Anesthesia & Analgesia

May 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

用脉搏波形分析得到的每搏输出量变异作为机械通气病人的补液反应指示

(廖庆武译  薛张纲校)

Stroke Volume Variation as an Indicator of Fluid Responsiveness Using Pulse Contour Analysis in Mechanically Ventilated Patients

Christoph Wiesenack, Christopher Prasser, Gabriele Rödig, and Cornelius Keyl

Anesth Analg 2003 96: 1254-1257.

 

常温心肺体外循环下行心脏手术后肾功能不全的发生率、危险因素和对临床结局的影响

(齐波  王祥瑞 )

Renal Dysfunction After Cardiac Surgery with Normothermic Cardiopulmonary Bypass: Incidence, Risk Factors, and Effect on Clinical Outcome

Sophie Provenchère, Gaetan Plantefève, Gilles Hufnagel, Eric Vicaut, Cyrille de Vaumas, Jean-Baptiste Lecharny, Jean-Pol Depoix, François Vrtovsnik, Jean-Marie Desmonts, and Ivan Philip

Anesth Analg 2003 96:

 

心脏术后检测肾功能不全的替代方法的评价

(王士雷 译 庄心良 校)

Evaluating Surrogate Measures of Renal Dysfunction After Cardiac Surgery

Duminda N. Wijeysundera, Vivek Rao, W. Scott Beattie, Joan Ivanov, and Keyvan Karkouti

Anesth Analg 2003 96: 1265-1273.

 

在进行心脏外科手术病人时心包抑制,房性起搏和心率加快对其心脏收缩舒张功能的影响

(廖庆武译  薛张纲校)

The Effect of Pericardial Restraint, Atrial Pacing, and Increased Heart Rate on Left Ventricular Systolic and Diastolic Function in Patients Undergoing Cardiac Surgery

Colin F. Royse, Alistair G. Royse, Christina T. Wong, and Paul F. Soeding

Anesth Analg 2003 96: 1274-1279.

 

心脏手术中呼吸力学的变化

(   王祥瑞 )

Changes in Respiratory Mechanics During Cardiac Surgery

Barna Babik, Tibor Asztalos, Ferenc Peták, Zoltán I. Deák, and Zoltán Hantos

Anesth Analg 2003 96: 1280-1287.

 

用食道超声心动图指导术中下腔静脉插管

(轩 泓 译  庄心良 校)

Guiding Surgical Cannulation of the Inferior Vena Cava with Transesophageal Echocardiography

Idar Kirkeby-Garstad, Arve Tromsdal, Olav F. M. Sellevold, Mads Bjørngaard, Lise K. Bjella, Einar M. Berg, Asbjørn Karevold, Rune Haaverstad, Alexander Wahba, Ole Tjomsland, Rafael Astudillo, Arne Krogstad, and Roar Stenseth

Anesth Analg 2003 96: 1288-1293.

 

心脏超声用彩色动能定量评价心脏外科病人区域性室壁运动和左室不同步性

(廖庆武译  薛张纲校)

Quantitative Echocardiographic Assessment of Regional Wall Motion and Left Ventricular Asynchrony with Color Kinesis in Cardiac Surgery Patients

Mihai V. Podgoreanu, George N. Djaiani, Elizabeth Davis, Barbara Phillips-Bute, and Joseph P. Mathew

Anesth Analg 2003 96: 1294-1300.

 

心脏手术后的神经肌肉功能恢复:潘库溴铵与罗库溴铵的比较

( 王祥瑞校)

Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium

Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Jeffery S. Vender, Michael J. Avram, Todd K. Rosengart, and Eihab A. Alwawi

Anesth Analg 2003 96: 1301-1307.

 

异氟醚对豚鼠心室肌慢激活延迟整流钾通道的影响

(王士雷 译 庄心良 校)

The Effects of Isoflurane on the Cardiac Slowly Activating Delayed-Rectifier Potassium Channel in Guinea Pig Ventricular Myocytes

Akihiro Suzuki, Zeljko J. Bosnjak, and Wai-Meng Kwok

Anesth Analg 2003 96: 1308-1315.

PEDIATRIC ANESTHESIA:

深麻醉下小儿气管拔管----地氟醚与七氟醚的比较

(   王祥瑞校)

Tracheal Extubation of Deeply Anesthetized Pediatric Patients: A Comparison of Desflurane and Sevoflurane

Robert D. Valley, Eugene B. Freid, Ann G. Bailey, Vincent J. Kopp, Linda S. Georges, James Fletcher, and Anne Keifer

Anesth Analg 2003 96: 1320-1324.

AMBULATORY ANESTHESIA:

梗阻性睡眠呼吸暂停综合征不是门诊手术患者意外住院的危险因素

(轩 泓 译  庄心良 校)

The Diagnosis of Obstructive Sleep Apnea as a Risk Factor for Unanticipated Admissions in Outpatient Surgery

Candace Sabers, David J. Plevak, Darrell R. Schroeder, and David O. Warner

Anesth Analg 2003 96: 1328-1335.

 

无肌松药时用雷米芬太尼和硫喷妥钠诱导插管

(嵇富海译  薛张纲校)

Remifentanil With Thiopental for Tracheal Intubation Without Muscle Relaxants

Mahmut Durmus, Gedik Ender, But A. Kadir, Gulhas Nurcin, Ozturk Erdogan, and M. Ozcan Ersoy

Anesth Analg 2003 96: 1336-1339.

ANESTHETIC PHARMACOLOGY:

氟烷,异氟醚和七氟醚对鼠小脑颗粒神经元非灭活钾离子通道的调控

(忻纪华   王祥瑞 )

Modulation of Noninactivating K+ Channels in Rat Cerebellar Granule Neurons by Halothane, Isoflurane, and Sevoflurane

Woo-Jong Shin and Bruce D. Winegar

Anesth Analg 2003 96: 1340-1344.

 

钾通道KCNK5 Kir3.2突变并不改变麻醉药的MAC

(王士雷 译  庄心良 校)

Mutation of KCNK5 or Kir3.2 Potassium Channels in Mice Does Not Change Minimum Alveolar Anesthetic Concentration

Karin M. Gerstin, Diane H. Gong, Mona Abdallah, Bruce D. Winegar, Edmond I Eger, II, and Andrew T. Gray

Anesth Analg 2003 96: 1345-1349.

 

氟烷和异氟醚在鼠有累加的MAC作用

(嵇富海译  薛张纲校)

Halothane and Isoflurane Have Additive Minimum Alveolar Concentration (MAC) Effects in Rats

Edmond I Eger, II, Yilei Xing, Michael Laster, James Sonner, Joseph F. Antognini, and Earl Carstens

Anesth Analg 2003 96: 1350-1353.

 

安氟醚通过对神经元突触前和突触后的作用,减少谷氨酸向脊髓运动神经元的神经传导

(忻纪华   王祥瑞 )

Enflurane Decreases Glutamate Neurotransmission to Spinal Cord Motor Neurons by Both Pre- and Postsynaptic Actions

Gong Cheng and Joan J. Kendig

Anesth Analg 2003 96: 1354-1359.

 

出血性休克对依托咪酯的影响:药理和药代动力学的分析

(王立中  译 庄心良 校)

The Influence of Hemorrhagic Shock on Etomidate: A Pharmacokinetic and Pharmacodynamic Analysis

Ken B. Johnson, Talmage D. Egan, Jennifer Layman, Steven E. Kern, Julia L. White, and Scott W. McJames

Anesth Analg 2003 96: 1360-1368.

 

异丙酚和丹曲林在慢性试验犬的血流动力学相互作用

(潘志浩译  薛张纲校)

Hemodynamic Interactions of Propofol and Dantrolene in Chronically Instrumented Dogs

Sungsam Cho, Shiping Zhang, Hiroyuki Ureshino, Tetsuya Hara, Shiro Tomiyasu, and Koji Sumikawa

Anesth Analg 2003 96: 1369-1373.

TECHNOLOGY, COMPUTING, AND SIMULATION:

痴呆病人脑电图的低基线双频指数

(殷文渊   王祥瑞 )

Low Baseline Bispectral Index of the Electroencephalogram in Patients with Dementia

Maurizio Renna, Jonathan Handy, and Ajit Shah

Anesth Analg 2003 96: 1380-1385.

PAIN MEDICINE:

咪唑安定能增强鞘内注射布比卡因对热或炎症疼痛的镇痛作用

(王士雷 译   庄心良校)

Midazolam Can Potentiate the Analgesic Effects of Intrathecal Bupivacaine on Thermal- or Inflammatory-Induced Pain

Tomoki Nishiyama and Kazuo Hanaoka

Anesth Analg 2003 96: 1386-1391.

 

经皮肝组织活检产生的疼痛发生及特征研究

(潘志浩译  薛张纲校)

Prevalence and Characteristics of Pain Induced by Percutaneous Liver Biopsy

E. Eisenberg, M. Konopniki, E. Veitsman, R. Kramskay, D. Gaitini, and Y. Baruch

Anesth Analg 2003 96: 1392-1396.

 

局部麻醉药抑制交感神经介导和C-纤维介导的滑液的神经性浆液外渗的差异性

(殷文渊   王祥瑞 )

Local Anesthetics Differentially Inhibit Sympathetic Neuron-Mediated and C Fiber-Mediated Synovial Neurogenic Plasma Extravasation

Christian Pietruck, Stefan Grond, Guo-Xi Xie, and Pamela P. Palmer

Anesth Analg 2003 96: 1397-1402.

 

脊髓m4毒蕈碱受体参与鞘内注射可乐定减少机械性损伤神经的过敏反应

(赵雪莲     庄心良  校)

Intrathecal Clonidine Reduces Hypersensitivity After Nerve Injury by a Mechanism Involving Spinal m4 Muscarinic Receptors

Yoo-Jin Kang and James C. Eisenach

Anesth Analg 2003 96: 1403-1408.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

确定PACU的床位数:计算机模拟流程法

(潘志浩译  薛张纲校)

Determining the Number of Beds in the Postanesthesia Care Unit: A Computer Simulation Flow Approach

Eric Marcon, Saïd Kharraja, Nicole Smolski, Brigitte Luquet, and Jean Paul Viale

Anesth Analg 2003 96: 1415-1423.

CRITICAL CARE AND TRAUMA:

在急救运输中局部加热对减少胆囊炎患者腹痛的作用

(    王祥瑞 )

The Influence of Local Active Warming on Pain Relief of Patients with Cholelithiasis During Rescue Transport

Alexander Kober, Thomas Scheck, Freia Tschabitscher, Stefanie Wiltschnig, Sabine Sator-Katzenschlager, Werner Madei, Burkhard Gustorff, and Klaus Hoerauf

Anesth Analg 2003 96: 1447-1452.

NEUROSURGICAL ANESTHESIA:

严重脑外伤病人反复输入大剂量新型羟基淀粉130/0.4

 (张军 译  庄心良 校)

Repetitive Large-Dose Infusion of the Novel Hydroxyethyl Starch 130/0.4 in Patients with Severe Head Injury

Thomas A. Neff, Martin Doelberg, Cornelius Jungheinrich, Andrea Sauerland, Donat R. Spahn, and Reto Stocker

Anesth Analg 2003 96: 1453-1459.

 

猫颅骨切开术中麻醉方法影响脑温度但不决定于中心体温

(张俊峰译  薛张纲校)

Anesthetic Technique Influences Brain Temperature, Independently of Core Temperature, During Craniotomy in Cats

Kirstin M. Erickson and William L. Lanier

Anesth Analg 2003 96: 1460-1466.

 

电磁共振技术测量麻醉大鼠的脑组织氧张力

(    王祥瑞 )

Electron Paramagnetic Resonance Assessment of Brain Tissue Oxygen Tension in Anesthetized Rats

Huagang Hou, Oleg Y. Grinberg, Satoshi Taie, Steve Leichtweis, Minoru Miyake, Stalina Grinberg, Haiyi Xie, Marie Csete, and Harold M. Swartz

Anesth Analg 2003 96: 1467-1472.

OBSTETRIC ANESTHESIA:

硬膜外注射罗哌卡因和布比卡因用于分娩镇痛:Meta分析

(王士雷  译 庄心良  校)

Epidural Ropivacaine Versus Bupivacaine for Labor: A Meta-Analysis

Stephen H. Halpern and Vivien Walsh

Anesth Analg 2003 96: 1473-1479.

REGIONAL ANESTHESIA:

腰硬联合麻醉与腰麻中相应的低血压发生率的比较

(张俊峰译  薛张纲校)

Differing Incidences of Relevant Hypotension with Combined Spinal-Epidural Anesthesia and Spinal Anesthesia

Joachim Klasen, Axel Junger, Bernd Hartmann, Matthias Benson, Andreas Jost, Anne Banzhaf, Myron Kwapisz, and Gunter Hempelmann

Anesth Analg 2003 96: 1491-1495.

 

随机、双盲观察可乐定联合小剂量布比卡因在脊髓麻醉下腹股沟疝修补术中的应用

(朱慧琛   王祥瑞 )

Clonidine Combined with Small-Dose Bupivacaine During Spinal Anesthesia for Inguinal Herniorrhaphy: A Randomized Double-Blinded Study

I. Dobrydnjov, K. Axelsson, S.-E. Thörn, P. Matthiesen, H. Klockhoff, B. Holmström, and A. Gupta

Anesth Analg 2003 96: 1496-1503.

腹股沟疝修补术脊麻时小剂量布比卡因复合可乐定:一个随机、双盲研究

(赵雪莲      庄心良  校)

GENERAL ARTICLES:

健康志愿者静脉输液的生理效应

(张俊峰译  薛张纲校)

Physiologic Effects of Intravenous Fluid Administration in Healthy Volunteers

Kathrine Holte, Peter Jensen, and Henrik Kehlet

Anesth Analg 2003 96: 1504-1509.

 

插入式喉罩通气用于病理性肥胖患者的气道处理

(朱慧琛   王祥瑞 )

Airway Management Using the Intubating Laryngeal Mask Airway for the Morbidly Obese Patient

Jérôme Frappier, Thierry Guenoun, Didier Journois, Hervé Philippe, Emma Aka, Philippe Cadi, Jacqueline Silleran-Chassany, and Denis Safran

Anesth Analg 2003 96: 1510-1515.

 

氧化亚氮减轻加压反应但增加去甲肾上腺素对喉镜和气管插管的反应

(王立中 译 庄心良 校)

Nitrous Oxide Attenuates Pressor but Augments Norepinephrine Response to Laryngoscopy and Endotracheal Intubation

Kyung Y. Yoo, Sung T. Jeong, In H. Ha, and JongUn Lee

Anesth Analg 2003 96: 1516-1521.

 

用脉搏波形分析得到的每搏输出量变异作为机械通气病人的补液反应指示

Stroke Volume Variation as an Indicator of Fluid Responsiveness Using Pulse Contour Analysis in Mechanically Ventilated Patients

Christoph Wiesenack, MD, Christopher Prasser, MD, Gabriele Rödig, MD, and Cornelius Keyl, MD

Department of Anesthesia, University Hospital, Regensburg, Germany

Anesth Analg 96: 1254-1257

 

对危重病人的心功能评估和恰当补液是临床医生的重要目的。因此我们设计了该研究来评价在心脏外科正常机械通气的病人中用脉搏波形分析得到的每搏输出量变异(SVV)和以前常用的前负荷(中心静脉压和肺动脉楔压)预测每搏输出量指数和心指数对补液量的反应。我们研究了20例选择性冠状动脉搭桥术病人。麻醉诱导后,在补液前(T1)和补液后分别测定血流动力学指标。补液用7ml/Kg6%羟乙基淀粉200/0.5并以1ml·kg-1·min-1输入。除心率外,其余的血流动力学变异在容量负荷后均有显著差异(P<0.01)。对T1时的SVV和补液后的{Delta}SVV进行线性相关分析表明具有显著相关性(r-0.97;P<0.01,而对T1时的SVV和每搏输出量指数(r=0.19)和心指数(r=0.17)的百分率变化进行线性相关分析并不表明变量间有显著相关性。我们的研究表明用脉搏波形分析得到的SVV不能作为心脏外科正常机械通气的病人的补液反应指示。(廖庆武译  薛张纲校)

Assessment of cardiac performance and adequate fluid replacement of a critically ill patient are important goals of a clinician. We designed this study to evaluate the ability of stroke volume variation (SVV), derived from pulse contour analysis, and frequently used preload variables (central venous pressure and pulmonary capillary wedge pressure) to predict the response of stroke volume index and cardiac index to volume replacement in normoventilated cardiac surgical patients. We studied 20 patients undergoing elective coronary artery bypass grafting. After the induction of anesthesia, hemodynamic measurements were performed before (T1) and subsequent to volume replacement by infusion of 6% hydroxyethyl starch 200/0.5 (7 mL/kg) with a rate of 1 mL · kg-1 · min-1. Except for heart rate, all hemodynamic variables changed significantly (P < 0.01) after volume loading. Linear regression analysis between SVV at baseline (T1) and {Delta}SVV after volume application showed a significant correlation (r = -0.97; P < 0.01), whereas linear regression analysis between SVV (T1) and percentage changes of stroke volume index (r = 0.19) and cardiac index (r = 0.17) did not reveal a significant relationship between variables. The results of our study suggest that SVV derived from pulse contour analysis cannot serve as an indicator of fluid responsiveness in normoventilated cardiac surgical patients.

 

 

在进行心脏外科手术病人时心包抑制,房性起搏和心率加快对其心脏收缩舒张功能的影响

The Effect of Pericardial Restraint, Atrial Pacing, and Increased Heart Rate on Left Ventricular Systolic and Diastolic Function in Patients Undergoing Cardiac Surgery

Colin F. Royse, MBBS MD, FANZCA , Alistair G. Royse, MBBS MD, FRAC*, Christina T. Wong, and Paul F. Soeding, MBBS FANZCA

*Department of Pharmacology, University of Melbourne; and Departments of Anaesthesia and Pain Management and Cardiothoracic Surgery, The Royal Melbourne Hospital, Australia

 Anesth Analg 96: 1274-1279

 

诱导麻醉后,在不同的生理条件下如打开心包和不同的心率或心律,收缩和舒张功能的基础测量可以和随后的测量相比较。我们从21位行冠状动脉手术的病人中获得数据。在打开心包之前和之后,心房本身频率起搏,和比这快30BPM的速率起搏时进行心超和肺动脉导管联合检查测量。收缩功能指数包括部分区域的改变,后负荷校正部分区域改变,和心肌工作能力指数。舒张功能包括二尖瓣流入和肺静脉的多普勒成像,彩色M型多普勒血流传播速度,瞬间舒张末硬度和等容松弛时间。血流动力学指数包括心脏指数,平均动脉压,右房压,肺动脉楔压和全身血管阻力指数。在打开心包或建立房性起搏时测量并没有变化。当心率加快时,心脏收缩功能没有变化,但瞬间舒张末硬度增加了。传播速度却显示一种自相矛盾的改善,心率增加而不是其他趋势。二尖瓣流入多普勒显示随着心率增加出现搏动融合。我们推荐在相似的心率下进行连续监测。(廖庆武译  薛张纲校)

Baseline measurements of systolic and diastolic function performed after the induction of anesthesia may be compared with subsequent measurements acquired under different physical conditions such as open pericardium and different heart rate or rhythm. We acquired data from 21 patients undergoing coronary artery surgery. Combined echocardiography and pulmonary artery catheter measurements were performed before and after pericardial opening, atrial pacing at the native rate, and atrial pacing 30 bpm faster. Indices of systolic function included fractional area change, afterload corrected fractional area change, and myocardial performance index; diastolic function included mitral inflow and pulmonary vein Doppler profiles, color M-Mode Doppler flow propagation velocity, instantaneous end-diastolic stiffness, and isovolumetric relaxation time. Hemodynamic indices included cardiac index, mean arterial, right atrial, and pulmonary capillary wedge pressures, and systemic vascular resistance index. There were no changes in measurements after opening of the pericardium or with institution of

atrial pacing. With increased heart rate, there were no changes in systolic function, but instantaneous end-diastolic stiffness increased. Propagation velocity showed a paradoxical improvement with increased heart rate opposite to other trends. Beat fusion occurs with increasing heart rate for mitral inflow Doppler. We recommend that serial measurements are performed at a similar heart rate.

 

心脏超声用彩色动能定量评价心脏外科病人区域性室壁运动和左室不同步性

Quantitative Echocardiographic Assessment of Regional Wall Motion and Left Ventricular Asynchrony with Color Kinesis in Cardiac Surgery Patients

Mihai V. Podgoreanu, MD, George N. Djaiani, MD, Elizabeth Davis, LPN RDCS  , Barbara Phillips-Bute, PhD, and Joseph P. Mathew, MD

*Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center/Duke Heart Center, Durham, North Carolina; Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; and Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 96: 1294-1300

 

传统心脏超声在解释区域性室壁反常运动时具有主观性和经验依赖性。在射血期的延迟收缩(迟收缩)和区域性收缩不同步即心肌缺血的敏感标记并不能被真正准确评定。我们对冠状动脉搭桥手术病人用彩色动能(CK),一种获得心内膜运动时空模型的技术,来客观检测其区域性室壁反常运动,并和缺少经验的检测者用灰度影像获得的传统评定结果进行比较。比较采用专家评级作为金标准。CK定量分析比缺少经验的检测者的检测结果更接近专家评级(系数,0.720.520.5)。26例病人(2例为正常的小部分区域改变)中有9例证明整体迟收缩与收缩不同步性的增加指数有关。150个片段中有48个证明为区域性迟收缩:27个片段为正常等级的室壁运动,18个是运动功能减退,3个是严重运动减退/运动不能。轻度运动减退表明延迟收缩运动,而剩下的严重运动减退/运动不能则发生在收缩早期,反应了邻近心肌收缩的被动效应。定量彩色动能可作为视觉评定的补充,特别是对于缺少经验的检测者来说。一般在心脏外科病人中甚至其射血期指数是正常标准的,定量彩色动能可通过迟收缩诊断来提高手术中区域性缺血性改变的检测。(廖庆武译  薛张纲校)

Conventional echocardiographic interpretation of regional wall motion abnormalities is subjective and experience dependent. Delayed contraction in the ejection phase (tardokinesis) and regional systolic asynchrony, sensitive markers of myocardial ischemia, cannot be accurately assessed visually. We used color kinesis (CK), a technique that evaluates spatiotemporal patterns of endocardial motion, to objectively detect regional wall motion abnormalities in patients undergoing coronary bypass surgery, and we compared it with conventional assessment of grayscale images by less experienced reviewers; we used expert grading as the gold standard for comparisons. Quantitative CK analysis agreed more closely with expert grading than less experienced reviewers coefficients, 0.74 versus 0.52 and 0.5). Global tardokinesis, identified in 9 of 26 patients (2 with normal fractional area change), was associated with an increased index of systolic asynchrony. Regional tardokinesis was identified in 48 of 150 segments: 27 segments had a normal magnitude of wall motion, 18 were hypokinetic, and 3 were severely hypokinetic/akinetic. Mildly hypokinetic segments showed delayed systolic motion, whereas residual motion of severely hypokinetic/akinetic segments occurred in early systole, reflecting passive effects produced by adjacent myocardial contraction. Quantitative CK may be a useful supplement to visual assessment, particularly for less experienced readers. By diagnosing tardokinesis, common among cardiac surgical patients even with normal standard ejection phase indices, quantitative CK may improve the intraoperative detection of regional ischemic changes

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无肌松药时用雷米芬太尼和硫喷妥钠诱导插管

Remifentanil With Thiopental for Tracheal Intubation Without Muscle Relaxants
Mahmut Durmus, MD, Gedik Ender, MD, But A. Kadir, MD, Gulhas Nurcin, MD, Ozturk Erdogan, MD, and M. Ozcan Ersoy, MD PhD

Department of Anesthesiology, Inonu University, School of Medicine, Malatya, Turkey

 Anesth Analg 2003 96: 1336-1339.

 

在没有肌松药的情况下雷米芬太尼和非阿片类的静脉全麻药复合应用于插管。在本研究中我们采用双盲、前瞻、随机的方式评估在没有肌松药的情况下雷米芬太尼和硫喷妥钠联合用于插管时的需要的剂量及心血管反应。先静脉注射咪唑安定0.03 mg/kg105个病人按照雷米芬太尼的剂量随机分为三组:2 µg/kg (I), 3 µg/kg ( II), 4 µg/kg ( III)。雷米芬太尼30秒内注完,采用硫喷妥钠5 mg/kg.诱导。麻醉医师在插管时估价插管的条件:(a) 优,(b) 满意,(c)一般,(d),不满意。在人口统计方面三组无明显不同,在插管内三组病人血压、心率无明显增加。在组II比组I、组 III比组I、组 III比组I插管条件明显改善(P < 0.001)。我们结论是在硫喷妥钠前给雷米芬太尼4 µg/kg94%的病人可获得满意的插管条件,抑制插管时的心血管反应。(嵇富海译  薛张纲校)

Tracheal intubation may be accomplished with remifentanil and a non-opioid IV anesthetic without a muscle relaxant. In this study, we evaluated in double-blinded, prospective, randomized manner the dose requirements for remifentanil with thiopental without muscle relaxant administration to obtain clinically acceptable intubation conditions and cardiovascular responses. After premedication with midazolam 0.03 mg/kg IV, 105 patients were randomized equally to one of three study groups, each receiving the following: remifentanil 2 µg/kg (Group I), 3 µg/kg (Group II), and 4 µg/kg (Group III). Remifentanil was administered over 30 s, and anesthesia was induced with thiopental 5 mg/kg. Tracheal intubation conditions were assessed by the anesthesiologist performing the intubation as: (a) excellent, (b) satisfactory, (c) fair, and (d) unsatisfactory. There were no statistically significant differences among groups regarding to demographic data. Blood pressure and heart rate did not increase in any group after accomplishing intubation. There was a significant improvement in intubation conditions between Groups I and II, I and III, and II and III (P < 0.001). We conclude that remifentanil 4 µg/kg administered before thiopental 5 mg/kg provided excellent or satisfactory intubation conditions in 94% of patients and prevented cardiovascular responses to intubation.

 

氟烷和异氟醚在鼠有累加的MAC作用

 Halothane and Isoflurane Have Additive Minimum Alveolar Concentration (MAC) Effects in Rats

Edmond I Eger, II, MD*, Yilei Xing, MD*, Michael Laster, DVM*, James Sonner, MD*, Joseph F. Antognini, MD, and Earl Carstens, PhD

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, and Department of Anesthesiology and the Section of Neurobiology, Physiology, and Behavior, University of California, Davis

Anesth Analg 2003 96: 1350-1353.

 

研究表明在接近MAC(抑制50%的病人对有害刺激没有反应时的最小肺泡内浓度)浓度时,氟烷抑制背角神经元超过异氟醚。同样这些麻醉药对它们靶点的各种受体和离子通道影响也不相同。所有结果表明这些麻醉药对有害刺激的体动反应的影响由于它们的累加、可能协同、甚至于拮抗效应而不同。我们用20只鼠来验证这种可能性。氟烷和异氟醚MA C值在联合试验前和后分别重复测定(每只鼠确定6MAC)。每个鼠的氟烷和异氟醚的总的MAC值产生一无反应值1.037 ± 0.082,和MAC1没有明显不同。就是氟烷和异氟醚的联合产生对夹尾无反应浓度和单独这种麻醉药的效应是一致的。这些结果表明吸入麻醉药引起的无反应不会是由于它们对传导背角神经元的能力。    (嵇富海译  薛张纲校)

Studies suggest that at concentrations surrounding MAC (the minimum alveolar concentration suppressing movement in 50% of subjects in response to noxious stimulation), halothane depresses dorsal horn neurons more than does isoflurane. Similarly, these anesthetics may differ in their effects on various receptors and ion channels that might be anesthetic targets. Both findings suggest that these anesthetics may have effects on movement in response to noxious stimulation that would differ from additivity, possibly producing synergism or even antagonism. We tested this possibility in 20 rats. MAC values for halothane and (separately) for isoflurane were determined in duplicate before and after testing the combination (also in duplicate; six determinations of MAC for each rat). The sum of the isoflurane and halothane MAC fractions for individual rats that produced immobility equaled 1.037 ± 0.082 and did not differ significantly from a value of 1.00. That is, the combination of halothane and isoflurane produced immobility in response to tail clamp at concentrations consistent with simple additivity of the effects of the anesthetics. These results suggest that the immobility produced by inhaled anesthetics need not result from their capacity to suppress transmission through dorsal horn neurons

 

异丙酚和丹曲林在慢性试验犬的血流动力学相互作用

Hemodynamic Interactions of Propofol and Dantrolene in Chronically Instrumented Dogs

Sungsam Cho, MD, Shiping Zhang, MD, Hiroyuki Ureshino, Tetsuya Hara, MD, Shiro Tomiyasu, MD, and Koji Sumikawa, MD

Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki, Japan

Anesth Analg 2003;96:1369-1373

 

恶性高热的特效药丹曲林和可在恶性高热易感病人上安全使用的异丙酚之间的血流动力学相互作用还未被研究。我们进行了这一试验来检验治疗剂量的丹曲林在异丙酚麻醉时的血流动力学作用。十只犬慢性试验以测定体循环和冠脉的血流动力学。这些犬在不同的试验日分别随机接受待药媒的异丙酚和丹曲林。异丙酚显著降低平均动脉压, 左室收缩和舒张末压, 左室压力增加的最大速率以及左室局部节段缩短。冠脉血流没有改变,但是冠脉血管阻力下降。丹曲林逆转了异丙酚导致的平均动脉压和左室收缩压力的变化,显著增加了心率。然而,左室舒张末压,心输出量,左室压力增加的最大速率以及节段缩短不变。冠脉血流显著增加而冠脉阻力不变。这些结果显示丹曲林逆转了异丙酚导致的低血压,导致冠脉血流的增加以及冠脉阻力的下降,但是没有显著改变负性肌力作用。因此,丹曲林在异丙酚麻醉时产生有益的血流动力学效应。

结论: 我们的研究显示丹曲林逆转了异丙酚产生的低血压,导致了冠脉血流的增加以及冠脉阻力的下降,但没有显著改变负性肌力作用。(潘志浩译  薛张纲校)

The hemodynamic interaction of dantrolene, a specific drug for malignant hyperthermia, and propofol which appears to be safe in malignant hyperthermia-susceptible patients, has not been investigated. We performed this study to examine the hemodynamic actions of dantrolene at a therapeutic dose during propofol anesthesia. Ten dogs were chronically instrumented for the measurements of systemic and coronary hemodynamics. The dogs were assigned to receive propofol with vehicle or dantrolene in a random manner on separate experimental days. Propofol significantly decreased mean arterial blood pressure, left ventricular systolic and end-diastolic pressure, the maximal rate of increase in left ventricular pressure, and left ventricular regional segment shortening. Coronary blood flow (CBF) was unchanged but coronary vascular resistance (CVR) decreased. Dantrolene reversed the decrease in mean arterial blood pressure and left ventricular systolic pressure caused by propofol, and significantly increased heart rate. However, left ventricular end-diastolic pressure, cardiac output, maximal rate of increase in left ventricular pressure, and segment shortening were unchanged. CBF was significantly increased with a decrease in CVR. These results suggest that dantrolene reverses the hypotensive action produced by propofol and causes an increase in CBF with a decrease in CVR, but does not significantly change the negative inotropic effects. Thus, dantrolene exerts favorable hemodynamic effects during propofol anesthesia.

 

经皮肝组织活检产生的疼痛发生及特征研究

Prevalence and Characteristics of Pain Induced by Percutaneous Liver Biopsy

E. Eisenberg, MD, M. Konopniki, MD, E. Veitsman, MD, R. Kramskay, MD, D. Gaitini, MD, and Y. Baruch, MD

Pain Relief Unit, Liver Unit and Department of Medical Imaging, Rambam Medical Center and the B. Rappaport Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel

Anesth Analg 2003;96:1392-1396


经皮针刺肝组织活检是诊断和评价肝脏疾病的重要手段,但常常会产生疼痛。该前瞻性研究目的在于明确此疼痛综合症的发生及特征。54例拟行超声导引下肝组织活检的患者术前1小时口服5 mg 安定,针刺前10 mL 2%利多卡因局部侵润阻滞。术后24小时应用视觉模拟评分(VAS)评定疼痛强度,并记录疼痛的定位,Spielberger问卷评定焦虑水平。54例中47例(84%)患者诉术后30 min疼痛(VAS, 4.2 ± 0.5; mean ± SEM)21(39%)患者诉术后24小时时疼痛。9例诉活检部位疼痛,14例右肩痛,两部位均痛24例。女患者和焦虑水平高的患者的疼痛强度高。该研究显示肝组织活检会致大多数患者疼痛,轻度镇静联合局部侵润麻醉不能有效的镇痛,因此需要寻找更为有效的镇痛方法。结论:经皮肝组织活检会致大多数患者疼痛,轻度镇静联合局部侵润麻醉不能有效的镇痛,因此需要寻找更为有效的镇痛方法。(潘志浩译  薛张纲校)

 

 Percutaneous needle liver biopsy is an important procedure for the diagnosis and evaluation of liver disease and is frequently associated with pain. In this prospective study, we investigated the prevalence and characteristics of this pain syndrome. Fifty-four subjects, who underwent liver biopsy under ultrasound guidance, received 5 mg of diazepam orally 1 h before the procedure and local infiltration with 10 mL of 2% lidocaine just before needle insertion. Outcome measures included the visual analog scale for measuring pain intensity over 24 h, pain localization on a body scheme, and the Spielberger questionnaire for measuring anxiety levels. Forty-seven (84%) of the 54 respondents reported pain 30 min after the biopsy (visual analog scale, 4.2 ± 0.5; mean ± SEM), and 21 (39%) reported pain at the 24-h time point. Biopsy site pain was reported by 9 subjects, right shoulder pain by 14, and pain at both sites by 24. Higher pain intensities were reported by women and by subjects with higher anxiety levels. This study indicates that liver biopsy is a painful condition in most patients. Mild anxiolytic treatment plus local anesthetic infiltration seem to produce insufficient analgesia, thus indicating that a more profound analgesic treatment is required for better control of this pain.

 

确定PACU的床位数:计算机模拟流程法

Determining the Number of Beds in the Postanesthesia Care Unit: A Computer Simulation Flow Approach

Eric Marcon, PhD*, Saïd Kharraja*, Nicole Smolski, MD{dagger}, Brigitte Luquet{ddagger}, and Jean Paul Viale, MD PhD{dagger}

*Department of Industrial Maintenance, Jean Monnet University, Saint Etienne; and Departments of {dagger}Anesthesiology and {ddagger}Surgery, Hospital Croix-Rousse, Lyon, France

Anesth Analg 2003;96:1415-1423

设计一个新手术室由于涉及工作人员的数目以及决策者想要减少手术室的直接和间接的费用而变得困难。在这一研究中,我们设计了一种计算机模拟流程模式,首先计算术后恢复室的最少床位数。在第二个阶段,我们对手术室在手术安排和有工作人员的PACU床位和搬运工人的数目方面的总体表现。我们设计了手术室安排的数学模型。随后我们建立了手术室的计算机模拟流程模型。两种模型相互关联;第一种模拟输入流程,第二种模拟手术室运转。计算机模拟检验了理想状态和搬运工人减少时的PACU床位。然后分析了PACU中当病人停留的时间和搬运工人数目变化每小时床位占用数的变化。结果显示了搬运工人数目对手术室表现,特别是PACU表现的强烈影响。

结论: 设计新手术室设施意味着很多关于手术室,PACU床位以及护士和搬运工人数目的决定。管理者常常凭经验和推荐作这些决定。我们的研究运用流程模拟来证实这些选择。在这一案例研究中,我们确定了PACU的床位和搬运工人数,评价了减少搬运工人对PACU床位需要的影响。   (潘志浩译  薛张纲校)

 

Designing a new operating room (OR) suite is a difficult process owing to the number of caregivers involved and because decision-making managers try to minimize the direct and indirect costs of operating the OR suite. In this study, we devised a computer simulation flow model to calculate, first, the minimum number of beds required in the postanesthesia care unit (PACU). In a second step, we evaluated the relationship between the global performance of the OR suite in terms of OR scheduling and number of staffed PACU beds and porters. We designed a mathematical model of OR scheduling. We then developed a computer simulation flow model of the OR suite. Both models were connected; the first one performed the input flows, and the second simulated the OR suite running. The simulations performed examined the number of beds in the PACU in an ideal situation or in the case of reduction in the number of porters. We then analyzed the variation of number of beds occupied per hour in the PACU when the time spent by patients in the PACU or the number of porters varied. The results highlighted the strong impact of the number of porters on the OR suite performance and particularly on PACU performances.

 

猫颅骨切开术中麻醉方法影响脑温度但不决定于中心体温

Anesthetic Technique Influences Brain Temperature, Independently of Core Temperature, During Craniotomy in Cats

Kirstin M. Erickson, MD, and William L. Lanier, MD

Department of Anesthesiology, Mayo Clinic and Mayo Medical School, Rochester, Minnesota

Anesth Analg 2003;96:1460-1466

 

由于麻醉对脑血流和脑代谢(二者均为脑自身调节的决定因素)有明显的潜在影响,我们假设颅骨切开术中麻醉影响脑温并且不决定于中心体温。21只猫 (2.7 ± 0.4 kg; mean ± SD)均行右乙状窦旁开颅术并随机分为3组: HN组(1.5%氟烷,血碳酸正常);HH组(1.5%氟烷,低碳酸血症);PN组(大剂量戊巴比妥钠,血碳酸正常)。加热器开始维持中心体温和右硬膜下体温正常 (38.0°C), 随后停止颅骨加热,则在3小时的研究过程中,脑中心体温梯度最大的部位是右硬膜下区域,各组分别平均为HN组:-2.5°C ± 0.9°CHH组:-2.5°C ± 0.8°C PN组:-4.1°C ± 1.1°C。在未暴露的左硬膜下和右脑表面下0.51.0 cm的脑皮质区域的体温梯度HN HH组中为-0.8°C ± 0.5°C-1.1°C ± 0.6°C之间,而PN组则是其两倍(-1.9°C ± 0.5°C-2.1°C ± 0.7°C) (P < 0.05 PNHN HH)。深戊巴比妥钠麻醉可独立于中心体温外降低脑温,可能是其降低脑代谢率和减少热产生的结果,降低的幅度足以增强巴比妥类药物的任何直接的脑保护作用。结论:深巴比妥钠麻醉可独立于中心体温外降低猫脑温,该作用显著强于氟烷麻醉,其体温降低幅度足以解释巴比妥类药物不同于其它任何药物的脑保护特性。(张俊峰译  薛张纲校)

Because anesthetic technique has the potential to dramatically affect cerebral blood flow and metabolism (two determinants of brain thermoregulation), we tested the hypothesis that, after craniotomy, anesthetic technique would influence brain temperature independent of core temperature. Twenty-one cats (2.7 ± 0.4 kg; mean ± SD) undergoing a uniform right parasagittal craniotomy received 1) halothane 1.5% end-expired and normocapnia (HN), 2) halothane 1.5% and hypocapnia (HH), or 3) large-dose pentobarbital and normocapnia (PN) (n = 7 per group). Heating devices initially maintained core and right subdural normothermia (38.0°C). Thereafter, cranial heating was discontinued. Brain-to-core temperature gradients during the 3 h study were greatest in the right subdural area, averaging -2.5°C ± 0.9°C in HN, -2.5°C ± 0.8°C in HH, and -4.1°C ± 1.1°C in PN. Gradients within the unexposed left subdural area and in the right cortex 0.5 and 1.0 cm below the brain surface were -0.8°C ± 0.5°C to -1.1°C ± 0.6°C for both HN and HH but were twice this amount in PN (-1.9°C ± 0.5°C to -2.1°C ± 0.7°C) (P < 0.05 for PN versus HN and HH). Deep barbiturate anesthesia can reduce brain temperature independently of core temperature, presumably by reducing the metabolic rate and associated brain heat production. The magnitude is sufficient to augment any direct cerebroprotective properties of the barbiturates

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腰硬联合麻醉与腰麻中相应的低血压发生率的比较

Differing Incidences of Relevant Hypotension with Combined Spinal-Epidural Anesthesia and Spinal Anesthesia

Joachim Klasen, Dr Med, Axel Junger, Dr Med, Bernd Hartmann, Dr Med, Matthias Benson, Dr Med, Andreas Jost, Anne Banzhaf, Dr Med, Myron Kwapisz, Dr Med, and Gunter Hempelmann, Prof. Dr. Dr. h.c.

Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Giessen, Giessen, Germany

Anesth Analg 2003;96:1491-1495

该研究中我们评价作为腰硬联合麻醉(CSE)中一部分的腰麻是否比单纯腰麻SPA更易导致低血压。从January 1, 1997 August 5, 2000间电子麻醉记录单中选择1596例择期行SPA1023例择期行 CSE的患者。低血压定义为:10-min 内平均动脉压降低超过30%并且在发生低血压20 min内需麻醉医师治疗。采用logistic回归分析递增法确定CSE后有关低血压发生率的独立因素,单变量分析用于评价两组间生物统计资料和低血压相应危险因素的差异。CSE低血压的发生率比SPA要高(10.9% 5.0%; P < 0.001)。多变量分析发现高血压(odds ratio, 1.83; 95%可信区间, 1.212.78)和阻滞平面>T6(odds ratio, 2.81; 95%可信区间, 1.884.22)CSE组低血压发生的有关因素。与SPA组相比,CSE组较少的局麻药可产生较高的阻滞平面并且CSE组病人中术前合并高血压较为常见(P < 0.01) 在该研究中,CSE组病人比SPA病人发生低血压的风险高,其原因部分好像与CSE本身有关,而不仅仅与CSE病人有高风险因素。结论:该研究基于大样本回顾性研究设计,结果提示CSE比单纯SPA更易导致低血压,术前存在的高血压及术中感觉阻滞平面超过T6是产生该并发症的主要因素。         (张俊峰译  薛张纲校)

In this investigation we assessed whether patients receiving spinal anesthesia (SPA) as part of combined spinal-epidural anesthesia (CSE) more often experience relevant hypotension than patients receiving SPA alone. From January 1, 1997, until August 5, 2000, electronic anesthesia records from 1596 patients having received SPA and 1023 patients having received CSE for elective surgery were collected by using a computerized anesthesia record-keeping system. Relevant hypotension was defined as a decrease of mean arterial blood pressure of more than 30% within a 10-min interval and a therapeutic action of the attending anesthesiologist within 20 min after onset. Electronic patient charts were reviewed by using logistic regression with a forward stepwise algorithm to identify independent risk factors that were associated with an increased incidence of hypotension after CSE. Univariate analysis was performed to assess differences in biometric data and relevant risk factors for hypotension between the two procedures. The incidence of relevant hypotension was more frequent with CSE than with SPA alone (10.9% versus 5.0%; P < 0.001). In the multivariate analysis, arterial hypertension (odds ratio, 1.83; 95% confidence interval, 1.21–2.78) and sensory block height >T6 (odds ratio, 2.81; 95% confidence interval, 1.88–4.22) were found to be factors associated with hypotension in the CSE group. Compared with patients receiving SPA alone, patients undergoing CSE had a significantly more frequent prevalence of arterial hypertension and higher sensory block levels (P < 0.01) despite smaller amounts of local anesthetics. In this study, patients receiving CSE had an increased risk for relevant hypotension as compared with patients with SPA alone. Part of this effect seems to be due to the procedure alone and not only because this population is at higher risk.

 

健康志愿者静脉输液的生理效应

Physiologic Effects of Intravenous Fluid Administration in Healthy Volunteers

Kathrine Holte, MD, Peter Jensen, MS, and Henrik Kehlet, MD PhD

Department of Surgical Gastroenterology, Hvidovre University Hospital, Denmark

Anesth Analg 2003;96:1504-1509

 

围术期液体管理的方案很少是循证的。因此,我们在健康志愿者上研究液体输注的反应来评价液体输注本身的生理效应。在这一个前瞻,双盲,交叉随机的研究中,12个平均年龄63岁(59–67岁)的健康志愿者分别接受随机顺序的乳酸林格液40 mL/kg (平均2820 mL) 5 mL/kg (平均353 mL;背景输注)。研究设计模仿围术期经过,术前禁食,在早晨输液3小时,另外24小时在标准化状态下住院。主要的预后评价为肺功能 (肺量计),运动能力(亚极量蹬车试验), 平衡功能(BalanceMaster®), 以及体重。输注40 mL/kg的乳酸林格液与背景输注(5 mL/kg)相比,肺功能显著降低,显著增重平均为0.85 kg (-0.2–1.6 kg; P = 0.003) ,在输注后持续达24小时。运动耐量和平衡功能没有被输液所影响。这些结果可以作为在应用不同量同样类型液体以确定不同外科手术围术期液体输注最佳量的临床研究的基础。

结论:在志愿者输注40 mL/kg乳酸林格液导致肺功能的显著下降以及体重增加达24小时而对运动耐量无影响。这些结果可以作为围术期液体管理的基本信息。                                   (张俊峰译  薛张纲校)

Dose regimens in perioperative fluid management are rarely evidence based. Therefore, we investigated responses to an IV fluid infusion in healthy volunteers to assess basic physiologic effects of a fluid infusion per se. In a prospective, double-blinded, cross-randomized study, 12 healthy volunteers with a median age of 63 yr (range, 59–67 yr) received an infusion of lactated Ringer’s solution 40 mL/kg (median, 2820 mL) or 5 mL/kg (median, 353 mL; background infusion) in random order on two separate occasions. The study was designed to mimic the perioperative course with preoperative fasting, infusion of the fluid over 3 h in the morning, and additionally 24-h hospitalization under standardized conditions. Primary outcome assessments were pulmonary function (spirometry), exercise capacity (submaximal treadmill test), balance function (BalanceMaster®), and weight. Infusion of 40 mL/kg of lactated Ringer’s solution compared with the background infusion (5 mL/kg) resulted in a significant decrease in pulmonary function and a significant weight gain of median 0.85 kg (range, -0.2–1.6 kg; P = 0.003) persisting 24 h after the infusion. Exercise capacity and balance function were not influenced by fluid administration. These findings may serve as a basis for clinical studies applying the same type of fluid in different amounts to determine the optimal amount of perioperative fluid in various surgical procedures.


 

常温心肺体外循环下行心脏手术后肾功能不全的发生率、危险因素和对临床结局的影响

Renal Dysfunction After Cardiac Surgery with Normothermic Cardiopulmonary Bypass: Incidence, Risk Factors, and Effect on Clinical Outcome

Sophie Provenchère, MD*, Gaetan Plantefève, MD*, Gilles Hufnagel, MD{dagger}, Eric Vicaut, MD{ddagger}, Cyrille de Vaumas, MD*, Jean-Baptiste Lecharny, MD*, Jean-Pol Depoix, MD*, François Vrtovsnik, MD{dagger}, Jean-Marie Desmonts, MD*, and Ivan Philip, MD*

*Département Anesthésie-Réanimation and {dagger}Service de Néphrologie, Hôpital Bichat-Claude Bernard; and {ddagger}Laboratoire de Biophysique, Hôpital Fernand Widal, Paris, France

Anesth Analg 2003;96:1258-1264


肾功能不全是传统低温心脏手术后经常发生的严重的并发症。但在常温条件下(通常大于36)行心肺体外循环(CPB)时有关肾功能不全的情况则所知甚少。因此,我们前瞻性研究了649例常温CPB下进行冠状动脉旁路术或瓣膜手术的病人。采用单一变量和多变量分析肾功能不全(定义为最大术后血浆肌酐水平较术前增加大于等于30%)与围术期变量之间的关系。结果表明术后肾功能不全发生率为17%,其中21名病人(3.2%)需要进行透析治疗。此并发症发生的一些独立的术前预见因素为:高龄、ASA分级>3级、活动性感染性心内膜炎、术前48小时内应用放射性对比剂和复合性大手术。当所有变量都存在时,活动性感染性心内膜炎、应用放射性对比剂、术后低心排量和术后出血成为肾功能不全发生的独立的危险因素。当病人发生肾功能不全时院内死亡率为27.5%(1.6%比;P<0.0001),因此,术后肾功能不全是院内死亡率独立的相关因素(概率为4.1[95%可信区间为1.3-12.8])。我们认为相对于CPB来说,高龄、活动性感染性心内膜炎、术前(48小时内)应用放射性对比剂以及术后血流动力学不稳定等因素可能是术后肾功能不全更为可靠的预见因素。(齐波   王祥瑞 )

Renal dysfunction is a frequent and severe complication after conventional hypothermic cardiac surgery. Little is known about this complication when cardiopulmonary bypass (CPB) is performed under normothermic conditions (e.g., more than 36°C). Thus, we prospectively studied 649 consecutive patients undergoing coronary artery bypass surgery or valve surgery with normothermic CPB. The association between renal dysfunction (defined as a >=30% preoperative-to-maximum postoperative increase in serum creatinine level) and perioperative variables was studied by univariate and multivariate analysis. Renal dysfunction occurred in 17% of the patients. Twenty-one (3.2%) patients required dialysis. Independent preoperative predictors of this complication were: advanced age, ASA class >3, active infective endocarditis, radiocontrast agent administration <48 h before surgery, and combined surgery. When all the variables were entered, active infective endocarditis, radiocontrast agent administration, postoperative low cardiac output, and postoperative bleeding were independently associated with renal dysfunction. The in-hospital mortality rate was 27.5% when this complication occurred (versus 1.6%; P < 0.0001).

Furthermore, postoperative renal dysfunction was independently associated with in-hospital mortality (odds ratio, 4.1 [95% confidence interval, 1.3–12.8]). We conclude that advanced age, active endocarditis, and recent (within 48 h) radiocontrast agent administration, as well as postoperative hemodynamic dysfunction, are more consistently predictive of postoperative renal dysfunction than CPB factors.

 

心脏手术中呼吸力学的变化

Changes in Respiratory Mechanics During Cardiac Surgery

Barna Babik, MD*,{dagger}, Tibor Asztalos, PhD{ddagger}, Ferenc Peták, PhD{ddagger}, Zoltán I. Deák, MD*,{dagger}, and Zoltán Hantos, PhD{ddagger}

*Institute of Anesthesiology and Intensive Therapy, {dagger}Division of Cardiac Surgery, and {ddagger}Department of Medical Informatics and Engineering, University of Szeged, Szeged, Hungary

Anesth Analg 2003;96:1280-1287


为观察心脏外科手术中心肺体外循环(CPB)对肺功能的影响,我们测量了应用(n=30CPB)或未应用心肺体外循环(n=29,在心脏手术组(n=30)、不停跳冠状动脉旁路组(n=29)CPB的病人在术中应用多巴胺(DA)治疗(n=12CPB-DA)观察低频呼吸阻抗(Zrs)。测量了5CPB的病人的血管外肺水及切皮前和关胸后的Zrs的变化。除Zrs外还测量了病人的气道阻力、惯性、组织衰减和弹性。结果表明CPB组病人的气道阻力增加(74.9%±20.8%P<0.05),而在OPCAB组病人无明显变化(11.8%±7.9%;无显著差异)CPB-DA组病人甚至会下降(-40.6%±9.2%P<0.05)CPB组和OPCAB组病人的组织衰减增加,而在CPB-DA组则保持不变。三组病人的组织弹性均显著增加。CPB前后的血管外肺水无差异,说明病人没有出现肺水肿。因此在CPB过程中病人会出现显著的、不均匀的气道狭窄,但在应用多巴胺时可被消除。组织力学的轻微改变反映了气道的部分关闭,可能与麻醉因素有关。(   王祥瑞 )

We investigated the role of cardiopulmonary bypass (CPB) in compromised lung function associated with cardiac surgery. Low-frequency respiratory impedance (Zrs) was measured in patients undergoing cardiac surgery with (n = 30; CPB group) or without (n = 29; off-pump coronary artery bypass [OPCAB] group) CPB. Another group of CPB patients received dopamine (DA) (n = 12; CPB-DA group). Extravascular lung water was determined in five CPB subjects. Zrs was measured before skin incision and after chest closure. Airway resistance and inertance and tissue damping and elastance were determined from Zrs data. Airway resistance increased in the CPB group (74.9% ± 20.8%; P < 0.05), whereas it did not change in the OPCAB group (11.8% ± 7.9%; not significant) and even decreased in the CPB-DA patients (-40.6% ± 9.2%; P < 0.05). Tissue damping increased in the CPB and OPCAB groups, whereas it remained constant in the CPB-DA patients. Significant increases in elastance were observed in all groups. There was no difference in extravascular lung water before and after CPB, suggesting that edema did not develop. These results indicate a significant and heterogeneous airway narrowing during CPB, which was counteracted by the administration of DA. The mild deterioration in tissue mechanics, reflecting partial closure of the airways, may be a consequence of the anesthesia itself.

 

心脏手术后的神经肌肉功能恢复:潘库溴铵与罗库溴铵的比较

Recovery of Neuromuscular Function After Cardiac Surgery: Pancuronium Versus Rocuronium

Glenn S. Murphy, MD*, Joseph W. Szokol, MD*, Jesse H. Marymont, MD*, Jeffery S. Vender, MD*, Michael J. Avram, PhD{dagger}, Todd K. Rosengart, MD{ddagger}, and Eihab A. Alwawi{ddagger}

Departments of *Anesthesia and {ddagger}Surgery, Evanston Northwestern Healthcare, Evanston, Illinois; and {dagger}Department of Anesthesia, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2003;96:1301-1307


临床上在“快通道”心脏手术病人中使用潘库溴铵可能使恢复延迟。本研究的目的是评估心脏手术病人使用潘库溴铵(0.08-0.1mg/kg)和罗库溴铵(0.6-0.8mg/kg)术后残余神经肌肉阻滞的发生率和严重程度。82名体外循环的手术病人随机分成潘库溴铵组(n=41)和罗库溴铵组(n=41),患者术中和术后按照标准化处理。在监护室,我们每小时测TOF率直到脱机支持开始。神经肌肉阻滞没有用药拮抗。拔管后检查患者残余麻痹的症状和体征。当脱机支持开始时,潘库溴铵组的神经肌肉阻滞作用(TOF率:平均,0.14;范围,0.00-1.11)要比罗库溴铵(TOF率:平均,0.99;范围,0.87-1.21)明显(P<0.05)。罗库溴铵组的残余麻痹的症状和体征明显比潘库溴铵组轻。我们的结果显示在心脏手术患者中使用长效肌松药不仅影响神经肌肉的恢复,而且在术后早期伴有残余的肌肉无力的症状和体征。

( 王祥瑞校)

The use of pancuronium in fast-track cardiac surgical patients may be associated with delays in clinical recovery. Our objective in this study was to evaluate the incidence and severity of residual neuromuscular blockade after cardiac surgery in patients randomized to receive either pancuronium (0.08–0.1 mg/kg) or rocuronium (0.6–0.8 mg/kg). Eighty-two patients undergoing cardiopulmonary bypass were randomized to a pancuronium (n = 41) or rocuronium (n = 41) group. Intraoperative and postoperative management was standardized. In the intensive care unit, train-of-four (TOF) ratios were measured each hour until weaning off ventilatory support was initiated. Neuromuscular blockade was not reversed. After tracheal extubation, patients were examined for signs and symptoms of residual paresis. When weaning of ventilatory support was initiated, significant neuromuscular blockade was present in the pancuronium subjects (TOF ratio: median, 0.14; range, 0.00–1.11) compared with the rocuronium subjects (TOF ratio: median, 0.99; range, 0.87–1.21) (P < 0.05). Patients in the rocuronium group were more likely to be free of signs and symptoms of residual paresis than patients in the pancuronium group. Our findings suggest that the use of longer-acting muscle relaxants in cardiac surgical patients is associated not only with impaired neuromuscular recovery, but also with signs and symptoms of residual muscle weakness in the early postoperative period.

 

深麻醉下小儿气管拔管----地氟醚与七氟醚的比较

Tracheal Extubation of Deeply Anesthetized Pediatric Patients: A Comparison of Desflurane and Sevoflurane

Robert D. Valley, MD FAAP, Eugene B. Freid, MD FAAP, FCCM, Ann G. Bailey, MD FAAP, Vincent J. Kopp, MD FAAP, Linda S. Georges, MD FAAP, James Fletcher, MBBS, and Anne Keifer, MD

Department of Anesthesiology, Division of Pediatric Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina

Anesth Analg 2003;96:1320-1324


为观察使用地氟醚和七氟醚在深度麻醉下小儿的气管拔管特点。将48个小儿随机分为两组,在手术结束时,在吸入麻醉剂的浓度达到最低有效浓度的1.5倍时拔除气管导管。记录每组的恢复特点和所发生的并发症。地氟醚组的患者在到达恢复室时的觉醒评分要高于七氟醚组,而后期的觉醒评分无显著的差异。两组都没有发生严重的并发症。地氟醚组病人的咳嗽及拔管后总的并发症的发生率较高。两组兴奋的发生都比较普遍(总体33%,地氟醚组46%,七氟醚组21%)。地氟醚组在恢复室内使用镇静剂发生率(10/24)要高于七氟醚组(3/24)。术前口服咪唑安定可显著延长强效吸入麻醉药的作用时间。(   王祥瑞校)

In this study, we examined the emergence characteristics of children tracheally extubated while deeply anesthetized with desflurane (Group D) or sevoflurane (Group S). Forty-eight children were randomly assigned to one of the two groups. At the end of the operation, all subjects were tracheally extubated while breathing 1.5 times the minimal effective concentration of assigned inhaled anesthetic. Recovery characteristics and complications were noted. Group D patients had higher arousal scores on arrival to the postanesthesia care unit than Group S patients. Later arousal scores were not significantly different. No serious complications occurred in either group. Coughing episodes and the overall incidence of complications after extubation were more frequent in Group D. Readiness for discharge and actual time to discharge were not significantly different between groups. Emergence agitation was common in both groups (33% overall, 46% for Group D, and 21% for Group S). Narcotic administration in the postanesthesia care unit occurred more frequently in Group D (10 of 24 patients) versus Group S (3 of 24 patients). Premedication with oral midazolam resulted in significantly longer emergence times regardless of the potent inhaled anesthetic administered.

 

氟烷,异氟醚和七氟醚对鼠小脑颗粒神经元非灭活钾离子通道的调控

Modulation of Noninactivating K+ Channels in Rat Cerebellar Granule Neurons by Halothane, Isoflurane, and Sevoflurane

Woo-Jong Shin, MD PhD, and Bruce D. Winegar, PhD

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

Anesth Analg 2003;96:1340-1344


神经原基质钾离子通道可由多种挥发性麻醉药激活。培养来源于七天大小的雄性Sprague-Dawley鼠的小脑Granule神经元,采用电导系数为1.1+/-0.3nS (n=20) 外向钾电流的,记录全细胞动作电位。通道激活为非灭活性,非电压门控,对常规的钾通道阻滞剂不敏感。临床相关浓度的氟烷(112224336448uM)溶于林格氏液中,外向电流分别增加29%50%63%94%,(n=5; p<0.05; 变异分析[ANOVA])。同样在异氟醚中(274411548882uM)外向电流分别增加22%47%52%60%n=5; p<0.05; [ANOVA])。七氟醚在浓度为518 uM时,电流增加225%n=10; p<0.05; [ANOVA])。所有实验中,经灌洗后通道活性迅速恢复至基线水平。外向调节的所有细胞的电流-电压曲线于麻醉药敏感的KCNC通道的特性一致。结果表明非灭活钾离子通道时挥发性麻醉药的重要靶位点。(忻纪华   王祥瑞 )

Neuronal baseline K+ channels were activated by several volatile anesthetics. Whole-cell recordings from cultured cerebellar granule neurons of 7-day-old male Sprague-Dawley rats showed outward-rectifying K+ currents with a conductance of ~1.1 ± 0.3 nS (n = 20) at positive potentials. The channel activity was noninactivating, exhibited no voltage gating, and was insensitive to conventional K+ channel blockers. Clinically relevant concentrations of halothane (112, 224, 336, and 448 µM) dissolved in Ringer’s solution increased outward currents by 29%, 50%, 63%, and 94%, respectively (n = 5; P < 0.05; analysis of variance [ANOVA]). Similar increases in currents were produced by isoflurane (274, 411, 548, and 822 µM), which increased outward currents by 22%, 47%, 52%, and 60%, respectively (n = 5; P < 0.05; ANOVA). Sevoflurane 518 µM increased outward currents by 225% (n = 10; P < 0.05; ANOVA). In all experiments, channel activity quickly returned to baseline levels during wash. The outward-rectifying whole-cell current-voltage curves were consistent with the properties of anesthetic-sensitive KCNK channels. These results support the idea that noninactivating baseline K+ channels are important target sites of volatile general anesthetics

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安氟醚通过对神经元突触前和突触后的作用,减少谷氨酸向脊髓运动神经元的神经传导

Enflurane Decreases Glutamate Neurotransmission to Spinal Cord Motor Neurons by Both Pre- and Postsynaptic Actions

Gong Cheng, MD, and Joan J. Kendig, PhD

Department of Anesthesia, Stanford University School of Medicine, Stanford, California

Anesth Analg 2003;96:1354-1359


我们已报道了挥发性麻醉药通过甘氨酸抑制脊髓运动神经元,本研究将与兴奋性递质谷氨酸作为比较。假设兴奋和抑制的平衡失调导致兴奋向抑制状态是由于大剂量的镇静剂对兴奋的抑制所致。采用膜片钳技术在小鼠脊髓切片中研究自主和诱发的谷氨酸α-氨基-3-羟基-5-甲基-4-异唑酮丙酸电流。安氟醚(0.6mM1分钟肺泡麻醉药浓度)可明显降低最小电流频率,在钠通道阻滞时(最小兴奋性突触后电位,mEPSCs)或钠离子通道未阻滞时(自主性兴奋性突触后电位,sEPSCs)。安氟醚不影响mEPSCsEPSC的振幅和动力学。对mEPSCsEPSC的影响相近。安氟醚明显降低α-氨基-3-羟基-5-甲基-4-异唑酮丙酸电流的振幅和范围,而不影响其动力学(p<0.050.01)。相反,当钠通道阻滞时,安氟醚增加最小甘氨酸电流频率,并延长甘氨酸电流持续时间。安氟醚作用于兴奋性递质谷氨酸,同时抑制了突触前和突触后电流,而甘氨酸只在某些情况下出现突触前抑制,通常是延长了突触后电流。因此,安氟醚通过直接抑制兴奋性递质,使兴奋和抑制的平衡失调。(忻纪华   王祥瑞 )

We have previously reported volatile anesthetic actions on glycinergic inhibitory transmission to spinal motor neurons. The present study is a comparable set of experiments on glutamatergic excitatory transmission. We tested the hypothesis that the balance between excitation and inhibition is shifted toward inhibition by larger depressant actions on excitation. Patch-clamp techniques were used to study spontaneous and evoked glutamate {alpha}-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid currents in rat spinal cord slices. Enflurane (0.6 mM, 1 minimum alveolar anesthetic concentration) significantly decreased spontaneous miniature current frequencies either when sodium channels were blocked (miniature excitatory postsynaptic currents, mEPSCs), or when sodium channels were not blocked (spontaneous excitatory postsynaptic currents, sEPSCs). Enflurane did not affect mEPSC or sEPSC amplitude or kinetics. The effects on mEPSCs and sEPSCs did not differ. Enflurane significantly decreased both amplitude and area of {alpha}-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid-evoked currents with no change in kinetics (P < 0.05 and 0.01, respectively). In contrast, enflurane increased miniature glycinergic current frequency when sodium channels were blocked, and prolonged glycinergic current duration. Enflurane actions on glutamatergic excitatory transmission are purely depressant both pre- and postsynaptically, whereas glycinergic inhibition is enhanced presynaptically under some conditions, and always prolonged postsynaptically. Thus, enflurane shifts the balance between synaptic excitation and inhibition in the direction of inhibition.

 

痴呆病人脑电图的低基线双频指数

Low Baseline Bispectral Index of the Electroencephalogram in Patients with Dementia

Maurizio Renna, MD FRCA*, Jonathan Handy, BSc MBBS, FRCA*, and Ajit Shah, MBChB MRCPsych{dagger}

*Department of Anaesthesia, Ealing Hospital; and {dagger}West London Mental Health NHS Trust, London, United Kingdom

Anesth Analg 2003;96:1380-1385


在清醒状态下双频指数(BIS)的基线值为96 – 99。患有Alzheimer病或血管性痴呆的病人的脑电图中会出现慢波活动增多而快波活动减少的现象。一般认为,随着脑电图的变缓双频指数会随之降低。假设痴呆病人的“清醒”双频指数要低于正常老年病人。选择36名患有Alzheimer病或多发性梗死痴呆病人和36名年龄大于75岁的对照组病人。两组均通过袖珍智力状态测试评估。使用Aspect A-2000 脑电图监测仪,从额叶引出双频指数(3.4版本)。离线数据分析使用的是较新的4.0版本的双频指数运算法则。36名痴呆病人中的14名(38%)和36名对照病人中的4名(11%)平均BIS 3.4<93P=0.006)。36名痴呆病人中的18名(50%)和36名对照病人中的8名(22%)平均BIS 4.0<93P=0.026)。痴呆病人的平均BIS 3.492.991-95),对照组病人为96.195-97)(P=0.02)。BIS 4.0的结果分别为89.186-92)和94.793-96)(P=0.002)。年龄、性别、脑电图活动和指数信号质量没有显著差别。如同所料,袖珍智力状态测试评分的差别显著(P<0.0001)。多数痴呆病人的BIS基线较低。痴呆病人BIS监测仪的使用有理由进行进一步的研究。 (殷文渊   王祥瑞 )

The baseline value of the Bispectral Index (BIS) is 96–99 in the awake state. Patients with Alzheimer’s disease or vascular dementia may show an increase in slow wave and a decrease in fast wave activity of the electroencephalogram (EEG). BIS is presumed to decrease with EEG slowing. We hypothesized that the baseline "awake" BIS is lower in dementia than in normal elderly patients. We studied 36 patients with Alzheimer’s disease or multiinfarct dementia and 36 control patients aged >75 yr. Both groups were assessed with a Mini-Mental State Test. BIS (version 3.4) was recorded from a frontal derivation using an Aspect A-2000 EEG monitor. Off-line data analysis was also performed with the newer version 4.0 of the BIS algorithm. Fourteen of 36 (38%) dementia patients and 4 of 36 (11%) controls had mean baseline BIS 3.4 <93 (P = 0.006). Eighteen of 36 (50%) dementia patients and 8 of 36 (22%) controls had mean BIS 4.0 <93 (P = 0.026). Mean (95% confidence interval) BIS 3.4 was 92.9 (91–95) in the dementia and 96.1 (95–97) in the control group (P = 0.02). Values with BIS 4.0 were, respectively, 89.1 (86–92) and 94.7 (93–96) (P = 0.002). No significant difference was found in age, sex, activity from the electromyogram, and signal quality index. As expected, the difference in Mini-Mental State Test scores was significant (P < 0.0001). A significant proportion of patients with dementia shows a low baseline BIS. The utility of the BIS monitor in detecting dementia warrants further investigation.

 

局部麻醉药抑制交感神经介导和C-纤维介导的滑液的神经性浆液外渗的差异性

Local Anesthetics Differentially Inhibit Sympathetic Neuron-Mediated and C Fiber-Mediated Synovial Neurogenic Plasma Extravasation

Christian Pietruck, MD, Stefan Grond, MD, Guo-Xi Xie, MD PhD, and Pamela P. Palmer, MD PhD

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

Anesth Analg 2003;96:1397-1402


许多种手术后都用局部麻醉药作局部冲洗。可是,近期持续使用高浓度局麻药产生中毒反应的事实说明使用降低浓度的局麻药作冲洗液是有益处的。在这个研究中,我们确定是否较低浓度局麻药可以维持抗炎和镇痛作用而不发生中毒反应。研究利多卡因和布比卡因抑制炎症两个组成部分的效能,即:老鼠膝关节中C-纤维介导的神经性炎和交感神经节后神经元介导的炎症。关节内冲洗0.02%利多卡因使5-羟色胺(5-HT)引起(SPGN介导)的浆液渗出(PE)降低35%,使用较大剂量利多卡因可以进一步降低之。关节内冲洗0.025%布比卡因可以抑制60% 5-HT引起的PE,而0.05%布比卡因可以抑制95%。较高浓度局麻药必然抑制C-纤维介导的PE要大于抑制SPGN介导的PE0.4%利多卡因使芥油引起的PE降低40%2%利多卡因将芥油引起的PE抑制到基线水平。使用0.1%布比卡因能降低80%PE0.25%布比卡因将芥油引起的PE降低到基线水平。我们的结果揭示了局麻药对SPGN-C-纤维介到的PE的特异性影响,证实了较小浓度局麻药可以抑制术后炎症的观点。(殷文渊   王祥瑞 )

Local anesthetics are used for local irrigation after many types of operations. However, recent evidence of toxic effects of local anesthetics at large concentrations during continuous administration suggests an advantage of using decreased local anesthetic concentrations for irrigation solutions. In this study, we determined whether smaller concentrations of local anesthetics may maintain an antiinflammatory and, therefore, analgesic effect without the risk of possible toxicity. Lidocaine and bupivacaine were studied for their ability to inhibit both components of neurogenic inflammation—C fiber-mediated and sympathetic postganglionic neuron (SPGN)-mediated inflammation—in the rat knee joint. Intraarticular lidocaine 0.02% reduced 5-hydroxytryptamine (5-HT)-induced (SPGN-mediated) plasma extravasation (PE) by 35%, and further decreases were obtained by perfusing larger concentrations of lidocaine. Intraarticular bupivacaine 0.025% inhibited 5-HT-induced PE by 60%, and a 95% inhibition was obtained with bupivacaine 0.05%. Larger local anesthetic concentrations were necessary to inhibit C fiber-mediated PE than those required to inhibit SPGN-mediated PE. Lidocaine 0.4% was required to reduce mustard oil-induced PE by 60%. Lidocaine 2% inhibited mustard oil-induced PE to baseline levels. Bupivacaine 0.1% was required for an 80% reduction of PE. Bupivacaine 0.25% inhibited mustard oil-induced PE to baseline levels. Our results demonstrate differential effects of local anesthetics on SPGN- and C fiber-mediated PE but confirm the concept of using smaller concentrations of local anesthetics to achieve inhibition of postoperative inflammation.

 

在急救运输中局部加热对减少胆囊炎患者腹痛的作用

The Influence of Local Active Warming on Pain Relief of Patients with Cholelithiasis During Rescue Transport

Alexander Kober, MD*, Thomas Scheck, MD*, Freia Tschabitscher, MD*, Stefanie Wiltschnig, MD*, Sabine Sator-Katzenschlager, MD*, Werner Madei, MD{dagger}, Burkhard Gustorff, MD*, and Klaus Hoerauf, MD*

*Department of Anesthesia and Intensive Care, University of Vienna; and {dagger}Department of Anesthesia, Armed Forces Medical Hospital, Amberg, Germany

Anesth Analg 2003;96:1447-1452


上腹部疼痛是胆囊疾病的常见症状,在澳大利亚急救呼叫中占6%的比例,胆囊炎所引起的疼痛是剧烈的。最近的数据表明:在急救运输途中局部加热能有效地减少疼痛。因此我们假设局部加热腹部是有效地减少急性胆囊炎的方法,并且能通过护理实现。60例患者(>19岁)同意参与本试验。分为两组:组1使用碳化纤维毯(42℃)接受上腹部加热治疗;组2没有采用腹部加热。两组没有患者接受止痛药物。要求患者使用视觉疼痛评分表(VAS)评价其疼痛和焦虑情况。统计学处理使用Student’s t检验,p0.05认为有显著性。根据VAS评分,组1所有患者疼痛均有显著改善,从86.8±5.5mm下降至41.2±16.2mm,而组2的评分前后保持相近,从88.38±9.9mm88.1±10.0mm。比较两组患者到达医院时的疼痛评分,差异有显著性,p0.01。在组1,焦虑VAS评分有显著改善,从治疗前82.7±10.8mm至治疗后39.0±14.0mm,组2的分数没有显著变化,从84.5±14.6mm83.5±8.4mm。两组到达医院时的焦虑评分有显著差异,p0.01。我们的结论是:局部加热是有效而且简单易学的治疗急诊胆囊炎引起的疼痛的方法。(    王祥瑞 )

Upper abdominal pain, a frequent symptom of the presence of gallstone disease, is the cause of 6% of the emergency calls of the Austrian emergency system. Pain resulting from cholelithiasis is characteristically severe. Recent data show that active warming during emergency transport of trauma victims is effective in reducing pain. Therefore, we hypothesized that local active warming of the abdomen would be an effective pain treatment for patients with acute cholelithiasis and could be provided by paramedics. Sixty patients (>19 yr) consented to participate in this study. They were divided into two groups: Group 1, who received active warming of the upper abdomen with a carbon-fiber warming blanket (42°C), and Group 2, who received no warming of the abdomen. Neither group received any drug-based pain care. Patients were asked to rate their pain and anxiety by using visual analog scales (VAS). Statistical evaluation was performed with Student’s t-test; P < 0.05 was considered significant. In Group 1, a significant (P < 0.01) pain reduction was recorded in all cases on a visual analog scale (VAS), from 86.8 ± 5.5 mm to 41.2 ± 16.2 mm. In Group 2, the patients’ pain scores remained comparable, from 88.3 ± 9.9 mm to 88.1 ± 10.0 mm on a VAS. In comparing Group 1 with Group 2 on arrival at the hospital, pain scores showed a significant difference (P < 0.01). In Group 1, the VAS score changes for anxiety were significantly reduced (P < 0.01), from 82.7 ± 10.8 mm before treatment to 39.0 ± 14.0 mm after treatment. In Group 2, a nonsignificant change of this score was noted, from 84.5 ± 14.6 mm to 83.5 ± 8.4 mm. Comparing Group 1 with Group 2 on arrival at the hospital showed a significant difference in anxiety scores (P < 0.01). We conclude that local active warming is an effective and easy-to-learn treatment for pain resulting from acute cholelithiasis in emergency care.

 

电磁共振技术测量麻醉大鼠的脑组织氧张力

Electron Paramagnetic Resonance Assessment of Brain Tissue Oxygen Tension in Anesthetized Rats

Huagang Hou, MD*, Oleg Y. Grinberg, PhD*, Satoshi Taie, MD{dagger}, Steve Leichtweis, PhD*, Minoru Miyake, MD PhD{dagger}, Stalina Grinberg, MS*, Haiyi Xie, PhD{ddagger}, Marie Csete, MD PhD§, and Harold M. Swartz, MD PhD*

*Department of Diagnostic Radiology, Dartmouth Medical School, Hanover, New Hampshire; {dagger}Department of Anesthesiology and Emergency Medicine, Kagawa Medical University, Kagawa, Japan; {ddagger}Department of Community and Family Medicine, Psychiatric Research Center, Dartmouth Medical School, Lebanon, New Hampshire; and §Anesthesiology and Cell Biology, Emory University, Atlanta, Georgia

Anesth Analg 2003;96:1467-1472

 

足够的脑组织氧合(PtO2)是危重病人和麻醉中患者的中枢性治疗目标。目前临床上通过间接方法测量PtO2,应用红外分光镜测量脑血管氧含量。实验室中使用正电子发射X线断层照片来测量。近年来电磁共振技术(EPR)的发展提高了测量的精确性、敏感性和可重复性。EPR与核磁共振相似但探测的是顺磁性的核素。有机体内大脑(或其他组织)中这些核素的含量不多,我们把顺磁性的锂苯二甲蓝晶体灌注入大脑皮质进行测量。组织中EPR光谱的宽度与PtO2成线性关系。在麻醉大鼠中应用EPR技术,研究接触不同吸入麻醉药物、静脉麻醉药物和吸入不同氧浓度时的PtO2。大鼠使用2MAC的异氟醚麻醉获得的PtO2最高(38.0±4.5mmHg),而氯胺酮/甲苯噻嗪麻醉时最低(3.5±0.3mmHg),吸入氧浓度(FIO2)为0.21 p0.05FIO21.0时,氯胺酮/甲苯噻嗪麻醉的PtO28.8±0.3mmHg p0.05。此时异氟醚麻醉的PtO256.3±1.7mmHgp0.05。这些数据说明了EPR在麻醉中测量PtO2的效用,并且可以作为进一步研究生理性影响和药物直接干预对预防脑缺血的基础。

                                                   (    王祥瑞 )

The adequacy of cerebral tissue oxygenation (PtO2) is a central therapeutic end point in critically ill and anesthetized patients. Clinically, PtO2 is currently measured indirectly, based on measurements of cerebrovascular oxygenation using near infrared spectroscopy and experimentally, using positron emission tomographic scanning. Recent developments in electron paramagnetic resonance (EPR) oximetry facilitate accurate, sensitive, and repeated measurements of PtO2. EPR is similar to nuclear magnetic resonance but detects paramagnetic species. Because these species are not abundant in brain (or other tissues) in vivo, oxygen-responsive paramagnetic lithium phthalocyanine crystals implanted into the cerebral cortex are used for the measurement of oxygen. The line widths of the EPR spectra of these materials are linear functions of PtO2. We used EPR oximetry in anesthetized rats to study the patterns of PtO2 during exposure to various inhaled and injected general anesthetics and to varying levels of inspired oxygen. Rats anesthetized with 2.0 minimum alveolar anesthetic concentration isoflurane maintained the largest PtO2 (38.0 ± 4.5 mm Hg) and rats anesthetized with ketamine/xylazine had the smallest PtO2 (3.5 ± 0.3 mm Hg) at a fraction of inspired oxygen (FIO2) of 0.21, P < 0.05. The maximal PtO2 achieved under ketamine/xylazine anesthesia with FIO2 of 1.0 was 8.8 ± 0.3 mm Hg, whereas PtO2 measured during isoflurane anesthesia with FIO2 of 1.0 was 56.3 ± 1.7 mm Hg (P < 0.05). These data highlight the experimental utility of EPR in measuring PtO2 during anesthesia and serve as a foundation for further study of PtO2 in response to physiologic perturbations and therapeutic interventions directed at preventing cerebral ischemia.


随机、双盲观察可乐定联合小剂量布比卡因在脊髓麻醉下腹股沟疝修补术中的应用

Clonidine Combined with Small-Dose Bupivacaine During Spinal Anesthesia for Inguinal Herniorrhaphy: A Randomized Double-Blinded Study

I. Dobrydnjov, MD*, K. Axelsson, MD PhD*, S.-E. Thörn, MD PhD*, P. Matthiesen, MD{dagger}, H. Klockhoff, MD PhD{dagger}, B. Holmström, MD PhD*, and A. Gupta, MD FRCA, PhD*

Departments of *Anesthesiology and Intensive Care and {dagger}Surgery, University Hospital, Örebro, Sweden

Anesth Analg 2003;96:1496-1503

在本次随机实验中主要研究小剂量可乐定联合小剂量布比卡因作为脊髓麻醉时是否会延长术后镇痛时间,同时提供有效的阻滞,从而适用于腹股沟疝修补手术。随机选择45位患者分为三组,鞘内均注入高比重的布比卡因6mgB组加入盐水,BC15组加入15ug可乐定,BC30组加入30ug可乐定,所有溶液都用盐水稀释至3mlB组中的5位患者术中感觉阻滞平面不满意,随后改用全身麻醉。而BC15BC30组的患者感觉阻滞平面较之B组显著提高了2-4个节段。然而BC30S1段感觉恢复及运动阻滞恢复的时间则明显长于B组。布比卡因中加入15ug30ug可乐定可延长起初的痛觉阻滞需要,同时减轻术后疼痛,而术后发生低血压的危险性也较小。因此,我们得出结论:布比卡因中加入15ug可乐定可提供一有效得脊髓麻醉效果,同时由于它不会延长运动阻滞时间而适用于腹股沟疝修补手术。 (朱慧琛   王祥瑞 )

The aim of this randomized double-blinded study was to see whether the addition of small-dose clonidine to small-dose bupivacaine for spinal anesthesia prolonged the duration of postoperative analgesia and also provided a sufficient block duration that would be adequate for inguinal herniorrhaphy. We randomized 45 patients to 3 groups receiving intrathecal hyperbaric bupivacaine 6 mg combined with saline (Group B), clonidine 15 µg (Group BC15), or clonidine 30 µg (Group BC30); all solutions were diluted with saline to 3 mL. The sensory block level was insufficient for surgery in five patients in Group B, and these patients were given general anesthesia. Patients in Groups BC15 and BC30 had a significantly higher spread of analgesia (two to four dermatomes) than those in Group B. Two-segment regression, return of S1 sensation, and regression of motor block were significantly longer in Group BC30 than in Group B. The addition of clonidine 15 and 30 µg to bupivacaine prolonged time to first analgesic request and decreased postoperative pain with minimal risk of hypotension. We conclude that clonidine 15 µg with bupivacaine 6 mg produced an effective spinal anesthesia and recommend this dose for inguinal herniorrhaphy, because it did not prolong the motor block.

 

插入式喉罩通气用于病理性肥胖患者的气道处理

Airway Management Using the Intubating Laryngeal Mask Airway for the Morbidly Obese Patient

Jérôme Frappier, MD, Thierry Guenoun, MD, Didier Journois, MD, Hervé Philippe, MD, Emma Aka, MD, Philippe Cadi, MD, Jacqueline Silleran-Chassany, MD, and Denis Safran, MD

Department of Anesthesiology and Intensive Care, European Hospital Georges Pompidou, Paris, France

Anesth Analg 2003;96:1510-1515

 

为观察病理性肥胖患者手术中应用插入式喉罩通气的效用。选择118位病理性肥胖患者(45+5kg/m2)。全麻诱导后首先进行喉部评估分类(CormackLehane法),随后置入喉罩通气(ILMA),然后将导管经由ILMA插入气管,其成功率为96.3%。喉部低位(Cormach1-2)或高位(Cormach3-4)患者置入ILMA的成功率、尝试次数及整个操作过程无明显区别。仅高位者插入ILMA的时间轻微延长。结果表明ILMA可作为病理性肥胖患者的一个新的气道管理方式。(朱慧琛  王祥瑞 )

We studied the effectiveness of the intubating laryngeal mask airway (ILMA) in morbidly obese patients scheduled for bariatric surgery. We included 118 consecutive morbidly obese patients (body mass index, 45 ± 5 kg/m2). After the induction of general anesthesia, the laryngeal view was classified by the first observer according to the method of Cormack and Lehane. The ILMA was then inserted, and the trachea was intubated through the ILMA by a second observer. The rate of successful tracheal intubation with ILMA was 96.3%. The success rate, the number of attempts, and the total duration of the procedure were not different among patients with low-grade (Cormack 1–2) and patients with high-grade (Cormack 3–4) laryngeal views. The time required for insertion of the ILMA was slightly longer in patients with high-grade laryngeal views. Failures of the technique were not explained by the experience of the practitioner or airway characteristics. No adverse effect related to the technique was reported. Results of this study suggest that using the ILMA provides an additional technique for airway management of morbidly obese patients.

心脏术后检测肾功能不全的替代方法的评价

Evaluating Surrogate Measures of Renal Dysfunction After Cardiac Surgery

Duminda N. Wijeysundera, MD*, Vivek Rao, MD PhD, FRCSC{dagger}, W. Scott Beattie, MD PhD, FRCPC{ddagger}, Joan Ivanov, RN MSc, PhD{dagger}, and Keyvan Karkouti, MD MSc, FRCPC{ddagger},§

*Department of Anaesthesia, University of Toronto; {dagger}Division of Cardiac Surgery, Toronto General Hospital, University Health Network; {ddagger}Department of Anaesthesia, University Health Network, University of Toronto; and §Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada    Anesth Analg 2003 96: 1265-1273.

心脏术后发生的肾功能不全使病人死亡率增加,ICU住院时间延长。应用简单方法对肾功能进行评价有利于肾功能的保护。本研究对以血肌酐72h的变化({Delta}Cr72h)和每72h血肌酐的变化(%{Delta}CrCl72h)为指标检测肾功能的方法进行了评价。选择Toronto医院 1999-2000年期间的2000例行冠状动脉搭桥术,瓣膜手术或同时行两种手术的病人为对象,用频度直方图和概率图对变量进行分析。用手术特征曲线图(ROC)对上述指标与透析、 死亡率、 ICU住院时间等关系进行分析。结果显示,{Delta}Cr72h分布向右偏斜, 而%{Delta}CrCl72h分布正常。ROC 曲线显示{Delta}Cr72h能较好预测透析(0.98) 、死亡率(0.83)和住院时间延长(0.74)ROC 曲线面积与透析(P = 0.89) 、 死亡率(P = 0.49)和住院时间延长(P = 0.85)之间无显著差异。两种变量都与病人的预后有关。将{Delta}Cr72h转化为%{Delta}CrCl72h使数据分布转化为正态。{Delta}Cr72h%{Delta}CrCl72h可以作为病人预后的指标。结论 {Delta}Cr72h%{Delta}CrCl72h都与预后有关,而%{Delta}CrCl72h更接近正态分布,易于统计。(王士雷 译 庄心良 校)

Renal insufficiency after cardiac surgery is associated with increased mortality, morbidity, and length of intensive care unit stay. A convenient surrogate measure would facilitate the evaluation of renal-protective therapies. We evaluated two measures: the 72-h change in serum creatinine (Cr) ({Delta}Cr72h) and the percentage 72-h change in calculated (Cockcroft-Gault equation) Cr clearance (%{Delta}CrCl72h). We randomly selected 2000 individuals who underwent aortocoronary bypass, valve surgery, or both at the Toronto General Hospital between May 1999 and August 2000. The variables were analyzed with frequency histograms and normal probability plots. Their association with dialysis, mortality, and prolonged intensive care unit stay was determined by using receiver operating characteristic (ROC) curves. {Delta}Cr72h was skewed to the right, whereas %{Delta}CrCl72h was normally distributed. ROC curve areas showed {Delta}Cr72h to be a good predictor of dialysis (0.98), death (0.83), and prolonged hospitalization (0.74). %{Delta}CrCl72h had similar ROC curve areas for predicting dialysis (0.97), death (0.82), and prolonged hospitalization (0.74). ROC curve areas did not differ significantly with respect to mortality (P = 0.89), dialysis (P = 0.49), or prolonged hospitalization (P = 0.85). Both variables were correlated with patient-relevant outcomes. Mathematical transformation of {Delta}Cr72h to %{Delta}CrCl72h results in a normal distribution that is amenable to parametric statistical tests. {Delta}Cr72h and %{Delta}CrCl72h may be used as surrogate outcomes in future trials.

 

用食道超声心动图指导术中下腔静脉插管

Guiding Surgical Cannulation of the Inferior Vena Cava with Transesophageal Echocardiography

Idar Kirkeby-Garstad, MD*, Arve Tromsdal, MD{dagger}, Olav F. M. Sellevold, MD PhD*, Mads Bjørngaard, MD*, Lise K. Bjella, MD*, Einar M. Berg, MD*, Asbjørn Karevold, MD{ddagger}, Rune Haaverstad, MD PhD{ddagger}, Alexander Wahba, MD PhD{ddagger}, Ole Tjomsland, MD PhD{ddagger}, Rafael Astudillo, MD PhD{ddagger}, Arne Krogstad, CCP{ddagger}, and Roar Stenseth, MD PhD*

Departments of *Anaesthesia, {dagger}Cardiology, and {ddagger}Surgery, St. Elisabeth Heart Centre, University Hospital of Trondheim, Norway

Anesth  Analg 2003 96: 1288-1293.

 

150例成年患者接受心脏手术,术中使用经食道超声心动图监测静脉套管的位置和静脉系统的情况,及套管置入肝静脉的发生率,记录图像质量,静脉直径,套管位置及静脉回流量。结果显示,下腔静脉和右肝静脉的图像质量满意度分别为95%87%。静脉直径的个体差异相当大。99%的套管位置可以确定。套管置入右肝静脉的发生率为10%。腔静脉瓣和右肝静脉的间距很短,套管容易进入右肝静脉。患者的其他情况不影响套管位置。套管在下腔静脉的深度与静脉回流量的下降有关,比套管误入肝静脉更影响回流量。结论:术中使用经食道超声心动图基本上可以准确监测套管的位置。(轩 泓 译  庄心良 校)

We studied 150 adult cardiac surgery patients to assess visualization of the venous cannula and the venous system by intraoperative transesophageal echocardiography and to register the incidence of cannulation of hepatic veins. The quality of images, the dimensions of the venous system, the position of the venous cannula, and the adequacy of venous return were registered. Acceptable image quality of the inferior vena cava and the right hepatic vein (RHV) was obtained in 95% and 87% of cases, respectively. Considerable individual variations were found in the dimensions of the venous system. The cannula position could be determined in 99% of the cases. Ten percent of venous cannulae were primarily placed in the RHV. A short distance between the eustachian valve and the RHV possibly predisposes to cannulation of the RHV. No other patient-related factors were associated with cannula position. Placement of the cannula deep in the inferior vena cava was associated with reduced venous return and may be a more important cause of reduced return than a cannula positioned in a hepatic vein

.

异氟醚对豚鼠心室肌慢激活延迟整流钾通道的影响

The Effects of Isoflurane on the Cardiac Slowly Activating Delayed-Rectifier Potassium Channel in Guinea Pig Ventricular Myocytes

Akihiro Suzuki, MD*, Zeljko J. Bosnjak, PhD*,{dagger}, and Wai-Meng Kwok, PhD*,{ddagger}

Departments of *Anesthesiology, {dagger}Physiology, and {ddagger}Pharmacology & Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2003 96: 1308-1315.

 

慢激活延迟整流钾通道是引起心脏动作电位去极化的主要外向电流。此通道的功能障碍可以引起动作电位时程延长,导致长QT综合征。我们推测麻醉药引起的动作电位延长除与其抑制快激活延迟整流钾通道有关外,尚与慢激活延迟整流钾通道有关。本文应用全细胞膜片钳技术探讨异氟醚对这两种通道电流的作用以及蛋白激酶C对这种作用的影响。结果显示,异氟醚以剂量依赖的方式抑制慢激活钾通道电流。在22°C时,临床相关浓度(0.3-0.6mM)异氟醚对通道的抑制作用较36°C 时强。异氟醚不影响电压依赖性慢激活钾通道的激活。在22°C 时,异氟醚加速慢激活钾通道的失活,但在36°C 时则无此现象。异氟醚对慢激活延迟整流钾通道的抑制作用明显比快激活延迟整流钾通道强。蛋白激酶C的激活使慢激活延迟整流钾通道电流增强,但是,不抑制异氟醚对此电流的抑制作用。结论:麻醉药对慢激活延迟整流钾通道的抑制作用是其引起动作电位延长和QT间期延长的机制之一。

(王士雷 译 庄心良 校)

The slowly activating delayed-rectifier potassium current, IKs, is a major outward current responsible for the repolarization of the cardiac action potential (AP). Dysfunction of this channel can lead to AP prolongation, resulting in the long QT syndrome. We hypothesized that anesthetic-induced AP prolongation is caused by inhibition of IKs, in addition to the inhibition of IKr (rapidly activating delayed-rectifier potassium channel current), a condition often found in drug-induced AP prolongation. The whole-cell patch clamp technique was used to study the effects of isoflurane on IKs and IKr recorded from guinea pig single ventricular myocytes. The effect of protein kinase C on IKs inhibition by isoflurane was also investigated. Isoflurane inhibited IKs in a concentration- and temperature-dependent manner. The inhibitory effects of isoflurane at clinically relevant concentrations of 0.3 and 0.6 mM were greater at 22°C than at 36°C. Voltage-dependent activation of IKs was not affected at these concentrations. IKs deactivation kinetics were accelerated by isoflurane at 22°C but not at 36°C. Isoflurane inhibition of IKs was significantly greater than that of IKr. Protein kinase C activation enhanced IKs but did not suppress the inhibitory effect of isoflurane. Our results suggest that IKs inhibition is one of the mechanisms underlying anesthetic-induced AP and QT prolongation. Because most of the ion channel studies on anesthetic effects are conducted at room temperature, the temperature-dependent effect on IKs confirms the importance of anesthetic experiments conducted at physiological temperature

.

梗阻性睡眠呼吸暂停综合征不是门诊手术患者意外住院的危险因素

The Diagnosis of Obstructive Sleep Apnea as a Risk Factor for Unanticipated Admissions in Outpatient Surgery

Candace Sabers, MD, David J. Plevak, MD, Darrell R. Schroeder, MS, and David O. Warner, MD

Anesthesia Clinical Research Unit, Departments of Anesthesiology and Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Anesth Analg 2003 96: 1328-1335

.

本研究目的是探讨术前梗阻性睡眠呼吸暂停综合症(OSA)是否是门诊患者行非耳鼻喉手术发生围术期并发症的独立危险因素。作者回顾性分析了某家三级治疗中心的234例患者的资料,术前用多导睡眠监测法确诊为OSA,于1997年到2000年间行门诊手术。对照组的麻醉方式,年龄,性别,体重指数,手术方式及手术日期与研究组相配。分析两组的围术期医疗记录。除OSA组较少使用喉罩外,两组的术中管理无显著差异。OSA组和非OSA组的意外住院率(23.9% 18.8%; 相对危险度 1.4; 95% 可信区间0.8–2.5)和其他不良事件的发生率(2.1% 1.3%; 相对危险度 1.7; 95% 可信区间 0.4–7.0)也无明显差别。意外住院基本上与心脏和呼吸事件无关。结论:术前OSA不是门诊手术患者意外住院或发生其他不良事件的危险因素。(轩   庄心良 校)

The goal of this study was to determine whether the preoperative diagnosis of obstructive sleep apnea (OSA) is an independent risk factor for perioperative complications in patients undergoing nonotorhinolaryngologic outpatient surgical procedures. We used existing databases to identify 234 patients with polysomnography-confirmed OSA who had outpatient surgical procedures in the years 1997 through 2000. Control patients were matched for type of anesthesia, age, sex, body mass index, surgical procedure, and surgical date. Their perioperative medical records were reviewed. There was no significant difference in the intraoperative management of OSA and control patients, except that the laryngeal mask airway was less likely to be used in OSA patients. There was no

significant difference in the rate of unplanned hospital admissions (23.9% versus 18.8%; odds ratio, 1.4; 95% confidence interval, 0.8–2.5) or other adverse events (2.1% versus 1.3%; odds ratio, 1.7; 95% confidence interval, 0.4–7.0) between OSA and non-OSA patients. Further, when admission did occur, it was generally unrelated to cardiac or respiratory events. In this retrospective analysis, the preoperative diagnosis of OSA was not a risk factor for either unanticipated hospital admission or for other adverse events among patients undergoing outpatient surgical procedures in a tertiary referral center.

 

 

钾通道KCNK5 Kir3.2突变并不改变麻醉药的MAC

Mutation of KCNK5 or Kir3.2 Potassium Channels in Mice Does Not Change Minimum Alveolar Anesthetic Concentration

Karin M. Gerstin, PhD, Diane H. Gong, BS, Mona Abdallah, PhD, Bruce D. Winegar, PhD, Edmond I Eger, II, MD, and Andrew T. Gray, MD PhD

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

Anesth Analg 2003 96: 1345-1349.

一些研究结果提示,临床浓度的吸入麻醉药通过使钾通道不失活而导致超极化状态,从而降低兴奋性,进一步导致麻醉状态的产生。因此,我们推测缺乏这些通道的动物可能对麻醉药不敏感。我们对缺乏钾通道功能亚单位KCNK5以及钾通道Kir3.2突变的大鼠的MAC进行了研究。结果,KCNK5缺乏大鼠的地氟醚、氟烷、 异氟醚MAC以及Kir3.2突变大鼠的异氟醚MAC与正常对照大鼠无差别。我们的结果不支持钾通道调节麻醉药制动作用的推论。(王士雷 译  庄心良 校)

Several reports suggest that clinically used concentrations of inhaled anesthetics can increase conductance through noninactivating potassium channels and that the resulting hyperpolarization might decrease excitability, thereby leading to the anesthetic state. We speculated that animals deficient in such potassium channels might be resistant to the effects of anesthetics. Thus, in the present study, we measured the minimum alveolar anesthetic concentration (MAC) needed to prevent movement in response to a noxious stimulus in 50% of adult mice lacking functional KCNK5 potassium channel subunits and compared these results with those for heterozygous and wild-type mice. We also measured MAC in weaver mice that had a mutation in the potassium channel Kir3.2 and compared the resulting values with those for wild-type mice. MAC values for desflurane, halothane, and isoflurane for KCNK5-deficient mice and isoflurane MAC values for weaver mice did not differ from MAC values found in control mice. Our results do not support the notion that these potassium channels mediate the capacity of inhaled anesthetics to produce immobility. In addition, we found that the weaver mice did not differ from control mice in their susceptibility to convulsions from the nonimmobilizers flurothyl [di-(2,2,2,-trifluoroethyl)ether] or 2N (1,2-dichlorohexafluorocyclobutane).

 

出血性休克对依托咪酯的影响:药理和药代动力学的分析

The Influence of Hemorrhagic Shock on Etomidate: A Pharmacokinetic and Pharmacodynamic Analysis

Ken B. Johnson, MD, Talmage D. Egan, MD, Jennifer Layman, BS, Steven E. Kern, PhD, Julia L. White, RN BS, and Scott W. McJames, MS

Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah

Anesth Analg 2003 96: 1360-1368.

 

我们研究了猪出血性休克对依托咪酯药理性的影响。16只动物随机分成对照组和休克组。休克组出血至平均动脉压50mmHg并维持至约30ml/kg血被放出。两组依托咪酯300 µg kg-1 · min-110 min内输入。给药后180 min内抽5次动脉血测血药浓度。每组以三室模型获得药代动力学参数。BIS作药物效应指标。药效学以S状最大抑制效应曲线为特征。数据显示休克组在药物输入10 min时血药浓度增加25%,之后渐下降,药代动力学显示两组轻微变化。两组依托咪酯产生相似的BIS分数。本实验显示中等出血性休克对依托咪酯药代动力学影响轻微,而对药效学则无影响,这与出血性休克对大多数其它镇静药或阿片药的影响不同。(王立中  译 庄心良 校)

We studied the influence of hemorrhagic shock on the pharmacology of etomidate in swine. Sixteen swine were randomly assigned to control and shock groups. The shock group was bled to a mean arterial blood pressure of 50 mm Hg and held there until 30 mL/kg blood was removed. Etomidate 300 µg · kg-1 · min-1 was infused for 10 min to both groups. Fifteen arterial samples were collected until 180 min after the infusion began to determine drug concentration. Pharmacokinetic variables for each group were estimated by using a three-compartment model. The bispectral index scale was used as a measure of drug effect. The pharmacodynamics were characterized by using a sigmoid inhibitory maximal effect model. The raw data revealed a 25% increase in the plasma etomidate concentration at the end of the 10-min infusion which resolved after termination of the infusion in the shock group. The pharmacokinetic analysis revealed subtle changes in the variable estimates between groups. The etomidate infusion produced a similar Bispectral Index Scale change in both groups. These results demonstrated that, unlike the influence of hemorrhagic shock on other sedative hypnotics and opioids, moderate hemorrhagic shock produced minimal changes in the pharmacokinetics and no change in the pharmacodynamics of etomidate.

 

咪唑安定能增强鞘内注射布比卡因对热或炎症疼痛的镇痛作用

Midazolam Can Potentiate the Analgesic Effects of Intrathecal Bupivacaine on Thermal- or Inflammatory-Induced Pain

Tomoki Nishiyama, MD PhD, and Kazuo Hanaoka, MD PhD

Department of Anesthesiology, The University of Tokyo, Tokyo, Japan

Anesth Analg 2003 96: 1386-1391.

 

硬膜外注射咪唑安定可以增强硬膜外注射布比卡因的镇痛效果。但是,仍不清楚这种作用是相加还是协同。我们研究了咪唑安定和布比卡因在脊髓部位的相互作用。药物通过预先埋置的蛛网膜下腔导管给予,用热甩尾实验和福尔马林实验进行疼痛刺激。通过行为学评价确定鞘内咪唑安定和布比卡因的50%有效剂量,用等效线图分析法研究两者的相互作用。结果,两种药物的镇痛作用均有剂量依赖性。复合用药的50%的有效剂量明显低于估计的两药相加的剂量(甩尾实验,P = 0.023; 福尔马林实验第一阶段,P = 0.0025 ,第二阶段,p0.047)。两种药物复合应用时行为的副作用显著低于两种药物单独应用。结论:鞘内注射咪唑安定和布比卡因对热和炎症导致的疼痛有协同作用,而副作用的发生率显著降低。

(王士雷 译   庄心良校)

Epidurally administered midazolam can potentiate analgesia by epidural bupivacaine. However, whether this effect is synergistic or additive is not known. In this study, we investigated the spinally-mediated analgesic interaction between midazolam and bupivacaine by using the tail-flick and formalin tests in rats with chronically implanted catheters. Behavioral effects were also observed. The dose dependency of analgesia and the 50% effective doses of intrathecal midazolam and bupivacaine were determined, and then the interaction of these two drugs was examined with an isobolographic analysis. Both drugs had dose-dependent analgesic effects in both the tail-flick test and the formalin test. The 50% effective dose values of the combination were significantly lower than the calculated additive values in both tests (P = 0.023 in the tail-flick test; P = 0.0025 in Phase 1 and 0.047 in Phase 2 of the formalin test). Behavioral side effects decreased in the combination group compared with each drug alone. In conclusion, intrathecally administered midazolam and bupivacaine had synergistic analgesic effects on acute thermal- or inflammatory-induced pain, with decreased behavioral side effects.

 

脊髓m4毒蕈碱受体参与鞘内注射可乐定减少机械性损伤神经的过敏反应

Intrathecal Clonidine Reduces Hypersensitivity After Nerve Injury by a Mechanism Involving Spinal m4 Muscarinic Receptors

Yoo-Jin Kang, and James C. Eisenach

Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2003;96:1403-1408


{alpha}2-肾上腺素能激动剂可减少神经损伤动物机械和热刺激引发的过敏反应,也可治疗人的神经病理性疼痛。先前研究表明,此作用是由于{alpha}2-肾上腺素能激动剂的脊髓胆碱能激动作用和对毒蕈碱受体的激动作用。正常动物脊髓中与防感受伤害的毒蕈碱受体亚型至今仍有争议,而且能减少过敏反应的亚型和其与神经损伤后{alpha}2-肾上腺素能系统相互作用的亚型尚无报道。本实验结果显示,牢固结扎大鼠L5L6左侧脊神经使针刺引发撤退反应的阈值降低。鞘内注射可乐定15 µg,使撤退反应阈值恢复。应用高度特异性m1m4拮抗剂,发现m1拮抗剂不能减弱可乐定的作用,而m4拮抗剂可抑制可乐定的作用。通过Westen 分析发现,结扎组和对照组脊髓背角m1m4受体蛋白表达量无区别,说明这种与m4受体的相互作用不能反映受体表达增多。结论:可乐定可有效治疗神经病理性疼痛并使人脑脊液中乙酰胆碱浓度增高。本实验表明m4受体在可乐定治疗神经损伤后的过敏反应起重要作用。(赵雪莲     庄心良  校)

{alpha}2-Adrenergic agonists reduce mechanical and thermal hypersensitivity in animals with nerve injury and effectively treat neuropathic pain in humans. Previous studies indicate a reliance of {alpha}2-adrenergic agonists in this setting on spinal cholinergic activation and stimulation of muscarinic receptors. The subtype(s) of muscarinic receptors in the spinal cord that produces antinociception in normal animals is controversial, and those involved in reducing hypersensitivity and interacting with {alpha}2-adrenergic systems after nerve injury are unstudied. To examine this, the left L5 and L6 spinal nerves were tightly ligated in rats, resulting in reduction in withdrawal threshold to punctate mechanical stimuli. Intrathecal clonidine, 15 µg, returned the withdrawal threshold to normal. Using highly specific m1 and m4 antagonists, we observed no reduction in the effect of clonidine by the m1 antagonist, but inhibition of clonidine’s effect by the m4 antagonist. Western analysis revealed no difference in quantitative expression of m1 and m4 receptor protein in the dorsal spinal cord of spinal nerve-injured animals compared with sham-operated controls, suggesting this interaction with m4 receptors

 

严重脑外伤病人反复输入大剂量新型羟基淀粉130/0.4

Repetitive Large-Dose Infusion of the Novel Hydroxyethyl Starch 130/0.4 in Patients with Severe Head Injury

Thomas A. Neff, MD*, Martin Doelberg, PhD{ddagger}, Cornelius Jungheinrich, MD{ddagger}, Andrea Sauerland{dagger}, Donat R. Spahn, MD*, and Reto Stocker, MD{dagger}

*Institute of Anesthesiology and {dagger}Division of Surgical Intensive Care, University Hospital, Zurich, Switzerland; {ddagger}Clinical Research Department, Fresenius Kabi, Bad Homburg, Germany

Anesth Analg 2003 96: 1453-1459.

 

在此前瞻性随机对照单中心试验中,我们研究了颅脑外伤病人大剂量反复输入新型羟基淀粉溶液(6% HES 130/0.4)的安全性。病人随机反复接受HES 130/0.4n16)剂量达70ml/kg/d(文献中报道的最大剂量)或在输入总量达70ml/kg/d白蛋白后给予对照的HES 200/0.5 (n = 15)直至最大限量33ml/kg/dHES 200/0.5+白蛋白)。我们发现两组在死亡率,肾功能,出血并发症及使用血制品之间没有差异。另外在凝血指标上也无大的不同。不过,在某些时间点,尽管输入大剂量羟基淀粉溶液,VIII因子,von Willebrand因子和ristocetin 辅因子在HES 130/0.4组仍较高。我们认为HES 130/0.4可以安全应用于重症脑外伤病人数天直至剂量达到70ml/kg/d

(张军 译  庄心良 校)

In this prospective, controlled, randomized, single-center study, we investigated the safety of repetitive large-dose infusion of a novel hydroxyethyl starch solution (6% HES 130/0.4) in cranio-cerebral trauma patients. Patients were randomized to receive either HES 130/0.4 (n = 16) at repetitive doses of up to 70 mL · kg-1 · d-1 (which is the largest HES dose reported in the literature) or the control HES 200/0.5 (n = 15) up to its approved dose limit of 33 mL · kg-1 · d-1 followed by human albumin up to a total dose (HES 200/0.5 + albumin) of 70 mL · kg-1 · d-1. We found no differences between groups in mortality, renal function, bleeding complications, and use of blood products. There were also no major differences in coagulation variables. However, at some time points, factor VIII, von Willebrand factor, and  ristocetin cofactor were higher in the HES 130/0.4 group despite the large HES doses administered. We conclude that HES 130/0.4 can safely be used in critically ill head trauma patients over several days at doses of up to 70mL·kg-1·d-1.

 

硬膜外注射罗哌卡因和布比卡因用于分娩镇痛:Meta分析

Epidural Ropivacaine Versus Bupivacaine for Labor: A Meta-Analysis

Stephen H. Halpern, MD MSc, FRCPC, and Vivien Walsh, BMed (Hons)

Department of Anaesthesia, Sunnybrook and Women’s Health Sciences Centre, Women’s College Site and the University of Toronto, Toronto, Ontario, Canada

Anesth Analg 2003 96: 1473-1479.

 

很多研究对罗哌卡因和布比卡因分娩镇痛进行了比较。早期的研究提示应用罗哌卡因时孕妇和新生儿的结果要好。我们对这些文献进行了系统复习,对这些结果进行了系统研究,以确定两药的结果是否有差别。我们收集了对孕妇进行研究的电子数据库和杂志资料。分析的指标包括经阴分娩率、镇痛效果以及孕妇和新生儿的情况。应用meta分析技术和随机效应模型。有23个随机实验共包括应用罗哌卡因的1043例病人和布比卡因的1031例病人。产妇经阴分娩的发生率(几率, 1.17; 95% 可信区间0.98–1.41; P = 0.12)和其它结果无显著差别。尽管有些实验报道布比卡因有更多的运动阻滞发生率,由于这些结果不统一,没有进行比较。结论:两种镇痛方式的孕妇和新生儿的结果无显著差别。应该进一步比较两药在合适的临床浓度时对运动阻滞的结果是否有差别。

(王士雷  译 庄心良  校)

Numerous studies have compared ropivacaine with bupivacaine for labor analgesia. Early studies suggested that obstetrical and some neonatal outcomes were improved when ropivacaine was used. We systematically reviewed and combined the results of the randomized controlled trials that compared ropivacaine with bupivacaine to determine whether or not there was a difference in these outcomes. We searched electronic databases and journals for randomized controlled trials composed of laboring parturients. The primary outcome was the incidence of spontaneous vaginal delivery. We examined other obstetrical, neonatal, and analgesic outcomes. Where possible, these were combined by using metaanalytic techniques and random effects modeling. We found 23 randomized controlled trials composed of 1043 patients receiving ropivacaine and 1031 receiving bupivacaine. There was no significant difference in the incidence of spontaneous vaginal delivery (odds ratio, 1.17; 95% confidence interval, 0.98–1.41; P = 0.12) or any of the other outcomes. Although more studies reported a more frequent incidence of motor block with bupivacaine, the results were heterogeneous and therefore not combined. We conclude that there is no statistically significant difference between the two drugs in the incidence of any obstetrical or neonatal outcome. Further studies using clinically appropriate concentrations of drugs are required to determine whether or not there is a difference in the incidence of motor block.

 

腹股沟疝修补术脊麻时小剂量布比卡因复合可乐定:一个随机、双盲研究

Clonidine Combined with Small-Dose Bupivacaine During Spinal Anesthesia for Inguinal Herniorrhaphy: A Randomized Double-Blinded Study

Dobrydnjov, MD*, K. Axelsson, MD PhD*, S.-E. Thörn, MD PhD*, P. Matthiesen, MD{dagger}, H. Klockhoff, MD PhD{dagger}, B. Holmström, MD PhD*, and A. Gupta, MD FRCA, PhD*

Departments of *Anesthesiology and Intensive Care and {dagger}Surgery, University Hospital, Örebro, Sweden

Anesth Analg 2003;96:1496-1503

本实验采用随机,双盲法研究小剂量布比卡因加入小剂量可乐定是否能延长术后镇痛时间和行腹股沟疝修补术时提供充足的阻滞。随机将45名患者分为3组,分别接受鞘内注射高张布比卡因加生理盐水(B组);加15µg可乐定(BC15组);30µg可乐定(BC30组)。所有液体均用生理盐水稀释到3 mLB组有5名患者感觉阻滞水平不足,而改用全麻。BC15BC30的镇痛范围明显大于B组。采用2段回归,S1感觉恢复和运动阻滞恢复在BC30组要明显长于B组。布比卡因中加入15 30 µg 可乐定可延长第一次要求镇痛的时间,也可减少术后镇痛发生低血压的危险。结论:6 mg 布比卡因和15 µg可乐定能完全达到腹股沟疝修补术的麻醉要求。(赵雪莲      庄心良  校)


The aim of this randomized double-blinded study was to see whether the addition of small-dose clonidine to small-dose bupivacaine for spinal anesthesia prolonged the duration of postoperative analgesia and also provided a sufficient block duration that would be adequate for inguinal herniorrhaphy. We randomized 45 patients to 3 groups receiving intrathecal hyperbaric bupivacaine 6 mg combined with saline (Group B), clonidine 15 µg (Group BC15), or clonidine 30 µg (Group BC30); all solutions were diluted with saline to 3 mL. The sensory block level was insufficient for surgery in five patients in Group B, and these patients were given general anesthesia. Patients in Groups BC15 and BC30 had a significantly higher spread of analgesia (two to four dermatomes) than those in Group B. Two-segment regression, return of S1 sensation, and regression of motor block were significantly longer in Group BC30 than in Group B. The addition of clonidine 15 and 30 µg to bupivacaine prolonged time to first analgesic request and decreased postoperative pain with minimal risk of hypotension. We conclude that clonidine 15 µg with bupivacaine 6 mg produced an effective spinal anesthesia and recommend this dose for inguinal herniorrhaphy, because it did not prolong the motor block.

 

氧化亚氮减轻加压反应但增加去甲肾上腺素对喉镜和气管插管的反应

Nitrous Oxide Attenuates Pressor but Augments Norepinephrine Response to Laryngoscopy and Endotracheal Intubation

Kyung Y. Yoo, MD PhD*, Sung T. Jeong, MD*, In H. Ha, MD PhD*, and JongUn Lee, MD PhD{dagger}

*Department of Anesthesiology and the {dagger}Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, South Korea

Anesth Analg 2003 96: 1516-1521.

氧化亚氮(N20)具有拟交感样作用。我们观察了N20能否调节全麻时气管插管的心血管反应。100例病人随机分4组,每组25例。每组分别在气管插管前3分钟吸入0%25%50%75%N20。麻醉诱导为静注硫喷妥钠5-7mg/kg,以指定浓度的N20通气,静注维可溴铵012mg/kg以利插管。插管后全部病人半紧闭吸入2%异氟醚。测定收缩压、心率、心律和血浆儿茶酚胺浓度。气管插管明显增加收缩压和心率。最大血压变化为75% N2O组血压下降46 ± 21 mm Hg,对照组65 ± 24 mm Hg(P < 0.05),但心率无明显变化。去甲肾上腺素浓度插管后1分钟增加,N2O可增加去甲肾上腺素浓度,但并不影响心律失常的发生。结论:氧化亚氮增加去甲肾上腺素浓度,但减轻气管插管时的加压反应。(王立中 译 庄心良 校)

Nitrous oxide (N2O) exerts a sympathomimetic action. We investigated whether N2O modifies the cardiovascular responses to tracheal intubation during general anesthesia. One-hundred healthy patients were assigned randomly to receive one of four concentrations (0%, 25%, 50%, or 75%; n = 25 each) of N2O in oxygen throughout the study beginning 3 min before tracheal intubation. Anesthesia was induced with IV thiopental (5–7 mg/kg) whereas patients were ventilated with designated concentrations of N2O. Tracheal intubation was facilitated with IV vecuronium (0.12 mg/kg). After intubation, all received 2% sevoflurane in oxygen via a semiclosed anesthesia circuit. Systolic arterial blood pressure, heart rate and rhythm, and plasma catecholamine concentrations were measured. The intubation significantly increased arterial blood pressure and heart rate. The maximum pressure changes were 46 ± 21 and 65 ± 24 mm Hg in 75% N2O and control groups, respectively (P < 0.05), being attenuated by N2O without affecting the tachycardiac response. Norepinephrine concentrations were increased at 1 min after the intubation, the magnitude of which was augmented by N2O. N2O did not affect the incidence of arrhythmias. It was shown that N2O suppressed the pressor response to endotracheal intubation, despite the augmented increase of norepinephrine concentrations.