Anesthesia & Analgesia

April 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

單劑量氨甲環酸可減少術前用阿司匹林的患者冠脈搭橋術後出血

(趙雪蓮譯 莊心良校)

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.

止血和血液稀釋:臨床實踐的定量分析指南

(張俊峰譯  薛張綱 )

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.

在急性等容血液稀釋的志願者中羥乙基澱粉(HES130/0.4HES 70/0.5 HES 200/0.5更大更快的提高組織氧張力

(忻紀華 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.

 

血壓測量間隔對血壓變化滯後效應的影響:一項電腦類比研究

(顏濤譯 莊心良校)

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.

 

七氟醚暴露產生超氧化物,但在離體心臟缺血再灌注中則降低超氧化物的產生

(張俊峰譯  薛張綱 )

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:

選擇性嬰兒手術術前放寬禁食原則並不增加平均胃液容量

(忻紀華 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.

家長對兒童再次手術時術前處理的選擇

(   莊心良 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.

可樂定有利於青少年患者的控制性降壓

(張俊峰譯  薛張綱 )

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:

肩胛上神經阻滯可延長非關節鏡肩部手術術後鎮痛效果但並不改善愈後

 (   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和對乙酰氨基酚控制耳鼻喉門診手術術後疼痛成本效益的對比研究

(趙雪蓮譯 莊心良校)

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:

異氟醚在脊髓上間接抑制了電刺激網狀結構伴隨的皮層活動

(潘志浩譯  薛張綱 )

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.

數周全身麻醉對年青鼠和老齡鼠記憶的影響

(   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.

異氟醚拮抗雙三氟乙醚或1,2二氯-6-己氟環丁烷損害動物對傷害條件反射和聲音反射的學習功能的作用

(王士雷    莊心良 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斷神經元和骨骼肌上電壓控制的鈉通道

(潘志浩譯  薛張綱 )

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受體部分介導氟烷抑制脊髓後角感覺神經元

(殷文淵 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.

吸入考福新對狗疲勞膈肌收縮性的影響

(王立中譯   莊心良校)

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.

異丙酚和乙咪酯在慢性缺氧大鼠對氣道收縮的效應

(潘志浩譯  薛張綱 )

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.

不同劑量麻黃素對維庫溴銨起效時間的影響

 (殷文淵 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.

雷米芬太尼對電驚厥療法病人癲癇發作持續時間和急性血流動力學反應的影響 (王士雷譯 莊心良校)

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:

吸入麻醉時不同新鮮氣流量的條件下使用了麻醉藥節約裝置的回路和普通回路之比較

(   薛張綱 )

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:

硝苯地平增強鼠水管周圍灰質微量注射Endomorph-1的鎮痛效果

(殷文淵 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.

鞘內注射5-羥色胺受體2A/2C激動劑{alpha}5羥色胺對兩種大鼠持續疼痛模型的抗傷害作用

(王士雷   莊心良 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.

對於硬膜外給芬太尼的患者術前靜脈使用小劑量的芬太尼可以預測鎮痛效果和副作用的發生率

(   薛張綱 )

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.

鞘內使用可樂定加布比卡因-嗎啡脊髓內麻醉劑可改善全膝關節整形手術後的疼痛

( 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.

連續肌間溝臂叢阻滯進行家庭術後鎮痛:一項隨機雙盲對照研究

(   莊心良 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在痛覺產生方面的作用

(   薛張綱 )

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:

假單胞菌屬銅綠菌敗血症綿羊使用去甲腎上腺素或氧化一氮合酶抑制劑不會引起腦血流的變化

( 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和尼卡地平對兔子大腦微循環影響的比較

(顧悅超   薛張綱 )

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.

急診神經外科患者麻醉期間艾司洛爾可減少顱內血流速率的增加

 (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.

靜脈注射羥乙基澱粉對有血腦屏障損害的病人腦脊液滲透的研究

(王士雷   莊心良校)

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對皮層體感誘發電位的保護作用

(顧悅超   薛張綱 )

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:

分娩麻醉時硬膜外應用新斯的明、羅呱卡因和舒芬太尼合劑對軸索的鎮痛效應

(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-硬膜外聯合技術用於分娩鎮痛時硬膜外試驗劑量對運動功能的影響

( 濤譯, 莊心良校)

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.

分娩時病人自控硬膜外鎮痛0.15%羅比卡因合用0.5ug/ml蘇芬太尼與0.10%羅比卡因合用0.5ug/ml蘇芬太尼是等效的

(顧悅超   薛張綱 )

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.

分娩第一產程芬太尼和舒芬太尼麻醉的最小鎮痛劑量

(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:

應用聲音輔助裝置確定硬膜外腔穿刺位置的臨床研究

(王士雷   莊心良校)

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:

一項前瞻性隨機研究:碳酸氫納或THAM液治療術中高氯性酸中毒

(顧悅超   薛張綱 )

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.

控制性低溫對兔止血功能的影響

(忻紀華 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.

僅經過類比人訓練的缺乏經驗的護士應用PAxpressTM 和面罩/ Guedel Airway 通氣的比較性研究

(王士雷    莊心良 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.

在急性等容血液稀釋的志願者中羥乙基澱粉(HES130/0.4HES 70/0.5 HES 200/0.5更大更快的提高組織氧張力

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


羥乙基澱粉(HES)行血液稀釋可獲得穩定的血流動力學和改善血液流變學,提高組織的氧張力(tpO2)。在本研究採用前瞻性,隨機性,雙盲,交叉實驗方法,觀察HES130/0.4和傳統HES溶液行急性等容血液稀釋對人體血流動力學和骨骼肌tpO2影響。每組志願者12人。在大於8天的間隔中,經計算志願者在30分鐘內捐出全身血液的18%,並按11.2的血液丟失隨機輸入6%HES 130/0.46%HES 70/0.5,或6%HES 200/0.5(交叉執行)。HES補液後6小時,測定血流動力學指標,四頭肌的tpO2,血球壓積,血漿HES濃度,血漿粘度,膠體滲透壓和血小板聚集能力。各組中血流動力學變化,血球壓積和血小板聚集功能無差異。HES200組的膠體滲透壓和血漿粘度較HES 70組高(p<0.05)。HES130組和HES70HES200組相比,擴容更快(血液稀釋後30min90min150min , P<0.05);tpO2基值相比上升更明顯(+93%+33%40%P,0.05)。在健康志願者中行急性等容血液稀釋顯示HES130/0.4HES70/0.5HES200/0.5預稀釋相比,更早更多的提高骨骼肌的tpO2

(忻紀華 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.

 

選擇性嬰兒手術術前放寬禁食原則並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


推薦嬰兒術前禁食時間在4-8小時。97ASA I-II準備行擇期嬰兒手術,行前瞻性的隨機雙盲試驗,以確定禁食4小時(放寬禁食組,L組)和術前8小時禁食固體,2小時禁食清潔流質(傳統禁食組,T組)的胃液容量(GFV)是否不同。L組中39人中31人按協議餵養至術前4-6小時。T58人中36人按照要求餵養清潔流質至麻醉誘導前2-5小時。30人禁食時間延長,採用二次分析。兩組的年齡(5.7+/-2.3vs6.4+/-2.4mo;範圍,0.7-10.5),體重(7.5+/-1.8vs7.5+/-1.1kg),最後餵食容量(4.9+/-2.2vs4.0+/-2.3oz)無差異。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)無差異。所有病例,GFVml/kg)隨年齡而增加(Spearman相關係數=+0.23p=0.03)。兩組嬰兒的興奮性,饑餓和父母的滿意度相似。結果表明規則餵養的嬰兒禁食4-6小時或術前2小時起停喂清潔流質的嬰兒GFV無顯著差異。基於這些發現,對準備選擇性手術,規則餵養的嬰兒術前禁食可放寬至4小時。

(忻紀華 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.

 

肩胛上神經阻滯可延長非關節鏡肩部手術術後鎮痛效果但並不改善愈後

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


肩胛上神經阻滯(SSNB)在全身麻醉時可以延長非關節鏡肩部手術術後鎮痛效果並改善24小時後的愈後情況。對門診非關節鏡肩部手術的病人中施行肩胛上神經阻滯作為臂叢神經阻滯(ISB)的輔助。50名病人隨機進行SSNB或安慰注射作為臂叢神經阻滯的輔助。在SSNB組術後首次明顯疼痛出現時間顯著延遲(594±369375±273分鐘,P=0.02)。2組病人麻醉後其他恢復情況,24小時疼痛評價,鎮痛藥追加情況及術後恢復情況並無差異。所以,我們可以得出結論,在非關節鏡肩部手術使用ISB時加用SSNB並無特別療效。

(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.

 

數周全身麻醉對年青鼠和老齡鼠記憶的影響

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術後會存在認知損害。我們假設這一認知損害是由於全身麻醉而引起的。共計有3446月或18月齡鼠,進行12道曲折的迷宮訓練,然後隨機分組接受1.2%異氟醚/70%笑氣/30%氧氣或30%氧氣通氣。所有鼠在恢復24小時後8周內每天進行迷宮試驗。作為對照的年青鼠均能順利通過迷宮試驗。老齡對照組鼠也能準確通過迷宮但所花費時間較多。麻醉組中,年青鼠通過迷宮的情況並無明顯改變,1周和3周後與老齡鼠有明顯差異(P<0.05),老齡麻醉鼠並不能順利通過反復的迷宮試驗,並且通過迷宮所花費的時間也較長(1周和3周時P0.05)。這一實驗證明,使用異氟醚和笑氣進行麻醉並不影響年青鼠的空間記憶能力,而老齡鼠在同樣的麻醉下空間記憶能力有所影響。因此,使用異氟醚和笑氣進行麻醉可以影響老齡鼠的空間記憶能力。

(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受體部分介導氟烷抑制脊髓後角感覺神經元

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


我們近期報導了A-型γ-氨基丁酸和士的寧(strychnine)敏感氨基乙酸受體系統部分介導氟烷抑制脊髓後角低閾值神經元。5-羥色胺亞型35-HT3)受體如同A-型γ-氨基丁酸和士的寧(strychnine)敏感氨基乙酸受體一樣同屬於配子啟動離子通道家族,所以觀察5-羥色胺受體在氟烷抑制脊髓後角感覺神經元中可能所起的作用。脊髓低閾值神經元的細胞外記錄值來自去大腦脊髓橫斷的老鼠。在存在或缺少1.1%氟烷以及存在或缺少5-HT抗體的情況下記錄和刷擦導致的活動。在有氟烷,二甲基麥角新堿(methysergide)— 一種非選擇性5-HT拮抗劑和(tropisetron)— 一種選擇性5-HT3拮抗劑時,顯著逆轉了氟烷引起的可接受的域值範圍的降低,但沒有改變氟烷抑制刷擦導致的活動的效應。(Methiothepin)— 一種5-HT1拮抗劑和(ketanserin)— 一種5-HT2拮抗劑沒有逆轉氟烷的抑制效應。這些結果支持了我們的假設,即5-HT3受體在氟烷對脊髓後角感覺神經元的抑制效應中起部分作用。

    殷文淵 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.

 

不同劑量麻黃素對維庫溴銨起效時間的影響

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


小劑量麻黃素減少羅庫溴銨和順式阿庫溴銨的起效時間,可是,麻黃素會產生不利的血流動力學影響。合適的麻黃素劑量並不確定。120名病人使用芬太尼2 µg /kg和丙泊酚2 -2.5 mg/kg進行麻醉,隨機給於麻黃素(3070110 µg /kg)或生理鹽水。在丙泊酚麻醉期間,通過肌電圖監測肌肉神經阻滯,使用的方法是閾下電流每十秒四個成串刺激。在胸骨上切跡處放置多普勒超聲探頭來測定心輸出量。在注射維庫溴銨兩分鐘後由非調查者施行插管。在麻醉誘導期間測量神經肌肉阻滯,插管條件,和血流動力學影響。70110µg /kg麻黃素在使用維庫溴銨兩分鐘後都可改善插管條件;但110µg /kg麻黃素會產生不利的血流動力學影響。結果表明在麻醉誘導前給與70µg/kg麻黃素,注射維庫溴銨兩分鐘後插管,可改善插管條件,大概是提高了心輸出量而沒有顯著不利血流動力學影響的結果。

                                               ( 殷文淵 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.

 

硝苯地平增強鼠水管周圍灰質微量注射Endomorph-1的鎮痛效果

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是一種新型的內源性µ-阿片樣配體。在老鼠中腦腹外側水管周圍灰質(vPAG)微量注射Endomorphin-1L-型鈣離子阻滯劑--硝苯地平 ,觀察兩者之間鎮痛效果的相互作用,使用脊髓傳導的尾部搖擺試驗和脊髓上傳導的尾部壓力試驗。Sprague-Dawley鼠在立體定位下將導管植入vPAG中。在尾部搖擺試驗和尾部壓力試驗中,在vPAG中微量注射Endomorphin-1會劑量依賴性地提高鎮痛效應。預注射µ-阿片樣受體選擇性阻滯劑β-funaltrexamine阻滯了Endomorphin-1的鎮痛效應。單獨預注射β-funaltrexamine對尾部搖擺反應時間和尾部壓力閾值沒有影響。在尾部搖擺試驗和尾部壓力試驗中,在vPAG中微量注射硝苯地平不產生鎮痛效應。可是,在vPAG中注射硝苯地平增強Endomorphin-1的鎮痛作用,使尾部搖擺試驗和尾部壓力試驗的Endomorphin-1劑量反應曲線顯著左移。這個結果說明在vPAG中微量注射布Endomorphin-1產生有力的鎮痛效果是通過阿片樣受體所介導的,且伴隨硝苯地平的使用而增強。

(殷文淵 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.

 

鞘內使用可樂定加布比卡因-嗎啡脊髓內麻醉劑可改善全膝關節整形手術後的疼痛

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


全膝關節整形術後的疼痛相當嚴重並影響早期的物理治療。我們假設鞘內使用可樂定及高比重布比卡因可改善全膝關節整形術後的疼痛並加以驗證。採用雙盲及安慰劑對照的實驗方法, 81名進行單側或雙側全膝關節整形術ASA-Ⅲ級的患者隨機分成4組分別注射2ml溶液及高比重布比卡因15mg1)消毒的生理鹽水,2)嗎啡250μg3)嗎啡250μg及可樂定25μg4)嗎啡250μg及可樂定75μg。然後在術後124612,及24小時評估視覺類比評分(VAS),累積靜脈嗎啡使用量,血流動力學,噁心,輔助用藥,及副作用。對嗎啡加可樂定組與使用嗎啡組進行比較,表明聯合使用可樂定和嗎啡組的患者24小時內靜脈使用嗎啡量比單純鞘內使用嗎啡組的患者少13mg(P=0.028),同時降低術後24小時的VAS評分1.3cmP=0.047)。除了使用可樂定組患者術後6小時可能會發生低血壓外其副作用與其他組基本相近。由此,我們得出結論鞘內聯合使用嗎啡和可樂定與鞘內單獨使用嗎啡相比,前者可降低術後24小時靜脈嗎啡量及VAS評分。

( 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.

 

假單胞菌屬銅綠菌敗血症綿羊使用去甲腎上腺素或氧化一氮合酶抑制劑不會引起腦血流的變化

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
敗血症的患者大腦功能障礙的起因至今還不清楚,但大腦灌注的變化可能在發病機制上起著很重要的作用。20只綿羊體內持續地注入活的假單胞菌屬銅綠菌從而建立一個慢性敗血症綿羊模型,然後評估這些綿羊的大腦灌注。在發生敗血症24小時之後,這些發生低血壓的綿羊(平均動脈壓降低16%P0.05〉被分別注入氧化一氮合酶抑制劑(L-NMMA7mg·kg-1·h-1;n=7 ,去甲腎上腺素(NEn=7),或生理鹽水(對照;n=6)。使用去甲腎上腺素的一組升高平均動脈壓的值與使用L-NMMA的一組相等,然後通過彩色微球體測量局部的灌注。儘管L-NMMA使全身周圍血管阻力指數顯著增高(1167±104793±59dyne·cm-5·m2;P<0.05),但它既不引起腦血管阻力的變化也不引起腦血流的變化。當全身周圍血流發生變化時,大腦血流的再分佈是顯而易見的。去甲腎上腺素引起動脈血壓增高(98±583±5P0.05〉,同時伴有心輸出量增加(7.8±0.56.7±0.6P0.05〉,由此引起全身周圍灌注的增加。然而,大腦的血流沒有受影響。雖然去甲腎上腺素和L-NMMA對血管的收縮作用是有害的,包括引起大腦低灌注,目前還有爭議,但在試驗中這兩種藥物都對腦灌注沒有影響。

( 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.

 

急診神經外科患者麻醉期間艾司洛爾可減少顱內血流速率的增加

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


神經外科患者實施急診麻醉時會出現顱內充血,但其產生機制尚不清楚。我們假設這是由於交感神經興奮所引起,並通過試驗證實這一推論。30名神經外科患者被隨機分為兩組,分別應用艾司洛爾(短效β受體阻滯劑)和安慰劑。拔管後15分鐘靜脈輸注艾司洛爾(0.3 mg .kg-1 .min-1) 在麻醉前、手術中、拔管及拔管後5-60分鐘分別記錄腦血流速率(CBFV),平均動脈血壓和心率。拔管後60分鐘經食管多譜樂測量心排出量(COe)。應用艾司洛爾組的CBFVCoe和心率都明顯下降,而兩組的平均動脈壓則無明顯區別。在試驗中CBFVCoe無相關性。綜上所述,對於急診病例艾司洛爾可以減弱CBFV的增加,由此也可證實神經外科患者恢復期的腦充血是由於交感神經興奮所引起。

   (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.

 

分娩麻醉時硬膜外應用新斯的明、羅呱卡因和舒芬太尼合劑對軸索的鎮痛效應

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


脊椎麻醉時應用新斯的明可避免產生呼吸抑制或低血壓,但可產生嚴重的胃腸道反應。硬膜外腔注入新斯的明後可有效避免產生偏側效應。本次實驗主要評定分娩早期持續大劑量麻醉時硬膜外新斯的明的效應,及其在隨後的局部麻醉時的殘留效應。在麻醉開始階段硬膜外注入新斯的明methylsulfate(最大劑量為4 µg/kg)和0.1%ropivacaine10 mL,可加入或不加入10 µg舒芬太尼,20分鐘後測定感覺平面和運動阻滯情況,並記錄直至追加劑量。0.1% ropivacaine通常作為追加劑。母親及胎兒的反應也被記錄下來。新斯的明(4 µg/kg)加入ropivacaine 10mg20mg效果相當,但卻不及加入10 µg舒芬太尼,此外新斯的明也不會影響隨後的局麻要求。它不會引起血流動力學的不穩定,也不會產生額外的運動阻滯和偏側效應。

                                                       (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.

 

分娩第一產程芬太尼和舒芬太尼麻醉的最小鎮痛劑量

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


觀察分娩者在單一硬膜外麻醉時輔用芬太尼及舒芬太尼的最小劑量及其相關影響。將自然分娩和要求硬膜外麻醉的初產婦隨機分為兩組每人均給以0.9% wt/vol芬太尼或舒芬太尼10ml,首劑為芬太尼125µg,舒芬太尼25µg,維持劑量根據孕婦反應給予(實驗誤差:芬太尼5µg、舒芬太尼1µg),芬太尼與舒芬太尼的最小麻醉劑量或者是平均起效劑量分別為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)。舒芬太尼與芬太尼的效價比為5.9 (95% CI, 5.6–6.3)。綜上所述,在分娩第一產程應用硬膜外麻醉時芬太尼和舒芬太尼的使用劑量及相關效應是相同的。   

  (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.

 

控制性低溫對兔止血功能的影響

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


在低溫病人中,即使止血功能看似正常仍可見出血傾向。凝血和血小板功能試驗通常在37時進行。應用Sonoclot Analyzer®(Sonoclot®)Thromboelastography®(TEG®)研究溫度調節對止血功能的影響。在15只雄性新西蘭白兔中以靜脈注射氯胺酮和芬太尼誘導和維持麻醉。應用水毯使溫度降至30和複溫至37。在四個時間取血樣本:低溫前,34℃時,30℃時,複溫後。標準凝血試驗在37℃時進行(C方法),同時進行實際溫度時的凝血試驗(R方法)。在Sonoclot®,活化凝血時間和到達高峰時間以及血塊凝集率與C方法相比在30℃明顯降低。在TEG®,反應時間和血塊形成時間和血塊形成率在30℃時明顯較37℃是延長。低溫使凝血串聯反應時間延長和血小板功能降低。在低溫期間,需在實際溫度下測量止血能力,以避免基於37℃的標準值而過高的評價止血能力。

(忻紀華 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.

 

止血和血液稀釋:臨床實踐的定量分析指南

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

 

血液稀釋中止血功能的定量改變目前仍不清楚。由於只能提供載氧功能的血液代用品的廣泛應用使得該問題變得更為複雜。我們建立了一個數學模型來定量分析血液稀釋中的止血功能並且使其適用於再計算的病人資料。我們計算並比較最大容許失血量(MABL與最低容許血細胞壓積Hct相關)、血小板濃度及血漿纖維蛋白原濃度。MABL是在沒有任何額外血液製品的情況下機體可耐受的最大失血量。最小的MABL則限制血液稀釋。血液稀釋包括應用膠體等容替代失血或急性等容血液稀釋(ANH)隨之應用膠體和ABS替代失血。我們也把結果與病人術前的資料相聯繫(n = 204)。血小板濃度的降低很少(<2% 的所有病人)限制血液稀釋。與之相比,如果病人的初始血漿纖維蛋白原濃度在正常的低限(<300 mg/dL)則血漿臨界纖維蛋白濃度(<=100 mg/dL)往往限制血液稀釋(<=20%的所有病人)。如果ANH聯合應用ABS則這些結果更為常見,在這種情況下ANH血液製品只單獨用於穩定止血功能,由此則未達到聯合應用ANHABS的既定目的。結論:血液稀釋中止血功能的定量改變原因及其臨床效果目前還不清楚,我們應用一個已驗證的數學模型證實止血功能尤其是血漿纖維蛋白原濃度會限制血液稀釋的程度。這種現象在ANH聯合應用人造血液代用品(ABS)時尤為顯著。

(張俊峰譯  薛張綱 )

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.

 

七氟醚暴露產生超氧化物,但在離體心臟缺血再灌注中則降低超氧化物的產生

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

反應性氧簇(ROS)是造成心臟缺血再灌注後損傷的主要原因,但是有證據顯示麻醉藥通過產生(ROS)誘導缺血預適應(APC)。我們事先假設七氟醚產生ROS (超氧化物O2·-),缺血中APC削弱O2·- 的形成,並且這種削弱作用可被O2·-的清除劑(MnTBAP)或已被公認的線粒體ATP敏感鉀通道阻製劑(mKATP) (5-HD)逆轉。應用DHE持續檢測豚鼠心臟的 O2·-。分別在缺血前30 min和再灌注後120 min單獨使用七氟醚(APC)、聯合使用MnTBAP5-HD。控制組心臟則不作任何預治療。七氟醚直接增加O2·-,這種作用可被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組被削弱,這種作用可被MnTBAP5-HD阻制。 我們認為七氟醚直接誘導O2·- 形成但是O2·- 形成在隨後缺血和再灌注中降低。前一作用好像與mKATP 獨立相關,而後一作用則無關。我們的研究表明APC ROS啟動反過來引起mKATP 通道開放。儘管ROS在激發和調節APC中的作用看似矛盾,但卻提供了一種可能機制。結論: ROS可啟動APC。持續檢測豚鼠離體心臟的ROS (O2·-) 七氟醚直接增加O2·- 但在缺血中削弱O2·- 的形成,該研究顯示APCROS啟動並且明確了缺血中的心臟保護機制。

     (張俊峰譯  薛張綱 )

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.

 

可樂定有利於青少年患者的控制性降壓

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

 

在此隨機、雙盲、安慰劑控制的臨床試驗中,我們研究了行口腔頜面部手術的青少年患者控制性降壓中應用可樂定是否減少異氟醚、芬太尼及拉貝樂爾的使用量。我們也研究了其術前鎮靜效果、對經鼻插管的血流動力學反應及恢復質量。39例健康患兒(10–16 yr)在術前晚和術前90 min使用5 µg/kg 可樂定或安慰劑。通過自身評價,兩組的患兒都顯示同樣的焦慮,而觀察者則顯示可樂定組病人更為鎮靜(P < 0.01)。與安慰組相比,可樂定組誘導時的心率顯著降低(P < 0.001),誘導前的動脈血壓(P < 0.01)和插管後的動脈峰壓(P < 0.001)也顯著降低。可樂定組維持平均動脈壓在60 ± 4 mm Hg時異氟醚的需要量顯著減少 (平均異氟醚濃度,可樂定組0.99% 安慰劑組1.33; P = 0.0004) ,芬太尼的需要量也顯著減少(P = 0.002)。需要拉貝樂爾治療的病人(可樂定組, n = 3 對安慰劑組, n = 13; P = 0.004)。在可樂定組有一較快的恢復趨勢,並且恢復室的停留時間較短  (P = 0.03)。我們認為可樂定是青少年患者控制性降壓中一種有效的輔助用藥。結論:該研究顯示青少年患者行大的下頜手術時應用可樂定有利於控制性降壓,可樂定減少吸入麻醉藥、止痛藥及降壓藥的使用,減少心率和血壓的波動並且提供較快的麻醉恢復。

(張俊峰譯  薛張綱 )

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.

 

異氟醚在脊髓上間接抑制了電刺激網狀結構伴隨的皮層活動

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

麻醉藥在脊髓上作用消除了運動和傷害性資訊的上升傳遞。我們研究異氟醚脊髓作用是否影響皮層活動(用電刺激中腦網狀結構發生的腦電圖去同步化來確定)。六隻山羊用異氟醚麻醉,頸部作切口使異氟醚可以輸送到頭部或軀體。腦電圖在中腦網狀結構局部電刺激 (0.05, 0.1, 0.2, 0.3, and 0.4 mA) 前中後記錄;每個動物腦內異氟醚維持穩定({approx}1%)。當軀體異氟醚濃度為0.3% ± 0.1%, 中腦網狀結構電刺激(15.3 ± 1.7 Hz, 所有刺激電流平均通過)後,頻譜的邊緣頻率超過了軀體異氟醚濃度1.2% ± 0.2% (12.9 ± 1.0 HzP < 0.05)時的邊緣頻率。雙頻指數指數值也同樣受到影響: 軀體異氟醚低時為60 ± 6 ,而軀體異氟醚高時為53 ± 7 (P < 0.05)。這些結果顯示異氟醚在脊髓體感上升傳遞的抑制作用可以影響網狀-丘腦皮層喚醒機制,因此可能減少了無意識和遺忘的麻醉藥物需要應可能與麻醉藥物誘導的遺忘和無意識有關。

(潘志浩譯  薛張綱 )

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斷神經元和骨骼肌上電壓控制的鈉通道

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,氯胺酮還有局麻藥樣的作用。我們對左旋和右旋氯胺酮與兩種電壓控制的鈉通道的電壓和使用依賴的相互作用進行研究,特別是強調在靜息和滅活狀態通道親和力的差異。大鼠腦Iia和人骨骼肌鈉通道在人胚腎293細胞上作不同等表達。左旋和右旋氯胺酮可逆抑制整個細胞的鈉內向電流;-70 mV的鉗電壓下50%的抑制濃度在神經元型上為 240 ± 60 µM 333 ± 93 µM,在骨骼肌型上為 59 ± 10 µM181 ± 49 µM。左旋氯胺酮在骨骼肌型上較右旋氯胺酮作用更強。氯胺酮對滅活型通道與靜息型相比具有更高的親和力。然而,這兩種通道親和力之間的估計差異僅僅810倍,藥物在這兩種通道之間的平衡時間太快以致在10 Hz時使用依賴的阻滯需要濃度高達300 µM。這些結果表明氯胺酮在穩定滅活通道狀態上效果較利多卡因樣局麻藥差。

(潘志浩譯  薛張綱 )

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.

 

異丙酚和乙咪酯在慢性缺氧大鼠對氣道收縮的效應

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

 

我們在慢性缺氧大鼠模型與正常大鼠上比較研究了兩種靜脈麻醉藥,異丙酚和乙咪酯對氣道反應性的影響。慢性低氧大鼠用低壓室內飼養 (380 mm Hg 的氣壓下飼養14)。麻醉藥鬆弛和預防激動劑誘發的收縮的能力在用膽鹼能激動劑carbachol (CCh)和去極化藥物KCl預收縮的離體的氣管環上進行評價。在兩種大鼠累積濃度的兩種藥物鬆弛了CCh KCl同等幅度預收縮的氣管環。在用CCh 預收縮的氣管環上,減少最大收縮30%的麻醉藥的負對數,也就是半數最大抑制濃度的負對數,異丙酚和乙咪酯在正常大鼠分別為4.10 ± 0.09 4.12 ± 0.15,在慢性缺氧大鼠為 4.20 ± 0.22 3.61 ± 0.19。在固定濃度下, 異丙酚(3 x 10-4 M)或乙咪酯(10-4 M)也抑制了慢性缺氧大鼠氣管環對累積濃度的CCh KCl的收縮反應。然而,在比較兩種麻醉藥同等程度舒張反應時,乙咪酯顯示抑制收縮效果較異丙酚低兩倍。這些結果表明異丙酚和乙咪酯在慢性缺氧大鼠氣道上保持了依靠對藥物和電機械耦聯作用而發揮的舒張效應。

(潘志浩譯  薛張綱 )

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.

 

吸入麻醉時不同新鮮氣流量的條件下使用了麻醉藥節約裝置的回路和普通回路之比較

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.

 

麻醉藥節約裝置(ACD)是一種僅適用於揮發性麻醉藥物的高流量系統。我們比較了在不同新鮮氣流量條件下有麻醉藥節約裝置的系統和普通回路的區別。81位進行重大手術的患者隨機分為兩組,一組是在Y段安裝了麻醉藥節約裝置的回路(n41),另一組是普通的吸入回路(n40)。在第一組新鮮氣流量設為8/分鐘,並且麻醉藥沒有重複吸入;在第二組經過蒸發罐的新鮮氣流量設為1/分鐘,1.5/分鐘,3/分鐘和6/分鐘。我們比較了第一組和第二組的四種情況下,七氟醚的用量、消耗量、潤濕效率和對環境的污染的不同。有麻醉藥節約裝置的回路和低流量的普通回路(新鮮氣流量為1/分鐘和1.5/分鐘)消耗的七氟醚最少;從吸入七氟醚的濃度上升來看,只有新鮮氣流量超過3/分鐘的普通回路才能夠比有麻醉藥節約裝置的回路快,而且後者清除回路中的七氟醚的速度是最快的,呼吸氣體的濕度也是足夠的,周圍環境中七氟醚的濃度是1-70ppb,因此安裝了麻醉藥節約裝置的回路可以有效而簡單地替代傳統的低流量系統。

(   薛張綱 )

 

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.

 

對於硬膜外給芬太尼的患者術前靜脈使用小劑量的芬太尼可以預測鎮痛效果和副作用的發生率

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

 

對於硬膜外給阿片類藥物的患者,存在個體差異可能會導致副作用的發生率和嚴重性以及鎮痛效果不同,因此根據個體差異來考慮最合適的用藥劑量就很重要了。通過評價患者對於靜脈使用小劑量芬太尼的反應,我們設計了這個研究項目來預測術後接受硬膜外芬太尼鎮痛的患者的鎮痛效果和副作用的發生率。在麻醉誘導前,靜脈給藥芬太尼50ug2分鐘後評價患者的反應情況。23個患者有噁心、嗜睡、頭暈、發熱感和其他主訴的被分為有反應組(R組),其餘的20人被分為無反應組(NR組)。手術結束後96個小時內硬膜外芬太尼的劑量是0.3mg/天,局麻藥是0.25%布比卡因。R組患者術後疼痛強度的視覺評分比NR組低,所需要的止痛藥的量也較少。R組患者副作用的發生率是74%NR組是10%P<0.05),而且R組患者的副作用要更嚴重。這個研究表明對於術後硬膜外給芬太尼鎮痛的患者術前麻醉誘導期間靜脈使用小劑量的芬太尼可以預測鎮痛效果和副作用的發生率和嚴重性。

(   薛張綱 )

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在痛覺產生方面的作用

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種很有意思的介質,由於它的分子生物結構上的特性、給予試驗性疼痛刺激後在局部的變化和它對於疼痛的調節效應引起了人們的重視。

(   薛張綱 )

 

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和尼卡地平對兔子大腦微循環影響的比較

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

 

對全身降壓藥物前列腺素E1(PGE1) 和尼卡地平對大腦微循環和腦血管在高二氧化碳和低氧時反應的影響作一比較。在48只進行異氟醚麻醉的兔子,經顱開窗測定大腦軟腦膜血管的直徑,條件為:a)靜脈注射PGE1或尼卡地平造成溫和適度的低血壓(平均動脈壓降至最初的60~80%),b)局部用藥,c)適度的低血壓並有高二氧化碳或低氧狀態。軟腦膜動脈的直徑在PGE1引起的低血壓時無改變,但尼卡地平引起的低血壓時增加。局部應用尼卡地平時有劑量依賴的軟腦膜動脈直徑增加,但局部應用PGE1時沒有。在這些實驗中觀測到大腦小靜脈直徑僅有細小改變。軟腦膜動脈的擴張反應在PGE1引起的低血壓並有高二氧化碳狀態時增強,而在尼卡地平所致低血壓並有高二氧化碳狀態時減弱。在低氧時,PGE1引起低血壓時血管擴張反應無改變,在尼卡地平所致低血壓時減弱。總之,作為全身降壓藥物,PGE1不擴張大腦血管並且在高二氧化碳或低氧狀態時維持大腦血管的反應性。然而尼卡地平擴張大腦血管並在高二氧化碳或低氧狀態時減弱血管反應性。結論:當應用全身降壓藥進行適度降壓時,PGE1不引起大腦血管擴張,並維持高二氧化碳或低氧狀態時腦血管反應性;然而尼卡地平擴張大腦血管並減弱高二氧化碳和低氧時的血管反應性。

(顧悅超   薛張綱 )
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對皮層體感誘發電位的保護作用

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時已進行有效的體感誘發電位監測,但尚未有系統研究SEPdexmedetomidine量效反應的報導。在本研究中,評估了大鼠應用一定劑量範圍的dexmedetomidine對皮層體感誘發電位的影響。12只大鼠先進行氯胺酮麻醉,並進行機械通氣,股動脈與股靜脈穿刺置管。麻醉維持採用持續注射瑞芬太尼5~15ug/kg.min,萬可松56ug/kg.mindexmedetomidine注射速率分別為0.10.250.51.0 2.0ug/kg.min,注射速率逐級增加,每一速率注射10分鐘;8只大鼠另行注射大劑量的dexmedetomidine,注射速率為10ug/kg.min,注射時間30 min。刺激脛神經並隨後記錄皮層體感誘發電位。所有大鼠SEP振幅的增加經統計學檢驗無顯著意義,dexmedetomidine增加SEP的潛伏期,但無統計學意義。資料表明dexmedetomidine未改變在大鼠中進行SEP監測所需的技術條件,並為在人身上進行dexmedetomidineSEP監測影響的研究提供支援。    

 (顧悅超   薛張綱 )

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.

 

分娩時病人自控硬膜外鎮痛0.15%羅比卡因合用0.5ug/ml蘇芬太尼與0.10%羅比卡因合用0.5ug/ml蘇芬太尼是等效的
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

 

比較分娩時病人自控硬膜外鎮痛(PCEA0.15%羅地卡合用0.5ug/ml蘇芬太尼與0.10%羅比卡因合用0.5ug/ml的鎮痛效果來評估羅比卡因濃度的降低是否可以產生同樣的鎮痛效果,130位健康臨產孕婦進行隨機雙盲研究。PCEA設置為:初始劑量12ml,每次的病人自控劑量5ml,鎖定時間5分鐘,基礎注射速度為10ml/h。兩組病人在人口統計學與身體特徵方面無顯著差別。疼痛評分,產婦的滿意度,鎮痛藥的使用總量,病人所需自控鎮痛的次數和給予的次數,額外需求的自控鎮痛次數,分娩方式,運動神經阻滯情況,副作用,Apgar評分兩組間無明顯差別。0.10%羅比卡因組(平均用量57mg 95%可信區間50.5~63.5mg)0.15%布比卡因組(平均用量88mg 95%可信區間74.4~93.3mg)的鎮痛藥用量要少(P<0.0001)。 0.10%羅比卡因合用0.5ug/ml蘇芬太尼與0.15%羅比卡因合用0.5ug/ml蘇芬太尼行PCEA分娩鎮痛是等效的,並且可節省的30%的局麻藥用量,40%的費用。然而這種局麻藥用量減少與運動神經阻滯,副作用或器械助產的發生率無關。結論:0.10%羅比卡因合用0.5ug/ml蘇芬太尼與0.15%羅比卡因合用0.5ug/ml蘇芬太尼在進行PCEA分娩鎮痛時是等效的,並且可節省30%的局麻藥用量,40%的費用。羅比卡因濃度降低與運動神經阻滯,副作用或器械助產發生率的降低無關。

(顧悅超   薛張綱 )

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.


一項前瞻性隨機研究:碳酸氫納或THAM液治療術中高氯性酸中毒

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

 

本研究評估在高氯性酸中毒時兩種緩衝液對酸堿平衡的作用。24例經腹行婦科手術的患者按計劃注射40mL/Kg.h的生理鹽水。手術時有8位元患者發生高氯性酸中毒。標準堿剩餘為-7mmol/L時,患者隨機分為兩組,在20分鐘內注射平均劑量為130+/-26mmol碳酸氫納(BIC1Mn=12)或者平均劑量為128+/-18mmolTHAM液(THAM3Mn=12)。在緩衝前,緩衝開始時,緩衝後10分鐘,20分鐘測定PaCO2PH,血清碳酸氫根離子濃度,標準堿剩餘,血清鈉離子濃度,鉀離子濃度,氯離子濃度,乳酸濃度,磷酸根離子濃度,總蛋白,白蛋白。計算表觀主要離子差別:血清鈉離子濃度+鉀離子濃度-氯離子濃度-乳酸濃度。應用電腦程式計算有效主要離子差別和血漿弱酸數值。緩衝後即刻,標準堿剩餘BIC組增加9.8mmol/LTHAM組增加7.2mmol/L。兩組中PaCO2和血漿弱酸數值保持不變。主要由於高鈉血症,表觀和有效主要離子差別在BIC組增加8.57.9mEq/LTHAM組表觀主要離子差別保持不變,但是有效主要離子差別增加6.4mEq/L,陰離子間隙由於存在無法測量的陽離子而減少5.8mmol/。總之,用BICTHAM作為緩衝液時,PH值的改變常伴隨著,也可能是由於,主要離子差別增加。結論:通過比較兩組患者術中發生高氯性酸中毒時接受同等劑量的碳酸氫納或THAM液,瞭解了這兩種藥物對酸堿平衡的影響。在進行緩衝時,PH值的改變常伴隨著,也可能是由於,主要離子差別的增加。

(顧悅超   薛張綱 )

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.

 

單劑量氨甲環酸可減少術前用阿司匹林的患者冠脈搭橋術後出血

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

 

氨甲環酸能減少冠脈搭橋患者術後出血。本文研究阿司匹林延用至手術前一天的冠脈搭橋患者在體外迴圈(CPB)前即刻單次給予氨甲環酸的效果。實驗為前瞻性、隨機、雙盲、設立安慰劑對照和平行實驗。將80位病人分為兩組,I:給予氨甲環酸30 mg/kg II:給予安慰劑-0.9% NaCl。體外迴圈開始前注射兩藥。記錄術後16小時的出血量和整個住院期間輸血量。CPB時血球壓積低於20%和術後血球壓積低於25%給予濃縮紅細胞。氨甲環酸組的患者術後出血明顯低於安慰劑組(475±274 mL 713 ± 243 mL; P < 0.001)在接受氨甲環酸的患者發現纖維蛋白溶解被明顯抑制。氨甲環酸可減少術前仍用阿司匹林的冠脈搭橋管患者術後出血。結論:術前仍繼用阿司匹林能增加冠脈搭橋患者術後出血。CPB前即刻給予氨甲環酸30 mg/kg可減少術後出血和抑制這些患者的纖維蛋白溶解。

(趙雪蓮譯 莊心良校)

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.

 

血壓測量間隔對血壓變化滯後效應的影響:一項電腦類比研究

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.

 

在常規麻醉中自動無創測血壓的頻率是能夠在對病人有害的頻繁測壓和可能使發現血壓波動的時間滯後的長時間間隔測壓之間尋找一種平衡。採用電腦模型,在一段時間穩定的血壓後產生隨機的血壓變化。將血壓的採樣時間設定為從1分鐘到10分鐘不等模擬無創血壓監測的情況。我們採用了根據Trigg’s跟蹤變數的獨立演算法表示在血壓發生波動和發現這種波動之間的時間間隔。對於每一種不同的變數(無創測壓間期)都重複計算1000次,記錄每次發現血壓變化所需要的時間。當測壓週期為1分鐘時,發現血壓變化所需的時間是8分鐘;週期為2分鐘時,發現時間是8.9分鐘;週期為5分鐘時,發現時間是10.8分鐘;週期為10分鐘時,發現時間為13.0分鐘。發現時間隨測壓間隔延長而延長,但是延長的幅度大約為測壓週期延長幅度的一半。當無創測壓間期延長後用於發現變化趨勢的演算法的最佳變數也隨著改變。結論:由於血壓的變化是無法預期的,12分鐘的無創測壓間期與更長的測壓間期相比並無優點。

                           (顏濤譯 莊心良校)

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.

 

家長對兒童再次手術時術前處理的選擇

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.

 

目前尚未報導過健康兒童再次手術時家長對術前處理的選擇。我們收集了83例患兒首次手術和再次手術的資料。首次手術的術前處理由醫生決定,分為口服咪唑安定(n=13);麻醉誘導時家長在場(PPIAn=27);PPIA加口服咪唑安定(n=10)及無任何術前處理(n=33)四種方式。再次手術的術前處理則由家長選擇。我們發現,無論首次採用何種方式,大於80%的家長在患兒再次手術時選擇PPIA(加或不加口服咪唑安定)。首次採用PPIA者,70%再次採用。相反,首次口服咪唑安定者,只有23%再次採用咪唑安定,而首次未進行術前處理者,只有15%仍未採用任何處理。凡是首次手術中非常焦慮的患兒,家長均在再次手術時選擇了術前處理(P=0.022)。無論患兒首次採用何種處理,再次手術時家長均傾向于PPIA。家長的選擇受到患兒首次手術時的焦慮程度的影響。結論:無論患兒首次手術的術前處理是藥物,家長在場,或未進行任何術前處理,再次手術時家長均傾向于麻醉誘導時家長在場。家長對兒童再次手術的術前處理的選擇受到兒童首次手術時焦慮程度的影響。

 

                                              (軒   莊心良 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和對乙酰氨基酚控制耳鼻喉門診手術術後疼痛成本效益的對比研究

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

作者設計隨機雙盲和用安慰劑做對照的實驗,用其對比環加氧酶抑制劑rofecoxib celecoxib和對乙酰氨基酚對240位健康的耳鼻喉門診手術患者的鎮痛效果。實驗分四組,組1:對照組, 500 mg 維他命C;組22 g對乙酰氨基酚 ;組3 celecoxib 200 mg;和組4rofecoxib 50 mg 。術前15–45 min 口服各藥。然後術後第一天晨起服用相同劑量的藥物。記錄恢復時間,藥物副作用,疼痛指數和其他鎮痛藥的使用。術後24-48小時;評估離院後疼痛,鎮痛劑需要,噁心和患者對其術後疼痛控制可滿意度及恢復質量。採用其他鎮痛藥的應用和最強疼痛值作為評估藥物效能的主要指標。用成本-效益對比法計算完全滿意疼痛治療的成本。相對於安慰劑術前口服rofecoxib (50 mg) celecoxib (200 mg)能顯著減輕術後疼痛評分和減少在術後觀察室及出院後的鎮痛劑用量。口服對乙酰氨基酚(2 g)在出院後鎮痛效果有限。患者對三組藥的鎮痛效果滿意度顯著高於安慰劑。然而患者對rofecoxibcelecoxib滿意度高於對乙酰氨基酚。術後Rofecoxib在減輕疼痛和改進患者滿意度方面優於celecoxib。在達到使患者完全滿意對疼痛的控制方面Rofecoxib celecoxib更經濟。其中一例用rofecoxib患者無須其他方法既能滿意控制疼痛。口服rofecoxib 50 mg 能比口服celecoxib 200 mg或對乙酰氨基酚2 g更經濟-效益減輕術後疼痛和提升門診患者對術後鎮痛的滿意度。結論:術前口服rofecoxib (50 mg)celecoxib (200 mg) 和對乙酰氨基酚 (2 g)能更有效減輕術後疼痛和改進恢復質量及提升耳鼻喉門診手術患者對疼痛治療的滿意度。其成本只是稍微增加。

(趙雪蓮譯 莊心良校)

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.


異氟醚拮抗雙三氟乙醚或1,2二氯-6-己氟環丁烷損害動物對傷害條件反射和聲音反射的學習功能的作用

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.

 

傳統吸入麻醉藥異氟醚在使人出現遺忘的濃度水平可以損害動物對條件反射和聲音反射的學習功能。吸入性非制動劑並不使動物對傷害性刺激的體動反應消失,也不減少傳統吸入麻醉藥的用量。和異氟醚一樣,非制動劑1,2二氯6己氟環丁烷在低於麻醉用量的時候就會損害學習功能,而非制動劑雙三氟乙醚對學習和記憶功能的影響還未被研究。兩種非制動劑都可以引起驚厥。我們推測異氟醚、雙三氟乙醚和1,2二氯6己氟環丁烷對損害學習和記憶有相同的機制,它們之間的作用呈現協同作用。我們發現異氟醚、雙三氟乙醚和1,2二氯6己氟環丁烷都損害動物對條件反射和聲音反射的學習功能,且非制動劑在不引起驚厥發生的劑量時就有這種作用。但是,異氟醚、 雙三氟乙醚和1,2二氯6己氟環丁烷之間呈現拮抗作用而不是協同作用,這和我們的假說是相互矛盾的。雙三氟乙醚的損害動物對條件反射和聲音反射學習功能的作用不比1,2二氯6己氟環丁烷強。結論:傳統的吸入麻醉藥和非制動劑以不同的機制損害學習功能。它們損害學習功能的機制仍不十分清楚。

 

(王士雷    莊心良 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.

 

吸入考福新對狗疲勞膈肌收縮性的影響

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

.

  我們研究了吸入性考福新—一種弗司扣林水溶性衍化物,對狗疲勞膈肌收縮性的影響。動物分三組,每組8例。每組頻率20HZ,時間30MIN的超強電刺激誘發狗膈肌疲勞。在刺激程式結束後1組立即吸入對照溶劑,2組吸入考福新0.1mg/ml,3組吸入考福新0.2mg/ml。通過測定經膈壓力(pdi)估計膈肌收縮性。膈肌疲勞產生後,每組低頻(20HZ)刺激時,pdi與基礎值相比下降(p<0.05),而在高頻時(100Hz)則未改變。2組及3組在吸入考福新時,二種刺激時pdi與疲勞值相比增加(p<0.05,3組增加明顯大於2組。每組膈肌整合電活動均無明顯改變。結論:吸入考福新能以劑量依賴方式增加疲勞膈肌的收縮性。

                                     (王立中譯   莊心良校)

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.

 

雷米芬太尼對電驚厥療法病人癲癇發作持續時間和急性血流動力學反應的影響

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.

 

本研究目的是觀察雷米芬太尼對電驚厥療法病人急性血流動力學反應和癲癇發作持續時間的影響。對20例有嚴重抑鬱症的病人應用電驚厥療法。病人術前用藥為胃長寧0.2 mg IV ;使意識消失用藥為甲己炔巴比妥1 mg/kg IV ;使肌肉鬆弛用藥為司可林1.2 mg/kg IV 。隨後,在4次連續電驚厥時病人應用雷米芬太尼25, 50, and 100 µg 或生理鹽水(對照組)。在出現高血壓時單次注射拉貝洛爾5-mg 。應用固定的閾上電刺激引出抽搐,記錄從刺激到抽搐停止的時間以及痙攣腦電持續的時間。 100-µg雷米芬太尼組病人在電驚厥前後的血壓均顯著低於對照組。抽搐時間(38 ± 9 s to 43 ± 15 s) 和痙攣性腦電的持續時間(55 ± 29 s to 60 ± 21 s) 各組間無顯著差異。睜眼、口頭應答和出恢復室的時間各組之間也無差異。各雷米芬太尼組電驚厥療法後拉貝洛爾的用量並不減少。結論:雷米芬太尼100 µg IV 減輕電驚厥療法的急性血流動力學反應,對電驚厥療法引起的抽搐持續時間無影響,而且不延長電驚厥療法後的恢復時間,也不增加電驚厥療法的副作用。

                                       (王士雷譯 莊心良校)

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.

 

鞘內注射5-羥色胺受體2A/2C激動劑{alpha}5羥色胺對兩種大鼠持續疼痛模型的抗傷害作用

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.

 

脊髓內5-羥色胺受體(5-HT2)有抗傷害作用,但是有關這種受體的激動劑對持續性疼痛的作用瞭解甚少。我們對鞘內注射5-羥色胺受體2A/2C激動劑{alpha}5羥色胺對兩種大鼠持續疼痛模型的抗傷害作用進行了研究。用福馬林注射和坐骨神經壓迫(CCI)法製備動物模型,藥物經預先留置的鞘內導管進行注射。在福馬林模型中,記錄1-2分鐘和5-6分鐘(第一階段)以及10-60分鐘(第二階段)內每間隔5分鐘動物1分鐘內退縮的情況;在CCI模中,記錄後肢對熱刺激的撤退潛伏期。結果,鞘內注射{alpha}5羥色胺(1 to 100 µg)能以劑量依賴性的方式抑制福馬林模型大鼠的退縮,也以劑量依賴性的方式縮短CCI大鼠熱刺激時的撤退反應潛伏期。這些作用被鞘內預先應用5-HT2A/2C  拮抗劑-酮色林(30 µg)所逆轉。結論:脊髓5-HT2A/2C受體調節炎症疼痛和神經病理性疼痛的抗傷害作用。

(王士雷   莊心良 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.

 

連續肌間溝臂叢阻滯進行家庭術後鎮痛:一項隨機雙盲對照研究

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.

 

我們研究了中度疼痛的門診肩部矯形手術後病人自控區域阻滯鎮痛術的鎮痛效果。20例病人術前接受肌間溝臂叢阻滯和臂叢神經周置管術。術後進行家庭鎮痛選用口服阿片類藥物,同時使用攜帶型輸注泵經導管輸注0.2%羅呱卡因或0.9%鹽水。每天評估疼痛評分阿片用量及其不良反應睡眠質量和技術併發症。資料用中位數和2575百分位數表示。結果:與生理鹽水(n=10)相比,羅呱卡因(n=10)可顯著緩解疼痛。術後第一天靜息時的疼痛評分(範圍:1-10):生理鹽水組為4.8 (4.0–5.0)羅呱卡因組為0.0 (0.0–2.0 P < 0.001)羅呱卡因組的阿片用量及其不良反應也明顯減少。術後第一天阿片用量:生理鹽水組為8.0 (6.5–9.5) 羅呱卡因組為0.5 (0.0–1.0)(P < 0.001)術後第一夜睡眠障礙評分:生理鹽水組比羅呱卡因組高約三倍(P = 0.013)。結論:中度疼痛的肩部矯形手術後,使用攜帶型輸注泵,經肌間溝臂叢周置管輸注羅呱卡因進行家庭鎮痛,可以緩解疼痛,減少阿片用量及其不良反應,改善睡眠質量。

                                     (軒   莊心良 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.

 

靜脈注射羥乙基澱粉對有血腦屏障損害的病人腦脊液滲透的研究

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

 

有血腦屏障損害的低血容量病人,常常靜脈輸注羥乙基澱粉以穩定心血管功能,提高腦的灌注壓。但是,在這種條件下羥乙基澱粉是否透過血腦屏障還不十分明確。我們對8例腦外傷和蛛網膜下腔出血出現血腦屏障損害行蛛網膜下腔引流的病人,輸注羥乙基澱粉,測量血漿和腦脊液中羥乙基澱粉的水平。通過電腦成像技術研究血腦屏障的損害情況。靜脈輸注500-1000ml羥乙基澱粉(HES 200,000/0.5)後測量血漿羥乙基澱粉的水平,並搜集8小時內的腦脊液,測量腦脊液中羥乙基澱粉的濃度。結果,病人血漿中羥乙基澱粉的水平為3.41 -9.95 mg/mL,而在腦脊液中不能檢測到羥乙基澱粉。結論:靜脈輸注羥乙基澱粉(HES 200,000/0.5)並不滲透到有血腦屏障損害的腦外傷和蛛網膜下腔出血病人的腦脊液。

(王士雷   莊心良校)

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-硬膜外聯合技術用於分娩鎮痛時硬膜外試驗劑量對運動功能的影響

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.

在分娩鎮痛開始時鞘內注射布比卡因和芬太尼而不在硬膜外腔注射局麻藥試驗劑量可以提供有效的鎮痛同時產婦可以下地活動。在本研究中,我們探索了在CSE技術首劑鞘內注射布比卡因2.5mg和芬太尼25ug後即刻硬膜外給予利多卡因—腎上腺素試驗劑量對產婦血流動力學穩定性、後柱功能、運動力量和行走的主觀能力的影響。153位產婦隨機地在硬膜外注射3ml生理鹽水或者含1200000腎上腺素的1.5%利多卡因。對完成試驗的110位產婦的血流動力學指標、本體感覺、直腿抬高試驗和改良Bromage評分進行了分析,兩組間沒有差異。但是利多卡因試驗劑量組在注射後30分鐘震動覺、完成深屈膝和攀階梯實驗的能力以及對行走的主觀願望受損者更多(P<0.05)。在60分鐘時兩組無差異但是利多卡因試驗劑量組能完成攀階梯實驗的產婦更少。抗阻力直腿抬高實驗和改良Bromage評分的結果與其他運動力量實驗的結果相關性不強(Spearmans {rho}, 0.273—0.405)。結論:為了達到可行走分娩鎮痛的目的,應該避免在CSE鎮痛開始後即刻使用試驗劑量。

                            (顏 濤譯, 莊心良校)

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.

 

應用聲音輔助裝置確定硬膜外腔穿刺位置的臨床研究

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.

 

本文評價了60例病人通過聲音信號判斷腰段硬膜外穿刺的成功率。一種聲音輔助裝置通過延長管和硬膜外穿刺針連接,可以在穿刺針穿透黃韌帶的過程中將壓力變化轉化為聲音和視覺信號。這個裝置使麻醉醫生不必雙手握持穿刺針,而通過這些信號判斷是否進入了硬膜外腔。所有病人均通過聲音信號成功進行了定位。同時對所有的病例也都進行了為大家公認的壓力測量。結果顯示,應用聲音輔助裝置判斷硬膜外穿刺具有容易控制穿刺針深度 、容易控制置管、 方便教學等優點,是硬膜外穿刺時非常好的輔助手段。

(王士雷   莊心良校)

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.

 

僅經過類比人訓練的缺乏經驗的護士應用PAxpressTM 和面罩/ Guedel Airway 通氣的比較性研究

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)是一種新的聲門外通氣裝置,包含一個解剖形的彎管,中段有一個可充氣的圓形氣囊,遠端包含一個不可充氣的錐形套囊,兩者之間是一個直角形的通氣口。我們比較了僅經過模擬人訓練的缺乏經驗的護士應用PAX 和面罩/ Guedel airway(FM/GA)的通氣情況。45 ASA I - II級麻醉且肌松後的病人,由僅通過模擬人訓練的缺乏經驗的護士應用PAxpressTM 和面罩/ Guedel Airway 通氣。首先用FM/GA 通氣,然後改用PAX 通氣。開始要求病人通氣的基本潮氣量是7 mL/kg,隨後要求進行最大潮氣量通氣。結果,兩種裝置均能達到預期的潮氣量,時間相同(PAX, 41 ± 15 s; FM/GA, 39 ± 25 s),成功插入的嘗試次數也一樣。PAX組最大潮氣量(1261 ± 306 versus 958 ± 220 mL; P < 0.0001)和最大氣道壓 (37 ± 5 versus 28 ± 6 cm H2O; P < 0.0001) 較大,需要進行頻繁的血氣檢測(22% versus 0%; P = 0.001)。結論:僅通過類比人訓練的缺乏經驗的護士應用PAxpressTM 和面罩/ Guedel Airway均能成功地為麻醉且肌松的病人提供基本潮氣量的通氣,但是,PAX的最大通氣量和氣道壓更大,氣道損傷更常見。

(王士雷    莊心良 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.