Anesthesia & Analgesia

October 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

細菌性中心靜脈導管污染的早期識別

(陸緒偉譯 薛張綱校)

Early Identification of Bacteria Leading to Central Venous Catheter Contamination

Christian Jeske, Claus Raedler, Achim von Goedecke, Andreas Mayr, Guido Hinterberger, Ch. Aspoeck, Cornelia Lass-Floerl, and Arnulf Benzer

Anesth Analg 2003 97: 940-943.

心臟手術後全身炎症反應和心肺併發症的增加與腫瘤壞死因數多態性現象有關

(周潔 譯 王祥瑞 校)

Tumor Necrosis Factor Gene Polymorphism Is Associated with Enhanced Systemic Inflammatory Response and Increased Cardiopulmonary Morbidity After Cardiac Surgery

Hildur Tomasdottir, Hjortur Hjartarson, Anne Ricksten, Carina Wasslavik, Anders Bengtsson, and Sven-Erik Ricksten

Anesth Analg 2003 97: 944-949.

通過經導電導管法的壓力-容量環評價圍術期左心室功能

(王士雷 莊心良 校)

Sven A. F. Tulner, Robert J. M. Klautz, Gerda L. van Rijk-Zwikker, Frank H. M. Engbers, Jeroen J. Bax, Jan Baan, Ernst E. van der Wall, Robert A. Dion, and Paul Steendijk

Perioperative Assessment of Left Ventricular Function by Pressure-Volume Loops Using the Conductance Catheter Method

Anesth Analg 2003 97: 950-957.

冠狀動脈搭橋術的血液使用:CPBHct、性別、年齡和體重等因素的影響

(王士雷 莊心良 校)

Blood Use in Patients Undergoing Coronary Artery Bypass Surgery: Impact Of Cardiopulmonary Bypass Pump, Hematocrit, Gender, Age, and Body Weight

Bharathi H. Scott, Frank C. Seifert, Peter S. A. Glass, and Roger Grimson

Anesth Analg 2003 97: 958-963.

Jarvik 2000TM 左室支援系統植入術的麻醉管理

(方芳譯 薛張綱校)

Anesthetic Management for Implantation of the Jarvik 2000TM Left Ventricular Assist System

Nancy A. Nussmeier, Charles B. Probert, Douglas Hirsch, John R. Cooper, Jr., Igor D. Gregoric, Timothy J. Myers, and O. H. Frazier

Anesth Analg 2003 97: 964-971.

急性等容血液稀釋時寒戰對血流動力學和代謝影響

(忻紀華 譯 王祥瑞 校)

The Hemodynamic and Metabolic Effects of Shivering During Acute Normovolemic Hemodilution

Valeria Perez-de-Sa, Doris Cunha-Goncalves, Henning Schou, Christer Jonmarker, and Olof Werner

Anesth Analg 2003 97: 972-978.

冠狀動脈搭橋術後發生四肢癱瘓一例報導

(王士雷 莊心良 校)

Tetraplegia After Coronary Artery Bypass Grafting (Case Report)

Susumu Fujioka, Yoshinari Niimi, Kazuo Hirata, Itaru Nakamura, and Shigeho Morita

Anesth Analg 2003 97: 979-980.

病態肥胖病人行腹主動脈瘤血管內修復術的麻醉技術

(陸緒偉譯 薛張綱校)

An Alternative Anesthetic Technique for the Morbidly Obese Patient Undergoing Endovascular Repair of an Abdominal Aortic Aneurysm (Case Report)

Maurice Lippmann, Sonny Rubin, Richard Ginsburg, Rodney A. White, Jason Lee, James Lee, and Ihab Aziz

Anesth Analg 2003 97: 981-983.

PEDIATRIC ANESTHESIA:

小兒麻醉中通過神經刺激器直接確定硬膜外導管的位置

(忻紀華 譯 王祥瑞 校)

Confirmation of Direct Epidural Catheter Placement Using Nerve Stimulation in Pediatric Anesthesia

Susan M. Goobie, Carolyne J. Montgomery, Rahul Basu, Jillian McFadzean, Gerald J. O’Connor, Kenneth Poskitt, and Ban C. H. Tsui

Anesth Analg 2003 97: 984-988.

吸入NO治療小兒和成人急性低氧性呼吸衰竭的Meta分析

(王士雷 莊心良 校)

Inhaled Nitric Oxide for Acute Hypoxic Respiratory Failure in Children and Adults: A Meta-analysis (Review Article)

Jennifer Sokol, Susan Elizabeth Jacobs, and Desmond Bohn

Anesth Analg 2003 97: 989-998.

五天的連顱雙生兒分離術的麻醉管理

(張俊峰譯 薛張綱校)

Anesthetic Management for a Five-Day Separation of Craniopagus Twins (Case Report)

Theodore G. Wong, Biauw-Chi Ong, Claire Ang, and Huei-Leng Chee

Anesth Analg 2003 97: 999-1002.

AMBULATORY ANESTHESIA:

門診病人膝關節鏡手術使用腰肌間隙神經阻滯、蛛網膜下腔麻醉及全身麻醉的比較

(朱輝 譯 王祥瑞 校)

A Comparison of Psoas Compartment Block and Spinal and General Anesthesia for Outpatient Knee Arthroscopy

Christopher J. Jankowski, James R. Hebl, Michael J. Stuart, Michael G. Rock, Mark W. Pagnano, Christopher M. Beighley, Darrell R. Schroeder, and Terese T. Horlocker

Anesth Analg 2003 97: 1003-1009.

外科病人的補充治療

(王士雷 莊心良 校)

The Use of Complementary and Alternative Medicines by Surgical Patients: A Follow-Up Survey Study

Shu-Ming Wang, Alison A. Caldwell-Andrews, and Zeev N. Kain

Anesth Analg 2003 97: 1010-1015.

術前炎症反應對門診關節鏡病人關節內給予?羅昔康鎮痛功效的作用

(張俊峰譯 薛張綱校)

The Effects of Preoperative Inflammation on the Analgesic Efficacy of Intraarticular Piroxicam for Outpatient Knee Arthroscopy

Seval Izdes, Sibel Orhun, Sacit Turanli, Ezgi Erkilic, and Orhan Kanbak

Anesth Analg 2003 97: 1016-1019.

ANESTHETIC PHARMACOLOGY:

應用鉀通道啟動劑利魯唑測試鉀通道是否與異氟醚穩定性有關

(朱輝 譯 王祥瑞 校)

The Use of the Potassium Channel Activator Riluzole to Test Whether Potassium Channels Mediate the Capacity of Isoflurane to Produce Immobility

Yilei Xing, Yi Zhang, Caroline R. Stabernack, Edmond I Eger, II, and Andrew T. Gray

Anesth Analg 2003 97: 1020-1024.

異氟醚對細胞內線粒體中三磷酸腺?致敏鉀通道的作用機制

(鄧羽霄 譯 王祥瑞 校)

Intracellular Mechanism of Mitochondrial Adenosine Triphosphate-Sensitive Potassium Channel Activation with Isoflurane

Yuri Nakae, Shinji Kohro, Quinn H. Hogan, and Zeljko J. Bosnjak

Anesth Analg 2003 97: 1025-1032.

吸入麻醉藥的MAC是否可以作為評價動物抗傷害作用的工具?

(王士雷 莊心良 校)

Can Determining the Minimum Alveolar Anesthetic Concentration of Volatile Anesthetic Be Used as an Objective Tool to Assess Antinociception in Animals?

Marie-Agnes Docquier, Patricia Lavand’homme, Christian Ledermann, Valerie Collet, and Marc De Kock

Anesth Analg 2003 97: 1033-1039.

丙泊酚或硫賁妥鈉麻醉腦電爆發抑制相比反射消失:氣管插管的兒茶酚胺和心血管反應變化的差異

(張俊峰譯 薛張綱校)

Electroencephalographic Burst Suppression Versus Loss of Reflexes Anesthesia with Propofol or Thiopental: Differences of Variance in the Catecholamine and Cardiovascular Response to Tracheal Intubation

Seppo T. Mustola, Gerhard A. Baer, Juhani K. Toivonen, Anne Salomaki, Mika Scheinin, Heini Huhtala, Pekka Laippala, and Ville Jantti

Anesth Analg 2003 97: 1040-1045.

氟馬西尼對接受異氟醚或安定慢性治療後的大鼠耐藥性的改變

(鄧羽霄 譯 王祥瑞 校)

Flumazenil Attenuates Development of Tolerance to Diazepam After Chronic Treatment of Mice with Either Isoflurane or Diazepam

Ron Flaishon, Avi A. Weinbroum, Leo Veenman, Svetlana Leschiner, Valerie Rudick, and Moshe Gavish

Anesth Analg 2003 97: 1046-1052.

左旋-、右旋和消旋布比卡因對LPS誘發的中性粒細胞遷移的影響

(王士雷 莊心良 校)

The Effects of S(-)-, R(+)-, and Racemic Bupivacaine on Lysophosphatidate-Induced Priming of Human Neutrophils

Markus W. Hollmann, Katrin Kurz, Susanne Herroeder, Danja Struemper, Klaus Hahnenkamp, Noud S. Berkelmans, Christel G. den Bakker, and Marcel E. Durieux

Anesth Analg 2003 97: 1053-1058.

氯化騰喜龍和新斯的明對鼠氣道平滑肌作用的相互影響

(齊波 譯 王祥瑞 校)

Interactions of Edrophonium with Neostigmine in the Rat Trachea

Osamu Shibata, Masataka Saito, Maki Yoshimura, Masakazu Yamaguchi, Tetsuji Makita, and Koji Sumikawa

Anesth Analg 2003 97: 1059-1063.

TECHNOLOGY, COMPUTING, AND SIMULATION:

二種液體輸注系統(H1025FMS 2000)快速輸注的實驗室評價

(王士雷 莊心良 校)

A Laboratory Evaluation of the Level 1 Rapid Infuser (H1025) and the Belmont Instrument Fluid Management System (FMS 2000) for Rapid Transfusion

Mark E. Comunale

Anesth Analg 2003 97: 1064-1069.

手術室工作人員呼出氣中七氟醚的含量

(鍾鳴譯 薛張綱校)

Sevoflurane in Exhaled Air of Operating Room Personnel

G. Summer, P. Lirk, K. Hoerauf, U. Riccabona, F. Bodrogi, H. Raifer, M. Deibl, J. Rieder, and W. Schobersberger

Anesth Analg 2003 97: 1070-1073.

Level 1和測距儀加壓輸液裝置的相對性能

(齊波 譯 王祥瑞 校)

Relative Performance of the Level 1 and Ranger Pressure Infusion Devices (Technical Communication)

Michael P. Eaton and Anahat K. Dhillon

Anesth Analg 2003 97: 1074-1077.

疼痛對術後短時間內與健康有關的生活質量的影響

(王士雷 莊心良 校)

The Effect of Pain on Health-Related Quality of Life in the Immediate Postoperative Period

Christopher L. Wu, Mohammad Naqibuddin, Andrew J. Rowlingson, Steven A. Lietman, Roland M. Jermyn, and Lee A. Fleisher

Anesth Analg 2003 97: 1078-1085.

PAIN MEDICINE:

持續的用羅呱卡因浸潤傷口可以減少肩部手術後鎮痛藥的用量

(鍾鳴譯 薛張綱校)

Continuous Wound Infiltration with Ropivacaine Reduces Pain and Analgesic Requirement After Shoulder Surgery

Andre Gottschalk, Marc-Alexander Burmeister, Patricia Radtke, Markus Krieg, Faraneh Farokhzad, Sonja Kreissl, Matthias Strauss, and Thomas Standl

Anesth Analg 2003 97: 1086-1091.

術中靜脈注射氯胺酮和硬膜外鎮痛:腎臟術後的鎮痛Intraoperative

(王士雷 莊心良 校)

Intraoperative Intravenous Ketamine in Combination with Epidural Analgesia: Postoperative Analgesia After Renal Surgery

Alper Kararmaz, Sedat Kaya, Haktan Karaman, Selim Turhanoglu, and Mehmet Ali Ozyilmaz

Anesth Analg 2003 97: 1092-1096.

在長期接受阿片類治療的患者中進行行為監測和尿的毒理學檢測

(鍾鳴譯 薛張綱校)

Behavioral Monitoring and Urine Toxicology Testing in Patients Receiving Long-Term Opioid Therapy

Nathaniel P. Katz, Summer Sherburne, Michael Beach, Robert J. Rose, Janet Vielguth, Joyce Bradley, and Gilbert J. Fanciullo

Anesth Analg 2003 97: 1097-1102.

鼠表面麻醉中嗎啡和氨苯丁酯間的協同鎮痛作用

(殷文淵 譯 王祥瑞 校)

Analgesic Synergy Between Topical Morphine and Butamben in Mice

Yuri A. Kolesnikov, Marcela Cristea, and Gavril W. Pasternak

Anesth Analg 2003 97: 1103-1107.

NMDA受體在疼痛中的作用(綜述)

(王士雷 莊心良 校)

The Role of N-Methyl-D-Aspartate (NMDA) Receptors in Pain: A Review (Review Article)

Andrei B. Petrenko, Tomohiro Yamakura, Hiroshi Baba, and Koki Shimoji

Anesth Analg 2003 97: 1108-1116.

帶狀皰疹病毒引起的嚴重的急性內臟疼痛

(張俊峰譯 薛張綱校)

Severe Acute Visceral Pain from Varicella Zoster Virus (Case Report)

Jacqueline M. Hyland and John Butterworth

Anesth Analg 2003 97: 1117-1118.

CRITICAL CARE AND TRAUMA:

膜表面溶質溶劑交換在白蛋白降低人造半滲透膜液體滲透係數中的作用

(殷文淵 譯 王祥瑞 校)

The Contribution of Solute-Solvent Exchange at the Membrane Surface to the Reduction by Albumin of the Hydraulic Permeability Coefficient of an Artificial Semipermeable Membrane

Tsuneo Tatara

Anesth Analg 2003 97: 1137-1142.

用人工神經網路評價機械通氣時呼吸系統的順應性

(王士雷 莊心良 校)

Estimating Respiratory System Compliance During Mechanical Ventilation Using Artificial Neural Networks

Gaetano Perchiazzi, Rocco Giuliani, Loreta Ruggiero, Tommaso Fiore, and Goran Hedenstierna

Anesth Analg 2003 97: 1143-1148.

Cefepime Cefpirome:對肌酐清除率的影響的差別

(方芳譯 薛張綱校)

Cefepime Versus Cefpirome: The Importance of Creatinine Clearance

Jeffrey Lipman, Steven C. Wallis, and Robert J. Boots

Anesth Analg 2003 97: 1149-1154. u

NEUROSURGICAL ANESTHESIA:

七氟醚和異丙酚對腦缺血大鼠腦內神經遞質濃度的影響

(陳潔 譯 王祥瑞 校)

The Effect of Sevoflurane and Propofol on Cerebral Neurotransmitter Concentrations During Cerebral Ischemia in Rats

Kristin Engelhard, Christian Werner, William E. Hoffman, Bianca Matthes, Manfred Blobner, and Eberhard Kochs

Anesth Analg 2003 97: 1155-1161.

急性和慢性脊髓損傷病人氣管插管時的心血管反應

(王士雷 莊心良 校)

Cardiovascular Responses to Endotracheal Intubation in Patients with Acute and Chronic Spinal Cord Injuries

Kyung Y. Yoo, Seong W. Jeong, Seok J. Kim, In H. Ha, and JongUn Lee

Anesth Analg 2003 97: 1162-1167.

REGIONAL ANESTHESIA:

0.5%1% 利多卡因硬膜外複合七氟醚全麻中抑制經皮電刺激反應七氟醚需要量的研究

(方芳譯 薛張綱校)

Sevoflurane Requirements to Suppress Responses to Transcutaneous Electrical Stimulation During Epidural Anesthesia with 0.5% and 1% Lidocaine

Atsuko Shono, Yoji Saito, Shinichi Sakura, Katsushi Doi, and Naomi Yokokawa

Anesth Analg 2003 97: 1168-1172.

布比卡因和羅呱卡因用於持續外周神經阻滯後的急性肌肉毒性作用

(陳潔 譯 王祥瑞 校)

The Acute Myotoxic Effects of Bupivacaine and Ropivacaine After Continuous Peripheral Nerve Blockades

Wolfgang Zink, Christoph Seif, Jurgen R. E. Bohl, Nicola Hacke, Peter M. Braun, Barbara Sinner, Eike Martin, Rainer H. A. Fink, and Bernhard M. Graf

Anesth Analg 2003 97: 1173-1179.

持續腰叢神經阻滯後出現坐骨神經麻痹一例

(王士雷 莊心良 校)

Sciatic Nerve Palsy After Total Hip Arthroplasty in a Patient Receiving Continuous Lumbar Plexus Block (Case Report)

Bruce Ben-David, Rama Joshi, and Jacques E. Chelly

Anesth Analg 2003 97: 1180-1182.

GENERAL ARTICLES:

直接壓迫男性的無髓鞘尺神經纖維比女性更易損傷

(方芳譯 薛張綱校)

Men Are More Susceptible Than Women to Direct Pressure on Unmyelinated Ulnar Nerve Fibers

Robert C. Morell, Richard C. Prielipp, Timothy N. Harwood, Robert L. James, and John F. Butterworth

Anesth Analg 2003 97: 1183-1188.

常規清洗和高壓滅菌不能清除可重複使用喉罩上的蛋白質沉澱物

(齊波 譯 王祥瑞 校)

Routine Cleaning and Autoclaving Does Not Remove Protein Deposits from Reusable Laryngeal Mask Devices

Gay Clery, Joseph Brimacombe, Tisha Stone, Christian Keller, and Sandy Curtis

Anesth Analg 2003 97: 1189-1191.

應用ProSealTM喉面罩時繼發於Foldover 錯位的胃內容物誤吸

(王士雷 莊心良 校)

Aspiration of Gastric Contents During Use of a ProSealTM Laryngeal Mask Airway Secondary to Unidentified Foldover Malposition (Case Report)

Joseph Brimacombe and Christian Keller

Anesth Analg 2003 97: 1192-1194.

心臟手術後全身炎症反應和心肺併發症的增加與腫瘤壞死因數多態性現象有關

Tumor Necrosis Factor Gene Polymorphism Is Associated with Enhanced Systemic Inflammatory Response and Increased Cardiopulmonary Morbidity After Cardiac Surgery

Hildur Tomasdottir, MD PhD, Hjortur Hjartarson, MD, Anne Ricksten, PhD, Carina Wasslavik, BSc, Anders Bengtsson, MD PhD, and Sven-Erik Ricksten, MD PhD

Departments of Anesthesia and Intensive Care and Clinical Chemistry, Section of Molecular Biology, Sahlgrenska University Hospital, Goteborg, Sweden

Anesth Analg 2003;97:944-949


體外迴圈改變了心肺功能並導致了全身性的炎症反應。介導上述變化的細胞因數包括腫瘤壞死因數(
TNF-α和白介素。由於TNF基因位點的多型現象,在一些嚴重的外傷和膿毒血症病人,可表現為高TNF-α水平和高死亡率。我們假設在進行選擇性心臟手術的病人中,TNF位點雙等位基因的多型現象與促炎介質的釋放和心肺併發症的發生有關。隨機選擇95名進行常規心臟手術的病人連續進行TNF基因型,血漿TNF-α濃度,白介素-6和心肺併發症情況的監測。TNF基因型通過排序方法測得。與TNFB1因數純合體和雜合體的病人(n=53)相比,TNFB2因數純合體的病人(n=42)表現出較高的TNF-α濃度峰值(11.3+1.37.8+0.7pg/mL;P=0.013)和白介素-6數值(153+2787+7pg/mL;P=0.010)。TNFB2因數純合體的病人左心室功能不良(31%9%P=0.029)和術後肺功能不良(24%6%P=0.016)的發生率較高,並易發生低氧合指數(29+1.936.1+1.8P=0.013)。所以說,TNFB2因數純合體的病人在心臟手術後易於發生全身嚴重的炎症反應,擁有較高的心肺併發症的發生率。

(周潔 譯 王祥瑞 校)

Cardiopulmonary bypass induces a systemic inflammatory response characterized by alterations in cardiopulmonary function. Mediators for this morbidity are the cytokines tumor necrosis factor (TNF)- and interleukins. A genomic polymorphism within the TNF locus is associated with increased TNF- levels and high mortality in severe trauma and sepsis. We assessed the relationship of biallelic polymorphisms of the TNF locus in patients undergoing elective cardiac surgery to release of proinflammatory cytokines and cardiopulmonary morbidity. TNF genotypes, plasma concentrations of TNF-, interleukin-6, and cardiopulmonary morbidity were studied in 95 unselected, consecutive patients undergoing routine cardiac surgery. TNF genotypes were determined by the solid-phase minisequencing method. Patients homozygous for the TNFB2 allele (n = 42) displayed larger peak concentrations of TNF- (11.3 ± 1.3 versus 7.8 ± 0.7 pg/mL; P = 0.013) and interleukin-6 (153 ± 27 versus 87 ± 7 pg/mL; P = 0.010) when compared with patients homozygous or heterozygous for TNFB1 (n = 53). The TNFB2 homozygotes had a higher incidence of left ventricular dysfunction (31% versus 9%; P = 0.029; odds ratio 3.84 [95% confidence interval, 1.40–24.3]), postoperative pulmonary dysfunction (24% versus 6%; P = 0.016; odds ratio 5.21 [95% confidence interval, 1.49–18.3]), and a lower pulmonary oxygenation index (29 ± 1.9 versus 36.1 ± 1.8; P = 0.013). Patients homozygous for the TNFB2 allele may develop an enhanced systemic inflammatory response with an increased risk of cardiopulmonary morbidity after cardiac surgery.

 

急性等容血液稀釋時寒戰對血流動力學和代謝影響

The Hemodynamic and Metabolic Effects of Shivering During Acute Normovolemic Hemodilution

Valeria Perez-de-Sa, MD PhD, DEAA*, Doris Cunha-Goncalves, MD DEAA, Henning Schou, MD PhD, Christer Jonmarker, MD PhD, DEAA, and Olof Werner, MD PhD, DEAA*

*Children’s Hospital, the Heart Lung Division, and the Department of Anesthesia and Intensive Care at the University Hospital, Lund, Sweden, and from Children’s Hospital and Regional Medical Center, The University of Washington, Seattle, Washington

Anesth Analg 2003;97:972-978

為了評價極度血液等容稀釋後寒戰對血動和代謝的影響,我們以芬太尼-咪唑安定-潘庫溴胺對16頭豬行麻醉。通過體表降溫行輕度低溫(36.5o+/-0.1℃),將豬隨機分為對照組(血紅蛋白118+/-3g/L)和血液稀釋組(血紅蛋白52+/-2g/L)。後組中以等滲的林格式液和右旋糖?70混合液置換。減少潘庫溴胺的注入速度誘發寒戰。兩組中寒戰均使氧耗增加(p<0.001)。首先,這種反應可通過氧輸出率(ER)來得到很好的補償,但當氧耗為基礎值的2.3+/-0.2倍時,貧血組動物的混合血靜脈氧飽和度(SvO2=18%+/-2%,PvO2=22.5+/-1.5mmHg)和ER82%+/-3%)達危險水平。對照組直至氧耗大最大時亦未出現危險狀態(3.7+/-0.3倍的基礎值)。貧血組中的最大氧耗較小(2.9+/-0.1倍的基礎值),在此水平兩頭豬心肌產生乳酸,其中一頭死於室顫。貧血組中的冠狀動脈灌注壓顯著降低(p<0.01)。我們得出結論在此實驗模型中,通過氧耗的監測發現最大寒戰受限於血液稀釋的動物,並且通過乳酸的攝取減少和產生證實左室氧平衡處於邊緣狀態。

(忻紀華 譯 王祥瑞 校)

To assess the hemodynamic and metabolic effects of shivering during extreme normovolemic hemodilution, we anesthetized 16 pigs with fentanyl-midazolam-pancuronium. Mild hypothermia (36.5° ± 0.1°C) was induced by surface cooling, and the animals were randomized to either a control group (hemoglobin 118 ± 3 g/L) or a hemodilution group (hemoglobin 52 ± 2 g/L). In the latter group, blood was replaced with an isotonic Ringer’s acetate/dextran 70 solution. Shivering was allowed to occur by a controlled decrease in the infusion rate of pancuronium. Shivering increased oxygen consumption (O2) in both groups (P < 0.001). Initially, this was predominantly compensated for by an increased oxygen extraction ratio (ER), but when O2 was 2.3 ± 0.2 times baseline, critical levels of mixed venous oxygenation (SO2 = 18% ± 2%; PO2 = 22.5 ± 1.5 mm Hg) and ER (82% ± 3%) were recorded in anemic animals. Control animals did not reach critical levels until O2 was maximal (3.7 ± 0.3 times baseline). Maximal attained O2 was less (2.9 ± 0.1 times baseline) in the anemic animals (P = 0.01), and at this stage two of these pigs had myocardial lactate production, one of which died in ventricular fibrillation. Coronary perfusion pressure was significantly less (P < 0.001) in the anemic animals. We conclude that in this experimental model, maximal shivering as measured by O2 was limited in hemodiluted animals, and left ventricular oxygen balance was marginal, as evidenced by a decreased lactate uptake and extraction.

小兒麻醉中通過神經刺激器直接確定硬膜外導管的位置

Confirmation of Direct Epidural Catheter Placement Using Nerve Stimulation in Pediatric Anesthesia

Susan M. Goobie, MD FRCPC*, Carolyne J. Montgomery, MD FRCPC*, Rahul Basu, MD*, Jillian McFadzean, MD*, Gerald J. O’Connor, MD FRCPC*, Kenneth Poskitt, MD FRCPC, and Ban C. H. Tsui, MSC MD, FRCPC

Departments of *Anesthesiology and Pain Management, and Radiology, British Columbia’s Children’s Hospital and University of British Columbia, Vancouver, BC; Department of Anesthesiology & Pain Medicine, University of Alberta Hospitals, Edmonton, AB

Anesth Analg 2003;97:984-988

在小兒中我們評估了以低電流刺激器(Tsui 試驗)來判斷和直接肯定硬膜外導管放置的成功率。30例病人在Tsui 試驗中通過硬膜外導管的放置接受了標準麻醉和用藥。比較硬膜外導管放置的想要節段和實際節段。除了一例病人外均見肌肉活動。肌肉活動的中值電位為5.3mA。通過攝片檢查想要節段和實際節段平均差1.8個節段。臨床成功率為93.9%Tsui 試驗的陽性預示率為82%;即28例病人中的23例,Tsui 試驗直接將硬膜外導管的位置肯定在兩個椎間隙內。對於盲探操作以皮膚標記和試驗劑量來判斷導管位置而言,本實驗在放置硬膜外導管時直接定位並無多大優點。

(忻紀華 譯 王祥瑞 校)

We evaluated the success rate of using low current electrical stimulation (the Tsui test) to identify and confirm direct epidural catheter placement in a pediatric population. Thirty subjects received a standard anesthetic and administration of the Tsui test on epidural placement. The distribution of myotomal activity was recorded. The intended and actual level of the epidural catheter was compared. Myotomal activity was seen in all patients but one. The median current resulting in myotomal activity was 5.3 mA. The median difference between the intended and actual level as confirmed on radiograph was 1.8 levels. The clinical success rate was 93.9%. The positive predictive value of the Tsui test was 82%; i.e., in 23 of 28 cases, the Tsui test correctly identified the position of the epidural catheter tip within 2 vertebral levels. The test did not offer any added advantage when used in the setting of directly placed epidural catheters in our institution over "blind" methods already used to confirm catheter position when using cutaneous landmarks and test dosing.

門診病人膝關節鏡手術使用腰肌間隙神經阻滯、蛛網膜下腔麻醉及全身麻醉的比較

A Comparison of Psoas Compartment Block and Spinal and General Anesthesia for Outpatient Knee Arthroscopy

Christopher J. Jankowski, MD*, James R. Hebl, MD*, Michael J. Stuart, MD, Michael G. Rock, MD, Mark W. Pagnano, MD, Christopher M. Beighley, MS, Darrell R. Schroeder, MS, and Terese T. Horlocker, MD*

Departments of *Anesthesiology, Orthopedic Surgery, and Biostatistics, Mayo Clinic, Rochester, Minnesota

Anesth Analg 2003;97:1003-1009

門診病人膝關節鏡手術使用哪種麻醉技術最為合理還有爭議。在這項研究中,我們評估關於腰肌間隙神經阻滯、蛛網膜下腔麻醉及全身麻醉的手術條件,病人滿意度,恢復時間以及術後鎮痛的需求等。我們隨機地將60名患者分成三組,第一組使用異丙酚/氧化亞氮/芬太尼全身麻醉,第二組使用6mg布比卡因和15μg芬太尼,第三組使用1.5%甲呱卡因40ml進行腰肌間隙神經阻滯。所有的患者靜脈注射酮咯酸並關節內注射布比卡因。結果全身麻醉的20名患者中有13名(65%)需要到麻醉後恢復室,21名蛛網膜下腔麻醉患者沒有人進恢復室,而腰肌間隙神經阻滯的19名患者有1名(5%)進恢復室(P0.001〉。三組麻醉的患者從手術結束到符合出醫院標準的平均時間分別為131129110分鐘。在醫院內,全身麻醉組45%的患者需要阿片類鎮痛劑,而蛛網膜下腔麻醉組和腰肌間隙神經阻滯組分別為14%21%P=0.087)。組間關於首次需要鎮痛的時間或需要阿片類鎮痛的患者數量沒有差異。全身麻醉患者術後30分鐘(P=0.032)和6090120分鐘(P0.001〉的疼痛評分最高。病人對麻醉方法(P=0.025)和疼痛處理(P=0.009)的滿意度在組間有顯著的差異;全身麻醉組所獲得的滿意度更低。我們得出結論:對於膝關節鏡手術如果要考慮資源的利用,病人的滿意程度和術後鎮痛處理的話,腰肌間隙神經阻滯和蛛網膜下腔麻醉要優於全身麻醉。

(朱輝 譯 王祥瑞 校)

The optimal anesthetic technique for outpatient knee arthroscopy remains controversial. In this study, we evaluated surgical operating conditions, patient satisfaction, recovery times, and postoperative analgesic requirements associated with psoas compartment block, general anesthetic, or spinal anesthetic techniques. Sixty patients were randomized to receive a propofol/nitrous oxide/fentanyl general anesthetic, spinal anesthesia with 6 mg of bupivacaine and 15 μg of fentanyl, or psoas compartment block with 40 mL of 1.5% mepivacaine. All patients received IV ketorolac and intraarticular bupivacaine. The frequency of postanesthesia recovery room admission was 13 (65%) of 20 for patients receiving general anesthesia, compared with 0 of 21 for patients receiving spinal anesthesia and 1 (5%) of 19 for patients receiving psoas block (P < 0.001). The median time from the end of surgery to meeting hospital discharge criteria did not differ across groups (131, 129, and 110 min for general, spinal, and psoas groups, respectively). In the hospital, 45% of general anesthesia patients received opioid analgesics, compared with 14% of spinal anesthesia and 21% of psoas block patients (P = 0.087). There was no difference among groups with respect to the time of first analgesic use or the number of patients requiring opioid analgesia. Pain scores were highest in patients receiving general anesthesia at 30 min (P = 0.032) and at 60, 90, and 120 min (P < 0.001). Patient satisfaction with anesthetic technique (P = 0.025) and pain management (P = 0.009) differed significantly across groups; patients receiving general anesthesia reported lower satisfaction ratings. We conclude that spinal anesthesia or psoas block is superior to general anesthesia for knee arthroscopy when considering resource utilization, patient satisfaction, and postoperative analgesic management.

應用鉀通道啟動劑利魯唑測試鉀通道是否與異氟醚穩定性有關

The Use of the Potassium Channel Activator Riluzole to Test Whether Potassium Channels Mediate the Capacity of Isoflurane to Produce Immobility

Yilei Xing, MD, Yi Zhang, MD, Caroline R. Stabernack, MD, Edmond I Eger, II, MD, and Andrew T. Gray, MD PhD

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

Anesth Analg 2003;97:1020-1024

吸入麻醉劑在有害刺激時期產生穩定性最初發生於脊髓。在這項研究中,我們研究鉀通道啟動劑KCNK亞型是否能夠改變揮發性麻醉劑的性能。我們4小時內給54SD大白鼠鞘內或靜脈注射非特異性KCNK啟動物利魯唑測定最低肺泡有效濃度。靜脈或鞘內注射利魯唑的量能同等地降低異氟醚的最低肺泡有效濃度但不會導致永久地損傷或死亡。我們得出結論:儘管利魯唑有麻醉效應,但從靜脈或鞘內注射相同劑量的效應提示全身的吸收和對大腦的作用要比脊髓明顯。

(朱輝 譯 王祥瑞 校)

Inhaled anesthetics produce immobility during noxious stimulation, primarily by actions on the spinal cord. In this study, we examined whether activation of potassium channels of the KCNK subfamily alters volatile anesthetic potency. We measured the change in isoflurane minimum alveolar anesthetic concentration (MAC) during 4-h intrathecal or IV infusions of the nonspecific KCNK activator riluzole in 54 Sprague-Dawley rats. IV or intrathecal infusions of riluzole doses that did not result in permanent injury or death equally decreased isoflurane MAC. We conclude that although riluzole exhibited anesthetic effects, the similar dose response from IV or intrathecal infusion suggests systemic absorption and actions in the brain rather than the spinal cord.

異氟醚對細胞內線粒體中三磷酸腺?致敏鉀通道的作用機制

Intracellular Mechanism of Mitochondrial Adenosine Triphosphate-Sensitive Potassium Channel Activation with Isoflurane

Yuri Nakae, MD PhD*, Shinji Kohro, MD PhD*, Quinn H. Hogan, MD*, and Zeljko J. Bosnjak, PhD*,

Departments of *Anesthesiology and Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2003;97:1025-1032

異氟醚對細胞內線粒體中三磷酸腺?致敏鉀通道的明確作用機制仍舊不清楚,儘管線粒體中三磷酸腺?致敏鉀通道可能是異氟醚介導調控的。我們研究了使用異氟醚後引起線粒體中三磷酸腺?致敏鉀通道改變的各種細胞內信號。在幾內亞豬的心肌細胞中發現線粒體的螢光黃素蛋白與三磷酸腺?致敏鉀通道有關。為明確異氟醚是否介導MFF,我們進行了這項實驗。將細胞放在Tyrode’s液中,其中包含異氟醚(1.0±0.1mM)或二氮?或兩者都有(每組n=10)。在另一項實驗中在給予異氟醚的同時加用以下藥物:腺?或腺?受體拮抗的SPTPKC的激動劑PMAPDBuPKC抑制劑多黏菌素B ;烙胺酸激?抑制劑 ;有絲分裂啟動蛋白激?抑制劑SB203580(每組n=10)。異氟醚可能通過二氮?介導MFF(100μM),二氮?也能增加異氟醚介導MFFMPA(0.2μM),PDBu(100μM)和腺?(100μM)介導MFF。然而SPT(100μM), 多黏菌素B(50μM), (200nM), A(0.5μM),SB203580(10μM)都不能抑制異氟醚的作用。我們的結論顯示異氟醚,腺?和PKC能啟動線粒體中三磷酸腺?致敏鉀通道。然而我們的資料不支援異氟醚的作用途徑包括腺?,PKC,烙氨酸激?,有絲分裂啟動蛋白激?。這些結果提示異氟醚能直接啟動內線粒體中三磷酸腺?致敏鉀通道。

(鄧羽霄 譯 王祥瑞 校)

The precise mechanism of isoflurane and mitochondrial adenosine triphosphate-sensitive potassium channel (mitoKATP) interaction is still unclear, although the mitoKATP is involved in isoflurane-induced preconditioning. We examined the role of various intracellular signaling systems in mitoKATP activation with isoflurane. Mitochondrial flavoprotein fluorescence (MFF) was measured to quantify mitoKATP activity in guinea pig cardiomyocytes. To confirm isoflurane-induced MFF, cells were exposed to Tyrode’s solution containing either isoflurane (1.0 ± 0.1 mM) or diazoxide and then both drugs together (n = 10 each). In other studies, the following drugs were each added during isoflurane administration: adenosine or the adenosine receptor antagonist 8-(p-sulfophenyl)-theophylline (SPT); the protein kinase C (PKC) activators phorbol-12-myristate-13-acetate (PMA) and phorbol-12,13-dibutyrate (PDBu); the PKC inhibitors polymyxin B and staurosporine; the tyrosine kinase inhibitor lavendustin A; or the mitogen-activated protein kinase inhibitor SB203580 (n = 10 each). Isoflurane potentiated MFF induced by diazoxide (100 μM), and diazoxide also increased isoflurane-induced MFF. PMA (0.2 μM), PDBu (1 μM), and adenosine (100 μM) induced MFF. However, SPT (100 μM), polymyxin B (50 μM), staurosporine (200 nM), lavendustin A (0.5 μM), and SB203580 (10 μM) all failed to inhibit the effect of isoflurane. Our results show that isoflurane, adenosine, and PKC activate mitoKATP. However, our data do not support an action of isoflurane through pathways involving adenosine, PKC, tyrosine kinase, or mitogen-activated protein kinase. These results suggest that isoflurane may directly activate mitoKATP.

氟馬西尼對接受異氟醚或安定慢性治療後的大鼠耐藥性的改變

Flumazenil Attenuates Development of Tolerance to Diazepam After Chronic Treatment of Mice with Either Isoflurane or Diazepam

Ron Flaishon, MD*, Avi A. Weinbroum, MD*, Leo Veenman, PhD, Svetlana Leschiner, PhD, Valerie Rudick, MD*, and Moshe Gavish, PhD,

*Department of Anesthesiology and Critical Care Medicine, Tel Aviv Sourasky Medical Center, and The Sackler Faculty of Medicine, Tel Aviv, Israel; Department of Pharmacology, Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel; and Rappaport Family Institute for Research in the Medical Sciences, Haifa, Israel

Anesth Analg 2003;97:1046-1052


通過揭示異氟醚的作用機制,我們研究了氟馬西尼對接受了異氟醚或安定慢性治療後的大鼠的影響。大鼠事先給予安定、異氟醚、鹽水、給予或不給予氟馬西尼。兩周後評估對異氟醚和安定的反應,以及中樞苯二氮卓受體(
CBR)的結合能力。事先給予大劑量異氟醚(0.5%)的大鼠在水平線實驗中比事先給予鹽水(0.4%)的大鼠要差(p<0.05)。當事先加用氟馬西尼後這些區別就沒有了。給予安定的實驗組中,20%的安定組和11%的異氟醚組的大鼠沒有通過水平線實驗,事先加用氟馬西尼後這兩組數字分別是50%44%p<0.02)。在加用或不加用氟馬西尼的鹽水實驗組中這兩組數字分別是80%100%。無論給予異氟醚或安定在加用氟馬西尼後都會引起CBR的增加。無論是異氟醚還是安定,氟馬西尼都減緩了長期治療後的耐藥性。氟馬西尼的使用還減少了CBR的結合。這些研究提示了異氟醚可能和安定的作用途徑相同都是通過?-氨基丁酸系統結合CBR

(鄧羽霄 譯 王祥瑞 校)

In an effort to clarify the mechanism of action of isoflurane, we studied the effect of flumazenil on mice chronically treated with isoflurane or diazepam. Mice were pretreated with diazepam, isoflurane, or saline, with and without flumazenil. After 2 wk, responses to isoflurane and diazepam were assessed, and central benzodiazepine receptor (CBR) binding characteristics were assayed. Mice pretreated with isoflurane failed the horizontal wire test at a larger isoflurane concentration (0.5%) compared with saline-pretreated mice (0.4%) (P < 0.05). These differences did not occur when flumazenil was added to the pretreatment. After the administration of diazepam, 20% of diazepam- and 11% of isoflurane-pretreated mice failed the horizontal wire test, versus 50% and 44% when flumazenil was added to either drug (P < 0.002) and 80% and 100% in the saline and saline plus flumazenil-treated mice. The increased CBR density due to flumazenil was attenuated by the coadministration of isoflurane or diazepam. Flumazenil attenuated the development of tolerance to diazepam after chronic treatment with diazepam or isoflurane and attenuated the development of tolerance to isoflurane. Isoflurane, like diazepam, attenuated the effect of flumazenil on CBR ligand binding. These findings suggest that isoflurane shares a mechanism of action with diazepam, probably via the gamma-aminobutyric acid system, most probably the CBR.

氯化騰喜龍和新斯的明對鼠氣道平滑肌作用的相互影響

Interactions of Edrophonium with Neostigmine in the Rat Trachea

Osamu Shibata, MD, Masataka Saito, MD, Maki Yoshimura, MD, Masakazu Yamaguchi, MD, Tetsuji Makita, MD, and Koji Sumikawa, MD

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

Anesth Analg 2003;97:1059-1063


氣道平滑肌的毒蕈堿M3受體具有垂直部位和變構部位兩個結合部位。氯化騰喜龍可能是與變構部位相結合,來抑制垂直結合部位活性的。為了進一步驗證,我們檢測了氯化騰喜龍對新斯的明誘發的鼠氣道平滑肌收縮和磷脂?肌醇反應的影響。在實驗中增加新斯的明的劑量使其終點濃度達到100μM後,加入氯化騰喜龍,然後檢測氣道平滑肌的環形張力。實驗結束後發現克-漢氏溶液中氯化騰喜龍和新斯的明的含量較新鮮溶液增加了三倍。將氣道平滑肌切片用肌醇溶液和含有或不含有氯化騰喜龍的新斯的明溶液進行培養。測量溶液中磷酸肌醇(IP3)的含量。實驗資料用平均數±SE表達,並採用變異分析法進行統計資料分析,如P<0.05表示有統計學意義。新斯的明誘發的張力和IP1的增加被100μM或更高濃度的氯化騰喜龍所減弱。如果用新鮮的克-漢氏溶液進行沖洗可將其逆轉並超過對照水平的80%。實驗結果表明可以與鼠氣道平滑肌毒蕈堿M3受體的變構部位相結合,從而抑制M3受體垂直結合部位的活性。

(齊波 譯 王祥瑞 校)

The muscarinic M3 receptor of airway smooth muscle has both an orthosteric binding site and an allosteric binding site. Edrophonium may bind to the allosteric site, resulting in the inhibition of the action of the orthosteric site. Therefore, we examined the effects of edrophonium on neostigmine-induced contractile and phosphatidylinositol responses of rat trachea. Neostigmine (100 μM in final concentration) was added, and ring tension was examined by the addition of edrophonium. After the completion of the experiment, Krebs-Henseleit (K-H) solution containing both edrophonium and neostigmine was changed three times with fresh K-H solution, and the tension was recorded. Tracheal slices were incubated with [3H]myo-inositol and 100 μM neostigmine in the presence or absence of edrophonium. The [3H]inositol monophosphate (IP1) was measured. Data were expressed as mean ± SE. Statistical significance (P < 0.05) was determined with analysis of variance. Neostigmine-induced tension and IP1 accumulation were attenuated by edrophonium at concentrations of 100 μM or more. This attenuation was reversed to more than 80% of control levels by washing with fresh K-H solution. The results suggest that edrophonium would bind to the allosteric site, resulting in the inhibition of the action of the orthosteric site of muscarinic M3 receptors of rat trachea.

Level 1和測距儀加壓輸液裝置的相對性能

Relative Performance of the Level 1 and Ranger Pressure Infusion Devices

Michael P. Eaton, MD, and Anahat K. Dhillon, BA

Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York

Anesth Analg 2003;97:1074-1077


加壓輸液裝置在手術室病人輸液時經常被使用,但可能會導致罕見的嚴重靜脈氣栓。本實驗的主要目的是在實驗室中檢驗Level 1和測距儀加壓輸液裝置的相對性能。相對於Level 1加壓輸液裝置,測距儀發生氣栓機率小、輸液速度快,但不能對液體或血進行加熱。雖然Ranger加壓輸液裝置在防止氣栓形成方面具有較高安全性,但其加熱性能差,說明最佳的加壓輸液裝置目前還沒有製造出來。

(齊波 譯 王祥瑞 校)

Pressure infusion devices are often used to administer fluids in the operating room, but they may rarely be associated with serious venous air embolism. We studied the performance of the Level 1 and the Ranger Pressure Infusor in the laboratory. The Ranger delivered less air and delivered fluid faster than the Level 1 but did not warm fluid or blood as well. Although the Ranger device may be safer in terms of the risk of air embolism, its inferior warming performance shows that the optimal pressure infusion device has yet to be manufactured.

鼠表面麻醉中嗎啡和氨苯丁酯間的協同鎮痛作用

Analgesic Synergy Between Topical Morphine and Butamben in Mice

Yuri A. Kolesnikov, MD PhD*, Marcela Cristea, MD, and Gavril W. Pasternak, MD PhD

*Department of Anesthesiology and Laboratory of Molecular Neuropharmacology, Memorial-Sloan Kettering Cancer Center, New York, New York

Anesth Analg 2003;97:1103-1107


一系列研究表明在熱輻射尾部擺動試驗中對老鼠尾部施行表面麻醉時,利多卡因是一種有效的鎮痛藥。此外,利多卡因和嗎啡混合施行表面麻醉時發現兩者之間有相互協同作用。在近期研究中,我們證明了在熱輻射尾部擺動試驗中使用氨苯丁酯,苯坐卡因(Benzocaine),和布比卡因進行表面麻醉是有效的。在這個試驗中,利多卡因有一個效果的最高限度,顯示為一條兩階段曲線,大劑量顯著降低了對基線水平的反應。相比較而言,氨苯丁酯是一條S型的劑量依賴反應曲線,,沒有象利多卡因的兩階段曲線,這說明氨苯丁酯進行表面麻醉也許優於利多卡因。在這個模型中苯坐卡因(Benzocaine)和布比卡因都顯示了劑量依賴性的鎮痛作用。的確,協同作用在氨苯丁酯/嗎啡混合液中更為顯著。我們也觀察了苯坐卡因(Benzocaine)和嗎啡的協同作用。雖然等測熱輻射儀記錄分析提示有協同作用,但統計學上沒有差異。這些研究提示一系列局麻藥在熱輻射尾部擺動試驗中都可以產生表面麻醉作用,其中幾個和嗎啡可以相互產生協同作用。在局麻藥試驗中,氨苯丁酯似乎有幾個在有和沒有嗎啡時的藥理學特徵,提示它也許優於其他局麻藥。總之,這些觀察提示將阿片類和局麻藥混和進行表面麻醉可以證實有臨床價值。

(殷文淵 譯 王祥瑞 校)

Studies have revealed that lidocaine is an effective analgesic when applied topically to the tail of a mouse in the radiant heat tail-flick assay. In addition, the topical combination of lidocaine with morphine revealed synergistic interactions between the two drugs. In the current studies, we demonstrate that topical butamben, benzocaine, and bupivacaine are active in the radiant heat tail-flick assay. In this assay, topical lidocaine has a ceiling effect and displays a biphasic curve, with large doses markedly decreasing the responses almost to baseline levels. In contrast, butamben has an S-shape dose-dependent response in the assay and did not display a biphasic curve as seen with lidocaine, suggesting that topical butamben may have advantages over lidocaine. Both benzocaine and bupivacaine also showed dose-dependent analgesic activity in this model. Like lidocaine, butamben/morphine combinations displayed synergistic interactions. Indeed, the synergy appeared more prominent with a butamben/morphine combination. We also observed synergy between topical benzocaine and morphine. Although the bupivacaine/morphine combination was suggestive of synergy on isobolographic analysis, it did not achieve statistical significance. These studies indicate that a series of local anesthetics are all active topically in the radiant heat tail-flick assay in mice and that several interact synergistically with morphine. Of the local anesthetics tested, butamben seemed to have several pharmacological characteristics, alone and in combination with morphine, which suggest that it may be superior to the other local anesthetics. Together, these observations suggest that topical combinations of opioids and local anesthetics may prove clinically valuable.

膜表面溶質溶劑交換在白蛋白降低人造半滲透膜液體滲透係數中的作用

The Contribution of Solute-Solvent Exchange at the Membrane Surface to the Reduction by Albumin of the Hydraulic Permeability Coefficient of an Artificial Semipermeable Membrane

Tsuneo Tatara, MD

Department of Anesthesiology, School of Medicine, Kyorin University, Tokyo, Japan

Anesth Analg 2003;97:1137-1142

在緊急情況下由於組織出血而輸注人造膠體會降低毛細血管膜的液體滲透係數(Lp)。可是,這些膠體微分子調節毛細血管膜的液體滲透係數(Lp)的分子機制還不清楚。在這個研究中,我調查了白蛋白對人造半滲透膜Lp的影響,從而確定是否膜表面溶質溶劑交換在膠體微分子降低人造半滲透膜液體滲透係數中起作用。使用這種人造膜是由於很明確的知道它的分子量限制大小,此外,這種膜和白蛋白之間沒有任何的相互作用。使用一種流體靜壓差(P)為30cmH2O的滲透量細胞測量有或沒有白蛋白情況下P030cmH2O時的超濾膜(分子量為30000Lp值。在所有濃度中,與沒有白蛋白時相比,白蛋白在P030cmH2O時都降低了Lp值(P<0.05)。這些降低差不多呈濃度依賴方式,為半數8 wt%白蛋白所引起。這個發現也許可以大概解釋當白蛋白濃度升高時膜表面溶質溶劑交換減緩。我們的結論是膠體微分子導致的毛細血管膜的液體滲透係數(Lp)降低不單單是毛細血管膜孔道阻塞所引起,也是膜表面溶質溶劑交換所導致的。

(殷文淵 譯 王祥瑞 校)

Infusion of synthetic colloids for tissue edema in inflammatory conditions reduces the hydraulic permeability coefficient (Lp) of capillary membranes. However, the molecular mechanisms governing the modulation of Lp of capillary membranes by these colloidal macromolecules are not known. In this study, I examined the effect of albumin on the Lp of an artificial semipermeable membrane to determine whether solute-solvent exchange at the membrane surface may contribute to reduction of the Lp of capillary membranes by colloidal macromolecules. The artificial membrane was used because of its well known molecular weight cutoff size and the absence of any specific interaction of albumin with such membranes. Lp values of ultrafiltration membranes (molecular weight cutoff, 30,000) were measured by using an osmotic flow cell at a hydrostatic pressure difference (P) of 30 cm H2O in the absence of albumin or in the presence of albumin (2.4–8 wt%) at a P of 0 or 30 cm H2O. At all concentrations, albumin decreased Lp values at both P values of 0 and 30 cm H2O compared with those in the absence of albumin (P < 0.05). These reductions were almost in a concentration-dependent manner and by almost half at 8 wt% albumin. This finding may be appropriately explained by slowed solute-solvent exchange at the membrane surface as the albumin concentration is increased. It is concluded that the reduction in the Lp of capillary membranes by colloidal macromolecules is not caused solely by plugging of the capillary pores, but also by solute-solvent exchange at the capillary membrane surface.

七氟醚和異丙酚對腦缺血大鼠腦內神經遞質濃度的影響

The Effect of Sevoflurane and Propofol on Cerebral Neurotransmitter Concentrations During Cerebral Ischemia in Rats

Kristin Engelhard, MD*, Christian Werner, MD*, William E. Hoffman, PhD, Bianca Matthes, BS, Manfred Blobner, MD*, and Eberhard Kochs, MD*

*Klinik fur Anaesthesiologie and Institut fur klinische Chemie und Pathobiochemie, Technische Universitat Munchen, Klinikum rechts der Isar, Munich, Germany; and Department of Anesthesiology, University of Illinois at Chicago

Anesth Analg 2003;97:1155-1161


七氟醚和異丙酚可能通過減少中樞和外周的兒茶酚胺具有神經保護作用。我們通過測量體內兒茶酚胺和大腦神經遞質的濃度來評價麻醉藥物的上述作用。40只雄性Sprague-Dawley大鼠隨機分為:芬太尼和笑氣/氧氣(對照組),2.0%的七氟醚組,0.8-1.2mg/kg/min異丙酚組。通過一側頸總動脈夾閉和控制性降壓至平均動脈壓32±2mmHg來產生腦缺血模型(30分鐘)。持續測量顱溫、動脈血氣、PH值,使用高壓液相色譜儀測定大腦兒茶酚胺和谷氨酸濃度以及血漿兒茶酚胺濃度。在缺血過程中,迴圈兒茶酚胺幾乎被異丙酚完全抑制,而七氟醚只能中度抑制。七氟醚和異丙酚分別減少75%58%腦內去甲腎上腺素,谷氨酸濃度均減少60%。這些結果提出了一個問題:七氟醚和異丙酚是否通過減少迴圈兒茶酚胺來產生腦保護。腦組織兒茶酚胺介導的缺血損傷與我們的觀點相一致。

(陳潔 譯 王祥瑞 校)

Sevoflurane and propofol are neuroprotective possibly by attenuating central or peripheral catecholamines. We evaluated the effect of these anesthetics on circulating catecholamines and brain neurotransmitters during ischemia in rats. Forty male Sprague-Dawley rats were randomly assigned to one of the following treatment groups: fentanyl and N2O/O2 (control), 2.0% sevoflurane, 0.8–1.2 mg · kg-1 · min-1 of propofol, and sham-operated rats with fentanyl and N2O/O2. Ischemia (30 min) was produced by unilateral common carotid artery occlusion plus hemorrhagic hypotension to a mean arterial blood pressure of 32 ± 2 mm Hg. Pericranial temperature, arterial blood gases, and pH value were maintained constant. Cerebral catecholamine and glutamate concentrations, sampled by microdialysis, and plasma catecholamine concentrations were analyzed using high-pressure liquid chromatography. During ischemia, circulating catecholamines were almost completely suppressed by propofol but only modestly decreased with sevoflurane. Sevoflurane and propofol suppressed brain norepinephrine concentration increases by 75% and 58%, respectively, compared with controls. Intra-ischemia cerebral glutamate concentration was decreased by 60% with both sevoflurane and propofol. These results question a role of circulating catecholamines as a common mechanism for cerebral protection during sevoflurane and propofol. A role of brain tissue catecholamines in mediating ischemic injury is consistent with our results.

布比卡因和羅呱卡因用於持續外周神經阻滯後的急性肌肉毒性作用

The Acute Myotoxic Effects of Bupivacaine and Ropivacaine After Continuous Peripheral Nerve Blockades

Wolfgang Zink, MD*,, Christoph Seif, MD, Jurgen R. E. Bohl, MD, Nicola Hacke*, Peter M. Braun, MD, Barbara Sinner, MD*,, Eike Martin, MD*, Rainer H. A. Fink, PhD, and Bernhard M. Graf, MD PhD*

*Department of Anesthesiology and Institute of Physiology & Pathophysiology, University of Heidelberg, Heidelberg, Germany; Department of Urology, University of Kiel, Kiel, Germany; and Department of Neuropathology, University of Mainz, Mainz, Germany

Anesth Analg 2003;97:1173-1179


布比卡因會引起肌肉損傷,而羅呱卡因的潛在肌肉毒性作用尚未闡明。因此,我們比較等效量的布比卡因和羅呱卡因對骨骼肌的作用。將股神經鞘置入麻醉小豬上,隨後注射20ml布比卡因(5mg/Ml)或羅呱卡因(7.5 mg/Ml),接著持續注入2.5 mg/Ml布比卡因和3.75 mg/Ml的羅呱卡因大於6小時,對照組接受等容量的生理鹽水,最後在注射部位取樣肌肉標本,經過處理和染色後,通過組織學方法觀察到肌肉損傷,(0=無破壞,3=肌肉壞死)。注射鹽水組僅觀察到間質水腫,布比卡因組發現嚴重的組織損傷(2.3±0.7分),羅呱卡因導致的肌肉損傷範圍小得多(1.3±0.8分)。另外,布比卡因還引起了肌纖維的凋亡。總之,兩種藥物均引起了肌肉組織學上的破壞。布比卡因導致壞死和凋亡,與之相比,羅呱卡因引起的組織損傷要小得多。我們的結論是:羅呱卡因與布比卡因相比,肌肉毒性作用更低。

(陳潔 譯 王祥瑞 校)

Bupivacaine causes muscle damage. However, the myotoxic potency of ropivacaine is still unexplored. Therefore, we performed this study to compare the effects of bupivacaine and ropivacaine on skeletal muscle tissue in equipotent concentrations. Femoral nerve catheters were inserted into anesthetized minipigs, and 20 mL of either bupivacaine (5 mg/mL) or ropivacaine (7.5 mg/mL) was injected. Subsequently, bupivacaine (2.5 mg/mL) and ropivacaine (3.75 mg/mL) were continuously infused over 6 h. Control animals were treated with corresponding volumes of normal saline. Finally, muscle samples were dissected at injection sites. After processing and staining, histological patterns of muscle damage were blindly examined, scored (0 = no damage to 3 = myonecrosis), and statistically analyzed. After normal saline, only interstitial edema was found. Bupivacaine treatment caused severe tissue damage (score, 2.3 ± 0.7), whereas ropivacaine induced fiber injury of a significantly smaller extent (score, 1.3 ± 0.8). Furthermore, bupivacaine, but not ropivacaine, induced apoptosis in muscle fibers. In summary, both drugs induce muscle damage with similar histological patterns. Compared with bupivacaine, which induces both necrosis and apoptosis, the tissue damage caused by ropivacaine is significantly less severe. We conclude that ropivacaine’s myotoxic potential is more moderate in comparison with that of bupivacaine.

常規清洗和高壓滅菌不能清除可重複使用喉罩上的蛋白質沉澱物

Routine Cleaning and Autoclaving Does Not Remove Protein Deposits from Reusable Laryngeal Mask Devices

Gay Clery, MB ChB, FRCA, MD*, Joseph Brimacombe, MB ChB, FRCA, MD*,, Tisha Stone, MB BS*, Christian Keller, MD, and Sandy Curtis, RN

*Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia; James Cook University, Townsville, Queensland, Australia; Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria; and Central Sterile Supply Department, Cairns Base Hospital, Cairns, Australia

Anesth Analg 2003;97:1189-1191


本實驗的目的是檢驗常規清洗和高壓滅菌不能清除可重複使用喉罩(LMAS)上的蛋白質沉澱物這一假說。所檢驗的標準和彎曲喉罩均來自同一所醫院。每一個喉罩均用含?的洗滌劑手洗3分鐘,用消毒劑在最高85℃溫度下機洗14分鐘,然後在75℃溫度下乾燥30分鐘後,用多孔滲水的薄膜包裝並置於134℃高溫下滅菌4分鐘。當將LMAS浸泡於1.2%的藻紅B溶液中時可發現沾染在其表面上的蛋白質沉澱物。在喉罩套囊和導管的內外表面均可檢測到沾染的蛋白質沉澱物。根據沾染面積的比例可將沾染的嚴重程度進行評分:無沾染、輕度沾染(>0%20%)、中度沾染(>20%80%)和嚴重沾染(>80%100%)。本實驗共收集了59個喉罩,其中包括16個標準式,43個彎曲式。檢驗結果發現有15個(94%)標準式喉罩和39個(91%)彎曲式喉罩被蛋白質沉澱物沾染。所有喉罩均為輕度沾染,且兩種喉罩的內表面沾染程度均小於其外表面或邊緣(P0.004=。另外還發現導管的沾染程度比套囊任何部位都輕(P0.02=。兩個作為對照的未經使用的喉罩均沒有被沾染。因此可得出結論:常規清洗和高壓滅菌不能清除可重複使用喉罩上的蛋白質沉澱物。

(齊波 譯 王祥瑞 校)

We tested the hypothesis that routine cleaning and autoclaving does not remove protein deposits from reusable laryngeal mask airways (LMAs). All previously used classic and flexible LMAs from a single hospital were tested. Each LMA was hand-washed in an enzymatic solution for 3 min, machine-washed with a disinfectant for 14 min at up to 85°C; dried for 30 min at 75°C, packaged in porous film, and autoclaved for 4 min at 134°C. Protein deposits were detected by immersion in a 1.2% erythrosin B solution, which stains for proteins present on surfaces. The outer surface, inner surface, and edges of the cuff, and the outer and inner surface of the airway tube were examined for the uptake of stain. The severity of staining was scored according to the percentage of surface area stained: nil, mild (>0%–20%), moderate (>20%–80%), and severe (>80%–100%). Fifty-nine LMAs were collected (16 classic and 43 flexible). Staining was detected on 15 (94%) classic LMAs and 39 (91%) flexible LMAs. All staining was graded as mild. Staining was less common on the inner surface than the outer surface or edges for both devices (all P < 0.004). Staining was less common with the airway tube than any location on the cuff (all P < 0.02). Two unused LMAs used as controls were without staining. We conclude that routine cleaning and autoclaving does not remove protein material from reusable LMAs.

病態肥胖病人行腹主動脈瘤血管內修復術的麻醉技術

An Alternative Anesthetic Technique for the Morbidly Obese Patient Undergoing Endovascular Repair of an Abdominal Aortic Aneurysm

Maurice Lippmann, MD*, Sonny Rubin, MD*, Richard Ginsburg, MD*, Rodney A. White, MD, Jason Lee, MD, James Lee, MD, and Ihab Aziz, MD

Depatrments of *Anesthesiology and Surgery, Harbor-UCLA Medical Center, Torrance, California

Anesth Analg 2003 97: 981-983.

 

腹主動脈瘤行開放性修復術已有多年了。發病率與腹主動脈瘤的自然史及開放性外科修復有關。最近採用了一項手術創傷更小的開放性修復。目前病例分析總結了一項對於病態肥胖病人的侵入創傷更小的麻醉技術。

(陸緒偉譯 薛張綱校)

Abdominal aortic aneurysms have been treated by open operative repair for many years. A frequent rate of morbidity is associated with the natural history of abdominal aortic aneurysms in combination with open surgical repair. Recently a new technique that is less surgically invasive has been developed as an alternative to open repair. The present case report outlines a less invasive anesthetic technique for the morbidly obese patient.

 

細菌性中心靜脈導管污染的早期識別

Early Identification of Bacteria Leading to Central Venous Catheter Contamination

Christian Jeske, MD*, Claus Raedler, MD*, Achim von Goedecke, MD*, Andreas Mayr, MD*, Guido Hinterberger, Ch. Aspoeck, MD, Cornelia Lass-Floerl, MD, and Arnulf Benzer, MD*

*Department of Anaesthesia and Department of Hygiene, University Hospital Innsbruck, Innsbruck, and Department of Hygiene, General Hospital St. Poelten, St. Poelten, Austria

Anesth Analg 2003 97: 940-943

 

導管相關性血液感染(CRBSI)是中心靜脈置管病人的常見問題。我們應用DNA分析技術,將在由於CRBSI症狀而取出的中心靜脈導管頭端分離的細菌與穿刺針、擴皮針、導絲上分離的細菌作比較。在由於CRBSI症狀而取出的中心靜脈導管中七分之五在其頭端分離的細菌與在穿刺設備上分離的細菌基本相同,證明這些事件中的導管污染是由於開始穿刺時接觸細菌所致。這些發現對於具有CRBSI危險病人應用抗菌素預防或治療將是重要的。

(陸緒偉譯 薛張綱校)

Catheter-related bloodstream infections (CRBSI) are a common problem in patients after central venous catheterization. Using DNA analysis we compared bacteria found on the tip of central venous catheters removed because of clinical signs of CRBSI with bacteria found on needle, dilator, and guidewire used for insertion of these catheters. In five of seven central venous catheters removed because of clinical signs of CRBSI, bacteria on the catheter tip were genetically identical to bacteria found on the insertion device, proving that catheter contamination in these cases was caused by contacting bacteria during the initial puncture. These findings may be important for antibiotic prophylaxis or therapy in patients at risk for CRBSI.

Jarvik 2000TM 左室支援系統植入術的麻醉管理

Anesthetic Management for Implantation of the Jarvik 2000TM Left Ventricular Assist System

Nancy A. Nussmeier, MD*, Charles B. Probert, MD*, Douglas Hirsch, MD*, John R. Cooper, Jr., MD*, Igor D. Gregoric, MD, Timothy J. Myers, BS, and O. H. Frazier, MD

*Department of Cardiovascular Anesthesiology and The Cullen Cardiovascular Surgical Research Laboratories, Texas Heart Institute at St. Lukes Episcopal Hospital, Houston, Texas

Anesth Analg 2003 97: 964-971.

Jarvik 2000心臟是通過一個旋轉的篷式單葉產生持續無搏動軸流的左室支援系統。Jarvik 2000心臟對於麻醉及圍手術期的考慮不同于傳統的支援系統。Jarvik 2000心臟是通過左胸切開術並借助隔離左肺植入左心室的。短期的心肺轉流及心室導絲有助於植入術。經食管心動超聲對於確認設備在心室內的確切位置及主動脈輸出量是必要的,它主要是通過觀察主動脈瓣在左室達到足夠充盈量時的開放。由於持續灌流裝置在系統及肺動脈阻力較低時功能最好,甲??酮常用作正性肌力藥物。在最先應用Jarvik 2000心臟的10個病人,泵提供了最高達8 L/min的心輸出量(取決於前負荷、後負荷及泵速)。這些手術無早期圍手術期死亡。平均支援時間為81.2天(13214天)。這10個病人中的7個存活到進行心臟移植手術,並且在泵支持期間達到了完全軀體康復。

(方芳譯 薛張綱校)

The Jarvik 2000 HeartTM is a left ventricular assist device that produces continuous nonpulsatile axial flow by means of a single, rotating, vaned impeller. Anesthetic and perioperative considerations of the Jarvik 2000 HeartTM differ from those of conventional assist devices. The Jarvik 2000 is implanted within the left ventricle through a left thoracotomy, which is aided by left lung isolation. A brief period of cardiopulmonary bypass and induced ventricular fibrillation facilitate implantation. Transesophageal echocardiography is essential to assure proper intraventricular positioning of the device and aortic outflow, confirmed by observation of aortic valve opening in the presence of adequate left ventricular volume. Because continuous flow devices function best in the presence of lower systemic and pulmonary vascular resistance, milrinone was preferentially used as an inotropic drug. In the first group of 10 patients to receive the Jarvik 2000, the pump provided a cardiac output of up to 8 L/min, depending on preload, afterload, and pump speed. There were no early perioperative deaths. The average support duration was 81.2 days; the range was 13214 days. Seven of the 10 patients survived to transplantation. Survivors underwent complete physical rehabilitation during pump support.

Cefepime Cefpirome:對肌酐清除率的影響的差別

Cefepime vesus Cefpirome:The Importance of Creatinine Clearance

Jeffrey Lipman, FFA (Crit Care), FJFICM, Steven C. Wallis, PhD, and Robert J. Boots, FRACP FJFICM ;

Intensive Care Unit, Royal Brisbane Hospital; and Department of Anaesthesiology and Critical Care, University of Queensland, Queensland, Australia

Anesth Analg 2003;97:1149-1154

.

標準推薦劑量的ß類?胺抗菌素在無腎功能障礙的外科監護室(IC)病人會導致較低的血藥濃度。我們比較兩個第四代頭孢菌素(cefepimecefpirome)的藥代動力學差異並比較肌酐清除率(CLCR)與藥物清除(CL)的關係。 兩種藥物分別每天兩次給藥。分別在初次和第二次給藥後抽取血標本,分別測量和比較血漿藥濃度及藥代動力學分析。Cefepimecefpirome的藥代動力學在IC中類似。任何CL的差異明顯決定CLCR 的差異。儘管在正常的血漿肌酐濃度下有54%病人在大於給藥間隔20%的時段內抗菌素濃度低於最低抑菌濃度(MIC) (4 mg/L)34%的病人CLCR >144 mL/min (比預期的最大值120 mL/min20%)。只有 CLCR 是抗菌素CL的獨立預測因素。有些IC病人有很高的CLCR,卻有很低的抗菌素血濃度。縮短給藥間隔或持續輸注可阻止低血藥濃度的發生並在較長時間內保持血藥濃度高於MIC。由於不能床邊直接測量頭孢菌素血藥濃度,我們建議監測CLCR以預測臨床低血藥濃度的發生。 結論:有些監護室病人有較高的肌酐清除率而致較低的四代頭孢菌素血藥濃度。臨床必須維持這些藥物的血漿濃度大於最低抑菌濃度。因為不可能常規測量頭孢菌素血藥濃度,我們建議監測CLCR以預測臨床低血藥濃度並以此調整給藥劑量。

(方芳譯 薛張綱校)

Standard dosage recommendations for s-lactam antibiotics can result in very low drug levels in intensive care (IC) patients without renal dysfunction. We compared the pharmacokinetics of two fourth-generation cephalosporins, cefepime and cefpirome, and examined the relationship of drug clearance (CL) to creatinine clearance (CLCR). Two separate but similar pharmacokinetic studies (which used 2 g twice daily for each antibiotic) were conducted. Blood was sampled after an initial and a subsequent antibiotic dose. Drug plasma concentrations were measured, and pharmacokinetic analyses were conducted and compared. The pharmacokinetics of cefepime and cefpirome are similar in IC patients. Any differences in drug CL can largely be attributed to differences in CLCR. Despite normal plasma creatinine concentrations, 54% of patients antibiotic concentrations were less than the minimum inhibitory concentration (MIC) (4 mg/L) for >20% of the dosing interval. Thirty-four percent of patients had CLCR >144 mL/min (20% higher than the expected maximum of 120 mL/min). Only CLCR was an independent predictor of antibiotic CL. Time above MIC was predicted only by CLCR. Some IC patients have a very large CLCR, which results in very low levels of studied antibiotics. Either shortening the dosage interval or using continuous infusions would prevent low levels and keep troughs above the MIC for longer periods. In view of the lack of bedside measurement of cephalosporin levels, we suggest that more frequent use be made of CLCR to allow prediction of small concentrations clinically.

0.5%1% 利多卡因硬膜外複合七氟醚全麻中抑制經皮電刺激反應七氟醚需要量的研究

Sevoflurane Requirements to Suppress Responses to Transcutaneous Electrical Stimulation During Epidural Anesthesia with 0.5% and 1% Lidocaine

Atsuko Shono, MD, Yoji Saito, MD, Shinichi Sakura, MD, Katsushi Doi, MD, and Naomi Yokokawa, MD

Department of Anesthesiology, Shimane Medical University, Izumo City, Japan

Anesth Analg 2003;97:1168-1172

該研究在於明確硬膜外複全麻中抑制經皮電刺激(TES)引起的皮膚血管收縮反射(SVmR)及瞳孔擴張的反應(PD)全麻藥的需要量。35例行下腹部手術病人隨機分為0.5% (Group 1) 1% lidocaine (Group 2)。所有病人均複合七氟醚全麻。硬膜外注射負荷量的0.51%利多卡因後測定冷覺喪失平面的中心(C),隨後持續輸注相同濃度的利多卡因。採用5%七氟醚和67%N2O全麻誘導後停用N2O並降低七氟醚的濃度。在CC的向頭測的上三個皮區處(U)分別TES以確定抑制SVmR PD 的七氟醚的需要量。抑制SVmRPD的呼末七氟醚濃度,Group 1的兩處 大於in Group 2的兩處,U 大於C。因此,我們認為硬膜外複合七氟醚全麻下,抑制SVmRPD 所需的七氟醚量與利多卡因的濃度及外科手術刺激的部位有關。結論:我們研究了複合硬膜外麻醉下在手術區域抑制經皮電刺激經皮電刺激(TES)引起的皮膚血管收縮反射(SVmR)及瞳孔擴張的反應(PD)七氟醚的需要量,結果顯示硬膜外複合七氟醚全麻下,抑制SVmRPD 所需的七氟醚量與利多卡因的濃度及外科手術刺激的部位有關。

(方芳譯 薛張綱校)

We sought to determine general anesthetic requirements to suppress skin vasomotor reflex (SVmR) and pupillary dilation (PD) in response to transcutaneous electrical stimulation (TES) during combined epidural-general anesthesia. Thirty-five patients undergoing lower abdominal surgery were randomly divided into 2 groups to epidurally receive 0.5% (Group 1) or 1% lidocaine (Group 2) with sevoflurane anesthesia. A bolus injection of either lidocaine was followed by the infusion of the same solution, and the central dermatomal level of loss of cold sensation (C) was determined. After the induction of general anesthesia with 5% sevoflurane and 67% nitrous oxide, nitrous oxide was discontinued, and sevoflurane concentration was decreased. TES was given at both site C and site three dermatomal segments (U) cephalad to C to determine the end-tidal sevoflurane concentration required to suppress SVmR and PD. End-tidal sevoflurane concentration that suppressed both responses was larger in Group 1 than in Group 2 at both sites and was larger at site U than at site C in both groups. We conclude that sevoflurane requirements to suppress SVmR and PD in response to TES during combined epidural-general anesthesia are different depending on the concentration of lidocaine and the site where surgical stimulation is applied

直接壓迫男性的無髓鞘尺神經纖維比女性更易損傷

Men Are More Susceptible Than Women to Direct Pressure on Unmyelinated Ulnar Nerve Fibers

Robert C. Morell, MD, Richard C. Prielipp, MD FCCM, Timothy N. Harwood, MD, Robert L. James, MStat, and John F. Butterworth, MD

Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2003 97: 1183-1188.

 

尺神經損傷是最常見的外周神經損傷,並且其男女比例為3:1 目前還不清楚圍術期尺神經損傷的機制和男性易損的原因。我們對3 40例男性和40女性自願者(總共240例),肘部屈曲,直接壓迫尺神經和前臂缺血作為引起尺神經誘發電位(CPTs)不良變化的明顯機制進行實驗模型研究。對A-s, A-,和無髓鞘C-fibers分別在2000-, 250-, 5-Hz下重複測量CPT。在三種頻率下缺血產生明顯的CPT升高,男性和女性間無明顯的差異。肘關節屈曲在三種頻率下均不能導致顯著的CPT升高,並且無顯著的性別差異。直接壓迫在5250 Hz是時引起CPT顯著增高,顯示其抑制無髓鞘的C-fibers和有髓鞘的 A- 纖維。C-fibers而非A-纖維顯示對直接壓迫有性別差異, 在男性要高1.7(95%CI, 1.2- 2.4)。缺血顯著抑制三種纖維的功能,可能充分說明性別差異。結論:男性比女性直接壓迫更易引起無髓鞘C-fibers的抑制,這可能有助於解釋男性對圍術期尺神經功能易損的原因。

(方芳譯 薛張綱校)

Ulnar nerve injury, the most common form of perioperative peripheral nerve injury, has a 3:1 male/female predominance. Neither the mechanism of perioperative ulnar nerve injury nor the reasons for the increased male susceptibility are well understood. We used an experimental model with arm flexion at the elbow, direct pressure on the ulnar nerve, and arm ischemia as distinct stress mechanisms to induce adverse changes in ulnar current perception thresholds (CPTs) on 3 groups of 40 male and 40 female volunteers (a total of 240 volunteers). CPT measurements were repeated at 2000-, 250-, and 5-Hz stimulating frequencies, specific to A-s, A-, and unmyelinated C-fibers, respectively. Ischemia produced significant increases in CPT with all three stimulating frequencies, and there were no detectable differences between men and women. Flexion failed to produce significant CPT increases at any of the three stimulating frequencies, with no sex-based differences. Direct pressure produced significant CPT increases at 5 and 250 Hz, indicating inhibition of both unmyelinated C-fibers and myelinated A- fibers. C-fibers, but not A- fibers, demonstrated sex differences with direct pressure; there was a 1.7-fold (95% confidence interval, 1.2- to 2.4-fold) greater effect in men. Ischemia significantly inhibited the function of all three fiber types, perhaps sufficient to overwhelm gender differences

手術室工作人員呼出氣中七氟醚的含量

Sevoflurane in Exhaled Air of Operating Room Personnel

G. Summer, MD*, P. Lirk, MD*, K. Hoerauf, MD, U. Riccabona, MD*, F. Bodrogi, MB*, H. Raifer, BSc*, M. Deibl, BSc, J. Rieder, MD*, and W. Schobersberger, MD*

*Department of Anesthesiology and Critical Care Medicine and Department of Medical Biostatistics, University of Innsbruck; and Department of Anesthesiology and General Intensive Care, University of Vienna, Austria

Anesth Analg 2003;97:1070-1073

關於暴露於揮發性吸入麻醉藥對健康帶來的危害至今尚有爭議。原則上可以通過對外周空氣或體內的途徑來監測暴露的程度。我們使用一種質子轉移反應質量分光術法來對手術室的40名員工進行篩選。我們選擇了開始工作前,開始工作,一小時,兩小時,三小時,以及第二天開始工作前等六個時間點,並設立對照組。他們的呼出氣中七氟醚的含量為百萬分之0.8明顯高於百萬分之0.26的基礎值(P < 0.05)。對變數通過反復測量的方法來調整相互關係後進行分析發現,他們有統計學意義的時效關係(P < 0.001)。我們得出兩個結論。一,質子轉移反應質量分光術法可以作為一種簡單,快捷的方法來測定職業性的暴露後呼出氣中揮發性麻醉藥量;二,每日暴露於七氟醚的人群中呼出氣中持續顯著存在七氟醚。

(鍾鳴譯 薛張綱校)

Evidence on potential health hazards arising from exposure to volatile anesthetics remains controversial. Exposure may, in principle, be supervised by monitoring of ambient air or, alternatively, in vivo. We used the Proton Transfer Reaction-Mass Spectrometry to screen the breath of 40 operating room staff members before operating room duty, 0, 1, 2, and 3 h after duty, and before commencing duty on the consecutive day, and control persons. Staff members exhibited significantly increased sevoflurane levels in exhaled air after duty, with a mean of 0.80 parts per billion as compared with baseline values of 0.26 parts per billion (P < 0.05). Analysis of variance with adjustment for within correlation (repeated measurements) showed a statistically significant time-effect (P < 0.001). We conclude that (a) Proton Transfer Reaction-Mass Spectrometry biomonitoring of exhaled sevoflurane can serve as a simple and rapid method to determine volatile anesthetic excretion after occupational exposure, and (b) significant concentrations of sevoflurane may be continuously present in persons exposed to sevoflurane on a daily basis

持續的用羅呱卡因浸潤傷口可以減少肩部手術後鎮痛藥的用量

Continuous Wound Infiltration with Ropivacaine Reduces Pain and Analgesic Requirement After Shoulder Surgery

Andre Gottschalk, MD*, Marc-Alexander Burmeister, MD*, Patricia Radtke, MD*, Markus Krieg*, Faraneh Farokhzad, MD*, Sonja Kreissl*, Matthias Strauss, MD, and Thomas Standl, MD*

*Department of Anesthesiology, University Hospital Eppendorf, and the Department of Orthopedics, University Hospital Eppendorf, Hamburg, Germany

Anesth Analg 2003;97:1086-1091


我們發現肩部手術後通過單次對傷口進行羅呱卡因浸潤麻醉可以緩解疼痛達十小時,於是通過對照,雙盲的方法對使用不同濃度的羅呱卡因進行傷口持續浸潤的鎮痛效果進行前瞻性的研究。45名肩部手術後的患者被隨機分為三組。縫皮後S組接受單次30毫升的生理鹽水治療;R2R3.75組接受7.5 mg/mL羅呱卡因的治療.手術後,S組接受48小時生理鹽水的持續浸潤,R2組為2 mg/mL羅呱卡因,R3.75組為3.75 mg/mL羅呱卡因.使用阿片類piritramide對靜脈病人自控鎮痛進行補充.手術後1,2,3,4,24,48小時使用視覺類比評分法(VAS)piritramide的需要量及副作用進行評估.血漿羅呱卡因的濃度在手術前,手術後24,48小時分別進行測量.48小時的R3.75組的VAS值(8 ± 9 mm)小於S組的(31 ± 14 mm)( P < 0.005),而且手術後4小時和48小時R3.75組的VAS值比R2組的更小(P < 0.05).術後piritramide的累計用量在R2R3.75組比S組更少(124 小時, P < 0.005; 48 小時, P < 0.05). 血漿羅呱卡因的濃度始終控制在中毒濃度以下.因此我們得出這樣一個結論肩部手術後使用持續傷口羅呱卡因浸潤與使用生理鹽水比較可以減小VAS值和阿片類藥的用量.

(鍾鳴譯 薛張綱校)

After achieving a reduction of pain scores for 10 h with a single dose wound infiltration after shoulder surgery, we examined in a prospective, placebo-controlled and double-blinded study the analgesic effects of continuous wound infiltration with different concentrations of ropivacaine. Forty-five patients undergoing shoulder surgery were randomly assigned into three groups to receive single dose wound infiltration with 30 mL saline (group S) or ropivacaine 7.5 mg/mL (groups R2 and R3.75) after skin closure. Postoperatively, patients received a continuous wound infiltration with saline (group S), ropivacaine 2 mg/mL (group R2) or ropivacaine 3.75 mg/mL (group R3.75) for 48 h. Supplemental pain relief was provided by IV patient-controlled analgesia with the opioid piritramide. At 1, 2, 3, 4, 24, and 48 h postoperatively visual analogue scale (VAS) values (0100 mm), piritramide requirements and side effects were registered. Plasma levels of ropivacaine were measured preoperatively and at 24 h and 48 h after surgery. Until 48 h VAS values were smaller in group R3.75 compared with group S (group R3.75, 8 ± 9 mm; group S, 31 ± 14 mm; P < 0.005), whereas 4 h and 48 h postoperatively VAS values were even smaller in group R3.75 compared with group R2 (P < 0.05). Cumulative piritramide consumption was always smaller in groups R2 and R3.75 compared with group S (124 h, P < 0.005; 48 h, P < 0.05). Plasma ropivacaine levels remained less than the toxic threshold. We conclude that continuous postoperative wound infiltration with ropivacaine, especially using 3.75 mg/mL, provides smaller VAS values and opioid requirement in comparison with saline after shoulder surgery

.

在長期接受阿片類治療的患者中進行行為監測和尿的毒理學檢測

Behavioral Monitoring and Urine Toxicology Testing in Patients Receiving Long-Term Opioid Therapy

Nathaniel P. Katz, MD*, Summer Sherburne, BA*, Michael Beach, MD PhD,, Robert J. Rose, MD, Janet Vielguth, RN, Joyce Bradley, RN, and Gilbert J. Fanciullo, MD MS

*Pain Trials Center, Brigham and Womens Hospital, Boston, Massachusetts; Departments of Anesthesiology and Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and Pain Management Center, Brigham and Womens Hospital, Boston, Massachusetts

Anesth Analg 2003;97:1097-1102

目前尚無研究來對因為慢性疼痛而接受阿片類藥物治療的患者中在行為監測的基礎上加用尿毒理學檢測的意義進行評價.對兩所大學鎮痛中心的兩位作者三年來所有接受慢性阿片類藥物治療的患者進行尿毒理學檢測和行為監測,以次作為發現不恰當用藥的方法.我們回顧性的摘錄了人口學資料,異常的服藥後行為和尿毒理學檢測報告.122位接受治療的患者中有43%(53)有問題(或陽性的尿檢報告,或一項以上的異常行為).在沒有行為問題的患者中21%(26)尿檢中出現違禁藥品或非處方控制藥物陽性.在尿檢陰性的患者中14%(17)有一項以上的行為異常.同時使用兩項監測手段更能發現不恰當的用藥.對使用阿片類藥物的患者提供一個尿檢和行為監測的報告使檢測系統變得更為全面.

(鍾鳴譯 薛張綱校)

No study has examined the role of urine toxicology in addition to behavioral monitoring in patients receiving opioid therapy for chronic pain. All patients maintained on chronic opioid therapy by the two senior authors at two university pain management centers were monitored for 3 yr with urine toxicology testing and for behaviors suggestive of inappropriate medication use. We retrospectively extracted demographic information, aberrant drug-taking behaviors, and urine toxicology information from the medical record. For 122 patients maintained on chronic opioid therapy, 43% (n = 53) had a "problem" (either positive urine toxicology or one or more aberrant drug-taking behaviors). Of patients with no behavioral issues, 21% (n = 26) had a positive urine screen for either an illicit drug or a nonprescribed controlled medication. Of patients with a negative urine screen, 14% (n = 17) had one or more behavioral issues. Monitoring both urine toxicology and behavioral issues captured more patients with inappropriate drug-taking behavior than either alone. Requiring a report of behavioral issues and urine toxicology screens for patients receiving chronic opioids creates a more comprehensive monitoring system than either alone.

帶狀皰疹病毒引起的嚴重的急性內臟疼痛

Severe Acute Visceral Pain from Varicella Zoster Virus

Jacqueline M. Hyland, MD, and John Butterworth, MD

From the Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2003;97:1117-1118

帶狀皰疹病毒感染在接受骨髓移植的患者往往並不出現特徵性區域的皮膚水皰表現.我們曾護理過一位51歲的接受骨髓移植治療的非霍奇金淋巴瘤患者.他在接受治療後出現嚴重的腹痛.直到他疼痛數天後出現擴散的血管性充血我們才意識到他患了帶狀皰疹病毒感染.我們報告這個病例是為了讓那些對相似的腫瘤病人的疼痛提供建議的同行們引起警惕.

(張俊峰譯 薛張綱校)

Varicella zoster virus infection often will not present in the characteristic dermatomal distribution of vesicles in patients who have undergone bone marrow transplantation. We cared for a 51-yr-old man with severe abdominal pain after bone marrow transplantation for non-Hodgkins lymphoma. The diagnosis of varicella zoster was not entertained until he developed a diffuse vesicular rash several days after the onset of pain. We report this case to alert others who may be consulted regarding pain management options for similiar oncology patients

五天的連顱雙生兒分離術的麻醉管理

Anesthetic Management for a Five-Day Separation of Craniopagus Twins

Wong, Theodore G. MD, FRCPC; Ong, Biauw-Chi MBBS, MMED; Ang, Claire MBBS, MMED;

Chee, Huei-Leng MBBS, MMED

Department of Anesthesia and Surgical Intensive Care, Singapore General Hospital

Anesth Analg 2003;97999-1002

連顱雙生是本已罕見的連體雙生兒病例中更少見的形式。隨著醫學科技和技術的發展,未來對這些日益複雜病例進行外科分離的嘗試有可能出現。儘管如此,關於這些病例的麻醉管理的文獻仍很稀少。如下這篇病例報導詳細記錄一對11個月的連顱雙生兒為期五天的分離術的計畫、過程和麻醉管理。該報導著重於強調團隊合作、交流的重要性和類似病例所需要的計畫。

(張俊峰譯 薛張綱校)

Craniopagus twinning is a rare form of the already uncommon entity of conjointtwins. With advances in medical technology and expertise, future attempts at surgical separation of these increasingly complex cases are likely to occur.Despite this, medical literature on the anesthetic management of these cases is sparse. The following case report details the anesthetic management and planning leading to and including the 5-dy separation of 11-mo-old craniopagus twins. The report emphasizes the importance of teamwork, communication, and advanced planning required in cases such as this.

術前炎症反應對門診關節鏡病人關節內給予?羅昔康鎮痛功效的作用

The Effects of Preoperative Inflammation on the Analgesic Efficacy of IntraarticularPiroxicam for Outpatient Knee Arthroscopy

Izdes, Seval MD*; Orhun, Sibel MD+; Turanli, Sacit MD++; Erkilic, Ezgi MD*;

Kanbak, Orhan MD*

Departments of *Anesthesia,+Pathology, and++Orthopaedic Surgery, Emergency And Traumatology Hospital, Ankara, Turkey

Anesth Analg 2003;971016-1019

 我們在90位行選擇性膝關節關節鏡手術的病人中實施了一項雙盲研究,以測定炎症反應在關節內給予?羅昔康鎮痛中的作用。所有病人採用標準的全身麻醉技術。在手術結束時,取完滑液活檢,將病人均等地分成三組關節內給藥。第一組給予25mL生理鹽水,第二組給予25mL0.25%布比卡因,第三組給予25mL0.25%布比卡因和?羅昔康20mg。滑液成分經顯微鏡檢查後將病人分為兩亞組,炎症反應陽性亞組(I+)和炎症反應陰性亞組(I-)。分別記錄術前和術後1246小時的疼痛分級、不痛時間和術後鎮痛劑的用量。第三組的I+亞組不痛時間明顯長於I-亞組(P<0.05)。第三組的I+亞組術後疼痛評分明顯低於I�亞組(P<0.05),然而在第一和第二組的兩亞組間無顯著差異。我們得出結論,術前炎症反應是關節內給予?羅昔康鎮痛效果最重要的決定因素之一。

(張俊峰譯 薛張綱校)

We conducted a double-blinded study in 90 patients undergoing elective arthroscopic knee surgery to determine whether there is a role of inflammation in the analgesic efficacy of intraarticular piroxicam. Standardized general anesthetic techniques were used for all patients. At the end of the operation, after harvesting synovial biopsies, patients were randomized into three intraarticular groups equally. Group 1 received 25 mL saline, Group 2 received 25 mL 0.25% bupivacaine, and Group 3 received 25 mL 0.25% bupivacaine and piroxicam 20 mg. After microscopic examination of the synovial materials, the patients were divided into two subgroups, inflammation positive (I+) and inflammation negative (I-). Preoperatively and postoperatively at 1, 2, 4, and 6 h, pain levels, analgesic duration, and postoperative analgesic consumption were recorded. Analgesic duration was significantly longer in the I+ subgroup than the I- subgroup of Group 3 (P < 0.05). Pain scores at 1, 2, and 4 h postoperatively were significantly lower in the I+ subgroup than the I- subgroup of Group 3 (P < 0.05), whereas there were no significant differences among the subgroups of Group 1 and 2. We concluded that preoperative inflammation is one of the most important determinants of analgesic efficacy of intraarticular piroxicam.

丙泊酚或硫賁妥鈉麻醉腦電爆發抑制相比反射消失:氣管插管的兒茶酚胺和心血管反應變化的差異

Electroencephalographic Burst Suppression Versus Loss of Reflexes Anesthesia

with Propofol or Thiopental: Differences of Variance in the Catecholamine and

Cardiovascular Response to Tracheal Intubation

Mustola, Seppo T. MD*; Baer, Gerhard A. MD, PhD+; Toivonen, Juhani K. MD, PhD*;

Salomaki, Anne Sc.lic.++; Scheinin, Mika PhD[S]; Huhtala, Heini MSc[//];

Laippala, Pekka PhD[P]; Jantti, Ville MD, PhD#

*Department of Anesthesia, South Carelia Central Hospital, Lappeenranta,Finland;+Department of Anesthesia, Tampere University Hospital, Tampere, Finland;++Department of Chemistry, Tampere University Hospital, Tampere, Finland;[S]Department of Pharmacology, University of Turku, Turku, Finland;[//]School of Public Health, University of Tampere, Tampere, Finland;[P]School of Public Health, Research Unit, Tampere University Hospital, Tampere,Finland; and#Ragnar Granit Institute, Tampere University of Technology, Tampere,Finland

Anesth Analg 2003;97 1040-1045

腦電爆發抑制模式(BSP)可能比臨床徵象更能準確地反映腦效應部位的麻醉藥濃度,因而用於採用不同誘導藥物進行氣管插管反應的研究,從而排除這些研究中的偏倚。為了驗證該假設,我們注射丙泊酚(30mg.kg-1.h,n=14)或硫賁妥鈉(75mg.kg-1.h-1,n=14)以誘導BSP,或者通過反復集中給藥達到反射消失(LR)的麻醉狀態,初始劑量丙泊酚2.5mg/kg(n=15)或硫賁妥鈉5mg/kg(n=15),來比較此時氣管插管的兒茶酚胺和心血管反應以及兩者的變化。BSP組的標準差要小於LR組,但變化差異的Levene’s test結果卻無顯著差異。在LR水平,丙泊酚能比硫賁妥鈉更好的減弱兒茶酚胺、動脈血壓和心率對插管的反應,但在BSP水平,只有去甲腎上腺素反應被更好的減弱了。在BSP開始時丙泊酚和硫賁妥鈉的Cp50濃度分別是9.6531.60ug/mL

(張俊峰譯 薛張綱校)

The electroencephalographic burst suppression pattern (BSP) might indicate the brain’s effect-site concentration of anesthetics more precisely than clinical signs and thus eliminate bias from studies on the reaction to tracheal intubation after different induction drugs. To test this hypothesis, we compared the catecholamine and cardiovascular responses and their variances to tracheal intubation when either BSP was induced by infusion of propofol (30 mg · kg-1 · h-1; n = 14) or thiopental (75 mg · kg-1 · h-1; n = 14) or anesthesia by repeated bolus doses until loss of reflexes (LR), initially of propofol 2.5 mg/kg (n = 15) or thiopental 5 mg/kg (n = 15). The standard deviations were more often smaller in the BSP than in the LR groups, but the results of Levene’s test for differences of variance were insignificant. At the LR level, propofol attenuated catecholamine, arterial blood pressure, and heart rate responses to intubation better than thiopental, but at the BSP level, only the norepinephrine response was better attenuated. Cp50 concentrations of propofol and thiopental at the onset of BSP were 9.65 and 31.60 μg/mL, respectively.

通過經導電導管法的壓力-容量環評價圍術期左心室功能

Perioperative Assessment of Left Ventricular Function by Pressure-Volume Loops Using the Conductance Catheter Method

Sven A. F. Tulner, MD*,, Robert J. M. Klautz, MD PhD, Gerda L. van Rijk-Zwikker, MD PhD, Frank H. M. Engbers, MD, Jeroen J. Bax, MD PhD*, Jan Baan, PhD*, Ernst E. van der Wall, MD PhD*, Robert A. Dion, MD, and Paul Steendijk, PhD*

Departments of *Cardiology, Cardio-Thoracic Surgery, and Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands

Anesth Analg 2003 97: 950-957.

麻醉、心肺轉流和外科手術操作等因素均引起心臟負荷的變化,使心臟外科手術病人心臟功能的測量變得非常複雜。由於經導電導管法的壓力-容量環充分考慮了負荷方面的因素,可能是評價左心室功能的好方法。因此,本文對8例冠狀動脈搭橋手術時經導電導管技術的方法學和左心室功能進行了研究。經超聲心動圖指引將導電導管跨過動脈弓,分別在平穩態和短暫阻斷下腔靜脈的前負荷降低期記錄壓力-動脈環。所有病人血流動力學穩定,無併發症發生。在CPB前後15min內得到了完整的資料。結果顯示,病人的心輸出量(5.2 ± 1.3 L/min to 6.0 ± 1.4 L/min)和左室射血分數(46% ± 17% to 48% ± 19%) CPB前後無變化,但是舒張末壓在CPB後顯著升高(8 ± 2 mm Hg to 16 ± 7 mm Hg; P < 0.05)。心臟收縮倒電容(end-systolic elastance)穩定不變(1.31 ± 1.20 mm Hg/mL 1.13 ± 0.59 mm Hg/mL)CPB後心室舒張功能顯著變化,舒張時間常數從 64 ± 6 ms 下降到52 ± 5 ms ,腔硬度常數從0.016 ± 0.014/mL 升高到 0.038 ± 0.016/mL (P < 0.05)。結論:導電導管法提供了圍術期心臟功能的詳細資料,是評價手術操作和麻醉等對心臟功能影響的有效方法。

(王士雷 莊心良 校)

Interpretation of perioperative measurements of cardiac function during cardiac surgery is complicated by changes in loading conditions induced by anesthesia, cardiopulmonary bypass (CPB), and the surgical procedure itself. Quantification of left ventricular (LV) function by pressure-volume relations as obtained by the conductance catheter would be advantageous because load-independent indices can be determined. Accordingly, we evaluated methodological aspects of the conductance-catheter technique and documented LV function before and after CPB in eight patients undergoing coronary artery bypass grafting. LV pressure-volume loops by transesophageal echocardiography-guided transaortic application of the conductance catheter were obtained at steady-state and during preload reduction by temporary occlusion of the inferior cava. All patients remained hemodynamically stable, and no complications occurred. Complete data were acquired within 15 min before and after CPB. Cardiac output (5.2 ± 1.3 L/min to 6.0 ± 1.4 L/min) and LV ejection fraction (46% ± 17% to 48% ± 19%) did not change, but end-diastolic pressure increased significantly after CPB (8 ± 2 mm Hg to 16 ± 7 mm Hg; P < 0.05). Load-independent systolic indices remained constant (end-systolic elastance: 1.31 ± 1.20 mm Hg/mL to 1.13 ± 0.59 mm Hg/mL). Diastolic function changed significantly after CPB, as the relaxation time constant decreased from 64 ± 6 ms to 52 ± 5 ms (P < 0.05) and the chamber stiffness constant increased from 0.016 ± 0.014/mL to 0.038 ± 0.016/mL (P < 0.05). We conclude that the conductance catheter method provides detailed data on perioperative myocardial function and may be useful for evaluating the effects of new surgical and anesthetic procedures.

冠狀動脈搭橋術的血液使用:CPBHct、性別、年齡和體重等因素的影響

Blood Use in Patients Undergoing Coronary Artery Bypass Surgery: Impact Of Cardiopulmonary Bypass Pump, Hematocrit, Gender, Age, and Body Weight

Bharathi H. Scott, MD*, Frank C. Seifert, MD, Peter S. A. Glass, MBChB*, and Roger Grimson, PhD*

Departments of *Anesthesiology and Surgery, State University of New York at Stony Brook, Stony Brook, New York

Anesth Analg 2003 97: 958-963.

我們對一個大型大學醫院冠狀動脈搭橋手術的血液使用影響因素-CPBHCT、年齡、性別和體重等進行了研究。研究物件包括2年內進行的1235例首次手術病人,其中681例在CPB下進行,554例在非CPB下進行。所有病人均從胸正中劈開胸骨。男性病人881例,女性病人354例。行CPB的病人輸注聚集紅細胞血3.4 U ,而不行CPB的病人輸注1.6 U CPB病人多次輸入紅細胞的比率(72.5%)遠遠大於非CPB病人45.7%。男女病人輸注聚集紅細胞的量分別是2.2 U 3.6U 。男性病人輸注的比率(52.6%)小於女性病人(79.4%)。對CPBHCT<35%、性別、年齡65歲和體重83 KG的中位數行logistic 回歸,結果表明,CPBHCT、女性、高齡、低體重對預測血液輸注均有幫助,其中,術前Hct<35%是預測輸血的最強指征。

(王士雷 莊心良 校)

We investigated the impact of cardiopulmonary bypass pump (CPB), hematocrit, gender, age, and body weight on blood use in patients undergoing coronary artery bypass graft surgery at a major university hospital. Participants were 1235 consecutive patients undergoing primary coronary artery surgery over a period of 2 yr (1999 and 2000); 681 patients underwent coronary surgery with use of CPB, and 554 patients underwent off-pump coronary artery bypass surgery using a median sternotomy incision. There were 881 males and 354 females. Average packed red blood cells (PRBC) transfusion for patients on CPB was 3.4 U compared with 1.6 U for the off-pump group (P = <0.001). Patients on CPB received more frequent PRBC transfusion (72.5%) compared with 45.7% of off-pump patients (P = <0.001). Average PRBC transfusion for males was 2.2 U compared with 3.6 U for females (P = <0.001). A lower percentage of males (52.6%) than females (79.4%) received transfusion (P = <0.001). T he impact of CPB, off-pump status, preoperative hematocrit <35%, gender, age 65 yr, and weight 83 kilograms using median values as cut points, on blood use was examined using logistic regression models. Use of CPB, preoperative hematocrit, (<35%) female gender, increasing age, and decreased body weight were significant predictors of transfusion (P = <0.001). Preoperative hematocrit <35% and use of CPB were the strongest predictors of PRBC transfusion.

冠狀動脈搭橋術後發生四肢癱瘓一例報導

Tetraplegia After Coronary Artery Bypass Grafting

Susumu Fujioka, MD*, Yoshinari Niimi, MD, Kazuo Hirata, MD*, Itaru Nakamura, MD*, and Shigeho Morita, MD

*Department of Anesthesia, Ageo Central General Hospital, Ageo, Saitama, Japan; and Department of Anesthesiology, School of Medicine, Teikyo University, Itabashi, Tokyo, Japan

Anesth Analg 2003 97: 979-980.

作者報導一例非複雜冠狀動脈搭橋術後頸髓功能障礙。術前檢查未發現任何神經功能異常,然而,術後的磁共振檢查卻發現在損害水平存在顯著的椎管狹窄。儘管不能肯定此病人頸髓功能障礙的病理生理基礎,然而,外科手術中將頸部放在伸展位置加重了預先存在的椎管狹窄,可能是造成脊髓損傷的重要因素。

(王士雷 莊心良 校)

The authors present a rare case of a cervical cord dysfunction after uncomplicated coronary artery bypass grafting. The preoperative neurological examination did not reveal any abnormalities; however, the postoperative magnetic resonance image showed significant spinal canal stenosis at the same levels as high signal lesions. Although the pathophysiological basis of the case was impossible to determine retrospectively, it seems probable that placing the neck in an extended position during surgery might have aggravated a preexisting spinal canal stenosis to produce cervical injury.

吸入NO治療小兒和成人急性低氧性呼吸衰竭的Meta分析

Inhaled Nitric Oxide for Acute Hypoxic Respiratory Failure in Children and Adults: A Meta-analysis

Jennifer Sokol, FRACP FJFICM*,, Susan Elizabeth Jacobs, FRACP, and Desmond Bohn, FRCPC*

*Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Department of Neonatology, School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia; and Division of Neonatology, Royal Women’s Hospital, University of Melbourne, Melbourne, Australia

Anesth Analg 2003 97: 989-998.

我們系統復習了吸入NO對小兒和成人急性呼吸窘迫綜合症或急性肺損傷的治療效果。根據Cochrane的方法對試驗資料進行meta分析。有5個臨床試驗符合本研究。研究結論是,在NO吸入的最初4d病人氧合狀態得到明顯改善,此後則未發現其療效;在未用通氣機的時間內,治療組和空白對照組之間無差別;沒有證據表明一種NO劑量較其他劑量效果更好;吸入NO對死亡率無顯著影響。其他臨床指標,如住院天數和重症監護時間,報導結論不一致。在進一步進行這方面的研究時,應該根據病因以及可能對結果造成影響的其他因素進行分層研究,以排除可能對NO治療效果造成影響的其他因素。

(王士雷 莊心良 校)

We systematically reviewed randomized controlled trials examining inhaled nitric oxide (INO) for the treatment of acute respiratory distress syndrome or acute lung injury in children and adults. Qualitative assessments of identified trials were made, and metaanalyses were performed according to Cochrane methodology. Five randomized controlled trials (n = 535) met entry criteria. One study demonstrated significant improvement in oxygenation in the first 4 days of treatment, with no difference after this. There was no difference in ventilator-free days between treatment and placebo groups, and no specific dose of INO was more advantageous than any other. INO had no effect on mortality in trials without crossover of treatment failures to open-label INO (relative risk, 0.98; 95% confidence interval, 0.66–1.44). Other clinical indicators of effectiveness, such as duration of hospital and intensive care stay, were inconsistently reported. Lack of data prevented assessment of all outcomes. If further trials assessing INO in acute respiratory distress syndrome or acute lung injury are to proceed, they should be stratified for primary etiology, incorporate other modalities that may affect outcome, and evaluate clinically relevant outcomes before any benefit of INO can be excluded.

外科病人的補充治療

The Use of Complementary and Alternative Medicines by Surgical Patients: A Follow-Up Survey Study

Shu-Ming Wang, MD*, Alison A. Caldwell-Andrews, PhD, and Zeev N. Kain, MD*,,

Departments of *Anesthesiology, Pediatrics, and Child Psychiatry, Yale University

Anesth Analg 2003 97: 1010-1015.

我們在以往的研究中發現,42%的外科門診病人對針灸用於預防和治療焦慮感興趣。我們對外科門診和病房病人對這些補充治療(complementary-alternative medical therapies CAM)的態度進行了研究。結果表明,大部分外科病人(57.4%)應用某種形式的CAM,包括為自己祈禱(29%)、脊柱按摩(23%)、普通按摩(15%)、放鬆(14%) 草藥、megavitamins (9%)和針灸(7%)。住院病人應用自我祈禱的要比門診病人多,但其他方式在住院和門診病人之間無差別。與外科門診病人相比,更多的住院病人願意向他們的醫生坦白CAM的應用。大部分外科病人願意接受CAM

(王士雷 莊心良 校)

In a previous study, we indicated that 42% of surgical outpatients are interested in using acupuncture as a treatment modality for preoperative anxiety. We designed this follow-up survey to assess differences in attitude toward complementary-alternative medical therapies (CAM) between patients undergoing outpatient surgeries and those undergoing inpatient surgeries. The results indicate that most surgical patients (57.4%) use some form of CAM, including self-prayer (praying for their own health; 29%), chiropractic treatment (23%), massage therapy (15%), relaxation (14%), herbs (13%), megavitamins (9%), and acupuncture (7%). Inpatient surgical respondents reported using self-prayer more than outpatient surgical respondents, but no other differences in CAM use were found between inpatient and outpatient respondents. More inpatient respondents reported disclosing their usage of CAM to perioperative physicians than did outpatient respondents. Most surgical patients were willing to accept CAM as part of their perioperative management but were not willing to pay out-of-pocket for CAM treatment. The leading CAM therapies that fewer of the respondents were willing to pay for out-of-pocket included relaxation, massage, chiropractic medicine, herbs, and acupuncture.

吸入麻醉藥的MAC是否可以作為評價動物抗傷害作用的工具?

Can Determining the Minimum Alveolar Anesthetic Concentration of Volatile Anesthetic Be Used as an Objective Tool to Assess Antinociception in Animals?

Marie-Agnes Docquier, MD*, Patricia Lavand’homme, MD PhD*, Christian Ledermann, MD, Valerie Collet, BS*, and Marc De Kock, MD PhD*

*Department of Anesthesiology, Laboratory of Anesthesia, University of Louvain, St. Luc Hospital, Brussels, Belgium; and Regional Clinic Hospital Conception, Chili

Anesth Analg 2003 97: 1033-1039.

我們試圖評價MAC作為麻醉藥物效能指標的可靠性。為此,我們檢驗了不同參數,並對結果進行了分析。在第一套實驗中,我們對在機械通氣情況下七氟醚麻醉進行了研究。對夾尾的甩尾反應、壓力增高時的撤退反應以及這些刺激後的心血管反應進行了記錄。在第二套實驗則在保留自主呼吸的情況下進行研究。對溫度和壓力刺激以及在麻醉狀態和清醒狀態下蘇芬太尼和可樂定對MAC的影響也進行了研究。對刺激強度講,抑制夾尾反射的七氟醚濃度比爪壓力和放射性溫度刺激的濃度要大(1.81 ± 0.28 versus 1.45 ± 0.22 and 1.53 ± 0.26; P < 0.05)。對前二種刺激,抑制運動和心血管反應的七氟醚濃度無差別。除小劑量的蘇芬太尼(0.005 μg · kg-1 · min-1) 明顯增高機械通氣動物的MACBAR以及自主通氣時的MAC MACBAR外,其他劑量的蘇芬太尼均顯著降低七氟醚的MAC。理想劑量的可樂定(10 μg/kg)顯著降低 MAC MACBAR。對清醒動物熱輻射和壓力刺激,可樂定和蘇芬太尼無顯著影響。結論:MAC對評價不同麻醉藥物的鎮痛作用來說是有效的指標,然而,觀察到的結果不僅僅是這些藥物抗傷害作用的結果,而且體現了這些藥物和鹵化物之間複雜的相互作用。

(王士雷 莊心良 校)

We intended to evaluate the reliability of the minimum anesthetic alveolar concentration (MAC)-sparing effect as an objective measure of the antinociceptive properties of a drug. For this purpose, we tested different variables and analyzed the significance of the results obtained. In a first set of experiments, we studied rats under mechanical ventilation and sevoflurane anesthesia. Outcome variables such as gross purposeful movements consecutive to tail clamping, paw withdrawal consecutive to increasing pressure, and cardio-circulatory reactivity (MACBAR) after these stimuli were recorded. In a second set of experiment, sevoflurane-anesthetized rats under spontaneous breathing conditions were used.Thermal stimuli were compared with pressure. The MAC-sparing effect of several doses of sufentanil and clonidine was evaluated in both anesthetized and awake rodents. When considering the stimulus applied, larger concentrations of sevoflurane were required to suppress reactivity after tail clamp than after paw pressure or radiant heat (1.81 ± 0.28 versus 1.45 ± 0.22 and 1.53 ± 0.26; P < 0.05). For the two first stimuli, no significant differences were noted between the concentrations that suppress motor or cardio-circulatory reactions. All doses of sufentanil tested significantly reduced (P < 0.05) the different MAC values except the smallest one (0.005 μg · kg-1 · min-1) that significantly increased MACBAR in ventilated animals and both MAC and MACBAR in spontaneously breathing rodents (P < 0.05). Clonidine, at its optimal dose (10 μg/kg), significantly reduced both MAC and MACBAR to the same degree. In awake animals submitted to radiant heat or pressure challenge, none of the clonidine doses nor sufentanil doses (0.005 and 0.07) were active. In conclusion, the MAC-sparing effect provides several reliable and quantifiable variables that allow comparison between different analgesic substances. However, the observations made are not simply the result of antinociceptive effects of the tested drugs but rather that of complex interactions between these drugs and a halogenated vapor.


左旋-、右旋和消旋布比卡因對LPS誘發的中性粒細胞遷移的影響

The Effects of S(-)-, R(+)-, and Racemic Bupivacaine on Lysophosphatidate-Induced Priming of Human Neutrophils

Markus W. Hollmann, MD PhD*,,, Katrin Kurz, MS*,, Susanne Herroeder, MS*,, Danja Struemper, MD,, Klaus Hahnenkamp, MD, Noud S. Berkelmans, MS, Christel G. den Bakker, MS, and Marcel E. Durieux, MD PhD,

*Department of Anesthesiology, University of Heidelberg, Germany; Department of Anesthesiology, University Hospital Maastricht, The Netherlands; and Department of Anesthesiology, University Hospital Muenster, Germany

Anesth Analg 2003 97: 1053-1058.

局部麻醉藥調節炎症反應,對減輕外周炎症反應可能是有益的。左旋布比卡因調節炎症反應的作用尚未被研究證實。因此,本研究探討左旋、右旋和消旋布比卡因對中性粒細胞的功能以及信號轉導的作用。通過細胞色素c還原法研究lysophosphatidic acid [LPA]N-formylmethionine-leucyl-phenylalanine 刺激中性粒細胞釋放過氧化物的量。用電壓鉗探討藥物對卵母細胞上LPA受體信號轉導的作用。所有三種局麻藥對啟動作用無影響。左旋布比卡因對起遷移作用的抑制大於消旋布比卡因,而右旋布比卡因對此無作用。在10-4 M濃度時,左旋布比卡因抑制接近50%。在我們的重組模型上進行的結果表明左旋布比卡因能更有效抑制LPA信號轉導。與右旋布比卡因和其他麻醉藥相比,左旋布比卡因對抑制中性粒細胞遷移特別有效,從而部分抑制過度的中性粒細胞反應。

(王士雷 莊心良 校)

Local anesthetics modulate inflammatory responses and may therefore be potentially useful in mitigating perioperative inflammatory injury. The inflammatory modulating effects of S(-)-bupivacaine are not known. Therefore, we compared the effects of S(-)-bupivacaine, R(+)-bupivacaine, and racemic bupivacaine on neutrophil function and receptor signaling. Priming (by lysophosphatidic acid [LPA]) and activation (by N-formylmethionine-leucyl-phenylalanine) of superoxide release by isolated human neutrophils was studied by using a cytochrome c-reduction assay. LPA receptor signaling in Xenopus oocytes was studied by using voltage clamp. All three local anesthetics were without effect on activation. S(-)-Bupivacaine inhibited priming more than did racemic bupivacaine; R(+)-bupivacaine was without effect. At 10-4 M, S(-)-bupivacaine inhibited approximately 50%. Comparable results were obtained in our recombinant model, where S(-)-bupivacaine most effectively inhibited LPA signaling. Compared with racemic bupivacaine and other anesthetics, S(-)-bupivacaine appears particularly effective in suppressing neutrophil priming, a process responsible in part for the overactive neutrophil response.

二種液體輸注系統(H1025FMS 2000)快速輸注的實驗室評價

A Laboratory Evaluation of the Level 1 Rapid Infuser (H1025) and the Belmont Instrument Fluid Management System (FMS 2000) for Rapid Transfusion

Mark E. Comunale, MD

Department of Anesthesia and Critical Care, St. Louis University Medical Center, St. Louis University School of Medicine, St. Louis, Missouri

Anesth Analg 2003 97: 1064-1069.

本研究比較二種輸注系統的加溫能力、輸注速率和空氣排出能力。加熱泵放置於靜脈輸注袋的尖端以便與FMS 2000 系統的加熱相匹配。在以250 500 mL/min輸注凝集紅細胞(PRBC)時,自輸注近端和遠端測定輸注溫度。二輸注系統的管道長度相同。在最大流速時,按上述方法測量輸注溫度。流速的測量以梯度圓桶和秒錶進行。空氣排放的情況以在最大流速時自近端加入10ml空氣到熱交換系統的方式進行。空氣經過管道後進行收集和測量。在250mL/min時,二種裝置的PRBC溫度都37°C。裝置1隨著時間而輸注溫度下降。 FMS 2000 的最大流速達500 mL/min H1025可以達到32°C 575 mL/min流速。空氣從H1025的遠端流出,FMS2000系統沒有空氣自遠端流出。結論:FMS 2000 在以生理溫度輸注、 檢測和排空氣方面,較目前使用的輸注系統均有優勢。

(王士雷 莊心良 校)

In this investigation I compared the heating capabilities, infusion rates, and air management system of the new FMS 2000 and the Level 1 infusion systems. A rollerhead pump was placed at the position of the IV bag spikes on the Level 1 disposable set and used to match the flow of the rollerhead pump of the FMS 2000. Infusate temperature was measured at 250 and 500 mL/min by using packed red blood cells (PRBC) at the infusate supply and distal end of the disposable tubing. Tubing lengths were equal for both systems. Devices were set at maximum flow while temperatures were measured as described previously. Flow was measured with a graduated cylinder and stopwatch. Air management was evaluated with a 10-mL air bolus injected proximal to the heat exchanger at maximum flow. Air passing through the system was collected and measured. At 250 mL/min, both devices provided infusate at 37°C. At 500 mL/min, only the FMS 2000 provided PRBC at 37°C. PRBC infusate temperature decreased over time with the Level 1 device. The FMS 2000 delivered PRBC at its maximum flow rate of 500 mL/min. The Level 1 attained a maximum flow of 575 mL/min of PRBC with a temperature of 32°C. Air (10 mL) was recovered from the distal tubing of the Level 1. No air was recovered from the tubing of the FMS 2000. In this laboratory investigation, the FMS 2000 performance was superior with respect to providing PRBC at physiologic temperatures (at 500 mL/min) and with respect to air detection and elimination compared with current widely used pressure-infuser technology.


疼痛對術後短時間內與健康有關的生活質量的影響

The Effect of Pain on Health-Related Quality of Life in the Immediate Postoperative Period

Christopher L. Wu, MD*, Mohammad Naqibuddin, MBBS, MPH*, Andrew J. Rowlingson, BA, Steven A. Lietman, MD, Roland M. Jermyn, BA*, and Lee A. Fleisher, MD*,

*Department of Anesthesiology and Critical Care Medicine, Joint Appointment in Medicine (Cardiology), Biomedical Information Sciences and Health Policy and Management, and the Department of Orthopaedic Surgery, The Johns Hopkins Hospital, Baltimore, Maryland

Anesth Analg 2003 97: 1078-1085.

本研究的目的是檢驗術後疼痛是否會影響術後短期內(術後2w內)病人與健康有關的生活質量。研究以前瞻 、非隨機的方式在醫學院監護中心進行。物件為選擇性全髖關節或膝關節置換術。在標準的全麻或硬膜外麻醉後,以病人自控靜脈或硬膜外鎮痛方式行術後鎮痛。在術後1-5714d評價靜息和活動時的疼痛程度以及惡性、瘙癢的情況。結果顯示,病人與生理和精神有關的疼痛均降低,瘙癢的情況無變化。噁心的精神部分程度降低,但生理部分不變。結論:術後疼痛將會降低病人的生活質量,然而,在評價術後生活質量時,應注意有幾種方法學上的方式。

(王士雷 莊心良 校)

The hypothesis of this study was to determine if the severity of postoperative pain would affect patients’ health-related quality of life (HRQL) in the immediate postoperative period (within 2 wk of surgery). We designed this study as a prospective, nonrandomized observational trial in a tertiary academic care center. Patients undergoing elective total hip or knee replacement surgery were eligible. Patients received a standardized intraoperative general or epidural anesthetic followed by IV patient-controlled analgesia or patient-controlled epidural analgesia. Short Form (SF)-12, visual analog scores for pain at rest and pain with activity, nausea, and itching were assessed on postoperative days 1–5, 7, and 14. The severity of pain correlated with a decrease in both the physical and mental component of the SF-12. The severity of nausea correlated with a decrease in the mental but not physical component of the SF-12. The severity of itching did not correlate with a change in the SF-12. Our findings suggest that an increase in postoperative pain will decrease a patient’s quality of life in the immediate postoperative period; however, several methodologic issues exist when assessing HRQL in the immediate postoperative period.

術中靜脈注射氯胺酮和硬膜外鎮痛:腎臟術後的鎮痛Intraoperative Intravenous Ketamine in Combination with Epidural Analgesia: Postoperative Analgesia After Renal Surgery

Alper Kararmaz, MD, Sedat Kaya, MD, Haktan Karaman, MD, Selim Turhanoglu, MD, and Mehmet Ali Ozyilmaz, MD

Department of Anesthesiology, Dicle University Hospital, Diyarbakir, Turkey

Anesth Analg 2003 97: 1092-1096.

本研究以雙盲、隨機、對照的方式評價小劑量靜脈注射氯胺酮結合硬膜外注射嗎啡和布比卡因對腎臟術後疼痛的影響。在外科手術前行硬膜外置管並開始自導管注入嗎啡和布比卡因。45例病人隨機分為2組:氯胺酮組和對照組。氯胺酮組術中給予氯胺酮單次注射後開始靜脈輸注。在術後最初的6h內,靜息狀況下的VAS評分的中位數在氯胺酮組顯著降低。咳嗽時的VAS分值也顯著小於對照組。在術後12d,鎮痛藥的消耗量顯著少於對照組。噁心和瘙癢的發生率也顯著少於對照組。結論:在脊髓和腦敏感化被硬膜外應用嗎啡/布比卡因和靜脈氯胺酮阻斷時,術後鎮痛效果變得更加理想。

(王士雷 莊心良 校)

We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketamine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 ± 11.5 min) than in the ketamine group (22.3 ± 17.1 min) (P < 0.0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/bupivacaine and IV


NMDA受體在疼痛中的作用(綜述)

The Role of N-Methyl-D-Aspartate (NMDA) Receptors in Pain: A Review

Andrei B. Petrenko, MD, Tomohiro Yamakura, MD PhD, Hiroshi Baba, MD PhD, and Koki Shimoji, MD PhD, FRCA

From the Department of Anesthesiology, Niigata University School of Medicine, Asahimachi 1–757, Niigata 951–8510, Japan

Anesth Analg 2003 97: 1108-1116

大量證據表明,NMDA受體對疼痛狀態下時中樞敏感化的形成和維持有重要的作用。然而,NMDA受體也參與外周敏感化和內臟痛的形成。NMDA受體包含NR1NR2ABCD)和NR3AB)亞單位,這些亞單位決定了NMDA受體的功能特徵。在NMDA受體的亞單位中,包含NR2B亞單位的受體對傷害性感受的作用特別重要,因此,NR2B阻滯劑在治療慢性疼痛時可能發揮重要的價值。

(王士雷 莊心良 校)

There is accumulating evidence to implicate the importance of N-methyl-D-aspartate (NMDA) receptors to the induction and maintenance of central sensitization during pain states. However, NMDA receptors may also mediate peripheral sensitization and visceral pain. NMDA receptors are composed of NR1, NR2 (A, B, C, and D), and NR3 (A and B) subunits, which determine the functional properties of native NMDA receptors. Among NMDA receptor subtypes, the NR2B subunit-containing receptors appear particularly important for nociception, thus leading to the possibility that NR2B-selective antagonists may be useful in the treatment of chronic pain.

用人工神經網路評價機械通氣時呼吸系統的順應性

Estimating Respiratory System Compliance During Mechanical Ventilation Using Artificial Neural Networks

Gaetano Perchiazzi, MD*, Rocco Giuliani, MD, Loreta Ruggiero, MD, Tommaso Fiore, MD, and Goran Hedenstierna, MD PhD*

*Department of Clinical Physiology, Uppsala University Hospital, Sweden; and Department of Emergency and Transplantation, Bari University Hospital, Italy

Anesth Analg 2003 97: 1143-1148.

本研究評價一種人工神經網路(ANN)是否可以反應機械通氣時呼吸系統的靜態順應性。豬急性肺損傷模型被用來類比不同機械通氣情況。每個記錄包括容量控制呼吸中的10次或更多次呼吸,隨後出現一次呼吸末暫停以便通過阻斷器(interrupter technique)評價靜態呼吸順應性。容量-壓力環立即輸送到人工神經網路。結果顯示,IT技術和ANN方法得出的肺順應性結果基本一致,誤差為-0.67 ± 1.52 mL/cm H2O (bias ± SD)。結論:在容量控制呼吸的時候,ANN可以在不停止呼吸的情況下提取靜態順應性。

(王士雷 莊心良 校)

In this study we evaluated whether a technology based on artificial neural networks (ANN) could estimate the static compliance (CRS) of the respiratory system, even in the absence of an end-inspiratory pause, during continuous mechanical ventilation. A porcine model of acute lung injury was used to provide recordings of different respiratory mechanics conditions. Each recording consisted of 10 or more consecutive breaths in volume-controlled mechanical ventilation, followed by a breath having an end-inspiratory pause used to calculate CRS according to the interrupter technique (IT). The volume-pressure loop of the breath immediately preceding the one with pause was given to the ANN for the training, together with the CRS separately calculated by the IT. The prospective phase consisted of giving only the loops to the trained ANN and comparing the results yielded by it to the compliance separately calculated by the investigators. Determination of measurement agreement between ANN and IT methods showed an error of -0.67 ± 1.52 mL/cm H2O (bias ± SD). We could conclude that ANN, during volume-controlled mechanical ventilation, can extract CRS without needing to stop inspiratory flow.

急性和慢性脊髓損傷病人氣管插管時的心血管反應

Cardiovascular Responses to Endotracheal Intubation in Patients with Acute and Chronic Spinal Cord Injuries

Kyung Y. Yoo, MD PhD, Seong W. Jeong, MD PhD, Seok J. Kim, MD, In H. Ha, MD PhD, and JongUn Lee, MD PhD

Department of Anesthesiology and Research Institute of Medical Sciences, Chonnam National University Medical School, Gwangju, South Korea

Anesth Analg 2003 97: 1162-1167

氣管插管常引起短暫的高血壓和心動過速。本研究目的是評價這種心血管反應在脊髓損傷的病人是否會隨著時間的消失而消退。創傷性完全脊髓損傷的106例病人根據時間分為急性和慢性脊髓損傷,根據損傷的平面分為四肢癱瘓和下肢癱瘓。其中急性四肢癱瘓26例,慢性四肢癱瘓27例,急性下肢癱瘓27例,慢性下肢癱瘓29例。25例無四肢癱瘓的病人為對照組。記錄血壓、心率和血漿兒茶酚胺濃度。結果,氣管插管不影響急性和慢性四肢癱瘓病人的血壓,但是顯著提高急性和慢性下肢癱瘓的血壓。所有實驗組病人的心率均出現顯著加快,然而,急性四肢癱瘓病人心率加快的幅度顯著小於其他各組。除急性四肢癱瘓組外,其餘各組血漿去甲腎上腺素的濃度均增高。慢性四肢癱瘓組和對照組血漿去甲腎上腺素的濃度增高幅度和對照組相同,均較輕,而急性下肢癱瘓組的增高幅度較大。各組間心律失常的發生率無差異。結論:氣管插管的心血管和兒茶酚胺反應隨脊髓損傷水平和時間的變化而變化。

(王士雷 莊心良 校)

Endotracheal intubation usually causes transient hypertension and tachycardia. We investigated whether the cardiovascular responses to intubation change as a function of the time elapsed in patients with spinal cord injury. One-hundred-six patients with traumatic complete spinal cord injury were grouped into acute and chronic groups according to the time elapsed (less than and more than 4 wk after injury) and into those with quadriplegia and paraplegia according to the level of injury (above C7 and below T5): acute quadriplegia, n = 26; chronic quadriplegia, n = 27; acute paraplegia, n = 24; and chronic paraplegia, n = 29. Twenty-five patients with no spinal cord injury served as controls. Systolic arterial blood pressure (SAP), heart rate, and plasma concentrations of catecholamines were measured. The intubation did not affect SAP in either the acute or chronic quadriplegics, but it significantly increased SAP in both acute and chronic paraplegics. Heart rate was significantly increased in all groups; however, the magnitude of change was less in acute quadriplegics than in the other groups. Plasma concentrations of norepinephrine increased in every group but the acute quadriplegics. The magnitude of increase was attenuated in chronic quadriplegics, accentuated in acute paraplegics, and similar in chronic paraplegics when compared with controls. The incidence of arrhythmias did not differ among groups. We conclude that the cardiovascular and catecholamine responses to endotracheal intubation may change as a function of the time elapsed and the level of spinal cord injury.

持續腰叢神經阻滯後出現坐骨神經麻痹一例

Sciatic Nerve Palsy After Total Hip Arthroplasty in a Patient Receiving Continuous Lumbar Plexus Block

Bruce Ben-David, MD, Rama Joshi, MD, and Jacques E. Chelly, MD PhD, MBA

Department of Anesthesiology, University of Pittsburgh Medical Centers, Shadyside Hospital, Pittsburgh, Pennsylvania

Anesth Analg 2003 97: 1180-1182.

我們報告一例30歲男性先天性髖發育不良行全髖置換病人出現了術後坐骨神經麻痹。病人接受持續腰叢神經阻滯,在出現症狀前3小時應用了低分子量肝素。神經阻滯和坐骨神經麻痹的解剖學上的差異使診斷和關節血腫的治療均非常迅速及時,病人神經功能恢復也很迅速。此例病人說明,隨著區域阻滯技術在急性疼痛中的重要作用,新發生的術後神經缺失必須由麻醉醫生和外科醫生共同診斷。及時開放的交流是迅速採取措施和受損害神經功能恢復的重要保證。

(王士雷 莊心良 校)

We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve.

應用ProSealTM喉面罩時繼發於Foldover 錯位的胃內容物誤吸

Aspiration of Gastric Contents During Use of a ProSealTM Laryngeal Mask Airway Secondary to Unidentified Foldover Malposition

Joseph Brimacombe, MB ChB, FRCA, MD*, and Christian Keller, MD

*Department of Anaesthesia and Intensive Care, James Cook University, Cairns Base Hospital, Australia; and Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria

Anesth Analg 2003 97: 1192-1194.

ProSealTM 排泄管的主要功能是防止胃內容物誤吸。我們報導一例經腹腔鏡膽囊切除術時PLMA引起的誤吸。病人為64歲男性,胃內容物誤吸繼發於foldover錯位。提示,排泄管的位置和開放在所有的病人中都是非常重要的。

(王士雷 莊心良 校)

The primary function of the drain tube of the ProSealTM laryngeal mask airway (PLMA) is to prevent aspiration of regurgitated stomach contents. We report a case of gastric aspiration with the PLMA during a laparoscopic cholecystectomy in a 64-yr-old healthy man secondary to an unidentified foldover malposition. It is imperative that the position and patency of the drain tube be verified in all patients with the PLMA.