Anesthesia & Analgesia

September 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

非心臟手術患者的心肌保護�� 一個數量系統評價

(趙雪蓮 譯 莊心良 校)

Pharmacologic Myocardial Protection in Patients Undergoing Noncardiac Surgery: A Quantitative Systematic Review

Robert D. Stevens, Haran Burri, and Martin R. Tramèr

Anesth Analg 2003 97: 623-633.

鈣通道阻滯劑(CCB)減少非心臟手術後心臟發病率的作用--Meta分析

(陸旭偉 譯 薛張綱 校)

Calcium Channel Blockers for Reducing Cardiac Morbidity After Noncardiac Surgery: A Meta-Analysis

Duminda N. Wijeysundera and W. Scott Beattie

Anesth Analg 2003 97: 634-641.

經食道超聲心動圖的兩種不同測量左室射血時間方法的評估

(殷文淵 譯 王祥瑞 校)

An Assessment of Two Different Methods of Left Ventricular Ejection Time Measurement by Transesophageal Echocardiography

Madhav Swaminathan, Barbara G. Phillips-Bute, and Joseph P. Mathew

Anesth Analg 2003 97: 642-647.

原位肝移植術中食道超聲引導下經皮頸內靜脈旁路置管

(黃施偉 譯,莊心良 校)

Transesophageal Echocardiography-Guided Placement of Internal Jugular Percutaneous Venovenous Bypass Cannula in Orthotopic Liver Transplantation

Raymond M. Planinsic, Ramona Nicolau-Raducu, John C. Caldwell, Shushma Aggarwal, and Ibtesam Hilmi

(Technical Communication)

Anesth Analg 2003 97: 648-649.

PEDIATRIC ANESTHESIA:

小兒中應用一次性注射泵進行圍手術期持續性周圍神經阻滯(CPNB)--前瞻描性研究

(陸旭偉 譯 薛張綱 校)

Perioperative Continuous Peripheral Nerve Blocks with Disposable Infusion Pumps in Children: A Prospective Descriptive Study

Christophe Dadure, Philippe Pirat, Olivier Raux, Rachel Troncin, Alain Rochette, Christine Ricard, and Xavier Capdevila

Anesth Analg 2003 97: 687-690.

ANESTHETIC PHARMACOLOGY:

吸入麻醉藥和制動:機制、疑惑和最低肺泡有效濃度

(王士雷譯 莊心良校)

Inhaled Anesthetics and Immobility: Mechanisms, Mysteries, and Minimum Alveolar Anesthetic Concentration (Review Article)

James M. Sonner, Joseph F. Antognini, Robert C. Dutton, Pamela Flood, Andrew T. Gray, R. Adron Harris, Gregg E. Homanics, Joan Kendig, Beverley Orser, Douglas E. Raines, James Trudell, Bryce Vissel, and Edmond I Eger, II

Anesth Analg 2003 97: 718-740.

狗大腦膜傷害/Orphanin FQ(N/OFQ)結合位點的特點

(陸旭偉 譯 薛張綱 校)

Characterization of Nociceptin/Orphanin FQ Binding Sites in Dog Brain Membranes (Review Article)

Emma E. Johnson, Helen Gibson, Beverley Nicol, Johannes Zanzinger, Peter Widdowson, Mark Hawthorn, Géza Toth, Judit Farkas, Remo Guerrini, and David G. Lambert

Anesth Analg 2003 97: 741-747.

硬膜外可樂定對老鼠壓力感受器交感神經反應的抑制依賴異氟醚濃度

(殷文淵 譯 王祥瑞 校)

Epidural Clonidine Suppresses the Baroreceptor-Sympathetic Response Depending on Isoflurane Concentrations in Cats (Review Article)

Yoshikazu Ikeda, Kiyonobu Nishikawa, Kenji Ohashi, Takashi Mori, and Akira Asada

Anesth Analg 2003 97: 748-754.

咪達唑倫可引起狗疲勞膈肌的功能障礙並影響其恢復

(趙雪蓮 譯 莊心良 校)

Midazolam-Induced Muscle Dysfunction and Its Recovery in Fatigued Diaphragm in Dogs (Review Article)

Yoshitaka Fujii, Aki Uemura, and Hidenori Toyooka

Anesth Analg 2003 97: 755-758.

多沙普侖可使兔顫閾降低並呈劑量相關性

(梁雅芬 譯 薛張綱 校)

Doxapram Produces a Dose-Dependent Reduction in the Shivering Threshold in Rabbits (Review Article)

Katsumi Okuyama, Takashi Matsukawa, Makoto Ozaki, Daniel I. Sessler, Tomoki Nishiyama, Makoto Imamura, and Teruo Kumazawa

Anesth Analg 2003 97: 759-762.

2-Bromomelationin的催眠和鎮痛效應

(齊 波 譯 王祥瑞 校)

The Hypnotic and Analgesic Effects of 2-Bromomelatonin (Review Article)

Mohamed Naguib, Max T. Baker, Gilberto Spadoni, and Marc Gregerson

Anesth Analg 2003 97: 763-768.

TECHNOLOGY, COMPUTING, AND SIMULATION:

大腦半球同步化聲和術中麻醉的需求

(王立中 莊心良 校)

Hemispheric Synchronized Sounds and Intraoperative Anesthetic Requirements

Susan Dabu-Bondoc, Jacqueline Drummond-Lewis, Dorothy Gaal, Maryanne McGinn, Alison A. Caldwell-Andrews, and Zeev N. Kain

Anesth Analg 2003 97: 772-775.

胸科手術麻醉時經皮CO2與呼氣末CO2監測的評估比較

(梁雅芬 譯 薛張綱 校)

A Comparative Evaluation of Transcutaneous and End-Tidal Measurements of CO2 in Thoracic Anesthesia

Motoko Oshibuchi, Sungsam Cho, Tetsuya Hara, Shiro Tomiyasu, Tetsuji Makita, and Koji Sumikawa

Anesth Analg 2003 97: 776-779.

在複合全麻和硬膜外麻醉過程中麻黃素可增加病人的腦電雙頻指數,而新福林則不能

(齊 波 譯 王祥瑞 校)

Ephedrine, but Not Phenylephrine, Increases Bispectral Index Values During Combined General and Epidural Anesthesia

Tadahiko Ishiyama, Takeshi Oguchi, Tetsuya Iijima, Takashi Matsukawa, Satoshi Kashimoto, and Teruo Kumazawa

Anesth Analg 2003 97: 780-784.

PAIN MEDICINE:

定義神經病理性痛

(王士雷 譯 莊心良 校)

Defining Neuropathic Pain (Medical Intelligence)

Misha-Miroslav Backonja

Anesth Analg 2003 97: 785-790.

緩解疼痛可以改善慢性疼痛患者的行為和情緒嗎?

(王柯 譯 薛張綱 校)

Does Pain Relief Improve Pain Behavior and Mood in Chronic Pain Patients? (Medical Intelligence)

Sabine M. Sator-Katzenschlager, Andreas W. Schiesser, Sibylle A. Kozek-Langenecker, Gerhard Benetka, Gudrun Langer, and Hans-Georg Kress

Anesth Analg 2003 97: 791-797.

神經類固醇藥物的鎮痛作用:阿法沙龍和阿法多龍對嗎啡類鎮痛藥的增強作用的比較

(忻紀華 譯 王祥瑞 校)

Antinociceptive Properties of Neurosteroids: A Comparison of Alphadolone and Alphaxalone in Potentiation of Opioid Antinociception (Medical Intelligence)

L. Winter, R. Nadeson, A. P. Tucker, and C. S. Goodchild

Anesth Analg 2003 97: 798-805.

納布啡及其長效酯在大鼠中的抗傷害作用

(王士雷 譯 莊心良 校

The Antinociceptive Effect of Nalbuphine and Its Long-Acting Esters in Rats (Medical Intelligence)

Koung-Shing Chu, Jhi-Joung Wang, Oliver Yoa-Pu Hu, Shung-Tai Ho, and Yu-Wen Chen

Anesth Analg 2003 97: 806-809.

在辣椒素引起痛覺過敏的自願者中靜脈使用雷米芬太尼會產生撤藥性的痛覺過敏

王柯 譯 薛張綱 校)

Intravenous Remifentanil Produces Withdrawal Hyperalgesia in Volunteers with Capsaicin-Induced Hyperalgesia (Medical Intelligence)

David D. Hood, Regina Curry, and James C. Eisenach

Anesth Analg 2003 97: 810-815.

氟呱利多對嗎啡自控鎮痛病人的止吐作用:隨機,對照,多種劑量-效應的研究。

(忻紀華 譯 王祥瑞 校)

The Antiemetic Efficacy of Droperidol Added to Morphine Patient-Controlled Analgesia: A Randomized, Controlled, Multicenter Dose-Finding Study (Medical Intelligence)

Xavier Culebras, Jean-Baptiste Corpataux, Giovanni Gaggero, and Martin R. Tramèr

Anesth Analg 2003 97: 816-821.

術後鎮痛對手術免疫反應的影響

(黃施偉 譯,莊心良 校)

The Effects of Postoperative Pain Management on Immune Response to Surgery (Medical Intelligence)

Benzion Beilin, Yehuda Shavit, Evelyn Trabekin, Boris Mordashev, Eduard Mayburd, Alexander Zeidel, and Hanna Bessler

Anesth Analg 2003 97: 822-827.

定量的感覺測試能夠預測對於坐骨神經痛患者硬膜外注射類固醇

的效果嗎?初步研究

(王柯 譯 薛張綱 校)

Can Quantitative Sensory Testing Predict the Outcome of Epidural Steroid Injections in Sciatica? A Preliminary Study (Medical Intelligence)

Elad Schiff and Elon Eisenberg

Anesth Analg 2003 97: 828-832.

CRITICAL CARE AND TRAUMA:

燒傷病人換敷料時使用異丙酚自控鎮靜:劑量效應的研究

(朱 輝 譯 王祥瑞 校)

Patient-Controlled Sedation Using Propofol for Dressing Changes in Burn Patients: A Dose-Finding Study

Claudia Coimbra, Manon Choinière, and Thomas M. Hemmerling

Anesth Analg 2003 97: 839-842.

小劑量氯胺酮對腹部大手術後住ICU的病人嗎啡用量的影響

(王士雷 譯 莊心良 校)

The Effects of Small-Dose Ketamine on Morphine Consumption in Surgical Intensive Care Unit Patients After Major Abdominal Surgery

Nicolas Guillou, Michèle Tanguy, Philippe Seguin, Bernard Branger, Jean-Pierre Campion, and Yannick Mallédant

Anesth Analg 2003 97: 843-847.

NEUROSURGICAL ANESTHESIA:

等壓高氧狀態下測量大腦的氧合:腦外傷時使用組織微探子,近紅外線分光鏡及頸靜脈血氧測定三種技術的比較

(方芳 譯 薛張綱 校)

Measuring Cerebral Oxygenation During Normobaric Hyperoxia: A Comparison of Tissue Microprobes, Near-Infrared Spectroscopy, and Jugular Venous Oximetry in Head Injury

Andrew D. McLeod, Farrell Igielman, Clare Elwell, Mark Cope, and Martin Smith

Anesth Analg 2003 97: 851-856.

兔子模型中細胞間黏附分子-1(ICAM-1)的單克隆抗體在硬膜外的治療作用:細胞間黏附分子-1(ICAM-1)引起脊索缺血的機制

(鄧羽霄 譯 王祥瑞 校)

The Therapeutic Effects of Epidural Intercellular Adhesion Molecule-1 Monoclonal Antibody in a Rabbit Model: Involvement of the Intercellular Adhesion Molecule-1 Pathway in Spinal Cord Ischemia

Kamatham A. Naidu, Eugene S. Fu, E. Truitt Sutton, Leon D. Prockop, and Alan Cantor

Anesth Analg 2003 97: 857-862.

OBSTETRIC ANESTHESIA:

嚴重先兆子癇產婦腰麻分娩時低血壓的發生率少於健康產婦:前瞻性佇列研究

(王士雷 譯 莊心良 校)

Patients with Severe Preeclampsia Experience Less Hypotension During Spinal Anesthesia for Elective Cesarean Delivery than Healthy Parturients: A Prospective Cohort Comparison

Antoine G. M. Aya, Roseline Mangin, Nathalie Vialles, Jean-Michel Ferrer, Colette Robert, Jacques Ripart, and Jean-Emmanuel de La Coussaye

Anesth Analg 2003 97: 867-872.

在晚期分娩時鞘內注射25ug芬太尼合用2.5mg的重比重布比卡因與合用等比重布比卡因相比延長了鎮痛時間

(方芳 譯 薛張綱 校)

Hyperbaric Bupivacaine 2.5 mg Prolongs Analgesia Compared with Plain Bupivacaine When Added to Intrathecal Fentanyl 25 μg in Advanced Labor

Wendy H. L. Teoh and Alex T. H. Sia

Anesth Analg 2003 97: 873-877.

母白鼠暴露於可卡因下對新生白鼠心功能的影響

(朱 輝 譯 王祥瑞 校)

The Effect of Maternal Cocaine Exposure on Neonatal Rat Cardiac Function

Lena S. Sun, Shin Takuma, Rui Lui, and Shunichi Homma

Anesth Analg 2003 97: 878-882.

REGIONAL ANESTHESIA:

左旋布比卡因和布比卡因神經阻滯的起效時間、阻滯質量和持續時間

(王士雷 譯 莊心良 校)

Onset Time, Quality of Blockade, and Duration of Three-in-One Blocks with Levobupivacaine and Bupivacaine

Bernhard Urbanek, Andreas Duma, Oliver Kimberger, Gudrun Huber, Peter Marhofer, Michael Zimpfer, and Stephan Kapral

Anesth Analg 2003 97: 888-892.

家兔中肺對羅比卡因和左旋布比卡因的攝取

(方芳 譯 薛張綱 校)

Pulmonary Uptake of Ropivacaine and Levobupivacaine in Rabbits

Shigeo Ohmura, Akiko Sugano, Masayuki Kawada, and Ken Yamamoto

Anesth Analg 2003 97: 893-897.

非心臟手術患者的心肌保護�� 一個數量系統評價

Myocardial Protection in Patients Undergoing Noncardiac Surgery: A Quantitative Systematic Review

Robert D. Stevens, MD*, Haran Burri, MD, and Martin R. Tramer, MD DPhil*

*Division of Anesthesiology, Department APSIC (Anesthesiology, Pharmacology & Surgical Intensive Care) and Division of Cardiology, Geneva University Hospitals, Switzerland

Anesth Analg 2003 97: 623-633.

一些臨床實驗測試了不同的藥物是否能減低非心臟手術患者的術後心臟併發症。我們採用數量系統評估法對這些實驗結果進行了整理。從Medline, Embase, 和 Cochrane 資料庫搜索相關的隨機化的實驗,提取有關心肌缺血、心肌梗塞、30天心臟死亡率和不良反應的資料。 應用固定效應模型整和資料,以Peto 的差率(OR)和95%可信限(CI)numbers-needed-to-treat/harm (NNT/H)表達。選中的21個實驗含3646名患者:11個實驗使用ß受體阻滯劑(6種藥,866名患者),6個使用可樂定或米伐西醇(共614名患者),3 個應用地爾硫卓或維拉帕米(共121名患者)和應用硝酸甘油的一個實驗(有45名患者)。所有實驗均有一個應用安慰劑的對照。ß-受體阻滯劑能減少手術期間的缺血(7.6%: 20.2%安慰劑; OR 0.32 [95% CI, 0.17�0.58]; NNT 8) 2-受體激動劑只能減少手術期間的缺血(19.4% 32.8%; OR 0.47 [95% CI, 0.33�0.68]; NNT 7). ß-受體阻滯劑能降低發生心肌梗塞的危險(0.9% versus 5.2%; OR 0.19 [95% CI, 0.08�0.48]; NNT 23)但研究高危患者的實驗只有2個。 2-受體激動劑對心肌梗塞發生無明顯作用(6.1% versus 7.3%; OR 0.85 [95% CI, 0.62�1.14]). ß-受體阻滯劑能明顯降低因心臟死亡的危險( 3.9% : 0.8% OR 0.25 [95% CI, 0.09�0.73], NNT 32). 2-受體激動劑也能明顯減少其死亡率(2.3% : 1.1% OR 0.50 [95% CI, 0.28�0.91], NNT 83)。鈣通道阻滯劑和硝酸甘油沒有這些作用。最常見的副作用是心動過緩。24.5%應用ß-受體阻滯劑的患者發生心動過緩而對照組只有9.1% (OR 3.76 [95% CI, 2.45�5.77], NNH 6).

結論:在這些隨機對照研究的藥物中ß-受體阻滯劑、可樂定和米伐西醇能有效的預防非心臟手術患者的心臟方面的併發症。高危患者應用ß-受體阻滯劑最佳 。還需有效的研究來直接對比這些類藥的效應及確定其劑量、時效和預後。

(趙雪蓮 譯 莊心良 校)

A number of drugs have been tested in clinical trials to decrease cardiac complications in patients undergoing noncardiac surgery. To compare the results of these studies, we conducted a quantitative systematic review. Medline, Embase, and Cochrane databases were searched for randomized trials that assessed myocardial ischemia, myocardial infarction, 30-day cardiac mortality, and adverse effects. Data were combined using a fixed-effect model and expressed as Peto odds ratios (OR) with 95% confidence interval (CI) and as numbers-needed-to-treat/harm (NNT/H). Twenty-one trials involving 3646 patients were included: 11 trials using s-blockers (6 drugs; 866 patients), 6 clonidine or mivazerol (614 patients), 3 diltiazem or verapamil (121 patients), and 1 nitroglycerin (45 patients). All trials had an inactive control; there were no direct comparisons. s-blockers decreased ischemic episodes during surgery (7.6% versus 20.2% with placebo; OR 0.32 [95% CI, 0.17–0.58]; NNT 8) and after surgery (15.2% versus 27.9% with control; OR 0.46 [95% CI, 0.26–0.81]; NNT 8). 2-agonists decreased ischemia during surgery only (19.4% versus 32.8%; OR 0.47 [95% CI, 0.33–0.68]; NNT 7). s-blockers reduced the risk of myocardial infarction (0.9% versus 5.2%; OR 0.19 [95% CI, 0.08–0.48]; NNT 23) but only when 2 trials with high-risk patients were included. The effect of 2-agonists on myocardial infarction was not significant (6.1% versus 7.3%; OR 0.85 [95% CI, 0.62–1.14]). s-blockers significantly decreased the risk of cardiac death from 3.9% to 0.8% (OR 0.25 [95% CI, 0.09–0.73], NNT 32). 2-agonists significantly decreased the risk of cardiac death from 2.3% to 1.1% (OR 0.50 [95% CI, 0.28–0.91], NNT 83). For calcium channel blockers and nitroglycerin, evidence of any benefit was lacking. The most common adverse effect was bradycardia, which occurred in 24.5% of patients receiving a s adrenergic blocker versus 9.1% of controls (OR 3.76 [95% CI, 2.45–5.77], NNH 6).

 

原位肝移植術中食道超聲引導下經皮頸內靜脈旁路置管

Transesophageal Echocardiography-Guided Placement of Internal Jugular Percutaneous Venovenous Bypass Cannula in Orthotopic Liver Transplantation

Raymond M. Planinsic, MD, Ramona Nicolau-Raducu, MD, John C. Caldwell, MD, Shushma Aggarwal, MD, and Ibtesam Hilmi, MD

Department of Anesthesiology, University of Pittsburgh Medical Center, Pennsylvania

Anesth Analg 2003 97: 648-649.

在原位肝移植領域,靜脈旁路可以改善病人的存活率,降低發病率和死亡率。許多移植中心的標準做法是將經皮頸內靜脈旁路置管(PVVBC)作為靜脈血回路。置入如此大的PVVBC(18F)可能導致嚴重的併發症,因此在使用前需要得到確認。使用經食道超聲引導PVVBC的置入被描述為是有效且快速的方法,並可將與置管相關的可能的併發症降至最低。

結論:在原位肝移植術中,一根靜脈旁路套管被插入頸內靜脈作為靜脈血回流的通路。本文描述了應用經食道超聲可幫助置管並可將相關併發症降至最低。

(黃施偉 譯,莊心良 校)

Venovenous bypass has improved patient survival and decreased morbidity and mortality in the field of orthotopic liver transplantation. The standard at many transplant centers is the use of the internal jugular percutaneous venovenous bypass cannulae (PVVBC) for venous return to the patient. Placement of these large (18F) PVVBC may lead to several complications and requires confirmation before use. Use of transesophageal echocardiography, an effective and rapid method to guide placement of the PVVBC and minimize potential complications associated with insertion of the device, is described.

吸入麻醉藥和制動:機制、疑惑和最低肺泡有效濃度

Inhaled Anesthetics and Immobility: Mechanisms, Mysteries, and Minimum Alveolar Anesthetic Concentration (Review Article)

James M. Sonner, MD*, Joseph F. Antognini, MD, Robert C. Dutton, MD*, Pamela Flood, MD, Andrew T. Gray, MD PhD*, R. Adron Harris, PhD, Gregg E. Homanics, PhD||, Joan Kendig, PhD?, Beverley Orser, MD#, Douglas E. Raines, MD**, James Trudell, PhD?, Bryce Vissel, PhD, and Edmond I Eger, II, MD* Section Editor

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; Department of Anesthesiology, University of California, Davis, California; Columbia University, New York, New York; University of Texas, Austin, Texas; ||University of Pittsburgh, Pittsburgh, Pennsylvania; ?Stanford University, Palo Alto, California; #University of Toronto, Toronto, Canada; **Department of Anaesthesia, Harvard Medical School, Cambridge, Massachusetts; and Garvan Institute of Medical Research, Darlinghurst, Australia
Anesth Analg 2003 97: 718-740.

通過分子模型、基因工程、神經生理、神經藥理和動物實驗等方面的研究,我們對吸入麻醉藥通過對脊髓的作用產生制動的機制有了更好的瞭解。許多配體和電壓門控離子通道可能參與了MAC的調節,而一些特殊的氨基酸部位可能是調節部位。然而,通過在體實驗發現,一些受體或通道可能不參與調節全麻制動作用的調節,這包括GABAAAchK+5-HT3、阿片受體和2-受體激動劑等。其他如甘氨酸、NMDA、鈉通道等的作用,則需要進一步驗證。

(王士雷譯 莊心良校)

Studies using molecular modeling, genetic engineering, neurophysiology/pharmacology, and whole animals have advanced our understanding of where and how inhaled anesthetics act to produce immobility (minimum alveolar anesthetic concentration; MAC) by actions on the spinal cord. Numerous ligand- and voltage-gated channels might plausibly mediate MAC, and specific animo acid sites in certain receptors present likely candidates for mediation. However, in vivo studies to date suggest that several channels or receptors may not be mediators (e.g., -aminobutyric acid A, acetylcholine, potassium, 5-hydroxytryptamine-3, opioids, and 2-adrenergic), whereas other receptors/channels (e.g., glycine, N-methyl-D-aspartate, and sodium) remain credible candidates.


咪達唑倫可引起狗疲勞膈肌的功能障礙並影響其恢復

Midazolam-Induced Muscle Dysfunction and Its Recovery in Fatigued Diaphragm in Dogs

Yoshitaka Fujii, MD, Aki Uemura, MD, and Hidenori Toyooka, MD

Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba City, Ibaraki, Japan

Anesth Analg 2003;97:755-758

咪噠唑倫廣泛用於鎮靜和麻醉,它能減少非疲勞膈肌的收縮。然而,它對疲勞膈肌的作用可能是引起呼吸障礙的原因之一。因此,我們研究咪噠唑倫對疲勞膈肌的影響極其恢復。將狗分為三組每組8條。每組均用間歇性超強雙側電刺激引發膈肌疲勞,頻率為20-Hz刺激 30 min.膈肌疲勞後,組 I不用藥; II給予鎮靜劑量的咪噠唑倫 (0.1 mg · kg-1 · h-1);組 III給予麻醉劑量的咪噠唑倫 (0.5 mg · kg-1 · h-1) 。以跨膈壓 (Pdi) 和 整和電活動(Edi) 評估膈肌功能(收縮性和電活動性)。膈肌疲勞時, Pdi 在低頻刺激(20-Hz)時從基線值下降stimulation decreased from baseline values (P < 0.05),而高頻刺激無變化(100-Hz), and Edi 在每種刺激均無變化。隨著咪噠唑倫的輸注, 在組 II和組 III, Pdi在兩種刺激及 Edi 在 100-Hz 從疲勞時的值降低 (P < 0.05)。 Pdi 和 Edi的降低組 III比組 II 明顯(P < 0.05).。咪噠唑倫用藥60 min終止後,在 II, Pdi和Edi由咪噠唑倫引起的值(P < 0.05)恢復到疲勞值 。而組 III,咪噠唑倫引發的Pdi 和Edi值未發生變化 。因此,咪噠唑倫以劑量依賴性使狗的疲勞膈肌發生功能障礙,鎮靜劑量的咪噠唑倫不延遲其恢復,而麻醉劑量的咪噠唑倫無此作用。

結論:咪噠唑倫廣泛用於鎮靜和麻醉,能抑制狗疲勞膈肌的功能,並呈劑量依賴性。

(趙雪蓮 譯 莊心良 校)

Midazolam, widely used for sedation and anesthesia, decreases contractility in nonfatigued diaphragm; however, its effects on contractility in fatigued diaphragm that are implicated as a cause of respiratory failure have not been established. We therefore studied the effects of midazolam on diaphragm muscle function and recovery in fatigued diaphragm. Dogs were divided into three groups of eight each. In each group, diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at a frequency of 20-Hz stimulation for 30 min. When fatigue was established, Group I received no study drug; Group II was infused with a sedative dose (0.1 mg · kg-1 · h-1) of midazolam; and Group III was infused with an anesthetic dose (0.5 mg · kg-1 · h-1) of midazolam. We assessed diaphragm muscle function (contractility and electrical activity) by transdiaphragmatic pressure (Pdi) and integrated electrical activity of the diaphragm (Edi). In the presence of fatigue, Pdi at low-frequency (20-Hz) stimulation decreased from baseline values (P < 0.05), Pdi at high-frequency (100-Hz) stimulation did not change, and Edi to each stimulus did not change. With an infusion of midazolam, in Groups II and III, Pdi at both stimuli and Edi at 100-Hz stimulation decreased from fatigued values (P < 0.05). The decrease in Pdi and Edi was more in Group III than in Group II (P < 0.05). At 60 min after the cessation of midazolam administration, in Group II, Pdi and Edi recovered from midazolam-induced values (P < 0.05) and returned to fatigued values. In Group III, Pdi and Edi did not change from midazolam-induced values. We conclude that midazolam causes, in a dose-related manner, diaphragm muscle dysfunction in fatigued canine diaphragm and that at a sedative dose, but not at an anesthetic dose, midazolam does not delay its recovery.

大腦半球同步化聲和術中麻醉的需求

Hemispheric Synchronized Sounds and Intraoperative Anesthetic Requirements

Susan Dabu-Bondoc, MD*, Jacqueline Drummond-Lewis, MD*, Dorothy Gaal, MD*, Maryanne McGinn, MA*, Alison A. Caldwell-Andrews, PhD*, and Zeev N. Kain, MD*,,

Departments of *Anesthesiology, Pediatrics, and Child Psychiatry, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut

Anesth Analg 2003 97: 772-775.

大腦半球同步化最近被作為減少術前焦慮和術中麻醉藥、鎮痛藥用量的措施之一。本研究觀察HemisyncR聲對麻醉鎮靜深度的影響。在知情同意後,把全麻和門診病人分為二組,處理組給予HemisyncR(n = 31),對照組給空白磁帶(n = 29)。兩組的於預均在術前和術中。異丙酚麻醉為主,記錄誘導及維持所需異丙酚的劑量,BIS監測確保所有病人麻醉鎮靜一致。我們發現兩組間異丙酚的誘導(2.49 ± 0.59 mg/kg versus 2.60 ± 0.59 mg/kg; P = 0.48)及維持劑量(0.141 ± 0.02 mg · kg-1 · min-1 versus 0.146 ± 0.04 mg · kg-1 · min-1; P = 0.62)無差異,兩組病人焦慮程度無差異。結論:HemisyncR聲不影響全麻病人的鎮靜作用。

(王立中 莊心良 校)

Hemispheric synchronization is currently promoted as a treatment for preoperative anxiety and for reduction of intraoperative anesthetic and analgesic consumption. We designed this study to examine the effect of HemisyncR sounds on anesthetic hypnotic depth. After obtaining informed consent, we randomized subjects undergoing general anesthesia and outpatient surgery into two groups: the treatment group received HemisyncR sounds (n = 31), and the control group received a blank cassette tape (n = 29). Both groups received the intervention in the preoperative area and during the surgical procedure. Subjects underwent a propofol-based anesthetic regimen, and propofol doses required for the induction and maintenance of anesthesia were recorded. A bispectral index monitor was used to ensure that the hypnotic component of the anesthetic state was the same in all patients. We found no differences in the amount of propofol used during the induction of anesthesia (2.49 ± 0.59 mg/kg versus 2.60 ± 0.59 mg/kg; P = 0.48) or the maintenance of anesthesia (0.141 ± 0.02 mg · kg-1 · min-1 versus 0.146 ± 0.04 mg · kg-1 · min-1; P = 0.62) between the HemisyncR and control groups. We also found no differences between the HemisyncR group and the control group for participants with high state anxiety (P = not significant). We conclude that HemisyncR sounds do not reduce the hypnotic component of the anesthetic state of patients undergoing general anesthesia and surgery.

定義神經病理性痛

Defining Neuropathic Pain

Misha-Miroslav Backonja, MD

Departments of Neurology, Anesthesiology, and Rehabilitation Medicine, University of Wisconsin Medical School, University of Wisconsin, Madison

Anesth Analg 2003 97: 785-790.

作者建議根據神經病理性和炎症痛機制的差異對神經病理性痛進行定義。神經病理性痛發生在神經性疾病影響的區域,而且常在疼痛的同時伴有無力和麻木感。

(王士雷 譯 莊心良 校)

A practical definition of neuropathic pain based on the distinction between neuropathic and inflammatory pain mechanisms is suggested. Neuropathic pain is in this case is defined as pain occurring in an area of the body affected by neurological disease. In addition to pain, the patient is likely to have weakness and numbness at the same time.


納布啡及其長效酯在大鼠中的抗傷害作用

The Antinociceptive Effect of Nalbuphine and Its Long-Acting Esters in Rats

Koung-Shing Chu, MD*, Jhi-Joung Wang, MD DMS*, Oliver Yoa-Pu Hu, PhD, Shung-Tai Ho, MD, and Yu-Wen Chen, MS*

*Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan; Department of Research and Education, National Defense Medical Center, Taipei, Taiwan; and Department of Anesthesiology, Tri-Service General Hospital, Taipei, Taiwan

Anesth Analg 2003 97: 806-809.

患長時間持續性疼痛的病人非常需要長效鎮痛藥。本研究擬觀察三種納布啡酯-納布啡丙酸鹽、納布啡庚酸鹽和納布啡奎酸鹽的鎮痛效果和持續時間。每組12只SD大鼠進行二個研究。研究1評價肌注納布啡酯0.25, 1.25, 2.5, 25和250 μmol/kg 的抗傷害效果。研究2評價肌注25 μmol/kg納布啡酯的抗傷害作用。結果顯示,納布啡2.5, 25和250 μmol/kg 產生劑量依賴性的抗傷害作用,持續時間分別為1.5, 2和4 h 。肌注25μmol/kg納布啡丙酸鹽、納布啡庚酸鹽和納布啡奎酸鹽的抗傷害作用時間分別是5, 30和60 h。結論:在等摩爾分子的情況下,納布啡酯的抗傷害作用比納布啡鹽酸的時間長。

(王士雷 譯 莊心良 校

A long-acting analgesic is particularly desirable in patients with long-lasting pain. In this study, we evaluated the antinociceptive effect and duration of action of three nalbuphine esters—nalbuphine propionate, enanthate, and decanoate—and observed whether these esters had a long-acting effect. Male Sprague-Dawley rats (n = 12 in each group) were used. Two studies were performed. In Study 1, we evaluated the antinociceptive effect of IM nalbuphine HCl with dosages of 0.25, 1.25, 2.5, 25, and 250 μmol/kg. In Study 2, we evaluated the antinociceptive effects of IM nalbuphine base and esters with a dosage of 25 μmol/kg. After 2.5, 25, and 250 μmol/kg IM injections, we found that nalbuphine HCl produced a dose-related antinociceptive effect with durations of action of 1.5, 2, and 4 h, respectively. After a 25 μmol/kg IM injection, the durations of action of the nalbuphine esters, nalbuphine propionate, enanthate, and decanoate were 5, 30, and 60 h, respectively. We conclude that, on an equimolar basis, nalbuphine esters produce relatively longer durations of action than nalbuphine HCl.

術後鎮痛對手術免疫反應的影響

The Effects of Postoperative Pain Management on Immune Response to Surgery

Benzion Beilin, MD*, Yehuda Shavit, PhD, Evelyn Trabekin, MD, Boris Mordashev, MD*, Eduard Mayburd, MD*, Alexander Zeidel, MD*, and Hanna Bessler, PhD

*Department of Anesthesiology and Research Institute, Rabin Medical Center, Golda-Hasharon Campus, affiliated with the Sackler School of Medicine, Tel-Aviv University; Department of Anesthesiology, Schneider Children’s Medical Center, Petah Tiqva; and Department of Psychology, Hebrew University, Jerusalem, Israel

Anesth Analg 2003 97: 822-827

.

手術可引起免疫改變,可能是組織損傷、麻醉、術後疼痛以及心理應激的綜合作用。在本研究中,我們比較了不同術後鎮痛技術對術後免疫功能的影響。住院行腹部手術的病人隨機接受三種術後鎮痛技術中的一種:按需給予阿片類藥物(間歇性阿片類藥物治療(IOR)),病人自控鎮痛(PCA)以及病人自控硬膜外鎮痛(PCEA)。術後疼痛被評估。手術前及術後24、48和72小時時進行血樣採集。分別測定IL-1ß、IL-2、和IL-6的水平,NK細胞的細胞毒性以及淋巴細胞的分裂反應。同IOR和PCA組相比,PCEA組病人術後24小時疼痛評分較低。淋巴細胞分裂反應在起初的24小時各組均被抑制,PCEA組在72小時恢復到術前水平,而PCA組仍保持抑制。IL-1ß 和 IL-6的量在IOA和PCA組有增加,而PCEA組則幾無變化。硬膜外混合應用阿片類藥和局麻藥可減少術後病人淋巴細胞增殖功能的抑制並可減輕炎前細胞因數的反應。

結論:本研究比較了三種鎮痛技術(間斷阿片類藥物治療,病人自控鎮痛,病人自控硬膜外鎮痛)對一些免疫功能的影響。病人自控硬膜外鎮痛組的病人表現出疼痛減輕、對淋巴細胞分裂反應抑制的降低以及手術引起炎前細胞因數反應的緩解。

(黃施偉 譯,莊心良 校)

Surgery is associated with immune alterations, which are the combined result of tissue damage, anesthesia, postoperative pain, and psychological stress. In the present study, we compared the effects of several postoperative pain management techniques on postoperative immune function. Patients hospitalized for abdominal surgery were randomly assigned to one of three postoperative pain management techniques: opiates on demand (intermittent opiate regimen [IOR]), patient-controlled analgesia (PCA), and patient-controlled epidural analgesia (PCEA). Postoperative pain was assessed. Blood samples were collected before and 24, 48, and 72 h after surgery. Production of interleukin (IL)-1s, IL-2, and IL-6, natural killer cell cytotoxicity, and lymphocyte mitogenic responses were assessed. Patients of the PCEA group exhibited lower pain scores in the first 24 h after surgery compared with patients of the IOR and PCA groups. Mitogenic responses were suppressed in all groups in the first 24 h, returned to preoperative values by 72 h in the PCEA group, but remained suppressed in the PCA group. Production of IL-1s and IL-6 increased in the IOR and PCA groups, whereas it remained almost unchanged in the PCEA group. Patients receiving an epidural mixture of opiate and local anesthetics (PCEA group) exhibited reduced suppression of lymphocyte proliferation and attenuated proinflammatory cytokine response in the postoperative period.

 

小劑量氯胺酮對腹部大手術後住ICU的病人嗎啡用量的影響

The Effects of Small-Dose Ketamine on Morphine Consumption in Surgical Intensive Care Unit Patients After Major Abdominal Surgery

Nicolas Guillou, MD*, Michele Tanguy, MD*, Philippe Seguin, MD*, Bernard Branger, MD, Jean-Pierre Campion, MD, and Yannick Malledant, MD*

*Surgical Intensive Care Unit, Biostatistical Unit, and Surgical Unit, Hopital Pontchaillou, Rennes, France

Anesth Analg 2003 97: 843-847.

本研究評價氯胺酮對腹部大手術後住ICU的病人的鎮痛效果。病人隨機應用嗎啡複合安慰劑自控鎮痛或嗎啡複合氯胺酮自控鎮痛。嗎啡的負荷劑量為2mg,每次按壓劑量為1mg,鎖定時間為7min。氯胺酮初始量為0.5mg/kg,第一個24h以2 μg · kg-1 · min-1 速度輸注,以後按1 μg · kg-1 · min-1 的速度輸注。記錄48h內每4h的嗎啡累積用量和VAS評分。結果,無論在運動或是在休息的情況下,VAS數值均很小。氯胺酮組嗎啡的用量顯著小於對照組。結論:小劑量氯胺酮是腹部大手術後住ICU病人嗎啡自控鎮痛的很有價值的輔助藥。

(王士雷 譯 莊心良 校)

In a randomized, double-blinded study, we evaluated the analgesic effect of ketamine in the management of pain in a surgical intensive care unit after major abdominal surgery. Patients received morphine patient-controlled analgesia with either placebo (Group M) or ketamine (Group K). Morphine was administered with initial loading doses of 2 mg until the visual analog scale (VAS) score was <30 and thereafter with bolus doses of 1 mg and a lockout time of 7 min. Ketamine was administered with an initial bolus of 0.5 mg/kg followed by a perfusion of 2 μg · kg-1 · min-1 during the first 24 h and 1 μg · kg-1 · min-1 during the following 24 h. The 4-h cumulative morphine doses were measured over 48 h. The VAS scores at rest and at The mobilization were measured every 4 h during 48 h. A total of 101 patients were enrolled, and 93 were analyzed (41 in Group K and 52 in Group M). VAS scores at rest and at mobilization were similar. cumulative consumption of morphine was significantly smaller in Group K (P < 0.05). We concluded that small doses of ketamine were a valuable adjunct to opioids in surgical intensive care unit patients after major abdominal surgery.

嚴重先兆子癇產婦腰麻分娩時低血壓的發生率少於健康產婦:前瞻性佇列研究

Patients with Severe Preeclampsia Experience Less Hypotension During Spinal Anesthesia for Elective Cesarean Delivery than Healthy Parturients: A Prospective Cohort Comparison

Antoine G. M. Aya, MD PhD, Roseline Mangin, MD MSc, Nathalie Vialles, MD, Jean-Michel Ferrer, MD, Colette Robert, MD, Jacques Ripart, MD PhD, and Jean-Emmanuel de La Coussaye, MD PhD

Division of Anesthesiology, Pain Management, Emergency and Critical Care Medicine, University Hospital, Nimes, France

Anesth Analg 2003 97: 867-872.

本研究比較嚴重先兆子癇和健康產婦剖宮產時與腰麻有關的低血壓的發生率。在靜脈輸注液體後,用重比重0.5%布比卡因-蘇芬太尼-嗎啡進行腰麻。在注藥前以及注藥後30min內每2分鐘記錄血壓。臨床有意義的低血壓以應用麻黃素為標準(產婦血壓降低基礎值的30%以上或健康產婦體循環血壓<100 mm Hg)。儘管先兆制癇產婦較健康產婦輸液量少((1653 ± 331 mL對 1895 ± 150 mL; P = 0.005),布比卡因用量多(10.5 ± 0.9對10.0 ± 0.7 mg; P = 0.019),但是,其低血壓的發生率低(16.6%對53.3%; P = 0.006),且低血壓程度較輕,需要麻黃素的量少。嚴重先兆子癇的產婦發生低血壓的危險性比健康產婦少6倍。

(王士雷 譯 莊心良 校)

In this prospective cohort study, we compared the incidence and severity of spinal anesthesia (SA)-associated hypotension in severely preeclamptic (n = 30) versus healthy (n = 30) parturients undergoing cesarean delivery. After the administration of IV fluids, SA was performed with hyperbaric 0.5% bupivacaine, sufentanil, and morphine. Blood pressure (BP) was recorded before and at 2-min intervals for 30 min after SA. Clinically significant hypotension was defined as the need for ephedrine (systolic BP decrease to <100 mm Hg in healthy parturients or 30% decrease in mean BP in both groups). Despite receiving a smaller fluid volume (1653 ± 331 mL versus 1895 ± 150 mL; P = 0.005) and a larger bupivacaine dose (10.5 ± 0.9 mg versus 10.0 ± 0.7 mg; P = 0.019), the severely preeclamptic patients had a less frequent incidence of clinically significant hypotension (16.6% versus 53.3%; P = 0.006), which was less severe and required less ephedrine. The risk of hypotension was almost six times less in severely preeclamptic patients (odds ratio, 0.17; 95% confidence interval, 0.05–0.58; P = 0.006) than that in healthy patients.

左旋布比卡因和布比卡因神經阻滯的起效時間、阻滯質量和持續時間

Onset Time, Quality of Blockade, and Duration of Three-in-One Blocks with Levobupivacaine and Bupivacaine

Bernhard Urbanek, MD, Andreas Duma, Oliver Kimberger, MD, Gudrun Huber, MD, Peter Marhofer, MD, Michael Zimpfer, MD MBA, and Stephan Kapral, MD

Department of Anesthesiology and General Intensive Care, University of Vienna, Vienna, Austria

Anesth Analg 2003 97: 888-892.

左旋布比卡因是消旋布比卡因的S(-)-立體異構體。在用於Three-in-One神經阻滯時其重要的藥效學特性還未被很好的認識。我們對60例ASA I�III行下肢手術的病人進行了研究。在神經刺激器的引導下穿刺並注射0.5%布比卡因、0.5%左旋布比卡因或0.25%羅呱卡因20ml。以針刺法確定股神經支配的中樞區域來確定感覺阻滯起效時間、阻斷質量和阻斷時間。神經阻滯等級評分通過其與對側的分值(100%(感覺正常)至0%(無感覺))計算。三組病人起效時間沒有差別,阻斷質量也無明顯不同,但0.25% 左旋布比卡因完全阻斷的例數較少(P = 0.02)。0.25% 左旋布比卡因的阻斷時間707 min (551�863 min)顯著少於0.5%布比卡因1053 min (802�1304 min)和0.5%左旋布比卡因1001 min (844�1158 min)。結論:0.5%左旋布比卡因可以代替0.5%布比卡因用於three-in-one神經阻滯。

(王士雷 譯 莊心良 校)

Levobupivacaine is the isolated S(-)-stereoisomer of racemic bupivacaine. Important pharmacodynamic properties of levobupivacaine have not been determined for the femoral three-in-one block. In this randomized, controlled, double-blinded trial, we studied 60 ASA physical status I–III patients scheduled for surgery of the lower limb. A nerve-stimulator-guided three-in-one block was performed as supplemental analgesic therapy with 20 mL of bupivacaine 0.5% (n = 20), levobupivacaine 0.5% (n = 20), or levobupivacaine 0.25% (n = 20). Sensory onset time, quality of blockade, and duration of blockade were assessed by pinprick test in the central sensory innervation region of the femoral nerve (distribution of the anterior femoral cutaneous nerve). A rating scale from 100% (normal sensation) to 0% (no sensation at all) as compared with the contralateral leg was used. No significant difference in sensory onset time among the three local anesthetic solutions was observed (mean [95% confidence interval]): bupivacaine 0.5%, 27 min (20–33 min); levobupivacaine 0.5%, 24 min (18–30 min); and levobupivacaine 0.25%, 30 min (23–36 min) (P = 0.49). The analgesic quality of the blockade was also not significantly different among the three groups, whereas a complete sensory block was achieved in significantly fewer patients in the levobupivacaine 0.25% group (P = 0.02). The duration of blockade was significantly shorter with levobupivacaine 0.25% compared with the other groups: bupivacaine 0.5%, 1053 min (802–1304 min); levobupivacaine 0.5%, 1001 min (844–1158 min); and levobupivacaine 0.25%, 707 min (551–863 min) (P = 0.01). Levobupivacaine 0.5% is recommended instead of bupivacaine 0.5% for the three-in-one block.

經食道超聲心動圖的兩種不同測量左室射血時間方法的評估

An Assessment of Two Different Methods of Left Ventricular Ejection Time Measurement by Transesophageal Echocardiography

Madhav Swaminathan, MD, Barbara G. Phillips-Bute, PhD, and Joseph P. Mathew, MD

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2003;97:642-647


左室射血時間(LVET)是評估左心室狀態的一個重要組成部分。這種測量方法通常依靠持續多普勒聲波測量某時經主動脈瓣的血流速率。雖然M型超聲也用來測量LVET,但它並((沒有與多普勒方法比較過。我們要試驗的假設是通過經食道超聲心動圖方法用M 型超聲測量主動脈瓣開放的持續時間與多普勒測量LVET具有可比性。對31名接受非主動脈瓣手術的病人中進行測量。持續多普勒聲波測定的某時經主動脈血流速率與M型測定的主動脈瓣開放時間相比較。M型超聲與多普勒之間具有很好的相關性(r=0.86;P<0.0001)。線性檢驗顯示兩種技術沒有顯著差別(P>0.1)。Bland-Altman分析顯示無偏倚。我們肯定了通過經食道超聲心動圖方法用M 型超聲測量主動脈瓣開放的持續時間與多普勒測量LVET具有可比性這一假設。M型超聲也許是一種可以選擇的多普勒發法,特別是當經瓣膜流速梯度不易獲得時。M 型超聲是一種簡單,但經常未利用的經食道超聲心動圖估算LVET的方法。

(殷文淵 譯 王祥瑞 校)

Left ventricular ejection time (LVET) is an important component in evaluating left ventricular performance. This measurement is usually made by measuring the timing of the transaortic valve flow velocity by continuous-wave Doppler. Although M-mode has also been used for measuring LVET, it has not been compared with the Doppler method. We tested the hypothesis that the M-mode-measured duration of aortic valve opening is comparable to Doppler-derived measurement of LVET by transesophageal echocardiography (TEE). Measurements were made in 31 patients undergoing nonaortic valve cardiac surgery. The timing of transaortic flow by continuous-wave Doppler was compared with the M-mode-derived timing of aortic valve opening. There was close correlation (Pearson correlation coefficient, r = 0.86; P < 0.0001) between M-mode and Doppler measurements. There was no significant difference between the two techniques by linearity tests (P > 0.1). Bland-Altman analysis showed no significant bias. We confirmed the hypothesis that M-mode-derived measurement of LVET is comparable to Doppler-derived measurement of LVET. M-mode may be an acceptable alternative to the Doppler method, especially when transvalvular velocity gradients cannot be readily obtained. M-mode is a simple, yet often underused, method of evaluating LVET during TEE.

硬膜外可樂定對老鼠壓力感受器交感神經反應的抑制依賴異氟醚濃度

Epidural Clonidine Suppresses the Baroreceptor-Sympathetic Response Depending on Isoflurane Concentrations in Cats

Yoshikazu Ikeda, MD*, Kiyonobu Nishikawa, MD*, Kenji Ohashi, MD, Takashi Mori, MD*, and Akira Asada, MD*

*Department of Anesthesiology and Intensive Care Medicine, Osaka City University Medical School, Osaka, Japan; and Department of Anesthesia, Hoshigaoka Kosei-nenkin Hospital, Osaka, Japan

Anesth Analg 2003;97:748-754


硬膜外使用可樂定會導致交感神經活動降低繼發的低血壓和心跳緩慢。在這個研究中,我們想要說明硬膜外可樂定引起的壓力反射的變化。36只老鼠被分為6組,在0.5,1.0或1.5個最小肺泡麻醉濃度(MAC)異氟醚麻醉下胸段硬膜外給予可樂定4 μg/kg或利多卡因2mg/kg。測量心率(HR),平均動脈壓(MAP)和心交感神經活動(CSNA)。降壓藥和升壓藥分別為靜脈注射硝酸甘油10 μg/kg和苯腎上腺素10 μg/kg。壓力反射通過相對於最大MAP變化的CSNA變化和HR變化來估計(分別為△CSNA/△MAP和△HR/△MAP)。這些測量結果在硬膜外藥物使用前和使用後30分鐘獲得。硬膜外使用可樂定和利多卡因降低MAP,CSNA和HR在近似的範圍內。所有組中降壓反應的△CSNA/△MAP和△HR/△MAP被硬膜外使用可樂定和利多卡因所抑制除了可樂定0.5MAC異氟醚組。所有組的升壓反射均被抑制。我們的結論是在異氟醚麻醉>1.0MAC時胸段硬膜外使用可樂定會抑制壓力反射,這與在0.5MAC異氟醚麻醉時使用利多卡因相比有某些益處,這個優點是在意外低血壓發生時可以保存壓力反射的敏感性。

(殷文淵 譯 王祥瑞 校)

Epidural administration of clonidine induces hypotension and bradycardia secondary to decreased sympathetic nerve activity. In this study, we sought to elucidate the change in baroreflex response caused by epidural clonidine. Thirty-six cats were allocated to six groups (n = 6 each) and were given either thoracic epidural clonidine 4 μg/kg or lidocaine 2 mg/kg during 0.5, 1.0, or 1.5 minimum alveolar anesthetic concentration (MAC) isoflurane anesthesia. Heart rate (HR), mean arterial blood pressure (MAP), and cardiac sympathetic nerve activity (CSNA) were measured. Depressor and pressor responses were induced by IV nitroprusside 10 μg/kg and phenylephrine 10 μg/kg, respectively. Baroreflex was evaluated by the change in both CSNA and HR relative to the peak change in MAP (CSNA/MAP and HR/MAP, respectively). These measurements were performed before and 30 min after epidural drug administration. Epidural clonidine and lidocaine decreased HR, MAP, and CSNA by similar extents. CSNA/MAP and HR/MAP for depressor response were suppressed with epidural lidocaine and clonidine in all groups but the clonidine 0.5 MAC isoflurane group (0.197 ± 0.053 to 0.063 ± 0.014 and 0.717 ± 0.156 to 0.177 ± 0.038, respectively, by epidural lidocaine [P < 0.05] but 0.221 ± 0.028 to 0.164 ± 0.041 and 0.721 ± 0.177 to 0.945 ± 0.239, respectively, by epidural clonidine during 0.5 MAC isoflurane). Those for pressor response were suppressed in all groups. We conclude that thoracic epidural clonidine suppresses baroreflex gain during isoflurane anesthesia >1.0 MAC but may offer certain advantages compared with epidural lidocaine during 0.5 MAC isoflurane by virtue of preserving baroreflex sensitivity when inadvertent hypotension occurs.

2-Bromomelationin的催眠和鎮痛效應

The Hypnotic and Analgesic Effects of 2-Bromomelatonin

Mohamed Naguib, MB BCh, MSc, FFARCSI, MD*, Max T. Baker, PhD*, Gilberto Spadoni, PhD, and Marc Gregerson, BS*

Departments of Anesthesia, *University of Iowa College of Medicine, Iowa City, Iowa; and Institute of Medicinal Chemistry and Toxicology, University of Urbino, piazza Rinascimento, Italy

Anesth Analg 2003;97:763-768


2-Bromomelationin是褪黑色素的類似物,具有較高的褪黑色素受體親合性。我們檢測了2-Bromomelationin的催眠和鎮痛特性,並與異丙酚的這些特性相比較。在研究中將斯普拉格-道利鼠分為三組,分別接受靜注2-Bromomelationin、靜注異丙酚或腹腔內注射嗎啡。然後評估實驗老鼠的翻正反應和夾尾反應,結果發現隨著2-Bromomelationin和異丙酚劑量的增加,表現為翻正反應和夾尾反應消失的老鼠的比例也在增加。之所以將2-Bromomelationin與異丙酚作比較是因為異丙酚起效快、催眠維持時間短。異丙酚和2-Bromomelationin使老鼠翻正反應消失的50%有效劑量(95%可信區間)分別為3.7(3.4-4.0)和38(35-41)mg/Kg,而使老鼠夾尾反應消失的50%有效劑量分別為2.9(3.5-4.0)和21(15-30)mg/Kg。結果表明異丙酚的效能為2-Bromomelationin的6-10倍。腹腔內注射30mg/Kg嗎啡對老鼠的翻正反應沒有影響,但使所有老鼠的夾尾反應均消失。2-Bromomelationin可產生與異丙酚相似的催眠和抗傷害防衛反應。與異丙酚不同的是,其減弱的傷害防衛反應可持續到老鼠翻正反應重新恢復後。本研究表明2-Bromomelationin具有麻醉藥物或麻醉輔助藥物的特性。

(齊 波 譯 王祥瑞 校)

2-Bromomelatonin is an analog of melatonin with a higher melatonin receptor affinity. We tested the hypnotic and analgesic properties of 2-bromomelatonin and compared them with those of propofol. Sprague-Dawley rats were assigned to receive 2-bromomelatonin or propofol IV, or morphine intraperitoneally. Righting reflex and response to tail clamping were assessed. Both 2-bromomelatonin and propofol caused a dose-dependent increase in the percent of rats displaying loss of both the righting reflex and the response to tail clamping. 2-Bromomelatonin was comparable to propofol in terms of its rapid onset and short duration of hypnosis. The 50% effective dose (95% confidence interval) for loss of righting reflex for propofol and 2-bromomelatonin were 3.7 (3.4–4.0) and 38 (35–41) mg/kg, respectively. Corresponding values for loss of response to tail clamp were 2.9 (3.5–4.0) and 21 (15–30) mg/kg, respectively. 2-Bromomelatonin is approximately 6–10 times less potent than propofol depending on the end-point used. Intraperitoneal 30 mg/kg morphine did not affect the righting reflex, but resulted in loss of response to tail clamping in all animals. 2-Bromomelatonin can exert hypnotic and antinocifensive effects similar to that observed with propofol. Unlike propofol, the reduced nocifensive behavior persisted after the animals had regained their righting reflex. This study provides evidence that 2-bromomelatonin has properties that are desirable in anesthetics or anesthetic adjuvants.

在複合全麻和硬膜外麻醉過程中麻黃素可增加病人的腦電雙頻指數,而新福林則不能

Ephedrine, but Not Phenylephrine, Increases Bispectral Index Values During Combined General and Epidural Anesthesia

Tadahiko Ishiyama, MD PhD, Takeshi Oguchi, MD PhD, Tetsuya Iijima, MD, Takashi Matsukawa, MD PhD, Satoshi Kashimoto, MD PhD, and Teruo Kumazawa, MD PhD

Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan

Anesth Analg 2003;97:780-784
在複合全麻和硬膜外麻醉過程中,通常應用麻黃素和新福林來處理病人的低血壓,兩種藥物可能會改變麻醉深度。在目前的研究中,我們比較了麻黃素和新福林對複合全麻和硬膜外麻醉病人腦電雙頻指(BIS)的影響。在通過硬膜外導管給予病人布比卡因後,應用異丙酚和維庫溴胺進行麻醉誘導,並採用0.75%七氟醚麻醉維持。氣管插管後約10分鐘,測定病人的BIS作為基礎值。在麻醉過程中選擇較麻醉前動脈血壓下降30%的病人作為對照組(n=9)。對於血壓下降較明顯而不得不應用藥物處理的病人隨機分為兩組,一組給予0.1mg/Kg麻黃素處理(n=17),另外一組給予2μg/Kg新福林處理(n=17)。在10分鐘內每間隔1分鐘測定BIS值。結果發現麻黃素組病人在第7到10分鐘內BIS明顯大於對照組和新福林組(P<0.05=而且麻黃素組有7個病人的BIS大於60,但在對照組和新福林組均沒有病人BIS大於60(P<0.005=。因此在複合全麻和硬膜外麻醉過程中麻黃素能增加了患者的BIS,而新福林則不能。

(齊 波 譯 王祥瑞 校)

Ephedrine and phenylephrine are used to treat hypotension during combined general and epidural anesthesia, and they may change anesthetic depth. In the current study, we evaluated the effects of ephedrine versus phenylephrine on bispectral index (BIS) during combined general and epidural anesthesia. After injection of ropivacaine through the epidural catheter, general anesthesia was induced with propofol and vecuronium, and was maintained with 0.75% sevoflurane. Approximately 10 min after the intubation, BIS was recorded as a baseline value. Patients with decreases in arterial blood pressure <30% of the preanesthetic values were defined as control group (n = 9). Patients who had to be treated for larger decreases in arterial blood pressure were randomly assigned to receive ephedrine 0.1 mg/kg (n = 17) or phenylephrine 2 μg/kg (n = 17). BIS values were recorded at 1-min intervals for 10 min. BIS in the ephedrine group was significantly larger from 7 to 10 min than that in the control and phenylephrine groups (P < 0.05). Seven patients in the ephedrine group had BIS >60, whereas no patient in the control and phenylephrine groups had BIS >60 (P < 0.005). Ephedrine, but not phenylephrine, increased BIS during general anesthesia combined with epidural anesthesia.

神經類固醇藥物的鎮痛作用:阿法沙龍和阿法多龍對嗎啡類鎮痛藥的增強作用的比較

Antinociceptive Properties of Neurosteroids: A Comparison of Alphadolone and Alphaxalone in Potentiation of Opioid Antinociception

L. Winter, R. Nadeson, A. P. Tucker, and C. S. Goodchild

Monash University Department of Anaesthesia, Monash Medical Centre, Clayton, Victoria, Australia

Anesth Analg 2003;97:798-805
本研究中,我們研究了單獨給予嗎啡類藥物芬太尼,嗎啡和氧可酮和合併給予兩種神經類固醇類藥物:阿法沙龍和阿法多龍對鎮痛和鎮靜作用的影響。將嗎啡類藥物和神經類固醇類藥物分別注射入Wistar雄鼠的腹腔內,以open-field活動監測和rotarod儀器來判斷鎮靜效果。在未達鎮靜劑量前,畫出鎮痛作用的劑量-反應曲線。在非鎮靜劑量下,芬太尼、嗎啡和氧可酮均可產生劑量依賴性的搖尾反應(tail flick latency,TFL)。由於兩種神經類固醇藥均不能改變TFL,所以通過電流強度來判斷非鎮靜劑量下這兩種藥對鎮痛作用的影響。在電流測試中,阿法多龍可產生明顯的鎮痛作用,而阿法沙龍則無此作用。儘管單獨用阿法多龍不影響TFL,但與三種鎮痛藥合用後均可使TFL的劑量-反應曲線左移。阿法沙龍單獨用藥和合併嗎啡類藥物則均無影響。與嗎啡類藥物合用時,兩種藥均無鎮靜作用。我們得出結論:與嗎啡、芬太尼和氧可酮合用時,阿法多龍可增強鎮痛作用而不加深鎮靜作用,而阿法沙龍無此作用。

(忻紀華 譯 王祥瑞 校)

In this study, we investigated the antinociceptive and sedative effects of the opioids fentanyl, morphine, and oxycodone given alone and in combination with two neurosteroids: alphadolone and alphaxalone. An open-field activity monitor and rotarod apparatus were used to define the sedative effects caused by opioid and neurosteroid compounds given alone intraperitoneally to male Wistar rats. Dose-response curves for antinociception were constructed using only nonsedative doses of these drugs. At nonsedating doses, fentanyl, morphine, and oxycodone all caused dose-dependent tail flick latency (TFL) antinociceptive effects. Because neither neurosteroid altered TFL, electrical current was used as the test to determine doses of neurosteroid that caused antinociceptive effects at nonsedative doses. Alphadolone 10 mg/kg intraperitoneally caused significant antinociceptive effects in the electrical test but alphaxalone did not. All three opioid dose-response curves for TFL antinociception were shifted to the left by coadministration of alphadolone even though alphadolone alone had no effect on TFL. Alphaxalone given alone had no antinociceptive effects at nonsedative doses and it had no effect on opioid antinociception. Neither neurosteroid caused sedative effects when combined with opioids. We conclude that coadministration of alphadolone, but not alphaxalone, with morphine, fentanyl, or oxycodone potentiates antinociception and that this effect is not caused by an increase in sedation.

氟呱利多對嗎啡自控鎮痛病人的止吐作用:隨機,對照,多種劑量-效應的研究。

The Antiemetic Efficacy of Droperidol Added to Morphine Patient-Controlled Analgesia: A Randomized, Controlled, Multicenter Dose-Finding Study

Xavier Culebras, MD*, Jean-Baptiste Corpataux, MD, Giovanni Gaggero, MD, and Martin R. Tramer, MD DPhil*

*Division d’Anesthesie, Departement APSIC (Anestheie, Pharmacologie et Soins Intensif de Chirurgie), Hopitaux Universitaires de Geneve, Geneve, Switzerland; Service d’Anesthesie, Hopital de La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland; and Service d’Anesthesie, Hopital Sud Fribourgeois, Riaz, Switzerland

Anesth Analg 2003;97:816-821


氟呱利多用於嗎啡自控鎮痛病人止吐的劑量-效應還不明確。我們將術後用嗎啡自控鎮痛(1mg/單次,5分鐘鎖定)的病人隨機分為四組:無氟呱利多組(對照組)或氟呱利多5,15,或50ug/mg嗎啡。記錄24小時內的效果和副作用,並在95%的可信區間內進行需要治療數(NNT)和需要刺激數(NNH)的分析。進行分析的對照組為82人,氟呱利多5ug組為82人,15ug組為82人,50ug組為83人。氟呱利多的平均用量在5ug組中為0.2mg/24hr,15ug組中為0.61 mg/24hr, 50ug組中為2.04mg/24hr。在對照組中噁心的發生率為48.8%,5ug組中為42.7%(與對照組的NNT相比,16[95%的可信區間,4.7�11]),15ug組中為32.9%(NNT,6.3[3.3�100]),50ug組中為21.7%(NNT,3.7[2.4�7.6])。嘔吐發生率在對照組為24.4%,5ug組中為23.2%(NNT,82[7�8.5]),15ug組中為22.0%(NNT,41[6.5�9.5]),50ug組中為12%(NNT,8.1[4.2�142])。皮膚瘙癢的發生率在對照組為12.2%,5ug組中為6.1%(NNT,16[6.7�37]),15ug和50ug組中為2.4%(NNT,10[5.7�52])。對照組中鎮靜的發生率為2.4%,5ug組中為8.5%(NNH,16[7.7�123]),15ug組中為6.1%(NNH,27[10�40]),

50ug組中為18.1%(NNH,6.4[4.1�15])。無椎體外系反應和心臟副作用。病人的滿意率無差異。氟呱利多的最佳止吐劑量為15�50ug/mg嗎啡。更大劑量的氟呱利多可能止吐作用更好,但同時鎮靜作用也更明顯。

(忻紀華 譯 王祥瑞 校)

The antiemetic dose response of droperidol when it is added to patient-controlled analgesia with morphine is not well known. We randomly allocated adults who received postoperative morphine patient-controlled analgesia (1-mg bolus, 5-min lockout) to one of four regimens: no droperidol (control) or 5, 15, or 50 μg of droperidol per milligram of morphine. Efficacy and adverse effects were recorded during 24 h and were analyzed with number needed to treat (NNT) and number needed to harm with 95% confidence intervals. Data from 82 controls, 82 patients receiving droperidol 5 μg, 82 receiving droperidol 15 μg, and 83 receiving droperidol 50 μg were analyzed. Average consumption of droperidol per 24 h was 0.2 mg with the 5-μg regimen, 0.61 mg with the 15-μg regimen, and 2.04 mg with the 50-μg regimen. In controls, the incidence of nausea was 48.8%; with droperidol 5 μg, it was 42.7% (NNT compared with control, 16 [95% confidence interval, 4.7 to -11]); with 15 μg, it was 32.9% (NNT, 6.3 [3.3–100]); and with 50 μg, it was 21.7% (NNT, 3.7 [2.4 to 7.6]). In controls, the incidence of vomiting was 24.4%; with droperidol 5 μg, it was 23.2% (NNT compared with control, 82 [7 to -8.5]); with 15 μg, it was 22.0% (NNT, 41 [6.5 to -9.6]); and with 50 μg, it was 12% (NNT, 8.1 [4.2–142]). In controls, the incidence of pruritus was 12.2%; with droperidol 5 μg, it was 6.1% (NNT compared with control, 16 [6.7 to -37]); and with 15 and 50 μg, it was 2.4% (NNT, 10 [5.7–52]). In controls, the incidence of sedation was 2.4%; with droperidol 5 μg, it was 8.5% (number needed to harm (NNH) compared with control, 16 [7.7 to -123]); with 15 μg, it was 6.1% (NNH, 27 [10 to -40]); and with 50 μg, it was 18.1% (NNH, 6.4 [4.1–15]). There were no extrapyramidal symptoms and no cardiac adverse events. There was no difference in patient satisfaction. The optimal antiemetic dose of droperidol is 15–50 μg/mg of morphine. Larger doses may have more antivomiting efficacy but are likely to be unacceptably sedating.

燒傷病人換敷料時使用異丙酚自控鎮靜:劑量效應的研究

Patient-Controlled Sedation Using Propofol for Dressing Changes in Burn Patients: A Dose-Finding Study

Claudia Coimbra, MSc MD, FRCPC*, Manon Choiniere, PhD, and Thomas M. Hemmerling, MD DEAA*

Department of *Anesthesiology and Burn Centre, Hotel-Dieu, Centre Hospitalier de l’Universite de Montreal (CHUM), Universite de Montreal, Quebec, Canada

Anesth Analg 2003;97:839-842


皮膚移植術後的燒傷病人在第一次換敷料時,由於疼痛以及突然首次面對皮膚移植後的樣子,因此會導致病人極大的焦慮。於是,我們設計了一項探討劑量的研究即使用異丙酚由病人控制鎮靜(PCS),以確定其可行性和安全性。我們讓20個熟悉PCS的病人,無論什麼時候感到不適或焦慮時就使用PCS。在換敷料的15分鐘之前,根據他們的每日攝取量單一給予靜脈注射嗎啡止痛。起先的10個病人固定給以0.3mg/kg異丙酚並5分鐘停頓一次,鎮靜程度利用雙頻指數監測(BIS)來測定,並記錄每次需要使用異丙酚的時間。我們讓護士給予換敷料,在此過程的1小時內評估病人疼痛程度及滿意評分。在這10個病人中,呼吸頻率都不低於10次/分,收縮和舒張壓變化在基礎值的25%內,並在小流量鼻吸氧時外周的氧飽和度不低於94%,患者需要異丙酚的要求次數是實際注射的兩倍。患者的BIS無明顯下降,沒有〈80,表明患者的鎮靜不夠充分。由於此種PCS步驟提示鎮靜不充足,所以我們讓另外10個病人實施不同的PCS步驟(個人化處理,調節異丙酚量使患者BIS明顯下降或處於睡眠狀態,並持續給藥)。第二組的病人表現出更加有效的鎮靜,而呼吸頻率和血液動力學數值與第一組無顯著不同。由此可見,在燒傷病人中使用異丙酚進行PCS是可行的,並可以是安全的。為了提供一個理想的鎮靜,我們建議起先就調節注射異丙酚量使BIS顯著下降或達到臨床上有效的鎮靜狀態並終止當中的停頓。

(朱 輝 譯 王祥瑞 校)

he first change of dressings after skin grafting in burn patients is a source of great anxiety because of pain anticipation and the immediate and first confrontation with the result of skin grafting. We designed this dose-finding study to determine the feasibility and safety of patient-controlled sedation (PCS) using propofol during these procedures. Twenty patients were familiarized with the PCS and asked to use PCS whenever they felt uncomfortable or anxious. Analgesia was provided by a single bolus of morphine IV 15 min before the procedure according to their daily intake. The first 10 patients used a fixed bolus of propofol 0.3 mg/kg and a lockout of 5 min. The degree of sedation was measured using bispectral index (BIS) monitoring. Demands versus delivery of propofol boluses were recorded. Within 1 h after the procedure, pain intensity was evaluated and satisfaction scores obtained from patients and nurses performing the dressing changes. In the first 10 patients, there were no respiratory rates <10 breaths/min, systolic and diastolic blood pressure were within 25% of baseline values, and peripheral saturation stayed more than 94% with additional small flow oxygen via nasal insufflation. There were double the demands than actual deliveries of propofol boluses. The BIS did not show significant decreases of <80 in any patient reflecting an insufficient state of sedation. Because the interim analysis of the efficacy of the PCS setup showed an insufficient state of sedation, a different PCS setup was evaluated in a second group of 10 patients (an individualized propofol bolus, titrated to achieve a significant decrease of BIS or a sleepy state, and no lockout period). The second group of patients showed a more effective sedation, with respiratory and hemodynamic variables being not significantly different from the first group of patients. PCS with propofol is feasible in burn patients and can be used safely. To provide an optimal sedation, we suggest to initially titrate the bolus to achieve a significant decrease of BIS or a clinically effective state of sedation and to abolish the lockout interval.

兔子模型中細胞間黏附分子-1(ICAM-1)的單克隆抗體在硬膜外的治療作用:細胞間黏附分子-1(ICAM-1)引起脊索缺血的機制

The Therapeutic Effects of Epidural Intercellular Adhesion Molecule-1 Monoclonal Antibody in a Rabbit Model: Involvement of the Intercellular Adhesion Molecule-1 Pathway in Spinal Cord Ischemia

Kamatham A. Naidu, PhD*, Eugene S. Fu, MD, E. Truitt Sutton, PhD, Leon D. Prockop, MD*, and Alan Cantor, PhD

Departments of *Neurology, Anesthesiology, and Physiology, College of Medicine, University of South Florida, Tampa, Florida; and Oncology Program, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida

Anesth Analg 2003;97:857-862


缺血或再灌注損傷的發生機制包括血管內白細胞向血管外損傷部位的遷移。白細胞的黏附和ICAM-1在白細胞的遷移中扮演了重要的角色。在這項研究中,我們評價了ICAM-1在脊索缺血損傷中的作用和硬膜外ICAM-1單克隆抗體的治療作用。試驗兔子用氟烷麻醉後在其降主動脈腎動脈的下方放置動脈瘤的支架。測評以下各種情況的資料:不同ICAM-1在脊索的表達,動物模型通過硬膜外導管接受鹽水或接受細胞間黏附分子-1(ICAM-1)單克隆抗體。(1)在主動脈內放置支架30分鐘後研究8小時後脊索(L6-7)毛細血管白細胞的遷移。(2)在主動脈內放置支架10,15,17.5,20,25分鐘後的第20小時進行神經系統的評價。癱瘓進行以下分級:0級,沒有影響;1級,部分影響;2級,完全癱瘓。ICAM-1在脊索毛細血管內皮的表達會增加脊索缺血的發生,並導致血管內的白細胞向血管外遷移倒脊索軟組織,這個現象可以用ICAM-1單克隆抗體消除。硬膜外ICAM-1單克隆抗體可以減少神經的影響並提供神經保護。這些研究揭示了細胞間黏附分子-1(ICAM-1)引起脊索缺血的機制和硬膜外ICAM-1單克隆抗體的神經保護作用。因此在脊髓腔內給予白細胞抗黏附分子可以改善脊索的缺血。

(鄧羽霄 譯 王祥瑞 校)

The pathophysiology of ischemia/reperfusion injury involves extravascular migration of leukocytes from the bloodstream to the site of injury. Leukocyte adhesion and intercellular adhesion molecule-1 (ICAM-1) play an important role in the recruitment of leukocytes to the site of injury. In this study, we evaluated the role of the ICAM-1 in spinal cord ischemia and the therapeutic effects of epidural ICAM-1 monoclonal antibody (Mab). The descending aorta was occluded below the renal artery with an aneurysm clip in rabbits anesthetized with halothane. The following variables were evaluated, in addition to ICAM-1 expression in the lumbar spinal cord, in animals receiving saline or ICAM-1 Mab via the epidural route: (1) leukocyte recruitment in the lumen of capillary vessels of the lumbar spinal cord (L6-7) at 8 h after 30 min of aortic occlusion and (2) neurological evaluation at 20 h after aortic occlusion of 10, 15, 17.5, 20, or 25 min. Paraplegia was graded with the following scale: Grade 0, no deficit; Grade 1, partial deficit; and Grade 2, complete paraplegia. Spinal cord ischemia increased the expression of ICAM-1 in the endothelium of spinal cord capillaries and led to capillary leukocyte recruitment and extravascular migration into the lumbar spinal cord parenchyma, which was ablated with epidural ICAM-1 Mab. Epidural ICAM-1 Mab reduced neurological deficits and offered neuroprotection. These findings demonstrate the involvement of the ICAM-1 pathway in spinal cord ischemia and the neuroprotective effects of epidural ICAM-1 Mab. Strategies to ameliorate spinal cord ischemia may entail the administration of leukocyte antiadhesion molecules into the neuraxial space.

母白鼠暴露於可卡因下對新生白鼠心功能的影響

The Effect of Maternal Cocaine Exposure on Neonatal Rat Cardiac Function

Lena S. Sun, MD*,, Shin Takuma, MD, Rui Lui, MD, and Shunichi Homma, MD

Departments of *Anesthesiology, Pediatrics, and Medicine, College of Physicians and Surgeons of Columbia University, New York, New York

Anesth Analg 2003;97:878-882
對於人類來說,胎兒暴露於下與其心血管功能異常有關。我們進行了一項實驗,即選擇了一群妊娠的大白鼠,在整個妊娠期及分娩後的14天通過胃灌洗生理鹽水或60mg/kg的可卡因。我們然後用高頻率經胸超聲心動圖檢查7天和14天的新生白鼠以確定在暴露可卡因下是否影響其心臟收縮功能。所有的研究都在沒有鎮靜且清醒狀態下。我們從二維圖像中計算乳頭中肌水平變化的面積來得知收縮功能和心率(HR)。兩組年齡段的可卡因暴露組,靜息狀態下的心率都快於對照組,但基礎心臟收縮功能對照組和暴露組無差異。只在使用最大劑量多巴酚丁胺下能使所有組的白鼠心率增快(出生7天的對照組心率由438±3bpm增快至462±10bpm;出生7天的可卡因組心率由466±3bpm增快至493±7bpm;出生14天的對照組心率由443±4bpm增快至487±4bpm;出生14天的可卡因組心率由477±4bpm增快至501±5bpm)。多巴酚丁胺能使出生7天(從76.6%±0.6%到81.5%±0.7%)和14天(從78.2%±0.7%到81.9%±0.7%)的對照組白鼠心臟收縮顯著增強,但對於可卡因組不明顯(出生7天的從76.7%±0.8%到78.9%±0.8%而出生14天的從76.8%±1.1%到79.3%±0.8%)。腎上腺素對出生7天的對照組有明顯的心臟收縮作用,但對可卡因組不明顯,而對出生14天的對照組和可卡因組都無明顯的變化。我們的研究結果提示圍產期暴露於可卡因不會使靜息心功能有所變化,但可削弱新生白鼠對β腎上腺素受體激動劑的反應。這些結果表明圍產期暴露於可卡因組可降低新生兒早期對影響心肌收縮力藥物的反應。

(朱 輝 譯 王祥瑞 校)

Fetal cocaine exposure has been associated with a variety of cardiovascular dysfunctions in humans. We treated pregnant rats with either saline or cocaine at 60 mg/kg by gastric lavage for the entire gestational period and for 14 days after parturition. We then performed high-frequency transthoracic echocardiography to determine whether cocaine exposure affected neonatal cardiac contractile function in vivo in 7- and 14-day-old neonatal rats. All studies were performed in the unsedated, conscious state. Heart rate (HR) and systolic function, expressed as fractional area of change at the midpapillary muscle level, were calculated from two-dimensional images. Resting HR was faster in the cocaine-exposed group at both ages, but baseline contractile function was not different between control (CTL) and cocaine-exposed (COC) neonatal rats. Dobutamine induced a significant increase in HR in all groups at only the largest dose tested (Day 7 CTL HR increased from 438 ± 3 bpm to 462 ± 10 bpm; Day 7 COC HR increased from 466 ± 3 bpm to 493 ± 7 bpm; Day 14 CTL HR increased from 443 ± 4 bpm to 487 ± 4 bpm; Day 14 COC HR increased from 477 ± 4 bpm to 501 ± 5 bpm). Dobutamine elicited a significant increase in contractile response at both Day 7 (from 76.6% ± 0.6% to 81.5% ± 0.7%) and Day 14 in CTL (from 78.2% ± 0.7% to 81.9% ± 0.7%), but not in COC, animals (from 76.7% ± 0.8% to 78.9% ± 0.8% at Day 7 and from 76.8% ± 1.1% to 79.3% ± 0.8% at Day 14). Epinephrine induced a significant increase in contractile response in CTL, but not in COC, rats at Day 7 and had no effect on fractional area of change at 14 days of age in either CTL or COC animals. Our results indicate that perinatal cocaine exposure does not modify resting contractile function but attenuates the contractile response to ß-adrenoceptor stimulation in the neonatal rat. These results suggest that perinatal cocaine exposure may lead to decreased responsiveness to inotropic drugs during the early neonatal period.

鈣通道阻滯劑(CCB)減少非心臟手術後心臟發病率的作用--Meta分析

Calcium Channel Blockers for Reducing Cardiac Morbidity After NoncardiacSurgery: A Meta-Analysis

Duminda N. Wijeysundera, MD*, and W. Scott Beattie, MD PhD, FRCPC

From the *Department of Anesthesia, University of Toronto, and the Department of Anesthesia, University Health Network, University of Toronto, Toronto, ON

Anesth Analg 2003;97:634-641

心臟併發症是非心臟手術後死亡的主要原因。儘管CCB理論上對此有益但仍未在圍手術期處理中廣泛應用。這篇系統性評論評估了CCB在非心臟外科手術中的效能。搜索了MEDLINE、EMBASE、SCIENCE CITATION IDEX、PUBMED及相關目錄中(無語言限制)評價CCB在非心臟外科手術中作用的隨機控制性研究(RCT)。由兩位評論者獨立的總結關於死亡、心梗(MI)、缺血、室上速(SVT)及充血性心衰(CHR)的資料,計算治療效果在95%置信區間(CI)下的相對危險度(RR),總共包括了11份研究(計1007名患者)。CCB顯著減少缺血(RR0.49,95%CI0.3-0.8,P=0.004)和SVT(RR0.52,95%CI0.37-0.72,P<0.0001)CCB也與死亡率及MI呈負相關。在post hoc分析中,CCB顯著減少死亡/心梗比值(RR0.35,95%CI0.15-0.86,P=0.02)及主要病態事件(MME),確切的講如死亡、MI、CHF(RR0.39,95%CI0.17-0.89,P=0.02).在亞群分析中,硫氮酮顯著減少缺血、SVT、死亡/心梗比值及MME。此次Meta分析顯示了CCB能顯著減少在非心臟外科手術中的缺血、SVT及複合終點。這些益處主要歸功於硫氮酮,並提示需在大的RCT中對該藥進行進一步評價。

(陸旭偉 譯 薛張綱 校)

Cardiac complications are the leading cause of death after noncardiac surgery. Despite theoretical benefits, calcium channel blockers (CCB) are not widely used in the perioperative setting. This systematic review assessed the efficacy of CCBs during noncardiac surgery. MEDLINE, EMBASE, Science Citation Index, PubMed, and reference lists were searched without language restriction for randomized controlled trials (RCT) evaluating CCBs during noncardiac surgery. Two reviewers independently abstracted data on death, myocardial infarction (MI), ischemia, supraventricular tachyarrhythmia (SVT), and congestive heart failure (CHF). Treatment effects were calculated as relative risks (RR) with 95% confidence intervals (CI). Eleven studies (1007 patients) were included. CCBs significantly reduced ischemia (RR, 0.49; 95% CI, 0.30–0.80; P = 0.004) and SVT (RR, 0.52; 95% CI, 0.37–0.72; P < 0.0001). CCBs were associated with trends towards reduced death and MI. In post hoc analyses, CCBs significantly reduced death/MI (RR, 0.35; 95% CI, 0.15–0.86; P = 0.02) and major morbid events (MME), defined as death, MI, or CHF (RR, 0.39; 95% CI, 0.17–0.89; P = 0.02). In subgroup analyses, diltiazem significantly reduced ischemia, SVT, death/MI, and MMEs. This meta-analysis shows CCBs significantly reduced ischemia, SVT, and combined end-points in the setting of noncardiac surgery. The majority of these benefits are attributable to diltiazem, suggesting the need for further evaluation of this drug in a large RCT.

小兒中應用一次性注射泵進行圍手術期持續性周圍神經阻滯(CPNB)--前瞻描性研究

Perioperative Continuous Peripheral Nerve Blocks with Disposable Infusion Pumps in Children: A Prospective Descriptive Study

Christophe Dadure, MD, Philippe Pirat, MD, Olivier Raux, MD, Rachel Troncin, MD, Alain Rochette, MD, Christine Ricard, MD, and Xavier Capdevila, MD PhD

Department of Anesthesia and Critical Care Medicine, Lapeyronie University Hospital, Montpellier, France

Anesth Analg 2003 97: 687-690

  

小兒重大矯形外科手術後的CPNB未廣泛應用。我們進行了一次前瞻描述性研究來評價一次性彈性注射泵在小兒CPNB中的作用。共計25位相鄰的計畫接受重大矯形外科手術的小兒于全麻誘導後在腋窩、股管、膕窩一次性注射1%利多卡因、0.25%布比卡因、腎上腺素混合液0.5ml/kg,並於術後接著一次性注射0.2%羅比卡因。注射量依據患者體重調節。術後疼的評價依據視覺分析表或嬰幼兒術後1小時、6小時、12小時、24小時、48小時疼痛評分表,以及應急止痛、不良反應、運動感覺阻滯的數量。同時也可應用小兒術後走動評分。共進行了11位膕窩、9位股管、5位腋窩持續阻滯。術中阻滯效果均完善。0.2%羅比卡因總用量平均為10.1mg/kg。一次注射量自-9.61%至+8.6%各不相同。術後止痛效果亦完善。各個時期研究中疼痛評分中值為0。運動感覺阻滯於第1小時記錄並於第6小時起減退。無不良反應。因此我們認為在小兒中應用一次性注射泵CPNB是一項非常有效的技術。

(陸旭偉 譯 薛張綱 校)

Continuous peripheral nerve blocks (CPNB) after pediatric major orthopedic surgery are not widely used. We conducted a prospective descriptive study to evaluate the effectiveness of disposable elastomeric pumps for CPNB in children. After inducing general anesthesia, 25 consecutive children scheduled for major orthopedic surgery received a 0.5-mL/kg bolus of a mixture of 1% lidocaine with epinephrine and 0.25% bupivacaine in axillary, femoral, or popliteal catheters. After surgery, disposable pumps with 0.2% ropivacaine were connected. Pump flows were adjusted to the patient’s weight. Postoperative pain was evaluated using a visual analog scale or Children and Infants Postoperative Pain Scale scores at H1, H6, H12, H24, and H48, as well as amounts of rescue analgesia, adverse events, and motor and sensory block. An ambulation score for the children was also evaluated. Eleven popliteal, nine femoral, and five axillary continuous blocks were performed. All the blocks were effective for surgery. The mean total dose consumption of 0.2% ropivacaine was 10.1 mg/kg. Disposable pump flow varied from -9.61% to +8.6% compared with the theoretical one. Postoperative analgesia was excellent. The median of pain score was zero at each period studied. Sensory and motor block were noted at H1 and decreased from the sixth hour. No adverse events were noted. We concluded that the use of elastomeric disposable pumps for CPNB in children was an effective technique

狗大腦膜傷害/Orphanin FQ(N/OFQ)結合位點的特點

Characterization of Nociceptin/Orphanin FQ Binding Sites in Dog Brain Membranes

Emma E. Johnson, BSc(Hons)*, Helen Gibson, BSc(Hons)*, Beverley Nicol, PhD, Johannes Zanzinger, PhD, Peter Widdowson, PhD, Mark Hawthorn, PhD, Geza Toth, PhD, Judit Farkas, PhD, Remo Guerrini, PhD, and David G. Lambert, PhD*

*University Department of Anaesthesia, Critical Care and Pain Management, Leicester Royal Infirmary, Leicester, United Kingdom; Veterinary Medicine Research & Development, Pfizer Ltd., Sandwich, Kent, United Kingdom; Isotope Laboratory, Institute of Biochemistry, Biological Research Centre, Szeged, Hungary; and Department of Pharmaceutical Sciences and Biotechnology Centre, University of Ferrara, Ferrara, Italy

Anesth Analg 2003 97: 741-747

N/OFQ是N/OFQ受體(NOP)的內源性配體,它在狗中的特點尚未知。因此我們將(H3)N/OFQ在狗及鼠大腦膜中的結合作了比較。放射性配體與亮氨?-(H3)N/OFQ(1-17)OH或新型配體(H3)N/OFQ(1-13)NH2的飽和/競爭決定於受體密度和配體親和力。經典阿片樣受體密度決定於使用(H3)diprenorphine。亮氨?-(H3)N/OFQ(1-17)OH的結合是濃度依賴的,並在狗(最大結合容量Bmax28.7+-2.8fmol/mg蛋白,解離常數的負對數值pKd10.27+-0.11)及鼠(Bmax137.0+-12.9fmol/mg蛋白,pKd10.41+-0.05)中達到飽和。相比較而(H3)diprenorphine的Bmax、pKd在狗中為77.7+-5.3fmol/mg蛋白、9.74+-0.09,在鼠中為79.1+-18.2fmol/mg蛋白、9.51+-0.04。在狗中,(H3)N/OFQ(1-13)NH2與NOP受體的結合也是飽和的(Bmax23.7+-2.0fmol/mg蛋白、pKd10.16+-0.12)。亮氨?-(H3)N/OFQ(1-17)OH在兩種動物中可被多種NOP配體替換。強啡?A、N/OFQ(1-5)NH2、nocistatin均無活性通過替換試驗得出的pKi值(作為親和力的評估)在狗與鼠中存在強烈正相關(r2=0.95,P<0.0001)。我們證明了在狗中NOP受體密度低,可用兩種放射性配體測量,而在鼠中這些受體卻表現出高度的藥理學單一性。

(陸旭偉 譯 薛張綱 校)

Nociceptin/orphanin FQ (N/OFQ) is the endogenous ligand for the N/OFQ receptor (NOP), whose characteristics in the dog are unknown. We therefore compared [3H]N/OFQ binding in dog and rat brain membranes. Radioligand saturation/competition studies with these membranes and leucyl-[3H]N/OFQ(1–17)OH or the novel radioligand [3H]N/OFQ(1–13)NH2 were performed to determine receptor density and ligand affinity. The density of classic opioid receptors was determined by using [3H]diprenorphine. Leucyl-[3H]N/OFQ(1–17)OH binding was concentration dependent and saturable in dog (maximum binding capacity [Bmax], 28.7 ± 2.8 fmol/mg of protein; equilibrium dissociation constant as negative log [pKd], 10.27 ± 0.11) and rat (Bmax, 137.0 ± 12.9 fmol/mg of protein; pKd, 10.41 ± 0.05). In comparison, the Bmax and pKd of [3H]diprenorphine were, respectively, 77.7 ± 5.3 fmol/mg of protein and 9.74 ± 0.09 in dog and 79.1 ± 18.2 fmol/mg of protein and 9.51 ± 0.04 in rat. In dog, [3H]N/OFQ(1–13)NH2 binding to NOP receptors was also saturable (Bmax, 23.7 ± 2.0 fmol/mg of protein; pKd, 10.16 ± 0.12). In both species, leucyl-[3H]N/OFQ(1–17)OH was displaced by various NOP ligands. Dynorphin A, N/OFQ(1–5)NH2, and nocistatin were essentially inactive. There was a significant positive correlation (r2 = 0.95; P < 0.0001) between pKi values (an estimate of affinity) obtained in displacement studies in rat and dog. We have demonstrated a low density of NOP receptors, measured with two radioligands, in dog, and these receptors display a high degree of pharmacological similarity with those natively expressed in the rat.

多沙普侖可使兔顫閾降低並呈劑量相關性

Doxapram Produces a Dose-Dependent Reduction in the Shivering Threshold in Rabbits

Katsumi Okuyama, MD*, Takashi Matsukawa, MD*, Makoto Ozaki, MD, Daniel I. Sessler, MD, Tomoki Nishiyama, MD, Makoto Imamura, MD*, and Teruo Kumazawa, MD*

Departments of Anesthesia, *University of Yamanashi, Faculty of Medicine, Yamanashi; Tokyo Women’s Medical University, and Tokyo University School of Medicine, Tokyo, Japan; and Outcomes ResearchTM Institute and Departments of Anesthesiology, University of Louisville, Louisville, Kentucky

Anesth Analg 2003 97: 759-762.

多巴胺時一種溫度調節神經遞質,當注射到下丘腦或下丘腦旁時可引起低溫。多沙普侖刺激頸動脈體釋放多巴胺,認為可通過相同或至少部分相同的機制引起中樞反應。我們通過這一試驗,以待證實多沙普侖在兔中確實可以降低顫閾,並呈劑量相關的假說。24只經異氟醚麻醉的兔子,隨機分為三組:1)生理鹽水組(對照組);2)多沙普侖. 0.25mg/kg/h 3)多沙普侖.0.50mg/kg/h。 這些劑量均在推薦的人體實驗劑量範圍內。然後從一個經直腸的U形熱電極灌注10C的水,體溫以每小時2-3C的速度下降,記錄食道遠端溫度即中心溫度。另一觀察者(即盲者)評價顫抖的程度。以開始顫抖時的中心溫度為閾值,資料採取單側分析,P<0.05認為有顯著差異。結果發現三組間血流動力學及呼吸變化有可比性。對照組兔子顫閾為36.3+/-0.3C, 第2組兔子顫閾為34.8+/-0.5C, 第三組兔子顫閾為33.7+/-0.6C。每兩組間的顫閾均有顯著差別(P<0.001)。如果多沙普侖在人體內也有類似的抑制作用的話,將有重要的臨床意義。本研究提示,多沙普侖確實可降低顫閾,並呈劑量相關性。因此可行進一步研究以確定此藥在誘導治療性低溫時能否抑制反應性寒顫。

(梁雅芬 譯 薛張綱 校)

Dopamine is a thermoregulatory neurotransmitter that provokes hypothermia when injected in or near the hypothalamus. Doxapram stimulates release of dopamine from carotid bodies, but is known to have central effects that are probably, at least in part, similarly mediated. We thus tested the hypothesis that doxapram produces a substantial, dose-dependent reduction in the shivering threshold in rabbits. Twenty-four rabbits, anesthetized with isoflurane, were randomly assigned to 1) saline (control), 2) 0.25 mg · kg-1 · h-1 doxapram, or 3) 0.50 mg · kg-1 · h-1 doxapram. These doses are within the recommended range for humans. Body temperature was reduced at a rate of 2° to 3°C/h by perfusing water at 10°C through a U-shaped thermode positioned in the colon. Core temperatures were recorded from the distal esophagus. A blinded observer evaluated shivering. Core temperature at the onset of shivering defined the threshold. Data were analyzed with a one-way analysis of variance; P < 0.05 was considered statistically significant. Hemodynamic and respiratory responses were comparable in the groups. The control rabbits shivered at 36.3° ± 0.3°C, those given 0.25 mg · kg-1 · h-1 doxapram shivered at 34.8° ± 0.5°C, and those given 0.50 mg · kg-1 · h-1 shivered at 33.7° ± 0.6°C. All the shivering thresholds significantly (P < 0.001) differed from one another. The magnitude of this inhibition, if similar in humans, would be clinically important.

胸科手術麻醉時經皮CO2與呼氣末CO2監測的評估比較

Comparative Evaluation of Transcutaneous and End-Tidal Measurements of CO2 in Thoracic Anesthesia

Motoko Oshibuchi, MD, Sungsam Cho, MD, Tetsuya Hara, MD, Shiro Tomiyasu, MD, Tetsuji Makita, MD, and Koji Sumikawa, MD

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

Anesth Analg 2003 97: 776-779.

通過這一研究,我們評估了胸科手術麻醉下經皮CO2監測(PTCCO2)與呼氣末CO2(PET CO2)監測相比的準確性。26例行開胸肺切除的患者(這些患者都需要一個長的單肺通氣時間),取側臥位行機械通氣,在雙肺(TLV)和單肺通氣(OLV)期間每隔15分鐘測定PTCCO2. PET CO2和動脈血CO2分壓(Pa CO2),所有患者均按實驗流程完成了實驗。Bland-Altman分析表明,PTCCO2和Pa CO2相比,雙肺時的偏差為-0.4mmHg,精確度為+/-2.5mmHg; 單肺時偏差為1.4mmHg,精確度為+/-4.3mmHg。PET CO2和Pa CO2相比,雙肺時的偏差為-5.8mmHg,精確度為+/-4.1mmHg; 單肺時偏差為-7.1mmHg,精確度為+/-4.6mmHg。由此可見,PTCCO2監測在胸科手術麻醉時可以正確反映動脈CO2水平。本研究提示,經皮CO2監測在胸科手術麻醉時單肺或雙肺通氣時都比呼氣末CO2更加準確地反映實際動脈CO2分壓水平。

(梁雅芬 譯 薛張綱 校)

We performed this study to assess the accuracy of transcutaneous CO2 (PTCCO2) monitoring compared with end-tidal CO2 (PETCO2) in thoracic anesthesia. Twenty-six patients undergoing pneumonectomy with thoracotomy for which a long period of one-lung ventilation (OLV) was required were studied. The lungs were mechanically ventilated in the lateral decubitus position. PTCCO2, PETCO2, and arterial CO2 (PaCO2) were simultaneously measured during two-lung ventilation (TLV) and during OLV at intervals of 15 min. All patients completed the study protocol. Bland-Altman analysis revealed a bias of -0.4 mm Hg with a precision of ±2.5 mm Hg during OLV and 1.4 mm Hg with ±4.3 mm Hg during TLV when PTCCO2 and PaCO2 were compared and revealed a bias of -5.8 mm Hg with a precision of ±4.1 mm Hg during OLV and -7.1 mm Hg with ±4.6 mm Hg during TLV when PETCO2 and PaCO2 were compared. We conclude that PTCCO2 monitoring is accurate for evaluating CO2 levels during thoracic anesthesia.

緩解疼痛可以改善慢性疼痛患者的行為和情緒嗎?

Does Pain Relief Improve Pain Behavior and Mood in Chronic Pain Patients?

Sabine M. Sator-Katzenschlager, MD*, Andreas W. Schiesser, PhD, Sibylle A. Kozek-Langenecker, MD*, Gerhard Benetka, PhD, Gudrun Langer, MD*, and Hans-Georg Kress, MD PhD*

Anesth Analg 2003 97: 791-797

 

慢性疼痛是一種主觀體驗,不僅有身體的而且有心理和社會的原因。在這個試驗中,我們研究慢性疼痛患者疼痛有效緩解是否能改善情緒、行為和認知方面的問題。我們對於在我們大學疼痛治療中心就診的477位患者在第一年進行前瞻性研究,病人接受了藥物療法、針灸療法、經皮神經刺激、理療和有創性的疼痛治療。疼痛的強度和性質採用視覺類比評定標準和多維疼痛評定標準進行評估,對於心理和社會方面的評估使用疼痛行為調查表和情緒特徵調查表。疼痛強度的明顯緩解(視覺類比評分,治療前7.35,12個月後1.03,P=0.01;多維疼痛評定,F = 6.185; P < 0.001)伴隨著行為和認知反面的改善(疼痛行為調查表,F = 9.483; P = 0.002)。然而,情緒和心理健康沒有改善(情緒特徵, F = 0.416; P = 0.551)。作者認為緩解疼痛強度可以改善行為和認知功能卻不能提高心理健康和認知的評估。

結論:嚴重的慢性疼痛伴隨著行為、認知和情緒的降低。我們證明了對於慢性癌性或者非癌性疼痛患者使用傳統的軀體痛治療方法後疼痛強度降低後患者行為和認知功能得到改善。然而,心理健康狀態和情緒卻沒有改善。

(王柯 譯 薛張綱 校)

Chronic pain is a subjective experience and has not only physical, but also psychological and social dimensions. In the present study, we sought to determine whether an effective pain reduction would improve mood, behavioral, and cognitive outcome measures in chronic pain patients. Four-hundred-seventy-seven patients entering pain therapy at our university pain center were prospectively studied during the first year of treatment. Patients received pharmacotherapy, acupuncture, transcutaneous nerve stimulation, physiotherapy, and invasive pain treatment. Intensity and quality of pain were assessed with the Visual Analog Scale and Multidimensional Pain Scale. Psychological and social aspects were evaluated using the Pain Behavior Questionnaire and the Profile of Mood States questionnaire. Significant reductions in pain intensity (Visual Analog Scale, 7.35 at pretreatment and 1.03 after 12 mo; P = 0.01; Multidimensional Pain Scale, F = 6.185; P < 0.001) were accompanied by improvements in behavioral and cognitive dimensions (Pain Behavior Questionnaire, F = 9.483; P = 0.002). However, mood and psychological well-being did not improve (Profile of Mood States, F = 0.416; P = 0.551). The authors conclude that reducing pain intensity improves behavioral and cognitive dimensions but not psychological well-being and cognitive assessment.

 

在辣椒素引起痛覺過敏的自願者中靜脈使用雷米芬太尼會產生撤藥性的痛覺過敏

Intravenous Remifentanil Produces Withdrawal Hyperalgesia in Volunteers with Capsaicin-Induced Hyperalgesia

David D. Hood, MD, Regina Curry, RN, and James C. Eisenach, MD

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

Anesth Analg 2003 97: 810-815.

通過超前鎮痛的機制術中使用阿片類藥物可能是有益的,也可能因為產生了急性耐受而對病人有害。這塈畯怞b自願者身上建立一個穩定的痛覺過敏的模型來證明是否經過一段時間使用阿片類藥物人體會發生痛覺敏感性增高。我們所研究的都是健康人。局部使用辣椒素和間斷加熱的方法可以引起一定範圍的痛覺過敏和異常性疼痛。由電腦控制靜脈持續輸注雷米芬太尼的濃度設定為使對於有害的熱刺激做出疼痛報告的人數減少70%,並且在這一濃度維持60-100分鐘,輸注過程之中和輸注之後的痛覺過敏和異常疼痛的範圍將被測量出來。雷米芬太尼(目標濃度是3.1 ± 1.2 ng/mL)輸注過程中減少的痛覺過敏和異常疼痛的範圍分別是33% ± 31%和65% ± 28%(P<0.05),輸注後痛覺過敏和異常疼痛的範圍持續增大,4小時後的範圍分別是180% ± 47%和180% ± 86%。我們的研究表明短期使用阿片藥物可以增加對疼痛的敏感性達停藥後數小時,如果用於手術期間,這將會增加術後鎮痛的用藥量,增加而不是降低術後的疼痛。

(王柯 譯 薛張綱 校)

Opioids administered during surgery may be beneficial by preempting postoperative pain or detrimental by causing acute tolerance. We used a stable model of hyperalgesia in volunteers to test whether acute opioid exposure also results in such pain sensitization over a period of hours in humans. Ten healthy volunteers were studied. Areas of mechanical hyperalgesia and allodynia were induced by topical capsaicin application plus intermittent heating. Computer-controlled IV remifentanil infusion was titrated to a targeted plasma concentration that reduced pain report to noxious heat by 70% and was maintained at this level for 60–100 min. Areas of hyperalgesia and allodynia were measured during and after remifentanil infusion. Remifentanil (targeted concentration of 3.1 ± 1.2 ng/mL) reduced areas of hyperalgesia and allodynia by 33% ± 31% and 65% ± 28%, respectively, during infusion (P < 0.05). Areas of hyperalgesia and allodynia continuously enlarged 4 h after remifentanil was stopped, to 180% ± 47% and 180% ± 86%, respectively. This study demonstrates that acute opioid exposure enhances hypersensitivity for hours after exposure. If applicable to the surgical setting, this could increase the dose of opioid required for postoperative analgesia and enhance, rather than inhibit, postoperative pain.

定量的感覺測試能夠預測對於坐骨神經痛患者硬膜外注射類固醇

的效果嗎?初步研究

Can Quantitative Sensory Testing Predict the Outcome of Epidural Steroid Injections in Sciatica? A Preliminary Study

Elad Schiff, MD*, and Elon Eisenberg, M

*Department of Internal Medicine B, Bnai-Zion Medical Center and Pain Relief Unit, Rambam Medical Center, and the Haifa Pain Research Group, the Technion, Israel Institute of Technology, Haifa, Israel

Anesth Analg 2003 97: 828-832.

定量的感覺測試(QST)是一項心理和生理的測試,用於鑒別一種類型的神經纖維的功能是否異常。在這個試驗中,我們研究對於坐骨神經痛患者選擇性的神經纖維功能障礙(使用QST來評價)是否和硬膜外注射類固醇(ESI)的效果有關。這個開放性的試驗包括了由椎間盤突出引起的單側坐骨神經痛20名患者。在進行硬膜外注射類固醇之前,我們在最痛的皮區和對側相應皮區進行定量的溫度和機械感覺試驗。主要的效果評價方法是每天2次自己記錄疼痛的強度,使用從0-10的數位化標準(NPS)。次要的方法包括McGill疼痛調查表、直腿抬高試驗和腰椎的活動度。患側和健側的各種感覺閾值的顯著差異可以在基線處探測到。所有的評估結果都對應到以後的硬膜外注射類固醇的效果。患側皮區的冷覺閾值的提高(A-纖維功能障礙)和NPS的改善成正相關,而觸覺閾值和振動覺閾值(Aß-纖維功能障礙)和NPS的改善成負相關,熱覺閾值(C纖維)與任何結果均無相關性。這些結果提示對於坐骨神經痛患者定量的感覺測試可能會成為一種用於選擇治療方法的重要工具(硬膜外注射類固醇還是者手術治療),而且可能有助於這些患者疼痛發生的機制。

(王柯 譯 薛張綱 校)

Quantitative Sensory Testing (QST) is a psycho-physiological test used to identify dysfunction of individual nerve fiber types. In the present study, we investigated whether selective nerve fiber dysfunction, as assessed by QST, correlates with the effectiveness of epidural steroid injections (ESI) in patients with lumbar radiculopathy. Twenty patients with unilateral painful sciatica caused by disc herniation participated in this open study. Before ESI, quantitative thermal and mechanical sensory testing was conducted at the most painful dermatome and the contralateral dermatome. The primary outcome measure used was the self-recording of pain intensity twice daily with a 0–10 numerical pain scale (NPS). Secondary efficacy measures included the Short Form of the McGill Pain Questionnaire, the straight leg raising test, and the lumbar range of motion. A significant difference in all types of sensory thresholds between the affected and the contralateral dermatomes was detected at baseline. All outcome measures improved subsequent to the ESI. A significant positive correlation was found between the increase in cold sensation thresholds of the affected dermatome (A-fiber dysfunction) and the improvement in NPS. The increase in touch and vibration thresholds (As-fiber dysfunction) was found to be inversely correlated with the improvement in NPS. No correlation was found between heat sensation thresholds (C fibers) and any of the outcome measures. These results suggest that QST has the potential to be an important tool in the selection of the appropriate treatment (e.g., ESI versus surgery) for patients with sciatica and may assist in identifying the mechanisms of pain generation in these patients.

等壓高氧狀態下測量大腦的氧合:腦外傷時使用組織微探子,近紅外線分光鏡及頸靜脈血氧測定三種技術的比較

Measuring Cerebral Oxygenation During Normobaric Hyperoxia:A Comparison of Tissue Microprobes, Near-Infrared Spectroscopy, and Jugular Venous Oximetry in Head Injury

Andrew D. McLeod, FRCA*, Farrell Igielman, FRCA*, Clare Elwell, PhD, Mark Cope, PhD, and Martin Smith, FRCA*

Departments of *Neuroanaesthesia and Medical Physics & Bioengineering, The National Hospital for Neurology and Neurosurgery, University College London Hospitals & Centre for Anaesthesia, UCL, London, United Kingdom

Anesth Analg 2003 97: 851-856.

我們在八位患嚴重腦外傷並處於等張高氧合的病人中使用了近紅外線分光鏡測量了頸靜脈血氧飽和度,腦氧分壓和大腦氧指數的相應變化。這些病患在使用基礎吸入氧分數(FIO2)通氣一段時間後,將吸入氧分數改為1.0 ,0.6和低於基礎值0.02-0.05。在FIO2 1.0 和 0.6的情況下,頸靜脈的氧飽和度(平均值+-標準差)從基礎狀態的79% ± 7%分別提高到89%± 6% 和84% ± 8%;腦的氧分壓從30 ± 5 mm Hg分別提高到147 ± 36 mm Hg 和63 ± 6 mm Hg;組織氧指數從78% ± 3%分別增加到83% ± 5% 和80% ± 4%。當吸入氧分數降到基礎值以下時組織氧指數降為76.2% ± 3.0%。這三種變數以相似的形式在變化但變化的程度和反應的速度是不同的。在腦外傷中吸入氧分數影響了腦氧合的變化。

(方芳 譯 薛張綱 校)

Measuring Cerebral Oxygenation DWe measured simultaneous changes in jugular venous oxygen saturation, brain tissue oxygen tension, and cerebral tissue oxygen index by using near-infrared spectroscopy during normobaric hyperoxygenation in eight severely brain-injured patients. Patients were ventilated at their baseline fraction of inspired oxygen (FIO2), followed by stepped changes in FIO2 to 1.0, 0.6, and 0.02–0.05 less than baseline. There was an increase (P < 0.01) in jugular venous saturation (mean ± SD) from a baseline value of 79% ± 7% to 89% ± 6% and 84% ± 8% at an FIO2 of 1.0 and 0.6, respectively. The changes in brain tissue oxygen tension were from a baseline of 30 ± 5 mm Hg to 147 ± 36 mm Hg and 63 ± 6 mm Hg at an FIO2 of 1.0 and 0.6, respectively (P < 0.01). The baseline tissue oxygen index was 78% ± 3%, and this increased to 83% ± 5% and 80% ± 4% at an FIO2 of 1.0 and 0.6, respectively. There was a reduction (P < 0.05) in tissue oxygen index to 76.2% ± 3.0% when the FIO2 was reduced to less than baseline. The changes in the three variables followed similar patterns but varied in their degree and speed of response. During brain injury, FIO2 affects measured variables of cerebral oxygenation.

在晚期分娩時鞘內注射25ug芬太尼合用2.5mg的重比重布比卡因與合用等比重布比卡因相比延長了鎮痛時間

Hyperbaric Bupivacaine 2.5 mg Prolongs Analgesia Compared with Plain Bupivacaine When Added to Intrathecal Fentanyl 25 μg in Advanced Labor

Wendy H. L. Teoh, MBBS, and Alex T. H. Sia, MMed

Department of Anesthesia, KK Women’s & Children’s Hospital, Singapore

Anesth Analg 2003 97: 873-877

我們調查了脊麻的病人在給予鞘內首劑低比重芬太尼後,使用連續的鞘內重比重布比卡因的效果。37位宮口大於5cm的初產婦被隨機的分為兩組。組P(N=19)使用25ug芬太尼和2.5mg等比重布比卡因。組H(N=18)使用25ug芬太尼和2.5mg重比重布比卡因(加入8%葡萄糖)。兩種混合液使用連續鞘內注射(25ug芬太尼用2ml生理鹽水稀釋,在0.5 mL 0.5%布比卡因後輸入)。病人保持軀幹抬高30度位30分鐘。我們使用0-100的疼痛分度法。在使用硬膜外/脊麻鎮痛前,阻滯後5,15,30分鐘分別評估。H組患者平均鎮痛時間(122 min;範圍 80�210 min)比P組(95 min; 範圍 75�125 min)時間長。H組窄的皮膚感覺阻滯區(最高的感覺阻滯平面T8,組P在T4)。兩組副反應相似。在這種背景下,重比重布比卡因比等比重布比卡因延長了椎管內鎮痛的時間。

(方芳 譯 薛張綱 校)

We investigated the effect of sequential administration of intrathecal (IT) hyperbaric bupivacaine (after the initial administration of IT hypobaric fentanyl) on the duration of spinal analgesia. Thirty-seven nulliparous parturients with a cervical dilation 5 cm were randomized to receive either IT fentanyl 25 μg and plain bupivacaine 2.5 mg (group P; n = 19) or IT fentanyl 25 μg and hyperbaric (with 8% glucose) bupivacaine 2.5 mg (group H; n = 18). The two components of the IT injectate were administered sequentially (fentanyl 25 μg diluted in 2 mL of normal saline, immediately followed by 0.5 mL of 0.5% bupivacaine). Patients were then positioned with their torso elevated at 30° for 30 min. Pain scores using 0–100 visual analog scales were collected before combined spinal/epidural analgesia and at 5, 15, and 30 min after the block. Patients in Group H had a longer median duration of analgesia (122 min; range, 80–210 min) than Group P (95 min; range, 75–125 min) (P < 0.01). Group H also had a more limited dermatomal spread (median highest sensory level of T8 versus T4 in group P; P < 0.05). The side-effect profile was similar. Under these circumstances, hyperbaric bupivacaine conferred an increased duration of IT analgesia compared with plain bupivacaine.

家兔中肺對羅比卡因和左旋布比卡因的攝取

Pulmonary Uptake of Ropivacaine and Levobupivacaine in Rabbits

Shigeo Ohmura, MD, Akiko Sugano, MD, Masayuki Kawada, MD, and Ken Yamamoto, MD

Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan

Anesth Analg 2003 97: 893-897.

通過肺對局麻藥的攝取可以減低靜脈內誤注的毒性。我們比較了在家兔體內注射一個劑量後肺對羅比卡因和左旋布比卡因的攝取。16只處於麻醉狀態的兔子被隨機分為羅比卡因和左旋布比卡因兩組。下腔靜脈內快速注射羅比卡因或左旋布比卡因0.5 mg/kg和??綠(一種靜脈內指示劑)0.25 mg/kg。動脈內以1.2-s的間隔連續採樣30 s。每個樣品中局麻藥和??綠的濃度取決於局麻藥在肺中的首過攝取。左旋布比卡因的首過攝取(31.4% ± 8.3%)比羅比卡因(22.9% ± 5.6%)大,最大的動脈藥物濃度羅比卡因(21.2 ± 2.8 μg/mL)比左旋布比卡因(18.6 ± 1.9 μg/mL)大。我們推出使用一個劑量的藥物後肺對左旋布比卡因的攝取比羅比卡因大。因此,靜脈誤注羅比卡因比左旋布比卡因心臟毒性小的優勢可能通過減少肺的攝取而實現的。

(方芳 譯 薛張綱 校)

Local anesthetic toxicity produced by an inadvertent IV injection is attenuated by the pulmonary uptake of local anesthetics. We compared the pulmonary uptake of ropivacaine and levobupivacaine after a bolus injection in rabbits. Sixteen anesthetized rabbits were randomly assigned to either a ropivacaine group or a levobupivacaine group. A bolus containing ropivacaine or levobupivacaine 0.5 mg/kg and indocyanine green (an intravascular indicator) 0.25 mg/kg was injected rapidly into the vena cava. Arterial blood samples were collected serially at 1.2-s intervals for 30 s. Concentrations of local anesthetic and indocyanine green in each sample were determined for the calculation of first-pass uptake of a local anesthetic in the lung. The first-pass uptake of levobupivacaine (31.4% ± 8.3%; mean ± SD) was larger than that of ropivacaine (22.9% ± 5.6%), and the maximum arterial concentration of ropivacaine (21.2 ± 2.8 μg/mL) was larger than that of levobupivacaine (18.6 ± 1.9 μg/mL). We conclude that the pulmonary uptake of levobupivacaine is larger than that of ropivacaine after a bolus injection. Therefore, the advantages of ropivacaine over levobupivacaine in terms of less cardiovascular toxicity may be offset by the smaller pulmonary uptake after an inadvertent IV injection.