Anesthesia & Analgesia

December 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

肺癌手术后急性肺损伤的危险因素

(王士雷 译 庄心良 校)

Risk Factors for Acute Lung Injury After Thoracic Surgery for Lung Cancer

Marc Licker, Marc de Perrot, Anastase Spiliopoulos, John Robert, John Diaper, Catherine Chevalley, and Jean-Marie Tschopp

Anesth Analg 2003 97: 1558-1565.

 

胸主动脉瘤血管内修补术术中经食管超声心动图的重要性

(钟鸣 薛张纲 )

The Importance of Intraoperative Transesophageal Echocardiography in Endovascular Repair of Thoracic Aortic Aneurysms

Madhav Swaminathan, Catherine K. Lineberger, Richard L. McCann, and Joseph P. Mathew

Anesth Analg 2003 97: 1566-1572.

 

地氟醚和丙泊酚对门高压病人门体静脉压力的影响

(殷文渊 译 王祥瑞 校)

The Effects of Desflurane and Propofol on Portosystemic Pressure in Patients with Portal Hypertension

M. Susan Mandell, Janette Durham, David Kumpe, James F. Trotter, Gregory T. Everson, and Claus U. Niemann

Anesth Analg 2003 97: 1573-1577.

比较二种不同红细胞洗涤方法时红细胞的恢复情况

(王士雷 译 庄心良 校)

A Comparison of Red Cell Recovery Between Two Different Methods of Red Cell Washing

Jonathan H. Waters, Paul Potter, and Donna F. Hobson

Anesth Analg 2003 97: 1578-1581.

 

老年体外循环心脏手术中的肾特异性蛋白

(钟鸣 译 薛张纲 校)

Kidney-Specific Proteins in Elderly Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

Joachim Boldt, Torsten Brenner, Johannes Lang, Bernhard Kumle, and Frank Isgro

Anesth Analg 2003 97: 1582-1589.

 

醋酸林格氏液的快速水排泄和缓慢钠排泄作用使细胞脱水

(殷文渊 译 王祥瑞 校)

Rapid Water and Slow Sodium Excretion of Acetated Ringer’s Solution Dehydrates Cells

Robert G. Hahn and Dan Drobin

Anesth Analg 2003 97: 1590-1594.

血管容量替代治疗策略的新启发:我们过去三年中学到了什么?

(王士雷 译 庄心良 校)

New Light on Intravascular Volume Replacement Regimens: What Did We Learn from the Past Three Years?

Joachim Boldt

Anesth Analg 2003 97: 1595-1604.

 

PEDIATRIC ANESTHESIA:

病人自控硬膜外镇痛与持续硬膜外腔注射布比卡因镇痛在小儿术后镇痛应用的比较

(齐波 译 王祥瑞 校)

Patient-Controlled Epidural Analgesia Versus Continuous Epidural Infusion with Ropivacaine for Postoperative Analgesia in Children

Emmanuel Antok, Fabienne Bordet, Frédéric Duflo, Sabine Lansiaux, Sylvie Combet, Patricia Taylor, Agnes Pouyau, Brigitte Paturel, Robert James, Bernard Allaouchiche, and Dominique Chassard

Anesth Analg 2003 97: 1608-1611.

小儿气管内插管的套囊压力是不可预测

(王士雷 庄心良 校)

Endotracheal Tube Cuff Pressure Is Unpredictable in Children

Marie-Louise Felten, Emmanuelle Schmautz, Sonia Delaporte-Cerceau, Gilles A. Orliaguet, and Pierre A. Carli

Anesth Analg 2003 97: 1612-1616.

AMBULATORY ANESTHESIA:

 

择期肩部手术术前斜角肌间神经阻滞:病人出院后在术后早期过后益处消失

(钟鸣 译 薛张纲 校)

Preoperative Interscalene Block for Elective Shoulder Surgery: Loss of Benefit over Early Postoperative Block After Patient Discharge to Home

W. Heinrich Wurm, Mercedes Concepcion, Andrew Sternlicht, Jean Marie Carabuena, Gary Robelen, Leonidas C. Goudas, Scott A. Strassels, and Daniel B. Carr

Anesth Analg 2003 97: 1620-1626.

 

切皮前治疗防止滑动疝术后疼痛

(陆旭伟 译 薛张纲 校)

Preincisional Treatment to Prevent Pain After Ambulatory Hernia Surgery

D. Janet Pavlin, Karen D. Horvath, Edward G. Pavlin, and Kristien Sima

Anesth Analg 2003 97: 1627-1632.

 

日间手术使用艾司洛尔和尼卡地平对术后恢复的影响

(肖洁 译 王祥瑞 校)

The Effect of Intraoperative Use of Esmolol and Nicardipine on Recovery After Ambulatory Surgery

Paul F. White, Baoguo Wang, Jun Tang, Ronald H. Wender, Robert Naruse, and Alexander Sloninsky

Anesth Analg 2003 97: 1633-1638.

ANESTHETIC PHARMACOLOGY:

异丙酚调节原位大鼠肠系膜血管平滑肌超极化的机制

(王士雷 庄心良 校)

The Mechanisms of Propofol-Mediated Hyperpolarization of In Situ Rat Mesenteric Vascular Smooth Muscle

Tamotsu Nagakawa, Mitsuaki Yamazaki, Noboru Hatakeyama, and Thomas A. Stekiel

Anesth Analg 2003 97: 1639-1645.

 

丙泊酚-利多卡因混合液的理化兼容性

(陆旭伟 译 薛张纲 校)

Physicochemical Compatibility of Propofol-Lidocaine Mixture

Yoko Masaki, Makoto Tanaka, and Toshiaki Nishikawa

Anesth Analg 2003 97: 1646-1651.

 

硬膜外或全身麻醉使用止吐药可引起瞳孔反射性扩张

(肖洁 译  王祥瑞 校)

The Effect of Antiemetics on Pupillary Reflex Dilation During Epidural/General Anesthesia

Merlin D. Larson

Anesth Analg 2003 97: 1652-1656.

全膝关节成形术用骨粘固粉引起血浆星形胶质细胞S-100B蛋白升高

(王士雷 庄心良 校)

The Use of Bone Cement Induces an Increase in Serum Astroglial S-100B Protein in Patients Undergoing Total Knee Arthroplasty

Hiroyuki Kinoshita, Hiroshi Iranami, Keisuke Fujii, Akinori Yamazaki, Manabu Shimogai, Katsutoshi Nakahata, Yasuo Hironaka, and Yoshio Hatano

Anesth Analg 2003 97: 1657-1660.

TECHNOLOGY, COMPUTING, AND SIMULATION:

 

全麻后恢复期脑电监护的作用:听觉诱发电位及双频谱指数仪在标准临床实践中的比较

(陆旭伟 译 薛张纲 校)

The Effect of Cerebral Monitoring on Recovery After General Anesthesia: A Comparison of the Auditory Evoked Potential and Bispectral Index Devices with Standard Clinical Practice

Alejandro Recart, Irina Gasanova, Paul F. White, Tojo Thomas, Babatunde Ogunnaike, Mohammed Hamza, and Agnes Wang

Anesth Analg 2003 97: 1667-1674.

经颅多普勒监测用于腹腔镜下腰椎融合术

(朱慧琛 译 王祥瑞 校)

Transcranial Doppler Monitoring During Laparoscopic Anterior Lumbar Interbody Fusion

Maria J. Colomina, Carmen Godet, Ferran Pellisé, Joan Bagó, and Carlos Villanueva

Anesth Analg 2003 97: 1675-1679.

 

闭合环路PhysioFlex Deltatrac II 间接测量仪测量氧耗的研究

(王士雷 庄心良 校)

Oxygen Consumption Measurement: Agreement Between the Closed-Circuit PhysioFlex Anesthesia Machine and the Deltatrac II Indirect Calorimeter

Antonio González-Arévalo, Juan I. Gómez-Arnau, Javier delaCruz, Felix Lacoma, Pedro Galdos, and Santiago García-del-Valle

Anesth Analg 2003 97: 1680-1685.

PAIN MEDICINE:

 

老年患者行髋关节成形术时鞘内吗啡剂量的优化

(陆旭伟 译 薛张纲 校)

Optimizing the Dose of Intrathecal Morphine in Older Patients Undergoing Hip Arthroplasty

P. M. Murphy, D. Stack, B. Kinirons, and J. G. Laffey

Anesth Analg 2003 97: 1709-1715.

 

硬膜外腔注入透明质酸后的神经毒性反应:光学和电子显微镜检测

(朱慧琛 译 王祥瑞 校)

The Neurotoxicity of Epidural Hyaluronic Acid in Rabbits: A Light and Electron Microscopic Examination

Young-Jin Lim, Woo-Seok Sim, Yong-Chul Kim, Sang-Chul Lee, and Yoon-La Choi

Anesth Analg 2003 97: 1716-1720.

 

二氢可待因和布洛芬间的镇痛作用是协同的

(王士雷 译 庄心良 校

The Synergistic Analgesic Interactions Between Hydrocodone and Ibuprofen

Yuri A. Kolesnikov, Roger S. Wilson, and Gavril W. Pasternak

Anesth Analg 2003 97: 1721-1723.

 

黄芩甙在爱兰苔胶引起的热痛觉过敏中的抗炎和镇痛作用

(方芳 译 薛张纲 校)

The Antiinflammatory and Analgesic Effects of Baicalin in Carrageenan-Evoked Thermal Hyperalgesia

Tz-Chong Chou, Li-Ping Chang, Chi-Yuan Li, Chih-Shung Wong, and Shih-Ping Yang

Anesth Analg 2003 97: 1724-1729.

CRITICAL CARE AND TRAUMA:

适应性支持通气的自动“呼吸和脱机”:对气管内插管时间和病人管理的影响

(王士雷 庄心良 校)

Automatic "Respirator/Weaning" with Adaptive Support Ventilation: The Effect on Duration of Endotracheal Intubation and Patient Management

Alexander H. Petter, René L. Chioléro, Tiziano Cassina, Pierre-Guy Chassot, Xavier M. Müller, and Jean-Pierre Revelly

Anesth Analg 2003 97: 1743-1750.

 

9ONO-1714,一种一氧化氮合成酶抑制剂,减轻家兔内毒素引起的急性肺损伤

(方芳 译 薛张纲 校)

ONO-1714, a Nitric Oxide Synthase Inhibitor, Attenuates Endotoxin-Induced Acute Lung Injury in Rabbits

Katsuya Mikawa, Kahoru Nishina, Yumiko Takao, and Hidefumi Obara

Anesth Analg 2003 97: 1751-1755.

 

内毒素休克模型中抗利尿激素对周围、内脏血液动力学以及代谢的影响

(朱辉 译 王祥瑞 校)

The Effects of Vasopressin on Systemic and Splanchnic Hemodynamics and Metabolism in Endotoxin Shock

Tero J. Martikainen, Jyrki J. Tenhunen, Ari Uusaro, and Esko Ruokonen

Anesth Analg 2003 97: 1756-1763.

 

用尿氧张力监测危重病人的肾氧耗

(王士雷 庄心良 校)

Monitoring Renal Oxygen Supply in Critically-Ill Patients Using Urinary Oxygen Tension

Andrea Morelli, Monica Rocco, Giorgio Conti, Alessandra Orecchioni, Roberto Alberto De Blasi, Flaminia Coluzzi, and Paolo Pietropaoli

Anesth Analg 2003 97: 1764-1768.

NEUROSURGICAL ANESTHESIA:

BRL 52537研究鼠缺血性神经保护中{kappa}-鸦片受体的选择性

(方芳 薛张纲 )

Kappa-Opioid Receptor Selectivity for Ischemic Neuroprotection with BRL 52537 in Rats

Zhizheng Zhang, Tsung-Ying Chen, Jeffrey R. Kirsch, Thomas J. K. Toung, Richard J. Traystman, Raymond C. Koehler, Patricia D. Hurn, and Anish Bhardwaj

Anesth Analg 2003 97: 1776-1783.

 

脑部脂类微血栓的动力学特征:对鼠电视显微镜的研究

(朱辉 译 王祥瑞 校)

Dynamic Characteristics of Cerebral Lipid Microemboli: Videomicroscopy Studies in Rats

Robert J. Byrick, J. Colin Kay, C. David Mazer, Zhilan Wang, and J. Brendan Mullen

Anesth Analg 2003 97: 1789-1794.

OBSTETRIC ANESTHESIA:

右侧和左侧卧位对剖宫产手术腰麻起效的影响

(王士雷 庄心良 校)

The Effect of Right Versus Left Lateral Decubitus Positions on Induction of Spinal Anesthesia for Cesarean Delivery

Alice C. S. Law, Kwok K. Lam, and Michael G. Irwin

Anesth Analg 2003 97: 1795-1799.

 

罗哌卡因与芬太尼用于分娩硬膜外自控镇痛时的浓度:容量范围的研究

(金琳 译 薛张纲 校)

Ropivacaine and Fentanyl Concentrations in Patient-Controlled Epidural Analgesia During Labor: A Volume-Range Study

Jean-Marc Bernard, Daniel Le Roux, and Jacques Frouin

Anesth Analg 2003 97: 1800-1807.

REGIONAL ANESTHESIA:

 

胸椎硬膜外麻醉改善了腹部手术中的组织氧合功能

(陈洁 译 王祥瑞 校)

Thoracic Epidural Anesthesia Increases Tissue Oxygenation During Major Abdominal Surgery

Barbara Kabon, Edith Fleischmann, Tanja Treschan, Akiko Taguchi, Stephan Kapral, and Andrea Kurz

Anesth Analg 2003 97: 1812-1817.

在腹腔镜胆囊切除术时胃壁内和动脉内CO2分压的差别显著增加:胸部硬膜外麻醉的作用

(王士雷 译 庄心良 校)

The Difference Between Intramural and Arterial Partial Pressure of Carbon Dioxide Increases Significantly During Laparoscopic Cholecystectomy: The Effect of Thoracic Epidural Anesthesia

Koichiroh Nandate, Masanori Ogata, Masahiro Nishimura, Takefumi Katsuki, Shinichi Kusuda, Kohji Okamoto, Naoki Nagata, and Akio Shigematsu

Anesth Analg 2003 97: 1818-1823.

 

在全麻和手术应激状态下,胸部硬膜外麻醉对健康猪的肝脏灌注和氧合作用的影响

(金琳 译 薛张纲 校)

The Effects of Thoracic Epidural Anesthesia on Hepatic Perfusion and Oxygenation in Healthy Pigs During General Anesthesia and Surgical Stress

Dierk A. Vagts, Thomas Iber, Marcus Puccini, Bela Szabo, Jörg Haberstroh, Florian Villinger, Klaus Geiger, and Gabriele F. E. Nöldge-Schomburg

Anesth Analg 2003 97: 1824-1832.  

GENERAL ARTICLES:

 

防止全麻诱导时的肺不张

(金琳 译 薛张纲 校)

Prevention of Atelectasis Formation During Induction of General Anesthesia

Marco Rusca, Stefania Proietti, Pierre Schnyder, Philippe Frascarolo, Göran Hedenstierna, Donat R. Spahn, and Lennart Magnusson

Anesth Analg 2003 97: 1835-1839.

 

新型有效的CO2排出和死腔通气的数学模型

(陈洁 译 王祥瑞 校)

Validation of an Original Mathematical Model of CO2 Elimination and Dead Space Ventilation

Jonathan G. Hardman and Alan R. Aitkenhead

Anesth Analg 2003 97: 1840-1845.

以动脉和呼吸末CO2的梯度估计肺泡死腔

(王士雷 庄心良 校)

Estimating Alveolar Dead Space from the Arterial to End-Tidal CO2 Gradient: A Modeling Analysis

Jonathan G. Hardman and Alan R. Aitkenhead

Anesth Analg 2003 97: 1846-1851.

 

 

肺癌手术后急性肺损伤的危险因素

Risk Factors for Acute Lung Injury After Thoracic Surgery for Lung Cancer

Marc Licker, MD*, Marc de Perrot, MD{dagger}, Anastase Spiliopoulos, MD{dagger}, John Robert, MD{dagger}, John Diaper, RN*, Catherine Chevalley, MD*, and Jean-Marie Tschopp, MD{ddagger}

*Department of Anaesthesiology, Pharmacology and Surgical Intensive Care and the {dagger}Unit of Thoracic Surgery, University Hospital of Geneva, Switzerland; and {ddagger}Chest Medical Center, Montana

Anesth Analg 2003 97: 1558-1565.

 

急性肺损伤是胸外科手术后的严重并发症,是造成术后死亡的主要因素之一。我们连续对879例非小肺癌肿瘤行肺切除术病人发生急性肺损伤的危险因素进行了分析。搜集临床麻醉、外科、放射、生化和组织病理等方面的资料。结果显示,胸外科术后急性肺损伤的总发病率为4.2%。有10例病人是由术后3-12天出现并发症(支气管肺炎, n = 5; 支气管肺瘘, n = 2; 胃内容物误吸, n = 2;血栓栓塞, n = 1)而诱发急性肺损伤,称为继发性肺损伤,其死亡率为60%。余下27例病人,在术后0-3天无临床不良事件发生,为原发性急性肺损伤,其死亡率为26%。原发性肺损伤有4个主要危险因素:术中高通气压指数(几率3.595%可信区间1.7-8.4)、过度输液(几率2.995%可信区间1.9-7.4)、肺切除术(几率2.895%可信区间1.4-6.3)、以及术前酒精滥用(几率1.995%可信区间1.1-5.6)。结论:降低胸外科术后发生急性肺损伤(包括中间并发症诱发的延迟性肺损伤和早期肺损伤)危险性的策略包括:术前戒酒、肺保护性通气模式和限制液体输入。

(王士雷 庄心良 校)

Acute lung injury (ALI) may complicate thoracic surgery and is a major contributor to postoperative mortality. We analyzed risk factors for ALI in a cohort of 879 consecutive patients who underwent pulmonary resections for non-small cell lung carcinoma. Clinical, anesthetic, surgical, radiological, biochemical, and histopathologic data were prospectively collected. The total incidence of ALI was 4.2% (n = 37). In 10 cases, intercurrent complications (bronchopneumonia, n = 5; bronchopulmonary fistula, n = 2; gastric aspiration, n = 2; thromboembolism, n = 1) triggered the onset of ALI 3 to 12 days after surgery, and this was associated with a 60% mortality rate (secondary ALI). In the remaining 27 patients, no clinical adverse event preceded the development of ALI—0 to 3 days after surgery—that was associated with a 26% mortality rate (primary ALI). Four independent risk factors for primary ALI were identified: high intraoperative ventilatory pressure index (odds ratio, 3.5; 95% confidence interval, 1.7–8.4), excessive fluid infusion (odds ratio, 2.9; 95% confidence interval, 1.9–7.4), pneumonectomy (odds ratio, 2.8; 95% confidence interval, 1.4–6.3), and preoperative alcohol abuse (odds ratio, 1.9; 95% confidence interval, 1.1–4.6). In conclusion, we describe two clinical forms of postthoracotomy ALI: 1) delayed-onset ALI triggered by intercurrent complications and 2) an early form of ALI amenable to risk-reducing strategies, including preoperative alcohol abstinence, lung-protective ventilatory modes, and limited fluid intake.

 

比较二种不同红细胞洗涤方法时红细胞的恢复情况

A Comparison of Red Cell Recovery Between Two Different Methods of Red Cell Washing

Jonathan H. Waters, MD, Paul Potter, MD, and Donna F. Hobson, BS

Department of General Anesthesiology and Clinical Pathology, Cleveland Clinic Foundation, Ohio

Anesth Analg 2003 97: 1578-1581.

 

红细胞血搜集回输的效果主要决定于从外科术野搜集的红细胞量以及回输给病人的红细胞数量。本文作者假设pneumatic disk (PD)比传统的方式Latham bowl (LB) 有更好的红细胞恢复度。比较二种机器搜集血液的速度和储存器血液容量为100 1000 mL时机器产生的血红蛋白量。PD可以提供连续血红蛋白浓缩(21.7 ± 0.8 g/dL),而LB提供血红蛋白浓缩程度依赖于储存器中血液的容量,浓度从2.9 ± 0.7 g/dL 18.4 ± 0.8 g/dLPDLB的回收效率高(79.4%56.3%; P = 0.001)。当满储存器的红细胞血液被处理时,LB提供的红细胞回输量大于PD79.4%83.6%p<0.001)。LB在任何起始储存容量的处理速度都快于PD。结论:当血液丢失量少而未达到满的LB时,PD每次处理过程都能够得到恒定血红蛋白的大容量细胞。

 

(王士雷 庄心良 校)

The success of cell salvage varies depending upon how many shed red blood cells (RBC) are captured from the surgical wound and returned to the patient. Here, the authors hypothesized that pneumatic disk (PD) processing might provide better RBC recovery when compared with traditional Latham bowl (LB) techniques. Comparison of the speed of processing, product hemoglobin and salvage efficiency was made between the two machines when their reservoirs were loaded with blood volumes ranging from 100 mL to 1000 mL. The PD provided a consistent hemoglobin concentration (21.7 ± 0.8 g/dL; mean ± SD), whereas the LB provided varying hemoglobin concentrations dependent upon the starting volume (range, 2.9 ± 0.7 g/dL to 18.4 ± 0.8 g/dL). The PD also provided more efficiency versus full LB only (79.4% versus 56.3%; P = 0.001). When all RBCs were processed, the LB technology provided statistically larger degrees of RBC return (79.4% versus 83.6% for the PD versus LB, respectively; P < 0.001). The processing speed of the LB was faster at all starting volumes. In conclusion, for small volumes of blood loss where a full LB is not achieved, the PD will return a larger number of cells with a more consistent hemoglobin per volume of blood processed.

 

血管容量替代治疗策略的新启发:我们过去三年中学到了什么?

New Light on Intravascular Volume Replacement Regimens: What Did We Learn from the Past Three Years?

Joachim Boldt, MD

Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany

Anesth Analg 2003 97: 1595-1604.

有关理想血管内容量替代治疗策略的定义仍然是一个非常具有挑战性的问题。本文从medline上搜集最近三年(1,1, 200012, 12, 2002)有关容量替代治疗的资料进行分析,共涉及2454人的50个原创性研究。其中5个研究在志愿者中进行,其它35个研究在不同的病人中进行(包括心外科、 创伤 、小儿和ICU病人)。不同容量治疗措施对凝血的影响是大家主要关心的主题,其它主题包括代谢状态、大循环和微循环的变化、容量分布和器官功能。(肾灌注和内脏灌注)。在所有的人工胶体中,羟乙基淀粉是研究最多的。关于白蛋白的研究只有二个。没有发现白蛋白比价格低廉的人工胶体有什么优越性。结论:羟乙基淀粉是研究容量替代治疗应用最多的胶体,而白蛋白研究很少,且未发现其明显优点。在这个领域的未来研究有望对理想的容量替代策略产生新的观点和思路。

(王士雷 庄心良 校)

Definition of the "ideal" intravascular fluid volume replacement strategy still remains a critical problem. This article analyzes studies on volume replacement by using a MEDLINE search of the past 3 years (from January 1, 2000, to December 12, 2002). Forty original studies in humans with a total of 2454 subjects were identified. Five studies were performed in volunteers (n = 113); the other 35 studies (n = 2341) were performed in a variety of patients (e.g., cardiac surgery, trauma patients, children, and intensive care unit patients). The influence of different volume replacement regimens on coagulation was one of the major topics of interest (16 studies with 1183 subjects), and other studies focused on metabolic state, alterations in macro- and microcirculation, volume distribution, and organ function (e.g., kidney function and splanchnic perfusion). Among all synthetic colloids, hydroxyethyl starch (HES) was the solution most often studied. Two new HES preparations have been approved (Hextend®, a balanced hetastarch solution, and a new third-generation HES [130/0.4]). Only two studies used albumin, and no superiority of albumin was found over less expensive synthetic colloids. In almost all studies, the outcome either was no end-point or was not reported. Volume replacement has often been hitherto based on dogma and personal beliefs. Future well performed studies in this area will hopefully help to shed new light on the ideal volume replacement strategy.

 

小儿气管内插管的套囊压力是不可预测

Endotracheal Tube Cuff Pressure Is Unpredictable in Children

Marie-Louise Felten, MD, Emmanuelle Schmautz, MD, Sonia Delaporte-Cerceau, MD, Gilles A. Orliaguet, MD PhD, and Pierre A. Carli, MD

Department of Anesthesia and Critical Care, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France

Anesth Analg 2003 97: 1612-1616.

 

尽管气囊高压充气可能引起气管粘膜损伤,近年在8岁以下的小儿中应用带套囊气管导管的情况越来越多。我们对最初充空气的气管套囊压力Pcuff以及随后用50%N2O麻醉期间套囊压力的演变情况。符合下列标准的174例年龄在0-9岁的小儿进入本研究:1)体重3-35KG2)ASA I II; 3)择期外科手术;4)用有套囊的气管插管进行麻醉,麻醉时间至少45min5)吸入的混合气体中包含50%N2O。最初充空气产生不同的Pcuff, 其中39%有过度充气。有85%的病人需要通过各种方法去除多余的气体以维持气囊压力在25cm以下。随着机械通气的延长,放气的数量减少,在105min后就很少了。在不同套囊的气管导管之间未观察到有区别。结论:充空气后Pcuff是不可预测的,在小儿N2O麻醉期间,要不断放气以维持套囊压力小于25cm H2O

 

(王士雷 庄心良 校)

The use of cuffed tracheal tubes in children younger than 8 yr of age has recently increased, although cuff hyperinflation may cause tracheal mucosal damage. In this study, we sought to measure the cuff pressure (Pcuff) after initial free air inflation (iPcuff) and to follow its evolution throughout the duration of 50% nitrous oxide (N2O) anesthesia. One-hundred-seventy-four children, aged 0 to 9 yr, fulfilling the following criteria, were studied: 1) weight of 3–35 kg; 2) ASA physical status I or II; 3) elective surgery; 4) anesthesia with tracheal intubation using a cuffed tube and lasting at least 45 min; and 5) gas mixture containing 50% N2O. Free air inflation results in variable iPcuff, with hyperinflation in 39% of cases. Numerous gas removals were required to maintain Pcuff less than 25 cm H2O in 85% of the patients. The number of deflations decreased with the duration of mechanical ventilation and was small after 105 min. No difference was observed among the different cuffed tube sizes. We conclude that iPcuff is unpredictable after free air inflation and that numerous gas removals are required to maintain Pcuff less than 25 cm H2O during N2O anesthesia in children.

 

异丙酚调节原位大鼠肠系膜血管平滑肌超极化的机制

The Mechanisms of Propofol-Mediated Hyperpolarization of In Situ Rat Mesenteric Vascular Smooth Muscle

Tamotsu Nagakawa, MD*, Mitsuaki Yamazaki, MD*, Noboru Hatakeyama, MD*, and Thomas A. Stekiel, MD{dagger}

*Department of Anesthesiology, Toyama Medical and Pharmaceutical University, Toyama, Japan, and the {dagger}Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2003 97: 1639-1645.

 

我们以前的研究表明异丙酚可以引起小动脉和静脉平滑肌细胞超极化。本研究探讨这种超极化是对血管平滑肌上存在的特殊钾通道的作用,还是继发于第二信使如NOcGMPcAMP的变化。以SD大鼠去交感支配的原位肠系膜小动脉和静脉为模型,探讨应用特殊血管平滑肌钙通道抑制剂、ATP敏感钾通道(KATP) 电压依赖钾通道 (Kv) 、内向整流钾通道(KIR) 抑制剂以及内源性血管舒张因子抑制剂前后异丙酚对这些平滑肌细胞膜电位的影响。结果,异丙酚使小肠系膜血管平滑肌显著超极化。在抑制KCa KATPNO cGMP (but not cAMP)后这种抑制超极化的作用消失。假定血管平滑肌跨膜电位的幅度和收缩力之间是逆向关系,本研究结果表明,异丙酚通过激活KCa KATP通道引起去神经支配的小肠系膜血管平滑肌的超极化和舒张。这些作用受第二信使NOcGMP的调节,而不受cAMP的调节。

(王士雷 庄心良 校)

Previously, we reported that propofol hyperpolarizes vascular smooth muscle (VSM) cells of small arteries and veins. The current study was designed to determine whether propofol-mediated hyperpolarization is the result of specific effects on potassium channels known to exist in VSM and on steps in the intracellular nitric oxide (NO), cyclic guanosine monophosphate (cGMP), and cyclic adenosine monophosphate (cAMP) second potassium channels messenger pathways. VSM transmembrane potentials (Em) were measured in situ in sympathetically denervated, small mesenteric arteries and veins of Sprague-Dawley rats. Effects of propofol on VSM Em were determined before and during superfusion with specific inhibitors of VSM calcium-activated (KCa), adenosine triphosphate-sensitive (KATP), voltage-dependent (Kv), and inward rectifying (KIR) potassium channels and with endogenous mediators of vasodilation. Propofol significantly hyperpolarized VSM in small mesenteric vessels. This hyperpolarization was abolished on inhibition of KCa and KATP channel activity and on inhibition of NO and cGMP (but not cAMP). Assuming a close inverse correlation between the magnitude of VSM Em and contractile force, these results suggest that propofol induces hyperpolarization and relaxation in denervated, small mesenteric vessels by activation of KCa and KATP channels. Such channel activation may be mediated by activation of NO and cGMP, but not cAMP, second messenger pathways.

 

全膝关节成形术用骨粘固粉引起血浆星形胶质细胞S-100B蛋白升高

The Use of Bone Cement Induces an Increase in Serum Astroglial S-100B Protein in Patients Undergoing Total Knee Arthroplasty

Hiroyuki Kinoshita, MD PhD*, Hiroshi Iranami, MD*, Keisuke Fujii, MD*, Akinori Yamazaki, MD*, Manabu Shimogai, MD*, Katsutoshi Nakahata, MD*, Yasuo Hironaka, MD*, and Yoshio Hatano, MD PhD{dagger}

*Department of Anesthesia, Japanese Red Cross Society, Wakayama Medical Center, Wakayama, Japan; and {dagger}Department of Anesthesiology, Wakayama Medical University, Wakayama, Japan

Anesth Analg 2003 97: 1657-1660.

 

骨粘固粉用于关节成形术可以引起大脑微栓子。星形胶质细胞S-100B蛋白是脑损伤比较敏感的指标。本实验以其为指标,观察骨粘固粉对骨外科手术病人脑影响。对14例行膝关节置换的病人(n7)和胫骨骨折髓内针固定术(n7)的病人进行了本研究。每例膝关节成形术均使用多甲基甲基丙烯酸酯和甲基甲基丙烯酸酯的骨粘固粉。在全麻诱导前、气囊止血带放气后15min、手术后3天抽取血样。在放止血带后15min时,膝关节成形术病人的星形胶质细胞S-100B蛋白远远高于胫骨骨折固定术(0.41 and 0.08 ng/mL, respectively; P < 0.05)。所有病人均未发现术后神经功能障碍。结论:尽管骨粘固粉并不改变膝关节成形术病人的神经功能评分,但可以产生短暂性的星形胶质细胞损伤。

(王士雷 庄心良 校)

Cerebral microemboli can occur during arthroplasty with the use of bone cement. Astroglial S-100B protein is a sensitive marker of cerebral damage. Therefore, we designed this study to determine the effect of bone cement on the brain by investigating serum levels of S-100B protein in patients undergoing bone surgery with or without bone cement. Fourteen patients undergoing knee arthroplasty (n = 7) or reamed intramedullary nailing for tibial fracture (n = 7) requiring a pneumatic tourniquet were enrolled in this study. Bone cement containing polymethyl methacrylate and methyl methacrylate was used for every patient undergoing knee arthroplasty. Serum samples were obtained from venous blood before the induction of general anesthesia, 15 min after deflation of a pneumatic tourniquet, and 3 days after the operation. The serum level of S-100B protein was significantly increased 15 min after a pneumatic tourniquet deflation in the knee arthroplasty group compared with the tibial fracture group (0.41 and 0.08 ng/mL, respectively; P < 0.05). In all patients studied, no neurological abnormalities were noted in the postoperative period. These results suggest that, in patients undergoing knee arthroplasty, bone cement may transiently induce astroglial injury, although it does not alter neurological outcome.

 

闭合环路PhysioFlex Deltatrac II 间接测量仪测量氧耗的研究

Oxygen Consumption Measurement: Agreement Between the Closed-Circuit PhysioFlex Anesthesia Machine and the Deltatrac II Indirect Calorimeter

Antonio González-Arévalo, MD*, Juan I. Gómez-Arnau, MD PhD{dagger}, Javier delaCruz, MD§, Felix Lacoma, MD{ddagger}, Pedro Galdos, MD||, and Santiago García-del-Valle, MD*

*Anesthesia Unit, {dagger}Department of Anesthesia and Critical Care, and {ddagger}Critical Care Unit, Fundación Hospital Alcorcón; §Clinical Epidemiology Unit, Hospital 12 de Octubre; and ||Intensive Care Unit, Hospital General de Móstoles, Madrid, Spain

Anesth Analg 2003 97: 1680-1685.

 

本研究探讨用PhysioFlex 闭路麻醉机和Deltatrac II 间接测量计测量的氧耗之间的结果是否有一致性。在危重病机械通气的病人通过这两种方式连续测量氧耗。在稳定读数的情况下,连续记录10次每分钟测量的平均值。通过Bland-Altman分析法对结果进行分析。共分析了21例病人中的54对数值,平均偏差为6.32 mL/min,二者吻合的限值是40.28 and -27.63 mL/min。组间相关系数为0.9595%可信区间为0.91-0.97。结论:用PhysioFlex麻醉机测量的氧耗和用间接测热法测量的氧耗结果有一致性。

(王士雷 庄心良 校)

We designed this study to ascertain whether, for the purpose of clinical interpretation, the direct measurement of O2 consumption with the PhysioFlex closed-circuit anesthesia machine and with the Deltatrac II indirect calorimeter are interchangeable. Oxygen consumption was measured using the two instruments successively in critically-ill, mechanically-ventilated patients. Measurements were recorded as the mean of 10 consecutive, minute-by-minute, stable readings. The degree of agreement between the measurements obtained with the two systems was estimated using Bland-Altman analysis and the intraclass correlation coefficient. Forty-four pairs of measurements made in 21 patients were analyzed, yielding a mean bias of 6.32 mL/min and limits of agreement of 40.28 and -27.63 mL/min. The intraclass correlation coefficient was 0.95, and the 95% confidence interval ranged from 0.91 to 0.97. The measurement of O2 consumption obtained with the PhysioFlex anesthesia machine is interchangeable with that obtained by indirect calorimetry.

 

二氢可待因和布洛芬间的镇痛作用是协同的

The Synergistic Analgesic Interactions Between Hydrocodone and Ibuprofen

Yuri A. Kolesnikov, MD PhD*,{dagger}, Roger S. Wilson, MD*, and Gavril W. Pasternak, MD PhD{dagger}

*Department of Anesthesiology and Critical Care and {dagger}The Laboratory of Molecular Neuropharmacology, Memorial Sloan-Kettering Cancer Center, New York

Anesth Analg 2003 97: 1721-1723

.

在急性和慢性疼痛的临床处理中,常复合应用阿片类和非固醇类抗炎药物。应用大鼠光照甩尾实验,我们观察了二氢可待因的镇痛效能。相比较而言,在这个模型上,单用布洛芬对中和重度疼痛无效,也许这反映了其镇痛作用的有限性。尽管布洛芬在这个模型上无效,合用布洛芬,显著增强二氢可待因的镇痛效果。剂量依赖关系的研究表明,单用二氢可待因的半数有效剂量为11 mg/kg 。但复合固定剂量的布洛芬研究不同剂量二氢可待因的镇痛作用,二氢可待因半数镇痛剂量向左移接近7倍,为1.6 mg/kg 。应用固定比率的二氢可待因和布洛芬(1:40),也显示剂量出现4倍的偏移(2.6 mg/kg )。结论:在非炎症痛动物模型上,二氢可待因和布洛芬的抗伤害作用是协同的。

(王士雷 庄心良 校)

The practice of combining opioids with nonsteroidal antiinflammatory drugs is widespread in the clinical management of acute and chronic pain. Using the mouse radiant heat tail-flick nociception model, we observed potent analgesia with hydrocodone. In contrast, ibuprofen as a single drug was inactive in this model of moderate to severe pain, perhaps reflecting its limited analgesic potential. Despite the inactivity of ibuprofen alone in this model, the inclusion of ibuprofen with hydrocodone markedly enhanced the analgesic response. Dose-response studies revealed an 50% effective dose for hydrocodone alone in mice of 11 mg/kg, SC. Inclusion of a fixed ibuprofen dose with the various hydrocodone doses shifted the 50% effective dose value almost seven-fold to the left to 1.6 mg/kg, SC, despite the lack of effect of ibuprofen alone in this model. Using a fixed hydrocodone:ibuprofen ratio (1:40) also revealed a marked four-fold shift to 2.6 mg/kg, SC. These findings suggest a synergistic interaction between ibuprofen and hydrocodone in a noninflammatory pain model.

 

适应性支持通气的自动“呼吸和脱机”:对气管内插管时间和病人管理的影响

Automatic "Respirator/Weaning" with Adaptive Support Ventilation: The Effect on Duration of Endotracheal Intubation and Patient Management

Alexander H. Petter, MD*, René L. Chioléro, MD*, Tiziano Cassina, MD*, Pierre-Guy Chassot, MD{dagger}, Xavier M. Müller, MD{ddagger}, and Jean-Pierre Revelly, MD*

*Surgical Intensive Care Unit, {dagger}Department of Anesthesiology, and {ddagger}Department of Cardiac Surgery, University Hospital, Lausanne, Switzerland

Address correspondence and reprint requests to Jean-Pierre Revelly, MD, Surgical Intensive Care Unit, Room 08.652, Lausanne University Hospital, CH-1011-Lausanne, Switzerland.

Anesth Analg 2003 97: 1743-1750.

 

适应性支持通气根据病人被动和主动的呼吸力学自动调节通气装置。本研究评价机械支持通气时自动呼吸停机在心外科早期拔管中的作用。病人在压力支持模式下随机分为固定模式机械支持通气组ASV和标准同步间歇指令通气组SIMV18例病人完成了固定模式机械通气,16例病人完成了标准同步间歇指令通气。病人围术期病情,气管插管留置时间,ICU停留时间和通气变量无显著差异,但ASV组病人在通气的最初阶段吸气压较低(17.5 ± 0.8 versus 22.2 ± 0.8 cm H2O; P < 0.01)ASV病人需要少的通气参数调节(2.4 ± 0.7 versus 4.0 ± 0.8 manipulations per patient; P < 0.05),和少的高吸气压报警(0.7 ± 2.4 versus 2.9 ± 3.0; P < 0.05)。本研究结果显示,用ASV模式自动通气的结果和对照组相同,但机器的内部固定程序使我们只需对机器进行少量的操作,使呼吸管理更加简单。

(王士雷 庄心良 校)

Adaptive support ventilation (ASV) provides an automatic adaptation of the ventilator settings to patient’s passive and active respiratory mechanics. In a randomized controlled study, we evaluated automatic respiratory weaning in ASV for early tracheal extubation after cardiac surgery. Eligible patients were assigned to either an ASV protocol or a standard one consisting of synchronized intermittent ventilation followed by pressure support. Eighteen patients completed the ASV protocol, and 16 completed the standard one. There were no differences between groups in perioperative characteristics, lengths of tracheal intubation and intensive care unit stay, and ventilatory variables, except less peak inspiratory pressure during the initial phase in ASV (17.5 ± 0.8 versus 22.2 ± 0.8 cm H2O; P < 0.01). ASV patients required fewer ventilatory settings manipulations (2.4 ± 0.7 versus 4.0 ± 0.8 manipulations per patient; P < 0.05) and endured less high-inspiratory pressure alarms (0.7 ± 2.4 versus 2.9 ± 3.0; P < 0.05). These results suggest that in this specific population of patients, automation of postoperative ventilation with ASV resulted in an outcome similar to the control group. The internal logic of the new device resulted in less manipulation of the setting and alarms that could simplify respiratory management.

 

用尿氧张力监测危重病人的肾氧耗

Monitoring Renal Oxygen Supply in Critically-Ill Patients Using Urinary Oxygen Tension

Andrea Morelli, MD*, Monica Rocco, MD*, Giorgio Conti, MD{dagger}, Alessandra Orecchioni, MD*, Roberto Alberto De Blasi, MD*, Flaminia Coluzzi, MD*, and Paolo Pietropaoli, MD*

*Department of Anesthesiology and Intensive Care, University of Rome "La Sapienza"; and {dagger}Department of Anesthesiology and Intensive Care, Catholic University of Rome, Italy

Anesth Analg 2003 97: 1764-1768.

 

危重病人可能由于全身低血压而发展为肾功能障碍的危险。本研究通过持续监测尿氧张力,一种相对无创但可以实时提供肾氧状态的技术,检验ICU病人应用非诺多泮(一种抗高血压药物)对氧利用的影响。50ICU病人应用不同剂量的非诺多泮(0.03, 0.06, and 0.09 µg • kg-1 • min-1)。每小时收集尿量以评价容量和电介质。在改变非诺多泮的剂量时以及输注末分析心率、平均动脉压、心输出量、肺动脉嵌压、动脉氧输送指数,以及氧耗指数在。通过置入桡动脉和膀胱中的传感器连续监测PaO2 and PuO2。在非诺多泮剂量提高时,PuO2 显著升高(P < 0.05), PaO2 维持不变。本研究中,心率、平均动脉压、心输出量、肺动脉嵌压、动脉氧输送指数,以及氧耗指数保持不变。 结论:与剂量有关的 PuO2 的升高, 与全身灌注指数和心脏功能无关,表明非诺多泮影响状态稳定的危重病人的肾氧供需平衡。

(王士雷 庄心良 校)

Critically-ill patients are at risk of developing renal disorders as a consequence of systemic hypoperfusion. Ischemic acute tubular necrosis and resulting acute renal failure are caused by hypotension or therapeutic management. In this study, we tested the change of O2 availability induced by fenoldopam mesylate using the continuous measurement of urinary oxygen tension (PuO2), a relatively noninvasive technique that could provide potentially important real-time data regarding renal oxygenation in Fenoldopam was administered at different doses (0.03, 0.06, and 0.09 µg • kg-1 • min-1) to 50 stable critically-ill patients. Urine output was collected every hour to assess volume and urinary electrolytes. Heart rate, mean arterial blood pressure, cardiac output, pulmonary artery occlusion pressure, arterial oxygen delivery index, and oxygen consumption index were analyzed after fenoldopam dose modifications and at infusion end. PaO2 and PuO2 continuous measurements were obtained through two sensors inserted in the radial artery and in the bladder. After a fenoldopam dose increase, PuO2 significantly increased (P < 0.05), whereas PaO2 remained unchanged. During the study, heart rate, mean arterial blood pressure, cardiac output, central venous pressure, pulmonary artery occlusion pressure, arterial oxygen delivery index, and oxygen consumption remained unchanged. Dose-dependent PuO2 increases, unrelated to indexes of systemic perfusion and cardiac function, demonstrate that fenoldopam affects the balance between renal oxygen supply and demand in stable critically-ill patients.

 

右侧和左侧卧位对剖宫产手术腰麻起效的影响

The Effect of Right Versus Left Lateral Decubitus Positions on Induction of Spinal Anesthesia for Cesarean Delivery

Alice C. S. Law, MB ChB*, Kwok K. Lam, MB ChB, FANZCA, FHKAM{dagger}, and Michael G. Irwin, MB ChB, FRCA, FHKAM{ddagger}

From the *Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, The Chinese University of Hong Kong, the {dagger}Department of Anaesthesia and Intensive Care, Tuen Mun Hospital, Hong Kong, and the {ddagger}Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong

Anesth Analg 2003 97: 1795-1799.

 

剖宫产左外侧卧位加之子宫左侧位可能影响局麻药的扩散,对腰麻的起效产生重要影响。本研究探讨60例剖宫产妇女用0.5%重比重布比卡因和芬太尼腰麻时左外侧和右外侧体位对腰麻起效的影响。尽管二组均有产妇T4冷感觉消失的时间均要15min后,但更多左侧卧位的产妇在5min时即达到这个要求。感觉消失的最大水平、液体入量、血管收缩药物、附加应用镇痛药物的量以及术后并发症的发生率二者之间无差异。结论:当在重比重布比卡因和芬太尼腰麻下行剖宫产时,二种体位都可以应用。

(王士雷 庄心良 校)

Induction of spinal anesthesia for cesarean delivery in the left lateral (LL) decubitus position combined with intraoperative left uterine displacement may result in pooling of local anesthetic onto one side of the body. We studied the effect of the right lateral (RL) and LL decubitus positions during placement of spinal anesthesia on the intrathecal spread of 0.5% hyperbaric bupivacaine plus fentanyl in 60 term parturients. Though all parturients acquired a loss of cold sensation at T4 15 min after intrathecal injection, more parturients in the LL group than in the RL group did so at 5 min (P < 0.05). The maximum levels of sensory blockades, amounts of fluid, vasopressor, and supplementary analgesia used, and the incidence of postoperative complications were similar. We conclude that the two positions can be used equally well when hyperbaric bupivacaine and fentanyl are used in cesarean delivery under spinal anesthesia.

 

在腹腔镜胆囊切除术时胃壁内和动脉内CO2分压的差别显著增加:胸部硬膜外麻醉的作用

The Difference Between Intramural and Arterial Partial Pressure of Carbon Dioxide Increases Significantly During Laparoscopic Cholecystectomy: The Effect of Thoracic Epidural Anesthesia

Koichiroh Nandate, MD*, Masanori Ogata, MD*, Masahiro Nishimura, MD*, Takefumi Katsuki, MD{dagger}, Shinichi Kusuda, MD{dagger}, Kohji Okamoto, MD{dagger}, Naoki Nagata, MD{dagger}, and Akio Shigematsu, MD*

Departments of *Anesthesiology and {dagger}First Surgery, University of Occupational and Environmental Health, Japan

Anesth Analg 2003 97: 1818-1823.

本研究探讨气腹对胃粘膜下灌注代谢的影响。用气体张力测量法得到20例择期腹腔镜胆囊切除术时PCO2差值(胃粘膜和动脉之间的差值),我们进一步检查胸部硬膜外对其的影响。病人随机分为全麻组和全麻复合硬膜外组,每组10例。二组病人在气腹期间,PCO2 差值均较基础值显著升高,直至手术结束都维持在高水平。在任何时间点,这些差值在二组之间都无差异。结论:气腹显著影响胃粘膜下灌注和代谢,胸部硬膜外麻醉并不减轻气腹期间和气腹后胃粘膜灌注的损害。

(王士雷 庄心良 校)

We studied the effects of pneumoperitoneum on gastric submucosal perfusion metabolism during elective laparoscopic cholecystectomy (LASC) by measuring the PCO2 gap, defined as the difference between intramucosal PCO2 and arterial PCO2, using gas tonometry in 20 patients. Furthermore, we examined whether thoracic epidural anesthesia (TEA) affects gastric submucosal perfusion metabolism during LASC. Patients were randomly allocated to receive general anesthesia (group G, n = 10) or general anesthesia combined with TEA (group E, n = 10). In both groups, the PCO2 gap increased significantly during pneumoperitoneum and remained at this level until the end of surgery compared with the baseline value. There were no significant differences in PCO2 gap values between the two groups at any time sampled. These results suggested that pneumoperitoneum significantly impaired gastric submucosal perfusion and metabolism and that TEA did not attenuate the impairment of gastric submucosal perfusion during or after pneumoperitoneum.

 

以动脉和呼吸末CO2的梯度估计肺泡死腔

Estimating Alveolar Dead Space from the Arterial to End-Tidal CO2 Gradient: A Modeling Analysis

Jonathan G. Hardman, FRCA, and Alan R. Aitkenhead, FRCA

From the University Department of Anaesthesia, University Hospital, Nottingham, NG7 2UH, UK

Anesth Analg 2003 97: 1846-1851.

我们应用原创有效高保真的肺生理模型,通过动脉CO2张力和肺死腔估算的方式,用传统的Fowler’s技术和 Bohr公式: (VDalv/VTalv)Bohr-Fowler.比较动脉和呼吸末CO2梯度。具体研究三种情况(不同的CO2产生量、静脉血掺杂和解剖死腔)下的Pa-E'CO2/PaCO2。在肺泡形状维持不变的情况下,检查的因素(VCO2肺动脉分流和 VDanat) 均引起(VDalv/VTalv)Bohr-Fowler Pa-E'CO2/PaCO2的变化。VDanat 变化诱发Pa-E'CO2/PaCO2 d的变异稍微大,但在静脉血掺杂和VCO2之间相同。结论:Pa-E'CO2/PaCO2可能是危重病人非常有用的测量方法,这种数值非常容易得到,且计算方法较(VDalv/VTalv)Bohr-Fowler简单。

(王士雷 庄心良 校)

 

Using an original, validated, high-fidelity model of pulmonary physiology, we compared the arterial to end-tidal CO2 gradient divided by the arterial CO2 tension (Pa-E'CO2/PaCO2) with alveolar dead space expressed as a fraction of alveolar tidal volume, calculated in the conventional manner using Fowler’s technique and the Bohr equation: (VDalv/VTalv)Bohr-Fowler. We examined the variability of Pa-E'CO2/PaCO2 and of (VDalv/VTalv)Bohr-Fowler in the presence of three ventilation-perfusion defects while varying CO2 production (VCO2), venous admixture, and anatomical dead space fraction (VDanat). Pa-E'CO2/PaCO2 was approximately 59.5% of (VDalv/VTalv)Bohr-Fowler. During constant alveolar configuration, the factors examined (VCO2, pulmonary shunt fraction, and VDanat) each caused variation in (VDalv/VTalv)Bohr-Fowler and in Pa-E'CO2/PaCO2. Induced variation was slightly larger for Pa-E'CO2/PaCO2 during changes in VDanat, but was similar during variation of venous admixture and VCO2. may be a useful serial measurement in the critically ill patient because all the necessary data are easily obtained and calculation is significantly simpler than for (VDalv/VTalv)Bohr-Fowler.

 

地氟醚和丙泊酚对门高压病人门体静脉压力的影响

The Effects of Desflurane and Propofol on Portosystemic Pressure in Patients with Portal Hypertension

M. Susan Mandell, MD PhD*, Janette Durham, MD{dagger}, David Kumpe, MD{dagger}, James F. Trotter, MD{ddagger}, Gregory T. Everson, MD{ddagger}, and Claus U. Niemann, MD§

Departments of *Anesthesiology, {dagger}Radiology, and {ddagger}Hepatology, University of Colorado Health Sciences Center, Denver; and §Department of Anesthesia and Perioperative Care, University of California, San Francisco

Anesth Analg 2003;97:1573-1577


肝血管压力的测量可用于指导减轻门高压的治疗。在全麻中,这些测量频繁使用。既然大多数麻醉药物会降低肝血流,也会影响肝血管压力。因此我们在一个前瞻性的随机的试验中观察了两种常用麻醉药物对肝血管压力的影响,以判断是否麻醉中测量出的压力与清醒状态下相似。我们研究了21名丙肝病人,排除了有门静脉血栓的病人。所有病人都在清醒镇静状态下和地氟醚或丙泊酚麻醉后进行了开放和楔入肝血管压力测定。地氟醚显著升高了开放肝血管压力(11.9±4.423.5±4.1mmHgP<0.05)降低了肝血管压力梯度(21.6±7.414.7±7.2mmHgP<0.05)。而丙泊酚没有改变这些参数。我们的结论是:地氟醚而不是丙泊酚会改变清醒状态下测得的肝血管压力。显著升高了开放肝血管压力;降低了肝血管压力梯度,一种门体静脉压力的间接测量。在使用地氟醚进行全麻时应考虑到肝血管压力梯度的改变。 

(殷文渊 译 王祥瑞 校)

Physicians perform hepatic venous pressure measurements to guide medical therapy aimed at reducing portal hypertension. These measurements are frequently performed during general anesthesia. Since most general anesthetic drugs reduce liver blood flow, it is likely that hepatic venous pressures will be altered. We therefore examined the effects of two frequently used anesthetic drugs on hepatic venous pressure in a prospective randomized study to determine if pressure measurements taken during general anesthesia were similar to awake values. We studied 21 patients with hepatitis C, excluding patients with hepatofugal flow and portal vein thrombosis. All patients had free and wedged hepatic venous pressures measured awake with sedation and after anesthesia with either propofol or desflurane. Desflurane significantly increased free hepatic venous pressure (11.9 ± 4.4 to 23.5 ± 4.1 mm Hg; P < 0.05) and decreased hepatic venous pressure gradient (21.6 ± 7.4 to 14.7 ± 5.2 mm Hg; P < 0.05), whereas propofol did not change these variables. We conclude that desflurane, but not propofol, alters hepatic venous pressure measurements from the awake state, significantly increasing free hepatic venous pressure and decreasing the hepatic venous pressure gradient, an indirect measure of portosystemic pressure. Changes in the hepatic venous pressure gradient must be interpreted with caution during desflurane general anesthesia.


醋酸林格氏液的快速水排泄和缓慢钠排泄作用使细胞脱水

Rapid Water and Slow Sodium Excretion of Acetated Ringer’s Solution Dehydrates Cells

Robert G. Hahn, MD PhD, and Dan Drobin, MD PhD

From the Department of Anesthesiology, Söder Hospital, S-118 83 Stockholm, Sweden

Anesth Analg 2003;97:1590-1594


醋酸林格氏液是一种缓慢的低渗液体(渗透压270mosmol/kg),被认为是使水容量转移到细胞内间隙的一种液体。给五名健康女性志愿者输注25ml/kg的醋酸林格氏液(平均1565ml),观察输注15304580分钟时间段的不同状况以评估肾脏在影响这种容量转换中的作用。忽略输注速度,排泄的尿液中只含有所输注液体一般的钠(平均67mmol/L)。但血清钠浓度仅略微提高了0.9mmol/L,物质守衡定律提示在输注结束30分钟后有274ml的水从细胞内转移到细胞外间隙(P<0.001)。在随后的90分钟仍有这种转移存在。总之,输注醋酸林格氏液并不会由于排泄的尿液中钠浓度低而促进细胞膨胀。在输注结束两小时后我们测量出仍有从细胞外间隙的少量脱水。    

(殷文渊 译 王祥瑞 校)

Acetated Ringer’s solution is a slightly hypotonic infusion fluid (osmolality 270 mosmol/kg) that has inspired the belief that the fluid causes a shift of water volume to the intracellular space. We assessed the role of the kidney in modifying this volume shift by infusing 25 mL/kg of Ringer’s acetate solution (mean, 1565 mL) over a time period of 15, 30, 45, and 80 min on different occasions in 5 healthy female volunteers. Regardless of the rate of administration, the excreted urine contained only half as much sodium (mean, 67 mmol/L) as the infused fluid. As there was only a slight increase of 0.9 mmol/L in the serum sodium level, mass balance calculations indicated that 274 mL of water had shifted from the intracellular to the extracellular space 30 min after the infusions ended (P < 0.001). This fluid shift was also maintained over the subsequent 90 min. In conclusion, infusion of Ringer’s acetate solution does not promote cellular swelling as a result of the excretion of urine that is low in sodium. A slight dehydration of fluid from the intracellular space still persisted when our measurements ended 2 h after completing the infusion.


病人自控硬膜外镇痛与持续硬膜外腔注射布比卡因镇痛在小儿术后镇痛应用的比较

Patient-Controlled Epidural Analgesia Versus Continuous Epidural Infusion with Ropivacaine for Postoperative Analgesia in Children

Emmanuel Antok, MD*, Fabienne Bordet, MD*, Frédéric Duflo, MD*, Sabine Lansiaux, MD*, Sylvie Combet, MD*, Patricia Taylor, MD*, Agnes Pouyau, MD*, Brigitte Paturel, MD*, Robert James, MS{dagger}, Bernard Allaouchiche, MD PhD*, and Dominique Chassard, MD PhD*

*Service d’Anesthésie-Réanimation, Hôpital de l’Hôtel-Dieu et Debrousse, Lyon, France; and {dagger}Department of Anesthesiology, Bowman Gray School of Medicine, Wake Forest University, Winston-Salem, North Carolina

Anesth Analg 2003;97:1608-1611


硬膜外腔注射布比卡因镇痛已经应用于小儿病人,然而,病人自控硬膜外镇痛(PCEA)至今还没有应用于小儿病人。本研究主要对PCEA和持续硬膜外腔注射镇痛(CEA)在小儿病人中应用的临床疗效进行比较。48名接受矫形外科手术的小儿病人随机分为两组,一组接受0.2%布比卡因PCEA,另外一组接受0.2%布比卡因CEA。所有病人均在标准全身麻醉下实施手术,同时也都给予酮洛芬和propacetamol治疗。术后48小时内记录小儿病人的疼痛评分和副反应。如果可视疼痛评分大于4分,最高10分,则认为术后镇痛是不完善的,需要追加镇痛药的剂量。结果两组病人均获得了满意的术后镇痛。但PCEA组病人所需局麻药的剂量明显小于CEA组病人(0.20±0.08mg•Kg-1•h-10.40±0.08 mg•Kg-1•h-1P0.001两组病人的运动反应、镇痛药追加剂量和副反应均无明显差异。因此0.2%布比卡因PCEA可以提供给接受矫形外科手术的小儿病人充分的术后镇痛,且所需局麻药的剂量小于CEA。                    

(齐波 译 王祥瑞 校)

Epidural ropivacaine infusion has been used in children; however, patient-controlled epidural analgesia (PCEA) has not been evaluated in the pediatric population. In this study, we compared the clinical efficiency of PCEA and of continuous epidural infusion analgesia (CEA) in children. Forty-eight children undergoing orthopedic surgery were randomized to receive PCEA or CEA with ropivacaine 0.2%. All patients underwent a standard general anesthetic. Children also received ketoprofen and propacetamol. Pain scores and side effects were recorded for 48 h. If the visual analog score scale score was >4 of 10, analgesia was considered inadequate, and rescue treatment was administered. Both groups obtained effective pain relief. Children in the PCEA group received significantly less local anesthetic than those in the CEA group (0.20 ± 0.08 mg • kg-1 • h-1 versus 0.40 ± 0.08 mg • kg-1 h-1; P < 0.001). Motor effects, supplemental analgesic requirements, and side effects did not differ. We concluded that PCEA with ropivacaine 0.2% can provide adequate postoperative analgesia for pediatric orthopedic procedures with smaller dose requirements than CEA.

日间手术使用艾司洛尔和尼卡地平对术后恢复的影响

The Effect of Intraoperative Use of Esmolol and Nicardipine on Recovery After Ambulatory Surgery

Paul F. White, PhD MD, FANZCA*, Baoguo Wang, MD*,{dagger}, Jun Tang, MD*,{dagger}, Ronald H. Wender, MD{dagger}, Robert Naruse, MD{dagger}, and Alexander Sloninsky, MD{dagger}

*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; and {dagger}Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California

Anesth Analg 2003;97:1633-1638


在麻醉过程中,维持血液动力学稳定最好的方法是学术界争论的问题。本实验是一个前瞻性、随机、双盲的研究,旨在证明门诊外科中,对全麻的病人运用一定的技术维护血液动力学的稳定有利于病人的预后。45位健康的妇产科病人(行宫腔镜检查)自愿参加本项研究,她们被随机分为3个治疗组:组1(对照组,n=15),生理盐水5ml 1 ml,然后再输入生理盐水0.005ml•kg-1•min-1,组2 (n=15),艾司洛尔50mg和生理盐水1 ml,然后再输入艾司洛尔5g•kg-1•min-1,组3(n=15),艾司洛尔50mg和尼卡地平1 ml,然后再输入艾司洛尔5g•kg-1•min-1。所有药物的使用都在麻醉诱导后进行,麻醉诱导给芬太尼1.5g/kg,普鲁泊福2mg/kg,维库溴铵0.12mg/kg后气管插管。麻醉起始时用地氟醚2%N2 O67%O2。术中,通过调节实验药物的滴注速度和地氟醚的浓度,使平均动脉压(MAP)维持在基线±15%。除MAP和心率外,术中还记录了患者的双频脑电图指数。我们还对患者术后复苏的时间和术后副反应做了评估。与对照组相比,气管插管后艾司洛尔和尼卡地平组心率(组2)和血压(组3)的增高都不明显。此外,在麻醉维持阶段,艾司洛尔配合地氟醚使用可以缩短急性自主反应发生的时间(4 ±27±4 min );在术后,还可以减少阿片类药物的使用(43%80%);提早肠蠕动恢复时间(209±89269±100 min)。本研究的结论是:麻醉诱导中使用艾司洛尔或配合尼卡地平,可以减少气管插管时对血液动力学的影响。此外,艾司洛尔作为地氟醚-N2O佐剂,在麻醉维持阶段可以控制急性血液动力学反应,从而有利于经腹腔镜检查的门诊病人的恢复。 

(肖洁 译 王祥瑞 校)

There is controversy regarding the optimal technique for maintaining hemodynamic stability during anesthesia. We designed this prospective, randomized, double-blinded study to test the hypothesis that the technique used for maintaining hemodynamic stability during general anesthesia can influence recovery after ambulatory surgery. Forty-five healthy consenting women undergoing gynecologic laparoscopy procedures were randomly assigned to 1 of 3 treatment groups: Group 1 (control, n = 15) received normal saline 5 mL and 1 mL, followed by a saline infusion at a rate of 0.005 mL • kg-1 • min-1; Group 2 (n = 15) received esmolol 50 mg and saline 1 mL, followed by an esmolol infusion 5 µg • kg-1 • min-1; and Group 3 (n = 15) received esmolol 50 mg and nicardipine 1 mg, followed by an esmolol infusion 5 µg • kg-1 • min-1. The study drugs were administered after the induction of anesthesia with fentanyl 1.5 µg/kg, and propofol 2 mg/kg IV. Tracheal intubation was facilitated with vecuronium 0.12 mg/kg IV. Anesthesia was initially maintained with desflurane 2% end-tidal and N2O 67% in oxygen in all 3 groups. During surgery, the mean arterial blood pressure (MAP) was maintained within ±15% of the baseline value by varying the study drug infusion rate and the inspired concentration of desflurane. In addition to MAP and heart rate values, electroencephalogram bispectral index values were recorded throughout the perioperative period. Recovery times and postoperative side effects were assessed. Compared with the control group, adjunctive use of esmolol and nicardipine attenuated the increase in heart rate (in Group 2) and MAP (in Group 3) after tracheal intubation. Furthermore, the use of an esmolol infusion as an adjunct to desflurane to control the acute autonomic responses during the maintenance period significantly decreased emergence times (4 ± 2 versus 7 ± 4 min), decreased the need for postoperative opioid analgesics (43% versus 80%), and reduced the time to discharge (209 ± 89 versus 269 ± 100 min). We conclude that the adjunctive use of esmolol alone or in combination with nicardipine during the induction of anesthesia reduced the hemodynamic response to tracheal intubation. Furthermore, use of an esmolol infusion as an adjuvant to desflurane-N2O anesthesia for controlling the acute hemodynamic responses during the maintenance period improved the recovery profile after outpatient laparoscopic surgery.


硬膜外或全身麻醉使用止吐药可引起瞳孔反射性扩张

The Effect of Antiemetics on Pupillary Reflex Dilation During Epidural/General Anesthesia

Merlin D. Larson, MD

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

Anesth Analg 2003;97:1652-1656


氯丙嗪和氟哌啶醇此类多巴胺D2受体拮抗药能够改变清醒生物瞳孔的大小,在全麻过程中,这些药物的使用也可以使瞳孔反射性扩张,改变其大小。47位接受复合麻醉(硬膜外加全身麻醉)行下腹部手术的病人,被随机分成5组,分别接受以下5种药物:10ml盐水,0.13mg/kg 奥丹西隆,0.25mg/kg甲氧氯普胺,0.5mg/kg甲氧氯普胺和0.02mg/kg氟哌利多。通过三种方法测量这些药物。并在给药后的51020,和40min进行测量。当硬膜外麻醉成功后(3/8%布比卡因,硬膜外腔连续注射),使用钛电流间断刺激(60-70mamp,100Hz,3s间隔)C5皮区诱导产生瞳孔反射性扩张。甲氧氯普胺组瞳孔的直径改变甚微,易过性反射也不明显。而氟哌利多组瞳孔直径变小长达10min ,在整个实验过程的40 min中,瞳孔反射性扩张均存在,最大的改变为6.6±3.3mm。奥丹西隆组瞳孔的直径没有丝毫的改变。因此,当实验员或临床医师想通过测量瞳孔的直径来价评阿片类药物的水平时,应该避免使用影响多巴胺D2受体的止吐剂。

(肖洁 译  王祥瑞 校)

The effect of dopamine D2 receptor antagonists, such as chlorpromazine and haloperidol, on pupil size in awake subjects suggests that these drugs might also alter pupillary reflex dilation and pupil size during general anesthesia. Forty-seven patients undergoing lower abdominal surgery under combined epidural/general anesthesia were randomized to receive one of the 5 following open labeled drugs: 10 mL saline, 0.13 mg/kg ondansetron, 0.25 mg/kg metoclopramide, 0.5 mg/kg metoclopramide, or 0.02 mg/kg droperidol. Three measurements of reflex dilation were taken at 5-min intervals and after the last measurement (time 0) the drug was administered. Measurements were then taken 5, 10, 20, and 40 min after IV drug administration. Reflex dilation was induced by intermittent noxious stimulation of the C5 dermatome with a tetanic electric current (60–70 mamp, 100 Hz, 3-s duration) after a stable level of epidural analgesia had been established with 3/8% bupivacaine and maintained with a continuous infusion. Metoclopramide produced a small decrease in pupil diameter and transiently depressed reflex dilation, whereas droperidol decreased pupil size at 10 min and depressed reflex dilation throughout the 40-min study period. Maximal change in reflex dilation was -6.6 ± 3.3 mm-sec after droperidol. Ondansetron had no effect on pupil diameter or reflex dilation. When pupillary diameter measurements are used to gauge opioid levels during experimental conditions or during surgical anesthesia, antiemetic medication acting on the dopamine D2 receptor should be avoided.


经颅多普勒监测用于腹腔镜下腰椎融合术

Transcranial Doppler Monitoring During Laparoscopic Anterior Lumbar Interbody Fusion

Maria J. Colomina, MD*, Carmen Godet, MD*, Ferran Pellisé, MD{dagger}, Joan Bagó, MD{dagger}, and Carlos Villanueva, MD{dagger}

Departments of *Anesthesiology and {dagger}Spine Surgery, Area de Traumatología, Hospital Universitario Vall d’Hebron, Barcelona, Spain

Anesth Analg 2003;97:1675-1679


我们研究了长时间腹腔镜手术中气腹和头低位对脑血流动力学的影响。自199510月至19994月臆共有17ASA级的患者(16位女性,1位男性,平均年龄38岁)进行了腹腔镜前腰椎融合术。腹腔镜术前监测生命体征,并通过经颅多普勒超声记录大脑中动脉血流速率和搏动指数。PaCO2和呼吸末CO2维持在正常水平(<40mmHg),所有病例都予以充分供氧,当病人由仰卧位转变为头低位时,心率和中心静脉压都显著增高(P0.05)。而经颅多普勒超声则显示在术四个阶段的任一时期其大脑中动脉平均血流速率和搏动指数无无明显差异。实验中无技术相关性并发症发生,除了第八位患者出现轻度术后头痛,后经氧疗治愈。综上所述,长时间腹腔镜手术中所采取的头低位对于一般情况较好的患者来说,对其脑循环无显著影响。

(朱慧琛 译 王祥瑞 校)

We studied the consequences on cerebral hemodynamics of lengthy laparoscopic procedures requiring pneumoperitoneum and head-down positioning. From October 1995 to April 1999, 17 ASA status I or II patients (16 women and 1 man; mean age, 38 yr) were treated with laparoscopic anterior lumbar fusion. Besides standard perioperative monitoring for laparoscopic surgery, the mean blood-flow velocity of both middle cerebral arteries and the pulsatility index were determined by transcranial Doppler ultrasound. Adequate acoustic windows were encountered in 11 of the 17 patients, and the remaining 6 were excluded from the analysis. PaCO2 and end-tidal CO2 were maintained within normal limits (<40 mm Hg); ventilation was optimized in all cases. There was a significant increase (P < 0.05) in heart rate and central venous pressure with the change from supine to head-down position in all patients. Transcranial Doppler results for mean middle cerebral artery blood-flow velocity and pulsatility index showed no significant variations at any of the four time points studied during the procedure. There were no technique-related complications, except for moderate postoperative headache in eight patients that resolved with rest and oxygen therapy. We conclude that lengthy laparoscopic procedures in the head-down position performed in otherwise healthy patients do not significantly affect intracranial circulation.


硬膜外腔注入透明质酸后的神经毒性反应:光学和电子显微镜检测

The Neurotoxicity of Epidural Hyaluronic Acid in Rabbits: A Light and Electron Microscopic Examination

Young-Jin Lim, MD*, Woo-Seok Sim, MD{dagger}, Yong-Chul Kim, MD*, Sang-Chul Lee, MD*, and Yoon-La Choi, MD{ddagger}

*Department of Anesthesiology and Pain Medicine, Seoul National University, the {dagger}Department of Anesthesiology and Pain Medicine, SungKyunKwan University, and the {ddagger}Department of Diagnostic Pathology, Samsung Medical Center, SungKyunKwan University School of Medicine, Seoul, Korea

Anesth Analg 2003;97:1716-1720


由于透明质酸(HA)有抗炎、防止和/或减少组织粘连的作用,所以我们相信在硬膜外腔注入HA可减轻慢性低位背部疼痛患者的痛楚。因此,我们进行此项前期临床动物实验,通过光学显微镜(LM)和电子显微镜(EM)评估硬膜外腔注入HA后的神经毒性反应,我们将20只兔子随机分为两组:生理盐水(NS)组(N10)和透明质酸(HA)组(N10),NSHA均以0.2mg/Kg注入硬膜外腔除了NS组的一只兔子表现出食欲减退、多动和体重下降外,其余均无感觉及表现异常。光镜发现NS组的两只兔子出现异常,这主要是由于插入导管时引起的损伤和感染所致。EM显示其它组实验动物无明显神经毒性出现。综上所述,动物实验中硬膜外腔注入HA不会产生神经毒性反应。

(朱慧琛 译 王祥瑞 校)

Because hyaluronic acid (HA) has an antiinflammatory effect and prevents and/or reduces tissue adhesion, we believed it possible that epidurally-administered HA during epidural adhesiolysis procedures could alleviate pain in patients with chronic lower back pain. Therefore, we performed this pre-clinical trial evaluation of epidurally-administered HA neurotoxicity by light microscopy (LM) and electron microscopy (EM) in rabbits. Twenty rabbits were randomly divided into two groups, a normal saline (NS) group (n = 10) and a HA group (n = 10). Saline (0.2 mL/kg of 0.9% solution) and the same volume of HA were injected into the epidural space. No rabbits showed any sensory-motor or behavior change during the 3-wk period, except for one rabbit in the NS group that showed decreased appetite, activity, and weight loss. By LM, two rabbits in the NS group showed abnormal findings considered to be the result of trauma and infection associated with epidural catheterization. EM findings showed no significant neurotoxic findings in either group. In conclusion, epidurally-administered HA did not cause neurotoxicity in rabbits.


内毒素休克模型中抗利尿激素对周围、内脏血液动力学以及代谢的影响

The Effects of Vasopressin on Systemic and Splanchnic Hemodynamics and Metabolism in Endotoxin Shock

Tero J. Martikainen, Jyrki J. Tenhunen, MD PhD, Ari Uusaro, MD PhD, MHSc (Epid), and Esko Ruokonen, MD PhD

Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Finland

Anesth Analg 2003;97:1756-1763


我们比较了抗利尿激素和去甲肾上腺素对内毒素性休克的猪周围和内脏循环以及代谢的影响。我们随机地把21只猪分成四组,即内毒素性休克组(注射大肠杆菌内毒素)(n=6,内毒素和抗利尿激素组(VASOn=6),内毒素和去甲肾上腺素组(NE;n=6),和对照组(n=3)。注射内毒素引起低血压,然后使用抗利尿激素或去甲肾上腺素保持外周平均动脉压》70mmHg。我们同时需要测定局部血流和动脉以及局部乳酸浓度。微透毛细血管张力计被置入胃、空肠和结肠内。VASONE组其外周平均动脉压都达到了》70 mmHg的要求。抗利尿激素降低了心排量,并降低肠系膜上动脉和门静脉的血流,然而肝动脉的血流是增高的。动脉乳酸值从2.0Mm1.6-2.1mM)增至4.7mM4.7-4.9mM)(P=0.007)。在VASO组外周和肠系膜的氧输送和氧耗是降低的而氧排出增加。抗利尿激素可使三处的的粘膜动脉PCO2 差值均增高,而肠腔乳酸的释放仅发生于空肠。NE组仍保持稳定。抗利尿激素纠正了低血压却降低了外周和内脏的血流。于是引起高乳酸血症,以及空肠内乳酸的释放。

(朱辉 译 王祥瑞 校)

We compared the effects of vasopressin and norepinephrine on systemic and splanchnic circulation and metabolism in endotoxin shock in pigs. Twenty-one pigs were randomized to endotoxin shock (Escherichia coli endotoxin infusion) (n = 6), endotoxin and vasopressin (VASO; n = 6), endotoxin and norepinephrine (NE; n = 6), and controls (n = 3). Endotoxin infusion was increased to induce hypotension, after which vasopressin or norepinephrine was started to keep systemic mean arterial blood pressure >70 mm Hg. Regional blood flows and arterial and regional lactate concentrations were measured. Tonometers with microdialysis capillaries were inserted into the stomach, jejunum, and colon. Systemic mean arterial blood pressure >70 mm Hg was achieved in the VASO and NE groups. Vasopressin decreased cardiac output, superior mesenteric artery, and portal vein blood flow, whereas hepatic arterial blood flow increased. Arterial lactate concentration increased from 2.0 mM (1.6–2.1 mM) to 4.7 mM (4.7–4.9 mM) (P = 0.007). Systemic and mesenteric oxygen delivery and consumption decreased and oxygen extraction increased in the VASO group. Vasopressin increased mucosal-arterial PCO2 gradients in all three locations, whereas luminal lactate release occurred only in the jejunum. Animals in the NE group remained stable. Vasopressin reversed hypotension but decreased systemic and gut blood flow. This was associated with hyperlactatemia, signs of visceral dysoxia, and jejunal luminal lactate release.


脑部脂类微血栓的动力学特征:对鼠电视显微镜的研究

Dynamic Characteristics of Cerebral Lipid Microemboli: Videomicroscopy Studies in Rats

Robert J. Byrick, MD*, J. Colin Kay{dagger}, C. David Mazer, MD*, Zhilan Wang, MSc{dagger}, and J. Brendan Mullen, MD{ddagger}

*Department of Anaesthesia and the {dagger}Anesthesia Research Laboratory, St. Michael’s Hospital, University of Toronto, and the {ddagger}Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario

Anesth Analg 2003;97:1789-1794


脑脂类微血栓(LME)可能是整形和心血管手术后认知功能障碍的原因。我们把13只已麻醉的老鼠打开颅骨通过直角偏振光谱成像电视显微镜来研究LME。我们从人类关节成形术中获取的骨髓脂肪0.2ml/只,注入到老鼠的上腔静脉内。其中5只老鼠尽管全力复苏但还是在几秒内死亡。七分钟之后,我们在活着的8只老鼠中的6只又另外注入0.1ml的骨髓脂肪。我们对8只老鼠用电视显微镜观察了一小时,并持续测量动脉压。在最初的7分钟我们没有观察到LME,然而,在额外注射了0.1ml的几秒内,平均动脉压从79±31mmHg降到28±12mmHgn=6;P<0.02)。通过注射肾上腺素以及晶体液使血压上升至161±9mmHg并在5分钟内看到了20-100LME。我们发现LME会变形并不断分裂侵蚀和流动,且在动脉内有短暂的阻塞(10-220s)。升高的血压导致阻塞的动脉再灌注。我们没有发现静脉内的骨髓脂肪。我们在死后的老鼠的卵圆孔内发现脑部和肺部LME。这个模型或许对脑部脂类微血栓的研究是有用的。

(朱辉 译 王祥瑞 校)

Cerebral lipid microemboli (LME) may cause postoperative cognitive dysfunction after orthopedic and cardiovascular surgery. In 13 anesthetized rats, we created a cranial window to study LME using orthogonal polarization spectral imaging videomicroscopy. All rats received 0.2 mL of human marrow fat, obtained from surgical waste during arthroplasty, injected into the superior vena cava. Five rats died within seconds of this injection, despite resuscitation efforts. Seven minutes later, we injected an additional 0.1 mL in 6 of the 8 surviving rats. We observed the videomicroscopy for 1 h in all 8 rats. Arterial blood pressure (BP) was continuously measured. No LME were observed in the first 7 min (n = 8); however, within seconds of the additional 0.1 mL injection, mean BP decreased from 79 ± 31 mm Hg to 28 ± 12 mm Hg (n = 6; P < 0.02). Epinephrine and crystalloid infusion increased BP to 161 ± 9 mm Hg and 20–100 LME were seen within 5 min. LME changed shape and fragmentation, erosion, and streaming patterns were noted, with transient arteriolar occlusion (10–220 s). Increasing BP resulted in reperfusion of occluded arterioles. No venous LME were noted. Postmortem, brain and lung LME were found with no patent foramen ovale. This model may be useful in studying cerebral LME.


胸椎硬膜外麻醉改善了腹部手术中的组织氧合功能

Thoracic Epidural Anesthesia Increases Tissue Oxygenation During Major Abdominal Surgery

Barbara Kabon, MD*, Edith Fleischmann, MD{dagger}, Tanja Treschan, MD{dagger}, Akiko Taguchi, MD*, Stephan Kapral, MD{ddagger}, and Andrea Kurz, MD*,§,||

*Department of Anesthesiology, Washington University, St. Louis, Missouri, {dagger}Department of Anesthesiology and General Intensive Care and {ddagger}Anesthesiology and Intensive Care Medicine, Vienna General Hospital, University of Vienna, Austria; §Department of Anesthesiology, University of Berne, Switzerland; and ||Outcomes Research InstituteTM, University of Louisville, Kentucky

Anesth Analg 2003;97:1812-1817
术中的手术刺激能显著增加交感神经活性和血浆儿茶酚胺浓度,引起外周血管收缩,降低组织氧分压,从而导致组织缺氧。组织缺氧与外科伤口感染率增加相关。胸椎硬膜外麻醉阻断了神经刺激的传入和疼痛刺激引起的交感神经传出。据此,我们假设:腹部手术辅以胸椎硬膜外麻醉能改善组织灌注并提高皮下氧分压。30例患者随机分成2组:全麻组(15例)和复合硬膜外麻醉组(15例)。麻醉操作和液体管理均标准化,同时通过上臂内clack电极持续测量皮下氧分压,使用非成对双列t检验统计数据,p0.05认为有显著差异。60分钟后,复合组的氧分压明显高于全麻组(54.3±7.4mmHg42.1±8.6mmHgp=0.0002)。在观察期内,复合组的氧分压均高于全麻组,两组的血流动力学反应和整体的氧和变化相似,同时,复合硬膜外麻醉还提高了阻滞区以外的组织氧分压。这样,我们的结果证明了复合神经阻滞阻断了由于手术应激和交感反应引起的血管收缩。

(陈洁 译 王祥瑞 校)

Intraoperative surgical stress may markedly increase adrenergic nerve activity and plasma catecholamine concentrations, which causes peripheral vasoconstriction and decreased tissue oxygen partial pressure possibly leading to tissue hypoxia. Tissue hypoxia is associated with an increased incidence of surgical wound infections. Thoracic epidural anesthesia blocks afferent neural stimuli and inhibits efferent sympathetic outflow in response to painful stimuli. Consequently, we tested the hypothesis that supplemental thoracic epidural anesthesia during major abdominal surgery improves tissue perfusion and subcutaneous oxygen tension. Thirty patients were randomly assigned to two groups: general (n = 15) or combined general and epidural anesthesia (n = 15). Anesthesia technique and fluid management were standardized. Subcutaneous tissue oxygen tension was measured continuously in the upper arm with a Clark type electrode. Data were compared with unpaired, two-tailed t-tests, Wilcoxon’s ranked sum test, or repeated-measures analysis of variance and Scheffé F tests as appropriate; P < 0.05 was considered statistically significant. After 60 min, intraoperative tissue oxygen tension was significantly larger during combined anesthesia than during general anesthesia (54.3 ± 7.4 mm Hg versus 42.1 ± 8.6 mm Hg; P = 0.0002). Subcutaneous tissue oxygen tension remained significantly higher in the combined general/epidural anesthesia group throughout the observation period. Hemodynamic responses and global oxygen variables were similar in the groups. Thoracic epidural anesthesia improved intraoperative tissue oxygen tension outside the area of the epidural block. Thus, our results give evidence that supplemental neural nociceptive block blunts generalized vasoconstriction caused by surgical stress and adrenergic responses.


新型有效的CO2排出和死腔通气的数学模型

Validation of an Original Mathematical Model of CO2 Elimination and Dead Space Ventilation

Jonathan G. Hardman, FRCA, and Alan R. Aitkenhead, FRCA

From the University Department of Anesthesia, University Hospital, Nottingham, UK

Anesth Analg 2003;97:1840-1845

我们设计了一种新型的精确计算通气和气体交换的数学模型,目的是用于以往和今后的临床调查。首先我们使用低死腔双腔气管导管(DLT),测量使用单腔和双腔气管导管时的PaCO2和气道压力(PAW),在固定每分通气量,改变潮气量时比较模型和患者的PaCO2 PAW。第二个研究我们比较麻醉中的死腔,使模型的VT、呼吸频率、CO2产量、温度、肺泡和死腔通气量达到机械通气时的指标,计算预计的PaCO2产生的百分率和精确性。DLT减少的模型死腔为6.9, PAW0.1%(峰压)和-5.13%(平均压),PaCO21.2%(DLT)1.5%(SLT)。第二个研究中,PaCO2-2.6%0.8%95%的可信区间)。以上结果确认我们的模型可以用于今后理论性的研究。

(陈洁 译 王祥瑞 校)

We present an original, mathematical model of ventilation and gas-exchange. Our aim was to validate it using data from previous clinical investigations, allowing our use of it in future investigations. The first previous investigation used a low-dead space, double-lumen, tracheal tube (DLT). We matched the model’s PaCO2 and airway pressures (PAW) to the patient mean during use of the DLT and a single-lumen tube (SLT). The model’s resulting PaCO2, PÉCO2 and PAW were compared with the patients’ as tidal volume (VT) changed with constant minute volume. The second investigation examined dead space during anesthesia. The model’s VT, respiratory rate, CO2 production, temperature, and alveolar and anatomical dead spaces were matched to each mechanically ventilated subject. Bias and precision in predictions of PaCO2 and PÉCO2 were calculated. The model’s bias in prediction of dead space reduction by the DLT was 6.9%. Bias in prediction of PAW was 0.1% (peak) and -5.13% (mean), of PaCO2 was 1.2% (DLT) and 1.5% (SLT) and of PÉCO2 was 1.7% (DLT) and 1.3% (SLT). Prediction of PaCO2 and PÉCO2 in the second investigation (as 95% confidence interval of bias): PaCO2 -2.6% to 0.8% and PÉCO2 -4.9% to 1.2%. This validation allows future application of our model in appropriate theoretical investigations.

 

胸主动脉瘤血管内修补术术中经食管超声心动图的重要性

The Importance of Intraoperative Transesophageal Echocardiography in Endovascular Repair of Thoracic Aortic Aneurysms

Madhav Swaminathan, MD*, Catherine K. Lineberger, MD*, Richard L. McCann, MD{dagger}, and Joseph P. Mathew, MD*

Departments of *Anesthesiology and {dagger}Surgery, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2003;97:1566-1572

 

主动脉血管内修补术(EVAR)是一种有希望替代开放手术的治疗措施。经食管超声心动图(TEE)是一种对主动脉疾病敏感的成像形式。我们回顾了所有胸主动脉EVAR中使用TEE的经验。七位病人在全麻下行胸主动脉EVAR。术中血管造影和TEE用于确定动脉瘤的范围和指导支架的放置。六位病人成功的植入了内支架。三位病人通过TEE发现存在内漏,其中两位通过动脉造影证实。一位病人因为TEE发现有大范围的动脉裂开而放弃EVAR。我们发现TEE在一下几方面是有价值的术中工具1)确定主动脉病理2)确认导丝在正确的管腔里3)辅助支架植入到位4)补充血管造影发现内漏。TEE能补充血管造影所获得的信息从而增强EVAR的精确性,从而改善预后。通过一种简单的成像形式,麻醉医师即能为血管外科团队提供至关重要的信息,包括支架的位置,内漏和心脏的表现。

(钟鸣 薛张纲 )

Endovascular repair of the aorta (EVAR) is a promising alternative to open repair. Transesophageal echocardiography (TEE) is a sensitive imaging modality for aortic disease. We reviewed our experience with TEE in thoracic EVAR. Seven patients underwent thoracic EVAR under general anesthesia. Intraoperative angiography and TEE were used to identify the extent of the aneurysm and guide placement of the stent. Doppler color flow was used to supplement angiography to detect flow within the aneurysmal sac after stent placement. The endograft was successfully deployed in six patients. Endoleak was identified by TEE in three patients and confirmed by angiography in two of them. EVAR was abandoned in one patient on the basis of TEE findings of extensive aortic dissection. We found TEE to be a valuable intraoperative tool for 1) identifying aortic pathology, 2) confirming that the guidewire is in the true lumen, 3) aiding stent graft positioning, and 4) supplementing angiography for detecting endoleaks. TEE can supplement information obtained by angiography to enhance the accuracy of EVAR and potentially improve outcomes. The anesthesiologist is ideally positioned to provide the endovascular team with vital information regarding stent positioning, endoleaks, and cardiac performance with a single imaging modality.

 

老年体外循环心脏手术中的肾特异性蛋白

Kidney-Specific Proteins in Elderly Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

Joachim Boldt, MD*, Torsten Brenner*, Johannes Lang, MD*, Bernhard Kumle, MD*, and Frank Isgro, MD

Department of Anesthesiology and Intensive Care Medicine and the {dagger}Clinic of Cardiac Surgery, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany

Anesth Analg 2003;97:1582-1589

在心脏手术中,老年病人比年轻病人更易发生急性肾衰(ARF)。我们通过检测肾特异性蛋白来评价老年和年轻心脏外科病人间肾功能的差别。40位连续的年龄小于60岁和40位年龄大于70岁的行择期心脏外科手术(CPB)的病人入选,这些病人术前都不存在肾功能不全。麻醉诱导后、手术结束时和术后(POD)在重症监护室的第一和第二天分别检测肌酐清除率、钠排泄分数和尿中N-乙酰-β-D-氨基葡萄糖苷酶、{alpha}-1-微球蛋白、谷胱甘肽转移酶piGSTpi)和谷胱甘肽转移酶{alpha}GST{alpha})的浓度。病人年龄分别为54 ± 4岁和77 ± 3岁。两组间术前肌酐浓度没有显著差异。旁路后老年组钠排泄分数明显高于年轻组。CPB后老年组尿中肾特异性蛋白的浓度升高(如,GSTpi16.2 ± 3.4升至27.7 ± 3.9 µg/L),然而在年轻组中几乎无变化。甚至在第二个POD老年组中所有肾特异性蛋白浓度均明显大于年轻组。虽然在我们的病人中没有发生需血透的ARF,但在老年组中CPB后尿中肾特异性蛋白浓度升高提示了,同年轻人群相比,在经历心脏手术后老年人肾完整性发生了不连续的和一过性的改变。

(钟鸣 译 薛张纲 校)

In cardiac surgery, acute renal failure (ARF) is more likely in elderly patients than in younger patients. We assessed whether kidney function is different between elderly and younger cardiac surgery patients by measuring kidney-specific proteins. Forty consecutive patients aged <60 yr and 40 patients aged >70 yr without preoperative kidney dysfunction undergoing elective cardiac surgery with cardiopulmonary bypass (CPB) were included. Creatinine clearance and fractional excretion of sodium, as well as urine concentrations of N-acetyl-ß-D-glucosaminidase, {alpha}-1-microglobulin, glutathione transferase-pi (GST-pi), and glutathione transferase-{alpha} (GST-{alpha}) were measured after induction of anesthesia, at the end of surgery, and at the first and second postoperative days (PODs) on the intensive care unit. Patients’ ages were 54 ± 4 and 77 ± 3 yr, respectively. Preoperative creatinine concentrations were without significant differences between the two groups. Fractional excretion of sodium was significantly higher after bypass in the elderly than in the younger patients. Urine concentrations of all kidney-specific proteins increased after CPB in the elderly (e.g., GST-pi from 16.2 ± 3.4 to 27.7 ± 3.9 µg/L), whereas they remained almost unchanged in the younger patients. Concentrations of all kidney-specific proteins were significantly larger in the elderly than in the younger patients even at the second POD. Although none of our patients suffered ARF requiring dialysis, increased post-CPB urine concentrations of kidney-specific proteins in the elderly suggest discrete and transient alterations in kidney integrity in comparison with a younger patient population undergoing cardiac surgery.

 

择期肩部手术术前斜角肌间神经阻滞:病人出院后在术后早期过后益处消失

Preoperative Interscalene Block for Elective Shoulder Surgery: Loss of Benefit over Early Postoperative Block After Patient Discharge to Home

W. Heinrich Wurm, MD*,{dagger}, Mercedes Concepcion, MD{ddagger}, Andrew Sternlicht, MD{dagger},§, Jean Marie Carabuena, MD{ddagger}, Gary Robelen, MD{dagger},§, Leonidas C. Goudas, MD PhD*,{dagger}, Scott A. Strassels, Pharm D*,{dagger}, and Daniel B. Carr, MD

Tufts-New England Medical Center; {dagger}Tufts University School of Medicine; {ddagger}Brigham and Women’s Hospital and Harvard Medical School; §Caritas St. Elizabeth’s Medical Center, Boston, Massachusetts

Anesth Analg 2003;97:1620-1626

我们完成了一项随机的、前瞻的、平行组、开放标注和多中心的试验来比较术前相比术后采用左旋布比卡因行斜角肌间阻滞在术后疼痛和镇痛需要效果方面的不同。102位门诊拟行择期肩部手术的病人被随机分位术前组(PRE组)和术后组(POST组),所有病人采用0.5%的布比卡因30mL阻滞。术后镇痛结果评价包括(a)手术后首次需要镇痛药物的时间,(b)在静止和上肢运动时采用可视的模拟量表来测量疼痛强度,(c)所有非甾体类消炎药和阿片类药物的消耗量。在两治疗组间首次需要镇痛的时间并无差异。然而,手术当天平均最大疼痛强度评分,无论在静止(P0.001)时还是在运动(P0.004)时,PRE组明显小于POST组。术中给予的阿片类药物量PRE组少于POST组(P<0.001)。两组均很好的耐受左旋布比卡因,没有发生与该局麻药相关的不良反应。我们得出结论,术前斜角肌间左旋布比卡因神经阻滞在术后首个12小时内有出众的疼痛控制效果,但这种益处在术后出院回家的一周内并不能维持,因为这些研究对象作为门诊病人被假定自我镇痛。

(钟鸣 译 薛张纲 校)

We performed a randomized, prospective, parallel-group, open-label, multicenter trial to compare the effects of pre- versus postoperative interscalene block using levobupivacaine on postoperative pain and analgesic requirements. One-hundred-two outpatients scheduled for elective shoulder surgery were randomized to receive 30 mL of 0.5% levobupivacaine either preoperatively (PRE group) or postoperatively (POST group). Analgesic outcome measures during the postoperative period were: (a) time to first request for analgesic medication after surgery, (b) pain intensity using the visual analog scale at rest and during arm movement, and (c) total analgesic consumption of nonsteroidal antiinflammatory drugs and opioids. The time to first analgesic request did not differ between treatment groups. However, mean maximum pain intensity scores during the day of surgery were significantly less for the PRE group than the POST group, both at rest (P = 0.001) and after movement (P = 0.004). The mean opioid administered during surgery was lower in the PRE than the POST group (P < 0.001). Levobupivacaine was well tolerated in both treatment groups, and no adverse reactions were related to this local anesthetic. In conclusion, preoperative interscalene block with levobupivacaine provided superior pain control for the first 12 h after surgery, but this benefit was not maintained during the week after discharge because the subjects assumed control of their own pain relief as outpatients.

 

切皮前治疗防止滑动疝术后疼痛

Preincisional Treatment to Prevent Pain After Ambulatory Hernia Surgery

D. Janet Pavlin, MD, Karen D. Horvath, MD, Edward G. Pavlin, MD, and Kristien Sima, BS

From the Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington

Anesth Analg 2003 97: 1627-1632.

 

我们设计了如下方法随机比较腹股沟疝修补术后采用切皮前三剂疗法及标准疗法的病人疼痛程度.三剂疗法包括切皮前应用非甾体类抗炎剂、局部区域阻滞麻醉、N-甲基-D-天冬氨酸止氧剂。治疗组(n = 17)rofecoxib 50mg PO, 0.25%布比卡因或0.5%利多卡行区域阻滞并于切皮前予氯胺酮0.2 mg/kg IV,而对照组(n = 17)予安慰剂术前口服。此项麻醉方案进行标化处理。术后疼痛予芬太尼静注和oxycodone 5mg(或对乙酰氨基酚325mg PO行按需止痛。术后7天内行疼痛评分及止痛剂记录。治疗组较对照组疼痛评分术中低47%,术后第124小时低18%;术后24小时口服止痛剂用量少34%。因此,我们认为切皮前三剂疗法有助于减少门诊病人疝修补术后疼痛及止痛剂用量,并且希望能有此方面的进一步研究。

(陆旭伟 译 薛张纲 校)

We designed this study as a randomized comparison of postoperative pain after inguinal hernia repair in patients treated with triple preincisional analgesic therapy versus standard care. Triple therapy consisted of a nonsteroidal antiinflammatory, a local anesthetic field block, and an N-methyl-D-aspartate inhibitor before incision. The treatment group (n = 17) received rofecoxib, 50 mg PO, a field block with 0.25% bupivacaine/0.5% lidocaine, and ketamine 0.2 mg/kg IV before incision; controls (n = 17) received a placebo PO before surgery. The anesthetic protocol was standardized. Postoperative pain was treated by fentanyl IV and oxycodone 5 mg/acetaminophen 325 mg PO as required for pain. Pain scores (0–10) and analgesic were recorded for the first 7 days after surgery. Pain scores were 47% lower in the treatment group before discharge (3.1 ± 0.6 versus 5.9 ± 0.6, P = 0.0026) (mean ± SE) and 18% less in the first 24 h after discharge (5.6 ± 0.4 versus 6.8 ± 0.5, P = 0.05); oral analgesic use was 34% less in the treatment group (4.6 ± 0.8 doses versus 7.1 ± 0.7 doses, P = 0.02) in the first 24 h after surgery. We conclude that triple preincisional therapy diminishes pain and analgesic use after outpatient hernia repair, and encourage further evaluation of this technique.

 

丙泊酚-利多卡因混合液的理化兼容性

Physicochemical Compatibility of Propofol-Lidocaine Mixture

Yoko Masaki, PhD, Makoto Tanaka, MD, and Toshiaki Nishikawa, MD

Department of Anesthesia, Akita University School of Medicine, Akita-city, Japan

Anesth Analg 2003 97: 1646-1651

 

为了测试临床上常用的普鲁泊酚-利多卡因混合液的理化稳定性,我们在市售的1%丙泊酚20ml中分别加入利多卡因5102040mg。配置混合液后24小时内用气相色谱仪对混合液中的丙泊酚浓度进行测试,以此来评估其化学稳定性。此外,应用电子扫描显微镜在随机视野内测定可见最小液滴的尺寸。宏观上可见:丙泊酚内加2040mg利多卡因混合液于混合后324小时即可见分离出无色的液层,而加510mg利多卡因的混合液则宏观上处稳定状态。加40mg利多卡因的混合液中丙泊酚浓度于配置后424小时呈线性显著下降,而加其他剂量利多卡因的混合液中丙泊酚浓度与基线值相比无改变。电子扫描显微镜显示:直径5um的小液滴最初在加入40mg利多卡因后30min出现,并且乳状小液滴随时间和剂量而增大。我们的结果提示,丙泊酚内加入利多卡因导致小油滴相互结合并最终形成可见的分离的液层。此种混合液随加入利多卡因的剂量以及混合液配置后持续时间的不同而不同程度的增加肺栓塞的危险性。

(陆旭伟 译 薛张纲 校)

To examine the physicochemical stability of combinations of propofol-lidocaine mixtures frequently used in clinical practice, we added lidocaine 5, 10, 20, or 40 mg to commercially available 1% propofol 20 mL. To assess chemical stability, propofol concentrations were determined by gas chromatography assay for 24 h after preparation of the mixture. In addition, scanning electron microscopy was used to determine the maximum detectable droplet size in randomly selected fields. Macroscopically, separate, colorless layers were first seen at 3 and 24 h after the addition of 40 and 20 mg of lidocaine to propofol, respectively, whereas the mixture with 5 or 10 mg of lidocaine was macroscopically stable. Propofol concentrations in the mixture with 40 mg of lidocaine decreased linearly and significantly from 4 to 24 h after preparation, whereas those combined with other lidocaine doses were unchanged compared with baseline concentrations .Scanning electron microscopy showed that droplets with diameters 5 µm first appeared 30 min after the addition of 40 mg of lidocaine to propofol, and the emulsion droplets were enlarged in a time- and dose-dependent fashion. Our results indicate that the addition of lidocaine to propofol results in a coalescence of oil droplets, which finally proceeds to a visible separate layer. Depending on the dose of lidocaine and the duration between its preparation and administration, this combination may pose the risk of pulmonary embolism.

 

全麻后恢复期脑电监护的作用:听觉诱发电位及双频谱指数仪在标准临床实践中的比较

The Effect of Cerebral Monitoring on Recovery After General Anesthesia: A Comparison of the Auditory Evoked Potential and Bispectral Index Devices with Standard Clinical Practice

Alejandro Recart, MD, Irina Gasanova, PhD MD, Paul F. White, PhD MD, Tojo Thomas, MS, Babatunde Ogunnaike, MD, Mohammed Hamza, MD, and Agnes Wang, MS

From the Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center at Dallas

Anesth Analg 2003 97: 1667-1674.

 

脑电监护的应用有助于提高麻醉医生更精确应用麻醉药物的能力。然而也有关于恢复期脑电监护截然相反的报道,即所谓的麻醉共享作用。我们设计了此项前瞻、双盲、假阳性控制的研究来评价地氟醚麻醉病人术中监测脑电双频指数或听觉诱发电位的作用,患者离开苏醒室的时间以及患者对麻醉、恢复过程的满意度。九十位标准麻醉下行腹腔镜普外科手术的健康患者随机的分为三组采取不同的监测方式:1)标准临床监测(对照组) 2)脑电双频指数监测(BIS组) 3)听觉诱发电位监测(AEP组)。所有患者全麻诱导前均予BISAEP监测。对照组中麻醉医生手术期间不允许观察BISAEPBIS监测组中间断给予挥发性麻醉药维持BIS值在4555之间。AEP监测组目标AEP值为1520之间。每隔35分钟记录BISAEP值、潮气末地氟醚浓度。每隔110分钟记录苏醒时间、拔管时间、PACU离观标准评分。另外于术后24小时按100分及18分标准对患者满意度和恢复质量进行分别评分。AEP BIS监测组术中潮气末地氟醚浓度平均值显著小于对照组。虽然术后睁眼、拔管、听从指令的时间AEP组和BIS组均短于对照组,但只有拔管时间的差别具有显著性。更重要的是,患者在PACU停留的时间AEP组和BIS组显著少于对照组,而且患者的恢复质量亦显著高于对照组。因此我们认为用BISAEP监测脑电可以减少麻醉维持期间(地氟醚)麻醉药的用量,从而导致患者腹腔镜术后PACU停留时间缩短并提高患者恢复质量。但是BISAEP两组的结果尚无显著差别。

(陆旭伟 译 薛张纲 校)

The use of cerebral monitoring may improve the ability of anesthesiologists to titrate anesthetic drugs. However, there is controversy regarding the impact of the alleged anesthetic-sparing effects of cerebral monitoring on the recovery process and patient outcome. We designed this prospective double-blinded, sham-controlled study to evaluate the impact of intraoperative monitoring with the electroencephalogram bispectral index (BISTM) or auditory evoked potential (AEP) device on the usage of desflurane and the time to discharge from the recovery room, as well as on patient satisfaction with their anesthetic experience and recovery. Ninety healthy patients undergoing laparoscopic general surgery procedures using a standardized anesthetic technique were randomly assigned to one of three monitoring groups: standard clinical practice (control), BIS-guided, or AEP-guided. Both the BIS and AEP monitors were connected to all patients before induction of general anesthesia. In the control group, the anesthesiologists were not permitted to observe the BIS or AEP index values during the intraoperative period. In the BIS-guided group, the volatile anesthetic was titrated to maintain a BIS value in the range of 45–55. In the AEP-guided group, the targeted AEP index range was 15–20. The BIS and AEP indices, as well as end-tidal desflurane concentration, were recorded at 3–5 min intervals. Recovery times to awakening, tracheal extubation, fast-track score 12, and postanesthesia care unit (PACU) discharge criteria were recorded at 1–10 min intervals. In addition, patient satisfaction with anesthesia and quality of recovery were evaluated on 100- and 18-point scales, respectively, at 24 h after surgery. The AEP- and BIS-guided groups were administered significantly smaller average end-tidal desflurane concentrations than the control group (3.8 ± 0.9 and 3.9 ± 0.6 versus 4.7 ± 1.7, respectively) (P < 0.01). Although the emergence times to eye opening, tracheal extubation, and obeying commands were consistently shorter in the AEP and BIS groups (6 ± 4 and 6 ± 5 versus 8 ± 8 min; 6 ± 5 and 6 ± 4 versus 11 ± 10 min; and 8 ± 4 and 7 ± 4 versus 12 ± 9 min, respectively), only the extubation times were significantly different from the control group (P < 0.05). More importantly, the length of the PACU stay was significantly shorter in both the AEP- and BIS-guided groups (79 ± 43 and 80 ± 47 versus 108 ± 58 min, respectively) (P < 0.05). The patients’ quality of recovery was also significantly higher in the two monitored groups (15 ± 2 versus 13 ± 3 in the control group, P < 0.05). We concluded that cerebral monitoring with either the BIS or AEP devices reduced the maintenance anesthetic (desflurane) requirement, resulting in a shorter length of stay in the PACU and improved quality of recovery after laparoscopic surgery. However, there were no significant outcome differences between the two cerebral monitored groups.

 

老年患者行髋关节成形术时鞘内吗啡剂量的优化

Optimizing the Dose of Intrathecal Morphine in Older Patients Undergoing Hip Arthroplasty

P. M. Murphy, MB FCARCSI*, D. Stack, MB FCARCSI*, B. Kinirons, MB FFARCSI*, and J. G. Laffey, MD MA, BSc, FFARCSI*,{dagger}

*Department of Anaesthesia, Merlin Park Regional Hospital, Galway; and {dagger}Clinical Sciences Institute, National University of Ireland, Galway, Ireland

Anesth Analg 2003 97: 1709-1715.

 

鞘内给予吗啡可提供很好的术后镇痛,但也可产生许多不良反应包括术后恶心呕吐、搔痒、呼吸抑制,特别在较大剂量时容易发生。而老年患者有更大的发生危险性。老年患者行髋关节成形术椎管内吗啡的最佳剂量目前尚未知。为此我们设计了此项前瞻性、随机、对照、双盲试验,对行择期髋关节成形术的老年患者予鞘内应用50200ug吗啡镇痛,以此来评估止痛剂的效力和副作用。共选择了6065岁以上行择期髋关节成形术的患者。患者分为4组,随机接受椎管内15mg布比卡因镇痛联和鞘内应用吗啡:10ug 250ug 310ug 4200ug。鞘内用100ug200ug吗啡组较对照组更有效缓解疼痛并减少术后吗啡需量。鞘内应用50ug吗啡不能提供有效的镇痛。而鞘内应用100ug200ug吗啡组均能产生有效的镇痛。各组术后恶心呕吐、镇静、呼吸抑制、尿潴留的发生率无差异。但是搔痒在200ug组的发生率显著增加,因此行髋关节成形术的老年患者鞘内应用100ug吗啡可在术后镇痛及副作用发生之间达到良好的平衡。

(陆旭伟 译 薛张纲 校)

Intrathecal (IT) morphine provides excellent postoperative analgesia but may result in many side effects, including postoperative nausea and vomiting, pruritus, and respiratory depression, particularly at larger doses. Older patients may be at particular risk. The optimal dose of spinal morphine in older patients undergoing hip arthroplasty is not known. We designed this prospective, randomized, controlled, double-blinded study to evaluate the analgesic efficacy and side effect profile of 50–200 µg of IT morphine in older patients undergoing elective hip arthroplasty. Sixty patients older than 65 years undergoing elective hip arthroplasty were enrolled. Patients were randomized to receive spinal anesthesia with 15 mg of bupivacaine and IT morphine in four groups: 1) 0 µg, 2) 50 µg, 3) 100 µg, and 4) 200 µg. IT morphine 100 and 200 µg produced effective pain relief and decreased the postoperative requirement for morphine compared with control. IT morphine 50 µg did not provide effective pain relief. Both 100 and 200 µg of IT morphine provided comparable levels of postoperative analgesia. There were no between-group differences in postoperative nausea and vomiting, sedation, respiratory depression, or urinary retention. Pruritus was significantly more frequent with 200 µg of IT morphine. In conclusion, 100 µg of IT morphine provided the best balance between analgesic efficacy and side effect profile in older patients undergoing hip arthroplasty.

 

黄芩甙在爱兰苔胶引起的热痛觉过敏中的抗炎和镇痛作用

The Antiinflammatory and Analgesic Effects of Baicalin in Carrageenan-Evoked Thermal Hyperalgesia

Tz-Chong Chou, PhD*, Li-Ping Chang, MD PhD{dagger}, Chi-Yuan Li, MD{ddagger}, Chih-Shung Wong, MD PhD{ddagger}, and Shih-Ping Yang, MD PhD§

*Department of Physiology and Biophysics, National Defense Medical Center, Taipei, Taiwan, Republic of China; and {dagger}Department of Radiation Oncology, {ddagger}Department of Anesthesiology, and §Division of Cardiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China

Anesth Analg 2003;97:1724-1729

我们用爱兰苔胶引起热痛觉过敏的老鼠模型测试了黄芩甙的抗过敏和镇痛作用及其机制。事前或事后运用黄芩甙(10, 30, or 100 mg/kg 腹膜内)所引起的镇痛效果与等剂量的布洛芬相似。而且,注射爱兰苔胶后四小时黄芩甙剂量依赖性的降低了肿瘤坏死因子-{alpha}(从3510 ± 150 pg/mL 2860 ± 148 pg/mL 1480 ± 210 pg/mL),白介素(IL)-1ß(从3210 ± 210 pg/mL 2200 ± 140 pg/mL 750 ± 95 pg/mL),IL-6 ( 58.5 ± 9.8 pg/mL 38.5 ± 9.0 21.0 ± 8.1 ng/mL)的生成,同时增加了IL-10 ( 18.1 ± 2.5 pg/mL 36.1 ± 5.5 pg/mL 71.2 ± 9.5 pg/mL)的产生。注射爱兰苔胶后四小时而不是1.5小时后,黄芩甙(10–100 mg/kg 腹膜内)剂量依赖性的抑制注射爱兰苔胶的鼠爪处前列腺素E2 (PGE2)和硝酸盐的量(PGE2: 15.9 ± 2.1 ng/mL 12.1 ± 1.6 ng/mL 6.2 ± 1.8 ng/mL;硝酸盐: 39.8 ± 4.8 µM 27.5 ± 3.0 µM 17.2 ± 1.6 µM)。同时也剂量依赖性的抑制注射爱兰苔胶后引起的髓过氧化酶活性的提高。这些发现提示我们黄芩甙的抗炎和镇痛机制可能与在炎症的局部抑制炎症因子,包括一氧化氮,PGE2,前炎症因子,增加IL-10的产生和中性粒细胞的浸润。

(方芳 译 薛张纲 校)

We tested baicalin for its antiinflammatory and analgesic effects (and the mechanisms) in a rat model of carrageenan-evoked thermal hyperalgesia. Pre- or posttreatment with baicalin (10, 30, or 100 mg/kg intraperitoneally) caused a significant analgesic effect with a similar effect of dose-matched ibuprofen. Furthermore, baicalin dose-dependently attenuated tumor necrosis factor-{alpha} (from 3510 ± 150 pg/mL to 2860 ± 148 pg/mL to 1480 ± 210 pg/mL), interleukin (IL)-1ß (from 3210 ± 210 pg/mL to 2200 ± 140 pg/mL to 750 ± 95 pg/mL), and IL-6 (from 58.5 ± 9.8 pg/mL to 38.5 ± 9.0 to 21.0 ± 8.1 ng/mL) formation but enhanced IL-10 (from 18.1 ± 2.5 pg/mL to 36.1 ± 5.5 pg/mL to 71.2 ± 9.5 pg/mL) production in paw exudates at 4 h after carrageenan injection. Prostaglandin E2 (PGE2) and nitrate formation in the carrageenan-injected paws were dose-dependently inhibited by baicalin (10–100 mg/kg intraperitoneally) (PGE2: from 15.9 ± 2.1 ng/mL to 12.1 ± 1.6 ng/mL to 6.2 ± 1.8 ng/mL; nitrate: from 39.8 ± 4.8 µM to 27.5 ± 3.0 µM to 17.2 ± 1.6 µM) at 4 h but not at 1.5 h after carrageenan injection. Increased myeloperoxidase activity in carrageenan-injected paws was also dose-dependently reduced by baicalin. These findings suggest that the antiinflammatory and analgesic mechanisms of baicalin may be associated with the inhibition of critical inflammatory mediators, including nitric oxide, PGE2, and proinflammatory cytokines, accompanied by an increase in IL-10 production, as well as neutrophil infiltration at sites of inflammation.

 

9ONO-1714,一种一氧化氮合成酶抑制剂,减轻家兔内毒素引起的急性肺损伤

ONO-1714, a Nitric Oxide Synthase Inhibitor, Attenuates Endotoxin-Induced Acute Lung Injury in Rabbits

Katsuya Mikawa, MD, Kahoru Nishina, MD, Yumiko Takao, MD, and Hidefumi Obara, MD

From the Department of Anesthesia & Perioperative Medicine, Faculty of Medical Sciences, Kobe University Graduate School of Medicine, Kobe, Japan

Anesth Analg 2003;97:1751-1755

由于诱发一氧化氮合成酶(iNOS)的表达而引起的一氧化氮的过度产生被认为是内毒素诱导的急性肺损伤(ALI)的主要发病机制。在这个研究中,我们想看看是否ONO-1714,一种新的选择性的iNOS抑制剂,可以减轻内毒素诱导的ALI。在研究的第一部分,一组家兔静脉注射生理盐水,另外四组静脉注射5 mg/kg的内毒素30分钟后引起ALI。后四组中,三组在注射内毒素之前10分钟,分别注射ONO-1714 0.1, 0.03, 0.01 mg/kg,另外一组注射生理盐水。研究的第二部分,所有六组都被注射内毒素而引起ALI,一组用生理盐水治疗,另外五组在不同的时间用ONO-1714 0.1 mg/kg治疗(ALI发生前10分钟,发生后1234小时)ALI发生后用40%的氧机械通气六小时。第一部分中,预先用0.1 mg/kg ONO-1714治疗组减轻了内毒素诱发的ALI。在第二部分,两小时之内使用ONO-1714和预先使用一样有效,都可以改善氧合,肺泡通气,肺的白细胞分离,肺水肿,和组织学改变。但是使用内毒素后34小时后它对减轻家兔肺损伤没什么帮助了。这些数据提示我们今天的研究为以后的临床研究提供一个依据去说明ONO-1714是否可以作为一个有效的治疗手段用于内毒素血症或败血症引起的急性呼吸窘迫综合征。

(方芳 译 薛张纲 校)

Overproduction of nitric oxide by inducible nitric oxide synthase (iNOS) expressed in the lung is thought to play a crucial role in the pathogenesis of endotoxin-induced acute lung injury (ALI). In this two-part study, we determined whether ONO-1714, a new selective iNOS inhibitor, attenuates endotoxin-induced ALI in rabbits. For Part I of the study, a control group received IV saline and ALI was induced by IV infusion of endotoxin 5 mg/kg over 30 min in 4 groups. Three groups received either 0.1, 0.03, or 0.01 mg/kg of ONO-1714 10 min before the start of endotoxin and the fourth group received saline. For Part II of the study, ALI was induced by endotoxin infusion in all 6 groups. One group was treated with saline. The other 5 groups received ONO-1714 0.1 mg/kg at various timings (10 min before or 1, 2, 3, or 4 h after ALI induction). The lungs were mechanically ventilated with 40% oxygen for 6 h after induction of ALI. In Part I, pretreatment with 0.1 mg/kg ONO-1714 mitigated endotoxin-induced ALI. In Part II, early posttreatment (within 2 h after the insult) with ONO-1714 was as effective as pretreatment in improving oxygenation, lung mechanics, lung leukosequestration, pulmonary edema, and histological change. However, lung damage was not improved in rabbits receiving the drug 3 or 4 h after endotoxin. These data suggest that the current study is a basis for future clinical trials to elucidate whether ONO-1714 can be a promising therapeutic approach in patients with acute respiratory distress syndrome induced by endotoxin/sepsis.

 

BRL 52537研究鼠缺血性神经保护中{kappa}-鸦片受体的选择性

Kappa-Opioid Receptor Selectivity for Ischemic Neuroprotection with BRL 52537 in Rats

Zhizheng Zhang, MD*, Tsung-Ying Chen, MD{dagger}, Jeffrey R. Kirsch, MD*, Thomas J. K. Toung, MD{dagger}, Richard J. Traystman, PhD*, Raymond C. Koehler, PhD{dagger}, Patricia D. Hurn, PhD*, and Anish Bhardwaj, MD{dagger},{ddagger}

*Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, Oregon; and Departments of {dagger}Anesthesiology/Critical Care Medicine and {ddagger}Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland

Anesth Analg 2003;97:1776-1783

{kappa}-鸦片受体(KOR)已经被应用于缺血性神经损伤后的神经保护,但是关于他在暂时性的脑缺血再灌注中的作用却还未被深入研究。我们测试了选择性,特异性的KOR激动剂BRL 52537盐酸盐[(±)-1-(3,4-dichlorophenyl)acetyl-2-(1-pyrrolidinyl)methylpiperidine]和标准的KOR拮抗nor-binaltorphiminedihydrochloride[nor-BNI;17,17'-(dicyclopropylmethyl)-6,6',7,7'-6,6'-imino-7,7'-binorphinan-3,4',14,14'-tetrol],对小鼠暂时性脑缺血后功能和组织学方面起的作用。通过使用腔内导丝技术,用氟烷麻醉的成年雄性Wistar小鼠的大脑中动脉被阻断2小时,并使用多普勒血流计监测。以随机双盲的方式,小鼠被分为以下几组:1)再灌注前15分钟及灌注后用生理盐水治疗22小时;2)再灌注前15分钟用生理盐水治疗,灌注后用BRL 52537 (1 mg • kg-1 • h-1)治疗22小时;3)再灌注前15分钟用生理盐水治疗,灌注后用nor-BNI (1 mg • kg-1 • h-1) 治疗22小时;4)再灌注前15分钟用nor-BNI (1 mg/kg),灌注后用BRL 52537 (1 mg • kg-1 • h-1) and nor-BNI (1 mg • kg-1 • h-1) 治疗22小时。再灌注四天后分析梗死区域(单侧结构)发现,生理盐水/ BRL 52537 (n = 8;皮质 , 10.2% ± 4.3%; 尾状核[CP], 23.8% ± 6.7%) (平均值 ± 标准差)与生理盐水/生理盐水组 (n = 8; 皮质, 28.6% ± 4.9%; CP, 53.3% ± 5.8%)相比损伤显著减轻。在BRL 52537中加入特异性的KOR 拮抗剂nor-BNI可以完全阻止BRL 52537的神经保护作用(n = 7; 皮质, 28.6% ± 5.3%; CP, 40.9% ± 6.2%)BRL 52537并不产生缺血后的低温。这些数据表明KOR可以为缺血性卒中的早期再关注提供一个治疗靶点。

(方芳 译 薛张纲 校)

 

{kappa}-Opioid receptors (KOR) have been implicated in neuroprotection from ischemic neuronal injury, but less work has been performed with transient focal cerebral ischemia to determine the role of KOR during reperfusion. We tested the effects of a selective and specific KOR agonist, BRL 52537 hydrochloride [(±)-1-(3,4-dichlorophenyl)acetyl-2-(1-pyrrolidinyl)methylpiperidine], and the standard KOR antagonist, nor-binaltorphimine dihydrochloride [nor-BNI; 17,17'-(dicyclopropylmethyl)-6,6',7,7'-6,6'-imino-7,7'-binorphinan-3,4',14,14'-tetrol], on functional and histological outcome after transient focal ischemia in the rat. By use of the intraluminal filament technique, halothane-anesthetized adult male Wistar rats were subjected to 2 h of middle cerebral artery occlusion confirmed by laser Doppler flowmetry. In a blinded, randomized fashion, rats were treated with 1) saline (vehicle) 15 min before reperfusion followed by saline at reperfusion for 22 h, 2) saline 15 min before reperfusion followed by BRL 52537 (1 mg • kg-1 • h-1) at reperfusion for 22 h, 3) saline 15 min before reperfusion followed by nor-BNI (1 mg • kg-1 • h-1) at reperfusion for 22 h, or 4) nor-BNI (1 mg/kg) 15 min before reperfusion followed by BRL 52537 (1 mg • kg-1 • h-1) and nor-BNI (1 mg • kg-1 • h-1) at reperfusion for 22 h. Infarct volume (percentage of ipsilateral structure) analyzed at 4 days of reperfusion was significantly attenuated in saline/BRL 52537 rats (n = 8; cortex, 10.2% ± 4.3%; caudoputamen [CP], 23.8% ± 6.7%) (mean ± SEM) compared with saline/saline treatment (n = 8; cortex, 28.6% ± 4.9%; CP, 53.3% ± 5.8%). Addition of the specific KOR antagonist nor-BNI to BRL 52537 completely prevented the neuroprotection (n = 7; cortex, 28.6% ± 5.3%; CP, 40.9% ± 6.2%) conferred by BRL 52537. BRL 52537 did not produce postischemic hypothermia. These data demonstrate that KORs may provide a therapeutic target during early reperfusion after ischemic stroke

 

罗哌卡因与芬太尼用于分娩硬膜外自控镇痛时的浓度:容量范围的研究

Ropivacaine and fentanyl concentrations in patient-controlled epidural analgesia during labor: a volume-range study.

Bernard JM, Le Roux D, Frouin J.

Departement d'Anesthesie-Reanimation, Polyclinique Jean-Villar, Bruges-Bordeaux,

Anesth Analg. 2003 ;97(6):1800-7.

 

我们选择了诱导分娩的初产妇进行此项随机试验,以明确在分娩过程中使用患者自控硬膜外镇痛(PECA)装置时,其中的药物浓度是否需要提高。病人被分为6(每组n=25)PECA泵使用的镇痛药浓度为罗哌卡因/芬太尼0.1%/0.5mg/mL0.2%/1mg/mL。其中3组在分娩早期(宫缩每3min一次且宫颈扩张4cm)使用的剂量为12ml16ml20ml稀释液,在分娩后期为6ml8ml10ml的浓缩液。另外3组在这两个时期接受的剂量都为12ml16ml20ml稀释液。锁定的时间间隔为25min。最初的结果测定数据为从开始到第一次请求医生追加止痛的时间,之后的评估包括疼痛评分(可以使用可视类比评分尺,VAS,从010分级)、满意度评分、动脉血压、运动阻滞的强度与硬膜外阻滞上部感觉缺失平面。患者、助产士与观测者均不知道实验药物和PECA的设置。疼痛评估的最高分被定义为每一患者在每一阶段最强烈的疼痛感觉,镇痛持续的时间被定义为从每一阶段开始到第一次注射补充的镇痛剂之间间隔的时间,并使用生存分析法比较。两组间一般人口学资料和产科变异、动脉血压、运动阻滞强度、硬膜外阻滞上部感觉缺失平面和满意度评分均无差异。在每一个阶段,都有至少75%的妇女,将满意度等级评为好或极好的水平。在分娩后期,使用20ml稀释液组的疼痛评估最高分低于使用6ml浓缩液组;而在20ml稀释液组与10ml浓缩液组之间的疼痛评估最高分无显著性差异(VAS值的差别=-0.495% 的可信限为-1.599 0.799P = 0.5055)。在分娩后期,使用20ml稀释液组的镇痛持续时间(99 +/- 4 min) (mean +/- SD)大于12ml稀释液组(77 +/- 30 min)16ml稀释液组(80 +/- 23 min);但在20ml稀释液组与10ml浓缩液组(92 +/- 23 min)之间以及12ml稀释液组与6ml浓缩液组(78 +/- 30 min)之间无显著性差异;8ml浓缩液组(94 +/- 16 min) 的镇痛持续时间大于16ml稀释液组。我们得出的结论是:在分娩的过程中,每一PECA使用20ml0.1%/0.5mg/mL的罗哌卡因/芬太尼镇痛是有效的。当分娩过程进入活跃期后,使用16mg罗哌卡因与8mg芬太尼这样的剂量,浓度加倍,可以延长镇痛持续时间。当使用12mg罗哌卡因与6mg芬太尼时,镇痛效果并不令人满意,即使药物浓度加倍也无临床效果。这个结果暗示了:PECA的作用效率取决于所用药物的总量,而不是每次成功泵注的药物体积或浓度。结论:若段患者自控硬膜外镇痛(PECA)的镇痛药物有效剂量已经给足,那么当分娩过程进入活跃期后,再增加药物浓度是没有临床意义的。PECA的镇痛质量取决于每个阶段所给药物的总量,而不是所加的输液泵内的药物浓度。

(金琳 薛张纲 )

We enrolled nulliparous women in induced labor in a randomized study to determine whether increasing the concentration of the solution used in a patient-controlled epidural analgesia (PCEA) device was required as labor progressed. Patients were assigned to 6 groups (n = 25 in each group), receiving ropivacaine/fentanyl in concentrations of either 0.1%/0.5 microg/mL or 0.2%/1 microg/mL via a PCEA pump. Three groups received boluses of 12, 16, or 20 mL dilute solution in early labor (uterine contractions every 3 min and 4-cm cervical dilation) then 6, 8, and 10 mL concentrated solution in late labor. Three other groups received boluses of 12, 16, or 20 mL dilute solution during both periods. The lockout interval was 25 min. The primary outcome was time until the first request for staff-administered analgesia supplement. Hourly assessments included pain scores on a visual analog scale (VAS) graded from 0 to 10, satisfaction scores, arterial blood pressure, motor block intensity, and the upper sensory level of epidural anesthesia. Patients, midwives, and the observer were unaware of study solutions and PCEA settings. The maximum pain score was defined as the highest score experienced by each patient during each period. Duration of analgesia was defined as the time from the start of each period to the first injection of rescue analgesia and was compared using a survival analysis. There were no differences among the groups with regard to demographic and obstetric variables, arterial blood pressure, motor block intensity, upper sensory level, or satisfaction scores. At least 75% of the women rated their satisfaction as either good or excellent during each period. During late labor, the maximum pain score was lower in the group receiving 20 mL dilute solution compared with the group receiving 6 mL concentrated solution. Maximum pain score was not significantly different between 20 mL dilute solution and 10 mL concentrated solution (difference between VAS values = -0.4; 95% confidence limits, -1.599 and 0.799; P = 0.5055). During late labor, the duration of analgesia was longer in groups receiving 20 mL dilute solution (99 +/- 4 min) (mean +/- SD) than in those receiving 12 mL (77 +/- 30 min) and 16 mL (80 +/- 23 min). Duration of analgesia did not differ between groups receiving 20 mL and 10 mL (92 +/- 23 min) or between groups receiving 12 mL and 6 mL (78 +/- 30 min) of each respective solution. Duration of analgesia was longer in the groups receiving 8 mL concentrated solution (94 +/- 16 min) than in those receiving 16 mL dilute solution. We concluded that 0.1%/0.5 microg/mL ropivacaine/fentanyl was effective throughout labor when 20 mL was injected with each PCEA demand. With 16 mg ropivacaine and 8 microg fentanyl, the duration of analgesia was prolonged by doubling the concentration when labor became active. When 12 mg ropivacaine and 6 microg fentanyl were injected at each demand, analgesia was less satisfactory and doubling the concentration was not clinically effective. These results suggest that the effectiveness of PCEA is dependent on drug mass rather than the volume or concentration administered with each successful pump demand. IMPLICATIONS: There is no clinical reason for increasing the concentration of the patient-controlled epidural analgesia (PCEA) solution when labor becomes active provided that an effective dose is already being administered with each demand. The quality of PCEA depends on the drug mass given with each demand rather than the concentration of the pump solution.

 

在全麻和手术应激状态下,胸部硬膜外麻醉对健康猪的肝脏灌注和氧合作用的影响

The effects of thoracic epidural anesthesia on hepatic perfusion and oxygenation in healthy pigs during general anesthesia and surgical stress.

Vagts DA, Iber T, Puccini M, Szabo B, Haberstroh J, Villinger F, Geiger K, Noldge-Schomburg GF.

Anaesthesiologische Universitatsklinik Freiburg, Freiburg im Breisgau, Germany. G

Anesth Anal 2003 ;97(6):1824-32.

 

在围手术期肝脏损伤的机制中,肝脏灌注的减少是继系统炎症反应综合症之后的一个重要发现。此项动物实验的设计是为了评估胸部硬膜外麻醉(TEA)引起的低血压是否会损伤肝脏的氧合作用。在伦理评估之后,19只已麻醉并进行灵敏监测的猪被随即分成3(对照组、单纯TEA组和TEA加容量负荷组)。每一阶段在硬膜外腔内注入0.5% 布比卡因0.75 mL,以保持T5T12的阻滞平面。首先获得基础值,在硬膜外注药之后,每隔60120分钟重复测量一次。TEA与平均动脉压的下降有关,但并没有改变肝脏总的血流量。肝脏氧的运输与摄取保持不变,肝组织的氧分压也没有下降,血浆吲哚青绿清除率保持稳定。TEA前的容量负荷并没有对肝脏总的血流量产生重大影响。得出的结论是:尽管TEA会使平均动脉压下降,但并不影响肝脏的氧合;容量负荷对肝脏的灌注并无显著的临床意义。

(金琳 薛张纲 )

 

 

Perioperative liver injury due to decreased perfusion may be an underlying mechanism behind the development of systemic inflammatory response syndrome. We designed this animal study to assess whether thoracic epidural anesthesia (TEA) impairs liver oxygenation due to induced hypotension. After ethical approval, 19 anesthetized and acutely instrumented pigs were randomly assigned to 3 groups (control and TEA alone versus TEA plus volume loading). Bupivacaine 0.5% 0.75 mL per segment was injected into the epidural space, aiming for a T5 to T12 block. After baseline values were obtained, measurements were repeated 60 and 120 min after epidural injection. TEA was associated with decreased mean arterial blood pressure but no change in total hepatic blood flow. Oxygen delivery to the liver and oxygen uptake remained unchanged. Liver tissue oxygen partial pressure did not decrease. The plasma indocyanine green disappearance rate remained stable. Volume loading before TEA did not relevantly affect total hepatic blood flow; it even decreased oxygen supply to the liver by hemodilution. We conclude that, despite decreased mean arterial blood pressure, TEA did not affect liver oxygenation. There was no clinically relevant effect of volume loading on total hepatic perfusion.

(金琳)

 

防止全麻诱导时的肺不张

Prevention of atelectasis formation during induction of general anesthesia.

Rusca M, Proietti S, Schnyder P, Frascarolo P, Hedenstierna G, Spahn DR, Magnusson L.

Departments of Anesthesiology, University Hospital, Lausanne, Switzerland.

Anesth Analg. 2003 ;97(6):1835-9.

 

全身麻醉有引起肺不张的可能,并且高浓度的氧气会增加危险危险性。我们研究了在全麻诱导时使用呼气末正压通气装置(PEEP)(吸入氧浓度[FiO2]1.0)对防止肺不张的效率。16名成年病人被随机分成两组,每组都吸入5分钟100%O2,在全麻诱导后使用FiO2 1.0进行面罩机械同气,5分钟后,气管内插管。第一组病人(PEEP)保持持续的气道内正压(CPAP) (6 cm H2O),并继续使用面罩进行机械通气,PEEP值为6 cm H2O。对照组没有使用CPAPPEEP。肺不张的确诊是通过CT以及血气分析取得,并在麻醉前和插管后即刻各检查一次。在气管内插管后,对照组病人肺不张区域的面积增加,由0.8% +/- 0.9%4.1% +/- 2.0% (P = 0.0002);而PEEP组的病人没有发现明显的改变(0.5% +/- 0.6%0.4% +/- 0.7%)。使用FiO2 1.0插管之后,PEEP组的PaO2较对照组有显著升高(591 +/- 54 mm Hg457 +/- 99 mm HgP = 0.005)。尽管仍然使用高浓度的氧气,在麻醉诱导期使用PEEP通气装置可以有效地防止肺不张的发生,提高氧合作用。结论:在全身麻醉诱导期使用呼气末正压通气装置可以防止肺不张的发生,提高氧合作用,并且在插管前提高安全线。因此,建议在所有的麻醉诱导期使用这项技术,至少用于怀疑有困难气道的病人。

(金琳 薛张纲 )

General anesthesia promotes atelectasis formation, which is augmented by administration of large oxygen concentrations. We studied the efficacy of positive end-expiratory pressure (PEEP) application during the induction of general anesthesia (fraction of inspired oxygen [FIO(2)] 1.0) to prevent atelectasis. Sixteen adult patients were randomly assigned to one of two groups. Both groups breathed 100% O(2) for 5 min and, after a general anesthesia induction, mechanical ventilation via a face mask with a FIO(2) of 1.0 for another 5 min before endotracheal intubation. Patients in the first group (PEEP group) had continuous positive airway pressure (CPAP) (6 cm H(2)O) and mechanical ventilation via a face mask with a PEEP of 6 cm H(2)O. No CPAP or PEEP was applied in the control group. Atelectasis, determined by computed radiograph tomography, and analysis of blood gases were measured twice: before the beginning of anesthesia and directly after the intubation. There was no difference between groups before the anesthesia induction. After endotracheal intubation, patients in the control group showed an increase of the mean area of atelectasis from 0.8% +/- 0.9% to 4.1% +/- 2.0% (P = 0.0002), whereas the patients of the PEEP group showed no change (0.5% +/- 0.6% versus 0.4% +/- 0.7%). After the intubation with a FIO(2) of 1.0, PaO(2) was significantly higher in the PEEP group than in the control (591 +/- 54 mm Hg versus 457 +/- 99 mm Hg; P = 0.005). Atelectasis formation is prevented by application of PEEP during the anesthesia induction despite the use of large oxygen concentrations, resulting in improved oxygenation.