Anesthesia & Analgesia

March 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

心臟術後併發症:急性腎功能不全與房顫的關係

(李紹清 薛張綱 )

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.

 

心肺轉流時Alpha-StatpH-Stat與頸靜脈血氧飽和度和腦血糖-血氧利用關係的比較

(趙雪蓮 莊心良 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.

 

鉗夾兔腹部動脈時及隨後的腦微循環改變:血栓素A2受體的作用

(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

 

圍術期 Dexmedetomidine 減低犬心肌乳酸產生

(李紹清 譯, 薛張綱 )

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.

短期應用乙醇不影響清醒狗心肌頓抑的功能恢復

(趙雪蓮 莊心良 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.

在正常鼠與高血壓鼠鹽酸美西氯通過動脈三磷酸腺苷敏感性鉀離子通道調節血管舒張功能的比較

(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:

兒童硬膜外自控鎮痛:能行嗎?

(李紹清 薛張綱 )

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受體阻斷劑可以劑量依賴性地拮抗丙泊酚而非氯胺酮或異氟醚引起的體動消失

( 莊心良  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.

 

丙泊酚對手術病人血小板和白細胞和紅細胞相互作用的影響

(殷文淵 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蘇醒時意識、記憶功能、腦電圖的改變  

(顧悅超 薛張綱 )

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.

 

小劑量氯胺酮對瑞米芬太尼的鎮痛作用、痛覺過敏和耐受的影響

(     莊心良校)

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.

 

豚鼠心臟中δ-和κ-阿片類激動劑對肌絲Ca2+敏感性的調節

(殷文淵   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.

 

氟烷和異氟醚對病人術後肝動脈和門靜脈血流影響的比較

(顧悅超 薛張綱 )

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在氮氣、氬氣及氧化亞氮麻醉中的神經藥理作用研究

(   莊心良 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.

 

和術前未使用慶大黴素相比,術中使用較大劑量較適當劑量慶大黴素更能增強維庫溴胺的肌松效應

(   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:

七氟醚分解產生一氧化氮:一項臨床研究模型:

(顧悅超 薛張綱 )

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.

 

靜脈氟呱利多導致腰麻時異丙酚鎮靜病人腦電雙頻指數下降

(   莊心良 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:

鞘內使用嗎啡(非小劑量)誘導的大鼠主動脈非損傷性間斷阻斷後的下肢痙攣性輕癱

(張俊峰 譯 薛張剛 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.

 

鞘內持續注射可樂定和替紮尼定對清醒狀態下犬的疼痛和血流動力學的影響

(王士雷    莊心良 校)

在清醒狗鞘內連續注射可樂寧和替托尼定的鎮痛和血流動力學效應

(   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.

小鼠鞘內注射曲馬多後對脊髓本體感應誘發電位和運動誘發電位的影響

 (忻紀華   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.

 

術後單次小劑量氯胺酮可快速持續地改善對嗎啡抵抗患者的嗎啡鎮痛效果

(   莊心良  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:

外科監護室病人體溫過低的預測

(   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.

 

術後機械通氣病人相繼使用咪唑安定和異丙酚進行長期鎮靜治療

(張俊峰 薛張剛 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:

細胞凋亡作為家兔脊髓缺血後遲發性截癱的原因缺乏足夠證據

(王士雷     莊心良  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.

在健康志願者無創性評估呼末二氧化碳的變化對腦灌注壓和零流壓的影響

(   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:

用磁共振顯像評估鎖骨上 Plumb-Bob技術在臂叢阻滯中的應用

(軒   莊心良 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.

 

經臀大肌下股二頭肌旁坐骨神經單次阻滯新方法的評估

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.

 

小劑量1%3%高張利多卡因溶液行腰麻的比較

(張軍   莊心良 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:

對志願者在特定一點(extra 1)施壓針療可減低腦電雙頻指數值和應激

(忻紀華 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.

 

三種插管設備在正常血壓和高血壓病人上的血流動力學反應

(潘志浩 薛張剛 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.

 

鉗夾兔腹部動脈時及隨後的腦微循環改變:血栓素A2受體的作用

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

有關鉗夾和鬆開兔腹部動脈時及隨後出現的腦血流動力學,尤其是腦微循環的改變我們所知甚少。觀察27只兔子通過一個密閉的顱窗觀測鉗夾和鬆開腹部動脈時使用或不使用血栓素(Tx A2受體拮抗劑對腦膜血管直徑的影響。結果表明在鉗夾腎下動脈時未發現腦膜血管直徑的改變,但鉗夾20分鐘鬆開後會引起腦膜血管的舒張隨後收縮。顯著的收縮至少持續了60分鐘(大血管收縮17% []75um)小血管收縮28% [<75um]). 局部使用TxA2受體拮抗劑(seratrodast10-7M10-6M後可明顯改善大小血管的收縮情況,鉗夾20分鐘後再鬆開腹部血管會引起腦膜動脈的持續性收縮,這一現象可通過局部使用seratrodast而削減,這可能是由於間接阻斷了TxA2對局部缺血區域的作用所致。

(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.


 

在正常鼠與高血壓鼠鹽酸美西氯通過動脈三磷酸腺苷敏感性鉀離子通道調節血管舒張功能的比較

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

慢性高血壓患者服用抗心律失常藥物後經由三磷酸腺苷(ATP)敏感性鉀離子通道調節血管舒張功能的研究尚未見報道。本研究測試患有高血壓的老鼠在服用鹽酸美西氯後是否可經由某些通路調節血管舒張功能。對正常老鼠與有高血壓的老鼠去除動脈內皮進行等容壓力記錄。健康鼠服用鹽酸美西氯 (3*10-5M)後經由左克羅卡林 (10-8-10-5M)作用增強血管舒張,而患有高血壓的老鼠則無反應。服用鹽酸美西氯(10-5 -- 3*10-5M)增強血管舒張功能相當於硝普鈉(10-10--10-5M),然而使用ATP敏感性鉀離子通道拮抗劑glivenclamide (10-5M)可抑制這種作用。一氧化氮清除劑(carboxy-2-phentl-4,4,5,5-tetramethylimidazoline-q-oxyl 3-oxide; 10-3 M)可抑制健康鼠動脈中鹽酸美西氯的血管擴張作用,然而可溶性鳥苷酸環化酶抑制劑則無上述作用。綜上所述鹽酸美西氯可經由健康鼠動脈中某些物質如一氧化氮活化ATP敏感性鉀離子通道而提高血管舒張功能,鹽酸美西氯的血管舒張作用部分也可能是由於一氧化氮的可溶性非鳥苷酸環化酶依賴性作用引起。

(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.


 

丙泊酚對手術病人血小板和白細胞和紅細胞相互作用的影響

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


 在手術病人體外試驗中測試丙泊酚的抗血小板作用。血小板聚合體由二磷酸腺苷誘導,在全血,含有豐富血小板的血漿(RPR),RPR+紅細胞,RPR+白細胞四種樣本中測定花生四烯酸。同時也測定血小板產物血栓烷(TxB2和白細胞產物6-酮前列腺素F1α(一種穩定的前列腺素代謝產物)和血漿中的硝酸鹽+亞硝酸鹽水平(氧化氮產物的指示劑)。麻醉誘導為靜脈注射硫噴妥鈉4 mg/kgn=10),丙泊酚2.5 mg/kgn=20),或全憑丙泊酚靜脈麻醉(n=20)。硫噴妥鈉對分析結果沒有任何影響。大劑量注射丙泊酚的病人,在全血和RPR+白細胞中的血小板聚合體顯著減少。血小板產物血栓烷(TxB2減少了35%;對6-酮前列腺素F1α的抑制在統計學上不是很顯著。血漿中的硝酸鹽+亞硝酸鹽水平增加了37%;這個變化與舒張壓和收縮壓的降低顯著相關(都P<0.05)。雖然數量較大,在全憑丙泊酚靜脈麻醉也可觀察到類似變化。總之,丙泊酚抑制了手術病人的血小板聚合體,這主要是抑制Tx合成和氧化氮產物增加的結果。這種影響被認為與這種麻醉相關的血壓降低有關。

(殷文淵 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.


豚鼠心臟中δ-和κ-阿片類激動劑對肌絲Ca2+敏感性的調節

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-阿片類激動劑是否會改變心肌功能,細胞內Ca2+濃度([Ca2+]i,和完整豚鼠心臟肌絲Ca2+敏感性以及這些影響是否由阿片類收體所介導。完整豚鼠心臟用 含有δ-TAN-67)和κ-(ICI-199441)阿片類激動劑的修正Krebs Ringer溶液灌注,存在以及不存在δ-BNTX)和κ-(nor-BNI)阿片類拮抗劑,分別記錄功能變化和[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但不改變左室壓增加(P<0.05)。TAN-671μMICI-1994411μM也會導致LVP增加也就是可利用[Ca2+]i功能曲線左移(P<0.05)。在相關曲線中,ICI-1994411μM會產生一個與基線相比較陡峭的斜坡(P<0.05)。BNTX1μM nor-BNI1μM分別阻滯了TAN-67ICI-199441的作用。在完整隔離的豚鼠心臟中,δ-和κ-阿片類激動劑雖然降低了可利用[Ca2+]I,但增強了肌絲Ca2+敏感性,這些作用為δ-和κ-阿片類激動劑受體刺激所介導。

(殷文淵   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.

和術前未使用慶大黴素相比,術中使用較大劑量較適當劑量慶大黴素更能增強維庫溴胺的肌松效應

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

 

比較了2種劑量的慶大黴素使用後及術前未使用慶大黴素的病人中,對維庫溴胺的肌松效應的影響。70例病人被隨機分組,LD組術前使用4mg/kg的慶大黴素,MD組術中使用1.24mg/kg的慶大黴素,NG組在萬可羅寧使用前不使用慶大黴素。比較各組病人間血清慶大黴素濃度,單次注射維庫溴胺後四個成串刺激的第一個抽搐強度達到25%的時間,以及末次使用維庫溴胺後到拔除氣管導管的時間。LD組的血清慶大黴素水平高於MD組(P<0.001)。T125%恢復時間在LD組略高於MD組(P=0.06),在LD組明顯高於NG組(P+0.001)(各組數值分別為42.9±23.636.2±1727.4±19.3分鐘)。在LD組和MD組拔管時間相近,LD組的拔管時間明顯長於NG組(P=0.008)(各組數值分別為34.7±19.227.4±19.319.4±10.1分鐘)。MD組和NG組的差別是顯而易見的。與不使用慶大黴素相比,使用大劑量慶大黴素較適當劑量明顯增強維庫溴胺的神經肌肉阻斷效果。

(   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.


 

在清醒狗鞘內連續注射可樂寧和替托尼定的鎮痛和血流動力學效應

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受體激動劑,例如可樂寧,在動物模型中使用鞘內注射後可以產生鎮痛效果。但由於有心血管系統的副作用,其臨床應用受到限制。為了研究選擇性α-2受體激動劑的鎮痛效應,我們在6只狗體內留置鞘內導管以及推注泵。在注入基礎負荷量之後,每週給予這些動物125-750μg/h的可樂寧或替托尼定,統計其鎮痛效果,血壓,心率,呼吸頻率,鎮靜程度及協調能力。實驗順利進行了28天,另有9只狗接受鞘內注射替托尼定(36mg/天)或生理鹽水。同等劑量的可樂寧和替托尼定的退熱效應相等。在使用125-500μg/h的可樂甯時出現了血壓下降,任何劑量的替托尼定都不伴有血壓下降。250μg/h的可樂寧會導致心率下降45.8%,並有5-6只實驗動物出現心率不齊(主要表現為心動過緩),而替托尼定可以使心率下降45.8%,但即使使用最大劑量時也不會出現心率失常。只有在大劑量使用上述2種藥時,才會出現鎮靜和不協調表現。本實驗提示,在狗體內,使用3mg/天的替托尼定不會出現明顯副反應及組織病理學改變。替托尼定可以選擇性地應用在鞘內注射可樂寧有明顯心血管副反應的病人中。

(   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.

 

小鼠鞘內注射曲馬多後對脊髓本體感應誘發電位和運動誘發電位的影響

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


在臨床和實驗室研究中,曲馬多均被證實對周圍神經有局部麻醉作用。本研究中,我們在小鼠鞘內用藥後,通過感覺和運動神經的傳導來評價曲馬多的作用。通過鞘內導管注入曲馬多012mg。刺激坐骨神經後記錄胸腰連接處的脊髓本體感覺誘發電位(SSEPs)。在電刺激低位(胸1213)椎間隙後記錄足部內在肌肉的複合肌肉動作電位(CMAP)。在用藥前記錄SSEPCMAP作為基礎值,記錄用藥後51530的值,以後4.5小時每個3060分鐘記錄一次。SSEP20次的平均值,而CMAP為單次刺激的值。所有小鼠中均能測得SSEPsCMAP值。鞘內注射曲馬多產生劑量依賴的SSEPsCMAP刺激高度減弱和潛伏期延長。總之,注藥後立即可產生抑制並能維持兩小時。聯合注射納洛酮20ug並不能減弱脊髓SSEPs的抑制。我們得出結論,鞘內注射曲馬多脊神經根的感覺或運動電位的傳導產生劑量依賴性的抑制。

                                               (忻紀華   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.


 

外科監護室病人體溫過低的預測

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


因疏忽導致術後病人中心體溫過低可給病人帶來許多生理影響,特別是對於監護室(ICU)中的病人。儘管關於病人、手術和麻醉因素與急性術後體溫降低關係的論文已有報導,但為了促進外科手術、麻醉和保溫技術的進一步發展,我們有必要將這些資料重新回顧一下。我們設計了一個包含194例普外科術後病人的前瞻性研究,來評估術後中心體溫降低(鼓膜溫度[TC]<36)的發生率、預見因素和後果,此研究中的病例均選自200012月至20013月期間large tertiary大學醫學中心普外科ICU中的病人。研究中所包含的變數如下:年齡、性別、體重、體表面積、術前體溫、ASA分級、有無糖尿病性神經病變史、是否急診手術、專科實施的手術、手術種類、麻醉選擇(全身麻醉、區域麻醉或硬膜外複合全身麻醉)、體溫監測、空氣保溫技術的應用、術中輸血補液量、麻醉持續時間、手術持續時間和手術室環境溫度。另外,對其他一些後果、在ICU中的住院時間和死亡率也作了評估。結果發現TC<36℃、<35.5℃、<35℃的發生率分別為57.1%41.3%28.3%。多元回歸分析顯示體溫降低的危險因素如下:高ASA分級(ASAII級的病人機率為2.8795%可信區間[CI]0.82-10.03ASA>II級的病人機率為8.3595%CI1.67-41.88),外科手術的大小(中等手術的機率為6.6095%CI1.66-26.19;大手術的機率為22.2395%CI5.41-91.36),應用硬膜外複合全身麻醉(機率為3.3995%CI1.05-10.88)和手術持續時間>2h(機率為4.5095%CI1.48-13.68)。另外,手術期間未進行體溫監測似乎也是一個危險因素(機率為3.0095%CI0.87-10.12)。一些重要的保護因素可防止中心體溫降低,主要包括:病人體重較重(機率為0.9495%CI0.89-0.98),術前體溫較高(機率為0.3195%CI0.15-0.65),和手術室內比較溫暖(機率為0.6795%CI0.51-0.88)。總之,在普外科ICU中病人發生體溫降低仍然較常見。為減少其發生率,我們應該付出更大的努力,並給予更多的關心,特別是對於哪些ASA分級較高,實施重大和長時間手術以及應用硬膜外複合全身麻醉的病人。

(   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.

在健康志願者無創性評估呼末二氧化碳的變化對腦灌注壓和零流壓的影響

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

 

腦迴圈中的零流壓(ZFP)是指血流終止點的動脈壓力。我們可以通過經腦多普勒超聲等無創性的方法來測定腦灌注壓(CPP)和ZFP。由二氧化碳變化引起所測的CPPeCPP)和ZFP的變化很少引起相關的生理資料的變化。我們對17名健康的志願者進行研究,觀察二氧化碳對eCPPZFP的影響。在測定了腦中動脈的血流速度和血壓後,我們讓志願者過度通氣使他們的呼末二氧化碳降低約7.5mmHg,然後再通過Mapleson D回路使呼末二氧化碳增高7.5mmHg。血流速度和血壓每一時段記錄一次,eCPPZFP通過已知的公式被計算出來,其結果再用統計方法分析。隨著呼末二氧化碳增高eCPP50.67 mmHg8.33 mmHg)(平均[SD])增高至60.87 mmHg9.28 mmHg)(增加20%P0.001〉,而ZFP相應降低(P=0.017);而低碳酸血症導致eCPPZFP相反的結果。這項研究結果提示我們在沒有神經功能紊亂的情況下二氧化碳的變化可以預計eCPPZFP的變化。

(   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.

經臀大肌下股二頭肌旁坐骨神經單次阻滯新方法的評估

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


臨床上使用標準的方法實施坐骨神經阻滯受到技術困難的限制,且患者在實施過程中非常不適,或需要兩次注射來阻滯脛神經和腓神經。在這項報導中,我們描述了通過經臀大肌下股二頭肌旁徑路採取單次注射方法進行坐骨神經阻滯,此神經沿股二頭肌的側緣經過。坐骨神經阻滯的實施採取俯臥或側臥位。當給予患者0.4mA的刺激同側的腳發生蹠屈曲或背伸便是進針的深度(平均為56±15mm)。然後給予濃度為0.625%1200000的腎上腺素的左旋布比卡因,劑量為0.4ml/kg。整個過程大概需要6±3分鐘。24%的患者在放置過程中因不適給以150-100µg的芬太尼。92%的患者在注射平均10(範圍,5-25)分鐘後感覺完全消失和運動阻滯。與蹠屈曲相比,足背伸發生率更高分別為86%100%,並且對脛神經,腓神經和腓腸神經感覺和運動阻滯的反應時間更短。此種方法沒有即刻發生或隨後發生的併發症。我們得出結論經臀大肌下股二頭肌旁坐骨神經阻滯是一種可行,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.

對志願者在特定一點(extra 1)施壓針療可減低腦電雙頻指數值和應激

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


我們對25名志願者研究了在特定一點(extra 1)和對照點進行施壓針療時BIS值和應激的改變。每一名志願者均隨機在不同的時間分別對“extra 1”點針療10分鐘和對照點針療5分鐘。在對“extra 1”點針療前測量BIS值,在針療中的10分鐘中每個30秒測量一次,在結束後再測量一次。而在對照組中,由於針刺引起的不適感故改為5分鐘。每一名志願者均在治療前後進行應激評分(0-10分)。在extra 1”點BIS值在2.557.510分鐘時均明顯減低(p<0.001,在壓力緩解後恢復到基礎值。對照組BIS值在2.55分鐘是減低(p<0.01p<0.05)。但是這些值維持在90%左右,且明顯高於extra 1”組(2.55分鐘對比值分別為p<0.001p<0.001)。治療後的口頭鎮靜評分在extra 1”組也明顯低於對照組(p<0.001)。

(忻紀華 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).

心臟術後併發症:急性腎功能不全與房顫的關係

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.

 

   心臟術後肌酐升高是不利後果。雖然,術後休克與腎功能不全有關,但房顫與腎功能不全的關係沒被評估。因此,我們驗證那個假設:冠脈搭橋術後有房顫的患者將有更高的肌酐升高。選取453術前無房顫而行冠脈搭橋手術採取資料。多因素衰減分析和肌酐峰值變化關係證明:年齡與房顫是一雙向關係(可變數估計,-1.1p=0.0002)。多因素衰減分析和術後肌酐峰值變化的關係也獲得類似結果(可變數估計,-0.01; P = 0.04)。也證實了我們的假設:新發房顫患者心外科術後更易發生腎功能不全。房顫與肌酐升高的關係隨年齡增加而下降。這些資料與冠脈搭橋術後急性腎功能不全與房顫在年齡依賴方式上的病因形成病理生理相一致。

結論:我們發現初發房顫和術後肌酐升高非依存性是受年齡影響。房顫與肌酐升高的關聯性隨年齡增加而下降。這提示兩併發症的一般病因對年輕患者更有意義。

                                           (李紹清 薛張綱 )

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.

 

圍術期 Dexmedetomidine 減低犬心肌乳酸產生

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—腎上腺素能拮抗劑Dexmedetomidine的交感阻滯效應可減輕患者心肌缺血負荷,但是,心肌缺血直接測量值,如心肌乳酸產量卻難測量。因此,我們用雜種犬研究,測心肌乳酸產量,心肌氧供,血流動力學變數,緊張反射的神經介質指數。完成心肌缺血臨界值標準化後,灌注Dexmedetomidine和標準鹽。麻醉後期和乳酸出現期90min10min反復測量。在Dexmedetomidine組,累積乳酸產率為46%,低於控制組(95%可信區間20%80%; P = 0.02)。同時,Dexmedetomidine增加心內、外膜血流率到35%(控制組0.4 ± 0.1; dexmed , 0.6 ± 0.1; P = 0.03)。這些抗缺血效應伴隨有去甲腎上腺素能(126 577 pg/mL) 和腎上腺素能 (158 1909 pg/mL) 下降和心率減慢 (123 ± 6 160 ± 10 bpm, dexmed 對控制組)。在作為缺血證據的乳酸產生前,這些抗缺血效應已出現。

   結論:Dexmedetomidine減低血漿兒茶酚胺濃度和心率。在冠脈狹窄犬,因抗交感效應而減少心肌乳酸產生,因而,心肌缺血發生最小。

  (李紹清 譯, 薛張綱 )

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).

 

兒童硬膜外自控鎮痛:能行嗎?

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

 

    廣泛臨床實踐和許多試驗均支持兒童術後靜脈自控鎮痛和局部鎮痛技術。相反,硬膜外自控鎮痛技術和效果在兒童中鮮有報導。我們收集了128例(歸圍為132例)術後急性疼痛硬膜外自控鎮痛的病例,作描述性分析。119例(90.1%)鎮痛效果滿意,持續103h無嚴重併發症和中毒症狀發生。89例對初始設置效果滿意,另外38例改變初始設置獲得滿意效果。5例因鎮痛不足改為靜脈鎮痛,8例因副反應改為靜脈鎮痛。5歲兒童有能力理解和期望硬膜外自控鎮痛的願望,與靜脈自控鎮痛報導一致。需要多加注意的是時間內用量超過設定值。我們預期資料證明:硬膜外自控鎮痛能在兒童中獲得滿意效果,且有較少併發症發生,應與另外一些鎮痛措施一同被考慮。

結論:132例描述性分析證明,小如5歲兒童行硬膜外自控鎮痛可獲得滿意效果而無嚴重毒性和副反應發生。它應該同另外鎮痛措施一樣在兒童術後鎮痛中被考慮。

                                             (李紹清 薛張綱 )

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蘇醒時意識、記憶功能、腦電圖的改變 

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

 

阿片藥物誘導的腦電圖或聽覺誘發電位改變與意識改變是否相關還尚未明確。評價以下關係:1)意識狀態的臨床評價,2)對片語的內隱或外顯記憶,3)多種測量方法:腦電圖、BISARX AEP指數、SVDEN(一種腦電圖複合測量技術)。對21位進行婦科手術而麻醉的婦女,研究其二階段的蘇醒過程(先進性七氟醚的洗出,再是瑞芬太尼的洗出)。所有研究物件均無術中知曉,19位在僅存瑞芬太尼時對口頭指令無反應。有6位在瑞芬太尼濃度下降時BIS亦平行下降:則主要是因為EEG的低振幅而被誤解為爆發性抑制。大多數的EEG/AEP變數對七氟醚濃度下降和意識恢復是敏感的,但是對瑞芬太尼

的濃度下降不敏感。SVDEN是唯一的在七氟醚洗出時和瑞芬太尼洗出時都有明顯上升的變數。瑞芬太尼洗出時具有預測價值的數值,SVDEN=0.79,邊頻指數=0.81ARX AEP=0.63,BIS=0.58。邊頻指數在對大批病人進行進一步臨床評估時有用。SVDEN是一個評估中樞神經系統麻醉和鎮痛作用的有效變數。結論:在瑞芬太尼麻醉的蘇醒過程中,評估意識程度的恢復,由於爆發抑制的干擾,BIS的預測價值不高。邊頻指數較可靠,但也不是評估麻醉深度的金標準。

                                          (顧悅超 薛張綱 )

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.

 

氟烷和異氟醚對病人術後肝動脈和門靜脈血流影響的比較

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

 

動物研究顯示氟烷通過減少肝動脈(HABF)和門靜脈(PVBF)血流來降低總肝血流量(THBF),然而異氟醚則起保護作用。在本研究中,採用脈搏多普勒技術來評估氟烷和異氟醚對手術病人HABFPVBF的影響。一項法律所允許的試驗中,首先應用6只猴子來比較脈搏多普勒技術和吲哚青清除率方法所測得的THBF數值。其次,運用植入脈搏多普勒探頭對6位(ASAI-II級)進行擇期膽囊切除術術後病人進行研究。對進行呼氣末濃度為1%氟烷和1.5%異氟醚麻醉的病人比較其THBF和肝血流的分流量。在動物實驗中,這兩項技術所測結果有較高的一致性。在氟硝安定麻醉的病人中,THBF1120+/-284mL/min。與此作為基準值,和相同的平均動脈壓下降幅度(10%),異氟醚麻醉的病人THBF保持穩定,然而氟烷麻醉的病人THBF減少36%P<0.05)。異氟醚麻醉病人PVBF增加25%P=0.067),HABF保持穩定;氟烷麻醉病人PVBF降低44%(P<0.05)HABF降低20%P<0.05)。氟烷對肝迴圈主要起血管收縮作用;異氟醚起血管舒張作用,從而對肝的氧供有益。結論:揮發性麻醉劑可改變肝迴圈,從而具有嚴重的副作用。對6位進行麻醉的病人運用植入脈搏多普勒技術,發現氟烷對肝血管床主要作為血管收縮劑;而異氟醚是作為血管舒張劑,對肝的氧供有益。

                                           (顧悅超 薛張綱 )

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.

 

七氟醚分解產生一氧化氮:一項臨床研究模型:

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

 

異氟醚,安氟醚,七氟醚,特別是地氟醚在與乾燥劑發生反應時能產生一氧化氮。其中,七氟醚被研究的最少。七氟醚分解產生一氧化氮有賴於吸收器的溫度,分鐘通氣量,新鮮氣流量。在分鐘通氣量分別為2.35.010.0升時,幹的鋇石灰與1.0 最低肺泡麻醉濃度(2.1%)的七氟醚發生反應時,測量吸收器的溫度和相應的一氧化氮濃度。應用一種可重複的方法來建立測量碳氧血紅蛋白濃度的數學模型。在低新鮮氣流量下,七氟醚的快速分解阻止了其達到最低肺泡麻醉濃度。在此分鐘通氣量和吸收器溫度超過80度的情況下,一氧化氮濃度在增加;但是在高新鮮氣流量下,一氧化氮濃度在下降。分鐘通氣量為2.35.0升時,平均一氧化氮濃度為150ppm600ppm;但是分鐘通氣量為10.0升時,一氧化氮濃度超過11000ppm,可引起爆炸和燃燒。亦有甲醇和甲醛存在,並對此可燃性混合物產生影響,但其濃度無法測量。數學模型顯示在普通病例中,僅僅是那些體重</=25Kg,或是嚴重貧血病人,在麻醉最初的60分鐘內,有碳氧血紅蛋白濃度>10%的危險。結論:在乾燥劑中七氟醚的分解期望僅產生較淡的一氧化氮。完全幹的乾燥劑和高分鐘通氣頻率可降低七氟醚分解所產生的高一氧化氮濃度。在極端的條件下存在著嚴重一氧化氮中毒或者呼吸回路中的可燃性氣體發生自燃的可能。

                                          (顧悅超 薛張綱 )

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.

 

鞘內使用嗎啡(非小劑量)誘導的大鼠主動脈非損傷性間斷阻斷後的下肢痙攣性輕癱

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.

 

我們研究鞘內使用嗎啡在大鼠脊髓短暫持久的缺血後的下肢痙攣性輕癱作用的量效關係。事先在鞘內置入注藥的導管,然後使用帶套囊的導管阻斷主動脈6分鐘產生脊髓缺血。缺血後再讓其恢復,在再灌注30分鐘後鞘內分別注射3, 10, 30 µg的嗎啡或生理鹽水。在每一組對鞘內嗎啡對缺血後的神經功能的作用採用定量生物鑒定計算其再灌注2小時時誘導下肢輕癱的50%有效量。隨後再再灌注48小時時對脊髓進行組織學檢測。鞘內注射30 10 µg嗎啡引起漸進性的下肢痙攣,而注射3 µg的嗎啡或生理鹽水則無此作用。在鞘內注射嗎啡2小時進行行為分析評價,則產生下肢輕癱的50%有效劑量為16.1 ± 1.5 µg嗎啡。 在30-µg組進行脊髓組織學分析顯示在腰背段的{alpha}-運動神經元上有黑色著色。 因此我們認為主動脈短暫阻斷後鞘內使用大劑量的嗎啡有產生下肢輕癱的潛在危險並產生相應的神經功能障礙。對於行胸腹動脈瘤修復的病人鞘內使用嗎啡術後止痛時應予注意。結論:短暫阻斷主動脈後鞘內使用大劑量的嗎啡有產生不可逆的脊髓功能退化及相應的神經功能障礙的可能。

                      (張俊峰 譯 薛張剛 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.

 

術後機械通氣病人相繼使用咪唑安定和異丙酚進行長期鎮靜治療

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.

 

急性戒斷綜合征(包括激動和長時間的被遺棄感)是使用咪唑安定長期鎮靜的常見不良反應。我們設計此研究以明確相繼使用咪唑安定和異丙酚與單獨使用咪唑安定相比是否會降低不良反應的發生。我們研究了26例術後機械通氣大於3天的病人。病人隨機分為兩組:M-P組(大約在預期停止鎮靜前24小時更換咪唑安定為異丙酚)和M 組(病人只使用咪唑安定鎮靜)。鎮靜水平維持在4 5(據Ramsay鎮靜評分),在拔管後24 h評價鎮靜激動評分。停止鎮靜到拔管的恢復時間M-P(1.3 ± 0.4 h)顯著短於M (4.0 ± 2.4 h) M-P組的激動發生率 (8%)顯著低於M(54%)。結果顯示與單獨使用咪唑安定相比相繼使用異丙酚長期鎮靜可降低激動的發生率。結論:該研究顯示與單獨使用咪唑安定相比相繼使用咪唑安定和異丙酚可降低激動的發生率。

                           (張俊峰 薛張剛 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.

 

三種插管設備在正常血壓和高血壓病人上的血流動力學反應

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.

 

我們在麻醉和肌松下的正常血壓和高血壓病人上對三種插管設備的血流動力學反應進行了比較,這三種設備為Macintosh喉鏡(LS), TrachlightTM燈杖 (LW), FastrachT插管喉罩 (ILM)75例正常血壓病人和 75例高血壓病人隨機接受各種插管設備 (n = 25) 無創收縮壓(SBP)和舒張壓(DBP)以及心率(HR)在誘導前即刻,插管前即刻,以及成功插管後頭5分鐘的每一分鐘作記錄。插管的次數,成功插管的時間以及任何氣道的損傷也作記錄。咽喉部的發病率在術後1824小時由一位不瞭解分組的調查者作調查。在所有的分組中,與基礎值相比,在插管前即刻都有SBP DBP的下降,但是 HR 不變。在所有分組中, HR增加,但是SBPDBP不增加,除了LS/高血壓組的DBP在插管後較基礎值上升。在正常血壓組,三種設備導致的血流動力學變化沒有差異。在高血壓病人, SBPDBP插管後2分鐘LS 組較ILM LW 組顯著升高,但是三種設備沒有導致 HR的變化差異。各組間插管的嘗試次數無差異,但在 ILM組插管時間顯著延長。氣道損傷的發生在ILM 組較 LS組和LW組更常見(16% 0% 0%)。咽喉部的發病在各組間無差別。我們總結ILM LWLS相比在麻醉和肌松狀態下的高血壓病人而非在正常血壓病人上減輕了插管引起的血流動力學應激反應。

                                           (潘志浩 薛張剛 校)

心肺轉流時Alpha-StatpH-Stat與頸靜脈血氧飽和度和腦血糖-血氧利用關係的比較

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

頸靜脈血氧飽和度(SJVO2)反映了腦血流和腦代謝間的平衡。本文研究兩種不同調節酸堿方法對頸靜脈去飽和(SJVO2<50%)和腦動靜脈血氧-血糖利用的影響。作者對52名行低溫(27°C)體外迴圈(CPB)患者進行了前瞻、隨機研究。患者隨機分為Alpha-Stat(n = 26)pH-Stat(n = 26)組。頸靜脈逆行插管,並在CPB期採集血樣。兩組術前各參數無差異。CPB 30 min時,pH-Stat組的SJVO2明顯高於Alpha-Stat組( 86.2% ± 6.1% 70.6% ± 9.3%; P < 0.001)。然而,此時pH-Stat組動靜脈血糖和血氧的差值明顯低於Alpha-Stat組( 血氧為1.9 ± 0.82 mL/dL 3.98 ± 1.12 mL/dL; P < 0.001; 血糖為 3.67 ± 2.8 mL/dL 10.1 ± 5.2 mL/dL; P < 0.001)。兩組患者複溫時都發生去飽和,且組間無統計學差異。所有患者均以良好狀態出院。相較於Alpha-Stat法, pH-Stat法能提高SJVO2和降低動靜脈血氧和血糖的差值。

結論:對52位行心肺轉流的患者進行前瞻性和隨機研究發現pH-Stat法能增加靜脈氧飽和度和降低動靜脈血氧和血糖的差值。頸靜脈去飽和發生率在兩組無差異,表明在pH-Stat時腦血流增加,但對頸靜脈去飽和無保護作用

(趙雪蓮 莊心良 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.

 

短期應用乙醇不影響清醒狗心肌頓抑的功能恢復

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

長期小劑量攝取乙醇(SAE)可保護缺血損傷的心肌。已有研究證明短期應用乙醇可改善被麻醉狗因快速阻塞引起頓抑心肌的恢復。這種情況是否會發生在清醒的狗尚不清楚。因此,本文研究乙醇對局部頓抑心肌的作用。長期監測36條狗的心率、左房壓、主動脈壓、左室壓、左室收縮順應性(dP/dtmax)和心室舒張功能(dP/dtmin)以及局部心肌壁厚分數(WTF)。阻塞冠狀動脈左前降枝(LAD)造成其支配的心肌可逆性缺血。將36條狗按照乙醇用量分為三組(I, 0.125 g/kg [n = 12]; II, 0.25 g/kg [n = 12]; III, 0.5 g/kg [n = 12])。每條狗施行兩次缺血(隨機且相隔數天)即在靜脈給予含乙醇或不含乙醇的液體30分鐘後阻塞LAD 10分鐘。測定WTF和血流動力學參數的基數值和心肌頓抑完全恢復時點的各參數值。LAD缺血使各組LAD-WTF值顯著降低。給予或不給SAEWTF和血流動力學參數值沒有差異。結論:0.125 g/kg, 0.25 g/kg, 0.5 g/kg SAE對清醒狗的心肌頓抑無顯著影響。

結論:清醒狗短期應用乙醇不會改善心肌頓抑,這與先前在麻醉狀態下的研究結論相反。

(趙雪蓮 莊心良 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受體阻斷劑可以劑量依賴性地拮抗丙泊酚而非氯胺酮或異氟醚引起的體動消失

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

一般認為丙泊酚對GABAA受體的加強作用是其麻醉效應的基礎。但是,最近的研究發現,GABAA拮抗劑並不改變丙泊酚對翻正反射的抑制作用。丙泊酚可以抑制大鼠對傷害性刺激(夾尾)的體動反應這與其麻醉效應有關。為此,我們研究了GABAA的非競爭性拮抗劑印防己毒素和競爭性拮抗劑gabazine對這種效應的影響。同時將該效應與異氟醚和氯胺酮對夾尾反應的作用相比較。印防己毒素使丙泊酚的50%有效劑量(ED50)增加約379%gabazine使ED50增加362%,而且其效應都呈劑量依賴性,沒有明顯的天花板效應(即效應沒有限制)。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%。印防己毒素使異氟醚的麻醉最小肺泡濃度增加約60%gabazing使之增加約70%。非GABA能甘氨酸受體拮抗劑士的寧也可以拮抗丙泊酚的ED50,由此確定通過非GABA能機制興奮中樞神經可以是丙泊酚ED50增加的重要原因。由於士的寧僅使丙泊酚的體動消失的ED50增加約50%,所以還是要用GABAA受體拮抗的機制解釋印防己毒素和gabazine的作用。我們的結論是,GABAA拮抗劑可以程度不等地影響丙泊酚和非GABA能麻醉藥氯胺酮的ED50,這反映出對氯胺酮的生理學拮抗作用(即通過調節神經元環路產生體動消失的間接效應)和對丙泊酚的生理學和藥理學拮抗作用(即通過拮抗丙泊酚的作用機制直接產生效應)。本研究還提示異氟醚的體動消失效應可能與GABAA受體無關,因為使用GABAA受體拮抗劑的動物在異氟醚麻醉時的質和量都與氯胺酮麻醉相似而與丙泊酚麻醉明顯不同。

(顏 莊心良  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.

 

小劑量氯胺酮對瑞米芬太尼的鎮痛作用、痛覺過敏和耐受的影響

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

阿片合用小劑量氯胺酮可能增加鎮痛作用,同時防止阿片誘發的痛覺過敏和急性耐受現象。我們採用隨機、安慰劑對照和雙盲的交叉試驗,研究了瑞米芬太尼複合小劑量氯胺酮在不同疼痛模型中的作用,記錄單次和重複肌肉電刺激的痛閾、重複經皮電刺激的痛閾、壓痛閾、及鎮靜、呼吸和心血管不良反應。14位健康志願者接受生理鹽水、瑞米芬太尼、瑞米芬太尼合用氯胺酮(血漿濃度為 50 100 ng/mL)。首先記錄基線資料,輸注氯胺酮達穩態濃度後再次記錄,然後輸注瑞米芬太尼,初始靶濃度為1 ng/mL,後升至2 ng/mL,再降為1 ng/mL。停用瑞米芬太尼後十分鐘進行下次試驗。壓痛試驗表明,氯胺酮不影響瑞米芬太尼急性用藥誘發的痛覺過和耐受現象。在所有疼痛模型中, 單用瑞米芬太尼均有顯著鎮痛作用。在肌肉電刺激試驗中氯胺酮能增強瑞米芬太尼的鎮痛作用。瑞米芬太尼的濃度達2 ng/mL時有輕度呼吸抑制,能被氯胺酮拮抗。我們的結論是氯胺酮對瑞米芬太尼鎮痛作用的影響與疼痛模型有關。

(軒     莊心良校)

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在氮氣、氬氣及氧化亞氮麻醉中的神經藥理作用研究

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

吸入麻醉藥,包括氣體麻醉劑氧化亞氮和氙氣,被認為是通過直接作用於離子通道受體而產生作用的。比較而言,對在高壓下僅顯示麻醉作用的惰性氣體如氮氣和氬氣其作用機制知之甚少。本實驗中,作者研究了選擇性GABA受體拮抗劑對由氮氣,氬氣及氧化亞氮產生麻醉作用的效應。用競爭性GABAA受體拮抗劑gabazine (0.2 nmol)而不是GABAB受體拮抗劑2-hydroxysaclofen (10 nmol)預處理增加了氮氣和氬氣翻正反射消失的閾值壓力(P < 0.005),但對氧化亞氮麻醉沒有作用。以GABAA-苯二氮卓受體拮抗劑氟馬澤尼(5nmol)也增加氬氣麻醉的閾值壓(P<0.025)。假定2-hydroxysaclofen, gabazine和氟馬澤尼均未達到用於誘發過度興奮性的劑量,那麼我們的結果支持氮氣和氬氣的麻醉作用可為gabazine和氟馬澤尼選擇性拮抗。氮氣和氬氣麻醉作用的某些機制可能與臨床使用的吸入麻醉藥相似。

                                    (張   莊心良 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.

 

靜脈氟呱利多導致腰麻時異丙酚鎮靜病人腦電雙頻指數下降

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

我們研究了靜脈應用氟呱利多對腰麻期間清醒和異丙酚鎮靜病人腦電雙頻指數(BIS)的影響。在腰麻後30分鐘後,20位病人除給予2mg氟呱利多外未給其他任何鎮靜藥物(清醒組)。其他組病人以異丙酚靜脈輸注鎮靜維持BIS值在60 ± 5,採用隨機雙盲法,分別靜脈應用生理鹽水(安慰劑組,n = 20),氟呱利多1mgdro-1 ; n = 20)或氟呱利多2mgdro-2; n = 20)。雖然在清醒組和安慰劑組BIS值保持不變,但在應用氟呱利多的dro-1 dro-2組卻顯著下降。而且dro-2組的BIS值下降顯著大於dro-1 組。這些結果提示止吐劑量的氟呱利多在腰麻時劑量依賴性地增強異丙酚的催眠效應。

                                    (張   莊心良 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.

 

鞘內持續注射可樂定和替紮尼定對清醒狀態下犬的疼痛和血流動力學的影響

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

鞘內注射可樂定等α2受體激動劑對實驗動物有抗傷害作用。但是,由於有心血管副作用,限制了其臨床應用。需要進一步尋找對血流動力學影響小的α2受體激動劑。為此,我們對鞘內注射可樂定和替紮尼定進行了比較性研究。6只犬每週接受可樂定或替紮尼定注射(交叉研究),並依次提高劑量125–750 μg/h,並對注射期間動物的疼痛、血壓、心率、鎮靜進行評價。另外9只犬鞘內注射替紮尼定(3 or 6 mg/d)或生理鹽水。結果,相同劑量的可樂定和替紮尼定產生相同的抗傷害作用。可樂定125500 μg/h 導致血壓降低,而任何劑量的替紮尼定均不引起血壓下降。可樂定250 μg/h 使心率減慢幅度為45.8%,其中5例出現了顯著心動過緩,而替紮尼定最大降壓幅度僅為15.1%,且未發生心律失常。可樂定劑量大於250 μg/h 時動物呼吸頻率降低。在大劑量應用時,兩藥均引起鎮靜和不配合的情況。對替紮尼定用藥的安全性評價表明,替紮尼定3 mg/d不引起嚴重的副作用和組織病理學損害。結論:鞘內注射替紮尼定可以替代可樂定用於疼痛治療,尤其適合那些應用可樂定後發生了嚴重血流動力學變化的病人。

(王士雷    莊心良 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.

 

術後單次小劑量氯胺酮可快速持續地改善對嗎啡抵抗患者的嗎啡鎮痛效果

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

臨床常見術後嗎啡抵抗性疼痛。氯胺酮的鎮痛潛能也已得到確證。本研究中,我們選擇在標準全身麻醉下手術,術後靜脈注射嗎啡劑量在30分鐘內超過0.1mg/kg仍然主訴疼痛(VAS10分制評分超過6分)的病人,評價了術後小劑量氯胺酮聯合嗎啡鎮痛對疼痛強度、脈搏氧飽和度和主觀評分的影響。在雙盲的情況下,病人被隨機分為兩組,一組接受10分鐘內最多三次每次30µg/kg嗎啡加生理鹽水靜脈注射(MSn114),另一組則每次注射15µg/kg嗎啡加250µg/kg氯胺酮(MKn131)。MS組在2.52 ± 0.56 次注射後,疼痛視覺評分在10鍾和120分鐘時分別為5.5 ± 1.18 3.8 ± 0.9MK組在1.35 ± 0.56p<0.001)次注射後,10分鐘和120分鐘時的疼痛視覺評分分別是2.94 ± 1.28 1.47 ± 0.65p<0.001MS組在10分鐘時的虛弱感評分(VAS 1-10)明顯低於MK組( 6.1 ± 1.5 vs 8.37 ± 1.19P < 0.001)。在10分鐘時,MS組脈搏氧飽和度下降了0.26%而MK組則升高了1.71%(P < 0.001)。MS30MK9人發生了噁心/嘔吐(P < 0.001)MK組有9人有持續2分鐘以上的頭輕感,有1人在第二次注射後做了怪夢。意義:小劑量氯胺酮和嗎啡配伍打斷了以前單純使用嗎啡不能解決的嚴重術後疼痛。氯胺酮使嗎啡用量減少,可以迅速和持續地改善嗎啡的鎮痛效果和病人的主觀感受,而沒有不可接受的副作用。

(顏   莊心良  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.

 

細胞凋亡作為家兔脊髓缺血後遲發性截癱的原因缺乏足夠證據

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

脊髓缺血後出現遲發性截癱的原因尚不清楚。為此,我們對運動神經元凋亡是否參與脊髓缺血後截癱的形成進行了研究。阻斷家兔腹主動脈15min造成家兔脊髓缺血。於再灌後8 24 48h評價後肢運動功能以及脊髓形態和生化的改變。每個時間點14只動物,其中各7只分別用於脊髓形態和生化研究,6只動物作為假手術對照組。結果有2/3的動物出現遲發性運動功能障礙。未出現截癱但發生了運動功能障礙的家兔,其運動神經元發生水腫和尼氏體碎裂。出現截癱的家兔則出現灰質破壞和炎症細胞浸潤。形態學未發現有運動神經元凋亡。caspase-3誘發的破裂產物fodrin未出現增高,也沒有出現DNAladder 結論:細胞凋亡不參與脊髓損傷後遲發性截癱的形成。

(王士雷     莊心良  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.

 

用磁共振顯像評估鎖骨上 Plumb-Bob技術在臂叢阻滯中的應用

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

依據磁共振顯像的結果,Plumb-Bob技術被用於臂叢阻滯可以降低氣胸的發生率。然而,氣胸的危險依然存在。我們分析了十位志願者的磁共振顯像結果,來判斷這種技術能否降低氣胸的發生率。穿刺點位於胸鎖乳突肌外側和鎖骨上緣的交界處,首先前後向進針,如果不成功,則沿原穿刺點,在矢狀面上將針向頭側或向尾側傾斜20°-30°,再從前向後進針。我們發現,在六位志願者中,單純前後向進針在未觸及鎖骨下動脈或臂叢時就已刺破胸膜和鎖骨下靜脈。穿刺針需向頭側平均傾斜21° 才能觸及臂叢,其中一例從頭側41° 到尾側 15°才找到臂叢。我們的結論是穿刺針先向頭側傾斜45°,而不是直接前後向進針,這樣可以降低刺破胸膜和鎖骨下靜脈的危險性。如果未觸及臂叢,傾角應逐漸下降。

                                    (軒   莊心良 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.

 

小劑量1%3%高張利多卡因溶液行腰麻的比較

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

 

我們研究了當劑量維持在30mg時,高張利多卡因的濃度是否影響運動阻滯的消退。我們也研究了感覺阻滯的擴散,時間和消退。65例擇期行會陰或下肢手術的病人入選此項研究。病人以3%1ml1%3ml利多卡因進行腰麻。65例病人中63例獲得足夠的手術阻滯平面。應用3ml 1%高張利多卡因溶液可以產生與應用1ml3%高張利多卡因相似的腰麻感覺阻滯平面。應用3ml1%高張利多卡因溶液導致更短的運動完全恢復時間。接受1%利多卡因的2例病人和接受3%4例病人由於發生低血壓而需要靜脈應用麻黃堿。結果顯示在短小手術時應用1%高張利多卡因進行腰麻優於3%的高張利多卡因溶液。

                                    (張軍   莊心良 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.