Anesthesia & Analgesia

February 2004

Table of Content

CARDIOVASCULAR ANESTHESIA:

心肺轉流期間肝素水平的抗凝管理:一項關於半量抑肽酶方案對術後失血和止血活以及炎症反應影響的實驗性研究

(顏濤 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.

用羥乙基澱粉作為體外迴圈灌注液可減弱心臟手術術後止血功能

(周曉敏 薛張綱 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 溫度管理系統與傳統方法對防止不停跳心臟手術中體溫降低比較--隨機對照試驗

(殷文淵 譯 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波離散度增加預示冠狀動脈旁路術後房顫

(顏濤 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.

主動脈瓣換瓣術後早期活動可導致混合靜脈血氧飽和度顯著下降

(周曉敏 薛張綱 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:

骶管麻醉對兒童七氟醚和氟烷麻醉後躁動發生的影響

(殷文淵 譯 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術後採用“非接觸”拔管技術的喉痙攣發生率

(顏濤 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.

提前阻滯耳大神經是否能改善行鼓膜乳突手術兒童的術後鎮痛

(周曉敏 薛張綱 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:

口服後再靜脈給COX-2特異性抑制劑後對腹腔鏡膽囊切除術病人鎮痛效果

(忻紀華 譯 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.

通過咳嗽法減少靜脈穿刺的疼痛:一項隨機交叉志願者研究

(顏濤 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:

異氟醚通過γ-氨基丁酸A易化苯巴比妥麻醉貓打嗝樣反射並經γ-氨基丁酸B受體抑制反射

(陸旭偉 薛張綱 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.

纈草和纈草酸對活化小鼠腦幹神經元的GABA能效應

(忻紀華 譯 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.

特異性環氧酶-2抑制劑美洛昔康不能增強嗎啡降低大鼠異氟醚MAC的作用

( 翻譯 李士通 審校)

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.

阿片類引起的巨細胞活化和血管反應不是通過µ受體介導的:一項人皮膚的體內微透析研究

(陸旭偉 薛張綱 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.

新超聲-放射治療方案可使EMLA產生快速浸潤麻醉效應

(朱慧琛 譯 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:

肌音描記儀和肌機械描記儀可相互代替監測拇內收肌的神經肌肉阻滯水平

( 翻譯 李士通 審校)

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.

汽熱交換設備是否真能起到如期效果

(陸旭偉 薛張綱 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.

利用電視醫療設備進行遠端麻醉監測的報導

(朱慧琛 譯 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:

腹部手術後硬膜外0.1%左旋布比卡因或0.1%羅呱卡因複合嗎啡的鎮痛效果相當

( 翻譯 李士通 審校)

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

靜脈應用Nefopam及嗎啡治療小型手術後疼痛的中間有效劑量:-項藥物鎮痛效果的隨機雙盲前瞻性研究

(陸旭偉 薛張綱 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.

瑞芬太尼和加巴噴丁對健康志願者新擴展的炎性皮膚疼痛模型的治療效果

(朱輝 譯 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-天門冬氨酸受體拮抗劑美金剛胺(Memantine)在慢性幻肢痛病人中的作用--安慰劑對照隨機交叉試驗

(王立中譯,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.

刺激大縫際核後由CA{delta}纖維介導的熱疼痛的不同阿片抑制

(鍾鳴 薛張綱 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.

持續鞘內使用內源性配體腺苷,胍丁胺和Endomorphin-1的鎮痛效應及相互作用

(朱輝 譯 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.

芬太尼病人自控經皮給藥系統用於急性術後鎮痛的安全性和有效性--多中心、安慰劑對照試驗

(王立中譯,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.

通過腦脊液盥洗撤銷無意的脊髓麻醉藥的作用

(鍾鳴 薛張綱 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:

大學附屬醫院住院醫生培訓水平和麻醉監測質量的評估

(齊波 譯 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.

麻醉雜誌中被引用的經典文章

(王立中譯,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:

油酸誘發的肺損傷中中性粒細胞和中性粒細胞產物並不介導內毒素的肺血流動力學效應

(鍾鳴 薛張綱 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.

豬模型使用大腦皮層刺激電極進行體外除顫並不引起熱損傷的急性組織病理學改變

(周潔 譯 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.

多巴胺在現代重症監護病房內是否還有其位置?

(黃施偉 譯,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:

異氟醚和異丙酚麻醉時靜脈使用氟比洛芬不影響腦血流速度和氧合

(方芳 薛張綱 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:

剖腹產行椎管內麻醉時靜注麻黃素預防低血壓的劑量反應的彙粹分析

(周潔 譯 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.

蛛網膜下腔阻滯後的感覺運動麻痹和低血壓:脊麻-硬膜外聯合麻醉與單次脊麻

(黃施偉 譯,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對懷孕羊的子宮血流的作用

(方芳 薛張綱 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.

人類免疫缺陷病毒——麻醉和產科手術的影響

(顧漪聞 譯 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:

新設計的Ballpen針和Sprotte針之間在脊麻的操作條件和副作用方面相似:一項多中心前瞻性隨機比較試驗的結果

(黃施偉 譯,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:

全麻狀態下音樂對手術帶來的神經激素反應的影響

(方芳 薛張綱 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.

半球同步對術中鎮痛的影響

(顧漪聞 譯 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.

恥骨後前列腺根治除術避免異體輸血-術前自體采血與血液回收比較

(黃施偉 譯,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.

患鐮狀紅細胞病人使用止血帶行雙側膝關節置換術

(方芳 薛張綱

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 溫度管理系統與傳統方法對防止不停跳心臟手術中體溫降低比較--隨機對照試驗

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

在這個試驗中我們比較了Arctic Sun 溫度管理系統(一個使溫度控制水通過粘附于病人身上的獨特的能量轉換墊迴圈的伺服調節系統。)與傳統溫度控制方法避免低溫的能力。將接受不停跳冠狀動脈旁路手術的病人隨機使用Arctic Sun 系統(AS組)或傳統方法(對照組;提高室溫,靜脈液體加溫,空氣加溫對流系統)防止體溫降低(定義為體溫<36℃)。AS組測量鼻咽溫度,伺服調節的目標溫度為36.8℃。整個術中的溫度都被記錄下來,兩組體溫<36℃的曲線下(AUC)時間和面積都進行比較。對29個病人(AS=14,對照組=15)進行了研究。AS組的體溫降低顯著少於對照組,無論低於36℃的持續時間(AS2.5[0-22],中線[四分位間範圍],對照組118[49-192]minP=0.0008)還是AUC<36℃(AS0.3[0-2.2] x min,對照組17.1[3.6-173.4] x minP=0.002)。Arctic Sun 溫度管理系統顯著減少了OPCAB術中低溫的發生。重要的是,這是在沒有其他溫度調節技術的情況下達到的,包括多使用的靜脈液體加溫或提高手術室周圍的溫度。

(殷文淵 譯 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.


骶管麻醉對兒童七氟醚和氟烷麻醉後躁動發生的影響

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術後燥動。術後疼痛可能是病因之一。我們設計了一個進行了骶管麻醉鎮痛的兒童在七氟醚和氟烷麻醉後躁動發生機率比較的研究。1812個月至6歲的接受斜疝修補的兒童被隨機分為接受氟烷或七氟醚麻醉。術前焦慮基線通過Yale術前焦慮表評價。兒童口服咪唑安定鎮靜,面罩誘導,骶管阻滯用以術後鎮痛。術後,兒童的行為通過四分躁動表評價。在到達麻醉後監護室(PACU5分鐘內,七氟醚的躁動發生機率高於氟烷(26%6%P<0.05),但餘下的時間內並非如此。較高水準的術前焦慮與面罩誘導困難,進入PACU躁動,和躁動事件更嚴重相關。躁動的發生似乎是進行了有效術後鎮痛的兒童在接受七氟醚麻醉後早期而短暫的現象。

(殷文淵 譯 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.


口服後再靜脈給COX-2特異性抑制劑後對腹腔鏡膽囊切除術病人鎮痛效果

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,雙盲,隨機,安慰劑對照實驗中,我們評估了腹腔鏡膽囊切除術術前口服Valdecoxib後靜脈注射Parecoxib後口服Valdecoxib對麻醉劑和嗎啡-異丙嗪的影響。麻醉誘導前病人隨機接受單次Parecoxib40mgn=134)靜脈注射或安慰劑(n=129)。靜脈注射12小時後,Parecoxib組接受Valdecoxib 40mg單次口服,然後在術後1-4天每天口服Valdecoxib 40mg,術後5-7天有需要時每天口服Valdecoxib40mg。安慰劑組按計劃口服安慰劑。在術後頭4小時(T0-240min)所有病人均允許靜注補充的芬太尼後應用氫化可待因5 mg/對乙酰氨基酚500 mgVicodin®; 如需要每4-6小時1-2粒口服)。接受Parecoxib的病人比接受安慰劑的病人芬太尼用量減少21%p=0.011)。鎮痛強度(PI)曲線下從0-240min p=0.011的平均區域面積在Parecoxib組為55.2%,安慰劑組為61.2%p=0.083)。180 min240min的平均PI得分分別為7.07.6點,低於安慰劑組(P<0.02)。

極少數Parecoxib的病人需靜脈補充鎮痛藥(P<0.05)。在240min和第7天,病人和醫生/護士的Global評分在兩組中有顯著差異(P<0.05)。不良反應的發生,不良反應的消除和焦慮在Parecoxib組明顯低於安慰劑組。作者於是總結到術前使用Parecoxib對於腹腔鏡膽囊切除術後的疼痛只了可作為嗎啡-異丙嗪的有用的附加用藥,且順序口服Valdecoxib可增加臨床收益。

(忻紀華 譯 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.


纈草和纈草酸對活化小鼠腦幹神經元的GABA能效應

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


纈草是一種藥草,可產生抗焦慮和鎮靜作用。通過Υ-氨基丁酸能機制作用。先前的研究顯示纈草的萃取物與GABA受體特異性結合,但結合物的功能作用尚未證實。在本研究中,我們評價了纈草萃取物和他的主要成分之一,纈草酸對離體新生小鼠腦幹神經元活化的GABA能效應。我們首先觀察了毒蠅蕈醇,一種GABAA受體激動劑,可以濃度依賴性的降低多數腦幹神經元的神經衝動頻率;30μM產生38.9%±3.0%抑制與對照組相比(p<0.01, 50%抑制濃度[IC50]20+0.1μM)。這種作用可以被荷包牡丹堿(10μM),一種GABAA拮抗劑所拮抗。然後我們發現3mg/ml的纈草萃取物誘導的抑制為29.6%+5.1%,其IC50240+18.7μg/ml,而100μM的纈草酸誘導的抑制為22.2%+3.4%,其IC5023+2.6μM(兩者均p<0.01)。荷包牡丹堿可對抗纈草和纈草酸的抑制作用。另外,纈草萃取物或纈草酸術前用藥可降低毒蠅蕈醇對腦幹的抑制作用(P<0.05),提示這些混合物在GABA的常規活化中扮演重要角色。本研究的資料顯示纈草萃取物或纈草酸的藥理作用是通過調控GABAA受體的功能而產生的。所以,纈草可以作為麻醉劑或其他用藥通過GABA受體產生鎮靜作用,術前應用可產生纈草-麻醉劑的相互作用。

(忻紀華 譯 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.


新超聲-放射治療方案可使EMLA產生快速浸潤麻醉效應

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
在這次隨機的42人實驗過程中,我們主要測試經短暫(將近10-s)皮下低頻(55KHz)超聲治療後,應用低熔混合局麻藥(EMLA)乳劑的浸潤麻醉起效速度。四種治療方案進行相互比較:前三組為應用超聲治療後緊接著使用1gEMLA或安慰劑5min10min15min的效應,另一對照組不使用超聲治療而直接用1gEMLA或安慰劑後60min的效應。用20g針進行疼痛測試。任何一時間點都測試疼痛評分和患者對EMLA和安慰劑的反應。在這一基礎上我們可以看出在所有的時間點,與安慰劑比較,EMLA可以起到浸潤麻醉的效應。使用超聲治療後,再應用EMLA5min10min15min的疼痛評分以及患者總體反應與單純使用EMLA60min是無明顯區別的,同時也未發現明顯副反應。低頻超聲在這次實驗中被證實可安全和有效地使EMLA產生效用,最早5min即可起效。

(朱慧琛 譯 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.


利用電視醫療設備進行遠端麻醉監測的報導

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

我們報導了一例應用電信科技實行遠端麻醉監測的事例。在厄爾瓜多亞馬遜雨林中的一次手術過程中,患者的生命體征、監測資料和錄像資料通過電信進行傳播。這種電信醫療科技使這次遠端手術獲得了專家們的有用建議。

(朱慧琛 譯  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.

 

瑞芬太尼和加巴噴丁對健康志願者新擴展的炎性皮膚疼痛模型的治療效果

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


我們對16名志願者進行雙盲,安慰劑對照和的試驗來評估用瑞芬太尼,加巴噴丁或聯合使用對因UVB引起的炎性疼痛模型的治療效果。我們先在志願者身上選擇一塊圓形的皮膚用紫外線燈照射20小時,然後使用加巴噴丁(600mg),兩小時後應用芬太尼(0.08μg•kg-1•min-140min)。在照射點我們觀察到熱疼痛知覺限度(HPPT;平均差,4.45℃;95%可信區間[CI]3.32°-5.59°)和熱疼痛耐受限度(HPTT;平均差,5.43℃;95%可信區間[CI]4.50°-6.35°)比正常皮膚下降。此外,我們對所有的研究物件用針刺鄰近的皮膚使其產生紅斑。總體上瑞芬太尼增加了HPPT(平均增加,2.47℃;95%可信區間[CI]1.86°-3.09°P0.001)和HPTT(平均增大,3.18℃;95%可信區間[CI]2.65°-3.71°P0.001)並且比安慰劑組減少了59%的繼發性痛覺過敏面積。在照射區瑞芬太尼比正常皮膚HPTT增加了86%(額外增加,2.57℃;95%可信區間[CI]1.71°-3.43°),而HPPT沒有這種明顯的差別。加巴噴丁除在照射區輕微增大HPTT外在兩痛覺過敏區沒有值得注意的效果。總之,阿片類鎮痛劑在新擴展的疼痛模型中有可靠的療效。

(朱輝 譯 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.


持續鞘內使用內源性配體腺苷,胍丁胺和Endomorphin-1的鎮痛效應及相互作用

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,有一系列的文章報導關於內源性配體腺苷,胍丁胺和Endomorphin-1在脊髓水平通過作用於不同的受體抑制有害刺激的傳導,然而很少有報導述及持續使用的效果以及它們的相互作用。在這項研究中,我們通過老鼠爪子縮回的檢測試驗來研究持續使用(60分鐘)腺苷,胍丁胺治療由角叉菜引起的灼痛的鎮同性質。Endomorphin-1與腺苷或胍丁胺的相互作用也在研究之列。在滴注期間持續使用腺苷(0.3-3μg/min)對於正常和灼燒的爪子的回縮時間沒有影響,而在停止滴注後給予更大劑量的腺苷時顯著地延長了反應時間。劑量依賴的腺苷(0.3-3μg/min)可降低痛覺過敏,但最大劑量的腺苷可引起50%的實驗動物興奮。持續使用腺苷或胍丁胺(3μg/min)可加強並延長Endomorphin-11μg/min)的鎮痛效應。我們的研究結果揭示了持續鞘內使用腺苷和胍丁胺有輕微的鎮痛效果並皆可加強Endomorphin-1的鎮痛效應。這些資料表明聯合使用這些內源性配體有益於疼痛的治療,當然,對全身副作用的檢查也是必需的。

(朱輝 譯 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.


大學附屬醫院住院醫生培訓水平和麻醉監測質量的評估

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,我們分析了住院醫生培訓與病人麻醉安全之間的關係。通過對麻醉質量改進資料庫的回顧,我們分析了圍術期病人任何麻醉質量問題和特殊類型質量問題(損傷、需加強監測、操作失敗)與CA1CA2CA3住院醫生麻醉工作組之間的相對風險。CA1階段的住院醫生相對經驗較少,他們在臨床上發生麻醉質量問題的概率要高於相對經驗豐富的CA2CA3階段的住院醫生。研究資料表明發生損傷的風險在三組之間無明顯差異。CA2住院醫生在圍術期發生緊急事件需加強監測的概率要高於CA1CA3住院醫生組,發生操作失敗的概率高於CA3CA2階段住院醫生在進入麻醉專業培訓之前,一般要求具備更先進的技術和更多的知識。他們在臨床上發生緊急事件需加強監測和操作失敗的概率相對較高可能反應了他們與CA3階段住院醫生相比臨床經驗不足,技術掌握不夠訓練。與CA2工作組相關的較高的操作失敗率和需加強監護的概率可能導致了醫療機構醫療費用的增加。

(齊波 譯  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.


豬模型使用大腦皮層刺激電極進行體外除顫並不引起熱損傷的急性組織病理學改變

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


存在長期左旋多巴綜合症的帕金森氏綜合症的病人在植入大腦皮層刺激裝置後症狀有望改善。在這些病人中使用如此裝置時,可能在電極臨近的大腦組織和刺激裝置部位產生單相電休克。在本實驗中,我們對6頭豬在刺激電極植入部位反復進行除顫試驗(2x200J(n=1),2x360J(n=5))。反復體外除顫在電極臨近的大腦組織並不引起熱損傷的急性組織病理學改變。除顫後刺激裝置的功能可能正常或完全失效。所以,在使用除顫時,必須在距離植入式刺激裝置合理的位置選擇適當的位點。這樣才能保證刺激裝置的功能。

(周潔 譯 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.


剖腹產行椎管內麻醉時靜注麻黃素預防低血壓的劑量反應的彙粹分析

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


我們對一些研究進行系統性的回顧以尋找在進行椎管內麻醉的剖腹產病人中靜脈使用麻黃素預防低血壓的劑量反應關係。我們通過MEDLINEEMBASE等途徑尋找隨機對照實驗(RCT)或佇列實驗,並研究了一些已發表的文章,後者對2種或2種以上不同劑量靜脈使用麻黃素用於預防剖腹產病人椎管內麻醉後低血壓的劑量反應關係。本文一共參考了4RCT1項佇列研究,結果發現在RCT實驗中,存在顯著的劑量反應關係,低血壓(斜率=-0.012895%可信度-0.0213—-0.0044),高血壓(斜率=-0.056395%可信度0.0235—0.0892),動脈血pH改變(斜率=-0.0395%可信度-0.05—0.00)。麻黃素用於預防低血壓的作用很小。在14mg劑量時,有效和無效的病例數相仿,在大劑量時,其引起高血壓的情況比預防低血壓更多見,動脈血pH略降低。

(周潔 譯 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.


人類免疫缺陷病毒——麻醉和產科手術的影響

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


獲得性免疫缺陷病(AIDS)的流行至今已經三十年了。世界衛生組織的統計顯示人類免疫缺陷病毒(HIV)的感染情況日益嚴重。而其中生育期婦女是病毒感染增長最快的人群。常見的感染後的症狀和體征已經變的更緩和,臨床症狀更輕,但是新的臨床表現又在出現,很明顯的是HIV往往影響多器官系統。現在在HIV的發病機理方面已經有了不少的進展,而且病毒測定和CD淋巴細胞的測定的分子學技術也可以估計和評價疾病的預後和治療。但是關於病人的麻醉和手術的整體危險性的估計的資訊還很有限。可以肯定的是,手術介入治療並不會增加病人術後的併發症或是死亡率,因此手術不必被限制。而且,也沒有足夠的證據可以證明抗病毒藥藥物會增加妊娠期的併發症或妊娠可以改變感染的過程。全麻被認為是安全的。但是藥物的相互作用和他們對於不同器官的影響必須于以充分考濾。區域阻滯也是可以選擇的方法。但是我們必須充分考慮到神經系統的表現,局部的感染,血凝異常。必須強調的是所有的麻醉醫生都要熟悉這個疾病並且應和胎兒科麻醉醫生會診,組成醫療小組以保證給予HIV患者以最佳的冶療。

(顧漪聞 譯 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.


半球同步對術中鎮痛的影響

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


在隨機對照雙盲的試驗中,我們發現給予全麻病人以半球同步的音樂可以減少病人在手術中對於鎮痛藥物的需求量,這一點和以前的試驗是一致的。在手術中,雙頻指數用於監測睡眠的深度,血流動力學用於決定鎮痛藥的用量。選擇肥胖病人的腹腔鏡手術或是單個腰椎間盤手術,在氣管插管後,給予雙耳機,記錄心率和血壓的基線,術中以異氟醚維持以保持腦電雙頻指數始終處於40—60,用25-的芬太尼注射以保證心率和血壓的穩定。我們發現肥胖病人只需要對照組的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術的試驗組和對照組的病人對於芬太尼的用量卻是相同的(0.012[0.01]vs0.015μg•kg-1•min-1[0.01])。呼氣末異氟醚的含量半球同步組和空白磁帶組是相同的(肥胖組,0.74%0.14vs0.77%(0.21);腰椎組,0.36%[0.16]vs0.39%[0.12])。因此,在這個研究中可以發現,對肥胖病人給予半球同步音樂可能是術中鎮痛的一個革新。

(顧漪聞 譯 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.

 

心肺轉流期間肝素水平的抗凝管理:一項關於半量抑肽酶方案對術後失血和止血活以及炎症反應影響的實驗性研究

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

 

涉及心肺轉流(CPB)的心臟手術會導致對止血/炎症系統的啟動。我們比較了在心臟手術中採用基於肝素水平的抗凝管理時,半量抑肽酶方案對術後血液喪失和對CPB期間止血/炎症系統啟動的影響。本研究為隨機的前瞻性研究,研究物件200例(每組100例)。組Ⅰ根據Hepcon HMS PlusTM監測結果僅加入肝素。組Ⅱ在CPB開始前即刻注射抑肽酶1 x 106激肽釋放酶抑制單位(KIU,CPB預充液內加入抑肽酶1 x 106KIU,在CPB期間以250000KIU/h的速度持續輸注。在手術後12小時確定術後失血量。肝素和抗凝血酶活性通過抗-Xa檢測和抗凝血酶Ⅲ活性測定來確定。止血啟動通過測量二磷酸腺苷啟動的血小板聚集、β血栓球蛋白(β-TG)、可溶性P-選擇蛋白(sPs)、凝血酶(TAT)、凝血酶原12的片段(PTF1+2)、Ⅻa因數(FⅫa)、纖維蛋白溶解酶(PAP)和D-二聚體來確定。炎症反應通過測定補體5b-9因數(C5b-9)、白細胞介素(IL-6和中性粒細胞彈性蛋白酶(NE)來確定。兩組在CPB前的數值和CPB時間均無差異。兩組間在CPB後血小板計數、血小板聚集、β-TGsPSTATPTF1+2C5b-9NEIL-6數值均無差異。加用抑肽酶導致PAPD-二聚體和術後12小時失血量減少,而接觸因數XIIa生成增加。應用抑肽酶明顯減少心臟手術和CPB後血液喪失。最可能的原因是抑肽酶的抗纖溶效應。未發現其對凝血酶生成、血小板啟動以及炎症反應和臨床結局的作用。

提示:在心臟手術中採用基於肝素水平的抗凝管理時應用半量抑肽酶使術後血液喪失明顯減少,最可能的原因是抑肽酶的抗纖溶效應,因為我們未發現對止血/炎症系統的啟動作用。

(顏濤 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波離散度增加預示冠狀動脈旁路術後房顫

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

 

房顫(AF)是冠狀動脈旁路手術(CABG)後常見的併發症。本研究中我們通過檢測P波特性反映手術對心房電生理的影響,確定其對預測CABG病人術後AF的潛在價值。對擇期行CABG手術的病人在住院期間持續遙測心電圖至出院以發現AF。比較12導聯心電圖P波特徵(P波時程、幅度、電軸、離散度、PR間期、節段壓低和離散度)術前與術後、以及AF與非AF病人間的差異。採用多變數logistic回歸分析潛在的臨床預測因素及P波特性與術後AF間的關聯。300例病人中82例(27%)發生AF。單變數分析表明後來發生AF的病人與未發生者相比平均年齡更大(68 ± 8 yr vs 63 ± 10 yr, P < 0.0001),體表面積更大(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),術前使用抗心律失常藥更頻繁(7/81 vs 4/219, P = 0.01),並且因術後併發症而重返手術室的比例也更高(9/81 vs 9/219, P = 0.029)。而且,術後發生AF的病人其術後P波時程減少的程度更大( -11.3 ± 0.1 ms vs -8.4 ± 0.1 ms, P < 0.0001),術後P波離散度增加程度也更大(3.1 ± 15.5 ms vs -1.6 ± 14.6 ms, P = 0.028)。多變數logistic回歸分析表明年齡(可能比[OR]1.195%可信區間[CI]: 1.061.15, P < 0.0001,體表面積(OR38.195CI8.2176, P < 0.0001)和術後P波離散度的增加(OR1.0395CI1.01-1.05P0.01)是術後AF的獨立預測因數。未發現任何手術因素與這一術後心房電生理變化有關。

提示:除高齡和體表面積大等臨床指標外,我們還證實術後P波離散度增加這一電生理變化是CABG病人術後AF的獨立預測因數。

顏濤 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術後採用“非接觸”拔管技術的喉痙攣發生率

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

 

在這個系列病例中,我們評價了對20例接受擇期扁桃腺切除術(伴或不伴增殖腺切除術)的兒童採用明確定義的清醒拔管技術的喉痙攣發生率。該技術要求病人在手術結束還沒有停止吸入揮發性麻醉藥時即翻轉為恢復體位。允許病人除了持續氧飽和度監測外,不給進一步的刺激直至其自然蘇醒(即“非接觸”)。記錄喉痙攣、氧飽和度和嗆咳。在我們的病人中沒有發現喉痙攣、氧飽和度下降和嚴重嗆咳。

提示:本研究再次強調了對兒童病人在拔出氣管導管時合理的麻醉技術的重要性。

顏濤 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.

 

通過咳嗽法減少靜脈穿刺的疼痛:一項隨機交叉志願者研究

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.

 

我們在一項交叉研究中檢驗了咳嗽法(CT)在周圍靜脈穿刺時減少疼痛的效果。20例健康志願者在3周的時間內在同一個手部靜脈上進行兩次穿刺,一次採用CT方法,另一次則不用。記錄疼痛的強度、縮手反應、手掌出汗、血壓、心率和血糖濃度。使用CT時靜脈穿刺疼痛強度比不使用CT技術者低,而其他變數則無顯著改變。雖然機制尚不明了,但簡單易行的咳嗽技法能有效減少靜脈穿刺時的疼痛。

顏濤 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.

 

多巴胺在現代重症監護病房內是否還有其位置?

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.

 

多年以來,多巴胺被認為是重症監護病房中的重要藥物,主要因其心血管效應,甚至更多的是由於其可能對腎功能和內臟粘膜灌注有保護作用。目前有充分的科學證據表明小劑量的多巴胺對急性腎衰的預防和治療以及對腸道的保護無效。直到最近為止,小劑量的多巴胺都被認為是相對無副作用的。然而,目前已經清楚,小劑量的多巴胺不僅不能達到預想的器官保護目標,還可能有害,因為它可以誘發正常和低血容量患者的腎衰。此外,多巴胺可以通過減少粘膜血流和加重胃動力的減弱來造成傷害。多巴胺還抑制垂體前葉激素的分泌和功能,從而加重分解代謝和細胞免疫的功能障礙,並導致中樞性的甲狀腺功能低下。另外,多巴胺使通氣動力減弱,增加了機械通氣患者脫機時產生呼吸衰竭的危險。我們得出結論:小劑量的多巴胺在ICU中已沒有位置,考慮到它的副作用,它廣泛用作血管收縮劑也可能受到質疑。

(黃施偉 譯,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.

 

蛛網膜下腔阻滯後的感覺運動麻痹和低血壓:脊麻-硬膜外聯合麻醉與單次脊麻比較

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.

 

蛛網膜下腔的大小取決於腦脊液和硬膜外負壓之間的平衡。硬膜外穿刺破壞了這種關係,而空氣阻力消失法穿刺對蛛網膜下腔阻滯特性的影響尚不清楚。本研究中我們試圖證實當蛛網膜下腔注入完全相同量的麻醉藥時,使用空氣阻力消失法行硬膜外-脊麻聯合麻醉(CSE)比單次注射脊麻(SSS)是否能產生更高的感覺阻滯平面。60例擇期行婦產科小手術的患者被隨機分成三組,均接受0.5%的重比重布比卡因10mg脊麻。在SSS組,蛛網膜下腔給藥是通過27號的Whitacre腰穿針在L34間隙穿刺;在CSE組,硬膜外腔隙是用18號的Tuohy針通過4mL空氣阻力消失來確定的,在蛛網膜下腔注藥後,一根20號的導管留置在硬膜外腔內,但無額外的藥物或鹽水通過導管注入;在無導管CSE組,操作過程同CSE組,只不過未置入導管。感覺運動麻痹每隔2.5分鐘進行評估直至恢復至T10水平。CSE和無導管CSE組之間在各個方面均無差別。感覺阻滯平面SSS組要低於CSE和無導管CSE組,中位數為T5[最高T3,最低T6]對T3T14]和T3T25](P<0.01)。在阻滯後的最初10min內,胸段阻滯節段在SSS組最低(P<0.05)。感覺恢復至T10水平的時間也是在SSS組最短。低血壓、麻黃素的用量以及運動恢復時間在CSECSE(無導管)組更明顯(大或長)。我們得出結論:由CSE進行的蛛網膜下腔阻滯較SSS產生更顯著的感覺運動麻痹且恢復時間延長。同時儘管使用相同劑量和比重的局麻藥,該組發生低血壓和使用血管收縮劑的比例也更高。

(黃施偉 譯,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.

 

新設計的Ballpen針和Sprotte針之間在脊麻的操作條件和副作用方面相似:一項多中心前瞻性隨機比較試驗的結果

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,我們檢驗了一種新設計的脊麻針(Ballpen[B])的特性,它的針芯形成鉛筆樣尖端,在穿透硬脊膜後退出。試驗的主要目的是B針和SprotteS)針相比,檢驗使用B針是否能通過改進穿刺條件從而縮短操作時間。4所醫院700例病人接受單次劑量脊麻,使用的是25BS針,藥物為0.5%的布比卡因。脊麻操作時間被定義為從置入穿刺引針到確定穿刺針針蒂中出現腦脊液的時間。當病人需要進行全麻時被評定為脊麻失敗。術後24天對所有病人進行訪視。兩組間的一般情況、穿刺部位以及布比卡因的劑量均無差別。B組的操作時間為98 ± 145 s,而S組為103 ± 159 sP0.68)。失敗率在B組和S組分別為3.8%3.9%,硬脊膜穿破後頭痛的發生率分別為1.8%0.9%P0.50)。我們的結論是BS針之間在操作技術常數和後果方面無差別。

(黃施偉 譯,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.

 

恥骨後前列腺根治除術避免異體輸血-術前自體采血與血液回收比較

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.

 

在根治性恥骨後前列腺切除術中有多種方法來防止使用異體血,其中許多方法已進行了彼此比較,但尚無研究比較術前自體采血貯存技術(PAD)和血液回收技術(CS)的效果。本研究中我們評估了這兩種方法在行根治性恥骨後前列腺切除術病人中的使用效果。在該前瞻性的佇列實驗中,一位元外科醫生常規讓其病人進行術前采血貯存,而另一位外科醫生則主要採用CS,比較這兩組病人中異體血輸注的情況。50例病人參與了研究: PAD26例,CS24例。兩組間異體血輸注未見差別。兩組紅細胞的丟失量有明顯差別(PADCS組分別為891 ± 298 mL1134 ± 358 mL)。我們得出結論:PADCS在避免異體血輸注方面的效力相當。CS組失血量較大提示在更嚴格的試驗設計中, CSPAD可能具有更好的避免異體血輸注的效力。

(黃施偉 譯,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.

 

特異性環氧酶-2抑制劑美洛昔康不能增強嗎啡降低大鼠異氟醚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.

 

已有報導研究了非選擇性環氧酶(COX)抑制劑協同嗎啡降低大鼠異氟醚MAC(肺泡最低有效濃度)的作用。我們研究了特異性環氧酶-2COX2)抑制劑對嗎啡降低大鼠異氟醚MAC作用。在異氟醚-氧氣麻醉下,64只雌性大鼠分為以下八組:靜脈注射生理鹽水組,阿司匹林 (30 mg/kg) ,嗎啡 (1 mg/kg) 組,嗎啡(1 mg/kg)阿司匹林 (30 mg/kg) 美洛昔康(1 3 mg/kg) 組,嗎啡 (1 mg/kg)美洛昔康(1 3 mg/kg) 組。鉗夾鼠尾的同時採樣肺泡氣計算異氟醚MAC。生理鹽水組、阿司匹林組及美洛昔康(1 3 mg/kg) 組的異氟醚MAC無統計學差異。嗎啡 (1 mg/kg)美洛昔康(1 3 mg/kg) 組的MAC顯著下降,但其降低程度與單用嗎啡組相同(MAC值嗎啡組為1.35% ± 0.07%,嗎啡+1 mg/kg美洛昔康組為1.36% ± 0.04%,嗎啡+3 mg/kg美洛昔康組為1.37% ± 0.08%)。嗎啡+阿司匹林組的MAC值最低(1.19% ± 0.05%)。美洛昔康不能增強嗎啡降低異氟醚MAC的作用。

(軒 翻譯 李士通 審校)

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.

 

肌音描記儀和肌機械描記儀可相互代替監測拇內收肌的神經肌肉阻滯水平

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.

 

監測神經肌肉傳遞功能的標準方法是用肌機械描記儀(MMG測定肌力。肌音描記儀(PMG)則是記錄肌肉收縮時的低頻聲音。本研究用這兩種方法監測拇內收肌的神經肌肉阻滯(NMB)水平,並進行比較。組Ⅰ14位受試者同時測PMGMMG,一個微型麥克風貼在大魚際上記錄PMG,同側上肢安裝標準MMG及其固定裝置。組Ⅱ14位受試者只測PMG,不用安裝標準裝置固定上肢。麻醉後用美維松0.1mg/kg誘導肌松。超強刺激尺神經,以單次顫搐刺激(0.1Hz)來檢測NMB的出現,以每隔12秒的四個成串刺激(TOF)來判斷NMB的恢復。用Student’s t檢驗比較PMGMMG記錄的NMB出現和恢復的指標,P<0.05為顯著性差異。同時比較組Ⅰ和組Ⅱ(用或不用標準固定裝置) PMG的結果。用Bland-Altman檢驗分析PMGMMG的一致性。組Ⅰ NMB的出現時間PMG165±68秒,MMG172±67秒,最大阻滯率分別為89±10%,90±11%(平均值±標準差),均無顯著性差異; NMB恢復25%、75%90%的時間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,亦無顯著性差異。兩種監測顫搐高度平均偏異度是0%(以MMG減去PMG),其差值的可信區間-10%到+10%。TOF0.50.70.80.9的時間,PMGMMG1分,其可信區間是-1.5 +3.5分。組Ⅰ和組Ⅱ比較,上肢固定與否不影響PMG的藥效動力學資料。監測拇內收肌的NMB水平,MMGPMG可相互代替。PMG操作簡單,無需固定裝置,常規使用結果同樣可靠。

(軒 翻譯 李士通 審校)

 

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.

 

腹部手術後硬膜外0.1%左旋布比卡因或0.1%羅呱卡因複合嗎啡的鎮痛效果相當

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.

 

羅呱卡因的運動阻滯作用比消旋的布比卡因小,更適用於硬膜外鎮痛。左旋布比卡因是否有類似優點需進一步研究。我們比較了腹部大手術後左旋布比卡因和羅呱卡因複合小劑量嗎啡硬膜外鎮痛60小時的效果、劑量、副作用和運動阻滯情況。50位術後患者,隨機雙盲分為兩組,接受硬膜外PCA,輸注參數設置相同,無背景輸注。組Ⅰ為0.1%左旋布比卡因,複合嗎啡0.1mg/h硬膜外輸注;組Ⅱ為0.1%羅呱卡因複合同量嗎啡。記錄鎮痛60小時內的疼痛評分、副反應、運動阻滯和局麻藥用量。疼痛評分採用視覺類比評分(VAS 0100mm)。兩組患者休息時的VAS約為20mm,運動時為40mm。術後第四小時所有患者的Bromage評分均為1分。術後48小時內兩種局麻藥的用量相似:左旋布比卡因為344±178mg,羅呱卡因為347±199mg。術後第二天,羅呱卡因組有19位患者可以走動,而左旋布比卡因組有12位(P<0.05)。副反應的發生率兩組沒有顯著性差異。我們的結論是0.1%左旋布比卡因和0.1%羅呱卡因複合小劑量嗎啡用於術後硬膜外PCA的鎮痛效果相當,副反應發生率相似。

(軒 翻譯 李士通 審校)

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-天門冬氨酸受體拮抗劑美金剛胺(Memantine)在慢性幻肢痛病人中的作用--安慰劑對照隨機交叉試驗

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.

 

本試驗中我們觀察了N-甲基-D-天門冬氨酸(NMDA)受體拮抗劑美金剛胺Memantine30 mg/d對慢性幻肢痛(PLP)及皮質功能重組的影響。以安慰劑對照雙盲交叉試驗觀察美金剛胺在8個慢性PLP病人中的效應,每個試驗持續4周。基礎期及治療期每小時根據視覺類比評分評定PLP強度。同時用神經磁性單孔顯像技術評定初級感覺皮層(SI)功能構建的變化。與基礎值及安慰劑相比,NMDA受體拮抗劑對慢性PLP強度無影響。同時SI功能構建也無明顯改變。儘管由於樣本小使本試驗臨床意義有限,但該結果仍提示NMDA受體拮抗劑美金剛胺以本試驗中的劑量對慢性PLP無效,對初級SI的相關神經可塑性下降也無影響。

(王立中譯,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.

 

芬太尼病人自控經皮給藥系統用於急性術後鎮痛的安全性和有效性--多中心、安慰劑對照試驗

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.

對病人和護理人員而言,通過胃腸外無創傷的方法給予阿片類藥物控制急性疼痛理論上能提供更多優點。開發中的病人自控經皮給藥系統(PCTS)由一個利用電子給藥技術、預先編程、自帶藥物的釋放系統組成(E-TRANS®, ALZA Corp, Mountain View, CA),該系統能在每次需要時在10 min內釋放40 µg鹽酸芬太尼。我們以隨機、雙盲、安慰劑對照試驗方法在205例腹部、整形或胸科大手術病人中比較了術後24小時內按需每次40 µg鹽酸芬太尼PCTS和安慰劑的安全性及有效性。效應評價指標主要包括退出試驗的病人百分率,即至少該系統使用3小時後仍不能提供充分鎮痛而退出試驗的病人;次要指標包括疼痛強度(視覺類比評分)、病人及觀察者的平均總體評價。在189例滿足可評價條件的病人,在40 µg鹽酸芬太尼PCTS組內25%病人由於不充分的鎮痛而退出試驗,而安慰劑組有40.4%(P < 0.05)。與安慰劑組相比,PCTS 40 µg鹽酸芬太尼組有較低的VSA評分和較高的病人及觀察者平均總體評估分。此外無一病人臨床上表現相關呼吸抑制。本研究顯示控制大手術後24小時內中至重度疼痛鹽酸芬太尼PCTS 40 µg優於安慰劑,並有較好的耐受性。

(王立中譯,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.

 

麻醉雜誌中被引用的經典文章

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.

一篇文章在發表後被引用的數量反映了該文章在科學領域內被承認的程度。因此我們分析了發表於麻醉學雜誌中被最常引用的頂尖100篇文章的特點。這些文章通過擴展科學引文索引資料庫(SCI-EXPANDED, 1945 至現在)SCIENCE®網站而確定。這些文章中被引用最多的次數是707次,最少是197次,平均每篇文章被引用次數為283次。這些文章於1954 1997期間發表於5本影響力較高的麻醉學雜誌上,最多為Anesthesiology (73 ),下面依次為 Anesthesia & Analgesia (10), British Journal of Anesthesia (10), Anesthesia (6), Acta Anaesthesiologica Scandinavica (2)78篇為原作文章,22篇為綜述,無1篇為編輯述評。它們來自於9個國家,其中美國70篇。而在美國來自加利福尼亞州最多,共25篇文章。29位作者擁有2篇或更多的文章。覆蓋這些文章的主題是有關藥理、揮發性麻醉藥、迴圈、局部麻醉和肺生理。對引文率的分析使我們能更好認識到麻醉學的進步和為本專業的科學進程提供一歷史觀點。

(王立中譯,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.

 

 

用羥乙基澱粉作為體外迴圈灌注液可減弱心臟手術術後止血功能

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.

 

我們研究了在45例選擇性冠脈搭橋手術中使用羥乙基澱粉 (HES) 作為體外迴圈 (CPB) 環路灌注液對術後止血功能的影響。在隨機化的情況下,20 mL/kg 的低分子量HES (HES 120; 分子量為120,000 Da)、高分子量HES (HES 400; 分子量為400,000 Da) 4% 人體白蛋白(ALB) 分別作為CPB灌注液的主要成分。凝血彈性描記法值顯示,在HES的兩個組,CPB 2小時後堅固血凝塊形成的速度(α-角)和纖維蛋白凝塊的強度(最大振幅和切變係數)都有所下降。術後4小時,HES組經胸管的血液丟失增加:HES 120組平均804 mL (範圍 330-1390 mL); HES 400組平均1008 mL (範圍505-1955 mL); ALB 組平均為681 mL (範圍 295-1500 mL) (HES 400 ALB 組間P < 0.05)。我們得出結論:使用20 mL/kgHES作為CPB的灌注液可損害心臟手術術後止血功能,這一效果顯示其與使用HES相比ALB較少形成穩定的血栓具有相關性。

(周曉敏 薛張綱 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.

 

主動脈瓣換瓣術後早期活動可導致混合靜脈血氧飽和度顯著下降

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.

 

在一項開放式、前瞻性研究中,我們研究了主動脈瓣換瓣手術後第一和第二天活動時的生理反應。我們使用一台肺動脈血氧監測儀記錄了15個病人的血液動力學和氧合的變化。其中有3個病人在手術進行時發生了嚴重事件,但所有病人都在術後第一天開始活動,而且活動時沒有發生臨床問題。術後第一天的靜息混合靜脈血氧飽和度 (SvO2) 58.0 +/- 7.7% (均值 +/- 標準差),第二天為58.0 +/- 6.2%。在活動期間,第一天和第二天的氧耗分別增加了64 +/- 41% 58 +/- 33% (P < 0.01)。未觀察到有心指數和氧供的代償性增加。活動時第一和第二天的SvO235.7 +/- 6.8%36.7 +/- 7.7% (P < 0.01),氧的攝取是增加的,然而兩天的混合靜脈血氧分壓均為3.0 +/- 0.4 kPa。記錄的最低SvO2值為10%。既往沒有關於早期活動後發生顯著和持續的混合靜脈血氧飽和度下降的描述。其臨床結果和基本機制有待進一步研究。

(周曉敏 薛張綱 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.

 

提前阻滯耳大神經是否能改善行鼓膜乳突手術兒童的術後鎮痛

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.

 

我們進行了一項雙盲、隨機化控制試驗來評估超前鎮痛在行鼓膜乳突手術的兒童中的效果。這些兒童被分為兩組:阻滯-阻滯(BB)組在切皮前使用0.25%布比卡因(含1:200,000腎上腺素)行超前的耳大神經阻滯,手術結束前1小時再用0.25%布比卡因(含1:200,000腎上腺素)行第二次耳大神經阻滯。對照組(SB-B)在切皮前使用生理鹽水行耳大神經阻滯,手術結束前1小時用0.25%布比卡因(含1:200,000腎上腺素)行耳大神經阻滯。所有病人都由一個盲法觀察者通過客觀的疼痛評分(OPS)進行疼痛評估。在鎮痛需求方面,不論是在麻醉後恢復室(BB對比SB-B20人中有1個對比3P= 0.60),留觀室(BB對比SB-B20人中有5個對比11個,P = 0.107),或是整個住院期間 (P = 0.20) 並無差異。在首次藥物鎮痛時間上兩組無顯著差異 (BB對比SB-B226 +/- 71分鐘和201 +/- 94分鐘)。在術後嘔吐方面兩組間也無顯著差異(P = 0.52)。我們得出結論:術前耳大神經阻滯在兒童行鼓膜乳突手術後緩解疼痛方面無顯著意義。

(周曉敏 薛張綱 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.

 

異氟醚通過γ-氨基丁酸A易化苯巴比妥麻醉貓打嗝樣反射並經γ-氨基丁酸B受體抑制反射

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.

 

揮發性麻醉藥對打嗝產生不一致作用的機制還不清楚。我們通過機械刺激機械通氣的貓的鼻咽背部來引發打嗝樣反射。這種反射的程度通過測量食管內的最大負壓(nPes)來量化。而這種負壓的產生是為了抵抗阻塞的氣道。首先,我們測量了不同呼氣末異氟醚的濃度對nPes的影響。然後,我們分別確定了靜脈使用外周性(GABA)A 受體拮抗劑 bicuculline methiodide (BM)GABAB 受體拮抗劑 CGP 35348,外周性GABAB 受體拮抗劑 CGP 54626,或鹽水後, 1.0MAC的異氟醚對nPes的影響。第三,在暴露於1.0MAC的異氟醚前,腦池內注射BM, CGP 35348或人工腦脊液。在異氟醚麻醉期間,他的濃度和 nPes成反比。靜脈預先用藥對nPes的影響是BM < 鹽水 < CGP54626 < CGP35348.腦室內預先用藥後對nPes的影響是BM < 人工腦脊液< CGP35348。異氟醚通過外周和中樞的GABAA GABAB 受體對打嗝反射產生相反的作用,兩者結合最終的效應是抑制了這種反射。

(陸旭偉 薛張綱 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

 

阿片類引起的巨細胞活化和血管反應不是通過µ受體介導的:一項人皮膚的體內微透析研究

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.

 

啟動巨細胞和釋放組胺是阿片類藥物的常見副反應。然而,芬太尼和他的衍生物只有輕微的巨細胞啟動和組胺以及類胰蛋白酶的釋放作用。在此項研究中,我們通過皮內的微透析技術來檢測阿片類藥物對巨細胞的活化是否于阿片類受體有關。這種方法讓我們可以在志願者中測量巨細胞劑量依賴性的釋放的組胺以及類胰蛋白酶的量,及其對血管和感覺的作用而不產生副作用。我們測試了天然阿片可待因,人工合成阿片類藥物,杜冷丁,芬太尼,阿芬太尼,和阿片類拮抗劑納絡酮。只有可待因和杜冷丁使巨細胞釋放組胺以及類胰蛋白酶,產生蛋白外滲,皮膚發紅和瘙癢。由於納絡酮並不能消除這種反應,所以認為巨細胞的活化與µ受體無關。

(陸旭偉 薛張綱 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.

 

汽熱交換設備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

 

汽熱交換儀(HMEs)常用于全麻中以提供濕熱的氣體。生產商提供的使用說明是基於ISO 9360方案提出的呼出蒸汽測量法。我們研究了應用相同ISO標準進行隨機交叉實驗的全麻病人中應用三種汽熱交換儀的區別。每種汽熱交換儀可測量吸入氣的溫度、對流熱喪失、揮發熱喪失、總熱喪失、相對濕度、絕對濕度。雖然所有汽熱交換儀改良了基數變異,但不同交換儀效果有顯著差異。其中僅有一種交換儀的呼出氣蒸汽測量值與ISO標準相符。因此,汽熱交換儀應用效果並不與生產商的說明書相符。

(陸旭偉 薛張綱 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.

 

靜脈應用Nefopam及嗎啡治療小型手術後疼痛的中間有效劑量:-項藥物鎮痛效果的隨機雙盲前瞻性研究

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.

 

此項研究的目的是為了明確靜脈應用nefopam及嗎啡治療小手術後疼痛的藥物相互作用。為此我們定義了單藥ED50中值及聯用時的ED50中值。通過二期研究中波動式續貫給藥來測定其中值有效量。首先,在一項30例病人的開放性研究後繼以一項包含60例小手術後輕重度疼痛病人的隨機雙盲前瞻性研究。試驗終點位元數字疼痛評分(NPS<3。起始劑量分別為:N(nefopam)16mgM(morphine)5mgN+M組為7.5mg Nefopam2.5mg Morphine。試驗間隔劑量分別為:N2mgM1mgNM1.5mg N+0.5mg MED5095%可信區間)分別為:N18mg1618mg),M5mg46mg),N+M12mg10.5-13.5mgN+4mg(3.5-4.5mg)M(劑量比31)。Isobolographic分析證明其相互作用低於兩者作用的疊加,而三組的副作用並無顯著差異。這些發現提示小手術後鎮痛聯用NefopamMorphine 並不比兩藥單用具有優勢。此項研究首次提出術後病人應用NefopamMorphineED50概念。總之,添加Nefopam可減少Morphine用量,但其聯用效果低於兩藥作用的疊加。

(陸旭偉 薛張綱 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.

 

刺激大縫際核後由CA{delta}纖維介導的熱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

 

雖然大縫際核在遞減疼痛的抑制性控制中的重要性已經很清楚了,但不同類型的傷害感受的這種效應是否相等還不清楚。因此,我們通過電刺激大縫際核來檢查由激動A{delta}C纖維的熱傷害刺激感受器所喚起的行為反應的不同抑制,以及參與其中的不同類型的阿片類受體。總體而言,A{delta}纖維介導的傷害反應同C纖維的相比,前者需要兩倍於後者的電流來刺激大縫際核以產生標準的抗傷害作用。鞘內給予非選擇性阿片受體拮抗劑,環丙甲羥二羥嗎啡酮,或者{delta}1 阿片受體拮抗劑,納曲吲哚,均能相似地減輕A{delta}C纖維的由刺激大縫際核誘導的抗傷害作用。相比而言,鞘內給予特異性µ受體拮抗劑naloxonazine,或特異性{delta}2受體拮抗劑naltriben,則相比A{delta}介導的反應,大縫際核誘導的C纖維抗傷害反應被優先減輕。這些發現提示,激動A{delta}C纖維傷害感受器喚起的疼痛反應是在大縫際核的藥理學上可識別的遞減控制之下。

(鍾鳴 薛張綱 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.

 

通過腦脊液盥洗撤銷無意的脊髓麻醉藥的作用

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

 

在此病例報導中,我們描述了通過腦脊液盥洗成功治療了一名硬膜外導管被放置到鞘內的女孩,這名女孩14歲,在硬膜外和全麻聯合下行整形外科手術。在此病例中,大量的局麻藥被注射到鞘內(總共可能的注射量是200mg利多卡因和61mg布比卡因),導致了手術結束時呼吸停止和散大固定的瞳孔。通過硬膜外導管,20ml腦脊液被10ml生理鹽水和10ml乳酸林格氏液所替代。5分鐘後自主呼吸恢復,30分鐘後拔除氣管導管。手術後未出現神經學缺陷和硬膜外刺穿後頭痛的發生。

(鍾鳴 薛張綱 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.

 

 

油酸誘發的肺損傷中中性粒細胞和中性粒細胞產物並不介導內毒素的肺血流動力學效應

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

 

在狗中通過油酸(OA)誘發的損傷後,導致氧合功能的明顯惡化。小劑量的內毒素(Etx)能防止肺灌注重新分佈到水腫的肺背側區域。我們假設小劑量Etx能通過多形核中性粒細胞(PMN)起動釋放炎性介質如血小板啟動因數(PAF)或分泌性磷酯酶A2sPLA2)來介導這一效應。為了驗證這一假設,我們給予特異性直接抑制每一介質的抑制劑,並採用兩種策略來產生中性粒細胞減少症。PAF sPLA2抑制劑在OA損傷之前給予,兩小時後給予小劑量Etx(每組n4)。試驗前五天給予羥基脲產生PMN的耗竭以達到中性粒細胞絕對計數<1000/mm3(n=4)。通過損傷前即刻給予抗CD18單克隆抗體來達到抑制PMN黏附到肺內皮細胞上(n5)。正電子放射X線斷層成像用於評估肺灌注分佈和肺水含量。我們觀察到在EtxOA後這些干預措施對於肺灌注模式沒有產生影響。因此,無論是中性粒細胞還是PAFsPLA2都沒有介導Etx對該肺損傷模型中灌注模式的影響。

(鍾鳴 薛張綱 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.

 

異氟醚和異丙酚麻醉時靜脈使用氟比洛芬不影響腦血流速度和氧合

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,一種非甾體類抗炎藥(NSAID),用於治療風濕性,骨關節炎性的疼痛和術後鎮痛。雖然其他非甾體類抗炎藥,如吲哚美辛,會減少腦血流,但是氟比洛芬對腦血流的影響還是個未知數。在這個研究中,我們觀察了在異氟醚和異丙酚麻醉時靜脈使用氟比洛芬對影響腦血流速度和氧合的影響。我們選擇了48位進行矯形外科手術和腹部手術的病人。把他們隨機分為異丙酚組(靶控輸注:效應室濃度3 µg/mL)和異氟醚組 (1 MAC)。每組再分成兩小組,每小組12人。各小組分別靜脈用1 mg/kg 的氟比洛芬(PROP-F and ISO-F ) 0.1 mL/kg的鹽水(PROP-S and ISO-S )五分鐘。在靜脈用藥期前5分鐘和用藥後60分鐘,分別用腦氧飽和度計(NIRO 300)和經顱的多譜勒測腦氧合參數(組織氧合指數 [TOI], 總血紅蛋白的改變 [{Delta}cHb],氧合血紅蛋白的改變 [{Delta}O2Hb], 和還原血紅蛋白的改變[{Delta}HHb])和大腦中動脈血液的流速(Vmca)。在使用氟比洛芬前,ISO-FISO-S組的TOI值比PRO-FPRO-S組顯著高(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後都沒有大的改變,和對照組相似。這些資料表明在異氟醚和異丙酚麻醉時靜脈使用氟比洛芬不影響腦血流速度和氧合。

(方芳 薛張綱 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對懷孕羊的子宮血流的作用

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

氯胺酮是一個在產科手術中很有用的用於母體的鎮痛藥,他可以避免阿片類藥物的使用及給新生兒帶來的副作用。消旋氯胺酮可以通過胎盤屏障並有催產素作用,但是看來對子宮的血流沒什麼影響。左旋氯胺酮近來在臨床上推薦使用,但是他對子宮血流的作用尚未確認。因此,我們主要研究左旋氯胺酮對母嬰血流動力學參數的影響。等效鎮痛劑量的左旋氯胺酮(10 mg • kg-1 • h-1)和消旋氯胺酮(20 mg • kg-1 • h-1)注入12只懷孕的母羊中。記錄母體和胎兒的生命體征,血氣和子宮血流120分鐘。兩種藥物對子宮的血流灌注和母胎的血流動力學都沒有受影響。但是消旋氯胺酮顯著增加了母體(+19%)和胎兒(+11%) PCO2 ,而左旋氯胺酮對此沒有影響 。同時兩種藥物又都顯著減少了母體(消旋, -0.05; 左旋, -0.03)和胎兒(消旋, -0.06; 左旋, -0.02) pH. 左旋氯胺酮和消旋氯胺酮對子宮血流的作用是相似的。但是由於消旋氯胺酮在血流動力學和呼吸方面的限制,左旋氯胺酮成為產科鎮痛的焦點。

(方芳 薛張綱 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

 

全麻狀態下音樂對手術帶來的神經激素反應的影響

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

一些藥物可以減少全麻圍術期應激激素的釋放。曾經有人研究過聽音樂和給予治療方面的建議。但是這些主要在清醒的病人,確實對術後恢復和鎮痛是有幫助的。在這項研究中,我們通過測量腎上腺素,去甲腎上腺素,皮質醇和促腎上腺皮質激素(ACTH)的值來評價全麻下音樂對手術刺激帶來的神經激素反應的影響。30位擇期行經腹婦科手術的患者被隨機分為兩組,NM(無音樂)組和M(有音樂)組。M組中,誘導後直至手術結束,我們一直播放音樂。NM組中,患者帶耳機但是沒有音樂。我們術中採用了三個採樣點測激素水平,術後在蘇醒室也測一次。全程記錄血流動力學資料,以及術後24小時的嗎啡用量。術中任一時刻或術後的平均動脈壓,心率,呼末異氟醚濃度,手術進行的時間,雙極指數(BIS),芬太尼的用量,和術後嗎啡的用量都沒有組間差異。血中腎上腺素,去甲腎上腺素,皮質醇和促腎上腺皮質激素(ACTH)的值雖然由於手術刺激而增高,但是兩組間沒有差異。總之我們認為全麻狀態下,音樂對手術帶來的神經激素反應無影響。

(方芳 薛張綱 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.

患鐮狀紅細胞病人使用止血帶行雙側膝關節置換術

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歲的男性鐮狀紅細胞患者,擇期行止血下雙側膝關節置換術。在這種患者中使用止血帶並不是沒有危險。雙側膝關節置換術前進行了輸血治療。患者對手術耐受很好。如果糾正血液問題,患有鐮狀紅細胞的病人使用止血帶還是有好處的。

(方芳 薛張綱 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.