Anesthesia & Analgesia

November 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

老年手术病人心脏舒张充盈功能异常的流行病学调查

(肖洁 王祥瑞校)

The Prevalence of Preoperative Diastolic Filling Abnormalities in Geriatric Surgical Patients

Bridget Phillip, Darwin Pastor, Wayne Bellows, and Jacqueline M. Leung

Anesth Analg 2003 97: 1214-1221.

 

甘露醇和多巴胺在体外循环病人中的作用:一个随机临床试验

(费敏译 薛张纲校)

Mannitol and Dopamine in Patients Undergoing Cardiopulmonary Bypass: A Randomized Clinical Trial

Olivia V. Carcoana, Joseph P. Mathew, Elizabeth Davis, Daniel W. Byrne, John P. Hayslett, Roberta L. Hines, and Susan Garwood

Anesth Analg 2003 97: 1222-1229.

 

异丙酚可减少由再灌注引起的豚鼠正常和缺血-再灌注之间边缘区的心侓失常

(赵雪莲 庄心良

Propofol Decreases Reperfusion-Induced Arrhythmias in a Model of "Border Zone" Between Normal and Ischemic-Reperfused Guinea Pig Myocardium

Jean-Luc Hanouz, Alexandra Yvon, Frédéric Flais, René Rouet, Pierre Ducouret, Henri Bricard, and Jean-Louis Gérard

Anesth Analg 2003 97: 1230-1238.

 

l-麻黄碱与d-伪麻黄碱的拟交感神经药作用:是直接激活受体还是通过去甲肾上腺素释放引起的?

(肖洁 王祥瑞 )

The Sympathomimetic Actions of l-Ephedrine and d-Pseudoephedrine: Direct Receptor Activation or Norepinephrine Release?

Shigeaki Kobayashi, Masayuki Endou, Fumika Sakuraya, Naoyuki Matsuda, Xiao-Hong Zhang, Mitsue Azuma, Noriyuki Echigo, Osamu Kemmotsu, Yuichi Hattori, and Satoshi Gando

Anesth Analg 2003 97: 1239-1245.

 

异氟醚诱导的脑电波爆发抑制效应对体外循环中脑血流速和脑氧摄取的影响

(费敏译 薛张纲校)

The Effects of Isoflurane-Induced Electroencephalographic Burst Suppression on Cerebral Blood Flow Velocity and Cerebral Oxygen Extraction During Cardiopulmonary Bypass

Björn Reinsfelt, Anne Westerlind, Erik Houltz, Sonny Ederberg, Mikael Elam, and Sven-Erik Ricksten

Anesth Analg 2003 97: 1246-1250.

PEDIATRIC ANESTHESIA:

儿童先心病手术中经食道心超的应用:两个中心的观察研究

(赵雪莲 庄心良 校)

Intraoperative Transesophageal Echocardiography in Pediatric Congenital Cardiac Surgery: A Two-Center Observational Study

Dominique A. Bettex, Daniel Schmidlin, Marc-André Bernath, René Prêtre, Michel Hurni, Rolf Jenni, Pierre-Guy Chassot, and Edith R. Schmid

Anesth Analg 2003 97: 1275-1282.

 

先天性心脏病手术患者术中脉搏曲线法心输出量监测的分析

(朱慧琛 王祥瑞 )

Pulse Contour Analysis for Cardiac Output Monitoring in Cardiac Surgery for Congenital Heart Disease

Aman Mahajan, Afshin Shabanie, Judi Turner, Michael J. Sopher, and Jure Marijic

Anesth Analg 2003 97: 1283-1288.

 

小儿心脏手术中组织因子激活的血栓弹力图:基础值和比较值

(费敏译 薛张纲校)

Tissue Factor-Activated Thromboelastograms in Children Undergoing Cardiac Surgery: Baseline Values and Comparisons

Bruce E. Miller, Nina A. Guzzetta, Steven R. Tosone, Jennifer L. Miller, Annabel R. Flunker, Eva M. Silvey, and Jerrold H. Levy

Anesth Analg 2003 97: 1289-1293.

 

小剂量氯胺酮预处理可以减少儿童与注射罗库溴铵有关的撤退运动

(王士雷 庄心良 )

Pretreatment with Small-Dose Ketamine Reduces Withdrawal Movements Associated with Injection of Rocuronium in Pediatric Patients

Jiin-Tarng Liou, Jee-Ching Hsu, Fu-Chao Liu, Daniel Ching-Wah Sum, and Ping-Wing Lui

Anesth Analg 2003 97: 1294-1297.

AMBULATORY ANESTHESIA:

足部和踝部手术后持续使用腘窝坐骨神经阻滞:能否提高恢复质量?

(殷文渊 王祥瑞 )

The Use of a Continuous Popliteal Sciatic Nerve Block After Surgery Involving the Foot and Ankle: Does It Improve the Quality of Recovery?

Paul F. White, Tijani Issioui, Gary D. Skrivanek, John S. Early, and Cynthia Wakefield

Anesth Analg 2003 97: 1303-1309.

ANESTHETIC PHARMACOLOGY:

利多卡因减弱了人类单核细胞趋化蛋白1的产生及其趋化作用:利多卡因在炎症中可能的机制

(张俊峰译 薛张纲校)

Lidocaine Attenuates Monocyte Chemoattractant Protein-1 Production and Chemotaxis in Human Monocytes: Possible Mechanisms for Its Effect on Inflammation

Chi-Yuan Li, Chien-Sung Tsai, Ping-Ching Hsu, Sheau-Huei Chueh, Chih-Shung Wong, and Shung-Tai Ho

Anesth Analg 2003 97: 1312-1316.

 

利多卡因和辛醇对外周神经TTX不敏感钠通道有不同的作用

(王士雷 庄心良 )

Lidocaine and Octanol Have Different Modes of Action at Tetrodotoxin-Resistant Na+ Channels of Peripheral Nerves

Deniz Poyraz, Michael E. Bräu, Friederike Wotka, Birgit Puhlmann, Andreas M. Scholz, Prof. Gunter Hempelmann, Prof. Wolfgang J. Kox, and Prof. Claudia D. Spies

Anesth Analg 2003 97: 1317-1324.

 

异丙酚抑制大鼠垂体细胞的胞内钙离子活化的作用

(齐波 王祥瑞 )

Inhibition by Propofol of Intracellular Calcium Mobilization in Cultured Mouse Pituitary Cells

Jacques T. Ya Deau, Christine M. Morelli, and Soléenne Desravines

Anesth Analg 2003 97: 1325-1330.

 

Ketamine, ThiopentalHalothane可抑制自然杀伤细胞活性,促进肿瘤转移,而异丙酚不会:调节机制和预防措施

(张俊峰译 薛张纲校)

Suppression of Natural Killer Cell Activity and Promotion of Tumor Metastasis by Ketamine, Thiopental, and Halothane, but Not by Propofol: Mediating Mechanisms and Prophylactic Measures

Rivka Melamed, Shahar Bar-Yosef, Guy Shakhar, Keren Shakhar, and Shamgar Ben-Eliyahu

Anesth Analg 2003 97: 1331-1339.

 

一个手术和麻醉的动物模型:特点是异氟烷麻醉和雷米芬太尼镇痛

(颜涛译 庄心良校)

An Animal Model for Surgical Anesthesia and Analgesia: Characterization with Isoflurane Anesthesia and Remifentanil Analgesia

Masakazu Hayashida, Atsuo Fukunaga, and Kazuo Hanaoka

Anesth Analg 2003 97: 1340-1346.

 

在兔注射雷米芬太尼后对镇痛和非镇痛作用的急性耐受性研究

(齐波 王祥瑞 )

Detection of Acute Tolerance to the Analgesic and Nonanalgesic Effects of Remifentanil Infusion in a Rabbit Model

Masakazu Hayashida, Atsuo Fukunaga, and Kazuo Hanaoka

Anesth Analg 2003 97: 1347-1352.

 

Thiamylal和苯巴比妥在体外人类血小板聚集中的相反作用

(张俊峰译 薛张纲校)

Thiamylal and Pentobarbital Have Opposite Effects on Human Platelet Aggregation In Vitro
Masami Sato, Hideo Hirakata, Takefumi Nakagawa, Kyoko Arai, and Kazuhiko Fukuda

Anesth Analg 2003 97: 1353-1359

 

静脉注射潘妥拉唑和雷尼替丁改善行择期手术病人术前胃内液体特性的效果

(颜涛译 庄心良校)

The Effect of Intravenous Pantoprazole and Ranitidine for Improving Preoperative Gastric Fluid Properties in Adults Undergoing Elective Surgery

Dilek Memis, Alparslan Turan, Beyhan Karamanlioglu, Pinar Saral, Mevlüt Türe, and Zafer Pamukçu

Anesth Analg 2003 97: 1360-1363..

猪七氟醚的最小麻醉药浓度与不同浓度氙的关系

(齐波 王祥瑞 )

Minimum Anesthetic Concentration of Sevoflurane with Different Xenon Concentrations in Swine

Klaus E. Hecker, Jan H. Baumert, Nicola Horn, Matthias Reyle-Hahn, Nicole Heussen, and Rolf Rossaint

Anesth Analg 2003 97: 1364-1369.

 

七氟醚的心脏保护效应依赖于蛋白激酶C活化、线粒体 K+ATP通道开放以及反应性氧分子的生成

(张俊峰译 薛张纲校)

The Cardioprotective Effect of Sevoflurane Depends on Protein Kinase C Activation, Opening of Mitochondrial K+ATP Channels, and the Production of Reactive Oxygen Species

Wouter de Ruijter, René J.P. Musters, Christa Boer, Ger J. M. Stienen, Warner S. Simonides, and Jaap J. de Lange

Anesth Analg 2003 97: 1370-1376.

 

单次剂量地塞米松对大鼠伤口愈合的影响

(唐俊 庄心良 )

The Effects of Single-Dose Dexamethasone on Wound Healing in Rats

Mahmut Durmus, Erol Karaaslan, Erdogan Ozturk, Mukaddes Gulec, Mustafa Iraz, Naci Edali, and M. Ozcan Ersoy

Anesth Analg 2003 97: 1377-1380.

 

围术期的过敏反应

(陈洁 王祥瑞 )

Anaphylaxis During the Perioperative Period (Review Article)

David L. Hepner and Mariana C. Castells

Anesth Analg 2003 97: 1381-1395. 

TECHNOLOGY, COMPUTING, AND SIMULATION:

人听觉稳定状态反应:录音技术效应和觉醒状态

(方芳译 薛张纲校)

Human Auditory Steady-State Responses: The Effects of Recording Technique and State of Arousal

Terence W. Picton, M. Sasha John, David W. Purcell, and Gilles Plourde

Anesth Analg 2003 97: 1396-1402.

 

一种高仿真模拟器的心血管图形化显示的评估

(唐俊 庄心良 )

Evaluation of Graphic Cardiovascular Display in a High-Fidelity Simulator

James Agutter, Frank Drews, Noah Syroid, Dwayne Westneskow, Rob Albert, David Strayer, Julio Bermudez, and Matthew B. Weinger

Anesth Analg 2003 97: 1403-1413.

 

一种新的可调节式的混合器测量麻醉机呼吸回路中混合呼出气体的浓度

(陈洁 王祥瑞 )

Novel, Adjustable, Clinical Bymixer Measures Mixed Expired Gas Concentrations in Anesthesia Circle Circuit

Abraham Rosenbaum and Peter H. Breen

Anesth Analg 2003 97: 1414-1420.

 

丙泊酚/芬太尼麻醉诱导后早期吲哚菁绿指示血浆容量可能存在估计过高

(方芳译 薛张纲校)

Possible Overestimation of Indocyanine Green-Derived Plasma Volume Early After Induction of Anesthesia with Propofol/Fentanyl

Wei-Dong Mi, Hironori Ishihara, Tetsuhiro Sakai, and Akitomo Matsuki

Anesth Analg 2003 97: 1421-1427.

PAIN MEDICINE:

人硬膜外应用芬太尼的作用部位:输注与单次注射的差异

(唐俊 庄心良 校)

The Site of Action of Epidural Fentanyl in Humans: The Difference Between Infusion and Bolus Administration

Yehuda Ginosar, Edward T. Riley, and Martin S. Angst

Anesth Analg 2003 97: 1428-1438.

 

硬膜外芬太尼注射的作用部位:初产妇最小局麻浓度的研究

(陈洁 王祥瑞 )

Yehuda Ginosar, Malachy O. Columb, Sheila E. Cohen, Edward Mirikatani, Martha S. Tingle, Emily F. Ratner, Martin S. Angst, and Edward T. Riley

The Site of Action of Epidural Fentanyl Infusions in the Presence of Local Anesthetics: A Minimum Local Analgesic Concentration Infusion Study in Nulliparous Labor

Anesth Analg 2003 97: 1439-1445.

 

椎管构造有利于镇痛的方面——应用苏芬太尼、布比卡因混合液行术后镇痛

(方芳译 薛张纲校)

Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia

Jean L. Joris, Eric A. Jacob, Daniel I. Sessler, Jean-François J. Deleuse, Abdourahamane Kaba, and Maurice L. Lamy

Anesth Analg 2003 97: 1446-1451.

 

鞘膜内吗啡用于术后镇痛:髋或膝关节成形术中的随机对照剂量对比研究

(唐俊 庄心良 校)

Intrathecal Morphine for Postoperative Analgesia: A Randomized, Controlled, Dose-Ranging Study After Hip and Knee Arthroplasty

James P. Rathmell, Carlos A. Pino, Richard Taylor, Terri Patrin, and Bruce A. Viani

Anesth Analg 2003 97: 1452-1457.

 

鼠外周神经系统对吗啡产生耐受时的Mu-阿片类受体mRNA的调节

(朱辉 王祥瑞 )

Mu-Opioid Receptor mRNA Regulation During Morphine Tolerance in the Rat Peripheral Nervous System

Thomas Meuser, Thorsten Giesecke, Anja Gabriel, Maria Horsch, Rainer Sabatowski, Jürgen Hescheler, Stefan Grond, and Pamela Pierce Palmer

Anesth Analg 2003 97: 1458-1463.

 

女性比男性更容易感到疼痛因而需要更多的吗啡来达到相近的止痛效果

(方芳译 薛张纲校)

Women Experience More Pain and Require More Morphine Than Men to Achieve a Similar Degree of Analgesia

M. Soledad Cepeda and Daniel B. Carr

Anesth Analg 2003 97: 1464-1468.

 

耳穴电针刺激较传统的机械压迫刺激对痛有更好的治疗作用

(王士雷 庄心良 校)

Electrical Stimulation of Auricular Acupuncture Points Is More Effective Than Conventional Manual Auricular Acupuncture in Chronic Cervical Pain: A Pilot Study

Sabine M. Sator-Katzenschlager, Jozef C. Szeles, Gisela Scharbert, Andrea Michalek-Sauberer, Alexander Kober, Georg Heinze, and Sibylle A. Kozek-Langenecker

Anesth Analg 2003 97: 1469-1473.

 

单次静注5HT3受体拮抗剂枢复宁可以治疗神经痛吗?双盲,安慰——对照交叉研究

(朱辉 王祥瑞 )

Does a Single Intravenous Injection of the 5HT3 Receptor Antagonist Ondansetron Have an Analgesic Effect in Neuropathic Pain? A Double-Blinded, Placebo-Controlled Cross-Over Study

Gary J. McCleane, Rie Suzuki, and Anthony H. Dickenson

Anesth Analg 2003 97: 1474-1478.

CRITICAL CARE AND TRAUMA:

心电图自动测量记录仪在社区医院综合性监护中的应用及效力

(钟鸣译 薛张纲校)

The Use and Effectiveness of Electrocardiographic Telemetry Monitoring in a Community Hospital General Care Setting

J. Paul Curry, C. William Hanson, III, Michael W. Russell, Cheryl Hanna, Gayle Devine, and E. Andrew Ochroch

Anesth Analg 2003 97: 1483-1487.

硅酮强化的半球形斜口导管减少经鼻气管插管的并发症

(王士雷 庄心良 校)

A Silicone-Based Wire-Reinforced Tracheal Tube with a Hemispherical Bevel Reduces Nasal Morbidity for Nasotracheal Intubation

Shinichi Kihara, Tetsuya Komatsuzaki, Joseph R. Brimacombe, Yuichi Yaguchi, Noriko Taguchi, and Seiji Watanabe

Anesth Analg 2003 97: 1488-1491

 

过氧化硝酸盐降低多巴胺的血管收缩性

(朱辉 王祥瑞 )

Peroxynitrite Decreases Dopamine’s Vasoconstrictive Activity

Ko Takakura, Wen Xiaohong, Kenji Takeuchi, and Satoru Fukuda

Anesth Analg 2003 97: 1492-1496.

 

小猪急性肺动脉高压模型中间断吸入一氧化氮联合静脉内注射双嘧达莫

(钟鸣译 薛张纲校)

Intermittent Nitric Oxide Combined with Intravenous Dipyridamole in a Piglet Model of Acute Pulmonary Hypertension

Luc Foubert, Daniël De Wolf, Koen Reyntjens, Yves Van Belleghem, Filip De Somer, Guido Van Nooten, and Eric Mortier

Anesth Analg 2003 97: 1497-1500

OBSTETRIC ANESTHESIA:

吸食可卡因的分娩病人舒芬太尼鞘内给药镇痛时间的减少

(钟鸣译 薛张纲校)

Reduced Duration of Intrathecal Sufentanil Analgesia in Laboring Cocaine Users

Vernon H. Ross, Charles H. Moore, Peter H. Pan, Regina Y. Fragneto, Robert L. James, and Gina B. Justis

Anesth Analg 2003 97: 1504-1508.

 

布比卡因和左旋布比卡因在分娩时的相对运动阻滞特性

(王士雷 庄心良 校)

The Relative Motor Blocking Potencies of Bupivacaine and Levobupivacaine in Labor

Héctor J. Lacassie and Malachy O. Columb

Anesth Analg 2003 97: 1509-1513.

REGIONAL ANESTHESIA:

超声引导锁骨上臂丛神经阻滞

(殷文渊 王祥瑞 )

Ultrasound-Guided Supraclavicular Brachial Plexus Block

Vincent W. S. Chan, Anahi Perlas, Regan Rawson, and Olusegun Odukoya

Anesth Analg 2003 97: 1514-1517.

 

超声引导加快了锁骨上阻滞的操作的速度和提高了阻滞质量

(钟鸣译 薛张纲校)

Ultrasound Guidance Speeds Execution and Improves the Quality of Supraclavicular Block

Stephan R. Williams, Philippe Chouinard, Geneviève Arcand, Patrick Harris, Monique Ruel, Daniel Boudreault, and François Girard

Anesth Analg 2003 97: 1518-1523.

GENERAL ARTICLES:

控制性低血压和最小膨胀压:上肢手术中使用充气式止血带的一项新技术

(朱慧琛 王祥瑞 )

Controlled Hypotension and Minimal Inflation Pressure: A New Approach for Pneumatic Tourniquet Application in Upper Limb Surgery

Bahattin Tuncali, Ayse Karci, Abdul Kadir Bacakoglu, Binnur Erdalkiran Tuncali, and Ahmet Ekin

Anesth Analg 2003 97: 1529-1532.

 

老年手术病人心脏舒张充盈功能异常的流行病学调查

The Prevalence of Preoperative Diastolic Filling Abnormalities in Geriatric Surgical Patients

Bridget Phillip, MD, Darwin Pastor, Wayne Bellows, MD, and Jacqueline M. Leung, MD MPH

From the Department of Anesthesia and Perioperative Care, University of California, San Francisco and Department of Cardiovascular Anesthesia, Kaiser Permanente Medical Center, San Francisco, California.

Anesth Analg 2003;97:1214-1221


术前评价心功能时,通常以评估左心射血分数(LVEF)为主。目前的临床证据表明心脏舒张功能衰竭也很常见,且占有一定的发病率和死亡率。本次研究对象为老年的手术病人,通过超声心动图评价他们的心脏舒张充盈功能,借以评价其发病情况。选择病人条件:年龄≥65岁,行冠状动脉手术(不伴有心脏瓣膜疾病),或行非心脏手术(至少伴有一个或一个以上的心血管疾病危险因素)。非心脏手术的病人,术前均进行超声心动图检查;心脏手术的病人,术中均进行食管超声心动图检查。超声心动图记录了LVEFE/A比值等评价左、右心室功能的指标。共观测了251个病人,平均年龄为72±7岁,多元线性回归分析表明,心肌梗塞病史的病人(P0.021),心绞痛的病人(β=-6.0995 CI:-9.66 2.52P0.001),瓣膜病的病人(β=-5.0595 CI:-9.56 0.55P0.028),这些病人的LVEF也明显低于那些没有症状的病人。LVEF正常的病人中,有61.5%的病人存在舒张功能异常。舒张功能异常包括E/A比值(β=-1.1195 CI:-6.02 3.78P0.65)和减速时间(β=-3.4295 CI:-31.2822.45P0.81)。舒张功能不全的病人没有特征性的临床表现。通过方差分析证明:对于那些进行非心脏手术的病人,可以根据其病史和体格检查的数据来评价LVEF的水平,但这种评价与超声心动图的评价结果两者之间纯在明显差异(P=0.0004)。通常情况下,人为的评价结果比超声心动图的结果偏低一些。虽然有经验的医生能够基本正确的评价出病人心脏收缩期的射血分数,但是有很多LVEF正常的老年病人独立的存在心脏舒张充盈功能缺陷,而这一缺陷是无法从临床上的表现来预言的。以上这些结果表明,对于老年手术病人单纯的评价左室收缩功能是不全面的,临床医生应近可能全面的考虑到老年人左室功能的特点。

(肖洁 王祥瑞校)

Preoperative assessment of heart function has typically focused on evaluating left ventricular ejection fraction (LVEF). Recent evidence suggests that diastolic heart failure is common and may cause substantial morbidity and mortality. We designed this study to examine the prevalence and potential clinical correlates of diastolic filling abnormalities as measured by echocardiography in geriatric surgical patients. Patients >=65 yr of age undergoing coronary artery surgery without concomitant valvular surgery or those with one or more risk factors for cardiovascular disease undergoing noncardiac surgery were prospectively studied. Preoperative precordial echocardiography was performed for patients undergoing noncardiac surgery, and intraoperative transesophageal echocardiography was performed for those undergoing cardiac surgery. LVEF and diastolic filling properties including E/A ratio and deceleration time were measured. Overall, 251 patients were enrolled. The mean age was 72 ± 7 yr. Multiple linear regression analyses showed that patients with a history of myocardial infarction P = 0.021), angina pectoris (ß = -6.09, 95% CI: -9.66, -2.52; P = 0.01), and valvular heart disease (ß = -5.05, 95% CI: -9.56, -0.55; P = 0.028) had lower LVEF than those without such conditions. Of the patients with normal LVEF, 61.5% had diastolic filling abnormalities. Diastolic filling indices including E/A ratio (ß = -1.11, 95% CI -6.02, 3.78; P = 0.65) and deceleration times (ß = -3.42, 95% CI -31.28, 24.45; P = 0.81) contributed no additional predictive value for LVEF. No clinical predictors could be identified to predict diastolic filling abnormalities. For patients undergoing noncardiac surgery, analysis of variance demonstrates that the clinical assessment of LVEF using history and physical examination data was able to grossly discriminate the different levels of LVEF as compared with echocardiography (P = 0.0004). However, under-estimation of LVEF occurred more frequently than over-estimation. Although physicians’ clinical assessment of systolic ejection fraction was generally accurate, geriatric patients with normal LVEF often had isolated diastolic filling abnormalities that could not be predicted by clinical factors. These results suggest that evaluation of LV systolic function alone is not discriminatory in comprehensively characterizing LV function in geriatric surgical patients.

 

l-麻黄碱与d-伪麻黄碱的拟交感神经药作用:是直接激活受体还是通过去甲肾上腺素释放引起的?

The Sympathomimetic Actions of l-Ephedrine and d-Pseudoephedrine: Direct Receptor Activation or Norepinephrine Release?

Shigeaki Kobayashi, MD*, Masayuki Endou, MD PhD{ddagger}, Fumika Sakuraya, MD*, Naoyuki Matsuda, MD PhD*, Xiao-Hong Zhang, MD*, Mitsue Azuma, Mphar*, Noriyuki Echigo, MD{ddagger}, Osamu Kemmotsu, MD PhD*, Yuichi Hattori, MD PhD{dagger}, and Satoshi Gando, MD PhD*

From the Departments of *Anesthesiology & Critical Care Medicine and {dagger}Pharmacology, Hokkaido University School of Medicine, Sapporo, Japan; and the {ddagger}Department of Anesthesiology, Yokohama City University School of Medicine, Yokohama, Japan

Anesth Analg 2003;97:1239-1245


长久以来,麻黄碱都是产科手术中血管加压剂的首选药物,但其作用的基础机制还并不明确。我们通过实验研究了两种药物的拟交感神经作用,目前常用的血管加压素l-麻黄碱和解充血药物d-伪麻黄碱。在已经麻醉的大鼠上, l-麻黄碱和d-伪麻黄碱都可以导致剂量依赖性的动脉血压增高和心率增快,但是,如果在用药前先给6-羟多巴胺(6-OHDA)阻断交感神经,则以上反应就会消失。实验结果表明,两种麻黄碱的异构体均产生浓度依赖性的提肛肌张力增加和右心房窦性心率。同样的,提肛肌和心房反应在使用6-羟多巴胺后都会消失,然而,有近50%使用l-麻黄碱的大鼠有对6-羟多巴胺耐药的表现。通过人的脐动、静脉给足够剂量的以上两种麻黄碱的异构体,没能产生任何反应(这些剂量能够引起提肛肌和心房组织明显反应)。虽然l-麻黄碱直接兴奋肾上腺素受体在组织学上也有一定证据,但该药物在人体内的反应应该完全归功于交感神经去甲肾上腺素的释放。这种间接机制比较容易解释为什么l-麻黄素可以在保证子宫胎盘血供的情况下升高母亲的动脉血压,因为子宫胎盘血供没有交感神经的支配。

(肖洁 王祥瑞 )

The basic mechanisms by which ephedrine is preferred over other vasopressors in obstetric anesthesia have not been clearly defined. We examined the sympathomimetic effects of l-ephedrine, currently used as a vasopressor, and d-pseudoephedrine, currently used as a decongestant. In anesthetized rats, l-ephedrine and d-pseudoephedrine caused dose-dependent increases in arterial blood pressure and heart rate, and these effects disappeared after destruction of the sympathetic nerve terminals with 6-hydroxydopamine (6-OHDA) pretreatment. The two ephedrine isomers produced concentration-dependent increases in tension of anococcygeal muscle and sinus rate of right atrium from rats. However, the anococcygeal and atrial responses to d-pseudoephedrine were abolished after 6-OHDA pretreatment, whereas approximately 50% of the responses to l-ephedrine were 6-OHDA-resistant. In human umbilical artery and vein, the two isomers failed to generate any contraction when given at the concentration that is capable of producing significant effects on anococcygeal and atrial tissues. Although direct adrenoceptor activation with l-ephedrine was detectable at tissue levels, the pressor response in vivo was entirely attributable to norepinephrine release from sympathetic nerves. This indirect mechanism could partly explain why l-ephedrine is better at increasing maternal arterial blood pressure while preserving the uteroplacental blood flow that is devoid of the involvement of the sympathetic innervation.

 

先天性心脏病手术患者术中脉搏曲线法心输出量监测的分析

Pulse Contour Analysis for Cardiac Output Monitoring in Cardiac Surgery for Congenital Heart Disease

Aman Mahajan, MD, Afshin Shabanie, MD, Judi Turner, MD PhD, Michael J. Sopher, MD, and Jure Marijic, MD

Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles

Anesth Analg 2003;97:1283-1288


肺动脉导管监测心输出量的方法并不适用于先天性心脏病患者,这主要是由于这些患者年纪太小,同时又存在解剖学上的异常。我们研究了儿童及成人先天性心脏病手术中利用脉搏曲线分析仪测量连续心输出量这一新方案的准确性。在这次实验中共有16位患者参与,平均年龄为7岁。在心肺转流前后共记录了191个数据。我们评估了经肺热稀释法心指数测定(TDCI)与脉搏曲线心指数测定(PCCI)两者之间的相互关系,TDCIPCCI的相关系数为0.7。虽然在先前的研究中PCCI被认为是成人心脏手术中较为准确的一个测量指标,但本研究病患中其还欠缺可靠性,甚至在经过分流改正后也存在这一问题。我们也同时研究容量负荷与压力负荷的相关性(胸内血液容量指数[ITBI]和中心静脉压心指数测定)。经过修正PCCITDCIITBI的相关性(分别为0.560.71)较PCCITDCICVP0.160.11)的相关性强,这一结论显示用ITBI测负荷较为可靠。

(朱慧琛 王祥瑞 )

Conventional methods of cardiac output monitoring using pulmonary artery catheters may not be feasible in patients with congenital heart disease because of patients’ small size or aberrant anatomy. We studied the accuracy of a new device, which uses pulse contour analysis to measure continuous cardiac output, in children and adults undergoing congenital heart surgery. Sixteen patients, median ages 7 yr old, were included in this prospective study. One-hundred-ninety-one data points were obtained in the pre- and postcardiopulmonary bypass periods and in the first 12 h after intensive care unit admission. We evaluated the relationship between cardiac index (CI) derived from transpulmonary thermodilution (TDCI) and CI derived from pulse contour analysis (PCCI). Bias and limits of agreement between TDCI and PCCI over all time periods were 0.1 ± 1.94, indicating a wide dispersion of the data. Coefficient of correlation (r) between the TDCI and PCCI was 0.7. Although in previous studies, PCCI has been suggested to be accurate in adult cardiac surgery, we found it to be less reliable in our study patients, even after shunt correction. The relationships of the volume and pressure based measures of preload, intrathoracic blood volume index (ITBI), and central venous pressure with CI were also investigated. After repair, correlation (r) between PCCI or TDCI and ITBI (0.56 and 0.71, respectively) was better than that between PCCI or TDCI and CVP (0.16 and 0.11, respectively), indicating greater validity of ITBI as a measure of preload.

 

足部和踝部手术后持续使用腘窝坐骨神经阻滞:能否提高恢复质量?

The Use of a Continuous Popliteal Sciatic Nerve Block After Surgery Involving the Foot and Ankle: Does It Improve the Quality of Recovery?

Paul F. White, PhD MD, FANZCA*, Tijani Issioui, MD*, Gary D. Skrivanek, MD*, John S. Early, MD{dagger}, and Cynthia Wakefield*

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

Anesth Analg 2003;97:1303-1309


持续腘窝坐骨神经阻滞是一种普遍用于足部和踝部手术的技术。可是,当区域麻醉作用消失后,疼痛很难控制住。因此,我们假设通过持续注射布比卡因(0.25%)来延长阻滞时间,从而减轻疼痛,有利于足部和踝部手术后的恢复。随机、双盲、安慰剂对照的研究中,对24名知情的在标准全麻下接受足部或踝部手术的病人进行研究。在手术前,使用18G Tuohy硬膜外针和经皮神经刺激仪对所有病人进行腘窝坐骨神经阻滞。在注射0.25%布比卡因30ml和放置20G导管后,病人随机分为使用0.9%生理盐水(对照)0.25%布比卡因,速度维持为5ml/h,直到术后48小时。使用一种11分口头评定表(0=不痛,10=痛的超乎想象)来评估疼痛的严重程度。术后特定时间段使用阿片类镇痛药都被记录下来。随后的评估在术后24h48h72h和一周进行,估算镇痛评分和病人对镇痛和恢复质量的满意程度,使用的是一种100分口头评定表(1=极度不满意到100=极度满意)。在布比卡因组,术后最大疼痛评分(>50%)和阿片类药物的使用(>60%)与对照组相比在统计学上都显著降低。布比卡因组中病人对术后镇痛和恢复质量的满意程度都显著提高(与对照组相比)。此外,40%的布比卡因组病人在术后当天可以出院回家。总之,在骨科足部和踝部手术后持续注射0.25%布比卡因减轻了术后疼痛、减少了阿片类药的使用,提高了病人的满意程度和恢复质量。

(殷文渊 王祥瑞 )

Popliteal sciatic nerve block is a commonly used technique for surgery involving the foot and ankle. However, pain can be difficult to control as the local anesthetic block wears off. Therefore, we hypothesized that extending the block by using a continuous infusion of bupivacaine (0.25%) would provide improved pain management and might facilitate the recovery process after foot or ankle surgery. In this randomized, double-blinded, placebo-controlled study, 24 consenting patients undergoing foot or ankle surgery with a standardized general anesthetic technique were studied. Before surgery, a popliteal sciatic nerve block was performed in all patients with an 18-gauge Tuohy epidural needle and a peripheral nerve stimulator. After injection of bupivacaine 0.25% 30 mL and placement of a 20-gauge catheter, patients were randomly assigned to receive either 0.9% saline (control) or bupivacaine 0.25% at a constant rate of 5 mL/h for up to 48 h after surgery. An 11-point verbal rating scale (0 = no pain to 10 = worst pain imaginable) was used to assess the severity of pain. Opioid analgesic use was recorded at specific time intervals after surgery. Follow-up evaluations were performed at 24 h, 48 h, 72 h, and 1 week after surgery to assess pain scores, as well as patient satisfaction with their pain management and quality of recovery, by using a 100-point verbal rating scale (1 = highly dissatisfied to 100 = highly satisfied). In the bupivacaine group, there was a statistically significant reduction in the maximal pain scores (>50%) and in opioid use (>60%) during the postoperative period compared with the control group. Patient satisfaction with postoperative pain management (95 ± 3 versus 77 ± 13) and quality of recovery (96 ± 7 versus 83 ± 14) was significantly improved in the bupivacaine group (versus control). In addition, 40% of the patients in the bupivacaine group (versus none in the control group) were able to be discharged home on the day of surgery (P = 0.087). In conclusion, a continuous infusion of bupivacaine 0.25% decreased postoperative pain and the need for opioid analgesic rescue medication after orthopedic surgery involving the foot and ankle, leading to improved patient satisfaction and quality of recovery.

 

异丙酚抑制大鼠垂体细胞的胞内钙离子活化的作用

Inhibition by Propofol of Intracellular Calcium Mobilization in Cultured Mouse Pituitary Cells

Jacques T. Ya Deau, MD PhD, Christine M. Morelli, BS, and Soléenne Desravines, BA

Anesthesiology Division, Hospital of Special Surgery, Weill Medical College of Cornell University, New York

Anesth Analg 2003;97:1325-1330


异丙酚可以抑制AtT20-细胞(一类垂体瘤的细胞系)分泌和调节β-内啡肽(神经肽)。神经肽的分泌有赖于细胞内钙离子浓度水平的升高。本次研究的目的是异丙酚改变AtT20-细胞内钙离子的浓度水平。异丙酚(100μM)并不能通过抑制钙离子而抑制细胞(可透过毛地黄皂甙)分泌β-内啡肽。因此,异丙酚并不是通过改变细胞内钙离子的浓度来抑制神经肽分泌的。细胞内钙离子的测定是通过一种特定的钙离子敏感染色实现的。钙离子可与KCL发生短暂的去极化或与thapsigargin(一类钙离子抑制剂,可被内质网摄取)相结合。异丙酚抑制完整细胞中钙离子介质(于KCL反应产生)的生成。(半价最大抑制率为14.9μMP<0.05)。硝基乙吡啶也可通过钾离子抑制钙离子峰的形成。异丙酚50μM可将thapsigargin组的钙离子峰值降至对照组的47%(P<0.05)。用硝基乙吡啶将钙通阻滞后,Thapsigargin组的作用不受其影响。异丙酚抑制的是刺激细胞内钙离子增加的因素。异丙酚可以抑制Thapsigargin钙离子介质,而硝基乙吡啶不能,这就说明异丙酚对细胞内钙离子的作用与L-型钙离子通道的阻断与否没有关系。异丙酚可以抑制细胞内储备钙离子的释放。以上的这些研究结果说明,异丙酚通过抑制刺激细胞内钙离子增加的因素而达到抑制神经肽分泌的。

(齐波 王祥瑞 )

Propofol inhibited regulated secretion of the neuropeptide ß-endorphin from AtT-20 cells, a pituitary tumor cell line. Neuropeptide secretion depends on an increase of intracellular calcium (Ca2+) levels. We investigated the hypothesis that propofol altered intracellular Ca2+ levels in AtT-20 cells. Propofol (100 µM) did not inhibit Ca2+-induced secretion of ß-endorphin from digitonin-permeabilized cells. Thus, propofol did not inhibit neuropeptide secretion by blocking the effects of increased intracellular Ca2+. Intracellular Ca2+ was measured in intact cells using a Ca2+-sensitive dye. Ca2+ transients were generated by depolarization with KCl or by incubation with thapsigargin (an inhibitor of Ca2+ uptake into the endoplasmic reticulum). Propofol inhibited generation of Ca2+ transients in intact cells by KCl (half-maximal inhibitory concentration of 14.9 µM; P < 0.05). Nitrendipine also inhibited potassium-induced Ca2+ peaks. Propofol 50 µM reduced the thapsigargin-induced Ca2+ peak to 47% of control (P < 0.05). Thapsigargin-induced Ca2+ peaks were not affected by calcium channel blockade by nitrendipine. Propofol inhibited the stimulus-induced increase in intracellular Ca2+. Propofol inhibited thapsigargin-induced Ca2+ transients, but nitrendipine did not, indicating that propofol had effects on intracellular Ca2+ independent of blockade of L-type Ca2+ channels. Propofol may inhibit release of Ca2+ from intracellular stores. These results are consistent with the hypothesis that propofol inhibits neuropeptide secretion by inhibiting the stimulus-induced increase in intracellular Ca2+.

 

在兔注射雷米芬太尼后对镇痛和非镇痛作用的急性耐受性研究

Detection of Acute Tolerance to the Analgesic and Nonanalgesic Effects of Remifentanil Infusion in a Rabbit Model

Masakazu Hayashida, MD PhD*, Atsuo Fukunaga, MD PhD{dagger}, and Kazuo Hanaoka, MD PhD*

*Department of Anesthesiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; and the {dagger}Department of Anesthesiology, Harbor UCLA Medical Center, Torrance, California

Anesth Analg 2003;97:1347-1352


虽然在注射雷米芬太尼后,急性耐受镇痛作用很快就会产生,但是对于那些非镇痛作用是否也纯在耐受作用仍不明确.本研究通过对兔子的动物实验研究在连续注射雷米芬太尼后的镇痛作用和心肺作用.10只新西兰大白兔,气管切开留取动静脉后用一根细绳固定,动物还有定的自主活动能力.对于有自主呼吸意识清醒的兔子以0.3μg/kg*min注射雷米芬太尼360分钟.在注射雷米芬太尼时,反复评价镇静和镇痛作用及心肺功能,包括钳夹前蹄后观察动物的动作,测量能引起动物抬头的皮下电刺激阈值(HLT:疼痛检测,觉醒阈值),和逃脱反应,同时伴有血压,心率和呼吸频率的降低.因此,所有的变量都随着药物的持续注射渐渐变回到药物使用前的水平.以上结果说明伴随着雷米芬太尼的注射,急性的耐受反应不仅发生在镇痛作用上还包括心肺反应等.

(齐波 王祥瑞 )

Although acute tolerance to analgesia develops rapidly with remifentanil, it is unknown whether acute tolerance also develops to its nonanalgesic effects. We investigated the analgesic and cardiorespiratory effects of remifentanil during a continuous infusion in a rabbit model. Ten tracheotomized New Zealand White rabbits with arterial and venous accesses were placed on a sling that allowed for reasonably free movement. In spontaneously breathing conscious animals, remifentanil was infused IV at a constant-rate of 0.3 µg • kg-1 • min-1 for 360 min. Sedative/analgesic and cardiorespiratory variables were assessed repeatedly during remifentanil infusion, including the number of animals behaviorally unresponsive to clamping the forepaw (nonresponders) and subcutaneous electrical stimulation thresholds required to elicit head lift (HLT: pain detection/arousal threshold) and escape movement responses (EMT: pain tolerance threshold). Within 60–120 min of starting the infusion, the number of nonresponders, HLT, EMT, and PaCO2 increased significantly, whereas blood pressure, heart rate, and respiratory rate decreased. Thereafter, all variables returned towards preinfusion levels despite continuing infusion. These results indicate that during a remifentanil infusion acute tolerance develops for both its analgesic and cardiorespiratory effects.

 

猪七氟醚的最小麻醉药浓度与不同浓度氙的关系

Minimum Anesthetic Concentration of Sevoflurane with Different Xenon Concentrations in Swine

Klaus E. Hecker, MD*, Jan H. Baumert, MD DEAA*, Nicola Horn, MD*, Matthias Reyle-Hahn, MD{ddagger}, Nicole Heussen, MSc{dagger}, and Rolf Rossaint, MD PhD*

Departments of *Anesthesiology and {dagger}Medical Statistics, Universitätsklinikum der RWTH Aachen, Aachen, Germany, and the {ddagger}Department of Anesthesiology and Intensive Care, Waldkrankenhaus Berlin, Berlin, Germany.

Anesth Analg 2003;97:1364-1369

 

在最近的一项研究中,我们描述了当氙与异氟醚共同应用时,有不同程度的拮抗作用。一个假想的解释是氙和异氟醚在神经原水平上通过不同的方式产生镇痛效果。本次实验将氙和其他吸入麻醉药混合以检测氙和其他麻醉药之间的关系。我们检测当氙与七氟醚相混合后,其肺泡最低浓度(MAC)的变化情况。研究的对象是10头猪(平均体重为30.8kg±2.6,)通气中分别给0%,15%,30%,40%,50%,65%氙。在不同浓度的氙气下,辅以不同浓度的七氟醚。在以上这些情况下都给一个强大的刺激(抓夹),有退缩表现的被记录下来。七氟醚的MAC定义为其最底的浓度时有50%的实验动物对刺激无反应。不同浓度的氙,动物对于疼痛的反应被归类并进行Logistic回归分析,并根据分析结果制定七氟醚的MAC。结果七氟醚的MAC随吸入氙的增加而减少,0%的氙时为2.5365%的氙时为1.54。与氙和异氟醚相比,氙和七氟醚的麻醉反应与其十分相似。

(齐波 王祥瑞 )

In a previous study, we described a partial antagonism of xenon (Xe) in combination with isoflurane. One hypothetical explanation suggested that Xe and isoflurane probably induced anesthesia via different pathways at the neuronal level. This warranted investigating the combination of Xe with other inhaled anesthetics to examine the relationship between Xe and volatile anesthetics in general. We therefore investigated the influence of Xe on the minimum alveolar concentration (MAC) of sevoflurane. The study was performed in 10 swine (weight 30.8 kg ± 2.6, mean ± SD) ventilated with xenon 0%, 15%, 30%, 40%, 50%, and 65% in oxygen. At each Xe concentration, various concentrations of sevoflurane were administered in a stepwise design. For each a supramaximal pain stimulus (claw clamp) was applied. The appearance of a withdrawal reaction was recorded. The sevoflurane MAC was defined as the end-tidal concentration required to produce a 50% response rate. At each Xe concentration, the animals’ responses to the pain stimulus were categorized and a logistic regression model was fitted to the results to determine sevoflurane MAC. Sevoflurane MAC was decreased by inhalation of Xe in a linear manner from 2.53 with 0% Xe to 1.54 with 65% Xe. In contrast to Xe and isoflurane, the anesthetic effects of Xe and sevoflurane appear to be simply linear.

 

围术期的过敏反应

Anaphylaxis During the Perioperative Period

David L. Hepner, MD*, and Mariana C. Castells, MD PhD{dagger}

*Department of Anesthesiology, Perioperative and Pain Medicine, and {dagger}Allergy and Clinical Immunology Training Program, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2003;97:1381-1395


麻醉医师在提供麻醉时会使用成千上万种药物。许多种药物存在剂量依赖的副作用,有一些会导致严重的免疫介导的副反应,过敏反应是其中最严重的一种。它通常发生于再次暴露于某一特殊抗原时,同时需要炎性介质的释放,其直接通过肥大细胞或补体反应释放而非IgE介导。围术期的过敏反应大多数是肌松剂和乳化剂所产生。症状可以累及所有的器官系统,在最严重的情况下表现为支气管的痉挛和心血管系统的衰竭。治疗包括停止接触可疑药物、心肺支持和使用肾上腺素。血清类胰蛋白酶能明确过敏反应的诊断,皮试和血清学检查可以明确过敏源,预防过敏反应的发生对降低患病率和死亡率是非常重要的。

(陈洁 王祥瑞 )

Anesthesiologists use a myriad of drugs during the provision of an anesthetic. Many of these drugs have side effects that are dose related, and some lead to severe immune-mediated adverse reactions. Anaphylaxis is the most severe immune-mediated reaction; it generally occurs on reexposure to a specific antigen and requires the release of proinflammatory mediators. Anaphylactoid reactions occur through a direct non-immunoglobulin E-mediated release of mediators from mast cells or from complement activation. Muscle relaxants and latex account for most cases of anaphylaxis during the perioperative period. Symptoms may include all organ systems and present with bronchospasm and cardiovascular collapse in the most severe cases. Management of anaphylaxis includes discontinuation of the presumptive drug (or latex) and anesthetic, aggressive pulmonary and cardiovascular support, and epinephrine. Although a serum tryptase confirms the diagnosis of an anaphylactic reaction, the offending drug can be identified by skinprick, intradermal testing, or serologic testing. Prevention of recurrences is critical to avoid mortality and morbidity.

 

一种新的可调节式的混合器测量麻醉机呼吸回路中混合呼出气体的浓度

Novel, Adjustable, Clinical Bymixer Measures Mixed Expired Gas Concentrations in Anesthesia Circle Circuit

Abraham Rosenbaum, MD*,{dagger}, and Peter H. Breen, MD FRCPC*

*Department of Anesthesiology, University of California, Irvine, California; and {dagger}Department of Anesthesiology, The Technion-Israel Institute of Technology, Haifa, Israel

Anesth Analg 2003;97:1414-1420


我们将一种新的、平行设计装置用于混合器,以连续测量同一回路中各种麻醉气体的比例。对机械通气模型在较大范围改变潮气量(300-1200mL)、频率(6-12/分)和PCO2之后,与呼出气体吸收装置相比,此装置的测量更为精确(平均斜率1.00y=-0.01 R2=0.9988)。改变混合气体的容积会改变混合器的反应时间。快的混合器可以测量的间歇为20.这种新的混合器由标准的麻醉机部件所制造,易于连接在吸气出口和呼气入口上,同时便于清洁和消毒,且不会积聚呼吸回路中的浓缩水分。这种新的混合器还可以直接反映麻醉状态下和非侵入性代谢装置(如无氧代谢)以及特殊情况下(肺栓塞)中的热量消耗(CO2消除,氧气的摄取)。

(陈洁 王祥瑞 )

We have introduced a novel, parallel design into a new clinical bymixer (patent pending), named for the bypass of a constant fraction of total flow through a mixing chamber. Over a wide range of tidal volumes (300–1200 mL), frequency (6–20 breaths/min), and PCO2 (6–50 mm Hg), the bymixer provided accurate measurement of mixed expired gas fractions in the ventilation circuit compared with an expired gas collection in a metabolic lung bench setup (average slope, 1.00; average y intercept, -0.01; average coefficient of determination, R2 = 0.9988). Simple changes in mixing chamber volume provided adjustable bymixer response times. The fast bymixer response (time constant, 6.4 s) should allow measurements to be updated every 20 s (where 95% response occurs by three time constants). The new clinical bymixer is constructed from standard anesthesia circuit components, attaches easily to the anesthesia machine inspired outlet and expired inlet ports, is simple to clean and sterilize, and has no reservoir to trap condensed water vapor from expired gas. The new clinical bymixer may facilitate indirect calorimetry (CO2 elimination, VCO2, and oxygen uptake, VCO2) during anesthesia and the noninvasive detection of metabolic upset (e.g., onset of anaerobic metabolism) and critical events (e.g., pulmonary embolism).

 

硬膜外芬太尼注射的作用部位:初产妇最小局麻浓度的研究

The Site of Action of Epidural Fentanyl Infusions in the Presence of Local Anesthetics: A Minimum Local Analgesic Concentration Infusion Study in Nulliparous Labor

Yehuda Ginosar, BSc MBBS*, Malachy O. Columb, FRCA{dagger}, Sheila E. Cohen, MBChB FRCA{ddagger}, Edward Mirikatani, MD{ddagger}, Martha S. Tingle, RN{ddagger}, Emily F. Ratner, MD{ddagger}, Martin S. Angst, MD{ddagger}, and Edward T. Riley, MD{dagger}

*Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University School of Medicine, Jerusalem, Israel, the {dagger}Department of Anaesthesia and Intensive Care Medicine, South Manchester University Hospitals, Wythenshawe, UK, and the {ddagger}Department of Anesthesia, Stanford University, Stanford, California

Anesth Analg 2003;97:1439-1445


我们以前曾经证实过,持续硬膜外注射芬太尼通过全身机制产生镇痛作用而不引起局部麻醉。在本试验中,我们假设;在硬膜外存在布比卡因的情况下,持续注射芬太尼通过脊髓机制产生镇痛。48例临产的初产妇接受了本次随机、前瞻性、双盲研究。她们在腰锥硬膜外腔注入20-30mL0.125%布比卡因直至疼痛缓解,然后随机分为IV或硬膜外(EPI)组,均持续注入芬太尼30ug/h,同时均以20ml/h的速度硬膜外持续注入布比卡因,浓度由同一组前一位妇女的反应所决定。与以往实验使用最小局麻有效浓度(MLAC)开始麻醉不同,本实验使用MLAC来维持生产的第一阶段。MLAC通过Dixon Massey所提供的持续分析法所测定。布比卡因的MLACIV组为.063%95%的可信区间,0.058-0.068),EPI组为0.01995%的可信区间,0.000-0.038)。EPIIV相比,有效性大于3倍。这次研究说明:硬膜外注射芬太尼,脊髓方式是其镇痛的主要机制。

(陈洁 王祥瑞 )

We have previously demonstrated that continuous epidural infusions of fentanyl without local anesthetics elicit analgesia by a systemic mechanism. In this study, we examined the hypothesis that, in the presence of epidural bupivacaine, continuous infusions of epidural fentanyl elicit analgesia by a spinal mechanism. Forty-eight nulliparous women in active labor participated in this prospective, randomized, double-blinded study. Women received lumbar epidural analgesia with 20–30 mL bupivacaine 0.125% until pain free. Subjects were then randomized to either IV or epidural (EPI) fentanyl infusion groups. Each infusion delivered fentanyl 30 µg/h. All women received an epidural infusion of bupivacaine at a rate of 20 mL/h, the concentration of which was determined by the response of the previous woman in the same group to the analgesic regimen used. Unlike previous studies that assessed the minimum local analgesic concentration (MLAC) for bolus administration at the initiation of analgesia, this study assessed MLACinfusion for the maintenance of analgesia throughout the first stage of labor. MLACinfusion was determined using the up-down sequential analysis described by Dixon and Massey. The MLACinfusion of epidural bupivacaine was 0.063% (95% confidence interval, 0.058–0.068) and 0.019% (95% confidence interval, 0.000–0.038) in the IV and EPI groups respectively. A continuous infusion of fentanyl was more than three times as potent when administered by the epidural than by the IV route. This marked increase in potency for the epidural route is highly suggestive for a predominantly spinal mechanism of action for infused epidural fentanyl under the conditions of this study.

 

鼠外周神经系统对吗啡产生耐受时的Mu-阿片类受体mRNA的调节

Mu-Opioid Receptor mRNA Regulation During Morphine Tolerance in the Rat Peripheral Nervous System

Thomas Meuser, MD*, Thorsten Giesecke, MD*, Anja Gabriel, MD*, Maria Horsch, MD*, Rainer Sabatowski, MD*, Jürgen Hescheler, MD{dagger}, Stefan Grond, MD{ddagger}, and Pamela Pierce Palmer, MD PhD§

Departments of *Anesthesiology and {dagger}Neurophysiology, University of Cologne, Cologne, Germany, {ddagger}Department of Anesthesiology, University of Halle Wittenberg, Halle, Germany, and the §Department of Anesthesia, University of California, San Francisco, CA

Anesth Analg 2003;97:1458-1463


在体暴露于阿片类激动剂的外周神经系统,关于其阿片类受体mRNA调节的文献数据相当缺乏。因此,我们将研究当老鼠对外周感觉中枢发生行为反应期间使用吗啡对Mu-阿片类受体调节的影响。19只老鼠被分成2组,一组皮下注射吗啡10mg/kg,另一组注射生理盐水并都超过4天。其中一部分在第5天注射纳洛酮并在第6天再注射吗啡或处死以便获得后根神经分析mRNA。在治疗期间老鼠的测试都在热的盘子上。使用吗啡超过4天时老鼠对吗啡产生耐受,爪子在热盘子上的收回时间由原来基线上的242%降到99%。通过RT-PCR我们证明在使用吗啡后Mu-阿片类受体mRNA下调至62%P0.05〉。当通过纳洛酮立即从Mu-阿片类受体上撤掉吗啡时,脊髓后根神经的Mu-阿片类受体mRNA24小时内恢复到对照水平,并且爪子收回时间也恢复到基线上的280%。这些数据表明外周神经系统可能是对阿片类药形成耐受的重要场所。

(朱辉 王祥瑞 )

In vivo data on opioid receptor mRNA regulation after agonist exposure in the peripheral nervous system are lacking. Therefore, we studied the impact of morphine treatment on the regulation of mu-opioid receptor mRNA during behavioral signs of tolerance in rat peripheral sensory ganglia. Nineteen rats were treated in 2 groups with either morphine (10 mg/kg subcutaneously) or saline over 4 days, and a subset of rats received naloxone on the fifth day followed by either morphine injection on the sixth day or death to obtain dorsal root ganglia for mRNA analysis. Animals were tested on the hot plate during treatment days. To assess the levels of mu-opioid receptor mRNA, quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) was used with the co-amplification of the "housekeeping" gene cyclophilin as internal control. Morphine treatment over 4 days induced tolerance as reflected on the hot-plate test by a significant reduction of paw-withdrawal latency from 242% to 99% above baseline. Using RT-PCR we demonstrated a down-regulation of mu-opioid receptor mRNA by 62% after morphine exposure (P < 0.05). After acute withdrawal of morphine from the mu-receptor by naloxone, the mu-opioid receptor mRNA levels in the dorsal root ganglia were restored to control levels within 24 h and the paw-withdrawal latency also returned to 280% above control. These data suggest that the peripheral nervous system may be an important site of opioid tolerance development.

 

单次静注5HT3受体拮抗剂枢复宁可以治疗神经痛吗?双盲,安慰——对照交叉研究

Does a Single Intravenous Injection of the 5HT3 Receptor Antagonist Ondansetron Have an Analgesic Effect in Neuropathic Pain? A Double-Blinded, Placebo-Controlled Cross-Over Study

Gary J. McCleane, MD, Rie Suzuki, PhD*, and Anthony H. Dickenson, PhD*

Rampark Pain Centre, Lurgan, Northern Ireland, and the *Department of Pharmacology, University College, Gower Street, London

Anesth Analg 2003;97:1474-1478

神经激肽-1-表达神经元位于脊髓的层,它与传导兴奋的上升和脊髓球路径密切相关。在动物试验中,切除了这些神经元就会降低对各种疼痛刺激的反应。此外,在动物中还发现脊髓内应用选择性5HT3受体拮抗剂Ondansetron可模拟这种作用,提示5HT3受体有预示疼痛的作用并可介与降低兴奋刺激以便允许脊髓神经元充分地感应外周的刺激。在这项研究中,我们在神经源性疼痛的人群中单一静脉注射Ondansetron测定其潜在的镇痛效果。每个经过同意的研究对象单一静脉注射8mgOndansetron,然后至少隔开1星期给予安慰剂并在之前48个小时和注射后48个小时记录疼痛评分。注射Ondansetron2小时疼痛评分显著降低(但其他时间点没有)。这项研究表明对于神经源性的疼痛Ondansetron可以达到镇痛效果,副作用叫小且不多见。

(朱辉 王祥瑞 )

Neurokinin–1-expressing neurones in lamina I to III of the spinal cord are intimately involved in the regulation of ascending and spino-bulbal pathways that regulate excitatory transmission. In experimental animals, ablation of these neurones reduces the responses to a variety of nociceptive stimuli. Furthermore, in animals, spinal application of the selective 5HT3 receptor antagonist ondansetron mimics these effects, indicating that 5HT3 receptors play a pronociceptive role and mediate descending excitatory controls that allow spinal neurones to fully code peripheral stimuli. In this study, we examined the potential analgesic effect of a single IV injection of ondansetron in humans with chronic neuropathic pain. Each consenting subject received a single IV injection of 8 mg ondansetron and placebo in varying order at least 1 wk apart with pain scores being recorded for the 48 h preceding and after each injection. Pain scores were significantly reduced 2 h after ondansetron injection (but at no other time point). This suggests that ondansetron can have an analgesic effect in neuropathic pain. Side effects were minor and infrequent.

 

过氧化硝酸盐降低多巴胺的血管收缩性

Peroxynitrite Decreases Dopamine’s Vasoconstrictive Activity

Ko Takakura, MD PhD*, Wen Xiaohong, MD{dagger}, Kenji Takeuchi, MD{dagger}, and Satoru Fukuda, MD PhD{dagger}

*Department of Anesthesiology, Asahi University, Hozumi, Gifu; and {dagger}Department of Anesthesiology and Reanimatology, Fukui Medical University, Matsuoka, Japan

Anesth Analg 2003;97:1492-1496


过氧化硝酸盐(ONOO-1)与多巴胺反应生成一种氧化衍生物。为了研究这种衍生物的血管收缩性,我们进行了一项功能性测试即在白鼠体内分离出的胸主动脉使用多巴胺和ONOO-1SIN-1(能产生ONOO-1)。为排除ONOO-1的直接作用,这段胸主动脉先用亚甲蓝即脒基环化酶抑制剂预处理。以多巴胺可引起浓度依赖的血管收缩,而预先用ONOO-1处理过的多巴胺其血管收缩性能明显降低,且也以ONOO-1浓度依赖的方式降低多巴胺的血管收缩性。预先用ONOO-1处理过的多巴胺其最大的血管收缩性以及50%有效的浓度值都明显降低。多巴胺与SIN-1混合也可降低其收缩性能,这取决于它们的混合时间。ONOO-1的形成是一个比较快的反应并且当细胞内一氧化氮和过氧化物生成增多时更加容易,如在败血症引起的休克。这些结果或许至少可部分解释在败血症引起的休克病人中使用多巴胺作为血管收缩剂其效果有限。

(朱辉 王祥瑞 )

Peroxynitrite (ONOO-1) reacts with dopamine to form an oxidized derivative. To investigate the vasoconstrictive activity of this derivative, we performed functional examinations with dopamine treated with ONOO-1 or 3-morpholinosydonimine-N-ethyl-carbamine (SIN-1; an ONOO-1 producer) on isolated strips of rat thoracic aorta. To exclude the direct effect of ONOO-1, the strips were pretreated with methylene blue, a guanylyl cyclase inhibitor. Dopamine induced concentration-dependent contraction, but dopamine pretreated with ONOO-1 decreased the contraction in an ONOO-1-concentration-dependent manner. Both maximum contractions and 50% effective concentration values for dopamine-induced vasocontraction were significantly decreased by pretreatment with ONOO-1. Dopamine incubated with SIN-1 also decreased the contraction, the decrease being dependent on the incubation time. ONOO-1 formation is a favored reaction and occurs easily when cellular production of both nitric oxide and superoxide increases, as in septic shock. These results may, at least in part, account for dopamine’s limitation as a vasoconstrictor in septic shock.

 

超声引导锁骨上臂丛神经阻滞

Ultrasound-Guided Supraclavicular Brachial Plexus Block

Vincent W. S. Chan, MD*, Anahi Perlas, MD*, Regan Rawson, RN{dagger}, and Olusegun Odukoya, MD{dagger}

*Department of Anesthesia, University of Toronto; and {dagger}Department of Anesthesia, Toronto Western Hospital, Toronto, Ontario, Canada

Anesth Analg 2003;97:1514-1517
40名门诊病人评估超声技术应用于锁骨上臂丛神经阻滞效果。阻滞前通过超声影像来确定臂丛神经。引导阻滞针到达目标神经,同时可以看见区域麻醉扩散的方式。在注射前通过神经刺激仪来进一步确认针头位置。我们描述的阻滞技术根据超声光线来调整针头路径。95%的病例都是一次阻滞成功,一次失败是由于皮下注射,另一次则是部分注入血管。没有发生气胸。我们的初步数据提示高分辨率超声探针可以很容易地确定锁骨下区域的臂丛神经和其临近结构。进针时的同步引导技术可以迅速地找到神经。在超声上观察到的清楚的局麻药扩散方式可以进一步确认准确的针头位置。

(殷文渊 王祥瑞 )

In this study, we evaluated state-of-the-art ultrasound technology for supraclavicular brachial plexus blocks in 40 outpatients. Ultrasound imaging was used to identify the brachial plexus before the block, guide the block needle to reach target nerves, and visualize the pattern of local anesthetic spread. Needle position was further confirmed by nerve stimulation before injection. The block technique we describe aligned the needle path with the ultrasound beam. The block was successful after one attempt in 95% of the cases, with one failure attributable to subcutaneous injection and one to partial intravascular injection. Pneumothorax did not occur. Our preliminary data suggest that a high-resolution ultrasound probe can reliably identify the brachial plexus and its neighboring structures in the supraclavicular region. The technique of real-time guidance during needle advancement can quickly localize nerves. Distinct patterns of local anesthetic spread observed on ultrasound can further confirm accurate needle location.

 

控制性低血压和最小膨胀压:上肢手术中使用充气式止血带的一项新技术

Controlled Hypotension and Minimal Inflation Pressure: A New Approach for Pneumatic Tourniquet Application in Upper Limb Surgery

Bahattin Tuncali, MD*, Ayse Karci, MD*, Abdul Kadir Bacakoglu, MD{dagger}, Binnur Erdalkiran Tuncali, MD*, and Ahmet Ekin, MD{dagger}

*Department of Anesthesiology and Reanimation, Dokuz Eylul University, and the {dagger}Department of Orthopaedics and Traumatology-Division of Hand Surgery, Dokuz Eylul University, Izmir, Turkey

Anesth Analg 2003;97:1529-1532
在四肢手术中我们要求运用最低的膨胀压以避免因充气式止血带的膨胀压上升而诱发并发症。我们运用控制性降压和最小膨胀压(CHAMIP)技术减少手术野出血。36名将要进行上肢末端手术的患者被随机分为两组,一组为正常血压麻醉和正常膨胀压,另一组为控制性降压(收缩压80-100mmHg、平均动脉压>60mmHg)和最小膨胀压。麻醉诱导及术中维持用异丙酚静注和瑞芬太尼持续静注,为了确定最小膨胀压,我们将数字式体积描记仪套于患者手术侧第二指末端,同时使止血带缓慢充气直至动脉搏动消失。几乎所有患者的手术野出血均减少,即使是在动脉收缩压和止血带膨胀压明显低的低血压组也是如此。综上所述,对于运用充气式止血带的上肢末端手术患者CHAMIP是一项安全而可靠的技术

(朱慧琛 王祥瑞 )

Minimal inflation pressures are recommended for limb surgery to eliminate complications attributable to high inflation pressures with the pneumatic tourniquets. We applied controlled hypotension and a minimal inflation pressure (CHAMIP) technique to provide a bloodless surgical field. Thirty-six patients scheduled for upper extremity surgery were randomized equally to receive either normotensive anesthesia and conventional inflation pressures or controlled hypotension (systolic arterial blood pressure of 80–100 mm Hg and mean arterial blood pressure >60 mm Hg) and minimum inflation pressures. Anesthesia was induced with propofol IV bolus and remifentanil IV continuous infusion and maintained with propofol and remifentanil IV continuous infusion. To determine the minimal inflation pressure, the digital plethysmograph was applied to the second finger at the side of the operation and the tourniquet was inflated slowly until the arterial pulsations disappeared on the oscilloscope. A bloodless surgical field was obtained in almost all patients, even though systolic arterial blood pressures (100–138 mm Hg versus 80–100 mm Hg) and applied tourniquet inflation pressures (270 mm Hg versus 110–140 mm Hg) were significantly lower in the hypotensive group. No complications associated with controlled hypotension were encountered. In conclusion, CHAMIP may be a safe and reliable method for upper extremity surgery performed with pneumatic tourniquets.

甘露醇和多巴胺在体外循环病人中的作用:一个随机临床试验

Mannitol and Dopamine in Patients Undergoing Cardiopulmonary Bypass: A Randomized Clinical Trial

Olivia V. Carcoana, MD*, Joseph P. Mathew, MD{dagger}, Elizabeth Davis, RDCS*, Daniel W. Byrne, MS{ddagger}, John P. Hayslett, MD§, Roberta L. Hines, MD*, and Susan Garwood, MB ChB* ;

*Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; {dagger}Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; {ddagger}Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN; and §Department of Internal Medicine (Section of Nephrology), Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2003;97:1222-1229

 

在这个前瞻性、随机双盲、安慰剂对照试验中,我们研究了体外循环(CPB)下行冠脉搭桥术中常用的两种辅助药(多巴胺和甘露醇)对病人ß2微球蛋白2M)分泌率的影响。 ß2M 分泌率是反映肾脏近曲小管功能的敏感指标。150例术前血清肌酐(CR<=1.5 mg/dL 的病人随机分为四组: 1)安慰剂组, 2) CPB预充液中加入甘露醇 1 g/kg , 3) 从麻醉诱导开始到CPB1小时持续输注多巴胺2 µg • kg-1 • min-1 组,4) 甘露醇联合多巴胺组。主要结果为 CPB1小时测定ß2M 分泌率;其次结果包括:CPB624 h再分别测定ß2M 分泌率; CPB1, 6, 24 h 测定尿量和肌酐清除率;及测定术后CR最高值。ICU滞留时间、住院时间及不良事件也包括在次要结果中; 与安慰剂相比(0.59 ± 1.04 µg/min; P = 0.001),多巴胺显著增加CPB1 h ß2M 分泌率 (2.48 ± 3.61 µg/min);该结果不因合用甘露醇(与安慰剂相比,ß2M 分泌率, 2.05 ± 2.77 µg/min; P = 0.007)而恶化。在单纯使用甘露醇组和安慰剂组ß2M 分泌率相似(P = 0.831)。除了作为CPB中保护性药的作用外,多巴胺单独或合用甘露醇还可增加ß2M分泌率。ß2M分泌率增加的临床意义及在已有肾功能障碍病人CPB中是否会增加的问题还有待进一步研究。结论:在临床中,ß2M 分泌率增加显示肾小管损伤。在此CPB研究中多巴胺输注(单独或合用甘露醇)导致ß2M分泌率增加。至于这种多巴胺相关的增加是否意味着CPB后肾损伤还不明确,还有待于研究明确该结果的机制和临床意义。

(费敏译 薛张纲校)

In this prospective, randomized, placebo-controlled, double-blinded study, we determined the effects of two commonly used adjuncts, mannitol and dopamine, on ß2-microglobulin (ß2M) excretion rates in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). ß2M excretion rate has been described as a sensitive marker of proximal renal tubular function. One-hundred patients with a preoperative serum creatinine level <=1.5 mg/dL were prospectively randomized into 4 groups: 1) placebo, 2) mannitol 1 g/kg added to the CPB prime, 3) dopamine 2 µg • kg-1 • min-1 from the induction of anesthesia to 1 h post-CPB, or 4) mannitol plus dopamine. The primary outcome measure was ß2M excretion rate at 1 h post-CPB. Secondary outcome measures included ß2M excretion rate at 6 and 24 h post-CPB; urinary flow rate and creatinine clearance at 1, 6, and 24 h post-CPB; and the highest postoperative serum creatinine level. Length of intensive care stay and hospitalization, as well as adverse events, were also considered secondary outcomes. Dopamine significantly increased ß2M excretion rate at 1 h post-CPB (2.48 ± 3.61 µg/min) compared with placebo (0.59 ± 1.04 µg/min; P = 0.001). This effect was not ameliorated by the addition of mannitol (ß2M excretion rate, 2.05 ± 2.77 µg/min; P = 0.007 compared with placebo). ß2M excretion rate was similar in patients given placebo or mannitol alone (P = 0.831). Rather than being a protective drug in the setting of CPB, dopamine alone or in combination with mannitol increases ß2M excretion rate, which may be a measure of renal tubular dysfunction. The clinical implications of this increase and whether it is also seen in patients with established renal dysfunction undergoing CPB require additional investigation.

 

异氟醚诱导的脑电波爆发抑制效应对体外循环中脑血流速和脑氧摄取的影响

The Effects of Isoflurane-Induced Electroencephalographic Burst Suppression on Cerebral Blood Flow Velocity and Cerebral Oxygen Extraction During Cardiopulmonary Bypass

Björn Reinsfelt, MD*, Anne Westerlind, MD PhD*, Erik Houltz, MD PhD*, Sonny Ederberg, MD*, Mikael Elam, MD PhD{dagger}, and Sven-Erik Ricksten, MD PhD* ;

Departments of *Cardiothoracic Anesthesia and Intensive Care and {dagger}Clinical Neurophysiology, Sahlgrenska University Hospital, Göteborg, Sweden

Anesth Analg 2003;97:1246-1250

 

我们研究了16例心脏手术病人(32°C轻度低温芬太尼麻醉非搏动体外循环)中异氟醚诱导的脑电(EEG)爆发抑制效应对脑血流速(CBFV)、脑氧摄取(COE)及自身调节的影响。持续监测大脑中动脉经颅多普勒流速、右颈静脉窦血氧饱和度及颈静脉压(JVP)。在使用异氟醚前和使用异氟醚使EEG爆发抑制水平在6–9/min时,应用硝普钠和新福林诱导平均动脉压(MAP)变化于40–80 mm,在此变化范围内检测脑自身调节。与使用异氟醚前相比,异氟醚引起CBFV降低 27%(P < 0.05)COE 降低13% (P < 0.05);与使用异氟醚前相比,CBFV与脑灌注压(CPP = MAP - JVP)间的正相关斜率及CPPCOE间的负相关斜率(P < 0.05)较陡(P < 0.05) 。因此,我们认为中度低温CPB中爆发抑制剂量的异氟醚降低CBFV并影响脑血流的自身调节功能;此外,在异氟醚使用中脑血流相对超过脑氧需,显示代谢性脑血流自身调节功能丧失。结论:我们研究了异氟醚对作为脑灌注功能指标:脑血流速(CBFV) 及脑氧摄取(COE)的影响,结果显示芬太尼麻醉中使用异氟醚降低CBFV27%COE13%CBFV更依赖于压力变化说明脑自身调节功能受损。

(费敏译 薛张纲校)

We investigated the effects of isoflurane-induced burst suppression, monitored with electroencephalography (EEG), on cerebral blood flow velocity (CBFV), cerebral oxygen extraction (COE), and autoregulation in 16 patients undergoing cardiac surgery. The experimental procedure was performed during nonpulsatile cardiopulmonary bypass (CPB) with mild hypothermia (32°C) in fentanyl-anesthestized patients. Middle cerebral artery transcranial Doppler flow velocity, right jugular vein bulb oxygen saturation, and jugular venous pressure (JVP) were continuously measured. Autoregulation was tested during changes in mean arterial blood pressure (MAP) within a range of 40–80 mm Hg, induced by sodium nitroprusside and phenylephrine before (control) and during additional isoflurane administration to an EEG burst-suppression level of 6–9/min. Isoflurane induced a 27% decrease in CBFV (P < 0.05) and a 13% decrease in COE (P < 0.05) compared with control. The slope of the positive relationship between CBFV and cerebral perfusion pressure (CPP = MAP - JVP) was steeper with isoflurane (P < 0.05) compared with control, as was the slope of the negative relationship between CPP and COE (P < 0.05). We conclude that burst-suppression doses of isoflurane decrease CBFV and impair autoregulation of cerebral blood flow during mildly hypothermic CPB. Furthermore, during isoflurane administration, blood flow was in excess relative to oxygen demand, indicating a loss of metabolic autoregulation of flow.

 

小儿心脏手术中组织因子激活的血栓弹力图:基础值和比较值

Tissue Factor-Activated Thromboelastograms in Children Undergoing Cardiac Surgery: Baseline Values and Comparisons

Bruce E. Miller, MD, Nina A. Guzzetta, MD, Steven R. Tosone, MD, Jennifer L. Miller, Annabel R. Flunker, MMSc, Eva M. Silvey, MMSc, and Jerrold H. Levy, MD;

Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta at Egleston, Atlanta, Georgia

Anesth Analg 2003;97:1289-1293

 

组织因子(TF)激活有利于快速评价血栓弹力图(TEG)但可能改变TEG变量值。我们选择250<2 yr 的行心脏手术的小儿测定TF激活的TEG建立TEG的基础值。然后分别评价5组年龄段(<30 days, 1–3 mo, 3–6 mo, 6–12 mo, and 12–24 mo)的小儿凝血因子缺乏的效应。凝血的激活(RK值)各组间相似;与其它组相比,1–3 mo小儿的凝血块的强度增加,该结果与以前无激活剂TEG的研究结果类似;TF激活的TEG中特征性的结果为TEG{alpha}值和最大幅度值在各年龄组间几乎完全一致;各组间的纤溶结果类似。因此,我们认为,当使用TEG作为治疗凝血功能障碍的评价指标及使用特定的TEG激活剂时,小儿TF激活的TEG 基础值可用于临床评价TEG;此外,各年龄组相似的TEG{alpha}值和最大幅度值更有利于快速解释TEG结果。结论:已建立的小儿心脏手术中TF激活的TEG基础值可用于准确评价和解释在处理凝血功能障碍时TEG的变化。

(费敏译 薛张纲校)

Activation of clotting with tissue factor (TF) allows rapid evaluation of thromboelastograms but alters the values of thromboelastogram variables. We have performed TF-activated thromboelastograms in 250 children <2 yr old undergoing cardiac surgery to establish baseline values. Five groups were distinguished to evaluate the effects of quantitative deficiencies in coagulation factor levels during infancy: <30 days, 1–3 mo, 3–6 mo, 6–12 mo, and 12–24 mo. Activation of clotting (R and K values) was similar among groups. Infants 1–3 mo of age demonstrated increased clot strength compared with the other groups, a finding similar to previous evaluation of native thromboelastograms. The {alpha}and maximum amplitude values were numerically almost identical in each age group, a unique finding in activated thromboelastograms. Fibrinolysis was similar among groups. We believe that knowledge of baseline TF-activated thromboelastogram variables in young children will be useful in interpreting these thromboelastograms in clinical scenarios, in using these thromboelastograms as part of coagulopathy treatment algorithms, and during the application of more specific thromboelastogram modifiers. Additionally, the similarity of {alpha}and maximum amplitude values in each age group will allow even faster interpretation of thromboelastogram data. IMPLICATIONS: Baseline values for tissue factor-activated thromboelastograms in young children undergoing cardiac surgery have been established and will permit accurate use and interpretation of this thromboelastogram modification in evaluating and managing coagulopathies.


利多卡因减弱了人类单核细胞趋化蛋白1的产生及其趋化作用:利多卡因在炎症中可能的机制

Lidocaine Attenuates Monocyte Chemoattractant Protein-1 Production and Chemotaxis in Human Monocytes: Possible Mechanisms for Its Effect on Inflammation

Chi-Yuan Li, MD MS*, Chien-Sung Tsai, MD{dagger}, Ping-Ching Hsu, MS{dagger}, Sheau-Huei Chueh, PhD{ddagger}, Chih-Shung Wong, MD PhD*, and Shung-Tai Ho, MD MS*

*Departments of Anesthesiology and {dagger}Division of Cardiovascular Surgery, Tri-Service General Hospital; and {ddagger}Departments of Biochemistry, National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China

Anesth Analg 2003;97:1312-1316

 

外周血中单核细胞的补充和激活是控制炎症的关键有力的因素。高水平的单核细胞趋化蛋白1(MCP-1)在一些炎症中被报道.在这篇研究中,我们检测了利多卡因在人单核细胞株THP-1中在脂多糖激发的MCP-1的分泌和MCP-1诱导的趋化作用方面的作用.和抑制信使RNA一样,利多卡因以剂量依赖方式抑制脂多糖激发的MCP-1的产生.而且,我们证明在THP-1细胞中利多卡因抑制MCP-1诱导的趋化作用和细胞内游离钙浓度.结果显示利多卡因在炎症细胞中可以调节MCP-1的产生和由他诱导的激活作用.

(张俊峰译 薛张纲校)

The recruitment and activation of peripheral blood monocytes are potentially critical regulatory events for the control of inflammation. Increased levels of monocyte chemoattractant protein (MCP)-1 have been reported in several inflammatory disorders. In this study, we examined the effect of lidocaine on lipopolysaccharide-stimulated MCP-1 secretion and MCP-1 induced chemotaxis in a human monocytic cell line, THP-1. Lidocaine inhibited lipopolysaccharide-induced MCP-1 production as well as messenger RNA expression in a dose-dependent manner. Furthermore, we demonstrated that lidocaine suppressed MCP-1-induced chemotaxis and peak cytosolic-free calcium in THP-1 cells. These results suggest that lidocaine may modulate MCP-1 production and MCP-1-induced activation in inflammatory cells.

 

Ketamine, ThiopentalHalothane可抑制自然杀伤细胞活性,促进肿瘤转移,而异丙酚不会:调节机制和预防措施

Suppression of Natural Killer Cell Activity and Promotion of Tumor Metastasis by Ketamine, Thiopental, and Halothane, but Not by Propofol: Mediating Mechanisms and Prophylactic Measures

Rivka Melamed, MSc*, Shahar Bar-Yosef, MD{dagger}, Guy Shakhar, PhD*, Keren Shakhar, MA*, and Shamgar Ben-Eliyahu, PhD*

*Neuroimmunology Research Unit, Department of Psychology, Tel Aviv University, Tel Aviv, Israel; and {dagger}Department of Anesthesiology, Rabin Medical Center-Beilinson Campus, Petach Tikva, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Anesth Analg 2003;97:1331-1339


手术后的免疫抑制部分归咎于麻醉并使患者对感染和肿瘤转移的抵抗力减弱.我们比较了不同的麻醉剂对自然杀伤细胞活性的作用和对抑制实验性的转移的作用并研究了调节机制和预防措施. 我们使用Fischer 344小鼠作为实验对象,把他们分为对照组,分别用Ketamine,硫喷妥钠,氟烷和异丙酚麻醉后一小时组.麻醉的小鼠或者保持正常温度或者自发达到33°C–35°C .接着静脉注入MADB106肿瘤细胞,24小时后检测肺部肿瘤细胞,3周以后计数肺部转移灶.另外麻醉后循环中NK细胞的数量和活性也被评估.所有的麻醉药除了异丙酚都显著减弱了NK细胞的活性,提高MADB106肺肿瘤细胞的存留和转移.低温没有显著作用. Ketamine对促进转移的作用最强,但是这种作用在预先用ß 肾上腺阻制剂(nadolol)或用小剂量的免疫促进剂(polyriboinosinic:polyribocytidylic acid)处理过的小鼠中被减弱.总之,麻醉药中对NK细胞不同的抑制作用看上去和他们不同的对MADB106肺肿瘤细胞的促进转移作用有关.预防措施可能包括预先使用免疫促进药物和ß 肾上腺阻制剂.

(张俊峰译 薛张纲校)

Postoperative immunosuppression is partly ascribed to anesthesia and has been suggested to compromise patients’ resistance to infection and tumor metastasis. We compared the effects of various anesthetics on natural killer (NK) cell activity and on resistance to experimental metastasis, and studied mediating mechanisms and prophylactic measures. Fischer 344 rats served as controls or were anesthetized for 1 h with ketamine, thiopental, halothane, or propofol. Anesthetized rats were either maintained in normothermia or left to spontaneously reach 33°C–35°C. Rats were then injected IV with MADB106 tumor cells, and 24 h later lung tumor retention was assessed, or 3 wk later, lung metastases were counted. Additionally, the number and activity of circulating NK cells were assessed after anesthesia. All anesthetics, except propofol, significantly reduced NK activity and increased MADB106 lung tumor retention or lung metastases. Hypothermia had no significant effects. Ketamine increased metastasis most potently, and this effect was markedly reduced in rats pretreated with a ß-adrenergic antagonist (nadolol) or with chronic small doses of an immunostimulator (polyriboinosinic:polyribocytidylic acid). Overall, the marked variation in the NK-suppressive effects of anesthetics seems to underlie their differential promotion of MADB106 metastasis. Prophylactic measures may include perioperative immunostimulation and the use of ß-blockers.

 

Thiamylal和苯巴比妥在体外人类血小板聚集中的相反作用

Thiamylal and Pentobarbital Have Opposite Effects on Human Platelet Aggregation In Vitro

Masami Sato, MD*, Hideo Hirakata, MD*, Takefumi Nakagawa, MD{dagger}, Kyoko Arai, MD{ddagger}, and Kazuhiko Fukuda, MD*

Departments of *Anesthesia and {dagger}Orthopedic Surgery, Kyoto University Hospital, Kyoto; and {ddagger}Department of Anesthesia, Shizuoka City Hospital, Shizuoka, Japan

Anesth Analg 2003;97:1353-1359


巴比妥类药物对人类血小板的作用还未完全被了解.我们设计这个实验来弄清Thiamylal 和苯巴比妥在人类血小板聚集方面的作用并说明其机制.通过用8通道光传播的集合度计来测量由二磷酸腺苷,肾上腺素,花生四烯酸(AA), (+)-9,11-epithia-11, 12-methano-thromboxane A2 (STA2)介导的人类血小板聚集来比较使用和未使用Thiamylal 和苯巴比妥的情况.为了评价血小板A2 因子(TXA2)受体亲和力, 我们使用[3H]-S145,一种特异的TXA2 受体拮抗剂来做Scatchard 分析. STA2-TXA2受体结合实验也开展了.通过使用液体闪烁分析仪,我们发现,[3H]-AA 事先孵育过,ADP激发的血小板会释放花生四烯酸.使用荧光计检测到fluo-3/AM负荷的血小板中的细胞内游离的钙离子([Ca2+]i). thiamylal 提高ADP,肾上腺素诱导的血小板聚集而苯巴比妥则抑制这种作用,但是他们都不影响AASTA2诱导的聚集.他们对TXA2受体亲和力没有作用.虽然thiamylal 促进, 苯巴比妥抑制ADP激活的血小板释放[3H]-AA ,但他们都对ADP 诱导的细胞内钙的增加没有作用.因此,我们认为在体外thiamylal促进,而苯巴比妥抑制血小板的聚集.而巴比妥类的作用通过促进AA的释放而不是增加细胞内钙而实现.

(张俊峰译 薛张纲校)

The effects of barbiturates on human platelet function are not fully understood. We designed the present study to clarify the effects of thiamylal and pentobarbital on human platelet aggregation and to elucidate the underlying mechanisms in vitro. Human platelet aggregation induced by adenosine diphosphate (ADP), epinephrine, arachidonic acid (AA), and (+)-9,11-epithia-11,12-methano-thromboxane A2 (STA2), measured with an 8-channel light transmission aggregometer, was compared in the absence and presence of thiamylal or pentobarbital. To estimate thromboxane A2 (TXA2) receptor binding affinity, Scatchard analysis was done using [3H]-S145, a specific TXA2 receptor antagonist. STA2-TXA2 receptor binding assay was also examined. The release of AA was determined in platelets preincubated with [3H]-AA and stimulated by ADP, using a liquid scintillation analyzer. Cytosolic free calcium concentration ([Ca2+]i) was measured in fluo-3/AM-loaded platelets using a fluorometer. Thiamylal enhanced, but pentobarbital suppressed, ADP- and epinephrine-induced platelet aggregation, but they did not affect AA- or STA2-induced platelet aggregation. They had no effect on TXA2 receptor binding affinity. Although thiamylal increased and pentobarbital decreased release of [3H]-AA from ADP-stimulated platelets, both barbiturates had no effect on ADP-induced [Ca2+]i increase. We conclude that thiamylal enhances but pentobarbital suppresses human platelet aggregation in vitro. These effects of barbiturates are mediated by altered AA release without affecting [Ca2+]i increase.

 

七氟醚的心脏保护效应依赖于蛋白激酶C活化、线粒体 K+ATP通道开放以及反应性氧分子的生成

The Cardioprotective Effect of Sevoflurane Depends on Protein Kinase C Activation, Opening of Mitochondrial K+ATP Channels, and the Production of Reactive Oxygen Species

Wouter de Ruijter, MD*, René J.P. Musters, PhD{dagger}, Christa Boer, PhD*,*{dagger}, Ger J. M. Stienen, PhD{dagger}, Warner S. Simonides, PhD{dagger}, and Jaap J. de Lange, MD PhD*

*Department of Anesthesiology and {dagger}Laboratory for Physiology, Vrije Universiteit University Medical Center, Institute for Cardiovascular Research Vrije Universiteit, Amsterdam, the Netherlands

Anesth Analg 2003;97:1370-1376


有研究示七氟醚的心脏保护效应依赖于蛋白激酶CPKC)活化、线粒体 K+ATP通道开放以及反应性氧分子(ROS)的生成。但是,它们的依据来自各自独立的实验模型。本文,我们研究在七氟醚产生心肌保护的同一模型中PKC、线粒体K+ATPROS三者的相互作用。经60分钟的再灌注后,大鼠小梁受含NaCN的缓冲液致缺血的代谢抑制(MI)影响。活性强度(Fa)的恢复用MI前强度的百分比来评估。时间控制,到实验结束Fa60% ± 5%MIFa恢复降至28% ± 5%P = 0.045较时间控制),而七氟醚可逆转MI的有害作用(Fa 恢复, 67% ± 8%; P = 0.01 MI)PKC抑制剂白屈菜赤碱、线粒体 K+ATP抑制剂5-羟基葵烷、ROS清除剂N-(2-巯基丙酰)-氨基乙酸能完全去处七氟醚的保护效应(Fa恢复分别为白屈菜赤碱31% ± 8%5-羟基葵烷33% ± 8%N-(2-巯基丙酰)-氨基乙酸24% ± 9%)。结论:PKC活化、线粒体 K+ATP通道开放以及ROS生成是七氟醚心脏保护效应的实质所在。这些信号事件是一个共同信号通路的连续反应而非平行。我们的发现提示围术期应用七氟醚保护心脏功能是通过预防缺血-再灌注损伤。

(张俊峰译 薛张纲校)

Several studies suggest that the cardioprotective effect of sevoflurane depends on protein kinase C (PKC) activation, mitochondrial K+ATP channel (mitoK+ATP) opening, and reactive oxygen species (ROS). However, evidence for their involvement was obtained in separate experimental models. Here, we studied the relative roles of PKC, mitoK+ATP, and ROS in sevoflurane-induced cardioprotection in one model. Rat trabeculae were subjected to simulated ischemia by applying metabolic inhibition (MI) through buffer containing NaCN, followed by 60-min reperfusion. Recovery of active force (Fa) was assessed as percentage of pre-MI force. In time controls, Fa amounted 60% ± 5% at the end of the experiment. The recovery of Fa after MI was reduced to 28% ± 5% (P = 0.045 versus time control), whereas sevoflurane reversed the detrimental effect of MI (Fa recovery, 67% ± 8%; P = 0.01 versus MI). The PKC inhibitor chelerythrine, the mitoK+ATP inhibitor 5-hydroxy decanoic, and the ROS scavenger N-(2-mercaptopropionyl)-glycine all completely abolished the protective effect of sevoflurane (recovery of Fa, 31% ± 8%, 33% ± 8%, and 24% ± 9% for chelerythrine, 5-hydroxy decanoic, and N-(2-mercaptopropionyl)-glycine, respectively). In conclusion, PKC activation, mitoK+ATP channel opening, and ROS production are all essential for sevoflurane-induced cardioprotection. These signaling events are arranged in series within a common signaling pathway, rather than in parallel cascades. Our findings implicate that the perioperative use of sevoflurane preserves cardiac function by preventing ischemia-reperfusion injury.

 

丙泊酚/芬太尼麻醉诱导后早期吲哚菁绿指示血浆容量可能存在估计过高

Possible Overestimation of Indocyanine Green-Derived Plasma Volume Early After Induction of Anesthesia with Propofol/Fentanyl

Wei-Dong Mi, MD, Hironori Ishihara, MD, Tetsuhiro Sakai, MD, and Akitomo Matsuki, MD

From the Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki-Shi, Japan

Anesth Analg 2003;97:1421-1427

吲哚菁绿(PV-ICG)指示的大量血浆容量在麻醉诱导后的初始阶段已经决定了。本研究检验如下假设: PV-ICG的过高估计发生在麻醉诱导早期。13名患者麻醉诱导采用芬太尼药团2 µg/kg和丙泊酚0.5 mg • kg-1 • min-1 IV至患者意识消失并用丙泊酚维持输注。PV-ICG和葡萄糖初始分布容量(IDVG)的测定在麻醉诱导前15分钟和诱导后15分钟。血浆ICG和葡萄糖浓度通过连续血样本采集在输注ICG 25 mg 、葡萄糖5 g之前和之后7分钟。PV-ICG IDVG通过一室模型计算。PV-ICG在诱导后有显著升高平均为15.3%,从2.29 ± 0.38 (SD) L2.64 ± 0.31 L (P < 0.001)。平均红细胞压积(Hct)、血红蛋白(Hb)浓度以及全血浆蛋白诱导后较诱导前各自下降2.9%2.2%2.3%(P < 0.05)。通过HbHct计算得的血浆容量百分比增加诱导前后为4%。因此,PV-ICG高估了11%IDVG无改变。所以,PV-ICG/IDVG从诱导前的0.40 ± 0.05增加到诱导后的0.48 ± 0.06(P < 0.01)。这些结果有效说明了假设PV-ICG在丙泊酚麻醉诱导后的一段时间内可能存在过高估计。现在的结果也支持PV-ICG/IDVG可衡量PV-ICG高估或液体从中央到周围组织的再分布。

(方芳译 薛张纲校)

Apparently large plasma volumes derived by indocyanine green (PV-ICG) have been determined in the initial period after induction of anesthesia. We tested the hypothesis that possible overestimation of PV-ICG occurs shortly after anesthetic induction. Anesthesia was induced in 13 patients with fentanyl bolus 2 µg/kg and propofol infusion 0.5 mg • kg-1 • min-1 IV until patients lost consciousness and was then maintained with a propofol infusion. PV-ICG and the initial distribution volume of glucose (IDVG) were assessed at 15 min before and at 15 min after anesthetic induction. Plasma ICG and glucose concentrations were measured from serial blood samples taken before and through 7 min after injection of ICG 25 mg and glucose 5 g. PV-ICG and IDVG were calculated using a one-compartment model. PV-ICG was significantly increased by an average of 15.3% after induction, from 2.29 ± 0.38 (SD) L to 2.64 ± 0.31 L (P < 0.001). The mean hematocrit (Hct), concentrations of hemoglobin (Hb), and total plasma proteins at postinduction decreased compared with those at preinduction by 2.9%, 2.2%, and 2.3%, respectively (P < 0.05). Percentile increase in plasma volume calculated from Hb and Hct before and after induction was 4%. Consequently, an 11% overestimation in PV-ICG was observed. IDVG remained unchanged. Therefore, the ratio of PV-ICG/IDVG increased from 0.40 ± 0.05 before induction to 0.48 ± 0.06 after induction (P < 0.01). These results validate the hypothesis that possible overestimation of PV-ICG occurs during a definable period of time after propofol anesthetic induction. The present results also support the PV-ICG/IDVG ratio as a measure of possible overestimation of PV-ICG or fluid redistribution from the central to the peripheral tissues.

 

人听觉稳定状态反应:录音技术效应和觉醒状态

Human Auditory Steady-State Responses: The Effects of Recording Technique and State of Arousal

Terence W. Picton, PhD*, M. Sasha John, PhD*, David W. Purcell, PhD*, and Gilles Plourde, MD{dagger}

*Rotman Research Institute, Baycrest Centre for Geriatric Care, University of Toronto, Toronto, Canada; and {dagger}Department of Anesthesia, Royal Victoria Hospital, Montreal, Canada

Anesth Analg 2003;97:1396-1402

 

听觉稳定状态反应(ASSRs)能在所有状况下被可靠记录还是这些反应在睡意中持续大幅减低在文献报道中存在争议。在10个项目中,40-Hz ASSRs能从脑电图活跃的背景中显著地区分开其概率为P < 0.01平均时间22 s (范围2–92 s),倘若这些反应分析经时间-领域较光谱更平均。在另外10个项目的实验中,在头顶和颈后之间40-Hz ASSRs记录在睡意和睡眠中持续大幅降低。研究发现ASSR在睡意中偶有增加可以用以乳突为标记的耳后肌肉反应来解释。这些可能在睡意中发生与动眼运动相关。ASSRs记录在头顶和颈后间的反应不会被这些现象所扭曲。这些发现与以往ASSR对全麻影响的文献可以认为ASSR是监测全麻催眠效应的有效选择。

(方芳译 薛张纲校)

There is some controversy in the literature about whether auditory steady-state responses (ASSRs) can be reliably recorded in all subjects and whether these responses consistently decrease in amplitude during drowsiness. In 10 subjects, 40-Hz ASSRs became significantly different from background electroencephalogram activity with a probability of P < 0.01 and an average time of 22 s (range, 2–92 s), provided that the responses were analyzed with time-domain averaging rather than spectral averaging. In a second experiment with 10 subjects, 40-Hz ASSRs recorded between the vertex and posterior neck consistently decreased in amplitude during drowsiness and sleep. Findings that the ASSR may occasionally increase during drowsiness may be explained by postauricular muscle responses recorded from a mastoid reference. These may occur during drowsiness in association with rolling-eye movements. ASSRs recorded between the vertex and posterior neck are not distorted by these reflexes. These findings combine with previous literature on the effects of general anesthetics on the ASSR to confirm that the ASSR is a valid option for monitoring the hypnotic effects of general anesthetics.

 

椎管构造有利于镇痛的方面——应用苏芬太尼、布比卡因混合液行术后镇痛

Spinal Mechanisms Contribute to Analgesia Produced by Epidural Sufentanil Combined with Bupivacaine for Postoperative Analgesia

Jean L. Joris, MD PhD*, Eric A. Jacob, MD*, Daniel I. Sessler, MD{dagger}, Jean-François J. Deleuse, MD*, Abdourahamane Kaba, MD*, and Maurice L. Lamy, MD*

*Department of Anesthesia and Intensive Care Medicine and {dagger}the Outcomes Research® Institute and Department of Anesthesiology, University of Louisville, Louisville, Kentucky

Anesth Analg 2003 97: 1446-1451

.

脂溶性阿片样药物当单独应用于硬膜外时通常被认为是通过系统吸收经脊髓以上的机制产生镇痛作用。然而在动物试验中发现椎管内阿片样药物与局麻药在脊髓水平产生协同作用。因此,我们验证了如下假设:重大腹部手术后若同时硬膜外应用布比卡因苏芬太尼的用量将比单纯静脉给药减少。40位病人予全麻(异氟醚吸入)联合硬膜外(布比卡因)麻醉下行腹部外科手术。术后每位患者均给予硬膜外持续输注布比卡因5mg/h以及苏芬太尼PCA(患者自控镇痛)。根据随机、双盲的模式,苏芬太尼或是硬膜外或是静脉给药。各组中PCA的设置相同。在术后60小时内测量以下变量:休息时、运动时、咳嗽时的疼痛评分;感觉阻滞范围;副反应;苏芬太尼用量。疼痛评分、感觉阻滞、副反应事件两组并无差别,而苏芬太尼用量硬膜外组却是静脉组的一半(术后48小时:硬膜外组107+-57ug、静脉组207+-100ugP<0.05)。因此认为,椎管构造有利于硬膜外应用苏芬太尼及布比卡因的镇痛。

(方芳译 薛张纲校)

When used alone, lipid-soluble epidural opioids are thought to produce analgesia supraspinally via systemic absorption. However, spinal opioids and local anesthetics have been shown to act synergistically at the spinal level in animal studies. We, therefore, tested the hypothesis that sufentanil requirements will be less when given epidurally than IV in patients simultaneously given epidural bupivacaine after major abdominal surgery. Forty patients were anesthetized with isoflurane and epidural bupivacaine for major abdominal surgery. After surgery, each was given a continuous epidural infusion of bupivacaine at a rate of 5 mg/h and sufentanil patient-controlled analgesia (PCA). In a randomized, double-blinded fashion, the sufentanil was given either epidurally or IV. PCA settings were the same in each group. For 60 hrs after surgery, the following variables were measured: pain scores at rest, during mobilization, and during coughing; extension of sensory block; side effects; and sufentanil consumption. Pain scores, extension of sensory block, and the incidence of side effects did not differ between the two groups. Consumption of sufentanil in the epidural group was half that of the IV group (48 h after surgery: 107 ± 57 µg versus 207 ± 100 µg for the epidural and IV groups, respectively; P < 0.05). We conclude that spinal mechanisms contribute to the analgesia produced by epidural sufentanil in combination with a local anesthetic.

 

女性比男性更容易感到疼痛因而需要更多的吗啡来达到相近的止痛效果

Women Experience More Pain and Require More Morphine Than Men to Achieve a Similar Degree of Analgesia

M. Soledad Cepeda, MD PhD*, and Daniel B. Carr, MD{dagger}

*Department of Anesthesia, San Ignacio Hospital, Javeriana University School of Medicine, Bogota, Colombia; and {dagger}Departments of Anesthesia and Medicine, Tufts University School of Medicine and Tufts-New England Medical Center, Boston, Massachusetts

Anesth Analg 2003 97: 1464-1468

疼痛感知及对阿片类药物反应的性别差异经常被报道,但这些结果并不一致。我们探求了性别对于疼痛感知、吗啡用量、术后吗啡止痛的影响。我们设计了一项包括423位女性和277位男性的预期群体性研究,这些受试者均为全麻下外科手术后患者并且疼痛强>=5(应用010的数字分级表,即NRS)。我们予以吗啡静注2.5mg/10min直至疼痛强度<=4。病人每10分钟对疼痛强度进行NRS评分并对疼痛减轻程度以5   Likert表进行评分。在对手术类型及年龄进行调整后,我们发现女性比男性疼痛感知更加强烈、吗啡用量更多,NRS疼痛强度评分的差异为0.4U95%可信区间,0.1-0.6U)。女性吗啡需要量比男性多0.03mg/kg95%可信区间,0.02-0.04 mg/kg)。因而总结认为相对于男性而言,女性有更强列的疼痛感知并且需要多出30%的吗啡用量来达到相同的止痛效果。临床医生应当预见到女性病人对阿片类药物需量的不同,避免疼痛方面的处理不足。

(方芳译 薛张纲校)

Sex differences in pain perception and in response to opioids have been described, but the findings are inconsistent. We sought to determine the effect of sex on pain perception, morphine consumption, and morphine analgesia after surgery. We designed a prospective cohort study and included 423 women and 277 men who emerged from general anesthesia after surgical procedures and who reported pain intensity of >=5 on the 0–10 numeric rating scale (NRS). We administered 2.5 mg of morphine IV every 10 min until the pain intensity was <=4 of 10. Every 10 min, patients rated their pain on the NRS and indicated the degree of pain relief on a 5-point Likert scale. After adjustment for type of operation and age, we found that women had more intense pain and had larger morphine consumption than men. The difference in NRS pain intensity was 0.4 U (95% confidence interval, 0.1–0.6 U). Women required 0.03 mg/kg more morphine than men (95% confidence interval, 0.02–0.04 mg/kg). We conclude that women have more intense pain and require 30% more morphine to achieve a similar degree of analgesia compared with men. Clinicians should anticipate the differences in opioid requirement to avoid undertreatment of pain in women.

 

心电图自动测量记录仪在社区医院综合性监护中的应用及效力

The Use and Effectiveness of Electrocardiographic Telemetry Monitoring in a Community Hospital General Care Setting

J. Paul Curry, MD*, C. William Hanson, III, MD FCCM{dagger}, Michael W. Russell, MD{dagger}, Cheryl Hanna, RN*, Gayle Devine, BSN CCRN{dagger}, and E. Andrew Ochroch, MD{dagger}

*Department of Anesthesiology and Critical Care, Hoag Memorial Presbyterian Hospital Newport Beach, CA, and the {dagger}Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA

Anesth Analg 2003 97: 1483-1487

 

此项研究的目的是为了确定当系统的应用心电图严格的使用标准时,是否实时记录事件发生率在有指征病人与无指征病人中有所不同。我们于200011日至2000331日在1097位可行实时记录的受试者中进行了一项群体回顾性研究。常规选举21位病人进行236项实时监测。有指征者的400天实时监测内共监测到162次心律失常。而无指征者345天实时监测中共监测到9次心律失常。两组的心律失常事件相关率明显不同(P<0.0001)。结果显示当前对心电图实时记录使用并非最佳,并且应当进行应用心电图实时记录严格指征的预期分析。

(钟鸣译 薛张纲校)

The purpose of this study was to determine if rates of telemetry events differ between patients whose monitoring is appropriately "indicated" versus "not indicated" by systematically applying rigorous criteria for appropriateness of electrocardiogram (ECG) telemetry usage. We performed a retrospective cohort study on 1097 telemetry admissions between January 1, 2000 and March 31, 2000. A convenience sample of 218 patients generated 236 telemetry admissions. One-hundred-sixty-two arrhythmic events were detected during 400 "indicated" telemetry days. Nine arrhythmic events were detected during 345 "not indicated" telemetry days. The relative rate for arrhythmic events was significantly different, at P < 0.0001, with the incidence rate ratio of 15 indicating a very large effect size. Consequently, current use of ECG telemetry may not be optimal, and a prospective analysis of the application of rigorous indications for ECG telemetry needs to be undertaken.

 

小猪急性肺动脉高压模型中间断吸入一氧化氮联合静脉内注射双嘧达莫

Intermittent Nitric Oxide Combined with Intravenous Dipyridamole in a Piglet Model of Acute Pulmonary Hypertension

Foubert, Luc MD, PhD *; De Wolf, Daniel MD, PhD +; Reyntjens, Koen MD *; Van Belleghem, Yves MD, DSc ++; De Somer, Filip CCP, PhD

Department of Anesthesia, Division of Cardiac Anesthesia;Department of Pediatrics, Division of Pediatric Cardiology; Department of Cardiac Surgery, University Hospital Ghent, and Laboratoryfor Experimental Cardiac Surgery, Ghent University, Ghent, Belgium

Anesth Analg 2003 97:1497-1500,

 

一氧化氮(NO)作为有效的选择性肺动脉扩张剂而被广泛使用于连续吸入。我们已经评价了静脉内给予双嘧达莫,一种环单磷酸鸟苷酸(cGMP)磷酸二酯酶抑制剂,对于吸入一氧化氮扩张肺动脉血管作用的程度和持久度的影响。我们假设cGMP降解作用的抑制能够放大和延长NO对肺血管的扩张作用,并使NO的吸入间断。给八只麻醉并机械通气的小猪静脉注射U46619,一种凝血噁烷A2类似物,以诱导出肺动脉高压模型。NO2510ppm的浓度各吸入4分钟,每种浓度吸入后间隔10分钟的无NO期,分别评价不予和给予双嘧达莫时各浓度的作用。肺血管阻力从825/49dynes.s.cm-5(U-46619)分别降至533/48 dynes.s.cm-510ppm)(P<0.05比较U-46619),和396/42 dynes.s.cm-5(双嘧达莫10mg/kg.min10ppmNO)(P<0.05比较NO),心输出量从1.93+/- 0.09 L/min升高到2.03 +/- 0.13 L/min2.60 +/- 0.30 L/minP<0.05比较NO)。平均动脉压从90 +/- 5 mm Hg (10 ppm NO)降至75 +/- 3 mm Hg(双嘧达莫加上10ppmNO)(P<0.01)。当吸入NO联合静脉内注射双嘧达莫后肺血管的扩张作用比单用NO延长了1242分钟,使时间加权的NO暴露减少了72%。我们得出结论,双嘧达莫增大了NO对右心室后负荷的作用,使得NO吸入可以间断,并能明显减少NO的暴露。

(钟鸣译 薛张纲校)

Continuous administration of inhaled nitric oxide is now widely used as a potent and selective pulmonary vasodilator. We have evaluated the effects of IV dipyridamole, a cyclic guanosine monophosphate (cGMP) phosphodiesterase inhibitor, on the magnitude and duration of action of inhaled nitric oxide (NO)-mediated pulmonary vasodilation. We hypothesized that inhibition of cGMP degradation could augment and prolong the pulmonary vasodilating effects of NO and allow for intermittent NO inhalation. In eight anesthetized and mechanically ventilated piglets, IV U-46619, a thromboxane A2 analog, was used to induce pulmonary hypertension. The effects of 2, 5, and 10 ppm of NO, delivered during 4 min for each concentration and followed by a 10-min NO-free interval after each NO concentration, were evaluated without and with dipyridamole. Pulmonary vascular resistance decreased from 825 +/- 49 dynes [middle dot] s [middle dot] cm-5 (U-46619) to 533 +/- 48 dynes [middle dot] s [middle dot] cm-5 (10 ppm NO) (P < 0.05 versus U-46619) and 396 +/- 42 dynes [middle dot] s [middle dot] cm-5 (dipyridamole 10 [mu]g [middle dot] kg-1 [middle dot] min-1 and 10 ppm NO) (P <0.05 versus NO), and cardiac output increased from 1.93 +/- 0.09 L/min to 2.03 +/- 0.13 L/min and 2.60 +/- 0.30 L/min (P < 0.05 versus NO). Mean arterial blood pressure decreased from 90 +/- 5 mm Hg (10 ppm NO) to 75 +/- 3 mm Hg (dipyridamole plus 10 ppm NO) (P < 0.01). The pulmonary vasodilation obtained with NO alone could be prolonged from 12 to 42 min when inhaled NO was combined with IV dipyridamole, accounting for a time-weighted reduction in NO exposure by 72%. We conclude that dipyridamole augments the effects of NO on right ventricular afterload, allows for intermittent NO inhalation, and can significantly reduce exposure to NO.

 

吸食可卡因的分娩病人舒芬太尼鞘内给药镇痛时间的减少

Reduced Duration of Intrathecal Sufentanil Analgesia in Laboring Cocaine Users

Ross, Vernon H. MD +; Moore, Charles H. PhD *; Pan, Peter H. MD +; Fragneto, Regina Y. MD ++; James, Robert L. MS, Mstat +; Justis, Gina B. MD

Department of Anesthesiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; University of Kentucky College of Medicine,Lexington, Kentucky

Anesth Analg. 2003 97:1504-1508

 

在此前临床经验的基础上,我们在该研究中假设,滥用可卡因的临产病人相比无可卡因滥用的病人,鞘内给予舒芬太尼产生的镇痛时间要短,而且(或)镇痛的效果要差。作为脊-硬联合(CSE)技术的一部分,我们给两组分娩病人鞘内注射舒芬太尼10mg,第一组是尿检可卡因阳性者(可卡因组),第二组是尿检可卡因阴性组(对照组)。病人要求额外的镇痛时,硬膜外导管内才予注射局麻药。从鞘内注射舒芬太尼到病人要求额外镇痛的时间被定义位镇痛时间。在CSE之前测量可视的类似疼痛评分(VAPS)的基线和宫口扩张程度。鞘内注射舒芬太尼后,定时记录VAPS。当病人再次要求镇痛时,记录宫口扩张的情况。我们发现两组病人VAPS基线都很高,在注射舒芬太尼后VAPS显著下降,且两组间没有差别。经宫口扩张程度调整后的镇痛时间的几何均数在可卡因组是87秒,在对照组中是139秒(P=0.019)。所有病人都有骚痒感。我们得出结论,滥用可卡因的临产病人相比无可卡因滥用者,鞘内给予舒芬太尼能产生类似的镇痛质量,但镇痛时间缩短了。

(钟鸣译 薛张纲校)

On the basis of our previous clinical experience, we hypothesized in this study that the duration and/or quality of labor analgesia produced by intrathecal sufentanil was less in cocaine-abusing parturients compared with nonabusing parturients. Ten [mu]g of sufentanil was given intrathecally as part of a combined spinal-epidural (CSE) technique to two groups of laboring parturients: 1) those whose urine tested positive for cocaine (cocaine group), and 2) those whose urine tested negative for cocaine (control group). The epidural catheter was not injected with local anesthetic until the patient requested additional pain relief. The time from injection of intrathecal sufentanil until patient request for additional pain relief was defined as duration of analgesia. Baseline visual analog pain score (VAPS) and cervical dilation were measured before the CSE was performed. After injection of intrathecal sufentanil, VAPS was recorded at specific intervals. Cervical dilation was again documented when the patient requested additional analgesia. We found that both groups reported high baseline VAPS and a marked decrease in VAPS after injection of sufentanil that did not differ between groups. Geometric mean duration of pain relief with adjustment for cervical dilation was 87 min in the cocaine group compared with 139 min in the control group (P = 0.019). All patients experienced itching. We conclude that intrathecal sufentanil produces a similar quality but shorter duration of analgesia in cocaine-abusing parturients compared with nonabusing parturients.

 

超声引导加快了锁骨上阻滞的操作的速度和提高了阻滞质量

Ultrasound Guidance Speeds Execution and Improves the Quality of Supraclavicular Block

Williams, Stephan R. MD, PhD *; Chouinard, Philippe MD, FRCPC *; Arcand, Genevieve MD *; Harris, Patrick MD, FRCSC +; Ruel, Monique RN *; Boudreault, Daniel MD, FRCPC *; Girard, Francois MD

Departments of *Anesthesiology and Surgery, Centre Hospitalier de l'Universite de Montreal, Hopital Notre-Dame, Montreal, Quebec

Anesth Analg. 2003 97:1518-1523

在该前瞻性研究中,我们比较了采用超声引导和神经刺激器进行锁骨上臂丛神经阻滞的方法和采用传统的解剖标志和神经刺激器的锁骨上阻滞技术,评价两者的质量、安全性和操作时间。我们假设超声引导能增加成功阻滞的比例,减少操作时间,减少气胸和神经损伤等并发症的发生。八位病人被随机分成两组,US组(通过二维超声图象实时引导的锁骨上阻滞,神经刺激器确定相关针头的位置)和NS组(采用锁骨上血管旁入路的锁骨上阻滞,同样使用神经刺激器确定针头位置)。阻滞药物使用0.5%的布比卡因、2%的利多卡因(容量11)和1200000的去甲肾上腺素的混合药物。在30分钟的时间内评估肌皮神经、正中神经、桡神经和尺神经的运动和感觉阻滞的起效。在30分钟时,US95%和NS85%的病人的所有神经支配区域都产生了部分或完全的感觉阻滞(P=0.13),US55%和NS65%的病人在所有神经支配区域产生了完全的阻滞(P=0.25)。US85%和NS78%的病人无需追加即获得满意的麻醉效果(P=0.28)。US组中无病人需全麻,而NS8%的病人需全麻(P=0.12)。NS组尺神经的阻滞效果明显差于其他神经的阻滞效果,在US组中无该情况;NS组和US组间尺神经的阻滞效果无显著差异。阻滞所用平均时间在NS组和US组分别位9.8分钟和5分钟(P=0.0001)。两组中均未出现明显的并发症。我们得出结论,相比采用解剖标志和神经刺激器的锁骨上阻滞而言,超声引导神经刺激器确认的锁骨上阻滞操作更迅速,阻滞效果更完全。

(钟鸣译 薛张纲校)

In this prospective study, we assessed the quality, safety, and execution time of supraclavicular block of the brachial plexus using ultrasonic guidance and neurostimulation compared with a supraclavicular technique that used anatomical landmarks and neurostimulation. It was hypothesized that ultrasonic guidance would increase the proportion of successful blocks, decrease block execution time, and reduce the incidence of complications such as pneumothorax and neuropathy. Eighty patients were randomized into two groups of 40, Group US (supraclavicular block guided in real time by a two-dimensional ultrasonic image, with neurostimulator confirmation of correct needle position) and Group NS (supraclavicular block using the subclavian perivascular approach, also with neurostimulator confirmation). Blocks were performed using bupivacaine 0.5% and lidocaine 2% (1:1 vol) with epinephrine 1:200,000 as the anesthetic mixture. The onset of motor and sensory block for the musculocutaneous, median, radial, and ulnar nerves was evaluated over a 30 min period. At 30 min 95% of patients in Group US and 85% of patients in Group NS had a partial or complete sensory block of all nerve territories (P = 0.13) and 55% of patients in Group US and 65% of patients in Group NS had a complete block of all nerve territories (P = 0.25). Surgical anesthesia without supplementation was achieved in 85% of patients in Group US and 78% of patients in Group NS (P = 0.28). No patient in Group US and 8% of patients in Group NS required general anesthesia (P = 0.12). The quality of ulnar block was significantly inferior to the quality of block in other nerve territories in Group NS, but not in Group US; the quality of ulnar block was not significantly different between Groups NS and US. The block was performed in an average of 9.8 min in Group NS and 5.0 min in Group US (P = 0.0001). No major complication occurred in either group. We conclude that ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a more complete block than supraclavicular block using anatomic landmarks and neurostimulator confirmation.

 

异丙酚可减少由再灌注引起的豚鼠正常和缺血-再灌注之间边缘区的心侓失常

Propofol Decreases Reperfusion-Induced Arrhythmias in a Model of "Border Zone" Between Normal and Ischemic-Reperfused Guinea Pig Myocardium

Jean-Luc Hanouz, MD PhD*, Alexandra Yvon, BSc{dagger}, Frédéric Flais, MD*, René Rouet, PhD{dagger}, Pierre Ducouret, PhD{dagger}, Henri Bricard, MD*, and Jean-Louis Gérard, MD PhD*,{dagger}

*Department of Anesthesiology, Centre Hospitalier Universitaire Caen, Caen, France; and {dagger}Laboratory of Experimental Anesthesiology and Cellular Physiology, Centre Hospitalier Universitaire Caen, Caen, France

Anesth Analg 2003;97:1230-1238

本文于体外研究异丙酚在缺血及再灌注中引发心不齐(如自发心率不齐、传导阻滞、复极离散度)相关的机制。在一个双浴槽中,在改变区(AZ)的豚鼠右室肌束缺血30分钟,再灌注30分钟。在正常区(NZ)则常规灌注。记录两区的动作电位(AP)参数。研究10-6, 10-5,2 x 10-5 M浓度下英脱利匹特和异丙酚对自发持续节律异常,传导阻滞和复极离散度的影响。在正常区,英脱利匹特和异丙酚没有明显影响各种动作电位的参数。异丙酚能削弱由缺血导致的动作电位时程的缩短,它主要影响复极90%APD90)的时间。而英脱利匹特无此作用。异丙酚还能减弱边缘区动作电位离散度。异丙酚对由缺血引起的心率失常无作用。 10-6 M的异丙酚能降低由缺血引发的传导阻滞的发生。异丙酚可减少由再灌注引起的自发节律异常的发生。结论:在体外实验中,异丙酚能缩小缺血引起边缘区APD90 离散,也能减少再灌注损伤导致的心肌自发节律异常。

赵雪莲 庄心良

We examined the effect of propofol on the main mechanisms involved in ischemia/reperfusion-induced arrhythmias (i.e., spontaneous arrhythmias, conduction blocks, and dispersion of repolarization) in vitro. In a double-chamber bath, guinea pig right ventricular muscle strips were subjected to 30 min of simulated ischemia followed by 30 min of reperfusion (altered zone; AZ) and to standard conditions (normal zone; NZ). Action potential (AP) parameters were recorded in the NZ and AZ. We studied the effects of Intralipid® and of propofol at 10-6, 10-5, and 2 x 10-5 M on the occurrence of spontaneous sustained arrhythmias, conduction blocks, and the dispersion of repolarization. In NZ, Intralipid and propofol did not significantly modify the AP parameters. Propofol, but not Intralipid, lessened the ischemia-induced decrease in AP duration (APD) at 90% of repolarization (APD90) and attenuated the APD dispersion around the "border zone." Propofol did not modify the occurrence of ischemia-induced arrhythmias. Propofol 10-6 M, but not Intralipid or propofol at 10-5 and 2 x 10-5 M, decreased the occurrence of ischemia-induced conduction blocks. Propofol decreased the occurrence of reperfusion-induced spontaneous sustained arrhythmias. We conclude that, in vitro, propofol attenuated the ischemia-induced APD90 dispersion around the "border zone" and decreased the occurrence of spontaneous arrhythmias related to myocardial reperfusion injury.

 

儿童先心病手术中经食道心超的应用:两个中心的观察研究

Intraoperative Transesophageal Echocardiography in Pediatric Congenital Cardiac Surgery: A Two-Center Observational Study

Dominique A. Bettex, MD*, Daniel Schmidlin, MD*, Marc-André Bernath, MD{dagger}, René Prêtre, MD{ddagger}, Michel Hurni, MD§, Rolf Jenni, MD MSEE||, Pierre-Guy Chassot, MD{dagger}, and Edith R. Schmid, MD*

*Division of Cardiovascular Anesthesia, University Hospital of Zurich, Switzerland; {dagger}Department of Anesthesia, University Hospital of Lausanne, Switzerland; {ddagger}Department of Cardiovascular Surgery, University Hospital of Zurich, Switzerland; §Department of Cardiovascular Surgery, University Hospital of Lausanne, Switzerland; ||Department of Cardiology, University Hospital of Zurich, Switzerland

Anesth Analg 2003;97:1275-1282

 

在儿童心脏手术中,经食道心超(TEE)是一种监测和诊断工具。从1994-2002年,对865例行先心病手术的患者(年龄小于17岁)常规应用经食道心超进行分析。患者平均年龄36个月(1-16岁)。第一个研究终点是外科和医疗管理决定因TEE结果改变的比率。第二个研究终点是诊断影响(排除旧诊断,建立新诊断)和手术结果。50%的检查由经高级培训的麻醉医师进行。所有检查操作者都有大于500TEE操作的经验。36.7%的病例要求高水平的麻醉医师监督。3.8%的病例要求外科医师监督。12.7%的病例要求变更手术术式,其中包括7.3%需再转流。19.4%需改变医疗管理。作者观察18.5%的病例TEE的诊断影响和27.6%病例的亚优但可接受的手术结果。4.0%病例TEE预术后困难。研究结果证实常规TEE在评估治疗先心病中的有效性。而且,本次研究由受过TEE培训的固定的心外麻醉医师执行。结论:在儿童心脏手术中,经食道心超(TEE)是一种必要的监测和诊断工具。TEE的手术和医疗影响在大宗病例研究中得到证实。这种措施可由得到合适培训的心外麻醉医师承担。

(赵雪莲 庄心良 校)

Transesophageal echocardiography (TEE) is a monitoring and diagnostic tool for the care of children undergoing cardiac surgery. We analyzed reports from 865 routine TEE examinations performed between January 1994 and March 2002 in patients younger than 17-yr-old who were undergoing surgery for congenital heart disease. Patients’ median age was 36 mo (range, 1 day–16 yr). The primary end-point of the study was the incidence of surgical and medical management decisions changed as a result of TEE findings; secondary end-points were diagnostic impact (diagnostic exclusions and new diagnoses) and surgical outcome. Fifty percent of the examinations were performed by anesthesiologists with an advanced level of training in perioperative TEE; all of the examiners had an experience of >=500 TEE examinations. Supervision by an anesthesiologist with an advanced level of training was requested in 36.7% of cases; supervision by a cardiologist was requested in 3.8%. Surgical alterations of management were reported in 12.7% of cases and included the need for a repeat bypass run in 7.3%; medical alterations of management were required in 19.4% of cases. We observed a diagnostic impact of TEE in 18.5% of cases and a suboptimal but acceptable surgical outcome in 27.6%; TEE findings predicted postoperative difficulties in 4.0%. Our results confirm the utility of routine TEE to assess repair of congenital heart defects. Furthermore, this service was competently performed by a regular team of cardiac anesthesiologists appropriately trained in TEE.

 

小剂量氯胺酮预处理可以减少儿童与注射罗库溴铵有关的撤退运动

Pretreatment with Small-Dose Ketamine Reduces Withdrawal Movements Associated with Injection of Rocuronium in Pediatric Patients

Jiin-Tarng Liou, MD, Jee-Ching Hsu, MD, Fu-Chao Liu, MD, Daniel Ching-Wah Sum, MD, and Ping-Wing Lui, MD PhD

Department of Anesthesiology, Chang Gung Memorial Hospital, and Chang Gung University, Taoyuan, Taiwan

Address correspondence

Anesth Analg 2003 97: 1294-1297

.

我们评价预处理小剂量氯胺酮对注射罗库溴铵引起的撤退运动的影响。100例儿童(年龄1-6岁,)随机分为2组。手背静脉置入22号静脉针,分别注射氯胺酮0.2 mg/kg 或生理盐水,随后注射硫贲妥钠5 mg/kg 5秒后注射罗库溴铵0.8 mg/kg 。用4点评分法评价注射罗库溴铵引起的撤退运动。生理盐水和氯胺酮组病人发生撤退运动的比率分别是83%27%。二组病人均有注射部位出现红斑的情况发生。结论:氯胺酮预处理显著减轻硫贲妥钠患儿注射罗库溴铵引起的撤退运动。

(王士雷 庄心良 )

We evaluated the pretreatment of small-dose of ketamine or normal saline in the reduction of withdrawal movements induced by rocuronium injection. One-hundred pediatric patients (aged 1–6 yr) were randomly assigned into 2 groups. A 22-gauge IV cannula was inserted into the dorsum of the hand, and ketamine 0.2 mg/kg or normal saline was given, followed by a 5 mg/kg thiopental injection 10 s later. IV rocuronium (0.8 mg/kg) was injected over 5 s. The patient’s response to rocuronium injection was graded by using a four-point scale in a double-blinded manner. We observed that the incidence of withdrawal movements was 83% in the saline group and 27% in patients pretreated with ketamine (P < 0.05). Some patients in both groups developed skin erythema at the site of injection. We conclude that pretreatment with small-dose ketamine significantly attenuates withdrawal movements associated with IV injection of rocuronium in pediatric patients anesthetized with thiopental.

 

利多卡因和辛醇对外周神经TTX不敏感钠通道有不同的作用

Lidocaine and Octanol Have Different Modes of Action at Tetrodotoxin-Resistant Na+ Channels of Peripheral Nerves

Deniz Poyraz, MD*, Michael E. Bräu, PD MD{dagger}, Friederike Wotka, Cand Med*, Birgit Puhlmann, MD*, Andreas M. Scholz, PD MD{ddagger}, Prof. Gunter Hempelmann, MD{dagger}, Prof. Wolfgang J. Kox, MD PhD*, and Prof. Claudia D. Spies, MD*

*Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité Campus Mitte, Humboldt University, Berlin, Germany; {dagger}Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Justus-Liebig-University, Giessen, Germany; and {ddagger}Department of Physiology, Justus-Liebig-University, Giessen, Germany

Anesth Analg 2003 97: 1317-1324.

局部麻醉药和乙醇阻断钠电流而阻断外周神经的冲动传导。在小的外周神经纤维,TTX不敏感钠通道在冲动的产生中起着重要的作用。我们研究了利多卡因和辛醇对TTX不敏感钠通道的作用。分离背根神经节,以全细胞膜片钳的方式记录钠电流。利多卡因和辛醇均以剂量依赖性的可逆性的阻断钠电流。利多卡因的阻断作用还呈现应用依赖性的特点。二者也呈现强烈的动力学阻断特点。双冲动模式显示利多卡因的作用在复极化时从通道慢性分离的特点。利多卡因和辛醇对钠通道的作用是非竞争性的。结论:利多卡因和辛醇对钠通道的阻滞作用的特点不同,二者在通道的结合部位是不同的。

(王士雷 庄心良 )

Local anesthetics and alcohols block impulse conduction in peripheral nerves by inhibiting Na+ currents. In small peripheral nerve fibers, tetrodotoxin-resistant (TTX-r) Na+ channels play an important role in impulse generation. We investigated the effects of lidocaine and the alcohol octanol on TTX-r Na+ channels. Currents were recorded with the whole-cell patch-clamp method from enzymatically isolated rat dorsal root ganglion cells (data evaluation: nonlinear least-squares fitting). Lidocaine and octanol blocked the TTX-r Na+ current in a reversible and concentration-dependent manner (50% inhibitory concentration values: 177 ± 25 and 455 ± 25 µM, respectively). Lidocaine additionally produced a strong use-dependent block. Both drugs showed a strong dynamic block (i.e., block developed during the time course of current activation and inactivation). Double-pulse protocols showed a slow dissociation of lidocaine from the channel during repolarization (time constant: 1763 ± 63 ms; 300 µM). The dissociation of octanol was too quick to be distinguished from normal current repriming kinetics of 2.2 ms. Lidocaine and octanol acted noncompetitively in the Na+ channel. Lidocaine and octanol have different blocking properties on the TTX-r Na+ current and bind to different channel sites.

 

一个手术和麻醉的动物模型:特点是异氟烷麻醉和雷米芬太尼镇痛

An Animal Model for Surgical Anesthesia and Analgesia: Characterization with Isoflurane Anesthesia and Remifentanil Analgesia

Masakazu Hayashida, MD PhD*, Atsuo Fukunaga, MD PhD{dagger}, and Kazuo Hanaoka, MD PhD*

From the *Department of Anesthesiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; and the {dagger}Department of Anesthesiology, Harbor/UCLA Medical Center, Torrance, California

Anesth Analg 2003;97:1340-1346

 

单独使用传统的“钳夹试验”对手术的麻醉/镇痛水平进行定量评价并不容易并不容易。我们开发了一个兔子模型,既使用机械又使用电刺激模拟手术刺激,从而可以对不同水平的手术麻醉/镇痛进行重复的定量的评价。在异氟烷麻醉下气管切开和血管内插管后,8只兔子被放置在吊带上使得头部和四肢可以自由活动。。将吸入异氟烷浓度从3%降到1.5%,再降到0%。同时按照4个级别的输注速率静脉注射雷米芬太尼(0.1–0.8 µg • kg-1 min-1)。每个剂量下通过观察对钳夹前肢无反应的动物数(无反应数)和记录引发动物抬头反应(HLT,痛觉感知/觉醒阈值)和动物逃跑运动反应(EMT,疼痛忍耐阈值)的皮下电刺激(2Hz5Hz50Hz)电压阈值确定镇痛参数。药物剂量增加时HLT5Hz时的EMT呈剂量依赖性增加,而且绝大多数都与无反应数成比例,后者是标准的麻醉/镇痛指标。所以使用5Hz时的HLTEMT并结合钳夹试验,本实验之兔动物模型可以对不同水平的手术麻醉/镇痛进行量化的评价。

(颜涛译 庄心良校)

 

With a traditional clamp test alone, quantitative evaluation of the level of surgical anesthesia/analgesia is not easy. We have developed a rabbit model that allows for repeated quantification of the varying level of surgical anesthesia/analgesia using both mechanical and electrical stimulation as simulated surgical stimuli. After tracheostomy and intravascular cannulations under isoflurane anesthesia, eight rabbits were placed on a sling that allowed for free movement of the head and extremities. The inspired isoflurane concentration was reduced from 3% to 1.5% and then to 0%. Remifentanil was then infused at 4 graded infusion rates (0.1–0.8 µg • kg-1 min-1). At each drug dose, analgesic variables were determined including the number of animals behaviorally unresponsive to clamping the forepaw (nonresponders) and threshold voltage of subcutaneous electrical stimulation (2 Hz, 5 Hz, and 50 Hz) required to evoke the head lift (HLT, pain detection/arousal threshold) and escape movement responses (EMT, pain tolerance threshold). With increasing drug doses, HLTs and EMTs at 5 Hz increased dose-dependently and most proportionately to increases in the number of nonresponders, a standard indicator of the anesthetic/analgesic level. Therefore, using the HLT and EMT at 5 Hz combined with a clamp test, this rabbit model allows for quantitative evaluation of the varying level of surgical anesthesia/analgesia.

 

静脉注射潘妥拉唑和雷尼替丁改善行择期手术病人术前胃内液体特性的效果

The Effect of Intravenous Pantoprazole and Ranitidine for Improving Preoperative Gastric Fluid Properties in Adults Undergoing Elective Surgery

Dilek Memis, MD*, Alparslan Turan, MD*, Beyhan Karamanlioglu, MD*, Pinar Saral, MD*, Mevlüt Türe, PhD{dagger}, and Zafer Pamukçu, MD*

Departments of *Anaesthesiology and {dagger}Biostatistics, Trakya University Medical Faculty, Edirne, Turkey

Anesth Analg 2003;97:1360-1363

 

我们研究了新的快速起效的质子泵抑制剂潘妥拉唑。该药对术前胃内液体的容积和PH值的影响仍未确定。在这个随机对照的研究中,我们检验了术前静脉注射潘妥拉唑或雷尼替丁对胃内容量和PH值的影响。研究了90例病人(ASA Ⅰ级和Ⅱ级,行择期手术)。在手术前1小时,组Ⅰ病人(n=30)静脉注射生理盐水5ml,组Ⅱ病人(n=30)静脉注射潘妥拉唑50mg,组Ⅲ病人(n=30)静脉注射雷尼替丁50mg。在麻醉诱导后即刻插入鼻胃管,吸取胃内容物,记录量和PH值。组ⅠPH值为3.73± 0.82,组Ⅱ为5.30 ± 1.84,组III4.80 ± 1.40。组Ⅱ和组Ⅲ间无统计学差异,但是在组Ⅰ和组Ⅱ及组Ⅲ间有统计学差异(P < 0.0005)。组Ⅰ胃内容物容积为28.67 ± 10.98 mL,组Ⅱ为15.20 ± 15.52 mL,组Ⅲ为7.77 ± 11.17 mL。在组2和组3间没有统计学差异,但是在组1和组2及组3之间有统计学显著差异(P < 0.0005)。各组病人在误吸时具有发生严重肺损伤危险的病人比例在组Ⅰ、组Ⅱ和组Ⅲ分别为20%10%3.3%。经过统计学评估,在各组之间没有差异。我们的结论是,术前1小时静脉注射潘妥拉唑和雷尼替丁能有效减少胃内容物PH值和容积。

(颜涛译 庄心良校)

We studied pantoprazole, a new potent and fast-acting proton pump inhibitor. Its effects on preoperative gastric fluid volume and pH have not yet been determined. In this randomized, controlled trial, we examined the effects of preoperative IV pantoprazole or ranitidine on gastric pH and volume. Ninety patients (ASA status I and II, scheduled for elective surgery) were studied. One hour before surgery, patients in Group I (n = 30) were given IV saline 5 mL, those in Group II (n = 30) were given 40 mg of pantoprazole IV, and those in Group III (n = 30) were given 50 mg of ranitidine IV. A nasogastric tube was inserted immediately after anesthesia induction. Gastric contents were aspirated, and volume and pH were recorded. The pH values determined in Group I were 3.73 ± 0.82; in Group II, they were 5.30 ± 1.84; and in Group III, they were 4.80 ± 1.40. There was no statistical difference between Groups 2 and 3, but there was a significant difference between Group I and Groups 2 and 3 (P < 0.0005). The volume of the gastric contents was 28.67 ± 10.98 mL in Group I, 15.20 ± 15.52 mL in Group II, and 7.77 ± 11.17 mL in Group III. There was no statistical difference between Groups 2 and 3, but there was a statistically significant difference between Group I and Groups 2 and 3 (P < 0.0005). The proportion of patients considered "at risk" of significant lung injury should aspiration occur was 20% of Group I, 10% of Group II, and 3.3% of Group III. When statistically evaluated, there was no difference among groups. We concluded that the administration of IV pantoprazole and ranitidine 1 h before surgery is effective in reducing gastric pH and volume.

 

单次剂量地塞米松对大鼠伤口愈合的影响

The Effects of Single-Dose Dexamethasone on Wound Healing in Rats

Mahmut Durmus, MD*, Erol Karaaslan, MD*, Erdogan Ozturk, MD*, Mukaddes Gulec, MD{dagger}, Mustafa Iraz, MD{ddagger}, Naci Edali, MD PhD§, and M. Ozcan Ersoy, MD PhD*

Departments of *Anaesthesiology and Reanimation, {dagger}Biochemistry, {ddagger}Pharmacology, and §Pathology, Inonu University School of Medicine, Malatya,

Anesth Analg 2003;97:1377-1380

 

在成人和小儿地塞米松可有效地减少恶心呕吐的发生率。本次实验采用前瞻随机实验动物模型评价了单次剂量地塞米松对伤口愈合的影响。麻醉采用100 mg/kg硫喷妥钠腹膜内注射诱导。地塞米松组用1 mg/kg地塞米松腹膜内注射,对照组用生理盐水。胶原化、上皮化和成纤维细胞含量在地塞米松组均显著减少(p值分别为:0.0020.0410.023)。血管分布和炎症细胞在地塞米松组均明显增多(p值分别为:0.0230.002)。白细胞计数两组相似,对照组:7.84 ± 2.09,地塞米松组:6.98 ± 2.12。平均羟基脯氨酸水平分别为:地塞米松组0.72 ± 0.13 mg/g,少于对照组1.03 ± 0.19 mg/gp=0.001)。结论:1 mg/kg地塞米松对伤口愈合有不利影响。

(唐俊 庄心良 )

Dexamethasone effectively decreases the incidence of nausea and vomiting among pediatric and adult patients. In this study, we evaluated the effects of single-dose dexamethasone on wound healing in a prospective, randomized, experimental animal model. Anesthesia was induced with thiopental 100 mg/kg intraperitoneally. Dexamethasone 1 mg/kg was administered intraperitoneally in a dexamethasone group, and physiological saline was administered in a control group. Collagenization, epithelization, and fibroblast content were significantly less in the dexamethasone group compared with the control group (P values of 0.002, 0.041, and 0.023, respectively). The vascularity and the degree of inflammatory cells were more intense in the dexamethasone group compared with the control group (P values of 0.023 and 0.002, respectively). The white blood cell count was similar in the control (7.84 ± 2.09) and dexamethasone (6.98 ± 2.12) groups. The mean hydroxyproline level was 0.72 ± 0.13 mg/g in the dexamethasone and 1.03 ± 0.19 mg/g in the control group. Hydroxyproline levels were significantly less in the dexamethasone group (P = 0.001). We conclude that dexamethasone at 1 mg/kg may have negative effects on wound healing.

 

一种高仿真模拟器的心血管图形化显示的评估

Evaluation of Graphic Cardiovascular Display in a High-Fidelity Simulator

James Agutter, M.Arch*, Frank Drews, PhD{ddagger}, Noah Syroid, MS{dagger}, Dwayne Westneskow, PhD{dagger}, Rob Albert, MS{ddagger}, David Strayer, PhD{ddagger}, Julio Bermudez, PhD*, and Matthew B. Weinger, MD§

*Graduate School of Architecture, {dagger}Department of Anesthesiology, and {ddagger}Department of Psychology, University of Utah, Salt Lake City, Utah; and §Department of Anesthesiology, University of California, San Diego, and San Diego Center for Patient Safety, Veterans Affairs San Diego Medical Center, San Diego, California

Anesth Analg 2003;97:1403-1413

 

麻醉中的“人为错误”可归结于对病人监护中的误解或医师对状况的认识失误。图形化显示监护数据可能更有利于发现、诊断和治疗。作者设计了一种血液动力学的图形化显示方法。20位麻醉医师被要求假定监护一个模拟病人。一半的参加者使用图形化心血管显示,另一半使用Datex As/3监护仪。第一个场景设为全髋置换术中错误血型输血后反应。第二个场景为根治性前列腺切除术中失血1.5L并发心肌梗塞。使用图形化显示的实验对象发现心肌梗塞比为使用者快2分钟。开始治疗也更为迅速(2.54.9分钟)。而髋关节置换术场景两组间没有明显差异。应用图形化显示组在病例结束时,相对于基础值收缩压较小,中心静脉压接近,动脉氧饱和度升高。结论:本实验对以下假说提供了支持:将临床信息图形化显示,并结合紧急特点和功能的关联性设计,可提高临床医师在模拟环境中发现、诊断、管理和治疗临床心血管事件的能力。

(唐俊 庄心良 )

"Human error" in anesthesia can be attributed to misleading information from patient monitors or to the physician’s failure to recognize a pattern. A graphic representation of monitored data may provide better support for detection, diagnosis, and treatment. We designed a graphic display to show hemodynamic variables. Twenty anesthesiologists were asked to assume care of a simulated patient. Half the participants used the graphic cardiovascular display; the other half used a Datex As/3 monitor. One scenario was a total hip replacement with a transfusion reaction to mismatched blood. The second scenario was a radical prostatectomy with 1.5 L of blood loss and myocardial ischemia. Subjects who used the graphic display detected myocardial ischemia 2 min sooner than those who did not use the display. Treatment was initiated sooner (2.5 versus 4.9 min). There were no significant differences between groups in the hip replacement scenario. Systolic blood pressure deviated less from baseline, central venous pressure was closer to its baseline, and arterial oxygen saturation was higher at the end of the case when the graphic display was used. The study lends some support for the hypothesis that providing clinical information graphically in a display designed with emergent features and functional relationships can improve clinicians’ ability to detect, diagnose, manage, and treat critical cardiovascular events in a simulated environment.

 

人硬膜外应用芬太尼的作用部位:输注与单次注射的差异

The Site of Action of Epidural Fentanyl in Humans: The Difference Between Infusion and Bolus Administration

Yehuda Ginosar, BSc MBBS*,{dagger}, Edward T. Riley, MD*, and Martin S. Angst, MD*

*Department of Anesthesia, Stanford University, Stanford, California, and the {dagger}Department of Anesthesiology and Critical Care Medicine, Hebrew University Hadassah School of Medicine, Jerusalem, Israel.

Anesth Analg 2003;97:1428-1438

 

目的:以单次法注射给药的大多数研究提示硬膜外应用芬太尼的主要作用部位是脊髓,而以输注法给药的研究则认为是脊髓上部位。本研究试图验证硬膜外应用芬太尼的模式(单次或输注)决定其作用部位的假说。方法:10名健康志愿者参加了这一随机对照交替试验。在不同的试验日,芬太尼分别以团块法注射(0.03mg,然后每210分钟给0.1mg),或者连续输注(0.03mg210分钟后继以0.1mg/h输注200分钟)。使用温度和电疼痛实验模型,在实验的420分钟内,重复评估导致可忍受的最大疼痛温度(℃)和电流(mA)。镇痛效果在一个腰部节段和一头部节段进行测量。整个实验期间测定血浆芬太尼浓度。硬膜外单次法注射芬太尼导致节段性镇痛(腿部优于头部),而硬膜外连续输注的镇痛效果没有差异(腿部等于头部)。在硬膜外输注组血浆芬太尼浓度与镇痛效果间有显著的线性相关,而单次法组则没有。结论:硬膜外单次法注射芬太尼产生节段性的镇痛效果,而连续输注导致系统性的镇痛,这一发现支持本试验的假说,可用以解释硬膜外应用芬太尼作用位点的文献上的争议。

(唐俊 庄心良 校)

Most published studies suggesting that epidural fentanyl acts predominantly at spinal sites administered the drug as a bolus injection, whereas most studies suggesting that it acts predominantly at supraspinal sites administered the drug as an infusion. In this study we tested the hypothesis that the mode of administration (bolus versus infusion) of epidural fentanyl determines its site of action. Ten healthy volunteers were enrolled in this randomized, double-blinded, cross-over study. On separate study days fentanyl was administered into the epidural space as a bolus (0.03 mg followed by 0.1 mg 210 min later) and as an infusion (0.03 mg/h followed by 0.1 mg/hr 210 min later for 200 min). Using a thermal and electrical experimental pain model, the heat (°C) and electrical current (mA) causing maximum tolerable pain were assessed repetitively over a period of 420 min. The analgesic efficacy measures were obtained at a lumbar and a cranial dermatome. Plasma fentanyl concentrations were determined throughout the study. Epidural bolus administration of fentanyl resulted in segmental analgesia (leg > head), whereas the epidural infusion of fentanyl produced nonsegmental analgesia (leg = head). There was a significant linear relationship between the analgesic effect and the plasma concentration of fentanyl for the epidural infusion but not for the epidural bolus administration of fentanyl. These findings support our hypothesis and might explain the apparent conflict in the literature regarding the site of action of epidural fentanyl.

 

鞘膜内吗啡用于术后镇痛:髋或膝关节成形术中的随机对照剂量对比研究

Intrathecal Morphine for Postoperative Analgesia: A Randomized, Controlled, Dose-Ranging Study After Hip and Knee Arthroplasty

James P. Rathmell, MD, Carlos A. Pino, MD, Richard Taylor, MD, Terri Patrin, RN, and Bruce A. Viani, MD

Department of Anesthesiology, University of Vermont College of Medicine, Burlington, Vermont

Anesth Analg 2003;97:1452-1457

 

目的:本试验检验鞘内0.0-0.3mg范围内硫酸吗啡(ITMS)用于髋或膝关节成形术后的镇痛效果和副作用。方法:进行髋关节或膝关节手术的病人各四十名,随机接受ITMS0.00.10.20.3mg)。病人自控镇痛(PCA)装置对镇痛要求提供额外支持。吗啡用量、疼痛缓解程度和副作用记录24小时。数据用方差分析和线性回归分析处理。结果:髋关节手术后,接受不同剂量ITMS者的吗啡用药量均明显少于对照组(p<0.05)。膝关节手术后,ITMS并不减少术后的吗啡需求量。恶心呕吐和氧饱和度下降(<93%)的发生率各组相似。给与ITMS者的搔痒发生更多。在髋或膝关节手术后,接受0.20.3mg ITMS的病人疼痛控制的满意度均优于0.000.1mg组。结论:结合使用小剂量(0.2mgITMSPCA给予吗啡可对大多数全髋或膝关节成形术的病人提供良好的疼痛控制。然而,PCA吗啡用量仅在髋关节手术因使用ITMS而减少。

(唐俊 庄心良 校)

 

Sabine M. Sator-Katzenschlager, Jozef C. Szeles, Gisela Scharbert, Andrea Michalek-Sauberer, Alexander Kober, Georg Heinze, and Sibylle A. Kozek-Langenecker

In this series, we examined analgesia and side effects of intrathecal morphine sulfate (ITMS) after hip and knee arthroplasty over a dose range of 0.0–0.3 mg. Eighty patients undergoing hip (n = 40) or knee (n = 40) arthroplasty were randomized to receive ITMS (0.0, 0.1, 0.2, or 0.3 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. Morphine use, pain relief, and side effects were recorded for 24 h. Data were analyzed with analysis of variance and linear regression. After hip arthroplasty, morphine use was less in patients receiving 0.1, 0.2, or 0.3 mg of ITMS than in control patients (P < 0.05). After knee arthroplasty, ITMS did not reduce postoperative morphine requirements. Nausea and vomiting and the incidence of oxygen saturation <93% were similar in all groups. Pruritus was more common after ITMS. Patients receiving 0.2 or 0.3 mg of ITMS were more satisfied with their pain control than those receiving 0.0 or 0.1 mg after both hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than after hip arthroplasty. We conclude that combining small-dose (0.2 mg) ITMS with PCA morphine provides good to excellent pain control in most patients after total hip or knee arthroplasty. However, PCA morphine use was reduced by the addition of ITMS only after hip arthroplasty.

 

耳穴电针刺激较传统的机械压迫刺激对痛有更好的治疗作用

Electrical Stimulation of Auricular Acupuncture Points Is More Effective Than Conventional Manual Auricular Acupuncture in Chronic Cervical Pain: A Pilot Study

Sabine M. Sator-Katzenschlager, MD*, Jozef C. Szeles, MD{dagger}, Gisela Scharbert, MD*, Andrea Michalek-Sauberer, MD*, Alexander Kober, MD*, Georg Heinze, PhD{ddagger}, and Sibylle A. Kozek-Langenecker, MD*

*Department of Anesthesiology and Intensive Care B, Outpatient Pain Center, {dagger}Department of Vascular Surgery, and {ddagger}Department of Medical Computer Science, University of Vienna, Vienna, Austria

Anesth Analg 2003 97: 1469-1473

 

本研究验证一个假说,即耳穴电刺激较机械刺激更能减轻疼痛。以21例没有神经根压迫症状,且用标准的镇痛方式效果不理想的慢性颈痛患者为研究对象。主要的穴位进:颈椎穴 肾门和库深。其中10例用电针,11例不用电刺激。所有针在48小时内拔出。每周一次,共6次。病人需完成关于疼痛程度 精神状态 睡眠和用其他药物治疗的调查问卷。结果,电针刺激组病人疼痛显著减轻,精神表现 睡眠也显著改善,应用其他镇痛药物的病人也显著少。结论:用P-STIMT持续耳穴电针刺激可以改善慢性颈部疼痛的治疗效果。

(王士雷 庄心良 校)

In this prospective, randomized, double-blinded, controlled study, we tested the hypothesis that auricular electroacupuncture relieves pain more effectively than conventional manual auricular acupuncture. We studied 21 chronic cervical pain patients without radicular symptoms with insufficient pain relief (visual analogue scale >5) treated with standardized analgesic therapy. All patients received disposable acupuncture needles on the dominant side on the following acupuncture points: cervical spine, shen men, and cushion. In 10 patients, needles were continuously stimulated (2-mA constant current, 1 Hz monophasic) by using the electrical point stimulation device P-STIMTM. In 11 control patients, no electrical stimulation was administered. All needles were withdrawn 48 h after insertion. Acupuncture was performed once a week for 6 wk. Patients had to complete a questionnaire assessing pain intensity, psychological well-being, activity, sleep, and demand for rescue medication (lornoxicam and tramadol). The reduction in pain scores was significant in the electrical acupuncture group. Similarly, psychological well-being, activity, and sleep were significantly improved in patients receiving electrical acupuncture, and consumption of rescue medication was significantly less. These results demonstrate that continuous electrical stimulation of auricular acupuncture points by using the new point stimulation device P-STIMTM improves the treatment of chronic cervical pain in an outpatient population.

 

硅酮强化的半球形斜口导管减少经鼻气管插管的并发症

A Silicone-Based Wire-Reinforced Tracheal Tube with a Hemispherical Bevel Reduces Nasal Morbidity for Nasotracheal Intubation

Shinichi Kihara, MD*, Tetsuya Komatsuzaki, MD*, Joseph R. Brimacombe, MB ChB, FRCA, MD{dagger}, Yuichi Yaguchi, MD*, Noriko Taguchi, MD*, and Seiji Watanabe, MD*

*Department of Anesthesia, Mito Saiseikai General Hospital, Ibaraki, Japan; and {dagger}University of Queensland and James Cook University, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia

Anesth Analg 2003 97: 1488-1491

.

我们检验一个假说,即在经鼻气管插管时,硅酮强化的半球形斜口气管导管较传统的预先弯曲的PVC管的并发症少。80例经鼻气管插管的扁桃体切除病人,随机分为二组,分别应用上述导管。插管分为3个阶段:1)从鼻到咽;2)喉镜引导至声门入口;3)喉镜引导进入气管。如果某个阶段不能顺利进行,则用特殊的方式辅助通气。结果,所有病人均插管成功。硅酮导管组病人咽和气管阶段插入的数量相同,但过声门的数量则显著多。鼻出血的数量和严重程度均较轻。硅酮管术后总的鼻症状的数量少。结论:硅酮管在插入咽和气管内的数量较PVC管少,但声门的试图插入次数较多。硅酮管术后鼻的发病率低。

 

(王士雷 庄心良 校)

We tested the hypothesis that a silicone-based wire-reinforced tracheal tube with a hemispherical bevel is superior to a polyvinyl chloride (PVC)-based precurved tube with a conventional diagonal bevel for nasotracheal intubation. Eighty anesthetized paralyzed adults (ASA physical status I–II) requiring nasotracheal intubation for tonsillectomy were randomly allocated into two equal-sized groups for airway management with the silicone tracheal tube or PVC tracheal tube. Intubation was subdivided into three phases: 1) passage through the nose into the pharynx, 2) laryngoscope-guided passage into the glottic inlet, and 3) laryngoscope-guided passage into the trachea. A specific sequence of airway maneuvers was followed at each stage if it was unsuccessful. The number of attempts and intubation time were documented by an unblinded observer. The frequency of epistaxis and postoperative nasal complications was documented by blinded observers. There were no intubation failures. The number of attempts at pharyngeal (47 versus 56; P = 0.04) and tracheal (43 versus 55; P = 0.005) placement was smaller for the silicone tracheal tube, but the number of attempts at glottic placement was more (72 versus 49; P < 0.0001). Intubation time was similar. The frequency (32% versus 80%; P < 0.0001) and severity of epistaxis were less for the silicone tracheal tube. The total number of postoperative nasal symptoms was smaller for the silicone tracheal tube (10 versus 21; P < 0.05). We conclude that the pharyngeal and tracheal placement phases of nasotracheal intubation require fewer attempts with the silicone tracheal tube than the PVC tracheal tube but that the glottic placement phase requires more attempts. Nasal morbidity is less common with the silicone tracheal tube.

 

布比卡因和左旋布比卡因在分娩时的相对运动阻滞特性

The Relative Motor Blocking Potencies of Bupivacaine and Levobupivacaine in Labor

Héctor J. Lacassie, MD*, and Malachy O. Columb, FRCA{dagger}

*Anesthesiology Department, Pontificia Universidad Católica de Chile, Santiago, Chile; and {dagger}South Manchester University Hospital, Wythenshawe, United Kingdom

Anesth Analg 2003 97: 1509-1513.

最小的局麻药浓度被用来研究布比卡因及其左旋体的硬膜外镇痛特性。没有研究比较这两种药物的运动阻滞特性。本研究比较二者运动阻滞的最小浓度和比率。60例病人随机分组。每组第一个病人接受0.25% wt/vol 。随后浓度以0.025% wt/vol递增。在30分钟内Bromage score <4 被认为是有效的运动阻断。用Dixon and Massey方法进行统计处理。布比卡因运动阻滞的最小浓度是0.27% wt/vol,左旋布比卡因是0.31% wt/vol。二者比率是 0.87 (95% CI, 0.77–0.98)。结论:布比卡因的左旋体较右旋体运动阻滞的效能低。

(王士雷 庄心良 校)

Minimum local analgesic concentrations (MLAC) have been used to determine the epidural analgesic potencies of bupivacaine and its levo- counterpart. There are no reports of the motor blocking potencies of these drugs. In this study we sought to determine the motor block MLAC of both drugs and determine the relative potency ratio. Sixty ASA physical status I–II parturients were randomized. The first woman in each group received 0.25% wt/vol. Up-down sequential allocation was used to determine subsequent concentrations at a testing interval of 0.025% wt/vol. Effective motor block was defined as a Bromage score <4 within 30 min. The up-down sequences were analyzed with the Dixon and Massey method and probit regression. Two-sided P < 0.05 defined significance. The motor block MLAC for bupivacaine was 0.27% wt/vol (95% confidence interval [CI], 0.25–0.30) and for levobupivacaine was 0.31% wt/vol (95% CI, 0.29–0.34) (P = 0.024), with a levobupivacaine/bupivacaine potency ratio of 0.87 (95% CI, 0.77–0.98). This is the first study to estimate the motor-blocking potency ratio of bupivacaine and levobupivacaine in labor. This study demonstrates that the S-enantiomer of bupivacaine is less potent at motor block than the racemate.