Anesthesia & Analgesia

December 2004

Table of Content

 

PEDIATRIC ANESTHESIA:

预测儿科病人术后呕吐发生可能性的风险评分的开发和验证

齐波 陈杰

The Development and Validation of a Risk Score to Predict the Probability of Postoperative Vomiting in Pediatric Patients

L. H. J. Eberhart, G. Geldner, P. Kranke, A. M. Morin, A. Schäuffelen, H. Treiber, and H. Wulf

Anesth Analg 2004 99: 1630-1637

 

扁桃腺肥大的麻醉儿童侧卧位时提下颌和托下颌(前伸)对喘鸣评分的影响

周志坚 译  李士通 校

The Effects of Chin Lift and Jaw Thrust While in the Lateral Position on Stridor Score in Anesthetized Children with Adenotonsillar Hypertrophy

Young-Chang P. Arai, Kayo Fukunaga, Seiji Hirota, and Shoji Fujimoto

Anesth Analg 2004 99: 1638-1641.

 

评价部分CO2重吸收无创监测儿童CO的价值

葛宁花译 薛张纲校

An Evaluation of a Noninvasive Cardiac Output Measurement Using Partial Carbon Dioxide Rebreathing in Children

Richard J. Levy, Rosetta M. Chiavacci, Susan C. Nicolson, Jonathan J. Rome, Richard J. Lin, Mark A. Helfaer, and Vinay M. Nadkarni

Anesth Analg 2004 99: 1642-1647.

 

术前焦虑与出现谵妄、术后行为不当的关系

齐波 陈杰

Preoperative Anxiety and Emergence Delirium and Postoperative Maladaptive Behaviors

Zeev N. Kain, Alison A. Caldwell-Andrews, Inna Maranets, Brenda McClain, Dorothy Gaal, Linda C. Mayes, Rui Feng, and Heping Zhang

Anesth Analg 2004 99: 1648-1654.

 

介绍一种关于模拟婴儿心血管生理教育的模型

黄丽娜      李士通  

A Model for Educational Simulation of Infant Cardiovascular Physiology

Jane A. Goodwin, Willem L. van Meurs, Carla D. Sá Couto, Jan E. W. Beneken, and Shirley A. Graves

Anesth Analg 2004 99: 1655-1664.

 

AMBULATORY ANESTHESIA:

比较高渗布比卡因腰麻和地氟醚全麻在门诊膝关节镜检查中的应用

葛宁花译 薛张纲校

A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy

Anna-Maija Korhonen, Jukka V. Valanne, Ritva M. Jokela, Pirjo Ravaska, and Kari T. Korttila

Anesth Analg 2004 99: 1668-1673.

 

ANESTHETIC PHARMACOLOGY:      

长期应用苯二氮卓类药物的老年人术后意识混乱发生率增加

赵延华 陈杰

Postoperative Confusion Increases in Elderly Long-Term Benzodiazepine Users

Akira Kudoh, Hajime Takase, Yoko Takahira, and Tomoko Takazawa

Anesth Analg 2004 99: 1674-1678.

 

全膝置换术后经口或经静脉给予氨甲环酸对节约术后用血的效应

邱郁薇      李士通 

The Postoperative Blood-Sparing Efficacy of Oral Versus Intravenous Tranexamic Acid After Total Knee Replacement

Edna Zohar, Martin Ellis, Nisim Ifrach, Avraham Stern, Oleg Sapir, and Brian Fredman

Anesth Analg 2004 99: 1679-1683.

 

硬膜外布比卡因阻滞对异丙酚诱导与维持和维持剂量芬太尼与维库溴胺的影响

葛宁花译 薛张纲校

The Effect of Epidural Bupivacaine on Induction and Maintenance Doses of Propofol (Evaluated by Bispectral Index) and Maintenance Doses of Fentanyl and Vecuronium

Anil Agarwal, Ravindra Pandey, Sanjay Dhiraaj, Prabhat K. Singh, Mehdi Raza, Chandra K. Pandey, Devendra Gupta, Arindam Choudhury, and Uttam Singh

Anesth Analg 2004 99: 1684-1688

 

氯胺酮对人离体心房肌的正性变力和松弛效应:肾上腺素能受体阻滞效应

赵延华 陈杰

The Inotropic and Lusitropic Effects of Ketamine in Isolated Human Atrial Myocardium: The Effect of Adrenoceptor Blockade

Jean-Luc Hanouz, Emmanuel Persehaye, Lan Zhu, Stéphane Lammens, Olivier Lepage, Massimo Massetti, Gérard Babatasi, André Khayat, Henri Bricard, and Jean-Louis Gérard

Anesth Analg 2004 99: 1689-1695

 

静脉内给予利多卡因抑制芬太尼引起的咳嗽:一个双盲、前瞻、随机、安慰剂对照研究

马皓琳      李士通 

Intravenous Lidocaine Suppresses Fentanyl-Induced Coughing: A Double-Blind, Prospective, Randomized Placebo-Controlled Study

Chandra K. Pandey, Mehdi Raza, Rajeev Ranjan, Archana Lakra, Anil Agarwal, Uttam Singh, R. B. Singh, and Prabhat K. Singh

Anesth Analg 2004 99: 1696-1698.

 

注射部位的疼痛:注射异丙酚前注射利多卡因或用异丙酚甘油三酸脂中长链剂型的对照双盲研究

葛宁花译 薛张纲校

Pain on Injection: A Double-Blind Comparison of Propofol with Lidocaine Pretreatment Versus Propofol Formulated with Long- and Medium-Chain Triglycerides

E. Schaub, C. Kern, and R. Landau

Anesth Analg 2004 99: 1699-1702.

 

麻黄素的血流动力学作用对猪罗库溴铵起效时间的影响

朱慧琛 译 陈杰 校

The Hemodynamic Effects of Ephedrine on the Onset Time of Rocuronium in Pigs

Annette Herweling, Federico Latorre, Andreas Herwig, Georg Horstick, Oliver Kempski, and Hendrik W. Gervais

Anesth Analg 2004 99: 1703-1707

 

异氟醚能保护原代混合培养的神经元/神经胶质细胞,使其凋亡不被NMDA的兴奋毒性增强

赵雪莲 译   李士通 校

Apoptosis Is Not Enhanced in Primary Mixed Neuronal/Glial Cultures Protected by Isoflurane AgainstN-Methyl-D-Aspartate Excitotoxicity

Lisa Wise-Faberowski, Mitsuo Aono, Robert D. Pearlstein, and David S. Warner

Anesth Analg 2004 99: 1708-1714.

 

临床浓度吸入麻醉药对人体K通道TRESK串联孔区的强大激活作用

葛宁花译 薛张纲校

Potent Activation of the Human Tandem Pore Domain K Channel TRESK with Clinical Concentrations of Volatile Anesthetics

Canhui Liu, John D. Au, Hilary Liao Zou, Joseph F. Cotten, and C. Spencer Yost

Anesth Analg 2004 99: 1715-1722.

 

TECHNOLOGY, COMPUTING, AND SIMULATION:

七氟谜降低脑双频指数较吸入MAC相等倍数的氟烷更明显

朱慧琛 译 陈杰 校

Sevoflurane Decreases Bispectral Index Values More than Does Halothane at Equal MAC Multiples

Hildebrand S. Schwab, Manfred D. Seeberger, Edmond I Eger, II, Christoph H. Kindler, and Miodrag Filipovic

Anesth Analg 2004 99: 1723-1727.

 

在健康志愿者控制输注异丙酚和雷米芬太尼期间用听觉诱发电位监测镇静深度

彭中美 译  李士通 校

Measuring Depth of Sedation with Auditory Evoked Potentials During Controlled Infusion of Propofol and Remifentanil in Healthy Volunteers

 Matthias Haenggi, Heidi Ypparila, Jukka Takala, Ilkka Korhonen, Martin Luginbühl, Steen Petersen-Felix, and Stephan M. Jakob

Anesth Analg 2004 99: 1728-1736.

 

用高保真的模拟病人来介绍新的麻醉装备

葛宁花译 薛张纲校

The Use of High-Fidelity Human Patient Simulation and the Introduction of New Anesthesia Delivery Systems

Paul Dalley, Brian Robinson, Jennifer Weller, and Catherine Caldwell

Anesth Analg 2004 99: 1737-1741.

 

利用凝胶涂层的水循环床垫进行热交换

朱辉 陈杰

Conductive Heat Exchange with a Gel-Coated Circulating Water Mattress

Anselm Bräuer, Larissa Pacholik, Thorsten Perl, Michael John Murray English, Wolfgang Weyland, and Ulrich Braun

Anesth Analg 2004 99: 1742-1746

 

PAIN MEDICINE:

比较供体右叶肝切除术和肝肿瘤肝大部切除术后的疼痛治疗

        李士通 

A Comparison of Postoperative Pain Control in Patients After Right Lobe Donor Hepatectomy and Major Hepatic Resection for Tumor

Jacek B. Cywinski, Brian M. Parker, Meng Xu, and Samuel A. Irefin

Anesth Analg 2004 99: 1747-1752.

 

静脉注射氯胺酮试验:预计口服Dextromethorphan对治疗神经性疼痛的效果

葛宁花译 薛张纲校

The Intravenous Ketamine Test: A Predictive Response Tool for Oral Dextromethorphan Treatment in Neuropathic Pain

Steven P. Cohen, Audrey S. Chang, Thomas Larkin, and Jianren Mao

Anesth Analg 2004 99: 1753-1759.

 

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

困难气道风险因素的评估:一项1956名意大利患者的调查

朱辉 陈杰

Risk Factors Assessment of the Difficult Airway: An Italian Survey of 1956 Patients

D. Cattano, E. Panicucci, A. Paolicchi, F. Forfori, F. Giunta, and C. Hagberg

Anesth Analg 2004 99: 1774-1779.

 

CRITICAL CARE AND TRAUMA:

机械通气狗分级低血容量和高血容量时心脏前负荷改变的比较

朱 慧      李士通 

A Comparison of Changes in Cardiac Preload Variables During Graded Hypovolemia and Hypervolemia in Mechanically Ventilated Dogs

Yoshihisa Fujita, Tokunori Yamamoto, Itsuro Sano, Naoki Yoshioka, and Hajime Hinenoya

Anesth Analg 2004 99: 1780-1786.

 

心室纤维颤动时的中位频率可能不是一个有效的监测心脏停止后用Endothelin-1和肾上腺素治疗的指标

葛宁花译 薛张纲校

Ventricular Fibrillation Median Frequency May Not Be Useful for Monitoring During Cardiac Arrest Treated with Endothelin-1 or Epinephrine

Michael Holzer, Wilhelm Behringer, Fritz Sterz, Julia Kofler, Elisabeth Oschatz, Ernst Schuster, and Anton N. Laggner

Anesth Analg 2004 99: 1787-1793

 

一种使用血栓弹力图评价Eptifibatide对血小板抑制的新方法

殷文渊 陈杰

A Novel Method to Assess Platelet Inhibition by Eptifibatide with Thrombelastograph®

Nobuyuki Katori, Fania Szlam, Jerrold H. Levy, and Kenichi A. Tanaka

Anesth Analg 2004 99: 1794-1799.

 

NEUROSURGICAL ANESTHESIA:

鞘内注射硫酸镁对家兔是否安全且是否保护其免于缺血性脊髓损伤?

周雅春      李士通 

Is Intrathecal Magnesium Sulfate Safe and Protective Against Ischemic Spinal Cord Injury in Rabbits?

Hiroshi Saeki, Mishiya Matsumoto, Shuichi Kaneko, Shunsuke Tsuruta, Ying Jun Cui, Kazunobu Ohtake, Kazuyoshi Ishida, and Takefumi Sakabe

Anesth Analg 2004 99: 1805-1812.

 

OBSTETRIC ANESTHESIA:

用心率变异性以发现产科患者腰麻时的危险性

葛宁花译 薛张纲校

Using Heart Rate Variability to Stratify Risk of Obstetric Patients Undergoing Spinal Anesthesia

Dmitri Chamchad, Valerie A. Arkoosh, Jay C. Horrow, Jodie L. Buxbaum, Igor Izrailtyan, Lev Nakhamchik, Dirk Hoyer, and J. Yasha Kresh

Anesth Analg 2004 99: 1818-1821

 

氟烷浓度提高速度和接头数量对大鼠氟烷最小肺泡麻醉浓度测定的影响

殷文渊 陈杰

Determining Minimum Alveolar Anesthetic Concentration of Halothane in Rats: The Effect of Incremental Change in Halothane Concentration and Number of Crossover

Avner Leon, Olga Mayzler, Mony Benifla, Michael Semionov, Yulia Fuxman, Israel Eilig, Vadim Passuga, Maryana K. Doitchinova, Boris Gurevich, Alan A. Artru, and Yoram Shapira

Anesth Analg 2004 99: 1822-1828.

 

 

REGIONAL ANESTHESIA:

 

坐位患者旁正中法腰段硬膜外导管置入在脊柱屈曲或不屈曲状况下的成功率相当

        李士通 

Paramedian Lumbar Epidural Catheter Insertion with Patients in the Sitting Position Is Equally Successful in the Flexed and Unflexed Spine

Subrata Podder, Neeraj Kumar, L. N. Yaddanapudi, and Pramila Chari

Anesth Analg 2004 99: 1829-1832.

 

颈部硬膜外麻醉用于颈部和上肢的联合手术:一项引导性研究

葛宁花译 薛张纲校

Cervical Epidural Anesthesia for Combined Neck and Upper Extremity Procedure: A Pilot Study

Pavel Michalek, Ivan David, Milos Adamec, and Libor Janousek

Anesth Analg 2004 99: 1833-1836

 

全麻前单次椎旁阻滞可增强乳癌手术是否拌有淋巴结活检后的镇痛效果

顾漪闻 陈杰

Single-Injection Paravertebral Block Before General Anesthesia Enhances Analgesia After Breast Cancer Surgery With and Without Associated Lymph Node Biopsy

Pekka M. Kairaluoma, Martina S. Bachmann, Aulikki K. Korpinen, Per H. Rosenberg, and Pertti J. Pere

Anesth Analg 2004 99: 1837-1843.

持续脊麻小孔径导管的机械特性

黄施伟      李士通  

The Mechanical Properties of Continuous Spinal Small-Bore Catheters

Engelbert Deusch, Justus Benrath, Lukas Weigl, Konrad Neumann, and Sibylle A. Kozek-Langenecker

Anesth Analg 2004 99: 1844-1847.

 

GENERAL ARTICLES:

比较地氟醚和七氟醚在成年病态肥胖患者外科手术后苏醒和恢复的特点:一项前瞻性和随机性研究

葛宁花译 薛张纲校

Emergence and Recovery Characteristics of Desflurane Versus Sevoflurane in Morbidly Obese Adult Surgical Patients: A Prospective, Randomized Study

Earl M. Strum, Janos Szenohradszki, Wayne A. Kaufman, Gary J. Anthone, Ingrid L. Manz, and Philip D. Lumb

Anesth Analg 2004 99: 1848-1853

 

腹腔镜胆囊切除术期间醋酸林格氏液容量动力学

顾漪闻 陈杰

The Volume Kinetics of Acetated Ringer’s Solution During Laparoscopic Cholecystectomy

Joel Olsson, Christer H. Svensén, and Robert G. Hahn

Anesth Analg 2004 99: 1854-1860.

 

 

预测儿科病人术后呕吐发生可能性的风险评分的开发和验证

The Development and Validation of a Risk Score to Predict the Probability of Postoperative Vomiting in Pediatric Patients
 L. H. J. Eberhart, MD*, G. Geldner, MD*, P. Kranke, MD{dagger}, A. M. Morin, MD*, A. Schäuffelen, MD{ddagger}, H. Treiber, MD{ddagger}, and H. Wulf, MD*

*Department of Anesthesia and Intensive Care, Philipps-University, Marburg; {dagger}Department of Anesthesiology and Intensive Care, University of Würzburg, Würzburg; and {ddagger}Ambulatory Surgical Center Söflingen, Ulm, Germany

Anesth Analg 2004 99: 1630-1637.

 

预测术后呕吐(PV)或恶心呕吐发生率的风险评分应用于成年病人已比较成熟,但不适用于儿童,因为几个风险因素很难进行评估或不适用于儿科病人(如吸烟状况等)。因此,本研究的目的是开发和验证一个简单的评分来预测儿科病人PV的发生(POVOC-score)。新评分开发和验证所需要的资料来自4个相互独立的研究机构,研究对象包括1257名在全麻下接受各种不同手术的儿童(年龄在0-14岁之间),这些儿童在术前均不预防性应用止吐药。术前记录几个潜在的风险因素。术后24小时内观察有无PV。数据随机分为评价组(n=675)和验证组(n=600),评价组数据通过Logistic回归分析;验证组数据通过受试者操作特征曲线下平均面积来确认预测的精确性。四个相互独立的PV风险因素(手术时间30分钟; 年龄3岁;斜视手术;以及受试儿童有PV的阳性病史或者其亲属(母亲、父亲、兄弟姐妹)有PV或术后恶心呕吐的阳性病史)通过最终分析并进行验证。结果发现当存在01234个风险因素时的PV发生率分别为9%10%30%55%70%。验证组应用这些率值作为定点,其受试者操作特征下曲线面积为0.7295%可信区间为0.68-0.77)。结果表明应用四项简单的风险评分能够比较精确地预测儿童PV的发生。

(齐波 陈杰 校)

Risk scores to predict the occurrence of postoperative vomiting (PV) or nausea and vomiting that were developed for adult patients do not fit for children, because several risk factors are difficult to assess or are usually not applicable in pediatric patients (e.g., smoking status). Thus, in the present study, we sought to develop and to validate a simple score to predict PV in children (POVOC-score). Development and validation of the new score was based on data from 4 independent institutions of 1257 children (aged 0–14 yr) undergoing various types of surgery under general anesthesia without antiemetic prophylaxis. Preoperatively, several potential risk factors were recorded. Postoperatively, the occurrence of PV was observed for up to 24 h. The dataset was randomly split into an evaluation set (n = 657) that was analyzed using a forward logistic regression technique and a validation set (n = 600) that was used to confirm the accuracy of prediction by means of the area under a receiver operating characteristic curve. Four independent risk factors for PV were identified in the final analysis: duration of surgery ≥30 min, age ≥3 yr, strabismus surgery, and a positive history of PV in the children or PV/postoperative nausea and vomiting in relatives (mother, father, or siblings). The incidence of PV was 9%, 10%, 30%, 55%, and 70% for 0, 1, 2, 3, and 4 risk factors observed. Using these incidences as cut-off values in the validation dataset, the area under the receiver operating characteristic curve was 0.72 (95% confidence interval: 0.68–0.77). Our data suggest that PV can be predicted with an acceptable accuracy using a four-item simplified risk score.

 

术前焦虑与出现谵妄、术后行为不当的关系

Preoperative Anxiety and Emergence Delirium and Postoperative Maladaptive Behaviors

Zeev N. Kain, MD, MBA, Alison A. Caldwell-Andrews, PhD, Inna Maranets, MD, Brenda McClain, MD, Dorothy Gaal, MD, Linda C. Mayes, MD, Rui Feng, MS, and Heping Zhang, PhD

The Center for the Advancement of Perioperative Health, and the Departments of Anesthesiology, Pediatrics, and Child and Adolescent Psychiatry, Yale University School of Medicine, Department of Epidemiology, School of Public Health, Yale University, New Haven, Connecticut

Anesth Analg 2004 99: 1648-1654.

 

基于先前的研究,作者假设临床上术前焦虑、谵妄发生和术后行为不当有密切相关。作者利用过去6年中该实验室获得的数据资料来验证此结论。选择七氟醚/O2/N2O复合全麻下实施外科手术的儿童为研究对象,且在术中不应用咪唑安定。术前焦虑通过改良的耶鲁术前焦虑评分(mYPAS)进行评估,谵妄评估在麻醉后监护室内进行,而病人动作行为的改变则在术后第1237,和14天时通过波斯特医院行为调查问卷(PHBQ)进行评定。回归分析显示儿童焦虑状态评分(mYPAS)每增加10点,出现具有显著症状的谵妄的可能性就增加10%。与无谵妄症状的儿童相比,具有显著症状的儿童在术后新出现行为不当的可能比率为1.43。当焦虑状态评分增加10点,导致儿童术后新出现行为不当的可能性增加12.5%。这个发现对临床医生来说具有重要意义,可以借此来预测术后有害事件的发生,如根据病人术前焦虑的水平,来预测术后可能发生谵妄和行为不当的情况。

(齐波 陈杰 校)

Based on previous studies, we hypothesized that the clinical phenomena of preoperative anxiety, emergence delirium, and postoperative maladaptive behavioral changes were closely related. We examined this issue using data obtained by our laboratory over the past 6 years. Only children who underwent surgery and general anesthesia using sevoflurane/O2/N2O and who did not receive midazolam were recruited. Children’s anxiety was assessed preoperatively with the modified Yale Preoperative Anxiety Scale (mYPAS), emergence delirium was assessed in the postanesthesia care unit, and behavioral changes were assessed with the Post Hospital Behavior Questionnaire (PHBQ) on postoperative days 1, 2, 3, 7, and 14. Regression analysis showed that the odds of having marked symptoms of emergence delirium increased by 10% for each increment of 10 points in the child’s state anxiety score (mYPAS). The odds ratio of having new-onset postoperative maladaptive behavior changes was 1.43 for children with marked emergence status as compared with children with no symptoms of emergence delirium. A 10-point increase in state anxiety scores led to a 12.5% increase in the odds that the child would have a new-onset maladaptive behavioral change after the surgery. This finding is highly significant to practicing clinicians, who can now predict the development of adverse postoperative phenomena, such as emergence delirium and postoperative behavioral changes, based on levels of preoperative anxiety.

 

长期应用苯二氮卓类药物的老年人术后意识混乱发生率增加

Postoperative Confusion Increases in Elderly Long-Term Benzodiazepine Users

Akira Kudoh, MD, Hajime Takase, MD, Yoko Takahira, MD, and Tomoko Takazawa, MD

Department of Anesthesiology, Hirosaki National Hospital, Hirosaki, Aomori, Japan

Anesth Analg 2004 99: 1674-1678.

 

作者研究了定期服用苯二氮卓类药物的老年病人术后意识混乱和药物应用时间、术前焦虑、压抑状态及认知功能的关系。研究对象为328名施行整形外科手术的病人,年龄65-80岁。研究者通过与病人面对面的交谈以及观察其药箱来获得有关病人服用苯二氮卓类药物方面的信息,术后应用意识混乱评分对病人的意识状态进行评价。病人分为两组,即定期服药组和非服药组。328名病人中有57名(17%)服用苯二氮卓类药物。两组病人术前简要精神状况(Mini Mental Status, MMS)评分、焦虑评分或压抑评分没有明显区别。57名服药者中有15名(26%)术后出现意识混乱,而非服药组271名病人中有34名(13%)出现术后意识混乱(P< 0.01)。57名服药者中有5名(9%MMS评分<23,而271名非服药者中有8名(3%)(P< 0.05)。37名长期服用苯二氮卓类药物者(每天服用,长达一年以上)中有13 名(35%)出现术后意识混乱。长期服用药物者术后意识混乱的发生率显著高于短期服药者和未服药者。37名长期服药者中有5名(14%MMS评分<2320名短期服药者中则没有(0%)。结论:长期服用苯二氮卓类药物者术后意识混乱的发生率明显升高。

(赵延华 陈杰 校)

We investigated the relationship between postoperative confusion and duration of benzodiazepine exposure, preoperative anxiety, depressive state, and cognitive function in elderly patients regularly taking benzodiazepines. We studied 328 patients ranging in age from 65 to 80 yr who underwent orthopedic surgery. Information on benzodiazepine use was obtained by face-to-face interview and visual assessment of the patient’s medicine chest. Postoperative confusion was assessed by using a confusion-assessment method. The patients were divided into two groups: those who regularly took benzodiazepines and those who did not. Fifty-seven (17%) of 328 patients were treated with benzodiazepines. There were no significant differences in preoperative Mini-Mental State (MMS) scores, anxiety scores, or depression scores between benzodiazepine users and nonusers. Postoperative confusion occurred in 15 (26%) of 57 benzodiazepine users and in 34 (13%) of 271 nonusers (P < 0.01). The patients who had a score <23 on the MMS were 5 (9%) of 57 benzodiazepine users and 8 (3%) of 271 nonusers (P < 0.05). Postoperative confusion occurred in 13 (35%) of 37 long-term benzodiazepine users (daily use for >1 yr) and in 2 (10%) of 20 short-term users (daily use for <1 yr). The incidence of postoperative confusion was significantly more frequent in long-term than in short-term benzodiazepine users or nonusers of benzodiazepines. The patients who developed a score <23 on the MMS were 5 (14%) of 37 long-term benzodiazepine users and 0 (0%) of 20 short-term benzodiazepine users. In conclusion, the incidence of postoperative confusion was significantly more frequent in long-term benzodiazepine users.

 

氯胺酮对人离体心房肌的正性变力和松弛效应:肾上腺素能受体阻滞效应

The Inotropic and Lusitropic Effects of Ketamine in Isolated Human Atrial Myocardium: The Effect of Adrenoceptor Blockade

Jean-Luc Hanouz, MD, PhD, Emmanuel Persehaye, MD, Lan Zhu, MD, Stéphane Lammens, MD, Olivier Lepage, MD, Massimo Massetti, MD, Gérard Babatasi, MD, PhD, André Khayat, MD, Henri Bricard, MD, and Jean-Louis Gérard, MD, PhD

Laboratoire d’Anesthésiologie Expérimentale et de Physiologie Cellulaire, UPRES EA 3212, Département d’Anesthésie-Réanimation, Centre Hospitalier Universitaire (CHU) Côte de Nacre, Caen; France

Anesth Analg 2004 99: 1689-1695.

 

作者研究了αβ-肾上腺素能受体阻滞剂作用下外消旋氯胺酮对人的离体右心房肌的直接效应。外消旋氯胺酮(浓度分别为10–610–510–4 M)单独应用或与α-肾上腺素能受体阻滞剂(酚妥拉明10–6 M)和β-肾上腺素能受体阻滞剂(心得安10–6 M)联合应用,在给药前后记录等长收缩力(FoC)及其与时间的一级导数(+dF/dt),收缩舒张耦合参数R2 = (+dF/dt) / (–dF/dt)、半量松弛时间(T1/2)。氯胺酮有中度正性变力效应,浓度为10–5 M FoC为基础值的104% ± 5%P = 0.0310–4 MFoC为基础值的107% ± 11%P = 0.09。在心得安作用下,外消旋氯胺酮有负性变力效应,氯胺酮浓度为10–6 MFoC为基础值的77% ± 11%10–5 MFoC为基础值的63% ± 16%10–4 MFoC为基础值的62% ± 17%P < 0.001)。但在酚妥拉明作用下氯胺酮的负性变力效应不明显,氯胺酮浓度为10–6 MFoC为基础值的94% ± 6% 10–5 MFoC为基础值的96% ± 5%10–4 MFoC为基础值的98% ± 15%。氯胺酮可缩短T1/2(浓度为10–5 MT1/2为基础值的94% ± 3%P < 0.00110–4 MT1/2为基础值的90% ± 9%P = 0.007),但没有改变R2。在人的右心房肌,外消旋氯胺酮可引起中度正性变力效应,加速等容舒张。在ß-肾上腺素能受体阻滞剂作用下,引起直接的负性变力效应。

(赵延华 陈杰 校)

We studied the direct myocardial effects of racemic ketamine, in the presence of {alpha}- and ß-adrenoceptor blockade, on isolated human right atrial myocardium. Isometric force of contraction (FoC), its first derivative with time (+dF/dt), the contraction relaxation coupling parameter R2 = (+dF/dt) / (–dF/dt), and time to half relaxation (T1/2) were recorded before and after addition of 10–6, 10–5 and 10–4 M racemic ketamine alone and in the presence of {alpha}-adrenoceptor blockade (phentolamine 10–6 M) and ß-adrenoceptor blockade (propranolol at 10–6 M). Ketamine had a moderate positive inotropic effect at 10–5 M (FoC, 104% ± 5% of baseline value; P = 0.03) and 10–4 M (FoC, 107% ± 11% of baseline value; P = 0.09). Racemic ketamine had a negative inotropic effect in the presence of propranolol (FoC, ketamine 10–6 M, 77% ± 11%; ketamine 10–5 M, 63% ± 16%; ketamine 10–4 M, 62% ± 17% of baseline; P < 0.001) but not phentolamine (FoC, ketamine at 10–6 M, 94% ± 6%; ketamine 10–5 M, 96% ± 5%; and ketamine 10–4 M, 98% ± 15% of baseline). Ketamine decreased T1/2 (ketamine 10–5 M, 94% ± 3% of baseline value; P < 0.001 and ketamine 10–4 M, 90% ± 9% of baseline value; P = 0.007) but did not modify R2. In human right atrial myocardium, racemic ketamine induced a moderate positive inotropic effect and hastened isometric relaxation. In the presence of ß-adrenoceptor blockade it induced a direct negative inotropic effect.

 

麻黄素的血流动力学作用对猪罗库溴铵起效时间的影响

The Hemodynamic Effects of Ephedrine on the Onset Time of Rocuronium in Pigs

Annette Herweling, MD*, Federico Latorre, MD, PhD*, Andreas Herwig, MD*, Georg Horstick, MD, PhD{dagger}, Oliver Kempski, MD, PhD{ddagger}, and Hendrik W. Gervais, MD, PhD*

*Department of Anesthesiology {dagger}2nd Medical Clinic, and {ddagger}Institute for Neurosurgical Pathophysiology, Johannes Gutenberg-University, Mainz, Germany

Anesth Analg 2004 99: 1703-1707

.

有些研究发现肌松起效时间与心指数和肌肉血流间存在相关性。麻黄素可加强这些血流动力学变化,进而缩短人类罗库溴铵起效时间。本实验的目的在于确定使用硫喷妥钠后,麻黄素对罗库溴铵起效时间、心指数和肌肉血流的影响。在每个预定的测试时点,测量平均动脉压和心指数,并用肌动图记录起效时间。24只猪随机分为三组:组1先用依托咪酯,随后使用罗库溴铵(2×95%有效剂量);组2以硫喷妥钠代替依托咪酯。组3在给予硫喷妥钠前先应用麻黄素100µg/kg,同时测量肌肉血流(荧光标记)。虽然组1与组2的血流动力学存在差异,但罗库溴铵的起效时间并无明显区别。组3中麻黄素补偿了硫喷妥钠引起的平均动脉压、心指数和肌肉血流的下降,但未明显缩短起效时间(组17421s;组27124s; 36922s)。结论:麻黄素相关性心指数和血流增加并不缩短健康猪罗库溴铵的起效时间。

(朱慧琛 译 陈杰 校)

Several studies have found a correlation between the onset time of muscle relaxants, cardiac index, and muscle blood flow. Ephedrine increases these hemodynamic variables and shortens onset time of rocuronium in humans. Our aim in this animal study was to determine the effect of ephedrine on the onset time of rocuronium, cardiac index, and muscle blood flow after administration of thiopental. At predefined measuring points, mean arterial blood pressure and cardiac index were measured invasively and onset time was determined mechanomyographically. Twenty-four pigs were randomly assigned to three groups. Group I received etomidate and subsequently rocuronium (2 x 95% effective dose). Instead of etomidate, Group II received thiopental. In Group III, ephedrine 100 µg/kg was given before thiopental; additionally, muscle blood flow was measured (fluorescent microspheres). Although there were differences in hemodynamics between Groups I and II, this was not reflected in different onset times of rocuronium. In Group III, ephedrine compensated the thiopental-induced decrease of mean arterial blood pressure, cardiac index, and muscle blood flow, but no significant shortening of onset time (Group I: 74 ± 21 s; Group II: 71 ± 24; Group III: 69 ± 22 s) was found. Our results demonstrated that ephedrine-related increases in cardiac index and blood flow did not shorten onset time of rocuronium in healthy pigs.

 

七氟谜降低脑双频指数较吸入MAC相等倍数的氟烷更明显

Sevoflurane Decreases Bispectral Index Values More than Does Halothane at Equal MAC Multiples

Hildebrand S. Schwab, MD*, Manfred D. Seeberger, MD*, Edmond I Eger, II, MD{dagger}, Christoph H. Kindler, MD*, and Miodrag Filipovic, MD*

*Department of Anesthesia, University Clinics Basel, Kantonsspital, CH-4031 Basel, Switzerland; {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California

Anesth Analg 2004 99: 1723-1727.

 

吸入麻醉的最低肺泡有效浓度(MAC)麻醉时,50%受试者对伤害性刺激可做出逃避反应。清醒MAC麻醉时,50%的受试者对指令可做出适当的反应。脑双频指数(BIS)通常测定麻醉药对清醒或意识状态的影响。作者假设在不同的MAC水平下,应用高倍率的清醒MAC / MAC的氟烷比七氟醚所得的BIS值更高。33名未使用术前用药的患者进行吸入麻醉实验,18个应用七氟醚,15个使用氟烷。在麻醉浓度1MAC前后、插管前后(以芬太尼和罗库溴铵辅助诱导)及吸入浓度1.5MAC时分别测试BIS。在达到稳态后继续测量BIS。本次实验的所有受试者都不接受外科手术。清醒患者七氟醚和氟烷组间BIS值无明显差异(962962)。在吸入1MAC(使用或不使用神经肌肉阻滞剂)和1.5MAC氟烷时患者BIS值(547567497)较吸入七氟醚的患者BIS值(346346295)高(P<0.0001)。这一发现与其它一些证据显示BIS有药物特异性。

(朱慧琛 译 陈杰 校)

At the minimum alveolar concentration (MAC) of inhaled anesthetics, 50% of subjects move in response to noxious stimulation. Similarly, at MAC-awake, 50% of subjects respond appropriately to command. The bispectral index (BIS) nominally measures the effect of anesthetics on wakefulness or consciousness. We postulated that the use of halothane with a larger MAC-awake/MAC ratio than sevoflurane would produce higher BIS values at comparable levels of MAC. We studied 33 unpremedicated patients anesthetized by inhalation, 18 with sevoflurane and 15 with halothane. We measured BIS before and during anesthesia at 1 MAC, both before and after tracheal intubation facilitated by fentanyl and rocuronium and then at 1.5 MAC. BIS measurements were made after meeting steady-state conditions. No surgery was performed during this study. BIS values in awake patients did not differ between the sevoflurane and halothane groups (96 ± 2 and 96 ± 2, mean ± SD, respectively). At 1 MAC without and with neuromuscular blockade and at 1.5 MAC, BIS values for patients anesthetized with halothane (54 ± 7, 56 ± 7, and 49 ± 7, respectively) exceeded those for patients anesthetized with sevoflurane (34 ± 6, 34 ± 6, and 29 ± 5, respectively) (P < 0.0001). This finding adds to other evidence indicating that BIS is drug specific.

 

利用凝胶涂层的水循环床垫进行热交换

Conductive Heat Exchange with a Gel-Coated Circulating Water Mattress

Anselm Bräuer, MD, DEAA*, Larissa Pacholik*, Thorsten Perl, MD*, Michael John Murray English, FRCA{dagger}, Wolfgang Weyland, MD, PhD, DEAA{ddagger}, and Ulrich Braun, MD, PhD*

*Department of Anesthesiology, Emergency and Intensive Care Medicine, Georg-August-University of Göttingen, Göttingen, Germany; {dagger}Department of Anaesthesia, Montreal General Hospital and McGill University, Montreal, Canada; and {ddagger}Department of Anaesthesia and Intensive Care Medicine, Evangelisches Bethesda-Krankenhaus, Essen, Germany

Anesth Analg 2004 99: 1742-1746

 

使用一次性毯子作为气体取暖存在费用问题,而作为改良方法,作者选择八十名健康志愿者利用可重复使用的凝胶涂层的水循环床垫放在其背下研究其热转换情况。通过六个热量传感器测量热量并测量床垫温度,皮肤温度和中心温度。水温分别设置为25℃30℃35℃41℃。热转换量等于热量乘以接触面积。利用床垫温度,皮肤温度和热量来确定传导中的热交换系数。热量和水温关系如下:热量=10.3×水温-374r2=0.98)。热传导的热交换系数是121W·m-2·℃-1。凝胶涂层的水循环床垫最大的热交换量是18.4±3.3W。由于凝胶涂层的水循环床垫对人体热平衡作用较小,它仅用于背部而不能替代气体取暖系统。

(朱辉 陈杰 校)

The use of forced-air warming is associated with costs for the disposable blankets. As an alternative method, we studied heat transfer with a reusable gel-coated circulating water mattress placed under the back in eight healthy volunteers. Heat flux was measured with six calibrated heat flux transducers. Additionally, mattress temperature, skin temperature, and core temperature were measured. Water temperature was set to 25°C, 30°C, 35°C, and 41°C. Heat transfer was calculated by multiplying heat flux by contact area. Mattress temperature, skin temperature, and heat flux were used to determine the heat exchange coefficient for conduction. Heat flux and water temperature were related by the following equation: heat flux = 10.3 x water temperature – 374 (r2 = 0.98). The heat exchange coefficient for conduction was 121 W · m–2 · °C–1. The maximal heat transfer with the gel-coated circulating water mattress was 18.4 ± 3.3 W. Because of the small effect on the heat balance of the body, a gel-coated circulating water mattress placed only on the back cannot replace a forced-air warming system.

 

困难气道风险因素的评估:一项1956名意大利患者的调查

Risk Factors Assessment of the Difficult Airway: An Italian Survey of 1956 Patients

D. Cattano, MD*, E. Panicucci, StD{dagger}, A. Paolicchi, MD*, F. Forfori, MD*, F. Giunta, MD*, and C. Hagberg, MD{ddagger}

*Department of Surgery, Anaesthesia and Intensive Care Division, Spedali Riuniti S. Chiara, University of Pisa, Pisa, Italy; {dagger}Department of Human and Environmental Sciences, University of Pisa, Pisa, Italy; and {ddagger}Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas

Anesth Analg 2004 99: 1774-1779.

 

在过去的十年里,发表的关于识别和预计困难气道的文献不断增加且认识程度不断增强。术前的气道评估时,必须彻底了解气道有关的病史和详细的体格检查。各种解剖特征的评估方法和无创临床测试可增强对气道的评价。在这项研究中,作者将Mallampati改良评分和其他与喉镜下观察到的困难气道的解剖和临床风险因素的指数作比较。作者连续收集了1956名选择性手术需气管插管实施全身麻醉的患者的数据。Mallampati分级与Cormack-LehaneC-L)线性相关指数是0.904Mallampati3级与C-L2级相关(0.94),而Mallampati 4级与C-L3级相关(0.85)与C-L4级相关(0.80)。通过简单的气管插管由操作者评估其困难程度与C-L组呈线性关系(0.96)。尽管口咽体积与困难插管相关,但Mallampati评分本身预计困难气管插管并不充足。

(朱辉 陈杰 校)

Over the last decade, there has been a heightened awareness and an increase in the amount of literature being published on recognition and prediction of the difficult airway. During the preoperative evaluation of the airway, a thorough history and physical specifically related to the airway should be performed. Various measurements of anatomic features and noninvasive clinical tests can be performed to enhance this assessment. In this study we correlated the Mallampati modified score and several other indexes with the laryngoscopic view to identify anatomical and clinical risk factors related to the difficult airway. We prospectively collected data on 1956 consecutive patients scheduled to receive general anesthesia requiring endotracheal intubation for elective surgery. The Mallampati classification versus the Cormack-Lehane (C-L) linear correlation index was 0.904. A Mallampati Class 3 correlated with a C-L Grade 2 (0.94), whereas a Mallampati Class 4 correlated with a C-L Grade 3 (0.85) and a C-L Grade 4 (0.80). Operator evaluation, performed by a simplified tracheal intubation difficulty scale, showed a linear correlation of 0.96 compared with the C-L groups. Although there is a correlation between oropharyngeal volume and difficult intubation, the Mallampati score by itself is insufficient for predicting difficult endotracheal intubation.

 

一种使用血栓弹力图评价Eptifibatide对血小板抑制的新方法

A Novel Method to Assess Platelet Inhibition by Eptifibatide with Thrombelastograph®

Nobuyuki Katori, MD, Fania Szlam, MMSc, Jerrold H. Levy, MD, and Kenichi A. Tanaka, MD

Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia

Anesth Analg 2004 99: 1794-1799.

 

本文作者研究使用血栓弹力图检测血小板抑制的新方法。作者假设这种方法适合监测依替巴肽(抗血栓药)的抗血小板效应。采集健康志愿者的全血,使用3.2%柠檬酸或未分馏肝素(7 IU/mL)抗凝。所有柠檬酸和肝素化样本均使用浓度逐渐提高的依替巴肽(00.20.40.81.64µg/mL)处理后进行血小板聚集试验。两种样本使用浓度分别为00.20.40.81.64824µg/mL 的依替巴肽处理后,柠檬酸样本使用传统的高岭土TEG方法,肝素化样本使用巴曲酶改良 TEG方法测试。依替巴肽浓度为4µg/mL 5’-二磷酸腺苷诱导的血小板聚集降低到6.4%±2.9%(柠檬酸)和10.3%±4.8%(肝素)。高岭土 TEG方法显示只有在依替巴肽浓度为24µg/mL 时最大振幅(MA)才有所降低,α角度没有变化。然而使用巴曲酶改良TEG方法在依替巴肽浓度≥0.8µg/mL时就可以观察到MAα角度的变化。此外,巴曲酶改良TEG方法达到最大MA的时间要短于高岭土 TEG方法。结论:巴曲酶改良TEG是一种监测依替巴肽导致血小板抑制的灵敏方法。

(殷文渊 陈杰 校)

We examined a novel method to detect platelet inhibition with thrombelastography (TEG®). We hypothesized that this method would be suitable for monitoring the antiplatelet effects of eptifibatide (Integrilin®). Whole blood from healthy volunteers was anticoagulated with 3.2% citrate or unfractionated heparin (7 IU/mL). For the platelet aggregation test, both citrate and heparinized samples were spiked with increasing concentrations of eptifibatide (0, 0.2, 0.4, 0.8, 1.6, and 4 µg/mL). Conventional kaolin TEG® was performed with citrated samples, and batroxobin-modified TEG® was performed with heparinized samples, which were spiked with eptifibatide at concentrations of 0, 0.4, 0.8, 1.6, 4, 8, and 24 µg/mL. Adenosine 5'-diphosphate-induced platelet aggregation was reduced to 6.4% ± 2.9% (citrate) and 10.3% ± 4.8% (heparin) with eptifibatide at the concentration of 4 µg/mL. The kaolin TEG® showed a decrease in maximum amplitude (MA) only at the eptifibatide concentration of 24 µg/mL and no change in {alpha}angle, whereas with the batroxobin-based TEG®, the difference in MA and {alpha}angle was observed at concentrations ≥0.8 µg/mL. Additionally, the time to achieve maximum MA was much shorter for batroxobin TEG® than for kaolin TEG®. We conclude that the batroxobin-modified TEG® is a sensitive method that detects platelet inhibition induced by eptifibatide.

 

氟烷浓度提高速度和接头数量对大鼠氟烷最小肺泡麻醉浓度测定的影响

Determining Minimum Alveolar Anesthetic Concentration of Halothane in Rats: The Effect of Incremental Change in Halothane Concentration and Number of Crossovers

Avner Leon, MD*,{dagger}, Olga Mayzler, MD{dagger},{ddagger}, Mony Benifla, MD{dagger},§, Michael Semionov, MD*, Yulia Fuxman, MD||, Israel Eilig, MD*, Vadim Passuga, MD*, Maryana K. Doitchinova, MD*, Boris Gurevich, MD*, Alan A. Artru, MD, and Yoram Shapira, MD, PhD*

*Division of Anesthesiology, {ddagger}Department of Surgery, and §Department of Neurosurgery, Soroka Medical Center, Beer Sheva, Israel; {dagger}Faculty of Health Science, Ben-Gurion University of the Negev, Beer Sheva, Israel; ||Department of Surgery, Barzilay Medical Center, Askelon, Israel; and ¶Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington

Anesth Analg 2004 99: 1822-1828.

 

计算机模拟评估病人最小肺泡麻醉浓度(MAC)技术提示氟烷浓度和接头数量增加会影响MAC。作者假设这些变化也符合大鼠MAC的测定。本研究测试了这个假设,同时将预期MAC不同的动物分为几组(怀孕[P]和不怀孕[NP]),评估这些变化是否由于不同组间的MAC差异引起。大鼠分为两群(n=27n=30)。每群包含未怀孕雌鼠,早孕雌鼠和怀孕晚期雌鼠。第一群每次变化0.20%逐渐提升浓度且使用一个接头,第二群提升幅度为0.10%且使用四个接头,然后测试MAC。第二群三组的MAC数值与第一群三组在统计学上有显著提高。每群组间的数值没有差别。结果显示36%的组间差别是由于提升幅度也就是试验因素导致的。作者的发现证实这样假设,即MAC研究中麻醉药物浓度上升速度和幅度会影响MAC的评估。

(殷文渊 陈杰 校)

Computer simulations for the technique of estimating minimum alveolar anesthetic concentration (MAC) in patients (quantal design) suggest that incremental concentration changes and the number of crossovers affect MAC. We hypothesized that these variables may also apply to estimating MAC in rats (bracketing design). This study tested that hypothesis and also examined whether these variables might mask differences in MAC between groups in which MAC might be expected to differ (pregnant [P] versus nonpregnant [NP]). There were 2 cohorts (n = 27 and n = 30 rats). Each cohort included NP females, females in early P, and females in late P. MAC was tested by using an incremental concentration change of 0.20% and one within-subject crossover in the first cohort and by using an increment size of 0.10% and four crossovers in the second cohort. MAC was statistically significantly increased in the three groups in the second cohort (NP, 1.16 ± 0.12; early P, 1.14 ± 0.10; late P, 1.07 ± 0.10; mean ± SD) compared with values in the three comparable groups in the first cohort (NP, 0.95 ± 0.06; early P, 1.01 ± 0.09; late P, 0.93 ± 0.13). Values did not differ among groups within each cohort. Post hoc simulations indicated that up to 36% of the difference between cohorts was due to increment size, with the balance due to experimental factors. Our findings confirmed the hypothesis that increment size affects estimates of MAC when a bracketing design is used.

 

全麻前单次椎旁阻滞可增强乳癌手术是否拌有淋巴结活检后的镇痛效果

Single-Injection Paravertebral Block Before General Anesthesia Enhances Analgesia After Breast Cancer Surgery With and Without Associated Lymph Node Biopsy

Pekka M. Kairaluoma, MD*, Martina S. Bachmann, MD, PhD*, Aulikki K. Korpinen, MD{dagger}, Per H. Rosenberg, MD, PhD*, and Pertti J. Pere, MD, PhD*

*Department of Anesthesia and Intensive Care Medicine, Helsinki University Hospital, Helsinki, Finland; and {dagger}Rheumatism Foundation Hospital, Heinola, Finland

Anesth Analg 2004 99: 1837-1843.

 

椎旁阻滞(PVB),可以减少乳癌术后疼痛和术后恶心呕吐(PONV)的发生,但在研究中,没有设置安慰剂对照。作者随机、双盲研究了60例乳癌病人,分为2组,分别在全麻前行T3椎旁阻滞,组0.5%布比卡因(1.5mg/kg),组为生理盐水对照组。PVB或假阻滞由不参与研究的麻醉科医生单独操作。结果:在麻醉后恢复室内,组患者的静脉阿片类药物的用量比组40%,第一次使用阿片药物的时间比组晚,24h后疼痛的缓解优于组P<0.01)。此外,组术后的恶心呕吐的发生少于组;术后90min的镇静情况,组优于组P<0.05)。在90min内的数字符号置换试验和术后120min内眼部的协调能力,组优于组P<0.05)。血浆内平均布比卡因峰值浓度为750ng/ml。一个病人在注射布比卡因后立刻发生双侧抽搐。作者认为在全麻前单次椎旁阻滞均可增强乳癌术后的镇痛效果,减少阿片药物用量,降低术后恶心呕吐的发生,并且改善麻醉的恢复情况。

(顾漪闻 陈杰 校)

Paravertebral block (PVB) seems to decrease postoperative pain and postoperative nausea and vomiting (PONV) after breast surgery, but the studies have not been placebo controlled. We studied 60 patients scheduled for breast cancer surgery randomly given single-injection PVB at T3 with bupivacaine 5 mg/mL (1.5 mg/kg) or saline before general anesthesia. The patient and attending investigators were blinded; the PVB or the sham block was performed behind a curtain by an anesthesiologist not involved in the study. The patients given PVB with bupivacaine needed 40% less IV opioid medication (primary outcome variable) in the postanesthesia care unit, had a longer latency to the first opioid dose, and had less pain at rest after 24 h than the control patients (P < 0.01). They also had less PONV in the postanesthesia care unit (P < 0.05), were less sedated until 90 min (P < 0.05), and performed better in the digit symbol substitution test at 90 min and the ocular coordination test 60–120 min after surgery (P < 0.05). The average peak bupivacaine plasma concentration was 750 ng/mL. One patient had bilateral convulsions immediately after bupivacaine injection. We conclude that PVB before general anesthesia for breast cancer surgery reduced postoperative pain, opioid consumption, and occurrence of PONV and improved recovery from anesthesia.

 

腹腔镜胆囊切除术期间醋酸林格氏液容量动力学

The Volume Kinetics of Acetated Ringer’s Solution During Laparoscopic Cholecystectomy

Joel Olsson, MD, PhD*, Christer H. Svensén, MD, PhD*, and Robert G. Hahn, MD, PhD{dagger}

*Department of Anesthesiology, University of Texas Medical Branch, Galveston; and {dagger}Department of Anesthesiology, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2004 99: 1854-1860

.

作者选择了12例女性病人,行腹腔镜胆囊切除术,研究静脉注射醋酸林格氏液20ml/kg(约为1500ml60min的分布和清除情况。虽然限制液体,但是在全麻诱导期间,血浆稀释率为4.2%。由于随后的容量扩张所造成额外的血浆稀释要比原来所预期的数据稍高,平均为18%,原来的预期数据则来自于志愿者试验。利尿剂对静脉内注射液体的反应很小,在4h后的中仅仅为20%。容量动力学分析显示:IV液体扩张了身体中央体腔3.2L。分布和清除常数分别为115ml/min6.8ml/min。这数据说明病人的液体半衰期(4.5h)要比血浆稀释(16min)长17倍,这就会造成周围组织的水肿趋势。以容量动力学为基础的列线图显示注射液体的速率在手术早期应该较快,但是在后期应该减慢。这一策略可产生稳定的期望血液稀释水平而不导致不恰当外周液体积聚。

(顾漪闻 陈杰 校)

We studied the distribution and elimination of an IV infusion of 20 mL/kg of acetated Ringer’s solution (approximately 1500 mL) over 60 min in 12 women undergoing laparoscopic cholecystectomy. A plasma dilution of 4.2% developed during the induction of general anesthesia, even though fluid was withheld. The additional plasma dilution induced by the subsequent volume expansion was slightly larger than expected from previous volunteer experiments and averaged 18%. The diuretic response to intravascular fluid administration was small, and only 20% of the infused fluid had been excreted 4 h later. Volume kinetic analysis showed that the IV fluid expanded a central body fluid space by 3.2 L. The clearance constants for distribution and elimination averaged 115 mL/min and 6.8 mL/min, respectively. These data represent a half-life of the fluid in the patients that is 17 times longer (median, 4.5 h) than the half-life of the plasma dilution (16 min), indicating a strong tendency to the formation of peripheral edema. A nomogram based on the kinetic variables suggests that infusion rates should be relatively rapid early on during surgery but slower later. This strategy creates a constant plasma dilution at any desired level without causing undue peripheral accumulation of fluid.

 

评价部分CO2重吸收无创监测儿童CO的价值

An Evaluation of a Noninvasive Cardiac Output Measurement Using Partial Carbon Dioxide Rebreathing in Children

Richard J. Levy, MD*, Rosetta M. Chiavacci, BSN*, Susan C. Nicolson, MD*, Jonathan J. Rome, MD{dagger}, Richard J. Lin, MD*, Mark A. Helfaer, MD*, and Vinay M. Nadkarni, MD*

*Department of Anesthesiology and Critical Care Medicine; and {dagger}Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania

Anesth Analg 2004;99:1642-1647

心排量(CO)是血流动力学监测的重要指标,有助于指导危重病人的治疗。因有创监测CO的危险性,一般不用于婴幼儿。通过部分重吸收,建立在二氧化碳Fick原理上的无创CO监测,近来开始应用。但没有验证在儿童中的准确性。这是前瞻性的观察性研究。对象为37位、年龄小于12岁、行心导管检查的患者。麻醉方式为气管内插管、导管无漏气。麻醉后用热稀释法测定CO 并与无创测得的结果比较。用Bland-Altman 图和线性回归对成对数据进行系统误差、精确性和相关性分析。无创检查结果与热稀释法CO的结果具有线性相关性,r 值为0.83(P < 0.03)Bland-Altman分析误差为–0.27 L/min,精确性为±1.49 L/min。心排指数显示r 值降低,为0.67 (P = 0.15),误差为–0.18 L · min–1 · m–2。精确性为±2.13 L · min–1 · m–2.在体表面积 ≤ 0.6 m2 ,潮气量 <300 mL的儿童中,部分重吸收数据与热稀释法数据差别最大。根据以上发现,部分重吸收这种无创方法监测的CO,可用于体表面积 > 0.6 m2 且潮气量 > 300 mL 的儿童。

(葛宁花译 薛张纲校)

Cardiac output (CO) is an important hemodynamic measure that helps to guide the therapy of critically ill patients. Invasive CO assessment in infants and children is often avoided because of the inherent risks. A noninvasive CO monitor that uses partial rebreathing has been recently developed to determine CO via the Fick principle for carbon dioxide. There have been no clinical studies confirming its accuracy in pediatric patients. This is a prospective observational study of 37 children <12 yr of age who underwent cardiac catheterization. Under general anesthesia via an endotracheal tube without a leak, we made multiple CO measurements using thermodilution and compared them with noninvasively determined CO measurements. Paired measurements were analyzed for bias, precision, and correlation via Bland-Altman plot and linear regression. Noninvasive measurements showed a linear correlation with thermodilution CO assessment with an r value of 0.83 (P < 0.03). Bland-Altman analysis yielded a bias of –0.27 L/min and a precision ±1.49 L/min. Cardiac index measurements demonstrated a decreased r value of 0.67 (P = 0.15) and a bias of –0.18 L · min–1 · m–2 and precision of ±2.13 L · min–1 · m–2. Differences between partial rebreathing measurements and thermodilution measurements were largest in children with a body surface area of ≤0.6 m2 ventilated with tidal volumes <300 mL. Based on these findings, noninvasive CO measurement using partial rebreathing may be clinically acceptable in children with >0.6 m2 body surface area and >300 mL tidal volume.

比较高渗布比卡因腰麻和地氟醚全麻在门诊膝关节镜检查中的应用

A Comparison of Selective Spinal Anesthesia with Hyperbaric Bupivacaine and General Anesthesia with Desflurane for Outpatient Knee Arthroscopy

Anna-Maija Korhonen, MD*,{dagger}, Jukka V. Valanne, MD, PhD*, Ritva M. Jokela, MD, PhD{dagger}, Pirjo Ravaska, MD*, and Kari T. Korttila, MD, PhD, FRCA{dagger}

*Department of Anaesthesia, Lapland Central Hospital, Rovaniemi, Finland; {dagger}Department of Anaesthesia and Intensive Care, University of Helsinki, Helsinki, Finland.

Anesth Analg 2004;99:1668-1673

在这随机对照研究中,64位门诊膝关节检查患者,分为选择性高渗布比卡因4 mg腰麻组(SSA)或地氟醚全麻组(GA)。我们旨在证实小剂量布比卡因是否同样能够提供快通道麻醉、在麻醉苏醒室内观察时间短、离院快。全麻后恶心、呕吐达到高危患者作预防性处理。两组患者快通道可能性或停留在术后麻醉监护室内的时间无差异,离院回家的时间SSA组和GA组分别为114 (31–174) 129 (28–245) min。在医院内,SSA组疼痛评分明显低于GA(P < 0.001)GA组需要更多的阿片类镇痛药(P = 0.008)。术后恶心呕吐的发生率SSA组为0%,而GA组为19% (P = 0.024)。我们的结论:门诊膝关节镜检查的麻醉方法,与地氟醚全麻比较,用高渗布比卡因同样能使患者迅速恢复且副作用少。

(葛宁花译 薛张纲校)

In this randomized and controlled trial, 64 adult ambulatory knee arthroscopy patients received either selective spinal anesthesia (SSA) with 4 mg of hyperbaric bupivacaine or general anesthesia (GA) with desflurane. We conducted the study to determine whether SSA with small-dose bupivacaine provides equal fast-tracking possibilities, a shorter stay in the postanesthesia care unit, and earlier discharge home compared with GA with desflurane. Patients with a high risk for postoperative nausea and vomiting received prophylaxis in the GA group. No difference was seen in the fast-tracking possibilities or time in the postanesthesia care unit between the groups. Home readiness was achieved after 114 (31–174) and 129 (28–245) min (NS) in the SSA and GA groups, respectively. In the hospital, the pain scores were significantly (P < 0.001) lower in the SSA group compared with the GA group and the need for postoperative opioids was significantly (P = 0.008) larger after GA. The incidence of postoperative nausea and vomiting was 0% versus 19% in the SSA and GA groups (P = 0.024), respectively. We conclude that for outpatients undergoing knee arthroscopy, SSA with hyperbaric bupivacaine provides equal recovery times with less frequent side effects compared with GA with desflurane.

 

 

 

 

硬膜外布比卡因阻滞对异丙酚诱导与维持和维持剂量芬太尼与维库溴胺的影响

The Effect of Epidural Bupivacaine on Induction and Maintenance Doses of Propofol (Evaluated by Bispectral Index) and Maintenance Doses of Fentanyl and Vecuronium

Anil Agarwal, MD*, Ravindra Pandey, MD*, Sanjay Dhiraaj, MD*, Prabhat K. Singh, MD*, Mehdi Raza, MD*, Chandra K. Pandey, MD*, Devendra Gupta, MD*, Arindam Choudhury, MBBS*, and Uttam Singh, PhD{dagger}

Departments of *Anesthesia and {dagger}Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2004;99:1684-1688


对局部麻醉和全身麻醉联合应用的越来越浓厚的兴趣 ,引导出一系列研究,研究全身麻醉与局部麻醉如腰麻、硬膜外阻滞、静脉或肌肉等途径联合应用时相互之间的作用。但是,局部麻醉剂同时对平衡麻醉意识丧失、镇痛、肌松这三要素的作用尚无研究。在这前瞻性、随机性和双盲研究中,我们探讨布比卡因硬膜外阻滞对全麻时异丙酚(监测双频指数BIS)、芬太尼、维库溴胺剂量的影响。这一研究,包括30位成年患有壶腹部周围癌的患者,ASA I II,行胰十二指肠切除的Whipple’s手术,手术时间 > 4 h。硬膜外导管放置在T9-10。按双盲原则,在硬膜外导管内注入负荷剂量的研究的药物10ml,然后连续注入6 mL/h。患者分成两组,每组15例。对照组硬膜外导管内注入生理盐水,实验组为0.1%布比卡因。全麻诱导为静脉注射芬太尼2 µg/kg,并根据BIS值推注异丙酚,直到BIS40-50。静脉注射维库溴胺0.1 mg/kg后行气管插管,吸入66%的笑气。插管后,滴注异丙酚,维持BIS40-50。如果收缩压和/或心率增加至基础值20%以上,认为镇痛不完善,一次性追加芬太尼0.5 µg/kg。监测肌松作用,以决定是否增加维库溴胺。用Student’s t-检验对数据进行统计处理, P ≤0.05为差异有显著性。布比卡因组,诱导和维持所需的异丙酚分别为1.3 ± 0.3 mg/kg 2.4 ± 0.9 mg · kg–1 · h–1,而对照组则分别为2.4 ± 0.6 mg/kg 4.4 ± 1.6 mg · kg–1 · h–1 (P < 0.05)。全麻维持时,布比卡因组维库溴胺和芬太尼的量显著性减少(P < 0.05)。结论,全麻诱导前在硬膜外导管内注入一定剂量的布比卡因,能减少全麻时异丙酚、芬太尼和维库溴胺的剂量。

(葛宁花译 薛张纲校)

The growing interest in combining local and general anesthesia has led to studies investigating possible interactions between general anesthesia and local anesthetics administered via spinal, epidural, IV, or IM routes. However, no study has evaluated the effect of local anesthetics on all three components of balanced anesthesia, i.e., hypnosis, analgesia, and muscle relaxation. In this prospective, randomized, double-blind study, we investigated the effect of epidural bupivacaine on the dose requirement of propofol (as evaluated by using the bispectral index [BIS]), fentanyl, and vecuronium for general anesthesia. This study consisted of 30 adults, ASA physical status I and II, undergoing Whipple’s pancreaticoduodenectomy for periampullary carcinoma lasting >4 h. An epidural catheter was placed between T9-10. Depending on the group allocation, 10 mL of the study drug was administered as a bolus followed by an infusion at 6 mL/h via the epidural catheter. Patients were divided into 2 groups of 15 each. Patients in the control group received epidural normal saline whereas those in the bupivacaine group received epidural bupivacaine 0.1%. Induction of anesthesia was performed with IV fentanyl 2 µg/kg and propofol titrated to achieve BIS between 40–50. Endotracheal intubation was facilitated by the IV administration of vecuronium 0.1 mg/kg and patient’s lungs were ventilated with 66% nitrous oxide in oxygen. After intubation, infusion of propofol 1% was titrated to maintain BIS between 40–50. Inadequate analgesia was defined as an increase in systolic blood pressure and/or heart rate by >20% of baseline values in response to surgical stimulus and was treated with bolus fentanyl 0.5 µg/kg. Neuromuscular monitoring was used to assess the need for additional doses of vecuronium. Data were analyzed by using the Student’s t-test and P ≤0.05 was considered significant. The requirement of propofol for induction and maintenance of anesthesia in the bupivacaine group was 1.3 ± 0.3 mg/kg and 2.4 ± 0.9 mg · kg–1 · h–1, respectively, compared with 2.4 ± 0.6 mg/kg and 4.4 ± 1.6 mg · kg–1 · h–1 observed in the control group (P < 0.05). Significant reduction was also observed in the requirement of vecuronium and fentanyl during maintenance in the bupivacaine group (P < 0.05). We conclude that epidural bupivacaine given before induction of anesthesia reduces the requirement of propofol, fentanyl, and vecuronium during general anesthesia.

 

注射部位的疼痛:注射异丙酚前注射利多卡因或用异丙酚甘油三酸脂中长链剂型的对照双盲研究

Pain on Injection: A Double-Blind Comparison of Propofol with Lidocaine Pretreatment Versus Propofol Formulated with Long- and Medium-Chain Triglycerides

E. Schaub, C. Kern, and R. Landau

Service d’Anesthésiologie, Département d’Anesthésiologie, Pharmacologie et Soins Intensifs de Chirurgie (APSIC), Hôpitaux Universitaires de Genčve, Switzerland

Anesth Analg 2004;99:1699-1702

 

据研究报道,注射异丙酚时,疼痛的发生率为70%。用甘油三酸脂中长链(LCT/MCT)制成的新型105乳剂的异丙酚,能减轻注射部位的疼痛。我们旨在比较用异丙酚LCT/MCT剂型或注射前先注入40 mg 利多卡因的Bier’阻滞法对疼痛的影响。200位健康女性进行门诊妇科时,进入两组中的任何一组。LIDO组给予1%的异丙酚2 mg/kg前,静脉注射2%利多卡因2 mL,并使用止血带1分钟;LCT/MCT组在给予1%异丙酚-LCT/MCT 2 mg/kg,静脉注射0.9%盐水2 mL,同样使用止血带1分钟。记录注射时研究对象是否说痛、手动、皱眉和呻吟等表现。在术后30分钟和1小时,评估疼痛的发生率和严重程度。如视觉模糊平分发(VAS >1,回顾性疼痛成立。VAS的范围为0-10分。许多女性在注射异丙酚-LCT/MCT时说痛(发生率为47%,对照组 24%; P = 0.0014; 相关危险性 1.61 [95% 自信区域, 1.22–2.13]);在有注射疼痛的女性中,术后疼痛的程度或回顾性疼痛无差异。与以往研究报道不同的是,注射异丙酚-LCT/MCT疼痛的发生率比用利多卡因预处理再注射1%异丙酚疼痛的发生率高。这可能与在研究时对疼痛的不同定义,或者与我们没有使用术前药有关。

(葛宁花译 薛张纲校)

The incidence of pain on injection of propofol has been reported to be 70%. A new propofol formulation with a 10% emulsion of long- and medium-chain triglycerides (LCT/MCT) is associated with less pain on injection. Our goal was to compare the effect of propofol-LCT/MCT on the incidence of pain versus propofol with lidocaine 40 mg IV pretreatment injected as a Bier’s block. Two hundred healthy women scheduled for ambulatory gynecological procedures were allocated to 1 of 2 groups in a randomized double-blind fashion. Group LIDO received lidocaine 2% 2 mL injected with a tourniquet 1 min before propofol 1% 2 mg/kg IV; group LCT/MCT received NaCl 0.9% 2 mL with tourniquet 1 min before propofol-LCT/MCT 1% 2 mg/kg IV. Spontaneous verbal expressions of pain, movement of hand, frowning, and moaning during the injection were recorded. The incidence and severity of pain were assessed 30 min and 6 h after surgery. Recall of pain was considered with a visual analog scale (VAS) score >1, and pain was graded as VAS 0–10. More women reported spontaneous verbal expression of pain with propofol-LCT/MCT (47% versus 24%; P = 0.0014; relative risk 1.61 [95% confidence interval, 1.22–2.13]). Among women with a painful injection, there was no difference after surgery regarding the intensity of pain or recall of pain. In contrast to previous reports, we found that propofol-LCT/MCT resulted in a more frequent incidence of pain than propofol 1% with IV lidocaine pretreatment. This may be due to the diversity of pain definitions used in studies or to the lack of premedication in our study.

 

 

 

临床浓度吸入麻醉药对人体K通道TRESK串联孔区的强大激活作用

 

Potent Activation of the Human Tandem Pore Domain K Channel TRESK with Clinical Concentrations of Volatile Anesthetics

Canhui Liu, PhD, John D. Au, BS, Hilary Liao Zou, MD, Joseph F. Cotten, MD, PhD, and C. Spencer Yost, MD

Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California

Anesth Analg 2004;99:1715-1722

 

K通道家族串联孔区调节着存在在兴奋细胞的背景K电流。通过家族某些细胞的电流被吸入麻醉药增强,因而认为是麻醉的机理。家族最新成员TRESK对麻醉的敏感性尚无研究。我们从人体脊髓RNA分离TRESK的基因序列,将它表达在非洲蟾蜍的卵母细胞中,并使COS-7细胞感染。在吸入临床浓度的异氟醚、氟烷、七氟醚和地氟醚时,用整个细胞的压力钳和补丁钳记录,发现TRESK电流可以增加三倍以上。非麻醉剂对TRESK无作用。各种静脉麻醉剂,包括依托米酯、硫贲妥钠和异丙酚对TRESK的电流作用较小。氨基类和酯类局麻药抑制TRESK,并呈浓度依赖型,但是浓度足够大时,抑制其他K通道的串联孔区。我们同样发现,TRESK不仅存在在脊髓,而且存在在人体大脑的RNA。这些结果说明TRESK是吸入麻醉药的靶目标,提示这种背景K通道在调节吸入麻醉药对中枢神经系统的作用时起到一定的作用。

(葛宁花译 薛张纲校)

The tandem pore domain K channel family mediates background K currents present in excitable cells. Currents passed by certain members of the family are enhanced by volatile anesthetics, thus suggesting a novel mechanism of anesthesia. The newest member of the family, termed TRESK (TWIK [tandem pore domain weak inward rectifying channel]-related spinal cord K channel), has not been studied for anesthetic sensitivity. We isolated the coding sequence for TRESK from human spinal cord RNA and functionally expressed it in Xenopus oocytes and transfected COS-7 cells. With both whole-cell voltage-clamp and patch-clamp recording, TRESK currents increased up to three-fold by clinical concentrations of isoflurane, halothane, sevoflurane, and desflurane. Nonanesthetics (nonimmobilizers) had no effect on TRESK. Various IV anesthetics, including etomidate, thiopental, and propofol, have a minimal effect on TRESK currents. Amide and ester local anesthetics inhibit TRESK in a concentration-dependent manner but at concentrations generally larger than those that inhibit other tandem pore domain K channels. We also determined that TRESK is found not only in spinal cord, but also in human brain RNA. These results identify TRESK as a target of volatile anesthetics and suggest a role for this background K channel in mediating the effects of inhaled anesthetics in the central nervous system.

 

用高保真的模拟病人来介绍新的麻醉装备

The Use of High-Fidelity Human Patient Simulation and the Introduction of New Anesthesia Delivery Systems

Paul Dalley, MbChB*, Brian Robinson, PhD{dagger}, Jennifer Weller, MClinEd, FANZCA{ddagger}, and Catherine Caldwell, MbBCh, FANZCA*

*Department of Anaesthesia and Pain Manaement, Wellington Hospital, {dagger}National Patient Simulation Training Centre, Wellington Hospital, and {ddagger}Wellington School of Medicine and Health Sciences, University of Otago, Wellington, New Zealand

Anesth Analg 2004;99:1737-1741

 

新的麻醉机系统越来越复扎。尽管麻醉装备包含大部分术中麻醉问题(大多数包括人为的错误),但是如何将新装备介绍至临床的应用,尚无研究。我们设计了随机、对照、前瞻性的研究,以调查介绍麻醉新装备的不同方法。15位麻醉医生接受培训。他们随机分配至常规介绍Dräger Fabius GS麻醉机组,并模拟临床将新装备用于高保真的模拟病人(HPS) ( 1),或者只是常规介绍(2)。我们用提问方法,询问他们对新装备的意见。反馈意见显示两组对安全使用新装备具有可比的自信性。所有的培训者测试如何应对2种模拟的新装备危急情况。他们的能力以解决危急所需的时间为标准,并由非实验组的人员通过观察录象进行分析。组1解决两个危急都迅速,具有显著性。HPS有利于我们发现设计的特点,而这些特点往往是常见错误的来源。

(葛宁花译 薛张纲校)

New anesthesia delivery systems are becoming increasingly complex. Although equipment is involved in a large proportion of intraoperative anesthesia problems (most also involving human error), the current methods of introducing new equipment into clinical practice have not been well studied. We designed a randomized, controlled, prospective study to investigate an alternative method of introducing new anesthesia equipment. Fifteen anesthesiology trainees were randomized to either the standard introduction to a Dräger Fabius GS anesthesia delivery machine plus simulated clinical use of the new machine in a high-fidelity human patient simulator (HPS) (Group 1) or to the standard introduction alone (Group 2). We used a questionnaire to seek their opinion on the new equipment, and responses showed that both groups were comparable in their reported confidence to use the new equipment safely. All trainees were then tested in two simulated anesthetic crises with the new machine. Performance was analyzed in terms of time to resolve the emergency, by using analysis of videos by an independent rater. Group 1 resolved both crises significantly faster. HPS allowed us to detect design features that were common sources of error.

 

 

 

 

 静脉注射氯胺酮试验:预计口服Dextromethorphan对治疗神经性疼痛的效果

The Intravenous Ketamine Test: A Predictive Response Tool for Oral Dextromethorphan Treatment in Neuropathic Pain

Steven P. Cohen, MD*, Audrey S. Chang, PhD{dagger}, Thomas Larkin, MD{ddagger}, and Jianren Mao, MD, PhD§

*Pain Management Centers, Departments of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD and Walter Reed Army Medical Center, Washington, DC; {dagger}Department of Clinical Investigation, Walter Reed Army Medical Center; {ddagger}Departments of Anesthesiology, Walter Reed Army Medical Center and Landstuhl Regional Army Medical Center, Landstuhl, Germany; and §Department of Anaesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2004;99:1753-1759
 

静脉注射试验剂量以预知随后口服镇痛药的效果,这是普遍使用的方法,以增加疗效和保存资源。因为没有一种静脉试验是完全正确的,因此必须评估这种试验潜在的好处、可能出现的异常和因假阳性而造成的资源浪费,或者因假阴性而放弃应用。进年来,有研究表明,N-甲基-D-天冬氨酸受体的拮抗剂是有效的辅助治疗疼痛的药物。为决定小剂量(0.1 mg/kg)氯胺酮预计口服dextromethorphan (DX)治疗剂量的价值,我们分析25位患者服药后对镇痛的反应。试验在2个三级军事治疗中心进行,在这些中心,DX不能轻易得到。两个药物≥50%的反应作为测试结果为成功时,氯胺酮试验阳性阳极预计值为64%,阴性预计值为73%,观察结果一致性为68%。但是,用氯胺酮缓解疼痛≥67%作为测试指标时,阳性预计值为90%,阴性预计值为80%,观察结果一致性为84%。根据以上结果,我们得出结论:静脉注射氯胺酮试验可能对预计口服DX的反应有用。需要作更多的试验,以决定这类试验的理想候选者、合理的剂量和停止氯胺酮后的反应。

(葛宁花译 薛张纲校)

IV infusion tests performed to predict subsequent response to oral analgesics are an increasingly popular method used to enhance medical care and conserve resources. Because no infusion test is completely accurate, the potential benefits of these tests must be weighed against the frustration and waste in resources encountered with false-positive results, and the failure to use a potentially beneficial treatment with false-negative results. In recent years, drugs that act antagonistically at N-methyl-D-aspartate receptors have been shown to be valuable adjuncts in the treatment of pain. To determine the predictive value of small-dose (0.1 mg/kg) IV ketamine on an oral dextromethorphan (DX) treatment regimen, we analyzed the analgesic response to these drugs in 25 patients at 2 tertiary care military treatment facilities, institutions at which DX is not readily accessible. When ≥50% response for both drugs was used as the outcome measure for success, the positive predictive value of the ketamine test was 64%, the negative predictive value 73%, and the observed agreement 68%. However, when ≥67% relief with ketamine was used as an outcome measure (as determined by a receiver operating characteristic curve), the positive predictive value was 90%, the negative predictive value 80%, and the observed agreement increased to 84%. Based on these results, we conclude that an IV ketamine test may be useful in predicting response to oral DX. More research is needed to determine the ideal candidates for such a test, and the optimal dose and cutoff value for the response to ketamine.

 

 

心室纤维颤动时的中位频率可能不是一个有效的监测心脏停止后用Endothelin-1和肾上腺素治疗的指标

Ventricular Fibrillation Median Frequency May Not Be Useful for Monitoring During Cardiac Arrest Treated with Endothelin-1 or Epinephrine

Michael Holzer, MD*, Wilhelm Behringer, MD*, Fritz Sterz, MD*, Julia Kofler, MD*, Elisabeth Oschatz, MD*, Ernst Schuster, PhD{dagger}, and Anton N. Laggner, MD*

Departments of *Emergency Medicine and {dagger}Medical Computer Sciences, University of Vienna, Vienna, Austria

Anesth Analg 2004;99:1787-1793

在这一研究中,我们评价中位纤维颤动的频率(MF)和平均纤维颤动的幅度(AMP)能否反应冠状动脉灌注压(CoPP)和预示除颤的成功率。在实验猪长时间的心室颤动(VF)和复苏过程中,监测MF, AMP CoPPVF 5 分钟后,开始心肺复苏。10分钟后,实验猪随机注入单次剂量endothelin-1 50 µg (n = 7), 100 µg (n = 7), 200 µg (n = 5),或重复肾上腺素0.04 mg/kg (n = 6),或每3分钟注射生理盐水 (n = 6)25分钟后,进行除颤,恢复自主循环系统(ROSC)。用光谱非参数分析单个MFCoPPAMPCoPP曲线时,我们发现在不同实验动物或不同治疗手段时,不同的曲线之间没有联系。除颤后ROSC (n = 8)组和没能ROSC (n = 23)组的MF没有显著性的差异(P = 0.85)。我们的数据提示,在持续性VF心脏停止中,MF AMP不能有效地反应心肌的灌注。

(葛宁花译 薛张纲校)

In this study, we evaluated whether median fibrillation frequency (MF) and mean fibrillation amplitude (AMP) reflect coronary perfusion pressure (CoPP) and predict successful defibrillation. MF, AMP, and CoPP were measured during prolonged ventricular fibrillation (VF) cardiac arrest and resuscitation in pigs. After 5 min of VF, cardiopulmonary resuscitation was started. At 10 min, the pigs received randomly a single dose of endothelin-1 50 µg (n = 7), 100 µg (n = 7), or 200 µg (n = 5), or repeated doses of epinephrine 0.04 mg/kg (n = 6), or saline (n = 6) every 3 min. At 25 min, the pigs were defibrillated to achieve restoration of spontaneous circulation (ROSC). In a nonparametric spectral analysis of the individual MF versus CoPP and AMP versus CoPP curves, we found no link between the different curves in different animals or therapies. No difference was found in MF in pigs with ROSC (n = 8) compared with animals not achieving ROSC (n = 23) immediately before defibrillation (P = 0.85). Our data suggest that, in prolonged VF cardiac arrest, MF and AMP might not be useful tools to reflect myocardial perfusion.

 

 

 

 


用心率变异性以发现产科患者腰麻时的危险性

Using Heart Rate Variability to Stratify Risk of Obstetric Patients Undergoing Spinal Anesthesia

Dmitri Chamchad, MD*, Valerie A. Arkoosh, MD*, Jay C. Horrow, MD, MSstat*, Jodie L. Buxbaum, MD*, Igor Izrailtyan, MD{dagger}, Lev Nakhamchik, MS{dagger}, Dirk Hoyer, PhD{dagger}, and J. Yasha Kresh, PhD{dagger}

Departments of *Anesthesiology and {dagger}Cardiovascular Medicine and Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania

Anesth Analg 2004;99:1818-1821


在这一研究中,我们评价点状相关系数 (PD2),一种监测心脏变异性的方法,能否预示剖腹产腰麻时的低血压。用布比卡因进行腰麻,当蛛网膜下腔注药后20分钟,收缩压低于基础值的≤75%时,认为发生低血压。用腰麻前PD2 (3.90)将实验对象分成两组:LO组和 HI组。所有11位低血压者在LO组,所有11位无低血压者在HI组。LO组的基础心率为95 bpm (10.2 SD)HI组则为81 bpm (9.6 SD) PD2显示能预计孕妇腰麻后的低血压。

(葛宁花译 薛张纲校)

In this study, we evaluated whether point correlation dimension (PD2), a measure of heart rate variability, can predict hypotension accompanying spinal anesthesia for cesarean delivery. After the administration of spinal anesthesia with bupivacaine, hypotension was defined as systolic blood pressure ≤75% of baseline within 20 min of intrathecal injection. Using the median prespinal PD2 (3.90) to form 2 groups, LO and HI, all 11 hypotensive patients were in the LO group, and all 11 patients without hypotension were in the HI group. Baseline heart rate in the LO group was 95 bpm (10.2 SD), versus 81 bpm (9.6 SD) in the HI group. PD2 shows promise as a predictor of hypotension in pregnant women receiving spinal anesthesia.

 


颈部硬膜外麻醉用于颈部和上肢的联合手术:一项引导性研究

Cervical Epidural Anesthesia for Combined Neck and Upper Extremity Procedure: A Pilot Study

Pavel Michalek, MD, PhD*, Ivan David, MD, PhD{dagger}, Milos Adamec, MD, PhD{ddagger}, and Libor Janousek, MD{ddagger}

*Department of Cardiovascular Anesthesia and Intensive Care, Na Homolce Hospital; and Department of {dagger}Anesthesia and Intensive Care and {ddagger}Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic

Anesth Analg 2004;99:1833-1836

在这一前瞻性的引导性研究中,我们评价能否用颈部硬膜外麻醉(CEA)进行甲状旁全切并将它移植至前臂的手术(颈部和上肢的联合手术)。穿刺点在C6-7,局麻药为罗哌卡因。适应症为患者所选,或者曾经因颈部的手术造成单侧的声带麻痹。麻醉药为10 mL0.75% 罗哌卡因加 10 µg 舒芬太尼2 mL。记录阻滞起效时间、成功率、镇痛效果、感觉阻滞的平面、循环和呼吸的改变、并发症和住院天数。15例手术均成功地在CEA麻醉下进行。感觉阻滞平面在C2-T10,最低在T3,所有患者的感觉阻滞上限在C2。呼吸系统唯一有显著性变化的是用力肺活量降低,没有患者出现临床呼吸功能不全的表现。我们的结论,颈部和上肢的联合手术可以用罗哌卡因的CEA麻醉。CEA麻醉可以术中与患者对话,及时发现声带麻痹。

(葛宁花译 薛张纲校)

In a prospective pilot study, we evaluated the possibility of performing a total parathyroidectomy with parathyroid gland implantation into the forearm (a combined neck and upper extremity procedure) under cervical epidural anesthesia (CEA) at C6-7 level using ropivacaine. The indication for CEA was the patient’s choice or a previous procedure on the neck with unilateral vocal cord paralysis. Anesthesia was induced by 10 mL of 0.75% ropivacaine plus 10 µg of sufentanil in 2 mL. Block onset time, success rate, analgesia, sensory block extent, changes in respiratory and hemodynamic variables, complications, and length of hospital stay were assessed. All 15 procedures were successfully performed under CEA. Sensory block was registered in the range C2-T10, with a lower median of T3. The upper margin of sensory block was C2 in all patients. Of the respiratory variables, the only significant decrease was observed in forced vital capacity; none of the patients developed clinically significant respiratory insufficiency. We conclude that combined procedures involving the neck and upper limbs can be performed using CEA with ropivacaine. CEA allows verbal communication with patients and early detection of vocal cord paralysis.

 

 

 

 

 

比较地氟醚和七氟醚在成年病态肥胖患者外科手术后苏醒和恢复的特点:一项前瞻性和随机性研究

Emergence and Recovery Characteristics of Desflurane Versus Sevoflurane in Morbidly Obese Adult Surgical Patients: A Prospective, Randomized Study

Earl M. Strum, MD, Janos Szenohradszki, MD, PhD, Wayne A. Kaufman, MD, Gary J. Anthone, MD, MS, BA, Ingrid L. Manz, CRNA, MSN, and Philip D. Lumb, MB, BS, FCCM

Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California.

Anesth Analg 2004;99:1848-1853
 我们比较地氟醚(n = 25)和七氟醚(n = 25)在病态肥胖(体重指数 ≥35)患者开腹行胃肠道旁路手术麻醉后,苏醒的不同。手术前1小时给予咪唑安定和灭吐灵,放置硬膜外导管,诱导用药为芬太尼、异丙酚,肌松剂司可林注射后行气管插管;维持为吸入地氟醚或七氟醚,按照年龄调节至1个最低肺泡吸入浓度(MAC)。用芬太尼、吗啡或硬膜外局麻药和血管活性药物维持血压在基础值的±20%、脑电图双频指数在40-60 U。尽管吸入地氟醚的时间长于七氟醚(分别为261 ± 50 min 234 ± 37 min, 均数 ±标准差; P < 0.05),并需要更多的MAC-小时(分别为4.2 ± 0.9 h 3.7 ± 0.8 h; P < 0.05) 但对指令反应时间和拔管时间均快于七氟醚。进入麻醉后监护室(PACU)时,吸入地氟醚组的Aldrete改良评分大于七氟醚组,差异有显著性(P = 0.01),但出麻醉后监护室时,两组的Aldrete 评分无差异(P = 0.47)。到达PACU后,地氟醚组氧饱和度(97.0% ± 2.4%)比七氟醚组的氧饱和度高(94.8% ± 4.4%, P = 0.035)。两组术后恶心呕吐的发生率和止吐药剂量无差异。我们得出的结论:前瞻性、随机性对病态肥胖患者行腹部大手术的研究显示:吸入地氟醚比吸入七氟醚,苏醒快,到达PACU时,氧饱和度也高,差异有显著性。

(葛宁花译 薛张纲校)

We compared postoperative recovery after desflurane (n = 25) versus sevoflurane (n = 25) anesthesia in morbidly obese adults (body mass index ≥35) who underwent gastrointestinal bypass surgery via an open laparotomy. After premedication with midazolam and metoclopramide 1 h before surgery, epidural catheter placement, induction of anesthesia with fentanyl and propofol, and tracheal intubation facilitated with succinylcholine, anesthesia was maintained with age-adjusted 1 minimum alveolar concentration (MAC) desflurane or sevoflurane. Fentanyl IV, morphine or local anesthetics epidurally, and vasoactive drugs as needed were used to maintain arterial blood pressure at ±20% of baseline value and to keep bispectral index of the electroencephalogram values between 40 to 60 U. Although patients were anesthetized with desflurane for a longer time (261 ± 50 min versus 234 ± 37 min, mean ± SD; P < 0.05, desflurane versus sevoflurane, respectively) and for more MAC-hours (4.2 ± 0.9 h versus 3.7 ± 0.8 h; P < 0.05), significantly earlier recovery of response to command and tracheal extubation occurred in patients given desflurane than in patients given sevoflurane. The modified Aldrete score was greater in desflurane-anesthetized patients on admission to the postanesthesia care unit (PACU) (P = 0.01) but not at discharge (P = 0.47). On admission to PACU, patients given desflurane had higher oxygen saturations (97.0% ± 2.4%) than patients given sevoflurane (94.8% ± 4.4%, P = 0.035). Overall, the incidence of postoperative nausea and vomiting and the use of antiemetics did not differ between the two anesthetic groups. We conclude that morbidly obese adult patients who underwent major abdominal surgery in a prospective, randomized study awoke significantly faster after desflurane than after sevoflurane anesthesia and the patients anesthetized with desflurane had higher oxygen saturation on entry to the PACU.

 

扁桃腺肥大的麻醉儿童侧卧位时提下颌和托下颌(前伸)对喘鸣评分的影响

The Effects of Chin Lift and Jaw Thrust While in the Lateral Position on Stridor Score in Anesthetized Children with Adenotonsillar Hypertrophy

Young-Chang P. Arai, MD*, Kayo Fukunaga, MD{dagger}, Seiji Hirota, MD{dagger}, and Shoji Fujimoto, MD{dagger}

*Department of Anesthesiology, Kochi Municipal Hospital; and {dagger}Department of Anesthesiology, Kochi Medical School, Kochi, Japan

Anesth Analg 2004;99:1638-1641

 

全麻病人保留自主呼吸时的上呼吸道梗阻问题,是麻醉医生主要的挑战,尤其是对患有扁桃腺肥大的小儿进行麻醉时。在处理阻塞性睡眠呼吸暂停时,最简单的方法是让病人侧卧位,也可以减轻有阻塞性睡眠呼吸暂停的成人麻醉时的咽部塌陷。本研究中,我们检验了麻醉下行扁桃腺摘除术儿童,改变体位和一般的气道操作如提下颌和托下颌对开放气道(喘鸣评分)的效果。三十例1-10岁儿童以七氟醚麻醉。吸入5%七氟醚并保留自主呼吸,记录喘鸣评分。记录基线水平后,分别在仰卧位和侧卧位时行提下颌和托下颌操作。结果是均能改善喘鸣评分。而且,侧卧位能显著地增强这些气道开放操作的效果。颌前伸结合侧卧位为麻醉医生提供了简便的气道管理方法。我们的结论是,相较于病人仰卧位时单独的气道操作,侧卧位结合气道操作能显著改善开放气道的效果。

(周志坚 译  李士通 校)

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients, especially in pediatric anesthesia with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers, such as chin lift and jaw thrust, on airway patency (stridor score) in anesthetized children scheduled for adenotonsillectomy. Thirty children aged 1–10 yr were anesthetized with sevoflurane. During spontaneous breathing of 5% sevoflurane, stridor score was recorded. After baseline recording, chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions. Chin lift and jaw thrust improved the stridor score. Furthermore, lateral positioning dramatically enhanced the effects of these airway maneuvers on airway patency. Jaw thrust combined with lateral positioning provided easy airway management for the anesthesiologists. We conclude that lateral positioning combined with airway maneuvers significantly improved airway patency compared with the airway maneuvers alone for patients in the supine position.

 

介绍一种关于模拟婴儿心血管生理教育的模型

A Model for Educational Simulation of Infant Cardiovascular Physiology

Jane A. Goodwin, MD*,{dagger}, Willem L. van Meurs, PhD*,{ddagger},§, Carla D. Sá Couto, MSc§, Jan E. W. Beneken, PhD*, and Shirley A. Graves, MD*

*Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida; {dagger}Nemours Children’s Clinic-Jacksonville, Jacksonville, Florida, and Mayo Medical School, Rochester, Minnesota; {ddagger}Medical Education Technologies, Inc., Sarasota, Florida; and §Instituto de Engenharia Biomédica, Laboratório de Sinal e Imagem Biomédica, Porto, Portugal

Anesth Analg 2004;99:1655-1664

 

关于病人全身情况的模拟器在消除了病人风险的同时,提供了极好的临床教育所必需的技术和环境。将以模拟器为基础的训练扩展到对复杂病人群中基本的及危重的情况的处理中,是很自然的。通过对一个已有的成人模型的整套参数的重新定义,我们描述了婴儿心血管模型。我们还专门记录了一个逐步参数估计过程、明确的单一化设想和这些参数的原始资料。这些模拟的生命体征都是在规定的血液动力学变量范围内。而且,模拟的全身动脉压波形和左心室压力容积环都是实际的。该系统对失血会作出适当的反应,且合并有主动脉狭窄也能明确。这一婴儿心血管模型能为基于屏幕教育模拟提供了基础。该模型的产生也为获得全身性的,模型驱动的婴儿模拟器迈出了必要的一步。

(黄丽娜      李士通  校)

Full-body patient simulators provide the technology and the environment necessary for excellent clinical education while eliminating risk to the patient. The extension of simulator-based training into management of basic and critical situations in complex patient populations is natural. We describe the derivation of an infant cardiovascular model through the redefinition of a complete set of parameters for an existing adult model. Specifically, we document a stepwise parameter estimation process, explicit simplifying assumptions, and sources for these parameters. The simulated vital signs are within the target hemodynamic variables, and the simulated systemic arterial pressure wave form and left ventricular pressure volume loop are realistic. The system reacts appropriately to blood loss, and incorporation of aortic stenosis is straightforward. This infant cardiovascular model can form the basis for screen-based educational simulations. The model is also an essential step in attaining a full-body, model-driven infant simulator.

 

全膝置换术后经口或经静脉给予氨甲环酸对节约术后用血的效应

The Postoperative Blood-Sparing Efficacy of Oral Versus Intravenous Tranexamic Acid After Total Knee Replacement

Edna Zohar, MD*, Martin Ellis, MB BCh{dagger}, Nisim Ifrach, MD*, Avraham Stern, MD{ddagger}, Oleg Sapir, MD{ddagger}, and Brian Fredman, MB BCh*

Departments of *Anesthesiology and Critical Care, {dagger}Blood Bank, and {ddagger}Orthopedic Surgery, Meir Hospital, Kfar Saba, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Anesth Analg 2004;99:1679-1683

 

为评估经口或经静脉注射不同剂量的氨甲环酸(TA)对节约用血的效应,按照前瞻、对照、随机、单盲的研究设计对择期行全膝置换术的80例病人进行了研究。病人被分为四个治疗组。在TA长时程组中,肢体止血带放气前30min 经静脉给予一冲击量的TA 15 mg/kg,给药持续30min,此后按 10 mg · kg–1 · h–1 的速率持续静脉输注直至最后一次止血带放气后12 h。在TA短时程组中,按相同方式给药,但在最后一次下肢止血带放气后2h停止静脉输注(其时间为出麻醉后监护室的时间),此后分别于6 h12 h口服TA 1 g。口服TA组病人,术后60min口服TA 1 g,术后的18h内每6h口服相同剂量的TA。对照组病人不给TA。出手术室后,与三个TA治疗组中的任意一组相比,对照组病人术后异体输血量显著增多。由于口服给药方法简单,且无需特殊的输注设备,因此作者建议:与静脉给药相比,口服TA是一种相对较好的节约用血的策略.

(邱郁薇      李士通  校)

To assess the blood-sparing efficacy of tranexamic acid (TA) administered orally or via a variable IV infusion, 80 healthy patients undergoing elective total knee replacement were studied according to a prospective, controlled, randomized, single-blinded study design. Patients were allocated to one of four treatment groups. In group TA-long, 30 min before deflation of the limb tourniquet, an IV bolus dose of TA 15 mg/kg was administered over 30 min. Thereafter, a constant IV infusion of 10 mg · kg–1 · h–1 was administered until 12 h after final deflation of the limb tourniquet. In group TA-short, a similar regimen was followed; however, the constant IV infusion was discontinued 2 h after final deflation of the limb tourniquet (time of discharge from the postanesthesia care unit). Thereafter, oral TA 1 g was administered after 6 and 12 h. In group TA-oral, 60 min before surgery an oral dose of TA 1 g was administered. After surgery, a similar dose of TA was administered every 6 h for the next 18 h. In the control group, TA was not administered. At patient discharge, postoperative allogeneic blood administration was significantly more in group Control when compared with each of the three TA treatment groups. Because oral drug administration is simple and does not require specific infusion equipment, the authors suggest that oral TA is a superior blood-sparing strategy compared with IV drug administration.

 

静脉内给予利多卡因抑制芬太尼引起的咳嗽:一个双盲、前瞻、随机、安慰剂对照研究

Intravenous Lidocaine Suppresses Fentanyl-Induced Coughing: A Double-Blind, Prospective, Randomized Placebo-Controlled Study

Chandra K. Pandey, MD, Mehdi Raza, MD, Rajeev Ranjan, MD, Archana Lakra, MD, Anil Agarwal, MD, Uttam Singh, PhD, R. B. Singh, MD, PDCC, and Prabhat K. Singh, MD

Department of Anaesthesiology and Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2004;99:1696-1698

 

IV利多卡因能有效抑制对气管插管、拔管、支气管造影、支气管镜检查和喉镜检查的咳嗽反射。我们在502ASA I-II的择期手术患者中观察了利多卡因对芬太尼引起的咳嗽的这个作用。以随机双盲的方式将患者分成2个等量的组,在给予芬太尼3 µg/kg1 min给予利多卡因1.5 mg/kg或安慰剂(0.9%盐水),给药时间5 s。观察有无咳嗽以及咳嗽分级:轻度(1-2)、中度(3-4)或重度(ł5)。研究结果提示给予芬太尼前1 min IV利多卡因1.5 mg/kg,与安慰剂(0.9%盐水)相比较,显著有效地抑制芬太尼引起的咳嗽(218165例患者)(P < 0.002),但不影响咳嗽程度(P > 0.05)。

(马皓琳      李士通  校)

IV lidocaine is effective in suppressing the cough reflex of tracheal intubation, extubation, bronchography, bronchoscopy, and laryngoscopy. We investigated this effect of lidocaine on fentanyl-induced cough in 502 patients of ASA physical status I and II scheduled for elective surgery. The patients were assigned to 2 equal groups to receive either lidocaine 1.5 mg/kg or placebo (0.9% saline) over 5 s 1 min before the administration of fentanyl 3 µg/kg in a randomized and double-blind fashion. Coughs were classified as coughing and graded as mild (1–2), moderate (3–4), or severe (5 or more). The results of the study suggest that IV lidocaine 1.5 mg/kg, when administered 1 min before fentanyl, is significantly effective in suppressing fentanyl-induced cough compared to placebo (0.9% saline) (218 versus 165 patients) (P < 0.002) but without affecting the severity of cough (P > 0.05).

 

异氟醚能保护原代混合培养的神经元/神经胶质细胞,使其凋亡不被NMDA的兴奋毒性增强

Apoptosis Is Not Enhanced in Primary Mixed Neuronal/Glial Cultures Protected by Isoflurane Against N-Methyl-D-Aspartate Excitotoxicity

Lisa Wise-Faberowski, MD*, Mitsuo Aono, MD{dagger}, Robert D. Pearlstein, PhD{ddagger}, and David S. Warner, MD*,{ddagger},§

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

Anesth Analg 2004;99:1708-1714

 

 吸入麻醉药能减少原代培养的神经元/神经胶质细胞的急性兴奋毒性死亡。我们假设异氟醚保护细胞免于N-甲基-D-门冬氨酸盐(NMDA)引起的细胞坏死而转为细胞凋亡。原代培养一级神经元/神经胶质细胞来自胎鼠的大脑,暴露在溶解的异氟醚(0 mM0.4 mM [1.8 MAC]1.6 mM [7 MAC]) NMDA (0 100 µM) 37°C 30 min。将Dizocilpine 10 µM)加100 µM NMDA中作为阳性对照。暴露后24/48 h时,应用 Hoechst/碘化丙啶染色法、TdT介导的缺口末端标记法、DNA片段酶连免疫吸附法和caspase-3激活实验检测细胞的坏死和凋亡。NMDA能增加坏死的细胞数。异氟醚(1.6 mM)和dizocilpine能部分减少细胞坏死,但并不能增加24 h时暴露于100 µM NMDA导致的形态学上凋亡或凋亡样的细胞数。48 h时,异氟醚所保护的细胞未出现凋亡或凋亡样的证据。然而,受dizocilpine保护而免于坏死的细胞显示caspase-3介导的凋亡证据。这些体外数据不支持这样的假说,即异氟醚保护细胞免于急性兴奋毒性坏死而使细胞凋亡。

(赵雪莲 译   李士通 校)

Volatile anesthetics reduce acute excitotoxic cell death in primary neuronal/glial cultures. We hypothesized that cells protected by isoflurane against N-methyl-D-aspartate (NMDA)-induced necrosis would instead become apoptotic. Primary mixed neuronal/glial cultures prepared from fetal rat brain were exposed to dissolved isoflurane (0 mM, 0.4 mM [1.8 minimum alveolar anesthetic concentration], or 1.6 mM [7 minimum alveolar anesthetic concentration]) and NMDA (0 or 100 µM) at 37°C for 30 min. Dizocilpine (10 µM) plus 100 µM NMDA served as a positive control. Necrosis and apoptosis were assessed at 24 and/or 48 h after exposure by using Hoechst/propidium iodide staining, terminal-deoxynucleotidyl transferase end-nick labeling, DNA fragmentation enzyme-linked immunoabsorbence, and caspase-3 activity assays. NMDA increased the number of necrotic cells. Isoflurane (1.6 mM) and dizocilpine partially reduced cellular necrosis but did not increase the number of morphologically apoptotic or apoptotic-like cells resulting from exposure to 100 µM NMDA at 24 h. At 48 h, no evidence was found to indicate that cells protected by isoflurane had become apoptotic or apoptotic-like. However, cells protected by dizocilpine against necrosis showed evidence of caspase-3-mediated apoptosis. These in vitro data do not support the hypothesis that isoflurane protection against acute excitotoxic necrosis results in apoptosis.

 

在健康志愿者控制输注异丙酚和雷米芬太尼期间用听觉诱发电位监测镇静深度

Measuring Depth of Sedation with Auditory Evoked Potentials During Controlled Infusion of Propofol and Remifentanil in Healthy Volunteers

Matthias Haenggi, MD*, Heidi Ypparila, Ph Lic{ddagger}, Jukka Takala, MD, PhD*, Ilkka Korhonen, PhD§, Martin Luginbühl, MD{dagger}, Steen Petersen-Felix, MD, PhD{dagger}, and Stephan M. Jakob, MD, PhD*

Departments of *Intensive Care Medicine and {dagger}Anesthesia, University Hospital Bern, Bern, Switzerland {ddagger}Department of Clinical Neurophysiology, Kuopio University Hospital, Kuopio, Finland, §VTT Information Technology, Tampere, Finland

Anesth Analg 2004;99:1728-1736

 

对于重症监护病人来说主要的问题是避免过度镇静。我们研究了是否能用长潜伏期听觉诱发电位来客观地评估临床上镇静的相应水平。我们在逐步升高临床上镇静的相应水平(Ramsay评分〔RS2-4)期间,对10个健康志愿者在刺激后100 ms时测定听觉诱发电位(N100)。在三种单独的条件下,对接受输注异丙酚或联合输注异丙酚和雷米芬太尼的志愿者进行研究。在靶控输注过程中试验单独输注雷米芬太尼的作用(血浆靶浓度为:123 ng/ml)。雷米芬太尼不影响诱发电位的振幅和潜伏期。在异丙酚诱导和异丙酚/雷米芬太尼诱导的镇静期间,镇静水平Ramsay评分从2级升高到4级时,N100的振幅同样下降而潜伏期反应时间并没有受到影响(P < 0.01)。在相同的临床镇静水平,单独用异丙酚达到镇静时的异丙酚血浆浓度较大(异丙酚比异丙酚/雷米芬太尼,RS 3: 2.12 µg/mL ± 0.511.32 ± 0.43, P < 0.01; RS 4: 3.37 ± 0.471.86 ± 0.34, P < 0.01)。我们的研究结果提示长潜伏期听觉诱发电位提供了一个客观的不依赖于所用镇静方案来评估临床镇静的电生理模拟方法。

(彭中美 译  李士通 校)

Avoiding excessively deep levels of sedation is a major problem in intensive care patients. We studied whether clinically relevant levels of sedation can be objectively assessed using long latency auditory evoked potentials. We measured the auditory evoked potentials at 100 ms after the stimulus (N100) in 10 healthy volunteers during stepwise increasing, clinically relevant levels of sedation (Ramsay score [RS] 2–4). The volunteers were studied on three separate occasions and received an infusion of either propofol or a combination of propofol and remifentanil. Effects of remifentanil infusion alone were tested during target controlled infusion (target plasma concentrations: 1, 2, and 3 ng/mL). Remifentanil did not affect evoked potential amplitudes and latencies. During both propofol-induced and propofol/remifentanil-induced sedation, the N100 amplitude decreased similarly without an effect on the latencies as the level of sedation increased from Ramsay score 2 to Ramsay score 4 (P < 0.01). At the same clinical level of sedation, propofol plasma concentrations were larger when sedation was achieved by propofol alone (propofol versus propofol/remifentanil, RS 3: 2.12 µg/mL ± 0.51 versus 1.32 ± 0.43, P < 0.01; RS 4: 3.37 ± 0.47 versus 1.86 ± 0.34, P < 0.01). Our results suggest that long latency auditory evoked potentials provide an objective electrophysiological analog to the clinical assessment of sedation independent of the sedation regime used.

 

 

比较供体右叶肝切除术和肝肿瘤肝大部切除术后的疼痛治疗

A Comparison of Postoperative Pain Control in Patients After Right Lobe Donor Hepatectomy and Major Hepatic Resection for Tumor

Jacek B. Cywinski, MD*, Brian M. Parker, MD*,{dagger}, Meng Xu, MS{ddagger}, and Samuel A. Irefin, MD*,{dagger}

*Department of General Anesthesiology, {dagger}Transplant Center, {ddagger}Department of Biostatistics & Epidemiology, Cleveland Clinic Foundation, Cleveland, Ohio

Anesth Analg 2004;99:1747-1752

 

在我们机构开始活供体肝移植计划后,尽管使用了胸段病人自控硬膜外镇痛(PCEA)输注导管,我们仍观察到供体病人经历了显著的手术后疼痛。为了阐述其原因, 我们回顾比较了接受供体右叶肝切除术的病人(RLDH, n = 15)和因为肿瘤接受肝大部切除术的病人(MHRT, n = 15)。所有病人术前放置胸段硬膜外导管,两组的外科手术暴露相似。收集和分析了病人的一般资料、术中变量,以视觉模拟疼痛评分(VAPS)的术后疼痛程度、副作用、需要的和给予的PCEA剂量以及术后48小时里给予的布比卡因总量(mg)和PCEA溶液的容积(mL)。RLDH组比MHRT组的手术时间显著延长。RLDH组的病人术后疼痛评分更高(P = 0.034),比MHRT组病人疼痛的可能性高2.76 (1.12–6.82, 95% CI)倍。给予的布比卡因的量和PCEA溶液的容积,在两组之间没有显著性差异。这些观察结果的部分原因可能为RLDH组的手术时间更长。文章讨论了通过PCEA输注的优先镇痛的可能作用和对PCEA使用的更好的围术期指导;这些可以使得RLDH组病人术后早期疼痛控制的改善。

(张        李士通  校)

After initiating a living donor liver transplant program at our institution, we observed that donor patients experienced significant postoperative pain despite the use of thoracic patient-controlled epidural analgesia (PCEA) infusion catheters. We retrospectively compared patients who underwent right lobe donor hepatectomy (RLDH, n = 15) with patients who had undergone major hepatic resection for tumor (MHRT, n = 15) to elucidate the cause for this observation. All patients had preoperative thoracic epidural catheters placed, and both groups had similar surgical exposure. Demographic information, intraoperative variables, intensity of postoperative pain by visual analog pain score (VAPS), side effects, total number of requested and delivered PCEA doses, and the total amount of bupivacaine (mg) and volume (mL) of PCEA solution administered through 48 h postoperatively were collected and analyzed. The RLDH group had a significantly longer surgical duration than did the MHRT group. The RLDH group patients had higher postoperative pain scores (P = 0.034), and were 2.76 (1.12–6.82, 95% CI) times more likely to have pain than those patients in the MHRT group. There was no significant difference between patient groups for the amount of bupivacaine and volume of PCEA solution administered. These observations may be explained, in part, by the longer duration of surgery in the RLDH group. The possible role of preemptive analgesia via PCEA infusion and better perioperative teaching of PCEA use are discussed; these may lead to improved early postoperative pain control in RLDH patients.

 

机械通气狗分级低血容量和高血容量时心脏前负荷改变的比较

A Comparison of Changes in Cardiac Preload Variables During Graded Hypovolemia and Hypervolemia in Mechanically Ventilated Dogs

Yoshihisa Fujita, MD*, Tokunori Yamamoto, MD{dagger}, Itsuro Sano, MD*, Naoki Yoshioka, MD*, and Hajime Hinenoya, MD*

Departments of *Anesthesiology & ICM and {dagger}Urology, Kawasaki Medical School, Okayama, Japan

Anesth Analg 2004;99:1780-1786

 

我们开发了一种测量收缩压变异性(SPV)及其高、低(dDown)成份以及脉压变异性(dPP)的在线监测系统。我们使用这个系统来比较机械通气狗在正常血量、分级低血容量(–200–350 mL)及高血容量(+200+350 mL)时各种心脏前负荷指标,例如每搏输出量变异性(SVV)和校正血流时间(FTc)及中心静脉压和肺动脉楔压。我们同时测量这些前负荷指标和全身血液动力学变量,并观察其评估前负荷变化的正确性和局限性。低血容量(–350 mL)SPV从基础值4.8 ± 1.4 mm Hg增加到11.2 ± 1.8 mm Hg,但高血容量时SPV无明显变化。观察到dDowndPPSVV相似的变化。相反,FTc在高血容量时增加,但低血容量时保持不变。研究结果显示SPVdDowndPPSVV是低血容量而非高血容量的有用指标。相反,用FTc不能可靠地察觉低血容量,但它能反映高血容量时的血容量变化。尽管SPVdDowndPP的测量无需动脉置管以外的有创操作和费用,但必须记住它们仅限于对机械通气的患者血容量状态的监测。

(朱 慧      李士通  校)

We developed an online monitoring system to measure systolic blood pressure variation (SPV) and its down (dDown) and up components, along with pulse pressure variation (dPP). Using the system, we compared different cardiac preload indicators—such as stroke volume variation (SVV) and corrected flow time (FTc)—along with central venous pressure and pulmonary artery occlusion pressure in mechanically-ventilated dogs during normovolemia, graded hypovolemia (–200 and –350 mL), and hypervolemia (+200 and +350 mL). We simultaneously measured these preload indicators along with global hemodynamic variables and investigated their validity and limitations to access preload changes. SPV increased from 4.8 ± 1.4 mm Hg at baseline to 11.2 ± 1.8 mm Hg during hypovolemia (–350 mL), but it did not change significantly during hypervolemia. Similar changes were observed with dDown, dPP, and SVV. FTc, conversely, increased during hypervolemia but remained unchanged during hypovolemia. The results of this study indicate that SPV, dDown, dPP, and SVV are useful indicators of hypovolemia, but not of hypervolemia. Conversely, hypovolemia could not be detected reliably by FTc, but it does reflect blood volume changes during hypervolemia. Although SPV, dDown, and dPP measurements require no additional invasion and cost beyond arterial cannulation, their limits must be kept in mind for the monitoring of blood volume status in mechanically-ventilated patients.

 

鞘内注射硫酸镁对家兔是否安全且是否保护其免于缺血性脊髓损伤?

Is Intrathecal Magnesium Sulfate Safe and Protective Against Ischemic Spinal Cord Injury in Rabbits?

Hiroshi Saeki, MD, Mishiya Matsumoto, MD, Shuichi Kaneko, MD, Shunsuke Tsuruta, MD, Ying Jun Cui, MD, Kazunobu Ohtake, MD, Kazuyoshi Ishida, MD, and Takefumi Sakabe, MD

Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Japan

Anesth Analg 2004;99:1805-1812

 

我们对家兔进行了三批实验,以研究鞘内注射硫酸镁的安全性及确定对于缺血性脊髓损伤是否存在保护作用以及产生保护作用的最佳剂量。第一批实验分别测定鞘内注射0.3123 mg/kg硫酸镁(每组n6)的神经毒性。3 mg/kg组在给药后7天出现较显著的感觉功能障碍。2 mg/kg组和3 mg/kg组各有2只家兔出现运动功能障碍。1 mg/kg组有1只家兔,2mg/kg组有2只家兔,3mg/kg组有1只家兔在脊髓V-VII 层出现损害区。第二批实验研究鞘内注射3 mg/kg硫酸镁后家兔的组织病理学改变的暂时特性(6 h48 h96 h〔各组n = 3〕,证实给药后4896 h出现运动功能障碍的家兔有相似的组织病理学改变。第三批实验评估了家兔脊髓缺血前分别鞘内注射硫酸镁0.3 mg/kg1 mg/kg和生理盐水(每组n6)对脊髓缺血后(15 min)家兔后肢运动功能及组织病理学改变的影响。镁剂并不能改善再灌注96 h后神经功能或组织病理学预后。该结果表明鞘内注射镁剂有产生神经毒性的风险性,且未显示证据证实其对脊髓缺血损伤具保护作用。

(周雅春      李士通  校)

We performed three sets of experiments to investigate the safety of intrathecal magnesium and to determine its optimal dose for protection, if any, against ischemic spinal cord injury in rabbits. First, we examined neurotoxicity of 0.3, 1, 2, or 3 mg/kg of magnesium sulfate (n = 6 each). Significant sensory dysfunction was observed in the 3-mg/kg group 7 days after administration. Motor dysfunction was found in two rabbits in both the 2- and 3-mg/kg groups. The area of destruction in laminae V-VII was observed in one, two, and one rabbit in the 1-, 2-, and 3-mg/kg groups, respectively. Second, we investigated the temporal profile (6 h, 48 h, and 96 h [n = 3 each]) of histopathologic changes after 3 mg/kg of magnesium sulfate and confirmed similar changes in the rabbits with motor dysfunction at 48 and 96 h. Third, we evaluated the effects of 0.3 mg/kg or 1 mg/kg of magnesium sulfate or saline (n = 6 each) administered before ischemia on hindlimb motor function and histopathology after spinal cord ischemia (15 min). Magnesium did not improve neurologic or histopathologic outcome 96 h after reperfusion. The results indicate that intrathecal magnesium has a risk of neurotoxicity and shows no evidence of protective effects against ischemic spinal cord injury.

 

坐位患者旁正中法腰段硬膜外导管置入在脊柱屈曲或不屈曲状况下的成功率相当

Paramedian Lumbar Epidural Catheter Insertion with Patients in the Sitting Position Is Equally Successful in the Flexed and Unflexed Spine

Subrata Podder, MD, Neeraj Kumar, MD, L. N. Yaddanapudi, MD, and Pramila Chari, MD, MNAMS, FAMS

Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Anesth Analg 2004;99:1829-1832

 

硬膜外导管放置所需的体位对下肢损伤的患者来说是非常痛苦的。我们随机将50名下肢损伤预备进行手术的患者分成两组,在背部处于中立不弯曲的坐位分别用直入法或旁正中法进行腰段硬膜外导管置入。如果尝试两次仍未成功,则使患者处于脊柱弯曲的体位再进行尝试。记录技术的困难度和并发症。直入法组的17名患者和旁正中法的1名患者最初无法进针,需要脊柱弯曲的体位(P < 0.05)。直入法导管置入遇到阻力(81)、有感觉异常的(70)及导管内见血的发生(60)与旁正中法相比明显更常见。直入法组所经历的舒适度也比旁正中法更差。我们得出结论:患者处于脊柱不弯曲的坐位时,用旁正中法置入硬膜外导管通常是可行的。

(陈        李士通  校)

Positioning for placement of an epidural catheter can be quite painful for patients with lower limb injuries. We randomly allocated 50 patients scheduled for surgery after lower limb injuries for placement of a lumbar epidural catheter in the sitting position with the back in the neutral unflexed position by either the midline or paramedian approach. If the approach failed after two attempts, patients were placed in a flexed-spine position, and the procedure was attempted again. Technical difficulties and complications were recorded. In 17 patients in the midline group, and 1 patient in the paramedian group, it was not possible to insert the needle initially, and a flexed-spine position was required (P < 0.05). The incidences of resistance to catheter insertion (eight versus one), paresthesia (seven versus zero), and appearance of blood in the catheter (six versus zero) were significantly more frequent in the midline compared with the paramedian approach. The midline group also experienced more discomfort than the paramedian group. We conclude that, with the patient sitting with an unflexed spine, it is usually possible to insert an epidural catheter with the paramedian approach.

 

持续脊麻小孔径导管的机械特性

The Mechanical Properties of Continuous Spinal Small-Bore Catheters

Engelbert Deusch, MD*, Justus Benrath, MD*, Lukas Weigl, PhD*, Konrad Neumann, PhD{dagger}, and Sibylle A. Kozek-Langenecker, MD*

*Department of General Anesthesiology and Intensive Care-B, Vienna Medical University, General Hospital Vienna, Vienna, Austria; and {dagger}Charité-University Medicine Berlin, Campus Benjamin Franklin, Department for Medical Computer Science, Biometry and Epidemiology, Berlin, Germany

Anesth Analg 2004;99:1844-1847

 

 持续脊麻(CSA)已有近百年的历史。当出现CSA小孔径导管拔除困难的情况时,不同导管的机械特性可能是非常重要的,因为导管可能发生断裂。我们比较了5种不同的小孔径导管(2228号,来自3家厂商)的抗张强度、张应力、延伸性以及弯曲强度。导管断裂前所用的力就是最大抗张强度。不同CSA小孔径导管在最大抗张强度的材料特性方面为:室温下22= 29.56 ± 1.56 (mean ± SD) 牛顿 (N), 24= 16.77 ± 1.61 N, 25= 9.20 ± 0.48 N, 27= 4.61 ± 0.25 N, 28= 5.07 ± 0.59 N。可以观察到,最大抗张强度和导管外径之间(r = 0.957, P < 0.001)以及最大抗张强度与管壁厚度之间(r = 0.9, P < 0.001)存在很强的相关性,。尽管用实验研究去外推到临床常规时必须十分小心,我们的资料提示较高强度特性的导管可以减少导管在病人体内断裂的危险性,尽管目前仍缺乏临床上的相关性。

(黄施伟      李士通  校)

Continuous spinal anesthesia (CSA) has a nearly 100-yr history. In situations of difficult removal of a CSA small-bore catheter, mechanical properties of the different catheters might be important, because breakage could occur. We compared 5 different CSA small-bore catheters, 22- to 28-gauge from 3 manufacturers, for tensile strength, tensile stress, distension, and yield strength. Maximal tensile strength is the force applied before breakage of the catheter. The material characteristics of different CSA small-bore catheters for maximal tensile strength were: 22-gauge = 29.56 ± 1.56 (mean ± SD) Newton (N), 24-gauge = 16.77 ± 1.61 N, 25-gauge = 9.20 ± 0.48 N, 27-gauge = 4.61 ± 0.25 N, 28-gauge = 5.07 ± 0.59 N at room temperature. A strong correlation between maximal tensile strength and the outer diameter (r = 0.957, P < 0.001) and maximal tensile strength and the wall thickness (r = 0.9, P < 0.001) was observed. Although extrapolation from experimental studies to clinical routine should be made with care, our data suggest that catheters with higher-strength characteristics may reduce the risk of catheter breakage in patients, although clinical correlations are lacking.