Anesthesia & Analgesia

December 2004

Table of Content

 

PEDIATRIC ANESTHESIA:

預測兒科病人術後嘔吐發生可能性的風險評分的開發和驗證

齊波 陳傑

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

 

扁桃腺肥大的麻醉兒童側臥位時提下頜和托下頜(前伸)對喘鳴評分的影響

周志堅譯  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.

 

評價部分CO2重吸收無創監測兒童CO的價值

葛甯花譯 薛張綱校

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.

 

術前焦慮與出現譫妄、術後行為不當的關係

齊波 陳傑

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.

 

介紹一種關於類比嬰兒心血管生理教育的模型

黃麗娜      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:

比較高滲布比卡因腰麻和地氟醚全麻在門診膝關節鏡檢查中的應用

葛甯花譯 薛張綱校

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:   

長期應用苯二氮卓類藥物的老年人術後意識混亂發生率增加

趙延華 陳傑

Postoperative Confusion Increases in Elderly Long-Term Benzodiazepine Users

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

Anesth Analg 2004 99: 1674-1678.

 

全膝置換術後經口或經靜脈給予氨甲環酸對節約術後用血的效應

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.

 

硬膜外布比卡因阻滯對異丙酚誘導與維持和維持劑量芬太尼與維庫溴胺的影響

葛甯花譯 薛張綱校

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

 

氯胺酮對人離體心房肌的正性變力和鬆弛效應:腎上腺素能受體阻滯效應

趙延華 陳傑

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

 

靜脈內給予利多卡因抑制芬太尼引起的咳嗽:一個雙盲、前瞻、隨機、安慰劑對照研究

馬皓琳      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:注射異丙酚前注射利多卡因或用異丙酚甘油三酸脂中長鏈劑型的對照雙盲研究

葛甯花譯 薛張綱校

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.

 

麻黃素的血流動力學作用對豬羅庫溴銨起效時間的影響

朱慧琛 譯 陳傑 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

 

異氟醚能保護原代混合培養的神經元/神經膠質細胞,使其凋亡不被NMDA的興奮毒性增強

趙雪蓮譯   李士通

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.

 

臨床濃度吸入麻醉藥對人體K通道TRESK串聯孔區的強大啟動作用

葛甯花譯 薛張綱校

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:

七氟謎降低腦雙頻指數較吸入MAC相等倍數的氟烷更明顯

朱慧琛 譯 陳傑 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.

 

在健康志願者控制輸注異丙酚和雷米芬太尼期間用聽覺誘發電位監測鎮靜深度

彭中美譯  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.

 

用高保真的模擬病人來介紹新的麻醉裝備

葛甯花譯 薛張綱校

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.

 

利用凝膠塗層的水迴圈床墊進行熱交換

朱輝 陳傑

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:

比較供體右葉肝切除術和肝腫瘤肝大部切除術後的疼痛治療

        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.

 

靜脈注射氯胺酮試驗:預計口服Dextromethorphan對治療神經性疼痛的效果

葛甯花譯 薛張綱校

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:

困難氣道風險因素的評估:一項1956名義大利患者的調查

朱輝 陳傑

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:

機械通氣狗分級低血容量和高血容量時心臟前負荷改變的比較

      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.

 

心室纖維顫動時的中位元頻率可能不是一個有效的監測心臟停止後用Endothelin-1和腎上腺素治療的指標

葛甯花譯 薛張綱校

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

 

一種使用血栓彈力圖評價Eptifibatide對血小板抑制的新方法

殷文淵 陳傑

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:

鞘內注射硫酸鎂對家兔是否安全且是否保護其免於缺血性脊髓損傷?

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:

用心率變異性以發現產科患者腰麻時的危險性

葛甯花譯 薛張綱校

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

 

氟烷濃度提高速度和接頭數量對大鼠氟烷最小肺泡麻醉濃度測定的影響

殷文淵 陳傑

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導管置入在脊柱屈曲或不屈曲狀況下的成功率相當

        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.

 

頸部硬膜外麻醉用於頸部和上肢的聯合手術:一項引導性研究

葛甯花譯 薛張綱校

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

 

全麻前單次椎旁阻滯可增強乳癌手術是否拌有淋巴結活檢後的鎮痛效果

顧漪聞 陳傑

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.

持續脊麻小孔徑導管的機械特性

黃施偉      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:

比較地氟醚和七氟醚在成年病態肥胖患者外科手術後蘇醒和恢復的特點:一項前瞻性和隨機性研究

葛甯花譯 薛張綱校

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

 

腹腔鏡膽囊切除術期間醋酸林格氏液容量動力學

顧漪聞 陳傑

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.

 

 

預測兒科病人術後嘔吐發生可能性的風險評分的開發和驗證

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.

 

預測術後嘔吐(PV)或噁心嘔吐發生率的風險評分應用于成年病人已比較成熟,但不適用於兒童,因為幾個風險因素很難進行評估或不適用於兒科病人(如吸煙狀況等)。因此,本研究的目的是開發和驗證一個簡單的評分來預測兒科病人PV的發生(POVOC-score)。新評分開發和驗證所需要的資料來自4個相互獨立的研究機構,研究物件包括1257名在全麻下接受各種不同手術的兒童(年齡在0-14歲之間),這些兒童在術前均不預防性應用止吐藥。術前記錄幾個潛在的風險因素。術後24小時內觀察有無PV。資料隨機分為評價組(n=675)和驗證組(n=600),評價組資料通過Logistic回歸分析;驗證組資料通過受試者操作特徵曲線下平均面積來確認預測的精確性。四個相互獨立的PV風險因素(手術時間30分鐘; 年齡3歲;斜視手術;以及受試兒童有PV的陽性病史或者其親屬(母親、父親、兄弟姐妹)有PV或術後噁心嘔吐的陽性病史)通過最終分析並進行驗證。結果發現當存在01234個風險因素時的PV發生率分別為9%10%30%55%70%。驗證組應用這些率值作為定點,其受試者操作特徵下曲線面積為0.7295%可信區間為0.68-0.77)。結果表明應用四項簡單的風險評分能夠比較精確地預測兒童PV的發生。

(齊波 陳傑 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.

 

術前焦慮與出現譫妄、術後行為不當的關係

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.

 

基於先前的研究,作者假設臨床上術前焦慮、譫妄發生和術後行為不當有密切相關。作者利用過去6年中該實驗室獲得的資料資料來驗證此結論。選擇七氟醚/O2/N2O複合全麻下實施外科手術的兒童為研究物件,且在術中不應用咪唑安定。術前焦慮通過改良的耶魯術前焦慮評分(mYPAS)進行評估,譫妄評估在麻醉後監護室內進行,而病人動作行為的改變則在術後第1237,和14天時通過波斯特醫院行為調查問卷(PHBQ)進行評定。回歸分析顯示兒童焦慮狀態評分(mYPAS)每增加10點,出現具有顯著症狀的譫妄的可能性就增加10%。與無譫妄症狀的兒童相比,具有顯著症狀的兒童在術後新出現行為不當的可能比率為1.43。當焦慮狀態評分增加10點,導致兒童術後新出現行為不當的可能性增加12.5%。這個發現對臨床醫生來說具有重要意義,可以借此來預測術後有害事件的發生,如根據病人術前焦慮的水平,來預測術後可能發生譫妄和行為不當的情況。

(齊波 陳傑 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.

 

長期應用苯二氮卓類藥物的老年人術後意識混亂發生率增加

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類藥物的老年病人術後意識混亂和藥物應用時間、術前焦慮、壓抑狀態及認知功能的關係。研究物件為328名施行整形外科手術的病人,年齡65-80歲。研究者通過與病人面對面的交談以及觀察其藥箱來獲得有關病人服用苯二氮卓類藥物方面的資訊,術後應用意識混亂評分對病人的意識狀態進行評價。病人分為兩組,即定期服藥組和非服藥組。328名病人中有57名(17%)服用苯二氮卓類藥物。兩組病人術前簡要精神狀況(Mini Mental Status, MMS)評分、焦慮評分或壓抑評分沒有明顯區別。57名服藥者中有15名(26%)術後出現意識混亂,而非服藥組271名病人中有34名(13%)出現術後意識混亂(P< 0.01)。57名服藥者中有5名(9%MMS評分<23,而271名非服藥者中有8名(3%)(P< 0.05)。37名長期服用苯二氮卓類藥物者(每天服用,長達一年以上)中有13 名(35%)出現術後意識混亂。長期服用藥物者術後意識混亂的發生率顯著高於短期服藥者和未服藥者。37名長期服藥者中有5名(14%MMS評分<2320名短期服藥者中則沒有(0%)。結論:長期服用苯二氮卓類藥物者術後意識混亂的發生率明顯升高。

(趙延華 陳傑 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.

 

氯胺酮對人離體心房肌的正性變力和鬆弛效應:腎上腺素能受體阻滯效應

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-腎上腺素能受體阻滯劑作用下外消旋氯胺酮對人的離體右心房肌的直接效應。外消旋氯胺酮(濃度分別為10–610–510–4 M)單獨應用或與α-腎上腺素能受體阻滯劑(酚妥拉明10–6 M)和β-腎上腺素能受體阻滯劑(心得安10–6 M)聯合應用,在給藥前後記錄等長收縮力(FoC)及其與時間的一級導數(+dF/dt),收縮舒張耦合參數R2 = (+dF/dt) / (–dF/dt)、半量鬆弛時間(T1/2)。氯胺酮有中度正性變力效應,濃度為10–5 M FoC為基礎值的104% ± 5%P = 0.0310–4 MFoC為基礎值的107% ± 11%P = 0.09。在心得安作用下,外消旋氯胺酮有負性變力效應,氯胺酮濃度為10–6 MFoC為基礎值的77% ± 11%10–5 MFoC為基礎值的63% ± 16%10–4 MFoC為基礎值的62% ± 17%P < 0.001)。但在酚妥拉明作用下氯胺酮的負性變力效應不明顯,氯胺酮濃度為10–6 MFoC為基礎值的94% ± 6% 10–5 MFoC為基礎值的96% ± 5%10–4 MFoC為基礎值的98% ± 15%。氯胺酮可縮短T1/2(濃度為10–5 MT1/2為基礎值的94% ± 3%P < 0.00110–4 MT1/2為基礎值的90% ± 9%P = 0.007),但沒有改變R2。在人的右心房肌,外消旋氯胺酮可引起中度正性變力效應,加速等容舒張。在ß-腎上腺素能受體阻滯劑作用下,引起直接的負性變力效應。

(趙延華 陳傑 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.

 

麻黃素的血流動力學作用對豬羅庫溴銨起效時間的影響

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

.

有些研究發現肌松起效時間與心指數和肌肉血流間存在相關性。麻黃素可加強這些血流動力學變化,進而縮短人類羅庫溴銨起效時間。本實驗的目的在於確定使用硫噴妥鈉後,麻黃素對羅庫溴銨起效時間、心指數和肌肉血流的影響。在每個預定的測試時點,測量平均動脈壓和心指數,並用肌動圖記錄起效時間。24只豬隨機分為三組:組1先用依託咪酯,隨後使用羅庫溴銨(2×95%有效劑量);組2以硫噴妥鈉代替依託咪酯。組3在給予硫噴妥鈉前先應用麻黃素100µg/kg,同時測量肌肉血流(螢光標記)。雖然組1與組2的血流動力學存在差異,但羅庫溴銨的起效時間並無明顯區別。組3中麻黃素補償了硫噴妥鈉引起的平均動脈壓、心指數和肌肉血流的下降,但未明顯縮短起效時間(組17421s;組27124s; 36922s)。結論:麻黃素相關性心指數和血流增加並不縮短健康豬羅庫溴銨的起效時間。

(朱慧琛 譯 陳傑 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.

 

七氟謎降低腦雙頻指數較吸入MAC相等倍數的氟烷更明顯

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濃度(MAC)麻醉時,50%受試者對傷害性刺激可做出逃避反應。清醒MAC麻醉時,50%的受試者對指令可做出適當的反應。腦雙頻指數(BIS)通常測定麻醉藥對清醒或意識狀態的影響。作者假設在不同的MAC水平下,應用高倍率的清醒MAC / MAC的氟烷比七氟醚所得的BIS值更高。33名未使用術前用藥的患者進行吸入麻醉實驗,18個應用七氟醚,15個使用氟烷。在麻醉濃度1MAC前後、插管前後(以芬太尼和羅庫溴銨輔助誘導)及吸入濃度1.5MAC時分別測試BIS。在達到穩態後繼續測量BIS。本次實驗的所有受試者都不接受外科手術。清醒患者七氟醚和氟烷組間BIS值無明顯差異(962962)。在吸入1MAC(使用或不使用神經肌肉阻滯劑)和1.5MAC氟烷時患者BIS值(547567497)較吸入七氟醚的患者BIS值(346346295)高(P<0.0001)。這一發現與其他一些證據顯示BIS有藥物特異性。

(朱慧琛 譯 陳傑 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.

 

利用凝膠塗層的水迴圈床墊進行熱交換

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

 

使用一次性毯子作為氣體取暖存在費用問題,而作為改良方法,作者選擇八十名健康志願者利用可重複使用的凝膠塗層的水迴圈床墊放在其背下研究其熱轉換情況。通過六個熱量感測器測量熱量並測量床墊溫度,皮膚溫度和中心溫度。水溫分別設置為25℃,30℃,35℃或41℃。熱轉換量等於熱量乘以接觸面積。利用床墊溫度,皮膚溫度和熱量來確定傳導中的熱交換係數。熱量和水溫關係如下:熱量=10.3×水溫-374r2=0.98)。熱傳導的熱交換係數是121W·m-2·-1。凝膠塗層的水迴圈床墊最大的熱交換量是18.4±3.3W。由於凝膠塗層的水迴圈床墊對人體熱平衡作用較小,它僅用於背部而不能替代氣體取暖系統。

(朱輝 陳傑 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.

 

困難氣道風險因素的評估:一項1956名義大利患者的調查

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.

 

在過去的十年裏,發表的關於識別和預計困難氣道的文獻不斷增加且認識程度不斷增強。術前的氣道評估時,必須徹底了解氣道有關的病史和詳細的體格檢查。各種解剖特徵的評估方法和無創臨床測試可增強對氣道的評價。在這項研究中,作者將Mallampati改良評分和其他與喉鏡下觀察到的困難氣道的解剖和臨床風險因素的指數作比較。作者連續收集了1956名選擇性手術需氣管插管實施全身麻醉的患者的資料。Mallampati分級與Cormack-LehaneC-L)線性相關指數是0.904Mallampati3級與C-L2級相關(0.94),而Mallampati 4級與C-L3級相關(0.85)與C-L4級相關(0.80)。通過簡單的氣管插管由操作者評估其困難程度與C-L組呈線性關係(0.96)。儘管口咽體積與困難插管相關,但Mallampati評分本身預計困難氣管插管並不充足。

(朱輝 陳傑 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.

 

一種使用血栓彈力圖評價Eptifibatide對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彈力圖檢測血小板抑制的新方法。作者假設這種方法適合監測依替巴肽(抗血栓藥)的抗血小板效應。採集健康志願者的全血,使用3.2%檸檬酸或未分餾肝素(7 IU/mL)抗凝。所有檸檬酸和肝素化樣本均使用濃度逐漸提高的依替巴肽(00.20.40.81.64µg/mL)處理後進行血小板聚集試驗。兩種樣本使用濃度分別為00.20.40.81.64824µg/mL 的依替巴肽處理後,檸檬酸樣本使用傳統的高嶺土TEG方法,肝素化樣本使用巴曲酶改良 TEG方法測試。依替巴肽濃度為4µg/mL 5’-二磷酸腺苷誘導的血小板聚集降低到6.4%±2.9%(檸檬酸)和10.3%±4.8%(肝素)。高嶺土 TEG方法顯示只有在依替巴肽濃度為24µg/mL 時最大振幅(MA)才有所降低,α角度沒有變化。然而使用巴曲酶改良TEG方法在依替巴肽濃度0.8µg/mL時就可以觀察到MAα角度的變化。此外,巴曲酶改良TEG方法達到最大MA的時間要短於高嶺土 TEG方法。結論:巴曲酶改良TEG是一種監測依替巴肽導致血小板抑制的靈敏方法。

(殷文淵 陳傑 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.

 

氟烷濃度提高速度和接頭數量對大鼠氟烷最小肺泡麻醉濃度測定的影響

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.

 

電腦類比評估病人最小肺泡麻醉濃度(MAC)技術提示氟烷濃度和接頭數量增加會影響MAC。作者假設這些變化也符合大鼠MAC的測定。本研究測試了這個假設,同時將預期MAC不同的動物分為幾組(懷孕[P]和不懷孕[NP]),評估這些變化是否由於不同組間的MAC差異引起。大鼠分為兩群(n=27n=30)。每群包含未懷孕雌鼠,早孕雌鼠和懷孕晚期雌鼠。第一群每次變化0.20%逐漸提升濃度且使用一個接頭,第二群提升幅度為0.10%且使用四個接頭,然後測試MAC。第二群三組的MAC數值與第一群三組在統計學上有顯著提高。每群組間的數值沒有差別。結果顯示36%的組間差別是由於提升幅度也就是試驗因素導致的。作者的發現證實這樣假設,即MAC研究中麻醉藥物濃度上升速度和幅度會影響MAC的評估。

(殷文淵 陳傑 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.

 

全麻前單次椎旁阻滯可增強乳癌手術是否拌有淋巴結活檢後的鎮痛效果

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.

 

椎旁阻滯(PVB),可以減少乳癌術後疼痛和術後噁心嘔吐(PONV)的發生,但在研究中,沒有設置安慰劑對照。作者隨機、雙盲研究了60例乳癌病人,分為2組,分別在全麻前行T3椎旁阻滯,組Ⅰ為0.5%布比卡因(1.5mg/kg),組Ⅱ為生理鹽水對照組。PVB或假阻滯由不參與研究的麻醉科醫生單獨操作。結果:在麻醉後恢復室內,組Ⅰ患者的靜脈阿片類藥物的用量比組Ⅱ少40%,第一次使用阿片藥物的時間比組Ⅱ晚,24h後疼痛的緩解優於組Ⅱ(P<0.01)。此外,組Ⅰ術後的噁心嘔吐的發生少於組Ⅱ;術後90min的鎮靜情況,組Ⅰ優於組Ⅱ(P<0.05)。在90min內的數位記號置換試驗和術後120min內眼部的協調能力,組Ⅰ優於組Ⅱ(P<0.05)。血漿內平均布比卡因峰值濃度為750ng/ml。一個病人在注射布比卡因後立刻發生雙側抽搐。作者認為在全麻前單次椎旁阻滯均可增強乳癌術後的鎮痛效果,減少阿片藥物用量,降低術後噁心嘔吐的發生,並且改善麻醉的恢復情況。

(顧漪聞 陳傑 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.

 

腹腔鏡膽囊切除術期間醋酸林格氏液容量動力學

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

.

作者選擇了12例女性病人,行腹腔鏡膽囊切除術,研究靜脈注射醋酸林格氏液20ml/kg(約為1500ml60min的分佈和清除情況。雖然限制液體,但是在全麻誘導期間,血漿稀釋率為4.2%。由於隨後的容量擴張所造成額外的血漿稀釋要比原來所預期的資料稍高,平均為18%,原來的預期資料則來自於志願者試驗。利尿劑對靜脈內注射液體的反應很小,在4h後的中僅僅為20%。容量動力學分析顯示:IV液體擴張了身體中央體腔3.2L。分佈和清除常數分別為115ml/min6.8ml/min。這資料說明病人的液體半衰期(4.5h)要比血漿稀釋(16min)長17倍,這就會造成周圍組織的水腫趨勢。以容量動力學為基礎的列線圖顯示注射液體的速率在手術早期應該較快,但是在後期應該減慢。這一策略可產生穩定的期望血液稀釋水平而不導致不恰當外周液體積聚。

(顧漪聞 陳傑 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.

 

評價部分CO2重吸收無創監測兒童CO的價值

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)是血流動力學監測的重要指標,有助於指導危重病人的治療。因有創監測CO的危險性,一般不用於嬰幼兒。通過部分重吸收,建立在二氧化碳Fick原理上的無創CO監測,近來開始應用。但沒有驗證在兒童中的準確性。這是前瞻性的觀察性研究。對象為37位元、年齡小於12歲、行心導管檢查的患者。麻醉方式為氣管內插管、導管無漏氣。麻醉後用熱稀釋法測定CO 並與無創測得的結果比較。用Bland-Altman 圖和線性回歸對成對資料進行系統誤差、精確性和相關性分析。無創檢查結果與熱稀釋法CO的結果具有線性相關性,r 值為0.83(P < 0.03)Bland-Altman分析誤差為–0.27 L/min,精確性為±1.49 L/min。心排指數顯示r 值降低,為0.67 (P = 0.15),誤差為–0.18 L · min–1 · m–2。精確性為±2.13 L · min–1 · m–2.在體表面積 ≤ 0.6 m2 ,潮氣量 <300 mL的兒童中,部分重吸收資料與熱稀釋法資料差別最大。根據以上發現,部分重吸收這種無創方法監測的CO,可用於體表面積 > 0.6 m2 且潮氣量 > 300 mL 的兒童。

(葛甯花譯 薛張綱校)

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.

比較高滲布比卡因腰麻和地氟醚全麻在門診膝關節鏡檢查中的應用

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


在這隨機對照研究中,64位門診膝關節檢查患者,分為選擇性高滲布比卡因4 mg腰麻組(SSA)或地氟醚全麻組(GA)。我們旨在證實小劑量布比卡因是否同樣能夠提供快通道麻醉、在麻醉蘇醒室內觀察時間短、離院快。全麻後噁心、嘔吐達到高危患者作預防性處理。兩組患者快通道可能性或停留在術後麻醉監護室內的時間無差異,離院回家的時間SSA組和GA組分別為114 (31–174) 129 (28–245) min。在醫院內,SSA組疼痛評分明顯低於GA(P < 0.001)GA組需要更多的阿片類鎮痛藥(P = 0.008)。術後噁心嘔吐的發生率SSA組為0%,而GA組為19% (P = 0.024)。我們的結論:門診膝關節鏡檢查的麻醉方法,與地氟醚全麻比較,用高滲布比卡因同樣能使患者迅速恢復且副作用少。

(葛甯花譯 薛張綱校)

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.

 

 

 

 

硬膜外布比卡因阻滯對異丙酚誘導與維持和維持劑量芬太尼與維庫溴胺的影響

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


對局部麻醉和全身麻醉聯合應用的越來越濃厚的興趣 ,引導出一系列研究,研究全身麻醉與局部麻醉如腰麻、硬膜外阻滯、靜脈或肌肉等途徑聯合應用時相互之間的作用。但是,局部麻醉劑同時對平衡麻醉意識喪失、鎮痛、肌松這三要素的作用尚無研究。在這前瞻性、隨機性和雙盲研究中,我們探討布比卡因硬膜外阻滯對全麻時異丙酚(監測雙頻指數BIS)、芬太尼、維庫溴胺劑量的影響。這一研究,包括30位成年患有壺腹部周圍癌的患者,ASA I II,行胰十二指腸切除的Whipple’s手術,手術時間 > 4 h。硬膜外導管放置在T9-10。按雙盲原則,在硬膜外導管內注入負荷劑量的研究的藥物10ml,然後連續注入6 mL/h。患者分成兩組,每組15例。對照組硬膜外導管內注入生理鹽水,實驗組為0.1%布比卡因。全麻誘導為靜脈注射芬太尼2 µg/kg,並根據BIS值推注異丙酚,直到BIS40-50。靜脈注射維庫溴胺0.1 mg/kg後行氣管插管,吸入66%的笑氣。插管後,滴注異丙酚,維持BIS40-50。如果收縮壓和/或心率增加至基礎值20%以上,認為鎮痛不完善,一次性追加芬太尼0.5 µg/kg。監測肌松作用,以決定是否增加維庫溴胺。用Student’s t-檢驗對資料進行統計處理, P ≤0.05為差異有顯著性。布比卡因組,誘導和維持所需的異丙酚分別為1.3 ± 0.3 mg/kg 2.4 ± 0.9 mg · kg–1 · h–1,而對照組則分別為2.4 ± 0.6 mg/kg 4.4 ± 1.6 mg · kg–1 · h–1 (P < 0.05)。全麻維持時,布比卡因組維庫溴胺和芬太尼的量顯著性減少(P < 0.05)。結論,全麻誘導前在硬膜外導管內注入一定劑量的布比卡因,能減少全麻時異丙酚、芬太尼和維庫溴胺的劑量。

(葛甯花譯 薛張綱校)

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:注射異丙酚前注射利多卡因或用異丙酚甘油三酸脂中長鏈劑型的對照雙盲研究

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 Genève, Switzerland

Anesth Analg 2004;99:1699-1702

 

據研究報導,注射異丙酚時,疼痛的發生率為70%。用甘油三酸脂中長鏈(LCT/MCT)製成的新型105乳劑的異丙酚,能減輕注射部位的疼痛。我們旨在比較用異丙酚LCT/MCT劑型或注射前先注入40 mg 利多卡因的Bier’阻滯法對疼痛的影響。200位健康女性進行門診婦科時,進入兩組中的任何一組。LIDO組給予1%的異丙酚2 mg/kg前,靜脈注射2%利多卡因2 mL,並使用止血帶1分鐘;LCT/MCT組在給予1%異丙酚-LCT/MCT 2 mg/kg,靜脈注射0.9%鹽水2 mL,同樣使用止血帶1分鐘。記錄注射時研究物件是否說痛、手動、皺眉和呻吟等表現。在術後30分鐘和1小時,評估疼痛的發生率和嚴重程度。如視覺模糊平分發(VAS >1,回顧性疼痛成立。VAS的範圍為0-10分。許多女性在注射異丙酚-LCT/MCT時說痛(發生率為47%,對照組 24%; P = 0.0014; 相關危險性 1.61 [95% 自信區域, 1.22–2.13]);在有注射疼痛的女性中,術後疼痛的程度或回顧性疼痛無差異。與以往研究報導不同的是,注射異丙酚-LCT/MCT疼痛的發生率比用利多卡因預處理再注射1%異丙酚疼痛的發生率高。這可能與在研究時對疼痛的不同定義,或者與我們沒有使用術前藥有關。

(葛甯花譯 薛張綱校)

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.

 

 

 

臨床濃度吸入麻醉藥對人體K通道TRESK串聯孔區的強大啟動作用

 

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通道家族串聯孔區調節著存在在興奮細胞的背景K電流。通過家族某些細胞的電流被吸入麻醉藥增強,因而認為是麻醉的機理。家族最新成員TRESK對麻醉的敏感性尚無研究。我們從人體脊髓RNA分離TRESK的基因序列,將它表達在非洲蟾蜍的卵母細胞中,並使COS-7細胞感染。在吸入臨床濃度的異氟醚、氟烷、七氟醚和地氟醚時,用整個細胞的壓力鉗和補丁鉗記錄,發現TRESK電流可以增加三倍以上。非麻醉劑對TRESK無作用。各種靜脈麻醉劑,包括依託米酯、硫賁妥鈉和異丙酚對TRESK的電流作用較小。氨基類和酯類局麻藥抑制TRESK,並呈濃度依賴型,但是濃度足夠大時,抑制其他K通道的串聯孔區。我們同樣發現,TRESK不僅存在在脊髓,而且存在在人體大腦的RNA。這些結果說明TRESK是吸入麻醉藥的靶目標,提示這種背景K通道在調節吸入麻醉藥對中樞神經系統的作用時起到一定的作用。

(葛甯花譯 薛張綱校)

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.

 

用高保真的模擬病人來介紹新的麻醉裝備

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

 

新的麻醉機系統越來越複紮。儘管麻醉裝備包含大部分術中麻醉問題(大多數包括人為的錯誤),但是如何將新裝備介紹至臨床的應用,尚無研究。我們設計了隨機、對照、前瞻性的研究,以調查介紹麻醉新裝備的不同方法。15位麻醉醫生接受培訓。他們隨機分配至常規介紹Dräger Fabius GS麻醉機組,並模擬臨床將新裝備用於高保真的模擬病人(HPS) ( 1),或者只是常規介紹(2)。我們用提問方法,詢問他們對新裝備的意見。反饋意見顯示兩組對安全使用新裝備具有可比的自信性。所有的培訓者測試如何應對2種類比的新裝備危急情況。他們的能力以解決危急所需的時間為標準,並由非實驗組的人員通過觀察錄像進行分析。組1解決兩個危急都迅速,具有顯著性。HPS有利於我們發現設計的特點,而這些特點往往是常見錯誤的來源。

(葛甯花譯 薛張綱校)

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.

 

 

 

 

 靜脈注射氯胺酮試驗:預計口服Dextromethorphan對治療神經性疼痛的效果

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
 

靜脈注射試驗劑量以預知隨後口服鎮痛藥的效果,這是普遍使用的方法,以增加療效和保存資源。因為沒有一種靜脈試驗是完全正確的,因此必須評估這種試驗潛在的好處、可能出現的異常和因假陽性而造成的資源浪費,或者因假陰性而放棄應用。進年來,有研究表明,N-甲基-D-天冬氨酸受體的拮抗劑是有效的輔助治療疼痛的藥物。為決定小劑量(0.1 mg/kg)氯胺酮預計口服dextromethorphan (DX)治療劑量的價值,我們分析25位患者服藥後對鎮痛的反應。試驗在2個三級軍事治療中心進行,在這些中心,DX不能輕易得到。兩個藥物≥50%的反應作為測試結果為成功時,氯胺酮試驗陽性陽極預計值為64%,陰性預計值為73%,觀察結果一致性為68%。但是,用氯胺酮緩解疼痛≥67%作為測試指標時,陽性預計值為90%,陰性預計值為80%,觀察結果一致性為84%。根據以上結果,我們得出結論:靜脈注射氯胺酮試驗可能對預計口服DX的反應有用。需要作更多的試驗,以決定這類試驗的理想候選者、合理的劑量和停止氯胺酮後的反應。

(葛甯花譯 薛張綱校)

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.

 

 

心室纖維顫動時的中位元頻率可能不是一個有效的監測心臟停止後用Endothelin-1和腎上腺素治療的指標

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


在這一研究中,我們評價中位元纖維顫動的頻率(MF)和平均纖維顫動的幅度(AMP)能否反應冠狀動脈灌注壓(CoPP)和預示除顫的成功率。在實驗豬長時間的心室顫動(VF)和復蘇過程中,監測MF, AMP CoPPVF 5 分鐘後,開始心肺復蘇。10分鐘後,實驗豬隨機注入單次劑量endothelin-1 50 µg (n = 7), 100 µg (n = 7), 200 µg (n = 5),或重複腎上腺素0.04 mg/kg (n = 6),或每3分鐘注射生理鹽水 (n = 6)25分鐘後,進行除顫,恢復自主循環系統(ROSC)。用光譜非參數分析單個MFCoPPAMPCoPP曲線時,我們發現在不同實驗動物或不同治療手段時,不同的曲線之間沒有聯繫。除顫後ROSC (n = 8)組和沒能ROSC (n = 23)組的MF沒有顯著性的差異(P = 0.85)。我們的資料提示,在持續性VF心臟停止中,MF AMP不能有效地反應心肌的灌注。

(葛甯花譯 薛張綱校)

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.

 

 

 

 


用心率變異性以發現產科患者腰麻時的危險性

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


在這一研究中,我們評價點狀相關係數 (PD2),一種監測心臟變異性的方法,能否預示剖腹產腰麻時的低血壓。用布比卡因進行腰麻,當蛛網膜下腔注藥後20分鐘,收縮壓低於基礎值的≤75%時,認為發生低血壓。用腰麻前PD2 (3.90)將實驗物件分成兩組:LO組和 HI組。所有11位低血壓者在LO組,所有11位無低血壓者在HI組。LO組的基礎心率為95 bpm (10.2 SD)HI組則為81 bpm (9.6 SD) PD2顯示能預計孕婦腰麻後的低血壓。

(葛甯花譯 薛張綱校)

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.

 


頸部硬膜外麻醉用於頸部和上肢的聯合手術:一項引導性研究

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


在這一前瞻性的引導性研究中,我們評價能否用頸部硬膜外麻醉(CEA)進行甲狀旁全切並將它移植至前臂的手術(頸部和上肢的聯合手術)。穿刺點在C6-7,局麻藥為羅呱卡因。適應症為患者所選,或者曾經因頸部的手術造成單側的聲帶麻痹。麻醉藥為10 mL0.75% 羅呱卡因加 10 µg 舒芬太尼2 mL。記錄阻滯起效時間、成功率、鎮痛效果、感覺阻滯的平面、迴圈和呼吸的改變、併發症和住院天數。15例手術均成功地在CEA麻醉下進行。感覺阻滯平面在C2-T10,最低在T3,所有患者的感覺阻滯上限在C2。呼吸系統唯一有顯著性變化的是用力肺活量降低,沒有患者出現臨床呼吸功能不全的表現。我們的結論,頸部和上肢的聯合手術可以用羅呱卡因的CEA麻醉。CEA麻醉可以術中與患者對話,及時發現聲帶麻痹。

(葛甯花譯 薛張綱校)

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.

 

 

 

 

 

比較地氟醚和七氟醚在成年病態肥胖患者外科手術後蘇醒和恢復的特點:一項前瞻性和隨機性研究

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
 
我們比較地氟醚(n = 25)和七氟醚(n = 25)在病態肥胖(體重指數 ≥35)患者開腹行胃腸道旁路手術麻醉後,蘇醒的不同。手術前1小時給予咪唑安定和滅吐靈,放置硬膜外導管,誘導用藥為芬太尼、異丙酚,肌松劑司可林注射後行氣管插管;維持為吸入地氟醚或七氟醚,按照年齡調節至1個最低肺泡吸入濃度(MAC)。用芬太尼、嗎啡或硬膜外局麻藥和血管活性藥物維持血壓在基礎值的±20%、腦電圖雙頻指數在40-60 U。儘管吸入地氟醚的時間長於七氟醚(分別為261 ± 50 min 234 ± 37 min, 均數 ±標準差; P < 0.05),並需要更多的MAC-小時(分別為4.2 ± 0.9 h 3.7 ± 0.8 h; P < 0.05) 但對指令反應時間和拔管時間均快於七氟醚。進入麻醉後監護室(PACU)時,吸入地氟醚組的Aldrete改良評分大於七氟醚組,差異有顯著性(P = 0.01),但出麻醉後監護室時,兩組的Aldrete 評分無差異(P = 0.47)。到達PACU後,地氟醚組氧飽和度(97.0% ± 2.4%)比七氟醚組的氧飽和度高(94.8% ± 4.4%, P = 0.035)。兩組術後噁心嘔吐的發生率和止吐藥劑量無差異。我們得出的結論:前瞻性、隨機性對病態肥胖患者行腹部大手術的研究顯示:吸入地氟醚比吸入七氟醚,蘇醒快,到達PACU時,氧飽和度也高,差異有顯著性。

(葛甯花譯 薛張綱校)

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.

 

扁桃腺肥大的麻醉兒童側臥位時提下頜和托下頜(前伸)對喘鳴評分的影響

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時的上呼吸道梗阻問題,是麻醉醫生主要的挑戰,尤其是對患有扁桃腺肥大的小兒進行麻醉時。在處理阻塞性睡眠呼吸暫停時,最簡單的方法是讓病人側臥位,也可以減輕有阻塞性睡眠呼吸暫停的成人麻醉時的咽部塌陷。本研究中,我們檢驗了麻醉下行扁桃腺摘除術兒童,改變體位和一般的氣道操作如提下頜和托下頜對開放氣道(喘鳴評分)的效果。三十例1-10歲兒童以七氟醚麻醉。吸入5%七氟醚並保留自主呼吸,記錄喘鳴評分。記錄基線水平後,分別在仰臥位和側臥位時行提下頜和托下頜操作。結果是均能改善喘鳴評分。而且,側臥位能顯著地增強這些氣道開放操作的效果。頜前伸結合側臥位為麻醉醫生提供了簡便的氣道管理方法。我們的結論是,相較于病人仰臥位時單獨的氣道操作,側臥位結合氣道操作能顯著改善開放氣道的效果。

(周志堅譯  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 110 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.

 

介紹一種關於類比嬰兒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 Childrens 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

 

關於病人全身情況的模擬器在消除了病人風險的同時,提供了極好的臨床教育所必需的技術和環境。將以模擬器為基礎的訓練擴展到對複雜病人群中基本的及危重的情況的處理中,是很自然的。通過對一個已有的成人模型的整套參數的重新定義,我們描述了嬰兒心血管模型。我們還專門記錄了一個逐步參數估計過程、明確的單一化設想和這些參數的原始資料。這些模擬的生命體征都是在規定的血液動力學變數範圍內。而且,模擬的全身動脈壓波形和左心室壓力容積環都是實際的。該系統對失血會作出適當的反應,且合併有主動脈狹窄也能明確。這一嬰兒心血管模型能為基於螢幕教育類比提供了基礎。該模型的產生也為獲得全身性的,模型驅動的嬰兒模擬器邁出了必要的一步。

(黃麗娜      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.

 

全膝置換術後經口或經靜脈給予氨甲環酸對節約術後用血的效應

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

 

為評估經口或經靜脈注射不同劑量的氨甲環酸(TA)對節約用血的效應,按照前瞻、對照、隨機、單盲的研究設計對擇期行全膝置換術的80例病人進行了研究。病人被分為四個治療組。在TA長時程組中,肢體止血帶放氣前30min 經靜脈給予一衝擊量的TA 15 mg/kg,給藥持續30min,此後按 10 mg · kg1 · h1 的速率持續靜脈輸注直至最後一次止血帶放氣後12 h。在TA短時程組中,按相同方式給藥,但在最後一次下肢止血帶放氣後2h停止靜脈輸注(其時間為出麻醉後監護室的時間),此後分別於6 h12 h口服TA 1 g。口服TA組病人,術後60min口服TA 1 g,術後的18h內每6h口服相同劑量的TA。對照組病人不給TA。出手術室後,與三個TA治療組中的任意一組相比,對照組病人術後異體輸血量顯著增多。由於口服給藥方法簡單,且無需特殊的輸注設備,因此作者建議:與靜脈給藥相比,口服TA是一種相對較好的節約用血的策略.

(邱鬱薇      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 · kg1 · h1 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.

 

靜脈內給予利多卡因抑制芬太尼引起的咳嗽:一個雙盲、前瞻、隨機、安慰劑對照研究

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對氣管插管、拔管、支氣管造影、支氣管鏡檢查和喉鏡檢查的咳嗽反射。我們在502ASA I-II的擇期手術患者中觀察了利多卡因對芬太尼引起的咳嗽的這個作用。以隨機雙盲的方式將患者分成2個等量的組,在給予芬太尼3 µg/kg1 min給予利多卡因1.5 mg/kg或安慰劑(0.9%鹽水),給藥時間5 s。觀察有無咳嗽以及咳嗽分級:輕度(1-2)、中度(3-4)或重度(³5)。研究結果提示給予芬太尼前1 min IV利多卡因1.5 mg/kg,與安慰劑(0.9%鹽水)相比較,顯著有效地抑制芬太尼引起的咳嗽(218165例患者)(P < 0.002),但不影響咳嗽程度(P > 0.05)。

(馬皓琳      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 (12), moderate (34), 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).

 

異氟醚能保護原代混合培養的神經元/神經膠質細胞,使其凋亡不被NMDA的興奮毒性增強

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

 

 吸入麻醉藥能減少原代培養的神經元/神經膠質細胞的急性興奮毒性死亡。我們假設異氟醚保護細胞免於N-甲基-D-門冬氨酸鹽(NMDA)引起的細胞壞死而轉為細胞凋亡。原代培養一級神經元/神經膠質細胞來自胎鼠的大腦,暴露在溶解的異氟醚(0 mM0.4 mM [1.8 MAC]1.6 mM [7 MAC]) NMDA (0 100 µM) 37°C 30 min。將Dizocilpine 10 µM)加100 µM NMDA中作為陽性對照。暴露後24/48 h時,應用 Hoechst/碘化丙啶染色法、TdT介導的缺口末端標記法、DNA片段酶連免疫吸附法和caspase-3啟動實驗檢測細胞的壞死和凋亡。NMDA能增加壞死的細胞數。異氟醚(1.6 mM)和dizocilpine能部分減少細胞壞死,但並不能增加24 h時暴露於100 µM NMDA導致的形態學上凋亡或凋亡樣的細胞數。48 h時,異氟醚所保護的細胞未出現凋亡或凋亡樣的證據。然而,受dizocilpine保護而免於壞死的細胞顯示caspase-3介導的凋亡證據。這些體外資料不支援這樣的假說,即異氟醚保護細胞免於急性興奮毒性壞死而使細胞凋亡。

(趙雪蓮譯   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.

 

在健康志願者控制輸注異丙酚和雷米芬太尼期間用聽覺誘發電位監測鎮靜深度

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

 

對於重症監護病人來說主要的問題是避免過度鎮靜。我們研究了是否能用長潛伏期聽覺誘發電位來客觀地評估臨床上鎮靜的相應水平。我們在逐步升高臨床上鎮靜的相應水平(Ramsay評分〔RS2-4)期間,對10個健康志願者在刺激後100 ms時測定聽覺誘發電位(N100)。在三種單獨的條件下,對接受輸注異丙酚或聯合輸注異丙酚和雷米芬太尼的志願者進行研究。在靶控輸注過程中試驗單獨輸注雷米芬太尼的作用(血漿靶濃度為:123 ng/ml)。雷米芬太尼不影響誘發電位的振幅和潛伏期。在異丙酚誘導和異丙酚/雷米芬太尼誘導的鎮靜期間,鎮靜水平Ramsay評分從2級升高到4級時,N100的振幅同樣下降而潛伏期反應時間並沒有受到影響(P < 0.01)。在相同的臨床鎮靜水平,單獨用異丙酚達到鎮靜時的異丙酚血漿濃度較大(異丙酚比異丙酚/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)。我們的研究結果提示長潛伏期聽覺誘發電位提供了一個客觀的不依賴于所用鎮靜方案來評估臨床鎮靜的電生理模擬方法。

(彭中美譯  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] 24). 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.

 

 

比較供體右葉肝切除術和肝腫瘤肝大部切除術後的疼痛治療

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

 

在我們機構開始活供體肝移植計畫後,儘管使用了胸段病人自控硬膜外鎮痛(PCEA)輸注導管,我們仍觀察到供體病人經歷了顯著的手術後疼痛。為了闡述其原因, 我們回顧比較了接受供體右葉肝切除術的病人(RLDH, n = 15)和因為腫瘤接受肝大部切除術的病人(MHRT, n = 15)。所有病人術前放置胸段硬膜外導管,兩組的外科手術暴露相似。收集和分析了病人的一般資料、術中變數,以視覺類比疼痛評分(VAPS)的術後疼痛程度、副作用、需要的和給予的PCEA劑量以及術後48小時裏給予的布比卡因總量(mg)和PCEA溶液的容積(mL)。RLDH組比MHRT組的手術時間顯著延長。RLDH組的病人術後疼痛評分更高(P = 0.034),比MHRT組病人疼痛的可能性高2.76 (1.126.82, 95% CI)倍。給予的布比卡因的量和PCEA溶液的容積,在兩組之間沒有顯著性差異。這些觀察結果的部分原因可能為RLDH組的手術時間更長。文章討論了通過PCEA輸注的優先鎮痛的可能作用和對PCEA使用的更好的圍術期指導;這些可以使得RLDH組病人術後早期疼痛控制的改善。

(張        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 (1.126.82, 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.

 

機械通氣狗分級低血容量和高血容量時心臟前負荷改變的比較

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

 

我們開發了一種測量收縮壓變異性(SPV)及其高、低(dDown)成份以及脈壓變異性(dPP)的線上監測系統。我們使用這個系統來比較機械通氣狗在正常血量、分級低血容量(–200和–350 mL)及高血容量(+200+350 mL)時各種心臟前負荷指標,例如每搏輸出量變異性(SVV)和校正血流時間(FTc)及中心靜脈壓和肺動脈楔壓。我們同時測量這些前負荷指標和全身血液動力學變數,並觀察其評估前負荷變化的正確性和局限性。低血容量(350 mL)SPV從基礎值4.8 ± 1.4 mm Hg增加到11.2 ± 1.8 mm Hg,但高血容量時SPV無明顯變化。觀察到dDowndPPSVV相似的變化。相反,FTc在高血容量時增加,但低血容量時保持不變。研究結果顯示SPVdDowndPPSVV是低血容量而非高血容量的有用指標。相反,用FTc不能可靠地察覺低血容量,但它能反映高血容量時的血容量變化。儘管SPVdDowndPP的測量無需動脈置管以外的有創操作和費用,但必須記住它們僅限於對機械通氣的患者血容量狀態的監測。

(朱       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 indicatorssuch 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.

 

鞘內注射硫酸鎂對家兔是否安全且是否保護其免於缺血性脊髓損傷?

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

 

我們對家兔進行了三批實驗,以研究鞘內注射硫酸鎂的安全性及確定對於缺血性脊髓損傷是否存在保護作用以及產生保護作用的最佳劑量。第一批實驗分別測定鞘內注射0.3123 mg/kg硫酸鎂(每組n6)的神經毒性。3 mg/kg組在給藥後7天出現較顯著的感覺功能障礙。2 mg/kg組和3 mg/kg組各有2只家兔出現運動功能障礙。1 mg/kg組有1只家兔,2mg/kg組有2只家兔,3mg/kg組有1只家兔在脊髓V-VII 層出現損害區。第二批實驗研究鞘內注射3 mg/kg硫酸鎂後家兔的組織病理學改變的暫時特性(6 h48 h96 h〔各組n = 3〕,證實給藥後4896 h出現運動功能障礙的家兔有相似的組織病理學改變。第三批實驗評估了家兔脊髓缺血前分別鞘內注射硫酸鎂0.3 mg/kg1 mg/kg和生理鹽水(每組n6)對脊髓缺血後(15 min)家兔後肢運動功能及組織病理學改變的影響。鎂劑並不能改善再灌注96 h後神經功能或組織病理學預後。該結果表明鞘內注射鎂劑有產生神經毒性的風險性,且未顯示證據證實其對脊髓缺血損傷具保護作用。

(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導管置入在脊柱屈曲或不屈曲狀況下的成功率相當

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

 

硬膜外導管放置所需的體位對下肢損傷的患者來說是非常痛苦的。我們隨機將50名下肢損傷預備進行手術的患者分成兩組,在背部處於中立不彎曲的坐位分別用直入法或旁正中法進行腰段硬膜外導管置入。如果嘗試兩次仍未成功,則使患者處於脊柱彎曲的體位再進行嘗試。記錄技術的困難度和併發症。直入法組的17名患者和旁正中法的1名患者最初無法進針,需要脊柱彎曲的體位元(P < 0.05)。直入法導管置入遇到阻力(81)、有感覺異常的(70)及導管內見血的發生(60)與旁正中法相比明顯更常見。直入法組所經歷的舒適度也比旁正中法更差。我們得出結論:患者處於脊柱不彎曲的坐位時,用旁正中法置入硬膜外導管通常是可行的。

(陳        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.

 

持續脊麻小孔徑導管的機械特性

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

 

 持續脊麻(CSA)已有近百年的歷史。當出現CSA小孔徑導管拔除困難的情況時,不同導管的機械特性可能是非常重要的,因為導管可能發生斷裂。我們比較了5種不同的小孔徑導管(2228號,來自3家廠商)的抗張強度、張應力、延伸性以及彎曲強度。導管斷裂前所用的力就是最大抗張強度。不同CSA小孔徑導管在最大抗張強度的材料特性方面為:室溫下22= 29.56 ± 1.56 (mean ± SD) 牛頓 (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。可以觀察到,最大抗張強度和導管外徑之間(r = 0.957, P < 0.001)以及最大抗張強度與管壁厚度之間(r = 0.9, P < 0.001)存在很強的相關性,。儘管用實驗研究去外推到臨床常規時必須十分小心,我們的資料提示較高強度特性的導管可以減少導管在病人體內斷裂的危險性,儘管目前仍缺乏臨床上的相關性。

(黃施偉      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.