Anesthesia & Analgesia

June 2003

Table of Content

REGIONAL ANESTHESIA:

腰部硬膜外置管发生严重神经并发症的危险性很小

(王士雷   庄心良 校)

Small Risk of Serious Neurologic Complications Related to Lumbar Epidural Catheter Placement in Anesthetized Patients

Terese T. Horlocker, Martin D. Abel, Joseph M. Messick, Jr, and Darrell R. Schroeder

Anesth Analg 2003 96: 1547-1552.

硬膜外麻醉和全身麻醉对组织氧合的影响

(朱辉 译 王祥瑞 校)

The Effects of Epidural and General Anesthesia on Tissue Oxygenation

Tanja A. Treschan, Akiko Taguchi, Syed Z. Ali, Neeru Sharma, Barbara Kabon, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2003 96: 1553-1557.

CARDIOVASCULAR ANESTHESIA:

关于行非心脏手术的患者围术期预防性使用β受体阻滞剂的实践:加拿大麻醉医师的调查

(张俊峰 译 薛张刚 校)

Knowledge and Practice Regarding Prophylactic Perioperative Beta Blockade in Patients Undergoing Noncardiac Surgery: A Survey of Canadian Anesthesiologists

Elizabeth G. VanDenKerkhof, Brian Milne, and Joel L. Parlow

Anesth Analg 2003 96: 1558-1565.

在冠状动脉搭桥术后不久行胸骨切除术发生的围手术期心肌缺血

(王士雷 庄心良 校)

Perioperative Myocardial Ischemia in Patients Undergoing Sternectomy Shortly After Coronary Artery Bypass Grafting

Lucio Glantz, Tiberiu Ezri, Yitzhak Cohen, Sergio Konichezky, Abraham Caspi, Daniel Geva, and Amos Leviav

Anesth Analg 2003 96: 1566-1571.

在中度低血容量时快速输注晶体液或胶体液进行扩容引起的急性血管内容量增加的比较

(齐波 王祥瑞 )

Acute Intravascular Volume Expansion with Rapidly Administered Crystalloid or Colloid in the Setting of Moderate Hypovolemia

David R. McIlroy and Evan D. Kharasch

Anesth Analg 2003 96: 1572-1577.

地塞米松对冠脉再血管化手术后副作用的影响

(张俊峰 译 薛张刚 校)

The Effect of Dexamethasone on Side Effects After Coronary Revascularization Procedures

Per Halvorsen, Johan Ræder, Paul F. White, Sven M. Almdahl, Kenneth Nordstrand, Kjell Saatvedt, and Terje Veel

Anesth Analg 2003 96: 1578-1583.

经胸心脏超声结合经食道心脏超声在经导管对前缘变薄的房间隔缺损封闭术中的应用——一组病例报道

(王立中    庄心良 校)

Supplementing Transesophageal Echocardiography with Transthoracic Echocardiography for Monitoring Transcatheter Closure of Atrial Septal Defects with Attenuated Anterior Rim: A Case Series

Su-Man Lin, Shen-Kou Tsai, Jou-Kou Wang, Yin-Yi Han, Wei-horng Jean, and Yu-Chang Yeh

Anesth Analg 2003 96: 1584-1588.

麻醉绵羊冠状动脉脉血中异丙酚浓度与异丙酚心血管效应的关系

(齐波 译 王祥瑞 校)

The Contribution of the Coronary Concentrations of Propofol to Its Cardiovascular Effects in Anesthetized Sheep

Da Zheng, Richard N. Upton, and Allison M. Martinez

Anesth Analg 2003 96: 1589-1597.

PEDIATRIC ANESTHESIA:

含镁预充液对开心手术血镁浓度和钾丢失的影响

(张俊峰 译 薛张刚 校)

The Effects of Magnesium Prime Solution on Magnesium Levels and Potassium Loss in Open Heart Surgery

Wang Jian, Liu Su, and Liang Yiwu

Anesth Analg 2003 96: 1617-1620.

儿童门诊鼓膜切开术和放置平衡导管后的镇痛

(王立中    庄心良 校)

Postoperative Analgesia in Children Undergoing Myringotomy and Placement Equalization Tubes in Ambulatory Surgery

Ana Lucia Pappas, Elaine M. Fluder, Steve Creech, Andrew Hotaling, and Albert Park

Anesth Analg 2003 96: 1621-1624.

小儿麻醉后恢复室中急性躁动的前瞻性群体性研究

(忻纪华 译 王祥瑞 校)

A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit

Terri Voepel-Lewis, Shobha Malviya, and Alan R. Tait

Anesth Analg 2003 96: 1625-1630.

AMBULATORY ANESTHESIA:

Celecoxib术前给药对门诊手术术后疼痛和恢复时间的影响:剂量范围研究

(潘志浩 译 薛张刚 校)

The Efficacy of Celecoxib Premedication on Postoperative Pain and Recovery Times After Ambulatory Surgery: A Dose-Ranging Study

Alejandro Recart, Tijani Issioui, Paul F. White, Kevin Klein, Mehernoor F. Watcha, Louis Stool, and Mary Shah

Anesth Analg 2003 96: 1631-1635.

脑电双频指数可否用于预测电惊厥治疗后惊厥时间和苏醒?

BIS能预测电抽搐疗法后癫痫发作时间和苏醒吗?

(王立中   庄心良  校)

 (忻纪华 译 王祥瑞 校)

Can the Bispectral Index Be Used to Predict Seizure Time and Awakening After Electroconvulsive Therapy?

Paul F. White, Shivani Rawal, Alejandro Recart, Larry Thornton, Mark Litle, and Louis Stool

Anesth Analg 2003 96: 1636-1639.

ANESTHETIC PHARMACOLOGY:

Remifentanil对人体交感和血管的影响

(潘志浩 译 薛张刚 校)

Sympathetic and Vascular Consequences from Remifentanil in Humans

Randa K. Noseir, David J. Ficke, Anjana Kundu, Shahbaz R. Arain, and Thomas J. Ebert

Anesth Analg 2003 96: 1645-1650.

意识恢复期异丙酚作用部位浓度与芬太尼浓度无相关性

(朱慧琛 翻 王祥瑞 校)

苏醒期异丙酚的效应室浓度与芬太尼的效应室浓度无关

(轩泓     庄心良 校)

 

Effect-Site Concentration of Propofol for Recovery of Consciousness Is Virtually Independent of Fentanyl Effect-Site Concentration

Hiroko Iwakiri, Osamu Nagata, Takashi Matsukawa, Makoto Ozaki, and Daniel I. Sessler

Anesth Analg 2003 96: 1651-1655.

{alpha}-2肾上腺素受体可能没有参与吸入麻醉药产生的体动抑制

(潘志浩 译 薛张刚 校)

Edmond I Eger, II, Yilei Xing, Michael J. Laster, and James M. Sonner

{alpha}-2 Adrenoreceptors Probably Do Not Mediate the Immobility Produced by Inhaled Anesthetics

Anesth Analg 2003 96: 1661-1664.

布比卡因抑制人类TREK-1通道

(轩泓 庄心良 校)

Inhibition of Human TREK-1 Channels by Bupivacaine

Mark A. Punke, Thomas Licher, Olaf Pongs, and Patrick Friederich

Anesth Analg 2003 96: 1665-1673.

安氟醚、异氟醚和静脉麻醉药对鼠膈肌功能及易疲劳性的影响

(朱慧琛 译 王祥瑞 校

The Effects of Enflurane, Isoflurane, and Intravenous Anesthetics on Rat Diaphragmatic Function and Fatigability

Kahoru Nishina, Katsuya Mikawa, Shun-ichi Kodama, Tetsuro Kagawa, Takanobu Uesugi, and Hidefumi Obara

Anesth Analg 2003 96: 1674-1678.

奥力农治疗但不能预防疲劳导致的豚鼠横膈收缩性改变

(廖庆武翻译,薛张纲校对)

Olprinone for the Treatment, but Not Prevention, of Fatigue-Induced Changes in Guinea-Pig Diaphragmatic Contractility

Aki Uemura, Yoshitaka Fujii, Hidenori Toyooka, Setsuko Suzuki, Kohei Sawada, and Hideyuki Adachi

Anesth Analg 2003 96: 1679-1782.

TECHNOLOGY, COMPUTING, AND SIMULATION:

隔热法和强力空气保暖法有相同的保暖效果

(王士雷    庄心良 校)

Resistive-Heating and Forced-Air Warming Are Comparably Effective

Chiharu Negishi, Kenji Hasegawa, Shihoko Mukai, Fumitoshi Nakagawa, Makoto Ozaki, and Daniel I. Sessler

Anesth Analg 2003 96: 1683-1687.

使用新型通气装置时的中心温度监测

(殷文渊 译 王祥瑞 校)

Core Temperature Monitoring with New Ventilatory Devices

Takashi Matsukawa, Takahisa Goto, Makoto Ozaki, Daniel I. Sessler, Akira Takeuchi, Tomoki Nishiyama, and Teruo Kumazawa

Anesth Analg 2003 96: 1688-1691.

低温对异丙酚/氯胺酮/芬太尼麻醉下兔子的单个和成串电刺激引起的肌源性运动诱发电位的影响

(廖庆武 译 薛张纲 校)

The Effect of Hypothermia on Myogenic Motor-Evoked Potentials to Electrical Stimulation with a Single Pulse and a Train of Pulses Under Propofol/Ketamine/Fentanyl Anesthesia in Rabbits

Takanori Sakamoto, Masahiko Kawaguchi, Meiko Kakimoto, Satoki Inoue, Masahiro Takahashi, and Hitoshi Furuya

Anesth Analg 2003 96: 1692-1697.

PAIN MEDICINE:

唑尼沙胺对实验性单神经痛大鼠温度和机械疼痛过敏的作用

(王士雷    庄心良  校)

The Effect of Systemic Zonisamide (ZonegranTM) on Thermal Hyperalgesia and Mechanical Allodynia in Rats with an Experimental Mononeuropathy

Allen H. Hord, Donald D. Denson, Amale G. Chalfoun, and M. Isabel Azevedo

Anesth Analg 2003 96: 1700-1706.

对鼠经皮吸收阿米替林(Amitriptyline)和利多卡因(Lidocaine)后皮肤痛觉丧失的比较

(殷文渊 译 王祥瑞 校)

Cutaneous Analgesia After Transdermal Application of Amitriptyline Versus Lidocaine in Rats

Anna Haderer, Peter Gerner, Grace Kao, Venkatesh Srinivasa, and Ging Kuo Wang

Anesth Analg 2003 96: 1707-1710.

白鼠蛛网膜下电刺激导致防感受伤害作用增强和耐受性减弱

(廖庆武 译 薛张纲 校)

Antinociceptive Potentiation and Attenuation of Tolerance by Intrathecal Electric Stimulation in Rats

Chung-Ren Lin, Lin-Cheng Yang, Huey-Ling You, Chien-Te Lee, Ming-Hong Tai, Ping-Heng Tan, Ming-Wei Lin, and Jiin-Tsuey Cheng

Anesth Analg 2003 96: 1711-1716

CRITICAL CARE AND TRAUMA:

联合应用加压素和肾上腺素使延迟心肺复苏的猪神经功能完全恢复

(王士雷   庄心良 校)

Survival with Full Neurologic Recovery After Prolonged Cardiopulmonary Resuscitation with a Combination of Vasopressin and Epinephrine in Pigs

Karl H. Stadlbauer, Horst G. Wagner-Berger, Volker Wenzel, Wolfgang G. Voelckel, Anette C. Krismer, Günter Klima, Klaus Rheinberger, Sebastian Pechlaner, Viktoria D. Mayr, and Karl H. Lindner

Anesth Analg 2003 96: 1743-1749.

评估全身麻醉行机械通气时喉管的应用

(赵雪莲        庄心良  校)

An Evaluation of the Laryngeal Tube® During General Anesthesia Using Mechanical Ventilation

Luis A. Gaitini, Sonia J. Vaida, Mostafa Somri, Victor Kaplan, Boris Yanovski, Robert Markovits, and Carin A. Hagberg

Anesth Analg 2003 96: 1750-1755.

俯卧位改善了COPD患者的肺顺应性和气体交换

(陈洁 王祥瑞 )

Prone Position Improves Lung Mechanical Behavior and Enhances Gas Exchange Efficiency in Mechanically Ventilated Chronic Obstructive Pulmonary Disease Patients

Spyros D. Mentzelopoulos, Spyros G. Zakynthinos, Charris Roussos, Maria J. Tzoufi, and Argyris S. Michalopoulos

Anesth Analg 2003 96: 1756-1767.

NEUROSURGICAL ANESTHESIA:

亚低温(36-32℃)对麻醉而无手术创伤患者的凝血功能的影响

(顾越超 薛张纲 校)  

不同程度的低温对无手术创伤刺激的麻醉病人凝血功能的影响

(黄施伟 庄心良 校)

The Effect of Graded Hypothermia (36°C–32°C) on Hemostasis in Anesthetized Patients Without Surgical Trauma

S. C. Kettner, C. Sitzwohl, M. Zimpfer, S. A. Kozek, A. Holzer, C. K. Spiss, and U. M. Illievich

Anesth Analg 2003 96: 1772-1776.

小胶质细胞、星形胶质细胞和巨噬细胞在兔脊髓缺血后延迟发生的运动功能障碍中的作用

(王士雷   庄心良 校)

The Temporal Profile of the Reaction of Microglia, Astrocytes, and Macrophages in the Delayed Onset Paraplegia After Transient Spinal Cord Ischemia in Rabbits

Satoshi Matsumoto, Mishiya Matsumoto, Atsuo Yamashita, Kazunobu Ohtake, Kazuyoshi Ishida, Yasuhiro Morimoto, and Takefumi Sakabe

Anesth Analg 2003 96: 1777-1784.

OBSTETRIC ANESTHESIA:

比较那布啡与奥丹思酮预防鞘内注射吗啡引起的剖腹产术后痒的作用

(陈洁 译王祥瑞 ) 

Nalbuphine Versus Ondansetron for Prevention of Intrathecal Morphine-Induced Pruritus After Cesarean Delivery

Somrat Charuluxananan, Oranuch Kyokong, Wanna Somboonviboon, Arunchai Narasethakamol, and Pissamai Promlok

Anesth Analg 2003 96: 1789-1793.

数字评分法与硬膜外分娩镇痛

(顾越超译 薛张纲 校)

The Numeric Rating Scale and Labor Epidural Analgesia

Yaakov Beilin, Sabera Hossain, and Carol A. Bodian

Anesth Analg 2003 96: 1794-1798.

硬膜外芬太尼稀释量对分娩早期止痛效果的影响

(黄施伟 译,庄心良 校)

Diluent Volume for Epidural Fentanyl and Its Effect on Analgesia in Early Labor

Neil Roy Connelly, Robert K. Parker, Thomas Pedersen, Thenu Manikantan, Tanya Lucas, Stelian Serban, Mervat El-Mansouri, Scott DuBois, Edgar Delos Santos, Asad Rizvi, and Charles Gibson

Anesth Analg 2003 96: 1799-1804.

GENERAL ARTICLES:

铅是否干扰HBOC功能?一项试验性研究:三种已获得或试验过的HBOCs中的铅浓度,随铅浓度变化HBOCs/或牛血液的氧和血红蛋白分数

(顾越超 译 薛张纲 校)

Does Lead Interfere with Hemoglobin-Based Oxygen Carrier (HBOC) Function? A Pilot Study of Lead Concentrations in Three Approved or Tested HBOCs and Oxyhemoglobin Dissociation with HBOCs and/or Bovine Blood with Varying Lead Concentrations

Ahsanul K. Khan, Jonathan S. Jahr, Susmita Nesargi, Stephen J. Rothenberg, Zuping Tang, Anthony Cheung, Robert A. Gunther, Gerald J. Kost, and Bernd Driessen

Anesth Analg 2003 96: 1813-1820.

 

关于行非心脏手术的患者围术期预防性使用β受体阻滞剂的实践:加拿大麻醉医师的调查

Knowledge and Practice Regarding Prophylactic Perioperative Beta Blockade in Patients Undergoing Noncardiac Surgery: A Survey of Canadian Elizabeth G. VanDenKerkhof, RN MSc, DrPH, Brian Milne, MD MSc, FRCPC, and Joel L. Anesthesiologists

Parlow, MD MSc, FRCPC

Department of Anesthesiology, Queen’s University, Kingston General Hospital, Ontario, Canada

Anesth Analg 2003;96:1558-1565

对近期最佳医疗手段缺乏认知是常被认为的实践循证医学的主要障碍之一。围术期预防性的使用β受体阻滞剂是近期文献广泛讨论并且认为该治疗对患者的临床预后有显著意义,本研究的目的在于调查加拿大麻醉医师对围术期预防性使用β受体阻滞剂的认知及应用情况。我们对加拿大麻醉学会的1234名会员进行问卷调查,总体回应率为54%,回应者中的95%了解围术期使用β受体阻滞剂的文献,而这些回应者中的93%赞同β受体阻滞剂对冠心病患者是有益的观点。57%的常常在冠心病患者中预防性的使用β受体阻滞剂,这些常规使用者中的34%使用β受体阻滞剂一直到术后早期。只有9%的回应者承认在其组织中有此医疗常规。改研究结果表明转化研究结果到临床实践的障碍与对近期的最佳医疗证据的缺乏认知无关, 至于围术期应用β受体阻滞剂的问题,文献中的争议和实践中的考虑可能是施行最佳循证的主要障碍。结论:改研究结果表明麻醉医师知道并支持对有冠心病风险或确诊冠心病的患者在围术期预防性的使用β受体阻滞剂的观点,然而只有57%的麻醉医师经常给病人使用β受体阻滞剂,对近期最佳医疗证据的认知并不是施行循证的障碍。

(张俊峰 译 薛张刚 校)

A lack of awareness of the "best" current practice is frequently cited as a major barrier to the practice of evidence-based medicine. The purpose of this study was to survey Canadian anesthesiologists to determine their knowledge and practices associated with prophylactic perioperative ß blockade, a therapy that has been widely discussed in the literature and has the potential for a significant positive impact on patient outcomes. We sent questionnaires to 1234 members of the Canadian Anesthesiologists’ Society. The overall response rate was 54%. Ninety-five percent of respondents were aware of the perioperative ß blocker literature, and of these, 93% agreed that ß blockers were beneficial in patients with known coronary artery disease (CAD). Fifty-seven percent reported always or usually administering prophylactic ß blockers in patients with known CAD, and 34% of these regular users continued therapy beyond the early postoperative period. Only 9% of respondents reported that a formal protocol existed at their facility. This study suggests that barriers to the translation of research to practice were not related to a lack of awareness of the current best evidence. With respect to perioperative ß blockers, controversies within the literature as well as practical considerations may be greater barriers to implementation of best evidence.

 

地塞米松对冠脉再血管化手术后副作用的影响

The Effect of Dexamethasone on Side Effects After Coronary Revascularization Procedures

Per Halvorsen, MD*, Johan Ræder, MD PhD{dagger}, Paul F. White, MD PhD{ddagger}, Sven M. Almdahl, MD PhD*, Kenneth Nordstrand, MD PhD*, Kjell Saatvedt, MD PhD*, and Terje Veel, MD PhD*

*Departments of Anesthesiology and Surgery, Feiring Heart Clinic; {dagger}Department of Anesthesiology, Ullevaal University Hospital, Oslo, Norway; and {ddagger}Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Anesth Analg 2003;96:1578-1583

皮质类固醇激素可降低非心脏择期手术的副作用。我们设计此随机、双盲、安慰剂控制的研究以证实:标准剂量的地塞米松(4 mg x2)能够减少术后的恶心呕吐及疼痛,降低房颤的发生率,改善心脏术后患者的胃口,从而有利于患者的术后恢复。300例行冠脉再血管化的患者入选此研究,所有的患者均采用标准的麻醉处理,麻醉诱导后使用地塞米松 (4 mg/mL)或生理盐水,在术后清晨再使用同样剂量的药物,术后的前72小时持续监测心电图确定房颤的发生率,在术后24h48h、出院时评价患者确定术后副作用(如恶心、呕吐、疼痛等)的发生率和程度及患者的满意评分。地塞米松显著降低术后第一天(30% versus 42%)抗呕吐药的需要及术后第二天恶心(15% versus 26%)、呕吐(5% versus 16%)的发生率(P < 0.05)。此外,地塞米松显著降低术后第二天患者的食欲降低的比例。然而,皮质类固醇激素不能降低房颤(27% versus 32%)的发生率和阿片类止痛药的使用总量。改研究的结果表明地塞米松 (8 mg分两次给药)可降低心脏术后的呕吐症状、改善患者的食欲,但该剂量的皮质类固醇激素无抗心律失常和减少止痛药用量的特性。结论:地塞米松(8 mg IV)有利于减少心脏术后的呕吐症状和改善患者食欲, 但该剂量的皮质类固醇激素不能降低术后疼痛,不能降低新发房颤的发生率。

(张俊峰 译 薛张刚 校)

Corticosteroids decrease side effects after noncardiac elective surgery. We designed this randomized, double-blinded, placebo-controlled study to test the hypothesis that standard doses of dexamethasone (4 mg x2) would reduce postoperative nausea, vomiting, and pain, decrease the incidence of atrial fibrillation (AF), and improve appetite after cardiac surgery, thereby facilitating the recovery process. A total of 300 patients undergoing coronary revascularization surgery were enrolled in this clinical study. The anesthetic management was standardized in all patients. Dexamethasone (4 mg/mL) or saline (1 mL) was administered after the induction of anesthesia and a second dose of the same study drug was given on the morning after surgery. The incidence of AF was determined by analyzing the first 72 h of continuously recorded electrocardiogram records after cardiac surgery. The patients were assessed at 24- and 48-h intervals after surgery, as well as at the time of hospital discharge, to determine the incidence and severity of postoperative side effects (e.g., nausea, vomiting, pain) and patient satisfaction scores. Dexamethasone significantly reduced the need for antiemetic rescue medication on the first postoperative day (30% versus 42%), and the incidences of nausea (15% versus 26%) and vomiting (5% versus 16%) on the second postoperative day (P < 0.05). In addition, dexamethasone significantly reduced the percentage of patients with a depressed appetite on the second postoperative day. However, the corticosteroid failed to decrease the incidence of AF (27% versus 32%) or the total dosage of opioid analgesic medication administered in the postoperative period. We conclude that dexamethasone (8 mg in divided doses) was beneficial in reducing emetic symptoms and improving appetite after cardiac surgery. However, this dose of the corticosteroid does not seem to have antiarrhythmic or analgesic-sparing properties.

 

含镁预充液对开心手术血镁浓度和钾丢失的影响

The Effects of Magnesium Prime Solution on Magnesium Levels and Potassium Loss in Open Heart Surgery

Wang Jian, MSc, Liu Su, MD, and Liang Yiwu, MD

Department of Cardiac Surgery, Second Hospital of Hebei Medical University, Shijiazhuang, People’s Republic of China

Anesth Analg 2003;96:1617-1620

改研究的目的在于明确在体外循环(CPB)预充液中加镁对小儿开心手术血镁浓度和钾丢失的影响。40例拟行开心手术的患儿随机分为预充液中加硫酸镁(magnesium group, n = 20; 0.25 mmol/kg)和生理盐水(placebo group; n = 20)组。分别在CPB过程中和CPB后的既定时间点测定离子化镁(Img)及尿镁、钾浓度。magnesium groupImg浓度在CPB过程中较高但在CPB后不高, 在placebo group ImgCPB早期阶段降低并且降低到CPB24h的较低水平。CPB中及CPB后,尿镁浓度magnesium group要高于placebo group,尿钾浓度则达CPB24 h的较低水平(44.2 ± 2.9 versus 60.9 ± 2.6 mmol/L; P < 0.01)。因此,我们认为在预充液中加镁可维持正常Img水平并且阻止围术期的钾丢失。结论:改研究的结果显示小儿开心手术中含镁的预充液可阻止CPB中及CPB后的低镁的发生,并且可降低钾的尿丢失。

(张俊峰 译 薛张刚 校)

In this study, we examined the effects of magnesium supplementation in the cardiopulmonary bypass (CPB) prime solution on pediatric patients’ magnesium levels and potassium loss with open heart surgery. Forty pediatric patients undergoing heart surgery were randomly assigned either magnesium sulfate (magnesium group, n = 20; 0.25 mmol/kg) or saline (placebo group; n = 20) supplementation to the prime solution. Ionized magnesium (IMg) and urinary magnesium and potassium were mea- sured at defined time points during and after CPB. In the magnesium group, IMg concentration was larger during CPB but not after CPB. IMg decreased in the early stages of CPB in the placebo group and decreased to an even smaller level 24 h after CPB. Urinary magnesium levels in the magnesium group were larger than those in the placebo group during and after CPB, and urinary potassium concentrations reached significantly smaller levels 24 h after CPB (44.2 ± 2.9 versus 60.9 ± 2.6 mmol/L; P < 0.01). We conclude that the addition of magnesium into prime solution maintains normal IMg levels and prevents potassium flux during the perioperative period.

 

Celecoxib术前给药对门诊手术术后疼痛和恢复时间的影响:剂量范围研究

The Efficacy of Celecoxib Premedication on Postoperative Pain and Recovery Times After Ambulatory Surgery: A Dose-Ranging Study

Alejandro Recart, MD*, Tijani Issioui, MD*, Paul F. White, PhD MD*, Kevin Klein, MD*, Mehernoor F. Watcha, MD{dagger}, Louis Stool, MD*, and Mary Shah, MD*

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

Anesth Analg 2003;96:1631-1635

近来,FDAcelecoxib用作急性疼痛治疗的推荐剂量从 200 mg增加到400 mg 还没有研究直接比较不同剂量celecoxib用于预防术后疼痛的效能。在这一前瞻,双盲,安慰剂对照研究中,我们对200 mg400 mg celecoxib口服用于小型耳鼻喉手术门诊病人术前用药进行比较。总共93例健康门诊病人分至13研究组:对照组 (安慰剂; n = 30), celecoxib 200 mg (n = 30)celecoxib 400 mg (n = 33)。研究药物在术前30–45分钟口服, 所有病人都接受标准化的全身麻醉技术。在术后阶段记录疼痛评分 (0–10), 恢复时间,止痛药物的需要, 恢复质量(0–100), 病人对疼痛处理的满意程度(0–100)以及副作用。 疼痛在PACU,昼间手术恢复区和术后24小时每隔30分钟用口头等级评分评价,0 = 无痛10 = 可想象的最严重的疼痛。Celecoxib 400 mg200 mg (以及安慰剂)相比在减轻术后疼痛上更有效。celecoxib 200 mg 400 mg在减少术后芬太尼的用量上较安慰剂更有效(分别为74 ± 67 µg56 ± 62 µg120 ± 86 µg) 更大剂量celecoxib显著减少出院时严重疼痛病人的比例 (celecoxib400 mg组,celecoxib 200 mg 组和对照组分别为6% 37% 30%)。出院后口服止痛药的剂量的中位数在celecoxib 400 mg 组显著减少(0 celecoxib 200 mg 组和对照组分别为22)。然而,三组在恢复时间和次要预后变量上没有差异 (如病人满意度和恢复质量)。我们认为术前口服celecoxib 400 mg200 mg相比在减轻术后严重疼痛和镇痛药物需要上更有效。

(潘志浩 译 薛张刚 校)

Recently, the Food and Drug Administration increased the celecoxib dosage recommendation from 200 mg to 400 mg for acute pain management. No studies have directly compared the analgesic efficacy of different doses of celecoxib for the prevention of postoperative pain. In this prospective, double-blinded, placebo-controlled study, we compared oral celecoxib 200 mg to 400 mg when administered for premedication of outpatients undergoing minor ear-nose-throat surgery. A total of 93 healthy outpatients were assigned to 1 of 3 study groups: control (placebo; n = 30), celecoxib 200 mg (n = 30), or celecoxib 400 mg (n = 33). The study drug was given orally 30–45 min before surgery, and all patients received a standardized general anesthetic technique. During the postoperative period, pain scores (0–10), recovery times, the need for rescue analgesics, quality of recovery (0–100), patient satisfaction with pain management (0–100), and side effects were recorded. Pain was assessed at 30-min intervals using a verbal rating scale, with 0 = no pain to 10 = worst pain imaginable, in the postanesthesia care unit and day surgery unit recovery areas and at 24 h after surgery. Celecoxib 400 mg was significantly more effective than 200 mg (and placebo) in reducing postoperative pain. Both celecoxib 200 mg and 400 mg were more effective than placebo in reducing the postoperative fentanyl requirement (74 ± 67 µg and 56 ± 62 µg versus 120 ± 86 µg, respectively). The larger dose of celecoxib significantly reduced the percentage of patients with severe pain at discharge (6% versus 37% and 30% in the celecoxib 200 mg and control groups, respectively). The median number of doses of oral analgesic medication after discharge was also significantly reduced in the celecoxib 400 mg group (0 versus 2 and 2 in the celecoxib 200 mg and control groups, respectively). However, no differences were found among the three study groups with respect to recovery times and secondary outcome variables (e.g., patient satisfaction and quality of recovery). We conclude that oral premedication with celecoxib 400 mg was more effective than 200 mg in reducing severe postoperative pain and the need for rescue analgesic medication in the postoperative period.

 

 Remifentanil对人体交感和血管的影响

Sympathetic and Vascular Consequences from Remifentanil in Humans

Randa K. Noseir, MD, David J. Ficke, BS, Anjana Kundu, MD, Shahbaz R. Arain, MD, and Thomas J. Ebert, MD PhD

Department of Anesthesiology, Medical College of Wisconsin and Veterans Affairs Medical Center, Milwaukee  

Anesth Analg 2003;96:1645-1650

 

我们对在年轻(ASA I)的志愿者(n = 24)应用镇静-镇痛剂量remifentanil导致低血压的可能机制进行研究。心肺和交感变量在基线和2 4 ng/mL血浆浓度的remifentanil应用时进行采集。监测包括心电图, 心率(HR),有创动脉压, 肌肉交感神经活性, 前臂血流 (FBF)。寒冷升压试验(手浸入冰水1分钟)量化镇痛效能(视觉模拟评分0–100)。寒冷升压试验中视觉模拟评分 (基线时为62) remifentanil 输注时从27减少到18 。呼吸频率下降,呼气末二氧化碳(ETCO2) remifentanil 剂量增加耳增加; HR,有创血压, 肌肉交感神经活性, SpO2 保持不变,FBF与安慰剂相比增加。在第二个研究中(n = 7),定时呼吸用来维持remifentani 输注时的ETCO2, FBF仍然增加。在第三个研究中(n = 11), remifentanil对血管张力的直接作用用在肱动脉上渐进增加输注(1 100 µg/h)来确定; FBF显著增加,从每100 mL 组织3.5 增加到 4.3 mL/min (~增加13%–18%)。镇静剂量的remifentanil 导致镇痛,但没有除了FBF外的神经循环终点的改变。Remifentanil对局部血管张力的直接作用可能在促进低血压发生上起作用。

(潘志浩 译 薛张刚 校)

 

We explored the possible mechanisms of hypotension during the administration of sedation-analgesia doses of remifentanil in young (ASA physical status I) volunteers (n = 24). Cardiorespiratory and sympathetic variables were collected at baseline and at plasma concentrations of remifentanil (2 and 4 ng/mL). Monitoring included electrocardiogram, heart rate (HR), direct blood pressure, muscle sympathetic nerve activity, and forearm blood flow (FBF). A cold pressor test (1-min hand immersion in ice water) quantified analgesia effectiveness (visual analog scale, 0–100). Visual analog scale to the cold pressor test (62 at baseline) decreased to 27 and 18 during remifentanil infusions. Respiratory rate decreased and end-tidal carbon dioxide (ETCO2) increased with increasing doses of remifentanil; HR, direct blood pressure, muscle sympathetic nerve activity, SpO2 remained unchanged, but FBF increased compared with placebo. In a second study (n = 7), timed respiration was used to maintain ETCO2 during remifentanil, but FBF still increased. In a third study (n = 11), direct effects of remifentanil on vascular tone were determined with progressive infusions from 1 to 100 µg/h into the brachial artery; FBF increased significantly from 3.5 to 4.3 mL/min per 100 mL of tissue (~13%–18% increase). Sedative doses of remifentanil resulted in analgesia but no changes in neurocirculatory end-points except FBF. Direct effects of remifentanil on regional vascular tone may play a role in promoting hypotension.

 

{alpha}-2肾上腺素受体可能没有参与吸入麻醉药产生的体动抑制

{alpha}-2 Adrenoreceptors Probably Do Not Mediate the Immobility Produced by Inhaled Anesthetics

Edmond I Eger, II, MD, Yilei Xing, MD, Michael J. Laster, DVM, and James M. Sonner, MD

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

Anesth Analg 2003;96:1661-1664

 

{alpha}-肾上腺素受体的激动具有强烈的麻醉药效影响,这部分通过对脊髓的作用产生。 {alpha}-肾上腺素受体激动剂(dexmedetomidine) 可以降低吸入麻醉药物(如氟烷)的MAC0,在氟烷和dexmedetomidine之间有明显的相加作用。我们对是否吸入麻醉药异氟醚在面对伤害型刺激时抑制体动的能力由于激动{alpha}-肾上腺素受体而产生进行研究。异氟醚的MAC在腹腔内注射{alpha}-肾上腺素受体阻滞剂yohimbine atipamezole应用前后测定。Yohimbineatipamezole的剂量等于和超过可以逆转竞争{alpha}-肾上腺素受体降低MAC的剂量。更小剂量yohimbine atipamezole 轻度增加 (小于10%) 异氟醚的 MAC, 这一增加 我们解释为阻滞少量张力性的活性{alpha}-肾上腺素受体的活性。更大的5倍剂量没有改变 MAC。 更大的10倍剂量降低了 MAC。我们认为{alpha}-肾上腺素受体没有或极少介导吸入麻醉药产生体动抑制的能力。     

(潘志浩 译 薛张刚 校)

Agonism of {alpha}-adrenoreceptors has a powerful anesthetic result mediated, in part, by effects on the spinal cord. {alpha}-adrenoreceptor agonists (e.g., dexmedetomidine) can decrease the minimum alveolar anesthetic concentration (MAC) of inhaled anesthetics (e.g., halothane) to zero, with an apparently additive interaction between halothane and dexmedetomidine. We tested whether the capacity of the inhaled anesthetic isoflurane to produce immobility in the face of noxious stimulation resulted from agonism of {alpha}-adrenoreceptors. MAC (the concentration required to eliminate movement in response to a noxious stimulus in 50% of subjects) of isoflurane was determined before and after intraperitoneal administration of the {alpha}-adrenoreceptor antagonists yohimbine and atipamezole. The doses of yohimbine and atipamezole equaled or exceeded those that reverse the ability of agonism of {alpha}-adrenoreceptors to decrease MAC. Smaller doses of yohimbine or atipamezole slightly increased (by 10%) the MAC of isoflurane, an increase we interpret as the result of blockade of a small amount of tonically active {alpha}-adrenoreceptor activity. Doses five-fold larger did not change MAC. Doses 10-fold larger decreased MAC. We conclude that {alpha}-adrenoreceptors do not or minimally mediate the capacity of inhaled anesthetics to produce immobility.

 

奥力农治疗但不能预防疲劳导致的豚鼠横膈收缩性改变

Olprinone for the Treatment, but Not Prevention, of Fatigue-Induced Changes in Guinea-Pig Diaphragmatic Contractility

Aki Uemura, MD, Yoshitaka Fujii, MD, Hidenori Toyooka, MD, Setsuko Suzuki, Kohei Sawada, PhD, and Hideyuki Adachi, PhD

Department of Anaesthesiology, University of Tsukuba Institute of Clinical Medicine; andTsukuba Research Laboratories, Eisai Co, Ltd, Tsukuba City, Ibaraki, Japan

Anesth Analg 2003;96:1679-1782

奥力农是一种磷酸二酯酶III抑制剂,在活体能提高疲劳横膈的收缩性,但是没有资料提供体外疲劳导致的收缩性改变的治疗和预防。因此我们用豚鼠横膈来检验奥力农对疲劳导致的收缩性改变的治疗和预防。豚鼠横膈条根据奥力农的剂量(0, 10-6, 10-5, and 10-4 M)随机分组(每组n=7),然后放在器官槽中直接刺激。通过在20-Hz100-Hz刺激下的横膈条颤动张力和力量来衡量其收缩性。用20-Hz刺激横膈条产生间歇,重复收缩并持续5分钟从而导致其疲劳。在第一个实验中,疲劳产生期后在器官槽中加入奥力农作用5分钟。第二个实验中预防使用奥力农5分钟,然后再产生横膈条疲劳。在第一个实验中,疲劳产生期后每次刺激产生的肌肉强直力量都比基线值减低(P<0.05)10-5–10-4 M的奥力农能使双次刺激产生的收缩力量比疲劳值增加(P<0.05)。在第二个实验中,观察到预防使用奥力农((0–10-4 M)并没有使肌肉强直力量发生改变。疲劳产生后每次刺激产生的肌肉强直力量都比基线值减低(P<0.05)。这些结果提示10-5–10-4 M的奥力农能改善疲劳导致的豚鼠横膈收缩性的改变,而预防性使用奥力农并不能防止横膈的易疲劳性。(廖庆武翻译,薛张纲校对

Olprinone, a phosphodiesterase III inhibitor, improves the contractility in fatigued diaphragm in vivo, but no data are available for the treatment and prevention of fatigue-induced changes in vitro. We therefore examined the efficacy of Olprinone for the treatment and prevention of fatigue-induced changes in guinea-pig diaphragmatic contractility. The guinea-pig diaphragm strips were randomly allocated according to dose of Olprinone (0, 10-6, 10-5, and 10-4 M) (n = 7 each) and were stimulated directly in an organ bath. Diaphragmatic contractility was measured by assessing twitch tension and force at 20-Hz and 100-Hz stimulation. Diaphragmatic fatigue was induced by generating rhythmic, repetitive contractions produced by 20-Hz stimulation for 5 min. In the first experiment, after the fatigue-producing period, Olprinone was administered to the organ bath for 5 min. In the second experiment, Olprinone was pretreated for 5 min, and then diaphragmatic fatigue was produced. In Experiment 1, after a fatigue-producing period, tetanic force to each stimulus decreased from baseline values (P < 0.05). Olprinone 10-5–10-4 M caused an increase in force at both stimuli from fatigued values (P < 0.05). In Experiment 2, no change in tetanic force was observed by pretreatment with Olprinone (0–10-4 M). After producing fatigue, tetanic force to each stimulus decreased from baseline values (P < 0.05). These results suggest that Olprinone 10-5–10-4 M improves the fatigue-induced changes in guinea-pig diaphragmatic contractility and that pretreatment with Olprinone does not prevent diaphragmatic fatigability.

 

低温对异丙酚/氯胺酮/芬太尼麻醉下兔子的单个和成串电刺激引起的肌源性运动诱发电位的影响

The Effect of Hypothermia on Myogenic Motor-Evoked Potentials to Electrical Stimulation with a Single Pulse and a Train of Pulses Under Propofol/Ketamine/Fentanyl Anesthesia in Rabbits

Takanori Sakamoto, MD, Masahiko Kawaguchi, MD, Meiko Kakimoto, MD, Satoki Inoue, MD, Masahiro Takahashi, MD, and Hitoshi Furuya, MD

Department of Anesthesiology, Nara Medical University, Japan

Anesth Analg 2003;96:1692-1697

在此研究中我们研究低温对兔子肌源性运动诱发电位(MEPs)的影响,评估刺激模式对诱发运动诱发电位(MEPs)的影响。我们以12只用氯胺酮,芬太尼和异丙酚麻醉的兔子作为研究对象,从比目鱼肌上记录单个与三个和五个成串对运动皮质的电刺激产生的肌源性运动诱发电位(MEPs)。在食道温度为38°C时记录下MEPs的对照值,然后对兔子进行表面降温,使其食道温度分别维持在35°C, 32°C, 30°C28°C并记录每一温度点MEPs。与体核温度为38°C时的对照值相比,当体核温度降到28°C时单个刺激诱发的运动诱发电位(MEP)幅度显著减小(0.8 ± 0.4 mV 2.3 ± 0.3 mV; P < 0.05),而在降温过程中成串刺激诱发的MEP幅度并没有显著变化。不管刺激模式如何,随着体核温度的降低,MEP的潜伏期成线性增加。总之,这些结果显示异丙酚/氯胺酮/芬太尼麻醉下兔子的体核温度降到28°C时并不影响成串刺激诱发的MEP幅度,但除外单个刺激诱发的。

(廖庆武 译 薛张纲 校)

In the present study, we investigated the effect of hypothermia on myogenic motor-evoked potentials (MEPs) in rabbits. The influence of stimulation paradigms to induce MEPs was evaluated. Twelve rabbits anesthetized with ketamine, fentanyl, and propofol were used for the study. Myogenic MEPs in response to electrical stimulation of the motor cortex with a single pulse and a train of three and five pulses were recorded from the soleus muscle. After the control recording of MEPs at 38°C of esophageal temperature, the rabbits were cooled by surface cooling. Esophageal temperature was maintained at 35°C, 32°C, 30°C, and 28°C, and MEPs were recorded at each point. MEP amplitude to single- pulse stimulation was significantly reduced with a re-duction of core temperature to 28°C compared with the control value at 38°C (0.8 ± 0.4 mV versus 2.3 ± 0.3 mV; P < 0.05), whereas MEP amplitude to train-pulse stimulation did not change significantly during the cooling. MEP latency was increased linearly with a reduction of core temperature regardless of stimulation paradigms. In conclusion, these results indicate that a reduction of core temperature to 28°C did not influence MEP amplitudes as long as a train of pulses, but not a single pulse, was used for stimulation in rabbits under propofol/ketamine/fentanyl anesthesia.

白鼠蛛网膜下电刺激导致防感受伤害作用增强和耐受性减弱

Antinociceptive Potentiation and Attenuation of Tolerance by Intrathecal Electric Stimulation in Rats

Chung-Ren Lin, MD PhD , Lin-Cheng Yang, MD, Huey-Ling You, MS, Chien-Te Lee, MD, Ming-Hong Tai, PhD, Ping-Heng Tan, MD, Ming-Wei Lin, MS, and Jiin-Tsuey Cheng, PhD

Department of Biological Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan; Departments of Anesthesiology and Nephrology, Kaohsiung Chung Gang Memorial Hospital, Kaohsiung, Taiwan; and Department of Medical Research, Kaohsiung Veteran General Hospital, Kaohsiung, Taiwan

Anesth Analg 2003;96:1711-1716

我们检验了蛛网膜下电刺激是否会降低慢性使用吗啡的耐量和吗啡戒断的严重程度。给大白鼠蛛网膜下置入带电极的导管,并从蛛网膜下持续7天注入吗啡(2 nmol/h)或生理盐水。每日在相同时期给予蛛网膜下电刺激(0, 20, or 200 V)各一次,并通过轻击大白鼠尾部和测试蛛网膜下吗啡需要量来评估蛛网膜下电刺激对防感受伤害作用与吗啡耐量的影响。用纳洛酮戒断(2 mg/kg)来评估吗啡依赖性,并用微透析检测脊髓神经递质的改变。200V电刺激使得蛛网膜下使用吗啡的抗感受伤害作用增加。与对照组(仅使用吗啡2nmol/h)相比,200V蛛网膜下电刺激使得用2 nmol/h吗啡持续输注的大白鼠的耐受程度降低(AD50, 13.6 vs 124.7 nmol)。用纳洛酮诱发接受200V电刺激的大白鼠的戒断症状,其严重程度较轻。因此,在接受慢性蛛网膜下持续输注吗啡的大白鼠,蛛网膜下刺激可增强镇痛效果和减轻纳洛酮诱发的戒断症状。这种方法也许对蛛网膜下长期使用阿片类药物来控制慢性疼痛的进一步研究有所价值。               

(廖庆武 译 薛张纲 校)

We tested whether intrathecal electric stimulation would reduce the tolerance to chronic morphine use and the severity of precipitated morphine withdrawal. Rats received intrathecal electrode catheter implantation and a continuous intrathecal infusion of morphine (2 nmol/h) or saline for 7 days. Intrathecal electric stimulations (0, 20, or 200 V) were performed once daily during the same period. Daily tail-flick and intrathecal morphine challenge tests were performed to assess the effect of intrathecal electric stimulation on antinociception and tolerance to morphine. Naloxone withdrawal (2 mg/kg) was performed to assess morphine dependence, and changes in spinal neurotransmitters were monitored by microdialysis. The antinociceptive effect of intrathecal morphine was increased by 200 V of electric stimulation. The magnitude of tolerance was decreased in the rats receiving the 2 nmol/h infusion with 200 V of intrathecal electric stimulation compared with the control group (morphine 2 nmol/h alone) (AD50, 13.6 vs 124.7 nmol). The severity of naloxone-induced withdrawal was less in the rats receiving 200 V of stimulation. Intrathecal stimulation thus enhances analgesia and attenuates naloxone-induced withdrawal symptoms in rats receiving chronic intrathecal morphine infusion. Increases in spinal glycine release may be the underlying mechanism. This method may merit further investigation in the context of the long-term use of intrathecal opioids for controlling chronic pain.

 

 

铅是否干扰HBOC功能?一项试验性研究:三种已获得或试验过的HBOCs中的铅浓度,随铅浓度变化HBOCs/或牛血液的氧和血红蛋白分数

Does lead interfere with hemoglobin-based oxygen carrier (HBOC) function? A pilot study of lead concentrations in three approved or tested HBOCs and oxyhemoglobin dissociation with HBOCs and/or bovine blood with varying lead concentrations.

Khan AK, Jahr JS, Nesargi S, Rothenberg SJ, Tang Z, Cheung A, Gunther RA, Kost GJ, Driessen B.

Department of Anesthesiology, Charles R. Drew University of Medicine and Science, King/Drew Medical Center, Los Angeles, California, USA.

Anesth Analg. 2003 ;96(6):1813-20

 

我们测量了三种以血红蛋白为基础的携氧物质(HBOCsOxyglobinHemopureHemolink)中的铅浓度,并与血库库存血中的铅浓度进行比较。测量了牛HBOC,有或无牛血,和牛血中存在高浓度铅时的氧和血红蛋白分数。每组样本均与生理盐水(对照组),低浓度铅(22ug/dL,中毒浓度的铅(70ug/dL)混合。它们在2个大气压下与氧浓度为2.5%5%8%10%21%,和95%CO(2) 浓度为5%,其余为氮气的气体混合5分钟,每份样本在每一氧浓度水平洗入15分钟后进行血氧测定。绘制氧饱和度氧分压曲线,数据符合四次多项式非线性回归方程。三种HBOCs的铅浓度分别为0.510.220.40 ug/dL。临床上氧和血红蛋白分数曲线无显著差别。三种经测试的HBOCs的铅浓度较小,不比血库库存血的铅浓度平均值大。在体外试验中,无论是浓缩的牛HBOC还是1:1HBOC和牛血混合物中增加的铅都不会影响血红蛋白的氧和。结论:枪伤会很快增加血循环中的铅浓度。三种HBOCs的铅浓度均较小,HBOCs或牛血都不会受铅浓度的影响而导致氧过度结合或解离。HBOCs在枪伤患者比较有用。     

(顾越超 译 薛张纲 校)

We measured lead concentrations in three hemoglobin-based oxygen carriers (HBOCs; Oxyglobin, Hemopure, and Hemolink) and compared them with lead concentrations from blood-bank blood. Oxyhemoglobin dissociation was measured with large concentrations of lead in bovine HBOC, with or without bovine blood, and in bovine blood. Samples of each were prepared by combining one with normal saline (control), the second with small lead concentrations (22 micro g/dL), and the third with toxic lead concentrations (70 micro g/dL). They were blended in 2 tonometers at oxygen concentrations (2.5%, 5%, 8%, 10%, 21%, and 95%) with 5% CO(2) and the remainder nitrogen for 5 min per sample after a 15-min wash-in with each level of oxygen and were measured with co-oximetry. Oxygen saturation was plotted against PO(2), fitting fourth-order polynomial nonlinear regression to the data. The lead concentrations of the three HBOCs were 0.51, 0.22, 0.40 micro g/dL. There were no clinically important differences of the oxyhemoglobin dissociation curves as a function of lead concentration. The lead concentrations of the three tested HBOCs were small and no larger than the average for blood-bank blood. The presence of increasing concentrations of lead in either concentrated solution of bovine HBOC or a 1:1 mixture of bovine HBOC and native bovine blood does not appear to affect hemoglobin oxygenation in an acute in vitro model of increased lead concentrations. IMPLICATIONS: Gunshot wounds rapidly increase circulating lead concentrations. Lead concentrations are small in three hemoglobin-based oxygen carriers (HBOCs), and HBOCs and/or bovine blood do not appear to be affected by lead concentrations in terms of immediate oxygen on-loading and off-loading. HBOCs may be useful in patients with gunshot wounds.

 

 

数字评分法与硬膜外分娩镇痛

The numeric rating scale and labor epidural analgesia.

Beilin Y, Hossain S, Bodian CA.

Departments of Anesthesiology, Obstetrics, Gynecology, and Reproductive Sciences, and. Biomathematical Sciences, Mount Sinai School of Medicine of New York University, New York City.

Anesth Analg. 2003 ;96(6):1794-8

 

口述数字(0-10)评分法(NRS)在研究中广泛用于疼痛评价,但是它对于临床医师的使用价值尚未明确。本研究中,把额外需求的镇痛药物量作为疼痛研究中一个临床相关指标,并把它与NRS的结果相比较。对先前进行的有关硬膜外分娩镇痛的三个研究进行统计分析。在这三个研究中,在进行硬膜外分娩镇痛之前和之后15分钟采取口述NRS数值。在进行硬膜外分娩镇痛15分钟时,询问产妇是否需要更多的镇痛药物。我们发现NRS数值为0-1的患者很少(2%)需要更多的镇痛药物,NRS数值为2-3的患者51%需要更多的镇痛药物,NRS数值为>3的患者几乎全部(93%)需要更多的镇痛药物。按最后的NRS数值分为三组(0123>3)比使用单独的NRS数值对临床医师来讲更有用。结论:本研究提示除非口述NRS数值为01,进行硬膜外分娩镇痛的产妇大部分需要更多的镇痛药物。另外,按最后的NRS数值分为三组(0123>3)进行分析对临床医师来讲比使用全部范围的NRS数值更有用。   

(顾越超译 薛张纲 校)

A verbal numeric 0-10 rating scale (NRS) is widely used to evaluate pain in research studies, but its usefulness to the clinician is not well established. In this study, we define desire for additional analgesic medication as a clinically relevant outcome in research studies about pain and compare it with the results of the NRS. A post hoc analysis of three studies that we previously conducted concerning labor epidural analgesia was performed. In all three studies, a verbal NRS score was obtained before and 15 min after labor epidural analgesia. At 15 min, the woman was also asked if she wanted more pain medication. We found that very few patients (2%) with a NRS score of 0-1 wanted more medication. When the NRS score was 2 or 3, 51% of the patients wanted more medication, and when the NRS score was >3, almost all patients (93%) wanted more medication. Grouping the final NRS scores into 3 categories (0 or 1, 2 or 3, and >3) is more useful to the clinician than using individual NRS scores.

 

亚低温(36-32℃)对麻醉而无手术创伤患者的凝血功能的影响

The Effect of Graded Hypothermia (36 degrees C-32 degrees C) on Hemostasis in Anesthetized Patients Without Surgical Trauma.

Kettner SC, Sitzwohl C, Zimpfer M, Kozek SA, Holzer A, Spiss CK, Illievich UM.

Department of Anesthesiology and General Intensive Care, University of Vienna, General Hospital Vienna, Vienna, Austria. Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care, Vienna, Austria.

Anesth Analg. 2003 ;96(6):1772-6

 

在健康人群中低温对凝血功能的独立作用尚未明确。将16例进行择期颅内手术的已麻醉患者的中心体温降至32℃,同时在麻醉诱导后外科手术之前监测36℃、34℃、32℃时的PT,APTT,TEG(R),止血时间,血小板计数。在降温过程中,APTT,血球压积,止血时间无变化;PT,血小板计数降低。血小板计数降低时不伴有血球压积的降低。因此,因输液而引起的血液稀释不可能引起此变化。在血小板计数与功能正常的患者血小板计数轻度下降无临床意义。PT的轻度下降提示外源性凝血途径的改变。TEG(R)测量显示在体温变化过程中血块凝结延迟,而在体温37℃时无改变。这提示低温降低血浆凝血因子和血小板的活性。但是,血块凝结的功能未改变。所有凝血功能的变化均维持在正常范围内。结果显示适度的短时间(4小时)的低温对健康人仅有微小的副作用。对长时间低温的作用未做出结论。结论:本研究调查了低温对健康已麻醉患者凝血功能的独立作用。发现体温降至32℃对凝血功能的变化仅有微小的作用,提示对健康人仅有微小影响。            

(顾越超 译 薛张纲 校)

The isolated effects of hypothermia on hemostasis have not been investigated in healthy humans. We cooled 16 anesthetized patients scheduled for elective intracranial surgery to 32 degrees C body core temperature and assessed prothrombin time (PT), activated partial thromboplastin time, thrombelastogram (TEG(R)), closure time, and platelet count at 36 degrees C, 34 degrees C, and 32 degrees C body core temperature after the induction of anesthesia but before surgical intervention. Activated partial thromboplastin time, hematocrit, and closure time did not change, whereas PT and platelet count decreased during cooling. Platelet count decreased without a decrease in hematocrit; hence, a dilution by administered fluids seemed unlikely. The small decrease of platelet count is probably clinically irrelevant in patients with normal platelet count and function. The small decrease in PT indicates an alteration of the extrinsic pathway of coagulation. TEG(R) measurements showed a delay of clot formation in temperature-adjusted measurements but showed no change if the test temperature was 37 degrees C. This indicates that hypothermia reduces plasmatic coagulation and platelet reactivity. However, the clot strength is not altered by hypothermia. All coagulation variables remained within the normal ranges. Our results may indicate that moderate short-term (4-h) hypothermia has only minor adverse effects in healthy humans. We can make no statement about the effects of hypothermia of longer duration. IMPLICATIONS: This study investigated the isolated effects of hypothermia in healthy anesthetized humans. We found only minor effects of body temperature reduction to 32 degrees C on assessed coagulation variables, indicating only minor effects in otherwise healthy humans.

 

 

硬膜外麻醉和全身麻醉对组织氧合的影响

The Effects of Epidural and General Anesthesia on Tissue Oxygenation

Tanja A. Treschan, MD*, Akiko Taguchi, MD§, Syed Z. Ali, MD§, Neeru Sharma, MD§, Barbara Kabon, MD*, Daniel I. Sessler, MD{dagger},¶,#, and Andrea Kurz, MD{ddagger},||,¶

*Department of Anesthesia and General Intensive Care, Vienna General Hospital, {dagger}Ludwig Boltzmann Institute, and {ddagger}Department of Anesthesia and Intensive Care Medicine, University of Vienna, Vienna, Austria; §Departments of Anesthesia and ||Anesthesiology, Washington University, St. Louis, Missouri; and ¶Outcomes ResearchTM Institute and #Department of Anesthesiology, University of Louisville, Louisville, Kentucky

Anesth Analg 2003;96:1553-1557

 

伤口感染和皮下组织氧分压呈负相关。全身麻醉可通过直接扩张血管和抑制体温调节中枢的血管收缩而增加局部血流。硬膜外麻醉通过抑制交感神经敏感性而增加阻滞区域的灌注。为证实在清醒或麻醉状态下硬膜外麻醉是否能够增加组织氧分压,15名健康志愿者分别实施硬膜外麻醉,全身麻醉,及硬膜外、全麻联合麻醉。采用气压计测定一侧上臂和大腿的皮下组织氧分压。0.75%mepivacaine实施硬膜外麻醉使平面到达T10水平;1.5%的七氟醚吸入30%的氧维持全身麻醉;在基础麻醉下通过封闭的面罩吸入30%的氧并实施硬膜外麻醉。上臂和大腿的皮下组织氧分压基础水平分别为57±1154±8mmHg。硬膜外麻醉显著增加大腿组织氧分压,可增加9 mmHg63±7 mmHg,但不增加上臂组织氧分压。单纯全身麻醉上臂和大腿的组织氧分压几乎没有什么变化,分别为58±11 mmHg63±12 mmHg。全身麻醉联合硬膜外麻醉上臂组织氧分压仍无变化而大腿皮下组织氧分压从63±12 mmHg增加到71±9 mmHg,增加了8±3 mmHg。虽然硬膜外麻醉合并或不合并全身麻醉能够显著增加组织氧分压,这种增加的幅度可能对外科伤口感染有一定的临床意义。

 (朱辉 译 王祥瑞 校)

The risk of wound infections is inversely related to subcutaneous tissue oxygen tension. General anesthesia increases local blood flow by direct vasodilation and central inhibition of thermoregulatory vasoconstriction. Epidural anesthesia can increase perfusion in blocked regions by decreasing sympathetic tone. We therefore tested the hypothesis that epidural anesthesia increases tissue oxygen tension in awake and anesthetized subjects. Fifteen healthy volunteers underwent epidural, general, and combined epidural and general anesthesia. Subcutaneous tissue oxygen tension was measured using tonometers in the lateral upper arm and the lateral thigh. Epidural anesthesia to a T10 level was maintained with 0.75% mepivacaine. General anesthesia was maintained with 1.5% sevoflurane in 30% oxygen; 30% inspired oxygen was given via a sealed facemask during baseline and epidural anesthesia. Baseline subcutaneous tissue oxygen tensions for arm and thigh were 57 ± 11 and 54 ± 8 mm Hg, respectively. Epidural anesthesia significantly increased tissue oxygenation in the thigh by 9 mm Hg, to 63 ± 7 mm Hg, without increasing arm oxygenation. Tissue oxygenation in the arm and thigh were similar during general anesthesia alone, 58 ± 11 and 63 ± 12 mm Hg. Arm oxygenation remained unchanged with the addition of epidural anesthesia; however, thigh subcutaneous oxygen partial pressure increased 8 ± 3 mm Hg, from 63 ± 12 to 71 ± 9 mm Hg. Although epidural anesthesia increased tissue oxygenation significantly with and without general anesthesia, the magnitude of this increase might be of marginal clinical importance in regard to surgical wound infections.

 

在中度低血容量时快速输注晶体液或胶体液进行扩容引起的急性血管内容量增加的比较

Acute Intravascular Volume Expansion with Rapidly Administered Crystalloid or Colloid in the Setting of Moderate Hypovolemia

David R. McIlroy, MB BS, FANZCA, and Evan D. Kharasch, MD PhD

Department of Anesthesiology, University of Washington Medical Center, Seattle

Anesth Analg 2003;96:1572-1577


虽然应用不同的晶体和胶体溶液均可建立容量平衡,但在快速输注晶体或胶体溶液进行扩容时所能达到的最大血管内容量值尚不清楚。通过交叉试验方法在8名健康男性志愿者,对输注1000ml乳酸林格氏液和同等容量的6%羟乙基淀粉液所能达到的最大血管内容量进行了比较。在实验过程中通过放900ml血液人为造成志愿者中度低血容量状态,然后在5-7分钟内快速输注晶体或胶体液。在30分钟内每5分钟测量一次血球压积来观察血容量的变化。结果发现应用乳酸钠林格氏液所能达到的最大血管内容量平均为630±127ml,其最大血管内容量是在快速补液刚刚结束时达到的,而应用6%羟乙基淀粉液所能达到的最大血管内容量平均为1123±116ml,其最大血管内容量是在快速补液后5分钟时达到的。实验结果存在显著差异(P<0.001)。结果表明即使在非常短的时间内,快速输注胶体也能更加有效地增加血容量,由此可推论,输注胶体液时心输出量的增加要大于输注同等容量的晶体液,即使非常快速输注晶体液时。

(齐波 译 王祥瑞 校)

Although the distribution of various crystalloid and colloid solutions at equilibrium has been well established, the acute peak expansion of intravascular volume that can be achieved with the rapid administration of crystalloid or colloid is unknown. We studied eight healthy male subjects in a two-part crossover trial designed to assess the maximal increase in intravascular volume achieved with 1000 mL of lactated Ringer’s solution compared with the same volume of 6% Hetastarch. Subjects were made moderately hypovolemic by the withdrawal of 900 mL of blood, and then the crystalloid or colloid solution was rapidly infused over 5–7 min. Serial dilution of hematocrit was measured every 5 min for 30 min to determine changes in blood volume. Peak expansion of intravascular volume with lactated Ringer’s solution was 630 ± 127 mL, occurring immediately the rapid infusion was complete, whereas the peak expansion of intravascular volume with 6% Hetastarch was 1123 ± 116 mL and occurred 5 min after the completion of the fluid infusion. The results were significantly different (P < 0.001). These results would suggest that even for very short periods of time, rapid infusion of colloid significantly more effectively increases blood volume and, by inference, cardiac output than the same volume of crystalloid, even if the crystalloid is administered very rapidly.

麻醉绵羊冠状动脉脉血中异丙酚浓度与异丙酚心血管效应的关系

The Contribution of the Coronary Concentrations of Propofol to Its Cardiovascular Effects in Anesthetized Sheep

Da Zheng, MD, Richard N. Upton, PhD, and Allison M. Martinez

Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital/University of Adelaide, North Terrace, Adelaide, Australia

 Anesth Analg 2003;96:1589-1597

将生理性药效动力学模型与心血管系统的模型相结合可了解药物心血管效应的体内作用部位。在本研究观察冠脉血异丙酚浓度的作用。9只绵羊用2%异氟醚麻醉后迅速进行心血管测量。通过随机交叉的实验设计,这些绵羊接受经冠状动脉(CA)应用异丙酚选择性作用于心肌(以冠状窦血浓度为标准)或经静脉应用异丙酚使全身各部位达到同样的药物浓度。结果表明左室心肌收缩力(LVdP/dtmax)和平均动脉压的下降与异丙酚的浓度呈线性相关。对于经CA途径用药的绵羊,冠状窦血异丙酚浓度每增加1mg/LLVdP/dtmax减少52mmHg/S。经静脉途径用药的绵羊,LVdP/dtmax的减少与CA途径相同,表明此种心血管效应的产生主要依赖于冠脉血异丙酚浓度。在CA途径组,冠状窦血异丙酚浓度每增加1mg/L则平均动脉压下降0.6mmHg。而在静脉用药组平均动脉压有更大的下降(2.5 mmHg·mg-1·L-1)。因此,这种效应主要由身体其它部位的异丙酚浓度来调节。

(齐波 译 王祥瑞 校)

Linking physiological pharmacokinetic models to models of the cardiovascular system requires knowledge of the sites in the body that mediate a drug’s cardiovascular effects. We examined the role of the coronary concentrations of propofol. Nine sheep anesthetized with isoflurane (2%) were instrumented acutely for cardiovascular measurements. In a random crossover design, they were administered ramped coronary artery (CA) infusions of propofol to selectively enrich the myocardium (as indicated by the coronary sinus blood concentration) or IV infusions to achieve the same concentration range in all sites of the body. Reductions in left ventricular myocardial contractility (LV dP/dtmax) and mean arterial blood pressure were linearly related to the propofol concentration. For the CA route, LV dP/dtmax was reduced by 52 mm Hg/s for each milligram per liter increase in coronary sinus propofol concentration. For the IV route, the reduction in LV dP/dtmax was equivalent to that with the CA route, showing that the coronary propofol concentration was the major contribution to this effect. For the CA route, mean arterial blood pressure was reduced by 0.6 mm Hg for each milligram per liter. There was a larger reduction (2.5 mm Hg · mg-1 · L-1) for the IV route. Therefore, this effect was predominantly mediated by propofol concentrations elsewhere in the body.

 

小儿麻醉后恢复室中急性躁动的前瞻性群体性研究

A Prospective Cohort Study of Emergence Agitation in the Pediatric Postanesthesia Care Unit

Terri Voepel-Lewis, MSN RN, Shobha Malviya, MD, and Alan R. Tait, PhD

Department of Anesthesiology, Section of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, Michigan

Anesth Analg 2003;96:1625-1630

麻醉后的躁动(EA)不仅影响小儿的恢复,而且也影响到麻醉后的评估和处理。在本研究中选取健康儿童观察EA的判断和评估EA的相关因素,并且描述相关预后情况。选择3-7岁的儿童进行全麻包括门诊病人。所有的围术期监护都经文件证明,同时记录麻醉后恢复室内的术后行为。3-7岁的儿童由父母完成行为调查问答卷。研究共包括了521名儿童,其中96例发生EA。一些病例中躁动可持续45分钟(范围,3-45分钟;平均,14+/-11分钟),需要药物干预的占52%,且与麻醉后恢复室内停留时间延长有关(与未躁动的儿童停留时间101+/-61分钟相比停留时间为117+/-66分钟;p=0.02)。发现10个因素与EA 有关,包括年龄,术前情况,适应性,眼科和耳鼻咽喉部位的操作,七氟醚,异氟醚,七氟醚/异氟醚,镇痛药和苏醒时间。这些因素中,耳鼻咽喉部位的手术,苏醒时间和异氟醚为独立影响因素。

(忻纪华 译 王祥瑞 校)

Emergence agitation (EA) is a postanesthetic problem that interferes with a child’s recovery and presents a challenge in terms of assessment and management. In this prospective cohort study, we sought to determine the incidence of EA, evaluate factors associated with and predictive of EA, and describe associated outcomes in healthy children. Children aged 3–7 yr who were undergoing general anesthesia for elective outpatient procedures were included. All perioperative care was documented, and postoperative behaviors in the postanesthesia care unit were recorded. Parents completed the Behavioral Style Questionnaire for 3- to 7-yr-olds. Five-hundred-twenty-one children were studied, of whom 96 (18%) had EA. Agitation lasted up to 45 min in some cases (range, 3–45 min; mean, 14 ± 11 min), required pharmacologic intervention in52% of children, and was associated with a prolonged postanesthesia care unit stay (117 ± 66 min versus 101 ± 61 min for nonagitated children; P = 0.02). Ten factors were found to be associated with EA, including age, previous surgery, adaptability, ophthalmology and otorhinolaryngology procedures, sevoflurane, isoflurane, sevoflurane/isoflurane, analgesics, and time to awakening. Of these, otorhinolaryngology procedures, time to awakening, and isoflurane were shown to be independent risk factors.

 

脑电双频指数可否用于预测电惊厥治疗后惊厥时间和苏醒?

Can the Bispectral Index Be Used to Predict Seizure Time and Awakening After Electroconvulsive Therapy?

Paul F. White, PhD MD, FANZCA*, Shivani Rawal, MD*, Alejandro Recart, MD*, Larry Thornton, MD{dagger}, Mark Litle, MD{dagger}, and Louis Stool, MD*

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

Anesth Analg 2003;96:1636-1639

脑电图双频指数(BIS)可测定麻醉时的镇静程度,并与麻醉中的紧急事件相关。因此,我们假设BIS可用于预测美索比妥麻醉下电惊厥治疗(ECT)——导致的惊厥时间和苏醒。选择25例严重抑郁症患者,经病人同意连续接受100次电惊厥治疗。所有病人麻醉前静脉注射0.2mg胃长宁,以美索比妥1mg/kg静注麻醉。连续监测BIS变化,在特定点记录BIS值,包括麻醉前(基础值),诱导后(ECT治疗前),ECT结束时(峰值),ECT治疗后(抑制状态)和苏醒时(睁眼时)。ECT治疗前的BIS值与运动(r=0.3)和EEG发作活动(r=0.4)有关 (p<0.05) ECT治疗后BIS峰值与EEG发作时间有关(r=0.5(p<0.05)EEG发作时间和到睁眼的时间呈正相关(r=0.4(p<0.05) 。但是,苏醒时BIS值从29-97,且75%的病例<60。我们得出结论:ECT刺激前BIS值可用于预测惊厥时间。但是,苏醒时的BIS值变化范围大,提示它不但反映了美索比妥的残留抑制作用而且反映了发作后的抑制。

(忻纪华 译 王祥瑞 校)

The electroencephalogram (EEG) bispectral index (BIS) measures the hypnotic component of the anesthetic state and correlates with emergence from general anesthesia. Therefore, we hypothesized that the BIS would be useful in predicting electroconvulsive therapy (ECT)-induced seizure times and awakening from methohexital anesthesia. Twenty-five consenting patients with major depressive disorders underwent 100 maintenance ECT treatments. All patients were premedicated with glycopyrrolate 0.2 mg IV, and anesthesia was induced with methohexital 1 mg/kg IV. The BIS was monitored continuously, and the values were recorded at specific end-points, including before anesthesia (baseline), after the induction of anesthesia (pre-ECT), at the end of ECT (peak), after ECT (suppression), and on awakening (eye opening). The pre-ECT BIS value correlated with the duration of both the motor (r = 0.3) and EEG (r = 0.4) seizure activity (P < 0.05). The peak post-ECT BIS value correlated with the duration of the EEG seizure activity (r = 0.5) (P < 0.05). A positive correlation was also found between the EEG seizure duration and the time to eye opening (r = 0.4) (P < 0.05). However, the BIS values on awakening from methohexital anesthesia varied from 29 to 97 and were <60 in 75% of the cases. We conclude that the BIS value before the ECT stimulus is applied could be useful in predicting the seizure time. However, the BIS values on awakening were highly variable, suggesting that it reflects both the residual depressant effects of methohexital and post-ictal depression.

 

意识恢复期异丙酚作用部位浓度与芬太尼浓度无相关性

Effect-Site Concentration of Propofol for Recovery of Consciousness Is Virtually Independent of Fentanyl Effect-Site Concentration

Hiroko Iwakiri, MD*, Osamu Nagata, MD*, Takashi Matsukawa, MD{dagger}, Makoto Ozaki, MD*, and Daniel I. Sessler, MD

Yamanashi, Japan; {ddagger}OUTCOMES RESEARCHTM Institute, Department of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky; and {ddagger}Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria  

Anesth Analg 2003;96:1651-1655

为了降低外科手术刺激产生的影响使用芬太尼可减少异丙酚的用量,但阿片类药物很少影响患者的意识,为此,本研究在清醒患者芬太尼很少影响异丙酚的作用部位浓度。50位妇产科腹部手术的患者随机分为五组,每组均给予异丙酚麻醉并分别加入芬太尼0.8,1.0,1.4,2.0,3.0 ng/Ml。术后的初始阶段仍按指定的速率持续运用芬太尼,同时我们将患者能睁眼对命令作出回应时的异丙酚浓度视为清醒浓度。实验中各清醒组的异丙酚作用部位浓度无明显差别(异丙酚1.9+0.5 ug/mL芬太尼0.8 ng/mL; 异丙酚1.6+0.4ug/mL芬太尼1.0 ng/mL;异丙酚1.6+0.2ug/mL芬太尼1.4 ng/mL;异丙酚 1.7+0.4ug/mL芬太尼2.0 ng/mL;异丙酚1.6+0.34ug/mL芬太尼3.0ng/mL(mean +SD). 在使用0.8 ng/Ml芬太尼的组中70%的患者主诉有疼痛,而使用23 ng/Ml芬太尼组的患者无此主诉。3ng/Ml9名患者中的五位(56%)出现术后呼吸频率<6/分,其中一名患者的心率降到〈40/分。这些数据显示妇产科腹腔镜手术病人恢复期芬太尼的理想作用浓度为1.4-- 2.0 ng/Ml

(朱慧琛 翻 王祥瑞 校)

Fentanyl reduces the amount of propofol necessary to prevent responses to surgical stimuli. However, opioids have relatively little effect on consciousness. We, therefore, tested the hypothesis that fentanyl minimally alters the effect-site concentration of propofol associated with awakening. Fifty women having gynecologic laparotomy with propofol anesthesia were randomly allocated into the following target effect-site fentanyl concentrations: 0.8, 1.0, 1.4, 2.0, and 3.0 ng/mL. Fentanyl was continued at the designated rate through the initial postoperative phase. The propofol effect-site concentration associated with eye opening in response to verbal command was regarded as the awakening concentration. The estimated propofol effect-site concentrations at awakening did not differ significantly among the groups and were 1.9 ± 0.5 µg/mL with a fentanyl effect-site concentration of 0.8 ng/mL; 1.6 ± 0.4 µg/mL with 1.0 ng/mL of fentanyl; 1.6 ± 0.2 µg/mL with 1.4 ng/mL of fentanyl; 1.7 ± 0.4 µg/mL with 2.0 ng/mL of fentanyl; and 1.6 ± 0.34 µg/mL with 3.0 ng/mL of fentanyl (mean ± SD). Seventy percent of the subjects in the 0.8 ng/mL fentanyl group spontaneously complained of pain, whereas none of the patients in the 2 or 3 ng/mL groups did. Five (56%) of 9 women in the 3 ng/mL group had a postoperative respiratory rate <6 breaths/min. Heart rate in one of these women decreased to <40 bpm. These data suggest that the optimal fentanyl effect-site concentration in patients recovering from gynecologic laparoscopy is between 1.4 and 2.0 ng/mL.

 

安氟醚、异氟醚和静脉麻醉药对鼠膈肌功能及易疲劳性的影响

The Effects of Enflurane, Isoflurane, and Intravenous Anesthetics on Rat Diaphragmatic Function and Fatigability

Kahoru Nishina, MD, Katsuya Mikawa, MD, Shun-ichi Kodama, MD, Tetsuro Kagawa, MD, Takanobu Uesugi, MD, and Hidefumi Obara, MD

Department of Anaesthesia & Perioperative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan  

Anesth Analg 2003;96:1674-1678
为观察异氟醚、安氟醚、咪哒唑伦、氯胺酮、异丙酚和硫喷妥类对老鼠膈肌功能的影响,对228只鼠的独立肌群在疲劳状态及非疲劳状态分别进行研究。实验分为两组,实验组运用一种麻醉剂的常用临床剂量或10100倍剂量,或者123倍的肺泡最低有效浓度(MAC),对照组不用药。两组实验鼠均接受反复的强直性肌肉刺激诱发肌肉疲劳,同时将膈肌抽搐特性记录下。异氟醚、咪哒唑伦、氯胺酮、异丙酚和硫喷妥类在肌肉疲劳或非疲劳状态下不会直接引起肌肉收缩或松弛。安氟醚不会改变膈肌的收缩与松弛,但2-3MAC的安氟醚可增强膈肌的易疲劳性同时增加疲劳引起的收缩功能降低。这种作用3MAC要较2MAC强。这些研究结果表明先前所提到的运用异丙酚、咪哒唑伦和异氟醚降低膈肌功能并不直接影响膈肌的收缩性能。结论亦显示高浓度的安氟醚并不是通过神经-肌肉偶联降低膈肌功能。

(朱慧琛 译 王祥瑞 校)

We examined the effect of isoflurane, enflurane, midazolam, ketamine, propofol, and thiopental on diaphragmatic functions under unfatigued and fatigued conditions in 228 rat isolated muscle strips. Diaphragmatic twitch characteristics and tetanic contractions were measured before and after muscle fatigue, which was induced by repetitive tetanic contraction with or without exposure to one of the anesthetics at clinically relevant plasma concentrations, and at 10 and 100 times this concentration, or at 1, 2, and 3 minimum alveolar anesthetic concentration (MAC). Isoflurane, midazolam, ketamine, propofol, and thiopental did not induce a direct inotropic or lusitropic effect under unfatigued and fatigued conditions. Enflurane did not change contraction or relaxation in fresh isolated diaphragm, but enflurane at 2–3 MAC enhanced diaphragmatic fatigability itself and fatigue-induced impairment of twitch characteristics and tetanic tensions. These effects were greater at 3 MAC than at 2 MAC. Our findings suggest that the reduction of diaphragm function previously reported in in vivo experiments using propofol, midazolam, and isoflurane is not related to a direct effect on intrinsicdiaphragmatic contractility. Our results also indicate that large concentrations of enflurane may impair the diaphragmatic function at sites other than excitation-contraction coupling.

 

使用新型通气装置时的中心温度监测

Core Temperature Monitoring with New Ventilatory Devices

Takashi Matsukawa, MD*, Takahisa Goto, MD{dagger}, Makoto Ozaki, MD{ddagger}, Daniel I. Sessler, MD, Akira Takeuchi, MD§, Tomoki Nishiyama, MD||, and Teruo Kumazawa, MD*

*Department of Anesthesia, University of Yamanashi, Faculty of Medicine; {dagger}Department of Anesthesia, Teikyo University, Tokyo; {ddagger}Department of Anesthesia, Tokyo Women’s Medical University; §Department of Oncology, St. Luke Hospital, Tokyo; ||Department of Anesthesia, Tokyo University School of Medicine, Japan; and ¶the Outcomes ResearchTM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, KY

Anesth Analg 2003;96:1688-1691

虽然新型通气装置的使用日益广泛,例如喉罩(LMA)和带有气囊的口咽通气道(COPA),但在使用这些装置是都无法在食道末端测量中心温度。因此,我们假设通过放置在LMACOPA中的热电偶测量出的中心温度足够精确可供临床使用,对此进行了验证。36名计划进行长时间整形外科手术或癌症热疗的病人接受了此项试验,温度从放置于LMACOPA气囊中的热电偶中获得。这些温度间隔15分钟测量一次,结果与同一时间从鼻咽和鼓室粘膜获得的温度作比较。数据通过线性回归比较,斜线计算。从LMA测量的温度与鼻咽(r2=0.94)和鼓室(r2=0.94)粘膜温度有良好的相关性。从COPA测量的温度与鼻咽(r2=0.97)和鼓室(r2=0.96)粘膜温度的相关性较好。8%LMA测量的温度和11%COPA测量的温度与鼻咽粘膜温度相差大于±0.5℃;7%LMA测量的温度和10%COPA测量的温度与鼓室粘膜温度相差大于±0.5℃。这些结果说明从LMACOPA的气囊测量的体温足够精确,可供临床使用。

(殷文渊 译 王祥瑞 校)

Widespread use of new airway devices, such as the laryngeal mask airway (LMA) and the cuffed oropharyngeal airway (COPA), preclude measuring core temperature in the distal esophagus. Therefore, we tested the hypothesis that core temperature measured with a thermocouple positioned on a LMA or COPA is sufficiently accurate and precise for clinical use. Temperatures were recorded from thermocouples positioned on the cuffs of LMAs or COPAs in 36 patients scheduled for prolonged orthopedic surgery or therapeutic hyperthermia for cancer. These temperatures, recorded at 15-min intervals, were compared with simultaneously obtained nasopharynx and tympanic membrane temperatures. Data were compared by linear regression and the bias calculated. Temperatures measured on the LMA correlated well with both nasopharyngeal (r2 = 0.94) and tympanic membrane (r2 = 0.94) temperatures. Temperatures measured on the COPA also correlated well with those on the nasopharynx (r2 = 0.97) and tympanic membrane (r2 = 0.96). The fraction of temperatures that differed from nasopharynx temperature by more than ±0.5°C was 8% with LMA and 11% with COPA; the fraction of temperatures that differed from tympanic temperature by more than ±0.5°C was 7% with LMA and 10% with COPA. These results suggest that body temperature measured from the cuffs of COPA or LMAs is sufficiently accurate for routine clinical use.

 

对鼠经皮吸收阿米替林(Amitriptyline)和利多卡因(Lidocaine)后皮肤痛觉丧失的比较

Cutaneous Analgesia After Transdermal Application of Amitriptyline Versus Lidocaine in Rats

Anna Haderer, MD*,{dagger}, Peter Gerner, MD{dagger}, Grace Kao, BA{dagger}, Venkatesh Srinivasa, MD{dagger}, and Ging Kuo Wang, PhD

*Department of Anesthesiology, Ried General Hospital, Ried, Austria; and {dagger}Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts  

Anesth Analg 2003;96:1707-1710

阿米替林(Amitriptyline),一种三环类抗抑郁药,具有特效局部麻醉药属性。可是,并没有经皮吸收后产生皮肤麻醉效应的报道。本研究观察老鼠经皮吸收阿米替林比注射利多卡因产生更有效的皮肤麻醉作用。基于50100500mM浓度的阿米替林溶液做成一种敷帖应用于老鼠身上,它们所产生的效应与基于相同浓度的利多卡因溶液和单独使用媒介物(45%水,45%异丙基酒精和10%甘油)相比较。每个试验组的老鼠在使用了药的部位均具有浓度依赖性的皮肤麻醉作用。可是,在相同的浓度下,阿米替林的阻滞时间要长于利多卡因。将阿米替林发展成一种长效局部麻醉药可以改善我们治疗慢性疼痛的能力,例如神经性疼痛和神经痛,在一些操作中镇痛,例如静脉穿刺。

(殷文渊 译 王祥瑞 校)

Amitriptyline, a tricyclic antidepressant, has potent local anesthetic properties. However, there is no report of cutaneous analgesic effects after transdermal application. We report here that transdermally applied amitriptyline is more potent than lidocaine in providing cutaneous analgesia in rats. Solutions of amitriptyline base in 50, 100, and 500 mM concentrations were applied as a patch to rats, and their effects were compared with those of lidocaine base at the same concentrations and of the vehicle alone (45% water, 45% isopropyl alcohol, and 10% glycerin). Rats in each test group developed a concentration-dependent cutaneous analgesic block in the areas to which the drugs were applied; however, amitriptyline produced a longer block than lidocaine at the same concentration. The development of amitriptyline as a longer-lasting topical analgesic may improve our ability to treat chronic pain, such as neuropathic pain and neuralgia, and to prevent pain in procedures such as venipuncture.

 

俯卧位改善了COPD患者的肺顺应性和气体交换

Prone Position Improves Lung Mechanical Behavior and Enhances Gas Exchange Efficiency in Mechanically Ventilated Chronic Obstructive Pulmonary Disease Patients

Spyros D. Mentzelopoulos, MD DEAA, Spyros G. Zakynthinos, MD PhD, Charris Roussos, MD PhD, Maria J. Tzoufi, MD DEAA, and Argyris S. Michalopoulos, MD FCCM

Department of Intensive Care Medicine, Henry Dunant General Hospital; and Evangelismos General Hospital, Athens, Greece

Anesth Analg 2003;96:1756-1767

俯卧体位有可能改善接受容量控制机械通气的COPD患者的呼吸系统力学和功能。10COPD患者首先采用仰卧位(基本体位,[supineBAS], 然后随机性地变成俯卧位(supinePROT)、半卧位和俯卧位。在恒定流量下,呼吸系统功能和吸入功在潮气量为基础值(0.6L)和叹息(1.2L)时(supinePROT除外)测定。记录所有血流动力学和血气改变。没有发生并发症。俯卧位与仰卧位、半卧位相比,(a)改善了在两种潮气量时的胸壁弹性顺应性和氧和功能;(b)在叹息潮气量时减少了肺阻力-容积比;(c)降低了两种潮气量时肺静态阻力并改善了CO2的排出;(d)改善了氧合。半卧位与supineBASsupinePROT相比,主要增加了胸壁的顺应性。潮气量-吸入功-物质改变与呼吸系统、胸壁和肺的机械性能相一致。总的呼吸系统血流动力学变化与体位改变无关。俯卧位后,5例患者重新改为仰卧位(supinePOSTPRO)。在supinePOSTPRO时,呼吸系统-肺静态顺应性降低,但氧合比supineBAS仍有改善。COPD患者取俯卧位与半卧位相比(金标准)增加了通气的顺应性和有效性并改善了氧合。

(陈洁 译 王祥瑞 校)

Pronation might favorably affect respiratory system (rs) mechanics and function in volume-controlled, mode-ventilated chronic obstructive pulmonary disease (COPD) patients. We studied 10 COPD patients, initially positioned supine (baseline supine [supineBAS]) and then randomly and consecutively changed to protocol supine (supinePROT), semirecumbent, and prone positions. Rs mechanics and inspiratory work (WI) were assessed at baseline (0.6 L) (all postures) and sigh (1.2 L) (supineBAS excluded) tidal volume (VT) with rapid airway occlusion during constant-flow inflation. Hemodynamics and gas exchange were assessed in all postures. There were no complications. Prone positioning resulted in (a) increased dynamic-static chest wall (cw) elastance (at both VTs) and improved oxygenation versus supineBAS, supinePROT, and semirecumbent, (b) decreased additional lung (L) resistance-elastance versus supinePROT and semirecumbent at sigh VT, (c) decreased L-static elastance (at both VTs) and improved CO2 elimination versus supineBAS and supinePROT, and (d) improved oxygenation versus all other postures. Semirecumbent positioning increased mainly additional cw-resistance versus supineBAS and supinePROT at baseline. VT WI-sub-component changes were consistent with changes in rs, cw, and L mechanical properties. Total rs-WI and hemodynamics were unaffected by posture change. After pronation, five patients were repositioned supine (supinePOSTPRO). In supinePOSTPRO, static rs-L elastance were lower, and oxygenation was still improved versus supineBAS. Pronation of mechanically ventilated COPD patients exhibits applicability and effectiveness and improves oxygenation and sigh-L mechanics versus semirecumbent ("gold standard") positioning.

 

比较那布啡与奥丹思酮预防鞘内注射吗啡引起的剖腹产术后搔痒的作用

Nalbuphine Versus Ondansetron for Prevention of Intrathecal Morphine-Induced Pruritus After Cesarean Delivery

Somrat Charuluxananan, MD MSc, FRCAT*,{dagger}, Oranuch Kyokong, MD MSc, FRACT*,{dagger}, Wanna Somboonviboon, MD FRCAT*, Arunchai Narasethakamol, MD*, and Pissamai Promlok, MD*

*Department of Anesthesiology and {dagger}Clinical Epidemiology Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand  

Anesth Analg 2003;96:1789-1793

在此前瞻性、随机双盲研究中,我们比较了那布啡与奥丹思酮对鞘内注射吗啡引起的剖腹产术后瘙痒的预防作用。240例临产妇随机分为4组:N-4组、O-4组、O-8组和对照组,分别在胎儿娩出后立刻静注4mg那布啡、4mg奥丹思酮、8mg奥丹思酮和4ml生理盐水。在麻醉术后恢复室,我们发现4组瘙痒评分有显著性差异(p<0.001)。N-4组、O-4组、O-8组和对照组预防瘙痒的成功率分别为20%13%12%6%p<0.001)。比较N-4组和安慰剂组的瘙痒评分以及O-4组和安慰剂组的瘙痒评分均有显著性差异(分别为p<0.001p=0.006)。4组患者要求对瘙痒进行治疗的发生率分别为25%47%51%72%p<0.001)。术后4824小时组间恶心呕吐评分、疼痛评分、镇静评分、寒战评分无差异。与安慰剂相比,那布啡和奥丹思酮预防鞘内注射吗啡引起的剖腹产术后瘙痒更为有效。

                       陈洁 译王祥瑞 校 

In this prospective, randomized, double-blinded study, we compared the prophylactic efficacy of nalbuphine and ondansetron for the prevention of intrathecal morphine-induced pruritus after cesarean delivery. Two-hundred-forty parturients were randomly allocated into four groups. The N-4 group, O-4 group, O-8 group, and placebo group received IV 4 mg of nalbuphine, 4 mg of ondansetron, 8 mg of ondansetron, and 4 mL of normal saline, respectively, immediately after the baby was delivered. In the postanesthesia care unit, we found that the severity of pruritus score in the four groups was significantly different (P < 0.001). The prophylactic success rate for pruritus of the N-4, O-4, O-8, and placebo groups was 20%, 13%, 12%, and 6%, respectively (P < 0.001). The pruritus score between N-4 and placebo and O-4 and placebo was significantly different (P < 0.001 and P = 0.006, respectively). Treatment for pruritus was requested by patients in 25%, 47%, 51%, and 72% of patients in the N-4, O-4, O-8, and placebo groups, respectively (P < 0.001). There were no differences among groups in nausea/vomiting score, pain score, sedation score, or shivering score at 4, 8, and 24 h after surgery. Nalbuphine and ondansetron are more effective than placebo for the prevention of intrathecal morphine-induced pruritus after cesarean delivery.

 

腰部硬膜外置管发生严重神经并发症的危险性很小

Small Risk of Serious Neurologic Complications Related to Lumbar Epidural Catheter Placement in Anesthetized Patients

Terese T. Horlocker, MD*, Martin D. Abel, MD*, Joseph M. Messick, Jr, MD*, and Darrell R. Schroeder, MS{dagger}

Departments of *Anesthesiology and {dagger}Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Anesth Analg 2003 96: 1547-1552.

以往的研究表明,硬膜外置管或注射局麻药时的疼痛是硬膜外阻滞麻醉后出现持续感觉异常的危险因素。由于硬膜外阻滞麻醉后病人对疼痛刺激不再有反应,从理论上讲硬膜外阻滞本身会增加术后神经并发症的危险性。本研究对全麻复合腰部硬膜外置管的4298例胸外科手术病人的神经并发症的发生率进行了评价。硬膜外置管的时间为麻醉诱导后、气管插管后或者手术结束至苏醒之间。其中大部分病人硬膜外置管的目的仅仅是为了术后镇痛(4220, 98.2%),只有少部分病人用其进行手术麻醉(78 1.8%)。有4239 (98.6%)例病人仅通过硬膜外导管给予阿片类药物,其余的病人56 (1.3%)则通过硬膜外导管给予局麻药或局麻药复合阿片类药物。有92.2% 的病人镇痛效果评价为优。副作用的发生分别为: 镇静455 (10.6%)、恶心或呕吐328 (7.6%)、瘙痒116 (2.7%)、呼吸抑制(pH <=7.3 and PaCO2 >=50 mm Hg) 308(7.2%)。没有发生脊髓血肿、硬膜外脓肿、导管部位的感染、根刺激综合征或持续性感觉异常等神经并发症(95% 可信区间是0%–0.08%)。一例病人在拔管时发生硬膜外导管断裂,未取出断裂的导管,长时间观察未发现不良后果。有6例出现与硬膜外导管无关的神经并发症或原来的神经病理症状恶化。结论:全麻病人应用硬膜外阻滞技术时发生与腰部硬膜外置管有关的神经并发症的危险性是非常小的。但是,对清醒病人应用这种技术的危险性仍应进一步评价。

(王士雷 译  庄心良 校)

Previous studies have identified pain during needle/catheter placement or during the injection of local anesthetic as a risk factor for the development of persistent paresthesias after regional anesthetic techniques. The performance of regional blockade on anesthetized patients theoretically increases the risk of postoperative neurologic complications, because these patients are unable to respond to painful stimuli. In this study, we evaluated the frequency of neurologic complications in 4298 thoracic surgical patients undergoing lumbar epidural catheter placement while under general anesthesia. Catheters were placed immediately after the induction and tracheal intubation or on completion of the surgical procedure, before emergence. Most epidural catheters (4220, or 98.2%) were used solely for postoperative analgesia; only 78 (1.8%) epidural catheters were used for intraoperative anesthesia. In 4239 (98.6%) patients, an opioid alone was administered. The remaining 56 (1.3%) patients received a local anesthetic or local anesthetic/opioid mixture epidurally. Analgesia was graded as excellent or good in 92.2% of patients. Side effects included sedation in 455 (10.6%), nausea or emesis in 328 (7.6%), pruritus in 116 (2.7%), and respiratory depression (pH <=7.3 and PaCO2 >=50 mm Hg) in 308 (7.2%) patients. The mean duration of epidural analgesia was 2.4 ± 0.8 days (range, 0–10.7 days). There were no neurologic complications, including spinal hematoma, epidural abscess or catheter site infections, radicular symptoms, or persistent paresthesias (95% confidence interval, 0%–0.08%). In one patient, the epidural catheter broke during removal, and a portion was retained. The patient was notified; no long-term sequelae were noted. Six patients developed new neurologic symptoms or postoperative worsening of a previous neurologic condition unrelated to epidural catheterization. We conclude that the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small. However, the relative risk of this practice, compared with epidural catheter placement in awake patients, is unknown.

 

在冠状动脉搭桥术后不久行胸骨切除术发生的围手术期心肌缺血

Perioperative Myocardial Ischemia in Patients Undergoing Sternectomy Shortly After Coronary Artery Bypass Grafting

Lucio Glantz, MD*,{dagger}, Tiberiu Ezri, MD{ddagger}, Yitzhak Cohen, MD§, Sergio Konichezky, MD||, Abraham Caspi, MD, Daniel Geva, MD#, and Amos Leviav, MD**

*Department of Anesthesiology, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel; {dagger}Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; {ddagger}Department of Anesthesiology, Wolfson Medical Center, Holon, Israel; §Department of Anesthesiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; and ||Intensive Care Unit and Departments of ¶Cardiology, #Anesthesiology, and **Plastic Surgery, Kaplan Medical Center, Rehovot, Israel (affiliated with The Hebrew University School of Medicine, Jerusalem, Israel)

Anesth Analg 2003 96: 1566-1571.

应用冠状动脉搭桥术恢复冠状动脉血流可以减少严重冠状动脉心脏病患者非心脏手术时的心脏并发症。然而,在冠状动脉术后不久就进行急症非心脏外科手术的病人仍然容易发生心肌缺血。我们前瞻性地研究了在冠状动脉搭桥术后第一周 (1; n35)和第二周( 2;n 47)进行sternectomy 手术的病人心肌缺血的发生率。二组病人进行冠状动脉搭桥术和sternectomy 术之间的间隔时间分别是4–7天(平均6天)和11天(平均8-14天)。应用双频道Holter记录48小时内的心电图变化以了解心脏缺血的发生情况。二组病人的急性生理和慢性健康状况评分、ß-阻滞剂的应用情况以及围手术期血流动力学变化的程度无差别。组1病人心肌缺血的发生率较组2病人高5(22.85% 4.25%; P < 0.05)。在组1发生心肌缺血的病人中,有25%发生急性围手术期心肌梗死(1例死亡),而在组2病人中没有发生心肌梗死。尽管如此,仍不清楚冠状动脉搭桥手术后不久发生的心肌缺血是否与非心脏手术有关,对此需要进一步研究。

(王士雷 译 庄心良 校)

Coronary revascularization reduces cardiac complications associated with noncardiac surgery in patients with severe coronary disease. However, patients undergoing emergency noncardiac surgery soon after coronary bypass operations may still be vulnerable to ischemic myocardial events. We prospectively evaluated the incidence of myocardial ischemia in 82 consecutive patents scheduled for sternectomy in the first (Group 1; 35 patients) or second (Group 2; 47 patients) week after coronary artery bypass graft (CABG) surgery. The interval between CABG surgery and sternectomy in Groups 1 and 2 was 6 days (range, 4–7 days) and 11 days (range, 8–14 days), respectively. Electrocardiographic (ECG) changes consistent with myocardial ischemia were assessed with a two-channel Holter system for 48 h. There were no between-group differences in updated Acute Physiology and Chronic Health Evaluation score, use of ß-blockers, or perioperative hemodynamic changes. The incidence of ECG changes consistent with myocardial ischemia was fivefold more frequent in Group 1 (22.85% versus 4.25%; P < 0.05). Of the ischemic patients in Group 1, 25% experienced a perioperative acute myocardial infarction (one was fatal). There were no infarcts in Group 2. Thus, patients appear to be prone to coronary events during sternectomy performed early after CABG surgery. Although the incidence of ischemia did not differ from that previously reported after CABG surgery alone, further investigation is required to determine whether the findings obtained in this high-risk population are generalizable to patients undergoing noncardiac surgery soon after uneventful CABG surgery.


经胸心脏超声结合经食道心脏超声在经导管对前缘变薄的房间隔缺损封闭术中的应用——一组病例报道

Supplementing Transesophageal Echocardiography with Transthoracic Echocardiography for Monitoring Transcatheter Closure of Atrial Septal Defects with Attenuated Anterior Rim: A Case Series

Su-Man Lin, MD*,§, Shen-Kou Tsai, MD PhD*,{ddagger},§, Jou-Kou Wang, MD PhD{dagger},{ddagger}, Yin-Yi Han, MD*,{ddagger}, Wei-horng Jean, MD*,{ddagger}, and Yu-Chang Yeh, MD*,{ddagger}

Departments of *Anesthesiology and {dagger}Pediatrics, {ddagger}National Taiwan University, School of Medicine; §National Yang-Ming University, School of Medicine and Taipei Veterans General Hospital, Taipei, Taiwan

Anesth Analg 2003 96: 1584-1588.

经食道心超(TEE)在经导管行房间隔缺损(ASD)封闭术中越来越常用。前缘变薄的ASD是变异的ASD,更适合于经导管封闭。TEE在这些手术中的成功率还不清楚,因此,我们评估了在TEE指导下,用Amplatzer封闭器行房间隔缺损封闭的124例病人。结果显示57 secundum型房间隔缺损TEE均能清楚显示Amplatzer盘的4个角及相应的边缘。然而,67例前缘变薄中6例(9%TEE不能显示封闭器在前缘的位置。而结合经胸心超能有助于解决这个问题。6例病人中4例前缘具有异常的形态,2例心脏右轴偏移,Q波大于90067例前缘变薄中35例缺少SA边缘,这些病人TEE显示盘的前缘接触主动脉壁但未扭曲。我们证实TEE在大部份ASD病人中有作用,而对伴有前缘变薄的房间隔缺损一小部分病人,则需要TEE结合经胸心超。

                                     (王立中 译   庄心良 校)

The use of transesophageal echocardiography (TEE) for guidance of transcatheter closure of secundum-type atrial septal defect (ASD) is increasingly becoming a routine procedure. ASD with attenuated anterior superior (SA) rim is a variant of secundum-type ASD and is suitable for transcatheter closure. The success rate of TEE guidance for device deployment in these patients is not known. Therefore, we assessed 124 consecutive patients with ASD (57 secundum-type, 67 with attenuated SA rim) closed with an Amplatzer Septal Occluder under TEE guidance. Our results show that the TEE was successful in depicting all 4 corners and corresponding edges of each Amplatzer disk, as well as the septal rims of all 57 secundum-type ASDs. However, in 6 of 67 ASDs (9%) with attenuated SA rim in which TEE failed to visualize the adequate placement of occluder on the anterior inferior (IA) rim, the additional use of transthoracic echocardiography helped to resolve this inadequacy. Four of these six patients had the unusual morphology of the IA rim tissue. Two had severe right axis deviation of the heart with large Q angle (>90°). The SA rim was absent in 35 of 67 ASDs with attenuated SA rim and in these cases TEE demonstrated the anterior surface of the disk against the wall of the aorta but without distortion. We conclude that TEE can be useful for confirming successful deployment of the occluder in most patients with ASDs. In a small number of ASDs with attenuated SA rim who have unusual IA morphology, supplemental transthoracic echocardiography is required to verify successful deployment of the occluder when TEE visualization fails to reliably diagnose adequate placement of the occluder.

儿童门诊鼓膜切开术和放置平衡导管后的镇痛

Postoperative Analgesia in Children Undergoing Myringotomy and Placement Equalization Tubes in Ambulatory Surgery

Ana Lucia Pappas, MD*, Elaine M. Fluder, RN MSN*, Steve Creech, MS*, Andrew Hotaling, MD{dagger}, and Albert Park, MD{dagger}

*Department of Anesthesiology, {dagger}Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois

Anesth Analg 2003 96: 1621-1624.

本研究对行双侧鼓膜切开术和放置平衡导管的120例儿童行随机、双盲观察。病人分4组,1组(对照组)口服对乙酰氨基酚10 mg/kg2组乙酰氨基酚10 mg/kg加口服可待因1 mg/kg3组麻醉诱导后立即经鼻给布托啡诺25 µg/kg4组麻醉诱导后立即肌注酮咯酸1 mg/kg。所有儿童术前均口服咪唑安定0.6 mg/kg。由一位不知道分组情况的护土用4分表法评估病儿在麻醉诱导后及麻醉后监测病房期的行为。每隔5 min用稍作修改的10分客观疼痛评分表确定镇痛效果。当疼痛评分大于4分或行为评分大于3分时,给予额外的镇痛药。结果显示在这些病人中肌注酮咯酸是最有希望的镇痛药,离首次给额外镇痛药的时间最长,术后没有恶心和呕吐。

 

                                 (王立中 译   庄心良 校)

 

We enrolled 120 children undergoing bilateral myringotomy and tube placement in this prospective, randomized, observer-blinded study. Patients were randomized into one of four groups: Group 1 (control) was plain acetaminophen 10 mg/kg orally, Group 2 was acetaminophen 10 mg/kg with 1 mg/kg of codeine orally, Group 3 was transnasal butorphanol 25 µg/kg given immediately after the induction of anesthesia, and Group 4 was ketorolac 1 mg/kg given IM immediately after the induction of anesthesia. All children received oral midazolam (0.6 mg/kg) before surgery. A nurse blinded to the analgesic technique used assessed the child’s behavior at the induction of anesthesia and in the postanesthesia care unit using a 4-point scale. Analgesic effectiveness was determined by assessing the child’s pain at 5-min intervals using a modified 10-point objective pain scale. In the postanesthesia care unit, rescue pain medication was administered for an objective pain scale >=4 or a behavior score >=3. Our data suggest that IM ketorolac is a promising analgesic to be used in this surgical population. Time to first rescue analgesic was longest in the ketorolac group, and there was no associated postoperative vomiting or nausea. IM ketorolac given during surgery was the best analgesic regimen for these procedures.


BIS能预测电抽搐疗法后癫痫发作时间和苏醒吗?

Can the Bispectral Index Be Used to Predict Seizure Time and Awakening After Electroconvulsive Therapy?

Paul F. White, PhD MD, FANZCA*, Shivani Rawal, MD*, Alejandro Recart, MD*, Larry Thornton, MD{dagger}, Mark Litle, MD{dagger}, and Louis Stool, MD*

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

Anesth Analg 2003 96: 1636-1639.

BIS指标能反映麻醉的镇静程度和苏醒情况,因此我们假设BIS能预测电抽搐疗法(ECT)后癫痫发作时间和从甲乙炔巴比妥麻醉中的苏醒时间。25例严重抑郁症患需100次维持ECT的病人同意本试验。所有病人ECT前静注胃长宁0.2 mg ,静注甲乙炔巴比妥1 mg/kg行麻醉诱导。持续监测BIS,并在特定时间点记录数值,包括麻醉前(基础值)、麻醉诱导后(ECT前)、ECT结束时(峰值)、ECT后(抑制)、苏醒(睁眼)。ECTBIS值与运动(r = 0.3)EEG(r = 0.4)癫痫样发作时间有关(P < 0.05),峰值BISEEG癫痫样发作时间有关(r = 0.5)(P < 0.05)EEG癫痫样发作时间与到睁眼时间也呈正相关(r = 0.4) (P < 0.05)。然而,苏醒时BIS值的变化较大,从29 97,且75%少于60。结论:ECT前应用BIS能预测癫痫发作时间,但苏醒时BIS值变化较大,提示其既能反映麻醉药残余镇静作用,又能反映post-ictal的抑制。

 

                                   (王立中 译  庄心良  校)

 

The electroencephalogram (EEG) bispectral index (BIS) measures the hypnotic component of the anesthetic state and correlates with emergence from general anesthesia. Therefore, we hypothesized that the BIS would be useful in predicting electroconvulsive therapy (ECT)-induced seizure times and awakening from methohexital anesthesia. Twenty-five consenting patients with major depressive disorders underwent 100 maintenance ECT treatments. All patients were premedicated with glycopyrrolate 0.2 mg IV, and anesthesia was induced with methohexital 1 mg/kg IV. The BIS was monitored continuously, and the values were recorded at specific end-points, including before anesthesia (baseline), after the induction of anesthesia (pre-ECT), at the end of ECT (peak), after ECT (suppression), and on awakening (eye opening). The pre-ECT BIS value correlated with the duration of both the motor (r = 0.3) and EEG (r = 0.4) seizure activity (P < 0.05). The peak post-ECT BIS value correlated with the duration of the EEG seizure activity (r = 0.5) (P < 0.05). A positive correlation was also found between the EEG seizure duration and the time to eye opening (r = 0.4) (P < 0.05). However, the BIS values on awakening from methohexital anesthesia varied from 29 to 97 and were <60 in 75% of the cases. We conclude that the BIS value before the ECT stimulus is applied could be useful in predicting the seizure time. However, the BIS values on awakening were highly variable, suggesting that it reflects both the residual depressant effects of methohexital and post-ictal depression.


 

苏醒期异丙酚的效应室浓度与芬太尼的效应室浓度无关

Effect-Site Concentration of Propofol for Recovery of Consciousness Is Virtually Independent of Fentanyl Effect-Site Concentration

Hiroko Iwakiri, MD*, Osamu Nagata, MD*, Takashi Matsukawa, MD{dagger}, Makoto Ozaki, MD*, and Daniel I. Sessler, MD{ddagger}

*Department of Anesthesiology, Tokyo Women’s Medical University, Tokyo, Japan; {dagger}Department of Anesthesiology, Yamanashi Medical University, Yamanashi, Japan; {ddagger}OUTCOMES RESEARCHTM Institute, Department of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky; and {ddagger}Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria

Anesth Analg 2003 96: 1651-1655.

 

芬太尼能够降低预防手术刺激所需的异丙酚用量。然而,阿片类基本上不影响神智。本研究旨在证实芬太尼不影响苏醒期异丙酚的效应室浓度。50例女性患者在异丙酚麻醉下行开腹妇科手术,随机分为5组,术后早期继续使用芬太尼,其效应室靶浓度分别为0.8, 1.0, 1.4, 2.0, 3.0 ng/mL。给予口头指令后睁眼的异丙酚的效应室浓度为苏醒浓度。预计的异丙酚苏醒期的效应室浓度在各组中无显著差异,分别为1.9 ± 0.5 µg/mL (芬太尼的效应室浓度为0.8 ng/mL; 1.6 ± 0.4 µg/mL (芬太尼为 1.0 ng/mL; 1.6 ± 0.2 µg/mL (芬太尼为 1.4 ng/mL ; 1.7 ± 0.4 µg/mL (芬太尼为 2.0 ng/mL );  1.6 ± 0.34 µg/mL(芬太尼为 3.0 ng/mL)(平均值±标准差)。芬太尼0.8 ng/mL70%的患者诉痛,而2.03.0 ng/mL组无人诉痛。3.0 ng/mL9例中5例(56%)术后呼吸频率低于6/分,其中1例心率低于40/分。上述数据提示妇科腹腔镜术后苏醒期芬太尼的最佳效应室浓度在1.4 2.0ng/mL间。结论:苏醒期异丙酚的效应室浓度与芬太尼的效应室浓度(0.8 3.0 ng/mL)无关。然而,0.8 ng/mL芬太尼术后镇痛效果欠佳,3.0 ng/mL芬太尼引起呼吸抑制。因此,异丙酚全麻下行妇科开腹手术,术后苏醒期芬太尼的最佳效应室浓度应该接近2.0 ng/mL

                                    (轩泓 译    庄心良 校)

Fentanyl reduces the amount of propofol necessary to prevent responses to surgical stimuli. However, opioids have relatively little effect on consciousness. We, therefore, tested the hypothesis that fentanyl minimally alters the effect-site concentration of propofol associated with awakening. Fifty women having gynecologic laparotomy with propofol anesthesia were randomly allocated into the following target effect-site fentanyl concentrations: 0.8, 1.0, 1.4, 2.0, and 3.0 ng/mL. Fentanyl was continued at the designated rate through the initial postoperative phase. The propofol effect-site concentration associated with eye opening in response to verbal command was regarded as the awakening concentration. The estimated propofol effect-site concentrations at awakening did not differ significantly among the groups and were 1.9 ± 0.5 µg/mL with a fentanyl effect-site concentration of 0.8 ng/mL; 1.6 ± 0.4 µg/mL with 1.0 ng/mL of fentanyl; 1.6 ± 0.2 µg/mL with 1.4 ng/mL of fentanyl; 1.7 ± 0.4 µg/mL with 2.0 ng/mL of fentanyl; and 1.6 ± 0.34 µg/mL with 3.0 ng/mL of fentanyl (mean ± SD). Seventy percent of the subjects in the 0.8 ng/mL fentanyl group spontaneously complained of pain, whereas none of the patients in the 2 or 3 ng/mL groups did. Five (56%) of 9 women in the 3 ng/mL group had a postoperative respiratory rate <6 breaths/min. Heart rate in one of these women decreased to <40 bpm. These data suggest that the optimal fentanyl effect-site concentration in patients recovering from gynecologic laparoscopy is between 1.4 and 2.0 ng/mL.

 

布比卡因抑制人类TREK-1通道

Inhibition of Human TREK-1 Channels by Bupivacaine

Mark A. Punke, MD*, Thomas Licher, PhD{dagger}, Olaf Pongs, PhD{dagger}, and Patrick Friederich, MD*

*Department of Anesthesiology, University Hospital Hamburg-Eppendorf; and {dagger}Institute

Anesth Analg 2003 96: 1665-1673.

人类TWIK相关性钾通道(TREK-1)稳定神经元膜电位,在膜兴奋性调节中起主要作用,布比卡因与其相互作用可能有重要的临床意义。本文以TREK-1转染的中华仓鼠卵细胞(CHO TREK-1)为对象,用膜片钳技术,研究TREK-1的特点和布比卡因的作用。转染TREK-1使CHO的膜电位从-33 ± 13 mV 超极化到-78 ± 4 mV。细胞内酸中毒使TREK-1开放。布比卡因对TREK-1的抑制作用呈可逆性,浓度依赖性和电压依赖性,并随细胞内酸中毒而加剧。布比卡因使CHO TREK-1的膜电位去极化,呈可逆性和浓度依赖性。抑制浓度与膜去极化浓度呈非线性相关,抑制TREK-150%抑制浓度是370±20µMHill系数是1.8±0.1n=51;膜去极化的50%抑制浓度是856±14µMHill系数是2.4±0.1(平均值±标准误),n=27。上述结果提示质子化布比卡因通过细胞内作用位点产生影响。结论:布比卡因抑制TREK-1通道,继而使胞膜去极化,可能是区域麻醉时阻滞神经信号传导的原因。

                                       (轩泓 译 庄心良 校)

 

Human TWIK-related K+ channels (TREK-1) stabilize the membrane potential (mp) of neurons and have a major role in the regulation of membrane excitability. In view of their physiological significance, interaction of bupivacaine with TREK-1 channels may be clinically important. Our aim was to characterize with the patch-clamp technique the properties of human TREK-1 channels and the effects of bupivacaine on these channels expressed in Chinese hamster ovary (CHO) cells. Transfection of CHO cells with TREK-1 channels (CHOTREK-1 cells) hyperpolarized the mp from -33 ± 13 to -78 ± 4 mV. The channels were stimulated by intracellular acidosis. Inhibition of TREK-1 channels by bupivacaine was reversible, concentration-dependent, voltage-independent, and increased with intracellular acidosis. Bupivacaine depolarized the mp of CHOTREK-1 cells in a reversible and concentration-dependent manner. Concentrations for channel inhibition and membrane depolarization were not linearly related (50% inhibitory concentration value for channel inhibition 370 ± 20 µM, Hill coefficient 1.8 ± 0.1, n = 51; 50% inhibitory concentration value for membrane depolarization 856 ± 14 µM, Hill coefficient 2.4 ± 0.1, mean ± SEM, n = 27). The results suggest that protonated bupivacaine elicits the observed effects via a site of interaction accessible from the intracellular space. Inhibition of TREK-1 channels and consecutive depolarization of the cell membrane by bupivacaine may contribute to

 

隔热法和强力空气保暖法有相同的保暖效果

Resistive-Heating and Forced-Air Warming Are Comparably Effective

Chiharu Negishi, MD*, Kenji Hasegawa, MD*, Shihoko Mukai, MD*, Fumitoshi Nakagawa, BS*, Makoto Ozaki, MD*, and Daniel I. Sessler, MD{ddagger}

Department of *Anesthesia, Tokyo Women’s Medical University, Tokyo, Japan; {ddagger}OUTCOMES RESEARCHTM Institute, Department of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky; and {ddagger}Ludwig Boltzmann Institute, University of Vienna, Vienna, Austria

Anesth Analg 2003 96: 1683-1687.

 

由于围术期低温常造成严重后果,术中保温已经成为一种工作常规。本研究目的是评价一种新的碳纤隔热系统的效果。24例开腹手术病人(手术持续时间约为4小时),随机采用以下措施进行保温:(142°C的循环水褥;(2)从高处的吹风机向下身吹气的空气保暖法;(342°C的三端碳纤隔热毯。麻醉方式采用全麻复合连续硬膜外麻醉。所有输入的液体都加热到37°C,环境温度则维持在22°C。组间中心体温(测鼓膜温度)的差异用方差分析和F检验进行统计学处理。各组之间影响体温的因素无差别。结果显示,在手术最初的2小时,循环水褥组中心温度下降1.9°C ± 0.5°C,空气保暖组中心温度下降1.0°C ± 0.6°C,碳纤隔热毯组中心温度下降 0.8°C ± 0.2°C 。在手术结束时,三组病人中心温度下降的幅度分别是2.0°C ± 0.8°C 0.6°C ± 1.0°C0.5°C ± 0.4°C 。用循环水褥的病人在150分钟后的各时间点的中心体温都显著降低,而空气保暖组和碳纤隔热毯组病人各时间点的中心体温均没有显著变化。结论:碳纤隔热毯组的保温效果和空气保暖组一样好。

 

                           (王士雷    庄心良 校)

Serious adverse outcomes from perioperative hypothermia are well documented. Consequently, intraoperative warming has become routine. We thus evaluated the efficacy of a novel, nondisposable carbon-fiber resistive-heating system. Twenty-four patients undergoing open abdominal surgery lasting approximately 4 h were randomly assigned to warming with 1) a full-length circulating water mattress set at 42°C, 2) a lower-body forced-air cover with the blower set on high, or 3) a three-extremity carbon-fiber resistive-heating blanket set to 42°C. Patients were anesthetized with a combination of continuous epidural and general anesthesia. All fluids were warmed to 37°C, and ambient temperature was kept near 22°C. Core (tympanic membrane) temperature changes among the groups were compared by using factorial analysis of variance and Scheffé F tests; results are presented as means ± SD. Potential confounding factors did not differ significantly among the groups. In the first 2 h of surgery, core temperature decreased by 1.9°C ± 0.5°C in the circulating-water group, 1.0°C ± 0.6°C in the forced-air group, and 0.8°C ± 0.2°C in the resistive-heating group. At the end of surgery, the decreases were 2.0°C ± 0.8°C in the circulating-water group, 0.6°C ± 1.0°C in the forced-air group, and 0.5°C ± 0.4°C in the resistive-heating group. Core temperature decreases were significantly greater in the circulating-water group at all times after 150 elapsed minutes; however, temperature changes in the forced-air and resistive-heating groups never differed significantly. Even during major abdominal surgery, resistive heating maintains core temperature as effectively as forced air.

 

唑尼沙胺对实验性单神经痛大鼠温度和机械疼痛过敏的作用

The Effect of Systemic Zonisamide (ZonegranTM) on Thermal Hyperalgesia and Mechanical Allodynia in Rats with an Experimental Mononeuropathy

Allen H. Hord, MD, Donald D. Denson, PhD, Amale G. Chalfoun, MD, and M. Isabel Azevedo, MD

Department of Anesthesiology, Division of Pain Medicine, Emory University School of Medicine, Atlanta, Georgia

Anesth Analg 2003 96: 1700-1706.

我们对唑尼沙胺减轻慢性缩窄性神经压迫疼痛模型的温度和机械疼痛过敏的作用进行了研究。在CCI术后456天分别经腹腔注射唑尼沙胺(25 50100 mg/kg)或生理盐水,记录CCI术前和术后4569天动物热和机械刺激时爪撤退的潜伏期。结果,唑尼沙胺以剂量依赖性的方式减轻热引起的疼痛过敏。除应用唑尼沙胺100 mg/kg后第5天的检查结果外,所有应用唑尼沙胺组大鼠爪撤退的潜伏期均较用药前延长。唑尼沙胺100 mg/kg使术后5天和9天时的撤退潜伏期显著延长,与小剂量相比,其这种作用有连续性。然而,除100mg/kg外,其余剂量的唑尼沙胺对机械疼痛过敏影响较小。唑尼沙胺100 mg/kg使术后4天和5天时大鼠撤退潜伏期延长,使术后4,56天时的疼痛评分降低。唑尼沙胺50 mg/kg 25 mg/kg 降低疼痛评分的作用是不连续的。结论:唑尼沙胺能以剂量依赖性的方式降低神经疼痛大鼠对热的敏感性,但仅在达到镇静剂量时才能减轻大鼠对机械刺激的敏感性。本研究提示,唑尼沙胺对某些神经痛疾病可能是有效的治疗方法。

                                    (王士雷 译   庄心良  校)

We studied the ability of zonisamide (ZonegranTM) to relieve thermal hyperalgesia and/or mechanical allodynia in the chronic constriction injury model of neuropathic pain. Zonisamide (25, 50, or 100 mg/kg) or saline was administered in a blinded, randomized manner by intraperitoneal injection on postoperative days (PODs) 4, 5, and 6. Paw withdrawal latency (PWL) to heat, paw withdrawal response to von Frey monofilaments, and pain scores based on weight-bearing were tested: before surgery; before and after zonisamide or saline (PODs 4, 5, and 6); and on POD 9. Systemic zonisamide relieved thermal hyperalgesia in a dose-dependent manner. All PWLs were significantly increased after zonisamide administration compared with pre-zonisamide measurements, except with the 100 mg/kg dose on POD 5. After zonisamide 100 mg/kg administration, there was a sustained increase in PWL on PODs 5 and 9, with significant carryover effect from the previous dose. However, zonisamide had little effect on mechanical allodynia, except at the 100 mg/kg dose, which was sedating in the rat. At the 100 mg/kg dose, paw withdrawal response was increased on PODs 4 and 5, whereas pain scores were reduced on PODs 4, 5, and 6. Pain scores were inconsistently reduced after 50 mg/kg or 25 mg/kg doses.


联合应用加压素和肾上腺素使延迟心肺复苏的猪神经功能完全恢复

Survival with Full Neurologic Recovery After Prolonged Cardiopulmonary Resuscitation with a Combination of Vasopressin and Epinephrine in Pigs

Karl H. Stadlbauer, MD*, Horst G. Wagner-Berger, MD*, Volker Wenzel, MD*, Wolfgang G. Voelckel, MD*, Anette C. Krismer, MD*, Günter Klima, MD{dagger}, Klaus Rheinberger, MSc*, Sebastian Pechlaner, BS*, Viktoria D. Mayr, MD*, and Karl H. Lindner, MD*

Departments of *Anesthesiology and Critical Care Medicine and {dagger}Histology, Leopold-Franzens-University, Innsbruck, Austria

Anesth Analg 2003 96: 1743-1749.

 

目的:评价联合应用加压素和肾上腺素对延迟心肺复苏的猪神经功能恢复的效果。方法:猪心脏骤停后4分钟进行3分钟的基础生命支持,随后每5分钟联合用加压素/肾上腺素〔加压素(IU/kg/肾上腺素(µg/kg):0.4/45, 0.4/45, and 0.8/45; n = 6〕、单用肾上腺素(45, 45, and 200 µg/kg; n = 6)或生理盐水(n5)。在心脏骤停后22分钟(其中包括18分钟的心肺复苏),应用电除颤技术以恢复猪的自主心脏跳动。结果:猪主动脉舒张压在每次联合应用肾上腺素/加压素后的90秒均高于单独用肾上腺素或用生理盐水(分别为:69 ± 3 mm Hg 45 ± 3 mm Hg 29 ± 2 mm Hg, 63 ± 4 mm Hg 27 ± 3 mm Hg 23 ± 1 mm Hg, 52 ± 4 mm Hg 21 ± 3 mm Hg 16 ± 3 mm Hg)。6头联合应用加压素和肾上腺素的猪均恢复了自主心脏跳动,而单用肾上腺素的6头猪和6头用生理盐水猪中的5头死亡。联合应用加压素和肾上腺素复苏的6头猪在复苏后24小时表现为步态不稳,但5天后神经功能均恢复正常。结论:在延迟心肺复苏的猪模型,重复应用加压素和肾上腺素,而不是单用肾上腺素和生理盐水,可以使猪长期存活且神经功能完全恢复。

 

                                    (王士雷 译  庄心良 校)

We sought to determine the effects of a combination of vasopressin and epinephrine on neurologic recovery in comparison with epinephrine alone and saline placebo alone in an established porcine model of prolonged cardiopulmonary resuscitation (CPR). After 4 min of cardiac arrest, followed by 3 min of basic life support CPR, 17 animals were randomly assigned to receive, every 5 min, either a combination of vasopressin and epinephrine (vasopressin [IU/kg]/epinephrine [µg/kg]: 0.4/45, 0.4/45, and 0.8/45; n = 6), epinephrine alone (45, 45, and 200 µg/kg; n = 6), or saline placebo alone (n = 5). After 22 min of cardiac arrest, including 18 min of CPR, defibrillation was attempted to achieve the return of spontaneous circulation. Aortic diastolic pressure was significantly (P < 0.01) increased 90 s after each of 3 vasopressin/epinephrine injections versus epinephrine alone versus saline placebo alone (mean ± SEM: 69 ± 3 mm Hg versus 45 ± 3 mm Hg versus 29 ± 2 mm Hg, 63 ± 4 mm Hg versus 27 ± 3 mm Hg versus 23 ± 1 mm Hg, and 52 ± 4 mm Hg versus 21 ± 3 mm Hg versus 16 ± 3 mm Hg, respectively). Spontaneous circulation was restored in six of six vasopressin/epinephrine pigs, whereas six of six epinephrine and five of five saline placebo pigs died (P < 0.01). Neurologic evaluation 24 h after successful resuscitation revealed only an unsteady gait and was normal 5 days after the experiment in all vasopressin/epinephrine-treated animals. In conclusion, in this porcine model of prolonged CPR, repeated vasopressin/epinephrine administration, but not epinephrine or saline placebo alone, ensured long-term survival with full neurologic recovery.


评估全身麻醉行机械通气时喉管的应用

An Evaluation of the Laryngeal Tube® During General Anesthesia Using Mechanical Ventilation

Luis A. Gaitini, MD*, Sonia J. Vaida, MD*, Mostafa Somri, MD*, Victor Kaplan, MD*, Boris Yanovski, MD*, Robert Markovits, MD*, and Carin A. Hagberg, MD{dagger}

*Department of Anesthesiology, Bnai-Zion Medical Center, Haifa, Israel; and {dagger}Department of Anesthesiology, University of Texas-Houston Medical School, Houston, Texas

Anesth Analg 2003 96: 1750-1755.

喉管是进行气道管理的一种新型声门上通气设备,经过改良可安全用于自发呼吸或机械通气。本研究期望明确在进行机械通气的常规手术应用喉管做最初气道管理的有效性。选择期手术的175名患者,ASA分级1-II级。常规诱导后插入4号喉管,测定氧饱和度、呼末CO2和异氟醚浓度和手术进程中每5分钟测定肺通气量。应用定容呼吸机。记录需插入喉管的次数和时间。96.6%的患者在整个手术进程能维持氧浓度、通气和呼吸力学的平稳。结论:喉管是择期手术应用机械通气的患者安全且有效气道管理的通气器具。

                         (赵雪莲        庄心良  校)

The Laryngeal Tube® is a new supraglottic ventilatory device for airway management. It has been developed to secure a patent airway during either spontaneous or mechanical ventilation. In this study, we sought to determine the effectiveness of the Laryngeal Tube for primary airway management during routine surgery with mechanical ventilation. One-hundred-seventy-five subjects classified as ASA physical status I and II, scheduled for elective surgery, were included in the study. After the induction of general anesthesia and insertion of a Size 4 Laryngeal Tube, measurements of oxygen saturation, end-tidal CO2 and isoflurane concentration, and breath-by-breath spirometry data were obtained every 5 min throughout surgery. The lungs were ventilated with volume-controlled mechanical ventilation. The number of attempts taken to insert the Laryngeal Tube and the insertion time were recorded. In 96.6% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics by using mechanical ventilation throughout the surgical procedure. The results of this study suggest that the Laryngeal Tube is an effective and safe airway device for airway management in mechanically ventilated patients during elective surgery.

      

不同程度的低温对无手术创伤刺激的麻醉病人凝血功能的影响

The Effect of Graded Hypothermia (36°C–32°C) on Hemostasis in Anesthetized Patients Without Surgical Trauma

S. C. Kettner, MD*,{dagger}, C. Sitzwohl, MD*, M. Zimpfer, MD MBA*,{dagger}, S. A. Kozek, MD*, A. Holzer, MD*, C. K. Spiss, MD*, and U. M. Illievich, MD*

*Department of Anesthesiology and General Intensive Care, University of Vienna, General Hospital Vienna, Vienna, Austria; and {dagger}Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care, Vienna, Austria

Anesth Analg 2003 96: 1772-1776.

低温对凝血功能的单独作用在健康人群中尚未见研究。在诱导后至手术开始前这段时间,我们将16例择期行颅内手术的麻醉病人的中心体温降至32°C,并分别测定病人在363432°C时的凝血酶原时间(PT)、部分激活凝血酶原时间、血栓弹性描记图(TEG)、凝血时间和血小板计数。部分激活凝血酶原时间、红细胞压积和凝血时间没有变化,而凝血酶原时间和血小板计数则在降温中有所下降。血小板计数下降而红细胞压积没有下降,因此不象是由于液体的稀释引起的。对于血小板计数和功能正常的病人,血小板数量的小幅下降可能临床意义不大。凝血酶原时间的轻度缩短提示外源性凝血途径的改变。血栓弹性容积描记图的结果表明在温度校正时有血凝块形成的延迟,但当测试温度为37°C时,则没有变化。这提示低温降低了血浆的凝集和血小板的反应性。但是,凝集的强度并为被低温所改变。所有的凝血功能参数值均保持在正常范围之内。我们的结果可以提示对健康人来说,中度的短期(4h)低温仅有微小的副作用。我们无法对更长时间的低温所产生的效应做出判断。结论:本研究探讨了低温在健康麻醉病人中的单独作用。我们发现体温降至32°C时对凝血功能参数的影响甚微,提示在别的健康人中影响不大。

(黄施伟 译 庄心良 校)

The isolated effects of hypothermia on hemostasis have not been investigated in healthy humans. We cooled 16 anesthetized patients scheduled for elective intracranial surgery to 32°C body core temperature and assessed prothrombin time (PT), activated partial thromboplastin time, thrombelastogram (TEG®), closure time, and platelet count at 36°C, 34°C, and 32°C body core temperature after the induction of anesthesia but before surgical intervention. Activated partial thromboplastin time, hematocrit, and closure time did not change, whereas PT and platelet count decreased during cooling. Platelet count decreased without a decrease in hematocrit; hence, a dilution by administered fluids seemed unlikely. The small decrease of platelet count is probably clinically irrelevant in patients with normal platelet count and function. The small decrease in PT indicates an alteration of the extrinsic pathway of coagulation. TEG® measurements showed a delay of clot formation in temperature-adjusted measurements but showed no change if the test temperature was 37°C. This indicates that hypothermia reduces plasmatic coagulation and platelet reactivity. However, the clot strength is not altered by hypothermia. All coagulation variables remained within the normal ranges. Our results may indicate that moderate short-term (4-h) hypothermia has only minor adverse effects in healthy humans. We can make no statement about the effects of hypothermia of longer duration.

 

小胶质细胞、星形胶质细胞和巨噬细胞在兔脊髓缺血后延迟发生的运动功能障碍中的作用
The Temporal Profile of the Reaction of Microglia, Astrocytes, and Macrophages in the Delayed Onset Paraplegia After Transient Spinal Cord Ischemia in Rabbits

Satoshi Matsumoto, MD, Mishiya Matsumoto, MD, Atsuo Yamashita, MD, Kazunobu Ohtake, MD, Kazuyoshi Ishida, MD, Yasuhiro Morimoto, MD, and Takefumi Sakabe, MD

Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine,

Anesth Analg 2003 96: 1777-1784.

本研究目的是评价小胶质细胞、星形胶质细胞和巨噬细胞在兔脊髓缺血(15分钟)后延迟发生的运动功能障碍中的作用。在兔脊髓再灌注后2, 4, 8, 12, 24 48 h n9),评价后肢的运动功能,并进行脊髓组织学检查。结果表明,大多数动物在脊髓缺血后48h发生迟发性运动功能障碍,而再灌注15min时的脊髓诱发电位恢复不良能预测这种功能障碍。不论脊髓诱发电位恢复如何,在腰髓的灰质,小胶质细胞和星形胶质细胞都会在再灌注后2h激活。相比较而言,星形胶质细胞的激活早期仅局限在发生退变的神经周围。巨噬细胞最早在再灌注后8h被发现,主要围绕在以后发生梗死的区域。尽管尚不明确小胶质细胞、 星形胶质细胞和巨噬细胞激活后的确切作用,此研究结果仍然提示,星形胶质细胞在迟发性运动功能障碍的发生方面可能有非常重要的作用。

                                 (王士雷 译  庄心良 校)

In the present study, we sought to elucidate the temporal profile of the reaction of microglia, astrocytes, and macrophages in the progression of delayed onset motor dysfunction after spinal cord ischemia (15 min) in rabbits. At 2, 4, 8, 12, 24, and 48 h after reperfusion (9 animals in each), hind limb motor function was assessed, and the lumbar spinal cord was histologically examined. Delayed motor dysfunction was observed in most animals at 48 h after ischemia, which could be predicted by a poor recovery of segmental spinal cord evoked potentials at 15 min of reperfusion. In the gray matter of the lumbar spinal cord, both microglia and astrocytes were activated early (2 h) after reperfusion. Microglia were diffusely activated and engulfed motor neurons irrespective of the recovery of segmental spinal cord evoked potentials. In contrast, early astrocytic activation was confined to the area where neurons started to show degeneration. Macrophages were first detected at 8 h after reperfusion and mainly surrounded the infarction area later. Although the precise roles of the activation of microglia, astrocytes, and macrophages are to be further determined, the results indicate that understanding functional changes of astrocytes may be important in the mechanism of delayed onset motor dysfunction including paraplegia.

 

硬膜外芬太尼稀释量对分娩早期止痛效果的影响

Diluent Volume for Epidural Fentanyl and Its Effect on Analgesia in Early Labor

Neil Roy Connelly, MD, Robert K. Parker, DO, Thomas Pedersen, MD, Thenu Manikantan, MD, Tanya Lucas, MD, Stelian Serban, MD, Mervat El-Mansouri, MD, Scott DuBois, MD, Edgar Delos Santos, MD, Asad Rizvi, MD, and Charles Gibson, RN MA

Department of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts

Anesth Analg 2003 96: 1799-1804.

硬膜外利多卡因加肾上腺素试验剂量之后给予芬太尼可以给分娩早期的产妇提供合适的镇痛且不影响行走。我们设计此项试验试图确定硬膜外芬太尼稀释量对效果的影响(如镇痛的起效和持续时间)。60例初产妇在硬膜外3ml利多卡因加肾上腺素的试验剂量后给予100µg芬太尼,容量分别为21020ml。记录每例病人的疼痛评分和副作用。三组之间镇痛的起效时间相似。再次给药之前的持续时间组间没有明显差别,分别为:2ml组(108 ± 40 min),10ml(126 ± 57 min)20ml(126 ± 41 min)。各组均无病人有明显可见的运动阻滞;1例病人(2ml组)称有轻度的膝部无力,未让其行走。在分娩早期的产妇中,硬膜外给予100µg芬太尼(在利多卡因加肾上腺素试验剂量之后),其容量对镇痛起效和持续时间无影响,也不影响其行走能力。

结论:在分娩早期的产妇中,硬膜外给予100µg芬太尼(在利多卡因加肾上腺素试验剂量之后),其容量对镇痛起效和持续时间无影响。

 

                                    (黄施伟 译,庄心良 校)

Epidural fentanyl after a lidocaine and epinephrine test dose provides adequate analgesia and allows for ambulation during early labor. We designed the current study to determine the influence of the diluent volume of the epidural fentanyl bolus (e.g., whether it has an effect on the onset and duration of analgesia). Sixty laboring primigravid women received a 3-mL epidural test dose of lidocaine with epinephrine and then received a fentanyl 100-µg bolus in either a 2-mL, 10-mL, or 20-mL volume. Pain scores and side effects were recorded for each patient. The onset of analgesia was similar in all three groups. The mean duration before re-dose was not significantly different in the 2-mL group (108 ± 40 min), the 10-mL group (126 ± 57 min), or the 20-mL group (126 ± 41 min). No patient in any group experienced any detectable motor block; one patient (2-mL group) complained of mild knee weakness and was not allowed to ambulate. In early laboring patients, the volume in which 100 µg of epidural fentanyl (after a lidocaine-epinephrine test dose) is administered does not affect the onset or duration of analgesia, nor does it affect the ability to ambulate.