Anesthesia & Analgesia

June 2003

Table of Content

REGIONAL ANESTHESIA:

腰部硬膜外置管發生嚴重神經併發症的危險性很小

(王士雷   莊心良 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對組織氧合的影響

(朱輝 譯 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:

關於行非心臟手術的患者圍術期預防性使用β受體阻滯劑的實踐:加拿大麻醉醫師的調查

(張俊峰 譯 薛張剛 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.

在冠狀動脈搭橋術後不久行胸骨切除術發生的圍手術期心肌缺血

(王士雷 莊心良 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.

在中度低血容量時快速輸注晶體液或膠體液進行擴容引起的急性血管內容量增加的比較

(齊波 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.

地塞米松對冠脈再血管化手術後副作用的影響

(張俊峰 譯 薛張剛 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.

經胸心臟超聲結合經食道心臟超聲在經導管對前緣變薄的房間隔缺損封閉術中的應用——一組病例報導

(王立中    莊心良 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.

麻醉綿羊冠狀動脈脈血中異丙酚濃度與異丙酚心血管效應的關係

(齊波 譯 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:

含鎂預充液對開心手術血鎂濃度和鉀丟失的影響

(張俊峰 譯 薛張剛 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.

兒童門診鼓膜切開術和放置平衡導管後的鎮痛

(王立中    莊心良 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.

小兒麻醉後恢復室中急性躁動的前瞻性群體性研究

(忻紀華 譯 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術前給藥對門診手術術後疼痛和恢復時間的影響:劑量範圍研究

(潘志浩 譯 薛張剛 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.

腦電雙頻指數可否用於預測電驚厥治療後驚厥時間和蘇醒?

BIS能預測電抽搐療法後癲癇發作時間和蘇醒嗎?

(王立中   莊心良  校)

 (忻紀華 譯 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對人體交感和血管的影響

(潘志浩 譯 薛張剛 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.

意識恢復期異丙酚作用部位濃度與芬太尼濃度無相關性

(朱慧琛 翻 王祥瑞 校)

蘇醒期異丙酚的效應室濃度與芬太尼的效應室濃度無關

(軒泓     莊心良 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腎上腺素受體可能沒有參與吸入麻醉藥產生的體動抑制

(潘志浩 譯 薛張剛 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.

布比卡因抑制人類TREK-1通道

(軒泓 莊心良 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、異氟醚和靜脈麻醉藥對鼠膈肌功能及易疲勞性的影響

(朱慧琛 譯 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.

奧力農治療但不能預防疲勞導致的豚鼠橫膈收縮性改變

(廖慶武翻譯,薛張綱校對)

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:

隔熱法和強力空氣保暖法有相同的保暖效果

(王士雷    莊心良 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.

使用新型通氣裝置時的中心溫度監測

(殷文淵 譯 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.

低溫對異丙酚/氯胺酮/芬太尼麻醉下兔子的單個和成串電刺激引起的肌源性運動誘發電位的影響

(廖慶武 譯 薛張綱 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:

唑尼沙胺對實驗性單神經痛大鼠溫度和機械疼痛過敏的作用

(王士雷    莊心良  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.

對鼠經皮吸收阿米替林(Amitriptyline)和利多卡因(Lidocaine)後皮膚痛覺喪失的比較

(殷文淵 譯 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.

白鼠蛛網膜下電刺激導致防感受傷害作用增強和耐受性減弱

(廖慶武 譯 薛張綱 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:

聯合應用加壓素和腎上腺素使延遲心肺復蘇的豬神經功能完全恢復

(王士雷   莊心良 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.

評估全身麻醉行機械通氣時喉管的應用

(趙雪蓮        莊心良  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.

俯臥位改善了COPD患者的肺順應性和氣體交換

(陳潔 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:

亞低溫(36-32℃)對麻醉而無手術創傷患者的凝血功能的影響

(顧越超 薛張綱 校)  

不同程度的低溫對無手術創傷刺激的麻醉病人凝血功能的影響

(黃施偉 莊心良 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.

小膠質細胞、星形膠質細胞和巨噬細胞在兔脊髓缺血後延遲發生的運動功能障礙中的作用

(王士雷   莊心良 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:

比較那布啡與奧丹思酮預防鞘內注射嗎啡引起的剖腹產術後癢的作用

(陳潔 譯王祥瑞 ) 

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.

數字評分法與硬膜外分娩鎮痛

(顧越超譯 薛張綱 校)

The Numeric Rating Scale and Labor Epidural Analgesia

Yaakov Beilin, Sabera Hossain, and Carol A. Bodian

Anesth Analg 2003 96: 1794-1798.

硬膜外芬太尼稀釋量對分娩早期止痛效果的影響

(黃施偉 譯,莊心良 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:

鉛是否干擾HBOC功能?一項試驗性研究:三種已獲得或試驗過的HBOCs中的鉛濃度,隨鉛濃度變化HBOCs/或牛血液的氧和血紅蛋白分數

(顧越超 譯 薛張綱 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.

 

關於行非心臟手術的患者圍術期預防性使用β受體阻滯劑的實踐:加拿大麻醉醫師的調查

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

對近期最佳醫療手段缺乏認知是常被認為的實踐循證醫學的主要障礙之一。圍術期預防性的使用β受體阻滯劑是近期文獻廣泛討論並且認為該治療對患者的臨床預後有顯著意義,本研究的目的在於調查加拿大麻醉醫師對圍術期預防性使用β受體阻滯劑的認知及應用情況。我們對加拿大麻醉學會的1234名會員進行問卷調查,總體回應率為54%,回應者中的95%了解圍術期使用β受體阻滯劑的文獻,而這些回應者中的93%贊同β受體阻滯劑對冠心病患者是有益的觀點。57%的常常在冠心病患者中預防性的使用β受體阻滯劑,這些常規使用者中的34%使用β受體阻滯劑一直到術後早期。只有9%的回應者承認在其組織中有此醫療常規。改研究結果表明轉化研究結果到臨床實踐的障礙與對近期的最佳醫療證據的缺乏認知無關, 至於圍術期應用β受體阻滯劑的問題,文獻中的爭議和實踐中的考慮可能是施行最佳循證的主要障礙。結論:改研究結果表明麻醉醫師知道並支持對有冠心病風險或確診冠心病的患者在圍術期預防性的使用β受體阻滯劑的觀點,然而只有57%的麻醉醫師經常給病人使用β受體阻滯劑,對近期最佳醫療證據的認知並不是施行循證的障礙。

(張俊峰 譯 薛張剛 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.

 

地塞米松對冠脈再血管化手術後副作用的影響

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

皮質類固醇激素可降低非心臟擇期手術的副作用。我們設計此隨機、雙盲、安慰劑控制的研究以證實:標準劑量的地塞米松(4 mg x2)能夠減少術後的噁心嘔吐及疼痛,降低房顫的發生率,改善心臟術後患者的胃口,從而有利於患者的術後恢復。300例行冠脈再血管化的患者入選此研究,所有的患者均採用標準的麻醉處理,麻醉誘導後使用地塞米松 (4 mg/mL)或生理鹽水,在術後清晨再使用同樣劑量的藥物,術後的前72小時持續監測心電圖確定房顫的發生率,在術後24h48h、出院時評價患者確定術後副作用(如噁心、嘔吐、疼痛等)的發生率和程度及患者的滿意評分。地塞米松顯著降低術後第一天(30% versus 42%)抗嘔吐藥的需要及術後第二天噁心(15% versus 26%)、嘔吐(5% versus 16%)的發生率(P < 0.05)。此外,地塞米松顯著降低術後第二天患者的食欲降低的比例。然而,皮質類固醇激素不能降低房顫(27% versus 32%)的發生率和阿片類止痛藥的使用總量。改研究的結果表明地塞米松 (8 mg分兩次給藥)可降低心臟術後的嘔吐症狀、改善患者的食欲,但該劑量的皮質類固醇激素無抗心律失常和減少止痛藥用量的特性。結論:地塞米松(8 mg IV)有利於減少心臟術後的嘔吐症狀和改善患者食欲, 但該劑量的皮質類固醇激素不能降低術後疼痛,不能降低新發房顫的發生率。

(張俊峰 譯 薛張剛 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.

 

含鎂預充液對開心手術血鎂濃度和鉀丟失的影響

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

改研究的目的在於明確在體外迴圈(CPB)預充液中加鎂對小兒開心手術血鎂濃度和鉀丟失的影響。40例擬行開心手術的患兒隨機分為預充液中加硫酸鎂(magnesium group, n = 20; 0.25 mmol/kg)和生理鹽水(placebo group; n = 20)組。分別在CPB過程中和CPB後的既定時間點測定離子化鎂(Img)及尿鎂、鉀濃度。magnesium groupImg濃度在CPB過程中較高但在CPB後不高, 在placebo group ImgCPB早期階段降低並且降低到CPB24h的較低水平。CPB中及CPB後,尿鎂濃度magnesium group要高於placebo group,尿鉀濃度則達CPB24 h的較低水平(44.2 ± 2.9 versus 60.9 ± 2.6 mmol/L; P < 0.01)。因此,我們認為在預充液中加鎂可維持正常Img水平並且阻止圍術期的鉀丟失。結論:改研究的結果顯示小兒開心手術中含鎂的預充液可阻止CPB中及CPB後的低鎂的發生,並且可降低鉀的尿丟失。

(張俊峰 譯 薛張剛 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術前給藥對門診手術術後疼痛和恢復時間的影響:劑量範圍研究

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

近來,FDAcelecoxib用作急性疼痛治療的推薦劑量從 200 mg增加到400 mg 還沒有研究直接比較不同劑量celecoxib用於預防術後疼痛的效能。在這一前瞻,雙盲,安慰劑對照研究中,我們對200 mg400 mg celecoxib口服用於小型耳鼻喉手術門診病人術前用藥進行比較。總共93例健康門診病人分至13研究組:對照組 (安慰劑; n = 30), celecoxib 200 mg (n = 30)celecoxib 400 mg (n = 33)。研究藥物在術前3045分鐘口服, 所有病人都接受標準化的全身麻醉技術。在術後階段記錄疼痛評分 (010), 恢復時間,止痛藥物的需要, 恢復質量(0100), 病人對疼痛處理的滿意程度(0100)以及副作用。 疼痛在PACU,晝間手術恢復區和術後24小時每隔30分鐘用口頭等級評分評價,0 = 無痛10 = 可想像的最嚴重的疼痛。Celecoxib 400 mg200 mg (以及安慰劑)相比在減輕術後疼痛上更有效。celecoxib 200 mg 400 mg在減少術後芬太尼的用量上較安慰劑更有效(分別為74 ± 67 µg56 ± 62 µg120 ± 86 µg) 更大劑量celecoxib顯著減少出院時嚴重疼痛病人的比例 (celecoxib400 mg組,celecoxib 200 mg 組和對照組分別為6% 37% 30%)。出院後口服止痛藥的劑量的中位數在celecoxib 400 mg 組顯著減少(0 celecoxib 200 mg 組和對照組分別為22)。然而,三組在恢復時間和次要預後變數上沒有差異 (如病人滿意度和恢復質量)。我們認為術前口服celecoxib 400 mg200 mg相比在減輕術後嚴重疼痛和鎮痛藥物需要上更有效。

(潘志浩 譯 薛張剛 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對人體交感和血管的影響

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

 

我們對在年輕(ASA I)的志願者(n = 24)應用鎮靜-鎮痛劑量remifentanil導致低血壓的可能機制進行研究。心肺和交感變數在基線和2 4 ng/mL血漿濃度的remifentanil應用時進行採集。監測包括心電圖, 心率(HR),有創動脈壓, 肌肉交感神經活性, 前臂血流 (FBF)。寒冷升壓試驗(手浸入冰水1分鐘)量化鎮痛效能(視覺類比評分0100)。寒冷升壓試驗中視覺類比評分 (基線時為62) remifentanil 輸注時從27減少到18 。呼吸頻率下降,呼氣末二氧化碳(ETCO2) remifentanil 劑量增加耳增加; HR,有創血壓, 肌肉交感神經活性, SpO2 保持不變,FBF與安慰劑相比增加。在第二個研究中(n = 7),定時呼吸用來維持remifentani 輸注時的ETCO2, FBF仍然增加。在第三個研究中(n = 11), remifentanil對血管張力的直接作用用在肱動脈上漸進增加輸注(1 100 µg/h)來確定; FBF顯著增加,從每100 mL 組織3.5 增加到 4.3 mL/min (~增加13%18%)。鎮靜劑量的remifentanil 導致鎮痛,但沒有除了FBF外的神經迴圈終點的改變。Remifentanil對局部血管張力的直接作用可能在促進低血壓發生上起作用。

(潘志浩 譯 薛張剛 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腎上腺素受體可能沒有參與吸入麻醉藥產生的體動抑制

{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}-腎上腺素受體的激動具有強烈的麻醉藥效影響,這部分通過對脊髓的作用產生。 {alpha}-腎上腺素受體激動劑(dexmedetomidine) 可以降低吸入麻醉藥物(如氟烷)的MAC0,在氟烷和dexmedetomidine之間有明顯的相加作用。我們對是否吸入麻醉藥異氟醚在面對傷害型刺激時抑制體動的能力由於激動{alpha}-腎上腺素受體而產生進行研究。異氟醚的MAC在腹腔內注射{alpha}-腎上腺素受體阻滯劑yohimbine atipamezole應用前後測定。Yohimbineatipamezole的劑量等於和超過可以逆轉競爭{alpha}-腎上腺素受體降低MAC的劑量。更小劑量yohimbine atipamezole 輕度增加 (小於10%) 異氟醚的 MAC, 這一增加 我們解釋為阻滯少量張力性的活性{alpha}-腎上腺素受體的活性。更大的5倍劑量沒有改變 MAC。 更大的10倍劑量降低了 MAC。我們認為{alpha}-腎上腺素受體沒有或極少介導吸入麻醉藥產生體動抑制的能力。     

(潘志浩 譯 薛張剛 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.

 

奧力農治療但不能預防疲勞導致的豚鼠橫膈收縮性改變

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

奧力農是一種磷酸二酯酶III抑制劑,在活體能提高疲勞橫膈的收縮性,但是沒有資料提供體外疲勞導致的收縮性改變的治療和預防。因此我們用豚鼠橫膈來檢驗奧力農對疲勞導致的收縮性改變的治療和預防。豚鼠橫膈條根據奧力農的劑量(0, 10-6, 10-5, and 10-4 M)隨機分組(每組n=7),然後放在器官槽中直接刺激。通過在20-Hz100-Hz刺激下的橫膈條顫動張力和力量來衡量其收縮性。用20-Hz刺激橫膈條產生間歇,重複收縮並持續5分鐘從而導致其疲勞。在第一個實驗中,疲勞產生期後在器官槽中加入奧力農作用5分鐘。第二個實驗中預防使用奧力農5分鐘,然後再產生橫膈條疲勞。在第一個實驗中,疲勞產生期後每次刺激產生的肌肉強直力量都比基線值減低(P<0.05)10-510-4 M的奧力農能使雙次刺激產生的收縮力量比疲勞值增加(P<0.05)。在第二個實驗中,觀察到預防使用奧力農((010-4 M)並沒有使肌肉強直力量發生改變。疲勞產生後每次刺激產生的肌肉強直力量都比基線值減低(P<0.05)。這些結果提示10-510-4 M的奧力農能改善疲勞導致的豚鼠橫膈收縮性的改變,而預防性使用奧力農並不能防止橫膈的易疲勞性。(廖慶武翻譯,薛張綱校對

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.

 

低溫對異丙酚/氯胺酮/芬太尼麻醉下兔子的單個和成串電刺激引起的肌源性運動誘發電位的影響

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

在此研究中我們研究低溫對兔子肌源性運動誘發電位(MEPs)的影響,評估刺激模式對誘發運動誘發電位(MEPs)的影響。我們以12只用氯胺酮,芬太尼和異丙酚麻醉的兔子作為研究物件,從比目魚肌上記錄單個與三個和五個成串對運動皮質的電刺激產生的肌源性運動誘發電位(MEPs)。在食道溫度為38°C時記錄下MEPs的對照值,然後對兔子進行表面降溫,使其食道溫度分別維持在35°C, 32°C, 30°C28°C並記錄每一溫度點MEPs。與體核溫度為38°C時的對照值相比,當體核溫度降到28°C時單個刺激誘發的運動誘發電位(MEP)幅度顯著減小(0.8 ± 0.4 mV 2.3 ± 0.3 mV; P < 0.05),而在降溫過程中成串刺激誘發的MEP幅度並沒有顯著變化。不管刺激模式如何,隨著體核溫度的降低,MEP的潛伏期成線性增加。總之,這些結果顯示異丙酚/氯胺酮/芬太尼麻醉下兔子的體核溫度降到28°C時並不影響成串刺激誘發的MEP幅度,但除外單個刺激誘發的。

(廖慶武 譯 薛張綱 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.

白鼠蛛網膜下電刺激導致防感受傷害作用增強和耐受性減弱

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

我們檢驗了蛛網膜下電刺激是否會降低慢性使用嗎啡的耐量和嗎啡戒斷的嚴重程度。給大白鼠蛛網膜下置入帶電極的導管,並從蛛網膜下持續7天注入嗎啡(2 nmol/h)或生理鹽水。每日在相同時期給予蛛網膜下電刺激(0, 20, or 200 V)各一次,並通過輕擊大白鼠尾部和測試蛛網膜下嗎啡需要量來評估蛛網膜下電刺激對防感受傷害作用與嗎啡耐量的影響。用納洛酮戒斷(2 mg/kg)來評估嗎啡依賴性,並用微透析檢測脊髓神經遞質的改變。200V電刺激使得蛛網膜下使用嗎啡的抗感受傷害作用增加。與對照組(僅使用嗎啡2nmol/h)相比,200V蛛網膜下電刺激使得用2 nmol/h嗎啡持續輸注的大白鼠的耐受程度降低(AD50, 13.6 vs 124.7 nmol)。用納洛酮誘發接受200V電刺激的大白鼠的戒斷症狀,其嚴重程度較輕。因此,在接受慢性蛛網膜下持續輸注嗎啡的大白鼠,蛛網膜下刺激可增強鎮痛效果和減輕納洛酮誘發的戒斷症狀。這種方法也許對蛛網膜下長期使用阿片類藥物來控制慢性疼痛的進一步研究有所價值。               

(廖慶武 譯 薛張綱 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.

 

 

鉛是否干擾HBOC功能?一項試驗性研究:三種已獲得或試驗過的HBOCs中的鉛濃度,隨鉛濃度變化HBOCs/或牛血液的氧和血紅蛋白分數

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

 

我們測量了三種以血紅蛋白為基礎的攜氧物質(HBOCsOxyglobinHemopureHemolink)中的鉛濃度,並與血庫庫存血中的鉛濃度進行比較。測量了牛HBOC,有或無牛血,和牛血中存在高濃度鉛時的氧和血紅蛋白分數。每組樣本均與生理鹽水(對照組),低濃度鉛(22ug/dL,中毒濃度的鉛(70ug/dL)混合。它們在2個大氣壓下與氧濃度為2.5%5%8%10%21%,和95%CO(2) 濃度為5%,其餘為氮氣的氣體混合5分鐘,每份樣本在每一氧濃度水平洗入15分鐘後進行血氧測定。繪製氧飽和度—氧分壓曲線,資料符合四次多項式非線性回歸方程。三種HBOCs的鉛濃度分別為0.510.220.40 ug/dL。臨床上氧和血紅蛋白分數曲線無顯著差別。三種經測試的HBOCs的鉛濃度較小,不比血庫庫存血的鉛濃度平均值大。在體外試驗中,無論是濃縮的牛HBOC還是1:1HBOC和牛血混合物中增加的鉛都不會影響血紅蛋白的氧和。結論:槍傷會很快增加血循環中的鉛濃度。三種HBOCs的鉛濃度均較小,HBOCs或牛血都不會受鉛濃度的影響而導致氧過度結合或解離。HBOCs在槍傷患者比較有用。      

(顧越超 譯 薛張綱 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.

 

 

數字評分法與硬膜外分娩鎮痛

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

 

口述數位(0-10)評分法(NRS)在研究中廣泛用於疼痛評價,但是它對於臨床醫師的使用價值尚未明確。本研究中,把額外需求的鎮痛藥物量作為疼痛研究中一個臨床相關指標,並把它與NRS的結果相比較。對先前進行的有關硬膜外分娩鎮痛的三個研究進行統計分析。在這三個研究中,在進行硬膜外分娩鎮痛之前和之後15分鐘採取口述NRS數值。在進行硬膜外分娩鎮痛15分鐘時,詢問產婦是否需要更多的鎮痛藥物。我們發現NRS數值為0-1的患者很少(2%)需要更多的鎮痛藥物,NRS數值為2-3的患者51%需要更多的鎮痛藥物,NRS數值為>3的患者幾乎全部(93%)需要更多的鎮痛藥物。按最後的NRS數值分為三組(0123>3)比使用單獨的NRS數值對臨床醫師來講更有用。結論:本研究提示除非口述NRS數值為01,進行硬膜外分娩鎮痛的產婦大部分需要更多的鎮痛藥物。另外,按最後的NRS數值分為三組(0123>3)進行分析對臨床醫師來講比使用全部範圍的NRS數值更有用。   

(顧越超譯 薛張綱 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.

 

亞低溫(36-32℃)對麻醉而無手術創傷患者的凝血功能的影響

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

 

在健康人群中低溫對凝血功能的獨立作用尚未明確。將16例進行擇期顱內手術的已麻醉患者的中心體溫降至32℃,同時在麻醉誘導後外科手術之前監測36℃、34℃、32℃時的PT,APTT,TEG(R),止血時間,血小板計數。在降溫過程中,APTT,血球壓積,止血時間無變化;PT,血小板計數降低。血小板計數降低時不伴有血球壓積的降低。因此,因輸液而引起的血液稀釋不可能引起此變化。在血小板計數與功能正常的患者血小板計數輕度下降無臨床意義。PT的輕度下降提示外源性凝血途徑的改變。TEG(R)測量顯示在體溫變化過程中血塊凝結延遲,而在體溫37℃時無改變。這提示低溫降低血漿凝血因數和血小板的活性。但是,血塊凝結的功能未改變。所有凝血功能的變化均維持在正常範圍內。結果顯示適度的短時間(4小時)的低溫對健康人僅有微小的副作用。對長時間低溫的作用未做出結論。結論:本研究調查了低溫對健康已麻醉患者凝血功能的獨立作用。發現體溫降至32℃對凝血功能的變化僅有微小的作用,提示對健康人僅有微小影響。            

(顧越超 譯 薛張綱 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對組織氧合的影響

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

 

傷口感染和皮下組織氧分壓呈負相關。全身麻醉可通過直接擴張血管和抑制體溫調節中樞的血管收縮而增加局部血流。硬膜外麻醉通過抑制交感神經敏感性而增加阻滯區域的灌注。為證實在清醒或麻醉狀態下硬膜外麻醉是否能夠增加組織氧分壓,15名健康志願者分別實施硬膜外麻醉,全身麻醉,及硬膜外、全麻聯合麻醉。採用氣壓計測定一側上臂和大腿的皮下組織氧分壓。0.75%mepivacaine實施硬膜外麻醉使平面到達T10水平;1.5%的七氟醚吸入30%的氧維持全身麻醉;在基礎麻醉下通過封閉的面罩吸入30%的氧並實施硬膜外麻醉。上臂和大腿的皮下組織氧分壓基礎水平分別為57±1154±8mmHg。硬膜外麻醉顯著增加大腿組織氧分壓,可增加9 mmHg63±7 mmHg,但不增加上臂組織氧分壓。單純全身麻醉上臂和大腿的組織氧分壓幾乎沒有什麼變化,分別為58±11 mmHg63±12 mmHg。全身麻醉聯合硬膜外麻醉上臂組織氧分壓仍無變化而大腿皮下組織氧分壓從63±12 mmHg增加到71±9 mmHg,增加了8±3 mmHg。雖然硬膜外麻醉合併或不合併全身麻醉能夠顯著增加組織氧分壓,這種增加的幅度可能對外科傷口感染有一定的臨床意義。

 (朱輝 譯 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.

 

在中度低血容量時快速輸注晶體液或膠體液進行擴容引起的急性血管內容量增加的比較

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


雖然應用不同的晶體和膠體溶液均可建立容量平衡,但在快速輸注晶體或膠體溶液進行擴容時所能達到的最大血管內容量值尚不清楚。通過交叉試驗方法在8名健康男性志願者,對輸注1000ml乳酸林格氏液和同等容量的6%羥乙基澱粉液所能達到的最大血管內容量進行了比較。在實驗過程中通過放900ml血液人為造成志願者中度低血容量狀態,然後在5-7分鐘內快速輸注晶體或膠體液。在30分鐘內每5分鐘測量一次血球壓積來觀察血容量的變化。結果發現應用乳酸鈉林格氏液所能達到的最大血管內容量平均為630±127ml,其最大血管內容量是在快速補液剛剛結束時達到的,而應用6%羥乙基澱粉液所能達到的最大血管內容量平均為1123±116ml,其最大血管內容量是在快速補液後5分鐘時達到的。實驗結果存在顯著差異(P<0.001)。結果表明即使在非常短的時間內,快速輸注膠體也能更加有效地增加血容量,由此可推論,輸注膠體液時心輸出量的增加要大於輸注同等容量的晶體液,即使非常快速輸注晶體液時。

(齊波 譯 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.

麻醉綿羊冠狀動脈脈血中異丙酚濃度與異丙酚心血管效應的關係

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

將生理性藥效動力學模型與心血管系統的模型相結合可瞭解藥物心血管效應的體內作用部位。在本研究觀察冠脈血異丙酚濃度的作用。9只綿羊用2%異氟醚麻醉後迅速進行心血管測量。通過隨機交叉的實驗設計,這些綿羊接受經冠狀動脈(CA)應用異丙酚選擇性作用於心肌(以冠狀竇血濃度為標準)或經靜脈應用異丙酚使全身各部位達到同樣的藥物濃度。結果表明左室心肌收縮力(LVdP/dtmax)和平均動脈壓的下降與異丙酚的濃度呈線性相關。對於經CA途徑用藥的綿羊,冠狀竇血異丙酚濃度每增加1mg/LLVdP/dtmax減少52mmHg/S。經靜脈途徑用藥的綿羊,LVdP/dtmax的減少與CA途徑相同,表明此種心血管效應的產生主要依賴於冠脈血異丙酚濃度。在CA途徑組,冠狀竇血異丙酚濃度每增加1mg/L則平均動脈壓下降0.6mmHg。而在靜脈用藥組平均動脈壓有更大的下降(2.5 mmHg·mg-1·L-1)。因此,這種效應主要由身體其他部位的異丙酚濃度來調節。

(齊波 譯 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.

 

小兒麻醉後恢復室中急性躁動的前瞻性群體性研究

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

麻醉後的躁動(EA)不僅影響小兒的恢復,而且也影響到麻醉後的評估和處理。在本研究中選取健康兒童觀察EA的判斷和評估EA的相關因素,並且描述相關預後情況。選擇3-7歲的兒童進行全麻包括門診病人。所有的圍術期監護都經檔證明,同時記錄麻醉後恢復室內的術後行為。3-7歲的兒童由父母完成行為調查問答卷。研究共包括了521名兒童,其中96例發生EA。一些病例中躁動可持續45分鐘(範圍,3-45分鐘;平均,14+/-11分鐘),需要藥物干預的占52%,且與麻醉後恢復室內停留時間延長有關(與未躁動的兒童停留時間101+/-61分鐘相比停留時間為117+/-66分鐘;p=0.02)。發現10個因素與EA 有關,包括年齡,術前情況,適應性,眼科和耳鼻咽喉部位的操作,七氟醚,異氟醚,七氟醚/異氟醚,鎮痛藥和蘇醒時間。這些因素中,耳鼻咽喉部位的手術,蘇醒時間和異氟醚為獨立影響因素。

(忻紀華 譯 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.

 

腦電雙頻指數可否用於預測電驚厥治療後驚厥時間和蘇醒?

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

腦電圖雙頻指數(BIS)可測定麻醉時的鎮靜程度,並與麻醉中的緊急事件相關。因此,我們假設BIS可用于預測美索比妥麻醉下電驚厥治療(ECT)——導致的驚厥時間和蘇醒。選擇25例嚴重抑鬱症患者,經病人同意連續接受100次電驚厥治療。所有病人麻醉前靜脈注射0.2mg胃長寧,以美索比妥1mg/kg靜注麻醉。連續監測BIS變化,在特定點記錄BIS值,包括麻醉前(基礎值),誘導後(ECT治療前),ECT結束時(峰值),ECT治療後(抑制狀態)和蘇醒時(睜眼時)。ECT治療前的BIS值與運動(r=0.3)和EEG發作活動(r=0.4)有關 (p<0.05) ECT治療後BIS峰值與EEG發作時間有關(r=0.5(p<0.05)EEG發作時間和到睜眼的時間呈正相關(r=0.4(p<0.05) 。但是,蘇醒時BIS值從29-97,且75%的病例<60。我們得出結論:ECT刺激前BIS值可用於預測驚厥時間。但是,蘇醒時的BIS值變化範圍大,提示它不但反映了美索比妥的殘留抑制作用而且反映了發作後的抑制。

(忻紀華 譯 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.

 

意識恢復期異丙酚作用部位濃度與芬太尼濃度無相關性

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

為了降低外科手術刺激產生的影響使用芬太尼可減少異丙酚的用量,但阿片類藥物很少影響患者的意識,為此,本研究在清醒患者芬太尼很少影響異丙酚的作用部位濃度。50位婦產科腹部手術的患者隨機分為五組,每組均給予異丙酚麻醉並分別加入芬太尼0.8,1.0,1.4,2.0,3.0 ng/Ml。術後的初始階段仍按指定的速率持續運用芬太尼,同時我們將患者能睜眼對命令作出回應時的異丙酚濃度視為清醒濃度。實驗中各清醒組的異丙酚作用部位濃度無明顯差別(異丙酚1.9+0.5 ug/mL芬太尼0.8 ng/mL; 異丙酚1.6+0.4ug/mL芬太尼1.0 ng/mL;異丙酚1.6+0.2ug/mL芬太尼1.4 ng/mL;異丙酚 1.7+0.4ug/mL芬太尼2.0 ng/mL;異丙酚1.6+0.34ug/mL芬太尼3.0ng/mL(mean +SD). 在使用0.8 ng/Ml芬太尼的組中70%的患者主訴有疼痛,而使用23 ng/Ml芬太尼組的患者無此主訴。3ng/Ml9名患者中的五位(56%)出現術後呼吸頻率<6/分,其中一名患者的心率降到〈40/分。這些資料顯示婦產科腹腔鏡手術病人恢復期芬太尼的理想作用濃度為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、異氟醚和靜脈麻醉藥對鼠膈肌功能及易疲勞性的影響

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
為觀察異氟醚、安氟醚、咪噠唑倫、氯胺酮、異丙酚和硫噴妥類對老鼠膈肌功能的影響,對228只鼠的獨立肌群在疲勞狀態及非疲勞狀態分別進行研究。實驗分為兩組,實驗組運用一種麻醉劑的常用臨床劑量或10100倍劑量,或者123倍的肺泡最低有效濃度(MAC),對照組不用藥。兩組實驗鼠均接受反復的強直性肌肉刺激誘發肌肉疲勞,同時將膈肌抽搐特性記錄下。異氟醚、咪噠唑倫、氯胺酮、異丙酚和硫噴妥類在肌肉疲勞或非疲勞狀態下不會直接引起肌肉收縮或鬆弛。安氟醚不會改變膈肌的收縮與鬆弛,但2-3MAC的安氟醚可增強膈肌的易疲勞性同時增加疲勞引起的收縮功能降低。這種作用3MAC要較2MAC強。這些研究結果表明先前所提到的運用異丙酚、咪噠唑倫和異氟醚降低膈肌功能並不直接影響膈肌的收縮性能。結論亦顯示高濃度的安氟醚並不是通過神經-肌肉偶聯降低膈肌功能。

(朱慧琛 譯 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.

 

使用新型通氣裝置時的中心溫度監測

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

雖然新型通氣裝置的使用日益廣泛,例如喉罩(LMA)和帶有氣囊的口咽通氣道(COPA),但在使用這些裝置是都無法在食道末端測量中心溫度。因此,我們假設通過放置在LMACOPA中的熱電偶測量出的中心溫度足夠精確可供臨床使用,對此進行了驗證。36名計畫進行長時間整形外科手術或癌症熱療的病人接受了此項試驗,溫度從放置於LMACOPA氣囊中的熱電偶中獲得。這些溫度間隔15分鐘測量一次,結果與同一時間從鼻咽和鼓室粘膜獲得的溫度作比較。資料通過線性回歸比較,斜線計算。從LMA測量的溫度與鼻咽(r2=0.94)和鼓室(r2=0.94)粘膜溫度有良好的相關性。從COPA測量的溫度與鼻咽(r2=0.97)和鼓室(r2=0.96)粘膜溫度的相關性較好。8%LMA測量的溫度和11%COPA測量的溫度與鼻咽粘膜溫度相差大於±0.5℃;7%LMA測量的溫度和10%COPA測量的溫度與鼓室粘膜溫度相差大於±0.5℃。這些結果說明從LMACOPA的氣囊測量的體溫足夠精確,可供臨床使用。

(殷文淵 譯 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.

 

對鼠經皮吸收阿米替林(Amitriptyline)和利多卡因(Lidocaine)後皮膚痛覺喪失的比較

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),一種三環類抗抑鬱藥,具有特效局部麻醉藥屬性。可是,並沒有經皮吸收後產生皮膚麻醉效應的報導。本研究觀察老鼠經皮吸收阿米替林比注射利多卡因產生更有效的皮膚麻醉作用。基於50100500mM濃度的阿米替林溶液做成一種敷帖應用於老鼠身上,它們所產生的效應與基於相同濃度的利多卡因溶液和單獨使用媒介物(45%水,45%異丙基酒精和10%甘油)相比較。每個試驗組的老鼠在使用了藥的部位均具有濃度依賴性的皮膚麻醉作用。可是,在相同的濃度下,阿米替林的阻滯時間要長於利多卡因。將阿米替林發展成一種長效局部麻醉藥可以改善我們治療慢性疼痛的能力,例如神經性疼痛和神經痛,在一些操作中鎮痛,例如靜脈穿刺。

(殷文淵 譯 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.

 

俯臥位改善了COPD患者的肺順應性和氣體交換

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

俯臥體位元有可能改善接受容量控制機械通氣的COPD患者的呼吸系統力學和功能。10COPD患者首先採用仰臥位(基本體位,[supineBAS], 然後隨機性地變成俯臥位(supinePROT)、半臥位和俯臥位。在恒定流量下,呼吸系統功能和吸入功在潮氣量為基礎值(0.6L)和歎息(1.2L)時(supinePROT除外)測定。記錄所有血流動力學和血氣改變。沒有發生併發症。俯臥位與仰臥位、半臥位相比,(a)改善了在兩種潮氣量時的胸壁彈性順應性和氧和功能;(b)在歎息潮氣量時減少了肺阻力-容積比;(c)降低了兩種潮氣量時肺靜態阻力並改善了CO2的排出;(d)改善了氧合。半臥位與supineBASsupinePROT相比,主要增加了胸壁的順應性。潮氣量-吸入功-物質改變與呼吸系統、胸壁和肺的機械性能相一致。總的呼吸系統血流動力學變化與體位改變無關。俯臥位後,5例患者重新改為仰臥位(supinePOSTPRO)。在supinePOSTPRO時,呼吸系統-肺靜態順應性降低,但氧合比supineBAS仍有改善。COPD患者取俯臥位與半臥位相比(金標準)增加了通氣的順應性和有效性並改善了氧合。

(陳潔 譯 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.

 

比較那布啡與奧丹思酮預防鞘內注射嗎啡引起的剖腹產術後搔癢的作用

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、隨機雙盲研究中,我們比較了那布啡與奧丹思酮對鞘內注射嗎啡引起的剖腹產術後瘙癢的預防作用。240例臨產婦隨機分為4組:N-4組、O-4組、O-8組和對照組,分別在胎兒娩出後立刻靜注4mg那布啡、4mg奧丹思酮、8mg奧丹思酮和4ml生理鹽水。在麻醉術後恢復室,我們發現4組瘙癢評分有顯著性差異(p<0.001)。N-4組、O-4組、O-8組和對照組預防瘙癢的成功率分別為20%13%12%6%p<0.001)。比較N-4組和安慰劑組的瘙癢評分以及O-4組和安慰劑組的瘙癢評分均有顯著性差異(分別為p<0.001p=0.006)。4組患者要求對瘙癢進行治療的發生率分別為25%47%51%72%p<0.001)。術後4824小時組間噁心嘔吐評分、疼痛評分、鎮靜評分、寒戰評分無差異。與安慰劑相比,那布啡和奧丹思酮預防鞘內注射嗎啡引起的剖腹產術後瘙癢更為有效。

                       陳潔 譯王祥瑞 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.

 

腰部硬膜外置管發生嚴重神經併發症的危險性很小

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藥時的疼痛是硬膜外阻滯麻醉後出現持續感覺異常的危險因素。由於硬膜外阻滯麻醉後病人對疼痛刺激不再有反應,從理論上講硬膜外阻滯本身會增加術後神經併發症的危險性。本研究對全麻複合腰部硬膜外置管的4298例胸外科手術病人的神經併發症的發生率進行了評價。硬膜外置管的時間為麻醉誘導後、氣管插管後或者手術結束至蘇醒之間。其中大部分病人硬膜外置管的目的僅僅是為了術後鎮痛(4220, 98.2%),只有少部分病人用其進行手術麻醉(78 1.8%)。有4239 (98.6%)例病人僅通過硬膜外導管給予阿片類藥物,其餘的病人56 (1.3%)則通過硬膜外導管給予局麻藥或局麻藥複合阿片類藥物。有92.2% 的病人鎮痛效果評價為優。副作用的發生分別為: 鎮靜455 (10.6%)、噁心或嘔吐328 (7.6%)、瘙癢116 (2.7%)、呼吸抑制(pH <=7.3 and PaCO2 >=50 mm Hg) 308(7.2%)。沒有發生脊髓血腫、硬膜外膿腫、導管部位的感染、根刺激綜合征或持續性感覺異常等神經併發症(95% 可信區間是0%0.08%)。一例病人在拔管時發生硬膜外導管斷裂,未取出斷裂的導管,長時間觀察未發現不良後果。有6例出現與硬膜外導管無關的神經併發症或原來的神經病理症狀惡化。結論:全麻病人應用硬膜外阻滯技術時發生與腰部硬膜外置管有關的神經併發症的危險性是非常小的。但是,對清醒病人應用這種技術的危險性仍應進一步評價。

(王士雷 譯  莊心良 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.

 

在冠狀動脈搭橋術後不久行胸骨切除術發生的圍手術期心肌缺血

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.

應用冠狀動脈搭橋術恢復冠狀動脈血流可以減少嚴重冠狀動脈心臟病患者非心臟手術時的心臟併發症。然而,在冠狀動脈術後不久就進行急症非心臟外科手術的病人仍然容易發生心肌缺血。我們前瞻性地研究了在冠狀動脈搭橋術後第一周 (1; n35)和第二周( 2;n 47)進行sternectomy 手術的病人心肌缺血的發生率。二組病人進行冠狀動脈搭橋術和sternectomy 術之間的間隔時間分別是47天(平均6天)和11天(平均8-14天)。應用雙頻道Holter記錄48小時內的心電圖變化以瞭解心臟缺血的發生情況。二組病人的急性生理和慢性健康狀況評分、ß-阻滯劑的應用情況以及圍手術期血流動力學變化的程度無差別。組1病人心肌缺血的發生率較組2病人高5(22.85% 4.25%; P < 0.05)。在組1發生心肌缺血的病人中,有25%發生急性圍手術期心肌梗死(1例死亡),而在組2病人中沒有發生心肌梗死。儘管如此,仍不清楚冠狀動脈搭橋手術後不久發生的心肌缺血是否與非心臟手術有關,對此需要進一步研究。

(王士雷 譯 莊心良 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.


經胸心臟超聲結合經食道心臟超聲在經導管對前緣變薄的房間隔缺損封閉術中的應用——一組病例報導

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.

經食道心超(TEE)在經導管行房間隔缺損(ASD)封閉術中越來越常用。前緣變薄的ASD是變異的ASD,更適合於經導管封閉。TEE在這些手術中的成功率還不清楚,因此,我們評估了在TEE指導下,用Amplatzer封閉器行房間隔缺損封閉的124例病人。結果顯示57 secundum型房間隔缺損TEE均能清楚顯示Amplatzer盤的4個角及相應的邊緣。然而,67例前緣變薄中6例(9%TEE不能顯示封閉器在前緣的位置。而結合經胸心超能有助於解決這個問題。6例病人中4例前緣具有異常的形態,2例心臟右軸偏移,Q波大於90067例前緣變薄中35例缺少SA邊緣,這些病人TEE顯示盤的前緣接觸主動脈壁但未扭曲。我們證實TEE在大部份ASD病人中有作用,而對伴有前緣變薄的房間隔缺損一小部分病人,則需要TEE結合經胸心超。

                                     (王立中 譯   莊心良 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.

兒童門診鼓膜切開術和放置平衡導管後的鎮痛

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.

本研究對行雙側鼓膜切開術和放置平衡導管的120例兒童行隨機、雙盲觀察。病人分4組,1組(對照組)口服對乙酰氨基酚10 mg/kg2組乙酰氨基酚10 mg/kg加口服可待因1 mg/kg3組麻醉誘導後立即經鼻給布托啡諾25 µg/kg4組麻醉誘導後立即肌注酮咯酸1 mg/kg。所有兒童術前均口服咪唑安定0.6 mg/kg。由一位元不知道分組情況的護土用4分表法評估病兒在麻醉誘導後及麻醉後監測病房期的行為。每隔5 min用稍作修改的10分客觀疼痛評分表確定鎮痛效果。當疼痛評分大於4分或行為評分大於3分時,給予額外的鎮痛藥。結果顯示在這些病人中肌注酮咯酸是最有希望的鎮痛藥,離首次給額外鎮痛藥的時間最長,術後沒有噁心和嘔吐。

 

                                 (王立中 譯   莊心良 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能預測電抽搐療法後癲癇發作時間和蘇醒嗎?

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指標能反映麻醉的鎮靜程度和蘇醒情況,因此我們假設BIS能預測電抽搐療法(ECT)後癲癇發作時間和從甲乙炔巴比妥麻醉中的蘇醒時間。25例嚴重抑鬱症患需100次維持ECT的病人同意本試驗。所有病人ECT前靜注胃長寧0.2 mg ,靜注甲乙炔巴比妥1 mg/kg行麻醉誘導。持續監測BIS,並在特定時間點記錄數值,包括麻醉前(基礎值)、麻醉誘導後(ECT前)、ECT結束時(峰值)、ECT後(抑制)、蘇醒(睜眼)。ECTBIS值與運動(r = 0.3)EEG(r = 0.4)癲癇樣發作時間有關(P < 0.05),峰值BISEEG癲癇樣發作時間有關(r = 0.5)(P < 0.05)EEG癲癇樣發作時間與到睜眼時間也呈正相關(r = 0.4) (P < 0.05)。然而,蘇醒時BIS值的變化較大,從29 97,且75%少於60。結論:ECT前應用BIS能預測癲癇發作時間,但蘇醒時BIS值變化較大,提示其既能反映麻醉藥殘餘鎮靜作用,又能反映post-ictal的抑制。

 

                                   (王立中 譯  莊心良  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.


 

蘇醒期異丙酚的效應室濃度與芬太尼的效應室濃度無關

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.

 

芬太尼能夠降低預防手術刺激所需的異丙酚用量。然而,阿片類基本上不影響神智。本研究旨在證實芬太尼不影響蘇醒期異丙酚的效應室濃度。50例女性患者在異丙酚麻醉下行開腹婦科手術,隨機分為5組,術後早期繼續使用芬太尼,其效應室靶濃度分別為0.8, 1.0, 1.4, 2.0, 3.0 ng/mL。給予口頭指令後睜眼的異丙酚的效應室濃度為蘇醒濃度。預計的異丙酚蘇醒期的效應室濃度在各組中無顯著差異,分別為1.9 ± 0.5 µg/mL (芬太尼的效應室濃度為0.8 ng/mL; 1.6 ± 0.4 µg/mL (芬太尼為 1.0 ng/mL; 1.6 ± 0.2 µg/mL (芬太尼為 1.4 ng/mL ; 1.7 ± 0.4 µg/mL (芬太尼為 2.0 ng/mL );  1.6 ± 0.34 µg/mL(芬太尼為 3.0 ng/mL)(平均值±標準差)。芬太尼0.8 ng/mL70%的患者訴痛,而2.03.0 ng/mL組無人訴痛。3.0 ng/mL9例中5例(56%)術後呼吸頻率低於6/分,其中1例心率低於40/分。上述資料提示婦科腹腔鏡術後蘇醒期芬太尼的最佳效應室濃度在1.4 2.0ng/mL間。結論:蘇醒期異丙酚的效應室濃度與芬太尼的效應室濃度(0.8 3.0 ng/mL)無關。然而,0.8 ng/mL芬太尼術後鎮痛效果欠佳,3.0 ng/mL芬太尼引起呼吸抑制。因此,異丙酚全麻下行婦科開腹手術,術後蘇醒期芬太尼的最佳效應室濃度應該接近2.0 ng/mL

                                    (軒泓 譯    莊心良 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.

 

布比卡因抑制人類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.

人類TWIK相關性鉀通道(TREK-1)穩定神經元膜電位,在膜興奮性調節中起主要作用,布比卡因與其相互作用可能有重要的臨床意義。本文以TREK-1轉染的中華倉鼠卵細胞(CHO TREK-1)為物件,用膜片鉗技術,研究TREK-1的特點和布比卡因的作用。轉染TREK-1使CHO的膜電位從-33 ± 13 mV 超極化到-78 ± 4 mV。細胞內酸中毒使TREK-1開放。布比卡因對TREK-1的抑制作用呈可逆性,濃度依賴性和電壓依賴性,並隨細胞內酸中毒而加劇。布比卡因使CHO TREK-1的膜電位去極化,呈可逆性和濃度依賴性。抑制濃度與膜去極化濃度呈非線性相關,抑制TREK-150%抑制濃度是370±20µMHill係數是1.8±0.1n=51;膜去極化的50%抑制濃度是856±14µMHill係數是2.4±0.1(平均值±標準誤),n=27。上述結果提示質子化布比卡因通過細胞內作用位點產生影響。結論:布比卡因抑制TREK-1通道,繼而使胞膜去極化,可能是區域麻醉時阻滯神經信號傳導的原因。

                                       (軒泓 譯 莊心良 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

 

隔熱法和強力空氣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.

 

由於圍術期低溫常造成嚴重後果,術中保溫已經成為一種工作常規。本研究目的是評價一種新的碳纖隔熱系統的效果。24例開腹手術病人(手術持續時間約為4小時),隨機採用以下措施進行保溫:(142°C的迴圈水褥;(2)從高處的吹風機向下身吹氣的空氣保暖法;(342°C的三端碳纖隔熱毯。麻醉方式採用全麻複合連續硬膜外麻醉。所有輸入的液體都加熱到37°C,環境溫度則維持在22°C。組間中心體溫(測鼓膜溫度)的差異用方差分析和F檢驗進行統計學處理。各組之間影響體溫的因素無差別。結果顯示,在手術最初的2小時,迴圈水褥組中心溫度下降1.9°C ± 0.5°C,空氣保暖組中心溫度下降1.0°C ± 0.6°C,碳纖隔熱毯組中心溫度下降 0.8°C ± 0.2°C 。在手術結束時,三組病人中心溫度下降的幅度分別是2.0°C ± 0.8°C 0.6°C ± 1.0°C0.5°C ± 0.4°C 。用迴圈水褥的病人在150分鐘後的各時間點的中心體溫都顯著降低,而空氣保暖組和碳纖隔熱毯組病人各時間點的中心體溫均沒有顯著變化。結論:碳纖隔熱毯組的保溫效果和空氣保暖組一樣好。

 

                           (王士雷    莊心良 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.

 

唑尼沙胺對實驗性單神經痛大鼠溫度和機械疼痛過敏的作用

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.

我們對唑尼沙胺減輕慢性縮窄性神經壓迫疼痛模型的溫度和機械疼痛過敏的作用進行了研究。在CCI術後456天分別經腹腔注射唑尼沙胺(25 50100 mg/kg)或生理鹽水,記錄CCI術前和術後4569天動物熱和機械刺激時爪撤退的潛伏期。結果,唑尼沙胺以劑量依賴性的方式減輕熱引起的疼痛過敏。除應用唑尼沙胺100 mg/kg後第5天的檢查結果外,所有應用唑尼沙胺組大鼠爪撤退的潛伏期均較用藥前延長。唑尼沙胺100 mg/kg使術後5天和9天時的撤退潛伏期顯著延長,與小劑量相比,其這種作用有連續性。然而,除100mg/kg外,其餘劑量的唑尼沙胺對機械疼痛過敏影響較小。唑尼沙胺100 mg/kg使術後4天和5天時大鼠撤退潛伏期延長,使術後4,56天時的疼痛評分降低。唑尼沙胺50 mg/kg 25 mg/kg 降低疼痛評分的作用是不連續的。結論:唑尼沙胺能以劑量依賴性的方式降低神經疼痛大鼠對熱的敏感性,但僅在達到鎮靜劑量時才能減輕大鼠對機械刺激的敏感性。本研究提示,唑尼沙胺對某些神經痛疾病可能是有效的治療方法。

                                    (王士雷 譯   莊心良  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.


聯合應用加壓素和腎上腺素使延遲心肺復蘇的豬神經功能完全恢復

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:評價聯合應用加壓素和腎上腺素對延遲心肺復蘇的豬神經功能恢復的效果。方法:豬心臟驟停後4分鐘進行3分鐘的基礎生命支持,隨後每5分鐘聯合用加壓素/腎上腺素〔加壓素(IU/kg/腎上腺素(µg/kg):0.4/45, 0.4/45, and 0.8/45; n = 6〕、單用腎上腺素(45, 45, and 200 µg/kg; n = 6)或生理鹽水(n5)。在心臟驟停後22分鐘(其中包括18分鐘的心肺復蘇),應用電除顫技術以恢復豬的自主心臟跳動。結果:豬主動脈舒張壓在每次聯合應用腎上腺素/加壓素後的90秒均高於單獨用腎上腺素或用生理鹽水(分別為: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頭聯合應用加壓素和腎上腺素的豬均恢復了自主心臟跳動,而單用腎上腺素的6頭豬和6頭用生理鹽水豬中的5頭死亡。聯合應用加壓素和腎上腺素復蘇的6頭豬在復蘇後24小時表現為步態不穩,但5天後神經功能均恢復正常。結論:在延遲心肺復蘇的豬模型,重複應用加壓素和腎上腺素,而不是單用腎上腺素和生理鹽水,可以使豬長期存活且神經功能完全恢復。

 

                                    (王士雷 譯  莊心良 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.


評估全身麻醉行機械通氣時喉管的應用

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.

喉管是進行氣道管理的一種新型聲門上通氣設備,經過改良可安全用於自發呼吸或機械通氣。本研究期望明確在進行機械通氣的常規手術應用喉管做最初氣道管理的有效性。選擇期手術的175名患者,ASA分級1-II級。常規誘導後插入4號喉管,測定氧飽和度、呼末CO2和異氟醚濃度和手術進程中每5分鐘測定肺通氣量。應用定容呼吸機。記錄需插入喉管的次數和時間。96.6%的患者在整個手術進程能維持氧濃度、通氣和呼吸力學的平穩。結論:喉管是擇期手術應用機械通氣的患者安全且有效氣道管理的通氣器具。

                         (趙雪蓮        莊心良  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.

      

不同程度的低溫對無手術創傷刺激的麻醉病人凝血功能的影響

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.

低溫對凝血功能的單獨作用在健康人群中尚未見研究。在誘導後至手術開始前這段時間,我們將16例擇期行顱內手術的麻醉病人的中心體溫降至32°C,並分別測定病人在363432°C時的凝血酶原時間(PT)、部分啟動凝血酶原時間、血栓彈性描記圖(TEG)、凝血時間和血小板計數。部分啟動凝血酶原時間、紅細胞壓積和凝血時間沒有變化,而凝血酶原時間和血小板計數則在降溫中有所下降。血小板計數下降而紅細胞壓積沒有下降,因此不像是由於液體的稀釋引起的。對於血小板計數和功能正常的病人,血小板數量的小幅下降可能臨床意義不大。凝血酶原時間的輕度縮短提示外源性凝血途徑的改變。血栓彈性容積描記圖的結果表明在溫度校正時有血凝塊形成的延遲,但當測試溫度為37°C時,則沒有變化。這提示低溫降低了血漿的凝集和血小板的反應性。但是,凝集的強度並為被低溫所改變。所有的凝血功能參數值均保持在正常範圍之內。我們的結果可以提示對健康人來說,中度的短期(4h)低溫僅有微小的副作用。我們無法對更長時間的低溫所產生的效應做出判斷。結論:本研究探討了低溫在健康麻醉病人中的單獨作用。我們發現體溫降至32°C時對凝血功能參數的影響甚微,提示在別的健康人中影響不大。

(黃施偉 譯 莊心良 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.

 

小膠質細胞、星形膠質細胞和巨噬細胞在兔脊髓缺血後延遲發生的運動功能障礙中的作用
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.

本研究目的是評價小膠質細胞、星形膠質細胞和巨噬細胞在兔脊髓缺血(15分鐘)後延遲發生的運動功能障礙中的作用。在兔脊髓再灌注後2, 4, 8, 12, 24 48 h n9),評價後肢的運動功能,並進行脊髓組織學檢查。結果表明,大多數動物在脊髓缺血後48h發生遲發性運動功能障礙,而再灌注15min時的脊髓誘發電位恢復不良能預測這種功能障礙。不論脊髓誘發電位恢復如何,在腰髓的灰質,小膠質細胞和星形膠質細胞都會在再灌注後2h啟動。相比較而言,星形膠質細胞的啟動早期僅局限在發生退變的神經周圍。巨噬細胞最早在再灌注後8h被發現,主要圍繞在以後發生梗死的區域。儘管尚不明確小膠質細胞、 星形膠質細胞和巨噬細胞啟動後的確切作用,此研究結果仍然提示,星形膠質細胞在遲發性運動功能障礙的發生方面可能有非常重要的作用。

                                 (王士雷 譯  莊心良 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.

 

硬膜外芬太尼稀釋量對分娩早期止痛效果的影響

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.

硬膜外利多卡因加腎上腺素試驗劑量之後給予芬太尼可以給分娩早期的產婦提供合適的鎮痛且不影響行走。我們設計此項試驗試圖確定硬膜外芬太尼稀釋量對效果的影響(如鎮痛的起效和持續時間)。60例初產婦在硬膜外3ml利多卡因加腎上腺素的試驗劑量後給予100µg芬太尼,容量分別為21020ml。記錄每例病人的疼痛評分和副作用。三組之間鎮痛的起效時間相似。再次給藥之前的持續時間組間沒有明顯差別,分別為:2ml組(108 ± 40 min),10ml(126 ± 57 min)20ml(126 ± 41 min)。各組均無病人有明顯可見的運動阻滯;1例病人(2ml組)稱有輕度的膝部無力,未讓其行走。在分娩早期的產婦中,硬膜外給予100µg芬太尼(在利多卡因加腎上腺素試驗劑量之後),其容量對鎮痛起效和持續時間無影響,也不影響其行走能力。

結論:在分娩早期的產婦中,硬膜外給予100µg芬太尼(在利多卡因加腎上腺素試驗劑量之後),其容量對鎮痛起效和持續時間無影響。

 

                                    (黃施偉 譯,莊心良 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.