Anesthesia & Analgesia

October 2004

Table of Content

 

 

CARDIOVASCULAR ANESTHESIA:

不停跳冠狀動脈搭橋手術是否降低多支搭橋後臨床腎功能障礙的發生率?

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.

非體外迴圈進行冠狀動脈搭橋手術時經食管超聲監測部分心室壁的運動

葛甯花譯 薛張剛校

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.

體外迴圈期間血液稀釋增加鼠大腦中動脈阻塞的腦梗塞容積

(殷文淵 譯 陳傑 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

依照體表標誌行頸內靜脈穿刺時頭部最佳的旋轉位置

裘毅敏 譯,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.

體外迴圈時零級平衡超濾體外清除高濃度的Tirofiban:一項體內的研究

葛甯花譯 薛張剛校

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啟動介導異氟醚引起的大鼠離體缺血心臟功能和代謝恢復的改善

殷文淵 譯 陳傑 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

比較持續正壓通氣和無創壓力支持通氣方法用於治療心臟手術後的肺不張

張俊傑 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.

老年心臟外科手術預防性聯合使用β- 阻滯劑艾司洛爾和磷酸二酯酶抑制劑依諾昔酮

葛甯花譯 薛張剛校

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

血管緊張素轉換酶活性:在全膝關節成形術期間估計肺變化的新方法

顧漪聞 譯 陳傑 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

腹主動脈瘤手術患者門靜脈乳酸鹽、乙狀結腸粘膜內pH和△CO2PaCO2局部 PCO2)作為併發症指數的比較

趙雪蓮 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:

經外周放置中心靜脈導管:小兒外科手術中的一項隨機、對照和前瞻性研究

葛甯花譯 薛張剛校

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.

麻醉下兒童應用動脈刺激靜脈採樣試驗(ASVS)對高胰島素血症病灶定位期間的血糖控制

顧漪聞 譯 陳傑 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.

接受丙泊酚麻醉的兒童對低碳酸血症的腦血管反應

周志堅 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.

小兒術前多系統的評估

葛甯花譯 薛張剛校

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

Lynne R. Ferrari

Anesth Analg 2004 99: 1058-1069

AMBULATORY ANESTHESIA:

電針穴位刺激或樞複寧與安慰劑比較在預防術後噁心嘔吐的隨機對照研究

朱慧琛 譯 陳傑 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.

異丙酚引起的注射疼痛:改良後的異丙酚乳劑與預混合利多卡因的標準異丙酚的比較

陳瑋      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:

異丙酚或七氟醚麻醉時用觸覺法評估拮抗羅庫嗅胺誘發的神經肌肉阻滯作用

葛甯花譯 薛張剛校

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.

病態肥胖患者根據真實體重或理想體重使用羅庫溴胺的藥效學比較

朱慧琛 譯 陳傑 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.

順式阿曲庫銨在病態肥胖女性的作用

馬皓琳 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

異丙酚對鼠海馬橫切面癲癇樣活動的抗驚厥作用

葛甯花譯 薛張剛校

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腸蠕動

朱輝 譯 陳傑 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.

吸入異氟醚增強正壓通氣時生理死腔的增加並使動脈氧合受損

張曦 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.

椎管內大劑量蘇芬太尼能預防腹部大手術時的激素應急反應:與靜脈使用蘇芬太尼的前瞻性

葛甯花譯 薛張剛校

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導的血小板選擇蛋白的表達和血小板-白細胞結合物的形成

朱輝 譯 陳傑 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-9四氫大麻酚對人類血小板的促凝血作用

吳儉 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.

異丙酚並不抑制利多卡因硬膜外阻滯時的代謝

葛甯花譯 薛張剛校

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受體GluRε1亞基的小鼠對氯胺酮和苯巴比妥的敏感性降低

趙延華 譯 陳傑 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:

七氟醚麻醉中腦電雙頻指數和快速提取聽覺誘發電位指數對傷害性刺激的反應的比較

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

清醒志願者俯臥位時軀體傾斜度對眼內壓的影響:兩種手術床的比較

趙延華 譯 陳傑 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.

低流量麻醉中基於模型的預測性顯示對七氟醚呼氣末濃度控制的效果

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:

緩激肽拮抗劑對切口疼痛沒有鎮痛作用

葛甯花譯 薛張剛校

Bradykinin Antagonists Have No Analgesic Effect on Incisional Pain

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

Anesth Analg 2004 99: 1166-1172.

腹膜內注射安慰劑或局麻藥緩解腹式子宮切除術後疼痛的雙盲對照試驗

齊波 譯 陳傑 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

 

用大鼠擊尾和壓爪試驗測試椎管內加巴噴丁對蛛網膜下腔嗎啡耐藥性的影響

黃施偉 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:

美國麻醉培訓計畫的人員和資金:2002-2003

葛甯花譯 薛張剛校

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:

雷米芬太尼對腦外傷病人行氣管內吸引時引起顱內壓升高的效果

齊波 譯 陳傑 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.

甲狀旁腺激素在枸櫞酸抗凝的急性重症血液透析維持患者中的分泌

軒泓 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:

嚴重顱腦外傷伴或不伴有顱內高壓時血壓變化對大腦血流動力學的影響

葛甯花譯 薛張剛校

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鎮痛:股神經阻滯和靜注芬太尼的比較

田婕 譯 陳傑 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.

比較單次或分次注射用於喙突旁鎖骨下臂叢神經阻滯對麻醉範圍的影響

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.

椎管內小劑量可樂定和等比重布比卡因用於矯形手術:一個劑量依賴的研究

葛甯花譯 薛張剛校

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:

全關節成形術中輸注同種異體血的預測

田婕 譯 陳傑 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.

圍手術期穩定的一氧化氮產物血漿濃度是腹腔鏡膽囊切除術後認知功能障礙的預測指標

黃麗娜 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.

氣管插管前用利多卡因進行喉氣管表面麻醉能減少全麻蘇醒拔管時的嗆咳反應

葛甯花譯 薛張剛校

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.

體外迴圈期間血液稀釋增加鼠大腦中動脈阻塞的腦梗塞容積

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.

 

雖然體外迴圈中理想的紅細胞壓積沒有定義,但過度的血液稀釋可能導致器官缺血,這是由於降低了氧輸送能力且不能通過血管自動調節和/或血流流變學的改變來增加器官血流。血液稀釋對病人腦缺血的風險並不十分明確。作者設計本實驗來評估CPB期間血液稀釋對存在局部腦缺血情況下的影響。準備CPB手術的Wister鼠隨機分為血液稀釋組〔血紅蛋白(Hb), 6 g/dL; n = 9〕或(Hb, 11 g/dL; n = 8)對照組,隨後接受大腦中動脈阻塞(MACO)引起的局部腦缺血。大腦中動脈阻塞開始後行低溫(28°CCPB65分鐘。24小時後,測定功能性神經學預後和腦梗塞容積。與對照組相比,血液稀釋組的神經學方面表現更差(血液稀釋組評分為8 [2], 對照組評分為10 [2], P = 0.030),腦梗面積更大(血液稀釋組182 ± 84 mm3,對照組103 ± 58 mm3, P = 0.043)。在這個可逆性MACO導致局部腦缺血的CPB試驗模型中,血液稀釋惡化了神經功能同時增加了腦梗塞容積。

(殷文淵 譯 陳傑 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啟動介導異氟醚引起的大鼠離體缺血心臟功能和代謝恢復的改善

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.

 

異氟醚能增強缺血後心肌功能恢復和改善能量水平。作者試圖測定異氟醚誘導的心肌保護是否通過蛋白激酶CPKC)來介導。使用Langendorff模型,離體灌注大鼠心臟被分為未治療組, 異氟醚組, 白屈菜紅堿(PKC抑制劑)加異氟醚組和白屈菜紅堿組。所有心臟都在缺血前接受治療,隨後30分鐘的缺血和60分鐘再灌注。記錄血流動力學參數,通過高效液相色譜儀測定代謝產物,通過Westen blot方法分析PKC亞型的亞細胞定位。異氟醚顯著改善左室壓力的恢復,減少了缺血15分鐘時心肌ATP和磷酸激酶的消耗,增強缺血後心肌ATP和肌磷酸的恢復。並且與PKC-{delta} -{epsilon}易位相關。白屈菜紅堿抑制了PKC-{delta}-{epsilon}的易位,阻滯了心功能和ATP的改善。作者認為缺血時異氟醚延長了ATP的下降,缺血後60分鐘改善了心肌機械功能和能量狀態的恢復。異氟醚的這些作用依賴PKC的啟動。

(殷文淵 譯 陳傑 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.

 

血管緊張素轉換酶活性:在全膝關節成形術期間估計肺變化的新方法

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.

 

全膝關節成形術(TKA)中,當止血帶釋放(TR)時,每個病人中都會形成栓子。這可能會導致脂肪栓塞綜合症性肺損傷。血管緊張素轉換酶(ACE)和肺內皮有關, ACE的代謝或HBPAP水解(H-benzoyl-Phe-Ala-Pro氫苯甲酰苯丙氨酸脯氨酸,ACE特有的底物)降低與肺損傷有關。作者評估了在TKA手術中這種測定法和肺損傷之間的關係。連續11個行雙側TKA的病人,在圍手術期測量ACE。作者檢測了ACE底物水解和肺毛細血管表面積(毛細血管灌注指數;CPI),以及與其相關的肺血管阻力(PVR)和臨床結果。在第一次或第二次釋放止血帶時,和基礎值相比,11個病人中有10個顯示出其ACE底物水解和CPI的增加,同時伴有PVR的降低(P<0.05)。一名病人在TR後,PVR持續增加,同時在手術結束後伴有CPIACE底物水解的降低。但是,與所有其他病人無不良臨床表現不同,該病人逐漸發展為神志不清,低氧。在以往的研究中, CPI增高伴有PVR降低,正像本試驗中的10個病人一樣,這與肺毛細血管的復原有關。作者相信存在一個非常重要的機制:在TR時,肺可以調節血栓形成。

(顧漪聞 譯 陳傑 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.

 

麻醉下兒童應用動脈刺激靜脈採樣試驗(ASVS)對高胰島素血症病灶定位期間的血糖控制

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.

 

先天性高胰島素血症的外科治療的效果通過動脈刺激靜脈采血採樣試驗(ASVS)對微小的、局灶性胰腺損傷功能失調的定位而提高, ASVS是通過選擇性的動脈注射鈣劑後,肝靜脈的胰島素濃度提高而證實。但是,麻醉相關的血糖濃度的增高可誘發胰島素的分泌,導致ASVS資料的分析困難。在這個回顧性研究中,作者檢查了68個兒童在進行ASVS試驗中,麻醉對血糖濃度的影響。在最後的分析之前僅僅考慮鈣劑注射之前的血糖濃度。作者發現麻醉誘導藥物(七氟醚,異丙酚,硫噴妥鈉),麻醉維持藥物(七氟醚,地氟醚或是異氟醚),以及布比卡因骶管麻醉,在ASVS試驗之前並沒有對平均血糖濃度有明顯的影響。但是,注射瑞芬太尼的病人,其平均血糖濃度更低(80±18vs100±44mg• dl–1P0.01)。而如果使用吸入麻醉複合瑞芬太尼,然後面罩吸氧,氣管插管的時間推遲到誘導後10分鐘,平均血糖濃度明顯降低(延遲插管組79±14 mg • dl–1,早期插管組為95±39 mg • dl–1p0.03)。與插管前的平均血糖濃度比較,延遲插管時其血糖增加的百分比較小(延遲插管為3.7±21.9%,早期插管為31.7±60.4%,P0.02)。結論:使用ASVS的病人,麻醉處理包括氣管插管前應用瑞芬太尼或吸入麻醉複合瑞芬太尼,麻醉誘導10分鐘以上,以便病人達到一個較深的麻醉狀態。

(顧漪聞 譯 陳傑 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.

 

電針穴位刺激或樞複寧與安慰劑比較在預防術後噁心嘔吐的隨機對照研究

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.

 

本研究主要評估電針穴位刺激或樞複寧與安慰劑相比預防術後噁心嘔吐(PONV)的效應。全麻胸部手術患者隨機分為電針穴位刺激組(A),樞複寧4 mg IVO)或對照組(放置電極而不給予電刺激;安慰劑(P))。標準麻醉下,在0306090120分鐘及24小時評估噁心、嘔吐的發生率、止吐藥的使用情況、疼痛程度和患者對PONV處理的反應。與安慰劑組相比其他兩組在術後2hA/O/P=77%/64%/42%P=0.01)和24hA/O/P=73%/52%/38%P=0.006)出現完善反應(無噁心、嘔吐或使用止吐藥)的機率明顯提高。治療組對於止吐藥的需求也明顯減少(A/O/P=19%/28%/54%P=0.04)。A組噁心的發生率和嚴重程度較其他組明顯低,而O組比P組低(A/O/P=19%/40%/79%)。在術後恢復室中A組患者疼痛程度最輕。與安慰劑組相比治療組的患者對PONV治療較為滿意。在預防PONV時,電針穴位刺激或樞複寧與安慰劑相比能更有效地提高患者的舒適程度,電針穴位刺激在控制噁心的發生方面比樞複寧有效。使用P6刺激還具有鎮痛效果。

(朱慧琛 譯 陳傑 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.

 

病態肥胖患者根據真實體重或理想體重使用羅庫溴胺的藥效學比較

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.

 

作者研究病態肥胖患者使用羅庫溴胺時的藥物效應。12位接受經腹胃減容術的病態肥胖女患者(體重指數>40kg/m2),隨機分為兩組。組1n=6)依據真實體重接受0.6mg/kg的羅庫溴胺,組2n=6)依據理想體重接受0.6mg/kg的羅庫溴胺。對照組為6個接受腹部手術的正常體重女患者,依據真實體重給予羅庫溴胺。應用拇內收肌加速度肌描記儀監測神經肌肉傳導,使用瑞米芬太尼和丙泊酚行麻醉誘導和維持。組1較對照組的起效時間較短,但無統計學意義。組125%肌力恢復時間(55分鐘)大約為其他兩組的兩倍(2225分鐘;P<0.001)。組2和對照組的有效時間相似。組1的恢復指數較長,但無統計學差異。綜上所述,病態肥胖患者若依據真實體重計算羅庫溴胺用量則將延長藥物作用時間,因此在臨床使用時應根據標準體重計算羅庫溴胺的用量。

(朱慧琛 譯 陳傑 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腸蠕動

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對小鼠胃排空和胃腸蠕動的作用。小鼠腹腔內注射丙泊酚和咪唑安定,十分鐘後在胃內灌注0.2ml含螢光珠的生理鹽水。30分鐘後,應用流式細胞儀測量胃腸道內的螢光珠數量以評估胃排空以及胃腸蠕動的情況。結果顯示,引起輕度鎮靜(老鼠扶正位置的時間在2秒內)時,兩種藥物都明顯抑制胃排空,但程度較輕(丙泊酚:與對照組比95%可信區間,4.9%-20.2%P<0.001;咪唑安定:與對照組比95%可信區間,7.8%-14.7%,P<0.001)。咪唑安定可延遲胃腸蠕動,丙泊酚無顯著影響(P<0.001)。大劑量深度鎮靜時(翻正反射缺失大於10秒),兩者顯著抑制胃排空(丙泊酚:P<0.00195%可信區間,31.4%-61.2%;咪唑安定:P<0.00195%可信區間,30.8%-61.1%)和胃腸蠕動(兩種藥物與對照組比P<0.001)。

(朱輝 譯 陳傑 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導的血小板選擇蛋白的表達和血小板-白細胞結合物的形成

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.

 

血小板表面血小板選擇蛋白的表達和血小板-白細胞結合物的形成被認為血小板啟動的標誌並在血栓和炎症疾病中非常重要。以往研究報導七氟醚對血小板的聚集有抑制作用。作者研究了七氟醚是否影響血小板選擇蛋白的表達和血小板-白細胞結合物的形成。選擇25名行肢體小手術的患者,以七氟醚為主的全身麻醉,經面罩誘導、插入喉罩建立氣道吸入七氟醚維持麻醉。在七氟醚麻醉前及麻醉後40分鐘抽取全血以作分析。無或用二磷酸腺苷刺激的全血和富含血小板的血漿樣本以螢光染料抗體標記。使用流式細胞儀測量血小板上的血小板選擇蛋白的表達和血小板-白細胞結合物的形成。結果;七氟醚抑制血小板選擇蛋白的表達。七氟醚呼末濃度為3%-4%時無論用還是不用二磷酸腺苷刺激的血標本中血小板-白細胞結合物的形成均減少。

(朱輝 譯 陳傑 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受體GluRε1亞基的小鼠對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.

 

氯胺酮是一種具有NMDA受體阻滯特性的靜脈麻醉藥,但是其全麻作用是否主要由於阻滯該受體尚不清楚。功能性的NMDA受體由GluRζ1亞基(NR1)和ε亞基(GluRε1-4NR2A-D)組成,完成其獨特功能。假設缺乏GluRε1亞基的動物,其大量表達的NMDA受體可能抵抗氯胺酮的作用。在本研究中,作者通過正位反射比較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。結果發現基因敲除鼠對氯胺酮抵抗。但沒有預料到的是,該基因突變鼠對苯巴比妥也有抵抗作用,而該類藥物被認為在臨床相關濃度並不與NMDA受體發生作用。儘管這些結果並不能否定NMDA受體的GluRε1亞基參與介導氯胺酮麻醉/催眠作用的可能性,但是可以提示用基因敲除動物的麻醉藥敏感性改變來分析麻醉作用較為困難。

(趙延華 譯 陳傑 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.

 

清醒志願者俯臥位時軀體傾斜度對眼內壓的影響:兩種手術床的比較

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.

 

失明是俯臥位手術時少見但非常嚴重的一種併發症。俯臥位可增加眼內壓(IOP),後者通過減少視神經前段的血液灌注可引起失明。本研究的作者觀察了反式Trandelenburg姿勢即頭高腳低位能否改善由俯臥位引起的IOP升高,而且進一步比較了兩種應用於俯臥位元的裝置。在隨機交叉研究中,通過測定10名健康清醒志願者處於3種傾斜度俯臥位(水平、頭高腳低10°和頭低腳高10°)以及坐位和仰臥位時眼內壓,對Jackson床和Wilson架進行比較。俯臥位IOP(頭高腳低10°、水平和頭低腳高10°)分別為20.3 mmHg16.3-22.5mmHg)、22.5 mmHg19.8-25.3 mmHg)、23.8 mmHg21.5-26.3 mmHg)。俯臥位IOP25-75%範圍中位數值超過坐位時15.0 mmHg12.8-16.3 mmHg)和仰臥位時16.8 mmHg14.0-18.3 mmHg)。反式Trandelenburg姿勢即頭高腳低位減輕了俯臥位引起的IOP增加。而且該姿勢能減少IOP明顯異常(>23mmHg)的病人數,與水平俯臥位元和頭低腳高位相比分別減少50%、75%。應用於俯臥位元的兩種裝置對IOP的影響沒有區別。俯臥位引起的IOP升高在頭高腳低位可明顯減輕,而在頭低腳高位則增加。改變體位元時壓力很快發生改變以及IOP的變化,提示眼靜脈壓對於IOP的重要作用。因此,俯臥位時可通過調節手術床的傾斜度使IOP發生有益的變化。

(趙延華 譯 陳傑 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.

 

腹膜內注射安慰劑或局麻藥緩解腹式子宮切除術後疼痛的雙盲對照試驗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

.

腹式子宮切除可引起病人術後中、重度疼痛。本實驗將40名擇期行腹式子宮切除術的病人(ASA III級)隨機分為兩組:P組的病人通過在術畢時放置於腹膜內的導管注射生理鹽水5ml/h,而L組的病人則通過此導管注射0.25%左旋布比卡因12.5mg/h(5ml/h)。通過病人自控鎮痛泵靜脈給予凱托米酮作為所有病人的應急鎮痛藥。術畢24小時後拔除該導管。在實驗中應用視覺類比評分系統在術後123481624h評估病人的切口疼痛、深疼痛和因咳嗽引起的疼痛,並記錄病人在072h內凱托米酮的用量,以及病人從術畢到可以坐、行走、進食、進水和出院的時間;測定病人血漿中左旋布比卡因的濃度。結果發現組L病人在術後12h的切口疼痛、深疼痛和因咳嗽引起的疼痛均較P組病人明顯減輕,術畢4h後病人在休息和咳嗽時的平均視覺類比評分均小於3cmL組病人在術後424h內的凱托米酮的用量明顯少於P組病人(平均為19mg31mg)。而且在這段時間內L組病人術後噁心的發生率也明顯小於P組病人,並且無一人嘔吐(P<0.025)。實驗中測定全血和血漿中左旋布比卡因的濃度較小。因此,擇期行腹式子宮切除術的病人在術後於腹膜內應用左旋布比卡因具有明顯的減少阿片類藥物需要。

(齊波 譯 陳傑 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.

 

雷米芬太尼對腦外傷病人行氣管內吸引時引起顱內壓升高的效果

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.

 

對嚴重顱腦外傷病人行支氣管沖洗可以引起顱內壓(ICP)變化,從而對病人產生不利的影響。為避免這些不利的影響,曾有人建議在靜脈內應用阿片類藥物。本實驗選擇20名機械通氣的病人,靜脈應用3種不同劑量的雷米芬太尼,其劑量逐漸升高。劑量11ug/Kg,輸注速度為0.25ug/Kg/min;劑量22ug/Kg,輸注速度為0.5ug/Kg/min;劑量34ug/Kg,輸注速度為1ug/Kg/min。在靜脈輸注開始後20分鐘進行氣管內吸引,直到病人出現咳嗽為止。在整個30分鐘的研究階段內監測病人的心率、ICP、平均動脈壓(MAP)、腦灌注壓(CPP)、大腦中動脈平均血流速率(VMCA)和雙頻指數。結果在劑量123組中分別有121519個病人需要血管加壓素才能維持CPP大於60mmHg;另外劑量123組中分別有16155個病人在吸引時出現的咳嗽。病人ICP升高,MAP的降低而無VMCA的變化說明病人腦自動調節功能存在。因此,腦外傷病人持續應用雷米芬太尼並不能有效防止不良的吸引反應。

(齊波 譯 陳傑 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鎮痛:股神經阻滯和靜注芬太尼的比較

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.

 

本項前瞻性、隨機性實驗旨在比較股神經阻滯和靜脈注射芬太尼在輔助股骨幹骨折患者實施坐位脊髓麻醉時的鎮痛效能。脊髓麻醉前5分鐘,FEM組患者(n=10)應用1.5%利多卡因15 mL進行股神經阻滯,IVA組患者(n=10)靜脈注射芬太尼3 ug/kgFEM組放置體位元時視覺類比分級評分較低(FEM組:0.50-1);IVA組:32-6),P < 0.001)FEM組進行脊髓鎮痛的時間較短(FEM組:1.8±0.7min IVA組:3.0±1.1minP<0.05)。FEM組麻醉前坐位放置的舒適度評分(0=不滿意,1=滿意,2=好,3=很好)較高(FEM組:32-3IVA組:1.51-3),P<0.005)。IVA組患者較少願意鎮痛方法(P<0.05)。IVA組一例患者麻醉過程中氧飽和度<90%。因此作者認為:在股骨幹骨折患者實施坐位脊髓麻醉時,輔助股神經阻滯優於靜脈注射芬太尼。

(田婕 譯 陳傑 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.

 

全關節成形術中輸注同種異體血的預測

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

.

全關節成形術(TJA)患者常常需要輸注同種異體血。本研究中,作者試圖建立和確認在TJA患者使用術前根據易於得到的資料來建立預測臨床輸血原則。應用邏輯回歸模型對2000年阿爾伯達省埃德蒙頓市所有TJA手術者(n=1875)進行回顧性研究。試驗組和驗證組運用該模型曲線下面積分別為0.800.76。結果顯示根據6種互不相關因素評分(年齡,性別,體重,血色素,ASA病情分級,以及是否需要術中改變術式),就可以對患者需要輸血的可能性做出評估。作者認為,根據簡單的術前臨床和實驗室檢查結果可以對TJA患者術中輸血幾率做出準確預測。這樣的預測有助於輸血策略選擇性地應用於那些輸血風險最大的患者。

(田婕 譯 陳傑 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.

 


非體外迴圈進行冠狀動脈搭橋手術時經食管超聲監測部分心室壁的運動

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


在這一前瞻性、觀察性的研究中,評價經食管超聲監測左心室部分心肌運動在非體外迴圈進行冠狀動脈搭橋手術(OPCAB)翻動心臟時的作用。根據以往有關在OPCAB手術時經常無法獲得經胃切面圖像的研究,我們僅僅分析經食管中段獲得的圖像。在60位患者開胸和放置心包外固定器時,記錄四腔心切面、二腔心切面和長軸切面的圖形。用16段模型,2個超聲心動圖獨立分析心室壁的運動。在基礎值、翻動心臟和放置心包外固定器時,分析那些≥14左心室段分辯率高的圖像的比例。在基礎值時,≥14段的60位患者中有59 位元(98%)的圖像清晰。心臟翻動後,≥14段的76支再通的冠狀動脈左前降支有5876%)(與基礎值比較,P < 0.01)、 40支再通的冠狀動脈迴旋支有33例(83%)(與基礎值比較,P < 0.01)和31支再通的右冠狀動脈有29例(94%)(與基礎值比較無顯著性的差異)的圖像解析度高、清晰。結論:在心臟翻動時,圖像解析度降低,但是≥14段清晰的圖像為5位元OPCAB患者中的4位提供可靠的監測。

(葛甯花譯 薛張剛校)

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.

 

體外迴圈時零級平衡超濾體外清除高濃度的Tirofiban:一項體內的研究

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 拮抗劑tirofiban對心臟手術有益。Tirofiban的清除半衰期為2小時。在腎衰患者中,半衰期延長,並持續抑制血小板的聚集,這種抑制對輸注血小板無反應。為防止在這種情況下的過分出血,體外清除是必要的。我們評價在體外迴圈的模型中,血液濾過器清除tirofiban的作用。評價兩種血液濾過器和血漿分離濾過器的功效。取每種類型中的三個進行系列研究。體外迴圈預充液總量為1000 ml,加入Tirofiban,至200 ng/mL。取濾過液50 mL,並在每次取出後,補充等量的液體。分析每次濾過後tirofiban的血藥濃度。重複取樣16次。Tirofiban的峰濃度為160 260 ng/mLtirofiban清除的指數衰減曲線和高治療濃度快速清除為250 50 ng/mL。沉澱係數b 顯示各種濾過器的清除能力無顯著性差異。資料提示超濾是體外迴圈中清除治療濃tirofiban 的有效方法。

(葛甯花譯 薛張剛校)

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.

老年心臟外科手術預防性聯合使用β- 阻滯劑艾司洛爾和磷酸二酯酶抑制劑依諾昔酮

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

 

我們研究預防性聯合靜脈使用β- 腎上腺素能阻滯劑艾司洛爾和磷酸二酯酶抑制劑依諾昔酮(enoximone)對搭橋術後血流動力學、炎性反應、內皮細胞和器官功能的影響。選擇42位年齡>65 歲、行主動脈冠狀動脈搭橋手術的患者,進行隨機、安慰劑對照和前瞻性研究。一組為21位患者,全麻誘導後開始靜脈注射β- 阻滯劑艾司洛爾(目標心率控制在70/分以下)和磷酸二酯酶抑制劑enoximone(起始劑量0.5 mg/kg,並以2.5 mg/kg/min速度持續注入),並持續至術後第一天早晨。另一組21位患者輸注生理鹽水作為安慰劑。記錄基礎值、體外迴圈開始前後、監護室直至術後第一天的血流動力學、內臟灌注壓(胃動脈 CO2間隙)、肝功能(血漿谷胱甘肽α轉換酶濃度)、腎功能(肌酐清除率、尿中N-乙酰基-β-D-氨基葡萄糖酶)、心肌缺血(血漿肌酐激酶MB和肌鈣蛋白T的濃度)、炎性反應(彈性蛋白酶、白介素-6-8的血漿水平)和內皮細胞的完整性(粘性分子的血漿水平)。在實驗組,兒茶酚胺所需量比對照組少、心率顯著較慢、心排指數較高和胃動脈CO2間隙低。肌鈣蛋白Tβ-N-乙酰基-β-D-氨基葡萄糖酶,α谷胱甘胎轉換酶和可溶性粘分子在對照組顯著增加,但在艾司洛爾+enoximone組幾乎正常。艾司洛爾+enoximone組的炎性反應因數( 彈性蛋白酶/白介素)減弱。結論:與對照組比較,在老年進行心臟體外迴圈手術患者中,預防性聯合使用艾司洛爾和enoximone,有益於體外迴圈後血流動力學的平穩、器官功能、炎性反應和內皮細胞的完整性。

(葛甯花譯 薛張剛校)

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.


經外周放置中心靜脈導管:小兒外科手術中的一項隨機、對照和前瞻性研究

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

 

經外周放置中心靜脈導管(PICCs),可長期用於靜脈給藥、抽血取樣或高營養。術後短期使用PICCs尚無報導。在這一對照、隨機研究中,患者分為二組:PICCs組或外周靜脈置管組(PIV)。觀察指標包括患者和父母的滿意度、不同靜脈通路的併發症、術後靜脈穿刺的次數和費用。在PICCs組,滿意度明顯高於PIV組(p<0.05),術後需要靜脈穿刺的次數明顯比PIV少(p<0.05)。PIV組常見的是微小併發症,但在兩組中均未出現嚴重的併發症。PICCs的費用高,但良好的滿意度使其價值得到體現。另外,在手術室內術前準備期間放置PICCs並不增加麻醉醫生的工作量和延長佔用手術室的時間。對術後住院超過4天的患者,麻醉醫生應放置PICCs,特別是那些需要頻繁抽血化驗或穿刺靜脈的患者。

(葛甯花譯 薛張剛校)

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.


小兒術前多系統的評估

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

 

越來越少的患者因為即將進行的手術或麻醉干預而住院。結果是越來越依賴術前徹底的評估以發現麻醉的危險因素。因此,每個醫療中心必須建立確切可行的部門,對手術患者術前進行判斷。在患兒人群中,需要特殊專一的人才和系統來積累各學科的資訊。這種花費是明智的,可以減少手術患兒因不完全或不恰當的術前準備而在手術室內浪費時間。以下仔細描述在大的兒童醫療中心如何成功地對圍術期的評估和術前準備進行已7年。

(葛甯花譯 薛張剛校)

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.


異丙酚或七氟醚麻醉時用觸覺法評估拮抗羅庫嗅胺誘發的神經肌肉阻滯作用

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

 

我們旨在探討在在異丙酚或七氟醚麻醉時,用觸覺法計數四個成串刺激(TOF)能否預計新斯的明拮抗羅庫嗅胺的作用,並觀察至TOF0.9160位患者,平均分為8個組,隨機用異丙酚或七氟醚維持麻醉。在患者一側手臂,用觸覺法評估拇內收肌對TOF的反應,在另一側手臂,則用機械肌動描記法記錄。用羅庫嗅胺阻滯神經肌肉,初始劑量為0.6 mg/kg,並維持肌松在最初TOF抽搐時的15%。在每次麻醉中,用觸覺法評估當TOF出現一個抽搐(第一組)、二個抽搐(第二組)、三個抽搐(第三組)或四個抽搐(第四組)時,用0.07 mg / kg的新司的明拮抗,並同時減少異丙酚或七氟醚的劑量。記錄開始拮抗至TOF比例達到0.70.80.9的時間。在異丙酚維持麻醉組,TOF比例為0.9的平均時間一至四組分別為8.6 ( 4.7 - 18.9 )7.5 ( 3.4 - 9.8 )5.4 ( 1.6 - 8.6 ) 4.7 ( 1.3 - 7.2 )分鐘;而七氟醚維持麻醉組,則分別為28.6 ( 8.8 - 75.8 )22.6 ( 8.3 - 57.4 )15.6 ( 7.3 - 43.9 )9.7 ( 5.1 - 26.4 )分鐘,P< 0.0001。我們建議,異丙酚麻醉時,出現2個以上TOF反應或七氟醚麻醉出現4TOF反應時,合適的拮抗時間分別在1015分鐘內。在拮抗期間,出現TOF反應越多,肌張力恢復得越完全。但在一定的時間內,觸覺法評估TOF的反應,並不是一個完全可靠的方法。
(葛甯花譯 薛張剛校)

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.


異丙酚對鼠海馬橫切面癲癇樣活動的抗驚厥作用

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

 

記錄鼠海馬橫切面CA1區細胞外電生理,以研究異丙酚對由缺乏Mg2+引起的興奮性突出後電位(fEPSP)、總體波峰和癲癇樣活動的影響。異丙酚抑制總體波峰、fEPSP和癲癇樣活動。氨茶鹼,非選擇性腺苷受體拮抗劑和8-cyclopentyl-1,3-dipropylxanthine, A1受體拮抗劑,都能顯著地抑制異丙酚對fEPSP振幅的作用。但是,3,7-二甲基-1-propagylxanthineA2受體拮抗劑,並不改變異丙酚對fEPSP振幅的作用。印防己毒素,一種特殊的氯離子通道阻滯劑,部分抑制異丙酚對癲癇樣電活動的作用;但是,荷包牡丹堿,一種競爭性{gamma}-氨基丁酸受體拮抗劑,不能拮抗它的作用。氨茶鹼顯著地抑制異丙酚抗癲癇樣活動的作用。異丙酚抗驚厥作用部分被8-cyclopentyl-1,3-dipropylxanthine減弱,而7-二甲基-1-propagylxanthine則無影響。腺苷抑制fEPSP的振幅,呈劑量依賴性,異丙酚能增強這種作用。結果顯示:在鼠海馬橫切面,異丙酚能抑制癲癇樣活動。此外,腺苷通過A1受體起到神經調節作用,可能有助於異丙酚的抗驚厥作用。

(葛甯花譯 薛張剛校)

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.


椎管內大劑量蘇芬太尼能預防腹部大手術時的激素應急反應:與靜脈使用蘇芬太尼的前瞻性、隨機性的對照研究

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

 

我們研究腹部大手術時椎管內大劑量蘇芬太尼對激素應急反應的作用。40位患者隨機分為靜脈輸注蘇芬太尼組(IVS)和椎管內注入150 µg蘇芬太尼組(ITS),作為全麻的一部分。在IVS組,促腎上腺皮質激素(ACTH)和皮質醇濃度分別比基礎值和ITS組、切皮後60分鐘和縫合皮膚時高。而ITS組,手術期間血漿皮質醇和ACTH的濃度與基礎值比較無差異。縫皮後6小時,兩組皮質醇濃度均高於基礎值。縫皮後2448小時,兩組皮質醇和ACTH相似。兩組去甲腎上腺素濃度在術後均增加。術中和術後,兩組的血糖升高。術後48小時,ITS組的疼痛評分和嗎啡需要量都低。資料顯示,在聯合麻醉時,椎管內大劑量蘇芬太尼能預防術中的激素應急反應。我們推測這是由於蘇芬太尼與脊髓和脊髓上受體的高親和力。與平衡麻醉比較,這種技術能增加術後的鎮痛作用。

(葛甯花譯 薛張剛校)

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.


異丙酚並不抑制利多卡因硬膜外阻滯時的代謝

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

 

異丙酚有時和利多卡因硬膜外阻滯聯合使用。在這一研究中,我們探討當利多卡因用於硬膜外麻醉時,異丙酚對其血漿濃度和主要代謝的影響。32位患者隨機分為異丙酚組或七氟醚組(n = 16)。在異丙酚組,麻醉的靶濃度控制在4 µg/mL。在七氟醚組,麻醉用1.5%的濃度維持。硬膜外利多卡因的初始劑量為5 mg/kg,然後以2.5 mg • kg–1 • h–1速度持續注入。在開始持續注入利多卡因後的3060120180分鐘,用高效液相色譜法檢測血漿中利多卡因游離部分和其代謝物monoethylglycinexylidide (MEGX) glycinexylidide (GX)的濃度。2 mL 血漿經過超濾得到游離的利多卡因、MEGX GX。兩組血流動力學資料相似,兩組血漿游離利多卡因濃度無顯著性差異。MEGX與游離利多卡因的比值和GXMEGX比值兩組無差異。結論:與七氟醚比較,異丙酚並不改變硬膜外利多卡因的代謝。

(葛甯花譯 薛張剛校)

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.


緩激肽拮抗劑對切口疼痛沒有鎮痛作用

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

 

緩激肽是內源性九肽和重要的炎症介質,同樣也是疼痛的啟動者和持續者。des-Arg8, Leu8-緩激肽 (dALBK) HOE-140, 緩激肽B1 B2受體拮抗劑,分別顯示在動物模型中,對持續性的傷害刺激具有減輕疼痛和炎性反應的作用。我們研究在鼠的模型中,以上因數對切皮產生疼痛的主動反應。氟烷麻醉下,在鼠後爪的足底作1cm的切口,並用5–0 尼龍線縫合。對點狀和非點狀機械刺激的回縮反應分別用von Frey 絲線和帶有塑膠圓盤的von Frey 絲線試驗。試驗對放射熱回縮反應潛伏期。在切皮前一天、切皮後1小時和注藥後0.5 1 1.5 2.5 小時記錄試驗結果。然後在術後第二天,在注藥前後相同的時間點,重複試驗一次。鼠分別靜脈注入鹽水dALBK (0.1, 0.3, 1.0, 3.0 mg/kg) HOE-140 (0.1, 0.3, 1.0, 3.0 mg/kg)。另一組鼠在切皮前1小時注藥後進行以上的試驗。資料用Kruskal-Wallis方法進行統計分析和二維方法分析變異,P < 0.05為差異有統計學意義。無論是超前給藥還是切皮後給藥,dALBK HOE-140的劑量都不影響對尖銳性刺痛或機械性鈍痛或熱刺激的反應。結果支持這一機制:切皮產生的疼痛與炎症介導的疼痛有關。儘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他模型中有所不同。

(葛甯花譯 薛張剛校)

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.


美國麻醉培訓計畫的人員和資金: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月之間,有三份報告遞交給美國麻醉培訓計畫的主席,要求增加各自部門的人員和資金。在本篇報告中,我們報導第四篇跟蹤調查的結果。同時詢問是否需要額外的資助以滿足住院醫生每週工作80小時的要求和調查醫生平均擁有的學習時間。每個科室平均有40位人員,其中78%的科室需要3.7位元人員。只有25%的科室計畫增加人員以滿足住院醫生每週工作80小時的要求。51%科室的有$15,908資金積餘/相當於每個專職麻醉人員(人員 FTE),而34%的科室則是負$42,603/人員FTE。總的資助是$85,607/人員FTE,比上一年增加43%。提供給每個人員的學術時間平均是13.8%,比2000年的20%有所下降。2003年,有25%的科室因缺乏人員而關閉麻醉培訓點。開放型人員培訓計畫從2000年到2003年保持良好的態勢,從8%增加到10%。自從2000年以來,醫院對科室培訓計畫的資助已成倍增加,在2003年達到$85,000/人員。

(葛甯花譯 薛張剛校)

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.


嚴重顱腦外傷伴或不伴有顱內高壓時血壓變化對大腦血流動力學的影響

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

 

如何維持嚴重顱腦外傷患者的大腦灌注壓(CPP)是一個有爭論的問題。最近提出腦血管自動調節的狀況決定每個個體的目標CPP。為尋找理想的灌注壓,我們用藥物控制13位嚴重顱腦外傷患者的CPP在受傷的當天、受傷後第一天和第二天在51 mm Hg (平均48–53 mm Hg) 108 mm Hg (102–112 mm Hg)範圍內,並研究對顱內壓(ICP)、自動調節能力和腦組織氧分壓的影響。自動調節表達為根據大腦中動脈血流速度而調節CPP 5-mm Hg間隔的固定率。當ICP正常時,CPP從基礎值78 mm Hg (74–83 mm Hg)開始改變,測得的其他值沒有大的變化,這意味著在自動調節的範圍內。相反,在顱內高壓時,CPP降低到77 mm Hg (73–82 mm Hg)以下,能加重ICP,降低自動調節能力和降低腦組織氧分壓,而CPP增加,以上指標好轉,這表示大腦在自動調節的低限工作。結論:經常觀察血壓的波動能提供有效的資訊以控制CPP在合適的範圍。

(葛甯花譯 薛張剛校)

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.


椎管內小劑量可樂定和等比重布比卡因用於矯形手術:一個劑量依賴的研究

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


我們研究椎管內小劑量可樂定(≤150 µg)延長布比卡因蛛網膜下腔麻醉時劑量與效果之間的關係。旨在探索椎管內注射可樂定的劑量:能延長蛛網膜下腔麻醉時的作用和緩解疼痛,而沒有嚴重的副作用。80位行矯形手術的患者,隨機分為四組:每組均在蛛網膜下腔注入等比重0.5%布比卡因18 mg,並在第一組內加入生理鹽水,第二組內加入可樂定37.5 µg,第三組內加入可樂定75 µg,第四組內加入可樂定150 µg。感覺阻滯持續的時間(感覺平面消退至L1)分別為288 ± 62 min(第一組,對照組),311 ± 101 min (第二組,+8%, 325 ± 69 min (第三組,+13%, 337 ± 78 min (第四組,+17% (95% 可信區域: –0.05–0.50)。從開始注入可樂定至第一次需要追加鎮痛藥的時間顯著延長,分別為295 ± 80 min (第一組,對照組), 343 ± 75 min(第二組,+16%, 381 ± 117 min(第三組,+29%, 445 ± 136 min (第四組,+51% (95% 可信區域: 0.59–1.45))。各組血流動力學穩定無差異,鎮靜評分無差異,結論:小劑量椎管內可樂定(≤150 µg)能顯著地延長布比卡因的麻醉和鎮痛作用,呈劑量依賴型。當希望延長蛛網膜下腔麻醉的時間時,≤150 µg可樂定就其副作用而言,是最佳選擇。

(葛甯花譯 薛張剛校)

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.



氣管插管前用利多卡因進行喉氣管表面麻醉能減少全麻蘇醒拔管時的嗆咳反應

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

 

蘇醒時嗆咳,會產生一系列不良的反應,包括高血壓、心動過速、快速性心律失常、增加顱內壓和增加眼內壓。在氣管插管時,用利多卡因進行氣管黏膜的表面麻醉能否預防蘇醒時的嗆咳反應尚不明了。在雙盲、對照研究中,我們選擇50ASA I II、行婦科手術患者,手術時間在2小時之內,隨機在插管時,分別用160 mg利多卡因或安慰劑進行表面噴霧。兩組患者的一般狀況和術中情況無顯著性差異。在利多卡因噴霧組,拔管前的嗆咳(26%)明顯比安慰劑組(66%)減少,P < 0.01,拔管後的嗆咳也減少(4%相對30%, P = 0.022)。研究支持這一觀點:在全麻下進行手術的時間小於2小時且蘇醒時的嗆咳對患者很不利,則插管前用利多卡因進行表面噴霧很有必要。

(葛甯花譯 薛張剛校)

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.

不停跳冠狀動脈搭橋手術是否降低多支搭橋後臨床腎功能障礙的發生率?

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

 

在這個前瞻性、觀察性試驗中,我們探討不停跳冠狀動脈搭橋手術(OPCAB)與體外迴圈下冠狀動脈搭橋手術(CABG)比較是否伴有較少的術後腎功能障礙(RD)。所有參加的病人都是首次于2000年在我機構中進行單獨的冠狀動脈搭橋手術。對每個病人收集的資料包括人口統計學、術前RD風險係數、圍術期事件以及從入院到出院或死亡的血清肌酐濃度。RD的診斷標準為血清肌酐濃度較術前上升50%,同時術後肌酐絕對濃度2.0 mg/dL (177 μM)。用Student’s t-核對總和Fisher’s 精確檢驗進行組間比較,逐步多因素對數回歸分析法來識別RD的決定性因素;P < 0.05為有顯著差異。CABG(n = 119)OPCAB(n = 220)相比在年齡(64 ± 13 67 ± 10 yr, P = 0.0074)和移植血管數量(中位數43, P = 0.0003)上有差異。手術的方式與術後RD的存在沒有聯繫:在220 OPCAB病人中有18 (8.2%)比在119 CABG病人中有12 (10%) 例(P = 0.55)。我們的資料提示手術技術的選擇 (OPCAB CABG)並不伴有較少的腎損害發生。

(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.

 

 

比較持續正壓通氣和無創壓力支持通氣方法用於治療心臟手術後的肺不張

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

 

肺不張常見於心臟手術後,可引起氣體交換不足。持續正壓通氣(CPAP)常用於預防或治療術後肺不張。我們假設無創壓力支援通氣(NIPSV)通過增加潮氣量,其改善肺不張進展的作用優於CPAP150名收入外科重症監護室(SICU)的心臟手術後患者,放射學肺不張評分≥2,隨機分為兩組,分別接受每天4次,每次30分鐘的CPAPNIPSV治療。兩組的呼氣末正壓都設定為5釐米水柱。在NIPSV組,壓力支持設定為潮氣量8-10 ml/kg。在離開SICU時,我們觀察到NIPSV組中60%患者的肺不張得到改善,而CPAP組中為 40%(P = 0.02)。兩組在氧合作用(離開SICU PaO2/吸入氧濃度:CPAP280 ± 38 vs NIPSV 301 ± 40)、肺功能檢查和SICU停留時間方面沒有差異。在輕度併發症方面,如胃脹,兩組相似。根據放射學評分,NIPSV改善肺不張的效果優於CPAP,但是它未能提供臨床意義上額外的益處,因此能否改善預後值得懷疑。

(張俊傑 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.

 

 

腹主動脈瘤手術患者門靜脈乳酸鹽、乙狀結腸粘膜內pH和△CO2PaCO2局部 PCO2)作為併發症指數的比較

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

 

我們在這個觀察性、前瞻性、非對照研究中的目的是探求29 腹主動脈瘤(AAA)手術後患者器官衰竭發生率與術中動脈和門靜脈乳酸變化、乙狀結腸粘膜內pH (pHi)變化、乙狀結腸粘膜PCO2和動脈PCO2差值(ΔCO2)以及血紅蛋白(Hb)的關係。在麻醉開始(T0)、鉗夾主動脈前(T1)、鉗夾30分鐘時(T2)以及手術結束(T3)時點測定Hb、動脈血乳酸濃度、pHiΔCO2 值(空氣張力測量法)。在T1T2時點測定門靜脈乳酸濃度。患者分為兩組:組A患者術後無器官衰竭,組B患者有一個或多個器官衰竭。相較於組An = 16),組B患者(n = 13)在T2T3時點pHi值更低,T3時點ΔCO2 更高。pHi<7.15能預計器官衰竭的敏感性為92.3%,特異性68.8%,正負預計值分別為70.6%91.7%。但是ΔCO2 >28 mm Hg預計後期器官衰竭的敏感性為92.3%,特異性62.5%,正負預計值分別為66.6% 90.9%T2點組B門靜脈乳酸濃度較高(P < 0.001),其增高5 g/dL預計後期器官衰竭其敏感性為92.3%,特異性100%,正負預計值分別為100%94.1%。對比檢驗每個變數識別力的特徵性曲線和對數回歸分析顯示門靜脈血乳酸濃度升高是最好的預計術後器官衰竭發展的指標。組B Hb濃度在T0T2時點明顯較低(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)。結論:pHiΔCO2 是對AAA術後器官衰竭相當敏感的預計性指數,但他們的特異性和精確度低於門靜脈血乳酸。

(趙雪蓮 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.

 

 

接受丙泊酚麻醉的兒童對低碳酸血症的腦血管反應

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

 

低碳酸血症常用於處理神經外科手術時的急性顱內壓升高。在丙泊酚麻醉中的兒童 ETCO2高於35 mmHg時,可保持腦血管對二氧化碳的反應(CCO2R);然而ETCO2低於35 mm Hg時,提示仍有一個平臺作用。為深入描繪這一現象,我們應用跨顱多普勒超聲技術(TCD),測量27例健康兒童在少量提高ETCO2時的CCO2R。麻醉由標準的丙泊酚輸注加骶管阻滯組成。放置TCD探頭來測定大腦中動脈血流速度(Vmca)。用一外源性CO2,使ETCO21–2 mm Hg增量逐步從24上升到40 mm Hg。當ETCO2值高於30 mm Hg時,ETCO2 Vmca之間呈指數關係(r = 0.82)。然而,只有當ETCO2上升到30 mm HgVmca才會開始隨之變化(r = 0.06)。心率和動脈壓均無顯著性改變。我們得出結論:當用作降低腦容量和顱內壓的方法時,過度通氣使ETCO2值低於30 mm Hg對接受丙泊酚麻醉的兒童來說可能是不必要的,因為腦血流速度不會進一步降低。

(周志堅 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.

 

 

異丙酚引起的注射疼痛:改良後的異丙酚乳劑與預混合利多卡因的標準異丙酚的比較

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

 

眾所周知,異丙酚在注射時會引起疼痛。減少此類疼痛的最常用方法是預先混合利多卡因。最近有人提倡一種改良的含有中鏈甘油三酯(MCT)和長鏈甘油三酯(LCT)的異丙酚脂肪乳劑與通常只含有長鏈甘油三酯(LCT)的異丙酚相比,能減輕疼痛。在222例外科患者中進行的一項隨機、前瞻性、對照、雙盲研究中,我們比較了上述兩種溶液對注射痛的發生率和強度的影響。患者被隨機地分入含MCT/LCT的異丙酚組(組Mn = 109)或只含LCT的標準異丙酚組(組Ln = 113),後一組每200 mg的異丙酚加入利多卡因20 mg1%的利多卡因2ml)。用從010分的視覺類比評分法(VAS)來進行疼痛評分。發現注射異丙酚時,組L(平均VAS2.5 ± 2.9)(mean ± SD )與組M(平均VAS3.8 ± 3.2 P = 0.002)相比注射疼痛能明顯要輕。關於術後回憶注射疼痛,組L患者所述疼痛(平均 VAS, 2.2 ± 2.4)與組M相比(平均VAS, 3.0 ± 2.7; P = 0.02)明顯要輕。預先混合利多卡因20 mg1%的利多卡因2ml)到200 mg的標準異丙酚LCT在注射時引起的疼痛要比異丙酚MCT/LCT要輕,從而增加了患者的舒適感。

(陳瑋      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.


順式阿曲庫銨在病態肥胖女性的作用

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

 

阿曲庫銨在肥胖患者的作用持續時間有不一致的報導。順式阿曲庫銨是阿曲庫銨的一個同分異構體。我們觀察了順式阿曲庫銨在病態肥胖患者的神經肌肉作用。20例肥胖女性患者(體重指數>40)隨機分成兩組。組In = 10)基於真實體重(RBW)給予順式阿曲庫銨0.2 mg/kg,而組IIn = 10)基於理想體重(IBW)計算劑量。在10例正常體重女性患者的對照組(體重指數20-24),順式阿曲庫銨的劑量基於RBW。用拇內收肌的肌加速度監測神經肌肉傳遞,用雷米芬太尼和異丙酚麻醉誘導和維持。組I和對照組的起效時間相近(132 s135 sP = ns)。組I25%持續時間比對照組長(74.6 min59.1 minP = 0.01),對照組比組II長(45.0 minP =0.016)。得出結論:如果根據RBW計算病態肥胖患者順式阿曲庫銨的劑量,則其作用持續時間比正常體重的對照組延長。對照組患者的作用持續時間也比基於IBW給予藥物的病態肥胖患者長。

(馬皓琳 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.

 

 

吸入異氟醚增強正壓通氣時生理死腔的增加並使動脈氧合受損

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

 

生理死腔容積(VDphys) 異常增加,包括肺泡死腔容積和氣道死腔容積,是誘發動脈血氣交換受損的病因因素之一。我們比較兩種全麻方法結合正壓通氣(PPV)對VDphys的影響:全憑靜脈麻醉(TIVA)和吸入異氟醚麻醉。研究40例沒有呼吸系統疾病病史的仰臥位擇期手術的病人。使用交叉方案,所有病人循序隨機接受全部兩種麻醉方式。與術前自主呼吸的基礎值相比,PPVTIVA使VDphys164 ± 60 mL 明顯增加到264 ± 79 mL (P < 0.05)。吸入異氟醚聯合PPV顯著增強此增加作用,使VDphys增加兩倍到315 ± 80 mL (P < 0.05)。同樣地,應用異氟醚時肺泡死腔容積增加超過200%。此外,異氟醚吸入(呼氣末濃度1.15%)導致動脈氧合減少,表現為PaO2/吸入氧分壓比從基礎值387 ± 35顯著降低到310 ± 70 (P < 0.05)。儘管TIVA結合PPV時顯著增加VDphys,這個不利的改變遠小於異氟醚吸入結合PPV。此發現可能適用於肺功能受損的病人(例如,急性呼吸窘迫綜合征或者嚴重的吸入性灼傷)。

(張曦 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-9四氫大麻酚對人類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-9四氫大麻酚(THC)在噁心,嘔吐,惡病質和慢性疼痛長期治療方面的運用逐漸增多。然而,最近的報導指出THC攝入後心肌梗塞和血栓性脈管炎的危險性增加。血小板在這兩種疾病的發病機理中起本質的作用,但血小板是否是大麻酚潛在的靶細胞仍不清楚。我們在這項離體研究中調查了THC對人類血小板的作用和其細胞膜上大麻酚受體的表達。用流式細胞儀測量THC(終濃度範圍10-7 10-5 M)對活化血小板纖維蛋白原受體(糖蛋白IIb-IIIa)表達以及P 物質的影響。用血小板膜標本施行Western blotting以確定在人類血小板表面上大麻酚受體的表達。THC以濃度依賴方式增加人血小板上糖蛋白IIb-IIIa的表達和P物質。兩個已知的大麻酚受體(CB1CB2)都在人類血小板細胞膜上檢測到。我們這個功能上的結果可能提示THC介導血小板活化的一種受體依賴途徑。無論如何,需要進一步的體內研究來評價大麻酚受體在介導已經證明的THC促凝血作用方面的影響。

(吳儉 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.


七氟醚麻醉中腦電雙頻指數和快速提取聽覺誘發電位指數對傷害性刺激的反應的比較

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,在傷害性刺激存在和不存在的情況下,同時比較其腦電雙頻指數(BIS)和快速提取聽覺誘發電位指數(AAI)顯示七氟醚腦內濃度增加時的效應的能力。BIS/AAI監測的同時,也監測血流動力學參數。於15分鐘內調節吸入七氟醚至BIS50-55,再使這一七氟醚呼氣末濃度(1.46% ±0.20%)加倍,隨後15分鐘內任意隨機時刻給予一傷害性刺激――喉鏡檢查。在七氟醚呼氣末濃度加倍後,BIS值明顯下降,而AAI值僅稍有下降(P <0.0001))。七氟醚吸入增加並未減輕BIS/AAI對於喉鏡檢查的反應。在傷害性刺激後,3名患者的AAI值超過了最高推薦參考值25,而所有患者的BIS值都沒有超過推薦閾值60BISAAI的反應時間分別為44.5 ± 26秒和47 ±31秒。結果提示,在與外科七氟醚麻醉相關的催眠水平,BISAAI或血流動力學參數能更好地顯示藥物相關性催眠水平的改變,但是BISAAI對於傷害性刺激的反應時間並無明顯差別。

(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.


低流量麻醉中基於模型的預測性顯示對七氟醚呼氣末濃度控制的效果

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

 

我們已經顯示多室模型能正確地預測七氟醚(sevo)和異氟醚的呼氣末(ET)濃度。這個模型已適於用即時新鮮氣流量和揮發罐設置來顯示10分鐘ET sevo濃度的預測值。在這項研究中,由麻醉醫生評估了這種預測性顯示反映ET sevo變化的速度和精確性的效果。研究15sevo麻醉預期持續超過 2 小時的病人。無協助或有預測性顯示時分別進行ET靶濃度的四步變化 (+0.5+1.0、–1.0 和–0.5 vol%)。新鮮氣流量為 1 L/min。通過用雙尾配對t檢驗來比較回應時間、最大過衝量以及達到靶濃度後5 分鐘的穩定性。有預測性顯示時的變化比沒有預測性顯示時平均快1.5~2.3倍。在+0.5+1.0和–0.5 vol% 這幾步變化時的差異有統計學意義 (P<0.05),但在–1.0 vol%時沒有統計學意義。過衝量的程度和穩定性沒有差異。這些差異和自動反饋控制系統相似。這種系統可以簡化揮發性麻醉的給藥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.


用大鼠擊尾和壓爪試驗測試椎管內加巴噴丁對蛛網膜下腔嗎啡耐藥性的影響

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

 

對阿片類藥物鎮痛作用的耐藥性在實驗和臨床條件中都有描述,這可能會限制此類藥物在臨床上的應用。我們以往的研究表明全身性應用加巴噴丁(GBP,一種非阿片類藥物)可以預防和逆轉大鼠對全身性應用嗎啡的耐藥性。在本研究中,我們探討了椎管內應用GBP對蛛網膜下腔嗎啡耐藥性的影響。實驗大鼠分別在7天裏給予椎管內注射生理鹽水(10µL)、GBP300µg)、嗎啡(15µg)或GBP-嗎啡聯合應用,在注藥前和注藥後30min進行打尾和壓爪試驗來測試鎮痛作用。在第8天時繪製每一實驗組的抗傷害性刺激的劑量-反應曲線並計算出嗎啡(單用)的50%有效劑量(ED50)。結果:同時注射GBP和嗎啡可以阻斷耐藥性的進展,與單用嗎啡組相比,可以維持嗎啡的鎮痛作用超過7天,而且第8天的嗎啡ED50值降低。儘管不能排除第17天期間GBP的附加鎮痛作用,GBP-嗎啡聯合應用組ED50的降低的確提示了對耐藥性的一些抑制。這些資料支援以往對GBP預防阿片類藥物耐藥性的證據,同時更明確地提示椎管內應用GBP能預防脊麻阿片類藥物耐藥性的發展。需要進一步的研究來檢查GBP-嗎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釋GBP影響阿片類藥物耐藥性作用的機制。

(黃施偉 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.


甲狀旁腺激素在枸櫞酸抗凝的急性重症血液透析維持患者中的分泌

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

 

有出血風險的患者在體外治療時使用局域性枸櫞酸抗凝。我們進行了一項前瞻性臨床實驗,研究枸櫞酸抗凝血透期間,大劑量或小劑量補鈣對鈣離子濃度和全血甲狀旁腺激素(iPTH)的影響。對25例活動性出血或有出血風險的患者進行研究治療。治療中大劑量補鈣組(15 mmol/h) 16例,小劑量組(5 mmol/h) 9例。大劑量鈣組16例中的13例鈣離子濃度增高,小劑量鈣組9例中的8例下降。全血甲狀旁腺激素在大劑量組下降了25%,在小劑量組增高了121%(變數值△的P = 0.0007,百分變數△%的P = 0.007 )。鈣離子增高的14例患者的iPTH降低。11例離子鈣下降的患者中有10iPTH增高。離子鈣的增高或降低比補鈣速度更能預測iPTH的變化(R2分別為0.5526 0.3962)。我們的結論是治療期間通過調節補鈣速度可以預測性地影響iPTH的水平。

(軒泓 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.


比較單次或分次注射用於喙突旁鎖骨下臂叢神經阻滯對麻醉範圍的影響

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

 

單次注射用於喙突旁鎖骨下臂叢神經阻滯對上肢產生的麻醉效果是不確切的。在本研究中,我們擬探討為提供完善的上肢麻醉效果所需要的鎖骨下臂叢神經阻滯的注射次數。75例病人用神經刺激器指導喙突旁臂叢神經阻滯,隨機用1.5%的甲呱卡因42ml行單次注射(組1)、分兩次注射(組2)或分三次注射(組3)。三組病人均未探索特異的的運動反應。局麻藥注射完畢後5分鐘和20分鐘測量感覺和運動阻滯。組1病人中 20分鐘時用針刺法測量的腋神經、肌皮神經、橈神經、尺神經和前臂內側皮神經分佈區域的麻醉明顯較不完善;手臂、腕和手的運動麻痹明顯也較不完善。組2病人與組3相比差別不顯著。我們得出結論,在神經刺激器指導下兩或三次注射局麻藥與單次注射相比,能增強臂叢神經阻滯的效果。

(邱鬱薇      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.


圍手術期穩定的一氧化氮產物血漿濃度是腹腔鏡膽囊切除術後認知功能障礙的預測指標

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

 

這個研究的目標是為了確定年齡在40歲和85歲之間的患者在七氟醚吸入麻醉下進行的腹腔鏡膽囊切除術術後認知障礙(POCD)的發生率,並檢驗i)S-100ß蛋白質及ii)穩定的一氧化氮(NO)產物這二者的血漿濃度與在這種臨床條件下發生POCD的聯繫。分別在術前一天及術後第四天和第六周,對42ASA病情分級I-II級的病人進行了神經心理學的試驗。並對患者的配偶(n=13)進行對照研究。將一種或更多的認知領域缺陷定義為認知功能障礙。在圍手術期對S-100ß蛋白質的血清濃度及穩定的NO產物(硝酸鹽/亞硝酸鹽,NOx)的血漿濃度進行了一系列的測定 。手術後第四天分別有16名患者(占40%)及1名對照物件(占7%)出現了新的認知缺陷(P = 0.01)。術後六周,有21名患者(占53%)及3名對照物件(占23%)出現新的認知缺陷(P = 0.03)。與“無缺陷組”相比,術後4天就表現出新的認知缺陷的病人,在每一個圍術期時間點的NOx血漿濃度均較大(每一的時間點均P < 0.05)。而兩組的S-100ß蛋白血清濃度相似。結論,手術前(及手術後)穩定的NO產物的血漿濃度(而不是S-100ß)與早期POCD有關。前者為POCD提供了一個可能的生化預報指標。

(黃麗娜 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.

 

依照體表標誌行頸內靜脈穿刺時頭部最佳的旋轉位置

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

 

外部解剖標誌歷來被用於估計頸部血管位置以最好地行頸內靜脈(IJV) 穿刺而避免誤穿頸總動脈(CCA).。頭部旋轉的位置影響血管的定位,然而大多數的定位方法並不規定其最佳的旋轉程度。我們在49位志願者身上以持握注射器及針頭的方式使用超聲波探頭,通過前路及中路法對右IJV模擬行導管置入。從中線往左15° 30° 45°60°,隨著頭部旋轉角度的逐漸增加,模擬針頭觸及IJVCCA的可能性也越大。對於這兩種方法而言,當頭位旋轉45°時,觸及CCA的危險性<10%。當頭位旋轉至45° 60°時,隨著體表面積(BSA)及體重指數(BMI)的增加,也更多地觸及CCA。為了最好地觸及IJV並減少不慎誤穿CCA的發生率,對於高BMIBSA的病人,須將頭旋轉至不大於30°,但對於低BMIBSA的病人,可將頭旋轉至60°

(裘毅敏 譯,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.