Anesthesia & Analgesia

November 2004

Table of Content

 

PEDIATRIC ANESTHESIA:

青少年脊柱融合術中丙泊酚、小劑量異氟醚和笑氣麻醉對皮層體感誘發電位及雙頻指數監測的影響

周志堅 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.

 

兒童心臟手術中纖維蛋白原有功能嗎?

朱輝 譯 陳傑 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

 

兒童全身麻醉後口服靜脈製劑檸檬酸芬太尼的藥代動力學

葛甯花譯,薛張綱校

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.

 

兒科鎮靜的綜述

黃麗娜      李士通

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

Anesth Analg 2004 99: 1355-1364.

 

先天性心臟病手術中神經學監測

朱輝 譯 陳傑 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:

健康人群水合氯醛嗎啡多次鼻腔給藥後的I相研究

葛甯花譯,薛張綱校

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、羅呱卡因或左旋布比卡因重比重液單側脊麻施行腹股溝疝修補術的前瞻性隨機雙盲比較

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:

老年大鼠接受異氟醚和異氟醚-NO2麻醉後兩周存在空間記憶損害

朱慧琛 譯 陳傑 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

 

氙氣並不延長羅庫溴胺的神經阻滯作用
葛甯花譯,薛張綱校

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

泮庫溴銨和米庫氯銨神經肌肉阻滯後F波恢復各異

趙雪蓮 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.

 

靜脈氯胺酮麻醉可抑制主動脈平滑肌細胞的增生

朱慧琛 譯 陳傑 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

 

異氟醚抑制C纖維誘發肢體回縮的觸發反應對鼠腰脊髓神經元疼痛刺激的影響

葛甯花譯,薛張綱校

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

 

七氟醚及異丙酚在人體增加11C-氟馬西尼與γ-氨基丁酸A受體的結合

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:

圍術期使用PSArray電極的病人狀態分析監護儀較腦雙頻指數監護儀有更好的效益成本比嗎?

朱玫娟 陳傑

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 固定器將中心靜脈導管固定於皮膚的有效性

葛甯花譯,薛張綱校

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

 

 

血栓彈性描記®過程中用電子顯微鏡評價血凝塊的形態學

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:

一種新的用來評估胸部手術後持續性疼痛的動物模型的特徵

朱玫娟 陳傑

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.

 

曲馬多用作皮下局部麻醉劑時的術後鎮痛效果

葛甯花譯,薛張綱校

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.

 

結腸直腸癌手術患者切皮前靜注己酮可哥堿可降低圍術期細胞因數反應,減少嗎啡用量並促進腸道功能恢復

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.

 

口服即時釋放二氫羥嗎啡酮用於術後疼痛治療的安全性和有效性

顧漪聞 譯 陳傑 校

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

Joseph Gimbel and Harry Ahdieh

Anesth Analg 2004 99: 1472-1477

 

複雜性區域疼痛綜合征導致的全身兒茶酚胺增高與心理因素的關係:一個初步研究

顧漪聞 譯 陳傑 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:

小劑量辣椒素降低敗血症鼠的全身炎症反應

葛甯花譯,薛張綱校

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-豆蔻酸鹽-醋酸鹽對人T淋巴細胞核因數{kappa}B啟動作用的體外實驗

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:

脊髓手術病人術中進行喚醒試驗和術後早期蘇醒:短效靜脈和吸入麻醉藥的比較

齊波 譯 陳傑 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:

比較產婦分娩自控硬膜外和靜脈鎮痛:多中心隨機對照研究

葛甯花譯,薛張綱校

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:

全膝成形術患者超聲輔助下單次股神經阻滯鎮痛的副作用較鞘內嗎啡少

張俊傑 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.

 

骶旁坐骨神經阻滯加選擇性閉孔神經阻滯的作用評估

趙延華 譯 陳傑 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喉罩通氣道與Soft SealTM喉罩的比較:一項在麻醉肌松下患者中隨機交叉研究

陳瑋     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.

 

難以解釋的術中出血病人其凝血因數XIII有效性降低以及血栓穩固性早期喪失

趙延華 譯 陳傑 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

 

 

兒童心臟手術中纖維蛋白原有功能嗎?

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.

嬰幼兒纖維蛋白原的功能完整性基於實驗和生化資料。最近的研究表明成人的纖維蛋白原水平與血栓彈性描計圖最大振幅的變化相關,而後者的變化是由於糖蛋白Ⅱb/a受體阻滯分離了血小板-纖維蛋白原間的相互作用。作者假設嬰幼兒的纖維蛋白原血中水平和功能完整也像成人一樣與血栓彈性描計圖最大振幅的變化相關。選擇250名小於2歲進行心臟手術的兒童,分成五個年齡組(<1mo13mo36mo612mo1224mo)比較血栓彈性描計圖值有無變化時的纖維蛋白原水平和血小板計數。結果顯示只有在1224mo組纖維蛋白原水平與血栓彈性描計圖最大振幅相關。該組維蛋白原水平與血栓彈性描計圖其他變數相關性與纖維蛋白原水平影響,正如成人血小板計數與血栓彈性描計圖變化相關性一樣。結論:患先天性心臟病年齡小於12個月的小孩其纖維蛋白原功能不全。

(朱輝 譯 陳傑 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.

先天性心臟病手術中神經學監測

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

 

小兒心臟手術後的神經併發症發生率2%到25%,其原因有多種,包括術前的腦畸形,圍術期低氧血症,低心排量狀態,心肺轉流的後遺症和深低溫停迴圈等。神經學的監測裝置易於提供,麻醉醫生可在小兒心臟手術期間進行腦部監測。在這項研究中,作者研究先天性心臟手術期間使用近紅外線腦血氧定量法,經顱多譜勒超聲以及腦電流描記法的監測情況。在復習了每種監測方式基本原理後再討論其在小兒心臟手術中的用途。證據顯示在先天性心臟手術患者使用多形式的神經學監測並聯合療法可改善神經系統方面的預後,作者同時闡述了這種工作的具體方法。

(朱輝 譯 陳傑 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.


老年大鼠接受異氟醚和異氟醚-NO2麻醉後兩周存在空間記憶損害

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.

 

老年大鼠在異氟醚-NO2麻醉後至少24—48h後可出現空間記憶損害。本次實驗中作者測試損害的持續時間及NO2的作用。18個月的大鼠隨機分為吸入1.2%異氟醚2h聯合或不聯合使用70%NO2或對照組(30%氧)。兩周後每天進行半徑為12臂長的迷宮測試共14天。記錄對第一次錯誤的校正次數、所有的差錯和完成迷宮的時間。1.2%異氟醚聯合使用70%NO2的大鼠在出現第一次錯誤前很少作出校正(P<0.05)。錯誤概率和完成迷宮的時間大致相似,但無統計學意義。對所有的麻醉大鼠和對照組進行了分析比較後認為麻醉大鼠對於第一次錯誤的校正率下降(P<0.05),同時其完成迷宮的時間也較長。出錯次數無明顯差異(P<0.06)。因此老年大鼠接受全身麻醉後兩周(無論是否聯合應用NO2)仍存在空間記憶損害。

(朱慧琛 譯 陳傑 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.


靜脈氯胺酮麻醉可抑制主動脈平滑肌細胞的增生

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.

平滑肌細胞(SMC)增生被認為是一些主要的血管疾病、動脈粥樣硬化症和高血壓的病理學關鍵因素。作者曾報導氯胺酮可抑制大鼠腎小球膜細胞增生,由此假設氯胺酮可抑制細胞生長。雖然臨床上已廣泛應用氯胺酮作為靜脈麻醉藥,但是關於氯胺酮對血管平滑肌細胞增生的實際效應尚未進行研究。本實驗中作者重點研究氯胺酮對血管平滑肌細胞增生作用的影響。氯胺酮抑制[3H]胸苷結合,同時通過濃度依賴方式減少SMCs數量;異丙酚和芬太尼都不抑制[3H]胸苷與人類動脈SMCs的結合。蛋白激酶CPKC)抑制劑GF109203x可解除氯胺酮對[3H]胸苷與SMC結合的抑制作用,但蛋白激酶A抑制劑H-89或蛋白激酶G抑制劑KT5823都無此作用。組織學分析顯示氯胺酮可抑制膨脹性損傷的大鼠大動脈的內膜增厚現象。臨床濃度的氯胺酮經PKC途徑抑制SMCs。結論:臨床應用氯胺酮可能預防SMCs增生。

(朱慧琛 譯 陳傑 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.

 

圍術期使用PSArray電極的病人狀態分析監護儀較腦雙頻指數監護儀有更好的效益成本比嗎?

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.

新的一次性電極PSArrayTM2 XP sensorTM,分別用在患者狀態分析(PSA)模式和腦雙頻指數(BIS)監護模式中。作者設計了這個臨床實驗來比較圍術期使用新電極後病人狀態指數(PSI)和BIS的靈敏度和特異性。22簽署同意書的選擇性腹腔鏡手術的患者參與這個前瞻性研究。記錄電極安放到獲得的基線的時間和基礎值,以及在接受標準全麻中,誘導、維持和蘇醒各階段的PSIBIS值。此外,在麻醉維持階段推注丙泊酚(20mg)後,或者在提高2%吸入濃度或降低2%吸入濃度的地氟醚後,記錄這些監測值的改變。兩種方法獲取監測值的時間相近(PSABIS中分別為66±32秒和72±41秒)。使用邏輯回歸模型,PSIBIS在預測意識喪失時同樣有效(例如呼之不應)。同樣在全麻的誘導和蘇醒期,PSIBIS也相關(R分別為0.850.74)。用來檢測意識狀態的接受手術特徵性曲線下的面積在PSIBIS中也相近(分別為0.98±0.050.97±0.05)。在麻醉維持階段,PSI的值比BIS的值略低;在丙泊酚和地氟醚改變時的反應相同。手術中,PSI的值與BIS的值相比,其受電烙單元的干擾更小(分別為31%73%)。儘管PSI的一次性電極的定價($24.95)比BISXP感應器($17.50)要高,但其平均售價($14.95)是相同的。結論:使用PSArrayPSA監護較使用XP感應器的BIS監護在全麻誘導和蘇醒時評估意識狀態有更高的效益成本比,同樣在丙泊酚和地氟醚作麻醉維持時也有更高的效益成本比。

(朱玫娟 陳傑 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.

 

一種新的用來評估胸部手術後持續性疼痛的動物模型的特徵

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.

 

胸部手術後慢性疼痛非常常見,儘管其發病基礎和原理還並不十分清楚。在本實驗中,作者探討胸部手術和肋骨牽引後的小鼠,對於異常性疼痛(機械或寒冷導致)的反應以及組織病理改變的特徵,同時評估全身或鞘內鎮痛的鎮痛效果。雄性Sprague-Dawley小鼠在麻醉狀態下暴露右側第四、五肋骨。打開肋骨間的胸膜,並在兩根肋骨下放置牽引器,打開至8毫米。牽引時間分別持續為5分鐘、30分鐘和60分鐘。對照組僅僅打開胸膜。在手術開始後的第二天,小鼠用標準von Frey纖維來測試機械刺激所致的異常疼痛,用丙酮來測試寒冷性異常疼痛。手術後兩周,小鼠用腹膜內和鞘內注射鎮痛來測試異常性疼痛。手術後14天,檢查小鼠肋間神經的組織學。在牽引60分鐘組中有50%出現了異常性疼痛,而在牽引5分鐘組和牽引30分鐘組中分別只有11%10%出現異常性疼痛,對照組中沒有一例出現異常性疼痛。出現異常性疼痛的小鼠中,其受牽引肋骨的肋間神經有廣泛的軸突減少。在肋骨牽引模型中,異常性疼痛在術後10天出現,並持續至少40天。全身應用硫酸嗎啡(ED501.06mg/kg)、加巴噴丁(ED5024.2 mg/kg),以及鞘內使用嗎啡(ED501.19 nmol)、加巴噴丁(ED5013.8 nmol)、可樂定(ED5072.7 nmol)及新斯的明(ED500.54 nmol)都能緩解異常性疼痛。肋骨牽引60分鐘的小鼠其異常性疼痛持續超過一個月,並且這種疼痛可以被嗎啡、加巴噴丁、可樂定和新斯的明緩解。這個新的模型可能在量化減少胸部手術後持續疼痛的頻率和嚴重程度的各種技術有價值。

(朱玫娟 陳傑 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.


口服即時釋放二氫羥嗎啡酮用於術後疼痛治療的安全性和有效性

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

 

作者設計雙盲、平行對照試驗,用安慰劑對照比較3種不同的劑量的即時釋放(IR)二氫羥嗎啡酮用於術後中重度疼痛的有效性,並比較其與14-羥基二氫可待因酮和安慰劑的安全性。採用單次注射(n300),患者分別接受IR二氫羥嗎啡酮10 mg20 mg30mgIR14-羥基二氫可待因酮以及安慰劑。結果3種劑量的IR二氫羥嗎啡酮都對術後8小時的疼痛有緩解(P<0.05),同時有明顯的鎮痛劑量相關性(P<0.001)。在術後45分鐘,疼痛的強度明顯不同(20mg 30mg劑量組,P<0.05)。由於缺乏鎮痛效果而放棄實驗,安慰劑組中占42% IR 14-羥基二氫可待因酮組中占27%。術後3小時需要補充藥物的病人每46小時接受額外的研究,並作為多劑量組(n=164)。所有的IR二氫羥嗎啡酮組鎮痛時間均大於48小時。30mg組平均間隔時間>9.5小時,而其他劑量的IR二氫羥嗎啡酮組,時間>7小時。在阿片類相關的副作用方面,各組相似,表現為輕中度。IR二氫羥嗎啡酮10mg20mg30mg組和安慰劑組相比較,表現出疼痛緩解和劑量的相關性,同時,這種疼痛的緩解可以持續數天,其安全性和IR 14-羥基二氫可待因酮組相當。

(顧漪聞 譯 陳傑 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.

 

複雜性區域疼痛綜合征導致的全身兒茶酚胺增高與心理因素的關係:一個初步研究

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.

 

已經證明在患有複雜性區域疼痛綜合征(CRPS)的病人,其受累肢體和非受累肢體的靜脈內的血漿去甲腎上腺素的濃度是不同的,其受累肢體的去甲腎上腺素(NE)水平明顯降低。本研究目的旨在瞭解患有CRPS的病人並伴有全身性持續疼痛(SMP)的病人,是否全身的靜脈內的兒茶酚胺水平和健康志願者有所不同。作者另研究是否兒茶酚胺水平和心理性因素,如抑鬱,焦慮,個性評分有關。採集33CRPS/SMP病人(從非患側肢體),和30個健康者(對照組)的血樣,測定其血樣中的NE濃度和腎上腺素(E)濃度。結果發現,CRPSNE濃度顯著增高(P < 0.001)。雖然52%CRPS/SMP病人的E濃度和基礎值比較大於95%的可信區間,但是組間比較E濃度沒有差異(P<0.06)。而E濃度和心理評分之間有明顯的正相關性(P<0.05),心理評分法採用的是明尼蘇達州的多相個性測試表-2中的Beck抑鬱評分測量表136。這些初步工作提示CRPS/SMP病人血漿中的去甲腎上腺素(NE)濃度和腎上腺素(E)濃度可能導致了CRPS 的疼痛,情感上的抑鬱,或者兩者兼有。作者的研究結果還可能說明了由於情感、內分泌、或者其他病理原因導致的前病態的腎上腺素的高活性,可能使這些個體易罹患為CRPS。這個假設還需要詳細的確切的研究。

(顧漪聞 譯 陳傑 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.


脊髓手術病人術中進行喚醒試驗和術後早期蘇醒:短效靜脈和吸入麻醉藥的比較

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.

 

脊柱外科手術可能會導致脊髓損傷,從而使病人產生神經系統的缺損,必須緊急治療。本實驗的目的是為了測定哪一種麻醉藥組合可以允許麻醉醫生在術中和術後實施快速的喚醒試驗,從而及時發現病人有無神經系統的缺損。54個病人隨機分為如下幾組:PR(丙泊酚/雷米芬太尼):通過靶控輸注丙泊酚(血漿濃度2-4µg /ml)和雷米芬太尼0.2-0.5µg /Kg/minPS(丙泊酚/舒芬太尼):靶控輸注丙泊酚(血漿濃度2-4µg/ml),舒芬太尼重複劑量為0.1-0.2mg/Kg,並根據病人需要調整;DR(地氟醚/雷米芬太尼):地氟醚/空氣3.0-4.0vol%複合雷米芬太尼0.2-0.5µg/Kg/min。結果PS組病人出現自主呼吸(8.9±1.6min)、抬頭(17.0±3.8min)以及足活動(17.0±7.4min) 時間均明顯長於PR(以上各項分別為6.9±2.6min9.3±2.2min9.4±2.4min)DR(以上各項分別為5.4±0.8min6.1±1.0min6.2±1.0min)。因此與丙泊酚和雷米芬太尼組合相比,地氟醚和雷米芬太尼組合可允許病人在術中和術後較快的蘇醒,從而可在脊髓手術後迅速進行神經系統的檢查。

(齊波 譯 陳傑 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.

 

骶旁坐骨神經阻滯加選擇性閉孔神經阻滯的作用評估

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

.

本研究目的是客觀評價骶旁阻滯後再進行閉孔神經阻滯的有效性。選擇擬行膝部手術的病人,先行內收肌肌力的基礎評價。用0.75%羅呱卡因30 ml行骶旁阻滯後,每5 min對坐骨神經支配區域皮膚的感覺(溫度辨別)減退情況和內收肌肌力進行評價。骶旁阻滯30min後效果不完全的病人(定義為坐骨神經支配區域的三個部位皮膚的溫度辨別評分小於2)被排除出本研究。隨後,用0.75%羅呱卡因7 ml進行選擇性閉孔神經阻滯,在15min內每5min對內收肌肌力進行評價。最後,用0.75%羅呱卡因10ml阻滯股神經。在每次阻滯過程中病人的不適程度用視覺類比尺規(VAS)進行評價。有30名病人完成該試驗,其中有5名病人被排除出試驗,因為在骶旁阻滯30min後坐骨神經支配區域的感覺阻滯不充分(成功率為89%)。骶旁阻滯30min後,內收肌肌力(85 ± 24 mmHg)與基礎值(97 ± 28 mmHg)相比,降低11.3% ± 7%P = 0.002)。閉孔神經阻滯15min後,內收肌肌力(16.6 ± 15 mmHg)又降低69% ± 7% P < 0.0001)。在骶旁、閉孔、股神經阻滯過程中VAS評分相似,分別為26 ± 1928 ± 2427 ± 19 mm。在兩具新鮮屍體用30ml有色乳液進行四次模擬骶旁阻滯上,評價乳液擴散速度與閉孔神經的關係。這些有色乳液引起局限于骶叢的擴散。這些發現證明,骶旁阻滯以獲得閉孔神經阻滯並不可靠,臨床上應考慮增加選擇性閉孔神經阻滯。

(趙延華 譯 陳傑 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.


難以解釋的術中出血病人其凝血因數XIII有效性降低以及血栓穩固性早期喪失

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

.

為了探究難以解釋的術中出血的有關變化,本研究評價了226名擇期手術病人凝血級聯反應的最終步驟。根據預先指定的標準確定發生難以解釋的術中出血病人,有20名病人(8.8%)發生難以解釋的出血,易出血者和非出血者術中平均失血量分別為1350ml400mlP < 0.001)。在易出血者纖維蛋白原和凝血因數XIII快速消耗(P < 0.001),整個手術過程中可溶性纖維蛋白原(纖維蛋白單體)的形成增加(P ≤0.014),但是在圍術期每單位凝血酶的XIII因數有效性顯著降低(P ≤0.051)。電腦化的血栓彈性圖顯示血栓穩固性顯著地降低。作者認為手術病人並存輕度凝血病並不少見,可能引起與臨床相關的圍術期出血。這種止血狀態的紊亂表現為血栓穩固性受損,可能繼發於交叉結合減少(由XIII因數缺失,其絕對值和每單位凝血酶)。因此作者建議對存在術中凝血障礙風險的病人,應用XIII因數以增加血栓穩固性是有價值的。

(趙延華 譯 陳傑 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.

 

兒童全身麻醉後口服靜脈製劑檸檬酸芬太尼的藥代動力學

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

經口腔黏膜給予兒童檸檬酸芬太尼(OTFC)的生物利用度與成人口服給藥相似。我們假設給予兒童口服芬太尼溶液後,其血漿芬太尼濃度和藥代動力學的變化與給予相同劑量OTFC相似。在這一前驅性的研究中,有10位術後鎮痛的健康兒童參加。每位元研究物件口服不稀釋的芬太尼靜脈製劑,大約10–15 µg/kg,最大劑量400 µg。服藥後15600分鐘採集靜脈血樣。用noncompartmental分析藥代動力學的變化,並與以往兒童人群服用相同劑量OTFC的研究結果比較。口服芬太尼靜脈製劑後藥代動力學參數如下:達到峰濃度的時間是1.7 ± 1.6 h,峰濃度是1.83 ± 1.19 ng/mL,半衰期是4.7 ± 2.8 h,血漿濃度時間曲線下面積是6.46 ± 3.96 h • ng–1 • mL–1,表觀容積分佈(V/F)17.5 ± 7.2 L/kg,表觀清除率(CL/F)3.33 ± 2.25 L • kg–1 • h–1。不論是OTFC還是口服靜脈製劑的芬太尼,相對於某一劑量,兩者的藥代動力學和血漿濃度相似,但是個體之間存在明顯的差異,特別是在口服靜脈製劑芬太尼的最初幾個小時。這就提示我們在用這種方法給藥時,應慎重,直到有更多研究資料的出現。

(葛甯花譯,薛張綱校)

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.

 

健康人群水合氯醛嗎啡多次鼻腔給藥後的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


我們在知道具體藥物情況下,用單次和多次給藥方法,研究鼻腔給1 2 mg水合氯醛嗎啡後的藥代動力學、耐受性和安全性。這一研究在24位健康志願者中進行(13 男性和11 女性)。分別將12-mg的嗎啡,精確至0.1-mL,噴入一側或兩側鼻孔。在單次注射或多次注射的最後一次(第七次)的012 h之間連續抽取血樣。用液相色譜法/物體光譜法檢測水合氯醛嗎啡的血藥濃度。用非房室模型分析藥代動力學的變化。連續7次鼻腔給藥1 2 mg( 6 h給藥一次)後,血漿平均峰濃度分別為2.8 ± 0.7 ng/mL 5.3 ± 2.3 ng/mL。單次和多次給藥後,達到血漿峰濃度的平均時間均為20分鐘。1- 2-mg 時,均出現與劑量成正比。副作用包括嗜睡、頭昏和服藥後味覺變差。鼻腔給予水合氯醛嗎啡具有很好的耐受性,吸收迅速且藥物蓄積有可預見性。這些研究結果支持臨床用鼻腔噴霧給藥,替代口服或肌肉注射給藥。

(葛甯花譯,薛張綱校)

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.

 

 

 

 

 

氙氣並不延長羅庫溴胺的神經阻滯作用
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

除了氙氣以外,肌肉鬆弛劑和吸入性麻醉藥之間的關係已經明瞭。我們因而比較吸入氙氣麻醉或全憑異丙酚靜脈麻醉時,羅庫溴胺的藥代動力學。氙氣和異丙酚組(每組20人),均用異丙酚和雷米芬太尼誘導。氙氣組,經面罩吸入氙氣,直到呼氣末濃度達到60%,並持續1 分鐘。同時用加速肌動描記儀(TOF監測儀 SX)監測,四個成串刺激,觀察拇內收肌的運動。監測儀信號穩定後5 分鐘,單次注入羅庫溴胺0.6 mg/kg。麻醉維持:氙氣組,氙氣和雷米芬太尼;異丙酚組,異丙酚和雷米芬太尼。兩組的起效時間(氙氣組:125 ± 33 s,異丙酚組:144 ± 43 s)、持續時間(氙氣組:33.2 ± 10.8 min,異丙酚組:32.6 ± 8.4 min)、恢復指數(氙氣組:9.4 ± 6.6 min,異丙酚組:8.4 ± 5.3 min)和臨床恢復時間(氙氣組:18.0 ± 10.2 min,異丙酚組:17.1 ± 8.5 min)均無顯著性差異。結論:全麻時,無論是與氙氣還是異丙酚合用,羅庫溴胺的神經肌肉阻滯作用沒有變化。

(葛甯花譯,薛張綱校)

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.

 

 

 




 

異氟醚抑制C纖維誘發肢體回縮的觸發反應對鼠腰脊髓神經元疼痛刺激的影響

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


觸發反應是脊髓神經元對反復電刺激C纖維這樣一種傷害性刺激的漸漸增強型反應。我們假設異氟醚抑制肢體對傷害性刺激時的有意識運動反應的最低肺泡濃度(MAC)能抑制觸發反應。記錄單個脊髓腰段神經元在1 Hz 15次的反復電刺激鼠後爪C纖維的觸發反應,同時記錄後爪回縮的力量。每15次刺激後總的動作電位(均數 ±標準差來表示每個神經元最大反應的百分數) 在異氟醚0.7, 0.9, 1.1, 1.4 MAC下分別為 83% ± 5%, 84% ± 5%, 67% ± 7%, 57% ± 8% 。異氟醚0.9 1.1 MAC時,兩組結果有顯著性的差異;而異氟醚0.7 0.9 MAC時,兩組的結果與異氟醚1.4 MAC組有顯著性的差異(P < 0.05)。這種抑制,在大多數的單元中,主要由於抑制C纖維激發的反應,並且在6個單元中,降低了最初5次刺激的觸發反應幅度。在異氟醚0.9, 1.1, 1.4 MAC時,肌肉回縮的力量分別為 67%, 11%, 4%。異氟醚抑制腰脊髓神經元的興奮性和觸發反應,抑制肢體的運動,並呈劑量依賴。

(葛甯花譯,薛張綱校)

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 固定器將中心靜脈導管固定於皮膚的有效性

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

我們驗證這樣的假設:如果需要用力才能將中心靜脈導管從與皮膚固定處拔除,主要歸功於固定方法。用三種不同的方法固定中心靜脈導管:用3-0絲線縫針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,然後比較將中心靜脈導管從與皮膚固定處拔除所需的沿導管軸心的最大力量和扭轉拔除的力量。我們用膝下截肢近端廢用肢體的組織,代替正常情況下與導管固定的人體皮膚。然後將中心靜脈導管與肉眼正常的組織用3-0絲線或4個固定器固定。每一種的固定方法,用力拔導管16次。沿導管軸心用力,拔除導管的平均峰力量3-0絲線組(40.9 ± 10.7 N; n = 16)4 0.022英寸的固定器組(34.0 ± 7.2 N; n = 16;P = 0.04)大,但與40.025英寸的固定器組(40.4 ± 5.8 N; n = 16)比較,無顯著性差異。這一研究顯示:為防止導管軸相拔除,用40.025英寸的固定器固定能達到與用3-0絲線縫合固定一樣的效果。

(葛甯花譯,薛張綱校)

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.

 

 

 

 

 


曲馬多用作皮下局部麻醉劑時的術後鎮痛效果

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


近來研究表明,曲馬多在小手術中是一有效的局部麻醉劑。在這一研究中,主要評價其術後的鎮痛作用。研究物件為40位元在局麻下進行小手術(脂肪瘤切除,疤痕整形術)的患者。患者隨機分為兩組:T組(n = 20),曲馬多2 mg/kgL (n = 20),利多卡因1 mg/kg,皮下注射。兩組注射藥物的容積均為5 mL,含1/200,000的腎上腺素。記錄注射點的紅斑、燒灼感和疼痛程度。切皮反應,主要是切皮時的疼痛,用視覺模糊法(VAS) 0–10進行評分記錄。切皮後,每隔15分鐘,記錄VAS。術中VAS如大於4分,追加相應的藥物0.5 mg/kg,並將這一劑量記入至總量。患者在手術當天出院。VAS ≥4的患者,建議必要時服用撲熱息痛。除了T組有一位患者在手術後30分鐘,出現噁心外,兩組患者均無其他副作用。24小時後,隨訪患者,記錄患者術後第一次用鎮痛藥的時間和用藥總量。在術後24小時期間,T20位患者中,有18位元(90%)不需要任何鎮痛藥,而L組中,只有10(50%)P < 0.05。術後第一次服用鎮痛藥的時間T(4.9 ± 0.3 h)L(4.4 ± 0.7 h) 長,P < 0.05。我們認為在小手術時,曲馬多是利多卡因之外的又一選擇,它能減少術後對鎮痛藥的需要。

(葛甯花譯,薛張綱校)

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.

小劑量辣椒素降低敗血症鼠的全身炎症反應

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

 

我們研究在鼠敗血症的不同階段,小劑量和大劑量辣椒素對調控全身炎症反應的影響。實驗鼠分為6組:C組,對照組;S組,敗血症組;CLC組,小劑量辣椒素組(1 mg/kg 皮下注射);SLC組,小劑量辣椒素加敗血症組;CHC組,大劑量辣椒素組(150 mg/kg 皮下注射);SHC組,大劑量辣椒素加敗血症組。結紮鼠的盲腸並刺破(CLP),造成敗血症。每組再分成兩個亞組。在CLP 918小時後,處死實驗鼠。檢測血漿中降鈣素基因關聯多肽(CGRP)、腫瘤壞死因數(TNF)-{alpha},,白介素(IL-6IL-10和亞硝酸鹽總量/硝酸鹽(NOx)。並檢測肝、肺和心臟組織的過氧化歧化酶和malondialdehyde (MDA)。與其他組比較,S組、CLC組和SLC組的CGRP增加。與S組和SHC組比較,CLP18小時後,SLC組的血漿TNF-{alpha}, IL-6, NOx 和組織的MDA水平降低而IL-10升高(P < 0.05)。小劑量辣椒素能增加抗炎指標IL-10的水平,並能減輕敗血症鼠中roinflammatory cytokines, NOx, 和組織 MDA增加的程度。

(葛甯花譯,薛張綱校)

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.

 

 

 

 

 

 

比較產婦分娩自控硬膜外和靜脈鎮痛:多中心隨機對照研究

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

 

在這一多中心、隨機對照研究中,我們分析患者自控硬膜外鎮痛(PCEA)是否影響剖宮產率,並與患者自控靜脈阿片類藥物鎮痛(PCIA)作比較。加拿大4個醫療結構將健康、足月初產婦作為研究物件,隨機給予PCIA芬太尼 (n = 118)PCEA 0.08%的布比卡因複合芬太尼1.6 µg/mL (n = 124)。兩組的剖宮產率分別為10.2% (118中的12)9.7% (124中的12)、產鉗助產率分別為21.2% (118中的25) 29% (124 中的36),兩組比較無顯著性差異。PCEA組的第二產程延長,平均延長23分鐘(P = 0.02)PCIA組有51位產婦(43%)改為硬膜外鎮痛:39人(33%)是因為靜脈鎮痛不完善,12人(10%)是改為手術分娩。PCIA組的產婦需要更多的鎮吐藥物(17% 比較 6.4%; P = 0.01)和更多的鎮靜藥物(39% 比較5%; P < 0.001)PCEA組,產婦對疼痛的評分和對鎮痛的滿意率比PCIA組高(分別為P < 0.001 P = 0.02)PCIA組和PCEA組新生兒娩出時需要搶救分別為52% 31%; P = 0.001,需要納洛酮治療分別為17% 3%; P < 0.001PCIA組多於PCEA組。這些研究結果支持這樣的觀點:與PCIA鎮痛比較,PCEA鎮痛並不影響產婦的產程,並能提供良好的鎮痛和對母嬰較少的鎮靜。

(葛甯花譯,薛張綱校)

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.

 

青少年脊柱融合術中丙泊酚、小劑量異氟醚和笑氣麻醉對皮層體感誘發電位及雙頻指數監測的影響

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,我們比較了接受脊柱融合術的青少年丙泊酚、小劑量異氟醚和笑氣(N2O)麻醉對皮層體感誘發電位(SSEP)和雙頻指數(BIS)監測的影響。以隨機次序決定十二例病人接受以下麻醉維持的方法組合:處理1:異氟醚0.4% + N2O 70% + O2 30%;處理2:異氟醚0.6% + N2O 70% + O2 30%;處理3:異氟醚0.6% + 空氣+ O2 30%;處理4:丙泊酚120 µg • kg–1 • min–1 +空氣+ O2 30%。結果:以處理3(異氟醚0.6%/空氣)維持麻醉時測得的皮層SSEP幅度高於處理1 (異氟醚0.4%/N2O 70%) (P < 0.0001) 和處理2 (異氟醚0.6%/N2O 70%) (P < 0.0052)。以處理4(丙泊酚120 µg • kg–1 • min–1 /空氣)維持麻醉時測得的皮層SSEP幅度高於處理1 (異氟醚0.4%/N2O 70%) (P < 0.0001) 、處理2 (異氟醚0.6%/N2O 70%) (P < 0.0007)和處理3 (異氟醚0.6%/空氣) (P < 0.0191)。另外,以處理1234麻醉時測得的平均BIS值分別為62626144。僅處理4(丙泊酚120 µg • kg–1 • min–1 /空氣)能始終如一地維持BIS值低於60。我們的研究證明,與聯合使用小劑量異氟醚/ N2O或者單用小劑量異氟醚麻醉相比,丙泊酚麻醉能更好地維持皮層SSEP幅度,且從BIS值上看,能提供更深的催眠水平。

(周志堅 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.

 

 

 

兒科鎮靜的綜述

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

 

為了診斷和治療給兒童實施鎮靜仍然是一個變化飛快且爭議相當大的領域。關於兒科鎮靜的技術及結局的報導發表於廣泛的各種專業刊物上,且很少進行全面檢驗,這就使這一主題的探討較困難。在這篇綜述文章中,我們將從麻醉醫師的角度出發,略微談及兒科鎮靜這一主題的許多方面。我們首先回顧麻醉醫師在兒科鎮靜現行標準的發展中所起的歷史性作用。我們還檢查了已發表的研究和報導中所反映的兒科鎮靜的現狀。還包括了關於鎮靜實施的安全性問題的專題綜述。另外,還注意到了在鎮靜實踐中的現行趨勢,包括強效鎮靜催眠藥在麻醉學以外領域的延伸作用。最後,我們提出科研前景範圍以及對於鎮靜實施者們來說臨床改進之處。

(黃麗娜      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、羅呱卡因或左旋布比卡因重比重液單側脊麻施行腹股溝疝修補術的前瞻性隨機雙盲比較

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例接受腹股溝疝修補術的病人中,我們比較了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%羅呱卡因重比重液12mgn = 20)所產生的單側脊麻的臨床效果。通過25Whitacre側向開口針緩慢注入試驗藥物,病人維持側臥位15min。三組的起效時間和術中效果相似。布比卡因組術側和非術側感覺神經阻滯的最高水平分別為T6(T12-5)L3(/[無感覺阻滯平面]-T4),左旋布比卡因組為T8(T12-5)L3(/-T3),羅呱卡因組為T5(T102)T11(/T3)(P = 0.11, P = 0.23) 。脊麻完全消退時間,羅呱卡因組為166 ± 42 min,左旋布比卡因組為210 ± 63 min,布比卡因組為 190 ± 51 min (P = 0.03 , P= 0.04);但是三組病人的出院回家時間無顯著差別(布比卡因組為329 ± 89 min,左旋布比卡因組為261 ± 112 min,羅呱卡因組為332 ± 57 min [P = 0.28])。我們得出結論,當脊麻限於腹股溝疝修補術的術側時,8mg的左旋布比卡因或者12mg的羅呱卡因可以很好地代替8mg的布比卡因。

(邱鬱薇 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.

 

泮庫溴銨和米庫氯銨神經肌肉阻滯後F波恢復各異

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


本研究目的是評估神經肌肉阻滯恢復期肌電圖F波分析法,此法對運動系統更近中心的部分比傳統的方法如肌機械圖(MMG)提供更多的資訊。20ASA -Ⅱ級神經外科手術患者,以芬太尼和咪唑安定靜脈麻醉誘導和維持。患者隨機術中給予0.25 mg/kg米庫氯銨MV 組,n = 10)或0.1 mg/kg泮庫溴銨PC組,n = 10)。持續監測拇內收肌的MMG。記錄TOF比為0.10.25 0.50.70.750.80.850.90.95時對側手的拇外展肌的F波。當MMG TOF比從0.70.95, 即臨床關鍵恢復期時, 泮庫溴銨神經肌肉阻滯後的F波振幅恢復明顯慢于米庫氯銨(P = 0.004)。這個電生理發現表明給予潘庫溴銨和米庫氯銨後運動系統的恢復存在MMG所不能發現的差異。

(趙雪蓮 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.

 

 

七氟醚及異丙酚在人體增加11C-氟馬西尼與γ-氨基丁酸A受體的結合

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


體外及動物實驗結果提示多數麻醉藥是通過γ-氨基丁酸A(GABAA)受體而發揮作用。但在人類對這個基本特徵尚缺乏廣泛研究。利用正電子發射X線斷層成像術(PET) 我們研究了七氟醚及異丙酚麻醉期11C-氟馬西尼在活體人腦中與GABAA受體結合情況。14個健康男性在應用了11C標記的氟馬西尼後分別在清醒及麻醉狀態下進行為時60 min的動態PET研究。以呼氣末2%七氟醚(n = 7)或血漿靶濃度9.0 ± 3.0 (mean ± SD)µg/mL的異丙酚(n = 7)維持麻醉。用雙頻指數(BIS)測定麻醉深度。以代謝校正的動脈血漿曲線及雙室模型計算幾個腦區的11C-氟馬西尼局部分佈容積(DV)值。用參數的DV影像分別進行統計分析以獲取詳細顯影。七氟醚組平均BIS指數為35 ± 6,異丙酚組為28 ± 8 (P = 0.02)。七氟醚明顯增加除了腦橋及白質外的其他所有研究腦區的11C-氟馬西尼的DV(P < 0.05)。異丙酚則明顯增加尾狀葉、核區、小腦、丘腦和額葉、顳葉及頂葉皮質區的DV(P < 0.05)。此外,七氟醚組在額葉、枕葉、頂葉和顳葉皮質區及核區DV值的增加明顯大於異丙酚組。我們的發現支持這二種麻醉藥在人類的作用機制涉及GABAA受體。

(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.

 

 

血栓彈性描記®過程中用電子顯微鏡評價血凝塊的形態學

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,我們用掃描電子顯微鏡(SEM)觀察在與常用的血栓彈性描記(TEG®)參數相對應的時間點時血凝塊的形態學,以此闡明TEG®記錄圖與物理血凝塊形成之間的相關性。TEG®分析儀的第一通道用來得到血凝塊形成的記錄圖,用來SEM的小量樣本從TEG®的第二通道得到。我們測定了不同種類的樣品,包括全血、添加了阿昔單抗的全血、富含血小板的血漿(PRP)以及添加了阿昔單抗的PRP。在反應時間、不同振幅(5–30 mm)、最大振幅(MA)以及最大幅度後60min振幅時獲得SEM影像。在全血中在反應時間時觀測到粗糙的纖維蛋白和活化的血小板反應,纖維蛋白絲逐漸變得更加堅固,並且在振幅10mm時及其後出現纏結。紅細胞在振幅為30mm時被纖維蛋白絲所圍繞,在MA時被纖維蛋白絲緊密包裹。在添加阿昔單抗的全血,紅細胞形態一直保持到MA期。同樣對 PRP中纖維蛋白形成以及血小板的活性也進行了測定。雖然TEG®分析儀顯示阿昔單抗阻斷了纖維蛋白與血小板的結合,但是其並未阻斷血小板形態的改變。總之,我們已經顯示了形成的凝血塊的結構改變與TEG®參數之間有相關性。

(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.

 

結腸直腸癌手術患者切皮前靜注己酮可哥堿可降低圍術期細胞因數反應,減少嗎啡用量並促進腸道功能恢復

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


手術期間細胞因數的釋放可以引起長時間的痛覺過敏。因此,術前給予細胞因數抑制劑可能會減少細胞因數的產生,降低中樞神經系統的敏感性並提高術後鎮痛的質量。本研究旨在瞭解擇期行結腸直腸癌手術的患者切皮前靜脈注射己酮可哥堿(PTX能否降低前炎性細胞因數(腫瘤壞死因數, 白細胞介素(IL-1ßIL-6IL-8)和抗炎性細胞因數(IL-1 受體拮抗劑)的釋放。40例患者隨機分為兩組,每組20例,PTX 組麻醉誘導前靜脈輸注 PTX 5 mg/kg,對照組注射等量生理鹽水。定時抽取靜脈血標本。術後所有患者均行PCA嗎啡用於術後鎮痛。與對照組相比,PTX 組患者PCA啟動給藥時間較晚,嗎啡用量較少,腸道功能恢復較快。此外,PTX 組的血漿IL-6IL-8 IL-1 受體拮抗劑的水平低於對照組。隨訪兩年,切口感染、腫瘤復發或轉移的發生率在兩組間無顯著性差異。

(軒 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-豆蔻酸鹽-醋酸鹽對人T淋巴細胞核因數{kappa}B啟動作用的體外實驗

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


腎上腺素能藥物常用于危重病人心輸出量及血管舒縮張力的血流動力學支持。最近有研究證實給予這些血管活性藥可以影響細胞因數的釋放及影響炎症反應。然而,影響該免疫調節作用的機制尚不清楚。核轉錄因數κB (NF-κB)調節許多細胞因數的表達,在免疫反應中起到重要的作用。因此,我們驗證了不同腎上腺素能藥物(多巴酚丁胺、紮莫特羅、氨哮素、腎上腺素、去甲腎上腺素及苯腎上腺素)對NF-κB的啟動作用、NF-κB驅動的應答基因活性及NF-κB靶基因白介素(IL)-8表達的影響。此外,我們定量了NF-κB抑制劑IκBα及IL-10。在此我們報導多巴酚丁胺能抑制NF-κB對人類原始的CD3+T淋巴細胞的啟動作用。NF-κB的抑制作用包括對其抑制劑IκBα的穩定作用。該作用看來具有ß2-受體選擇性,因為ß1及α腎上腺素能物質(即紮莫特羅、腎上腺素、去甲腎上腺素及苯腎上腺素)並不影響NF-κB的啟動作用,且多巴酚丁胺介導的對NF-κB的抑制作用可用選擇性ß2-受體阻斷劑來預防。我們的研究結果證實:多巴酚丁胺是一種有效的特異性的NF-κB抑制劑,這一結果可能提供了ß腎上腺素能藥物治療相關的免疫調節的分子機制。

(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.

 

全膝成形術患者超聲輔助下單次股神經阻滯鎮痛的副作用較鞘內嗎啡少

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


全膝成形術(TKA)後疼痛非常嚴重,如何獲得充分的鎮痛效果仍然是臨床上的一大挑戰。我們檢驗了這樣一個假設:在鞘內(IT)麻醉下行單側全膝成形術的患者中,再加股神經阻滯可以比IT嗎啡獲得更佳的鎮痛效果,且不良副作用更少。在這次單盲對照試驗中,41ASA I–III行單側TKA的患者隨機分成兩組。兩組均採用布比卡因15 mg IT注射作為手術麻醉藥。術後鎮痛ITM組給予IT嗎啡250 µgFNB組在超聲輔助下行股神經阻滯,注入0.5%布比卡因40ml、腎上腺素5 µg/mL和可樂定75 µg。在術後第12461224小時用視覺類比尺規記錄疼痛評分、靜脈嗎啡累計用量、血流動力學指標和副作用。兩組在嗎啡用量、靜息疼痛評分和活動疼痛評分方面沒有顯著差異。但是,FNB組圍術期的副作用包括噁心、嘔吐和瘙癢均較少(每項均P < 0.05)。相應地,在ITM組中患者的滿意度較低,其中20%將其經歷定級為“不滿意”(P < 0.05)。總之,對於布比卡因鞘內麻醉下行TKA的患者,單次注射股神經阻滯可以獲得與IT嗎啡鎮痛相同的鎮痛效果但顯著較少的副作用。

(張俊傑 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喉罩通氣道與Soft SealTM喉罩的比較:一項在麻醉肌松下患者中隨機交叉研究

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


我們驗證這樣一個假說,Soft SealTM牌喉罩通氣道(SSLM)UniqueTM牌喉罩通氣道(LMA-U)其插入的難易程度、口咽部的洩漏壓、光纖定位、通氣的難易程度和粘膜的損傷程度是不同的。我們在90例肌松麻醉下的患者(ASA I–II18–80歲)中進行了研究。兩種裝置按隨機順序插入每一位元患者。在氣囊充氣以10毫升遞增、從040毫升的過程中和在氣囊內壓為60 cm H2O時測定口咽部的洩漏壓和光纖定位。測定通氣的難易程度系在潮氣量為812 mL/kg時控制通氣10分鐘,記錄血氧飽和度、呼氣末CO2、洩漏分數、氣道峰壓以及是否存在胃充氣。通過檢測首次隨機置入的裝置上是否存在可視出血和隱性出血來測定粘膜損傷。LMA-U的置入時間更短( P = 0.0001)、嘗試次數更少( P = 0.005)。兩種裝置都能成功置入使用。兩者的口咽部洩漏壓相似,但是光纖定位LMA-U的位置更佳(P £ 0.0003)。血紅蛋白氧飽和度、呼氣末CO2、洩漏分數及氣道峰壓在兩種設定的潮氣量通氣時沒有區別。兩組患者在兩種設定的潮氣量通氣下沒發現胃充氣。可視出血( P = 0.009)和隱性出血( P = 0.0001)的發生在LMA-U組更少。我們得出這樣一個結論,在置入的難易程度、光纖定位和粘膜損傷方面LMA-U均優於SSLM,口咽部的洩漏壓和通氣難易程度相似。

(陳瑋     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.