Anesthesia & Analgesia

February 2003

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

间断或持续CO2充气法去除心胸外科伤口腔内的空气— 一种新的气体扩散器的实验研究

 (王士雷     庄心良  校)

Intermittent or Continuous Carbon Dioxide Insufflation for De-Airing of the Cardiothoracic Wound Cavity? An Experimental Study with a New Gas-Diffuser

Peter Svenarud, Mikael Persson, and Jan van der Linden

Anesth Analg 2003 96: 321-327.

 

冠状动脉旁路术中BIS指导麻醉用药

(忻纪华    王祥瑞 校)

Bispectral Index-Guided Anesthesia in Patients Undergoing Aortocoronary Bypass Grafting
Andreas Lehmann, Julia Karzau, Joachim Boldt, Elfi Thaler, Johannes Lang, and Frank Isgro

Anesth Analg 2003 96: 336-343.

 

肝素诱导的血小板减少症伴血栓形成症Ⅱ型患者在体外循环下行心脏手术:一组前瞻性病例分析

(   庄心良 校)

Patients with a History of Type II Heparin-Induced Thrombocytopenia with Thrombosis Requiring Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Observational Case Series

Gregory A. Nuttall, William C. Oliver, Jr, Paula J. Santrach, Robert D. McBane, Daniel B. Erpelding, Christina L. Marver, and Kenton J. Zehr

Anesth Analg 2003 96: 344-350.

 

活体肝移植的供体进行右半肝切除时的输血需要量和血液稀释

( 薛张纲 校)

Blood-Transfusion Requirements and Blood Salvage in Donors Undergoing Right Hepatectomy for Living Related Liver Transplantation

Jürgen T. Lutz, Camino Valentín-Gamazo, Klaus Görlinger, Massimo Malagó, and Jürgen Peters

Anesth Analg 2003 96: 351-355.

 

肝脏切除术和移植术中异氟醚和地氟醚的摄取

(忻纪华    王祥瑞 校)

Isoflurane and Desflurane Uptake During Liver Resection and Transplantation
Jan F.A. Hendrickx, Michael K. Dishart, and Andre M. De Wolf

Anesth Analg 2003 96: 356-362.

 

急性等容血液稀释中晶体液和胶体液替代的影响:凝血标记物的初步研究

(   庄心良 校)

The Influence of Crystalloid and Colloid Replacement Solutions in Acute Normovolemic Hemodilution: A Preliminary Survey of Hemostatic Markers

Stephanie B. Jones, Charles W. Whitten, George J. Despotis, and Terri G. Monk

Anesth Analg 2003 96: 363-368.

 

减少不必要的交叉匹配:病人特异性备血系统在预测输血方面比最大备血系统更准确

( 薛张纲校)

Reducing Unnecessary Cross-Matching: A Patient-Specific Blood Ordering System Is More Accurate in Predicting Who Will Receive a Blood Transfusion Than the Maximum Blood Ordering System

Thalia Palmer, Joyce A. Wahr, Michael O’Reilly, and Mary Lou V.H. Greenfield

Anesth Analg 2003 96: 369-375.

PEDIATRIC ANESTHESIA:

小儿用传统静脉针与可伸缩式静脉针的比较:是否更安全,更能保护谁?

(    庄心良   校)

Traditional Versus New Needle Retractable IV Catheters in Children: Are They Really Safer, and Whom Are They Protecting?

Charles J. Coté, Andrew G. Roth, Melissa Wheeler, Carolyn ter Rahe, Bronwyn R. Rae, Richard M. Dsida, and H. J. Przybylo

Anesth Analg 2003 96: 387-391.

 

小儿咪唑安定麻醉前给药:两种口服剂量方案在镇静评分及血浆浓度的比较

(潘志浩 薛张纲 校)

Midazolam Premedication in Children: A Comparison of Two Oral Dosage Formulations on Sedation Score and Plasma Midazolam Levels
Keith K. Brosius and Carolyn F. Bannister

Anesth Analg 2003 96: 392-395.

 

EMLA® 乳膏和阴茎背神经阻滞用于小儿包皮环切术后镇痛的研究

(王士雷   庄心良  校)

EMLA® Cream Versus Dorsal Penile Nerve Block for Postcircumcision Analgesia in Children

W.Y. Choi, M.G. Irwin, T.W.C. Hui, H.H. Lim, and K.L. Chan

Anesth Analg 2003 96: 396-399.

 

小儿吸入诱导期间七氟醚和笑气的摄取

(张俊峰 薛张纲 校)

Anesthetic Uptake of Sevoflurane and Nitrous Oxide During an Inhaled Induction in Children

Luis J. Goldman

Anesth Analg 2003 96: 400-406.

 

AMBULATORY ANESTHESIA:

门诊整形外科手术病人术后周围神经自控镇痛:电子泵和弹性泵的比较

(黄施伟 庄心良 校)

Patient-Controlled Perineural Analgesia After Ambulatory Orthopedic Surgery: A Comparison of Electronic Versus Elastomeric Pumps

Xavier Capdevila, Philippe Macaire, Philippe Aknin, Christophe Dadure, Nathalie Bernard, and Sandrine Lopez

(Technical Communication)

Anesth Analg 2003 96: 414-417.

 

TECHNOLOGY, COMPUTING, AND SIMULATION:

采用电荷耦合装置摄像机的气管插管设备

(张俊峰 薛张纲 校)

Endotracheal Intubation Device with a Charge Couple Device Camera (Review Article)

Hikaru Kohase, Hiroshi Sehata, Hirohito Inada, Yoko Ikeda, and Masahiro Umino

Anesth Analg 2003 96: 432-434.

 

ANESTHETIC PHARMACOLOGY:

固定肢体后兔使用米库溴铵与罗库溴铵的药效学研究

(    王祥瑞 校)

The Duration of Immobilization Causes the Changing Pharmacodynamics of Mivacurium and Rocuronium in Rabbits

Kyo S. Kim, Jeong W. Jeon, Myoung S. Koh, Jae H. Shim, Sang Y. Cho, and Jung K. Suh

Anesth Analg 2003 96: 438-442.

 

氧化亚氮和氙气可抑制表达于Xenopus卵的人({alpha}7)5烟碱型乙酰胆碱受体

 (赵雪莲  庄心良 校)

Nitrous Oxide and Xenon Inhibit the Human ({alpha}7)5 Nicotinic Acetylcholine Receptor Expressed in Xenopus Oocyte

Takahiro Suzuki, Kazuyoshi Ueta, Masahiro Sugimoto, Ichiro Uchida, and Takashi Mashimo

Anesth Analg 2003 96: 443-448.

 

异丙酚损害运动系统的中枢部分而非外周部分

(潘志浩 薛张纲 校)

Propofol Impairs the Central but Not the Peripheral Part of the Motor System

Michael H. Dueck, Aloys Oberthuer, Christoph Wedekind, Matthias Paul, and Ulf Boerner

Anesth Analg 2003 96: 449-455

 

芬太尼对活体鼠骨骼微循环的剂量依赖效应

(殷文渊    王祥瑞 校)

The Dose-Dependent Effects of Fentanyl on Rat Skeletal Muscle Microcirculation In Vivo

Zoë L. S Brookes, Nicola J. Brown, and Charles S. Reilly

Anesth Analg 2003 96: 456-462.

 

硬膜外注射消炎痛治疗椎板切除术后综合征:初步报告

(   庄心良 校)

Epidural Injections of Indomethacin for Postlaminectomy Syndrome: A Preliminary Report

J. Antonio Aldrete

Anesth Analg 2003 96: 463-468.

 

胃旁路术后多模式围术期镇痛与硬膜外镇痛的比较

(张俊峰 薛张纲 校)

A Comparison of Multimodal Perioperative Analgesia to Epidural Pain Management After Gastric Bypass Surgery

Roman Schumann, Scott Shikora, Jocelyn M. Weiss, Heinrich Wurm, Scott Strassels, and Daniel B. Carr

Anesth Analg 2003 96: 469-474.

 

肝硬化病人肝脏切除手术术后镇痛:单次硬膜外小剂量氯胺酮加吗啡的效果观察

(殷文渊    王祥瑞 校)

Postoperative Pain Relief After Hepatic Resection in Cirrhotic Patients: The Efficacy of a Single Small Dose of Ketamine Plus Morphine Epidurally

Pilar Taurá, Josep Fuster, Anabel Blasi, Julia Martinez-Ocon, Teresa Anglada, Joan Beltran, Jaume Balust, Javier Tercero, and Juan-Carlos Garcia-Valdecasas Anesth

Analg 2003 96: 475-480.

 

围术期ß-内啡呔免疫反应物释放入血和脑脊液对术后疼痛的作用重要吗?

( 庄心良 校)

Release of ß-Endorphin Immunoreactive Material Under Perioperative Conditions into Blood or Cerebrospinal Fluid: Significance for Postoperative Pain?

Reginald Matejec, Ralph Ruwoldt, Rolf-Hasso Bödeker, Gunter Hempelmann, and Hansjörg Teschemacher

Anesth Analg 2003 96: 481-486.

 

大鼠试验中鞘内导管位置的意义

(潘志浩 薛张纲 校)

The Significance of Intrathecal Catheter Location in Rats

Ildiko Dobos, Kalman Toth, Gabriella Kekesi, Gabriella Joo, Emese Csullog, Walter Klimscha, Gyorgy Benedek, and Gyongyi Horvath

Anesth Analg 2003 96: 487-492.

 

微球针压法不能减少术后疼痛或吗啡用量

(齐波    王祥瑞 校)

Minute Sphere Acupressure Does Not Reduce Postoperative Pain or Morphine Consumption

Masatomo Sakurai, Muhammad-Irfan Suleman, Nobutada Morioka, Ozan Akça, and Daniel I. Sessler

Anesth Analg 2003 96: 493-497.

ECOMONICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

协议中疼痛和危险对病人自愿参加临床试验的影响:一项随机试验

(黄施伟     庄心良 校)

The Influence of Protocol Pain and Risk on Patients’ Willingness to Consent for Clinical Studies: A Randomized Trial

Tanja A. Treschan, Thomas Scheck, Alexander Kober, Edith Fleischmann, Beatrice Birkenberg, Brigitte Petschnigg, Ozan Akça, Franz X. Lackner, Elisabeth Jandl-Jager, and Daniel I. Sessler

Anesth Analg 2003 96: 498-506.

 

怎样分配手术室时间增加效率:手术室没有充分利用手术室时间

(李绍清 薛张纲 校)

How to Release Allocated Operating Room Time to Increase Efficiency: Predicting Which Surgical Service Will Have the Most Underutilized Operating Room Time

Franklin Dexter, Rodney D. Traub, and Alex Macario

Anesth Analg 2003 96: 507-512.

美国作者在主要麻醉学期刊上发表文章的比例正在下降

(    王祥瑞 校)

Declining Proportion of Publications by American Authors in Major Anesthesiology Journals

Joseph W. Szokol, Glenn S. Murphy, Michael J. Avram, Martin Nitsun, Theodore M. Wynnychenko, and Jeffery S. Vender

Anesth Analg 2003 96: 513-517.

 

CRITICAL CARE AND TRAUMA:

肾上腺素抑制脂多糖(LPS)诱导人单核细胞释放巨噬细胞炎症蛋白-1{alpha} 蛋白—ß-肾上腺素能受体的作用

(王士雷 庄心良 校)

Adrenaline Inhibits Lipopolysaccharide-Induced Macrophage Inflammatory Protein-1{alpha} in Human Monocytes: The Role of ß-Adrenergic Receptors

Chi-Yuan Li, Tz-Chong Chou, Chian-Her Lee, Chien-Sung Tsai, Shih-Hurng Loh, and Chih-Shung Wong

Anesth Analg 2003 96: 518-523.

 

NEUROSURGICAL ANESTHESIA:

α2激动剂dexmedetomidineN-甲基-D天冬氨酸拮抗剂S(+)-氯氨酮在大鼠脑缺血再灌注后对细胞凋亡调节蛋白表达的影响

(李绍清 薛张纲 校)

The Effect of the {alpha}2-Agonist Dexmedetomidine and the N-Methyl-D-Aspartate Antagonist S(+)-Ketamine on the Expression of Apoptosis-Regulating Proteins After Incomplete Cerebral Ischemia and Reperfusion in Rats

Kristin Engelhard, Christian Werner, Eva Eberspächer, Monika Bachl, Manfred Blobner, Eberhard Hildt, Peter Hutzler, and Eberhard Kochs

Anesth Analg 2003 96: 524-531.

 

大鼠中{sigma}1-受体配合4-苯基-1-4-苯丁基)哌啶对缺血性神经保护而不改变多巴胺浓度

(邓羽宵    王祥瑞 校)

Potent {sigma}1-Receptor Ligand 4-Phenyl-1-(4-Phenylbutyl) Piperidine Provides Ischemic Neuroprotection Without Altering Dopamine Accumulation In Vivo in Rats

Toru Goyagi, Anish Bhardwaj, Raymond C. Koehler, Richard J. Traystman, Patricia D. Hurn, and Jeffrey R. Kirsch

Anesth Analg 2003 96: 532-538.

OBSTETRIC ANESTHESIA:

肼苯达嗪、尼卡地平、硝酸甘油和酚多帕对人脐动脉的舒张作用

(赵雪莲 庄心良 校)

The Vasodilatory Effects of Hydralazine, Nicardipine, Nitroglycerin, and Fenoldopam in the Human Umbilical Artery

Nobukazu Sato, Kenichi A. Tanaka, Fania Szlam, Atsushi Tsuda, Maria E. Arias, and Jerrold H. Levy

Anesth Analg 2003 96: 539-544.

 

REGIONAL ANESTHESIA:

高风险患者腹部手术后围术期硬膜外镇痛和后果

(李绍清 薛张纲 校)

Perioperative Epidural Analgesia and Outcome After Major Abdominal Surgery in High-Risk Patients

Philip J. Peyton, Paul S. Myles, Brendan S. Silbert, John A. Rigg, Konrad Jamrozik, and and Richard Parsons

Anesth Analg 2003 96: 548-54.

 

尿毒症患者和非尿毒症患者应用罗哌卡因腋路臂丛阻滞后的药物代谢动力学

(杨保仲 庄心良 校)

Pharmacokinetics of Ropivacaine in Uremic and Nonuremic Patients After Axillary Brachial Plexus Block

Pertti Pere, Merja Salonen, Mika Jokinen, Per H. Rosenberg, Pertti J. Neuvonen, and Juhani Haasio

Anesth Analg 2003 96: 563-569.

 

鞘内注射布比卡因或sameridine后所致的高二氧化碳和低氧通气反应

(嵇富海 薛张纲 校)

Hypercarbic and Hypoxic Ventilatory Responses After Intrathecal Administration of Bupivacaine and Sameridine

Åsa Österlund Modalen, Lars Westman, Eva Arlander, Lars I. Eriksson, and Sten G. E. Lindahl

Anesth Analg 2003 96: 570-575.

 

地塞米松对健康志愿者使用布比卡因微胶囊进行T9-11肋间神经阻滞量效反应

(    王祥瑞 校)

The Dose Response and Effects of Dexamethasone on Bupivacaine Microcapsules for Intercostal Blockade (T9 to T11) in Healthy Volunteers

Dan J. Kopacz, Peter G. Lacouture, Danlin Wu, Partha Nandy, Ruth Swanton, and Craig Landau

Anesth Analg 2003 96: 576-582.

 

GENERAL ARTICLES:

老年患者院内术后并发症的预后重要性,I. 长期幸存者

(    王祥瑞 校)

Prognostic Significance of Postoperative In-Hospital Complications in Elderly Patients. I. Long-Term Survival

Kawalpreet Manku, Peter Bacchetti, and Jacqueline M. Leung

Anesth Analg 2003 96: 583-589.

 

一项前瞻性盲法试验:上唇咬合试验(一项简单的新技术)和Mallampati分级预测气管插管难度的比较

(嵇富海 薛张纲 校)

Zahid Hussain Khan, Arash Kashfi, and Elham Ebrahimkhani

A Comparison of the Upper Lip Bite Test (a Simple New Technique) with Modified Mallampati Classification in Predicting Difficulty in Endotracheal Intubation: A Prospective Blinded Study

Anesth Analg 2003 96: 595-599.

 

ProsealTM喉罩与Laryngeal TubeTM喉管用于自主呼吸的麻醉病人时的比较

(   庄心良 校)

A Comparison of the ProSealTM Laryngeal Mask and the Laryngeal Tube® in Spontaneously Breathing Anesthetized Patients

Eduardo Figueredo, Miguel Martínez, and Teresa Pintanel

Anesth Analg 2003 96: 600-605.

 

氧化亚氮麻醉后Brandt导管减轻套囊漏气现象

(嵇富海 薛张纲 校)

The BrandtTM Tube System Attenuates the Cuff Deflationary Phenomenon After Anesthesia with Nitrous Oxide

Fujio Karasawa, Akira Takita, Tomohisa Mori, Isao Takamatsu, Yasushi Kawatani, and Takashi Oshima

Anesth Analg 2003 96: 606-610.

 

术中输注胶体液较晶体液能减少术后恶心呕吐和改善预后

(朱慧琛    王祥瑞 校)

Intraoperative Colloid Administration Reduces Postoperative Nausea and Vomiting and Improves Postoperative Outcomes Compared with Crystalloid Administration

Eugene W. Moretti, Kerri M. Robertson, Habib El-Moalem, and Tong J. Gan

Anesth Analg 2003 96: 611-617.

 

Abstracts

冠状动脉旁路术中BIS指导麻醉用药

Bispectral Index-Guided Anesthesia in Patients Undergoing Aortocoronary Bypass Grafting

Andreas Lehmann, MD*, Julia Karzau*, Joachim Boldt, MD*, Elfi Thaler, MD*, Johannes Lang*, and Frank Isgro, MD{dagger}

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Cardiac Surgery, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany

Anesth Analg 2003;96:336-343

随机前瞻性研究62例在两种不同麻醉深度下首次行CABG 术的病人的血流动力学,氧供,及可能出现的术中知晓和费用。通过BIS评价麻醉深度。所有的病人以舒芬太尼/咪唑安定麻醉。通过剂量的控制使32例病人的BIS维持于45-55BIS50组),另外32例病人的BIS维持于35-45BIS40组)。术前,术中和术后共监测6组数据。术后第三天向所有病人询问是否有术中知晓。两组的血流动力学和氧供无明显差异。BIS40组的舒芬太尼和咪唑安定的用量明显大于BIS50组(p<0.05),舒芬太尼分别为888+/-211ug, 514+/-99ug;咪唑安定分别为22.4+/-5.6mg, 16.6+/-3.7mgBIS50每位病人节约US$12.54 (P<0.05), 但必需支付额外的费用——BIS电极的费用US$18.15BIS40组拔管时间无明显延长(BIS4014.3+/-4.6hBIS50组,11.8+/-3.8h)。两组均未出现术中知晓。BIS可以减少麻醉用药节约费用而并不增加术中知晓的危险性。但是由于需支付BIS电极的费用,总的麻醉费用还是增加的。

(忻纪华    王祥瑞 校)

In this prospective, randomized study, we compared hemodynamics, oxygenation, possible intraoperative awareness, and costs in 62 patients undergoing first-time elective coronary artery bypass grafting at 2 different levels of anesthesia. Depth of anesthesia was assessed with bispectral index (BIS). All patients were anesthetized with sufentanil/midazolam. The dosage of sufentanil/midazolam was adjusted to achieve a BIS level of 45–55 in 32 patients (Group BIS 50), whereas in 30 patients a BIS level of 35–45 was intended (Group BIS 40). Data were obtained at six different time points before, during, and after surgery. All patients were asked about possible intraoperative awareness on the third postoperative day. There were no significant differences of any hemodynamic or oxygenation variables at any time between the two groups. BIS 40 patients received significantly (P < 0.05) more sufentanil (BIS 40, 888 ± 211 µg; BIS 50, 514 ± 99 µg) and midazolam (BIS 40, 22.4 ± 5.6 mg; BIS 50, 16.6 ± 3.7 mg) than BIS 50 patients. The reduction in anesthetic drugs used saved {euro}13.78/US$12.54 per patient (P < 0.05) in Group BIS 50, but one BIS electrode caused additional costs of {euro}19.95/US$18.15. Time to extubation was not significantly prolonged in Group BIS 40 (BIS 40, 14.3 ± 4.6 h; BIS 50, 11.8 ± 3.8 h). There was no explicit memory during anesthesia in either group. BIS-guided reduction of anesthetic medication saved costs and did not increase the risk of intraoperative awareness. However, total costs were increased by monitoring BIS, because of the BIS electrodes.


肝脏切除术和移植术中异氟醚和地氟醚的摄取

Isoflurane and Desflurane Uptake During Liver Resection and Transplantation

Jan F.A. Hendrickx, MD*, Michael K. Dishart, MD*, and Andre M. De Wolf, MD*,{dagger}

*Department of Anesthesiology and CCM, University of Pittsburgh School of Medicine, Pennsylvania; and {dagger}The Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Anesth Analg 2003;96:356-362

减少新鲜气流量时,为达蒸发罐的设定、维持恒定的呼气末麻醉剂浓度所需的时间更多的取决于吸入性麻醉药的摄取方式。但是,长时间手术吸入性麻醉剂的摄取方式无法量化。为此,本研究在肝脏切除术(LR, n=17)和肝脏原位移植术(OLT, n=18)中吸入异氟醚和地氟醚,采用液体喷射紧闭回路使呼气末浓度分别维持于0.8%4.5%。个体和平均的摄取曲线符合一系列代数公式,并比较时间方根和四次方。LR组在13小时;OLT组在138小时后的异氟醚和地氟醚的累积浓度与个体差异和每个病人的平均心输出量和心脏指数有关。平均摄取可以双指数公式表示:Viso(LR)=1.5×(1-e-t×0.525)+16.4×(1-e-t×0.00506) (R²=0.9996); Viso(OLT)=1.4+3.1×(1-e-t×0.472)+26.7×(1-e-t×0.00307) (R²=0.9994); Vdes(LR)=2.7×(1-e-t×0.763)+28.7×(1-e-t×0.00568) (R²=0.9984); Vdes(OLT)=1.4×(1-e-t×0.472)+26.7×(1-e-t×0.00307) (R²=0.9994)。摄取有明显的个体差异,但摄取变化和个体特征之间无关。当摄取率下降减慢后符合摄取模式。由于现有的模式和病人的特征均不能准确的预示每例病人的摄取,所以麻醉方法包括应用低流量麻醉都必须依赖持续的药物监测。但是,长时间手术麻醉气体的摄取率下降缓慢提示应用蒸发罐刻度的调整来维持呼气末浓度是有限的。

(忻纪华    王祥瑞 校)

When reducing fresh gas flows, the course of the vaporizer dial settings required to maintain a constant end-expired concentration of a potent inhaled anesthetic becomes more dependent on the uptake pattern of the inhaled anesthetic. However, the uptake  pattern of potent inhaled anesthetics during prolonged procedures remains poorly quantified. Therefore, we determined isoflurane and desflurane uptake (Viso and Vdes, respectively) during liver resection (LR, n = 17) and orthotopic liver transplantation (OLT, n = 18) using a liquid injection closed-circuit anesthesia technique maintaining the end-expired concentration at 0.8% and 4.5%, respectively. Individual and average uptake curves were fit to a series of mathematical functions and compared with the square root of time and four-compartment models. Cumulative doses of isoflurane and desflurane after 1 and 3 h in the LR group and after 1, 3, and 8 h in the OLT group were correlated with demographic variables and each patient’s average cardiac output and cardiac index. Average uptake was best described by a biexponential fit: Viso (LR) = 1.5 x (1 - e-t x 0.525) + 16.4 x (1 - e-t x 0.00506) (R2 = 0.9996); Viso (OLT) = 1.4 + 3.1 x (1 - e-t x 0.472) + 26.7 x (1 - e-t x 0.00307) (R2 = 0.9994); Vdes (LR) = 2.7 x (1 - e-t x 0.763) + 28.7 x (1 - e-t x 0.00568) (R2 = 0.9984); and Vdes (OLT) = 1.4 x (1 - e-t x 0.472) + 26.7 x (1 - e-t x 0.00307) (R2 = 0.9994). Uptake showed significant interindividual variability, and correlations between uptake variables and patient characteristics were inconsistent. The rate of uptake decreased more slowly then predicted by the uptake models. Because neither existing models nor patient characteristics accurately predict uptake in the individual patient, anesthesia techniques involving the use of low fresh gas flows will continue to have to rely on drug monitoring. However, the slowly decreasing rate of uptake during prolonged procedures suggests that the number of vaporizer adjustments to keep the end-expired concentration constant should be limited.


固定肢体后兔使用米库溴铵与罗库溴铵的药效学研究

The Duration of Immobilization Causes the Changing Pharmacodynamics of Mivacurium and Rocuronium in Rabbits

Kyo S. Kim, MD, PhD, Jeong W. Jeon, MD, Myoung S. Koh, MD, Jae H. Shim, MD, PhD, Sang Y. Cho, MD, PhD, and Jung K. Suh, MD, PhD

Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea

Anesth Analg 2003;96:438-442

临床上暂时还无法研究对于管状石膏固定的病人在使用米库溴铵和罗库溴铵时药效动力学的影响。在本实验中对56只分别使用米库溴铵和罗库溴铵麻醉的家兔进行剂量反应关系和神经肌肉阻断效果的比较,家兔持续固定肢体时间分别为246周。每10秒一次对双侧腓总神经同时给予四个成串刺激,同时监测胫前肌肉的收缩情况。对米库溴铵和罗库溴铵的剂量反应曲线研究发现,在对侧肢体尚未发生移动时,固定侧肢体先恢复移动。在固定肢体时间分别为0246周的家兔中使用米库溴铵的50%有效剂量分别为15.1±1.418.2±1.521.5±1.927.8±2.5μg/kg,而对侧肢体的数值并无改变。在固定肢体时间分别为0246周的家兔中使用罗库溴铵的50%有效剂量分别为48.1±4.156.2±4.264.8±4.975.1±5.5μg/kg,而对侧肢体的数值并无改变。虽然对侧肢体的数值并无改变,使用米库溴铵和罗库溴铵时,固定肢体的家兔与安慰剂组间加速度的恢复情况有明显差异。这一研究结果显示,管状石膏固定后引起的废用性肌萎缩会阻碍米库溴铵和罗库溴铵的起效,但并不影响对侧肢体。所以,在对这类病人建议使用健侧肢体进行肌松监测,以避免废用性肌萎缩对肌松效果的影响干扰临床用药。

(周    王祥瑞 校)

In the clinical setting, in patients with a cast, it is not known whether the monitoring of the neuromuscular paralysis induced by either mivacurium or rocuronium in the contralateral limb is the correct interpretation. We compared the dose-response relationships and the neuromuscular blocking effects of mivacurium and rocuronium in 56 anesthetized rabbits immobilized in a plaster cast for 2, 4, and 6 wk. Train-of-four stimuli were simultaneously applied every 10 s to both common peroneal nerves, and the force of contraction of both tibialis anterior muscles was measured. Immobilization was associated with a rightward shift of the mivacurium and rocuronium dose-response curves after the duration of the immobilized limb, whereas no shift occurred in the contralateral limb. The 50% effective dose values for 0, 2, 4, and 6 wk of immobilization in the immobilized limb of mivacurium were 15.1 ± 1.4, 18.2 ± 1.5, 21.5 ± 1.9, and 27.8 ± 2.5 µg/kg, respectively, and they were unchanged in the contralateral limb. The calculated 50% effective dose values for the correspondence of rocuronium were 48.1 ± 4.1, 56.2 ± 4.2, 64.8 ± 4.9, and 75.1 ± 5.5 µg/kg, respectively, and they were unchanged in the contralateral limb. The rabbits receiving mivacurium and rocuronium had a significantly accelerated recovery from neuromuscular blockade compared with the placebo group in the immobilized limb after the immobilized duration, whereas there were no differences in the contralateral limb. The results of the present study showed that immobilization disuse atrophy produced by casting led to the development of resistance to both mivacurium and rocuronium; however, no resistance was shown in the contralateral limb. The peripheral nerve stimulator could be applied on the nonimmobilized limb, which might be associated with a normal recording if either mivacurium or rocuronium was used as neuromuscular relaxants.


芬太尼对活体鼠骨骼微循环的剂量依赖效应

The Dose-Dependent Effects of Fentanyl on Rat Skeletal Muscle Microcirculation In Vivo

Zoë L. S Brookes, BSc, PhD, Nicola J. Brown, BSc, PhD, and Charles S. Reilly, FRCA, MD

Section of Surgical and Anesthetic Sciences, Division of Clinical Sciences, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom

Anesth Analg 2003;96:456-462

判断镇痛对微循环的影响很困难,因为手术往往需要麻醉。本研究利用背微循环腔(DMC)来比较意识控制状态静脉注射大剂量(LF)和小剂量(SF)芬太尼对微循环的影响。雄性Wister鼠被植入DMC来放大单层横纹肌。实验动物在恢复三周后,在随后的两周内使用活体微缩本(1次注射/周),在清醒的动物中观察微循环(t=0-30min),在注射一次诱导剂量后(t=40-45min),以下列一种方式逐步维持:LF (40–90 µg · kg-1 · h-1)SF(10–60 µg · kg-1 · h-1),或生理盐水(5–10 µg · kg-1 · h-1) (t =45–105 min)。用LF诱导后小动脉(<30 µm)扩张(23.6% ± 7.1%),而SF则收缩(-21.3% ± 7.1%) (P < 0.05)。在维持期间,随着LFSF剂量的增大,收缩程度也随之增大(-21.9% ± 4.0%) (t = 105 min, P < 0.05)。所有的动脉(10–120 µm)和静脉(15–250 µm)都可观察到相似的情况。因此DMC提供了一种观察微循环对芬太尼反应的优秀技术,在活体的鼠骨骼肌,静脉注射芬太尼产生显著的动脉收缩。

(殷文渊    王祥瑞 校)

Determining the effects of analgesia on the microcirculation is difficult because the surgery needed to allow in vivo observation often requires anesthesia. In this study, we used the dorsal microcirculatory chamber (DMC) to determine the effects of large (LF) and small (SF) dose IV fentanyl on the microcirculation compared with a conscious control. Male Wistar rats (130 g, n = 5) were implanted with the DMC to enclose a single layer of striated muscle. Animals were allowed 3 wk to recover from surgery and then, over the following 2 wk (1 infusion/wk) using intravital microscopy, the microcirculation was viewed in conscious animals (t = 0–30 min), followed by an induction bolus dose (t = 40–45 min), then a "step-up" maintenance infusion of one of the following, LF (40–90 µg · kg-1 · h-1), SF (10–60 µg · kg-1 · h-1), or saline (5–10 µg · kg-1 · h-1) (t = 45–105 min). Small arterioles (<30 µm) dilated (23.6% ± 7.1%) after induction with LF, but constricted (-21.3% ± 7.1%) with SF (P < 0.05). During maintenance, constriction increased with increasing dose of LF (-21.9% ± 4.0%) and SF (-16.7% ± 9.1%) (t = 105 min, P < 0.05). Similar patterns were observed in all arterioles (10–120 µm) and venules (15–250 µm). We conclude that the DMC provides an excellent technique for observing microcirculatory responses to fentanyl, and in rat skeletal muscle in vivo, an IV infusion of fentanyl produces significant constriction of arterioles.


肝硬化病人肝脏切除手术术后镇痛:单次硬膜外小剂量氯胺酮加吗啡的效果观察

Postoperative Pain Relief After Hepatic Resection in Cirrhotic Patients: The Efficacy of a Single Small Dose of Ketamine Plus Morphine Epidurally

Pilar Taurá, MD*, Josep Fuster, MD, PhD{dagger}, Anabel Blasi, MD*, Julia Martinez-Ocon, MD*, Teresa Anglada, MD, PhD*, Joan Beltran, MD*, Jaume Balust, MD*, Javier Tercero, MD*, and Juan-Carlos Garcia-Valdecasas, MD, PhD{dagger}

Departments of *Anesthesiology and {dagger}Surgery, Universitat de Barcelona, Hospital Clínic, Barcelona, Spain

Anesth Analg 2003;96:475-480

肝硬化病人接受肝脏手术时,术后镇痛仍是一项挑战。在研究中,我们评价硬膜外给予单次剂量吗啡混合小剂量氯胺酮作为术后镇痛的效果。104Child分级为“A”的肝硬化病人被随机分为两组:1)(MKGn=50)。硬膜外给予吗啡(3.5-5mg)加(氯胺酮20/30mg;2)硬膜外给予吗啡(3.5/5mg)(MGn=50)。记录镇痛的深度,副作用,精神和神经方面的紊乱,额外添加止痛剂和总体的镇痛质量。MKG组的平均镇痛时间较长(27.2±8h16.4±10h;P>0.05)。在MKG组中,术后14小时至研究结束的睡眠和术后12小时至研究结束的咳嗽的视觉模拟等级(VAS)评分开始显著降低。MKG组的额外镇痛剂需求也较少(P<0.05):到24小时,MKG组中只有10%的病人需要添加镇痛剂,而在MG组中为100%P = 0.003)。两组的副作用都较小。没有观察到精神副作用和神经紊乱。这些结果说明接受上腹部手术的ChildA”级肝硬化病人通过硬膜外给予单次剂量吗啡和小剂量氯胺酮作为术后镇痛是有效的。

(殷文渊    王祥瑞 校)

In cirrhotic patients undergoing hepatic surgery, postoperative analgesia remains a challenge. In this study, we evaluated the efficacy of a single dose of morphine combined with small-dose ketamine given epidurally for postoperative pain relief. One-hundred-four classification "Child A" cirrhotic patients were randomly assigned to two groups: 1) (MKG, n = 54): epidural morphine (3.5–5 mg) plus ketamine (20/30 mg); and 2) epidural morphine (3.5/5 mg) (MG, n = 50). The level of analgesia, side effects, psychomimetic and neurological disorders, additional analgesic needs, and overall quality of the analgesia were recorded. The mean duration of analgesia was longer in the MKG group (27.2 ± 8 h versus 16.4 ± 10 h; P < 0.05). In the MKG group, the visual analog scale (VAS) score began to be significantly lower from 14 h at rest and 12 h on coughing until the end of the study. The need for additional analgesia was also smaller in the MKG group (P < 0.05): at 24 h, only 10% of patients in the MKG group needed complementary analgesia, whereas in the MG group it was 100% (P = 0.003). Side effects were similar in both groups. Psychomimetic side effects and neurological disorders were not detected. These results suggest that postoperative analgesia provided by a single dose of epidural morphine with small-dose ketamine is effective in cirrhotic Child’s A patients having major upper abdominal surgery.


微球针压法不能减少术后疼痛或吗啡用量

Minute Sphere Acupressure Does Not Reduce Postoperative Pain or Morphine Consumption

Masatomo Sakurai, MD*, Muhammad-Irfan Suleman, MD*, Nobutada Morioka, MD*, Ozan Akça, MD*, and Daniel I. Sessler, MD*,{dagger}

*Outcomes Research® Institute and Department of Anesthesiology, University of Louisville, Louisville, Kentucky; and {dagger}Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria

Anesth Analg 2003;96:493-497

微球针压法已经有2000多年的应用历史,且目前在日本仍很盛行。与腹部手术密切相关的穴位就是在腹腔中穿行或起源的经络。我们假设微球针压法可以减少手术后疼痛,降低腹部手术镇痛药用量。本研究病人实施标准的地氟醚和芬太尼麻醉。术毕,病人被随机分为对照组和微球针压治疗组,在微球针压组,用微球针压内关、足三里、三阴交和公孙穴,并用棉纱覆盖针刺部位,以便病人不能确定自己的分组治疗情况。两组病人全部通过病人自控镇痛泵静注吗啡实施术后镇痛。在本实验取术后第一天晨病人的疼痛评分和吗啡用量作为研究数据。统计数据取中间值(第2575中位数)。共有53位病人(对照组30位、23位)完成了本实验研究。对照组和微球针压治疗组病人的吗啡用量(47mg41mg)和疼痛评分(29.5mm40mm)是相似的。因此腹部手术后用微球针压内关、足三里、三阴交和公孙穴并不能提供镇痛。微球治疗是针灸的一种形式。在本实验中为验证腹部手术后用微球针压与腹部手术相关的穴位是否可以减少病人疼痛和术后镇痛的吗啡用量。结果发现两组病人的恢复情况相似,疼痛评分和吗啡用量相似。

(齐波    王祥瑞 校)

Minute sphere acupressure has been used for more than 2000 yr and remains popular in Japan. The points most relevant to abdominal surgery are those associated with meridian flows crossing or originating in the abdomen. We tested the hypothesis that minute sphere therapy reduces pain and analgesic requirements after open abdominal surgery. Participating patients were given standardized desflurane and fentanyl anesthetic. On completion of surgery, they were randomly assigned to untreated control or minute sphere acupressure at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points. Each site was covered with bulky gauze dressings so that patients could not determine their assignments. Postoperative pain was treated with IV morphine via a patient-controlled analgesia pump. Our primary a priori end-points were pain and opioid consumption on the first postoperative morning. Data are reported as median (25th percentile, 75th percentile). Fifty-three patients (30 controls and 23 minute spheres) completed the study. Morphine requirements (47 mg [27, 58] vs 41 mg [25, 69]) and pain scores (29.5 mm [16, 59] vs 40 mm [22, 58]) were similar in the control and acupressure groups. These data provide an 80% power for detecting a 50% difference in morphine consumption at an {alpha}of 0.05. Minute sphere treatment at the Neiguan, Zusanli, Sanyinjiao, and Gongsun points thus failed to provide analgesia after abdominal surgery. Minute sphere therapy is a form of acupuncture. We tested whether minute spheres placed on three acupressure points relevant to abdominal surgery reduced pain and morphine requirements after abdominal surgery. Treatment and control patients received a similar covering. Neither pain nor morphine requirements were different between the groups.


美国作者在主要麻醉学期刊上发表文章的比例正在下降

Declining Proportion of Publications by American Authors in Major Anesthesiology Journals

Joseph W. Szokol, MD*,{dagger}, Glenn S. Murphy, MD*,{dagger}, Michael J. Avram, PhD{dagger}, Martin Nitsun, MD*,{dagger}, Theodore M. Wynnychenko, MD*,{dagger}, and Jeffery S. Vender, MD*,{dagger}

Departments of Anesthesiology, *Evanston Northwestern Healthcare, Evanston; and {dagger}Northwestern University Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2003;96:513-517

据报道称美国作者在医学期刊上发表的文章的比例有所下降。因此我们决定研究一下在19802000年期间美国作者在三个主要的麻醉学期刊上发表的文章是否有所改变。我们选择三个比较有影响力的期刊--《疼痛学》、《麻醉学》和《麻醉与镇痛》作为评估研究对象,回顾了三种期刊在19801985199019952000年发表的所有临床研究和基础科学研究论文。并用Χ2检验和最小平方线性回归分析法分析了文章出处(美国或国外)与发表年份之间的联系。因为国外作者在19802000年期间在主要麻醉专业期刊上发表的文章比例的增加与他们发表的文章数量的增加不成比例,所以美国作者发表文章的比例下地正在下降。在本研究中没有对发生这种变化的原因进行分析。我们认为其中可能包含了多种因素,包括:由于经济因素,美国作者将工作重点放在临床工作上而非实验研究上;美国作者将文章发表于除主要专业期刊外的其它期刊上以及国外作者投递的文章质量逐渐增加。

(    王祥瑞 校)

A decline in the proportion of articles published by American authors in medical journals has been reported. We therefore sought to determine whether the contributions of authors from the United States to the three leading anesthesia journals changed between the years 1980 to 2000. The journals Pain, Anesthesiology, and Anesthesia & Analgesia were selected for evaluation on the basis of their respective impact factors. All clinical studies and basic science studies published in the years 1980, 1985, 1990, 1995, and 2000 were evaluated. The country of origin of the lead author of each article was determined by two of the investigators. {chi}2 Tests and least squares linear regression analyses were used to determine associations between the source of publication (United States or abroad) and year of publication. The proportion of American publications in the leading anesthesia specialty journals was found to be decreasing over the period 1980–2000 because of an increase in the rate of publication from abroad that is disproportionate to the increase in the total number of publications in the journals over that time. The reasons for changes in anesthesia-related publications by American authors were not established by this study. The authors speculate that multiple factors are involved, including an increased emphasis on clinical care over research because of economic constraints, American publication in journals other than the leading specialty journals, and the increased quality of submissions from abroad.


大鼠中{sigma}1-受体配合4-苯基-1-4-苯丁基)哌啶对缺血性神经保护而不改变多巴胺浓度

Potent {sigma}1-Receptor Ligand 4-Phenyl-1-(4-Phenylbutyl) Piperidine Provides Ischemic Neuroprotection Without Altering Dopamine Accumulation In Vivo in Rats

Toru Goyagi, MD*, Anish Bhardwaj, MD*,{dagger}, Raymond C. Koehler, PhD*, Richard J. Traystman, PhD*, Patricia D. Hurn, PhD*, and Jeffrey R. Kirsch, MD*,{dagger}

Departments of *Anesthesiology and Critical Care Medicine and {dagger}Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland

Anesth Analg 2003;96:532-538

缺血性神经原保护的活性信号有{varsigma}-受体络合物提供,这个机制还不明确。儿茶酚胺出现在缺血性神经损伤的修复中。最近的研究表明{varsigma}-络合物调节了多巴胺原性的神经转运。在这个研究中,我们验证了一个假设。在缺血的纹状体中{varsigma}-受体配合4-苯基-1-4-苯丁基)哌啶(PPBP)能削弱细胞外多巴胺的增加。在受控制的生理条件下,一个微透析的探针进入到成年雄性Wistar大鼠的右侧尾状核(CP)中。大鼠接受了2小时的大脑中动脉栓塞(MCAO),用官腔内缝合技术。在双盲随机的条件下,大鼠被分为5组:组1n=8;盐水-盐水)在MCAO前持续用盐水注射30分钟,然后用盐水再灌注直到实验结束前;组2n=8;PPBP-PPBP)在MCAO前静脉注射PPBP30分钟然后用1μmmol/Kg/hPPBP;组3n=8;盐水-PPBP)在MCAO前静脉注射盐水然后用PPBP;组4n=4)手术方法(盐水-盐水);组5n=4)手术方法(PPBP-PPBP)。梗塞容量为22小时的灌注,用PPBP-PPBP和盐水- PPBP的大鼠与用盐水-盐水的大鼠有明显的区别。在MCAO发生的40分钟内微透析发现多巴胺的浓度上升3/4。多巴胺和它的代谢产物二羟基苯醋酸水平在MCAO的三组中基本相似。因此在大鼠中尾状核出现缺血改变时,PPBP能提供对缺血神经保护而没有多巴胺浓度的急剧改变。

(邓羽宵    王祥瑞 校)

The in vivo signaling of ischemic neuroprotection provided by {varsigma}-receptor ligands remains unclear. Catecholamines have been implicated in the propagation of ischemic neuronal injury, and previous in vitro studies suggest that {varsigma}ligands modulate dopaminergic neurotransmission. In this study, we tested the hypothesis that the potent {varsigma}1-receptor ligand 4-phenyl-1-(4-phenylbutyl) piperidine (PPBP) attenuates the increase of extracellular dopamine in ischemic striatum. Under controlled physiological conditions, a microdialysis probe was implanted in right caudoputamen (CP) complex of adult male Wistar rats. Rats were subjected to 2 h of transient middle cerebral artery occlusion (MCAO) by the intraluminal suture technique. In a blinded, randomized fashion, rats were divided into five treatment groups: Group 1 (n = 8; saline-saline) continuous IV infusion of saline vehicle 30 min before MCAO followed by saline at reperfusion until the end of the experiment; Group 2 (n = 8; PPBP-PPBP) IV PPBP 30 min before MCAO followed by 1 µmol · kg-1 · h-1 of PPBP; Group 3 (n = 8; saline-PPBP) IV saline before MCAO followed by PPBP; Group 4 (n = 4) surgical shams (saline-saline); and Group 5 (n = 4) surgical shams (PPBP-PPBP). Infarction volume at 22 h of reperfusion in the CP complex (percentage of ipsilateral structure) was significantly attenuated in rats treated with PPBP-PPBP (27.3% ± 9.1%) and saline-PPBP (27.8% ± 12.7%) compared with saline-saline (59.3% ± 7.3%) treatment. There was a three- to fourfold increase in dopamine concentrations in the microdialysates within 40 min of the onset of MCAO. Dopamine and its metabolites dihydroxy phenylacetic acid and homovallinic acid levels were similar among the three groups subjected to MCAO. Therefore, PPBP provides significant ischemic neuroprotection in the CP complex without altering the acute accumulation of dopamine in vivo during transient focal ischemia in the rat.


高危患者腹部术后硬膜外镇痛和预后

Perioperative Epidural Analgesia and Outcome After Major Abdominal Surgery in High-Risk Patients

Philip J. Peyton, MBBS, FANZCA, Paul S. Myles, MBBS, MPH, MD, FANZCA, Brendan S. Silbert, MBBS, FANZCA, John A. Rigg, MBBS, FANZCA, Konrad Jamrozik, MBBS, Dphil, FAFPHM, MFPHM, and and Richard Parsons, MSc, PhD

Department of Anesthesia, Austin and Repatriation Medical Centre, Melbourne, Australia

Anesth Analg 2003;96:548-54

在最近对915 位接受腹部手术的高危患者的调查中,我们发现患者术后接受硬膜外镇痛或静脉镇痛并发症没有明显区别,特别是呼衰。因此我们设计了一个实验,根据患者不同特点分成不同亚组观察他们是否能从硬膜外镇痛中得到益处。在对呼吸,心脏并发症较高的小组,接受主动脉手术的小组和硬膜外阻滞失败的小组和接受硬膜外镇痛小组的分析后发现并发症没有区别(P>0.05)。术后控制呼吸的时间有小的区别,其他组为6.5小时,硬膜外组为4.8小时;P=0.048。在术后ICU和住院时间上没有区别。我们发现没有证据证明围手术期使用硬膜外镇痛对接受腹部手术的生存率和死亡率有影响。

(邓羽宵    王祥瑞 校)

In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h; P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery.


地塞米松对健康志愿者使用布比卡因微胶囊进行T9-11肋间神经阻滞量效反应

The Dose Response and Effects of Dexamethasone on Bupivacaine Microcapsules for Intercostal Blockade (T9 to T11) in Healthy Volunteers

Dan J. Kopacz, MD*, Peter G. Lacouture, PhD{dagger}, Danlin Wu, PhD{ddagger}, Partha Nandy, PhD{ddagger}, Ruth Swanton, MPH§, and Craig Landau, MD||

*Virginia Mason Clinic, Seattle, Washington; {dagger}Magidom Discovery LLC, Westport, Connecticut; and {ddagger}Clinical Pharmacokinetics and ||Medical Research, §Purdue Pharma LP, Stamford, Connecticut

Anesth Analg 2003;96:576-582

能生物降解的含有布比卡因/地塞米松微胶囊在动物模型中可产生7——11天的镇痛疗效。本研究中应用布比卡因微胶囊麻醉并揭示增加剂量或加用地塞米松对其起效时间作用强度及作用时间的影响。浓度范围在0.3125%5.0%的微胶囊与0.25%的布比卡因水溶液相比较(双侧注射,三条肋间神经,每条2ml)(Part1)。Part2是比较2.5%的布比卡因微胶囊单侧神经阻滞用或不用地塞米松的效果。通过针刺,温觉及主观麻木感(0,没有麻木;10,完全麻木)来评估感觉阻滞效果。药效评估及布比卡因和地塞米松血浆药物浓度测量将持续96小时。当浓度超过0.3125%-5.0%范围时起效时间缩短及镇痛时间延长。(P0.02)。2.5%的布比卡因微胶囊起效时间与0.25%的布比卡因水溶液相似。使用微胶囊阻滞时间延长至少达96小时并显著长于布比卡因水溶液(P0.001)。使用2.5%的布比卡因微胶囊再加用地塞米松将延长对刺痛感觉阻滞的时间(P=0.03)。因此使用布比卡因和地塞米松混合微胶囊行肋间神经阻滞方法可行,在起效时间和作用时间上有明显的剂量相关效应。加用地塞米松增强了肋间神经阻滞麻醉的效果。

(    王祥瑞 校)

Biodegradable microcapsules containing bupivacaine/dexamethasone produce an anesthetic duration of 7–11 days in animal models. In this investigation, we explored the effect of increasing doses (Part 1) and the effect of including dexamethasone (Part 2) on the onset, density, and duration of analgesia and anesthesia produced by bupivacaine microcapsules. Concentrations ranging from 0.3125% to 5.0% in microcapsules were compared with 0.25% aqueous bupivacaine (bilateral injection, three intercostal nerves, 2 mL per nerve) (Part 1). Part 2 compared 2.5% microcapsules with or without the inclusion of dexamethasone by unilateral blockade. Sensory block was assessed by pinprick, temperature sensation, and subjective numbness (0, not numb; 10, totally numb). Pharmacodynamic assessments and plasma drug concentrations of bupivacaine and dexamethasone were measured for 96 h. The onset time was reduced and the duration of analgesia increased over the 0.3125%–5.0% dose range (P < 0.02). Onset with 2.5% microcapsules approximated that of 0.25% aqueous bupivacaine. Microcapsule block duration increased to at least 96 h and was significantly longer than aqueous bupivacaine (P < 0.001). Inclusion of dexamethasone increased the duration of pinprick anesthesia in 2.5% microcapsules (P = 0.03). We conclude that bupivacaine/dexamethasone microcapsules are well tolerated and demonstrate a dose-related effect in onset and duration of intercostal blockade. Inclusion of dexamethasone increases intercostal block anesthesia.


老年患者院内术后并发症的预后重要性,I. 长期幸存者

Prognostic Significance of Postoperative In-Hospital Complications in Elderly Patients. I. Long-Term Survival

Kawalpreet Manku, MBBS*, Peter Bacchetti, PhD{dagger}, and Jacqueline M. Leung, MD, MPH*

Departments of *Anesthesia and Perioperative Care, and {dagger}Epidemiology and Biostatistics, University of California, San Francisco, California

Anesth Analg 2003;96:583-589

为了确定院内术后并发症对其长期存活的影响,我们前瞻性地持续研究≥70岁经受非心脏手术的患者。我们分析可能的临床风险因素并评估它们与长时期的术后死亡率的联系。长时期存活的定义通过Kaplan-Meier方法确定。存活的多元化因素通过Cox比例风险模型来综合分析。存活的研究组还要与年龄及性别相匹配的普通美国人群作比较。我们对517名存活的住院患者进行研究。平均跟踪随访的时间为28.6±12.8个月。其中164名患者在随访的过程中被去除。有癌症病史(危险指数[HR]2.4495%置信区间[CI]1.78-3.38P0.0001〉,ASA)Ⅱ级(HR2.2795%CI1.61-3.21P0.0001〉,神经科疾病(HR1.5995%1.13-2.24P=0.008),年龄(每十年HR1.4295%CI1.11-1.81P=0.005),术后肺部并发症(HR2.4195%CI1.30-4.48P=0.005),和肾脏并发症(HR6.0795%CI2.23-16.52P0.0001〉都是明显降低生存时间的独立预示因素。与普通的美国人群作比较,那些有并发症的患者手术后3个月死亡率(相对普通人群HR7.3)比那些没有并发症的病人(HR2.9P=0.023)将显著增加。为改善老年患者围手术期的护理必须首先尽可能降低院内的术后并发症,尤其是那些累及肺或肾脏的并发症。

(    王祥瑞 校)

To determine the impact of in-hospital postoperative complications on long-term survival, we prospectively studied consecutive patients >=70 yr of age undergoing noncardiac surgery. Potential clinical risk factors were measured and evaluated for their association with the occurrence of long-term postoperative mortality. Long-term survival was determined by using the Kaplan-Meier method. Multivariate correlates of survival were analyzed with the Cox proportional hazards model. The survival of the study group was also compared with the age- and gender-matched general United States population. Five hundred seventeen patients who survived the initial hospitalization were studied. The mean follow-up duration was 28.6 ± 12.8 mo. One hundred sixty-four of 517 patients (31.7%) were deceased at the time of follow-up. A history of cancer (hazard ratio [HR] 2.44, 95% confidence interval [CI] 1.78–3.38, P < 0.0001), ASA physical status >II (HR 2.27, 95% CI 1.61–3.21, P < 0.0001), neurologic disease (HR 1.59, 95% CI 1.13–2.24, P = 0.008), age (HR 1.42 per decade, 95% CI 1.11–1.81, P = 0.005), postoperative pulmonary complications (HR 2.41, 95% CI 1.30–4.48, P = 0.005), and renal complications (HR 6.07, 95% CI 2.23–16.52, P < 0.0001) were significant independent predictors of decreased long-term survival. Compared with the United States population, patients with complications had a greater increase in mortality risk in the first 3 mo after surgery (HR 7.3 versus general population) than those without complications (HR 2.9, P = 0.023). An effort to improve perioperative care delivery to elderly surgical patients must include measures to minimize in-hospital postoperative complications, particularly those involving the pulmonary and renal systems.


术中输注胶体液较晶体液能减少术后恶心呕吐和改善预后

Intraoperative Colloid Administration Reduces Postoperative Nausea and Vomiting and Improves Postoperative Outcomes Compared with Crystalloid Administration

Eugene W. Moretti, MD, Kerri M. Robertson, MD, Habib El-Moalem, PhD, and Tong J. Gan, MB, FRCA, FFARCS(I)

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2003;96:611-617

何种液体输注是最佳的术中液体管理方案至今尚未有定论,既往研究表明术后死亡率与术中输液无明显关系。此外,胶体液或晶体液对术后恢复质量的影响尚未见报道。采用双盲前瞻性研究用胶体液及晶体液患者性术后恶心呕吐发生率及术后恢复情况。选择性非心脏手术患者随机给予6%羟乙基淀粉碱(HS-NS)、6%羟乙基淀粉平衡盐(HS-BS)或乳酸林格氏液(LR)作为术中输液,采用标准麻醉方法,血流动力学处理包括持续动脉压监测、心率及尿量在预定范围。术后发病率的调查在术后当日开始每日按基线进行。90位患者每30人为一组,HS-NSHS-BSLR的输注量分别为 1301+1079 mL, 1448+759 mL5946+1909 mLHS-NSHS-BS组的术后恶心呕吐发生率相较于另一组明显减少,使用止吐剂及产生剧烈疼痛、眶周水肿和复视的情况也相对较少。因此术中使用胶体液较晶体液能改善术后恢复质量。

(朱慧琛    王祥瑞 校)

The debate over colloid versus crystalloid as the best solution for intraoperative fluid resuscitation is not resolved. Published studies have shown that mortality is not related to the specific fluid used for resuscitation. In addition, the quality of postoperative  recovery between colloid and crystalloid has not been well investigated. In a prospective, blinded fashion, we investigated the effects of colloid and crystalloid resuscitation on nausea and vomiting and on the postoperative patient recovery profile. Patients undergoing major elective noncardiac surgery were randomized to receive 6% hetastarch in saline (HS-NS), 6% hetastarch in balanced salt (HS-BS), or lactated Ringer’s solution (LR) on the basis of a fluid administration algorithm. The anesthetic was standardized. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. A postoperative morbidity survey was performed at baseline and daily after surgery. Ninety patients participated in the study, with 30 patients in each group. The amounts of study fluid (mean ± SD) administered were 1301 ± 1079 mL, 1448 ± 759 mL, and 5946 ± 1909 mL for the HS-NS, HS-BS, and LR groups, respectively (P < 0.05, HS-NS and HS-BS versus LR). Both the HS-NS and HS-BS (colloid) groups had a significantly less frequent incidence of nausea and vomiting, use of rescue antiemetics, severe pain, periorbital edema, and double vision. We concluded that intraoperative fluid resuscitation with colloid, when compared with crystalloid administration, is associated with an improvement in the quality of postoperative  recovery.


尿毒症患者和非尿毒症患者应用罗哌卡因腋路臂丛阻滞后的药物代谢动力学

Pharmacokinetics of Ropivacaine in Uremic and Nonuremic Patients After Axillary Brachial Plexus Block

Pertti Pere, MD, PhD*, Merja Salonen, MD*, Mika Jokinen, MD*, Per H. Rosenberg, MD, PhD*, Pertti J. Neuvonen, MD, PhD{dagger}, and Juhani Haasio, MD, PhD*

*Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland; and {dagger}Department of Clinical Pharmacology, University of Helsinki, Helsinki, Finland

Anesth Analg 2003;96:563-569

局部麻醉药对于尿毒症患者的效力和药物代谢动力学特征各家报道不一。本研究拟对此问题作进一步的探讨。29例尿毒症患者和28例非尿毒症患者接受了腋路臂丛神经阻滞,均给予罗哌卡因300 mg /50 mL。用药后24小时内取各时点的静脉血样,测定血浆总罗比卡因、血浆游离罗比卡因、罗哌卡因的代谢产物3-hydroxyropivacaine pipecoloxylidide (PPX)以及{alpha}1-酸性糖蛋白含量。神经阻滞效果两组相似,两组均无毒性反应发生。比较两组的各项指标,在尿毒症患者组,罗哌卡因血浆清除率较小,浓度-时间曲线(药-时曲线)下面积、3-hydroxyropivacaine PPX含量较高,血浆PPX含量增高可持续到用药后24小时,血浆{alpha}1-酸性糖蛋白浓度亦较高。用药后1小时和12小时,血浆中游离罗哌卡因所占比例较小,但游离罗哌卡因浓度在用药后12小时较大。尿毒症患者吸收入血液循环的罗哌卡因量增加。药物与AAG结合量增加,尿中代谢物排泄量减少,可能是导致罗哌卡因及其代谢物总血浆浓度增加的原因。

(杨保仲 译 庄心良 校)

Reports on the efficacy and pharmacokinetics of local anesthetics in uremic patients have been controversial. Our study involved 29 uremic and 28 nonuremic patients. We performed axillary block with ropivacaine 300 mg (50 mL). Venous blood samples were drawn for 24 h for assay of total and unbound plasma ropivacaine, 3-hydroxyropivacaine, pipecoloxylidide (PPX), and serum {alpha}1-acid glycoprotein (AAG). Block quality was similar in both groups. No toxicity occurred. Plasma clearance of ropivacaine was smaller and the area under the concentration-time curve of ropivacaine, 3-hydroxyropivacaine, and PPX larger in the uremic patients. The plasma concentration of PPX increased until 24 h in uremic patients whose AAG concentrations were also larger throughout the study. The free fraction of ropivacaine in plasma was smaller in the uremic group when measured 60 min and 12 h after the block, but the unbound concentration of ropivacaine was larger in the uremic group at 12 h. Enhanced absorption of ropivacaine into circulation, increased binding to AAG, and probably reduced urinary excretion of the metabolites lead to larger total plasma concentrations of ropivacaine and its main metabolites in uremic patients.

 

 小儿用传统静脉针与可伸缩式静脉针的比较:是否更安全,更能保护谁?

Traditional Versus New Needle Retractable IV Catheters in Children: Are They Really Safer, and Whom Are They Protecting?

Charles J. Coté, MD, DABA, FAAP*,{dagger}, Andrew G. Roth, MD, DABA, FAAP{ddagger}, Melissa Wheeler, MD, DABA, FAAP, DABPM{ddagger}, Carolyn ter Rahe, MD, DABA{ddagger}, Bronwyn R. Rae, MBBS, FANZCA, DCH (Lond), DABA{ddagger}, Richard M. Dsida, MD, DABA, FAAP{ddagger}, and H. J. Przybylo, MD, DABA, FAAP{ddagger}

*Department of Anesthesiology and Pediatrics, Feinberg Medical School, Northwestern University; and Departments of {dagger}Pediatric Anesthesiology and {ddagger}Anesthesiology, Children’s Memorial Hospital, Northwestern University Medical School, Chicago, Illinois

Anesth Analg 2003 96: 387-391

 

目的:研究新型可伸缩式静脉针是否可以减少针刺造成的损伤。方法:前瞻性地收集传统的静脉针(JELCO)与新式静脉针(AngiocathTM AutoguardTM)的资料。每周随机指定所使用的静脉针的类型。比较两种穿刺针建立静脉通路的难度、使用的穿刺针数量以及在穿刺过程中血液溢出或溅出到皮肤、敷料、地板、衣物以及手术台的次数。结果:20天内,共对330位病人进行了473次静脉穿刺。没有发生针刺造成的损伤。在42例病人发生了77次血液溢出或溅出。新型穿刺针发生血液溢出或溅出的次数是传统穿刺针的4倍。如果是由主治医生而不是实习医生进行静脉穿刺的话,使用新型静脉穿刺针发生血液溢出或血液溅出的总事件数以及发生该事件的病人数明显多于传统穿刺针。结论:有经验的麻醉医生使用这种新穿刺针将使他们更多地受到血源性疾病的威胁。开业医生应该选择能够更有效地建立静脉通路同时受到血液污染机会最少的穿刺针。医疗机构也应该允许在该机构内工作的医生自己选择穿刺针。

(颜 涛 译   庄心良   校)

Retractable needle IV catheters are designed to reduce needle-stick injuries; their use is mandated by federal regulations. We undertook a prospective data collection with the "traditional" IV catheters (JELCO) versus the "new" (AngiocathTM AutoguardTM). Assignment of catheter type was randomized by week. Data collected included assessment of the difficulty of IV access; number of catheters used; and splatters or spills of blood on skin, linen, floor, clothing, and operating room table. There were 473 attempted insertions in 330 patients over 20 days. No needle-stick injuries occurred. Seventy-seven blood spills or splatters occurred in 42 patients. The number of splatters or spills was four times more with the new compared with the traditional catheters. There were significantly more total splatters or spills and patients who experienced splatters or spills with new catheters when they were placed by attendings but not when placed by trainees. Our study suggests that use of this technology by more experienced anesthesiologists may increase the risk of exposure of health care providers to blood-borne pathogens. Practitioners should choose the IV system that allows the most efficient venous access with the least potential for blood contamination. Hospitals should allow the choice to be made by the individuals using the devices.

 

ProsealTM喉罩与Laryngeal TubeTM喉管用于自主呼吸的麻醉病人时的比较

A Comparison of the ProSealTM Laryngeal Mask and the Laryngeal Tube® in Spontaneously Breathing Anesthetized Patients

Eduardo Figueredo, MD*, Miguel Martínez, MD{dagger}, and Teresa Pintanel, MD{ddagger}

Department of Anesthesiology, *Hospital Torrecardenas, Almería; {dagger}Hospital Costa del Sol, Málaga; and {ddagger}Hospital Germans Trias i Pujol, Barcelona, Spain

Anesth Analg 2003 96: 600-605.

 

目的:比较喉罩(PLMA)和喉管(LT)气道在自主呼吸的麻醉病人中的使用。方法:在这项多中心随机研究中,比较ProsealTM喉罩气道(PLMA)和Laryngeal TubeTM喉管(LT)置管的难度、置管后血流动力学的反应、通气质量以及是否可以实现“不用手的麻醉”。在保留自主呼吸行短时间外科手术的病人还观察了术后咽喉部不适的发生率。在芬太尼和丙泊酚诱导后,分别给70ASAⅠ-Ⅱ级的病人(每组35位)使用上述通气道。结果:PLMALT的一次成功率高(分别为77%51%P< 0.05),但是尝试三次后两者的成功率相似(分别为100%和97%)。麻醉学家认为PLMA的置入更容易(P< 0.001)。PLMA的呼气潮气量比LT大(分别为404.9mL328.4mLp< 0.005),使用PLMA的病例更容易达到“不用手的麻醉”(分别为32例和21例;p< 0.004)。对于使用LT的病人采用改变体位的方法纠正通气不足并不总是完全有效(13例中5例不完全有效)。两组间病人不能耐受、喉咙痛、吞咽困难和/或发音困难的发生率没有差别。结论:对于没有使用肌松药的病人,PLMA置管更容易,使用更可靠。

(颜 涛 译  庄心良 校)

In this multicenter, randomized study, we compared ease of insertion, postinsertion hemodynamic repercussion, quality of ventilation, and the capacity to achieve a "hands-free" anesthesia delivery between two new devices: the ProSealTM laryngeal mask airway (PLMA) and the Laryngeal Tube® (LT). The incidence of postoperative laryngopharyngeal discomfort was examined after short surgical interventions in spontaneously breathing patients. After induction with fentanyl and propofol, the respective airways were inserted into 70 adult ASA physical status I and II patients (35 patients in each group). First-attempt insertion success rates were more frequent for the PLMA (77% versus 51%; P < 0.05), but success rates were similar (100% versus 97%) after 3 attempts. The anesthesiologists considered that insertion of the PLMA was easier (P < 0.001). Expired tidal volume was larger with the PLMA (404.9 versus 328.4 mL; P < 0.005) and the ability to achieve hands-free ventilation was more frequent with the PLMA (32 versus 21 cases; P < 0.004). Positional maneuvers with the LT to correct ventilation deficiencies were not always completely effective (5 of 13). There were no differences in the incidence of intolerance, sore throat, dysphagia, and/or dysphonia between the two devices. We conclude that the PLMA showed greater ease of insertion and reliability than the LT for use in nonparalyzed anesthetized patients.

.

急性等容血液稀释中晶体液和胶体液替代的影响:凝血标记物的初步研究

The Influence of Crystalloid and Colloid Replacement Solutions in Acute Normovolemic Hemodilution: A Preliminary Survey of Hemostatic Markers

Stephanie B. Jones, MD*, Charles W. Whitten, MD*, George J. Despotis, MD{dagger}, and Terri G. Monk, MD{ddagger}

*Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas; {dagger}Departments of Anesthesiology, Pathology, and Immunology, Washington University School of Medicine; {ddagger}Department of Anesthesiology, University of Florida College of Medicine

Anesth Analg 2003 96: 363-368.

 

目的:急性等容血液稀释(ANH)是在手术失血开始前即刻收集血液作为一种自体血获得方法而得到推荐使用的血液保护技术。ANH期间,晶体和胶体液用于维持等容。但很少有资料来确定哪种特定液体的使用。为此,我们设计了一项前瞻性随机研究以确定是否替代液体的选择影响了各种凝血指标和围术期的失血。方法:40ASA 1-3级,在根治性前列腺切除术时拟行ANH的成年患者根据替代液体随机分为4组:(a)乳酸林格氏液;(b5%白蛋白;(c6%右旋糖酐70DEX);或(d6%羟乙基淀粉(HES)。标准全身麻醉诱导后,所有患者实行ANH至最终血红蛋白水平为 9 g/dL 。手术过程中在同一时间点进行全血计数、凝血酶元时间、部分凝血激酶时间、纤维蛋白原、V VIII因子水平、出血时间和凝血弹性描记术(TEG)测定 。结果:与基础值比较,在麻醉后监护室内乳酸林格氏液组和5%白蛋白组患者的部分激活凝血激酶时间缩短,VIII 因子水平升高。而在术前和麻醉后监护室,DEX组和HES组表现为TEG最大幅度的下降以及DEX组的TEG {alpha}()低于基础值。结论:VIII 因子水平,部分激活酶原时间和TEG测量的改变提示HESDEX可能减轻与手术相关的高凝状态。

(张 军 译  庄心良 校)

Acute normovolemic hemodilution (ANH), in which blood for autologous use is collected immediately before the onset of surgical blood loss, is a recommended autologous blood procurement technique for blood conservation. Both crystalloid and colloid replacement fluids have been used to maintain normovolemia during ANH, but few data are available to justify the use of a particular replacement fluid. Therefore, we designed a prospective, randomized study to determine if the replacement fluid choice affects various coagulation variables and perioperative blood loss. Forty adult patients, ASA physical status 1–3, scheduled for ANH during radical prostatectomy were randomly assigned to one of four replacement fluid groups: (a) Ringer’s lactate, (b) 5% albumin, (c) 6% dextran 70 (DEX), or (d) 6% hetastarch (HES). After the induction of a standardized general anesthetic, all patients underwent ANH to a final hemoglobin level of 9 g/dL. Complete blood count, prothrombin time, partial thromboplastin time, fibrinogen, factors V and VIII levels, bleeding time, and thromboelastography (TEG®) measurements were obtained at similar time points in the procedure. When compared with baseline, activated partial thromboplastin time decreased and factor VIII levels increased in the postanesthesia care unit in both the Ringer’s lactate and 5% albumin groups. The DEX and HES groups demonstrated a decrease in TEG® maximum amplitude between preoperative and postanesthesia care unit measurements and TEG® {alpha}(angle) was decreased from baseline in the DEX group. The changes in factor VIII, activated partial thromboplastin time, and TEG® measurements indicate that HES and DEX may attenuate the hypercoagulability related to surgery.


 围术期ß-内啡呔免疫反应物释放入血和脑脊液对术后疼痛的作用重要吗?

Release of ß-Endorphin Immunoreactive Material Under Perioperative Conditions into Blood or Cerebrospinal Fluid: Significance for Postoperative Pain?

Reginald Matejec*, Ralph Ruwoldt*, Rolf-Hasso Bödeker{dagger}, Gunter Hempelmann*, and Hansjörg Teschemacher{ddagger}

*Department of Anaesthesiology and Intensive Care Medicine, {dagger}Institute of Medical Informatics, and {ddagger}Rudolf-Buchheim-Institute for Pharmacology, Justus-Liebig-University, Giessen, Germany

Anesth Analg 2003 96: 481-486.

 

围术期ß-内啡呔免疫反应物(IRM)释放的功能尚有待阐明。我们对17例行骨科手术的患者分别在手术前(tA),仍在施行腰麻(tB) 但手术和麻醉结束之后,术后发生疼痛(tC)及术后一天(tD)测定静脉血中的ß-内啡呔IRM。疼痛严重程度由患者根据视觉模拟评分进行分级。结果患者均发生术后疼痛(tC),但在tA, tB, tD时间点时未感到疼痛。术前(tA)或发生术后疼痛(tC) ß-内啡呔IRM血浆水平显示明显高于术后但仍在进行腰麻(tB)或术后一天(tD)的测定水平。tA tC 时间点的ß-内啡呔IRM血浆水平与术后疼痛严重程度(tC)呈正相关。术后但仍行腰麻(tB)的脑脊液中ß-内啡呔IRM水平显著高于tA, tC, tD时间点的测定水平。脑脊液ß-内啡呔IRM的水平与疼痛严重程度没有相关性。结论:术后疼痛严重程度似与术前及发生术后疼痛时血浆中的ß-内啡呔IRM水平有关。这种物质的镇痛意义仍有待阐明。

                                                 (张 庄心良 校)

The function of ß-endorphin immunoreactive material (IRM) released under perioperative conditions remains to be clarified. In 17 patients undergoing orthopedic surgery, we determined ß-endorphin IRM in venous blood plasma and in cerebrospinal fluid (CSF) before surgery (tA); after termination of surgery and general anesthesia, but still under spinal anesthesia (tB); on occurrence of postoperative pain (tC); and 1 day after the operation (tD). Pain severity was rated by the patients by using a visual analog scale. Patients felt postoperative pain (tC), but they felt no pain at times tA, tB, and tD. ß-Endorphin IRM plasma levels before surgery (tA) or with postoperative pain (tC) proved to be significantly higher than levels determined just after surgery, but still under spinal anesthesia (tB), or those determined 1 day after the operation (tD); ß-endorphin IRM plasma levels at times tA and tC correlated positively with postoperative pain severity (tC). ß-Endorphin IRM CSF levels after surgery, but still under spinal anesthesia (tB), were significantly higher than levels determined at times tA, tC, or tD. No correlation was found between ß-endorphin IRM CSF levels and pain severity. In conclusion, postoperative pain severity appears to be related to ß-endorphin IRM levels in plasma before surgery as well as with postoperative pain; the analgesic significance of this material remains to be elucidated.

 

肝素诱导的血小板减少症伴血栓形成症Ⅱ型患者在体外循环下行心脏手术:一组前瞻性病例分析

Patients with a History of Type II Heparin-Induced Thrombocytopenia with Thrombosis Requiring Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Observational Case Series

Gregory A. Nuttall, MD*, William C. Oliver, Jr, MD*, Paula J. Santrach, MD{dagger}, Robert D. McBane, MD{ddagger}, Daniel B. Erpelding, CCP||, Christina L. Marver, MT (ASAP)||, and Kenton J. Zehr, MD§

Department of *Anesthesiology and {dagger}Laboratory Medicine, {ddagger}Division of Hematology, and §Division of Cardiovascular Surgery, ||Mayo Clinic, Rochester, Minnesota

Anesth Analg 2003 96: 344-350.

 

肝素诱导的血小板减少症伴血栓形成症(HITT)Ⅱ型是肝素治疗的一种致命性并发症,部分由特异性抗体介导,通常发生于治疗后5到10天。此类患者在体外循环(CPB)下行心脏手术时必须使用抗凝剂。我们报道了12例患者。其中6例术前抗体阴性,CPB期间使用肝素抗凝,患者经过顺利,未发生血栓形成。另外6例抗体阳性,使用水蛭素抗凝,并用ecarin凝血时间指导抗凝治疗。患者经过顺利,但出血量大,需输入多种血制品,而且CPB后重新打开纵膈的比例较高。

(轩   庄心良 校)

Heparin-induced thrombocytopenia with thrombosis (HITT) type II is a life-threatening complication of heparin therapy that most often occurs after 5–10 days of exposure to heparin. Anticoagulation is a significant concern for patients with HITT type II being prepared for cardiac surgery requiring cardiopulmonary bypass (CPB). We report a case series of 12 patients with a history HITT type II who underwent CPB and cardiac surgery. Six patients did not express the antibody that mediates HITT type II immediately before surgery. Heparin was used as the anticoagulant for the duration of CPB only, and all these patients did well without thrombotic complications. Six patients expressed the antibody that mediates HITT type II immediately before surgery. Hirudin was used as the anticoagulant for CPB in these patients. The ecarin clotting time was used to guide hirudin therapy during CPB. The patients receiving hirudin did well, but they had a large amount of bleeding, required transfusions of multiple allogeneic blood products, and had a frequent rate of reexploration of the mediastinum after CPB.

 

硬膜外注射消炎痛治疗椎板切除术后综合征:初步报告

Epidural Injections of Indomethacin for Postlaminectomy Syndrome: A Preliminary Report

J. Antonio Aldrete, MD, MS

Department of Anesthesiology, University of South Florida, College of Medicine, Tampa, and Aldrete Pain Care Center, Chipley, Florida

Anesth Analg 2003 96: 463-468.

 

硬膜外使用糖皮质激素可能发生不良反应,因而限制了激素的使用。由于部分非甾体类抗炎药具有中枢和脊髓的抗伤害作用,我们比较了硬膜外注射消炎痛(INM)和甲强龙(MTP)的效果。这是一项在流动性疼痛治疗中心进行的前瞻性比较研究。206例患者曾接受两次或多次腰椎板切除术,术后出现复发性腰痛(视觉模拟评分VAS>7)和神经根病,确诊为“椎板切除术后综合征”等病人,随机分为三组。组I(64 ),两次硬膜外注射冻干INM1 mg。组 II (60 ),注射INM2 mg。组III (82 ),注射MTP80 mg,三组注射间隔相同。所有药物均用3 mL 0.5%布比卡因稀释。用VAS的改变来评估疼痛的缓解,治疗前和治疗后两周用疼痛进展评分(PPS)分级记录患者的身体运动,情感体验和药物摄入。结果:每次注射均缓解疼痛(VAS<3)。 组 II患者二次注射后或组III患者镇痛程度高(P < 0.05)PPS总平均分在组 II二次注射后或组III有显著性差异。身体运动,情感体验和药物摄入均有改善,但无显著性差异。结论:组I和组 II患者中INM具有足够的镇痛作用,两次注射2 mg INM与注射80 mg MTP的作用水平相当。将来可以开发其他的非甾体类抗炎药硬膜外注射治疗椎板切除术后综合征。

(轩 泓 译  庄心良 校)

Since there have been side effects reported with the administration of corticosteroids epidurally, their application has been limited. Because some nonsteroidal antiinflammatory drugs have central and spinal antinociceptive actions, we have compared the effects of indomethacin (INM) given by the epidural route to methylprednisolone (MTP). This was a prospective, comparative study in an ambulatory pain care center. Two hundred six patients with recurrent low back pain (Visual Analog Scale >7) and radiculopathy after they had had 2 or more lumbar laminectomies with the diagnosis of "postlaminectomy syndrome" were randomly assigned to 1 of 3 groups. Group I (64 patients) was given 2 epidural injections of lyophilized INM 1 mg. Group II (60 patients) received 2 injections of 2 mg of INM at the same intervals. Group III (82 patients) was treated by 2 epidural injections of MTP 80 mg. In every case, the medication was diluted in 3 mL of 0.5% bupivacaine. Reductions of pain were assessed by changes in the Visual Analog Scale; physical activities, attitude, and medication intake were graded by the Pain Progress Score recorded before each treatment and 2 wk after the last. After each injection, all patients had pain relief to Visual Analog Scale <3. Increased analgesia (P < 0.05) was noted when a double dose of INM was used (Group II) or when 80 mg of MTP was given. The total average scores of the Pain Progress Score showed significant differences at the second injection in Groups II and III only. Physical activity, emotional attitudes, and medication intake were also improved but the changes were not statistically significant. In conclusion, in this group of patients, INM produced adequate analgesia in Groups I and II, with evidence suggesting that 2 mg of INM may produce a similar degree of pain relief as 80 mg of MTP after the second injection. Other nonsteroidal antiinflammatory drugs may be explored in the future for the same purpose.

 

氧化亚氮和氙气可抑制表达于Xenopus卵的人({alpha}7)5烟碱型乙酰胆碱受体

Nitrous Oxide and Xenon Inhibit the Human ({alpha}7)5 Nicotinic Acetylcholine Receptor Expressed in Xenopus Oocyte

Takahiro Suzuki, MD, Kazuyoshi Ueta, MD, Masahiro Sugimoto, MD, Ichiro Uchida, MD, PhD, and Takashi Mashimo, MD, PhD

Department of Anesthesiology, Osaka University Medical School, Japan

Anesth Analg 2003;96:443-448

 

目的:神经型烟碱样乙酰胆碱受体(nACh)属于配体门控离子通道,能调节中枢神经系统突触处的神经递质释放。因为,许多全麻药在临床应用浓度即可抑制他们功能,所以nACh可能为全麻药作用的靶目标而引起关注。已知一些全麻药可抑制({alpha}  7)5 nACh受体(属于神经型nACh受体的一种亚型),但氧化亚氮(N2O)和氙气(Xe)对其作用还没有报道。本文研究N2OXe({alpha}7)5 nACh受体的作用。方法:采用双电极电压钳技术,作者研究了N2OXe对表达于Xenopus卵上人({alpha}7)5 nACh受体的作用。结果:临床相关浓度的N2O Xe可逆性抑制Ach引起电流而且呈浓度依赖性。两种麻醉药对受体({alpha}7)5 nACh的抑制是非竞争性并且与膜钳制电压有关。结论:N2O Xe({alpha}7)5 nACh受体的抑制作用可能与他们的麻醉作用有关。

                                       (赵雪莲  译 庄心良 校)

The neuronal nicotinic acetylcholine (nACh) receptor is one of the ligand-gated ion channels that regulate the synaptic release of neurotransmitters in the central nervous system. Recently, neuronal nACh receptors have received attention as a potential target for general anesthetics because many general anesthetics inhibit their functions at clinical concentrations. Several general anesthetics are known to inhibit the homomeric ({alpha}7)5 nACh receptor, a subtype of neuronal nACh receptors, but the effects of two gaseous anesthetics, nitrous oxide (N2O) and xenon (Xe), remain unknown. Using the two-electrode voltage-clamping technique, we investigated the effects of N2O and Xe at the human ({alpha}7)5 nACh receptor expressed in Xenopus oocytes. At clinically relevant concentrations, N2O and Xe reversibly inhibited the ACh-induced currents of the ({alpha}7)5 nACh receptor in a concen-tration-dependent manner. The inhibitory actions of both anesthetics at the ({alpha}7)5 nACh receptor were noncompetitive and voltage-independent. Our results suggest that inhibition of the ({alpha}7)5 nACh receptor by N2O and Xe may play a role in their anesthetic effects.

     

肼苯达嗪、尼卡地平、硝酸甘油和酚多帕对人脐动脉的舒张作用

The Vasodilatory Effects of Hydralazine, Nicardipine, Nitroglycerin, and Fenoldopam in the Human Umbilical Artery

 Nobukazu Sato, MD*, Kenichi A. Tanaka, MD*, Fania Szlam, MMS*, Atsushi Tsuda, MD*,

Maria E. Arias, MD{dagger}, and Jerrold H. Levy, MD*

*Department of Anesthesiology, Emory University School of Medicine, Division of Cardiothoracic Anesthesia and Critical Care, Emory Healthcare, Atlanta; and {dagger}Atlanta Women’s Specialists, Atlanta, GA

Anesth Analg 2003;96:539-544

 

目的:研究肼苯达嗪、尼卡地平、硝酸甘油和酚多帕(一种多巴胺 D1-激动剂)对离体人脐动脉(HUA)的作用。方法:分别采取血压正常和妊高征患者(PIH)脐动脉。第一部分:先用血栓素A2拟似物(U46619; 10-8 M)使脐动脉环收缩,再将其浸入不同浓度酚多帕、肼苯达嗪、尼卡地平和硝酸甘油。第二部分:将脐动脉环预先分别浸入10-5 M哌唑嗪、10-5 M苯氧苄胺或空白液后再加入渐增剂量的酚多帕或多巴胺,并记录其收缩反应。结果:不论是血压正常或PIH患者,硝酸甘油、肼苯达嗪和尼卡地平均可舒张预先使用U46619的脐动脉环,并呈浓度依赖性。酚多帕和多巴胺在浓度>=10-3 M时使正常血压和PIH患者的脐动脉环收缩。苯氧苄胺可翻转酚多帕引起的脐动脉环收缩,二哌唑嗪无此作用。在此体外实验,硝酸甘油是预先使用U46619最强的HUA舒张剂,余次为尼卡地平和肼苯达嗪。此外,酚多帕只在高于治疗浓度时才引起HUA收缩。在血压正常和PIH两组间,酚多帕(P = 0.3534)、肼苯达嗪(P = 0.5514)、尼卡地平(P = 0.0615)和硝酸甘油(P = 0.7416)引起HUA血管反应无统计学差异。结论:常规治疗急性高血压的药物不会影响脐动脉张力。但大剂量酚多帕(>=10-3 M)可使脐动脉收缩。

                                          (赵雪莲 译 庄心良 校)

We studied the effects of hydralazine, nicardipine, nitroglycerin, and fenoldopam (a dopamine D1-agonist) on isolated human umbilical arteries (HUA) from patients classified as normotensive and with pregnancy-induced hypertension (PIH). Umbilical artery rings were contracted with the thromboxane A2 analog (U46619; 10-8 M) and then exposed to cumulative concentrations of fenoldopam, hydralazine, nicardipine, and nitroglycerin. Second, rings were preexposed to prazosin (10-5 M), phenoxybenzamine (10-5 M), or none, and the constriction responses to increasing doses of fenoldopam or dopamine were recorded. Nitroglycerin, hydralazine, and nicardipine produced concentration-dependent relaxation of U46619-preconstricted HUA segments from normotensive and PIH patients. Fenoldopam and dopamine induced umbilical artery constriction in both normal and PIH rings at concentrations >=10-5 M and >=10-3 M, respectively. Phenoxybenzamine, but not prazosin, pretreatment irreversibly abolished fenoldopam-induced contraction. In this in vitro study, nitroglycerin was the most potent vasodilator of the HUA constricted with U46619, followed by nicardipine and hydralazine. However, fenoldopam constricted HUA rings only at supratherapeutic concentrations. No significant differences of vascular responses to fenoldopam (P = 0.3534), nitroglycerin (P = 0.7416), nicardipine (P = 0.0615), and hydralazine (P = 0.5514) between rings from normotensive or hypertensive pregnant patients were shown.

 

门诊整形外科手术病人术后周围神经自控镇痛:电子泵和弹性泵的比较

Patient-Controlled Perineural Analgesia After Ambulatory Orthopedic Surgery: A Comparison of Electronic Versus Elastomeric Pumps

Xavier Capdevila, MD, PhD*, Philippe Macaire, MD{dagger}, Philippe Aknin, MD{dagger}, Christophe Dadure, MD*, Nathalie Bernard, MD*, and Sandrine Lopez, MD*

*Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier; and {dagger}Department of Anesthesia, Clinique du Parc, Lyon, France.

Anesth Analg 2003 96: 414-417

提示:门诊整形外科手术后,病人自控周围神经镇痛技术(Infusor LV5 弹性泵或两种电子泵)均为在家病人提供了有效的疼痛缓解。弹性泵由于技术操作问题少因而比电子泵的病人满意度为高。

                                           (黄施伟 译 庄心良 校)

 

IMPLICATIONS: Patient-controlled perineural analgesia techniques using Infusor LV5® disposable elastomeric or two types of electronic pumps provide efficient pain relief at home after ambulatory orthopedic procedures. Elastomeric pumps resulted in fewer technical problems and led to better patient satisfaction scores than Microjet® electronic pumps.

 

协议中疼痛和危险对病人自愿参加临床试验的影响:一项随机试验

The Influence of Protocol Pain and Risk on Patients’ Willingness to Consent for Clinical Studies: A Randomized Trial

Tanja A. Treschan, MD*, Thomas Scheck, BS*, Alexander Kober, MD*, Edith Fleischmann, MD*, Beatrice Birkenberg, MD*, Brigitte Petschnigg, RN*, Ozan Akça, MD§,||, Franz X. Lackner, MD*, Elisabeth Jandl-Jager, PhD{dagger}, and Daniel I. Sessler, MD{ddagger},§,||

*Department of Anesthesia and General Intensive Care, {dagger}University Clinic for Psychoanalysis and Psychotherapy, and the Ludwig Boltzmann Institute, University of Vienna, Austria; and §the Outcomes Research® Institute and ||Department of Anesthesiology, University of Louisville, Kentucky

Anesth Analg 2003 96: 498-506.

 

我们对与临床试验有关的危险性和不适会影响病人决定的假设进行了研究。同时,我们还评估了可能对患者做决定有影响的一些因素如对与试验有关的危险性和不适的理解、患者年龄、受教育程度以及心理状态。经IRB批准,而且参与者都相信被要求参与的试验是真实的,他们被安排进入三个虚拟的协议中:无危险或疼痛(对照组 n48),有疼痛但无危险(疼痛组 n51),或有危险但无疼痛(危险组 n51)。在会谈结束时病人听取了报告。我们主要的结果指标包括:(a)对与试验相关的疼痛或危险的理解 (b)病人对参与试验所感到压力的程度(c)参与的自愿性。尽管三组病人对试验的理解比较相似(对照组68%,疼痛组67%,危险组72%),参与的自愿性却差异明显(对照组64%,疼痛组35&,危险组26%P<0.001)。能理解危险和疼痛水平的患者中自愿参加者是未理解者的两倍(49%vs24&p0.003)。在同意参加有危险或疼痛试验的患者中有9%的人并不理解其中的危险性。那些感到压力的患者都不同意参与。因此,尽管原因出人意料,知情同意书的过程的确保护了患者。对试验的理解是缺乏的,但那些对其中危险性或疼痛不理解或感到有压力的患者很少同意参加。因此,很少有患者在一无所知的情况下会同意参加一些有危险性或疼痛的试验。

                                  (黄施伟 译    庄心良 校)

We tested the hypothesis that the risk or discomfort associated with a clinical trial influence patients’ decisions to participate. Simultaneously, we evaluated factors likely to influence patients’ decisions such as understanding of the risk and discomfort associated with the study, patient age, educational level, and psychological status. With IRB approval, participants, who believed they were being asked to participate in a real trial, were presented one of three sham protocols: no risk or pain (Control, n = 48), pain but no risk (Pain, n = 51), or risk but no pain (Risk, n = 51). Patients were debriefed at the end of the interview. Our major outcome measures were (a) understanding risk or pain associated with the proposed studies, (b) the extent to which patients felt pressured to participate, and (c) willingness to participate. Whereas understanding was similar in all groups (Control, 68%; Pain, 67%; and Risk, 72%), willingness to participate differed significantly (Control, 64%; Pain, 35%; Risk, 26%; P < 0.001). Patients who understood the level of risk or pain associated with the protocols were twice as likely to participate than those who did not (49% versus 24%; P = 0.003). Nine percent agreed to participate in the risky or painful protocols without understanding the risks involved. Patients who felt pressured did not agree to participate. Thus, the consent process protected patients, although for unexpected reasons. Understanding was poor, but patients who did not understand the risks or pain involved or who felt pressured rarely consented. Consequently, relatively few patients unknowingly agreed to participate in risky or painful studies.


间断或持续CO2充气法去除心胸外科伤口腔内的空气— 一种新的气体扩散器的实验研究

Intermittent or Continuous Carbon Dioxide Insufflation for De-Airing of the Cardiothoracic Wound Cavity? An Experimental Study with a New Gas-Diffuser

Peter Svenarud, MD*, Mikael Persson, MSc*,{dagger}, and Jan van der Linden, MD, PhD*

*Department of Cardiothoracic Surgery & Anesthesiology, Huddinge University Hospital, Huddinge, Sweden; and {dagger}Division of Medical Engineering, Department of Medical Laboratory Science & Technology, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2003 96: 321-327.

 

胸部伤口中吹入CO2是心脏手术时常用的去除心脏和大血管中的空气的方法。在一个心胸伤口模型,我们比较了一种新的充气仪器—gas-diffuser,与一种端口开放的管子,在稳态以及CO2气流在2.5, 5, 7.5 10 L/min时的空气置换的效果。我们也研究了这种仪器在CO2充气开始和中断后的空气置换效果以及开放胸膜对其造成的影响。在稳态时,在CO2>=5 L/mingas-diffuser 能产生有效的空气置换(遗留留空气<=0.65%),而端口开放的管子在所有CO2气流时均排气不足(遗留空气>=82%) (P < 0.001)。胸膜腔开放使伤口腔隙内空气置换的时间显著延长(P = 0.001)。在切开心脏和大血管前至少1min,心胸伤口应该进行气流速度为10 L/minCO2充气,并且在外科伤口关闭 前继续充至少气流速度超过5 L/minCO2气体。   

                                   (王士雷     庄心良  校)

Insufflation of carbon dioxide into the chest wound is used in open-heart surgery to de-air the heart and great vessels. In a cardiothoracic wound model, we compared the degree of air displacement achieved by a new insufflation device, a gas-diffuser, with that of a thin open-ended tube during steady-state and with carbon dioxide flows of 2.5, 5, 7.5, and 10 L/min. We also studied air displacement at the start of and after discontinuation of carbon dioxide insufflation with the gas-diffuser and evaluated the influence of an open pleura.  During steady state, the gas-diffuser produced efficient air displacement in the wound cavity model at carbon dioxide flows of >=5 L/min (<=0.65% remaining air), whereas the open-ended tube was inefficient (>=82% remaining air) at all studied carbon dioxide flows (P < 0.001). An open pleural cavity prolonged the time needed to obtain a high degree of air displacement in the wound cavity (P = 0.001). Carbon dioxide insufflation of the cardiothoracic wound cavity should be initiated at a carbon dioxide flow of 10 L/min at least 1 min before the incision of the heart and great vessels and should be continued at a carbon dioxide flow of at least 5 L/min until surgical closure.

 

EMLA® 乳膏和阴茎背神经阻滞用于小儿包皮环切术后镇痛的研究

EMLA® Cream Versus Dorsal Penile Nerve Block for Postcircumcision Analgesia in Children

W.Y. Choi, MB, BS*, M.G. Irwin, MB, ChB, FRCA, FHKAM{dagger}, T.W.C. Hui, MB, BS, FANZCA, FHKAM{dagger}, H.H. Lim, MB, BS, FHKAM{dagger}, and K.L. Chan, MB, BS, FRCS, FHKAM{ddagger}

*Department of Anaesthesia and Intensive Care, Pamela Youde Nethersole Eastern Hospital, Chai Wan; and Department of {dagger}Anaesthesiology and {ddagger}Surgery, Queen Mary Hospital, Hong Kong

Anesth Analg 2003 96: 396-399.

 

目的:以前瞻、随机、双盲的方式比较术前用EMLA®乳膏和布比卡因阴茎背神经阻滞用于小儿包皮环切术后镇痛的效果。方法:31例病人术前给予EMLA®乳膏,阴茎背神经注射生理盐水作为安慰剂;另外32例病人阴茎背神经用布比卡因阻滞,而用空白乳膏作为安慰剂。术后疼痛评价用改进的Eastern Ontario 疼痛评分,并记录术后第一次给予镇痛药的时间。结果:二组间病人术后疼痛评分无显著差异。布比卡因阴茎背神经阻滞组术后镇痛时间较EMLA®乳膏组长(P = 0.003)。二组病人均无全身和局部并发症,呕吐发生率很低。结论:术前用EMLA®乳膏是包皮环切术后镇痛的简便而有效的方法,而且副作用发生率低。

(王士雷 译  庄心良  校)

We conducted a prospective, randomized, double-blinded trial comparing preoperative application of EMLA® cream and sodium chloride solution dorsal penile block (n = 31) with placebo cream and bupivacaine dorsal penile nerve block (n = 32) for postcircumcision analgesia. Pain was assessed using modified Children’s Hospital of Eastern Ontario Pain Scale and the duration of block by the time to requirement of first dose of postoperative analgesic. There was no difference in Children’s Hospital of Eastern Ontario Pain Scale between the two groups, but bupivacaine dorsal penile nerve block resulted in longer analgesia (P = 0.003). There were no local or systemic complications related to either technique, and there was a very small incidence of vomiting. We conclude that preoperative application of EMLA® cream is an effective and simple method to produce postcircumcision analgesia with a very small incidence of adverse effects.

 

肾上腺素抑制脂多糖(LPS)诱导人单核细胞释放巨噬细胞炎症蛋白-1{alpha} 蛋白—ß-肾上腺素能受体的作用

Adrenaline Inhibits Lipopolysaccharide-Induced Macrophage Inflammatory Protein-1{alpha} in Human Monocytes: The Role of ß-Adrenergic Receptors

Chi-Yuan Li, MD, MS*, Tz-Chong Chou, PhD{dagger}, Chian-Her Lee, MD{ddagger}, Chien-Sung Tsai, MD§, Shih-Hurng Loh, PhD||, and Chih-Shung Wong, MD, PhD*

Departments of *Anesthesiology, {ddagger}Orthopedics, and §Surgery, Tri-Service General Hospital; and {dagger}Departments of Physiology, Graduate Institute of Medical Sciences and ||Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China

Anesth Analg 2003 96: 518-523.

 

目的:巨噬细胞炎症蛋白-1{alpha}(MIP-1{alpha})对调节白细胞的游走和功能有重要作用,并因而影响感染性炎症的发展过程。本文探讨肾上腺素对脂多糖诱导的人白细胞和THP-1产生MIP-1的作用。方法:在37°C、有或无肾上腺素以及特异性{alpha}- ß-受体激动剂和拮抗剂存在的条件下, 单核细胞与LPS在一起培养4h,以ELISA测定MIP-1{alpha}  的含量,并用RT_PCR监测其RNA的水平。结果:肾上腺素以剂量依赖的方式抑制LPS诱导的MIP-1{alpha}  的产生,这种作用可以被心得安阻断,但是不被酚托拉明阻断。特异性ß-肾上腺素能激动剂异丙肾上腺素对LPS诱导的MIP-1{alpha}有同样的抑制作用,而{alpha}-肾上腺素能激动剂苯肾上腺素的作用则微乎其微。此外,这种抑制作用与细胞内cAMP有关。肾上腺素对MIP-1{alpha} mRNA也有抑制作用。结论:肾上腺素对炎症和脓毒血症时MIP-1{alpha} 的产生有调节作用。

(王士雷 译 庄心良 校)

Macrophage inflammatory protein-1{alpha} (MIP-1{alpha}) has an important role in the development of inflammatory responses during infection by regulating leukocyte trafficking and function. Our study was conducted to investigate the effect of adrenaline on lipopolysaccharide (LPS)-induced MIP-1{alpha} production by human peripheral blood monocytes and human monocytic THP-1 cells. monocytes were incubated in vitro with LPS for 4 h at 37°C in the presence and absence of adrenaline and/or specific {alpha}- and ß-adrenergic receptor antagonists and agonists. The effects of adrenaline on MIP-1{alpha} synthesis were studied at the protein level by using enzyme-linked immunosorbent assays and at the messenger RNA level by using reverse transcriptase-polymerase chain reaction. Adrenaline inhibited LPS-induced MIP-1{alpha} production in a dose-dependent manner. The suppressive effect could be completely prevented by propranolol, but not by phentolamine. The specific ß-adrenergic agonist isoproterenol produced the same inhibitory effect on LPS-induced MIP-1{alpha} production, whereas the {alpha}-adrenergic agonist phenylephrine had a minimal effect. In addition, suppression of MIP-1{alpha} production was associated with an increase of intracellular cyclic adenosine monophosphate (cAMP) by the cell membrane-permeable cAMP analog dibutyryl-cAMP. Furthermore, we found that adrenaline inhibited LPS-induced MIP-1{alpha} messenger RNA expression. These findings suggest that adrenaline can modulate MIP-1{alpha} production in inflammatory diseases and sepsis.



高风险患者腹部手术后围术期硬膜外镇痛和后果

Perioperative epidural analgesia and outcome after major abdominal surgery in high-risk patients.
Peyton PJ, Myles PS, Silbert BS, Rigg JA, Jamrozik K, Parsons R.
Department of Anesthesia, Austin and Repatriation Medical Centre,Melbourne, Australia.

Anesth Analg 2003 96: 548-54.

 

对最近完成的915例高风险患者进行腹部手术的随机试验的最初分析,除呼吸衰竭发生率外,在围手术期硬膜外镇痛和静脉阿片剂镇痛并无差异。因此,我们选择一组能确实可从硬膜外镇痛获益的患者进行调查。结果:在硬膜外组合控制组间,呼吸及心脏或大动脉手术的风险增加并无差别,即使在硬膜外阻滞失败组也无差别(所有P > 0.05),仅有少许通气功能下降。长时住ICU和普通病房的患者间也无差异。在硬膜外镇痛试验组和日常硬膜外镇痛之间发生率也不相关。没有证据证明围术期硬膜外镇痛明显增加腹部手术后患病率或死亡率。

(李绍清 译 薛张纲 校)

In a primary analysis of a large recently completed randomized trial in 915 high-risk patients undergoing major abdominal surgery, we found no difference in outcome between patients receiving perioperative epidural analgesia and those receiving IV opioids, apart from the incidence of respiratory failure. Therefore, we performed a selected number of predetermined subgroup analyses to identify specific types of patients who may have derived benefit from epidural analgesia. We found no difference in outcome between epidural and control groups in subgroups at increased risk of respiratory or cardiac complications or undergoing aortic surgery, nor in a subgroup with failed epidural block (all P > 0.05). There was a small reduction in the duration of postoperative ventilation (geometric mean [SD]: control group, 0.3 [6.5] h, versus epidural group, 0.2 [4.8] h; P = 0.048). No differences were found in length of stay in intensive care or in the hospital. There was no relationship between frequency of use of epidural analgesia in routine practice outside the trial and benefit from epidural analgesia in the trial. We found no evidence that perioperative epidural analgesia significantly influences major morbidity or mortality after major abdominal surgery.
 

α-2激动剂dexmedetomidineN-甲基-D天冬氨酸拮抗剂S(+)-氯氨酮在大鼠脑缺血再灌注后对细胞凋亡调节蛋白表达的影响

The effect of the alpha 2-agonist dexmedetomidine and the N-methyl-D-aspartate antagonist S (+)-ketamine on the expression of apoptosis-regulating proteins after incomplete cerebral ischemia and reperfusion in rats.
Engelhard K, Werner C, Eberspacher E, Bachl M, Blobner M, Hildt E, Hutzler P, Kochs E.
Klinik fur Anaesthesiologie, Technische Universitat Munchen, KlinikumRechtsderIsra,Munich,Germany.

Anesth Analg 2003 96: 524-531.

 

这个研究,目的是调查神经蛋白dexmedetomidine S(+)-ketamine是否参与原凋亡蛋白(Bax and p53)和抗凋亡蛋白(Bcl-2 and Mdm-2)的调节。异氟醚诱导大鼠,试验开始后停异氟醚,然后随机三组给药,一组用芬太尼和笑氧混合气加100微克/千克dexmedetomidine在缺血前30min腹膜内给药(n = 8), 二组1 mg x kg(-1) x min(-1) of S(+)-ketamine 和氧空气混合(n = 8),三是芬太尼和笑氧混合气(n = 8)。所有处理组均通过单侧颈动脉阻塞和出血至低血压到30-35 mm Hg诱发缺血(30min)。再灌注4小时后取出脑组织,通过荧光免疫和西氏污点法分析凋亡调节蛋白表达。结果与佯装处理组(n = 8)比较。脑缺血再灌注后,与dexmedetomidine S(+)-ketamine处理组相比,Bax相关蛋白浓度增加110%,与佯装处理组(n = 8)比较,增加140%。Dexmedetomidine处理动物内Bcl-2 and Mdm-2比控制组大(各自为68%,210%),或与佯装处理组比较(各自为110%,180%)。因此,先前研究提示dexmedetomidine S(+)-ketamine在原凋亡蛋白和抗凋亡蛋白平衡调节的神经保护特性可能存在。

(李绍清 薛张纲 校)

In this study, we investigated whether the neuroprotection previously seen with dexmedetomidine or S (+)-ketamine involves regulation of proapoptotic (Bax and p53) and antiapoptotic (Bcl-2 and Mdm-2) proteins. Rats were anesthetized with isoflurane. After surgical preparation of isoflurane was discontinued, animals were randomly assigned to receive fentanyl and nitrous oxide (N (2) O)/oxygen plus 100 microg/kg of dexmedetomidine intraperitoneally 30 min before ischemia (n = 8), 1 mg x kg (-1) xmin (-1) of S (+)-ketamine and oxygen/air (n = 8), or fentanyl and N (2) O/oxygen (n = 8; control group). In all three treatment groups, incomplete cerebral ischemia (30 min) was induced by unilateral carotid artery occlusion and hemorrhagic hypotension to a mean arterial blood pressure of 30-35 mm Hg. Four hours after the start of reperfusion, the brains were removed, and the expression of apoptosis-regulating proteins was determined by using immunofluorescence and Western blot analysis. The results were compared with sham-operated animals (n = 8). After cerebral ischemia/reperfusion, the relative protein concentration of Bax was increased by 110% in control animals compared with the dexmedetomidine- and S (+)-ketamine-treated rats and by 140% compared with the sham-operated animals. In animals treated with dexmedetomidine, the expression of Bcl-2 and Mdm-2 was larger compared with control (68% and 210%, respectively) or sham-operated (110% and 180%, respectively) animals. Therefore, it is possible that the neuroprotective properties of dexmedetomidine and S (+)-ketamine seen in previous studies involve ultra-early modulation of the balance between pro- and antiapoptotic proteins.
 

怎样分配手术室时间增加效率:手术室没有充分利用手术室时间

How to release allocated operating room time to increaseefficiency: predicting which surgical service will have the most underutilized operating room time.
Dexter F, Traub RD, Macario A.
Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa 52242, USA.

Anesth Analg 2003 96: 507-512.


   在许多机构,外科医生和患者选择手术日,病例不被转移,工作人员最大化手术效率。当以充分安排了手术时间,如果有新病人需安排时,通过安排新病人在未充分利用的手术室时间,可提高手术室效率。后面的服务被认为是释放手术室分配时间。在这个研究中,我们分析了从中等到大医疗外科单位3年的手术室时间安排数据。理论上,有手术室时间释放服务是那些手术日有最大未充分利用时间的手术工作日。但是,当新的病例被安排是在那些已充分最大分配时间的服务而非未利用的手术时间时,我们研究显示手术效率仅轻度下降。相反,除了通过在最大分配手术室时间释放手术室时间外,在未安排手术时间中却显剧降低手术室效率。手术室管理人员释放手术室时间时,可考虑这个结果。

(李绍清 薛张纲 校)

 

At many facilities, surgeons and patients choose the day of surgery, cases are not turned away, and staffing is adjusted to maximize operating room (OR) efficiency. If a surgical service has already filled its allocated OR time, but has an additional case to schedule, then OR efficiency is increased by scheduling the new case into the OR time of a different service with much underutilized OR time. The latter service is said to be "releasing" its allocated OR time. In this study, we analyzed 3 years of scheduling data from a medium-sized and a large surgical suite. Theoretically, the service that should have its OR time released is the service expected to have the most underutilized OR time on the day of surgery (i.e., any future cases that may be scheduled into that service's time also need to be factored in). However, we show that OR efficiency is only slightly less when the service whose time is released is the service that has the most allocated but unscheduled (i.e., unfilled) OR time at the moment the new case is scheduled. In contrast, compromising by releasing the OR time of a service other than the one with the most allocated but unscheduled OR time markedly reduces OR efficiency. OR managers can use these results when releasing allocated OR time.

 

胃旁路术后多模式围术期镇痛与硬膜外镇痛的比较

A Comparison of Multimodal Perioperative Analgesia to Epidural Pain Management After Gastric Bypass Surgery

Roman Schumann, MD, Scott Shikora, MD, Jocelyn M. Weiss, MPH, Heinrich Wurm, MD, Scott Strassels, PharmD, and Daniel B. Carr, MD

Tufts University School of Medicine and Tufts-New England Medical Center, Boston, Massachusetts

Anesth Analg 2003 96: 469-474.

 

我们在114例全麻下行胃旁路手术的病人上对疼痛的强度,镇痛药物的消耗量,病人的满意程度,住院时间进行了比较。病人随机分为切口局麻药侵润加术后自控镇痛组 ( A),硬膜外麻醉和镇痛组 ( B)和术后病人自控镇痛组 (C)。所有病人都给以非固醇抗炎药。年龄,性别,体重指数,住院时间以及病人的满意程度在各组间都一致。组B0时间点和36 小时疼痛者最小,A组较多,C组最多。A组病人的疼痛评分在任何时间都比B组和C组低,但只在0, 12, and 36 小时时间点有显著差异。对于治疗有效的病人来说,侵润镇痛作为多模式方案的一部分成为一种替代硬膜外镇痛的简单,安全,廉价的方法。

(张俊峰 薛张纲 校)

We compared pain intensity, analgesic consumption, patient satisfaction, and length of stay in 114 patients undergoing gastric bypass surgery under general anesthesia. Patients were randomized to incisional local anesthetic infiltration plus postoperative patient-controlled analgesia (Group A), epidural anesthesia and analgesia (Group B), or postoperative patient-controlled analgesia (Group C). All received perioperative nonsteroidal antiinflammatory drugs. Age, sex, body mass index, length of stay, and patient satisfaction were equivalent in all groups. Pain at time 0 and 36 h was the smallest in Group B, greater in Group A, and greatest in Group C. Pain scores in a subset of Group A were lower at all times than in Groups B and C, but this difference was significant only at 0, 12, and 36 h. In responders, infiltration analgesia as part of a multimodal regimen offers a simple, safe, and inexpensive alternative to epidural pain control.

 

小儿吸入诱导期间七氟醚和笑气的摄取

Anesthetic Uptake of Sevoflurane and Nitrous Oxide During an Inhaled Induction in Children

Luis J. Goldman, MD, PhD

Department of Pediatric Anesthesiology, La Paz Children’s University Hospital, Madrid, Spain

Anesth Analg 2003 96: 400-406.

 

在健康小儿面罩诱导七氟醚和笑气的摄取有其特点。我们依靠两种不同的吸入笑气浓度对FA/FI增加速度的影响对浓度效应和第二气体效应进行评价。18412岁的小儿随机分为接受6%七氟醚与高浓度或低浓度的笑气的混合气体。呼气末和吸入的麻醉药浓度在诱导时持续评价。低浓度的笑气FA/FI 0.87 ± 0.09 ,而高浓度的笑气则为 0.92 ± 0.08 (P < 0.01)。两组在3, 45分钟差异显著。七氟醚的FA/FI 也增加但较笑气增加慢,而且仅仅在3分钟差异显著。笑气和七氟醚的FA FI的平衡都快速达到。与他们各自的血气分配系数一致,笑气的 FA/FI的增加较七氟醚快。在气体平衡曲线上,增加的笑气吸入浓度产生了曲线左移。用笑气证实的浓度效应和简单的第二气体效应可能可以用七氟醚的更高溶解性来解释。

(张俊峰 译 薛张纲 校)

The uptake of sevoflurane and nitrous oxide (N2O) was characterized during the mask induction of anesthesia in healthy children. We assessed concentration and second gas effects by determining the influence of two different inspiratory N2O concentrations on the rate at which the estimated alveolar concentration (FA) increased to the inspired gas concentration (FI). Eighteen children aged 4–12 yr old were randomly assigned to receive a 6% sevoflurane mixture with either a large or a small N2O concentration with balance O2. End-tidal and inspiratory concentrations of respiratory and anesthetic gases were continuously assessed during the induction. The FA/FI for the small N2O was 0.87 ± 0.09 (mean ± SD) and increased to 0.92 ± 0.08 for the large N2O (P < 0.01). Both groups differed significantly at 3, 4, and 5 min. The FA/FI for sevoflurane increased but more slowly than for N2O. The mean only differed significantly at 3 min. Equilibration between FA and FI for N2O and sevoflurane was attained rapidly. Consistent with their respective blood/gas partition coefficients, the FA/FI for N2O increased more rapidly than that for sevoflurane. Increasing FI-N2O produced a leftward shift in gas equilibration curves. A concentration effect was confirmed with N2O and a brief second gas effect, probably explained by the higher solubility of sevoflurane.

 

采用电荷耦合装置摄像机的气管插管设备

Endotracheal Intubation Device with a Charge Couple Device Camera

Hikaru Kohase, DDS, PhD*, Hiroshi Sehata, DDS, PhD, Hirohito Inada, DDS*, Yoko Ikeda, DDS*, and Masahiro Umino, DDS, PhD*

*Section of Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Sciences, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan; and Sehata Dental Clinic, Chiba, Japan

Anesth Analg 2003 96: 432-434.

 

我们发明了一种装有电荷耦合装置摄像机的经口插管设备,它提供了一个更加宽广的视野。我们用这种设备在62例牙科,口腔手术麻醉病人上应用。检验用这种系统进行气管插管所需的时间 。下面介绍这种系统的使用。带有CCD摄像机的装置插入口咽腔。口咽,包括会厌,声门,可以在监视器上看到。导管导引条经声带在装置旁插入气管。带CCD摄像机的装置撤出,留下导管导引条在气管内。气管导管用导引条作引导插入气管。测定整个过程的时间。平均费时41.2 s (最大155 s;最少14 s)。病人根据CormackLehane分级分组在这一过程费时无显著差异。用这一系统没有失败的插管。因为这一设备不但可以在监视器上看见喉,声门和声带,而且可以看到导引条的运动,当声带在监视器上看到,气管插管也就可以轻易进行。

(张俊峰 译 薛张纲 校)

We developed an orotracheal intubation device equipped with a charge couple device (CCD) camera, providing a wide field of vision. We used this device to perform endotracheal intubations in 62 anesthetized patients undergoing dental treatment and oral surgery. The time required to perform an endotracheal intubation with this system was examined. The use of this system is described below. The wand with the CCD camera was inserted into the oropharyngeal cavity. The oropharynx, including the epiglottis and glottis, could be visualized on the monitor screen. The tube introducer was inserted into the trachea through the vocal cords via the side tube of the wand. The wand with the CCD camera was withdrawn, leaving the tube introducer in the trachea. The endotracheal tube was then inserted into the trachea by using the tube introducer as a guide. The time required for the procedure was determined. The mean total time for the procedure was 41.2 s (maximum, 155 s; minimum, 14 s). There were no significant differences in this procedure when the patients were grouped according to the Cormack and Lehane classification. There was no failure to intubate using this system. Because the device can extensively visualize not only the larynx, glottis, and vocal cords, but also the movement of the tube introducer, on the monitor screen via the CCD camera, endotracheal intubation can be easily performed while the vocal cords are visualized on the monitor screen.

 

小儿咪唑安定麻醉前给药:两种口服剂量方案在镇静评分及血浆浓度的比较

Midazolam Premedication in Children: A Comparison of Two Oral Dosage Formulations on Sedation Score and Plasma Midazolam Levels

Keith K. Brosius, MD, and Carolyn F. Bannister, MD

Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia

Anesth Analg 2003 96: 432-434.

 

本研究目的在于比较现有的两种口服咪唑安定方案应用于小儿(210岁)外科手术前镇静评分和血浆浓度的差异。市售的口服糖浆咪唑安定制剂和现配置的静脉咪唑安定与糖浆混合的制剂(二者的等效咪唑安定浓度均为2 mg/mL)进行比较。ASA I–II的病人麻醉前都口服0.5 mg/kg的咪唑安定并随机分为两组:市售的糖浆组(组1)和混合制剂组(组2),给药后1530 min分别由双盲观测者评定并记录警觉/镇静评分。给药后45, 60, and 90 min测定血浆咪唑安定浓度。 组2病人给药后30 min 时的警觉/镇静评分中位数值显著(P < 0.03)低于组1病人(Group 1, 17; Group 2, 15),在给药后的三个测定时间组2 病人的血浆咪唑安定浓度均值显著高于组1病人(mean ± SD) (45 min: 63.1 ± 23.9 ng/mL, Group 2; 43.4 ± 19.6 ng/mL, Group 1; 60 min: 45.8 ± 18.2 ng/mL, Group 2; 30.8 ± 17.9 ng/mL, Group 1; 90 min: 28.9 ± 12.6 ng/mL, Group 2; 21.0 ± 8.9 ng/mL, Group 1) (P < 0.02)。因此,我们认为现配置的静脉咪唑安定与糖浆混合的制剂比等剂量的市售的咪唑安定糖浆可提供更为可靠的镇静效果及较高的血浆浓度。结论:现配置的静脉咪唑安定与糖浆混合的制剂在小儿外科病人麻醉前用药时比等剂量的市售的咪唑安定糖浆可提供更为可靠的镇静效果及较高的血浆浓度。

   (潘志浩 译 薛张纲 校)

 We compared two available oral formulations of midazolam with respect to sedation score and plasma midazolam levels in pediatric surgical patients 2–10 yr old. The commercially available oral syrup was compared with a mixture of the IV midazolam preparation in Syrpalta® syrup at an equivalent concentration of 2 mg/mL. ASA status I–II patients were randomly assigned to receive 0.5 mg/kg of either the commercial syrup (Group 1) or the prepared mixture (Group 2) as anesthetic premedication. Observer’s Assessment of Alertness/Sedation scores were obtained by a blinded observer at 15 and 30 min after drug administration. Plasma midazolam levels were acquired exactly 45, 60, and 90 min after administration. Group 2 patients had a significantly lower median Observer’s Assessment of Alertness/Sedation score (Group 1, 17; Group 2, 15) at 30 min (P < 0.03) and significantly higher mean plasma midazolam levels at all three acquisition times (mean ± SD) (45 min: 63.1 ± 23.9 ng/mL, Group 2; 43.4 ± 19.6 ng/mL, Group 1; 60 min: 45.8 ± 18.2 ng/mL, Group 2; 30.8 ± 17.9 ng/mL, Group 1; 90 min: 28.9 ± 12.6 ng/mL, Group 2; 21.0 ± 8.9 ng/mL, Group 1) (P < 0.02). We conclude that IV midazolam mixed in Syrpalta syrup yields more reliable sedation and correspondingly higher plasma levels than an equivalent dose of the commercially formulated and marketed preparation.

 

异丙酚损害运动系统的中枢部分而非外周部分

Propofol Impairs the Central but Not the Peripheral Part of the Motor System

Michael H. Dueck, MD, DEAA*, Aloys Oberthuer, MD*, Christoph Wedekind, MD{dagger}, Matthias Paul, MD, DEAA*, and Ulf Boerner, MD*

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Neurosurgery, University of Cologne, Cologne, Germany

Anesth Analg 2003 96: 449-455.

 

异丙酚产生一定程度的肌肉松弛效应。以往的试验要么只研究异丙酚对运动系统的中枢部分作用,要么就只研究其对外周部分的作用。该研究则同时评价其中枢(脊髓)和外周作用。15例病人全麻诱导和维持采用芬太尼、咪唑安定,不使用肌松药。我们监测脊髓的F 波(一种{alpha}运动神经元兴奋性的电生理变量)评价运动系统的中枢部分,测定直接肌肉电生理(M)反应和肌肉机械图评价异丙酚对神经肌肉传导或肌肉收缩力的外周作用。记录基础值后,3次静脉注射异丙酚(两次1 mg/kg 随后 2 mg/kg,每次注射间隔5-min)。与基础值相比,F波平均幅度(mean ± SD, 0.22 ± 0.13 mV)在分别3次注射异丙酚后显著降低,其中第一次(0.13 ± 0.08 mV; P < 0.05), 第二次(0.08 ± 0.09 mV; P < 0.05), 和第三次(0.03 ± 0.04 mV; P < 0.01)M波幅度和肌肉机械图信号则无改变。该资料显示单次注射异丙酚影响运动系统的中枢部分而非外周部分。结论:人单次静注异丙酚产生一定程度的肌肉松弛,我们的研究显示静注异丙酚后脊髓运动神经元兴奋性(通过F波分析测定)降低,肌电图信号延迟,对神经肌肉传导或肌肉收缩力(通过测定肌电图和肌肉机械图评价)则无影响。

(潘志浩 译 薛张纲 校)

Propofol provides some degree of muscle relaxation. Previous studies have investigated the effects of propofol on either the central or peripheral parts of the motor system. In this study, we simultaneously assessed both central (spinal) and peripheral effects. In 15 patients, general anesthesia was induced and maintained with fentanyl and midazolam. Neuromuscular blocking drugs were not administered. To investigate the central portion of the motor system, we monitored spinal F waves, an electrophysiologic variable of {alpha}-motoneuron excitability. Direct electrophysiologic muscle responses (M waves) and mechanomyography were studied to detect the peripheral effects of propofol on neuromuscular transmission or muscle contraction strength. After baseline recordings, 3 IV boluses of propofol (2 times 1 mg/kg followed by 2 mg/kg) were administered at 5-min intervals. Mean F-wave amplitudes were significantly reduced compared with baseline measurements (mean ± SD, 0.22 ± 0.13 mV) after the first (0.13 ± 0.08 mV; P < 0.05), second (0.08 ± 0.09 mV; P < 0.05), and third (0.03 ± 0.04 mV; P < 0.01) propofol injections. M-wave amplitudes and mechanomyography signals remained unchanged. Our data suggest that the central part, but not the peripheral part, of the motor system is impaired after bolus administration of propofol.

 

大鼠试验中鞘内导管位置的意义

The Significance of Intrathecal Catheter Location in Rats

Ildiko Dobos*, Kalman Toth, MD{dagger}, Gabriella Kekesi*, Gabriella Joo*, Emese Csullog, MD*, Walter Klimscha, MD{ddagger}, Gyorgy Benedek, MD, DSc*, and Gyongyi Horvath, MD, PhD*,§

*Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary; {dagger}Department of Orthopedics, Bacs-Kiskun County Hospital, Kecskemet, Hungary; {ddagger}Department of Anesthesiology and Intensive Care, University of Vienna, Vienna, Austria; and §Department of Physical Therapy, Faculty of Health Science, University of Szeged, Hungary

Anesth Analg 2003 96: 487-492虽然大鼠鞘内置管是一广泛采用的方法,但还无校准试验进行。该研究中我们研究了大鼠鞘内注射利多卡因后鞘内导管头端的位置与所观测到的运动感觉阻滞的相关性。通过爪撤回试验确定感觉阻滞的存在,运动阻滞通过观察后爪完全抛锚及后爪的握力评价。试验使用后,我们确定了导管头的位置。结果导管头在大鼠蛛网膜下腔横截面的各个方向。利多卡因注射 (100 or 500 µg/5 µL; n = 264 and 112, respectively)导致剂量依赖性的感觉和运动阻滞。100 µg 的利多卡因显示单侧效应,运动(r = 0.77)和感觉(r = 0.60右侧,r = 0.67左侧)阻滞的程度都与导管头的位置显著相关。 我们的资料显示在进行计划的实验前使用小剂量的利多卡因检测运动和/或抗伤害效应是一简单、可靠预测导管头端位置的方法。因此,我们认为导管的位置可能导致药效的单侧差异,尤其在使用小剂量药物并且需研究其双侧效应时。结论:该研究显示在进行计划的实验前使用小剂量的利多卡因检测运动和/或抗伤害效应是一简单、可靠预测导管头端位置的方法。我们认为导管的位置可能导致药效的单侧差异。

(潘志浩 译 薛张纲 校)

Although chronic intrathecal catheterization is a widely used method in rats, few calibration experiments have been performed. In this study, we investigated the correlation between the side position of the catheter tip and the side differences observed in the motor and sensory disturbances after intrathecal administration of lidocaine to a large number of rats. The existence of a sensory block was determined by the paw withdrawal test. The motor impairment was assessed by observing the complete clubbing of the hindpaw and measuring the hindpaw grip strength. After experimental use, we established the position of the catheter tip. The catheter tips were variously located in all directions of the transverse plane in the rat spinal subarachnoid space. Lidocaine administration (100 or 500 µg/5 µL; n = 264 and 112, respectively) led to dose-dependent motor and sensory disturbances. The effect of 100 µg of lidocaine exhibited side differences; i.e., the extents of both motor (r = 0.77) and sensory (r = 0.60 and r = 0.67 for the right and the left side, respectively) disturbances correlated significantly with the location of the catheter tip. Our data have shown that detection of the paralytic and/or antinociceptive effect of small-dose lidocaine before planned experiments is a simple and reliable method for prediction of the location of the catheter tip. We suggest that the position of the catheter might cause side differences in the drug effect, especially if small doses of drugs are administered and their effects are investigated on both sides.

 

减少不必要的交叉匹配:病人特异性备血系统在预测输血方面比最大备血系统更准确

Reducing Unnecessary Cross-Matching: A Patient-Specific Blood Ordering System Is More Accurate in Predicting Who Will Receive a Blood Transfusion Than the Maximum Blood Ordering System

Thalia Palmer, BS, Joyce A. Wahr, MD, Michael O’Reilly, MD, and Mary Lou V.H. Greenfield, MPH, MS

Department of Anesthesiology, University of Michigan Health System, Ann Arbor

Anesth Analg 2003 96: 369-375.

 

绝大多数的输血发生在手术室里。70年代外科最大备血表的采用减少了不必交叉匹配的血液数量,但是全国的交叉匹配输血的比率维持在2:1,我们做试验得出病人特异性备血系统(PSBOS)能够更加准确地预测可能发生的输血。在密歇根大学的医院里所有的进行择期手术(1999年2月至6月)的成年患者在手术前都进行了交叉配血,这些手术不包括复杂的手术,外科医生估计出术中可能的出血量和术后的红细胞压积,除了一些患有冠心病和ASAIII级以上的病人,输血的底线是红细胞压积21%,病人特异性备血系统的敏感性、特异性、阳性预测值和阴性预测值可以计算出来。我们分析了178个进行了术前交叉配血的患者,总共进行了69种不同的手术,有42个外科医生参与,只有16%的患者术中接受了输血,根据病人特异性备血系统预测的156个不需要输血的患者中139人没有输血,而预测的12个需要输血的患者中有11人输了血,通过计算得出敏感性是41%,特异性是93%,阳性预测值55%,阴性预测值89%。我们的结论是:由于根据病人特异性备血系统预测输血包括了病人和外科医生两方面的因素,所以它要比单纯依靠手术预测输血的最大备血表要准确。

薛张纲校)

Adoption of the Maximum Surgical Blood Ordering Schedule in the 1970s reduced the amount of blood unnecessarily cross-matched, but the national cross-match-to-transfusion ratio remains at approximately two-to-one. We tested the ability of a patient-specific blood ordering system (PSBOS) to more accurately predict potential operative transfusion. All adult patients who had blood cross-matched before surgery (February through June 1999) for elective operative procedures at the University of Michigan Hospital were identified. Complex surgeries were excluded. Surgeons estimated the expected blood loss for their surgeries, and the expected postoperative hematocrit was calculated using the patient’s blood volume, the surgeon-defined expected blood loss, and preoperative hematocrit. Lowest tolerated hematocrit was set at 21% except in patients with coronary artery disease or who were ASA physical status III or more (28%). Sensitivity, specificity, positive predictive value, and negative predictive value of the PSBOS were calculated. Our analysis included 178 cases in which blood was cross-matched before surgery, representing 69 different surgeries and 42 surgeons. Only 16% of patients received an intraoperative transfusion. Of the 156 patients that PSBOS predicted would not require an operating room transfusion, 139 were not transfused. Of the 21 patients PSBOS predicted would be transfused, 11 were. The sensitivity of the algorithm as tested was 41%, the specificity 93%, the positive predictive value was 55%, and the negative predictive value was 89%. We conclude that PSBOS, which includes patient and surgeon variables in transfusion prediction, is more accurate than the Maximum Surgical Blood Ordering Schedule, which uses only surgical procedure.

 

活体肝移植的供体进行右半肝切除时的输血需要量和血液稀释

Blood-Transfusion Requirements and Blood Salvage in Donors Undergoing Right Hepatectomy for Living Related Liver Transplantation

Jürgen T. Lutz, MD, DEAA*, Camino Valentín-Gamazo, MD{dagger}, Klaus Görlinger, MD*, Massimo Malagó, MD{dagger}, and Jürgen Peters, MD*

Klinik für *Anästhesiologie und Intensivmedizin, und {dagger}Allgemein- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Germany

Anesth Analg 2003 96: 351-355.

 

活体肝移植中供体的危险因素越来越受到重视,我们提供了44个供体的数据,重点讨论输血量和如何避免输异体血,评估的输血量(术前采集的自体血和异体血)包括术中做等容量血液稀释得到的血液、回收的红细胞和重新回输的量。在术前和术中规定的时间测量血红蛋白浓度和中心静脉压,术中出血量可以计算并且和切肝的时间、切掉肝的容量以及中心静脉压有关。在这期间没有发生麻醉诱发的并发症,有4个供体发生了大出血(出血量>2000),平均失血量是902±564 mL,允许的最小血红蛋白浓度是8.1±1.2 g/dL。有一位供体输了3个单位的异体血,30位供体输了他们术前采集的自体血、手术时等容量血液稀释得到的592±112 mL自体血和红细胞回收装置收集的421±333 mL洗涤红细胞。对于成年肝移植供体避免输注异体血,综合使用节约用血技术和有效地术后镇痛是非常重要的。当我们综合使用术中红细胞收集、术前自体血采集和血液稀释,绝大多数供体就可以避免输注库血。

薛张纲 校)

Living related liver donation for liver transplantation in adults including its risks is receiving increased attention. We present data from 44 liver donors focusing on transfusion requirements and avoidance of heterologous transfusion. The volume of blood transfused (both autologous from preoperative donation and heterologous) was assessed including that derived from intraoperative isovolemic hemodilution, cell-saver salvaged and retransfused blood. Hemoglobin concentration and central venous pressure were measured at specified time points before and during surgery. Intraoperative blood loss was calculated and correlated to the duration of parenchymal transsection, liver volume resected, and central venous pressure. There were no specific anesthesia-evoked complications. In 4 donors, major bleeding (>2000 mL) occurred. Blood loss averaged 902 ± 564 mL (SD), yielding a minimal mean hemoglobin concentration of 8.1 ± 1.2 g/dL. One donor received 3 U of heterologous blood and 30 donors received autologous blood from their preoperative donation. An average of 592 ± 112 mL of blood derived from perioperative acute isovolemic hemodilution was retransfused as was 421 ± 333 mL of washed red cells from the cell-saving system. Avoidance of heterologous blood transfusion, application of blood-saving techniques, and efficient pain management are crucial for adult living liver donors. Transfusion of banked blood can be avoided in most patients when intraoperative cell salvage, preoperative autologous blood donation, and intraoperative hemodilution are combined.

 

鞘内注射布比卡因或sameridine后所致的高二氧化碳和低氧通气反应

 Hypercarbic and hypoxic ventilatory responses after intrathecal administration of bupivacaine and sameridine.

Modalen AO, Westman L, Arlander E, Eriksson LI, Lindahl SG.

Department of Anesthesiology and Intensive Care, Karolinska Hospital and Institute, Stockholm, Sweden.

Anesth Analg 2003 96: 570-575

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Sameridine是一种新的药物,兼有局麻作用和阿片类药物的特性(部分为轻微的阿片受体拮抗作用)。用它进行鞘内注射,可为外科手术提供麻醉以及长时间的术后镇痛治疗。在这个双盲,平行对照的药效学试验中,持续观察鞘内注射布比卡因或sameridine24小时内对患者在安静或有高二氧化碳及低氧情况下的通气状况的影响。24名健康志愿者接受了25mgsameridine或者15mg布比卡因的鞘内注射。观测肺血流速度和相应的二氧化碳曲线图以评价通气状况。采用视觉模糊评分法(VAS)来评估镇静情况。两组的节段扩散与感觉和运动阻滞情况相似。布比卡因组在注射后有2.5-6小时潮气量降低,而sameridine组仅持续4小时。安静情况下两组间没有其它明显的通气差别。Sameridine组高二氧化碳(潮气量,平均吸气流量)和低氧(平均吸气流量)通气反应的发生率有轻微降低,而布比卡因组没有。因此得出结论:在24小时的观察期内,给健康志愿者鞘内注射sameridine或布比卡因对通气反应产生相似而较小的影响。

嵇富海 薛张纲 校)

Sameridine is a new compound with both local anesthetic and opioid properties (partial micro -opioid receptor agonist). It was intended for intrathecal administration to provide anesthesia for surgery and extended postoperative analgesia. In this double-blinded pharmacodynamic study with a two-parallel-group design, we investigated, during a 24-h period, the effects of intrathecal sameridine and bupivacaine on ventilation at rest and at ventilatory challenges during hypercarbia and hypoxia. Twenty-four healthy volunteers received either 25 mg of sameridine or 15 mg of bupivacaine intrathecally. Ventilation was measured by pneumotachography and in-line capnography. Sedation was rated by a visual analog scale. Segmental spread and development of motor and sensory block were similar in both groups. There was a decrease in tidal volume 2.5 to 6 h after injection in the bupivacaine group. This was seen only at 4 h in the sameridine group. There were no other major ventilatory differences between sameridine and bupivacaine during resting ventilation. Hypercarbic (tidal volume, mean inspiratory flow) and hypoxic (mean inspiratory flow) ventilatory responses were slightly decreased in the sameridine group, but not in the bupivacaine group. We conclude that intrathecal administration of sameridine or bupivacaine in healthy volunteers produces similar, minor effects on ventilatory responses over a 24-h observation period.

 

一项前瞻性盲法试验:上唇咬合试验(一项简单的新技术)和Mallampati分级预测气管插管难度的比较

A comparison of the upper lip bite test (a simple new technique) with modified Mallampati classification in predicting difficulty in endotracheal intubation: a prospective blinded study.

Khan ZH, Kashfi A, Ebrahimkhani E.

Department of Anesthesiology, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Anesth Analg 2003 96: 469-474.

 

探索用一项简单的测试取代Mallampati评分来评估有难度的或面临缺氧而未完成气管插管的病人情况。300名成年患者入选本试验。按 照以下标准对他们进行评估:1)根据Mallampati标准进行口咽评估;2)根据新的上唇咬和标准进行评估,组I:下切牙可咬至上唇的唇红缘以上;组II:下切牙可咬至上唇的唇红缘以下;组III:下切牙不能咬到上唇;3)根据Cormacks标准评估声门暴露情况。发生困难插管的比率为5.7%。上唇咬和试验比Mallampati评分显著显示出较高的专一性和准确性(P<0.001)。但是比较两种方法的敏感性、正确和错误预测的比值,没有显著差异(P>0.05)。由此得出结论:作为一项简单的测试,在预测困难气管插管方面,上唇咬和试验是可以接受的。

嵇富海 薛张纲 校)

We explored the possibility that a simple and single test could replace the modified Mallampati score for either a difficult or an unaccomplished tracheal intubation in an impending hypoxic patient. Three hundred adult patients were enrolled in this study. They were subjected to the following assessments: 1) oropharyngeal class according to the modified Mallampati criteria; 2) the new, upper lip bite criteria-class I = lower incisors can bite the upper lip above the vermilion line, class II = lower incisors can bite the upper lip below the vermilion line, and class III = lower incisors cannot bite the upper lip; and 3) laryngeal view grading according to Cormack's criteria. The incidence of difficult intubation was 5.7%. The upper lip bite test showed significantly higher specificity and accuracy than the modified Mallampati test (P < 0.001). Comparisons of sensitivity, positive and negative predictive values, between the two tests, however, did not reveal any significant differences (P > 0.05). In conclusion, the upper lip bite test is an acceptable option for predicting difficult intubation as a simple, single test.

 

氧化亚氮麻醉后Brandt导管减轻套囊漏气现象

The Brandt tube system attenuates the cuff deflationary phenomenon after anesthesia with nitrous oxide.

Karasawa F, Takita A, Mori T, Takamatsu I, Kawatani Y, Oshima T.

Department of Anesthesiology, National Defense Medical College, Tokorozawa, Saitama, Japan.

Anesth Analg 2003 96: 606-610.

 

Brandt导管在氧化亚氮麻醉时可以限制过高的套囊压力。但是缺乏数据来评估Brandt导管是否可以在中止一氧化氮麻醉后避免套囊漏气。在本试验中,以Brandt导管为试验组,Hi-Contour导管(Mallinckrodt,Athlone,爱尔兰)为对照组,分别记录67%一氧化氮麻醉时充满空气的套囊压力;如果套囊压力超过22mmHg,则抽出套囊内的空气。180分钟后用氧气来替代一氧化氮。两组的套囊压力均有明显下降,但是Brandt组的套囊压力恢复到最初的水平所需时间比对照组长(分别为76.5+/-35.2分钟和36.5+/-18.1分钟;P=0.03)。对照组发生漏气的概率要比Brandt组频繁(P=0.015);与对照组(从46.2+/-3.8%18.6+/-5.6%)相比,Brandt组(从6.6+/-1.2%3.4+/-0.9%套囊内氧化亚氮变化较小。因此,氧化亚氮麻醉后Brandt导管可以减轻套囊的漏气现象。有鉴于此,氧化亚氮麻醉时反复的套囊漏气可以引起中止氧化亚氮麻醉后的套囊漏气,从而存在导管漏气的危险。

嵇富海 薛张纲 校)

The Brandt tube system can limit excessive cuff pressure during nitrous oxide (N (2) O) anesthesia, but there is a lack of data assessing whether the Brandt tube system avoids cuff deflation after cessation of N (2) O administration. In this study, we recorded air-filled cuff pressures of the Mallinckrodt Brandt or Hi-Contour (control) tracheal tubes (Mallinckrodt, Athlone, Ireland) during 67% N(2)O anesthesia and the cuffs were aspirated if the cuff pressure exceeded 22 mm Hg; 180 min later, O(2) was substituted for N(2)O. The cuff pressure of both groups significantly decreased after N(2)O anesthesia but the time required for the cuff pressure to return to the initial pressure was longer in the Brandt group than in the control group (76.5 +/- 35.2 min and 36.5 +/- 18.1 min, respectively; P = 0.03). The incidence of air leaks was more frequent in the control group than in the Brandt group (P = 0.015); changes in intracuff N (2) O were small in the Brandt group (6.6 +/- 1.2% to 3.4 +/- 0.9%) compared with those in the control group (46.2 +/- 3.8% to 18.6 +/- 5.6%). Therefore, the Brandt tube system attenuates the cuff deflationary phenomenon after N (2)O anesthesia, whereas repeated cuff deflation during N(2)O anesthesia causes cuff deflation after cessation of N(2)O, resulting in a possible risk of air leaks.