Anesthesia & Analgesia

November 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

老年手術病人心臟舒張充盈功能異常的流行病學調查

(肖潔 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.

 

甘露醇和多巴胺在體外迴圈病人中的作用:一個隨機臨床試驗

(費敏譯 薛張綱校)

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.

 

異丙酚可減少由再灌注引起的豚鼠正常和缺血-再灌注之間邊緣區的心侓失常

(趙雪蓮 莊心良

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-麻黃堿與d-偽麻黃堿的擬交感神經藥作用:是直接啟動受體還是通過去甲腎上腺素釋放引起的?

(肖潔 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.

 

異氟醚誘導的腦電波爆發抑制效應對體外迴圈中腦血流速和腦氧攝取的影響

(費敏譯 薛張綱校)

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:

兒童先心病手術中經食道心超的應用:兩個中心的觀察研究

(趙雪蓮 莊心良 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.

 

先天性心臟病手術患者術中脈搏曲線法心輸出量監測的分析

(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.

 

小兒心臟手術中組織因數啟動的血栓彈力圖:基礎值和比較值

(費敏譯 薛張綱校)

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.

 

小劑量氯胺酮預處理可以減少兒童與注射羅庫溴銨有關的撤退運動

(王士雷 莊心良 )

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:

足部和踝部手術後持續使用膕窩坐骨神經阻滯:能否提高恢復質量?

(殷文淵 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:

利多卡因減弱了人類單核細胞趨化蛋白1的產生及其趨化作用:利多卡因在炎症中可能的機制

(張俊峰譯 薛張綱校)

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.

 

利多卡因和辛醇對外周神經TTX不敏感鈉通道有不同的作用

(王士雷 莊心良 )

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.

 

異丙酚抑制大鼠垂體細胞的胞內鈣離子活化的作用

(齊波 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可抑制自然殺傷細胞活性,促進腫瘤轉移,而異丙酚不會:調節機制和預防措施

(張俊峰譯 薛張綱校)

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.

 

一個手術和麻醉的動物模型:特點是異氟烷麻醉和雷米芬太尼鎮痛

(顏濤譯 莊心良校)

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後對鎮痛和非鎮痛作用的急性耐受性研究

(齊波 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和苯巴比妥在體外人類血小板聚集中的相反作用

(張俊峰譯 薛張綱校)

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

 

靜脈注射潘妥拉唑和雷尼替丁改善行擇期手術病人術前胃內液體特性的效果

(顏濤譯 莊心良校)

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..

豬七氟醚的最小麻醉藥濃度與不同濃度氙的關係

(齊波 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.

 

七氟醚的心臟保護效應依賴於蛋白激酶C活化、線粒體 K+ATP通道開放以及反應性氧分子的生成

(張俊峰譯 薛張綱校)

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.

 

單次劑量地塞米松對大鼠傷口癒合的影響

(唐俊 莊心良 )

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.

 

圍術期的過敏反應

(陳潔 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:

人聽覺穩定狀態反應:錄音技術效應和覺醒狀態

(方芳譯 薛張綱校)

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.

 

一種高仿真模擬器的心血管圖形化顯示的評估

(唐俊 莊心良 )

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.

 

一種新的可調節式的混合器測量麻醉機呼吸回路中混合呼出氣體的濃度

(陳潔 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/芬太尼麻醉誘導後早期吲哚菁綠指示血漿容量可能存在估計過高

(方芳譯 薛張綱校)

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:

人硬膜外應用芬太尼的作用部位:輸注與單次注射的差異

(唐俊 莊心良 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:初產婦最小局麻濃度的研究

(陳潔 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.

 

椎管構造有利於鎮痛的方面——應用蘇芬太尼、布比卡因混合液行術後鎮痛

(方芳譯 薛張綱校)

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.

 

鞘膜內嗎啡用於術後鎮痛:髖或膝關節成形術中的隨機對照劑量對比研究

(唐俊 莊心良 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.

 

鼠外周神經系統對嗎啡產生耐受時的Mu-阿片類受體mRNA的調節

(朱輝 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嗎啡來達到相近的止痛效果

(方芳譯 薛張綱校)

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.

 

耳穴電針刺激較傳統的機械壓迫刺激對痛有更好的治療作用

(王士雷 莊心良 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.

 

單次靜注5HT3受體拮抗劑樞複寧可以治療神經痛嗎?雙盲,安慰——對照交叉研究

(朱輝 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:

心電圖自動測量記錄儀在社區醫院綜合性監護中的應用及效力

(鍾鳴譯 薛張綱校)

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.

矽酮強化的半球形斜口導管減少經鼻氣管插管的併發症

(王士雷 莊心良 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

 

過氧化硝酸鹽降低多巴胺的血管收縮性

(朱輝 王祥瑞 )

Peroxynitrite Decreases Dopamine’s Vasoconstrictive Activity

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

Anesth Analg 2003 97: 1492-1496.

 

小豬急性肺動脈高壓模型中間斷吸入一氧化氮聯合靜脈內注射雙嘧達莫

(鍾鳴譯 薛張綱校)

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內給藥鎮痛時間的減少

(鍾鳴譯 薛張綱校)

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時的相對運動阻滯特性

(王士雷 莊心良 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:

超聲引導鎖骨上臂叢神經阻滯

(殷文淵 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.

 

超聲引導加快了鎖骨上阻滯的操作的速度和提高了阻滯質量

(鍾鳴譯 薛張綱校)

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:

控制性低血壓和最小膨脹壓:上肢手術中使用充氣式止血帶的一項新技術

(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.

 

老年手術病人心臟舒張充盈功能異常的流行病學調查

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


術前評價心功能時,通常以評估左心射血分數(LVEF)為主。目前的臨床證據表明心臟舒張功能衰竭也很常見,且佔有一定的發病率和死亡率。本次研究物件為老年的手術病人,通過超聲心動圖評價他們的心臟舒張充盈功能,藉以評價其發病情況。選擇病人條件:年齡≥65歲,行冠狀動脈手術(不伴有心臟瓣膜疾病),或行非心臟手術(至少伴有一個或一個以上的心血管疾病危險因素)。非心臟手術的病人,術前均進行超聲心動圖檢查;心臟手術的病人,術中均進行食管超聲心動圖檢查。超聲心動圖記錄了LVEFE/A比值等評價左、右心室功能的指標。共觀測了251個病人,平均年齡為72±7歲,多元線性回歸分析表明,心肌梗塞病史的病人(P0.021),心絞痛的病人(β=-6.0995 CI:-9.66 2.52P0.001),瓣膜病的病人(β=-5.0595 CI:-9.56 0.55P0.028),這些病人的LVEF也明顯低於那些沒有症狀的病人。LVEF正常的病人中,有61.5%的病人存在舒張功能異常。舒張功能異常包括E/A比值(β=-1.1195 CI:-6.02 3.78P0.65)和減速時間(β=-3.4295 CI:-31.2822.45P0.81)。舒張功能不全的病人沒有特徵性的臨床表現。通過方差分析證明:對於那些進行非心臟手術的病人,可以根據其病史和體格檢查的資料來評價LVEF的水平,但這種評價與超聲心動圖的評價結果兩者之間純在明顯差異(P=0.0004)。通常情況下,人為的評價結果比超聲心動圖的結果偏低一些。雖然有經驗的醫生能夠基本正確的評價出病人心臟收縮期的射血分數,但是有很多LVEF正常的老年病人獨立的存在心臟舒張充盈功能缺陷,而這一缺陷是無法從臨床上的表現來預言的。以上這些結果表明,對於老年手術病人單純的評價左室收縮功能是不全面的,臨床醫生應近可能全面的考慮到老年人左室功能的特點。

(肖潔 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-麻黃堿與d-偽麻黃堿的擬交感神經藥作用:是直接啟動受體還是通過去甲腎上腺素釋放引起的?

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


長久以來,麻黃堿都是產科手術中血管加壓劑的首選藥物,但其作用的基礎機制還並不明確。我們通過實驗研究了兩種藥物的擬交感神經作用,目前常用的血管加壓素l-麻黃堿和解充血藥物d-偽麻黃堿。在已經麻醉的大鼠上, l-麻黃堿和d-偽麻黃堿都可以導致劑量依賴性的動脈血壓增高和心率增快,但是,如果在用藥前先給6-羥多巴胺(6-OHDA)阻斷交感神經,則以上反應就會消失。實驗結果表明,兩種麻黃堿的異構體均產生濃度依賴性的提肛肌張力增加和右心房竇性心率。同樣的,提肛肌和心房反應在使用6-羥多巴胺後都會消失,然而,有近50%使用l-麻黃堿的大鼠有對6-羥多巴胺耐藥的表現。通過人的臍動、靜脈給足夠劑量的以上兩種麻黃堿的異構體,沒能產生任何反應(這些劑量能夠引起提肛肌和心房組織明顯反應)。雖然l-麻黃堿直接興奮腎上腺素受體在組織學上也有一定證據,但該藥物在人體內的反應應該完全歸功於交感神經去甲腎上腺素的釋放。這種間接機制比較容易解釋為什麼l-麻黃素可以在保證子宮胎盤血供的情況下升高母親的動脈血壓,因為子宮胎盤血供沒有交感神經的支配。

(肖潔 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.

 

先天性心臟病手術患者術中脈搏曲線法心輸出量監測的分析

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


肺動脈導管監測心輸出量的方法並不適用於先天性心臟病患者,這主要是由於這些患者年紀太小,同時又存在解剖學上的異常。我們研究了兒童及成人先天性心臟病手術中利用脈搏曲線分析儀測量連續心輸出量這一新方案的準確性。在這次實驗中共有16位患者參與,平均年齡為7歲。在心肺轉流前後共記錄了191個資料。我們評估了經肺熱稀釋法心指數測定(TDCI)與脈搏曲線心指數測定(PCCI)兩者之間的相互關係,TDCIPCCI的相關係數為0.7。雖然在先前的研究中PCCI被認為是成人心臟手術中較為準確的一個測量指標,但本研究病患中其還欠缺可靠性,甚至在經過分流改正後也存在這一問題。我們也同時研究容量負荷與壓力負荷的相關性(胸內血液容量指數[ITBI]和中心靜脈壓心指數測定)。經過修正PCCITDCIITBI的相關性(分別為0.560.71)較PCCITDCICVP0.160.11)的相關性強,這一結論顯示用ITBI測負荷較為可靠。

(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.

 

足部和踝部手術後持續使用膕窩坐骨神經阻滯:能否提高恢復質量?

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


持續膕窩坐骨神經阻滯是一種普遍用於足部和踝部手術的技術。可是,當區域麻醉作用消失後,疼痛很難控制住。因此,我們假設通過持續注射布比卡因(0.25%)來延長阻滯時間,從而減輕疼痛,有利於足部和踝部手術後的恢復。隨機、雙盲、安慰劑對照的研究中,對24名知情的在標準全麻下接受足部或踝部手術的病人進行研究。在手術前,使用18G Tuohy硬膜外針和經皮神經刺激儀對所有病人進行膕窩坐骨神經阻滯。在注射0.25%布比卡因30ml和放置20G導管後,病人隨機分為使用0.9%生理鹽水(對照)0.25%布比卡因,速度維持為5ml/h,直到術後48小時。使用一種11分口頭評定表(0=不痛,10=痛的超乎想像)來評估疼痛的嚴重程度。術後特定時間段使用阿片類鎮痛藥都被記錄下來。隨後的評估在術後24h48h72h和一周進行,估算鎮痛評分和病人對鎮痛和恢復質量的滿意程度,使用的是一種100分口頭評定表(1=極度不滿意到100=極度滿意)。在布比卡因組,術後最大疼痛評分(>50%)和阿片類藥物的使用(>60%)與對照組相比在統計學上都顯著降低。布比卡因組中病人對術後鎮痛和恢復質量的滿意程度都顯著提高(與對照組相比)。此外,40%的布比卡因組病人在術後當天可以出院回家。總之,在骨科足部和踝部手術後持續注射0.25%布比卡因減輕了術後疼痛、減少了阿片類藥的使用,提高了病人的滿意程度和恢復質量。

(殷文淵 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.

 

異丙酚抑制大鼠垂體細胞的胞內鈣離子活化的作用

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


異丙酚可以抑制AtT20-細胞(一類垂體瘤的細胞系)分泌和調節β-內啡肽(神經肽)。神經肽的分泌有賴於細胞內鈣離子濃度水平的升高。本次研究的目的是異丙酚改變AtT20-細胞內鈣離子的濃度水平。異丙酚(100μM)並不能通過抑制鈣離子而抑制細胞(可透過毛地黃皂甙)分泌β-內啡肽。因此,異丙酚並不是通過改變細胞內鈣離子的濃度來抑制神經肽分泌的。細胞內鈣離子的測定是通過一種特定的鈣離子敏感染色實現的。鈣離子可與KCL發生短暫的去極化或與thapsigargin(一類鈣離子抑制劑,可被內質網攝取)相結合。異丙酚抑制完整細胞中鈣離子介質(於KCL反應產生)的生成。(半價最大抑制率為14.9μMP<0.05)。硝基乙吡啶也可通過鉀離子抑制鈣離子峰的形成。異丙酚50μM可將thapsigargin組的鈣離子峰值降至對照組的47%(P<0.05)。用硝基乙吡啶將鈣通阻滯後,Thapsigargin組的作用不受其影響。異丙酚抑制的是刺激細胞內鈣離子增加的因素。異丙酚可以抑制Thapsigargin鈣離子介質,而硝基乙吡啶不能,這就說明異丙酚對細胞內鈣離子的作用與L-型鈣離子通道的阻斷與否沒有關係。異丙酚可以抑制細胞內儲備鈣離子的釋放。以上的這些研究結果說明,異丙酚通過抑制刺激細胞內鈣離子增加的因素而達到抑制神經肽分泌的。

(齊波 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後對鎮痛和非鎮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


雖然在注射雷米芬太尼後,急性耐受鎮痛作用很快就會產生,但是對於那些非鎮痛作用是否也純在耐受作用仍不明確.本研究通過對兔子的動物實驗研究在連續注射雷米芬太尼後的鎮痛作用和心肺作用.10只新西蘭大白兔,氣管切開留取動靜脈後用一根細繩固定,動物還有定的自主活動能力.對於有自主呼吸意識清醒的兔子以0.3μg/kg*min注射雷米芬太尼360分鐘.在注射雷米芬太尼時,反復評價鎮靜和鎮痛作用及心肺功能,包括鉗夾前蹄後觀察動物的動作,測量能引起動物抬頭的皮下電刺激閾值(HLT:疼痛檢測,覺醒閾值),和逃脫反應,同時伴有血壓,心率和呼吸頻率的降低.因此,所有的變數都隨著藥物的持續注射漸漸變回到藥物使用前的水平.以上結果說明伴隨著雷米芬太尼的注射,急性的耐受反應不僅發生在鎮痛作用上還包括心肺反應等.

(齊波 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.

 

豬七氟醚的最小麻醉藥濃度與不同濃度氙的關係

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

 

在最近的一項研究中,我們描述了當氙與異氟醚共同應用時,有不同程度的拮抗作用。一個假想的解釋是氙和異氟醚在神經原水平上通過不同的方式產生鎮痛效果。本次實驗將氙和其他吸入麻醉藥混合以檢測氙和其他麻醉藥之間的關係。我們檢測當氙與七氟醚相混合後,其肺泡最低濃度(MAC)的變化情況。研究的物件是10頭豬(平均體重為30.8kg±2.6,)通氣中分別給0%,15%,30%,40%,50%,65%氙。在不同濃度的氙氣下,輔以不同濃度的七氟醚。在以上這些情況下都給一個強大的刺激(抓夾),有退縮表現的被記錄下來。七氟醚的MAC定義為其最底的濃度時有50%的實驗動物對刺激無反應。不同濃度的氙,動物對於疼痛的反應被歸類並進行Logistic回歸分析,並根據分析結果制定七氟醚的MAC。結果七氟醚的MAC隨吸入氙的增加而減少,0%的氙時為2.5365%的氙時為1.54。與氙和異氟醚相比,氙和七氟醚的麻醉反應與其十分相似。

(齊波 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.

 

圍術期的過敏反應

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


麻醉醫師在提供麻醉時會使用成千上萬種藥物。許多種藥物存在劑量依賴的副作用,有一些會導致嚴重的免疫介導的副反應,過敏反應是其中最嚴重的一種。它通常發生于再次暴露於某一特殊抗原時,同時需要炎性介質的釋放,其直接通過肥大細胞或補體反應釋放而非IgE介導。圍術期的過敏反應大多數是肌松劑和乳化劑所產生。症狀可以累及所有的器官系統,在最嚴重的情況下表現為支氣管的痙攣和心血管系統的衰竭。治療包括停止接觸可疑藥物、心肺支援和使用腎上腺素。血清類胰蛋白酶能明確過敏反應的診斷,皮試和血清學檢查可以明確過敏源,預防過敏反應的發生對降低患病率和死亡率是非常重要的。

(陳潔 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.

 

一種新的可調節式的混合器測量麻醉機呼吸回路中混合呼出氣體的濃度

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


我們將一種新的、平行設計裝置用於混合器,以連續測量同一回路中各種麻醉氣體的比例。對機械通氣模型在較大範圍改變潮氣量(300-1200mL)、頻率(6-12/分)和PCO2之後,與呼出氣體吸收裝置相比,此裝置的測量更為精確(平均斜率1.00y=-0.01 R2=0.9988)。改變混合氣體的容積會改變混合器的反應時間。快的混合器可以測量的間歇為20.這種新的混合器由標準的麻醉機部件所製造,易於連接在吸氣出口和呼氣入口上,同時便於清潔和消毒,且不會積聚呼吸回路中的濃縮水分。這種新的混合器還可以直接反映麻醉狀態下和非侵入性代謝裝置(如無氧代謝)以及特殊情況下(肺栓塞)中的熱量消耗(CO2消除,氧氣的攝取)。

(陳潔 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:初產婦最小局麻濃度的研究

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


我們以前曾經證實過,持續硬膜外注射芬太尼通過全身機制產生鎮痛作用而不引起局部麻醉。在本試驗中,我們假設;在硬膜外存在布比卡因的情況下,持續注射芬太尼通過脊髓機制產生鎮痛。48例臨產的初產婦接受了本次隨機、前瞻性、雙盲研究。她們在腰錐硬膜外腔注入20-30mL0.125%布比卡因直至疼痛緩解,然後隨機分為IV或硬膜外(EPI)組,均持續注入芬太尼30ug/h,同時均以20ml/h的速度硬膜外持續注入布比卡因,濃度由同一組前一位婦女的反應所決定。與以往實驗使用最小局麻有效濃度(MLAC)開始麻醉不同,本實驗使用MLAC來維持生產的第一階段。MLAC通過Dixon Massey所提供的持續分析法所測定。布比卡因的MLACIV組為.063%95%的可信區間,0.058-0.068),EPI組為0.01995%的可信區間,0.000-0.038)。EPIIV相比,有效性大於3倍。這次研究說明:硬膜外注射芬太尼,脊髓方式是其鎮痛的主要機制。

(陳潔 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.

 

鼠外周神經系統對嗎啡產生耐受時的Mu-阿片類受體mRNA的調節

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


在體暴露于阿片類激動劑的外周神經系統,關於其阿片類受體mRNA調節的文獻資料相當缺乏。因此,我們將研究當老鼠對外周感覺中樞發生行為反應期間使用嗎啡對Mu-阿片類受體調節的影響。19只老鼠被分成2組,一組皮下注射嗎啡10mg/kg,另一組注射生理鹽水並都超過4天。其中一部分在第5天注射納洛酮並在第6天再注射嗎啡或處死以便獲得後根神經分析mRNA。在治療期間老鼠的測試都在熱的盤子上。使用嗎啡超過4天時老鼠對嗎啡產生耐受,爪子在熱盤子上的收回時間由原來基線上的242%降到99%。通過RT-PCR我們證明在使用嗎啡後Mu-阿片類受體mRNA下調至62%P0.05〉。當通過納洛酮立即從Mu-阿片類受體上撤掉嗎啡時,脊髓後根神經的Mu-阿片類受體mRNA24小時內恢復到對照水平,並且爪子收回時間也恢復到基線上的280%。這些資料表明外周神經系統可能是對阿片類藥形成耐受的重要場所。

(朱輝 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.

 

單次靜注5HT3受體拮抗劑樞複寧可以治療神經痛嗎?雙盲,安慰——對照交叉研究

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

神經激肽-1-表達神經元位於脊髓的Ⅲ層,它與傳導興奮的上升和脊髓球路徑密切相關。在動物試驗中,切除了這些神經元就會降低對各種疼痛刺激的反應。此外,在動物中還發現脊髓內應用選擇性5HT3受體拮抗劑Ondansetron可模擬這種作用,提示5HT3受體有預示疼痛的作用並可介與降低興奮刺激以便允許脊髓神經元充分地感應外周的刺激。在這項研究中,我們在神經源性疼痛的人群中單一靜脈注射Ondansetron測定其潛在的鎮痛效果。每個經過同意的研究物件單一靜脈注射8mgOndansetron,然後至少隔開1星期給予安慰劑並在之前48個小時和注射後48個小時記錄疼痛評分。注射Ondansetron2小時疼痛評分顯著降低(但其他時間點沒有)。這項研究表明對於神經源性的疼痛Ondansetron可以達到鎮痛效果,副作用叫小且不多見。

(朱輝 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.

 

過氧化硝酸鹽降低多巴胺的血管收縮性

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


過氧化硝酸鹽(ONOO-1)與多巴胺反應生成一種氧化衍生物。為了研究這種衍生物的血管收縮性,我們進行了一項功能性測試即在白鼠體內分離出的胸主動脈使用多巴胺和ONOO-1SIN-1(能產生ONOO-1)。為排除ONOO-1的直接作用,這段胸主動脈先用亞甲藍即脒基環化酶抑制劑預處理。以多巴胺可引起濃度依賴的血管收縮,而預先用ONOO-1處理過的多巴胺其血管收縮性能明顯降低,且也以ONOO-1濃度依賴的方式降低多巴胺的血管收縮性。預先用ONOO-1處理過的多巴胺其最大的血管收縮性以及50%有效的濃度值都明顯降低。多巴胺與SIN-1混合也可降低其收縮性能,這取決於它們的混合時間。ONOO-1的形成是一個比較快的反應並且當細胞內一氧化氮和過氧化物生成增多時更加容易,如在敗血症引起的休克。這些結果或許至少可部分解釋在敗血症引起的休克病人中使用多巴胺作為血管收縮劑其效果有限。

(朱輝 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.

 

超聲引導鎖骨上臂叢神經阻滯

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名門診病人評估超聲技術應用于鎖骨上臂叢神經阻滯效果。阻滯前通過超聲影像來確定臂叢神經。引導阻滯針到達目標神經,同時可以看見區域麻醉擴散的方式。在注射前通過神經刺激儀來進一步確認針頭位置。我們描述的阻滯技術根據超聲光線來調整針頭路徑。95%的病例都是一次阻滯成功,一次失敗是由於皮下注射,另一次則是部分注入血管。沒有發生氣胸。我們的初步資料提示高解析度超聲探針可以很容易地確定鎖骨下區域的臂叢神經和其臨近結構。進針時的同步引導技術可以迅速地找到神經。在超聲上觀察到的清楚的局麻藥擴散方式可以進一步確認準確的針頭位置。

(殷文淵 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.

 

控制性低血壓和最小膨脹壓:上肢手術中使用充氣式止血帶的一項新技術

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
在四肢手術中我們要求運用最低的膨脹壓以避免因充氣式止血帶的膨脹壓上升而誘發併發症。我們運用控制性降壓和最小膨脹壓(CHAMIP)技術減少手術野出血。36名將要進行上肢末端手術的患者被隨機分為兩組,一組為正常血壓麻醉和正常膨脹壓,另一組為控制性降壓(收縮壓80-100mmHg、平均動脈壓>60mmHg)和最小膨脹壓。麻醉誘導及術中維持用異丙酚靜注和瑞芬太尼持續靜注,為了確定最小膨脹壓,我們將數字式體積描記儀套于患者手術側第二指末端,同時使止血帶緩慢充氣直至動脈搏動消失。幾乎所有患者的手術野出血均減少,即使是在動脈收縮壓和止血帶膨脹壓明顯低的低血壓組也是如此。綜上所述,對於運用充氣式止血帶的上肢末端手術患者CHAMIP是一項安全而可靠的技術

(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.

甘露醇和多巴胺在體外迴圈病人中的作用:一個隨機臨床試驗

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

 

在這個前瞻性、隨機雙盲、安慰劑對照試驗中,我們研究了體外迴圈(CPB)下行冠脈搭橋術中常用的兩種輔助藥(多巴胺和甘露醇)對病人ß2微球蛋白2M)分泌率的影響。 ß2M 分泌率是反映腎臟近曲小管功能的敏感指標。150例術前血清肌酐(CR<=1.5 mg/dL 的病人隨機分為四組: 1)安慰劑組, 2) CPB預充液中加入甘露醇 1 g/kg , 3) 從麻醉誘導開始到CPB1小時持續輸注多巴胺2 µg • kg-1 • min-1 組,4) 甘露醇聯合多巴胺組。主要結果為 CPB1小時測定ß2M 分泌率;其次結果包括:CPB624 h再分別測定ß2M 分泌率; CPB1, 6, 24 h 測定尿量和肌酐清除率;及測定術後CR最高值。ICU滯留時間、住院時間及不良事件也包括在次要結果中; 與安慰劑相比(0.59 ± 1.04 µg/min; P = 0.001),多巴胺顯著增加CPB1 h ß2M 分泌率 (2.48 ± 3.61 µg/min);該結果不因合用甘露醇(與安慰劑相比,ß2M 分泌率, 2.05 ± 2.77 µg/min; P = 0.007)而惡化。在單純使用甘露醇組和安慰劑組ß2M 分泌率相似(P = 0.831)。除了作為CPB中保護性藥的作用外,多巴胺單獨或合用甘露醇還可增加ß2M分泌率。ß2M分泌率增加的臨床意義及在已有腎功能障礙病人CPB中是否會增加的問題還有待進一步研究。結論:在臨床中,ß2M 分泌率增加顯示腎小管損傷。在此CPB研究中多巴胺輸注(單獨或合用甘露醇)導致ß2M分泌率增加。至於這種多巴胺相關的增加是否意味著CPB後腎損傷還不明確,還有待於研究明確該結果的機制和臨床意義。

(費敏譯 薛張綱校)

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.

 

異氟醚誘導的腦電波爆發抑制效應對體外迴圈中腦血流速和腦氧攝取的影響

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

 

我們研究了16例心臟手術病人(32°C輕度低溫芬太尼麻醉非搏動體外迴圈)中異氟醚誘導的腦電(EEG)爆發抑制效應對腦血流速(CBFV)、腦氧攝取(COE)及自身調節的影響。持續監測大腦中動脈經顱多普勒流速、右頸靜脈竇血氧飽和度及頸靜脈壓(JVP)。在使用異氟醚前和使用異氟醚使EEG爆發抑制水平在6–9/min時,應用硝普鈉和新福林誘導平均動脈壓(MAP)變化於40–80 mm,在此變化範圍內檢測腦自身調節。與使用異氟醚前相比,異氟醚引起CBFV降低 27%(P < 0.05)COE 降低13% (P < 0.05);與使用異氟醚前相比,CBFV與腦灌注壓(CPP = MAP - JVP)間的正相關斜率及CPPCOE間的負相關斜率(P < 0.05)較陡(P < 0.05) 。因此,我們認為中度低溫CPB中爆發抑制劑量的異氟醚降低CBFV並影響腦血流的自身調節功能;此外,在異氟醚使用中腦血流相對超過腦氧需,顯示代謝性腦血流自身調節功能喪失。結論:我們研究了異氟醚對作為腦灌注功能指標:腦血流速(CBFV) 及腦氧攝取(COE)的影響,結果顯示芬太尼麻醉中使用異氟醚降低CBFV27%COE13%CBFV更依賴於壓力變化說明腦自身調節功能受損。

(費敏譯 薛張綱校)

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.

 

小兒心臟手術中組織因數啟動的血栓彈力圖:基礎值和比較值

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

 

組織因數(TF)啟動有利於快速評價血栓彈力圖(TEG)但可能改變TEG變數值。我們選擇250<2 yr 的行心臟手術的小兒測定TF啟動的TEG建立TEG的基礎值。然後分別評價5組年齡段(<30 days, 1–3 mo, 3–6 mo, 6–12 mo, and 12–24 mo)的小兒凝血因數缺乏的效應。凝血的啟動(RK值)各組間相似;與其他組相比,1–3 mo小兒的凝血塊的強度增加,該結果與以前無啟動劑TEG的研究結果類似;TF啟動的TEG中特徵性的結果為TEG{alpha}值和最大幅度值在各年齡組間幾乎完全一致;各組間的纖溶結果類似。因此,我們認為,當使用TEG作為治療凝血功能障礙的評價指標及使用特定的TEG啟動劑時,小兒TF啟動的TEG 基礎值可用於臨床評價TEG;此外,各年齡組相似的TEG{alpha}值和最大幅度值更有利於快速解釋TEG結果。結論:已建立的小兒心臟手術中TF啟動的TEG基礎值可用於準確評價和解釋在處理凝血功能障礙時TEG的變化。

(費敏譯 薛張綱校)

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.


利多卡因減弱了人類單核細胞趨化蛋白1的產生及其趨化作用:利多卡因在炎症中可能的機制

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

 

外周血中單核細胞的補充和啟動是控制炎症的關鍵有力的因素。高水準的單核細胞趨化蛋白1(MCP-1)在一些炎症中被報導.在這篇研究中,我們檢測了利多卡因在人單核細胞株THP-1中在脂多糖激發的MCP-1的分泌和MCP-1誘導的趨化作用方面的作用.和抑制信使RNA一樣,利多卡因以劑量依賴方式抑制脂多糖激發的MCP-1的產生.而且,我們證明在THP-1細胞中利多卡因抑制MCP-1誘導的趨化作用和細胞內游離鈣濃度.結果顯示利多卡因在炎症細胞中可以調節MCP-1的產生和由他誘導的啟動作用.

(張俊峰譯 薛張綱校)

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可抑制自然殺傷細胞活性,促進腫瘤轉移,而異丙酚不會:調節機制和預防措施

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


手術後的免疫抑制部分歸咎於麻醉並使患者對感染和腫瘤轉移的抵抗力減弱.我們比較了不同的麻醉劑對自然殺傷細胞活性的作用和對抑制實驗性的轉移的作用並研究了調節機制和預防措施. 我們使用Fischer 344小鼠作為實驗物件,把他們分為對照組,分別用Ketamine,硫噴妥鈉,氟烷和異丙酚麻醉後一小時組.麻醉的小鼠或者保持正常溫度或者自發達到33°C–35°C .接著靜脈注入MADB106腫瘤細胞,24小時後檢測肺部腫瘤細胞,3周以後計數肺部轉移灶.另外麻醉後迴圈中NK細胞的數量和活性也被評估.所有的麻醉藥除了異丙酚都顯著減弱了NK細胞的活性,提高MADB106肺腫瘤細胞的存留和轉移.低溫沒有顯著作用. Ketamine對促進轉移的作用最強,但是這種作用在預先用ß 腎上腺阻製劑(nadolol)或用小劑量的免疫促進劑(polyriboinosinic:polyribocytidylic acid)處理過的小鼠中被減弱.總之,麻醉藥中對NK細胞不同的抑制作用看上去和他們不同的對MADB106肺腫瘤細胞的促進轉移作用有關.預防措施可能包括預先使用免疫促進藥物和ß 腎上腺阻製劑.

(張俊峰譯 薛張綱校)

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和苯巴比妥在體外人類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


巴比妥類藥物對人類血小板的作用還未完全被瞭解.我們設計這個實驗來弄清Thiamylal 和苯巴比妥在人類血小板聚集方面的作用並說明其機制.通過用8通道光傳播的集合度計來測量由二磷酸腺苷,腎上腺素,花生四烯酸(AA), (+)-9,11-epithia-11, 12-methano-thromboxane A2 (STA2)介導的人類血小板聚集來比較使用和未使用Thiamylal 和苯巴比妥的情況.為了評價血小板A2 因數(TXA2)受體親和力, 我們使用[3H]-S145,一種特異的TXA2 受體拮抗劑來做Scatchard 分析. STA2-TXA2受體結合實驗也開展了.通過使用液體閃爍分析儀,我們發現,[3H]-AA 事先孵育過,ADP激發的血小板會釋放花生四烯酸.使用螢光計檢測到fluo-3/AM負荷的血小板中的細胞內游離的鈣離子([Ca2+]i). thiamylal 提高ADP,腎上腺素誘導的血小板聚集而苯巴比妥則抑制這種作用,但是他們都不影響AASTA2誘導的聚集.他們對TXA2受體親和力沒有作用.雖然thiamylal 促進, 苯巴比妥抑制ADP啟動的血小板釋放[3H]-AA ,但他們都對ADP 誘導的細胞內鈣的增加沒有作用.因此,我們認為在體外thiamylal促進,而苯巴比妥抑制血小板的聚集.而巴比妥類的作用通過促進AA的釋放而不是增加細胞內鈣而實現.

(張俊峰譯 薛張綱校)

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.

 

七氟醚的心臟保護效應依賴於蛋白激酶C活化、線粒體 K+ATP通道開放以及反應性氧分子的生成

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臟保護效應依賴於蛋白激酶CPKC)活化、線粒體 K+ATP通道開放以及反應性氧分子(ROS)的生成。但是,它們的依據來自各自獨立的實驗模型。本文,我們研究在七氟醚產生心肌保護的同一模型中PKC、線粒體K+ATPROS三者的相互作用。經60分鐘的再灌注後,大鼠小梁受含NaCN的緩衝液致缺血的代謝抑制(MI)影響。活性強度(Fa)的恢復用MI前強度的百分比來評估。時間控制,到實驗結束Fa60% ± 5%MIFa恢復降至28% ± 5%P = 0.045較時間控制),而七氟醚可逆轉MI的有害作用(Fa 恢復, 67% ± 8%; P = 0.01 MI)PKC抑制劑白屈菜赤堿、線粒體 K+ATP抑制劑5-羥基葵烷、ROS清除劑N-(2-巰基丙酰)-氨基乙酸能完全去處七氟醚的保護效應(Fa恢復分別為白屈菜赤堿31% ± 8%5-羥基葵烷33% ± 8%N-(2-巰基丙酰)-氨基乙酸24% ± 9%)。結論:PKC活化、線粒體 K+ATP通道開放以及ROS生成是七氟醚心臟保護效應的實質所在。這些信號事件是一個共同信號通路的連續反應而非平行。我們的發現提示圍術期應用七氟醚保護心臟功能是通過預防缺血-再灌注損傷。

(張俊峰譯 薛張綱校)

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/芬太尼麻醉誘導後早期吲哚菁綠指示血漿容量可能存在估計過高

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

吲哚菁綠(PV-ICG)指示的大量血漿容量在麻醉誘導後的初始階段已經決定了。本研究檢驗如下假設: PV-ICG的過高估計發生在麻醉誘導早期。13名患者麻醉誘導採用芬太尼藥團2 µg/kg和丙泊酚0.5 mg • kg-1 • min-1 IV至患者意識消失並用丙泊酚維持輸注。PV-ICG和葡萄糖初始分佈容量(IDVG)的測定在麻醉誘導前15分鐘和誘導後15分鐘。血漿ICG和葡萄糖濃度通過連續血樣本採集在輸注ICG 25 mg 、葡萄糖5 g之前和之後7分鐘。PV-ICG IDVG通過一室模型計算。PV-ICG在誘導後有顯著升高平均為15.3%,從2.29 ± 0.38 (SD) L2.64 ± 0.31 L (P < 0.001)。平均紅細胞壓積(Hct)、血紅蛋白(Hb)濃度以及全血漿蛋白誘導後較誘導前各自下降2.9%2.2%2.3%(P < 0.05)。通過HbHct計算得的血漿容量百分比增加誘導前後為4%。因此,PV-ICG高估了11%IDVG無改變。所以,PV-ICG/IDVG從誘導前的0.40 ± 0.05增加到誘導後的0.48 ± 0.06(P < 0.01)。這些結果有效說明了假設PV-ICG在丙泊酚麻醉誘導後的一段時間內可能存在過高估計。現在的結果也支持PV-ICG/IDVG可衡量PV-ICG高估或液體從中央到周圍組織的再分佈。

(方芳譯 薛張綱校)

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.

 

人聽覺穩定狀態反應:錄音技術效應和覺醒狀態

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

 

聽覺穩定狀態反應(ASSRs)能在所有狀況下被可靠記錄還是這些反應在睡意中持續大幅減低在文獻報導中存在爭議。在10個專案中,40-Hz ASSRs能從腦電圖活躍的背景中顯著地區分開其概率為P < 0.01平均時間22 s (範圍2–92 s),倘若這些反應分析經時間-領域較光譜更平均。在另外10個項目的實驗中,在頭頂和頸後之間40-Hz ASSRs記錄在睡意和睡眠中持續大幅降低。研究發現ASSR在睡意中偶有增加可以用以乳突為標記的耳後肌肉反應來解釋。這些可能在睡意中發生與動眼運動相關。ASSRs記錄在頭頂和頸後間的反應不會被這些現象所扭曲。這些發現與以往ASSR對全麻影響的文獻可以認為ASSR是監測全麻催眠效應的有效選擇。

(方芳譯 薛張綱校)

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.

 

椎管構造有利於鎮痛的方面——應用蘇芬太尼、布比卡因混合液行術後鎮痛

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

.

脂溶性阿片樣藥物當單獨應用於硬膜外時通常被認為是通過系統吸收經脊髓以上的機制產生鎮痛作用。然而在動物試驗中發現椎管內阿片樣藥物與局麻藥在脊髓水平產生協同作用。因此,我們驗證了如下假設:重大腹部手術後若同時硬膜外應用布比卡因蘇芬太尼的用量將比單純靜脈給藥減少。40位病人予全麻(異氟醚吸入)聯合硬膜外(布比卡因)麻醉下行腹部外科手術。術後每位患者均給予硬膜外持續輸注布比卡因5mg/h以及蘇芬太尼PCA(患者自控鎮痛)。根據隨機、雙盲的模式,蘇芬太尼或是硬膜外或是靜脈給藥。各組中PCA的設置相同。在術後60小時內測量以下變數:休息時、運動時、咳嗽時的疼痛評分;感覺阻滯範圍;副反應;蘇芬太尼用量。疼痛評分、感覺阻滯、副反應事件兩組並無差別,而蘇芬太尼用量硬膜外組卻是靜脈組的一半(術後48小時:硬膜外組107+-57ug、靜脈組207+-100ugP<0.05)。因此認為,椎管構造有利於硬膜外應用蘇芬太尼及布比卡因的鎮痛。

(方芳譯 薛張綱校)

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嗎啡來達到相近的止痛效果

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

疼痛感知及對阿片類藥物反應的性別差異經常被報導,但這些結果並不一致。我們探求了性別對於疼痛感知、嗎啡用量、術後嗎啡止痛的影響。我們設計了一項包括423位女性和277位男性的預期群體性研究,這些受試者均為全麻下外科手術後患者並且疼痛強>=5(應用010的數位分級表,即NRS)。我們予以嗎啡靜注2.5mg/10min直至疼痛強度<=4。病人每10分鐘對疼痛強度進行NRS評分並對疼痛減輕程度以5 Likert表進行評分。在對手術類型及年齡進行調整後,我們發現女性比男性疼痛感知更加強烈、嗎啡用量更多,NRS疼痛強度評分的差異為0.4U95%可信區間,0.1-0.6U)。女性嗎啡需要量比男性多0.03mg/kg95%可信區間,0.02-0.04 mg/kg)。因而總結認為相對於男性而言,女性有更強列的疼痛感知並且需要多出30%的嗎啡用量來達到相同的止痛效果。臨床醫生應當預見到女性病人對阿片類藥物需量的不同,避免疼痛方面的處理不足。

(方芳譯 薛張綱校)

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.

 

心電圖自動測量記錄儀在社區醫院綜合性監護中的應用及效力

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

 

此項研究的目的是為了確定當系統的應用心電圖嚴格的使用標準時,是否即時記錄事件發生率在有指征病人與無指征病人中有所不同。我們於200011日至2000331日在1097位元可行即時記錄的受試者中進行了一項群體回顧性研究。常規選舉21位病人進行236項即時監測。有指征者的400天即時監測內共監測到162次心律失常。而無指征者345天即時監測中共監測到9次心律失常。兩組的心律失常事件相關率明顯不同(P<0.0001)。結果顯示當前對心電圖即時記錄使用並非最佳,並且應當進行應用心電圖即時記錄嚴格指征的預期分析。

(鍾鳴譯 薛張綱校)

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.

 

小豬急性肺動脈高壓模型中間斷吸入一氧化氮聯合靜脈內注射雙嘧達莫

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)作為有效的選擇性肺動脈擴張劑而被廣泛使用於連續吸入。我們已經評價了靜脈內給予雙嘧達莫,一種環單磷酸鳥苷酸(cGMP)磷酸二酯酶抑制劑,對於吸入一氧化氮擴張肺動脈血管作用的程度和持久度的影響。我們假設cGMP降解作用的抑制能夠放大和延長NO對肺血管的擴張作用,並使NO的吸入間斷。給八隻麻醉並機械通氣的小豬靜脈注射U46619,一種凝血噁烷A2類似物,以誘導出肺動脈高壓模型。NO2510ppm的濃度各吸入4分鐘,每種濃度吸入後間隔10分鐘的無NO期,分別評價不予和給予雙嘧達莫時各濃度的作用。肺血管阻力從825/49dynes.s.cm-5(U-46619)分別降至533/48 dynes.s.cm-510ppm)(P<0.05比較U-46619),和396/42 dynes.s.cm-5(雙嘧達莫10mg/kg.min10ppmNO)(P<0.05比較NO),心輸出量從1.93+/- 0.09 L/min升高到2.03 +/- 0.13 L/min2.60 +/- 0.30 L/minP<0.05比較NO)。平均動脈壓從90 +/- 5 mm Hg (10 ppm NO)降至75 +/- 3 mm Hg(雙嘧達莫加上10ppmNO)(P<0.01)。當吸入NO聯合靜脈內注射雙嘧達莫後肺血管的擴張作用比單用NO延長了1242分鐘,使時間加權的NO暴露減少了72%。我們得出結論,雙嘧達莫增大了NO對右心室後負荷的作用,使得NO吸入可以間斷,並能明顯減少NO的暴露。

(鍾鳴譯 薛張綱校)

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內給藥鎮痛時間的減少

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

 

在此前臨床經驗的基礎上,我們在該研究中假設,濫用可卡因的臨產病人相比無可卡因濫用的病人,鞘內給予舒芬太尼產生的鎮痛時間要短,而且(或)鎮痛的效果要差。作為脊-硬聯合(CSE)技術的一部分,我們給兩組分娩病人鞘內注射舒芬太尼10mg,第一組是尿檢可卡因陽性者(可卡因組),第二組是尿檢可卡因陰性組(對照組)。病人要求額外的鎮痛時,硬膜外導管內才予注射局麻藥。從鞘內注射舒芬太尼到病人要求額外鎮痛的時間被定義位鎮痛時間。在CSE之前測量可視的類似疼痛評分(VAPS)的基線和宮口擴張程度。鞘內注射舒芬太尼後,定時記錄VAPS。當病人再次要求鎮痛時,記錄宮口擴張的情況。我們發現兩組病人VAPS基線都很高,在注射舒芬太尼後VAPS顯著下降,且兩組間沒有差別。經宮口擴張程度調整後的鎮痛時間的幾何均數在可卡因組是87秒,在對照組中是139秒(P=0.019)。所有病人都有騷癢感。我們得出結論,濫用可卡因的臨產病人相比無可卡因濫用者,鞘內給予舒芬太尼能產生類似的鎮痛質量,但鎮痛時間縮短了。

(鍾鳴譯 薛張綱校)

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.

 

超聲引導加快了鎖骨上阻滯的操作的速度和提高了阻滯質量

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

在該前瞻性研究中,我們比較了採用超聲引導和神經刺激器進行鎖骨上臂叢神經阻滯的方法和採用傳統的解剖標誌和神經刺激器的鎖骨上阻滯技術,評價兩者的質量、安全性和操作時間。我們假設超聲引導能增加成功阻滯的比例,減少操作時間,減少氣胸和神經損傷等併發症的發生。八位病人被隨機分成兩組,US組(通過二維超聲圖像即時引導的鎖骨上阻滯,神經刺激器確定相關針頭的位置)和NS組(採用鎖骨上血管旁入路的鎖骨上阻滯,同樣使用神經刺激器確定針頭位置)。阻滯藥物使用0.5%的布比卡因、2%的利多卡因(容量11)和1200000的去甲腎上腺素的混合藥物。在30分鐘的時間內評估肌皮神經、正中神經、橈神經和尺神經的運動和感覺阻滯的起效。在30分鐘時,US95%和NS85%的病人的所有神經支配區域都產生了部分或完全的感覺阻滯(P=0.13),US55%和NS65%的病人在所有神經支配區域產生了完全的阻滯(P=0.25)。US85%和NS78%的病人無需追加即獲得滿意的麻醉效果(P=0.28)。US組中無病人需全麻,而NS8%的病人需全麻(P=0.12)。NS組尺神經的阻滯效果明顯差於其他神經的阻滯效果,在US組中無該情況;NS組和US組間尺神經的阻滯效果無顯著差異。阻滯所用平均時間在NS組和US組分別位9.8分鐘和5分鐘(P=0.0001)。兩組中均未出現明顯的併發症。我們得出結論,相比採用解剖標誌和神經刺激器的鎖骨上阻滯而言,超聲引導神經刺激器確認的鎖骨上阻滯操作更迅速,阻滯效果更完全。

(鍾鳴譯 薛張綱校)

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.

 

異丙酚可減少由再灌注引起的豚鼠正常和缺血-再灌注之間邊緣區的心侓失常

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

本文於體外研究異丙酚在缺血及再灌注中引發心不齊(如自發心率不齊、傳導阻滯、複極離散度)相關的機制。在一個雙浴槽中,在改變區(AZ)的豚鼠右室肌束缺血30分鐘,再灌注30分鐘。在正常區(NZ)則常規灌注。記錄兩區的動作電位(AP)參數。研究10-6, 10-5,2 x 10-5 M濃度下英脫利匹特和異丙酚對自發持續節律異常,傳導阻滯和複極離散度的影響。在正常區,英脫利匹特和異丙酚沒有明顯影響各種動作電位的參數。異丙酚能削弱由缺血導致的動作電位時程的縮短,它主要影響複極90%APD90)的時間。而英脫利匹特無此作用。異丙酚還能減弱邊緣區動作電位離散度。異丙酚對由缺血引起的心率失常無作用。 10-6 M的異丙酚能降低由缺血引發的傳導阻滯的發生。異丙酚可減少由再灌注引起的自發節律異常的發生。結論:在體外實驗中,異丙酚能縮小缺血引起邊緣區APD90 離散,也能減少再灌注損傷導致的心肌自發節律異常。

趙雪蓮 莊心良

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.

 

兒童先心病手術中經食道心超的應用:兩個中心的觀察研究

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

 

在兒童心臟手術中,經食道心超(TEE)是一種監測和診斷工具。從1994-2002年,對865例行先心病手術的患者(年齡小於17歲)常規應用經食道心超進行分析。患者平均年齡36個月(1-16歲)。第一個研究終點是外科和醫療管理決定因TEE結果改變的比率。第二個研究終點是診斷影響(排除舊診斷,建立新診斷)和手術結果。50%的檢查由經高級培訓的麻醉醫師進行。所有檢查操作者都有大於500TEE操作的經驗。36.7%的病例要求高水準的麻醉醫師監督。3.8%的病例要求外科醫師監督。12.7%的病例要求變更手術術式,其中包括7.3%需再轉流。19.4%需改變醫療管理。作者觀察18.5%的病例TEE的診斷影響和27.6%病例的亞優但可接受的手術結果。4.0%病例TEE預術後困難。研究結果證實常規TEE在評估治療先心病中的有效性。而且,本次研究由受過TEE培訓的固定的心外麻醉醫師執行。結論:在兒童心臟手術中,經食道心超(TEE)是一種必要的監測和診斷工具。TEE的手術和醫療影響在大宗病例研究中得到證實。這種措施可由得到合適培訓的心外麻醉醫師承擔。

(趙雪蓮 莊心良 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.

 

小劑量氯胺酮預處理可以減少兒童與注射羅庫溴銨有關的撤退運動

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

.

我們評價預處理小劑量氯胺酮對注射羅庫溴銨引起的撤退運動的影響。100例兒童(年齡1-6歲,)隨機分為2組。手背靜脈置入22號靜脈針,分別注射氯胺酮0.2 mg/kg 或生理鹽水,隨後注射硫賁妥鈉5 mg/kg 5秒後注射羅庫溴銨0.8 mg/kg 。用4點評分法評價注射羅庫溴銨引起的撤退運動。生理鹽水和氯胺酮組病人發生撤退運動的比率分別是83%27%。二組病人均有注射部位出現紅斑的情況發生。結論:氯胺酮預處理顯著減輕硫賁妥鈉患兒注射羅庫溴銨引起的撤退運動。

(王士雷 莊心良 )

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.

 

利多卡因和辛醇對外周神經TTX不敏感鈉通道有不同的作用

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.

局部麻醉藥和乙醇阻斷鈉電流而阻斷外周神經的衝動傳導。在小的外周神經纖維,TTX不敏感鈉通道在衝動的產生中起著重要的作用。我們研究了利多卡因和辛醇對TTX不敏感鈉通道的作用。分離背根神經節,以全細胞膜片鉗的方式記錄鈉電流。利多卡因和辛醇均以劑量依賴性的可逆性的阻斷鈉電流。利多卡因的阻斷作用還呈現應用依賴性的特點。二者也呈現強烈的動力學阻斷特點。雙衝動模式顯示利多卡因的作用在複極化時從通道慢性分離的特點。利多卡因和辛醇對鈉通道的作用是非競爭性的。結論:利多卡因和辛醇對鈉通道的阻滯作用的特點不同,二者在通道的結合部位是不同的。

(王士雷 莊心良 )

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.

 

一個手術和麻醉的動物模型:特點是異氟烷麻醉和雷米芬太尼鎮痛

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

 

單獨使用傳統的“鉗夾試驗”對手術的麻醉/鎮痛水平進行定量評價並不容易並不容易。我們開發了一個兔子模型,既使用機械又使用電刺激模擬手術刺激,從而可以對不同水平的手術麻醉/鎮痛進行重複的定量的評價。在異氟烷麻醉下氣管切開和血管內插管後,8只兔子被放置在吊帶上使得頭部和四肢可以自由活動。。將吸入異氟烷濃度從3%降到1.5%,再降到0%。同時按照4個級別的輸注速率靜脈注射雷米芬太尼(0.1–0.8 µg • kg-1 min-1)。每個劑量下通過觀察對鉗夾前肢無反應的動物數(無反應數)和記錄引發動物抬頭反應(HLT,痛覺感知/覺醒閾值)和動物逃跑運動反應(EMT,疼痛忍耐閾值)的皮下電刺激(2Hz5Hz50Hz)電壓閾值確定鎮痛參數。藥物劑量增加時HLT5Hz時的EMT呈劑量依賴性增加,而且絕大多數都與無反應數成比例,後者是標準的麻醉/鎮痛指標。所以使用5Hz時的HLTEMT並結合鉗夾試驗,本實驗之兔動物模型可以對不同水平的手術麻醉/鎮痛進行量化的評價。

(顏濤譯 莊心良校)

 

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.

 

靜脈注射潘妥拉唑和雷尼替丁改善行擇期手術病人術前胃內液體特性的效果

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

 

我們研究了新的快速起效的質子泵抑制劑潘妥拉唑。該藥對術前胃內液體的容積和PH值的影響仍未確定。在這個隨機對照的研究中,我們檢驗了術前靜脈注射潘妥拉唑或雷尼替丁對胃內容量和PH值的影響。研究了90例病人(ASA Ⅰ級和Ⅱ級,行擇期手術)。在手術前1小時,組Ⅰ病人(n=30)靜脈注射生理鹽水5ml,組Ⅱ病人(n=30)靜脈注射潘妥拉唑50mg,組Ⅲ病人(n=30)靜脈注射雷尼替丁50mg。在麻醉誘導後即刻插入鼻胃管,吸取胃內容物,記錄量和PH值。組ⅠPH值為3.73± 0.82,組Ⅱ為5.30 ± 1.84,組III4.80 ± 1.40。組Ⅱ和組Ⅲ間無統計學差異,但是在組Ⅰ和組Ⅱ及組Ⅲ間有統計學差異(P < 0.0005)。組Ⅰ胃內容物容積為28.67 ± 10.98 mL,組Ⅱ為15.20 ± 15.52 mL,組Ⅲ為7.77 ± 11.17 mL。在組2和組3間沒有統計學差異,但是在組1和組2及組3之間有統計學顯著差異(P < 0.0005)。各組病人在誤吸時具有發生嚴重肺損傷危險的病人比例在組Ⅰ、組Ⅱ和組Ⅲ分別為20%10%3.3%。經過統計學評估,在各組之間沒有差異。我們的結論是,術前1小時靜脈注射潘妥拉唑和雷尼替丁能有效減少胃內容物PH值和容積。

(顏濤譯 莊心良校)

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.

 

單次劑量地塞米松對大鼠傷口癒合的影響

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

 

在成人和小兒地塞米松可有效地減少噁心嘔吐的發生率。本次實驗採用前瞻隨機實驗動物模型評價了單次劑量地塞米松對傷口癒合的影響。麻醉採用100 mg/kg硫噴妥鈉腹膜內注射誘導。地塞米松組用1 mg/kg地塞米松腹膜內注射,對照組用生理鹽水。膠原化、上皮化和成纖維細胞含量在地塞米松組均顯著減少(p值分別為:0.0020.0410.023)。血管分佈和炎症細胞在地塞米松組均明顯增多(p值分別為:0.0230.002)。白細胞計數兩組相似,對照組:7.84 ± 2.09,地塞米松組:6.98 ± 2.12。平均羥基脯氨酸水平分別為:地塞米松組0.72 ± 0.13 mg/g,少於對照組1.03 ± 0.19 mg/gp=0.001)。結論:1 mg/kg地塞米松對傷口癒合有不利影響。

(唐俊 莊心良 )

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.

 

一種高仿真模擬器的心血管圖形化顯示的評估

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“人為錯誤”可歸結于對病人監護中的誤解或醫師對狀況的認識失誤。圖形化顯示監護資料可能更有利於發現、診斷和治療。作者設計了一種血液動力學的圖形化顯示方法。20位麻醉醫師被要求假定監護一個模擬病人。一半的參加者使用圖形化心血管顯示,另一半使用Datex As/3監護儀。第一個場景設為全髖置換術中錯誤血型輸血後反應。第二個場景為根治性前列腺切除術中失血1.5L併發心肌梗塞。使用圖形化顯示的實驗物件發現心肌梗塞比為使用者快2分鐘。開始治療也更為迅速(2.54.9分鐘)。而髖關節置換術場景兩組間沒有明顯差異。應用圖形化顯示組在病例結束時,相對於基礎值收縮壓較小,中心靜脈壓接近,動脈氧飽和度升高。結論:本實驗對以下假說提供了支援:將臨床資訊圖形化顯示,並結合緊急特點和功能的關聯性設計,可提高臨床醫師在模擬環境中發現、診斷、管理和治療臨床心血管事件的能力。

(唐俊 莊心良 )

"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.

 

人硬膜外應用芬太尼的作用部位:輸注與單次注射的差異

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:以單次法注射給藥的大多數研究提示硬膜外應用芬太尼的主要作用部位是脊髓,而以輸注法給藥的研究則認為是脊髓上部位。本研究試圖驗證硬膜外應用芬太尼的模式(單次或輸注)決定其作用部位的假說。方法:10名健康志願者參加了這一隨機對照交替試驗。在不同的試驗日,芬太尼分別以團塊法注射(0.03mg,然後每210分鐘給0.1mg),或者連續輸注(0.03mg210分鐘後繼以0.1mg/h輸注200分鐘)。使用溫度和電疼痛實驗模型,在實驗的420分鐘內,重複評估導致可忍受的最大疼痛溫度(℃)和電流(mA)。鎮痛效果在一個腰部節段和一頭部節段進行測量。整個實驗期間測定血漿芬太尼濃度。硬膜外單次法注射芬太尼導致節段性鎮痛(腿部優於頭部),而硬膜外連續輸注的鎮痛效果沒有差異(腿部等於頭部)。在硬膜外輸注組血漿芬太尼濃度與鎮痛效果間有顯著的線性相關,而單次法組則沒有。結論:硬膜外單次法注射芬太尼產生節段性的鎮痛效果,而連續輸注導致系統性的鎮痛,這一發現支持本試驗的假說,可用以解釋硬膜外應用芬太尼作用位元點的文獻上的爭議。

(唐俊 莊心良 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.

 

鞘膜內嗎啡用於術後鎮痛:髖或膝關節成形術中的隨機對照劑量對比研究

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:本試驗檢驗鞘內0.0-0.3mg範圍內硫酸嗎啡(ITMS)用於髖或膝關節成形術後的鎮痛效果和副作用。方法:進行髖關節或膝關節手術的病人各四十名,隨機接受ITMS0.00.10.20.3mg)。病人自控鎮痛(PCA)裝置對鎮痛要求提供額外支援。嗎啡用量、疼痛緩解程度和副作用記錄24小時。資料用方差分析和線性回歸分析處理。結果:髖關節手術後,接受不同劑量ITMS者的嗎啡用藥量均明顯少於對照組(p<0.05)。膝關節手術後,ITMS並不減少術後的嗎啡需求量。噁心嘔吐和氧飽和度下降(<93%)的發生率各組相似。給與ITMS者的搔癢發生更多。在髖或膝關節手術後,接受0.20.3mg ITMS的病人疼痛控制的滿意度均優於0.000.1mg組。結論:結合使用小劑量(0.2mgITMSPCA給予嗎啡可對大多數全髖或膝關節成形術的病人提供良好的疼痛控制。然而,PCA嗎啡用量僅在髖關節手術因使用ITMS而減少。

(唐俊 莊心良 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.

 

耳穴電針刺激較傳統的機械壓迫刺激對痛有更好的治療作用

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

 

本研究驗證一個假說,即耳穴電刺激較機械刺激更能減輕疼痛。以21例沒有神經根壓迫症狀,且用標準的鎮痛方式效果不理想的慢性頸痛患者為研究物件。主要的穴位進:頸椎穴 腎門和庫深。其中10例用電針,11例不用電刺激。所有針在48小時內拔出。每週一次,共6次。病人需完成關於疼痛程度 精神狀態 睡眠和用其他藥物治療的調查問卷。結果,電針刺激組病人疼痛顯著減輕,精神表現 睡眠也顯著改善,應用其他鎮痛藥物的病人也顯著少。結論:用P-STIMT持續耳穴電針刺激可以改善慢性頸部疼痛的治療效果。

(王士雷 莊心良 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.

 

矽酮強化的半球形斜口導管減少經鼻氣管插管的併發症

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

.

我們檢驗一個假說,即在經鼻氣管插管時,矽酮強化的半球形斜口氣管導管較傳統的預先彎曲的PVC管的併發症少。80例經鼻氣管插管的扁桃體切除病人,隨機分為二組,分別應用上述導管。插管分為3個階段:1)從鼻到咽;2)喉鏡引導至聲門入口;3)喉鏡引導進入氣管。如果某個階段不能順利進行,則用特殊的方式輔助通氣。結果,所有病人均插管成功。矽酮導管組病人咽和氣管階段插入的數量相同,但過聲門的數量則顯著多。鼻出血的數量和嚴重程度均較輕。矽酮管術後總的鼻症狀的數量少。結論:矽酮管在插入咽和氣管內的數量較PVC管少,但聲門的試圖插入次數較多。矽酮管術後鼻的發病率低。

 

(王士雷 莊心良 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時的相對運動阻滯特性

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.

最小的局麻藥濃度被用來研究布比卡因及其左旋體的硬膜外鎮痛特性。沒有研究比較這兩種藥物的運動阻滯特性。本研究比較二者運動阻滯的最小濃度和比率。60例病人隨機分組。每組第一個病人接受0.25% wt/vol 。隨後濃度以0.025% wt/vol遞增。在30分鐘內Bromage score <4 被認為是有效的運動阻斷。用Dixon and Massey方法進行統計處理。布比卡因運動阻滯的最小濃度是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)。結論:布比卡因的左旋體較右旋體運動阻滯的效能低。

(王士雷 莊心良 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.