Anesthesia & Analgesia

May 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

用脈搏波形分析得到的每搏輸出量變異作為機械通氣病人的補液反應指示

(廖慶武譯  薛張綱校)

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.

 

常溫心肺體外迴圈下行心臟手術後腎功能不全的發生率、危險因素和對臨床結局的影響

(齊波  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:

 

心臟術後檢測腎功能不全的替代方法的評價

(王士雷 譯 莊心良 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.

 

在進行心臟外科手術病人時心包抑制,房性起搏和心率加快對其心臟收縮舒張功能的影響

(廖慶武譯  薛張綱校)

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.

 

心臟手術中呼吸力學的變化

(   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.

 

用食道超聲心動圖指導術中下腔靜脈插管

(軒 泓 譯  莊心良 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.

 

心臟超聲用彩色動能定量評價心臟外科病人區域性室壁運動和左室不同步性

(廖慶武譯  薛張綱校)

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.

 

心臟手術後的神經肌肉功能恢復:潘庫溴銨與羅庫溴銨的比較

( 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.

 

異氟醚對豚鼠心室肌慢啟動延遲整流鉀通道的影響

(王士雷 譯 莊心良 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:

深麻醉下小兒氣管拔管----地氟醚與七氟醚的比較

(   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:

梗阻性睡眠呼吸暫停綜合征不是門診手術患者意外住院的危險因素

(軒 泓 譯  莊心良 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.

 

無肌松藥時用雷米芬太尼和硫噴妥鈉誘導插管

(嵇富海譯  薛張綱校)

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,異氟醚和七氟醚對鼠小腦顆粒神經元非滅活鉀離子通道的調控

(忻紀華   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.

 

鉀通道KCNK5 Kir3.2突變並不改變麻醉藥的MAC

(王士雷 譯  莊心良 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.

 

氟烷和異氟醚在鼠有累加的MAC作用

(嵇富海譯  薛張綱校)

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.

 

安氟醚通過對神經元突觸前和突觸後的作用,減少谷氨酸向脊髓運動神經元的神經傳導

(忻紀華   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.

 

出血性休克對依託咪酯的影響:藥理和藥代動力學的分析

(王立中  譯 莊心良 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.

 

異丙酚和丹曲林在慢性試驗犬的血流動力學相互作用

(潘志浩譯  薛張綱校)

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:

癡呆病人腦電圖的低基線雙頻指數

(殷文淵   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:

咪唑安定能增強鞘內注射布比卡因對熱或炎症疼痛的鎮痛作用

(王士雷 譯   莊心良校)

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.

 

經皮肝組織活檢產生的疼痛發生及特徵研究

(潘志浩譯  薛張綱校)

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.

 

局部麻醉藥抑制交感神經介導和C-纖維介導的滑液的神經性漿液外滲的差異性

(殷文淵   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毒蕈堿受體參與鞘內注射可樂定減少機械性損傷神經的過敏反應

(趙雪蓮     莊心良  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:

確定PACU的床位數:電腦類比流程法

(潘志浩譯  薛張綱校)

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:

在急救運輸中局部加熱對減少膽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:

嚴重腦外傷病人反復輸入大劑量新型羥基澱粉130/0.4

 (張軍 譯  莊心良 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.

 

貓顱骨切開術中麻醉方法影響腦溫度但不決定於中心體溫

(張俊峰譯  薛張綱校)

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.

 

電磁共振技術測量麻醉大鼠的腦組織氧張力

(    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:

硬膜外注射羅呱卡因和布比卡因用於分娩鎮痛:Meta分析

(王士雷  譯 莊心良  校)

Epidural Ropivacaine Versus Bupivacaine for Labor: A Meta-Analysis

Stephen H. Halpern and Vivien Walsh

Anesth Analg 2003 96: 1473-1479.

REGIONAL ANESTHESIA:

腰硬聯合麻醉與腰麻中相應的低血壓發生率的比較

(張俊峰譯  薛張綱校)

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.

 

隨機、雙盲觀察可樂定聯合小劑量布比卡因在脊髓麻醉下腹股溝疝修補術中的應用

(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.

腹股溝疝修補術脊麻時小劑量布比卡因複合可樂定:一個隨機、雙盲研究

(趙雪蓮      莊心良  校)

GENERAL ARTICLES:

健康志願者靜脈輸液的生理效應

(張俊峰譯  薛張綱校)

Physiologic Effects of Intravenous Fluid Administration in Healthy Volunteers

Kathrine Holte, Peter Jensen, and Henrik Kehlet

Anesth Analg 2003 96: 1504-1509.

 

插入式喉罩通氣用於病理性肥胖患者的氣道處理

(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.

 

氧化亞氮減輕加壓反應但增加去甲腎上腺素對喉鏡和氣管插管的反應

(王立中 譯 莊心良 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.

用脈搏波形分析得到的每搏輸出量變異作為機械通氣病人的補液反應指示

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

 

對危重病人的心功能評估和恰當補液是臨床醫生的重要目的。因此我們設計了該研究來評價在心臟外科正常機械通氣的病人中用脈搏波形分析得到的每搏輸出量變異(SVV)和以前常用的前負荷(中心靜脈壓和肺動脈楔壓)預測每搏輸出量指數和心指數對補液量的反應。我們研究了20例選擇性冠狀動脈搭橋術病人。麻醉誘導後,在補液前(T1)和補液後分別測定血流動力學指標。補液用7ml/Kg6%羥乙基澱粉200/0.5並以1ml·kg-1·min-1輸入。除心率外,其餘的血流動力學變異在容量負荷後均有顯著差異(P<0.01)。對T1時的SVV和補液後的{Delta}SVV進行線性相關分析表明具有顯著相關性(r-0.97;P<0.01,而對T1時的SVV和每搏輸出量指數(r=0.19)和心指數(r=0.17)的百分率變化進行線性相關分析並不表明變數間有顯著相關性。我們的研究表明用脈搏波形分析得到的SVV不能作為心臟外科正常機械通氣的病人的補液反應指示。(廖慶武譯  薛張綱校)

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.

 

 

在進行心臟外科手術病人時心包抑制,房性起搏和心率加快對其心臟收縮舒張功能的影響

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

 

誘導麻醉後,在不同的生理條件下如打開心包和不同的心率或心律,收縮和舒張功能的基礎測量可以和隨後的測量相比較。我們從21位行冠狀動脈手術的病人中獲得資料。在打開心包之前和之後,心房本身頻率起搏,和比這快30BPM的速率起搏時進行心超和肺動脈導管聯合檢查測量。收縮功能指數包括部分區域的改變,後負荷校正部分區域改變,和心肌工作能力指數。舒張功能包括二尖瓣流入和肺靜脈的多普勒成像,彩色M型多普勒血流傳播速度,瞬間舒張末硬度和等容鬆弛時間。血流動力學指數包括心臟指數,平均動脈壓,右房壓,肺動脈楔壓和全身血管阻力指數。在打開心包或建立房性起搏時測量並沒有變化。當心率加快時,心臟收縮功能沒有變化,但瞬間舒張末硬度增加了。傳播速度卻顯示一種自相矛盾的改善,心率增加而不是其他趨勢。二尖瓣流入多普勒顯示隨著心率增加出現搏動融合。我們推薦在相似的心率下進行連續監測。(廖慶武譯  薛張綱校)

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.

 

心臟超聲用彩色動能定量評價心臟外科病人區域性室壁運動和左室不同步性

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

 

傳統心臟超聲在解釋區域性室壁反常運動時具有主觀性和經驗依賴性。在射血期的延遲收縮(遲收縮)和區域性收縮不同步即心肌缺血的敏感標記並不能被真正準確評定。我們對冠狀動脈搭橋手術病人用彩色動能(CK),一種獲得心內膜運動時空模型的技術,來客觀檢測其區域性室壁反常運動,並和缺少經驗的檢測者用灰度影像獲得的傳統評定結果進行比較。比較採用專家評級作為金標準。CK定量分析比缺少經驗的檢測者的檢測結果更接近專家評級(係數,0.720.520.5)。26例病人(2例為正常的小部分區域改變)中有9例證明整體遲收縮與收縮不同步性的增加指數有關。150個片段中有48個證明為區域性遲收縮:27個片段為正常等級的室壁運動,18個是運動功能減退,3個是嚴重運動減退/運動不能。輕度運動減退表明延遲收縮運動,而剩下的嚴重運動減退/運動不能則發生在收縮早期,反應了鄰近心肌收縮的被動效應。定量彩色動能可作為視覺評定的補充,特別是對於缺少經驗的檢測者來說。一般在心臟外科病人中甚至其射血期指數是正常標準的,定量彩色動能可通過遲收縮診斷來提高手術中區域性缺血性改變的檢測。(廖慶武譯  薛張綱校)

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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無肌松藥時用雷米芬太尼和硫噴妥鈉誘導插管

 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.

 

在沒有肌松藥的情況下雷米芬太尼和非阿片類的靜脈全麻藥複合應用于插管。在本研究中我們採用雙盲、前瞻、隨機的方式評估在沒有肌松藥的情況下雷米芬太尼和硫噴妥鈉聯合用於插管時的需要的劑量及心血管反應。先靜脈注射咪唑安定0.03 mg/kg105個病人按照雷米芬太尼的劑量隨機分為三組:2 µg/kg (I), 3 µg/kg ( II), 4 µg/kg ( III)。雷米芬太尼30秒內注完,採用硫噴妥鈉5 mg/kg.誘導。麻醉醫師在插管時估價插管的條件:(a) 優,(b) 滿意,(c)一般,(d),不滿意。在人口統計方面三組無明顯不同,在插管內三組病人血壓、心率無明顯增加。在組II比組I、組 III比組I、組 III比組I插管條件明顯改善(P < 0.001)。我們結論是在硫噴妥鈉前給雷米芬太尼4 µg/kg94%的病人可獲得滿意的插管條件,抑制插管時的心血管反應。                   (嵇富海譯  薛張綱校)

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.

 

氟烷和異氟醚在鼠有累加的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%的病人對有害刺激沒有反應時的最小肺泡內濃度)濃度時,氟烷抑制背角神經元超過異氟醚。同樣這些麻醉藥對它們靶點的各種受體和離子通道影響也不相同。所有結果表明這些麻醉藥對有害刺激的體動反應的影響由於它們的累加、可能協同、甚至於拮抗效應而不同。我們用20只鼠來驗證這種可能性。氟烷和異氟醚MA C值在聯合試驗前和後分別重複測定(每只鼠確定6MAC)。每個鼠的氟烷和異氟醚的總的MAC值產生一無反應值1.037 ± 0.082,和MAC1沒有明顯不同。就是氟烷和異氟醚的聯合產生對夾尾無反應濃度和單獨這種麻醉藥的效應是一致的。這些結果表明吸入麻醉藥引起的無反應不會是由於它們對傳導背角神經元的能力。    (嵇富海譯  薛張綱校)

 

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

 

異丙酚和丹曲林在慢性試驗犬的血流動力學相互作用

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

惡性高熱的特效藥丹曲林和可在惡性高熱易感病人上安全使用的異丙酚之間的血流動力學相互作用還未被研究。我們進行了這一試驗來檢驗治療劑量的丹曲林在異丙酚麻醉時的血流動力學作用。十隻犬慢性試驗以測定體循環和冠脈的血流動力學。這些犬在不同的試驗日分別隨機接受待藥媒的異丙酚和丹曲林。異丙酚顯著降低平均動脈壓, 左室收縮和舒張末壓, 左室壓力增加的最大速率以及左室局部節段縮短。冠脈血流沒有改變,但是冠脈血管阻力下降。丹曲林逆轉了異丙酚導致的平均動脈壓和左室收縮壓力的變化,顯著增加了心率。然而,左室舒張末壓,心輸出量,左室壓力增加的最大速率以及節段縮短不變。冠脈血流顯著增加而冠脈阻力不變。這些結果顯示丹曲林逆轉了異丙酚導致的低血壓,導致冠脈血流的增加以及冠脈阻力的下降,但是沒有顯著改變負性肌力作用。因此,丹曲林在異丙酚麻醉時產生有益的血流動力學效應。

結論: 我們的研究顯示丹曲林逆轉了異丙酚產生的低血壓,導致了冠脈血流的增加以及冠脈阻力的下降,但沒有顯著改變負性肌力作用。(潘志浩譯  薛張綱校)

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.

 

經皮肝組織活檢產生的疼痛發生及特徵研究

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


經皮針刺肝組織活檢是診斷和評價肝臟疾病的重要手段,但常常會產生疼痛。該前瞻性研究目的在於明確此疼痛綜合症的發生及特徵。54例擬行超聲導引下肝組織活檢的患者術前1小時口服5 mg 安定,針刺前10 mL 2%利多卡因局部侵潤阻滯。術後24小時應用視覺類比評分(VAS)評定疼痛強度,並記錄疼痛的定位,Spielberger問卷評定焦慮水平。54例中47例(84%)患者訴術後30 min疼痛(VAS, 4.2 ± 0.5; mean ± SEM)21(39%)患者訴術後24小時時疼痛。9例訴活檢部位疼痛,14例右肩痛,兩部位均痛24例。女患者和焦慮水平高的患者的疼痛強度高。該研究顯示肝組織活檢會致大多數患者疼痛,輕度鎮靜聯合局部侵潤麻醉不能有效的鎮痛,因此需要尋找更為有效的鎮痛方法。結論:經皮肝組織活檢會致大多數患者疼痛,輕度鎮靜聯合局部侵潤麻醉不能有效的鎮痛,因此需要尋找更為有效的鎮痛方法。             (潘志浩譯  薛張綱校)

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.

 

確定PACU的床位數:電腦類比流程法

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

設計一個新手術室由於涉及工作人員的數目以及決策者想要減少手術室的直接和間接的費用而變得困難。在這一研究中,我們設計了一種電腦類比流程模式,首先計算術後恢復室的最少床位數。在第二個階段,我們對手術室在手術安排和有工作人員的PACU床位和搬運工人的數目方面的總體表現。我們設計了手術室安排的數學模型。隨後我們建立了手術室的電腦類比流程模型。兩種模型相互關聯;第一種類比輸入流程,第二種類比手術室運轉。電腦類比檢驗了理想狀態和搬運工人減少時的PACU床位。然後分析了PACU中當病人停留的時間和搬運工人數目變化每小時床位佔用數的變化。結果顯示了搬運工人數目對手術室表現,特別是PACU表現的強烈影響。

結論: 設計新手術室設施意味著很多關於手術室,PACU床位以及護士和搬運工人數目的決定。管理者常常憑經驗和推薦作這些決定。我們的研究運用流程類比來證實這些選擇。在這一案例研究中,我們確定了PACU的床位和搬運工人數,評價了減少搬運工人對PACU床位需要的影響。   (潘志浩譯  薛張綱校)

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.

 

貓顱骨切開術中麻醉方法影響腦溫度但不決定於中心體溫

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

 

由於麻醉對腦血流和腦代謝(二者均為腦自身調節的決定因素)有明顯的潛在影響,我們假設顱骨切開術中麻醉影響腦溫並且不決定於中心體溫。21只貓 (2.7 ± 0.4 kg; mean ± SD)均行右乙狀竇旁開顱術並隨機分為3組: HN組(1.5%氟烷,血碳酸正常);HH組(1.5%氟烷,低碳酸血症);PN組(大劑量戊巴比妥鈉,血碳酸正常)。加熱器開始維持中心體溫和右硬膜下體溫正常 (38.0°C), 隨後停止顱骨加熱,則在3小時的研究過程中,腦中心體溫梯度最大的部位是右硬膜下區域,各組分別平均為HN組:-2.5°C ± 0.9°CHH組:-2.5°C ± 0.8°C PN組:-4.1°C ± 1.1°C。在未暴露的左硬膜下和右腦表面下0.51.0 cm的腦皮質區域的體溫梯度HN HH組中為-0.8°C ± 0.5°C-1.1°C ± 0.6°C之間,而PN組則是其兩倍(-1.9°C ± 0.5°C-2.1°C ± 0.7°C) (P < 0.05 PNHN HH)。深戊巴比妥鈉麻醉可獨立於中心體溫外降低腦溫,可能是其降低腦代謝率和減少熱產生的結果,降低的幅度足以增強巴比妥類藥物的任何直接的腦保護作用。結論:深巴比妥鈉麻醉可獨立於中心體溫外降低貓腦溫,該作用顯著強於氟烷麻醉,其體溫降低幅度足以解釋巴比妥類藥物不同於其他任何藥物的腦保護特性。(張俊峰譯  薛張綱校)

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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腰硬聯合麻醉與腰麻中相應的低血壓發生率的比較

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

該研究中我們評價作為腰硬聯合麻醉(CSE)中一部分的腰麻是否比單純腰麻SPA更易導致低血壓。從January 1, 1997 August 5, 2000間電子麻醉記錄單中選擇1596例擇期行SPA1023例擇期行 CSE的患者。低血壓定義為:10-min 內平均動脈壓降低超過30%並且在發生低血壓20 min內需麻醉醫師治療。採用logistic回歸分析遞增法確定CSE後有關低血壓發生率的獨立因素,單變數分析用於評價兩組間生物統計資料和低血壓相應危險因素的差異。CSE低血壓的發生率比SPA要高(10.9% 5.0%; P < 0.001)。多變數分析發現高血壓(odds ratio, 1.83; 95%可信區間, 1.212.78)和阻滯平面>T6(odds ratio, 2.81; 95%可信區間, 1.884.22)CSE組低血壓發生的有關因素。與SPA組相比,CSE組較少的局麻藥可產生較高的阻滯平面並且CSE組病人中術前合併高血壓較為常見(P < 0.01) 在該研究中,CSE組病人比SPA病人發生低血壓的風險高,其原因部分好像與CSE本身有關,而不僅僅與CSE病人有高風險因素。結論:該研究基於大樣本回顧性研究設計,結果提示CSE比單純SPA更易導致低血壓,術前存在的高血壓及術中感覺阻滯平面超過T6是產生該併發症的主要因素。       (張俊峰譯  薛張綱校)

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.

 

健康志願者靜脈輸液的生理效應

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

 

圍術期液體管理的方案很少是循證的。因此,我們在健康志願者上研究液體輸注的反應來評價液體輸注本身的生理效應。在這一個前瞻,雙盲,交叉隨機的研究中,12個平均年齡63歲(59–67歲)的健康志願者分別接受隨機順序的乳酸林格液40 mL/kg (平均2820 mL) 5 mL/kg (平均353 mL;背景輸注)。研究設計模仿圍術期經過,術前禁食,在早晨輸液3小時,另外24小時在標準化狀態下住院。主要的預後評價為肺功能 (肺量計),運動能力(亞極量蹬車試驗), 平衡功能(BalanceMaster®), 以及體重。輸注40 mL/kg的乳酸林格液與背景輸注(5 mL/kg)相比,肺功能顯著降低,顯著增重平均為0.85 kg (-0.2–1.6 kg; P = 0.003) ,在輸注後持續達24小時。運動耐量和平衡功能沒有被輸液所影響。這些結果可以作為在應用不同量同樣類型液體以確定不同外科手術圍術期液體輸注最佳量的臨床研究的基礎。

結論:在志願者輸注40 mL/kg乳酸林格液導致肺功能的顯著下降以及體重增加達24小時而對運動耐量無影響。這些結果可以作為圍術期液體管理的基本資訊。         (張俊峰譯  薛張綱校)

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.

 

常溫心肺體外迴圈下行心臟手術後腎功能不全的發生率、危險因素和對臨床結局的影響

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


腎功能不全是傳統低溫心臟手術後經常發生的嚴重的併發症。但在常溫條件下(通常大於36)行心肺體外迴圈(CPB)時有關腎功能不全的情況則所知甚少。因此,我們前瞻性研究了649例常溫CPB下進行冠狀動脈旁路術或瓣膜手術的病人。採用單一變數和多變數分析腎功能不全(定義為最大術後血漿肌酐水平較術前增加大於等於30%)與圍術期變數之間的關係。結果表明術後腎功能不全發生率為17%,其中21名病人(3.2%)需要進行透析治療。此併發症發生的一些獨立的術前預見因素為:高齡、ASA分級>3級、活動性感染性心內膜炎、術前48小時內應用放射性對比劑和複合性大手術。當所有變數都存在時,活動性感染性心內膜炎、應用放射性對比劑、術後低心排量和術後出血成為腎功能不全發生的獨立的危險因素。當病人發生腎功能不全時院內死亡率為27.5%(1.6%比;P<0.0001),因此,術後腎功能不全是院內死亡率獨立的相關因素(概率為4.1[95%可信區間為1.3-12.8])。我們認為相對於CPB來說,高齡、活動性感染性心內膜炎、術前(48小時內)應用放射性對比劑以及術後血流動力學不穩定等因素可能是術後腎功能不全更為可靠的預見因素。

(齊波   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.

 

心臟手術中呼吸力學的變化

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


為觀察心臟外科手術中心肺體外迴圈(CPB)對肺功能的影響,我們測量了應用(n=30CPB)或未應用心肺體外迴圈(n=29,在心臟手術組(n=30)、不停跳冠狀動脈旁路組(n=29)CPB的病人在術中應用多巴胺(DA)治療(n=12CPB-DA)觀察低頻呼吸阻抗(Zrs)。測量了5CPB的病人的血管外肺水及切皮前和關胸後的Zrs的變化。除Zrs外還測量了病人的氣道阻力、慣性、組織衰減和彈性。結果表明CPB組病人的氣道阻力增加(74.9%±20.8%P<0.05),而在OPCAB組病人無明顯變化(11.8%±7.9%;無顯著差異)CPB-DA組病人甚至會下降(-40.6%±9.2%P<0.05)CPB組和OPCAB組病人的組織衰減增加,而在CPB-DA組則保持不變。三組病人的組織彈性均顯著增加。CPB前後的血管外肺水無差異,說明病人沒有出現肺水腫。因此在CPB過程中病人會出現顯著的、不均勻的氣道狹窄,但在應用多巴胺時可被消除。組織力學的輕微改變反映了氣道的部分關閉,可能與麻醉因素有關。(   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.


心臟手術後的神經肌肉功能恢復:潘庫溴銨與羅庫溴銨的比較

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


臨床上在“快通道”心臟手術病人中使用潘庫溴銨可能使恢復延遲。本研究的目的是評估心臟手術病人使用潘庫溴銨(0.08-0.1mg/kg)和羅庫溴銨(0.6-0.8mg/kg)術後殘餘神經肌肉阻滯的發生率和嚴重程度。82名體外迴圈的手術病人隨機分成潘庫溴銨組(n=41)和羅庫溴銨組(n=41),患者術中和術後按照標準化處理。在監護室,我們每小時測TOF率直到脫機支持開始。神經肌肉阻滯沒有用藥拮抗。拔管後檢查患者殘餘麻痹的症狀和體征。當脫機支持開始時,潘庫溴銨組的神經肌肉阻滯作用(TOF率:平均,0.14;範圍,0.00-1.11)要比羅庫溴銨(TOF率:平均,0.99;範圍,0.87-1.21)明顯(P<0.05)。羅庫溴銨組的殘餘麻痹的症狀和體征明顯比潘庫溴銨組輕。我們的結果顯示在心臟手術患者中使用長效肌松藥不僅影響神經肌肉的恢復,而且在術後早期伴有殘餘的肌肉無力的症狀和體征。( 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.

 

深麻醉下小兒氣管拔管----地氟醚與七氟醚的比較

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


為觀察使用地氟醚和七氟醚在深度麻醉下小兒的氣管拔管特點。將48個小兒隨機分為兩組,在手術結束時,在吸入麻醉劑的濃度達到最低有效濃度的1.5倍時拔除氣管導管。記錄每組的恢復特點和所發生的併發症。地氟醚組的患者在到達恢復室時的覺醒評分要高於七氟醚組,而後期的覺醒評分無顯著的差異。兩組都沒有發生嚴重的併發症。地氟醚組病人的咳嗽及拔管後總的併發症的發生率較高。兩組興奮的發生都比較普遍(總體33%,地氟醚組46%,七氟醚組21%)。地氟醚組在恢復室內使用鎮靜劑發生率(10/24)要高於七氟醚組(3/24)。術前口服咪唑安定可顯著延長強效吸入麻醉藥的作用時間。(   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,異氟醚和七氟醚對鼠小腦顆粒神經元非滅活鉀離子通道的調控

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


神經原基質鉀離子通道可由多種揮發性麻醉藥啟動。培養來源於七天大小的雄性Sprague-Dawley鼠的小腦Granule神經元,採用電導係數為1.1+/-0.3nS (n=20) 外向鉀電流的,記錄全細胞動作電位。通道啟動為非滅活性,非電壓門控,對常規的鉀通道阻滯劑不敏感。臨床相關濃度的氟烷(112224336448uM)溶于林格氏液中,外向電流分別增加29%50%63%94%,(n=5; p<0.05; 變異分析[ANOVA])。同樣在異氟醚中(274411548882uM)外向電流分別增加22%47%52%60%n=5; p<0.05; [ANOVA])。七氟醚在濃度為518 uM時,電流增加225%n=10; p<0.05; [ANOVA])。所有實驗中,經灌洗後通道活性迅速恢復至基線水平。外向調節的所有細胞的電流-電壓曲線於麻醉藥敏感的KCNC通道的特性一致。結果表明非滅活鉀離子通道時揮發性麻醉藥的重要靶位點。(忻紀華   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

.

安氟醚通過對神經元突觸前和突觸後的作用,減少谷氨酸向脊髓運動神經元的神經傳導

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


我們已報導了揮發性麻醉藥通過甘氨酸抑制脊髓運動神經元,本研究將與興奮性遞質谷氨酸作為比較。假設興奮和抑制的平衡失調導致興奮向抑制狀態是由於大劑量的鎮靜劑對興奮的抑制所致。採用膜片鉗技術在小鼠脊髓切片中研究自主和誘發的谷氨酸α-氨基-3-羥基-5-甲基-4-異唑酮丙酸電流。安氟醚(0.6mM1分鐘肺泡麻醉藥濃度)可明顯降低最小電流頻率,在鈉通道阻滯時(最小興奮性突觸後電位,mEPSCs)或鈉離子通道未阻滯時(自主性興奮性突觸後電位,sEPSCs)。安氟醚不影響mEPSCsEPSC的振幅和動力學。對mEPSCsEPSC的影響相近。安氟醚明顯降低α-氨基-3-羥基-5-甲基-4-異唑酮丙酸電流的振幅和範圍,而不影響其動力學(p<0.050.01)。相反,當鈉通道阻滯時,安氟醚增加最小甘氨酸電流頻率,並延長甘氨酸電流持續時間。安氟醚作用於興奮性遞質谷氨酸,同時抑制了突觸前和突觸後電流,而甘氨酸只在某些情況下出現突觸前抑制,通常是延長了突觸後電流。因此,安氟醚通過直接抑制興奮性遞質,使興奮和抑制的平衡失調。(忻紀華   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.

 

癡呆病人腦電圖的低基線雙頻指數

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


在清醒狀態下雙頻指數(BIS)的基線值為96 – 99。患有Alzheimer病或血管性癡呆的病人的腦電圖中會出現慢波活動增多而快波活動減少的現象。一般認為,隨著腦電圖的變緩雙頻指數會隨之降低。假設癡呆病人的“清醒”雙頻指數要低於正常老年病人。選擇36名患有Alzheimer病或多發性梗死癡呆病人和36名年齡大於75歲的對照組病人。兩組均通過袖珍智力狀態測試評估。使用Aspect A-2000 腦電圖監測儀,從額葉引出雙頻指數(3.4版本)。離線資料分析使用的是較新的4.0版本的雙頻指數運算法則。36名癡呆病人中的14名(38%)和36名對照病人中的4名(11%)平均BIS 3.4<93P=0.006)。36名癡呆病人中的18名(50%)和36名對照病人中的8名(22%)平均BIS 4.0<93P=0.026)。癡呆病人的平均BIS 3.492.991-95),對照組病人為96.195-97)(P=0.02)。BIS 4.0的結果分別為89.186-92)和94.793-96)(P=0.002)。年齡、性別、腦電圖活動和指數信號質量沒有顯著差別。如同所料,袖珍智力狀態測試評分的差別顯著(P<0.0001)。多數癡呆病人的BIS基線較低。癡呆病人BIS監測儀的使用有理由進行進一步的研究。 (殷文淵   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.

 

局部麻醉藥抑制交感神經介導和C-纖維介導的滑液的神經性漿液外滲的差異性

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


許多種手術後都用局部麻醉藥作局部沖洗。可是,近期持續使用高濃度局麻藥產生中毒反應的事實說明使用降低濃度的局麻藥作沖洗液是有益處的。在這個研究中,我們確定是否較低濃度局麻藥可以維持抗炎和鎮痛作用而不發生中毒反應。研究利多卡因和布比卡因抑制炎症兩個組成部分的效能,即:老鼠膝關節中C-纖維介導的神經性炎和交感神經節後神經元介導的炎症。關節內沖洗0.02%利多卡因使5-羥色胺(5-HT)引起(SPGN介導)的漿液滲出(PE)降低35%,使用較大劑量利多卡因可以進一步降低之。關節內沖洗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%。較高濃度局麻藥必然抑制C-纖維介導的PE要大於抑制SPGN介導的PE0.4%利多卡因使芥油引起的PE降低40%2%利多卡因將芥油引起的PE抑制到基線水平。使用0.1%布比卡因能降低80%PE0.25%布比卡因將芥油引起的PE降低到基線水平。我們的結果揭示了局麻藥對SPGN-C-纖維介到的PE的特異性影響,證實了較小濃度局麻藥可以抑制術後炎症的觀點。 (殷文淵   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.

 

在急救運輸中局部加熱對減少膽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


上腹部疼痛是膽囊疾病的常見症狀,在澳大利亞急救呼叫中占6%的比例,膽囊炎所引起的疼痛是劇烈的。最近的資料表明:在急救運輸途中局部加熱能有效地減少疼痛。因此我們假設局部加熱腹部是有效地減少急性膽囊炎的方法,並且能通過護理實現。60例患者(>19歲)同意參與本試驗。分為兩組:組1使用碳化纖維毯(42℃)接受上腹部加熱治療;組2沒有採用腹部加熱。兩組沒有患者接受止痛藥物。要求患者使用視覺疼痛評分表(VAS)評價其疼痛和焦慮情況。統計學處理使用Student’s t檢驗,p0.05認為有顯著性。根據VAS評分,組1所有患者疼痛均有顯著改善,從86.8±5.5mm下降至41.2±16.2mm,而組2的評分前後保持相近,從88.38±9.9mm88.1±10.0mm。比較兩組患者到達醫院時的疼痛評分,差異有顯著性,p0.01。在組1,焦慮VAS評分有顯著改善,從治療前82.7±10.8mm至治療後39.0±14.0mm,組2的分數沒有顯著變化,從84.5±14.6mm83.5±8.4mm。兩組到達醫院時的焦慮評分有顯著差異,p0.01。我們的結論是:局部加熱是有效而且簡單易學的治療急診膽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.



電磁共振技術測量麻醉大鼠的腦組織氧張力

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

 

足夠的腦組織氧合(PtO2)是危重病人和麻醉中患者的中樞性治療目標。目前臨床上通過間接方法測量PtO2,應用紅外分光鏡測量腦血管氧含量。實驗室中使用正電子發射X線斷層照片來測量。近年來電磁共振技術(EPR)的發展提高了測量的精確性、敏感性和可重複性。EPR與核磁共振相似但探測的是順磁性的核素。有機體內大腦(或其他組織)中這些核素的含量不多,我們把順磁性的鋰苯二甲藍晶體灌注入大腦皮質進行測量。組織中EPR光譜的寬度與PtO2成線性關係。在麻醉大鼠中應用EPR技術,研究接觸不同吸入麻醉藥物、靜脈麻醉藥物和吸入不同氧濃度時的PtO2。大鼠使用2MAC的異氟醚麻醉獲得的PtO2最高(38.0±4.5mmHg),而氯胺酮/甲苯噻嗪麻醉時最低(3.5±0.3mmHg),吸入氧濃度(FIO2)為0.21 p0.05FIO21.0時,氯胺酮/甲苯噻嗪麻醉的PtO28.8±0.3mmHg p0.05。此時異氟醚麻醉的PtO256.3±1.7mmHgp0.05。這些資料說明了EPR在麻醉中測量PtO2的效用,並且可以作為進一步研究生理性影響和藥物直接干預對預防腦缺血的基礎。

                                                   (    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.


隨機、雙盲觀察可樂定聯合小劑量布比卡因在脊髓麻醉下腹股溝疝修補術中的應用

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

在本次隨機實驗中主要研究小劑量可樂定聯合小劑量布比卡因作為脊髓麻醉時是否會延長術後鎮痛時間,同時提供有效的阻滯,從而適用於腹股溝疝修補手術。隨機選擇45位患者分為三組,鞘內均注入高比重的布比卡因6mgB組加入鹽水,BC15組加入15ug可樂定,BC30組加入30ug可樂定,所有溶液都用鹽水稀釋至3mlB組中的5位患者術中感覺阻滯平面不滿意,隨後改用全身麻醉。而BC15BC30組的患者感覺阻滯平面較之B組顯著提高了2-4個節段。然而BC30S1段感覺恢復及運動阻滯恢復的時間則明顯長於B組。布比卡因中加入15ug30ug可樂定可延長起初的痛覺阻滯需要,同時減輕術後疼痛,而術後發生低血壓的危險性也較小。因此,我們得出結論:布比卡因中加入15ug可樂定可提供一有效得脊髓麻醉效果,同時由於它不會延長運動阻滯時間而適用於腹股溝疝修補手術。 (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.

 

插入式喉罩通氣用於病理性肥胖患者的氣道處理

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

 

為觀察病理性肥胖患者手術中應用插入式喉罩通氣的效用。選擇118位病理性肥胖患者(45+5kg/m2)。全麻誘導後首先進行喉部評估分類(CormackLehane法),隨後置入喉罩通氣(ILMA),然後將導管經由ILMA插入氣管,其成功率為96.3%。喉部低位(Cormach1-2)或高位(Cormach3-4)患者置入ILMA的成功率、嘗試次數及整個操作過程無明顯區別。僅高位者插入ILMA的時間輕微延長。結果表明ILMA可作為病理性肥胖患者的一個新的氣道管理方式。

(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.

心臟術後檢測腎功能不全的替代方法的評價

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.

心臟術後發生的腎功能不全使病人死亡率增加,ICU住院時間延長。應用簡單方法對腎功能進行評價有利於腎功能的保護。本研究對以血肌酐72h的變化({Delta}Cr72h)和每72h血肌酐的變化(%{Delta}CrCl72h)為指標檢測腎功能的方法進行了評價。選擇Toronto醫院 1999-2000年期間的2000例行冠狀動脈搭橋術,瓣膜手術或同時行兩種手術的病人為物件,用頻度直方圖和概率圖對變數進行分析。用手術特徵曲線圖(ROC)對上述指標與透析、 死亡率、 ICU住院時間等關係進行分析。結果顯示,{Delta}Cr72h分佈向右偏斜, 而%{Delta}CrCl72h分佈正常。ROC 曲線顯示{Delta}Cr72h能較好預測透析(0.98) 、死亡率(0.83)和住院時間延長(0.74)ROC 曲線面積與透析(P = 0.89) 、 死亡率(P = 0.49)和住院時間延長(P = 0.85)之間無顯著差異。兩種變數都與病人的預後有關。將{Delta}Cr72h轉化為%{Delta}CrCl72h使資料分佈轉化為正態。{Delta}Cr72h%{Delta}CrCl72h可以作為病人預後的指標。結論 {Delta}Cr72h%{Delta}CrCl72h都與預後有關,而%{Delta}CrCl72h更接近正態分佈,易於統計。(王士雷 譯 莊心良 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.

 

用食道超聲心動圖指導術中下腔靜脈插管

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例成年患者接受心臟手術,術中使用經食道超聲心動圖監測靜脈套管的位置和靜脈系統的情況,及套管置入肝靜脈的發生率,記錄圖像質量,靜脈直徑,套管位置及靜脈回流量。結果顯示,下腔靜脈和右肝靜脈的圖像質量滿意度分別為95%87%。靜脈直徑的個體差異相當大。99%的套管位置可以確定。套管置入右肝靜脈的發生率為10%。腔靜脈瓣和右肝靜脈的間距很短,套管容易進入右肝靜脈。患者的其他情況不影響套管位置。套管在下腔靜脈的深度與靜脈回流量的下降有關,比套管誤入肝靜脈更影響回流量。結論:術中使用經食道超聲心動圖基本上可以準確監測套管的位置。

(軒 泓 譯  莊心良 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

.

異氟醚對豚鼠心室肌慢啟動延遲整流鉀通道的影響

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.

 

慢啟動延遲整流鉀通道是引起心臟動作電位去極化的主要外向電流。此通道的功能障礙可以引起動作電位時程延長,導致長QT綜合征。我們推測麻醉藥引起的動作電位延長除與其抑制快啟動延遲整流鉀通道有關外,尚與慢啟動延遲整流鉀通道有關。本文應用全細胞膜片鉗技術探討異氟醚對這兩種通道電流的作用以及蛋白激酶C對這種作用的影響。結果顯示,異氟醚以劑量依賴的方式抑制慢啟動鉀通道電流。在22°C時,臨床相關濃度(0.3-0.6mM)異氟醚對通道的抑制作用較36°C 時強。異氟醚不影響電壓依賴性慢啟動鉀通道的啟動。在22°C 時,異氟醚加速慢啟動鉀通道的失活,但在36°C 時則無此現象。異氟醚對慢啟動延遲整流鉀通道的抑制作用明顯比快啟動延遲整流鉀通道強。蛋白激酶C的啟動使慢啟動延遲整流鉀通道電流增強,但是,不抑制異氟醚對此電流的抑制作用。結論:麻醉藥對慢啟動延遲整流鉀通道的抑制作用是其引起動作電位延長和QT間期延長的機制之一。(王士雷 譯 莊心良 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

.

梗阻性睡眠呼吸暫停綜合征不是門診手術患者意外住院的危險因素

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

.

本研究目的是探討術前梗阻性睡眠呼吸暫停綜合症(OSA)是否是門診患者行非耳鼻喉手術發生圍術期併發症的獨立危險因素。作者回顧性分析了某家三級治療中心的234例患者的資料,術前用多導睡眠監測法確診為OSA,於1997年到2000年間行門診手術。對照組的麻醉方式,年齡,性別,體重指數,手術方式及手術日期與研究組相配。分析兩組的圍術期醫療記錄。除OSA組較少使用喉罩外,兩組的術中管理無顯著差異。OSA組和非OSA組的意外住院率(23.9% 18.8%; 相對危險度 1.4; 95% 可信區間0.8–2.5)和其他不良事件的發生率(2.1% 1.3%; 相對危險度 1.7; 95% 可信區間 0.4–7.0)也無明顯差別。意外住院基本上與心臟和呼吸事件無關。結論:術前OSA不是門診手術患者意外住院或發生其他不良事件的危險因素。

(軒 泓 譯  莊心良 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.

 

 

鉀通道KCNK5 Kir3.2突變並不改變麻醉藥的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.

一些研究結果提示,臨床濃度的吸入麻醉藥通過使鉀通道不失活而導致超極化狀態,從而降低興奮性,進一步導致麻醉狀態的產生。因此,我們推測缺乏這些通道的動物可能對麻醉藥不敏感。我們對缺乏鉀通道功能亞單位KCNK5以及鉀通道Kir3.2突變的大鼠的MAC進行了研究。結果,KCNK5缺乏大鼠的地氟醚、氟烷、 異氟醚MAC以及Kir3.2突變大鼠的異氟醚MAC與正常對照大鼠無差別。我們的結果不支援鉀通道調節麻醉藥制動作用的推論。

(王士雷 譯  莊心良 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).

 

出血性休克對依託咪酯的影響:藥理和藥代動力學的分析

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.

 

我們研究了豬出血性休克對依託咪酯藥理性的影響。16只動物隨機分成對照組和休克組。休克組出血至平均動脈壓50mmHg並維持至約30ml/kg血被放出。兩組依託咪酯300 µg kg-1 · min-110 min內輸入。給藥後180 min內抽5次動脈血測血藥濃度。每組以三室模型獲得藥代動力學參數。BIS作藥物效應指標。藥效學以S狀最大抑制效應曲線為特徵。資料顯示休克組在藥物輸入10 min時血藥濃度增加25%,之後漸下降,藥代動力學顯示兩組輕微變化。兩組依託咪酯產生相似的BIS分數。本實驗顯示中等出血性休克對依託咪酯藥代動力學影響輕微,而對藥效學則無影響,這與出血性休克對大多數其他鎮靜藥或阿片藥的影響不同。(王立中  譯 莊心良 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.

 

咪唑安定能增強鞘內注射布比卡因對熱或炎症疼痛的鎮痛作用

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強硬膜外注射布比卡因的鎮痛效果。但是,仍不清楚這種作用是相加還是協同。我們研究了咪唑安定和布比卡因在脊髓部位的相互作用。藥物通過預先埋置的蛛網膜下腔導管給予,用熱甩尾實驗和福馬林實驗進行疼痛刺激。通過行為學評價確定鞘內咪唑安定和布比卡因的50%有效劑量,用等效線圖分析法研究兩者的相互作用。結果,兩種藥物的鎮痛作用均有劑量依賴性。複合用藥的50%的有效劑量明顯低於估計的兩藥相加的劑量(甩尾實驗,P = 0.023; 福馬林實驗第一階段,P = 0.0025 ,第二階段,p0.047)。兩種藥物複合應用時行為的副作用顯著低於兩種藥物單獨應用。結論:鞘內注射咪唑安定和布比卡因對熱和炎症導致的疼痛有協同作用,而副作用的發生率顯著降低。(王士雷 譯   莊心良校)

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毒蕈堿受體參與鞘內注射可樂定減少機械性損傷神經的過敏反應

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-腎上腺素能激動劑可減少神經損傷動物機械和熱刺激引發的過敏反應,也可治療人的神經病理性疼痛。先前研究表明,此作用是由於{alpha}2-腎上腺素能激動劑的脊髓膽鹼能激動作用和對毒蕈堿受體的激動作用。正常動物脊髓中與防感受傷害的毒蕈堿受體亞型至今仍有爭議,而且能減少過敏反應的亞型和其與神經損傷後{alpha}2-腎上腺素能系統相互作用的亞型尚無報導。本實驗結果顯示,牢固結紮大鼠L5L6左側脊神經使針刺引發撤退反應的閾值降低。鞘內注射可樂定15 µg,使撤退反應閾值恢復。應用高度特異性m1m4拮抗劑,發現m1拮抗劑不能減弱可樂定的作用,而m4拮抗劑可抑制可樂定的作用。通過Westen 分析發現,結紮組和對照組脊髓背角m1m4受體蛋白表達量無區別,說明這種與m4受體的相互作用不能反映受體表達增多。結論:可樂定可有效治療神經病理性疼痛並使人腦脊液中乙酰膽鹼濃度增高。本實驗表明m4受體在可樂定治療神經損傷後的過敏反應起重要作用。(趙雪蓮     莊心良  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

 

嚴重腦外傷病人反復輸入大劑量新型羥基澱粉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.

 

在此前瞻性隨機對照單中心試驗中,我們研究了顱腦外傷病人大劑量反復輸入新型羥基澱粉溶液(6% HES 130/0.4)的安全性。病人隨機反復接受HES 130/0.4n16)劑量達70ml/kg/d(文獻中報導的最大劑量)或在輸入總量達70ml/kg/d白蛋白後給予對照的HES 200/0.5 (n = 15)直至最大限量33ml/kg/dHES 200/0.5+白蛋白)。我們發現兩組在死亡率,腎功能,出血併發症及使用血製品之間沒有差異。另外在凝血指標上也無大的不同。不過,在某些時間點,儘管輸入大劑量羥基澱粉溶液,VIII因數,von Willebrand因數和ristocetin 輔因數在HES 130/0.4組仍較高。我們認為HES 130/0.4可以安全應用於重症腦外傷病人數天直至劑量達到70ml/kg/d。(張軍 譯  莊心良 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.

 

硬膜外注射羅呱卡因和布比卡因用於分娩鎮痛: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.

 

很多研究對羅呱卡因和布比卡因分娩鎮痛進行了比較。早期的研究提示應用羅呱卡因時孕婦和新生兒的結果要好。我們對這些文獻進行了系統復習,對這些結果進行了系統研究,以確定兩藥的結果是否有差別。我們收集了對孕婦進行研究的電子資料庫和雜誌資料。分析的指標包括經陰分娩率、鎮痛效果以及孕婦和新生兒的情況。應用meta分析技術和隨機效應模型。有23個隨機實驗共包括應用羅呱卡因的1043例病人和布比卡因的1031例病人。產婦經陰分娩的發生率(幾率, 1.17; 95% 可信區間0.98–1.41; P = 0.12)和其他結果無顯著差別。儘管有些實驗報導布比卡因有更多的運動阻滯發生率,由於這些結果不統一,沒有進行比較。結論:兩種鎮痛方式的孕婦和新生兒的結果無顯著差別。應該進一步比較兩藥在合適的臨床濃度時對運動阻滯的結果是否有差別。(王士雷  譯 莊心良  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.

 

腹股溝疝修補術脊麻時小劑量布比卡因複合可樂定:一個隨機、雙盲研究

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

本實驗採用隨機,雙盲法研究小劑量布比卡因加入小劑量可樂定是否能延長術後鎮痛時間和行腹股溝疝修補術時提供充足的阻滯。隨機將45名患者分為3組,分別接受鞘內注射高張布比卡因加生理鹽水(B組);加15µg可樂定(BC15組);30µg可樂定(BC30組)。所有液體均用生理鹽水稀釋到3 mLB組有5名患者感覺阻滯水平不足,而改用全麻。BC15BC30的鎮痛範圍明顯大於B組。採用2段回歸,S1感覺恢復和運動阻滯恢復在BC30組要明顯長於B組。布比卡因中加入15 30 µg 可樂定可延長第一次要求鎮痛的時間,也可減少術後鎮痛發生低血壓的危險。結論:6 mg 布比卡因和15 µg可樂定能完全達到腹股溝疝修補術的麻醉要求。(趙雪蓮      莊心良  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.

 

氧化亞氮減輕加壓反應但增加去甲腎上腺素對喉鏡和氣管插管的反應

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.

氧化亞氮(N20)具有擬交感樣作用。我們觀察了N20能否調節全麻時氣管插管的心血管反應。100例病人隨機分4組,每組25例。每組分別在氣管插管前3分鐘吸入0%25%50%75%N20。麻醉誘導為靜注硫噴妥鈉5-7mg/kg,以指定濃度的N20通氣,靜注維可溴銨012mg/kg以利插管。插管後全部病人半緊閉吸入2%異氟醚。測定收縮壓、心率、心律和血漿兒茶酚胺濃度。氣管插管明顯增加收縮壓和心率。最大血壓變化為75% N2O組血壓下降46 ± 21 mm Hg,對照組65 ± 24 mm Hg(P < 0.05),但心率無明顯變化。去甲腎上腺素濃度插管後1分鐘增加,N2O可增加去甲腎上腺素濃度,但並不影響心律失常的發生。結論:氧化亞氮增加去甲腎上腺素濃度,但減輕氣管插管時的加壓反應。(王立中 譯 莊心良 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.