Anesthesia & Analgesia

August 2004

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

心脏手术期间正常血糖的维持

殷文渊 译 陈杰 校

Maintenance of Normoglycemia During Cardiac Surgery

George Carvalho, Anne Moore, Baqir Qizilbash, Kevin Lachapelle, and Thomas Schricker

Anesth Analg 2004 99: 319-324.

糖尿病影响颈静脉氧饱和度对苯肾上腺素的反应性和脑血管二氧化碳反应性之间关系

葛宁花译 薛张纲校

The Effect of Diabetes on the Interrelationship Between Jugular Venous Oxygen Saturation Responsiveness to Phenylephrine Infusion and Cerebrovascular Carbon Dioxide Reactivity

Yuji Kadoi, Shigeru Saito, Fumio Goto, and Nao Fujita

Anesth Analg 2004 99: 325-331

用组织多普勒成象技术观察负荷改变对收缩期二尖瓣管处流速的影响响

沈浩   李士通 

The Effects of Load on Systolic Mitral Annular Velocity by Tissue Doppler Imaging

Ruggero Amà, Patrick Segers, Carl Roosens, Tom Claessens, Pascal Verdonck, and Jan Poelaert
Anesth Analg 2004 99: 332-338.

 

原位肝移植手术中脑局部氧饱和度是脑低灌注的敏感指标

葛宁花译 薛张纲校

Regional Cerebral Oxygen Saturation Is a Sensitive Marker of Cerebral Hypoperfusion During Orthotopic Liver Transplantation
Jens Plachky, Stefan Hofer, Martin Volkmann, Eike Martin, Hubert J. Bardenheuer, and Markus A. Weigand

Anesth Analg 2004 99: 344-349

PEDIATRIC ANESTHESIA:

氟烷真的比七氟醚更好保护心脏压力反射?儿童麻醉中七氟醚和氟烷的自主性压力反射的无创研究

张曦      李士通 

Does Halothane Really Preserve Cardiac Baroreflex Better Than Sevoflurane? A Noninvasive Study of Spontaneous Baroreflex in Children Anesthetized with Sevoflurane Versus Halothane

Isabelle Constant, Dominique Laude, Elizabeth Hentzgen, and Isabelle Murat

Anesth Analg 2004 99: 360-369.

AMBULATORY ANESTHESIA:

耳鼻喉手术监护麻醉中使用加巴喷丁的镇痛效果

朱辉 译 陈杰 校

The Analgesic Effects of Gabapentin in Monitored Anesthesia Care for Ear-Nose-Throat Surgery

Alparslan Turan, Dilek Memis, Beyhan Karamanlioglu, Recep Yagiz, Zafer Pamukçu, and Ebru Yavuz

Anesth Analg 2004 99: 375-378.

 

呼气末二氧化碳监测能准确发现监护麻醉时无呼吸

葛宁花译 薛张纲校

Capnography Accurately Detects Apnea During Monitored Anesthesia Care

Roy G. Soto, Eugene S. Fu, Hector Vila, Jr., and Rafael V. Miguel

Anesth Analg 2004 99: 379-382.

ANESTHETIC PHARMACOLOGY:

大面积烧伤病人中罗库溴铵的神经肌肉阻滞药效学

马皓琳      李士通 

Neuromuscular Pharmacodynamics of Rocuronium in Patients with Major Burns

TaeHyung Han, HyeongSeok Kim, JiYoung Bae, KwangMin Kim, and J. A. Jeevendra Martyn

Anesth Analg 2004 99: 386-392.

 

丙泊酚可抑制人由脂类促炎症介质引起的血小板聚集

朱辉 译 陈杰 校

Propofol Inhibits Human Platelet Aggregation Induced by Proinflammatory Lipid Mediators

Olivier Fourcade, Marie-Françoise Simon, Lawrence Litt, Kamran Samii, and Hugues Chap

Anesth Analg 2004 99: 393-398.

 

相同药理作用下硫喷妥钠和异丙酚作用于大脑的不同部位

(葛宁花译 薛张纲校)

Thiopental and Propofol Affect Different Regions of the Brain at Similar Pharmacologic Effects

Robert A. Veselis, Vladimir A. Feshchenko, Ruth A. Reinsel, Ann M. Dnistrian, Bradley Beattie, and Timothy J. Akhurst

Anesth Analg 2004 99: 399-408.

 

氟烷和异丙酚调节γ—氨基丁酸A受体单通道电流

王立中      李士通 

Halothane and Propofol Modulation of {gamma}-Aminobutyric AcidA Receptor Single-Channel Currents

Akira Kitamura, Ryoichi Sato, William Marszalec, Jay Z. Yeh, Ryo Ogawa, and Toshio Narahashi

Anesth Analg 2004 99: 409-415

 

非洲爪蛙 Ca激动的Cl电流通过蛋白激酶C和蛋白磷酸酯酶调节:有关麻醉机制的研究

朱慧琛 译 陈杰 校

Modulation of Xenopus laevis Ca-Activated Cl Currents by Protein Kinase C and Protein Phosphatases: Implications for Studies of Anesthetic Mechanisms

Klaus Hahnenkamp, Marcel E. Durieux, Hugo van Aken, Sascha Berning, Thomas J. Heyse, Christian W. Hönemann, and Bettina Linck

Anesth Analg 2004 99: 416-422.

 

七氟醚促进人离体网膜动脉和静脉内皮细胞依赖的平滑肌松弛

葛宁花译 薛张纲校

Sevoflurane Promotes Endothelium-Dependent Smooth Muscle Relaxation in Isolated Human Omental Arteries and Veins

Karin Thorlacius and Mikael Bodelsson

Anesth Analg 2004 99: 423-428.

 

雷米芬太尼导致的胃排空延迟不受体位的影响

吴俭      李士通 

The Delay of Gastric Emptying Induced by Remifentanil Is Not Influenced by Posture

Jakob Walldén, Sven-Egron Thörn, and Magnus Wattwil

Anesth Analg 2004 99: 429-434.

 

心脏斯里兰卡肉桂碱受体缺陷患者中挥发性麻醉药和琥珀胆碱的应用

朱慧琛 译 陈杰 校

Volatile Anesthetics and Succinylcholine in Cardiac Ryanodine Receptor Defects

Heikki Swan, Päivi J. Laitinen, and Lauri Toivonen

Anesth Analg 2004 99: 435-437.

TECHNOLOGY, COMPUTING, AND SIMULATION:

术后或麻醉后呼出气中CO浓度增加

      李士通 

Increased Carbon Monoxide Concentration in Exhaled Air After Surgery and Anesthesia

Masao Hayashi, Toru Takahashi, Hiroshi Morimatsu, Hiromi Fujii, Naoyuki Taga, Satoshi Mizobuchi, Masaki Matsumi, Hiroshi Katayama, Masataka Yokoyama, Masahiro Taniguchi, and Kiyoshi Morita

Anesth Analg 2004 99: 444-448.

PAIN MEDICINE:

两种不同的神经性疼痛模型对止痛剂有不同敏感性

顾漪闻 译 陈杰 校

Differential Analgesic Sensitivity of Two Distinct Neuropathic Pain Models

Isabelle Decosterd, Andrew Allchorne, and Clifford J. Woolf

Anesth Analg 2004 99: 457-463.

 

Ic 类抗心律失常药对鼠感觉神经元中抗河豚毒素Na+电流的作用

葛宁花译 薛张纲校

The Effects of Class Ic Antiarrhythmics on Tetrodotoxin-Resistant Na+ Currents in Rat Sensory Neurons

Yoko Osawa, Akiyoshi Oda, Hiroki Iida, Shigeaki Tanahashi, and Shuji Dohi

Anesth Analg 2004 99: 464-471.

 

椎间盘内纤维环热成形术治疗多节段椎间盘退行性病变所致的腰椎间盘源性疼痛

周雅春   李士通

Intradiscal Thermal Annuloplasty for the Treatment of Lumbar Discogenic Pain in Patients with Multilevel Degenerative Disc Disease

Leonardo Kapural, Nagy Mekhail, Zdenko Korunda, and Ayman Basali

Anesth Analg 2004 99: 472-476.

 

慢性和急性下腰痛时活动度和疼痛的关系分析

顾漪闻 译 陈杰 校

An Analysis of the Relationship Between Activity and Pain in Chronic and Acute Low Back Pain

John J. Liszka-Hackzell and David P. Martin

Anesth Analg 2004 99: 477-481.

 

氯胺酮用作阿片类药物的辅助镇痛剂:定量和定性的系统总结

葛宁花译 薛张纲校

Ketamine as Adjuvant Analgesic to Opioids: A Quantitative and Qualitative Systematic Review

Kathirvel Subramaniam, Balachundhar Subramaniam, and Richard A. Steinbrook

Anesth Analg 2004 99: 482-495.

 

局麻药行腰部节段性神经阻滞的疼痛缓解和运动功能:一项利多卡因和罗哌卡因之间的前瞻性双盲对比研究

黄施伟     李士通

Lumbar Segmental Nerve Blocks with Local Anesthetics, Pain Relief, and Motor Function: A Prospective Double-Blind Study Between Lidocaine and Ropivacaine

André P. Wolff, Oliver H. G. Wilder Smith, Ben J. P. Crul, Marc P. van de Heijden, and Gerbrand J. Groen

Anesth Analg 2004 99: 496-501.

 

围术期硬膜外应用可乐定对结直肠手术后病人细胞因子,术后镇痛和肠功能的影响

忻纪华 译 陈杰 校

The Effect of Epidural Clonidine on Perioperative Cytokine Response, Postoperative Pain, and Bowel Function in Patients Undergoing Colorectal Surgery

Ching-Tang Wu, Shu-Wen Jao, Cecil O. Borel, Chun-Chang Yeh, Chi-Yuan Li, Chueng-He Lu, and Chih-Shung Wong

Anesth Analg 2004 99: 502-509.

CRITICAL CARE AND TRAUMA:

用以血红蛋白为基础的氧携带液进行深度血液稀释能增加脑组织的氧张力

葛宁花译 薛张纲校

Increased Cerebral Tissue Oxygen Tension After Extensive Hemodilution with a Hemoglobin-Based Oxygen Carrier

Gregory M. T. Hare, Kathryn M. Hum, Steve Y. Kim, Aiala Barr, Andrew J. Baker, and C. David Mazer

Anesth Analg 2004 99: 528-535.

 

 

比较高张生理盐水及高张生理盐水6%右旋糖酐-70用于狗出血性休克复苏后的早期组织及胃肠氧合作用的研究

裘毅敏      李士通 

The Early Systemic and Gastrointestinal Oxygenation Effects of Hemorrhagic Shock Resuscitation with Hypertonic Saline and Hypertonic Saline 6% Dextran-70: A Comparative Study in Dogs

José Reinaldo Cerqueira Braz, Paulo do Nascimento, Jr., Odilar Paiva Filho, Leandro Gobbo Braz, Luiz Antonio Vane, Pedro Thadeu Galvão Vianna, and Geraldo Rolim Rodrigues, Jr.

Anesth Analg 2004 99: 536-546

 

N-乙酰甲基半胱氨酸阻止犬血液稀释导致的缺氧性肺血管收缩的抑制作用

忻纪华 译 陈杰 校

Prevention of Hemodilution-Induced Inhibition of Hypoxic Pulmonary Vasoconstriction by N-Acetylcysteine in Dogs

François Kerbaul, Philippe Van der Linden, Sébastien Pierre, Benoît Rondelet, Christian Melot, Serge Brimioulle, and Robert Naeije

Anesth Analg 2004 99: 547-551

 

病人自控芬太尼镇痛用于烧伤换药

葛宁花译 薛张纲校

Patient-Controlled Analgesia with Fentanyl for Burn Dressing Changes

Smita Prakash, Tazeen Fatima, and Mridula Pawar

Anesth Analg 2004 99: 552-555.  

 

蛋白激酶CATP敏感性钾通道激动剂对抗大鼠内皮细胞和血管平滑肌细胞炎症反应的保护作用:离体和在体研究

轩泓      李士通 

The Protective Effect of Protein Kinase C and Adenosine Triphosphate-Sensitive Potassium Channel Agonists Against Inflammation in Rat Endothelium and Vascular Smooth Muscle In Vitro and In Vivo

Roman V. Plachinta, Manuela J. M. de Klaver, John K. Hayes, and George F. Rich

NEUROSURGICAL ANESTHESIA:

异丙酚镇静对颅内占位患者颅内压的影响

朱玫娟 译 陈杰 校

The Effect of Propofol Sedation on the Intracranial Pressure of Patients with an Intracranial Space-Occupying Lesion

François Girard, Robert Moumdjian, Daniel Boudreault, Philippe Chouinard, Alain Bouthilier, Éric Sauvageau, Monique Ruel, and Dominique C. Girard Anesth Analg 2004 99: 573-577.

REGIONAL ANESTHESIA:

神经刺激器辅助诱发的运动反应能预计单次阻滞坐骨神经的潜伏期和成功率

葛宁花译 薛张纲校

Nerve Stimulator-Assisted Evoked Motor Response Predicts the Latency and Success of a Single-Injection Sciatic Block

Radha Sukhani, Antoun Nader, Kenneth D. Candido, Robert Doty, Jr., Honorio T. Benzon, Edward Yaghmour, Mark Kendall, and Robert McCarthy Anesth Analg 2004 99: 584-588

 

肩关节腔镜术后三种镇痛方法之比较:关节腔内镇痛,肩胛上神经阻滞和肌间沟臂丛神经阻滞

张俊杰      李士通 

Pain Relief After Arthroscopic Shoulder Surgery: A Comparison of Intraarticular Analgesia, Suprascapular Nerve Block, and Interscalene Brachial Plexus Block

François J. Singelyn, Laurence Lhotel, and Bertrand Fabre

Anesth Analg 2004 99: 589-592

GENERAL ARTICLES:

围术期血糖控制的一种简单的葡萄糖胰岛素疗法:Vellore疗法

朱玫娟 译 陈杰 校

A Simple Glucose Insulin Regimen for Perioperative Blood Glucose Control: The Vellore Regimen

Ann Miriam and Grace Korula

Anesth Analg 2004 99: 598-602.

 

判断甲状腺手术困难气道插管

葛宁花译 薛张纲校

Prediction of Difficult Tracheal Intubation in Thyroid Surgery

Abderrahmane Bouaggad, Sif Eddine Nejmi, Moulay Ahmed Bouderka, and Omar Abbassi

Anesth Analg 2004 99: 603-606.

 

 

相同药理作用下硫喷妥钠和异丙酚作用于大脑的不同部位

Thiopental and Propofol Affect Different Regions of the Brain at Similar Pharmacologic Effects

Robert A. Veselis, MD*,{ddagger}, Vladimir A. Feshchenko, PhD*, Ruth A. Reinsel, PhD*, Ann M. Dnistrian, PhD§, Bradley Beattie, BS||, and Timothy J. Akhurst, MBBS FRACP{dagger},{ddagger}

Departments of *Anesthesiology and Critical Care Medicine, {dagger}Radiology, Nuclear Medicine Service, §Clinical Laboratories, Clinical Chemistry Service, and ||Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York; and {ddagger}Weill Medical College of Cornell University, New York, New York

Anesth Analg 2004;99:399-408

 

异丙酚的遗忘作用比硫喷妥钠强。在这一研究中,我们探讨在相同强度的药物作用下,异丙酚和硫喷妥钠是否作用于大脑的不同部位。用15O标记液体,采用SPM99 方法分析通过正电子发射成像获得的大脑局部血流变化图象。十位右利手的志愿者(年龄35 ± 10 岁,体重74.1 ± 7.5 kg)随机分为硫喷妥钠组(n = 4)或异丙酚组 (n = 6)。用BIS监测达到镇静和催眠的目标浓度。在清醒、镇静和睡眠状态下,得到4个正电子发射成像图。异丙酚组的2个志愿者对镇静剂量无反应,因而不包括在最后的分析中。异丙酚镇静和催眠的血浆平均浓度分别是1.2µg/mL2.7µg/mL,而硫喷妥钠则是4.8µg/mL10.6µg/mL。在两组中BIS随剂量下降。脑血流量变化的波形两组明显不同,异丙酚主要降低大脑前端的血流量(镇静时,在大脑的右侧),而硫喷妥钠主要降低小脑和大脑后端的血流量。在相同强度的药物作用下,异丙酚和硫喷妥钠作用于大脑的不同部位。这种不同,有助于解释异丙酚非镇静如遗忘作用时的部位。

(葛宁花译 薛张纲校)

Propofol has a greater amnesic effect than thiopental. In this study we tested whether different brain regions were affected by propofol and thiopental at similar drug effects. Changes in regional cerebral blood flow (rCBF) were identified by using SPM99 analysis of images obtained with positron emission tomography with 15O water. Ten right-handed male volunteers (age, 35 ± 10 yr; weight, 74.1 ± 7.5 kg; mean ± SD) were randomized to receive thiopental (n = 4) or propofol (n = 6) to target sedative and hypnotic concentrations with bispectral index (BIS) monitoring. Four positron emission tomography images  were obtained during various tasks at baseline and with sedative and hypnotic effects. Two participants receiving propofol were unresponsive at sedative concentrations and were not included in the final analyses. Median serum concentrations were 1.2 and 2.7 µg/mL for sedative and hypnotic propofol effects, respectively. Similarly, thiopental concentrations were 4.8 and 10.6 µg/mL. BIS decreased similarly in both groups. The pattern of rCBF change was markedly different for propofol and thiopental. Propofol decreased rCBF in the anterior (right-sided during sedation) brain regions, whereas thiopental decreased rCBF primarily in the cerebellar and posterior brain regions. At similar levels of drug effect, propofol and thiopental affect different regions of the brain. These differences may help to identify the loci of action for the nonsedative effects of propofol, such as amnesia.

 

七氟醚促进人离体网膜动脉和静脉内皮细胞依赖的平滑肌松弛

Sevoflurane Promotes Endothelium-Dependent Smooth Muscle Relaxation in Isolated Human Omental Arteries and Veins

Karin Thorlacius, MD PhD, and Mikael Bodelsson, MD PhD

Department of Anesthesia and Intensive Care, Lund University Hospital, Sweden

Anesth Analg 2004;99:423-428

 

七氟醚麻醉伴有血管扩张。这主要由于七氟醚有内皮细胞依赖的平滑肌松弛作用。我们监测当吸入七氟醚不同浓度时(0%, 1%, 2%,4%),人离体网膜动脉和静脉对P 物质或三硝酸甘油反应时的肌张力。用酶联免疫吸附剂测量血管水平的鸟嘌呤35-环一磷酸。P物质引起内皮细胞和浓度依赖的网膜血管松弛作用不受七氟醚的影响。如合用L-N-硝基精氨酸甲基酯(氧化氮合成酶抑制剂),或合用氯化钾(防止过极化),或两者同时合用时,4%的七氟醚能增强动脉的松弛(P < 0.05)。在合用氯化钾时,4%的七氟醚能增强静脉的松弛作用,而同时合用L-N-硝基精氨酸甲基酯和氯化钾时,2%4%的七氟醚均能增加静脉的松弛作用(P < 0.05)4%的七氟醚能增强动脉和静脉由三硝酸甘油诱导的内皮细胞非依赖的松弛作用(P < 0.05)。无论是否使用七氟醚,P物质能增加鸟嘌呤35-环一磷酸含量。这些结果显示,七氟醚与它在动物体内的作用不同,通过增加平滑肌细胞对第二松弛信使的反应,能促进人体网膜动脉和静脉的内皮细胞依赖的松弛作用。

(葛宁花译 薛张纲校)

Anesthesia with sevoflurane is accompanied by vasodilatation. This could be due to the effects of sevoflurane on endothelium-dependent relaxation. We measured muscle tension of isolated human omental arteries and veins in response to substance P or glyceryl trinitrate in the presence of sevoflurane (0%, 1%, 2%, or 4%). Vascular levels of guanosine 3', 5'-cyclic monophosphate were measured with enzyme-linked immunosorbent assay. Substance P induced an endothelium- and concentration-dependent relaxation in omental vessels that was not affected by sevoflurane. In the presence of L-NG-nitroarginine methyl ester (nitric oxide synthase inhibitor), KCl (prevention of hyperpolarization), or both, sevoflurane at 4% enhanced the relaxation in the arteries (P < 0.05). In the vein segments, the relaxation was enhanced by sevoflurane at 4% in the presence of KCl and 2% and 4% in the presence of both L-NG-nitroarginine methyl ester and KCl (P < 0.05). The glyceryl trinitrate-induced endothelium-independent relaxation was enhanced by sevoflurane at 4% in both artery and vein segments (P < 0.05). Substance P increased the levels of guanosine 3', 5'-cyclic monophosphate similarly in the presence and absence of sevoflurane. These results show that sevoflurane, in contrast to its effect in animal models, promotes endothelium-dependent relaxation in human omental arteries and veins via an enhancement of the smooth muscle response to relaxing second messengers.

 

神经刺激器辅助诱发的运动反应能预计单次阻滞坐骨神经的潜伏期和成功率

Nerve Stimulator-Assisted Evoked Motor Response Predicts the Latency and Success of a Single-Injection Sciatic Block

Radha Sukhani, MD, Antoun Nader, MD, Kenneth D. Candido, MD, Robert Doty, Jr., MD, Honorio T. Benzon, MD, Edward Yaghmour, MD, Mark Kendall, MD, and Robert McCarthy, PharmD

Department of Anesthesiology, Northwestern University/Feinberg School of Medicine, Chicago, IL

Anesth Analg 2004;99:584-588
 

单次阻滞坐骨神经的起效时间各有差异,主要由于药物未能足够地积聚在所有神经纤维的周围。假设这种差异是因为相对于神经组织的针尖位置所致,而后者能客观地在注射局麻药之前通过诱发运动反应(EMR)而决定。100ASA I–II行踝关节矫形术患者,在臀下和股二头肌周围阻滞坐骨神经,局麻药为0.625%的左旋布比卡因,0.4 mL/kg(最大剂量35 mL)。最终注射点为最初出现EMR的点:刺激频率为0.2-0.4 mA,内翻(I,跖屈(PF),背曲(DF),或外翻(E)。出现不同EMR的频率为:I 40%PF 43%, E 14%, DF 3%。如胫前神经和腓总神经均被阻滞,则认为坐骨神经阻滞完全;如观察30分钟或麻醉后60分钟,仍然对针刺有痛觉,则坐骨神经阻滞失败。出现IEMR至完全阻滞的平均时间(±95% 可信区间,CI)为8.5 min95% CI, 6.2–10.8 min),比出现PFEMR至完全阻滞的平均时间 27 min 95% CI, 20.6–33.4) 出现EEMR至完全阻滞的平均时间 30.4 min95% CI, 24.9–35.8 min)都快(P < 0.001)。在I组,不需要额外的阻滞,而在PEE组分别有24%71%需要。结论:在单次注射阻滞坐骨神经时,神经刺激器诱发的各类EMR,能预计神经完全阻滞的潜伏期和成功率。因为观察到的各类EMR与注射针尖和胫前、腓总神经相关位置有关。

(葛宁花译 薛张纲校)

Variable onset latency of single-injection sciatic nerve block (SNB) may result from drug deposition insufficiently close to all components of the nerve. We hypothesized that this variability is caused by the needle tip position relative to neural components, which is objectified by the type of evoked motor response (EMR) elicited before local anesthetic injection. One-hundred ASA I–II patients undergoing reconstructive ankle surgery received infragluteal-parabiceps SNB using 0.4 mL/kg (maximum 35 mL) of levobupivacaine 0.625%. The end-point for injection was the first elicited EMR: inversion (I), plantar flexion (PF), dorsiflexion (DF), or eversion (E) at 0.2–0.4 mA. The frequencies of the EMRs were: I 40%, PF 43%, E 14%, and DF 3%. SNB was considered complete if both tibial and common peroneal nerves were blocked and failed if either analgesia to pinprick was not observed at 30 min or anesthesia at 60 min. Patients with an EMR of I demonstrated shorter mean times (±95% confidence interval [CI]) to complete the block with 8.5 (95% CI, 6.2–10.8) min compared to 27.0 (95% CI, 20.6–33.4) min after PF (P < 0.001) and 30.4 (95% CI, 24.9–35.8) min after E (P < 0.001). No rescue blocks were required in group I compared with 24% (P = 0.001) and 71% (P < 0.001) of patients in groups PF and E, respectively. We conclude that EMR type during nerve stimulator-assisted single-injection SNB predicts latency and success of complete SNB because the observed EMR is related to the positioning of the needle tip relative to the tibial and common peroneal nerves.

 

氯胺酮用作阿片类药物的辅助镇痛剂:定量和定性的系统总结

Ketamine as Adjuvant Analgesic to Opioids: A Quantitative and Qualitative Systematic Review

Kathirvel Subramaniam, MD, Balachundhar Subramaniam, MD, and Richard A. Steinbrook, MD

From the Department of Anesthesiology, Critical Care & Pain Management, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;99:482-495

 

氯胺酮和阿片类药物的动物耐药性研究结果喜人。但临床系列研究与之矛盾。我们将氯胺酮和阿片类镇痛药物合用,进行随机、双盲的系统研究,包含51支研究队、2385名患者参加的37个系列。研究分为5大组:单次氯胺酮静脉注射组(n = 11),连续注射组(n = 11),患者自控镇痛组(PCA) (n = 6),硬膜外氯胺酮和阿片类药物合用组(n = 8),儿童中的研究(n = 4).观察指标包括:疼痛评分,第一次需要镇痛的时间,补充的镇痛剂和副作用。观察指标的统计学分析,评估镇痛的疗效,并且统计术后24小时镇痛效果是否有显著性的差异。与单独使用吗啡组比较,静脉PCA 联合使用氯胺酮和吗啡并不能增加镇痛的效果。在11系列的研究中,有6组研究显示,静脉连续输注氯胺酮能减少静脉和硬膜外吗啡的需要量,7组研究显示氯胺酮单次负荷量,能减少吗啡的需要量。在8个系列的研究中,有5组研究显示硬膜外注射氯胺酮有效。小剂量的氯胺酮不增加副作用。结论是用作标准阿片类镇痛的辅助剂,小剂量的氯胺酮是安全的和有效的。

(葛宁花译 薛张纲校)

Animal studies on ketamine and opioid tolerance have shown promising results. Clinical trials have been contradictory. We performed a systematic review of randomized, double-blind clinical trials of ketamine added to opioid analgesia. Thirty-seven trials with 51 treatment arms and 2385 patients were included. Studies were divided into 5 subgroups: IV ketamine as single dose (n = 11), continuous infusion (n = 11), patient-controlled analgesia (PCA) (n = 6), epidural ketamine with opioids (n = 8), and studies in children (n = 4). Outcome measures included pain scores, time to first request for analgesia, supplemental analgesics, and adverse events. Efficacy was estimated by statistical significance (P < 0.05) of outcome measures as reported in studies and also by calculation of weighted mean difference for pain scores during the first 24 h after surgery. As compared to morphine alone, IV PCA with ketamine and morphine did not improve analgesia. Intravenous infusion of ketamine decreased IV and epidural opioid requirements in 6 of 11 studies. A single bolus dose of ketamine decreased opioid requirements in 7 of 11 studies. Five of 8 trials with epidural ketamine showed beneficial effects. Adverse effects were not increased with small dose ketamine. We conclude that small dose ketamine is a safe and useful adjuvant to standard practice opioid-analgesia.

 

呼气末二氧化碳监测能准确发现监护麻醉时无呼吸

Capnography Accurately Detects Apnea During Monitored Anesthesia Care

Roy G. Soto, MD*, Eugene S. Fu, MD*, Hector Vila, Jr., MD{dagger}, and Rafael V. Miguel, MD*

*Department of Anesthesiology and {dagger}Department of Interdisciplinary Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, Florida

Anesth Analg 2004;99:379-382

 

无呼吸和呼吸道梗阻是监护麻醉(MAC)时的常见现象。早期发现很重要,我们在MAC 时,通过比较不同的氧流量和胸阻抗,评估二氧化碳监测作为无呼吸

指标的可靠性。麻醉监护操作者采用标准美国麻醉医生学会的监护方式,不知晓是否使用二氧化碳和胸阻抗监测。39位患者中有10位(26%),持续出现无呼吸20秒,无一例由麻醉操作者发现,均由二氧化碳和胸阻抗监测发现。两种方法发现无呼吸的敏感率无差异。高氧流量降低二氧化碳波形的幅度,但并不影响无呼吸的发现率。这小样本试验显示在MAC 麻醉时,每4个患者就有一个出现持续20秒的无呼吸。尽管麻醉操作者未能发现这些异常,但二氧化碳和呼吸体积描记仪能可靠地发现。因此鼻腔呼气末CO2监测是提高MAC 麻醉安全性的重要途径。

(葛宁花译 薛张纲校)

Apnea and airway obstruction are common during monitored anesthesia care (MAC). Because their early detection is essential, we sought to measure the efficacy of capnography as an indicator of apnea during MAC at a variety of oxygen flow rates compared with thoracic impedance. Anesthesia care providers using standard American Society of Anesthesiologists monitors were blinded to capnography and thoracic impedance monitoring. Ten (26%) of the 39 patients studied developed 20 s of apnea; none was detected by the anesthesia provider, but all were detected by capnography and impedance monitoring. There was no difference in detection rates between the two methods. Higher oxygen flow rates decreased the amplitude of the capnograph but did not interfere with apnea detection. This pilot study revealed that apnea of at least 20 s in duration may occur in every fourth patient undergoing MAC. Although these episodes were undetected by the anesthesia provider, they were reliably detected by both capnography and respiratory plethysmography. Monitoring of nasal end-tidal CO2 is an important way to improve safety in patients undergoing MAC.


病人自控芬太尼镇痛用于烧伤换药

Patient-Controlled Analgesia with Fentanyl for Burn Dressing Changes

Smita Prakash, MD, Tazeen Fatima, MD, and Mridula Pawar, MD

Department of Anaesthesia and Intensive Care, Vardhman Mahavir Medical College and Safdarjang Hospital, New Delhi, India

Anesth Analg 2004;99:552-555

 

60ASA I II级、烧伤面积 20%的成年患者中进行随机、双盲研究,研究病人自控芬太尼镇痛在烧伤换药中应用的可行性,并决定其最佳芬太尼的剂量。最初的负荷剂量是静脉注射芬太尼1 µg/kg。当视觉模拟评分(VAS)〉2时,患者按组注入芬太尼(10, 20, 30, 40 µg)1020µg组的VAS平均值(分别为7.73 ± 1.33 7.20 ± 1.21 )显著高于3040µg组的VAS平均值(分别为4.47 ± 0.833.90 ± 0.63) (所有的 P = 0.000)1020µg组的按压次数/实际有效次数(分别为3.03 ± 1.06 2.54 ± 0.49)显著大于3040µg组的按压次数/实际有效次数(分别为1.36 ± 0.34 1.37 ± 0.36) (所有的 P = 0.000)3040µg组的VAS评分和按压次数/实际有效次数均相似(P 分别为  0.260 0.977),意味着镇痛效果相似。无循环系统不稳定和呼吸抑制。PCA芬太尼镇痛的适宜剂量为30µg5 分钟的锁定时间),最初负荷剂量为1 µg/kg

(葛宁花译 薛张纲校)

In this randomized, double-blinded study in 60 ASA I or II adults with >20% body-surface area thermal burns, we investigated the feasibility of patient-controlled analgesia (PCA) with fentanyl for pain management during dressing changes and determined the optimal PCA-fentanyl demand dose. An initial loading dose of IV fentanyl 1 µg/kg was administered. Patients received on-demand analgesia with fentanyl (10, 20, 30, and 40 µg) whenever their visual analog scale (VAS) score was >2. Mean VAS scores in the 10 and 20 µg groups (7.73 ± 1.33 and 7.20 ± 1.21, respectively) were significantly higher than those in the 30 and 40 µg groups (4.47 ± 0.83 and 3.90 ± 0.63, respectively) (all P = 0.000). Demand/delivery ratios were significantly larger in the 10 and 20 µg groups (3.03 ± 1.06 and 2.54 ± 0.49, respectively) than those in the 30 and 40 µg groups (1.36 ± 0.34 and 1.37 ± 0.36, respectively) (all P = 0.000). VAS scores and demand/delivery ratios were comparable in the 30 and 40 µg groups (P = 0.260 and P = 0.977, respectively), which suggests comparable analgesic efficacy. There was no hemodynamic instability or respiratory depression. The optimal demand dose of PCA-fentanyl was 30 µg (5-min lockout interval) after an initial loading dose of IV fentanyl 1 µg/kg.


原位肝移植手术中脑局部氧饱和度是脑低灌注的敏感指标

Regional Cerebral Oxygen Saturation Is a Sensitive Marker of Cerebral Hypoperfusion During Orthotopic Liver Transplantation

Jens Plachky, MD*, Stefan Hofer, MD*, Martin Volkmann, MD{dagger}, Eike Martin, MD*, Hubert J. Bardenheuer, MD*, and Markus A. Weigand, MD DEAA*

*Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany; and {dagger}Central Laboratory, Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany

Anesth Analg 2004;99:344-349

 

原位肝移植手术后,中枢神经系统的并发症是发病率和死亡率的重要因素。引起术后神经系统并发症的原因之一是手术过程中的脑缺血。在这研究中,我们探讨术中局部脑氧饱和度(rSO2)的变化与术后神经元-特殊磷酸丙酮酸水合酶(NSE)和S-100的关系,后二者是缺氧/缺血引起脑异常的特殊指标。在16位原位肝移植手术的患者,以接近红外线的光谱,连续监测rSO2。此外,在手术前和供肝再灌注后24小时,测定动脉血的NSES-100。有趣的是,有8位患者在切除受体病肝时,rSO2出现了显著降低,其余患者则能耐受,而rSO2没有大的变化。这种在切除病肝后,rSO2的降低与术后NSE(r2 = 0.57)S-100 (r2 = 0.52)增加有显著的相关性。但是,比较rSO2降低和rSO2正常的两组患者,循环变化无显著性差异。{Delta}rSO2 和心排血量(r2 = 0.20)之间、NSE和心排血量(r2 = 0.37)之间,或S-100 和心排血量 (r2 = 0.24)之间无显著性相关性。在原位肝移植手术中,rSO2是无创监测手段,对估计神经系统的异常可能有效。
(葛宁花译 薛张纲校)

Neurological complications contribute significantly to morbidity and mortality of patients after orthotopic liver transplantation (OLT). One possible cause of postoperative neurological complications is cerebral ischemia during the surgical procedure. In this study, we investigated the relationship between intraoperative changes in regional cerebral oxygen saturation (rSO2) and postoperative values of neuron-specific enolase (NSE) and S-100, which are specific variables that indicate cerebral disturbances due to hypoxia/ischemia. The rSO2 was monitored continuously by near-infrared spectroscopy in 16 patients undergoing OLT. In addition, NSE and S-100 were determined in arterial blood before surgery and 24 h after reperfusion of the donor liver. Interestingly, clamping of the recipient’s liver led to a significant decline in rSO2 in eight patients, whereas the others tolerated clamping without major changes in rSO2. The decrease in rSO2 after clamping correlated significantly with postoperative increases in NSE (r2 = 0.57) and S-100 (r2 = 0.52). However, there were no significant differences between patients with and without rSO2 decline concerning hemodynamic variables. There were no significant correlations between {Delta}rSO2 and cardiac output (r2 = 0.20), NSE and cardiac output (r2 = 0.37), or S-100 and cardiac output (r2 = 0.24). Monitoring of rSO2 may be a useful noninvasive tool to estimate disturbances in rSO2 during OLT.


Ic 类抗心律失常药对鼠感觉神经元中抗河豚毒素Na+电流的作用

The Effects of Class Ic Antiarrhythmics on Tetrodotoxin-Resistant Na+ Currents in Rat Sensory Neurons

Yoko Osawa, MD, Akiyoshi Oda, MD, Hiroki Iida, MD, Shigeaki Tanahashi, MD, and Shuji Dohi, MD

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

Anesth Analg 2004;99:464-471


有报道静脉或口服抗心律失常药对缓解神经元性疼痛有效。最近研究认为抗河豚毒素(TTX-R) Na+通道在神经传导伤害性冲动时起重要作用。本实验中,我们用完整细胞膜片钳的方法,研究在鼠背侧节神经元中,氟卡尼、pilsicainideIc 类抗心律失常药)和利多卡因(Ib 类药)对TTX-R Na+电流的影响。氟卡尼、pilsicainide和利多卡因能可逆性阻断TTX-R Na+电流的峰值,呈浓度依赖性。阻断峰值一半时,三组的浓度分别为8.5 ± 6.6 µM (n = 7), 78 ± 6.9 µM (n = 7), 73 ± 6.8 µM (n = 7)。每个药物使TTX-R Na+电流的失活曲线向超极化移动,并产生实用依赖性的阻滞。我们同样研究这些作用于TTX-R Na+通道的抗心律失常药物之间的相互作用。利多卡因与氟卡尼或pilsicainide 合用,导致阻滞强度增加和实用依赖性的阻滞。这些结果显示,抗心律失常药阻滞背侧节神经元TTX-R Na+ 电流是因为或至少部分原因是它们阻滞神经传导伤害性冲动。

(葛宁花译 薛张纲校)

IV or oral administration of antiarrhythmics has been reported to be effective for relieving neuropathic pain. Recent reports have indicated that tetrodotoxin-resistant (TTX-R) Na+ channels play important roles in the nerve conduction of nociceptive sensation. In the present study, we investigated the effects of flecainide, pilsicainide (class Ic antiarrhythmics), and lidocaine (a class Ib drug) on TTX-R Na+ currents in rat dorsal root ganglion neurons using the whole-cell patch-clamp method. Flecainide, pilsicainide, and lidocaine reversibly blocked the peak amplitude of TTX-R Na+ currents in a concentration-dependent manner with half-maximum inhibitory concentration values of 8.5 ± 6.6 µM (n = 7), 78 ± 6.9 µM (n = 7), and 73 ± 6.8 µM (n = 7), respectively. Each drug shifted the inactivation curve for the TTX-R Na+ currents in the hyperpolarizing direction and caused a use-dependent block. We also studied an interaction between these antiarrhythmics on TTX-R Na+ channels. Additional application of flecainide or pilsicainide to lidocaine resulted in an additive increase of tonic and use-dependent block. These results suggest that the inhibition of TTX-R Na+ currents of dorsal root ganglion neurons by such antiarrhythmics is attributable, at least partly, to their antinociceptive effects.

 

糖尿病影响颈静脉氧饱和度对苯肾上腺素的反应性和脑血管二氧化碳反应性之间关系

The Effect of Diabetes on the Interrelationship Between Jugular Venous Oxygen Saturation Responsiveness to Phenylephrine Infusion and Cerebrovascular Carbon Dioxide Reactivity

Yuji Kadoi, MD*, Shigeru Saito, MD{dagger}, Fumio Goto, MD{dagger}, and Nao Fujita, MD{ddagger}

Departments of *Intensive Care and {dagger}Anesthesiology, Gunma University, Graduate School of Medicine; and {ddagger}Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center and Keiyu Orthopedic Hospital, Japan

Anesth Analg 2004;99:325-331


在这一实验中,我们研究糖尿病患者在体外循环时,脑血管CO2反应性是否与颈静脉氧饱和度(SjvO2)对苯肾上腺素的反应性有关。40例行冠状动脉搭桥术的糖尿病患者为研究组,另外40例非糖尿病患者,年龄匹配,同样行冠状动脉搭桥术,为对照组。经颅外Doppler连续监测脑血管CO2反应性,重复注射苯肾上腺素以增加平均动脉压直至基础值的100%。两组之间,绝对CO2反应性有显著性差异(对照组, 2.8 ± 0.7 cm • s–1 • mm Hg–1; 糖尿病组, 2.2 ± 1.1 cm • s–1 • mm Hg–1; P = 0.02)。糖尿病组中,绝对CO2反应值在胰岛素依赖患者中比非胰岛素依赖患者中低(饮食控制组,3.2 ± 0.7;优降糖组,2.6 ± 0.7,胰岛素依赖组,1.0 ± 0.7; P < 0.01)。绝对CO2反应性与SjvO2的平均倾斜度/MAP有关(r = 0.54; P < 0.0001)。结论,SjvO2 对苯肾上腺素反应性和脑血管CO2 反应性之间的关系和脑血管自动调节功能受损一样,与以往高血糖症有关。

(葛宁花译 薛张纲校)

In this study, we examined whether cerebrovascular carbon dioxide (CO2) reactivity was related to the response of jugular venous oxygen saturation (SjvO2) to phenylephrine infusion in diabetic patients during cardiopulmonary bypass. Forty diabetic patients scheduled for coronary artery bypass graft surgery were studied, and 40 age-matched nondiabetic cardiopulmonary bypass patients served as controls. Cerebrovascular CO2 reactivity was measured continuously using transcranial Doppler. Mean arterial blood pressure (MAP) was increased by repeated phenylephrine infusion until reaching 100% of baseline values. There was a significant difference in absolute CO2 reactivity between the diabetic and control groups (controls, 2.8 ± 0.7 cm • s–1 • mm Hg–1; diabetics, 2.2 ± 1.1 cm • s–1 • mm Hg–1; P = 0.02). Among the diabetics, absolute CO2 reactivity in insulin-dependent patients was less than that in noninsulin-dependent patients (diet therapy group, 3.2 ± 0.7; glibenclamide group, 2.6 ± 0.7; insulin-dependent group, 1.0 ± 0.7; P < 0.01). There was a correlation between absolute CO2 reactivity and the mean slope of SjvO2 versus MAP for increasing MAP (r = 0.54; P < 0.0001). In conclusion, we found that the interrelationship between SjvO2 responsiveness to phenylephrine infusion and cerebrovascular CO2 reactivity, as well as impaired cerebrovascular autoregulation, were associated with previous hyperglycemia.


用以血红蛋白为基础的氧携带液进行深度血液稀释能增加脑组织的氧张力

Increased Cerebral Tissue Oxygen Tension After Extensive Hemodilution with a Hemoglobin-Based Oxygen Carrier

Gregory M. T. Hare, MD PhD, FRCPC*, Kathryn M. Hum*, Steve Y. Kim*, Aiala Barr, PhD{dagger}, Andrew J. Baker, MD FRCPC*, and C. David Mazer, MD FRCPC*

Departments of *Anesthesia and {dagger}Public Health, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada

Anesth Analg 2004;99:603-606


对贫血患者输注以血红蛋白为基础的氧携带液(HBOCs),能提高大脑氧供。但是,输注HBOCs后,脑血管收缩,能使这一作用受限。我们假设,用HBOCs作血液稀释,尽管出现大脑血管收缩,仍能维持脑组织的氧供。用异氟醚维持麻醉(吸入100%的氧)。用HBOCs (hemoglobin raffimer; HemolinkTM))或胶体液pentastarch (n = 6)稀释血液。在血液稀释之预计血容量的50%前后(30 mL/kg),监测直接动脉平均血压,末梢组织氧张力(PBrO2)和局部大脑皮层血流量(rCBF)。用以血红蛋白为基础的氧携带液稀释组,能使PBrO暂时升高,从24.9 ± 13.3 mm Hg 增加到32.2 ± 19.1 mm Hg (P < 0.05);动脉平均压持续增加,rCBF无变化。尽管高铁血红蛋白增加和氧饱和度降低,但仍能维持动脉氧含量。用胶体液稀释组,平均动脉压暂时升高,PBrO2 无变化,rCBF的持续增加(P < 0.05),而血红蛋白浓度和氧含量显著降低。同样程度的血液稀释,以血红蛋白为基础的氧携带液组能增加PBrO2和防止rCBF增加。实验数据提示,在严重贫血患者中,输注以血红蛋白为基础的氧携带液能维持大脑的氧供。

(葛宁花译 薛张纲校)

Transfusion of anemic patients with hemoglobin-based oxygen carriers (HBOCs) may improve cerebral oxygen delivery. Conversely, cerebral vasoconstriction, associated with HBOC transfusion, could limit optimal cerebral tissue oxygenation. We hypothesized that hemodilution with a HBOC would maintain cerebral tissue oxygenation, despite the occurrence of cerebral vasoconstriction. Isoflurane-anesthetized rats (100% oxygen) underwent direct measurement of mean arterial blood pressure (MAP), caudate tissue oxygen tension (PBrO2), and regional cortical cerebral blood flow (rCBF) before and after 50% of the estimated blood volume (30 mL/kg) was exchanged with either an HBOC (hemoglobin raffimer; HemolinkTM) or pentastarch (n = 6). Hemodilution with hemoglobin raffimer caused a transient increase in PBrO2 from 24.9 ± 13.3 mm Hg to 32.2 ± 19.1 mm Hg (P < 0.05), a sustained increase in MAP, and no change in rCBF. Arterial blood oxygen content was maintained despite an increase in methemoglobin and reduced oxygen saturation. Hemodilution with pentastarch caused a transient increase in MAP, no change in PBrO2, and a sustained increase in rCBF (P < 0.05), whereas the hemoglobin concentration and oxygen content were significantly reduced. Hemodilution with hemoglobin raffimer augmented PBrO2 and prevented the increase in rCBF observed after similar hemodilution with pentastarch. These data suggest that transfusion with hemoglobin raffimer may help to maintain cerebral oxygenation during severe anemia.

 

判断甲状腺手术困难气道插管

Prediction of Difficult Tracheal Intubation in Thyroid Surgery

Abderrahmane Bouaggad, MD, Sif Eddine Nejmi, MD, Moulay Ahmed Bouderka, MD, and Omar Abbassi, MD

Department of Anesthesiology and Intensive Care, CHU Ibn Rochd Casablanca, Morocco

Anesth Analg 2004;99:603-606


很少报道甲状腺切除术患者困难气管内插管的发生率,评价困难气管内插管因素的研究亦有限。我们为此进行前瞻性的研究,探讨当甲状腺肿大时,困难气管内插管的发生率和评估与困难气管内插管有关的因素。连续观察320位行甲状腺切除术患者。术前进行困难气道评估。由麻醉医生在没有他人的帮助下进行气管插管,并且再次评估是否存在插管困难。先进行单因素分析,在有其他预示困难气道因素存在时,进行多因素分析。有17位患者中出现困难气管内插管。插管无困难率是36.9%,轻度困难率是57.8%。在单因素分析中,性别(男性)、体重指数、Mallampati 分级、颌下距离、颈部活动度、Cormack 评级,癌性甲状腺和气管移位或受压等预示是否存在潜在的困难气管内插管。在多因素分析中,二个互不依赖的因素(如Cormack 评级 III IV和癌性甲状腺肿大)都预示困难气管内插管。我们的结论:肿大的甲状腺并不增加困难气道的发生率。但是,癌性甲状腺是预示困难气道的主要因素。

(葛宁花译 薛张纲校)

The incidence of difficult endotracheal intubation (DEI) for patients undergoing thyroidectomy has rarely been studied, and evaluation of factors linked to DEI is limited to a few studies. We undertook this prospective study to investigate the incidence of DEI in the presence of goiter (an enlargement of the thyroid gland) and to evaluate factors linked to DEI. We studied 320 consecutive patients scheduled for thyroidectomy. DEI was evaluated by an intubation difficulty scale. The trachea was intubated by an unassisted anesthesiologist, and the intubation difficulty scale was calculated. A univariate analysis was performed to identify potential factors predicting DEI, followed by a multivariate analysis. DEI was reported in 17 patients. The rate of easy tracheal intubation was 36.9%; the rate for patients who had minor difficulty of intubation was 57.8%. Sex (male), body mass index, Mallampati class, thyromental distance, neck mobility, Cormack grade, cancerous goiter, and tracheal deviation or compression were identified in the univariate analysis as potential DEI risk factors. With multivariate analysis, two criteria were recognized as independent for DEI (Cormack Grade III or IV and cancerous goiter). We conclude that the large goiter is not associated with a more frequent DEI. However, the presence of a cancerous goiter is a major factor for predicting DEI.




用组织多普勒成象技术观察负荷改变对收缩期二尖瓣管处流速的影

The Effects of Load on Systolic Mitral Annular Velocity by Tissue Doppler Imaging

Ruggero Amà, MD*, Patrick Segers, PhD*, Carl Roosens, MD{dagger}, Tom Claessens*, Pascal Verdonck, PhD*, and Jan Poelaert, MD PhD{dagger}

*Hydraulics Laboratory, Institute Biomedical Technology; and {dagger}Department of Intensive Care Unit, Ghent University Hospital and International Research Center, Ghent University, Belgium

Anesth Analg 2004;99:332-338

 

组织多普勒成像显示技术(TDI) 通过测定收缩期二尖瓣环血流速率波型提供了丰富的关于收缩功能的信息,它反映了心肌纤维纵向收缩功能的收缩速率峰值。在本研究中,我们评估负荷变化对于了收缩期二尖瓣环处血流速率波(Sm)的影响。连续选择42例左心室射血分数>60%心脏手术病人,24个病人以静脉推注了新福林或硝酸甘油改变后负荷;18个病人以快速输注了500ml明胶溶液改变前负荷,组织多普勒成像显示技术(TDI)通过食道中段心脏四腔室切面超声进行记录。结果:以新福林和硝酸甘油改变负荷的病人Sm没有影响,而以快速输注了500ml胶体溶液改变容量负荷的病人Sm有明显增加(从基础的8.4 ±2.6 cm/s增加到9.6 ±2.5 cm/s; P = 0.001)。我们推测,Sm依赖于容量补充导致的前负荷变化,而并不能反映那些有明显心室充盈问题的重危病人的心室收缩功能。

(沈浩   李士通  校)

Tissue Doppler Imaging (TDI) provides information on systolic function through its systolic mitral annulus velocity wave (Sm), reflecting the peak velocity of shortening of the myocardial fibers oriented in the longitudinal direction. In this study, we evaluated the effect of load changes on Sm. Forty-two cardiac surgical patients with left ventricular ejection fraction >60% were consecutively evaluated. In 24 patients, load was changed with an IV bolus of phenylephrine (50–100 µg) or nitroglycerine (300–500 µg); in 18 patients, preload was changed with a rapid infusion of 500 mL of a gelatin solution. The sample volume of TDI was placed at the lateral side of the mitral annulus in the mid-esophageal 4-chamber view. Changing loading conditions with phenylephrine or nitroglycerine had no effect on Sm; the increase of preload in 18 patients resulted in a statistically significant increase of Sm (baseline, 8.4 ± 2.6 cm/s; after increase of preload, 9.6 ± 2.5 cm/s; P = 0.001). We conclude that Sm is dependent on changes in preload obtained by volume loading and cannot be recommended as an index of ventricular contractile performance in critically ill patients where significant changes in ventricular filling occur.

 

 

氟烷真的比七氟醚更好保护心脏压力反射?儿童麻醉中七氟醚和氟烷的自主性压力反射的无创研究

Does Halothane Really Preserve Cardiac Baroreflex Better Than Sevoflurane? A Noninvasive Study of Spontaneous Baroreflex in Children Anesthetized with Sevoflurane Versus Halothane

Isabelle Constant, MD PhD*, Dominique Laude, BSc{dagger}, Elizabeth Hentzgen, MD*, and Isabelle Murat, MD PhD*

*Service d’Anesthésie Réanimation Pédiatrique, Hôpital Armand Trousseau, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; and {dagger}Institut National de la Santé et de la Recherche Médicale E0107, Paris, France

Anesth Analg 2004;99:360-369

 

应用七氟醚和氟烷的麻醉诱导过程中心率的变化明显不同。过去的研究显示氟烷比七氟醚更多保护心脏的副交感活性。因为迷走神经调节窦房节是动脉压力反射控制心率的主要效应器,所以氟烷可能比七氟醚更好保护心脏的压力反射。为了调查儿童麻醉中心脏的压力反射,我们使用两种不同途径的无创方法取得动脉血压(BP)R-R间期(RRI)的关系:连续调查每搏BP变化和RRI(时域)间的变化和交叉光谱分析调查血压波动和RRI(频域)间的关系。儿童被随机分配,面罩诱导用100%氧加七氟醚,50%氧气50%笑气加七氟醚,或者50%氧气50%笑气加氟烷。气管插管以后,挥发性麻醉剂减少到一个MAC(最小肺泡有效浓度)。自主压力反射(SBR)敏感性由连续记录基础值、诱导过程、和插管以后计算。心脏压力反射也通过交叉光谱分析基础值和1MAC时(固定情况)来估计。在三组中,麻醉诱导导致SBR敏感度明显减少,七氟醚发生的比氟烷早。插管后5分钟(1MAC),连续方法显示三组中相似的SBR敏感度减少。相同地,交叉光谱分析收缩压和RRI显示了低频带计算的增益的减少,但是呼吸带增益氟烷比七氟醚高。在儿童,氟烷和七氟醚麻醉诱导导致心脏压力反射活性明显下降。与有效的副交感压力反射活性相比,氟烷的呼吸RRI波动的持续存在可能更能反映反射性呼吸不规律。

(张曦      李士通  校)

Heart rate profiles during the induction of anesthesia differ markedly between the administration of sevoflurane and halothane. Previous investigations have shown that halothane preserves cardiac parasympathetic activity more than sevoflurane. Because vagal drive to the sinus node is the main effector of arterial baroreflex control of heart rate, halothane may preserve cardiac baroreflex better than sevoflurane. To investigate cardiac baroreflex in anesthetized children, we used two noninvasive methods providing different approaches to the arterial blood pressure (BP) and R-R interval (RRI) relationship: the sequence methods investigating beat-to-beat changes in BP and RRI (time domain) and the cross-spectral analysis investigating relationships between oscillations of BP and RRI (frequency domain). Children were randomly assigned to mask induction with sevoflurane in 100% oxygen, sevoflurane in 50% nitrous oxide/50% oxygen, or halothane in 50% nitrous oxide/50% oxygen. After tracheal intubation, the inspired fraction of volatile anesthetic was reduced to 1 minimum alveolar anesthetic concentration (MAC). The spontaneous baroreflex (SBR) sensitivity was calculated with the sequence method at baseline, during induction, and after intubation. The cardiac baroreflex was also estimated with cross-spectral analysis at baseline and at 1 MAC (stationary conditions). In the three groups, the induction of anesthesia was associated with a marked decrease of SBR sensitivity, which occurred earlier with sevoflurane than with halothane. Five minutes after intubation (1 MAC), the sequence method showed a similar decrease of the SBR sensitivity in the three groups. Similarly, the cross-spectral analysis between systolic blood pressure and RRI showed a decrease of the gain calculated in the low-frequency band, but the gain in the respiratory band was higher with halothane compared with sevoflurane. In children, the induction of anesthesia with halothane and sevoflurane is associated with a marked decrease of cardiac baroreflex activity. The persistence of respiratory RRI fluctuations under halothane might reflect reflex respiratory arrhythmia rather than efficient parasympathetic baroreflex activity.

 

大面积烧伤病人中罗库溴铵的神经肌肉阻滞药效学

Neuromuscular Pharmacodynamics of Rocuronium in Patients with Major Burns

TaeHyung Han, MD PhD, FAAFP*, HyeongSeok Kim, MD*, JiYoung Bae, MD*, KwangMin Kim, MD PhD*, and J. A. Jeevendra Martyn, MD FRCA, FCCM{dagger}

*Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University, School of Medicine, Seoul, Korea; and {dagger}Department of Anesthesiology and Critical Care, Harvard Medical School, Massachusetts General Hospital, and Shriners Hospital for Children, Boston, Massachusetts

Anesth Analg 2004;99:386-392

 

罗库溴铵起效时间短,无升血钾作用,被认为可用于烧伤病人的麻醉快速诱导。在本研究中,我们评价了大面积烧伤病人中罗库溴铵的神经肌肉药效学。收入病人为年龄18-59岁的大面积烧伤成人(n56)和44例非烧伤病人的对照组。用罗库溴铵3倍(0.9 mg/kg)或4倍(1.2 mg/kg)的95%有效量。麻醉包括异丙酚、芬太尼、笑气和氧气。用四个成串刺激的加速度仪监测神经肌肉阻滞。烧伤病人的神经肌肉阻滞95%的起效时间比非烧伤病人长(0.9 mg/kg 115 ± 58 s 68 ± 16 s 1.2 mg/kg 86 ± 20 s 57 ± 11 s )。增大剂量可缩短烧伤病人的起效时间,延长作用持续时间,并改善插管条件。烧伤组两个剂量的所有恢复指标均比非烧伤组显著较短。通过增大剂量可部分克服罗库溴铵神经肌肉作用的耐药性。在大面积烧伤后,大到1.2 mg/kg的一个剂量可提供良好的气管插管条件。

(马皓琳      李士通  校)

Rocuronium, which has a short onset time and is free of hyperkalemic effects, could be considered for rapid-sequence induction of anesthesia in patients with burns. In this study, we assessed the neuromuscular pharmacodynamics of rocuronium in patients with major burns. Adults aged 18–59 yr who had a major burn injury (n = 56) and a control group of 44 nonburned patients were included. Rocuronium was used at 3 times (0.9 mg/kg) or 4 times (1.2 mg/kg) the 95% effective dose. Anesthesia consisted of propofol and fentanyl with nitrous oxide and oxygen. Neuromuscular block was monitored with an acceleromyograph by using train-of-four stimulation. The onset time to 95% neuromuscular block was prolonged in burned compared with nonburned patients (115 ± 58 s versus 68 ± 16 s for 0.9 mg/kg; 86 ± 20 s versus 57 ± 11 s for 1.2 mg/kg). Dose escalation shortened the onset time, prolonged the duration of action, and improved intubating conditions in burned patients. All recovery profiles were significantly shorter in burned versus nonburned groups with both doses. Resistance to the neuromuscular effects of rocuronium was partially overcome by increasing the dose. A dose up to 1.2 mg/kg provides good tracheal intubating conditions after major burns.

 

氟烷和异丙酚调节γ—氨基丁酸A受体单通道电流

Halothane and Propofol Modulation of {gamma}-Aminobutyric AcidA Receptor Single-Channel Currents

Akira Kitamura, MD PhD*,{dagger}, Ryoichi Sato, MD PhD*, William Marszalec, PhD*, Jay Z. Yeh, PhD*, Ryo Ogawa, MD PhD{dagger}, and Toshio Narahashi, DVM PhD*

*Department of Molecular Pharmacology and Biological Chemistry, Northwestern University Medical School, Chicago, Illinois; and {dagger}Department of Anesthesiology, Nippon Medical School, Tokyo, Japan

Anesth Analg 2004;99:409-415

氟烷和异丙酚能增强麻醉机理中最重要系统γ—氨基丁酸(GABA)系统的活性。为确定氟烷和异丙酚是否以相同的机理增强GABA神经元反应,我们在原代培养的大鼠皮质神经元上行单通道膜片钳实验。用快和慢时间常数的总和表示每个GABAA受体单通道开放及关闭时间。氟烷和异丙酚均不能改变单通道电导。氟烷通过延长开放时间的缓慢相而增加通道开放概率,而异丙酚通过缩短关闭时间的缓慢相而增加通道开放概率。因此虽然氟烷和异丙酚均能通过增加通道开放概率而增加抑制性递质作用过程中电迁移,但二者机制不同。

(王立中      李士通  校)

Halothane and propofol enhance the activity of the {gamma}-aminobutyric acid (GABA) system, which is one of the most important systems in the mechanism of anesthesia. To determine whether halothane and propofol enhance GABAergic responses by the same mechanism, we performed single-channel patch-clamp experiments with rat cortical neurons in primary culture. Each of the open-time and closed-time distributions of GABAA receptor single channels was expressed by a sum of fast and slow time constants. Neither halothane nor propofol changed the single-channel conductance. Halothane increased the probability of the channel being open via a prolongation of the slow phase of open time, whereas propofol increased the channel open probability via a shortening of the slow phase of closed time. Thus, although both halothane and propofol augmented the channel open probability, thereby causing an increase in charge transfer during inhibitory transmitter action, they acted by different mechanisms.

 

雷米芬太尼导致的胃排空延迟不受体位的影响

The Delay of Gastric Emptying Induced by Remifentanil Is Not Influenced by Posture

Jakob Walldén, MD*,{dagger}, Sven-Egron Thörn, MD PhD*, and Magnus Wattwil, MD PhD*,{dagger}

*Department of Anesthesia and Intensive Care, Örebro University Hospital, Örebro, Sweden; and {dagger}Department of Medicine and Care, Faculty of Health Sciences, Linköping, Sweden

Anesth Analg 2004;99:429-434

体位对胃排空有一定作用。在这项研究中,我们调查了体位是否对阿片类镇痛药引起的胃排空延迟有影响。10位健康男性用对乙酰氨基酚方法进行4项胃排空研究。两项研究中受试者取20°头高右侧卧位或20°头低左侧卧位,给予持续雷米芬太尼输注(0.2 µg • kg–1 min–1)。另两项研究(对照),不输注药物,受试者取同样两种体位。给予雷米芬太尼后,两种体位时的血清最大对乙酰氨基酚浓度(右侧位34 µmol • L–1;左侧位16 µmol • L–1)、达到峰浓度时间(94 109 min)以及对乙酰氨基酚浓度时间曲线下面积从060分钟(962197 min • µmol • L–1)都无显著差别。在对照组,两种体位间的最大对乙酰氨基酚浓度(13894 µmol • L–1; P < 0.0001)和血清对乙酰氨基酚浓度时间曲线下面积从060分钟(5092 3793 min • µmol • L–1; P < 0.0001)有差异,但达到峰浓度时间无明显差异(25 47 min)。相比于对照组,两种体位下雷米芬太尼都延迟胃排空。我们得出结论雷米芬太尼延迟胃排空,但这种作用不受体位影响。

(吴俭      李士通  校)

Posture has an effect on gastric emptying. In this study, we investigated whether posture influences the delay in gastric emptying induced by opioid analgesics. Ten healthy male subjects underwent 4 gastric emptying studies with the acetaminophen method. On two occasions the subjects were given a continuous infusion of remifentanil (0.2 µg • kg–1 min–1) while lying either on the right lateral side in a 20° head-up position or on the left lateral side in a 20° head-down position. On two other occasions no infusion was given, and the subjects were studied lying in the two positions. When remifentanil was given, there were no significant differences between the two postures in maximal acetaminophen concentration (right side, 34 µmol • L–1; versus left side, 16 µmol • L–1), time taken to reach the maximal concentration (94 versus 109 min), or area under the serum acetaminophen concentration time curve from 0 to 60 min (962 versus 197 min • µmol • L–1). In the control situation, there were differences between the postures in maximal acetaminophen concentration (138 versus 94 µmol • L–1; P < 0.0001) and area under the serum acetaminophen concentration time curves from 0 to 60 min (5092 versus 3793 min • µmol • L–1; P < 0.0001), but there was no significant difference in time taken to reach the maximal concentration (25 versus 47 min). Compared with the control situation, remifentanil delayed gastric emptying in both postures. We conclude that remifentanil delays gastric emptying and that this delay is not influenced by posture.

 

 

术后或麻醉后呼出气中CO浓度增加

Increased Carbon Monoxide Concentration in Exhaled Air After Surgery and Anesthesia

Masao Hayashi, MD*, Toru Takahashi, MD{dagger}, Hiroshi Morimatsu, MD{dagger}, Hiromi Fujii, MD{dagger}, Naoyuki Taga, MD{dagger}, Satoshi Mizobuchi, MD{dagger}, Masaki Matsumi, MD{dagger}, Hiroshi Katayama, MD{dagger}, Masataka Yokoyama, MD{dagger}, Masahiro Taniguchi, MD*, and Kiyoshi Morita, MD{dagger}

*Department of Anesthesiology, National Okayama Medical Center, Tamasu, Okayama, Japan; and {dagger}Department of Anesthesiology and Resuscitology, Okayama University Medical School, Okayama, Japan

Anesth Analg 2004;99:444-448

 

血红素加氧酶-1 (HO-1)是氧化应激中产生的,被认为有对抗组织氧化损伤的保护作用。HO-1催化亚铁血红素蛋白的亚铁血红素部分如血色素、肌球素及细胞色素P450转化为胆绿素,在此过程中释放一氧化碳(CO)。CO和血色素起反应生成碳氧血红蛋白。本研究为探索麻醉和/或手术对于内源性CO生成的影响,测量在全麻或椎管内麻醉下手术患者的呼出CO量和动脉碳氧血红蛋白浓度。结果发现,不管哪种麻醉,患者术后一日CO和碳氧血红蛋白浓度都明显比术前 (P < 0.05) 和恢复室(P < 0.05)中升高。全麻和椎管内麻醉并无明显不同。这些结果显示麻醉和/或手术引起的氧化应激会产生HO-1,促使亚铁血红素产生CO,增加呼出CO浓度。

(朱       李士通  校)

Heme oxygenase-1 (HO-1) is induced by oxidative stress and is thought to confer protection against oxidative tissue injuries. HO-1 catalyzes the conversion of the heme moiety of hemeproteins, such as hemoglobin, myoglobin, and cytochrome P450, to biliverdin, liberating carbon monoxide (CO) in the process. CO reacts with hemoglobin to form carboxyhemoglobin. In this study, to examine the effect of anesthesia and/or surgery on endogenous CO production, we measured the amount of exhaled CO and the arterial carboxyhemoglobin concentration of patients who underwent surgery under general or spinal anesthesia. Both CO and carboxyhemoglobin concentrations were significantly larger on the day after surgery than during the preoperative period (P < 0.05) and in the recovery room (P < 0.05), regardless of anesthesia. However, neither index differed between general and spinal anesthesia. These results suggest that oxidative stress caused by anesthesia and/or surgery may induce HO-1, which catalyzes heme to produce CO, leading to increased exhaled CO concentration.

 

 

椎间盘内纤维环热成形术治疗多节段椎间盘退行性病变所致的腰椎间盘源性疼痛

Intradiscal Thermal Annuloplasty for the Treatment of Lumbar Discogenic Pain in Patients with Multilevel Degenerative Disc Disease

Leonardo Kapural, MD PhD, Nagy Mekhail, MD PhD, Zdenko Korunda, MD, and Ayman Basali, MD MSci

Pain Management Department, The Cleveland Clinic Foundation, Ohio

Anesth Analg 2004;99:472-476

有症状的椎间盘退行性病变(DDD)可显著降低生活质量并导致功能障碍。椎间盘内纤维环热成形术(IDTA)是一种治疗疼痛性椎间盘退行性病变的微创疗法。假设多节段DDD病人在IDTA术后疼痛评分和疼痛致残指数(PDI)可能有所改善。本研究选择的病例年龄在24-66岁之间,性别不限,将多节段DDDMDDD)与12节段DDD1,2DDD)病人进行配对研究。术后12个月内观察记录视觉模拟疼痛评分(VAS) PDI1,2DDD病人组椎间盘内纤维环热成形术后12个月的VAS评分为2.5 ± 2.4,较术前评分7.7 ± 2有所改善。MDDD组病人术后12个月VAS评分为4.9 ± 2.9较术前评分7.4 ± 1.8也有所改善。术后PDI也有类似的改善。1,2DDD组其疼痛缓解和PDI改善显著优于MDDD组(P分别为0.00370.041)。可以推断:IDTA是一种治疗椎间盘源性疼痛的有效疗法,且退行性病变所累及的椎间盘数目是IDTA疗效的一个重要决定因子。

(周雅春   李士通 校)

Symptomatic degenerative disc disease (DDD) may lead to significant deterioration of quality of life and increased disability. Intradiscal thermal annuloplasty (IDTA) is a minimally invasive treatment for painful DDD. We hypothesized that there may be an improvement in pain scores and the pain disability index (PDI) of patients who have multilevel DDD after IDTA. Patients 24–66 yr old, male and female with multilevel DDD (MDDD) and matched 1 or 2 level DDD (1,2-DDD) patients were enrolled in the study. Visual analog pain scale (VAS) score and PDI were observed for 12 mo. The 1,2-DDD patient group had a 2.5 ± 2.4 VAS score at 12 mo after annuloplasty compared to 7.7 ± 2 before the procedure. The MDDD VAS score was 4.9 ± 2.9 at 12 mo compared to 7.4 ± 1.8 before the procedure. Similar improvements in PDI were found. The pain relief and PDI were significantly better in patients with 1,2-DDD than in the MDDD group (P = 0.0037 and P = 0.041, respectively). We concluded that IDTA is an effective treatment of discogenic pain and that the number of discs affected by degeneration is an important determinant of the procedure outcome.

 

 

局麻药行腰部节段性神经阻滞的疼痛缓解和运动功能:一项利多卡因和罗哌卡因之间的前瞻性双盲对比研究

Lumbar Segmental Nerve Blocks with Local Anesthetics, Pain Relief, and Motor Function: A Prospective Double-Blind Study Between Lidocaine and Ropivacaine

André P. Wolff, MD*,{dagger},{ddagger}, Oliver H. G. Wilder Smith, MD PhD{dagger}, Ben J. P. Crul, MD PhD{dagger}, Marc P. van de Heijden{dagger}, and Gerbrand J. Groen, MD PhD{ddagger}

*Pain Centre, Department of Anaesthesiology, Bernhoven Hospital, Oss, The Netherlands; {dagger}Pain Centre, Institute for Anaesthesiology, University Hospital Nijmegen, Nijmegen, The Netherlands; and {ddagger}Division of Perioperative Medicine, Anaesthesiology and Pain Treatment, University Medical Centre Utrecht, Utrecht, The Netherlands

Anesth Analg 2004;99:496-501

 

局麻药行选择性节段性神经阻滞被用于判断慢性背痛病人的疼痛节段。我们进行本项研究试图去明确使用利多卡因和罗哌卡因行L4脊神经阻滞后的肌肉运动减退效应及其与疼痛之间的关系。因此,20例有腰骶部神经根痛而无神经功能缺损的病人接受了利多卡因和罗哌卡因的L4段神经阻滞,其中19例完成了整个试验。分别在疼痛侧和对照侧对疼痛强度评分(视觉数字评定量表;VNRS)和胫骨前肌和股四头肌的最大主动肌力(MVMF;使用牛顿来表示的测力计)进行评估。VNRS中位数下降了4.0P < 0.00001Wilcoxon符号等级检验),但在罗哌卡因和利多卡因之间无显著性差异(Mann-Whitney U-检验)。患侧和对照侧在MVME上有差异(P = 0.016Tukey检验)。多元回归分析显示VNRS评分变化和MVMF中位数变化之间呈显著负相关(Spearman R = ?C0.48P = 0.00001)。本研究证实在单侧下腰痛伴大腿放射的患者中,局麻药行节段性(L4)神经阻滞所致的疼痛减轻与股四头肌及胫骨前肌MVMF的增加相关,而利多卡因和罗哌卡因之间无差异。

(黄施伟     李士通 校)

Selective segmental nerve blocks with local anesthetics are applied for diagnostic purposes in patients with chronic back pain to determine the segmental level of the pain. We performed this study to establish myotomal motor effects after L4 spinal nerve blocks by lidocaine and ropivacaine and to evaluate the relationship with pain. Therefore, 20 patients, of which 19 finished the complete protocol, with chronic lumbosacral radicular pain without neurological deficits underwent segmental nerve blocks at L4 with both lidocaine and ropivacaine. Pain intensity scores (verbal numeric rating scale; VNRS) and the maximum voluntary muscle force (MVMF; using a dynamometer expressed in newtons) of the tibialis anterior and quadriceps femoris muscles were measured on the painful side and on the control side. The median VNRS decrease was 4.0 (P < 0.00001; Wilcoxon’s signed rank test), without significant differences between ropivacaine and lidocaine (Mann-Whitney U-test). A difference in effect on MVMF was found for affected versus control side (P = 0.016; Tukey test). Multiple regression revealed a significant negative correlation for change in VNRS score versus change in median MVMF (Spearman R = –0.48: P = 0.00001). This study demonstrates that in patients with unilateral chronic low back pain radiating to the leg, pain reduction induced by local anesthetic segmental nerve (L4) block is associated with increased quadriceps femoris and tibialis anterior MVMF, without differences for lidocaine and ropivacaine.

 

比较高张生理盐水及高张生理盐水6%右旋糖酐-70用于狗出血性休克复苏后的早期组织及胃肠氧合作用的研究

The Early Systemic and Gastrointestinal Oxygenation Effects of Hemorrhagic Shock Resuscitation with Hypertonic Saline and Hypertonic Saline 6% Dextran-70: A Comparative Study in Dogs

José Reinaldo Cerqueira Braz, MD PhD, Paulo do Nascimento, Jr., MD PhD, Odilar Paiva Filho, MD, Leandro Gobbo Braz, MD, Luiz Antonio Vane, MD PhD, Pedro Thadeu Galvão Vianna, MD PhD, and Geraldo Rolim Rodrigues, Jr., MD PhD

Department of Anesthesiology, School of Medicine, University of São Paulo State, Botucatu, São Paulo, Brazil

Anesth Analg 2004;99:536-546

在处理出血性休克时用较小容量7.5%高张生理盐水(HS)的方法与传统的血浆扩充剂比较,全身氧输送及组织的氧合较差。在狗的出血性休克模型中,我们分别使用HS或高张(6%)右旋糖酐-70HS的联合 (HSD),与乳酸林格氏液(LR)6%羟乙基淀粉(HES)进行比较,比较它们对组织及胃肠的氧合效应。将48条杂种狗麻醉、机械通气下行脾切除术。在其胃内放置一个胃气体张力计以测量胃黏膜内的CO2(Pg CO2)及计算黏膜内的pH(pHi):

[pHi=pHa-log(Pg CO2/ PaCO2)]

半小时内控制狗的出血量为血容量的42%,维持平均动脉压在40-50mmHg,然后复苏,LR(n=12)输入3倍于出血量;HS(n=12),6ml/kgHSD(n=12),6ml/kgHES(平均分子量200kDa、取代级0.5)(n=12)输入量等同于出血量。在基础、出血后30min、血管内输入液体复苏后560120 min时测量血流动力学、组织及胃氧合作用的变化。液体复苏后,与输入LRHES相比,输入HS后,动脉血pH及混合静脉PO2低,组织摄氧指数及组织摄氧率高(p<0.05)。而与输入LRHES相比,输入HSD后,动脉血pH低(p<0.05)。仅在输入HSHSD两组动脉pHpHi不能恢复到对照水平(p<0.05)。结论:所有液体都改善了狗出血性休克后组织及胃肠的氧合作用。然而,与LRHES相比,输入HS后表现出的组织氧合作用最差,而输入HSD后表现出的组织氧合作用居中。输入HSHSD的方法不能使局部氧合作用恢复到对照值水平。

(裘毅敏      李士通  校)

The smaller volemic state from hypertonic (7.5%) saline (HS) solution administration in hemorrhagic shock can determine lesser systemic oxygen delivery and tissue oxygenation than conventional plasma expanders. In a model of hemorrhagic shock in dogs, we studied the systemic and gastrointestinal oxygenation effects of HS and hyperoncotic (6%) dextran-70 in combination with HS (HSD) solutions in comparison with lactated Ringer’s (LR) and (6%) hydroxyethyl starch (HES) solutions. Forty-eight mongrel dogs were anesthetized, mechanically ventilated, and subjected to splenectomy. A gastric air tonometer was placed in the stomach for intramucosal gastric CO2 (PgCO2) determination and for the calculation of intramucosal pH (pHi):

The dogs were hemorrhaged (42% of blood volume) to hold mean arterial blood pressure at 40–50 mm Hg over 30 min and were then resuscitated with LR (n = 12) in a 3:1 relation to removed blood volume; HS (n = 12), 6 mL/kg; HSD (n = 12), 6 mL/kg; and HES (mean molecular weight, 200 kDa; degree of substitution, 0.5) (n = 12) in a 1:1 relation to the removed blood volume. Hemodynamic, systemic, and gastric oxygenation variables were measured at baseline, after 30 min of hemorrhage, and 5, 60, and 120 min after intravascular fluid resuscitation. After fluid resuscitation, HS showed significantly lower arterial pH and mixed venous PO2 and higher systemic oxygen uptake index and systemic oxygenation extraction than LR and HES (P < 0.05), whereas HSD showed significantly lower arterial pH than LR and HES (P < 0.05). Only HS and HSD did not return arterial pH and pHi to control levels (P < 0.05). In conclusion, all solutions improved systemic and gastrointestinal oxygenation after hemorrhagic shock in dogs. However, the HS solution showed the worst response in comparison to LR and HES solutions in relation to systemic oxygenation, whereas HSD showed intermediate values. HS and HSD solutions did not return regional oxygenation to control values.

 

 

蛋白激酶CATP敏感性钾通道激动剂对抗大鼠内皮细胞和血管平滑肌细胞炎症反应的保护作用:离体和在体研究

The Protective Effect of Protein Kinase C and Adenosine Triphosphate-Sensitive Potassium Channel Agonists Against Inflammation in Rat Endothelium and Vascular Smooth Muscle In Vitro and In Vivo

Roman V. Plachinta, MD*, Manuela J. M. de Klaver, MD*, John K. Hayes, PhD*, and George F. Rich, MD PhD*,{dagger}

Departments of *Anesthesiology and {dagger}Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia

Anesth Analg 2004;99:556-561

 

吸入性麻醉药预处理通过激活ATP敏感性钾通道(KATP)或蛋白激酶C(PKC),预防血管系统的炎症损伤。所以我们假设在体外和体内给予KATP PKC激动剂可模拟吸入性麻醉药的保护作用。离体实验:观察KATP开放剂克罗卡林(CRK)PKC激动剂豆蔻酰佛波醇乙酯(PMA)预处理大鼠血管平滑肌细胞(VSM)和主动脉内皮细胞(AEC)能否减轻脂多糖(LPS)诱发的细胞损伤。6小时后用台盼蓝染色评估细胞存活率。在体实验:大鼠PMA CRK预处理组及未处理组,全身给予LPS或生理盐水,6小时后测量平均动脉压、对血管扩张药(内皮依赖性扩管药乙酰胆碱,非内皮依赖性扩管药硝普钠)的反应及动脉血气分析。离体实验结果:对照组VSM AEC的生存率均超过90%,且不受PMA CRK影响。LPS组细胞生存率明显下降;PMA (0.1–10 µM)使LPS的损伤作用减少28%–37% VSM 39%–53% AEC);CRK (1 mM)使细胞生存率增加 24% VSM )或 22% AEC)。在体试验结果:对照组PMA CRK预处理对观测指标无明显影响。LPS组平均动脉压下降,乙酰胆碱和硝普钠的扩管作用减弱,血糖降低;6小时后 PMA使乙酰胆碱的扩管作用增加46%CRK无效;两种激动机对LPS的其他损害均无作用。结论:离体实验中KATP 开放剂和 PKC激动剂对VSMAEC的炎症损伤有一定保护作用;而我们的在体模型中,KATP 开放剂和 PKC激动剂全身给药几乎没有保护作用。

(轩泓      李士通  校)

Volatile anesthetic pretreatment protects the vasculature from inflammation-induced injury via mechanisms involving the activation of adenosine triphosphate-sensitive potassium (KATP) channels and/or protein kinase C (PKC). Therefore, we hypothesized that KATP and PKC agonists may mimic the protective effects of volatile anesthetics in vitro and in vivo. In vitro, rat vascular smooth muscle cells (VSM) and aortic endothelial cells (AEC) were used to evaluate whether pretreatment with a KATP agonist, cromakalim (CRK), or a PKC agonist, phorbol 12-myristate 13-acetate (PMA), decreases lipopolysaccharide (LPS)-induced cell injury. Cell survival was determined by trypan blue staining after 6 h. In vivo, rats received systemic LPS or saline with or without pretreatment with PMA or CRK. Mean arterial blood pressure, the response to endothelium-dependent (acetylcholine; ACH) and -independent (sodium nitroprusside) vasodilators, and arterial blood gases were determined after 6 h. Cell survival in VSM and AEC control cultures was more than 90%, which was not altered in the presence of PMA or CRK, whereas LPS significantly decreased cell survival. PMA (0.1–10 µM) significantly attenuated the LPS-induced decrease in cell survival by 28%–37% in VSM and 39%–53% in AEC, and CRK (1 mM) increased cell survival by 24% in VSM and 22% in AEC. In vivo, PMA and CRK pretreatment had no significant effect on measured variables in control rats. LPS decreased mean arterial blood pressure and vasodilation to ACH and sodium nitroprusside and caused hypoglycemia. PMA, but not CRK, increased ACH-dependent vasodilation (46%) at 6 h, but neither agonist altered the other detrimental effects of LPS. In conclusion, PKC and KATP agonists appear to protect AEC and VSM cells against inflammation in vitro, but the systemic administration of PKC and KATP agonists appeared to exert minimal or no protection in our in vivo model.

 

肩关节腔镜术后三种镇痛方法之比较:关节腔内镇痛,肩胛上神经阻滞和肌间沟臂丛神经阻滞

Pain Relief After Arthroscopic Shoulder Surgery: A Comparison of Intraarticular Analgesia, Suprascapular Nerve Block, and Interscalene Brachial Plexus Block

François J. Singelyn, MD PhD*, Laurence Lhotel, MD*, and Bertrand Fabre, MD{dagger}

*Department of Anesthesiology, Université Catholique de Louvain School of Medicine, St. Luc Hospital, Brussels, Belgium; and {dagger}Department of Anesthesiology, Clinique St. Léonard, Angers, France

Anesth Analg 2004;99:589-592

本实验采用前瞻,随机和盲法,评估关节镜肩峰成形术后肌间沟臂丛神经阻滞(ISB)、肩胛上神经阻滞(SSB)和关节腔内局麻药(IA)的镇痛效能。120例患者平均分为4组。SSB组:0.25%布比卡因10ml阻滞肩胛上神经。IA组:手术结束时关节腔内注入0.25%布比卡因20mlISB组:0.25%布比卡因20ml肌间沟阻滞臂丛神经。对照组用于对比镇痛作用。所有患者术中均采用全麻。24小时内观察病人。分别在术后第4小时和第24小时记录以下指标:疼痛评分、追加使用的镇痛药、满意度评分和副作用。IA组和对照组之间各项指标没有显著差异。与它们相比,SSB组和ISB组疼痛评分明显降低。术后第4小时,ISB组活动时的疼痛缓解好于SSB组。与对照组相比,只有ISB组吗啡使用量明显减少,满意度评分明显增高。我们认为在关节镜下肩峰成形术后ISB是最有效的镇痛技术。从临床角度来说SSB也是一个不错的选择。

(张俊杰      李士通  校)

In this prospective, randomized, blinded study, we assessed the analgesic efficacy of interscalene brachial plexus block (ISB), suprascapular nerve block (SSB), and intraarticular local anesthetic (IA) after arthroscopic acromioplasty. One-hundred-twenty patients were divided into 4 groups of 30. In Group SSB, the block was performed with 10 mL of 0.25% bupivacaine. In Group IA, 20 mL of 0.25% bupivacaine was administered intraarticularly at the end of surgery. In Group ISB, the block was performed with 20 mL of 0.25% bupivacaine. A control group was included for comparison. General anesthesia was administered to all patients. Patients were observed during the first 24 h. Pain scores, supplemental analgesia, satisfaction scores, and side effects were recorded at 4 and 24 h. No significant difference was observed between the IA and control groups. When compared with these groups, Groups SSB and ISB had significantly lower pain scores. At 4-h follow-up, better pain relief on movement was noted in Group ISB than in Group SSB. When compared with controls, a significant reduction in morphine consumption and a better satisfaction score were noted only in Group ISB. We conclude that ISB is the most efficient analgesic technique after arthroscopic acromioplasty. SSN block would be a clinically appropriate alternative.

 

紧急气管插管:与反复喉镜尝试相关的并发症

Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts

Thomas C. Mort, MD

Department of Anesthesiology, Hartford Hospital, University of Connecticut School of Medicine

Anesth Analg 2004;99:607-613

多次尝试传统的气管插管可能会增加患者并发症的发病率。收集患有心血管疾病、肺部疾病、代谢疾病、神经性疾病及损伤相关的退行性疾病的危重病人(n=2833)行紧急插管的数据进行质量改进分析。该临床分析依据一套确定的指标来评估气道和血流动力学相关并发症,这些指标与手术室外成功的气管插管所需的尝试次数相关。当喉镜尝试次数增加( 2次以下比>2),气道相关并发症的比率呈现有意义的增高:缺氧(11.8%70%),胃内容物返流(1.9%22%),胃内容物误吸(0.8%13%),心动过缓(1.6%21%)及心脏停搏(0.7%11%P<0.001)。虽然这些结果是预期的,但是这项分析提供了数据证实喉镜尝试次数与气道和血流动力学并发症的发生相关。这些数据也支持ASA困难气道管理任务组提出的建议,限制喉镜尝试次数在三次以下以防可能发生的相当严重的损害。

(陈玮      李士通  校)

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (≤2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.

心脏手术期间正常血糖的维持

Maintenance of Normoglycemia During Cardiac Surgery

George Carvalho, MD*, Anne Moore, MD*, Baqir Qizilbash, MD*, Kevin Lachapelle, MD{dagger}, and Thomas Schricker, MD PhD*

Departments of *Anesthesia and {dagger}Cardiac Surgery, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada

Anesth Analg 2004;99:319-324


作者使用高胰岛素正常血糖稳定技术来保持选择性心脏手术期间的血糖正常,即以一个恒定的速率输注胰岛素同时点滴葡萄糖从而使血糖位于一个特殊的水平。10名非糖尿病和7名糖尿病病人参加了此次试验。同时评估接受传统剂量胰岛素输注的19名非糖尿病和11名糖尿病病人(对照组)的术中血糖。实验组的病人,在诱导前开始给予2U胰岛素的初始负荷剂量,之后按5mU•kg•min-1输注胰岛素同时给予不同剂量的葡萄糖。实验组每5分钟测一次动脉血糖,对照组每20分钟测一次。血糖控制正常定义为≥95%的血糖水平控制在4.0-6.0mmol/L内。记录手术前,体外循环(CPB)前15分钟,体外循环早期和晚期和关胸时的血糖浓度。对照组病人在手术期间有较频繁的高血糖发生(CPB晚期; 非糖尿病病人, 9.0 ± 3.2 mmol/L; 糖尿病病人, 10.1 ± 3.6 mmol/L)。然而,实验组病人则血糖正常(CPB晚期; 非糖尿病病人, 5.5 ± 0.7 mmol/L; 糖尿病病人, 4.9 ± 0.6 mmol/L;  P < 0.05 与对照组相比)。总之,使用高胰岛素正常血糖稳定技术可以在非糖尿病和糖尿病病人的心脏手术中可靠地保持血糖正常。

(殷文渊 译 陈杰 校)

We used the hyperinsulinemic normoglycemic clamp technique, i.e., infusion of insulin at a constant rate combined with dextrose titrated to clamp blood glucose at a specific level, to preserve normoglycemia during elective cardiac surgery. Ten nondiabetic and seven diabetic patients entered the clamp protocols. Perioperative glucose control was also assessed in 19 nondiabetic and 11 diabetic patients (control group) receiving a conventional insulin infusion sliding scale. In patients of the clamp group, a priming bolus of insulin (2 U) was started before the induction of anesthesia followed by infusions of insulin at 5 mU • kg–1 • min–1 and of variable amounts of dextrose. Arterial blood glucose was measured every 5 min in the clamp group and every 20 min in the control group. Control of normoglycemia was defined as ≥95% of the glucose levels within 4.0–6.0 mmol/L. Glucose concentration was recorded before surgery, 15 min before cardiopulmonary bypass (CPB), during early and late CPB, and at sternal closure. Patients of the control group became progressively hyperglycemic during surgery (late CPB; nondiabetics, 9.0 ± 3.2 mmol/L; diabetics, 10.1 ± 3.6 mmol/L), whereas normoglycemia was achieved in the study group (late CPB; nondiabetics, 5.5 ± 0.7 mmol/L; diabetics, 4.9 ± 0.6 mmol/L; P < 0.05 versus control group). In conclusion, it seems that normal blood glucose concentration during open heart surgery can be reliably maintained in nondiabetic and diabetic patients by using the hyperinsulinemic normoglycemic clamp technique.


 

咪唑安定:心脏手术后的有效止吐药-一项临床实验

Midazolam: An Effective Antiemetic After Cardiac Surgery—A Clinical Trial

Orathy Patangi Sanjay, MD, and Deepak Ivan Tauro, MBBS

Department of Anesthesiology, St. John’s Medical College Hospital, Bangalore, Karnataka, India

Anesth Analg 2004;99:339-343


心脏手术后常伴有恶心、呕吐(PONV) 。为了评价咪唑安定的止吐特性,作者在200名接受体外循环心脏手术的病人中进行了这项双盲随机实验,将它预防术后恶心呕吐的疗效与枢复宁(ondansetron)相比较。在气管插管后24小时内定期评价术后恶心呕吐的发生,同时进行镇静和疼痛评分。结果显示咪唑安定组6%的病人发生恶心,没有病人发生呕吐,枢复宁组有21%的病人发生了术后恶心呕吐(P < 0.001)。枢复宁组的21名病人(18名女性和3名男性)需要追加止吐药,而咪唑安定组的6名病人(全部是女性)则没人需要追加(P < 0.001)。两组患者的镇静和术后疼痛评分相似。结论:咪唑安定,开始以0.02 mg • kg–1 • h–1持续输注,比每6小时静注枢复宁0.02 mg • kg–1 • h–1, 对预防心脏手术后恶心呕吐的发生更有效。

(殷文渊 译 陈杰 校)

Cardiac surgery has been associated with a significant incidence of postoperative nausea and vomiting (PONV). To assess the antiemetic property of midazolam, we undertook this double-blinded, randomized trial in 200 patients undergoing cardiac surgery involving cardiopulmonary bypass, and we compared its efficacy with that of ondansetron in preventing PONV. Assessments on the occurrence of PONV were made at regular intervals for the first 24 h after tracheal extubation, along with sedation and pain scoring. We report a 6% incidence of nausea and no incidence of vomiting in the midazolam group, compared with a 21% incidence of PONV in the ondansetron group (P < 0.001). All 21 patients (18 women and 3 men) in the ondansetron group and none of the 6 patients (all women) in the midazolam group required a rescue antiemetic drug (P < 0.001). The sedation scores and postoperative pain scores were comparable in both groups. We conclude that midazolam, instituted as a continuous infusion in a dose of 0.02 mg • kg–1 • h–1, is a more effective antiemetic than ondansetron in a dose of 0.1 mg/kg IV every 6 h for the prevention of PONV after cardiac surgery.


耳鼻喉手术监护麻醉中使用加巴喷丁的镇痛效果

The Analgesic Effects of Gabapentin in Monitored Anesthesia Care for Ear-Nose-Throat Surgery

Alparslan Turan, MD*, Dilek Memis, MD*, Beyhan Karamanlioglu, MD*, Recep Yagiz, MD{dagger}, Zafer Pamukçu, MD*, and Ebru Yavuz{ddagger}

Departments of *Anaesthesiology, {dagger}Ear-Nose-Throat Surgery, and {ddagger}Biostatistics, Trakya University Medical Faculty, Edirne, Turkey

Anesth Analg 2004;99:375-378


作者研究了鼻成形术或内窥镜下鼻窦手术中使用加巴喷丁效果和安全性。患者在手术前1小时口服安慰剂或加巴喷丁1200mg。在标准的术前给药后,每组25名患者术中使用丙泊酚,芬太尼并在手术部位使用局部麻醉药。持续滴注丙泊酚并根据Ramsay评分调整剂量维持镇静。在手术开始后5153045,和60分钟以及手术后30分钟,2468121620,和24小时记录镇静和疼痛评分。经肌肉注射二氯芬酸作为补救镇痛药。加巴喷丁组的患者术后和术中的4560分钟疼痛评分明显低于对照组,芬太尼(122±40µg148±42µgP<0.05)和二氯芬酸(33±53mg111±92mgP<0.001)的消耗较少,第一次需要镇痛的时间更长(18±9h9±7hP<0.001)。加巴喷丁组头晕的发生率高于对照组(24%对4%)。结论:对于不需卧床休息的鼻成形术或内窥镜下的鼻窦手术患者,加巴喷丁有明显减轻疼痛的作用;头晕可能是其不需卧床患者的应用缺陷。

(朱辉 译 陈杰 校)

We investigated the efficacy and safety of gabapentin in rhinoplasty or endoscopic sinus surgery patients. Patients received either oral placebo or gabapentin 1200 mg 1 h before surgery. After standard premedication, 25 patients in each group received propofol, fentanyl, and local anesthesia at the operative site. Sedation was maintained by a continuous infusion of propofol adjusted according to the Ramsay scale. Sedation and pain scores were obtained at 5, 15, 30, 45, and 60 min during surgery and 30 min and 2, 4, 6, 8, 12, 16, 20, and 24 h after the procedure. Diclofenac 75 mg IM was administered as a rescue analgesic. Postoperative pain scores and intraoperative pain scores at 45 and 60 min were significantly lower in the gabapentin group. Fentanyl (122 ± 40 µg versus 148 ± 42 µg; P < 0.05) and diclofenac (33 ± 53 mg versus 111 ± 92 mg; P < 0.001) consumption was smaller and the time to first analgesic request (18 ± 9 h versus 9 ± 7 h; P < 0.001) was longer in the gabapentin group. A more frequent incidence of dizziness was found in the gabapentin (versus placebo) group (24% versus 4%, respectively). We conclude that gabapentin provided a significant analgesic benefit for intraoperative and postoperative pain relief in patients undergoing ambulatory rhinoplasty or endoscopic sinus surgery; however, dizziness may be a handicap for ambulatory use.


丙泊酚可抑制人由脂类促炎症介质引起的血小板聚集

Propofol Inhibits Human Platelet Aggregation Induced by Proinflammatory Lipid Mediators

Olivier Fourcade, MD PhD*, Marie-Françoise Simon, PhD{dagger}, Lawrence Litt, MD PhD{ddagger}, Kamran Samii, MD*, and Hugues Chap, MD PhD{dagger}

Department of Anesthesia, Purpan Hospital, University of Toulouse, Toulouse, France; {dagger}Institut National de la Santé et de la Recherche Médicale, Unit 326, Purpan Hospital, Toulouse, France; and {ddagger}Department of Anesthesia, University of California, San Francisco, California

Anesth Analg 2004;99:393-398


溶血磷脂酸(LPA),血小板激活因子(PAF),血栓素A2均为脂类炎症介质可激活血小板表面受体使细胞内钙增加,这是血小板聚集所必须的。作者研究丙泊酚对这三种激动剂引起的血小板聚集和细胞内钙动员的影响。来自志愿者的血小板放在含LPA1μM),U46619(血栓素A2类似体;1μM)或PAF10nM)的缓冲液内,然后加入丙泊酚乳剂或溶于酒精的26diisopropylphenol(无脂肪乳剂的丙泊酚)使其达到临床使用的浓度5μg/ml10μg/ml2分钟后,通过光学技术测试聚集作用或钙的浓度。丙泊酚乳剂和溶于酒精的丙泊酚对LPA1μM),U46619PAF引起的血小板聚集有相似的剂量依赖的抑制作用。丙泊酚没有缓解LPA1μM),U46619PAF引起的细胞内钙的增加作用。由于丙泊酚不会显著改变因受体激活导致的细胞内钙增加,所以抑制作用出现在血小板受体的远端,如肌醇三磷酸和磷脂酶C。由于这三种脂类介质在炎症中起着关键作用,所以丙泊酚对它们的抑制作用可能在临床上有重要意义。

(朱辉 译 陈杰 校)

Lysophosphatidic acid (LPA), platelet-activating factor (PAF), and thromboxane A2 are proinflammatory lipid mediators that activate surface receptors on platelets, producing increased intracellular calcium, which is necessary for aggregation. We investigated propofol’s effect on platelet aggregation and intracellular calcium mobilization caused by these three agonists. Platelets from human volunteers were incubated in buffers containing LPA (1 µM), U46619 (thromboxane A2 analog; 1 µM), or PAF (10 nM). Propofol emulsion or 2,6-diisopropylphenol (propofol without fat emulsion) dissolved in ethanol was added to achieve concentrations of propofol used clinically: 5 or 10 µg/mL. After 2 min, aggregation or intracellular calcium concentrations were measured with optical techniques. Propofol emulsion and propofol in ethanol produced similar inhibition of platelet aggregation induced by LPA, PAF, and U46619 in a dose-dependent fashion. LPA, PAF, and U46619 each caused significant increases in intracellular calcium that were not modified by propofol. Because propofol does not significantly alter intracellular calcium increases caused by receptor activation, inhibition appears to act distal to platelet receptors, inositol phosphate 3, and phospholipase C. Because the three lipid mediators play a key role in inflammation, their inhibition by propofol might be clinically important.


非洲爪蛙 Ca激动的Cl电流通过蛋白激酶C和蛋白磷酸酯酶调节:有关麻醉机制的研究

Modulation of Xenopus laevis Ca-Activated Cl Currents by Protein Kinase C and Protein Phosphatases: Implications for Studies of Anesthetic Mechanisms

Klaus Hahnenkamp, MD*, Marcel E. Durieux, MD PhD*, Hugo van Aken, MD PhD*, Sascha Berning*, Thomas J. Heyse*, Christian W. Hönemann, MD*, and Bettina Linck, MD PhD{dagger}

*Department of Anesthesiology and Intensive Care, and {dagger}Institute of Pharmacology and Toxicology, University Hospital, Muenster, Germany

Anesth Analg 2004;99:416-422


Ca激动的Cl电流(IC1(Ca))通常是麻醉药对非洲爪蛙卵母细胞G蛋白偶联受体研究的标志物。麻醉可影响蛋白激酶CPKC),如果电流受磷酸化调节则间接影响IC1(Ca)。作者在非洲爪蛙卵母细胞用电压钳制技术研究PKC或蛋白磷酸酯酶PP1αPP2A IC1(Ca)的调节作用。IC1(Ca) 激发是通过溶血磷脂(LPA)信号系统或微泵注射钙。大鼠卵母细胞内的PP1αPP2A过分表达。将PP,IP3,PP抑制剂冈田酸能抑制磷脂酶A,PKC抑制剂白屈菜红碱或CaCl2直接注入卵母细胞内,无论是否使用PP抑制剂斑蝥素或OA均测量在一控制电位-70mV时对激动剂的反应(LPA 10-6M, IP310-4M,CaCl2 0.5M)。PP1αPP2AIC1(Ca) 的抑制分别为7.6 ± 0.9μC2.5 ± 0.9μC 3.2 ± 1.4μCPP抑制剂提升了卵母细胞内IC1(Ca)并逆转了对PP1αPP2A表达的抑制作用。白屈菜红碱通过抑制PKC而增强LPA-CaCl2介导的IC1(Ca)。资料显示非洲爪蛙IC1(Ca)是由磷酸化调节,它可通过对G蛋白偶联受体的研究得以证实。

(朱慧琛 译 陈杰 校)

Ca-activated Cl currents (ICl(Ca)) are used frequently as reporters in functional studies of anesthetic effects on G protein-coupled receptors using Xenopus laevis oocytes. However, because anesthetics affect protein kinase C (PKC), they could indirectly affect ICl(Ca) if this current is regulated by phosphorylation. We therefore studied the effect of modulation of either PKC or protein phosphatases PP1{alpha} and PP2A on ICl(Ca) stimulated either by lysophosphatidate (LPA) signaling or by microinjection of Ca. X. laevis oocytes were studied under voltage clamp. Rat PP1{alpha} and PP2A were overexpressed in oocytes. PP, inositoltrisphosphate (IP3), the PP inhibitor okadaic acid (OA), the PKC inhibitor chelerythrine, or CaCl2 were directly injected into the oocyte. Responses to agonists (LPA 10–6 M, IP3 10–4 M, CaCl2 0.5 M) were measured at a holding potential of –70 mV in the presence or absence of the PP inhibitors cantharidin or OA. PP1 {alpha}and PP2A inhibited ICl(Ca) from 7.6 ± 0.9 µC to 2.5 ± 0.9 µC and 3.2 ± 1.4 µC, respectively. PP inhibition enhanced ICl(Ca) in control oocytes and reversed the inhibitory effect in oocytes expressing PP1 {alpha}or PP2A. PKC inhibition by chelerythrine enhanced both LPA- and CaCl2-induced ICl(Ca). Our data indicate that the Xenopus ICl(Ca) is modulated by phosphorylation. This may complicate design and interpretation of studies of G protein-coupled receptors using this model.


心脏斯里兰卡肉桂碱受体缺陷患者中挥发性麻醉药和琥珀胆碱的应用

Volatile Anesthetics and Succinylcholine in Cardiac Ryanodine Receptor Defects

Heikki Swan, MD*, Päivi J. Laitinen, MSc{dagger}, and Lauri Toivonen, MD*

Departments of *Cardiology and {dagger}Medicine, Helsinki University Central Hospital, Helsinki, Finland

Anesth Analg 2004;99:435-437


遗传性多源性(儿茶酚胺能)室性心动过速是一种节律异常的心脏疾病,主要由于心肌等位斯里兰卡肉桂碱受体基因突变所致(RyR2)。骨骼肌等位基因突变(RyR1)患者在接受挥发性麻醉药和琥珀胆碱时易产生恶性高热,加重了遗传性细胞内钙离子释放障碍。作者报道了一系列存在心脏斯里兰卡肉桂咸受体缺陷的患者接受全麻后却并未出现并发症。RyR2缺陷患者在临床上使用琥珀胆碱和挥发性麻醉药无明显影响。

(朱慧琛 译 陈杰 校)

Familial polymorphic (catecholaminergic) ventricular tachycardia is an arrhythmogenic cardiac disorder caused by mutations of the myocardial isoform of the ryanodine receptor gene (RyR2). Mutations of the corresponding gene in the skeletal muscle (RyR1) predispose its carriers to malignant hyperthermia upon use of volatile anesthetics or succinylcholine, which further deteriorate the inherited intracellular calcium release disorder. We report a series of patients with cardiac RyR defects who underwent general anesthesia without complications. Succinylcholine and volatile anesthetics did not have a clinically significant effect on RyR2 defects.


两种不同的神经性疼痛模型对止痛剂有不同敏感性

Differential Analgesic Sensitivity of Two Distinct Neuropathic Pain Models

Isabelle Decosterd, MD*,{dagger}, Andrew Allchorne{ddagger}, and Clifford J. Woolf, MD PhD{ddagger}

*Anesthesiology Pain Research Group, Department of Anesthesiology, University Hospital Lausanne (CHUV), Lausanne, Switzerland; {dagger}Department of Cell Biology and Morphology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland; and {ddagger}Neural Plasticity Research Group, Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts

Anesth Analg 2004;99:457-463

对啮齿动物的坐骨神经挤压所造成的渐进性的触觉过敏(PTH)和不伴神经损伤的神经痛(SNI)是两种不同的神经痛的试验模型。PTH的概念是,在坐骨神经移植术后,对其所支配的皮肤给予间断的重复的低阈值的机械刺激所造成的神经损伤,这种损伤数月后发生了PTH,它代表的是一种刺激诱导的疼痛模型。而SNI是指切开坐骨神经的其它两个终末分支后,所造成的腓神经控制区域的皮肤,对于刺激唤起的疼痛早期、持续的敏感性的增加。作者对两组实验模型分别检验吗啡(0.5–10 mg/kg)加巴喷丁(30–200 mg/kg)MK801(0.01–0.02 mg/kg)阿米替林(10–25 mg/kg)卡马西平(5–7.5 mg/kg)的效果。结果发现:吗啡,加巴喷丁卡马西平都可以逆转和防止刺激诱导的PTH,但是MK801阿米替林仅仅能够减少而不能防止刺激诱导的PTH.。相反,这些药物在SNI模型中刺激唤醒的行为性的高敏感性却鲜有作用。这两种各自独立的神经痛的模型显示了其对镇痛药物治疗的不同的敏感性。作者认为,这是由于和神经痛相关行为的不同机制所造成。因此,为了研究神经痛的机制,并预测镇痛药物对于各种不同神经痛综合症的效果,需要更多的动物模型。

(顾漪闻 译 陈杰 校)

Progressive tactile hypersensitivity (PTH) manifesting after sciatic nerve crush and spared nerve injury (SNI) are two distinct rodent experimental models of neuropathic pain. PTH develops months after recovery from the nerve crush in response to repeated intermittent low-threshold mechanical stimulation of the reinnervated sciatic nerve skin territory and represents a model of stimulus-induced pain. SNI is characterized by an early and sustained increase in stimulus-evoked pain sensitivity in the intact skin territory of the spared sural nerve after sectioning of the two other terminal branches of the sciatic nerve. We examined the effects of morphine (0.5–10 mg/kg), gabapentin (30–200 mg/kg), MK801 (0.01–0.02 mg/kg), amitriptyline (10–25 mg/kg), and carbamazepine (5–7.5 mg/kg) in both models. Morphine, gabapentin, and carbamazepine both reversed and prevented stimulus-induced PTH, whereas MK801 and amitriptyline reduced but did not prevent stimulus-induced PTH. In contrast, the stimulus-evoked behavioral hypersensitivity in the SNI model was poorly modified by these drugs. Independent neuropathic pain models show differential sensitivity to analgesic drug treatment. We suggest that this is due to the different mechanisms responsible for the neuropathic pain-related behavior. Multiple models are required, therefore, to study the mechanisms that contribute to neuropathic pain and to predict analgesic efficacy for different components of the neuropathic pain syndrome.


慢性和急性下腰痛时活动度和疼痛的关系分析

An Analysis of the Relationship Between Activity and Pain in Chronic and Acute Low Back Pain

John J. Liszka-Hackzell, MD PhD*, and David P. Martin, MD PhD{dagger}

*Department of Anesthesiology, University of Arizona, Tucson; and {dagger}Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota

Anesth Analg 2004;99:477-481


作者研究了慢性和急性下腰痛患者的活动度和疼痛之间的关系。方法:观察急性下腰痛和大于3周的慢性下腰痛病人各15例。用腕式加速仪来自动记录活动度水平,每1分钟记录一次。而疼痛水平则用袖珍式电子日记记录,至少每90分钟记录一次。每个病人的时间按顺序排列,然后分为不同时间区域,用交叉相关函数来分析。结果:急性下腰痛病人的头七天,活动度和疼痛之间有明显的相关性(P<0.01)。通常活动后大约30分钟产生疼痛。但是当这些病人症状改善、疼痛减轻后,活动和疼痛之间的关系就消失了。而在慢性下腰痛的病人,则没有发现这种相关性。

(顾漪闻 译 陈杰 校)

We studied the temporal relationship between pain and activity in patients with acute or chronic low back pain. We studied 15 patients with acute low back pain and 15 patients with chronic low back pain over 3 wk. The activity levels were collected automatically using a wrist accelerometer and were sampled every minute. The pain levels were recorded at least every 90 min using a pocket-sized electronic diary. The time series from each patient were then analyzed using the cross-correlation function at various time offsets. We found that during the first 7 days of acute low back pain, there was a significant (P < 0.01) degree of cross-correlation between activity and pain. On average, pain followed activity by approximately 30 min. As these patients improved and reported less pain, the relationship between activity and pain disappeared. There was no such relationship at any point among the patients with chronic low back pain.

 

围术期硬膜外应用可乐定对结直肠手术后病人细胞因子,术后镇痛和肠功能的影响

The Effect of Epidural Clonidine on Perioperative Cytokine Response, Postoperative Pain, and Bowel Function in Patients Undergoing Colorectal Surgery

Ching-Tang Wu, MD*, Shu-Wen Jao, MD{dagger}, Cecil O. Borel, MD{ddagger}, Chun-Chang Yeh, MD*, Chi-Yuan Li, MD*, Chueng-He Lu, MD*, and Chih-Shung Wong, MD PhD*

Departments of *Anesthesiology and {dagger}Colon and Rectal Surgery, Tri-Service General Hospital and National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China; and {ddagger}Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004;99:502-509


术后细胞因子的生成增加使疼痛的敏感性增加。作者研究如下假设:硬膜外可乐定预处理和术后病人硬膜外自控镇痛(PCEA)中应用可乐定可减少选择性结直肠手术后病人炎性细胞因子(白介素(IL)-6, IL-1βIL-8和肿瘤坏死因子)和抗炎因子(IL-1受体拮抗剂)的释放,并提供更佳的术后镇痛。40例病人随机分为2组,每组20人:对照组术前硬膜外用生理盐水10ml,可乐定组硬膜外用可乐定150ug溶于9ml生理盐水。诱导前,手术结束时,术后12-24小时取静脉血做细胞因子水平检测。可乐定组术后PCEA为:吗啡(0.1mg/ml­)+可乐定(1.5ug /ml)+0.2%罗哌卡因100ml。对照组仅用吗啡和罗哌卡因。术后72小时内与对照组相比可乐定组病人按压PCEA的间隙时间长,静息和咳嗽时的疼痛评分低,吗啡的消耗量少,肠功能恢复快。可乐定组病人手术结束时,术后1224小时IL-1RA, IL-6, IL-8显著减少。但是,IL-1ß  TNF-{alpha}的浓度无明显增加。

(忻纪华 译 陈杰 校)

The postoperative period is associated with an increased production of cytokines, which augment pain sensitivity. We investigated the hypothesis that epidural clonidine premedication and postoperative patient-controlled epidural analgesia (PCEA) including clonidine would decrease the release of proinflammatory (interleukin (IL)-6, IL-1ß, IL-8, and tumor necrosis factor (TNF)-{alpha}) and antiinflammatory (IL-1 receptor antagonist (RA)) cytokines in patients who underwent elective colorectal surgery and that they would provide better postoperative analgesia. Forty patients were randomly assigned to 1 of 2 groups of 20 each: the control group received normal saline 10 mL, whereas the clonidine group received epidural clonidine 150 µg diluted with 9 mL of normal saline 30 min before surgery. Venous blood samples for cytokine levels were obtained before induction, at the end of surgery, and after surgery at 12 and 24 h. After surgery, the clonidine group patients received PCEA with morphine (0.1 mg/mL) and clonidine (1.5 µg/mL) in 0.2% ropivacaine 100 mL, whereas control group patients received only PCEA morphine and ropivacaine. Patients in the clonidine group exhibited longer PCEA trigger times, lower pain scores at rest and while coughing, less morphine consumption, and a faster return of bowel function throughout the 72-h postoperative observation period, compared with patients in the control group. For patients in the clonidine group, production of IL-1RA, IL-6, and IL-8 was significantly less increased at the end of the surgical procedure and at 12 and 24 h after surgery. However, the concentrations of IL-1ß and TNF-{alpha} were not significantly increased.


N-乙酰甲基半胱氨酸阻止犬血液稀释导致的缺氧性肺血管收缩的抑制作用

Prevention of Hemodilution-Induced Inhibition of Hypoxic Pulmonary Vasoconstriction by N-Acetylcysteine in Dogs

François Kerbaul, MD*, Philippe Van der Linden, MD PhD{dagger}, Sébastien Pierre, MD{ddagger}, Benoît Rondelet, MD{ddagger}, Christian Melot, MD PhD§, Serge Brimioulle, MD PhD§, and Robert Naeije, MD PhD{ddagger}

*Department of Anesthesia and Intensive Care, Timone Hospital, Marseille, France; {dagger}Department of Anesthesia, Centre Hospitalo-Universitaire, Charleroi, Belgium; {ddagger}Department of Physiology, Faculty of Medicine, Free University of Brussels, Brussels, Belgium; and §Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium

Anesth Analg 2004;99:547-551


作者研究了氧自由基和血液黏性的改变是否与犬血液稀释所致的缺氧性肺血管收缩(HPV)的抑制作用有关。14只犬异氟醚麻醉诱导后随机分为两组:一组静注N-乙酰甲基半胱氨酸(NAC200mg/kgn7),一组接受安慰剂(n7)。持续测量高氧(吸入氧指数,0.4)和低氧(吸入氧指数,0.1)时及血球压积逐渐由40%降至20%时平均肺动脉压(Ppa)和心排量。低氧时Ppa值减去高氧时Ppa值为HPV的抑制值。血液稀释可使HPV7 ± 1 mm Hg 降至 3 ± 1 mm Hg (P < 0.01),而这种反应可被NAC抑制(HPV未改变, 8 ± 1 8 ± 1 mm Hg)。血液稀释模型的HPV 8 ± 1 mm Hg 降至 6 ± 1 mm Hg (P < 0.05)。结论:血液稀释导致的HPV抑制部分是由于血液粘性的改变所致,可被NAC抑制,后者作用可能由于NAC清除氧自由基所致。

(忻纪华 译 陈杰 校)

We investigated the possible contributions of reactive oxygen species and of viscosity changes to hemodilution-induced inhibition of hypoxic pulmonary vasoconstriction (HPV) in dogs. Fourteen isoflurane-anesthetized dogs were randomly assigned to receive N-acetylcysteine (NAC) 200 mg/kg IV (n = 7) or placebo (n = 7). Mean pulmonary artery pressure (Ppa) was measured with cardiac output maintained constant by a manipulation of venous return in hyperoxia (fraction of inspired oxygen, 0.4) and in hypoxia (fraction of inspired oxygen, 0.1) at baseline and after stepwise reductions in hematocrit from 40% to 20%. Measured Ppa was compared with predicted Ppa by using a viscoelastic model. HPV was expressed as hypoxic Ppa minus hyperoxic Ppa. Hemodilution was associated with a decrease in HPV from 7 ± 1 mm Hg to 3 ± 1 mm Hg (P < 0.01), and this was completely prevented by NAC (HPV was unchanged, from 8 ± 1 to 8 ± 1 mm Hg; not significant). Hemodilution in the model decreased HPV from 8 ± 1 mm Hg to 6 ± 1 mm Hg (P < 0.05). We conclude that hemodilution-induced inhibition of HPV is in part explained by viscosity changes and can be prevented by the administration of NAC, which is possibly explained by the scavenging of reactive oxygen species.


异丙酚镇静对颅内占位患者颅内压的影响

The Effect of Propofol Sedation on the Intracranial Pressure of Patients with an Intracranial Space-Occupying Lesion

François Girard, MD FRCPC*, Robert Moumdjian, MD FRCSC{dagger}, Daniel Boudreault, MD FRCPC*, Philippe Chouinard, MD FRCPC*, Alain Bouthilier, MD FRCSC{dagger}, Éric Sauvageau, MD{dagger}, Monique Ruel, RN*, and Dominique C. Girard*

Department of *Anesthesiology and {dagger}Neurosurgery Division, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montréal, Canada

Anesth Analg 2004;99:573-577


因为担心可能会产生CO2蓄积和继发性颅内压升高,有时会妨碍镇静剂在有自主呼吸的颅内占位患者中的使用。本研究作者评估了局麻下接受立体定位颅内肿瘤活检患者术中用中等深度异丙酚镇静对颅内压的影响。30名患者随机分为两组,镇静组:异丙酚滴注,清醒/镇静评分2级,另一组为非镇静组。通过活检针来测定颅内压。两组患者术前颅内压数值相似。镇静组术中有更高的PaCO248±8mmHg41±3mmHgP=0.005)(两组95%可信区间分别为43-53mmHg39-43mmHg),更低的动脉血pH值。镇静组与非镇静组平均颅内压相似,分别为13mmHg15mmHg,其95%可信区间分别为8.2-16.2mmHg8.3-21.7mmHg,(P=0.66)。镇静组颅内灌注压更低(76±18mmHg89±18mmHgP=0.003)。对于立体定位颅内肿瘤活检的患者来说,中等深度的异丙酚镇静并不会导致颅内压增高。其他镇静药物对颅内压的影响还需进一步研究。

(朱玫娟 译 陈杰 校)

The fear of producing CO2 retention and a secondary increase of intracranial pressure (ICP) sometimes precludes the use of sedation for the spontaneously breathing patient in the presence of an intracranial space-occupying lesion. In this study we assessed the effect of moderately deep propofol sedation on the ICP of patients undergoing stereotactic brain tumor biopsy under regional anesthesia. Thirty patients were randomized into 2 groups to receive propofol titrated to a level of 2 on the Observer’s Assessment of Alertness/Sedation Scale or no sedation. ICP was measured via the biopsy needle. Preoperative data were similar in both groups. During surgery, patients receiving propofol had a higher arterial PCO2 (48 ± 8 mm Hg versus 41 ± 3 mm Hg; P = 0.005) (95% confidence interval, 43–53 mm Hg and 39–43 mm Hg, respectively), resulting in a lower arterial pH (P = 0.002) than patients in the no-sedation group. The median ICP (95% confidence interval) for both groups was similar—13 mm Hg (8.2–16.2 mm Hg) and 15 mm Hg (8.3–21.7 mm Hg)—for the propofol and no-sedation groups, respectively (P = 0.66). Cerebral perfusion pressure was lower in the propofol group (76 ± 18 mm Hg versus 89 ± 18 mm Hg; P = 0.003). Moderately deep propofol sedation does not result in a higher ICP than no sedation in patients undergoing stereotactic brain tumor biopsy. Further studies are needed to assess the effect on ICP of other sedative medications.


围术期血糖控制的一种简单的葡萄糖胰岛素疗法:Vellore疗法

A Simple Glucose Insulin Regimen for Perioperative Blood Glucose Control: The Vellore Regimen

Ann Miriam, MD, and Grace Korula, MD

Department of Anaesthesia, Christian Medical College Hospital, Vellore, India

Anesth Analg 2004;99:598-602


在这项研究中,作者试图在大型、多学科的教学医院中寻找一种简单易行的方法来控制糖尿病患者术中的血糖。作者评估了Vellore疗法,后者优点在于将葡萄糖胰岛素和输液变化率相结合。方法:血糖超过100mg/dL后血糖浓度每超过1-50mg/dL5%葡萄糖溶液100mL中增加一个单位的胰岛素,每小时测量血糖浓度。作者比较了这种血糖控制方法和在此医院中所用的其他方法,随机选取了204个患者,研究组98名,对照组106名。研究组的患者血糖为156±36mg/dL,对照组的患者血糖为189±63mg/dLP=0.003)。通过Vellore疗法,血糖控制不良的患者(血糖在100-200 mg/dL范围以外)从51%下降到28%(没有患者血糖低于60 mg/dL),而对照组血糖控制不良的患者从49%上升到72%(有10个患者血糖低于60 mg/dL)(P=0.0013)。结论:Vellore疗法是一种简单、有效和安全的术中血糖控制的方法。

(朱玫娟 译 陈杰 校)

In this study, we sought a simple, easily implemented method of intraoperative control of blood glucose in diabetic patients in a large multispecialty teaching hospital. The Vellore regimen, which offers the advantages of a combined glucose insulin and variable rate infusion was evaluated. For every 1 to 50-mg/dL increase in blood glucose concentration more than 100 mg/dL, 1 U of insulin was added to the injection port of a 100-mL measured volume set containing 5% dextrose in water. Hourly monitoring of blood glucose was performed. The blood glucose control was compared with the different existing techniques followed in the hospital in 204 randomized patients: 98 in the study and 106 in the control group. The study group had a mean ± SD blood glucose value of 156 ± 36 mg/dL, and the control group’s value was 189 ± 63 mg/dL (P = 0.003). The percentage of patients who were poorly controlled (outside 100 to 200-mg/dL range) decreased from 51% to 28% (no patient less than 60 mg/dL) with this regimen as compared with the control group in which it increased from 49% to 72% (10 patients less than 60 mg/dL) (P = 0.0013). We conclude that the Vellore regimen is simple, effective, and safe for intraoperative blood glucose control.