Anesthesia & Analgesia

May 2004

Table of Content

 

EDITORIALS:

 

体外循环中自体血回输不能减少心脏术后血制品的应用

 (朱慧琛 译 王祥瑞 校)

The Failure of Retrograde Autologous Priming of the Cardiopulmonary Bypass Circuit to Reduce Blood Use After Cardiac Surgical Procedures

Glenn S. Murphy, Joseph W. Szokol, Martin Nitsun, David A. Alspach, Michael J. Avram, Jeffery S. Vender, Timothy V. Votapka, and Todd K. Rosengart

Anesth Analg 2004 98: 1201-1207.  

 

减少心肺转流中的凝血激活:一项联合措施

黄施伟 译,李士通 校

Reducing Hemostatic Activation During Cardiopulmonary Bypass: A Combined Approach
Michael J. Eisses, Kristy Seidel, Gabriel S. Aldea, and Wayne L. Chandler

Anesth Analg 2004 98: 1208-1216

 

关于非体外循环下冠脉手术的综合性节约用血协议中使用中等量的急性等容血液稀释技术的研究

周晓敏译 薛张纲审校

Intraoperative Moderate Acute Normovolemic Hemodilution Associated with a Comprehensive Blood-Sparing Protocol in Off-Pump Coronary Surgery
Valter Casati, Stefano Benussi, Luca Sandrelli, Maria Antonietta Grasso, Salvatore Spagnolo, and Armando D’Angelo

Anesth Analg 2004 98: 1217-1223

 

美托洛尔与冠状动脉旁路移植术:心脏手术中美托洛尔是否可减弱急性肾上腺素受体失敏

(朱慧琛 译 王祥瑞 校)

Metoprolol and Coronary Artery Bypass Grafting Surgery: Does Intraoperative Metoprolol Attenuate Acute ß-Adrenergic Receptor Desensitization During Cardiac Surgery?

John V. Booth, Erin E. Ward, Kelly C. Colgan, Bonita L. Funk, Habib El-Moalem, Michael P. Smith, Carmelo Milano, Peter K. Smith, Mark F. Newman, and Debra A. Schwinn

Anesth Analg 2004 98: 1224-1231.

 

食道彩色多普勒超声心动图测定心输出量

王立中 译,李士通

Automated Cardiac Output Measurement by Transesophageal Color Doppler Echocardiography

Shigeru Akamatsu, Akiyoshi Oda, Etsuji Terazawa, Takuji Yamamoto, Hiroto Ohata, Tomohiro Michino, and Shuji Dohi

Anesth Analg 2004 98: 1232-1238.

 

心率变异性动态学的障碍可预测长期的心肌缺血

周晓敏译 薛张纲审校

The Breakdown of Fractal Heart Rate Dynamics Predicts Prolonged Postoperative Myocardial Ischemia

Laitio TT, Huikuri HV, Makikallio TH, Jalonen J, Kentala ES, Helenius H, Pullisaar O, Hartiala J, Scheinin H.


Anesth Analg 2004 98: 1239-1244

 

肝移植的输血

齐波 译 王祥瑞 校

Transfusion Predictors in Liver Transplant)

 Luc Massicotte, Marie-Pascale Sassine, Serge Lenis, and André Ro

Anesth Analg 2004 98: 1245-1251

PEDIATRIC ANESTHESIA:

儿童麻醉诱导时家长在场和术前镇静的趋势:一项1995–2002年全美随访调查的结果

  李士通

Trends in the Practice of Parental Presence During Induction of Anesthesia and the Use of Preoperative Sedative Premedication in the United States, 1995–2002: Results of a Follow-Up National Survey

Zeev N. Kain, Alison A. Caldwell-Andrews, Dawn M. Krivutza, Megan E. Weinberg, Shu-Ming Wang, and Dorothy Gaal

Anesth Analg 2004 98: 1252-1259.

 

交互式音乐治疗儿童术前焦虑的随机对照试验

(齐波 译 王祥瑞 校

Interactive Music Therapy as a Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial

Zeev N. Kain, Alison A. Caldwell-Andrews, Dawn M. Krivutza, Megan E. Weinberg, Dorothy Gaal, Shu-Ming Wang, and Linda C. Mayes

Anesth Analg 2004 98: 1260-1266  

新生儿主动脉弓重建术中必须监测双侧大脑血氧饱和度吗?

张俊杰译 李士通校

Is Bilateral Monitoring of Cerebral Oxygen Saturation Necessary During Neonatal Aortic Arch Reconstruction?

Dean B. Andropoulos, Laura K. Diaz, Charles D. Fraser, Jr., E. Dean McKenzie, and Stephen A. Stayer

Anesth Analg 2004 98: 1267-1272.

 

气管内使用重组表面活性物质蛋白C可减弱由气管内吸入酸性婴儿乳粉引起的兔的急性肺损伤

周晓敏译 薛张纲审校

Intratracheal Application of Recombinant Surfactant Protein-C Surfactant to Rabbits Attenuates Acute Lung Injury Induced by Intratracheal Acidified Infant Formula
Katsuya Mikawa, Kahoru Nishina, Yumiko Takao, and Hidefumi Obara

Anesth Analg 2004 98: 1273-1279.

 

布比卡因脊麻减少了前早产儿的脑血流

钟鸣译 薛张纲审校

Spinal Anesthesia with Bupivacaine Decreases Cerebral Blood Flow in Former Preterm Infants

Marie-Pierre Bonnet, Eric Larousse, Karim Asehnoune, and Dan Benhamou

Anesth Analg 2004 98: 1280-1283.

AMBULATORY ANESTHESIA:

咪唑安定镇静缓解牙科术后疼痛

忻纪华 译 王祥瑞 校

Sedation with Midazolam Leads to Reduced Pain After Dental Surgery

Cliff K. S. Ong, Robin A. Seymour, and Juliana M.-H. Tan

Anesth Analg 2004 98: 1289-1293.

ANESTHETIC PHARMACOLOGY:

异氟醚对减敏感的野生型和{alpha}1(S270H) {gamma}氨酪酸型A受体的影响

钟鸣译 薛张纲审校

The Effects of Isoflurane on Desensitized Wild-Type and {alpha}1(S270H) {gamma}-Aminobutyric Acid Type A Receptors

Adam C. Hall, Kathleen C. Rowan, Renna J. N. Stevens, Jill C. Kelley, and Neil L. Harrison

Anesth Analg 2004 98: 1297-1304.

 

幼年和老年小鼠重复异氟醚吸入麻醉对空间定向和精神运动的影响

忻纪华 译 王祥瑞 校

The Effect of Repeated Isoflurane Anesthesia on Spatial and Psychomotor Performance in Young and Aged Mice

Noam N. Butterfield, Peter Graf, Craig R. Ries, and Bernard A. MacLeod

Anesth Analg 2004 98: 1305-1311.

 

过氧化亚硝盐降低组织纤溶酶原激活因子的活性

裘毅敏译  李士通校

Peroxynitrite Inactivates Tissue Plasminogen Activator

Vance G. Nielsen, John P. Crow, Fen Zhou, and Dale A. Parks

Anesth Analg 2004 98: 1312-1317.

 

丹曲林降低寒战的域值和增益

钟鸣译 薛张纲审校

Dantrolene Reduces the Threshold and Gain for Shivering
Chun-Ming Lin, Sharma Neeru, Anthony G. Doufas, Edwin Liem, Yunus Muneer Shah, Anupama Wadhwa, Rainer Lenhardt, Andrew Bjorksten, Akiko Taguchi, Barhara Kabon, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2004 98: 1318-1324.

 

甲氧氯普胺通过抑制鼠气管毒蕈碱M3受体而产生气道平滑肌舒张

沈浩译  李士通校

Metoclopramide Causes Airway Smooth Muscle Relaxation Through Inhibition of Muscarinic M3 Receptor in the Rat Trachea
Masataka Saito, Osamu Shibata, Masakazu Yamaguchi, Maki Yoshimura, Tetsuji Makita, Noboru Harada, Masami Niwa, and Koji Sumikawa

Anesth Analg 2004 98: 1325-1329.

 

评估氟哌利多对平均QTc间期影响的模型

赵雪莲译 李士通校

A Model for Evaluating Droperidol’s Effect on the Median QTc Interval (Special Article)
Yongfeng Zhang, Ziping Luo, and Paul F. White

Anesth Analg 2004 98: 1330-1335

TECHNOLOGY, COMPUTING, AND SIMULATION:

异氟醚麻醉中脑电双频指数和脑电图参数之间的关系

陈洁 译 王祥瑞 校

The Relationship Between Bispectral Index and Electroencephalographic Parameters During Isoflurane Anesthesia

Yasuhiro Morimoto, Satoshi Hagihira, Yumika Koizumi, Kazuyoshi Ishida, Mishiya Matsumoto, and Takefumi Sakabe

Anesth Analg 2004 98: 1336-1340.

 

比较三种不同脑电监护仪的临床实用性:双频谱指数、处理后的脑电图和Alaris听觉诱发电位

颜涛译 李士通

A Comparison of the Clinical Usefulness of Three Different Electroencephalogram Monitors: Bispectral Index, Processed Electroencephalogram, and Alaris Auditory Evoked Potentials

Tomoki Nishiyama, Takashi Matsukawa, and Kazuo Hanaoka

Anesth Analg 2004 98: 1341-1345.

 

异丙酚/雷米芬太尼复合麻醉诱导、维持和终止时应用NarcotrendTM ,BIS指数及经典脑电图评估作用的比较

陆旭伟译 薛张纲审校

Comparative Evaluation of NarcotrendTM, Bispectral IndexTM, and Classical Electroencephalographic Variables During Induction, Maintenance, and Emergence of a Propofol/Remifentanil Anesthesia

Gunter N. Schmidt, Petra Bischoff, Thomas Standl, Gunnar Lankenau, Mathias Hilbert, and Jochen Schulte am Esch

Anesth Analg 2004 98: 1346-1353

 

不同脉搏血氧探头的比较

(陈洁 译 王祥瑞 校)

Comparative Testing of Pulse Oximeter Probes

Johannes H. van Oostrom and Richard J. Melker

Anesth Analg 2004 98: 1354-1358

PAIN MEDICINE:

比较辅助电针刺与人工耳部针刺用于慢性下背部疼痛的短期和长期疗效

马皓琳 译  李士通 校

The Short- and Long-Term Benefit in Chronic Low Back Pain Through Adjuvant Electrical Versus Manual Auricular Acupuncture

Sabine M. Sator-Katzenschlager, Gisela Scharbert, Sibylle A. Kozek-Langenecker, Jozef C. Szeles, Gabriele Finster, Andreas W. Schiesser, Georg Heinze, and Hans Georg Kress

Anesth Analg 2004 98: 1359-1364.

 

单胺类物再摄取抑制剂Milnacipran不影响大鼠急性内脏膨胀疼痛

陆旭伟译 薛张纲审校

The Monoamine Reuptake Inhibitor Milnacipran Does Not Affect Nociception to Acute Visceral Distension in Rats

Sang-Wook Shin, James C. Eisenach, Srinias G. Rao, and Chuanyao Tong

Anesth Analg 2004 98: 1365-1369.

 

加巴喷丁用于腹式全子宫切除术术后镇痛的效果

顾漪闻 译 王祥瑞 校

The Analgesic Effects of Gabapentin After Total Abdominal Hysterectomy

Alparslan Turan, Beyhan Karamanlioglu, Dilek Memis, Pinar Usar, Zafer Pamukçu, and Mevlüt Türe

Anesth Analg 2004 98: 1370-1373.

 

鞘内应用加巴潘汀和氯压定或加巴潘汀和新斯的明在福尔马林试验中相互作用的特性

(彭中美   李士通 校)

Characteristic of Interactions Between Intrathecal Gabapentin and Either Clonidine or Neostigmine in the Formalin Test
Myung Ha Yoon, Jeong Il Choi, and Sang Hyun Kwak

Anesth Analg 2004 98: 1374-1379.

 

GABA拮抗剂及Diltiazem应用于消除大鼠内脏疼痛中的相互作用

陆旭伟译 薛张纲审校

The Interaction Between Gamma-Aminobutyric Acid Agonists and Diltiazem in Visceral Antinociception in Rats
Kaoru Hara, Yoji Saito, Yumiko Kirihara, and Shinichi Sakura

Anesth Analg 2004 98: 1380-1384.

关于 N-甲基-D-天冬氨酸受体拮抗剂在预防性镇痛中的系统回顾

顾漪闻 译 王祥瑞 校

Colin J. L. McCartney, Avinash Sinha, and Joel Katz

A Qualitative Systematic Review of the Role of N-Methyl-D-Aspartate Receptor Antagonists in Preventive Analgesia

Anesth Analg 2004 98: 1385-1400.

 

曲马多对非洲蟾蜍卵母细胞5-羟色胺2C受体表达的抑制效应

张曦译 李士通校

The Inhibitory Effects of Tramadol on 5-Hydroxytryptamine Type 2C Receptors Expressed in Xenopus Oocytes

Junichi Ogata, Kouichiro Minami, Yasuhito Uezono, Takashi Okamoto, Munehiro Shiraishi, Akio Shigematsu, and Yoichi Ueta

Anesth Analg 2004 98: 1401-140

 

快速皮肤麻醉使用丁卡因新配方:一项临床前研究

方芳译 薛张纲审校

Rapid Skin Anesthesia Using a New Topical Amethocaine Formulation: A Preclinical Study
M. I. Arévalo, E. Escribano, A. Calpena, J. Domenech, and J. Queralt

Anesth Analg 2004 98: 1407-1412.

 

静脉注射S+-氯胺酮有助于腹部大手术的疼痛治疗

朱辉 译 王祥瑞 校

Improvement of Pain Treatment After Major Abdominal Surgery by Intravenous S(+)-Ketamine
Helena Argiriadou, Sabine Himmelseher, Pinelopi Papagiannopoulou, Mary Georgiou, Fotios Kanakoudis, Maria Giala, and Eberhard Kochs

Anesth Analg 2004 98: 1413-1418.

CRITICAL CARE AND TRAUMA:

比较肾上腺素和加压素对快速静脉注射布比卡因致心搏停止的猪模型的作用

吴俭 译,李士通

A Comparison of Epinephrine and Vasopressin in a Porcine Model of Cardiac Arrest After Rapid Intravenous Injection of Bupivacaine

Viktoria D. Mayr, Claus Raedler, Volker Wenzel, Karl H. Lindner, and Hans-Ulrich Strohmenger

Anesth Analg 2004 98: 1426-1431.

 

健康猪肺在肺泡复张过程中内脏循环的改变

方芳译 薛张纲审校

Changes in Splanchnic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs

Silvia Nunes, Hans Ulrich Rothen, Lukas Brander, Jukka Takala, and Stephan M. Jakob

Anesth Analg 2004 98: 1432-1438.

 

肺动脉内应用已酮可可碱可改善出血性休克后的心功能和氧利用状况:一新的复苏策略。

朱辉 译 王祥瑞 校

Intraarterial Pulmonary Pentoxifylline Improves Cardiac Performance and Oxygen Utilization After Hemorrhagic Shock: A Novel

Resuscitation Strategy

Raul Coimbra, Alvaro Razuk-Filho, Margareth M. Yada-Langui, and Mauricio Rocha-e-Silva

Anesth Analg 2004 98: 1439-1446.

 

颈内动脉内麻醉药引起的脑电静止并不影响兔脑暂时性缺血后的早期充血

朱 慧译 李士通校

Electrocerebral Silence by Intracarotid Anesthetics Does Not Affect Early Hyperemia After Transient Cerebral Ischemia in Rabbits

Shailendra Joshi, Mei Wang, Ervant V. Nishanian, and Ronald G. Emerson

Anesth Analg 2004 98: 1454-1459

OBSTETRIC ANESTHESIA:

剖宫产术后镇痛使用脊髓吗啡,可乐定及其混合物

方芳译 薛张纲审校

Postcesarean Analgesia with Spinal Morphine, Clonidine, or Their Combination

Michael J. Paech, Timothy J. G. Pavy, Christopher E. P. Orlikowski, Seng T. Yeo, Samantha L. Banks, Sharon F. Evans, and Jennifer Henderson

Anesth Analg 2004 98: 1460-1466.

REGIONAL ANESTHESIA:

硬膜外针头旋转对硬膜外阻滞扩散影响的前瞻性、随机性评估

(殷文渊 译 王祥瑞 校)

Battista Borghi, Vanni Agnoletti, Alessandro Ricci, Hanna van Oven, Nicoletta Montone, and Andrea Casati

A Prospective, Randomized Evaluation of the Effects of Epidural Needle Rotation on the Distribution of Epidural Block

Anesth Analg 2004 98: 1473-1478.

 

与蛛网膜下腔麻醉有关的人类软脊膜超微结构发现

周雅春译 李士通校

Ultrastructural Findings in Human Spinal Pia Mater in Relation to Subarachnoid Anesthesia
Miguel Angel Reina, Oscar De León Casasola, M. C. Villanueva, Andrés López, Fabiola Machés, and José Antonio De Andrés

Anesth Analg 2004 98: 1479-1485.

 

一项针对矫形外科医生对区域麻醉的态度和了解的调查

方芳译 薛张纲审校

A Survey of Orthopedic Surgeons’ Attitudes and Knowledge Regarding Regional Anesthesia

Matthew Oldman, Colin J. L. McCartney, Andrea Leung, Regan Rawson, Anahi Perlas, Jeff Gadsden, and Vincent W. S. Chan

Anesth Analg 2004 98: 1486-1490

GENERAL ARTICLES:

防止病理性肥胖病人全麻诱导时的肺膨胀不全状态

殷文渊 译 王祥瑞 校

Prevention of Atelectasis Formation During the Induction of General Anesthesia in Morbidly Obese Patients

Marta Coussa, Stefania Proietti, Pierre Schnyder, Philippe Frascarolo, Michel Suter, Donat R. Spahn, and Lennart Magnusson

Anesth Analg 2004 98: 1491-1495.

体外循环中自体血回输不能减少心脏术后血制品的应用

The Failure of Retrograde Autologous Priming of the Cardiopulmonary Bypass Circuit to Reduce Blood Use After Cardiac Surgical Procedures

Glenn S. Murphy, MD, Joseph W. Szokol, MD, Martin Nitsun, MD, David A. Alspach, MD, Michael J. Avram, PhD, Jeffery S. Vender, MD, Timothy V. Votapka, MD, and Todd K. Rosengart, MD

From the Department of Anesthesiology, Evanston Northwestern Healthcare, Evanston, Illinois

Anesth Analg 2004;98:1201-1207

体外循环(CPB)期间血液稀释是心脏手术病人输血的主要危险因素。CPB环路中输入患者自己的血(自体血预充,RAP)是一项用于限制血液稀释和减少输血的技术。作者设计这项实验以测试RAP对围术期血制品应用的影响。回顾性队列研究,分析同一外科医生在CPB下(排除循环停止病例)施行手术的所有患者的医疗文件。收集RAP作为常规血液保护方法病人(RAP组,n=257 24个月的数据资料与未用RAP (非RAP组,n=288)的资料相比较。资料显示RAP组患者输浓缩红细胞的比率为44%,非RAP组为51%,统计学上无明显差异。围术期输浓缩红细胞、血小板或新鲜冰冻血浆组间也无明显差别。由此可知,RAP作为一项血液保护技术并无显著临床效益。

(朱慧琛 译 王祥瑞 校)

Hemodilution during cardiopulmonary bypass (CPB) is a primary risk factor for blood transfusion in cardiac surgical patients. Priming of the CPB circuit with the patients’ own blood (retrograde autologous priming, RAP) is a technique used to limit hemodilution and reduce transfusion requirements. We designed this study to examine the impact of RAP on perioperative blood product use. Using a retrospective cohort study design, the medical records of all patients undergoing CPB (excluding circulatory arrest cases) by a single surgeon were examined. Data were collected over a 24-mo period when RAP was routinely used as a blood conservation strategy (RAP group, n = 257). This group was compared with a cohort of patients during the 24 mo immediately preceding the introduction of RAP into clinical practice (no RAP group, n = 288). A small, statistically insignificant reduction in the percentage of patients receiving packed red blood cells was observed in the RAP group (44% versus 51% no RAP, P = 0.083). No differences were found between the groups in the number of units of packed red blood cells, platelets, or fresh frozen plasma transfused throughout the perioperative period. These results suggest that overall, RAP does not offer a clinically important benefit as a blood conservation technique.


美托洛尔与冠状动脉旁路移植术:心脏手术中美托洛尔是否可减弱急性肾上腺素受体失敏

Metoprolol and Coronary Artery Bypass Grafting Surgery: Does Intraoperative Metoprolol Attenuate Acute ß-Adrenergic Receptor Desensitization During Cardiac Surgery?

John V. Booth, MBChB FRCA*, Erin E. Ward, BS*, Kelly C. Colgan, BS{ddagger}, Bonita L. Funk, BS*, Habib El-Moalem, PhD*, Michael P. Smith, BS*, Carmelo Milano, MD{dagger}, Peter K. Smith, MD{dagger}, Mark F. Newman, MD*, and Debra A. Schwinn, MD*

Departments of *Anesthesiology, {dagger}Surgery, and {ddagger}Medicine, Duke University Medical Center, Durham, North Carolina, for the Duke Heart Center Perioperative Desensitization Group

Anesth Analg 2004;98:1224-1231
心脏手术可使ß-肾上腺素受体(ß AR)功能明显受损,同时使术后心肌功能下降。作者曾报道动物模型中CABGCPB期间使用ß AR阻滞药可减弱的ß AR失敏,而长期口服ß AR阻滞药不能达到预防效果。因此作者假设在CABG手术中紧急应用美托洛尔可预防心肌ßAR失敏。开始应用安慰剂(n=72)后随机分为两组,分别在CPB前使用美托洛尔10mg或安慰剂。第二阶段的剂量实验中患者分别使用美托洛尔20mgn=20)或30mg(n=20)。同时测定血流动力学、心房膜腺苷酸环化酶活性和心房ßAR密度。所有组都显示异丙肾刺激所至的腺酐酸环化酶活性降低程度相似(13%-24%)。4组病人术中和术后的心输出量相似。另外,美托洛尔 20mg30mg组与美托洛尔10mg和安慰剂组相比,术后24小时出现室上性心律失常较少。结论:与先前的动物实验不同,美托洛尔并不能减弱心肌ßAR失敏。

(朱慧琛 译 王祥瑞 校)

Cardiac surgery results in significant impairment of ß-adrenergic receptor (ßAR) function and is a cause of depressed myocardial function after surgery. We previously demonstrated that acute administration of ßAR blocker during cardiopulmonary bypass (CPB) in an animal model of coronary artery bypass grafting (CABG) surgery attenuates ßAR desensitization, whereas chronic oral ß-blockade therapy in patients undergoing CABG surgery does not prevent it. Therefore we hypothesized that acute administration of metoprolol during CABG surgery would prevent acute myocardial ßAR desensitization. A placebo-controlled initial phase (n = 72) was performed whereby patients were randomized to either metoprolol 10 mg or placebo immediately before CPB. Then a second dose-finding study was performed where patients received 20 mg (n = 20) or 30 mg (n = 20) of metoprolol. Hemodynamic monitoring, atrial membrane adenylyl cyclase activity, atrial ßAR density, and postoperative outcomes were measured. All groups showed similar decreases in isoproterenol-stimulated adenylyl cyclase activity (13%–24%). Cardiac output remained similar in all 4 groups throughout the intraoperative and postoperative period. In addition, patients receiving metoprolol 20 or 30 mg had less supraventricular arrhythmias 24 h postoperatively compared with patients receiving metoprolol 10 mg or placebo. Therefore, unlike our previous animal model of CABG surgery, metoprolol did not attenuate myocardial ßAR desensitization.


肝移植的输血指征

Transfusion Predictors in Liver Transplant

Luc Massicotte, MD*, Marie-Pascale Sassine, CPhD*, Serge Lenis, MD FRCPS*, and André Roy, MD FRCPS{dagger}

*Anesthesiology Department and the {dagger}Department of Surgery, Hepato-Biliary Service, Centre Hospitalier de l’Université de Montréal, Montréal, Canada

Anesth Analg 2004;98:1245-1251

本研究目的确定肝移植病人输注红细胞(RBC)的影响因素,并探讨肝脏移植手术中麻醉医生输血工作。作者对过去52个月中 206例肝脏移植手术病人进行了回顾性研究。先确定手术中输注的血制品。并对20个变量在单变量形式下进行分析。为了进行多变量分析,将病例分为2个亚组:一组病人为术中输注RBC大于4个单位,第二组病人为输注RBC4个单位或少于4个单位。术中平均输注RBC的量为2.8±3.5)单位/病人,其中32%的病人未输RBC19.4%的病人没有输任何血制品。研究发现有三个变量与输注的RBC数量相关:术前国际标准比值、术前血小板数量和手术持续时间。研究中作者发现术中不同麻醉医生的输血常规存在很大的差异。由于人为因素的影响,当输注RBC的量较小时确定输注RBC的指征是困难的。术中输血浆并不能减少RBC输注率,有时正好相反。

(齐波 译 王祥瑞 校)

In this study we sought to determine the factors influencing red blood cell (RBC) transfusions and to study the transfusion practice of anesthesiologists during liver transplants. A retrospective study of 206 successive liver transplants was undertaken during a period of 52 mo. Transfused blood products were identified. Twenty variables were analyzed in a univariate fashion. For the multivariate analysis, the cases were divided in 2 subgroups: more than 4 RBC units transfused and 4 or less RBC units transfused. The average number of RBC units transfused during a liver transplant was 2.8 (± 3.5) per patient, 32.0% did not receive any RBC, and 19.4% did not receive any blood products during the transplant. Three variables were related to the number of RBC units transfused: the starting International Normalized Ratio value, the starting platelet count, and the duration of surgery. We found that there was a wide difference in the transfusion practice of the anesthesiologists involved in this series of liver transplants. It was difficult to identify predictive factors for RBC transfusions when the transfusion rate was small and because of the variability in human factors. Plasma transfusion did not decrease the rate of RBC transfusions; sometimes it was the contrary.


交互式音乐治疗儿童术前焦虑的随机对照试验

Interactive Music Therapy as a Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial

Zeev N. Kain, MD MBA*,{dagger},{ddagger}, Alison A. Caldwell-Andrews, PhD*, Dawn M. Krivutza*, Megan E. Weinberg, MA*, Dorothy Gaal, MD*, Shu-Ming Wang, MD*, and Linda C. Mayes, MD{dagger},{ddagger}

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2004;98:1260-1266

本研究目的是测定交互式音乐治疗是否可以有效缓解儿童术前焦虑。接受门诊手术的儿童随机分为三组:交互式音乐治疗组(n=51,口服咪唑安定组(n=34)和对照组(n=38)。研究的主要结果是看在围术期儿童是否有焦虑情绪。结果发现在麻醉诱导期口服咪唑安定组儿童的焦虑情况要少于音乐治疗组和对照组(分别为P0.015P0.005),而音乐治疗组和对照组儿童无明显差异。通过分析控制不同的音乐治疗师显示了一个明显的治疗师效应,经过特定治疗师治疗的儿童在其准备去手术室(OR)(P0.05)和进入手术室时(P0.05)发生紧张焦虑的情况要明显少于其它治疗师组和对照组,但在扣麻醉面罩阶段无差异。即使是在去除治疗师效应后,咪唑安定组儿童的情绪也最为安静(P0.05)。因此总结认为音乐治疗可能对缓解儿童在准备去和进入手术室时的紧张焦虑情绪有帮助作用,但要依赖治疗师的作用。然而,音乐治疗不能缓解麻醉诱导期儿童的紧张焦虑情绪。

 (齐波 译 王祥瑞 校)

In this study, we examined whether interactive music therapy is an effective treatment for preinduction anxiety. Children undergoing outpatient surgery were randomized to 3 groups: interactive music therapy (n = 51), oral midazolam (n = 34), or control (n = 38). The primary outcome of the study was children’s perioperative anxiety. We found that children who received midazolam were significantly less anxious during the induction of anesthesia than children in the music therapy and control groups (P = 0.015 and P = 0.005, respectively). We found no difference in anxiety during the induction of anesthesia between children in the music therapy group and children in the control group. An analysis controlling for therapist revealed a significant therapist effect; i.e., children treated by one of the therapists were significantly less anxious than children in the other therapist group and the control group on separation to the operating room (OR) (P < 0.05) and on entrance to the OR (P < 0.05), but not on the introduction of the anesthesia mask (P = not significant). Children in the midazolam group were the least anxious even after controlling for therapist effect (P < 0.05). We conclude that music therapy may be helpful on separation and entrance to the OR, depending on the therapist. However, music therapy does not appear to relieve anxiety during the induction of anesthesia.

 

咪唑安定镇静缓解牙科术后疼痛

Sedation with Midazolam Leads to Reduced Pain After Dental Surgery

Cliff K. S. Ong, DDS MS, Robin A. Seymour, DDS PhD, and Juliana M.-H. Tan, MD MS Section Editor

From the Faculty of Dentistry, Department of Oral & Maxillofacial Surgery and the Faculty of Medicine, Department of Anesthesiology, National University of Singapore, and the Faculty of Dentistry, Department of Restorative Dentistry, University of Newcastle upon Tyne, Newcastle upon Tyne, United Kingdom

Anesth Analg 2004;98:1289-1293

本研究目的是评估口腔手术中静注咪唑安定对缓解术后疼痛的潜在作用。125例因第三臼齿陷在鄂骨中需行局麻下拔除术的病人随机分为2组。第一组(n=64),在术前局麻后,以咪唑安定静脉滴注直至临床清醒镇静状态;第二组(n=61),作为对照组,术前仅接受局麻。两组病人由同一外科医生行标准手术。用四个标准进行预后评价:每8小时以100mm视觉模拟评分和四项分来评价疼痛强度;首次开始疼痛的时间;48小时内镇痛药(布洛芬)的总剂量,5级病人总体评分(0=差,1=一般,2=好,3=非常好, 4=极好)。经过8小时的研究阶段,咪唑安定组的疼痛强度评分显著低于对照组(19.0±13.2mm28.1±12.8mm,p<0.05)。咪唑安定组术后至第一次用镇痛药的时间显著延长(165.5±56.5分钟对202.2±79.0分钟,p<0.05),镇痛药的剂量显著减少(1275±364mg1688±407mg,p<0.01,总体评价显著好于对照组(3.34±0.82.4±0.9p<0.001)。作者认为全身应用咪唑安定可缓解第三臼齿手术后的疼痛。

(忻纪华 译 王祥瑞 校)

Our principal objective in this study was to evaluate the potential pain reducing effect of IV midazolam in patients undergoing oral surgery. One-hundred-twenty-five patients with impacted mandibular third molars requiring removal under local anesthetic were randomized into 2 groups. The first group (n = 64) was administered IV midazolam by titration until a clinical end-point of conscious sedation followed by local anesthetic before surgery; the second group (n = 61) was the control and was administered only local anesthetic before surgery. The surgery was performed in a standardized manner in both groups by the same surgeon. Outcome measures were four primary end-points: pain intensity as assessed by a 100-mm visual analogue scale and a 4-point categorized scale hourly for 8 h, time to first analgesic, total analgesic (ibuprofen) consumption over the first 48 h, and a 5-point categorical patient global assessment scale (0 = poor, 1 = fair, 2 = good, 3 = very good, and 4 = excellent). Throughout the 8-h investigation period, patients in the midazolam group reported significantly lower pain intensity scores than those in the control group (19.0 ± 13.2 mm versus 28.1 ± 12.8 mm, P < 0.05). The patients in the midazolam group also reported significantly longer time to first analgesic (165.5 ± 56.5 min versus 202.2 ± 79.0 min, P < 0.05), less analgesic consumption (1275 ± 364 mg versus 1688 ± 407 mg, P < 0.001) and better patient global assessment (3.34 ± 0.8 versus 2.4 ± 0.9, P < 0.001). We conclude that systemically administered midazolam is effective in reducing postoperative pain after third molar surgery.

 

幼年和老年小鼠重复异氟醚吸入麻醉对空间定向和精神运动的影响

The Effect of Repeated Isoflurane Anesthesia on Spatial and Psychomotor Performance in Young and Aged Mice

Noam N. Butterfield, PhD*, Peter Graf, PhD{dagger}, Craig R. Ries, MD FRCPC, PhD*,{ddagger}, and Bernard A. MacLeod, MD FRCPC*,{ddagger}

From the Centre for Anesthesia & Analgesia, Departments of *Pharmacology & Therapeutics, {dagger}Psychology, and {ddagger}Anesthesia, The University of British Columbia, Vancouver, British Columbia

Anesth Analg 2004;98:1305-1311

老年病人全麻后可能导致认识损害,但两者的关系知之甚少。我们以空间记忆(Barnes迷宫)和精神运动行为(rotarod)来观察老年鼠(18-19个月)术后认识损害是否较幼年鼠(3-4个月)明显。首先研究单次麻醉对渐近线迷宫操作的影响。然后试验重复麻醉是否对老年鼠的空间记忆和精神运动行为损害更明显。以异氟醚(1.4%atm)麻醉30分钟,对照组接受90%的氧。在渐近线迷宫操作的学习阶段麻醉,不损害随后一天的模拟试验(p>0.05)。重复麻醉(每隔2-3小时)也不损害幼年和老年鼠所有的迷宫操作或rotarod操作(p>0.05)。集中结果表明麻醉似乎有利于定向空间学习,F1024=7.97p<0.01。渐近线操作——当学习已经稳固——仍未显示迷宫和rotarod操作受损。这些结果提示与年龄相关的麻醉诱导危险性仅限于新的运动技能,麻醉不会导致老年鼠延迟的认识障碍。

(忻纪华 译 王祥瑞 校)

Exposure to general anesthesia may contribute to postoperative cognitive impairment in elderly patients, but the relationship remains poorly understood. We investigated whether aged mice, 18–19 mo, are more susceptible to postanesthetic cognitive impairment than young mice, 3–4 mo, using spatial memory (Barnes maze) and psychomotor (rotarod) tasks. Initially we studied the effect of a single anesthetic episode on asymptotic maze performance. We then tested whether repeated anesthesia would impair spatial memory and psychomotor performance to a greater extent in aged mice. Mice were anesthetized with isoflurane (1.4% atm) for 30 min; controls received 90% oxygen. Anesthesia, administered during the asymptotic period of maze learning, did not impair performance tested the following day (P > 0.05). Repeated anesthesia, 2–3 h after each session, did not impair overall maze or rotarod performance in young or aged mice (P > 0.05). Spatial learning appeared to be facilitated by anesthesia, F(1,204) = 7.97, P < 0.01 for pooled results. Asymptotic performance—when learning had stabilized—remained unimpaired in both the maze and rotarod tasks. These results suggest that an age-related risk of anesthetic-induced impairment appears to be limited to acquisition of a novel motor skill and that anesthesia alone does not lead to prolonged cognitive impairments in aged mice.

 

异氟醚麻醉中脑电双频指数和脑电图参数之间的关系

The Relationship Between Bispectral Index and Electroencephalographic Parameters During Isoflurane Anesthesia

Yasuhiro Morimoto, MD*, Satoshi Hagihira, MD{dagger}, Yumika Koizumi, MD*, Kazuyoshi Ishida, MD*, Mishiya Matsumoto, MD*, and Takefumi Sakabe, MD*

*Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Yamaguchi, Japan; and {dagger}Department of Anesthesiology, Osaka Prefectural Habikino Hospital, Osaka, Japan

Anesth Analg 2004;98:1336-1340


脑电双频指数(BIS)是将不同脑电图(EEG)参数整合为单一变量,但其确切的运算法则尚不明确。作者评价了笑气/异氟醚麻醉下BISEEG两者的关系。20例择期眼科手术患者, BIS监测仪(A-1050)记录EEG后, 0.5%~2%的异氟醚/66%的笑气全麻诱导和维持,持续记录BIS, SEF95 EEG参数如(BetaRatio), 快慢波的相对同步性(SynchFastSlow)和爆发抑制率(burst suppression ratio)。当BIS大于60时,BetaRatioBIS成线性相关(r0.90p<0.01n253)。当BIS范围在3080时,SynchFastSlowr0.60p<0.01n3314)和SEF95r0.75p<0.01n3339)和BIS成线性相关。BISSEF95的相关性优于BISSynchFastSlowp<0.01)。BIS小于30, 爆发抑制率和BIS成负相关(r0.76p<0.01n65)。在BIS小于80,补偿burstSPF95BIS成线性相关(r0.78p<0.01n3404)。BIS60~100可以通过BetaRatio来计算。在手术麻醉深度下,BISSynchFastSlow和补偿burstSPF95成良好相关性, 结果表明SynchFastSlowSPF95相比,在计算BIS时没有优势。

(陈洁 译 王祥瑞 校)

Bispectral index (BIS) integrates various electroencephalographic (EEG) parameters into a single variable. However, the exact algorithm used to synthesize the parameters to BIS values is not known. The relationship between BIS and EEG parameters was evaluated during nitrous oxide/isoflurane anesthesia. Twenty patients scheduled for elective ophthalmic surgery were enrolled in the study. After EEG recording with a BIS monitor (A-1050) was begun, general anesthesia was induced and maintained with 0.5%–2% isoflurane and 66% nitrous oxide. Using software we developed, we continuously recorded BIS, spectral edge frequency 95% (SEF95), and EEG parameters such as relative beta ratio (BetaRatio), relative synchrony of fast and slow wave (SynchFastSlow), and burst suppression ratio. BetaRatio was linearly correlated with BIS (r = 0.90; P < 0.01; n = 253) at BIS more than 60. At a BIS range of 30 to 80, SynchFastSlow (r = 0.60; P < 0.01; n = 3314) and SEF95 (r = 0.75; P < 0.01; n = 3339) were linearly correlated with BIS. The correlation between BIS and SEF95 was significantly better than the correlation between BIS and SynchFastSlow (P < 0.01). At BIS less than 30, the burst suppression ratio was inversely linearly correlated with BIS (r = 0.76; P < 0.01; n = 65). At BIS less than 80, burst-compensated SEF95 was linearly correlated with BIS (r = 0.78; P < 0.01; n = 3404). In the range of BIS from 60 to 100, BIS can be calculated from BetaRatio. At surgical levels of anesthesia, BIS and SynchFastSlow (a parameter derived from bispectral analysis) or burst-compensated SEF95 (derived from power spectral analysis) are well correlated. However, our results show that SynchFastSlow has no advantage over SEF95 in calculation of BIS.


不同脉搏血氧探头的比较

Comparative Testing of Pulse Oximeter Probes

Johannes H. van Oostrom, PhD*,{ddagger},§, and Richard J. Melker, MD PhD*,{dagger},§

Departments of *Anesthesiology and {dagger}Pediatrics, College of Medicine, the {ddagger}Department of Biomedical Engineering, College of Engineering, and the §McKnight Brain Institute, University of Florida, Gainesville, Florida

Anesth Analg 2004;98:1354-1358


脉搏血氧饱和度探头的测试通常局限于电路的完整性,不包括探头的光学特性。很少有实验评价监护仪和探头的准确性。作者设计了一项实验,比较Nellcor, Datex-Ohmeda和重症监护脉氧监护仪的OSS Medical的专利探头和他们的相应产品,不包括测试脉氧探头的光学特性。通过模拟急性窒息来进行测试,用数据记录计算机自动记录脉氧监护仪的饱和度曲线。比较两种探头的同等数据,使用单一变量和多变量的线性模型进行分析。五钟OSS探头优于相对应的产品,其余的在统计学上相似。模拟研究较人体研究更为有利,因为它更为经济有效,对患者没有危险,但模拟的真实性受到限制。

(陈洁 译 王祥瑞 校)

The testing of pulse oximeter probes is generally limited to the integrity of the electrical circuit and does not include the optical properties of the probes. Few pulse oximeter testers evaluate the accuracy of both the monitor and the probe. We designed a study to compare the accuracy of nonproprietary probes (OSS Medical) designed for use with Nellcor, Datex-Ohmeda, and Criticare pulse oximeter monitors with that of their corresponding proprietary probes by using a commercial off-the-shelf pulse oximeter tester (Index). The Index pulse oximeter tester does include testing of the optical properties of the pulse oximeter probes. The pulse oximeter tester was given a controlled input that simulated acute apnea. Desaturation curves were automatically recorded from the pulse oximeter monitors with a data-collection computer. Comparisons between equivalent proprietary and nonproprietary probes were performed. Data were analyzed by using univariate and multivariate general linear model analysis. Five OSS Medical probe models were statistically better than the equivalent proprietary probes. The remainder of the probes were statistically similar. Comparative and simulation studies can have significant advantages over human studies because they are cost-effective, evaluate equipment in a clinically relevant scenario, and pose no risk to patients, but they are limited by the realism of the simulation.

 

加巴喷丁用于腹式全子宫切除术术后镇痛的效果

The Analgesic Effects of Gabapentin After Total Abdominal Hysterectomy

Alparslan Turan, MD*, Beyhan Karamanlioglu, MD*, Dilek Memis, MD*, Pinar Usar, MD*, Zafer Pamukçu, MD*, and Mevlüt Türe, MD PhD{dagger}

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

Anesth Analg 2004;98:1370-1373

 

我们采用随机,双盲,安慰剂对照研究加巴喷丁对于腹式全子宫切除术术后镇痛的效果,安全性, 以及曲马多的消耗量。方法:50个病人随机分配为两组,分别在术前1小时口服安慰剂或是加巴喷丁1200mg。麻醉诱导用异丙酚,维持麻醉用七氟醚混合50%N2O/O2,气体流量为2L/min以及芬太尼(2µg/kg)。所有病人都接受曲马多术后自控镇痛,初始剂量为50mg,添加剂量20mg,锁定间隔时间10-min4小时总量限定于300mg。术后1小时,如果镇痛不够,可增加到30mg/h。分别检测术后48121620、和24小时的VAS疼痛评分,心率,外周氧饱和度,平均动脉压,呼吸频率,镇静和曲马多的消耗。结果:术后148121620小时,坐位和仰卧位的VAS疼痛评分,加巴喷丁组均明显低于安慰剂组,直到术后20小时才相近。而在术后12162024小时,加巴喷丁组的曲马多的消耗也明显低于安慰剂组。镇静评分在所有测试时间均相同。两组病人副作用方面没有明显差异。结论:腹式全子宫切除术病人术前口服加巴喷丁能减少术后疼痛评分以及曲马多术后的消耗量。

(顾漪闻 译 王祥瑞 校)

We investigated, in a randomized, placebo-controlled, double-blind study, the efficacy and safety of gabapentin on pain after abdominal hysterectomy and on tramadol consumption in patients. The 50 patients were randomized to receive either oral placebo or gabapentin 1200 mg 1 h before surgery. Anesthesia was induced with propofol and maintained with sevoflurane in 50% N2O/O2 with a fresh gas flow of 2 L/min (50% N2O in O2) and fentanyl (2 µg/kg). All patients received patient-controlled analgesia with tramadol with a 50 mg initial loading dose, 20 mg incremental dose, 10-min lockout interval, and 4-h limit of 300 mg. The incremental dose was increased to 30 mg if analgesia was inadequate after 1 h. Patients were studied at 4, 8, 12, 16, 20, and 24 h for visual analog (VAS) pain scores, heart rate, peripheral oxygen saturation, mean arterial blood pressure, respiratory rate, sedation, and tramadol consumption. The VAS scores in the sitting and supine position at 1, 4, 8, 12, 16, and 20 h were significantly lower in the gabapentin group when compared with the placebo group up to 20 h after surgery. The tramadol consumption at 12, 16, 20, and 24 h and total tramadol consumption were significantly less in the gabapentin group when compared with placebo group. Sedation scores were similar at all the measured times. There were no differences between groups in adverse effects. Preoperative oral gabapentin decreased pain scores and postoperative tramadol consumption in patients after abdominal hysterectomy.

 

关于 N-甲基-D-天冬氨酸受体拮抗剂在预防性镇痛中的系统回顾

A Qualitative Systematic Review of the Role of N-Methyl-D-Aspartate Receptor Antagonists in Preventive Analgesia

Colin J. L. McCartney, FRCA*, Avinash Sinha, FRCA*, and Joel Katz, PhD{dagger},{ddagger},§

*Department of Anesthesia and Pain Management, Toronto Western Hospital and University of Toronto; {dagger}Department of Anesthesia, University of Toronto; {ddagger}Department of Anesthesia and Pain Management, Toronto General Hospital and Mount Sinai Hospital; and §Department of Psychology and School of Kinesiology and Health Science, York University, Toronto, Ontario, Canada

Anesth Analg 2004;98:1385-1400


作者对于N-甲基-D-天冬氨酸受体(NMDA拮抗剂在减轻术后疼痛,镇痛药的消耗, 预防性镇痛药物NMDA拮抗剂临床上作用持续时间等作了全面和系统的评估。 方法:首先,MEDLINE1966-2003)和 EMBASE1985-2003)上搜索在术后使用NMDA拮抗剂的随机试验,并且参考这些试验的相关参考文献。其次对术中给予NMDA拮抗剂的病人,且评估术后镇痛研究论文文献也作参考。结果:基本结论是NMDA拮抗剂在药物五个半衰期内减轻了疼痛和/或镇痛药的消耗。第二个结论是包括了第一次对镇痛药的需求和副作用40篇文献符合标准:24篇氯胺酮,12右美沙芬,和4。结果可以证明氯胺酮,右美沙芬在预防性的镇痛中,无论是在减轻疼痛,在减少镇痛药的消耗,或是在延长相关药物临床上的持续时间方面都有很强的效果,分别为67%58%。四篇关于镁的研究中没有显示其有预防性镇痛的作用。

(顾漪闻 译 王祥瑞 校)

We evaluated in a qualitative systematic review the effect of N-methyl-D-aspartate (NMDA) receptor antagonists on reducing postoperative pain and analgesic consumption beyond the clinical duration of action of the target drug (preventive analgesia). Randomized trials examining the use of an NMDA antagonist in the perioperative period were sought by using a MEDLINE (1966–2003) and EMBASE (1985–2003) search. Reference sections of relevant articles were reviewed, and additional articles were obtained if they evaluated postoperative analgesia after the administration of NMDA antagonists. The primary outcome was a reduction in pain, analgesic consumption, or both in a time period beyond five half-lives of the drug under examination. Secondary outcomes included time to first analgesic request and adverse effects. Forty articles met the inclusion criteria (24 ketamine, 12 dextromethorphan, and 4 magnesium). The evidence in favor of preventive analgesia was strongest in the case of dextromethorphan and ketamine, with 67% and 58%, respectively, of studies demonstrating a reduction in pain, analgesic consumption, or both beyond the clinical duration of action of the drug concerned. None of the four studies examining magnesium demonstrated preventive analgesia.


 

静脉注射S+-氯胺酮有助于腹部大手术的疼痛治疗

Improvement of Pain Treatment After Major Abdominal Surgery by Intravenous S(+)-Ketamine

Helena Argiriadou, MD*, Sabine Himmelseher, MD{dagger}, Pinelopi Papagiannopoulou, MD{ddagger}, Mary Georgiou, MD{ddagger}, Fotios Kanakoudis, MD{ddagger}, Maria Giala, MD*, and Eberhard Kochs, MD PhD{dagger}

*Department of Anesthesiology, AHEPA University Hospital, Thessaloniki, Greece; {dagger}Klinik für Anaesthesiologie, Technische Universität München, Munich, Germany; and {ddagger}Department of Anesthesiology, G. Gennimatas University Hospital, Thessaloniki, Greece

Anesth Analg 2004;98:1413-1418


术中使用外消旋氯胺酮预防腹部手术后的疼痛目前是有争议的。我们选择45例硬膜外复合全身麻醉的手术患者,比较切皮前静脉注射S+-氯胺酮与切皮前和术中重复使用S+-氯胺酮两种方法的差异。S+-氯胺酮是一种含更多氯胺酮异构体的新药物。患者被随机分成三组,安慰剂组,切皮前注射0.5mg/kgS+-氯胺酮组,切皮前注射0.5mg/kgS+-氯胺酮并术中隔20分钟重复用S+-氯胺酮0.2mg/kg组。术后患者给予罗哌卡因进行硬膜外镇痛(2mg/ml;0.12ml•kg-1•h-1)。结果发现重复使用S+-氯胺酮的患者苏醒、苏醒后3小时和苏醒后6小时疼痛评分比安慰剂组更小(P≤0.05),并且要求额外使用镇痛药的病人数要少于后者(P≤0.05)。单纯注射(P0.05〉和重复使用S+-氯胺酮组(P0.05〉的患者24小时累积消耗二氯芬酸和右丙氧芬的量要少于安慰剂组。患者苏醒后,重复使用S+-氯胺酮组的患者比其他组有更佳的情绪状态(P0.05〉,且没有类似精神症状的副作用。总而言之,硬膜外合并全身麻醉的患者在切皮前以及术中重复使用小剂量的S+-氯胺酮比单纯实施硬膜外合并全身麻醉能更好地减轻患者术后的疼痛。

(朱辉 译 王祥瑞 校)

The use of intraoperative racemic ketamine for pain prevention after abdominal surgery is controversial. We compared one preincisional IV injection of S(+)-ketamine with its preincisional and repeated intraoperative use in 45 patients undergoing surgery with epidural and general anesthesia. S(+)-ketamine is a new drug formulation that contains the more potent S(+)-stereoisomer of ketamine. Patients were randomized to receive placebo, 0.5 mg/kg preincisional S(+)ketamine, or 0.5 mg/kg preincisional and 0.2 mg/kg intraoperative S(+)-ketamine repeated at 20-min intervals. In the postoperative period, epidural ropivacaine (2 mg/mL; 0.12 mL • kg–1 • h–1) was infused for pain therapy. Patients who received repeated S(+)-ketamine reported smaller pain scores than those who received placebo after awakening and 3 and 6 h later (P <=0.05). Fewer patients with repeated S(+)-ketamine required additional analgesics than those with placebo (P <=0.05). Cumulative consumption of additional diclofenac and dextropropoxyphene at 24 h was less after single (P < 0.05) and repeated (P < 0.05) S(+)-ketamine versus placebo. After awakening, patients who received repeated S(+)-ketamine reported being in a better mood than those in the other groups (P < 0.05). No psychotomimetic side effects were noted. In conclusion, preincisional and repeated intraoperative small-dose S(+)-ketamine added to general and epidural anesthesia causes better postoperative pain relief than general and epidural anesthesia alone.

 

肺动脉内应用已酮可可碱可改善出血性休克后的心功能和氧利用状况:一新的复苏策略。

Intraarterial Pulmonary Pentoxifylline Improves Cardiac Performance and Oxygen Utilization After Hemorrhagic Shock: A Novel Resuscitation Strategy

Raul Coimbra, MD PhD*, Alvaro Razuk-Filho, MD PhD{dagger}, Margareth M. Yada-Langui, BS{ddagger}, and Mauricio Rocha-e-Silva, MD PhD{ddagger}

*Division of Trauma, Department of Surgery, University of California San Diego School of Medicine, San Diego, California; {dagger}Santa Casa School of Medicine, São Paulo, Brazil; and {ddagger}Research Division, Heart Institute (InCor), University of São Paulo, São Paulo, Brazil

Anesth Analg 2004;98:1439-1446


已酮可可碱(PTX)作为出血性休克患者复苏的辅助药其作用还不明了。肺动脉内注射PTX对心功能和氧利用状况的作用还不肯定。作者假定肺PTX要优于全身PTX或单一的乳酸林格氏液(LR)。选取狗出血性休克的模型来比较LR液,全身PTX和肺PTX对心功能和氧利用的作用。动物放血使其平均动脉压(MAP)在40mmHg持续30分钟并随机分成3个复苏组:LR液组(2倍出血量),全身PTX组(静脉注射10mg/kg+ LR液(2倍出血量)+PTX(静脉注射5mg/kg维持 45分钟),肺PTX(通过肺动脉导管注射10mg/kg+5mg/kg维持45分钟)+LR液(2倍出血量,IV)。然后连续测动脉血气,血红蛋白水平,MAP,心指数,全身血管阻力指数,肺血管阻力指数,氧输送,氧耗和氧摄取率(O2ER)。肺PTX可提高心指数(P=0.012)并降低全身血管阻力指数和肺血管阻力指数(P0.0001〉。肺PTX增加氧输送和氧耗。LR液组的狗复苏后的O2ER维持在高于基础水平的状态(P0.0001〉。与休克水平值比较全身和肺PTX显著降低O2ERPTX用于抢救复苏优于单一使用LR液。动脉内使用肺PTX是安全的,同时能改善心功能和氧利用状况。

(朱辉 译 王祥瑞 校)

The role of pentoxifylline (PTX) as a resuscitation adjunct in hemorrhagic shock is unclear. PTX infusion into the pulmonary artery and its effects on cardiac performance and oxygen utilization have not been defined. We hypothesized that pulmonary PTX is superior to systemic PTX or lactated Ringer’s (LR) solution alone. The effects of LR solution, systemic PTX, and pulmonary PTX on cardiac performance and oxygen utilization in a hemorrhagic shock model in dogs were compared. Animals were bled to a mean arterial blood pressure (MAP) of 40 mm Hg maintained for 30 min and randomized into 3 resuscitation groups: LR solution (2x shed blood), systemic PTX (10 mg/kg bolus IV) in addition to LR solution (2x shed blood) + PTX (5 mg/kg for 45 min IV), and pulmonary PTX (10 mg/kg bolus + 5 mg/kg for 45 min via a pulmonary artery catheter) plus LR solution (2x shed blood, IV). Arterial blood gases, hemoglobin levels, MAP, cardiac index, systemic vascular resistance index, pulmonary vascular resistance index, oxygen delivery, oxygen consumption, and oxygen extraction ratio (O2ER) were measured serially. No differences in blood loss, hemoglobin, and MAP were observed. Pulmonary PTX increased cardiac index to levels more than baseline (P = 0.012) and decreased systemic vascular resistance index and pulmonary vascular resistance index to levels less than baseline (P < 0.0001). Pulmonary PTX increased oxygen delivery and oxygen consumption to baseline levels. Postresuscitation O2ER levels in LR-treated animals remained more than baseline (P < 0.0001). Systemic and pulmonary PTX significantly decreased O2ER compared with shock levels. PTX resuscitation is superior compared with LR solution alone. Intraarterial pulmonary PTX administration is safe, and improves cardiac performance as well as O2 utilization.


硬膜外针头旋转对硬膜外阻滞扩散影响的前瞻性、随机性评估

A Prospective, Randomized Evaluation of the Effects of Epidural Needle Rotation on the Distribution of Epidural Block

Battista Borghi, MD*, Vanni Agnoletti, MD{dagger}, Alessandro Ricci, MD*, Hanna van Oven, MD*, Nicoletta Montone, MD*, and Andrea Casati, MD{ddagger} Section Editor

*Anesthesia Research Staff, IRCCS Istituti Ortopedici Rizzoli, Bologna, Italy, the {dagger}Department of Surgical Sciences, University of Bologna, Bologna, Italy, and the {ddagger}Department of Anesthesiology, Vita-Salute University of Milano, IRCCS H San Raffaele, Milano, Italy

Anesth Analg 2004;98:1473-1478


作者在48名接受全髋置换管手术的病人中比较了在置入硬膜外导管前将Tuohy针头尖端向手术侧旋转45°45°旋转组,n 24)与Tuohy针头朝向头部90°的传统置管方法(对照组,n 24)对0.75%布比卡因10ml加舒芬太尼10 µg 扩散的影响。留置导管超过Tuohy针头34cm 。一名盲观察者记录双侧的感觉和运动阻滞,麻醉质量和在病人自控硬膜外镇痛第一个48h期间局麻药使用量。等待效果时间在对照组为21±6min45°旋转组为17±7minP >0.50)。手术侧的最高感觉阻滞平面对照组为T10T10-7),45°旋转组为T9T12-9)(P >0.50);然而非手术侧的最高感觉阻滞平面对照组为T10T10-7),45°旋转组为L3L5-T12)(P 0.0005)。45°旋转组手术肢体运动神经达到完全阻滞要早于对照组,对照组病人非手术侧运动神经阻滞更完全。两组手术侧两个节段感觉水平的消退过程相似,但45°旋转组非手术侧开始较对照组早。两组术后镇痛相似,但45°旋转组(242±35ml)所用的局麻药比对照组(297±60ml)少(P 0.0005)。作者认为,在置入硬膜外导管前将Tuohy针头尖端向手术侧旋转45°使手术侧感觉和运动神经优先得到阻滞,减少了术后镇痛的局麻药剂量。

(殷文渊 译 王祥瑞 校)

We evaluated the effects of turning the tip of the Tuohy needle 45° toward the operative side before threading the epidural catheter (45°-rotation group, n = 24) as compared to a conventional insertion technique with the tip of the Tuohy needle oriented at 90° cephalad (control group, n = 24) on the distribution of 10 mL of 0.75% ropivacaine with 10 µg sufentanil in 48 patients undergoing total hip replacement. The catheter was introduced 3 to 4 cm beyond the tip of the Tuohy needle. A blinded observer recorded sensory and motor blocks on both sides, quality of analgesia, and volumes of local anesthetic used during the first 48 h of patient-controlled epidural analgesia. Readiness to surgery required 21 ± 6 min in the control group and 17 ± 7 min in the 45°-rotation group (P > 0.50). The maximum sensory level reached on the operative side was T10 (T10-7) in the control group and T9 (T10-6) in the 45°-rotation group (P > 0.50); whereas the maximum sensory level reached on the nonoperative side was T10 (T12-9) in the control group and L3 (L5-T12) in the 45°-rotation group (P = 0.0005). Complete motor blockade of the operative limb was achieved earlier in the 45°-rotation than in the control group, and motor block of the nonoperative side was more intense in patients in the control group. Two-segment regression of sensory level on the surgical side was similar in the two groups, but occurred earlier on the nonoperative side in the 45°-rotation group (94 ± 70 min) than in the control group (178 ± 40 min) (P = 0.0005). Postoperative analgesia was similar in the 2 groups, but the 45°-rotation group consumed less local anesthetic (242 ± 35 mL) than the control group (297 ± 60 mL) (P = 0.0005). We conclude that the rotation of the Tuohy introducer needle 45° toward the operative side before threading the epidural catheter provides a preferential distribution of sensory and motor block toward the operative side, reducing the volume of local anesthetic solution required to maintain postoperative analgesia.


 

防止病理性肥胖病人全麻诱导时的肺膨胀不全状态

Prevention of Atelectasis Formation During the Induction of General Anesthesia in Morbidly Obese Patients

Marta Coussa, MD*, Stefania Proietti, MD{dagger}, Pierre Schnyder, MD{dagger}, Philippe Frascarolo, PhD*, Michel Suter, MD PhD{ddagger}, Donat R. Spahn, MD*, and Lennart Magnusson, MD PhD*

Departments of *Anesthesiology, {dagger}Diagnostic Radiology, and {ddagger}General Surgery, University Hospital, Lausanne, Switzerland

Anesth Analg 2004;98:1491-1495


在病理性肥胖病人中全麻引起的肺膨胀不全日益增多。作者曾介绍了在非肥胖病人诱导时采用呼气末正压通气(PEEP)可以防止肺膨胀不全。本文作者研究了PEEP对防止病理性肥胖病人肺膨胀不全的效果。23名成年病理性肥胖病人(体表指数>35kg/m2)随机分为两组。在PEEP组中,病人呼吸100%氧气(5分钟)并持续10cmH20气道正压,在诱导后,通过面罩以PEEP 10 cmH20机械通气。在对照组中,诱导过程相同,但没有持续气道正压或PEEP。肺膨胀不全,通过CT诊断,诱导前和插管后行血气分析。在气管插管后,对照组较PEEP组肺膨胀不全多(对照组10.4±4.8%PEEP1.7%±1.3%P<0.001)。插管后吸入100%氧气,PEEP组的PaO2显著高于对照组(分别为457±130mmHg315±100mmHgP0.035)。结论:在病理性肥胖病人中,在麻醉诱导过程中使用PEEP可以大大预防肺膨胀不全状态,从而获得更好的氧合。

(殷文渊 译 王祥瑞 校)

Atelectasis caused by general anesthesia is increased in morbidly obese patients. We have shown that application of positive end-expiratory pressure (PEEP) during the induction of anesthesia prevents atelectasis formation in nonobese patients. We therefore studied the efficacy of PEEP in morbidly obese patients to prevent atelectasis. Twenty-three adult morbidly obese patients (body mass index >35 kg/m2) were randomly assigned to one of two groups. In the PEEP group, patients breathed 100% oxygen (5 min) with a continuous positive airway pressure of 10 cm H2O and, after the induction, mechanical ventilation via a face mask with a PEEP of 10 cm H2O. In the control group, the same induction was applied but without continuous positive airway pressure or PEEP. Atelectasis, determined by computed tomography, and blood gas analysis were measured twice: before the induction and directly after intubation. After endotracheal intubation, patients of the control group showed an increase in the amount of atelectasis, which was much larger than in the PEEP group (10.4% ± 4.8% in control group versus 1.7% ± 1.3% in PEEP group; P < 0.001). After intubation with a fraction of inspired oxygen of 1.0, PaO2 was significantly higher in the PEEP group compared with the control group (457 ± 130 mm Hg versus 315 ± 100 mm Hg, respectively; P = 0.035) We conclude that in morbidly obese patients, atelectasis formation is largely prevented by PEEP applied during the anesthetic induction and is associated with a better oxygenation.

 

比较辅助电针刺与人工耳部针刺用于慢性下背部疼痛的短期和长期疗效

The Short- and Long-Term Benefit in Chronic Low Back Pain Through Adjuvant Electrical Versus Manual Auricular Acupuncture

Sabine M. Sator-Katzenschlager, MD*, Gisela Scharbert, MD*, Sibylle A. Kozek-Langenecker, MD*, Jozef C. Szeles, MD{dagger}, Gabriele Finster, MD*, Andreas W. Schiesser, PhD{ddagger}, Georg Heinze, PhD§, and Hans Georg Kress, MD PhD* Section Editor

*Department of Anesthesiology and Intensive Care Medicine (B), Outpatient Pain Center, the {dagger}Department of Vascular Surgery, the {ddagger}Ludwig Boltzmann Institute of Consciousness Psychology and Transculture Psychotherapy, and the §Department of Medical Computer Science, University of Vienna, Vienna, Austria

Anesth Analg 2004;98:1359-1364

 

针刺疗法是一个用于慢性疼痛治疗的确定的辅助镇痛方法。一般认为针刺点的电刺激增强针刺的镇痛作用。在这个前瞻、随机、双盲的对照性研究中,我们检验了如下假设,即在用标准镇痛治疗中仍不能充分缓解疼痛(视觉模拟分数[VAS] >=5)的慢性下背部疼痛病人,用耳部电针刺(EA)缓解疼痛比常规耳部人工手法针刺(CO)更有效。一次性针刺针插入优势侧的耳部针刺点294055,并与一个新近开发的以电池为动力、戴在耳后的小型刺激器相连接。病人随机分成用持续低频耳部EA1 Hz 2 mA双相恒定电流)的EA组(n = 31)和无电刺激(佯装电刺激)的CO组(n = 30)。每周进行一次治疗,持续6 wk,且每组的针在插入后 48 h拔除。在研究期和3个月随访期中,要求病人完成McGill调查表。用VAS方法评价心理快乐、行为水平、睡眠质量和疼痛强度;同时记录镇痛药的使用量。在研究期和随访期中,EA组的疼痛缓解显著优于CO组。同样,EA组的心理快乐、行为和睡眠比CO组显著改善,补充应用的镇痛药消耗量较少,恢复全职工作的病人较多。尤其是用EA治疗的病人神经性痛得到改善。无不良反应。这些结果第一次证明了耳部针刺点的持续EA刺激改善对慢性腰背部疼痛的门诊病人的治疗效果。

(马皓琳 译  李士通 校)

Acupuncture is an established adjuvant analgesic modality for the treatment of chronic pain. Electrical stimulation of acupuncture points is considered to increase acupuncture analgesia. In this prospective, randomized, double-blind, controlled study we tested the hypothesis that auricular electroacupuncture (EA) relieves pain more effectively than conventional manual auricular acupuncture (CO) in chronic low back pain patients with insufficient pain relief (visual analogue scale [VAS] >=5) treated with standardized analgesic therapy. Disposable acupuncture needles were inserted in the auricular acupuncture points 29, 40, and 55 of the dominant side and connected to a newly developed battery-powered miniaturized stimulator worn behind the ear. Patients were randomized into group EA (n = 31) with continuous low-frequency auricular EA (1 Hz biphasic constant current of 2 mA) and group CO (n = 30) without electrical stimulation (sham-electroacupuncture). Treatment was performed once weekly for 6 wk, and in each group needles were withdrawn 48 h after insertion. During the study period and a 3-mo follow-up, patients were asked to complete the McGill questionnaire. Psychological well being, activity level, quality of sleep, and pain intensity were assessed by means of VAS; moreover, analgesic drug consumption was documented. Pain relief was significantly better in group EA during the study and the follow-up period as compared with group CO. Similarly, psychological well-being, activity, and sleep were significantly improved in group EA versus group CO, the consumption of analgesic rescue medication was less, and more patients returned to full-time employment. Neuropathic pain in particular improved in patients treated with EA. There were no adverse side effects. These results are the first to demonstrate that continuous EA stimulation of auricular acupuncture points improves the treatment of chronic low back pain in an outpatient population.

 

过氧化亚硝盐降低组织纤溶酶原激活因子的活性

Peroxynitrite Inactivates Tissue Plasminogen Activator

Vance G. Nielsen, MD*, John P. Crow, PhD§, Fen Zhou, MD*, and Dale A. Parks, PhD*,{dagger},{ddagger}

Departments of *Anesthesiology, {dagger}Physiology and Biophysics, and {ddagger}Pediatrics, The Center for Free Radical Biology, The University of Alabama at Birmingham, Birmingham, Alabama; and §Departments of Pharmacology and Toxicology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas

Anesth Analg 2004 98: 1312-1317.

 

 组织纤溶酶原激活因子(tPA)在体内生理性纤溶过程中有重要的作用。血栓形成与某些临床病变有关(如:动脉粥样硬化性疾病),这些疾病涉及到局部tPA活性的降低及伴有反应性氮素的形成,如过氧化亚硝盐(OONO–),它是一种由氧化氮及过氧化物形成的分子。我们假设tPA遇到OONO–将导致tPA活性降低。OONO–来自3-morpholinosydnonimine (SIN-1),后者能同时产生含氮氧化物及过氧化物分子。tPA重组体用0 µM SIN-1 100 µM SIN-1100 µM SIN-1合用4000 U/mL人类重组超氧化物歧化酶在37°C下孵育60 min;或用 4000 U/mL的人类重组超氧化物歧化酶孵育60 minn = 8,每种条件都收集各自的反应结果)。通过在组织因子暴露的人体血浆中添加tPA样本的方法及用血栓弹性图监测血凝块纤溶作用的方法来评估tPA活性的改变。与其它三种条件组有明显不同的是,暴露于SIN-1的一组导致tPA介导的纤溶作用显著降低(P < 0.001)tPA活性小于不暴露于SIN-11%)。另外几组则无明显差别。由此得出结论,tPAOONO–抑制,OONO–在临床血栓形成疾病中起一定作用。

(裘毅敏译  李士通校)

Tissue plasminogen activator (tPA) has a prominent role in physiological fibrinolysis in vivo. Thrombosis has been associated with clinical scenarios (e.g., atherosclerotic disease) known to involve local decreases in tPA activity with concomitant formation of reactive nitrogen species such as peroxynitrite (OONO), a molecule formed from nitric oxide and superoxide. We hypothesized that exposure of tPA to OONO would result in a decrease in tPA activity. OONO was generated with 3-morpholinosydnonimine (SIN-1), a molecule that produces both nitric oxide and superoxide. Recombinant tPA was incubated at 37°C for 60 min with 0 µM SIN-1; 100 µM SIN-1; 100 µM SIN-1 and 4000 U/mL recombinant human superoxide dismutase; or 4000 U/mL recombinant human superoxide dismutase (n = 8 separate reactions per condition). Changes in tPA activity were assessed by addition of tPA samples to tissue factor-exposed human plasma and measuring clot fibrinolysis with a thrombelastograph®. Exposure to SIN-1 resulted in a decrease in tPA-mediated fibrinolysis (<1% activity of tPA not exposed to SIN-1) that was significantly (P < 0.001) different from the other three conditions. There were no significant differences between the other conditions. We conclude that tPA is inhibited by OONO, and that OONO may have a role in clinical thrombotic scenarios.

 

鞘内应用加巴潘汀和氯压定或加巴潘汀和新斯的明在福尔马林试验中相互作用的特性

Characteristic of Interactions Between Intrathecal Gabapentin and Either Clonidine or Neostigmine in the Formalin Test

Myung Ha Yoon, MD, Jeong Il Choi, MD, and Sang Hyun Kwak, MD

Department of Anesthesiology and Pain Medicine, Chonnam National University, Medical School, Gwangju, Korea

Anesth Analg 2004;98:1374-1379

 

鞘内应用加巴潘汀(抗癫痫药)对于福尔马林致痛反应的第二期是有效的,但对急性痛无效。不同于加巴潘汀,鞘内应用氯压定和新斯的明能减弱剧痛和福尔马林痛反应的第二期。我们估计在福尔马林致痛实验中加入加巴潘汀到氯压定或新斯的明中可产生相互作用。用雄性Sprague-Dawley鼠进行福尔马林实验,将50微升5%福尔马林溶液注射入后爪。用固定剂量分析或等效图分析研究药物的相互作用。在福尔马林实验中,鞘内应用加巴潘汀对第二期的退缩反应产生抑制效果,但对第一期反应没有影响。鞘内应用氯压定或新斯的明则导致两个阶段的疼痛反应都减轻。第一期痛反应固定剂量分析显示加巴潘汀能加强氯压定和新斯的明抗伤害感受的作用。等效图分析第二期疼痛显示在鞘内应用加巴潘汀-氯压定混合物或加巴潘汀-新斯的明混合物后产生协同作用。我们认为在脊髓水平应用加巴潘汀和氯压定或新斯的明的混合物不仅对剧痛,而且对福尔马林反应的第二期痛中起重要作用。

(彭中美   李士通 校)

Intrathecal gabapentin is effective for phase 2 of the formalin response but not for acute pain. Unlike gabapentin, intrathecal clonidine and neostigmine attenuate both acute pain and phase 2 of the formalin response. We evaluated gabapentin’s interactions with either clonidine or neostigmine in the formalin test. Male Sprague-Dawley rats were used. For the formalin test, 50 µL of 5% formalin solution was injected into the hindpaw. The interaction of drugs was investigated by a fixed-dose analysis or an isobolographic analysis. Intrathecal gabapentin produced a suppression of the phase 2 flinching response, but not the phase 1 response, in the formalin test. Intrathecal clonidine and neostigmine resulted in a reduction of the pain behavior in both phases. A fixed-dose analysis in phase 1 showed that gabapentin potentiated the antinociceptive effect of clonidine and neostigmine. An isobolographic analysis in phase 2 revealed a synergistic interaction after intrathecal administration of gabapentin-clonidine or gabapentin-neostigmine mixture. We conclude that the combination of gabapentin with either clonidine or neostigmine at the level of the spinal cord could play a major role not only in acute pain, but also in phase 2 of the formalin response.

 

曲马多对非洲蟾蜍卵母细胞5-羟色胺2C受体表达的抑制效应

The Inhibitory Effects of Tramadol on 5-Hydroxytryptamine Type 2C Receptors Expressed in Xenopus Oocytes

Junichi Ogata, MD*, Kouichiro Minami, MD PhD*, Yasuhito Uezono, MD PhD{dagger}, Takashi Okamoto, MD*, Munehiro Shiraishi, MD*, Akio Shigematsu, MD PhD*, and Yoichi Ueta, MD PhD{ddagger}

*Department of Anesthesiology, University of Occupational and Environmental Health School of Medicine, Fukuoka, Japan, the {dagger}Second Department of Pharmacology, Nagasaki University School of Medicine, Nagasaki, Japan, and the {ddagger}First Department of Physiology, University of Occupational and Environmental Health School of Medicine, Fukuoka, Japan

Anesth Analg 2004 98: 1401-1406.

 

尽管曲马多作为镇痛剂广泛应用,其抵抗伤害的机制仍然没有解决。血清素(5-羟色胺,5-HT)是一种单胺类神经递质,调制众多的感觉、运动和行为过程。5-HT2C受体(5-HT2CR)5-HT受体的主要亚型,和5-HT的很多重要效应有关,包括疼痛、摄食和运动。在此研究中,我们使用全细胞电压钳来检测曲马多对在蟾蜍卵母细胞上表达的5-HT2CR 所介导的、由5-HT诱导的Ca2+-激活Cl电流的影响。曲马多在药理学相关浓度抑制5-HT诱导的Cl电流。蛋白激酶C抑制剂bisindolylmaleimide I (GF109203x)不能消除曲马多对5-HT2CR介导的作用的抑制效应。我们也研究了曲马多对蟾蜍卵母细胞表达5-HT2CR [3H]5-HT 结合情况,发现其抑制[3H]5-HT5-HT2CR特异结合。[3H]5-HT结合的Scatchard分析显示,曲马多改变了结合的表观离解常数,不改变最大结合力,表明是竞争性抑制。结果提示,曲马多抑制5--HT2CR的功能,此抑制效应的机制可能是竞争性取代5-HT5-HT2CR结合,而不是通过激活蛋白激酶C途径。

(张曦译 李士通校)

Although tramadol is widely available as an analgesic, its mechanism of antinociception remains unresolved. Serotonin (5-hydroxytryptamine, 5-HT) is a monoaminergic neurotransmitter that modulates numerous sensory, motor, and behavioral processes. The 5-HT type 2C receptor (5-HT2CR) is one of the major 5-HT receptor subtypes and is implicated in many important effects of 5-HT, including pain, feeding, and locomotion. In this study, we used a whole-cell voltage clamp to examine the effects of tramadol on 5-HT-induced Ca2+-activated Cl currents mediated by 5-HT2CR expressed in Xenopus oocytes. Tramadol inhibited 5-HT-induced Clcurrents at pharmacologically relevant concentrations. The protein kinase C (PKC) inhibitor, bisindolylmaleimide I (GF109203x), did not abolish the inhibitory effects of tramadol on the 5-HT2CR-mediated events. We also studied the effects of tramadol on [3H]5-HT binding to 5-HT2CR expressed in Xenopus oocytes, and found that it inhibited the specific binding of [3H]5-HT to 5-HT2CR. Scatchard analysis of [3H]5-HT binding revealed that tramadol altered the apparent dissociation constant for binding without changing maximal binding, indicating competitive inhibition. The results suggest that tramadol inhibits 5-HT2CR function, and the mechanism of this inhibitory effect seems to involve competitive displacement of the 5-HT binding to the 5-HT2CR, rather than via activation of the PKC pathway.

 

新生儿主动脉弓重建术中必须监测双侧大脑血氧饱和度吗?

Is Bilateral Monitoring of Cerebral Oxygen Saturation Necessary During Neonatal Aortic Arch Reconstruction?

Dean B. Andropoulos, MD*,{dagger},{ddagger}, Laura K. Diaz, MD*,{ddagger}, Charles D. Fraser, Jr., MD||,¶, E. Dean McKenzie, MD||,¶, and Stephen A. Stayer, MD*,{dagger},{ddagger}

Departments of *Anesthesiology, {dagger}Pediatrics, and ||Surgery, Baylor College of Medicine, Houston, Texas; and Divisions of {ddagger}Pediatric Cardiovascular Anesthesiology and ¶Congenital Heart Surgery, Texas Children’s Hospital, Houston, Texas

Anesth Analg 2004 98: 1267-1272.

 

本研究中我们应用近红外分光技术监测了大脑局部低流量灌注(RLFP)前、中、后三个时段大脑两侧半球血氧饱和度的差异,以确定术中是否必须同时监测两侧大脑血氧饱和度。病例为采用RLFP技术行主动脉弓重建术的新生儿。在以下各时间段每1分钟测定和记录双侧局部大脑血氧饱和度:1)转机前,2)转机后RLFP前,3RLFP时,4)转机时停RLFP后,5)停机后。在转机前和转机后RLFP前,两侧大脑的血氧饱和度相关性(r = 0.979 0.852)和一致性(平均偏差,右比左,0 +2)都很好。但在RLFP时,相关性(r = 0.35)和一致性(平均偏差,右比左,+6.3)明显变差,停RLFP后只有部分恢复接近基础值。19例病例中有9例的双侧大脑血氧饱和度差异超过10%,均为左侧低于右侧。通过双侧监测方法,我们发现RLFP时左侧大脑半球的血氧饱和度有下降,但是下降引起的远期结果尚不明确。

(张俊杰译 李士通校)

In this study, we measured cerebral oxygenation in both cerebral hemispheres by using near-infrared spectroscopy before, during, and after regional low-flow cerebral perfusion (RLFP) to determine whether bilateral monitoring was necessary. Neonates undergoing aortic arch reconstruction with RLFP were studied. The bilateral regional cerebral oxygenation index was measured and recorded at 1-min intervals during the following periods: 1) before bypass, 2) during bypass before RLFP, 3) during RLFP, 4) on bypass after RLFP, and 5) post-bypass. Before bypass and on bypass before RLFP, the correlation (r = 0.979 and 0.852) and agreement (mean bias, right versus left, 0 and +2) between hemispheres were excellent. During RLFP, however, correlation (r = 0.35) and agreement (mean bias of the right versus left side, +6.3) worsened and only partially returned to baseline values after RLFP. Nine of 19 patients had sustained differences in cerebral oxygen saturation of >10%, always with the left side values less than the right. Bilateral monitoring detects desaturation in the left cerebral hemisphere during RLFP. The long-term consequences of lower saturations on the left side of the brain are unclear.

reconstruction.

 

比较三种不同脑电监护仪的临床实用性:双频谱指数、处理后的脑电图和Alaris听觉诱发电位

A Comparison of the Clinical Usefulness of Three Different Electroencephalogram Monitors: Bispectral Index, Processed Electroencephalogram, and Alaris Auditory Evoked Potentials

Tomoki Nishiyama, MD PhD, Takashi Matsukawa, MD PhD*, and Kazuo Hanaoka, MD PhD

From the Department of Anesthesiology, The University of Tokyo, Tokyo, Japan, and the *Department of Anesthesia, Yamanashi University, Medical School, Yamanashi, Japan

Anesth Analg 2004 98: 1341-1345.

 

我们比较了脑电双频谱指数(BIS)、处理后的脑电图(pEEG)和Alaris听觉诱发电位(A-AEP)的实用性。90名拟行择期乳房切除术的女性病人被分为3组。使用丙泊酚和芬太尼进行诱导,放置喉罩气道,加用氧化亚氮维持麻醉。通过BISpEEGA-AEP监测脑电图。我们记录了第一次放置电极即可达到足够低的阻抗以提取脑电信号的病人数(反映成功率),监护仪提供的指数超出全身麻醉下合理范围的次数(不符合率),放置喉罩气道以及手术切皮时指数的变化(反映了监护仪的反应性)和术中电灼对信号的干扰停止后恢复良好脑电信号的时间(恢复时间)。成功率的顺序是BIS>A-AEP>pEEG,不符合率是A-AEP<BIS<pEEGA-AEP的反应性最高。恢复时间的顺序是pEEG<A-AEP<BIS。总之,BIS的成功率最高,A-AEP不符合率最低,反应性最好,而pEEG的恢复时间最快。

(颜涛译 李士通校)

We compared the usefulness of the Bispectral Index (BIS), Processed electroencephalogram (pEEG), and Alaris auditory evoked potentials (A-AEP). Ninety females scheduled for mastectomy were divided into three groups. Anesthesia was induced with propofol and fentanyl to insert a laryngeal mask airway (LMA) and was maintained by adding nitrous oxide. EEG was monitored by either BIS, spectral edge frequency by pEEG, or A-AEP index by A-AEP. We recorded the number of patients with impedance low enough to extract good EEG signals at the first electrodes application (success rate), the number with an index outside of the range considered appropriate for general anesthesia (inappropriateness rate), changes of the index by LMA insertion or surgical incision (responsiveness), and time to return to good EEG signals after signal disturbance by electric cautery (recovery time). The success rate was larger in BIS > A-AEP > pEEG. The inappropriateness rate was smaller in A-AEP< BIS< pEEG. The A-AEP group showed the largest responsiveness. The recovery time was shorter in pEEG < A-AEP < BIS. In summary, the BIS had the largest success rate, the A-AEP had the least inappropriateness rate and the largest responsiveness, and the pEEG had the fastest recovery time.

 

与蛛网膜下腔麻醉有关的人类软脊膜超微结构发现

Ultrastructural Findings in Human Spinal Pia Mater in Relation to Subarachnoid Anesthesia

Miguel Angel Reina, MD*,{dagger}, Oscar De León Casasola, MD{ddagger}, M. C. Villanueva, MD§, Andrés López, MD*,{dagger}, Fabiola Machés, MD{dagger}, and José Antonio De Andrés, MD||

*Department of Anesthesiology and Critical Care, Hospital General de Móstoles, Madrid, Spain; {dagger}Department of Anesthesiology and Critical Care, Hospital Madrid Montepríncipe, Madrid, Spain; {ddagger}Department of Anesthesiology and Critical Care Medicine, Roswell Park Cancer Institute, Buffalo, New York; §Department of Pathology, Hospital General de Móstoles, Madrid, Spain; and ||Department of Anesthesiology and Critical Care of Hospital General Universitario, Valencia, Spain

Anesth Analg 2004 98: 1479-1485.

为了明确人软脊膜上是否存在窗孔,我们检查了人软脊膜超微结构的细节如细胞组成和膜的厚度。我们假设软脊膜不是一个连续的膜结构,而是有窗孔穿过软脊膜细胞。腰部硬膜囊取自7具人新鲜尸体,腰软脊膜标本经特殊的染色技术(免疫组织化学法)及透射扫描电镜进行研究。观察由重叠的扁平细胞软膜层和软膜下组织。我们发现窗孔存在于人胸腰连接处的软脊膜、脊髓圆锥和神经根水平,但是胸段水平不存在窗孔。我们推测在腰脊髓和神经根水平的软脊膜窗孔可能影响局麻药跨膜转移。

(周雅春译 李士通校)

We examined ultrastructural details such as the cellular component and membrane thickness of human spinal pia mater with the aim of determining whether fenestrations are present. We hypothesized that pia mater is not a continuous membrane but, instead, that there are fenestrations across the pial cellular membrane. The lumbar dural sac from 7 fresh human cadavers was removed, and samples from lumbar spinal pia mater were studied by special staining techniques, immunohistochemistry, and transmission and scanning electron microscopy. A pial layer made by flat overlapping cells and subpial tissue was identified. We found fenestrations in samples from human spinal pia mater at the thoracic-lumbar junction, conus medullaris, and nerve root levels, but these fenestrations did not appear at the thoracic level. We speculate whether the presence of fenestrations in human spinal pia mater at the level of the lumbar spinal cord and at the nerve root levels has any influence on the transfer of local anesthetics across this membrane.

 

评估氟哌利多对平均QTc间期影响的模型

A Model for Evaluating Droperidol’s Effect on the Median QTc Interval

Yongfeng Zhang, PhD*, Ziping Luo, PhD*, and Paul F. White, PhD MD, FANZCA{dagger}

*New Drug Center at Amphastar Pharmaceuticals Inc., Rancho Cucamonga, California; and {dagger}Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Anesth Analg 2004;98:1330-1335

由于FDA告诫围术期使用预防呕吐的氟哌利多,即使小剂量也能导致严重甚至致命的心律失常,使氟哌利多的应用引起了广泛的争论。我们采用数学模型来评估由专家评审的论文的数据得到的心电图QT间期,观察静注0.1–0.25 mg/kg氟哌利多和QTc 延长间的关系。在由对数模型得到的QTc (27–63 ms),由线性模型得QTc (27–67 ms)和由方根模型得QTc (36–57 ms)中,方根模型与实际QTc (37–59 ms)最相近。我们选用的其他模型包括多项式模型、多指数模型(包括四次方根模型、立方根模型,平方模型和立方模型)。结果显示静注0.625–1.25 mg 的氟哌利多引起的平均QTc 间期延长为9 ± 3 18 ± 3 ms 之间。因此,此回归分析显示围术期应用小于1.25 mg的氟哌利多抗恶性呕吐不可能引起心律失常效应。结论:应用方根曲线拟合模型分析氟哌利多剂量与QTc 延长间的关系显示,静注小剂量氟哌利多(0.625–1.25 mg IV) QTc 间期延长小于30毫秒。因此,手术患者预防应用小剂量止吐药氟哌利多不会产生心律失常效应。

(赵雪莲译 李士通校)

Controversy surrounds the use of the antiemetic droperidol, because of the Food and Drug Administration-imposed "black box" warning alleging that even small doses of the drug can lead to serious (even fatal) arrhythmias when it is used for antiemetic prophylaxis during the perioperative period. We used mathematical modeling of electrocardiographic QT interval data published in a peer-reviewed manuscript to evaluate the relationship between the dose of droperidol (0.1–0.25 mg/kg IV) and QTc prolongation. In comparing the calculated QTc values based on the logarithm model (27–63 ms), the linear model (27–67 ms) and the square-root model (36–57 ms) to the actual measured QTc values (37–59 ms), the square-root model provided the best simulation of the experimental findings. Other models that we evaluated included the polynomial model and various exponent models (e.g., quartic-root model, cubic-root model, square model, and cubic model). The estimated median prolongation of the median QTc interval produced by droperidol 0.625–1.25 mg IV would vary from 9 ± 3 to 18 ± 3 ms. Therefore, this regression analysis suggests that small "antiemetic" doses of droperidol (<=1.25 mg) would be unlikely to produce proarrhythmogenic effects in the perioperative period.

 

儿童麻醉诱导时家长在场和术前镇静的趋势:一项1995–2002年全美随访调查的结果

Trends in the Practice of Parental Presence During Induction of Anesthesia and the Use of Preoperative Sedative Premedication in the United States, 1995–2002: Results of a Follow-Up National Survey

Zeev N. Kain, MD*,{dagger},{ddagger}, Alison A. Caldwell-Andrews, PhD*, Dawn M. Krivutza, MA*, Megan E. Weinberg, MA*, Shu-Ming Wang, MD*, and Dorothy Gaal, MD* Section Editor

Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2004;98:1252-1259

 

目前,麻醉诱导时家长陪伴在场和术前使用镇静药均可用于缓解儿童术前焦虑。1995年的一项研究显示,多数患儿进入手术室时没有享受到这两种措施。2002年我们进行了一项随访,将五千份调查问卷随机邮寄给美国麻醉医师协会的会员,并对邮件进行无反应偏差评估。投递三次后总共收到27%的回复(n = 1362)。我们发现,与1995(30%)相比,2002年更多患儿(50%, P = 0.001)术前使用镇静药,并且术前用药的地理差异减小(F = 8.31, P = 0.006)。同样与1995年相比,2002年美国有更多家长在患儿麻醉诱导时被允许在场陪伴({chi}2 = 26.3, P = 0.0001)。与1995年相同的是,咪达唑仑是最常使用的术前药。

(轩   李士通 校)

Both parental presence during induction of anesthesia and sedative premedication are currently used to treat preoperative anxiety in children. A survey study conducted in 1995 demonstrated that most children are taken into the operating room without the benefit of either of these two interventions. In 2002 we conducted a follow-up survey study. Five thousand questionnaires were mailed to randomly selected physician members of the American Society of Anesthesiologists. Mailings were followed by a nonresponse bias assessment. Twenty-seven percent (n = 1362) returned the questionnaire after 3 mailings. We found that a significantly larger proportion of young children undergoing surgery in the United States were reported to receive sedative premedication in 2002 as compared with 1995 (50% vs 30%, P = 0.001). We also found that in 2002 there was significantly less geographical variability in the use of sedative premedication as compared with the 1995 survey (F = 8.31, P = 0.006). Similarly, we found that in 2002 parents of children undergoing surgery in the United States were allowed to be present more often during induction of anesthesia as compared with 1995 ({chi}2 = 26.3, P = 0.0001). Finally, similar to our findings in the 1995 survey, midazolam was uniformly selected most often to premedicate patients before surgery.

 

比较肾上腺素和加压素对快速静脉注射布比卡因致心搏停止的猪模型的作用

A Comparison of Epinephrine and Vasopressin in a Porcine Model of Cardiac Arrest After Rapid Intravenous Injection of Bupivacaine

Viktoria D. Mayr, MD, Claus Raedler, MD, Volker Wenzel, MD, Karl H. Lindner, MD, and Hans-Ulrich Strohmenger, MD

Department of Anesthesiology and Critical Care Medicine, Leopold-Franzens-University, Innsbruck, Austria

Anesth Analg 2004 98: 1426-1431.

 

在猪模型上,我们比较了肾上腺素、加压素或肾上腺素联合加压素对布比卡因致心博停止成活率的有效性,盐水为安慰剂对照。静脉注射5mg/kg0.5%布比卡因后,通气中断3 ± 1分钟直至发生心搏停止。心搏停止1分钟后开始心肺复苏。心肺复苏2分钟后,28个动物每5分钟给予肾上腺素;加压素;肾上腺素联合加压素;或安慰剂。每种药物注射3分钟后,施行3次电除颤(3, 4 6 J/kg);其后所有电击能量都是6 J/kg。实验中抽血测血浆布比卡因浓度。加压素/肾上腺素联合组,所有猪存活(P < 0.01较之安慰组);加压素组7个猪中5个存活,肾上腺素组7个猪中4个存活,安慰组中无一个猪存活。血浆总布比卡因浓度组间比较无差异。在这个布比卡因导致心搏停止的模型中,心肺复苏时加压素联合肾上腺素比安慰组有显著高的生存率。

(吴俭 译,李士通 校)

In a porcine model, we compared the efficacy of epinephrine, vasopressin, or the combination of epinephrine and vasopressin with that of saline placebo on the survival rate after bupivacaine-induced cardiac arrest. After the administration of 5 mg/kg of a 0.5% bupivacaine solution IV, ventilation was interrupted for 3 ± 1 min (mean ± SD) until asystole occurred. Cardiopulmonary resuscitation (CPR) was initiated after 1 min of cardiac arrest. After 2 min of CPR, 28 animals received, every 5 min, epinephrine; vasopressin; epinephrine combined with vasopressin; or placebo IV. Three minutes after each drug administration, up to 3 countershocks (3, 4, and 6 J/kg) were administered; all subsequent shocks were 6 J/kg. Blood was drawn throughout the experiment for the determination of plasma bupivacaine concentration. In the vasopressin/epinephrine combination group, all pigs survived (P < 0.01 versus placebo); in the vasopressin group 5 of 7, in the epinephrine group 4 of 7, and in the placebo group none of 7 swine survived. The plasma concentration of total bupivacaine showed no significant difference among groups. In this model of bupivacaine-induced cardiac arrest, CPR with a combination of vasopressin and epinephrine resulted in significantly better survival rates than in the placebo group.

食道彩色多普勒超声心动图测定心输出量

Automated Cardiac Output Measurement by Transesophageal Color Doppler Echocardiography

Shigeru Akamatsu, MD, Akiyoshi Oda, MD, Etsuji Terazawa, MD, Takuji Yamamoto, MD, Hiroto Ohata, MD, Tomohiro Michino, MD, and Shuji Dohi, MD

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

Anesth Analg 2004 98: 1232-1238

 

自动心输出量测定(ACOM)方法是一种在空间及时间上对数字彩色多普勒血流速率的整合方法,虽然已通过经胸超声心动图证实,但经食道超声心动图(TEE)方法则尚未得到验证。因此我们在36例心脏手术病人中确定利用TEEACOM方法的可行性。有利于分析ACOM方法的部位主要是横切过肺主动脉(PA)、二尖瓣口和左室流出道的彩色扇面。在每个超声视野中测定PA流量、二尖瓣流量及左室射血流量以确定心输出量。我们对ACOM方法及同时进行热稀释法(TD)测定的心输出量进行比较。在二尖瓣流量分析中,ACOM法与TD法所得的值有很好的相关(R2=0.85;在二室视野中均差=0.01 ± 0.58 L/min; R2 = 0.78;在四室视野中均差= –0.10 ± 0.68 L/min)。在PA流量分析中,ACOM并不与TD相关(R2 = 0.30)。而在左室流出道分析中,很难获取到彩色多普勒流量信号充分的最佳视野(44%)。我们应用ACOM方法测定二尖瓣流量以确定心输出量,与TD法有很好的相关性和一致性。因此通过TEEACOM来测定二尖瓣流量是一种实用及快速的测定心输出量的方法。

(王立中 译,李士通 校)

Automated cardiac output measurement (ACOM), which integrates digital color Doppler velocities in space and in time, has been validated using transthoracic echocardiography but has not been tested using transesophageal echocardiography (TEE). Therefore, we determined the feasibility of the ACOM method by TEE in 36 patients undergoing cardiovascular surgery. Regions of interest for ACOM were placed within a color sector across the main pulmonary artery (PA), the mitral annulus, and the left ventricular outflow tract. Cardiac output was determined from the PA flow, the mitral flow, and the left ventricular ejection flow at each view using the ACOM method. We compared measurements of cardiac output derived from the ACOM method with measurements simultaneously obtained by thermodilution (TD). In the mitral flow analysis, the values derived from ACOM correlated well with those from TD (R2 = 0.85; mean difference = 0.01 ± 0.58 L/min in the 2-chamber view; R2 = 0.78; mean difference = –0.10 ± 0.68 L/min in the 4-chamber view). In the PA flow analysis, the values derived from ACOM did not correlate with those from TD (R2 = 0.30). In the left ventricular outflow tract analysis, it was very difficult to obtain the optimal view (44%) in which color Doppler flow signals adequately appeared. Using the ACOM method, we obtained good correlation and agreement for cardiac output measurements in the mitral flow analysis compared with TD. The ACOM method is a practical and rapid method to measure cardiac output by TEE analysis of mitral flow.

 

甲氧氯普胺通过抑制鼠气管毒蕈碱M3受体而产生气道平滑肌舒张

Metoclopramide Causes Airway Smooth Muscle Relaxation Through Inhibition of Muscarinic M3 Receptor in the Rat Trachea

Masataka Saito, MD*, Osamu Shibata, MD*, Masakazu Yamaguchi, MD*, Maki Yoshimura, MD*, Tetsuji Makita, MD*, Noboru Harada, MD*, Masami Niwa, MD, and Koji Sumikawa, MD*

Departments of *Anesthesiology and Pharmacology 1, Nagasaki University School of Medicine, Nagasaki, Japan

Anesth Analg 2004;98:1325-1329

 

虽然常用作止吐药甲氧氯普胺也被认为有抗胆碱酯酶作用但是其对于气道平滑肌的作用还不十分的清楚。我们通过实验来探讨甲氧氯普胺对鼠气道肌肉收缩、磷脂酰肌醇反应以及对毒蕈碱M3受体亲和力的影响。雄性Wistar鼠麻醉后取其气管,制成3mm宽的气管环和1mm宽的切片,或10微米厚的冰冻切片。收缩反应是以0.55mg氯化氨甲酰胆碱所诱发,在30min后加入甲氧氯普胺(10uM-1mM)。切片被孵育在3[H]-肌-环己六醇、0.55mg氯化氨甲酰胆碱和甲氧氯普胺中,检测孵育液中的环己六醇环腺苷一磷酸的量。在气管切片上用放射标记[3H] 4-diphenylacetoxy-N-methyl-piperidine methobromide4DAMP)(一种毒蕈碱M3受体拮抗药)来进一步研究甲氧氯普胺与受体的结合作用。结果:甲氧氯普胺浓度增加,CCh引起的收缩逐渐减弱、毒蕈碱M3受体与4DAMP结合能力也降低。甲氧氯普胺50%抑制4DAMP毒蕈碱M3受体结合的浓度为24uM。本研究提示,甲氧氯普胺抑制CCh产生的肌肉收缩和磷脂酰肌醇反应可能通过毒蕈碱M3受体介导。

(沈浩译  李士通校)

Although metoclopramide, often used as an antiemetic, is reported to have an anticholinesterase action, the effect on airway smooth muscle remains unclear. We investigated the effect of metoclopramide on the contraction, phosphatidylinositol response, and binding affinity of muscarinic M3 receptors in rat trachea preparations. Male Wistar rats were anesthetized and their tracheas excised and chopped into 3-mm-wide rings, 1-mm-wide slices, or frozen 10-&micro;m-thick sections. Contraction was induced with 0.55 &micro;M carbachol (CCh) and, 30 min later, metoclopramide (10 &micro;M to 1 mM) was added. The slices were incubated with 3[H]myo-inositol, 0.55 &micro;M CCh, and metoclopramide, and the formation of 3[H] inositol monophosphate was measured. A radioligand binding study was conducted to examine the effects of metoclopramide using [3H] 4-diphenylacetoxy-N-methyl-piperidine methobromide (4-DAMP), a muscarinic M3 receptor antagonist, in sections of the trachea. Metoclopramide

 concentration dependently attenuated CCh-induced contraction and inositol monophosphate accumulation, and also attenuated the binding affinity of 4-DAMP to muscarinic M3 receptors. The 50% inhibitory concentration of metoclopramide against the binding affinity of 4-DAMP to muscarinic M3 receptors of rat trachea was 24 &micro;M. These findings suggest that the attenuation by metoclopramide of CCh-induced contraction and phosphatidylinositol response may be mediated through the muscarinic M3 receptors.

 

颈内动脉内麻醉药引起的脑电静止并不影响兔脑暂时性缺血后的早期充血

Electrocerebral Silence by Intracarotid Anesthetics Does Not Affect Early Hyperemia After Transient Cerebral Ischemia in Rabbits

Shailendra Joshi, MD*, Mei Wang, MS*, Ervant V. Nishanian, MD*, and Ronald G. Emerson, MD{dagger} Section Editor

Departments of *Anesthesiology and {dagger}Neurology, College of Physicians and Surgeons of Columbia University, New York

Anesth Analg 2004;98:1454-1459

有证据显示,缺血后早期充血由神经和血管机制同时介导。我们假设,如果神经元活动是再灌注充血的主要因素,那么利用异丙酚和硫喷妥钠进行颈内动脉麻醉引起脑电静止应该能够减轻充血反应。用双侧颈动脉进行阻断以及全身低血压的方法,造成新西兰白兔10分钟的短暂脑缺血。然后解除阻断,并将动脉平均压提升到基础水平。在对照组,再灌注期颈动脉内定期注入生理盐水,在实验组,颈内动脉中用异丙酚和硫喷妥钠造成10分钟的脑电静止。记录缺血期和再灌注期各生理数据。19只兔子中16只取得了令人满意的数据。两组在颈动脉阻断期平均动脉压,呼吸末二氧化碳,脑血流明显降低。在再灌注期,三组的脑血流基础值接近(生理盐水,异丙酚,硫喷妥钠分别为:192% ± 76%, 218% ± 84%, and 185% ± 101%,结果提示,再灌注期神经活动的抑制并不能影响短暂性脑缺血后的充血。

(朱 慧译 李士通校)

Evidence suggests that early postischemic hyperemia is mediated by both neurological and vascular mechanisms. We hypothesized that if neuronal activity were primarily responsible for reperfusion hyperemia, then electrocerebral silence induced by intracarotid anesthetics (propofol and pentothal) would attenuate the hyperemic response. New Zealand white rabbits were subjected to 10 min of cerebral ischemia using bilateral carotid occlusion and systemic hypotension. Subsequently, carotid occlusion was released, and the mean arterial blood pressure was increased to baseline values. In the control group, intracarotid saline was periodically injected during reperfusion. In the treatment groups, intracarotid propofol or thiopental was administered to maintain electrocerebral silence for 10 min. Physiological data were measured at baseline, during ischemia, and at reperfusion. Satisfactory data were available for 16 of 19 rabbits. Mean arterial blood pressure, end-tidal CO2, and cerebral blood flows decreased significantly in both groups during carotid occlusion. During early reperfusion, a similar percent increase in cerebral blood flow from baseline values was observed in all 3 groups (192% ± 76%, 218% ± 84%, and 185% ± 101% for saline, propofol, and pentothal, respectively). These results suggest that suppression of neuronal activity during reperfusion does not affect early hyperemia after transient cerebral ischemia.

 

减少心肺转流中的凝血激活:一项联合措施

Reducing hemostatic activation during cardiopulmonary bypass: a combinedapproach.

Eisses MJ, Seidel K, Aldea GS, Chandler WL.

Department of Anesthesiology, University of Washington School of Medicine,

Seattle, 98105, USA.

Anesth Analg 2004;98:1208-16

 

心肺转流(CPB)中用来限制凝血激活的干预措施如肝素涂层管道、e-氨基己酸以及减少散失血液的回输等单独应用的效果报道不一。我们对传统的CPB(对照)(CTRL)期间使用非涂层管道、无抗纤溶剂和开放性心脏切开与一项联合策略(HAC)包括使用肝素涂层管道、e-氨基己酸和闭合性心脏手术时的凝血和纤溶激活进行了比较。9CTRL患者和10HAC患者行初次冠脉搭桥手术,分别于CPB转前、转中和转后进行采血。CPB30min后凝血酶-抗凝血酶复合物和纤维蛋白肽A的水平(凝血酶和纤维蛋白生成的标志物)在HAC组较CTRL组为低(p<0.05)。经过30minCPB,组织纤维蛋白溶酶原激活物(tPA)的平均水平在HAC组明显较低(p<0.05),继而维持了CPB期间的纤溶酶原激活剂抑制物(PAI)-1p<0.05)。CPB转中和转后,D-二聚体这一用来评估血管内纤维蛋白的形成和清除的指标,在HAC组较低(p<0.05)。总而言之,联合策略可减少CPB引起的凝血酶产生、纤维蛋白形成、tPA释放以及纤维蛋白的降解,并更好地保护PAI1

(黄施伟 译,李士通 校)

Interventions such as heparin-coated circuits, epsilon-aminocaproic acid, and

reduced shed blood reinfusion have shown mixed results when applied individually

for limiting hemostatic activation during cardiopulmonary bypass (CPB). We

compared coagulation and fibrinolytic activation during conventional CPB

(control) (CTRL) using noncoated circuits, no antifibrinolytics, and open

cardiotomy with a combined strategy (HAC) that used heparin-coated circuits,

epsilon-aminocaproic acid, and closed cardiotomy. Blood samples were drawn

before, during, and after CPB for primary coronary bypass grafting surgery from

9 CTRL patients and 10 HAC patients. Thrombin-antithrombin complex and

fibrinopeptide A levels (markers of thrombin and fibrin generation) were reduced

in the HAC versus CTRL group after 30 min of CPB (P < 0.05). Average tissue

plasminogen activator (tPA) levels were significantly lower in the HAC group by

30 min on CPB (P < 0.05), resulting in preservation of plasminogen activator

inhibitor (PAI)-1 during CPB (P < 0.05). D-Dimer, a measure of intravascular

fibrin formation and removal, was reduced in the HAC group during and after CPB

(P < 0.005). Overall, the combined strategy was associated with a reduction in

CPB-induced increases in markers of thrombin generation, fibrin formation, tPA

release, and fibrin degradation and better preservation of PAI-1.

 

关于非体外循环下冠脉手术的综合性节约用血协议中使用中等量的急性等容血液稀释技术的研究

Intraoperative moderate acute normovolemic hemodilution associated with a comprehensive blood-sparing protocol in off-pump coronary surgery.

Casati V, Benussi S, Sandrelli L, Grasso MA, Spagnolo S, D'Angelo A.

Division of Cardiovascular Anesthesia and Intensive Care, Policlinico di Monza, Monza, Italy.

Anesth Analg 2004 98: 1217-1223

 

我们评估了在非体外循环下行冠脉搭桥手术(OPCAB)的病人术中使用急性等容血液稀释(ANH)联合止血环酸治疗和出血再回输时的节约用血效力。连续的100个行OPCAB的病人(基础hct>34%)被前瞻性、随机化分至止血环酸治疗组(对照组;50人)和止血环酸治疗加等容稀释组(ANH组;50人),用胶体等容稀释17% +/- 2%的循环血量。所有的病人在术中出血超过250 mL时予回输血液。异体输血则根据事先制定的严格标准给予,其需要量为我们此研究的主要目的,并记录血液生化、出血、主要并发症和其它后果。人口统计学、基础血液生化指标和手术特点在两组中相似。ANH组的病人平均回收850 mL血液,术中最小hct值较低(31% 37%; P < 0.0001),需要输红细胞的病人ANH组为2个,而对照组为10(优势比, 0.17; 95% 可信限, 0.03-0.89; P = 0.028),红细胞单位的需要量也显著低于对照组(5 24; P < 0.001)。两组病人术后的血液生化变量、出血和转归相似。中等量的ANH联合止血环酸治疗和出血再回输可减少OPCAB病人的异体输血的需要量。

(周晓敏译 薛张纲审校)

We evaluated the blood-sparing effects of intraoperative moderate acute normovolemic hemodilution (ANH) combined with intraoperative tranexamic acid treatment and shed blood reinfusion in patients undergoing off-pump coronary artery bypass (OPCAB). One-hundred consecutive OPCAB patients (baseline hematocrit >34%) were prospectively randomized to tranexamic acid treatment (control group; 50 patients) or to tranexamic acid treatment plus normovolemic (1:1 replacement with colloids) withdrawal of 17% +/- 2% of the circulating blood volume (ANH group; 50 patients). All patients had shed blood reinfused with intraoperative bleeding in excess of 250 mL. The requirement for allogeneic transfusions, based on strict a priori defined criteria, was the primary end point of the study. Hematochemical evaluations, bleeding, major complications, and other outcomes were also recorded. Demographics, baseline hematochemical data, and operative characteristics were similar in the two groups. Patients in the ANH group had a median of 850 mL of blood withdrawn and showed a lower intraoperative minimum hematocrit (31% vs 37%; P < 0.0001). Two patients in the ANH group versus 10 patients in the control group (odds ratio, 0.17; 95% confidence interval, 0.03-0.89; P = 0.028) required transfusion of a significantly smaller number of packed red blood cell units (5 vs 24; P < 0.001). Postoperative hematochemical variables, bleeding, and outcomes were similar in the two groups of patients. Moderate ANH, combined with tranexamic acid administration and on-demand shed blood reinfusion, may reduce allogeneic transfusion requirements in OPCAB patients.       

 

心率变异性动态学的障碍可预测长期的心肌缺血

The breakdown of fractal heart rate dynamics predicts prolonged postoperative myocardial ischemia.

Laitio TT, Huikuri HV, Makikallio TH, Jalonen J, Kentala ES, Helenius H, Pullisaar O, Hartiala J, Scheinin H.

Department of Anesthesiology and Intensive Care, Turku University Hospital, Turku, Finland

Anesth Analg 2004 98: 1239-1244.

 

心肌缺血的病人行非心脏手术后发生心脏不良事件的风险增加了39倍。在本研究中我们证实了以下假设:行外科手术的老年病人其变化的术前的心率变异性(HRV)预示术后的长期心肌缺血(>10 分钟)3260岁以上,拟行外伤性髋部骨折修复术的住院病人进入了我们的研究,术前予持续的 Holter检查,从入院开始直到术后第3天早晨。每个病人均行晚间( 2 AM 5 AM)和白天(7 AM 12 AM)的常规HRV测量及RR间期的短期不规则刻度指数(alpha1)分析。术后有心肌缺血的病人其术前夜间的alpha1值显著低于(即HRV随机的升高)白天(均值 +/- 标准差; 0.92 +/- 0.08 1.03 +/- 0.06; P = 0.002),无心肌缺血的病人则没有区别。在逐步多变量逻辑回归分析中,术前夜间与白天alpha1值的差值的升高是术后长期心肌缺血的唯一独立预测因子。夜间与白天alpha1值的差值升高0.16 U其优势比为7.7(95% 可信限, 1.9-51.4; P = 0.0018)。在行外伤性髋部骨折急症手术的老年病人,心率变异性动态学的障碍预示着术后的长期心肌缺血。

(周晓敏译 薛张纲审校)

Patients with myocardial ischemia after noncardiac surgery have a three- to ninefold increased risk of adverse cardiac events. In this study we tested the hypothesis that altered preoperative heart rate variability (HRV) predicts postoperative prolonged myocardial ischemia (>10 min) in elderly surgical patients. Thirty-two patients, age 60 yr or older, admitted to hospital for surgical repair of a traumatic hip fracture with preoperative night and daytime Holter recordings were included. Holter monitoring was initiated at arrival at hospital and continued until the third postoperative morning. Conventional HRV measures along with analysis of short-term fractal scaling exponent (alpha(1)) of RR intervals were assessed for night (from 2 AM to 5 AM) and day (7 AM to 12 AM) periods in each patient. Preoperative alpha(1) was significantly lower (i.e., increased randomness in HRV) during the nighttime compared with daytime (mean +/- SEM; 0.92 +/- 0.08 versus 1.03 +/- 0.06; P = 0.002) in patients with postoperative myocardial ischemia. Patients without ischemia had no such difference. In stepwise multivariate logistic regression analysis, increased preoperative night-day difference of alpha(1) was the only independent predictor of postoperative prolonged ischemia. The odds ratio for an increase of 0.16 U in night-day difference of alpha(1) (corresponding to interquartile range) was 7.7 (95% confidence interval, 1.9-51.4; P = 0.0018). Breakdown of fractal-like heart rate dynamics is predictive for postoperative prolonged myocardial ischemia in elderly patients having emergency surgery for traumatic hip fracture.

 

气管内使用重组表面活性物质蛋白C可减弱由气管内吸入酸性婴儿乳粉引起的兔的急性肺损伤

Intratracheal application of recombinant surfactant protein-C surfactant to rabbits attenuates acute lung injury induced by intratracheal acidified infant formula.

Mikawa K, Nishina K, Takao Y, Obara H.

Department of Anesthesia and Perioperative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.

Anesth Analg 2004 98: 1273-1279.

 

本研究中我们的目的是确定重组表面活性物质蛋白C(rSP-C)是否可以改善由气管内吸入酸性乳制品引起的急性肺损伤(ALI)28只兔子随机分为4组,3组通过气管内吸入酸性的婴儿乳粉(0.8 mL/kg, pH 1.8)诱发ALI,对照组使用酸性的盐水。治疗组在使用酸性婴儿乳粉30分钟后气管内予0.5 2 mg/kg的表面活性物质rSP-C,诱发ALI后用纯氧行肺通气4小时,酸性婴儿乳粉显著地减少了氧合和肺顺应性并增加了阻力,而两个剂量的rSP-C均可改善指标[4h时的平均 PaO2 (mm Hg) 顺应性 (mL/cm H2O)分别是: 婴儿乳粉为61 0.4, 小剂量rSP-C162 1.0, 大剂量rSP-C 152 1.2; P < 0.05]rSP-C治疗可减轻肺的白细胞浸润和水肿及严重的形态学变化(婴儿乳粉组、小剂量rSP-C组和大剂量rSP-C组的ALI 评分分别为 14, 7, 7; P < 0.05)。两个剂量的rSP-C的效果相仿。以上结果提示气管内使用rSP-C可改善由误吸酸性的乳制品引起的ALI

(周晓敏译 薛张纲审校)

Our aim in the current study was to determine whether recombinant surfactant protein-C (rSP-C) surfactant improves acute lung injury (ALI) induced by intratracheal acidified milk products. Twenty-eight rabbits were randomly divided into four groups. ALI was induced with intratracheal acidified infant formula (0.8 mL/kg, pH 1.8) in 3 groups. The control group received intratracheal acidified saline. Therapy groups received 1 of 2 doses of intratracheal rSP-C surfactant (0.5 or 2 SP-C mg/kg) 30 min after the acidified infant formula. The lungs were ventilated with 100% oxygen for 4 h after induction of ALI. Acidified infant formula dramatically reduced oxygenation and lung compliance, and increased resistance. Both doses of rSP-C improved the variables [mean PaO(2) (mm Hg) and compliance (mL/cm H(2)O) at 4 h: 61 and 0.4 for infant formula, 162 and 1.0 for small-dose rSP-C, and 152 and 1.2 for large-dose rSP-C, respectively; P < 0.05]. Pulmonary leukosequestration and edema, and severe morphological changes were attenuated by rSP-C treatment (ALI score: 14, 7, 7 in infant formula, small-dose rSP-C, and large-dose rSP-C; P < 0.05). The efficacy was similar for the two doses of rSP-C. These findings suggest that intratracheal administration of rSP-C ameliorates ALI induced by aspiration of acidified milk products.

 

布比卡因脊麻减少了前早产儿的脑血流

Spinal Anesthesia with Bupivacaine Decreases Cerebral Blood Flow in Former Preterm Infants

Marie-Pierre Bonnet, MD, Eric Larousse, MD, Karim Asehnoune, MD, and Dan Benhamou, MD PhD

the Département d’Anesthésie Réanimation, Centre Hospitalo-Universitaire de Bicêtre, Kremlin Bicêtre, France

Anesth Analg 2004;98:1280-1283

 

脊麻被普遍应用于前早产儿(FPI)中。在这些患者中,脊麻导致的低血压可能会减少脑血流。我们通过经颅多普勒超声来测量脑血流速率(CBFV)以评估由脊麻导致的低血压对脑血流动力学的影响。12个择期行腹股沟疝修补的FPI1mg/kg等比重0.5%布比卡因的脊麻下进行手术。在脊麻前5分钟和之后的5分钟、10分钟分别通过经颅的脉搏多普勒超声测量大脑中动脉的收缩、舒张和平均的CBFV,并同时记录动脉血压和心率。脑动脉阻力指数(RI)通过公式RI=(收缩峰CBFV-舒张末期CBFV/收缩峰CBFV来计算。舒张CBFV5分钟时明显地从30.0 ± 11.1 cm/s 降至20.1 ± 8.4 cm/s10分钟时降至20.1 ± 7.0 cm/sRI5分钟和10分钟时明显地从0.7 ± 0.1 降至0.8 ± 0.1。在同一时间间隔内收缩期、舒张期和平均动脉血压也明显下降了。我们提示在FPI中,脊麻通过动脉血压的改变而导致了脑血流的减少。这些改变是否会造成有害的结果还有待查明。

(钟鸣译 薛张纲审校)

Spinal anesthesia is commonly used in former preterm infants (FPI). In these patients, hypotension induced by spinal anesthesia may impair cerebral blood flow. We measured cerebral blood flow velocity (CBFV) by transcranial Doppler ultrasound to assess the effect of hypotension induced by spinal anesthesia on cerebral hemodynamics. Twelve FPI scheduled for inguinal hernia repair were operated under spinal anesthesia using 1 mg/kg isobaric 0.5% bupivacaine. Systolic, diastolic, and mean middle cerebral artery CBFV were measured at 5 min before and 5 min and 10 min after spinal anesthesia using a transcranial pulsed Doppler ultrasonography. Arterial blood pressure and heart rate were recorded simultaneously. Cerebral arteries resistance index (RI) was calculated as RI = (peak systolic CBFV – end-diastolic CBFV)/peak systolic CBFV. Diastolic CBFV decreased significantly from 30.0 ± 11.1 cm/s to 20.1 ± 8.4 cm/s at 5 min and to 20.1 ± 7.0 cm/s at 10 min. RI increased significantly from 0.7 ± 0.1 to 0.8 ± 0.1 at 5 min and 10 min. Systolic, diastolic, and mean arterial blood pressures decreased significantly at the same time intervals. We suggest that in FPI, spinal anesthesia induces a decrease in cerebral blood flow related to changes in arterial blood pressure. Whether these changes have deleterious consequences remains to be determined.

 

异氟醚对减敏感的野生型和{alpha}1(S270H) {gamma}氨酪酸型A受体的影响

The Effects of Isoflurane on Desensitized Wild-Type and {alpha}1(S270H) {gamma}-Aminobutyric Acid Type A Receptors

Adam C. Hall, PhD*, Kathleen C. Rowan, MA*, Renna J. N. Stevens*, Jill C. Kelley{dagger}, and Neil L. Harrison, PhD{dagger} Section Editor

Department of Biological Sciences, Neuroscience Program, Smith College, Northampton, Massachusetts, and the {dagger}Department of Anesthesiology, Weill Medical College, Cornell University, New York, New York

Anesth Analg 2004;98:1297-1304

 

{gamma}氨酪酸型A受体(GABAA-R)介导了突触抑制,并符合许多重要的全麻药目标所需要的药理学准则。在突触传递时GABA释放足以饱和、最大程度的激活突触后GABAA-Rs和一过性的降低其敏感性。这种因而发生的抑制性突触后电流(IPSCs)能被吸入性麻醉药如异氟醚所延长。我们研究了异氟醚对在爪蟾卵母细胞内表达的被最大化激活和减敏感的GABAA-R电流的影响。野生型{alpha}1ß2 {alpha}1ß2{gamma}2s受体暴露于600µMGABA中直至电流达到去敏感水平的稳态。在临床浓度(0.02–0.3 mM),异氟醚对{alpha}1ß2受体的去敏感电流的稳态产生剂量依赖性的增强作用,这种作用在包含{gamma}2s亚基的受体中并不明显。当{alpha}1-亚基的第二跨膜节段270位置的丝氨酸变成组氨酸({alpha}1(S270H))后,由亚饱和浓度的GABA激发的电流变得对异氟醚的增强作用更加不敏感。另外,异氟醚对去敏感电流的增强作用能被这种突变所大大减弱,并在{alpha}1(S270H)ß2{gamma}2s 受体中无法探查。总结之,异氟醚对由饱和浓度激动剂激发的GABAA-R电流的增强作用是亚基依赖性的。异氟醚对去敏感受体的这种作用可能部分在于在麻醉中延长了IPSCs

(钟鸣译 薛张纲审校)

{gamma}-aminobutyric acid type A receptors (GABAA-R) mediate synaptic inhibition and meet many pharmacological criteria required of important general anesthetic targets. During synaptic transmission GABA release is sufficient to saturate, maximally activate, and transiently desensitize postsynaptic GABAA-Rs. The resulting inhibitory postsynaptic currents (IPSCs) are prolonged by volatile anesthetics like isoflurane. We investigated the effects of isoflurane on maximally activated and desensitized GABAA-R currents expressed in Xenopus oocytes. Wild-type {alpha}1ß2 and {alpha}1ß2{gamma}2s receptors were exposed to 600 µM GABA until currents reached a steady-state desensitized level. At clinical concentrations (0.02–0.3 mM), isoflurane produced a dose-dependent enhancement of steady-state desensitized current in {alpha}1ß2 receptors, an effect that was less apparent in receptors including a {gamma}2s-subunit. When serine at position 270 is mutated to histidine ({alpha}1(S270H)) in the second transmembrane segment of the {alpha}1-subunit, the currents evoked by sub-saturating concentrations of GABA became less sensitive to isoflurane enhancement. In addition, isoflurane enhancements of desensitized currents were greatly attenuated by this mutation and were undetectable in {alpha}1(S270H)ß2{gamma}2s receptors. In conclusion, isoflurane enhancement of GABAA-R currents evoked by saturating concentrations of agonist is subunit-dependent. The effects of isoflurane on desensitized receptors may be partly responsible for the prolongation of IPSCs during anesthesia.

 

丹曲林降低寒战的域值和增益

Dantrolene Reduces the Threshold and Gain for Shivering

Chun-Ming Lin, MD*, Sharma Neeru, MD§, Anthony G. Doufas, MD PhD*,{dagger}, Edwin Liem, MD*,{dagger}, Yunus Muneer Shah, MD*,{dagger}, Anupama Wadhwa, MD*,{dagger}, Rainer Lenhardt, MD*,{dagger}, Andrew Bjorksten, PhD#, Akiko Taguchi, MD§, Barhara Kabon, MD§, Daniel I. Sessler, MD*,{dagger},{ddagger}, and Andrea Kurz, MD

Outcomes ResearchTM Institute and the Departments of {dagger}Anesthesiology and {ddagger}Pharmacology, University of Louisville, Louisville, Kentucky, the §Department of Anesthesia, Washington University, St. Louis, Missouri, #the Royal Melbourne Hospital, Melbourne, Victoria, Australia, and the ¶Department of Anesthesia, University of Bern, Bern, Switzerland

Anesth Analg 2004;98:1318-1324

 

丹曲林用于治疗威胁生命的高热,但其温度调节作用还不清楚。我们测试了这样一种假设,即丹曲林能降低寒战的域值(触发体核温度)和增益(增加的量值)。健康的志愿者在两个随机的日子里被评估:对照组和丹曲林组({approx}2.5 mg/kg加上持续输注)。在研究一中,9名男子被加热直至出汗然后冷却动静脉分流收缩和寒战出现。出汗通过胸部的通气被膜来定量。右中指尖的绝对血流通过静脉阻塞的容积体积描记法来定量。通过耗氧量的持续不变的升高来识别寒战的域值。在研究二,9名男子通过静脉输注冷的乳酸钠林格氏液来达到体核温度降低{approx}2°C/h。当体核温度降低不再增加寒战强度时降温停止。寒战的增益就是耗氧量比上体核温度的斜率。在研究一,出汗和血管收缩域值在两天内相似。相比而言,在丹曲林天中寒战域值降低了0.3 ± 0.3°C, P = 0.004。在研究二,丹曲林将寒战域值从36.7 ± 0.2 降至 36.3 ± 0.3°C, P = 0.01,增益从353 ± 144 降至211 ± 93 mL • min–1 • °C–1, P = 0.02。因此,丹曲林从本质上讲降低了寒战的增益,但几乎不产生中心体温调节抑制。

(钟鸣译 薛张纲审校)

Dantrolene is used for treatment of life-threatening hyperthermia, yet its thermoregulatory effects are unknown. We tested the hypothesis that dantrolene reduces the threshold (triggering core temperature) and gain (incremental increase) of shivering. Healthy volunteers were evaluated on 2 random days: control and dantrolene ({approx}2.5 mg/kg plus a continuous infusion). In Study 1, 9 men were warmed until sweating was provoked and then cooled until arteriovenous shunt constriction and shivering occurred. Sweating was quantified on the chest using a ventilated capsule. Absolute right middle fingertip blood flow was quantified using venous-occlusion volume plethysmography. A sustained increase in oxygen consumption identified the shivering threshold. In Study 2, 9 men were given cold lactated Ringer’s solution IV to reduce core temperature {approx}2°C/h. Cooling was stopped when shivering intensity no longer increased with further core cooling. The gain of shivering was the slope of oxygen consumption versus core temperature regression. In Study 1, sweating and vasoconstriction thresholds were similar on both days. In contrast, shivering threshold decreased 0.3 ± 0.3°C, P = 0.004, on the dantrolene day. In Study 2, dantrolene decreased the shivering threshold from 36.7 ± 0.2 to 36.3 ± 0.3°C, P = 0.01 and systemic gain from 353 ± 144 to 211 ± 93 mL • min–1 • °C–1, P = 0.02. Thus, dantrolene substantially decreased the gain of shivering, but produced little central thermoregulatory inhibition.

 

异丙酚/雷米芬太尼复合麻醉诱导、维持和终止时应用NarcotrendTM ,BIS指数及经典脑电图评估作用的比较

Comparative Evaluation of NarcotrendTM, Bispectral IndexTM, and Classical Electroencephalographic Variables During Induction, Maintenance, and Emergence of a Propofol/Remifentanil Anesthesia

Gunter N. Schmidt, MD, Petra Bischoff, MD, Thomas Standl, MD, Gunnar Lankenau, MD, Mathias Hilbert, and Jochen Schulte am Esch, MD

Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany

Anesth Analg 2004 98: 1346-1353.

 

在此项研究中比较了在标准化麻醉自诱导至拔管期间应用NarcotrendTM BIS指数及脑电图监测意识深度的能力。我们观察了26位行椎板切除术病人。观测项目包括:清醒、反应消失、睫毛反射消失及麻醉稳态时的BIS指数及脑电图表现。并同步记录NT,BISTM 光谱边缘频率,{delta}{theta}{alpha} ß波的相对电压及血流动力学。分析各参数在清醒及反应消失、清醒及睫毛反射消失、清醒及麻醉稳态、麻醉稳态及首次体动出现和拔管时的区别从而判断各参数的预测准确性。异丙酚麻醉中应用雷米芬太尼的作用可通过Friedman’sWilcoxon’s试验观察。只有NTBISTM能准确的区分各个麻醉状态且其预测准确性>0.95。雷米芬太尼开始输注后只有血流动力学的改变具显著统计学意义(P < 0.05)NT BIS较脑电图和血流动力学更可靠的用于监测麻醉深度但却不能用于监测镇痛强度。

(陆旭伟译 薛张纲审校)

 In the present study, we sought to compare the abilities of NarcotrendTM (NT) with the Bispectral IndexTM (BISTM) electroencephalographic system to monitor depth of consciousness immediately before induction of anesthesia until extubation during a standardized anesthetic. We investigated 26 patients undergoing laminectomy. Investigated states of anesthesia were: awake, loss of response, loss of eyelash reflex, steady-state anesthesia, first reaction, and extubation during emergence. NT, BISTM, spectral edge frequency, median frequency, relative power in {delta}, {theta}, {alpha}, ß, and hemodynamics were recorded simultaneously. The ability of all variables to distinguish between awake versus loss of response, awake versus loss of eyelash reflex, awake versus steady-state anesthesia, steady-state anesthesia versus first reaction and extubation were analyzed with the prediction probability. Effects of remifentanil during propofol infusion were investigated with Friedman’s and post hoc with Wilcoxon’s test. Only NT and BISTM were able to distinguish all investigated states accurately with a prediction probability >0.95. After start of remifentanil infusion, only hemodynamics changed statistically significantly (P < 0.05). NT and BISTM are more reliable indicators for the assessment of anesthetic states than classical electroencephalographic variables and hemodynamics, whereas the analgesic potency of depth of anesthesia could not be detected by NT and BISTM.

 

单胺类物再摄取抑制剂Milnacipran不影响大鼠急性内脏膨胀疼痛

Monoamine Reuptake Inhibitor Milnacipran Does Not Affect Nociception to Acute Visceral Distension in Rats

Sang-Wook Shin, MD*, James C. Eisenach, MD*, Srinias G. Rao, MD PhD{dagger}, and Chuanyao Tong, MD*

*Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and {dagger}Cypress Bioscience Inc., San Diego, California

Anesth Analg 2004 98: 1365-1369.

 

抗抑郁药治疗内脏疼痛的作用未广泛研究。Milnacipran是一种抑制单胺类物质再摄取的抗抑郁药,广泛用于治疗抑郁及纤维肌痛。在此项研究中我们探讨Milnacipran治疗急性内脏疼痛的机理。将双侧卵巢切除术后7天的雌性处女大鼠作为研究对象。全麻下在子宫颈内插入金属杆产生人为膨胀以此造成子宫颈膨胀(UCD)。而结直肠膨胀(CRD)则通过在降结肠、直肠内置入球囊管后人为充气产生。在腹直肌内置入两个电极记录UCDCRD引起的腹直肌收缩,并量化为肌电图(EMG)。Milnacipran单剂反应则通过静脉或鞘内应用milnacipran后予以UCDCRD刺激获得。Milnacipran不能抑制UCD相关的EMG反应(不管静脉或鞘内应用),相似的milnacipran也不能抑制CRD相关的EMG反应(不管静脉或鞘内应用)。CRDUCD非常适合于在动物模型中研究急性内脏疼痛。尽管Milnacipran较其他抗抑郁药有独一无二的优点,但它对急性内脏疼痛无效。

(陆旭伟译 薛张纲审校)

The role of antidepressants in the treatment of visceral pain has not been extensively examined. Milnacipran, an antidepressant that inhibits monoamine reuptake, is widely used in the treatment of depression and fibromyalgia. In this study, we sought to determine the activity of milnacipran against acute visceral nociception. Female virgin rats were studied 7 days after bilateral ovariectomy. For uterine cervical distension (UCD), two metal rods were inserted into the cervical osses under general anesthesia for manual distension. Colorectal distension (CRD) was performed by insertion of a balloon catheter into the descending colon and rectum, followed by manual inflation. Two electrodes were inserted into the rectus abdominus muscle for recording UCD- or CRD-induced reflex contraction, which was quantified by electromyography (EMG). A dose response for milnacipran, administered intrathecally or IV, was obtained for UCD and CRD stimulation. Milnacipran failed to inhibit the UCD-induced EMG response, whether administered IV or intrathecally. Similarly, IV milnacipran, administered either acutely or chronically, failed to inhibit the CRD-induced EMG response. CRD and UCD are well established animal models for the study of acute visceral pain. Milnacipran, although it provides some unique advantages compared with other antidepressants, is unlikely to produce analgesia after acute administration in the setting of acute visceral pain.

 

GABA拮抗剂及Diltiazem应用于消除大鼠内脏疼痛中的相互作用

The Interaction Between Gamma-Aminobutyric Acid Agonists and Diltiazem in Visceral Antinociception in Rats

Kaoru Hara, MD, Yoji Saito, MD, Yumiko Kirihara, DVM, and Shinichi Sakura, MD

From the Department of Anesthesiology, Shimane University School of Medicine, Izumo City, Japan

Anesth Analg 2004 98: 1380-1384.

 

为了测试是否GABA受体拮抗剂及L型电压门控钙离子通道阻滞剂在脊髓水平的抗内脏疼痛作用是否存在潜在的相互影响,我们在结直肠内置入导管产生结直肠膨胀从而造成内脏疼痛。共分三组,分别经鞘内应用GABA拮抗剂(muscimolbaclofen)、钙离子通道阻滞剂(diltiazem)、两者联用。CD阈值在应用muscimol 0.1 µg,baclofen 0.01 µg,diltiazem 100 µg后无改变,而应用muscimol 1 µg baclofen 0.1 µg后轻度增加。当muscimol 0.1 µg1 µg联合应用diltiazem时,CD阈值显著增加(5分钟时分别为26.2% 0.6% MPE84.5%19.5%MPEP < 0.01)(MPE最大有效强度)。联用baclofen 0.1 µg diltiazem时也较单用baclofen引起CD阈值的显著增加(5分钟时为 48.0% 14.3% MPE; P < 0.01)。Muscimol 1 µg时可有运动神经阻滞,但当其联用diltiazem时并不加重神经阻滞。总之,鞘内应用diltiazemGABA拮抗剂(muscimolbaclofen)增强GABA拮抗剂的内脏镇痛作用但不增加运动神经阻滞。

(陆旭伟译 薛张纲审校)

To examine whether the {gamma}-aminobutyric acid (GABA) receptor agonists and L-type voltage-dependent calcium channel blockers potentiate each other on the visceral antinociceptive effects at the spinal cord, we assessed visceral nociception with colorectal distension (CD) test in rats with an intrathecal catheter. The measurements were performed after intrathecal administration of a GABA agonist (muscimol or baclofen), a calcium channel blocker (diltiazem), or the combination of the two. CD threshold did not change after muscimol 0.1 µg, baclofen 0.01 µg, or diltiazem 100 µg, but increased slightly after muscimol 1 µg and baclofen 0.1 µg. When muscimol 0.1 µg or 1 µg was administered with diltiazem, the increase in CD threshold was significantly larger than muscimol alone (at 5 min, 26.2% versus 0.6% MPE (maximum possible effect) or 84.5% versus 19.5%MPE, respectively; P < 0.01). The CD threshold after the combination of baclofen 0.1 µg and diltiazem also showed a significantly larger increase than that seen after baclofen alone (at 5 min, 48.0% versus 14.3% MPE; P < 0.01). Motor paralysis observed with muscimol 1 µg did not increase when muscimol was coadministered with diltiazem. In conclusion, intrathecal diltiazem in combination with a GABA agonist, muscimol or baclofen, potentiated the GABA agonists-induced visceral antinociception without increasing motor paralysis.

 

快速皮肤麻醉使用丁卡因新配方:一项临床前研究

Rapid Skin Anesthesia Using a New Topical Amethocaine Formulation: A Preclinical Study

M. I. Arévalo*, E. Escribano{dagger}, A. Calpena{dagger}, J. Domenech{dagger}, and J. Queralt*

*Departament de Fisiologia-Divisió IV and {dagger}Departament de Farmàcia, Unitat de Biofarmàcia i Farmacocinètica, Universitat de Barcelona, Spain

Anesth Analg 2004 98: 1407-1412.

 

我们开发了一种快速起作用的丁卡因乳胶,并且在鼠爪模型上测试他在镇痛方面的效果,主要是由热和机械引起的疼痛。第一项实验在老鼠身上进行。用角叉菜胶诱发炎症反应,使老鼠痛觉过敏。老鼠被分为以下几组:丁卡因乳胶,丁卡因凝胶(Ametop®gel)EMLA霜(易熔的局麻药混合物),丁卡因浸润,空白(对照)。第二项实验在健康的,选择性的对热或接触敏感的老鼠身上,按第一次实验一样分组。将鼠爪受热和机械刺激后产生退缩反应的时间作为疼痛反应的指标。在第一项实验中使用丁卡因乳胶,丁卡因凝胶(Ametop®gel)EMLA霜,丁卡因浸润,抗痛觉过敏作用分别出现在使用后4.2, 13.8, and 14 分钟。丁卡因乳胶是其中唯一产生抗异常疼痛的表面麻醉剂,但比丁卡因浸润麻醉的效果要差一些。在健康的老鼠中(实验二),所有的表面麻醉剂型对同侧的鼠爪受热刺激后的镇痛效果都是一样的。使用丁卡因乳胶后对侧的鼠爪的反应出现的更早,这是一个唯一使用后使老鼠对接触刺激产生的反应时间延长的药物。因此,乳胶可以有效的提高丁卡因的皮肤渗透性,由此快速起效。

(方芳译 薛张纲审校)

We developed a fast-acting topical amethocaine emulsion and tested its analgesic activity against heat or mechanically induced pain in a rat paw model. The first experiment was performed in rats made hyperalgesic or allodynic after carrageenan-induced inflammation. Rats were distributed in five subgroups, each receiving topically one of the following: amethocaine microemulsion, amethocaine gel (Ametop®gel), EMLA (Eutectic Mixture of Local Anesthetics) cream, amethocaine infiltration, or nothing (controls). The second experiment was conducted on healthy, selected heat- or touch-hypersensitive rats, which were distributed as in the first experiment. Paw withdrawal time from a heat and a mechanical stimulus was used as a pain index. In the first experiment, antihyperalgesic activity appeared at 4.2, 13.8, and 14 min after amethocaine microemulsion, gel, or EMLA cream, respectively. Amethocaine microemulsion was the only topical formulation with an antiallodynic effects, although less than with amethocaine infiltration. In healthy rats (second experiment), all topical formulations produced similar analgesic effects in heat-induced pain of the ipsilateral paw. Activity in the contralateral paw appeared earlier with amethocaine microemulsion, which was also the only one that increased touch-induced withdrawal time in the ipsi- and contralateral paws. Therefore, the microemulsion could be valuable for improving amethocaine skin penetration and thus bringing rapid pain relief.

 

健康猪肺在肺泡复张过程中内脏循环的改变

Changes in Splanchnic Circulation During an Alveolar Recruitment Maneuver in Healthy Porcine Lungs

Silvia Nunes, MD, Hans Ulrich Rothen, MD PhD, Lukas Brander, MD, Jukka Takala, MD PhD, and Stephan M. Jakob, MD PhD

From the Department of Intensive Care Medicine, University Hospital, Bern, Switzerland

Anesth Analg 2004;98:1432-1438

在急性肺损伤和麻醉中复张手法(RM)被认为是机械通气的补充。然而他可能产生胸内压和容量增高,影响血流动力学。我们此研究的目的在于分析RM对十只麻醉的猪的血流动力学的影响。我们测颈动脉,肺动脉,股动脉,和肝动脉的压力,肝静脉和门静脉的压力,总内脏(腹腔干+肠系膜上动脉),肝,脾,肾和颈动脉的血流,门脉血流。我们在RM前和RM8分钟(持续充气使气道压力到达40 cm H2O保持20秒)测血流动力学,呼吸力学和血气。血流动力学指标在RM期间,135分钟后也记录下来。所有的血流(P = 0.030)和动脉压(P <=0.048)RM 期间均下降,而静脉压是伸高的(P = 0.030)。血流和压力在RM 后马上恢复到75%–109%的基准。总的内脏,肾和门脉血流在RM8分钟继续保持低值(P <=0.042)。在所有的血管中,RM对血流产生一个虽然短暂但是显著的影响。虽然有部分很快恢复,总的内脏循环在RM8分钟后继续保持低值。这个下降在显著的循环储备受损的情况下会带来危险。

(方芳译 薛张纲审校)

 Recruitment maneuvers (RM) are advocated as a complement to mechanical ventilation during anesthesia and in acute lung injury. However, they produce high intrathoracic pressures and volumes that may compromise hemodynamics. Our aim was to analyze the effect of a RM on hemodynamics in 10 anesthetized pigs. We assessed carotid, pulmonary, femoral, and hepatic arterial pressures, hepatic and portal venous pressures, total splanchnic (celiac trunk + superior mesenteric artery), hepatic, splenic, renal, and carotid arterial flows, and portal venous flow. We recorded hemodynamics, respiratory mechanics and blood gases before and at 8 min after RM (sustained inflation to 40 cm H2O of airway pressure lasting 20 s). Hemodynamics were also measured during RM, and at 1, 3, and 5 min after RM. All flows (P = 0.030) and arterial pressures (P <=0.048) decreased during RM, whereas venous pressures increased (P = 0.030). Flows and pressures returned to 75%–109% of baseline immediately after RM. Total splanchnic, renal and portal flows remained decreased at 8 min after RM (P <=0.042). Oxygenation did not change, and respiratory mechanics improved after the RM. RM produced a marked, though transitory, impairment of blood flow in all studied vessels. Despite prompt partial recovery, total splanchnic circulation remained reduced at 8 min after RM. This residual decrease may present a risk in conditions with markedly compromised circulatory reserves

 

剖宫产术后镇痛使用脊髓吗啡,可乐定及其混合物

Postcesarean Analgesia with Spinal Morphine, Clonidine, or Their Combination

Michael J. Paech, FANZCA*,{ddagger}, Timothy J. G. Pavy, FANZCA*, Christopher E. P. Orlikowski, FRCA*, Seng T. Yeo, FRCA*, Samantha L. Banks, FRCA*, Sharon F. Evans, PhD{dagger}, and Jennifer Henderson, MPH{dagger} Section Editor

*School of Medicine and Pharmacology, University of Western Australia and {ddagger}Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth; and {dagger}Biostatistics and Research Support, Women and Infants Research Foundation, Subiaco, Western Australia

Anesth Analg 2004;98:1460-146

 

在这项随机双盲的实验中,我们在240名妇女中观察蛛网膜下腔15 µg芬太尼和吗啡,可乐定,或吗啡加可乐定在剖宫产中的镇痛效果。一项剂量分析显示100 µg吗啡和可乐定6090150 µg在术后和副反应方面没有差异。这些组的数据(MC60–150, n = 113)和其他组,吗啡100 µg (n = 39),可乐定150µg (n = 39),吗啡100 µg加可乐定30 µg (n = 41),相比较。这四组在病人自控吗啡使用的其始时间和总的用量上是有区别的(P < 0.0001 and P < 0.001,分别)。在MC60–150组时间最久,剂量最少。组间的疼痛评分是有显著差异的。感觉阻滞的起始时间,麻黄素的需要量,低血压的发生,患者满意程度和恢复都是相似的。使用可乐定后镇静效果更好。吗啡组有较多严重的皮肤瘙痒,MC60–150组术中更易呕吐。和单使用吗啡100 µg,可乐定150 µg比较,蛛网膜下腔使用吗啡100 µg加至少60 µg可乐定可以延长术后镇痛,减少吗啡的用量,加强术中镇静。

(方芳译 薛张纲审校)

In this randomized, double-blind trial in 240 women, we investigated the analgesic efficacy and duration of subarachnoid fentanyl 15 µg with morphine, clonidine, or both morphine and clonidine for cesarean delivery. A dose-finding analysis showed similar postoperative efficacy and side effects for groups receiving morphine 100 µg with clonidine 60, 90, or 150 µg. Data from these groups were combined (MC60–150, n = 113) and compared with groups receiving morphine 100 µg (n = 39), clonidine 150 µg (n = 39), or morphine 100 µg plus clonidine 30 µg (n = 41). The four groups differed in the time to patient-controlled morphine use and cumulative morphine consumption (P < 0.0001 and P < 0.001, respectively), with the longest duration and smallest dose in MC60–150. Pain scores were significantly different among groups. Onset of sensory block, ephedrine requirement and incidence of hypotension, patient satisfaction, and recovery were similar. Groups receiving clonidine had greater sedation, those receiving morphine had more severe pruritus, and group MC60–150 showed a trend to more vomiting intraoperatively. Compared with morphine 100 µg or clonidine 150 µg alone, the combination of subarachnoid morphine 100 µg and at least 60 µg of clonidine was found to increase the duration of postcesarean analgesia, reduce opioid requirement, and increase intraoperative sedation

 

一项针对矫形外科医生对区域麻醉的态度和了解的调查

A Survey of Orthopedic Surgeons’ Attitudes and Knowledge Regarding Regional Anesthesia

Matthew Oldman, FRCA, Colin J. L. McCartney, FRCA, Andrea Leung, BSc, Regan Rawson, RN, Anahi Perlas, MD, Jeff Gadsden, MD, and Vincent W. S. Chan, FRCPC

Department of Anaesthesia, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada

Anesth Analg 2004;98:1486-1490

我们设计了一张加拿大矫形外科医生对区域麻醉的态度和喜好的调查表。我们发出768张表,收到46861%)张回复。48%会指导他们患者对麻醉方式的选择。40%的医生知道他们的患者选择区域麻醉。他们选择区域麻醉是基于减少术后疼痛(32%),减少恶心呕吐(12%),和安全(14%)。不选择区域麻醉主要是因为,麻醉起效慢(43%)和不可预知的成功率(12%)。这项调查表明,矫形外科医生还是偏好区域麻醉的,普及区域麻醉的最大障碍是起效慢和效果不可靠。

(方芳译 薛张纲审校)

We conducted a survey to explore the surgical attitudes and preferences regarding regional anesthesia among Canadian orthopedic surgeons. Surveys were returned by 468 (61%) of 768 surgeons. Forty-eight percent of respondents directed their patients’ choice of anesthetic. Forty percent of surgeons directed their patients to choose regional anesthesia. The principal reasons for favoring regional anesthesia were less postoperative pain (32%), decreased nausea and vomiting (12%), and safety (14%). Reasons for not favoring regional anesthesia were delays in the induction of anesthesia (43%) and an unpredictable success rate (12%). This survey suggests that orthopedic surgeons are supportive of regional anesthesia. Barriers to increased popularity include perceived delays and unreliability