Anesthesia & Analgesia

March 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

心脏术后并发症:急性肾功能不全与房颤的关系

(李绍清 薛张纲 )

Postcardiac Surgery Complications: Association of Acute Renal Dysfunction and Atrial Fibrillation

Maher J. Albahrani, Madhav Swaminathan, Barbara Phillips-Bute, Peter K. Smith, Mark F. Newman, Joseph P. Mathew, and Mark Stafford-Smith

Anesth Analg 2003 96: 637-643.

 

心肺转流时Alpha-StatpH-Stat与颈静脉血氧饱和度和脑血糖-血氧利用关系的比较

(赵雪莲 庄心良 校)

Comparison of Alpha-Stat and pH-Stat Cardiopulmonary Bypass in Relation to Jugular Venous Oxygen Saturation and Cerebral Glucose-Oxygen Utilization

H. Tarik Kiziltan, Mehmet Baltali, Ahmet Bilen, Gülsah Seydaoglu, Muzaffer Incesoz, Atilay Tasdelen, and Sait Aslamaci

Anesth Analg 2003 96: 644-650.

 

钳夹兔腹部动脉时及随后的脑微循环改变:血栓素A2受体的作用

(朱慧琛   王祥瑞 )

Changes in Cerebral Microcirculation During and After Abdominal Aortic Cross-Clamping in Rabbits: The Role of Thromboxane A2 Receptor

Masayoshi Uchida, Hiroki Iida, Mami Iida, and Shuji Dohi

Anesth Analg 2003 96: 651-656

 

围术期 Dexmedetomidine 减低犬心肌乳酸产生

(李绍清 译, 薛张纲 )

Dexmedetomidine Decreases Perioperative Myocardial Lactate Release in Dogs

Henriëtte M. Willigers, Frits W. Prinzen, Paul M. Roekaerts, Simon de Lange, and Marcel E. Durieux

Anesth Analg 2003 96: 657-664.

短期应用乙醇不影响清醒狗心肌顿抑的功能恢复

(赵雪莲 庄心良 校)

Short-Term Administration of Ethanol Does Not Affect Functional Recovery from Myocardial Stunning in Awake Dogs

Thomas Peter Weber, Maike Anja Große Hartlage, Norbert Rolf, Michael Booke, Elmar Berendes, Hugo Van Aken, and Andreas Meißner

Anesth Analg 2003 96: 665-672.

在正常鼠与高血压鼠盐酸美西氯通过动脉三磷酸腺苷敏感性钾离子通道调节血管舒张功能的比较

(朱慧琛   王祥瑞 )

 

Mexiletine Differentially Modulates Vasorelaxation Mediated by Adenosine Triphosphate-Sensitive K+ Channels in Aortas from Normotensive and Hypertensive Rats

Yoshiki Kimoto, Hiroyuki Kinoshita, Katsutoshi Nakahata, Mayuko Dojo, Hiroshi Iranami, and Yoshio Hatano

Anesth Analg 2003 96: 673-679.

PEDIATRIC ANESTHESIA:

儿童硬膜外自控镇痛:能行吗?

(李绍清 薛张纲 )

Patient-Controlled Epidural Analgesia in Children: Can They Do It?

Patrick K. Birmingham, Melissa Wheeler, Santhanam Suresh, Richard M. Dsida, Bronwyn R. Rae, Jennifer Obrecht, Vicki A. Andreoni, Steven C. Hall, and Charles J. Coté

Anesth Analg 2003 96: 686-691.

ANESTHETIC PHARMACOLOGY:

GABAA受体阻断剂可以剂量依赖性地拮抗丙泊酚而非氯胺酮或异氟醚引起的体动消失

( 庄心良  校)

GABAA Receptor Blockade Antagonizes the Immobilizing Action of Propofol but Not Ketamine or Isoflurane in a Dose-Related Manner

James M. Sonner, Yi Zhang, Caroline Stabernack, Wella Abaigar, Yilei Xing, and Michael J. Laster

Anesth Analg 2003 96: 706-712.

 

丙泊酚对手术病人血小板和白细胞和红细胞相互作用的影响

(殷文渊 王祥瑞 )

The Effect of Propofol on the Interaction of Platelets with Leukocytes and Erythrocytes in Surgical Patients

D. Mendez, J.P. De La Cruz, M.M. Arrebola, A. Guerrero, J.A. González-Correa, E. García-Temboury, and F. Sánchez de la Cuesta

Anesth Analg 2003 96: 713-719.

 

七氟醚麻醉和瑞芬太尼麻醉苏醒时意识、记忆功能、脑电图的改变  

(顾悦超 薛张纲 )

Changes in Consciousness, Conceptual Memory, and Quantitative Electroencephalographical Measures During Recovery from Sevoflurane- and Remifentanil-Based Anesthesia

Andrew Ronald Gordon Muncaster, James Wallace Sleigh, and Murray Williams

Anesth Analg 2003 96: 720-725.

 

小剂量氯胺酮对瑞米芬太尼的镇痛作用、痛觉过敏和耐受的影响

(     庄心良校)

Modulation of Remifentanil-Induced Analgesia, Hyperalgesia, and Tolerance by Small-Dose Ketamine in Humans

Martin Luginbühl, Andrea Gerber, Thomas W. Schnider, Steen Petersen-Felix, Lars Arendt-Nielsen, and Michele Curatolo

Anesth Analg 2003 96: 726-732.

 

豚鼠心脏中δ-和κ-阿片类激动剂对肌丝Ca2+敏感性的调节

(殷文渊   王祥瑞 )

Modulation of Myofilament Ca2+ Sensitivity by {delta}- and {kappa}-Opioid Agonists in Intact Guinea Pig Hearts

Yuri Nakae, Satoshi Fujita, and Akiyoshi Namiki

Anesth Analg 2003 96: 733-739.

 

氟烷和异氟醚对病人术后肝动脉和门静脉血流影响的比较

(顾悦超 薛张纲 )

The Postoperative Effects of Halothane Versus Isoflurane on Hepatic Artery and Portal Vein Blood Flow in Humans

Claire Gatecel, Marie-Reine Losser, and Didier Payen

Anesth Analg 2003 96: 740-745.

 

GABA在氮气、氩气及氧化亚氮麻醉中的神经药理作用研究

(   庄心良 校)

Gamma-Aminobutyric Acid Neuropharmacological Investigations on Narcosis Produced by Nitrogen, Argon, or Nitrous Oxide

Jacques H. Abraini, Badreddine Kriem, Norbert Balon, Jean-Claude Rostain, and Jean-Jacques Risso

Anesth Analg 2003 96: 746-749.

 

和术前未使用庆大霉素相比,术中使用较大剂量较适当剂量庆大霉素更能增强维库溴胺的肌松效应

(   王祥瑞 )

The Effect of Vecuronium Is Enhanced by a Large Rather than a Modest Dose of Gentamicin as Compared with No Preoperative Gentamicin

Zohar A. Dotan, Rene Hana, Daniel Simon, Daniel Geva, Reuven A. Pfeffermann, and Tiberiu Ezri

Anesth Analg 2003 96: 750-754.

TECHNOLOGY, COMPUTING, AND SIMULATION:

七氟醚分解产生一氧化氮:一项临床研究模型:

(顾悦超 薛张纲 )

Carbon Monoxide Production from Sevoflurane Breakdown: Modeling of Exposures Under Clinical Conditions

Elena J. Holak, David A. Mei, Marshall B. Dunning, III, Rao Gundamraj, Randa Noseir, Lu Zhang, and Harvey J. Woehlck

Anesth Analg 2003 96: 757-764.

 

静脉氟哌利多导致腰麻时异丙酚镇静病人脑电双频指数下降

(   庄心良 校)

Intravenous Droperidol Causes a Reduction in the Bispectral Index in Propofol-Sedated Patients During Spinal Anesthesia

Masayasu Nakayama, Noriaki Kanaya, Hiromichi Ichinose, Shuji Yamamoto, and Akiyoshi Namiki

Anesth Analg 2003 96: 765-768.

PAIN MEDICINE:

鞘内使用吗啡(非小剂量)诱导的大鼠主动脉非损伤性间断阻断后的下肢痉挛性轻瘫

(张俊峰 译 薛张刚 校)

Intrathecal Administration of Morphine, but Not Small Dose, Induced Spastic Paraparesis After a Noninjurious Interval of Aortic Occlusion in Rats

Manabu Kakinohana, Tatsuya Fuchigami, Seiya Nakamura, Takeshi Sasara, Tetsuya Kawabata, and Kazuhiro Sugahara

Anesth Analg 2003 96: 769-775.

 

鞘内持续注射可乐定和替扎尼定对清醒状态下犬的疼痛和血流动力学的影响

(王士雷    庄心良 校)

在清醒狗鞘内连续注射可乐宁和替托尼定的镇痛和血流动力学效应

(   王祥瑞 )

Continuous Intrathecal Clonidine and Tizanidine in Conscious Dogs: Analgesic and Hemodynamic Effects

Jeffrey S. Kroin, Robert J. McCarthy, Richard D. Penn, Timothy J. Lubenow, and Anthony D. Ivankovich

Anesth Analg 2003 96: 776-782.

小鼠鞘内注射曲马多后对脊髓本体感应诱发电位和运动诱发电位的影响

 (忻纪华   王祥瑞 )

The Effects of Intrathecal Tramadol on Spinal Somatosensory-Evoked Potentials and Motor-Evoked Responses in Rats

I-Ming Jou, Koung-Shing Chu, Hsing-Hong Chen, Pei-Jung Chang, and Yu-Chuan Tsai

Anesth Analg 2003 96: 783-788.

 

术后单次小剂量氯胺酮可快速持续地改善对吗啡抵抗患者的吗啡镇痛效果

(   庄心良  校)

A Single Small Dose of Postoperative Ketamine Provides Rapid and Sustained Improvement in Morphine Analgesia in the Presence of Morphine-Resistant Pain

Avi A. Weinbroum

Anesth Analg 2003 96: 789-795.

CRITICAL CARE AND TRAUMA:

外科监护室病人体温过低的预测

(   王祥瑞 )

Predictor of Core Hypothermia and the Surgical Intensive Care Unit

(Special Article)

Suneerat Kongsayreepong, Crirapha Chaibundit, Jittika Chadpaibool, Chulaluk Komoltri, Suwannee Suraseranivongse, Pudsadee Suwannanonda, Em-orn Raksamanee, Pensri Noocharoen, Aurasa Silapadech, Sudta Parakkamodom, Chusri Pum-In, and Lilanuch Sojeoyya

Anesth Analg 2003 96: 826-833.

 

术后机械通气病人相继使用咪唑安定和异丙酚进行长期镇静治疗

(张俊峰 薛张刚 校)

Sequential Use of Midazolam and Propofol for Long-Term Sedation in Postoperative Mechanically Ventilated Patients (Special Article)

Masataka Saito, Yoshiaki Terao, Makoto Fukusaki, Tetsuji Makita, Osamu Shibata, and Koji Sumikawa

Anesth Analg 2003 96: 834-838.

NEUROSURGICAL ANESTHESIA:

细胞凋亡作为家兔脊髓缺血后迟发性截瘫的原因缺乏足够证据

(王士雷     庄心良  校)

Lack of Evidence for Apoptosis as a Cause of Delayed Onset Paraplegia After Spinal Cord Ischemia in Rabbits

Takashi Kiyoshima, Shiro Fukuda, Mishiya Matsumoto, Yasuhiko Iida, Satoe Oka, Kazuhiko Nakakimura, and Takefumi Sakabe

Anesth Analg 2003 96: 839-846.

在健康志愿者无创性评估呼末二氧化碳的变化对脑灌注压和零流压的影响

(   王祥瑞 )

Noninvasive Estimation of Cerebral Perfusion Pressure and Zero Flow Pressure in Healthy Volunteers: The Effects of Changes in End-Tidal Carbon Dioxide

Sally M. Hancock, Ravi P. Mahajan, and Labros Athanassiou

Anesth Analg 2003 96: 847-851.

REGIONAL ANESTHESIA:

用磁共振显像评估锁骨上 Plumb-Bob技术在臂丛阻滞中的应用

(轩   庄心良 校)

An Evaluation of the Supraclavicular Plumb-Bob Technique for Brachial Plexus Block by Magnetic Resonance Imaging

Øivind Klaastad, Timothy R. VadeBoncouer, Terje Tillung, and Örjan Smedby

Anesth Analg 2003 96: 862-867.

 

经臀大肌下股二头肌旁坐骨神经单次阻滞新方法的评估

Infragluteal-Parabiceps Sciatic Nerve Block: An Evaluation o

(   王祥瑞 )

Infragluteal-Parabiceps Sciatic Nerve Block: An Evaluation of a Novel Approach Using a Single-Injection Technique

Radha Sukhani, Kenneth D. Candido, Robert Doty, Jr., Edward Yaghmour, and Robert J. McCarthy

Anesth Analg 2003 96: 868-873.

 

小剂量1%3%高张利多卡因溶液行腰麻的比较

(张军   庄心良 校)

A Comparison of Hyperbaric 1% and 3% Solutions of Small-Dose Lidocaine in Spinal Anesthesia

Yurie Tohdoh Kawamata, Koki Nishikawa, Tomoyuki Kawamata, Keiichi Omote, Motohiko Igarashi, Masanori Yamauchi, Koichi Sato, Masayasu Nakayama, and Akiyoshi Namiki

Anesth Analg 2003 96: 881-884.

GENERAL ARTICLES:

对志愿者在特定一点(extra 1)施压针疗可减低脑电双频指数值和应激

(忻纪华 王祥瑞 )

Pressure Applied on the Extra 1 Acupuncture Point Reduces Bispectral Index Values and Stress in Volunteers

Argyro Fassoulaki, Adia Paraskeva, Konstantinos Patris, Theodora Pourgiezi, and Georgia Kostopanagiotou

Anesth Analg 2003 96: 885-890.

 

三种插管设备在正常血压和高血压病人上的血流动力学反应

(潘志浩 薛张刚 校)

Hemodynamic Responses Among Three Tracheal Intubation Devices in Normotensive and Hypertensive Patients

S. Kihara, J. Brimacombe, Y. Yaguchi, S. Watanabe, N. Taguchi, and T. Komatsuzaki

Anesth Analg 2003 96: 890-895.

 

钳夹兔腹部动脉时及随后的脑微循环改变:血栓素A2受体的作用

Changes in Cerebral Microcirculation During and After Abdominal Aortic Cross-Clamping in Rabbits: The Role of Thromboxane A2 Receptor

Masayoshi Uchida, MD*, Hiroki Iida, MD*, Mami Iida, MD{dagger}, and Shuji Dohi, MD*

Departments of *Anesthesiology and Critical Care Medicine and {dagger}Internal Medicine, Gifu University School of Medicine, Gifu City, Japan

Anesth Analg 2003;96:651-656

有关钳夹和松开兔腹部动脉时及随后出现的脑血流动力学,尤其是脑微循环的改变我们所知甚少。观察27只兔子通过一个密闭的颅窗观测钳夹和松开腹部动脉时使用或不使用血栓素(Tx A2受体拮抗剂对脑膜血管直径的影响。结果表明在钳夹肾下动脉时未发现脑膜血管直径的改变,但钳夹20分钟松开后会引起脑膜血管的舒张随后收缩。显著的收缩至少持续了60分钟(大血管收缩17% []75um)小血管收缩28% [<75um]). 局部使用TxA2受体拮抗剂(seratrodast10-7M10-6M后可明显改善大小血管的收缩情况,钳夹20分钟后再松开腹部血管会引起脑膜动脉的持续性收缩,这一现象可通过局部使用seratrodast而削减,这可能是由于间接阻断了TxA2对局部缺血区域的作用所致。

(朱慧琛   王祥瑞 )

Little is known about any changes in cerebral hemodynamics, during and after abdominal aortic cross-clamping and unclamping, especially in the cerebral microcirculation. We studied the effects of abdominal aortic cross-clamping and unclamping on cerebral pial vessel diameter in the presence or absence of the thromboxane (Tx)A2 receptor antagonist using a closed cranial window in 27 rabbits. Although infrarenal aortic cross-clamping did not affect pial vessel diameter, release of a 20-min aortic cross-clamp caused pial arterioles to dilate and then constrict. A significant constriction persisted for at least 60 min (maximum, -17% for large [>=75 µm] and -28% for small arterioles [<75 µm] compared with baseline). Topical administration of a TxA2 receptor antagonist, seratrodast, at 10-7 M and 10-6 M, significantly attenuated the constriction of large and small arterioles (at 60 min, -9% and -13% constriction for 10-7 M, and -6% and -7% for 10-6 M). Release of a 20-min aortic cross-clamp induced a sustained pial arteriolar constriction. Because this unclamping-induced vasoconstriction was attenuated by topical administration of seratrodast, it was likely partially mediated via the washout of TxA2 produced in the ischemic region during the clamp and after cross-clamp release.


 

在正常鼠与高血压鼠盐酸美西氯通过动脉三磷酸腺苷敏感性钾离子通道调节血管舒张功能的比较

Mexiletine Differentially Modulates Vasorelaxation Mediated by Adenosine Triphosphate-Sensitive K+ Channels in Aortas from Normotensive and Hypertensive Rats

Yoshiki Kimoto, MD*, Hiroyuki Kinoshita, MD{dagger}, Katsutoshi Nakahata, MD{dagger}, Mayuko Dojo, MD*, Hiroshi Iranami, MD{dagger}, and Yoshio Hatano, MD

*Department of Anesthesiology, Wakayama Medical College; and {dagger}Department of Anesthesia, Japanese Red Cross Society, Wakayama Medical Center, Japan *

Anesth Analg 2003;96:673-679

慢性高血压患者服用抗心律失常药物后经由三磷酸腺苷(ATP)敏感性钾离子通道调节血管舒张功能的研究尚未见报道。本研究测试患有高血压的老鼠在服用盐酸美西氯后是否可经由某些通路调节血管舒张功能。对正常老鼠与有高血压的老鼠去除动脉内皮进行等容压力记录。健康鼠服用盐酸美西氯 (3*10-5M)后经由左克罗卡林 (10-8-10-5M)作用增强血管舒张,而患有高血压的老鼠则无反应。服用盐酸美西氯(10-5 -- 3*10-5M)增强血管舒张功能相当于硝普钠(10-10--10-5M),然而使用ATP敏感性钾离子通道拮抗剂glivenclamide (10-5M)可抑制这种作用。一氧化氮清除剂(carboxy-2-phentl-4,4,5,5-tetramethylimidazoline-q-oxyl 3-oxide; 10-3 M)可抑制健康鼠动脉中盐酸美西氯的血管扩张作用,然而可溶性鸟苷酸环化酶抑制剂则无上述作用。综上所述盐酸美西氯可经由健康鼠动脉中某些物质如一氧化氮活化ATP敏感性钾离子通道而提高血管舒张功能,盐酸美西氯的血管舒张作用部分也可能是由于一氧化氮的可溶性非鸟苷酸环化酶依赖性作用引起。

(朱慧琛   王祥瑞 )

The modification of vasodilation through adenosine triphosphate (ATP)-sensitive K+ channels induced by antiarrhythmic drugs has not been studied in chronic hypertension. We designed the present study to examine whether mexiletine modulates vasorelaxation via these channels in hypertensive rat aortas. Normotensive and hypertensive rat aortas without endothelium were suspended for isometric force recording. Mexiletine (3 x 10-5 M) increased vasorelaxation induced by levcromakalim (10-8–10-5 M) in normotensive, but not hypertensive, rat aortas. Mexiletine (10-5 to 3 x 10-5 M) also augmented vasorelaxation to sodium nitroprusside (10-10–10-5 M) only in normotensive rat aortas, whereas mexiletine (3 x 10-5 M) did not affect this vasodilation in aortas treated with an ATP-sensitive K+ channel antagonist glibenclamide (10-5 M). A nitric oxide scavenger (carboxy-2-phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl 3-oxide; 10-3 M) abolished augmented vasorelaxation to sodium nitroprusside induced by mexiletine (3 x 10-5 M) in normotensive rat aortas, whereas a soluble guanylate cyclase inhibitor (1H-[1,2,4]oxadiazolo [4,3,-a]quinoxaline-1-one; 10-5 M) failed to alter this augmentation of vasorelaxation. These results suggest that mexiletine induces augmentation of vasodilation via ATP-sensitive K+ channels activated by the opener as well as a nitric oxide donor only in normotensive rat aortas. The vasodilator effects of mexiletine are partly caused by the soluble guanylate cyclase-independent action of nitric oxide on these channels.


 

丙泊酚对手术病人血小板和白细胞和红细胞相互作用的影响

The Effect of Propofol on the Interaction of Platelets with Leukocytes and Erythrocytes in Surgical Patients

D. Mendez, PhD*, J.P. De La Cruz, PhD{dagger}, M.M. Arrebola, PhD{dagger}, A. Guerrero, PhD{dagger}, J.A. González-Correa, PhD{dagger}, E. García-Temboury, MD*, and F. Sánchez de la Cuesta, PhD{dagger}

*Anesthesiology and Resuscitation Unit, Carlos Haya University Hospital, Málaga; and {dagger}Department of Pharmacology and Therapeutics, School of Medicine, University of Málaga, Spain

Anesth Analg 2003;96:713-719


 在手术病人体外试验中测试丙泊酚的抗血小板作用。血小板聚合体由二磷酸腺苷诱导,在全血,含有丰富血小板的血浆(RPR),RPR+红细胞,RPR+白细胞四种样本中测定花生四烯酸。同时也测定血小板产物血栓烷(TxB2和白细胞产物6-酮前列腺素F1α(一种稳定的前列腺素代谢产物)和血浆中的硝酸盐+亚硝酸盐水平(氧化氮产物的指示剂)。麻醉诱导为静脉注射硫喷妥钠4 mg/kgn=10),丙泊酚2.5 mg/kgn=20),或全凭丙泊酚静脉麻醉(n=20)。硫喷妥钠对分析结果没有任何影响。大剂量注射丙泊酚的病人,在全血和RPR+白细胞中的血小板聚合体显著减少。血小板产物血栓烷(TxB2减少了35%;对6-酮前列腺素F1α的抑制在统计学上不是很显著。血浆中的硝酸盐+亚硝酸盐水平增加了37%;这个变化与舒张压和收缩压的降低显著相关(都P<0.05)。虽然数量较大,在全凭丙泊酚静脉麻醉也可观察到类似变化。总之,丙泊酚抑制了手术病人的血小板聚合体,这主要是抑制Tx合成和氧化氮产物增加的结果。这种影响被认为与这种麻醉相关的血压降低有关。

(殷文渊 王祥瑞 )

We tested the antiplatelet effect described for propofol in vitro in surgical patients. Platelet aggregation induced by adenosine diphosphate, collagen, and arachidonic acid was tested in samples of whole blood, platelet-rich plasma (PRP), PRP with red blood cells, and PRP with leukocytes. Also measured were platelet production of thromboxane (Tx)B2 and leukocyte production of 6-keto-prostaglandin F1{alpha} (a stable metabolite of prostacyclin) and plasma levels of nitrites + nitrates (indicator of nitric oxide production). Anesthesia was induced with a bolus IV injection of sodium thiopental 4 mg/kg (n = 10), with a bolus dose of 2.5 mg/kg of propofol (n = 20), or with propofol total IV anesthesia (n = 20). Sodium thiopental did not modify any of the analytical values. In patients who received a bolus injection of propofol, platelet aggregation was significantly reduced in whole blood and in PRP + leukocytes. Platelet production of TxB2 was reduced by 35%; the inhibition of 6-keto-prostaglandin F1{alpha} was not statistically significant. Plasma levels of nitrites + nitrates increased by 37%; this change correlated significantly with the decrease in systolic and diastolic blood pressure (both P < 0.05). Similar changes, albeit of larger magnitude, were seen in patients who were given total IV anesthesia with propofol. In conclusion, propofol inhibited platelet aggregation in surgical patients mainly as a result of the inhibition of Tx synthesis and the increase in nitric oxide production. These effects are thought to be related to the hypotensive effect of this anesthetic.


豚鼠心脏中δ-κ-阿片类激动剂对肌丝Ca2+敏感性的调节

Modulation of Myofilament Ca2+ Sensitivity by {delta}- and {kappa}-Opioid Agonists in Intact Guinea Pig Hearts

Yuri Nakae, MD PhD*, Satoshi Fujita, MD PhD{dagger}, and Akiyoshi Namiki, MD PhD*

*Department of Anesthesiology, Sapporo Medical University School of Medicine; and {dagger}Departments of Anesthesiology and Critical Care Medicine, Asahikawa Medical College, Japan  

Anesth Analg 2003;96:733-739

 

研究δ-和κ-阿片类激动剂是否会改变心肌功能,细胞内Ca2+浓度([Ca2+]i,和完整豚鼠心脏肌丝Ca2+敏感性以及这些影响是否由阿片类收体所介导。完整豚鼠心脏用 含有δ-TAN-67)和κ-(ICI-199441)阿片类激动剂的修正Krebs Ringer溶液灌注,存在以及不存在δ-BNTX)和κ-(nor-BNI)阿片类拮抗剂,分别记录功能变化和[Ca2+]i。δ-TAN-67)和κ-(ICI-199441)降低心率(P<0.05)。TAN-671μMICI-1994411μM降低可使用[Ca2+]i但不改变左室压增加(P<0.05)。TAN-671μMICI-1994411μM也会导致LVP增加也就是可利用[Ca2+]i功能曲线左移(P<0.05)。在相关曲线中,ICI-1994411μM会产生一个与基线相比较陡峭的斜坡(P<0.05)。BNTX1μM nor-BNI1μM分别阻滞了TAN-67ICI-199441的作用。在完整隔离的豚鼠心脏中,δ-和κ-阿片类激动剂虽然降低了可利用[Ca2+]I,但增强了肌丝Ca2+敏感性,这些作用为δ-和κ-阿片类激动剂受体刺激所介导。

(殷文渊   王祥瑞 )

We investigated whether {delta}- and {kappa}-opioid agonists alter myocardial function, intracellular Ca2+ concentration ([Ca2+]i), and myofilament Ca2+ sensitivity in intact guinea pig beating hearts and whether these effects are mediated by an opioid receptor. Intact guinea pig hearts were perfused with modified Krebs Ringer solution containing {delta}- (TAN-67) and {kappa}- (ICI-199441) opioid agonists in the absence and presence of {delta}- (BNTX) and {kappa}- (nor-BNI) opioid antagonists, respectively, while functional variables and [Ca2+]i were recorded. TAN-67 (1 µM) and ICI-199441 (1 µM) decreased heart rate (P < 0.05). TAN-67 (1 µM) and ICI-199441 (1 µM) decreased available [Ca2+]i without changing developed left ventricular pressure (LVP) (P < 0.05). TAN-67 (1 µM) and ICI-199441 (1 µM) also caused a leftward shift in the curve of developed LVP as a function of available [Ca2+]i (P < 0.05). ICI-199441 (1 µM) produced a steeper slope in the relation curve compared with baseline (P < 0.05). BNTX (1 µM) and nor-BNI (1 µM) blocked the effects of TAN-67 and ICI-199441, respectively. {delta}- and {kappa}-opioid agonists enhance myofilament Ca2+ sensitivity despite decreasing available [Ca2+]i in intact isolated guinea pig hearts, and these effects are mediated by {delta}- and {kappa}-opioid receptor stimulation.

和术前未使用庆大霉素相比,术中使用较大剂量较适当剂量庆大霉素更能增强维库溴胺的肌松效应

The Effect of Vecuronium Is Enhanced by a Large Rather than a Modest Dose of Gentamicin as Compared with No Preoperative Gentamicin

Zohar A. Dotan, MD*, Rene Hana, MD{dagger}, Daniel Simon, MD{dagger}, Daniel Geva, MD{ddagger}, Reuven A. Pfeffermann, MD{dagger}, and Tiberiu Ezri, MD§

*Department of Urology, Sheba Medical Center, Ramat Gan; Departments of {dagger}General Surgery and {ddagger}Anesthesia, Kaplan Medical Center, Rehovot; and §Department of Anesthesia, Wolfson Medical Center, Holon, Israel (Affiliated with *§Sackler School of Medicine, Tel Aviv and {dagger}{ddagger}Hadassah Medical School, Jerusalem, Israel)

 Anesth Analg 2003;96:750-754

 

比较了2种剂量的庆大霉素使用后及术前未使用庆大霉素的病人中,对维库溴胺的肌松效应的影响。70例病人被随机分组,LD组术前使用4mg/kg的庆大霉素,MD组术中使用1.24mg/kg的庆大霉素,NG组在万可罗宁使用前不使用庆大霉素。比较各组病人间血清庆大霉素浓度,单次注射维库溴胺后四个成串刺激的第一个抽搐强度达到25%的时间,以及末次使用维库溴胺后到拔除气管导管的时间。LD组的血清庆大霉素水平高于MD组(P<0.001)。T125%恢复时间在LD组略高于MD组(P=0.06),在LD组明显高于NG组(P+0.001)(各组数值分别为42.9±23.636.2±1727.4±19.3分钟)。在LD组和MD组拔管时间相近,LD组的拔管时间明显长于NG组(P=0.008)(各组数值分别为34.7±19.227.4±19.319.4±10.1分钟)。MD组和NG组的差别是显而易见的。与不使用庆大霉素相比,使用大剂量庆大霉素较适当剂量明显增强维库溴胺的神经肌肉阻断效果。

(   王祥瑞 )

We compared the effect of two doses of gentamicin versus no gentamicin (NG) given before surgery on the neuromuscular relaxant effect of vecuronium. Seventy patients (intraabdominal procedures) were randomly allocated to receive preoperative large-dose (4 mg/kg) gentamicin (LD), a modest dose (1.2 mg/kg) of gentamicin (MD), or NG. No more than one dose of gentamicin was given before the vecuronium administration. Serum gentamicin levels, the time for 25% recovery of the first twitch in the train-of-four after a bolus of vecuronium, and the time from cessation of the vecuronium infusion to extubation of the trachea were estimated. Serum gentamicin levels were higher (P < 0.001) for LD than MD. The time for 25% recovery of the first twitch after the vecuronium bolus was slightly longer with LD than MD (P = 0.06) and longer in LD than NG (P = 0.001) (42.9 ± 23.6 min versus 36.2 ± 17 min and 27.4 ± 9 min, respectively). The time to extubation was similar with LD and MD and longer for LD than NG (P = 0.008) (34.7 ± 19.2 min versus 27.4 ± 19.3 min and 19.4 ± 10.1 min, respectively). The differences in these times were insignificant between MD and NG. Gentamicin administered as a LD rather than MD enhanced the neuromuscular blockade of vecuronium as compared with NG given before surgery.


 

在清醒狗鞘内连续注射可乐宁和替托尼定的镇痛和血流动力学效应

Continuous Intrathecal Clonidine and Tizanidine in Conscious Dogs: Analgesic and Hemodynamic Effects

Jeffrey S. Kroin, PhD*, Robert J. McCarthy, PharmD*, Richard D. Penn, MD{dagger}, Timothy J. Lubenow, MD*, and Anthony D. Ivankovich, MD

Departments of *Anesthesiology and {dagger}Neurosurgery, Rush Medical College, Chicago, Illinois

 Anesth Analg 2003;96:776-782


α-2受体激动剂,例如可乐宁,在动物模型中使用鞘内注射后可以产生镇痛效果。但由于有心血管系统的副作用,其临床应用受到限制。为了研究选择性α-2受体激动剂的镇痛效应,我们在6只狗体内留置鞘内导管以及推注泵。在注入基础负荷量之后,每周给予这些动物125-750μg/h的可乐宁或替托尼定,统计其镇痛效果,血压,心率,呼吸频率,镇静程度及协调能力。实验顺利进行了28天,另有9只狗接受鞘内注射替托尼定(36mg/天)或生理盐水。同等剂量的可乐宁和替托尼定的退热效应相等。在使用125-500μg/h的可乐宁时出现了血压下降,任何剂量的替托尼定都不伴有血压下降。250μg/h的可乐宁会导致心率下降45.8%,并有5-6只实验动物出现心率不齐(主要表现为心动过缓),而替托尼定可以使心率下降45.8%,但即使使用最大剂量时也不会出现心率失常。只有在大剂量使用上述2种药时,才会出现镇静和不协调表现。本实验提示,在狗体内,使用3mg/天的替托尼定不会出现明显副反应及组织病理学改变。替托尼定可以选择性地应用在鞘内注射可乐宁有明显心血管副反应的病人中。

(   王祥瑞 )

Alpha-2-adrenergic agonists, such as clonidine, produce antinociception in animal pain models after intrathecal administration. However, clinical usage is limited by cardiovascular side effects. To investigate alternative {alpha}2-adrenergic agonists as analgesics, we implanted six dogs with an intrathecal catheter and infusion pump. After baseline saline infusion, animals received clonidine or tizanidine (crossover study) each week at escalating doses of 125–750 µg/h. Analgesia, blood pressure, heart rate, respiratory rate, sedation, and coordination were evaluated. A 28-day safety study was performed with another nine dogs receiving intrathecal tizanidine (3 or 6 mg/d) or saline. Equal doses of clonidine and tizanidine produce the same antinociception in thermal withdrawal tests. Blood pressure was reduced with 125–500 µg/h of clonidine, but not with tizanidine at any dose. Clonidine 250 µg/h reduced heart rate by 45.8%, and five of six animals had bradyarrhythmias (marked bradycardia), whereas tizanidine decreased heart rate by 15.1% without arrhythmias, even at the largest dose. Respiratory rate decreased with 250 µg/h of clonidine and larger doses. Sedation or incoordination occurred only at the largest dose for either drug. The safety study indicated that 3 mg/d of tizanidine in dogs produced no side effects or histopathologic changes. Tizanidine may be a useful alternative in patients experiencing cardiovascular side effects with intrathecal infusion of clonidine.

 

小鼠鞘内注射曲马多后对脊髓本体感应诱发电位和运动诱发电位的影响

The Effects of Intrathecal Tramadol on Spinal Somatosensory-Evoked Potentials and Motor-Evoked Responses in Rats

I-Ming Jou, MD*, Koung-Shing Chu, MD{dagger}, Hsing-Hong Chen, MD{ddagger}, Pei-Jung Chang, MD{dagger}, and Yu-Chuan Tsai, MD{dagger}

Departments of *Orthopedics, {dagger}Anesthesiology, and {ddagger}Neurosurgery, National Cheng Kung University Medical Center, Tainan, Taiwan

Anesth Analg 2003;96:783-788


在临床和实验室研究中,曲马多均被证实对周围神经有局部麻醉作用。本研究中,我们在小鼠鞘内用药后,通过感觉和运动神经的传导来评价曲马多的作用。通过鞘内导管注入曲马多012mg。刺激坐骨神经后记录胸腰连接处的脊髓本体感觉诱发电位(SSEPs)。在电刺激低位(胸1213)椎间隙后记录足部内在肌肉的复合肌肉动作电位(CMAP)。在用药前记录SSEPCMAP作为基础值,记录用药后51530的值,以后4.5小时每个3060分钟记录一次。SSEP20次的平均值,而CMAP为单次刺激的值。所有小鼠中均能测得SSEPsCMAP值。鞘内注射曲马多产生剂量依赖的SSEPsCMAP刺激高度减弱和潜伏期延长。总之,注药后立即可产生抑制并能维持两小时。联合注射纳洛酮20ug并不能减弱脊髓SSEPs的抑制。我们得出结论,鞘内注射曲马多脊神经根的感觉或运动电位的传导产生剂量依赖性的抑制。

                                               (忻纪华   王祥瑞 )

Tramadol has been proven to exert a local anesthetic-type effect on peripheral nerves in both clinical and laboratory studies. In this study, we evaluated the effects of tramadol on sensory and motor neural conduction when administered intrathecally in the rat. Tramadol (0, 1, or 2 mg) was administered through an intrathecal catheter. Spinal somatosensory-evoked potentials (SSEPs) were recorded at the thoracolumbar junction after stimulation of the sciatic nerve. An evoked compound muscle action potential (CMAP) was recorded in the intrinsic muscles of the foot in response to electric stimulation of the lower thoracic (T1213) interspinous space. Both SSEP and CMAP were obtained before drug application as the pretreatment baseline and at 5, 15, and 30 min after treatment, and at 30- or 60-min intervals thereafter for another 4.5 h. SSEP was averaged from 20 responses, whereas CMAP was obtained from a single stimulation. Reproducible SSEPs and CMAP were consistently recorded in all rats. Intrathecal tramadol dose-dependently reduced the amplitude and delayed the latency in both SSEPs and CMAP. Generally, the suppressive effects occurred immediately after injection and recovered over 2 h. Combined administration with 20 µg of intrathecal naloxone did not attenuate the inhibition of spinal SSEPs. We conclude that intrathecal tramadol causes a dose-related suppressive effect on both sensory and motor neural conduction in the spinal cord.


 

外科监护室病人体温过低的预测

Predictor of Core Hypothermia and the Surgical Intensive Care Unit

Suneerat Kongsayreepong, MD*, Crirapha Chaibundit, MD*, Jittika Chadpaibool, MD*, Chulaluk Komoltri, DrPH{dagger}, Suwannee Suraseranivongse, MD MS*, Pudsadee Suwannanonda, BSN*, Em-orn Raksamanee, BSN*, Pensri Noocharoen, BSN*, Aurasa Silapadech, BSN*, Sudta Parakkamodom, BSN*, Chusri Pum-In, BSN{ddagger}, and Lilanuch Sojeoyya, BSN{ddagger}

Department of *Anesthesiology, {dagger}Clinical Epidemiology Unit, and {ddagger}Department of Nursing, Siriraj Hospital, Faculty of Medicine, Mahidol University, Bangkok, Thailand

Anesth Analg 2003;96:826-833


因疏忽导致术后病人中心体温过低可给病人带来许多生理影响,特别是对于监护室(ICU)中的病人。尽管关于病人、手术和麻醉因素与急性术后体温降低关系的论文已有报道,但为了促进外科手术、麻醉和保温技术的进一步发展,我们有必要将这些资料重新回顾一下。我们设计了一个包含194例普外科术后病人的前瞻性研究,来评估术后中心体温降低(鼓膜温度[TC]<36)的发生率、预见因素和后果,此研究中的病例均选自200012月至20013月期间large tertiary大学医学中心普外科ICU中的病人。研究中所包含的变量如下:年龄、性别、体重、体表面积、术前体温、ASA分级、有无糖尿病性神经病变史、是否急诊手术、专科实施的手术、手术种类、麻醉选择(全身麻醉、区域麻醉或硬膜外复合全身麻醉)、体温监测、空气保温技术的应用、术中输血补液量、麻醉持续时间、手术持续时间和手术室环境温度。另外,对其它一些后果、在ICU中的住院时间和死亡率也作了评估。结果发现TC<36℃、<35.5℃、<35℃的发生率分别为57.1%41.3%28.3%。多元回归分析显示体温降低的危险因素如下:高ASA分级(ASAII级的病人机率为2.8795%可信区间[CI]0.82-10.03ASA>II级的病人机率为8.3595%CI1.67-41.88),外科手术的大小(中等手术的机率为6.6095%CI1.66-26.19;大手术的机率为22.2395%CI5.41-91.36),应用硬膜外复合全身麻醉(机率为3.3995%CI1.05-10.88)和手术持续时间>2h(机率为4.5095%CI1.48-13.68)。另外,手术期间未进行体温监测似乎也是一个危险因素(机率为3.0095%CI0.87-10.12)。一些重要的保护因素可防止中心体温降低,主要包括:病人体重较重(机率为0.9495%CI0.89-0.98),术前体温较高(机率为0.3195%CI0.15-0.65),和手术室内比较温暖(机率为0.6795%CI0.51-0.88)。总之,在普外科ICU中病人发生体温降低仍然较常见。为减少其发生率,我们应该付出更大的努力,并给予更多的关心,特别是对于哪些ASA分级较高,实施重大和长时间手术以及应用硬膜外复合全身麻醉的病人。

(   王祥瑞 )

Inadvertent postoperative core hypothermia is associated with multiple physiological effects, especially in patients admitted to the intensive care unit (ICU). Despite previous reports of the relationship between patient, surgical, and anesthetic factors and immediate postoperative core hypothermia, this information might need to be reconsidered in the light of progress in surgery, anesthetic, and warming techniques. We designed this prospective study of 194 postgeneral surgical patients to assess the incidence, predictive factors, and outcome of core hypothermia (tympanic membrane core temperature [Tc] <36.0°C) at the time of admission to the general ICU in a large tertiary university medical center from December 2000 to March 2001. The following variables were studied: age, sex, body weight, body surface area, preoperative body temperature, ASA physical status, history of diabetic neuropathy, emergency surgery, surgical subspecialty performing surgery, type of surgery, type of anesthesia (general, regional, or combined epidural and general), temperature monitoring, use of a forced air warming technique, amount of fluid and blood replacement, duration of anesthesia, duration of surgery, and the ambient operating room temperature. Other outcomes, i.e., length of ICU stay and mortality, were also assessed. The incidence of core hypothermia was 57.1%, 41.3%, and 28.3% according to the definition of Tc <36.0°C, <35.5°C, and <35.0°C, respectively. Multiple logistic regression showed the following risk factors for core hypothermia: high ASA physical status (odds ratio, 2.87; 95% confidence interval [CI], 0.82–10.03 for ASA II; odds ratio, 8.35; 95% CI, 1.67–41.88 for ASA >II), magnitude of surgical procedure (odds ratio, 6.60; 95% CI, 1.66–26.19 for medium surgery; odds ratio, 22.23; 95% CI, 5.41–91.36 for major surgery), use of combined epidural and general anesthesia (odds ratio, 3.39; 95% CI, 1.05–10.88), and duration of surgery >2 h (odds ratio, 4.50; 95% CI, 1.48–13.68). Not using temperature monitoring seems to be a risk factor as well (odds ratio, 3.00; 95% CI, 0.87–10.12). Significant protective factors against core hypothermia were heavier body weight (odds ratio, 0.94; 95% CI, 0.89–0.98), higher preoperative body temperature (odds ratio, 0.31; 95% CI, 0.15–0.65), and warmer ambient operating room temperature (odds ratio, 0.67; 95% CI, 0.51–0.88). In conclusion, the incidence of core hypothermia (Tc <36.0°C) at the time of admission to the general ICU is still frequent. To reduce the incidence, more efforts and concern should be taken to prevent core hypothermia, especially in the patient with high ASA physical status, undergoing more intensive and lengthy surgery, and using combined epidural and general anesthesia.

在健康志愿者无创性评估呼末二氧化碳的变化对脑灌注压和零流压的影响

Noninvasive Estimation of Cerebral Perfusion Pressure and Zero Flow Pressure in Healthy Volunteers: The Effects of Changes in End-Tidal Carbon Dioxide

Sally M. Hancock, FRCA, Ravi P. Mahajan, FRCA DM, and Labros Athanassiou, FRCA

University Departments of Anaesthesia and Intensive Care, Queen’s Medical Centre and City Hospital NHS Trust, Nottingham, United Kingdom

Anesth Analg 2003;96:847-851

 

脑循环中的零流压(ZFP)是指血流终止点的动脉压力。我们可以通过经脑多普勒超声等无创性的方法来测定脑灌注压(CPP)和ZFP。由二氧化碳变化引起所测的CPPeCPP)和ZFP的变化很少引起相关的生理数据的变化。我们对17名健康的志愿者进行研究,观察二氧化碳对eCPPZFP的影响。在测定了脑中动脉的血流速度和血压后,我们让志愿者过度通气使他们的呼末二氧化碳降低约7.5mmHg,然后再通过Mapleson D回路使呼末二氧化碳增高7.5mmHg。血流速度和血压每一时段记录一次,eCPPZFP通过已知的公式被计算出来,其结果再用统计方法分析。随着呼末二氧化碳增高eCPP50.67 mmHg8.33 mmHg)(平均[SD])增高至60.87 mmHg9.28 mmHg)(增加20%P0.001〉,而ZFP相应降低(P=0.017);而低碳酸血症导致eCPPZFP相反的结果。这项研究结果提示我们在没有神经功能紊乱的情况下二氧化碳的变化可以预计eCPPZFP的变化。

(   王祥瑞 )

Zero flow pressure (ZFP) in the cerebral circulation is defined as the arterial pressure at which flow ceases. Noninvasive methods of estimating cerebral perfusion pressure (CPP) and ZFP using transcranial Doppler ultrasonography have been described. There is a paucity of normal physiological data related to changes in estimated CPP (eCPP) and ZFP induced by changes in carbon dioxide (CO2). We studied the effects of CO2 on eCPP and ZFP in 17 healthy volunteers. After baseline measurements of middle cerebral artery blood-flow velocity and blood pressure, subjects voluntarily hyperventilated to decrease their end-tidal CO2 (PE'CO2) by approximately 7.5 mm Hg, and then they increased their PE'CO2 by approximately 7.5 mm Hg by breathing through a Mapleson D circuit. Blood-flow velocity and blood pressure were recorded at each stage. The eCPP and ZFP were calculated by using established formulas, and the results were analyzed with analysis of variance. With increasing PE'CO2, eCPP increased from 50.67 mm Hg (8.33 mm Hg) (mean [SD]) to 60.87 mm Hg (9.28 mm Hg) (20% increase; P < 0.001), with a corresponding decrease in ZFP (P = 0.017); hypocapnia resulted in the opposite effects on eCPP and ZFP. These results indicate physiological changes in eCPP and ZFP that can be expected from changes in CO2 in subjects without any neurological disorder.

经臀大肌下股二头肌旁坐骨神经单次阻滞新方法的评估

Infragluteal-Parabiceps Sciatic Nerve Block: An Evaluation of a Novel Approach Using a Single-Injection Technique

Radha Sukhani, MD, Kenneth D. Candido, MD, Robert Doty, Jr., MD, Edward Yaghmour, MD, and Robert J. McCarthy, PharmD

Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2003;96:868-873


临床上使用标准的方法实施坐骨神经阻滞受到技术困难的限制,且患者在实施过程中非常不适,或需要两次注射来阻滞胫神经和腓神经。在这项报道中,我们描述了通过经臀大肌下股二头肌旁径路采取单次注射方法进行坐骨神经阻滞,此神经沿股二头肌的侧缘经过。坐骨神经阻滞的实施采取俯卧或侧卧位。当给予患者0.4mA的刺激同侧的脚发生跖屈曲或背伸便是进针的深度(平均为56±15mm)。然后给予浓度为0.625%1200000的肾上腺素的左旋布比卡因,剂量为0.4ml/kg。整个过程大概需要6±3分钟。24%的患者在放置过程中因不适给以150-100µg的芬太尼。92%的患者在注射平均10(范围,5-25)分钟后感觉完全消失和运动阻滞。与跖屈曲相比,足背伸发生率更高分别为86%100%,并且对胫神经,腓神经和腓肠神经感觉和运动阻滞的反应时间更短。此种方法没有即刻发生或随后发生的并发症。我们得出结论经臀大肌下股二头肌旁坐骨神经阻滞是一种可行,有效,安全且患者易接受的方法。

(   王祥瑞 )

Clinical use of the sciatic nerve block (SNB) has been limited by technical difficulties in performing the block using standard approaches, substantial patient discomfort during the procedure, or the need for two injections to block the tibial and peroneal nerves. In this report, we describe a single-injection method for SNB using an infragluteal-parabiceps approach, where the nerve is located along the lateral border of the biceps femoris muscle. SNB was performed in the prone or lateral decubitus position. The needle was positioned (average depth, 56 ± 15 mm) to the point where plantar flexion (53%) or inversion (45%) of the ipsilateral foot was obtained at <=0.4 mA. Levobupivacaine 0.625% with epinephrine (1:200:000) was administered at a dose of 0.4 mL/kg. The procedure was completed in 6 ± 3 min. Discomfort during block placement was treated with fentanyl 50–100 µg in 24% of patients. Complete sensory loss and motor paralysis occurred in 92% of subjects at a median time of 10 (range, 5–25) min after injection. Compared with plantar flexion, foot inversion was associated with a more frequent incidence (86% versus 100%), and shorter latency for both sensory loss and motor paralysis of the peroneal, tibial, and sural nerves. There were no immediate or delayed complications. We conclude that the infragluteal-parabiceps approach to SNB is reliable, efficient, safe, and well tolerated by patients.

对志愿者在特定一点(extra 1)施压针疗可减低脑电双频指数值和应激

Pressure Applied on the Extra 1 Acupuncture Point Reduces Bispectral Index Values and Stress in Volunteers

Argyro Fassoulaki, MD PhD, DEAA*, Adia Paraskeva, MD{dagger}, Konstantinos Patris, MD{dagger}, Theodora Pourgiezi, MD*, and Georgia Kostopanagiotou, MD*

*Department of Anesthesiology, Aretaieion Hospital; and {dagger}Department of Anesthesiology, St Savas Hospital, Athens, Greece  

Anesth Analg 2003;96:885-890


我们对25名志愿者研究了在特定一点(extra 1)和对照点进行施压针疗时BIS值和应激的改变。每一名志愿者均随机在不同的时间分别对“extra 1”点针疗10分钟和对照点针疗5分钟。在对“extra 1”点针疗前测量BIS值,在针疗中的10分钟中每个30秒测量一次,在结束后再测量一次。而在对照组中,由于针刺引起的不适感故改为5分钟。每一名志愿者均在治疗前后进行应激评分(0-10分)。在extra 1”点BIS值在2.557.510分钟时均明显减低(p<0.001,在压力缓解后恢复到基础值。对照组BIS值在2.55分钟是减低(p<0.01p<0.05)。但是这些值维持在90%左右,且明显高于extra 1”组(2.55分钟对比值分别为p<0.001p<0.001)。治疗后的口头镇静评分在extra 1”组也明显低于对照组(p<0.001)。

(忻纪华 王祥瑞 )

We investigated the effect of pressure application on the acupuncture point "extra 1" and on a control point on the bispectral index (BIS) values and on stress in 25 volunteers. In each volunteer, pressure was applied on the extra 1 point for 10 min and on a control point for 5 min on different days and in a randomized manner. The BIS value was recorded before applying pressure on the extra 1 point, during pressure application every 30 s for 10 min, and after pressure release. Regarding the control point, BIS values were recorded for 5 instead of 10 min during pressure application because acupressure on that point was associated with an unpleasant feeling. Each volunteer was asked to score stress before and after pressure application from 0 to 10. The BIS values were significantly reduced 2.5, 5, 7.5, and 10 min during pressure application on the extra 1 point (P < 0.001 for each comparison, respectively) and returned to the baseline values after pressure release. Pressure application on the control point decreased BIS values (P < 0.01 and P < 0.05 at 2.5 and 5 min, respectively). However, these values were maintained close to 90% and were significantly higher than those obtained during pressure on the extra 1 point (P < 0.001 and P < 0.001 for the 2.5- and 5-min comparisons). The verbal sedation score values obtained after pressure application on the extra 1 point were also lower when compared with the values obtained after pressure application on the control point (P < 0.001).

心脏术后并发症:急性肾功能不全与房颤的关系

Postcardiac Surgery Complications: Association of Acute Renal Dysfunction and Atrial Fibrillation

Maher J. Albahrani, MBChB*, Madhav Swaminathan, MD*, Barbara Phillips-Bute, PhD*, Peter K. Smith, MD{dagger}, Mark F. Newman, MD*, Joseph P. Mathew, MD*, and Mark Stafford-Smith, FRCPC*

Departments of *Anesthesiology and {dagger}Surgery, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2003 96: 637-643.

 

   心脏术后肌酐升高是不利后果。虽然,术后休克与肾功能不全有关,但房颤与肾功能不全的关系没被评估。因此,我们验证那个假设:冠脉搭桥术后有房颤的患者将有更高的肌酐升高。选取453术前无房颤而行冠脉搭桥手术采取数据。多因素衰减分析和肌酐峰值变化关系证明:年龄与房颤是一双向关系(可变量估计,-1.1p=0.0002)。多因素衰减分析和术后肌酐峰值变化的关系也获得类似结果(可变量估计,-0.01; P = 0.04)。也证实了我们的假设:新发房颤患者心外科术后更易发生肾功能不全。房颤与肌酐升高的关系随年龄增加而下降。这些数据与冠脉搭桥术后急性肾功能不全与房颤在年龄依赖方式上的病因形成病理生理相一致。

结论:我们发现初发房颤和术后肌酐升高非依存性是受年龄影响。房颤与肌酐升高的关联性随年龄增加而下降。这提示两并发症的一般病因对年轻患者更有意义。

                                           (李绍清 薛张纲 )

Postoperative creatinine increase is associated with adverse outcome after cardiac surgery. Although postoperative stroke and renal dysfunction are associated after cardiac surgery, suggesting a common systemic insult, a similar assessment of atrial fibrillation and renal dysfunction has not been performed. Therefore, we tested the hypothesis that patients with new-onset atrial fibrillation complicating coronary bypass surgery have a greater postoperative creatinine increase. Data were obtained for 453 elective coronary bypass surgery patients with no history of atrial fibrillation. Multivariate regression analyses of factors associated with peak fractional change in creatinine demonstrated a two-way interaction between age and atrial fibrillation (variable estimate, -1.1; P = 0.002). Similar results were obtained in a secondary multivariate model analyzing factors associated with peak postoperative creatinine (variable estimate, -0.01; P = 0.04). We confirmed our hypothesis that patients with new-onset atrial fibrillation are more likely to have acute renal dysfunction after cardiac surgery. The association of atrial fibrillation and creatinine increase diminishes with advancing age. These data are consistent with a common pathophysiology that contributes in an age-dependent fashion to the etiology of both acute renal dysfunction and atrial fibrillation after coronary bypass surgery.

 

围术期 Dexmedetomidine 减低犬心肌乳酸产生

Dexmedetomidine Decreases Perioperative Myocardial Lactate Release in Dogs

Henriëtte M. Willigers, MD*, Frits W. Prinzen, PhD{dagger}, Paul M. Roekaerts, MD PhD*, Simon de Lange, MB BS, PhD, FRCA*, and Marcel E. Durieux, MD PhD*

*Department of Anesthesiology, University Hospital Maastricht; and {dagger}Department of Physiology, Maastricht University, Maastricht, The Netherlands

Anesth Analg 2003 96: 657-664.

 

  α2—肾上腺素能拮抗剂Dexmedetomidine的交感阻滞效应可减轻患者心肌缺血负荷,但是,心肌缺血直接测量值,如心肌乳酸产量却难测量。因此,我们用杂种犬研究,测心肌乳酸产量,心肌氧供,血流动力学变量,紧张反射的神经介质指数。完成心肌缺血临界值标准化后,灌注Dexmedetomidine和标准盐。麻醉后期和乳酸出现期90min10min反复测量。在Dexmedetomidine组,累积乳酸产率为46%,低于控制组(95%可信区间20%80%; P = 0.02)。同时,Dexmedetomidine增加心内、外膜血流率到35%(控制组0.4 ± 0.1; dexmed , 0.6 ± 0.1; P = 0.03)。这些抗缺血效应伴随有去甲肾上腺素能(126 577 pg/mL) 和肾上腺素能 (158 1909 pg/mL) 下降和心率减慢 (123 ± 6 160 ± 10 bpm, dexmed 对控制组)。在作为缺血证据的乳酸产生前,这些抗缺血效应已出现。

   结论:Dexmedetomidine减低血浆儿茶酚胺浓度和心率。在冠脉狭窄犬,因抗交感效应而减少心肌乳酸产生,因而,心肌缺血发生最小。

  (李绍清 译, 薛张纲 )

The sympatholytic effect of the {alpha}2-adrenergic agonist dexmedetomidine may decrease emergence-related myocardial ischemic load in patients. However, a direct measure of myocardial ischemia, such as myocardial lactate release, is difficult to obtain in patients. Therefore, we studied mongrel dogs and measured myocardial lactate release, myocardial oxygen supply, hemodynamic variables, and neurohumoral indices of the stress response. After the induction of a standardized degree of borderline myocardial ischemia, either dexmedetomidine (dexmed group, n = 9) or normal saline (control group, n = 9) was infused. Measurements were repeated at the end of the anesthetic period and every 10 min during the 90-min emergence period. In the dexmed group, the cumulative emergence-related lactate release was 46% less than in the control group (95% confidence interval, 20%–80%; P = 0.02). Simultaneously, dexmedetomidine increased the endo-/epicardial blood flow ratio by 35% (control group, 0.4 ± 0.1; dexmed group, 0.6 ± 0.1; P = 0.03). These antiischemic effects of dexmedetomidine were accompanied by reduced plasma concentrations of norepinephrine (126 versus 577 pg/mL) and epinephrine (158 versus 1909 pg/mL) and a slower heart rate (123 ± 6 versus 160 ± 10 bpm, dexmed versus control). The antiischemic effect of dexmedetomidine started before emergence, as evidenced by a decreased prevalence of myocardial lactate release at that time (zero of eight dogs in the dexmed group and four of seven dogs in the control group had lactate release before emergence; P = 0.03).

 

儿童硬膜外自控镇痛:能行吗?

Patient-Controlled Epidural Analgesia in Children: Can They Do It?

Patrick K. Birmingham, MD DABA, FAAP*, Melissa Wheeler, MD DABA, FAAP, DABPM*, Santhanam Suresh, MD DABA, FAAP*, Richard M. Dsida, MD DABA, FAAP*, Bronwyn R. Rae, MBBS FANZCA, DCH (Lond), DABA*, Jennifer Obrecht, RN MS, APN{dagger}, Vicki A. Andreoni, RN MS, APN{dagger}, Steven C. Hall, MD DABA, FAAP*, and Charles J. Coté, MD DABA, FAAP*,{ddagger}

Departments of *Anesthesiology, {dagger}Nursing, and {ddagger}Pediatrics, Children’s Memorial Hospital at Northwestern University Medical School, Chicago, Illinois

Anesth Analg 2003 96: 686-691

 

    广泛临床实践和许多试验均支持儿童术后静脉自控镇痛和局部镇痛技术。相反,硬膜外自控镇痛技术和效果在儿童中鲜有报道。我们收集了128例(归围为132例)术后急性疼痛硬膜外自控镇痛的病例,作描述性分析。119例(90.1%)镇痛效果满意,持续103h无严重并发症和中毒症状发生。89例对初始设置效果满意,另外38例改变初始设置获得满意效果。5例因镇痛不足改为静脉镇痛,8例因副反应改为静脉镇痛。5岁儿童有能力理解和期望硬膜外自控镇痛的愿望,与静脉自控镇痛报道一致。需要多加注意的是时间内用量超过设定值。我们预期数据证明:硬膜外自控镇痛能在儿童中获得满意效果,且有较少并发症发生,应与另外一些镇痛措施一同被考虑。

结论:132例描述性分析证明,小如5岁儿童行硬膜外自控镇痛可获得满意效果而无严重毒性和副反应发生。它应该同另外镇痛措施一样在儿童术后镇痛中被考虑。

                                             (李绍清 薛张纲 )

Extensive clinical experience and many studies support the use of IV patient-controlled analgesia (IV PCA) and regional anesthesia techniques for the treatment of postoperative pain in children. In contrast, little has been reported about the ability of children to use patient-controlled epidural analgesia (PCEA) or about the efficacy of this technique. We report a descriptive analysis of prospectively recorded data in 128 children (132 procedures) in whom PCEA was used for acute postoperative pain control. Satisfactory analgesia was obtained in 119 patients (90.1%) for up to 103 h with no episodes of desaturation and without clinical evidence of toxicity or serious adverse effects. Analgesia was satisfactory with the initial settings in 89 patients; in 38 others, this was achieved with changes in PCEA settings or solution. Five patients were switched to IV PCA because of inadequate analgesia. Eight patients with satisfactory analgesia were converted to IV PCA because of adverse effects. Children as young as 5 yr had the cognitive ability to understand and the willingness to use PCEA, consistent with reported use of IV PCA. Careful attention should be paid to the total hourly local anesthetic dose to avoid exceeding the recommended limits. Our prospectively collected data demonstrate that PCEA provides satisfactory analgesia with a small incidence of adverse side effects in children and should be considered along with other strategies in pediatric postoperative pain management.

 

七氟醚麻醉和瑞芬太尼麻醉苏醒时意识、记忆功能、脑电图的改变 

Changes in consciousness, conceptual memory, and quantitative electroencephalographical measures during recovery from sevoflurane- and remifentanil-based anesthesia.

Muncaster AR, Sleigh JW, Williams M.

Waikato Clinical School, Waikato Hospital, Hamilton, New Zealand.

Anesth Analg 2003 Mar;96(3):720-5

 

阿片药物诱导的脑电图或听觉诱发电位改变与意识改变是否相关还尚未明确。评价以下关系:1)意识状态的临床评价,2)对词组的内隐或外显记忆,3)多种测量方法:脑电图、BISARX AEP指数、SVDEN(一种脑电图复合测量技术)。对21位进行妇科手术而麻醉的妇女,研究其二阶段的苏醒过程(先进性七氟醚的洗出,再是瑞芬太尼的洗出)。所有研究对象均无术中知晓,19位在仅存瑞芬太尼时对口头指令无反应。有6位在瑞芬太尼浓度下降时BIS亦平行下降:则主要是因为EEG的低振幅而被误解为爆发性抑制。大多数的EEG/AEP变量对七氟醚浓度下降和意识恢复是敏感的,但是对瑞芬太尼

的浓度下降不敏感。SVDEN是唯一的在七氟醚洗出时和瑞芬太尼洗出时都有明显上升的变量。瑞芬太尼洗出时具有预测价值的数值,SVDEN=0.79,边频指数=0.81ARX AEP=0.63,BIS=0.58。边频指数在对大批病人进行进一步临床评估时有用。SVDEN是一个评估中枢神经系统麻醉和镇痛作用的有效变量。结论:在瑞芬太尼麻醉的苏醒过程中,评估意识程度的恢复,由于爆发抑制的干扰,BIS的预测价值不高。边频指数较可靠,但也不是评估麻醉深度的金标准。

                                          (顾悦超 薛张纲 )

It is unclear whether opioid-induced changes in electroencephalogram (EEG) or auditory evoked potentials (AEPs) reliably correspond with consciousness. We examined the correlation between 1) the clinically assessed state of consciousness, 2) implicit and explicit memory (by use of word pairs), and 3) various measures of EEG and AEP-bispectral index (BIS), A-Line ARX AEP index, spectral entropy, and entropy of the singular value decomposition (SVDEN; a measure of the complexity of the EEG). We studied 21 women during a two-stage awakening (sevoflurane washout followed by remifentanil washout) after anesthesia for gynecological surgery. All were amnesic, and 19 were unresponsive to verbal command with remifentanil alone. In six patients, BIS decreased paradoxically as the remifentanil concentration decreased; this was caused by a low-amplitude EEG, which was misinterpreted by the Aspect algorithm as burst suppression. Most of the EEG/AEP variables were sensitive to the decrease in sevoflurane and the recovery of consciousness, but not to the effects of decreasing remifentanil concentrations. SVDEN was the only variable that demonstrated significant increases for both the sevoflurane and remifentanil washout phases. With the prediction probability statistic during remifentanil washout, SVDEN = 0.79, spectral entropy = 0.81, A-Line ARX AEP index = 0.63, and BIS = 0.58. Entropy measures appear to be worthy of further clinical evaluation in a larger series of patients. SVDEN may be a useful variable for assessing anesthetic and analgesic effects on the central nervous system.

 

氟烷和异氟醚对病人术后肝动脉和门静脉血流影响的比较

The postoperative effects of halothane versus isoflurane on hepatic artery and portal vein blood flow in humans.

Gatecel C, Losser MR, Payen D.

Departement d'Anesthesie-Reanimation Chirurgicale, Centre Hospitalier Universitaire Lariboisiere, Assistance Publique-Hopitaux de Paris, France.

Anesth Analg 2003 Mar;96(3):740-5

 

动物研究显示氟烷通过减少肝动脉(HABF)和门静脉(PVBF)血流来降低总肝血流量(THBF),然而异氟醚则起保护作用。在本研究中,采用脉搏多普勒技术来评估氟烷和异氟醚对手术病人HABFPVBF的影响。一项法律所允许的试验中,首先应用6只猴子来比较脉搏多普勒技术和吲哚青清除率方法所测得的THBF数值。其次,运用植入脉搏多普勒探头对6位(ASAI-II级)进行择期胆囊切除术术后病人进行研究。对进行呼气末浓度为1%氟烷和1.5%异氟醚麻醉的病人比较其THBF和肝血流的分流量。在动物实验中,这两项技术所测结果有较高的一致性。在氟硝安定麻醉的病人中,THBF1120+/-284mL/min。与此作为基准值,和相同的平均动脉压下降幅度(10%),异氟醚麻醉的病人THBF保持稳定,然而氟烷麻醉的病人THBF减少36%P<0.05)。异氟醚麻醉病人PVBF增加25%P=0.067),HABF保持稳定;氟烷麻醉病人PVBF降低44%(P<0.05)HABF降低20%P<0.05)。氟烷对肝循环主要起血管收缩作用;异氟醚起血管舒张作用,从而对肝的氧供有益。结论:挥发性麻醉剂可改变肝循环,从而具有严重的副作用。对6位进行麻醉的病人运用植入脉搏多普勒技术,发现氟烷对肝血管床主要作为血管收缩剂;而异氟醚是作为血管舒张剂,对肝的氧供有益。

                                           (顾悦超 薛张纲 )

Animal studies have shown that halothane decreases total hepatic blood flow (THBF) by reducing both arterial (HABF) and portal (PVBF) inflow, whereas isoflurane appears to preserve them. In this study we assessed the effect of halothane and isoflurane on HABF and PVBF in surgical patients by using the pulsed Doppler technique. A validation study was conducted in six cynomolgus monkeys to compare the values of THBF obtained by the pulsed Doppler and indocyanine green clearance methods. Subsequently, six patients (ASA status I and II) undergoing elective open cholecystectomy were studied after surgery by using implanted pulsed Doppler probes. THBF and liver flow partition were compared during 1% halothane and 1.5% isoflurane (end-tidal concentrations). In the animal study, there was good agreement between the techniques (Bland and Altmann representation). In flunitrazepam-anesthetized patients, THBF was 1120 +/- 284 mL/min. Compared with this baseline and for a similar mean arterial blood pressure decrease (10%), THBF was maintained with isoflurane, whereas it decreased by 36% (P < 0.05) under halothane. With isoflurane, PVBF increased (25%; P = 0.067) with a maintained HABF. With halothane, both PVBF (-44%; P < 0.05) and HABF (-20%; P < 0.05) were reduced. Halothane acted mainly as a vasoconstrictor of the hepatic circulation, whereas isoflurane was a vasodilator, confirming the beneficial effect of isoflurane on hepatic oxygen supply. IMPLICATIONS: Volatile anesthetics may alter liver circulation with serious adverse effects. Using implanted pulsed Doppler probes in six anesthetized patients, we showed that halothane acted mainly as a vasoconstrictor of the liver vascular bed, whereas isoflurane was a vasodilator, confirming the beneficial effect of isoflurane on liver oxygen supply.

 

七氟醚分解产生一氧化氮:一项临床研究模型:

Carbon monoxide production from sevoflurane breakdown: modeling of exposures under clinical conditions.

Holak EJ, Mei DA, Dunning MB 3rd, Gundamraj R, Noseir R, Zhang L, Woehlck HJ.

Department of Anesthesiology and. Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee.

Anesth Analg 2003 Mar;96(3):757-64

 

异氟醚,安氟醚,七氟醚,特别是地氟醚在与干燥剂发生反应时能产生一氧化氮。其中,七氟醚被研究的最少。七氟醚分解产生一氧化氮有赖于吸收器的温度,分钟通气量,新鲜气流量。在分钟通气量分别为2.35.010.0升时,干的钡石灰与1.0 最低肺泡麻醉浓度(2.1%)的七氟醚发生反应时,测量吸收器的温度和相应的一氧化氮浓度。应用一种可重复的方法来建立测量碳氧血红蛋白浓度的数学模型。在低新鲜气流量下,七氟醚的快速分解阻止了其达到最低肺泡麻醉浓度。在此分钟通气量和吸收器温度超过80度的情况下,一氧化氮浓度在增加;但是在高新鲜气流量下,一氧化氮浓度在下降。分钟通气量为2.35.0升时,平均一氧化氮浓度为150ppm600ppm;但是分钟通气量为10.0升时,一氧化氮浓度超过11000ppm,可引起爆炸和燃烧。亦有甲醇和甲醛存在,并对此可燃性混合物产生影响,但其浓度无法测量。数学模型显示在普通病例中,仅仅是那些体重</=25Kg,或是严重贫血病人,在麻醉最初的60分钟内,有碳氧血红蛋白浓度>10%的危险。结论:在干燥剂中七氟醚的分解期望仅产生较淡的一氧化氮。完全干的干燥剂和高分钟通气频率可降低七氟醚分解所产生的高一氧化氮浓度。在极端的条件下存在着严重一氧化氮中毒或者呼吸回路中的可燃性气体发生自燃的可能。

                                          (顾悦超 薛张纲 )

Isoflurane, enflurane, sevoflurane, and especially desflurane produce carbon monoxide (CO) during reaction with desiccated absorbents. Of these, sevoflurane is the least studied. We investigated the dependence of CO production from sevoflurane on absorbent temperature, minute ventilation (VE), and fresh gas flow rates. We measured absorbent temperature and in vitro CO concentrations when desiccated Baralyme reacted with 1 minimum alveolar anesthetic concentration of (2.1%) sevoflurane at 2.3-, 5.0-, and 10.0-L VE. Mathematical modeling of carboxyhemoglobin concentrations was performed using an existing iterative method. Rapid breakdown of sevoflurane prevented the attainment of 1 minimum alveolar anesthetic concentration with low fresh gas flow rates. CO concentrations increased with VE and with absorbent temperatures exceeding 80 degrees C, but concentrations decreased with higher fresh gas flow rates. Average CO concentrations were 150 and 600 ppm at 2.3- and 5.0-L VE; however, at 10 L, over 11,000 ppm of CO were produced followed by an explosion and fire. Methanol and formaldehyde were present and may have contributed to the flammable mixture but were not quantitated. Mathematical modeling of exposures indicates that in average cases, only patients </=25 kg, or severely anemic patients, are at risk of carboxyhemoglobin concentrations >10% during the first 60 min of anesthesia. IMPLICATIONS: Sevoflurane breakdown in desiccated absorbents is expected to result in only mild carbon monoxide (CO) exposure. Completely dry absorbent and high minute ventilation rates may degrade sevoflurane to extremely large CO concentrations. Serious CO poisoning or spontaneous ignition of flammable gases within the breathing circuit are possible in extreme circumstances.

 

鞘内使用吗啡(非小剂量)诱导的大鼠主动脉非损伤性间断阻断后的下肢痉挛性轻瘫

Intrathecal Administration of Morphine, but Not Small Dose, Induced Spastic Paraparesis After a Noninjurious Interval of Aortic Occlusion in Rats

Manabu Kakinohana, MD PhD, Tatsuya Fuchigami, MD PhD, Seiya Nakamura, MD, Takeshi Sasara, MD, Tetsuya Kawabata, MD, and Kazuhiro Sugahara, MD PhD

Department of Anesthesiology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan

Anesth Analg 2003 96: 769-775.

 

我们研究鞘内使用吗啡在大鼠脊髓短暂持久的缺血后的下肢痉挛性轻瘫作用的量效关系。事先在鞘内置入注药的导管,然后使用带套囊的导管阻断主动脉6分钟产生脊髓缺血。缺血后再让其恢复,在再灌注30分钟后鞘内分别注射3, 10, 30 µg的吗啡或生理盐水。在每一组对鞘内吗啡对缺血后的神经功能的作用采用定量生物鉴定计算其再灌注2小时时诱导下肢轻瘫的50%有效量。随后再再灌注48小时时对脊髓进行组织学检测。鞘内注射30 10 µg吗啡引起渐进性的下肢痉挛,而注射3 µg的吗啡或生理盐水则无此作用。在鞘内注射吗啡2小时进行行为分析评价,则产生下肢轻瘫的50%有效剂量为16.1 ± 1.5 µg吗啡。 在30-µg组进行脊髓组织学分析显示在腰背段的{alpha}-运动神经元上有黑色着色。 因此我们认为主动脉短暂阻断后鞘内使用大剂量的吗啡有产生下肢轻瘫的潜在危险并产生相应的神经功能障碍。对于行胸腹动脉瘤修复的病人鞘内使用吗啡术后止痛时应予注意。结论:短暂阻断主动脉后鞘内使用大剂量的吗啡有产生不可逆的脊髓功能退化及相应的神经功能障碍的可能。

                      (张俊峰 译 薛张刚 校)

We sought to investigate the dose-response relationship for the effect of intrathecal morphine on the transient spastic paraparesis after short-lasting spinal ischemia in rats. Spinal ischemia was induced by aortic occlusion for 6 min with a balloon catheter in rats previously implanted with an intrathecal catheter for drug delivery. After ischemia, the animals were allowed to recover, and 3, 10, or 30 µg of morphine or saline was injected intrathecally at 30 min after reperfusion. In a separate group, the quantal bioassay for the effect of intrathecal morphine on neurological function after ischemia was performed to calculate 50% effective dose values for inducing paraparesis at 2 h of reperfusion. Subsequently, histopathology of the spinal cord was assessed at 48 h of reperfusion. Intrathecal injection of 30 or 10 µg of morphine, but 3 µg of neither morphine nor saline, caused a progressive development of hindlimb spasticity. The 50% effective dose values for inducing paraparesis were 16.1 ± 1.5 µg in assessing behavioral analysis at 2 h after intrathecal morphine. Histopathological analysis of spinal cords in the 30-µg group revealed the presence of dark-staining {alpha}-motoneurons in lumbosacral segments. We conclude that spinal administration of a large dose of morphine after transient aortic occlusion may be associated with a potential risk of paraparesis and the corresponding development of neurological dysfunction. Careful attention should be paid when intrathecal morphine is used for pain control after thoracoabdominal aortic aneurysm repair.

 

术后机械通气病人相继使用咪唑安定和异丙酚进行长期镇静治疗

Sequential Use of Midazolam and Propofol for Long-Term Sedation in Postoperative Mechanically Ventilated Patients

Masataka Saito, MD*, Yoshiaki Terao, MD*, Makoto Fukusaki, MD{dagger}, Tetsuji Makita, MD{ddagger}, Osamu Shibata, MD*, and Koji Sumikawa, MD*

*Department of Anesthesiology and {ddagger}Intensive Care Unit, Nagasaki University School of Medicine, Nagasaki, Japan; and {dagger}Department of Anesthesia, Nagasaki Rosai Hospital, Sasebo, Japan

Anesth Analg 2003 96: 834-838.

 

急性戒断综合征(包括激动和长时间的被遗弃感)是使用咪唑安定长期镇静的常见不良反应。我们设计此研究以明确相继使用咪唑安定和异丙酚与单独使用咪唑安定相比是否会降低不良反应的发生。我们研究了26例术后机械通气大于3天的病人。病人随机分为两组:M-P组(大约在预期停止镇静前24小时更换咪唑安定为异丙酚)和M 组(病人只使用咪唑安定镇静)。镇静水平维持在4 5(据Ramsay镇静评分),在拔管后24 h评价镇静激动评分。停止镇静到拔管的恢复时间M-P(1.3 ± 0.4 h)显著短于M (4.0 ± 2.4 h) M-P组的激动发生率 (8%)显著低于M(54%)。结果显示与单独使用咪唑安定相比相继使用异丙酚长期镇静可降低激动的发生率。结论:该研究显示与单独使用咪唑安定相比相继使用咪唑安定和异丙酚可降低激动的发生率。

                           (张俊峰 薛张刚 校)

 Acute withdrawal syndromes, including agitation and a long weaning time, are common adverse effects after long-term sedation with midazolam. We performed this study to determine whether the sequential use of midazolam and propofol could reduce adverse effects as compared with midazolam alone. We studied 26 patients receiving mechanical ventilation for three or more days after surgery. Patients were randomly assigned to two groups. In Group M, patients were sedated with midazolam alone. In Group M-P, midazolam was switched to propofol approximately 24 h before the expected stopping of sedation. The level of sedation was maintained at 4 or 5 on the Ramsay sedation scale. The sedation agitation scale was evaluated for 24 h after extubation. The recovery time from stopping of sedation to extubation was significantly shorter in Group M-P (1.3 ± 0.4 h) compared with Group M (4.0 ± 2.4 h). The incidence of agitation in Group M-P (8%) was significantly less frequent than that in Group M (54%). The results indicate that sequential use of midazolam and propofol for long-term sedation could reduce the incidence of agitation compared with midazolam alone.

 

三种插管设备在正常血压和高血压病人上的血流动力学反应

Hemodynamic Responses Among Three Tracheal Intubation Devices in Normotensive and Hypertensive Patients

S. Kihara, MD, J. Brimacombe, FRCA MD, Y. Yaguchi, MD, S. Watanabe, MD PhD, N. Taguchi, MD, and T. Komatsuzaki, MD

Department of Anaesthesia, Pain Clinic, and Clinical Toxicology, Mito Saiseikai General Hospital, Ibaraki, Japan  

Anesth Analg 2003 96: 890-895.

 

我们在麻醉和肌松下的正常血压和高血压病人上对三种插管设备的血流动力学反应进行了比较,这三种设备为Macintosh喉镜(LS), TrachlightTM灯杖 (LW), FastrachT插管喉罩 (ILM)75例正常血压病人和 75例高血压病人随机接受各种插管设备 (n = 25) 无创收缩压(SBP)和舒张压(DBP)以及心率(HR)在诱导前即刻,插管前即刻,以及成功插管后头5分钟的每一分钟作记录。插管的次数,成功插管的时间以及任何气道的损伤也作记录。咽喉部的发病率在术后1824小时由一位不了解分组的调查者作调查。在所有的分组中,与基础值相比,在插管前即刻都有SBP DBP的下降,但是 HR 不变。在所有分组中, HR增加,但是SBPDBP不增加,除了LS/高血压组的DBP在插管后较基础值上升。在正常血压组,三种设备导致的血流动力学变化没有差异。在高血压病人, SBPDBP插管后2分钟LS 组较ILM LW 组显著升高,但是三种设备没有导致 HR的变化差异。各组间插管的尝试次数无差异,但在 ILM组插管时间显著延长。气道损伤的发生在ILM 组较 LS组和LW组更常见(16% 0% 0%)。咽喉部的发病在各组间无差别。我们总结ILM LWLS相比在麻醉和肌松状态下的高血压病人而非在正常血压病人上减轻了插管引起的血流动力学应激反应。

                                           (潘志浩 薛张刚 校)

心肺转流时Alpha-StatpH-Stat与颈静脉血氧饱和度和脑血糖-血氧利用关系的比较

Comparison of Alpha-Stat and pH-Stat Cardiopulmonary Bypass in Relation to Jugular Venous Oxygen Saturation and Cerebral Glucose-Oxygen Utilization

H. Tarik Kiziltan, MD*, Mehmet Baltal, MD, Ahmet Bilen, MD, Gülah Seydaoglu, MD, Muzaffer Incesoz, BS||, Atlay Tasdelen, MD*, and Sait Aslamaci, MD*

Departments of *Cardiothoracic Surgery, Cardiology, Anesthesiology, Preventive Medicine and Biostatistics, and ||Assisted Circulation, Baskent University, Adana Medical Center, Adana, Turkey

Anesth Analg 2003;96:644-650

颈静脉血氧饱和度(SJVO2)反映了脑血流和脑代谢间的平衡。本文研究两种不同调节酸碱方法对颈静脉去饱和(SJVO2<50%)和脑动静脉血氧-血糖利用的影响。作者对52名行低温(27°C)体外循环(CPB)患者进行了前瞻、随机研究。患者随机分为Alpha-Stat(n = 26)pH-Stat(n = 26)组。颈静脉逆行插管,并在CPB期采集血样。两组术前各参数无差异。CPB 30 min时,pH-Stat组的SJVO2明显高于Alpha-Stat组( 86.2% ± 6.1% 70.6% ± 9.3%; P < 0.001)。然而,此时pH-Stat组动静脉血糖和血氧的差值明显低于Alpha-Stat组( 血氧为1.9 ± 0.82 mL/dL 3.98 ± 1.12 mL/dL; P < 0.001; 血糖为 3.67 ± 2.8 mL/dL 10.1 ± 5.2 mL/dL; P < 0.001)。两组患者复温时都发生去饱和,且组间无统计学差异。所有患者均以良好状态出院。相较于Alpha-Stat法, pH-Stat法能提高SJVO2和降低动静脉血氧和血糖的差值。

结论:对52位行心肺转流的患者进行前瞻性和随机研究发现pH-Stat法能增加静脉氧饱和度和降低动静脉血氧和血糖的差值。颈静脉去饱和发生率在两组无差异,表明在pH-Stat时脑血流增加,但对颈静脉去饱和无保护作用

(赵雪莲 庄心良 校)

Jugular venous oxygen saturation (SJVO2) reflects the balance between cerebral blood flow and metabolism. This study was designed to compare the effects of two different acid-base strategies on jugular venous desaturation (SJVO2 <50%) and cerebral arteriovenous oxygen-glucose use. We performed a prospective, randomized study in 52 patients undergoing cardiopulmonary bypass (CPB) at 27°C with either alpha-stat (n = 26) or pH-stat (n = 26) management. A retrograde internal jugular vein catheter was inserted, and blood samples were obtained at intervals during CPB. There were no differences in preoperative variables between the groups. SJVO2 was significantly higher in the pH-stat group (at 30 min CPB: 86.2% ± 6.1% versus 70.6% ± 9.3%; P < 0.001). The differences in arteriovenous oxygen and glucose were smaller in the pH-stat group (at 30 min CPB: 1.9 ± 0.82 mL/dL versus 3.98 ± 1.12 mL/dL; P < 0.001; and 3.67 ± 2.8 mL/dL versus 10.1 ± 5.2 mL/dL; P < 0.001, respectively). All episodes of desaturation occurred during rewarming, and the difference in the incidence of desaturation between the two groups was not significant. All patients left the hospital in good condition. Compared with alpha-stat, the pH-stat strategy promotes an increase in SJVO2 and a decrease in arteriovenous oxygen and arteriovenous glucose differences. These findings indicate an increased cerebral supply with pH-stat; however, this strategy does not eliminate jugular venous desaturation during CPB.

 

短期应用乙醇不影响清醒狗心肌顿抑的功能恢复

Short-Term Administration of Ethanol Does Not Affect Functional Recovery from Myocardial Stunning in Awake Dogs

Thomas Peter Weber, MD*, Maike Anja Große Hartlage, MD*, Norbert Rolf, PhD, Michael Booke, PhD*, Elmar Berendes, PhD*, Hugo Van Aken, PhD*, and Andreas Meißner, PhD*

*Department of Anaesthesiology and Intensive Care, University Hospital Münster; and Department of Anaesthesiology and Intensive Care, Marienkrankenhaus GmbH, Hamburg, Germany

Anesth Analg 2003;96:665-672

长期小剂量摄取乙醇(SAE)可保护缺血损伤的心肌。已有研究证明短期应用乙醇可改善被麻醉狗因快速阻塞引起顿抑心肌的恢复。这种情况是否会发生在清醒的狗尚不清楚。因此,本文研究乙醇对局部顿抑心肌的作用。长期监测36条狗的心率、左房压、主动脉压、左室压、左室收缩顺应性(dP/dtmax)和心室舒张功能(dP/dtmin)以及局部心肌壁厚分数(WTF)。阻塞冠状动脉左前降枝(LAD)造成其支配的心肌可逆性缺血。将36条狗按照乙醇用量分为三组(I, 0.125 g/kg [n = 12]; II, 0.25 g/kg [n = 12]; III, 0.5 g/kg [n = 12])。每条狗施行两次缺血(随机且相隔数天)即在静脉给予含乙醇或不含乙醇的液体30分钟后阻塞LAD 10分钟。测定WTF和血流动力学参数的基数值和心肌顿抑完全恢复时点的各参数值。LAD缺血使各组LAD-WTF值显著降低。给予或不给SAEWTF和血流动力学参数值没有差异。结论:0.125 g/kg, 0.25 g/kg, 0.5 g/kg SAE对清醒狗的心肌顿抑无显著影响。

结论:清醒狗短期应用乙醇不会改善心肌顿抑,这与先前在麻醉状态下的研究结论相反。

(赵雪莲 庄心良 校)

Chronic ingestion of small doses of ethanol protects the myocardium from ischemic damage. It was demonstrated that short-term administration of ethanol (SAE) enhances the recovery of stunned myocardium in acutely instrumented, anesthetized dogs. It is unclear whether this beneficial effect of SAE also occurs in awake dogs. Therefore, we investigated the effects of SAE on regional myocardial stunning in awake dogs. Thirty-six dogs were chronically instrumented for measurement of heart rate, left atrial, aortic, and left ventricular pressure, left systolic ventricular contactility (dP/dtmax) and diastolic ventricular function (dP/dtmin), and regional myocardial wall-thickening fraction (WTF). Occluders around the left anterior descending (LAD) artery allowed the induction of reversible ischemia in the LAD-perfused myocardium. The dogs were assigned to one of three groups that differed in the dose of ethanol administered in the ethanol experiment (I, 0.125 g/kg [n = 12]; II, 0.25 g/kg [n = 12]; III, 0.5 g/kg [n = 12]). In each group, the dogs underwent two ischemic episodes (randomized crossover fashion; separate days): 10 min of LAD occlusion after the application of ethanol IV over 30 min (ethanol group) and without ethanol (control). WTF and hemodynamic variables were measured at baseline and at predetermined time points until complete recovery of myocardial stunning occurred. LAD-ischemia led to a significant decrease of LAD-WTF in all groups. There was no difference in WTF and hemodynamic variables with or without SAE during reperfusion. We conclude that SAE (0.125 g/kg, 0.25 g/kg, and 0.5 g/kg) does not significantly affect myocardial stunning in conscious dogs.

 

GABAA受体阻断剂可以剂量依赖性地拮抗丙泊酚而非氯胺酮或异氟醚引起的体动消失

GABAA Receptor Blockade Antagonizes the Immobilizing Action of Propofol but Not Ketamine or Isoflurane in a Dose-Related Manner

James M. Sonner, MD, Yi Zhang, MD, Caroline Stabernack, MD, Wella Abaigar, BS, Yilei Xing, MD, and Michael J. Laster, DVM

Department of Anesthesia and Perioperative Care, University of California, San Francisco

Anesth Analg 2003;96:706-712

一般认为丙泊酚对GABAA受体的加强作用是其麻醉效应的基础。但是,最近的研究发现,GABAA拮抗剂并不改变丙泊酚对翻正反射的抑制作用。丙泊酚可以抑制大鼠对伤害性刺激(夹尾)的体动反应这与其麻醉效应有关。为此,我们研究了GABAA的非竞争性拮抗剂印防己毒素和竞争性拮抗剂gabazine对这种效应的影响。同时将该效应与异氟醚和氯胺酮对夹尾反应的作用相比较。印防己毒素使丙泊酚的50%有效剂量(ED50)增加约379%gabazine使ED50增加362%,而且其效应都呈剂量依赖性,没有明显的天花板效应(即效应没有限制)。印防己毒素最多可以使氯胺酮的ED50增加40-50%gabazine最多可以使氯胺酮的ED50增加50%-60%。印防己毒素使异氟醚的麻醉最小肺泡浓度增加约60%gabazing使之增加约70%。非GABA能甘氨酸受体拮抗剂士的宁也可以拮抗丙泊酚的ED50,由此确定通过非GABA能机制兴奋中枢神经可以是丙泊酚ED50增加的重要原因。由于士的宁仅使丙泊酚的体动消失的ED50增加约50%,所以还是要用GABAA受体拮抗的机制解释印防己毒素和gabazine的作用。我们的结论是,GABAA拮抗剂可以程度不等地影响丙泊酚和非GABA能麻醉药氯胺酮的ED50,这反映出对氯胺酮的生理学拮抗作用(即通过调节神经元环路产生体动消失的间接效应)和对丙泊酚的生理学和药理学拮抗作用(即通过拮抗丙泊酚的作用机制直接产生效应)。本研究还提示异氟醚的体动消失效应可能与GABAA受体无关,因为使用GABAA受体拮抗剂的动物在异氟醚麻醉时的质和量都与氯胺酮麻醉相似而与丙泊酚麻醉明显不同。

(颜 庄心良  校)

 

The enhancing action of propofol on -amino-n-butyric acid subtype A (GABAA) receptors purportedly underlies its anesthetic effects. However, a recent study found that a GABAA antagonist did not alter the capacity of propofol to depress the righting reflex. We examined whether the noncompetitive GABAA antagonist picrotoxin and the competitive GABAA antagonist gabazine affected a different anesthetic response, immobility in response to a noxious stimulus (a tail clamp in rats), produced by propofol. This effect was compared with that seen with ketamine and isoflurane. Picrotoxin increased the 50% effective dose (ED50) for propofol by approximately 379%; gabazine increased it by 362%, and both antagonists acted in a dose-related manner with no apparent ceiling effect (i.e., no limit). Picrotoxin maximally increased the ED50 for ketamine by approximately 40%–50%, whereas gabazine increased it by 50%–60%. The isoflurane minimum alveolar anesthetic concentration increased by approximately 60% with the picrotoxin and 70% with the gabazine infusion. The ED50 for propofol was also antagonized by strychnine, a non-GABAergic glycine receptor antagonist and convulsant, to determine whether excitation of the central nervous system by a non-GABAergic mechanism could account for the increases in propofol ED50 observed. Because strychnine only increased the immobilizing ED50 of propofol by approximately 50%, GABAA receptor antagonism accounted for the results seen with picrotoxin and gabazine. We conclude that GABAA antagonism can influence the ED50 for immobility of propofol and the non-GABAergic anesthetic ketamine, although to a different degree, reflecting physiologic antagonism for ketamine (i.e., an indirect effect via a modulatory effect on the neural circuitry underlying immobility) versus physiologic and pharmacologic antagonism for propofol (i.e., a direct effect by antagonism of propofol’s mechanism of action). This study also suggests that the immobilizing action of isoflurane probably does not involve the GABAA receptor because antagonism of GABAA receptors for animals anesthetized with isoflurane produces results quantitatively and qualitatively similar to ketamine and markedly different from propofol.

 

小剂量氯胺酮对瑞米芬太尼的镇痛作用、痛觉过敏和耐受的影响

Modulation of Remifentanil-Induced Analgesia, Hyperalgesia, and Tolerance by Small-Dose Ketamine in Humans

Martin Luginbühl, MD*, Andrea Gerber, MD*, Thomas W. Schnider, PhD, Steen Petersen-Felix, PhD*, Lars Arendt-Nielsen, PROFESSOR, and Michele Curatolo, PhD

*Department of Anesthesiology and Division of Pain Therapy, University Hospital of Bern, Switzerland; Department of Anesthesia and Intensive Care, Kantonsspital St. Gallen, Switzerland; and Center for Sensory-Motor Interaction, University of Aalborg, Aalborg, Denmark

Anesth Analg 2003;96:726-732

阿片合用小剂量氯胺酮可能增加镇痛作用,同时防止阿片诱发的痛觉过敏和急性耐受现象。我们采用随机、安慰剂对照和双盲的交叉试验,研究了瑞米芬太尼复合小剂量氯胺酮在不同疼痛模型中的作用,记录单次和重复肌肉电刺激的痛阈、重复经皮电刺激的痛阈、压痛阈、及镇静、呼吸和心血管不良反应。14位健康志愿者接受生理盐水、瑞米芬太尼、瑞米芬太尼合用氯胺酮(血浆浓度为 50 100 ng/mL)。首先记录基线数据,输注氯胺酮达稳态浓度后再次记录,然后输注瑞米芬太尼,初始靶浓度为1 ng/mL,后升至2 ng/mL,再降为1 ng/mL。停用瑞米芬太尼后十分钟进行下次试验。压痛试验表明,氯胺酮不影响瑞米芬太尼急性用药诱发的痛觉过和耐受现象。在所有疼痛模型中, 单用瑞米芬太尼均有显著镇痛作用。在肌肉电刺激试验中氯胺酮能增强瑞米芬太尼的镇痛作用。瑞米芬太尼的浓度达2 ng/mL时有轻度呼吸抑制,能被氯胺酮拮抗。我们的结论是氯胺酮对瑞米芬太尼镇痛作用的影响与疼痛模型有关。

(轩     庄心良校)

Adding a small dose of ketamine to opioids may increase the analgesic effect and prevent opioid-induced hyperalgesia and acute tolerance to opioids. In this randomized, double-blinded, placebo-controlled crossover study, we investigated the effect of remifentanil combined with small concentrations of ketamine on different experimental pain models. Pain detection thresholds to single and repeated IM electrical stimulation and to repeated transcutaneous electrical stimulation, pressure pain tolerance threshold, and sedative, respiratory, and cardiovascular side effects were assessed in 14 healthy volunteers. Saline, remifentanil alone, and remifentanil combined with ketamine at target plasma concentrations of 50 or 100 ng/mL were administered in four study sessions. The ketamine infusion was started after baseline testing at a constant target concentration. Remifentanil was started after testing with ketamine alone at an initial target concentration of 1 ng/mL and then increased to 2 ng/mL and decreased to 1 ng/mL. The last test series were started 10 min after discontinuation of remifentanil. Acute remifentanil-induced hyperalgesia and tolerance were detected only by the pressure pain test and were not suppressed by ketamine. Remifentanil alone induced significant analgesia with all pain tests. Ketamine further increased the remifentanil effect only on IM electrical pain. Remifentanil at a 2 ng/mL target concentration induced a slight respiratory depression that was antagonized by ketamine. We conclude that ketamine effects on opioid analgesia are pain-modality specific.

 

GABA在氮气、氩气及氧化亚氮麻醉中的神经药理作用研究

Gamma-Aminobutyric Acid Neuropharmacological Investigations on Narcosis Produced by Nitrogen, Argon, or Nitrous Oxide

Jacques H. Abraini*, Badreddine Kriem, Norbert Balon, Jean-Claude Rostain, and Jean-Jacques Risso,

*UMR CNRS 6551 Mort Neuronale, Neuroprotection, Neurotransmission, Université de Caen, Centre Cyceron; EMI INSERM 0014, Université Henri Poincaré Nancy 1; UPRES EA3280, Université de la Méditerranée, Marseille; and Institut de Médecine Navale du Service de Santé des Armées (IMNSSA), Toulon, France

Anesth Analg 2003;96:746-749

吸入麻醉药,包括气体麻醉剂氧化亚氮和氙气,被认为是通过直接作用于离子通道受体而产生作用的。比较而言,对在高压下仅显示麻醉作用的惰性气体如氮气和氩气其作用机制知之甚少。本实验中,作者研究了选择性GABA受体拮抗剂对由氮气,氩气及氧化亚氮产生麻醉作用的效应。用竞争性GABAA受体拮抗剂gabazine (0.2 nmol)而不是GABAB受体拮抗剂2-hydroxysaclofen (10 nmol)预处理增加了氮气和氩气翻正反射消失的阈值压力(P < 0.005),但对氧化亚氮麻醉没有作用。以GABAA-苯二氮卓受体拮抗剂氟马泽尼(5nmol)也增加氩气麻醉的阈值压(P<0.025)。假定2-hydroxysaclofen, gabazine和氟马泽尼均未达到用于诱发过度兴奋性的剂量,那么我们的结果支持氮气和氩气的麻醉作用可为gabazine和氟马泽尼选择性拮抗。氮气和氩气麻醉作用的某些机制可能与临床使用的吸入麻醉药相似。

                                    (张   庄心良 校)

Inhaled anesthetics, including the gaseous anesthetics nitrous oxide and xenon, are thought to act by interacting directly with ion-channel receptors. In contrast, little is known about the mechanism of action of inert gases that show only narcotic potency at high pressures, such as nitrogen or argon. In the present study, we investigated the effects of selective -aminobutyric acid (GABA) receptor antagonists on narcosis produced by nitrogen, argon, and nitrous oxide. Pretreatment with the competitive GABAA receptor antagonist gabazine (0.2 nmol) but not the GABAB receptor antagonist 2-hydroxysaclofen (10 nmol) increased the nitrogen and argon threshold pressure for loss-of-righting-reflex (P < 0.005) but had no effect on nitrous oxide narcosis. Pretreatment with the GABAA benzodiazepine receptor antagonist flumazenil (5 nmol) also increased the narcosis threshold pressure of argon (P < 0.025). Given that neither 2-hydroxysaclofen, gabazine, nor flumazenil at the doses used induced hyperexcitability, our results support a selective antagonism by gabazine and flumazenil of the narcotic action of nitrogen and argon. Some mechanisms of nitrogen and argon narcotic action might be similar to those of clinical inhaled anesthetics.

 

静脉氟哌利多导致腰麻时异丙酚镇静病人脑电双频指数下降

Intravenous Droperidol Causes a Reduction in the Bispectral Index in Propofol-Sedated Patients During Spinal Anesthesia

Masayasu Nakayama, MD*, Noriaki Kanaya, MD*, Hiromichi Ichinose, MD, Shuji Yamamoto, MD, and Akiyoshi Namiki, MD PhD*

*Department of Anesthesiology, Sapporo Medical University School of Medicine; and Division of Anesthesia, Obihiro Kosei Hospital, Japan

Anesth Analg 2003;96:765-768

我们研究了静脉应用氟哌利多对腰麻期间清醒和异丙酚镇静病人脑电双频指数(BIS)的影响。在腰麻后30分钟后,20位病人除给予2mg氟哌利多外未给其它任何镇静药物(清醒组)。其它组病人以异丙酚静脉输注镇静维持BIS值在60 ± 5,采用随机双盲法,分别静脉应用生理盐水(安慰剂组,n = 20),氟哌利多1mgdro-1 ; n = 20)或氟哌利多2mgdro-2; n = 20)。虽然在清醒组和安慰剂组BIS值保持不变,但在应用氟哌利多的dro-1 dro-2组却显著下降。而且dro-2组的BIS值下降显著大于dro-1 组。这些结果提示止吐剂量的氟哌利多在腰麻时剂量依赖性地增强异丙酚的催眠效应。

                                    (张   庄心良 校)

We investigated the effect of IV droperidol on the bispectral index (BIS) in conscious and propofol-sedated patients during spinal anesthesia. Thirty minutes after the induction of spinal anesthesia, 20 patients were given 2 mg of droperidol IV without administration of other sedatives (conscious group). Another group of patients were sedated with a propofol infusion to maintain BIS at 60 ± 5 and were administered IV saline (placebo group; n = 20), droperidol 1 mg (dro-1 group; n = 20), or droperidol 2 mg (dro-2 group; n = 20) in a randomized order and in a double-blinded fashion. Although BIS remained the same in the conscious and placebo groups, it significantly decreased after administration of droperidol in the dro-1 and dro-2 groups. The decrease in BIS was significantly larger in the dro-2 group than in the dro-1 group. These results suggest that an antiemetic dose of droperidol enhances the hypnotic effect of propofol in a dose-dependent manner during spinal anesthesia.

 

鞘内持续注射可乐定和替扎尼定对清醒状态下犬的疼痛和血流动力学的影响

Continuous Intrathecal Clonidine and Tizanidine in Conscious Dogs: Analgesic and Hemodynamic Effects

 

Jeffrey S. Kroin, PhD*, Robert J. McCarthy, PharmD*, Richard D. Penn, MD, Timothy J. Lubenow, MD*, and Anthony D. Ivankovich, MD*

Departments of *Anesthesiology and Neurosurgery, Rush Medical College, Chicago, Illinois

Anesth Analg 2003;96:776-782

鞘内注射可乐定等α2受体激动剂对实验动物有抗伤害作用。但是,由于有心血管副作用,限制了其临床应用。需要进一步寻找对血流动力学影响小的α2受体激动剂。为此,我们对鞘内注射可乐定和替扎尼定进行了比较性研究。6只犬每周接受可乐定或替扎尼定注射(交叉研究),并依次提高剂量125–750 μg/h,并对注射期间动物的疼痛、血压、心率、镇静进行评价。另外9只犬鞘内注射替扎尼定(3 or 6 mg/d)或生理盐水。结果,相同剂量的可乐定和替扎尼定产生相同的抗伤害作用。可乐定125500 μg/h 导致血压降低,而任何剂量的替扎尼定均不引起血压下降。可乐定250 μg/h 使心率减慢幅度为45.8%,其中5例出现了显著心动过缓,而替扎尼定最大降压幅度仅为15.1%,且未发生心律失常。可乐定剂量大于250 μg/h 时动物呼吸频率降低。在大剂量应用时,两药均引起镇静和不配合的情况。对替扎尼定用药的安全性评价表明,替扎尼定3 mg/d不引起严重的副作用和组织病理学损害。结论:鞘内注射替扎尼定可以替代可乐定用于疼痛治疗,尤其适合那些应用可乐定后发生了严重血流动力学变化的病人。

(王士雷    庄心良 校)

Alpha-2-adrenergic agonists, such as clonidine, produce antinociception in animal pain models after intrathecal administration. However, clinical usage is limited by cardiovascular side effects. To investigate alternative 2-adrenergic agonists as analgesics, we implanted six dogs with an intrathecal catheter and infusion pump. After baseline saline infusion, animals received clonidine or tizanidine (crossover study) each week at escalating doses of 125–750 μg/h. Analgesia, blood pressure, heart rate, respiratory rate, sedation, and coordination were evaluated. A 28-day safety study was performed with another nine dogs receiving intrathecal tizanidine (3 or 6 mg/d) or saline. Equal doses of clonidine and tizanidine produce the same antinociception in thermal withdrawal tests. Blood pressure was reduced with 125–500 μg/h of clonidine, but not with tizanidine at any dose. Clonidine 250 μg/h reduced heart rate by 45.8%, and five of six animals had bradyarrhythmias (marked bradycardia), whereas tizanidine decreased heart rate by 15.1% without arrhythmias, even at the largest dose. Respiratory rate decreased with 250 μg/h of clonidine and larger doses. Sedation or incoordination occurred only at the largest dose for either drug. The safety study indicated that 3 mg/d of tizanidine in dogs produced no side effects or histopathologic changes. Tizanidine may be a useful alternative in patients experiencing cardiovascular side effects with intrathecal infusion of clonidine.

 

术后单次小剂量氯胺酮可快速持续地改善对吗啡抵抗患者的吗啡镇痛效果

A Single Small Dose of Postoperative Ketamine Provides Rapid and Sustained Improvement in Morphine Analgesia in the Presence of Morphine-Resistant Pain

Avi A. Weinbroum, MD

Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

Anesth Analg 2003;96:789-795

临床常见术后吗啡抵抗性疼痛。氯胺酮的镇痛潜能也已得到确证。本研究中,我们选择在标准全身麻醉下手术,术后静脉注射吗啡剂量在30分钟内超过0.1mg/kg仍然主诉疼痛(VAS10分制评分超过6分)的病人,评价了术后小剂量氯胺酮联合吗啡镇痛对疼痛强度、脉搏氧饱和度和主观评分的影响。在双盲的情况下,病人被随机分为两组,一组接受10分钟内最多三次每次30µg/kg吗啡加生理盐水静脉注射(MSn114),另一组则每次注射15µg/kg吗啡加250µg/kg氯胺酮(MKn131)。MS组在2.52 ± 0.56 次注射后,疼痛视觉评分在10钟和120分钟时分别为5.5 ± 1.18 3.8 ± 0.9MK组在1.35 ± 0.56p<0.001)次注射后,10分钟和120分钟时的疼痛视觉评分分别是2.94 ± 1.28 1.47 ± 0.65p<0.001MS组在10分钟时的虚弱感评分(VAS 1-10)明显低于MK组( 6.1 ± 1.5 vs 8.37 ± 1.19P < 0.001)。在10分钟时,MS组脉搏氧饱和度下降了0.26%而MK组则升高了1.71%(P < 0.001)。MS30MK9人发生了恶心/呕吐(P < 0.001)MK组有9人有持续2分钟以上的头轻感,有1人在第二次注射后做了怪梦。意义:小剂量氯胺酮和吗啡配伍打断了以前单纯使用吗啡不能解决的严重术后疼痛。氯胺酮使吗啡用量减少,可以迅速和持续地改善吗啡的镇痛效果和病人的主观感受,而没有不可接受的副作用。

(颜   庄心良  校)

It is a common clinical observation that postoperative pain may be resistant to morphine. The analgesic potentials of ketamine have also been well documented. In this study, we evaluated the effects of postoperative coadministration of small doses of ketamine and morphine on pain intensity, SpO2, and subjectively rated variables in surgical patients who underwent standardized general anesthesia and complained of pain (6 of 10 on a visual analog scale [VAS]) despite >0.1 mg/kg of IV morphine administration within 30 min. Patients randomly received up to three boluses of 30 µg/kg of morphine plus saline (MS; n = 114) or 15 µg/kg of morphine plus 250 µg/kg of ketamine (MK; n = 131) within 10 min in a double-blinded manner. The MS group’s pain VAS scores were 5.5 ± 1.18 and 3.8 ± 0.9 after 10 and 120 min, respectively, after 2.52 ± 0.56 injections, versus the MK group’s VAS scores of 2.94 ± 1.28 and 1.47 ± 0.65, respectively (P < 0.001), after 1.35 ± 0.56 injections (P < 0.001). The 10-min level of wakefulness (1–10 VAS) in the MS group was significantly (P < 0.001) less (6.1 ± 1.5) than the MK group’s (8.37 ± 1.19). SpO2 decreased by 0.26% in the MS group but increased by 1.71% in the MK patients at the 10-min time point (P < 0.001). Thirty MS versus nine MK patients (P < 0.001) experienced nausea/vomiting; nine MK patients sustained a 2-min light-headed sensation, and one patient had a weird dream after the second drug injection.

 

细胞凋亡作为家兔脊髓缺血后迟发性截瘫的原因缺乏足够证据

Lack of Evidence for Apoptosis as a Cause of Delayed Onset Paraplegia After Spinal Cord Ischemia in Rabbits

Takashi Kiyoshima, MD, Shiro Fukuda, MD, Mishiya Matsumoto, MD, Yasuhiko Iida, MD, Satoe Oka, MD, Kazuhiko Nakakimura, MD, and Takefumi Sakabe, MD

Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Japan

Anesth Analg 2003;96:839-846

脊髓缺血后出现迟发性截瘫的原因尚不清楚。为此,我们对运动神经元凋亡是否参与脊髓缺血后截瘫的形成进行了研究。阻断家兔腹主动脉15min造成家兔脊髓缺血。于再灌后8 24 48h评价后肢运动功能以及脊髓形态和生化的改变。每个时间点14只动物,其中各7只分别用于脊髓形态和生化研究,6只动物作为假手术对照组。结果有2/3的动物出现迟发性运动功能障碍。未出现截瘫但发生了运动功能障碍的家兔,其运动神经元发生水肿和尼氏体碎裂。出现截瘫的家兔则出现灰质破坏和炎症细胞浸润。形态学未发现有运动神经元凋亡。caspase-3诱发的破裂产物fodrin未出现增高,也没有出现DNAladder 结论:细胞凋亡不参与脊髓损伤后迟发性截瘫的形成。

(王士雷     庄心良  校)

The mechanisms for delayed onset paraplegia after transient spinal cord ischemia are not fully understood. We investigated whether apoptotic motor neuron death is involved in its development. Spinal cord ischemia was induced for 15 min by occlusion of the abdominal aorta in rabbits. At 8, 24, or 48 h after reperfusion, hind limb motor function was assessed, and the lumbar spinal cord

was examined morphologically (hematoxylin-eosin and terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling staining) and biochemically (breakdown products of -fodrin and patterns of DNA changes). At each time point, 14 rabbits were studied (7 for histopathology and 7 for biochemical analysis). Six rabbits served as sham controls. Delayed motor dysfunction developed in two thirds of the rabbits. The motor neurons in the rabbits with motor dysfunction (not paraplegia) showed swelling and a finely granular dispersed Nissl substance. In paraplegic rabbits, destruction of the gray matter and prominent inflammatory cell infiltration were observed. No apoptotic motor neuron was found in any rabbit. There was neither detectable increase in a caspase-3-mediated breakdown product of -fodrin, nor DNA laddering in any rabbit. The results suggest that apoptosis has a negligible role in the pathophysiology of delayed paraplegia in the spinal cord ischemia model examined.

 

用磁共振显像评估锁骨上 Plumb-Bob技术在臂丛阻滞中的应用

An Evaluation of the Supraclavicular Plumb-Bob Technique for Brachial Plexus Block by Magnetic Resonance Imaging

Øivind Klaastad, MD*, Timothy R. VadeBoncouer, MD, Terje Tillung, RT, and Örjan Smedby, DrMedSci,

*Department of Anesthesiology and The Interventional Centre, Rikshospitalet University Hospital, Oslo, Norway; Department of Anesthesiology, University of Illinois at Chicago College of Medicine, Chicago, Illinois; and Department of Radiology, University Hospital Linköping, Linköping, Sweden

Anesth Analg 2003;96:862-867

依据磁共振显像的结果,Plumb-Bob技术被用于臂丛阻滞可以降低气胸的发生率。然而,气胸的危险依然存在。我们分析了十位志愿者的磁共振显像结果,来判断这种技术能否降低气胸的发生率。穿刺点位于胸锁乳突肌外侧和锁骨上缘的交界处,首先前后向进针,如果不成功,则沿原穿刺点,在矢状面上将针向头侧或向尾侧倾斜20°-30°,再从前向后进针。我们发现,在六位志愿者中,单纯前后向进针在未触及锁骨下动脉或臂丛时就已刺破胸膜和锁骨下静脉。穿刺针需向头侧平均倾斜21° 才能触及臂丛,其中一例从头侧41° 到尾侧 15°才找到臂丛。我们的结论是穿刺针先向头侧倾斜45°,而不是直接前后向进针,这样可以降低刺破胸膜和锁骨下静脉的危险性。如果未触及臂丛,倾角应逐渐下降。

                                    (轩   庄心良 校)

Partly based on magnetic resonance imaging studies, the "plumb-bob" approach for brachial plexus block was designed to minimize the risk of pneumothorax. Nevertheless, the risk of pneumothorax has remained a concern. We analyzed magnetic resonance images from 10 volunteers to determine whether the risk of pneumothorax was decreased with this method. The recommended initial needle direction is anteroposterior through the junction between the lateral-most part of the sternocleidomastoid muscle and the superior edge of the clavicle. If the initial placement is not successful, the brachial plexus may be sought in sectors 20°–30° cephalad or caudad to the anteroposterior line in a sagittal plane through the insertion point. We found that the anteroposterior line reached the pleura in 6 of 10 volunteers without prior contact with the subclavian artery or the brachial plexus, but always with contact with the subclavian vein. To reach the middle of the brachial plexus, a mean cephalad redirection of the simulated needle by 21° was required (range from 41° cephalad to 15° caudad in one case). We conclude that the risk of contacting the pleura and the subclavian vessels may be reduced by initially directing the needle 45° cephalad instead of anteroposterior. If the brachial plexus is not contacted, the angle should be gradually reduced.

 

小剂量1%3%高张利多卡因溶液行腰麻的比较

A Comparison of Hyperbaric 1% and 3% Solutions of Small-Dose Lidocaine in Spinal Anesthesia

Yurie Tohdoh Kawamata, MD, Koki Nishikawa, MD, Tomoyuki Kawamata, MD, Keiichi Omote, MD, Motohiko Igarashi, MD, Masanori Yamauchi, MD, Koichi Sato, MD, Masayasu Nakayama, MD, and Akiyoshi Namiki, MD

Department of Anesthesiology, Sapporo Medical University School of Medicine, Japan

Anesth Analg 2003;96:881-884

 

我们研究了当剂量维持在30mg时,高张利多卡因的浓度是否影响运动阻滞的消退。我们也研究了感觉阻滞的扩散,时间和消退。65例择期行会阴或下肢手术的病人入选此项研究。病人以3%1ml1%3ml利多卡因进行腰麻。65例病人中63例获得足够的手术阻滞平面。应用3ml 1%高张利多卡因溶液可以产生与应用1ml3%高张利多卡因相似的腰麻感觉阻滞平面。应用3ml1%高张利多卡因溶液导致更短的运动完全恢复时间。接受1%利多卡因的2例病人和接受3%4例病人由于发生低血压而需要静脉应用麻黄碱。结果显示在短小手术时应用1%高张利多卡因进行腰麻优于3%的高张利多卡因溶液。

                                    (张军   庄心良 校)

We examined whether the concentration of hyperbaric lidocaine affected the regression of motor block when the dose of lidocaine was kept constant at 30 mg. We also examined the spread, duration, and regression of sensory block. Sixty-five patients (ASA physical status I or II), scheduled for elective perineum or lower limb surgery, were enrolled in this study. Patients received spinal anesthesia with 1 mL of 3% lidocaine or 3 mL of 1% lidocaine. Adequate level of block was obtained for surgery in 63 of 65 patients. Whereas the administration of 3 mL of hyperbaric 1% lidocaine solution produced a level of sensory block similar to that produced by the administration of 1 mL of hyperbaric 3% lidocaine solution in spinal anesthesia, the administration of 3 mL of hyperbaric 1% lidocaine solution resulted in shorter times to full motor recovery and to urination and produced less motor block compared with 1 mL of hyperbaric 3% lidocaine solution. Two patients receiving 1% lidocaine and four patients receiving 3% lidocaine required IV ephedrine because of hypotension. Our results showed the clinical advantages of hyperbaric 1% lidocaine spinal anesthesia compared with hyperbaric 3% lidocaine spinal anesthesia for surgery of short duration.