Anesthesia & Analgesia

April 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

单剂量氨甲环酸可减少术前用阿司匹林的患者冠脉搭桥术后出血

(赵雪莲译 庄心良校)

Single-Dose Tranexamic Acid Reduces Postoperative Bleeding After Coronary Surgery in Patients Treated with Aspirin Until Surgery

Hilde Pleym, Roar Stenseth, Alexander Wahba, Lise Bjella, Asbjørn Karevold, and Ola Dale

Anesth Analg 2003 96: 923-928.

止血和血液稀释:临床实践的定量分析指南

(张俊峰译  薛张纲 )

Hemostasis and Hemodilution: A Quantitative Mathematical Guide for Clinical Practice

Kai Singbartl, Petra Innerhofer, Jens Radvan, Birgit Westphalen, Dietmar Fries, Raimund Stögbauer, and Hugo Van Aken

Anesth Analg 2003 96: 929-935.

在急性等容血液稀释的志愿者中羟乙基淀粉(HES130/0.4HES 70/0.5 HES 200/0.5更大更快的提高组织氧张力

(忻纪华 王祥瑞 )

Hydroxyethyl Starch (HES) 130/0.4 Provides Larger and Faster Increases in Tissue Oxygen Tension in Comparison with Prehemodilution Values than HES 70/0.5 or HES 200/0.5 in Volunteers Undergoing Acute Normovolemic Hemodilution

Thomas Standl, Marc-Alexander Burmeister, Frank Schroeder, Eike Currlin, Jan Schulte am Esch, Marc Freitag, and Jochen Schulte am Esch

Anesth Analg 2003 96: 936-943.

 

血压测量间隔对血压变化滞后效应的影响:一项计算机模拟研究

(颜涛译 庄心良校)

The Effect of the Interval Between Blood Pressure Determinations on the Delay in the Detection of Changes: A Computer Simulation
R. Ross Kennedy and Richard French

Anesth Analg 2003 96: 944-948.

七氟醚暴露产生超氧化物,但在离体心脏缺血再灌注中则降低超氧化物的产生

(张俊峰译  薛张纲 )

Sevoflurane Exposure Generates Superoxide but Leads to Decreased Superoxide During Ischemia and Reperfusion in Isolated Hearts
Leo G. Kevin, Enis Novalija, Matthias L. Riess, Amadou K. S. Camara, Samhita S. Rhodes, and David F. Stowe

Anesth Analg 2003 96: 949-955.

PEDIATRIC ANESTHESIA:

选择性婴儿手术术前放宽禁食原则并不增加平均胃液容量

(忻纪华 王祥瑞 校)

Scott D. Cook-Sather, Kathleen A. Harris, Rosetta Chiavacci, Paul R. Gallagher, and Mark S. Schreiner

A Liberalized Fasting Guideline for Formula-Fed Infants Does Not Increase Average Gastric Fluid Volume Before Elective Surgery

Anesth Analg 2003 96: 965-969.

家长对儿童再次手术时术前处理的选择

(   庄心良 校)

Parental Intervention Choices for Children Undergoing Repeated Surgeries

Zeev N. Kain, Alison A. Caldwell-Andrews, Shu-Ming Wang, Dawn M. Krivutza, Megan E. Weinberg, and Linda C. Mayes

Anesth Analg 2003 96: 970-975.

可乐定有利于青少年患者的控制性降压

(张俊峰译  薛张纲 )

Clonidine Facilitates Controlled Hypotension in Adolescent Children

Thomas Hackmann, Marvin Friesen, Suzanne Allen, and David S. Precious

Anesth Analg 2003 96: 976-981.

AMBULATORY ANESTHESIA:

肩胛上神经阻滞可延长非关节镜肩部手术术后镇痛效果但并不改善愈后

 (   王祥瑞 校)

Suprascapular Nerve Block Prolongs Analgesia After Nonarthroscopic Shoulder Surgery but Does Not Improve Outcome

Joseph M. Neal, Susan B. McDonald, Kathleen L. Larkin, and Nayak L. Polissar

Anesth Analg 2003 96: 982-986.

RofecoxibCelecoxib和对乙酰氨基酚控制耳鼻喉门诊手术术後疼痛成本效益的对比研究

(赵雪莲译 庄心良校)

Costs and Effectiveness of Rofecoxib, Celecoxib, and Acetaminophen for Preventing Pain After Ambulatory Otolaryngologic Surgery

Mehernoor F. Watcha, Tijani Issioui, Kevin W. Klein, and Paul F. White

Anesth Analg 2003 96: 987-994.

ANESTHETIC PHARMACOLOGY:

异氟醚在脊髓上间接抑制了电刺激网状结构伴随的皮层活动

(潘志浩译  薛张纲 )

Isoflurane Action in Spinal Cord Indirectly Depresses Cortical Activity Associated with Electrical Stimulation of the Reticular Formation

Joseph F. Antognini, Richard Atherley, and Earl Carstens

Anesth Analg 2003 96: 999-1003.

数周全身麻醉对年青鼠和老龄鼠记忆的影响

(   王祥瑞 校)

Deborah J. Culley, Mark Baxter, Rustam Yukhananov, and Gregory Crosby

The Memory Effects of General Anesthesia Persist for Weeks in Young and Aged Rats

Anesth Analg 2003 96: 1004-1009.

异氟醚拮抗双三氟乙醚或1,2二氯-6-己氟环丁烷损害动物对伤害条件反射和声音反射的学习功能的作用

(王士雷    庄心良 校)

Isoflurane Antagonizes the Capacity of Flurothyl or 1,2-Dichlorohexafluorocyclobutane to Impair Fear Conditioning to Context and Tone

Edmond I Eger, II, Yilei Xing, Robert Pearce, Steven Shafer, Michael J. Laster, Yi Zhang, Michael S. Fanselow, and James M. Sonner

Anesth Analg 2003 96: 1010-1018.

左旋和右旋氯胺酮阻断神经元和骨骼肌上电压控制的钠通道

(潘志浩译  薛张纲 )

Blockade of Voltage-Operated Neuronal and Skeletal Muscle Sodium Channels by S(+)- and R(-)-Ketamine
Gertrud Haeseler, Diana Tetzlaff, Johannes Bufler, Reinhard Dengler, Sinikka Münte, Hartmut Hecker, and Martin Leuwer

Anesth Analg 2003 96: 1019-1026.

5-HT3受体部分介导氟烷抑制脊髓后角感觉神经元

(殷文渊 王祥瑞 校)

5-HT3 Receptors Partially Mediate Halothane Depression of Spinal Dorsal Horn Sensory Neurons

Masayuki Koshizaki, Mikito Kawamata, Steven G. Shimada, Yoji Saito, and J. G. Collins

Anesth Analg 2003 96: 1027-1031.

吸入考福新对狗疲劳膈肌收缩性的影响

(王立中译   庄心良校)

The Effect of Inhaled Colforsin Daropate on Contractility of Fatigued Diaphragm in Dogs

Yoshitaka Fujii, Aki Uemura, and Hidenori Toyooka

Anesth Analg 2003 96: 1032-1034.

异丙酚和乙咪酯在慢性缺氧大鼠对气道收缩的效应

(潘志浩译  薛张纲 )

The Effects of Propofol and Etomidate on Airway Contractility in Chronically Hypoxic Rats

Nazinigouba Ouédraogo, Roger Marthan, and and Etienne Roux

Anesth Analg 2003 96: 1035-1041.

不同剂量麻黄素对维库溴铵起效时间的影响

 (殷文渊 王祥瑞 )

The Dose Effect of Ephedrine on the Onset Time of Vecuronium

Kyo S. Kim, Mi A. Cheong, Jeong W. Jeon, Jeong H. Lee, and Jae C. Shim

Anesth Analg 2003 96: 1042-1046.

雷米芬太尼对电惊厥疗法病人癫痫发作持续时间和急性血流动力学反应的影响 (王士雷译 庄心良校)

The Effect of Remifentanil on Seizure Duration and Acute Hemodynamic Responses to Electroconvulsive Therapy

Alejandro Recart, Shivani Rawal, Paul F. White, Stephanie Byerly, and Larry Thornton

Anesth Analg 2003 96: 1047-1050.

TECHNOLOGY, COMPUTING, AND SIMULATION:

吸入麻醉时不同新鲜气流量的条件下使用了麻醉药节约装置的回路和普通回路之比较

(   薛张纲 )

The Anesthetic Conserving Device Compared with Conventional Circle System Used Under Different Flow Conditions for Inhaled Anesthesia

Augusto Tempia, Maddalena C. Olivei, Eliana Calza, Hans Lambert, Luca Scotti, Eugenio Orlando, Sergio Livigni, and Enrica Guglielmotti

Anesth Analg 2003 96: 1056-1061.

PAIN MEDICINE:

硝苯地平增强鼠水管周围灰质微量注射Endomorph-1的镇痛效果

(殷文渊 王祥瑞 )

Nifedipine Potentiates the Antinociceptive Effect of Endomorphin-1 Microinjected into the Periaqueductal Gray in Rats

Shuanglin Hao, Keiko Mamiya, Osamu Takahata, Hiroshi Iwasaki, Marina Mata, and David J. Fink

Anesth Analg 2003 96: 1065-1071. t.

鞘内注射5-羟色胺受体2A/2C激动剂{alpha}5羟色胺对两种大鼠持续疼痛模型的抗伤害作用

(王士雷   庄心良 校)

Antinociception with Intrathecal {alpha}-Methyl-5-Hydroxytryptamine, a 5-Hydroxytryptamine2A/2C Receptor Agonist, in Two Rat Models of Sustained Pain

Masayuki Sasaki, Hideaki Obata, Shigeru Saito, and Fumio Goto

Anesth Analg 2003 96: 1072-1078.

对于硬膜外给芬太尼的患者术前静脉使用小剂量的芬太尼可以预测镇痛效果和副作用的发生率

(   薛张纲 )

A Small Preoperative Test Dose of Intravenous Fentanyl Can Predict Subsequent Analgesic Efficacy and Incidence of Side Effects in Patients Due to Receive Epidural Fentanyl

Kazuyoshi Ueta, Kiyoshi Takeda, Hisatoshi Ohsumi, Junichi Haruna, Hiromi Shibuya, and Takashi Mashimo

Anesth Analg 2003 96: 1079-1082.

鞘内使用可乐定加布比卡因-吗啡脊髓内麻醉剂可改善全膝关节整形手术后的疼痛

( 王祥瑞 )

Intrathecal Clonidine Added to a Bupivacaine-Morphine Spinal Anesthetic Improves Postoperative Analgesia for Total Knee Arthroplasty

Brian D. Sites, Michael Beach, Russell Biggs, Christopher Rohan, Christopher Wiley, Athos Rassias, Janice Gregory, and Gilbert Fanciullo

Anesth Analg 2003 96: 1083-1088.

连续肌间沟臂丛阻滞进行家庭术后镇痛:一项随机双盲对照研究

(   庄心良 校)

Continuous Interscalene Brachial Plexus Block for Postoperative Pain Control at Home: A Randomized, Double-Blinded, Placebo-Controlled Study

Brian M. Ilfeld, Timothy E. Morey, Thomas W. Wright, Larry K. Chidgey, and F. Kayser Enneking

Anesth Analg 2003 96: 1089-1095.

白介素-6在痛觉产生方面的作用

(   薛张纲 )

The Role of Interleukin-6 in Nociception and Pain (Review Article)

Raf F. De Jongh, Kris C. Vissers, Theo F. Meert, Leo H. D. J. Booij, Catharina S. De Deyne, and René J. Heylen

Anesth Analg 2003 96: 1096-1103.

CRITICAL CARE AND TRAUMA:

假单胞菌属铜绿菌败血症绵羊使用去甲肾上腺素或氧化一氮合酶抑制剂不会引起脑血流的变化

( 王祥瑞 )

Cerebral Blood Flow Is Not Altered in Sheep with Pseudomonas aeruginosa Sepsis Treated with Norepinephrine or Nitric Oxide Synthase Inhibition

Michael Booke, Martin Westphal, Frank Hinder, Lillian D. Traber, and Daniel L. Traber

Anesth Analg 2003 96: 1122-1128.

NEUROSURGICAL ANESTHESIA:

前列腺素E1和尼卡地平对兔子大脑微循环影响的比较

(顾悦超   薛张纲 )

The Comparative Effects of Prostaglandin E1 and Nicardipine on Cerebral Microcirculation in Rabbits

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

Anesth Analg 2003 96: 1139-1144.

急诊神经外科患者麻醉期间艾司洛尔可减少颅内血流速率的增加

 (朱慧琛 王祥瑞 )

Esmolol Blunts the Cerebral Blood Flow Velocity Increase During Emergence from Anesthesia in Neurosurgical Patients

Philippe Grillo, Nicolas Bruder, Pascal Auquier, Daniel Pellissier, and François Gouin

Anesth Analg 2003 96: 1145-1149.

静脉注射羟乙基淀粉对有血脑屏障损害的病人脑脊液渗透的研究

(王士雷   庄心良校)

Penetration of Intravenous Hydroxyethyl Starch into the Cerebrospinal Fluid in Patients with Impaired Blood-Brain Barrier Function

Hans-Jürgen Dieterich, Jörg Reutershan, Thomas W. Felbinger, and Holger K. Eltzschig

Anesth Analg 2003 96: 1150-1154.

大鼠注射dexmedetomidine对皮层体感诱发电位的保护作用

(顾悦超   薛张纲 )

Preservation of the Cortical Somatosensory-Evoked Potential During Dexmedetomidine Infusion in Rats

Bai-Han Li, Jeffrey S. Lohmann, H. Gregg Schuler, and Arthur J. Cronin

Anesth Analg 2003 96: 1155-1160.

OBSTETRIC ANESTHESIA:

分娩麻醉时硬膜外应用新斯的明、罗哌卡因和舒芬太尼合剂对轴索的镇痛效应

(朱慧琛 王祥瑞 )

The Effect of Epidural Neostigmine Combined with Ropivacaine and Sufentanil on Neuraxial Analgesia During Labor

Fabienne Roelants, Michella Rizzo, and Patricia Lavand’homme

Anesth Analg 2003 96: 1161-1166.

脊髓-硬膜外联合技术用于分娩镇痛时硬膜外试验剂量对运动功能的影响

( 涛译, 庄心良校)

The Effect of Epidural Test Dose on Motor Function After a Combined Spinal-Epidural Technique for Labor Analgesia

Arthur L. Calimaran, Tina P. Strauss-Hoder, Warren Y. Wang, Robert J. McCarthy, and Cynthia A. Wong

Anesth Analg 2003 96: 1167-1172.

分娩时病人自控硬膜外镇痛0.15%罗比卡因合用0.5ug/ml苏芬太尼与0.10%罗比卡因合用0.5ug/ml苏芬太尼是等效的

(顾悦超   薛张纲 )

Ropivacaine 0.15% Plus Sufentanil 0.5 µg/mL and Ropivacaine 0.10% Plus Sufentanil 0.5 µg/mL Are Equivalent for Patient-Controlled Epidural Analgesia During Labor

Emmanuel Boselli, Richard Debon, Frédéric Duflo, Boris Bryssine, Bernard Allaouchiche, and Dominique Chassard

Anesth Analg 2003 96: 1173-1177.

分娩第一产程芬太尼和舒芬太尼麻醉的最小镇痛剂量

(朱慧琛 王祥瑞 )

Minimum Analgesic Doses of Fentanyl and Sufentanil for Epidural Analgesia in the First Stage of Labor

Giorgio Capogna, Michela Camorcia, and Malachy O. Columb

Anesth Analg 2003 96: 1178-1182.

REGIONAL ANESTHESIA:

应用声音辅助装置确定硬膜外腔穿刺位置的临床研究

(王士雷   庄心良校)

Clinical Results with the Acoustic Puncture Assist Device, a New Acoustic Device to Identify the Epidural Space

Timo J. Lechner, Maarten G. van Wijk, Ad J. Maas, Frank R. van Dorsten, Ronald A. Drost, Chris J. Langenberg, Leo J. Teunissen, Paul H. Cornelissen, and Jan van Niekerk

Anesth Analg 2003 96: 1183-1187.

GENERAL ARTICLES:

一项前瞻性随机研究:碳酸氢纳或THAM液治疗术中高氯性酸中毒

(顾悦超   薛张纲 )

Treating Intraoperative Hyperchloremic Acidosis with Sodium Bicarbonate or Tris-Hydroxymethyl Aminomethane: A Randomized Prospective Study

Markus Rehm and Udilo Finsterer

Anesth Analg 2003 96: 1201-1208.

控制性低温对兔止血功能的影响

(忻纪华 王祥瑞 )

The Influence of Induced Hypothermia for Hemostatic Function on Temperature-Adjusted Measurements in Rabbits

Mitsuru Shimokawa, Katsuyasu Kitaguchi, Masahiko Kawaguchi, Takanori Sakamoto, Meiko Kakimoto, and Hitoshi Furuya

Anesth Analg 2003 96: 1209-1213.

仅经过模拟人训练的缺乏经验的护士应用PAxpressTM 和面罩/ Guedel Airway 通气的比较性研究

(王士雷    庄心良 校)

A Comparison of the PAxpressTM and Face Mask Plus Guedel Airway by Inexperienced Personnel After Mannequin-Only Training

V. Dimitriou, G. S. Voyagis, C. Iatrou, and J. Brimacombe

Anesth Analg 2003 96: 1214-1217.

在急性等容血液稀释的志愿者中羟乙基淀粉(HES130/0.4HES 70/0.5 HES 200/0.5更大更快的提高组织氧张力

Hydroxyethyl Starch (HES) 130/0.4 Provides Larger and Faster Increases in Tissue Oxygen Tension in Comparison with Prehemodilution Values than HES 70/0.5 or HES 200/0.5 in Volunteers Undergoing Acute Normovolemic Hemodilution

Thomas Standl, MD*, Marc-Alexander Burmeister, MD*, Frank Schroeder, MD*, Eike Currlin*, Jan Schulte am Esch, MD{dagger}, Marc Freitag, MD*, and Jochen Schulte am Esch, MD*

*Departments of Anesthesiology and {dagger}Surgery, University Hospital Hamburg-Eppendorf, Hamburg, Germany

Anesth Analg 2003;96:936-943


羟乙基淀粉(HES)行血液稀释可获得稳定的血流动力学和改善血液流变学,提高组织的氧张力(tpO2)。在本研究采用前瞻性,随机性,双盲,交叉实验方法,观察HES130/0.4和传统HES溶液行急性等容血液稀释对人体血流动力学和骨骼肌tpO2影响。每组志愿者12人。在大于8天的间隔中,经计算志愿者在30分钟内捐出全身血液的18%,并按11.2的血液丢失随机输入6%HES 130/0.46%HES 70/0.5,或6%HES 200/0.5(交叉执行)。HES补液后6小时,测定血流动力学指标,四头肌的tpO2,血球压积,血浆HES浓度,血浆粘度,胶体渗透压和血小板聚集能力。各组中血流动力学变化,血球压积和血小板聚集功能无差异。HES200组的胶体渗透压和血浆粘度较HES 70组高(p<0.05)。HES130组和HES70HES200组相比,扩容更快(血液稀释后30min90min150min , P<0.05);tpO2基值相比上升更明显(+93%+33%40%P,0.05)。在健康志愿者中行急性等容血液稀释显示HES130/0.4HES70/0.5HES200/0.5预稀释相比,更早更多的提高骨骼肌的tpO2

(忻纪华 王祥瑞 )

Stable hemodynamics and improved rheology are important effects of hemodilution with hydroxyethyl starch (HES) infusions. One clinical indicator of improved rheology is increased tissue oxygen tension (tpO2). In this prospective, randomized, double-blinded, crossover study, we examined the effects of acute normovolemic hemodilution with HES 130/0.4 on hemodynamics and skeletal muscle tpO2 in comparison with conventional HES solutions. Twelve healthy volunteers were randomly enrolled in each group. At an interval of >8 days, volunteers donated 18% of their calculated blood volume within 30 min and randomly received 6% HES 130/0.4, 6% HES 70/0.5, or 6% HES 200/0.5 (crossover design) in a 1:1.2 ratio to their blood loss. Hemodynamic variables, tpO2 in the quadriceps muscle, hematocrit, plasmatic HES concentrations, plasma viscosity, colloid osmotic pressures, and platelet aggregation were measured until 6 h after the infusion of HES. No differences were found among groups with respect to changes of hemodynamics, hematocrit, or platelet aggregation. With HES 200, colloid osmotic pressures and plasma viscosities were larger than after HES 70 (P < 0.05). HES 130 in comparison with HES 70 and 200 caused the fastest (30 min versus 90 min and 150 min after hemodilution; P < 0.05) and largest increase of tpO2 in comparison to baseline (+93% versus +33% and 40%; P < 0.05). In healthy volunteers undergoing acute normovolemic hemodilution, the newly designed HES 130/0.4 showed a more pronounced and earlier increase of skeletal muscle tpO2 in comparison with prehemodilution values than HES 70/0.5 or 200/0.5.

 

选择性婴儿手术术前放宽禁食原则并不增加平均胃液容量

A Liberalized Fasting Guideline for Formula-Fed Infants Does Not Increase Average Gastric Fluid Volume Before Elective Surgery

Scott D. Cook-Sather, MD*, Kathleen A. Harris, RN BSN*, Rosetta Chiavacci, RN BSN*, Paul R. Gallagher, MA{dagger}, and Mark S. Schreiner, MD*

Departments of *Anesthesiology and Critical Care Medicine and {dagger}Pediatrics, Division of Biostatistics and Epidemiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Anesth Analg 2003;96:965-969


推荐婴儿术前禁食时间在4-8小时。97ASA I-II准备行择期婴儿手术,行前瞻性的随机双盲试验,以确定禁食4小时(放宽禁食组,L组)和术前8小时禁食固体,2小时禁食清洁流质(传统禁食组,T组)的胃液容量(GFV)是否不同。L组中39人中31人按协议喂养至术前4-6小时。T58人中36人按照要求喂养清洁流质至麻醉诱导前2-5小时。30人禁食时间延长,采用二次分析。两组的年龄(5.7+/-2.3vs6.4+/-2.4mo;范围,0.7-10.5),体重(7.5+/-1.8vs7.5+/-1.1kg),最后喂食容量(4.9+/-2.2vs4.0+/-2.3oz)无差异。GFVL:0.19+/-0.38vs T:0.16+/-0.30ml)和胃液的pH(L: 2.5+/-0.5vs T:2.9+/-1.3)无差异。所有病例,GFVml/kg)随年龄而增加(Spearman相关系数=+0.23p=0.03)。两组婴儿的兴奋性,饥饿和父母的满意度相似。结果表明规则喂养的婴儿禁食4-6小时或术前2小时起停喂清洁流质的婴儿GFV无显著差异。基于这些发现,对准备选择性手术,规则喂养的婴儿术前禁食可放宽至4小时。

(忻纪华 王祥瑞 校)

 

Recommended preoperative fasting intervals for infant formula vary from 4 to 8 h. We conducted a prospective, randomized, observer-blinded trial of 97 ASA physical status I and II infants scheduled for elective surgery to determine whether average gastric fluid volume (GFV) recovered from infants formula-fasted for 4 h (liberalized fast, Group L) differed from that recovered from infants allowed clear liquids up until 2 h, but fasted 8 h for formula and solids (traditional fast, Group T). In Group L, 31 of 39 subjects followed protocol and ingested formula 4–6 h before surgery. In Group T, 36 of 58 subjects followed protocol, taking clear liquids 2–5 h before the induction of anesthesia. Thirty subjects had prolonged fasts and were included only in a secondary intent-to-treat analysis. Respective mean age (5.7 ± 2.3 versus 6.4 ± 2.4 mo; range, 0.7–10.5 mo), weight (7.5 ± 1.8 versus 7.5 ± 1.1 kg), and volume of last feed (4.9 ± 2.2 versus 4.0 ± 2.3 oz.) did not vary between Groups L and T. GFV (L: 0.19 ± 0.38 versus T: 0.16 ± 0.30 mL/kg) and gastric fluid pH (L: 2.5 ± 0.5 versus T: 2.9 ± 1.3) did not vary. For all subjects, GFV (mL/kg) increased with age (Spearman correlation coefficient = +0.23, P = 0.03). Infant irritability and hunger and parent satisfaction were similar between groups. We conclude that average GFV after either a 4- to 6-h fast for infant formula or 2-h fast after clear liquids is small and not significantly different between groups. On the basis of these findings, clinicians may consider liberalizing formula feedings to 4 h before surgery in selected infants.

 

肩胛上神经阻滞可延长非关节镜肩部手术术后镇痛效果但并不改善愈后

Suprascapular Nerve Block Prolongs Analgesia After Nonarthroscopic Shoulder Surgery but Does Not Improve Outcome

Joseph M. Neal, MD*, Susan B. McDonald, MD*, Kathleen L. Larkin, MD*, and Nayak L. Polissar, PhD{dagger}

*Department of Anesthesiology, Virginia Mason Medical Center; and {dagger}The Mountain-Whisper-Light Statistical Consulting, Seattle, Washington

Anesth Analg 2003;96:982-986


肩胛上神经阻滞(SSNB)在全身麻醉时可以延长非关节镜肩部手术术后镇痛效果并改善24小时后的愈后情况。对门诊非关节镜肩部手术的病人中施行肩胛上神经阻滞作为臂丛神经阻滞(ISB)的辅助。50名病人随机进行SSNB或安慰注射作为臂丛神经阻滞的辅助。在SSNB组术后首次明显疼痛出现时间显著延迟(594±369375±273分钟,P=0.02)。2组病人麻醉后其他恢复情况,24小时疼痛评价,镇痛药追加情况及术后恢复情况并无差异。所以,我们可以得出结论,在非关节镜肩部手术使用ISB时加用SSNB并无特别疗效。

(周   王祥瑞 校)

Suprascapular nerve block (SSNB) reportedly improves analgesia and 24-h outcomes after arthroscopic shoulder surgery performed under general anesthesia. In this study, we assessed the analgesic and clinical outcome efficacy of SSNB as an adjunct to interscalene brachial plexus block (ISB) for ambulatory nonarthroscopic shoulder surgery. Fifty patients were randomized to receive either a SSNB or sham injection as part of a standardized ISB-general anesthesia regimen. Time to first significant pain (the primary outcome measure) was significantly delayed in the SSNB group (594 ± 369 min versus 375 ± 273 min, respectively; P = 0.02). There were no other differences between groups with regard to postanesthesia recovery unit measures, 24-h assessment of pain, supplemental analgesic use, or quality of life outcomes. We conclude that adjunctive SSNB adds minimal value to a primary ISB anesthetic for nonarthroscopic shoulder surgery.

 

数周全身麻醉对年青鼠和老龄鼠记忆的影响

The Memory Effects of General Anesthesia Persist for Weeks in Young and Aged Rats

Deborah J. Culley, MD*, Mark Baxter, PhD{dagger}, Rustam Yukhananov, MD PhD*, and Gregory Crosby, MD*

*Department of Anesthesia, Harvard Medical School, Brigham & Women’s Hospital, Boston, Massachusetts; and {dagger}Department of Psychology, Harvard University, Cambridge, Massachusetts

Anesth Analg 2003;96:1004-1009


有研究表明老年病人在全身麻醉手术后会存在认知损害。我们假设这一认知损害是由于全身麻醉而引起的。共计有3446月或18月龄鼠,进行12道曲折的迷宫训练,然后随机分组接受1.2%异氟醚/70%笑气/30%氧气或30%氧气通气。所有鼠在恢复24小时后8周内每天进行迷宫试验。作为对照的年青鼠均能顺利通过迷宫试验。老龄对照组鼠也能准确通过迷宫但所花费时间较多。麻醉组中,年青鼠通过迷宫的情况并无明显改变,1周和3周后与老龄鼠有明显差异(P<0.05),老龄麻醉鼠并不能顺利通过反复的迷宫试验,并且通过迷宫所花费的时间也较长(1周和3周时P0.05)。这一实验证明,使用异氟醚和笑气进行麻醉并不影响年青鼠的空间记忆能力,而老龄鼠在同样的麻醉下空间记忆能力有所影响。因此,使用异氟醚和笑气进行麻醉可以影响老龄鼠的空间记忆能力。

(周   王祥瑞 校)

Studies demonstrate lasting cognitive impairment in elderly persons after anesthesia and surgery. We tested the hypothesis that general anesthesia contributes to this cognitive impairment. Six- and 18-mo-old Fischer 344 rats were trained in a 12-arm radial arm maze and were then randomized to anesthesia for 2 h with 1.2% isoflurane/70% nitrous oxide/30% oxygen or a control treatment consisting of 30% oxygen. Rats recovered for 24 h and then were tested daily on the radial arm maze for 8 wk. Performance of young control rats was stable throughout the experiment. In contrast, aged control rats improved their performance as measured by time to complete the maze but not by error rate. After anesthesia, time to complete the maze did not change in young rats, but error rate decreased (P < 0.05 at 1 and 3 wk), indicating improved performance. In contrast, previously anesthetized aged rats failed to improve with repeated testing and took longer to complete the maze than aged control rats (P < 0.05 at 1 and 3 wk). These data demonstrate that general anesthesia with isoflurane and nitrous oxide improves the memory performance on an established spatial memory task in young rats, but in aged rats it attenuates the improvement in performance that otherwise occurs with repeated testing. Therefore, isoflurane and nitrous oxide anesthesia produces a sustained learning impairment in aged rats.

 

5-HT3受体部分介导氟烷抑制脊髓后角感觉神经元

5-HT3 Receptors Partially Mediate Halothane Depression of Spinal Dorsal Horn Sensory Neurons

Masayuki Koshizaki, MD, Mikito Kawamata, MD PhD, Steven G. Shimada, PhD, Yoji Saito, MD PhD, and J. G. Collins, PhD

Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2003;96:1027-1031


我们近期报道了A-型γ-氨基丁酸和士的宁(strychnine)敏感氨基乙酸受体系统部分介导氟烷抑制脊髓后角低阈值神经元。5-羟色胺亚型35-HT3)受体如同A-型γ-氨基丁酸和士的宁(strychnine)敏感氨基乙酸受体一样同属于配子激活离子通道家族,所以观察5-羟色胺受体在氟烷抑制脊髓后角感觉神经元中可能所起的作用。脊髓低阈值神经元的细胞外记录值来自去大脑脊髓横断的老鼠。在存在或缺少1.1%氟烷以及存在或缺少5-HT抗体的情况下记录和刷擦导致的活动。在有氟烷,二甲基麦角新碱(methysergide)— 一种非选择性5-HT拮抗剂和(tropisetron)— 一种选择性5-HT3拮抗剂时,显著逆转了氟烷引起的可接受的域值范围的降低,但没有改变氟烷抑制刷擦导致的活动的效应。(Methiothepin)— 一种5-HT1拮抗剂和(ketanserin)— 一种5-HT2拮抗剂没有逆转氟烷的抑制效应。这些结果支持了我们的假设,即5-HT3受体在氟烷对脊髓后角感觉神经元的抑制效应中起部分作用。

    殷文渊 王祥瑞 校)

We recently reported that {gamma}-aminobutyric acid type A- and strychnine-sensitive glycine receptor systems partially mediate halothane depression of spinal dorsal horn low-threshold neurons. Serotonin subtype 3 (5-HT3) receptors belong to the same ligand-activated ion-channel family as {gamma}-aminobutyric acid type A- and strychnine-sensitive glycine receptors, so we examined the possible involvement of 5-HT receptor systems in halothane depression of spinal sensory neurons. Extracellular recordings of spinal low-threshold neurons were obtained in decerebrate, spinally transected rats. Receptive field size and brush-induced activity were recorded in the presence or absence of 5-HT antagonists and in the presence or absence of 1.1% (1 minimum alveolar anesthetic concentration) halothane. In the absence of halothane, antagonists had no effect on receptive field size or brush-induced activity. In the presence of halothane, methysergide, a nonselective 5-HT antagonist, and tropisetron, a selective 5-HT3 antagonist, significantly reversed the halothane-induced reduction in receptive field size but did not alter halothane depression of brush-induced activity. Methiothepin, a 5-HT1 antagonist, and ketanserin, a 5-HT2 antagonist, did not reverse halothane depression. These results support the hypothesis that 5-HT3 receptors partially mediate some inhibitory effects of halothane on spinal dorsal horn neurons.

 

不同剂量麻黄素对维库溴铵起效时间的影响

The Dose Effect of Ephedrine on the Onset Time of Vecuronium

Kyo S. Kim, MD PhD, Mi A. Cheong, MD, Jeong W. Jeon, MD, Jeong H. Lee, MD, and Jae C. Shim, MD PhD

Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea

Anesth Analg 2003;96:1042-1046


小剂量麻黄素减少罗库溴铵和顺式阿库溴铵的起效时间,可是,麻黄素会产生不利的血流动力学影响。合适的麻黄素剂量并不确定。120名病人使用芬太尼2 µg /kg和丙泊酚2 -2.5 mg/kg进行麻醉,随机给于麻黄素(3070110 µg /kg)或生理盐水。在丙泊酚麻醉期间,通过肌电图监测肌肉神经阻滞,使用的方法是阈下电流每十秒四个成串刺激。在胸骨上切迹处放置多普勒超声探头来测定心输出量。在注射维库溴铵两分钟后由非调查者施行插管。在麻醉诱导期间测量神经肌肉阻滞,插管条件,和血流动力学影响。70110µg /kg麻黄素在使用维库溴铵两分钟后都可改善插管条件;但110µg /kg麻黄素会产生不利的血流动力学影响。结果表明在麻醉诱导前给与70µg/kg麻黄素,注射维库溴铵两分钟后插管,可改善插管条件,大概是提高了心输出量而没有显著不利血流动力学影响的结果。

                                               ( 殷文渊 王祥瑞 )

A small dose of ephedrine decreases the onset time of rocuronium and cisatracurium; however, ephedrine might be associated with adverse hemodynamic effects. The appropriate dose of ephedrine has not been determined. We, therefore, studied 120 patients anesthetized with fentanyl 2 µg/kg and propofol 2–2.5 mg/kg who were randomly divided to receive either ephedrine (30, 70, or 110 µg/kg) or saline. During propofol anesthesia, the neuromuscular block was monitored by mechanomyography by using submaximal current of train-of-four stimulation every 10 s. To determine cardiac output, a transcutaneous Doppler probe was placed externally at the suprasternal notch. Tracheal intubation was performed by a blinded investigator at 2 min after vecuronium. Neuromuscular block, intubating conditions, and hemodynamic effects were measured during the induction of anesthesia. Both ephedrine 70 and 110 µg/kg improved intubating conditions at 2 min after vecuronium; however, 110 µg/kg was associated with adverse hemodynamic effects. We conclude that ephedrine 70 µg/kg given before the induction of anesthesia improved intubating conditions at 2 min after vecuronium, probably by increased cardiac output without significant adverse hemodynamic effects.

 

硝苯地平增强鼠水管周围灰质微量注射Endomorph-1的镇痛效果

Nifedipine Potentiates the Antinociceptive Effect of Endomorphin-1 Microinjected into the Periaqueductal Gray in Rats

Shuanglin Hao, MD PhD*,{dagger}, Keiko Mamiya, MD*, Osamu Takahata, MD PhD*, Hiroshi Iwasaki, MD PhD*, Marina Mata, MD{dagger}, and David J. Fink, MD{dagger}

*Department of Anesthesiology & Critical Care Medicine, Asahikawa Medical College, Asahikawa, Japan; and {dagger}Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania

Anesth Analg 2003;96:1065-1071


Endomorphin-1是一种新型的内源性µ-阿片样配体。在老鼠中脑腹外侧水管周围灰质(vPAG)微量注射Endomorphin-1L-型钙离子阻滞剂--硝苯地平 ,观察两者之间镇痛效果的相互作用,使用脊髓传导的尾部摇摆试验和脊髓上传导的尾部压力试验。Sprague-Dawley鼠在立体定位下将导管植入vPAG中。在尾部摇摆试验和尾部压力试验中,在vPAG中微量注射Endomorphin-1会剂量依赖性地提高镇痛效应。预注射µ-阿片样受体选择性阻滞剂β-funaltrexamine阻滞了Endomorphin-1的镇痛效应。单独预注射β-funaltrexamine对尾部摇摆反应时间和尾部压力阈值没有影响。在尾部摇摆试验和尾部压力试验中,在vPAG中微量注射硝苯地平不产生镇痛效应。可是,在vPAG中注射硝苯地平增强Endomorphin-1的镇痛作用,使尾部摇摆试验和尾部压力试验的Endomorphin-1剂量反应曲线显著左移。这个结果说明在vPAG中微量注射布Endomorphin-1产生有力的镇痛效果是通过阿片样受体所介导的,且伴随硝苯地平的使用而增强。

(殷文渊 王祥瑞 )

Endomorphin-1 is a novel endogenous µ-opioid ligand. We investigated the antinociceptive interaction between endomorphin-1 and nifedipine, an L-type calcium channel blocker, microinjected into the midbrain ventrolateral periaqueductal gray (vPAG), using the spinally-organized tail-flick test and the supraspinally-organized tail-pressure test in rats. Sprague-Dawley rats were stereotaxically implanted with a guide cannula lowered into the vPAG. Microinjection of endomorphin-1 into the vPAG led to dose-related increases in antinociceptive responses in the tail-flick test and tail-pressure test. Pretreatment with the µ-opioid receptor-selective antagonist ß-funaltrexamine blocked the antinociceptive effect of endomorphin-1. Pretreatment with ß-funaltrexamine alone had no effect on the tail-flick latency and tail-pressure threshold. Microinjection of nifedipine alone into the vPAG did not produce an antinociceptive response in the tail-flick test and tail-pressure test. However, injection of nifedipine into the vPAG potentiated the antinociceptive effect of endomorphin-1, producing a significant leftward shift in the dose-response curve of endomorphin-1 in both the tail-flick and tail-pressure tests. This result shows that the potent antinociceptive effect of endomorphin-1 microinjected into the vPAG is mediated through the µ-opioid receptor and is potentiated by concomitant administration of nifedipine.

 

鞘内使用可乐定加布比卡因-吗啡脊髓内麻醉剂可改善全膝关节整形手术后的疼痛

Intrathecal Clonidine Added to a Bupivacaine-Morphine Spinal Anesthetic Improves Postoperative Analgesia for Total Knee Arthroplasty

Brian D. Sites, MD*, Michael Beach, MD PhD*, Russell Biggs, MD*, Christopher Rohan, MD*,{dagger}, Christopher Wiley, MD*, Athos Rassias, MD*, Janice Gregory, RN*, and Gilbert Fanciullo, MD*

Departments of Anesthesiology, *Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and {dagger}Central Vermont Medical Center, Berlin, Vermont

Anesth Analg 2003;96:1083-1088


全膝关节整形术后的疼痛相当严重并影响早期的物理治疗。我们假设鞘内使用可乐定及高比重布比卡因可改善全膝关节整形术后的疼痛并加以验证。采用双盲及安慰剂对照的实验方法, 81名进行单侧或双侧全膝关节整形术ASA-Ⅲ级的患者随机分成4组分别注射2ml溶液及高比重布比卡因15mg1)消毒的生理盐水,2)吗啡250μg3)吗啡250μg及可乐定25μg4)吗啡250μg及可乐定75μg。然后在术后124612,及24小时评估视觉模拟评分(VAS),累积静脉吗啡使用量,血流动力学,恶心,辅助用药,及副作用。对吗啡加可乐定组与使用吗啡组进行比较,表明联合使用可乐定和吗啡组的患者24小时内静脉使用吗啡量比单纯鞘内使用吗啡组的患者少13mg(P=0.028),同时降低术后24小时的VAS评分1.3cmP=0.047)。除了使用可乐定组患者术后6小时可能会发生低血压外其副作用与其他组基本相近。由此,我们得出结论鞘内联合使用吗啡和可乐定与鞘内单独使用吗啡相比,前者可降低术后24小时静脉吗啡量及VAS评分。

( 王祥瑞 )

Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I–III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 µg), 3) morphine (250 µg) with clonidine (25 µg), and 4) morphine (250 µg) with clonidine (75 µg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone.

 

假单胞菌属铜绿菌败血症绵羊使用去甲肾上腺素或氧化一氮合酶抑制剂不会引起脑血流的变化

Cerebral Blood Flow Is Not Altered in Sheep with Pseudomonas aeruginosa Sepsis Treated with Norepinephrine or Nitric Oxide Synthase Inhibition

Michael Booke, MD*, Martin Westphal, MD{dagger}, Frank Hinder, MD{dagger}, Lillian D. Traber{ddagger}, and Daniel L. Traber, PhD{ddagger}

*Department of Anesthesiology, Klinikum des Main-Taunus-Kreises GmbH, Bad Soden am Taunus, Germany; {dagger}Department of Anesthesiology and Intensive Care, University of Münster, Münster, Germany; and {ddagger}Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas

Anesth Analg 2003;96:1122-1128
败血症的患者大脑功能障碍的起因至今还不清楚,但大脑灌注的变化可能在发病机制上起着很重要的作用。20只绵羊体内持续地注入活的假单胞菌属铜绿菌从而建立一个慢性败血症绵羊模型,然后评估这些绵羊的大脑灌注。在发生败血症24小时之后,这些发生低血压的绵羊(平均动脉压降低16%P0.05〉被分别注入氧化一氮合酶抑制剂(L-NMMA7mg·kg-1·h-1;n=7 ,去甲肾上腺素(NEn=7),或生理盐水(对照;n=6)。使用去甲肾上腺素的一组升高平均动脉压的值与使用L-NMMA的一组相等,然后通过彩色微球体测量局部的灌注。尽管L-NMMA使全身周围血管阻力指数显著增高(1167±104793±59dyne·cm-5·m2;P<0.05),但它既不引起脑血管阻力的变化也不引起脑血流的变化。当全身周围血流发生变化时,大脑血流的再分布是显而易见的。去甲肾上腺素引起动脉血压增高(98±583±5P0.05〉,同时伴有心输出量增加(7.8±0.56.7±0.6P0.05〉,由此引起全身周围灌注的增加。然而,大脑的血流没有受影响。虽然去甲肾上腺素和L-NMMA对血管的收缩作用是有害的,包括引起大脑低灌注,目前还有争议,但在试验中这两种药物都对脑灌注没有影响。

( 王祥瑞 )

The origin of cerebral dysfunction in patients with sepsis is still unclear. However, altered cerebral perfusion may play an important role in its pathogenesis. Using an established, chronic model of hyperdynamic ovine sepsis, we examined cerebral perfusion in 20 sheep subjected to a continuous infusion of live Pseudomonas aeruginosa. After 24 h of sepsis, the hypotensive sheep (reduction in mean arterial blood pressure by 16%; P < 0.05) received the nitric oxide synthase inhibitor NG-mono-methyl-L-arginine (L-NMMA; 7 mg · kg-1 · h-1; n = 7), norepinephrine (NE; n = 7), or normal saline (control; n = 6). NE infusion was individually targeted to achieve the same increase in mean arterial blood pressure as that observed in matched sheep of the L-NMMA group. Regional perfusion was measured by using colored microspheres. Although L-NMMA caused a significant increase in systemic vascular resistance index (1167 ± 104 versus 793 ± 59 dyne · cm-5 · m2; P < 0.05), it caused a change neither in cerebrovascular resistance nor in cerebral blood flow. When related to systemic blood flow, a redistribution of blood flow to the brain became obvious. The NE-associated increase in systemic blood pressure (98 ± 5 versus 83 ± 5; P < 0.05) was accompanied by an increase in cardiac output (7.8 ± 0.5 versus 6.7 ± 0.6; P < 0.05) and, hence, systemic perfusion. However, blood flow to the brain remained unaffected. Although detrimental vasoconstrictive effects of NE and L-NMMA, including cerebral hypoperfusion, are discussed, neither drug had any effect on cerebral perfusion during experimental hyperdynamic sepsis.

 

急诊神经外科患者麻醉期间艾司洛尔可减少颅内血流速率的增加

Esmolol Blunts the Cerebral Blood Flow Velocity Increase During Emergence from Anesthesia in Neurosurgical Patients

Philippe Grillo, MD*, Nicolas Bruder, MD*, Pascal Auquier, MD{dagger}, Daniel Pellissier, MD*, and François Gouin, MD*

*Département d’Anesthésie-Réanimation and {dagger}Service de Santé Publique et de Biostatistiques, Marseille, France

Anesth Analg 2003;96:1145-1149


神经外科患者实施急诊麻醉时会出现颅内充血,但其产生机制尚不清楚。我们假设这是由于交感神经兴奋所引起,并通过试验证实这一推论。30名神经外科患者被随机分为两组,分别应用艾司洛尔(短效β受体阻滞剂)和安慰剂。拔管后15分钟静脉输注艾司洛尔(0.3 mg .kg-1 .min-1) 在麻醉前、手术中、拔管及拔管后5-60分钟分别记录脑血流速率(CBFV),平均动脉血压和心率。拔管后60分钟经食管多谱乐测量心排出量(COe)。应用艾司洛尔组的CBFVCoe和心率都明显下降,而两组的平均动脉压则无明显区别。在试验中CBFVCoe无相关性。综上所述,对于急诊病例艾司洛尔可以减弱CBFV的增加,由此也可证实神经外科患者恢复期的脑充血是由于交感神经兴奋所引起。

   (朱慧琛 王祥瑞 )

Cerebral hyperemia has been demonstrated during emergence from anesthesia in neurosurgical patients, but its mechanism is speculative. We performed this study to test the hypothesis that this could be attributed to sympathetic overactivity. Thirty neurosurgical patients were included in a prospective, randomized, double-blinded study comparing esmolol, a short-acting ß-blocker, and a placebo. Esmolol (0.3 mg · kg-1 · min-1) was infused from the end of anesthesia to 15 min after extubation. Cerebral blood flow velocity (CBFV), mean arterial blood pressure, and heart rate were recorded before anesthesia, during anesthesia after surgery, at extubation, and 5–60 min after extubation. Cardiac output (COe) was estimated by using an esophageal Doppler from anesthesia to 60 min after extubation. CBFV, COe, and heart rate were significantly lower in the esmolol group. Mean arterial blood pressure was comparable between the groups. There was no correlation between CBFV and COe at any time point during the study. In conclusion, esmolol blunted the CBFV increase during emergence, confirming that sympathetic overactivity contributes to cerebral hyperemia during neurosurgical recovery.

 

分娩麻醉时硬膜外应用新斯的明、罗哌卡因和舒芬太尼合剂对轴索的镇痛效应

The Effect of Epidural Neostigmine Combined with Ropivacaine and Sufentanil on Neuraxial Analgesia During Labor

Fabienne Roelants, MD, Michella Rizzo, MD, and Patricia Lavand’homme, MD PhD

Department of Anesthesiology, Université Catholique de Louvain, St. Luc Hospital, Brussels, Belgium

Anesth Analg 2003;96:1161-1166


脊椎麻醉时应用新斯的明可避免产生呼吸抑制或低血压,但可产生严重的胃肠道反应。硬膜外腔注入新斯的明后可有效避免产生偏侧效应。本次实验主要评定分娩早期持续大剂量麻醉时硬膜外新斯的明的效应,及其在随后的局部麻醉时的残留效应。在麻醉开始阶段硬膜外注入新斯的明methylsulfate(最大剂量为4 µg/kg)和0.1%ropivacaine10 mL,可加入或不加入10 µg舒芬太尼,20分钟后测定感觉平面和运动阻滞情况,并记录直至追加剂量。0.1% ropivacaine通常作为追加剂。母亲及胎儿的反应也被记录下来。新斯的明(4 µg/kg)加入ropivacaine 10mg20mg效果相当,但却不及加入10 µg舒芬太尼,此外新斯的明也不会影响随后的局麻要求。它不会引起血流动力学的不稳定,也不会产生额外的运动阻滞和偏侧效应。

                                                       (朱慧琛 王祥瑞 )

Spinal neostigmine produces analgesia without respiratory depression or hypotension but provokes major gastrointestinal side effects. Epidural injection of this drug, however, appears to induce analgesia devoid of such side effects. In this study, we evaluated the effect of a bolus of epidural neostigmine on the duration and magnitude of analgesia in early labor and assessed its eventual sparing effect on subsequent local anesthetic requirements. Epidural neostigmine methylsulfate (maximal dose 4 µg/kg) was added to 10 mL of ropivacaine 0.1%, with and without sufentanil 10 µg, to initiate analgesia. Twenty minutes after injection, pain score, sensory level, and motor block were assessed. Time until request for supplemental epidural medication was also recorded. Patient-controlled epidural analgesia with ropivacaine 0.1% was used for epidural supplementation. Maternal and fetal side effects were closely recorded. Neostigmine (4 µg/kg), when added to ropivacaine 10 mg, provided equivalent analgesia to ropivacaine 20 mg but was less effective than sufentanil 10 µg for the initiation of labor epidural analgesia. Further, neostigmine did not modify the subsequent patient-controlled epidural analgesia local anesthetic requirements during labor. No hemodynamic instability, additional motor block, or bothersome side effects were recorded.

 

分娩第一产程芬太尼和舒芬太尼麻醉的最小镇痛剂量

Minimum Analgesic Doses of Fentanyl and Sufentanil for Epidural Analgesia in the First Stage of Labor

Giorgio Capogna, MD*, Michela Camorcia, MD*, and Malachy O. Columb{dagger}

*Department of Anesthesia, Città di Roma Hospital, Rome, Italy; and {dagger}Department of Anaesthesia and Intensive Care, South Manchester University Hospital, Wythenshawe, Manchester, United Kingdom

Anesth Analg 2003;96:1178-1182


观察分娩者在单一硬膜外麻醉时辅用芬太尼及舒芬太尼的最小剂量及其相关影响。将自然分娩和要求硬膜外麻醉的初产妇随机分为两组每人均给以0.9% wt/vol芬太尼或舒芬太尼10ml,首剂为芬太尼125µg,舒芬太尼25µg,维持剂量根据孕妇反应给予(实验误差:芬太尼5µg、舒芬太尼1µg),芬太尼与舒芬太尼的最小麻醉剂量或者是平均起效剂量分别为124.2 µg (95% CI, 118.1–130.6 µg)21.1 µg (95% confidence interval [CI], 20.2–21.9 µg) (P < 0.0001)。舒芬太尼与芬太尼的效价比为5.9 (95% CI, 5.6–6.3)。综上所述,在分娩第一产程应用硬膜外麻醉时芬太尼和舒芬太尼的使用剂量及相关效应是相同的。   

  (朱慧琛 王祥瑞 )

In this study, we sought to determine the minimum analgesic doses and relative potencies of fentanyl and sufentanil when they are used as the sole epidural analgesic during the first stage of labor. Nulliparous parturients (n = 66) in spontaneous labor at term gestation and requesting epidural analgesia were enrolled into this prospective, double-blinded, randomized, sequential-allocation study. Each woman received fentanyl or sufentanil diluted with 0.9% wt/vol saline to a volume of 10 mL. The initial dose was arbitrarily chosen to be 125 µg for fentanyl and 25 µg for sufentanil, with subsequent doses being determined by the response of the previous patient (testing interval, 5 µg for fentanyl and 1 µg for sufentanil). Efficacy was accepted if the visual analog score decreased to <=10 mm on a 100-mm scale within 30 min. The minimum analgesic dose or median effective dose was 21.1 µg (95% confidence interval [CI], 20.2–21.9 µg) for sufentanil and 124.2 µg (95% CI, 118.1–130.6 µg) for fentanyl (P < 0.0001). The sufentanil/fentanyl potency ratio was 5.9 (95% CI, 5.6–6.3). In conclusion, we have established the equivalent doses and relative potencies of fentanyl and sufentanil for epidural analgesia in the first stage of labor.

 

控制性低温对兔止血功能的影响

The Influence of Induced Hypothermia for Hemostatic Function on Temperature-Adjusted Measurements in Rabbits

Mitsuru Shimokawa, MD, Katsuyasu Kitaguchi, MD, Masahiko Kawaguchi, MD, Takanori Sakamoto, MD, Meiko Kakimoto, MD, and Hitoshi Furuya, MD

Department of Anesthesiology, Nara Medical University, Japan

Anesth Analg 2003;96:1209-1213


在低温病人中,即使止血功能看似正常仍可见出血倾向。凝血和血小板功能试验通常在37时进行。应用Sonoclot Analyzer®(Sonoclot®)Thromboelastography®(TEG®)研究温度调节对止血功能的影响。在15只雄性新西兰白兔中以静脉注射氯胺酮和芬太尼诱导和维持麻醉。应用水毯使温度降至30和复温至37。在四个时间取血样本:低温前,34℃时,30℃时,复温后。标准凝血试验在37℃时进行(C方法),同时进行实际温度时的凝血试验(R方法)。在Sonoclot®,活化凝血时间和到达高峰时间以及血块凝集率与C方法相比在30℃明显降低。在TEG®,反应时间和血块形成时间和血块形成率在30℃时明显较37℃是延长。低温使凝血串联反应时间延长和血小板功能降低。在低温期间,需在实际温度下测量止血能力,以避免基于37℃的标准值而过高的评价止血能力。

(忻纪华 王祥瑞 )

In hypothermic patients, a tendency to bleed may be observed even when hemostatic tests seem to be normal. Coagulation and platelet function tests are usually performed at 37°C. We investigated the influence of induced hypothermia on temperature-adjusted hemostasis function testing using Sonoclot Analyzer® (Sonoclot®) and Thromboelastography® (TEG®). Anesthesia was induced and maintained with IV ketamine and fentanyl on 15 male New-Zealand White rabbits. A water blanket was used to induce hypothermia to 30°C and to rewarm to 37°C. Blood samples were obtained at four points: before hypothermia, at 34°C, at 30°C, and after rewarming. Standard coagulation tests were performed at 37°C (C method), and simultaneously, real temperature hemostasis function tests (R method) were run. In Sonoclot®, activated clotting time and time to peak increased and clot rate decreased significantly at 30°C in the R method compared with those in the C method. In TEG®, reaction time and clot formation time were prolonged and clot formation rate was diminished at 30°C in the R method compared with those in the C method. Induced hypothermia delayed the coagulation cascade and reduced platelet function. During hypothermia, hemostatic measurements should be performed at real temperature to avoid overestimating patient hemostatic function based on results measured at the standard 37°C.

 

止血和血液稀释:临床实践的定量分析指南

Hemostasis and Hemodilution: A Quantitative Mathematical Guide for Clinical Practice

Kai Singbartl, MD*, Petra Innerhofer, MD{dagger}, Jens Radvan, MSc{ddagger}, Birgit Westphalen, MD§, Dietmar Fries, MD{dagger}, Raimund Stögbauer, MD§, and Hugo Van Aken, MD PhD*

*Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Germany; {dagger}Klinik für Anästhesiologie und Intensivmedizin, Leopold Franzens-Universität Innsbruck, Innsbruck, Austria; {ddagger}Institut für Biomedizinische Technologien, Rheinisch-Westfälische Technische Hochschule Aachen, Germany; and §Klinik für Anästhesie, Krankenhaus Bethanien, Moers, Germany

Anesth Analg 2003;96:929-935

 

血液稀释中止血功能的定量改变目前仍不清楚。由于只能提供载氧功能的血液代用品的广泛应用使得该问题变得更为复杂。我们建立了一个数学模型来定量分析血液稀释中的止血功能并且使其适用于再计算的病人资料。我们计算并比较最大容许失血量(MABL与最低容许血细胞压积Hct相关)、血小板浓度及血浆纤维蛋白原浓度。MABL是在没有任何额外血液制品的情况下机体可耐受的最大失血量。最小的MABL则限制血液稀释。血液稀释包括应用胶体等容替代失血或急性等容血液稀释(ANH)随之应用胶体和ABS替代失血。我们也把结果与病人术前的资料相联系(n = 204)。血小板浓度的降低很少(<2% 的所有病人)限制血液稀释。与之相比,如果病人的初始血浆纤维蛋白原浓度在正常的低限(<300 mg/dL)则血浆临界纤维蛋白浓度(<=100 mg/dL)往往限制血液稀释(<=20%的所有病人)。如果ANH联合应用ABS则这些结果更为常见,在这种情况下ANH血液制品只单独用于稳定止血功能,由此则未达到联合应用ANHABS的既定目的。结论:血液稀释中止血功能的定量改变原因及其临床效果目前还不清楚,我们应用一个已验证的数学模型证实止血功能尤其是血浆纤维蛋白原浓度会限制血液稀释的程度。这种现象在ANH联合应用人造血液代用品(ABS)时尤为显著。

(张俊峰译  薛张纲 )

Quantitative changes of hemostasis during hemodilution remain unclear. With the increasing popularity of artificial blood substitutes (ABS), which solely provide oxygen-transport capacity, this issue becomes even more complex. We developed a mathematical model to quantitatively analyze hemostasis during hemodilution and validated it by recalculating patient data. We calculated and compared maximal allowable blood losses (MABL) related to minimal acceptable hematocrit, platelet concentration, and plasma fibrinogen concentration. MABL is the maximal blood loss that can be tolerated without any additional blood products. The variable with the smallest MABL thus limits hemodilution foremost. Hemodilution included isovolemic replacement of blood loss with colloid or acute normovolemic hemodilution (ANH) followed by isovolemic replacement of blood loss with colloid and ABS. We also related our findings to preoperative patient data (n = 204). The decline in platelet concentrations rarely (<2% of all patients) limits hemodilution. By contrast, critical plasma fibrinogen (<=100 mg/dL) concentrations can often (<=20% of all patients) limit hemodilution if their initial concentrations are within the lower normal range (<300 mg/dL). These findings become more frequent if ANH is combined with ABS. Under those circumstances ANH blood products are solely required for stabilization of hemostasis, thereby defeating the original purpose of combining ANH with ABS.

 

七氟醚暴露产生超氧化物,但在离体心脏缺血再灌注中则降低超氧化物的产生

Sevoflurane Exposure Generates Superoxide but Leads to Decreased Superoxide During Ischemia and Reperfusion in Isolated Hearts

Leo G. Kevin, FCARCSI*, Enis Novalija, MD*,{dagger}, Matthias L. Riess, MD*,{dagger}, Amadou K. S. Camara, PhD*, Samhita S. Rhodes*,{ddagger}, and David F. Stowe, MD PhD*,{dagger},{ddagger},§,||

Anesthesiology Research Laboratories, Departments of *Anesthesiology and {dagger}Physiology, and §Cardiovascular Research Center, The Medical College of Wisconsin, Milwaukee, Wisconsin; {ddagger}Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin; and ||Research Service, Veterans Affairs Medical Center, Milwaukee, Wisconsin

Anesth Analg 2003;96:949-955

反应性氧簇(ROS)是造成心脏缺血再灌注后损伤的主要原因,但是有证据显示麻醉药通过产生(ROS)诱导缺血预适应(APC)。我们事先假设七氟醚产生ROS (超氧化物O2·-),缺血中APC削弱O2·- 的形成,并且这种削弱作用可被O2·-的清除剂(MnTBAP)或已被公认的线粒体ATP敏感钾通道阻制剂(mKATP) (5-HD)逆转。应用DHE持续检测豚鼠心脏的 O2·-。分别在缺血前30 min和再灌注后120 min单独使用七氟醚(APC)、联合使用MnTBAP5-HD。控制组心脏则不作任何预治疗。七氟醚直接增加O2·-,这种作用可被MnTBAP(不能被5-HD)所阻制。 O2·- 在缺血和再灌注中都增加, O2·- 的增加在APC组被削弱,这种作用可被MnTBAP5-HD阻制。 我们认为七氟醚直接诱导O2·- 形成但是O2·- 形成在随后缺血和再灌注中降低。前一作用好像与mKATP 独立相关,而后一作用则无关。我们的研究表明APC ROS启动反过来引起mKATP 通道开放。尽管ROS在激发和调节APC中的作用看似矛盾,但却提供了一种可能机制。结论: ROS可激活APC。持续检测豚鼠离体心脏的ROS (O2·-) 七氟醚直接增加O2·- 但在缺血中削弱O2·- 的形成,该研究显示APCROS激活并且明确了缺血中的心脏保护机制。

     (张俊峰译  薛张纲 )

Reactive oxygen species (ROS) are largely responsible for cardiac injury consequent to ischemia and reperfusion, but, paradoxically, there is evidence suggesting that anesthetics induce preconditioning (APC) by generating ROS. We hypothesized that sevoflurane generates the ROS superoxide (O2·-), that APC attenuates O2·- formation during ischemia, and that this attenuation is reversed by bracketing APC with the O2·- scavenger manganese (III) tetrakis (4-benzoic acid) porphyrin chloride (MnTBAP) or the putative mitochondrial adenosine triphosphate-sensitive potassium (mKATP) channel blocker 5-hydroxydecanoate (5-HD). O2·- was measured continuously in guinea pig hearts by using dihydroethidium. Sevoflurane was administered alone (APC), with MnTBAP, or with 5-HD before 30 min of ischemia and 120 min of reperfusion. Control hearts underwent no pretreatment. Sevoflurane directly increased O2·-; this was blocked by MnTBAP but not by 5-HD. O2·- increased during ischemia and during reperfusion. These increases in O2·- were attenuated in the APC group, but this was prevented by MnTBAP or 5-HD. We conclude that sevoflurane directly induces O2·- formation but that O2·- formation is decreased during subsequent ischemia and reperfusion. The former effect appears independent of mKATP channels, but not the latter. Our study indicates that APC is initiated by ROS that in turn cause mKATP channel opening. Although there appears to be a paradoxical role for ROS in triggering and mediating APC, a possible mechanism is offered.

 

可乐定有利于青少年患者的控制性降压

Clonidine Facilitates Controlled Hypotension in Adolescent Children

Thomas Hackmann, MD FRCPC*,{dagger}, Marvin Friesen, MD FRCPC*, Suzanne Allen, BSc RRT*, and David S. Precious, DDS MSc, FRCD{ddagger}

*Department of Paediatric Anaesthesia, IWK Health Centre, Halifax, Nova Scotia, Canada; and Departments of {dagger}Anesthesia and {ddagger}Oral and Maxillofacial Sciences, Dalhousie University, Halifax, Nova Scotia, Canada

Anesth Analg 2003;96:976-981

 

在此随机、双盲、安慰剂控制的临床试验中,我们研究了行口腔颌面部手术的青少年患者控制性降压中应用可乐定是否减少异氟醚、芬太尼及拉贝乐尔的使用量。我们也研究了其术前镇静效果、对经鼻插管的血流动力学反应及恢复质量。39例健康患儿(10–16 yr)在术前晚和术前90 min使用5 µg/kg 可乐定或安慰剂。通过自身评价,两组的患儿都显示同样的焦虑,而观察者则显示可乐定组病人更为镇静(P < 0.01)。与安慰组相比,可乐定组诱导时的心率显著降低(P < 0.001),诱导前的动脉血压(P < 0.01)和插管后的动脉峰压(P < 0.001)也显著降低。可乐定组维持平均动脉压在60 ± 4 mm Hg时异氟醚的需要量显著减少 (平均异氟醚浓度,可乐定组0.99% 安慰剂组1.33; P = 0.0004) ,芬太尼的需要量也显著减少(P = 0.002)。需要拉贝乐尔治疗的病人(可乐定组, n = 3 对安慰剂组, n = 13; P = 0.004)。在可乐定组有一较快的恢复趋势,并且恢复室的停留时间较短  (P = 0.03)。我们认为可乐定是青少年患者控制性降压中一种有效的辅助用药。结论:该研究显示青少年患者行大的下颌手术时应用可乐定有利于控制性降压,可乐定减少吸入麻醉药、止痛药及降压药的使用,减少心率和血压的波动并且提供较快的麻醉恢复。

(张俊峰译  薛张纲 )

In this randomized, double-blinded, placebo-controlled trial, we investigated whether clonidine lessened the requirements for isoflurane, fentanyl, and labetalol to provide controlled hypotension in children who underwent oromaxillofacial surgery. We also studied preoperative sedative effects, the hemodynamic response to nasotracheal intubation, and recovery characteristics. Thirty-nine healthy children, aged 10–16 yr, received clonidine 5 µg/kg or placebo on the night before surgery and 90 min before surgery. By self-assessment, children in both groups showed similar anxiety, whereas observers rated clonidine patients as more sedated (P < 0.01). Heart rate during induction remained significantly decreased in clonidine patients compared with placebo patients (P < 0.001), as did arterial blood pressure before induction (P < 0.01) and peak pressure after intubation (P < 0.001). Children who took clonidine required significantly less isoflurane to maintain a mean arterial blood pressure of 60 ± 4 mm Hg (mean isoflurane concentration, clonidine 0.99% versus placebo 1.33; P = 0.0004) and required less fentanyl than placebo patients (P = 0.002). Fewer treatment patients received labetalol (clonidine, n = 3 versus placebo, n = 13; P = 0.004). There was a trend toward faster recovery in the clonidine group, with a shortened recovery room stay (P = 0.03). We conclude that clonidine is a useful adjunct for controlled hypotension in children.

 

异氟醚在脊髓上间接抑制了电刺激网状结构伴随的皮层活动

Isoflurane Action in Spinal Cord Indirectly Depresses Cortical Activity Associated with Electrical Stimulation of the Reticular Formation

Joseph F. Antognini, MD*, Richard Atherley, BS*, and Earl Carstens, PhD{dagger}

*Department of Anesthesiology and Pain Medicine and {dagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis, Davis, California

Anesth Analg 2003;96:999-1003

麻醉药在脊髓上作用消除了运动和伤害性信息的上升传递。我们研究异氟醚脊髓作用是否影响皮层活动(用电刺激中脑网状结构发生的脑电图去同步化来确定)。六只山羊用异氟醚麻醉,颈部作切口使异氟醚可以输送到头部或躯体。脑电图在中脑网状结构局部电刺激 (0.05, 0.1, 0.2, 0.3, and 0.4 mA) 前中后记录;每个动物脑内异氟醚维持稳定({approx}1%)。当躯体异氟醚浓度为0.3% ± 0.1%, 中脑网状结构电刺激(15.3 ± 1.7 Hz, 所有刺激电流平均通过)后,频谱的边缘频率超过了躯体异氟醚浓度1.2% ± 0.2% (12.9 ± 1.0 HzP < 0.05)时的边缘频率。双频指数指数值也同样受到影响: 躯体异氟醚低时为60 ± 6 ,而躯体异氟醚高时为53 ± 7 (P < 0.05)。这些结果显示异氟醚在脊髓体感上升传递的抑制作用可以影响网状-丘脑皮层唤醒机制,因此可能减少了无意识和遗忘的麻醉药物需要应可能与麻醉药物诱导的遗忘和无意识有关。

(潘志浩译  薛张纲 )

Anesthetics act in the spinal cord to ablate both movement and the ascending transmission of nociceptive information. We investigated whether a spinal cord action of isoflurane affected cortical activity as determined by the electroencephalogram desynchronization that occurs after electrical stimulation of the midbrain reticular formation (MRF). Six goats were anesthetized with isoflurane, and neck dissections were performed to permit differential isoflurane delivery to the head and torso. The electroencephalogram was recorded before, during, and after focal electrical stimulation (0.05, 0.1, 0.2, 0.3, and 0.4 mA) in the MRF; in each animal, the brain isoflurane was maintained constant ({approx}1%). When the torso isoflurane was 0.3% ± 0.1%, the spectral edge frequency after MRF electrical stimulation (15.3 ± 1.7 Hz, averaged across all stimulus currents) was more than the spectral edge frequency when the torso isoflurane was 1.2% ± 0.2% (12.9 ± 1.0 Hz, averaged across all stimulus currents; P < 0.05). Bispectral index values were similarly affected: 60 ± 6 when torso isoflurane was low versus 53 ± 7 at high torso isoflurane (P < 0.05). These results suggest that a spinal depressant action of isoflurane on ascending somatosensory transmission can modulate reticulo-thalamocortical arousal mechanisms, hence possibly reducing anesthetic requirements for unconsciousness and amnesia.

 

左旋和右旋氯胺酮阻断神经元和骨骼肌上电压控制的钠通道

Blockade of Voltage-Operated Neuronal and Skeletal Muscle Sodium Channels by S(+)- and R(-)-Ketamine

Gertrud Haeseler, MD*, Diana Tetzlaff*, Johannes Bufler, MD{dagger}, Reinhard Dengler, MD{dagger}, Sinikka Münte, MD*, Hartmut Hecker, PhD{ddagger}, and Martin Leuwer, MD§

*Anesthesiology, {dagger}Neurology and Neurophysiology, and {ddagger}Biometrics, Hannover Medical School, Hannover, Germany; and §University Department of Anaesthesia, The University of Liverpool, Liverpool, United Kingdom

 Anesth Analg 2003;96:1019-1026

 

除了全麻作用外,氯胺酮还有局麻药样的作用。我们对左旋和右旋氯胺酮与两种电压控制的钠通道的电压和使用依赖的相互作用进行研究,特别是强调在静息和灭活状态通道亲和力的差异。大鼠脑Iia和人骨骼肌钠通道在人胚肾293细胞上作不同等表达。左旋和右旋氯胺酮可逆抑制整个细胞的钠内向电流;-70 mV的钳电压下50%的抑制浓度在神经元型上为 240 ± 60 µM 333 ± 93 µM,在骨骼肌型上为 59 ± 10 µM181 ± 49 µM。左旋氯胺酮在骨骼肌型上较右旋氯胺酮作用更强。氯胺酮对灭活型通道与静息型相比具有更高的亲和力。然而,这两种通道亲和力之间的估计差异仅仅810倍,药物在这两种通道之间的平衡时间太快以致在10 Hz时使用依赖的阻滞需要浓度高达300 µM。这些结果表明氯胺酮在稳定灭活通道状态上效果较利多卡因样局麻药差。

(潘志浩译  薛张纲 )

Besides its general anesthetic effect, ketamine has local anesthetic-like actions. We studied the voltage- and use-dependent interaction of S(+)- and R(-)-ketamine with two different isoforms of voltage-operated sodium channels, with a special emphasis on the difference in affinity between resting and inactivated channel states. Rat brain IIa and human skeletal muscle sodium channels were heterologously expressed in human embryonic kidney 293 cells. S(+)- and R(-)-ketamine reversibly suppressed whole-cell sodium inward currents; the 50% inhibitory concentration values at -70 mV holding potential were 240 ± 60 µM and 333 ± 93 µM for the neuronal isoform and 59 ± 10 µM and 181 ± 49 µM for the skeletal muscle isoform. S(+)-ketamine was significantly more potent than R(-)-ketamine in the skeletal muscle isoform only. Ketamine had a higher affinity to inactivated than to resting channels. However, the estimated difference in affinity between inactivated and resting channels was only 8- to 10-fold, and the time course of drug equilibration between inactivated and resting channels was too fast to cause use-dependent block at 10 Hz up to a concentration of 300 µM. These results suggest that ketamine is less effective than lidocaine-like local anesthetics in stabilizing the inactivated channel state.

 

异丙酚和乙咪酯在慢性缺氧大鼠对气道收缩的效应

The Effects of Propofol and Etomidate on Airway Contractility in Chronically Hypoxic Rats

Nazinigouba Ouédraogo, MD*,{dagger}, Roger Marthan, MD PhD*, and and Etienne Roux, DMV PhD*

*Laboratoire de Physiologie Cellulaire Respiratoire, INSERM EMI9937, Université Victor Segalen, Bordeaux, France; and {dagger}UFR/SDS Université de Ouagadougou, Burkina Faso, Africa

Anesth Analg 2003;96:1035-1041

 

我们在慢性缺氧大鼠模型与正常大鼠上比较研究了两种静脉麻醉药,异丙酚和乙咪酯对气道反应性的影响。慢性低氧大鼠用低压室内饲养 (380 mm Hg 的气压下饲养14)。麻醉药松弛和预防激动剂诱发的收缩的能力在用胆碱能激动剂carbachol (CCh)和去极化药物KCl预收缩的离体的气管环上进行评价。在两种大鼠累积浓度的两种药物松弛了CCh KCl同等幅度预收缩的气管环。在用CCh 预收缩的气管环上,减少最大收缩30%的麻醉药的负对数,也就是半数最大抑制浓度的负对数,异丙酚和乙咪酯在正常大鼠分别为4.10 ± 0.09 4.12 ± 0.15,在慢性缺氧大鼠为 4.20 ± 0.22 3.61 ± 0.19。在固定浓度下, 异丙酚(3 x 10-4 M)或乙咪酯(10-4 M)也抑制了慢性缺氧大鼠气管环对累积浓度的CCh KCl的收缩反应。然而,在比较两种麻醉药同等程度舒张反应时,乙咪酯显示抑制收缩效果较异丙酚低两倍。这些结果表明异丙酚和乙咪酯在慢性缺氧大鼠气道上保持了依靠对药物和电机械耦联作用而发挥的舒张效应。

(潘志浩译  薛张纲 )

We investigated the effect of two IV anesthetics, propofol and etomidate, on airway responsiveness in a rat model of chronic hypoxia (CH) in comparison with normoxic rats. CH rats were obtained using a hypobaric chamber (14 days at a barometric pressure of 380 mm Hg). The ability of both anesthetics to relax and prevent agonist-induced contraction was assessed in isolated tracheal rings precontracted with the muscarinic agonist carbachol (CCh) and the depolarizing agent KCl. Cumulative concentrations of both compounds relaxed tracheal rings precontracted with CCh or KCl with a similar amplitude in CH and normoxic rats. In tracheal rings precontracted with CCh, the negative logarithm of anesthetics that reduced the maximal contraction by 30%, i.e., -log half-maximal inhibitory concentration, for propofol and etomidate were 4.10 ± 0.09 and 4.12 ± 0.15 in normoxic rats and 4.20 ± 0.22 and 3.61 ± 0.19 in CH rats, respectively. At a fixed concentration, propofol (3 x 10-4 M) or etomidate (10-4 M) also inhibited CH tracheal rings contraction in response to cumulative concentrations of CCh and KCl. However, in contrast with the equivalent relaxant effect of both anesthetics, etomidate was two-fold less effective than propofol for inhibiting the subsequent contraction to CCh and KCl. These results indicate that propofol and etomidate retain their relaxant properties in CH rat airways by acting on the pharmaco- and electromechanical coupling.

 

吸入麻醉时不同新鲜气流量的条件下使用了麻醉药节约装置的回路和普通回路之比较

The Anesthetic Conserving Device Compared with Conventional Circle System Used Under Different Flow Conditions for Inhaled Anesthesia

Augusto Tempia, MD, Maddalena C. Olivei, MD, Eliana Calza, MD, Hans Lambert, MS, Luca Scotti, MD, Eugenio Orlando, MD, Sergio Livigni, MD, and Enrica Guglielmotti, MD

*Istituto di Anestesia e Rianimazione Ospedale San Luigi, Orbassano, Italy; Servizio di Anestesia {dagger}A e {ddagger}B, Ospedale San Giovanni Bosco, Torino, Italy; §Istituto di Anestesia e Rianimazione Ospedale San Giovanni Battista, Torino, Italy; and ||Hudson RCI, Upplands Väsby, Sweden

Anesth Analg 2003 96: 1056-1061.

 

麻醉药节约装置(ACD)是一种仅适用于挥发性麻醉药物的高流量系统。我们比较了在不同新鲜气流量条件下有麻醉药节约装置的系统和普通回路的区别。81位进行重大手术的患者随机分为两组,一组是在Y段安装了麻醉药节约装置的回路(n41),另一组是普通的吸入回路(n40)。在第一组新鲜气流量设为8/分钟,并且麻醉药没有重复吸入;在第二组经过蒸发罐的新鲜气流量设为1/分钟,1.5/分钟,3/分钟和6/分钟。我们比较了第一组和第二组的四种情况下,七氟醚的用量、消耗量、润湿效率和对环境的污染的不同。有麻醉药节约装置的回路和低流量的普通回路(新鲜气流量为1/分钟和1.5/分钟)消耗的七氟醚最少;从吸入七氟醚的浓度上升来看,只有新鲜气流量超过3/分钟的普通回路才能够比有麻醉药节约装置的回路快,而且后者清除回路中的七氟醚的速度是最快的,呼吸气体的湿度也是足够的,周围环境中七氟醚的浓度是1-70ppb,因此安装了麻醉药节约装置的回路可以有效而简单地替代传统的低流量系统。

(   薛张纲 )

 

The Anesthetic Conserving Device (ACD) is a high-flow anesthesia system closed to volatile anesthetics only. We compared the ACD with a circle system under different fresh gas flow (FGF) conditions. Eighty-one patients undergoing major surgery were randomly allocated to receive sevoflurane from a circle circuit combined either with the ACD placed at the Y-piece (n = 41) or with a vaporizer (n = 40). The FGF was set to 8 L/min in the ACD system, where the circle circuit served as a nonrebreather. In the conventional circle system without ACD, the vaporizer was supplied with 1-, 1.5-, 3-, and 6-L/min FGFs. We compared the ACD with the circle system under the four FGFs in terms of sevoflurane dosing, sevoflurane consumption, humidification efficiency, and environmental pollution. The ACD and the low-flow circle system (1.5- and 1-L/min FGFs) resulted in the smallest sevoflurane consumption. The increase in inspired sevoflurane concentration was faster with the circle system than with the ACD only with FGFs >=3 L/min. The removal of ACD from the circuit allowed the fastest washout of sevoflurane. Respiratory gas humidification was always adequate. Sevoflurane ambient concentration with the ACD was 1–70 ppb. The ACD is a valid and simple alternative to low-flow systems.

 

对于硬膜外给芬太尼的患者术前静脉使用小剂量的芬太尼可以预测镇痛效果和副作用的发生率

A Small Preoperative Test Dose of Intravenous Fentanyl Can Predict Subsequent Analgesic Efficacy and Incidence of Side Effects in Patients Due to Receive Epidural Fentanyl

Kazuyoshi Ueta, MD*,{dagger}, Kiyoshi Takeda, MD PhD*,{ddagger}, Hisatoshi Ohsumi, MD PhD*, Junichi Haruna, MD*, Hiromi Shibuya, MD*, and Takashi Mashimo, MD PhD{dagger}

*Department of Anesthesia, Osaka National Hospital, Osaka, Japan; {dagger}Department of Anesthesiology, Osaka University Medical School, Osaka, Japan; and {ddagger}Department of Anesthesiology, Fujita Health University, Aich, Japan

Anesth Analg 2003 96: 1079-1082

 

对于硬膜外给阿片类药物的患者,存在个体差异可能会导致副作用的发生率和严重性以及镇痛效果不同,因此根据个体差异来考虑最合适的用药剂量就很重要了。通过评价患者对于静脉使用小剂量芬太尼的反应,我们设计了这个研究项目来预测术后接受硬膜外芬太尼镇痛的患者的镇痛效果和副作用的发生率。在麻醉诱导前,静脉给药芬太尼50ug2分钟后评价患者的反应情况。23个患者有恶心、嗜睡、头晕、发热感和其他主诉的被分为有反应组(R组),其余的20人被分为无反应组(NR组)。手术结束后96个小时内硬膜外芬太尼的剂量是0.3mg/天,局麻药是0.25%布比卡因。R组患者术后疼痛强度的视觉评分比NR组低,所需要的止痛药的量也较少。R组患者副作用的发生率是74%NR组是10%P<0.05),而且R组患者的副作用要更严重。这个研究表明对于术后硬膜外给芬太尼镇痛的患者术前麻醉诱导期间静脉使用小剂量的芬太尼可以预测镇痛效果和副作用的发生率和严重性。

(   薛张纲 )

Because individual variation is a likely factor affecting both the incidence and severity of side effects and the analgesic efficacy of epidural opioids, assessment of individual variation could be useful in deciding optimal dosage. By evaluating the response to a small test dose of IV fentanyl, we designed this study to predict the degree of pain relief and the incidence of side effects in patients who would be receiving postoperative epidural fentanyl. Before the induction of anesthesia, 50 µg of fentanyl was administered IV, and 2 min after fentanyl, the patient response was evaluated. Twenty-three patients, who reported nausea, sleepiness, dizziness, sensation of warmth, and other symptoms, were categorized as responders (Group R); the remaining 20 patients were categorized as nonresponders (Group NR). At the completion of surgery, infusion of epidural fentanyl was administered (0.3 mg/d in 0.25% bupivacaine) for 96 h. At postoperative Hours 6 and 24, Group R had significantly lower visual analog scale scores for postoperative pain intensity and required fewer analgesics than Group NR. The incidence of side effects, however, was 74% for Group R and 10% for Group NR (P < 0.05), and side effects were more serious in Group R. This study demonstrates that preoperative administration of a small dose of fentanyl during the induction of anesthesia enables prediction of the analgesic efficacy of postoperative epidural fentanyl and the incidence and severity of side effects.

 

白介素-6在痛觉产生方面的作用

The Role of Interleukin-6 in Nociception and Pain (Review Article)

Raf F. De Jongh, MD*, Kris C. Vissers, MD*, Theo F. Meert, PhD{dagger}, Leo H. D. J. Booij, MD PhD, FRCA{ddagger}, Catharina S. De Deyne, MD PhD*, and René J. Heylen, MD PhD

*Department of Anesthesia, Intensive Care, and Emergency Care and the Multidisciplinary Pain Centre, Ziekenhuis Oost Limburg, Genk, Belgium; {dagger}Johnson & Johnson, Pharmaceutical Research and Development, Beerse, Belgium; and {ddagger}Department of Anesthesia, University Hospital of Nijmegen, Nijmegen, The Netherlands

*Anesth Analg 2003 96: 1096-1103.

 

提示:白介素-6在疼痛的研究中是一种很有意思的介质,由于它的分子生物结构上的特性、给予试验性疼痛刺激后在局部的变化和它对于疼痛的调节效应引起了人们的重视。

(   薛张纲 )

 

IMPLICATIONS: That IL-6 is an interesting target in the study of pain is underscored by its biomolecular properties, its localization after experimental pain, and its modulating effect on pain after administration.

 

前列腺素E1和尼卡地平对兔子大脑微循环影响的比较

The comparative effects of prostaglandin e1 and nicardipine on cerebral microcirculation in rabbits.

Takenaka M, Iida H, Iida M, Uchida M, Dohi S.
Department of Anesthesia, Ibi General Hospital, Ibi County, Gifu, and. Department of Anesthesiology and Critical Care Medicine and. Internal Medicine, Gifu University School of Medicine, Gifu, Japan.

Anesth Analg 2003 Apr;96(4):1139-44

 

对全身降压药物前列腺素E1(PGE1) 和尼卡地平对大脑微循环和脑血管在高二氧化碳和低氧时反应的影响作一比较。在48只进行异氟醚麻醉的兔子,经颅开窗测定大脑软脑膜血管的直径,条件为:a)静脉注射PGE1或尼卡地平造成温和适度的低血压(平均动脉压降至最初的60~80%),b)局部用药,c)适度的低血压并有高二氧化碳或低氧状态。软脑膜动脉的直径在PGE1引起的低血压时无改变,但尼卡地平引起的低血压时增加。局部应用尼卡地平时有剂量依赖的软脑膜动脉直径增加,但局部应用PGE1时没有。在这些实验中观测到大脑小静脉直径仅有细小改变。软脑膜动脉的扩张反应在PGE1引起的低血压并有高二氧化碳状态时增强,而在尼卡地平所致低血压并有高二氧化碳状态时减弱。在低氧时,PGE1引起低血压时血管扩张反应无改变,在尼卡地平所致低血压时减弱。总之,作为全身降压药物,PGE1不扩张大脑血管并且在高二氧化碳或低氧状态时维持大脑血管的反应性。然而尼卡地平扩张大脑血管并在高二氧化碳或低氧状态时减弱血管反应性。结论:当应用全身降压药进行适度降压时,PGE1不引起大脑血管扩张,并维持高二氧化碳或低氧状态时脑血管反应性;然而尼卡地平扩张大脑血管并减弱高二氧化碳和低氧时的血管反应性。

(顾悦超   薛张纲 )
We compared the effects of the systemic hypotensive drugs prostaglandin E1 (PGE1) and nicardipine on the cerebral microcirculation and on the cerebrovascular reactivities to hypercapnia and hypoxia. In isoflurane-anesthetized rabbits (n = 48), we measured cerebral pial vessel diameters using a cranial-window preparation: (a) during IV PGE1- or nicardipine-induced mild or moderate hypotension (to 80% or 60% of initial mean arterial blood pressure), (b) after topical administration of these drugs, and (c) during hypercapnia or hypoxia induced during such mild or moderate hypotension. Pial arteriolar diameters were (a) unchanged when hypotension (mild or moderate) was induced by PGE1 but increased when it was induced by nicardipine and (b) increased dose-dependently by topical administration of nicardipine but not PGE1. Only small changes in cerebral venular diameter were observed in these experiments. The pial arteriolar dilator response to hypercapnia was potentiated during hypotension (mild or moderate) when it was induced by PGE1 but decreased when it was induced by nicardipine, whereas the response to hypoxia was maintained during PGE1-induced hypotension but decreased during nicardipine-induced hypotension. In conclusion, as a systemic hypotensive drug, PGE1 does not dilate cerebral arterioles and maintains cerebrovascular reactivities to hypercapnia and hypoxia, whereas nicardipine dilates such vessels and reduces these cerebrovascular reactivities.

大鼠注射dexmedetomidine对皮层体感诱发电位的保护作用

Preservation of the cortical somatosensory-evoked potential during dexmedetomidine infusion in rats.

Li BH, Lohmann JS, Schuler HG, Cronin AJ.
Department of Anesthesiology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center.
Anesth Analg 2003 Apr;96(4):1155-60

 

在病人使用dexmedetomidine时已进行有效的体感诱发电位监測,但尚未有系统研究SEPdexmedetomidine量效反应的报道。在本研究中,评估了大鼠应用一定剂量范围的dexmedetomidine对皮层体感诱发电位的影响。12只大鼠先进行氯胺酮麻醉,并进行机械通气,股动脉与股静脉穿刺置管。麻醉维持采用持续注射瑞芬太尼5~15ug/kg.min,万可松56ug/kg.mindexmedetomidine注射速率分别为0.10.250.51.0 2.0ug/kg.min,注射速率逐级增加,每一速率注射10分钟;8只大鼠另行注射大剂量的dexmedetomidine,注射速率为10ug/kg.min,注射时间30 min。刺激胫神经并随后记录皮层体感诱发电位。所有大鼠SEP振幅的增加经统计学检验无显著意义,dexmedetomidine增加SEP的潜伏期,但无统计学意义。数据表明dexmedetomidine未改变在大鼠中进行SEP监測所需的技术条件,并为在人身上进行dexmedetomidineSEP监測影响的研究提供支持。    

 (顾悦超   薛张纲 )

Successful somatosensory-evoked potential (SEP) monitoring has been performed during the administration of dexmedetomidine to patients, but a systematic investigation of the dose response of the SEP to dexmedetomidine has not been reported. In this study, we evaluated the effect of a range of dexmedetomidine doses on the cortical SEP in rats. Twelve rats were initially anesthetized with ketamine and the lungs were mechanically ventilated. Femoral arterial and venous catheters were placed. Anesthesia was maintained with constant infusions of remifentanil (5-15 micro g. kg(-1). min(-1)) and vecuronium (56 micro g. kg(-1). min(-1)). Dexmedetomidine was infused at 0.1, 0.25, 0.5, 1.0, and 2.0 micro g. kg(-1). min(-1) in a stepwise manner with 10-min infusion periods at each step. In eight rats, an additional large-dose infusion of dexmedetomidine at 10 micro g. kg(-1). min(-1) was administered for 30 min. The cortical SEPs were recorded after stimulation of the tibial nerve. At all infusion rates, there was a statistically insignificant increase in the SEP amplitude. Dexmedetomidine consistently increased the SEP latency, but these increases were not statistically significant. These data demonstrate that dexmedetomidine maintains technically adequate conditions for SEP monitoring in rats and provides support for future studies of the effect of dexmedetomidine on SEP monitoring in humans.

 

分娩时病人自控硬膜外镇痛0.15%罗比卡因合用0.5ug/ml苏芬太尼与0.10%罗比卡因合用0.5ug/ml苏芬太尼是等效的
Ropivacaine 0.15% Plus Sufentanil 0.5 micro g/mL and Ropivacaine 0.10% Plus Sufentanil 0.5 micro g/mL Are Equivalent for Patient-Controlled Epidural Analgesia During Labor.
Boselli E, Debon R, Duflo F, Bryssine B, Allaouchiche B, Chassard D.
Service d'Anesthesie-Reanimation, Hotel-Dieu, Lyon, France.
Anesth Analg 2003 Apr;96(4):1173-7

 

比较分娩时病人自控硬膜外镇痛(PCEA0.15%罗地卡合用0.5ug/ml苏芬太尼与0.10%罗比卡因合用0.5ug/ml的镇痛效果来评估罗比卡因浓度的降低是否可以产生同样的镇痛效果,130位健康临产孕妇进行随机双盲研究。PCEA设置为:初始剂量12ml,每次的病人自控剂量5ml,锁定时间5分钟,基础注射速度为10ml/h。两组病人在人口统计学与身体特征方面无显著差别。疼痛评分,产妇的满意度,镇痛药的使用总量,病人所需自控镇痛的次数和给予的次数,额外需求的自控镇痛次数,分娩方式,运动神经阻滞情况,副作用,Apgar评分两组间无明显差别。0.10%罗比卡因组(平均用量57mg 95%可信区间50.5~63.5mg)0.15%布比卡因组(平均用量88mg 95%可信区间74.4~93.3mg)的镇痛药用量要少(P<0.0001)。 0.10%罗比卡因合用0.5ug/ml苏芬太尼与0.15%罗比卡因合用0.5ug/ml苏芬太尼行PCEA分娩镇痛是等效的,并且可节省的30%的局麻药用量,40%的费用。然而这种局麻药用量减少与运动神经阻滞,副作用或器械助产的发生率无关。结论:0.10%罗比卡因合用0.5ug/ml苏芬太尼与0.15%罗比卡因合用0.5ug/ml苏芬太尼在进行PCEA分娩镇痛时是等效的,并且可节省30%的局麻药用量,40%的费用。罗比卡因浓度降低与运动神经阻滞,副作用或器械助产发生率的降低无关。

(顾悦超   薛张纲 )

We compared the administration of 0.15% ropivacaine plus 0.5 micro g/mL of sufentanil with that of 0.10% ropivacaine plus 0.5 micro g/mL of sufentanil for labor analgesia with patient-controlled epidural analgesia (PCEA) to determine whether a decreased concentration of ropivacaine could produce equally effective analgesia. One-hundred-thirty healthy pregnant women at term were randomized in a double-blinded fashion. The PCEA settings were as follows: 12-mL initial bolus, 5-mL bolus dose, 5-min lockout interval, and 10 mL/h basal infusion. Patient demographics and labor characteristics were comparable in both groups. No differences were observed for pain scores, maternal satisfaction, volume of anesthetic solution administered, number of boluses requested and delivered, need for supplemental boluses, mode of delivery, motor block, side effects, or Apgar scores. Patients in the 0.10% ropivacaine group used significantly less drug than those in the 0.15% group (mean, 57 mg; 95% confidence interval, 50.5-63.5 mg; versus mean, 88.0 mg; 95% confidence interval, 74.4-93.3 mg, respectively; P < 0.0001). Ropivacaine 0.10% plus 0.5 micro g/mL of sufentanil administered via PCEA for labor analgesia is equally effective as ropivacaine 0.15% plus 0.5 micro g/mL of sufentanil, with a 30% local anesthetic-sparing effect and a 40% reduction in cost. However, this reduction in local anesthetic is not associated with a decrease in the incidence of motor block, side effects, or instrumental deliveries.


一项前瞻性随机研究:碳酸氢纳或THAM液治疗术中高氯性酸中毒

Treating intraoperative hyperchloremic acidosis with sodium bicarbonate or tris-hydroxymethyl aminomethane: a randomized prospective study.
Rehm M, Finsterer U.
Klinik fur Anaesthesiologie, Ludwig-Maximilians-Universitat, Klinikum Grosshadern, Munich, Germany.
Anesth Analg 2003 Apr;96(4):1201-8

 

本研究评估在高氯性酸中毒时两种缓冲液对酸碱平衡的作用。24例经腹行妇科手术的患者按计划注射40mL/Kg.h的生理盐水。手术时有8位患者发生高氯性酸中毒。标准碱剩余为-7mmol/L时,患者随机分为两组,在20分钟内注射平均剂量为130+/-26mmol碳酸氢纳(BIC1Mn=12)或者平均剂量为128+/-18mmolTHAM液(THAM3Mn=12)。在缓冲前,缓冲开始时,缓冲后10分钟,20分钟测定PaCO2PH,血清碳酸氢根离子浓度,标准碱剩余,血清钠离子浓度,钾离子浓度,氯离子浓度,乳酸浓度,磷酸根离子浓度,总蛋白,白蛋白。计算表观主要离子差别:血清钠离子浓度+钾离子浓度-氯离子浓度-乳酸浓度。应用计算机程序计算有效主要离子差别和血浆弱酸数值。缓冲后即刻,标准碱剩余BIC组增加9.8mmol/LTHAM组增加7.2mmol/L。两组中PaCO2和血浆弱酸数值保持不变。主要由于高钠血症,表观和有效主要离子差别在BIC组增加8.57.9mEq/LTHAM组表观主要离子差别保持不变,但是有效主要离子差别增加6.4mEq/L,阴离子间隙由于存在无法测量的阳离子而减少5.8mmol/。总之,用BICTHAM作为缓冲液时,PH值的改变常伴随着,也可能是由于,主要离子差别增加。结论:通过比较两组患者术中发生高氯性酸中毒时接受同等剂量的碳酸氢纳或THAM液,了解了这两种药物对酸碱平衡的影响。在进行缓冲时,PH值的改变常伴随着,也可能是由于,主要离子差别的增加。

(顾悦超   薛张纲 )

In this study, we evaluated the action of two buffer solutions on acid-base equilibrium in cases of hyperchloremic acidosis. Twenty-four patients undergoing major gynecological intraabdominal surgery received 40 mL. kg(-1). h(-1) of 0.9% saline per protocol. During surgery, in every patient, hyperchloremic acidosis occurred. At a standard base excess of -7 mmol/L, the patients were randomly assigned to receive within 20 min either a mean of 130 +/- 26 mmol of sodium bicarbonate (BIC, 1 M; n = 12) or a mean of 128 +/- 18 mmol of tris-hydroxymethyl aminomethane (THAM, 3 M; n = 12). PaCO(2), pH, serum bicarbonate concentration, standard base excess, and serum concentrations of sodium, potassium, chloride, lactate, phosphate, total protein, and albumin were determined before and 0, 10, and 20 min after buffering. The apparent strong ion difference was calculated as: serum sodium plus serum potassium minus serum chloride minus serum lactate. The effective strong ion difference and the amount of weak plasma acid were calculated by using a computer program. Immediately after buffering, standard base excess increased by 9.8 mmol/L in the BIC group and by 7.2 mmol/L in the THAM group. In both groups, PaCO(2) and the amount of weak plasma acid remained constant. Mainly because of hypernatremia, the apparent and effective strong ion difference increased in the BIC group by 8.5 and 7.9 mEq/L, respectively. In the THAM group, the apparent strong ion difference remained constant; however, the effective strong ion difference increased by 6.4 mEq/L and the anion gap decreased by 5.8 mmol/L because of the occurrence of an unmeasured cation. In conclusion, in case of buffering with BIC or THAM, the changes in pH were accompanied by, and probably caused by, an increase in strong ion difference.

 

单剂量氨甲环酸可减少术前用阿司匹林的患者冠脉搭桥术后出血

Single-Dose Tranexamic Acid Reduces Postoperative Bleeding After Coronary Surgery in Patients Treated with Aspirin Until Surgery

Hilde Pleym, MD*, Roar Stenseth, MD PhD*, Alexander Wahba, MD PhD{dagger}, Lise Bjella, MD*, Asbjørn Karevold, MD{dagger}, and Ola Dale, MD PhD*,{ddagger}

Departments of *Anesthesiology and {dagger}Cardiothoracic Surgery, St. Olav University Hospital, Trondheim, Norway; and {ddagger}Department of Anaesthesia and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

Anesth Analg 2003;96:923-928

 

氨甲环酸能减少冠脉搭桥患者术後出血。本文研究阿司匹林延用至手术前一天的冠脉搭桥患者在体外循环(CPB)前即刻单次给予氨甲环酸的效果。实验为前瞻性、随机、双盲、设立安慰剂对照和平行实验。将80位病人分为两组,I:给予氨甲环酸30 mg/kg II:给予安慰剂-0.9% NaCl。体外循环开始前注射两药。记录术後16小时的出血量和整个住院期间输血量。CPB时血球压积低于20%和术後血球压积低于25%给予浓缩红细胞。氨甲环酸组的患者术後出血明显低于安慰剂组(475±274 mL 713 ± 243 mL; P < 0.001)在接受氨甲环酸的患者发现纤维蛋白溶解被明显抑制。氨甲环酸可减少术前仍用阿司匹林的冠脉搭桥管患者术後出血。结论:术前仍继用阿司匹林能增加冠脉搭桥患者术後出血。CPB前即刻给予氨甲环酸30 mg/kg可减少术後出血和抑制这些患者的纤维蛋白溶解。

(赵雪莲译 庄心良校)

Tranexamic acid reduces postoperative bleeding after coronary artery bypass grafting. We evaluated the effects of a single dose of tranexamic acid given immediately before cardiopulmonary bypass (CPB) in patients treated with aspirin until the day before surgery. The study was a prospective, randomized, double-blinded, placebo-controlled, parallel-group trial. Eighty patients were included and divided into two groups: one group received tranexamic acid 30 mg/kg, and one group received placebo (0.9% NaCl) as a bolus injection before CPB. Postoperative blood loss was recorded for 16 h. Transfusions of blood products were recorded for the whole hospital stay. Transfusions of packed red cells were given when the hematocrit value was less than 20% during CPB and less than 25% after surgery. The patients in the tranexamic acid group had significantly less postoperative bleeding compared with the patients in the placebo group (mean [SD]) (475 [274] mL versus 713 [243] mL; P < 0.001). An effective inhibition of fibrinolysis was found in patients receiving tranexamic acid. Tranexamic acid reduces postoperative bleeding in coronary artery bypass grafting patients treated with aspirin until the day before surgery.

 

血压测量间隔对血压变化滞后效应的影响:一项计算机模拟研究

The Effect of the Interval Between Blood Pressure Determinations on the Delay in the Detection of Changes: A Computer Simulation

R. Ross Kennedy, MB ChB, PhD, FANZCA, and Richard French, MB BS, FANZCA

Department of Anaesthesia, Christchurch Hospital, New Zealand

Anesth Analg 2003 96: 944-948.

 

在常规麻醉中自动无创测血压的频率是能够在对病人有害的频繁测压和可能使发现血压波动的时间滞后的长时间间隔测压之间寻找一种平衡。采用计算机模型,在一段时间稳定的血压后产生随机的血压变化。将血压的采样时间设定为从1分钟到10分钟不等模拟无创血压监测的情况。我们采用了根据Trigg’s跟踪变量的独立算法表示在血压发生波动和发现这种波动之间的时间间隔。对于每一种不同的变量(无创测压间期)都重复计算1000次,记录每次发现血压变化所需要的时间。当测压周期为1分钟时,发现血压变化所需的时间是8分钟;周期为2分钟时,发现时间是8.9分钟;周期为5分钟时,发现时间是10.8分钟;周期为10分钟时,发现时间为13.0分钟。发现时间随测压间隔延长而延长,但是延长的幅度大约为测压周期延长幅度的一半。当无创测压间期延长后用于发现变化趋势的算法的最佳变量也随着改变。结论:由于血压的变化是无法预期的,12分钟的无创测压间期与更长的测压间期相比并无优点。

                           (颜涛译 庄心良校)

The frequency of automated noninvasive blood pressure (NIBP) measurements during routine anesthesia is a balance between potentially deleterious effects of frequent cycling and a delay in detecting changes caused by a long cycle time. A computer model generated systolic blood pressures that changed to a new, random value after a period of stability. We sampled these data at intervals between 1 and 10 min to simulate NIBP measurements. A separate algorithm, based on Trigg’s Tracking Variable, indicated when a change had been detected. For each set of variables, the simulation was repeated 1000 times, and the average time to detect a change was recorded. The mean time to detect a change was 8.0 min with a 1-min cycle, 8.9 min with a 2-min cycle, 10.8 min with a 5-min cycle, and 13.0 min with a 10-min cycle. As the cycle time increased, the delay in detecting changes increased but only by approximately half the increase in the cycle time. The optimum variables for the trend detection algorithm also changed as the NIBP interval increased. Provided that abrupt changes in blood pressure are not anticipated, a 1- or 2-min cycle time for NIBP offers little advantage over a longer period.

 

家长对儿童再次手术时术前处理的选择

Parental Intervention Choices for Children Undergoing Repeated Surgeries

Zeev N. Kain, MD*,{ddagger}, Alison A. Caldwell-Andrews, PhD*, Shu-Ming Wang, MD*, Dawn M. Krivutza, MA*, Megan E. Weinberg, MA*, and Linda C. Mayes, MD{dagger},{ddagger}

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2003 96: 970-975.

 

目前尚未报道过健康儿童再次手术时家长对术前处理的选择。我们收集了83例患儿首次手术和再次手术的数据。首次手术的术前处理由医生决定,分为口服咪唑安定(n=13);麻醉诱导时家长在场(PPIAn=27);PPIA加口服咪唑安定(n=10)及无任何术前处理(n=33)四种方式。再次手术的术前处理则由家长选择。我们发现,无论首次采用何种方式,大于80%的家长在患儿再次手术时选择PPIA(加或不加口服咪唑安定)。首次采用PPIA者,70%再次采用。相反,首次口服咪唑安定者,只有23%再次采用咪唑安定,而首次未进行术前处理者,只有15%仍未采用任何处理。凡是首次手术中非常焦虑的患儿,家长均在再次手术时选择了术前处理(P=0.022)。无论患儿首次采用何种处理,再次手术时家长均倾向于PPIA。家长的选择受到患儿首次手术时的焦虑程度的影响。结论:无论患儿首次手术的术前处理是药物,家长在场,或未进行任何术前处理,再次手术时家长均倾向于麻醉诱导时家长在场。家长对儿童再次手术的术前处理的选择受到儿童首次手术时焦虑程度的影响。

 

                                              (轩   庄心良 校)

 

No studies have examined parental preference for a preoperative intervention in healthy children undergoing subsequent surgeries. We collected data prospectively from 83 children who previously underwent surgery and were part of an investigation by our study group, then returned for a subsequent surgery. At the initial surgery, children were assigned (no parental intervention) to receive oral midazolam (n = 13), or parental presence during the induction of anesthesia (PPIA, n = 27), or PPIA + midazolam (n = 10) or no intervention (n = 33). At a subsequent surgery, parents chose the preoperative intervention. We found that >80% of all parents chose PPIA (with or without midazolam) at the subsequent surgery regardless of the intervention they received previously. Of parents whose children received PPIA at the initial surgery, 70% chose PPIA again. In contrast, only 23% of the patients who received midazolam at the initial surgery requested midazolam at the subsequent surgery and only 15% of the patients who received no intervention at the initial surgery requested no intervention at the subsequent surgery. All parents of very anxious children at the initial surgery chose some intervention at the subsequent surgery (P = 0.022). Parents of children who underwent a subsequent surgery preferred PPIA regardless of any previous intervention. Also, parents’ intervention preferences at the subsequent surgery were influenced by children’s anxiety at the initial surgery.

 

RofecoxibCelecoxib和对乙酰氨基酚控制耳鼻喉门诊手术术後疼痛成本效益的对比研究

Costs and Effectiveness of Rofecoxib, Celecoxib, and Acetaminophen for Preventing Pain After Ambulatory Otolaryngologic Surgery

Mehernoor F. Watcha, MD*, Tijani Issioui, MD{dagger}, Kevin W. Klein, MD{dagger}, and Paul F. White, PhD MD FANZCA{dagger}

*Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, University of Pennsylvania; and {dagger}Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas

Anesth Analg 2003;96:987-994

作者设计随机双盲和用安慰剂做对照的实验,用其对比环加氧酶抑制剂rofecoxib celecoxib和对乙酰氨基酚对240位健康的耳鼻喉门诊手术患者的镇痛效果。实验分四组,组1:对照组, 500 mg 维他命C;组22 g对乙酰氨基酚 ;组3 celecoxib 200 mg;和组4rofecoxib 50 mg 。术前15–45 min 口服各药。然后术後第一天晨起服用相同剂量的药物。记录恢复时间,药物副作用,疼痛指数和其他镇痛药的使用。术後24-48小时;评估离院后疼痛,镇痛剂需要,恶心和患者对其术後疼痛控制可满意度及恢复质量。采用其他镇痛药的应用和最强疼痛值作为评估药物效能的主要指标。用成本-效益对比法计算完全满意疼痛治疗的成本。相对于安慰剂术前口服rofecoxib (50 mg) celecoxib (200 mg)能显著减轻术後疼痛评分和减少在术後观察室及出院后的镇痛剂用量。口服对乙酰氨基酚(2 g)在出院后镇痛效果有限。患者对三组药的镇痛效果满意度显著高于安慰剂。然而患者对rofecoxibcelecoxib满意度高于对乙酰氨基酚。术後Rofecoxib在减轻疼痛和改进患者满意度方面优于celecoxib。在达到使患者完全满意对疼痛的控制方面Rofecoxib celecoxib更经济。其中一例用rofecoxib患者无须其他方法既能满意控制疼痛。口服rofecoxib 50 mg 能比口服celecoxib 200 mg或对乙酰氨基酚2 g更经济-效益减轻术後疼痛和提升门诊患者对术後镇痛的满意度。结论:术前口服rofecoxib (50 mg)celecoxib (200 mg) 和对乙酰氨基酚 (2 g)能更有效减轻术後疼痛和改进恢复质量及提升耳鼻喉门诊手术患者对疼痛治疗的满意度。其成本只是稍微增加。

(赵雪莲译 庄心良校)

We designed this randomized, double-blinded, placebo-controlled study to compare the analgesic effect of the cyclooxygenase-2 inhibitors rofecoxib and celecoxib with acetaminophen when administered before outpatient otolaryngologic surgery in 240 healthy subjects. Patients were assigned to one of four study groups: Group 1, control (vitamin C 500 mg); Group 2, acetaminophen 2 g; Group 3, celecoxib 200 mg; or Group 4, rofecoxib 50 mg. The first oral dose of the study medication was administered 15–45 min before surgery, and a second dose of the same medication was given on the morning after surgery. Recovery times, side effects, pain scores, and the use of rescue analgesics were recorded. Follow-up evaluations were performed at 24 and 48 h after surgery to assess postdischarge pain, analgesic requirements, nausea, and patient satisfaction with their postoperative pain management and quality of recovery. The need for rescue analgesia and peak pain scores were used as the primary end points for estimating efficacy, and the costs to achieve complete satisfaction with analgesia were used for the cost-efficacy comparisons. Premedication with oral rofecoxib (50 mg) or celecoxib (200 mg) was more effective than placebo in reducing postoperative pain scores and analgesic requirements in the postoperative care unit and after discharge. The analgesic efficacy of oral acetaminophen (2 g) was limited to the postdischarge period. Patient satisfaction with pain management was improved in all three treatment groups compared with placebo but was higher with celecoxib and rofecoxib compared with acetaminophen. Rofecoxib was also more effective than celecoxib in reducing pain and improving patient satisfaction after otolaryngologic surgery. Rofecoxib achieved complete satisfaction with pain control in one additional patient, who would not have otherwise been satisfied, at lower incremental costs to the institution compared with celecoxib. We conclude that rofecoxib 50 mg orally is more cost-effective for reducing postoperative pain and improving patient satisfaction with their postoperative pain management than celecoxib (200 mg) or acetaminophen (2 g) in the ambulatory setting.


异氟醚拮抗双三氟乙醚或1,2二氯-6-己氟环丁烷损害动物对伤害条件反射和声音反射的学习功能的作用

Isoflurane Antagonizes the Capacity of Flurothyl or 1,2-Dichlorohexafluoro cyclobutane to Impair Fear Conditioning to Context and Tone

Edmond I Eger, II, MD*, Yilei Xing, MD*, Robert Pearce, MD{dagger}, Steven Shafer, MD{ddagger}, Michael J. Laster, DVM*, Yi Zhang, MD*, Michael S. Fanselow, PhD§, and James M. Sonner, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; {dagger}Department of Anesthesiology, University of Wisconsin, Madison, Wisconsin; {ddagger}Department of Anesthesiology, Stanford University, Stanford, California; and §Department of Psychology, University of California, Los Angeles, California

Anesth Analg 2003 96: 1010-1018.

 

传统吸入麻醉药异氟醚在使人出现遗忘的浓度水平可以损害动物对条件反射和声音反射的学习功能。吸入性非制动剂并不使动物对伤害性刺激的体动反应消失,也不减少传统吸入麻醉药的用量。和异氟醚一样,非制动剂1,2二氯6己氟环丁烷在低于麻醉用量的时候就会损害学习功能,而非制动剂双三氟乙醚对学习和记忆功能的影响还未被研究。两种非制动剂都可以引起惊厥。我们推测异氟醚、双三氟乙醚和1,2二氯6己氟环丁烷对损害学习和记忆有相同的机制,它们之间的作用呈现协同作用。我们发现异氟醚、双三氟乙醚和1,2二氯6己氟环丁烷都损害动物对条件反射和声音反射的学习功能,且非制动剂在不引起惊厥发生的剂量时就有这种作用。但是,异氟醚、 双三氟乙醚和1,2二氯6己氟环丁烷之间呈现拮抗作用而不是协同作用,这和我们的假说是相互矛盾的。双三氟乙醚的损害动物对条件反射和声音反射学习功能的作用不比1,2二氯6己氟环丁烷强。结论:传统的吸入麻醉药和非制动剂以不同的机制损害学习功能。它们损害学习功能的机制仍不十分清楚。

 

(王士雷    庄心良 校)

In animals, the conventional inhaled anesthetic, isoflurane, impairs learning fear to context and fear to tone, doing so at concentrations that produce amnesia in humans. Nonimmobilizers are inhaled compounds that do not produce immobility in response to noxious stimulation, nor do they decrease the requirement for conventional inhaled anesthetics. Like isoflurane, the nonimmobilizer 1,2-dichlorohexafluorocyclobutane (2N) impairs learning at concentrations less than those predicted from its lipophilicity to produce anesthesia. The capacity of the nonimmobilizer di-(2,2,2,-trifluoroethyl) ether (flurothyl) to affect learning and memory has not been studied. Both nonimmobilizers can cause convulsions. We hypothesized that if isoflurane, 2N, and flurothyl act by the same mechanism to impair learning and memory, their effects should be additive. We found that isoflurane, 2N, and flurothyl (each, alone) impaired learning fear to context and fear to tone in rats, with the nonimmobilizers doing so at concentrations less than those that cause convulsions. (Fear was defined by freezing [volitional immobility] in the presence of the conditioned stimulus [context or tone].) However, the combination of isoflurane and 2N or flurothyl produced an antagonistic rather than an additive effect on learning, a finding in conflict with our hypothesis. And flurothyl was no less potent than 2N (at least no less potent relative to the concentration of each that produced convulsions) in its capacity to impair learning. We conclude that conventional inhaled anesthetics and nonimmobilizers impair learning and memory by different mechanisms. The basis for this impairment remains unknown.

 

吸入考福新对狗疲劳膈肌收缩性的影响

The Effect of Inhaled Colforsin Daropate on Contractility of Fatigued Diaphragm in Dogs

Yoshitaka Fujii, MD, Aki Uemura, MD, and Hidenori Toyooka, MD

Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba City, Ibaraki, Japan

Anesth Analg 2003 96: 1032-1034

.

  我们研究了吸入性考福新—一种弗司扣林水溶性衍化物,对狗疲劳膈肌收缩性的影响。动物分三组,每组8例。每组频率20HZ,时间30MIN的超强电刺激诱发狗膈肌疲劳。在刺激程序结束后1组立即吸入对照溶剂,2组吸入考福新0.1mg/ml,3组吸入考福新0.2mg/ml。通过测定经膈压力(pdi)估计膈肌收缩性。膈肌疲劳产生后,每组低频(20HZ)刺激时,pdi与基础值相比下降(p<0.05),而在高频时(100Hz)则未改变。2组及3组在吸入考福新时,二种刺激时pdi与疲劳值相比增加(p<0.05,3组增加明显大于2组。每组膈肌整合电活动均无明显改变。结论:吸入考福新能以剂量依赖方式增加疲劳膈肌的收缩性。

                                     (王立中译   庄心良校)

We studied the effect of inhaled colforsin daropate, a water-soluble forskolin derivative, on the contractility of fatigued diaphragm in dogs. Animals were divided into 3 groups of 8. In each group, diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at a frequency of 20-Hz stimulation applied for 30 min. Immediately after the end of the fatigue-producing period, Group 1 received inhaled vehicle, Group 2 received inhaled colforsin daropate 0.1 mg/mL, and Group 3 received inhaled colforsin daropate 0.2 mg/mL. We assessed diaphragmatic contractility by transdiaphragmatic pressure (Pdi). After fatigue was produced, in each group, Pdi at low-frequency (20-Hz) stimulation decreased from baseline values (P < 0.05), and there was no change in Pdi at high-frequency (100-Hz) stimulation. In Groups 2 and 3, during colforsin daropate inhalation, Pdi at both stimuli increased from fatigued values (P < 0.05). The increase in Pdi was significantly larger in Group 3 than in Group 2. The integrated electrical activity of the diaphragm did not change in any group. We conclude that inhaled colforsin daropate causes an increase in contractility of fatigued canine diaphragm in a dose-related fashion.

 

雷米芬太尼对电惊厥疗法病人癫痫发作持续时间和急性血流动力学反应的影响

The Effect of Remifentanil on Seizure Duration and Acute Hemodynamic Responses to Electroconvulsive Therapy

Alejandro Recart, MD*, Shivani Rawal, MD*, Paul F. White, MD PhD, FANZCA*, Stephanie Byerly, MD*, and Larry Thornton, MD{dagger}

Departments of *Anesthesiology and Pain Management and {dagger}Psychiatry, University of Texas Southwestern Medical Center at Dallas, Texas

Anesth Analg 2003 96: 1047-1050.

 

本研究目的是观察雷米芬太尼对电惊厥疗法病人急性血流动力学反应和癫痫发作持续时间的影响。对20例有严重抑郁症的病人应用电惊厥疗法。病人术前用药为胃长宁0.2 mg IV ;使意识消失用药为甲己炔巴比妥1 mg/kg IV ;使肌肉松弛用药为司可林1.2 mg/kg IV 。随后,在4次连续电惊厥时病人应用雷米芬太尼25, 50, and 100 µg 或生理盐水(对照组)。在出现高血压时单次注射拉贝洛尔5-mg 。应用固定的阈上电刺激引出抽搐,记录从刺激到抽搐停止的时间以及痉挛脑电持续的时间。 100-µg雷米芬太尼组病人在电惊厥前后的血压均显著低于对照组。抽搐时间(38 ± 9 s to 43 ± 15 s) 和痉挛性脑电的持续时间(55 ± 29 s to 60 ± 21 s) 各组间无显著差异。睁眼、口头应答和出恢复室的时间各组之间也无差异。各雷米芬太尼组电惊厥疗法后拉贝洛尔的用量并不减少。结论:雷米芬太尼100 µg IV 减轻电惊厥疗法的急性血流动力学反应,对电惊厥疗法引起的抽搐持续时间无影响,而且不延长电惊厥疗法后的恢复时间,也不增加电惊厥疗法的副作用。

                                       (王士雷译 庄心良校)

We designed this prospective, randomized, double-blinded, placebo-controlled, crossover study to evaluate the effect of different doses of remifentanil on the acute hemodynamic response and duration of seizure activity after a standardized electroconvulsive therapy (ECT) stimulus. Twenty consenting patients with major depressive disorders receiving maintenance ECT participated in this study. Eighty ECT treatments were evaluated. All patients were premedicated with glycopyrrolate 0.2 mg IV, unconsciousness was induced with methohexital 1 mg/kg IV, and muscle paralysis was produced with succinylcholine 1.2 mg/kg IV. Subsequently, patients received 1 of 3 different doses of remifentanil 25, 50, and 100 µg or saline (control) in a random sequence immediately after methohexital at 4 consecutive ECT treatments. Labetalol, in 5-mg IV boluses, was used as a rescue antihypertensive medication. A fixed suprathreshold electrical stimulus was administered to elicit a seizure, and the times from the stimulus to the cessation of the motor and electroencephalographic (EEG) seizure activity were noted. Pre- and post-ECT blood pressure values were significantly decreased in the 100-µg remifentanil group compared with the control group. The durations of motor (38 ± 9 s to 43 ± 15 s) and EEG (55 ± 29 s to 60 ± 21 s) seizure activity were not significantly different among the four groups. Similarly, recovery times to eye opening, obeying commands, and discharge from the recovery room did not differ among the four study groups. The requirement for labetalol after ECT was nonsignificantly decreased in the remifentanil groups. In conclusion, remifentanil 100 µg IV attenuated the acute hemodynamic response to ECT. Furthermore, remifentanil had no adverse effect on the duration of ECT-induced seizure activity. Finally, adjunctive use of remifentanil did not prolong recovery times or increase post-ECT side effects.

 

鞘内注射5-羟色胺受体2A/2C激动剂{alpha}5羟色胺对两种大鼠持续疼痛模型的抗伤害作用

Antinociception with Intrathecal {alpha}-Methyl-5-Hydroxy tryptamine, a 5-Hydroxytryptamine2A/2C Receptor Agonist, in Two Rat Models of Sustained Pain

Masayuki Sasaki, MD, Hideaki Obata, MD, Shigeru Saito, MD, and Fumio Goto, MD

Department of Anesthesiology and Reanimatology, Gunma University School of Medicine, Maebashi, Japan

Anesth Analg 2003 96: 1072-1078.

 

脊髓内5-羟色胺受体(5-HT2)有抗伤害作用,但是有关这种受体的激动剂对持续性疼痛的作用了解甚少。我们对鞘内注射5-羟色胺受体2A/2C激动剂{alpha}5羟色胺对两种大鼠持续疼痛模型的抗伤害作用进行了研究。用福尔马林注射和坐骨神经压迫(CCI)法制备动物模型,药物经预先留置的鞘内导管进行注射。在福尔马林模型中,记录1-2分钟和5-6分钟(第一阶段)以及10-60分钟(第二阶段)内每间隔5分钟动物1分钟内退缩的情况;在CCI模中,记录后肢对热刺激的撤退潜伏期。结果,鞘内注射{alpha}5羟色胺(1 to 100 µg)能以剂量依赖性的方式抑制福尔马林模型大鼠的退缩,也以剂量依赖性的方式缩短CCI大鼠热刺激时的撤退反应潜伏期。这些作用被鞘内预先应用5-HT2A/2C  拮抗剂-酮色林(30 µg)所逆转。结论:脊髓5-HT2A/2C受体调节炎症疼痛和神经病理性疼痛的抗伤害作用。

(王士雷   庄心良 校)

Type 2 serotonin (5-hydroxytryptamine [5-HT]2) receptors in the spinal cord have been reported to mediate antinociception using pain threshold tests, but little is known about the actions of spinal 5-HT2 receptors in sustained pain. In rats, we examined antinociceptive effects of the intrathecal administration of a 5-HT2A/2C receptor agonist, {alpha}-methyl-5-HT maleate ({alpha}-m-5-HT), using the formalin test and the chronic constriction injury (CCI) model. An intrathecal catheter was implanted for injection of drugs. In the formalin test, flinches were counted from Minute 1 to 2 and Minute 5 to 6 (Phase 1) and then for 1-min periods at 5-min intervals from 10 to 60 min (Phase 2). In rats with CCI, hind paw withdrawal latency after thermal stimulation was measured. In the formalin test, intrathecal administration of {alpha}-m-5-HT (1 to 100 µg) dose-dependently suppressed the number of flinches in both Phases 1 and 2. In the CCI model, intrathecally administered {alpha}-m-5-HT (10 to 100 µg) attenuated thermal hyperalgesia in a dose-dependent manner. These effects were reversed by intrathecal pretreatment with a 5-HT2A/2C antagonist, ketanserin (30 µg), or a muscarinic receptor antagonist, atropine (30 µg). These findings suggest that spinal 5-HT2A/2C receptors mediate antinociception in inflammatory pain and neuropathic pain, and the muscarinic receptors contribute to this action.

 

连续肌间沟臂丛阻滞进行家庭术后镇痛:一项随机双盲对照研究

Continuous Interscalene Brachial Plexus Block for Postoperative Pain Control at Home: A Randomized, Double-Blinded, Placebo-Controlled Study

Brian M. Ilfeld, MD*, Timothy E. Morey, MD*, Thomas W. Wright, MD{dagger}, Larry K. Chidgey, MD{dagger}, and F. Kayser Enneking, MD*,{dagger}

Departments of *Anesthesiology and {dagger}Orthopedics and Rehabilitation, University of Florida College of Medicine, Gainesville, Florida

Anesth Analg 2003 96: 1089-1095.

 

我们研究了中度疼痛的门诊肩部矫形手术后病人自控区域阻滞镇痛术的镇痛效果。20例病人术前接受肌间沟臂丛阻滞和臂丛神经周置管术。术后进行家庭镇痛选用口服阿片类药物,同时使用便携式输注泵经导管输注0.2%罗哌卡因或0.9%盐水。每天评估疼痛评分阿片用量及其不良反应睡眠质量和技术并发症。数据用中位数和2575百分位数表示。结果:与生理盐水(n=10)相比,罗哌卡因(n=10)可显著缓解疼痛。术后第一天静息时的疼痛评分(范围:1-10):生理盐水组为4.8 (4.0–5.0)罗哌卡因组为0.0 (0.0–2.0 P < 0.001)罗哌卡因组的阿片用量及其不良反应也明显减少。术后第一天阿片用量:生理盐水组为8.0 (6.5–9.5) 罗哌卡因组为0.5 (0.0–1.0)(P < 0.001)术后第一夜睡眠障碍评分:生理盐水组比罗哌卡因组高约三倍(P = 0.013)。结论:中度疼痛的肩部矫形手术后,使用便携式输注泵,经肌间沟臂丛周置管输注罗哌卡因进行家庭镇痛,可以缓解疼痛,减少阿片用量及其不良反应,改善睡眠质量。

                                     (轩   庄心良 校)

 

In this study, we investigated the efficacy of patient-controlled regional analgesia for outpatients undergoing moderately painful orthopedic surgery of the shoulder. Preoperatively, patients (n = 20) received an interscalene nerve block and perineural catheter. Postoperatively, patients were discharged home with both oral opioids and a portable infusion pump delivering either 0.2% ropivacaine or 0.9% saline, determined randomly in a double-blinded manner. Daily end points included pain scores, opioid use and side effects, sleep quality, and technique complications. Ropivacaine (n = 10) infusion significantly reduced pain compared with saline (n = 10) infusion. The average pain at rest (scale: 0–10) on postoperative day 1 (median, 25th–75th percentiles) was 4.8 (4.0–5.0) for the saline group, versus 0.0 (0.0–2.0) for the ropivacaine group (P < 0.001). Oral opioid use and related side effects were also significantly decreased in the ropivacaine group. On postoperative day 1, median tablet consumption was 8.0 (6.5–9.5) and 0.5 (0.0–1.0) for the saline and ropivacaine groups, respectively (P < 0.001). Sleep disturbance scores were nearly threefold greater on the first postoperative night for patients receiving saline (P = 0.013). We conclude that after moderately painful orthopedic surgery of the shoulder, ropivacaine infusion using a portable infusion pump and an interscalene perineural catheter at home decreased pain, opioid use and related side effects, and sleep disturbances.

 

静脉注射羟乙基淀粉对有血脑屏障损害的病人脑脊液渗透的研究

Penetration of Intravenous Hydroxyethyl Starch into the Cerebrospinal Fluid in Patients with Impaired Blood-Brain Barrier Function

Hans-Jürgen Dieterich, MD*, Jörg Reutershan, MD*, Thomas W. Felbinger, MD{dagger},{ddagger}, and Holger K. Eltzschig, MD*,{ddagger}

*Department of Anesthesiology and Intensive Care Medicine, University of Tübingen; {dagger}Department of Anesthesiology, University of Munich Medical Center, Germany; and {ddagger}Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2003 96: 1150-1154

 

有血脑屏障损害的低血容量病人,常常静脉输注羟乙基淀粉以稳定心血管功能,提高脑的灌注压。但是,在这种条件下羟乙基淀粉是否透过血脑屏障还不十分明确。我们对8例脑外伤和蛛网膜下腔出血出现血脑屏障损害行蛛网膜下腔引流的病人,输注羟乙基淀粉,测量血浆和脑脊液中羟乙基淀粉的水平。通过计算机成像技术研究血脑屏障的损害情况。静脉输注500-1000ml羟乙基淀粉(HES 200,000/0.5)后测量血浆羟乙基淀粉的水平,并搜集8小时内的脑脊液,测量脑脊液中羟乙基淀粉的浓度。结果,病人血浆中羟乙基淀粉的水平为3.41 -9.95 mg/mL,而在脑脊液中不能检测到羟乙基淀粉。结论:静脉输注羟乙基淀粉(HES 200,000/0.5)并不渗透到有血脑屏障损害的脑外伤和蛛网膜下腔出血病人的脑脊液。

(王士雷   庄心良校)

Hypovolemic patients with impairment of the blood-brain barrier may receive IV hydroxyethyl starch (HES) to stabilize cardiovascular function and to increase cerebral perfusion pressure. It is not known whether HES can penetrate into the cerebrospinal fluid (CSF) under those conditions. We investigated plasma and CSF levels of HES after IV infusion in patients with suspected disturbance of the blood-brain barrier. Eight adult patients were studied who were being treated for head trauma or subarachnoid hemorrhage, with an external CSF drain in place. All patients exhibited radiographic signs of blood-brain barrier impairment diagnosed by cerebral computed tomography. After IV infusion of 500 to 1000 mL of HES 200,000/0.5, plasma HES levels were measured. Additionally, all CSF that was drained within 8 h after the HES infusion was collected, and HES concentrations were measured. All patients had detectable HES plasma concentrations (3.41 to 9.95 mg/mL). In contrast, no HES could be detected in the CSF of any patient. These data indicate that IV HES 200,000/0.5 does not penetrate into the CSF in patients with disturbed blood-brain barrier function after subarachnoid hemorrhage or head trauma. Further study is required to determine whether HES penetrates into the intracranial interstitium, despite the absence of HES in the CSF.

 

脊髓-硬膜外联合技术用于分娩镇痛时硬膜外试验剂量对运动功能的影响

The Effect of Epidural Test Dose on Motor Function After a Combined Spinal-Epidural Technique for Labor Analgesia

Arthur L. Calimaran, MD, Tina P. Strauss-Hoder, MS RN, Warren Y. Wang, MD, Robert J. McCarthy, PharmD, and Cynthia A. Wong, MD

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

Anesth Analg 2003 96: 1167-1172.

在分娩镇痛开始时鞘内注射布比卡因和芬太尼而不在硬膜外腔注射局麻药试验剂量可以提供有效的镇痛同时产妇可以下地活动。在本研究中,我们探索了在CSE技术首剂鞘内注射布比卡因2.5mg和芬太尼25ug后即刻硬膜外给予利多卡因—肾上腺素试验剂量对产妇血流动力学稳定性、后柱功能、运动力量和行走的主观能力的影响。153位产妇随机地在硬膜外注射3ml生理盐水或者含1200000肾上腺素的1.5%利多卡因。对完成试验的110位产妇的血流动力学指标、本体感觉、直腿抬高试验和改良Bromage评分进行了分析,两组间没有差异。但是利多卡因试验剂量组在注射后30分钟震动觉、完成深屈膝和攀阶梯实验的能力以及对行走的主观愿望受损者更多(P<0.05)。在60分钟时两组无差异但是利多卡因试验剂量组能完成攀阶梯实验的产妇更少。抗阻力直腿抬高实验和改良Bromage评分的结果与其它运动力量实验的结果相关性不强(Spearmans {rho}, 0.273—0.405)。结论:为了达到可行走分娩镇痛的目的,应该避免在CSE镇痛开始后即刻使用试验剂量。

                            (颜 涛译, 庄心良校)

Labor analgesia initiated with intrathecal bupivacaine and fentanyl, without a local anesthetic epidural test dose, provides effective analgesia and allows ambulation. In this study, we sought to determine the effect of a lidocaine-epinephrine test dose administered immediately after the initiation of combined spinal-epidural (CSE) analgesia with bupivacaine 2.5 mg and fentanyl 25 µg on parturients’ hemodynamic stability, posterior column function, motor strength, and subjective ability to walk. Parturients (n = 153) were randomized to receive either 3 mL of epidural saline or lidocaine 1.5% with epinephrine 1:200,000. Hemodynamic variables, proprioception, straight leg raise, and the modified Bromage score were analyzed in 110 parturients who completed the study protocol and were not different between groups. Vibratory sense, the ability to perform a partial deep knee bend and to step up on a stool, and the subjective ability to walk were impaired in a larger number of parturients in the lidocaine-epinephrine group at 30 min (P < 0.05). At 60 min, there were no differences between the groups except that fewer parturients in the lidocaine-epinephrine group could step up on a stool. The straight leg raise against resistance and the modified Bromage scale did not correlate well with other tests of motor strength (Spearman’s {rho}, 0.273—0.405). These data suggest that the test dose should be avoided immediately after initiation of CSE analgesia when early ambulation is desired.

 

应用声音辅助装置确定硬膜外腔穿刺位置的临床研究

Clinical Results with the Acoustic Puncture Assist Device, a New Acoustic Device to Identify the Epidural Space

Timo J. Lechner, MD*, Maarten G. van Wijk, MD*, Ad J. Maas, PhD{dagger}, Frank R. van Dorsten, MD*, Ronald A. Drost, MD*, Chris J. Langenberg, MD*, Leo J. Teunissen, MD*, Paul H. Cornelissen, MD*, and Jan van Niekerk, PhD*

Departments of *Anesthesiology and Pain Therapy and {dagger}Clinical Physics, Jeroen Bosch Ziekenhuis, ‘s-Hertogenbosch, The Netherlands

Anesth Analg 2003 96: 1183-1187.

 

本文评价了60例病人通过声音信号判断腰段硬膜外穿刺的成功率。一种声音辅助装置通过延长管和硬膜外穿刺针连接,可以在穿刺针穿透黄韧带的过程中将压力变化转化为声音和视觉信号。这个装置使麻醉医生不必双手握持穿刺针,而通过这些信号判断是否进入了硬膜外腔。所有病人均通过声音信号成功进行了定位。同时对所有的病例也都进行了为大家公认的压力测量。结果显示,应用声音辅助装置判断硬膜外穿刺具有容易控制穿刺针深度 、容易控制置管、 方便教学等优点,是硬膜外穿刺时非常好的辅助手段。

(王士雷   庄心良校)

Sixty patients scheduled for lumbar epidural anesthesia were included in a study in which we evaluated the efficacy of localizing the epidural space by means of an acoustic signal. A prototype of an acoustic puncture assist device, connected to the epidural needle by an extension tube, generated the pressure needed to perform the epidural puncture and translated this pressure into corresponding acoustic and visible signals. The device frees the anesthesiologist to handle the epidural needle with both hands and to detect the epidural space by means of these signals. In all 60 patients (100%), the epidural space was successfully located by using the acoustic signal. In all cases, this was confirmed by the pressure measurement, which proved to be a reliable indicator for correct identification of the epidural space. We conclude that it is possible to locate the epidural space by means of the acoustic puncture assist device. The method proved to be reliable, safe, and simple in this study. The benefits of this new epidural puncture technique include better needle control, teaching, control of correct catheter placement, and documentation. The last can be an important adjunct to anesthesia practice.

 

仅经过模拟人训练的缺乏经验的护士应用PAxpressTM 和面罩/ Guedel Airway 通气的比较性研究

A Comparison of the PAxpressTM and Face Mask Plus Guedel Airway by Inexperienced Personnel After Mannequin-Only Training

V. Dimitriou, MD DEAA*, G. S. Voyagis, MD{dagger}, C. Iatrou, MD*, and J. Brimacombe, MB ChB, FRCA, MD{ddagger}

*Department of Anaesthesia, University of Thrace; {dagger}Department of Anaesthesia, Sotiria Hospital, Greece; and {ddagger}Department of Anaesthesia and Intensive Care, University of Queensland and James Cook University, Cairns Base Hospital, Australia

Anesth Analg 2003 96: 1214-1217.

 

PAxpressTM (PAX)是一种新的声门外通气装置,包含一个解剖形的弯管,中段有一个可充气的圆形气囊,远端包含一个不可充气的锥形套囊,两者之间是一个直角形的通气口。我们比较了仅经过模拟人训练的缺乏经验的护士应用PAX 和面罩/ Guedel airway(FM/GA)的通气情况。45 ASA I - II级麻醉且肌松后的病人,由仅通过模拟人训练的缺乏经验的护士应用PAxpressTM 和面罩/ Guedel Airway 通气。首先用FM/GA 通气,然后改用PAX 通气。开始要求病人通气的基本潮气量是7 mL/kg,随后要求进行最大潮气量通气。结果,两种装置均能达到预期的潮气量,时间相同(PAX, 41 ± 15 s; FM/GA, 39 ± 25 s),成功插入的尝试次数也一样。PAX组最大潮气量(1261 ± 306 versus 958 ± 220 mL; P < 0.0001)和最大气道压 (37 ± 5 versus 28 ± 6 cm H2O; P < 0.0001) 较大,需要进行频繁的血气检测(22% versus 0%; P = 0.001)。结论:仅通过模拟人训练的缺乏经验的护士应用PAxpressTM 和面罩/ Guedel Airway均能成功地为麻醉且肌松的病人提供基本潮气量的通气,但是,PAX的最大通气量和气道压更大,气道损伤更常见。

(王士雷    庄心良 校)

The PAxpressTM (PAX) is a new extraglottic airway device consisting of an anatomically curved tube, an inflatable circular cuff in the midsection, a noninflatable gilled conical cuff at the distal end, and an anterior-facing, rectangular hooded vent between the two cuffs. We compared the ability of nurses with no previous airway management experience to ventilate the lungs of 45 ASA physical status I and II anesthetized, paralyzed patients using either the PAX or face mask and Guedel airway (FM/GA) after mannequin-only training. Nurses were asked to ventilate the patient to an expired target tidal volume of 7 mL/kg and then to the maximum tidal volume achievable. The FM/GA was used first and the then the PAX. The target tidal volume was achieved in all patients with both devices. There were no differences in the time taken (PAX, 41 ± 15 s; FM/GA, 39 ± 25 s) or the number of insertion attempts to achieve the target tidal volume. There were no differences in the frequency of esophageal leaks at the target (PAX, 9%; FM/GA, 4%) and maximum tidal volume (PAX, 51%; FM/GA, 49%). The maximal tidal volume (1261 ± 306 versus 958 ± 220 mL; P < 0.0001) and peak airway pressure (37 ± 5 versus 28 ± 6 cm H2O; P < 0.0001) was larger for the PAX, but blood was detected more frequently (22% versus 0%; P = 0.001). We conclude that ventilation to a target tidal volume of 7 mL/kg in anesthetized, paralyzed adults is equally successful for the PAX and FM/GA by inexperienced nurses after mannequin-only training. However, the maximal tidal volume and peak airway pressure is larger and airway trauma more common with the PAX.