Anesthesia & Analgesia

November 2004

Table of Content

 

PEDIATRIC ANESTHESIA:

青少年脊柱融合术中丙泊酚、小剂量异氟醚和笑气麻醉对皮层体感诱发电位及双频指数监测的影响

周志坚 李士通

The Effects of Propofol, Small-Dose Isoflurane, and Nitrous Oxide on Cortical Somatosensory Evoked Potential and Bispectral Index Monitoring in Adolescents Undergoing Spinal Fusion

Anthony J. Clapcich, Ronald G. Emerson, David P. Roye, Jr., Hui Xie, Edward J. Gallo, Kathy C. Dowling, Brian Ramnath, and Eric J. Heyer

Anesth Analg 2004 99: 1334-1340.

 

儿童心脏手术中纤维蛋白原有功能吗?

朱辉 译 陈杰 校)

Fibrinogen in Children Undergoing Cardiac Surgery: Is It Effective?

Bruce E. Miller, Steven R. Tosone, Nina A. Guzzetta, Jennifer L. Miller, and Keith K. Brosius

Anesth Analg 2004 99: 1341-1346

 

儿童全身麻醉后口服静脉制剂柠檬酸芬太尼的药代动力学

葛宁花译,薛张纲校

The Pharmacokinetics of the Intravenous Formulation of Fentanyl Citrate Administered Orally in Children Undergoing General Anesthesia

Melissa Wheeler, Patrick K. Birmingham, Ralph A. Lugo, Corri L. Heffner, and Charles J. Coté

Anesth Analg 2004 99: 1347-1351.

 

儿科镇静的综述

黄丽娜      李士通

Review of Pediatric Sedation (Review Article)
Joseph P. Cravero and George T. Blike

Anesth Analg 2004 99: 1355-1364.

 

先天性心脏病手术中神经学监测

朱辉 译 陈杰 校

Neurological Monitoring for Congenital Heart Surgery (Review Article)

Dean B. Andropoulos, Stephen A. Stayer, Laura K. Diaz, and Chandra Ramamoorthy

Anesth Analg 2004 99: 1365-1375.

 

AMBULATORY ANESTHESIA:

健康人群水合氯醛吗啡多次鼻腔给药后的I相研究

葛宁花译,薛张纲校

A Multiple-Dose Phase I Study of Intranasal Hydromorphone Hydrochloride in Healthy Volunteers
Anita C. Rudy, Barbara A. Coda, Sanford M. Archer, and Daniel P. Wermeling

Anesth Analg 2004 99: 1379-1386.

 

布比卡因、罗哌卡因或左旋布比卡因重比重液单侧脊麻施行腹股沟疝修补术的前瞻性随机双盲比较

邱郁薇 李士通

A Prospective, Randomized, Double-Blind Comparison of Unilateral Spinal Anesthesia with Hyperbaric Bupivacaine, Ropivacaine, or Levobupivacaine for Inguinal Herniorrhaphy
Andrea Casati, Elena Moizo, Chiara Marchetti, and Federico Vinciguerra

Anesth Analg 2004 99: 1387-1392.

 

ANESTHETIC PHARMACOLOGY:

老年大鼠接受异氟醚和异氟醚-NO2麻醉后两周存在空间记忆损害

朱慧琛 译 陈杰 校

Impaired Acquisition of Spatial Memory 2 Weeks After Isoflurane and Isoflurane-Nitrous Oxide Anesthesia in Aged Rats

Deborah J. Culley, Mark G. Baxter, Catherine A. Crosby, Rustam Yukhananov, and Gregory Crosby

Anesth Analg 2004 99: 1393-1397

 

氙气并不延长罗库溴胺的神经阻滞作用
葛宁花译,薛张纲校

Xenon Does Not Prolong Neuromuscular Block of Rocuronium

Oliver Kunitz, Jan-Hinrich Baumert, Klaus Hecker, Thorben Beeker, Mark Coburn, André Zühlsdorff, and Rolf Rossaint

Anesth Analg 2004 99: 1398-1401

泮库溴铵和米库氯铵神经肌肉阻滞后F波恢复各异

赵雪莲 李士通

Different F-Wave Recovery After Neuromuscular Blockade with Pancuronium and Mivacurium
Michael H. Dueck, Matthias Paul, Philipp Sagawe, Aloys Oberthuer, Christoph Wedekind, and Ulf Boerner

Anesth Analg 2004 99: 1402-1407.

 

静脉氯胺酮麻醉可抑制主动脉平滑肌细胞的增生

朱慧琛 译 陈杰 校

The Inhibition of Aortic Smooth Muscle Cell Proliferation by the Intravenous Anesthetic Ketamine

Yousuke Shiga, Kouichiro Minami, Kayoko Segawa, Yasuhito Uezono, Munehiro Shiraishi, Takeyoshi Sata, Chieko Yamamoto, and Kim Sung-Teh

Anesth Analg 2004 99: 1408-1412

 

异氟醚抑制C纤维诱发肢体回缩的触发反应对鼠腰脊髓神经元疼痛刺激的影响

葛宁花译,薛张纲校

Isoflurane Depresses Windup of C Fiber-Evoked Limb Withdrawal with Variable Effects on Nociceptive Lumbar Spinal Neurons in Rats
Steven L. Jinks, Joseph F. Antognini, Robert C. Dutton, Earl Carstens, and Edmond I Eger, II

Anesth Analg 2004 99: 1413-1419

 

七氟醚及异丙酚在人体增加11C-氟马西尼与γ-氨基丁酸A受体的结合

王立中 李士通

Sevoflurane and Propofol Increase 11C-Flumazenil Binding to Gamma-Aminobutyric AcidA Receptors in Humans

Elina Salmi, Kaike K. Kaisti, Liisa Metsähonkala, Vesa Oikonen, Sargo Aalto, Kjell Någren, Susanna Hinkka, Jarmo Hietala, Esa R. Korpi, and Harry Scheinin

Anesth Analg 2004 99: 1420-1426.

TECHNOLOGY, COMPUTING, AND SIMULATION:

围术期使用PSArray电极的病人状态分析监护仪较脑双频指数监护仪有更好的效益成本比吗?

朱玫娟 陈杰

Is the Patient State Analyzer with the PSArray2 a Cost-Effective Alternative to the Bispectral Index Monitor During the Perioperative Period?

Paul F. White, Jun Tang, Hong Ma, Ronald H. Wender, Alexander Sloninsky, and Robert Kariger

Anesth Analg 2004 99: 1429-1435.

 

Arrow 固定器将中心静脉导管固定于皮肤的有效性

葛宁花译,薛张纲校

The Efficacy of the Arrow Staple Device for Securing Central Venous Catheters to Human Skin
Gregg K. Motonaga, Keith K. Lee, and Jeffrey R. Kirsch

Anesth Analg 2004 99: 1436-1439

 

 

血栓弹性描记®过程中用电子显微镜评价血凝块的形态学

沈浩 李士通

Electron Microscopic Evaluations of Clot Morphology During Thrombelastography®
Jun Kawasaki, Nobuyuki Katori, Mitsuharu Kodaka, Hideki Miyao, and Kenichi A. Tanaka

Anesth Analg 2004 99: 1440-1444.

PAIN MEDICINE:

一种新的用来评估胸部手术后持续性疼痛的动物模型的特征

朱玫娟 陈杰

Characterization of a New Animal Model for Evaluation of Persistent Postthoracotomy Pain

Asokumar Buvanendran, Jeffrey S. Kroin, James M. Kerns, Subhash N. K. Nagalla, and Kenneth J. Tuman

Anesth Analg 2004 99: 1453-1460.

 

曲马多用作皮下局部麻醉剂时的术后镇痛效果

葛宁花译,薛张纲校

The Postoperative Analgesic Effect of Tramadol When Used as Subcutaneous Local Anesthetic
Hanife Altunkaya, Yetkin Ozer, Eksal Kargi, Isil Ozkocak, Mübin Hosnuter, Cengiz Bekir Demirel, and Orhan Babuccu

Anesth Analg 2004 99: 1461-1464.

 

结肠直肠癌手术患者切皮前静注己酮可可碱可降低围术期细胞因子反应,减少吗啡用量并促进肠道功能恢复

李士通

Preincisional Intravenous Pentoxifylline Attenuating Perioperative Cytokine Response, Reducing Morphine Consumption, and Improving Recovery of Bowel Function in Patients Undergoing Colorectal Cancer Surgery
Chueng-He Lu, Pei-Chieh Chao, Cecil O. Borel, Chih-Ping Yang, Chun-Chang Yeh, Chih-Shung Wong, and Ching-Tang Wu

Anesth Analg 2004 99: 1465-1471.

 

口服即时释放二氢羟吗啡酮用于术后疼痛治疗的安全性和有效性

顾漪闻 译 陈杰 校

The Efficacy and Safety of Oral Immediate-Release Oxymorphone for Postsurgical Pain

Joseph Gimbel and Harry Ahdieh

Anesth Analg 2004 99: 1472-1477

 

复杂性区域疼痛综合征导致的全身儿茶酚胺增高与心理因素的关系:一个初步研究

顾漪闻 译 陈杰 校

Increased Systemic Catecholamines in Complex Regional Pain Syndrome and Relationship to Psychological Factors: A Pilot Study
R. Norman Harden, Nathan J. Rudin, Stephen Bruehl, William Kee, Devang K. Parikh, Jason Kooch, Thomas Duc, and Richard H. Gracely

Anesth Analg 2004 99: 1478-1485.

CRITICAL CARE AND TRAUMA:

小剂量辣椒素降低败血症鼠的全身炎症反应

葛宁花译,薛张纲校

Small-Dose Capsaicin Reduces Systemic Inflammatory Responses in Septic Rats

Semra Demirbilek, M. Ozcan Ersoy, Savas Demirbilek, Abdurrahman Karaman, Necla Gürbüz, Nihayet Bayraktar, and Mehmet Bayraktar

Anesth Analg 2004 99: 1501-1507.

 

多巴酚丁胺抑制佛波醇-豆蔻酸盐-醋酸盐对人T淋巴细胞核因子{kappa}B激活作用的体外实验

裘毅敏 李士通

Dobutamine Inhibits Phorbol-Myristate-Acetate-Induced Activation of Nuclear Factor-{kappa}B in Human T Lymphocytes In Vitro
Torsten Loop, Tobias Bross, Matjaz Humar, Alexander Hoetzel, Rene Schmidt, Heike L. Pahl, Klaus K. Geiger, and Benedikt H. J. Pannen

Anesth Analg 2004 99: 1508-1515.

 

NEUROSURGICAL ANESTHESIA:

脊髓手术病人术中进行唤醒试验和术后早期苏醒:短效静脉和吸入麻醉药的比较

齐波 译 陈杰 校

Intraoperative Wake-Up Test and Postoperative Emergence in Patients Undergoing Spinal Surgery: A Comparison of Intravenous and Inhaled Anesthetic Techniques Using Short-Acting Anesthetics

Oliver Grottke, Peter Johannes Dietrich, Stefanie Wiegels, and Frank Wappler

Anesth Analg 2004 99: 1521-1527.

OBSTETRIC ANESTHESIA:

比较产妇分娩自控硬膜外和静脉镇痛:多中心随机对照研究

葛宁花译,薛张纲校

A Multicenter Randomized Controlled Trial Comparing Patient-Controlled Epidural with Intravenous Analgesia for Pain Relief in Labor

Stephen H. Halpern, Holly Muir, Terrance W. Breen, David C. Campbell, Jon Barrett, Robert Liston, and J. Wade Blanchard

Anesth Analg 2004 99: 1532-1538

 

REGIONAL ANESTHESIA:

全膝成形术患者超声辅助下单次股神经阻滞镇痛的副作用较鞘内吗啡少

张俊杰 李士通

A Single Injection Ultrasound-Assisted Femoral Nerve Block Provides Side Effect-Sparing Analgesia When Compared with Intrathecal Morphine in Patients Undergoing Total Knee Arthroplasty
Brian D. Sites, Michael Beach, John D. Gallagher, Robert A. Jarrett, Michael B. Sparks, and C. Johan F. Lundberg

Anesth Analg 2004 99: 1539-1543.

 

骶旁坐骨神经阻滞加选择性闭孔神经阻滞的作用评估

赵延华 译 陈杰 校

Adding a Selective Obturator Nerve Block to the Parasacral Sciatic Nerve Block: An Evaluation
Denis Jochum, Gabriella Iohom, Olivier Choquet, Dioukamady Macalou, Samba Ouologuem, Pascal Meuret, Freddy Kayembe, Michel Heck, Paul-Michel Mertes, and Hervé Bouaziz

Anesth Analg 2004 99: 1544-1549.

GENERAL ARTICLES:

UniqueTM喉罩通气道与Soft SealTM喉罩的比较:一项在麻醉肌松下患者中随机交叉研究

陈玮     李士通

The Laryngeal Mask Airway UniqueTM versus the Soft SealTM Laryngeal Mask: A Randomized, Crossover Study in Paralyzed, Anesthetized Patients (Medical Intelligence)
Joseph Brimacombe, Achim von Goedecke, Christian Keller, Lawrence Brimacombe, and Moira Brimacombe

Anesth Analg 2004 99: 1560-1563.

 

难以解释的术中出血病人其凝血因子XIII有效性降低以及血栓稳固性早期丧失

赵延华 译 陈杰 校

Decreased Factor XIII Availability for Thrombin and Early Loss of Clot Firmness in Patients with Unexplained Intraoperative Bleeding (Medical Intelligence)
Patrick Wettstein, André Haeberli, Monika Stutz, Miriam Rohner, Cinzia Corbetta, Konrad Gabi, Thomas Schnider, and Wolfgang Korte

Anesth Analg 2004 99: 1564-1569

 

 

儿童心脏手术中纤维蛋白原有功能吗?

Fibrinogen in Children Undergoing Cardiac Surgery: Is It Effective?

Bruce E. Miller, MD, Steven R. Tosone, MD, Nina A. Guzzetta, MD, Jennifer L. Miller, and Keith K. Brosius, MD

Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta at Egleston, Atlanta, Georgia

Anesth Analg 2004 99: 1341-1346.

婴幼儿纤维蛋白原的功能完整性基于实验和生化数据。最近的研究表明成人的纤维蛋白原水平与血栓弹性描计图最大振幅的变化相关,而后者的变化是由于糖蛋白Ⅱb/Ⅲa受体阻滞分离了血小板-纤维蛋白原间的相互作用。作者假设婴幼儿的纤维蛋白原血中水平和功能完整也像成人一样与血栓弹性描计图最大振幅的变化相关。选择250名小于2岁进行心脏手术的儿童,分成五个年龄组(<1mo13mo36mo612mo1224mo)比较血栓弹性描计图值有无变化时的纤维蛋白原水平和血小板计数。结果显示只有在1224mo组纤维蛋白原水平与血栓弹性描计图最大振幅相关。该组维蛋白原水平与血栓弹性描计图其它变量相关性与纤维蛋白原水平影响,正如成人血小板计数与血栓弹性描计图变化相关性一样。结论:患先天性心脏病年龄小于12个月的小孩其纤维蛋白原功能不全。

(朱辉 译 陈杰 校)

There is speculation based on laboratory tests and biochemical data regarding the functional integrity of the fibrinogen in young children. Recent investigations in adults have demonstrated that their fibrinogen level correlates with the thromboelastogram maximum amplitude (MA) after modification with a glycoprotein IIb/IIIa receptor blocker that uncouples platelet-fibrinogen interactions. We postulate that if the fibrinogen of young children is functionally intact then their fibrinogen levels should also correlate with modified thromboelastogram MA values as they do in adults. We compared modified and unmodified thromboelastogram variables of 250 children <2 yr old undergoing cardiac surgery with their fibrinogen levels and platelet counts. Five age groups were distinguished to determine if and when correlations become significant (<1 mo, 1–3 mo, 3–6 mo, 6–12 mo, and 12–24 mo). Fibrinogen levels correlated with modified thromboelastogram MAs only in the 12–24 mo group. In this 12–24 mo age group other correlations between fibrinogen levels and thromboelastogram variables influenced by fibrinogen also became significant, as did correlations noted in adults between platelet counts and thromboelastogram variables. We conclude that the fibrinogen of children <12 mo old with congenital heart disease is qualitatively dysfunctional.

先天性心脏病手术中神经学监测

Neurological Monitoring for Congenital Heart Surgery

Dean B. Andropoulos, MD, Stephen A. Stayer, MD, Laura K. Diaz, MD, and Chandra Ramamoorthy, MB BS, FFA (UK)

Department of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Departments of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston Texas, Department of Pediatric Cardiac Anesthesiology, Lucile Packard Children’s Hospital at Stanford, Department of Anesthesiology, Stanford University School of Medicine, Stanford, California

Anesth Analg 2004 99: 1365-1375

 

小儿心脏手术后的神经并发症发生率2%到25%,其原因有多种,包括术前的脑畸形,围术期低氧血症,低心排量状态,心肺转流的后遗症和深低温停循环等。神经学的监测装置易于提供,麻醉医生可在小儿心脏手术期间进行脑部监测。在这项研究中,作者研究先天性心脏手术期间使用近红外线脑血氧定量法,经颅多谱勒超声以及脑电流描记法的监测情况。在复习了每种监测方式基本原理后再讨论其在小儿心脏手术中的用途。证据显示在先天性心脏手术患者使用多形式的神经学监测并联合疗法可改善神经系统方面的预后,作者同时阐述了这种工作的具体方法。

(朱辉 译 陈杰 校)

The incidence of neurological complications after pediatric cardiac surgery ranges from 2% to 25%. The causes are multifactorial and include preoperative brain malformations, perioperative hypoxemia and low cardiac output states, sequelae of cardiopulmonary bypass, and deep hypothermic circulatory arrest. Neurological monitoring devices are readily available and the anesthesiologist can now monitor the brain during pediatric cardiac surgery. In this review we discuss near-infrared cerebral oximetry, transcranial Doppler ultrasound, and electroencephalographic monitors for use during congenital heart surgery. After review of the basic principles of each monitoring modality, we discuss their uses during pediatric heart surgery. We present evidence that multimodal neurological monitoring in conjunction with a treatment algorithm may improve neurological outcome for patients undergoing congenital heart surgery and present one such algorithm.


老年大鼠接受异氟醚和异氟醚-NO2麻醉后两周存在空间记忆损害

Impaired Acquisition of Spatial Memory 2 Weeks After Isoflurane and Isoflurane-Nitrous Oxide Anesthesia in Aged Rats

Deborah J. Culley, MD*, Mark G. Baxter, PhD{dagger}, Catherine A. Crosby{dagger}, Rustam Yukhananov, MD PhD*, and Gregory Crosby, MD*

*Department of Anesthesia, Harvard Medical School, Brigham & Women’s Hospital, Boston, Massachusetts; {dagger}Department of Psychology, Harvard University, Cambridge, Massachusetts

Anesth Analg 2004 99: 1393-1397.

 

老年大鼠在异氟醚-NO2麻醉后至少24—48h后可出现空间记忆损害。本次实验中作者测试损害的持续时间及NO2的作用。18个月的大鼠随机分为吸入1.2%异氟醚2h联合或不联合使用70%NO2或对照组(30%氧)。两周后每天进行半径为12臂长的迷宫测试共14天。记录对第一次错误的校正次数、所有的差错和完成迷宫的时间。1.2%异氟醚联合使用70%NO2的大鼠在出现第一次错误前很少作出校正(P<0.05)。错误概率和完成迷宫的时间大致相似,但无统计学意义。对所有的麻醉大鼠和对照组进行了分析比较后认为麻醉大鼠对于第一次错误的校正率下降(P<0.05),同时其完成迷宫的时间也较长。出错次数无明显差异(P<0.06)。因此老年大鼠接受全身麻醉后两周(无论是否联合应用NO2)仍存在空间记忆损害。

(朱慧琛 译 陈杰 校)

Aged rats are impaired on a spatial memory task for at least 24–48 h after isoflurane-nitrous oxide anesthesia. In this study, we tested how long the impairment lasts and investigated the role of nitrous oxide. Eighteen-month-old rats were randomized to anesthesia for 2 h with 1.2% isoflurane with or without 70% nitrous oxide or a control group (30% oxygen). Two weeks later, rats were tested daily for 14 days on a 12-arm radial maze. The number of correct choices to first error, total errors, and time to complete the maze were recorded. Rats anesthetized with 1.2% isoflurane with 70% nitrous oxide made fewer correct choices before first error (P ≤0.05). Trends toward similar results were noted for error rate and time to complete the maze, but these did not achieve statistical significance. Post hoc analysis comparing all anesthetized rats to controls demonstrated that anesthetized rats made fewer correct choices to first error (P ≤0.05) and took longer to complete the maze (P ≤0.05). There were no differences in total number of errors (P ≤0.06). Thus, spatial memory is impaired for 2 wk after general anesthesia in aged rats independent of whether nitrous oxide is used.


静脉氯胺酮麻醉可抑制主动脉平滑肌细胞的增生

The Inhibition of Aortic Smooth Muscle Cell Proliferation by the Intravenous Anesthetic Ketamine

Yousuke Shiga, MD PhD*, Kouichiro Minami, MD PhD*, Kayoko Segawa, MD PhD{dagger}, Yasuhito Uezono, MD PhD{ddagger}, Munehiro Shiraishi, MD*, Takeyoshi Sata, MD PhD*, Chieko Yamamoto, PhD{dagger}, and Kim Sung-Teh, MD{dagger}

*Department of Anesthesiology, University of Occupational and Environmental Health, Kitakyushu, Japan; {dagger}Kitakyushu Institute of Biophysics, Fukuoka, Japan; and {ddagger}Department of Pharmacology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan

Anesth Analg 2004 99: 1408-1412.

平滑肌细胞(SMC)增生被认为是一些主要的血管疾病、动脉粥样硬化症和高血压的病理学关键因素。作者曾报道氯胺酮可抑制大鼠肾小球膜细胞增生,由此假设氯胺酮可抑制细胞生长。虽然临床上已广泛应用氯胺酮作为静脉麻醉药,但是关于氯胺酮对血管平滑肌细胞增生的实际效应尚未进行研究。本实验中作者重点研究氯胺酮对血管平滑肌细胞增生作用的影响。氯胺酮抑制[3H]胸苷结合,同时通过浓度依赖方式减少SMCs数量;异丙酚和芬太尼都不抑制[3H]胸苷与人类动脉SMCs的结合。蛋白激酶CPKC)抑制剂GF109203x可解除氯胺酮对[3H]胸苷与SMC结合的抑制作用,但蛋白激酶A抑制剂H-89或蛋白激酶G抑制剂KT5823都无此作用。组织学分析显示氯胺酮可抑制膨胀性损伤的大鼠大动脉的内膜增厚现象。临床浓度的氯胺酮经PKC途径抑制SMCs。结论:临床应用氯胺酮可能预防SMCs增生。

(朱慧琛 译 陈杰 校)

Smooth muscle cell (SMC) proliferation has been recognized as central to the pathology of both major forms of vascular disease, atherosclerosis and hypertension. Recently, we reported that ketamine inhibits rat mesangial cell proliferation, suggesting that ketamine inhibits cell growth. Although the IV anesthetic ketamine has been widely used clinically, the exact effects of ketamine on vascular SMC proliferation have not been studied. In this study, we investigated the effects of ketamine on vascular SMC proliferation. Ketamine inhibited [3H]thymidine incorporation and decreased the number of SMCs in a concentration-dependent manner (10–200 µM); neither propofol nor fentanyl inhibited [3H]thymidine incorporation into human aortic SMCs. The protein kinase C (PKC) inhibitor GF109203x abolished the ketamine-induced inhibition of [3H]thymidine incorporation into SMC, but the inhibition was not affected by either the protein kinase A inhibitor H-89 or the protein kinase G inhibitor KT5823. A histological analysis demonstrated the inhibitory effect of ketamine on the intimal thickening of the balloon-injured rat aorta. Based on these results, ketamine inhibits SMCs at clinical concentrations via the PKC pathway. Our results indicate that ketamine might prevent the proliferation of SMCs clinically.

 

围术期使用PSArray电极的病人状态分析监护仪较脑双频指数监护仪有更好的效益成本比吗?

Is the Patient State Analyzer with the PSArray2 a Cost-Effective Alternative to the Bispectral Index Monitor During the Perioperative Period?

Paul F. White, PhD MD, FANZCA*, Jun Tang, MD*, Hong Ma, MD*, Ronald H. Wender, MD{dagger}, Alexander Sloninsky, MD{dagger}, and Robert Kariger, MD{dagger}

*Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; and {dagger}Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California

Anesth Analg 2004 99: 1429-1435.

新的一次性电极PSArrayTM2 XP sensorTM,分别用在患者状态分析(PSA)模式和脑双频指数(BIS)监护模式中。作者设计了这个临床实验来比较围术期使用新电极后病人状态指数(PSI)和BIS的灵敏度和特异性。22签署同意书的选择性腹腔镜手术的患者参与这个前瞻性研究。记录电极安放到获得的基线的时间和基础值,以及在接受标准全麻中,诱导、维持和苏醒各阶段的PSIBIS值。此外,在麻醉维持阶段推注丙泊酚(20mg)后,或者在提高2%吸入浓度或降低2%吸入浓度的地氟醚后,记录这些监测值的改变。两种方法获取监测值的时间相近(PSABIS中分别为66±32秒和72±41秒)。使用逻辑回归模型,PSIBIS在预测意识丧失时同样有效(例如呼之不应)。同样在全麻的诱导和苏醒期,PSIBIS也相关(R分别为0.850.74)。用来检测意识状态的接受手术特征性曲线下的面积在PSIBIS中也相近(分别为0.98±0.050.97±0.05)。在麻醉维持阶段,PSI的值比BIS的值略低;在丙泊酚和地氟醚改变时的反应相同。手术中,PSI的值与BIS的值相比,其受电烙单元的干扰更小(分别为31%73%)。尽管PSI的一次性电极的定价($24.95)比BISXP感应器($17.50)要高,但其平均售价($14.95)是相同的。结论:使用PSArrayPSA监护较使用XP感应器的BIS监护在全麻诱导和苏醒时评估意识状态有更高的效益成本比,同样在丙泊酚和地氟醚作麻醉维持时也有更高的效益成本比。

(朱玫娟 陈杰 校)

New disposable electrodes, the PSArrayTM2 and XP sensorTM, have been developed for the patient state analyzer (PSA) and the bispectral index (BIS) monitors, respectively. We designed this clinical study to compare the sensitivity and specificity of the patient state index (PSI) with the BIS during the perioperative period when the new electrode sensors were used. Twenty-two consenting patients scheduled for elective laparoscopic procedures were enrolled in this prospective study. The elapsed time to apply electrodes and obtain a baseline index value was recorded, as were the comparative PSI and BIS values at specific time intervals during the induction, maintenance, and emergence periods in patients who were administered a standardized general anesthetic. In addition, the changes in these indices were recorded after a bolus dose of propofol (20 mg IV) or a 2% increase or decrease in the inspired concentration of desflurane during the maintenance period. The total elapsed time to obtain an index value was similar with both devices (66 ± 32 s versus 72 ± 41 s for the PSA and BIS, respectively). By using logistic regression models, both the BIS and PSI were found to be equally effective as predictors of unconsciousness (i.e., failure to respond to verbal stimuli). The PSI also correlated with the BIS during both the induction of (R = 0.85) and the emergence from (R = 0.74) general anesthesia. The area under the receiver operating characteristic curve for detection of consciousness also indicated a similar performance with the PSI (0.98 ± 0.05) and the BIS (0.97 ± 0.05). During the maintenance period, the PSI values tended to be lower than the BIS value; however, the responses to changes in propofol and desflurane were similar. Finally, the PSI (versus BIS) values showed less interference from the electrocautery unit during the operation (31% versus 73%, respectively). Although the list price of the PSArray2 disposable electrode strip ($24.95) was higher than that of the BIS XP sensor ($17.50), the average sale price ($14.95) was identical for both electrode systems. Therefore, we conclude that the PSA monitor with the PSArray2 is a cost-effective alternative to the BIS monitor with the XP sensor for evaluating consciousness during the induction of and emergence from general anesthesia, as well as for titrating propofol and desflurane during the maintenance period.

 

一种新的用来评估胸部手术后持续性疼痛的动物模型的特征

Characterization of a New Animal Model for Evaluation of Persistent Postthoracotomy Pain

Asokumar Buvanendran, MD, Jeffrey S. Kroin, PhD, James M. Kerns, PhD*, Subhash N. K. Nagalla, MD, and Kenneth J. Tuman, MD

Departments of Anesthesiology and *Anatomy, Rush Medical College at Rush University Medical Center, Chicago, Illinois.

Anesth Analg 2004 99: 1453-1460.

 

胸部手术后慢性疼痛非常常见,尽管其发病基础和原理还并不十分清楚。在本实验中,作者探讨胸部手术和肋骨牵引后的小鼠,对于异常性疼痛(机械或寒冷导致)的反应以及组织病理改变的特征,同时评估全身或鞘内镇痛的镇痛效果。雄性Sprague-Dawley小鼠在麻醉状态下暴露右侧第四、五肋骨。打开肋骨间的胸膜,并在两根肋骨下放置牵引器,打开至8毫米。牵引时间分别持续为5分钟、30分钟和60分钟。对照组仅仅打开胸膜。在手术开始后的第二天,小鼠用标准von Frey纤维来测试机械刺激所致的异常疼痛,用丙酮来测试寒冷性异常疼痛。手术后两周,小鼠用腹膜内和鞘内注射镇痛来测试异常性疼痛。手术后14天,检查小鼠肋间神经的组织学。在牵引60分钟组中有50%出现了异常性疼痛,而在牵引5分钟组和牵引30分钟组中分别只有11%10%出现异常性疼痛,对照组中没有一例出现异常性疼痛。出现异常性疼痛的小鼠中,其受牵引肋骨的肋间神经有广泛的轴突减少。在肋骨牵引模型中,异常性疼痛在术后10天出现,并持续至少40天。全身应用硫酸吗啡(ED501.06mg/kg)、加巴喷丁(ED5024.2 mg/kg),以及鞘内使用吗啡(ED501.19 nmol)、加巴喷丁(ED5013.8 nmol)、可乐定(ED5072.7 nmol)及新斯的明(ED500.54 nmol)都能缓解异常性疼痛。肋骨牵引60分钟的小鼠其异常性疼痛持续超过一个月,并且这种疼痛可以被吗啡、加巴喷丁、可乐定和新斯的明缓解。这个新的模型可能在量化减少胸部手术后持续疼痛的频率和严重程度的各种技术有价值。

(朱玫娟 陈杰 校)

Chronic pain after thoracotomy is common, although its basis and therapy have not been well characterized. In this study we characterize the allodynic responses (mechanical and cold) as well as the histopathologic changes after thoracotomy and rib retraction in rats. The antinociceptive effect of systemic and intrathecal analgesics was also evaluated. Male Sprague-Dawley rats were anesthetized and the right 4th and 5th ribs surgically exposed. The pleura was opened between the ribs and a retractor placed under both ribs and opened 8 mm. Retraction was maintained for 5, 30, or 60 min. Control animals had pleural incision only. Beginning Day 2 postsurgery, animals were tested for mechanical allodynia using calibrated von Frey filaments and cold allodynia using acetone applied to the incision site. Two weeks after surgery, animals were tested for reduction of allodynia with intraperitoneal and intrathecal injections of analgesics. Intercostal nerve histology was examined at 14 days postsurgery. Allodynia developed in 50% of the animals with 60 min retraction but in only 11% and 10% of animals when the retraction time was 5 and 30 min, respectively, and in none of the control animals. Allodynic animals showed extensive axon loss in the intercostal nerves of the retracted ribs. Allodynia appeared by Day 10 in the rib-retraction model and lasted at least 40 days. Systemic morphine sulfate (50% effective dose [ED50], 1.06 mg/kg) and gabapentin (ED50, 24.2 mg/kg), as well as intrathecal morphine (ED50, 1.19 nmol), gabapentin (ED50, 13.8 nmol), clonidine (ED50, 72.7 nmol), and neostigmine (ED50, 0.54 nmol) reduced allodynia. Rib-retraction in rats for 60 min produces allodynia that lasts more than 1 mo, and this allodynia is reduced by morphine, gabapentin, clonidine, and neostigmine. This new model may be useful for quantifying the efficacy of techniques to reduce the frequency and severity of long-term postthoracotomy pain.


口服即时释放二氢羟吗啡酮用于术后疼痛治疗的安全性和有效性

The Efficacy and Safety of Oral Immediate-Release Oxymorphone for Postsurgical Pain

Joseph Gimbel, MD*, and Harry Ahdieh, PhD{dagger}

*Arizona Research Center, Phoenix, Arizona; and {dagger}Endo Pharmaceuticals Inc., Chadds Ford, Pennsylvania

Anesth Analg 2004 99: 1472-1477

 

作者设计双盲、平行对照试验,用安慰剂对照比较3种不同的剂量的即时释放(IR)二氢羟吗啡酮用于术后中重度疼痛的有效性,并比较其与14-羟基二氢可待因酮和安慰剂的安全性。采用单次注射(n300),患者分别接受IR二氢羟吗啡酮10 mg20 mg30mgIR14-羟基二氢可待因酮以及安慰剂。结果3种剂量的IR二氢羟吗啡酮都对术后8小时的疼痛有缓解(P<0.05),同时有明显的镇痛剂量相关性(P<0.001)。在术后45分钟,疼痛的强度明显不同(20mg 30mg剂量组,P<0.05)。由于缺乏镇痛效果而放弃实验,安慰剂组中占42% IR 14-羟基二氢可待因酮组中占27%。术后3小时需要补充药物的病人每46小时接受额外的研究,并作为多剂量组(n=164)。所有的IR二氢羟吗啡酮组镇痛时间均大于48小时。30mg组平均间隔时间>9.5小时,而其他剂量的IR二氢羟吗啡酮组,时间>7小时。在阿片类相关的副作用方面,各组相似,表现为轻中度。IR二氢羟吗啡酮10mg20mg30mg组和安慰剂组相比较,表现出疼痛缓解和剂量的相关性,同时,这种疼痛的缓解可以持续数天,其安全性和IR 14-羟基二氢可待因酮组相当。

(顾漪闻 译 陈杰 校)

In this double-blind, parallel-group study, we compared 3 oxymorphone immediate-release (IR) doses with placebo for efficacy and with oxycodone IR and placebo for safety in patients with acute moderate-to-severe postsurgical pain. During the single-dose phase (n = 300), patients received oxymorphone IR 10, 20, or 30 mg; oxycodone IR 10 mg; or placebo. All oxymorphone IR doses were superior for providing pain relief for 8 h (P < 0.05), with a significant analgesic dose response (P < 0.001). Significant pain intensity differences occurred by 45 min (20- and 30-mg doses; P < 0.05). Discontinuations for lack of efficacy totaled 42% among placebo-treated patients and 27% among those treated with oxymorphone IR. Patients requiring rescue medication after 3 h were allowed to receive additional study drug every 4 to 6 h as needed for the multiple-dose phase (n = 164). All oxymorphone groups maintained analgesia for 48 h. The median dosing interval was >9.5 h for oxymorphone IR 30 mg and ≥7 h for the other groups. Opioid-related adverse events, similar among groups, were generally mild or moderate. Oxymorphone IR 10, 20, or 30 mg provided significant dose-related pain relief compared with placebo, and this relief was maintained over several days with a safety profile comparable to that of oxycodone IR.

 

复杂性区域疼痛综合征导致的全身儿茶酚胺增高与心理因素的关系:一个初步研究

Increased Systemic Catecholamines in Complex Regional Pain Syndrome and Relationship to Psychological Factors: A Pilot Study

R. Norman Harden, MD*,{dagger},{ddagger}, Nathan J. Rudin, MA MD§, Stephen Bruehl, PhD||, William Kee, PhD, Devang K. Parikh, MS#, Jason Kooch, MD{dagger}, Thomas Duc, MD, and Richard H. Gracely, PhD**

Center for Pain Studies, Chicago, Illinois; {dagger}Rehabilitation Institute of Chicago, Chicago, Illinois; {ddagger}Northwestern University Medical School, Chicago, Illinois; §Department of Orthopedics and Rehabilitation Medicine and Pain Treatment and Research Center, University of Wisconsin Medical School, Madison, Wisconsin; ||Vanderbilt University School of Medicine, Nashville, Tennessee; ¶Medical University of South Carolina, Charleston, South Carolina; #University of Pennsylvania, Philadelphia, Pennsylvania; and **Chronic Pain and Fatigue Research Program, University of Michigan Health System, Ann Arbor, Michigan

Anesth Analg 2004 99: 1478-1485.

 

已经证明在患有复杂性区域疼痛综合征(CRPS)的病人,其受累肢体和非受累肢体的静脉内的血浆去甲肾上腺素的浓度是不同的,其受累肢体的去甲肾上腺素(NE)水平明显降低。本研究目的旨在了解患有CRPS的病人并伴有全身性持续疼痛(SMP)的病人,是否全身的静脉内的儿茶酚胺水平和健康志愿者有所不同。作者另研究是否儿茶酚胺水平和心理性因素,如抑郁,焦虑,个性评分有关。采集33CRPS/SMP病人(从非患侧肢体),和30个健康者(对照组)的血样,测定其血样中的NE浓度和肾上腺素(E)浓度。结果发现,CRPSNE浓度显著增高(P < 0.001)。虽然52%CRPS/SMP病人的E浓度和基础值比较大于95%的可信区间,但是组间比较E浓度没有差异(P<0.06)。而E浓度和心理评分之间有明显的正相关性(P<0.05),心理评分法采用的是明尼苏达州的多相个性测试表-2中的Beck抑郁评分测量表136。这些初步工作提示CRPS/SMP病人血浆中的去甲肾上腺素(NE)浓度和肾上腺素(E)浓度可能导致了CRPS 的疼痛,情感上的抑郁,或者两者兼有。作者的研究结果还可能说明了由于情感、内分泌、或者其他病理原因导致的前病态的肾上腺素的高活性,可能使这些个体易罹患为CRPS。这个假设还需要详细的确切的研究。

(顾漪闻 译 陈杰 校)

We have demonstrated that subjects with complex regional pain syndrome (CRPS) have asymmetric venous pool plasma concentrations of norepinephrine (NE) when affected and unaffected limbs are compared, with most demonstrating decreased NE levels in the affected limb. This pilot study explored whether systemic venous plasma catecholamine levels in CRPS subjects with sympathetically maintained pain (SMP) differ from those found in healthy volunteers. We also explored whether catecholamine levels were correlated with scores on psychometric measures of depression, anxiety, and personality. Venous blood samples from 33 CRPS/SMP patients (from unaffected limbs) and 30 healthy control subjects were assayed for plasma NE and epinephrine (E) concentrations. Plasma NE levels were significantly higher in the CRPS group (P < 0.001). Statistical comparisons of E levels across groups did not achieve significance (P < 0.06), although 52% of CRPS/SMP patients had E levels exceeding the 95% confidence interval based on control data. Significant positive correlations were found between E levels and scores on the Beck Depression Inventory and Scales 1, 3, and 6 on the Minnesota Multiphasic Personality Inventory-2 (all P < 0.05). This preliminary work suggests that increased NE and E levels in CRPS/SMP patients may result from the pain of CRPS, consequent affective distress, or both. Alternatively, our findings could reflect premorbid adrenergic hyperactivity caused by affective, endocrine, or other pathology, which might predispose these individuals to develop the syndrome. Definitive studies are needed to examine these hypotheses in detail.


脊髓手术病人术中进行唤醒试验和术后早期苏醒:短效静脉和吸入麻醉药的比较

Intraoperative Wake-Up Test and Postoperative Emergence in Patients Undergoing Spinal Surgery: A Comparison of Intravenous and Inhaled Anesthetic Techniques Using Short-Acting Anesthetics

Oliver Grottke, MD MSc*, Peter Johannes Dietrich, MD*, Stefanie Wiegels, MD*, and Frank Wappler, MD{dagger}

*Department of Anesthesiology, University Hospital Eppendorf, Hamburg, Germany; and {dagger}Department of Anesthesiology, University Witten/Herdecke, Cologne, Germany

Anesth Analg 2004 99: 1521-1527.

 

脊柱外科手术可能会导致脊髓损伤,从而使病人产生神经系统的缺损,必须紧急治疗。本实验的目的是为了测定哪一种麻醉药组合可以允许麻醉医生在术中和术后实施快速的唤醒试验,从而及时发现病人有无神经系统的缺损。54个病人随机分为如下几组:PR(丙泊酚/雷米芬太尼):通过靶控输注丙泊酚(血浆浓度2-4µg /ml)和雷米芬太尼0.2-0.5µg /Kg/minPS(丙泊酚/舒芬太尼):靶控输注丙泊酚(血浆浓度2-4µg/ml),舒芬太尼重复剂量为0.1-0.2mg/Kg,并根据病人需要调整;DR(地氟醚/雷米芬太尼):地氟醚/空气3.0-4.0vol%复合雷米芬太尼0.2-0.5µg/Kg/min。结果PS组病人出现自主呼吸(8.9±1.6min)、抬头(17.0±3.8min)以及足活动(17.0±7.4min) 时间均明显长于PR(以上各项分别为6.9±2.6min9.3±2.2min9.4±2.4min)DR(以上各项分别为5.4±0.8min6.1±1.0min6.2±1.0min)。因此与丙泊酚和雷米芬太尼组合相比,地氟醚和雷米芬太尼组合可允许病人在术中和术后较快的苏醒,从而可在脊髓手术后迅速进行神经系统的检查。

(齐波 译 陈杰 校)

Surgical procedures on the vertebral column may result in spinal cord damage, leading to neurological deficits that demand immediate therapeutical intervention. We designed this study to determine which anesthetic regimen allows a rapid wake-up test during and after surgery to detect neurological deficits. Fifty-four patients were randomly allocated to the following groups: group PR (propofol/remifentanil): target-controlled infusion with propofol (plasma concentration, 2–4 µg/mL) and remifentanil 0.2–0.5 µg • kg–1 • min–1; group PS (propofol/sufentanil): propofol (2–4 µg/mL) and repetitive boluses of 0.1–0.2 µg/kg of sufentanil adjusted to patients requirements; and group DR (desflurane/remifentanil): desflurane/air 3.0–4.0 vol% combined with remifentanil 0.2–0.5 µg • kg–1 • min–1. Group PS required significantly longer times for the onset of breathing (8.9 ± 1.6 min), elevation of the head (17.0 ± 3.8 min), and motion of the feet (17.0 ± 7.4 min) than group PR (6.9 ± 2.6 min, 9.3 ± 2.2 min, and 9.4 ± 2.4 min, respectively) or group DR (5.4 ± 0.8 min, 6.1 ± 1.0 min, and 6.2 ± 1.0 min, respectively). The anesthetic regimen with desflurane and remifentanil allowed faster awakening during and after surgery that permitted immediate neurological examination after spinal surgery compared with propofol/remifentanil.

 

骶旁坐骨神经阻滞加选择性闭孔神经阻滞的作用评估

Adding a Selective Obturator Nerve Block to the Parasacral Sciatic Nerve Block: An Evaluation

Denis Jochum, MD*, Gabriella Iohom, FCARCSI{dagger}, Olivier Choquet, MD{ddagger}, Dioukamady Macalou, MD{dagger}, Samba Ouologuem, MD{dagger}, Pascal Meuret, MD{dagger}, Freddy Kayembe, MD{dagger}, Michel Heck, MD{dagger}, Paul-Michel Mertes, MD PhD{dagger}, and Hervé Bouaziz, MD PhD{dagger}

*Department of Anesthesiology and Intensive Care Medicine, Private Hospital Group of Center Alsace, Colmar, France; {dagger}Department of Anesthesiology and Intensive Care Medicine, Nancy University Hospitals, Nancy, France; {ddagger}Department of Anesthesiology, Hôpital de la Conception, Marseille, France

Anesth Analg 2004 99: 1544-1549

.

本研究目的是客观评价骶旁阻滞后再进行闭孔神经阻滞的有效性。选择拟行膝部手术的病人,先行内收肌肌力的基础评价。用0.75%罗哌卡因30 ml行骶旁阻滞后,每5 min对坐骨神经支配区域皮肤的感觉(温度辨别)减退情况和内收肌肌力进行评价。骶旁阻滞30min后效果不完全的病人(定义为坐骨神经支配区域的三个部位皮肤的温度辨别评分小于2)被排除出本研究。随后,用0.75%罗哌卡因7 ml进行选择性闭孔神经阻滞,在15min内每5min对内收肌肌力进行评价。最后,用0.75%罗哌卡因10ml阻滞股神经。在每次阻滞过程中病人的不适程度用视觉模拟标尺(VAS)进行评价。有30名病人完成该试验,其中有5名病人被排除出试验,因为在骶旁阻滞30min后坐骨神经支配区域的感觉阻滞不充分(成功率为89%)。骶旁阻滞30min后,内收肌肌力(85 ± 24 mmHg)与基础值(97 ± 28 mmHg)相比,降低11.3% ± 7%P = 0.002)。闭孔神经阻滞15min后,内收肌肌力(16.6 ± 15 mmHg)又降低69% ± 7% P < 0.0001)。在骶旁、闭孔、股神经阻滞过程中VAS评分相似,分别为26 ± 1928 ± 2427 ± 19 mm。在两具新鲜尸体用30ml有色乳液进行四次模拟骶旁阻滞上,评价乳液扩散速度与闭孔神经的关系。这些有色乳液引起局限于骶丛的扩散。这些发现证明,骶旁阻滞以获得闭孔神经阻滞并不可靠,临床上应考虑增加选择性闭孔神经阻滞。

(赵延华 译 陈杰 校)

Our aim was to objectively evaluate the efficacy of obturator nerve anesthesia after a parasacral block. Patients scheduled for knee surgery had a baseline adductor strength evaluation. After a parasacral block with 30 mL 0.75% ropivacaine, sensory deficit in the sciatic distribution (temperature discrimination) and adductor strength were assessed at 5-min intervals. Patients with an incomplete sensory block (defined as a temperature discrimination score of less than 2 in the 3 cutaneous distributions of the sciatic nerve tested) 30 min after the parasacral block were excluded from the study. Subsequently, a selective obturator block was performed with 7 mL 0.75% ropivacaine and adductor strength was reassessed at 5 min intervals for 15 min. Finally, a femoral block was performed using 10 mL 0.75% ropivacaine. Patient discomfort level during each block was assessed using a visual analog scale (VAS). Thirty-one patients completed the study. Five patients were excluded as a result of inadequate sensory block in the sciatic distribution 30 min after the parasacral block (success rate of 89%). Thirty min after the parasacral block, adductor strength decreased by 11.3% ± 7% compared with baseline (85 ± 24 versus 97 ± 28 mm Hg, P = 0.002). Fifteen min after the obturator nerve block, adductor muscle strength decreased by an additional 69% ± 7% (16.6 ± 15 versus 85 ± 24 mm Hg, P < 0.0001). VAS scores were similar for all blocks (26 ± 19, 28 ± 24, and 27 ± 19 mm for parasacral, obturator, and femoral respectively). Four parasacral blocks were simulated in 2 fresh cadavers using 30 mL of colored latex solution. The spread of the die in relation to the obturator nerve was assessed. Injection of 30 mL colored latex into cadavers resulted in spread of the injectate restricted to the sacral plexus. These findings demonstrate the unreliability of parasacral block to achieve anesthesia of the obturator nerve. A selective obturator block should be considered in the clinical setting when this is desirable.


难以解释的术中出血病人其凝血因子XIII有效性降低以及血栓稳固性早期丧失

Decreased Factor XIII Availability for Thrombin and Early Loss of Clot Firmness in Patients with Unexplained Intraoperative Bleeding

Patrick Wettstein, MD*,{dagger}, André Haeberli, PhD{ddagger}, Monika Stutz{ddagger}, Miriam Rohner{dagger}, Cinzia Corbetta{dagger}, Konrad Gabi, MD*, Thomas Schnider, MD*, and Wolfgang Korte, MD{dagger}

*Institute for Anesthesiology and {dagger}Institute for Clinical Chemistry and Hematology, Kantonsspital, St. Gallen, Switzerland; and {ddagger}Department of Clinical Research, University of Bern, Bern, Switzerland

Anesth Analg 2004 99: 1564-1569

.

为了探究难以解释的术中出血的有关变化,本研究评价了226名择期手术病人凝血级联反应的最终步骤。根据预先指定的标准确定发生难以解释的术中出血病人,有20名病人(8.8%)发生难以解释的出血,易出血者和非出血者术中平均失血量分别为1350ml400mlP < 0.001)。在易出血者纤维蛋白原和凝血因子XIII快速消耗(P < 0.001),整个手术过程中可溶性纤维蛋白原(纤维蛋白单体)的形成增加(P ≤0.014),但是在围术期每单位凝血酶的XIII因子有效性显著降低(P ≤0.051)。计算机化的血栓弹性图显示血栓稳固性显著地降低。作者认为手术病人并存轻度凝血病并不少见,可能引起与临床相关的围术期出血。这种止血状态的紊乱表现为血栓稳固性受损,可能继发于交叉结合减少(由XIII因子缺失,其绝对值和每单位凝血酶)。因此作者建议对存在术中凝血障碍风险的病人,应用XIII因子以增加血栓稳固性是有价值的。

(赵延华 译 陈杰 校)

To explore relevant changes in unexplained intraoperative bleeding, we evaluated elements of the final steps of the coagulation cascade in 226 consecutive patients undergoing elective surgery. Patients were stratified for the occurrence of unexplained intraoperative bleeding according to predefined criteria. Twenty patients (8.8%) developed unexplained bleeding. The median intraoperative blood loss was 1350 mL (bleeders) and 400 mL (nonbleeders) (P < 0.001). Fibrinogen and Factor XIII (F. XIII) were more rapidly consumed in bleeders (P < 0.001). Soluble fibrin formation (fibrin monomer) was increased in bleeders throughout surgery (P ≤0.014). However, F. XIII availability per unit thrombin generated was significantly decreased in bleeders before, during, and after surgery (P ≤0.051). Computerized thrombelastography showed a parallel, significant reduction in clot firmness. We suggest that mild preexisting coagulopathy is not rare in surgical patients and probably can result in clinically relevant intraoperative bleeding. This hemostatic disorder shows impaired clot firmness, probably secondary to decreased cross-linking (due to a loss of F. XIII, both in absolute measures and per unit thrombin generated). We suggest that the application of F. XIII might be worthwhile to test in a prospective clinical trial to increase clot firmness in patients at risk for this intraoperative coagulopathy.

 

儿童全身麻醉后口服静脉制剂柠檬酸芬太尼的药代动力学

The Pharmacokinetics of the Intravenous Formulation of Fentanyl Citrate Administered Orally in Children Undergoing General Anesthesia

Melissa Wheeler, MD*, Patrick K. Birmingham, MD*, Ralph A. Lugo, PharmD{ddagger}, Corri L. Heffner, RN*, and Charles J. Coté, MD*,{dagger}

Department of *Anesthesiology and the {dagger}Pediatrics, Children’s Memorial Hospital, The Feinberg School of Medicine at Northwestern University, Chicago, Illinois, and the {ddagger}University of Utah College of Pharmacy and School of Medicine, Salt Lake City, Utah

Anesth Analg 2004;99:1347-1351

经口腔黏膜给予儿童柠檬酸芬太尼(OTFC)的生物利用度与成人口服给药相似。我们假设给予儿童口服芬太尼溶液后,其血浆芬太尼浓度和药代动力学的变化与给予相同剂量OTFC相似。在这一前驱性的研究中,有10位术后镇痛的健康儿童参加。每位研究对象口服不稀释的芬太尼静脉制剂,大约10–15 µg/kg,最大剂量400 µg。服药后15600分钟采集静脉血样。用noncompartmental分析药代动力学的变化,并与以往儿童人群服用相同剂量OTFC的研究结果比较。口服芬太尼静脉制剂后药代动力学参数如下:达到峰浓度的时间是1.7 ± 1.6 h,峰浓度是1.83 ± 1.19 ng/mL,半衰期是4.7 ± 2.8 h,血浆浓度时间曲线下面积是6.46 ± 3.96 h • ng–1 • mL–1,表观容积分布(V/F)17.5 ± 7.2 L/kg,表观清除率(CL/F)3.33 ± 2.25 L • kg–1 • h–1。不论是OTFC还是口服静脉制剂的芬太尼,相对于某一剂量,两者的药代动力学和血浆浓度相似,但是个体之间存在明显的差异,特别是在口服静脉制剂芬太尼的最初几个小时。这就提示我们在用这种方法给药时,应慎重,直到有更多研究数据的出现。

(葛宁花译,薛张纲校)

The bioavailability of oral transmucosal fentanyl citrate (OTFC) in children is similar to that of fentanyl solution administered orally to adults. We hypothesized that administering an oral fentanyl solution to children would result in similar fentanyl plasma concentrations and pharmacokinetic variables as administering comparable doses of OTFC. In this pilot study, 10 healthy children requiring postoperative analgesia were enrolled. Each received the undiluted IV fentanyl formulation orally (approximately 10–15 µg/kg; maximum, 400 µg). Venous blood samples were collected from 15 to 600 min after administration. Pharmacokinetic variables were determined using noncompartmental analysis and were compared with a previously studied population of children who received a similar dose of OTFC. Pharmacokinetic variables for the orally administered IV fentanyl formulation were as follows: time to reach peak concentration = 1.7 ± 1.6 h, peak concentration = 1.83 ± 1.19 ng/mL, half-life = 4.7 ± 2.8 h, area under the plasma concentration time curve = 6.46 ± 3.96 h • ng–1 • mL–1, apparent oral volume of distribution (V/F) = 17.5 ± 7.2 L/kg, apparent oral clearance (CL/F) = 3.33 ± 2.25 L • kg–1 • h–1. Although both OTFC and orally administered IV fentanyl resulted in similar pharmacokinetic variables and plasma concentrations for a given dose, there was marked interpatient variability, particularly in the early hours after oral administration of the IV formulation of fentanyl. This suggests that this method of administration be used with caution until further data are available.

 

健康人群水合氯醛吗啡多次鼻腔给药后的I相研究

A Multiple-Dose Phase I Study of Intranasal Hydromorphone Hydrochloride in Healthy Volunteers

Anita C. Rudy, PhD*, Barbara A. Coda, MD{dagger},{ddagger}, Sanford M. Archer, MD§, and Daniel P. Wermeling, PharmD*,||

*Intranasal Technology, Inc., Lexington, Kentucky; {dagger}Department of Anesthesiology, University of Washington, Seattle, Washington; {ddagger}McKenzie Anesthesia Group, Springfield, Oregon; §Division of Otolaryngology-Head &Neck Surgery, University of Kentucky A. B. Chandler Medical Center, Lexington, Kentucky; and ||University of Kentucky College of Pharmacy, Lexington, Kentucky

Anesth Analg 2004;99:1379-1386


我们在知道具体药物情况下,用单次和多次给药方法,研究鼻腔给1 2 mg水合氯醛吗啡后的药代动力学、耐受性和安全性。这一研究在24位健康志愿者中进行(13 男性和11 女性)。分别将12-mg的吗啡,精确至0.1-mL,喷入一侧或两侧鼻孔。在单次注射或多次注射的最后一次(第七次)的012 h之间连续抽取血样。用液相色谱法/物体光谱法检测水合氯醛吗啡的血药浓度。用非房室模型分析药代动力学的变化。连续7次鼻腔给药1 2 mg( 6 h给药一次)后,血浆平均峰浓度分别为2.8 ± 0.7 ng/mL 5.3 ± 2.3 ng/mL。单次和多次给药后,达到血浆峰浓度的平均时间均为20分钟。1- 2-mg 时,均出现与剂量成正比。副作用包括嗜睡、头昏和服药后味觉变差。鼻腔给予水合氯醛吗啡具有很好的耐受性,吸收迅速且药物蓄积有可预见性。这些研究结果支持临床用鼻腔喷雾给药,替代口服或肌肉注射给药。

(葛宁花译,薛张纲校)

We evaluated the pharmacokinetics, tolerability, and safety of 1 and 2 mg of intranasal hydromorphone hydrochloride in an open-label, single- and multiple-dose study. This Phase I study was conducted in 24 healthy volunteers (13 men and 11 women). Intranasal doses were delivered as 0.1-mL metered-dose sprays into one or both nostrils for 1- and 2-mg doses, respectively. Venous blood samples were taken serially from 0 to 12 h after the first single dose and the last (seventh) multiple dose. Plasma hydromorphone concentrations were determined by liquid chromatography/mass spectrometry/mass spectrometry. Noncompartmental analysis was used to estimate pharmacokinetic variables. After 7 intranasal doses of 1 and 2 mg (once every 6 h), mean ± SD peak plasma concentrations of 2.8 ± 0.7 ng/mL and 5.3 ± 2.3 ng/mL, respectively, were observed. The median time to peak concentration was 20 min for both single and multiple doses. Dose proportionality was observed for the 1- and 2-mg doses. Adverse events included somnolence, dizziness, and bad taste after dose administration. Intranasal hydromorphone hydrochloride was well tolerated and demonstrated rapid nasal drug absorption and predictable accumulation. These results support clinical investigation of hydromorphone hydrochloride nasal spray for use as an alternative to oral and IM administration.

 

 

 

 

 

氙气并不延长罗库溴胺的神经阻滞作用
Xenon Does Not Prolong Neuromuscular Block of Rocuronium

Oliver Kunitz, MD, Jan-Hinrich Baumert, MD, Klaus Hecker, MD, Thorben Beeker, MD, Mark Coburn, MD, André Zühlsdorff, MD, and Rolf Rossaint

Department of Anesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany

Anesth Analg 2004;99:1398-1401

除了氙气以外,肌肉松弛剂和吸入性麻醉药之间的关系已经明了。我们因而比较吸入氙气麻醉或全凭异丙酚静脉麻醉时,罗库溴胺的药代动力学。氙气和异丙酚组(每组20人),均用异丙酚和雷米芬太尼诱导。氙气组,经面罩吸入氙气,直到呼气末浓度达到60%,并持续1 分钟。同时用加速肌动描记仪(TOF监测仪 SX)监测,四个成串刺激,观察拇内收肌的运动。监测仪信号稳定后5 分钟,单次注入罗库溴胺0.6 mg/kg。麻醉维持:氙气组,氙气和雷米芬太尼;异丙酚组,异丙酚和雷米芬太尼。两组的起效时间(氙气组:125 ± 33 s,异丙酚组:144 ± 43 s)、持续时间(氙气组:33.2 ± 10.8 min,异丙酚组:32.6 ± 8.4 min)、恢复指数(氙气组:9.4 ± 6.6 min,异丙酚组:8.4 ± 5.3 min)和临床恢复时间(氙气组:18.0 ± 10.2 min,异丙酚组:17.1 ± 8.5 min)均无显著性差异。结论:全麻时,无论是与氙气还是异丙酚合用,罗库溴胺的神经肌肉阻滞作用没有变化。

(葛宁花译,薛张纲校)

With the exception of xenon, the interaction between muscle relaxants and inhaled anesthetics is known. We therefore compared the pharmacodynamics of rocuronium during xenon anesthesia versus a total IV anesthesia with propofol. Anesthesia was induced with propofol and remifentanil in both the xenon and propofol groups (each n = 20). The xenon group received xenon via face mask until an end-expiratory concentration of 60% was maintained for 1 min. Meanwhile, the acceleromyograph (TOF-Watch SX®) was calibrated and a frequent train-of-four stimulation of the musculus adductor pollicis was started. After stabilization of the signal for 5 min, a single bolus of 0.6 mg/kg rocuronium was injected. Anesthesia was maintained with xenon and remifentanil (xenon group) or with propofol and remifentanil (propofol group). There were no significant differences between the groups concerning the onset time (xenon group 125 ± 33 and propofol group 144 ± 43 s), duration (xenon group 33.2 ± 10.8 and propofol group 32.6 ± 8.4 min), recovery index (xenon group 9.4 ± 6.6 and propofol group 8.4 ± 5.3 min), and clinical recovery (xenon group 18.0 ± 10.2 and propofol group 17.1 ± 8.5 min). We conclude that the neuromuscular blocking effects of rocuronium are not different when given during propofol versus xenon anesthesia.

 

 

 




 

异氟醚抑制C纤维诱发肢体回缩的触发反应对鼠腰脊髓神经元疼痛刺激的影响

Isoflurane Depresses Windup of C Fiber-Evoked Limb Withdrawal with Variable Effects on Nociceptive Lumbar Spinal Neurons in Rats

Steven L. Jinks, PhD*, Joseph F. Antognini, MD*,{dagger}, Robert C. Dutton, MD{ddagger}, Earl Carstens, PhD{dagger}, and Edmond I Eger, II, MD{ddagger}

*Department of Anesthesiology and Pain Medicine, and {dagger}Section of Neurobiology, Physiology, and Behavior, University of California, Davis; and {ddagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California

Anesth Analg 2004;99:1413-1419


触发反应是脊髓神经元对反复电刺激C纤维这样一种伤害性刺激的渐渐增强型反应。我们假设异氟醚抑制肢体对伤害性刺激时的有意识运动反应的最低肺泡浓度(MAC)能抑制触发反应。记录单个脊髓腰段神经元在1 Hz 15次的反复电刺激鼠后爪C纤维的触发反应,同时记录后爪回缩的力量。每15次刺激后总的动作电位(均数 ±标准差来表示每个神经元最大反应的百分数) 在异氟醚0.7, 0.9, 1.1, 1.4 MAC下分别为 83% ± 5%, 84% ± 5%, 67% ± 7%, 57% ± 8% 。异氟醚0.9 1.1 MAC时,两组结果有显著性的差异;而异氟醚0.7 0.9 MAC时,两组的结果与异氟醚1.4 MAC组有显著性的差异(P < 0.05)。这种抑制,在大多数的单元中,主要由于抑制C纤维激发的反应,并且在6个单元中,降低了最初5次刺激的触发反应幅度。在异氟醚0.9, 1.1, 1.4 MAC时,肌肉回缩的力量分别为 67%, 11%, 4%。异氟醚抑制腰脊髓神经元的兴奋性和触发反应,抑制肢体的运动,并呈剂量依赖。

(葛宁花译,薛张纲校)

Windup is a progressive increase in responses of nociceptive spinal cord neurons to repeated electrical C fiber stimulation. We hypothesized that isoflurane would depress windup at approximately the minimum alveolar anesthetic concentration (MAC) required to suppress purposeful movement in response to noxious stimulation. We recorded windup responses in single lumbar spinal neurons (n = 17) to a series of 15 repetitive electrical stimuli delivered at 1 Hz to the hindpaw at C fiber strength; hindpaw withdrawal force was simultaneously recorded. The total number of action potentials per 15 stimuli (mean ± SEM as a percentage of each neuron’s maximal response) was 83% ± 5%, 84% ± 5%, 67% ± 7%, and 57% ± 8% at 0.7, 0.9, 1.1, and 1.4 MAC, respectively. The 0.9 and 1.1 MAC values differed significantly from each other, whereas the 0.7 and 0.9 MAC values differed from the 1.4 MAC value (P < 0.05). The reduced firing was attributed to a depression of the initial C fiber-evoked responses in most units, and a reduction in windup slope over the initial 5 stimuli in 6 units. Muscle force was 67%, 11%, and 4% of the 0.7 MAC value at 0.9, 1.1, and 1.4 MAC, respectively. Isoflurane depressed excitability and variably affected windup of lumbar spinal cord neurons, while uniformly depressing windup of limb withdrawals in a concentration-dependent manner.


 

Arrow 固定器将中心静脉导管固定于皮肤的有效性

The Efficacy of the Arrow Staple Device for Securing Central Venous Catheters to Human Skin

Gregg K. Motonaga, MD, Keith K. Lee, DO, and Jeffrey R. Kirsch, MD

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland

Anesth Analg 2004;99:1436-1439

我们验证这样的假设:如果需要用力才能将中心静脉导管从与皮肤固定处拔除,主要归功于固定方法。用三种不同的方法固定中心静脉导管:用3-0丝线缝针2次,用4 0.022英寸的固定器固定,或用40.025英寸的固定器固定,然后比较将中心静脉导管从与皮肤固定处拔除所需的沿导管轴心的最大力量和扭转拔除的力量。我们用膝下截肢近端废用肢体的组织,代替正常情况下与导管固定的人体皮肤。然后将中心静脉导管与肉眼正常的组织用3-0丝线或4个固定器固定。每一种的固定方法,用力拔导管16次。沿导管轴心用力,拔除导管的平均峰力量3-0丝线组(40.9 ± 10.7 N; n = 16)4 0.022英寸的固定器组(34.0 ± 7.2 N; n = 16;P = 0.04)大,但与40.025英寸的固定器组(40.4 ± 5.8 N; n = 16)比较,无显著性差异。这一研究显示:为防止导管轴相拔除,用40.025英寸的固定器固定能达到与用3-0丝线缝合固定一样的效果。

(葛宁花译,薛张纲校)

We tested the hypothesis that the force necessary to dislodge a central venous catheter from human skin is related to its method of attachment. Specifically, we compared the peak axial force and torque required to remove a catheter hub attached to human skin with 2 3-0 silk sutures, 4 0.022-in. staples, or 4 0.025-in. staples. We used the tissue from the proximal end of discarded extremities after below-knee amputations to serve as a surrogate for the skin of living humans that would normally be the site for catheter stabilization. Central venous catheter hubs were secured to the area of grossly normal appearing tissue with 2 3-0 silk sutures or 4 staples. For each attachment method, 16 dislodgement trials were conducted. The mean peak force required for axial dislodgement with 3-0 silk sutures (40.9 ± 10.7 N; n = 16) was more than that for 4 0.022-in. staples (34.0 ± 7.2 N; n = 16;P = 0.04) but was not different from that for 4 0.025-in. staples (40.4 ± 5.8 N; n = 16). The major finding of this study is that securing a central venous hub with 4 0.025-in. staples is as effective as 2 3-0 silk sutures in preventing axial dislodgement.

 

 

 

 

 


曲马多用作皮下局部麻醉剂时的术后镇痛效果

The Postoperative Analgesic Effect of Tramadol When Used as Subcutaneous Local Anesthetic

Hanife Altunkaya, MD*, Yetkin Ozer, MD*, Eksal Kargi, MD{dagger}, Isil Ozkocak, MD*, Mübin Hosnuter, MD{dagger}, Cengiz Bekir Demirel, MD*, and Orhan Babuccu, MD{dagger}

Departments of *Anesthesiology and {dagger}Plastic and Reconstructive Surgery, Zonguldak Karaelmas University, School of Medicine, Kozlu/Zonguldak, Turkey

Anesth Analg 2004;99:1461-1464


近来研究表明,曲马多在小手术中是一有效的局部麻醉剂。在这一研究中,主要评价其术后的镇痛作用。研究对象为40位在局麻下进行小手术(脂肪瘤切除,疤痕整形术)的患者。患者随机分为两组:T组(n = 20),曲马多2 mg/kgL (n = 20),利多卡因1 mg/kg,皮下注射。两组注射药物的容积均为5 mL,含1/200,000的肾上腺素。记录注射点的红斑、烧灼感和疼痛程度。切皮反应,主要是切皮时的疼痛,用视觉模糊法(VAS) 0–10进行评分记录。切皮后,每隔15分钟,记录VAS。术中VAS如大于4分,追加相应的药物0.5 mg/kg,并将这一剂量记入至总量。患者在手术当天出院。VAS ≥4的患者,建议必要时服用扑热息痛。除了T组有一位患者在手术后30分钟,出现恶心外,两组患者均无其他副作用。24小时后,随访患者,记录患者术后第一次用镇痛药的时间和用药总量。在术后24小时期间,T20位患者中,有18(90%)不需要任何镇痛药,而L组中,只有10(50%)P < 0.05。术后第一次服用镇痛药的时间T(4.9 ± 0.3 h)L(4.4 ± 0.7 h) 长,P < 0.05。我们认为在小手术时,曲马多是利多卡因之外的又一选择,它能减少术后对镇痛药的需要。

(葛宁花译,薛张纲校)

Recently, it has been shown that tramadol was an effective local anesthetic in minor surgery. In this study, its efficacy for relieving postoperative pain was evaluated. Forty patients undergoing minor surgery (lipoma excision and scar revision) under local anesthesia were included. The patients were randomly allocated into two groups: In group T (n = 20), tramadol, and in group L (n = 20), 1 mg/kg lidocaine were given subcutaneously. In both groups, the injection volume was 5 mL containing 1/200,000 adrenalin. The degree of the erythema, burning sensation, and pain at the injection site were recorded. Incision response, which is a degree of the pain sensation during incision, was recorded and graded with the visual analog scale (VAS) 0–10. After incision, VAS values were recorded at 15-min intervals. When the VAS score of the pain during surgery exceeded 4, an additional 0.5 mg/kg of the study drug was injected and this dosage was added to the total amount. Patients were discharged on the same day. Subjects with VAS ≥4 were advised to take paracetamol as needed. No side effects were recorded in either group except for 1 patient complaining of nausea in group T at the 30th min of operation. After 24 h, patients were called and the time of first analgesic use and total analgesic dose taken during the postoperative period were recorded. During the 24 postoperative hours, 18 of 20 (90%) subjects did not need any type of analgesia in group T, whereas this number was 10 (50%) in group L (P < 0.05). The time span before taking first analgesic medication was longer (4.9 ± 0.3 h) in group T than that of group L (4.4 ± 0.7 h) (P < 0.05). We propose that tramadol can be used as an alternative drug to lidocaine for minor surgeries because of its ability to decrease the demand for postoperative analgesia.

小剂量辣椒素降低败血症鼠的全身炎症反应

Small-Dose Capsaicin Reduces Systemic Inflammatory Responses in Septic Rats

Semra Demirbilek, MD*, M. Ozcan Ersoy, MD*, Savas Demirbilek, MD{dagger}, Abdurrahman Karaman, MD{dagger}, Necla Gürbüz, MD{dagger}, Nihayet Bayraktar, MD{ddagger}, and Mehmet Bayraktar, MD§

Departments of *Anesthesiology and Reanimation, {dagger}Pediatric Surgery, {ddagger}Biochemistry, and §Microbiology, Medical School of Inönü University, Malatya, Turkey

Anesth Analg 2004;99:1501-1507

 

我们研究在鼠败血症的不同阶段,小剂量和大剂量辣椒素对调控全身炎症反应的影响。实验鼠分为6组:C组,对照组;S组,败血症组;CLC组,小剂量辣椒素组(1 mg/kg 皮下注射);SLC组,小剂量辣椒素加败血症组;CHC组,大剂量辣椒素组(150 mg/kg 皮下注射);SHC组,大剂量辣椒素加败血症组。结扎鼠的盲肠并刺破(CLP),造成败血症。每组再分成两个亚组。在CLP 918小时后,处死实验鼠。检测血浆中降钙素基因关联多肽(CGRP)、肿瘤坏死因子(TNF)-{alpha},,白介素(IL-6IL-10和亚硝酸盐总量/硝酸盐(NOx)。并检测肝、肺和心脏组织的过氧化歧化酶和malondialdehyde (MDA)。与其他组比较,S组、CLC组和SLC组的CGRP增加。与S组和SHC组比较,CLP18小时后,SLC组的血浆TNF-{alpha}, IL-6, NOx 和组织的MDA水平降低而IL-10升高(P < 0.05)。小剂量辣椒素能增加抗炎指标IL-10的水平,并能减轻败血症鼠中roinflammatory cytokines, NOx, 和组织 MDA增加的程度。

(葛宁花译,薛张纲校)

We investigated the influence of small- and large-dose capsaicin in modulating systemic inflammatory responses during different stages of sepsis in rats. Rats were divided into six groups: group C, control; group S, sepsis; group CLC, small dose of capsaicin (1 mg/kg subcutaneously); group SLC, small dose of capsaicin plus sepsis; group CHC, large dose of capsaicin (150 mg/kg subcutaneously); group SHC, large dose of capsaicin plus sepsis. Rats were made septic by cecal ligation and puncture (CLP). Each group was subdivided into two subgroups. The animals were killed at 9 or 18 h after CLP. Plasma concentrations of calcitonin gene-related peptide (CGRP), tumor necrosis factor (TNF)-{alpha}, interleukin (IL)-6, IL-10, and total nitrite/nitrate (NOx) were measured. Superoxide dismutase and malondialdehyde (MDA) were determined in liver, lung, and heart tissues. CGRP was increased in groups S, CLC, and SLC when compared with the other groups. In the SLC group, plasma concentrations of TNF-{alpha}, IL-6, NOx, and tissue MDA levels were reduced and IL-10 level was increased when compared with groups S and SHC 18 h after CLP (P < 0.05). Small-dose capsaicin treatment increased antiinflammatory IL-10 levels and attenuated the increases in proinflammatory cytokines, NOx, and tissue MDA in septic rats.

 

 

 

 

 

 

比较产妇分娩自控硬膜外和静脉镇痛:多中心随机对照研究

A Multicenter Randomized Controlled Trial Comparing Patient-Controlled Epidural with Intravenous Analgesia for Pain Relief in Labor

Stephen H. Halpern, MD MSc, FRCPC*, Holly Muir, MD FRCPC{dagger}, Terrance W. Breen, MD FRCPC{dagger}, David C. Campbell, MD MSc, FRCPC{ddagger}, Jon Barrett, MBBch MD, MRCOG, FRCSC§, Robert Liston, MB ChB, FRCSC||, and J. Wade Blanchard, MSc

*Department of Anaesthesia, Sunnybrook and Women’s College Health Sciences Centre, and the University of Toronto, Toronto, Ontario, Canada; {dagger}Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; {ddagger}Department of Anesthesia, Royal University Hospital, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, and College of Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada; §Department of Obstetrics and Gynaecology, University of Toronto, and Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario, Canada; ||Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia Women’s Hospital, Vancouver, British Columbia, Canada; and ¶Department of Mathematics & Statistics, Statistical Consulting Service, Dalhousie University, Halifax, Nova Scotia, Canada

Anesth Analg 2004;99:1532-1538

 

在这一多中心、随机对照研究中,我们分析患者自控硬膜外镇痛(PCEA)是否影响剖宫产率,并与患者自控静脉阿片类药物镇痛(PCIA)作比较。加拿大4个医疗结构将健康、足月初产妇作为研究对象,随机给予PCIA芬太尼 (n = 118)PCEA 0.08%的布比卡因复合芬太尼1.6 µg/mL (n = 124)。两组的剖宫产率分别为10.2% (118中的12)9.7% (124中的12)、产钳助产率分别为21.2% (118中的25) 29% (124 中的36),两组比较无显著性差异。PCEA组的第二产程延长,平均延长23分钟(P = 0.02)PCIA组有51位产妇(43%)改为硬膜外镇痛:39人(33%)是因为静脉镇痛不完善,12人(10%)是改为手术分娩。PCIA组的产妇需要更多的镇吐药物(17% 比较 6.4%; P = 0.01)和更多的镇静药物(39% 比较5%; P < 0.001)PCEA组,产妇对疼痛的评分和对镇痛的满意率比PCIA组高(分别为P < 0.001 P = 0.02)PCIA组和PCEA组新生儿娩出时需要抢救分别为52% 31%; P = 0.001,需要纳洛酮治疗分别为17% 3%; P < 0.001PCIA组多于PCEA组。这些研究结果支持这样的观点:与PCIA镇痛比较,PCEA镇痛并不影响产妇的产程,并能提供良好的镇痛和对母婴较少的镇静。

(葛宁花译,薛张纲校)

In this multicenter, randomized, controlled trial, we sought to determine whether patient-controlled epidural analgesia (PCEA) for labor affected the incidence of cesarean delivery when compared with patient-controlled IV opioid analgesia (PCIA). Healthy, term nulliparous patients in 4 Canadian institutions were randomly assigned to receive PCIA with fentanyl (n = 118) or PCEA with 0.08% bupivacaine and fentanyl 1.6 µg/mL (n = 124). There was no difference in the incidence of cesarean delivery—10.2% (12 of 118) versus 9.7% (12 of 124)—or instrumental vaginal delivery—21.2% (25 of 118) versus 29% (36 of 124)—between groups. The duration of the second stage of labor was increased in the PCEA group by a median of 23 min (P = 0.02). Fifty-one patients (43%) in the PCIA group received epidural analgesia: 39 (33%) because of inadequate pain relief and 12 (10%) to facilitate operative delivery. Patients in the PCIA group required more antiemetic therapy (17% versus 6.4%; P = 0.01) and had more sedation (39% versus 5%; P < 0.001). Maternal mean pain and satisfaction with analgesia scores were better in the PCEA group (P < 0.001 and P = 0.02, respectively). More neonates in the PCIA group required active resuscitation (52% versus 31%; P = 0.001) and naloxone (17% versus 3%; P < 0.001). These observations support the hypothesis that PCEA does not result in an increased incidence of obstetrical intervention compared with PCIA. PCEA provides superior analgesia and less maternal and neonatal sedation compared with PCIA.

 

青少年脊柱融合术中丙泊酚、小剂量异氟醚和笑气麻醉对皮层体感诱发电位及双频指数监测的影响

The Effects of Propofol, Small-Dose Isoflurane, and Nitrous Oxide on Cortical Somatosensory Evoked Potential and Bispectral Index Monitoring in Adolescents Undergoing Spinal Fusion

Anthony J. Clapcich, MD*, Ronald G. Emerson, MD{dagger}, David P. Roye, Jr., MD{ddagger}, Hui Xie, PhD§, Edward J. Gallo, REEGT{dagger}, Kathy C. Dowling, REEGT{dagger}, Brian Ramnath, REEGT{dagger}, and Eric J. Heyer, MD*

Departments of *Anesthesiology, {dagger}Neurology, {ddagger}Orthopaedics, and §Biostatistics, Children’s Hospital of New York, New York-Presbyterian Hospital, New York, New York

Anesth Analg 2004;99:1334-1340

 

在本研究中,我们比较了接受脊柱融合术的青少年丙泊酚、小剂量异氟醚和笑气(N2O)麻醉对皮层体感诱发电位(SSEP)和双频指数(BIS)监测的影响。以随机次序决定十二例病人接受以下麻醉维持的方法组合:处理1:异氟醚0.4% + N2O 70% + O2 30%;处理2:异氟醚0.6% + N2O 70% + O2 30%;处理3:异氟醚0.6% + 空气+ O2 30%;处理4:丙泊酚120 µg • kg–1 • min–1 +空气+ O2 30%。结果:以处理3(异氟醚0.6%/空气)维持麻醉时测得的皮层SSEP幅度高于处理1 (异氟醚0.4%/N2O 70%) (P < 0.0001) 和处理2 (异氟醚0.6%/N2O 70%) (P < 0.0052)。以处理4(丙泊酚120 µg • kg–1 • min–1 /空气)维持麻醉时测得的皮层SSEP幅度高于处理1 (异氟醚0.4%/N2O 70%) (P < 0.0001) 、处理2 (异氟醚0.6%/N2O 70%) (P < 0.0007)和处理3 (异氟醚0.6%/空气) (P < 0.0191)。另外,以处理1234麻醉时测得的平均BIS值分别为62626144。仅处理4(丙泊酚120 µg • kg–1 • min–1 /空气)能始终如一地维持BIS值低于60。我们的研究证明,与联合使用小剂量异氟醚/ N2O或者单用小剂量异氟醚麻醉相比,丙泊酚麻醉能更好地维持皮层SSEP幅度,且从BIS值上看,能提供更深的催眠水平。

(周志坚 李士通 校)

In this study we compared the effects of propofol, small-dose isoflurane, and nitrous oxide (N2O) on cortical somatosensory evoked potentials (SSEP) and bispectral index (BIS) monitoring in adolescents undergoing spinal fusion. Twelve patients received the following anesthetic maintenance combinations in a randomly determined order: treatment #1: isoflurane 0.4% + N2O 70% + O2 30%; treatment #2: isoflurane 0.6% + N2O 70% + O2 30%; treatment #3: isoflurane 0.6% + air + O2 30%; treatment #4: propofol 120 µg • kg–1 • min–1 + air + O2 30%. Cortical SSEP amplitudes measured during anesthesia maintenance with treatment #3 (isoflurane 0.6%/air) were more than those measured during maintenance with treatment #1 (isoflurane 0.4%/N2O 70%) (P < 0.0001) and treatment #2 (isoflurane 0.6%/N2O 70%) (P < 0.0052). Cortical SSEP amplitudes measured during treatment #4 (propofol 120 µg • kg–1 • min–1/air) were more than treatment #1 (isoflurane 0.4%/N2O 70%) (P < 0.0001), treatment #2 (Iso 0.6%/N2O 70%) (P < 0.0007), and treatment #3 (isoflurane 0.6%/air) (P < 0.0191). In addition, average BIS values measured during treatments 1, 2, 3 and 4 were 62, 62, 61, and 44 respectively. Only treatment #4 (propofol 120 µg • kg–1 • min–1/air) uniformly maintained BIS values less than 60. Our study demonstrates that propofol better preserves cortical SSEP amplitude measurement and provides a deeper level of hypnosis as measured by BIS values than combinations of small-dose isoflurane/N2O or small-dose isoflurane alone.

 

 

 

儿科镇静的综述

Review of Pediatric Sedation

Joseph P. Cravero, MD, and George T. Blike, MD

Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Anesth Analg 2004;99:1355-1364

 

为了诊断和治疗给儿童实施镇静仍然是一个变化飞快且争议相当大的领域。关于儿科镇静的技术及结局的报道发表于广泛的各种专业刊物上,且很少进行全面检验,这就使这一主题的探讨较困难。在这篇综述文章中,我们将从麻醉医师的角度出发,略微谈及儿科镇静这一主题的许多方面。我们首先回顾麻醉医师在儿科镇静现行标准的发展中所起的历史性作用。我们还检查了已发表的研究和报道中所反映的儿科镇静的现状。还包括了关于镇静实施的安全性问题的专题综述。另外,还注意到了在镇静实践中的现行趋势,包括强效镇静催眠药在麻醉学以外领域的延伸作用。最后,我们提出科研前景范围以及对于镇静实施者们来说临床改进之处。

(黄丽娜      李士通 校)

Sedating children for diagnostic and therapeutic procedures remains an area of rapid change and considerable controversy. Exploration of this topic is made difficult by the fact that the reports of techniques and outcomes for pediatric sedation appear in a wide range of subspecialty publications and rarely undergo comprehensive examination. In this review article, we will touch on many aspects of the topic of pediatric sedation from the perspective of the anesthesiologist. We begin with a review of the historical role of anesthesiologists in the development of the current standards for pediatric sedation. We also examine the current status of pediatric sedation as reflected in published studies and reports. A specific review of the issues surrounding safety of sedation services is included. Current trends in sedation practice, including the expanding role of potent sedative hypnotic drugs outside the field of anesthesiology, are noted. Finally, we suggest future areas for research and clinical improvement for sedation providers.

 

布比卡因、罗哌卡因或左旋布比卡因重比重液单侧脊麻施行腹股沟疝修补术的前瞻性随机双盲比较

A Prospective, Randomized, Double-Blind Comparison of Unilateral Spinal Anesthesia with Hyperbaric Bupivacaine, Ropivacaine, or Levobupivacaine for Inguinal Herniorrhaphy

 

Andrea Casati, MD{dagger}, Elena Moizo, MD*, Chiara Marchetti, MD*, and Federico Vinciguerra, MD*

*Department of Anesthesiology, Vita-Salute University of Milano, IRCCS H San Raffaele, Milano, Italy; and {dagger}Department of Anesthesiology, University of Parma, Azienda Ospedaliera Parma, Parma, Italy

Anesth Analg 2004;99:1387-1392


60例接受腹股沟疝修补术的病人中,我们比较了0.5%布比卡因重比重液8mgn = 20)、0.5%左旋布比卡因重比重液8mgn = 20)或0.5%罗哌卡因重比重液12mgn = 20)所产生的单侧脊麻的临床效果。通过25Whitacre侧向开口针缓慢注入试验药物,病人维持侧卧位15min。三组的起效时间和术中效果相似。布比卡因组术侧和非术侧感觉神经阻滞的最高水平分别为T6(T12-5)L3(/[无感觉阻滞平面]-T4),左旋布比卡因组为T8(T12-5)L3(/-T3),罗哌卡因组为T5(T102)T11(/T3)(P = 0.11, P = 0.23) 。脊麻完全消退时间,罗哌卡因组为166 ± 42 min,左旋布比卡因组为210 ± 63 min,布比卡因组为 190 ± 51 min (P = 0.03 , P= 0.04);但是三组病人的出院回家时间无显著差别(布比卡因组为329 ± 89 min,左旋布比卡因组为261 ± 112 min,罗哌卡因组为332 ± 57 min [P = 0.28])。我们得出结论,当脊麻限于腹股沟疝修补术的术侧时,8mg的左旋布比卡因或者12mg的罗哌卡因可以很好地代替8mg的布比卡因。

(邱郁薇 李士通 校)

In 60 patients undergoing inguinal hernia repair, we compared the clinical profile of unilateral spinal anesthesia produced with either 8 mg of hyperbaric bupivacaine 0.5% (n = 20), 8 mg of hyperbaric levobupivacaine 0.5% (n = 20), or 12 mg of hyperbaric ropivacaine 0.5% (n = 20). The study drug was injected slowly through a 25-gauge Whitacre directional needle and patients maintained the lateral decubitus position for 15 min. The onset time and intraoperative efficacy were similar in the three groups. The maximal level of sensory block on the operative and nonoperative sides was T6 (T12–5) and L3 (/[no sensory level detectable]–T4) with bupivacaine, T8 (T12–5) and L3 (/–T3) with levobupivacaine, T5 (T10–2) and T11 (/–T3) with ropivacaine (P = 0.11, P = 0.23, respectively). Complete regression of spinal anesthesia occurred after 166 ± 42 min with ropivacaine, 210 ± 63 min with levobupivacaine, and 190 ± 51 min with bupivacaine (P = 0.03 and P = 0.04, respectively); however, no differences were observed in time for home discharge (329 ± 89 min with bupivacaine, 261 ± 112 min with levobupivacaine, and 332 ± 57 min with ropivacaine [P = 0.28]). We conclude that 8 mg of levobupivacaine or 12 mg of ropivacaine are acceptable alternatives to 8 mg of bupivacaine when limiting spinal block at the operative side for inguinal hernia repair.

 

泮库溴铵和米库氯铵神经肌肉阻滞后F波恢复各异

Different F-Wave Recovery After Neuromuscular Blockade with Pancuronium and Mivacurium

 

Michael H. Dueck, MD DEAA, Matthias Paul, MD DEAA, Philipp Sagawe, Aloys Oberthuer, MD, Christoph Wedekind, MD, and Ulf Boerner, MD

Department of Anesthesiology, University of Cologne, Cologne, Germany

Anesth Analg 2004;99:1402-1407


本研究目的是评估神经肌肉阻滞恢复期肌电图F波分析法,此法对运动系统更近中心的部分比传统的方法如肌机械图(MMG)提供更多的信息。20ASA -Ⅱ级神经外科手术患者,以芬太尼和咪唑安定静脉麻醉诱导和维持。患者随机术中给予0.25 mg/kg米库氯铵MV 组,n = 10)或0.1 mg/kg泮库溴铵PC组,n = 10)。持续监测拇内收肌的MMG。记录TOF比为0.10.25 0.50.70.750.80.850.90.95时对侧手的拇外展肌的F波。当MMG TOF比从0.70.95, 即临床关键恢复期时, 泮库溴铵神经肌肉阻滞后的F波振幅恢复明显慢于米库氯铵(P = 0.004)。这个电生理发现表明给予潘库溴铵和米库氯铵后运动系统的恢复存在MMG所不能发现的差异。

(赵雪莲 李士通 校)

We performed this study to assess the recovery period after neuromuscular blockade by electromyographic F-wave analysis, a method that supplies more information about more proximal parts of the motor system than conventionally used methods, e.g., mechanomyography (MMG). In 20 neurosurgical ASA physical status I or II patients anesthesia was induced and maintained with IV fentanyl and midazolam. Patients were randomly assigned to receive either 0.25 mg/kg mivacurium (MV group, n = 10) or 0.1 mg/kg pancuronium (PC group, n = 10) intraoperatively. MMG monitoring of the adductor pollicis muscle was performed continuously. F waves were recorded at the abductor pollicis muscle of the contralateral hand at train-of-four (TOF) ratios of 0.1, 0.25, 0.5, 0.7, 0.75, 0.8, 0.85, 0.9, and 0.95. Recovery of F-wave amplitudes after neuromuscular blockade with pancuronium was significantly slower compared with mivacurium (P = 0.004) during the clinically important recovery period defined by MMG TOF ratios from 0.7 to 0.95. This electrophysiologic finding suggests a differential recovery of the motor system after administration of pancuronium and mivacurium not detected by MMG.

 

 

七氟醚及异丙酚在人体增加11C-氟马西尼与γ-氨基丁酸A受体的结合

Sevoflurane and Propofol Increase 11C-Flumazenil Binding to Gamma-Aminobutyric AcidA Receptors in Humans

Elina Salmi, MD, Kaike K. Kaisti, MD, Liisa Metsähonkala, MD, Vesa Oikonen, MSc, Sargo Aalto, MSc, Kjell Någren, PhD, Susanna Hinkka, PhLic, Jarmo Hietala, MD, Esa R. Korpi, MD, and Harry Scheinin, MD

Turku PET Centre, University of Turku and the Department of Anesthesiology and Intensive Care, Turku University Hospital, Turku, Finland.

Anesth Analg 2004;99:1420-1426


体外及动物实验结果提示多数麻醉药是通过γ-氨基丁酸A(GABAA)受体而发挥作用。但在人类对这个基本特征尚缺乏广泛研究。利用正电子发射X线断层成像术(PET) 我们研究了七氟醚及异丙酚麻醉期11C-氟马西尼在活体人脑中与GABAA受体结合情况。14个健康男性在应用了11C标记的氟马西尼后分别在清醒及麻醉状态下进行为时60 min的动态PET研究。以呼气末2%七氟醚(n = 7)或血浆靶浓度9.0 ± 3.0 (mean ± SD)µg/mL的异丙酚(n = 7)维持麻醉。用双频指数(BIS)测定麻醉深度。以代谢校正的动脉血浆曲线及双室模型计算几个脑区的11C-氟马西尼局部分布容积(DV)值。用参数的DV影像分别进行统计分析以获取详细显影。七氟醚组平均BIS指数为35 ± 6,异丙酚组为28 ± 8 (P = 0.02)。七氟醚明显增加除了脑桥及白质外的其它所有研究脑区的11C-氟马西尼的DV(P < 0.05)。异丙酚则明显增加尾状叶、核区、小脑、丘脑和额叶、颞叶及顶叶皮质区的DV(P < 0.05)。此外,七氟醚组在额叶、枕叶、顶叶和颞叶皮质区及核区DV值的增加明显大于异丙酚组。我们的发现支持这二种麻醉药在人类的作用机制涉及GABAA受体。

(王立中 李士通 校)

Based on in vitro studies and animal data, most anesthetics are supposed to act via {gamma}-aminobutyric acid type A (GABAA) receptors. However, this fundamental characteristic has not been extensively investigated in humans. We studied 11C-flumazenil binding to GABAA receptors during sevoflurane and propofol anesthesia in the living human brain using positron emission tomography (PET). Fourteen healthy male subjects underwent 2 60-min dynamic PET studies with 11C-labeled flumazenil, awake and during anesthesia. Anesthesia was maintained with 2% end-tidal sevoflurane (n = 7) or propofol at a target plasma concentration of 9.0 ± 3.0 (mean ± SD) µg/mL (n = 7). The depth of anesthesia was measured with bispectral index (BIS). Values of regional distribution volumes (DV) of 11C-flumazenil were calculated in several brain areas using metabolite-corrected arterial plasma curves and a two-compartment model. Separate voxel-based statistical analysis using parametric DV images was performed for detailed visualization. The average BIS index was 35 ± 6 in the sevoflurane group and 28 ± 8 in the propofol group (P = 0.02). Sevoflurane increased the DV of 11C-flumazenil significantly (P < 0.05) in all brain areas studied except the pons and the white matter. In the propofol group the increases were significant (P < 0.05) in the caudatus, putamen, cerebellum, thalamus and the frontal, temporal, and parietal cortices. Furthermore, the DV increases in the frontal, occipital, parietal, and temporal cortical areas and in the putamen were statistically significantly larger in the sevoflurane than in the propofol group. Our findings support the involvement of GABAA receptors in the mechanism of action of both anesthetics in humans.

 

 

血栓弹性描记®过程中用电子显微镜评价血凝块的形态学

Electron Microscopic Evaluations of Clot Morphology During Thrombelastography®

Jun Kawasaki, MD*, Nobuyuki Katori, MD{dagger}, Mitsuharu Kodaka, MD*, Hideki Miyao, MD*, and Kenichi A. Tanaka, MD{dagger}

*Department of Anesthesiology, Saitama Medical Center, Saitama Medical School, Saitama, Japan, and the {dagger}Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.

Anesth Analg 2004;99:1440-1444


在本研究中,我们用扫描电子显微镜(SEM)观察在与常用的血栓弹性描记(TEG®)参数相对应的时间点时血凝块的形态学,以此阐明TEG®记录图与物理血凝块形成之间的相关性。TEG®分析仪的第一通道用来得到血凝块形成的记录图,用来SEM的小量样本从TEG®的第二通道得到。我们测定了不同种类的样品,包括全血、添加了阿昔单抗的全血、富含血小板的血浆(PRP)以及添加了阿昔单抗的PRP。在反应时间、不同振幅(5–30 mm)、最大振幅(MA)以及最大幅度后60min振幅时获得SEM影像。在全血中在反应时间时观测到粗糙的纤维蛋白和活化的血小板反应,纤维蛋白丝逐渐变得更加坚固,并且在振幅10mm时及其后出现缠结。红细胞在振幅为30mm时被纤维蛋白丝所围绕,在MA时被纤维蛋白丝紧密包裹。在添加阿昔单抗的全血,红细胞形态一直保持到MA期。同样对 PRP中纤维蛋白形成以及血小板的活性也进行了测定。虽然TEG®分析仪显示阿昔单抗阻断了纤维蛋白与血小板的结合,但是其并未阻断血小板形态的改变。总之,我们已经显示了形成的凝血块的结构改变与TEG®参数之间有相关性。

(沈浩 李士通 校)

 

In this study, we characterized clot morphology with a scanning electron microscope (SEM) at time points corresponding to the commonly used thrombelastography (TEG®) variables, illustrating the correlation of the physical clot formation with TEG® tracings. The first channel of the TEG® analyzer was used to obtain the tracings of clot formation, while the sub-samples for the SEM were obtained from the second TEG® channel. Different types of samples were examined, including whole blood, abciximab-treated whole blood, platelet-rich plasma (PRP), and abciximab-treated PRP. The SEM images were obtained at reaction time, different amplitudes (5–30 mm), maximum amplitude (MA), and at amplitude 60 min after MA. In the whole blood, coarse fibrin and activated platelets were observed at reaction time and fibrin strands progressively became more solid and intertwined at amplitude 10 mm and thereafter. Red blood cells were surrounded with fibrin strands at amplitude 30 mm and were tightly packed by fibrin strands at MA. In abciximab-treated whole blood, red blood cell shape was maintained at MA. The process of fibrin formation and platelet activation was also examined in PRP. Abciximab did not block platelet shape change, although the blockage of fibrin binding to platelets was shown on the TEG® analyzer. In summary, we have shown structural changes of the forming clot in relation to TEG® variables.

 

结肠直肠癌手术患者切皮前静注己酮可可碱可降低围术期细胞因子反应,减少吗啡用量并促进肠道功能恢复

Preincisional Intravenous Pentoxifylline Attenuating Perioperative Cytokine Response, Reducing Morphine Consumption, and Improving Recovery of Bowel Function in Patients Undergoing Colorectal Cancer Surgery

Chueng-He Lu, MD*, Pei-Chieh Chao, MD{dagger}, Cecil O. Borel, MD{ddagger}, Chih-Ping Yang, MD*, Chun-Chang Yeh, MD*, Chih-Shung Wong, MD PhD*, and Ching-Tang Wu, MD*

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

Anesth Analg 2004;99:1465-1471


手术期间细胞因子的释放可以引起长时间的痛觉过敏。因此,术前给予细胞因子抑制剂可能会减少细胞因子的产生,降低中枢神经系统的敏感性并提高术后镇痛的质量。本研究旨在了解择期行结肠直肠癌手术的患者切皮前静脉注射己酮可可碱(PTX能否降低前炎性细胞因子(肿瘤坏死因子, 白细胞介素(IL-1ßIL-6IL-8)和抗炎性细胞因子(IL-1 受体拮抗剂)的释放。40例患者随机分为两组,每组20例,PTX 组麻醉诱导前静脉输注 PTX 5 mg/kg,对照组注射等量生理盐水。定时抽取静脉血标本。术后所有患者均行PCA吗啡用于术后镇痛。与对照组相比,PTX 组患者PCA启动给药时间较晚,吗啡用量较少,肠道功能恢复较快。此外,PTX 组的血浆IL-6IL-8 IL-1 受体拮抗剂的水平低于对照组。随访两年,切口感染、肿瘤复发或转移的发生率在两组间无显著性差异。

(轩 李士通 校)

Cytokine release during surgery can produce a long-lasting hyperalgesia. Thus, preoperatively-administered cytokine inhibitors might reduce the production of cytokines, decreasing central nervous system sensitization and improving the quality of postoperative pain relief. We investigated the hypothesis that preincisional IV pentoxifylline (PTX) treatment could attenuate the release of proinflammatory (tumor necrosis factor, interleukin (IL)-1ß, IL-6, and IL-8) and antiinflammatory (IL-1 receptor antagonist) cytokines in patients who underwent elective colorectal cancer surgery. Forty patients were randomly assigned to 1 of 2 groups of 20 each: the PTX group received a PTX 5 mg/kg IV infusion before the induction of anesthesia, whereas the control group received an equal volume of normal saline. Venous blood samples were obtained at frequent intervals. After surgery, all patients received patient-controlled analgesia (PCA) morphine for postoperative pain relief. Patients in the PTX group exhibited longer PCA trigger times, less morphine consumption, and a faster return of bowel function compared with patients in the control group. Moreover, the plasma levels of IL-6, IL-8, and IL-1 receptor antagonist were less in the treatment group, and there was no significant difference in wound infections, tumor recurrence, or metastatic rates between groups during a 2-yr follow-up.

 

多巴酚丁胺抑制佛波醇-豆蔻酸盐-醋酸盐对人T淋巴细胞核因子{kappa}B激活作用的体外实验

Dobutamine Inhibits Phorbol-Myristate-Acetate-Induced Activation of Nuclear Factor-{kappa}B in Human T Lymphocytes In Vitro

Torsten Loop, MD, Tobias Bross, Matjaz Humar, PhD, Alexander Hoetzel, MD, Rene Schmidt, MD, Heike L. Pahl, PhD, Klaus K. Geiger, MD, and Benedikt H. J. Pannen, MD

Department of Anesthesiology and Critical Care Medicine, University Hospital, Freiburg, Germany

Anesth Analg 2004;99:1508-1515


肾上腺素能药物常用于危重病人心输出量及血管舒缩张力的血流动力学支持。最近有研究证实给予这些血管活性药可以影响细胞因子的释放及影响炎症反应。然而,影响该免疫调节作用的机制尚不清楚。核转录因子κB (NF-κB)调节许多细胞因子的表达,在免疫反应中起到重要的作用。因此,我们验证了不同肾上腺素能药物(多巴酚丁胺、扎莫特罗、氨哮素、肾上腺素、去甲肾上腺素及苯肾上腺素)对NF-κB的激活作用、NF-κB驱动的应答基因活性及NF-κB靶基因白介素(IL)-8表达的影响。此外,我们定量了NF-κB抑制剂IκBα及IL-10。在此我们报导多巴酚丁胺能抑制NF-κB对人类原始的CD3+T淋巴细胞的激活作用。NF-κB的抑制作用包括对其抑制剂IκBα的稳定作用。该作用看来具有ß2-受体选择性,因为ß1及α肾上腺素能物质(即扎莫特罗、肾上腺素、去甲肾上腺素及苯肾上腺素)并不影响NF-κB的激活作用,且多巴酚丁胺介导的对NF-κB的抑制作用可用选择性ß2-受体阻断剂来预防。我们的研究结果证实:多巴酚丁胺是一种有效的特异性的NF-κB抑制剂,这一结果可能提供了ß肾上腺素能药物治疗相关的免疫调节的分子机制。

(裘毅敏 李士通 校)

Adrenergic drugs are often used for hemodynamic support of cardiac output and vasomotor tone in critically ill patients. Recent evidence shows that the administration of these vasoactive drugs may affect cytokine release and could influence the inflammatory response. However, the mechanism of this immunomodulatory effect remains unknown. The nuclear transcription factor-{kappa}B (NF-{kappa}B) regulates the expression of many cytokines and plays a central role in the immune response. Therefore, we examined the effects of various adrenergic drugs (dobutamine, xamoterol, clenbuterol, epinephrine, norepinephrine, and phenylephrine) on the activation of NF-{kappa}B, on the NF-{kappa}B-driven reporter gene activity, and on the expression of the NF-{kappa}B target gene interleukin (IL)-8. In addition, we quantified the amount of the NF-{kappa}B inhibitors I{kappa}B{alpha} and IL-10. Here we report that dobutamine inhibited the activation of NF-{kappa}B in primary human CD3+ T lymphocytes. Suppression of NF-{kappa}B involved the stabilization of its inhibitor, I{kappa}B{alpha}. The effect appears to be ß2-receptor specific, because ß1-adrenergic and {alpha}-adrenergic substances (i.e., xamoterol, epinephrine, norepinephrine, and phenylephrine) did not affect NF-{kappa}B activation and because dobutamine-mediated inhibition of NF-{kappa}B could be prevented by a specific ß2-antagonist. Our results demonstrate that dobutamine is a potent and specific inhibitor of NF-{kappa}B, and they thus provide a possible molecular mechanism for the immunomodulation associated with ß-adrenergic therapy.

 

全膝成形术患者超声辅助下单次股神经阻滞镇痛的副作用较鞘内吗啡少

A Single Injection Ultrasound-Assisted Femoral Nerve Block Provides Side Effect-Sparing Analgesia When Compared with Intrathecal Morphine in Patients Undergoing Total Knee Arthroplasty

Brian D. Sites, MD, Michael Beach, MD PhD, John D. Gallagher, MD, Robert A. Jarrett, MD, Michael B. Sparks, MD, and C. Johan F. Lundberg, MD PhD

Department of Anesthesiology and Orthopedic Surgery, Dartmouth Medical School, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Anesth Analg 2004;99:1539-1543


全膝成形术(TKA)后疼痛非常严重,如何获得充分的镇痛效果仍然是临床上的一大挑战。我们检验了这样一个假设:在鞘内(IT)麻醉下行单侧全膝成形术的患者中,再加股神经阻滞可以比IT吗啡获得更佳的镇痛效果,且不良副作用更少。在这次单盲对照试验中,41ASA I–III行单侧TKA的患者随机分成两组。两组均采用布比卡因15 mg IT注射作为手术麻醉药。术后镇痛ITM组给予IT吗啡250 µgFNB组在超声辅助下行股神经阻滞,注入0.5%布比卡因40ml、肾上腺素5 µg/mL和可乐定75 µg。在术后第12461224小时用视觉模拟标尺记录疼痛评分、静脉吗啡累计用量、血流动力学指标和副作用。两组在吗啡用量、静息疼痛评分和活动疼痛评分方面没有显著差异。但是,FNB组围术期的副作用包括恶心、呕吐和瘙痒均较少(每项均P < 0.05)。相应地,在ITM组中患者的满意度较低,其中20%将其经历定级为“不满意”(P < 0.05)。总之,对于布比卡因鞘内麻醉下行TKA的患者,单次注射股神经阻滞可以获得与IT吗啡镇痛相同的镇痛效果但显著较少的副作用。

(张俊杰 李士通 校)

Postoperative pain after total knee arthroplasty (TKA) is severe, and achieving adequate analgesia remains a clinical challenge. We tested the hypothesis that, in patients having unilateral TKA under intrathecal (IT) anesthesia, the addition of a femoral nerve block would provide superior analgesia when compared with IT morphine and demonstrate fewer adverse side effects. In a single-blinded and controlled trial, 41 ASA I–III patients undergoing unilateral TKA were randomized into 2 groups. Both groups received 15 mg of IT hyperbaric bupivacaine for the surgical anesthetic. Group ITM received 250 µg of IT morphine and group FNB received an ultrasound-assisted femoral nerve block with 40 mL of 0.5% ropivacaine, 5 µg/mL of epinephrine, and 75 µg of clonidine. At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales for pain, cumulative IV morphine consumption, hemodynamics, and side effects. There were no statistically significant differences in morphine consumption, pain at rest, or pain with movement. However, group FNB had fewer perioperative side effects including nausea, vomiting, and pruritus (P < 0.05 for each event). This corresponded to a decrease in patient satisfaction in group ITM, in which 20% of the patients rated their experience as "unsatisfactory" (P < 0.05). We conclude that, in comparison with IT morphine, a single injection femoral nerve block provides equivalent analgesia but with a significant reduction in side effects for patients having TKA under bupivacaine intrathecal anesthesia.

 

UniqueTM喉罩通气道与Soft SealTM喉罩的比较:一项在麻醉肌松下患者中随机交叉研究

The Laryngeal Mask Airway UniqueTM versus the Soft SealTM Laryngeal Mask: A Randomized, Crossover Study in Paralyzed, Anesthetized Patients

Joseph Brimacombe, MD*, Achim von Goedecke, MD{dagger}, Christian Keller, MD{dagger}, Lawrence Brimacombe, MB ChB*, and Moira Brimacombe, MB ChB*

*Department of Anaesthesia and Intensive Care, James Cook University, Cairns Base Hospital, The Esplanade, Australia; and {dagger}Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria

Anesth Analg 2004;99:1560-1563


我们验证这样一个假说,Soft SealTM牌喉罩通气道(SSLM)UniqueTM牌喉罩通气道(LMA-U)其插入的难易程度、口咽部的泄漏压、光纤定位、通气的难易程度和粘膜的损伤程度是不同的。我们在90例肌松麻醉下的患者(ASA I–II18–80岁)中进行了研究。两种装置按随机顺序插入每一位患者。在气囊充气以10毫升递增、从040毫升的过程中和在气囊内压为60 cm H2O时测定口咽部的泄漏压和光纤定位。测定通气的难易程度系在潮气量为812 mL/kg时控制通气10分钟,记录血氧饱和度、呼气末CO2、泄漏分数、气道峰压以及是否存在胃充气。通过检测首次随机置入的装置上是否存在可视出血和隐性出血来测定粘膜损伤。LMA-U的置入时间更短( P = 0.0001)、尝试次数更少( P = 0.005)。两种装置都能成功置入使用。两者的口咽部泄漏压相似,但是光纤定位LMA-U的位置更佳(P £ 0.0003)。血红蛋白氧饱和度、呼气末CO2、泄漏分数及气道峰压在两种设定的潮气量通气时没有区别。两组患者在两种设定的潮气量通气下没发现胃充气。可视出血( P = 0.009)和隐性出血( P = 0.0001)的发生在LMA-U组更少。我们得出这样一个结论,在置入的难易程度、光纤定位和粘膜损伤方面LMA-U均优于SSLM,口咽部的泄漏压和通气难易程度相似。

(陈玮     李士通 校)

We tested the hypothesis that ease of insertion, oropharyngeal leak pressure, fiberoptic position, ease of ventilation, and mucosal trauma are different for the Soft SealTM laryngeal mask airway (SSLM) and the laryngeal mask airway UniqueTM (LMA-U). Ninety paralyzed, anesthetized adult patients (ASA I–II; 18–80 yr old) were studied. Both devices were inserted into each patient in random order. Oropharyngeal leak pressure and fiberoptic position were determined during cuff inflation from 0–40 mL in 10-mL increments and at an intracuff pressure of 60 cm H2O. Ease of ventilation was determined by controlling ventilation for 10 min at 8 and 12-mL/kg tidal volume and recording hemoglobin oxygen saturation, end-tidal CO2, leak fraction, peak airway pressure, and the presence or absence of gastric insufflation. Mucosal trauma was determined by examining the first randomized device for the presence of visible and occult blood. Insertion time was shorter (P = 0.0001) and fewer attempts were required (P = 0.005) for the LMA-U. There were no failed uses of either device. Oropharyngeal leak pressures were similar, but fiberoptic position was superior with the LMA-U (P ≤0.0003). There were no differences in hemoglobin oxygen saturation, end-tidal CO2, leak fraction, or peak airway pressure at either tidal volume. Gastric insufflation was not detected in either group at either tidal volume. The frequency of visible (P = 0.009) and occult blood (P = 0.0001) was less with the LMA-U. We conclude that the LMA-U is superior to the SSLM in terms of ease of insertion, fiberoptic position, and mucosal trauma, but similar in terms of oropharyngeal leak pressure and ease of ventilation.