Anesthesia & Analgesia

February 2004

Table of Content

CARDIOVASCULAR ANESTHESIA:

心肺转流期间肝素水平的抗凝管理:一项关于半量抑肽酶方案对术后失血和止血活以及炎症反应影响的实验性研究

(颜涛 译 李士通 校)

Heparin-Level-Based Anticoagulation Management During Cardiopulmonary Bypass: A Pilot Investigation on the Effects of a Half-Dose Aprotinin Protocol on Postoperative Blood Loss and Hemostatic Activation and Inflammatory Response

Andreas Koster, Sabine Huebler, Frank Merkle, Thomas Hentschel, Marcus Gründel, Thomas Krabatsch, Luc Tambeur, Michael Praus, Helmut Habazettl, Wolfgang M. Kuebler, and Hermann Kuppe

Anesth Analg 2004 98: 285-290.

用羟乙基淀粉作为体外循环灌注液可减弱心脏手术术后止血功能

(周晓敏 薛张纲 校)

Hydroxyethyl Starch as a Priming Solution for Cardiopulmonary Bypass Impairs Hemostasis After Cardiac Surgery

Anne H. Kuitunen, Markku J. Hynynen, Elina Vahtera, and Markku T. Salmenperä

Anesth Analg 2004 98: 291-297.

Arctic Sun 温度管理系统与传统方法对防止不停跳心脏手术中体温降低比较--随机对照试验

(殷文渊 译 王祥瑞 校)

A Randomized Controlled Trial of the Arctic Sun® Temperature Management System Versus Conventional Methods for Preventing Hypothermia During Off-Pump Cardiac Surgery

Hilary P. Grocott, Joseph P. Mathew, Elizabeth H. Carver, Barbara Phillips-Bute, Kevin P. Landolfo, and Mark F. Newman

Anesth Analg 2004 98: 298-302.

P波离散度增加预示冠状动脉旁路术后房颤

(颜涛 李士通 校)

Increases in P-Wave Dispersion Predict Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery

Joby Chandy, Toshiko Nakai, Randall J. Lee, Wayne H. Bellows, Samir Dzankic, and Jacqueline M. Leung

Anesth Analg 2004 98: 303-310.

主动脉瓣换瓣术后早期活动可导致混合静脉血氧饱和度显著下降

(周晓敏 薛张纲 校)

Marked Mixed Venous Desaturation During Early Mobilization After Aortic Valve Surgery

Idar Kirkeby-Garstad, Olav F. M. Sellevold, Roar Stenseth, Eirik Skogvoll, and Asbjørn Karevold

Anesth Analg 2004 98: 311-317.

PEDIATRIC ANESTHESIA:

骶管麻醉对儿童七氟醚和氟烷麻醉后躁动发生的影响

(殷文渊 译 王祥瑞 校)

The Effect of Caudal Analgesia on Emergence Agitation in Children After Sevoflurane Versus Halothane Anesthesia

B. Craig Weldon, Martin Bell, and Thomas Craddock

Anesth Analg 2004 98: 321-326.

扁桃腺切除和增殖腺切除术后采用“非接触”拔管技术的喉痉挛发生率

(颜涛 李士通 校)

The Incidence of Laryngospasm with a "No Touch" Extubation Technique After Tonsillectomy and Adenoidectomy

Ban C. H. Tsui, Alese Wagner, Dominic Cave, Clark Elliott, Hamdy El-Hakim, and Stephan Malherbe

Anesth Analg 2004 98: 327-329.

提前阻滞耳大神经是否能改善行鼓膜乳突手术儿童的术后镇痛

(周晓敏 薛张纲 校)

Does a Preemptive Block of the Great Auricular Nerve Improve Postoperative Analgesia in Children Undergoing Tympanomastoid Surgery?

Santhanam Suresh, Sandra L. Barcelona, Nancy M. Young, Corri L. Heffner, and Charles J. Coté

Anesth Analg 2004 98: 330-333.

AMBULATORY ANESTHESIA:

口服后再静脉给COX-2特异性抑制剂后对腹腔镜胆囊切除术病人镇痛效果

(忻纪华 译 王祥瑞 校)

Effective Treatment of Laparoscopic Cholecystectomy Pain with Intravenous Followed by Oral COX-2 Specific Inhibitor

Girish P. Joshi, Eugene R. Viscusi, Tong J. Gan, Harold Minkowitz, Mark Cippolle, Rienhard Schuller, Raymond Y. Cheung, and John G. Fort

Anesth Analg 2004 98: 336-342.

通过咳嗽法减少静脉穿刺的疼痛:一项随机交叉志愿者研究

(颜涛 李士通 校)

Reducing Venipuncture Pain by a Cough Trick: A Randomized Crossover Volunteer Study

Taras I. Usichenko, Dragan Pavlovic, Sebastian Foellner, and Michael Wendt

Anesth Analg 2004 98: 343-345.

ANESTHETIC PHARMACOLOGY:

异氟醚通过γ-氨基丁酸A易化苯巴比妥麻醉猫打嗝样反射并经γ-氨基丁酸B受体抑制反射

(陆旭伟 薛张纲 校)

Isoflurane Facilitates Hiccup-Like Reflex Through Gamma Aminobutyric Acid (GABA)A- and Suppresses Through GABAB-Receptors in Pentobarbital-Anesthetized Cats

Tsutomu Oshima and Shuji Dohi

Anesth Analg 2004 98: 346-352.

缬草和缬草酸对活化小鼠脑干神经元的GABA能效应

(忻纪华 译 王祥瑞 校)

The Gamma-Aminobutyric Acidergic Effects of Valerian and Valerenic Acid on Rat Brainstem Neuronal Activity

Chun-Su Yuan, Sangeeta Mehendale, Yingping Xiao, Han H. Aung, Jing-Tian Xie, and Michael K. Ang-Lee

Anesth Analg 2004 98: 353-358.

特异性环氧酶-2抑制剂美洛昔康不能增强吗啡降低大鼠异氟醚MAC的作用

( 翻译 李士通 审校)

Martín Santos, Viviana Kunkar, Palma García-Iturralde, and Francisco J. Tendillo

Meloxicam, a Specific COX-2 Inhibitor, Does Not Enhance the Isoflurane Minimum Alveolar Concentration Reduction Produced by Morphine in the Rat

Anesth Analg 2004 98: 359-363.

阿片类引起的巨细胞活化和血管反应不是通过µ受体介导的:一项人皮肤的体内微透析研究

(陆旭伟 薛张纲 校)

Opioid-Induced Mast Cell Activation and Vascular Responses Is Not Mediated by µ-Opioid Receptors: An In Vivo Microdialysis Study in Human Skin

James A. Blunk, Martin Schmelz, Susanne Zeck, Per Skov, Rudolf Likar, and Wolfgang Koppert

Anesth Analg 2004 98: 364-370.

新超声-放射治疗方案可使EMLA产生快速浸润麻醉效应

(朱慧琛 译 王祥瑞 校)

Rapid Onset of Cutaneous Anesthesia with EMLA Cream After Pretreatment with a New Ultrasound-Emitting Device

Nathaniel P. Katz, David E. Shapiro, Timothy E. Herrmann, Joseph Kost, and Linda M. Custer

Anesth Analg 2004 98: 371-376.

TECHNOLOGY, COMPUTING, AND SIMULATION:

肌音描记仪和肌机械描记仪可相互代替监测拇内收肌的神经肌肉阻滞水平

( 翻译 李士通 审校)

Phonomyography and Mechanomyography Can Be Used Interchangeably to Measure Neuromuscular Block at the Adductor Pollicis Muscle

Thomas M. Hemmerling, Guillaume Michaud, Guillaume Trager, Stéphane Deschamps, Denis Babin, and François Donati

Anesth Analg 2004 98: 377-381.

汽热交换设备是否真能起到如期效果

(陆旭伟 薛张纲 校)

Harry J. M. Lemmens and John G. Brock-Utne

Heat and Moisture Exchange Devices: Are They Doing What They Are Supposed to Do?
Anesth Analg 2004 98: 382-385.

利用电视医疗设备进行远程麻醉监测的报道

(朱慧琛 译 王祥瑞 校)

Case Report of Remote Anesthetic Monitoring Using Telemedicine (Case Report)

Stephen W. Cone, Lynne Gehr, Russell Hummel, Azhar Rafiq, Charles R. Doarn, and Ronald C. Merrell

Anesth Analg 2004 98: 386-388.

PAIN MEDICINE:

腹部手术后硬膜外0.1%左旋布比卡因或0.1%罗哌卡因复合吗啡的镇痛效果相当

( 翻译 李士通 审校)

Epidural Levobupivacaine 0.1% or Ropivacaine 0.1% Combined with Morphine Provides Comparable Analgesia After Abdominal Surgery

Marc Senard, Abdourhamane Kaba, Murielle J. Jacquemin, Luc M. Maquoi, Marie-Pierre N. Geortay, Pierre D. Honoré, Maurice L. Lamy, and Jean L. Joris

Anesth Analg 2004 98: 389-394

静脉应用Nefopam及吗啡治疗小型手术后疼痛的中间有效剂量:-项药物镇痛效果的随机双盲前瞻性研究

(陆旭伟 薛张纲 校)

The Median Effective Dose of Nefopam and Morphine Administered Intravenously for Postoperative Pain After Minor Surgery: A Prospective Randomized Double-Blinded Isobolographic Study of Their Analgesic Action

Hélène Beloeil, Noémie Delage, Isabelle Nègre, Jean-Xavier Mazoit, and Dan Benhamou

Anesth Analg 2004 98: 395-400.

瑞芬太尼和加巴喷丁对健康志愿者新扩展的炎性皮肤疼痛模型的治疗效果

(朱辉 译 王祥瑞 校)

The Effects of Remifentanil and Gabapentin on Hyperalgesia in a New Extended Inflammatory Skin Pain Model in Healthy Volunteers

Burkhard Gustorff, Katharina Hoechtl, Thomas Sycha, Evangelos Felouzis, Stephan Lehr, and Hans G. Kress

Anesth Analg 2004 98: 401-407.

N-甲基-D-天门冬氨酸受体拮抗剂美金刚胺(Memantine)在慢性幻肢痛病人中的作用--安慰剂对照随机交叉试验

(王立中译,李士通校)

A Placebo-Controlled Randomized Crossover Trial of the N-Methyl-D-Aspartic Acid Receptor Antagonist, Memantine, in Patients with Chronic Phantom Limb Pain

Katja Wiech, Ralph-Thomas Kiefer, Stephanie Töpfner, Hubert Preissl, Christoph Braun, Klaus Unertl, Herta Flor, and Niels Birbaumer

Anesth Analg 2004 98: 408-413.

刺激大缝际核后由CA{delta}纤维介导的热疼痛的不同阿片抑制

(钟鸣 薛张纲 校)

Differential Opioid Inhibition of C- and A{delta}- Fiber Mediated Thermonociception After Stimulation of the Nucleus Raphe Magnus

Ying Lu, Sarah M. Sweitzer, Charles E. Laurito, and David C. Yeomans

Anesth Analg 2004 98: 414-419.

持续鞘内使用内源性配体腺苷,胍丁胺和Endomorphin-1的镇痛效应及相互作用

(朱辉 译 王祥瑞 校)

The Antinociceptive Potencies and Interactions of Endogenous Ligands During Continuous Intrathecal Administration: Adenosine, Agmatine, and Endomorphin-1

Gabriella Kekesi, Ildiko Dobos, György Benedek, and Gyöngyi Horvath

Anesth Analg 2004 98: 420-426.

芬太尼病人自控经皮给药系统用于急性术后镇痛的安全性和有效性--多中心、安慰剂对照试验

(王立中译,李士通校)

The Safety and Efficacy of a Fentanyl Patient-Controlled Transdermal System for Acute Postoperative Analgesia: A Multicenter, Placebo-Controlled Trial

Jacques E. Chelly, Jeffrey Grass, Timothy W. Houseman, Harold Minkowitz, and Alex Pue

Anesth Analg 2004 98: 427-433.

通过脑脊液盥洗撤销无意的脊髓麻醉药的作用

(钟鸣 薛张纲 校)

Reversal of an Unintentional Spinal Anesthetic by Cerebrospinal Lavage (Case Report)

Ban C. H. Tsui, Stephan Malherbe, John Koller, and Keith Aronyk

Anesth Analg 2004 98: 434-436.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

大学附属医院住院医生培训水平和麻醉监测质量的评估

(齐波 译 王祥瑞 校)

Resident Training Level and Quality of Anesthesia Care in a University Hospital

Karen L. Posner and Peter R. Freund

Anesth Analg 2004 98: 437-442.

麻醉杂志中被引用的经典文章

(王立中译,李士通校)

Citation Classics in Anesthetic Journals

Anja Baltussen and Christoph H. Kindler

Anesth Analg 2004 98: 443-451.

CRITICAL CARE AND TRAUMA:

油酸诱发的肺损伤中中性粒细胞和中性粒细胞产物并不介导内毒素的肺血流动力学效应

(钟鸣 薛张纲 校)

Neutrophils and Neutrophil Products Do Not Mediate Pulmonary Hemodynamic Effects of Endotoxin on Oleic Acid-Induced Lung Injury

Laureen L. Hill, Delphine L. Chen, James Kozlowski, and Daniel P. Schuster

Anesth Analg 2004 98: 452-457.

猪模型使用大脑皮层刺激电极进行体外除颤并不引起热损伤的急性组织病理学改变

(周洁 译 王祥瑞 校)

External Cardiac Defibrillation Does Not Cause Acute Histopathological Changes Typical of Thermal Injuries in Pigs with In Situ Cerebral Stimulation Electrodes

Christian Kolbitsch, Wilhelm Eisner, Axel Kleinsasser, Matthias Biebl, Thomas Fiegele, Alexander Löckinger, Ingo H. Lorenz, Gregor Mikuz, and Patrizia L. Moser

Anesth Analg 2004 98: 458-460.

多巴胺在现代重症监护病房内是否还有其位置?

(黄施伟 译,李士通 校)

Is There Still a Place for Dopamine in the Modern Intensive Care Unit? (Review Article)

Yves A. Debaveye and Greet H. Van den Berghe

Anesth Analg 2004 98: 461-468.  

NEUROSURGICAL ANESTHESIA:

异氟醚和异丙酚麻醉时静脉使用氟比洛芬不影响脑血流速度和氧合

(方芳 薛张纲 校)

Intravenous Administration of Flurbiprofen Does Not Affect Cerebral Blood Flow Velocity and Cerebral Oxygenation Under Isoflurane and Propofol Anesthesia
Kenji Yoshitani, Masahiko Kawaguchi, Kazuyuki Tatsumi, Noriyuki Sasaoka, Norio Kurumatani, and Hitoshi Furuya

Anesth Analg 2004 98: 471-476

OBSTETRIC ANESTHESIA:

剖腹产行椎管内麻醉时静注麻黄素预防低血压的剂量反应的汇粹分析

(周洁 译 王祥瑞 校)

A Dose-Response Meta-Analysis of Prophylactic Intravenous Ephedrine for the Prevention of Hypotension During Spinal Anesthesia for Elective Cesarean Delivery

Anna Lee, Warwick D. Ngan Kee, and Tony Gin

Anesth Analg 2004 98: 483-490.

蛛网膜下腔阻滞后的感觉运动麻痹和低血压:脊麻-硬膜外联合麻醉与单次脊麻

(黄施伟 译,李士通 校)

Sensorimotor Anesthesia and Hypotension After Subarachnoid Block: Combined Spinal-Epidural Versus Single-Shot Spinal Technique

Raymond Wee-Lip Goy and Alex Tiong-Heng Sia

Anesth Analg 2004 98: 491-496.

左旋氯胺酮和消旋氯胺酮对怀孕羊的子宫血流的作用

(方芳 薛张纲 校)

The Effects of S(+)-Ketamine and Racemic Ketamine on Uterine Blood Flow in Chronically Instrumented Pregnant Sheep

Danja Strümper, Wiebke Gogarten, Marcel E. Durieux, Kristian Hartleb, Hugo Van Aken, and Marco A. E. Marcus

Anesth Analg 2004 98: 497-502.

人类免疫缺陷病毒——麻醉和产科手术的影响

(顾漪闻 译 王祥瑞 校)

Human Immunodeficiency Virus: Anesthetic and Obstetric Considerations (Review Article)

Shmuel Evron, Marek Glezerman, Ethan Harow, Oscar Sadan, and Tiberiu Ezri

Anesth Analg 2004 98: 503-511.

REGIONAL ANESTHESIA:

新设计的Ballpen针和Sprotte针之间在脊麻的操作条件和副作用方面相似:一项多中心前瞻性随机比较试验的结果

(黄施伟 译,李士通 校)

Spinal Anesthesia Performance Conditions and Side Effects Are Comparable Between the Newly Designed Ballpen and the Sprotte Needle: Results of a Prospective Comparative Randomized Multicenter Study

Thomas Standl, Ales Stanek, Marc-Alexander Burmeister, Sven Grüschow, Bianca Wahlen, Katrin Müller, Jürgen Biscoping, and Hans-Anton Adams

Anesth Analg 2004 98: 512-517.

GENERAL ARTICLES:

全麻状态下音乐对手术带来的神经激素反应的影响

(方芳 薛张纲 校)

The Effect of Music on the Neurohormonal Stress Response to Surgery Under General Anesthesia

Brigitte Migneault, François Girard, Caroline Albert, Philippe Chouinard, Daniel Boudreault, Diane Provencher, Alexandre Todorov, Monique Ruel, and Dominique C. Girard

Anesth Analg 2004 98: 527-532.

半球同步对术中镇痛的影响

(顾漪闻 译 王祥瑞 校)

The Effect of Hemispheric Synchronization on Intraoperative Analgesia

Ariane K. Lewis, Irene P. Osborn, and Ram Roth

Anesth Analg 2004 98: 533-536.

耻骨后前列腺根治除术避免异体输血-术前自体采血与血液回收比较

(黄施伟 译,李士通 校)

Preoperative Autologous Donation Versus Cell Salvage in the Avoidance of Allogeneic Transfusion in Patients Undergoing Radical Retropubic Prostatectomy

Jonathan H. Waters, Julia ShinJung Lee, Eric Klein, Jerome O’Hara, Craig Zippe, and Paul S. Potter

Anesth Analg 2004 98: 537-542.

患镰状红细胞病人使用止血带行双侧膝关节置换术

(方芳 薛张纲

Bilateral Total Knee Replacement with Tourniquets in a Homozygous Sickle Cell Patient (Case Report)

Abdulmohsin Abdulla Al-Ghamdi

Anesth Analg 2004 98: 543-544.

 

Arctic Sun 温度管理系统与传统方法对防止不停跳心脏手术中体温降低比较--随机对照试验

A Randomized Controlled Trial of the Arctic Sun® Temperature Management System Versus Conventional Methods for Preventing Hypothermia During Off-Pump Cardiac Surgery

Hilary P. Grocott, MD FRCPC, Joseph P. Mathew, MD, Elizabeth H. Carver, BSN, Barbara Phillips-Bute, PhD, Kevin P. Landolfo, MD, and Mark F. Newman, MD and the Neurologic Outcome Research Group (NORG) of the Duke Heart Center

From the Department of Anesthesiology and Surgery, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004;98:298-302

在这个试验中我们比较了Arctic Sun 温度管理系统(一个使温度控制水通过粘附于病人身上的独特的能量转换垫循环的伺服调节系统。)与传统温度控制方法避免低温的能力。将接受不停跳冠状动脉旁路手术的病人随机使用Arctic Sun 系统(AS组)或传统方法(对照组;提高室温,静脉液体加温,空气加温对流系统)防止体温降低(定义为体温<36℃)。AS组测量鼻咽温度,伺服调节的目标温度为36.8℃整个术中的温度都被记录下来,两组体温<36℃的曲线下(AUC)时间和面积都进行比较。对29个病人(AS=14,对照组=15)进行了研究。AS组的体温降低显著少于对照组,无论低于36℃的持续时间(AS2.5[0-22],中线[四分位间范围]对照组118[49-192]minP=0.0008)还是AUC<36℃AS0.3[0-2.2] ℃ x min对照组17.1[3.6-173.4] ℃ x minP=0.002)。Arctic Sun 温度管理系统显著减少了OPCAB术中低温的发生。重要的是,这是在没有其他温度调节技术的情况下达到的,包括多使用的静脉液体加温或提高手术室周围的温度。

(殷文渊 译 王祥瑞 校)

In this trial we compared the hypothermia avoidance abilities of the Arctic Sun® Temperature Management System (a servo-regulated system that circulates temperature-controlled water through unique energy transfer pads adherent to the patient’s body) with conventional temperature control methods. Patients undergoing off-pump coronary artery bypass (OPCAB) surgery were randomized to either the Arctic Sun System alone (AS group) or conventional methods (control group; increased room temperature, heated IV fluids, convective forced air warming system) for the prevention of hypothermia (defined by a temperature <36°C). The AS group had nasopharyngeal temperature servo-regulated to a target of 36.8°C. Temperature was recorded throughout the operative period and comparisons were made between groups for both the time and area under the curve (AUC) for a temperature <36°C (AUC<36°C). Twenty-nine patients (AS group = 14, control group = 15) were studied. The AS group had significantly less hypothermia than the control group, both for duration of time <36°C (2.5 [0–22] min, median [interquartile range] AS group versus 118 [49–192] min, control group; P = 0.0008) as well as for AUC<36°C (0.3 [0–2.2] °C x min, AS group versus 17.1 [3.6–173.4] °C x min, control group; P = 0.002). The Arctic Sun Temperature Management System significantly reduced intraoperative hypothermia during OPCAB surgery. Importantly, this was achieved in the absence of any other temperature modulating techniques, including the use of IV fluid warming or increases in the ambient operating room temperature.


骶管麻醉对儿童七氟醚和氟烷麻醉后躁动发生的影响

The Effect of Caudal Analgesia on Emergence Agitation in Children After Sevoflurane Versus Halothane Anesthesia

B. Craig Weldon, MD*, Martin Bell, MD{dagger}, and Thomas Craddock, MD{dagger}

*Departments of Anesthesiology and Pediatrics, University of Florida College of Medicine, Gainesville, Florida; and {dagger}Department of Pediatric Surgery, St. John’s Mercy Medical Center, St. Louis, Missouri

Anesth Analg 2004;98:321-326


在幼童麻醉中七氟醚比氟烷更易引起术后燥动。术后疼痛可能是病因之一。我们设计了一个进行了骶管麻醉镇痛的儿童在七氟醚和氟烷麻醉后躁动发生机率比较的研究。1812个月至6岁的接受斜疝修补的儿童被随机分为接受氟烷或七氟醚麻醉。术前焦虑基线通过Yale术前焦虑表评价。儿童口服咪唑安定镇静,面罩诱导,骶管阻滞用以术后镇痛。术后,儿童的行为通过四分躁动表评价。在到达麻醉后监护室(PACU5分钟内,七氟醚的躁动发生机率高于氟烷(26%6%P<0.05),但余下的时间内并非如此。较高水平的术前焦虑与面罩诱导困难,进入PACU躁动,和躁动事件更严重相关。躁动的发生似乎是进行了有效术后镇痛的儿童在接受七氟醚麻醉后早期而短暂的现象。

(殷文渊 译 王祥瑞 校)

Sevoflurane anesthesia in young children has been associated with an increased incidence of emergence agitation compared with halothane. Postoperative pain may be an etiologic factor. We designed a study to compare the incidence of emergence agitation after halothane and sevoflurane anesthesia in children whose pain was managed with caudal analgesia. Eighty children undergoing inguinal hernia repair between the ages of 12 mo and 6 yr were randomly assigned to receive either halothane or sevoflurane anesthesia. Baseline preoperative anxiety was assessed with the Yale Preoperative Anxiety Scale. The children were sedated with oral midazolam, underwent a mask induction, and had a caudal block placed for postoperative analgesia. After surgery, the children’s behavior was assessed with a four-point agitation scale. At 5 min after arrival in the postanesthesia care unit (PACU), sevoflurane was associated with a greater incidence of emergence agitation than halothane (26% vs 6%; P < 0.05), but not during the remainder of the PACU stay. Higher levels of preoperative anxiety were associated with difficult mask induction, agitation on admission to the PACU, and more severe agitation episodes. Emergence agitation appears to be an early and transient phenomenon after sevoflurane anesthesia in children with effective postoperative analgesia.


口服后再静脉给COX-2特异性抑制剂后对腹腔镜胆囊切除术病人镇痛效果

Effective Treatment of Laparoscopic Cholecystectomy Pain with Intravenous Followed by Oral COX-2 Specific Inhibitor

Girish P. Joshi, MBBS MD, Eugene R. Viscusi, MD, Tong J. Gan, MD, Harold Minkowitz, MD, Mark Cippolle, MD PhD, Rienhard Schuller, MSc, Raymond Y. Cheung, BPharm PhD, and John G. Fort, MD

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

Anesth Analg 2004;98:336-342

在本多中心,双盲,随机,安慰剂对照实验中,我们评估了腹腔镜胆囊切除术术前口服Valdecoxib后静脉注射Parecoxib后口服Valdecoxib对麻醉剂和吗啡-异丙嗪的影响。麻醉诱导前病人随机接受单次Parecoxib40mgn=134)静脉注射或安慰剂(n=129)。静脉注射12小时后,Parecoxib组接受Valdecoxib 40mg单次口服,然后在术后1-4天每天口服Valdecoxib 40mg,术后5-7天有需要时每天口服Valdecoxib40mg。安慰剂组按计划口服安慰剂。在术后头4小时(T0-240min)所有病人均允许静注补充的芬太尼后应用氢化可待因5 mg/对乙酰氨基酚500 mgVicodin®; 如需要每4-6小时1-2粒口服)。接受Parecoxib的病人比接受安慰剂的病人芬太尼用量减少21%p=0.011)。镇痛强度(PI)曲线下从0-240min p=0.011的平均区域面积在Parecoxib组为55.2%,安慰剂组为61.2%p=0.083)。180 min240min的平均PI得分分别为7.07.6点,低于安慰剂组(P<0.02)。

极少数Parecoxib的病人需静脉补充镇痛药(P<0.05)。在240min和第7天,病人和医生/护士的Global评分在两组中有显著差异(P<0.05)。不良反应的发生,不良反应的消除和焦虑在Parecoxib组明显低于安慰剂组。作者于是总结到术前使用Parecoxib对于腹腔镜胆囊切除术后的疼痛只了可作为吗啡-异丙嗪的有用的附加用药,且顺序口服Valdecoxib可增加临床收益。

(忻纪华 译 王祥瑞 校)

In this multicenter, double-blinded, randomized, placebo-controlled study we evaluated the analgesic and opioid-sparing efficacy of a preoperative dose of IV parecoxib followed by oral valdecoxib in treating pain associated with elective laparoscopic cholecystectomy. Patients were randomized to receive a single IV dose of parecoxib 40 mg (n = 134) or placebo (n = 129) 30–45 min before induction of anesthesia. Six to 12 h after the IV dose, the parecoxib group received a single oral dose of valdecoxib 40 mg, followed by valdecoxib 40 mg qd on postoperative days 1–4, then 40 mg qd prn days 5–7. The placebo IV group received oral placebo on an identical schedule. All patients were allowed supplemental IV fentanyl as needed during the first 4 h postoperatively (T0–240 min) followed by hydrocodone 5 mg/acetaminophen 500 mg (Vicodin®; 1–2 tablets orally every 4–6 h as needed). Patients taking parecoxib used 21% less fentanyl than those receiving placebo (P = 0.011). The mean area under the curve of pain intensity (PI) scores over time from T0–240 min was 55.2 for parecoxib and 61.2 for placebo (P = 0.083). At T180 and T240 min, mean PI score was 7.0 and 7.6 points lower in the parecoxib group, respectively (P < 0.02). Fewer patients on valdecoxib required supplemental analgesics (P < 0.05) after discharge. At T240 min and at day 7, Patient’s and Physician’s/Nurse’s Global Evaluations were significantly better in the parecoxib/valdecoxib group (P < 0.05). Incidences of adverse events, adverse events causing withdrawal, and serious adverse events were less for parecoxib/valdecoxib than for placebo. The authors conclude that preoperative parecoxib is a valuable opioid-sparing adjunct to the standard of care for treating pain after laparoscopic cholecystectomy, and subsequent treatment with oral valdecoxib extends this clinical benefit.


缬草和缬草酸对活化小鼠脑干神经元的GABA能效应

The Gamma-Aminobutyric Acidergic Effects of Valerian and Valerenic Acid on Rat Brainstem Neuronal Activity

Chun-Su Yuan, MD PhD*,{dagger},{ddagger}, Sangeeta Mehendale, MD PhD*,{dagger}, Yingping Xiao, PhD{dagger}, Han H. Aung, MD*,{dagger}, Jing-Tian Xie, MD{dagger}, and Michael K. Ang-Lee, MD*

*Department of Anesthesia & Critical Care, {dagger}Tang Center for Herbal Medicine Research, and {ddagger}Committee on Clinical Pharmacology and Pharmacogenomics, Pritzker School of Medicine, University of Chicago, Chicago, Illinois

Anesth Analg 2004;98:353-358


缬草是一种药草,可产生抗焦虑和镇静作用。通过Υ-氨基丁酸能机制作用。先前的研究显示缬草的萃取物与GABA受体特异性结合,但结合物的功能作用尚未证实。在本研究中,我们评价了缬草萃取物和他的主要成分之一,缬草酸对离体新生小鼠脑干神经元活化的GABA能效应。我们首先观察了毒蝇蕈醇,一种GABAA受体激动剂,可以浓度依赖性的降低多数脑干神经元的神经冲动频率;30μM产生38.9%±3.0%抑制与对照组相比(p<0.01, 50%抑制浓度[IC50]20+0.1μM)。这种作用可以被荷包牡丹碱(10μM),一种GABAA拮抗剂所拮抗。然后我们发现3mg/ml的缬草萃取物诱导的抑制为29.6%+5.1%,其IC50240+18.7μg/ml,而100μM的缬草酸诱导的抑制为22.2%+3.4%,其IC5023+2.6μM(两者均p<0.01)。荷包牡丹碱可对抗缬草和缬草酸的抑制作用。另外,缬草萃取物或缬草酸术前用药可降低毒蝇蕈醇对脑干的抑制作用(P<0.05),提示这些混合物在GABA的常规活化中扮演重要角色。本研究的数据显示缬草萃取物或缬草酸的药理作用是通过调控GABAA受体的功能而产生的。所以,缬草可以作为麻醉剂或其他用药通过GABA受体产生镇静作用,术前应用可产生缬草-麻醉剂的相互作用。

(忻纪华 译 王祥瑞 校)

Valerian is a medicinal herb that produces anxiolytic and sedative effects. It was suggested that valerian acts via gamma-aminobutyric acid (GABA)ergic mechanisms. Previous studies showed binding of valerian extract to GABA receptors, but the functional effect of the binding has not been demonstrated. In this study we evaluated the GABAergic effect of valerian extract and one of its major constituents, valerenic acid, on brainstem neuronal activity in an in vitro neonatal rat brainstem preparation. We first observed that muscimol, a GABAA receptor agonist, decreased the firing rate in most brainstem neurons in a concentration-related fashion; 30 µM produced a 38.9% ± 3.0% (mean ± SE) inhibition compared with control values (P < 0.01; 50% inhibitory concentration [IC50], 2.0 ± 0.1 µM). This effect was antagonized by bicuculline (10 µM), a GABAA antagonist. Then we showed that valerian extract 3 mg/mL induced a 29.6% ± 5.1% inhibition with an IC50 of 240 ± 18.7 µg/mL, whereas 100 µM valerenic acid induced a 22.2% ± 3.4% inhibition with an IC50 of 23 ± 2.6 µM (both P < 0.01). Bicuculline antagonized the inhibitory effects of both the valerian extract and valerenic acid. In addition, pretreatment with valerian extract or valerenic acid decreased the brainstem inhibitory effects produced by muscimol (both P < 0.05), suggesting that these compounds play an important role in the regulation of GABAergic activity. Data from this study suggest that the pharmacological effects of valerian extract and valerenic acid are mediated through modulation of GABAA receptor function. Thus, valerian may potentiate the sedative effects of anesthetics and other medications that act on GABA receptors, and presurgical valerian use may cause a valerian-anesthetic interaction.


新超声-放射治疗方案可使EMLA产生快速浸润麻醉效应

Rapid Onset of Cutaneous Anesthesia with EMLA Cream After Pretreatment with a New Ultrasound-Emitting Device

Nathaniel P. Katz, MD, David E. Shapiro, PhD, Timothy E. Herrmann, Joseph Kost, PhD, and Linda M. Custer, PhD

From the Pain Trials Center, Brigham & Women’s Hospital, Boston, Massachusetts

Anesth Analg 2004;98:371-376
在这次随机的42人实验过程中,我们主要测试经短暂(将近10-s)皮下低频(55KHz)超声治疗后,应用低熔混合局麻药(EMLA)乳剂的浸润麻醉起效速度。四种治疗方案进行相互比较:前三组为应用超声治疗后紧接着使用1gEMLA或安慰剂5min10min15min的效应,另一对照组不使用超声治疗而直接用1gEMLA或安慰剂后60min的效应。用20g针进行疼痛测试。任何一时间点都测试疼痛评分和患者对EMLA和安慰剂的反应。在这一基础上我们可以看出在所有的时间点,与安慰剂比较,EMLA可以起到浸润麻醉的效应。使用超声治疗后,再应用EMLA5min10min15min的疼痛评分以及患者总体反应与单纯使用EMLA60min是无明显区别的,同时也未发现明显副反应。低频超声在这次实验中被证实可安全和有效地使EMLA产生效用,最早5min即可起效。

(朱慧琛 译 王祥瑞 校)

In this randomized, double-blinded, placebo-controlled, crossover trial of 42 human subjects, we examined the speed of onset of cutaneous anesthesia by eutectic mixture of local anesthetics (EMLA) cream after brief (approximately 10-s) pretreatment of the underlying skin with low-frequency (55 kHz) ultrasound. Four treatments were compared: ultrasound pretreatment followed by application of 1 g EMLA or placebo cream for 5 min, 10 min, 15 min, and 60 min without ultrasound pretreatment as positive control. Pain was tested by pricks with a 20 g needle. Pain scores and patient preference for EMLA or placebo cream were measured at each time point. Based on both pain scores and patient preference, cutaneous anesthesia was achieved in the EMLA groups as compared with placebo at all time points. After ultrasound pretreatment and then 5, 10, or 15 min after EMLA cream application, pain scores and overall preference were statistically indistinguishable from EMLA cream application for 60 min (without ultrasound pretreatment). There were no significant adverse effects. Low-frequency ultrasound pretreatment appears to be safe and effective in producing rapid onset of EMLA cream in this model, with results as early as 5 min.


利用电视医疗设备进行远程麻醉监测的报道

Case Report of Remote Anesthetic Monitoring Using Telemedicine

Stephen W. Cone, MD, Lynne Gehr, MD, Russell Hummel, MS, Azhar Rafiq, MD, Charles R. Doarn, MBA, and Ronald C. Merrell, MD FACS

From the Medical Informatics and Technology Applications Consortium (MITAC), Department of Surgery, Virginia Commonwealth University, Richmond, Virginia

Anesth Analg 2004;98:386-388

我们报道了一例应用电信科技实行远程麻醉监测的事例。在厄尔瓜多亚马逊雨林中的一次手术过程中,患者的生命体征、监测数据和录象资料通过电信进行传播。这种电信医疗科技使这次远程手术获得了专家们的有用建议。

(朱慧琛 译  王祥瑞 校)

We report a case supporting the use of telecommunications technology from a remote location to monitor anesthetic events. Vital signs, data, and video were transmitted from surgery conducted in the remote Amazonian rainforests of Ecuador to Richmond, VA. This application of telemedicine technologies makes available expert advice from remote locations during surgical procedures.

 

瑞芬太尼和加巴喷丁对健康志愿者新扩展的炎性皮肤疼痛模型的治疗效果

The Effects of Remifentanil and Gabapentin on Hyperalgesia in a New Extended Inflammatory Skin Pain Model in Healthy Volunteers

Burkhard Gustorff, MD DEAA, Katharina Hoechtl, Cand med, Thomas Sycha, MD, Evangelos Felouzis, MD DEAA, Stephan Lehr, MSc, and Hans G. Kress, MD PhD

From the Department of Anesthesia and General Intensive Care Medicine (B), University of Vienna, Vienna, Austria

Anesth Analg 2004;98:401-407


我们对16名志愿者进行双盲,安慰剂对照和的试验来评估用瑞芬太尼,加巴喷丁或联合使用对因UVB引起的炎性疼痛模型的治疗效果。我们先在志愿者身上选择一块圆形的皮肤用紫外线灯照射20小时,然后使用加巴喷丁(600mg),两小时后应用芬太尼(0.08μg•kg-1•min-140min)。在照射点我们观察到热疼痛知觉限度(HPPT;平均差,4.45℃95%可信区间[CI]3.32°-5.59°)和热疼痛耐受限度(HPTT;平均差,5.43℃95%可信区间[CI]4.50°-6.35°)比正常皮肤下降。此外,我们对所有的研究对象用针刺邻近的皮肤使其产生红斑。总体上瑞芬太尼增加了HPPT(平均增加,2.47℃95%可信区间[CI]1.86°-3.09°P0.001)和HPTT(平均增大,3.18℃95%可信区间[CI]2.65°-3.71°P0.001)并且比安慰剂组减少了59%的继发性痛觉过敏面积。在照射区瑞芬太尼比正常皮肤HPTT增加了86%(额外增加,2.57℃95%可信区间[CI]1.71°-3.43°),而HPPT没有这种明显的差别。加巴喷丁除在照射区轻微增大HPTT外在两痛觉过敏区没有值得注意的效果。总之,阿片类镇痛剂在新扩展的疼痛模型中有可靠的疗效。

(朱辉 译 王祥瑞 校)

We tested the responsiveness of measures of hyperalgesia in a model of UVB-induced inflammatory hyperalgesia with remifentanil, gabapentin, and the combination of both drugs in a double-blinded, active placebo-controlled, 4-way-crossover design in 16 volunteers. A circular skin area was irradiated with UVB-light 20 h before the application of gabapentin (600 mg) and 2 h later remifentanil (0.08 µg • kg-1 • min-1, 40 min). In the sunburn spots we observed stable decreases of the heat pain perception thresholds (HPPT, mean difference, 4.45°C; 95% confidence interval [CI], 3.32°–5.59°) and heat pain tolerance thresholds (HPTT; mean difference, 5.43°C; 95% CI, 4.50°–6.35°) compared with normal skin. Further, large areas of mechanical hyperalgesia to pinprick adjacent to the erythema spots developed in all subjects. Overall remifentanil increased the HPPT (mean increase, 2.47°C; 95% CI, 1.86°–3.09°, P < 0.001) and HPTT (mean increase, 3.18°C; 95% CI, 2.65°–3.71°, P < 0.001) and reduced the area of secondary hyperalgesia by 59% (mean decrease, 5326 mm2; 95% CI, 4233–6419 mm2, P < 0.001) compared with placebo. In the sunburn remifentanil markedly increased the HPTT by 86% compared with normal skin (additional increase, 2.57°C; 95% CI, 1.71°–3.43°). This different effect was not seen in the HPPT. With the exception of a small increase of HPTT in the sunburn (P = 0.02) gabapentin had no noticeable effect on either hyperalgesia. In conclusion, opioid analgesia was reliably demonstrated in this new extended pain model.


持续鞘内使用内源性配体腺苷,胍丁胺和Endomorphin-1的镇痛效应及相互作用

The Antinociceptive Potencies and Interactions of Endogenous Ligands During Continuous Intrathecal Administration: Adenosine, Agmatine, and Endomorphin-1

Gabriella Kekesi*, Ildiko Dobos*, György Benedek, MD DSc*, and Gyöngyi Horvath, MD PhD*,{dagger}

*Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary; and {dagger}Department of Physical Therapy, Faculty of Health Science, University of Szeged, Szeged, Hungary

Anesth Analg 2004;98:420-426


最近,有一系列的文章报道关于内源性配体腺苷,胍丁胺和Endomorphin-1在脊髓水平通过作用于不同的受体抑制有害刺激的传导,然而很少有报道述及持续使用的效果以及它们的相互作用。在这项研究中,我们通过老鼠爪子缩回的检测试验来研究持续使用(60分钟)腺苷,胍丁胺治疗由角叉菜引起的灼痛的镇同性质。Endomorphin-1与腺苷或胍丁胺的相互作用也在研究之列。在滴注期间持续使用腺苷(0.3-3μg/min)对于正常和灼烧的爪子的回缩时间没有影响,而在停止滴注后给予更大剂量的腺苷时显著地延长了反应时间。剂量依赖的腺苷(0.3-3μg/min)可降低痛觉过敏,但最大剂量的腺苷可引起50%的实验动物兴奋。持续使用腺苷或胍丁胺(3μg/min)可加强并延长Endomorphin-11μg/min)的镇痛效应。我们的研究结果揭示了持续鞘内使用腺苷和胍丁胺有轻微的镇痛效果并皆可加强Endomorphin-1的镇痛效应。这些数据表明联合使用这些内源性配体有益于疼痛的治疗,当然,对全身副作用的检查也是必需的。

(朱辉 译 王祥瑞 校)

Recently, a series of endogenous ligands related to inhibition of sensory transduction of noxious stimuli at the spinal level has been described, including endomorphins, agmatine, and adenosine, which act on different receptors; however, little data exist concerning their effect during continuous administration or their interactions. In this study, we investigated the antinociceptive properties of continuously administered (for 60 min) adenosine and agmatine on carrageenan-induced thermal hyperalgesia by means of a thermal paw withdrawal test in awake rats. The possible interaction between endomorphin-1 and adenosine or agmatine was also determined. Continuous administration of adenosine (0.3–3 µg/min) did not influence the paw withdrawal latencies of the normal or inflamed paws during the infusion but in larger doses it resulted in a significant increase in latencies after the cessation of the infusion. Agmatine (0.3–3 µg/min) dose-dependently decreased the hyperalgesia, but the largest dose caused a temporary excitation in 50% of animals. The continuous administration of adenosine or agmatine (3 µg/min) potentiated and prolonged the antinociceptive effect of endomorphin-1 (1 µg/min). Our results revealed that adenosine and agmatine have a small antinociceptive efficacy during continuous intrathecal administration but that both potentiate the effect of endomorphin-1. These data suggest that the combination of these endogenous ligands might represent novel targets for the therapeutic modulation of pain; however, the systematic examination of side effects is essential.


大学附属医院住院医生培训水平和麻醉监测质量的评估

Resident Training Level and Quality of Anesthesia Care in a University Hospital

Karen L. Posner, PhD*,{dagger}, and Peter R. Freund, MD*,{ddagger}

*Departments of Anesthesiology and {dagger}Anthropology, University of Washington; and {ddagger}Anesthesia Clinical Services, University of Washington Medical Center, Seattle

 

Anesth Analg 2004;98:437-442

在本研究中,我们分析了住院医生培训与病人麻醉安全之间的关系。通过对麻醉质量改进数据库的回顾,我们分析了围术期病人任何麻醉质量问题和特殊类型质量问题(损伤、需加强监测、操作失败)与CA1CA2CA3住院医生麻醉工作组之间的相对风险。CA1阶段的住院医生相对经验较少,他们在临床上发生麻醉质量问题的概率要高于相对经验丰富的CA2CA3阶段的住院医生。研究数据表明发生损伤的风险在三组之间无明显差异。CA2住院医生在围术期发生紧急事件需加强监测的概率要高于CA1CA3住院医生组,发生操作失败的概率高于CA3CA2阶段住院医生在进入麻醉专业培训之前,一般要求具备更先进的技术和更多的知识。他们在临床上发生紧急事件需加强监测和操作失败的概率相对较高可能反应了他们与CA3阶段住院医生相比临床经验不足,技术掌握不够训练。与CA2工作组相关的较高的操作失败率和需加强监护的概率可能导致了医疗机构医疗费用的增加。

(齐波 译  王祥瑞 校)

In this study, we analyzed the relationship between resident training and patient safety in anesthesia. A retrospective quality improvement database review was used to calculate the relative risk of any quality problem and specific types of quality problems (injury, escalation of care, or operational inefficiency) between anesthesia teams with CA1, CA2, and CA3 residents. It was expected that teams with less experienced residents (CA1) would have more frequent quality problems than teams with more experienced residents (CA2 and CA3 teams). Data showed that risk of injury did not differ between CA1, CA2, and CA3 teams. CA2 teams had higher rates of critical incidents and escalation of care than CA1 and CA3 teams and higher rates of operational inefficiency than CA3 teams. The CA2 yr is when residents move into specialty training, requiring more advanced skills and a larger knowledge base. Their higher relative risk for critical incidents, escalation of care, and operational inefficiencies may reflect lack of experience, uncertainty, and less skill mastery compared with CA3 residents. The higher inefficiency and escalation of care rates associated with CA2 teams may translate into larger costs for the institution.


猪模型使用大脑皮层刺激电极进行体外除颤并不引起热损伤的急性组织病理学改变

External Cardiac Defibrillation Does Not Cause Acute Histopathological Changes Typical of Thermal Injuries in Pigs with In Situ Cerebral Stimulation Electrodes

Christian Kolbitsch, MD DEAA*, Wilhelm Eisner, MD{dagger}, Axel Kleinsasser, MD*, Matthias Biebl, MD{ddagger}, Thomas Fiegele, PhD{dagger}, Alexander Löckinger, MD*, Ingo H. Lorenz, MD*, Gregor Mikuz, MD FRCPath§, and Patrizia L. Moser, MD§

Departments of *Anaesthesia and Intensive Care Medicine, {dagger}Neurosurgery, {ddagger}Vascular Surgery, and §Pathology, University of Innsbruck, Austria

Anesth Analg 2004;98:458-460


存在长期左旋多巴综合症的帕金森氏综合症的病人在植入大脑皮层刺激装置后症状有望改善。在这些病人中使用如此装置时,可能在电极临近的大脑组织和刺激装置部位产生单相电休克。在本实验中,我们对6头猪在刺激电极植入部位反复进行除颤试验(2x200J(n=1),2x360J(n=5))。反复体外除颤在电极临近的大脑组织并不引起热损伤的急性组织病理学改变。除颤后刺激装置的功能可能正常或完全失效。所以,在使用除颤时,必须在距离植入式刺激装置合理的位置选择适当的位点。这样才能保证刺激装置的功能。

(周洁 译 王祥瑞 校)

Parkinson’s disease patients with long-term L-dopa syndrome may benefit from an implanted cerebral stimulation device. When advanced life support demands cardioversion or defibrillation in these patients, undesired effects of monophasic electroshocks might occur in brain tissue adjacent to the stimulation electrodes (e.g., thermal injury), but also in the stimulation device itself. Thus, in this animal study (n = 6 pigs), we investigated the effects of repeated defibrillation (2 x 200 J [n = 1] and 2 x 360 J [n = 5]) at the implantation site of cerebral stimulation electrodes and on stimulation device function. Repeated external cardiac defibrillation did not cause acute histopathologic changes typical of thermal injury to brain tissue adjacent to the cerebral stimulation electrodes. Functionality of the stimulator device after defibrillation, however, ranged from normal to total loss of function. Therefore, when defibrillation is performed, the greatest possible distance between the defibrillation site and the stimulator device implantation site should be considered. Subsequent testing of the stimulator device’s function is mandatory.


剖腹产行椎管内麻醉时静注麻黄素预防低血压的剂量反应的汇粹分析

A Dose-Response Meta-Analysis of Prophylactic Intravenous Ephedrine for the Prevention of Hypotension During Spinal Anesthesia for Elective Cesarean Delivery

Anna Lee, MPH PhD, Warwick D. Ngan Kee, MBChB MD, FANZCA, and Tony Gin, MBChB MD, FANZCA, FRCA

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China

Anesth Analg 2004;98:483-490


我们对一些研究进行系统性的回顾以寻找在进行椎管内麻醉的剖腹产病人中静脉使用麻黄素预防低血压的剂量反应关系。我们通过MEDLINEEMBASE等途径寻找随机对照实验(RCT)或队列实验,并研究了一些已发表的文章,后者对2种或2种以上不同剂量静脉使用麻黄素用于预防剖腹产病人椎管内麻醉后低血压的剂量反应关系。本文一共参考了4RCT1项队列研究,结果发现在RCT实验中,存在显著的剂量反应关系,低血压(斜率=-0.012895%可信度-0.0213—-0.0044),高血压(斜率=-0.056395%可信度0.0235—0.0892),动脉血pH改变(斜率=-0.0395%可信度-0.05—0.00)。麻黄素用于预防低血压的作用很小。在14mg剂量时,有效和无效的病例数相仿,在大剂量时,其引起高血压的情况比预防低血压更多见,动脉血pH略降低。

(周洁 译 王祥瑞 校)

We systematically reviewed available studies to determine the dose-response characteristics of prophylactic IV ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. We searched for randomized controlled trials (RCTs) or cohort studies—obtained through MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and reference lists of published articles—in which two or more different doses of prophylactic IV ephedrine were used to prevent hypotension during spinal anesthesia for cesarean delivery. Four RCTs and one cohort study were found (total n = 390). There was a significant dose-response relationship in the RCTs pooled for hypotension (slope = -0.0128; 95% confidence interval [CI], -0.0213 to -0.0044), hypertension (slope = 0.0563; 95% CI, 0.0235 to 0.0892), and umbilical arterial pH (slope = -0.03; 95% CI, -0.05 to 0.00). The efficacy of ephedrine for preventing hypotension was small. At 14 mg, the number-needed-to-treat was only 7.6 (95% CI, 4.8–21.1), and this was the same as the number-needed-to-harm (7.6; 95% CI, 3.7–23.4). At larger doses, the likelihood of causing hypertension was actually more than that of preventing hypotension, and there was also a minor decrease in umbilical arterial pH.


人类免疫缺陷病毒——麻醉和产科手术的影响

Human Immunodeficiency Virus: Anesthetic and Obstetric Considerations

Shmuel Evron, MD*, Marek Glezerman, MD{dagger}, Ethan Harow, DO{ddagger}, Oscar Sadan, MD§, and Tiberiu Ezri, MD||

*Obstetric Anesthesia Unit, the {dagger}Department of Obstetrics and Gynecology, the {ddagger}Ambulatory Surgical Unit, §Delivery Ward, ||Department of Anesthesia, The Edith Wolfson Medical Center, Holon (Israel), Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Anesth Analg 2004;98:503-511


获得性免疫缺陷病(AIDS)的流行至今已经三十年了。世界卫生组织的统计显示人类免疫缺陷病毒(HIV)的感染情况日益严重。而其中生育期妇女是病毒感染增长最快的人群。常见的感染后的症状和体征已经变的更缓和,临床症状更轻,但是新的临床表现又在出现,很明显的是HIV往往影响多器官系统。现在在HIV的发病机理方面已经有了不少的进展,而且病毒测定和CD淋巴细胞的测定的分子学技术也可以估计和评价疾病的预后和治疗。但是关于病人的麻醉和手术的整体危险性的估计的信息还很有限。可以肯定的是,手术介入治疗并不会增加病人术后的并发症或是死亡率,因此手术不必被限制。而且,也没有足够的证据可以证明抗病毒药药物会增加妊娠期的并发症或妊娠可以改变感染的过程。全麻被认为是安全的。但是药物的相互作用和他们对于不同器官的影响必须于以充分考滤。区域阻滞也是可以选择的方法。但是我们必须充分考虑到神经系统的表现,局部的感染,血凝异常。必须强调的是所有的麻醉医生都要熟悉这个疾病并且应和胎儿科麻醉医生会诊,组成医疗小组以保证给予HIV患者以最佳的冶疗。

(顾漪闻 译 王祥瑞 校)

The pandemic of acquired immune deficiency syndrome (AIDS) is on the threshold of its third decade of existence. The World Health Organization-United Nations statistics show that human immunodeficiency virus (HIV)/AIDS pandemia is set to get much worse. Women of reproductive age are the fastest growing population with HIV. Common signs and symptoms have become more moderate or subclinical, and new clinical presentations have emerged. It is quite apparent that HIV-disease affects multiple organ systems. Advances have been made in elucidating the pathogenesis of HIV. In addition, the molecular technique of viral load determination and the CD + 4 T-lymphocyte count enable evaluation of the disease, its prognosis, and its response to therapy. There is limited specific information concerning the overall risk of anesthesia and surgery of HIV/AIDS patients. However, as far as can be determined, surgical interventions do not increase the postoperative risk for complications or death and should therefore not be withheld. There is also little evidence to suggest that HIV or antiretroviral drugs increase the rate of pregnancy complications or that pregnancy may alter the course of HIV infection. General anesthesia is considered safe, but drug interactions and their impact on various organ systems should be considered preoperatively. Regional anesthesia is often the technique of choice. Yet, one must take into consideration the presence of neuropathies, local infection, or blood clotting abnormalities. It should be emphasized that all practicing anesthesiologists should be familiar with the disease and should use prenatal anesthesia consultations and a team approach to assure optimal treatment for HIV patients.


半球同步对术中镇痛的影响

The Effect of Hemispheric Synchronization on Intraoperative Analgesia

Ariane K. Lewis, Irene P. Osborn, MD, and Ram Roth, MD

Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York

Anesth Analg 2004;98:533-536


在随机对照双盲的试验中,我们发现给予全麻病人以半球同步的音乐可以减少病人在手术中对于镇痛药物的需求量,这一点和以前的试验是一致的。在手术中,双频指数用于监测睡眠的深度,血流动力学用于决定镇痛药的用量。选择肥胖病人的腹腔镜手术或是单个腰椎间盘手术,在气管插管后,给予双耳机,记录心率和血压的基线,术中以异氟醚维持以保持脑电双频指数始终处于40—60,用25-的芬太尼注射以保证心率和血压的稳定。我们发现肥胖病人只需要对照组的1/3的芬太尼的用量(SD:0.015[0.01]vs0.024μg•kg-1•min-1[0.01](P=0.009)。但是有趣的是腰椎手术的试验组和对照组的病人对于芬太尼的用量却是相同的(0.012[0.01]vs0.015μg•kg-1•min-1[0.01])。呼气末异氟醚的含量半球同步组和空白磁带组是相同的(肥胖组,0.74%0.14vs0.77%(0.21);腰椎组,0.36%[0.16]vs0.39%[0.12])。因此,在这个研究中可以发现,对肥胖病人给予半球同步音乐可能是术中镇痛的一个革新。

(顾漪闻 译 王祥瑞 校)

In this double-blinded randomized study, we sought to confirm that patients undergoing general anesthesia who were exposed to a hemispheric synchronization (Hemi-Sync) musical recording during surgery had a smaller analgesia requirement, as was suggested in a previous study. Bispectral index monitoring was used to adjust depth of hypnosis, and hemodynamic variables were used to determine analgesia administration. Consented patients underwent either laparoscopic bariatric or one-level lumbar disk surgery. After endotracheal intubation and application of headphones, baseline heart rate and arterial blood pressure were established. Isoflurane was titrated to maintain sedation on the basis of a target bispectral index range of 40–60, and 25-µg increments of fentanyl were administered in response to increases in heart rate and systolic arterial blood pressure. Bariatric patients who listened to Hemi-Sync required one-third less fentanyl than the control group (mean [SD]: 0.015 [0.01] vs 0.024 µg • kg-1 • min-1 [0.01]) (P = 0.009). It is interesting to note that lumbar patients in the experimental and control groups required similar amounts of fentanyl (0.012 [0.01] vs 0.015 µg • kg-1 • min-1 [0.01]). End-tidal isoflurane concentration was similar for Hemi-Sync and blank-tape patients (bariatric, 0.74% (0.14) vs 0.77% (0.21); lumbar, 0.36% [0.16] vs 0.39% [0.12]). The bariatric patients in this study demonstrated that Hemi-Sync may be an innovative intraoperative supplement to analgesia.

 

心肺转流期间肝素水平的抗凝管理:一项关于半量抑肽酶方案对术后失血和止血活以及炎症反应影响的实验性研究

Heparin-Level-Based Anticoagulation Management During Cardiopulmonary Bypass: A Pilot Investigation on the Effects of a Half-Dose Aprotinin Protocol on Postoperative Blood Loss and Hemostatic Activation and Inflammatory Response

Andreas Koster, MD, Sabine Huebler, MD, Frank Merkle, EBCP, Thomas Hentschel, MD, Marcus Gründel, MD, Thomas Krabatsch, MD, Luc Tambeur, MD, Michael Praus, MD, Helmut Habazettl, MD, Wolfgang M. Kuebler, MD, and Hermann Kuppe, MD

From the Department of Anesthesia, Deutsches Herzzentrum, Berlin, Germany

Anesth Analg 2004 98: 281-282

 

涉及心肺转流(CPB)的心脏手术会导致对止血/炎症系统的激活。我们比较了在心脏手术中采用基于肝素水平的抗凝管理时,半量抑肽酶方案对术后血液丧失和对CPB期间止血/炎症系统激活的影响。本研究为随机的前瞻性研究,研究对象200例(每组100例)。组Ⅰ根据Hepcon HMS PlusTM监测结果仅加入肝素。组Ⅱ在CPB开始前即刻注射抑肽酶1 x 106激肽释放酶抑制单位(KIU,CPB预充液内加入抑肽酶1 x 106KIU,在CPB期间以250000KIU/h的速度持续输注。在手术后12小时确定术后失血量。肝素和抗凝血酶活性通过抗-Xa检测和抗凝血酶Ⅲ活性测定来确定。止血激活通过测量二磷酸腺苷激活的血小板聚集、β血栓球蛋白(β-TG)、可溶性P-选择蛋白(sPs)、凝血酶(TAT)、凝血酶原12的片段(PTF1+2)、Ⅻa因子(Fa)、纤维蛋白溶解酶(PAP)和D-二聚体来确定。炎症反应通过测定补体5b-9因子(C5b-9)、白细胞介素(IL-6和中性粒细胞弹性蛋白酶(NE)来确定。两组在CPB前的数值和CPB时间均无差异。两组间在CPB后血小板计数、血小板聚集、β-TGsPSTATPTF1+2C5b-9NEIL-6数值均无差异。加用抑肽酶导致PAPD-二聚体和术后12小时失血量减少,而接触因子XIIa生成增加。应用抑肽酶明显减少心脏手术和CPB后血液丧失。最可能的原因是抑肽酶的抗纤溶效应。未发现其对凝血酶生成、血小板激活以及炎症反应和临床结局的作用。

提示:在心脏手术中采用基于肝素水平的抗凝管理时应用半量抑肽酶使术后血液丧失明显减少,最可能的原因是抑肽酶的抗纤溶效应,因为我们未发现对止血/炎症系统的激活作用。

(颜涛 李士通 校)

Cardiac surgery involving cardiopulmonary bypass (CPB) leads to activation of the hemostatic/inflammatory system. We compared the influence of a half-dose aprotinin regimen on postoperative blood loss and the activation of the hemostatic/inflammatory system during CPB, when used during a heparin-level-based heparin management for cardiac surgery. Two-hundred patients (n = 100 in each group) were enrolled in this randomized prospective study. In Group I only heparin was given according to the results of the Hepcon HMS PlusTM. In Group II aprotinin was added with a bolus of 1 x 106 kallikrein inhibiting units (KIU) for the patient immediately before initiation of CPB, 1 x 106 KIU in the priming solution of the CPB, and a continuous infusion of 250,000 KIU/h during CPB. Postoperative blood loss was determined after 12 h. Heparin and antithrombin activity were evaluated by an anti-Xa assay and measurement of antithrombin III activity. Hemostatic activation was evaluated by adenosine diphosphate-stimulated platelet aggregometry and by measurements of the generation/release of ß-thromboglobulin (ß-TG), soluble P-selectin (sPS), thrombin (TAT), prothrombin 1 and 2 fragments (PTF1+2), factor XIIa (FXIIa), plasmin (PAP), and D-dimers. Inflammatory response was evaluated by measuring complement factors 5b-9 (C5b-9), interleukin (IL)-6, and neutrophil elastase (NE). There were no differences in the pre-CPB values or duration of CPB between the two groups. There were no differences in the post-CPB values for platelet count, platelet aggregation, ß-TG, sPS, TAT, PTF1+2, C5b-9, NE, or IL-6. The additional use of aprotinin resulted in a significant decrease of PAP, D-dimers, and 12 h postoperative blood loss, whereas generation of the contact factor XIIa was increased. The administration of aprotinin significantly reduced postoperative blood loss after cardiac surgery and CPB. This most likely has to be attributed to the antifibrinolytic effects of aprotinin. No effects on thrombin generation, platelet activation, inflammatory response, or clinical outcome were noted.

 

P波离散度增加预示冠状动脉旁路术后房颤

Increases in P-Wave Dispersion Predict Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery

Joby Chandy, MD*, Toshiko Nakai, MD, Randall J. Lee, MD PhD, Wayne H. Bellows, MD, Samir Dzankic, MD*, and Jacqueline M. Leung, MD MPH*

*Department of Anesthesia and Perioperative Care; the Department of Medicine, Section of Cardiac Electrophysiology, University of California, San Francisco, CA, and the Department of Cardiovascular Anesthesia, Kaiser Permanente Medical Center, San Francisco, California

Anesth Analg 2004 98: 303-310

 

房颤(AF)是冠状动脉旁路手术(CABG)后常见的并发症。本研究中我们通过检测P波特性反映手术对心房电生理的影响,确定其对预测CABG病人术后AF的潜在价值。对择期行CABG手术的病人在住院期间持续遥测心电图至出院以发现AF。比较12导联心电图P波特征(P波时程、幅度、电轴、离散度、PR间期、节段压低和离散度)术前与术后、以及AF与非AF病人间的差异。采用多变量logistic回归分析潜在的临床预测因素及P波特性与术后AF间的关联。300例病人中82例(27%)发生AF。单变量分析表明后来发生AF的病人与未发生者相比平均年龄更大(68 ± 8 yr vs 63 ± 10 yr, P < 0.0001),体表面积更大(BSA)(2.03 ± 0.24 vs 1.92 ± 0.22 m2, P = 0.0002),具有AF病史的可能性更大((8/81 vs 1/219, P = 0.003),术前使用抗心律失常药更频繁(7/81 vs 4/219, P = 0.01),并且因术后并发症而重返手术室的比例也更高(9/81 vs 9/219, P = 0.029)。而且,术后发生AF的病人其术后P波时程减少的程度更大( -11.3 ± 0.1 ms vs -8.4 ± 0.1 ms, P < 0.0001),术后P波离散度增加程度也更大(3.1 ± 15.5 ms vs -1.6 ± 14.6 ms, P = 0.028)。多变量logistic回归分析表明年龄(可能比[OR]1.195%可信区间[CI]: 1.061.15, P < 0.0001,体表面积(OR38.195CI8.2176, P < 0.0001)和术后P波离散度的增加(OR1.0395CI1.01-1.05P0.01)是术后AF的独立预测因子。未发现任何手术因素与这一术后心房电生理变化有关。

提示:除高龄和体表面积大等临床指标外,我们还证实术后P波离散度增加这一电生理变化是CABG病人术后AF的独立预测因子。

颜涛 李士通 校)

Atrial fibrillation (AF) is a common complication after coronary artery bypass graft (CABG) surgery. In this study we examined the effect of surgery on atrial electrophysiology as measured by P-wave characteristics and to determine the potential predictive value of P-wave characteristics on the incidences of postoperative AF in patients undergoing CABG surgery. Patients undergoing elective CABG surgery were monitored by continuous electrocardiogram (ECG) telemetry during the in-hospital period until discharge for the occurrence of postoperative AF. Differences in P-wave characteristics (P-wave duration, amplitude, axis, dispersion, PR interval, segment depression, and dispersion) were compared between the pre- and postoperative 12-lead ECG measurements, and also between patients with and without postoperative AF. The association of postoperative AF and potential clinical predictors and P-wave characteristics were determined by multivariate logistic regression. Postoperative AF occurred in 81 (27%) of 300 patients. Univariate analysis showed that patients who subsequently developed postoperative AF compared with those without AF were significantly older (mean age 68 ± 8 versus 63 ± 10 yr, P < 0.0001), had a larger body surface area (BSA) (2.03 ± 0.24 versus 1.92 ± 0.22 m2, P = 0.0002), were more likely to have a history of AF (8 of 81 versus 1 of 219, P = 0.003), used preoperative antiarrhythmic medications more frequently (7 of 81 versus 4 of 219, P = 0.01), and had a more frequent rate of return to the operating room for postoperative complications (9 of 81 versus 9 of 219, P = 0.029).

Furthermore, the postoperative P-wave duration decreased to a larger extent (mean change -11.3 ± 0.1 ms versus -8.4 ± 0.1 ms, P < 0.0001), and the P-wave dispersion increased postoperatively to a larger extent (3.1 ± 15.5 ms versus -1.6 ± 14.6 ms, P = 0.028) in those who subsequently developed AF compared with those without AF. Multivariate logistic regression showed age (odds ratio [OR] = 1.1, 95% confidence interval [CI]: 1.06–1.15, P < 0.0001), BSA (OR = 38.1, 95% CI: 8.2–176, P < 0.0001), and an increase in postoperative P-wave dispersion (OR = 1.03, 95% CI: 1.01–1.05, P = 0.01) to be independent predictors of postoperative AF. No surgical factor was identified to be responsible for this postoperative change in atrial electrophysiology.

 

 

扁桃腺切除和增殖腺切除术后采用“非接触”拔管技术的喉痉挛发生率

The Incidence of Laryngospasm with a "No Touch" Extubation Technique After Tonsillectomy and Adenoidectomy

Ban C. H. Tsui, MD MSc, FRCP(C)*, Alese Wagner, BSc*, Dominic Cave, MB FRCP(C)*, Clark Elliott, MD FRCS, Hamdy El-Hakim, MD FRCS(Ed), FRCS(ORL), and Stephan Malherbe, MB ChB, FCA(SA), MMed(Anes)*

*Department of Anesthesiology and Pain Medicine and Department of Surgery, University of Alberta Hospitals, Edmonton, Canada

Anesth Analg 2004 98: 327-329

 

在这个系列病例中,我们评价了对20例接受择期扁桃腺切除术(伴或不伴增殖腺切除术)的儿童采用明确定义的清醒拔管技术的喉痉挛发生率。该技术要求病人在手术结束还没有停止吸入挥发性麻醉药时即翻转为恢复体位。允许病人除了持续氧饱和度监测外,不给进一步的刺激直至其自然苏醒(即“非接触”)。记录喉痉挛、氧饱和度和呛咳。在我们的病人中没有发现喉痉挛、氧饱和度下降和严重呛咳。

提示:本研究再次强调了对儿童病人在拔出气管导管时合理的麻醉技术的重要性。

颜涛 李士通 校)

In this case series, we evaluated the incidence of laryngospasm using a clearly defined awake tracheal extubation technique in 20 children undergoing elective tonsillectomy with or without adenoidectomy. This technique required patients to be turned to the recovery position at the end of the procedure before discontinuing the volatile anesthetics. No further stimulation, besides continuous oximetry monitoring, was allowed until the patients spontaneously woke up ("no touch" technique). The incidence of laryngospasm, oxygen saturation, and coughing was recorded. No cases of laryngospasm, oxygen desaturation, or severe coughing occurred in our patient population.

 

通过咳嗽法减少静脉穿刺的疼痛:一项随机交叉志愿者研究

Reducing Venipuncture Pain by a Cough Trick: A Randomized Crossover Volunteer Study

Taras I. Usichenko, MD, Dragan Pavlovic, MD, Sebastian Foellner, and Michael Wendt, MD PhD

Department of Anesthesiology and Intensive Care Medicine, Ernst-Moritz-Arndt University, Greifswald, Germany

Anesth Analg 2004 98: 343-345.

 

我们在一项交叉研究中检验了咳嗽法(CT)在周围静脉穿刺时减少疼痛的效果。20例健康志愿者在3周的时间内在同一个手部静脉上进行两次穿刺,一次采用CT方法,另一次则不用。记录疼痛的强度、缩手反应、手掌出汗、血压、心率和血糖浓度。使用CT时静脉穿刺疼痛强度比不使用CT技术者低,而其他变量则无显著改变。虽然机制尚不明了,但简单易行的咳嗽技法能有效减少静脉穿刺时的疼痛。

颜涛 李士通 校)

We tested the effectiveness of the cough trick (CT) as a method of pain relief during peripheral venipuncture (VP) in a crossover study. Twenty healthy volunteers were punctured twice in the same hand vein within an interval of 3 wk, once with the CT procedure and once without it. The intensity of pain, hand withdrawal, palm sweating, blood pressure, heart rate, and serum glucose concentration were recorded. The intensity of pain during VP with the CT procedure was less than without it, whereas the other variables changed insignificantly. The easily performed CT was effective in pain reduction during VP, although the mechanism remains unclear.

 

多巴胺在现代重症监护病房内是否还有其位置?

Is There Still a Place for Dopamine in the Modern Intensive Care Unit?

Yves A. Debaveye, MD, and Greet H. Van den Berghe, MD PhD

Department of Intensive Care Medicine, Catholic University of Leuven, Leuven, Belgium

Anesth Analg 2004 98: 461-468.

 

多年以来,多巴胺被认为是重症监护病房中的重要药物,主要因其心血管效应,甚至更多的是由于其可能对肾功能和内脏粘膜灌注有保护作用。目前有充分的科学证据表明小剂量的多巴胺对急性肾衰的预防和治疗以及对肠道的保护无效。直到最近为止,小剂量的多巴胺都被认为是相对无副作用的。然而,目前已经清楚,小剂量的多巴胺不仅不能达到预想的器官保护目标,还可能有害,因为它可以诱发正常和低血容量患者的肾衰。此外,多巴胺可以通过减少粘膜血流和加重胃动力的减弱来造成伤害。多巴胺还抑制垂体前叶激素的分泌和功能,从而加重分解代谢和细胞免疫的功能障碍,并导致中枢性的甲状腺功能低下。另外,多巴胺使通气动力减弱,增加了机械通气患者脱机时产生呼吸衰竭的危险。我们得出结论:小剂量的多巴胺在ICU中已没有位置,考虑到它的副作用,它广泛用作血管收缩剂也可能受到质疑。

(黄施伟 译,李士通 校)

For many years, dopamine was considered an essential drug in the intensive care unit (ICU) for its cardiovascular effects and, even more, for its supposedly protective effects on renal function and splanchnic mucosal perfusion. There is now ample scientific evidence that low dose dopamine is ineffective for prevention and treatment of acute renal failure and for protection of the gut. Until recently, low-dose dopamine was considered to be relatively free of side effects. However, it is now clear that low-dose dopamine, besides not achieving the preset goal of organ protection, may also be deleterious because it can induce renal failure in normo- and hypovolemic patients. Furthermore, dopamine may cause harm by impairing mucosal blood flow and by aggravating reduced gastric motility. Dopamine also suppresses the secretion and function of anterior pituitary hormones, thereby aggravating catabolism and cellular immune dysfunction and inducing central hypothyroidism. In addition, dopamine blunts the ventilatory drive, increasing the risk of respiratory failure in patients who are being weaned from mechanical ventilation. We conclude that there is no longer a place for low-dose dopamine in the ICU and that, in view of its side effects, its extended use as a vasopressor may also be questioned.

 

蛛网膜下腔阻滞后的感觉运动麻痹和低血压:脊麻-硬膜外联合麻醉与单次脊麻比较

Sensorimotor Anesthesia and Hypotension After Subarachnoid Block: Combined Spinal-Epidural Versus Single-Shot Spinal Technique

Raymond Wee-Lip Goy, MMed, and Alex Tiong-Heng Sia, MMed

From the Department of Anesthesia, KK Women’s and Children’s Hospital, Singapore

Anesth Analg 2004 98: 491-496.

 

蛛网膜下腔的大小取决于脑脊液和硬膜外负压之间的平衡。硬膜外穿刺破坏了这种关系,而空气阻力消失法穿刺对蛛网膜下腔阻滞特性的影响尚不清楚。本研究中我们试图证实当蛛网膜下腔注入完全相同量的麻醉药时,使用空气阻力消失法行硬膜外-脊麻联合麻醉(CSE)比单次注射脊麻(SSS)是否能产生更高的感觉阻滞平面。60例择期行妇产科小手术的患者被随机分成三组,均接受0.5%的重比重布比卡因10mg脊麻。在SSS组,蛛网膜下腔给药是通过27号的Whitacre腰穿针在L34间隙穿刺;在CSE组,硬膜外腔隙是用18号的Tuohy针通过4mL空气阻力消失来确定的,在蛛网膜下腔注药后,一根20号的导管留置在硬膜外腔内,但无额外的药物或盐水通过导管注入;在无导管CSE组,操作过程同CSE组,只不过未置入导管。感觉运动麻痹每隔2.5分钟进行评估直至恢复至T10水平。CSE和无导管CSE组之间在各个方面均无差别。感觉阻滞平面SSS组要低于CSE和无导管CSE组,中位数为T5[最高T3,最低T6]对T3T14]和T3T25](P<0.01)。在阻滞后的最初10min内,胸段阻滞节段在SSS组最低(P<0.05)。感觉恢复至T10水平的时间也是在SSS组最短。低血压、麻黄素的用量以及运动恢复时间在CSECSE(无导管)组更明显(大或长)。我们得出结论:由CSE进行的蛛网膜下腔阻滞较SSS产生更显著的感觉运动麻痹且恢复时间延长。同时尽管使用相同剂量和比重的局麻药,该组发生低血压和使用血管收缩剂的比例也更高。

(黄施伟 译,李士通 校)

The extent of the intrathecal compartment depends on the balance between cerebrospinal fluid and subatmospheric epidural pressure. Epidural insertion disrupts this relationship, and the full impact of loss-of-resistance on the qualities of subarachnoid block is unknown. In this study we sought to determine if subarachnoid block, induced by combined spinal-epidural (CSE) using loss-of-resistance to air could render higher sensory anesthesia than single-shot spinal (SSS) when an identical mass of intrathecal anesthetic was injected. Sixty patients, scheduled for minor gynecological procedures, were randomly allocated into three groups all receiving 10 mg of 0.5% hyperbaric bupivacaine. In the SSS group, intrathecal administration was through a 27-gauge Whitacre spinal needle inserted at the L3-4 level. For the CSE group, the epidural space was identified with an 18-gauge Tuohy needle using loss-of-resistance to 4 mL of air. After intrathecal administration, a 20-gauge catheter was left in the epidural space. No further drug or saline was administered through the catheter. The procedure was repeated in group CSE (no-catheter) except without insertion of a catheter. Sensorimotor anesthesia was assessed at regular 2.5-min intervals until T10 was reached. In all aspects, there was no difference between CSE and CSE (no-catheter). Peak sensory level in SSS was lower than CSE and CSE (no-catheter) (median T5 [max T3–min T6] versus (T3 [T1–4] and (T3 [T2–5]) (P < 0.01). During the first 10 min postblock, dermatomal thoracic block was the lowest in SSS (P < 0.05). Time for regression of sensory level to T10 was also shortest in SSS. Hypotension, ephedrine use and period of motor recovery were more pronounced in CSE and CSE (no-catheter). We conclude that subarachnoid block induced by CSE produces greater sensorimotor anesthesia and prolonged recovery compared with SSS. There is also a more frequent incidence of hypotension and vasoconstrictor use despite using identical doses and baricity of local anesthetic.

 

新设计的Ballpen针和Sprotte针之间在脊麻的操作条件和副作用方面相似:一项多中心前瞻性随机比较试验的结果

Spinal Anesthesia Performance Conditions and Side Effects Are Comparable Between the Newly Designed Ballpen and the Sprotte Needle: Results of a Prospective Comparative Randomized Multicenter Study

Thomas Standl, MD*, Ales Stanek, MD, Marc-Alexander Burmeister, MD*, Sven Grüschow*, Bianca Wahlen, MD, Katrin Müller, Jürgen Biscoping, MD, and Hans-Anton Adams, MD

*Department of Anesthesiology, University Hospital Eppendorf, Hamburg; Department of Anesthesiology, University Hospital, Mainz; Department of Anesthesiology, University Hospital Hannover-Oststadt; and Department of Anesthesiology, St. Vincentius Hospital, Karlsruhe, Germany

Anesth Analg 2004 98: 512-517.

 

本研究中,我们检验了一种新设计的脊麻针(Ballpen[B])的特性,它的针芯形成铅笔样尖端,在穿透硬脊膜后退出。试验的主要目的是B针和SprotteS)针相比,检验使用B针是否能通过改进穿刺条件从而缩短操作时间。4所医院700例病人接受单次剂量脊麻,使用的是25BS针,药物为0.5%的布比卡因。脊麻操作时间被定义为从置入穿刺引针到确定穿刺针针蒂中出现脑脊液的时间。当病人需要进行全麻时被评定为脊麻失败。术后24天对所有病人进行访视。两组间的一般情况、穿刺部位以及布比卡因的剂量均无差别。B组的操作时间为98 ± 145 s,而S组为103 ± 159 sP0.68)。失败率在B组和S组分别为3.8%3.9%,硬脊膜穿破后头痛的发生率分别为1.8%0.9%P0.50)。我们的结论是BS针之间在操作技术常数和后果方面无差别。

(黄施伟 译,李士通 校)

In this study, we examined the characteristics of a newly designed spinal needle (Ballpen [B]) with a pencil-like tip formed by a stylet that is withdrawn after penetration of the dura. The main goal was to examine whether the use of the B needle could reduce performance time by improved puncture conditions in comparison with the Sprotte (S) needle. Seven-hundred patients at 4 hospitals received single-dose spinal anesthesia with a 25-gauge B or S needle and 0.5% bupivacaine. The performance time of spinal anesthesia was defined as the time between insertion of the introducer needle and the first identification of cerebrospinal fluid in the hub of the spinal needle. Failed spinals were assessed when patients required general anesthesia. On postoperative Day 2–4, all patients were visited and interviewed. Groups did not differ with respect to demographics, puncture site, and dose of bupivacaine. Performance time was 98 ± 145 s in Group B and 103 ± 159 s in Group S (P = 0.68). The failure rate in Groups B and S was 3.8% and 3.9%, respectively, and the incidence of postdural puncture headache was 1.8% and 0.9% (P = 0.50), respectively. We conclude that there was no difference in technical variables or outcome between the B and S needles.

 

耻骨后前列腺根治除术避免异体输血-术前自体采血与血液回收比较

Preoperative Autologous Donation Versus Cell Salvage in the Avoidance of Allogeneic Transfusion in Patients Undergoing Radical Retropubic Prostatectomy

Jonathan H. Waters, MD*, Julia ShinJung Lee, MPH MS, Eric Klein, MD, Jerome O’Hara, MD*, Craig Zippe, MD, and Paul S. Potter, MD*

Departments of *General Anesthesiology, Biostatistics, and Urology, Cleveland Clinic Foundation, Cleveland, Ohio

Anesth Analg 2004 98: 537-542.

 

在根治性耻骨后前列腺切除术中有多种方法来防止使用异体血,其中许多方法已进行了彼此比较,但尚无研究比较术前自体采血贮存技术(PAD)和血液回收技术(CS)的效果。本研究中我们评估了这两种方法在行根治性耻骨后前列腺切除术病人中的使用效果。在该前瞻性的队列实验中,一位外科医生常规让其病人进行术前采血贮存,而另一位外科医生则主要采用CS,比较这两组病人中异体血输注的情况。50例病人参与了研究: PAD26例,CS24例。两组间异体血输注未见差别。两组红细胞的丢失量有明显差别(PADCS组分别为891 ± 298 mL1134 ± 358 mL)。我们得出结论:PADCS在避免异体血输注方面的效力相当。CS组失血量较大提示在更严格的试验设计中, CSPAD可能具有更好的避免异体血输注的效力。

(黄施伟 译,李士通 校)

There are many methods for preventing allogeneic blood administration during radical retropubic prostatectomy, and many of these methods have been compared with each other, but no studies have compared preoperative autologous donation (PAD) and cell salvage (CS). In this study, we evaluated these two methods in patients undergoing radical retropubic prostatectomy. In a prospective cohort model, allogeneic exposure in patients from one surgeon who routinely had his patients donate blood before surgery was compared with that in patients from a different surgeon who predominantly used CS. Fifty patients were enrolled in the study: 26 in the PAD group and 24 in the CS group. No difference in allogeneic exposure was seen between the two groups. A significant difference was seen in the volume of red blood cells lost (891 ± 298 mL versus 1134 ± 358 mL in the PAD and CS groups, respectively). We conclude that PAD and CS are equivalent in their ability to avoid allogeneic transfusion. Larger surgical blood loss in the CS group would suggest that in a more rigorously designed study, CS might provide better allogeneic avoidance than PAD.

 

特异性环氧酶-2抑制剂美洛昔康不能增强吗啡降低大鼠异氟醚MAC的作用

Meloxicam, a Specific COX-2 Inhibitor, Does Not Enhance the Isoflurane Minimum Alveolar Concentration Reduction Produced by Morphine in the Rat

Santos, Martín DVM, PhD; Kunkar, Viviana DVM; García-Iturralde, Palma DVM; Tendillo,

Francisco J. DVM, PhD, Dip.ECVA

From the Servicio de Cirugía Experimental, Hospital Universitario Puerta de Hierro, Madrid, Spain

Anesth Analg. 2004 Feb; 98(2):359-363.

 

已有报导研究了非选择性环氧酶(COX)抑制剂协同吗啡降低大鼠异氟醚MAC(肺泡最低有效浓度)的作用。我们研究了特异性环氧酶-2COX2)抑制剂对吗啡降低大鼠异氟醚MAC作用。在异氟醚-氧气麻醉下,64只雌性大鼠分为以下八组:静脉注射生理盐水组,阿司匹林 (30 mg/kg) ,吗啡 (1 mg/kg) 组,吗啡(1 mg/kg)阿司匹林 (30 mg/kg) 美洛昔康(1 3 mg/kg) 组,吗啡 (1 mg/kg)美洛昔康(1 3 mg/kg) 组。钳夹鼠尾的同时采样肺泡气计算异氟醚MAC。生理盐水组、阿司匹林组及美洛昔康(1 3 mg/kg) 组的异氟醚MAC无统计学差异。吗啡 (1 mg/kg)美洛昔康(1 3 mg/kg) 组的MAC显著下降,但其降低程度与单用吗啡组相同(MAC值吗啡组为1.35% ± 0.07%,吗啡+1 mg/kg美洛昔康组为1.36% ± 0.04%,吗啡+3 mg/kg美洛昔康组为1.37% ± 0.08%)。吗啡+阿司匹林组的MAC值最低(1.19% ± 0.05%)。美洛昔康不能增强吗啡降低异氟醚MAC的作用。

(轩 翻译 李士通 审校)

A synergistic effect of nonselective cyclooxygenase (COX) inhibitors on morphine-induced decrease of isoflurane minimum alveolar concentration (MACISO) has been observed in the rat. We studied the influence of specific COX-2 inhibitors on this decrease of MAC. Sixty-four female rats were anesthetized with isoflurane in oxygen. The animals were grouped into saline solution, aspirin (30 mg/kg), morphine (1 mg/kg), morphine (1 mg/kg) + aspirin (30 mg/kg), meloxicam (1 and 3 mg/kg), and morphine (1 mg/kg) + meloxicam (1 and 3 mg/kg). Then the MACISO was determined from alveolar gas samples at the time of tail clamp. The groups treated with saline solution, aspirin, and 1 and 3 mg/kg meloxicam did not express any statistically relevant changes among them. The administration of morphine + meloxicam 1 or 3 mg/kg significantly reduced the MACISO just as in the group where only morphine was administered (morphine 1.35% ± 0.07%, morphine + 1 mg/kg meloxicam 1.36% ± 0.04%, and morphine + 3 mg/kg meloxicam 1.37% ± 0.08%). The greatest reduction of MACISO was after administration of morphine + aspirin (1.19% ± 0.05%). The administration of meloxicam does not potentiate the morphine-induced decrease of MACISO in the rat.

 

肌音描记仪和肌机械描记仪可相互代替监测拇内收肌的神经肌肉阻滞水平

Phonomyography and Mechanomyography Can Be Used Interchangeably to Measure Neuromuscular Block at the Adductor Pollicis Muscle

Hemmerling, Thomas M. MD, DEAA; Michaud, Guillaume; Trager, Guillaume DESS; Deschamps, Stéphane DESS; Babin, Denis MSc; Donati, François MD, PhD, FRCPC

From the Neuromuscular Research Group (NRG), Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM) Hôtel-Dieu, Université de Montréal, Montréal, Canada

Anesth Analg. 2004 Feb;98(2):377-381.

 

监测神经肌肉传递功能的标准方法是用肌机械描记仪(MMG测定肌力。肌音描记仪(PMG)则是记录肌肉收缩时的低频声音。本研究用这两种方法监测拇内收肌的神经肌肉阻滞(NMB)水平,并进行比较。组Ⅰ14位受试者同时测PMGMMG,一个微型麦克风贴在大鱼际上记录PMG,同侧上肢安装标准MMG及其固定装置。组Ⅱ14位受试者只测PMG,不用安装标准装置固定上肢。麻醉后用美维松0.1mg/kg诱导肌松。超强刺激尺神经,以单次颤搐刺激(0.1Hz)来检测NMB的出现,以每隔12秒的四个成串刺激(TOF)来判断NMB的恢复。用Student’s t检验比较PMGMMG记录的NMB出现和恢复的指标,P<0.05为显著性差异。同时比较组Ⅰ和组Ⅱ(用或不用标准固定装置) PMG的结果。用Bland-Altman检验分析PMGMMG的一致性。组Ⅰ NMB的出现时间PMG165±68秒,MMG172±67秒,最大阻滞率分别为89±10%,90±11%(平均值±标准差),均无显著性差异; NMB恢复25%、75%90%的时间PMG16.5 ±4.2 分、22.1 ±6.9分、24.5±8.2分,MMG16.7±4分、22.8±8.1分、24.8±8.8分,亦无显著性差异。两种监测颤搐高度平均偏异度是0%(以MMG减去PMG),其差值的可信区间-10%到+10%。TOF0.50.70.80.9的时间,PMGMMG1分,其可信区间是-1.5 +3.5分。组Ⅰ和组Ⅱ比较,上肢固定与否不影响PMG的药效动力学数据。监测拇内收肌的NMB水平,MMGPMG可相互代替。PMG操作简单,无需固定装置,常规使用结果同样可靠。

(轩 翻译 李士通 审校)

 

The standard of neuromuscular monitoring is the measurement of the force of contraction (mechanomyography, MMG). Phonomyography (PMG) consists of recording low-frequency sounds created during muscle contraction. In this study, we compared and used both methods to determine neuromuscular blockade (NMB) at the adductor pollicis muscle. In 14 patients, PMG was recorded via a small condenser microphone taped to the thenar mass, and a standard mechanomyographic device was applied to the same arm. In another group of 14 patients, only PMG was measured. After induction of anesthesia, the ulnar nerve was stimulated supramaximally using single twitch stimulation (0.1 Hz) for onset and train-of-four (TOF) stimulation every 12 s during offset of NMB produced by mivacurium 0.1 mg/kg. Onset and recovery indices measured by the 2 methods were compared using Student’s t-test (P < 0.05). Similar comparisons were made between the two PMG groups (with or without special board). Agreement between PMG and MMG was examined using a Bland-Altman test. Onset was 165 (68) s versus 172 (67) s [mean (sd)], and maximum blockade was 89 (10)% versus 90 (11)%, for PMG and MMG respectively (NS). Time to 25%, 75%, and 90% recovery was 16.5 (4.2) min, 22.1 (6.9) min, and 24.5 (8.2) min, respectively for PMG, not different from 16.7 (4) min, 22.8 (8.1) min, and 24.8 (8.8) min for MMG. Mean bias was 0% with limits of agreement of -10 and + 10% of twitch height for all signals (MMG minus PMG). Time to TOF of 0.5, 0.7, 0.8, and 0.9, was 1 min faster with PMG than with MMG, with limits of agreement of -1.5 to 3.5 min. Pharmacodynamic data derived without or with special arm fixation were not significantly different. MMG and PMG can be used interchangeably to determine NMB at the adductor pollicis muscle. PMG is easier to apply, does not need a special monitoring board and could be a reliable monitor to determine NMB in daily routine.

 

腹部手术后硬膜外0.1%左旋布比卡因或0.1%罗哌卡因复合吗啡的镇痛效果相当

Epidural Levobupivacaine 0.1% or Ropivacaine 0.1% Combined with Morphine Provides Comparable Analgesia After Abdominal Surgery

Senard,Marc MD*;Kaba,Abdourhamane MD*;Jacquemin,Murielle J.MD*;Maquoi,Luc M.MD*;Geortay,Marie-Pierre N.MD*;Honoré, Pierre D.MD†;Lamy,Mauricel.MD*.Joris,Jean L.MD,PhD*

*Department of Anesthesia and Intensive Care Medicine and

†Service of Abdominal Surgery, CHU de Liège, Belgium

Anesth Analg.2004 Feb;98(2):389-394.

 

罗哌卡因的运动阻滞作用比消旋的布比卡因小,更适用于硬膜外镇痛。左旋布比卡因是否有类似优点需进一步研究。我们比较了腹部大手术后左旋布比卡因和罗哌卡因复合小剂量吗啡硬膜外镇痛60小时的效果、剂量、副作用和运动阻滞情况。50位术后患者,随机双盲分为两组,接受硬膜外PCA,输注参数设置相同,无背景输注。组Ⅰ为0.1%左旋布比卡因,复合吗啡0.1mg/h硬膜外输注;组Ⅱ为0.1%罗哌卡因复合同量吗啡。记录镇痛60小时内的疼痛评分、副反应、运动阻滞和局麻药用量。疼痛评分采用视觉模拟评分(VAS 0100mm)。两组患者休息时的VAS约为20mm,运动时为40mm。术后第四小时所有患者的Bromage评分均为1分。术后48小时内两种局麻药的用量相似:左旋布比卡因为344±178mg,罗哌卡因为347±199mg。术后第二天,罗哌卡因组有19位患者可以走动,而左旋布比卡因组有12位(P<0.05)。副反应的发生率两组没有显著性差异。我们的结论是0.1%左旋布比卡因和0.1%罗哌卡因复合小剂量吗啡用于术后硬膜外PCA的镇痛效果相当,副反应发生率相似。

(轩 翻译 李士通 审校)

Ropivacaine appears attractive for epidural analgesia because it produces less motor block than racemic bupivacaine. The potential benefits of levobupivacaine with regard to motor blockade require further investigations. In this study, we compared the efficacy, dose requirements, side effects, and motor block observed with epidural levobupivacaine and ropivacaine when given in combination with small-dose morphine for 60 h after major abdominal surgery. Postoperatively, 50 patients were randomly allocated, in a double-blinded manner, to patient-controlled epidural analgesia with the same settings and without basal infusion, using 0.1% levobupivacaine or 0.1% ropivacaine. Both were combined with an epidural infusion of 0.1 mg/h morphine. Pain scores, side effects, motor block, and local anesthetic consumption were measured for 60 h. Pain scores measured on a 100-mm visual analog scale were approximately 20 mm at rest and 40 mm during mobilization in both groups. Bromage scores were 1 for all patients after the fourth postoperative hour. Consumption of levobupivacaine and ropivacaine were similar: 344 ± 178 mg levobupivacaine versus 347 ± 199 mg ropivacaine 48 h postoperatively. On postoperative day 2, 19 patients in the ropivacaine group versus 12 in the levobupivacaine group were able to ambulate (P < 0.05). No difference was noted concerning incidence of side effects. We conclude that when used as patient-controlled epidural analgesia and combined with small-dose epidural morphine, 0.1% levobupivacaine and 0.1% ropivacaine produce comparable postoperative analgesia with a similar incidence of side effects.

 

N-甲基-D-天门冬氨酸受体拮抗剂美金刚胺(Memantine)在慢性幻肢痛病人中的作用--安慰剂对照随机交叉试验

A Placebo-Controlled Randomized Crossover Trial of the N-Methyl-D-Aspartic Acid Receptor Antagonist, Memantine, in Patients with Chronic Phantom Limb Pain

Katja Wiech, PhD1,*, Ralph-Thomas Kiefer, MD1,{dagger}, Stephanie Töpfner, MD{dagger}, Hubert Preissl, PhD*, Christoph Braun, PhD*, Klaus Unertl, MD{dagger}, Herta Flor, PhD{ddagger}, and Niels Birbaumer, PhD*,§

*Institute of Medical Psychology and Behavioral Neurobiology and the {dagger}Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany, the {ddagger}Department of Neuropsychology, University of Heidelberg, Central Institute of Mental Health, Mannheim, Germany, and the §Center for Cognitive Neuroscience, University of Trento, Trento, Italy

Anesth Analg 2004 98: 408-413.

 

本试验中我们观察了N-甲基-D-天门冬氨酸(NMDA)受体拮抗剂美金刚胺Memantine30 mg/d对慢性幻肢痛(PLP)及皮质功能重组的影响。以安慰剂对照双盲交叉试验观察美金刚胺在8个慢性PLP病人中的效应,每个试验持续4周。基础期及治疗期每小时根据视觉模拟评分评定PLP强度。同时用神经磁性单孔显像技术评定初级感觉皮层(SI)功能构建的变化。与基础值及安慰剂相比,NMDA受体拮抗剂对慢性PLP强度无影响。同时SI功能构建也无明显改变。尽管由于样本小使本试验临床意义有限,但该结果仍提示NMDA受体拮抗剂美金刚胺以本试验中的剂量对慢性PLP无效,对初级SI的相关神经可塑性下降也无影响。

(王立中译,李士通校)

In the present study we investigated the effect of the N-methyl-D-aspartic acid (NMDA) receptor antagonist memantine (30 mg/d) on the intensity of chronic phantom limb pain (PLP) and cortical reorganization. In 8 patients with chronic PLP, memantine was tested in a placebo-controlled double-blinded crossover trial of 4 wk duration per trial. The intensity of PLP was rated hourly by the patients on a visual analog scale during baseline and both treatment periods. At the same time points, the functional organization of the primary somatosensory cortex (SI) was determined by neuromagnetic source imaging. In comparison to baseline and placebo, the NMDA receptor antagonist had no effect on the intensity of chronic PLP. In none of the periods were significant changes in the functional organization of SI observed. Although the conclusions regarding the clinical effect are limited because of the small sample size, the data indicate that in the studied dosage the NMDA receptor antagonist memantine is ineffective in the treatment of chronic PLP and is also ineffective for the reduction of associated neural plasticity in the primary SI.

 

芬太尼病人自控经皮给药系统用于急性术后镇痛的安全性和有效性--多中心、安慰剂对照试验

The Safety and Efficacy of a Fentanyl Patient-Controlled Transdermal System for Acute Postoperative Analgesia: A Multicenter, Placebo-Controlled Trial

Jacques E. Chelly, MD PhD, MBA*, Jeffrey Grass, MD{dagger}, Timothy W. Houseman, MD{ddagger}, Harold Minkowitz, MD§, and Alex Pue, MD||

*University of Pittsburgh Medical Center and {dagger}The Western Pennsylvania Hospital, Pittsburgh, Pennsylvania, {ddagger}Thomas Hospital, Fairhope, Alabama, §Memorial City Hospital, Houston, Texas, and the ||Mary Birch Hospital for Women, San Diego, California

Anesth Analg 2004 98: 427-433.

对病人和护理人员而言,通过胃肠外无创伤的方法给予阿片类药物控制急性疼痛理论上能提供更多优点。开发中的病人自控经皮给药系统(PCTS)由一个利用电子给药技术、预先编程、自带药物的释放系统组成(E-TRANS®, ALZA Corp, Mountain View, CA),该系统能在每次需要时在10 min内释放40 µg盐酸芬太尼。我们以随机、双盲、安慰剂对照试验方法在205例腹部、整形或胸科大手术病人中比较了术后24小时内按需每次40 µg盐酸芬太尼PCTS和安慰剂的安全性及有效性。效应评价指标主要包括退出试验的病人百分率,即至少该系统使用3小时后仍不能提供充分镇痛而退出试验的病人;次要指标包括疼痛强度(视觉模拟评分)、病人及观察者的平均总体评价。在189例满足可评价条件的病人,在40 µg盐酸芬太尼PCTS组内25%病人由于不充分的镇痛而退出试验,而安慰剂组有40.4%(P < 0.05)。与安慰剂组相比,PCTS 40 µg盐酸芬太尼组有较低的VSA评分和较高的病人及观察者平均总体评估分。此外无一病人临床上表现相关呼吸抑制。本研究显示控制大手术后24小时内中至重度疼痛盐酸芬太尼PCTS 40 µg优于安慰剂,并有较好的耐受性。

(王立中译,李士通校)

A noninvasive method of delivery of parenteral opioids for management of acute pain may offer logistic advantages for patients and nursing staff. A patient-controlled transdermal system (PCTS) under development consists of a preprogrammed, self-contained drug-delivery system that uses electrotransport technology (E-TRANS®, ALZA Corp, Mountain View, CA) to deliver 40 µg of fentanyl HCl over 10 min per on-demand dose for patient-controlled analgesia (PCA). In this randomized, double-blinded, placebo-controlled trial we compared the efficacy and safety of on-demand fentanyl HCl PCTS 40 µg against placebo for postoperative pain up to 24 h after major abdominal, orthopedic, or thoracic surgery in 205 patients. The primary efficacy measurement was the percentage of patients withdrawn from the study because of inadequate analgesia after completing at least 3 h of treatment. Secondary efficacy measures included mean pain intensity (using visual analog scales), patient global assessments, and investigator global assessments. Of 189 patients considered evaluable for efficacy, 25% of patients in the fentanyl HCl PCTS 40 µg group withdrew because of inadequate analgesia, compared with 40.4% of the placebo group (P < 0.05). Use of fentanyl HCl PCTS 40 µg was associated with lower VAS scores and higher mean patient and investigator global assessment scores compared with placebo. No patient experienced clinically relevant respiratory depression. This study showed that a fentanyl HCl PCTS 40 µg for PCA was superior to placebo and well tolerated for the control of moderate to severe postoperative pain for up to 24 h after major surgery.

 

麻醉杂志中被引用的经典文章

Citation Classics in Anesthetic Journals

Anja Baltussen, MD, and Christoph H. Kindler, MD

From the Department of Anesthesia, University Clinics Basel, Kantonsspital, CH-4031 Basel, Switzerland

Anesth Analg 2004 98: 443-451.

一篇文章在发表后被引用的数量反映了该文章在科学领域内被承认的程度。因此我们分析了发表于麻醉学杂志中被最常引用的顶尖100篇文章的特点。这些文章通过扩展科学引文索引数据库(SCI-EXPANDED, 1945 至现在)SCIENCE®网站而确定。这些文章中被引用最多的次数是707次,最少是197次,平均每篇文章被引用次数为283次。这些文章于1954 1997期间发表于5本影响力较高的麻醉学杂志上,最多为Anesthesiology (73 ),下面依次为 Anesthesia & Analgesia (10), British Journal of Anesthesia (10), Anesthesia (6), Acta Anaesthesiologica Scandinavica (2)78篇为原作文章,22篇为综述,无1篇为编辑述评。它们来自于9个国家,其中美国70篇。而在美国来自加利福尼亚州最多,共25篇文章。29位作者拥有2篇或更多的文章。覆盖这些文章的主题是有关药理、挥发性麻醉药、循环、局部麻醉和肺生理。对引文率的分析使我们能更好认识到麻醉学的进步和为本专业的科学进程提供一历史观点。

(王立中译,李士通校)

The number of citations an article receives after its publication reflects its recognition in the scientific community. In the present study, therefore, we identified and examined the characteristics of the top 100 most frequently cited articles published in anesthetic journals. These articles were identified using the database of the Science Citation Index Expanded (SCI-EXPANDED, 1945 to present) and the Web of SCIENCE®. The most-cited article received 707 citations and the least cited article received 197 citations, with a mean of 283 citations per article. These citation classics were published between 1954 and 1997 in 5 high-impact anesthetic journals, led by Anesthesiology (73 articles) followed by Anesthesia & Analgesia (10), British Journal of Anesthesia (10), Anesthesia (6), and Acta Anaesthesiologica Scandinavica (2). Seventy-eight articles were original publications, 22 were review articles, and one was an editorial. They originated from nine countries, with the United States contributing 70 articles. Within the United States, California leads the list of citation classics with 25 articles. Twenty-nine persons authored two or more of the top-cited articles. The main topics covered by the top-cited articles are pharmacology, volatile anesthetics, circulation, regional anesthesia, and lung physiology. This analysis of citation rates allows for the recognition of seminal advances in anesthesia and gives a historic perspective on the scientific progress of this specialty.

 

 

用羟乙基淀粉作为体外循环灌注液可减弱心脏手术术后止血功能

Hydroxyethyl Starch as a Priming Solution for Cardiopulmonary Bypass Impairs Hemostasis After Cardiac Surgery.

Kuitunen AH, Hynynen MJ, Vahtera E, Salmenpera MT.

Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Meilahti Hospital, Helsinki, Finland. Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Jorvi Hospital, Espoo, Finland. Finnish Red Cross Blood Transfusion Service, Helsinki, Finland.

Anesth Analg 2004 98: 291-297.

 

我们研究了在45例选择性冠脉搭桥手术中使用羟乙基淀粉 (HES) 作为体外循环 (CPB) 环路灌注液对术后止血功能的影响。在随机化的情况下,20 mL/kg 的低分子量HES (HES 120; 分子量为120,000 Da)、高分子量HES (HES 400; 分子量为400,000 Da) 4% 人体白蛋白(ALB) 分别作为CPB灌注液的主要成分。凝血弹性描记法值显示,在HES的两个组,CPB 2小时后坚固血凝块形成的速度(α-角)和纤维蛋白凝块的强度(最大振幅和切变系数)都有所下降。术后4小时,HES组经胸管的血液丢失增加:HES 120组平均804 mL (范围 330-1390 mL); HES 400组平均1008 mL (范围505-1955 mL); ALB 组平均为681 mL (范围 295-1500 mL) (HES 400 ALB 组间P < 0.05)。我们得出结论:使用20 mL/kgHES作为CPB的灌注液可损害心脏手术术后止血功能,这一效果显示其与使用HES相比ALB较少形成稳定的血栓具有相关性。

(周晓敏 薛张纲 校)

We investigated the influence of hydroxyethyl starch (HES) as a priming solution for the cardiopulmonary bypass (CPB) circuit on postoperative hemostasis in 45 patients undergoing elective coronary artery bypass grafting. In a randomized sequence, 20 mL/kg of low-molecular-weight HES (HES 120; molecular weight 120,000 daltons), high-molecular-weight HES (HES 400; molecular weight 400,000 daltons), or 4% human albumin (ALB) was used as the main component of the CPB priming solution. The thromboelastographic values indicating the speed of solid clot formation (alpha-angle) and the strength of the fibrin clot (maximum amplitude and shear elastic modulus) were decreased up to 2 h after CPB in both HES groups. Four hours after the operation, blood loss through the chest tubes had increased in the HES groups: HES 120, mean 804 mL (range, 330-1390 mL); HES 400, mean 1008 mL (range, 505-1955 mL); and ALB, mean 681 mL (range, 295-1500 mL) (P < 0.05 between the HES 400 and ALB groups). We conclude that HES solutions, when given in doses of 20 mL/kg in connection with the CPB prime, compromise hemostasis after cardiac surgery. This effect appears related to formation of a less stable thrombus compared with that formed in the presence of ALB.

 

主动脉瓣换瓣术后早期活动可导致混合静脉血氧饱和度显著下降

Marked Mixed Venous Desaturation During Early Mobilization After Aortic Valve Surgery.

Kirkeby-Garstad I, Sellevold OF, Stenseth R, Skogvoll E, Karevold A.
Section of Cardiothoracic Anesthesia and the. Department of Cardiothoracic Surgery, St. Elisabeth Heart Center, University Hospital of Trondheim, Trondheim, Norway, and the. Unit for Applied Clinical Research, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.

Anesth Analg 2004 98: 311-317.

 

在一项开放式、前瞻性研究中,我们研究了主动脉瓣换瓣手术后第一和第二天活动时的生理反应。我们使用一台肺动脉血氧监测仪记录了15个病人的血液动力学和氧合的变化。其中有3个病人在手术进行时发生了严重事件,但所有病人都在术后第一天开始活动,而且活动时没有发生临床问题。术后第一天的静息混合静脉血氧饱和度 (SvO2) 58.0 +/- 7.7% (均值 +/- 标准差),第二天为58.0 +/- 6.2%。在活动期间,第一天和第二天的氧耗分别增加了64 +/- 41% 58 +/- 33% (P < 0.01)。未观察到有心指数和氧供的代偿性增加。活动时第一和第二天的SvO235.7 +/- 6.8%36.7 +/- 7.7% (P < 0.01),氧的摄取是增加的,然而两天的混合静脉血氧分压均为3.0 +/- 0.4 kPa。记录的最低SvO2值为10%。既往没有关于早期活动后发生显著和持续的混合静脉血氧饱和度下降的描述。其临床结果和基本机制有待进一步研究。

(周晓敏 薛张纲 校)

We investigated the physiological reaction to mobilization the first and second day after aortic valve replacement in an open, prospective study. Hemodynamic and oxygenation variables were recorded in 15 patients using a pulmonary artery oximetry catheter and bench oximetry. Serious intraoperative events occurred in 3 patients, but all patients began mobilization on the first postoperative day and mobilization was accomplished without clinical problems. Mixed venous oxygen saturation (SvO(2)) at rest was 58.0 +/- 7.7% (mean +/- SD) on the first postoperative day and 58.0 +/- 6.2% on the second day (NS). During mobilization, oxygen consumption increased by 64 +/- 41% and 58 +/- 33% on the first and second days (P < 0.01; NS between days). No compensatory increase in cardiac index and oxygen delivery was seen. Oxygen extraction increased, resulting in SvO(2) values during exercise of 35.7 +/- 6.8% on the first day and 36.7 +/- 7.7% on the second day (P < 0.01; NS between days), whereas mixed venous oxygen partial pressure was 3.0 +/- 0.4 kPa on both days. The lowest recorded value for SvO(2) was 10%. The marked and consistent mixed venous desaturation during early mobilization has not been described before and the clinical consequences and underlying mechanism require further investigation.

 

提前阻滞耳大神经是否能改善行鼓膜乳突手术儿童的术后镇痛

Does a Preemptive Block of the Great Auricular Nerve Improve Postoperative Analgesia in Children Undergoing Tympanomastoid Surgery?
Suresh S, Barcelona SL, Young NM, Heffner CL, Cote CJ.
Northwestern University Feinberg School of Medicine, the. Department of Pediatric Anesthesiology, Children's Memorial Hospital, Chicago, Illinois, and the. Section of Otology and Neurotology, Division of Pediatric Otolaryngology, Children's Memorial Hospital, Chicago, Illinois.
Anesth Analg 2004 98: 330-333.

 

我们进行了一项双盲、随机化控制试验来评估超前镇痛在行鼓膜乳突手术的儿童中的效果。这些儿童被分为两组:阻滞-阻滞(BB)组在切皮前使用0.25%布比卡因(含1:200,000肾上腺素)行超前的耳大神经阻滞,手术结束前1小时再用0.25%布比卡因(含1:200,000肾上腺素)行第二次耳大神经阻滞。对照组(SB-B)在切皮前使用生理盐水行耳大神经阻滞,手术结束前1小时用0.25%布比卡因(含1:200,000肾上腺素)行耳大神经阻滞。所有病人都由一个盲法观察者通过客观的疼痛评分(OPS)进行疼痛评估。在镇痛需求方面,不论是在麻醉后恢复室(BB对比SB-B20人中有1个对比3P= 0.60),留观室(BB对比SB-B20人中有5个对比11个,P = 0.107),或是整个住院期间 (P = 0.20) 并无差异。在首次药物镇痛时间上两组无显著差异 (BB对比SB-B226 +/- 71分钟和201 +/- 94分钟)。在术后呕吐方面两组间也无显著差异(P = 0.52)。我们得出结论:术前耳大神经阻滞在儿童行鼓膜乳突手术后缓解疼痛方面无显著意义。

(周晓敏 薛张纲 校)

We performed a double-blinded randomized controlled trial to evaluate the efficacy of preemptive analgesia in children undergoing tympanomastoid surgery. Children were divided into two groups: group block-block (BB) received a preemptive great auricular nerve block (GAN-block) with 0.25% bupivacaine with 1:200,000 epinephrine before incision followed by a second GAN-block with 0.25% bupivacaine with 1:200,000 epinephrine 1 h before the end of the procedure. Group sham block-block (SB-B) received a preemptive GAN-block with normal saline before surgical incision followed by a GAN-block with 0.25% bupivacaine with 1:200000 epinephrine 1 h before the completion of the procedure. All patients were evaluated for pain with the objective pain score (OPS) by a blinded observer. There was no difference in pain rescue requirements in the postanesthesia care unit (BB versus SB-B, 1 of 20 versus 3 of 20, P= 0.60) or in the short-stay unit (BB versus SB-B, 5 of 20 versus 11 of 20, P = 0.107) or for the entire hospital stay (P = 0.20). There was no significant difference between groups in the time to first rescue pain medication (BB versus SB-B, 226 +/- 71 min versus 201 +/- 94 min). There was no significant difference between groups regarding vomiting in the postoperative period (P = 0.52). We conclude that a preoperative GAN-block does not offer significant advantages for postoperative pain relief in children undergoing tympanomastoid surgery.

 

异氟醚通过γ-氨基丁酸A易化苯巴比妥麻醉猫打嗝样反射并经γ-氨基丁酸B受体抑制反射

Isoflurane Facilitates Hiccup-Like Reflex Through Gamma Aminobutyric Acid (GABA)A- and Suppresses Through GABAB-Receptors in Pentobarbital-Anesthetized Cats

Tsutomu Oshima, MD, and Shuji Dohi, MD

Department of Anesthesiology and Critical Care Medicine, Gifu University School of Medicine, Gifu-City, Japan

Anesth Analg 2004 98: 346-352.

 

挥发性麻醉药对打嗝产生不一致作用的机制还不清楚。我们通过机械刺激机械通气的猫的鼻咽背部来引发打嗝样反射。这种反射的程度通过测量食管内的最大负压(nPes)来量化。而这种负压的产生是为了抵抗阻塞的气道。首先,我们测量了不同呼气末异氟醚的浓度对nPes的影响。然后,我们分别确定了静脉使用外周性(GABA)A 受体拮抗剂 bicuculline methiodide (BM)GABAB 受体拮抗剂 CGP 35348,外周性GABAB 受体拮抗剂 CGP 54626,或盐水后, 1.0MAC的异氟醚对nPes的影响。第三,在暴露于1.0MAC的异氟醚前,脑池内注射BM, CGP 35348或人工脑脊液。在异氟醚麻醉期间,他的浓度和 nPes成反比。静脉预先用药对nPes的影响是BM < 盐水 < CGP54626 < CGP35348.脑室内预先用药后对nPes的影响是BM < 人工脑脊液< CGP35348。异氟醚通过外周和中枢的GABAA GABAB 受体对打嗝反射产生相反的作用,两者结合最终的效应是抑制了这种反射。

(陆旭伟 薛张纲 校)

 

The mechanism by which volatile anesthetics exert inconsistent effects on hiccups is unknown. We elicited a hiccup-like reflex by mechanical stimulation of the dorsal epipharynx in mechanically ventilated cats. The magnitude of the hiccup-like reflex was measured as the peak negative esophageal pressure (nPes) generated against an occluded airway. First, we examined the effects of different end-expiratory concentrations of isoflurane on nPes. Second, we determined the effects of 1.0 minimum alveolar anesthetic concentration of isoflurane on nPes after a peripherally restricted gamma aminobutyric acid (GABA)A-receptor antagonist, bicuculline methiodide (BM), a GABAB-receptor antagonist, CGP 35348, a peripherally restricted GABAB-receptor antagonist, CGP 54626, or saline had been administered IV. Third, BM, CGP 35348, or artificial cerebrospinal fluid was administered intracisternally before 1.0 minimum alveolar anesthetic concentration of isoflurane exposure. During isoflurane anesthesia, nPes was inversely proportional to the end-expiratory isoflurane concentration. The rank order of nPes values obtained after IV drug pretreatment and isoflurane exposure was BM < saline < CGP54626 < CGP35348. After intracisternal drug pretreatment and isoflurane administration, the order of nPes was BM < artificial cerebrospinal fluid < CGP35348. Isoflurane modulates the hiccup-like reflex in opposite directions through both central and peripheral GABAA and GABAB receptors, with the net effect being a dose-dependent suppression

 

阿片类引起的巨细胞活化和血管反应不是通过µ受体介导的:一项人皮肤的体内微透析研究

Opioid-Induced Mast Cell Activation and Vascular Responses Is Not Mediated by µ-Opioid Receptors: An In Vivo Microdialysis Study in Human Skin

James A. Blunk, MD*, Martin Schmelz, MD{dagger}, Susanne Zeck, MD*, Per Skov, MD{ddagger}, Rudolf Likar, MD§, and Wolfgang Koppert, MD*

*Department of Anesthesiology, University Hospital, Erlangen; {dagger}Department of Anesthesiology and Critical Care Medicine Mannheim, University Heidelberg, Germany; {ddagger}The Reference Laboratory, University Hospital Kopenhagen, Denmark; and §Department of Anesthesiology, LKH Klagenfurt, Austria

Anesth Analg 2004 98: 364-370.

 

激活巨细胞和释放组胺是阿片类药物的常见副反应。然而,芬太尼和他的衍生物只有轻微的巨细胞激活和组胺以及类胰蛋白酶的释放作用。在此项研究中,我们通过皮内的微透析技术来检测阿片类药物对巨细胞的活化是否于阿片类受体有关。这种方法让我们可以在志愿者中测量巨细胞剂量依赖性的释放的组胺以及类胰蛋白酶的量,及其对血管和感觉的作用而不产生副作用。我们测试了天然阿片可待因,人工合成阿片类药物,杜冷丁,芬太尼,阿芬太尼,和阿片类拮抗剂纳络酮。只有可待因和杜冷丁使巨细胞释放组胺以及类胰蛋白酶,产生蛋白外渗,皮肤发红和瘙痒。由于纳络酮并不能消除这种反应,所以认为巨细胞的活化与µ受体无关。

(陆旭伟 薛张纲 校)

Activation of mast cells and the systemic release of histamine is a common side effect of opioids. Nevertheless, fentanyl and its derivatives show only a slight activation of mast cells with a subsequent liberation of histamine and tryptase. In this study, we used intradermal microdialysis to assess whether this stimulatory effect of opioids on mast cells depends on the activation of opioid receptors. This new approach allowed us to measure the dose-dependent release of histamine and tryptase from mast cells and the subsequent vascular and sensory effect without systemic side effects in volunteers. The opiate codeine and the synthetic opioids meperidine, fentanyl, alfentanil, sufentanil, remifentanil, buprenorphine, and the opioid antagonist naloxone were tested. Only codeine and meperidine induced mast cell activation with the release of tryptase and histamine, leading to protein extravasation, flare reactions, and itch sensations. Because naloxone did not attenuate these effects, it is unlikely that µ-opioid receptors are involved in the activation of mast cells.

 

汽热交换设备是否真能起到如期效果

heat and Moisture Exchange Devices: Are They Doing What They Are Supposed to Do?

Harry J. M. Lemmens, MD PhD, and John G. Brock-Utne, MD PhD

From the Department of Anesthesia, Stanford University School of Medicine, Stanford, California

Anesth Analg 2004 98: 382-385

 

汽热交换仪(HMEs)常用于全麻中以提供湿热的气体。生产商提供的使用说明是基于ISO 9360方案提出的呼出蒸汽测量法。我们研究了应用相同ISO标准进行随机交叉实验的全麻病人中应用三种汽热交换仪的区别。每种汽热交换仪可测量吸入气的温度、对流热丧失、挥发热丧失、总热丧失、相对湿度、绝对湿度。虽然所有汽热交换仪改良了基数变异,但不同交换仪效果有显著差异。其中仅有一种交换仪的呼出气蒸汽测量值与ISO标准相符。因此,汽热交换仪应用效果并不与生产商的说明书相符。

(陆旭伟 薛张纲 校)

Heat and moisture exchangers (HMEs) are used to provide humidification and warming of the inspiratory gases during general anesthesia. The performance specifications provided by manufacturers of HMEs are based on in vitro measurements of moisture output using the International Standards Organization (ISO) 9360 method. We studied the in vivo performance of three different HMEs with similar ISO specifications in a randomized crossover fashion in patients under general anesthesia. The effect of each HME on temperature, convective heat loss, evaporative heat loss, total heat loss, relative humidity, and absolute humidity of inspiratory gases was determined. Although all HMEs in general improved baseline variables, we found significant differences in performance for the different HMEs. In only one type did the moisture output correspond with ISO specifications. We conclude that the in vivo performance of HMEs may not correspond with manufacturer’s specifications.

 

静脉应用Nefopam及吗啡治疗小型手术后疼痛的中间有效剂量:-项药物镇痛效果的随机双盲前瞻性研究

The Median Effective Dose of Nefopam and Morphine Administered Intravenously for Postoperative Pain After Minor Surgery: A Prospective Randomized Double-Blinded Isobolographic Study of Their Analgesic Action

Hélène Beloeil, MD, Noémie Delage, MD, Isabelle Nègre, MD, Jean-Xavier Mazoit, MD PhD, and Dan Benhamou, MD

From the Department of Anesthesiology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris and the Anesthesia Laboratory UPRES EA 3540, Faculté de Médecine du Kremlin-Bicêtre Université de Paris-Sud, Le Kremlin-Bicêtre, France

Anesth Analg 2004 98: 395-400.

 

此项研究的目的是为了明确静脉应用nefopam及吗啡治疗小手术后疼痛的药物相互作用。为此我们定义了单药ED50中值及联用时的ED50中值。通过二期研究中波动式续贯给药来测定其中值有效量。首先,在一项30例病人的开放性研究后继以一项包含60例小手术后轻重度疼痛病人的随机双盲前瞻性研究。试验终点位数字疼痛评分(NPS<3。起始剂量分别为:N(nefopam)16mgM(morphine)5mgN+M组为7.5mg Nefopam2.5mg Morphine。试验间隔剂量分别为:N2mgM1mgNM1.5mg N+0.5mg MED5095%可信区间)分别为:N18mg1618mg),M5mg46mg),N+M12mg10.5-13.5mgN+4mg(3.5-4.5mg)M(剂量比31)。Isobolographic分析证明其相互作用低于两者作用的叠加,而三组的副作用并无显著差异。这些发现提示小手术后镇痛联用NefopamMorphine 并不比两药单用具有优势。此项研究首次提出术后病人应用NefopamMorphineED50概念。总之,添加Nefopam可减少Morphine用量,但其联用效果低于两药作用的叠加。

(陆旭伟 薛张纲 校)

The aim of this study was to characterize the nature of analgesic interaction between nefopam and morphine administered IV for postoperative pain after minor surgery. To do so, we defined the median effective analgesic dose (ED50) for each drug and also the median ED50 of their combination and compared them using the isobolographic method. Determination of median effective doses was performed by the up-and-down sequential drug administration in a two-stage study. First, in a prospective, randomized, double-blinded study, we enrolled 60 patients with mild to moderate pain after minor surgery; this was followed by an open study enrolling 30 patients. The end-point was a pain score less than 3 on a Numerical Pain Scale (0–10). Initial doses were 16 mg in group N, 5 mg in group M, and 7.5 mg of N combined with 2.5 mg of M in group N+M. The testing interval was 2 mg in group N, 1 mg in group M, and 1.5 mg of N combined with 0.5 mg of M in group N+M. ED50 (95% confidence interval) was 5 mg (4–6 mg) for morphine, 18 mg (16–18 mg) for nefopam, and 4 mg (3.5–4.5 mg) with 12 mg (10.5–13.5 mg) for the combination of morphine and nefopam administered at a 3:1 dose ratio. Isobolographic analysis demonstrated a significant infra-additive interaction. The incidence of side effects did not differ significantly among morphine, nefopam, and their combination. These findings suggest that the combination of nefopam and morphine does not offer any advantage compared to each drug administered IV or alone after minor surgery. This study is the first to define the ED50 of nefopam and morphine in postoperative patients. In conclusion, the addition of nefopam has a morphine-sparing effect, but the combination is infra-additive.

 

刺激大缝际核后由CA{delta}纤维介导的热疼痛的不同阿片抑制

Differential Opioid Inhibition of C- and A{delta}- Fiber Mediated Thermonociception After Stimulation of the Nucleus Raphe Magnus

Ying Lu, MD*, Sarah M. Sweitzer, PhD{dagger}, Charles E. Laurito, MD*, and David C. Yeomans, PhD

Department of Anesthesiology, University of Illinois at Chicago, Chicago, Illinois, and the {dagger}Department of Anesthesia, Stanford University School of Medicine, Stanford, California

Anesth Analg 2004;98:414-419

 

虽然大缝际核在递减疼痛的抑制性控制中的重要性已经很清楚了,但不同类型的伤害感受的这种效应是否相等还不清楚。因此,我们通过电刺激大缝际核来检查由激动A{delta}C纤维的热伤害刺激感受器所唤起的行为反应的不同抑制,以及参与其中的不同类型的阿片类受体。总体而言,A{delta}纤维介导的伤害反应同C纤维的相比,前者需要两倍于后者的电流来刺激大缝际核以产生标准的抗伤害作用。鞘内给予非选择性阿片受体拮抗剂,环丙甲羟二羟吗啡酮,或者{delta}1 阿片受体拮抗剂,纳曲吲哚,均能相似地减轻A{delta}C纤维的由刺激大缝际核诱导的抗伤害作用。相比而言,鞘内给予特异性µ受体拮抗剂naloxonazine,或特异性{delta}2受体拮抗剂naltriben,则相比A{delta}介导的反应,大缝际核诱导的C纤维抗伤害反应被优先减轻。这些发现提示,激动A{delta}C纤维伤害感受器唤起的疼痛反应是在大缝际核的药理学上可识别的递减控制之下。

(钟鸣 薛张纲 校)

Although the importance of the nucleus raphe magnus in descending inhibitory control of nociception is clear, it is not known whether these effects are equivalent for different types of nociception. Thus, we examined the differential inhibition of behavioral responses evoked by A{delta} or C fiber thermonociceptor activation by electrical stimulation of nucleus raphe magnus neurons as well as the involvement of different classes of opiate receptors in this inhibition. In general, it was necessary to apply twice as much current to the nucleus raphe magnus to produce criterion antinociception for A{delta} mediated versus C fiber mediated nociceptive responses. Intrathecal administration of the nonselective opioid receptor antagonist, naltrexone, or the {delta}1 opioid receptor antagonist, naltrindole, attenuated both A{delta} and C fiber antinociception induced by nucleus raphe magnus stimulation with similar efficacy. In contrast, intrathecal administration of naloxonazine, a µ specific opioid receptor antagonist, or naltriben, a {delta}2 specific opioid receptor antagonist, preferentially attenuated nucleus raphe magnus induced antinociception for C fiber responses when compared with A{delta} mediated responses. These findings suggest that nociception evoked by the activation of A{delta} or C fiber nociceptors is under pharmacologically distinguishable descending control from the nucleus raphe magnus.

 

通过脑脊液盥洗撤销无意的脊髓麻醉药的作用

Reversal of an Unintentional Spinal Anesthetic by Cerebrospinal Lavage

Ban C. H. Tsui, MD MSc, FRCP(C)*, Stephan Malherbe, MB ChB, MMed, FCA(SA)*, John Koller, MD FRCP(C)*, and Keith Aronyk, MD FRCS(C)

Departments of *Anesthesiology and Pain Medicine and {dagger}Neurosurgery, University of Alberta, Edmonton, Alberta, Canada

Anesth Analg 2004;98:434-436

 

在此病例报道中,我们描述了通过脑脊液盥洗成功治疗了一名硬膜外导管被放置到鞘内的女孩,这名女孩14岁,在硬膜外和全麻联合下行整形外科手术。在此病例中,大量的局麻药被注射到鞘内(总共可能的注射量是200mg利多卡因和61mg布比卡因),导致了手术结束时呼吸停止和散大固定的瞳孔。通过硬膜外导管,20ml脑脊液被10ml生理盐水和10ml乳酸林格氏液所替代。5分钟后自主呼吸恢复,30分钟后拔除气管导管。手术后未出现神经学缺陷和硬膜外刺穿后头痛的发生。

(钟鸣 薛张纲 校)

In this case report, we describe the use of cerebrospinal fluid lavage as a successful treatment of an inadvertent intrathecally placed epidural catheter in a 14-yr-old girl who underwent a combination of epidural anesthesia and general anesthesia for orthopedic surgery. In this case, a large amount of local anesthetic was injected (the total possible intrathecal injection was 200 mg of lidocaine and 61 mg of bupivacaine), resulting in apnea and fixed dilated pupils in the patient at the end of surgery. Twenty milliliters of cerebrospinal fluid was replaced with 10 mL of normal saline and 10 mL of lactated Ringer’s solution from the "epidural" catheter. Spontaneous respiration returned 5 min later, and the patient was tracheally extubated after 30 min. No signs of neurological deficit or postdural puncture headache were noted after surgery.

 

 

油酸诱发的肺损伤中中性粒细胞和中性粒细胞产物并不介导内毒素的肺血流动力学效应

Neutrophils and Neutrophil Products Do Not Mediate Pulmonary Hemodynamic Effects of Endotoxin on Oleic Acid-Induced Lung Injury

Laureen L. Hill, MD*, Delphine L. Chen, MD{dagger}, James Kozlowski, MS{dagger}, and Daniel P. Schuster, MD

Departments of *Anesthesia, {dagger}Radiology, and {ddagger}Internal Medicine, Washington University School of Medicine, St. Louis, Missouri

Anesth Analg 2004;98:452-457

 

在狗中通过油酸(OA)诱发的损伤后,导致氧合功能的明显恶化。小剂量的内毒素(Etx)能防止肺灌注重新分布到水肿的肺背侧区域。我们假设小剂量Etx能通过多形核中性粒细胞(PMN)起动释放炎性介质如血小板激活因子(PAF)或分泌性磷酯酶A2sPLA2)来介导这一效应。为了验证这一假设,我们给予特异性直接抑制每一介质的抑制剂,并采用两种策略来产生中性粒细胞减少症。PAF sPLA2抑制剂在OA损伤之前给予,两小时后给予小剂量Etx(每组n4)。试验前五天给予羟基脲产生PMN的耗竭以达到中性粒细胞绝对计数<1000/mm3(n=4)。通过损伤前即刻给予抗CD18单克隆抗体来达到抑制PMN黏附到肺内皮细胞上(n5)。正电子放射X线断层成像用于评估肺灌注分布和肺水含量。我们观察到在EtxOA后这些干预措施对于肺灌注模式没有产生影响。因此,无论是中性粒细胞还是PAFsPLA2都没有介导Etx对该肺损伤模型中灌注模式的影响。

(钟鸣 薛张纲 校)

Small-dose endotoxin (Etx) prevents pulmonary perfusion redistribution away from edematous dorsal lung regions after oleic acid (OA)-induced injury in dogs, causing a significant deterioration in oxygenation. We hypothesized that small-dose Etx might mediate this effect via polymorphonuclear neutrophil (PMN) priming with release of inflammatory mediators such as platelet activating factor (PAF) or secretory phospholipase A2 (sPLA2). To test this hypothesis, we administered specific inhibitors directed against each mediator and used two strategies to generate neutropenia. PAF and sPLA2 inhibitors were administered before OA injury, followed 2 h later by small-dose Etx (n = 4 each group). PMN depletion was achieved by hydroxyurea administration for 5 days before the study to achieve absolute neutrophil counts <1000/mm3 (n = 4). Inhibition of PMN adherence to lung endothelium was achieved by the administration of an anti-CD18 monoclonal antibody immediately before lung injury (n = 5). Positron emission tomography was used to evaluate pulmonary perfusion distribution and lung water content. We observed no effect of these interventions on the perfusion pattern after Etx + OA. Thus, neither neutrophils nor PAF or sPLA2 mediate the effects of Etx on the pattern of perfusion in this model of lung injury.

 

异氟醚和异丙酚麻醉时静脉使用氟比洛芬不影响脑血流速度和氧合

Intravenous Administration of Flurbiprofen Does Not Affect Cerebral Blood Flow Velocity and Cerebral Oxygenation Under Isoflurane and Propofol Anesthesia

Kenji Yoshitani, MD, Masahiko Kawaguchi, MD, Kazuyuki Tatsumi, MD{dagger}, Noriyuki Sasaoka, MD, Norio Kurumatani, MD*, and Hitoshi Furuya, MD

From the Departments of Anesthesiology and *Hygiene, Nara Medical University, Nara, Japan, and the {dagger}Department of Anesthesia, Seikeikai Hospital, Osaka, Japan

Anesth Analg 2004;98:471-476

 

氟比洛芬,一种非甾体类抗炎药(NSAID),用于治疗风湿性,骨关节炎性的疼痛和术后镇痛。虽然其他非甾体类抗炎药,如吲哚美辛,会减少脑血流,但是氟比洛芬对脑血流的影响还是个未知数。在这个研究中,我们观察了在异氟醚和异丙酚麻醉时静脉使用氟比洛芬对影响脑血流速度和氧合的影响。我们选择了48位进行矫形外科手术和腹部手术的病人。把他们随机分为异丙酚组(靶控输注:效应室浓度3 µg/mL)和异氟醚组 (1 MAC)。每组再分成两小组,每小组12人。各小组分别静脉用1 mg/kg 的氟比洛芬(PROP-F and ISO-F ) 0.1 mL/kg的盐水(PROP-S and ISO-S )五分钟。在静脉用药期前5分钟和用药后60分钟,分别用脑氧饱和度计(NIRO 300)和经颅的多谱勒测脑氧合参数(组织氧合指数 [TOI], 总血红蛋白的改变 [{Delta}cHb],氧合血红蛋白的改变 [{Delta}O2Hb], 和还原血红蛋白的改变[{Delta}HHb])和大脑中动脉血液的流速(Vmca)。在使用氟比洛芬前,ISO-FISO-S组的TOI值比PRO-FPRO-S组显著高(ISO-S PROP-S, 67% ± 4% 60% ± 7%; IOS-F PROP-F, 69% ± 4% 63% ± 8%; P < 0.05)。然而,TOI, {Delta}cHb, {Delta}O2Hb, {Delta}HHb, Vmca 在使用氟比洛芬的前后都没有大的改变,和对照组相似。这些数据表明在异氟醚和异丙酚麻醉时静脉使用氟比洛芬不影响脑血流速度和氧合。

(方芳 薛张纲 校)

Flurbiprofen, a nonsteroidal antiinflammatory drug (NSAID), has been used to treat rheumatic and osteoarthritic pain and to reduce postoperative pain. Although other NSAIDs, such as indomethacin, reduce cerebral blood flow (CBF), the effect of flurbiprofen on CBF is unknown. In the present study, we investigated the effects of flurbiprofen on cerebral blood flow velocity (CBFV) and cerebral oxygenation under isoflurane or propofol anesthesia. Forty-eight patients undergoing orthopedic or abdominal surgery were enrolled. Patients were randomly allocated to receive either propofol (target control infusion: target site effect concentration 3 µg/mL) or isoflurane (1 MAC) for maintenance of anesthesia. In each group (n = 12), 1 mg/kg of flurbiprofen (PROP-F and ISO-F groups) or 0.1 mL/kg saline (PROP-S and ISO-S groups) was administered IV for 5 min. During and after the administration of flurbiprofen or saline, cerebral oxygenation variables (tissue oxygen index [TOI], total hemoglobin change [{Delta}cHb], oxygenated hemoglobin changes [{Delta}O2Hb], and deoxygenated hemoglobin changes [{Delta}HHb]), and middle cerebral artery flow velocity (Vmca) were measured using a cerebral oximeter (NIRO 300) and transcranial Doppler, respectively, from 5 min before study drug administration to 60 min postadministration. Before the administration of flurbiprofen, control values of TOI in the ISO-S and ISO-F groups were significantly higher than those in the PROP-S and PROP-F groups, respectively (ISO-S versus PROP-S, 67% ± 4% versus 60% ± 7%; IOS-F versus PROP-F, 69% ± 4% versus 63% ± 8%; P < 0.05). However, values of TOI, {Delta}cHb, {Delta}O2Hb, {Delta}HHb, and Vmca did not change significantly during and after the administration of flurbiprofen under propofol or isoflurane anesthesia, and these values were similar to those during and after the administration of saline in the same anesthesia group. These data indicate that flurbiprofen does not affect CBFV and cerebral oxygenation under propofol or isoflurane anesthesia.

 

左旋氯胺酮和消旋氯胺酮对怀孕羊的子宫血流的作用

The Effects of S(+)-Ketamine and Racemic Ketamine on Uterine Blood Flow in Chronically Instrumented Pregnant Sheep

Danja Strümper, MD*,{dagger}, Wiebke Gogarten, MD*, Marcel E. Durieux, MD PhD*,{dagger},{ddagger}, Kristian Hartleb, MS*, Hugo Van Aken, MD PhD*, and Marco A. E. Marcus, MD PhD*,{dagger}

*Department of Anesthesiology and Intensive Care Medicine, University Hospital Münster, Münster, Germany, the {dagger}Department of Anesthesiology, Pain Therapy and Home Ventilation, University Hospital Maastricht, Maastricht, The Netherlands, and the {ddagger}Department of Anesthesiology, University of Virginia Health Sciences Center, Charlottesville, Virginia

Anesth Analg 2004;98:497-502

氯胺酮是一个在产科手术中很有用的用于母体的镇痛药,他可以避免阿片类药物的使用及给新生儿带来的副作用。消旋氯胺酮可以通过胎盘屏障并有催产素作用,但是看来对子宫的血流没什么影响。左旋氯胺酮近来在临床上推荐使用,但是他对子宫血流的作用尚未确认。因此,我们主要研究左旋氯胺酮对母婴血流动力学参数的影响。等效镇痛剂量的左旋氯胺酮(10 mg • kg-1 • h-1)和消旋氯胺酮(20 mg • kg-1 • h-1)注入12只怀孕的母羊中。记录母体和胎儿的生命体征,血气和子宫血流120分钟。两种药物对子宫的血流灌注和母胎的血流动力学都没有受影响。但是消旋氯胺酮显著增加了母体(+19%)和胎儿(+11%) PCO2 ,而左旋氯胺酮对此没有影响 。同时两种药物又都显著减少了母体(消旋, -0.05; 左旋, -0.03)和胎儿(消旋, -0.06; 左旋, -0.02) pH. 左旋氯胺酮和消旋氯胺酮对子宫血流的作用是相似的。但是由于消旋氯胺酮在血流动力学和呼吸方面的限制,左旋氯胺酮成为产科镇痛的焦点。

(方芳 薛张纲 校)

Ketamine could be a useful maternal analgesic in obstetric surgery, as it might avoid the need for opioid administration and associated side effects in the newborn. Racemic ketamine passes the placental barrier and has oxytocin-like properties but does not seem to affect uterine blood flow (UBF). S(+)-ketamine was recently approved for clinical use, but its effects on UBF have not been evaluated. Therefore, we studied the effects of S(+)-ketamine on maternal and fetal hemodynamic variables. Equianalgesic doses of S(+)-ketamine (10 mg • kg-1 • h-1) or racemic ketamine (20 mg • kg-1 • h-1) were infused in 12 chronically instrumented pregnant sheep. Maternal and fetal vital signs, blood gases, and UBF were recorded over 120 min. Neither compound affected uterine perfusion or maternal and fetal hemodynamics. Whereas racemic ketamine increased maternal (+19%) and fetal (+11%) PCO2 significantly, S(+)-ketamine was without effect. However, both compounds significantly decreased maternal (racemic, -0.05; S(+), -0.03) and fetal (racemic, -0.06; S(+), -0.02) pH. The effects of racemic ketamine and S(+)-ketamine on uterine perfusion are similar, and because of its limited effect on hemodynamics and respiration, S(+)-ketamine might therefore be of interest as an analgesic in the obstetric setting

 

全麻状态下音乐对手术带来的神经激素反应的影响

The Effect of Music on the Neurohormonal Stress Response to Surgery Under General Anesthesia

Brigitte Migneault, MD*, François Girard, MD FRCPC*, Caroline Albert, PhD{dagger}, Philippe Chouinard, MD FRCPC*, Daniel Boudreault, MD FRCPC*, Diane Provencher, MD FRCSC{ddagger}, Alexandre Todorov, PhD§, Monique Ruel, RN*, and Dominique C. Girard, MD FRCPC*

Departments of *Anesthesiology, {dagger}Biochemistry, and {ddagger}Gynecology, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montréal, Canada; and §Department of Psychiatry, Washington University Medical Center, St. Louis, Missouri

Anesth Analg 2004;98:527-532

一些药物可以减少全麻围术期应激激素的释放。曾经有人研究过听音乐和给予治疗方面的建议。但是这些主要在清醒的病人,确实对术后恢复和镇痛是有帮助的。在这项研究中,我们通过测量肾上腺素,去甲肾上腺素,皮质醇和促肾上腺皮质激素(ACTH)的值来评价全麻下音乐对手术刺激带来的神经激素反应的影响。30位择期行经腹妇科手术的患者被随机分为两组,NM(无音乐)组和M(有音乐)组。M组中,诱导后直至手术结束,我们一直播放音乐。NM组中,患者带耳机但是没有音乐。我们术中采用了三个采样点测激素水平,术后在苏醒室也测一次。全程记录血流动力学数据,以及术后24小时的吗啡用量。术中任一时刻或术后的平均动脉压,心率,呼末异氟醚浓度,手术进行的时间,双极指数(BIS),芬太尼的用量,和术后吗啡的用量都没有组间差异。血中肾上腺素,去甲肾上腺素,皮质醇和促肾上腺皮质激素(ACTH)的值虽然由于手术刺激而增高,但是两组间没有差异。总之我们认为全麻状态下,音乐对手术带来的神经激素反应无影响。

(方芳 薛张纲 校)

Several pharmacological interventions reduce perioperative stress hormone release during surgery under general anesthesia. Listening to music and therapeutic suggestions were also studied, but mostly in awake patients, and these have a positive effect on postoperative recovery and the need for analgesia. In this study, we evaluated the effect of listening to music under general anesthesia on the neurohormonal response to surgical stress as measured by epinephrine, norepinephrine, cortisol, and adrenocorticotropic hormone (ACTH) blood levels. Thirty female patients scheduled for abdominal gynecological procedures were enrolled and randomly divided into two groups: group NM (no music) and group M (music). In group M, music was played from after the induction of anesthesia until the end of surgery. In the NM group, the patients wore the headphones but no music was played. We established three sample times for hormonal dosage during the procedure and one in the recovery room. Hemodynamic data were recorded at all times, and postoperative consumption of morphine in the first 24 h was noted. There was no group difference at any sample time or in the postoperative period in terms of mean arterial blood pressure, heart rate, isoflurane end-tidal concentration, time of the day at which the surgery was performed, bispectral index (BIS) value, doses of fentanyl, or consumption of postoperative morphine. There was no difference between the two groups with regard to plasmatic levels of norepinephrine, epinephrine, cortisol, or ACTH at any sample time, although the blood level of these hormones significantly increased in each group with surgical stimulation. In conclusion, we could not demonstrate a significant effect of intraoperative music on surgical stress when used under general anesthesia.

患镰状红细胞病人使用止血带行双侧膝关节置换术

Bilateral Total Knee Replacement with Tourniquets in a Homozygous Sickle Cell Patient

Abdulmohsin Abdulla Al-Ghamdi, MD

From the King Fahd Hospital of the University, Al-Khobar, King Faisal University, Saudi Arabia

Anesth Analg 2004;98:543-544

一位27岁的男性镰状红细胞患者,择期行止血下双侧膝关节置换术。在这种患者中使用止血带并不是没有危险。双侧膝关节置换术前进行了输血治疗。患者对手术耐受很好。如果纠正血液问题,患有镰状红细胞的病人使用止血带还是有好处的。

(方芳 薛张纲 校)

A 27-yr-old male patient, with homozygous sickle cell disease was scheduled for bilateral total knee replacement under tourniquet. The use of tourniquet in sickle cell patients is not without hazard. After preoperative exchange transfusion, total knee replacement was performed. The patient tolerated the procedure well. Patients with sickle cell disease should not be denied the benefit of a tourniquet if hematological correction has been undertaken.