼樣受體與高度親和力的激動劑—— epibatidine結合處於平衡.我們分別研究了雌性和雄性的大腦,因為有報導煙鹼反應存在性別差異。麻醉前兩類大腦中有等量的epibatidine結合。異氟醚和七氟醚減少了[3H] epibatidine與煙鹼樣受體的結合,但僅在濃度等於或高於麻醉要求時。異氟醚抑制雄性大腦中[3H] epibatidine與煙鹼樣受體的結合達到50%時的濃度時 0.58±0.07mM,雌性為1.62±0.30mM。七氟醚的作用濃度在雄性為0.77±0.05 mM,雌性為0.77±0.04 mM。兩種性別之間的藥物作用無顯著差異(p0.05)。雖然在麻醉濃度下存在激動劑 親和力的輕微下降,但是nAChRs功能的顯著下降不能完全有激動劑親和力的改變來解釋。                                                                                                                                          

                                                   (   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.

 

吸入性麻醉藥對大鼠非腎上腺能非膽鹼能反應的作用

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

 

吸入性麻醉藥物對降鈣素基因相關肽(CGRP)所介導的非腎上腺能非膽鹼能(NANC)用尚未明瞭.我門研究了異氟醚,氟烷和七氟醚對電刺激脊髓大鼠NANC抑制反應的作用,實驗過程中通過持續性輸注甲氧胺以維持平均動脈壓在120mmHg左右,自主性的流出由六甲銨所阻斷.吸入30分鐘不同濃度的麻醉藥後,刺激低胸段的脊髓30(10 V 4Hz 持續1ms)以引起NANC抑制反應. 2%的異氟醚和1.5%的氟烷顯著地減弱了NANC抑制反應,然而1%的異氟醚和0.75%的氟烷和2%4%的七氟醚未起作用. 吸入性麻醉藥物沒有減少脊髓刺激後CGRP的釋放,2%的異氟醚 1.5%的七氟醚顯著地抑制了當攝入外源性CGRP時的抑制反應.4%的七氟醚沒有顯著影響CGRP所介導的抑制反應.這樣,高濃度的異氟醚和氟烷通過減少CGRP所介導的抑制反應而不是CGRP的釋放減弱了NANC抑制反應.                                                                                                 

                                                   ( 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.

 

異丙酚靶控輸注的人工計算尺的研製和評估

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

 

我們在此闡述簡易計算尺的研製並對其進行評估,它能夠在床邊確定異丙酚的輸注速率以使異丙酚達到特定的血漿靶濃度。為使異丙酚準時達到靶濃度,其滴注速率是由所需的靶濃度,體重,以及開始時間決定的。我們的靶控制輸注(TCI)計算尺,是按照乘法運算法則建立起來的,就如同經典的計算尺是按照指數加法構造的。我們通過STANPUMP計算使用TCI計算尺所達到的預期血漿濃度的偏差百分率。使用STANPUMP評估結果顯示如果異丙酚的靶濃度 3µg/ml,在第一個15分鐘平均偏差為4.05%(最大為6.97%),16300分鐘之間平均偏差為0.5%(最大為2.03%)。當靶濃度從3µg/ml改為124,和5µg/ml時其平均偏差也相應從1.15%變至17.76%。這種口袋大小的TCI計算尺除了比較精確還有成本低的優點。

                                                 ( 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.

 

鞘內鎮痛治療病人和導管有關的腫塊

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

 

七名接受鞘內鎮痛藥物治療慢性難治性疼痛的病人接受放射對比鞘內攝影和CT檢查來篩查導管相關鞘內腫塊。七名檢查病人中的三名病人在總共118個月的治療後有與注射導管尖端想關的脊髓內腫塊。索引患者存在神經痛惡化和左側下肢麻痹。另外通過CT鞘內攝影檢查出的兩名患者沒有症狀。診斷出導管相關腫塊前的平均治療時間為11.6個月,範圍為16-25個月。通過對有和沒有導管相關腫塊兩組在統計學上和病人間治療差異進行比較,發現有腫塊的患者與沒有的患者相比較,年齡較輕且接受的嗎啡劑量較大。統計學上有顯著差異(P=0.05)。一名沒有症狀的鞘內導管相關腫塊病人,在停止治療後發現腫塊有所減小。第二個無症狀的病人在用hydromorphone替代嗎啡持續治療後,腫塊在一年多的時間裏維持穩定。無症狀的病人在發現鞘內導管相關腫塊和進行臨床干預後,沒有人繼發其他的神經系統發現和損傷。我們建議所有病人在接受長期鞘內麻醉患者都應接受定期的X光檢查以進一步確定發生導管相關腫塊的風險,在發生神經損傷前進行治療。

                                                    (殷文淵 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.

 

離體兔肺模型中用大潮氣量及零呼期末正壓單肺通氣是有害的

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

我們驗證了這樣一個假設,在單肺通氣中使用高潮氣量及零呼期末正壓可能會導致呼吸機引起的肺損傷。在一個獨立的完好的兔子肺模型中,在持續的氣流下實施雙肺通氣時設置適當的潮氣量及呼期末正壓以避免肺塌陷及過度膨脹。然後我們隨機選擇動物把它分成三組,I組為無保護性單肺通氣(左肺)(n=6),並使呼期末正壓為零及使潮氣量與雙肺通氣前一樣高;II組為保護性單肺通氣(左肺)n=6),並使潮氣量減少50%以及使呼期末正壓同雙肺通氣前一樣;III組為對照組(n=6),就與試驗前一樣實施雙肺通氣。在無保護性單肺通氣組中,小程度地使肺塌陷使肺過度膨脹(P<0.01),氣道峰壓升高並在觀察期間漸進性增高(P<0.01) ,肺動脈平均壓和肺的重量以及凝血氧烷B2濃度都相對增高(P<0.05)。因此在臨床中實施單肺通氣使用高潮氣量以及零呼氣末正壓會導致呼吸機引起的肺損傷,但這可以通過降低潮氣量和呼氣末正壓來避免肺過度膨脹和肺塌陷。

                                                    ( 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次連續腋路臂叢阻滯的神經併發症

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

 

由於導管所致的機械損傷或局部麻醉藥的毒性反應,持續腋路臂叢神經阻滯理論上會增加神經併發症的風險。本研究回顧了使用當前技術和設備發生併發症的頻率。在368名病人使用了405根腋窩導管。41名病人先前就存在神經異常(10.1%),包括30名病人有術前尺神經病。305名病人(75.3%)在肘部手術後留置腋窩導管輔助恢復。導管常規在術後記錄病人正常神經功能檢查後放置。355名病人(88.7%)注射的局麻藥為布比卡因而45名病人(11.1%)mepivacaine。平均注射速度為10±2ml/h。導管留置55±32h31名病人是由於技術問題或麻醉不充分而放置腋窩導管。有8名病人存在9種併發症,總發生率為2.2%。併發症包括下例之一:局部感染(除去導管和抗生素治療),腋窩血腫,導管碎片殘留需要手術取出。此外,有兩名病人報導有全身局麻藥中毒的症狀和體征。四名病人(1.0%)報導術後有新的神經功能缺陷。在兩名病人中,神經功能喪失與麻醉無關。所有四名病人都在肘部手術後持續放置導管。我們的結論是持續腋路臂叢阻滯神經併發症的風險與單次注射技術相似。

                                                    (殷文淵 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.

 

體外迴圈時體外肝素酶處理後的血標本和體外迴圈魚精蛋白給藥後的血標本之間凝血酶原時間的一致性

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.

 

凝血酶原時間(PT)測定對確定體外迴圈(CPB)後凝血因數缺乏是有效的。然而,其測定和新鮮冰凍血漿(FFP)加熱所需時間延誤了凝血因數的替代治療。我們假設,體外迴圈結束前採集的血標本用肝素酶處理後,能提供PT結果以決定CPBFFP的需要量。即時監測可彌補實驗室的延遲。我們研究了158例成人非急診心臟手術。脫離CPB前采得的血樣與肝素酶混和,在實驗室中用HemoTec測定PT。這些結果與用魚精蛋白拮抗後采得血樣測定的結果進行比較,應用閾值為±1.0 秒的Bland and Altman曲線。結果發現CPB中和CPB後的實驗室PT值具有可比性,但其一致性的限值超越了這些閾值。同樣,CPB前、中、後HemoTec和實驗室測得的PT結果之間,一致性不滿意。在CPB中測得的每個PT值,計算相應的魚精蛋白拮抗後PT值的可信區間。CPB中實驗室PT16秒或18秒,提示CPB83%的可能性不需要或93%的可能性需要FFP。我們的結論:大部分CPB停機前采得血樣經肝素酶體外處理後測得的PT值與CPB後是否需要FFP的可能性高度相關。

結論:體外迴圈後凝血功能障礙可能會引起出血。獲得凝血測定結果和新鮮冰凍血漿需要一定的時間,從而延遲對需要新鮮冰凍血漿患者的治療。我們設計了一種早期估計體外迴圈後凝血功能狀態的方法。                    

(張 鴻 譯    薛張剛 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

 

                                                    

血管手術患者靶控輸注雷米芬太尼改善血流動力學並減少雷米芬太尼用量

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.

 

雷米芬太尼是一種強效、超短作用時間、快速蘇醒的阿片類藥物。然而,雷米芬太尼價格昂貴,過量時對血流動力學可能有不良影響。靶控輸注可按藥代動力學模型調整輸注。在這個前瞻性隨機研究中,我們比較了擇期頸動脈手術患者,應用體重調整(RIVA)或靶控(TCIR)輸注雷米芬太尼情況下,術中術後的血流動力學、麻醉期間雷米芬太尼的需要量、術後嗎啡的需要量。46位患者進入本研究:均用異丙酚靶控輸注麻醉。23位病人在麻醉誘導和氣管內插管時應用RIVA(0.5 µg · kg-1 · min-1),插管後輸注速率降至0.25 µg · kg-1 · min-1,然後根據血流動力學按照0.05 µg · kg-1 · min-1逐步調整輸注速率。23位元病人應用TCIR(Minto model, Rugloop),誘導時效應室濃度為4 ng/mL,然後根據血流動力學按照1 ng/mL逐步調整靶濃度。所有病人給予阿曲庫銨和50%笑氧混合氣體。每分鐘記錄血流動力學參數。兩組病人均收集血流動力學事件發生次數和持續時間,麻醉藥物(雷米芬太尼和異丙酚)和血管活性藥物的總量。資料用非配對t檢驗進行分析。與TCIR相比,RIVA組發生更多術中低血壓事件(166, P < 0.001)、更多需頻繁應用ß腎上腺素能受體阻滯劑的術後高血壓/心動過速事件(1610, P < 0.04)。兩組間嗎啡需要量無顯著差異。TCIR組在異丙酚需要量無明顯差異的情況下,雷米芬太尼需要量明顯減少(700 ± 290 1390 ± 555 µg, P < 0.001)。這一前瞻性隨機研究顯示,在頸動脈內膜剝脫術中,與雷米芬太尼的持續RIVA給藥相比,TCI給藥在麻醉誘導期低血壓事件較少,在蘇醒期心動過速和/或高血壓事件較少,且ß腎上腺素能受體阻滯劑需要量較少,以及蘇醒期雷米芬太尼需要量減少。推薦在頸動脈剝脫術中應用雷米芬太尼靶控給藥可能是合理的。

結論:雷米芬太尼用於頸動脈手術中鎮痛時,靶控給藥較之體重調整輸注可提供更平穩的圍術期血流動力學。這可能與靶控輸注時需要量較少和給藥方式平穩有關。

(張 鴻 譯    薛張剛 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

 

計算修正的血栓彈力圖和血小板功能分析對常規心臟手術後失血的預測價值

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.

 

體外迴圈(CPB)後出血仍是一個臨床問題。床旁用來判定凝血紊亂的即時檢測方法是非常需要的。本研究評價了兩種即時檢測方法對常規心臟手術後出血的預測價值。前瞻性比較修正血栓彈力圖(ROTEGTM)和血小板功能分析儀(PFA-100TM),對連續的255位病人術後失血的預測能力。在三個時點進行測量:術前、CPB過程中、魚精蛋白給藥後進行三次修正血栓彈力圖和血小板功能分析測定。出血傾向增加的最佳預測值是CPB後做的測定。角是最佳預測因數(ROC曲線下面積為0.69),聯合應用二磷酸腺酐-PFA監測時,預測的精確性增加(ROC曲線下面積為0.73)。儘管角的陽性預測值較小(41%),其陰性預測值為82%。血栓彈力圖的預測能力比PFA強。在常規心臟手術中,由即時監測判定的凝血紊亂並不一定導致術後出血,但測定結果正常的患者不可能因凝血原因而出血。這些病人的出血可能由手術引起。高陰性預測值支援早期判定和針對性治療手術出血,將手術出血與凝血異常區分開來。結論:常規心臟手術中的血栓彈力圖和血小板功能分析顯示了對術後出血的高陰性預測值,這支援早期判定和針對性治療手術出血,將手術出血與凝血異常區分開來。陽性預測值較小。最佳預測值為體外迴圈後的血栓彈力圖測定值。

(張鴻     薛張剛 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-天冬氨酸受體可能抑制異氟醚作用

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.

 

我們目的在於證實N-甲基-d-天冬氨酸(NMDA)受體是否通過脊髓或脊椎上影響異氟醚抑制和性。方法:通過鞘內(IT)、腦室內(ICV)和靜脈(IV)注入MK801(一個非競爭的NMDA拮抗劑)對抗NMDA受體,同時測定異氟醚MAC下降變化和MK801脊索上下段、腦皮層和全腦組織勻漿濃度。結果:通過ITMK801減低異氟醚MAC比通過ICVIV給藥效果強。低位脊髓索異氟醚MAC變化與MK801濃度有關(P < 0.01),而脊椎上與濃度無關。ITMK801最大可達到一個無麻醉效應平臺;無異氟醚時,IT給藥的270IV劑量也不能產生麻醉效果。這些結果表明MK801減低異氟醚MAC能力是因為主要對脊髓索影響,而NMDA受體通過異氟醚產生部分抑制調節作用。因為ITIVMK801均不能產生麻醉,引起了對NMDA獨自可以在面對傷害性刺激起抑制作用而產生麻醉效果的定義的質疑。結論:脊髓索NMDA受體可調節部分異氟醚抑制作用;通過MK801在脊髓中的NMDA受體的阻滯可產生異氟醚MAC下降效應,但是MK801自己並不產生完善麻醉。                                                       (李紹清譯 薛張綱校)
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.

異氟醚MAC與不同氙氣濃度在豬身上的研究

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.

 

對患者吸入氧濃度大於30%,而氙氣MAC大到71%,故獨自用氙氣麻醉受限,這個試驗研究氙氣與其他麻醉氣混合使用。因而我們研究了氙氣對異氟醚MAC的影響。10只豬(重28-35 kg),與氧混合的氙氣濃度分別為0%, 15%, 30%, 40%, 50%, 65%,每一氙氣濃度,用智慧方式給不同異氟醚濃度。每一混合濃度下給予大強度疼痛刺激,記錄撤退反應。異氟醚MAC定義為50%無痛反應的呼氣末濃度,每一氙氣濃度下,痛反應均被分類,用邏輯回歸模式分析異氟醚MAC值結果。吸入氙氣後異氟醚MAC非線性減少,從1.92% (95% 可信區間, 1.70%-2.15%) 混合0% Xe 1.17% (95%可信區間, 0.75%-1.59%) 混合 65% Xe。雖然這表明兩麻醉氣體有部分對抗,但氙氣與異氟醚混合對要求吸氧濃度大於30%的患者仍有價值。

結論:我們研究了氙氣對異氟醚MAC的影響。這個試驗用固定氙氣與不同異氟醚濃10只豬上進行。吸入氙氣後異氟醚MAC非線性減少。                                                     (李紹清譯 薛張綱校)

 

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.

麻醉前使用可樂定對老年和青年患者異丙酚麻醉中麻黃素的血壓和心動過速反應性的影響

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.

我們研究了異丙酚麻醉麻醉前使用可樂定或咪唑安定的老年和青年患者對麻黃素的升壓和心率增快反應。第一部分試驗中,老年(>60 yr)和青年 (20–45 y )患者根據年齡和麻醉前用藥方案隨機分為四組(每組16例):老年可樂定組[EC], 老年咪唑安定組[EM],青年可樂定組[YC]和青年咪唑安定組[YM]。異丙酚麻醉下    注射麻黃素後觀察血流動力學變化;第二部分試驗中,麻醉前使用可樂定,老年(16例)予以較少劑量的異丙酚注射(EC-LP),青年(16例)予以增加劑量的異丙酚注射(YC-HP),然後注射麻黃素並觀測血流動力學變化。結果在EC組中平均動脈壓和心率的增加比EMYM EC-LP組明顯(P < 0.05) 。與YC組相比YC-HP組的麻黃素升壓反應增強但無統計學意義。該結果顯示麻醉前使用可樂定(尤其在標準劑量異丙酚麻醉下的老年患者)增強麻黃素的升壓和心動過速反應,並且可樂定、年齡及異丙酚都可能與此反應增強有關。結論: 可樂定麻醉前用藥增強老年患者標準劑量或大劑量異丙酚麻醉下麻黃素的升壓和心動過速反應,但並不增加小劑量異丙酚麻醉的麻黃素的反應性,可樂定、年齡及異丙酚都可能與此反應增強有關。

(潘志浩譯 薛張綱校)

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.

可樂定作為肌間溝阻滯鎮痛藥用於肩關節鏡時的鎮痛作用

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.

 

作為一種單獨的鎮痛藥,可樂定在中樞神經阻滯和關節內注射後產生鎮痛作用,但在腋路阻滯時沒有作用。在本研究中,我們要確定是否肌間溝內可樂定會在關節鏡手術產生鎮痛效果。40例要進行肩關節鏡手術的病人包含在這一雙盲的研究中。應用神經刺激器技術,置入一肌間溝導管。病人隨機分為兩組。肌間溝組 (n = 20)通過導管給溶於15毫升鹽水的可樂定 150 µg以及1毫升皮下鹽水;全身給藥組(n = 20)通過導管給15毫升的鹽水,皮下給150 µg (1 mL)的可樂定。所有病人均用全麻進行手術,在關節鏡結束後,所有病人都接受自控鎮痛,負荷劑量為8 mL0.2%的羅呱卡因(經導管),鎖定時間為1小時。術後疼痛每隔4小時用視覺類比評分測定共24小時。如果需要則用胃腸外給納布啡作另外的術後鎮痛直到VAS < 3。在蘇醒室內全身給藥組VAS與肌間溝組相比明顯高(P < 0.0001)。鎮痛時間也是肌間溝組較長 (P < 0.00001),而羅呱卡因的消耗量在全身給藥組顯著低 (P < 0.0001)。兩組間納布啡的消耗量並無差異,不良反應液相似。結論: 可樂定通過肌間溝導管給藥與全身給藥相比增強了鎮痛效果。然而,可樂定在這一劑量的不良反應限制了它常規用於術後鎮痛的處理。

(潘志浩 薛張綱 )

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運動神經元處或遠程減弱了肌源性運動誘發位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.

我們在兔模型上電刺激運動皮質後S(+)-氯胺酮對脊髓誘發電位 (ESCPs)和肌源性運動誘發電位的影響進行了研究。設計這一研究是為了確定ESCP特徵和前後肢衍生的混合肌電位的相應改變之間的關係。直接(D)和間接(I)的皮質脊髓電位(ESCP)用兩個雙極硬膜外電極在上胸段和低胸段脊髓處記錄,16只新西蘭白兔在用單個脈衝雙極以50 (閾值), 6070伏電刺激運動皮質時評價靜注 0.02, 0.05, 0.10.2 mg · kg-1 · min-1 S(+)-氯胺酮的影響,每一次都在神經肌肉阻滯前後 (0.4 mg/kgcisatracurium)進行評價。 在以0.10.2 mL · kg-1 · min-1 的速度輸注時,CMAP在前後肢的振幅明顯抑制 (P < 0.01), 而相應的D- I-波都沒有改變。在刺激振幅變化(50–70 V)時也有同樣的發現。對CMAP的振幅和不同的ESCP特徵的多變數回歸分析顯示並無明顯的參數間的相關。這些發現顯示S(+)-氯胺酮影響CMAP與皮質脊髓D-I-波介導的脊髓α運動神經元或遠程的易化作用無關。結論: S(+)-氯胺酮結合了幾種麻醉藥的特性適合全靜脈神經外科麻醉,這其中包括了它對神經生理監測的影響極小。對電刺激運動皮質神經和肌源性反應的記錄顯示S(+)-氯胺酮依靠脊髓α運動神經元或其遠端的外周機制影響肌源性的運動誘發電位。

(潘志浩 薛張綱 )

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在慢性應用停止後不會造成痛覺過敏

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.

人類慢性應用阿片中止後會出現痛覺過敏,在慢性全身和鞘內用藥的齧齒類上複製模型。然而,現在不清楚這種鎮痛後的痛覺過敏是否是阿片類藥物所特有的。 2-腎上腺素能激動劑, dexmedetomidine (Dex),與阿片相類似,也是一種鎮痛藥,它與抑制腺苷酸環化酶相關聯的細胞表面受體相互作用以及調節離子通道的活性 。在這些研究中,我們首先確立了 Dex和嗎啡(MSO4)抗傷害性感受的量效曲線。C57Bl/6小鼠腹腔內用Dex MSO450%有效劑量分別為75 µg/kg5.2 mg/kg。用等效劑量,我們在不同組的小鼠上用Dex MSO4一天兩次共5天。之後可以發現有對這些藥物的耐受。在停藥後16–72 小時, MSO4-治療的小鼠顯示出熱和機械痛覺過敏。然而, Dex-治療小鼠並未顯示有撤藥有熱、機械閾值的改變。我們通過這一研究得出結論。阿片而非2-腎上腺素能激動劑在慢性應用停藥後出現了痛覺過敏。 結論: 在人體和其他一些動物中止應用阿片會出現痛覺過敏。然而,抗傷害的 dexmedetomidine在停用期間沒有出現這種痛覺過敏綜合征。

(張俊峰 薛張綱 )

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.

 

加強術後疼痛治療的干涉研究

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

這一研究,在一家一千張病床的醫院中急性疼痛服務執行的前後進行,描述了急性疼痛服務執行的過程。包含了護理、麻醉和手術科室。在這一研究,我們對用確定質量指標和應用質量工具的持續質量改善程式的結果進行評估。目前已經根據急性疼痛治療(多模式)的標準制定的質量程式來強化所有外科病人的疼痛解除。一項對護士關於術後疼痛知識的調查已經進行,用視覺類比評分來評價疼痛強度。護士和醫生都對關於術後疼痛的循證指南熟悉。三個連續的調查監測了整個過程,包含了2383個手術病人。以VAS為基礎的疼痛指針和鎮痛藥物的消耗在術後頭72小時進行記錄。在關於當前的鎮痛實踐的基礎調查進行之後,一個護士為基礎,麻醉師監控的APS進行。在兩個進一步的研究中,對用VAS評分表達的鎮痛的改善也進行了評價。完成了一本質量手冊並執行。在APS開始後疼痛評分有了一個重大的改善。 結論: 急性疼痛服務的執行, 包括用視覺類比評分進行疼痛評價,標準的多模式疼痛治療,持續的質量評價,改善的術後鎮痛。建立外科醫生,麻醉師和護士的隊伍是這一改善的先決條件。

(張俊峰 薛張綱 )

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).

 

在惡性高熱試驗中延長骨骼肌的生存期

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

 

咖啡因氟烷攣縮試驗是用於診斷惡性高熱易感性和顯性易感家族的唯一的有效試驗。儘管大多數的實驗室診斷試驗可以通過使用標準的對照樣品來檢查實驗室之間和實驗室內部的一致性,但對於咖啡因氟烷攣縮試驗來說這一方法不可行。診斷中心之間的距離和咖啡因氟烷攣縮試驗程式的時間限制 (5 h) 使得診斷中心不能分享組織樣品。在這一研究中,我們研究了不同的儲存條件下將骨骼肌的標準生存期延長到24小時。20MHS病人根據北美方法進行檢測。在標準的咖啡因氟烷攣縮試驗後,剩餘的肌肉樣品放入四個治療組其中之一。在組12, 肌肉在Krebs 緩衝液(pH 7.4)中在23°C–25°C (鉗-熱)4°C (鉗-冷)張力下保存。在組3 4, 肌肉條被切開,末端用絲線系上,從鉗上切下,放在23°C–25°C(游離-熱)和4°C(游離-冷)的 Krebs緩衝液中。在切除後2226小時測定各治療組對氟烷 (3%) 和咖啡因(0.5–32 mM) 的反應。在所有的病人中鉗-熱儲存組都準確地診斷了MHS結論:本文研究了不同的肌肉儲存條件在惡性高熱試驗中將肌肉生存期從5延長到24小時。在室溫張力下保存24小時肌肉仍然存活並正確診斷了MH的易感性。

(張俊峰 薛張綱 )

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.