Anesthesia & Analgesia

April 2004

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

豬急性三尖瓣反流不改變熱稀釋法心輸出量測定的準確性或精確性

(黃施偉 譯,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

變力性藥物改善主動脈瓣狹窄行主動脈瓣置換術病人的右心功能

(周潔 譯 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..

鞘內應用嗎啡減少缺血-再灌注損傷大鼠模型的心梗面積
Intrathecal Morphine Reduces Infarct Size in a Rat Model of Ischemia-Reperfusion Injury

(鍾鳴 薛張綱 校)

Leanne Groban, Jason C. Vernon, and John Butterworth

Anesth Analg 2004 98: 903-909

中心靜脈導管正確放置:用經食道心超比較靜脈內心電圖和表面標誌技術

(王立中譯,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

多巴胺對冠狀動脈旁路吻合術常用離體動脈的不同效應

(周潔 譯 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.  

擇期肝切除術需用異體血患者中應用促紅細胞生成素的作用:一項類比模型

(鍾鳴 薛張綱 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:

蒽環類抗腫瘤藥對麻醉期間心功能的影響

( 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.

多巴胺對冠狀動脈旁路吻合術常用離體動脈的不同效應

(周潔 譯 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.

小兒脊柱術後鞘內及硬膜外鎮痛的回顧

(鍾鳴目譯 薛張綱 校)

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

Anesth Analg 2004 98: 956-965.

青春期心臟手術後並發硬膜外血腫一例

(張俊傑譯, 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:

圍術期使用羅非考昔(Rofecoxib)可促進門診疝修補術患者的早期康復

(朱輝 譯 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改善全麻後恢復

(陸旭偉 薛張綱 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

熱蒸氣法增強利多卡因的局部麻醉作用

(裘毅敏 譯,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:

羅庫溴胺和維庫溴胺的皮膚敏感性——健康志願者的隨機對照研究

(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.

比較七氟醚和異氟醚複合笑氣和硬膜外阻滯麻醉下肝硬化病人行肝切除術後的肝功能

(陸旭偉 薛張綱 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

術前口服右美沙芬可減輕全麻下行膝關節十字韌帶再造術中止血帶引起的動脈血壓和心率的增加

(沈浩 李士通 )

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.

脂多糖誘導炎症反應中預防性使用異氟醚可促進血流動力學穩定並增加大鼠腸系膜白細胞運動速率

(朱慧琛 譯 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.

氙氣和異氟醚在調節LPS介導的NF-κB活性和單核細胞TNF-αIL-6生成方面的不同

(陸旭偉 薛張綱 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.

芬太尼對大鼠阿心室肌細胞內鈣離子和細胞收縮性的作用

(趙雪蓮 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

異丙酚對大鼠下丘腦室旁核神經元的作用

(陳潔 譯 王祥瑞 校)

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

局麻藥對單核細胞mCD14和人類白細胞抗原-DR表達的影響

(周曉敏 薛張綱 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:

術後口服羅非考昔(Rofecoxib)減輕經腹子宮切除術後疼痛和減少曲馬多的用量

(陳潔 譯 陳傑 校)

術前口服Rofecoxib減少經腹子宮切除病人術後疼痛和曲馬多用量

(顔濤譯, 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

圍術期靜脈注射利多卡因對腹部大手術術後疼痛和嗎啡消耗有預防作用

(周曉敏 薛張綱 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.

 

鞘內可樂定與布比卡因對大鼠急性熱性或炎性痛具有協同鎮痛作用

(馬皓琳 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

關節鏡膝部手術後關節內給予蘇芬太尼和蘇芬太尼加甲強龍的鎮痛作用

(周曉敏 薛張綱 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.

單次劑量氟呱啶醇用於預防術後硬膜外嗎啡鎮痛引起的噁心和嘔吐

(彭中美 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.

對接受皮膚移植術的燒傷病人應用連續髂筋膜腔隙阻滯(FICB)的效果

(忻紀華 譯 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

乙酰水楊酸鹽、二氯芬酸和芬諾昔而非羅非考昔影響血小板CD62表達

(周曉敏 薛張綱 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

硬膜外鎮痛保持脊柱大手術後淋巴細胞免疫功能,而不是單核細胞

(張曦 譯,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.

大鼠足底切開前使用利多卡因和布比卡因預處理對脊髓C-FOS蛋白在時間和空間上表達的影響

(齊波 譯 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:

臨床術前評估中心術前評估患者的滿意程度

(方芳 薛張綱 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:

氯胺酮在內毒素血症的大鼠中低溫和淺低溫時的抗炎作用

(吳儉譯, 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.

複合外傷後反常栓子引起的腦血管意外

(朱輝 譯 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.

因未識別的乳膠過敏引起的長時間心血管衰竭

(方芳譯 薛張綱 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:

地氟醚和異氟醚對行腦幕上腫瘤顱骨切開術的患者腰椎腦脊液壓力的作用比較

( 慧譯 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.

蛛網膜下腔出血時腦自主調節功能的持續評估

(殷文淵 譯 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:

低位剖宮術中雙指數在1%.5%七氟醚中的價值

(方芳 薛張綱 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.

 

硬膜外注射羅呱卡因和布比卡因用於分娩鎮痛:一項關於産科預後的隨機雙盲試驗

(周雅春譯 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.

用雙盲,雙安慰劑對照試驗比較兩組腰硬聯合和硬膜外阻滯行分娩時鞘內舒芬太尼與胎兒心率異常關係

(殷文淵 譯 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:

用神經刺激器行鎖骨上阻滯降低抑未降低成功率?

(方芳 薛張綱 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

曲馬多加入1.5%甲呱卡因劑量依賴性增強腋路臂叢阻滯術後鎮痛效果

(周志堅 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

 

曲馬多加入1.5%甲呱卡因劑量依賴性增強腋路臂叢阻滯術後鎮痛效果

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

 

進行外周神經叢中阻滯麻醉時,在局麻藥中加入附加藥物,可以增強麻醉及術後止痛的質量,延長其時效。作爲止痛劑,曲馬多獨特的作用機制使其作爲附加藥可能有效。它顯示出了中樞止痛和外周局麻作用。我們設計了一個隨機對照、雙盲、前瞻性臨床試驗,來評估臂叢神經阻滯時加入曲馬多的效果。100例擬于臂叢神經阻滯下行腕管松解術的病人隨機分成四組。所有病例都用1.5%甲呱卡因40ml進行臂叢阻滯,所附加的成分四組分別爲等滲鹽水(P,17)、曲馬多40mg(T40,22)、曲馬多100mg(T100, 20) 、曲馬多200mg(T200, 20)。評價其麻醉起效時間、感覺和運動阻滯時間、術後止痛時間和質量及其不良反應。四組病例的感覺運動阻滯起效時間和持續時間無差異。和對照組相比,三組曲馬多病例術後要求額外止痛的病人數顯著減少(P=0.02);同時T200組相比於對照組和T40組,也存在這一差異。在對照組和T40之間、T100 T200之間,其差異無統計意義。進一步用Cochran-Armitage趨勢檢驗,四組病例趨勢差別有顯著意義(P=0.003),提示加入曲馬多減少術後額外止痛需求呈劑量依賴性。不良反應發生數在曲馬多組相對較多,但差異無顯著性。我們的研究提示,在用1.5%甲呱卡因進行臂叢阻滯時,加入曲馬多對延長止痛時間呈劑量依賴性,其不良反應在可接受範圍之內。然而,在被允許用於臨床實踐之前,曲馬多的安全性需要進一步研究。

(周志堅 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.

鞘內可樂定與布比卡因對大鼠急性熱性或炎性痛具有協同鎮痛作用

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

 

我們用一個急性和炎性痛的動物模型觀察了鞘內給予的布比卡因與可樂定的相互作用。對置入腰段鞘內導管的大鼠鞘內注射鹽水(對照)、布比卡因(1~100 µg)或可樂定(0.1~3 µg),並測試它們對尾部熱刺激(尾部擺打試驗)和後爪皮下注射福馬林(福馬林試驗)的反應。用等輻射分析測試合用布比卡因與可樂定對這兩個刺激的作用。檢查一般行爲和運動功能作爲副作用。在尾部擺打試驗及福馬林試驗的第一相和第二相中,布比卡因與可樂定合用時的50%有效劑量均顯著低於單個藥物的50%有效劑量(尾部擺打試驗2.820.11 µg 7.10.29 µg,福馬林試驗的第一相0.240.009 µg vs. 5.70.15 µg,第二相0.310.012 µg vs. 3.20.16 µg)。兩藥合用時副作用減少。這些結果提示鞘內合用布比卡因與可樂定在處理急性和炎性痛方面的作用令人滿意。

(馬皓琳 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.

 

中心靜脈導管正確放置:用經食道心超比較靜脈內心電圖和表面標誌技術

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

 

我們利用經食道心超(TEE)技術定位經右鎖骨下靜脈置入中心靜脈導管尖端位置,對靜脈心電圖(IV-ECG)引導導管尖端放置與傳統利用體表面標誌定位技術進行比較。60例病人隨機分成2組。在E組,通過充滿NaHCO3導管傳導IV-ECG信號以指導導管放置。在S組利用胸壁表面標誌以確定合適的導管長度。標準是用TEE確定導管尖端是否在交界脊上緣即上腔靜脈(SVC)與右心房(RA)交界處。當導管尖端處於交界脊上緣1.0 cm之內認爲導管位置滿意。當ECGP波最大時,E組所有30例病人導管尖端位置滿意。相反,S30例病人中只有16例位置滿意(P < 0.001)。所有導管在TEE指導下均重新調整以使導管尖端恰好位於SVC-RA連接處。當導管尖端證實處於SVC-RA連接處時,仰臥位元胸片仍顯示60例病人中有12例尖端位於RA中。結論:用IV-ECG引導靜脈導管放置可獲得滿意的位置,與TEE一致。而用胸壁表面標誌技術來確定導管尖端處於SVC-RA交界處則是不可靠的方法。

(王立中譯,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.


地氟醚和異氟醚對行腦幕上腫瘤顱骨切開術的患者腰椎腦脊液壓力的作用比較

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.

 

我們比較了腦幕下腫塊行開顱術的患者麻醉過程中使用地氟醚和異氟醚對大腦灌注壓(CPP)、腰椎腦脊液壓力(LCSFP)和平均動脈壓(MAP)的影響。另外,也觀察蘇醒情況以確定異氟醚或地氟醚麻醉哪個能進行更早期的神經功能評估。36名患者隨機使用1.2 MAC的地氟醚或異氟醚維持麻醉。通過蛛網膜下導管獲得腰椎腦脊液壓力(LCSFP)基礎值後對患者進行過度通氣 (PaCO2, 30 ± 2 mm Hg) 1.2MAC時,兩組過度通氣前後的平均LCSFP無統計學差異。此外,兩組的CPP亦沒有顯著的差異。地氟醚組患者對指令能應答的時間(30 ± 36 min)比異氟醚組(72 ± 126 min)50%,然而,這並沒有統計學差異(P = 0.17)。對腦幕上腫塊行開顱術的患者而言,地氟醚和異氟醚對CPPMAP的作用相似。過度通氣後地氟醚對LCSFP的影響不明顯。

(朱 慧譯 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.

 

單次劑量氟呱啶醇用於預防術後硬膜外嗎啡鎮痛引起的噁心和嘔吐

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

 

硬膜外應用嗎啡鎮痛經常引起術後噁心和嘔吐(PONV)。我們研究用單次,小劑量,較便宜的長效多巴胺受體阻滯劑——氟呱啶醇來防止脊麻局麻藥加嗎啡0.3mg鎮痛後引起的噁心和嘔吐的效果。我們選擇108個擇期在脊麻下行下肢整形外科或內窺鏡泌尿外科手術的成年病人,在脊麻注射後隨機給肌注氟呱啶醇1mgH1組),氟呱啶醇2mgH2組)或安慰劑(P組)。術後24小時內評估病人,噁心大於1釐米(10釐米的視覺類比評分法),或有嘔吐,需使用止吐藥治療的爲治療失敗。絕大多數治療失敗是發生在術後的最初12小時內(60%),且隨著氟呱啶醇劑量增加,發生率下降(最初的12小時:P76%H156%H250%P=0.012)。不論在哪組,病人以前有術後噁心和嘔吐史者與本次術後噁心和嘔吐的發生率明顯相關。氟呱啶醇兩組均未見肌張力增高反應。我們得出結論,雖然使用氟呱啶醇治療,嗎啡鎮痛引起的術後噁心和嘔吐(PONV)的發生率仍是重要問題,但氟呱啶醇能減輕鞘內嗎啡後噁心和嘔吐的發生率。

(彭中美 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.

 

豬急性三尖瓣反流不改變熱稀釋法心輸出量測定的準確性或精確性

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)時使用熱稀釋法測定心輸出量(TDCO)是否準確仍有爭議。我們在豬體內通過和電磁流量計(EMCO)在主動脈上獲得的資料比較來評估熱稀釋法技術的準確性和精確性。通過縫線將三尖瓣游離小葉固定來形成TR,而心輸出量用多巴酚丁胺來調整使其數值與對照測量值相一致。TR使每搏輸出量由原先的17.2ml減少爲12.6ml,並導致右房擴大以及搏動與右室同步。急性TR不影響TDCOEMCO之間的直線回歸關係且不改變其相關係數(對照和TR時均爲r = 0.94)。這些資料證明豬急性TR不影響TDCO的準確性和精確性。提示:心輸出量是一項有價值的指標可用來指導有心肺疾病患者的處理。本研究證明豬存在三尖瓣反流時用熱稀釋法測定心輸出量是準確的。

(黃施偉 譯,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.

 

熱蒸氣法增強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

熱蒸汽法可用於濕化皮膚,以增加皮膚的通透性。我們作了這樣一項研究,對15例女性志願者的皮膚使用45°C 的蒸汽毛巾熱敷5分鐘作預處理,以研究該法能否增強局部利多卡因粘膏的麻醉作用。將每位志願者一隻前臂的皮膚作熱敷預處理後,將利多卡因粘膏用於已處理的及未處理的前臂皮膚處並保留30分鐘。用27號針頭針刺5次,通過記錄患者疼痛體驗的次數來評估表面麻醉作用。單次穿刺27號針頭入皮深度達3 mm,作VAS評分以評估深層的麻醉作用。結果表明表面麻醉評分(感知疼痛次數)有明顯的減少(中數[範圍]:治療的前臂,2 [05], 未治療的前臂, 4 [15]; P < 0.01)及深層穿刺的 VAS評分 (中數[範圍]: 治療的前臂, 4.5 [08], 未治療的前臂, 8 [210]; P < 0.01)。結論,使用熱蒸汽毛巾增強了局部利多卡因粘膏的麻醉作用。

(裘毅敏 譯,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.

 

 

硬膜外鎮痛保持脊柱大手術後淋巴細胞免疫功能,而不是單核細胞

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.

 

脊柱大手術造成術後的疼痛。硬膜外疼痛治療可以減輕術後應激反應和由此影響免疫功能。在一個隨機雙盲對照的前瞻性研究中,54個病人接受傳統的病人自控靜脈鎮痛(PCIA;嗎啡3mg/15min),或者接受病人自控硬膜外鎮痛(PCEA;0.125%羅比卡因和蘇芬太尼1 µg/mL,背景劑量12ml/h,單次劑量5 mL/15 min)。爲了描繪免疫功能的特徵,在圍手術期測量迴圈中的細胞因數,C-反應蛋白(CRP),皮質醇,和免疫細胞表面的受體表達(區分簇CD14,人類白細胞抗原-DRCD86, CD71, CD3, CD4, CD8, CD16, CD19)。與PCIA比較,PCEA沒有影響迴圈中的細胞因數(白介素 (IL)-6, IL-8, IL-10, 腫瘤壞死因數a,單核細胞化學誘導蛋白-1, 巨噬細胞抑制因數)或者應激反應的指標(CRP和皮質醇)。同樣,單核細胞數或其人類白細胞抗原-DRCD86,CD71的表達沒有顯著性差異。相反,術後B淋巴細胞和T-輔助細胞的減少在PCEA組有統計學意義。自然殺傷細胞的減少在接受PCEA的病人較PCIA中顯著。因此,術後硬膜外疼痛治療對單核細胞功能沒有影響,但是減少自然殺傷細胞和保持B-細胞和T-輔助細胞數。因此,硬膜外鎮痛干擾特異性免疫系統而不是先天性免疫系統,可能減輕術後淋巴細胞抑制,有利於抵抗感染。

(張曦 譯,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.

 

 

術前口服Rofecoxib減少經腹子宮切除病人術後疼痛和曲馬多用量

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.

 

我們設計本試驗是爲了確定術前給一劑量的rofecoxib對於接受經腹子宮切除術的病人是否可以減少病人自控鎮痛(PCA)曲馬多的應用或者能夠加強鎮痛作用。60例病人被隨機分配到兩個組,一個組術前口服50mg rofecoxib另一組口服安慰劑。所有的病人都接受標準的麻醉方法,並記錄術中失血量。在手術結束時,所有病人都通過PCA裝置靜脈應用曲馬多。在術後124681224小時對病人的疼痛評分、鎮靜評分、平均動脈壓、心率和外周血氧飽和度進行評價。通過PCA裝置記錄同一時刻病人使用的曲馬多的總量和追加用量。記錄術後最初24小時鎮吐藥的用量和其他不良反應。還記錄了病人的住院時間。在術後最初12小時內,rofecoxb組病人與安慰劑組病人相比,六個觀察時間點疼痛評分均顯著低於後者(P<0.05)。安慰劑組病人曲馬多的總用量(627 ± 69 mg 535 ± 45 mg; P < 0.05)和追加用量在術後1246812小時時均顯著多於rofecixb組的病人。兩組間術中出血量、鎮靜評分、血流動力學參數、外周氧飽和度、鎮吐藥用量和術後不良反應均無差異。兩組病人的住院時間也相同。我們的結論是,在接受經腹子宮切除術的病人,術前口服rofecoxib能夠提供明顯的鎮痛效應,減少阿片類藥物需求量。

(顔濤譯, 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.

 

蒽環類抗腫瘤藥對麻醉期間心功能的影響

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

 

蒽環類抗腫瘤(anthracycline AC)的主要不良反應是心臟毒性。兒童腫瘤患者使用該藥後的生存者可遺留難以捉摸的心功能障礙,靜息時正常,運動後心功能明顯下降。爲瞭解在用過AC的小兒患者與正常兒童和青少年比較,麻醉引起的心功能改變是否有區別,我們前瞻性地研究了43位患者,並對其中42例進行了分析。AC21例,平均年齡9.6歲(範圍3-16歲),AC的平均累積劑量是193 mg/m2(範圍30490 mg/m2),靜息時心功能正常,收縮分數(SF0.34(正常值>0.3),在全麻下進行Hickman導管取出術。對照組(C組)21例,平均年齡10.9歲(範圍4-17歲),化療前行Hickman導管置入術。所有患者術前口服咪唑安定0.5 mg/kg,麻醉誘導採用硫噴妥鈉5 mg/kg,芬太尼3 µg/kg,羅庫溴銨0.6 mg/kg,麻醉維持用異氟醚1 MACN2O/O2 70/30)。選取以下四個時間點:誘導前(基礎值),誘導後5分鐘(T1),誘導後20分鐘(T2),拔管後20分鐘(對照值)。誘導前和拔管後採用經胸廓超聲心動圖,麻醉期間用經食道超聲測量心功能。兩組患者心功能的基礎值無顯著差異:SF 34.9 ± 3.7 AC組)比 34.1 ± 3.7 C組);每搏指數(SVI 36 ± 6 mL/m2AC組)比 35 ± 4 mL/m2C組);心指數(CI3.6 ± 0.6 L/min/m2AC組)比 3.2 ± 0.5 L/min/m2C組)。T1時和T2時兩組的SF值和SVI均明顯下降,AC組下降更明顯:T1 SF:26.2 ± 3.6 AC組)比 28.6 ± 3.6 C組)(P < 0.05),SVI:26 ± 4 mL/m2 AC組)比 30 ± 46 mL/m2 C組)(P < 0.05); T2 SF:24.1 ± 3.2 AC組)比 28.2 ± 2.5 C組)(P < 0.01),SVI:26 ± 6 mL/m2 AC組)比 31 ± 5 mL/m2 [C]P < 0.01)。兩組舒張功能(E/A比值,等容舒張時間)均無明顯變化。靜息時心功能正常的患者,過去的AC療法能增強現在的麻醉藥的心功能抑制作用。

(軒 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.

 

氯胺酮在內毒素血症的大鼠中低溫和淺低溫時的抗炎作用

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.

 

內毒素血症是危重病人的一個常見問題。我們以前的研究發現大鼠內毒素血症時氯胺酮能抑制低血壓和代謝性酸中毒,增加血漿細胞素濃度。雖然內毒素血症的病人常發生低體溫,但是氯胺酮在低體溫時能否保持抗炎作用仍未確定。我們研究了氯胺酮對中低溫和淺低溫內毒素血症大鼠的作用。雄性Wistar大鼠(n = 100)用戊巴比妥鈉腹腔內麻醉,分爲兩部分:一部分爲中低溫(30°C32°C)而另一部分爲淺低溫(33°C35°C)。每部分包括數量相同的5個小組:1) 正常體溫埃希氏大腸桿菌內毒素(15 mg/kg IV)組;2)正常體溫,在內毒素注射時和注射後注射氯胺酮組(10 mg kg-1 h-1 IV)3)低溫生理鹽水組;4)低溫下注射內毒素(15 mg/kg IV)組;5)低溫下注射內毒素後注射氯胺酮(10 mg kg-1 h-1 IV)組。然後通過加溫或降溫使實驗大鼠直腸溫度保持上述溫度6小時。我們測量血流動力學,酸堿狀況,血漿腫瘤壞死因數α和白介素-6的濃度。內毒素血症的大鼠發生了低血壓和代謝性酸中毒,以及血漿細胞素濃度升高。在內毒素注射後6小時,鹽水/正常體溫/內毒素組的平均收縮壓下降達71%,而氯胺酮/正常體溫/內毒素組、鹽水/中低溫/內毒素組和氯胺酮/中等低溫/內毒素組分別只下降6%, 41%29%。低溫的內毒素血症大鼠注射氯胺酮,不論中低溫或淺低溫,均可減弱低血壓,代謝性酸中毒和細胞素的增加,但這些作用並不優於單獨低體溫的效應。我們的發現提示,低溫期間氯胺酮注射可能沒有額外的有益的抗炎作用。

(吳儉譯, 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.

 

硬膜外注射羅呱卡因和布比卡因用於分娩鎮痛:一項關於産科預後的隨機雙盲試驗

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.

 

以往的試驗表明分娩時進行硬膜外鎮痛用0.25%的羅呱卡因較使用0.25%的布比卡因有更好的産科結果,但是對於此兩種藥物在更小濃度運用的情況下對産科預後影響是否有差別仍存在著爭議。該試驗爲前瞻性雙盲試驗,將350ASA分級III級的頭位單胎産婦隨機分爲羅呱卡因硬膜外鎮痛組和布比卡因硬膜外鎮痛組。鎮痛初始採用0.25%的藥液(羅呱卡因或布比卡因),維持採用0.1%的藥液(羅呱卡因或布比卡因)複合0.0002%芬太尼。需要時給予0.25%的藥液(羅呱卡因或布比卡因)作爲補充劑量。按照醫院標準産房協定處理分娩過程。在經陰道分娩的病人中,第一産程時間羅呱卡因組(中位數520分鐘,四分位數間距377-745分鐘)較布比卡因組(中位數645分鐘,四分位數間距460-820分鐘;P0.009)短,但是兩組間其他的産科預後或新生兒預後沒有差別。組間分娩方式相似,手術性分娩(經陰道器械輔助分娩及剖宮産)所占比例羅呱卡因組爲61.8%(95%可信限爲54.4-68.8%),布比卡因組爲58.4%(95%可信限爲50.9%65.5%)(P0.72)。

(周雅春譯 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).

 

青春期心臟手術後並發硬膜外血腫一例

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歲患者在全麻聯合胸部硬膜外阻滯下行主動脈瓣置換術,置換瓣膜爲生物瓣,手術過程順利。術後第二天患者開始接受抗凝和抗血栓治療,但是在行走時感覺後背疼痛,並發現硬膜外導管中有血。導管取出後,患者出現運動和感覺功能缺失。立即行椎管減壓術後神經系統功能恢復正常。就此類問題如何預防和處理進行了討論。

提示:硬膜外血腫是硬膜外麻醉中一種少見的並發症,在兒科心臟手術中未見報道。此類並發症能否處理成功的關鍵是及早發現,診斷和手術治療。

(張俊傑譯, 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.

 

芬太尼對大鼠阿心室肌細胞內鈣離子和細胞收縮性的作用

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

先前有關阿片類鎮痛藥對心臟作用的研究多集中於其對心肌收縮程度和時程的影響,而他們對心肌細胞內Ca2+的作用研究甚少。在本實驗中我們以酶消化和分離大鼠心室細胞,研究阿芬太尼對心肌收縮和細胞內暫態Ca2+的影響。以fura-2負載心肌細胞,並以1Hz電流刺激細胞,在30°C記錄細胞內暫態Ca2+流和心肌收縮程度。10-810-7M阿芬太尼對細胞收縮的幅度和時程以及細胞內暫態Ca2+流均無影響。然而,10-6M阿芬太尼引起細胞明顯的正性變力作用(P<0.001,平均無負荷縮短從7.3 ± 1.3 µm to 8.7 ± 1.4 µm(±SEM),即增加了20%。但對細胞內暫態Ca2+流無影響。10-6M阿芬太尼可提高肌纖維對Ca2+敏感性(P = 0.027),而 10-7M阿芬太尼無此作用。以上資料表明10-6M阿芬太尼(此濃度接近阿芬太尼臨床最大血漿濃度)能引起正性變力作用的機制是肌纖維對Ca2+敏感性增高而不是增加細胞內Ca2+濃度。

(趙雪蓮 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.


術前口服右美沙芬可減輕全麻下行膝關節十字韌帶再造術中止血帶引起的動脈血壓和心率的增加

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

 

止血帶引起的動脈血壓增高的機理還不清楚。我們觀察了術前口服右美沙芬對於全麻下行膝關節十字韌帶重建術的病人在術中使用止血帶所引起的動脈血壓以及心率的變化。在麻醉前2小時右美沙芬組(n38)病人服用右美沙芬30mg。對照組(n38)病人口服安慰劑。麻醉以2.0%七氟醚67N2O維持,術中氣管插管直到手術結束。動脈血壓和心率分別在止血帶充氣03060分鐘進行測定。對照組60分鐘時動脈收縮壓和心率都明顯高於右美沙芬組組。(分別爲: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],)右美沙芬組的動脈收縮壓和心率增加的百分率也較對照組小。結論,術前口服右美沙芬組30mg能明顯降低全麻下膝十字韌帶重建術中病人使用止血帶所引起的病人心率和動脈血壓的增加。

(沈浩 李士通 )

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.

鞘內應用嗎啡減少缺血-再灌注損傷大鼠模型的心梗面積

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.

 

全身性應用嗎啡減少心肌缺血再灌注損傷大鼠模型的梗死面積。我們試圖探索脊髓腔內應用極少量的嗎啡具有相似的心肌保護作用。Wistar 大鼠以巴比妥酸麻醉,開放胸腔,留置長期胸腔內管,並予血流動力學監測下閉塞冠脈30min後恢復灌注90min。以triphenyl-tetrazolium 染色來確定心肌梗塞面積。大鼠隨機分爲四組分別於閉塞前20min予鞘內(IT0.9% NS(對照組)、IV嗎啡(0.3 mg/kg+IT NSIT嗎啡(0.3 µg/kg)IT嗎啡(3 µg/kg)。與對照組相比另外三組均可減少梗死面積,以梗死面積占危險心肌面積的百分比(%AN/AAR)表示。%AN/AAR 值分別如下:IV(n = 7), 30% ± 6%; ITsmall-dose (n = 9), 30% ± 5%; ITlarge-dose (n = 9), 18% ± 4%;對照組 (n = 10), 47% ± 5%.預防性應用嗎啡的大鼠之間心肌梗死面積無顯著區別。缺血再灌注期間ITlarge-dose 組心率無明顯改變,而ITsmall-dose組,IV組及對照組心率出現了顯著的下降。各組之間血壓改變無明顯區別。這些結果表明鞘內應用嗎啡可減少大鼠心梗面積且效果與靜脈應用嗎啡相近。

(鍾鳴 薛張綱 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.

 

擇期肝切除術需用異體血患者中應用促紅細胞生成素的作用:一項類比模型

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.

 

我們觀察擇期肝切除術患者應用重組人促紅細胞生成素(rHuEPO)可減少紅細胞輸注需求。共回顧了200例擇期肝切除術患者,以邏輯衰減分析圍手術期紅細胞輸注的可能預見因素。構建一個數學模型來類比紅細胞輸注需求:a)輸注閾值設爲Hb78 g/dL b)術前Hb1013 g/dL 的患者應用rHuEPO 使其Hb術前提高至15 g/dL c)以上兩種方式合用。並對rHuEPO的應用行費用/效果評價。紅細胞輸注與肝大部或小部切除、全肝血流阻斷、聯合腹部非肝手術有關,而與術前Hb1013g/dL無關。應用小的輸注閾值或單獨應用rHuEPO僅輕度減少紅細胞輸注量及輸注頻率,而聯合應用兩種干預方法將顯著減少以上兩個變數。118位行肝部分或大部切除術患者92%接受紅細胞輸注。這118位患者中66位術前Hb1013g/dL並于術前應用了rHuEPO。單獨應用rHuEPO避免了203位患者中的63位輸注紅細胞,以及31位患者中12位輸注紅細胞(P = 0.02)。這66位患者應用rHuEPO耗費186,000歐元,而避免63位患者輸注紅細胞僅節約10,710歐元。

(鍾鳴 薛張綱 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.

 

小兒脊柱術後鞘內及硬膜外鎮痛的回顧

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

 

鑒於區域麻醉技術應用于控制嬰幼兒術後疼痛的經驗,大型矯形外科如前、後入路脊柱融合術後應用區域麻醉鎮痛具有相似的有效性及安全性。我回顧了兒科脊柱手術後應用神經阻滯鎮痛的相關報道。手術方式及麻醉方法的差異使得對照研究難以實施。麻醉方法的差異包括:1)劑量;2)給藥途徑如鞘內或硬膜外;3)給藥方法(單劑、間斷給藥、持續注藥);4)硬膜外導管數量(一或二根);5)注射藥物(阿片類、局麻藥或二藥合用);6)阿片藥物種類(嗎啡、芬太尼、水合嗎啡);7)麻醉鎮痛控制組(間斷按需注射嗎啡或病人自控麻醉)。雖然尚無足夠資料證明此種麻醉技術優於腸道外應用阿片類藥物,但臨床資料確證了其他的優點包括減少術中失血量及腸道功能早期恢復。

(鍾鳴目譯 薛張綱 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改善全麻後恢復

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

 

全麻後恢復常有殘餘鎮靜、嗜睡、疲勞和乏力,這些將持續幾小時到幾天。Modafinil是治療發作性睡眠症(白天過分嗜睡)病人,有助於促進覺醒的藥物。我們評估了全麻後恢復病人使用單劑量modafinil (200 mg)和安慰劑的效果。經IRB同意,34個病人進入到此項前瞻性、隨機化和雙盲性的研究。術前,使用VAS量表要求病人評估此前24小時他們的各種症狀,此量表爲010的不連續標度量表。術後,一旦病人可以口服並符合制度標準,就給予一小口水服用研究的藥物(modafinil 200 mg 或安慰劑)。給藥後24小時接觸病人以評估給藥後的症狀。安慰劑組病人反應術後明顯更疲勞(4.8 [3.3] 對比 1.4 [1.8]),更疲憊(4.3 [3.3] 對比 2.4 [3.1]),或更感到筋疲力盡(4.7 [3.6] 對比 2.9 [2.4])。很明顯,安慰劑組的病人更多出現中到重度的疲勞(65% 對比 12%)。在“敏捷”和“精神”兩個主要專案中,服用modafinil的病人有71%,而服用安慰劑組只有18%Modafinil明顯有助於全麻後病人恢復。

(陸旭偉 薛張綱 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.

 

比較七氟醚和異氟醚複合笑氣和硬膜外阻滯麻醉下肝硬化病人行肝切除術後的肝功能

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,我們比較了肝硬化病人在異氟醚和七氟醚複合笑氣和硬膜外麻醉下術後肝功能的情況。40Child-Pugh分級爲A4070歲、準備行肝部分切除的病人,使用0.1 mg/kg的咪達唑侖和4 mg/kg的芬太尼行麻醉誘導,麻醉維持使用硬膜外間歇注入1.5%的利多卡因46 mL、七氟醚或異氟醚、3 L/min的笑氣和3 L/min的氧氣。術前和術後的137天測量天門冬氨酸轉氨酶、丙氨酸轉氨酶、總膽紅素、鹼性磷酸酶、膽鹼酯酶、白蛋白、凝血酶原時間和血小板計數。兩組病人的天門冬氨酸轉氨酶、丙氨酸轉氨酶和鹼性磷酸酶都在術後第3天顯著升高並達峰值。異氟醚組的這些變數的升高顯著大於七氟醚組。沒有病人發展爲肝功能衰竭。所有肝酶的升高都很小並且無可疑的臨床相關性。對於肝硬化病人的肝損害方面,複合笑氣和硬膜外阻滯時使用七氟醚是否優於異氟醚尚無定論。結論:在Child-Pugh分級爲A的肝硬化病人,複合笑氣和硬膜外阻滯時異氟醚引起的術後血清肝酶濃度的升高較七氟醚大。然而這種升高是很小的,不會導致臨床肝損害。

(陸旭偉 薛張綱 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

 

氙氣和異氟醚在調節LPS介導的NF-κB活性和單核細胞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

 

麻醉藥已知可干擾炎性細胞因數的生成。在本研究中,我們研究了氙氣和異氟醚在體外試驗中對LPS介導的NF-κB活性和TNF-αIL-6生成的影響。在含有或不含氙氣(30 60 Vol%)或異氟醚(1 2 MAC)的全血中培養LPS4小時後測定離心血清中的TNF-αIL-6含量。使用從血液樣本中分離出的單核細胞來研究NF-κB,待整個細胞溶解後,用測定NF-κB的酶聯免疫吸附劑試劑盒來測定結合到靶定DNANF-κB p50 p65亞單位的量。相對於對照組,含氙氣組中LPS介導的TNF-αIL-6的生成及NF-κB的活性均有顯著升高;與之相反,異氟醚抑制NF-κB的活性,這與TNF-α和IL-6生成減少有關。我們的結果顯示:氙氣和異氟醚在LPS介導的TNF-α和IL-6生成方面有著相反的作用,此外,氙氣升高NF-κB的活性,而異氟醚則抑制,這可能爲兩者對單核細胞生成TNF-α和IL-6作用的不同影響提供了分子機制。

(陸旭偉 薛張綱 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.

 

局麻藥對單核細胞mCD14和人類白細胞抗原-DR表達的影響

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

 

現已證明局麻藥對免疫系統有多重作用。單核細胞和巨嗜細胞是對微生物感染的宿主反應的必要組份;然而,局麻藥對單核細胞表面受體的表達仍不清楚。我們設計了該試驗以研究局麻藥對單核細胞mCD14和人類白細胞抗原(HLA)-DR表達以及脂多糖(LPS)或葡萄球菌腸毒素BSEB)誘導的腫瘤壞死因數(TNF{alpha}産生的影響。從10名健康志願者抽取血標本。局麻藥對LPSSEB誘導的TNF{alpha}産生的影響通過酶聯免疫吸附實驗來檢測。在給予不同劑量的局麻藥後,血液被LPS10ng/mL)或SEB10ug/mL)刺激4小時。局麻藥對單核細胞mCD14HLADR表達的影響通過雙單克隆抗體染色和流式細胞分析來檢測。局麻藥並未顯示對人類全血LPSSEB誘導的TNF{alpha}的産生有何影響。局麻藥對單核細胞HLADR表達呈劑量依賴性抑制(P<0.05)但對單核細胞mCD14表達無影響。該試驗證明了局麻藥對人類單核細胞表面HLADR的表達有抑制作用。

(周曉敏 薛張綱 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.

 

圍術期靜脈注射利多卡因對腹部大手術術後疼痛和嗎啡消耗有預防作用

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

 

鈉通道阻滯劑已被認可靜脈內給予以治療神經性疼痛狀態。亞臨床研究已提示抗痛覺過敏藥物影響外周和中樞神經系統。本研究目的在於檢測圍手術期給予利多卡因的鎮痛和抗痛覺過敏的經時反應進程機制。40名將行大型腹部手術的病人參與了該項隨機雙盲試驗。20名患者接受了2%的利多卡因(首劑1.5mg/kg10分鐘內注射,隨後以1.5 mg • kg-1 • h-1的速度維持),另20名患者接受了生理鹽水安慰劑。注射在切皮前30分鐘開始,手術結束後1小時結束。我們檢測了利多卡因的血藥濃度。至術後72小時評估了術後疼痛分級(010級的數位分級量表)和嗎啡的消耗量。手術期間平均利多卡因濃度爲1.9 ± 0.7 µg/mL。病人自控鎮痛獲得滿意的效果(靜止時的數位化分級量表,<= 390%-95%;無組間差異)。接受利多卡因的病人主訴在術後首個72小時運動時較少的疼痛和需要更少的嗎啡(103.1 ± 72.0 mg對應159.0 ± 73.3 mgStudent’s t-test; P < 0.05)。因爲這種減少阿片類藥物的作用幾乎都在術後第三天明顯,故利多卡因可能確實存在預防性鎮痛作用,而從臨床相關的角度來講極有可能是通過預防中樞性痛覺過敏的方式發揮這種作用。

(周曉敏 薛張綱 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.

 

關節鏡膝部手術後關節內給予蘇芬太尼和蘇芬太尼加甲強龍的鎮痛作用

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

 

我們研究了在膝關節鏡半月板切除術後關節內給予生理鹽水、蘇芬太尼和蘇芬太尼加甲強龍的作用。在一項隨機雙盲試驗中,60名患者被分配到全麻關節鏡結束時關節內給予生理鹽水組、蘇芬太尼10ug組和蘇芬太尼10ug加甲強龍40mg組。術後,病人靜止和運動時(例如,主動曲膝)時的疼痛水平通過一個視覺化的類比量表來評測,結果顯示同對照組相比,蘇芬太尼和蘇芬太尼加甲強龍組的疼痛水平明顯下降。此外,我們還發現在膝關節鏡半月板切除術後使用關節內給予蘇芬太尼和蘇芬太尼加甲強龍後能使術後早期鎮痛劑的需要量下降。另外,同對照組相比,我們發現蘇芬太尼的鎮痛作用能延長至24小時,然而當我們聯合使用蘇芬太尼加甲強龍時,我們發現疼痛和鎮痛劑的用量比使用蘇芬太尼時進一步下降了。

(周曉敏 薛張綱 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.

 

酰水楊酸鹽、二氯芬酸和芬諾昔而非羅非考昔影響血小板CD62表達

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

 

非甾體類抗炎藥作爲常規在圍手術期使用。由於血小板內缺乏環氧化酶,所以環氧化酶2選擇性藥物被認爲沒有血小板抑制作用。由於血小板在凝血過程中扮演重要角色,故若無血小板抑制可能減少術後出血並發症。我們通過流式細胞分析研究阿司匹林、二氯芬酸、芬諾昔康和羅非考昔布對花生四烯酸和膠原誘導的CD62P選擇)表達。68名志願者在口服攝入由研究隨機設計的藥物前和之後的1312小時抽血。阿司匹林、二氯芬酸、芬諾昔康對血小板的花生四烯酸和膠原誘導的CD62P選擇表達有明顯的影響而羅非考昔則未顯示這種影響。我們得出結論,考慮到抑制血小板功能方面,在圍手術期使用羅非考昔是安全的。

(周曉敏 薛張綱 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.

 

臨床術前評估中心術前評估患者的滿意程度

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

 

臨床術前評估中心(PATCS)包括術前外科,麻醉,護理和實驗室等方面的考慮。雖然這些已經被認爲是有效的,但是患者的體驗和對它的滿意程度尚未得到評價。我們向在三個不同的時間段來PATCS的患者分發了一頁紙的問卷。包括對臨床和非臨床的幫助者的滿意程度。18道題目分別有5Likert 程度的選項,從好(5分)到差(1分)。問卷的回收率是71.4%。代表各項滿意率的均數是4.48 ± 0.67,總的表的均數是4.46 ± 0.55。雖然最高分出現在麻醉,護理和實驗室檢查方面,但是只有麻醉的分數隨著時間在上升(P = 0.007)。代表知情和交流的選項和滿意程度的相關性最高(r = 0.76; P < 0.0001)。對整個臨床訪視過程的滿意程度(3.71 ± 1.26)顯著(P < 0.0001)低於其他專案。作者認爲術前訪視者和術前訪視功能性的方面對患者的滿意程度有很大的影響。其中告知和交流是正性影響因素,而訪視的時間是負性影響因素。

(方芳 薛張綱 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.

 

因未識別的乳膠過敏引起的長時間心血管衰竭

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

我們提供了一個持續的過敏反應病例,和使用頭孢唑啉有關係。其後的過敏源試驗出人意料地顯示對乳膠過敏而對頭孢唑啉不過敏。我們的病例說明過敏反應發生前的用藥不能想當然地認爲是過敏源,乳膠過敏應該作爲一種鑒別診斷。由於過敏源不可能馬上確定,術中處理患者的心血管崩潰應該在一個無乳膠的環境中。

(方芳譯 薛張綱 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

 

低位剖宮術中雙指數在1%.5%七氟醚中的價值

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

 

剖宮産術中知曉率的上升可能和缺少阿片類藥物鎮痛而引起的催眠不夠有關。在術中潮氣末0.5MAC的異氟醚和50%N2O的情況下雙極指數(BIS)>60,這是術中無知曉的域值.我們研究的目的是爲了確定相同濃度的七氟醚時的BIS,是否加大濃度可以使BIS值持續保持小於6020ASAI-II的臨産婦隨機分爲兩組,一組在50%N2O中加入1%七氟醚,一組加入1..5%的七氟醚。誘導使用4 mg/kg的硫噴妥鈉。胎兒娩出後使用0.1–0.15 mg/kg的嗎啡。切皮到胎兒娩出這段時間1%的七氟醚組的平均BIS值是61(95% 可信區間, 57–64),另外一組是42 (95%可信區間, 37–47)BIS值在切皮,切子宮,分娩和分娩後10分鐘兩組間有顯著差異,其後則無。母親和新生兒的預後是沒有差別的。

(方芳 薛張綱 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.


用神經刺激器行鎖骨上阻滯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

 

使用攜帶型的神經刺激器進行神經阻滯已有40多年的歷史了。廣泛認爲在低刺激電流的情況下尋找到運動反應可以提高成功率。一般都是開始使用一個大的電流。如果觀察到足夠的反應,在注入局麻藥前調小電流。然而,多小的電流足夠小了,多大的電流足夠大了尚未確定。我們的經驗顯示,行鎖骨上阻滯時,反應的形式和電流的大小一樣重要。而電流不大與1 mA。這樣來說,如果有合適的反應的話,我們使用0.9 mA的電流作爲注射電流在理論上也是可能的。我們設計了這樣一個實驗。用0.9 mA的電流引起指伸和屈的活動,然後注入局麻藥。我們的目的不是爲了確定是0.9 mA還是0.5 mA是最小的電流,而是爲了引出一個無誤的運動。60位患者隨機分爲2組。組1(n = 30)0.5 mA的電流下還能看到運動,然後注入藥物。組2(n = 30)0.9 mA的刺激下看到和組1一樣的反應後就注入藥物,不再降低電流。總共注入40毫升的局麻藥。一位患者由於不符合納入標準而退出實驗。剩下的59人的成功率爲100%。成功的標準是注藥後30分鐘內,手部的尺,橈,正中神經支配區域的感覺完全阻滯,不需要加藥也不需要複合全麻。事實上,所有的阻滯都在22分鐘內完成。組1的起效時間是10.9 ± 5.4分鐘,組2 11.4 ± 4.8分鐘。沒有顯著差異。沒有並發症,受試者的滿意程度也是一樣的。我們認爲在鎖骨上阻滯中使用0.9 mA的電流引出手指可見的反應後可以立即注入藥物,因爲降低到0.5 mA並不提高總的起效,持續時間和病人的滿意程度。

(方芳 薛張綱 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


變力性藥物改善主動脈瓣狹窄行主動脈瓣置換術病人的右心功能

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


目前主動脈瓣狹窄行主動脈瓣置換術病人術中使用變力性藥物尚有爭議。問題在於是否影響左心室收縮功能以及是否引起左心室舒張功能障礙,左室功能是否保持並得到改善。本實驗中,作者總結了主動脈瓣狹窄行主動脈瓣置換術病人術中應用變力性藥的益處。34名病人隨機分爲3組:腎上腺素,米力農和安慰劑組。在CPB前和結束時記錄血流動力學和心功能資料。使用變力性藥物後,右心室(RV)明顯增大(安慰劑,+0.5%;腎上腺素,+9%;米力農,+8%P<0.01),左心室(LV)明顯增大(安慰劑,+7%;腎上腺素,+18%;米力農,+20%P=0.07),EFCOCPB之後也有明顯增加。心輸出量和心指數與RVEFr=0.56, r=0.47, )較與LVEFr=0.22r=0.08)相關性更顯著(P<0.01)。使用腎上腺素和米力農的病人中,只有一名病人(1/22)出現RVEF降低,而使用安慰劑的病人中,有6名病人(6/12)在CPB後出現RVEF降低。同樣,在所有使用腎上腺素和米力農的病人中,只有一名病人(1/22)出現LVEF降低,而使用安慰劑的病人中,有3名病人(3/12)在CPB後出現LVEF降低。沒有病人出現左心室流出道梗阻(LVOTO)的情況。因此,主動脈瓣狹窄行主動脈瓣置換術病人術中使用變力性藥物可以改善血流動力學狀況,其對右室功能的改善明顯高於對左室功能的改善。

(周潔 譯 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.

 

多巴胺對冠狀動脈旁路吻合術常用離體動脈的不同效應

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

多巴胺對冠狀動脈旁路移植動脈的直接效應目前尚未得知。作者研究了離體動脈(取自於用作冠狀動脈旁路吻合術的橈動脈(RA),胃網膜動脈(GEA),乳內動脈(IMA))對多巴胺的效應。多巴胺對RA呈現一個劑量相關性的收縮作用,這一效應與功能性內皮細胞沒有直接關係。使用多巴胺A1受體拮抗劑SCH23390後這一收縮作用會增強,而使用α1腎上腺素能拮抗劑呱唑嗪後,這一收縮功能會減弱。在GEAIMA,也出現類似的結果,但效應較弱。在RA,多巴胺可以增強去甲腎上腺素(NE)引起的血管收縮,而多巴胺的這一效應可以被SCH23390增強。在GEA,低濃度(<10-7mol/L)的多巴胺可以減弱NE引起的血管收縮,而高濃度時則無此作用。在IMA,只有較高濃度的多巴胺(10-6-10-5mol/L)才能對NE收縮的血管有擴張作用。在GEAIMA,由多巴胺産生的對NE收縮的血管的擴張作用都可以被SCH23390抑制。上述結果表明,多巴胺與DA1和α1腎上腺素能受體的密切關係可以用來解釋其對各動脈的不同作用。

(周潔 譯 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.


小兒硬膜外麻醉後阻滯擴散平面與腎上腺素對心輸出量的影響:隨機,雙盲,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

 
小兒硬膜外麻醉一般認爲對血流動力學沒有嚴重的影響。然而,與成人不同的是,很少有人研究小兒硬膜外麻醉時心輸出量的變化。作者前瞻性研究的選擇48名小兒 (平均年齡22.5) 使用食管多譜勒超聲儀監測心輸出量,研究血流動力學的變化。使用七氟醚複合尾部或胸腰部硬膜外麻醉,隨機分成兩組:對照組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),腎上腺素組用同樣的局麻混合液1mL/kg,再加入腎上腺素5μg/mL。結果:對照組除了引起輕度的心率下降以外,沒有明顯的血流動力學的變化。腎上腺素組,平均動脈壓下降14%-17%,系統血管阻力下降24%-40%,而心輸出量則增加20%-34%。並且這種腎上腺素效應在胸腰部阻滯比在尾部阻滯更明顯。結論:小兒硬膜外麻醉局麻藥混合液中加入腎上腺素引起心輸出量的增加,原因可能是硬膜外間隙吸收腎上腺素所致。
(齊波 譯 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.



圍術期使用羅非考昔(Rofecoxib)可促進門診疝修補術患者的早期康復

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

非阿片類鎮痛藥作爲多制式鎮痛方法的一部分越來越普遍。作者隨機,雙盲,安慰劑對照研究腹股溝疝患者圍術期使用環氧合酶抑制劑羅非考昔(Rofecoxib)的效果。60名疝修補術病人隨機對照組(維生素C500mg)和羅非考昔組(羅非考昔50mg)。第一次使用藥物是在患者進入手術間前的30-40分鐘口服,第二次是術後第一天的早晨。病人在出恢復室之前每110分鐘記錄一次恢復時間,疼痛評分,需追加鎮痛劑情況以及副作用。術後36小時,7天和14天再次評估疼痛情況,鎮痛需求,運動恢復正常狀況及患者對術後鎮痛的滿意度。羅非考昔顯著降低了早期恢復時間,並使患者手術後能更早回家(88±30min126±44minP0.05),羅非考昔組患者平均恢復評分也明顯高於對照組(18[14-18]16[13-18]P0.05)。恢復期,對照組的病人需要追加鎮痛藥的比例明顯高於羅非考昔組(67%37%P0.05)。患者術後36小時的再次評估中,羅非考昔組的患者口服鎮痛藥明顯少於對照組(0[0-20]9[1-33] 顆,P0.05),並且最大疼痛評分降低,術後鎮痛的滿意度提高(3[1-4]2[0-3]P0.05)。兩組病人日常活動恢復的時間沒有顯著差異。總之,圍術期口服羅非考昔50mg/次,能顯著減輕術後的疼痛並減少鎮痛藥的追加量,促進門診疝手術患者更快更好地恢復。但並不能改善最終的恢復時間。

(朱輝 譯 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.


羅庫溴胺和維庫溴胺的皮膚敏感性——健康志願者的隨機對照研究

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

皮膚過敏試驗常用以判斷麻醉中出現的過敏反應是否由於神經肌肉阻滯藥(NMBDs)所致。然而皮膚過敏試驗中神經肌肉阻滯劑應用濃度仍存在爭議。本實驗觀察羅庫溴胺和維庫溴胺進行皮膚過敏試驗時皮疹和水皰的發生情況。30位健康、無過敏遺傳史的1840歲的志願者(男14,女16),隨機分爲10組:羅庫溴胺和維庫溴胺分別被稀釋爲1100011001101,另兩組爲對照組。用藥後立即及15分鐘後記錄NMBDs引起的全身和皮膚反應情況並測量皮疹和水皰的表面積。在使用維庫溴胺和羅庫溴胺後沒有一名志願者立即出現全身和皮膚過敏症狀。濃度爲11000羅庫溴胺和維庫溴胺用藥後15分鐘無陽性反應,純濃度的羅庫溴胺和維庫溴胺分別有50%40%出現陽性反應。實驗中存在性別差異。作者認爲純濃度羅庫溴胺和維庫溴胺皮膚過敏試驗診斷過敏反應源不一定可靠。

(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.

 

脂多糖誘導炎症反應中預防性使用異氟醚可促進血流動力學穩定並增加大鼠腸系膜白細胞運動速率

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

作者假定預防性使用異氟醚可對脈管系統起到保護作用,部分原因是通過改變白細胞-內皮細胞的相互作用所致。大鼠戊巴比妥麻醉後隨機分爲四組:對照組、異氟醚組(吸入1.4%的異氟醚30分鐘)、脂多糖組(LPS10mg/kg IV)、ISO-LPS組(先吸入異氟醚後使用LPS)。隨後在電視顯微鏡下在體觀察腸系膜,並每小時測量平均動脈壓(MAP)和微循環變化,包括毛細血管後小靜脈和小動脈的血流速率以及白細胞動態。在LPS組應用異氟醚後2—4小時可明顯減少MAP的下降程度並提高了白細胞的運動速率(P<0.05)。4小時後白細胞的運動速率增快>200%ISO-LPS組與LPS組相比爲63.7+27.6m/s19.8+6.4m/s)。在對照組預防性使用ISOMAP和白細胞速率無影響但可增加白細胞的數量。預防性使用ISO不會影響LPS組的小動脈和毛細血管後小靜脈的運動速率,也並不影響LPS組和對照組白細胞的附著性。結論:預防性使用異氟醚可以維持血流動力學穩定以及增加大鼠腸系膜白細胞運動速率,但它並不能改變LPS引起的炎症反應中白細胞的數量和附著性。

(朱慧琛 譯 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.

 

異丙酚對大鼠下丘腦室旁核神經元的作用

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

麻醉引起低血壓的機理尚未完全明瞭,尚無電生理實驗發現異丙酚對交感系統和心血管功能的影響。通過膜片箝技術的全細胞模式作用於大鼠下丘腦室旁核神經元(PVN)切片,內研究了異丙酚對大鼠下丘腦室旁核神經元的作用。異丙酚在濃度10-5~10-4M時,産生Cl-電流,對印防己毒素敏感,在更小濃度範圍內,對番木鼈堿敏感。10-6M的異丙酚加強GABAA 産生的電流,另外,異丙酚(10-510-4M)顯著地增加了突觸後誘發-抑制電流的衰退時間,提示了GABAA受體的突觸後調節作用。另外,異丙酚(10-510-4M2*10-4M)可逆性地抑制了電壓門控Ca2+通道,這些結果顯示異丙酚在中樞水平加強了GABAA受體介導的電流並抑制了電壓門控Ca2+通道,可能影響了心血管和交感神經系統,至少部分與全麻所導致的低血壓有關。

(陳潔 譯 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.


 

術後口服羅非考昔(Rofecoxib)減輕經腹子宮切除術後疼痛和減少曲馬多的用量

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
本實驗探討經腹子宮切除術後口服羅非考昔(Rofecoxib)是否能減少患者自控鎮痛(PCA)的曲馬多用量或增強鎮痛效果。術後60例患者隨機口服安慰劑或羅非考昔50mg。所有患者接受標準的麻醉方案,記錄術中的血液丟失量。手術後,所有的患者接受靜脈曲馬多PCA。術後124681224小時測定疼痛評分、鎮靜評分、平均動脈血壓、心率和外周血氧飽和度。同時記錄曲馬多的總量和增加劑量、術後24小時的抗嘔吐藥需要和副作用。術後12小時羅非考昔組的疼痛評分低於安慰劑組6倍(P0.05)。安慰劑組的曲馬多總量顯著高於羅非考昔組(627±69mg 535±45mgP<0.05)。組間術中血液丟失、鎮靜評分、血流動力學變化、外周血氧飽和度、術後不良反應無顯著性差異。兩組病人住院時間相似。結論:羅非考昔術後口服有明顯的鎮痛作用並減少了經腹子宮切除術後患者的阿片類藥物的需要量。

(陳潔 譯 陳傑 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.

 

對接受皮膚移植術的燒傷病人應用連續髂筋膜腔隙阻滯(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

術後取皮部位的疼痛強度常較植皮部位更高。作者前瞻性隨機雙盲試驗中評估應用連續髂筋膜腔隙阻滯減輕取皮部位疼痛的效果。表面燒傷面積爲16%±13%20例患者隨機接受0.2%的羅呱卡因或0.9%的生理鹽水。所有的病人均在全麻後於髂筋膜腔隙(FICB)預先隨機注射藥液40毫升,隨後連續注射羅呱卡因或生理鹽水(速度爲10ml/h)直至首次更換敷料(72小時後)。術後聯合應用propacetamol 2g/6h,病人靜脈自控鎮痛鹽酸嗎啡2mg/ml,在首次傷口換藥前60分鐘口服鹽酸嗎啡0.5mg/kg。術前、術後24h48h、首次傷口換藥時,應用視覺類比評分和Mann-Whitney U檢驗。如果需要累積嗎啡消耗量對比Scheffe法重復測量變異分析。接受連續FICB的病人術後所有時段的嗎啡用量均減少(與對照組相比,分別爲23±20mg88±29mgp<0.05)。FICB組在首次換藥時的視覺類比評分明顯降低(3[1]7[3];中線值[四位數範圍]p<0.05)。結論FICB對減輕大腿部位供皮部位的疼痛是有效的。

(忻紀華 譯 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)


 
大鼠足底切開前使用利多卡因和布比卡因預處理對脊髓C-FOS蛋白在時間和空間上表達的影響

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開時脊髓背角中C-FOS蛋白在時間和空間上的表達及局麻藥預處理後對表達的影響。大鼠麻醉下在足底切開前分別給用0.5%布比卡因(B組),2%利多卡因(L組)和生理鹽水(C組)做神經阻滯和局部浸潤麻醉。切開後1,3,6,24,48,72120 h, 評估疼痛和在脊髓的腰4,5節段c-FOS的表達。結果顯示在1-120h間,機械刺激的興奮域的明顯下降,(1-72h,p<0.01;120h,p<0.05)B組和C組,其域值明顯提高(與C組相比1h: B組和Cp<0.013h: B組和Cp<0.01);6h(B,p<0.01L,p<0.05)C,FOS的表達主要在一到二層細胞,和五到六層細胞,表達高峰出現在切開後一小時,然後逐漸下降。結論:使用了局麻藥可以在各個層面抑制FOS的表達,而這種抑制可以持續幾天。這項研究爲證明因足底切開而引起的FOS在時間和空間的表達的變化提供了證據。研究顯示使用局麻藥可以在術後的幾天內抑制FOS的表達,而止痛效果的長短有賴於局麻藥的持續時間。

(齊波 譯 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.


 

合外傷後反復常栓子引起的腦血管意外

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

作者報道了一例機動車輛撞傷的57歲患者3天後發生了無法解釋的腦血管意外。這例患者在診斷檢查中發現既往未知的卵圓孔疾病。我們在此討論反常栓子的病因。

(朱輝 譯 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.

 

蛛網膜下腔出血時腦自主調節功能的持續評估

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

腦血管痙攣一直是蛛網膜下腔出血後主要的致殘和致死原因。當腦自我調節功能不能代償痙攣時就産生腦缺血。作者應用經多譜勒研究血管痙攣對自我調節功能的影響。動脈血壓的緩慢變化和平均血流速率(MFV)或收縮血流速率(SFV)之間的動態關聯係數分別以“Mx”和“Sx”來表示,並以此代表腦自我調節功能。當MFV增加到大於120cm/s以及lindegaard比大於3可確定有血管痙攣。32名蛛網膜出血病人中的15人有血管痙攣。根據血管痙攣病人雙側大腦中動脈的顱內多普勒報告,計算基線和血管痙攣時的MxSx值。血管痙攣時Mx0.46±0.32)顯著高於基線水平(0.21± 0.24P0.021)。Sx也升高(0.22±0.260.05±0.21P0.03)。MxMFVr0.577P0.025)和lindegaard比相關聯。血管痙攣側的MxSx比對側均升高。血管痙攣期間的MxSx升高說明腦自我調節功能受損。MxSx提供了蛛網膜下腔出血病人自主調節功能變化的額外資訊。

(殷文淵 譯 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.


 

用雙盲,雙安慰劑對照試驗比較兩組腰硬聯合和硬膜外阻滯行分娩時鞘內舒芬太尼與胎兒心率異常關係

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

腰硬聯合鎮痛用於分娩鎮痛變得越來越普遍了。可是,鞘內舒芬太尼對子宮活躍過度的發生和胎兒心率異常的影響仍有爭議。我們假設鞘內使用舒芬太尼7.5μg比小劑量舒芬太尼與布比卡因聯合應用脊麻或硬膜外鎮痛容易産生FHR異常。300名臨産産婦隨機分爲三組。第一組,EPD組,硬膜外應用布比卡因12.5mg,腎上腺素12.5μg和舒芬太尼7.5μg 混合液10ml;第二組,BSE組,鞘內注射布比卡因2.5mg,腎上腺素2.5μg和舒芬太尼1.5μg;第三組,SUF組,蛛網膜下腔注射舒芬太尼7.5µg。所有患者使用病人自控硬膜外鎮痛,用0.125%布比卡因,腎上腺素1.25µg/ml和舒芬太尼0.75μg/ml(負荷劑量4ml;鎖定時間15分鐘)。在鎮痛前15分鐘和鎮痛開始後的60分鐘內監測心張力圖。記錄鎮痛效果,分娩質量,新生兒結果和副作用。在開始麻醉的第一個小內SUF24%病人發生了FHR異常(速率增加和晚期減速)BSE組爲12%EPD組爲11%SUF12%臨産婦發生了子宮活躍過度,而在其他組只有2%CSE組麻醉起效快於EPD組。嚴重低血壓發生率分別爲BSE組爲29%EPD組爲7%SUF12%。所有這些差別均有統計學意義。上述結果證實大劑量舒芬太尼(7.5μg或更多)脊麻時存在子宮活躍過度和FHR異常的危險。

(殷文淵 譯 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.