Anesthesia & Analgesia

October 2004

Table of Content

 

 

CARDIOVASCULAR ANESTHESIA:

不停跳冠状动脉搭桥手术是否降低多支搭桥后临床肾功能障碍的发生率?

沈浩 李士通

Does Off-Pump Coronary Artery Bypass Reduce the Incidence of Clinically Evident Renal Dysfunction After Multivessel Myocardial Revascularization?
Nanette M. Schwann, Jay C. Horrow, Michael D. Strong, III, Dmitri Chamchad, Albert Guerraty, and Andrew S. Wechsler

Anesth Analg 2004 99: 959-964.

非体外循环进行冠状动脉搭桥手术时经食管超声监测部分心室壁的运动

葛宁花译 薛张刚校

Transesophageal Echocardiography for Monitoring Segmental Wall Motion During Off-Pump Coronary Artery Bypass Surgery

Jianwen Wang, Miodrag Filipovic, Ainars Rudzitis, Isabelle Michaux, Karl Skarvan, Peter Buser, Atanas Todorov, Franziska Bernet, and Manfred D. Seeberger Anesth Analg 2004 99: 965-973.

体外循环期间血液稀释增加鼠大脑中动脉阻塞的脑梗塞容积

(殷文渊 译 陈杰 校)

Hemodilution During Cardiopulmonary Bypass Increases Cerebral Infarct Volume After Middle Cerebral Artery Occlusion in Rats

H. Mayumi Homi, Hong Yang, Robert D. Pearlstein, and Hilary P. Grocott

Anesth Analg 2004 99: 974-981

依照体表标志行颈内静脉穿刺时头部最佳的旋转位置

裘毅敏 译,李士通

Optimal Head Rotation for Internal Jugular Vein Cannulation When Relying on External Landmarks

Jeremy A. Lieberman, Kayode A. Williams, and Andrew L. Rosenberg

Anesth Analg 2004 99: 982-988.

体外循环时零级平衡超滤体外清除高浓度的Tirofiban:一项体内的研究

葛宁花译 薛张刚校

Extracorporeal Elimination of Large Concentrations of Tirofiban by Zero-Balanced Ultrafiltration During Cardiopulmonary Bypass: An In Vitro Investigation
Andreas Koster, Derek Chew, Frank Merkle, Marcus Gruendel, Michael Jurmann, Hermann Kuppe, and Rainhard Oertel

Anesth Analg 2004 99: 989-992.

蛋白激酶C激活介导异氟醚引起的大鼠离体缺血心脏功能和代谢恢复的改善

殷文渊 译 陈杰 校

Activation of Protein Kinase C Contributes to the Isoflurane-Induced Improvement of Functional and Metabolic Recovery in Isolated Ischemic Rat Hearts

Pengcheng Xu, Jun Wang, Ramesh Kodavatiganti, Yinming Zeng, and Ira S. Kass

Anesth Analg 2004 99: 993-1000

比较持续正压通气和无创压力支持通气方法用于治疗心脏手术后的肺不张

张俊杰 李士通

Continuous Positive Airway Pressure Versus Noninvasive Pressure Support Ventilation to Treat Atelectasis After Cardiac Surgery

Patrick Pasquina, Paolo Merlani, Jean Max Granier, and Bara Ricou

Anesth Analg 2004 99: 1001-1008.

老年心脏外科手术预防性联合使用β- 阻滞剂艾司洛尔和磷酸二酯酶抑制剂依诺昔酮

葛宁花译 薛张刚校

The Prophylactic Use of the ß-Blocker Esmolol in Combination with Phosphodiesterase III Inhibitor Enoximone in Elderly Cardiac Surgery Patients
Joachim Boldt, Christian Brosch, Andreas Lehmann, Stephan Suttner, and Frank Isgro

Anesth Analg 2004 99: 1009-1017

血管紧张素转换酶活性:在全膝关节成形术期间估计肺变化的新方法

顾漪闻 译 陈杰 校

Angiotensin-Converting Enzyme Activity: A Novel Way of Assessing Pulmonary Changes During Total Knee Arthroplasty

Kethy Jules-Elysee, Thomas J. J. Blanck, John D. Catravas, George Chimento, Alexander Miric, Richard Kahn, Leonardo Paroli, and Thomas Sculco

Anesth Analg 2004 99: 1018-1023

腹主动脉瘤手术患者门静脉乳酸盐、乙状结肠粘膜内pH和△CO2PaCO2局部 PCO2)作为并发症指数的比较

赵雪莲 李士通

A Comparison Among Portal Lactate, Intramucosal Sigmoid pH, and {Delta}CO2 (PaCO2 – Regional PCO2) as Indices of Complications in Patients Undergoing Abdominal Aortic Aneurysm Surgery
Abele Donati, Oriana Cornacchini, Silvia Loggi, Sandro Caporelli, Giovanna Conti, Stefano Falcetta, Francesco Alò, Gabriele Pagliariccio, Elisabetta Bruni, Jean-Charles Preiser, and Paolo Pelaia

Anesth Analg 2004 99: 1024-1031.

PEDIATRIC ANESTHESIA:

经外周放置中心静脉导管:小儿外科手术中的一项随机、对照和前瞻性研究

葛宁花译 薛张刚校

Peripherally Inserted Central Catheters: A Randomized, Controlled, Prospective Trial in Pediatric Surgical Patients

Deborah A. Schwengel, John McGready, Sean M. Berenholtz, Lori J. Kozlowski, David G. Nichols, and Myron Yaster

Anesth Analg 2004 99: 1038-1043.

麻醉下儿童应用动脉刺激静脉采样试验(ASVS)对高胰岛素血症病灶定位期间的血糖控制

顾漪闻 译 陈杰 校

Blood Glucose Control During Selective Arterial Stimulation and Venous Sampling for Localization of Focal Hyperinsulinism Lesions in Anesthetized Children
Giovanni Cucchiaro, Scott D. Markowitz, Robin Kaye, N. Scott Adzick, Ronald S. Litman, Charles A. Stanley, and Mehernoor F. Watcha

Anesth Analg 2004 99: 1044-1048.

接受丙泊酚麻醉的儿童对低碳酸血症的脑血管反应

周志坚 李士通

The Cerebrovascular Response to Hypocapnia in Children Receiving Propofol

Cengiz Karsli, Igor Luginbuehl, and Bruno Bissonnette

Anesth Analg 2004 99: 1049-1052.

小儿术前多系统的评估

葛宁花译 薛张刚校

Preoperative Evaluation of Pediatric Surgical Patients with Multisystem Considerations (Review Article)

Lynne R. Ferrari

Anesth Analg 2004 99: 1058-1069

AMBULATORY ANESTHESIA:

电针穴位刺激或枢复宁与安慰剂比较在预防术后恶心呕吐的随机对照研究

朱慧琛 译 陈杰 校

A Randomized Controlled Comparison of Electro-Acupoint Stimulation or Ondansetron Versus Placebo for the Prevention of Postoperative Nausea and Vomiting
Tong J. Gan, Kui Ran Jiao, Michael Zenn, and Gregory Georgiade

Anesth Analg 2004 99: 1070-1075.

异丙酚引起的注射疼痛:改良后的异丙酚乳剂与预混合利多卡因的标准异丙酚的比较

陈玮      李士通  

Propofol-Induced Injection Pain: Comparison of a Modified Propofol Emulsion to Standard Propofol with Premixed Lidocaine
Sigrid Adam, Jasper van Bommel, Michal Pelka, Maaike Dirckx, David Jonsson, and Jan Klein

Anesth Analg 2004 99: 1076-1079

ANESTHETIC PHARMACOLOGY:

异丙酚或七氟醚麻醉时用触觉法评估拮抗罗库嗅胺诱发的神经肌肉阻滞作用

葛宁花译 薛张刚校

Tactile Assessment for the Reversibility of Rocuronium-Induced Neuromuscular Blockade During Propofol or Sevoflurane Anesthesia
Kyo S. Kim, Mi A. Cheong, Hee J. Lee, and Jae M. Lee

Anesth Analg 2004 99: 1080-1085.

病态肥胖患者根据真实体重或理想体重使用罗库溴胺的药效学比较

朱慧琛 译 陈杰 校

The Pharmacodynamic Effects of Rocuronium When Dosed According to Real Body Weight or Ideal Body Weight in Morbidly Obese Patients
Yigal Leykin, Tommaso Pellis, Mariella Lucca, Giacomina Lomangino, Bernardo Marzano, and Antonino Gullo

Anesth Analg 2004 99: 1086-1089.

顺式阿曲库铵在病态肥胖女性的作用

马皓琳 李士通

The Effects of Cisatracurium on Morbidly Obese Women

Yigal Leykin, Tommaso Pellis, Mariella Lucca, Giacomina Lomangino, Bernardo Marzano, and Antonino Gullo

Anesth Analg 2004 99: 1090-1094

异丙酚对鼠海马横切面癫痫样活动的抗惊厥作用

葛宁花译 薛张刚校

The Anticonvulsant Action of Propofol on Epileptiform Activity in Rat Hippocampal Slices
Hideya Ohmori, Yasumitsu Sato, and Akiyoshi Namiki

Anesth Analg 2004 99: 1095-1101.

丙泊酚和咪唑安定可抑制小鼠胃排空和胃肠蠕动

朱辉 译 陈杰 校

Propofol and Midazolam Inhibit Gastric Emptying and Gastrointestinal Transit in Mice

Takefumi Inada, Takashi Asai, Makiko Yamada, and Koh Shingu

Anesth Analg 2004 99: 1102-1106.

吸入异氟醚增强正压通气时生理死腔的增加并使动脉氧合受损

张曦 李士通

Isoflurane Inhalation Enhances Increased Physiologic Deadspace Volume Associated with Positive Pressure Ventilation and Compromises Arterial Oxygenation
Claudia Praetel, Michael J. Banner, Terri Monk, and Andrea Gabrielli

Anesth Analg 2004 99: 1107-1113.

椎管内大剂量苏芬太尼能预防腹部大手术时的激素应急反应:与静脉使用苏芬太尼的前瞻性

葛宁花译 薛张刚校

Large-Dose Intrathecal Sufentanil Prevents the Hormonal Stress Response During Major Abdominal Surgery: A Comparison with Intravenous Sufentanil in a Prospective Randomized Trial
Paul J. Borgdorff, Traian I. Ionescu, Peter L. Houweling, and Johannes T. A. Knape

Anesth Analg 2004 99: 1114-1120.

七氟醚麻醉削弱二磷酸腺苷介导的血小板选择蛋白的表达和血小板-白细胞结合物的形成

朱辉 译 陈杰 校

Sevoflurane Anesthesia Attenuates Adenosine Diphosphate-Induced P-Selectin Expression and Platelet-Leukocyte Conjugate Formation

Go-Shine Huang, Chi-Yuan Li, Ping-Ching Hsu, Chien-Sung Tsai, Tso-Chou Lin, and Chih-Shung Wong

Anesth Analg 2004 99: 1121-1126.

Delta-9四氢大麻酚对人类血小板的促凝血作用

吴俭 李士通

The Procoagulatory Effects of Delta-9-Tetrahydrocannabinol in Human Platelets

Engelbert Deusch, Hans Georg Kress, Birgit Kraft, and Sibylle A. Kozek-Langenecker

Anesth Analg 2004 99: 1127-1130.

异丙酚并不抑制利多卡因硬膜外阻滞时的代谢

葛宁花译 薛张刚校

Propofol Does Not Inhibit Lidocaine Metabolism During Epidural Anesthesia

Shin Nakayama, Masayuki Miyabe, Yoshihiro Kakiuchi, Shinichi Inomata, Yoshiko Osaka, Taeko Fukuda, Yukinao Kohda, and Hidenori Toyooka

Anesth Analg 2004 99: 1131-1135.

缺乏NMDA受体GluRε1亚基的小鼠对氯胺酮和苯巴比妥的敏感性降低

赵延华 译 陈杰 校

Reduced Sensitivity to Ketamine and Pentobarbital in Mice Lacking the N-Methyl-D-Aspartate Receptor GluR{epsilon}1 Subunit
Andrey B. Petrenko, Tomohiro Yamakura, Naoshi Fujiwara, Ahmed R. Askalany, Hiroshi Baba, and Kenji Sakimura

Anesth Analg 2004 99: 1136-1140.

TECHNOLOGY, COMPUTING, AND SIMULATION:

七氟醚麻醉中脑电双频指数和快速提取听觉诱发电位指数对伤害性刺激的反应的比较

周雅春 李士通      

A Comparison of Bispectral Index and Rapidly Extracted Auditory Evoked Potentials Index Responses to Noxious Stimulation During Sevoflurane Anesthesia

A. Ekman, L. Brudin, and R. Sandin

Anesth Analg 2004 99: 1141-1146

清醒志愿者俯卧位时躯体倾斜度对眼内压的影响:两种手术床的比较

赵延华 译 陈杰 校

The Effect of Body Inclination During Prone Positioning on Intraocular Pressure in Awake Volunteers: A Comparison of Two Operating Tables
Mehmet S. Ozcan, Claudia Praetel, M. Tariq Bhatti, Nikolaus Gravenstein, Michael E. Mahla, and Christoph N. Seubert

Anesth Analg 2004 99: 1152-1158.

低流量麻醉中基于模型的预测性显示对七氟醚呼气末浓度控制的效果

李士通

The Effect of a Model-Based Predictive Display on the Control of End-Tidal Sevoflurane Concentrations During Low-Flow Anesthesia

R. Ross Kennedy, Richard A. French, and Sandra Gilles

Anesth Analg 2004 99: 1159-1163.

PAIN MEDICINE:

缓激肽拮抗剂对切口疼痛没有镇痛作用

葛宁花译 薛张刚校

Bradykinin Antagonists Have No Analgesic Effect on Incisional Pain

Paul A. Leonard, Radha Arunkumar, and Timothy J. Brennan

Anesth Analg 2004 99: 1166-1172.

腹膜内注射安慰剂或局麻药缓解腹式子宫切除术后疼痛的双盲对照试验

齐波 译 陈杰 校

Postoperative Pain After Abdominal Hysterectomy: A Double-Blind Comparison Between Placebo and Local Anesthetic Infused Intraperitoneally
Anil Gupta, Andrea Perniola, Kjell Axelsson, Sven E. Thörn, Kristina Crafoord, and Narinder Rawal

Anesth Analg 2004 99: 1173-1179

 

用大鼠击尾和压爪试验测试椎管内加巴喷丁对蛛网膜下腔吗啡耐药性的影响

黄施伟 李士通

The Effects of Intrathecal Gabapentin on Spinal Morphine Tolerance in the Rat Tail-Flick and Paw Pressure Tests

C. Hansen, I. Gilron, and M. Hong

Anesth Analg 2004 99: 1180-1184.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

美国麻醉培训计划的人员和资金:2002-2003

葛宁花译 薛张刚校

Faculty and Finances of United States Anesthesiology Training Programs: 2002–2003

Kevin K. Tremper, Amy Shanks, Michelle Sliwinski, Steven J. Barker, Roberta Hines, and Alan R. Tait

Anesth Analg 2004 99: 1185-1192.

CRITICAL CARE AND TRAUMA:

雷米芬太尼对脑外伤病人行气管内吸引时引起颅内压升高的效果

齐波 译 陈杰 校

The Effects of Remifentanil on Endotracheal Suctioning-Induced Increases in Intracranial Pressure in Head-Injured Patients

Marc Leone, Jacques Albanèse, Xavier Viviand, Franck Garnier, Aurelie Bourgoin, Karine Barrau, and Claude Martin

Anesth Analg 2004 99: 1193-1198.

甲状旁腺激素在枸橼酸抗凝的急性重症血液透析维持患者中的分泌

轩泓 李士通

Parathyroid Hormone Secretion During Citrate Anticoagulated Hemodialysis in Acutely Ill Maintenance Hemodialysis Patients

Robert Apsner, Diego Gruber, Walter H. Hörl, and Gere Sunder-Plassmann

Anesth Analg 2004 99: 1199-1204

NEUROSURGICAL ANESTHESIA:

严重颅脑外伤伴或不伴有颅内高压时血压变化对大脑血流动力学的影响

葛宁花译 薛张刚校

Cerebral Hemodynamic Responses to Blood Pressure Manipulation in Severely Head-Injured Patients in the Presence or Absence of Intracranial Hypertension
Olaf L. Cremer, Gert W. van Dijk, Gerrit J. Amelink, Anne Marie G. A. de Smet, Karel G. M. Moons, and Cornelis J. Kalkman

Anesth Analg 2004 99: 1211-1217.

REGIONAL ANESTHESIA:

股骨骨折患者坐位行脊麻前镇痛:股神经阻滞和静注芬太尼的比较

田婕 译 陈杰 校

Analgesia Before Performing a Spinal Block in the Sitting Position in Patients with Femoral Shaft Fracture: A Comparison Between Femoral Nerve Block and Intravenous Fentanyl

Salvatore Sia, Francesco Pelusio, Remo Barbagli, and Calogero Rivituso

Anesth Analg 2004 99: 1221-1224.

比较单次或分次注射用于喙突旁锁骨下臂丛神经阻滞对麻醉范围的影响

邱郁薇      李士通 

A Comparison of Single Versus Multiple Injections on the Extent of Anesthesia with Coracoid Infraclavicular Brachial Plexus Block

Jaime Rodríguez, M. Bárcena, M. Taboada-Muñiz, J. Lagunilla, and J. Álvarez

Anesth Analg 2004 99: 1225-1230.

椎管内小剂量可乐定和等比重布比卡因用于矫形手术:一个剂量依赖的研究

葛宁花译 薛张刚校

Small-Dose Intrathecal Clonidine and Isobaric Bupivacaine for Orthopedic Surgery: A Dose-Response Study
Stephan Strebel, Jürg A. Gurzeler, Markus C. Schneider, Armin Aeschbach, and Christoph H. Kindler

Anesth Analg 2004 99: 1231-1238

GENERAL ARTICLES:

全关节成形术中输注同种异体血的预测

田婕 译 陈杰 校

Predicting Allogeneic Blood Transfusion Use in Total Joint Arthroplasty

Saifudin Rashiq, Meera Shah, Ava K. Chow, Paul J. O’Connor, and Barry A. Finegan

Anesth Analg 2004 99: 1239-1244.

围手术期稳定的一氧化氮产物血浆浓度是腹腔镜胆囊切除术后认知功能障碍的预测指标

黄丽娜 李士通

Perioperative Plasma Concentrations of Stable Nitric Oxide Products Are Predictive of Cognitive Dysfunction After Laparoscopic Cholecystectomy
G. Iohom, S. Szarvas, V. Larney, J. O’Brien, E. Buckley, M. Butler, and G. Shorten

Anesth Analg 2004 99: 1245-1252.

气管插管前用利多卡因进行喉气管表面麻醉能减少全麻苏醒拔管时的呛咳反应

葛宁花译 薛张刚校

Laryngotracheal Topicalization with Lidocaine Before Intubation Decreases the Incidence of Coughing on Emergence from General Anesthesia
Sean C. Minogue, James Ralph, and Martin J. Lampa

Anesth Analg 2004 99: 1253-1257.

体外循环期间血液稀释增加鼠大脑中动脉阻塞的脑梗塞容积

Hemodilution During Cardiopulmonary Bypass Increases Cerebral Infarct Volume After Middle Cerebral Artery Occlusion in Rats

H. Mayumi Homi, MD*, Hong Yang, MD*, Robert D. Pearlstein, PhD*, and Hilary P. Grocott, MD{dagger}

Departments of *Surgery and {dagger}Anesthesiology (Multidisciplinary Neuroprotection Laboratories), Duke University Medical Center, Durham, North Carolina

Anesth Analg 2004 99: 974-981.

 

虽然体外循环中理想的红细胞压积没有定义,但过度的血液稀释可能导致器官缺血,这是由于降低了氧输送能力且不能通过血管自动调节和/或血流流变学的改变来增加器官血流。血液稀释对病人脑缺血的风险并不十分明确。作者设计本实验来评估CPB期间血液稀释对存在局部脑缺血情况下的影响。准备CPB手术的Wister鼠随机分为血液稀释组〔血红蛋白(Hb), 6 g/dL; n = 9〕或(Hb, 11 g/dL; n = 8)对照组,随后接受大脑中动脉阻塞(MACO)引起的局部脑缺血。大脑中动脉阻塞开始后行低温(28°CCPB65分钟。24小时后,测定功能性神经学预后和脑梗塞容积。与对照组相比,血液稀释组的神经学方面表现更差(血液稀释组评分为8 [2], 对照组评分为10 [2], P = 0.030),脑梗面积更大(血液稀释组182 ± 84 mm3,对照组103 ± 58 mm3, P = 0.043)。在这个可逆性MACO导致局部脑缺血的CPB试验模型中,血液稀释恶化了神经功能同时增加了脑梗塞容积。

(殷文渊 译 陈杰 校)

Although the optimal hematocrit during cardiopulmonary bypass (CPB) is not defined, excessive hemodilution may lead to organ ischemia via a reduction in oxygen-carrying capacity uncompensated by autoregulatory and/or rheologic increases in organ blood flow. As a result, the consequences of hemodilution in patients at risk for cerebral ischemia are not clearly understood. We designed this study to evaluate the effects of hemodilution in the setting of focal cerebral ischemia during CPB. Wistar rats surgically prepared for CPB were randomized to either hemodilution (hemoglobin (Hb), 6 g/dL; n = 9) or control (Hb, 11 g/dL; n = 8) groups and subsequently exposed to focal cerebral ischemia induced by middle cerebral artery occlusion (MCAO). Immediately after the onset of MCAO (maintained for 90 min), 65 min of hypothermic (28°C) CPB was initiated. Twenty-four hours later, functional neurological outcome and cerebral infarct volume were determined. Compared with controls, the hemodilution group had worse neurological performance (new score = 8 [2], hemodilution; versus 10 [2], control; P = 0.030) and larger total cerebral infarct volumes (182 ± 84 mm3, hemodilution; versus 103 ± 58 mm3, control; P = 0.043). In this experimental model of CPB with reversible MCAO-induced focal cerebral ischemia, hemodilution worsened neurological function and increased cerebral infarct volume.

 

蛋白激酶C激活介导异氟醚引起的大鼠离体缺血心脏功能和代谢恢复的改善

Activation of Protein Kinase C Contributes to the Isoflurane-Induced Improvement of Functional and Metabolic Recovery in Isolated Ischemic Rat Hearts

Pengcheng Xu, MD*,{dagger}, Jun Wang, MD*,{dagger}, Ramesh Kodavatiganti, MD*, Yinming Zeng, MD{dagger}, and Ira S. Kass, PhD*,{dagger},{ddagger}

Departments of *Anesthesiology and {ddagger}Physiology & Pharmacology, State University of New York Downstate Medical Center, Brooklyn, New York; and {dagger}Anesthesiology Key Laboratory of Jiangsu Province, Xuzhou Medical College, Xuzhou, People’s Republic of China

Anesth Analg 2004 99: 993-1000.

 

异氟醚能增强缺血后心肌功能恢复和改善能量水平。作者试图测定异氟醚诱导的心肌保护是否通过蛋白激酶CPKC)来介导。使用Langendorff模型,离体灌注大鼠心脏被分为未治疗组, 异氟醚组, 白屈菜红碱(PKC抑制剂)加异氟醚组和白屈菜红碱组。所有心脏都在缺血前接受治疗,随后30分钟的缺血和60分钟再灌注。记录血流动力学参数,通过高效液相色谱仪测定代谢产物,通过Westen blot方法分析PKC亚型的亚细胞定位。异氟醚显著改善左室压力的恢复,减少了缺血15分钟时心肌ATP和磷酸激酶的消耗,增强缺血后心肌ATP和肌磷酸的恢复。并且与PKC-{delta} -{epsilon}易位相关。白屈菜红碱抑制了PKC-{delta}-{epsilon}的易位,阻滞了心功能和ATP的改善。作者认为缺血时异氟醚延长了ATP的下降,缺血后60分钟改善了心肌机械功能和能量状态的恢复。异氟醚的这些作用依赖PKC的激活。

(殷文渊 译 陈杰 校)

Isoflurane enhances myocardial functional recovery and improves energy levels after ischemia. We sought to determine whether isoflurane-induced cardioprotection is mediated by protein kinase C (PKC). The Langendorff model was used, and isolated perfused rat hearts were separated into untreated, isoflurane, chelerythrine (PKC inhibitor) plus isoflurane, and chelerythrine groups. All hearts were subjected to treatment before ischemia, followed by 30 min of ischemia and 60 min of reperfusion. We recorded hemodynamic variables, measured metabolites by high-performance liquid chromatography, and analyzed subcellular localization of PKC isoforms by Western blot analysis. Isoflurane significantly improved the recovery of left ventricular developed pressure, attenuated the depletion of myocardial adenosine triphosphate (ATP) and creatine phosphate at 15 min of ischemia, enhanced the recovery of myocardial ATP and creatine phosphate concentrations after ischemia, and was associated with the translocation of PKC-{delta} and -{epsilon} to the membrane. Chelerythrine suppressed the translocation of PKC-{delta} and -{epsilon} and blocked the improvement of cardiac function and ATP. We conclude that isoflurane delays the decrease in ATP during ischemia and improves the recovery of mechanical function and the energy state 60 min after ischemia. These effects of isoflurane are dependent on the activation of PKC.

 

血管紧张素转换酶活性:在全膝关节成形术期间估计肺变化的新方法

Angiotensin-Converting Enzyme Activity: A Novel Way of Assessing Pulmonary Changes During Total Knee Arthroplasty

Kethy Jules-Elysee, MD, Thomas J. J. Blanck, MD, John D. Catravas, PhD, George Chimento, MD, Alexander Miric, MD, Richard Kahn, MD, Leonardo Paroli, MD, and Thomas Sculco, MD

Department of Anesthesiology, Hospital for Special Surgery, New York, New York

Anesth Analg 2004 99: 1018-1023.

 

全膝关节成形术(TKA)中,当止血带释放(TR)时,每个病人中都会形成栓子。这可能会导致脂肪栓塞综合症性肺损伤。血管紧张素转换酶(ACE)和肺内皮有关, ACE的代谢或HBPAP水解(H-benzoyl-Phe-Ala-Pro氢苯甲酰苯丙氨酸脯氨酸,ACE特有的底物)降低与肺损伤有关。作者评估了在TKA手术中这种测定法和肺损伤之间的关系。连续11个行双侧TKA的病人,在围手术期测量ACE。作者检测了ACE底物水解和肺毛细血管表面积(毛细血管灌注指数;CPI),以及与其相关的肺血管阻力(PVR)和临床结果。在第一次或第二次释放止血带时,和基础值相比,11个病人中有10个显示出其ACE底物水解和CPI的增加,同时伴有PVR的降低(P<0.05)。一名病人在TR后,PVR持续增加,同时在手术结束后伴有CPIACE底物水解的降低。但是,与所有其他病人无不良临床表现不同,该病人逐渐发展为神志不清,低氧。在以往的研究中, CPI增高伴有PVR降低,正像本试验中的10个病人一样,这与肺毛细血管的复原有关。作者相信存在一个非常重要的机制:在TR时,肺可以调节血栓形成。

(顾漪闻 译 陈杰 校)

Emboli after tourniquet release (TR) during total knee arthroplasty (TKA) occur in all patients. This may lead to fat embolism syndrome with lung injury. Angiotensin-converting enzyme (ACE) lines the pulmonary endothelium, and a decrease in ACE metabolism or hydrolysis of 3HBPAP (3H-benzoyl-Phe-Ala-Pro; a substrate specific for ACE) has been associated with lung injury. We evaluated the association of this assay with pulmonary changes during TKA. Eleven consecutive patients undergoing bilateral TKA had the ACE assay performed perioperatively. We determined substrate hydrolysis and pulmonary capillary surface area (capillary perfusion index; CPI) and correlated it with pulmonary vascular resistance (PVR) and clinical outcome. Ten of the 11 patients demonstrated an increase in substrate hydrolysis and CPI along with a decrease in PVR after first or second TR when compared with baseline values (P < 0.05). In the other patient, PVR continued to increase even after TR, whereas CPI and substrate hydrolysis decreased after surgery. Whereas all others did well clinically, this patient developed confusion and hypoxemia. In previous studies, a decrease in PVR with an increase in CPI, as exhibited by the 10 patients, has been associated with pulmonary capillary recruitment. We believe this to be an important mechanism by which the lungs are able to accommodate the burden of emboli at the time of TR.

 

麻醉下儿童应用动脉刺激静脉采样试验(ASVS)对高胰岛素血症病灶定位期间的血糖控制

Blood Glucose Control During Selective Arterial Stimulation and Venous Sampling for Localization of Focal Hyperinsulinism Lesions in Anesthetized Children

Giovanni Cucchiaro, MD, Scott D. Markowitz, MD, Robin Kaye, MD, N. Scott Adzick, Ronald S. Litman, DO, Charles A. Stanley, MD, and Mehernoor F. Watcha, MD

From The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania.

Anesth Analg 2004 99: 1044-1048.

 

先天性高胰岛素血症的外科治疗的效果通过动脉刺激静脉采血采样试验(ASVS)对微小的、局灶性胰腺损伤功能失调的定位而提高, ASVS是通过选择性的动脉注射钙剂后,肝静脉的胰岛素浓度提高而证实。但是,麻醉相关的血糖浓度的增高可诱发胰岛素的分泌,导致ASVS数据的分析困难。在这个回顾性研究中,作者检查了68个儿童在进行ASVS试验中,麻醉对血糖浓度的影响。在最后的分析之前仅仅考虑钙剂注射之前的血糖浓度。作者发现麻醉诱导药物(七氟醚,异丙酚,硫喷妥钠),麻醉维持药物(七氟醚,地氟醚或是异氟醚),以及布比卡因骶管麻醉,在ASVS试验之前并没有对平均血糖浓度有明显的影响。但是,注射瑞芬太尼的病人,其平均血糖浓度更低(80±18vs100±44mg• dl–1P0.01)。而如果使用吸入麻醉复合瑞芬太尼,然后面罩吸氧,气管插管的时间推迟到诱导后10分钟,平均血糖浓度明显降低(延迟插管组79±14 mg • dl–1,早期插管组为95±39 mg • dl–1p0.03)。与插管前的平均血糖浓度比较,延迟插管时其血糖增加的百分比较小(延迟插管为3.7±21.9%,早期插管为31.7±60.4%,P0.02)。结论:使用ASVS的病人,麻醉处理包括气管插管前应用瑞芬太尼或吸入麻醉复合瑞芬太尼,麻醉诱导10分钟以上,以便病人达到一个较深的麻醉状态。

(顾漪闻 译 陈杰 校)

Surgical management of congenital hyperinsulinism is improved by accurate localization of small, focal dysregulated pancreatic lesions using the arterial stimulation and venous sampling (ASVS) test, which can demonstrate increased hepatic venous insulin concentrations after selective arterial injections of calcium. However, anesthesia-related increases in blood glucose can induce insulin secretion, making it difficult to interpret ASVS test data. In this retrospective study, we examined the effect of anesthetic interventions on blood glucose concentrations in 68 children undergoing ASVS testing. We considered only the glucose concentrations observed before calcium stimulation in the final analysis. The choice of drugs for induction (sevoflurane, propofol, or thiopentone), maintenance inhaled anesthetics (sevoflurane, desflurane, or isoflurane), and the use of caudal epidural bupivacaine were not associated with significant differences in the mean blood glucose concentration before ASVS. However, patients receiving remifentanil infusions had smaller mean glucose concentrations (80 ± 18 versus 100 ± 44 mg • dl–1, P = 0.01). These concentrations were also significantly smaller if tracheal intubation was delayed for at least 10 min after induction while patients received inhaled anesthetics via a face mask along with remifentanil infusions (79 ± 14 for delayed intubation versus 95 ± 39 mg • dl–1 for early intubation, respectively, P = 0.03). The percentage increase in glucose concentrations from preintubation values was significantly smaller in these subjects (3.7% ± 21.9% for delayed intubation versus 31.7% ± 60.4% for early intubation, P = 0.02). We conclude that the anesthetic management protocol for these patients should include the use of remifentanil infusions and the administration of inhaled anesthetics and remifentanil infusions for a minimum of 10 min to establish a deep plane of anesthesia before tracheal intubation.

 

电针穴位刺激或枢复宁与安慰剂比较在预防术后恶心呕吐的随机对照研究

A Randomized Controlled Comparison of Electro-Acupoint Stimulation or Ondansetron Versus Placebo for the Prevention of Postoperative Nausea and Vomiting

Tong J. Gan, MB FRCA, FFARCS(I), Licentiate in Acupuncture*, Kui Ran Jiao, MD*, Michael Zenn, MD{dagger}, and Gregory Georgiade, MD{dagger}

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

Anesth Analg 2004 99: 1070-1075.

 

本研究主要评估电针穴位刺激或枢复宁与安慰剂相比预防术后恶心呕吐(PONV)的效应。全麻胸部手术患者随机分为电针穴位刺激组(A),枢复宁4 mg IVO)或对照组(放置电极而不给予电刺激;安慰剂(P))。标准麻醉下,在0306090120分钟及24小时评估恶心、呕吐的发生率、止吐药的使用情况、疼痛程度和患者对PONV处理的反应。与安慰剂组相比其它两组在术后2hA/O/P=77%/64%/42%P=0.01)和24hA/O/P=73%/52%/38%P=0.006)出现完善反应(无恶心、呕吐或使用止吐药)的机率明显提高。治疗组对于止吐药的需求也明显减少(A/O/P=19%/28%/54%P=0.04)。A组恶心的发生率和严重程度较其它组明显低,而O组比P组低(A/O/P=19%/40%/79%)。在术后恢复室中A组患者疼痛程度最轻。与安慰剂组相比治疗组的患者对PONV治疗较为满意。在预防PONV时,电针穴位刺激或枢复宁与安慰剂相比能更有效地提高患者的舒适程度,电针穴位刺激在控制恶心的发生方面比枢复宁有效。使用P6刺激还具有镇痛效果。

(朱慧琛 译 陈杰 校)

In this study we evaluated the efficacy of electro-acupoint stimulation, ondansetron versus placebo for the prevention of postoperative nausea and vomiting (PONV). Patients undergoing major breast surgery under general anesthesia were randomized into active electro-acupoint stimulation (A), ondansetron 4 mg IV (O), or sham control (placement of electrodes without electro-acupoint stimulation; placebo [P]). The anesthetic regimen was standardized. The incidence of nausea, vomiting, rescue antiemetic use, pain, and patient satisfaction with management of PONV were assessed at 0, 30, 60, 90, 120 min, and at 24 h. The complete response (no nausea, vomiting, or use of rescue antiemetic) was significantly more frequent in the active treatment groups compared with placebo both at 2 h (A/O/P = 77%/64%/42%, respectively; P = 0.01) and 24 h postoperatively (A/O/P = 73%/52%/38%, respectively; P = 0.006). The need for rescue antiemetic was less in the treatment groups (A/O/P = 19%/28%/54%; P = 0.04). Specifically, the incidence and severity of nausea were significantly less in the A group compared with the other groups, and in the O group compared with the P group (A/O/P = 19%/40%/79%, respectively). The A group experienced less pain in the postanesthesia care unit, compared with the O and P groups. Patients in the treatment groups were more satisfied with their management of PONV compared with placebo. When used for the prevention of PONV, electro-acupoint stimulation or ondansetron was more effective than placebo with greater degree of patient satisfaction, but electro-acupoint stimulation seems to be more effective in controlling nausea, compared with ondansetron. Stimulation at P6 also has analgesic effects.

 

病态肥胖患者根据真实体重或理想体重使用罗库溴胺的药效学比较

The Pharmacodynamic Effects of Rocuronium When Dosed According to Real Body Weight or Ideal Body Weight in Morbidly Obese Patients

Yigal Leykin, MD MSc*, Tommaso Pellis, MD{dagger}, Mariella Lucca, MD*, Giacomina Lomangino, MD{dagger}, Bernardo Marzano, MD{ddagger}, and Antonino Gullo, MD{dagger}

*Department of Anesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy; {dagger}Department of Perioperative Medicine, Intensive Care and Emergency, Trieste University Medical School, Trieste, Italy; and {ddagger}Department of Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy

Anesth Analg 2004 99: 1086-1089.

 

作者研究病态肥胖患者使用罗库溴胺时的药物效应。12位接受经腹胃减容术的病态肥胖女患者(体重指数>40kg/m2),随机分为两组。组1n=6)依据真实体重接受0.6mg/kg的罗库溴胺,组2n=6)依据理想体重接受0.6mg/kg的罗库溴胺。对照组为6个接受腹部手术的正常体重女患者,依据真实体重给予罗库溴胺。应用拇内收肌加速度肌描记仪监测神经肌肉传导,使用瑞米芬太尼和丙泊酚行麻醉诱导和维持。组1较对照组的起效时间较短,但无统计学意义。组125%肌力恢复时间(55分钟)大约为其它两组的两倍(2225分钟;P<0.001)。组2和对照组的有效时间相似。组1的恢复指数较长,但无统计学差异。综上所述,病态肥胖患者若依据真实体重计算罗库溴胺用量则将延长药物作用时间,因此在临床使用时应根据标准体重计算罗库溴胺的用量。

(朱慧琛 译 陈杰 校)

We investigated the pharmacodynamic effects of rocuronium on morbidly obese patients. Twelve morbidly obese female patients (body mass index >40 kg/m2) admitted for laparoscopic gastric banding were randomized into two groups. Group 1 (n = 6) received 0.6 mg/kg of rocuronium based on real body weight, whereas Group 2 (n = 6) received 0.6 mg/kg of rocuronium based on ideal body weight. In a control group of six normal-weight female patients admitted for laparoscopic surgery, rocuronium was dosed on the basis of their real body weight. Neuromuscular transmission was monitored by using acceleromyography of the adductor pollicis; anesthesia was induced and maintained with remifentanil and propofol. The onset time tended to be shorter in Group 1 and the control group compared with Group 2, but this did not achieve statistical significance. Duration of action to 25% of twitch tension was more than double in Group 1 (55 min) compared with the other two groups (22 and 25 min; P < 0.001). Duration of action was similar between Group 2 and control. Recovery index tended to be longer in Group 1, but without a significant difference. In conclusion, in morbidly obese patients, the duration of action of rocuronium is significantly prolonged when it is dosed according to real body weight. Therefore, the dosage should be assessed on the basis of ideal rather than on real body weight in clinical practice.

 

丙泊酚和咪唑安定可抑制小鼠胃排空和胃肠蠕动

Propofol and Midazolam Inhibit Gastric Emptying and Gastrointestinal Transit in Mice

Takefumi Inada, MD, Takashi Asai, MD PhD, Makiko Yamada, MD, and Koh Shingu, MD

Department of Anesthesiology, Kansai Medical University, Osaka, Japan

Anesth Analg 2004 99: 1102-1106

.

作者研究丙泊酚和咪唑安定对小鼠胃排空和胃肠蠕动的作用。小鼠腹腔内注射丙泊酚和咪唑安定,十分钟后在胃内灌注0.2ml含荧光珠的生理盐水。30分钟后,应用流式细胞仪测量胃肠道内的荧光珠数量以评估胃排空以及胃肠蠕动的情况。结果显示,引起轻度镇静(老鼠扶正位置的时间在2秒内)时,两种药物都明显抑制胃排空,但程度较轻(丙泊酚:与对照组比95%可信区间,4.9%-20.2%P<0.001;咪唑安定:与对照组比95%可信区间,7.8%-14.7%,P<0.001)。咪唑安定可延迟胃肠蠕动,丙泊酚无显著影响(P<0.001)。大剂量深度镇静时(翻正反射缺失大于10秒),两者显著抑制胃排空(丙泊酚:P<0.00195%可信区间,31.4%-61.2%;咪唑安定:P<0.00195%可信区间,30.8%-61.1%)和胃肠蠕动(两种药物与对照组比P<0.001)。

(朱辉 译 陈杰 校)

We studied the effect of propofol and midazolam on gastric emptying and gastrointestinal transit in mice. Ten minutes after intraperitoneal injection of propofol or midazolam, 0.2 mL of saline containing fluorescent microbeads was infused into the stomach. Thirty minutes later, the gastrointestinal tract was excised, and gastric emptying and gastrointestinal transit were calculated by measuring the quantity of fluorescent microbeads in the gastrointestinal tract by using a flow cytometer. At a dose that produced a light level of sedation (mice righted themselves within 2 s), both drugs significantly, but weakly, inhibited gastric emptying to a similar degree (propofol: P < 0.001 versus control value; 95% confidence interval [CI] for difference, 4.9%–20.2%; midazolam: P < 0.001 versus control value; 95% CI for difference, 7.8%–14.7%). Midazolam, but not propofol, delayed gastrointestinal transit (P < 0.001). At a larger dose that produced a deeper level of sedation (absence of righting reflex >10 s), both drugs significantly inhibited gastric emptying (propofol: P < 0.001; 95% CI for difference, 31.4%–61.2%; midazolam: P < 0.001; 95% CI for difference, 30.8%–61.1%) and gastrointestinal transit (P < 0.001 for both drugs).

 

七氟醚麻醉削弱二磷酸腺苷介导的血小板选择蛋白的表达和血小板-白细胞结合物的形成

Sevoflurane Anesthesia Attenuates Adenosine Diphosphate-Induced P-Selectin Expression and Platelet-Leukocyte Conjugate Formation

Go-Shine Huang, MD*, Chi-Yuan Li, MD MS*, Ping-Ching Hsu, MS{dagger}, Chien-Sung Tsai, MD{dagger}, Tso-Chou Lin, MD*, and Chih-Shung Wong, MD PhD*

*Department of Anesthesiology and {dagger}Division of Cardiovascular Surgery, Tri-Service General Hospital, National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China

Anesth Analg 2004 99: 1121-1126.

 

血小板表面血小板选择蛋白的表达和血小板-白细胞结合物的形成被认为血小板激活的标志并在血栓和炎症疾病中非常重要。以往研究报道七氟醚对血小板的聚集有抑制作用。作者研究了七氟醚是否影响血小板选择蛋白的表达和血小板-白细胞结合物的形成。选择25名行肢体小手术的患者,以七氟醚为主的全身麻醉,经面罩诱导、插入喉罩建立气道吸入七氟醚维持麻醉。在七氟醚麻醉前及麻醉后40分钟抽取全血以作分析。无或用二磷酸腺苷刺激的全血和富含血小板的血浆样本以荧光染料抗体标记。使用流式细胞仪测量血小板上的血小板选择蛋白的表达和血小板-白细胞结合物的形成。结果;七氟醚抑制血小板选择蛋白的表达。七氟醚呼末浓度为3%-4%时无论用还是不用二磷酸腺苷刺激的血标本中血小板-白细胞结合物的形成均减少。

(朱辉 译 陈杰 校)

The expression of P-selectin on the surface of platelets and platelet-leukocyte conjugate formation are considered to be an indicator of platelet activation and are important in thrombotic and inflammatory disease. Previous studies have reported the inhibitory effects of sevoflurane on platelet aggregation. We investigated whether sevoflurane alters the expression of P-selectin on platelets and the formation of platelet-leukocyte conjugates. Twenty-five patients undergoing minor extremity surgery received sevoflurane-based general anesthesia, with mask induction and laryngeal mask airway anesthesia maintenance. Whole blood was obtained before and 40 min after sevoflurane anesthesia. Unstimulated and adenosine diphosphate-stimulated samples of whole blood and platelet rich plasma were stained with fluorochrome-conjugated antibodies. The expression of P-selectin on platelets and the formation of platelet-leukocyte conjugates were measured using flow cytometry. Sevoflurane inhibited platelet P-selectin expression. It also reduced the formation of platelet-leukocyte conjugates, both in unstimulated and adenosine diphosphate-stimulated blood samples at 3%–4% end-expiratory sevoflurane concentrations used to maintain anesthesia.

 

缺乏NMDA受体GluRε1亚基的小鼠对氯胺酮和苯巴比妥的敏感性降低

Reduced Sensitivity to Ketamine and Pentobarbital in Mice Lacking the N-Methyl-D-Aspartate Receptor GluR{epsilon}1 Subunit

Andrey B. Petrenko, MD*,{dagger}, Tomohiro Yamakura, MD PhD*, Naoshi Fujiwara, PhD{ddagger}, Ahmed R. Askalany, MD*, Hiroshi Baba, MD PhD*, and Kenji Sakimura, PhD{dagger}

*Department of Anesthesiology, Niigata University School of Medicine, Niigata, Japan; {dagger}Department of Cellular Neurobiology, Brain Research Institute, Niigata University, Niigata; and {ddagger}Department of Medical Technology, Niigata University School of Health Sciences, Niigata, Japan

Anesth Analg 2004 99: 1136-1140.

 

氯胺酮是一种具有NMDA受体阻滞特性的静脉麻醉药,但是其全麻作用是否主要由于阻滞该受体尚不清楚。功能性的NMDA受体由GluRζ1亚基(NR1)和ε亚基(GluRε1-4NR2A-D)组成,完成其独特功能。假设缺乏GluRε1亚基的动物,其大量表达的NMDA受体可能抵抗氯胺酮的作用。在本研究中,作者通过正位反射比较GluRε1基因敲除鼠和野生型鼠腹腔注射氯胺酮的全麻/催眠效能。结果发现基因敲除鼠对氯胺酮抵抗。但没有预料到的是,该基因突变鼠对苯巴比妥也有抵抗作用,而该类药物被认为在临床相关浓度并不与NMDA受体发生作用。尽管这些结果并不能否定NMDA受体的GluRε1亚基参与介导氯胺酮麻醉/催眠作用的可能性,但是可以提示用基因敲除动物的麻醉药敏感性改变来分析麻醉作用较为困难。

(赵延华 译 陈杰 校)

Ketamine is an IV anesthetic with N-methyl-D-aspartate receptor (NMDAR)-blocking properties. However, it is still unclear whether ketamine’s general anesthetic actions are mediated primarily via blockade of NMDAR. Functional NMDARs are composed by the assembly of a GluR{zeta}1 (NR1) subunit with GluR{epsilon} (GluR{epsilon}1–4; NR2A–D) subunits, which confer unique properties on native NMDARs. We hypothesized that animals deficient in GluR{epsilon}1, an abundant and ubiquitously postnatally expressed NMDAR subunit, might be resistant to the effects of ketamine. Here, we evaluated a righting reflex to determine the general anesthetic/hypnotic potency of ketamine administered intraperitoneally to GluR{epsilon}1 knockout mice and compared these results with those for wild-type mice. Mutant mice were more resistant to ketamine than control mice. Unexpectedly, mutant mice were also more resistant to pentobarbital, which is thought not to interact with NMDAR at clinically relevant concentrations. Although these data in no way eliminate the possibility of the involvement of the NMDAR GluR{epsilon}1 subunit in mediation of ketamine anesthesia/hypnosis, they suggest the difficulties with interpretation of altered anesthetic sensitivity in knockout animal models.

 

清醒志愿者俯卧位时躯体倾斜度对眼内压的影响:两种手术床的比较

The Effect of Body Inclination During Prone Positioning on Intraocular Pressure in Awake Volunteers: A Comparison of Two Operating Tables

Mehmet S. Ozcan, MD*, Claudia Praetel, MD*, M. Tariq Bhatti, MD{dagger},{ddagger},§, Nikolaus Gravenstein, MD*,§, Michael E. Mahla, MD*,§, and Christoph N. Seubert, MD PhD*

Departments of *Anesthesiology, {dagger}Ophthalmology, {ddagger}Neurology, and §Neurosurgery, University of Florida, College of Medicine, Gainesville, Florida

Anesth Analg 2004 99: 1152-1158.

 

失明是俯卧位手术时少见但非常严重的一种并发症。俯卧位可增加眼内压(IOP),后者通过减少视神经前段的血液灌注可引起失明。本研究的作者观察了反式Trandelenburg姿势即头高脚低位能否改善由俯卧位引起的IOP升高,而且进一步比较了两种应用于俯卧位的装置。在随机交叉研究中,通过测定10名健康清醒志愿者处于3种倾斜度俯卧位(水平、头高脚低10°和头低脚高10°)以及坐位和仰卧位时眼内压,对Jackson床和Wilson架进行比较。俯卧位IOP(头高脚低10°、水平和头低脚高10°)分别为20.3 mmHg16.3-22.5mmHg)、22.5 mmHg19.8-25.3 mmHg)、23.8 mmHg21.5-26.3 mmHg)。俯卧位IOP25-75%范围中位数值超过坐位时15.0 mmHg12.8-16.3 mmHg)和仰卧位时16.8 mmHg14.0-18.3 mmHg)。反式Trandelenburg姿势即头高脚低位减轻了俯卧位引起的IOP增加。而且该姿势能减少IOP明显异常(>23mmHg)的病人数,与水平俯卧位和头低脚高位相比分别减少50%、75%。应用于俯卧位的两种装置对IOP的影响没有区别。俯卧位引起的IOP升高在头高脚低位可明显减轻,而在头低脚高位则增加。改变体位时压力很快发生改变以及IOP的变化,提示眼静脉压对于IOP的重要作用。因此,俯卧位时可通过调节手术床的倾斜度使IOP发生有益的变化。

(赵延华 译 陈杰 校)

Visual loss is a rare, but catastrophic, complication of surgery in the prone position. The prone position increases intraocular pressure (IOP), which may lead to visual loss by decreasing perfusion of the anterior optic nerve. We tested whether the reverse Trendelenburg position ameliorates the increase in IOP caused by prone positioning. Furthermore, we compared two prone positioning setups. The IOP of 10 healthy awake volunteers was measured in the prone position at 3 different degrees of inclination (horizontal, 10° reverse Trendelenburg, and 10° Trendelenburg) and in the sitting and supine positions in a randomized crossover study comparing the Jackson table and the Wilson frame. In a given eye, all prone IOP values (median [25th–75th percentile] exceeded those of the sitting (15.0 mm Hg [12.8–16.3 mm Hg]) and supine (16.8mm Hg [14.0–18.3 mm Hg]) positions. IOPs in the reverse Trendelenburg, horizontal, and Trendelenburg positions were 20.3 mm Hg (16.3–22.5 mm Hg), 22.5 mm Hg (19.8–25.3 mm Hg),* and 23.8 mm Hg (21.5–26.3 mm Hg),*{dagger} respectively (*P < 0.001 versus reverse Trendelenburg; {dagger}P < 0.001 versus horizontal). The reverse Trendelenburg position ameliorated the increase in IOP caused by the prone position. Furthermore, the reverse Trendelenburg position decreased the number of grossly abnormal IOP values (>23 mm Hg) by 50% and 75% compared with the prone horizontal and Trendelenburg positions, respectively. The prone positioning setups did not differ in their effect on IOP. The increase in IOP caused by prone positioning was ameliorated by the reverse Trendelenburg position and was aggravated by the Trendelenburg position. The short time period between changes in position and changes in IOP suggests an important role for ocular venous pressures in determining IOP. Therefore, IOP can be beneficially manipulated by operating table inclination in the prone position.

 

腹膜内注射安慰剂或局麻药缓解腹式子宫切除术后疼痛的双盲对照试验Postoperative Pain After Abdominal Hysterectomy: A Double-Blind Comparison Between Placebo and Local Anesthetic Infused Intraperitoneally

Anil Gupta, MD FRCA, PhD*, Andrea Perniola, MD*, Kjell Axelsson, MD PhD*, Sven E. Thörn, MD PhD*, Kristina Crafoord, MD{dagger}, and Narinder Rawal, MD PhD*

Department of Clinical Medicine, *Division of Anesthesiology, and {dagger}Obstetrics and Gynecology, University Hospital, Örebro, Sweden

Anesth Analg 2004 99: 1173-1179

.

腹式子宫切除可引起病人术后中、重度疼痛。本实验将40名择期行腹式子宫切除术的病人(ASA III级)随机分为两组:P组的病人通过在术毕时放置于腹膜内的导管注射生理盐水5ml/h,而L组的病人则通过此导管注射0.25%左旋布比卡因12.5mg/h(5ml/h)。通过病人自控镇痛泵静脉给予凯托米酮作为所有病人的应急镇痛药。术毕24小时后拔除该导管。在实验中应用视觉模拟评分系统在术后123481624h评估病人的切口疼痛、深疼痛和因咳嗽引起的疼痛,并记录病人在072h内凯托米酮的用量,以及病人从术毕到可以坐、行走、进食、进水和出院的时间;测定病人血浆中左旋布比卡因的浓度。结果发现组L病人在术后12h的切口疼痛、深疼痛和因咳嗽引起的疼痛均较P组病人明显减轻,术毕4h后病人在休息和咳嗽时的平均视觉模拟评分均小于3cmL组病人在术后424h内的凯托米酮的用量明显少于P组病人(平均为19mg31mg)。而且在这段时间内L组病人术后恶心的发生率也明显小于P组病人,并且无一人呕吐(P<0.025)。实验中测定全血和血浆中左旋布比卡因的浓度较小。因此,择期行腹式子宫切除术的病人在术后于腹膜内应用左旋布比卡因具有明显的减少阿片类药物需要。

(齐波 译 陈杰 校)

Abdominal hysterectomy is associated with moderate to severe postoperative pain. We randomly divided 40 patients (ASA status I–II) undergoing elective abdominal hysterectomy into 2 groups: group P received an infusion of normal saline 5 mL/h via a catheter placed intraperitoneally at the end of surgery, and group L received 0.25% levobupivacaine 12.5 mg/h (5 mL/h). Ketobemidone was administered IV via a patient-controlled analgesia pump as a rescue analgesic in all patients. The catheter was removed after 24 h. Incisional pain, deep pain, and pain on coughing were assessed 1, 2, 3, 4, 8, 16, and 24 h after surgery by using a visual analog scale. Ketobemidone consumption during 0–72 h was recorded. Time to sit, walk, eat, and drink; home discharge; and plasma concentrations of levobupivacaine were also determined. Pain at the incision site, deep pain, and pain on coughing were all significantly less in group L compared with group P at 1–2 h after surgery. After 4 h, the mean visual analog scale pain scores at rest and during coughing remained <3 cm during most time periods. Total ketobemidone consumption during 4–24 h was significantly less in group L compared with group P (mean, 19 versus 31 mg, respectively). A less frequent incidence of postoperative nausea, but not vomiting, was also found during 4–24 h in group L compared with group P (P < 0.025). Total and free plasma concentrations of levobupivacaine were small. We conclude that levobupivacaine used as an infusion intraperitoneally after elective abdominal hysterectomy has significant opioid-sparing effects.

 

雷米芬太尼对脑外伤病人行气管内吸引时引起颅内压升高的效果

The Effects of Remifentanil on Endotracheal Suctioning-Induced Increases in Intracranial Pressure in Head-Injured Patients

Marc Leone, MD*, Jacques Albanèse, MD*, Xavier Viviand, MD*, Franck Garnier, MD*, Aurelie Bourgoin, MD*, Karine Barrau, MD{dagger}, and Claude Martin, MD*

*Intensive Care Unit and Department of Anesthesiology and the {dagger}Department of Biostatistics and Epidemiology, Nord Hospital, Marseilles University Hospital System (AP-HM), Marseilles School of Medicine, Marseilles, France

Anesth Analg 2004 99: 1193-1198.

 

对严重颅脑外伤病人行支气管冲洗可以引起颅内压(ICP)变化,从而对病人产生不利的影响。为避免这些不利的影响,曾有人建议在静脉内应用阿片类药物。本实验选择20名机械通气的病人,静脉应用3种不同剂量的雷米芬太尼,其剂量逐渐升高。剂量11ug/Kg,输注速度为0.25ug/Kg/min;剂量22ug/Kg,输注速度为0.5ug/Kg/min;剂量34ug/Kg,输注速度为1ug/Kg/min。在静脉输注开始后20分钟进行气管内吸引,直到病人出现咳嗽为止。在整个30分钟的研究阶段内监测病人的心率、ICP、平均动脉压(MAP)、脑灌注压(CPP)、大脑中动脉平均血流速率(VMCA)和双频指数。结果在剂量123组中分别有121519个病人需要血管加压素才能维持CPP大于60mmHg;另外剂量123组中分别有16155个病人在吸引时出现的咳嗽。病人ICP升高,MAP的降低而无VMCA的变化说明病人脑自动调节功能存在。因此,脑外伤病人持续应用雷米芬太尼并不能有效防止不良的吸引反应。

(齐波 译 陈杰 校)

In patients with severe traumatic brain injury, bronchotracheal toilet may be accompanied by deleterious variations in intracranial pressure (ICP). To avoid these effects, IV opioids have been proposed. Twenty mechanically-ventilated patients received 3 ascending IV doses of remifentanil: dose 1 (1 µg/kg bolus, 0.25 µg/kg/min infusion); dose 2 (2 µg/kg bolus, 0.5 µg/kg/min infusion); and dose 3: (4 µg/kg bolus, 1 µg/kg/min infusion). Endotracheal suction was performed 20 min after the beginning of infusion to assess coughing. Heart rate, ICP, mean arterial blood pressure (MAP), cerebral perfusion pressure (CPP), middle cerebral artery mean flow velocity (VMCA), and bispectral index were monitored throughout the 30-min study period. Twelve, 15, and 19 patients receiving dose 1, 2, and 3, respectively, required vasopressors to maintain CPP >60 mm Hg. Suctioning resulted in coughing in 16, 15, and 5 patients receiving dose 1, 2, and 3, respectively. An increase in ICP, without change in VMCA, corresponded to the reduction in MAP consistent with the preservation of autoregulation. Remifentanil used as a continuous infusion in head-injured patients is not an effective drug to block responses to suctioning.

 

股骨骨折患者坐位行脊麻前镇痛:股神经阻滞和静注芬太尼的比较

Analgesia Before Performing a Spinal Block in the Sitting Position in Patients with Femoral Shaft Fracture: A Comparison Between Femoral Nerve Block and Intravenous Fentanyl

Salvatore Sia, MD, Francesco Pelusio, MD, Remo Barbagli, MD, and Calogero Rivituso, MD

Department of Anesthesiology, Centro Traumatologico Ortopedico, Azienda Ospedaliera Careggi, Firenze, Italy

Anesth Analg 2004 99: 1221-1224.

 

本项前瞻性、随机性实验旨在比较股神经阻滞和静脉注射芬太尼在辅助股骨干骨折患者实施坐位脊髓麻醉时的镇痛效能。脊髓麻醉前5分钟,FEM组患者(n=10)应用1.5%利多卡因15 mL进行股神经阻滞,IVA组患者(n=10)静脉注射芬太尼3 ug/kgFEM组放置体位时视觉模拟分级评分较低(FEM组:0.50-1);IVA组:32-6),P < 0.001)FEM组进行脊髓镇痛的时间较短(FEM组:1.8±0.7min IVA组:3.0±1.1minP<0.05)。FEM组麻醉前坐位放置的舒适度评分(0=不满意,1=满意,2=好,3=很好)较高(FEM组:32-3IVA组:1.51-3),P<0.005)。IVA组患者较少愿意镇痛方法(P<0.05)。IVA组一例患者麻醉过程中氧饱和度<90%。因此作者认为:在股骨干骨折患者实施坐位脊髓麻醉时,辅助股神经阻滞优于静脉注射芬太尼。

(田婕 译 陈杰 校)

We conducted this prospective, randomized study to compare the analgesic effect of femoral nerve block and IV fentanyl administration when given to facilitate the sitting position for spinal anesthesia in patients undergoing surgery for femoral shaft fracture. Five minutes before the placement of spinal block, group FEM patients (n = 10) received a femoral nerve block with lidocaine 1.5% 15 mL, and group IVA patients (n = 10) received IV fentanyl 3 µg/kg. Visual analog scale values during positioning (median and range) were lower in group FEM: 0.5 (0–1) versus 3 (2–6) (P < 0.001). Time to perform spinal anesthesia (mean ± SD) was shorter in group FEM: 1.8 ± 0.7 min versus 3.0 ± 1.1 min (P < 0.05). Quality of patient positioning for spinal anesthesia (0 = not satisfactory, 1 = satisfactory, 2 = good, and 3 = optimal) (median and range) was higher in group FEM: 3 (2–3) versus 1.5 (1–3) (P < 0.005). Patient acceptance was less in group IVA (P < 0.05). In one group IVA patient, an oxygen saturation <90% was recorded during the procedure. We conclude that femoral nerve block is more advantageous than IV administration of fentanyl to facilitate the sitting position for spinal anesthesia in patients undergoing surgery for femoral shaft fractures.

 

全关节成形术中输注同种异体血的预测

Predicting Allogeneic Blood Transfusion Use in Total Joint Arthroplasty

Saifudin Rashiq, MB MSc, FRCPC, Meera Shah, Ava K. Chow, MSc, Paul J. O’Connor, MB FFARCSI, and Barry A. Finegan, MB FRCPC

Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada

Anesth Analg 2004 99: 1239-1244

.

全关节成形术(TJA)患者常常需要输注同种异体血。本研究中,作者试图建立和确认在TJA患者使用术前根据易于得到的资料来建立预测临床输血原则。应用逻辑回归模型对2000年阿尔伯达省埃德蒙顿市所有TJA手术者(n=1875)进行回顾性研究。试验组和验证组运用该模型曲线下面积分别为0.800.76。结果显示根据6种互不相关因素评分(年龄,性别,体重,血色素,ASA病情分级,以及是否需要术中改变术式),就可以对患者需要输血的可能性做出评估。作者认为,根据简单的术前临床和实验室检查结果可以对TJA患者术中输血几率做出准确预测。这样的预测有助于输血策略选择性地应用于那些输血风险最大的患者。

(田婕 译 陈杰 校)

Total joint arthroplasty (TJA) patients often receive allogeneic blood transfusion. In this study we sought to create and validate a clinical prediction rule for transfusion in TJA using data that are easily available when scheduling the procedure. Logistic regression modeling was applied to retrospective data from all TJA procedures performed in Edmonton, Alberta in 2000 (n = 1875). The area under the receiver operating curve for the resulting model in the training and validation data sets was 0.80 and 0.76 respectively. By assigning a simple score based on six independent predictors (age, gender, weight, hemoglobin, ASA operative risk classification and whether revision surgery was planned), it was possible to classify a given subject’s risk of receiving allogeneic transfusion. We conclude that accurate prediction of transfusion risk in TJA is possible using a rule based on simple preoperative clinical and laboratory data. Such prediction could allow transfusion prevention strategies to be applied selectively to those at greatest risk.

 


非体外循环进行冠状动脉搭桥手术时经食管超声监测部分心室壁的运动

Transesophageal Echocardiography for Monitoring Segmental Wall Motion During Off-Pump Coronary Artery Bypass Surgery

Jianwen Wang, MD*, Miodrag Filipovic, MD*, Ainars Rudzitis, MD{dagger}, Isabelle Michaux, MD*, Karl Skarvan, MD*, Peter Buser, MD{dagger}, Atanas Todorov, MD{ddagger}, Franziska Bernet, MD{ddagger}, and Manfred D. Seeberger, MD*

Departments of *Anesthesia, {dagger}Internal Medicine (Division of Cardiology), and {ddagger}Surgery (Division of Cardiothoracic Surgery), University of Basel, Basel, Switzerland

Anesth Analg 2004;99:965-973


在这一前瞻性、观察性的研究中,评价经食管超声监测左心室部分心肌运动在非体外循环进行冠状动脉搭桥手术(OPCAB)翻动心脏时的作用。根据以往有关在OPCAB手术时经常无法获得经胃切面图像的研究,我们仅仅分析经食管中段获得的图像。在60位患者开胸和放置心包外固定器时,记录四腔心切面、二腔心切面和长轴切面的图形。用16段模型,2个超声心动图独立分析心室壁的运动。在基础值、翻动心脏和放置心包外固定器时,分析那些≥14左心室段分辩率高的图像的比例。在基础值时,≥14段的60位患者中有59 位(98%)的图像清晰。心脏翻动后,≥14段的76支再通的冠状动脉左前降支有5876%)(与基础值比较,P < 0.01)、 40支再通的冠状动脉回旋支有33例(83%)(与基础值比较,P < 0.01)和31支再通的右冠状动脉有29例(94%)(与基础值比较无显著性的差异)的图像分辨率高、清晰。结论:在心脏翻动时,图像分辨率降低,但是≥14段清晰的图像为5OPCAB患者中的4位提供可靠的监测。

(葛宁花译 薛张刚校)

In this prospective, observational study, we evaluated whether transesophageal echocardiography allows for monitoring left ventricular segmental wall motion during cardiac displacement for off-pump coronary artery bypass (OPCAB) surgery. On the basis of a pilot study that showed frequent loss of transgastric views during OPCAB surgery, we analyzed only midesophageal views. The midesophageal 4-chamber view, 2-chamber view, and long-axis view were recorded in 60 patients after opening the chest and placing an epicardial stabilizer on the displaced heart. Using the 16-segment model, 2 echocardiographers independently performed offline analysis of segmental wall motion. The percentage of patients in whom ≥14 left ventricular segments were readable was calculated at baseline and after cardiac displacement and placement of an epicardial stabilizer. At baseline, ≥14 segments were readable in 59 (98%) of 60 patients. After cardiac displacement, ≥14 segments were readable during 58 (76%) of 76 revascularizations of the left anterior descending coronary artery (P < 0.01 versus baseline), during 33 (83%) of 40 revascularizations of the left circumflex coronary artery (P < 0.01 versus baseline), and during 29 (94%) of 31 revascularizations of the right coronary artery (not significant). We conclude that the number of readable segments decreased after cardiac displacement but that availability of ≥14 readable segments allowed for reliable monitoring of segmental wall motion in 4 of 5 patients during OPCAB surgery.

 

体外循环时零级平衡超滤体外清除高浓度的Tirofiban:一项体内的研究

Extracorporeal Elimination of Large Concentrations of Tirofiban by Zero-Balanced Ultrafiltration During Cardiopulmonary Bypass: An In Vitro Investigation

Andreas Koster, MD*, Derek Chew, MD{dagger}, Frank Merkle, ECCP{ddagger}, Marcus Gruendel, MD§, Michael Jurmann, MD||, Hermann Kuppe, MD*, and Rainhard Oertel, MD

*Department of Anesthesia, Deutsches Herzzentrum Berlin, Berlin, Germany; {dagger}Department of Cardiology, Flinders Medical Centre, Bedford Park, Australia; {ddagger}Department of Perfusion, Deutsches Herzzentrum Berlin, Berlin, Germany; §Department of Anesthesia and Intensive Care Medicine, Charite, Campus Virchow, Berlin, Germany; ||Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; and ¶Institute of Clinical Pharmacology, Carl Gustav Carus Faculty of Medicine, University of Technology, Dresden, Germany

Anesth Analg 2004;99:989-992

 

短效血小板糖蛋白IIb/IIIa 拮抗剂tirofiban对心脏手术有益。Tirofiban的清除半衰期为2小时。在肾衰患者中,半衰期延长,并持续抑制血小板的聚集,这种抑制对输注血小板无反应。为防止在这种情况下的过分出血,体外清除是必要的。我们评价在体外循环的模型中,血液滤过器清除tirofiban的作用。评价两种血液滤过器和血浆分离滤过器的功效。取每种类型中的三个进行系列研究。体外循环预充液总量为1000 ml,加入Tirofiban,至200 ng/mL。取滤过液50 mL,并在每次取出后,补充等量的液体。分析每次滤过后tirofiban的血药浓度。重复取样16次。Tirofiban的峰浓度为160 260 ng/mLtirofiban清除的指数衰减曲线和高治疗浓度快速清除为250 50 ng/mL。沉淀系数b 显示各种滤过器的清除能力无显著性差异。数据提示超滤是体外循环中清除治疗浓tirofiban 的有效方法。

(葛宁花译 薛张刚校)

The short-acting platelet glycoprotein IIb/IIIa antagonist tirofiban is beneficial when used in the context of cardiac surgery. Tirofiban has an elimination half-life of 2 h. Renal failure prolongs the half-life and continues inhibition of platelet aggregation refractory to transfusions of platelets. Extracorporeal elimination is necessary to prevent excessive hemorrhage in this condition. We assessed the elimination of tirofiban by hemofiltration in an in vitro model of cardiopulmonary bypass (CPB). Two hemofilters and one plasmapheresis filter were assessed. Three separate filters of each type were tested serially. The CPB circuit was primed with a total volume of 1000 mL. Tirofiban was added to a calculated concentration of 200 ng/mL. Portions of 50 mL of filtrate were retrieved from the dialyzer, and equal amounts of fluid were substituted in the circuit. After each filtration, the tirofiban blood level was analyzed. The procedure was repeated 16 times. Peak tirofiban concentrations ranged from 160 to 260 ng/mL. The elimination of tirofiban followed an exponential decay curve with fast clearance of the large therapeutic concentrations of 250 to 50 ng/mL. The subsidence coefficient b revealed no significant differences in elimination between the filter systems. These data suggest that ultrafiltration is an effective means for extracorporeal elimination of therapeutic levels of tirofiban.

老年心脏外科手术预防性联合使用β- 阻滞剂艾司洛尔和磷酸二酯酶抑制剂依诺昔酮

The Prophylactic Use of the ß-Blocker Esmolol in Combination with Phosphodiesterase III Inhibitor Enoximone in Elderly Cardiac Surgery Patients

Joachim Boldt, MD PhD*, Christian Brosch, MD*, Andreas Lehmann, MD*, Stephan Suttner, MD*, and Frank Isgro, MD{dagger}

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

Anesth Analg 2004;99:1009-1017

 

我们研究预防性联合静脉使用β- 肾上腺素能阻滞剂艾司洛尔和磷酸二酯酶抑制剂依诺昔酮(enoximone)对搭桥术后血流动力学、炎性反应、内皮细胞和器官功能的影响。选择42位年龄>65 岁、行主动脉冠状动脉搭桥手术的患者,进行随机、安慰剂对照和前瞻性研究。一组为21位患者,全麻诱导后开始静脉注射β- 阻滞剂艾司洛尔(目标心率控制在70/分以下)和磷酸二酯酶抑制剂enoximone(起始剂量0.5 mg/kg,并以2.5 mg/kg/min速度持续注入),并持续至术后第一天早晨。另一组21位患者输注生理盐水作为安慰剂。记录基础值、体外循环开始前后、监护室直至术后第一天的血流动力学、内脏灌注压(胃动脉 CO2间隙)、肝功能(血浆谷胱甘肽α转换酶浓度)、肾功能(肌酐清除率、尿中N-乙酰基-β-D-氨基葡萄糖酶)、心肌缺血(血浆肌酐激酶MB和肌钙蛋白T的浓度)、炎性反应(弹性蛋白酶、白介素-6-8的血浆水平)和内皮细胞的完整性(粘性分子的血浆水平)。在实验组,儿茶酚胺所需量比对照组少、心率显著较慢、心排指数较高和胃动脉CO2间隙低。肌钙蛋白Tβ-N-乙酰基-β-D-氨基葡萄糖酶,α谷胱甘胎转换酶和可溶性粘分子在对照组显著增加,但在艾司洛尔+enoximone组几乎正常。艾司洛尔+enoximone组的炎性反应因子( 弹性蛋白酶/白介素)减弱。结论:与对照组比较,在老年进行心脏体外循环手术患者中,预防性联合使用艾司洛尔和enoximone,有益于体外循环后血流动力学的平稳、器官功能、炎性反应和内皮细胞的完整性。

(葛宁花译 薛张刚校)

We assessed the influence of the prophylactic use of a combination of the IV ß-adrenergic blocker, esmolol, and the phosphodiesterase III inhibitor, enoximone, on postbypass hemodynamic status, inflammation, and endothelial and organ function in a prospective, randomized, placebo-controlled study in 42 patients aged >65 yr undergoing aortocoronary bypass grafting. In 21 patients, esmolol (aim: heart rate <70 bpm) plus enoximone (initial bolus of 0.5 mg/kg followed by a continuous infusion of 2.5 µg • kg–1 • min–1) was started after induction of anesthesia and continued until the morning of the first postoperative day; another 21 patients received saline solution as placebo. Hemodynamics, splanchnic perfusion (gastric-arterial CO2 gap), liver function (glutathione transferase-{alpha} plasma levels), renal function (creatinine clearance, urine concentrations of N-acetyl-ß-D-glucosaminidase), myocardial ischemia (creatine-kinase MB and troponin T plasma levels), inflammation (elastase, interleukin-6 and -8 plasma levels), and endothelial integrity (adhesion molecules plasma levels) were assessed at baseline, before and after cardiopulmonary bypass (CPB), and in the intensive care unit until the first postoperative day. Catecholamine requirements were significantly less in the treated than in the nontreated patients. Heart rate was significantly slower, cardiac index was higher, and gastric-arterial CO2 gap was significantly lower in the treatment group. Troponin T, ß-N-acetyl-ß-D-glucosaminidase, glutathione transferase-{alpha}, and soluble adhesion molecules increased significantly in the untreated control, but remained almost normal in the esmolol+enoximone patients. Inflammatory responses (elastase/interleukins) were attenuated by esmolol+enoximone. We conclude that, in comparison to an untreated control, the prophylactic use of a combination of esmolol and enoximone in elderly patients undergoing cardiac surgery with cardiopulmonary bypass resulted in overall beneficial effects on postbypass hemodynamic status, organ function, inflammatory response, and endothelial integrity.


经外周放置中心静脉导管:小儿外科手术中的一项随机、对照和前瞻性研究

Peripherally Inserted Central Catheters: A Randomized, Controlled, Prospective Trial in Pediatric Surgical Patients

Deborah A. Schwengel, MD*, John McGready, MS{dagger}, Sean M. Berenholtz, MD MHS*, Lori J. Kozlowski, RN MS, CPNP*, David G. Nichols, MD MBA*, and Myron Yaster, MD*

*Departments of Anesthesiology and Critical Care Medicine, Surgery, and Pediatrics, The Johns Hopkins University School of Medicine; and {dagger}Department of Biostatistics, The Johns Hopkins University School of Public Health, Baltimore, Maryland

Anesth Analg 2004;99:1038-1043

 

经外周放置中心静脉导管(PICCs),可长期用于静脉给药、抽血取样或高营养。术后短期使用PICCs尚无报道。在这一对照、随机研究中,患者分为二组:PICCs组或外周静脉置管组(PIV)。观察指标包括患者和父母的满意度、不同静脉通路的并发症、术后静脉穿刺的次数和费用。在PICCs组,满意度明显高于PIV组(p<0.05),术后需要静脉穿刺的次数明显比PIV少(p<0.05)。PIV组常见的是微小并发症,但在两组中均未出现严重的并发症。PICCs的费用高,但良好的满意度使其价值得到体现。另外,在手术室内术前准备期间放置PICCs并不增加麻醉医生的工作量和延长占用手术室的时间。对术后住院超过4天的患者,麻醉医生应放置PICCs,特别是那些需要频繁抽血化验或穿刺静脉的患者。

(葛宁花译 薛张刚校)

Peripherally-inserted central catheters (PICCs) are long-term IV catheters used for drug and fluid administration, blood sampling, or hyperalimentation. The short-term use of PICCs in postoperative patients has not been studied. In this randomized, controlled trial, patients received either a PICC or peripheral IV catheter (PIV). Our outcome measures were patient and parent satisfaction with care, complications of the venous access devices, number of postoperative venipunctures, and cost-effectiveness of use. Satisfaction was significantly more frequent in the PICC group (P < 0.05), and there were significantly fewer postoperative needle punctures in the PICC group compared with the PIV group (P < 0.05). Minor complications were common in the PIV group; major complications were uncommon in both groups. PICCs are more expensive, but better satisfaction can make them a cost-effective option. Additionally, insertion during surgical preparation time in the operating room (OR) means that cost is not increased by adding anesthesiologist and OR time. Anesthesiologists should consider placing PICCs in patients requiring more than 4 days of in-hospital postoperative care, especially if frequent blood sampling or IV access is required.


小儿术前多系统的评估

Preoperative Evaluation of Pediatric Surgical Patients with Multisystem Considerations

Lynne R. Ferrari, MD

Medical Director Perioperative Services, Children’s Hospital, and Department of Anesthesia, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;99:1058-1069

 

越来越少的患者因为即将进行的手术或麻醉干预而住院。结果是越来越依赖术前彻底的评估以发现麻醉的危险因素。因此,每个医疗中心必须建立确切可行的部门,对手术患者术前进行判断。在患儿人群中,需要特殊专一的人才和系统来积累各学科的信息。这种花费是明智的,可以减少手术患儿因不完全或不恰当的术前准备而在手术室内浪费时间。以下仔细描述在大的儿童医疗中心如何成功地对围术期的评估和术前准备进行已7年。

(葛宁花译 薛张刚校)

Fewer and fewer patients spend time in the hospital in advance of a surgical or interventional procedure requiring anesthesia care. As a result, there is increasing reliance on a thorough preoperative evaluation directed toward identifying anesthetic risks. For this to occur, each medical institution must have a clear and comprehensive system that processes patients during the preoperative period. There are specific and unique personnel and system requirements for the accumulation of multidisciplinary information in the pediatric patient population. The justification for the cost of this type of program is the savings realized by the decrease in wasted operating room time due to inadequate or incomplete patient preparation. The following is a description of a successful perioperative evaluation and preparation process that has been in place for 7 yr in a major pediatric academic institution.


异丙酚或七氟醚麻醉时用触觉法评估拮抗罗库嗅胺诱发的神经肌肉阻滞作用

Tactile Assessment for the Reversibility of Rocuronium-Induced Neuromuscular Blockade During Propofol or Sevoflurane Anesthesia

Kyo S. Kim, MD PhD, Mi A. Cheong, MD PhD, Hee J. Lee, MD, and Jae M. Lee, MD

Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea

Anesth Analg 2004;99:1080-1085

 

我们旨在探讨在在异丙酚或七氟醚麻醉时,用触觉法计数四个成串刺激(TOF)能否预计新斯的明拮抗罗库嗅胺的作用,并观察至TOF0.9160位患者,平均分为8个组,随机用异丙酚或七氟醚维持麻醉。在患者一侧手臂,用触觉法评估拇内收肌对TOF的反应,在另一侧手臂,则用机械肌动描记法记录。用罗库嗅胺阻滞神经肌肉,初始剂量为0.6 mg/kg,并维持肌松在最初TOF抽搐时的15%。在每次麻醉中,用触觉法评估当TOF出现一个抽搐(第一组)、二个抽搐(第二组)、三个抽搐(第三组)或四个抽搐(第四组)时,用0.07 mg / kg的新司的明拮抗,并同时减少异丙酚或七氟醚的剂量。记录开始拮抗至TOF比例达到0.70.80.9的时间。在异丙酚维持麻醉组,TOF比例为0.9的平均时间一至四组分别为8.6 ( 4.7 - 18.9 )7.5 ( 3.4 - 9.8 )5.4 ( 1.6 - 8.6 ) 4.7 ( 1.3 - 7.2 )分钟;而七氟醚维持麻醉组,则分别为28.6 ( 8.8 - 75.8 )22.6 ( 8.3 - 57.4 )15.6 ( 7.3 - 43.9 )9.7 ( 5.1 - 26.4 )分钟,P< 0.0001。我们建议,异丙酚麻醉时,出现2个以上TOF反应或七氟醚麻醉出现4TOF反应时,合适的拮抗时间分别在1015分钟内。在拮抗期间,出现TOF反应越多,肌张力恢复得越完全。但在一定的时间内,触觉法评估TOF的反应,并不是一个完全可靠的方法。
(葛宁花译 薛张刚校)

We sought to determine whether tactile train-of-four (TOF) count can predict the efficacy of neostigmine administration for rocuronium-induced blockade during propofol or sevoflurane anesthesia, and to follow subsequent recovery until the TOF ratio reached 0.9. One-hundred-sixty patients, divided into eight equal groups, were randomly allocated to maintenance of anesthesia with propofol or sevoflurane. The tactile response of the adductor pollicis to TOF stimulation was evaluated on one arm, and the mechanomyographic response was recorded on the other. Neuromuscular block was induced with rocuronium 0.6 mg/kg and maintained with rocuronium to 15% of the control first twitch in TOF. Neostigmine 0.07 mg/kg was administered on reappearance of the first (Group I), second (Group II), third (Group III), or fourth (Group IV) tactile TOF response in each anesthesia. At this time, sevoflurane or the propofol dosage was reduced in each group (n = 20 in each group). The times from administration of neostigmine until the TOF ratio recovered to 0.7, 0.8, and 0.9 were recorded. The times [median (range)] to TOF ratio = 0.9 were 8.6 (4.7–18.9), 7.5 (3.4–9.8), 5.4 (1.6–8.6), and 4.7 (1.3–7.2) min in Groups I–IV during propofol anesthesia, respectively, and 28.6 (8.8–75.8), 22.6 (8.3–57.4), 15.6 (7.3–43.9), and 9.7 (5.1–26.4) min in corresponding groups during sevoflurane anesthesia, respectively (P < 0.0001). We recommend more than 2 TOF responses with propofol anesthesia and 4 TOF responses with sevoflurane anesthesia for adequate reversal within 10 and 15 min, respectively. The more tactile TOF responses present at the time of reversal achieved greater adequate recovery; however, tactile TOF responses are not a completely reliable predictor within a reasonable time period.


异丙酚对鼠海马横切面癫痫样活动的抗惊厥作用

The Anticonvulsant Action of Propofol on Epileptiform Activity in Rat Hippocampal Slices

Hideya Ohmori, MD*, Yasumitsu Sato, MD PhD{dagger}, and Akiyoshi Namiki, MD PhD{ddagger}

*Department of Anesthesiology, Kitami Red Cross Hospital; {dagger}Department of Anesthesiology, Moriyama Hospital; and {ddagger}Department of Anesthesiology, Sapporo Medical University School of Medicine, Hokkaido, Japan

Anesth Analg 2004;99:1095-1101

 

记录鼠海马横切面CA1区细胞外电生理,以研究异丙酚对由缺乏Mg2+引起的兴奋性突出后电位(fEPSP)、总体波峰和癫痫样活动的影响。异丙酚抑制总体波峰、fEPSP和癫痫样活动。氨茶碱,非选择性腺苷受体拮抗剂和8-cyclopentyl-1,3-dipropylxanthine, A1受体拮抗剂,都能显著地抑制异丙酚对fEPSP振幅的作用。但是,3,7-二甲基-1-propagylxanthineA2受体拮抗剂,并不改变异丙酚对fEPSP振幅的作用。印防己毒素,一种特殊的氯离子通道阻滞剂,部分抑制异丙酚对癫痫样电活动的作用;但是,荷包牡丹碱,一种竞争性{gamma}-氨基丁酸受体拮抗剂,不能拮抗它的作用。氨茶碱显著地抑制异丙酚抗癫痫样活动的作用。异丙酚抗惊厥作用部分被8-cyclopentyl-1,3-dipropylxanthine减弱,而7-二甲基-1-propagylxanthine则无影响。腺苷抑制fEPSP的振幅,呈剂量依赖性,异丙酚能增强这种作用。结果显示:在鼠海马横切面,异丙酚能抑制癫痫样活动。此外,腺苷通过A1受体起到神经调节作用,可能有助于异丙酚的抗惊厥作用。

(葛宁花译 薛张刚校)

We used extracellular electrophysiological recordings from the CA1 region in rat hippocampal slices to investigate the effects of propofol on the field excitatory postsynaptic potential (fEPSP), population spike, and epileptiform activity induced by a Mg2+-free condition. Propofol depressed the population spike, fEPSP, and epileptiform activity. Both aminophylline, a nonselective adenosine receptor antagonist, and 8-cyclopentyl-1,3-dipropylxanthine, an A1 receptor antagonist, significantly reduced the effect of propofol on fEPSP amplitude. However, 3,7-dimethyl-1-propagylxanthine, an A2 receptor antagonist, did not alter the effect of propofol on fEPSP amplitude. Picrotoxin, a specific chloride channel blocker, partly reduced the effect of propofol on epileptiform activity, but bicuculline, a competitive {gamma}-aminobutyric acidA receptor antagonist, failed to antagonize it. Aminophylline significantly reduced the action of propofol on the epileptiform activity. The anticonvulsant action of propofol was partly reduced by 8-cyclopentyl-1,3-dipropylxanthine, whereas 3,7-dimethyl-1-propagylxanthine failed to affect it. Adenosine depressed the amplitude of fEPSPs in a dose-dependent manner, and propofol enhanced this inhibition. The results demonstrated that, in rat hippocampal slices, propofol inhibits epileptiform activity. In addition, adenosine neuromodulation through the A1 receptor may contribute to the anticonvulsant action of propofol.


椎管内大剂量苏芬太尼能预防腹部大手术时的激素应急反应:与静脉使用苏芬太尼的前瞻性、随机性的对照研究

Large-Dose Intrathecal Sufentanil Prevents the Hormonal Stress Response During Major Abdominal Surgery: A Comparison with Intravenous Sufentanil in a Prospective Randomized Trial

Paul J. Borgdorff, MD*, Traian I. Ionescu, MD PhD{dagger}, Peter L. Houweling, MD PhD*, and Johannes T. A. Knape, MD PhD{dagger}

*Department of Anaesthesiology, Diakonessenhuis Hospital, Utrecht, The Netherlands; and {dagger}Division for Perioperative and Emergency Medicine, University Medical Centre, Utrecht, The Netherlands

Anesth Analg 2004;99:1114-1120

 

我们研究腹部大手术时椎管内大剂量苏芬太尼对激素应急反应的作用。40位患者随机分为静脉输注苏芬太尼组(IVS)和椎管内注入150 µg苏芬太尼组(ITS),作为全麻的一部分。在IVS组,促肾上腺皮质激素(ACTH)和皮质醇浓度分别比基础值和ITS组、切皮后60分钟和缝合皮肤时高。而ITS组,手术期间血浆皮质醇和ACTH的浓度与基础值比较无差异。缝皮后6小时,两组皮质醇浓度均高于基础值。缝皮后2448小时,两组皮质醇和ACTH相似。两组去甲肾上腺素浓度在术后均增加。术中和术后,两组的血糖升高。术后48小时,ITS组的疼痛评分和吗啡需要量都低。数据显示,在联合麻醉时,椎管内大剂量苏芬太尼能预防术中的激素应急反应。我们推测这是由于苏芬太尼与脊髓和脊髓上受体的高亲和力。与平衡麻醉比较,这种技术能增加术后的镇痛作用。

(葛宁花译 薛张刚校)

We studied the effect of large-dose intrathecal sufentanil (ITS) for major abdominal surgery on the hormonal stress response. Forty patients were randomly allocated to receive either IV sufentanil (IVS) or 150 µg of ITS as part of general anesthesia. In the IVS group, adrenocorticotropic hormone (ACTH) and cortisol concentrations were larger than baseline and the ITS group, 60 min after incision and at skin closure. Plasma concentrations of cortisol and ACTH were not different from baseline in the ITS group during surgery. Six hours after skin closure, cortisol concentrations were larger than baseline in both groups. Twenty-four and 48 h after skin closure, ACTH and cortisol values were similar between groups. Norepinephrine concentrations increased after surgery in both groups. Blood glucose levels increased in both groups during and after surgery. Pain scores and morphine consumption during the first 48 h after surgery were lower in the ITS group. The data show that large-dose ITS prevents the intraoperative hormonal stress response in comparison with balanced anesthesia. We speculate that this is due to the highly specific binding of sufentanil to spinal and supraspinal receptors. This technique improves postoperative analgesia when compared with balanced anesthesia.


异丙酚并不抑制利多卡因硬膜外阻滞时的代谢

Propofol Does Not Inhibit Lidocaine Metabolism During Epidural Anesthesia

Shin Nakayama, MD*, Masayuki Miyabe, MD*, Yoshihiro Kakiuchi, PhD{dagger}, Shinichi Inomata, MD*, Yoshiko Osaka, MD*, Taeko Fukuda, MD*, Yukinao Kohda, PhD{dagger}, and Hidenori Toyooka, MD*

Departments of *Anesthesiology and {dagger}Pharmacy, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Japan

Anesth Analg 2004;99:1131-1135

 

异丙酚有时和利多卡因硬膜外阻滞联合使用。在这一研究中,我们探讨当利多卡因用于硬膜外麻醉时,异丙酚对其血浆浓度和主要代谢的影响。32位患者随机分为异丙酚组或七氟醚组(n = 16)。在异丙酚组,麻醉的靶浓度控制在4 µg/mL。在七氟醚组,麻醉用1.5%的浓度维持。硬膜外利多卡因的初始剂量为5 mg/kg,然后以2.5 mg • kg–1 • h–1速度持续注入。在开始持续注入利多卡因后的3060120180分钟,用高效液相色谱法检测血浆中利多卡因游离部分和其代谢物monoethylglycinexylidide (MEGX) glycinexylidide (GX)的浓度。2 mL 血浆经过超滤得到游离的利多卡因、MEGX GX。两组血流动力学数据相似,两组血浆游离利多卡因浓度无显著性差异。MEGX与游离利多卡因的比值和GXMEGX比值两组无差异。结论:与七氟醚比较,异丙酚并不改变硬膜外利多卡因的代谢。

(葛宁花译 薛张刚校)

Propofol is sometimes used in combination with epidural anesthesia with lidocaine. In this study, we investigated the effect of propofol on the plasma concentration of lidocaine and its principal metabolites during epidural anesthesia with lidocaine. Thirty-two patients were randomly allocated to receive either propofol or sevoflurane anesthesia (n = 16 each). In the propofol group, anesthesia was maintained with a target concentration of propofol of 4 µg/mL. In the sevoflurane group, anesthesia was maintained with 1.5% sevoflurane. Lidocaine was administered epidurally in an initial dose of 5 mg/kg, followed by a continuous infusion at 2.5 mg • kg–1 • h–1. Free components of plasma lidocaine and its metabolites—monoethylglycinexylidide (MEGX) and glycinexylidide (GX)—were measured 30, 60, 120, and 180 min after the initiation of continuous epidural injection by using high-performance liquid chromatography. Free lidocaine, MEGX, and GX were separated from 2 mL of plasma by ultrafiltration filter units. Hemodynamic data were similar between groups. The plasma concentrations of free lidocaine were not significantly different between groups. The ratios of free MEGX to free lidocaine and free GX to free MEGX were not different between groups. In conclusion, propofol does not alter the metabolism of epidural lidocaine compared with sevoflurane.


缓激肽拮抗剂对切口疼痛没有镇痛作用

Bradykinin Antagonists Have No Analgesic Effect on Incisional Pain

Paul A. Leonard, MD PhD, Radha Arunkumar, MD, and Timothy J. Brennan, MD PhD

Department of Anesthesia, University of Iowa, Iowa City, Iowa

Anesth Analg 2004;99:1166-1172

 

缓激肽是内源性九肽和重要的炎症介质,同样也是疼痛的启动者和持续者。des-Arg8, Leu8-缓激肽 (dALBK) HOE-140, 缓激肽B1 B2受体拮抗剂,分别显示在动物模型中,对持续性的伤害刺激具有减轻疼痛和炎性反应的作用。我们研究在鼠的模型中,以上因子对切皮产生疼痛的主动反应。氟烷麻醉下,在鼠后爪的足底作1cm的切口,并用5–0 尼龙线缝合。对点状和非点状机械刺激的回缩反应分别用von Frey 丝线和带有塑料圆盘的von Frey 丝线试验。试验对放射热回缩反应潜伏期。在切皮前一天、切皮后1小时和注药后0.5 1 1.5 2.5 小时记录试验结果。然后在术后第二天,在注药前后相同的时间点,重复试验一次。鼠分别静脉注入盐水dALBK (0.1, 0.3, 1.0, 3.0 mg/kg) HOE-140 (0.1, 0.3, 1.0, 3.0 mg/kg)。另一组鼠在切皮前1小时注药后进行以上的试验。数据用Kruskal-Wallis方法进行统计分析和二维方法分析变异,P < 0.05为差异有统计学意义。无论是超前给药还是切皮后给药,dALBK HOE-140的剂量都不影响对尖锐性刺痛或机械性钝痛或热刺激的反应。结果支持这一机制:切皮产生的疼痛与炎症介导的疼痛有关。尽管炎症是引起切皮疼痛的部分原因,但是炎症的病因和其作用在其它模型中有所不同。

(葛宁花译 薛张刚校)

Bradykinin, an endogenous nonapeptide and an important mediator of inflammation, is also implicated in the initiation and maintenance of pain. Both des-Arg8, Leu8-bradykinin (dALBK) and HOE-140, the prototypic bradykinin B1 and B2 receptor antagonists, respectively, have been shown to reduce pain behaviors and inflammation in animal models of persistent nociception. We studied them for activity against incision-induced pain behaviors in a rat model for postoperative pain. A 1-cm plantar incision was made in the hind paw of halothane-anesthetized rats and closed with 5–0 nylon. Withdrawal responses to punctate and nonpunctate mechanical stimuli were tested with von Frey filaments and a plastic disk attached to a von Frey filament, respectively. Withdrawal latency to radiant heat was also tested. Rats were tested 1 day before the incision, 1 h after the incision, and 0.5, 1, 1.5, and 2.5 h after the injection of the drug. They were then retested at the same times before and after the injection of the drug on each of the first 2 postoperative days. The rats received the saline vehicle dALBK (0.1, 0.3, 1.0, or 3.0 mg/kg) or HOE-140 (0.1, 0.3, 1.0, or 3.0 mg/kg) IV. Another group of rats had the drug injected 1 h before incision and tested as above. Statistical significance (P < 0.05) was determined with Kruskal-Wallis test and a two-way analysis of variance. None of the doses of either dALBK or HOE-140 affected the responses to punctate or blunt mechanical stimulation or heat, either as a pretreatment or as a posttreatment. These data support the unique mechanisms for incision-induced pain relative to inflammation-related pain. Although inflammation may represent a component of incisional pain, the etiology of inflammation and its role seem different than in other models.


美国麻醉培训计划的人员和资金:2002-2003

Faculty and Finances of United States Anesthesiology Training Programs: 2002–2003

Kevin K. Tremper, PhD MD*, Amy Shanks, MS*, Michelle Sliwinski, MS*, Steven J. Barker, PhD MD{dagger}, Roberta Hines, MD{ddagger}, and Alan R. Tait, PhD*

*Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; {dagger}Department of Anesthesiology, University of Arizona, Tucson, Arizona; and {ddagger}Department of Anesthesiology, Yale University, New Haven, Connecticut

Anesth Analg 2004;99:1185-1192


20002月至8月之间,有三份报告递交给美国麻醉培训计划的主席,要求增加各自部门的人员和资金。在本篇报告中,我们报道第四篇跟踪调查的结果。同时询问是否需要额外的资助以满足住院医生每周工作80小时的要求和调查医生平均拥有的学习时间。每个科室平均有40位人员,其中78%的科室需要3.7位人员。只有25%的科室计划增加人员以满足住院医生每周工作80小时的要求。51%科室的有$15,908资金积余/相当于每个专职麻醉人员(人员 FTE),而34%的科室则是负$42,603/人员FTE。总的资助是$85,607/人员FTE,比上一年增加43%。提供给每个人员的学术时间平均是13.8%,比2000年的20%有所下降。2003年,有25%的科室因缺乏人员而关闭麻醉培训点。开放型人员培训计划从2000年到2003年保持良好的态势,从8%增加到10%。自从2000年以来,医院对科室培训计划的资助已成倍增加,在2003年达到$85,000/人员。

(葛宁花译 薛张刚校)

Between February, 2000 and August, 2002 three surveys have been submitted to the program directors of the anesthesiology training programs in the United States (U.S.) to assess the departments’ needs for faculty and financial support from their institutions. In this article we present the results of a fourth follow-up survey. This survey also asked questions regarding the need for additional support to meet the new 80-h workweek resident requirement and asked the average academic time offered to faculty. The average department has 40 faculty members with 3.7 open faculty positions in the 78% of departments with open positions. Only 25% of the departments planned to add personnel to comply with the 80-h resident workweek. Fifty-one percent of the departments had a positive financial margin of $15,908/full-time equivalent (FTE) faculty anesthesiologist (faculty FTE), whereas 34% had a negative margin of $42,603/faculty FTE. The overall institutional support was $85,607/faculty FTE, which is a 43% increase over the previous year. The average academic time provided to faculty was 13.8%, a decline from 20% in 2000. Twenty-five percent of departments have closed an anesthetizing location as a result of a lack of faculty in 2003. Open faculty positions in U.S. training programs have remained fairly constant at 8% to 10% from 2000 to 2003. Institutional support for training departments has more than doubled since 2000, reaching approximately $85,000/faculty in 2003.


严重颅脑外伤伴或不伴有颅内高压时血压变化对大脑血流动力学的影响

Cerebral Hemodynamic Responses to Blood Pressure Manipulation in Severely Head-Injured Patients in the Presence or Absence of Intracranial Hypertension

Olaf L. Cremer, MD MSc*,§, Gert W. van Dijk, MD PhD{dagger}, Gerrit J. Amelink, MD PhD{ddagger}, Anne Marie G. A. de Smet, MD*, Karel G. M. Moons, PhD*,§, and Cornelis J. Kalkman, MD PhD*

*Division of Perioperative Care and Emergency Medicine, Departments of {dagger}Neurology and {ddagger}Neurosurgery, and the §Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands

Anesth Analg 2004;99:1211-1217

 

如何维持严重颅脑外伤患者的大脑灌注压(CPP)是一个有争论的问题。最近提出脑血管自动调节的状况决定每个个体的目标CPP。为寻找理想的灌注压,我们用药物控制13位严重颅脑外伤患者的CPP在受伤的当天、受伤后第一天和第二天在51 mm Hg (平均48–53 mm Hg) 108 mm Hg (102–112 mm Hg)范围内,并研究对颅内压(ICP)、自动调节能力和脑组织氧分压的影响。自动调节表达为根据大脑中动脉血流速度而调节CPP 5-mm Hg间隔的固定率。当ICP正常时,CPP从基础值78 mm Hg (74–83 mm Hg)开始改变,测得的其他值没有大的变化,这意味着在自动调节的范围内。相反,在颅内高压时,CPP降低到77 mm Hg (73–82 mm Hg)以下,能加重ICP,降低自动调节能力和降低脑组织氧分压,而CPP增加,以上指标好转,这表示大脑在自动调节的低限工作。结论:经常观察血压的波动能提供有效的信息以控制CPP在合适的范围。

(葛宁花译 薛张刚校)

The management of cerebral perfusion pressure (CPP) remains a controversial issue in the critical care of severely head-injured patients. Recently, it has been proposed that the state of cerebrovascular autoregulation should determine individual CPP targets. To find optimal perfusion pressure, we pharmacologically manipulated CPP in a range of 51 mm Hg (median; 25th–75th percentile, 48–53 mm Hg) to 108 mm Hg (102–112 mm Hg) on Days 0, 1, and 2 after severe head injury in 13 patients and studied the effects on intracranial pressure (ICP), autoregulation capacity, and brain tissue partial pressure of oxygen. Autoregulation was expressed as a static rate of regulation for 5-mm Hg CPP intervals based on middle cerebral artery flow velocity. When ICP was normal (26 occasions), there were no major changes in the measured variables when CPP was altered from a baseline level of 78 mm Hg (74–83 mm Hg), indicating that the brain was within autoregulation limits. Conversely, when intracranial hypertension was present (11 occasions), CPP reduction to less than 77 mm Hg (73–82 mm Hg) further increased ICP, decreased the static rate of regulation, and decreased brain tissue partial pressure of oxygen, whereas a CPP increase improved these variables, indicating that the brain was operating at the lower limit of autoregulation. We conclude that daily trial manipulation of arterial blood pressure over a wide range can provide information that may be used to optimize CPP management.


椎管内小剂量可乐定和等比重布比卡因用于矫形手术:一个剂量依赖的研究

Small-Dose Intrathecal Clonidine and Isobaric Bupivacaine for Orthopedic Surgery: A Dose-Response Study

Stephan Strebel, MD*, Jürg A. Gurzeler, MD{dagger}, Markus C. Schneider, MD*, Armin Aeschbach, MD*, and Christoph H. Kindler, MD*

*Department of Anesthesia, University Clinics, Kantonsspital, Basel; and {dagger}Department of Surgery, Kantonsspital Luzern, Luzern, Switzerland

Anesth Analg 2004;99:1231-1238


我们研究椎管内小剂量可乐定(≤150 µg)延长布比卡因蛛网膜下腔麻醉时剂量与效果之间的关系。旨在探索椎管内注射可乐定的剂量:能延长蛛网膜下腔麻醉时的作用和缓解疼痛,而没有严重的副作用。80位行矫形手术的患者,随机分为四组:每组均在蛛网膜下腔注入等比重0.5%布比卡因18 mg,并在第一组内加入生理盐水,第二组内加入可乐定37.5 µg,第三组内加入可乐定75 µg,第四组内加入可乐定150 µg。感觉阻滞持续的时间(感觉平面消退至L1)分别为288 ± 62 min(第一组,对照组),311 ± 101 min (第二组,+8%, 325 ± 69 min (第三组,+13%, 337 ± 78 min (第四组,+17% (95% 可信区域: –0.05–0.50)。从开始注入可乐定至第一次需要追加镇痛药的时间显著延长,分别为295 ± 80 min (第一组,对照组), 343 ± 75 min(第二组,+16%, 381 ± 117 min(第三组,+29%, 445 ± 136 min (第四组,+51% (95% 可信区域: 0.59–1.45))。各组血流动力学稳定无差异,镇静评分无差异,结论:小剂量椎管内可乐定(≤150 µg)能显著地延长布比卡因的麻醉和镇痛作用,呈剂量依赖型。当希望延长蛛网膜下腔麻醉的时间时,≤150 µg可乐定就其副作用而言,是最佳选择。

(葛宁花译 薛张刚校)

We examined the dose-response relationship of intrathecal clonidine at small doses (≤150 µg) with respect to prolonging bupivacaine spinal anesthesia. We aimed for establishing doses of intrathecal clonidine that would produce clinically relevant prolongation of spinal anesthesia and pain relief without significant side effects. Eighty orthopedic patients were randomly assigned to intrathecally receive isobaric 0.5% bupivacaine, 18 mg, plus saline (Group 1), clonidine 37.5 µg (Group 2), clonidine 75 µg (Group 3), and clonidine 150 µg (Group 4). Duration of the sensory block (regression below level L1) was increased in patients receiving intrathecal clonidine: 288 ± 62 min (Group 1, control), 311 ± 101 min in Group 2 (+8%), 325 ± 69 min in Group 3 (+13%), and 337 ± 78 min in Group 4 (+17%) (estimated parameter for dose 0.23 [95% confidence interval –0.05–0.50]). Duration of pain relief from intrathecal clonidine administration until the first request for supplemental analgesia was significantly prolonged: 295 ± 80 min (Group 1, control), 343 ± 75 min in Group 2 (+16%), 381 ± 117 min in Group 3 (+29%), and 445 ± 136 min in Group 4 (+51%) (estimated parameter for dose 1.02 [95% confidence interval 0.59–1.45]). Relative hemodynamic stability was maintained and there were no between-group differences in the sedation score. We conclude that small doses of intrathecal clonidine (≤150 µg) significantly prolong the anesthetic and analgesic effects of bupivacaine in a dose-dependent manner and that 150 µg of clonidine seems to be the preferred dose, in terms of effect versus unwarranted side effects, when prolongation of spinal anesthesia is desired.



气管插管前用利多卡因进行喉气管表面麻醉能减少全麻苏醒拔管时的呛咳反应

Laryngotracheal Topicalization with Lidocaine Before Intubation Decreases the Incidence of Coughing on Emergence from General Anesthesia

Sean C. Minogue, FCARCSI, James Ralph, FRCA, and Martin J. Lampa, FRCPC

From the Department of Anesthesia, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada

Anesth Analg 2004;99:1253-1257

 

苏醒时呛咳,会产生一系列不良的反应,包括高血压、心动过速、快速性心律失常、增加颅内压和增加眼内压。在气管插管时,用利多卡因进行气管黏膜的表面麻醉能否预防苏醒时的呛咳反应尚不明了。在双盲、对照研究中,我们选择50ASA I II、行妇科手术患者,手术时间在2小时之内,随机在插管时,分别用160 mg利多卡因或安慰剂进行表面喷雾。两组患者的一般状况和术中情况无显著性差异。在利多卡因喷雾组,拔管前的呛咳(26%)明显比安慰剂组(66%)减少,P < 0.01,拔管后的呛咳也减少(4%相对30%, P = 0.022)。研究支持这一观点:在全麻下进行手术的时间小于2小时且苏醒时的呛咳对患者很不利,则插管前用利多卡因进行表面喷雾很有必要。

(葛宁花译 薛张刚校)

Coughing on emergence can result in a number of undesirable side effects, including hypertension, tachycardia, tachyarrhythmias, increased intracranial pressure, and increased intraocular pressure. The efficacy of endotracheal spraying with lidocaine at the time of intubation in preventing coughing on emergence is unknown. In a double-blind placebo-controlled study, we randomized 50 ASA physical status I and II patients presenting for elective gynecological surgery <2 h duration to receive either endotracheal lidocaine 160 mg or placebo before intubation. Both groups were comparable in terms of demographics and intraoperative conditions. The incidence of coughing before tracheal extubation was less frequent in the lidocaine group (26%) than in the placebo group (66%, P < 0.01), as was the incidence after tracheal extubation (4% versus 30%, P = 0.022). This study supports the use of endotracheal lidocaine before intubation in patients undergoing general anesthesia for surgery <2 h duration where coughing on emergence is undesirable.

不停跳冠状动脉搭桥手术是否降低多支搭桥后临床肾功能障碍的发生率?

Does Off-Pump Coronary Artery Bypass Reduce the Incidence of Clinically Evident Renal Dysfunction After Multivessel Myocardial Revascularization?

 

Nanette M. Schwann, MD, Jay C. Horrow, MD MS, Michael D. Strong, III, MD, Dmitri Chamchad, MD, Albert Guerraty, MD, and Andrew S. Wechsler, MD

Departments of Anesthesiology, and Cardiovascular Medicine and Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania

Anesth Analg 2004;99:959-964

 

在这个前瞻性、观察性试验中,我们探讨不停跳冠状动脉搭桥手术(OPCAB)与体外循环下冠状动脉搭桥手术(CABG)比较是否伴有较少的术后肾功能障碍(RD)。所有参加的病人都是首次于2000年在我机构中进行单独的冠状动脉搭桥手术。对每个病人收集的数据包括人口统计学、术前RD风险系数、围术期事件以及从入院到出院或死亡的血清肌酐浓度。RD的诊断标准为血清肌酐浓度较术前上升≥50%,同时术后肌酐绝对浓度≥2.0 mg/dL (177 μM)。用Student’s t-检验和Fisher’s 精确检验进行组间比较,逐步多因素对数回归分析法来识别RD的决定性因素;P < 0.05为有显著差异。CABG(n = 119)OPCAB(n = 220)相比在年龄(64 ± 13 67 ± 10 yr, P = 0.0074)和移植血管数量(中位数43, P = 0.0003)上有差异。手术的方式与术后RD的存在没有联系:在220 OPCAB病人中有18 (8.2%)比在119 CABG病人中有12 (10%) 例(P = 0.55)。我们的资料提示手术技术的选择 (OPCAB CABG)并不伴有较少的肾损害发生。

(沈浩 李士通 校)

 

In this prospective, observational trial, we determined whether off-pump coronary artery bypass (OPCAB) was associated with less postoperative renal dysfunction (RD) compared with coronary bypass surgery with cardiopulmonary bypass (CABG). All patients undergoing primary, isolated coronary surgery at our institution in the year 2000 participated. Data collected on each patient included demographics, preoperative risk factors for RD, perioperative events, and serum creatinine concentrations from date of admission until discharge or death. The criteria for RD was both a ≥50% increase from preoperative creatinine and an absolute postoperative creatinine ≥2.0 mg/dL (177 µM). Student’s t-test or the Fisher’s exact test was used to compare groups. Stepwise multiple logistic regression identified determinants of RD; P < 0.05 significant. The CABG group (n = 119) differed from the OPCAB group (n = 220) with respect to age (64 ± 13 versus 67 ± 10 yr, P = 0.0074) and number of distal grafts (median 4 versus 3, P = 0.0003). Type of operation did not associate with the presence of postoperative RD: 18 (8.2%) of 220 OPCAB patients versus 12 (10%) of 119 CABG patients (P = 0.55). Our data suggest that choice of operative technique (OPCAB versus CABG) is not associated with reduced renal morbidity.

 

 

比较持续正压通气和无创压力支持通气方法用于治疗心脏手术后的肺不张

Continuous Positive Airway Pressure Versus Noninvasive Pressure Support Ventilation to Treat Atelectasis After Cardiac Surgery

 

Patrick Pasquina, RN*, Paolo Merlani, MD{dagger}, Jean Max Granier, RN*, and Bara Ricou, MD{dagger}

*Respiratory Therapy Unit of the Division of Surgical Intensive Care, {dagger}Division of Surgical Intensive Care, Department of Anaesthesiology, Pharmacology and Surgical Intensive Care, Geneva University Hospital, Geneva, Switzerland

Anesth Analg 2004;99:1001-1008

 

肺不张常见于心脏手术后,可引起气体交换不足。持续正压通气(CPAP)常用于预防或治疗术后肺不张。我们假设无创压力支持通气(NIPSV)通过增加潮气量,其改善肺不张进展的作用优于CPAP150名收入外科重症监护室(SICU)的心脏手术后患者,放射学肺不张评分≥2,随机分为两组,分别接受每天4次,每次30分钟的CPAPNIPSV治疗。两组的呼气末正压都设定为5厘米水柱。在NIPSV组,压力支持设定为潮气量8-10 ml/kg。在离开SICU时,我们观察到NIPSV组中60%患者的肺不张得到改善,而CPAP组中为 40%(P = 0.02)。两组在氧合作用(离开SICU PaO2/吸入氧浓度:CPAP280 ± 38 vs NIPSV 301 ± 40)、肺功能检查和SICU停留时间方面没有差异。在轻度并发症方面,如胃胀,两组相似。根据放射学评分,NIPSV改善肺不张的效果优于CPAP,但是它未能提供临床意义上额外的益处,因此能否改善预后值得怀疑。

(张俊杰 李士通 校)

 

Atelectasis is common after cardiac surgery and may result in impaired gas exchange. Continuous positive airway pressure (CPAP) is often used to prevent or treat postoperative atelectasis. We hypothesized that noninvasive pressure support ventilation (NIPSV) by increasing tidal volume could improve the evolution of atelectasis more than CPAP. One-hundred-fifty patients admitted to our surgical intensive care unit (SICU) with a Radiological Atelectasis Score ≥2 after cardiac surgery were randomly assigned to receive either CPAP or NIPSV four times a day for 30 min. Positive end-expiratory pressure was set at 5 cm H2O in both groups. In the NIPSV group, pressure support was set to provide a tidal volume of 8–10 mL/kg. At SICU discharge, we observed an improvement of the Radiological Atelectasis Score in 60% of the patients with NIPSV versus 40% of those receiving CPAP (P = 0.02). There was no difference in oxygenation (PaO2/fraction of inspired oxygen at SICU discharge: 280 ± 38 in the CPAP group versus 301 ± 40 in the NIPSV group), pulmonary function tests, or length of stay. Minor complications, such as gastric distensions, were similar in the two groups. NIPSV was superior to CPAP regarding the improvement of atelectasis based on radiological score but did not confer any additional clinical benefit, raising the question of its usefulness for altering outcome.

 

 

腹主动脉瘤手术患者门静脉乳酸盐、乙状结肠粘膜内pH和△CO2PaCO2局部 PCO2)作为并发症指数的比较

A Comparison Among Portal Lactate, Intramucosal Sigmoid pH, and {Delta}CO2 (PaCO2 – Regional PCO2) as Indices of Complications in Patients Undergoing Abdominal Aortic Aneurysm Surgery

 

Abele Donati, MD*, Oriana Cornacchini, MD*, Silvia Loggi, MD*, Sandro Caporelli, MD*, Giovanna Conti, MD*, Stefano Falcetta, MD*, Francesco Alò, MD{dagger}, Gabriele Pagliariccio, MD{dagger}, Elisabetta Bruni, MD*, Jean-Charles Preiser, MD PhD{ddagger}, and Paolo Pelaia, MD*

*Department of Neuroscience, Anesthesia and Intensive Care Unit, and {dagger}Department of Vascular Surgery, Marche Polytechnique University, Ancona, Italy; and {ddagger}Department of Intensive Care, University Hospital of Liege, Liege, Belgium

Anesth Analg 2004;99:1024-1031

 

我们在这个观察性、前瞻性、非对照研究中的目的是探求29 腹主动脉瘤(AAA)手术后患者器官衰竭发生率与术中动脉和门静脉乳酸变化、乙状结肠粘膜内pH (pHi)变化、乙状结肠粘膜PCO2和动脉PCO2差值(ΔCO2)以及血红蛋白(Hb)的关系。在麻醉开始(T0)、钳夹主动脉前(T1)、钳夹30分钟时(T2)以及手术结束(T3)时点测定Hb、动脉血乳酸浓度、pHiΔCO2 值(空气张力测量法)。在T1T2时点测定门静脉乳酸浓度。患者分为两组:组A患者术后无器官衰竭,组B患者有一个或多个器官衰竭。相较于组An = 16),组B患者(n = 13)在T2T3时点pHi值更低,T3时点ΔCO2 更高。pHi<7.15能预计器官衰竭的敏感性为92.3%,特异性68.8%,正负预计值分别为70.6%91.7%。但是ΔCO2 >28 mm Hg预计后期器官衰竭的敏感性为92.3%,特异性62.5%,正负预计值分别为66.6% 90.9%T2点组B门静脉乳酸浓度较高(P < 0.001),其增高≥5 g/dL预计后期器官衰竭其敏感性为92.3%,特异性100%,正负预计值分别为100%94.1%。对比检验每个变量识别力的特征性曲线和对数回归分析显示门静脉血乳酸浓度升高是最好的预计术后器官衰竭发展的指标。组B Hb浓度在T0T2时点明显较低(T0-13.8 ± 1.0 g/dL 12.2 ± 2.2 g/dL T2-10.9 ± 1.2 g/dL 9.1 ± 1.9 g/dL)。结论:pHiΔCO2 是对AAA术后器官衰竭相当敏感的预计性指数,但他们的特异性和精确度低于门静脉血乳酸。

(赵雪莲 李士通 校)

 

Our aim in this observational, prospective, noncontrolled study was to detect, in 29 patients who underwent abdominal aortic aneurysm (AAA) surgery, correlations between the incidence of postoperative organ failure and intraoperative changes in arterial and portal blood lactate; changes in intramucosal sigmoid pH (pHi); differences between sigmoid PCO2 and arterial PCO2 ({Delta}CO2); and hemoglobin (Hb). Hb, arterial blood lactate concentrations, pHi, and {Delta}CO2 (air tonometry) were recorded at the start of anesthesia (T0), before aorta clamping (T1), 30 minutes after clamping (T2), and at the end of surgery (T3). Portal venous lactate concentrations were recorded at T1 and T2. Patients were stratified into two groups: group A patients had no postoperative organ failure, and group B patients had one or more organ failures. As compared with group A (n = 16), group B patients (n = 13) had a lower pHi value at T2 and T3 and a higher {Delta}CO2 at T3. A pHi value of <7.15 was a predictor of organ failure, with a sensitivity of 92.3%, a specificity of 68.8%, and positive and negative predictive values of 70.6% and 91.7%, respectively, whereas a {Delta}CO2 value of >28 mm Hg predicted later organ failure with a sensitivity of 92.3%, a specificity of 62.5%, and positive and negative predictive values of 66.6% and 90.9%, respectively. Portal venous lactate concentrations were larger in group B at T2 (P < 0.001), and an increase ≥5 g/dL predicted later postoperative organ failure with a sensitivity of 92.3%, a specificity of 100%, and positive and negative predictive values of 100% and 94.1%, respectively. The comparison of the receiving operator characteristic curves to test the discrimination of each variable and the logistic regression analysis revealed that the increase in portal lactate was the best predictor for the development of postoperative organ failure. Hb concentration was significantly smaller in group B at T0 (13.8 ± 1.0 g/dL versus 12.2 ± 2.2 g/dL) and T2 (10.9 ± 1.2 g/dL versus 9.1 ± 1.9 g/dL). In conclusion, both pHi and {Delta}CO2 are reasonably sensitive prognostic indices of organ failures after AAA surgery, but they are less specific and accurate than portal venous lactate.

 

 

接受丙泊酚麻醉的儿童对低碳酸血症的脑血管反应

The Cerebrovascular Response to Hypocapnia in Children Receiving Propofol

 

Cengiz Karsli, BSc MD, FRCPC, Igor Luginbuehl, MD, and Bruno Bissonnette, BSc MD, FRCPC

From the Department of Anesthesia, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2004;99:1049-1052

 

低碳酸血症常用于处理神经外科手术时的急性颅内压升高。在丙泊酚麻醉中的儿童 ETCO2高于35 mmHg时,可保持脑血管对二氧化碳的反应(CCO2R);然而ETCO2低于35 mm Hg时,提示仍有一个平台作用。为深入描绘这一现象,我们应用跨颅多普勒超声技术(TCD),测量27例健康儿童在少量提高ETCO2时的CCO2R。麻醉由标准的丙泊酚输注加骶管阻滞组成。放置TCD探头来测定大脑中动脉血流速度(Vmca)。用一外源性CO2,使ETCO21–2 mm Hg增量逐步从24上升到40 mm Hg。当ETCO2值高于30 mm Hg时,ETCO2 Vmca之间呈指数关系(r = 0.82)。然而,只有当ETCO2上升到30 mm HgVmca才会开始随之变化(r = 0.06)。心率和动脉压均无显著性改变。我们得出结论:当用作降低脑容量和颅内压的方法时,过度通气使ETCO2值低于30 mm Hg对接受丙泊酚麻醉的儿童来说可能是不必要的,因为脑血流速度不会进一步降低。

(周志坚 李士通 )

 

Hypocapnia is used to treat acute increases in intracranial pressure during neurosurgery. Cerebrovascular reactivity to carbon dioxide (CCO2R) is preserved above 35 mm Hg ETCO2 in children during propofol anesthesia; however, a plateau effect has been suggested below 35 mm Hg. To further delineate this phenomenon, we measured CCO2R by transcranial Doppler (TCD) sonography over small increments in ETCO2 in 27 healthy children. Anesthesia comprised a standardized propofol infusion and a caudal epidural block. A TCD probe was placed to measure middle cerebral artery blood flow velocity (Vmca). ETCO2 was adjusted between 24 and 40 mm Hg at 1–2 mm Hg increments using an exogenous source of CO2. There was an exponential relationship between ETCO2 and Vmca above an ETCO2 value of 30 mm Hg (r = 0.82). However, Vmca did not change with ETCO2 less than 30 mm Hg (r = 0.06). There were no significant changes in heart rate or arterial blood pressure. We conclude that when contemplating methods to decrease brain volume and intracranial pressure, hyperventilation to ETCO2 values less than 30 mm Hg may not be necessary in children receiving propofol, as no further reduction in cerebral blood flow velocity will be achieved.

 

 

异丙酚引起的注射疼痛:改良后的异丙酚乳剂与预混合利多卡因的标准异丙酚的比较

Propofol-Induced Injection Pain: Comparison of a Modified Propofol Emulsion to Standard Propofol with Premixed Lidocaine

 

Sigrid Adam, MD, Jasper van Bommel, MD PhD, Michal Pelka, Maaike Dirckx, MD, David Jonsson, MD, and Jan Klein, MD PhD

Department of Anesthesiology, Erasmus Medical Center Rotterdam, The Netherlands

Anesth Analg 2004;99:1076-1079

 

众所周知,异丙酚在注射时会引起疼痛。减少此类疼痛的最常用方法是预先混合利多卡因。最近有人提倡一种改良的含有中链甘油三酯(MCT)和长链甘油三酯(LCT)的异丙酚脂肪乳剂与通常只含有长链甘油三酯(LCT)的异丙酚相比,能减轻疼痛。在222例外科患者中进行的一项随机、前瞻性、对照、双盲研究中,我们比较了上述两种溶液对注射痛的发生率和强度的影响。患者被随机地分入含MCT/LCT的异丙酚组(组Mn = 109)或只含LCT的标准异丙酚组(组Ln = 113),后一组每200 mg的异丙酚加入利多卡因20 mg1%的利多卡因2ml)。用从010分的视觉模拟评分法(VAS)来进行疼痛评分。发现注射异丙酚时,组L(平均VAS2.5 ± 2.9)(mean ± SD )与组M(平均VAS3.8 ± 3.2 P = 0.002)相比注射疼痛能明显要轻。关于术后回忆注射疼痛,组L患者所述疼痛(平均 VAS, 2.2 ± 2.4)与组M相比(平均VAS, 3.0 ± 2.7; P = 0.02)明显要轻。预先混合利多卡因20 mg1%的利多卡因2ml)到200 mg的标准异丙酚LCT在注射时引起的疼痛要比异丙酚MCT/LCT要轻,从而增加了患者的舒适感。

(陈玮      李士通  校)

 

Propofol is well known for its association with pain on injection. The most frequently used method to reduce this pain is premixture with lidocaine. Recently, a modified lipid emulsion of propofol containing medium-chain triglycerides (MCT) with long-chain triglycerides (LCT), in contrast to the usual LCT formulation, has been advocated to alleviate pain. In a randomized, prospective, controlled, double-blind study on 222 surgical patients, we compared the effect of the two solutions on the incidence and intensity of injection pain. Patients were randomly allocated to receive either propofol MCT/LCT (group M; n = 109) or standard propofol LCT with the addition of 20 mg of lidocaine (2 mL of lidocaine 1%) to 200 mg of propofol (group L; n = 113). Pain scores were assessed using a verbal analog scale (VAS) ranging from 0–10. Group L was found to have significantly less pain on the injection of propofol (mean VAS, 2.5 ± 2.9) (mean ± SD) than group M (mean VAS, 3.8 ± 3.2; P = 0.002). Regarding postoperative recall of pain on injection, patients in group L indicated significantly less pain (mean VAS, 2.2 ± 2.4) than patients in group M (mean VAS, 3.0 ± 2.7; P = 0.02). Premixing of 20 mg of lidocaine (2 mL of lidocaine 1%) to 200 mg of standard propofol LCT causes less pain on injection than propofol MCT/LCT and thus increases patient comfort.


顺式阿曲库铵在病态肥胖女性的作用

The Effects of Cisatracurium on Morbidly Obese Women

Yigal Leykin, MD MSc*, Tommaso Pellis, MD{ddagger}, Mariella Lucca, MD*, Giacomina Lomangino, MD{ddagger}, Bernardo Marzano, MD{dagger}, and Antonino Gullo, MD{ddagger}

*Departments of Anesthesia, Pain, Perioperative Medicine and Intensive Care, and {dagger}Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy; and the {ddagger}Department of Perioperative Medicine, Intensive Care and Emergency, Trieste University Medical School, Trieste, Italy

Anesth Analg 2004;99:1090-1094

 

阿曲库铵在肥胖患者的作用持续时间有不一致的报导。顺式阿曲库铵是阿曲库铵的一个同分异构体。我们观察了顺式阿曲库铵在病态肥胖患者的神经肌肉作用。20例肥胖女性患者(体重指数>40)随机分成两组。组In = 10)基于真实体重(RBW)给予顺式阿曲库铵0.2 mg/kg,而组IIn = 10)基于理想体重(IBW)计算剂量。在10例正常体重女性患者的对照组(体重指数20-24),顺式阿曲库铵的剂量基于RBW。用拇内收肌的肌加速度监测神经肌肉传递,用雷米芬太尼和异丙酚麻醉诱导和维持。组I和对照组的起效时间相近(132 s135 sP = ns)。组I25%持续时间比对照组长(74.6 min59.1 minP = 0.01),对照组比组II长(45.0 minP =0.016)。得出结论:如果根据RBW计算病态肥胖患者顺式阿曲库铵的剂量,则其作用持续时间比正常体重的对照组延长。对照组患者的作用持续时间也比基于IBW给予药物的病态肥胖患者长。

(马皓琳 李士通 校)

 

There is conflicting evidence on the duration of action of atracurium in obese patients. Cisatracurium is one of the stereoisomers of atracurium. We investigated the neuromuscular effects of cisatracurium in morbidly obese patients. Twenty obese female patients (body mass index >40) were randomized in two groups. Group I (n = 10) received 0.2 mg/kg of cisatracurium on the basis of real body weight (RBW), whereas in Group II (n = 10) the dose was calculated on ideal body weight (IBW). In a control group of 10 normal weight female patients (body mass index 20–24), the dose of cisatracurium was based on RBW. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis, and anesthesia was induced and maintained with remifentanil and propofol. Onset time was comparable between Group I and the control group (132 s versus 135 s; P = ns). The duration 25% was longer in Group I than in the control group (74.6 min versus 59.1 min; P = 0.01) and in the control group compared with Group II (45.0 min; P = 0.016). In conclusion, the duration of action of cisatracurium was prolonged in morbidly obese patients when dosed according to RBW compared with a control group of normal weight patients. Duration was also prolonged in the control group patients compared with morbidly obese patients to whom the drug was administered on the basis of IBW.

 

 

吸入异氟醚增强正压通气时生理死腔的增加并使动脉氧合受损

Isoflurane Inhalation Enhances Increased Physiologic Deadspace Volume Associated with Positive Pressure Ventilation and Compromises Arterial Oxygenation

 

Claudia Praetel, MD*, Michael J. Banner, PhD*,{dagger}, Terri Monk, MD*, and Andrea Gabrielli, MD*,{ddagger}

Departments of *Anesthesiology, {dagger}Physiology, and {ddagger}Surgery, University of Florida College of Medicine, Gainesville, Florida

Anesth Analg 2004;99:1107-1113

 

生理死腔容积(VDphys) 异常增加,包括肺泡死腔容积和气道死腔容积,是诱发动脉血气交换受损的病因因素之一。我们比较两种全麻方法结合正压通气(PPV)对VDphys的影响:全凭静脉麻醉(TIVA)和吸入异氟醚麻醉。研究40例没有呼吸系统疾病病史的仰卧位择期手术的病人。使用交叉方案,所有病人循序随机接受全部两种麻醉方式。与术前自主呼吸的基础值相比,PPVTIVA使VDphys164 ± 60 mL 明显增加到264 ± 79 mL (P < 0.05)。吸入异氟醚联合PPV显著增强此增加作用,使VDphys增加两倍到315 ± 80 mL (P < 0.05)。同样地,应用异氟醚时肺泡死腔容积增加超过200%。此外,异氟醚吸入(呼气末浓度1.15%)导致动脉氧合减少,表现为PaO2/吸入氧分压比从基础值387 ± 35显著降低到310 ± 70 (P < 0.05)。尽管TIVA结合PPV时显著增加VDphys,这个不利的改变远小于异氟醚吸入结合PPV。此发现可能适用于肺功能受损的病人(例如,急性呼吸窘迫综合征或者严重的吸入性灼伤)。

(张曦 李士通 校)

 

Abnormally increased physiologic deadspace volume (VDphys), consisting of alveolar deadspace volume and airway deadspace volume, is one of several causative factors predisposing to compromised arterial blood gas exchange. We compared the effects of two methods of general anesthesia on VDphys when combined with positive pressure ventilation (PPV): total IV anesthesia (TIVA) and inhaled anesthesia with isoflurane. Forty patients with no history of pulmonary pathology undergoing elective surgery in the supine position were studied. A crossover design was used, and all patients received both anesthetic methods sequentially in randomized order. PPV and TIVA significantly increased VDphys compared with baseline (preoperative and breathing spontaneously) from 164 ± 60 mL to 264 ± 79 mL (P < 0.05). Isoflurane inhalation combined with PPV significantly enhanced this increase, resulting in a twofold increase in VDphys to 315 ± 80 mL (P < 0.05). Also, alveolar deadspace volume increased by more than 200% with isoflurane. Furthermore, isoflurane inhalation (1.15% end-tidal concentration) resulted in impaired arterial oxygenation, as evidenced by a significant decrease in the PaO2/fractional inspired oxygen concentration ratio compared with baseline values from 387 ± 35 to 310 ± 70 (P < 0.05). Although significant increases in VDphys resulted with PPV combined with TIVA, these adverse changes were much less compared with isoflurane inhalation and PPV. These findings may apply to subjects with compromised pulmonary function (i.e., acute respiratory distress syndrome or severe inhalational burn injury).



Delta-9四氢大麻酚对人类血小板的促凝血作用

The Procoagulatory Effects of Delta-9-Tetrahydrocannabinol in Human Platelets

 

Engelbert Deusch, MD, Hans Georg Kress, MD PhD, Birgit Kraft, MD, and Sibylle A. Kozek-Langenecker, MD

Department of General Anesthesiology and Intensive Care B, Vienna Medical University, Vienna, Austria

Anesth Analg 2004;99:1127-1130

 

Delta-9四氢大麻酚(THC)在恶心,呕吐,恶病质和慢性疼痛长期治疗方面的运用逐渐增多。然而,最近的报道指出THC摄入后心肌梗塞和血栓性脉管炎的危险性增加。血小板在这两种疾病的发病机理中起本质的作用,但血小板是否是大麻酚潜在的靶细胞仍不清楚。我们在这项离体研究中调查了THC对人类血小板的作用和其细胞膜上大麻酚受体的表达。用流式细胞仪测量THC(终浓度范围10-7 10-5 M)对活化血小板纤维蛋白原受体(糖蛋白IIb-IIIa)表达以及P 物质的影响。用血小板膜标本施行Western blotting以确定在人类血小板表面上大麻酚受体的表达。THC以浓度依赖方式增加人血小板上糖蛋白IIb-IIIa的表达和P物质。两个已知的大麻酚受体(CB1CB2)都在人类血小板细胞膜上检测到。我们这个功能上的结果可能提示THC介导血小板活化的一种受体依赖途径。无论如何,需要进一步的体内研究来评价大麻酚受体在介导已经证明的THC促凝血作用方面的影响。

(吴俭 李士通 校)

 

Delta-9-tetrahydrocannabinol (THC) is increasingly used for the long-term treatment of nausea, vomiting, cachexia, and chronic pain. Recent reports, however, have indicated an increased risk of myocardial infarction and thromboangiitis obliterans after THC intake. Blood platelets have an essential role in the pathogenesis of these two diseases, but it is unclear whether platelets are potential target cells for cannabinoids. We investigated the effects of THC on human platelets and the expression of cannabinoid receptors on their cell membranes in this in vitro study. The effects of THC (final concentrations 10–7 to 10–5 M) on the expression of activated platelet fibrinogen receptor (glycoprotein IIb-IIIa) and P selectin were characterized by flow cytometry. Western blotting was performed with platelet membrane preparations to determine the surface expression of cannabinoid receptors on human platelets. THC increased the expression of glycoprotein IIb-IIIa and P selectin on human platelets in a concentration-dependent manner. The two known cannabinoid receptors (CB1 and CB2) were both detected on the cell membrane of human platelets. Our functional results may suggest a receptor-dependent pathway of THC-induced platelet activation. However, further in vivo studies are warranted to evaluate the role of cannabinoid receptors in mediating the demonstrated procoagulatory effect of THC.


七氟醚麻醉中脑电双频指数和快速提取听觉诱发电位指数对伤害性刺激的反应的比较

A Comparison of Bispectral Index and Rapidly Extracted Auditory Evoked Potentials Index Responses to Noxious Stimulation During Sevoflurane Anesthesia

 

A. Ekman, MD DEAA*, L. Brudin, MD PhD{dagger}, and R. Sandin, MD PhD*

Departments of *Anesthesiology and Intensive Care and {dagger}Clinical Physiology, Regional Hospital, Kalmar, Sweden

Anesth Analg 2004;99:1141-1146

 

21名患者接受七氟醚麻醉,在伤害性刺激存在和不存在的情况下,同时比较其脑电双频指数(BIS)和快速提取听觉诱发电位指数(AAI)显示七氟醚脑内浓度增加时的效应的能力。BIS/AAI监测的同时,也监测血流动力学参数。于15分钟内调节吸入七氟醚至BIS50-55,再使这一七氟醚呼气末浓度(1.46% ±0.20%)加倍,随后15分钟内任意随机时刻给予一伤害性刺激――喉镜检查。在七氟醚呼气末浓度加倍后,BIS值明显下降,而AAI值仅稍有下降(P <0.0001))。七氟醚吸入增加并未减轻BIS/AAI对于喉镜检查的反应。在伤害性刺激后,3名患者的AAI值超过了最高推荐参考值25,而所有患者的BIS值都没有超过推荐阈值60BISAAI的反应时间分别为44.5 ± 26秒和47 ±31秒。结果提示,在与外科七氟醚麻醉相关的催眠水平,BISAAI或血流动力学参数能更好地显示药物相关性催眠水平的改变,但是BISAAI对于伤害性刺激的反应时间并无明显差别。

(周雅春 李士通 )

 

In 21 patients given sevoflurane anesthesia, we simultaneously compared the abilities of Bispectral Index (BIS) and rapidly extracted auditory evoked potentials index (AAI) to display the effect of an increasing cerebral concentration of sevoflurane, with and without noxious stimulation. In addition to BIS/AAI, hemodynamic variables were monitored. After titrating sevoflurane to BIS = 50–55 during 15 min, the end-tidal concentration of sevoflurane (1.46% ± 0.20%) was doubled followed by a noxious stimulus, laryngoscopy, applied at random time points within the following 15 min. After the end-tidal concentration of sevoflurane was doubled, a substantial reduction in BIS was observed, whereas only a slight reduction in AAI was seen (P < 0.0001). BIS/AAI responses to laryngoscopy were not attenuated with increasing wash-in of sevoflurane. After noxious stimulation, AAI exceeded the highest recommended value, 25, in 3 cases, whereas BIS did not exceed the recommended threshold, 60, in any of the patients. Response times for BIS and AAI were 44.5 ± 26 and 47 ± 31 s, respectively. These results suggest that, at a hypnotic level associated with surgical sevoflurane anesthesia, BIS better displays drug-related alterations in the level of hypnosis than AAI or hemodynamic variables but there is no difference between BIS and AAI in the time to response to a noxious stimulus.


低流量麻醉中基于模型的预测性显示对七氟醚呼气末浓度控制的效果

The Effect of a Model-Based Predictive Display on the Control of End-Tidal Sevoflurane Concentrations During Low-Flow Anesthesia

 

R. Ross Kennedy, MB ChB, PhD, FANZCA, Richard A. French, MB BS, FANZCA, and Sandra Gilles, BAgSci

Department of Anaesthesia, Christchurch Hospital and Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

Anesth Analg 2004;99:1159-1163

 

我们已经显示多室模型能正确地预测七氟醚(sevo)和异氟醚的呼气末(ET)浓度。这个模型已适于用实时新鲜气流量和挥发罐设置来显示10分钟ET sevo浓度的预测值。在这项研究中,由麻醉医生评估了这种预测性显示反映ET sevo变化的速度和精确性的效果。研究15sevo麻醉预期持续超过 2 小时的病人。无协助或有预测性显示时分别进行ET靶浓度的四步变化 (+0.5+1.0、–1.0 和–0.5 vol%)。新鲜气流量为 1 L/min。通过用双尾配对t检验来比较响应时间、最大过冲量以及达到靶浓度后5 分钟的稳定性。有预测性显示时的变化比没有预测性显示时平均快1.5~2.3倍。在+0.5+1.0和–0.5 vol% 这几步变化时的差异有统计学意义 (P<0.05),但在–1.0 vol%时没有统计学意义。过冲量的程度和稳定性没有差异。这些差异和自动反馈控制系统相似。这种系统可以简化挥发性麻醉的给药和低流量麻醉的使用。

(朱 李士通 校)

 

We have shown that a multicompartment model accurately predicts end-tidal (ET) sevoflurane (sevo) and isoflurane concentrations. The model has been adapted to use real-time fresh gas flow and vaporizer settings to display a 10-min prediction of ET sevo concentrations. In this study, we evaluated the effect of the predictive display on the speed and accuracy of changes in ET sevo by the anesthesiologist. Fifteen patients were studied in whom sevo-based anesthesia was expected to last more than 2 h. Four step changes of target ET concentration (+0.5, +1.0, –1.0, and –0.5 vol%) were made either unaided or with the prediction display. Fresh gas flow was 1 L/min. Response time, maximum overshoot, and stability in the 5 min after the target was achieved were compared by using two-tailed paired Student’s t-tests. Changes were made on average 1.5–2.3 times faster with the predictive display than without it. These differences were statistically significant (P < 0.05) for the +0.5, +1.0, and –0.5 vol% step changes but not for the –1.0 vol% change. There were no differences in the degree of overshoot or stability. These differences are comparable to those seen with an automatic feedback control system. This system may simplify the administration of volatile anesthesia and the use of low-flow anesthesia.


用大鼠击尾和压爪试验测试椎管内加巴喷丁对蛛网膜下腔吗啡耐药性的影响

The Effects of Intrathecal Gabapentin on Spinal Morphine Tolerance in the Rat Tail-Flick and Paw Pressure Tests

 

C. Hansen*, I. Gilron*,{dagger}, and M. Hong*,{dagger}

Departments of {dagger}Anesthesiology and *Pharmacology & Toxicology, Kingston General Hospital, Queen’s University, Ontario, Canada

Anesth Analg 2004;99:1180-1184

 

对阿片类药物镇痛作用的耐药性在实验和临床条件中都有描述,这可能会限制此类药物在临床上的应用。我们以往的研究表明全身性应用加巴喷丁(GBP,一种非阿片类药物)可以预防和逆转大鼠对全身性应用吗啡的耐药性。在本研究中,我们探讨了椎管内应用GBP对蛛网膜下腔吗啡耐药性的影响。实验大鼠分别在7天里给予椎管内注射生理盐水(10µL)、GBP300µg)、吗啡(15µg)或GBP-吗啡联合应用,在注药前和注药后30min进行打尾和压爪试验来测试镇痛作用。在第8天时绘制每一实验组的抗伤害性刺激的剂量-反应曲线并计算出吗啡(单用)的50%有效剂量(ED50)。结果:同时注射GBP和吗啡可以阻断耐药性的进展,与单用吗啡组相比,可以维持吗啡的镇痛作用超过7天,而且第8天的吗啡ED50值降低。尽管不能排除第17天期间GBP的附加镇痛作用,GBP-吗啡联合应用组ED50的降低的确提示了对耐药性的一些抑制。这些资料支持以往对GBP预防阿片类药物耐药性的证据,同时更明确地提示椎管内应用GBP能预防脊麻阿片类药物耐药性的发展。需要进一步的研究来检查GBP-吗啡相互作用在脊髓以上和外周部位各自所起的作用以及研究解释GBP影响阿片类药物耐药性作用的机制。

(黄施伟 李士通 校)

 

Analgesic tolerance to opioids has been described in both experimental and clinical conditions and may limit the clinical utility of these drugs. We have previously shown that systemic gabapentin (GBP), a non-opioid drug, prevents and reverses tolerance to systemic morphine in the rat. In this study, we investigated the effect of intrathecal GBP on spinal morphine tolerance. Studied rats were given 7 days of intrathecal injections with saline (10 µL), GBP (300 µg), morphine (15 µg), or a GBP-morphine combination, and analgesic testing using tail-flick and paw-pressure tests was conducted before and 30 min after the drug injection. On Day 8, an antinociceptive dose-response curve was constructed and the 50% effective dose (ED50) values for morphine (given alone) were calculated for each study group. Coinjection of GBP with morphine blocked the development of tolerance, as shown by the preservation of morphine analgesia over 7 days as well as by a concomitant decrease in ED50 values on Day 8, as compared with the morphine-alone group. Although additive analgesia over Days 1–7 cannot be ruled out, ED50 reductions in the GBP-morphine combination group indeed suggest some suppression of tolerance. These data support previous evidence that GBP prevents opioid tolerance and, more specifically, indicate that intrathecal GBP prevents the development of spinal opioid tolerance. Future studies are required to examine the respective roles of supraspinal and peripheral sites of GBP-morphine interaction and to investigate the mechanisms underlying the action of GBP on opioid tolerance.


甲状旁腺激素在枸橼酸抗凝的急性重症血液透析维持患者中的分泌

Parathyroid Hormone Secretion During Citrate Anticoagulated Hemodialysis in Acutely Ill Maintenance Hemodialysis Patients

 

Robert Apsner, MD*, Diego Gruber{dagger}, Walter H. Hörl, MD PhD, FRCP*, and Gere Sunder-Plassmann, MD*

*Department of Medicine III, Division of Nephrology and Dialysis, and {dagger}Department of Medical Statistics, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:1199-1204

 

有出血风险的患者在体外治疗时使用局域性枸橼酸抗凝。我们进行了一项前瞻性临床实验,研究枸橼酸抗凝血透期间,大剂量或小剂量补钙对钙离子浓度和全血甲状旁腺激素(iPTH)的影响。对25例活动性出血或有出血风险的患者进行研究治疗。治疗中大剂量补钙组(15 mmol/h) 16例,小剂量组(5 mmol/h) 9例。大剂量钙组16例中的13例钙离子浓度增高,小剂量钙组9例中的8例下降。全血甲状旁腺激素在大剂量组下降了25%,在小剂量组增高了121%(变量值△的P = 0.0007,百分变量△%的P = 0.007 )。钙离子增高的14例患者的iPTH降低。11例离子钙下降的患者中有10iPTH增高。离子钙的增高或降低比补钙速度更能预测iPTH的变化(R2分别为0.5526 0.3962)。我们的结论是治疗期间通过调节补钙速度可以预测性地影响iPTH的水平。

(轩泓 李士通 校)

 

Regional citrate anticoagulation during extracorporeal treatment is used in patients at risk for hemorrhage. We conducted a prospective clinical trial on the effect of large- versus small-dose calcium supplementation during citrate anticoagulated hemodialysis on ionized calcium and intact parathyroid hormone (iPTH). Twenty-five treatments were studied in 25 patients with active bleeding or at risk for hemorrhage. Sixteen patients received large-dose calcium (15 mmol/h), and 9 received small-dose calcium (5 mmol/h) substitution during treatment. Ionized calcium increased in 13 of 16 patients in the large-dose calcium group and decreased in 8 of 9 patients in the small-dose calcium group. Intact PTH decreased by 25% in the large-dose group and increased by 121% in the small-dose group (P = 0.0007 for {Delta}; P = 0.007 for {Delta}%). In the 14 patients in whom ionized calcium increased, iPTH decreased. In 10 of 11 patients in whom ionized calcium decreased, iPTH increased. The increase or decrease of ionized calcium was more predictive for changes in iPTH than was the calcium-substitution rate (R2 = 0.5526 versus 0.3962, respectively). We conclude that the behavior of iPTH can be influenced in a predictive manner by adjusting the calcium-substitution rate during treatment.


比较单次或分次注射用于喙突旁锁骨下臂丛神经阻滞对麻醉范围的影响

A Comparison of Single Versus Multiple Injections on the Extent of Anesthesia with Coracoid Infraclavicular Brachial Plexus Block

 

Jaime Rodríguez, MD PhD, M. Bárcena, MD, M. Taboada-Muñiz, MD, J. Lagunilla, MD, and J. Álvarez, MD PhD

Department of Anesthesiology, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain

Anesth Analg 2004;99:1225-1230

 

单次注射用于喙突旁锁骨下臂丛神经阻滞对上肢产生的麻醉效果是不确切的。在本研究中,我们拟探讨为提供完善的上肢麻醉效果所需要的锁骨下臂丛神经阻滞的注射次数。75例病人用神经刺激器指导喙突旁臂丛神经阻滞,随机用1.5%的甲哌卡因42ml行单次注射(组1)、分两次注射(组2)或分三次注射(组3)。三组病人均未探索特异的的运动反应。局麻药注射完毕后5分钟和20分钟测量感觉和运动阻滞。组1病人中 20分钟时用针刺法测量的腋神经、肌皮神经、桡神经、尺神经和前臂内侧皮神经分布区域的麻醉明显较不完善;手臂、腕和手的运动麻痹明显也较不完善。组2病人与组3相比差别不显著。我们得出结论,在神经刺激器指导下两或三次注射局麻药与单次注射相比,能增强臂丛神经阻滞的效果。

(邱郁薇      李士通  校)

 

Single-injection coracoid infraclavicular brachial plexus block produces inconsistent anesthesia of the upper limb. In this study, we sought to determine the number of injections needed to provide a reasonably complete anesthesia of the upper limb with this approach. Seventy-five patients were randomly assigned to receive a coracoid block guided by nerve stimulator with 42 mL of 1.5% mepivacaine with a single-injection (Group 1), dual-injection (Group 2), or triple-injection (Group 3) technique. No search for a specific motor response was performed in any group. Sensory and motor block was assessed 5 and 20 min after the end of the injection of local anesthetic. Significantly less complete anesthesia to pinprick in the distributions of the axillary, musculocutaneous, radial, ulnar, and medial cutaneous forearm nerves was found in Group 1 at 20 min. Significantly less complete paralysis for arm, wrist, and hand movements was found in Group 1 at 20 min. No significant difference was found between Groups 2 and 3. We conclude that dual and triple injection of local anesthetic guided by nerve stimulator increases the efficacy of coracoid block when compared with a single-injection technique.


围手术期稳定的一氧化氮产物血浆浓度是腹腔镜胆囊切除术后认知功能障碍的预测指标

Perioperative Plasma Concentrations of Stable Nitric Oxide Products Are Predictive of Cognitive Dysfunction After Laparoscopic Cholecystectomy

 

G. Iohom, FCARCSI*, S. Szarvas, MD DEEA*, V. Larney, FCARCSI*, J. O’Brien, FCARCSI*, E. Buckley, FCARCSI*, M. Butler, MSc{dagger}, and G. Shorten, PhD*

Departments of *Anaesthesia and Intensive Care Medicine and {dagger}Clinical Biochemistry, Cork University Hospital, Cork, Ireland

Anesth Analg 2004;99:1245-1252

 

这个研究的目标是为了确定年龄在40岁和85岁之间的患者在七氟醚吸入麻醉下进行的腹腔镜胆囊切除术术后认知障碍(POCD)的发生率,并检验i)S-100ß蛋白质及ii)稳定的一氧化氮(NO)产物这二者的血浆浓度与在这种临床条件下发生POCD的联系。分别在术前一天及术后第四天和第六周,对42ASA病情分级I-II级的病人进行了神经心理学的试验。并对患者的配偶(n=13)进行对照研究。将一种或更多的认知领域缺陷定义为认知功能障碍。在围手术期对S-100ß蛋白质的血清浓度及稳定的NO产物(硝酸盐/亚硝酸盐,NOx)的血浆浓度进行了一系列的测定 。手术后第四天分别有16名患者(占40%)及1名对照对象(占7%)出现了新的认知缺陷(P = 0.01)。术后六周,有21名患者(占53%)及3名对照对象(占23%)出现新的认知缺陷(P = 0.03)。与“无缺陷组”相比,术后4天就表现出新的认知缺陷的病人,在每一个围术期时间点的NOx血浆浓度均较大(每一的时间点均P < 0.05)。而两组的S-100ß蛋白血清浓度相似。结论,手术前(及手术后)稳定的NO产物的血浆浓度(而不是S-100ß)与早期POCD有关。前者为POCD提供了一个可能的生化预报指标。

(黄丽娜 李士通 校)

 

In this study our objectives were to determine the incidence of postoperative cognitive dysfunction (POCD) after laparoscopic cholecystectomy under sevoflurane anesthesia in patients aged >40 and <85 yr and to examine the associations between plasma concentrations of i) S-100ß protein and ii) stable nitric oxide (NO) products and POCD in this clinical setting. Neuropsychological tests were performed on 42 ASA physical status I–II patients the day before, and 4 days and 6 wk after surgery. Patient spouses (n = 13) were studied as controls. Cognitive dysfunction was defined as deficit in one or more cognitive domain(s). Serial measurements of serum concentrations of S-100ß protein and plasma concentrations of stable NO products (nitrate/nitrite, NOx) were performed perioperatively. Four days after surgery, new cognitive deficit was present in 16 (40%) patients and in 1 (7%) control subject (P = 0.01). Six weeks postoperatively, new cognitive deficit was present in 21 (53%) patients and 3 (23%) control subjects (P = 0.03). Compared with the "no deficit" group, patients who demonstrated a new cognitive deficit 4 days postoperatively had larger plasma NOx at each perioperative time point (P < 0.05 for each time point). Serum S-100ß protein concentrations were similar in the 2 groups. In conclusion, preoperative (and postoperative) plasma concentrations of stable NO products (but not S-100ß) are associated with early POCD. The former represents a potential biochemical predictor of POCD.

 

依照体表标志行颈内静脉穿刺时头部最佳的旋转位置

Optimal Head Rotation for Internal Jugular Vein Cannulation When Relying on External Landmarks

Jeremy A. Lieberman, MD, Kayode A. Williams, MD, and Andrew L. Rosenberg, MD

Department of Anesthesiology and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan

Anesth Analg 2004;99:982-988

 

外部解剖标志历来被用于估计颈部血管位置以最好地行颈内静脉(IJV) 穿刺而避免误穿颈总动脉(CCA).。头部旋转的位置影响血管的定位,然而大多数的定位方法并不规定其最佳的旋转程度。我们在49位志愿者身上以持握注射器及针头的方式使用超声波探头,通过前路及中路法对右IJV模拟行导管置入。从中线往左15° 30° 45°60°,随着头部旋转角度的逐渐增加,模拟针头触及IJVCCA的可能性也越大。对于这两种方法而言,当头位旋转≤45°时,触及CCA的危险性<10%。当头位旋转至45° 60°时,随着体表面积(BSA)及体重指数(BMI)的增加,也更多地触及CCA。为了最好地触及IJV并减少不慎误穿CCA的发生率,对于高BMIBSA的病人,须将头旋转至不大于30°,但对于低BMIBSA的病人,可将头旋转至60°

(裘毅敏 译,李士通 校)

 

External anatomic landmarks have traditionally been used to approximate the location of the neck blood vessels to optimize central venous cannulation of the internal jugular vein (IJV) while avoiding the common carotid artery (CCA). Head rotation affects vessel orientation, but most landmark techniques do not specify its optimal degree. We simulated catheter insertion via both an anterior and central approach to the right IJV using an ultrasound probe held in the manner of a syringe and needle in 49 volunteers. Increased head rotation from 0°, 15°, 30°, 45°, and 60° to the left of midline was associated with higher probability of a simulated needle contacting the IJV and the CCA. For both approaches, the risk of CCA contact was <10% for head rotations of ≤45°. Increased body surface area (BSA) and body mass index (BMI) were associated with more CCA contact at head rotations of 45° or 60°. To optimize IJV contact while reducing the likelihood of inadvertent contact with the CCA, the head should be rotated no more than 30° in patients with high BMI or BSA, but it may be turned to 60° if BMI or BSA is low.