Anesthesia & Analgesia

June 2004

Table of Content

 

PAIN MEDICINE:

咪達唑侖的椎管內應用I:一項調查安全性的佇列研究

(黃施偉   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.

鞘內使用咪達唑侖II:鞘內合用芬太尼用於分娩

陸旭偉 薛張綱

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.

綿羊持續鞘內注射咪達唑侖的安全性

朱慧琛 譯 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.

人鞘內咪噠唑侖應用的研究過程

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

 

關節腔內注鹽水可減輕膝關節鏡後中度到重度疼痛:一項隨機對照試驗

陸旭偉 薛張綱

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.

一種簡單、快速、方便的驗證疼痛治療研究方法:單獨應用電腦檢索方案可驗證隨機對照實驗的質量

朱慧琛 譯 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.

己酮可哥堿和丙戊茶鹼局部用藥對福馬林誘發痛和大鼠爪炎性組織腫瘤壞死因數αmRNA水平的影響

    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

系統聯用氯胺酮、嗎啡治療實驗誘發投射痛的協同作用

方芳 薛張綱

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

塗肝素的體外迴圈管道對肺功能和炎症介質釋放的影響

殷文淵 譯 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.

評估消旋氯胺酮在心內直視手術中的神經保護作用

趙雪蓮   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.

肺複張可提高單肺通氣時的通氣、換氣效率

方芳 薛張綱

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.

體外迴圈後胃腸道副反應:是否可通過術前危險因數來預測

肖潔 譯 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.

米力農對兒茶酚胺預收縮的肺小動脈的擴張作用增強

    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:

小兒異氟醚麻醉中的腦電雙頻指數

鍾鳴 薛張綱

Bispectral Index During Isoflurane Anesthesia in Pediatric Patients

Simon D. Whyte and Peter D. Booker

Anesth Analg 2004 98: 1644-1649.

肝素酶改良的血栓彈性描記儀在足月和早產兒中應用

顧漪聞 譯 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:

在婦產科門診腹腔鏡檢查中用口服長效暈海寧預防術後噁心和嘔吐

馬皓琳    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

術前腸外給予Parecoxib隨後口服Valdecoxib縮短了腹腔鏡膽囊切除術後恢復時間並提高蘇醒質量

鍾鳴 薛張綱

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:

琥珀膽鹼和電休克治療後的肌肉損傷

    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.

小劑量琥珀酰膽鹼使用後的神經肌肉阻滯效應及氣管內插管條件

張俊峰 薛張綱

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.

琥珀膽鹼阻滯過程中對強直和TOF刺激反應的強直後易化和衰減

陳潔 譯 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.

美沙酮用於麻醉誘導:血漿組胺濃度,動脈血壓和心率

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.

高血壓大鼠中嗎啡引起的鎮痛,低血壓及心動過緩的作用增強

周潔 譯 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

氟烷及其它揮發性全麻藥引起黑腹果蠅視網膜電流圖的特殊變化

慧譯 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.

胰島素降低大鼠異氟醚最低肺泡有效濃度與異氟醚的脊髓效應無關

張俊峰譯 薛張綱校

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.

異氟醚可減少脊髓背角神經元內谷氨酸傳遞:鎮痛作用在突觸前起效的證據

朱輝 譯 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.

丙泊酚對脂多糖處理的單個核細胞和淋巴細胞的細胞毒性及凋亡的影響

    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:

用肌音描計法可同時監測喉部內收肌和外展肌的神經肌肉阻滯

張俊峰 薛張綱

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:

多傷亡的恐怖事件: 麻醉醫師的展望

王柯 薛張綱

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.

用先進的模擬實驗評價骨內血管途徑救助化學戰爭中傷員的應用價值:建議改變治療方案

忻紀華 譯 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.

肝外傷後未控制的失血性休克治療:液體復蘇產生致命效果和使用血管加壓素後改善轉歸

周志堅   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.

血小板活化因數受體拮抗劑能抑制細菌毒素和細菌引起的人全血細胞因數的釋放

蘇殿三 譯 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:

鞘內注射羅呱卡因所產生的相關肌肉阻滯:濃度的影響

張俊傑   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:

前路坐骨神經阻滯:適合病人身高

王柯 薛張綱

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-氯普魯卡因靜脈區域麻醉前瞻性、隨機、雙盲試驗的比較

齊波 譯 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:

髖部骨折病人術後短暫譫妄可影響術後功能狀態三個月

蘇殿三 譯 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

 

有無N2O情況下喉管氣囊內壓力和時間的相關性

王柯 薛張綱

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.

咪達唑侖的椎管內應用I:一項調查安全性的佇列研究

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

 

儘管動物研究中關於咪達唑侖椎管內應用的安全性的證據仍存在爭議,其臨床應用正在增加。我們調查了椎管內應用咪達唑侖產生神經損傷相關症狀的可能性。本研究比較兩組病人,分別接受或不接受椎管內應用咪達唑侖(2mg)。與代表潛在神經系統併發症症狀相關的18項危險因素被評估。對這些症狀的定義被放寬直至盡可能地統計到椎管內注射後有神經系統後遺症的病人。通過術後1周的病史復習和術後1月的郵寄問卷,對1100例病人進行了回顧性隨訪。包括運動或感覺改變以及膀胱或腸功能障礙等提示有神經系統損傷的症狀都被調查。椎管內應用咪達唑侖和出現神經症狀的危險性增加無關。相反,神經症狀被發現在年齡>70歲(相對危險度,8.72)和發生椎管內穿刺時有出血(相對危險度,8.07)時有增加。與一些臨床前的動物實驗結果不同,椎管內應用咪達唑侖2mg 並不增加神經系統或泌尿系統症狀。

(黃施偉   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.

 

 

人鞘內咪噠唑侖應用的研究過程

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

 

早期臨床前試驗顯示苯二氮卓類藥物在脊髓水平可能調節疼痛信號傳遞。我們對這種臨床前試驗及近來逐漸在人類應用鞘內咪噠唑侖行疼痛處理的工作進行了回顧。鞘內咪噠唑侖在人類應用的主要考慮是安全性問題,一些臨床前試驗報導增加了我們對鞘內咪噠唑侖毒性的認識。我們著重探詢這些研究的時間過程,以及如何整合以能提供可信的資料來推動臨床的應用。就咪噠唑侖而言,我們主要集中於當臨床前試驗中安全性資料被不合理地忽視時可能產生的問題和如何考慮通過顯示合理的安全特性,即對病人具有最小程度可能危害,來促進藥物的發展。此外也考慮了對鞘內應用咪噠唑侖的相關問題包括用藥方案及藥物動力學。

(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.

 

 

己酮可哥堿和丙戊茶鹼局部用藥對福馬林誘發痛和大鼠爪炎性組織腫瘤壞死因數αmRNA水平的影響

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

 

本研究旨在瞭解局部使用黃嘌呤衍生物己酮可哥堿(pentoxifylline PTF) 或丙戊茶鹼(propentofylline PPTF) 抑制細胞因數合成,能否影響大鼠痛閾、福馬林誘發痛的表現和鼠爪炎性組織腫瘤壞死因數α(TNF-{alpha})信使RNA(mRNA)的水平。PTF (0.5, 1, or 2 mg) PPTF (1 or 2 mg) 足底注射對痛閾無明顯影響。左後肢足背皮下注射12%福馬林0.1 mL可誘發疼痛表現(每5分鐘47.6 ± 4.6次),預先足底注射PTF 1 2 mg 100 µL減少福馬林誘發痛的表現(1 mg 為每5分鐘33.6 ± 2.5 次, 2 mg 23.6 ± 3.4),而事後注射無效。注射PPTF 2 mg 100 µL有類似抗痛作用;與PTF不同的是,實驗晚期,即福馬林注射後85–90 分鐘,PPTF的作用與注射時機無關,即預先注射和事後注射的效果一樣。PTF對福馬林誘發痛的影響與體積描記儀測出的鼠爪體積的變化不平行;事實上,PTF本身顯著增加鼠爪的體積。注射福馬林明顯提高鼠爪炎性組織TNF-{alpha} mRNA的水平(150%)。預先注射PTF明顯抑制(40%)TNF-{alpha} mRNA的水平的增高。本實驗證明:預先使用PTF PPTF抑制磷酸二酯酶和膠質細胞啟動,能抑制前炎性細胞因數的合成,從而拮抗福馬林誘發痛的痛覺過敏現象;而且PTF局部注射是治療炎性疼痛的有效方法。

(軒    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.

 

評估消旋氯胺酮在心內直視手術中的神經保護作用

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

我們在106例行心臟外科手術的病人中對比了應用消旋氯胺酮和雷米芬太尼兩者與異丙酚複合對神經認知功能的作用。對病人在術前和術後1周和10周進行神經認知功能測試。術後10周在對照組中有14例(25%)病人和消旋氯胺酮組有10例(20%P = 0.54)病人有2項和2項以上測試出現認知障礙(較術前降低至少一個所有病人測試的標準差)。所有測試均計算Z-評分。除了術後10周的“B”示蹤試驗(Trailmaking B test),消旋氯胺酮未表現明顯的優勢。因此我們認為與雷米芬太尼相較,在心臟直視術中氯胺酮沒有明顯的神經保護功能。

(趙雪蓮   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.

                    

 

米力農對兒茶酚胺預收縮的肺小動脈的擴張作用增強

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

 

在圍手術期經常聯合應用b-腎上腺素能激動劑(如腎上腺素和去甲腎上腺素)和磷酸二酯酶-III抑制劑(如米力農)以增強心室功能。在心肌,米力農與b-腎上腺素能激動劑產生協同作用增強心肌收縮力。但是,同時具有ab腎上腺素能活性的兒茶酚胺類藥物與米力農之間對肺循環的潛在相互作用還不確定。我們評價了米力農和硝酸甘油對分別經過具有ab腎上腺素能活性的兒茶酚胺(腎上腺素和去甲腎上腺素)、a受體激動劑苯腎上腺素、非腎上腺素能激動劑-血栓素類似物U46619預收縮的豬肺彈性大血管和含肌肉小血管環的舒張作用。在肺小動脈,米力農對腎上腺素或者去甲腎上腺素預收縮的血管環的舒張作用比使用苯腎上腺素或者U46619預收縮的血管環的舒張作用明顯增強。然而,在大的肺動脈,米力農對所有血管環的擴張作用均相似,不受預收縮藥物的影響。與此明顯不同的是,不管是大的肺血管還是小血管環對硝酸甘油的血管擴張反應均不受預收縮藥物的影響。所以,當聯合使用具有b腎上腺素能激動活性的藥物時,米力農對肺血管的作用增強。磷酸二酯酶-III抑制劑和兒茶酚胺(腎上腺素和去甲腎上腺素)的擴血管相互作用表明當心室功能障礙合併肺血管阻力增加時聯合使用這兩種藥物是有利的。

(顏    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.

 

 

在婦產科門診腹腔鏡檢查中用口服長效暈海寧預防術後噁心和嘔吐

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

 

暈海寧是一個便宜的止吐藥,副作用極少,現有含25 mg即刻釋放藥物及50 mg緩釋藥物的口服長效(LA)製劑(Gravol L/A)。我們設計了這個雙盲比較試驗來評價門診婦產科腹腔鏡檢查中暈海寧LA對比氟呱利多單用及二者合用預防噁心、嘔吐和幹嘔的功效。141例女性隨機分成3組:1) 氟呱利多(術前安慰劑膠囊,誘導前氟呱利多0.625 mg IV);2) 術前暈海寧LA,誘導前安慰劑IV3) 合用。在麻醉後恢復室(PACU)記錄關於噁心、嘔吐、幹嘔、疼痛和鎮靜的資訊,並通過電話收集病人剛到家、睡覺前、術後第一天起床和午餐時症狀的發生。氟呱利多組、暈海寧組和合用組各症狀治療失敗(在PACU中解救藥物治療或在任何時點噁心、嘔吐或作嘔)的總發生率分別為28/4661%)、28/4858%)和22/4747%),嘔吐治療失敗(在PACU中解救藥物治療或在任何時點嘔吐或幹嘔)的總發生率分別為16/4635%)、11/4823%)和5/4711%)(氟呱利多組對比合用組P0.007)。在鎮靜和疼痛方面無差異。術前給予一個口服劑量的LA暈海寧和氟呱利多合用與單用氟呱利多比較,有效降低擇期門診婦產科腹腔鏡檢查的女性嘔吐(而非噁心)的發生率。

(馬皓琳    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.

 

琥珀膽鹼和電休克治療後的肌肉損傷

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
 

在電休克治療中,琥珀膽鹼和抽搐都能引起肌肉損傷。我們比較了兩組別人的肌肉損害。精神病人組在電休克治療前使用琥珀膽鹼。外科病人組使用琥珀膽鹼行氣管插管。測定血清肌紅蛋白作為肌肉損傷的指標,同時記錄肌痛症狀。兩組在用藥後5分鐘和20分鐘時的血清肌紅蛋白值都比基礎值增加。但是給予琥珀膽鹼後5分鐘和20分鐘,外科病人組比精神病人組的肌紅蛋白水平更高(P < 0.001)20分鐘時精神病人組的肌紅蛋白濃度的中位數(範圍)是32.6 (23.1–60.1) ng/mL,外科病人組為61.2 (31.6–1687.0) ng/mL。肌痛的發生率兩組沒有差異。結論,我們意外地發現,由琥珀膽鹼引起的肌肉損傷,在接受電休克治療的精神病人比外科病人輕。

(張    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.

 

美沙酮用於麻醉誘導:血漿組胺濃度,動脈血壓和心率

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

 

儘管美沙酮廣泛用於緩解急慢性疼痛,還沒有人研究過靜脈單次給予美沙酮對血流動力學的效應。我們比較麻醉誘導採用依託咪酯0.3mg/kg複合靜脈給予單次劑量美沙酮20mg或芬太尼10ug/kg對血流動力學的效應。接受大手術的43名患者按雙盲隨機原則分為2組。給予美沙酮或芬太尼前和給藥後2分鐘測定血漿組胺濃度。通過有創動脈壓監測在給予美沙酮或芬太尼前、依託咪酯前、氣管插管之前、氣管插管時和氣管插管後1分鐘分別測定血壓和心率。美沙酮組和芬太尼組在任何時點其平均心率無顯著差異。芬太尼組在插管前、插管時和插管後1分鐘的收縮壓和舒張壓明顯降低,且差異具有統計學意義(P < 0.05)。在給予美沙酮前後,血漿組胺濃度均值分別為1.54 ng/mL (SD, 0.65 ng/mL)1.57 ng/mL (SD, 1.37 ng/mL);給予芬太尼前後,血漿組胺濃度均值分別為1.00 ng/mL (SD, 0.58 ng/mL) 1.04 ng/mL (SD, 0.47 ng/mL)。儘管兩組血漿組胺濃度均值無顯著差異,但是美沙酮組的23名患者中有2名患者血漿組胺濃度明顯升高。但當血漿組胺濃度高達6.2 ng/mL時,未發現與之有關的明顯的血流動力學改變。美沙酮可能引起組胺釋放。儘管在此次試驗中,美沙酮並沒有造成血流動力學不穩,但是當靜脈給予單次大劑量美沙酮時應該考慮到有可能因為組胺釋放而產生血流動力學方面的副作用。

(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.

 

氟烷及其它揮發性全麻藥引起黑腹果蠅視網膜電流圖的特殊變化

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
 

對較高級生物的生理研究為研究麻醉藥物對整體生物行為的影響提供了頗有價值的補充。然而,儘管對黑腹果蠅的運動功能進行的大量研究用來識別與麻醉有關的基因,但是對這種無脊椎動物麻醉作用的電生理研究仍非常有限。我們發現視網膜電流圖(ERG)這種從眼球表面細胞外記錄的由光觸發總體電位,在氟烷、安氟醚、異氟醚以及地氟醚麻醉時有明顯的影響。這些揮發性麻醉藥在作用相關濃度時,明顯抑制ERG光關閉時的暫態成分,而ERG的其他主要成分,如光感受器電位和燈亮瞬間電流並不總是受這些藥物的影響。令人驚訝的是,對大多數麻醉藥物來說, ERG光關閉暫態電流的抑制僅在短光脈衝時可見。不使用麻醉藥物而是抑制Shaker鉀離子通道的功能也能達到同樣的效果。通過一個簡單的基因試驗驗證了氟烷通過關閉鉀離子通道作用於視覺環路的可能性,結果與假設基本一致,但缺乏確切的證據支持。不過,我們的研究確定ERG作為一種有用的工具,不但可用於檢驗揮發性麻醉藥物對一個簡單環路的影響,而且可識別對麻醉藥物敏感度起作用的基因。

(朱 慧譯 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

 

丙泊酚對脂多糖處理的單個核細胞和淋巴細胞的細胞毒性及凋亡的影響

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

靜脈麻醉藥可能抑制適當的免疫反應和進一步損害已降低的抵禦系統。為評定丙泊酚在膿毒血症時對人類免疫功能的可能作用,我們研究了單個核細胞(MNCs)的細胞毒性和凋亡。外周血單個核細胞在1µg/mL脂多糖中預孵育,然後在不同濃度的丙泊酚(1 µg/mL, 5 µg/mL, 10 µg/mL,50 µg/mL)中再次孵育。將單個核細胞(4 x 105/100 µL)和作為靶細胞的K-562腫瘤細胞 (1 x 104/100 µL) (E: T 比率 40:1)混合,通過檢測乳酸脫氫酶釋放來確定細胞毒性。用流式細胞儀測annexin陽性細胞來確定凋亡。脂多糖處理的單個核細胞的細胞毒性和凋亡在臨床可接受的丙泊酚濃度(1 µg/mL, 5 µg/mL, 10 µg/mL)下無改變。然而,50 µg/mL丙泊酚處理組則可以觀察到細胞毒性(P = 0.004)和凋亡(P = 0.002)有顯著變化。通過對單個核細胞的分選,我們發現50 µg/mL丙泊酚使淋巴細胞凋亡顯著增加,但單核細胞未受影響(P = 0.02)。從細胞毒性和凋亡的方面來說,丙泊酚使單個核細胞通過保護免疫細胞不凋亡,使其在膿毒血症時保持細胞毒性。

(吳    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.

 

肝外傷後未控制的失血性休克治療:液體復蘇產生致命效果和使用血管加壓素後改善轉歸

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

 

在一個失控性出血性休克豬的模型中,我們對使用血管加壓素、等量安慰劑鹽水或液體復蘇這三種方法,在血液動力學參數和近期生存效果上進行評估。二十一頭麻醉的豬被用於嚴重肝外傷的研究。當平均動脈壓低於20mmHg、心率下降時,隨機給予血管加壓素(0.4 U/kg; n = 7),等量安慰劑鹽水(n = 7)或復蘇液體(乳酸林格氏液及羥乙基澱粉hetastarch1000 mL; n = 7)。干預後三十分鐘,存活的豬使用手術方法止住出血同時,進行進一步液體復蘇。在血管加壓素組,干預後五分鐘的平均動脈壓(± SEM)高於安慰劑組和液體組(三組分別為58±97±3 32±6 mmHg),差異有顯著性(P < 0.05)。使用血管加壓素能改善腹部器官血流量,但不會導致進一步出血(干預後十分鐘血管加壓素組、安慰劑組、液體復蘇組失血量分別為1343 ± 60ml1350 ± 22ml2536 ± 93 mLP < 0.01)。血管加壓素組的全部七頭豬都存活至出血被控制,並維持60min。然而七頭安慰劑組和七頭液體組的豬都死亡(P < 0.01)。故我們得出結論:血管加壓素,而不是安慰劑或液體復蘇,在失控性失血性休克中可以顯著改善短期生存率。

(周志堅   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.

 

 

鞘內注射羅呱卡因所產生的相關肌肉阻滯:濃度的影響

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.

 

我們通過觀察鞘內注射1%和0.1%的羅呱卡因時肌肉阻滯的平均ED50值,來判斷其不同濃度對肌肉的阻滯作用。本實驗為前瞻,隨機,雙盲和序列分配,對象為54例擇期行剖腹產孕婦,麻醉方法為硬膜外聯合蛛網膜下腔阻滯。孕婦隨機分入鞘內注射1%羅呱卡因組或0.1%羅呱卡因組。首次劑量為4mg,隨後劑量根據前一患者的反應來決定(試驗劑量差距為1mg)。用藥後5分鐘內雙下肢產生任何肌肉阻滯作用即被認為有效。5分鐘內產生肌肉阻滯作用的1%羅呱卡因組劑量為6.1mg95% 可信區間, 5.1–7.1),0.1%羅呱卡因組劑量為9.1mg95% 可信區間, 7.8–10.3(P = 0.0013; 95% 可信區間差異, 1.3–4.7)。高濃度組的效能是低濃度組的1.5(95% 可信區間 1.2–1.9)。妊娠患者蛛網膜下腔使用羅呱卡因肌肉阻滯作用的ED50明顯受到藥物濃度的影響,在低濃度時所需劑量增加約50%。

(張俊傑   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.

 

 


綿羊持續鞘內注射咪達唑侖的安全性

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

 
作者研究了動物模型中持續鞘內注射咪達唑侖的安全性。利用自動輸注系統(SynchroMed泵加上矽樹脂導管)給羊和豬持續鞘內注射無添加劑的咪達唑侖。羊咪達唑侖注射劑量為5mg/d (n=4)15mg/d (n=7)或生理鹽水(n=2),125 µL/h43天。另一頭羊注入咪達唑侖10mg/d。注射濃度從1.7—2.5mg/ml5mg/d)和2.5—5.0mg/ml15mg/d)。豬組僅注射咪達唑侖15mg/dn=2)或生理鹽水(n=1),輸注速率125 µL/h,共43天。記錄動物行為表現、神經系統功能及生命體征,評估血清和腦脊液的生化及細胞學形態、脊髓的組織學狀況。結果:所有受試動物的行為表現和神經系統功能都正常,肉眼和顯微鏡下均觀測到導管周圍的組織有輕度炎症反應,炎症可能由於導管自身的機械因素所引起。結論:持續鞘內注入不含添加劑的咪達唑侖(15mg/d以下)是安全的。

(朱慧琛 譯 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.


一種簡單、快速、方便的驗證疼痛治療研究方法:單獨應用電腦檢索方案可驗證隨機對照實驗的質量

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


臨床醫生需要一個簡單、快速、可靠、價廉的方法以驗證其基於臨床實踐中的觀察結果。通常認為唯一的方法就是人工查閱一些文獻輔助電腦檢索,但這很繁複且勞動強度大。疼痛醫學研究中大多數隨機對照試驗均在電腦資料庫中。作者設計了兩組實驗方案以確定其有效性即敏感性、特異性及精確性,後者通過三種電腦方案檢索。即Cochrane 協作, 隨機臨床試驗標準聯機醫學文獻分析與檢索系統隨機雙盲臨床試驗(DBRCT.af)是一種新的獨立電腦系統,假設要檢索雙盲、隨機實驗可以雙盲”“隨機在任何一個MEDLINE醫學文摘資料庫(EMBASE)中查找。DBRCT.af在檢索鎮痛研究的隨機實驗中有很高的敏感性(97%)、精確性82%,在去除非隨機實驗時的特異性為98%。結論:臨床醫師在鎮痛研究時可運用DBRCT.af獲取最新資料。

(朱慧琛 譯 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.



塗肝素的體外迴圈管道對肺功能和炎症介質釋放的影響

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
體外迴圈(CPB)中和CPB後往往使用塗有肝素的管道來減少炎症反應。但這種減少的反應是否也降低了CPB導致的肺功能不全仍存爭議。因此作者評估了塗抹肝素的體外迴圈管道和相類似的無肝素塗抹的管道對CPB中和後的肺指數和炎症補體啟動標誌物(C3b/c,彈性蛋白酶-α1-抗胰蛋白酶複合體和分泌型的磷脂酶A2sPLA2)的影響。51名接受冠狀動脈旁路移植手術病人隨機分為兩組,分別使用肝素塗抹組(組1)或肝素未塗抹組(組2)。CPB期間,維持持續氣道正壓(5cmH2O)和吸入氧濃度21%。CPB後和監護室內兩組病人的肺分流分數(P<0.05)和肺血管阻抗指數(P<0.05)和PaO2/FIO2比(P<0.05)支援應用肝素塗抹管道。CPB期間和CPB後,組1顯示較低的sPLA2。在CPB後,組1 C3b/c和彈性蛋白酶-α1-抗胰蛋白酶複合體顯著減少(P<0.001)。肝素塗抹管道減少炎症反應,降低肺血管阻力指數和肺分流分數,增加PaO2/FIO2比,可能對肺功能有益。sPLA2相關白細胞反應和術後白細胞計數均支持肝素塗抹管道降低了肺毛細血管內皮細胞啟動。

(殷文淵 譯 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.


體外迴圈後胃腸道副反應:是否可通過術前危險因數來預測

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
雖然心臟手術後胃腸道副反應的發生率不高,但由於其可導致發病率和死亡率的增加而成為臨床上重要問題。如果在術前能證實患者具有危險因數對圍術期處理策略大為有益。作者觀察了來自24家不同的美國醫療中心圍術期缺血研究中2417位患者(均接受心肺轉流的心臟手術),評價並記錄患者是否發生了胃腸道副反應。結果5.5%的患者存在胃腸道副反應(133/2417),院內死亡率上升6.5%,ICU入住時間延長1周,術後的住院時間延長一倍(P<0.0001)。術後出現胃腸道副反應的預測因數包括:左室功能減低,高膽紅素血症,血小板減少症,部分凝血活酶時間延長,心血管手術史,冠狀動脈旁路移植聯合心內或近端主動脈手術,心血管藥物支持和術中輸血。本文顯示心臟手術後胃腸道副反應繼發於內臟灌注的減少,並有許多預測因數。因此,術前存在危險因數的病人可從術中嚴密的血流動力學處理中獲益。

(肖潔 譯 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


肝素酶改良的血栓彈性描記儀在足月和早產兒中應用

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


血栓彈性描記儀用於評估嬰兒和兒童的凝血功能,是一種非常有前景的測試方法。它僅用300µL全血就可以快速評估凝血功能,並且還可以提供很多資訊:如血漿凝血,血小板功能,纖維蛋白溶解功能。在這項研究中,作者用TEG來評價早產和足月兒的凝血系統,以瞭解其由於凝血因數不足所造成止血功能的影響。臨床情況穩定的的嬰兒分成四組:重度早產兒(孕齡:27-31周);中度早產兒(孕齡:32-36周);足月兒(孕齡:36-40周);前早產兒(修正孕齡:34-40周),評估其肝素酶修正TEG,血小板和紅細胞計數,血漿纖維蛋白原,以及前凝血酶原時間等,並以健康成人志願者作為對照組。結果顯示,和成人組相比,TEG測試臨床情況穩定的嬰兒其凝血功能正常,部分患兒而且常規凝血功能測試的易變性。與常規的凝血功能檢查不穩定。由於臨床穩定早產兒和足月兒相對較少出血,儘管延長常規凝血功能檢查時間,TEG較常規凝血功能檢查更好地反映嬰兒的凝血狀態。

(顧漪聞 譯 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.


琥珀膽鹼阻滯過程中對強直和TOF刺激反應的強直後易化和衰減

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

 
本實驗研究單次注射琥珀膽鹼後TOF或強直刺激後的衰減和易化情況。前瞻性、隨機、雙中心觀察100名患者,分為5組,在異丙酚、芬太尼和笑氣麻醉中分別接受0.10.20.50.751mg/kg的琥珀膽鹼。使用TOF肌動圖來監測神經肌肉功能。在10%~20%的肌力恢復時,TOF的刺激模式改變為1 Hz的單次刺激,接著持續5秒的50Hz的強直性刺激,3秒鐘之後,1 Hz的單次刺激反復持續30秒直至TOF反應完全恢復。琥珀膽鹼誘導的神經肌肉阻滯具有以下特點:1)抽搐增強先於抽搐抑制,小劑量(0.1~0.3mg/kg)比大劑量(0.5~1.0mg/kg)更明顯;2TOF衰減貫穿於阻滯的開始和恢復;3)強直衰減;4)強直後易化。強直後易化的程度與強直前抽搐的程度相關,與琥珀膽鹼的劑量無關。在劑量減少到0.3mg/kg時,在作用開始和恢復中均能觀察到II 相阻滯。不同劑量琥珀膽鹼後強直刺激和TOF刺激引起強直後易化和衰減。

(陳潔 譯 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.


高血壓大鼠中嗎啡引起的鎮痛,低血壓及心動過緩的作用增強

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

許多研究顯示心血管功能和急性非炎症性疼痛兩者間經阿片類相互聯繫。通過對照有關的研究發現,阿片類藥物、高血壓和炎症性疼痛之間存在聯繫。作者使用甲醛建立急性炎症疼痛模型,比較自發性高血壓鼠(SHR),同基因源正常血壓組,Wistar-Kyoto(WKY)Sprague-Dawley(SD)之間嗎啡的抗傷害性作用。傷害性的評估包括行為和心血管功能變化 (平均動脈壓和心率的增加)。嗎啡(3.0mg/kg) 皮下注射後SHR組比WKY組和SD組更易發生低血壓和心動過緩。給予甲醛(5%;50µL)後在1階段和2階段SHR對照組比WY對照組有更明顯的傷害性表現。嗎啡組結果與之不同,顯示嗎啡減弱了甲醛疼痛刺激敏感性。SHR組,嗎啡抑制了水腫,但不能抑制過高熱,瑞芬太尼在階段1至階段2的過渡中產生一個相對短的延遲。作者建議術中(為了減少心血管系統併發症)和術後(使鎮痛作用盡可能完善)使用阿片類藥物時要考慮術前是否存在高血壓。  

(周潔 譯 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).


異氟醚可減少脊髓背角神經元內谷氨酸傳遞:鎮痛作用在突觸前起效的證據

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


揮發性麻醉劑的最低肺泡濃度(MAC)定義是麻醉劑對傷害性刺激下體動反射的抑制能力。因此,MAC可在一定程度上反映對運動神經興奮能力的抑制。在這項研究中作者評估異氟醚對大鼠體外輸入固定疼痛刺激後脊髓水平的電生理變化。作者用全細胞膜片鉗技術記錄大鼠脊髓橫切片神經細胞及膠質細胞的電位變化。研究異氟醚對背根刺激(eEPSC),自發電流 (sEPSC)和微小電流(mEPSC)誘發的興奮性突觸後電流(EPSC)的影響。異氟醚能可逆地降低eEPSC的振幅至39%±22%,降低sEPSC mEPSC的頻率分別為39%±26%63%±7%,而mEPSC sEPSC的振幅和動力學沒有變化。結論:異氟醚能抑制疼痛刺激初級傳導途徑突觸內傳遞,可能通過降低興奮性遞質釋放實現的。這種作用可能是揮發性麻醉劑在脊髓水平產生的抗傷害作用。

(朱輝 譯 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.



用先進的模擬實驗評價骨內血管途徑救助化學戰爭中傷員的應用價值:建議改變治療方案

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


本研究中治療方案是針對化學戰爭中傷員在早期治療階段無靜脈開放途徑而進行的。在大量傷員救助時,由於時間限制和醫務人員身著防護裝備而無法靈活操作以及受害者複雜的臨床表現致使標準靜脈注射方法變得不實用。一種新開發的彈簧驅動、扳機操作骨內注射裝置可以提供有效的補液。精密的模擬器用於類比化學戰爭傷員的救治,評價骨內注射裝置的可行性。作者評價了醫務人員在全套防護裝備時的臨床操作。模擬實驗中觀察骨內插入的成功率,完成治療目標的時間和預後。醫療隊來自以色列的大醫院,對化學戰爭中的傷亡做緊急反應,接受模擬實驗的培訓。全部94名優秀的內科醫生提供傳統的治療程式,64名實驗組的內科醫生接受骨內內注射裝置的培訓。結果實驗組的存活率為73.4%,對照組為3.3% p<0.001)。實驗組在3.5分鐘(範圍,1-9分鐘)內達到治療目標,對照組則用了10分鐘以上。骨內注射的併發症為13.8%。醫務人員對骨內注射裝置表示滿意。因此,新一代的骨內注射方法對化學戰爭中傷員的早期救治具有很大的潛在價值。

(忻紀華 譯 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.


血小板活化因數受體拮抗劑能抑制細菌毒素和細菌引起的人全血細胞因數的釋放

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,血小板活化因數受體(PAFR)抑制劑(TCV-309)能夠減少由於脂多糖(LPS)誘導的小鼠的死亡率和腫瘤壞死因數(TNF)的釋放。但是TCV-309對於葡萄球菌毒素BSEB)或細菌誘導的細胞因數釋放的影響還沒有報導。本研究中作者報導了TCV-309LPSSEB和革蘭氏陽性及陰性細菌引起的細胞因數釋放的影響。研究者將人類全血5:1稀釋後置入24孔板中。將10ulLPSSEB、大腸桿菌或金黃色葡萄球菌分別加入到24孔板中。37°C孵育6小時後檢測孵育液TNFIL-6IL-8。結果表明,在6小時的孵育過程中,TCV-309並不影響大腸桿菌和金黃色葡萄球菌的生長。LPSSEB、大腸桿菌和金黃色葡萄球菌都能夠誘導人全血的釋放TNFIL-6IL-8TCV-309則能夠明顯抑制這種誘導反應。作者認為,血小板啟動因數受體在細菌和細菌毒素誘導的細胞因數釋放中具有重要作用。

(蘇殿三 譯 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-氯普魯卡因靜脈區域麻醉前瞻性、隨機、雙盲試驗的比較

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


本隨機、前瞻性、雙盲試驗比較研究了0.5%氯普魯卡因和1%氯普魯卡因各40ml在靜脈區域麻醉時起效至作用完全的時間及對止血帶耐受情況。採用雙袖帶技術150名患者在靜脈區域麻醉下實施前臂手術,試驗中疼痛評分超過4分,則從近端袖帶轉換至遠端袖帶。結果發現當轉換至遠端袖帶時,0.5%氯普魯卡因組中69%的病人的疼痛評分降到4分以下,而1%濃度組則達到88%P0.0477)。另外,兩組病人對遠端止血帶疼痛的反應不同(P0.020)。注藥後起效到作用完全的時間:0.5%氯普魯卡因組為13±1分鐘, 1%氯普魯卡因組為11±1分鐘(P0.0006)。止血帶鬆馳後,0.5%濃度組6名病人出現全身局麻藥中毒症狀,1%濃度組則有28名(P0.0001)。因此,1%氯普魯卡因鎮痛起效時間增快,並增加病人對遠端止血帶疼痛的耐受性,但在獲取上述益處同時副反應增加了4倍。

(齊波 譯 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.



髖部骨折病人術後短暫譫妄可影響術後功能狀態三個月

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
目前對於短暫的術後譫妄DEL)如何影響術後的功能狀態還不清楚。本研究中,作者研究了有術後短暫DEL的髖部骨折病人和沒有DEL病人生活質量差異。研究者應用意識錯亂評分法(CAM)每天評估髖部骨折的老年病人術後DEL情況。術後第6周和第3個月再次進行CAM評分、生活狀況和每天的活動情況。病人分成兩組:DEL組是指在術後住院期間任何時候發生DEL的病人,沒有DEL組指病人住院期間術後沒有觀察到DEL的病人。共有92個病人參與了該項研究,其中有26人(28%)有DEL出現。第6周時81人,第3個月時76名患者參加了調查。有8個病人在研究期間內死亡。在第6周和第3個月的調查中大部分DEL病人沒有和家庭生活在一起(第3個月時27%出現DEL的患者沒有和家人生活在一起,而沒有出現DEL的患者只有8%)。第三個月時兩組病人的日常活動情況沒有明顯的區別。研究者認為術後DEL持續到術後6周是髖部骨折病人術後長期功能預後的較差危險因素,能夠明顯影響術後病人的獨立生活能力。

(蘇殿三 譯 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.

鞘內使用咪達唑侖II:鞘內合用芬太尼用於分娩

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

最近的研究致力於通過在芬太尼中加入其他類的鎮痛藥來提高鞘內鎮痛的效果。在這項研究中,我們評價了鞘內使用咪達唑侖在提高芬太尼鎮痛效果及持續時間方面的效果而且不引起副反應。30名宮口開大2-6公分的產婦被隨機分為三組。組1,鞘內使用咪達唑侖2mg;2,鞘內使用芬太尼10μg;組3,兩者合用。在注藥前,注藥後30分鐘內每隔5分鐘,然後每隔30分鐘直到患者再次需要鎮痛藥,這幾個時間點測痛覺評分。監測噁心,嘔吐,皮膚瘙癢,頭痛,鎮靜的發生率及程度加上動脈壓,心率,呼吸頻率,對冷的感覺異常,運動損害,心電圖和Apgar評分。在2天後及1月評價產婦神經損傷。單獨鞘內使用咪達唑侖對注藥前的疼痛評分沒有影響,芬太尼可以輕微降低疼痛評分。加用咪達唑侖可以提高芬太尼的鎮痛作用。沒有一種治療方法對迴圈呼吸及運動有影響。鞘內芬太尼中加用的咪達唑侖不會增加母體產生不良反應的幾率。總之,鞘內使用咪達唑侖可以增強芬太尼的鎮痛作用並且不增加母嬰不良反應的發生率。

(陸旭偉 薛張綱 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.

                                                                   

 


關節腔內注鹽水可減輕膝關節鏡後中度到重度疼痛:一項隨機對照試驗

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

我們以前在2項隨機臨床試驗中比較過關節內使用鎮痛藥和鹽水10 mL。關節內使用鹽水的患者疼痛很快緩解。鹽水可能通過冷凍或稀釋關節內的致痛物質達到局麻藥的作用。這項雙盲隨機研究比較了關節內10 mL鹽水和純安慰劑組,1 mL鹽水。在79位患者的關節內置入一根軟管。我們採納了60名在全麻下行膝關節鏡的患者。他們術後1小時內都發生中到重度的疼痛。然後我們用10 mL1 mL鹽水進行隨機雙盲的研究。我們記錄了疼痛的程度,疼痛的緩解以及鎮痛藥的用量。在1小時內,兩組患者的疼痛程度(VAS 0-100 mm)從50降到27。在36小時的觀察期中疼痛的程度保持低水平,在其他項目上兩組也沒有差別。患者關節內使用1mL10mL的鹽水的作用是一樣的。我們發現了安慰劑的主要作用,這可以用於解釋以前發表的安慰劑對照的關節內鎮痛研究。

(陸旭偉 薛張綱 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.

                                                               

 

系統聯用氯胺酮、嗎啡治療實驗誘發投射痛的協同作用

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.

 

我們在此項研究中評價是否聯用氯胺酮(KET)——NMDA受體拮抗劑、嗎啡(MO)可以導致增強的止痛效果。有11名大腿皮膚燒傷的患者充當志願者。實驗採取隨即、交叉、雙盲,共分為4組如下(1)單用KET靜注9 µg • kg–1 • min–1; 45 min (2) 單用MO靜注10 µg • kg–1 • min–1; 10 min (3)以上兩者聯用(4)安慰劑組,生理鹽水; 10 min。相對於安慰劑而言,KET可減少機械刺激次級痛覺過敏(SH)區域。KET單用或聯用MO均可成倍提高初級痛覺過敏(PH,即燒傷)區域和SH區域的機械疼痛閾值,而MO靜注則對SH區域或疼痛閾值無效。通過給予30s重複刺激(40-g 3 Hz)並連續進行視覺類比評分,而後分析評分總和。聯用KETMO幾乎可以消除PHSH區域放射痛,而單用KETMO則無此效果。這項研究NMDA受體拮抗劑及阿片樣藥物在中樞疼痛總和中具有協同作用提供了實驗室依據。

這是首次人體試驗關於聯用NMDA受體拮抗劑氯胺酮及嗎啡在中樞感覺促進程式中的協同鎮痛作用。

(方芳 薛張綱 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.

                                                                

肺複張可提高單肺通氣時的通氣、換氣效率

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.

 

單肺通氣(OLV)時通氣側肺不張損害動脈血氧合,增加死腔量。我們通過單次呼吸CO2 測試(SBT-CO2)研究了單肺通氣期間肺泡複充(ARS)對肺通氣及換氣的影響。12名胸外科手術患者依次觀察三個時間點:(a)雙肺通氣期間(b)OLV期間ARS(c) OLV期間ARS後。ARS選擇性應用於通氣側肺,增加吸氣峰壓至40 cm H2O ,呼氣末壓20 cm H2O ,如此連續10次呼吸持續3分鐘。每個時間點末記錄動脈血氣、SBT-CO 、代謝及血液動力學變數。雙肺通氣期間的動脈血氧合及死腔量要好於OLVOLV期間肺複充後PaO2提高(分別是244 ± 89 mm Hg144 ± 73 mm Hg; P < 0.001),同時 SBT-CO2提示死腔量減少、肺通氣效率提高。總之,OLV期間ARS可提高肺通氣換氣效率。

(方芳 薛張綱 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.

 

                                                           

小兒異氟醚麻醉中的腦電雙頻指數

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

 

腦電雙頻指數(BIS)是過去用於成人的麻醉深度監測,但現已研究用於七氟醚麻醉的小兒.我們測試了BIS和異氟醚的濃度-反應關係.30例小兒行心導管術術中連續接受BIS監測,並記錄6個濃度在1.5%0.5%之間的異氟醚呼氣末穩態(EtIso)和覺醒時的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間存在負相關(r = –0.634; P < 0.01).1.5%比之1.3%,所有病例相鄰EtIso 的平均BIS值間存在顯著差異.抑制性的SEmax模式可最佳的描述這種BIS和異氟醚的濃度相關性,其中50%有效劑量濃度為0.85%(95%可信區間,0.72%-0.98%).初次覺醒的BIS平均值為78.5 ± 12.3. EtIso BIS間的關係在質和量上都與異氟醚在成人中和七氟醚在小兒中所描述的類似.這些結果進一步證實了BIS足以校正而用於大於1歲的小兒

(鍾鳴 薛張綱 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.

                                                            

術前腸外給予Parecoxib隨後口服Valdecoxib縮短了腹腔鏡膽囊切除術後恢復時間並提高蘇醒質量

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

 

在這項隨機、雙盲、安慰劑對照研究中,我們評價了行選擇性腹腔鏡膽囊切除病人術前靜脈給予Parecoxib以及術後口服Valdecoxib在恢復時間、資源利用、阿片藥物相關的副作用和病人蘇醒等方面的作用。病人在誘導前3045分鐘被隨機分為單一靜脈給予Parecoxib 40mg組(n134)和安慰劑組(n129)。靜脈給藥612小時後,parecoxib組給予單一口服劑量的Valdecoxib 40mg,術後14天每日口服Valdecoxib 40mg一次,57天按需每日口服40mg一次。parecoxib/valdecoxib組病人與對照組(90 ± 49 min)相比在麻醉後監護室的停留時間更短(78 ± 47 minp<0.05)。parecoxib/valdecoxib組病人同對照組相比疼痛強度降低了,在送回病房後首個24小時內嘔吐減少了,睡眠更好,更早恢復正常活動,顯示出更多的滿意(p<0.05)。術前Parecoxib術後valdecoxib是腹腔鏡膽囊切除術後疼痛治療和提高病人預後的有價值的附加治療。

(鍾鳴 薛張綱 )

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.

 

小劑量琥珀酰膽鹼使用後的神經肌肉阻滯效應及氣管內插管條件

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的琥珀酰膽鹼通常能夠在60 s 內產生良好的氣管插管調節。然而在該劑量下,如果不作扶助呼吸,呼吸肌的恢復時間要長於血紅蛋白去氧和的時間。該研究中,我們比較明確使用較小劑量的琥珀酰膽鹼是否能夠產生滿意的插管條件,並且是否縮短恢復時間。芬太尼和異丙酚麻醉誘導,異丙酚和N2O麻醉維持。 麻醉誘導後,115例患者根據琥珀酰膽鹼的劑量隨機分為5組(0.3 mg/kg, 0.4 mg/kg, 0.5 mg/kg, 0.6 mg/kg, or 1.0 mg/kg)。採用加速肌電圖記錄1-Hz持續超強刺激尺神經時拇內收肌的收縮反應。 注射琥珀酰膽鹼後60 s時評價氣管插管的條件。 分別記錄起效時間、最大肌顫搐抑制程度、麻痹後開始監測到肌顫搐的時間、恢復10%, 25%, 50%90% 的肌顫搐高度的時間。計算膈肌開始運動的時間和恢復規律自主呼吸運動的時間。起效時間範圍在5282 s,並且隨著琥珀酰膽鹼劑量的增加起效時間縮短, 但是在起效時間在0.6 1 mg/kg組間無顯著性差異。0.5, 0.61 mg/kg (98.2%–100%)組間最大肌顫搐抑制程度相似。肌顫除高度的恢復及呼吸窒息時間呈劑量依賴性效應。注射0.3 0.4mg/kg的琥珀酰膽鹼後不能獲得可接受的插管條件。在0.5, 0.61 mg/kg組均可獲得可接受的插管條件。在0.61 mg/kg組間插管條件相同,而T1 = 50% 90%及恢復規律自主的呼吸囊運動的時間在0.6mg/kg (分別為5.78, 7.25, 4.0 min) 1 mg/kg (分別為8.55, 10.54, 6.16 min)間有顯著性差異。使用0.50.6 mg/kg的琥珀酰膽鹼後60 s時都可獲得可接受的插管條件。0.6 mg/kg1.0mg/kg的琥珀酰膽鹼可產生相似的臨床插管條件,但是0.6 mg/kg的琥珀酰膽鹼具有較短的肌顫除恢復時間和呼吸窒息時間。結論:在正常健康患者中, 0.6 mg/kg1.0mg/kg的琥珀酰膽鹼可產生相似的臨床插管條件,但是0.6 mg/kg的琥珀酰膽鹼具有較短的恢復時間。

(張俊峰 薛張綱 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.

 

胰島素降低大鼠異氟醚最低肺泡有效濃度與異氟醚的脊髓效應無關

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

 

觀察結果發現胰島素具有鎮痛效應的成分,這提示使用胰島素可能降低產生MAC(指消除50%患者對傷害性刺激反應的最低肺泡麻醉藥濃度)的吸入麻醉藥濃度。我們假設胰島素通過直接影響神經系統和/或降低血糖濃度降低MAC。使用異氟醚麻醉大鼠,分別採用鞘內注射或靜脈注射胰島素,通過增加胰島素的輸入速度記錄相應異氟醚的MAC 的變化(分開評估大鼠前肢和後肢的運動)。輸注胰島素產生劑量相關性的MAC降低效應,但是在組間無顯著性差異。也就是說在相同的胰島素輸注速度下靜脈輸注組和鞘內注射組產生相似的MAC降低效應。在同時輸注胰島素和5%葡萄糖液的大鼠中血糖濃度要高。然而分別根據大鼠前肢和後肢確定的MAC值變化百分比間無顯著性差異。在某一胰島素輸注速度下,MAC 的變化和血糖水平不具有相關性,但是在最大的胰島素輸注速度下有可能在較小的血糖濃度下合併MAC的邊緣性的大的下降。鞘內注射胰島素不導致脊髓損傷。總之,我們發現胰島素可劑量相關性的降低異氟醚的MAC,該效應與胰島素對血糖濃度的影響作用無關。胰島素降低MAC的作用部位可能在脊髓上而非脊髓部位。該效應可能與胰島素通過作用於一個或多個神經遞質的受體所產生的鎮痛作用有關。結論: 不論血糖濃度的多少,鞘內注射和靜脈注射胰島素同樣降低大鼠的異氟醚MAC。該結果提示胰島素降低MAC,但是該效應不是通過作用於脊髓而介導的。

(張俊峰譯 薛張綱校)

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.

 

用肌音描計法可同時監測喉部內收肌和外展肌的神經肌肉阻滯

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

 

肌音描計法(PMG)是一種監測喉部神經肌肉阻滯(NMB)的新方法。在該研究中,我們使用PMG比較人類環杓軟骨後肌(PCA)和類環杓軟骨側肌(LCA)NMB12例患者入選該研究。在不使用神經肌肉阻滯下施行氣管內插管。第一個小麥克風置於聲帶旁邊的杓狀軟骨基底部的肌肉間記錄LCA(聲帶內收肌)的聲學反應。。另一個麥克風置於喉的後面監測PCA(聲帶外展肌)NMB。通過頸部皮膚表面的電極(位於頸靜脈切跡和環狀軟骨中點的位置)刺激喉返神經,刺激方式為每隔12 s四個成串刺激(TOF)。超強刺激後靜注美維松 0.1 mg/kg,記錄NMB的起效時間、峰效應及消退並使用t檢驗 (P < 0.05) 所有資料均採用(均值±標準差)表示。峰效應、起效時間及肌顫除強度恢復到對照值25%的時間在PCALCA 間無顯著性差異,分別為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,肌顫除強度恢復到對照值75%90%的時間以及TOF恢復到0.8的時間在PCA組顯著長於LCA組,分別為14 min (4)11 min (5), 17 min (5) 11.8 min (5.6), 17.5 min (5.6) 12.3 min (5.5)。通過該研究發現人類在使用美維松後PCANMB恢復時間要長於LCA的恢復時間。 結論:在人類神經肌肉阻滯後,聲帶張開能力的恢復時間比聲帶關閉能力恢復的時間要長。

 (張俊峰 薛張綱 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.

 

多傷亡的恐怖事件: 麻醉醫師的展望

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個月內發生了14起涉及多人傷亡的恐怖活動,這對於該市唯一的一級創傷中心的麻醉科和重症監護科室是一個考驗。我們根據科室的反應能力做了一項回顧性的研究來評價醫務人員的活動、資源的應用(急診室、手術室和重症監護室ICU)和病人的流動情況。總共有1062名人員在這14起多傷亡事件中受了傷。急診室治療了355名傷員;108人接受入院治療,58人在最初8小時內進行了手術,只有2人在最初2小時內就接受了手術,接受第一次手術治療的平均時間是124分鐘。在恐怖事件發生了平均5.5小時之後共有51人進入重症監護室。恐怖事件一發生,麻醉科就同時動員起來,包括在急診室裏的最初的復蘇工作、為手術和血管造影術的病人麻醉,以及在恢復室和ICU治療病人。因此,這類事件明顯地影響了麻醉科的工作,必須制定計劃來最大程度的優化現有人員和設備的使用。

提示:在恐怖事件發生中麻醉醫師為病人提供了必不可少的治療,從最初的復蘇工作到治療或診斷性的操作。我們考察了在恐怖活動發生後的最初8小時內麻醉科所面臨的操作性的問題,這些都需要科室的多方面同時的努力。

(王柯 薛張綱 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.

                                                                 

前路坐骨神經阻滯:適合病人身高

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.

 

為了提高近來介紹的前路行坐骨神經阻滯時阻滯股後側皮神經(PFCN)的機率,我們假設腹股溝連線到穿刺點之間的距離和病人的升高有關。對於13名患者行初步的放射學研究得到了關於病人升高和穿刺點“S”之間關係的一個方程式。從髂前上脊到恥骨結節上角連一直線(腹股溝線),從腹股溝線中點到穿刺點“S”再連一直線,“S”點離開腹股溝線中點的距離根據公式計算:(身高(cm)-100/10。我們對53個病人進行了前瞻性的研究,結果顯示的是平均值(範圍:0.25-0.75),需要2分鐘來定位深達12cm10.513cm)的坐骨神經,92%的病人完全阻滯了坐骨神經和股後側皮神經。我們的結論是在行前路坐骨神經阻滯時應該考慮病人的身高,這樣似乎能夠提高阻滯股後側皮神經的成功率,這對於病人止血帶疼痛很重要。提示:我們進行了前瞻性的研究,而非對照性研究來評價一種新的前路坐骨神經阻滯技術,正如Chelly Delaunay所描述的一樣,這一方法是根據解剖標誌的變化,病人身高的差異而進行了穿刺點的調整。

(王柯 薛張綱 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.

                                                     

有無N2O情況下喉管氣囊內壓力和時間的相關性

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)是一種新型的會厭上的氣道裝置,它由一根管道、兩個氣囊和氣囊之間的兩個位於遠端的孔組成。使用這種裝置時的一個注意點是可能引起口咽部粘膜缺血性的改變。我們研究了使用和不使用N2O時氣囊內壓力隨時間的變化,這反映出部所受到的壓力。我們將插入喉管後的24位病人隨機分成2組,一組使用了66%的N2O(組N),另外一組不使用N2O(組A),2組病人均用七氟醚維持麻醉,記錄氣囊內壓力隨時間的變化和術後氣道併發症。組N的氣囊內壓力隨時間顯著增加(P<0.001,最高壓力:120cmH2O)然而組A氣囊內壓力保持不變,組N的氣囊內壓力要顯著高於組AP<0.0001,差異的95%可信區間:30分鐘時620 cmH2O)。組A2位病人、組N1位病人術後述有咽喉輕微疼痛。提示:由於N2O會引起喉管氣囊內壓力升高而導致咽部所受的壓力增加,因此為了最大度減少口咽部粘膜缺血性改變的可能性我們建議麻醉中監測和調整喉管氣囊內的壓力。

(王柯 薛張綱 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.