Anesthesia & Analgesia

May 2004

Table of Content

 

EDITORIALS:

 

體外迴圈中自體血回輸不能減少心臟術後血製品的應用

 (朱慧琛 譯 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.  

 

減少心肺轉流中的凝血啟動:一項聯合措施

黃施偉 譯,李士通

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

 

關於非體外迴圈下冠脈手術的綜合性節約用血協定中使用中等量的急性等容血液稀釋技術的研究

周曉敏譯 薛張綱審校

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

 

美托洛爾與冠狀動脈旁路移植術:心臟手術中美托洛爾是否可減弱急性腎上腺素受體失敏

(朱慧琛 譯 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.

 

食道彩色多普勒超聲心動圖測定心輸出量

王立中 譯,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.

 

心率變異性動態學的障礙可預測長期的心肌缺血

周曉敏譯 薛張綱審校

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

 

肝移植的輸血

齊波 譯 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:

兒童麻醉誘導時家長在場和術前鎮靜的趨勢:一項1995–2002年全美隨訪調查的結果

  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.

 

互動式音樂治療兒童術前焦慮的隨機對照試驗

(齊波 譯 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  

新生兒主動脈弓重建術中必須監測雙側大腦血氧飽和度嗎?

張俊傑譯 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.

 

氣管內使用重組表面活性物質蛋白C可減弱由氣管內吸入酸性嬰兒乳粉引起的兔的急性肺損傷

周曉敏譯 薛張綱審校

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.

 

布比卡因脊麻減少了前早產兒的腦血流

鍾鳴譯 薛張綱審校

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:

咪唑安定鎮靜緩解牙科術後疼痛

忻紀華 譯 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:

異氟醚對減敏感的野生型和{alpha}1(S270H) {gamma}氨酪酸型A受體的影響

鍾鳴譯 薛張綱審校

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.

 

幼年和老年小鼠重複異氟醚吸入麻醉對空間定向和精神運動的影響

忻紀華 譯 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.

 

過氧化亞硝鹽降低組織纖溶酶原啟動因數的活性

裘毅敏譯  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.

 

丹曲林降低寒戰的域值和增益

鍾鳴譯 薛張綱審校

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.

 

甲氧氯普胺通過抑制鼠氣管毒蕈堿M3受體而產生氣道平滑肌舒張

沈浩譯  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.

 

評估氟呱利多對平均QTc間期影響的模型

趙雪蓮譯 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:

異氟醚麻醉中腦電雙頻指數和腦電圖參數之間的關係

陳潔 譯 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.

 

比較三種不同腦電監護儀的臨床實用性:雙頻譜指數、處理後的腦電圖和Alaris聽覺誘發電位

顏濤譯 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.

 

異丙酚/雷米芬太尼複合麻醉誘導、維持和終止時應用NarcotrendTM ,BIS指數及經典腦電圖評估作用的比較

陸旭偉譯 薛張綱審校

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

 

不同脈搏血氧探頭的比較

(陳潔 譯 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:

比較輔助電針刺與人工耳部針刺用於慢性下背部疼痛的短期和長期療效

馬皓琳   李士通

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.

 

單胺類物再攝取抑制劑Milnacipran不影響大鼠急性內臟膨脹疼痛

陸旭偉譯 薛張綱審校

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.

 

加巴噴丁用於腹式全子宮切除術術後鎮痛的效果

顧漪聞 譯 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.

 

鞘內應用加巴潘汀和氯壓定或加巴潘汀和新斯的明在福馬林試驗中相互作用的特性

(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拮抗劑及Diltiazem應用於消除大鼠內臟疼痛中的相互作用

陸旭偉譯 薛張綱審校

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.

關於 N-甲基-D-天冬氨酸受體拮抗劑在預防性鎮痛中的系統回顧

顧漪聞 譯 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.

 

曲馬多對非洲蟾蜍卵母細胞5-羥色胺2C受體表達的抑制效應

張曦譯 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

 

快速皮膚麻醉使用丁卡因新配方:一項臨床前研究

方芳譯 薛張綱審校

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.

 

靜脈注射S+-氯胺酮有助於腹部大手術的疼痛治療

朱輝 譯 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:

比較腎上腺素和加壓素對快速靜脈注射布比卡因致心搏停止的豬模型的作用

吳儉 譯,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.

 

健康豬肺在肺泡複張過程中內臟迴圈的改變

方芳譯 薛張綱審校

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.

 

肺動脈內應用已酮可哥堿可改善出血性休克後的心功能和氧利用狀況:一新的復蘇策略。

朱輝 譯 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.

 

頸內動脈內麻醉藥引起的腦電靜止並不影響兔腦暫時性缺血後的早期充血

慧譯 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:

剖宮產術後鎮痛使用脊髓嗎啡,可樂定及其混合物

方芳譯 薛張綱審校

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:

硬膜外針頭旋轉對硬膜外阻滯擴散影響的前瞻性、隨機性評估

(殷文淵 譯 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.

 

與蛛網膜下腔麻醉有關的人類軟脊膜超微結構發現

周雅春譯 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.

 

一項針對矯形外科醫生對區域麻醉的態度和瞭解的調查

方芳譯 薛張綱審校

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誘導時的肺膨脹不全狀態

殷文淵 譯 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.

體外迴圈中自體血回輸不能減少心臟術後血製品的應用

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

體外迴圈(CPB)期間血液稀釋是心臟手術病人輸血的主要危險因素。CPB環路中輸入患者自己的血(自體血預充,RAP)是一項用於限制血液稀釋和減少輸血的技術。作者設計這項實驗以測試RAP對圍術期血製品應用的影響。回顧性佇列研究,分析同一外科醫生在CPB下(排除迴圈停止病例)施行手術的所有患者的醫療檔。收集RAP作為常規血液保護方法病人(RAP組,n=257 24個月的資料資料與未用RAP (非RAP組,n=288)的資料相比較。資料顯示RAP組患者輸濃縮紅細胞的比率為44%,非RAP組為51%,統計學上無明顯差異。圍術期輸濃縮紅細胞、血小板或新鮮冰凍血漿組間也無明顯差別。由此可知,RAP作為一項血液保護技術並無顯著臨床效益。

(朱慧琛 譯 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.


美托洛爾與冠狀動脈旁路移植術:心臟手術中美托洛爾是否可減弱急性腎上腺素受體失敏

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
心臟手術可使ß-腎上腺素受體(ß AR)功能明顯受損,同時使術後心肌功能下降。作者曾報導動物模型中CABGCPB期間使用ß AR阻滯藥可減弱的ß AR失敏,而長期口服ß AR阻滯藥不能達到預防效果。因此作者假設在CABG手術中緊急應用美托洛爾可預防心肌ßAR失敏。開始應用安慰劑(n=72)後隨機分為兩組,分別在CPB前使用美托洛爾10mg或安慰劑。第二階段的劑量實驗中患者分別使用美托洛爾20mgn=20)或30mg(n=20)。同時測定血流動力學、心房膜腺苷酸環化酶活性和心房ßAR密度。所有組都顯示異丙腎刺激所至的腺酐酸環化酶活性降低程度相似(13%-24%)。4組病人術中和術後的心輸出量相似。另外,美托洛爾 20mg30mg組與美托洛爾10mg和安慰劑組相比,術後24小時出現室上性心律失常較少。結論:與先前的動物實驗不同,美托洛爾並不能減弱心肌ßAR失敏。

(朱慧琛 譯 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.


肝移植的輸血指征

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

本研究目的確定肝移植病人輸注紅細胞(RBC)的影響因素,並探討肝臟移植手術中麻醉醫生輸血工作。作者對過去52個月中 206例肝臟移植手術病人進行了回顧性研究。先確定手術中輸注的血製品。並對20個變數在單變數形式下進行分析。為了進行多變數分析,將病例分為2個亞組:一組病人為術中輸注RBC大於4個單位,第二組病人為輸注RBC4個單位或少於4個單位。術中平均輸注RBC的量為2.8±3.5)單位/病人,其中32%的病人未輸RBC19.4%的病人沒有輸任何血製品。研究發現有三個變數與輸注的RBC數量相關:術前國際標準比值、術前血小板數量和手術持續時間。研究中作者發現術中不同麻醉醫生的輸血常規存在很大的差異。由於人為因素的影響,當輸注RBC的量較小時確定輸注RBC的指征是困難的。術中輸血漿並不能減少RBC輸注率,有時正好相反。

(齊波 譯 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.


互動式音樂治療兒童術前焦慮的隨機對照試驗

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

本研究目的是測定互動式音樂治療是否可以有效緩解兒童術前焦慮。接受門診手術的兒童隨機分為三組:互動式音樂治療組(n=51,口服咪唑安定組(n=34)和對照組(n=38)。研究的主要結果是看在圍術期兒童是否有焦慮情緒。結果發現在麻醉誘導期口服咪唑安定組兒童的焦慮情況要少於音樂治療組和對照組(分別為P0.015P0.005),而音樂治療組和對照組兒童無明顯差異。通過分析控制不同的音樂治療師顯示了一個明顯的治療師效應,經過特定治療師治療的兒童在其準備去手術室(OR)(P0.05)和進入手術室時(P0.05)發生緊張焦慮的情況要明顯少於其他治療師組和對照組,但在扣麻醉面罩階段無差異。即使是在去除治療師效應後,咪唑安定組兒童的情緒也最為安靜(P0.05)。因此總結認為音樂治療可能對緩解兒童在準備去和進入手術室時的緊張焦慮情緒有幫助作用,但要依賴治療師的作用。然而,音樂治療不能緩解麻醉誘導期兒童的緊張焦慮情緒。

 (齊波 譯 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.

 

咪唑安定鎮靜緩解牙科術後疼痛

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

本研究目的是評估口腔手術中靜注咪唑安定對緩解術後疼痛的潛在作用。125例因第三臼齒陷在鄂骨中需行局麻下拔除術的病人隨機分為2組。第一組(n=64),在術前局麻後,以咪唑安定靜脈滴注直至臨床清醒鎮靜狀態;第二組(n=61),作為對照組,術前僅接受局麻。兩組病人由同一外科醫生行標準手術。用四個標準進行預後評價:每8小時以100mm視覺類比評分和四項分來評價疼痛強度;首次開始疼痛的時間;48小時內鎮痛藥(布洛芬)的總劑量,5級病人總體評分(0=差,1=一般,2=好,3=非常好, 4=極好)。經過8小時的研究階段,咪唑安定組的疼痛強度評分顯著低於對照組(19.0±13.2mm28.1±12.8mm,p<0.05)。咪唑安定組術後至第一次用鎮痛藥的時間顯著延長(165.5±56.5分鐘對202.2±79.0分鐘,p<0.05),鎮痛藥的劑量顯著減少(1275±364mg1688±407mg,p<0.01,總體評價顯著好於對照組(3.34±0.82.4±0.9p<0.001)。作者認為全身應用咪唑安定可緩解第三臼齒手術後的疼痛。

(忻紀華 譯 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.

 

幼年和老年小鼠重複異氟醚吸入麻醉對空間定向和精神運動的影響

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

老年病人全麻後可能導致認識損害,但兩者的關係知之甚少。我們以空間記憶(Barnes迷宮)和精神運動行為(rotarod)來觀察老年鼠(18-19個月)術後認識損害是否較幼年鼠(3-4個月)明顯。首先研究單次麻醉對漸近線迷宮操作的影響。然後試驗重複麻醉是否對老年鼠的空間記憶和精神運動行為損害更明顯。以異氟醚(1.4%atm)麻醉30分鐘,對照組接受90%的氧。在漸近線迷宮操作的學習階段麻醉,不損害隨後一天的模擬試驗(p>0.05)。重複麻醉(每隔2-3小時)也不損害幼年和老年鼠所有的迷宮操作或rotarod操作(p>0.05)。集中結果表明麻醉似乎有利於定向空間學習,F1024=7.97p<0.01。漸近線操作——當學習已經穩固——仍未顯示迷宮和rotarod操作受損。這些結果提示與年齡相關的麻醉誘導危險性僅限於新的運動技能,麻醉不會導致老年鼠延遲的認識障礙。

(忻紀華 譯 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.

 

異氟醚麻醉中腦電雙頻指數和腦電圖參數之間的關係

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


腦電雙頻指數(BIS)是將不同腦電圖(EEG)參數整合為單一變數,但其確切的運算法則尚不明確。作者評價了笑氣/異氟醚麻醉下BISEEG兩者的關係。20例擇期眼科手術患者, BIS監測儀(A-1050)記錄EEG後, 0.5%~2%的異氟醚/66%的笑氣全麻誘導和維持,持續記錄BIS, SEF95 EEG參數如(BetaRatio), 快慢波的相對同步性(SynchFastSlow)和爆發抑制率(burst suppression ratio)。當BIS大於60時,BetaRatioBIS成線性相關(r0.90p<0.01n253)。當BIS範圍在3080時,SynchFastSlowr0.60p<0.01n3314)和SEF95r0.75p<0.01n3339)和BIS成線性相關。BISSEF95的相關性優於BISSynchFastSlowp<0.01)。BIS小於30, 爆發抑制率和BIS成負相關(r0.76p<0.01n65)。在BIS小於80,補償burstSPF95BIS成線性相關(r0.78p<0.01n3404)。BIS60~100可以通過BetaRatio來計算。在手術麻醉深度下,BISSynchFastSlow和補償burstSPF95成良好相關性, 結果表明SynchFastSlowSPF95相比,在計算BIS時沒有優勢。

(陳潔 譯 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.


不同脈搏血氧探頭的比較

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


脈搏血氧飽和度探頭的測試通常局限於電路的完整性,不包括探頭的光學特性。很少有實驗評價監護儀和探頭的準確性。作者設計了一項實驗,比較Nellcor, Datex-Ohmeda和重症監護脈氧監護儀的OSS Medical的專利探頭和他們的相應產品,不包括測試脈氧探頭的光學特性。通過類比急性窒息來進行測試,用資料記錄電腦自動記錄脈氧監護儀的飽和度曲線。比較兩種探頭的同等資料,使用單一變數和多變數的線性模型進行分析。五鍾OSS探頭優於相對應的產品,其餘的在統計學上相似。模擬研究較人體研究更為有利,因為它更為經濟有效,對患者沒有危險,但模擬的真實性受到限制。

(陳潔 譯 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.

 

加巴噴丁用於腹式全子宮切除術術後鎮痛的效果

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

 

我們採用隨機,雙盲,安慰劑對照研究加巴噴丁對於腹式全子宮切除術術後鎮痛的效果,安全性, 以及曲馬多的消耗量。方法:50個病人隨機分配為兩組,分別在術前1小時口服安慰劑或是加巴噴丁1200mg。麻醉誘導用異丙酚,維持麻醉用七氟醚混合50%N2O/O2,氣體流量為2L/min以及芬太尼(2µg/kg)。所有病人都接受曲馬多術後自控鎮痛,初始劑量為50mg,添加劑量20mg,鎖定間隔時間10-min4小時總量限定於300mg。術後1小時,如果鎮痛不夠,可增加到30mg/h。分別檢測術後48121620、和24小時的VAS疼痛評分,心率,外周氧飽和度,平均動脈壓,呼吸頻率,鎮靜和曲馬多的消耗。結果:術後148121620小時,坐位和仰臥位的VAS疼痛評分,加巴噴丁組均明顯低於安慰劑組,直到術後20小時才相近。而在術後12162024小時,加巴噴丁組的曲馬多的消耗也明顯低於安慰劑組。鎮靜評分在所有測試時間均相同。兩組病人副作用方面沒有明顯差異。結論:腹式全子宮切除術病人術前口服加巴噴丁能減少術後疼痛評分以及曲馬多術後的消耗量。

(顧漪聞 譯 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.

 

關於 N-甲基-D-天冬氨酸受體拮抗劑在預防性鎮痛中的系統回顧

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


作者對於N-甲基-D-天冬氨酸受體(NMDA拮抗劑在減輕術後疼痛,鎮痛藥的消耗, 預防性鎮痛藥物NMDA拮抗劑臨床上作用持續時間等作了全面和系統的評估。 方法:首先,MEDLINE1966-2003)和 EMBASE1985-2003)上搜索在術後使用NMDA拮抗劑的隨機試驗,並且參考這些試驗的相關參考文獻。其次對術中給予NMDA拮抗劑的病人,且評估術後鎮痛研究論文文獻也作參考。結果:基本結論是NMDA拮抗劑在藥物五個半衰期內減輕了疼痛和/或鎮痛藥的消耗。第二個結論是包括了第一次對鎮痛藥的需求和副作用40篇文獻符合標準:24篇氯胺酮,12右美沙芬,和4。結果可以證明氯胺酮,右美沙芬在預防性的鎮痛中,無論是在減輕疼痛,在減少鎮痛藥的消耗,或是在延長相關藥物臨床上的持續時間方面都有很強的效果,分別為67%58%。四篇關於鎂的研究中沒有顯示其有預防性鎮痛的作用。

(顧漪聞 譯 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.


 

靜脈注射S+-氯胺酮有助於腹部大手術的疼痛治療

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


術中使用外消旋氯胺酮預防腹部手術後的疼痛目前是有爭議的。我們選擇45例硬膜外複合全身麻醉的手術患者,比較切皮前靜脈注射S+-氯胺酮與切皮前和術中重複使用S+-氯胺酮兩種方法的差異。S+-氯胺酮是一種含更多氯胺酮異構體的新藥物。患者被隨機分成三組,安慰劑組,切皮前注射0.5mg/kgS+-氯胺酮組,切皮前注射0.5mg/kgS+-氯胺酮並術中隔20分鐘重複用S+-氯胺酮0.2mg/kg組。術後患者給予羅呱卡因進行硬膜外鎮痛(2mg/ml;0.12ml•kg-1•h-1)。結果發現重複使用S+-氯胺酮的患者蘇醒、蘇醒後3小時和蘇醒後6小時疼痛評分比安慰劑組更小(P≤0.05),並且要求額外使用鎮痛藥的病人數要少於後者(P≤0.05)。單純注射(P0.05〉和重複使用S+-氯胺酮組(P0.05〉的患者24小時累積消耗二氯芬酸和右丙氧芬的量要少於安慰劑組。患者蘇醒後,重複使用S+-氯胺酮組的患者比其他組有更佳的情緒狀態(P0.05〉,且沒有類似精神症狀的副作用。總而言之,硬膜外合併全身麻醉的患者在切皮前以及術中重複使用小劑量的S+-氯胺酮比單純實施硬膜外合併全身麻醉能更好地減輕患者術後的疼痛。

(朱輝 譯 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.

 

肺動脈內應用已酮可哥堿可改善出血性休克後的心功能和氧利用狀況:一新的復蘇策略。

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


已酮可哥堿(PTX)作為出血性休克患者復蘇的輔助藥其作用還不明了。肺動脈內注射PTX對心功能和氧利用狀況的作用還不肯定。作者假定肺PTX要優於全身PTX或單一的乳酸林格氏液(LR)。選取狗出血性休克的模型來比較LR液,全身PTX和肺PTX對心功能和氧利用的作用。動物放血使其平均動脈壓(MAP)在40mmHg持續30分鐘並隨機分成3個復蘇組:LR液組(2倍出血量),全身PTX組(靜脈注射10mg/kg+ LR液(2倍出血量)+PTX(靜脈注射5mg/kg維持 45分鐘),肺PTX(通過肺動脈導管注射10mg/kg+5mg/kg維持45分鐘)+LR液(2倍出血量,IV)。然後連續測動脈血氣,血紅蛋白水平,MAP,心指數,全身血管阻力指數,肺血管阻力指數,氧輸送,氧耗和氧攝取率(O2ER)。肺PTX可提高心指數(P=0.012)並降低全身血管阻力指數和肺血管阻力指數(P0.0001〉。肺PTX增加氧輸送和氧耗。LR液組的狗復蘇後的O2ER維持在高於基礎水平的狀態(P0.0001〉。與休克水平值比較全身和肺PTX顯著降低O2ERPTX用於搶救復蘇優於單一使用LR液。動脈內使用肺PTX是安全的,同時能改善心功能和氧利用狀況。

(朱輝 譯 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.


硬膜外針頭旋轉對硬膜外阻滯擴散影響的前瞻性、隨機性評估

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名接受全髖置換管手術的病人中比較了在置入硬膜外導管前將Tuohy針頭尖端向手術側旋轉45°45°旋轉組,n 24)與Tuohy針頭朝向頭部90°的傳統置管方法(對照組,n 24)對0.75%布比卡因10ml加舒芬太尼10 µg 擴散的影響。留置導管超過Tuohy針頭34cm 。一名盲觀察者記錄雙側的感覺和運動阻滯,麻醉質量和在病人自控硬膜外鎮痛第一個48h期間局麻藥使用量。等待效果時間在對照組為21±6min45°旋轉組為17±7minP >0.50)。手術側的最高感覺阻滯平面對照組為T10T10-7),45°旋轉組為T9T12-9)(P >0.50);然而非手術側的最高感覺阻滯平面對照組為T10T10-7),45°旋轉組為L3L5-T12)(P 0.0005)。45°旋轉組手術肢體運動神經達到完全阻滯要早於對照組,對照組病人非手術側運動神經阻滯更完全。兩組手術側兩個節段感覺水平的消退過程相似,但45°旋轉組非手術側開始較對照組早。兩組術後鎮痛相似,但45°旋轉組(242±35ml)所用的局麻藥比對照組(297±60ml)少(P 0.0005)。作者認為,在置入硬膜外導管前將Tuohy針頭尖端向手術側旋轉45°使手術側感覺和運動神經優先得到阻滯,減少了術後鎮痛的局麻藥劑量。

(殷文淵 譯 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誘導時的肺膨脹不全狀態

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脹不全日益增多。作者曾介紹了在非肥胖病人誘導時採用呼氣末正壓通氣(PEEP)可以防止肺膨脹不全。本文作者研究了PEEP對防止病理性肥胖病人肺膨脹不全的效果。23名成年病理性肥胖病人(體表指數>35kg/m2)隨機分為兩組。在PEEP組中,病人呼吸100%氧氣(5分鐘)並持續10cmH20氣道正壓,在誘導後,通過面罩以PEEP 10 cmH20機械通氣。在對照組中,誘導過程相同,但沒有持續氣道正壓或PEEP。肺膨脹不全,通過CT診斷,誘導前和插管後行血氣分析。在氣管插管後,對照組較PEEP組肺膨脹不全多(對照組10.4±4.8%PEEP1.7%±1.3%P<0.001)。插管後吸入100%氧氣,PEEP組的PaO2顯著高於對照組(分別為457±130mmHg315±100mmHgP0.035)。結論:在病理性肥胖病人中,在麻醉誘導過程中使用PEEP可以大大預防肺膨脹不全狀態,從而獲得更好的氧合。

(殷文淵 譯 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.

 

比較輔助電針刺與人工耳部針刺用於慢性下背部疼痛的短期和長期療效

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

 

針刺療法是一個用於慢性疼痛治療的確定的輔助鎮痛方法。一般認為針刺點的電刺激增強針刺的鎮痛作用。在這個前瞻、隨機、雙盲的對照性研究中,我們檢驗了如下假設,即在用標準鎮痛治療中仍不能充分緩解疼痛(視覺類比分數[VAS] >=5)的慢性下背部疼痛病人,用耳部電針刺(EA)緩解疼痛比常規耳部人工手法針刺(CO)更有效。一次性針刺針插入優勢側的耳部針刺點294055,並與一個新近開發的以電池為動力、戴在耳後的小型刺激器相連接。病人隨機分成用持續低頻耳部EA1 Hz 2 mA雙相恒定電流)的EA組(n = 31)和無電刺激(佯裝電刺激)的CO組(n = 30)。每週進行一次治療,持續6 wk,且每組的針在插入後 48 h拔除。在研究期和3個月隨訪期中,要求病人完成McGill調查表。用VAS方法評價心理快樂、行為水平、睡眠質量和疼痛強度;同時記錄鎮痛藥的使用量。在研究期和隨訪期中,EA組的疼痛緩解顯著優於CO組。同樣,EA組的心理快樂、行為和睡眠比CO組顯著改善,補充應用的鎮痛藥消耗量較少,恢復全職工作的病人較多。尤其是用EA治療的病人神經性痛得到改善。無不良反應。這些結果第一次證明了耳部針刺點的持續EA刺激改善對慢性腰背部疼痛的門診病人的治療效果。

(馬皓琳   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.

 

過氧化亞硝鹽降低組織纖溶酶原啟動因數的活性

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.

 

 組織纖溶酶原啟動因數(tPA)在體內生理性纖溶過程中有重要的作用。血栓形成與某些臨床病變有關(如:動脈粥樣硬化性疾病),這些疾病涉及到局部tPA活性的降低及伴有反應性氮素的形成,如過氧化亞硝鹽(OONO–),它是一種由氧化氮及過氧化物形成的分子。我們假設tPA遇到OONO–將導致tPA活性降低。OONO–來自3-morpholinosydnonimine (SIN-1),後者能同時產生含氮氧化物及過氧化物分子。tPA重組體用0 µM SIN-1 100 µM SIN-1100 µM SIN-1合用4000 U/mL人類重組超氧化物歧化酶在37°C下孵育60 min;或用 4000 U/mL的人類重組超氧化物歧化酶孵育60 minn = 8,每種條件都收集各自的反應結果)。通過在組織因數暴露的人體血漿中添加tPA樣本的方法及用血栓彈性圖監測血凝塊纖溶作用的方法來評估tPA活性的改變。與其他三種條件組有明顯不同的是,暴露於SIN-1的一組導致tPA介導的纖溶作用顯著降低(P < 0.001)tPA活性小於不暴露於SIN-11%)。另外幾組則無明顯差別。由此得出結論,tPAOONO–抑制,OONO–在臨床血栓形成疾病中起一定作用。

(裘毅敏譯  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.

 

鞘內應用加巴潘汀和氯壓定或加巴潘汀和新斯的明在福馬林試驗中相互作用的特性

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

 

鞘內應用加巴潘汀(抗癲癇藥)對於福馬林致痛反應的第二期是有效的,但對急性痛無效。不同于加巴潘汀,鞘內應用氯壓定和新斯的明能減弱劇痛和福馬林痛反應的第二期。我們估計在福馬林致痛實驗中加入加巴潘汀到氯壓定或新斯的明中可產生相互作用。用雄性Sprague-Dawley鼠進行福馬林實驗,將50微升5%福馬林溶液注射入後爪。用固定劑量分析或等效圖分析研究藥物的相互作用。在福馬林實驗中,鞘內應用加巴潘汀對第二期的退縮反應產生抑制效果,但對第一期反應沒有影響。鞘內應用氯壓定或新斯的明則導致兩個階段的疼痛反應都減輕。第一期痛反應固定劑量分析顯示加巴潘汀能加強氯壓定和新斯的明抗傷害感受的作用。等效圖分析第二期疼痛顯示在鞘內應用加巴潘汀-氯壓定混合物或加巴潘汀-新斯的明混合物後產生協同作用。我們認為在脊髓水平應用加巴潘汀和氯壓定或新斯的明的混合物不僅對劇痛,而且對福馬林反應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.

 

曲馬多對非洲蟾蜍卵母細胞5-羥色胺2C受體表達的抑制效應

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.

 

儘管曲馬多作為鎮痛劑廣泛應用,其抵抗傷害的機制仍然沒有解決。血清素(5-羥色胺,5-HT)是一種單胺類神經遞質,調製眾多的感覺、運動和行為過程。5-HT2C受體(5-HT2CR)5-HT受體的主要亞型,和5-HT的很多重要效應有關,包括疼痛、攝食和運動。在此研究中,我們使用全細胞電壓鉗來檢測曲馬多對在蟾蜍卵母細胞上表達的5-HT2CR 所介導的、由5-HT誘導的Ca2+-啟動Cl電流的影響。曲馬多在藥理學相關濃度抑制5-HT誘導的Cl電流。蛋白激酶C抑制劑bisindolylmaleimide I (GF109203x)不能消除曲馬多對5-HT2CR介導的作用的抑制效應。我們也研究了曲馬多對蟾蜍卵母細胞表達5-HT2CR [3H]5-HT 結合情況,發現其抑制[3H]5-HT5-HT2CR特異結合。[3H]5-HT結合的Scatchard分析顯示,曲馬多改變了結合的表觀離解常數,不改變最大結合力,表明是競爭性抑制。結果提示,曲馬多抑制5--HT2CR的功能,此抑制效應的機制可能是競爭性取代5-HT5-HT2CR結合,而不是通過啟動蛋白激酶C途徑。

(張曦譯 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.

 

新生兒主動脈弓重建術中必須監測雙側大腦血氧飽和度嗎?

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.

 

本研究中我們應用近紅外分光技術監測了大腦局部低流量灌注(RLFP)前、中、後三個時段大腦兩側半球血氧飽和度的差異,以確定術中是否必須同時監測兩側大腦血氧飽和度。病例為採用RLFP技術行主動脈弓重建術的新生兒。在以下各時間段每1分鐘測定和記錄雙側局部大腦血氧飽和度:1)轉機前,2)轉機後RLFP前,3RLFP時,4)轉機時停RLFP後,5)停機後。在轉機前和轉機後RLFP前,兩側大腦的血氧飽和度相關性(r = 0.979 0.852)和一致性(平均偏差,右比左,0 +2)都很好。但在RLFP時,相關性(r = 0.35)和一致性(平均偏差,右比左,+6.3)明顯變差,停RLFP後只有部分恢復接近基礎值。19例病例中有9例的雙側大腦血氧飽和度差異超過10%,均為左側低於右側。通過雙側監測方法,我們發現RLFP時左側大腦半球的血氧飽和度有下降,但是下降引起的遠期結果尚不明確。

(張俊傑譯 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.

 

比較三種不同腦電監護儀的臨床實用性:雙頻譜指數、處理後的腦電圖和Alaris聽覺誘發電位

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.

 

我們比較了腦電雙頻譜指數(BIS)、處理後的腦電圖(pEEG)和Alaris聽覺誘發電位(A-AEP)的實用性。90名擬行擇期乳房切除術的女性病人被分為3組。使用丙泊酚和芬太尼進行誘導,放置喉罩氣道,加用氧化亞氮維持麻醉。通過BISpEEGA-AEP監測腦電圖。我們記錄了第一次放置電極即可達到足夠低的阻抗以提取腦電信號的病人數(反映成功率),監護儀提供的指數超出全身麻醉下合理範圍的次數(不符合率),放置喉罩氣道以及手術切皮時指數的變化(反映了監護儀的反應性)和術中電灼對信號的干擾停止後恢復良好腦電信號的時間(恢復時間)。成功率的順序是BIS>A-AEP>pEEG,不符合率是A-AEP<BIS<pEEGA-AEP的反應性最高。恢復時間的順序是pEEG<A-AEP<BIS。總之,BIS的成功率最高,A-AEP不符合率最低,反應性最好,而pEEG的恢復時間最快。

(顏濤譯 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.

 

與蛛網膜下腔麻醉有關的人類軟脊膜超微結構發現

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.

為了明確人軟脊膜上是否存在窗孔,我們檢查了人軟脊膜超微結構的細節如細胞組成和膜的厚度。我們假設軟脊膜不是一個連續的膜結構,而是有窗孔穿過軟脊膜細胞。腰部硬膜囊取自7具人新鮮屍體,腰軟脊膜標本經特殊的染色技術(免疫組織化學法)及透射掃描電鏡進行研究。觀察由重疊的扁平細胞軟膜層和軟膜下組織。我們發現窗孔存在於人胸腰連接處的軟脊膜、脊髓圓錐和神經根水平,但是胸段水平不存在窗孔。我們推測在腰脊髓和神經根水平的軟脊膜窗孔可能影響局麻藥跨膜轉移。

(周雅春譯 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.

 

評估氟呱利多對平均QTc間期影響的模型

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

由於FDA告誡圍術期使用預防嘔吐的氟呱利多,即使小劑量也能導致嚴重甚至致命的心律失常,使氟呱利多的應用引起了廣泛的爭論。我們採用數學模型來評估由專家評審的論文的資料得到的心電圖QT間期,觀察靜注0.1–0.25 mg/kg氟呱利多和QTc 延長間的關係。在由對數模型得到的QTc (27–63 ms),由線性模型得QTc (27–67 ms)和由方根模型得QTc (36–57 ms)中,方根模型與實際QTc (37–59 ms)最相近。我們選用的其他模型包括多項式模型、多指數模型(包括四次方根模型、立方根模型,平方模型和立方模型)。結果顯示靜注0.625–1.25 mg 的氟呱利多引起的平均QTc 間期延長為9 ± 3 18 ± 3 ms 之間。因此,此回歸分析顯示圍術期應用小於1.25 mg的氟呱利多抗惡性嘔吐不可能引起心律失常效應。結論:應用方根曲線擬合模型分析氟呱利多劑量與QTc 延長間的關係顯示,靜注小劑量氟呱利多(0.625–1.25 mg IV) QTc 間期延長小於30毫秒。因此,手術患者預防應用小劑量止吐藥氟呱利多不會產生心律失常效應。

(趙雪蓮譯 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.

 

兒童麻醉誘導時家長在場和術前鎮靜的趨勢:一項1995–2002年全美隨訪調查的結果

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,麻醉誘導時家長陪伴在場和術前使用鎮靜藥均可用于緩解兒童術前焦慮。1995年的一項研究顯示,多數患兒進入手術室時沒有享受到這兩種措施。2002年我們進行了一項隨訪,將五千份調查問卷隨機郵寄給美國麻醉醫師協會的會員,並對郵件進行無反應偏差評估。投遞三次後總共收到27%的回復(n = 1362)。我們發現,與1995(30%)相比,2002年更多患兒(50%, P = 0.001)術前使用鎮靜藥,並且術前用藥的地理差異減小(F = 8.31, P = 0.006)。同樣與1995年相比,2002年美國有更多家長在患兒麻醉誘導時被允許在場陪伴({chi}2 = 26.3, P = 0.0001)。與1995年相同的是,咪達唑侖是最常使用的術前藥。

(軒   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.

 

比較腎上腺素和加壓素對快速靜脈注射布比卡因致心搏停止的豬模型的作用

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.

 

在豬模型上,我們比較了腎上腺素、加壓素或腎上腺素聯合加壓素對布比卡因致心博停止成活率的有效性,鹽水為安慰劑對照。靜脈注射5mg/kg0.5%布比卡因後,通氣中斷3 ± 1分鐘直至發生心搏停止。心搏停止1分鐘後開始心肺復蘇。心肺復蘇2分鐘後,28個動物每5分鐘給予腎上腺素;加壓素;腎上腺素聯合加壓素;或安慰劑。每種藥物注射3分鐘後,施行3次電除顫(3, 4 6 J/kg);其後所有電擊能量都是6 J/kg。實驗中抽血測血漿布比卡因濃度。加壓素/腎上腺素聯合組,所有豬存活(P < 0.01較之安慰組);加壓素組7個豬中5個存活,腎上腺素組7個豬中4個存活,安慰組中無一個豬存活。血漿總布比卡因濃度組間比較無差異。在這個布比卡因導致心搏停止的模型中,心肺復蘇時加壓素聯合腎上腺素比安慰組有顯著高的生存率。

(吳儉 譯,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.

食道彩色多普勒超聲心動圖測定心輸出量

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

 

自動心輸出量測定(ACOM)方法是一種在空間及時間上對數位彩色多普勒血流速率的整合方法,雖然已通過經胸超聲心動圖證實,但經食道超聲心動圖(TEE)方法則尚未得到驗證。因此我們在36例心臟手術病人中確定利用TEEACOM方法的可行性。有利於分析ACOM方法的部位主要是橫切過肺主動脈(PA)、二尖瓣口和左室流出道的彩色扇面。在每個超聲視野中測定PA流量、二尖瓣流量及左室射血流量以確定心輸出量。我們對ACOM方法及同時進行熱稀釋法(TD)測定的心輸出量進行比較。在二尖瓣流量分析中,ACOM法與TD法所得的值有很好的相關(R2=0.85;在二室視野中均差=0.01 ± 0.58 L/min; R2 = 0.78;在四室視野中均差= –0.10 ± 0.68 L/min)。在PA流量分析中,ACOM並不與TD相關(R2 = 0.30)。而在左室流出道分析中,很難獲取到彩色多普勒流量信號充分的最佳視野(44%)。我們應用ACOM方法測定二尖瓣流量以確定心輸出量,與TD法有很好的相關性和一致性。因此通過TEEACOM來測定二尖瓣流量是一種實用及快速的測定心輸出量的方法。

(王立中 譯,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.

 

甲氧氯普胺通過抑制鼠氣管毒蕈堿M3受體而產生氣道平滑肌舒張

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

 

雖然常用作止吐藥甲氧氯普胺也被認為有抗膽鹼酯酶作用但是其對於氣道平滑肌的作用還不十分的清楚。我們通過實驗來探討甲氧氯普胺對鼠氣道肌肉收縮、磷脂酰肌醇反應以及對毒蕈堿M3受體親和力的影響。雄性Wistar鼠麻醉後取其氣管,製成3mm寬的氣管環和1mm寬的切片,或10微米厚的冰凍切片。收縮反應是以0.55mg氯化氨甲酰膽鹼所誘發,在30min後加入甲氧氯普胺(10uM1mM)。切片被孵育在3[H]-肌-環己六醇、0.55mg氯化氨甲酰膽鹼和甲氧氯普胺中,檢測孵育液中的環己六醇環腺苷一磷酸的量。在氣管切片上用放射標記[3H] 4-diphenylacetoxy-N-methyl-piperidine methobromide4DAMP)(一種毒蕈堿M3受體拮抗藥)來進一步研究甲氧氯普胺與受體的結合作用。結果:甲氧氯普胺濃度增加,CCh引起的收縮逐漸減弱、毒蕈堿M3受體與4DAMP結合能力也降低。甲氧氯普胺50%抑制4DAMP毒蕈堿M3受體結合的濃度為24uM。本研究提示,甲氧氯普胺抑制CCh產生的肌肉收縮和磷脂酰肌醇反應可能通過毒蕈堿M3受體介導。

(沈浩譯  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.

 

頸內動脈內麻醉藥引起的腦電靜止並不影響兔腦暫時性缺血後的早期充血

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

有證據顯示,缺血後早期充血由神經和血管機制同時介導。我們假設,如果神經元活動是再灌注充血的主要因素,那麼利用異丙酚和硫噴妥鈉進行頸內動脈麻醉引起腦電靜止應該能夠減輕充血反應。用雙側頸動脈進行阻斷以及全身低血壓的方法,造成新西蘭白兔10分鐘的短暫腦缺血。然後解除阻斷,並將動脈平均壓提升到基礎水平。在對照組,再灌注期頸動脈內定期注入生理鹽水,在實驗組,頸內動脈中用異丙酚和硫噴妥鈉造成10分鐘的腦電靜止。記錄缺血期和再灌注期各生理資料。19只兔子中16只取得了令人滿意的資料。兩組在頸動脈阻斷期平均動脈壓,呼吸末二氧化碳,腦血流明顯降低。在再灌注期,三組的腦血流基礎值接近(生理鹽水,異丙酚,硫噴妥鈉分別為:192% ± 76%, 218% ± 84%, and 185% ± 101%,結果提示,再灌注期神經活動的抑制並不能影響短暫性腦缺血後的充血。

(朱 慧譯 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.

 

減少心肺轉流中的凝血啟動:一項聯合措施

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

 

心肺轉流(CPB)中用來限制凝血啟動的干預措施如肝素塗層管道、e-氨基己酸以及減少散失血液的回輸等單獨應用的效果報導不一。我們對傳統的CPB(對照)(CTRL)期間使用非塗層管道、無抗纖溶劑和開放性心臟切開與一項聯合策略(HAC)包括使用肝素塗層管道、e-氨基己酸和閉合性心臟手術時的凝血和纖溶啟動進行了比較。9CTRL患者和10HAC患者行初次冠脈搭橋手術,分別於CPB轉前、轉中和轉後進行采血。CPB30min後凝血酶-抗凝血酶複合物和纖維蛋白肽A的水平(凝血酶和纖維蛋白生成的標誌物)在HAC組較CTRL組為低(p<0.05)。經過30minCPB,組織纖維蛋白溶酶原啟動物(tPA)的平均水平在HAC組明顯較低(p<0.05),繼而維持了CPB期間的纖溶酶原啟動劑抑制物(PAI)-1p<0.05)。CPB轉中和轉後,D-二聚體這一用來評估血管內纖維蛋白的形成和清除的指標,在HAC組較低(p<0.05)。總而言之,聯合策略可減少CPB引起的凝血酶產生、纖維蛋白形成、tPA釋放以及纖維蛋白的降解,並更好地保護PAI1

(黃施偉 譯,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.

 

關於非體外迴圈下冠脈手術的綜合性節約用血協定中使用中等量的急性等容血液稀釋技術的研究

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

 

我們評估了在非體外迴圈下行冠脈搭橋手術(OPCAB)的病人術中使用急性等容血液稀釋(ANH)聯合止血環酸治療和出血再回輸時的節約用血效力。連續的100個行OPCAB的病人(基礎hct>34%)被前瞻性、隨機化分至止血環酸治療組(對照組;50人)和止血環酸治療加等容稀釋組(ANH組;50人),用膠體等容稀釋17% +/- 2%的迴圈血量。所有的病人在術中出血超過250 mL時予回輸血液。異體輸血則根據事先制定的嚴格標準給予,其需要量為我們此研究的主要目的,並記錄血液生化、出血、主要併發症和其他後果。人口統計學、基礎血液生化指標和手術特點在兩組中相似。ANH組的病人平均回收850 mL血液,術中最小hct值較低(31% 37%; P < 0.0001),需要輸紅細胞的病人ANH組為2個,而對照組為10(優勢比, 0.17; 95% 可信限, 0.03-0.89; P = 0.028),紅細胞單位的需要量也顯著低於對照組(5 24; P < 0.001)。兩組病人術後的血液生化變數、出血和轉歸相似。中等量的ANH聯合止血環酸治療和出血再回輸可減少OPCAB病人的異體輸血的需要量。

(周曉敏譯 薛張綱審校)

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.       

 

心率變異性動態學的障礙可預測長期的心肌缺血

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臟手術後發生心臟不良事件的風險增加了39倍。在本研究中我們證實了以下假設:行外科手術的老年病人其變化的術前的心率變異性(HRV)預示術後的長期心肌缺血(>10 分鐘)3260歲以上,擬行外傷性髖部骨折修復術的住院病人進入了我們的研究,術前予持續的 Holter檢查,從入院開始直到術後第3天早晨。每個病人均行晚間( 2 AM 5 AM)和白天(7 AM 12 AM)的常規HRV測量及RR間期的短期不規則刻度指數(alpha1)分析。術後有心肌缺血的病人其術前夜間的alpha1值顯著低於(即HRV隨機的升高)白天(均值 +/- 標準差; 0.92 +/- 0.08 1.03 +/- 0.06; P = 0.002),無心肌缺血的病人則沒有區別。在逐步多變數邏輯回歸分析中,術前夜間與白天alpha1值的差值的升高是術後長期心肌缺血的唯一獨立預測因數。夜間與白天alpha1值的差值升高0.16 U其優勢比為7.7(95% 可信限, 1.9-51.4; P = 0.0018)。在行外傷性髖部骨折急症手術的老年病人,心率變異性動態學的障礙預示著術後的長期心肌缺血。

(周曉敏譯 薛張綱審校)

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.

 

氣管內使用重組表面活性物質蛋白C可減弱由氣管內吸入酸性嬰兒乳粉引起的兔的急性肺損傷

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.

 

本研究中我們的目的是確定重組表面活性物質蛋白C(rSP-C)是否可以改善由氣管內吸入酸性乳製品引起的急性肺損傷(ALI)28只兔子隨機分為4組,3組通過氣管內吸入酸性的嬰兒乳粉(0.8 mL/kg, pH 1.8)誘發ALI,對照組使用酸性的鹽水。治療組在使用酸性嬰兒乳粉30分鐘後氣管內予0.5 2 mg/kg的表面活性物質rSP-C,誘發ALI後用純氧行肺通氣4小時,酸性嬰兒乳粉顯著地減少了氧合和肺順應性並增加了阻力,而兩個劑量的rSP-C均可改善指標[4h時的平均 PaO2 (mm Hg) 順應性 (mL/cm H2O)分別是: 嬰兒乳粉為61 0.4, 小劑量rSP-C162 1.0, 大劑量rSP-C 152 1.2; P < 0.05]rSP-C治療可減輕肺的白細胞浸潤和水腫及嚴重的形態學變化(嬰兒乳粉組、小劑量rSP-C組和大劑量rSP-C組的ALI 評分分別為 14, 7, 7; P < 0.05)。兩個劑量的rSP-C的效果相仿。以上結果提示氣管內使用rSP-C可改善由誤吸酸性的乳製品引起的ALI

(周曉敏譯 薛張綱審校)

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.

 

布比卡因脊麻減少了前早產兒的腦血流

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

 

脊麻被普遍應用於前早產兒FPI中。在這些患者中,脊麻導致的低血壓可能會減少腦血流。我們通過經顱多普勒超聲來測量腦血流速率(CBFV)以評估由脊麻導致的低血壓對腦血流動力學的影響。12個擇期行腹股溝疝修補的FPI1mg/kg等比重0.5%布比卡因的脊麻下進行手術。在脊麻前5分鐘和之後的5分鐘、10分鐘分別通過經顱的脈搏多普勒超聲測量大腦中動脈的收縮、舒張和平均的CBFV,並同時記錄動脈血壓和心率。腦動脈阻力指數(RI)通過公式RI=(收縮峰CBFV-舒張末期CBFV/收縮峰CBFV來計算。舒張CBFV5分鐘時明顯地從30.0 ± 11.1 cm/s 降至20.1 ± 8.4 cm/s10分鐘時降至20.1 ± 7.0 cm/sRI5分鐘和10分鐘時明顯地從0.7 ± 0.1 降至0.8 ± 0.1。在同一時間間隔內收縮期、舒張期和平均動脈血壓也明顯下降了。我們提示在FPI中,脊麻通過動脈血壓的改變而導致了腦血流的減少。這些改變是否會造成有害的結果還有待查明。

(鍾鳴譯 薛張綱審校)

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.

 

異氟醚對減敏感的野生型和{alpha}1(S270H) {gamma}氨酪酸型A受體的影響

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受體(GABAA-R)介導了突觸抑制,並符合許多重要的全麻藥目標所需要的藥理學準則。在突觸傳遞時GABA釋放足以飽和、最大程度的啟動突觸後GABAA-Rs和一過性的降低其敏感性。這種因而發生的抑制性突觸後電流(IPSCs)能被吸入性麻醉藥如異氟醚所延長。我們研究了異氟醚對在爪蟾卵母細胞內表達的被最大化啟動和減敏感的GABAA-R電流的影響。野生型{alpha}1ß2 {alpha}1ß2{gamma}2s受體暴露於600µMGABA中直至電流達到去敏感水平的穩態。在臨床濃度(0.02–0.3 mM),異氟醚對{alpha}1ß2受體的去敏感電流的穩態產生劑量依賴性的增強作用,這種作用在包含{gamma}2s亞基的受體中並不明顯。當{alpha}1-亞基的第二跨膜節段270位置的絲氨酸變成組氨酸({alpha}1(S270H))後,由亞飽和濃度的GABA激發的電流變得對異氟醚的增強作用更加不敏感。另外,異氟醚對去敏感電流的增強作用能被這種突變所大大減弱,並在{alpha}1(S270H)ß2{gamma}2s 受體中無法探查。總結之,異氟醚對由飽和濃度激動劑激發的GABAA-R電流的增強作用是亞基依賴性的。異氟醚對去敏感受體的這種作用可能部分在於在麻醉中延長了IPSCs

(鍾鳴譯 薛張綱審校)

{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.

 

丹曲林降低寒戰的域值和增益

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

 

丹曲林用於治療威脅生命的高熱,但其溫度調節作用還不清楚。我們測試了這樣一種假設,即丹曲林能降低寒戰的域值(觸發體核溫度)和增益(增加的量值)。健康的志願者在兩個隨機的日子裏被評估:對照組和丹曲林組({approx}2.5 mg/kg加上持續輸注)。在研究一中,9名男子被加熱直至出汗然後冷卻動靜脈分流收縮和寒戰出現。出汗通過胸部的通氣被膜來定量。右中指尖的絕對血流通過靜脈阻塞的容積體積描記法來定量。通過耗氧量的持續不變的升高來識別寒戰的域值。在研究二,9名男子通過靜脈輸注冷的乳酸鈉林格氏液來達到體核溫度降低{approx}2°C/h。當體核溫度降低不再增加寒戰強度時降溫停止。寒戰的增益就是耗氧量比上體核溫度的斜率。在研究一,出汗和血管收縮域值在兩天內相似。相比而言,在丹曲林天中寒戰域值降低了0.3 ± 0.3°C, P = 0.004。在研究二,丹曲林將寒戰域值從36.7 ± 0.2 降至 36.3 ± 0.3°C, P = 0.01,增益從353 ± 144 降至211 ± 93 mL • min–1 • °C–1, P = 0.02。因此,丹曲林從本質上講降低了寒戰的增益,但幾乎不產生中心體溫調節抑制。

(鍾鳴譯 薛張綱審校)

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.

 

異丙酚/雷米芬太尼複合麻醉誘導、維持和終止時應用NarcotrendTM ,BIS指數及經典腦電圖評估作用的比較

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.

 

在此項研究中比較了在標準化麻醉自誘導至拔管期間應用NarcotrendTM BIS指數及腦電圖監測意識深度的能力。我們觀察了26位行椎板切除術病人。觀測項目包括:清醒、反應消失、睫毛反射消失及麻醉穩態時的BIS指數及腦電圖表現。並同步記錄NTBISTM 光譜邊緣頻率,{delta} {theta} {alpha} ß波的相對電壓及血流動力學。分析各參數在清醒及反應消失、清醒及睫毛反射消失、清醒及麻醉穩態、麻醉穩態及首次體動出現和拔管時的區別從而判斷各參數的預測準確性。異丙酚麻醉中應用雷米芬太尼的作用可通過Friedman’sWilcoxon’s試驗觀察。只有NTBISTM能準確的區分各個麻醉狀態且其預測準確性>0.95。雷米芬太尼開始輸注後只有血流動力學的改變具顯著統計學意義(P < 0.05)NT BIS較腦電圖和血流動力學更可靠的用於監測麻醉深度但卻不能用於監測鎮痛強度。

(陸旭偉譯 薛張綱審校)

 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.

 

單胺類物再攝取抑制劑Milnacipran不影響大鼠急性內臟膨脹疼痛

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.

 

抗抑鬱藥治療內臟疼痛的作用未廣泛研究。Milnacipran是一種抑制單胺類物質再攝取的抗抑鬱藥,廣泛用於治療抑鬱及纖維肌痛。在此項研究中我們探討Milnacipran治療急性內臟疼痛的機理。將雙側卵巢切除術後7天的雌性處女大鼠作為研究物件。全麻下在子宮頸內插入金屬杆產生人為膨脹以此造成子宮頸膨脹(UCD)。而結直腸膨脹(CRD)則通過在降結腸、直腸內置入球囊管後人為充氣產生。在腹直肌內置入兩個電極記錄UCDCRD引起的腹直肌收縮,並量化為肌電圖(EMG)。Milnacipran單劑反應則通過靜脈或鞘內應用milnacipran後予以UCDCRD刺激獲得。Milnacipran不能抑制UCD相關的EMG反應(不管靜脈或鞘內應用),相似的milnacipran也不能抑制CRD相關的EMG反應(不管靜脈或鞘內應用)。CRDUCD非常適合於在動物模型中研究急性內臟疼痛。儘管Milnacipran較其他抗抑鬱藥有獨一無二的優點,但它對急性內臟疼痛無效。

(陸旭偉譯 薛張綱審校)

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拮抗劑及Diltiazem應用於消除大鼠內臟疼痛中的相互作用

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.

 

為了測試是否GABA受體拮抗劑及L型電壓門控鈣離子通道阻滯劑在脊髓水平的抗內臟疼痛作用是否存在潛在的相互影響,我們在結直腸內置入導管產生結直腸膨脹從而造成內臟疼痛。共分三組,分別經鞘內應用GABA拮抗劑(muscimolbaclofen)、鈣離子通道阻滯劑(diltiazem)、兩者聯用。CD閾值在應用muscimol 0.1 µg,baclofen 0.01 µg,diltiazem 100 µg後無改變,而應用muscimol 1 µg baclofen 0.1 µg後輕度增加。當muscimol 0.1 µg1 µg聯合應用diltiazem時,CD閾值顯著增加(5分鐘時分別為26.2% 0.6% MPE84.5%19.5%MPEP < 0.01)(MPE最大有效強度)。聯用baclofen 0.1 µg diltiazem時也較單用baclofen引起CD閾值的顯著增加(5分鐘時為 48.0% 14.3% MPE; P < 0.01)。Muscimol 1 µg時可有運動神經阻滯,但當其聯用diltiazem時並不加重神經阻滯。總之,鞘內應用diltiazemGABA拮抗劑(muscimolbaclofen)增強GABA拮抗劑的內臟鎮痛作用但不增加運動神經阻滯。

(陸旭偉譯 薛張綱審校)

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.

 

快速皮膚麻醉使用丁卡因新配方:一項臨床前研究

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.

 

我們開發了一種快速起作用的丁卡因乳膠並且在鼠爪模型上測試他在鎮痛方面的效果主要是由熱和機械引起的疼痛。第一項實驗在老鼠身上進行。用角叉菜膠誘發炎症反應,使老鼠痛覺過敏。老鼠被分為以下幾組:丁卡因乳膠,丁卡因凝膠(Ametop®gel)EMLA霜(易熔的局麻藥混合物),丁卡因浸潤,空白(對照)。第二項實驗在健康的,選擇性的對熱或接觸敏感的老鼠身上,按第一次實驗一樣分組。將鼠爪受熱和機械刺激後產生退縮反應的時間作為疼痛反應的指標。在第一項實驗中使用丁卡因乳膠,丁卡因凝膠(Ametop®gel)EMLA霜,丁卡因浸潤,抗痛覺過敏作用分別出現在使用後4.2, 13.8, and 14 分鐘。丁卡因乳膠是其中唯一產生抗異常疼痛的表面麻醉劑,但比丁卡因浸潤麻醉的效果要差一些。在健康的老鼠中(實驗二),所有的表面麻醉劑型對同側的鼠爪受熱刺激後的鎮痛效果都是一樣的。使用丁卡因乳膠後對側的鼠爪的反應出現的更早,這是一個唯一使用後使老鼠對接觸刺激產生的反應時間延長的藥物。因此,乳膠可以有效的提高丁卡因的皮膚滲透性,由此快速起效。

(方芳譯 薛張綱審校)

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.

 

健康豬肺在肺泡複張過程中內臟迴圈的改變

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

在急性肺損傷和麻醉中複張手法(RM)被認為是機械通氣的補充。然而他可能產生胸內壓和容量增高,影響血流動力學。我們此研究的目的在於分析RM對十隻麻醉的豬的血流動力學的影響。我們測頸動脈,肺動脈,股動脈,和肝動脈的壓力,肝靜脈和門靜脈的壓力,總內臟(腹腔幹+腸系膜上動脈),肝,脾,腎和頸動脈的血流,門脈血流。我們在RM前和RM8分鐘(持續充氣使氣道壓力到達40 cm H2O保持20秒)測血流動力學,呼吸力學和血氣。血流動力學指標在RM期間,135分鐘後也記錄下來。所有的血流(P = 0.030)和動脈壓(P <=0.048)RM 期間均下降,而靜脈壓是伸高的(P = 0.030)。血流和壓力在RM 後馬上恢復到75%–109%的基準。總的內臟,腎和門脈血流在RM8分鐘繼續保持低值(P <=0.042)。在所有的血管中,RM對血流產生一個雖然短暫但是顯著的影響。雖然有部分很快恢復,總的內臟迴圈在RM8分鐘後繼續保持低值。這個下降在顯著的迴圈儲備受損的情況下會帶來危險。

(方芳譯 薛張綱審校)

 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

 

剖宮產術後鎮痛使用脊髓嗎啡,可樂定及其混合物

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

 

在這項隨機雙盲的實驗中,我們在240名婦女中觀察蛛網膜下腔15 µg芬太尼和嗎啡,可樂定,或嗎啡加可樂定在剖宮產中的鎮痛效果。一項劑量分析顯示100 µg嗎啡和可樂定6090150 µg在術後和副反應方面沒有差異。這些組的資料(MC60–150, n = 113)和其他組,嗎啡100 µg (n = 39),可樂定150µg (n = 39),嗎啡100 µg加可樂定30 µg (n = 41),相比較。這四組在病人自控嗎啡使用的其始時間和總的用量上是有區別的(P < 0.0001 and P < 0.001,分別)。在MC60–150組時間最久,劑量最少。組間的疼痛評分是有顯著差異的。感覺阻滯的起始時間,麻黃素的需要量,低血壓的發生,患者滿意程度和恢復都是相似的。使用可樂定後鎮靜效果更好。嗎啡組有較多嚴重的皮膚瘙癢,MC60–150組術中更易嘔吐。和單使用嗎啡100 µg,可樂定150 µg比較,蛛網膜下腔使用嗎啡100 µg加至少60 µg可樂定可以延長術後鎮痛,減少嗎啡的用量,加強術中鎮靜。

(方芳譯 薛張綱審校)

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

 

一項針對矯形外科醫生對區域麻醉的態度和瞭解的調查

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

我們設計了一張加拿大矯形外科醫生對區域麻醉的態度和喜好的調查表。我們發出768張表,收到46861%)張回復。48%會指導他們患者對麻醉方式的選擇。40%的醫生知道他們的患者選擇區域麻醉。他們選擇區域麻醉是基於減少術後疼痛(32%),減少噁心嘔吐(12%),和安全(14%)。不選擇區域麻醉主要是因為,麻醉起效慢(43%)和不可預知的成功率(12%)。這項調查表明,矯形外科醫生還是偏好區域麻醉的,普及區域麻醉的最大障礙是起效慢和效果不可靠。

(方芳譯 薛張綱審校)

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