Anesthesia & Analgesia

June 2004

Table of Content

 

PAIN MEDICINE:

咪达唑仑的椎管内应用I:一项调查安全性的队列研究

(黄施伟   李士通 校)

Intrathecal Midazolam I: A Cohort Study Investigating Safety

Adam P. Tucker, Cindy Lai, Raymond Nadeson, and Colin S. Goodchild

Anesth Analg 2004 98: 1512-1520.

鞘内使用咪达唑仑II:鞘内合用芬太尼用于分娩

陆旭伟 薛张纲

Intrathecal Midazolam II: Combination with Intrathecal Fentanyl for Labor Pain

Adam P. Tucker, Joseph Mezzatesta, Raymond Nadeson, and Colin S. Goodchild

Anesth Analg 2004 98: 1521-1527.

绵羊持续鞘内注射咪达唑仑的安全性

朱慧琛 译 王祥瑞 校

Safety of Continuous Intrathecal Midazolam Infusion in the Sheep Model
Mary J. Johansen, Tamara Lee Gradert, William C. Satterfield, Wallace B. Baze, Keith Hildebrand, Lawrence Trissel, and Samuel J. Hassenbusch

Anesth Analg 2004 98: 1528-1535.

人鞘内咪哒唑仑应用的研究过程

王立中   李士通

The Use of Intrathecal Midazolam in Humans: A Case Study of Process (Special Article)
Tony L. Yaksh and Jeffrey W. Allen

Anesth Analg 2004 98: 1536-1545

 

关节腔内注盐水可减轻膝关节镜后中度到重度疼痛:一项随机对照试验

陆旭伟 薛张纲

Moderate-to-Severe Pain After Knee Arthroscopy Is Relieved by Intraarticular Saline: A Randomized Controlled Trial

Leiv A. Rosseland, Knut G. Helgesen, Harald Breivik, and Audun Stubhaug

Anesth Analg 2004 98: 1546-1551.

一种简单、快速、方便的验证疼痛治疗研究方法:单独应用计算机检索方案可验证随机对照实验的质量

朱慧琛 译 王祥瑞 校

A Simple, Fast, Easy Method to Identify the Evidence Base in Pain-Relief Research: Validation of a Computer Search Strategy Used Alone to Identify Quality Randomized Controlled Trials

Tony K. F. Chow, Elean To, Colin S. Goodchild, and John J. McNeil

Anesth Analg 2004 98: 1557-1565.

己酮可可碱和丙戊茶碱局部用药对福尔马林诱发痛和大鼠爪炎性组织肿瘤坏死因子αmRNA水平的影响

   李士通

The Effects of Local Pentoxifylline and Propentofylline Treatment on Formalin-Induced Pain and Tumor Necrosis Factor-{alpha} Messenger RNA Levels in the Inflamed Tissue of the Rat Paw
Magdalena Dorazil-Dudzik, Joanna Mika, Martin K.- H. Schafer, Yanzhang Li, Ilona Obara, Jerzy Wordliczek, and Barbara Przewlocka

Anesth Analg 2004 98: 1566-1573

系统联用氯胺酮、吗啡治疗实验诱发投射痛的协同作用

方芳 薛张纲

The Synergistic Effect of Combined Treatment with Systemic Ketamine and Morphine on Experimentally Induced Windup-Like Pain in Humans

Helène Schulte, Alf Sollevi, and Märta Segerdahl

Anesth Analg 2004 98: 1574-1580.

CARDIOVASCULAR ANESTHESIA

涂肝素的体外循环管道对肺功能和炎症介质释放的影响

殷文渊 译 王祥瑞 校

The Impact of Heparin-Coated Cardiopulmonary Bypass Circuits on Pulmonary Function and the Release of Inflammatory Mediators

R. de Vroege, W. van Oeveren, J. van Klarenbosch, W. Stooker, M. A. J. M. Huybregts, C. E. Hack, L. van Barneveld, L. Eijsman, and C. R. H. Wildevuur Anesth Analg 2004 98: 1586-1594.

评估消旋氯胺酮在心内直视手术中的神经保护作用

赵雪莲   李士通校

Evaluation of the Neuroprotective Effects of S(+)-Ketamine During Open-Heart Surgery
W. Nagels, R. Demeyere, J. Van Hemelrijck, E. Vandenbussche, K. Gijbels, and E. Vandermeersch

Anesth Analg 2004 98: 1595-1603.

肺复张可提高单肺通气时的通气、换气效率

方芳 薛张纲

Lung Recruitment Improves the Efficiency of Ventilation and Gas Exchange During One-Lung Ventilation Anesthesia

Gerardo Tusman, Stephan H. Böhm, Fernando Suárez Sipmann, and Stefan Maisch

Anesth Analg 2004 98: 1604-1609.

体外循环后胃肠道副反应:是否可通过术前危险因子来预测

肖洁 译 王祥瑞 校

Adverse Gastrointestinal Complications After Cardiopulmonary Bypass: Can Outcome Be Predicted from Preoperative Risk Factors?

Mary E. McSweeney, Susan Garwood, Jack Levin, Maria R. Marino, Shirley X. Wang, David Kardatzke, Dennis T. Mangano, and Richard L. Wolman

Anesth Analg 2004 98: 1610-1617.

米力农对儿茶酚胺预收缩的肺小动脉的扩张作用增强

    李士通

Enhanced Vasodilatory Responses to Milrinone in Catecholamine-Precontracted Small Pulmonary Arteries

Rajiv Jhaveri, Soonyul Kim, A. Ron White, Sean Burke, Dan E. Berkowitz, and Daniel Nyhan

Anesth Analg 2004 98: 1618-1622.

PEDIATRIC ANESTHESIA:

小儿异氟醚麻醉中的脑电双频指数

钟鸣 薛张纲

Bispectral Index During Isoflurane Anesthesia in Pediatric Patients

Simon D. Whyte and Peter D. Booker

Anesth Analg 2004 98: 1644-1649.

肝素酶改良的血栓弹性描记仪在足月和早产儿中应用

顾漪闻 译 王祥瑞 校

Heparinase-Modified Thrombelastography in Term and Preterm Neonates

Stephan C. Kettner, Arnold Pollak, Michael Zimpfer, Tanja Seybold, Andrea R. Prusa, Kurt Herkner, and Stefan Kuhle

Anesth Analg 2004 98: 1650-1652.

AMBULATORY ANESTHESIA:

在妇产科门诊腹腔镜检查中用口服长效晕海宁预防术后恶心和呕吐

马皓琳    李士通

Prophylaxis of Postoperative Nausea and Vomiting with Oral, Long-Acting Dimenhydrinate in Gynecologic Outpatient Laparoscopy

Kim E. Turner, Joel L. Parlow, Nicole D. Avery, Deborah A. Tod, and Andrew G. Day

Anesth Analg 2004 98: 1660-1664

术前肠外给予Parecoxib随后口服Valdecoxib缩短了腹腔镜胆囊切除术后恢复时间并提高苏醒质量

钟鸣 薛张纲

Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery

Tong J. Gan, Girish P. Joshi, Eugene Viscusi, Raymond Y. Cheung, William Dodge, John G. Fort, and Connie Chen

Anesth Analg 2004 98: 1665-1673.

ANESTHETIC PHARMACOLOGY:

琥珀胆碱和电休克治疗后的肌肉损伤

   李士通校

Muscular Injury After Succinylcholine and Electroconvulsive Therapy

Thewarug Werawatganon, Oranuch Kyokong, Somrat Charuluxananan, and Sahadol Punyatavorn

Anesth Analg 2004 98: 1676-1679.

小剂量琥珀酰胆碱使用后的神经肌肉阻滞效应及气管内插管条件

张俊峰 薛张纲

The Neuromuscular Effects and Tracheal Intubation Conditions After Small Doses of Succinylcholine
Mohammad I. El-Orbany, Ninos J. Joseph, M. Ramez Salem, and Arthur J. Klowden

Anesth Analg 2004 98: 1680-1685.

琥珀胆碱阻滞过程中对强直和TOF刺激反应的强直后易化和衰减

陈洁 译 王祥瑞 校

Posttetanic Potentiation and Fade in the Response to Tetanic and Train-of-Four Stimulation During Succinylcholine-Induced Block
Mohamed Naguib, Cynthia A. Lien, John Aker, and Rudolfo Eliazo

Anesth Analg 2004 98: 1686-1691.

美沙酮用于麻醉诱导:血浆组胺浓度,动脉血压和心率

周雅春    李士通

Methadone for the Induction of Anesthesia: Plasma Histamine Concentration, Arterial Blood Pressure, and Heart Rate

T. Andrew Bowdle, Aaron Even, Danny D. Shen, and Meghan Swardstrom

Anesth Analg 2004 98: 1692-1697.

高血压大鼠中吗啡引起的镇痛,低血压及心动过缓的作用增强

周洁 译 王祥瑞 校

Morphine-Induced Analgesia, Hypotension, and Bradycardia Are Enhanced in Hypertensive Rats

Tania B. Mahinda, Blaise M. Lovell, and Bradley K. Taylor

Anesth Analg 2004 98: 1698-1704

氟烷及其他挥发性全麻药引起黑腹果蝇视网膜电流图的特殊变化

慧译 李士通校

A Specific Alteration in the Electroretinogram of Drosophila melanogaster Is Induced by Halothane and Other Volatile General Anesthetics

Shantadurga Rajaram and Howard A. Nash

Anesth Analg 2004 98: 1705-1711.

胰岛素降低大鼠异氟醚最低肺泡有效浓度与异氟醚的脊髓效应无关

张俊峰译 薛张纲校

Insulin Decreases Isoflurane Minimum Alveolar Anesthetic Concentration in Rats Independently of an Effect on the Spinal Cord

Yilei Xing, Jim Sonner, Michael J. Laster, Wella Abaigar, Valerie B. Caraiscos, Beverley Orser, and Edmond I Eger, II

Anesth Analg 2004 98: 1712-1717.

异氟醚可减少脊髓背角神经元内谷氨酸传递:镇痛作用在突触前起效的证据

朱辉 译 王祥瑞 校

Isoflurane Reduces Glutamatergic Transmission in Neurons in the Spinal Cord Superficial Dorsal Horn: Evidence for a Presynaptic Site of an Analgesic Action
Rainer Haseneder, Jörge Kurz, Hans-Ulrich U. Dodt, Eberhard Kochs, Walter Zieglgänsberger, Michaela Scheller, Gerhard Rammes, and Gerhard Hapfelmeier

Anesth Analg 2004 98: 1718-1723.

丙泊酚对脂多糖处理的单个核细胞和淋巴细胞的细胞毒性及凋亡的影响

    李士通

The Effect of Propofol on Cytotoxicity and Apoptosis of Lipopolysaccharide-Treated Mononuclear Cells and Lymphocytes

Ho-Kyung Song and Dae Chul Jeong

Anesth Analg 2004 98: 1724-1728.

TECHNOLOGY, COMPUTING, AND SIMULATION:

用肌音描计法可同时监测喉部内收肌和外展肌的神经肌肉阻滞

张俊峰 薛张纲

Simultaneous Determination of Neuromuscular Blockade at the Adducting and Abducting Laryngeal Muscles Using Phonomyography

Thomas M. Hemmerling, Guillaume Michaud, Guillaume Trager, and François Donati

Anesth Analg 2004 98: 1729-1733.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

多伤亡的恐怖事件: 麻醉医师的展望

王柯 薛张纲

Multiple Casualty Terror Events: The Anesthesiologist’s Perspective

Micha Y. Shamir, Yoram G. Weiss, Dafna Willner, Yoav Mintz, Allan I. Bloom, Yuval Weiss, Charles L. Sprung, and Charles Weissman

Anesth Analg 2004 98: 1746-1752.

用先进的模拟实验评价骨内血管途径救助化学战争中伤员的应用价值:建议改变治疗方案

忻纪华 译 王祥瑞 校

Intraosseous Vascular Access in the Treatment of Chemical Warfare Casualties Assessed by Advanced Simulation: Proposed Alteration of Treatment Protocol
Amir Vardi, Haim Berkenstadt, Inbal Levin, Ariel Bentencur, and Amitai Ziv

Anesth Analg 2004 98: 1753-1758.

肝外伤后未控制的失血性休克治疗:液体复苏产生致命效果和使用血管加压素后改善转归

周志坚   李士通

Treatment of Uncontrolled Hemorrhagic Shock After Liver Trauma: Fatal Effects of Fluid Resuscitation Versus Improved Outcome After Vasopressin
Claus Raedler, Wolfgang G. Voelckel, Volker Wenzel, Anette C. Krismer, Christian A. Schmittinger, Holger Herff, Viktoria D. Mayr, Karl H. Stadlbauer, Karl H. Lindner, and Alfred Königsrainer

Anesth Analg 2004 98: 1759-1766.

血小板活化因子受体拮抗剂能抑制细菌毒素和细菌引起的人全血细胞因子的释放

苏殿三 译 王祥瑞 校

A Platelet Activating Factor Receptor Antagonist Inhibits Cytokine Production in Human Whole Blood by Bacterial Toxins and Live Bacteria

Masanori Ogata, Koichiroh Nandate, Takashi Kawasaki, Chika Kawasaki, Masayuki Ozaki, and Akio Shigematsu

Anesth Analg 2004 98: 1767-1772.

OBSTETRIC ANESTHESIA:

鞘内注射罗哌卡因所产生的相关肌肉阻滞:浓度的影响

张俊杰   李士通

The Relative Motor Blocking Potencies of Intrathecal Ropivacaine: Effects of Concentration

Michela Camorcia, Giorgio Capogna, Gordon Lyons, and Malachy O. Columb

Anesth Analg 2004 98: 1779-1782.

REGIONAL ANESTHESIA:

前路坐骨神经阻滞:适合病人身高

王柯 薛张纲

Anterior Approach to the Sciatic Nerve Block: Adaptation to the Patient’s Height

Carole Barbero, Régis Fuzier, and Kamran Samii

Anesth Analg 2004 98: 1785-1788.

.5%1%2-氯普鲁卡因静脉区域麻醉前瞻性、随机、双盲试验的比较

齐波 译 王祥瑞 校

0.5% Versus 1.0% 2-Chloroprocaine for Intravenous Regional Anesthesia: A Prospective, Randomized, Double-Blind Trial

Stephan C. Marsch, Mathias Sluga, Wolfgang Studer, Jonas Barandun, Domenic Scharplatz, and Wolfgang Ummenhofer

Anesth Analg 2004 98: 1789-1793.

GENERAL ARTICLES:

髋部骨折病人术后短暂谵妄可影响术后功能状态三个月

苏殿三 译 王祥瑞 校

Brief Postoperative Delirium in Hip Fracture Patients Affects Functional Outcome at Three Months

Khwaja Zakriya, Frederick E. Sieber, Colleen Christmas, James F. Wenz, Sr., and Shawn Franckowiak

Anesth Analg 2004 98: 1798-1802

 

有无N2O情况下喉管气囊内压力和时间的相关性

王柯 薛张纲

Time-Related Cuff Pressures of the Laryngeal Tube With and Without the Use of Nitrous Oxide

Takashi Asai and Koh Shingu

Anesth Analg 2004 98: 1803-1806.

咪达唑仑的椎管内应用I:一项调查安全性的队列研究

Intrathecal Midazolam I: A Cohort Study Investigating Safety

Adam P. Tucker, MB, ChB, FANZCA, PhD, Cindy Lai, MB, BS, FANZCA, Raymond Nadeson, PhD, and Colin S. Goodchild, MA, MB, BChir, PhD, FANZCA, FFPMANZCA

Department of Anaesthesia, Monash Medical Centre, and Department of Anaesthesia, Monash University, Victoria, Australia

Anesth Analg 2004;98:1512-1520

 

尽管动物研究中关于咪达唑仑椎管内应用的安全性的证据仍存在争议,其临床应用正在增加。我们调查了椎管内应用咪达唑仑产生神经损伤相关症状的可能性。本研究比较两组病人,分别接受或不接受椎管内应用咪达唑仑(2mg)。与代表潜在神经系统并发症症状相关的18项危险因素被评估。对这些症状的定义被放宽直至尽可能地统计到椎管内注射后有神经系统后遗症的病人。通过术后1周的病史复习和术后1月的邮寄问卷,对1100例病人进行了回顾性随访。包括运动或感觉改变以及膀胱或肠功能障碍等提示有神经系统损伤的症状都被调查。椎管内应用咪达唑仑和出现神经症状的危险性增加无关。相反,神经症状被发现在年龄>70岁(相对危险度,8.72)和发生椎管内穿刺时有出血(相对危险度,8.07)时有增加。与一些临床前的动物实验结果不同,椎管内应用咪达唑仑2mg 并不增加神经系统或泌尿系统症状。

(黄施伟   李士通 校)

Despite conflicting evidence regarding the safety of intrathecal midazolam from animal investigations, its clinical use is increasing. We investigated the potential of intrathecal midazolam to produce symptomatology suggestive of neurological damage. This study compared two cohorts of patients who received intrathecal anesthesia with or without intrathecal midazolam (2 mg). Eighteen risk factors were evaluated with respect to symptoms representing potential neurological complications. The definitions of these symptoms were made wide to maximize the chance of counting patients with neurological sequelae after intrathecal injections. Eleven-hundred patients were followed up prospectively during the first postoperative week by a hospital chart review and 1 mo later by a mailed questionnaire. Symptoms suggestive of neurological impairment, including motor or sensory changes and bladder or bowel dysfunction, were investigated. Intrathecal midazolam was not associated with an increased risk of neurologic symptoms. In contrast, neurologic symptoms were found to be increased by age >70 yr (relative risk, 8.72) and the occurrence of a blood-stained spinal tap (relative risk, 8.07). The administration of intrathecal midazolam, 2 mg, did not increase the occurrence of neurologic or urologic symptoms, as suggested by some preclinical animal experimentation.

 

 

人鞘内咪哒唑仑应用的研究过程

The Use of Intrathecal Midazolam in Humans: A Case Study of Process

Tony L. Yaksh, PhD, and Jeffrey W. Allen, PhD

Department of Anesthesiology, University of California, San Diego, La Jolla, California

Anesth Analg 2004;98:1536-1545

 

早期临床前试验显示苯二氮卓类药物在脊髓水平可能调节疼痛信号传递。我们对这种临床前试验及近来逐渐在人类应用鞘内咪哒唑仑行疼痛处理的工作进行了回顾。鞘内咪哒唑仑在人类应用的主要考虑是安全性问题,一些临床前试验报道增加了我们对鞘内咪哒唑仑毒性的认识。我们着重探询这些研究的时间过程,以及如何整合以能提供可信的数据来推动临床的应用。就咪哒唑仑而言,我们主要集中于当临床前试验中安全性资料被不合理地忽视时可能产生的问题和如何考虑通过显示合理的安全特性,即对病人具有最小程度可能危害,来促进药物的发展。此外也考虑了对鞘内应用咪哒唑仑的相关问题包括用药方案及药物动力学。

(王立中   李士通 校)

Early preclinical work demonstrated the potential role of spinal benzodiazepine pharmacology in regulating spinal nociceptive transmission. We review this preclinical activity and the evolving implementation of intrathecal midazolam in humans for pain management. Important elements in this development for use in humans are issues pertinent to safety and the preclinical reports that have increased our understanding of intrathecal midazolam toxicity. We seek to emphasize the time course of these studies and how they merged to provide enabling data that drove the clinical implementation. In the case of midazolam, we point to the potential issues that arose when preclinical safety data were unreasonably ignored and how consideration of preclinical safety data can serve to facilitate drug development by demonstrating reasonable safety profiles that document the minimal degree of potential risk to the patient. Issues that are of continuing relevance to the use of intrathecal midazolam,  including issues of formulation and kinetics, are considered.

 

 

己酮可可碱和丙戊茶碱局部用药对福尔马林诱发痛和大鼠爪炎性组织肿瘤坏死因子αmRNA水平的影响

The Effects of Local Pentoxifylline and Propentofylline Treatment on Formalin-Induced Pain and Tumor Necrosis Factor-{alpha} Messenger RNA Levels in the Inflamed Tissue of the Rat Paw

Magdalena Dorazil-Dudzik, PhD*, Joanna Mika, PhD{dagger},{ddagger}, Martin K.- H. Schafer, MD{ddagger}, Yanzhang Li, MSc{ddagger}, Ilona Obara, MSc{dagger}, Jerzy Wordliczek, PhD*, and Barbara Przewlocka, PhD{dagger}

*Department of Anaesthesiology and Intensive Care, Jagiellonian University, Kraków, Poland; {dagger}Department of Molecular Neuropharmacology, Institute of Pharmacology, Polish Academy of Sciences, Kraków, Poland; and {ddagger}Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany

Anesth Analg 2004;98:1566-157

 

本研究旨在了解局部使用黄嘌呤衍生物己酮可可碱(pentoxifylline PTF) 或丙戊茶碱(propentofylline PPTF) 抑制细胞因子合成,能否影响大鼠痛阈、福尔马林诱发痛的表现和鼠爪炎性组织肿瘤坏死因子α(TNF-{alpha})信使RNA(mRNA)的水平。PTF (0.5, 1, or 2 mg) PPTF (1 or 2 mg) 足底注射对痛阈无明显影响。左后肢足背皮下注射12%福尔马林0.1 mL可诱发疼痛表现(每5分钟47.6 ± 4.6次),预先足底注射PTF 1 2 mg 100 µL减少福尔马林诱发痛的表现(1 mg 为每5分钟33.6 ± 2.5 次, 2 mg 23.6 ± 3.4),而事后注射无效。注射PPTF 2 mg 100 µL有类似抗痛作用;与PTF不同的是,实验晚期,即福尔马林注射后85–90 分钟,PPTF的作用与注射时机无关,即预先注射和事后注射的效果一样。PTF对福尔马林诱发痛的影响与体积描记仪测出的鼠爪体积的变化不平行;事实上,PTF本身显著增加鼠爪的体积。注射福尔马林明显提高鼠爪炎性组织TNF-{alpha} mRNA的水平(150%)。预先注射PTF明显抑制(40%)TNF-{alpha} mRNA的水平的增高。本实验证明:预先使用PTF PPTF抑制磷酸二酯酶和胶质细胞激活,能抑制前炎性细胞因子的合成,从而拮抗福尔马林诱发痛的痛觉过敏现象;而且PTF局部注射是治疗炎性疼痛的有效方法。

(轩   李士通 校)

We sought to determine whether local administration of pentoxifylline (PTF) or propentofylline (PPTF), which hinders cytokine production, influences pain threshold and formalin-induced pain behavior in rats or the level of tumor necrosis factor-{alpha} (TNF-{alpha}) messenger RNA (mRNA) concentrations in the inflamed paw tissue. PTF (0.5, 1, or 2 mg) and PPTF (1 or 2 mg) injected intraplantarly (i.pl.) had no significant effect on pain threshold. Injection of 0.1 mL of a 12% formalin solution subcutaneously into the dorsal surface of the left hindpaw induced pain behavior (47.6 ± 4.6 incidents per 5 min), and PTF injected at doses of 1 and 2 mg/100 µL i.pl. before (but not after) formalin was effective in antagonizing (33.6 ± 2.5 and 23.6 ± 3.4 incidents per 5 min, respectively) formalin-induced pain behavior. A similar antagonistic effect was observed after PPTF treatment at a dose of 2 mg/100 µL; however, in contrast to PTF, at a later time point (85–90 min) after the formalin challenge, this effect was independent of the scheme of PPTF administration, before or after formalin. The effect of PTF on formalin-induced pain behavior did not parallel paw volume as measured by plethysmometer; however, PTF per se significantly increased the paw volume. Formalin injection significantly increased the TNF-{alpha} mRNA level in the inflamed tissue of the rat hind paw (150%). PTF administered before, but not after, formalin significantly antagonized (by approximately 40%) the observed increase in the level of TNF-{alpha} mRNA. Our study demonstrates and provides biochemical evidence that preemptive inhibition of proinflammatory cytokine synthesis by the use of PTF and PPTF, phosphodiesterase, and glial activation inhibitors is useful in antagonizing hyperalgesia in formalin-induced pain. Moreover, local administration of PTF may be a valuable approach to the treatment of inflammatory pain.

 

评估消旋氯胺酮在心内直视手术中的神经保护作用

Evaluation of the Neuroprotective Effects of S(+)-Ketamine During Open-Heart Surgery

W. Nagels, MD*, R. Demeyere, MD, PhD*, J. Van Hemelrijck, MD, PhD*, E. Vandenbussche, MD, PhD{dagger}, K. Gijbels, MD, PhD{ddagger}, and E. Vandermeersch, MD, PhD*

Departments of *Anesthesiology, {dagger}Neuropsychology, and {ddagger}Laboratory Medicine, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Belgium

Anesth Analg 2004;98:1595-1603

我们在106例行心脏外科手术的病人中对比了应用消旋氯胺酮和雷米芬太尼两者与异丙酚复合对神经认知功能的作用。对病人在术前和术后1周和10周进行神经认知功能测试。术后10周在对照组中有14例(25%)病人和消旋氯胺酮组有10例(20%P = 0.54)病人有2项和2项以上测试出现认知障碍(较术前降低至少一个所有病人测试的标准差)。所有测试均计算Z-评分。除了术后10周的“B”示踪试验(Trailmaking B test),消旋氯胺酮未表现明显的优势。因此我们认为与雷米芬太尼相较,在心脏直视术中氯胺酮没有明显的神经保护功能。

(赵雪莲   李士通校)

We compared the effect of S(+)-ketamine to remifentanil, both in combination with propofol, on the neurocognitive outcome after open-heart surgery in 106 patients. A battery of neurocognitive tests was administered before surgery and 1 and 10 wk after surgery. Fourteen patients (25%) in the control group and 10 patients (20%) in the S(+)-ketamine group had 2 or more tests with a cognitive deficit (decline by at least one preoperative SD of that test in all patients) 10 wk after surgery (P = 0.54). Z-scores were calculated for all tests. No significantly better performance could be detected in the S(+)-ketamine group, except for the Trailmaking B test 10 wk after surgery. We conclude that S(+)-ketamine offers no greater neuroprotection compared with remifentanil during open-heart surgery.

                    

 

米力农对儿茶酚胺预收缩的肺小动脉的扩张作用增强

Enhanced Vasodilatory Responses to Milrinone in Catecholamine-Precontracted Small Pulmonary Arteries

Rajiv Jhaveri, MD, Soonyul Kim, A. Ron White, PhD, Sean Burke, BS, Dan E. Berkowitz, MD, and Daniel Nyhan, MD

Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland

Anesth Analg 2004;98:1724-1728

 

在围手术期经常联合应用b-肾上腺素能激动剂(如肾上腺素和去甲肾上腺素)和磷酸二酯酶-III抑制剂(如米力农)以增强心室功能。在心肌,米力农与b-肾上腺素能激动剂产生协同作用增强心肌收缩力。但是,同时具有ab肾上腺素能活性的儿茶酚胺类药物与米力农之间对肺循环的潜在相互作用还不确定。我们评价了米力农和硝酸甘油对分别经过具有ab肾上腺素能活性的儿茶酚胺(肾上腺素和去甲肾上腺素)、a受体激动剂苯肾上腺素、非肾上腺素能激动剂-血栓素类似物U46619预收缩的猪肺弹性大血管和含肌肉小血管环的舒张作用。在肺小动脉,米力农对肾上腺素或者去甲肾上腺素预收缩的血管环的舒张作用比使用苯肾上腺素或者U46619预收缩的血管环的舒张作用明显增强。然而,在大的肺动脉,米力农对所有血管环的扩张作用均相似,不受预收缩药物的影响。与此明显不同的是,不管是大的肺血管还是小血管环对硝酸甘油的血管扩张反应均不受预收缩药物的影响。所以,当联合使用具有b肾上腺素能激动活性的药物时,米力农对肺血管的作用增强。磷酸二酯酶-III抑制剂和儿茶酚胺(肾上腺素和去甲肾上腺素)的扩血管相互作用表明当心室功能障碍合并肺血管阻力增加时联合使用这两种药物是有利的。

(颜    李士通 校)

ß-Adrenergic agonists (e.g., epinephrine [E] and norepinephrine [NE]) and phosphodiesterase-III inhibitors (e.g., milrinone) are often used in combination to augment ventricular function in the perioperative period. In the myocardium, milrinone acts synergistically with ß-adrenergic agonists to increase contractility. However, the potential interaction between catecholamines with combined {alpha}- and ß-adrenergic activity and milrinone in the pulmonary circulation has not been determined. We evaluated the vasodilatory effects of milrinone and nitroglycerine on large elastic and small muscular porcine pulmonary vascular rings precontracted with catecholamines with ß-adrenergic agonist activity (E and NE), the {alpha}-adrenergic agonist phenylephrine, and a nonadrenergic agonist, the thromboxane analog U46619. In small pulmonary arteries, the vasorelaxation with milrinone was significantly enhanced in rings precontracted with E or NE compared with those precontracted with phenylephrine or U46619. However, in large pulmonary arteries, the vasorelaxation with milrinone was similar in all vessel rings and was not influenced by the agonist used to induce precontraction. In marked contrast, the vasorelaxant responses to nitroglycerine were not altered by the specific agonist used for precontraction in either small or large pulmonary vascular rings. Thus, the pulmonary vascular effects of milrinone are enhanced when combined with drugs with ß-adrenoreceptor agonist activity. The vasodilatory interactions exhibited by phosphodiesterase-III inhibitors and the catecholamines NE and E suggest that their combined use might be beneficial in circumstances in which ventricular dysfunction and increased pulmonary vascular resistance occur.

 

 

在妇产科门诊腹腔镜检查中用口服长效晕海宁预防术后恶心和呕吐

Prophylaxis of Postoperative Nausea and Vomiting with Oral, Long-Acting Dimenhydrinate in Gynecologic Outpatient Laparoscopy

Kim E. Turner, MD*, Joel L. Parlow, MD*, Nicole D. Avery, MSc*, Deborah A. Tod, RN*, and Andrew G. Day, MSc{dagger}

*Department of Anesthesiology and {dagger}Clinical Research Unit, Queen’s University, Kingston, Ontario, Canada

Anesth Analg 2004;98:1660-1664

 

晕海宁是一个便宜的止吐药,副作用极少,现有含25 mg即刻释放药物及50 mg缓释药物的口服长效(LA)制剂(Gravol L/A)。我们设计了这个双盲比较试验来评价门诊妇产科腹腔镜检查中晕海宁LA对比氟哌利多单用及二者合用预防恶心、呕吐和干呕的功效。141例女性随机分成3组:1) 氟哌利多(术前安慰剂胶囊,诱导前氟哌利多0.625 mg IV);2) 术前晕海宁LA,诱导前安慰剂IV3) 合用。在麻醉后恢复室(PACU)记录关于恶心、呕吐、干呕、疼痛和镇静的信息,并通过电话收集病人刚到家、睡觉前、术后第一天起床和午餐时症状的发生。氟哌利多组、晕海宁组和合用组各症状治疗失败(在PACU中解救药物治疗或在任何时点恶心、呕吐或作呕)的总发生率分别为28/4661%)、28/4858%)和22/4747%),呕吐治疗失败(在PACU中解救药物治疗或在任何时点呕吐或干呕)的总发生率分别为16/4635%)、11/4823%)和5/4711%)(氟哌利多组对比合用组P0.007)。在镇静和疼痛方面无差异。术前给予一个口服剂量的LA晕海宁和氟哌利多合用与单用氟哌利多比较,有效降低择期门诊妇产科腹腔镜检查的女性呕吐(而非恶心)的发生率。

(马皓琳    李士通 校)

Dimenhydrinate is an inexpensive antiemetic with few side effects available as an oral, long-acting (LA) formulation (Gravol L/A) containing 25 mg of immediate and 50 mg of sustained release drug. We designed this double-blind comparison trial to assess the efficacy of dimenhydrinate LA versus droperidol alone and the combination for prophylaxis of nausea, vomiting, and retching in outpatient gynecologic laparoscopy. One-hundred-forty-one women were randomized into 3 groups: 1) droperidol (placebo capsule preoperatively and IV droperidol 0.625 mg before induction), 2) dimenhydrinate LA preoperatively and IV placebo before induction, or 3) combination. Information regarding nausea, vomiting, retching, pain, and sedation was recorded in the postanesthesia care unit (PACU) and collected by telephone for the presence of symptoms: on arrival home; at bedtime; upon arising, and at lunchtime the following day. The overall incidence of complete treatment failure (rescue medication in PACU or nausea, vomiting, or retching at any time point) was 28 of 46 (61%), 28 of 48 (58%), and 22 of 47 (47%); and for treatment failure vomiting (rescue medication in PACU or vomiting or retching at any time point) was 16 of 46 (35%), 11 of 48 (23%), and 5 of 47 (11%), for the droperidol, dimenhydrinate, and combination groups, respectively (P = 0.007 for droperidol versus combination). There were no differences in sedation or pain. Preoperative administration of an oral dose of LA dimenhydrinate in combination with droperidol when compared with droperidol alone effectively reduced the incidence of vomiting but not nausea in women undergoing elective outpatient gynecologic laparoscopy.

 

琥珀胆碱和电休克治疗后的肌肉损伤

Muscular Injury After Succinylcholine and Electroconvulsive Therapy

Thewarug Werawatganon, MD, Oranuch Kyokong, MD, MSc, Somrat Charuluxananan, MD, MSc, and Sahadol Punyatavorn, MD

From the Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Anesth Analg 2004;98:1676-1679
 

在电休克治疗中,琥珀胆碱和抽搐都能引起肌肉损伤。我们比较了两组别人的肌肉损害。精神病人组在电休克治疗前使用琥珀胆碱。外科病人组使用琥珀胆碱行气管插管。测定血清肌红蛋白作为肌肉损伤的指标,同时记录肌痛症状。两组在用药后5分钟和20分钟时的血清肌红蛋白值都比基础值增加。但是给予琥珀胆碱后5分钟和20分钟,外科病人组比精神病人组的肌红蛋白水平更高(P < 0.001)20分钟时精神病人组的肌红蛋白浓度的中位数(范围)是32.6 (23.1–60.1) ng/mL,外科病人组为61.2 (31.6–1687.0) ng/mL。肌痛的发生率两组没有差异。结论,我们意外地发现,由琥珀胆碱引起的肌肉损伤,在接受电休克治疗的精神病人比外科病人轻。

(张   李士通校)

 

Both succinylcholine and seizures cause muscular injury during electroconvulsive therapy. We compared the muscular damage in two groups of patients. The psychiatric patient group received succinylcholine for electroconvulsive therapy. The surgical patient group received succinylcholine for endotracheal intubation. Serum myoglobin was measured as a marker for muscular injury and myalgic symptoms were also recorded. Serum myoglobin increased from baseline in both groups at 5 and 20 min. The surgical patients, however, had a higher myoglobin level than the psychiatric patients at 5 and 20 min after the administration of succinylcholine (P < 0.001). The median (range) of myoglobin concentration at 20 min in psychiatric patients was 32.6 (23.1–60.1) ng/mL, compared with 61.2 (31.6–1687.0) ng/mL in surgical patients. The incidence of myalgia was not different between the two groups. In conclusion, we unexpectedly conclude that the psychiatric patients who received electroconvulsive therapy had less effect of muscular damage associated with succinylcholine than the surgical patients did.

 

美沙酮用于麻醉诱导:血浆组胺浓度,动脉血压和心率

Methadone for the Induction of Anesthesia: Plasma Histamine Concentration, Arterial Blood Pressure, and Heart Rate

T. Andrew Bowdle, MD, PhD*,{dagger}, Aaron Even, MD*, Danny D. Shen, PhD{dagger},{ddagger}, and Meghan Swardstrom, BS*

Departments of *Anesthesiology, {dagger}Pharmaceutics, and {ddagger}Pharmacy, University of Washington, Seattle, Washington

Anesth Analg 2004;98:1692-1697

 

尽管美沙酮广泛用于缓解急慢性疼痛,还没有人研究过静脉单次给予美沙酮对血流动力学的效应。我们比较麻醉诱导采用依托咪酯0.3mg/kg复合静脉给予单次剂量美沙酮20mg或芬太尼10ug/kg对血流动力学的效应。接受大手术的43名患者按双盲随机原则分为2组。给予美沙酮或芬太尼前和给药后2分钟测定血浆组胺浓度。通过有创动脉压监测在给予美沙酮或芬太尼前、依托咪酯前、气管插管之前、气管插管时和气管插管后1分钟分别测定血压和心率。美沙酮组和芬太尼组在任何时点其平均心率无显著差异。芬太尼组在插管前、插管时和插管后1分钟的收缩压和舒张压明显降低,且差异具有统计学意义(P < 0.05)。在给予美沙酮前后,血浆组胺浓度均值分别为1.54 ng/mL (SD, 0.65 ng/mL)1.57 ng/mL (SD, 1.37 ng/mL);给予芬太尼前后,血浆组胺浓度均值分别为1.00 ng/mL (SD, 0.58 ng/mL) 1.04 ng/mL (SD, 0.47 ng/mL)。尽管两组血浆组胺浓度均值无显著差异,但是美沙酮组的23名患者中有2名患者血浆组胺浓度明显升高。但当血浆组胺浓度高达6.2 ng/mL时,未发现与之有关的明显的血流动力学改变。美沙酮可能引起组胺释放。尽管在此次试验中,美沙酮并没有造成血流动力学不稳,但是当静脉给予单次大剂量美沙酮时应该考虑到有可能因为组胺释放而产生血流动力学方面的副作用。

(周雅春    李士通 校)

 

Despite the widespread use of methadone for the treatment of acute and chronic pain, the hemodynamic effects of methadone administered by IV bolus have not been studied. We compared the hemodynamic effects of an IV bolus of methadone 20 mg with those of fentanyl 10 µg/kg for the induction of anesthesia in combination with etomidate 0.3 mg/kg. Forty-three patients undergoing major surgery were randomized to one of the two treatments in a double-blinded fashion. Plasma concentrations of histamine were measured before and 2 min after opioid administration. Heart rate and arterial blood pressure were measured via an arterial line just before opioid administration, etomidate administration, and tracheal intubation; during intubation; and 1 min after intubation. There were no significant differences in mean heart rate between the methadone and fentanyl groups at any time point. Systolic and diastolic blood pressures were significantly lower (P < 0.05) in the fentanyl group just before intubation, during intubation, and 1 min after intubation. Mean plasma concentrations of histamine before and after the administration of methadone or fentanyl were 1.54 ng/mL (SD, 0.65 ng/mL) and 1.57 ng/mL (SD, 1.37 ng/mL) or 1.00 ng/mL (SD, 0.58 ng/mL) and 1.04 ng/mL (SD, 0.47 ng/mL), respectively. Despite the lack of a significant change in mean plasma concentrations of histamine, substantial increases in plasma histamine occurred in 2 of 23 patients who received methadone. There were no obvious hemodynamic effects associated with histamine concentrations up to 6.2 ng/mL. Methadone appears to have the potential for producing histamine release. Although methadone administration did not produce hemodynamic instability in this study, the possible hemodynamic side effects of histamine release should be considered when IV boluses of methadone are given.

 

氟烷及其他挥发性全麻药引起黑腹果蝇视网膜电流图的特殊变化

A Specific Alteration in the Electroretinogram of Drosophila melanogaster Is Induced by Halothane and Other Volatile General Anesthetics

Shantadurga Rajaram, PhD, and Howard A. Nash, MD, PhD

Laboratory of Molecular Biology, National Institute of Mental Health, Bethesda, Maryland

Anesth Analg 2004;98:1705-1711
 

对较高级生物的生理研究为研究麻醉药物对整体生物行为的影响提供了颇有价值的补充。然而,尽管对黑腹果蝇的运动功能进行的大量研究用来识别与麻醉有关的基因,但是对这种无脊椎动物麻醉作用的电生理研究仍非常有限。我们发现视网膜电流图(ERG)这种从眼球表面细胞外记录的由光触发总体电位,在氟烷、安氟醚、异氟醚以及地氟醚麻醉时有明显的影响。这些挥发性麻醉药在作用相关浓度时,明显抑制ERG光关闭时的瞬时成分,而ERG的其他主要成分,如光感受器电位和灯亮瞬间电流并不总是受这些药物的影响。令人惊讶的是,对大多数麻醉药物来说, ERG光关闭瞬时电流的抑制仅在短光脉冲时可见。不使用麻醉药物而是抑制Shaker钾离子通道的功能也能达到同样的效果。通过一个简单的基因试验验证了氟烷通过关闭钾离子通道作用于视觉环路的可能性,结果与假设基本一致,但缺乏确切的证据支持。不过,我们的研究确定ERG作为一种有用的工具,不但可用于检验挥发性麻醉药物对一个简单环路的影响,而且可识别对麻醉药物敏感度起作用的基因。

(朱 慧译 李士通校)

In higher organisms, physiological investigations have provided a valuable complement to assays of anesthetic effects on whole-animal behavior. However, although complex motor programs of Drosophila melanogaster have been used to identify genes that influence anesthesia, electrophysiological studies of anesthetic effects in this invertebrate have been limited. Here we show that the electroretinogram (ERG), the extracellular recording of light-evoked mass potentials from the surface of the eye, reveals a distinct effect of halothane, enflurane, isoflurane, and desflurane. Behaviorally relevant concentrations of these volatile anesthetics severely reduced the transient component of the ERG at lights-off. Other prominent ERG components, such as the photoreceptor potential and the lights-on transient, were not consistently affected by these drugs. Surprisingly, for most anesthetics, a diminished off-transient was obtained only with short light pulses. An identical effect was observed in the absence of anesthetic by depressing the function of Shaker potassium channels. The possibility that halothane acts in the visual circuit by closing potassium channels was examined with a simple genetic test; the results were consistent with the hypothesis but fell short of providing definitive support. Nevertheless, our studies establish the ERG as a useful tool both for examining the influence of volatile anesthetics on a simple circuit and for identifying genes that contribute to anesthetic sensitivity

 

丙泊酚对脂多糖处理的单个核细胞和淋巴细胞的细胞毒性及凋亡的影响

The Effect of Propofol on Cytotoxicity and Apoptosis of Lipopolysaccharide-Treated Mononuclear Cells and Lymphocytes

Ho-Kyung Song, MD*, and Dae Chul Jeong, MD{dagger}

Department of *Anesthesiology and {dagger}Pediatrics, Our Lady of Mercy Hospital, College of Medicine, The Catholic University of Korea, Inchon, South Korea

Anesth Analg 2004;98:1724-1728

静脉麻醉药可能抑制适当的免疫反应和进一步损害已降低的抵御系统。为评定丙泊酚在脓毒血症时对人类免疫功能的可能作用,我们研究了单个核细胞(MNCs)的细胞毒性和凋亡。外周血单个核细胞在1µg/mL脂多糖中预孵育,然后在不同浓度的丙泊酚(1 µg/mL, 5 µg/mL, 10 µg/mL,50 µg/mL)中再次孵育。将单个核细胞(4 x 105/100 µL)和作为靶细胞的K-562肿瘤细胞 (1 x 104/100 µL) (E: T 比率 40:1)混合,通过检测乳酸脱氢酶释放来确定细胞毒性。用流式细胞仪测annexin阳性细胞来确定凋亡。脂多糖处理的单个核细胞的细胞毒性和凋亡在临床可接受的丙泊酚浓度(1 µg/mL, 5 µg/mL, 10 µg/mL)下无改变。然而,50 µg/mL丙泊酚处理组则可以观察到细胞毒性(P = 0.004)和凋亡(P = 0.002)有显著变化。通过对单个核细胞的分选,我们发现50 µg/mL丙泊酚使淋巴细胞凋亡显著增加,但单核细胞未受影响(P = 0.02)。从细胞毒性和凋亡的方面来说,丙泊酚使单个核细胞通过保护免疫细胞不凋亡,使其在脓毒血症时保持细胞毒性。

(吴    李士通 校)

IV anesthetics may inhibit proper immune responses and further compromise an already depressed defense system. To assess the possible role of propofol on human immune function in sepsis, we studied cytotoxicity, and apoptosis of mononuclear cells (MNCs). Peripheral blood MNCs were preincubated in 1 µg/mL of lipopolysaccharide (LPS) and then reincubated in different concentrations of propofol (1 µg/mL, 5 µg/mL, 10 µg/mL, or 50 µg/mL). To determine cytotoxicity, lactate dehydrogenase release was assayed by mixing MNCs (4 x 105/100 µL) with K-562 tumor cells as target cells (1 x 104/100 µL)(E: T ratio of 40:1). Apoptosis was determined by measuring the annexin positive cells using flow cytometry. Cytotoxicity and apoptosis of LPS-treated MNCs were unchanged by clinically acceptable concentrations of propofol (1 µg/mL, 5 µg/mL, and 10 µg/mL). However, significant differences were observed in cytotoxicity (P = 0.004) and apoptosis (P = 0.002) with propofol 50 µg/mL. By gating MNCs, we found that lymphocyte apoptosis was significantly increased at 50 µg/mL of propofol, but monocytes were unaffected (P = 0.02). In terms of cytotoxicity and apoptosis, propofol allowed MNCs to retain their cytotoxicity in septic conditions by protecting immune cells from apoptosis.

 

肝外伤后未控制的失血性休克治疗:液体复苏产生致命效果和使用血管加压素后改善转归

Treatment of Uncontrolled Hemorrhagic Shock After Liver Trauma: Fatal Effects of Fluid Resuscitation Versus Improved Outcome After Vasopressin

Claus Raedler, MD*, Wolfgang G. Voelckel, MD*, Volker Wenzel, MD*, Anette C. Krismer, MD*, Christian A. Schmittinger, DVM*, Holger Herff, BS*, Viktoria D. Mayr, MD*, Karl H. Stadlbauer, MD*, Karl H. Lindner, MD*, and Alfred Königsrainer, MD{dagger}

Departments of *Anesthesiology and Critical Care Medicine and {dagger}Surgery, Leopold-Franzens-University, Innsbruck, Austria

Anesth Analg 2004 98: 1759-1766

 

在一个失控性出血性休克猪的模型中,我们对使用血管加压素、等量安慰剂盐水或液体复苏这三种方法,在血液动力学参数和近期生存效果上进行评估。二十一头麻醉的猪被用于严重肝外伤的研究。当平均动脉压低于20mmHg、心率下降时,随机给予血管加压素(0.4 U/kg; n = 7),等量安慰剂盐水(n = 7)或复苏液体(乳酸林格氏液及羟乙基淀粉hetastarch1000 mL; n = 7)。干预后三十分钟,存活的猪使用手术方法止住出血同时,进行进一步液体复苏。在血管加压素组,干预后五分钟的平均动脉压(± SEM)高于安慰剂组和液体组(三组分别为58±97±3 32±6 mmHg),差异有显著性(P < 0.05)。使用血管加压素能改善腹部器官血流量,但不会导致进一步出血(干预后十分钟血管加压素组、安慰剂组、液体复苏组失血量分别为1343 ± 60ml1350 ± 22ml2536 ± 93 mLP < 0.01)。血管加压素组的全部七头猪都存活至出血被控制,并维持60min。然而七头安慰剂组和七头液体组的猪都死亡(P < 0.01)。故我们得出结论:血管加压素,而不是安慰剂或液体复苏,在失控性失血性休克中可以显著改善短期生存率。

(周志坚   李士通 )

In a porcine model of uncontrolled hemorrhagic shock, we evaluated the effects of vasopressin versus an equal volume of saline placebo versus fluid resuscitation on hemodynamic variables and short-term survival. Twenty-one anesthetized pigs were subjected to severe liver injury. When mean arterial blood pressure was <20 mm Hg and heart rate decreased, pigs randomly received either vasopressin IV (0.4 U/kg; n = 7), an equal volume of saline placebo (n = 7), or fluid resuscitation (1000 mL each of lactated Ringer’s solution and hetastarch; n = 7). Thirty minutes after intervention, surviving pigs were fluid resuscitated while bleeding was surgically controlled. Mean (± SEM) arterial blood pressure 5 min after the intervention was significantly (P < 0.05) higher after vasopressi n than with saline placebo or fluid resuscitation (58 ± 9 versus 7 ± 3 versus 32 ± 6 mm Hg, respectively). Vasopressin improved abdominal organ blood flow but did not cause further blood loss (vasopressin versus saline placebo versus fluid resuscitation 10 min after intervention, 1343 ± 60 versus 1350 ± 22 versus 2536 ± 93 mL, respectively; P < 0.01). Seven of 7 vasopressin pigs survived until bleeding was controlled and 60 min thereafter, whereas 7 of 7 saline placebo and 7 of 7 fluid resuscitation pigs died (P < 0.01). We conclude that vasopressin, but not saline placebo or fluid resuscitation, significantly improves short-term survival during uncontrolled hemorrhagic shock.

 

 

鞘内注射罗哌卡因所产生的相关肌肉阻滞:浓度的影响

The Relative Motor Blocking Potencies of Intrathecal Ropivacaine: Effects of Concentration

 

Michela Camorcia, MD*, Giorgio Capogna, MD*, Gordon Lyons, FRCA{dagger}, and Malachy O. Columb, FRCA{ddagger}

*Department of Obstetric Anesthesia, Città di Roma Hospital, Italy; {dagger}Department of Anaesthesia, St James’ University Hospital, Leeds; {ddagger}Consultant in Anaesthesia and Intensive Care, South Manchester University Hospital, Wythenshawe, United Kingdom

Anesth Analg 2004 98: 1779-1782.

 

我们通过观察鞘内注射1%和0.1%的罗哌卡因时肌肉阻滞的平均ED50值,来判断其不同浓度对肌肉的阻滞作用。本实验为前瞻,随机,双盲和序列分配,对象为54例择期行剖腹产孕妇,麻醉方法为硬膜外联合蛛网膜下腔阻滞。孕妇随机分入鞘内注射1%罗哌卡因组或0.1%罗哌卡因组。首次剂量为4mg,随后剂量根据前一患者的反应来决定(试验剂量差距为1mg)。用药后5分钟内双下肢产生任何肌肉阻滞作用即被认为有效。5分钟内产生肌肉阻滞作用的1%罗哌卡因组剂量为6.1mg95% 可信区间, 5.1–7.1),0.1%罗哌卡因组剂量为9.1mg95% 可信区间, 7.8–10.3(P = 0.0013; 95% 可信区间差异, 1.3–4.7)。高浓度组的效能是低浓度组的1.5(95% 可信区间 1.2–1.9)。妊娠患者蛛网膜下腔使用罗哌卡因肌肉阻滞作用的ED50明显受到药物浓度的影响,在低浓度时所需剂量增加约50%。

(张俊杰   李士通 校)

 

This study established the median effective dose (ED50) for motor block of intrathecal 1% and 0.1% ropivacaine and determined the effects of the concentration of the solution injected on the motor block obtained. We enrolled into this prospective, randomized, double-blind, sequential allocation study 54 parturients undergoing elective Cesarean delivery under combined spinal-epidural technique. Parturients were randomized to receive intrathecal ropivacaine either 1% or 0.1%. The initial dose was chosen to be 4 mg, with subsequent doses being determined by the response of the previous patient (testing interval, 1 mg). The occurrence of any motor block in either lower limb within 5 min from the intrathecal injection of the study solution was considered effective. The motor block at 5 min was 6.1 mg for 1% ropivacaine (95% confidence interval [CI], 5.1–7.1) and was 9.1 mg (95% CI, 7.8–10.3) for 0.1% ropivacaine (P = 0.0013; 95% CI difference, 1.3–4.7). The relative efficacy ratio of the 2 concentrations was 1.5 (95% CI difference, 1.2–1.9) in favor of the larger concentration. The ED50 of spinal ropivacaine to produce motor block in pregnant patients was significantly influenced by the concentration of the local anesthetic, with dose requirements being increased by 50% for the smaller concentration.

 

 


绵羊持续鞘内注射咪达唑仑的安全性

Safety of Continuous Intrathecal Midazolam Infusion in the Sheep Model

Mary J. Johansen, PharmD*, Tamara Lee Gradert, BS{dagger}, William C. Satterfield, DVM{ddagger}, Wallace B. Baze, DVM, PhD{ddagger}, Keith Hildebrand, PhD§, Lawrence Trissel, BS||, and Samuel J. Hassenbusch, MD, PhD{dagger}

Departments of *Experimental Therapeutics, {dagger}Neurosurgery, and {ddagger}Veterinary Sciences and ||Division of Pharmacy, The University of Texas M. D. Anderson Cancer Center, Houston, Texas; and §Medtronic, Inc., Minneapolis, Minnesota

Anesth Analg 2004;98:1528-1535

 
作者研究了动物模型中持续鞘内注射咪达唑仑的安全性。利用自动输注系统(SynchroMed泵加上矽树脂导管)给羊和猪持续鞘内注射无添加剂的咪达唑仑。羊咪达唑仑注射剂量为5mg/d (n=4)15mg/d (n=7)或生理盐水(n=2),125 µL/h43天。另一头羊注入咪达唑仑10mg/d。注射浓度从1.7—2.5mg/ml5mg/d)和2.5—5.0mg/ml15mg/d)。猪组仅注射咪达唑仑15mg/dn=2)或生理盐水(n=1),输注速率125 µL/h,共43天。记录动物行为表现、神经系统功能及生命体征,评估血清和脑脊液的生化及细胞学形态、脊髓的组织学状况。结果:所有受试动物的行为表现和神经系统功能都正常,肉眼和显微镜下均观测到导管周围的组织有轻度炎症反应,炎症可能由于导管自身的机械因素所引起。结论:持续鞘内注入不含添加剂的咪达唑仑(15mg/d以下)是安全的。

(朱慧琛 译 王祥瑞 校)

We investigated the safety of midazolam administered by continuous intrathecal infusion in relevant animal models. Preservative-free midazolam was delivered to sheep and pigs by using implanted infusion systems (SynchroMed® pumps plus silicone catheters). Sheep received midazolam 5 mg/d (n = 4) or 15 mg/d (n = 7) or saline (n = 2) for 43 days at 125 µL/h. One sheep received 10 mg/d. Infusion concentrations ranged from 1.7 to 2.5 mg/mL (5 mg/d) and from 2.5 to 5.0 mg/mL (15 mg/d). Pigs were evaluated for toxicity only and received 15 mg/d (n = 2) or saline (n = 1) for 43 days at 125 µL/h. Behavior, neurologic function, and vital signs were documented. Serum and cerebrospinal fluid chemistry and cytology were evaluated, and histology was performed on spinal cord tissue. Behavior and neurologic function remained normal in all subjects. Gross and microscopic evaluation of spinal tissue revealed mild inflammation surrounding the catheter tract in both the midazolam-treated and the saline-treated groups. This inflammation was likely attributable to the mechanical presence of the catheter. These data demonstrate that continuous intrathecal infusion of preservative-free midazolam at doses up to 15 mg/d were well tolerated.


一种简单、快速、方便的验证疼痛治疗研究方法:单独应用计算机检索方案可验证随机对照实验的质量

A Simple, Fast, Easy Method to Identify the Evidence Base in Pain-Relief Research: Validation of a Computer Search Strategy Used Alone to Identify Quality Randomized Controlled Trials

Tony K. F. Chow, FANZCA*, Elean To, MB, BS{dagger}, Colin S. Goodchild, PhD*, and John J. McNeil, PhD{ddagger}

*Department of Anaesthesia, Monash University, Monash Medical Centre, Clayton, Victoria, Australia; {dagger}Templestowe District Medical Centre, Templestowe, Victoria, Australia; and {ddagger}Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Prahran, Victoria, Australia

Anesth Analg 2004;98:1557-1565


临床医生需要一个简单、快速、可靠、价廉的方法以验证其基于临床实践中的观察结果。通常认为唯一的方法就是人工查阅一些文献辅助计算机检索,但这很繁复且劳动强度大。疼痛医学研究中大多数随机对照试验均在计算机数据库中。作者设计了两组实验方案以确定其有效性即敏感性、特异性及精确性,后者通过三种计算机方案检索。即Cochrane 协作, 随机临床试验标准联机医学文献分析与检索系统随机双盲临床试验(DBRCT.af)是一种新的独立计算机系统,假设要检索双盲、随机实验可以双盲”“随机在任何一个MEDLINE医学文摘资料库EMBASE)中查找。DBRCT.af在检索镇痛研究的随机实验中有很高的敏感性(97%)、精确性82%,在去除非随机实验时的特异性为98%。结论:临床医师在镇痛研究时可运用DBRCT.af获取最新资料。

(朱慧琛 译 王祥瑞 校)

Clinicians need a simple, fast, reliable, and inexpensive way of identifying the evidence base relevant to their clinical practice. It is often believed that the only way to identify all relevant evidence is to perform hand-searches of the literature to supplement computer searches; this is complex and labor intensive. However, most of quality randomized controlled trials cited in systematic reviews in pain medicine are listed in computer databases. We performed two studies to investigate the efficiency—in terms of sensitivity, specificity, and precision—of three computer search strategies: Optimally Sensitive Search Strategy, which is used by the Cochrane Collaboration; RCT.pt, a standard MEDLINE strategy; and DBRCT.af, which is a new single-line computer algorithm based on the assumption that double-blinded, randomized controlled trials would be indexed with "double-blind," "random," or variations of these terms in MEDLINE and EMBASE. DBRCT.af was found to be highly sensitive (97%) in identifying quality randomized controlled trials in pain medicine. The precision (ratio of randomized controlled trials to the number of nonrandomized trials identified) was 82%, and the specificity in excluding the nonrandomized controlled trials was 98%. We conclude that clinicians can now use DBRCT.af to update and conduct de novo systematic reviews in pain-relief research.



涂肝素的体外循环管道对肺功能和炎症介质释放的影响

The Impact of Heparin-Coated Cardiopulmonary Bypass Circuits on Pulmonary Function and the Release of Inflammatory Mediators

R. de Vroege, PhD*, W. van Oeveren, PhD{dagger}, J. van Klarenbosch, MD{ddagger}, W. Stooker, MD§, M. A. J. M. Huybregts, MD§, C. E. Hack, MD, PhD||, L. van Barneveld, CP*, L. Eijsman, MD, PhD§, and C. R. H. Wildevuur, MD, PhD§

Departments of *Extracorporeal Circulation, {ddagger}Anesthesiology, and §Cardiac Surgery, Vrije Universiteit Medisch Centrum, Amsterdam, The Netherlands; {dagger}Department of Biomaterials, University of Groningen, Groningen, The Netherlands; and ||Central Laboratory of the Netherlands Red Cross Blood Transfusion Service, Amsterdam, The Netherlands

Anesth Analg 2004;98:1586-1594
体外循环(CPB)中和CPB后往往使用涂有肝素的管道来减少炎症反应。但这种减少的反应是否也降低了CPB导致的肺功能不全仍存争议。因此作者评估了涂抹肝素的体外循环管道和相类似的无肝素涂抹的管道对CPB中和后的肺指数和炎症补体激活标志物(C3b/c,弹性蛋白酶-α1-抗胰蛋白酶复合体和分泌型的磷脂酶A2sPLA2)的影响。51名接受冠状动脉旁路移植手术病人随机分为两组,分别使用肝素涂抹组(组1)或肝素未涂抹组(组2)。CPB期间,维持持续气道正压(5cmH2O)和吸入氧浓度21%。CPB后和监护室内两组病人的肺分流分数(P<0.05)和肺血管阻抗指数(P<0.05)和PaO2/FIO2比(P<0.05)支持应用肝素涂抹管道。CPB期间和CPB后,组1显示较低的sPLA2。在CPB后,组1 C3b/c和弹性蛋白酶-α1-抗胰蛋白酶复合体显著减少(P<0.001)。肝素涂抹管道减少炎症反应,降低肺血管阻力指数和肺分流分数,增加PaO2/FIO2比,可能对肺功能有益。sPLA2相关白细胞反应和术后白细胞计数均支持肝素涂抹管道降低了肺毛细血管内皮细胞激活。

(殷文渊 译 王祥瑞 校)

Reduction of the inflammatory reaction with the use of heparin coating has been found during and after cardiopulmonary bypass (CPB). The question remains whether this reduced reaction also decreases the magnitude of CPB-induced pulmonary dysfunction. We therefore evaluated the effects of a heparin-coated circuit versus a similar uncoated circuit on pulmonary indices as well as on inflammatory markers of complement activation (C3b/c), elastase-{alpha}1-antitrypsin complex, and secretory phospholipase A2 (sPLA2) during and after CPB. Fifty-one patients were randomly assigned into two groups undergoing coronary artery bypass grafting with either a heparin-coated (Group 1) or an uncoated (Group 2) circuit. During CPB, a continuous positive airway pressure of 5 cm H2O and a fraction of inspired oxygen (FIO2) of 0.21 were maintained. Differences in favor of the coated circuit were found in pulmonary shunt fraction (P < 0.05), pulmonary vascular resistance index (P < 0.05), and PaO2/FIO2 ratio (P < 0.05) after CPB and in the intensive care unit. During and after CPB, the coated group demonstrated lower levels of sPLA2. After CPB, C3b/c and the elastase-{alpha}1-antitrypsin complex were significantly less in the coated group (P < 0.001). The coated circuit was associated with a reduced inflammatory response, decreased pulmonary vascular resistance index and pulmonary shunt fraction, and increased PaO2/FIO2 ratio, suggesting that the coated circuit may have beneficial effects on pulmonary function. The correlation with sPLA2, leukocyte activation, and postoperative leukocyte count suggests reduced activation of pulmonary capillary endothelial cells.


体外循环后胃肠道副反应:是否可通过术前危险因子来预测

Adverse Gastrointestinal Complications After Cardiopulmonary Bypass: Can Outcome Be Predicted from Preoperative Risk Factors?

Mary E. McSweeney, MD*, Susan Garwood, MB, ChB{dagger}, Jack Levin, MD{ddagger}, Maria R. Marino, MD§, Shirley X. Wang, PhD||, David Kardatzke, PhD||, Dennis T. Mangano, PhD, MD||, and Richard L. Wolman, MD* for the Investigators of the Ischemia Research and Education Foundation and the Multicenter Study of Perioperative Ischemia Research Group

*Multicenter Study of Perioperative Ischemia Research Group and University of Wisconsin Medical School, Madison, Wisconsin; {dagger}Yale University School of Medicine, New Haven, Connecticut; {ddagger}School of Medicine and VA Medical Center, San Francisco, California; §Centro Cardiologico Monzino, Milano, Italy; and ||The Ischemia Research and Education Foundation, San Francisco, California

Anesth Analg 2004;98:1610-1617
虽然心脏手术后胃肠道副反应的发生率不高,但由于其可导致发病率和死亡率的增加而成为临床上重要问题。如果在术前能证实患者具有危险因子对围术期处理策略大为有益。作者观察了来自24家不同的美国医疗中心围术期缺血研究中2417位患者(均接受心肺转流的心脏手术),评价并记录患者是否发生了胃肠道副反应。结果5.5%的患者存在胃肠道副反应(133/2417),院内死亡率上升6.5%,ICU入住时间延长1周,术后的住院时间延长一倍(P<0.0001)。术后出现胃肠道副反应的预测因子包括:左室功能减低,高胆红素血症,血小板减少症,部分凝血活酶时间延长,心血管手术史,冠状动脉旁路移植联合心内或近端主动脉手术,心血管药物支持和术中输血。本文显示心脏手术后胃肠道副反应继发于内脏灌注的减少,并有许多预测因子。因此,术前存在危险因子的病人可从术中严密的血流动力学处理中获益。

(肖洁 译 王祥瑞 校)

Adverse gastrointestinal (GI) outcome after cardiac surgery is an infrequent event but is a clinically important health care problem because of associated increased morbidity and mortality. The ability to identify patients at greatest risk before surgery may be helpful in planning appropriate perioperative management strategies. We examined the pre- and intraoperative characteristics of 2417 patients from 24 diverse United States medical centers enrolled in the Multicenter Study of Perioperative Ischemia Study who were undergoing cardiac surgery using cardiopulmonary bypass as predictors for adverse GI outcome. Resource utilization was evaluated for patients with and without adverse GI outcomes. Adverse GI outcomes occurred in 5.5% of patients (133 of 2417), increased in-hospital mortality 6.5-fold, prolonged the mean intensive care unit length of stay by 1 wk, and more than doubled the mean postoperative hospital stay (P < 0.0001). Predictors of adverse GI outcome included decreased left ventricular function, hyperbilirubinemia, thrombocytopenia, prolonged partial thromboplastin time, prior cardiovascular surgery, combined coronary artery bypass graft surgery and intracardiac or proximal aortic surgery, pharmacological cardiovascular support, and intraoperative transfusion. The literature suggests that adverse GI outcome after cardiac surgery is secondary to poor splanchnic perfusion, which many of these risk factors may predict. Therefore, patients deemed to be at risk before surgery may benefit from tightly controlled hemodynamic management


肝素酶改良的血栓弹性描记仪在足月和早产儿中应用

Heparinase-Modified Thrombelastography in Term and Preterm Neonates

Stephan C. Kettner, MD*,{dagger}, Arnold Pollak, MD{ddagger}, Michael Zimpfer, MD*,{dagger}, Tanja Seybold, MD*, Andrea R. Prusa, MD{ddagger}, Kurt Herkner, MD§, and Stefan Kuhle, MD{ddagger}

*Department of Anesthesiology and General Intensive Care, University of Vienna; {dagger}Ludwig Boltzmann Institute of Clinical Anesthesiology and Intensive Care; {ddagger}Department of Neonatology and Intensive Care, University of Vienna; and §Ludwig Boltzmann Institute of Pediatric Endocrinology and Immunology, University of Vienna, Vienna, Austria

Anesth Analg 2004;98:1650-1652


血栓弹性描记仪用于评估婴儿和儿童的凝血功能,是一种非常有前景的测试方法。它仅用300µL全血就可以快速评估凝血功能,并且还可以提供很多信息:如血浆凝血,血小板功能,纤维蛋白溶解功能。在这项研究中,作者用TEG来评价早产和足月儿的凝血系统,以了解其由于凝血因子不足所造成止血功能的影响。临床情况稳定的的婴儿分成四组:重度早产儿(孕龄:27-31周);中度早产儿(孕龄:32-36周);足月儿(孕龄:36-40周);前早产儿(修正孕龄:34-40周),评估其肝素酶修正TEG,血小板和红细胞计数,血浆纤维蛋白原,以及前凝血酶原时间等,并以健康成人志愿者作为对照组。结果显示,和成人组相比,TEG测试临床情况稳定的婴儿其凝血功能正常,部分患儿而且常规凝血功能测试的易变性。与常规的凝血功能检查不稳定。由于临床稳定早产儿和足月儿相对较少出血,尽管延长常规凝血功能检查时间,TEG较常规凝血功能检查更好地反映婴儿的凝血状态。

(顾漪闻 译 王祥瑞 校)

Thrombelastography (TEG®) appears to be a promising test to assess coagulation in infants and children. TEG® enables a rapid assessment of hemostatic function with only 300 µL of whole blood and provides information about plasmatic coagulation, platelet function, and fibrinolysis. In this study, we used TEG® to assess the coagulation system of preterm and term neonates to determine the effects of their deficient coagulation factor levels on global hemostatic function. Heparinase-modified TEG®, platelet and red blood cell count, plasma fibrinogen, and prothrombin time were assessed in four groups of clinically stable infants: severely preterm (gestational age [GA], 27–31 wk), moderately preterm (GA, 32–36 wk), term (GA, 36–40 wk), and former preterm (corrected GA, 34–40 wk). Healthy adult volunteers served as a control group. When compared with the adult group, thromboelastography revealed no defects in coagulation from groups of clinically stable infants, documenting the functional integrity of coagulation despite, in part, decreased conventional coagulation variables. Because clinically stable preterm and term infants show a relatively small incidence of bleeding, despite prolonged conventional coagulation tests, TEG® may better reflect the hemostatic potential of these patients compared with conventional coagulation tests.


琥珀胆碱阻滞过程中对强直和TOF刺激反应的强直后易化和衰减

Posttetanic Potentiation and Fade in the Response to Tetanic and Train-of-Four Stimulation During Succinylcholine-Induced Block

Mohamed Naguib, MB, BCh, MSc, FFARCSI, MD*, Cynthia A. Lien, MD{dagger}, John Aker, CRNA, MS*, and Rudolfo Eliazo, BA{dagger}

*Department of Anesthesia, University of Iowa College of Medicine, Iowa City, Iowa; and {dagger}Department of Anesthesiology, The Weill Medical College of Cornell University, New York Presbyterian Hospital, New York, New York

Anesth Analg 2004;98:1686-1691

 
本实验研究单次注射琥珀胆碱后TOF或强直刺激后的衰减和易化情况。前瞻性、随机、双中心观察100名患者,分为5组,在异丙酚、芬太尼和笑气麻醉中分别接受0.10.20.50.751mg/kg的琥珀胆碱。使用TOF肌动图来监测神经肌肉功能。在10%~20%的肌力恢复时,TOF的刺激模式改变为1 Hz的单次刺激,接着持续5秒的50Hz的强直性刺激,3秒钟之后,1 Hz的单次刺激反复持续30秒直至TOF反应完全恢复。琥珀胆碱诱导的神经肌肉阻滞具有以下特点:1)抽搐增强先于抽搐抑制,小剂量(0.1~0.3mg/kg)比大剂量(0.5~1.0mg/kg)更明显;2TOF衰减贯穿于阻滞的开始和恢复;3)强直衰减;4)强直后易化。强直后易化的程度与强直前抽搐的程度相关,与琥珀胆碱的剂量无关。在剂量减少到0.3mg/kg时,在作用开始和恢复中均能观察到II 相阻滞。不同剂量琥珀胆碱后强直刺激和TOF刺激引起强直后易化和衰减。

(陈洁 译 王祥瑞 校)

We designed this study to confirm anecdotal observations that neuromuscular block after a single administration of succinylcholine is characterized by fade to train-of-four (TOF) or tetanic stimulation, as well as posttetanic potentiation. This prospective, randomized, 2-center observational study involved 100 patients. Patients were allocated to 1 of 5 groups and received 0.1, 0.3, 0.5, 0.75, or 1.0 mg/kg succinylcholine during propofol/fentanyl/nitrous oxide anesthesia. Neuromuscular function was monitored by TOF using mechanomyography. At 10%–20% spontaneous recovery of the first twitch of TOF, the mode of stimulation was changed from TOF to 1-Hz single-twitch stimulation followed by a tetanic stimulus (50 Hz) for 5 s. Three seconds later, the single twitch (1 Hz) was applied again for approximately 30 s followed by TOF stimulation until full recovery of the TOF response. Succinylcholine-induced neuromuscular block had the following characteristics: 1) twitch augmentation before twitch depression, which was seen more frequently in patients given smaller doses (0.1 and 0.3 mg/kg) than in those given larger doses (0.5–1.0 mg/kg); 2) TOF fade during onset and recovery of the block; 3) tetanic fade; and 4) and posttetanic potentiation. Posttetanic potentiation was related to the pretetanic twitch height but was not related to the dose of succinylcholine administered. Some characteristics of Phase II block were detectable during onset and recovery from doses of succinylcholine as small as 0.30 mg/kg. Posttetanic potentiation and fade in response to train-of-four and tetanic stimuli are characteristics of neuromuscular block after bolus administration of different doses of succinylcholine.


高血压大鼠中吗啡引起的镇痛,低血压及心动过缓的作用增强

Morphine-Induced Analgesia, Hypotension, and Bradycardia Are Enhanced in Hypertensive Rats

Tania B. Mahinda, MS*, Blaise M. Lovell, MS{dagger}, and Bradley K. Taylor, PhD{dagger}

*Division of Pharmacology, School of Pharmacy, University of Missouri-Kansas City, Kansas City, Missouri; and {dagger}Department of Pharmacology, School of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana

Anesth Analg 2004;98:1698-1704

许多研究显示心血管功能和急性非炎症性疼痛两者间经阿片类相互联系。通过对照有关的研究发现,阿片类药物、高血压和炎症性疼痛之间存在联系。作者使用甲醛建立急性炎症疼痛模型,比较自发性高血压鼠(SHR),同基因源正常血压组,Wistar-Kyoto(WKY)Sprague-Dawley(SD)之间吗啡的抗伤害性作用。伤害性的评估包括行为和心血管功能变化 (平均动脉压和心率的增加)。吗啡(3.0mg/kg) 皮下注射后SHR组比WKY组和SD组更易发生低血压和心动过缓。给予甲醛(5%;50µL)后在1阶段和2阶段SHR对照组比WY对照组有更明显的伤害性表现。吗啡组结果与之不同,显示吗啡减弱了甲醛疼痛刺激敏感性。SHR组,吗啡抑制了水肿,但不能抑制过高热,瑞芬太尼在阶段1至阶段2的过渡中产生一个相对短的延迟。作者建议术中(为了减少心血管系统并发症)和术后(使镇痛作用尽可能完善)使用阿片类药物时要考虑术前是否存在高血压。  

(周洁 译 王祥瑞 校)

Several studies have emphasized an opioidergic link between the central regulation of cardiovascular function and acute noninflammatory pain. By contrast, relatively few studies have investigated the relationships between opioids, hypertension, and inflammatory pain. We used the formalin model of acute inflammatory pain to compare morphine antinociception among spontaneously hypertensive (SHR) rats, their genetic normotensive controls, Wistar-Kyoto (WKY) rats, and Sprague-Dawley (SD) rats. Measures of nociception included both behavioral and cardiovascular end-points (increased mean arterial blood pressure and heart rate). Morphine (3.0 mg/kg subcutaneously) produced greater hypotension and bradycardia in SHR than in WKY or SD rats. We next administered formalin (5%; 50 µL) and observed greater nociception during both Phase 1 and Phase 2 in SHR controls than in WKY controls. The morphine-treated groups did not differ, suggesting that morphine attenuates hypersensitivity to formalin pain in the SHR. Morphine inhibited edema but not paw hyperthermia to a greater degree in SHR, whereas Phase 1 remifentanil produced a relatively shorter delay in the onset of Phase 2 in SHR. We suggest that the presentation of essential hypertension be considered when opioid regimens are planned both during surgery (to minimize cardiovascular complications) and during the postoperative period (to optimize analgesic effects).


异氟醚可减少脊髓背角神经元内谷氨酸传递:镇痛作用在突触前起效的证据

Isoflurane Reduces Glutamatergic Transmission in Neurons in the Spinal Cord Superficial Dorsal Horn: Evidence for a Presynaptic Site of an Analgesic Action

Rainer Haseneder*, Jörge Kurz*, Hans-Ulrich U. Dodt{dagger}, Eberhard Kochs*, Walter Zieglgänsberger{dagger}, Michaela Scheller*, Gerhard Rammes{dagger}, and Gerhard Hapfelmeier*

*Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, and the {dagger}Department of Clinical Neuropharmacology, Max-Planck-Institute of Psychiatry, Munich, Germany

Anesth Analg 2004;98:1718-1723


挥发性麻醉剂的最低肺泡浓度(MAC)定义是麻醉剂对伤害性刺激下体动反射的抑制能力。因此,MAC可在一定程度上反映对运动神经兴奋能力的抑制。在这项研究中作者评估异氟醚对大鼠体外输入固定疼痛刺激后脊髓水平的电生理变化。作者用全细胞膜片钳技术记录大鼠脊髓横切片神经细胞及胶质细胞的电位变化。研究异氟醚对背根刺激(eEPSC),自发电流 (sEPSC)和微小电流(mEPSC)诱发的兴奋性突触后电流(EPSC)的影响。异氟醚能可逆地降低eEPSC的振幅至39%±22%,降低sEPSC mEPSC的频率分别为39%±26%63%±7%,而mEPSC sEPSC的振幅和动力学没有变化。结论:异氟醚能抑制疼痛刺激初级传导途径突触内传递,可能通过降低兴奋性递质释放实现的。这种作用可能是挥发性麻醉剂在脊髓水平产生的抗伤害作用。

(朱辉 译 王祥瑞 校)

The minimum alveolar concentration (MAC) of a volatile anesthetic defines anesthetic potency in terms of a suppressed motor response to a noxious stimulus. Therefore, the MAC of an anesthetic might in part reflect depression of motor neuron excitability. In the present study we evaluated the effect of isoflurane (ISO) on neurons in the substantia gelatinosa driven synaptically by putative nociceptive inputs in an in vitro spinal cord preparation of the rat. Whole-cell patch-clamp recordings were performed in neurons with their soma in the substantia gelatinosa of transverse rat spinal cord slices. We investigated the effect of ISO on excitatory postsynaptic currents (EPSC) evoked by dorsal root stimulation (eEPSC), spontaneous (sEPSC), and miniature (mEPSC) EPSC. ISO reversibly reduced the amplitude of eEPSC to 39% ± 22% versus control. ISO decreased the frequency of sEPSC and mEPSC to 39% ± 26% and 63% ± 7%. Neither the amplitudes nor the kinetics of mEPSC and sEPSC were altered by ISO. We conclude that ISO depresses glutamatergic synaptic transmission of putative nociceptive primary-afferent inputs, presumably by reducing the release of the excitatory transmitter. This effect may contribute to an antinociceptive action of volatile anesthetics at the spinal cord level.



用先进的模拟实验评价骨内血管途径救助化学战争中伤员的应用价值:建议改变治疗方案

Intraosseous Vascular Access in the Treatment of Chemical Warfare Casualties Assessed by Advanced Simulation: Proposed Alteration of Treatment Protocol

Amir Vardi, MD*,{dagger}, Haim Berkenstadt, MD*,{ddagger}, Inbal Levin, PCCRN*,{dagger}, Ariel Bentencur, MD*,§, and Amitai Ziv, MD*

*The Israel Center for Medical Simulation, Sheba Medical Center, Tel-Hashomer, Israel; and Departments of {dagger}Pediatric Critical Care, {ddagger}Anesthesiology and Intensive Care, and §Emergency Medicine, the Chaim Sheba Medical Center, Tel-Hashomer, Israel (affiliated with the Tel-Aviv University, Sackler School of Medicine, Tel-Aviv, Israel

Anesth Analg 2004;98:1753-1758


本研究中治疗方案是针对化学战争中伤员在早期治疗阶段无静脉开放途径而进行的。在大量伤员救助时,由于时间限制和医务人员身着防护装备而无法灵活操作以及受害者复杂的临床表现致使标准静脉注射方法变得不实用。一种新开发的弹簧驱动、扳机操作骨内注射装置可以提供有效的补液。精密的模拟器用于模拟化学战争伤员的救治,评价骨内注射装置的可行性。作者评价了医务人员在全套防护装备时的临床操作。模拟实验中观察骨内插入的成功率,完成治疗目标的时间和预后。医疗队来自以色列的大医院,对化学战争中的伤亡做紧急反应,接受模拟实验的培训。全部94名优秀的内科医生提供传统的治疗程序,64名实验组的内科医生接受骨内内注射装置的培训。结果实验组的存活率为73.4%,对照组为3.3% p<0.001)。实验组在3.5分钟(范围,1-9分钟)内达到治疗目标,对照组则用了10分钟以上。骨内注射的并发症为13.8%。医务人员对骨内注射装置表示满意。因此,新一代的骨内注射方法对化学战争中伤员的早期救治具有很大的潜在价值。

(忻纪华 译 王祥瑞 校)

Current treatment protocols for chemical warfare casualties assume no IV access during the early treatment stages. Time constraints in mass casualty scenarios, impaired manual dexterity of medical personnel wearing protective gear, and victims’ complex clinical presentations render standard IV access techniques impractical. A newly developed spring-driven, trigger-operated intraosseous infusion device may offer an effective solution. Sophisticated simulators were developed and used to mimic scenarios of chemical warfare casualties for assessing the feasibility of intraosseous infusion delivery. We evaluated the clinical performance of medical teams in full protective gear. The success rate in intraosseous insertion, time to completion of treatment goals, and outcome were measured in a simulated setting. Medical teams from major hospitals in Israel, designated for emergency response in a real chemical warfare mass casualty scenario, were trained in a simulated setting. All 94 participating physicians were supplied with conventional treatment modalities: only the 64 study group physicians received intraosseous devices. The simulated survival rate was 73.4% for the study group and 3.3% for the controls (P < 0.001). Treatment goals were achieved within 3.5 min (range, 1–9 min) in the study group and within >10 min for controls (P < 0.001), and the complication rate for intraosseous use was 13.8%. Personnel satisfaction with the intraosseous device was unanimous and high. New-generation intraosseous infusions have great potential value in the early treatment stages of chemical warfare casualties.


血小板活化因子受体拮抗剂能抑制细菌毒素和细菌引起的人全血细胞因子的释放

A Platelet Activating Factor Receptor Antagonist Inhibits Cytokine Production in Human Whole Blood by Bacterial Toxins and Live Bacteria

Masanori Ogata, MD, Koichiroh Nandate, MD, Takashi Kawasaki, MD, Chika Kawasaki, MD, Masayuki Ozaki, MD, and Akio Shigematsu, MD

From the Department of Anesthesiology, University of Occupational and Environmental Health, Japan

Anesth Analg 2004;98:1767-1772


先前的研究表明,血小板活化因子受体(PAFR)抑制剂(TCV-309)能够减少由于脂多糖(LPS)诱导的小鼠的死亡率和肿瘤坏死因子(TNF)的释放。但是TCV-309对于葡萄球菌毒素BSEB)或细菌诱导的细胞因子释放的影响还没有报导。本研究中作者报导了TCV-309LPSSEB和革兰氏阳性及阴性细菌引起的细胞因子释放的影响。研究者将人类全血5:1稀释后置入24孔板中。将10ulLPSSEB、大肠杆菌或金黄色葡萄球菌分别加入到24孔板中。37°C孵育6小时后检测孵育液TNFIL-6IL-8。结果表明,在6小时的孵育过程中,TCV-309并不影响大肠杆菌和金黄色葡萄球菌的生长。LPSSEB、大肠杆菌和金黄色葡萄球菌都能够诱导人全血的释放TNFIL-6IL-8TCV-309则能够明显抑制这种诱导反应。作者认为,血小板激活因子受体在细菌和细菌毒素诱导的细胞因子释放中具有重要作用。

(苏殿三 译 王祥瑞 校)

We previously reported that a platelet-activating factor receptor (PAFR) antagonist (TCV-309) suppressed lipopolysaccharide (LPS)-induced mortality and tumor necrosis factor (TNF) production in mice. However, the effect of TCV-309 on cytokine production induced by Staphylococcus enterotoxin B (SEB) or live bacteria has not been reported. In this study we investigated the effect of TCV-309 on cytokine production in human whole blood induced by LPS, SEB, and both Gram-positive and -negative bacteria. Human whole blood diluted 5:1 (980 µL) was placed in the wells of a 24-well plate. Ten microliters of LPS, SEB, Escherichia coli O18 K+, or Staphylococcus aureus were added to each well. After incubation at 37°C for 6 h, TNF, interleukin (IL)-6, and IL-8 in the culture medium were measured. TCV-309 did not affect the growth of either E. coli or S. aureus bacteria in the culture medium for the 6 h incubation. LPS, SEB, and both E. coli and S. aureus induced TNF, IL-6, and IL-8 in human whole blood. TCV-309 significantly inhibited the production of TNF, IL-6, and IL-8 induced by LPS, SEB, and bacteria. A PAFR antagonist suppressed cytokine production induced by LPS, SEB, and both Gram-positive and -negative bacteria in human whole blood. A PAFR plays an important role of producing proinflammatory cytokines induced by both toxins and live bacteria.


0.5%1%2-氯普鲁卡因静脉区域麻醉前瞻性、随机、双盲试验的比较

0.5% Versus 1.0% 2-Chloroprocaine for Intravenous Regional Anesthesia: A Prospective, Randomized, Double-Blind Trial

Stephan C. Marsch, MD, DPhil*, Mathias Sluga, MD*, Wolfgang Studer, MD*, Jonas Barandun, MD{dagger}, Domenic Scharplatz, MD{dagger}, and Wolfgang Ummenhofer, MD*

From the Departments of *Anesthesia and {dagger}Surgery, Krankenhaus Thusis, Thusis, Switzerland

Anesth Analg 2004;98:1789-1793


本随机、前瞻性、双盲试验比较研究了0.5%氯普鲁卡因和1%氯普鲁卡因各40ml在静脉区域麻醉时起效至作用完全的时间及对止血带耐受情况。采用双袖带技术150名患者在静脉区域麻醉下实施前臂手术,试验中疼痛评分超过4分,则从近端袖带转换至远端袖带。结果发现当转换至远端袖带时,0.5%氯普鲁卡因组中69%的病人的疼痛评分降到4分以下,而1%浓度组则达到88%P0.0477)。另外,两组病人对远端止血带疼痛的反应不同(P0.020)。注药后起效到作用完全的时间:0.5%氯普鲁卡因组为13±1分钟, 1%氯普鲁卡因组为11±1分钟(P0.0006)。止血带松驰后,0.5%浓度组6名病人出现全身局麻药中毒症状,1%浓度组则有28名(P0.0001)。因此,1%氯普鲁卡因镇痛起效时间增快,并增加病人对远端止血带疼痛的耐受性,但在获取上述益处同时副反应增加了4倍。

(齐波 译 王祥瑞 校)

In this randomized prospective double-blind study we tested the hypothesis that compared with 40 mL chloroprocaine 0.5%, 40 mL chloroprocaine 1% results in an earlier onset to analgesia duration and improves distal tourniquet tolerance in 150 patients undergoing forearm surgery under IV regional anesthesia using a double-cuff technique, switching from the proximal to the distal cuff was performed if pain scores increased above 4 of 10. Switching to the distal cuff resulted in pain scores below 4 in 69% of patients in the 0.5% group and in 88% of patients in the 1% group (P = 0.047). In addition, both groups differed in the sustained effect on distal tourniquet pain (P = 0.020). Time between injection and onset to analgesia duration was 13 ± 1 min in the 0.5% group and 11 ± 1 min in the 1% group (P = 0.0006). On release of the tourniquet, signs of systemic local anesthetic toxicity occurred in 6 patients of the 0.5% group and 28 of the 1% group (P < 0.0001). We conclude that chloroprocaine 1% resulted in an earlier onset of analgesia and improved distal tourniquet tolerance. However, these beneficial effects must be weighed against a fourfold increase in side effects.



髋部骨折病人术后短暂谵妄可影响术后功能状态三个月

Brief Postoperative Delirium in Hip Fracture Patients Affects Functional Outcome at Three Months

Khwaja Zakriya, MD*, Frederick E. Sieber, MD*, Colleen Christmas, MD{dagger}, James F. Wenz, Sr., MD{ddagger}, and Shawn Franckowiak, BS{dagger}

*Department of Anesthesiology, {dagger}School of Medicine, Division of Geriatrics and Gerontology, and {ddagger}Department of Orthopedics, Johns Hopkins Bayview Medical Center, Baltimore, Maryland

Anesth Analg 2004;98:1798-1802
目前对于短暂的术后谵妄DEL)如何影响术后的功能状态还不清楚。本研究中,作者研究了有术后短暂DEL的髋部骨折病人和没有DEL病人生活质量差异。研究者应用意识错乱评分法(CAM)每天评估髋部骨折的老年病人术后DEL情况。术后第6周和第3个月再次进行CAM评分、生活状况和每天的活动情况。病人分成两组:DEL组是指在术后住院期间任何时候发生DEL的病人,没有DEL组指病人住院期间术后没有观察到DEL的病人。共有92个病人参与了该项研究,其中有26人(28%)有DEL出现。第6周时81人,第3个月时76名患者参加了调查。有8个病人在研究期间内死亡。在第6周和第3个月的调查中大部分DEL病人没有和家庭生活在一起(第3个月时27%出现DEL的患者没有和家人生活在一起,而没有出现DEL的患者只有8%)。第三个月时两组病人的日常活动情况没有明显的区别。研究者认为术后DEL持续到术后6周是髋部骨折病人术后长期功能预后的较差危险因素,能够明显影响术后病人的独立生活能力。

(苏殿三 译 王祥瑞 校)

It is unclear how brief postoperative delirium (DEL) affects functional outcomes. In this study, we sought to determine if patients with brief postoperative DEL (<6-wk duration) have different living situations when compared with non-DEL patients after hip fracture repair. In a prospective study, patients admitted to the geriatric hip fracture service were assessed every postoperative day for the presence of DEL using the confusion assessment method (CAM) score. Patients were reassessed at 6 wk and 3 mo postoperatively for CAM score, current living situation, and activities of daily living. Group comparisons were tested after dividing patients into two groups: DEL (DEL; [+] CAM at any time during the postoperative period while in the hospital); no-DEL (no DEL; [–] CAM throughout the postoperative period while in the hospital). The study included 92 patients of whom 26 (28%) were CAM (+) after surgery. At 6 wk follow-up, n = 81; at 3 mo follow-up, n = 76. Eight patients died during the study. At 6 wk and 3 mo, a larger percentage of DEL patients were not living with a family member (27% versus 8% patients not living with a family member at 3 mo follow-up in DEL and no-DEL, respectively). There was no difference in activities of daily living by 3 mo. We conclude that brief postoperative DEL lasting <6 wk is a determining factor for poor long-term functional outcome after hip fracture repair, because it significantly impacts the ability to live independently.

鞘内使用咪达唑仑II:鞘内合用芬太尼用于分娩

Intrathecal Midazolam II: Combination with Intrathecal Fentanyl for Labor Pain

Adam P. Tucker, MBChB, DA, DRACOG, FANZCA, Joseph Mezzatesta, MBBS, FANZCA, Raymond Nadeson, PhD, and Colin S. Goodchild, MA, MB BChir, PhD, FANZCA, FFPMANZCA

 Anesth Analg 2004;98:1521-1527

最近的研究致力于通过在芬太尼中加入其他类的镇痛药来提高鞘内镇痛的效果。在这项研究中,我们评价了鞘内使用咪达唑仑在提高芬太尼镇痛效果及持续时间方面的效果而且不引起副反应。30名宫口开大2-6公分的产妇被随机分为三组。组1,鞘内使用咪达唑仑2mg;2,鞘内使用芬太尼10μg;组3,两者合用。在注药前,注药后30分钟内每隔5分钟,然后每隔30分钟直到患者再次需要镇痛药,这几个时间点测痛觉评分。监测恶心,呕吐,皮肤瘙痒,头痛,镇静的发生率及程度加上动脉压,心率,呼吸频率,对冷的感觉异常,运动损害,心电图和Apgar评分。在2天后及1月评价产妇神经损伤。单独鞘内使用咪达唑仑对注药前的疼痛评分没有影响,芬太尼可以轻微降低疼痛评分。加用咪达唑仑可以提高芬太尼的镇痛作用。没有一种治疗方法对循环呼吸及运动有影响。鞘内芬太尼中加用的咪达唑仑不会增加母体产生不良反应的几率。总之,鞘内使用咪达唑仑可以增强芬太尼的镇痛作用并且不增加母婴不良反应的发生率。

(陆旭伟 薛张纲 校)

Recent investigations have sought to improve intrathecal analgesia by combining opioids with other classes of analgesics. In this study we assessed the ability of intrathecal midazolam to increase the potency and duration of the analgesic effects of intrathecal fentanyl without causing adverse effects. Thirty parturients with cervical dilations 2–6 cm were randomized to receive either intrathecal midazolam 2 mg, fentanyl 10 µg, or both combined to initiate analgesia. Pain scores were recorded before and at 5-min intervals for 30 min after the injection and then every 30 minutes until the patient requested further analgesia. The presence and severity of nausea, emesis, pruritus, headache, and sedation, in addition to arterial blood pressure, heart rate, respiratory rate, sensory changes to ice, motor impairment, cardiotocograph, and Apgar score were also recorded. The parturients were assessed after 2 days and 1 mo for neurologic impairment. Preinjection pain scores were unaltered by intrathecal midazolam alone and moderately decreased by fentanyl. Intrathecal midazolam increased the analgesic effect of fentanyl. No treatment altered cardiorespiratory variables or caused motor impairment. The addition of intrathecal midazolam to fentanyl did not increase the occurrence of any maternal adverse event or abnormalities on the cardiotocograph. We conclude that intrathecal midazolam enhanced the analgesic effect of fentanyl without increasing maternal or fetal adverse effects.

                                                                   

 


关节腔内注盐水可减轻膝关节镜后中度到重度疼痛:一项随机对照试验

Moderate-to-Severe Pain After Knee Arthroscopy Is Relieved by Intraarticular Saline: A Randomized Controlled Trial

Leiv A. Rosseland, MD*, Knut G. Helgesen, MD DMSc{dagger}, Harald Breivik, MD DMSc FRCA*, and Audun Stubhaug, MD DMSc*

*Department of Anesthesia, Rikshospitalet University Hospital and the {dagger}Department of Anesthesia, Lovisenberg Diakonale Hospital, Oslo, Norway

Anesth Analg 2004;98:1546-1551

我们以前在2项随机临床试验中比较过关节内使用镇痛药和盐水10 mL。关节内使用盐水的患者疼痛很快缓解。盐水可能通过冷冻或稀释关节内的致痛物质达到局麻药的作用。这项双盲随机研究比较了关节内10 mL盐水和纯安慰剂组,1 mL盐水。在79位患者的关节内置入一根软管。我们采纳了60名在全麻下行膝关节镜的患者。他们术后1小时内都发生中到重度的疼痛。然后我们用10 mL1 mL盐水进行随机双盲的研究。我们记录了疼痛的程度,疼痛的缓解以及镇痛药的用量。在1小时内,两组患者的疼痛程度(VAS 0-100 mm)从50降到27。在36小时的观察期中疼痛的程度保持低水平,在其他项目上两组也没有差别。患者关节内使用1mL10mL的盐水的作用是一样的。我们发现了安慰剂的主要作用,这可以用于解释以前发表的安慰剂对照的关节内镇痛研究。

(陆旭伟 薛张纲 校)

We have previously studied intraarticular (IA) analgesics compared with saline 10 mL in 2 randomized clinical trials. The patients who were given IA saline experienced rapid pain relief. Hypothetically, saline may produce a local analgesic effect by cooling or by diluting IA algogenic substances. This randomized double-blind study compared the analgesic effect of IA saline 10 mL with saline 1 mL, which should be a pure placebo. A soft catheter was left IA in 79 patients. We included 60 patients who developed moderate-to-severe pain within 1 h after knee arthroscopy under general anesthesia. A randomized, double-blind controlled comparison of IA saline 10 mL with saline 1 mL followed. Outcome measures were pain intensity, pain relief, and analgesic consumption. Within 1 h pain intensity decreased in both groups from approximately 50 to approximately 27 on a 0–100 mm visual analog scale. Pain intensity remained low and other pain outcome measures were similar during the 36-h observation period. The patients experienced equally good pain relief after IA injection of saline 10 mL and 1 mL. Our finding of a major placebo effect may have implications for the interpretation of previously published placebo-controlled IA analgesia studies.

                                                               

 

系统联用氯胺酮、吗啡治疗实验诱发投射痛的协同作用

The Synergistic Effect of Combined Treatment with Systemic Ketamine and Morphine on Experimentally Induced Windup-Like Pain in Humans

Helène Schulte, MD, Alf Sollevi, MD, PhD, and Märta Segerdahl, MD, PhD

Center for Surgical Sciences, Unit for Anaesthesia, Karolinska Institutet at Huddinge University Hospital, Huddinge, Sweden

Anesth Analg 2004 98: 1574-1580.

 

我们在此项研究中评价是否联用氯胺酮(KET)——NMDA受体拮抗剂、吗啡(MO)可以导致增强的止痛效果。有11名大腿皮肤烧伤的患者充当志愿者。实验采取随即、交叉、双盲,共分为4组如下(1)单用KET静注9 µg • kg–1 • min–1; 45 min (2) 单用MO静注10 µg • kg–1 • min–1; 10 min (3)以上两者联用(4)安慰剂组,生理盐水; 10 min。相对于安慰剂而言,KET可减少机械刺激次级痛觉过敏(SH)区域。KET单用或联用MO均可成倍提高初级痛觉过敏(PH,即烧伤)区域和SH区域的机械疼痛阈值,而MO静注则对SH区域或疼痛阈值无效。通过给予30s重复刺激(40-g 3 Hz)并连续进行视觉模拟评分,而后分析评分总和。联用KETMO几乎可以消除PHSH区域放射痛,而单用KETMO则无此效果。这项研究NMDA受体拮抗剂及阿片样药物在中枢疼痛总和中具有协同作用提供了实验室依据。

这是首次人体试验关于联用NMDA受体拮抗剂氯胺酮及吗啡在中枢感觉促进程序中的协同镇痛作用。

(方芳 薛张纲 校)

In this study, we evaluated whether combined treatment with ketamine (KET), an N-methyl-D-aspartate receptor antagonist, and morphine (MO) results in positive analgesic effects. Eleven volunteers were exposed to a skin burn injury on the leg. The effects of IV KET (9 µg • kg–1 • min–1; 45 min) and MO (10 µg • kg–1 • min–1; 10 min) alone and in combination, as well as placebo (saline; 10 min), were studied in a randomized, crossover, double-blinded design. The area of secondary hyperalgesia (SH) for mechanical stimulation was diminished by KET as compared with placebo. Mechanical pain thresholds were increased severalfold with KET and with KET plus MO, both in the primary hyperalgesic (PH; burn injury) and SH area. MO infusion showed no effect on the SH area or pain threshold. Windup-like pain was evaluated by continuous assessment on a visual analog scale during 30 s of repetitive stimulation (40-g load at 3 Hz) and analyzed as a sum of pain scores. The combined treatment (KET plus MO) almost abolished windup-like pain both in the PH and the SH areas, an effect that was not present with monotherapy with KET or MO. This study provides experimental support for a positive analgesic interaction between an N-methyl-D-aspartate receptor antagonist and an opioid on central summation of pain.

                                                                

肺复张可提高单肺通气时的通气、换气效率

Lung Recruitment Improves the Efficiency of Ventilation and Gas Exchange During One-Lung Ventilation Anesthesia

Gerardo Tusman, MD*, Stephan H. Böhm, MD{dagger}, Fernando Suárez Sipmann, MD{ddagger}, and Stefan Maisch, MD{dagger}

*Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina; {dagger}Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; and {ddagger}Department of Critical Care Medicine, Fundación Jimenez Diaz, Madrid, Spain

Anesth Analg 2004 98: 1604-1609.

 

单肺通气(OLV)时通气侧肺不张损害动脉血氧合,增加死腔量。我们通过单次呼吸CO2 测试(SBT-CO2)研究了单肺通气期间肺泡复充(ARS)对肺通气及换气的影响。12名胸外科手术患者依次观察三个时间点:(a)双肺通气期间(b)OLV期间ARS(c) OLV期间ARS后。ARS选择性应用于通气侧肺,增加吸气峰压至40 cm H2O ,呼气末压20 cm H2O ,如此连续10次呼吸持续3分钟。每个时间点末记录动脉血气、SBT-CO 、代谢及血液动力学变量。双肺通气期间的动脉血氧合及死腔量要好于OLVOLV期间肺复充后PaO2提高(分别是244 ± 89 mm Hg144 ± 73 mm Hg; P < 0.001),同时 SBT-CO2提示死腔量减少、肺通气效率提高。总之,OLV期间ARS可提高肺通气换气效率。

(方芳 薛张纲 校)

Atelectasis in the dependent lung during one-lung ventilation (OLV) impairs arterial oxygenation and increases dead space. We studied the effect of an alveolar recruitment strategy (ARS) on gas exchange and lung efficiency during OLV by using the single-breath test of CO2 (SBT-CO2). Twelve patients undergoing thoracic surgery were studied at three points in time: (a) during two-lung ventilation and (b) during OLV before and (c) after an ARS. The ARS was applied selectively to the dependent lung and consisted of an increase in peak inspiratory pressure up to 40 cm H2O combined with a peak end-expiratory pressure level of 20 cm H2O for 10 consecutive breaths. The ARS took approximately 3 min. Arterial blood gases, SBT-CO2, and metabolic and hemodynamic variables were recorded at the end of each study period. Arterial oxygenation and dead space were better during two-lung ventilation compared with OLV. PaO2 increased during OLV after lung recruitment (244 ± 89 mm Hg) when compared with OLV without recruitment (144 ± 73 mm Hg; P < 0.001). The SBT-CO2 analysis showed a significant decrease in dead-space variables and an increase in the variables related to the efficiency of ventilation during OLV after an ARS when compared with OLV alone. In conclusion, ARS improves gas exchange and ventilation efficiency during OLV.

 

                                                           

小儿异氟醚麻醉中的脑电双频指数

Bispectral Index During Isoflurane Anesthesia in Pediatric Patients

Simon D. Whyte, MB, BS, FRCA, and Peter D. Booker, MB, BS, MD, FRCA

Jackson-Rees Department of Anesthesia, Royal Liverpool Children’s Hospital and the Liverpool University Department of Anesthesia, United Kingdom

Anesth Analg 2004;98:1644-1649

 

脑电双频指数(BIS)是过去用于成人的麻醉深度监测,但现已研究用于七氟醚麻醉的小儿.我们测试了BIS和异氟醚的浓度-反应关系.30例小儿行心导管术术中连续接受BIS监测,并记录6个浓度在1.5%0.5%之间的异氟醚呼气末稳态(EtIso)和觉醒时的BIS.BIS平均值如下: 1.5%, 32.3 ± 11.7; 1.3%, 34.7 ± 12.5; 1.1%, 40.5 ± 13.3; 0.9%, 48.0 ± 13.7; 0.7%, 55.9 ± 14.4; and 0.5%, 61.8 ± 13.1. EtIsoBIS间存在负相关(r = –0.634; P < 0.01).1.5%比之1.3%,所有病例相邻EtIso 的平均BIS值间存在显著差异.抑制性的SEmax模式可最佳的描述这种BIS和异氟醚的浓度相关性,其中50%有效剂量浓度为0.85%(95%可信区间,0.72%-0.98%).初次觉醒的BIS平均值为78.5 ± 12.3. EtIso BIS间的关系在质和量上都与异氟醚在成人中和七氟醚在小儿中所描述的类似.这些结果进一步证实了BIS足以校正而用于大于1岁的小儿

(钟鸣 薛张纲 校)

Bispectral index (BIS) was developed to monitor anesthetic depth in adults, but has been investigated for use in children, using sevoflurane. We examined the concentration-response relationship between BIS and isoflurane. Thirty children undergoing cardiac catheterization received continuous intraoperative BIS monitoring and had BIS values recorded at 6 steady-state end-tidal isoflurane (EtIso) concentrations between 1.5% and 0.5% and at first arousal. The mean (SD) values for BIS were as follows: 1.5%, 32.3 ± 11.7; 1.3%, 34.7 ± 12.5; 1.1%, 40.5 ± 13.3; 0.9%, 48.0 ± 13.7; 0.7%, 55.9 ± 14.4; and 0.5%, 61.8 ± 13.1. There was an inverse correlation between EtIso and BIS (r = –0.634; P < 0.01). There were significant differences (P < 0.0001) in mean BIS values between adjacent EtIso in all cases except 1.5% versus 1.3%. An inhibitory sigmoid Emax model best described the BIS-isoflurane concentration relationship, with an 50% effective dose of 0.85% (95% confidence interval, 0.72%–0.98%). The mean value of BIS at first arousal was 78.5 ± 12.3. The relationship between EtIso and BIS is qualitatively and quantitatively similar to that described for isoflurane in adults and sevoflurane in children. These results add to the body of evidence that BIS is adequately calibrated for use in children older than 1 yr.

                                                            

术前肠外给予Parecoxib随后口服Valdecoxib缩短了腹腔镜胆囊切除术后恢复时间并提高苏醒质量

Preoperative Parenteral Parecoxib and Follow-Up Oral Valdecoxib Reduce Length of Stay and Improve Quality of Patient Recovery After Laparoscopic Cholecystectomy Surgery

Tong J. Gan, MD, Girish P. Joshi, MD, Eugene Viscusi, MD, Raymond Y. Cheung, BPharm, PhD, William Dodge, MSc, John G. Fort, MD, and Connie Chen, PharmD

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004;98:1665-1673

 

在这项随机、双盲、安慰剂对照研究中,我们评价了行选择性腹腔镜胆囊切除病人术前静脉给予Parecoxib以及术后口服Valdecoxib在恢复时间、资源利用、阿片药物相关的副作用和病人苏醒等方面的作用。病人在诱导前3045分钟被随机分为单一静脉给予Parecoxib 40mg组(n134)和安慰剂组(n129)。静脉给药612小时后,parecoxib组给予单一口服剂量的Valdecoxib 40mg,术后14天每日口服Valdecoxib 40mg一次,57天按需每日口服40mg一次。parecoxib/valdecoxib组病人与对照组(90 ± 49 min)相比在麻醉后监护室的停留时间更短(78 ± 47 minp<0.05)。parecoxib/valdecoxib组病人同对照组相比疼痛强度降低了,在送回病房后首个24小时内呕吐减少了,睡眠更好,更早恢复正常活动,显示出更多的满意(p<0.05)。术前Parecoxib术后valdecoxib是腹腔镜胆囊切除术后疼痛治疗和提高病人预后的有价值的附加治疗。

(钟鸣 薛张纲 )

In this randomized, double-blinded, placebo-controlled study, we evaluated the effects of preoperative IV parecoxib sodium (parecoxib) followed by postoperative oral valdecoxib on length of stay, resource utilization, opioid-related side effects, and patient recovery after elective laparoscopic cholecystectomy. Patients were randomized to receive a single IV dose of parecoxib 40 mg (n = 134) or placebo (n = 129) 30–45 min before the induction of anesthesia. Six to 12 h after the IV dose, the parecoxib group received a single oral dose of valdecoxib 40 mg, followed by valdecoxib 40 mg once daily on postoperative Days 1–4 and then 40 mg once daily as needed on Days 5–7. Patients in the parecoxib/valdecoxib group had a shorter length of stay in the postanesthesia care unit (78 ± 47 min) compared with those taking placebo (90 ± 49 min; P < 0.05). Patients in the parecoxib/valdecoxib group also had reduced pain intensity and, after discharge, experienced a significant reduction in vomiting in the first 24 h, slept better, returned to normal activity earlier, and expressed greater satisfaction than placebo patients (P < 0.05). Preoperative parecoxib followed by postoperative valdecoxib is a valuable adjunct for treating pain and improving patient outcome after laparoscopic cholecystectomy.

 

小剂量琥珀酰胆碱使用后的神经肌肉阻滞效应及气管内插管条件

The Neuromuscular Effects and Tracheal Intubation Conditions After Small Doses of Succinylcholine

Mohammad I. El-Orbany, MD, Ninos J. Joseph, BS, M. Ramez Salem, MD, and Arthur J. Klowden, MD.

Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois

Anesth Analg 2004;98:1680-1685

 

 1.0mg/kg的琥珀酰胆碱通常能够在60 s 内产生良好的气管插管调节。然而在该剂量下,如果不作扶助呼吸,呼吸肌的恢复时间要长于血红蛋白去氧和的时间。该研究中,我们比较明确使用较小剂量的琥珀酰胆碱是否能够产生满意的插管条件,并且是否缩短恢复时间。芬太尼和异丙酚麻醉诱导,异丙酚和N2O麻醉维持。 麻醉诱导后,115例患者根据琥珀酰胆碱的剂量随机分为5组(0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg, or 1.0 mg/kg)。采用加速肌电图记录1-Hz持续超强刺激尺神经时拇内收肌的收缩反应。 注射琥珀酰胆碱后60 s时评价气管插管的条件。 分别记录起效时间、最大肌颤搐抑制程度、麻痹后开始监测到肌颤搐的时间、恢复10%, 25%, 50%90% 的肌颤搐高度的时间。计算膈肌开始运动的时间和恢复规律自主呼吸运动的时间。起效时间范围在5282 s,并且随着琥珀酰胆碱剂量的增加起效时间缩短, 但是在起效时间在0.6 1 mg/kg组间无显著性差异。0.5, 0.61 mg/kg (98.2%–100%)组间最大肌颤搐抑制程度相似。肌颤除高度的恢复及呼吸窒息时间呈剂量依赖性效应。注射0.3 0.4mg/kg的琥珀酰胆碱后不能获得可接受的插管条件。在0.5, 0.61 mg/kg组均可获得可接受的插管条件。在0.61 mg/kg组间插管条件相同,而T1 = 50% 90%及恢复规律自主的呼吸囊运动的时间在0.6mg/kg (分别为5.78, 7.25, 4.0 min) 1 mg/kg (分别为8.55, 10.54, 6.16 min)间有显著性差异。使用0.50.6 mg/kg的琥珀酰胆碱后60 s时都可获得可接受的插管条件。0.6 mg/kg1.0mg/kg的琥珀酰胆碱可产生相似的临床插管条件,但是0.6 mg/kg的琥珀酰胆碱具有较短的肌颤除恢复时间和呼吸窒息时间。结论:在正常健康患者中, 0.6 mg/kg1.0mg/kg的琥珀酰胆碱可产生相似的临床插管条件,但是0.6 mg/kg的琥珀酰胆碱具有较短的恢复时间。

(张俊峰 薛张纲 校)

Succinylcholine 1.0 mg/kg usually produces excellent tracheal intubation conditions in 60 s. Recovery of respiratory muscle function after this dose, however, is not fast enough to forestall oxyhemoglobin desaturation when ventilation cannot be assisted. In this study, we investigated whether smaller doses of succinylcholine can produce satisfactory intubation conditions fast enough to allow rapid sequence induction with a shorter recovery time. Anesthesia was induced with fentanyl/propofol and maintained by propofol infusion and N2O in O2. After the induction, 115 patients were randomly allocated to five groups according to the dose of succinylcholine (0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg, or 1.0 mg/kg). Evoked adductor pollicis responses to continuous 1-Hz supramaximal ulnar nerve stimulation were recorded using acceleromyography. Tracheal intubation conditions were graded 60 s after succinylcholine administration. Onset time, maximal twitch depression, time to initial twitch detection after paralysis, and to 10%, 25%, 50%, and 90% twitch height recovery were recorded. Time to initial diaphragmatic movement as well as time to resumption of regular spontaneous respiratory movements were calculated. Onset times ranged between 82 s and 52 s, decreasing with increasing doses of succinylcholine but not differing between 0.6 and 1 mg/kg. Maximum twitch depression was similar after 0.5, 0.6, and 1 mg/kg (98.2%–100%). Recoveries of twitch height and apnea time were dose-dependent. Intubation conditions were often unacceptable after 0.3- and 0.4-mg/kg doses. Acceptable intubation conditions were achieved in all patients receiving a 0.5, 0.6, and 1 mg/kg dose of succinylcholine. Intubation conditions in patients receiving 0.6 and 1 mg/kg were identical, whereas times to T1 = 50% and 90% and time to regular spontaneous reservoir bag movements were significantly shorter in the 0.6-mg/kg dose group (5.78, 7.25, and 4.0 min, respectively) versus patients receiving 1 mg/kg (8.55, 10.54, and 6.16 min, respectively). The use of 0.5 to 0.6 mg/kg of succinylcholine can produce acceptable intubation conditions 60 s after administration. The conditions achieved after 0.6 mg/kg are similar to those after 1.0 mg/kg. These smaller doses are associated with faster twitch recovery and shorter apnea time.

 

胰岛素降低大鼠异氟醚最低肺泡有效浓度与异氟醚的脊髓效应无关

Insulin Decreases Isoflurane Minimum Alveolar Anesthetic Concentration in Rats Independently of an Effect on the Spinal Cord

Yilei Xing, MD*, Jim Sonner, MD*, Michael J. Laster, DVM*, Wella Abaigar, BS*, Valerie B. Caraiscos, MSc{dagger}, Beverley Orser, MD{dagger}, and Edmond I Eger, II, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; and {dagger}Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada

Anesth Analg 2004;98:1712-1717

 

观察结果发现胰岛素具有镇痛效应的成分,这提示使用胰岛素可能降低产生MAC(指消除50%患者对伤害性刺激反应的最低肺泡麻醉药浓度)的吸入麻醉药浓度。我们假设胰岛素通过直接影响神经系统和/或降低血糖浓度降低MAC。使用异氟醚麻醉大鼠,分别采用鞘内注射或静脉注射胰岛素,通过增加胰岛素的输入速度记录相应异氟醚的MAC 的变化(分开评估大鼠前肢和后肢的运动)。输注胰岛素产生剂量相关性的MAC降低效应,但是在组间无显著性差异。也就是说在相同的胰岛素输注速度下静脉输注组和鞘内注射组产生相似的MAC降低效应。在同时输注胰岛素和5%葡萄糖液的大鼠中血糖浓度要高。然而分别根据大鼠前肢和后肢确定的MAC值变化百分比间无显著性差异。在某一胰岛素输注速度下,MAC 的变化和血糖水平不具有相关性,但是在最大的胰岛素输注速度下有可能在较小的血糖浓度下合并MAC的边缘性的大的下降。鞘内注射胰岛素不导致脊髓损伤。总之,我们发现胰岛素可剂量相关性的降低异氟醚的MAC,该效应与胰岛素对血糖浓度的影响作用无关。胰岛素降低MAC的作用部位可能在脊髓上而非脊髓部位。该效应可能与胰岛素通过作用于一个或多个神经递质的受体所产生的镇痛作用有关。结论: 不论血糖浓度的多少,鞘内注射和静脉注射胰岛素同样降低大鼠的异氟醚MAC。该结果提示胰岛素降低MAC,但是该效应不是通过作用于脊髓而介导的。

(张俊峰译 薛张纲校)

The observation that insulin supplies an element of analgesia suggests that insulin administration might decrease the concentration of inhaled anesthetic required to produce MAC (the minimum alveolar anesthetic concentration required to eliminate movement in response to noxious stimulation in 50% of subjects). We hypothesized that insulin decreases MAC by directly affecting the nervous system, by decreasing blood glucose, or both. To test these hypotheses, we infused increasing doses of insulin either intrathecally or IV in rats anesthetized with isoflurane and determined the resulting MAC change (assessing forelimb and hindlimb movement separately). Infusion of insulin produced a dose-related decrease in MAC that did not differ among groups. That is, the IV and intrathecal infusions caused similar decreases in MAC at a given infusion rate. Blood glucose concentrations were larger in the rats given insulin with 5% dextrose. However, the percentage change in MAC determined from forelimb versus hindlimb movement did not differ. For a given insulin infusion rate, MAC changes and glucose levels did not correlate with each other, except, possibly, for the most rapid infusion rate, for which smaller glucose concentrations were associated with a marginally larger decrease in MAC. Intrathecal infusions of insulin did not produce spinal cord injury. In summary, we found that insulin decreases isoflurane MAC in a dose-related manner independently of its effects on the blood concentration of glucose. The sites at which insulin acts to decrease MAC appear to be supraspinal rather than spinal. The effect may be due to a capacity of insulin to produce analgesia through an action on one or more neurotransmitter receptors.

 

用肌音描计法可同时监测喉部内收肌和外展肌的神经肌肉阻滞

Simultaneous Determination of Neuromuscular Blockade at the Adducting and Abducting Laryngeal Muscles Using Phonomyography

Thomas M. Hemmerling, MD, DEAA, Guillaume Michaud, Guillaume Trager, DESS, and François Donati, PhD, MD, FRCPC

Neuromuscular Research Group (NRG), Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM) Hôtel-Dieu, Université de Montréal, Canada

Anesth Analg 2004;98:1729-1733

 

肌音描计法(PMG)是一种监测喉部神经肌肉阻滞(NMB)的新方法。在该研究中,我们使用PMG比较人类环杓软骨后肌(PCA)和类环杓软骨侧肌(LCA)NMB12例患者入选该研究。在不使用神经肌肉阻滞下施行气管内插管。第一个小麦克风置于声带旁边的杓状软骨基底部的肌肉间记录LCA(声带内收肌)的声学反应。。另一个麦克风置于喉的后面监测PCA(声带外展肌)NMB。通过颈部皮肤表面的电极(位于颈静脉切迹和环状软骨中点的位置)刺激喉返神经,刺激方式为每隔12 s四个成串刺激(TOF)。超强刺激后静注美维松 0.1 mg/kg,记录NMB的起效时间、峰效应及消退并使用t检验 (P < 0.05) 所有数据均采用(均值±标准差)表示。峰效应、起效时间及肌颤除强度恢复到对照值25%的时间在PCALCA 间无显著性差异,分别为86% (13) 78% (16), 2.3 min (0.45)2.3 min (1.0), 9.55 min (3.05)8.5 min (4.7)。然而,肌颤除强度恢复到对照值75%90%的时间以及TOF恢复到0.8的时间在PCA组显著长于LCA组,分别为14 min (4)11 min (5), 17 min (5) 11.8 min (5.6), 17.5 min (5.6) 12.3 min (5.5)。通过该研究发现人类在使用美维松后PCANMB恢复时间要长于LCA的恢复时间。 结论:在人类神经肌肉阻滞后,声带张开能力的恢复时间比声带关闭能力恢复的时间要长。

 (张俊峰 薛张纲 校)

Phonomyography (PMG) is a new method for measuring neuromuscular blockade (NMB) at the larynx. In this study, we used PMG to compare NMB at the posterior cricoarytenoid (PCA) and the lateral cricoarytenoid muscle (LCA) in humans. Twelve patients were included in this study. Endotracheal intubation was performed without aid of neuromuscular blocking drugs. One small condenser microphone was inserted beside the vocal cords into the muscular process at the base of the arytenoid cartilage to record acoustic responses of the LCA (vocal cord adduction), and a second microphone was placed behind the larynx to measure NMB of the PCA (vocal cord abduction). Stimulation of the recurrent laryngeal nerve was performed using superficial electrodes placed at the neck (midline between jugular notch and cricoid cartilage) using train-of-four (TOF) stimulation every 12 s. After supramaximal stimulation, mivacurium 0.1 mg/kg was injected and onset, peak effect, and offset of NMB measured and compared using t-test (P < 0.05). The data are presented as mean (SD). Peak effect, onset time, and early recovery to 25% of control twitch height were not significantly different between PCA and LCA at 86% (13) versus 78% (16), 2.3 min (0.45) versus 2.3 min (1.0), and 9.55 min (3.05) versus 8.5 min (4.7), respectively. However, recovery to 75%, 90% of control twitch height, and recovery to a TOF ratio of 0.8 were significantly longer at the PCA than at the LCA at 14 min (4) versus 11 min (5), 17 min (5) versus 11.8 min (5.6), and 17.5 min (5.6) versus 12.3 min (5.5), respectively. The authors conclude that recovery of NMB at the PCA takes longer than at the LCA in humans after mivacurium.

 

多伤亡的恐怖事件: 麻醉医师的展望

Multiple Casualty Terror Events: The Anesthesiologist’s Perspective

Micha Y. Shamir, MD*,{dagger}, Yoram G. Weiss, MD*,{ddagger}, Dafna Willner, MD*, Yoav Mintz, MD§, Allan I. Bloom, MD#, Yuval Weiss, MD, Charles L. Sprung, MD*, and Charles Weissman, MD*

*Departments of Anesthesiology and Critical Care Medicine, §General Surgery, and #Radiology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; {dagger}Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, FL; {ddagger}University of Pennsylvania Medical School, Philadelphia, PA; and ¶Deputy Hospital Director, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Anesth Analg 2004 98: 1746-1752.

  

耶路撒冷在28个月内发生了14起涉及多人伤亡的恐怖活动,这对于该市唯一的一级创伤中心的麻醉科和重症监护科室是一个考验。我们根据科室的反应能力做了一项回顾性的研究来评价医务人员的活动、资源的应用(急诊室、手术室和重症监护室ICU)和病人的流动情况。总共有1062名人员在这14起多伤亡事件中受了伤。急诊室治疗了355名伤员;108人接受入院治疗,58人在最初8小时内进行了手术,只有2人在最初2小时内就接受了手术,接受第一次手术治疗的平均时间是124分钟。在恐怖事件发生了平均5.5小时之后共有51人进入重症监护室。恐怖事件一发生,麻醉科就同时动员起来,包括在急诊室里的最初的复苏工作、为手术和血管造影术的病人麻醉,以及在恢复室和ICU治疗病人。因此,这类事件明显地影响了麻醉科的工作,必须制定计划来最大程度的优化现有人员和设备的使用。

提示:在恐怖事件发生中麻醉医师为病人提供了必不可少的治疗,从最初的复苏工作到治疗或诊断性的操作。我们考察了在恐怖活动发生后的最初8小时内麻醉科所面临的操作性的问题,这些都需要科室的多方面同时的努力。

(王柯 薛张纲 校)

In a 28-mo period 14 multiple-casualty terror events occurred in Jerusalem, challenging the Department of Anesthesiology and Critical Care Medicine of the city’s sole Level 1 trauma center. We performed a retrospective review of the response of the department to evaluate staff activities, resource use (emergency department, operating rooms, and intensive care unit [ICU]), and patient flow. A total of 1062 people were injured in the 14 multi-casualty terror incidents. The emergency department treated 355 victims; 108 of them were hospitalized, and 58 underwent surgery during the first 8 h. Only two surgeries were performed during the first hour, and the average time to the first surgery was 124 min. Fifty-one patients were admitted to the ICU an average of 5.5 h after the terror event. After a terrorist act, multiple, simultaneous efforts were required of the anesthesiology department, including taking part in the initial resuscitation in the emergency department, anesthetizing victims for surgery and angiographies, and caring for them in the recovery room and ICU. Therefore, anesthesiology departments are greatly impacted by such events and must plan for them to maximize the use of available personnel and to have the appropriate equipment and supplies available.

                                                                

前路坐骨神经阻滞:适合病人身高

Anterior Approach to the Sciatic Nerve Block: Adaptation to the Patient’s Height

Carole Barbero, MD, Régis Fuzier, MD, and Kamran Samii, MD

Service d’Anesthésie Réanimation, Chu Rangueil, Cedex, France

Anesth Analg 2004 98: 1785-1788.

 

为了提高近来介绍的前路行坐骨神经阻滞时阻滞股后侧皮神经(PFCN)的机率,我们假设腹股沟连线到穿刺点之间的距离和病人的升高有关。对于13名患者行初步的放射学研究得到了关于病人升高和穿刺点“S”之间关系的一个方程式。从髂前上嵴到耻骨结节上角连一直线(腹股沟线),从腹股沟线中点到穿刺点“S”再连一直线,“S”点离开腹股沟线中点的距离根据公式计算:(身高(cm)-100/10。我们对53个病人进行了前瞻性的研究,结果显示的是平均值(范围:0.25-0.75),需要2分钟来定位深达12cm10.513cm)的坐骨神经,92%的病人完全阻滞了坐骨神经和股后侧皮神经。我们的结论是在行前路坐骨神经阻滞时应该考虑病人的身高,这样似乎能够提高阻滞股后侧皮神经的成功率,这对于病人止血带疼痛很重要。提示:我们进行了前瞻性的研究,而非对照性研究来评价一种新的前路坐骨神经阻滞技术,正如Chelly Delaunay所描述的一样,这一方法是根据解剖标志的变化,病人身高的差异而进行了穿刺点的调整。

(王柯 薛张纲 校)

To improve the incidence of block of the posterior femoral cutaneous nerve (PFCN) when using an anterior approach as described recently, we hypothesized that the distance between the inguinal line and the puncture site depends on the patient’s height. A preliminary radiological study performed in 13 patients established a formula describing the relationships between the patient’s height and the puncture site "S." A line was drawn between the anterior iliac spine and the superior angle of the pubic tubercle (inguinal line) and another line from the midpoint of the inguinal line to the puncture site "S." "S" was calculated from the midpoint of the inguinal line as "S" = (height in cm – 100)/10. A prospective study was conducted in 53 patients. Results are presented as median (range, 0.25–0.75). Two minutes were required to locate the sciatic nerve at a depth of 12 cm (10.5–13.0 cm). Complete sciatic and PFCN blocks were observed in 92% of the patients. We conclude that consideration should be given to the patient’s height when the sciatic nerve is blocked using an anterior approach. This technique seems to improve the success of block of the PFCN, essential to tolerate a thigh tourniquet.

                                                      

有无N2O情况下喉管气囊内压力和时间的相关性

Time-Related Cuff Pressures of the Laryngeal Tube With and Without the Use of Nitrous Oxide

Takashi Asai, MD, PhD, and Koh Shingu, MD

Department of Anesthesiology, Kansai Medical University, Osaka, Japan

Anesth Analg 2004 98: 1803-1806.

 

喉管(VBM Medizintechnik, Sulz, Germany)是一种新型的会厌上的气道装置,它由一根管道、两个气囊和气囊之间的两个位于远端的孔组成。使用这种装置时的一个注意点是可能引起口咽部粘膜缺血性的改变。我们研究了使用和不使用N2O时气囊内压力随时间的变化,这反映出部所受到的压力。我们将插入喉管后的24位病人随机分成2组,一组使用了66%的N2O(组N),另外一组不使用N2O(组A),2组病人均用七氟醚维持麻醉,记录气囊内压力随时间的变化和术后气道并发症。组N的气囊内压力随时间显著增加(P<0.001,最高压力:120cmH2O)然而组A气囊内压力保持不变,组N的气囊内压力要显著高于组AP<0.0001,差异的95%可信区间:30分钟时620 cmH2O)。组A2位病人、组N1位病人术后述有咽喉轻微疼痛。提示:由于N2O会引起喉管气囊内压力升高而导致咽部所受的压力增加,因此为了最大度减少口咽部粘膜缺血性改变的可能性我们建议麻醉中监测和调整喉管气囊内的压力。

(王柯 薛张纲 校)

The Laryngeal tube (VBM Medizintechnik, Sulz, Germany), a new supraglottic airway, consists of an airway tube, two cuffs, and two distal apertures between the two cuffs. One concern with the use of this device is ischemic change to the oropharyngeal mucosa. We studied the time-course change of the intracuff pressure (which reflects the pharyngeal pressure) of the laryngeal tube during anesthesia with and without nitrous oxide. After insertion of a laryngeal tube, 24 patients were randomly allocated to 1 of 2 groups. In one group (group N or nitrous oxide group), 66% nitrous oxide was used, whereas in the other group nitrous oxide was not used (group A or air group). In both groups, sevoflurane was used to maintain anesthesia. Time-course changes of the intracuff pressure and postoperative airway complications were recorded. In group N, the intracuff pressure significantly increased over time (P < 0.001; the maximal pressure: 120 cm H2O), whereas in group A the intracuff pressure remained stable. The intracuff pressure was significantly higher in group N than in group A (P < 0.0001; 95% confidence intervals for difference: 6–20 cm H2O at 30 min). Postoperatively, two patients in group A and one patient in group N complained of mild sore throat.