Anesthesia & Analgesia

December 2003

Table of Content

CARDIOVASCULAR ANESTHESIA:

肺癌手術後急性肺損傷的危險因素

(王士雷 譯 莊心良 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.

 

胸主動脈瘤血管內修補術術中經食管超聲心動圖的重要性

(鍾鳴 薛張綱 )

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.

 

地氟醚和丙泊酚對門高壓病人門體靜脈壓力的影響

(殷文淵 譯 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.

比較二種不同紅細胞洗滌方法時紅細胞的恢復情況

(王士雷 譯 莊心良 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.

 

老年體外迴圈心臟手術中的腎特異性蛋白

(鍾鳴 譯 薛張綱 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緩慢鈉排泄作用使細胞脫水

(殷文淵 譯 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.

血管容量替代治療策略的新啟發:我們過去三年中學到了什麼?

(王士雷 譯 莊心良 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:

病人自控硬膜外鎮痛與持續硬膜外腔注射布比卡因鎮痛在小兒術後鎮痛應用的比較

(齊波 譯 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.

小兒氣管內插管的套囊壓力是不可預測

(王士雷 莊心良 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:

 

擇期肩部手術術前斜角肌間神經阻滯:病人出院後在術後早期過後益處消失

(鍾鳴 譯 薛張綱 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.

 

切皮前治療防止滑動疝術後疼痛

(陸旭偉 譯 薛張綱 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.

 

日間手術使用艾司洛爾和尼卡地平對術後恢復的影響

(肖潔 譯 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:

異丙酚調節原位大鼠腸系膜血管平滑肌超極化的機制

(王士雷 莊心良 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相容性

(陸旭偉 譯 薛張綱 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藥可引起瞳孔反射性擴張

(肖潔 譯  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.

全膝關節成形術用骨粘固粉引起血漿星形膠質細胞S-100B蛋白升高

(王士雷 莊心良 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:

 

全麻後恢復期腦電監護的作用:聽覺誘發電位及雙頻譜指數儀在標準臨床實踐中的比較

(陸旭偉 譯 薛張綱 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.

經顱多普勒監測用於腹腔鏡下腰椎融合術

(朱慧琛 譯 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.

 

閉合環路PhysioFlex Deltatrac II 間接測量儀測量氧耗的研究

(王士雷 莊心良 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:

 

老年患者行髖關節成形術時鞘內嗎啡劑量的優化

(陸旭偉 譯 薛張綱 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.

 

硬膜外腔注入透明質酸後的神經毒性反應:光學和電子顯微鏡檢測

(朱慧琛 譯 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.

 

二氫可待因和布洛芬間的鎮痛作用是協同的

(王士雷 譯 莊心良 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.

 

黃芩甙在愛蘭苔膠引起的熱痛覺過敏中的抗炎和鎮痛作用

(方芳 譯 薛張綱 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:

適應性支援通氣的自動“呼吸和脫機”:對氣管內插管時間和病人管理的影響

(王士雷 莊心良 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-1714,一種一氧化氮合成酶抑制劑,減輕家兔內毒素引起的急性肺損傷

(方芳 譯 薛張綱 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.

 

內毒素休克模型中抗利尿激素對周圍、內臟血液動力學以及代謝的影響

(朱輝 譯 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.

 

用尿氧張力監測危重病人的腎氧耗

(王士雷 莊心良 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研究鼠缺血性神經保護中{kappa}-鴉片受體的選擇性

(方芳 薛張綱 )

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.

 

腦部脂類微血栓的動力學特徵:對鼠電視顯微鏡的研究

(朱輝 譯 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:

右側和左側臥位對剖宮產手術腰麻起效的影響

(王士雷 莊心良 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.

 

羅呱卡因與芬太尼用於分娩硬膜外自控鎮痛時的濃度:容量範圍的研究

(金琳 譯 薛張綱 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術中的組織氧合功能

(陳潔 譯 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.

在腹腔鏡膽囊切除術時胃壁內和動脈內CO2分壓的差別顯著增加:胸部硬膜外麻醉的作用

(王士雷 譯 莊心良 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.

 

在全麻和手術應激狀態下,胸部硬膜外麻醉對健康豬的肝臟灌注和氧合作用的影響

(金琳 譯 薛張綱 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:

 

防止全麻誘導時的肺不張

(金琳 譯 薛張綱 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排出和死腔通氣的數學模型

(陳潔 譯 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.

以動脈和呼吸末CO2的梯度估計肺泡死腔

(王士雷 莊心良 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.

 

 

肺癌手術後急性肺損傷的危險因素

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.

 

急性肺損傷是胸外科手術後的嚴重併發症,是造成術後死亡的主要因素之一。我們連續對879例非小肺癌腫瘤行肺切除術病人發生急性肺損傷的危險因素進行了分析。搜集臨床麻醉、外科、放射、生化和組織病理等方面的資料。結果顯示,胸外科術後急性肺損傷的總發病率為4.2%。有10例病人是由術後3-12天出現併發症(支氣管肺炎, n = 5; 支氣管肺瘺, n = 2; 胃內容物誤吸, n = 2;血栓栓塞, n = 1)而誘發急性肺損傷,稱為繼發性肺損傷,其死亡率為60%。餘下27例病人,在術後0-3天無臨床不良事件發生,為原發性急性肺損傷,其死亡率為26%。原發性肺損傷有4個主要危險因素:術中高通氣壓指數(幾率3.595%可信區間1.7-8.4)、過度輸液(幾率2.995%可信區間1.9-7.4)、肺切除術(幾率2.895%可信區間1.4-6.3)、以及術前酒精濫用(幾率1.995%可信區間1.1-5.6)。結論:降低胸外科術後發生急性肺損傷(包括中間併發症誘發的延遲性肺損傷和早期肺損傷)危險性的策略包括:術前戒酒、肺保護性通氣模式和限制液體輸入。

(王士雷 莊心良 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.

 

比較二種不同紅細胞洗滌方法時紅細胞的恢復情況

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.

 

紅細胞血搜集回輸的效果主要決定於從外科術野搜集的紅細胞量以及回輸給病人的紅細胞數量。本文作者假設pneumatic disk (PD)比傳統的方式Latham bowl (LB) 有更好的紅細胞恢復度。比較二種機器搜集血液的速度和記憶體血液容量為100 1000 mL時機器產生的血紅蛋白量。PD可以提供連續血紅蛋白濃縮(21.7 ± 0.8 g/dL),而LB提供血紅蛋白濃縮程度依賴於記憶體中血液的容量,濃度從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)。當滿記憶體的紅細胞血液被處理時,LB提供的紅細胞回輸量大於PD79.4%83.6%p<0.001)。LB在任何起始儲存容量的處理速度都快於PD。結論:當血液丟失量少而未達到滿的LB時,PD每次處理過程都能夠得到恒定血紅蛋白的大容量細胞。

 

(王士雷 莊心良 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.

 

血管容量替代治療策略的新啟發:我們過去三年中學到了什麼?

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.

有關理想血管內容量替代治療策略的定義仍然是一個非常具有挑戰性的問題。本文從medline上搜集最近三年(1,1, 200012, 12, 2002)有關容量替代治療的資料進行分析,共涉及2454人的50個原創性研究。其中5個研究在志願者中進行,其他35個研究在不同的病人中進行(包括心外科、 創傷 、小兒和ICU病人)。不同容量治療措施對凝血的影響是大家主要關心的主題,其他主題包括代謝狀態、大循環和微循環的變化、容量分佈和器官功能。(腎灌注和內臟灌注)。在所有的人工膠體中,羥乙基澱粉是研究最多的。關於白蛋白的研究只有二個。沒有發現白蛋白比價格低廉的人工膠體有什麼優越性。結論:羥乙基澱粉是研究容量替代治療應用最多的膠體,而白蛋白研究很少,且未發現其明顯優點。在這個領域的未來研究有望對理想的容量替代策略產生新的觀點和思路。

(王士雷 莊心良 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.

 

小兒氣管內插管的套囊壓力是不可預測

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.

 

儘管氣囊高壓充氣可能引起氣管粘膜損傷,近年在8歲以下的小兒中應用帶套囊氣管導管的情況越來越多。我們對最初充空氣的氣管套囊壓力Pcuff以及隨後用50%N2O麻醉期間套囊壓力的演變情況。符合下列標準的174例年齡在0-9歲的小兒進入本研究:1)體重3-35KG2)ASA I II; 3)擇期外科手術;4)用有套囊的氣管插管進行麻醉,麻醉時間至少45min5)吸入的混合氣體中包含50%N2O。最初充空氣產生不同的Pcuff, 其中39%有過度充氣。有85%的病人需要通過各種方法去除多餘的氣體以維持氣囊壓力在25cm以下。隨著機械通氣的延長,放氣的數量減少,在105min後就很少了。在不同套囊的氣管導管之間未觀察到有區別。結論:充空氣後Pcuff是不可預測的,在小兒N2O麻醉期間,要不斷放氣以維持套囊壓力小於25cm H2O

 

(王士雷 莊心良 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.

 

異丙酚調節原位大鼠腸系膜血管平滑肌超極化的機制

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.

 

我們以前的研究表明異丙酚可以引起小動脈和靜脈平滑肌細胞超極化。本研究探討這種超極化是對血管平滑肌上存在的特殊鉀通道的作用,還是繼發于第二信使如NOcGMPcAMP的變化。以SD大鼠去交感支配的原位腸系膜小動脈和靜脈為模型,探討應用特殊血管平滑肌鈣通道抑制劑、ATP敏感鉀通道(KATP) 電壓依賴鉀通道 (Kv) 、內向整流鉀通道(KIR) 抑制劑以及內源性血管舒張因數抑制劑前後異丙酚對這些平滑肌細胞膜電位的影響。結果,異丙酚使小腸系膜血管平滑肌顯著超極化。在抑制KCa KATPNO cGMP (but not cAMP)後這種抑制超極化的作用消失。假定血管平滑肌跨膜電位的幅度和收縮力之間是逆向關係,本研究結果表明,異丙酚通過啟動KCa KATP通道引起去神經支配的小腸系膜血管平滑肌的超極化和舒張。這些作用受第二信使NOcGMP的調節,而不受cAMP的調節。

(王士雷 莊心良 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.

 

全膝關節成形術用骨粘固粉引起血漿星形膠質細胞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.

 

骨粘固粉用於關節成形術可以引起大腦微栓子。星形膠質細胞S-100B蛋白是腦損傷比較敏感的指標。本實驗以其為指標,觀察骨粘固粉對骨外科手術病人腦影響。對14例行膝關節置換的病人(n7)和脛骨骨折髓內針固定術(n7)的病人進行了本研究。每例膝關節成形術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。在全麻誘導前、氣囊止血帶放氣後15min、手術後3天抽取血樣。在放止血帶後15min時,膝關節成形術病人的星形膠質細胞S-100B蛋白遠遠高於脛骨骨折固定術(0.41 and 0.08 ng/mL, respectively; P < 0.05)。所有病人均未發現術後神經功能障礙。結論:儘管骨粘固粉並不改變膝關節成形術病人的神經功能評分,但可以產生短暫性的星形膠質細胞損傷。

(王士雷 莊心良 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.

 

閉合環路PhysioFlex Deltatrac II 間接測量儀測量氧耗的研究

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.

 

本研究探討用PhysioFlex 閉路麻醉機和Deltatrac II 間接測量計測量的氧耗之間的結果是否有一致性。在危重病機械通氣的病人通過這兩種方式連續測量氧耗。在穩定讀數的情況下,連續記錄10次每分鐘測量的平均值。通過Bland-Altman分析法對結果進行分析。共分析了21例病人中的54對數值,平均偏差為6.32 mL/min,二者吻合的限值是40.28 and -27.63 mL/min。組間相關係數為0.9595%可信區間為0.91-0.97。結論:用PhysioFlex麻醉機測量的氧耗和用間接測熱法測量的氧耗結果有一致性。

(王士雷 莊心良 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.

 

二氫可待因和布洛芬間的鎮痛作用是協同的

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臨床處理中,常複合應用阿片類和非固醇類抗炎藥物。應用大鼠光照甩尾實驗,我們觀察了二氫可待因的鎮痛效能。相比較而言,在這個模型上,單用布洛芬對中和重度疼痛無效,也許這反映了其鎮痛作用的有限性。儘管布洛芬在這個模型上無效,合用布洛芬,顯著增強二氫可待因的鎮痛效果。劑量依賴關係的研究表明,單用二氫可待因的半數有效劑量為11 mg/kg 。但複合固定劑量的布洛芬研究不同劑量二氫可待因的鎮痛作用,二氫可待因半數鎮痛劑量向左移接近7倍,為1.6 mg/kg 。應用固定比率的二氫可待因和布洛芬(1:40),也顯示劑量出現4倍的偏移(2.6 mg/kg )。結論:在非炎症痛動物模型上,二氫可待因和布洛芬的抗傷害作用是協同的。

(王士雷 莊心良 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.

 

適應性支援通氣的自動“呼吸和脫機”:對氣管內插管時間和病人管理的影響

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.

 

適應性支援通氣根據病人被動和主動的呼吸力學自動調節通氣裝置。本研究評價機械支持通氣時自動呼吸停機在心外科早期拔管中的作用。病人在壓力支援模式下隨機分為固定模式機械支援通氣組ASV和標準同步間歇指令通氣組SIMV18例病人完成了固定模式機械通氣,16例病人完成了標準同步間歇指令通氣。病人圍術期病情,氣管插管留置時間,ICU停留時間和通氣變數無顯著差異,但ASV組病人在通氣的最初階段吸氣壓較低(17.5 ± 0.8 versus 22.2 ± 0.8 cm H2O; P < 0.01)ASV病人需要少的通氣參數調節(2.4 ± 0.7 versus 4.0 ± 0.8 manipulations per patient; P < 0.05),和少的高吸氣壓報警(0.7 ± 2.4 versus 2.9 ± 3.0; P < 0.05)。本研究結果顯示,用ASV模式自動通氣的結果和對照組相同,但機器的內部固定程式使我們只需對機器進行少量的操作,使呼吸管理更加簡單。

(王士雷 莊心良 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.

 

用尿氧張力監測危重病人的腎氧耗

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.

 

危重病人可能由於全身低血壓而發展為腎功能障礙的危險。本研究通過持續監測尿氧張力,一種相對無創但可以即時提供腎氧狀態的技術,檢驗ICU病人應用非諾多泮(一種抗高血壓藥物)對氧利用的影響。50ICU病人應用不同劑量的非諾多泮(0.03, 0.06, and 0.09 µg • kg-1 • min-1)。每小時收集尿量以評價容量和電介質。在改變非諾多泮的劑量時以及輸注末分析心率、平均動脈壓、心輸出量、肺動脈嵌壓、動脈氧輸送指數,以及氧耗指數在。通過置入橈動脈和膀胱中的感測器連續監測PaO2 and PuO2。在非諾多泮劑量提高時,PuO2 顯著升高(P < 0.05), PaO2 維持不變。本研究中,心率、平均動脈壓、心輸出量、肺動脈嵌壓、動脈氧輸送指數,以及氧耗指數保持不變。 結論:與劑量有關的 PuO2 的升高, 與全身灌注指數和心臟功能無關,表明非諾多泮影響狀態穩定的危重病人的腎氧供需平衡。

(王士雷 莊心良 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.

 

右側和左側臥位對剖宮產手術腰麻起效的影響

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.

 

剖宮產左外側臥位加之子宮左側位可能影響局麻藥的擴散,對腰麻的起效產生重要影響。本研究探討60例剖宮產婦女用0.5%重比重布比卡因和芬太尼腰麻時左外側和右外側體位對腰麻起效的影響。儘管二組均有產婦T4冷感覺消失的時間均要15min後,但更多左側臥位的產婦在5min時即達到這個要求。感覺消失的最大水平、液體入量、血管收縮藥物、附加應用鎮痛藥物的量以及術後併發症的發生率二者之間無差異。結論:當在重比重布比卡因和芬太尼腰麻下行剖宮產時,二種體位元都可以應用。

(王士雷 莊心良 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.

 

在腹腔鏡膽囊切除術時胃壁內和動脈內CO2分壓的差別顯著增加: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.

本研究探討氣腹對胃粘膜下灌注代謝的影響。用氣體張力測量法得到20例擇期腹腔鏡膽囊切除術時PCO2差值(胃粘膜和動脈之間的差值),我們進一步檢查胸部硬膜外對其的影響。病人隨機分為全麻組和全麻複合硬膜外組,每組10例。二組病人在氣腹期間,PCO2 差值均較基礎值顯著升高,直至手術結束都維持在高水準。在任何時間點,這些差值在二組之間都無差異。結論:氣腹顯著影響胃粘膜下灌注和代謝,胸部硬膜外麻醉並不減輕氣腹期間和氣腹後胃粘膜灌注的損害。

(王士雷 莊心良 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.

 

以動脈和呼吸末CO2的梯度估計肺泡死腔

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.

我們應用原創有效高保真的肺生理模型,通過動脈CO2張力和肺死腔估算的方式,用傳統的Fowler’s技術和 Bohr公式: (VDalv/VTalv)Bohr-Fowler.比較動脈和呼吸末CO2梯度。具體研究三種情況(不同的CO2產生量、靜脈血摻雜和解剖死腔)下的Pa-E'CO2/PaCO2。在肺泡形狀維持不變的情況下,檢查的因素(VCO2肺動脈分流和 VDanat) 均引起(VDalv/VTalv)Bohr-Fowler Pa-E'CO2/PaCO2的變化。VDanat 變化誘發Pa-E'CO2/PaCO2 d的變異稍微大,但在靜脈血摻雜和VCO2之間相同。結論:Pa-E'CO2/PaCO2可能是危重病人非常有用的測量方法,這種數值非常容易得到,且計算方法較(VDalv/VTalv)Bohr-Fowler簡單。

(王士雷 莊心良 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.

 

地氟醚和丙泊酚對門高壓病人門體靜脈壓力的影響

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


肝血管壓力的測量可用於指導減輕門高壓的治療。在全麻中,這些測量頻繁使用。既然大多數麻醉藥物會降低肝血流,也會影響肝血管壓力。因此我們在一個前瞻性的隨機的試驗中觀察了兩種常用麻醉藥物對肝血管壓力的影響,以判斷是否麻醉中測量出的壓力與清醒狀態下相似。我們研究了21名丙肝病人,排除了有門靜脈血栓的病人。所有病人都在清醒鎮靜狀態下和地氟醚或丙泊酚麻醉後進行了開放和楔入肝血管壓力測定。地氟醚顯著升高了開放肝血管壓力(11.9±4.423.5±4.1mmHgP<0.05)降低了肝血管壓力梯度(21.6±7.414.7±7.2mmHgP<0.05)。而丙泊酚沒有改變這些參數。我們的結論是:地氟醚而不是丙泊酚會改變清醒狀態下測得的肝血管壓力。顯著升高了開放肝血管壓力;降低了肝血管壓力梯度,一種門體靜脈壓力的間接測量。在使用地氟醚進行全麻時應考慮到肝血管壓力梯度的改變。 

(殷文淵 譯 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緩慢鈉排泄作用使細胞脫水

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


醋酸林格氏液是一種緩慢的低滲液體(滲透壓270mosmol/kg),被認為是使水容量轉移到細胞內間隙的一種液體。給五名健康女性志願者輸注25ml/kg的醋酸林格氏液(平均1565ml),觀察輸注15304580分鐘時間段的不同狀況以評估腎臟在影響這種容量轉換中的作用。忽略輸注速度,排泄的尿液中只含有所輸注液體一般的鈉(平均67mmol/L)。但血清鈉濃度僅略微提高了0.9mmol/L,物質守衡定律提示在輸注結束30分鐘後有274ml的水從細胞內轉移到細胞外間隙(P<0.001)。在隨後的90分鐘仍有這種轉移存在。總之,輸注醋酸林格氏液並不會由於排泄的尿液中鈉濃度低而促進細胞膨脹。在輸注結束兩小時後我們測量出仍有從細胞外間隙的少量脫水。    

(殷文淵 譯 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.


病人自控硬膜外鎮痛與持續硬膜外腔注射布比卡因鎮痛在小兒術後鎮痛應用的比較

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鎮痛已經應用于小兒病人,然而,病人自控硬膜外鎮痛(PCEA)至今還沒有應用于小兒病人。本研究主要對PCEA和持續硬膜外腔注射鎮痛(CEA)在小兒病人中應用的臨床療效進行比較。48名接受矯形外科手術的小兒病人隨機分為兩組,一組接受0.2%布比卡因PCEA,另外一組接受0.2%布比卡因CEA。所有病人均在標準全身麻醉下實施手術,同時也都給予酮洛芬和propacetamol治療。術後48小時內記錄小兒病人的疼痛評分和副反應。如果可視疼痛評分大於4分,最高10分,則認為術後鎮痛是不完善的,需要追加鎮痛藥的劑量。結果兩組病人均獲得了滿意的術後鎮痛。但PCEA組病人所需局麻藥的劑量明顯小於CEA組病人(0.20±0.08mg•Kg-1•h-10.40±0.08 mg•Kg-1•h-1P0.001)兩組病人的運動反應、鎮痛藥追加劑量和副反應均無明顯差異。因此0.2%布比卡因PCEA可以提供給接受矯形外科手術的小兒病人充分的術後鎮痛,且所需局麻藥的劑量小於CEA。                    

(齊波 譯 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.

日間手術使用艾司洛爾和尼卡地平對術後恢復的影響

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


在麻醉過程中,維持血液動力學穩定最好的方法是學術界爭論的問題。本實驗是一個前瞻性、隨機、雙盲的研究,旨在證明門診外科中,對全麻的病人運用一定的技術維護血液動力學的穩定有利於病人的預後。45位健康的婦產科病人(行宮腔鏡檢查)自願參加本項研究,她們被隨機分為3個治療組:組1(對照組,n=15),生理鹽水5ml 1 ml,然後再輸入生理鹽水0.005ml•kg-1•min-1,組2 (n=15),艾司洛爾50mg和生理鹽水1 ml,然後再輸入艾司洛爾5g•kg-1•min-1,組3(n=15),艾司洛爾50mg和尼卡地平1 ml,然後再輸入艾司洛爾5g•kg-1•min-1。所有藥物的使用都在麻醉誘導後進行,麻醉誘導給芬太尼1.5g/kg,普魯泊福2mg/kg,維庫溴銨0.12mg/kg後氣管插管。麻醉起始時用地氟醚2%N2 O67%O2。術中,通過調節實驗藥物的滴注速度和地氟醚的濃度,使平均動脈壓(MAP)維持在基線±15%。除MAP和心率外,術中還記錄了患者的雙頻腦電圖指數。我們還對患者術後復蘇的時間和術後副反應做了評估。與對照組相比,氣管插管後艾司洛爾和尼卡地平組心率(組2)和血壓(組3)的增高都不明顯。此外,在麻醉維持階段,艾司洛爾配合地氟醚使用可以縮短急性自主反應發生的時間(4 ±27±4 min );在術後,還可以減少阿片類藥物的使用(43%80%);提早腸蠕動恢復時間(209±89269±100 min)。本研究的結論是:麻醉誘導中使用艾司洛爾或配合尼卡地平,可以減少氣管插管時對血液動力學的影響。此外,艾司洛爾作為地氟醚-N2O佐劑,在麻醉維持階段可以控制急性血液動力學反應,從而有利於經腹腔鏡檢查的門診病人的恢復。 

(肖潔 譯 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藥可引起瞳孔反射性擴張

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


氯丙嗪和氟呱啶醇此類多巴胺D2受體拮抗藥能夠改變清醒生物瞳孔的大小,在全麻過程中,這些藥物的使用也可以使瞳孔反射性擴張,改變其大小。47位接受複合麻醉(硬膜外加全身麻醉)行下腹部手術的病人,被隨機分成5組,分別接受以下5種藥物:10ml鹽水,0.13mg/kg 奧丹西隆,0.25mg/kg甲氧氯普胺,0.5mg/kg甲氧氯普胺和0.02mg/kg氟呱利多。通過三種方法測量這些藥物。並在給藥後的51020,和40min進行測量。當硬膜外麻醉成功後(3/8%布比卡因,硬膜外腔連續注射),使用鈦電流間斷刺激(60-70mamp,100Hz,3s間隔)C5皮區誘導產生瞳孔反射性擴張。甲氧氯普胺組瞳孔的直徑改變甚微,易過性反射也不明顯。而氟呱利多組瞳孔直徑變小長達10min ,在整個實驗過程的40 min中,瞳孔反射性擴張均存在,最大的改變為6.6±3.3mm。奧丹西隆組瞳孔的直徑沒有絲毫的改變。因此,當實驗員或臨床醫師想通過測量瞳孔的直徑來價評阿片類藥物的水平時,應該避免使用影響多巴胺D2受體的止吐劑。

(肖潔 譯  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.


經顱多普勒監測用於腹腔鏡下腰椎融合術

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


我們研究了長時間腹腔鏡手術中氣腹和頭低位對腦血流動力學的影響。自199510月至19994月臆共有17ASA級的患者(16位女性,1位男性,平均年齡38歲)進行了腹腔鏡前腰椎融合術。腹腔鏡術前監測生命體征,並通過經顱多普勒超聲記錄大腦中動脈血流速率和搏動指數。PaCO2和呼吸末CO2維持在正常水平(<40mmHg),所有病例都予以充分供氧,當病人由仰臥位轉變為頭低位時,心率和中心靜脈壓都顯著增高(P0.05)。而經顱多普勒超聲則顯示在術四個階段的任一時期其大腦中動脈平均血流速率和搏動指數無無明顯差異。實驗中無技術相關性併發症發生,除了第八位元患者出現輕度術後頭痛,後經氧療治癒。綜上所述,長時間腹腔鏡手術中所採取的頭低位元對於一般情況較好的患者來說,對其腦迴圈無顯著影響。

(朱慧琛 譯 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.


硬膜外腔注入透明質酸後的神經毒性反應:光學和電子顯微鏡檢測

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


由於透明質酸(HA)有抗炎、防止和/或減少組織粘連的作用,所以我們相信在硬膜外腔注入HA可減輕慢性低位背部疼痛患者的痛楚。因此,我們進行此項前期臨床動物實驗,通過光學顯微鏡(LM)和電子顯微鏡(EM)評估硬膜外腔注入HA後的神經毒性反應,我們將20只兔子隨機分為兩組:生理鹽水(NS)組(N10)和透明質酸(HA)組(N10),NSHA均以0.2mg/Kg注入硬膜外腔除了NS組的一隻兔子表現出食欲減退、多動和體重下降外,其餘均無感覺及表現異常。光鏡發現NS組的兩隻兔子出現異常,這主要是由於插入導管時引起的損傷和感染所致。EM顯示其他組實驗動物無明顯神經毒性出現。綜上所述,動物實驗中硬膜外腔注入HA不會產生神經毒性反應。

(朱慧琛 譯 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.


內毒素休克模型中抗利尿激素對周圍、內臟血液動力學以及代謝的影響

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


我們比較了抗利尿激素和去甲腎上腺素對內毒素性休克的豬周圍和內臟迴圈以及代謝的影響。我們隨機地把21只豬分成四組,即內毒素性休克組(注射大腸桿菌內毒素)(n=6,內毒素和抗利尿激素組(VASOn=6),內毒素和去甲腎上腺素組(NE;n=6),和對照組(n=3)。注射內毒素引起低血壓,然後使用抗利尿激素或去甲腎上腺素保持外周平均動脈壓》70mmHg。我們同時需要測定局部血流和動脈以及局部乳酸濃度。微透毛細血管張力計被置入胃、空腸和結腸內。VASONE組其外周平均動脈壓都達到了》70 mmHg的要求。抗利尿激素降低了心排量,並降低腸系膜上動脈和門靜脈的血流,然而肝動脈的血流是增高的。動脈乳酸值從2.0Mm1.6-2.1mM)增至4.7mM4.7-4.9mM)(P=0.007)。在VASO組外周和腸系膜的氧輸送和氧耗是降低的而氧排出增加。抗利尿激素可使三處的的粘膜動脈PCO2 差值均增高,而腸腔乳酸的釋放僅發生於空腸。NE組仍保持穩定。抗利尿激素糾正了低血壓卻降低了外周和內臟的血流。於是引起高乳酸血症,以及空腸內乳酸的釋放。

(朱輝 譯 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.


腦部脂類微血栓的動力學特徵:對鼠電視顯微鏡的研究

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


腦脂類微血栓(LME)可能是整形和心血管手術後認知功能障礙的原因。我們把13只已麻醉的老鼠打開顱骨通過直角偏振光譜成像電視顯微鏡來研究LME。我們從人類關節成形術中獲取的骨髓脂肪0.2ml/只,注入到老鼠的上腔靜脈內。其中5只老鼠儘管全力復蘇但還是在幾秒內死亡。七分鐘之後,我們在活著的8只老鼠中的6只又另外注入0.1ml的骨髓脂肪。我們對8只老鼠用電視顯微鏡觀察了一小時,並持續測量動脈壓。在最初的7分鐘我們沒有觀察到LME,然而,在額外注射了0.1ml的幾秒內,平均動脈壓從79±31mmHg降到28±12mmHgn=6;P<0.02)。通過注射腎上腺素以及晶體液使血壓上升至161±9mmHg並在5分鐘內看到了20-100LME。我們發現LME會變形並不斷分裂侵蝕和流動,且在動脈內有短暫的阻塞(10-220s)。升高的血壓導致阻塞的動脈再灌注。我們沒有發現靜脈內的骨髓脂肪。我們在死後的老鼠的卵圓孔內發現腦部和肺部LME。這個模型或許對腦部脂類微血栓的研究是有用的。

(朱輝 譯 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術中的組織氧合功能

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
術中的手術刺激能顯著增加交感神經活性和血漿兒茶酚胺濃度,引起外周血管收縮,降低組織氧分壓,從而導致組織缺氧。組織缺氧與外科傷口感染率增加相關。胸椎硬膜外麻醉阻斷了神經刺激的傳入和疼痛刺激引起的交感神經傳出。據此,我們假設:腹部手術輔以胸椎硬膜外麻醉能改善組織灌注並提高皮下氧分壓。30例患者隨機分成2組:全麻組(15例)和複合硬膜外麻醉組(15例)。麻醉操作和液體管理均標準化,同時通過上臂內clack電極持續測量皮下氧分壓,使用非成對雙列t檢驗統計資料,p0.05認為有顯著差異。60分鐘後,複合組的氧分壓明顯高於全麻組(54.3±7.4mmHg42.1±8.6mmHgp=0.0002)。在觀察期內,複合組的氧分壓均高於全麻組,兩組的血流動力學反應和整體的氧和變化相似,同時,複合硬膜外麻醉還提高了阻滯區以外的組織氧分壓。這樣,我們的結果證明了複合神經阻滯阻斷了由於手術應激和交感反應引起的血管收縮。

(陳潔 譯 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排出和死腔通氣的數學模型

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

我們設計了一種新型的精確計算通氣和氣體交換的數學模型,目的是用於以往和今後的臨床調查。首先我們使用低死腔雙腔氣管導管(DLT),測量使用單腔和雙腔氣管導管時的PaCO2和氣道壓力(PAW),在固定每分通氣量,改變潮氣量時比較模型和患者的PaCO2 PAW。第二個研究我們比較麻醉中的死腔,使模型的VT、呼吸頻率、CO2產量、溫度、肺泡和死腔通氣量達到機械通氣時的指標,計算預計的PaCO2產生的百分率和精確性。DLT減少的模型死腔為6.9, PAW0.1%(峰壓)和-5.13%(平均壓),PaCO21.2%(DLT)1.5%(SLT)。第二個研究中,PaCO2-2.6%0.8%95%的可信區間)。以上結果確認我們的模型可以用於今後理論性的研究。

(陳潔 譯 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.

 

胸主動脈瘤血管內修補術術中經食管超聲心動圖的重要性

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

 

主動脈血管內修補術(EVAR)是一種有希望替代開放手術的治療措施。經食管超聲心動圖(TEE)是一種對主動脈疾病敏感的成像形式。我們回顧了所有胸主動脈EVAR中使用TEE的經驗。七位病人在全麻下行胸主動脈EVAR。術中血管造影和TEE用於確定動脈瘤的範圍和指導支架的放置。六位病人成功的植入了內支架。三位病人通過TEE發現存在內漏,其中兩位通過動脈造影證實。一位病人因為TEE發現有大範圍的動脈裂開而放棄EVAR。我們發現TEE在一下幾方面是有價值的術中工具1)確定主動脈病理2)確認導絲在正確的管腔裏3)輔助支架植入到位4)補充血管造影發現內漏。TEE能補充血管造影所獲得的資訊從而增強EVAR的精確性,從而改善預後。通過一種簡單的成像形式,麻醉醫師即能為血管外科團隊提供至關重要的資訊,包括支架的位置,內漏和心臟的表現。

(鍾鳴 薛張綱 )

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.

 

老年體外迴圈心臟手術中的腎特異性蛋白

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

在心臟手術中,老年病人比年輕病人更易發生急性腎衰(ARF)。我們通過檢測腎特異性蛋白來評價老年和年輕心臟外科病人間腎功能的差別。40位連續的年齡小於60歲和40位年齡大於70歲的行擇期心臟外科手術(CPB)的病人入選,這些病人術前都不存在腎功能不全。麻醉誘導後、手術結束時和術後(POD)在重症監護室的第一和第二天分別檢測肌酐清除率、鈉排泄分數和尿中N-乙酰-β-D-氨基葡萄糖苷酶、{alpha}-1-微球蛋白、谷胱甘肽轉移酶piGSTpi)和谷胱甘肽轉移酶{alpha}GST{alpha})的濃度。病人年齡分別為54 ± 4歲和77 ± 3歲。兩組間術前肌酐濃度沒有顯著差異。旁路後老年組鈉排泄分數明顯高於年輕組。CPB後老年組尿中腎特異性蛋白的濃度升高(如,GSTpi16.2 ± 3.4升至27.7 ± 3.9 µg/L),然而在年輕組中幾乎無變化。甚至在第二個POD老年組中所有腎特異性蛋白濃度均明顯大於年輕組。雖然在我們的病人中沒有發生需血透的ARF,但在老年組中CPB後尿中腎特異性蛋白濃度升高提示了,同年輕人群相比,在經歷心臟手術後老年人腎完整性發生了不連續的和一過性的改變。

(鍾鳴 薛張綱 )

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.

 

擇期肩部手術術前斜角肌間神經阻滯:病人出院後在術後早期過後益處消失

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

我們完成了一項隨機的、前瞻的、平行組、開放標注和多中心的試驗來比較術前相比術後採用左旋布比卡因行斜角肌間阻滯在術後疼痛和鎮痛需要效果方面的不同。102位門診擬行擇期肩部手術的病人被隨機分位術前組(PRE組)和術後組(POST組),所有病人採用0.5%的布比卡因30mL阻滯。術後鎮痛結果評價包括(a)手術後首次需要鎮痛藥物的時間,(b)在靜止和上肢運動時採用可視的模擬量表來測量疼痛強度,(c)所有非甾體類消炎藥和阿片類藥物的消耗量。在兩治療組間首次需要鎮痛的時間並無差異。然而,手術當天平均最大疼痛強度評分,無論在靜止(P0.001)時還是在運動(P0.004)時,PRE組明顯小於POST組。術中給予的阿片類藥物量PRE組少於POST組(P<0.001)。兩組均很好的耐受左旋布比卡因,沒有發生與該局麻藥相關的不良反應。我們得出結論,術前斜角肌間左旋布比卡因神經阻滯在術後首個12小時內有出眾的疼痛控制效果,但這種益處在術後出院回家的一周內並不能維持,因為這些研究物件作為門診病人被假定自我鎮痛。

(鍾鳴 薛張綱 )

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.

 

切皮前治療防止滑動疝術後疼痛

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.

 

我們設計了如下方法隨機比較腹股溝疝修補術後採用切皮前三劑療法及標準療法的病人疼痛程度.三劑療法包括切皮前應用非甾體類抗炎劑、局部區域阻滯麻醉、N-甲基-D-天冬氨酸止氧劑。治療組(n = 17)rofecoxib 50mg PO, 0.25%布比卡因或0.5%利多卡行區域阻滯並于切皮前予氯胺酮0.2 mg/kg IV,而對照組(n = 17)予安慰劑術前口服。此項麻醉方案進行標化處理。術後疼痛予芬太尼靜注和oxycodone 5mg(或對乙酰氨基酚325mg PO行按需止痛。術後7天內行疼痛評分及止痛劑記錄。治療組較對照組疼痛評分術中低47%,術後第124小時低18%;術後24小時口服止痛劑用量少34%。因此,我們認為切皮前三劑療法有助於減少門診病人疝修補術後疼痛及止痛劑用量,並且希望能有此方面的進一步研究。

(陸旭偉 薛張綱 )

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相容性

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

 

為了測試臨床上常用的普魯泊酚-利多卡因混合液的理化穩定性,我們在市售的1%丙泊酚20ml中分別加入利多卡因5102040mg。配置混合液後24小時內用氣相色譜儀對混合液中的丙泊酚濃度進行測試,以此來評估其化學穩定性。此外,應用電子掃描顯微鏡在隨機視野內測定可見最小液滴的尺寸。宏觀上可見:丙泊酚內加2040mg利多卡因混合液於混合後324小時即可見分離出無色的液層,而加510mg利多卡因的混合液則宏觀上處穩定狀態。加40mg利多卡因的混合液中丙泊酚濃度於配置後424小時呈線性顯著下降,而加其他劑量利多卡因的混合液中丙泊酚濃度與基線值相比無改變。電子掃描顯微鏡顯示:直徑5um的小液滴最初在加入40mg利多卡因後30min出現,並且乳狀小液滴隨時間和劑量而增大。我們的結果提示,丙泊酚內加入利多卡因導致小油滴相互結合並最終形成可見的分離的液層。此種混合液隨加入利多卡因的劑量以及混合液配置後持續時間的不同而不同程度的增加肺栓塞的危險性。

(陸旭偉 薛張綱 )

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.

 

全麻後恢復期腦電監護的作用:聽覺誘發電位及雙頻譜指數儀在標準臨床實踐中的比較

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.

 

腦電監護的應用有助於提高麻醉醫生更精確應用麻醉藥物的能力。然而也有關於恢復期腦電監護截然相反的報導,即所謂的麻醉共用作用。我們設計了此項前瞻、雙盲、假陽性控制的研究來評價地氟醚麻醉病人術中監測腦電雙頻指數或聽覺誘發電位的作用,患者離開蘇醒室的時間以及患者對麻醉、恢復過程的滿意度。九十位標準麻醉下行腹腔鏡普外科手術的健康患者隨機的分為三組採取不同的監測方式:1)標準臨床監測(對照組) 2)腦電雙頻指數監測(BIS組) 3)聽覺誘發電位監測(AEP組)。所有患者全麻誘導前均予BISAEP監測。對照組中麻醉醫生手術期間不允許觀察BISAEPBIS監測組中間斷給予揮發性麻醉藥維持BIS值在4555之間。AEP監測組目標AEP值為1520之間。每隔35分鐘記錄BISAEP值、潮氣末地氟醚濃度。每隔110分鐘記錄蘇醒時間、拔管時間、PACU離觀標準評分。另外於術後24小時按100分及18分標準對患者滿意度和恢復質量進行分別評分。AEP BIS監測組術中潮氣末地氟醚濃度平均值顯著小於對照組。雖然術後睜眼、拔管、聽從指令的時間AEP組和BIS組均短於對照組,但只有拔管時間的差別具有顯著性。更重要的是,患者在PACU停留的時間AEP組和BIS組顯著少於對照組,而且患者的恢復質量亦顯著高於對照組。因此我們認為用BISAEP監測腦電可以減少麻醉維持期間(地氟醚)麻醉藥的用量,從而導致患者腹腔鏡術後PACU停留時間縮短並提高患者恢復質量。但是BISAEP兩組的結果尚無顯著差別。

(陸旭偉 薛張綱 )

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.

 

老年患者行髖關節成形術時鞘內嗎啡劑量的優化

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.

 

鞘內給予嗎啡可提供很好的術後鎮痛,但也可產生許多不良反應包括術後噁心嘔吐、搔癢、呼吸抑制,特別在較大劑量時容易發生。而老年患者有更大的發生危險性。老年患者行髖關節成形術椎管內嗎啡的最佳劑量目前尚未知。為此我們設計了此項前瞻性、隨機、對照、雙盲試驗,對行擇期髖關節成形術的老年患者予鞘內應用50200ug嗎啡鎮痛,以此來評估止痛劑的效力和副作用。共選擇了6065歲以上行擇期髖關節成形術的患者。患者分為4組,隨機接受椎管內15mg布比卡因鎮痛聯和鞘內應用嗎啡:10ug 250ug 310ug 4200ug。鞘內用100ug200ug嗎啡組較對照組更有效緩解疼痛並減少術後嗎啡需量。鞘內應用50ug嗎啡不能提供有效的鎮痛。而鞘內應用100ug200ug嗎啡組均能產生有效的鎮痛。各組術後噁心嘔吐、鎮靜、呼吸抑制、尿瀦留的發生率無差異。但是搔癢在200ug組的發生率顯著增加,因此行髖關節成形術的老年患者鞘內應用100ug嗎啡可在術後鎮痛及副作用發生之間達到良好的平衡。

(陸旭偉 薛張綱 )

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.

 

黃芩甙在愛蘭苔膠引起的熱痛覺過敏中的抗炎和鎮痛作用

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

我們用愛蘭苔膠引起熱痛覺過敏的老鼠模型測試了黃芩甙的抗過敏和鎮痛作用及其機制。事前或事後運用黃芩甙(10, 30, or 100 mg/kg 腹膜內)所引起的鎮痛效果與等劑量的布洛芬相似。而且,注射愛蘭苔膠後四小時黃芩甙劑量依賴性的降低了腫瘤壞死因數-{alpha}(從3510 ± 150 pg/mL 2860 ± 148 pg/mL 1480 ± 210 pg/mL),白介素(IL)-1ß(從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,同時增加了IL-10 ( 18.1 ± 2.5 pg/mL 36.1 ± 5.5 pg/mL 71.2 ± 9.5 pg/mL)的產生。注射愛蘭苔膠後四小時而不是1.5小時後,黃芩甙(10–100 mg/kg 腹膜內)劑量依賴性的抑制注射愛蘭苔膠的鼠爪處前列腺素E2 (PGE2)和硝酸鹽的量(PGE2: 15.9 ± 2.1 ng/mL 12.1 ± 1.6 ng/mL 6.2 ± 1.8 ng/mL;硝酸鹽: 39.8 ± 4.8 µM 27.5 ± 3.0 µM 17.2 ± 1.6 µM)。同時也劑量依賴性的抑制注射愛蘭苔膠後引起的髓過氧化酶活性的提高。這些發現提示我們黃芩甙的抗炎和鎮痛機制可能與在炎症的局部抑制炎症因數,包括一氧化氮,PGE2,前炎症因數,增加IL-10的產生和中性粒細胞的浸潤。

(方芳 薛張綱 )

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-1714,一種一氧化氮合成酶抑制劑,減輕家兔內毒素引起的急性肺損傷

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

由於誘發一氧化氮合成酶(iNOS)的表達而引起的一氧化氮的過度產生被認為是內毒素誘導的急性肺損傷(ALI)的主要發病機制。在這個研究中,我們想看看是否ONO-1714,一種新的選擇性的iNOS抑制劑,可以減輕內毒素誘導的ALI。在研究的第一部分,一組家兔靜脈注射生理鹽水,另外四組靜脈注射5 mg/kg的內毒素30分鐘後引起ALI。後四組中,三組在注射內毒素之前10分鐘,分別注射ONO-1714 0.1, 0.03, 0.01 mg/kg,另外一組注射生理鹽水。研究的第二部分,所有六組都被注射內毒素而引起ALI,一組用生理鹽水治療,另外五組在不同的時間用ONO-1714 0.1 mg/kg治療(ALI發生前10分鐘,發生後1234小時)ALI發生後用40%的氧機械通氣六小時。第一部分中,預先用0.1 mg/kg ONO-1714治療組減輕了內毒素誘發的ALI。在第二部分,兩小時之內使用ONO-1714和預先使用一樣有效,都可以改善氧合,肺泡通氣,肺的白細胞分離,肺水腫,和組織學改變。但是使用內毒素後34小時後它對減輕家兔肺損傷沒什麼幫助了。這些資料提示我們今天的研究為以後的臨床研究提供一個依據去說明ONO-1714是否可以作為一個有效的治療手段用於內毒素血症或敗血症引起的急性呼吸窘迫綜合征。

(方芳 薛張綱 )

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研究鼠缺血性神經保護中{kappa}-鴉片受體的選擇性

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}-鴉片受體(KOR)已經被應用於缺血性神經損傷後的神經保護,但是關於他在暫時性的腦缺血再灌注中的作用卻還未被深入研究。我們測試了選擇性,特異性的KOR激動劑BRL 52537鹽酸鹽[(±)-1-(3,4-dichlorophenyl)acetyl-2-(1-pyrrolidinyl)methylpiperidine]和標準的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],對小鼠暫時性腦缺血後功能和組織學方面起的作用。通過使用腔內導絲技術,用氟烷麻醉的成年雄性Wistar小鼠的大腦中動脈被阻斷2小時,並使用多普勒血流計監測。以隨機雙盲的方式,小鼠被分為以下幾組:1)再灌注前15分鐘及灌注後用生理鹽水治療22小時;2)再灌注前15分鐘用生理鹽水治療,灌注後用BRL 52537 (1 mg • kg-1 • h-1)治療22小時;3)再灌注前15分鐘用生理鹽水治療,灌注後用nor-BNI (1 mg • kg-1 • h-1) 治療22小時;4)再灌注前15分鐘用nor-BNI (1 mg/kg),灌注後用BRL 52537 (1 mg • kg-1 • h-1) and nor-BNI (1 mg • kg-1 • h-1) 治療22小時。再灌注四天後分析梗死區域(單側結構)發現,生理鹽水/ BRL 52537 (n = 8;皮質 , 10.2% ± 4.3%; 尾狀核[CP], 23.8% ± 6.7%) (平均值 ± 標準差)與生理鹽水/生理鹽水組 (n = 8; 皮質, 28.6% ± 4.9%; CP, 53.3% ± 5.8%)相比損傷顯著減輕。在BRL 52537中加入特異性的KOR 拮抗劑nor-BNI可以完全阻止BRL 52537的神經保護作用(n = 7; 皮質, 28.6% ± 5.3%; CP, 40.9% ± 6.2%)BRL 52537並不產生缺血後的低溫。這些資料表明KOR可以為缺血性卒中的早期再關注提供一個治療靶點。

(方芳 薛張綱 )

 

{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

 

羅呱卡因與芬太尼用於分娩硬膜外自控鎮痛時的濃度:容量範圍的研究

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.

 

我們選擇了誘導分娩的初產婦進行此項隨機試驗,以明確在分娩過程中使用患者自控硬膜外鎮痛(PECA)裝置時,其中的藥物濃度是否需要提高。病人被分為6(每組n=25)PECA泵使用的鎮痛藥濃度為羅呱卡因/芬太尼0.1%/0.5mg/mL0.2%/1mg/mL。其中3組在分娩早期(宮縮每3min一次且宮頸擴張4cm)使用的劑量為12ml16ml20ml稀釋液,在分娩後期為6ml8ml10ml的濃縮液。另外3組在這兩個時期接受的劑量都為12ml16ml20ml稀釋液。鎖定的時間間隔為25min。最初的結果測定資料為從開始到第一次請求醫生追加止痛的時間,之後的評估包括疼痛評分(可以使用可視類比評分尺,VAS,從010分級)、滿意度評分、動脈血壓、運動阻滯的強度與硬膜外阻滯上部感覺缺失平面。患者、助產士與觀測者均不知道實驗藥物和PECA的設置。疼痛評估的最高分被定義為每一患者在每一階段最強烈的疼痛感覺,鎮痛持續的時間被定義為從每一階段開始到第一次注射補充的鎮痛劑之間間隔的時間,並使用生存分析法比較。兩組間一般人口學資料和產科變異、動脈血壓、運動阻滯強度、硬膜外阻滯上部感覺缺失平面和滿意度評分均無差異。在每一個階段,都有至少75%的婦女,將滿意度等級評為好或極好的水平。在分娩後期,使用20ml稀釋液組的疼痛評估最高分低於使用6ml濃縮液組;而在20ml稀釋液組與10ml濃縮液組之間的疼痛評估最高分無顯著性差異(VAS值的差別=-0.495% 的可信限為-1.599 0.799P = 0.5055)。在分娩後期,使用20ml稀釋液組的鎮痛持續時間(99 +/- 4 min) (mean +/- SD)大於12ml稀釋液組(77 +/- 30 min)16ml稀釋液組(80 +/- 23 min);但在20ml稀釋液組與10ml濃縮液組(92 +/- 23 min)之間以及12ml稀釋液組與6ml濃縮液組(78 +/- 30 min)之間無顯著性差異;8ml濃縮液組(94 +/- 16 min) 的鎮痛持續時間大於16ml稀釋液組。我們得出的結論是:在分娩的過程中,每一PECA使用20ml0.1%/0.5mg/mL的羅呱卡因/芬太尼鎮痛是有效的。當分娩過程進入活躍期後,使用16mg羅呱卡因與8mg芬太尼這樣的劑量,濃度加倍,可以延長鎮痛持續時間。當使用12mg羅呱卡因與6mg芬太尼時,鎮痛效果並不令人滿意,即使藥物濃度加倍也無臨床效果。這個結果暗示了:PECA的作用效率取決於所用藥物的總量,而不是每次成功泵注的藥物體積或濃度。結論:若段患者自控硬膜外鎮痛(PECA)的鎮痛藥物有效劑量已經給足,那麼當分娩過程進入活躍期後,再增加藥物濃度是沒有臨床意義的。PECA的鎮痛質量取決於每個階段所給藥物的總量,而不是所加的輸液泵內的藥物濃度。

(金琳 薛張綱 )

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.

 

在全麻和手術應激狀態下,胸部硬膜外麻醉對健康豬的肝臟灌注和氧合作用的影響

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.

 

在圍手術期肝臟損傷的機制中,肝臟灌注的減少是繼系統炎症反應綜合症之後的一個重要發現。此項動物實驗的設計是為了評估胸部硬膜外麻醉(TEA)引起的低血壓是否會損傷肝臟的氧合作用。在倫理評估之後,19只已麻醉並進行靈敏監測的豬被隨即分成3(對照組、單純TEA組和TEA加容量負荷組)。每一階段在硬膜外腔內注入0.5% 布比卡因0.75 mL,以保持T5T12的阻滯平面。首先獲得基礎值,在硬膜外注藥之後,每隔60120分鐘重複測量一次。TEA與平均動脈壓的下降有關,但並沒有改變肝臟總的血流量。肝臟氧的運輸與攝取保持不變,肝組織的氧分壓也沒有下降,血漿吲哚青綠清除率保持穩定。TEA前的容量負荷並沒有對肝臟總的血流量產生重大影響。得出的結論是:儘管TEA會使平均動脈壓下降,但並不影響肝臟的氧合;容量負荷對肝臟的灌注並無顯著的臨床意義。

(金琳 薛張綱 )

 

 

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)

 

防止全麻誘導時的肺不張

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張的可能,並且高濃度的氧氣會增加危險危險性。我們研究了在全麻誘導時使用呼氣末正壓通氣裝置(PEEP)(吸入氧濃度[FiO2]1.0)對防止肺不張的效率。16名成年病人被隨機分成兩組,每組都吸入5分鐘100%O2,在全麻誘導後使用FiO2 1.0進行面罩機械同氣,5分鐘後,氣管內插管。第一組病人(PEEP)保持持續的氣道內正壓(CPAP) (6 cm H2O),並繼續使用面罩進行機械通氣,PEEP值為6 cm H2O。對照組沒有使用CPAPPEEP。肺不張的確診是通過CT以及血氣分析取得,並在麻醉前和插管後即刻各檢查一次。在氣管內插管後,對照組病人肺不張區域的面積增加,由0.8% +/- 0.9%4.1% +/- 2.0% (P = 0.0002);而PEEP組的病人沒有發現明顯的改變(0.5% +/- 0.6%0.4% +/- 0.7%)。使用FiO2 1.0插管之後,PEEP組的PaO2較對照組有顯著升高(591 +/- 54 mm Hg457 +/- 99 mm HgP = 0.005)。儘管仍然使用高濃度的氧氣,在麻醉誘導期使用PEEP通氣裝置可以有效地防止肺不張的發生,提高氧合作用。結論:在全身麻醉誘導期使用呼氣末正壓通氣裝置可以防止肺不張的發生,提高氧合作用,並且在插管前提高安全線。因此,建議在所有的麻醉誘導期使用這項技術,至少用於懷疑有困難氣道的病人。

(金琳 薛張綱 )

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.