Anesthesia & Analgesia

July 2004

Table of Content

CARDIOVASCULAR ANESTHESIA:

比较心脏手术后输注异体红细胞或100%纯氧通气对全身氧传输和骨骼肌氧分压的影响

黄施伟 译    李士通

The Influence of Allogeneic Red Blood Cell Transfusion Compared with 100% Oxygen Ventilation on Systemic Oxygen Transport and Skeletal Muscle Oxygen Tension After Cardiac Surgery
Stefan Suttner, Swen N. Piper, Bernhard Kumle, Katrin Lang, Kerstin D. Röhm, Frank Isgro, and Joachim Boldt

Anesth Analg 2004 99: 2-11

利用术中经食管超声确诊肺栓塞

葛宁花 译

Utility of Intraoperative Transesophageal Echocardiography for Diagnosis of Pulmonary Embolism

Peter Rosenberger, Stanton K. Shernan, Simon C. Body, and Holger K. Eltzschig

Anesth Analg 2004 99: 12-16.

清洗后的血小板活性

殷文渊 译 陈杰 校

Platelet Activity in Washed Platelet Concentrates

Helge Schoenfeld, Manfred Muhm, Ulrich Doepfmer, Aristomenis Exadaktylos, and Hartmut Radtke

Anesth Analg 2004 99: 17-20.

过氧亚硝基阴离子减低人类血浆止血效应的体外实验

王立中     李士通

Peroxynitrite Decreases Hemostasis in Human Plasma In Vitro
Vance G. Nielsen, John P. Crow, Ashish Mogal, Fen Zhou, and Dale A. Parks

Anesth Analg 2004 99: 21-26.

 

PEDIATRIC ANESTHESIA:

比较硬膜外布比卡因、左旋布比卡因和罗哌卡因对术后镇痛和运动阻滞的作用

葛宁花 译

A Comparison of Epidural Bupivacaine, Levobupivacaine, and Ropivacaine on Postoperative Analgesia and Motor Blockade
Pasquale De Negri, Giorgio Ivani, Tiziana Tirri, Pasqualina Modano, Cesare Reato, Staffan Eksborg, and Per-Arne Lonnqvist

Anesth Analg 2004 99: 45-48.

丙泊酚导致新生大鼠中枢性呼吸抑制的神经机制

殷文渊 译 陈杰 校

A Neuronal Mechanism of Propofol-Induced Central Respiratory Depression in Newborn Rats

Masanori Kashiwagi, Yasumasa Okada, Shun-ichi Kuwana, Shigeki Sakuraba, Ryoichi Ochiai, and Junzo Takeda

Anesth Analg 2004 99: 49-55

儿童双侧呼吸音听诊不能排除支气管内插管

    泓 译    李士通 校

Auscultation of Bilateral Breath Sounds Does Not Rule Out Endobronchial Intubation in Children

Susan T. Verghese, Raafat S. Hannallah, Michael C. Slack, Russell R. Cross, and Kantilal M. Patel

Anesth Analg 2004 99: 56-58.

 

AMBULATORY ANESTHESIA:

评估住院医生麻醉前咨询能力的方法的发展及应用

陆续伟 译 葛宁花 校

The Development and Application of an Instrument for Assessing Resident Competence During Preanesthesia Consultation
Getúlio Rodrigues de Oliveira Filho and Leonardo Schonhorst

Anesth Analg 2004 99: 62-69

门诊手术后夜间动脉去氧饱和和间歇性气道阻塞

殷文渊 译 陈杰 校

Nocturnal Arterial Oxygen Desaturation and Episodic Airway Obstruction After Ambulatory Surgery

T. Andrew Bowdle

Anesth Analg 2004 99: 70-76.

 

ANESTHETIC PHARMACOLOGY:

随机比较综合处理策略和复合应用止吐剂预防术后恶心呕吐

张俊杰     李士通

A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting

Ashraf S. Habib, William D. White, Steve Eubanks, Theodore N. Pappas, and Tong J. Gan

Anesth Analg 2004 99: 77-81.

 

抑制脊髓蛋白激酶C-ε或 {gamma}同工酶不影响鼠吸入氟烷最低肺泡浓度

葛宁花 译

Inhibition of Spinal Protein Kinase C-{epsilon} or -{gamma} Isozymes Does Not Affect Halothane Minimum Alveolar Anesthetic Concentration in Rats
Jennifer A. Shumilla, Sarah M. Sweitzer, Edmond I Eger, II, Michael J. Laster, and Joan J. Kendig

Anesth Analg 2004 99: 82-84.

GABAA受体不介导异氟醚所致的制动作用

顾漪闻 译 陈杰 校

Gamma-Aminobutyric AcidA Receptors Do Not Mediate the Immobility Produced by Isoflurane

Yi Zhang, James M. Sonner, Edmond I Eger, II, Caroline R. Stabernack, Michael J. Laster, Douglas E. Raines, and R. Adron Harris

Anesth Analg 2004 99: 85-90.

异丙酚的非麻醉性类似物2,6-双叔丁基酚(2,6 Di-tert-butylphenol)调整a1ß甘氨酸受体功能的方式有别于异丙酚

裘毅敏 译    李士通 校

2,6 Di-tert-butylphenol, a Nonanesthetic Propofol Analog, Modulates {alpha}1ß Glycine Receptor Function in a Manner Distinct from Propofol

Jörg Ahrens, Gertrud Haeseler, Martin Leuwer, Bahram Mohammadi, Klaus Krampfl, Reinhard Dengler, and Johannes Bufler

Anesth Analg 2004 99: 91-96.

布比卡因抑制大鼠胸主动脉血栓烷A2诱导的血管收缩

钟鸣 译 葛宁花 校

Bupivacaine Inhibits Thromboxane A2-Induced Vasoconstriction in Rat Thoracic Aorta

Klaus Hahnenkamp, Joke Nollet, Danja Strümper, Tobias Halene, Pia Rathman, Eike Mortier, Hugo Van Aken, Joerg Knapp, Marcel E. Durieux, and Christian W. Hoenemann

Anesth Analg 2004 99: 97-102.

恶性高热易感者的选择性微创诊断试验中四氯甲酚不能检测恶性高热可疑细胞

苏殿三 译 陈杰 校

4-Chloro-m-Cresol Cannot Detect Malignant Hyperthermia Equivocal Cells in an Alternative Minimally Invasive Diagnostic Test of Malignant Hyperthermia Susceptibility
Lukas G. Weigl, Carmen Ludwig-Papst, and Hans G. Kress

Anesth Analg 2004 99: 103-107.

志愿者静注吗啡、可待因和曲马多对瞳孔的影响

    浩 译   李士通 校

The Pupillary Effects of Intravenous Morphine, Codeine, and Tramadol in Volunteers

Roger D. Knaggs, Isla M. Crighton, Timothy F. Cobby, Anthony J. P. Fletcher, and Gregory J. Hobbs

Anesth Analg 2004 99: 108-112.

犬异丙酚苏醒期引起膈肌收缩减少的研究

方芳 葛宁花 校

The Recovery Profile of Reduced Diaphragmatic Contractility Induced by Propofol in Dogs

Yoshitaka Fujii, Aki Uemura, and Hidenori Toyooka

Anesth Analg 2004 99: 113-116.

预注布托非诺对丙泊酚注射疼痛的效果

齐波 译 陈杰 校

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Anil Agarwal, Mehdi Raza, Sanjay Dhiraaj, Ravinder Pandey, Devendra Gupta, Chandra Kant Pandey, Prabhat K Singh, and Uttam Singh

Anesth Analg 2004 99: 117-119

 

TECHNOLOGY, COMPUTING, AND SIMULATION:

用血栓弹性描记图研究XIII因子对凝血过程和血块强度的作用

赵雪莲      李士通 校

The Impact of Factor XIII on Coagulation Kinetics and Clot Strength Determined by Thrombelastography

Vance G. Nielsen, William Q. Gurley, Jr, and Thomas M. Burch

Anesth Analg 2004 99: 120-123.

老年病人鞘内注射可乐定行术后镇痛:比重对血流动力学和镇痛效果的影响

忻纪华 译 陈杰 校

Intrathecal Clonidine for Postoperative Analgesia in Elderly Patients: The Influence of Baricity on Hemodynamic and Analgesic Effects
Amir Baker, Walter Klimscha, James C. Eisenach, Xin-Hui Li, Eckart Wildling, Wolfgang A. Menth-Chiari, and Astrid I. Chiari

Anesth Analg 2004 99: 128-134.

幼鼠术前坐骨神经阻滞更多地降低机械性痛觉超敏:预先镇痛是否随发育不同而调整?

马皓琳      李士通 

Preoperative Sciatic Nerve Block Decreases Mechanical Allodynia More in Young Rats: Is Preemptive Analgesia Developmentally Modulated?

Douglas G. Ririe, David Barclay, Heather Prout, Chuanyo Tong, Joseph R. Tobin, and James C. Eisenach

Anesth Analg 2004 99: 140-145.

大鼠关节腔内预注氯胺酮或美金刚有助于减少关节痛及脊髓 c- Fos 表达

周洁 译 陈杰 校

Intraarticular Pretreatment with Ketamine and Memantine Could Prevent Arthritic Pain: Relevance to the Decrease of Spinal c-Fos Expression in Rats
Guo Hua Zhang, Sun Seek Min, Kyu Sang Lee, Seung Keun Back, Seong Jun Yoon, Young Wook Yoon, Yang In Kim, Heung Sik Na, Seung Kil Hong, and Hee Chul Han

Anesth Analg 2004 99: 152-158.

 

CRITICAL CARE AND TRAUMA:

单腔和多腔中心静脉导管置管的细菌定植和血液感染:一项定量的系统评估

彭中美 译 李士通 校

Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review

Mathias Zürcher, Martin R. Tramèr, and Bernhard Walder

Anesth Analg 2004 99: 177-182

经胸部超声引导腋静脉置管:标准锁骨下静脉置管的另一选择

葛宁花 译

Transpectoral Ultrasound-Guided Catheterization of the Axillary Vein: An Alternative to Standard Catheterization of the Subclavian Vein
NavParkash S. Sandhu

Anesth Analg 2004 99: 183-187.

二十个月常规使用新的带可控旋转扩张器的经皮气管造瘘套管

        李士通 

Twenty Months’ Routine Use of a New Percutaneous Tracheostomy Set Using Controlled Rotating Dilation

Neel Sengupta, Keng Leong Ang, Doraiswamy Prakash, Vivien Ng, and Shane J. George

Anesth Analg 2004 99: 188-192.

较小潮气量通气:随机对照定量系统回顾

Ventilation with Smaller Tidal Volumes: A Quantitative Systematic Review of Randomized Controlled Trials

Nicola Petrucci and Walter Iacovelli

Anesth Analg 2004 99: 193-200.

在伴有严重多器官功能障碍综合征的晚期血管扩张性休克病人中应用精氨酸抗利尿激素会影响凝血系统吗?

慧译 李士通校

Does Arginine Vasopressin Influence the Coagulation System in Advanced Vasodilatory Shock with Severe Multiorgan Dysfunction Syndrome?

Martin W. Dünser, Dietmar R. Fries, Wolfgang Schobersberger, Hanno Ulmer, Volker Wenzel, Barbara Friesenecker, Walter R. Hasibeder, and Andreas J. Mayr

Anesth Analg 2004 99: 201-206.

增加氧和二氧化碳均能增加皮下和肠粘膜的氧合。

葛宁花 译

Supplemental Oxygen and Carbon Dioxide Each Increase Subcutaneous and Intestinal Intramural Oxygenation

Jebadurai Ratnaraj, Barbara Kabon, Michael R. Talcott, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2004 99: 207-211

 

NEUROSURGICAL ANESTHESIA:

动脉-颈内静脉血氧含量差与颅脑外伤病人预后

周雅春 译  李士通 校

Arterio-Jugular Difference of Oxygen Content and Outcome After Head Injury

Nino Stocchetti, Katia Canavesi, Sandra Magnoni, Valerio Valeriani, Valeria Conte, Sandra Rossi, Luca Longhi, Elisa Roncati Zanier, and Angelo Colombo

Anesth Analg 2004 99: 230-234

阿片受体激动剂SNC80对脊髓缺血后大鼠后肢运动功能和神经元损伤的影响

王柯 译 葛宁花

The Effects of the {delta}-Opioid Agonist SNC80 on Hind-Limb Motor Function and Neuronal Injury After Spinal Cord Ischemia in Rats

Toshinori Horiuchi, Masahiko Kawaguchi, Takanori Sakamoto, Naoko Kurita, Satoki Inoue, Mitsutoshi Nakamura, Noboru Konishi, and Hitoshi Furuya

Anesth Analg 2004 99: 235-240

 

OBSTETRIC ANESTHESIA:

连硬下剖腹产时下肢加压包扎预防低血压而不能预防低温或寒战

 陈洁 译   陈杰 校

Lower Limb Wrapping Prevents Hypotension, but Not Hypothermia or Shivering, After the Introduction of Epidural Anesthesia for Cesarean Delivery
Hsiao Lun Sun, Qing Dong Ling, Wei Zen Sun, Rick Sai-Chuen Wu, Tzong Jeng Wu, Shih Chieh Wang, and Chih Cheng Chien

Anesth Analg 2004 99: 241-244.

 

REGIONAL ANESTHESIA:

判断进入硬脊膜外腔:分别用空气、利多卡因或复合空气和利多卡因阻力消失法

陈玮译 李士通 校

Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine

Samuel Evron, Daniel Sessler, Oscar Sadan, Mona Boaz, Marek Glezerman, and Tiberiu Ezri

Anesth Analg 2004 99: 245-250.

全膝置换术后镇痛:闭孔神经阻滞加股神经31神经阻滞

葛宁花 译

Postoperative Analgesia After Total Knee Replacement: The Effect of an Obturator Nerve Block Added to the Femoral 3-in-1 Nerve Block

D. Macalou, S. Trueck, P. Meuret, M. Heck, F. Vial, S. Ouologuem, X. Capdevila, J. -M. Virion, and H. Bouaziz

Anesth Analg 2004 99: 251-254.

 

GENERAL ARTICLES:

全髋或全膝关节成形术病人限制用重组人血红细胞生成素和自体血回输是有效对策

肖洁 译 陈杰 校

A Restrictive Use of Both Autologous Donation and Recombinant Human Erythropoietin Is an Efficient Policy for Primary Total Hip or Knee Arthroplasty
Claude Couvret, Marc Laffon, Annick Baud, Valérie Payen, Philippe Burdin, and Jacques Fusciardi

Anesth Analg 2004 99: 262-271.

新型喉周通气道(CobraPLATM)与喉罩通气道(LMATM)相比同样有效,且提供更好的气道密闭性

周志坚 译  李士通 校)

The New Perilaryngeal Airway (CobraPLATM) Is as Efficient as the Laryngeal Mask Airway (LMATM) but Provides Better Airway Sealing Pressures
Ozan Akça, Anupama Wadhwa, Papiya Sengupta, Jaleel Durrani, Keith Hanni, Mary Wenke, Yüksel Yücel, Rainer Lenhardt, Anthony G. Doufas, and Daniel I. Sessler

Anesth Analg 2004 99: 272-278

光导辅助插管在侧卧位患者中的应用

葛宁花 译

Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position
Kuang-I Cheng, Koung-Shing Chu, Siu-Wah Chau, Soo-Lee Ying, Hong-Te Hsu, Yin-Lung Chang, and Chao-Shun Tang

Anesth Analg 2004 99: 279-283.

轻度体温增高可下调受体依赖的噬中性粒细胞功能

朱辉 译 陈杰 校

Mild Hyperthermia Down-Regulates Receptor-Dependent Neutrophil Function

Dieter Fröhlich, Sigrid Wittmann, Gregor Rothe, Daniel I. Sessler, Peter Vogel, and Kai Taeger

Anesth Analg 2004 99: 284-292.

 

 

 

清洗后的血小板活性

Platelet Activity in Washed Platelet Concentrates

Helge Schoenfeld, MD*,{dagger}, Manfred Muhm, MD*,{ddagger}, Ulrich Doepfmer, MD FRCA{dagger}, Aristomenis Exadaktylos, MD*, and Hartmut Radtke, MD§

*Department of Anesthesiology, University Hospital of Bern, Inselspital, Switzerland, the {dagger}Department of Anesthesiology and Intensive Care Medicine, University Hospital Charité, Berlin, Germany, the {ddagger}Department of Anesthesiology and Intensive Care Medicine, Hospital of Oberpullendorf and Department of Cardiothoracic Anesthesia and Intensive Care Medicine, University of Vienna, Austria, and the §Institute of Transfusion Medicine, University Hospital Charité Berlin, Germany

Anesth Analg 2004;99:17-20

输注血小板浓缩液(PCs)后发生的威胁生命的过敏和非溶血性发热输血反应是一个很严重的临床问题,这是由所接受的血浆成分过敏而引起的,例如免疫球蛋白A、细胞因子等。血小板减少病人可能是使用清洗过的血小板浓缩液的指征。可是,只有在生理刺激下血小板功能激活才是有用的。作者测定了清洗前和清洗后的血小板自主和诱导激活功能。11份连续采集的血液部分成分清除的血小板浓缩液。在采集和去除白细胞后,PCs15%右旋柠檬酸溶液中清洗。通过流式细胞计量仪测定自主和二磷酸腺苷诱导以及胶原质诱导的血小板激活。此外,测定ADP和胶原诱导的聚集反应。结果:未经清洗的血小板16%自主激活,清洗血小板浓缩液导致血小板自主激活提高三倍(47.4%)。因为清洗后会增加自主激活,所以洗涤后血小板的诱导活性下降。因此,作者认为应减少浓缩血小板清洗的使用频率,使用清洗血小板的唯一指征是有严重的非溶血性输血反应史的病人。

(殷文渊 译 陈杰 校)

Life-threatening anaphylaxis or febrile nonhemolytic transfusion reactions after transfusion of platelet concentrates (PCs) is a serious clinical problem caused by the sensitizing of recipients to plasma components, such as immunoglobulin A, or by cytokines. There is a possible indication for washing of PCs in these thrombocytopenic patients. However, only platelets that show activation after physiological stimulation are useful. We determined the spontaneous and induced activation of platelets before and after washing. We investigated 11 consecutive single-donor-apheresis PCs. After production and leukocyte-depletion the PCs were washed in 15% acid-citrate-dextrose-solution. The spontaneous and the adenosine diphosphate (ADP)-induced, as well as collagen-induced activation, were determined by flow cytometry. Additionally, ADP- and collagen-induced aggregation were measured. Unwashed platelets (16.1%) were activated spontaneously. The washing of PCs led to a threefold increase of spontaneous activation of platelets (47.4%). Because of increased spontaneous activation after washing we could demonstrate cytometrically a loss of induced activation of washed platelets. Furthermore, washing resulted in an impaired ADP-induced aggregability of platelets. These results have led us to reduce the frequency of washing of PCs in our institution, where the only current indication for washing of PCs is in patients with a history of severe nonhemolytic transfusion reactions.


丙泊酚导致新生大鼠中枢性呼吸抑制的神经机制

A Neuronal Mechanism of Propofol-Induced Central Respiratory Depression in Newborn Rats

Masanori Kashiwagi, MD*, Yasumasa Okada, MD{ddagger}, Shun-ichi Kuwana, PhD{dagger}, Shigeki Sakuraba, MD*, Ryoichi Ochiai, MD*, and Junzo Takeda, MD*

*Department of Anesthesiology, School of Medicine, Keio University; {dagger}Department of Physiology, Teikyo University School of Medicine, Tokyo; and {ddagger}Department of Medicine, Keio University Tsukigase Rehabilitation Center, Shizuoka-ken, Japan

Anesth Analg 2004;99:49-55

丙泊酚导致的中枢性呼吸抑制的神经机制至今仍不很明确。作者研究了γ-羟基丁酸(GABAA)受体在丙泊酚导致的中枢性呼吸抑制中的作用。分离出1-4天幼鼠的脑干和脊髓并保存在氧合人工脑脊液中备用。记录来自C4脊神经前根的节律性吸气冲动。使用一种打孔膜片钳技术记录位于延髓腹外侧区神经元的活动。作者发现丙泊酚降低C4脊神经前根的节律性吸气冲动频率,并可以通过使用GABAA拮抗剂,荷包牡丹碱而逆转。丙泊酚会使吸气前和呼气神经元静息膜电位超极化从而抑制动作电位的激发。相比较而言,丙泊酚对吸气神经元静息膜电位超极化和动作电位的激发影响较小。结果显示丙泊酚的抑制作用至少部分通过拮抗GABAA受体起作用。GABAA受体介导的吸气前神经元超极化可能是丙泊酚引起的新生幼鼠呼吸抑制的神经基础。

(殷文渊 译 陈杰 校)

The neural mechanisms of propofol-induced central respiratory depression remain poorly understood. In the present study, we studied these mechanisms and the involvement of {gamma}-aminobutyric acid (GABA)A receptors in propofol-induced central respiratory depression. The brainstem and the cervical spinal cord of 1- to 4-day-old rats were isolated, and preparations were maintained in vitro with oxygenated artificial cerebrospinal fluid. Rhythmic inspiratory burst activity was recorded from the C4 spinal ventral root. The activity of respiratory neurons in the ventrolateral medulla was recorded using a perforated patch-clamp technique. We found that bath-applied propofol decreased C4 inspiratory burst rate, which could be reversed by the administration of a GABAA antagonist, bicuculline. Propofol caused resting membrane potentials to hyperpolarize and suppressed the firing of action potentials in preinspiratory and expiratory neurons. In contrast, propofol had little effect on resting membrane potentials and action potential firing in inspiratory neurons. Our findings suggest that the depressive effects of propofol are, at least in part, mediated by the agonistic action of propofol on GABAA receptors. It is likely that the GABAA receptor-mediated hyperpolarization of preinspiratory neurons serves as the neuronal basis of propofol-induced respiratory depression in the newborn rat.


门诊手术后夜间动脉去氧饱和和间歇性气道阻塞

Nocturnal Arterial Oxygen Desaturation and Episodic Airway Obstruction After Ambulatory Surgery

T. Andrew Bowdle, MD PhD

Departments of Anesthesiology and Pharmaceutics, University of Washington, Seattle, Washington

Anesth Analg 2004;99:70-76

一些住院病人在重大手术后常有睡眠时呼吸不规则和动脉去氧饱和的经历。作者研究了门诊手术后是否也有相类似的事件发生。45名不限量使用麻醉药的门诊手术病人,连续记录手术前和手术后回家后的第一、二个晚上病人的呼吸和氧饱和度。结果:9名病人呼吸干扰指数>10/或至少一个晚上1%的记录时间氧饱和度<90%。这9名病人年龄和体表指数均显著大于均值,术后第一天夜间呼吸干扰指数均数和氧饱和度<90%时间百分比的均数显著高于术前夜间。

(殷文渊 译 陈杰 校)

Some patients experience disordered breathing during sleep and arterial oxygen desaturation after major inpatient surgery. We performed this study to determine whether similar events occur after ambulatory surgery. Forty-five ambulatory surgery patients received an unrestricted anesthetic. Continuous unattended nocturnal recordings of breathing pattern and oxygen saturation were made in the patients’ homes before surgery and during the first and second postoperative nights. Nine patients had a respiratory disturbance index >10 and/or >1% of recording time with oxygen saturation <90% on at least one study night. These nine patients had a significantly older median age and a significantly larger median body mass index. Their median respiratory disturbance index and median percentage of time with oxygen saturation <90% were significantly higher on the first postoperative night than on the preoperative night.


GABAA受体不介导异氟醚所致的制动作用

Gamma-Aminobutyric AcidA Receptors Do Not Mediate the Immobility Produced by Isoflurane

Yi Zhang, MD*, James M. Sonner, MD{dagger}, Edmond I Eger, II, MD*, Caroline R. Stabernack, MD*, Michael J. Laster, DVM*, Douglas E. Raines, MD{dagger}, and R. Adron Harris, PhD{ddagger}

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, {dagger}Harvard Medical School, Boston, Massachusetts, and the {ddagger}University of Texas, Austin, Texas

Anesth Analg 2004;99:85-90

许多吸入性麻醉药可以增强抑制性神经递质GABA作用,支持GABAA受体介导吸入性麻醉药物在对伤害刺激时所产生制动作用(例如:MAC是指在伤害性刺激时,50%的人可以达到没有反应的最小肺泡浓度)。但是,只有很有限的证据支持GABAAMAC之间有关联。因此,作者根据两个研究结果来检验此受体和异氟醚的制动作用之间的关系:1)不同的麻醉药物在增加GABA系统的受体表达上是不同的。例如:异氟醚是大量的增加;环丙烷是轻度增加;氙也是轻度增加。2)研究显示:脊髓介导异氟醚的MAC。如果GABAA受体介导异氟醚的MAC,那么抑制脊髓GABAA受体,就可以提高异氟醚的MAC,其提高的幅度要大于环丙烷和氙的 MAC的提高,而且在体外试验中,MAC的提高与GABAA受体的增强是成比例的。为了验证这一假设,作者做了以下试验:异氟醚,环丙烷,氙分别麻醉小鼠,这些小鼠事先都已通过埋入的连续导管,在鞘内注射了人造的αCSF液(人造脑脊液),然后检测三者的MAC。然后,再分别以含有印防己毒素(一种非竞争性的GABA受体阻滞剂)0.62.4mg/mlαCSF(1μL/min的速度)注入小鼠,同时检测其异氟醚,环丙烷,氙三者的MAC。结果发现:印防己毒素的浓度从0.6μg/min提高到2.4μg/min,异氟醚,环丙烷,氙三者的MAC并没有相应的增加,说明此时在脊髓中已达到了对GABAA受体的最大的阻滞。印防己毒素可以增加所有麻醉药的MAC大约40%。说明GABA在脊髓的释放影响了对麻醉药的需求。但是,这种增加在不同的麻醉药中是不同的,而且在体外试验中,这些麻醉药对GABAA受体的增强作用并不相关。此结果支持了GABAA受体并不能增强异氟醚的制动作用的假设。

(顾漪闻 译 陈杰 校)

Many inhaled anesthetics enhance the effect of the inhibitory neurotransmitter gamma aminobutyric acid (GABA), supporting the view that the GABAA receptor could mediate the capacity of inhaled anesthetics to produce immobility in the face of noxious stimulation (i.e., MAC, the minimum alveolar concentration required to suppress movement in response to a noxious stimulus in 50% of subjects). However, only limited in vivo data support the relevance of the GABAA receptor to MAC. In the present study we used two findings to test for the relevance of this receptor to immobilization for isoflurane: 1) differences among anesthetics in their capacity to enhance the response of receptor expression systems to GABA: isoflurane (considerable enhancement), xenon (minimal enhancement), and cyclopropane (minimal enhancement); and 2) studies showing that the spinal cord mediates MAC for isoflurane. If GABAA receptors mediate isoflurane MAC, then their blockade in the spinal cord should increase isoflurane MAC more than cyclopropane or xenon MAC and the MAC increase should be proportional to the in vitro enhancement of the GABAA receptor. To test this thesis, isoflurane, cyclopropane, or xenon MAC was determined in rats during intrathecal infusion of artificial cerebrospinal fluid (aCSF) via chronically implanted catheters. Then MAC was redetermined during infusion of 1 µL/min aCSF containing either 0.6 or 2.4 mg/mL picrotoxin, which noncompetitively blocks GABAA receptors. There was no consistent increase in MAC consequent to increasing the picrotoxin dose from 0.6 to 2.4 µg/min, which suggests that maximal blockade of GABAA receptors in the spinal cord had been achieved. Picrotoxin infusion increased MAC approximately 40% with all anesthetics. This indicates that GABA release in the spinal cord influences anesthetic requirement. However, the increase did not consistently differ among anesthetics and did not correlate with in vitro enhancement of GABAA receptors by these anesthetics. This supports the view that GABAA receptors do not mediate immobilization for isoflurane.


恶性高热易感者的选择性微创诊断试验中四氯甲酚不能检测恶性高热可疑细胞

4-Chloro-m-Cresol Cannot Detect Malignant Hyperthermia Equivocal Cells in an Alternative Minimally Invasive Diagnostic Test of Malignant Hyperthermia Susceptibility

Lukas G. Weigl, PhD*, Carmen Ludwig-Papst, PhD{dagger}, and Hans G. Kress, MD PhD*

Departments of *Anesthesiology and Intensive Care Medicine (B) and {dagger}Surgery, Medical University Vienna, Vienna, Austria

Anesth Analg 2004;99:103-107

恶性高热(MH)是一种遗传性的骨骼肌病变,可以被麻醉药物触发。斯里兰卡肉桂碱受体突变被认为是MH的分子基础。临床上一般首先将患者的骨骼肌标本进行体外挛缩实验,根据实验结果分成MH易感患者(MHS)、正常人(MHN)和疑似患者(MHEH)。然后进一步应用促进钙离子释放的药物四氯甲酚(4-CmC)和咖啡因进行刺激观察钙离子释放情况,以期进一步评估肌管的敏感度。在本研究中,作者研究了是否可以通过4-CmC促进钙离子释放的作用对MHEH患者做出明确的诊断。以Fura2作为染料,应用光度镜检测细胞内的钙离子浓度。斯里兰卡肉桂碱受体1基因含有大部分的MH基因突变。在一名MHS患者发现一种MH突变(Gly2434Arg)。咖啡因诱导的钙离子释放在MHSMHN患者与体外挛缩实验具有良好的相关性。MHS患者的细胞表现出对咖啡因的敏感性比4-CmC高。MHEH患者的细胞对于咖啡因和4-CmC的敏感性均较低。因此,用肌管,咖啡因可鉴别MHSMHN细胞,但是咖啡因和4-CMC都不能鉴别MHEH细胞。

(苏殿三 译 陈杰 校)

Malignant hyperthermia (MH) is an inherited skeletal muscle disorder triggered by commonly used anesthetics. Mutated ryanodine receptors have been identified as molecular targets. The sensitivity of myotubes from individuals classified by the in vitro contracture test as MH susceptible (MHS), normal (MHN), and equivocal (MHEH) was assessed for the Ca2+-releasing activity of 4-chloro-m-cresol (4-CmC) and caffeine. In this study, we sought to determine whether 4-CmC can differentiate the MH status of an individual on the basis of the release of intracellular Ca2+, particularly in regard to MHEH diagnosis. Intracellular Ca2+ concentration was determined photometrically with Fura2. Regions of the ryanodine receptor 1 harboring most of the described MH mutations were sequenced from MHS and MHEH cells. One MH mutation (Gly2434Arg) was found in one MHS individual. Results of the caffeine-induced Ca2+ release in MHS and MHN cells correlated well with the in vitro contracture test results. MHS cells showed a higher sensitivity against caffeine and, to a lesser extent, against 4-CmC. Cells of MHEH individuals showed low sensitivities against both caffeine and 4-CmC, comparable to those of the MHN group. Therefore, with myotubes, caffeine was able to discriminate between MHS and MHN cells, but both caffeine and 4-CmC failed to detect MHEH cells.


预注布托非诺对丙泊酚注射疼痛的效果

Pain During Injection of Propofol: The Effect of Prior Administration of Butorphanol

Anil Agarwal, MD, Mehdi Raza, MD, Sanjay Dhiraaj, MD, Ravinder Pandey, MD, Devendra Gupta, MD, Chandra Kant Pandey, MD, Prabhat K Singh, MD, and Uttam Singh, PhD

Departments of Anesthesia and Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2004;99:117-119

静脉注射丙泊酚可使28%90%的病人感到疼痛或不适。目前,有许多方法用于减轻注射丙泊酚而引起的疼痛,但效果参差不齐。本实验比较布托非诺和利多卡因预防丙泊酚注射疼痛的效果。选择150ASA III 择期手术的成年病人,并随机分为三组,每组50名病人。组INS)预注生理盐水,组II预注2%利多卡因40mg,组III预注布托非诺2mg。预注药物用生理盐水稀释至2ml,注射时间超过5秒。1分钟后注射病人所需丙泊酚总量(2.5mg/Kg)的1/4,时间超过5秒。采用4分制疼痛评分法评估病人的疼痛:0=无疼痛,1=轻度疼痛,2=中度疼痛,3=严重疼痛。结果发现在对照组有39个(78%)病人在注射丙泊酚时感到疼痛;而利多卡因组和布托非诺组分别只有21个(42%)和10个(20%)病人感到疼痛(P0.05),布托非诺是最有效的。因此静脉预先注射布托非诺2mg可减轻因注射丙泊酚而引起的疼痛。

(齐波 译 陈杰 校)

Propofol causes pain or discomfort on injection in 28%–90% of patients. A number of techniques have been tried for minimizing propofol-induced pain with variable results. We compared the efficacy of butorphanol and lidocaine for prevention of propofol-induced pain. One-hundred-fifty ASA I–II adults, undergoing elective surgery were randomly assigned into 3 groups of 50 each. Group I (NS) received normal saline, Group II (L) received lidocaine 2% (40 mg), and Group III (B) received butorphanol 2 mg. All patients received pretreatment solutions made in 2 mL with normal saline administered over 5 s. One min after pretreatment patients received one-fourth of the total calculated dose of propofol (2.5 mg/kg) over 5 s. Assessment of pain with IV propofol was done by using a four-point scale: 0 = no pain, 1 = mild pain, 2 = moderate pain and 3 = severe pain at the time of propofol injection. In the control Group 39 (78%) patients had pain during propofol injection as compared to 21 (42%) and 10 (20%) in the lidocaine and butorphanol groups, respectively (P < 0.05). Butorphanol was the most effective. We therefore suggest the IV pretreatment with butorphanol 2 mg for attenuation of pain associated with propofol injection.


老年病人鞘内注射可乐定行术后镇痛:比重对血流动力学和镇痛效果的影响

Intrathecal Clonidine for Postoperative Analgesia in Elderly Patients: The Influence of Baricity on Hemodynamic and Analgesic Effects

Amir Baker, MD*, Walter Klimscha, MD*, James C. Eisenach, MD{dagger}, Xin-Hui Li, PhD{dagger}, Eckart Wildling, MD*, Wolfgang A. Menth-Chiari, MD{ddagger}, and Astrid I. Chiari, MD*

*Department of Anesthesiology and General Intensive Care, University of Vienna, Vienna, Austria; {dagger}Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and {ddagger}Department of Traumatology, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:128-134

鞘内注射可乐定是一种有效的镇痛方式,但可能抑制血流动力学和产生镇静,可能与鞘内注射可乐定后在脑脊液内向头端扩散有关。作者假设鞘内用可乐定的不良作用可通过使用高比重可乐定液和抬高躯干的方法而减少,同时不影响镇痛时间和效果。随机选择30例老年病人接受150ug重比重(HYPER)或等比重(ISO)的可乐定用于外伤性髋骨骨折修补术后镇痛。选择时段记录血流动力学、静脉补液、视觉镇痛模拟评分、镇静评分和可乐定在脑脊液中的浓度。ISO组病人需要的晶体液明显多于HYPER组(ISO组为:1500ml3000ml,平均2500mlHYPER500ml3000ml,平均1500ml)以维持有效动脉血压(p<0.01)。同样,ISO组心率下降较HYPER组显著(p<0.01)。镇痛时间ISO组(115400min,平均400min)较HYPER组(205400min,平均265min)增加显著(p<0.05),镇痛评分两组无差异。结论:增加鞘内注射可乐定溶液的比重可减少血流动力学的不利影响同时产生镇痛作用。

(忻纪华 译 陈杰 校)

Intrathecal (IT) clonidine is an effective analgesic, but it also produces hemodynamic depression and sedation which are likely to be related to IT clonidine’s cephalad spread within the cerebrospinal fluid. We hypothesized that IT clonidine’s side effects could be reduced without compromising the duration and quality of analgesia by injecting clonidine IT in a hyperbaric solution and elevating the patient’s trunk. We prospectively randomized 30 elderly patients to receive IT 150 µg of either isobaric (ISO) or hyperbaric (HYPER) clonidine for postoperative analgesia after surgical repair of traumatic hip fracture. Hemodynamics, IV fluid administration, visual analog pain scores, sedation scores, and clonidine cerebrospinal fluid levels were recorded at fixed intervals. Patients in the ISO group required significantly more crystalloid fluid administration (median, 2500 mL; range, 1500–3000 mL) than those in the HYPER group (median, 1500; range, 500–3000 mL) to maintain adequate arterial blood pressure (P < 0.01). Also, the decrease in heart rate was significantly more pronounced in the ISO than in the HYPER group (P < 0.01). The duration of analgesia was significantly larger in the ISO (median, 400 min; range, 115–400 min) than in the HYPER (median, 265 min; range, 205–400 min) group (P < 0.05). Sedation scores did not differ between groups. We conclude that increasing the baricity of IT clonidine solution in the conditions of our experiment reduces hemodynamic side effects but also analgesia from IT administered clonidine.


大鼠关节腔内预注氯胺酮或美金刚有助于减少关节痛及脊髓 c- Fos 表达

Intraarticular Pretreatment with Ketamine and Memantine Could Prevent Arthritic Pain: Relevance to the Decrease of Spinal c-Fos Expression in Rats

Guo Hua Zhang, MD PhD*, Sun Seek Min, PhD*, Kyu Sang Lee, MS*, Seung Keun Back, MS*, Seong Jun Yoon, MD PhD{dagger}, Young Wook Yoon, MD PhD*, Yang In Kim, PhD, Heung Sik Na, MD PhD*, Seung Kil Hong, MD PhD*, and Hee Chul Han, MD PhD*

*Department of Physiology, College of Medicine and Neuroscience Research Institute, Medical Science Research Center, Korea University, Seoul; and {dagger}Department of Obstetrics & Gynecology, Gil Medical Center, Gachon Medical School, Inchon, South Korea

Anesth Analg 2004;99:152-158

为了确定人体关节内使用N-甲基-D天冬氨酸受体拮抗剂氯胺酮或美金刚预注射是否可以预防关节疼痛,作者用大鼠研究膝关节内注射角叉胶之前注入上述药物对疼痛相关行为和脊髓c-Fos受体的表达程度。在膝关节内注入角叉胶(2%40μL)之前注入氯胺酮(0.2mg1mg)或美金刚(0.1mg,0.2mg1mg),而不是注入腹腔,可以明显改善疼痛相关行为。关节内注入氯胺酮(1mg)或美金刚(0.2mg)还可以抑制c-Fos受体在L3-4脊髓水平的表达。随后的统计学分析显示,脊髓c-Fos受体表达程度与疼痛相关行为的程度呈正相关。上述结果提示在外周神经末梢给予NMDA受体拮抗剂对于关节痛有预防性镇痛作用,这可能与中枢疼痛信号减弱有关。由于目前认为氯胺酮与美金刚用于临床病人是安全的,其对关节痛有一定治疗价值。

(周洁 译 陈杰 校)

To determine whether intraarticular pretreatment with N-methyl-D-aspartic (NMDA) receptor antagonist ketamine or memantine currently used in humans has prophylactic analgesia in arthritic pain, we examined the effects of their intraarticular injection before carrageenan injection into the knee joint on pain-related behavior and spinal c-Fos expression in rats. Injection of ketamine (0.2 mg and 1 mg) or memantine (0.1 mg, 0.2 mg, and 1 mg) into the knee joint, but not the abdominal cavity, immediately before carrageenan injection (2%, 40 µL) significantly prevented pain-related behavior. The intraarticular injection of ketamine (1 mg) or memantine (0.2 mg) also suppressed c-Fos expression in the laminae I-II and laminae V-VI at the L3-4 spinal level. Subsequent statistical analyses revealed that the degree of the spinal c-Fos expression was correlated with the extent of the pain-related behavior. These results suggest that peripheral administration of NMDA receptor antagonists has prophylactic analgesic effects in arthritic pain, which might be associated with the decrease of central nociceptive signaling. Because ketamine and memantine are currently used in humans and considered clinically safe, they may have therapeutic value in the treatment of joint pain.


连硬下剖腹产时下肢加压包扎预防低血压而不能预防低温或寒战

Lower Limb Wrapping Prevents Hypotension, but Not Hypothermia or Shivering, After the Introduction of Epidural Anesthesia for Cesarean Delivery

Hsiao Lun Sun, MD*, Qing Dong Ling, PhD{dagger}, Wei Zen Sun, MD{ddagger}, Rick Sai-Chuen Wu, MD§, Tzong Jeng Wu, MD*, Shih Chieh Wang, MD*, and Chih Cheng Chien, MD PhD{dagger}

*Department of Anesthesiology and {dagger}Cathay Medical Research Institute, Cathay General Hospital, Taipei, Taiwan; {ddagger}Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan; and §Department of Anesthesiology, Pain Service and Critical Care Medicine, China Medical College Hospital, Taipei, Taiwan

Anesth Analg 2004;99:241-244

连硬和蛛网膜下腔麻醉后体温和血压降低被认为是交感神经阻滞,血流重新分布下肢所致。研究证实下肢用弹力绷带加压包扎可以减少脊麻后低血压的发生率,我们在此基础上进一步研究,验证下肢使用弹力绷带加压包扎是否可以减少硬膜外麻醉后低血压的发生,同时评价此措施对低温和寒战的效果。60例临产妇随机分为下肢加压包扎组和不加压对照组,记录5个阶段的舌下温度:基础值,麻醉后,皮肤消毒后,开皮和分娩时。观察期间,同时记录患者低温和寒战的情况。包扎组低血压的发生率(23%)显著低于对照组(50%) (p=0.03);两组寒战的发生率近似(70%70%);两组的舌下温度均显著降低(p<0.001),但温度降低的程度没有显著差异。结论:下肢加压包扎显著降低了产妇连硬麻醉后低血压的发生率,但没有减少寒战和低温的数量和程度。

( 陈洁 译   陈杰 校)

The decrease of arterial blood pressure and body temperature after epidural or spinal anesthesia is thought to be the result of sympathetic block, which could cause pooling and redistribution of blood into the lower extremities. Studies have demonstrated that leg wrapping with elastic bandages may reduce the incidence of hypotension after spinal anesthesia. We tried to extend these previous observations to epidural anesthesia by testing the hypothesis that leg wrapping with elastic bandages should decrease the incidence of hypotension in patients receiving epidural anesthesia. Moreover, we evaluated the effect of this maneuver as regards hypothermia and shivering. Sixty parturients were randomly allocated to receive either leg wrapping with tight elastic bandages (leg-wrapped group) or not (control group) before anesthesia. Sublingual temperature was observed at five periods: baseline, immediately after epidural anesthesia, abdominal skin disinfection, skin incision, and delivery. Hypotension and shivering during the observation periods were also recorded. The incidence of hypotension was significantly less frequent (P = 0.03) in the leg-wrapped group (23%) compared with the control group (50%). Shivering incidences were similar in both groups (70% versus 70%). Sublingual temperature decreased significantly (P < 0.001) throughout the procedure in each group. However, no differences were found between the two groups at each designated observation, even if compared by the magnitude of temperature decrease. We conclude that although leg wrapping with elastic bandages prevents maternal hypotension after epidural anesthesia, it does not reduce the incidence or magnitude of hypothermia or prevent shivering.


全髋或全膝关节成形术病人限制用重组人血红细胞生成素和自体血回输是有效对策

A Restrictive Use of Both Autologous Donation and Recombinant Human Erythropoietin Is an Efficient Policy for Primary Total Hip or Knee Arthroplasty

Claude Couvret, MD*, Marc Laffon, MD*, Annick Baud, MD*, Valérie Payen, MD*, Philippe Burdin, MD{dagger}, and Jacques Fusciardi*

Departments of *Anesthesiology and Critical Care and {dagger}Orthopedic Surgery, Trousseau University Hospital, Tours, France

Anesth Analg 2004;99:262-271

在全髋(THA)或全膝(TKA)关节成形术前,非贫血病人限制使用自体血回输(PABD),贫血病人(血球压迹〔Hct≤39%)限制使用重组人血红细胞生成素(EPO),可以有效的改善输血的花费-受益比。根据这两种不同的输血方案,我们评价了THATKA手术中需要输血的病人的比率和花费情况。本研究为保证质量,病人的治疗和护理均由同一医疗小组完成,并前瞻性的观察了连续性的一个时间段。在研究1中(n182),当医师们认为红细胞储备不足且预期生命≥10年时,就采用PABD,不使用EPO,也不使用常规的输血标准。因为,常规的标准可导致异体输血率50%以上(Hct≤37%)和非贫血患者自体血的浪费(Hct≤39)。在研究2(n=708),又分为两种情况,当Hct≤37%,预期生命≥10年使用EPO,而不用PABD;非贫血病人不用PABD。结果发现输血比率明显下降(在非贫血病人中,从41%降到7%P<0.0002;在贫血病人中,从58%降到27%P<0.003;总输血率,从43%降到12%P<0.0001), 异体输血比率(10%)Hct没有明显改变,节约经济花费39%。经济节约主要原因是限制了非贫血病人PABD的使用(常规75%的手术病人使用PABD)。虽然促红细胞生成素很贵,但它可以节省部分病人输血的费用,减少总费用。

(肖洁 译 陈杰 校)

A limitation of preoperative autologous blood donation (PABD) in nonanemics and the use of recombinant human erythropoietin (EPO) in anemics (baseline hematocrit [Hct] ≤39%) could be an efficient approach of the cost-benefit ratio of transfusion during primary total hip (THA) or knee (TKA) arthroplasties. We evaluated the consequences on transfusion rates and costs of two different applications of a transfusion policy based on personal requirements during primary THA or TKA. This quality assurance observational study compared two prospective successive time periods; each included successive patients treated by the same medical team and standardized care. In Study 1 (n = 182), PABD was indicated if there were insufficient estimated red blood cell reserve and a life expectancy ≥10 yr, no use of EPO, and identical criteria for any transfusion. Because this policy led to a 50% allogeneic transfusion rate when baseline Hct ≤37% and autologous blood wastage in the nonanemics (baseline Hct > 39%), 2 refinements were introduced in Study 2 (n = 708): EPO without PABD when baseline Hct ≤37%, and life expectancy ≥10 yr, and avoidance of PABD in nonanemics. This novel care induced a marked decrease in transfusion rates (respectively, from 41% to 7%, P < 0.0002, in nonanemics; from 58% to 27%, P < 0.003, in anemics; and from 43% to 12%, P < 0.0001, overall), with no change in allogeneic transfusion (10%) and discharge Hct, and a 39% financial savings. This saving effect is a result of the suppression of PABD in nonanemics, who represent 75% of this surgical population. Although erythropoietin is expensive, it can be used with cost savings in selected patients because the overall cost of transfusion is reduced.


轻度体温增高可下调受体依赖的噬中性粒细胞功能

Mild Hyperthermia Down-Regulates Receptor-Dependent Neutrophil Function

Dieter Fröhlich, MD*, Sigrid Wittmann, MD*, Gregor Rothe, MD{dagger}, Daniel I. Sessler, MD§, Peter Vogel, MD{ddagger}, and Kai Taeger, MD*

Departments of *Anesthesia, {dagger}Clinical Chemistry and Laboratory Medicine, and {ddagger}Surgery, University of Regensburg, Regensburg, Germany; and §Outcomes ResearchTM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:284-292

轻度体温降低可削弱噬中性粒细胞对感染的抵抗力,还可削弱其噬菌作用和对非调理素作用细菌的氧化毒杀作用。我们从志愿者身上提取噬中性粒细胞并放在33°41°C的温度环境下评估其各种功能。我们通过光学显微镜判断其黏附内皮细胞的作用,通过流式细胞分析来测定粘附分子的表达,受体,噬菌作用和活性氧化剂的释放。休眠的嗜中性粒细胞中粘附蛋白CD11b的表达是温度无关的。然而,CD11b与肿瘤坏死因子TNF-α的上调作用在体温过低温时增强而在体温过高时下降。噬中性粒细胞粘附休眠或激活的噬中性粒细胞不是温度依赖的。细菌的摄取作用与温度反相关,这一点大肠杆菌比金黄色葡萄球菌更明显。温度依赖的噬菌作用仅发生在受调理素作用的细菌。低温可轻微增加噬中性粒细胞中的N-甲酰甲硫亮氨酸苯丙氨酰基受体,高温则降低表达,尤其在伴有TNF-α的情况下。N-甲酰甲硫亮氨酸苯丙氨酰基引起的过氧化氢的产生与温度呈反相关,尤其当TNF-α存在的情况下。相反地,phorbol-13-myristate-12-acetate,蛋白酶C的激活物,当温度升高时可过度地释放同源的活性氧化剂。与非受体依赖的噬菌作用以及氧化毒杀作用相比,许多重要的受体依赖的噬中性粒细胞活性作用需温度依赖的调节,低温可增强其功能。温度依赖的噬中性粒细胞功能远比先前预料的复杂。

(朱辉 译 陈杰 校)

Mild hypothermia impairs resistance to infection and, reportedly, impairs phagocytosis and oxidative killing of un-opsonized bacteria. We evaluated various functions at 33°–41°C in neutrophils taken from volunteers. Adhesion on endothelial cells was determined using light microscopy. Adhesion molecule expression and receptors, phagocytosis, and release of reactive oxidants were assessed using flow cytometric assays. Adhesion protein CD11b expression on resting neutrophils was temperature-independent. However, up-regulation of CD11b with tumor necrosis factor (TNF)-{alpha} was increased by hypothermia and decreased with hyperthermia. Neutrophil adhesion to either resting or activated endothelial cells was not temperature-dependent. Bacterial uptake was inversely related to temperature, more so with Escherichia coli than Staphylococcus aureus. Temperature dependence of phagocytosis occurred only with opsonized bacteria. Hypothermia slightly increased N-formyl-L-methionyl-L-leucyl-phenylalanine receptors on neutrophils: hyperthermia decreased expression, especially with TNF-{alpha}. N-formyl-L-methionyl-L-leucyl-phenylalanine-induced H2O2 production was inversely related to temperature, especially in the presence of TNF-{alpha}. Conversely, phorbol-13-myristate-12-acetate, an activator of protein kinase C, induced an extreme and homogenous release of reactive oxidants that increased with temperature. In contrast to nonreceptor-dependent phagocytosis and oxidative killing, several crucial receptor-dependent neutrophil activities show temperature-dependent regulation, with hypothermia increasing function. The temperature dependence of neutrophil function is thus more complicated than previously appreciated.

抑制脊髓蛋白激酶C-ε或 {gamma}同工酶不影响鼠吸入氟烷最低肺泡浓度

Inhibition of Spinal Protein Kinase C-{epsilon} or -{gamma} Isozymes Does Not Affect Halothane Minimum Alveolar Anesthetic Concentration in Rats

Jennifer A. Shumilla, PhD*, Sarah M. Sweitzer, PhD*, Edmond I Eger, II, MD{dagger}, Michael J. Laster, DVM{dagger}, and Joan J. Kendig, PhD*

*Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, California

Anesth Analg 2004;99:82-84

麻醉剂通过酶如蛋白激酶 C PKC)作用于受体或离子通道磷酸化的假设能解释麻醉某些方面的作用。离体试验显示麻醉剂对一些受体的作用受PKC的调节。为验证PKC在吸入麻醉药后抑制体动中的重要性,我们在出生7天和21天的Sprague-Dawley鼠的椎管内注入PKC-εPKC-{gamma}的抑制剂,观察其对氟烷最低肺泡浓度的影响。抑制剂的规格:溶液,100 pmol/5µL7天鼠给予5µLP7),21天鼠给予10µLP21)。对照组给予同样浓度和容积的盐水或多肽载体,每组有6只实验鼠。在P7中,生理盐水对照组的MAC1.63±0.0727 ( 均数±标准差),载体组的MAC1.55±0.141PKC-{epsilon}组的MAC1.54±0.0800PKC-{gamma}组的MAC1.69 ± 0.0554。在P21中,各组的MAC 分别为1.20 ± 0.0490, 1.31 ± 0.0124, 1.27 ± 0.0367, and 1.15 ± 0.0483。注射抑制剂,并不改变各年龄组的MAC。这些结果,并不支持麻醉剂对磷酸化的作用作为一种机制来解释吸入麻醉药后抑制躯体对伤害性刺激反应的体动,不直接支持对受体或离子通道的直接作用。

(葛宁花 译)

Anesthetic effects on receptor or ion channel phosphorylation by enzymes such as protein kinase C (PKC) have been postulated to underlie some aspects of anesthesia. In vitro studies show that anesthetic effects on several receptors are mediated by PKC. To test the importance of PKC for the immobility produced by inhaled anesthetics, we measured the effect of intrathecal injections of PKC-{epsilon} and -{gamma} inhibitors on halothane minimum alveolar anesthetic concentration (MAC) in 7-day-old and 21-day-old Sprague-Dawley rats. The inhibitors were made as solutions of 100 pmol/5 µL and were given in a volume of 5 µL (7-day-old [P7] rats) or 10 µL (21-day-old [P21] rats). Controls were saline injections or injections of the peptide carrier at the same concentration and volumes; there were six animals in each group. In P7 rats, MAC values (in percentage of an atmosphere) were 1.63 ± 0.0727 (mean ± SEM) in saline controls, 1.55 ± 0.141 in carrier controls, 1.54 ± 0.0800 in rats given PKC-{epsilon}, and 1.69 ± 0.0554 in rats given PKC-{gamma}. In P21 animals, the values were 1.20 ± 0.0490, 1.31 ± 0.0124, 1.27 ± 0.0367, and 1.15 ± 0.0483, respectively. Injection of the inhibitors did not change MAC in either age group. These results do not support an anesthetic effect on phosphorylation as a mechanism underlying the capacity of inhaled anesthetics to prevent movement in response to noxious stimulation, and they indirectly support a direct action on receptors or ion channels.

 

经胸部超声引导腋静脉置管:标准锁骨下静脉置管的另一选择

Transpectoral Ultrasound-Guided Catheterization of the Axillary Vein: An Alternative to Standard Catheterization of the Subclavian Vein

NavParkash S. Sandhu, MD

Department of Anesthesiology, New York University School of Medicine, New York, New York

Anesth Analg 2004;99:183-187

锁骨下静脉置管常因损伤肺和锁骨下动脉而失败或产生并发症。锁骨下静脉位于锁骨和第一肋之间,使得超声显像困难。在超声探头中点穿刺,通过针尖显示整个穿刺针有一定的难度。腋静脉位于胸廓外,容易在纵切位确切显示穿刺针、导引钢丝、扩张器和导管的位置。所有用超声定位静脉的技术,均显示静脉的横切面,而穿刺针并不能完全显像。本文描述5例腋静脉置管,通过超声在纵切面的静脉定位,随后穿刺,放置导引钢丝和导管,图象显示和真实操作一致。建议使用较长的穿刺针和引导鞘。同时需要更多的实践来评价这种技术的可能性。

(葛宁花 译)

Subclavian vein catheterization is associated with failure and complications because of injury to the nearby lung and subclavian artery. Its position, sandwiched between the clavicle and the first rib, makes sonographic imaging difficult. The medially pointed sonography probe makes it difficult to align the needle as well as image the entire needle. The axillary vein lies outside of the thoracic cage and can be easily imaged in its longitudinal view along with the entire needle, guidewire, dilator, and catheter in real-time. All described techniques of venous access using sonography have used transverse images of veins, and the needle is not completely visualized. Five cases of axillary vein catheterization using longitudinal section images of the vein, and following the needle, guidewire, and line with real-time sonography, are described. The use of longer puncture needles and introducer sheaths is suggested. A larger study is required to assess the potential of this technique.

 

利用术中经食管超声确诊肺栓塞

Utility of Intraoperative Transesophageal Echocardiography for Diagnosis of Pulmonary Embolism

Peter Rosenberger, MD*, Stanton K. Shernan, MD*, Simon C. Body, MBChB*, and Holger K. Eltzschig, MD{dagger}

*Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts; and {dagger}Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany

Anesth Analg 2004;99:12-16

 

围术期的肺栓塞(PE)与死亡率和发病率有密切关系。经食管超声能直接显示肺栓塞,或肺动脉阻塞的继发症状。但是,用于术中诊断肺栓塞尚有待于明确。我们对46位在肺叶切除前一刻进行术中TEE检查。主要检查左肺动脉、右肺动脉和肺动脉主干有无栓塞、急性肺动脉阻塞的继发症状(右心衰竭、中度到重度的三尖瓣反流、房间隔左移)。栓塞的确切部位由手术确定。超声诊断PE的正确率是46%n = 21 / 46)。但是,即使栓塞在某一特殊部位,敏感率也只有26%TEE诊断左肺动脉栓塞最不敏感(17%)。在检查过程中,TEE能观察到96%的右心功能不全,50%的三尖瓣反流,98%的房间隔左移。因此,与直接手术诊断PE比较,术中TEE诊断急性PE有局限性。TEE对间接症状肺动脉阻塞的证据有助于PE的诊断。

(葛宁花 译)

Pulmonary embolism (PE) is associated with significant perioperative morbidity and mortality. Transesophageal echocardiography (TEE) may permit direct visualization of PE or secondary signs of pulmonary artery (PA) obstruction. However, its utility in diagnosing PE in the intraoperative setting has yet to be defined. Therefore, we performed intraoperative TEE examinations in 46 patients immediately before pulmonary embolectomy. TEE examinations were reviewed for signs of thromboemboli within the right, left, and main PA, and secondary signs of acute PA obstruction (right ventricular dysfunction, moderate-to-severe tricuspid regurgitation, leftward bowing of the interatrial septum). The definitive location of thromboemboli was determined from the surgical record. Echocardiographic evidence for the presence of PE was correctly demonstrated in 46% of all patients (n = 21 of 46). However, the sensitivity for direct visualization of thromboemboli at any specific location was only 26%. TEE was least sensitive for thromboemboli in the left PA (17%). TEE evidence of right ventricular dysfunction was observed in 96%, tricuspid regurgitation in 50%, and leftward interatrial septal bowing in 98% of examinations. Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization is limited. Indirect TEE evidence of PA obstruction may be helpful in supporting a diagnosis of PE.

 

增加氧和二氧化碳均能增加皮下和肠粘膜的氧合。

Supplemental Oxygen and Carbon Dioxide Each Increase Subcutaneous and Intestinal Intramural Oxygenation

Jebadurai Ratnaraj, MD*, Barbara Kabon, MD*, Michael R. Talcott, DVM{dagger}, Daniel I. Sessler, MD{ddagger}, and Andrea Kurz, MD§

Departments of *Anesthesiology and {dagger}Veterinary Surgical Services, Washington University, St. Louis, MO; the {ddagger}Outcomes Research Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, KY; and §the Department of Anesthesiology, University of Bern, Switzerland and the Department of Anesthesiology and Intensive Care Medicine, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:207-211


中性粒细胞的氧化灭菌是防御手术病菌的主要手段,直接与组织的氧供有关。我们验证这一理论:增加吸入氧浓度或轻度高碳酸血症(呼气末PCO2 保持在50 mmHg)能增加肠道组织的氧供。实验猪(重量25 ± 2.5 kg)随机分为以下两类:1 氧供研究:在保持呼气末PCO2 40 mmHg的前提下,吸入30%的氧与吸入100%的氧对照;2 二氧化碳研究:在吸入30%氧的条件下,呼气末PCO2 30 mmHg50 mmHg对照。各组研究中,治疗顺序随机,持续1.5小时;检测数据平均延续至实验的最后一小时。在左侧大腿的皮下放置压力器测量皮下氧张力,在肠壁放置压力器,测量小肠和大肠黏膜下的氧张力。100%的氧供能使皮下氧分压(PO2)(57 ± 10 107 ± 48 mm Hg, P = 0.006)和大肠黏膜下氧分压(PO2) (53 ± 14 to 118 ± 72 mm Hg, P = 0.014)增加一倍,能使小肠黏膜下氧分压增加40%。呼气末PCO2 50 mm Hg组,大肠黏膜下PO2增加 16%(49 ± 10 57 ± 12 mm Hg, P = 0.039),小肠黏膜下PO2增加45% (31 ± 12 to 44 ± 16 mm Hg, P = 0.002).增加氧供和轻度的高碳酸血症均能增加皮下和肠黏膜下组织的氧分压,而增加氧供的效果更有效。

(葛宁花 译)

Oxidative killing by neutrophils, a primary defense against surgical pathogens, is directly related to tissue oxygenation. We tested the hypothesis that supplemental inspired oxygen or mild hypercapnia (end-tidal PCO2 of 50 mm Hg) improves intestinal oxygenation. Pigs (25 ± 2.5 kg) were used in 2 studies in random order: 1) Oxygen Study: 30% versus 100% inspired oxygen concentration at an end-tidal PCO2 of 40 mm Hg, and 2) Carbon Dioxide Study: end-tidal PCO2 of 30 mm Hg versus 50 mm Hg with 30% oxygen. Within each study, treatment order was randomized. Treatments were maintained for 1.5 h; measurements were averaged over the final hour. A tonometer inserted in the subcutaneous tissue of the left upper foreleg measured subcutaneous oxygen tension. Tonometers inserted into the intestinal wall measured intestinal intramural oxygen tension from the small and large intestines. Oxygen 100% administration doubled subcutaneous oxygen partial pressure (PO2) (57 ± 10 to 107 ± 48 mm Hg, P = 0.006) and large intestine intramural PO2 (53 ± 14 to 118 ± 72 mm Hg, P = 0.014); intramural PO2 increased 40% in the small intestine (37 ± 10 to 52 ± 25 mm Hg, P = 0.004). An end-tidal PCO2 of 50 mm Hg increased large intestinal PO2 approximately 16% (49 ± 10 to 57 ± 12 mm Hg, P = 0.039), whereas intramural PO2 increased by 45% in the small intestine (31 ± 12 to 44 ± 16 mm Hg, P = 0.002). Supplemental oxygen and mild hypercapnia each increased subcutaneous and intramural tissue PO2, with supplemental oxygen being most effective.

 

比较硬膜外布比卡因、左旋布比卡因和罗哌卡因对术后镇痛和运动阻滞的作用

A Comparison of Epidural Bupivacaine, Levobupivacaine, and Ropivacaine on Postoperative Analgesia and Motor Blockade

Pasquale De Negri, MD*, Giorgio Ivani, MD{dagger}, Tiziana Tirri, MD*, Pasqualina Modano, MD*, Cesare Reato, MD*, Staffan Eksborg, PhD{ddagger}, and Per-Arne Lonnqvist, MD PhD{ddagger}

*Department of Anesthesia, ICU and Pain Management, Centro di Riferimento Oncologico della Basilicata-Cancer Center, Rionero in Vulture, Potenza, Italy; {dagger}Department of Pediatric Anesthesia and Intensive Care Unit, "Regina Margherita" Children’s Hospital, Turin, Italy; and {ddagger}Department of Women and Child Health and Department of Surgical Sciences, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2004;99:45-48


在前瞻性、随机性和观察者不知情的临床试验中,我们在小儿尿道下裂修补术后硬膜外腔分别注射小剂量(0.125% 0.2 mg • kg–1 • h–1)的布比卡因(B组,n = 26),左旋布比卡因(L组,n = 27)和罗哌卡因(R组,n = 26),比较下肢出现运动阻滞与镇痛的效果。术后48小时,在事先固定的时间,用改良的Bromage评分法评估运动阻滞的程度,用儿童和婴儿术后疼痛评分法(CHIPPS)评估疼痛的程度。三组患者术后镇痛效果几乎一致(CHIPPS评分 0–3),没有任何患者需要另外增加镇痛药。但是,在观察期间,B组出现运动阻滞的人数 (n = 6) L(n = 0)R(n = 0)比较明显增加,差异有显著性(P = 0.03)。结论,小儿尿道下裂修补术后在硬膜外腔连续注射0.125%的左旋布比卡因和罗哌卡因,与注射相同剂量的布比卡因比较,运动阻滞发生率明显减少;但三组的镇痛效果无显著性差异。

(葛宁花 译)

In this prospective, randomized, observer-blinded clinical trial, we compared the incidence of unwanted lower extremity motor blockade and the analgesic efficacy between small-dose (0.125%; 0.2 mg • kg–1 • h–1) postoperative epidural infusions of bupivacaine (Group B; n = 28), levobupivacaine (Group L; n = 27), and ropivacaine (Group R; n = 26) in children after hypospadias repair. Motor blockade and pain were assessed at predetermined time points during 48 h by using a modified Bromage scale and the Children’s and Infant’s Postoperative Pain Scale (CHIPPS). Postoperative analgesia was almost identical in all three study groups (CHIPPS range, 0–3), with no need for the administration of supplemental analgesia in any patient. However, significantly more patients in Group B (n = 6; P = 0.03) displayed signs of unwanted motor blockade during the observation period compared with Group L (n = 0) and Group R (n = 0). In conclusion, significantly less unwanted motor blockade was associated with postoperative epidural infusions of 0.125% levobupivacaine or ropivacaine in children after hypospadias repair as compared with a similar infusion of bupivacaine. However, no difference with regard to postoperative analgesia could be detected among the three different local anesthetics studied.

 

全膝置换术后镇痛:闭孔神经阻滞加股神经31神经阻滞

Postoperative Analgesia After Total Knee Replacement: The Effect of an Obturator Nerve Block Added to the Femoral 3-in-1 Nerve Block

D. Macalou, MD*, S. Trueck, MD*, P. Meuret, MD*, M. Heck, MD*, F. Vial, MD*, S. Ouologuem, MD*, X. Capdevila, MD PhD{dagger}, J. -M. Virion{ddagger}, and H. Bouaziz, MD PhD*

*Department of Anesthesiology and Intensive Care, Central University Hospital, Nancy, France, the {dagger}Department of Anesthesiology and Intensive Care, Lapeyronie University Hospital, Montpellier, France, and the {ddagger}Department of Epidemiology & Clinical Evaluation and Centre of Clinical Investigation, University Hospital, Nancy, France

Anesth Analg 2004;99:251-254
 

股神经阻滞并不包括闭孔神经。在这单盲、随机和对照研究中,我们在阻滞股神经的基础上,选择闭孔神经阻滞,分析其在全膝置换术后镇痛中的作用。在全身麻醉前,90位行全膝置换术的患者随机分为股神经阻滞组(组1),股神经加选择性闭孔神经阻滞组(组2)和安慰剂股神经阻滞组(组3)。此外由病人自控静脉吗啡注射镇痛。记录术后最初6小时内镇痛效果和副作用。在组1中,内收肌肌力减弱是18% ± 9%,而在组2,是78% ± 22%(P < 0.0001)。与组1和组3比较,组2的吗啡总用量减少(P ≤0.0001)。组2的疼痛评分比组1和组3(P = 0.0003)。恶心的发生率在组1和组3(P = 0.01)。结论,只有股神经阻滞而没有闭孔神经的阻滞,并不能产生完全的镇痛作用。在术后的早期,单次股神经阻滞对静止时的镇痛作用并不比静脉镇痛有优势。在全膝置换术后增加闭孔神经的阻滞能增加术后镇痛效果。

(葛宁花 译)

Femoral nerve block (FNB) does not consistently produce anesthesia of the obturator nerve. In this single-blind, randomized, controlled study we added a selective obturator nerve block (ONB) to FNB to analyze its influence on postoperative analgesia after total knee replacement (TKR). Before general anesthesia, 90 patients undergoing TKR received FNB (Group 1), FNB and selective ONB (Group 2), or placebo FNB (Group 3). Postoperative analgesia was further provided by morphine IV via patient-controlled analgesia. Analgesic efficacy and side effects were recorded in the first 6 h after surgery. Adductor strength decreased by 18% ± 9% in Group 1 and by 78% ± 22% in Group 2 (P < 0.0001). Total morphine consumption was reduced in Group 2 compared with Groups 1 and 3 (P ≤0.0001). Patients in Group 2 reported lower pain scores than those in Groups 1 and 3 (P = 0.0003). The incidence of nausea was more frequent in Groups 1 and 3 (P = 0.01). We conclude that FNB does not produce complete anesthesia of the obturator nerve. Single-shot FNB does not provide additional benefits on pain at rest over opioids alone in the early postoperative period. The addition of an ONB to FNB improves postoperative analgesia after TKR.

.

 

较小潮气量通气:随机对照定量系统回顾

Ventilation with Smaller Tidal Volumes: A Quantitative Systematic Review of Randomized Controlled Trials

Nicola Petrucci, MD MSc, and Walter Iacovelli, MD

Department of Anaesthesia & Intensive Care, Azienda Ospedaliera Desenzano, Desenzano, Italy

Anesth Analg 2004;99:193-200


在这一详细的系统回顾中,我们评估用较小潮气量通气在16岁以上患有急性肺损伤和急性呼吸窘迫综合征患者中的作用。5个随机试验(1202名患者),随机比较用较小的VT/或低气道驱动压力(平台压30cm H2O或以下)通气,保持Vt 7 mL/kg 以下,和对照组Vt10 - 15 mL/kg,结果由Cochrance中心注册的对照试验,MEDLINEEMBASECINAHL,当代数据研究,参考目录和“灰色文献”等系统研究后确定。28天的死亡率在肺保护性通气组有明显降低(相对危险因素RR 0.74CI0.61-0.88),而对死亡率的长期有利性作用不确切(RR0.84CI0.68-1.05)。如果对照组的平台压力小于或等于31cm H2O (RR, 1.13; CI, 0.88–1.45),则小潮气量组和常规潮气量组无显著性差异。临床试验的不均一性,如随访时间长短不同,对照组较高的平台压力,使得合理解释结果有一定的困难。

In this quantitative systematic review we assessed the effects of ventilation with smaller tidal volume (VT) on morbidity and mortality in patients aged 16 yr or older affected by acute lung injury and acute respiratory distress syndrome. Five randomized trials (1202 patients) comparing ventilation using smaller VT and/or low airway driving pressure (plateau pressure 30 cm H2O or less), resulting in VT of 7 mL/kg or less versus ventilation that uses VT in the range of 10 to 15 mL/kg, were identified after a systematic search of The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, databases of current research, reference lists, and "gray literature." Mortality at day 28 was significantly reduced by lung-protective ventilation (relative risk [RR], 0.74; confidence interval [CI], 0.61–0.88), whereas beneficial effect on long-term mortality was uncertain (RR, 0.84; CI, 0.68–1.05). The comparison between small and conventional VT was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR, 1.13; CI, 0.88–1.45). Clinical heterogeneity, such as different lengths of follow-up and higher plateau pressures in control arms in two trials, make the interpretation of the combined results difficult.

 

犬异丙酚苏醒期引起膈肌收缩减少的研究

The Recovery Profile of Reduced Diaphragmatic Contractility Induced by Propofol in Dogs

Yoshitaka Fujii, MD, Aki Uemura, MD, and Hidenori Toyooka, MD

Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba City, Ibaraki, Japan

Anesth Analg 2004;99:113-116
 

异丙酚可以减少膈肌的收缩,但是尚无资料显示其在苏醒时的作用。我们在狗身上研究了苏醒时异丙酚减少膈肌收缩的作用。动物分为4组,每组7个。组1,不伴有膈肌疲劳,只接受维持7的补液;组2,不伴有膈肌疲劳,输注异丙酚;组3,伴有膈肌疲劳,不接受任何药物;组4,伴有膈肌疲劳,输注异丙酚。麻醉剂量的异丙酚(初始0.1 mg/kg  持续6.0 mg • kg–1 • h–1)持续60分钟。在组34中,使用20赫兹持续30分钟超大的双侧电刺激达到膈肌疲劳的目的。我们通过测跨膈肌压力(Pdi)来评价膈肌收缩力。组2中,低频(20-Hz)时的 Pdi小于基础值(P < 0.05),高频(100-Hz)刺激时没有改变。停止异丙酚输注后10分钟,低频(20-Hz)时的 Pdi恢复到基础值。当出现疲劳时,组3和组4,低频(20-Hz)时的 Pdi降到基础值以下(P < 0.05),高频(100-Hz)刺激时没有改变。组4中使用异丙酚以后低频(20-Hz)时的 Pdi降到疲劳值以下(P < 0.05)。停止异丙酚输注后20分钟,低频(20-Hz)时的 Pdi恢复到疲劳值。我们于是认为在犬身上,由于异丙酚引起的膈肌收缩下降,无论是否伴有膈肌疲劳,在停止异丙酚输注后20分钟可以恢复。

(方芳 葛宁花 校)

Propofol decreases contractility of the diaphragm, but no data are available for its effects on recovery. We studied the recovery profile of reduced diaphragmatic contractility induced by propofol in dogs. Animals were divided into 4 groups of 7 each. Group I, without fatigue, received only maintenance fluid; Group II, without fatigue, was infused with propofol; Group III, with fatigue, received no study drug; Group IV, with fatigue, was infused propofol. Propofol at an anesthetic dose (0.1 mg/kg initial dose plus 6.0 mg • kg–1 • h–1) was administered for 60 min. In Groups III and IV, diaphragmatic fatigue was induced by intermittent supramaximal bilateral electrophrenic stimulation at 20-Hz for 30 min. We assessed diaphragmatic contractility by transdiaphragmatic pressure (Pdi). In group II, Pdi at low-frequency (20-Hz) stimulation decreased to less than baseline (P < 0.05), whereas there was no change in Pdi at high-frequency (100-Hz) stimulation. At 10 min after the end of propofol administration, Pdi at 20-Hz stimulation returned to baseline. When

 fatigue was established, in Groups III and IV, Pdi at 20-Hz stimulation decreased to less than baseline (P < 0.05), whereas Pdi at 100-Hz stimulation did not change. After administering propofol in Group IV, Pdi at 20-Hz stimulation decreased from fatigued values (P < 0.05). At 20 min after the end of propofol administration, Pdi at 20-Hz stimulation returned to fatigued values. We conclude that reduced contractility in nonfatigued and fatigued canine diaphragm induced by propofol recovers within 20 min after the cessation of administration

 

评估住院医生麻醉前咨询能力的方法的发展及应用

The Development and Application of an Instrument for Assessing Resident Competence During Preanesthesia Consultation

Getúlio Rodrigues de Oliveira Filho, MD, and Leonardo Schonhorst, MD

Department of Anesthesiology, Hospital Governador Celso Ramos, Florianópolis-SC, Brazil

Anesth Analg 2004;99:62-69

 

在此项研究中,我们着眼于建立、验证并应用评估住院医生在门诊病人麻醉前咨询(PAC)方面能力的方法。Delphi专题专家组制定了门诊病人PAC中应包含的几个典型项目,这几项的采用与否正是能力的体现。而由这几项组成的方案在几位受过鉴定的麻醉医生的PAC中得到验证。此项咨询方案易于建立,评估准确性高,适中的内部连贯性,并在圈内得到高度认同,共37项归结为5个方面(医患关系、医疗史、体检、病人宣教、麻醉前记录)。此项方案在7位第一年住院医师进行的连续317PAC中被应用于评估其能力。通过建立各个方面评分及总评分的指数变动均数表来分析数据。而后可通过统计数据显著的区分能力水平,并且结果稳定。连续在项目列表评分方案中应用指数变动均数表可以可靠的评估住院医师的能力。麻醉前咨询评分列表在住院医师的培训期间包括门诊病人麻醉前评估方面是一项非常有效的格式化及累积性的方法。

(陆续伟 译 葛宁花 校)

In this study, we aimed to construct, validate, and apply an instrument for assessing resident performance at outpatient preanesthesia consultation (PAC). A focus group and a Delphi panel of experts defined component items of a typical outpatient PAC, which could be used as indicators of competence. Items were incorporated in a checklist, which was further validated in a sample of consultations performed by board-certified anesthesiologists. The resulting instrument contained 37 items, grouped into five domains (physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records), with high construct validity, high discriminant validity, moderate internal consistency, and high probability of inter-raters agreement. The instrument was applied to evaluate the performance of seven first-year residents at 317 consecutive PAC. Data were analyzed by constructing exponentially weighted moving average charts for domain and total scores. Statistically significant differing levels of performance could be consistently detected. Applying exponentially weighted moving average charts to the sequential analysis of the developed checklist scores can reliably assess resident performance at the devised criteria. The Preanesthesia Consultation Scoring Checklist is a potentially useful instrument for both formative and summative assessment of residents during their training in processes involved in outpatient preanesthesia evaluation.


光导辅助插管在侧卧位患者中的应用

Lightwand-Assisted Intubation of Patients in the Lateral Decubitus Position

Kuang-I Cheng, MD*, Koung-Shing Chu, MD{dagger}, Siu-Wah Chau, MD*, Soo-Lee Ying, MD*, Hong-Te Hsu, MD*, Yin-Lung Chang, MD*, and Chao-Shun Tang, PhD*

*Department of Anesthesiology, Kaohsiung Medical University, Kaohsiung, Taiwan, and the {dagger}Department of Anesthesiology, Kuo General Hospital, Tainan, Taiwan

Anesth Analg 2004;99:279-283

在某些情况下,侧卧位的手术患者需要气管插管以维持呼吸道的通畅。在这一研究中,我们选择120患者,随机分配至平卧、左侧卧位和右侧卧位,比较光导辅助插管的可行性。S组患者首先平卧,气管插管后改为侧卧位。R组患者右侧卧位进行诱导和气管插管。L组患者左侧卧位进行诱导和气管插管。记录每次插管的时间,总的插管成功时间,与插管有关的口腔损伤,血流动力学变化,术后咽喉疼痛和声音嘶哑等等。插管所需的时间相似,平卧位:14.5±13.4s,左侧卧位:13.3 ± 10.2s,右侧卧位:15.5 ± 13.0s;血流动力学变化的趋势相似。患者在平卧和侧卧位时,第一次插管的成功率、咽喉痛、声音嘶哑、口腔黏膜损伤和心率失常等发生率均相似。与平卧位比较,第一次插管时,侧卧位更容易误入食管,但差异无显著性意义。在重新插管后都能纠正。我们得出的结论是光导辅助插管简单可行,不论是侧卧位、俯卧位还是平卧位,技术方法相同。这种方法可用于临床,并建议用于那些插管和手术时保持侧卧位的患者。

(葛宁花 译)

In some situations, patients need endotracheal intubation to maintain airway patency while they are constrained in the lateral position. In this study we compared lightwand-guided intubation of 120 randomly enrolled patients placed in the supine, right, or left lateral position. Group S patients were initially placed in the supine position, and subsequent to the artificial airway having been established they were turned to the lateral decubitus position. Group R patients were initially placed in a right decubitus position during induction and intubation. Group L patients were initially placed in a left decubitus position during induction and intubation. The duration of each intubation attempt, the total time to successful intubation, and the incidence of intubation-related intraoral injury, hemodynamic changes, and postoperative sore throat and hoarseness were recorded. Intubation took a similar length of time in the supine (14.5 ± 13.4 s), left lateral (13.3 ± 10.2 s), and right lateral positions (15.5 ± 13.0 s) and resulted in a similar trend in hemodynamic changes. Patients in the lateral and supine positions revealed a comparable incidence of successful first-attempt intubation, sore throat, hoarseness, oral mucosal injury, and dysrhythmia. Insignificantly more esophageal intubations were performed in the lateral position in the first attempt at intubation; however, all patients were correctly intubated shortly after reattempting intubation. We concluded that lightwand-assisted intubation is easily performed and a similar technique may be used whether the patient is in a lateral, recumbent, or a supine position. This alternative technique should be practiced and is recommended for patients who must remain in a lateral position during intubation and surgery.

 

 

{delta}阿片受体激动剂SNC80对脊髓缺血后大鼠后肢运动功能和神经元损伤的影响

The Effects of the {delta}-Opioid Agonist SNC80 on Hind-Limb Motor Function and Neuronal Injury After Spinal Cord Ischemia in Rats

Toshinori Horiuchi, MD*, Masahiko Kawaguchi, MD*, Takanori Sakamoto, MD*, Naoko Kurita, MD*, Satoki Inoue, MD*, Mitsutoshi Nakamura, MD{dagger}, Noboru Konishi, MD{dagger}, and Hitoshi Furuya, MD*

Departments of *Anesthesiology and {dagger}Pathology, Nara Medical University, Nara, Japan

Address correspondence and reprint requests to Masahiko Kawaguchi, MD, Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.

Anesth Analg 2004;99:235-240

最近的研究表明{delta}-阿片受体激动剂在大脑内具有神经保护作用,我们研究了椎管内使用{delta}-阿片受体激动剂(SNC80)对于脊髓缺血(SCI)大鼠的影响。我们放置主动脉内球囊导管以产生脊髓缺血。这些老鼠随机分配到下面5组之一:(1)脊髓缺血前9分钟使用SNC80 (SNC-9; n = 12);(2)脊髓缺血前9分钟使用安慰剂(V-9; n = 12);(3)脊髓缺血前11分钟使用SNC80(SNC-11; n = 10);(4)脊髓缺血前11分钟使用安慰剂(V-11; n = 12);(5)模拟组(n = 12),脊髓缺血前15分钟给予SNC80(400 nmol)或者安慰剂。再灌注48小时后,我们使用Basso, Beattie, Bresnahan (BBB)评分法评估了后肢的运动功能,并且对L4L5脊髓节段进行了组织学评分。SNC-9组的BBB评分要高于V-9(P < 0.05),然而SNC-11组和V-11组的BBB评分没有差异。SNC-9组和SNC-11组正常神经元的数目比V-9组和V-11组明显要多(P < 0.05)。结果提示椎管内使用{delta}-阿片受体激动剂(SNC80)可以减轻脊髓缺血后大鼠的后肢运动障碍和神经元损伤。

(王柯 译 葛宁花 校)

Recent investigation suggested neuroprotective efficacy of a {delta}-opioid agonist in the brain. We investigated the effects of intrathecal treatment with a {delta}-opioid agonist (SNC80) on spinal cord ischemia (SCI) in rats. SCI was induced with an intraaortic balloon catheter. The animals were randomly allocated to one of the following five groups: 1) SNC80 before 9 min of SCI (SNC-9; n = 12), 2) vehicle before 9 min of SCI (V-9; n = 12), 3) SNC80 before 11 min of SCI (SNC-11; n = 10), 4) vehicle before 11 min of SCI (V-11; n = 12), or 5) sham (n = 12). SNC80 (400 nmol) or vehicle was administered 15 min before SCI. Forty-eight hours after reperfusion, hind-limb motor function was assessed by using the Basso, Beattie, Bresnahan (BBB) scale (0 = paraplegia; 21 = normal) and histological assessment of the L4 and L5 spinal segments was performed. BBB scores in the SNC-9 group were higher compared with those in the V-9 group (P < 0.05), whereas there were no differences in BBB scores between the SNC-11 and V-11 groups. There were significantly more normal neurons in the SNC-9 and SNC-11 groups than in the V-9 and V-11 groups (P < 0.05). The results indicate that intrathecal treatment with the {delta}-opioid agonist SNC80 can attenuate hind-limb motor dysfunction and neuronal injury after SCI in rats.

 

布比卡因抑制大鼠胸主动脉血栓烷A2诱导的血管收缩

Bupivacaine Inhibits Thromboxane A2-Induced Vasoconstriction in Rat Thoracic Aorta

Klaus Hahnenkamp, , Joke Nollet, , Danja Strümper, , Tobias Halene, Pia Rathman*, Eike Mortier, , Hugo Van Aken, , Joerg Knapp, , Marcel E. Durieux, , and Christian W. Hoenemann,

Department of Anesthesiology and Intensive Care, University Hospital, Münster, Germany, the Department of Anesthesiology, University Hospital, Gent, Belgium, the Institute of Pharmacology and Toxicology, Westfälische-Wilhelms-Universität, Münster, Germany, and the Department of Anesthesiology, Marienhospital, Vechta, Germany

Anesth Analg 2004;99:97-102

 

作为一种诱导血小板聚集,支气管收缩和血管收缩的炎性介质,血栓烷A2(TXA2)的血浆水平在围手术期增高了.围手术期血栓性和缺血性综合症的发病机制主要归因于这种前列腺素样物质.在细胞模型中局麻药(LA)抑制了TXA2的信号表达.因此,我们假设LA能抑制大鼠胸主动脉由TXA2类似物U46619诱导的血管收缩.大鼠胸主动脉圈(长度3-mm)架在器官浴器内并测量其等容收缩力.带或不带内皮的圈在布比卡因(106 or 105 M) Krebs-Henseleit溶液中孵化60分钟,随后暴露于累积浓度的U46619(10-1010-6M).我们也研究了布比卡因所致的TXA2诱导血管收缩的可逆性.用布比卡因对大鼠胸主动脉圈预处理能剂量依赖性减轻TXA2诱导的胸主动脉圈的收缩.我们发现有或无内皮对布比卡因的舒张作用无显著差异.U46619所致的动脉圈收缩并不能被累积浓度的布比卡因所逆转.布比卡因抑制卡巴胆碱诱导的血管舒张作用.本研究给我们提供了实验性证据,即对于TXA2诱导的大鼠胸主动脉血管收缩,布比卡因是非内皮依赖的抑制剂.

(钟鸣 译 葛宁花 校)

Plasma levels of thromboxane A2 (TXA2), an inflammatory mediator inducing platelet aggregation, bronchoconstriction, and vasoconstriction, are increased in the perioperative period. A major role in the pathogenesis of perioperative thromboembolic and ischemic syndromes is attributed to this prostanoid. Local anesthetics (LA) inhibit signaling of TXA2 receptors expressed in cell models. Therefore, we hypothesized that LA may inhibit vasoconstriction induced by the TXA2 analog U46619 in rat thoracic aorta. Rings (3-mm length) of the rat thoracic aorta were mounted in organ baths and isometric contractile force was measured. Rings, with or without endothelium, were incubated for 60 min in bupivacaine (10–6 or 10–5 M) or Krebs-Henseleit solution (control group) and subsequently exposed to cumulative concentrations of U46619 (10–10 to 10–6 M). The reversibility of the TXA2-induced vasoconstriction by bupivacaine was also studied. Pretreatment of rings with bupivacaine concentration-dependently diminished TXA2-induced contraction in rat aortic rings. We found no significant differences in relaxing effect of bupivacaine between rings with and without endothelium. Contraction in rings established with U46619 could not be reversed by cumulative concentrations of bupivacaine. Bupivacaine inhibited carbachol-induced vascular relaxation. This study provides experimental evidence that bupivacaine is an endothelium-independent inhibitor of TXA2-induced vasoconstriction of rat thoracic aorta.

 

比较心脏手术后输注异体红细胞或100%纯氧通气对全身氧传输和骨骼肌氧分压的影响

The Influence of Allogeneic Red Blood Cell Transfusion Compared with 100% Oxygen Ventilation on Systemic Oxygen Transport and Skeletal Muscle Oxygen Tension After Cardiac Surgery

Stefan Suttner, MD*, Swen N. Piper, MD*, Bernhard Kumle, MD*, Katrin Lang, MD*, Kerstin D. Röhm, MD*, Frank Isgro, MD{dagger}, and Joachim Boldt, MD*

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Cardiac Surgery, Klinikum Ludwigshafen, Ludwigshafen, Germany

Anesth Analg 2004;99:2-11

 

本研究中我们使用全身氧传输参数和骨骼肌氧分压(PtiO2)来比较异体红细胞(RBC)输注或100%纯氧通气对组织氧合的影响。51例择期冠脉搭桥术后接受机械通气的患者在容量补足后最低血红蛋白浓度为7.58.5之间者被随机分配接受1个单位(输注1n = 17)或2个单位(输注2n = 17)异体红细胞的同时吸入40%氧;或者不输异体红细胞而吸入纯氧通气(100%氧;n = 17)。3小时内每隔30min记录有创动脉压和肺动脉压并计算氧的输送(氧输送指数)和消耗的指数(氧耗指数)。通过植入的极谱微探针可持续测量PtiO2。全身氧运输参数和PtiO2的基础值在组间相似。随着异体红细胞的输入和100%氧的通气,氧输送指数显著增加而氧耗指数则维持不变。100%氧的通气显著增加PtiO2(从24.0 ± 5.1 mm Hg 34.2 ± 6.2 mm Hg)而异体红细胞输注后则无变化。PtiO2的峰值在输注1组和2组分别为25.2 ± 5.2 mm Hg 26.3 ± 6.5 mm Hg。输注库存异体红细胞只对改善全身氧输送指数有效而100%氧通气可同时改善全身氧输送和PtiO2。这种氧合状态的改善最有可能归功于对流性氧输送的增加伴巨大的驱动梯度使血浆内溶解的氧向组织弥散。

(黄施伟 译    李士通 校)

In this study we investigated the effects of allogeneic red blood cell (RBC) transfusion on tissue oxygenation compared with those of 100% oxygen ventilation by using systemic oxygen transport variables and skeletal muscle oxygen tension (PtiO2). Fifty-one volume-resuscitated, mechanically ventilated patients with a nadir hemoglobin concentration in the range from 7.5 to 8.5 g/dL after elective coronary artery bypass grafting were allocated randomly to receive 1 unit (transfusion 1; n = 17) or 2 units (transfusion 2; n = 17) of allogeneic RBCs and ventilation with 40% oxygen or pure oxygen ventilation (100% oxygen; n = 17) and no allogeneic blood for 3 hours. Invasive arterial and pulmonary artery pressures and calculations of oxygen delivery (oxygen delivery index) and consumption indices (oxygen consumption index) were documented at 30-min intervals. PtiO2 was measured continuously by using implantable polarographic microprobes. Systemic oxygen transport variables and PtiO2 were similar between groups at baseline. The oxygen delivery index increased significantly with transfusion of allogeneic RBCs and 100% oxygen ventilation, whereas the oxygen consumption index remained unchanged. Oxygen 100% ventilation increased PtiO2 significantly (from 24.0 ± 5.1 mm Hg to 34.2 ± 6.2 mm Hg), whereas no change was found after transfusion of allogeneic RBCs. Peak PtiO2 values were 25.2 ± 5.2 mm Hg and 26.3 ± 6.5 mm Hg in the transfusion 1 and 2 groups, respectively. Transfusion of stored allogeneic RBCs was effective only in improving systemic oxygen delivery index, whereas 100% oxygen ventilation improved systemic oxygen transport and PtiO2. This improved oxygenation status was most likely due to an increase in convective oxygen transport with a large driving gradient for diffusion of plasma-dissolved oxygen into the tissue.

 

 

过氧亚硝基阴离子减低人类血浆止血效应的体外实验

Peroxynitrite Decreases Hemostasis in Human Plasma In Vitro

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

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

Anesth Analg 2004;99:21-26

 

凝血紊乱与涉及活性氮如过氧亚硝基阴离子(OONO–) 等产生的临床情况有关。此外体外实验显示OONO–能减少组织因子和纤维蛋白原功能。因此我们假设血浆与OONO–接触能通过减低凝血蛋白活性而降低血浆止血功能,OONO–3-morpholinosydnonimine (SIN-1)产生,它是能产生氧化氮和超氧阴离子的分子。 在超氧化物岐化酶(SOD)或OONO–清除剂存在或缺少的情况下,血浆暴露于SIN-137°C 浓度分别0, 1, 5, 10 mM ,时间60 min )后利用血栓弹力描记图、部分凝血活酶时间和凝血酶原时间来评估血浆凝血功能。SIN-1导致显著(P < 0.05)及剂量相关的血浆凝血功能下降,同时伴有VII因子、 VIII 因子复合物及 X 因子活性下降(P < 0.05),纤维蛋白原浓度并不受影响。抗凝血酶及C蛋白活性也明显下降(P < 0.05)。超氧岐化酶(SOD)或OONO–清除剂明显缓解SIN-1引起的止血及促凝/抗凝活性的改变(P < 0.05)。我们认为OONO–能通过对关健促凝物质的硝基化而减低人类血浆止血功能,可能在出血状况下起重要作用。

(王立中     李士通 校)

Coagulopathy has been associated with clinical scenarios that involve reactive nitrogen species such as peroxynitrite (OONO). Further, OONO decreases tissue factor and fibrinogen function in vitro. Thus, we hypothesized that exposure of plasma to the OONO generated with 3-morpholinosydnonimine (SIN-1), a molecule that produces both nitric oxide and superoxide, would result in a decrease in hemostatic function via diminished coagulation protein activity. Hemostatic function of plasma exposed to SIN-1 (0, 1, 5, and 10 mM for 60 min at 37°C) was assessed with thrombelastography, activated partial thromboplastin time, and prothrombin time in the presence or absence of superoxide dismutase (SOD) or an OONO scavenger. SIN-1 exposure resulted in a significant (P < 0.05), dose-dependent decrease in plasma hemostatic function and concurrent significant (P < 0.05) decreases in activities of factor VII, factor VIII complex, and factor X. Fibrinogen concentration was not affected by SIN-1. Antithrombin and protein C activity also decreased significantly (P < 0.05). Coincubation with SOD or an OONO scavenger significantly (P < 0.05) attenuated SIN-1 mediated changes in hemostasis and procoagulant/anticoagulant activity. We conclude that OONO may decrease hemostatic function in human plasma by nitration of key procoagulants and that OONO may play a significant role in hemorrhagic states.

 

儿童双侧呼吸音听诊不能排除支气管内插管

Auscultation of Bilateral Breath Sounds Does Not Rule Out Endobronchial Intubation in Children

Susan T. Verghese, MD*, Raafat S. Hannallah, MD*, Michael C. Slack, MD{dagger}, Russell R. Cross, MD{dagger}, and Kantilal M. Patel, PhD{ddagger}

Departments of *Anesthesiology, {dagger}Pediatric Cardiology, and {ddagger}Pediatrics, Children’s National Medical Center and George Washington University Medical Center, Washington, DC

Anesth Analg 2004;99:56-58

 

连续153例患儿在经口气管插管全麻下行心导管术。听诊双侧呼吸音以确定导管位置。透视检查发现18例患儿(11.8%)气管导管(ETT)顶端位于右主支气管,29例患儿(19.0%)插管偏深(即导管顶端距隆突1 cm以内)。18例管端位于右主支气管内的患儿年龄均小于120个月,其中7例小于12个月 (Fisher’s exact test; P = 0.013)。支气管内插管或插管偏深者的年龄、体重、ETT大小明显小于管端位于气管中段的患儿(P < 0.001)。单纯听诊呼吸音未能发现支气管内插管可能与有侧孔的MurphyETT的使用有关,其降低了听诊判断支气管内插管的可信度。预防支气管内插管的建议方法有:对听诊的不确切性保持警惕,检查导管刻度以确定置管深度,尽量减少插管后的头颈活动。插管后颈部过曲或过伸会改变管端的位置,对此必须有预见性,并慎重考虑插管深度。本组起初插管过深的发生率是20%,使用上述措施后,最后98例患儿降为7.1%

(轩    泓 译    李士通 校)

We performed orotracheal intubation in 153 consecutive pediatric patients undergoing cardiac catheterization. Auscultation of bilateral breath sounds was confirmed. By fluoroscopy, the tip of the endotracheal tube (ETT) was seen in the right mainstem bronchus in 18 patients (11.8%) and in a low position, defined as within 1 cm above the carina, in 29 patients (19.0%). All of the 18 patients with right mainstem intubation were children <120 mo of age, and 7 were infants <12 mo of age (Fisher’s exact test; P = 0.013). The age, weight, and ETT size for children who had endobronchial and low tracheal positions were significantly (P < 0.001) less than for those who had midtracheal positions. The failure to diagnose mainstem intubation by auscultation alone may be related to the use of the Murphy eye ETT, which reduces the reliability of chest auscultation in detecting endobronchial intubation. Suggested measures for preventing endobronchial intubation include maintaining increased awareness of the imperfection or lack of accuracy of the auscultatory method, assessing insertion depth by checking the length scale on the tube, and minimizing the patient’s head and neck movement after intubation. When extreme flexion or extension of the neck is expected after ETT insertion, the resultant change in ETT final position must be anticipated and taken into consideration when deciding on the depth of ETT insertion. This approach resulted in a decrease in improper tube positioning from 20% when the study was initiated to 7.1% in the last 98 patients.

 

 

随机比较综合处理策略和复合应用止吐剂预防术后恶心呕吐

A Randomized Comparison of a Multimodal Management Strategy Versus Combination Antiemetics for the Prevention of Postoperative Nausea and Vomiting

Ashraf S. Habib, MBBCh MSc, FRCA*, William D. White, MPH*, Steve Eubanks, MD{dagger}, Theodore N. Pappas, MD{dagger}, and Tong J. Gan, MB FRCA, FFARCS(I)*

Departments of *Anesthesiology and {dagger}Surgery, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004;99:77-81

综合处理策略在防止术后恶心和呕吐方面(PONV)优于使用单个预防恶心和呕吐的药物。我们检验了以下假设:异丙酚全凭静脉麻醉复合恩丹司琼和氟哌利多的综合处理预防PONV方案效果优于吸入麻醉时使用这些止吐剂。90例行腹腔镜胆囊切除术的患者被随机分为3组。综合处理组(组1):异丙酚全凭静脉麻醉复合恩丹司琼,氟哌利多。复合止吐剂(组2恩丹司琼,氟哌利多,术中异氟醚、笑气维持麻醉。全凭静脉组(组3:异丙酚诱导并维持麻醉。术后2小时 123的完全有效率(未发生PONV和另外使用止吐剂)分别为90%63% 66%( 1 与组2比较,P < 0.05)24小时3组的有效率分别为80%, 63%, 43%( 1 与组3比较,P < 0.05)。在麻醉复苏室,综合组的患者满意度也优于其它两组(P < 0.05)。总之,相对于吸入麻醉复合止吐剂或者异丙酚全凭静脉麻醉这两种方法,综合处理策略在预防PONV的有效性和患者满意度方面更好。

(张俊杰     李士通 校)

A multimodal management strategy for the prevention of postoperative nausea and vomiting (PONV) appears to be superior to single-drug prophylaxis. We tested the hypothesis that a multimodal PONV prophylaxis regimen incorporating total IV anesthesia (TIVA) with propofol and a combination of ondansetron and droperidol is more effective than a combination of these antiemetics in the presence of an inhaled anesthetic. Ninety patients undergoing laparoscopic cholecystectomy were randomized to one of three groups. Group 1 (multimodal group) received TIVA with propofol, droperidol, and ondansetron. Group 2 (combination group) received droperidol and ondansetron with isoflurane and nitrous oxide for the maintenance of anesthesia. Group 3 (TIVA group) received propofol for the induction and maintenance of anesthesia. The complete response rate (no PONV and no rescue antiemetic) at 2 h after surgery was 90%, 63%, and 66% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 2). At 24 h, the complete response rate was 80%, 63%, and 43% in Groups 1, 2, and 3, respectively (P < 0.05, Group 1 versus Group 3). Patient satisfaction was also greater in the multimodal group than in the other two groups in the postanesthesia care unit (P < 0.05). In conclusion, the multimodal management strategy for PONV was associated with a higher complete response rate and greater patient satisfaction when compared with similar antiemetic prophylaxis with inhaled anesthesia or TIVA with propofol.

 

异丙酚的非麻醉性类似物2,6-双叔丁基酚(2,6 Di-tert-butylphenol)调整a1ß甘氨酸受体功能的方式有别于异丙酚

2,6 Di-tert-butylphenol, a Nonanesthetic Propofol Analog, Modulates {alpha}1ß lycine Receptor Function in a Manner Distinct from Propofol

Jörg Ahrens, MD*, Gertrud Haeseler, MD*, Martin Leuwer, MD{dagger}, Bahram Mohammadi, MD{ddagger}, Klaus Krampfl, MD{ddagger}, Reinhard Dengler, MD{ddagger}, and Johannes Bufler, MD{ddagger}

Departments of *Anaesthesiology and {ddagger}Neurology and Neurophysiology, Hannover Medical School, Hannover, Germany; and {dagger}University Department of Anaesthesia, The University of Liverpool, Liverpool, United Kingdom

Anesth Analg 2004;99:91-96

 

麻醉药异丙酚(2,6 diisopropylphenol)通过激活脑干较低部位及脊髓部位抑制性氯电流而起到部分麻醉作用。这些作用包括在没有天然激动剂存在时对GABA-A受体及甘氨酸受体的直接兴奋,也包括对亚最大激动浓度的激动剂的增强作用。用双叔丁基替代异丙酚中的异丙基所产生的化合物在体内无麻醉作用。我们通过异种杂交方法在人胚肾细胞表达大鼠a甘氨酸受体,研究异丙酚及2,6-双叔丁基酚对内向氯电流的作用。异丙酚可直接活化甘氨酸受体,而2,6-双叔丁基酚不能激活之。异丙酚114 ± 27 µM时可观察到半量最大电流活动。两种化合物都可将亚最大激动浓度的甘氨酸(10 µM甘氨酸)的作用增强到最大值,异丙酚增强10 µM甘氨酸的作用136% ± 71%2,6-双叔丁基酚增强279% ± 109%。该作用50%的有效浓度:异丙酚为12.5 ± 6.4 µM2,6-双叔丁基酚9.4 ± 10.2 µM。异丙酚及其非麻醉性类似物在对甘氨酸受体的天然激动剂的增强作用上无差别,但在无天然激动剂存在时直接激活受体的能力上有差别。

(裘毅敏 译    李士通 校)

The anesthetic propofol (2,6 diisopropylphenol) mediates some of its effects by activating inhibitory chloride currents in the lower brainstem and spinal cord. The effects comprise direct activation of {gamma}-aminobutyric acid-A and glycine receptors in the absence of the natural agonist, as well as potentiation of the effect of submaximal agonist concentrations. Replacement of propofol’s isopropyl groups by di-tert-butyl groups yields a compound without in vivo anesthetic effects. We have studied the effects of propofol and 2,6 di-tert-butylphenol on chloride inward currents via rat {alpha}1ß glycine receptors heterologously expressed in human embryonic kidney cells. Propofol, but not 2,6 di-tert-butylphenol, directly activated glycine receptors; half-maximal current activation was observed with propofol 114 ± 27 µM. Both compounds potentiated the effect of a submaximal glycine concentration (10 µM) to a maximum value of 136% ± 71% (propofol) and 279% ± 109% (2,6 di-tert-butylphenol) of the response to glycine 10 µM. The 50% effective concentration for this effect was 12.5 ± 6.4 µM and 9.4 ± 10.2 µM for propofol and 2,6 di-tert-butylphenol, respectively. Propofol and its nonanesthetic structural analog do not differ in their ability to coactivate the glycine receptor but differ in their ability to directly activate the receptor in the absence of the natural agonist.

 

志愿者静注吗啡、可待因和曲马多对瞳孔的影响

The Pupillary Effects of Intravenous Morphine, Codeine, and Tramadol in Volunteers

Roger D. Knaggs, PhD MRPharmS, Isla M. Crighton, MBChB FRCA, Timothy F. Cobby, MBChB FRCA, Anthony J. P. Fletcher, BMBS FRCA, and Gregory J. Hobbs, BMBS FRCA

University Department of Anaesthesia, Queen’s Medical Centre, University Hospital, Nottingham, UK

Anesth Analg 2004;99:108-112

 

阿片类镇痛药有多个器官的药理作用,其中也包括眼睛。由于吗啡和可待因的代谢产物在其整个药效中起一定作用,所以瞳孔测量持续6个小时。我们研究了10个健康志愿者静脉注射吗啡(1.25mg/kg),可待因(1mg/kg),曲马多(1.25mg/kg),安慰剂(10ml 0.9%生理盐水)后瞳孔的变化。瞳孔直径用瞳孔直径测量器每隔30min进行测定并比较不同药物对于瞳孔的影响。统计方法以方差分析法。安慰剂组瞳孔直径前后没有明显的改变。静脉注射吗啡和可待因后瞳孔直径缩小了26P<0.001。在实验中,所用志愿者的瞳孔都渐渐的恢复到原来的大小。在注射了曲马多后150min内瞳孔没有明显的改变,而其后剩余的实验时间中瞳孔缩小P<0.01。药物对于瞳孔直径的影响可能部分是由于所研究的阿片类药物的药代动力学不同所致。测定瞳孔直径可以作为一种监测阿片药物中枢作用的参考方法。

(沈    浩 译   李士通 校)

Opioid analgesics have pharmacological effects in many organ systems, including the eye. Because the metabolites of morphine and codeine contribute to their overall pharmacological effect pupil diameter measurements were made over a 6-h period. We studied the pupillary effects of IV morphine (0.125 mg/kg), codeine (1 mg/kg), tramadol (1.25 mg/kg), or placebo (10 mL 0.9% w/v sodium chloride) in 10 healthy volunteers. Pupil diameter was measured every 30 min using a pupil densitometer. Comparisons of the change in pupil diameter for each drug were made using analysis of variance with repeated measures. No significant change in pupil diameter was observed after placebo. After IV morphine and codeine administration there was a 26% decrease in pupil diameter (P < 0.001). Over the course of the study period, pupil diameter gradually returned to baseline values. After administration of tramadol there were no significant changes in pupil diameter until 150 min after administration, after which there was a significant reduction for the remainder of the study period (P < 0.01). The changes in pupil diameter may be explained in part by the pharmacokinetic profiles of the opioids studied. Measurement of pupil diameter may have a place in monitoring the central effect of opioids.

 

用血栓弹性描记图研究XIII因子对凝血过程和血块强度的作用

The Impact of Factor XIII on Coagulation Kinetics and Clot Strength Determined by Thrombelastography

Vance G. Nielsen, MD, William Q. Gurley, Jr, MD, and Thomas M. Burch, MD

Department of Anesthesiology, The University of Alabama at Birmingham

Anesth Analg 2004;99:120-123

 

纤维蛋白原与血栓弹性描记图记录的许多由蛋白介导的血块凝固强度有关。但是XIII因子(FXIII)的活性在血块凝固进展过程中也起重要的作用。我们假设不同FXIII活性能显著增强血块的凝固。活性为正常值0% 1%6.25% 12.5% 25% 50% 100%FXIII配制成相同容量,并将其与内含1%组织因子和CaCl2的无FXIII的血浆混合并行血栓弹性描记图测定10min。测定参数包括反应时间R凝血开始时间)α,血块形成速率;幅度(A,血块强度);剪力弹性系数(G,血块强度)。结果发现FXIII活性能显著降低R,使其呈指数性衰减(R2 = 0.77; P < 0.001)FXIII活性以S形曲线模式明显增加α(R2 = 0.88; P < 0.001); 增加FXIII活性能显著提高AG,也呈S形曲线模式(R2 = 0.89; P < 0.001)。因此,我们认为FXIII可显著影响R,α,AG。由蛋白介导的血栓弹性描记图提供的输血决策受纤维蛋白原和FXIII双重影响。

(赵雪莲      李士通 校)

Fibrinogen has been shown to be responsible for most protein-mediated clot strength via thrombelastography. However, factor XIII (FXIII) activity also plays a prominent role in the development of clot strength. Thus, we hypothesized that changes in FXIII activity would significantly increase clot strength. FXIII (0%, 1%, 6.25%, 12.5%, 25%, 50%, and 100% normal activity) was placed in a fixed volume of citrated FXIII-deficient plasma with 1% tissue factor and calcium chloride and underwent thrombelastography for 10 min. We measured the variables reaction time (R; a measurement of clot initiation), {alpha}(a measure of the rate of clot formation), amplitude (A; a measure of clot strength), and shear elastic modulus (G; a measure of clot strength). FXIII activity significantly decreased R in a pattern of exponential decay (R2 = 0.77; P < 0.001). FXIII activity significantly increased {alpha}, following a sigmoidal pattern (R2 = 0.88; P < 0.001). Finally, increases in FXIII activity significantly increased A and G in a sigmoidal pattern (R2 = 0.89; P < 0.001). We concluded that FXIII significantly affects R, alpha, A, and G. Thus, transfusion decision making with protein-mediated thrombelastographic patterns must account for the contribution of both fibrinogen and FXIII.

 

幼鼠术前坐骨神经阻滞更多地降低机械性痛觉超敏:预先镇痛是否随发育不同而调整?

Preoperative Sciatic Nerve Block Decreases Mechanical Allodynia More in Young Rats: Is Preemptive Analgesia Developmentally Modulated?

Douglas G. Ririe, MD, David Barclay, MD, Heather Prout, BA, Chuanyo Tong, MD, Joseph R. Tobin, MD, and James C. Eisenach, MD

Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2004;99:140-145

 

术后对触觉刺激的敏感性随年龄而不同。在本研究中,我们假设幼鼠术前坐骨神经阻滞(SNB)通过提供预先镇痛比术后SNB镇痛效果好。用爪底切口的术后疼痛模型,24周龄的雄性Sprague-Dawley鼠接受全身麻醉,然后给予左侧0.5%布比卡因5 µL/g或生理盐水的SNBSNB在术前或术后进行。在SNB和手术前后各时点用von Frey细丝评价机械性痛觉超敏。在2周龄大鼠,术前SNB显著降低机械性痛觉超敏,该组的机械性痛觉超敏的阈值在术后2524 h比生理盐水组高(P<0.03)。在术后24 h时,术前SNB组的阈值为4.0 ± 0.7 g,术后SNB组为1.6 ± 0.3 gP=0.004)。4周大小的鼠在任何时点,术前与术后SNB之间均无差异。这些结果提示年幼的动物术前SNB提供与年龄或发育相关的对机械性痛觉超敏的预先镇痛作用。

(马皓琳      李士通  校)

Postoperative sensitivity to tactile stimuli differs as a function of age. In this study, we hypothesized that preoperative sciatic nerve block (SNB), by providing preemptive analgesia, would result in better analgesia than postoperative SNB in the young rat. With the paw incision model of postoperative pain, male Sprague-Dawley rats, aged 2 or 4 wk, underwent general anesthesia and then received a left SNB with 5 µL/g of 0.5% bupivacaine or normal saline. SNB was performed either before or after surgery. Mechanical allodynia was assessed by using von Frey filaments before and at various times after SNB and surgery. In the 2-wk-old rats, preoperative SNB produced a significant reduction in mechanical allodynia, as reflected by a higher threshold at 2, 5, and 24 h when compared with saline control (P < 0.03). At 24 h, the threshold was 4.0 ± 0.7 g in the preoperative SNB group compared with 1.6 ± 0.3 g in the postoperative SNB group (P = 0.004). There was no difference at any time point between the preoperative and the postoperative SNB in the 4-wk-old animals. These results suggest that preoperative SNB in young animals provides a preemptive analgesic effect on mechanical allodynia that is age or developmentally dependent.

 

单腔和多腔中心静脉导管置管的细菌定植和血液感染:一项定量的系统评估

Colonization and Bloodstream Infection with Single- Versus Multi-Lumen Central Venous Catheters: A Quantitative Systematic Review

Mathias Zürcher, MD, Martin R. Tramèr, MD DPhil, and Bernhard Walder, MD

Division of Surgical Intensive Care and the Center for Evidence-Based Critical Care, Anesthesia and Pain Treatment, Division of Anesthesiology, Geneva University Hospitals, Geneva, Switzerland

Anesth Analg 2004;99:177-182

 

中心静脉导管的腔数是否会影响与置管相关的血液感染的发生率仍有争论。我们对随机地比较单腔中心静脉导管和多腔导管的全部报告(截至到20034月的MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies收录的所有文字发表的文献)进行了系统的研究。研究必须包括导管的细菌定植或者血液感染的资料。用固定效应模式进行Meta分析。资料用概率和95%可信区间的需要治疗的病人数来表示。五个随机试验(1987-1995)纳入分析,分析了255个单腔中心静脉导管和275个多腔中心静脉导管的资料。平均置管时间:多腔导管为821天,单腔导管为924天。在四个试验中,多腔有23/176发生细菌定植,单腔有26/177(概率,0.92;95%可信区间,0.49-1.72)。在五个试验中,多腔导管的血液感染发生率为23/2758.4%),单腔导管为8/2553.1%)(概率,2.58;95%可信区间1.24-5.37;需要治疗的病人数1995%可信区间11-75)。如果用单腔中心静脉导管代替多腔导管,每20个病人可避免一个病人发生血液感染。导管细菌定植的危险性没有下降。尽管这些结论是基于有限的资料,但是单腔中心静脉导管应尽可能在可行的时候选用。

(彭中美 译 李士通 校)

There is a controversy as to whether the number of lumens in the central venous catheters may impact the incidence of catheter-related bloodstream infection. We performed a systematic search (MEDLINE, PREMEDLINE, Cochrane Library, EMBASE, BIOSIS Previews, CINAHL, HealthSTAR/Ovid healthstar, bibliographies, any language, to April, 2003) for full reports on randomized comparisons of single-lumen and multi-lumen catheters. Trials had to report on dichotomous data of catheter colonization or bloodstream infection. Meta-analyses were performed using a fixed effect model. Data were expressed as odds ratio (OR) and number-needed-to-treat (NNT) with 95% confidence interval (CI). Five randomized trials (1987–1995) with data on 255 single-lumen and 275 multi-lumen catheters were analyzed. Average insertion times were 8 to 21 days with multi-lumen catheters and 9 to 24 days with single-lumen catheters. In 4 trials, 23 of 176 (13.1%) multi-lumen and 26 of 177 (14.7%) single-lumen catheters were colonized (OR, 0.92; 95% CI, 0.49–1.72). In 5 trials, bloodstream infection occurred with 23 of 275 (8.4%) multi-lumen and with 8 of 255 (3.1%) single-lumen catheters (OR, 2.58; 95% CI, 1.24–5.37; NNT, 19; 95% CI, 11–75). For every 20 single-lumen catheters inserted, one bloodstream infection will be avoided that would have occurred had multi-lumen catheters been used. The risk of catheter colonization is not decreased. Although these conclusions are based on limited data, single-lumen catheters should be used whenever feasible.

 

二十个月常规使用新的带可控旋转扩张器的经皮气管造瘘套管

Twenty Months’ Routine Use of a New Percutaneous Tracheostomy Set Using Controlled Rotating Dilation

Neel Sengupta, BSc (Hons), MBBS, Keng Leong Ang, MBBCh BAO, MRCS, Doraiswamy Prakash, FRCA, Vivien Ng, BSc (Hons), MBBS, and Shane J. George, FRCP FRCA

Intensive Care Unit, Harefield Hospital, Royal Brompton & Harefield Hospitals NHS Trust, Middlesex, UK

Anesth Analg 2004;99:188-192

 

通过一个理想的试用期后,我们在20022月采用新的PercuTwistTM经皮气管造瘘套装置做为常规。接下来20个月,进行了90例此项操作,只有极小的并发症。为了前瞻性评估此经历,我们收集的信息包括病人进入监护病房的原因、手术者先前的经验、原先气管插管的持续时间、操作所需要时间、困难分级、出血量和操作并发症。其中90个操作过程中22(24.4%)由高年资的有经验的医生完成;90个操作中的68(75.6%)由监护病房的住院医生在床旁密切指导下安全完成。操作所需要的平均时间为13分钟7秒。在全部研究中只有一例在插入过程中觉得有困难,原因是最初的皮肤切口太小。没有遇到大的出血和并发症。

(张        李士通  校)

After a favorable trial period, we introduced the new percutaneous tracheostomy set, PercuTwistTM, in February of 2002 for our routine procedures. Over the next 20 mo, 90 procedures were performed with minimal complications. To prospectively evaluate this experience, we collected information on reasons for unit admission, operators’ previous experience, the duration of prior tracheal intubation, the time needed for the procedure, the grading of the difficulty, the amount of bleeding, and the complications of the procedure. Twenty-two of 90 (24.4%) procedures were performed by senior consultants with experience; 68 of 90 (75.6%) were safely performed by intensive care residents under close bedside supervision. The mean time needed for the procedure was 13 min 7 s. In only one procedure during the entire study was any difficulty observed during the insertion process. This occurred because the initial skin incision was too small. However, no major bleeding or complications were encountered.

 

在伴有严重多器官功能障碍综合征的晚期血管扩张性休克病人中应用精氨酸抗利尿激素会影响凝血系统吗?

Does Arginine Vasopressin Influence the Coagulation System in Advanced Vasodilatory Shock with Severe Multiorgan Dysfunction Syndrome?

Martin W. Dünser, MD*, Dietmar R. Fries, MD*, Wolfgang Schobersberger, MD*, Hanno Ulmer, PhD{dagger}, Volker Wenzel, MD*, Barbara Friesenecker, MD*, Walter R. Hasibeder, MD*, and Andreas J. Mayr, MD*

*Division of General and Surgical Intensive Care Medicine, Department of Anesthesiology and Critical Care Medicine, and the {dagger}Institute of Medical Biostatistics, The University of Innsbruck, Innsbruck, Austria

Anesth Analg 2004;99:201-206

 

精氨酸抗利尿激素(AVP) 对晚期血管扩张性休克是有效的强化性血管收缩药,但是在  AVP 治疗期间已有关于血小板计数减少的报道。 在这项研究中,我们评估了晚期血管扩张性休克时AVP输注对凝血系统的影响,并与单独注入去甲肾上腺素相比较。42例血管扩张性休克的病人 (去甲肾上腺素需求 >0.5 μ g • kg– 1 • min– 1,平均动脉压 <70 mmHg)随机接受额外的AVP输注 (4 U/h) 或单独输注去甲肾上腺素。大多数的病人应用了激活凝血系统的治疗 (新鲜冷冻血浆,浓缩血小板,凝血因子和肝素下持续静-静脉血液透析滤过)。在随机化分组前和分组治疗后 12448 h 时,检测凝血系统的实验室指标和改良血栓弹力图。组间血浆凝血物质没有明显差异。尽管组间比较没有统计学差异,但血小板在使用AVP 的病人明显减少 (P = 0.036)。 改良血栓弹力图分析的结果在组间无明显差异。 在伴有严重多器官功能障碍综合的晚期血管扩张性休克病人中应用精氨酸抗利尿激素不会影响血浆中VIII因子、von Willebrand因子抗原和 ristocetin 辅助因子的浓度,但可能促使血小板聚合而且引起血小板减少症。改良血栓弹力图测定的总体凝血功能与单独输注去甲肾上腺素的病人比较没有不同。

(朱 慧译 李士通校)

Arginine vasopressin (AVP) is a potent supplementary vasopressor in advanced vasodilatory shock, but decreases in platelet count have been reported during AVP therapy. In this study we evaluated the effects of AVP infusion on the coagulation system in advanced vasodilatory shock when compared to norepinephrine (NE) infusion alone. Forty-two patients with advanced vasodilatory shock (NE requirements >0.5 µg • kg–1 • min–1, mean arterial blood pressure <70 mm Hg) were prospectively randomized to receive an additional AVP infusion (4 U/h) or NE infusion alone. Most patients received coagulation active treatment (fresh-frozen plasma, thrombocyte concentrates, coagulation factors, and continuous veno-venous hemofiltration with heparin). At baseline and 1, 24, and 48 h after randomization, coagulation laboratory variables and a modified thrombelastography were measured. There were no differences between groups in plasmatic coagulation variables. Although there was no significant difference between groups, platelet count significantly decreased in AVP patients (P = 0.036). There were no differences in results of modified thrombelastography analyses between groups. AVP infusion in advanced vasodilatory shock with severe multiorgan dysfunction syndrome does not increase plasma concentrations of Factor VIII, von Willebrand Factor antigen, and ristocetin Co-Factor but may stimulate platelet aggregation and induce thrombocytopenia. Global coagulation, assessed by modified thrombelastography, is not different from patients receiving NE infusion alone.

 

动脉-颈内静脉血氧含量差与颅脑外伤病人预后

Arterio-Jugular Difference of Oxygen Content and Outcome After Head Injury

Nino Stocchetti, MD, Katia Canavesi, MD, Sandra Magnoni, MD, Valerio Valeriani, MD, Valeria Conte, MD, Sandra Rossi, MD, Luca Longhi, MD, Elisa Roncati Zanier, MD, and Angelo Colombo, MD

Istituto Anestesia e Rianimazione, Università di Milano, Terapia Intensiva Neuroscienze, Ospedale Maggiore Policlinico, Istituto Ricovero e Cura a Carattere Scientifico, Milan, Italy

Anesth Analg 2004;99:230-234

 

本研究通过调查大样本严重颅脑外伤病人的AJDO2(动脉-颈内静脉血氧含量差),确定AJDO2在外伤后最初几天内的模式并描述其与急性神经功能障碍的严重程度和外伤后6个月预后的关系。229名昏迷状态的颅脑外伤病人,监测颅内压,脑灌注压和AJDO2。在外伤后六个月评价这些病人的预后。颈内静脉血氧饱和度(SjO2)平均值为68%。AJDO2平均值为4.24 vol% (标准差, 1.3 vol%)。有80个测量值(4.6%)其SjO2 <55%304个测量值SjO2 >75%8个测量值AJDO2高于8.7 vol% (0.4%)718个测量值AJDO2低于3.9 vol% (42%)。病人AJDO2第一个测量值比较高,而在随后的几天里其值逐步下降。预后良好的病人AJDO2平均值(4.3 vol%; 标准差, 0.3 vol%)高于那些发生严重残疾或陷入植物状态(3.8 vol%; 标准差, 1.3 vol%)和死亡的病人(3.6 vol%; 标准差, 1 vol%),且差别具有统计学意义(P < 0.001)。可以推断低水平的AJDO2与不良预后有关而正常或高水平的AJDO2预示较好的预后。

(周雅春 译  李士通 校)

This study investigated AJDO2 (arterio-jugular difference of oxygen content) in a large sample of severely head-injured patients to identify its pattern during the first days after injury and to describe the relationship of AJDO2 with acute neurological severity and with outcome 6 mo after trauma. In 229 comatose head-injured patients, we monitored intracranial pressure, cerebral perfusion pressure, and AJDO2. Outcome was defined 6 mo after injury. Jugular hemoglobin oxygen saturation (SjO2) averaged 68%. The mean AJDO2 was 4.24 vol% (SD, 1.3 vol%). There were 80 measurements (4.6%) with SjO2 <55% and 304 (17.6%) with saturation >75%. AJDO2 was higher than 8.7 vol% in 8 measurements (0.4%) and was lower than 3.9 vol% in 718 (42%) measurements. AJDO2 was higher during the first tests and decreased steadily over the next few days. Cases with a favorable outcome had a higher mean AJDO2 (4.3 vol%; SD, 0.3 vol%) than patients with severe disability or vegetative status (3.8 vol%; SD, 1.3 vol%) and patients who died (3.6 vol%; SD, 1 vol%). This difference was significant (P < 0.001). We conclude that low levels of AJDO2 are correlated with a poor prognosis, whereas normal or high levels of AJDO2 are predictive of better results.

 

判断进入硬脊膜外腔:分别用空气、利多卡因或复合空气和利多卡因阻力消失法

Identification of the Epidural Space: Loss of Resistance with Air, Lidocaine, or the Combination of Air and Lidocaine

Samuel Evron, MD*, Daniel Sessler, MD{dagger}, Oscar Sadan, MD{ddagger}, Mona Boaz§, Marek Glezerman, MD{ddagger}, and Tiberiu Ezri, MD||

*Obstetric Anesthesia Unit, {ddagger}Department of Obstetrics and Gynecology, §Epidemiology Unit, and ||Department of Anesthesia, The Edith Wolfson Medical Center, Holon, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Israel; and {dagger}Outcomes ResearchTM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:245-250

 

判断进入硬脊膜外腔的理想技术仍不清楚。547例需要硬脊膜外腔镇痛的即将分娩的孕妇根据判断进入硬脊膜外腔的技术随机分成三组:1)空气阻力消失法(空气组,n=180);2)利多卡因阻力消失法(利多卡因组,n=185);3)空气和利多卡因阻力消失法(空气+利多卡因组,n=182)。评估硬脊膜外腔导管置入的难易程度、阻滞的特性、镇痛的效果及并发症。不能置入硬脊膜外腔导管的发生率在空气组是16%,利多卡因组是4%,空气+利多卡因组是3%P<0.001);在空气组有更多的患者阻滞不全(分别是6.6%3.2%2.2%P<0.02);意外的硬脊膜穿破的发生也是在空气组较高(1.7%对另两组的0%P<0.02)。疼痛评分、镇痛的起效时间、上面的感觉阻滞平面、运动阻滞、低血压的发生、瞬时的神经症状、产后尿潴留和硬脊膜刺破后的头痛均相当。用空气判断进入硬脊膜外腔比用利多卡因或空气+利多卡因更困难,刺破硬脊膜的发生更高。另外,按顺序应用空气和利多卡因与单独应用利多卡因相比没有优势。

(陈玮译 李士通 校)

The ideal technique for identifying the epidural space remains unclear. Five-hundred-forty-seven women in labor who requested epidural analgesia were randomly allocated to three groups according to the technique by which the epidural space was identified: 1) loss-of-resistance with air (air; n = 180), 2) loss-of-resistance with lidocaine (lidocaine; n = 185), and 3) loss-of-resistance with both air and lidocaine (air-plus-lidocaine; n = 182). We assessed ease of epidural catheter insertion, characteristics of the blockade, quality of analgesia, and complications. The inability to thread the epidural catheter occurred in 16% of the air, 4% of the lidocaine, and 3% of the air-plus-lidocaine patients (P < 0.001). More patients from the air group had unblocked segments (6.6% versus 3.2% and 2.2%, respectively; P < 0.02). The incidence of accidental dural puncture was greater in the air group (1.7% versus 0% in the other two groups; P < 0.02). Pain scores, time to onset of analgesia, upper sensory level, motor blockade, and the incidence of hypotension, transient neurological deficits, postpartum urinary retention, and postdural puncture headache were comparable. Identification of the epidural space with air was more difficult and caused more dural punctures than with lidocaine or air plus lidocaine. Additionally, sequential use of air and lidocaine had no advantage over lidocaine alone.

 

新型喉周通气道(CobraPLATM)与喉罩通气道(LMATM)相比同样有效,且提供更好的气道密闭性

The New Perilaryngeal Airway (CobraPLATM) Is as Efficient as the Laryngeal Mask Airway (LMATM) but Provides Better Airway Sealing Pressures

Ozan Akça, MD, Anupama Wadhwa, MD, Papiya Sengupta, MD, Jaleel Durrani, MD, Keith Hanni, MD, Mary Wenke, CRNA, Yüksel Yücel, MD, Rainer Lenhardt, MD, Anthony G. Doufas, MD PhD, and Daniel I. Sessler, MD

OUTCOMES RESEARCHTM Institute and the Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2004;99:272-278

 

喉罩通气道(LMA)是一种常用的有效通气装置,然而其密闭性差,降低了正压通气的有效性。喉周通气道(CobraPLA)是一种新型的通气装置,它带有一个更大的喉部套囊(充气时)。我们检验了这样一个假设:CobraPLA在置入时间和气道密闭压力方面优于LMA,而气道通畅性和术后恢复情况相同。81ASA I–II级的择期门诊手术病人随机分组,先给予咪唑安定、芬太尼,然后用丙泊酚2.5 mg/kg IV麻醉诱导,置入LMA CobraPLA。我们观测:1) 置入时间;2) 通气的足够性( 15-cm-H2O峰压下或潮气量达 5 mL/kg无漏气)3) 气道密闭压力;4)调整置管的次数;5) 密闭性(在潮气量达8 mL/kg时无漏气)。在手术结束之后,我们对胃胀气、喉咙痛、发音困难、吞咽困难进行评价。数据用非配对Student t检验、卡方检验或Fisher确切概率法进行统计分析,P < 0.05为有显著性差异。两组病人在一般特性、通气道置入时间、通气足够性、调整置管次数和术后恢复方面相似。而CobraPLA 组的气道密闭压显著高于LMA(23±6cm H2O vs 18±5cm H2O, P < 0.001)。因此,CobraPLALMA有相似的置入特性,而具有更好的气道密闭性能。

(周志坚 译  李士通 校)

The Laryngeal Mask Airway (LMA) is a frequently used efficient airway device, yet it sometimes seals poorly, thus reducing the efficacy of positive-pressure ventilation. The Perilaryngeal Airway (CobraPLA) is a novel airway device with a larger pharyngeal cuff (when inflated). We tested the hypothesis that the CobraPLA was superior to the LMA with regard to insertion time and airway sealing pressure and comparable to the LMA in airway adequacy and recovery characteristics. After midazolam and fentanyl administration, 81 ASA physical status I–II outpatients having elective surgery were randomized to receive an LMA or CobraPLA. Anesthesia was induced with propofol (2.5 mg/kg IV), and the airway was inserted. We measured 1) insertion time; 2) adequacy of the airway (no leak at 15-cm-H2O peak pressure or tidal volume of 5 mL/kg); 3) airway sealing pressure; 4) number of repositioning attempts; and 5) sealing quality (no leak at tidal volume of 8 mL/kg). At the end of surgery, gastric insufflation, postoperative sore throat, dysphonia, and dysphagia were evaluated. Data were compared with unpaired Student’s t-tests, {chi}2 tests, or Fisher’s exact tests; P < 0.05 was significant. Patient characteristics, insertion times, airway adequacy, number of repositioning attempts, and recovery were similar in each group. Airway sealing pressure was significantly greater with CobraPLA (23 ± 6 cm H2O) than LMA (18 ± 5 cm H2O, P < 0.001). The CobraPLA has insertion characteristics similar to the LMA but better airway sealing capabilities.

 

 

                                                           

 

IMPLICATIONS: The skilled anesthesiologist can easily and effectively perform a lightwand-assisted intubation for patients in a lateral position. This alternative technique should be practiced before attempting it for the first time, and it is recommended for patients who must remain in a lateral position.