Anesthesia & Analgesia

February 2003

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

間斷或持續CO2充氣法去除心胸外科傷口腔內的空氣— 一種新的氣體擴散器的實驗研究

 (王士雷     莊心良  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.

 

冠狀動脈旁路術中BIS指導麻醉用藥

(忻紀華    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.

 

肝素誘導的血小板減少症伴血栓形成症Ⅱ型患者在體外迴圈下行心臟手術:一組前瞻性病例分析

(   莊心良 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.

 

活體肝移植的供體進行右半肝切除時的輸血需要量和血液稀釋

( 薛張綱 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.

 

肝臟切除術和移植術中異氟醚和地氟醚的攝取

(忻紀華    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.

 

急性等容血液稀釋中晶體液和膠體液替代的影響:凝血標記物的初步研究

(   莊心良 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.

 

減少不必要的交叉匹配:病人特異性備血系統在預測輸血方面比最大備血系統更準確

( 薛張綱校)

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:

小兒用傳統靜脈針與可伸縮式靜脈針的比較:是否更安全,更能保護誰?

(    莊心良   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.

 

小兒咪唑安定麻醉前給藥:兩種口服劑量方案在鎮靜評分及血漿濃度的比較

(潘志浩 薛張綱 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® 乳膏和陰莖背神經阻滯用於小兒包皮環切術後鎮痛的研究

(王士雷   莊心良  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.

 

小兒吸入誘導期間七氟醚和笑氣的攝取

(張俊峰 薛張綱 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:

門診整形外科手術病人術後周圍神經自控鎮痛:電子泵和彈性泵的比較

(黃施偉 莊心良 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:

採用電荷耦合裝置攝像機的氣管插管設備

(張俊峰 薛張綱 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:

固定肢體後兔使用米庫溴銨與羅庫溴銨的藥效學研究

(    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.

 

氧化亞氮和氙氣可抑制表達於Xenopus卵的人({alpha}7)5煙鹼型乙酰膽鹼受體

 (趙雪蓮  莊心良 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.

 

異丙酚損害運動系統的中樞部分而非外周部分

(潘志浩 薛張綱 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

 

芬太尼對活體鼠骨骼微循環的劑量依賴效應

(殷文淵    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療椎板切除術後綜合征:初步報告

(   莊心良 校)

Epidural Injections of Indomethacin for Postlaminectomy Syndrome: A Preliminary Report

J. Antonio Aldrete

Anesth Analg 2003 96: 463-468.

 

胃旁路術後多模式圍術期鎮痛與硬膜外鎮痛的比較

(張俊峰 薛張綱 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.

 

肝硬化病人肝臟切除手術術後鎮痛:單次硬膜外小劑量氯胺酮加嗎啡的效果觀察

(殷文淵    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.

 

圍術期ß-內啡呔免疫反應物釋放入血和腦脊液對術後疼痛的作用重要嗎?

( 莊心良 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.

 

大鼠試驗中鞘內導管位置的意義

(潘志浩 薛張綱 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.

 

微球針壓法不能減少術後疼痛或嗎啡用量

(齊波    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:

協議中疼痛和危險對病人自願參加臨床試驗的影響:一項隨機試驗

(黃施偉     莊心良 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.

 

怎樣分配手術室時間增加效率:手術室沒有充分利用手術室時間

(李紹清 薛張綱 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.

 

美國作者在主要麻醉學期刊上發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:

腎上腺素抑制脂多糖(LPS)誘導人單核細胞釋放巨噬細胞炎症蛋白-1{alpha} 蛋白—ß-腎上腺素能受體的作用

(王士雷 莊心良 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:

α-2激動劑dexmedetomidineN-甲基-D天冬氨酸拮抗劑S(+)-氯氨酮在大鼠腦缺血再灌注後對細胞凋亡調節蛋白表達的影響

(李紹清 薛張綱 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-受體配合4-苯基-1-4-苯丁基)呱啶對缺血性神經保護而不改變多巴胺濃度

(鄧羽宵    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:

肼苯達嗪、尼卡地平、硝酸甘油和酚多帕對人臍動脈的舒張作用

(趙雪蓮 莊心良 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:

 

高風險患者腹部手術後圍術期硬膜外鎮痛和後果

(李紹清 薛張綱 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.

 

尿毒癥患者和非尿毒癥患者應用羅呱卡因腋路臂叢阻滯後的藥物代謝動力學

(楊保仲 莊心良 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.

 

鞘內注射布比卡因或sameridine後所致的高二氧化碳和低氧通氣反應

(嵇富海 薛張綱 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.

 

地塞米松對健康志願者使用布比卡因微膠囊進行T9-11肋間神經阻滯量效反應

(    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:

老年患者院內術後併發症的預後重要性,I. 長期倖存者

(    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.

一項前瞻性盲法試驗:上唇咬合試驗(一項簡單的新技術)和Mallampati分級預測氣管插管難度的比較

(嵇富海 薛張綱 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喉罩與Laryngeal TubeTM喉管用於自主呼吸的麻醉病人時的比較

(   莊心良 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.

 

氧化亞氮麻醉後Brandt導管減輕套囊漏氣現象

(嵇富海 薛張綱 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.

 

術中輸注膠體液較晶體液能減少術後噁心嘔吐和改善預後

(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

冠狀動脈旁路術中BIS指導麻醉用藥

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

隨機前瞻性研究62例在兩種不同麻醉深度下首次行CABG 術的病人的血流動力學,氧供,及可能出現的術中知曉和費用。通過BIS評價麻醉深度。所有的病人以舒芬太尼/咪唑安定麻醉。通過劑量的控制使32例病人的BIS維持於45-55BIS50組),另外32例病人的BIS維持於35-45BIS40組)。術前,術中和術後共監測6組資料。術後第三天向所有病人詢問是否有術中知曉。兩組的血流動力學和氧供無明顯差異。BIS40組的舒芬太尼和咪唑安定的用量明顯大於BIS50組(p<0.05),舒芬太尼分別為888+/-211ug, 514+/-99ug;咪唑安定分別為22.4+/-5.6mg, 16.6+/-3.7mgBIS50每位病人節約US$12.54 (P<0.05), 但必需支付額外的費用——BIS電極的費用US$18.15BIS40組拔管時間無明顯延長(BIS4014.3+/-4.6hBIS50組,11.8+/-3.8h)。兩組均未出現術中知曉。BIS可以減少麻醉用藥節約費用而並不增加術中知曉的危險性。但是由於需支付BIS電極的費用,總的麻醉費用還是增加的。

(忻紀華    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.


肝臟切除術和移植術中異氟醚和地氟醚的攝取

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

減少新鮮氣流量時,為達蒸發罐的設定、維持恒定的呼氣末麻醉劑濃度所需的時間更多的取決於吸入性麻醉藥的攝取方式。但是,長時間手術吸入性麻醉劑的攝取方式無法量化。為此,本研究在肝臟切除術(LR, n=17)和肝臟原位移植術(OLT, n=18)中吸入異氟醚和地氟醚,採用液體噴射緊閉回路使呼氣末濃度分別維持於0.8%4.5%。個體和平均的攝取曲線符合一系列代數公式,並比較時間方根和四次方。LR組在13小時;OLT組在138小時後的異氟醚和地氟醚的累積濃度與個體差異和每個病人的平均心輸出量和心臟指數有關。平均攝取可以雙指數公式表示: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)。攝取有明顯的個體差異,但攝取變化和個體特徵之間無關。當攝取率下降減慢後符合攝取模式。由於現有的模式和病人的特徵均不能準確的預示每例病人的攝取,所以麻醉方法包括應用低流量麻醉都必須依賴持續的藥物監測。但是,長時間手術麻醉氣體的攝取率下降緩慢提示應用蒸發罐刻度的調整來維持呼氣末濃度是有限的。

(忻紀華    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.


固定肢體後兔使用米庫溴銨與羅庫溴銨的藥效學研究

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

臨床上暫時還無法研究對於管狀石膏固定的病人在使用米庫溴銨和羅庫溴銨時藥效動力學的影響。在本實驗中對56只分別使用米庫溴銨和羅庫溴銨麻醉的家兔進行劑量反應關係和神經肌肉阻斷效果的比較,家兔持續固定肢體時間分別為246周。每10秒一次對雙側腓總神經同時給予四個成串刺激,同時監測脛前肌肉的收縮情況。對米庫溴銨和羅庫溴銨的劑量反應曲線研究發現,在對側肢體尚未發生移動時,固定側肢體先恢復移動。在固定肢體時間分別為0246周的家兔中使用米庫溴銨的50%有效劑量分別為15.1±1.418.2±1.521.5±1.927.8±2.5μg/kg,而對側肢體的數值並無改變。在固定肢體時間分別為0246周的家兔中使用羅庫溴銨的50%有效劑量分別為48.1±4.156.2±4.264.8±4.975.1±5.5μg/kg,而對側肢體的數值並無改變。雖然對側肢體的數值並無改變,使用米庫溴銨和羅庫溴銨時,固定肢體的家兔與安慰劑組間加速度的恢復情況有明顯差異。這一研究結果顯示,管狀石膏固定後引起的廢用性肌萎縮會阻礙米庫溴銨和羅庫溴銨的起效,但並不影響對側肢體。所以,在對這類病人建議使用健側肢體進行肌松監測,以避免廢用性肌萎縮對肌松效果的影響干擾臨床用藥。

(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.


芬太尼對活體鼠骨骼微循環的劑量依賴效應

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

判斷鎮痛對微循環的影響很困難,因為手術往往需要麻醉。本研究利用背微循環腔(DMC)來比較意識控制狀態靜脈注射大劑量(LF)和小劑量(SF)芬太尼對微循環的影響。雄性Wister鼠被植入DMC來放大單層橫紋肌。實驗動物在恢復三周後,在隨後的兩周內使用活體微縮本(1次注射/周),在清醒的動物中觀察微循環(t=0-30min),在注射一次誘導劑量後(t=40-45min),以下列一種方式逐步維持:LF (40–90 µg · kg-1 · h-1)SF(10–60 µg · kg-1 · h-1),或生理鹽水(5–10 µg · kg-1 · h-1) (t =45–105 min)。用LF誘導後小動脈(<30 µm)擴張(23.6% ± 7.1%),而SF則收縮(-21.3% ± 7.1%) (P < 0.05)。在維持期間,隨著LFSF劑量的增大,收縮程度也隨之增大(-21.9% ± 4.0%) (t = 105 min, P < 0.05)。所有的動脈(10–120 µm)和靜脈(15–250 µm)都可觀察到相似的情況。因此DMC提供了一種觀察微循環對芬太尼反應的優秀技術,在活體的鼠骨骼肌,靜脈注射芬太尼產生顯著的動脈收縮。

(殷文淵    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.


肝硬化病人肝臟切除手術術後鎮痛:單次硬膜外小劑量氯胺酮加嗎啡的效果觀察

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

肝硬化病人接受肝臟手術時,術後鎮痛仍是一項挑戰。在研究中,我們評價硬膜外給予單次劑量嗎啡混合小劑量氯胺酮作為術後鎮痛的效果。104Child分級為“A”的肝硬化病人被隨機分為兩組:1)(MKGn=50)。硬膜外給予嗎啡(3.5-5mg)加(氯胺酮20/30mg;2)硬膜外給予嗎啡(3.5/5mg)(MGn=50)。記錄鎮痛的深度,副作用,精神和神經方面的紊亂,額外添加止痛劑和總體的鎮痛質量。MKG組的平均鎮痛時間較長(27.2±8h16.4±10h;P>0.05)。在MKG組中,術後14小時至研究結束的睡眠和術後12小時至研究結束的咳嗽的視覺類比等級(VAS)評分開始顯著降低。MKG組的額外鎮痛劑需求也較少(P<0.05):到24小時,MKG組中只有10%的病人需要添加鎮痛劑,而在MG組中為100%P = 0.003)。兩組的副作用都較小。沒有觀察到精神副作用和神經紊亂。這些結果說明接受上腹部手術的ChildA”級肝硬化病人通過硬膜外給予單次劑量嗎啡和小劑量氯胺酮作為術後鎮痛是有效的。

(殷文淵    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.


微球針壓法不能減少術後疼痛或嗎啡用量

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

微球針壓法已經有2000多年的應用歷史,且目前在日本仍很盛行。與腹部手術密切相關的穴位就是在腹腔中穿行或起源的經絡。我們假設微球針壓法可以減少手術後疼痛,降低腹部手術鎮痛藥用量。本研究病人實施標準的地氟醚和芬太尼麻醉。術畢,病人被隨機分為對照組和微球針壓治療組,在微球針壓組,用微球針壓內關、足三裏、三陰交和公孫穴,並用棉紗覆蓋針刺部位,以便病人不能確定自己的分組治療情況。兩組病人全部通過病人自控鎮痛泵靜注嗎啡實施術後鎮痛。在本實驗取術後第一天晨病人的疼痛評分和嗎啡用量作為研究資料。統計資料取中間值(第2575中位數)。共有53位病人(對照組30位、23位)完成了本實驗研究。對照組和微球針壓治療組病人的嗎啡用量(47mg41mg)和疼痛評分(29.5mm40mm)是相似的。因此腹部手術後用微球針壓內關、足三裏、三陰交和公孫穴並不能提供鎮痛。微球治療是針灸的一種形式。在本實驗中為驗證腹部手術後用微球針壓與腹部手術相關的穴位是否可以減少病人疼痛和術後鎮痛的嗎啡用量。結果發現兩組病人的恢復情況相似,疼痛評分和嗎啡用量相似。

(齊波    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.


美國作者在主要麻醉學期刊上發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

據報導稱美國作者在醫學期刊上發表的文章的比例有所下降。因此我們決定研究一下在19802000年期間美國作者在三個主要的麻醉學期刊上發表的文章是否有所改變。我們選擇三個比較有影響力的期刊--《疼痛學》、《麻醉學》和《麻醉與鎮痛》作為評估研究物件,回顧了三種期刊在19801985199019952000年發表的所有臨床研究和基礎科學研究論文。並用Χ2核對總和最小平方線性回歸分析法分析了文章出處(美國或國外)與發表年份之間的聯繫。因為國外作者在19802000年期間在主要麻醉專業期刊上發表的文章比例的增加與他們發表的文章數量的增加不成比例,所以美國作者發表文章的比例下地正在下降。在本研究中沒有對發生這種變化的原因進行分析。我們認為其中可能包含了多種因素,包括:由於經濟因素,美國作者將工作重點放在臨床工作上而非實驗研究上;美國作者將文章發表於除主要專業期刊外的其他期刊上以及國外作者投遞的文章質量逐漸增加。

(    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-受體配合4-苯基-1-4-苯丁基)呱啶對缺血性神經保護而不改變多巴胺濃度

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

缺血性神經原保護的活性信號有{varsigma}-受體絡合物提供,這個機制還不明確。兒茶酚胺出現在缺血性神經損傷的修復中。最近的研究表明{varsigma}-絡合物調節了多巴胺原性的神經轉運。在這個研究中,我們驗證了一個假設。在缺血的紋狀體中{varsigma}-受體配合4-苯基-1-4-苯丁基)呱啶(PPBP)能削弱細胞外多巴胺的增加。在受控制的生理條件下,一個微透析的探針進入到成年雄性Wistar大鼠的右側尾狀核(CP)中。大鼠接受了2小時的大腦中動脈栓塞(MCAO),用官腔內縫合技術。在雙盲隨機的條件下,大鼠被分為5組:組1n=8;鹽水-鹽水)在MCAO前持續用鹽水注射30分鐘,然後用鹽水再灌注直到實驗結束前;組2n=8;PPBP-PPBP)在MCAO前靜脈注射PPBP30分鐘然後用1μmmol/Kg/hPPBP;組3n=8;鹽水-PPBP)在MCAO前靜脈注射鹽水然後用PPBP;組4n=4)手術方法(鹽水-鹽水);組5n=4)手術方法(PPBP-PPBP)。梗塞容量為22小時的灌注,用PPBP-PPBP和鹽水- PPBP的大鼠與用鹽水-鹽水的大鼠有明顯的區別。在MCAO發生的40分鐘內微透析發現多巴胺的濃度上升3/4。多巴胺和它的代謝產物二羥基苯醋酸水平在MCAO的三組中基本相似。因此在大鼠中尾狀核出現缺血改變時,PPBP能提供對缺血神經保護而沒有多巴胺濃度的急劇改變。

(鄧羽宵    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.


高危患者腹部術後硬膜外鎮痛和預後

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

在最近對915 位接受腹部手術的高危患者的調查中,我們發現患者術後接受硬膜外鎮痛或靜脈鎮痛併發症沒有明顯區別,特別是呼衰。因此我們設計了一個實驗,根據患者不同特點分成不同亞組觀察他們是否能從硬膜外鎮痛中得到益處。在對呼吸,心臟併發症較高的小組,接受主動脈手術的小組和硬膜外阻滯失敗的小組和接受硬膜外鎮痛小組的分析後發現併發症沒有區別(P>0.05)。術後控制呼吸的時間有小的區別,其他組為6.5小時,硬膜外組為4.8小時;P=0.048。在術後ICU和住院時間上沒有區別。我們發現沒有證據證明圍手術期使用硬膜外鎮痛對接受腹部手術的生存率和死亡率有影響。

(鄧羽宵    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.


地塞米松對健康志願者使用布比卡因微膠囊進行T9-11肋間神經阻滯量效反應

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/地塞米松微膠囊在動物模型中可產生7——11天的鎮痛療效。本研究中應用布比卡因微膠囊麻醉並揭示增加劑量或加用地塞米松對其起效時間作用強度及作用時間的影響。濃度範圍在0.3125%5.0%的微膠囊與0.25%的布比卡因水溶液相比較(雙側注射,三條肋間神經,每條2ml)(Part1)。Part2是比較2.5%的布比卡因微膠囊單側神經阻滯用或不用地塞米松的效果。通過針刺,溫覺及主觀麻木感(0,沒有麻木;10,完全麻木)來評估感覺阻滯效果。藥效評估及布比卡因和地塞米松血漿藥物濃度測量將持續96小時。當濃度超過0.3125%-5.0%範圍時起效時間縮短及鎮痛時間延長。(P0.02)。2.5%的布比卡因微膠囊起效時間與0.25%的布比卡因水溶液相似。使用微膠囊阻滯時間延長至少達96小時並顯著長於布比卡因水溶液(P0.001)。使用2.5%的布比卡因微膠囊再加用地塞米松將延長對刺痛感覺阻滯的時間(P=0.03)。因此使用布比卡因和地塞米松混合微膠囊行肋間神經阻滯方法可行,在起效時間和作用時間上有明顯的劑量相關效應。加用地塞米松增強了肋間神經阻滯麻醉的效果。

(    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.


老年患者院內術後併發症的預後重要性,I. 長期倖存者

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

為了確定院內術後併發症對其長期存活的影響,我們前瞻性地持續研究≥70歲經受非心臟手術的患者。我們分析可能的臨床風險因素並評估它們與長時期的術後死亡率的聯繫。長時期存活的定義通過Kaplan-Meier方法確定。存活的多元化因素通過Cox比例風險模型來綜合分析。存活的研究組還要與年齡及性別相匹配的普通美國人群作比較。我們對517名存活的住院患者進行研究。平均跟蹤隨訪的時間為28.6±12.8個月。其中164名患者在隨訪的過程中被去除。有癌症病史(危險指數[HR]2.4495%置信區間[CI]1.78-3.38P0.0001〉,ASA)Ⅱ級(HR2.2795%CI1.61-3.21P0.0001〉,神經科疾病(HR1.5995%1.13-2.24P=0.008),年齡(每十年HR1.4295%CI1.11-1.81P=0.005),術後肺部併發症(HR2.4195%CI1.30-4.48P=0.005),和腎臟併發症(HR6.0795%CI2.23-16.52P0.0001〉都是明顯降低生存時間的獨立預示因素。與普通的美國人群作比較,那些有併發症的患者手術後3個月死亡率(相對普通人群HR7.3)比那些沒有併發症的病人(HR2.9P=0.023)將顯著增加。為改善老年患者圍手術期的護理必須首先盡可能降低院內的術後併發症,尤其是那些累及肺或腎臟的併發症。

(    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.


術中輸注膠體液較晶體液能減少術後噁心嘔吐和改善預後

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

何種液體輸注是最佳的術中液體管理方案至今尚未有定論,既往研究表明術後死亡率與術中輸液無明顯關係。此外,膠體液或晶體液對術後恢復質量的影響尚未見報道。採用雙盲前瞻性研究用膠體液及晶體液患者性術後噁心嘔吐發生率及術後恢復情況。選擇性非心臟手術患者隨機給予6%羥乙基澱粉堿(HS-NS)、6%羥乙基澱粉平衡鹽(HS-BS)或乳酸林格氏液(LR)作為術中輸液,採用標準麻醉方法,血流動力學處理包括持續動脈壓監測、心率及尿量在預定範圍。術後發病率的調查在術後當日開始每日按基線進行。90位患者每30人為一組,HS-NSHS-BSLR的輸注量分別為 1301+1079 mL, 1448+759 mL5946+1909 mLHS-NSHS-BS組的術後噁心嘔吐發生率相較於另一組明顯減少,使用止吐劑及產生劇烈疼痛、眶周水腫和複視的情況也相對較少。因此術中使用膠體液較晶體液能改善術後恢復質量。

(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.


尿毒癥患者和非尿毒癥患者應用羅呱卡因腋路臂叢阻滯後的藥物代謝動力學

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

局部麻醉藥對於尿毒癥患者的效力和藥物代謝動力學特徵各家報導不一。本研究擬對此問題作進一步的探討。29例尿毒癥患者和28例非尿毒癥患者接受了腋路臂叢神經阻滯,均給予羅呱卡因300 mg /50 mL。用藥後24小時內取各時點的靜脈血樣,測定血漿總羅比卡因、血漿游離羅比卡因、羅呱卡因的代謝產物3-hydroxyropivacaine pipecoloxylidide (PPX)以及{alpha}1-酸性糖蛋白含量。神經阻滯效果兩組相似,兩組均無毒性反應發生。比較兩組的各項指標,在尿毒癥患者組,羅呱卡因血漿清除率較小,濃度-時間曲線(藥-時曲線)下面積、3-hydroxyropivacaine PPX含量較高,血漿PPX含量增高可持續到用藥後24小時,血漿{alpha}1-酸性糖蛋白濃度亦較高。用藥後1小時和12小時,血漿中游離羅呱卡因所占比例較小,但游離羅呱卡因濃度在用藥後12小時較大。尿毒癥患者吸收入血液迴圈的羅呱卡因量增加。藥物與AAG結合量增加,尿中代謝物排泄量減少,可能是導致羅呱卡因及其代謝物總血漿濃度增加的原因。

(楊保仲 譯 莊心良 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.

 

 小兒用傳統靜脈針與可伸縮式靜脈針的比較:是否更安全,更能保護誰?

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:研究新型可伸縮式靜脈針是否可以減少針刺造成的損傷。方法:前瞻性地收集傳統的靜脈針(JELCO)與新式靜脈針(AngiocathTM AutoguardTM)的資料。每週隨機指定所使用的靜脈針的類型。比較兩種穿刺針建立靜脈通路的難度、使用的穿刺針數量以及在穿刺過程中血液溢出或濺出到皮膚、敷料、地板、衣物以及手術臺的次數。結果:20天內,共對330位病人進行了473次靜脈穿刺。沒有發生針刺造成的損傷。在42例病人發生了77次血液溢出或濺出。新型穿刺針發生血液溢出或濺出的次數是傳統穿刺針的4倍。如果是由主治醫生而不是實習醫生進行靜脈穿刺的話,使用新型靜脈穿刺針發生血液溢出或血液濺出的總事件數以及發生該事件的病人數明顯多於傳統穿刺針。結論:有經驗的麻醉醫生使用這種新穿刺針將使他們更多地受到血源性疾病的威脅。開業醫生應該選擇能夠更有效地建立靜脈通路同時受到血液污染機會最少的穿刺針。醫療機構也應該允許在該機構內工作的醫生自己選擇穿刺針。

(顏 濤 譯   莊心良   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喉罩與Laryngeal TubeTM喉管用於自主呼吸的麻醉病人時的比較

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:比較喉罩(PLMA)和喉管(LT)氣道在自主呼吸的麻醉病人中的使用。方法:在這項多中心隨機研究中,比較ProsealTM喉罩氣道(PLMA)和Laryngeal TubeTM喉管(LT)置管的難度、置管後血流動力學的反應、通氣質量以及是否可以實現“不用手的麻醉”。在保留自主呼吸行短時間外科手術的病人還觀察了術後咽喉部不適的發生率。在芬太尼和丙泊酚誘導後,分別給70ASAⅠ-Ⅱ級的病人(每組35位)使用上述通氣道。結果:PLMALT的一次成功率高(分別為77%51%P< 0.05),但是嘗試三次後兩者的成功率相似(分別為100%和97%)。麻醉學家認為PLMA的置入更容易(P< 0.001)。PLMA的呼氣潮氣量比LT大(分別為404.9mL328.4mLp< 0.005),使用PLMA的病例更容易達到“不用手的麻醉”(分別為32例和21例;p< 0.004)。對於使用LT的病人採用改變體位的方法糾正通氣不足並不總是完全有效(13例中5例不完全有效)。兩組間病人不能耐受、喉嚨痛、吞咽困難和/或發音困難的發生率沒有差別。結論:對於沒有使用肌松藥的病人,PLMA置管更容易,使用更可靠。

(顏 濤 譯  莊心良 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.

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急性等容血液稀釋中晶體液和膠體液替代的影響:凝血標記物的初步研究

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:急性等容血液稀釋(ANH)是在手術失血開始前即刻收集血液作為一種自體血獲得方法而得到推薦使用的血液保護技術。ANH期間,晶體和膠體液用於維持等容。但很少有資料來確定哪種特定液體的使用。為此,我們設計了一項前瞻性隨機研究以確定是否替代液體的選擇影響了各種凝血指標和圍術期的失血。方法:40ASA 1-3級,在根治性前列腺切除術時擬行ANH的成年患者根據替代液體隨機分為4組:(a)乳酸林格氏液;(b5%白蛋白;(c6%右旋糖酐70DEX);或(d6%羥乙基澱粉(HES)。標準全身麻醉誘導後,所有患者實行ANH至最終血紅蛋白水平為 9 g/dL 。手術過程中在同一時間點進行全血計數、凝血酶元時間、部分凝血激酶時間、纖維蛋白原、V VIII因數水平、出血時間和凝血彈性描記術(TEG)測定 。結果:與基礎值比較,在麻醉後監護室內乳酸林格氏液組和5%白蛋白組患者的部分啟動凝血激酶時間縮短,VIII 因數水平升高。而在術前和麻醉後監護室,DEX組和HES組表現為TEG最大幅度的下降以及DEX組的TEG {alpha}()低於基礎值。結論:VIII 因數水平,部分啟動酶原時間和TEG測量的改變提示HESDEX可能減輕與手術相關的高凝狀態。

(張 軍 譯  莊心良 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.


 圍術期ß-內啡呔免疫反應物釋放入血和腦脊液對術後疼痛的作用重要嗎?

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.

 

圍術期ß-內啡呔免疫反應物(IRM)釋放的功能尚有待闡明。我們對17例行骨科手術的患者分別在手術前(tA),仍在施行腰麻(tB) 但手術和麻醉結束之後,術後發生疼痛(tC)及術後一天(tD)測定靜脈血中的ß-內啡呔IRM。疼痛嚴重程度由患者根據視覺類比評分進行分級。結果患者均發生術後疼痛(tC),但在tA, tB, tD時間點時未感到疼痛。術前(tA)或發生術後疼痛(tC) ß-內啡呔IRM血漿水平顯示明顯高於術後但仍在進行腰麻(tB)或術後一天(tD)的測定水平。tA tC 時間點的ß-內啡呔IRM血漿水平與術後疼痛嚴重程度(tC)呈正相關。術後但仍行腰麻(tB)的腦脊液中ß-內啡呔IRM水平顯著高於tA, tC, tD時間點的測定水平。腦脊液ß-內啡呔IRM的水平與疼痛嚴重程度沒有相關性。結論:術後疼痛嚴重程度似與術前及發生術後疼痛時血漿中的ß-內啡呔IRM水平有關。這種物質的鎮痛意義仍有待闡明。

                                                 (張 莊心良 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.

 

肝素誘導的血小板減少症伴血栓形成症Ⅱ型患者在體外迴圈下行心臟手術:一組前瞻性病例分析

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.

 

肝素誘導的血小板減少症伴血栓形成症(HITT)Ⅱ型是肝素治療的一種致命性併發症,部分由特異性抗體介導,通常發生於治療後5到10天。此類患者在體外迴圈(CPB)下行心臟手術時必須使用抗凝劑。我們報導了12例患者。其中6例術前抗體陰性,CPB期間使用肝素抗凝,患者經過順利,未發生血栓形成。另外6例抗體陽性,使用水蛭素抗凝,並用ecarin凝血時間指導抗凝治療。患者經過順利,但出血量大,需輸入多種血製品,而且CPB後重新打開縱膈的比例較高。

(軒   莊心良 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療椎板切除術後綜合征:初步報告

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.

 

硬膜外使用糖皮質激素可能發生不良反應,因而限制了激素的使用。由於部分非甾體類抗炎藥具有中樞和脊髓的抗傷害作用,我們比較了硬膜外注射消炎痛(INM)和甲強龍(MTP)的效果。這是一項在流動性疼痛治療中心進行的前瞻性比較研究。206例患者曾接受兩次或多次腰椎板切除術,術後出現復發性腰痛(視覺類比評分VAS>7)和神經根病,確診為“椎板切除術後綜合征”等病人,隨機分為三組。組I(64 ),兩次硬膜外注射凍幹INM1 mg。組 II (60 ),注射INM2 mg。組III (82 ),注射MTP80 mg,三組注射間隔相同。所有藥物均用3 mL 0.5%布比卡因稀釋。用VAS的改變來評估疼痛的緩解,治療前和治療後兩周用疼痛進展評分(PPS)分級記錄患者的身體運動,情感體驗和藥物攝入。結果:每次注射均緩解疼痛(VAS<3)。 組 II患者二次注射後或組III患者鎮痛程度高(P < 0.05)PPS總平均分在組 II二次注射後或組III有顯著性差異。身體運動,情感體驗和藥物攝入均有改善,但無顯著性差異。結論:組I和組 II患者中INM具有足夠的鎮痛作用,兩次注射2 mg INM與注射80 mg MTP的作用水平相當。將來可以開發其他的非甾體類抗炎藥硬膜外注射治療椎板切除術後綜合征。

(軒 泓 譯  莊心良 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.

 

氧化亞氮和氙氣可抑制表達於Xenopus卵的人({alpha}7)5煙鹼型乙酰膽鹼受體

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:神經型煙鹼樣乙酰膽鹼受體(nACh)屬於配體門控離子通道,能調節中樞神經系統突觸處的神經遞質釋放。因為,許多全麻藥在臨床應用濃度即可抑制他們功能,所以nACh可能為全麻藥作用的靶目標而引起關注。已知一些全麻藥可抑制({alpha}  7)5 nACh受體(屬於神經型nACh受體的一種亞型),但氧化亞氮(N2O)和氙氣(Xe)對其作用還沒有報導。本文研究N2OXe({alpha}7)5 nACh受體的作用。方法:採用雙電極電壓鉗技術,作者研究了N2OXe對表達于Xenopus卵上人({alpha}7)5 nACh受體的作用。結果:臨床相關濃度的N2O Xe可逆性抑制Ach引起電流而且呈濃度依賴性。兩種麻醉藥對受體({alpha}7)5 nACh的抑制是非競爭性並且與膜鉗制電壓有關。結論:N2O Xe({alpha}7)5 nACh受體的抑制作用可能與他們的麻醉作用有關。

                                       (趙雪蓮  譯 莊心良 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.

     

肼苯達嗪、尼卡地平、硝酸甘油和酚多帕對人臍動脈的舒張作用

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:研究肼苯達嗪、尼卡地平、硝酸甘油和酚多帕(一種多巴胺 D1-激動劑)對離體人臍動脈(HUA)的作用。方法:分別採取血壓正常和妊高征患者(PIH)臍動脈。第一部分:先用血栓素A2擬似物(U46619; 10-8 M)使臍動脈環收縮,再將其浸入不同濃度酚多帕、肼苯達嗪、尼卡地平和硝酸甘油。第二部分:將臍動脈環預先分別浸入10-5 M呱唑嗪、10-5 M苯氧苄胺或空白液後再加入漸增劑量的酚多帕或多巴胺,並記錄其收縮反應。結果:不論是血壓正常或PIH患者,硝酸甘油、肼苯達嗪和尼卡地平均可舒張預先使用U46619的臍動脈環,並呈濃度依賴性。酚多帕和多巴胺在濃度>=10-3 M時使正常血壓和PIH患者的臍動脈環收縮。苯氧苄胺可翻轉酚多帕引起的臍動脈環收縮,二呱唑嗪無此作用。在此體外實驗,硝酸甘油是預先使用U46619最強的HUA舒張劑,餘次為尼卡地平和肼苯達嗪。此外,酚多帕只在高於治療濃度時才引起HUA收縮。在血壓正常和PIH兩組間,酚多帕(P = 0.3534)、肼苯達嗪(P = 0.5514)、尼卡地平(P = 0.0615)和硝酸甘油(P = 0.7416)引起HUA血管反應無統計學差異。結論:常規治療急性高血壓的藥物不會影響臍動脈張力。但大劑量酚多帕(>=10-3 M)可使臍動脈收縮。

                                          (趙雪蓮 譯 莊心良 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.

 

門診整形外科手術病人術後周圍神經自控鎮痛:電子泵和彈性泵的比較

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:門診整形外科手術後,病人自控周圍神經鎮痛技術(Infusor LV5 彈性泵或兩種電子泵)均為在家病人提供了有效的疼痛緩解。彈性泵由於技術操作問題少因而比電子泵的病人滿意度為高。

                                           (黃施偉 譯 莊心良 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.

 

協議中疼痛和危險對病人自願參加臨床試驗的影響:一項隨機試驗

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.

 

我們對與臨床試驗有關的危險性和不適會影響病人決定的假設進行了研究。同時,我們還評估了可能對患者做決定有影響的一些因素如對與試驗有關的危險性和不適的理解、患者年齡、受教育程度以及心理狀態。經IRB批准,而且參與者都相信被要求參與的試驗是真實的,他們被安排進入三個虛擬的協議中:無危險或疼痛(對照組 n48),有疼痛但無危險(疼痛組 n51),或有危險但無疼痛(危險組 n51)。在會談結束時病人聽取了報告。我們主要的結果指標包括:(a)對與試驗相關的疼痛或危險的理解 (b)病人對參與試驗所感到壓力的程度(c)參與的自願性。儘管三組病人對試驗的理解比較相似(對照組68%,疼痛組67%,危險組72%),參與的自願性卻差異明顯(對照組64%,疼痛組35&,危險組26%P<0.001)。能理解危險和疼痛水平的患者中自願參加者是未理解者的兩倍(49%vs24&p0.003)。在同意參加有危險或疼痛試驗的患者中有9%的人並不理解其中的危險性。那些感到壓力的患者都不同意參與。因此,儘管原因出人意料,知情同意書的過程的確保護了患者。對試驗的理解是缺乏的,但那些對其中危險性或疼痛不理解或感到有壓力的患者很少同意參加。因此,很少有患者在一無所知的情況下會同意參加一些有危險性或疼痛的試驗。

                                  (黃施偉 譯    莊心良 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.


間斷或持續CO2充氣法去除心胸外科傷口腔內的空氣— 一種新的氣體擴散器的實驗研究

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.

 

胸部傷口中吹入CO2是心臟手術時常用的去除心臟和大血管中的空氣的方法。在一個心胸傷口模型,我們比較了一種新的充氣儀器—gas-diffuser,與一種埠開放的管子,在穩態以及CO2氣流在2.5, 5, 7.5 10 L/min時的空氣置換的效果。我們也研究了這種儀器在CO2充氣開始和中斷後的空氣置換效果以及開放胸膜對其造成的影響。在穩態時,在CO2>=5 L/mingas-diffuser 能產生有效的空氣置換(遺留留空氣<=0.65%),而埠開放的管子在所有CO2氣流時均排氣不足(遺留空氣>=82%) (P < 0.001)。胸膜腔開放使傷口腔隙內空氣置換的時間顯著延長(P = 0.001)。在切開心臟和大血管前至少1min,心胸傷口應該進行氣流速度為10 L/minCO2充氣,並且在外科傷口關閉 前繼續充至少氣流速度超過5 L/minCO2氣體。   

                                   (王士雷     莊心良  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® 乳膏和陰莖背神經阻滯用於小兒包皮環切術後鎮痛的研究

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、隨機、雙盲的方式比較術前用EMLA®乳膏和布比卡因陰莖背神經阻滯用於小兒包皮環切術後鎮痛的效果。方法:31例病人術前給予EMLA®乳膏,陰莖背神經注射生理鹽水作為安慰劑;另外32例病人陰莖背神經用布比卡因阻滯,而用空白乳膏作為安慰劑。術後疼痛評價用改進的Eastern Ontario 疼痛評分,並記錄術後第一次給予鎮痛藥的時間。結果:二組間病人術後疼痛評分無顯著差異。布比卡因陰莖背神經阻滯組術後鎮痛時間較EMLA®乳膏組長(P = 0.003)。二組病人均無全身和局部併發症,嘔吐發生率很低。結論:術前用EMLA®乳膏是包皮環切術後鎮痛的簡便而有效的方法,而且副作用發生率低。

(王士雷 譯  莊心良  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.

 

腎上腺素抑制脂多糖(LPS)誘導人單核細胞釋放巨噬細胞炎症蛋白-1{alpha} 蛋白—ß-腎上腺素能受體的作用

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:巨噬細胞炎症蛋白-1{alpha}(MIP-1{alpha})對調節白細胞的遊走和功能有重要作用,並因而影響感染性炎症的發展過程。本文探討腎上腺素對脂多糖誘導的人白細胞和THP-1產生MIP-1的作用。方法:在37°C、有或無腎上腺素以及特異性{alpha}- ß-受體激動劑和拮抗劑存在的條件下, 單核細胞與LPS在一起培養4h,以ELISA測定MIP-1{alpha}  的含量,並用RT_PCR監測其RNA的水平。結果:腎上腺素以劑量依賴的方式抑制LPS誘導的MIP-1{alpha}  的產生,這種作用可以被心得安阻斷,但是不被酚托拉明阻斷。特異性ß-腎上腺素能激動劑異丙腎上腺素對LPS誘導的MIP-1{alpha}有同樣的抑制作用,而{alpha}-腎上腺素能激動劑苯腎上腺素的作用則微乎其微。此外,這種抑制作用與細胞內cAMP有關。腎上腺素對MIP-1{alpha} mRNA也有抑制作用。結論:腎上腺素對炎症和膿毒血症時MIP-1{alpha} 的產生有調節作用。

(王士雷 譯 莊心良 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.



高風險患者腹部手術後圍術期硬膜外鎮痛和後果

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.

 

對最近完成的915例高風險患者進行腹部手術的隨機試驗的最初分析,除呼吸衰竭發生率外,在圍手術期硬膜外鎮痛和靜脈阿片劑鎮痛並無差異。因此,我們選擇一組能確實可從硬膜外鎮痛獲益的患者進行調查。結果:在硬膜外組合控制組間,呼吸及心臟或大動脈手術的風險增加並無差別,即使在硬膜外阻滯失敗組也無差別(所有P > 0.05),僅有少許通氣功能下降。長時住ICU和普通病房的患者間也無差異。在硬膜外鎮痛試驗組和日常硬膜外鎮痛之間發生率也不相關。沒有證據證明圍術期硬膜外鎮痛明顯增加腹部手術後患病率或死亡率。

(李紹清 譯 薛張綱 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激動劑dexmedetomidineN-甲基-D天冬氨酸拮抗劑S(+)-氯氨酮在大鼠腦缺血再灌注後對細胞凋亡調節蛋白表達的影響

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.

 

這個研究,目的是調查神經蛋白dexmedetomidine S(+)-ketamine是否參與原凋亡蛋白(Bax and p53)和抗凋亡蛋白(Bcl-2 and Mdm-2)的調節。異氟醚誘導大鼠,試驗開始後停異氟醚,然後隨機三組給藥,一組用芬太尼和笑氧混合氣加100微克/千克dexmedetomidine在缺血前30min腹膜內給藥(n = 8), 二組1 mg x kg(-1) x min(-1) of S(+)-ketamine 和氧空氣混合(n = 8),三是芬太尼和笑氧混合氣(n = 8)。所有處理組均通過單側頸動脈阻塞和出血至低血壓到30-35 mm Hg誘發缺血(30min)。再灌注4小時後取出腦組織,通過螢光免疫和西氏污點法分析凋亡調節蛋白表達。結果與佯裝處理組(n = 8)比較。腦缺血再灌注後,與dexmedetomidine S(+)-ketamine處理組相比,Bax相關蛋白濃度增加110%,與佯裝處理組(n = 8)比較,增加140%。Dexmedetomidine處理動物內Bcl-2 and Mdm-2比控制組大(各自為68%,210%),或與佯裝處理組比較(各自為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調節的神經保護特性可能存在。

(李紹清 薛張綱 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.
 

怎樣分配手術室時間增加效率:手術室沒有充分利用手術室時間

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.


   在許多機構,外科醫生和患者選擇手術日,病例不被轉移,工作人員最大化手術效率。當以充分安排了手術時間,如果有新病人需安排時,通過安排新病人在未充分利用的手術室時間,可提高手術室效率。後面的服務被認為是釋放手術室分配時間。在這個研究中,我們分析了從中等到大醫療外科單位3年的手術室時間安排資料。理論上,有手術室時間釋放服務是那些手術日有最大未充分利用時間的手術工作日。但是,當新的病例被安排是在那些已充分最大分配時間的服務而非未利用的手術時間時,我們研究顯示手術效率僅輕度下降。相反,除了通過在最大分配手術室時間釋放手術室時間外,在未安排手術時間中卻顯劇降低手術室效率。手術室管理人員釋放手術室時間時,可考慮這個結果。

(李紹清 薛張綱 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.

 

胃旁路術後多模式圍術期鎮痛與硬膜外鎮痛的比較

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.

 

我們在114例全麻下行胃旁路手術的病人上對疼痛的強度,鎮痛藥物的消耗量,病人的滿意程度,住院時間進行了比較。病人隨機分為切口局麻藥侵潤加術後自控鎮痛組 ( A),硬膜外麻醉和鎮痛組 ( B)和術後病人自控鎮痛組 (C)。所有病人都給以非固醇抗炎藥。年齡,性別,體重指數,住院時間以及病人的滿意程度在各組間都一致。組B0時間點和36 小時疼痛者最小,A組較多,C組最多。A組病人的疼痛評分在任何時間都比B組和C組低,但只在0, 12, and 36 小時時間點有顯著差異。對於治療有效的病人來說,侵潤鎮痛作為多模式方案的一部分成為一種替代硬膜外鎮痛的簡單,安全,廉價的方法。

(張俊峰 薛張綱 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.

 

小兒吸入誘導期間七氟醚和笑氣的攝取

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.

 

在健康小兒面罩誘導七氟醚和笑氣的攝取有其特點。我們依靠兩種不同的吸入笑氣濃度對FA/FI增加速度的影響對濃度效應和第二氣體效應進行評價。18412歲的小兒隨機分為接受6%七氟醚與高濃度或低濃度的笑氣的混合氣體。呼氣末和吸入的麻醉藥濃度在誘導時持續評價。低濃度的笑氣FA/FI 0.87 ± 0.09 ,而高濃度的笑氣則為 0.92 ± 0.08 (P < 0.01)。兩組在3, 45分鐘差異顯著。七氟醚的FA/FI 也增加但較笑氣增加慢,而且僅僅在3分鐘差異顯著。笑氣和七氟醚的FA FI的平衡都快速達到。與他們各自的血氣分配係數一致,笑氣的 FA/FI的增加較七氟醚快。在氣體平衡曲線上,增加的笑氣吸入濃度產生了曲線左移。用笑氣證實的濃度效應和簡單的第二氣體效應可能可以用七氟醚的更高溶解性來解釋。

(張俊峰 譯 薛張綱 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.

 

採用電荷耦合裝置攝像機的氣管插管設備

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.

 

我們發明了一種裝有電荷耦合裝置攝像機的經口插管設備,它提供了一個更加寬廣的視野。我們用這種設備在62例牙科,口腔手術麻醉病人上應用。檢驗用這種系統進行氣管插管所需的時間 。下面介紹這種系統的使用。帶有CCD攝像機的裝置插入口咽腔。口咽,包括會厭,聲門,可以在監視器上看到。導管導引條經聲帶在裝置旁插入氣管。帶CCD攝像機的裝置撤出,留下導管導引條在氣管內。氣管導管用導引條作引導插入氣管。測定整個過程的時間。平均費時41.2 s (最大155 s;最少14 s)。病人根據CormackLehane分級分組在這一過程費時無顯著差異。用這一系統沒有失敗的插管。因為這一設備不但可以在監視器上看見喉,聲門和聲帶,而且可以看到導引條的運動,當聲帶在監視器上看到,氣管插管也就可以輕易進行。

(張俊峰 譯 薛張綱 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.

 

小兒咪唑安定麻醉前給藥:兩種口服劑量方案在鎮靜評分及血漿濃度的比較

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.

 

本研究目的在於比較現有的兩種口服咪唑安定方案應用于小兒(210歲)外科手術前鎮靜評分和血漿濃度的差異。市售的口服糖漿咪唑安定製劑和現配置的靜脈咪唑安定與糖漿混合的製劑(二者的等效咪唑安定濃度均為2 mg/mL)進行比較。ASA I–II的病人麻醉前都口服0.5 mg/kg的咪唑安定並隨機分為兩組:市售的糖漿組(組1)和混合製劑組(組2),給藥後1530 min分別由雙盲觀測者評定並記錄警覺/鎮靜評分。給藥後45, 60, and 90 min測定血漿咪唑安定濃度。 組2病人給藥後30 min 時的警覺/鎮靜評分中位數值顯著(P < 0.03)低於組1病人(Group 1, 17; Group 2, 15),在給藥後的三個測定時間組2 病人的血漿咪唑安定濃度均值顯著高於組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,我們認為現配置的靜脈咪唑安定與糖漿混合的製劑比等劑量的市售的咪唑安定糖漿可提供更為可靠的鎮靜效果及較高的血漿濃度。結論:現配置的靜脈咪唑安定與糖漿混合的製劑在小兒外科病人麻醉前用藥時比等劑量的市售的咪唑安定糖漿可提供更為可靠的鎮靜效果及較高的血漿濃度。

   (潘志浩 譯 薛張綱 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.

 

異丙酚損害運動系統的中樞部分而非外周部分

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.

 

異丙酚產生一定程度的肌肉鬆弛效應。以往的試驗要麼只研究異丙酚對運動系統的中樞部分作用,要麼就只研究其對外周部分的作用。該研究則同時評價其中樞(脊髓)和外周作用。15例病人全麻誘導和維持採用芬太尼、咪唑安定,不使用肌松藥。我們監測脊髓的F 波(一種{alpha}運動神經元興奮性的電生理變數)評價運動系統的中樞部分,測定直接肌肉電生理(M)反應和肌肉機械圖評價異丙酚對神經肌肉傳導或肌肉收縮力的外周作用。記錄基礎值後,3次靜脈注射異丙酚(兩次1 mg/kg 隨後 2 mg/kg,每次注射間隔5-min)。與基礎值相比,F波平均幅度(mean ± SD, 0.22 ± 0.13 mV)在分別3次注射異丙酚後顯著降低,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波幅度和肌肉機械圖信號則無改變。該資料顯示單次注射異丙酚影響運動系統的中樞部分而非外周部分。結論:人單次靜注異丙酚產生一定程度的肌肉鬆弛,我們的研究顯示靜注異丙酚後脊髓運動神經元興奮性(通過F波分析測定)降低,肌電圖信號延遲,對神經肌肉傳導或肌肉收縮力(通過測定肌電圖和肌肉機械圖評價)則無影響。

(潘志浩 譯 薛張綱 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.

 

大鼠試驗中鞘內導管位置的意義

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雖然大鼠鞘內置管是一廣泛採用的方法,但還無校準試驗進行。該研究中我們研究了大鼠鞘內注射利多卡因後鞘內導管頭端的位置與所觀測到的運動感覺阻滯的相關性。通過爪撤回試驗確定感覺阻滯的存在,運動阻滯通過觀察後爪完全拋錨及後爪的握力評價。試驗使用後,我們確定了導管頭的位置。結果導管頭在大鼠蛛網膜下腔橫截面的各個方向。利多卡因注射 (100 or 500 µg/5 µL; n = 264 and 112, respectively)導致劑量依賴性的感覺和運動阻滯。100 µg 的利多卡因顯示單側效應,運動(r = 0.77)和感覺(r = 0.60右側,r = 0.67左側)阻滯的程度都與導管頭的位置顯著相關。 我們的資料顯示在進行計畫的實驗前使用小劑量的利多卡因檢測運動和/或抗傷害效應是一簡單、可靠預測導管頭端位置的方法。因此,我們認為導管的位置可能導致藥效的單側差異,尤其在使用小劑量藥物並且需研究其雙側效應時。結論:該研究顯示在進行計畫的實驗前使用小劑量的利多卡因檢測運動和/或抗傷害效應是一簡單、可靠預測導管頭端位置的方法。我們認為導管的位置可能導致藥效的單側差異。

(潘志浩 譯 薛張綱 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.

 

減少不必要的交叉匹配:病人特異性備血系統在預測輸血方面比最大備血系統更準確

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.

 

絕大多數的輸血發生在手術室裏。70年代外科最大備血表的採用減少了不必交叉匹配的血液數量,但是全國的交叉匹配輸血的比率維持在2:1,我們做試驗得出病人特異性備血系統(PSBOS)能夠更加準確地預測可能發生的輸血。在密歇根大學的醫院裏所有的進行擇期手術(1999年2月至6月)的成年患者在手術前都進行了交叉配血,這些手術不包括複雜的手術,外科醫生估計出術中可能的出血量和術後的紅細胞壓積,除了一些患有冠心病和ASAIII級以上的病人,輸血的底線是紅細胞壓積21%,病人特異性備血系統的敏感性、特異性、陽性預測值和陰性預測值可以計算出來。我們分析了178個進行了術前交叉配血的患者,總共進行了69種不同的手術,有42個外科醫生參與,只有16%的患者術中接受了輸血,根據病人特異性備血系統預測的156個不需要輸血的患者中139人沒有輸血,而預測的12個需要輸血的患者中有11人輸了血,通過計算得出敏感性是41%,特異性是93%,陽性預測值55%,陰性預測值89%。我們的結論是:由於根據病人特異性備血系統預測輸血包括了病人和外科醫生兩方面的因素,所以它要比單純依靠手術預測輸血的最大備血表要準確。

薛張綱校)

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.

 

活體肝移植的供體進行右半肝切除時的輸血需要量和血液稀釋

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.

 

活體肝移植中供體的危險因素越來越受到重視,我們提供了44個供體的資料,重點討論輸血量和如何避免輸異體血,評估的輸血量(術前採集的自體血和異體血)包括術中做等容量血液稀釋得到的血液、回收的紅細胞和重新回輸的量。在術前和術中規定的時間測量血紅蛋白濃度和中心靜脈壓,術中出血量可以計算並且和切肝的時間、切掉肝的容量以及中心靜脈壓有關。在這期間沒有發生麻醉誘發的併發症,有4個供體發生了大出血(出血量>2000),平均失血量是902±564 mL,允許的最小血紅蛋白濃度是8.1±1.2 g/dL。有一位元供體輸了3個單位的異體血,30位供體輸了他們術前採集的自體血、手術時等容量血液稀釋得到的592±112 mL自體血和紅細胞回收裝置收集的421±333 mL洗滌紅細胞。對於成年肝移植供體避免輸注異體血,綜合使用節約用血技術和有效地術後鎮痛是非常重要的。當我們綜合使用術中紅細胞收集、術前自體血採集和血液稀釋,絕大多數供體就可以避免輸注庫血。

薛張綱 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.

 

鞘內注射布比卡因或sameridine後所致的高二氧化碳和低氧通氣反應

 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

\.

Sameridine是一種新的藥物,兼有局麻作用和阿片類藥物的特性(部分為輕微的阿片受體拮抗作用)。用它進行鞘內注射,可為外科手術提供麻醉以及長時間的術後鎮痛治療。在這個雙盲,平行對照的藥效學試驗中,持續觀察鞘內注射布比卡因或sameridine24小時內對患者在安靜或有高二氧化碳及低氧情況下的通氣狀況的影響。24名健康志願者接受了25mgsameridine或者15mg布比卡因的鞘內注射。觀測肺血流速度和相應的二氧化碳曲線圖以評價通氣狀況。採用視覺模糊評分法(VAS)來評估鎮靜情況。兩組的節段擴散與感覺和運動阻滯情況相似。布比卡因組在注射後有2.5-6小時潮氣量降低,而sameridine組僅持續4小時。安靜情況下兩組間沒有其他明顯的通氣差別。Sameridine組高二氧化碳(潮氣量,平均吸氣流量)和低氧(平均吸氣流量)通氣反應的發生率有輕微降低,而布比卡因組沒有。因此得出結論:在24小時的觀察期內,給健康志願者鞘內注射sameridine或布比卡因對通氣反應產生相似而較小的影響。

嵇富海 薛張綱 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.

 

一項前瞻性盲法試驗:上唇咬合試驗(一項簡單的新技術)和Mallampati分級預測氣管插管難度的比較

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.

 

探索用一項簡單的測試取代Mallampati評分來評估有難度的或面臨缺氧而未完成氣管插管的病人情況。300名成年患者入選本試驗。按 照以下標準對他們進行評估:1)根據Mallampati標準進行口咽評估;2)根據新的上唇咬和標準進行評估,組I:下切牙可咬至上唇的唇紅緣以上;組II:下切牙可咬至上唇的唇紅緣以下;組III:下切牙不能咬到上唇;3)根據Cormacks標準評估聲門暴露情況。發生困難插管的比率為5.7%。上唇咬和試驗比Mallampati評分顯著顯示出較高的專一性和準確性(P<0.001)。但是比較兩種方法的敏感性、正確和錯誤預測的比值,沒有顯著差異(P>0.05)。由此得出結論:作為一項簡單的測試,在預測困難氣管插管方面,上唇咬和試驗是可以接受的。

嵇富海 薛張綱 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.

 

氧化亞氮麻醉後Brandt導管減輕套囊漏氣現象

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導管在氧化亞氮麻醉時可以限制過高的套囊壓力。但是缺乏資料來評估Brandt導管是否可以在中止一氧化氮麻醉後避免套囊漏氣。在本試驗中,以Brandt導管為試驗組,Hi-Contour導管(Mallinckrodt,Athlone,愛爾蘭)為對照組,分別記錄67%一氧化氮麻醉時充滿空氣的套囊壓力;如果套囊壓力超過22mmHg,則抽出套囊內的空氣。180分鐘後用氧氣來替代一氧化氮。兩組的套囊壓力均有明顯下降,但是Brandt組的套囊壓力恢復到最初的水平所需時間比對照組長(分別為76.5+/-35.2分鐘和36.5+/-18.1分鐘;P=0.03)。對照組發生漏氣的概率要比Brandt組頻繁(P=0.015);與對照組(從46.2+/-3.8%18.6+/-5.6%)相比,Brandt組(從6.6+/-1.2%3.4+/-0.9%套囊內氧化亞氮變化較小。因此,氧化亞氮麻醉後Brandt導管可以減輕套囊的漏氣現象。有鑒於此,氧化亞氮麻醉時反復的套囊漏氣可以引起中止氧化亞氮麻醉後的套囊漏氣,從而存在導管漏氣的危險。

嵇富海 薛張綱 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.