Anesthesia & Analgesia

April 2004

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

猪急性三尖瓣反流不改变热稀释法心输出量测定的准确性或精确性

(黄施伟 译,李士通 校)

Neither the Accuracy nor the Precision of Thermal Dilution Cardiac Output Measurements Is Altered by Acute Tricuspid Regurgitation in Pigs

Charles W. Buffington and Elisabet U. M. Nystrom

Anesth Analg 2004 98: 884-890

变力性药物改善主动脉瓣狭窄行主动脉瓣置换术病人的右心功能

(周洁 译 王祥瑞 校)

Inotropes Improve Right Heart Function in Patients Undergoing Aortic Valve Replacement for Aortic Stenosis

Andrew D. Maslow, Meredith M. Regan, Carl Schwartz, Arthur Bert, and Arun Singh

Anesth Analg 2004 98: 891-902..

鞘内应用吗啡减少缺血-再灌注损伤大鼠模型的心梗面积
Intrathecal Morphine Reduces Infarct Size in a Rat Model of Ischemia-Reperfusion Injury

(钟鸣 译 薛张纲 校)

Leanne Groban, Jason C. Vernon, and John Butterworth

Anesth Analg 2004 98: 903-909

中心静脉导管正确放置:用经食道心超比较静脉内心电图和表面标志技术

(王立中译,李士通校)

Accurate Central Venous Port-A Catheter Placement: Intravenous Electrocardiography and Surface Landmark Techniques Compared by Using Transesophageal Echocardiography

Koung-Shing Chu, Jong-Hau Hsu, Shie-Shan Wang, Chao-Shun Tang, Kuang-I Cheng, Chien-Kuo Wang, and Jiunn-Ren Wu

Anesth Analg 2004 98: 910-914

多巴胺对冠状动脉旁路吻合术常用离体动脉的不同效应

(周洁 译 王祥瑞 校)

The Variable Effects of Dopamine Among Human Isolated Arteries Commonly Used for Coronary Bypass Grafts

Rumi Katai, Isao Tsuneyoshi, Junichirou Hamasaki, Masanori Onomoto, Shoichi Suehiro, Ryuzo Sakata, and Yuichi Kanmura

Anesth Analg 2004 98: 915-920.  

择期肝切除术需用异体血患者中应用促红细胞生成素的作用:一项模拟模型

(钟鸣 译 薛张纲 校)

The Effect of Erythropoietin on Allogeneic Blood Requirement in Patients Undergoing Elective Liver Resection: A Model Simulation

Claude Lentschener, Alexandra Gomola, Sophie Grabar, Olivier Soubrane, Bertrand Dousset, Pierre-Philippe Massault, Catherine Penhoud, and Yves Ozier

Anesth Analg 2004 98: 921-926

PEDIATRIC ANESTHESIA:

蒽环类抗肿瘤药对麻醉期间心功能的影响

(轩 泓 译 李士通 校)

The Influence of Anthracycline Therapy on Cardiac Function During Anesthesia

Egbert Huettemann, Thomas Junker, Kyriasis P. Chatzinikolaou, Gritta Petrat, Samir G. Sakka, Lothar Vogt, and Konrad Reinhart

Anesth Analg 2004 98: 941-947.

多巴胺对冠状动脉旁路吻合术常用离体动脉的不同效应

(周洁 译 王祥瑞 校)

The Effects of Spread of Block and Adrenaline on Cardiac Output After Epidural Anesthesia in Young Children: A Randomized, Double-Blind, Prospective Study
Olivier Raux, Alain Rochette, Estelle Morau, Christophe Dadure, Christine Vergnes, and Xavier Capdevila

Anesth Analg 2004 98: 948-955.

小儿脊柱术后鞘内及硬膜外镇痛的回顾

(钟鸣目译 薛张纲 校)

A Review of Intrathecal and Epidural Analgesia After Spinal Surgery in Children (Review Article)
Joseph D. Tobias

Anesth Analg 2004 98: 956-965.

青春期心脏手术后并发硬膜外血肿一例

(张俊杰译, 李士通校)

An Epidural Hematoma in an Adolescent Patient After Cardiac Surgery (Case Report)

David A. Rosen, Denzil W. Hawkinberry, II, Kathleen R. Rosen, Robert A. Gustafson, Jeffery P. Hogg, and Lynn M. Broadman

Anesth Analg 2004 98: 966-969

AMBULATORY ANESTHESIA:

围术期使用罗非考昔(Rofecoxib)可促进门诊疝修补术患者的早期康复

(朱辉 译 王祥瑞 校)

Perioperative Rofecoxib Improves Early Recovery After Outpatient Herniorrhaphy

Hong Ma, Jun Tang, Paul F. White, Alan Zaentz, Ronald H. Wender, Alexander Sloninsky, Robert Naruse, Robert Kariger, Raymond Quon, Dennis Wood, and Brendan J. Carroll

Anesth Analg 2004 98: 970-975

Modafinil改善全麻后恢复

(陆旭伟 薛张纲 校)

Modafinil Improves Recovery After General Anesthesia

Ghassem E. Larijani, Michael E. Goldberg, Mohammadreza Hojat, Behnam Khaleghi, Jeffrey B. Dunn, and Alex T. Marr

Anesth Analg 2004 98: 976-981

热蒸气法增强利多卡因的局部麻醉作用

(裘毅敏 译,李士通 校)
Warm Steaming Enhances the Topical Anesthetic Effect of Lidocaine

Young-Chang P. Arai and Wasa Ueda

Anesth Analg 2004 98: 982-985.

ANESTHETIC PHARMACOLOGY:

罗库溴胺和维库溴胺的皮肤敏感性——健康志愿者的随机对照研究

(朱慧琛 王祥瑞 校)

Skin Sensitivity to Rocuronium and Vecuronium: A Randomized Controlled Prick-Testing Study in Healthy Volunteers

Gilles Dhonneur, Xavier Combes, Didier Chassard, and Jean Claude Merle

Anesth Analg 2004 98: 986-989.

比较七氟醚和异氟醚复合笑气和硬膜外阻滞麻醉下肝硬化病人行肝切除术后的肝功能

(陆旭伟 译 薛张纲 校)

A Comparison of Liver Function After Hepatectomy in Cirrhotic Patients Between Sevoflurane and Isoflurane in Anesthesia with Nitrous Oxide and Epidural Block

Tomoki Nishiyama, Takahiro Fujimoto, and Kazuo Hanaoka

Anesth Analg 2004 98: 990-993

术前口服右美沙芬可减轻全麻下行膝关节十字韧带再造术中止血带引起的动脉血压和心率的增加

(沈浩 译 李士通 校)

Preoperative Oral Dextromethorphan Attenuated Tourniquet-Induced Arterial Blood Pressure and Heart Rate Increases in Knee Cruciate

Ligament Reconstruction Patients Under General Anesthesia

Soichiro Yamashita, Hiroshi Yamaguchi, Yu Hisajima, Kazuhiro Ijima, Kaori Saito, Ai Chiba, and Toru Yasunaga

Anesth Analg 2004 98: 994-998.

脂多糖诱导炎症反应中预防性使用异氟醚可促进血流动力学稳定并增加大鼠肠系膜白细胞运动速率

(朱慧琛 译 王祥瑞 校)

Isoflurane Pretreatment Supports Hemodynamics and Leukocyte Rolling Velocities in Rat Mesentery During Lipopolysaccharide-Induced Inflammation

John K. Hayes, Dmytro M. Havaleshko, Roman V. Plachinta, and George F. Rich

Anesth Analg 2004 98: 999-1006.

氙气和异氟醚在调节LPS介导的NF-κB活性和单核细胞TNF-αIL-6生成方面的不同

(陆旭伟 译 薛张纲 校)

Xenon and Isoflurane Differentially Modulate Lipopolysaccharide-Induced Activation of the Nuclear Transcription Factor KB and Production of Tumor Necrosis Factor-{alpha} and Interleukin-6 in Monocytes
Lothar W. de Rossi, Martina Brueckmann, Steffen Rex, Marco Barderschneider, Wolfgang Buhre, and Rolf Rossaint

Anesth Analg 2004 98: 1007-1012.

芬太尼对大鼠阿心室肌细胞内钙离子和细胞收缩性的作用

(赵雪莲 译 李士通 校)
The Effects of Alfentanil on Cytosolic Ca2+ and Contraction in Rat Ventricular Myocytes
Mark D. Graham, Philip M. Hopkins, and Simon M. Harrison

Anesth Analg 2004 98: 1013-1016

Tetsuro Shirasaka, Yasuhiro Yoshimura, De-Lai Qiu, and Mayumi Takasaki

异丙酚对大鼠下丘脑室旁核神经元的作用

(陈洁 译 王祥瑞 校)

The Effects of Propofol on Hypothalamic Paraventricular Nucleus Neurons in the Rat
Anesth Analg 2004 98: 1017-1023.

局麻药对单核细胞mCD14和人类白细胞抗原-DR表达的影响

(周晓敏 译 薛张纲 校)

The Effect of Local Anesthetics on Monocyte mCD14 and Human Leukocyte Antigen- DR Expression
Takashi Kawasaki, Chika Kawasaki, Masanori Ogata, and Akio Shigematsu

Anesth Analg 2004 98: 1024-9.

PAIN MEDICINE:

术后口服罗非考昔(Rofecoxib)减轻经腹子宫切除术后疼痛和减少曲马多的用量

(陈洁 译 陈杰 校)

术前口服Rofecoxib减少经腹子宫切除病人术后疼痛和曲马多用量

(颜涛译, 李士通 校)

Preoperative Oral Rofecoxib Reduces Postoperative Pain and Tramadol Consumption in Patients After Abdominal Hysterectomy

Beyhan Karamanlioglu, Alparslan Turan, Dilek Memis, and Mevlüt Türe

Anesth Analg 2004 98: 1039-1043

围术期静脉注射利多卡因对腹部大手术术后疼痛和吗啡消耗有预防作用

(周晓敏 译 薛张纲 校)

Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and Morphine Consumption After Major Abdominal Surgery
Wolfgang Koppert, Marc Weigand, Frank Neumann, Reinhard Sittl, Jürgen Schuettler, Martin Schmelz, and Werner Hering

Anesth Analg 2004 98: 1050-1055.

 

鞘内可乐定与布比卡因对大鼠急性热性或炎性痛具有协同镇痛作用

(马皓琳 译 李士通 校)

Intrathecal Clonidine and Bupivacaine Have Synergistic Analgesia for Acute Thermally or Inflammatory-Induced Pain in Rats

Tomoki Nishiyama and Kazuo Hanaoka

Anesth Analg 2004 98: 1056-1061

关节镜膝部手术后关节内给予苏芬太尼和苏芬太尼加甲强龙的镇痛作用

(周晓敏 译 薛张纲 校)

Analgesic Effects of Intraarticular Sufentanil and Sufentanil Plus Methylprednisolone After Arthroscopic Knee Surgery

Mehmet Kizilkaya, Omer Selim Yildirim, Nazim Dogan, Husnu Kursad, and Ali Okur

Anesth Analg 2004 98: 1062-1065.

单次剂量氟哌啶醇用于预防术后硬膜外吗啡镇痛引起的恶心和呕吐

(彭中美 译 李士通 校)

Single-Dose Haloperidol for the Prophylaxis of Postoperative Nausea and Vomiting After Intrathecal Morphine

Joel L. Parlow, Ioana Costache, Nicole Avery, and Kim Turner

Anesth Analg 2004 98: 1072-1076.

对接受皮肤移植术的烧伤病人应用连续髂筋膜腔隙阻滞(FICB)的效果

(忻纪华 译 王祥瑞 校)

The Efficacy of Continuous Fascia Iliaca Compartment Block for Pain Management in Burn Patients Undergoing Skin Grafting Procedures

Olivier Cuignet, Jean Pirson, Jenna Boughrouph, and Diane Duville

Anesth Analg 2004 98: 1077-81

乙酰水杨酸盐、二氯芬酸和芬诺昔而非罗非考昔影响血小板CD62表达

(周晓敏 译 薛张纲 校)

Acetylsalicylic Acid, Diclofenac, and Lornoxicam, but Not Rofecoxib, Affect Platelet CD 62 Expression

Alex M. Blaicher, Harald T. Landsteiner, Olga Al-Falaki, Jochen Zwerina, Ivo Volf, Diego Gruber, Michael Zimpfer, and Klaus Hoerauf

Anesth Analg 2004 98: 1082-1085

硬膜外镇痛保持脊柱大手术后淋巴细胞免疫功能,而不是单核细胞

(张曦 译,李士通校)

Postoperative Epidural Anesthesia Preserves Lymphocyte, but Not Monocyte, Immune Function After Major Spine Surgery

Thomas Volk, Michael Schenk, Kristina Voigt, Stefan Tohtz, Michael Putzier, and Wolfgang J. Kox

Anesth Analg 2004 98: 1086-1092.

大鼠足底切开前使用利多卡因和布比卡因预处理对脊髓C-FOS蛋白在时间和空间上表达的影响

(齐波 译 王祥瑞 校)

The Effects of Pretreatment with Lidocaine or Bupivacaine on the Spatial and Temporal Expression of c-Fos Protein in the Spinal Cord Caused by Plantar Incision in the Rat
Xiaohui Sun, Masataka Yokoyama, Satoshi Mizobuchi, Ryuji Kaku, Hideki Nakatsuka, Toru Takahashi, and Kiyoshi Morita

Anesth Analg 2004 98: 1093-1098.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

临床术前评估中心术前评估患者的满意程度

(方芳 译 薛张纲 校)

Patient Satisfaction with Preoperative Assessment in a Preoperative Assessment Testing Clinic

David L. Hepner, Angela M. Bader, Shelley Hurwitz, Michael Gustafson, and Lawrence C. Tsen

Anesth Analg 2004 98: 1099-1105

CRITICAL CARE AND TRAUMA:

氯胺酮在内毒素血症的大鼠中低温和浅低温时的抗炎作用

(吴俭译, 李士通校)

The Antiinflammatory Effects of Ketamine in Endotoxemic Rats During Moderate and Mild Hypothermia

Takumi Taniguchi, Hiroko Kanakura, Yasuhiro Takemoto, and Ken Yamamoto

Anesth Analg 2004 98: 1114-1120.

复合外伤后反常栓子引起的脑血管意外

(朱辉 译 王祥瑞 校)

Paradoxical Embolus After Multiple Trauma Resulting in a Cerebrovascular Accident (Case Report)

Mark D. Price, Pranay Kanake, and Daniel Talmor

Anesth Analg 2004 98: 1121-1123.

因未识别的乳胶过敏引起的长时间心血管衰竭

(方芳译 薛张纲 校)

Prolonged Cardiovascular Collapse Due to Unrecognized Latex Anaphylaxis (Case Report)
James R. Hebl, Brian A. Hall, and Juraj Sprung

Anesth Analg 2004 98: 1124-1126.

NEUROSURGICAL ANESTHESIA:

地氟醚和异氟醚对行脑幕上肿瘤颅骨切开术的患者腰椎脑脊液压力的作用比较

(朱 慧译 李士通校)

The Comparative Effects of Desflurane and Isoflurane on Lumbar Cerebrospinal Fluid Pressure in Patients Undergoing Craniotomy for Supratentorial Tumors

Alan Kaye, Ian J. Kucera, James Heavner, Adrian Gelb, Muhamed Anwar, Marilyn Duban, A. Salam Arif, Rosemary Craen, Cheng-Tao Chang, Raul Trillo, and Marc Hoffman

Anesth Analg 2004 98: 1127-32.

蛛网膜下腔出血时脑自主调节功能的持续评估

(殷文渊 译 王祥瑞 校)

Continuous Assessment of Cerebral Autoregulation in Subarachnoid Hemorrhage

Martin Soehle, Marek Czosnyka, John D. Pickard, and Peter J. Kirkpatrick

Anesth Analg 2004 98: 1133-1139.

OBSTETRIC ANESTHESIA:

低位剖宫术中双指数在1%.5%七氟醚中的价值

(方芳 译 薛张纲 校)

Bispectral Index Values at Sevoflurane Concentrations of 1% and 1.5% in Lower Segment Cesarean Delivery

Ki Jinn Chin and Seow Woon Yeo

Anesth Analg 2004 98: 1140-1144.

 

硬膜外注射罗哌卡因和布比卡因用于分娩镇痛:一项关于产科预后的随机双盲试验

(周雅春译 李士通校)

Epidural Infusions of Ropivacaine and Bupivacaine for Labor Analgesia: A Randomized, Double-Blind Study of Obstetric Outcome

Bee B. Lee, Warwick D. Ngan Kee, Floria F. Ng, Tze K. Lau, and Eliza L. Y. Wong

Anesth Analg 2004 98: 1145-1152.

用双盲,双安慰剂对照试验比较两组腰硬联合和硬膜外阻滞行分娩时鞘内舒芬太尼与胎儿心率异常关系

(殷文渊 译 王祥瑞 校)

Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial Comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor
M. Van de Velde, A. Teunkens, M. Hanssens, E. Vandermeersch, and J. Verhaeghe

Anesth Analg 2004 98: 1153-1159

REGIONAL ANESTHESIA:

用神经刺激器行锁骨上阻滞降低抑未降低成功率?

(方芳 译 薛张纲 校)

The Supraclavicular Block with a Nerve Stimulator: To Decrease or Not to Decrease, That Is the Question

Carlo D. Franco, Vitaliy Domashevich, Gennadiy Voronov, Amir B. Rafizad, and Tanyu J. Jelev

Anesth Analg 2004 98: 1167-1171

曲马多加入1.5%甲哌卡因剂量依赖性增强腋路臂丛阻滞术后镇痛效果

(周志坚 译 李士通 校)

Tramadol Added to 1.5% Mepivacaine for Axillary Brachial Plexus Block Improves Postoperative Analgesia Dose-Dependently
Anesth Analg 2004 98: 1172-1177.

Sébastien Robaux, Cornelia Blunt, Eric Viel, Philippe Cuvillon, Philippe Nouguier, Gilles Dautel, Sylvie Boileau, Florence Girard, and Hervé Bouaziz

 

曲马多加入1.5%甲哌卡因剂量依赖性增强腋路臂丛阻滞术后镇痛效果

Tramadol Added to 1.5% Mepivacaine for Axillary Brachial Plexus Block Improves Postoperative Analgesia Dose-Dependently

Sébastien Robaux, MD*, Cornelia Blunt, FRCA*, Eric Viel, MD{dagger}, Philippe Cuvillon, MD{dagger}, Philippe Nouguier, MD*, Gilles Dautel, MD{ddagger}, Sylvie Boileau, MD*, Florence Girard, MD§, and Hervé Bouaziz, MD, PhD*

*Department of Anesthesiology and Critical Care Medicine, Hôpital Central, Nancy Cedex, the {dagger}Department of Anesthesiology and Pain Management, Hôpital Caremeau, Nimes Cedex 9, France, the {ddagger}Department of Plastic and Hand Surgery, Hôpital Jeanne d’Arc, Nancy, France, and the §Department of Clinical Epidemiology and Evaluation, Hôpital Marin, Nancy Cedex, France

Anesth Analg 2004;98:1172-1177

 

进行外周神经丛中阻滞麻醉时,在局麻药中加入附加药物,可以增强麻醉及术后止痛的质量,延长其时效。作为止痛剂,曲马多独特的作用机制使其作为附加药可能有效。它显示出了中枢止痛和外周局麻作用。我们设计了一个随机对照、双盲、前瞻性临床试验,来评估臂丛神经阻滞时加入曲马多的效果。100例拟于臂丛神经阻滞下行腕管松解术的病人随机分成四组。所有病例都用1.5%甲哌卡因40ml进行臂丛阻滞,所附加的成分四组分别为等渗盐水(P,17)、曲马多40mg(T40,22)、曲马多100mg(T100, 20) 、曲马多200mg(T200, 20)。评价其麻醉起效时间、感觉和运动阻滞时间、术后止痛时间和质量及其不良反应。四组病例的感觉运动阻滞起效时间和持续时间无差异。和对照组相比,三组曲马多病例术后要求额外止痛的病人数显著减少(P=0.02);同时T200组相比于对照组和T40组,也存在这一差异。在对照组和T40之间、T100 T200之间,其差异无统计意义。进一步用Cochran-Armitage趋势检验,四组病例趋势差别有显著意义(P=0.003),提示加入曲马多减少术后额外止痛需求呈剂量依赖性。不良反应发生数在曲马多组相对较多,但差异无显著性。我们的研究提示,在用1.5%甲哌卡因进行臂丛阻滞时,加入曲马多对延长止痛时间呈剂量依赖性,其不良反应在可接受范围之内。然而,在被允许用于临床实践之前,曲马多的安全性需要进一步研究。

(周志坚 译 李士通 校)

Adjuncts to local anesthetics for peripheral plexus blockade may enhance the quality and duration of anesthesia and postoperative analgesia. The analgesic, tramadol, has a unique mechanism of action that suggests efficacy as such an adjunct. It displays a central analgesic and peripheral local anesthetic effect. We designed a prospective, randomized, controlled and double-blind clinical trial to assess the effect of tramadol added to brachial plexus anesthesia. One-hundred patients scheduled for carpal tunnel release surgery under brachial plexus anesthesia were randomized into four groups. All patients received 1.5% mepivacaine 40 mL plus a study solution containing either isotonic sodium chloride (Group P, n = 17), tramadol 40 mg (Group T40, n = 22), tramadol 100 mg (Group T100, n = 20) or tramadol 200 mg (Group T200, n = 20). We evaluated the time of onset of anesthesia, duration of sensory and motor blockade, duration and quality of postoperative analgesia, and occurrence of adverse effects. Onset and duration of sensory and motor blocks were not different among groups. The number of patients requesting analgesia in the postoperative period was significantly less in the 3 tramadol groups compared with the placebo group (P = 0.02); this was also noted with the placebo and T40 groups compared with the T200 group. No statistical significance was demonstrated between the placebo and the T40 group or the T100 group and the T200 group. Furthermore, there was a significant trend effect among groups applying the Cochran-Armitage tendency test (P = 0.003), suggesting a dose-dependent decrease for additional postoperative analgesia requirements when tramadol was added. Side effects did not differ among groups, although they were more frequently recorded in the T groups. Our study suggests that tramadol added to 1.5% mepivacaine for brachial plexus block enhances in a dose-dependent manner the duration of analgesia with acceptable side effects. However, the safety of tramadol has to be investigated before allowing its use in clinical practice.

鞘内可乐定与布比卡因对大鼠急性热性或炎性痛具有协同镇痛作用

Intrathecal Clonidine and Bupivacaine Have Synergistic Analgesia for Acute Thermally or Inflammatory-Induced Pain in Rats

Tomoki Nishiyama, MD, PhD, and Kazuo Hanaoka, MD, PhD

Department of Anesthesiology, The University of Tokyo, Faculty of Medicine, Tokyo, Japan

Anesth Analg 2004;98:1056-1061

 

我们用一个急性和炎性痛的动物模型观察了鞘内给予的布比卡因与可乐定的相互作用。对置入腰段鞘内导管的大鼠鞘内注射盐水(对照)、布比卡因(1~100 µg)或可乐定(0.1~3 µg),并测试它们对尾部热刺激(尾部摆打试验)和后爪皮下注射福尔马林(福尔马林试验)的反应。用等辐射分析测试合用布比卡因与可乐定对这两个刺激的作用。检查一般行为和运动功能作为副作用。在尾部摆打试验及福尔马林试验的第一相和第二相中,布比卡因与可乐定合用时的50%有效剂量均显著低于单个药物的50%有效剂量(尾部摆打试验2.820.11 µg 7.10.29 µg,福尔马林试验的第一相0.240.009 µg vs. 5.70.15 µg,第二相0.310.012 µg vs. 3.20.16 µg)。两药合用时副作用减少。这些结果提示鞘内合用布比卡因与可乐定在处理急性和炎性痛方面的作用令人满意。

(马皓琳 译 李士通 校)

We investigated the interaction between spinally administered bupivacaine and clonidine using an animal model of acute and inflammatory pain. Rats implanted with lumbar intrathecal catheters were injected intrathecally with saline (control), bupivacaine (1 to 100 µg), or clonidine (0.1 to 3 µg) and tested for their responses to thermal stimulation to the tail (tail flick test) and subcutaneous formalin injection into the hindpaw (formalin test). The effects of the combination of bupivacaine and clonidine on both stimuli were tested by isobolographic analysis. General behavior and motor function were examined as side effects. The 50% effective doses of bupivacaine and clonidine were significantly smaller when combined compared with each single drug in both the tail flick test (2.82 and 0.11 µg versus 7.1 and 0.29 µg, respectively) and phase 1 (0.24 and 0.009 µg versus 5.7 and 0.15 µg) and phase 2 (0.31 and 0.012 µg versus 3.2 and 0.16 µg) of the formalin test. Side effects were decreased by the combination. These results suggest a favorable combination of intrathecal bupivacaine and clonidine in the management of acute and inflammatory pain.

 

中心静脉导管正确放置:用经食道心超比较静脉内心电图和表面标志技术

Accurate Central Venous Port-A Catheter Placement: Intravenous Electrocardiography and Surface Landmark Techniques Compared by Using Transesophageal Echocardiography

Koung-Shing Chu,MD*,Jong-Hau Hsu,MD,Shie-Shan Wang, MD, Chao-Shun Tang, PhD,Kuang-I Cheng, MD, Chien-Kuo Wang, MD||, and Jiunn-Ren Wu, MD{dagger}

*Department of Anesthesiology, Kuo General Hospital, Tainan, Taiwan; and Departments of {dagger}Pediatrics, {ddagger}Surgery, §Anesthesiology, and Medical Imaging, Kaohsiung Medical University, Kaohsiung City, Taiwan

Anesth Analg 2004;98:910-914

 

我们利用经食道心超(TEE)技术定位经右锁骨下静脉置入中心静脉导管尖端位置,对静脉心电图(IV-ECG)引导导管尖端放置与传统利用体表面标志定位技术进行比较。60例病人随机分成2组。在E组,通过充满NaHCO3导管传导IV-ECG信号以指导导管放置。在S组利用胸壁表面标志以确定合适的导管长度。标准是用TEE确定导管尖端是否在交界嵴上缘即上腔静脉(SVC)与右心房(RA)交界处。当导管尖端处于交界嵴上缘1.0 cm之内认为导管位置满意。当ECGP波最大时,E组所有30例病人导管尖端位置满意。相反,S30例病人中只有16例位置满意(P < 0.001)。所有导管在TEE指导下均重新调整以使导管尖端恰好位于SVC-RA连接处。当导管尖端证实处于SVC-RA连接处时,仰卧位胸片仍显示60例病人中有12例尖端位于RA中。结论:用IV-ECG引导静脉导管放置可获得满意的位置,与TEE一致。而用胸壁表面标志技术来确定导管尖端处于SVC-RA交界处则是不可靠的方法。

(王立中译,李士通校)
Using transesophageal echocardiography (TEE) to locate the tip of central venous catheters inserted via the right subclavian vein, we compared IV electrocardiography (IV-ECG)-guided catheter tip placement with the conventional surface landmark technique. Sixty patients were randomly assigned into two groups. In Group E, the IV-ECG signal was conducted along an NaHCO3-filled catheter to facilitate catheter placement. In Group S, surface landmarks on the chest wall were used to determine the appropriate catheter length. The goal was to visualize the catheter tip with TEE at the superior edge of the crista terminalis, which is the junction of the superior vena cava (SVC) and right atrium (RA). The catheter tip position was considered to be satisfactory, as the tip was within 1.0 cm of the upper crista terminalis edge. All 30 Group E patients had satisfactory catheter tip placement when the ECG P wave was at its maximum. In contrast, 16 of the 30 patients in Group S had satisfactory tip positions (P < 0.001). All catheters were repositioned under TEE guidance to adjust the tip to the SVC-RA junction. After the catheter tips were confirmed to be located at the SVC-RA junction, the catheter tips were still visualized in the mid portion of RA in 12 of 60 patients on supine chest radiographs. We concluded that IV-ECG guidance to position a catheter resulted in satisfactory catheter tip placement that is in accordance with TEE views. Catheter placement at the SVC-RA junction with the surface landmark technique was unreliable.


地氟醚和异氟醚对行脑幕上肿瘤颅骨切开术的患者腰椎脑脊液压力的作用比较

The Comparative Effects of Desflurane and Isoflurane on Lumbar Cerebrospinal Fluid Pressure in Patients Undergoing Craniotomy for Supratentorial Tumors

Alan Kaye, MD, PhD, Ian J. Kucera, MD, PharmD, James Heavner, DVM, PhD, Adrian Gelb, MD, Muhamed Anwar, MD, Marilyn Duban, MD, A. Salam Arif, MD, Rosemary Craen, MB, Cheng-Tao Chang, PhD, Raul Trillo, MD, and Marc Hoffman, MD Section Editor

From the Department of Anesthesiology, Texas Tech University, Lubbock, Texas

Anesth Analg 2004 98: 1127-32.

 

我们比较了脑幕下肿块行开颅术的患者麻醉过程中使用地氟醚和异氟醚对大脑灌注压(CPP)、腰椎脑脊液压力(LCSFP)和平均动脉压(MAP)的影响。另外,也观察苏醒情况以确定异氟醚或地氟醚麻醉哪个能进行更早期的神经功能评估。36名患者随机使用1.2 MAC的地氟醚或异氟醚维持麻醉。通过蛛网膜下导管获得腰椎脑脊液压力(LCSFP)基础值后对患者进行过度通气 (PaCO2, 30 ± 2 mm Hg)。 在1.2MAC时,两组过度通气前后的平均LCSFP无统计学差异。此外,两组的CPP亦没有显著的差异。地氟醚组患者对指令能应答的时间(30 ± 36 min)比异氟醚组(72 ± 126 min)50%,然而,这并没有统计学差异(P = 0.17)。对脑幕上肿块行开颅术的患者而言,地氟醚和异氟醚对CPPMAP的作用相似。过度通气后地氟醚对LCSFP的影响不明显。

(朱 慧译 李士通校)

We compared the effects of desflurane and isoflurane on cerebral perfusion pressure (CPP), lumbar cerebrospinal fluid pressure (LCSFP), and mean arterial blood pressure (MAP) in patients anesthetized with desflurane or isoflurane undergoing craniotomy for supratentorial mass lesions. Additionally, emergence from anesthesia was examined to determine if neurologic function could be assessed earlier after isoflurane or desflurane anesthesia. Thirty-six patients were randomized to receive either desflurane or isoflurane for maintenance of anesthesia at 1.2 minimum alveolar concentration (MAC). Patients were hyperventilated (PaCO2, 30 ± 2 mm Hg) after baseline LCSFP was obtained via the subarachnoid catheter. At a MAC of 1.2, mean LCSFP was not statistically different between the two study groups either before or after hyperventilation. Additionally, CPP was not significantly different between the two groups. Finally, patient’s time to respond to commands was 50% shorter in the desflurane group (30 ± 36 min) (mean ± SD) when compared with the isoflurane group (72 ± 126 min); however, this was not significant (P = 0.17). In patients undergoing craniotomy for supratentorial mass lesions, desflurane and isoflurane have similar effects on CPP and MAP. Additionally, desflurane in the setting of hyperventilation does not cause significant changes in LCSFP.

 

单次剂量氟哌啶醇用于预防术后硬膜外吗啡镇痛引起的恶心和呕吐

Single-Dose Haloperidol for the Prophylaxis of Postoperative Nausea and Vomiting After Intrathecal Morphine

Joel L. Parlow, MD, MSc, FRCPC, Ioana Costache, MD, FRCPC, Nicole Avery, MSc, and Kim Turner, MD, FRCPC

Department of Anesthesiology, Queen’s University, Kingston, Ontario

Anesth Analg 2004;98:1072-1076

 

硬膜外应用吗啡镇痛经常引起术后恶心和呕吐(PONV)。我们研究用单次,小剂量,较便宜的长效多巴胺受体阻滞剂——氟哌啶醇来防止脊麻局麻药加吗啡0.3mg镇痛后引起的恶心和呕吐的效果。我们选择108个择期在脊麻下行下肢整形外科或内窥镜泌尿外科手术的成年病人,在脊麻注射后随机给肌注氟哌啶醇1mgH1组),氟哌啶醇2mgH2组)或安慰剂(P组)。术后24小时内评估病人,恶心大于1厘米(10厘米的视觉模拟评分法),或有呕吐,需使用止吐药治疗的为治疗失败。绝大多数治疗失败是发生在术后的最初12小时内(60%),且随着氟哌啶醇剂量增加,发生率下降(最初的12小时:P76%H156%H250%P=0.012)。不论在哪组,病人以前有术后恶心和呕吐史者与本次术后恶心和呕吐的发生率明显相关。氟哌啶醇两组均未见肌张力增高反应。我们得出结论,虽然使用氟哌啶醇治疗,吗啡镇痛引起的术后恶心和呕吐(PONV)的发生率仍是重要问题,但氟哌啶醇能减轻鞘内吗啡后恶心和呕吐的发生率。

(彭中美 译 李士通 校)

Postoperative nausea and vomiting (PONV) occurs frequently with the use of intrathecal morphine. We studied the ability of a single, small dose of the inexpensive, long-acting, dopamine receptor-blocking drug, haloperidol, to prevent PONV after spinal anesthesia using local anesthetic with morphine 0.3 mg. One-hundred-eight adult patients undergoing elective lower limb orthopedic or endoscopic urologic procedures under spinal anesthesia were randomized to receive IM haloperidol 1 mg (H1), haloperidol 2 mg (H2), or placebo (P) after an intrathecal injection. Patients were assessed for 24 h after surgery, with treatment failure being defined as nausea >1 on a 10-cm visual analog scale or any vomiting or request for rescue antiemetic. Most treatment failures occurred during the first 12 h (60% overall), and haloperidol led to a dose-dependent decrease in PONV (first 12 h: 76% P, 56% H1, and 50% H2; P = 0.012). A history of PONV was strongly associated with PONV in the current study, regardless of treatment group. There were no dystonic reactions noted to either dose of haloperidol. We conclude that haloperidol reduces the incidence of PONV after intrathecal morphine, although this incidence remains a significant problem even with treatment.

 

猪急性三尖瓣反流不改变热稀释法心输出量测定的准确性或精确性

Neither the accuracy nor the precision of thermal dilution cardiac output

measurements is altered by acute tricuspid regurgitation in pigs.

Buffington CW, Nystrom EU.

Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.

Anesth Analg. 2004 Apr;98(4):884-90

 

存在三尖瓣反流(TR)时使用热稀释法测定心输出量(TDCO)是否准确仍有争议。我们在猪体内通过和电磁流量计(EMCO)在主动脉上获得的数据比较来评估热稀释法技术的准确性和精确性。通过缝线将三尖瓣游离小叶固定来形成TR,而心输出量用多巴酚丁胺来调整使其数值与对照测量值相一致。TR使每搏输出量由原先的17.2ml减少为12.6ml,并导致右房扩大以及搏动与右室同步。急性TR不影响TDCOEMCO之间的直线回归关系且不改变其相关系数(对照和TR时均为r = 0.94)。这些资料证明猪急性TR不影响TDCO的准确性和精确性。提示:心输出量是一项有价值的指标可用来指导有心肺疾病患者的处理。本研究证明猪存在三尖瓣反流时用热稀释法测定心输出量是准确的。

(黄施伟 译,李士通 校)

Whether measurement of cardiac output using the thermal dilution technique (TDCO) is valid in the presence of tricuspid regurgitation (TR) is controversial. We assessed the accuracy and precision of the technique in pigs by comparison with data from an electromagnetic flowmeter on the aorta (EMCO). TR was created with sutures that immobilized the free-wall leaflets of the tricuspid valve, and cardiac output was adjusted with dobutamine to give values comparable to control measurements. TR reduced forward stroke volume from 17.2 to 12.6 mL/beat and caused the right atrium to dilate and pulse in synchrony with the right ventricle. Acute TR did not affect the linear regression relation between TDCO and EMCO and did not alter the correlation coefficient (r = 0.94 during both control and TR). These data demonstrate that acute TR does not affect the accuracy or precision of TDCO in pigs. IMPLICATIONS: Cardiac output is a valuable measurement that guides the medical care of patients with heart and lung disease. This study demonstrates that the thermal dilution technique of determining cardiac output is valid when acute tricuspid valve regurgitation is present in pigs.

 

热蒸气法增强利多卡因的局部麻醉作用

Warm Steaming Enhances the Topical Anesthetic Effect of Lidocaine

Young-Chang P. Arai, MD*, and Wasa Ueda, MD{dagger}

From the *Department of Anesthesiology, Kochi Municipal Hospital, and the Department of Anesthesiology, Clinical Physiology and Pharmacology, School of Nursing, Kochi Medical School, Kochi, Japan

Anesth Analg 2004;98:1086-1092

热蒸汽法可用于湿化皮肤,以增加皮肤的通透性。我们作了这样一项研究,对15例女性志愿者的皮肤使用45°C 的蒸汽毛巾热敷5分钟作预处理,以研究该法能否增强局部利多卡因粘膏的麻醉作用。将每位志愿者一只前臂的皮肤作热敷预处理后,将利多卡因粘膏用于已处理的及未处理的前臂皮肤处并保留30分钟。用27号针头针刺5次,通过记录患者疼痛体验的次数来评估表面麻醉作用。单次穿刺27号针头入皮深度达3 mm,作VAS评分以评估深层的麻醉作用。结果表明表面麻醉评分(感知疼痛次数)有明显的减少(中数[范围]:治疗的前臂,2 [05], 未治疗的前臂, 4 [15]; P < 0.01)及深层穿刺的 VAS评分 (中数[范围]: 治疗的前臂, 4.5 [08], 未治疗的前臂, 8 [210]; P < 0.01)。结论,使用热蒸汽毛巾增强了局部利多卡因粘膏的麻醉作用。

(裘毅敏 译,李士通 校)
Warm steaming has been used for hydrating the skin, thereby increasing its permeability. We studied whether skin pretreatment with a steamed towel (at 45°C) for 5 min could enhance the anesthetic effect of a topical lidocaine tape in 14 female volunteers. After each volunteer received the skin pretreatment on one of the forearms, lidocaine tape was applied for 30 min on both the treated and the untreated forearms. Superficial anesthesia was scored by recording the number of painful experience during 5 pinpricks delivered with a 27-gauge needle. To assess anesthesia of the deeper layer, single insertion of a 27-gauge needle to a depth of 3 mm was made and pain was scored by a visual analog scale (VAS). There were significant reductions in the scores of superficial anesthesia (median [range]: treated arm, 2 [0–5], versus untreated arm, 4 [1–5]; P < 0.01) and the VAS scores of deeper insertion (median [range]: treated arm, 4.5 [0–8], versus untreated arm, 8 [2–10]; P < 0.01). In conclusion, the application of a warm steamed towel enhanced the anesthetic effect of a topical lidocaine tape.

 

 

硬膜外镇痛保持脊柱大手术后淋巴细胞免疫功能,而不是单核细胞

Postoperative Epidural Anesthesia Preserves Lymphocyte, but Not Monocyte, Immune Function After Major Spine Surgery

Thomas Volk, MD*, Michael Schenk, MD*, Kristina Voigt, cand. med.*, Stefan Tohtz, MD, Michael Putzier, MD, and Wolfgang J. Kox, MD, PhD, FRCP*

Departments of *Anesthesiology and Intensive Care and Orthopedic Surgery, University Hospital Charité, Campus Mitte, Humboldt-University, Berlin, Germany

Anesth Analg 2004 98: 1086-1092.

 

脊柱大手术造成术后的疼痛。硬膜外疼痛治疗可以减轻术后应激反应和由此影响免疫功能。在一个随机双盲对照的前瞻性研究中,54个病人接受传统的病人自控静脉镇痛(PCIA;吗啡3mg/15min),或者接受病人自控硬膜外镇痛(PCEA;0.125%罗比卡因和苏芬太尼1 µg/mL,背景剂量12ml/h,单次剂量5 mL/15 min)。为了描绘免疫功能的特征,在围手术期测量循环中的细胞因子,C-反应蛋白(CRP),皮质醇,和免疫细胞表面的受体表达(区分簇CD14,人类白细胞抗原-DRCD86, CD71, CD3, CD4, CD8, CD16, CD19)。与PCIA比较,PCEA没有影响循环中的细胞因子(白介素 (IL)-6, IL-8, IL-10, 肿瘤坏死因子a,单核细胞化学诱导蛋白-1, 巨噬细胞抑制因子)或者应激反应的指标(CRP和皮质醇)。同样,单核细胞数或其人类白细胞抗原-DRCD86,CD71的表达没有显著性差异。相反,术后B淋巴细胞和T-辅助细胞的减少在PCEA组有统计学意义。自然杀伤细胞的减少在接受PCEA的病人较PCIA中显著。因此,术后硬膜外疼痛治疗对单核细胞功能没有影响,但是减少自然杀伤细胞和保持B-细胞和T-辅助细胞数。因此,硬膜外镇痛干扰特异性免疫系统而不是先天性免疫系统,可能减轻术后淋巴细胞抑制,有利于抵抗感染。

(张曦 译,李士通校)

Extensive spine surgery is associated with postsurgical pain. Epidural pain therapy may reduce postoperative stress responses and thereby influence immune functions. In a randomized, controlled, double-blinded prospective trial, 54 patients received either conventional patient-controlled IV analgesia (PCIA; morphine 3 mg/15 min) or patient-controlled epidural analgesia (PCEA; 0.125% ropivacaine plus sufentanil 1 µg/mL at a base rate of 12 mL/h and bolus application of 5 mL/15 min). Circulating cytokines, C-reactive protein (CRP), cortisol, and cell-surface receptor expression of immune cells (cluster of differentiation [CD]14, human leukocyte antigen-DR, CD86, CD71, CD3, CD4, CD8, CD16, and CD19) were measured perioperatively to characterize immunological functions. PCEA, compared with PCIA, had no influence on altered levels of circulating cytokines (interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-a, monocyte chemoattractant protein-1, and macrophage inhibitory factor) or indicators of the stress response (CRP and cortisol). Also, no significant difference was found in monocyte numbers or their human leukocyte antigen-DR, CD86, or CD71 expression. In contrast, the postoperative decrease in B lymphocytes and T-helper cells was significant in the PCEA group. Natural killer cells decreased significantly in patients receiving PCEA compared with PCIA. Therefore, postoperative epidural pain therapy has no influence on monocyte functions but reduces natural killer cells and preserves B-cell and T-helper cell populations. Epidural analgesia thus influences the specific rather than the innate immune system and potentially blunts the postsurgical lymphocyte depression, which is relevant for infectious resistance.

 

 

术前口服Rofecoxib减少经腹子宫切除病人术后疼痛和曲马多用量

Preoperative Oral Rofecoxib Reduces Postoperative Pain and Tramadol Consumption in Patients After Abdominal Hysterectomy

Beyhan Karamanlioglu, MD*, Alparslan Turan, MD*, Dilek Memis, MD*, and Mevlüt Türe, PhD{dagger} Section Editor

Department of *Anesthesiology and {dagger}Biostatistics, Trakya University, Medical Faculty, Edirne, Turkey

Anesth Analg 2004 98: 1039-1043.

 

我们设计本试验是为了确定术前给一剂量的rofecoxib对于接受经腹子宫切除术的病人是否可以减少病人自控镇痛(PCA)曲马多的应用或者能够加强镇痛作用。60例病人被随机分配到两个组,一个组术前口服50mg rofecoxib另一组口服安慰剂。所有的病人都接受标准的麻醉方法,并记录术中失血量。在手术结束时,所有病人都通过PCA装置静脉应用曲马多。在术后124681224小时对病人的疼痛评分、镇静评分、平均动脉压、心率和外周血氧饱和度进行评价。通过PCA装置记录同一时刻病人使用的曲马多的总量和追加用量。记录术后最初24小时镇吐药的用量和其他不良反应。还记录了病人的住院时间。在术后最初12小时内,rofecoxb组病人与安慰剂组病人相比,六个观察时间点疼痛评分均显著低于后者(P<0.05)。安慰剂组病人曲马多的总用量(627 ± 69 mg 535 ± 45 mg; P < 0.05)和追加用量在术后1246812小时时均显著多于rofecixb组的病人。两组间术中出血量、镇静评分、血流动力学参数、外周氧饱和度、镇吐药用量和术后不良反应均无差异。两组病人的住院时间也相同。我们的结论是,在接受经腹子宫切除术的病人,术前口服rofecoxib能够提供明显的镇痛效应,减少阿片类药物需求量。

(颜涛译, 李士通 校)

We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 ± 69 mg versus 535 ± 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.

 

蒽环类抗肿瘤药对麻醉期间心功能的影响

The Influence of Anthracycline Therapy on Cardiac Function During Anesthesia

Egbert Huettemann, MD, DEAA*, Thomas Junker, MD*, Kyriasis P. Chatzinikolaou, MD, Gritta Petrat, MD*, Samir G. Sakka, MD*, Lothar Vogt, MD, and Konrad Reinhart, MD* Section Editor

From the Departments of *Anesthesiology and Intensive Care Medicine and Pediatrics, University Hospital, Friedrich-Schiller-University, Jena, Germany; and Department of Intensive Care, Hippocration General Hospital, Thessaloniki, Greece

Anesth Analg 2004;98:941-947

 

蒽环类抗肿瘤(anthracycline AC)的主要不良反应是心脏毒性。儿童肿瘤患者使用该药后的生存者可遗留难以捉摸的心功能障碍,静息时正常,运动后心功能明显下降。为了解在用过AC的小儿患者与正常儿童和青少年比较,麻醉引起的心功能改变是否有区别,我们前瞻性地研究了43位患者,并对其中42例进行了分析。AC21例,平均年龄9.6岁(范围3-16岁),AC的平均累积剂量是193 mg/m2(范围30490 mg/m2),静息时心功能正常,收缩分数(SF0.34(正常值>0.3),在全麻下进行Hickman导管取出术。对照组(C组)21例,平均年龄10.9岁(范围4-17岁),化疗前行Hickman导管置入术。所有患者术前口服咪唑安定0.5 mg/kg,麻醉诱导采用硫喷妥钠5 mg/kg,芬太尼3 µg/kg,罗库溴铵0.6 mg/kg,麻醉维持用异氟醚1 MACN2O/O2 70/30)。选取以下四个时间点:诱导前(基础值),诱导后5分钟(T1),诱导后20分钟(T2),拔管后20分钟(对照值)。诱导前和拔管后采用经胸廓超声心动图,麻醉期间用经食道超声测量心功能。两组患者心功能的基础值无显著差异:SF 34.9 ± 3.7 AC组)比 34.1 ± 3.7 C组);每搏指数(SVI 36 ± 6 mL/m2AC组)比 35 ± 4 mL/m2C组);心指数(CI3.6 ± 0.6 L/min/m2AC组)比 3.2 ± 0.5 L/min/m2C组)。T1时和T2时两组的SF值和SVI均明显下降,AC组下降更明显:T1 SF:26.2 ± 3.6 AC组)比 28.6 ± 3.6 C组)(P < 0.05),SVI:26 ± 4 mL/m2 AC组)比 30 ± 46 mL/m2 C组)(P < 0.05); T2 SF:24.1 ± 3.2 AC组)比 28.2 ± 2.5 C组)(P < 0.01),SVI:26 ± 6 mL/m2 AC组)比 31 ± 5 mL/m2 [C]P < 0.01)。两组舒张功能(E/A比值,等容舒张时间)均无明显变化。静息时心功能正常的患者,过去的AC疗法能增强现在的麻醉药的心功能抑制作用。

(轩 泓 译 李士通 校)

Cardiotoxicity is a well recognized complication of anthracycline (AC) therapy. Subtle abnormalities in myocardial function that become apparent only after exercise may exist in survivors of childhood cancer who have previously received AC, yet have normal resting cardiac function. To evaluate if anesthesia-induced changes in cardiac function differ in pediatric patients with previous AC therapy from healthy children and adolescents, we evaluated in a prospective study 43 patients, of whom 42 were analyzed. Twenty-one patients (AC-group), mean age 9.6 yr (range, 316 yr), who had received 193 (30490) mg/m2 of AC as a mean cumulative dose with normal resting cardiac function (shortening fraction [SF] 0.34, normal value > 0.30) underwent removal of a Hickman catheter under general anesthesia. Twenty-one patients, mean age 10.9 yr (range, 417 yr), who underwent placement of a Hickman catheter before chemotherapy served as the control. All children were premedicated with midazolam 0.5 mg/kg orally. Anesthesia was induced by sodium thiopental (5 mg/kg), fentanyl (3 µg/kg), and rocuronium (0.6 mg/kg) and maintained with isoflurane (1 MAC) in N2O/O2 (70/30). Before induction (baseline), 5 and 20 min after intubation (T1 and T2), and 20 min after extubation (control), cardiac function was assessed by transthoracic (baseline, control) and transesophageal (T1, T2) echocardiography. Compared with baseline (SF: 34.9 ± 3.7 [AC], 34.1 ± 3.7 [C] [not significant]; stroke volume index [SVI] 36 ± 6 mL/m2[AC], 35 ± 4 mL/m2[C] [not significant]; cardiac index [CI] 3.6 ± 0.6 L/min/m2[AC], 3.2 ± 0.5 L/min/m2[C] [not significant]), we found a significant decrease in SF and SVI in both groups at T1 (SF: 26.2 ± 3.6 [AC] versus 28.6 ± 3.6 [C] [P < 0.05]; SVI: 26 ± 4 mL/m2 [AC] versus 30 ± 46 mL/m2 [C] [P < 0.05]) and T2 (SF: 24.1 ± 3.2 [AC] versus 28.2 ± 2.5 [C] [P < 0.01], SVI: 26 ± 6 mL/m2 [AC] versus 31 ± 5 mL/m2 [C] [P < 0.01]), which was significantly greater in the AC group. There were no significant changes of variables of diastolic function (E/A ratio, isovolumetric relaxation time) between both groups. Previous treatment with AC may enhance the myocardial depressive effect of anesthetics even in patients with normal resting cardiac function.

 

氯胺酮在内毒素血症的大鼠中低温和浅低温时的抗炎作用

The Antiinflammatory Effects of Ketamine in Endotoxemic Rats During Moderate and Mild Hypothermia

Takumi Taniguchi, MD*, Hiroko Kanakura, MD, Yasuhiro Takemoto, MD, and Ken Yamamoto, MD Section Editor

*Department of Emergency and Critical Care Medicine, and the Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medical Science, Kanazawa University, anazawa, Japan

Anesth Analg 2004 98: 1114-1120.

 

内毒素血症是危重病人的一个常见问题。我们以前的研究发现大鼠内毒素血症时氯胺酮能抑制低血压和代谢性酸中毒,增加血浆细胞素浓度。虽然内毒素血症的病人常发生低体温,但是氯胺酮在低体温时能否保持抗炎作用仍未确定。我们研究了氯胺酮对中低温和浅低温内毒素血症大鼠的作用。雄性Wistar大鼠(n = 100)用戊巴比妥钠腹腔内麻醉,分为两部分:一部分为中低温(30°C32°C)而另一部分为浅低温(33°C35°C)。每部分包括数量相同的5个小组:1) 正常体温埃希氏大肠杆菌内毒素(15 mg/kg IV)组;2)正常体温,在内毒素注射时和注射后注射氯胺酮组(10 mg kg-1 h-1 IV)3)低温生理盐水组;4)低温下注射内毒素(15 mg/kg IV)组;5)低温下注射内毒素后注射氯胺酮(10 mg kg-1 h-1 IV)组。然后通过加温或降温使实验大鼠直肠温度保持上述温度6小时。我们测量血流动力学,酸碱状况,血浆肿瘤坏死因子α和白介素-6的浓度。内毒素血症的大鼠发生了低血压和代谢性酸中毒,以及血浆细胞素浓度升高。在内毒素注射后6小时,盐水/正常体温/内毒素组的平均收缩压下降达71%,而氯胺酮/正常体温/内毒素组、盐水/中低温/内毒素组和氯胺酮/中等低温/内毒素组分别只下降6%, 41%29%。低温的内毒素血症大鼠注射氯胺酮,不论中低温或浅低温,均可减弱低血压,代谢性酸中毒和细胞素的增加,但这些作用并不优于单独低体温的效应。我们的发现提示,低温期间氯胺酮注射可能没有额外的有益的抗炎作用。

(吴俭译, 李士通校)

Endotoxemia is a common problem among critically-ill patients. We previously found that ketamine inhibited hypotension, metabolic acidosis, and increase of plasma cytokines during endotoxemia in rats. Although endotoxic patients often develop hypothermia, it has not been determined whether ketamine retains its antiinflammatory effects during hypothermia. We investigated the effects of ketamine on endotoxemic rats subjected to moderate and mild hypothermia.Male Wistar rats (n = 100) were anesthetized intraperitoneally with pentobarbital sodium and assigned to one of two protocols: one representing moderate hypothermia (30°C–32°C) and the other, mild hypothermia (33°C–35°C). Each protocol included 5 equal groups: 1) Escherichia coli endotoxin (15 mg/kg IV) in normothermia, 2) ketamine (10 mg • kg-1 • h-1 IV) during and after endotoxin injection in normothermia, 3) saline in hypothermia, 4) endotoxin (15 mg/kg IV) in hypothermia, and 5) ketamine (10 mg • kg-1 • h-1 IV) in hypothermia after endotoxin injection. Rats were then warmed or cooled to maintain rectal temperatures as above for 6 h. We assessed hemodynamics, acid-base status, and plasma concentrations of tumor necrosis factor-α, and interleukin-6. Endotoxemic rats developed hypotension and metabolic acidosis as well as increased plasma cytokine concentrations. At 6 h after endotoxin injection, the mean systolic arterial blood pressure decreased by 71% in the saline/normothermia/endotoxin group, whereas it decreased by only 6%, 41%, and 29% in the ketamine/normothermia/endotoxin, saline/moderate hypothermia/endotoxin, and ketamine/moderate hypothermia/endotoxin groups, respectively. Ketamine administration to endotoxemic rats with hypothermia, whether moderate or mild, also attenuated hypotension, metabolic acidosis, and cytokine increase, but these effects were not superior to those of hypothermia alone. Our findings suggest that, during hypothermia, ketamine administration may not have additive beneficial antiinflammatory effects.

 

硬膜外注射罗哌卡因和布比卡因用于分娩镇痛:一项关于产科预后的随机双盲试验

Epidural Infusions of Ropivacaine and Bupivacaine for Labor Analgesia: A Randomized, Double-Blind Study of Obstetric Outcome

Bee B. Lee, MBBS, FANZCA*, Warwick D. Ngan Kee, MBChB, MD, FANZCA*, Floria F. Ng, RN, BASc*, Tze K. Lau, MBBS, MD, MRCOG, and Eliza L. Y. Wong, RN, MPH*

*Department of Anaesthesia & Intensive Care and Department of Obstetric and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, China

Anesth Analg 2004 98: 1145-1152.

 

以往的试验表明分娩时进行硬膜外镇痛用0.25%的罗哌卡因较使用0.25%的布比卡因有更好的产科结果,但是对于此两种药物在更小浓度运用的情况下对产科预后影响是否有差别仍存在着争议。该试验为前瞻性双盲试验,将350ASA分级III级的头位单胎产妇随机分为罗哌卡因硬膜外镇痛组和布比卡因硬膜外镇痛组。镇痛初始采用0.25%的药液(罗哌卡因或布比卡因),维持采用0.1%的药液(罗哌卡因或布比卡因)复合0.0002%芬太尼。需要时给予0.25%的药液(罗哌卡因或布比卡因)作为补充剂量。按照医院标准产房协议处理分娩过程。在经阴道分娩的病人中,第一产程时间罗哌卡因组(中位数520分钟,四分位数间距377-745分钟)较布比卡因组(中位数645分钟,四分位数间距460-820分钟;P0.009)短,但是两组间其他的产科预后或新生儿预后没有差别。组间分娩方式相似,手术性分娩(经阴道器械辅助分娩及剖宫产)所占比例罗哌卡因组为61.8%(95%可信限为54.4-68.8%),布比卡因组为58.4%(95%可信限为50.9%65.5%)(P0.72)。

(周雅春译 李士通校)

Studies have shown better obstetric outcome when ropivacaine 0.25% was used for labor epidural analgesia compared with bupivacaine 0.25%, but it is controversial whether there is any difference at smaller concentrations. In a prospective, double-blind trial, we randomized 350 ASA physical status I and II parturients with term cephalic singleton pregnancies to receive epidural labor analgesia using ropivacaine or bupivacaine. Analgesia was initiated with a 0.25% solution and maintained with a continuous infusion of a 0.1% solution with fentanyl 0.0002%. Supplementary boluses of 0.25% solution were given when requested. Labor was managed according to institutional standard labor ward protocols. Among patients who delivered vaginally, the duration of the first stage of labor was shorter in the ropivacaine group (median, 520 min; interquartile range, 377–745 min) compared with the bupivacaine group (645 min; interquartile range, 460–820 min; P = 0.009), but there was no difference in any other obstetric or neonatal outcomes. The mode of delivery was similar between groups, with operative (instrumental vaginal and cesarean) delivery rates of 61.8% (95% confidence interval, 54.4%–68.8%) in the ropivacaine group and 58.4% (95% confidence interval, 50.9%–65.5%) in the bupivacaine group (P = 0.72).

 

青春期心脏手术后并发硬膜外血肿一例

An Epidural Hematoma in an Adolescent Patient After Cardiac Surgery

David A. Rosen, MD*,, Denzil W. Hawkinberry, II, MD*, Kathleen R. Rosen, MD*,, Robert A. Gustafson, MD,, Jeffery P. Hogg, MD, and Lynn M. Broadman, MD*,

Departments of *Anesthesiology, Pediatrics, Surgery, and Radiology, West Virginia University Children’s Hospital, West Virginia University School of Medicine, Morgantown

Anesth Analg 2004;98:966-969

 

一名18岁患者在全麻联合胸部硬膜外阻滞下行主动脉瓣置换术,置换瓣膜为生物瓣,手术过程顺利。术后第二天患者开始接受抗凝和抗血栓治疗,但是在行走时感觉后背疼痛,并发现硬膜外导管中有血。导管取出后,患者出现运动和感觉功能缺失。立即行椎管减压术后神经系统功能恢复正常。就此类问题如何预防和处理进行了讨论。

提示:硬膜外血肿是硬膜外麻醉中一种少见的并发症,在儿科心脏手术中未见报道。此类并发症能否处理成功的关键是及早发现,诊断和手术治疗。

(张俊杰译, 李士通校)

An 18-yr-old patient had a thoracic epidural placed under general anesthesia preceding an uneventful aortic valve replacement with a bioprosthetic valve. On the second postoperative day, he was anticoagulated and also received an antithrombotic medication. While ambulating, he experienced pain in his back, and there was blood in his epidural catheter. The catheter was removed, and he developed motor and sensory loss. Rapid surgical decompression resulted in recovery of his lost neurological function. Management and strategies for preventing this problem are discussed.

IMPLICATIONS: Epidural hematoma is a rare complication of epidural anesthesia and has not been reported in pediatric patients undergoing cardiac surgery. The successful treatment of this complication requires swift recognition, diagnosis, and surgical intervention.

 

芬太尼对大鼠阿心室肌细胞内钙离子和细胞收缩性的作用

The Effects of Alfentanil on Cytosolic Ca2+ and Contraction in Rat Ventricular Myocytes

Mark D. Graham, BSc*, Philip M. Hopkins, MD{dagger}, and Simon M. Harrison, PhD*

Address correspondence and reprint requests to Simon M. Harrison, PhD, School of Biomedical Sciences, University of Leeds, Leeds, LS2 9JT, UK.

Anesth Analg 2004;98:1013-1016

先前有关阿片类镇痛药对心脏作用的研究多集中于其对心肌收缩程度和时程的影响,而他们对心肌细胞内Ca2+的作用研究甚少。在本实验中我们以酶消化和分离大鼠心室细胞,研究阿芬太尼对心肌收缩和细胞内瞬时Ca2+的影响。以fura-2负载心肌细胞,并以1Hz电流刺激细胞,在30°C记录细胞内瞬时Ca2+流和心肌收缩程度。10-810-7M阿芬太尼对细胞收缩的幅度和时程以及细胞内瞬时Ca2+流均无影响。然而,10-6M阿芬太尼引起细胞明显的正性变力作用(P<0.001,平均无负荷缩短从7.3 ± 1.3 µm to 8.7 ± 1.4 µm(±SEM),即增加了20%。但对细胞内瞬时Ca2+流无影响。10-6M阿芬太尼可提高肌纤维对Ca2+敏感性(P = 0.027),而 10-7M阿芬太尼无此作用。以上数据表明10-6M阿芬太尼(此浓度接近阿芬太尼临床最大血浆浓度)能引起正性变力作用的机制是肌纤维对Ca2+敏感性增高而不是增加细胞内Ca2+浓度。

(赵雪莲 译 李士通 校)

Previous investigations of the effects of potent opioid analgesics on the heart have concentrated on effects on contraction magnitude and time course, but little is known about their effects on cytosolic Ca2+ regulation in cardiac tissue. In this study, we sought to assess the effects of alfentanil on contractility and the cytosolic Ca2+ transient in ventricular myocytes isolated from the rat ventricle by enzymatic dispersion. Cells were loaded with fura-2 and electrically stimulated at 1 Hz, and Ca2+ transients and contractions were recorded optically at 30°C. Alfentanil 10-8 and 10-7 M had no effect on the magnitude or time course of contraction or the cytosolic Ca2+ transient. In contrast, 10-6 M alfentanil induced a significant (P < 0.001) positive inotropic effect, increasing the mean (±SEM) unloaded shortening from 7.3 ± 1.3 µm to 8.7 ± 1.4 µm (an increase of 20%), with no change in the cytosolic Ca2+ transient. Myofilament Ca2+ sensitivity was significantly (P = 0.027) increased by 10-6 M alfentanil but unaffected at 10-7 M alfentanil. These data show that 10-6 M alfentanil, a concentration close to the maximum clinical free plasma concentration, induced a positive inotropic effect due to sensitization of the myofilaments to Ca2+ rather than to modified cytosolic Ca2+ regulation.


术前口服右美沙芬可减轻全麻下行膝关节十字韧带再造术中止血带引起的动脉血压和心率的增加

Preoperative Oral Dextromethorphan Attenuated Tourniquet-Induced Arterial Blood Pressure and Heart Rate Increases in Knee Cruciate Ligament Reconstruction Patients Under General Anesthesia

Anesth Analg 2004 98: 994-998.

Soichiro Yamashita, MD*, Hiroshi Yamaguchi, MD, Yu Hisajima, MD*, Kazuhiro Ijima,MD*,Kaori Saito, MD*, Ai Chiba, MD*, and Toru Yasunaga, MD{ddagger}

Departments of *Anesthesia and Critical Care Medicine and Orthopedics, Iwaki Kyoritsu General Hospital, Iwaki, Fukushima, Japan; and Department of Anesthesia, Ryugasaki Saiseikai Hospital, Ryugasaki, Ibaraki, Japan

 

止血带引起的动脉血压增高的机理还不清楚。我们观察了术前口服右美沙芬对于全麻下行膝关节十字韧带重建术的病人在术中使用止血带所引起的动脉血压以及心率的变化。在麻醉前2小时右美沙芬组(n38)病人服用右美沙芬30mg。对照组(n38)病人口服安慰剂。麻醉以2.0%七氟醚67N2O维持,术中气管插管直到手术结束。动脉血压和心率分别在止血带充气03060分钟进行测定。对照组60分钟时动脉收缩压和心率都明显高于右美沙芬组组。(分别为:131.1 ± 15.8 mm Hg 123.6 ± 15.9 mm Hg [P < 0.05] 74.1 ± 11.3 bpm 67.8 ± 8.5 bpm [P < 0.01],)右美沙芬组的动脉收缩压和心率增加的百分率也较对照组小。结论,术前口服右美沙芬组30mg能明显降低全麻下膝十字韧带重建术中病人使用止血带所引起的病人心率和动脉血压的增加。

(沈浩 译 李士通 校)

The precise mechanism of tourniquet-induced arterial blood pressure increase is unknown. We determined the effect of preoperative oral dextromethorphan (DM) on arterial blood pressure and heart rate changes during tourniquet inflation in knee cruciate ligament reconstruction patients under general anesthesia. Patients in the DM group (n = 38) received oral DM 30 mg, and patients in the control group (n = 38) received oral placebo 2 h before the induction of anesthesia. Anesthesia was maintained with sevoflurane 2.0% and N2O in 33% oxygen, and the trachea was intubated until the end of surgery. Arterial blood pressure and heart rate were measured at 0, 30, and 60 min after the start of tourniquet inflation. Systolic arterial blood pressure and heart rate at 60 min in the control group were significantly more than those in the DM group (131.1 ± 15.8 mm Hg versus 123.6 ± 15.9 mm Hg [P < 0.05] and 74.1 ± 11.3 bpm versus 67.8 ± 8.5 bpm [P < 0.01], respectively). The percentage increase in systolic arterial blood pressure and heart rate in the DM group was also attenuated when compared with that in the control group (P < 0.05). In conclusion, preoperative oral DM 30 mg significantly attenuated arterial blood pressure and heart rate increases during tourniquet inflation under general anesthesia.

鞘内应用吗啡减少缺血-再灌注损伤大鼠模型的心梗面积

Intrathecal Morphine Reduces Infarct Size in a Rat Model of Ischemia-Reperfusion Injury

Leanne Groban, MD, Jason C. Vernon, BS, MBA, and John Butterworth, MD

From the Department of Anesthesiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina

Anesth Analg 2004 98: 903-909.

 

全身性应用吗啡减少心肌缺血再灌注损伤大鼠模型的梗死面积。我们试图探索脊髓腔内应用极少量的吗啡具有相似的心肌保护作用。Wistar 大鼠以巴比妥酸麻醉,开放胸腔,留置长期胸腔内管,并予血流动力学监测下闭塞冠脉30min后恢复灌注90min。以triphenyl-tetrazolium 染色来确定心肌梗塞面积。大鼠随机分为四组分别于闭塞前20min予鞘内(IT0.9% NS(对照组)、IV吗啡(0.3 mg/kg+IT NSIT吗啡(0.3 µg/kg)IT吗啡(3 µg/kg)。与对照组相比另外三组均可减少梗死面积,以梗死面积占危险心肌面积的百分比(%AN/AAR)表示。%AN/AAR 值分别如下:IV(n = 7), 30% ± 6%; ITsmall-dose (n = 9), 30% ± 5%; ITlarge-dose (n = 9), 18% ± 4%;对照组 (n = 10), 47% ± 5%.预防性应用吗啡的大鼠之间心肌梗死面积无显著区别。缺血再灌注期间ITlarge-dose 组心率无明显改变,而ITsmall-dose组,IV组及对照组心率出现了显著的下降。各组之间血压改变无明显区别。这些结果表明鞘内应用吗啡可减少大鼠心梗面积且效果与静脉应用吗啡相近。

(钟鸣 译 薛张纲 校)

Systemically-administered morphine reduces infarct size in rat models of myocardial ischemia-reperfusion. We sought to determine whether much smaller doses of spinally-administered morphine offer a similar cardioprotective benefit. Barbiturate-anesthetized, open-chested, Wistar rats with chronic indwelling thoracic intrathecal catheters were instrumented for hemodynamic measurements and subjected to 30 min of coronary occlusion and 90 min of reperfusion. Myocardial infarct size was determined using triphenyl-tetrazolium staining. Rats were randomly assigned to receive intrathecal (IT) 0.9% saline (vehicle), IV morphine (0.3 mg/kg) plus IT saline, small-dose IT morphine (0.3 µg/kg), or large-dose IT morphine (3 µg/kg) 20 min before occlusion. IV and both doses of IT morphine reduced infarct size, defined as area of necrosis expressed as a percentage of area at risk (%AN/AAR), as compared with vehicle. The %AN/AAR group means were as follows: IV (n = 7), 30% ± 6%; ITsmall-dose (n = 9), 30% ± 5%; ITlarge-dose (n = 9), 18% ± 4%; and vehicle (n = 10), 47% ± 5%. There were no significant differences in infarct size among the morphine-pretreated rats. During ischemia-reperfusion, heart rate was unchanged from baseline in the ITlarge-dose group, whereas in the ITsmall-dose, IV and vehicle groups, significant declines in heart rate occurred. Changes in arterial blood pressure were similar among groups. These results indicate that IT morphine reduces infarct size in rats, and this benefit is as great as that provided by IV morphine administration.

 

择期肝切除术需用异体血患者中应用促红细胞生成素的作用:一项模拟模型

The Effect of Erythropoietin on Allogeneic Blood Requirement in Patients Undergoing Elective Liver Resection: A Model Simulation

 

Claude Lentschener, MD*, Alexandra Gomola, MD*, Sophie Grabar, MD{dagger}, Olivier Soubrane, MD{ddagger}, Bertrand Dousset, MD{ddagger}, Pierre-Philippe Massault, MD{ddagger}, Catherine Penhoud*, and Yves Ozier, MD*

*Departments of Anesthesia and Critical Care, {dagger}Biostatistics, and {ddagger}Surgery, Université Paris V-René Descartes, Hôpital Cochin, Paris, France

Anesth Analg 2004 98: 921-926.

 

我们观察择期肝切除术患者应用重组人促红细胞生成素(rHuEPO)可减少红细胞输注需求。共回顾了200例择期肝切除术患者,以逻辑衰减分析围手术期红细胞输注的可能预见因素。构建一个数学模型来模拟红细胞输注需求:a)输注阈值设为Hb78 g/dL b)术前Hb1013 g/dL 的患者应用rHuEPO 使其Hb术前提高至15 g/dL c)以上两种方式合用。并对rHuEPO的应用行费用/效果评价。红细胞输注与肝大部或小部切除、全肝血流阻断、联合腹部非肝手术有关,而与术前Hb1013g/dL无关。应用小的输注阈值或单独应用rHuEPO仅轻度减少红细胞输注量及输注频率,而联合应用两种干预方法将显著减少以上两个变量。118位行肝部分或大部切除术患者92%接受红细胞输注。这118位患者中66位术前Hb1013g/dL并于术前应用了rHuEPO。单独应用rHuEPO避免了203位患者中的63位输注红细胞,以及31位患者中12位输注红细胞(P = 0.02)。这66位患者应用rHuEPO耗费186,000欧元,而避免63位患者输注红细胞仅节约10,710欧元。

(钟鸣 译 薛张纲 校)

We investigated whether recombinant human erythropoietin (rHuEPO) administration would reduce red blood cell (RBC) transfusion requirements in patients undergoing elective liver resection. We retrospectively investigated 200 patients undergoing elective liver resection. Factors likely to predict perioperative RBC transfusion were studied using a logistic regression analysis. A mathematical model was used to simulate RBC transfusion requirements if (a) transfusion thresholds had been predefined at a hemoglobin concentration of 7–8 g/dL, (b) preoperative hemoglobin concentrations had been increased to 15 g/dL by rHuEPO administration in patients with preoperative hemoglobin concentration in the range 10–13 g/dL, and (c) both interventions had been used. A cost/benefit evaluation of rHuEPO administration formed part of this simulation. RBC transfusion was correlated with major and median liver resection, total liver vascular exclusion, and a combined nonhepatic abdominal surgery but was not correlated with a preoperative hemoglobin concentration in the range 10–13 g/dL. Adherence to a small transfusion threshold or rHuEPO administration alone would have resulted in a slight reduction in transfusion requirements and transfusion rates for the whole population. However, the two interventions in combination would have significantly reduced both variables. One-hundred-eighteen patients undergoing median and major liver resection received 92% of RBC transfused. Sixty-six of these 118 patients had preoperative hemoglobin concentrations in the range 10–13 g/dL and could have received rHuEPO before surgery. rHuEPO alone would have avoided the transfusion of 63 RBC packs of 203 in this subgroup and 12 transfused patients of 31 (P = 0.02). rHuEPO administration to these 66 patients would have cost 186,000 Euro. The 63 RBC saved would have cost 10,710 Euro.

 

小儿脊柱术后鞘内及硬膜外镇痛的回顾

Review of Intrathecal and Epidural Analgesia After Spinal Surgery in Children

Joseph D. Tobias, MD

From the Departments of Child Health and Anesthesiology and the Division of Pediatric Critical Care/Pediatric Anesthesiology, The University of Missouri, Columbia, Missouri

Anesth Analg 2004 98: 956-965

 

鉴于区域麻醉技术应用于控制婴幼儿术后疼痛的经验,大型矫形外科如前、后入路脊柱融合术后应用区域麻醉镇痛具有相似的有效性及安全性。我回顾了儿科脊柱手术后应用神经阻滞镇痛的相关报道。手术方式及麻醉方法的差异使得对照研究难以实施。麻醉方法的差异包括:1)剂量;2)给药途径如鞘内或硬膜外;3)给药方法(单剂、间断给药、持续注药);4)硬膜外导管数量(一或二根);5)注射药物(阿片类、局麻药或二药合用);6)阿片药物种类(吗啡、芬太尼、水合吗啡);7)麻醉镇痛控制组(间断按需注射吗啡或病人自控麻醉)。虽然尚无足够数据证明此种麻醉技术优于肠道外应用阿片类药物,但临床数据确证了其他的优点包括减少术中失血量及肠道功能早期恢复。

(钟鸣目译 薛张纲 校)

In view of the overall experience regarding regional anesthetic techniques to control postoperative pain in infants and children, it is feasible that a similar efficacy and safety profile can be obtained when using such techniques after major orthopedic procedures such as anterior or posterior spinal fusion. I reviewed previous reports regarding the use of neuraxial techniques to provide analgesia after spine surgery in the pediatric population. Variations in both the surgical procedure and the analgesic technique may make the comparison among studies somewhat impractical. Variations of the analgesic technique include 1) the dose of the medications used; 2) the route of delivery (intrathecal or epidural); 3) the mode of delivery (single dose, intermittent bolus dosing, and continuous infusion); 4) the number of epidural catheters used (one versus two); 5) the medications infused (opioids, local anesthetics, or both); 6) the opioid used (morphine, fentanyl, hydromorphone); and 7) the analgesic regimen of the control group (intermittent "as needed" morphine or patient-controlled analgesia). Although limited data are available to document the analgesic superiority of these techniques over parenteral opioids, clinical data offer evidence of other benefits, including decreased intraoperative blood loss and quicker return of gastrointestinal function.

 

Modafinil改善全麻后恢复

Modafinil improves recovery after general anesthesia.

Larijani GE, Goldberg ME, Hojat M, Khaleghi B, Dunn JB, Marr AT.

Department of Anesthesiology, University of Medicine and Dentistry of New Jersey, Cooper Health System, Camden, New Jersey 08103, USA.

Anesth Analg 2004 98: 976-981

 

全麻后恢复常有残余镇静、嗜睡、疲劳和乏力,这些将持续几小时到几天。Modafinil是治疗发作性睡眠症(白天过分嗜睡)病人,有助于促进觉醒的药物。我们评估了全麻后恢复病人使用单剂量modafinil (200 mg)和安慰剂的效果。经IRB同意,34个病人进入到此项前瞻性、随机化和双盲性的研究。术前,使用VAS量表要求病人评估此前24小时他们的各种症状,此量表为010的不连续标度量表。术后,一旦病人可以口服并符合制度标准,就给予一小口水服用研究的药物(modafinil 200 mg 或安慰剂)。给药后24小时接触病人以评估给药后的症状。安慰剂组病人反应术后明显更疲劳(4.8 [3.3] 对比 1.4 [1.8]),更疲惫(4.3 [3.3] 对比 2.4 [3.1]),或更感到筋疲力尽(4.7 [3.6] 对比 2.9 [2.4])。很明显,安慰剂组的病人更多出现中到重度的疲劳(65% 对比 12%)。在“敏捷”和“精神”两个主要项目中,服用modafinil的病人有71%,而服用安慰剂组只有18%Modafinil明显有助于全麻后病人恢复。

(陆旭伟 译 薛张纲 校)

Recovery from general anesthesia often involves residual sedation, drowsiness, fatigue, and lack of energy that may last hours to days. Modafinil is a wakefulness-promoting drug approved for patients with excessive daytime sleepiness associated with narcolepsy. We evaluated the effect of single doses of modafinil (200 mg) and placebo in patients recovering from general anesthesia. Thirty-four subjects participated in this prospective, randomized, double-blind study approved by our IRB. Preoperatively, patients were asked to rate various symptoms they had experienced over the previous 24-h using a verbal analog scale (VAS) of 0 to 10 as well as discrete scale when indicated. Postoperatively, once the patient was able to tolerate oral intake and met our institutional discharge criteria, the study drug (modafinil 200 mg or placebo) was administered with a sip of water. Patients were contacted 24 (1) hours after dosing to evaluate postdischarge symptoms. Patients in the placebo group reported significantly more postoperative fatigue (4.8 [3.3] versus 1.4 [1.8]), exhaustion (4.3 [3.3] versus 2.4 [3.1]), or degree of feeling worn out (4.7 [3.6] versus 2.9 [2.4]). Significantly more patients reported moderate to severe fatigue in the placebo group (65% versus 12%). Two major themes of "alertness" and "energy" were expressed by 71% of the patients receiving modafinil versus 18% of those receiving placebo. Patients recovering from general anesthesia can significantly benefit from modafinil.

 

比较七氟醚和异氟醚复合笑气和硬膜外阻滞麻醉下肝硬化病人行肝切除术后的肝功能

A comparison of liver function after hepatectomy in cirrhotic patients between sevoflurane and isoflurane in anesthesia with nitrous oxide and epidural block.

Nishiyama T, Fujimoto T, Hanaoka K.

Department of Anesthesiology, The University of Tokyo, Tokyo, Japan.

Anesth Analg 2004 98: 990-993.

 

在本研究中,我们比较了肝硬化病人在异氟醚和七氟醚复合笑气和硬膜外麻醉下术后肝功能的情况。40Child-Pugh分级为A4070岁、准备行肝部分切除的病人,使用0.1 mg/kg的咪达唑仑和4 mg/kg的芬太尼行麻醉诱导,麻醉维持使用硬膜外间歇注入1.5%的利多卡因46 mL、七氟醚或异氟醚、3 L/min的笑气和3 L/min的氧气。术前和术后的137天测量天门冬氨酸转氨酶、丙氨酸转氨酶、总胆红素、碱性磷酸酶、胆碱酯酶、白蛋白、凝血酶原时间和血小板计数。两组病人的天门冬氨酸转氨酶、丙氨酸转氨酶和碱性磷酸酶都在术后第3天显著升高并达峰值。异氟醚组的这些变量的升高显著大于七氟醚组。没有病人发展为肝功能衰竭。所有肝酶的升高都很小并且无可疑的临床相关性。对于肝硬化病人的肝损害方面,复合笑气和硬膜外阻滞时使用七氟醚是否优于异氟醚尚无定论。结论:在Child-Pugh分级为A的肝硬化病人,复合笑气和硬膜外阻滞时异氟醚引起的术后血清肝酶浓度的升高较七氟醚大。然而这种升高是很小的,不会导致临床肝损害。

(陆旭伟 译 薛张纲 校)

In this study, we compared postoperative liver function in patients with liver cirrhosis between isoflurane and sevoflurane anesthesia with nitrous oxide (N(2)O) and epidural block. Forty cirrhotic patients with Child-Pugh Grade A, aged 40 to 70 yr, scheduled for liver segmentectomy, had anesthesia induced with midazolam 0.1 mg/kg and fentanyl 4 micro g/kg. For maintenance, intermittent epidural administration of 1.5% lidocaine 4 to 6 mL and sevoflurane (sevoflurane group) or isoflurane (isoflurane group) with N(2)O 3 L/min in oxygen 3 L/min was used. Aspartate aminotransferase, alanine aminotransferase, total bilirubin, alkaline phosphatase, choline esterase, albumin, prothrombin time, and platelet count were measured before and 1, 3, and 7 days after surgery. Aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased significantly, with the peaks at 3 days after surgery in both groups. The increases in these variables were significantly larger in the isoflurane group than those in the sevoflurane group. No patient developed hepatic failure. All increases in liver enzymes were small and of questionable clinical relevance. Whether sevoflurane might be a better anesthetic when combined with N(2)O and epidural block for cirrhotic patients than isoflurane with respect to live

 

氙气和异氟醚在调节LPS介导的NF-κB活性和单核细胞TNF-αIL-6生成方面的不同

Xenon and isoflurane differentially modulate lipopolysaccharide-induced activation of the nuclear transcription factor KB and production of tumor necrosis factor-alpha and interleukin-6 in monocytes.

de Rossi LW, Brueckmann M, Rex S, Barderschneider M, Buhre W, Rossaint R.

Department of Anesthesiology, University Hospital, Rheinisch-Westfalische Technische Hochschule Aachen, Germany.

Anesth Analg 2004 98: 1007-1012

 

麻醉药已知可干扰炎性细胞因子的生成。在本研究中,我们研究了氙气和异氟醚在体外试验中对LPS介导的NF-κB活性和TNF-αIL-6生成的影响。在含有或不含氙气(30 60 Vol%)或异氟醚(1 2 MAC)的全血中培养LPS4小时后测定离心血清中的TNF-αIL-6含量。使用从血液样本中分离出的单核细胞来研究NF-κB,待整个细胞溶解后,用测定NF-κB的酶联免疫吸附剂试剂盒来测定结合到靶定DNANF-κB p50 p65亚单位的量。相对于对照组,含氙气组中LPS介导的TNF-αIL-6的生成及NF-κB的活性均有显著升高;与之相反,异氟醚抑制NF-κB的活性,这与TNF-α和IL-6生成减少有关。我们的结果显示:氙气和异氟醚在LPS介导的TNF-α和IL-6生成方面有着相反的作用,此外,氙气升高NF-κB的活性,而异氟醚则抑制,这可能为两者对单核细胞生成TNF-α和IL-6作用的不同影响提供了分子机制。

(陆旭伟 译 薛张纲 校)

Anesthetics are known to interfere with the production of inflammatory cytokines. In this study, we investigated the effect of xenon and isoflurane on the lipopolysaccharide (LPS)-induced activation of the nuclear transcription factor (NF)-kappaB and production of tumor necrosis factor (TNF)-alpha and interleukin (IL)-6 in vitro. Whole blood was incubated with LPS in the absence or presence of the either xenon (30 and 60 Vol%) and isoflurane (1 and 2 minimum alveolar anesthetic concentration [MAC]). After 4 h, TNF-alpha and IL-6 were assayed in the supernatant. Involvement of NF-kappaB was investigated using isolated monocytes from the blood samples. Whole-cell lysates were prepared, and binding of the NF-kappaB p50 and p65 subunit to its target DNA were measured with an enzyme-linked immunosorbent assay-based NF-kappaB kit. LPS-induced production of TNF-alpha and IL-6 as well as activation of NF-kappaB were significantly increased in the presence of xenon compared with controls. In contrast, isoflurane inhibited the activation of NF-kappaB, which was associated with a decreased production of TNF-alpha and IL-6. Our results demonstrate that xenon and isoflurane have opposite effects on the LPS-induced production of TNF-alpha and IL-6. Furthermore, xenon increases, whereas isoflurane inhibits the activation of NF-kappaB, providing a possible molecular mechanism for the different effects on monocyte TNF-alpha and IL-6 production.

 

局麻药对单核细胞mCD14和人类白细胞抗原-DR表达的影响

The Effect of Local Anesthetics on Monocyte mCD14 and Human Leukocyte Antigen-DR Expression

Takashi Kawasaki, MD, Chika Kawasaki, MD, Masanori Ogata, MD, and Akio Shigematsu, MD

Department of Anesthesiology, University of Occupational and Environmental Health, Kitakyushu, Japan

Anesth Analg 2004;98:1024-9

 

现已证明局麻药对免疫系统有多重作用。单核细胞和巨嗜细胞是对微生物感染的宿主反应的必要组份;然而,局麻药对单核细胞表面受体的表达仍不清楚。我们设计了该试验以研究局麻药对单核细胞mCD14和人类白细胞抗原(HLA)-DR表达以及脂多糖(LPS)或葡萄球菌肠毒素B(SEB)诱导的肿瘤坏死因子(TNF){alpha}产生的影响。从10名健康志愿者抽取血标本。局麻药对LPSSEB诱导的TNF{alpha}产生的影响通过酶联免疫吸附实验来检测。在给予不同剂量的局麻药后,血液被LPS10ng/mL)或SEB10ug/mL)刺激4小时。局麻药对单核细胞mCD14HLADR表达的影响通过双单克隆抗体染色和流式细胞分析来检测。局麻药并未显示对人类全血LPSSEB诱导的TNF{alpha}的产生有何影响。局麻药对单核细胞HLADR表达呈剂量依赖性抑制(P<0.05)但对单核细胞mCD14表达无影响。该试验证明了局麻药对人类单核细胞表面HLADR的表达有抑制作用。

(周晓敏 译 薛张纲 校)

It has been demonstrated that local anesthetics have several effects on the immune system. Monocytes and macrophages are essential components of the host response to microbial infection; however, the effect of local anesthetics on monocyte surface receptor expression remains unclear. We designed this study to investigate the effects of local anesthetics on monocyte mCD14 and human leukocyte antigen (HLA)-DR expression and lipopolysaccharide (LPS)-induced or staphylococcal enterotoxin B (SEB)-induced tumor necrosis factor (TNF)-{alpha} production. Blood samples were obtained from 10 healthy volunteers. The effects of local anesthetics on LPS- or SEB-induced TNF-{alpha} production were determined by using an enzyme-linked immunosorbent assay. After different doses of local anesthetics were added, the blood was stimulated with LPS (10 ng/mL) or SEB (10 µg/mL) for 4 h. The effects of local anesthetics on monocyte mCD14 and HLA-DR expression were measured by dual monoclonal antibody staining and flow cytometry. Local anesthetics showed no effect on LPS- or SEB-induced TNF-{alpha} production in human whole blood. Local anesthetics suppressed monocyte HLA-DR expression in a dose-dependent manner (P < 0.05) but had no effect on monocyte mCD14 expression. This study demonstrated that local anesthetics suppress HLA-DR expression on the surface of human monocytes.

 

围术期静脉注射利多卡因对腹部大手术术后疼痛和吗啡消耗有预防作用

Perioperative Intravenous Lidocaine Has Preventive Effects on Postoperative Pain and Morphine Consumption After Major Abdominal Surgery

Wolfgang Koppert, MD*, Marc Weigand, MD*, Frank Neumann, MD*, Reinhard Sittl, MD*, Jürgen Schuettler, MD*, Martin Schmelz, MD, and Werner Hering, MD

Department of Anesthesiology, University of Erlangen, Erlangen, Germany; Department of Anesthesiology Mannheim, University of Heidelberg, Mannheim, Germany; and Department of Anesthesiology, St. Marien Hospital Siegen, Siegen, Germany

Anesth Analg 2004;98:1050-1055

 

钠通道阻滞剂已被认可静脉内给予以治疗神经性疼痛状态。亚临床研究已提示抗痛觉过敏药物影响外周和中枢神经系统。本研究目的在于检测围手术期给予利多卡因的镇痛和抗痛觉过敏的经时反应进程机制。40名将行大型腹部手术的病人参与了该项随机双盲试验。20名患者接受了2%的利多卡因(首剂1.5mg/kg10分钟内注射,随后以1.5 mg • kg-1 • h-1的速度维持),另20名患者接受了生理盐水安慰剂。注射在切皮前30分钟开始,手术结束后1小时结束。我们检测了利多卡因的血药浓度。至术后72小时评估了术后疼痛分级(010级的数字分级量表)和吗啡的消耗量。手术期间平均利多卡因浓度为1.9 ± 0.7 µg/mL。病人自控镇痛获得满意的效果(静止时的数字化分级量表,<= 390%-95%;无组间差异)。接受利多卡因的病人主诉在术后首个72小时运动时较少的疼痛和需要更少的吗啡(103.1 ± 72.0 mg对应159.0 ± 73.3 mgStudent’s t-test; P < 0.05)。因为这种减少阿片类药物的作用几乎都在术后第三天明显,故利多卡因可能确实存在预防性镇痛作用,而从临床相关的角度来讲极有可能是通过预防中枢性痛觉过敏的方式发挥这种作用。

(周晓敏 译 薛张纲 校)

Sodium channel blockers are approved for IV administration in the treatment of neuropathic pain states. Preclinical studies have suggested antihyperalgesic effects on the peripheral and central nervous system. Our objective in this study was to determine the time course of the analgesic and antihyperalgesic mechanisms of perioperative lidocaine administration. Forty patients undergoing major abdominal surgery participated in this randomized and double-blinded study. Twenty patients received lidocaine 2% (bolus injection of 1.5 mg/kg in 10 min followed by an IV infusion of 1.5 mg • kg-1 • h-1), and 20 patients received saline placebo. The infusion started 30 min before skin incision and was stopped 1 h after the end of surgery. Lidocaine blood concentrations were measured. Postoperative pain ratings (numeric rating scale of 0–10) and morphine consumption (patient-controlled analgesia) were assessed up to 72 h after surgery. Mean lidocaine levels during surgery were 1.9 ± 0.7 µg/mL. Patient-controlled analgesia with morphine produced good postoperative analgesia (numeric rating scale at rest, <=3; 90%–95%; no group differences). Patients who received lidocaine reported less pain during movement and needed less morphine during the first 72 h after surgery (103.1 ± 72.0 mg versus 159.0 ± 73.3 mg; Student’s t-test; P < 0.05). Because this opioid-sparing effect was most pronounced on the third postoperative day, IV lidocaine may have a true preventive analgesic activity, most likely by preventing the induction of central hyperalgesia in a clinically relevant manner.

 

关节镜膝部手术后关节内给予苏芬太尼和苏芬太尼加甲强龙的镇痛作用

Analgesic Effects of Intraarticular Sufentanil and Sufentanil Plus Methylprednisolone After Arthroscopic Knee Surgery

Mehmet Kizilkaya, MD*, Omer Selim Yildirim, MD, Nazim Dogan, MD*, Husnu Kursad, MD*, and Ali Okur, MD

Departments of *Anesthesiology and Reanimation and Orthopaedic Surgery, The School of Medicine, Ataturk University, Erzurum, Turkey

Anesth Analg 2004;98:1062-1065

 

我们研究了在膝关节镜半月板切除术后关节内给予生理盐水、苏芬太尼和苏芬太尼加甲强龙的作用。在一项随机双盲试验中,60名患者被分配到全麻关节镜结束时关节内给予生理盐水组、苏芬太尼10ug组和苏芬太尼10ug加甲强龙40mg组。术后,病人静止和运动时(例如,主动曲膝)时的疼痛水平通过一个可视化的模拟量表来评测,结果显示同对照组相比,苏芬太尼和苏芬太尼加甲强龙组的疼痛水平明显下降。此外,我们还发现在膝关节镜半月板切除术后使用关节内给予苏芬太尼和苏芬太尼加甲强龙后能使术后早期镇痛剂的需要量下降。另外,同对照组相比,我们发现苏芬太尼的镇痛作用能延长至24小时,然而当我们联合使用苏芬太尼加甲强龙时,我们发现疼痛和镇痛剂的用量比使用苏芬太尼时进一步下降了。

(周晓敏 译 薛张纲 校)

We studied the effect of intraarticular saline, sufentanil, or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy. In a double-blind randomized study, 60 patients undergoing knee arthroscopic meniscectomy were allocated to groups receiving intraarticular saline, intraarticular sufentanil 10 µg, or sufentanil 10 µg plus methylprednisolone 40 mg at the end of arthroscopy during general anesthesia. Postoperatively, pain levels at rest and during movement (i.e., active flexion of the knee) were measured by a visual analog scale and were significantly decreased in the sufentanil and sufentanil plus methylprednisolone groups compared with the control group. Moreover, we found that there was a significant reduction in intraarticular sufentanil and sufentanil plus methylprednisolone in the postoperative consumption of analgesics. We also found that the use of intraarticular sufentanil or sufentanil plus methylprednisolone after knee arthroscopic meniscectomy decreases the amount of supplementary analgesic needed for pain relief during the early postoperative period. In addition, we detected that sufentanil provided prolonged pain relief up to 24 h when compared with control, whereas when we combined sufentanil plus methylprednisolone, we found that it further reduced pain and use of analgesics when compared with sufentanil.

 

酰水杨酸盐、二氯芬酸和芬诺昔而非罗非考昔影响血小板CD62表达

Acetylsalicylic Acid, Diclofenac, and Lornoxicam, but Not Rofecoxib, Affect Platelet CD 62 Expression

Alex M. Blaicher, MD, Harald T. Landsteiner, ME Olga Al-Falaki, CM, Jochen Zwerina, CM, Ivo Volf, PhD, Diego Gruber, MS Michael Zimpfer, MD, MBA*, , and Klaus Hoerauf, MD, PhD

Department of Anesthesiology and General Intensive Care, University of Vienna; Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care; Institute of Medical Physiology, University of Vienna; and Department of Medical Statistics, University of Vienna, Vienna, Austria

Anesth Analg 2004;98:1082-1085

 

非甾体类抗炎药作为常规在围手术期使用。由于血小板内缺乏环氧化酶,所以环氧化酶2选择性药物被认为没有血小板抑制作用。由于血小板在凝血过程中扮演重要角色,故若无血小板抑制可能减少术后出血并发症。我们通过流式细胞分析研究阿司匹林、二氯芬酸、芬诺昔康和罗非考昔布对花生四烯酸和胶原诱导的CD62(P选择)表达。68名志愿者在口服摄入由研究随机设计的药物前和之后的1、3、12小时抽血。阿司匹林、二氯芬酸、芬诺昔康对血小板的花生四烯酸和胶原诱导的CD62P选择表达有明显的影响而罗非考昔则未显示这种影响。我们得出结论,考虑到抑制血小板功能方面,在围手术期使用罗非考昔是安全的。

(周晓敏 译 薛张纲 校)

Nonsteroidal antiinflammatory drugs are routinely administered in the perioperative period. Because of the absence of cyclooxygenase-2 in platelets, cyclooxygenase-2-selective drugs are thought not to cause platelet inhibition. Because platelets play an important role in the coagulation process, the absence of platelet function inhibition may lead to fewer bleeding complications after surgery. We studied the influence of aspirin, diclofenac, lornoxicam, and rofecoxib on arachidonic acid and collagen-induced CD 62 P (P selectin) expression by using flow cytometry. Blood from 68 volunteers was obtained before and 1, 3, and 12 h after the oral ingestion of 1 of the randomly assigned study medications. Aspirin, diclofenac, and lornoxicam had a significant effect on arachidonic acid and collagen-induced CD 62 P expression in platelets, whereas rofecoxib did not show this effect. We conclude that rofecoxib is safe to use perioperatively with respect to inhibition of platelet function.

 

临床术前评估中心术前评估患者的满意程度

Patient Satisfaction with Preoperative Assessment in a Preoperative Assessment Testing Clinic

David L. Hepner, MD*, Angela M. Bader, MD*, Shelley Hurwitz, PhD, MS, MA{dagger}, Michael Gustafson, MD, MBA{ddagger},§, and Lawrence C. Tsen, MD* Section Editor

Departments of *Anesthesiology, Perioperative and Pain Medicine, {dagger}Medicine, and {ddagger}Surgery, and the §Center for Clinical Excellence, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;98:1099-1105

 

临床术前评估中心(PATCS)包括术前外科,麻醉,护理和实验室等方面的考虑。虽然这些已经被认为是有效的,但是患者的体验和对它的满意程度尚未得到评价。我们向在三个不同的时间段来PATCS的患者分发了一页纸的问卷。包括对临床和非临床的帮助者的满意程度。18道题目分别有5Likert 程度的选项,从好(5分)到差(1分)。问卷的回收率是71.4%。代表各项满意率的均数是4.48 ± 0.67,总的表的均数是4.46 ± 0.55。虽然最高分出现在麻醉,护理和实验室检查方面,但是只有麻醉的分数随着时间在上升(P = 0.007)。代表知情和交流的选项和满意程度的相关性最高(r = 0.76; P < 0.0001)。对整个临床访视过程的满意程度(3.71 ± 1.26)显著(P < 0.0001)低于其他项目。作者认为术前访视者和术前访视功能性的方面对患者的满意程度有很大的影响。其中告知和交流是正性影响因素,而访视的时间是负性影响因素。

(方芳 译 薛张纲 校)

Preoperative Assessment Testing Clinics (PATCs) coordinate preoperative surgical, anesthesia, nursing, and laboratory care. Although such clinics have been noted to lead to efficiencies in perioperative care, patient experience and satisfaction with PATCs has not been evaluated. We distributed a one-page questionnaire consisting of satisfaction with clinical and nonclinical providers to patients presenting to our PATC over three different time periods. Eighteen different questions had five Likert scale options that ranged from excellent (5) to poor (1). We achieved a 71.4% collection rate. The average for the subscale that indicated overall satisfaction was 4.48 ± 0.67 and the average for the total instrument was 4.46 ± 0.55. Although the highest scores were given for subscales describing the anesthesia, nurse, and lab, only the anesthesia subscale improved with time (P = 0.007). The subscale that involved information and communication had the highest correlation with the overall satisfaction subscale (r = 0.76; P < 0.0001). The satisfaction with the total duration of the clinic visit (3.71 ± 1.26) was significantly less (P < 0.0001) than the satisfaction to the other items. The authors conclude that the practitioner and functional aspects of the preoperative visit have a significant impact on patient satisfaction, with information and communication versus the total amount of time spent being the most positive and negative components, respectively.

 

因未识别的乳胶过敏引起的长时间心血管衰竭

Prolonged Cardiovascular Collapse Due to Unrecognized Latex Anaphylaxis

James R. Hebl, MD, Brian A. Hall, MD, and Juraj Sprung, MD, PhD

Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota

 

Anesth Analg 2004;98:1124-1126

我们提供了一个持续的过敏反应病例,和使用头孢唑啉有关系。其后的过敏源试验出人意料地显示对乳胶过敏而对头孢唑啉不过敏。我们的病例说明过敏反应发生前的用药不能想当然地认为是过敏源,乳胶过敏应该作为一种鉴别诊断。由于过敏源不可能马上确定,术中处理患者的心血管崩溃应该在一个无乳胶的环境中。

(方芳译 薛张纲 校)

We present a case of a prolonged anaphylactic reaction that occurred in temporal relationship to the administration of cefazolin. Subsequent allergy testing was positive for latex and negative for cefazolin—both unexpected results. Our case illustrates that medications administered before the onset of anaphylaxis should not be assumed to be the causative allergen and that a latex allergy should be considered in the differential diagnosis. Because the etiology of an anaphylactic reaction cannot be immediately determined, patients experiencing intraoperative cardiovascular collapse should be treated in a latex-free environment

 

低位剖宫术中双指数在1%.5%七氟醚中的价值

Bispectral Index Values at Sevoflurane Concentrations of 1% and 1.5% in Lower Segment Cesarean Delivery

Ki Jinn Chin, MBBS, and Seow Woon Yeo, MMed Section Editor

From the Department of Obstetric and Gynecological Anaesthesia, KK Women’s and Children’s Hospital, Singapore

Anesth Analg 2004;98:1140-1144

 

剖宫产术中知晓率的上升可能和缺少阿片类药物镇痛而引起的催眠不够有关。在术中潮气末0.5MAC的异氟醚和50%N2O的情况下双极指数(BIS)>60,这是术中无知晓的域值.我们研究的目的是为了确定相同浓度的七氟醚时的BIS,是否加大浓度可以使BIS值持续保持小于6020ASAI-II的临产妇随机分为两组,一组在50%N2O中加入1%七氟醚,一组加入1..5%的七氟醚。诱导使用4 mg/kg的硫喷妥钠。胎儿娩出后使用0.1–0.15 mg/kg的吗啡。切皮到胎儿娩出这段时间1%的七氟醚组的平均BIS值是61(95% 可信区间, 57–64),另外一组是42 (95%可信区间, 37–47)BIS值在切皮,切子宫,分娩和分娩后10分钟两组间有显著差异,其后则无。母亲和新生儿的预后是没有差别的。

(方芳 译 薛张纲 校)

Inadequate hypnosis in the absence of opioid analgesia may account for the increased incidence of awareness in cesarean delivery. An end-tidal concentration of 0.5 MAC isoflurane in 50% nitrous oxide (N2O) during cesarean delivery resulted in bispectral index (BIS) values >60, the threshold below which consciousness is unlikely. Our aim was to determine the BIS values achieved with the equivalent end-tidal concentration of sevoflurane and to determine if a larger concentration would consistently maintain BIS values <60. Twenty ASA physical status I–II parturients were randomized to receive an end-tidal concentration of either 1% sevoflurane or 1.5% sevoflurane delivered in 50% N2O throughout surgery. Thiopental 4 mg/kg was used for anesthetic induction. Morphine 0.1–0.15 mg/kg was administered only after delivery. Mean BIS values in the period between skin incision and neonatal delivery were 61 (95% confidence interval, 57–64) in the 1% sevoflurane group, versus 42 (95% confidence interval, 37–47) in the 1.5% sevoflurane group. BIS values were significantly different between groups at skin incision, uterine incision, delivery, and 10 min after delivery, but not thereafter. Indices of maternal and neonatal outcome were similar between groups.


用神经刺激器行锁骨上阻滞降低抑未降低成功率?

The Supraclavicular Block with a Nerve Stimulator: To Decrease or Not to Decrease, That Is the Question

Carlo D. Franco, MD, Vitaliy Domashevich, MD, Gennadiy Voronov, MD, Amir B. Rafizad, MD, and Tanyu J. Jelev, MD Section Editor

Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois

Anesth Analg 2004;98:1167-1171

 

使用便携式的神经刺激器进行神经阻滞已有40多年的历史了。广泛认为在低刺激电流的情况下寻找到运动反应可以提高成功率。一般都是开始使用一个大的电流。如果观察到足够的反应,在注入局麻药前调小电流。然而,多小的电流足够小了,多大的电流足够大了尚未确定。我们的经验显示,行锁骨上阻滞时,反应的形式和电流的大小一样重要。而电流不大与1 mA。这样来说,如果有合适的反应的话,我们使用0.9 mA的电流作为注射电流在理论上也是可能的。我们设计了这样一个实验。用0.9 mA的电流引起指伸和屈的活动,然后注入局麻药。我们的目的不是为了确定是0.9 mA还是0.5 mA是最小的电流,而是为了引出一个无误的运动。60位患者随机分为2组。组1(n = 30)0.5 mA的电流下还能看到运动,然后注入药物。组2(n = 30)0.9 mA的刺激下看到和组1一样的反应后就注入药物,不再降低电流。总共注入40毫升的局麻药。一位患者由于不符合纳入标准而退出实验。剩下的59人的成功率为100%。成功的标准是注药后30分钟内,手部的尺,桡,正中神经支配区域的感觉完全阻滞,不需要加药也不需要复合全麻。事实上,所有的阻滞都在22分钟内完成。组1的起效时间是10.9 ± 5.4分钟,组2 11.4 ± 4.8分钟。没有显著差异。没有并发症,受试者的满意程度也是一样的。我们认为在锁骨上阻滞中使用0.9 mA的电流引出手指可见的反应后可以立即注入药物,因为降低到0.5 mA并不提高总的起效,持续时间和病人的满意程度。

(方芳 译 薛张纲 校)

Portable nerve stimulators for nerve blocks have been available for more than 40 yr. It is generally accepted that seeking a motor response at low outputs increases the chances of success. It is customary to start the procedure at a higher current with the goal of finding the nerve. After an adequate response is elicited, the current is decreased before the local anesthetic is injected. However, how low is low enough and, for that matter, how high is too high have not been adequately determined. Our experience seems to indicate that, in the supraclavicular block, the type of response obtained is as important as the output at which it is elicited, provided that this current is not higher than 1 mA. In this context, it is theoretically possible that our initial seeking current of 0.9 mA could be an adequate injection current if it is combined with an appropriate response. We designed this study to test the hypothesis that a response of the fingers in flexion or extension, elicited at 0.9 mA, could be followed immediately by the local anesthetic injection. We did not intend to compare 0.5 and 0.9 mA as minimum stimulating currents but rather as currents able to elicit an unmistakable motor twitch. Sixty patients were randomly assigned to one of two groups. Group 1 (n = 30) was injected with a motor twitch in the fingers that was still visible at 0.5 mA. Group 2 (n = 30) was injected after a similar response to that in Group 1 was elicited, but at the initial output of 0.9 mA, without any further decrease. The blocks were injected with 40 mL of local anesthetic solution. One patient was excluded from the study for failing to meet protocol criteria. The success rate in the remaining 59 patients was 100%; success was defined as complete sensory blockade at the median, ulnar, and radial nerve territories of the hand that was accomplished in <=30 min from the time of injection and that did not require supplementation or general anesthesia. In fact, all blocks became complete within 22 min of the injection. The onset of anesthesia occurred in 10.9 ± 5.4 min in the 0.5-mA group and 11.4 ± 4.8 min in the 0.9-mA group; this difference was not statistically different. The onset of analgesia and the duration of anesthesia were also similar in both groups. There were no complications, and the respondents in both groups graded their experience at a similar level of satisfaction. We conclude that during the performance of a supraclavicular block eliciting a clearly visible response of the fingers at 0.9 mA can be immediately followed by the injection of local anesthetic, because decreasing the output to 0.5 mA does not seem to improve the overall quality of the block as measured by the onset and duration of anesthesia or patient satisfaction


变力性药物改善主动脉瓣狭窄行主动脉瓣置换术病人的右心功能

Inotropes Improve Right Heart Function in Patients Undergoing Aortic Valve Replacement for Aortic Stenosis

Andrew D. Maslow, MD, Meredith M. Regan, ScD, Carl Schwartz, MD, Arthur Bert, MD, and Arun Singh, MD

From the Departments of Anesthesia and Surgery; Rhode Island Hospital, Providence Rhode Island; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts

Anesth Analg 2004;98:891-902


目前主动脉瓣狭窄行主动脉瓣置换术病人术中使用变力性药物尚有争议。问题在于是否影响左心室收缩功能以及是否引起左心室舒张功能障碍,左室功能是否保持并得到改善。本实验中,作者总结了主动脉瓣狭窄行主动脉瓣置换术病人术中应用变力性药的益处。34名病人随机分为3组:肾上腺素,米力农和安慰剂组。在CPB前和结束时记录血流动力学和心功能数据。使用变力性药物后,右心室(RV)明显增大(安慰剂,+0.5%;肾上腺素,+9%;米力农,+8%P<0.01),左心室(LV)明显增大(安慰剂,+7%;肾上腺素,+18%;米力农,+20%P=0.07),EFCOCPB之后也有明显增加。心输出量和心指数与RVEFr=0.56, r=0.47, )较与LVEFr=0.22r=0.08)相关性更显著(P<0.01)。使用肾上腺素和米力农的病人中,只有一名病人(1/22)出现RVEF降低,而使用安慰剂的病人中,有6名病人(6/12)在CPB后出现RVEF降低。同样,在所有使用肾上腺素和米力农的病人中,只有一名病人(1/22)出现LVEF降低,而使用安慰剂的病人中,有3名病人(3/12)在CPB后出现LVEF降低。没有病人出现左心室流出道梗阻(LVOTO)的情况。因此,主动脉瓣狭窄行主动脉瓣置换术病人术中使用变力性药物可以改善血流动力学状况,其对右室功能的改善明显高于对左室功能的改善。

(周洁 译 王祥瑞 校)

The administration of inotropes after aortic valve replacement (AVR) for aortic stenosis (AS) is controversial. Issues include the risk of left ventricular (LV) systolic outflow obstruction (LVOTO) and the proper treatment of diastolic dysfunction for patients in whom LV systolic function is often preserved and subsequently improved. In this study, we assessed the hemodynamic benefits of inotropes for patients undergoing AVR for AS. Thirty-four patients were prospectively randomized to one of three groups: epinephrine, milrinone, or placebo. Hemodynamic and echocardiographic data were obtained before and immediately after cardiopulmonary bypass (CPB). Data were also obtained before and after increases in ventricular preload to assess the effects of inotropes on diastolic function. The use of inotropes was associated with significantly larger increases in right ventricular (RV) (placebo, 0.5%; epinephrine, +9%; milrinone, +8%; P < 0.01) and LV (placebo, +7%; epinephrine, +18%; milrinone, +20%; P = 0.07) ejection fractions (EF) and cardiac output after CPB. Changes in cardiac output and index were more strongly correlated with changes in RVEF (r = 0.56, P < 0.01; r = 0.47, P < 0.01, respectively) than with LVEF (r = 0.22, r = 0.08). Of all patients receiving epinephrine or milrinone, only one (1 of 22) had a decrease in RVEF, whereas 6 of 12 patients receiving placebo had a reduction in RVEF from pre-CPB to post-CPB. Correspondingly, for LVEF, 1 of 22 patients receiving inotropes had a decrease in LVEF, whereas 3 of 12 placebo patients had a reduction in LVEF from pre-CPB to post-CPB. No patient had evidence of LVOTO. Inotropes improved hemodynamics after AVR for AS. This was attributable more to improved RV function than to changes in LV function. Although there were no changes in diastolic function, it is possible that this study did not allow significant timing to observe benefits of inotropes on diastolic function in this setting.

 

多巴胺对冠状动脉旁路吻合术常用离体动脉的不同效应

The Variable Effects of Dopamine Among Human Isolated Arteries Commonly Used for Coronary Bypass Grafts

Rumi Katai, MD*, Isao Tsuneyoshi, MD*, Junichirou Hamasaki, MD*, Masanori Onomoto, MD*, Shoichi Suehiro, MD{dagger}, Ryuzo Sakata, MD{dagger}, and Yuichi Kanmura, MD*

*Department of Anesthesiology and Critical Care Medicine, and the {dagger}Second Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan

Anesth Analg 2004;98:915-920

多巴胺对冠状动脉旁路移植动脉的直接效应目前尚未得知。作者研究了离体动脉(取自于用作冠状动脉旁路吻合术的桡动脉(RA),胃网膜动脉(GEA),乳内动脉(IMA))对多巴胺的效应。多巴胺对RA呈现一个剂量相关性的收缩作用,这一效应与功能性内皮细胞没有直接关系。使用多巴胺A1受体拮抗剂SCH23390后这一收缩作用会增强,而使用α1肾上腺素能拮抗剂哌唑嗪后,这一收缩功能会减弱。在GEAIMA,也出现类似的结果,但效应较弱。在RA,多巴胺可以增强去甲肾上腺素(NE)引起的血管收缩,而多巴胺的这一效应可以被SCH23390增强。在GEA,低浓度(<10-7mol/L)的多巴胺可以减弱NE引起的血管收缩,而高浓度时则无此作用。在IMA,只有较高浓度的多巴胺(10-6-10-5mol/L)才能对NE收缩的血管有扩张作用。在GEAIMA,由多巴胺产生的对NE收缩的血管的扩张作用都可以被SCH23390抑制。上述结果表明,多巴胺与DA1α1肾上腺素能受体的密切关系可以用来解释其对各动脉的不同作用。

(周洁 译 王祥瑞 校)

The direct actions of dopamine on human arterial coronary bypass grafts are not well known. We investigated its effects on isolated rings cut from radial arteries (RA), gastroepiploic arteries (GEA), and internal mammary arteries (IMA) harvested from patients undergoing coronary artery bypass surgery. Dopamine produced dose-dependent contractile responses in RA, an effect independent of the presence of a functional endothelium. The contractions were enhanced by the dopamine A1 (DA1)-receptor antagonist SCH23390, whereas they were blocked by an {alpha}1-adrenergic antagonist, prazosin. Results qualitatively similar to these were obtained in both GEA and IMA, although the contractile responses were far smaller. In RA, DA enhanced the norepinephrine (NE)-induced contraction, and this action of dopamine was enhanced by SCH23390. In GEA, small concentrations (<10-7 mol/L) of DA attenuated the NE-induced contraction but larger concentrations did not. In IMA, DA induced a vasorelaxation on the NE-contraction only at higher concentrations (10-6–10-5 mol/L). In both GEA and IMA, the dopamine-induced vasorelaxations on the NE contraction were completely inhibited by SCH23390. These results suggest that the affinities of DA for DA1- and {alpha}1-adrenergic receptors may explain its variable contractile and vasorelaxant effects among these arteries.


小儿硬膜外麻醉后阻滞扩散平面与肾上腺素对心输出量的影响:随机,双盲,前瞻性研究

The Effects of Spread of Block and Adrenaline on Cardiac Output After Epidural Anesthesia in Young Children: A Randomized, Double-Blind, Prospective Study

Olivier Raux, MD*, Alain Rochette, MD*, Estelle Morau, MD*, Christophe Dadure, MD*, Christine Vergnes, MD{dagger}, and Xavier Capdevila, PhD*

From the Departments of *Anesthesiology and {dagger}Medical Information, CHU Montpellier, France

Anesth Analg 2004;98:948-95

 
小儿硬膜外麻醉一般认为对血流动力学没有严重的影响。然而,与成人不同的是,很少有人研究小儿硬膜外麻醉时心输出量的变化。作者前瞻性研究的选择48名小儿 (平均年龄22.5), 使用食管多谱勒超声仪监测心输出量,研究血流动力学的变化。使用七氟醚复合尾部或胸腰部硬膜外麻醉,随机分成两组:对照组用普通的局麻混合液0.8mL/kg(1%利多卡因+0.25%布比卡因+1μg/mL芬太尼),肾上腺素组用同样的局麻混合液1mL/kg,再加入肾上腺素5μg/mL。结果:对照组除了引起轻度的心率下降以外,没有明显的血流动力学的变化。肾上腺素组,平均动脉压下降14%-17%,系统血管阻力下降24%-40%,而心输出量则增加20%-34%。并且这种肾上腺素效应在胸腰部阻滞比在尾部阻滞更明显。结论:小儿硬膜外麻醉局麻药混合液中加入肾上腺素引起心输出量的增加,原因可能是硬膜外间隙吸收肾上腺素所致。
(齐波 译 王祥瑞 校)

Epidural anesthesia is considered to be without significant hemodynamic consequence in young children. However, conversely to adults, few studies have investigated cardiac output. Using transesophageal Doppler monitoring of cardiac output, we prospectively investigated hemodynamic alterations in 48 children (median age, 22.5 mo) receiving sevoflurane general anesthesia combined with caudal or thoracolumbar epidural anesthesia. They were randomly assigned to receive 0.8 mL/kg of plain local anesthetic mixture (lidocaine 1% + bupivacaine 0.25% (50/50) + 1 µg/mL of fentanyl) or 1 mL/kg of the same mixture with 5 µg/mL of adrenaline. No significant hemodynamic alteration was elicited in caudal and thoracolumbar groups receiving the plain mixture except a moderate decrease in heart rate. Conversely, a mixture with adrenaline added provoked a significant decrease in mean arterial blood pressure by 14% and 17%, in systemic vascular resistance by 24% and 40%, and an increase in cardiac output by 20% and 34% in caudal and thoracolumbar groups, respectively. The adrenaline effect was greater by the thoracolumbar than the caudal approach. In young children, epidural anesthesia induces an increase in cardiac output only when adrenaline is added to local anesthetics, probably through its systemic absorption from the epidural space.



围术期使用罗非考昔(Rofecoxib)可促进门诊疝修补术患者的早期康复

Perioperative Rofecoxib Improves Early Recovery After Outpatient Herniorrhaphy

Hong Ma, MD, PhD*, Jun Tang, MD*, Paul F. White, PhD, MD, FANZCA*, Alan Zaentz, MD{dagger}, Ronald H. Wender, MD{dagger}, Alexander Sloninsky, MD{dagger}, Robert Naruse, MD{dagger}, Robert Kariger, MD{dagger}, Raymond Quon{dagger}, Dennis Wood, MD{ddagger}, and Brendan J. Carroll, MD{ddagger} Section Editor

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

Anesth Analg 2004;98:970-975

非阿片类镇痛药作为多制式镇痛方法的一部分越来越普遍。作者随机,双盲,安慰剂对照研究腹股沟疝患者围术期使用环氧合酶抑制剂罗非考昔(Rofecoxib)的效果。60名疝修补术病人随机对照组(维生素C500mg)和罗非考昔组(罗非考昔50mg)。第一次使用药物是在患者进入手术间前的30-40分钟口服,第二次是术后第一天的早晨。病人在出恢复室之前每110分钟记录一次恢复时间,疼痛评分,需追加镇痛剂情况以及副作用。术后36小时,7天和14天再次评估疼痛情况,镇痛需求,运动恢复正常状况及患者对术后镇痛的满意度。罗非考昔显著降低了早期恢复时间,并使患者手术后能更早回家(88±30min126±44minP0.05),罗非考昔组患者平均恢复评分也明显高于对照组(18[14-18]16[13-18]P0.05)。恢复期,对照组的病人需要追加镇痛药的比例明显高于罗非考昔组(67%37%P0.05)。患者术后36小时的再次评估中,罗非考昔组的患者口服镇痛药明显少于对照组(0[0-20]9[1-33] 颗,P0.05),并且最大疼痛评分降低,术后镇痛的满意度提高(3[1-4]2[0-3]P0.05)。两组病人日常活动恢复的时间没有显著差异。总之,围术期口服罗非考昔50mg/次,能显著减轻术后的疼痛并减少镇痛药的追加量,促进门诊疝手术患者更快更好地恢复。但并不能改善最终的恢复时间。

(朱辉 译 王祥瑞 校)

Non-opioid analgesics have become increasingly popular as part of a multimodal regimen for pain management in the ambulatory setting. We designed this randomized, double-blind, placebo-controlled study to evaluate the effect of perioperative administration of the cyclooxygenase-2 inhibitor rofecoxib on patient outcome after inguinal herniorrhaphy procedures. Sixty consenting outpatients undergoing elective hernia repair surgery were randomly assigned to one of two treatment groups: control (vitamin C, 500 mg) or rofecoxib (rofecoxib, 50 mg). The first oral dose of the study medication was administered 30–40 min before entering the operating room, and a second dose of the same medication was given on the morning of the first postoperative day. Recovery times, postoperative pain scores, the need for "rescue" analgesics, and side effects were recorded at 1- to 10-min intervals before discharge from the recovery room. Follow-up evaluations were performed at 36 h, 7 days, and 14 days after surgery to assess postdischarge pain, analgesic requirements, resumption of normal activities, as well as patient satisfaction with their postoperative pain management. Rofecoxib significantly decreased the early recovery times, leading to an earlier discharge home after surgery (88 ± 30 vs 126 ± 44 min, P < 0.05). When compared with the control group, the patients’ median [range] quality of recovery score was also significantly higher in the rofecoxib group (18 [14–18] vs 16 [13–18], P < 0.05). In the predischarge period, a significantly larger percentage of patients required rescue pain medications in the control group (67% vs 37% in the rofecoxib group, P < 0.05). At the 36-h follow-up assessment, rofecoxib-treated patients reported significantly reduced oral analgesic requirements (0 [0–20] vs 9 [1–33] pills, P < 0.05) and lower maximal pain scores, resulting in improved patient satisfaction with their postoperative pain management (3 [1–4] vs 2 [0–3], P < 0.05). However, there were no differences in the times required to resume their activities of daily living. In conclusion, perioperative rofecoxib, 50 mg per os, significantly decreased postoperative pain and the need for analgesic rescue medication, leading to a faster and improved quality of recovery after outpatient hernia surgery. However, perioperative use of rofecoxib failed to improve recovery end points in the postdischarge period.


罗库溴胺和维库溴胺的皮肤敏感性——健康志愿者的随机对照研究

Skin Sensitivity to Rocuronium and Vecuronium: A Randomized Controlled Prick-Testing Study in Healthy Volunteers

Gilles Dhonneur, MD*, Xavier Combes, MD*, Didier Chassard, MD{dagger}, and Jean Claude Merle, MD* Section Editor

*Department of Anesthesia and Critical Care Medicine, University Hospital and Paris XII Val-de-Marne School of Medicine, Créteil, France; and {dagger}Clinical Research Organisation, CEPHAC.ASTER Institut, Paris, France

Anesth Analg 2004;98:986-989

皮肤过敏试验常用以判断麻醉中出现的过敏反应是否由于神经肌肉阻滞药(NMBDs)所致。然而皮肤过敏试验中神经肌肉阻滞剂应用浓度仍存在争议。本实验观察罗库溴胺和维库溴胺进行皮肤过敏试验时皮疹和水疱的发生情况。30位健康、无过敏遗传史的1840岁的志愿者(男14,女16),随机分为10组:罗库溴胺和维库溴胺分别被稀释为1100011001101,另两组为对照组。用药后立即及15分钟后记录NMBDs引起的全身和皮肤反应情况并测量皮疹和水疱的表面积。在使用维库溴胺和罗库溴胺后没有一名志愿者立即出现全身和皮肤过敏症状。浓度为11000罗库溴胺和维库溴胺用药后15分钟无阳性反应,纯浓度的罗库溴胺和维库溴胺分别有50%40%出现阳性反应。实验中存在性别差异。作者认为纯浓度罗库溴胺和维库溴胺皮肤过敏试验诊断过敏反应源不一定可靠。

(朱慧琛 王祥瑞 校)

Prick tests are frequently used for the authentication of neuromuscular blocking drugs (NMBDs) as causative drugs for anaphylactic reactions during anesthesia. Unfortunately, the actual threshold concentration for skin testing remains debatable for most NMBDs. We studied the flare and wheal responses to prick tests with rocuronium and vecuronium. Thirty healthy, nonatopic, anesthesia-naive male and female volunteers (14 men and 16 women) from 18 to 40 yr of age were assigned randomly to receive a total of 10 prick tests—4 ascending dilutions (1:1000, 1:100, 1:10, and 1) of rocuronium and vecuronium and 2 controls—on both forearms. An assessor blinded to the assignment monitored systemic and skin responses to NMBDs and measured wheal and flare surfaces immediately after and 15 min after prick tests. None of the volunteers experienced any immediate systemic or cutaneous responses to rocuronium or vecuronium. Although a dilution of 1:1000 of both NMBDs failed to promote any skin response at 15 min, 50% and 40% of the subjects had a positive skin reaction to undiluted rocuronium and vecuronium, respectively. We demonstrated a sex effect related to smaller threshold concentration-induced cutaneous reactions in female volunteers to both muscle relaxants. Our observation questions the reliability of prick testing with undiluted solutions of rocuronium and vecuronium for the diagnosis of allergy.

 

脂多糖诱导炎症反应中预防性使用异氟醚可促进血流动力学稳定并增加大鼠肠系膜白细胞运动速率

Isoflurane Pretreatment Supports Hemodynamics and Leukocyte Rolling Velocities in Rat Mesentery During Lipopolysaccharide-Induced Inflammation

John K. Hayes, PhD, Dmytro M. Havaleshko, MD, Roman V. Plachinta, MD, and George F. Rich, MD, PhD

Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia

Anesth Analg 2004;98:999-1006

作者假定预防性使用异氟醚可对脉管系统起到保护作用,部分原因是通过改变白细胞-内皮细胞的相互作用所致。大鼠戊巴比妥麻醉后随机分为四组:对照组、异氟醚组(吸入1.4%的异氟醚30分钟)、脂多糖组(LPS10mg/kg IV)、ISO-LPS组(先吸入异氟醚后使用LPS)。随后在电视显微镜下在体观察肠系膜,并每小时测量平均动脉压(MAP)和微循环变化,包括毛细血管后小静脉和小动脉的血流速率以及白细胞动态。在LPS组应用异氟醚后2—4小时可明显减少MAP的下降程度并提高了白细胞的运动速率(P<0.05)。4小时后白细胞的运动速率增快>200%ISO-LPS组与LPS组相比为63.7+27.6m/s19.8+6.4m/s)。在对照组预防性使用ISOMAP和白细胞速率无影响但可增加白细胞的数量。预防性使用ISO不会影响LPS组的小动脉和毛细血管后小静脉的运动速率,也并不影响LPS组和对照组白细胞的附着性。结论:预防性使用异氟醚可以维持血流动力学稳定以及增加大鼠肠系膜白细胞运动速率,但它并不能改变LPS引起的炎症反应中白细胞的数量和附着性。

(朱慧琛 译 王祥瑞 校)

We hypothesized that the protective effects of isoflurane (ISO) pretreatment on the vasculature may be attributed, in part, to altered leukocyte-endothelial interactions. Rats were anesthetized with pentobarbital and then randomized into four groups: control, ISO-control (pretreatment with 30 min of 1.4% ISO), lipopolysaccharide (LPS; 10 mg/kg IV), and ISO-LPS (ISO pretreatment and then LPS). The mesentery was prepared for intravital videomicroscopy. Mean arterial blood pressure (MAP), along with microcirculatory variables that included postcapillary venular and arteriolar blood flow velocity and leukocyte dynamics (number of rolling and adherent leukocytes and individual rolling leukocyte velocities), were measured hourly (baseline and at 0–4 h). In LPS rats, ISO pretreatment significantly (P < 0.05) attenuated the decrease in MAP at 2 and 4 h after LPS and increased leukocyte rolling velocities after 2–4 h. Four hours after LPS, leukocyte rolling velocities were >200% more rapid (63.7 ± 27.6 µm/s versus 19.8 ± 6.4 µm/s) in ISO-LPS versus LPS rats. In control rats, ISO pretreatment had no effect on MAP or leukocyte rolling velocities but increased the number of rolling leukocytes. ISO pretreatment had no effect on arteriolar and postcapillary venular blood flow velocity in LPS rats or leukocyte adherence in LPS or control rats. In conclusion, ISO pretreatment supported hemodynamics and increased leukocyte rolling velocities but did not alter the number of rolling or adherent leukocytes in the mesenteric microcirculation during LPS-induced inflammation.

 

异丙酚对大鼠下丘脑室旁核神经元的作用

The Effects of Propofol on Hypothalamic Paraventricular Nucleus Neurons in the Rat

Tetsuro Shirasaka*, Yasuhiro Yoshimura*, De-Lai Qiu{dagger}, and Mayumi Takasaki*

Departments of *Anesthesiology and {dagger}Physiology, Miyazaki Medical College, Kiyotake, Japan

Anesth Analg 2004;98:1017-1023

麻醉引起低血压的机理尚未完全明了,尚无电生理实验发现异丙酚对交感系统和心血管功能的影响。通过膜片箝技术的全细胞模式作用于大鼠下丘脑室旁核神经元(PVN)切片,内研究了异丙酚对大鼠下丘脑室旁核神经元的作用。异丙酚在浓度10-5~10-4M时,产生Cl-电流,对印防己毒素敏感,在更小浓度范围内,对番木鳖碱敏感。10-6M的异丙酚加强GABAA 产生的电流,另外,异丙酚(10-510-4M)显著地增加了突触后诱发-抑制电流的衰退时间,提示了GABAA受体的突触后调节作用。另外,异丙酚(10-510-4M2*10-4M)可逆性地抑制了电压门控Ca2+通道,这些结果显示异丙酚在中枢水平加强了GABAA受体介导的电流并抑制了电压门控Ca2+通道,可能影响了心血管和交感神经系统,至少部分与全麻所导致的低血压有关。

(陈洁 译 王祥瑞 校)

The mechanism of hypotension induced by anesthetics is not completely understood. Because no electrophysiologic examination of the effects of propofol on the central nervous system has shown its involvement in the control of sympathetic and cardiovascular functions, we investigated the actions of propofol on rat hypothalamic paraventricular nucleus (PVN) neurons using the whole-cell mode of the patch-clamp technique in rat hypothalamic PVN slice preparations. Propofol induced Cl- currents at concentrations of 10-5 and 10-4 M, which were sensitive to picrotoxin and, to a lesser extent, to strychnine. Propofol (10-6 M) enhanced {gamma}-aminobutyric acidA (GABAA; 10-6 M)-induced current synergistically. Moreover, propofol (10-5 and 10-4 M) significantly increased the decay time of evoked-inhibitory postsynaptic currents, which suggests a postsynaptic modulation of GABAA receptors. In addition, propofol (10-5, 10-4, and 2 x 10-4 M) reversibly inhibited voltage-gated Ca2+ currents. Taken together, these results suggest that propofol enhancement of GABAA-receptor mediated currents and inhibition of voltage-gated Ca2+ currents at the central level, which is involved in the control of cardiovascular and sympathetic functions may be, at least in part, involved in general anesthetic-induced cardiovascular and sympathetic depression.


 

术后口服罗非考昔(Rofecoxib)减轻经腹子宫切除术后疼痛和减少曲马多的用量

Preoperative Oral Rofecoxib Reduces Postoperative Pain and Tramadol Consumption in Patients After Abdominal Hysterectomy

Beyhan Karamanlioglu, MD*, Alparslan Turan, MD*, Dilek Memis, MD*, and Mevlüt Türe, PhD{dagger} Section Editor

Department of *Anesthesiology and {dagger}Biostatistics, Trakya University, Medical Faculty, Edirne, Turkey

Anesth Analg 2004;98:1039-1043
本实验探讨经腹子宫切除术后口服罗非考昔(Rofecoxib)是否能减少患者自控镇痛(PCA)的曲马多用量或增强镇痛效果。术后60例患者随机口服安慰剂或罗非考昔50mg。所有患者接受标准的麻醉方案,记录术中的血液丢失量。手术后,所有的患者接受静脉曲马多PCA。术后124681224小时测定疼痛评分、镇静评分、平均动脉血压、心率和外周血氧饱和度。同时记录曲马多的总量和增加剂量、术后24小时的抗呕吐药需要和副作用。术后12小时罗非考昔组的疼痛评分低于安慰剂组6倍(P0.05)。安慰剂组的曲马多总量显著高于罗非考昔组(627±69mg 535±45mgP<0.05)。组间术中血液丢失、镇静评分、血流动力学变化、外周血氧饱和度、术后不良反应无显著性差异。两组病人住院时间相似。结论:罗非考昔术后口服有明显的镇痛作用并减少了经腹子宫切除术后患者的阿片类药物的需要量。

(陈洁 译 陈杰 校)

We designed this study to determine whether the administration of a preoperative dose of rofecoxib to patients undergoing abdominal hysterectomy would decrease patient-controlled analgesia (PCA) tramadol use or enhance analgesia. Sixty patients were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received a standard anesthetic protocol. Intraoperative blood loss was determined. At the end of surgery, all patients received tramadol IV via a PCA-device. Pain scores, sedation scores, mean arterial blood pressure, heart rate, and peripheral oxygen saturation were assessed at 1, 2, 4, 6, 8, 12, and 24 h after surgery. Total and incremental tramadol consumption at the same times was recorded from the PCA-device. Antiemetic requirements and adverse effects were noted during the first postoperative 24 h. Duration of hospital stay was also recorded. The pain scores were significantly lower in the rofecoxib group compared with the placebo group at 6 times during the first 12 postoperative h (P < 0.05). The total consumption of tramadol (627 ± 69 mg versus 535 ± 45 mg; P < 0.05) and the incremental doses at 1, 2, 4, 6, 8, and 12 h after surgery were significantly more in the placebo group than in the rofecoxib group. There were no differences between groups in intraoperative blood loss, sedation scores, hemodynamic variables, peripheral oxygen saturation, antiemetic requirements, or adverse effects after surgery. The length of hospital stay was also similar in the groups. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the opioid requirements in patients undergoing abdominal hysterectomy.

 

对接受皮肤移植术的烧伤病人应用连续髂筋膜腔隙阻滞(FICB)的效果

The Efficacy of Continuous Fascia Iliaca Compartment Block for Pain Management in Burn Patients Undergoing Skin Grafting Procedures

Olivier Cuignet, MD*, Jean Pirson, MD*, Jenna Boughrouph, MD{dagger}, and Diane Duville, FRCC*

*Burn Center, Queen Astrid Military Hospital, Military Medical Research Program and Development Committee, Brussels, Belgium, and the {dagger}Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium

Anesth Analg 2004;98:1077-81

术后取皮部位的疼痛强度常较植皮部位更高。作者前瞻性随机双盲试验中评估应用连续髂筋膜腔隙阻滞减轻取皮部位疼痛的效果。表面烧伤面积为16%±13%20例患者随机接受0.2%的罗哌卡因或0.9%的生理盐水。所有的病人均在全麻后于髂筋膜腔隙(FICB)预先随机注射药液40毫升,随后连续注射罗哌卡因或生理盐水(速度为10ml/h)直至首次更换敷料(72小时后)。术后联合应用propacetamol 2g/6h,病人静脉自控镇痛盐酸吗啡2mg/ml,在首次伤口换药前60分钟口服盐酸吗啡0.5mg/kg。术前、术后24h48h、首次伤口换药时,应用视觉模拟评分和Mann-Whitney U检验。如果需要累积吗啡消耗量对比Scheffe法重复测量变异分析。接受连续FICB的病人术后所有时段的吗啡用量均减少(与对照组相比,分别为23±20mg88±29mgp<0.05)。FICB组在首次换药时的视觉模拟评分明显降低(3[1]7[3];中线值[四位数范围]p<0.05)。结论FICB对减轻大腿部位供皮部位的疼痛是有效的。

(忻纪华 译 王祥瑞 校)

Postoperative pain from split skin donor sites is often more intense than the pain at the grafted site. In this prospective, randomized, double-blind study we assessed the efficacy of a continuous fascia iliaca compartment block (FICB) in reducing the pain at the thigh donor site. Twenty patients, with a total burn surface area of 16% ± 13% (mean ± SD) were randomized 1:1 to receive either ropivacaine 0.2% or saline 0.9%. All patients received a general anesthesic followed by preincision continuous FICB with 40 mL of the randomized solution, then an infusion of 10 mL/h of either ropivacaine or saline until the first dressing change (72 h later). Postoperative analgesia consisted of propacetamol 2g/6h, IV patient-controlled analgesia of morphine chlorhydrate (2 mg/mL), and morphine hydrochlorate 0.5 mg/kg PO once 60 min before first dressing change. The visual analog scale (VAS) scores were compared using the Mann-Whitney U-test preoperatively, 24 and 48 h postoperatively, and during the first dressing change. The cumulative morphine consumption was compared with repeated-measures analysis of variance followed by Scheffé’s method if indicated. Patients with continuous FICB had significantly reduced postoperative morphine consumption at all time points (23 ± 20 versus 88 ± 29 mg after 72 h, study versus control groups, respectively; P < 0.05). In both groups, VAS scores remained low but were only significantly lower for patients with continuous FICB during the first dressing change (3 [1] versus 7 [3]; median [interquartile range]; P < 0.05). We conclude that continuous FICB is an efficient method for diminishing pain at the thigh donor site. (250 words)


 
大鼠足底切开前使用利多卡因和布比卡因预处理对脊髓C-FOS蛋白在时间和空间上表达的影响

The Effects of Pretreatment with Lidocaine or Bupivacaine on the Spatial and Temporal Expression of c-Fos Protein in the Spinal Cord Caused by Plantar Incision in the Rat

Xiaohui Sun, MD, Masataka Yokoyama, MD, Satoshi Mizobuchi, MD, Ryuji Kaku, MD, Hideki Nakatsuka, MD, Toru Takahashi, MD, and Kiyoshi Morita, MD

Department of Anesthesiology and Resuscitology, Okayama University Medical School, Okayama City, Okayama, Japan

Anesth Analg 2004;98:1093-1098

作者研究大鼠足底切开时脊髓背角中C-FOS蛋白在时间和空间上的表达及局麻药预处理后对表达的影响。大鼠麻醉下在足底切开前分别给用0.5%布比卡因(B组),2%利多卡因(L组)和生理盐水(C组)做神经阻滞和局部浸润麻醉。切开后1,3,6,24,48,72120 h, 评估疼痛和在脊髓的腰4,5节段c-FOS的表达。结果显示在1-120h间,机械刺激的兴奋域的明显下降,(1-72h,p<0.01;120h,p<0.05)B组和C组,其域值明显提高(与C组相比1h: B组和Cp<0.013h: B组和Cp<0.01);6h(B,p<0.01L,p<0.05)C,FOS的表达主要在一到二层细胞,和五到六层细胞,表达高峰出现在切开后一小时,然后逐渐下降。结论:使用了局麻药可以在各个层面抑制FOS的表达,而这种抑制可以持续几天。这项研究为证明因足底切开而引起的FOS在时间和空间的表达的变化提供了证据。研究显示使用局麻药可以在术后的几天内抑制FOS的表达,而止痛效果的长短有赖于局麻药的持续时间。

(齐波 译 王祥瑞 校)

We investigated the spatial and temporal patterns of c-Fos protein (Fos) expression in the dorsal horn of the spinal cord caused by plantar incision in the rat and the effects of pretreatment with local anesthetics. Bupivacaine (0.5%), lidocaine (2%), or saline for control was injected for nerve block and local infiltration before the plantar incision was made under anesthesia. Pain behavior and Fos expression in the L4-L5 segments of the spinal cord were assessed at 1, 3, 6, 24, 48, 72, and 120 h after the incision. The withdrawal threshold to mechanical stimulation decreased significantly at 1 h until 120 h (1–72 h, P < 0.01;120 h, P < 0.05), and pretreatment with local anesthetics increased the threshold significantly at 1 h (both groups: P < 0.01), 3 h (both groups: P < 0.01), and 6 h (bupivacaine, P < 0.01; lidocaine, P < 0.05) in comparison with that in the saline group. In the saline group, Fos expression was detected predominantly in laminae I–II and V–VI, and the total Fos expression was maximal at 1 h and then decreased gradually. Pretreatment with local anesthetics suppressed Fos expression significantly in all layers, and this suppression continued for several days. This study provides evidence of spatial and temporal changes in Fos expression induced by plantar incision. Our results indicate that although pretreatment with local anesthetics suppresses Fos expression for several days in the postoperative period, the analgesic effect is observed only for the expected duration of the local anesthetic used.


 

合外伤后反复常栓子引起的脑血管意外

Paradoxical Embolus After Multiple Trauma Resulting in a Cerebrovascular Accident

Mark D. Price*, Pranay Kanake, MD{dagger}, and Daniel Talmor, MD, MPH{dagger}

*Division of Health Sciences and Technology and {dagger}Department of Anaesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;98:1121-1123

作者报道了一例机动车辆撞伤的57岁患者3天后发生了无法解释的脑血管意外。这例患者在诊断检查中发现既往未知的卵圆孔疾病。我们在此讨论反常栓子的病因。

(朱辉 译 王祥瑞 校)

We present the case of a 57-yr-old patient who suffered an unexplained cerebrovascular event 3 days after being struck by a motor vehicle. Workup demonstrated a previously unknown patient foramen ovale. The etiologies of paradoxical embolism in trauma are discussed.

 

蛛网膜下腔出血时脑自主调节功能的持续评估

Continuous Assessment of Cerebral Autoregulation in Subarachnoid Hemorrhage

Martin Soehle, MD*,{dagger}, Marek Czosnyka, PhD{dagger}, John D. Pickard, MCh, FRCS{dagger}, and Peter J. Kirkpatrick, FRCS(SN){dagger}

*Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany; and {dagger}Academic Neurosurgery Unit, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom

Anesth Analg 2004;98:1133-1139

脑血管痉挛一直是蛛网膜下腔出血后主要的致残和致死原因。当脑自我调节功能不能代偿痉挛时就产生脑缺血。作者应用经多谱勒研究血管痉挛对自我调节功能的影响。动脉血压的缓慢变化和平均血流速率(MFV)或收缩血流速率(SFV)之间的动态关联系数分别以“Mx”和“Sx”来表示,并以此代表脑自我调节功能。当MFV增加到大于120cm/s以及lindegaard比大于3可确定有血管痉挛。32名蛛网膜出血病人中的15人有血管痉挛。根据血管痉挛病人双侧大脑中动脉的颅内多普勒报告,计算基线和血管痉挛时的MxSx值。血管痉挛时Mx0.46±0.32)显著高于基线水平(0.21± 0.24P0.021)。Sx也升高(0.22±0.260.05±0.21P0.03)。MxMFVr0.577P0.025)和lindegaard比相关联。血管痉挛侧的MxSx比对侧均升高。血管痉挛期间的MxSx升高说明脑自我调节功能受损。MxSx提供了蛛网膜下腔出血病人自主调节功能变化的额外信息。

(殷文渊 译 王祥瑞 校)

Cerebral vasospasm remains a leading cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Cerebral ischemia may ensue when autoregulation fails to compensate for spasm. We examined how autoregulation is affected by vasospasm by using transcranial Doppler. The moving correlation coefficient between slow changes of arterial blood pressure and mean or systolic flow velocity (FV), termed "Mx" and "Sx," respectively, was used to characterize cerebral autoregulation. Vasospasm was declared when the mean FV increased to more than 120 cm/s and the Lindegaard ratio was more than 3. This occurred in 15 of 32 SAH patients. On the basis of the bilateral transcranial Doppler recordings of the middle cerebral artery in vasospastic patients, Mx and Sx were calculated for baseline and vasospasm. Mx increased during vasospasm (0.46 ± 0.32; mean ± SD) and was significantly higher (P = 0.021) than at baseline (0.21 ± 0.24). Sx was also increased (0.22 ± 0.26 vs 0.05 ± 0.21 at baseline; P = 0.03). Mx correlated with mean FV (r = 0.577; P = 0.025) and the Lindegaard ratio (r = 0.672; P < 0.006). Mx (P = 0.006) and Sx (P = 0.044) were higher on the vasospastic side (Mx, 0.44 ± 0.27; Sx, 0.24 ± 0.23) when compared with the contralateral side (Mx, 0.34 ± 0.29; Sx, 0.16 ± 0.25). The increased Mx and Sx during cerebral vasospasm demonstrate impaired cerebral autoregulation. Mx and Sx provide additional information on changes in autoregulation in SAH patients.


 

用双盲,双安慰剂对照试验比较两组腰硬联合和硬膜外阻滞行分娩时鞘内舒芬太尼与胎儿心率异常关系

Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial Comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor

M. Van de Velde, MD, PhD*, A. Teunkens, MD*, M. Hanssens, MD, PhD, FRCOG{dagger}, E. Vandermeersch, MD, PhD*, and J. Verhaeghe, MD, PhD{dagger}

Departments of *Anesthesiology and {dagger}Obstetrics and Gynecology, University Hospitals Gasthuisberg, Katholieke Universiteit Leuven, Herestraat, Belgium

Anesth Analg 2004;98:1153-1159

腰硬联合镇痛用于分娩镇痛变得越来越普遍了。可是,鞘内舒芬太尼对子宫活跃过度的发生和胎儿心率异常的影响仍有争议。我们假设鞘内使用舒芬太尼7.5μg比小剂量舒芬太尼与布比卡因联合应用脊麻或硬膜外镇痛容易产生FHR异常。300名临产产妇随机分为三组。第一组,EPD组,硬膜外应用布比卡因12.5mg,肾上腺素12.5μg和舒芬太尼7.5μg 混合液10ml;第二组,BSE组,鞘内注射布比卡因2.5mg,肾上腺素2.5μg和舒芬太尼1.5μg;第三组,SUF组,蛛网膜下腔注射舒芬太尼7.5µg。所有患者使用病人自控硬膜外镇痛,用0.125%布比卡因,肾上腺素1.25µg/ml和舒芬太尼0.75μg/ml(负荷剂量4ml;锁定时间15分钟)。在镇痛前15分钟和镇痛开始后的60分钟内监测心张力图。记录镇痛效果,分娩质量,新生儿结果和副作用。在开始麻醉的第一个小内SUF组24%病人发生了FHR异常(速率增加和晚期减速)BSE组为12%,EPD组为11%。SUF组12%临产妇发生了子宫活跃过度,而在其它组只有2%。CSE组麻醉起效快于EPD组。严重低血压发生率分别为BSE组为29%,EPD组为7%,SUF为12%。所有这些差别均有统计学意义。上述结果证实大剂量舒芬太尼(7.5μg或更多)脊麻时存在子宫活跃过度和FHR异常的危险。

(殷文渊 译 王祥瑞 校)

Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 µg is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 µg of epinephrine, and 7.5 µg of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 µg of epinephrine, and 1.5 µg of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 µg of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 µg/mL of epinephrine, and 0.75 µg/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 µg or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities.