Anesthesia & Analgesia

January 2005

Table of Content

 

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

麻醉管理与非心脏手术术后一年死亡率

沈洪 薛张刚

Anesthetic Management and One-Year Mortality After Noncardiac Surgery

Terri G. Monk, Vikas Saini, B. Craig Weldon, and Jeffrey C. Sigl

Anesth Analg 2005 100: 4-10.

CARDIOVASCULAR ANESTHESIA:

急性等容血液稀释在单肺通气时对氧合作用的影响

李士通

The Effects of Acute Isovolemic Hemodilution on Oxygenation During One-Lung Ventilation

Laszlo L. Szegedi, Philippe Van der Linden, Anne Ducart, Pieter Cosaert, Jan Poelaert, Frank Vermassen, Eric P. Mortier, and Alain A. d’Hollander

Anesth Analg 2005 100: 15-20.

 

经皮血管造影下显示导引钢丝J型头端的方向是锁骨下静脉导管位置不正确的显著影响因素:一项随机,对照研究

朱辉 译 陈杰 校

Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study
Mukesh Tripathi, Prakash K. Dubey, and Sushil P. Ambesh

Anesth Analg 2005 100: 21-24.

 

地氟醚麻醉心脏手术后应用左布比卡因胸骨旁阻滞和浸润对术后疼痛、肺功能以及拔管时间的影响

沈洪 薛张刚

Parasternal Block and Local Anesthetic Infiltration with Levobupivacaine After Cardiac Surgery with Desflurane: The Effect on Postoperative Pain, Pulmonary Function, and Tracheal Extubation Times
Susan B. McDonald, Eric Jacobsohn, Dan J. Kopacz, Seema Desphande, James D. Helman, Francis Salinas, and R. Alan Hall

Anesth Analg 2005 100: 25-32.

 

继发于中枢神经系统中一氧化氮增加的交感传出减少导致肝素后鱼精蛋白产生的低血压

李士通

Protamine After Heparin Produces Hypotension Resulting from Decreased Sympathetic Outflow Secondary to Increased Nitric Oxide in the Central Nervous System

Yoshikazu Hamada, Yoshiyuki Kameyama, Hideyuki Narita, Kirk T. Benson, and Hiroshi Goto

Anesth Analg 2005 100: 33-37.

 

Fick’s公式导出的实时估算混合静脉血异氟醚浓度的方法

殷文渊 译 陈杰 校

A Real-Time Method for Estimating the Concentrations of Isoflurane in Mixed Venous Blood by a Derived Fick’s Equation

Wai M. Ho, Nae C. Yang, K. C. Wong, and Kai L. Hwang

Anesth Analg 2005 100: 38-45

 

麻醉药预处理:自由基在几内亚猪离体心脏由七氟醚介导的减弱线粒体电子传导中的作用

沈洪 薛张刚

Anesthetic Preconditioning: The Role of Free Radicals in Sevoflurane-Induced Attenuation of Mitochondrial Electron Transport in Guinea Pig Isolated Hearts

Matthias L. Riess, Leo G. Kevin, Joseph McCormick, Ming T. Jiang, Samhita S. Rhodes, and David F. Stowe

Anesth Analg 2005 100: 46-53.

PEDIATRIC ANESTHESIA:

麻醉对上呼吸道感染的患儿:还困难吗?

裘毅敏 李士通

Anesthesia for the Child with an Upper Respiratory Tract Infection: Still a Dilemma? (Review Article)

Alan R. Tait and Shobha Malviya

Anesth Analg 2005 100: 59-65.

 

等比重罗哌卡因(5 mg/ml)在儿童脊麻中的应用

殷文渊 译 陈杰 校

Isobaric Ropivacaine 5 mg/mL for Spinal Anesthesia in Children

Hannu Kokki, Paula Ylönen, Merja Laisalmi, Marja Heikkinen, and Matti Reinikainen

Anesth Analg 2005 100: 66-70

 

异丙酚和七氟醚对儿童QT间期及复极化跨膜弥散的影响

孙敏莉 薛张纲

The Effects of Propofol and Sevoflurane on the QT Interval and Transmural Dispersion of Repolarization in Children

Simon D. Whyte, Peter D. Booker, and David G. Buckley

Anesth Analg 2005 100: 71-77.

 

容量减少性浓缩血小板中的血小板功能完整性

周志坚 李士通  

The Functional Integrity of Platelets in Volume-Reduced Platelet Concentrates

Helge Schoenfeld, Manfred Muhm, Ulrich R. Doepfmer, Wolfgang J. Kox, Claudia Spies, and Hartmut Radtke

Anesth Analg 2005 100: 78-81

AMBULATORY ANESTHESIA:

一般患者和医疗保健专职人员对术后恢复和术后恶心呕吐处理方面的比较

顾漪闻 译 陈杰 校

A Comparison of Patients’ and Health Care Professionals’ Preferences for Symptoms During Immediate Postoperative Recovery and the Management of Postoperative Nausea and Vomiting
Anna Lee, Tony Gin, Angel S. C. Lau, and Floria F. Ng

Anesth Analg 2005 100: 87-93.

 

眼球周围麻醉:小剂量麻醉剂经皮注射技术

孙敏莉 薛张纲

Peribulbar Anesthesia: A Percutaneous Single Injection Technique with a Small Volume of Anesthetic

Leonardo Rizzo, Maurizio Marini, Chiara Rosati, Italo Calamai, Michela Nesi, Roberto Salvini, Cinzia Mazzini, Fiamma Campana, and Enzo Brizzi

Anesth Analg 2005 100: 94-96.

ANESTHETIC PHARMACOLOGY:

对猫静脉给予利多卡因对异氟醚肺泡最低浓度的影响

彭中美 李士通

The Effects of Intravenous Lidocaine Administration on the Minimum Alveolar Concentration of Isoflurane in Cats

Bruno H. Pypendop and Jan E. Ilkiw

Anesth Analg 2005 100: 97-101.

α2肾上腺素能受体在哌替啶对小鼠体温调节中枢的影响

顾漪闻 译 陈杰 校

The Effect of Meperidine on Thermoregulation in Mice: Involvement of {alpha}2-Adrenoceptors

Andrea Paris, Christina Ohlendorf, Michael Marquardt, Berthold Bein, James M. Sonner, Jens Scholz, and Peter H. Tonner
Anesth Analg 2005 100: 102-106.

 

在意识丧失和清醒时异丙酚个体效应点浓度是类似的

孙敏莉 薛张纲

在意识丧失及唤醒时丙泊酚的个体作用部位浓度相似

周雅春   李士通

Individual Effect-Site Concentrations of Propofol Are Similar at Loss of Consciousness and at Awakening

Hiroko Iwakiri, Noboru Nishihara, Osamu Nagata, Takashi Matsukawa, Makoto Ozaki, and Daniel I. Sessler

Anesth Analg 2005 100: 107-110.


三磷酸腺苷对维库溴铵神经肌肉阻滞的影响

朱慧琛 译 陈杰 校

The Effect of Adenosine Triphosphate on Vecuronium-Induced Neuromuscular Block

Keiichi Nitahara, Shinjiro Shono, Takamitsu Hamada, Hideyuki Higuchi, Tadakazu Sakuragi, and Kazuo Higa

Anesth Analg 2005 100: 116-119.

 

对乙酰氨基酚、阿司匹林和安乃近对几内亚猪离体小肠蠕动的影响

吴德华 薛张刚

Peristalsis in the Guinea Pig Small Intestine In Vitro Is Impaired by Acetaminophen but Not Aspirin and Dipyrone

Michael K. Herbert, Rebecca Weis, Peter Holzer, and Norbert Roewer

Anesth Analg 2005 100: 120-127.

 

硫喷妥钠在大鼠身上产生制动主要通过脊髓上位作用

黄施伟 李士通

Thiopental Produces Immobility Primarily by Supraspinal Actions in Rats

Caroline Stabernack, Yi Zhang, James M. Sonner, Michael Laster, and Edmond I Eger, II

Anesth Analg 2005 100: 128-136

TECHNOLOGY, COMPUTING, AND SIMULATION:

异丙酚诱导意识丧失和SNAP指数之间的关系

孙敏莉 薛张纲

The Association Between Propofol-Induced Loss of Consciousness and the SNAPTM Index

Cynthia A. Wong, Robert J. Fragen, Paul C. Fitzgerald, and Robert J. McCarthy

Anesth Analg 2005 100: 141-148.

用于拇内收肌神经肌肉监测的四个成串刺激可置于腕部或手上

马皓琳 李士通

Train-of-Four Stimulation for Adductor Pollicis Neuromuscular Monitoring Can Be Applied at the Wrist or Over the Hand

Marie-Eve Nepveu, François Donati, and Louis-Philippe Fortier

Anesth Analg 2005 100: 149-154

PAIN MEDICINE:

医疗保健鉴定联合委员会对疼痛围术期阿片类药物需求量和恢复室停留时间的影响

朱慧琛 译 陈杰 校

The Impact of the Joint Commission for Accreditation of Healthcare Organizations Pain Initiative on Perioperative Opiate Consumption and Recovery Room Length of Stay
Peter E. Frasco, Juraj Sprung, and Terrence L. Trentman

Anesth Analg 2005 100: 162-168.

 

奈福泮与氯氨酮在增强术后镇痛中的比较

金琳 薛张纲

Nefopam and Ketamine Comparably Enhance Postoperative Analgesia

Barbara Kapfer, Pascal Alfonsi, Bruno Guignard, Daniel I. Sessler, and Marcel Chauvin

Anesth Analg 2005 100: 169-174.

 

利多卡因兴奋重组椎实螺(Lymnaea stagnalis呼吸模式发生器的突触前及后神经元

王立中 译,李士通

Lidocaine Excites Both Pre- and Postsynaptic Neurons of Reconstructed Respiratory Pattern Generator in Lymnaea stagnalis
Shin Onizuka, Toshiharu Kasaba, Toshiro Hamakawa, and Mayumi Takasaki

Anesth Analg 2005 100: 175-182.

REVIEW ARTICLES:

术后胃肠道功能紊乱

金琳 薛张纲

Postoperative Gastrointestinal Tract Dysfunction

Michael G. Mythen

Anesth Analg 2005 100: 196-204.

 

心脏手术后拔除胸腔引流管三种镇痛方法的随机比较

轩泓 李士通

A Randomized Comparison of Three Methods of Analgesia for Chest Drain Removal in Postcardiac Surgical Patients
Maria Akrofi, Scott Miller, Steve Colfar, Peter R. Corry, Brian M. Fabri, Mark D. Pullan, Glenn N. Russell, and Mark A. Fox

Anesth Analg 2005 100: 205-209.

 

气管损伤的保守治疗

齐波 译 陈杰 校

Conservative Treatment of Tracheal Injuries
Martin Beiderlinden, Michael Adamzik, and Jürgen Peters

Anesth Analg 2005 100: 210-214.

NEUROSURGICAL ANESTHESIA:

对海马切片培养标本有神经保护作用的是轻度低温,而不是异丙酚

金琳 薛张纲

Mild Hypothermia, but Not Propofol, Is Neuroprotective in Organotypic Hippocampal Cultures
John R. Feiner, Philip E. Bickler, Sergio Estrada, Paul H. Donohoe, Christian S. Fahlman, and Jennifer A. Schuyler

Anesth Analg 2005 100: 215-225.

 

可乐定在神经外科手术中的应用

张俊杰 李士通

Intraoperative Clonidine Administration to Neurosurgical Patients
Claudia Stapelfeldt, Errol P. Lobo, Ronald Brown, and Pekka O. Talke

Anesth Analg 2005 100: 226-232

OBSTETRIC ANESTHESIA:

雷米芬太尼:一种新的分娩全身镇痛药

齐波 译 陈杰 校

Remifentanil: A Novel Systemic Analgesic for Labor Pain
Shmuel Evron, Marek Glezerman, Oskar Sadan, Mona Boaz, and Tiberiu Ezri

Anesth Analg 2005 100: 233-238.

 

鞘内注射吗啡用于产后双侧输卵管结扎后的镇痛

廖庆武 薛张纲校

Intrathecal Morphine for Analgesia After Postpartum Bilateral Tubal Ligation

Ashraf S. Habib, Holly A. Muir, William D. White, Tede E. Spahn, Adeyemi J. Olufolabi, Terrance W. Breen, and The Duke Women’s Anesthesia Research Group

Anesth Analg 2005 100: 239-243.

REGIONAL ANESTHESIA:

用区域麻醉和镇痛抑制乳房癌手术应激反应并不影响血管内皮生长因子和前列腺素E2

沈浩 李士通

Inhibition of the Stress Response to Breast Cancer Surgery by Regional Anesthesia and Analgesia Does Not Affect Vascular Endothelial Growth Factor and Prostaglandin E2
S. C. O’Riain, D. J. Buggy, M. J. Kerin, R. W. G. Watson, and D. C. Moriarty

Anesth Analg 2005 100: 244-249.

 

拉氏坐骨神经阻滞时足跖曲比背曲更具可信度:一个前瞻性、随机对比

赵雪莲 李士通

Plantar Flexion Seems More Reliable than Dorsiflexion with Labat’s Sciatic Nerve Block: A Prospective, Randomized Comparison

Manuel Taboada, Peter G. Atanassoff, Jaime Rodríguez, Joaquín Cortés, Sabela Del Rio, Juan Lagunilla, Francisco Gude, and Julián Álvarez

Anesth Analg 2005 100: 250-254.

 

清醒大鼠持续胸段硬膜外麻醉引起节段性交感神经阻滞

赵延华 译 陈杰 校

Continuous Thoracic Epidural Anesthesia Induces Segmental Sympathetic Block in the Awake Rat

Hendrik Freise, Sören Anthonsen, Lars G. Fischer, Hugo K. Van Aken, and Andreas W. Sielenkämper

Anesth Analg 2005 100: 255-262.

GENERAL ARTICLES:

胸腔内视镜交感神经切断术时外周皮肤血流量和温度的比较

廖庆武 薛张纲

A Comparison of Peripheral Skin Blood Flow and Temperature During Endoscopic Thoracic Sympathotomy

John H. Eisenach, Tasha L. Pike, Diane E. Wick, Niki M. Dietz, Robert D. Fealey, John L. D. Atkinson, and Nisha Charkoudian

Anesth Analg 2005 100: 269-276.

 

内窥镜交感神经切除术全程中手掌皮肤血流和温度反应

  李士通

Palmar Skin Blood Flow and Temperature Responses Throughout Endoscopic Sympathectomy

Craig G. Crandall, Dan M. Meyer, Scott L. Davis, and Suzanne M. Dellaria

Anesth Analg 2005 100: 277-283.

 

经喉罩插入常规的气管导管

赵延华 译 陈杰 校

Conventional Tracheal Tubes for Intubation Through the Intubating Laryngeal Mask Airway

Pankaj Kundra, N. Sujata, and M. Ravishankar

Anesth Analg 2005 100: 284-288.

 

 

麻醉管理与非心脏手术术后一年死亡率

Anesthetic management and one-year mortality after noncardiac surgery

Monk TG, Saini V, Weldon BC, Sigl JC.

Department of Anesthesiology Duke University Medical Center, Durham, NC 27705, USA.

Anesth Analg. 2005 Jan;100(1):4-10.

 

麻醉管理对长期效果的影响人们还知之甚少。我们设计了一个前瞻性观测研究:研究成人在全麻下非心脏手术术后一年内死亡率是否与人口统计学、术前临床状况、外科手术、以及术中情况等变量有关。在所有病人(N1064)中一年死亡率是5.5%65岁(包括65岁)以上病人(N=243)死亡率是10.3%。多变异Cox回归分析比例转机模型表明这三个变量具有显著的独立预测作用:病人合并症(相对危险=16.116P<0.0001,累计深度麻醉时间(双频谱指数<45)(相对危险=1.224/h;P0.0121),术中低血压(相对危险=1.036/minP0.0125)。术后一年的死亡率主要与先前的疾病史有关。然而累计深度麻醉时间以及术中低血压同样是死亡率增加的显著的独立预测因素。这种关联表明术中麻醉管理对手术结果的影响可能比预期时间要长。

(沈洪 薛张刚 校)

Little is known about the effect of anesthetic management on long-term outcomes. We designed a prospective observational study of adult patients undergoing major noncardiac surgery with general anesthesia to determine if mortality in the first year after surgery is associated with demographic, preoperative clinical, surgical, or intraoperative variables. One-year mortality was 5.5% in all patients (n = 1064) and 10.3% in patients > or =65 yr old (n=243). Multivariate Cox Proportional Hazards modeling identified three variables as significant independent predictors of mortality: patient comorbidity (relative risk, 16.116; P <0.0001), cumulative deep hypnotic time (Bispectral Index <45) (relative risk=1.244/h; P=0.0121) and intraoperative systolic hypotension (relative risk=1.036/min; P=0.0125). Death during the first year after surgery is primarily associated with the natural history of preexisting conditions. However, cumulative deep hypnotic time and intraoperative hypotension were also significant, independent predictors of increased mortality. These associations suggest that intraoperative anesthetic management may affect outcomes over longer time periods than previously appreciated.

 

地氟醚麻醉心脏手术后应用左布比卡因胸骨旁阻滞和浸润对术后疼痛、肺功能以及拔管时间的影响

Parasternal block and local anesthetic infiltration with levobupivacaine after cardiac surgery with desflurane: the effect on postoperative pain, pulmonary function, and tracheal extubation times

McDonald SB, Jacobsohn E, Kopacz DJ, Desphande S, Helman JD, Salinas F, Hall RA.

Department of Anesthesiology, Virginia Mason Medical Center, 1100 Ninth Ave., PO Box 900, Mailstop B2-AN, Seattle, WA 98111, USA.

Anesth Analg. 2005 Jan;100(1):25-32.

早期拔管在心脏术后已很常见。达到这一目标麻醉技术面临早期术后镇痛的挑战。我们采取随机,安慰剂对照,双盲研究术后胸骨旁阻滞对镇痛,呼吸功能以及拔管时间的影响。我们选择了20例胸骨正中切口的心脏手术病人;17例完成了研究。麻醉过程以地氟醚为基础,应用小剂量阿片类维持。在胸骨金属丝放置前,胸外科医生进行胸骨旁阻滞以及切口和放置引流管处局部浸润。应用含有1400000肾上腺素0.25%的左布比卡因54ml,或以54ml的生理盐水为安慰剂。24小时内观察镇痛效果以及肺功能。左布比卡因组病人在术后第一个4小时应用吗啡量比对照组明显要少(20.8 +/- 6.2 mg 33.2 +/- 10.9 mgP0.013);而且在拔管过程中有更好的氧合。对照组9个人中有4个人需要疼痛救助,而左布比卡因组8个人中无人需要疼痛救助(P0.08)。所有病人血浆左布比卡因浓度均低于潜在毒性水平(0.64 +/- 0.43 microg/mL;范围:0.24-1.64 microg/mL)。应用左布比卡因胸骨旁阻滞以及伤口和放置引流管处局部浸润对于早期想拔除气管导管的心脏病人是很有效的。

(沈洪 薛张刚 校)

Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.

 

麻醉药预处理:自由基在几内亚猪离体心脏由七氟醚介导的减弱线粒体电子传导中的作用

Anesthetic preconditioning: the role of free radicals in sevoflurane-induced attenuation of mitochondrial electron transport in Guinea pig isolated hearts

Riess ML, Kevin LG, McCormick J, Jiang MT, Rhodes SS, Stowe DF.

Anesthesiology Research Laboratories, Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA.

Anesth Analg. 2005 Jan;100(1):46-53.

 

心脏保护的麻醉预处理作用可以被一氧化氮合成酶抑制剂或活性氧物质(ROS)清除剂消除。我们以前报道过七氟醚预处理中线粒体电子传递(ET)减弱以及活性氧物质的增加是激发心脏保护的麻醉预处理机制。我们假定是一氧化氮和活性氧物质参与了麻醉药介导的减弱电子传递(ET)的作用。在线检测68Langendorff灌流的几内亚猪离体心脏的心功能和减少的烟酰胺腺嘌呤二核苷酸(NADH)荧光,这是线粒体电子传递指标。所有心脏都经过30分钟完全缺血和120分钟的再灌注。在缺血前,无论是否给以1.3mM的七氟醚进行心脏保护的预处理,所有心脏都临时给予超氧化物歧化酶、过氧化氢酶、谷光甘肽以清除ROSL-NG-硝基精氨酸甲酯(L-NAME)来阻止一氧化氮合成酶。心脏保护的麻醉预处理能够暂时增加缺血前的NADH,换言之,能够减弱线粒体的电子传递。这种NADH的增加以及麻醉预处理对再灌注的心脏保护作用都可以被超氧化物歧化酶、过氧化氢酶、谷光甘肽、L-NG-硝基精氨酸甲酯所阻断。因此,活性氧物质和一氧化氮或包括过(氧化)亚硝盐等反应产物都参与了七氟醚介导的减弱电子传递作用。这可能导致正反馈机制使活性氧物质增加继发改变线粒体功能从而激活麻醉预处理的心脏保护作用。

(沈洪 薛张刚 校)

Cardioprotection by anesthetic preconditioning (APC) can be abolished by nitric oxide (NO*) synthase inhibitors or by reactive oxygen species (ROS) scavengers. We previously reported attenuated mitochondrial electron transport (ET) and increased ROS generation during preconditioning sevoflurane exposure as part of the triggering mechanism of APC. We hypothesized that NO* and other ROS mediate anesthetic-induced ET attenuation. Cardiac function and reduced nicotinamide adenine dinucleotide (NADH) fluorescence, an index of mitochondrial ET, were measured online in 68 Langendorff-prepared guinea pig hearts. Hearts underwent 30 min of global ischemia and 120 min of reperfusion. Before ischemia, hearts were temporarily perfused with superoxide dismutase, catalase, and glutathione to scavenge ROS or N(G)-nitro-L-arginine-methyl-ester (L-NAME) to inhibit NO* synthase in the presence or absence of 1.3 mM sevoflurane (APC). APC temporarily increased NADH before ischemia, i.e., it attenuated mitochondrial ET. Both this NADH increase and the cardioprotection by APC on reperfusion were prevented by superoxide dismutase, catalase, and glutathione and by N(G)-nitro-L-arginine-methyl-ester. Thus, ROS and NO*, or reaction products including peroxynitrite, mediate sevoflurane-induced ET attenuation. This may lead to a positive feedback mechanism with augmented ROS generation to trigger APC secondary to altered mitochondrial function.

 

异丙酚和七氟醚对儿童QT间期及复极化跨膜弥散的影响

The effects of propofol and sevoflurane on the QT interval and transmural dispersion of repolarization in children.

Whyte SD, Booker PD, Buckley DG.

Children's Hospital, Department of Anesthesia, Room 1L7, 4480 Oak Street, Vancouver, BC, V6H 3V4.

Anesth Analg. 2005 Jan;100(1):71-7

 

QT间期延长与尖端扭转型室性心动过速(TdP)相关,特别是在有长QT综合症的儿童和青年中。TdP的敏感性起源于穿透心肌细胞壁的复极化跨膜弥散(TDR)增加。几种麻醉药物可以延长QT间期,但是对于TDR的影响尚不清楚。TDR可以在心电图上被测量(ECG),即T波波峰和T波终点(Tp-e)之间的时间间隔。我们随机抽取了50ASA体格状态III级,年龄在116岁的儿童,随机接受异丙酚(组P)或七氟醚(组S),调查异丙酚和七氟醚对校正QTQTc)及Tp-e的影响。十二导联心电图在术前及术中被记录。七氟醚显著延长术前QTc;而异丙酚却无。两者对于术前Tp-e没有任何显著影响。在儿童,七氟醚较异丙酚极大延长了心肌复极化持续时间,但是对于复极化弥散度无影响,因此两种麻醉剂的TdP的危险性有可能是很小的。

(孙敏莉 薛张纲 校)

Prolongation of the QT interval is associated with torsades de pointes (TdP), especially in children or young adults with long QT syndromes. Susceptibility to TdP arises from increased transmural dispersion of repolarization (TDR) across the myocardial wall. Several anesthetic drugs prolong the QT interval, but their effect on TDR is unknown. TDR can be measured on the electrocardiograph (ECG) as the time interval between the peak and end of the T wave (Tp-e). We investigated the effects of propofol and sevoflurane on the corrected QT (QTc) and Tp-e intervals in 50 unpremedicated ASA physical status I-II children, aged 1-16 yr, who were randomized to receive propofol (group P) or sevoflurane (group S). Twelve-lead ECGs were recorded preoperatively and intraoperatively. Sevoflurane significantly prolonged the preoperative QTc; propofol did not. Neither anesthetic had any significant effect on the preoperative Tp-e. Sevoflurane increases the duration of myocardial repolarization in children to a larger extent than does propofol, but as the dispersion of repolarization appears unaffected, the risk of TdP is likely to be minimal with either anesthetic.

 

眼球周围麻醉:小剂量麻醉剂经皮注射技术.

Peribulbar anesthesia: a percutaneous single injection technique with a small volume of anesthetic

Rizzo L, Marini M, Rosati C, Calamai I, Nesi M, Salvini R, Mazzini C, Campana F, Brizzi E.

Department of Critical Care Medicine and Surgery, Section of Anesthesiology, University of Florence, Viale Morgagni 85, 50134, Florence, Italy.

Anesth Analg. 2005 Jan;100(1):94-6

 

我们评估使用小剂量麻醉剂注射技术用于眼球周围麻醉的效能及安全性。我们收集了接受各种眼科操作的857名患者。麻醉包括经皮注射5-6.5ml2%利多卡因。2分钟时,85.6%的患者出现至少50%的运动阻滞;5分钟时,78.6%患者有>80%的运动阻滞;5分钟以后100%的患者有了充足的外科麻醉。所有患者没有严重阻滞相关并发症。对于经典技术,本文所描述的技术是一项简单而令人满意的选择。

(孙敏莉 薛张纲 校)

We evaluated the efficacy and safety of a single injection technique with a small volume of anesthetic for ocular peribulbar anesthesia. We included 857 patients undergoing various ophthalmic procedures. Anesthesia consisted of a medial percutaneous injection of 5-6.5 mL of 2% lidocaine. At 2 min 85.6% of the patients had a motor block of at least 50% and at 5 min 78.6% had a motor block >80%. After 5 min 100% of the patients had adequate surgical anesthesia. There were no serious block-related complications. The described technique is a simple and satisfactory alternative to the classical techniques.

 

在意识丧失和清醒时异丙酚个体效应点浓度是类似的

Individual effect-site concentrations of propofol are similar at loss of consciousness and at awakening.

Iwakiri H, Nishihara N, Nagata O, Matsukawa T, Ozaki M, Sessler DI.

Department of Anesthesiology, Tokyo Women's Medical University, Tokyo 162-8666, Japan.

Anesth Analg. 2005 Jan;100(1):107-10.

 

关于异丙酚在意识丧失和意识恢复的效应点浓度的报道很大程度上不同。因此,没有以总体均数为依据的单一浓度来证明对于个体患者最佳浓度。所以我们测试的假说:在意识丧失和恢复期个体异丙酚效应点浓度是类似的。在20名成年志愿者中,通过靶控输注系统评估在意识丧失和恢复时异丙酚效应点浓度。异丙酚效应点浓度逐步升高直到志愿者丧失意识(对声音刺激无反应);无意识状态维持15分钟,志愿者渐清醒。这样的实验在每个者愿者重复3次。我们主要的结果是浓度产生无意识及评估的意识丧失和恢复的效应点浓度之间的关系。靶效应点异丙酚浓度在意识丧失时是2.0±0.9,意识恢复时是1.8±0.7(P <0.001)。平均个体效应点浓度在意识恢复与丧失之间差仅为0.17±0.32 微克/mL95%的可信区间差为0.09-0.25 微克/mL)。我们的结果提示,意识丧失浓度个体滴定可基于平均总体需要量定量异丙酚剂量是一种选择。

(孙敏莉 薛张纲 校)

Reported effect-site concentrations of propofol at loss of consciousness and recovery of consciousness vary widely. Thus, no single concentration based on a population average will prove optimal for individual patients. We therefore tested the hypothesis that individual propofol effect-site concentrations at loss and return of consciousness are similar. Propofol effect-site concentrations at loss and recovery of consciousness were estimated with a target-control infusion system in 20 adults. Propofol effect-site concentrations were gradually increased until the volunteers lost consciousness (no response to verbal stimuli); unconsciousness was maintained for 15 min, and the volunteers were then awakened. This protocol was repeated three times in each volunteer. Our major outcomes were the concentration producing unconsciousness and the relationship between the estimated effect-site concentrations at loss and recovery of consciousness. The target effect-site propofol concentration was 2.0 +/- 0.9 at loss of consciousness and 1.8 +/- 0.7 at return of consciousness (P <0.001). The average difference between individual effect-site concentrations at return and loss of consciousness was only 0.17 +/- 0.32 microg/mL (95% confidence interval for the difference 0.09-0.25 microg/mL). Our results thus suggest that individual titration to loss of consciousness is an alternative to dosing propofol on the basis of average population requirements.

对乙酰氨基酚、阿司匹林和安乃近对几内亚猪离体小肠蠕动的影响

Peristalsis in the Guinea pig small intestine in vitro is impaired by acetaminophen but not aspirin and dipyrone

Herbert MK, Weis R, Holzer P, Roewer. N

Department of Anesthesiology, University of Wuerzburg, Oberduerrbacher Str. 6, D-97080 Wuerzburg, Germany.

Anesth Analg. 2005 Jan;100(1):120-7.

 

小肠蠕动受抑制是阿片类镇痛药的一个主要副作用。而非阿片类镇痛药,如对乙酰氨基酚,阿司匹林和安乃近,是否对小肠蠕动有影响仍不知。本研究中,我们探讨了这些非阿片类镇痛药对小肠蠕动的影响,并分析了其中的一些机理。在几内亚猪小肠多个离体段内通过灌注诱导增加小肠管腔内压力来激发小肠蠕动。小肠蠕动压力阈值(小肠蠕动被激发的压力,PPT)被用来量化药物对小肠的作用。把媒介液(Tyrode’s 溶液),对乙酰氨基酚(0.01-100uM),阿司匹林(100-300uM),安乃近(10-100uM)加入浸泡小肠的容器中,当对乙酰氨基酚浓度达10uM时,在6个肠段中有4个肠段对对乙酰氨基酚产生浓度依赖性地增加了PPT,小肠蠕动受抑制。当达到100uM时,所有肠段PPT增加,肠蠕动受抑制(EC50=6.0uM)。当浓度达到3uM时,对乙酰氨基酚对PPT的增加能被纳络酮及蜂毒明肽减轻,但L-硝基精氨酸甲酯(L-NAME),D-硝基精氨酸甲酯(D-NAME;与L-NAME对应的无活性右旋结构),阿司匹林,二甲麦角新碱及曲匹西隆不具此减轻作用。乙酰水杨酸以及安乃近不影响小肠蠕动。此结果首次显示对乙酰氨基酚对小肠蠕动抑制的影响具有浓度依赖性,而阿司匹林和安乃近无此作用。 对乙酰氨基酚对小肠蠕动的抑制作用涉及一些Ca2+依赖性K+通道的信号传导,内源性阿片类途径,可能还与环氧化酶-3受抑制有关。

(吴德华 薛张刚 校)

Inhibition of intestinal peristalsis is a major side effect of opioid analgesics. It is unknown whether non-opioid analgesics, such as acetaminophen, acetylsalicylic acid, and dipyrone, exert any effect on intestinal motility. In the current in vitro study we examined the effect of these analgesics on intestinal peristalsis and analyzed some of their mechanisms of action. In isolated segments of the guinea pig small intestine peristalsis was triggered by a perfusion-induced increase of the intraluminal pressure. The peristaltic pressure threshold (PPT) at which peristaltic waves were elicited was used to quantify drug effects on peristalsis. Vehicle (Tyrode's solution), acetaminophen (0.01-100 microM), acetylsalicylic acid (100-300 microM), and dipyrone (10-100 microM) were added extraserosally to the organ bath. Acetaminophen concentration-dependently increased PPT and abolished peristalsis in four of six segments at the concentration of 10 microM and in all segments tested at 100 microM (EC50=6.0 microM). The increase in PPT resulting from 3 microM acetaminophen was reduced by naloxone and apamin but not changed by L-nitro-arginine methylester (L-NAME), its inactive enantiomer D-NAME, acetylsalicylic acid, methysergide or tropisetron. Acetylsalicylic acid and dipyrone did not affect peristalsis. The results reveal, for the first time, that acetaminophen concentration-dependently impairs intestinal peristalsis, whereas acetylsalicylic acid and dipyrone lacked such an effect. The inhibition caused by acetaminophen involves transmitters acting via small conductance Ca2+-activated potassium channels, endogenous opioidergic pathways, and presumably inhibition of cyclooxygenase-3.

 

异丙酚诱导意识丧失和SNAP指数之间的关系

The association between propofol-induced loss of consciousness and the SNAP index.

Wong CA, Fragen RJ, Fitzgerald PC, McCarthy RJ.

Department of Anesthesiology, Northwestern University Feinberg School of Medicine, 251 E. Huron St., F 5-704, Chicago, IL 60611, USA.

Anesth Analg. 2005 Jan;100(1):141-8.

 

SNAP是经处理的脑电图监测仪,其运作基于低和高频光谱元件的运算法则,从而衍生出SNAP指数。在本项研究中,我们力求明确SNAP指数与接受异丙酚推注受试者意识丧失之间的关系。随机抽取的受试者随机接受11种静脉推注异丙酚剂量中的1种(00.60.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, 2.4 mg/kg; n=20/组)。当受试者开始意识丧失时(终点)或在接受注射后160秒,SNAP指数被记录。65%受试者到达终点(定义为接受试者停止注射时间)。50%异丙酚有效剂量是0.97 mg/kg (95%可信区间[CI], 0.86-1.07 mg/kg)SNAP指数清醒中位数为92(范围为78-99),而且在达到终点和没有达到终点的受试者之间没有不同。停止注射的受试者其终点SNAP指数低于基线,中位数为76 (范围为57-94),其剂量>=1.0 mg/kg,但在不同剂量之间没有不同。在160秒受试者没有到达终点,指数没有不同于基线。二元逻辑回归模式预测SNAP指数95%意识丧失有效剂量71 (95% CI, 63-74) 19 (95% CI, 16-22) SNAP指数不同于基线。这些模型在接受操作器特征曲线下面积为0.837 0.864SNAP指数与异丙酚诱导意识丧失相关联。SNAP指数是意识丧是有用的显示器,而且可以作为麻醉深度监测,进行进一步的研究。

(孙敏莉 薛张纲 校)

The SNAP is a processed electroencephalogram monitor that uses an algorithm based on low- and high-frequency spectral components to derive a SNAP index. In this study we sought to determine the relationship of the SNAP index with loss of consciousness in subjects receiving a bolus of propofol. Unpremedicated subjects were randomized to receive 1 of 11 doses of IV propofol (0, 0.6, 0.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, or 2.4 mg/kg; n=20 per group). The SNAP index was recorded when the subject became unconscious (end-point) or at 160 s after the injection. Sixty-five percent of subjects achieved the end-point (defined as the time at which the subject dropped a weighted syringe). The 50% effective dose for propofol was 0.97 mg/kg (95% confidence interval [CI], 0.86-1.07 mg/kg). The median awake SNAP index was 92 (range 78-99) and did not differ between subjects who reached the end-point and those who did not. The end-point SNAP index decreased from baseline in the subjects who dropped the syringe to a median of 76 (range, 57-94) at doses > or =1.0 mg/kg but was not different among doses. The index was not different from baseline at 160 s in subjects who did not reach the end-point. Binary logistic regression models predicted a SNAP index 95% effective dose for loss of consciousness of 71 (95% CI, 63-74) and 19 (95% CI, 16-22) for changes in SNAP index from baseline. The areas under the receiver operator characteristic curves for these models were 0.837 and 0.864. The SNAP index correlated with propofol-induced loss of consciousness. It appears to be a useful indicator of loss of consciousness and should be further investigated as a monitor of anesthesia depth.

 

奈福泮与氯氨酮在增强术后镇痛中的比较

Nefopam and Ketamine Comparably Enhance Postoperative Analgesia

Barbara Kapfer, MD*, Pascal Alfonsi, MD*, Bruno Guignard, MD*, Daniel I. Sessler, MD{dagger}, and Marcel Chauvin, MD*,{ddagger}

Department of Anesthesia and {ddagger}INSERM E 332, Hôpital Ambroise Pare, Assistance Publique Hôpitaux de Paris, Boulogne, France; and {dagger}Outcomes Research Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2005;100(1):169-174

 

单独使用阿片类药物有时会引起术后镇痛不完全,而联合用药可能可以减少阿片类药物的用量,增加疗效。有部分患者术后单独使用吗啡只能减轻部分疼痛,因此我们提出了一个假说,将奈福泮或氯氨酮用于此类患者,是否可以减少后续需要使用的阿片类药物的药量,并且产生适当的镇痛效果。我们通过实验验证了这个假说。经历了大手术的患者(n77)每人静注9mg吗啡,将那些仍然感觉到疼痛的患者随机分为3组,使用盲法给予1)等张盐水(对照组,n = 21),2)10mg氯氨酮(氯氨酮组,n = 23),3)20mg奈福泮(奈福泮组,n = 22)。随后每隔5min给予3mg吗啡直到达到合适的镇痛效果,或者给试验性药物后60min,或者出现通气不足(呼吸频率<10/分或脉搏氧饱和度<95%)。在使用试验性药物之后追加的吗啡的量对照组(平均值±标准差;17 ± 10 mg)明显大于奈福泮组(10 ± 5 mgP < 0.005),与氯氨酮组(9 ± 5 mgP < 0.001)。吗啡成功使用于所有奈福泮与氯氨酮组的患者,而对照组的4位患者没有能够耐受吗啡(2位出现呼吸抑制,2位持续疼痛)。奈福泮组的患者较多地出现心悸和多汗症状,氯氨酮组的患者的镇静程度更深。并没有发现奈福泮与氯氨酮组在其他潜在并发症上有所不同。

(金琳 薛张纲 校)

Opioids alone sometimes provide insufficient postoperative analgesia. Coadministration of drugs may reduce opioid use and improve opioid efficacy. We therefore tested the hypothesis that the administration of ketamine or nefopam to postoperative patients with pain only partly alleviated by morphine reduces the amount of subsequent opioid necessary to produce adequate analgesia. Patients (n = 77) recovering from major surgery were given up to 9 mg of IV morphine. Those who still had pain were randomly assigned to blinded administration of 1) isotonic saline (control group; n = 21), 2) ketamine 10 mg (ketamine group; n = 22), or 3) nefopam 20 mg (nefopam group; n = 22). Three-milligram morphine boluses were subsequently given at 5-min intervals until adequate analgesia was obtained, until 60 min elapsed after the beginning of study drug administration, or until ventilation became insufficient (respiratory rate <10 breaths/min or saturation by pulse oximetry <95%). Supplemental morphine (i.e., after test drug administration) requirements were significantly more in the control group (mean ± SD; 17 ± 10 mg) than in the nefopam (10 ± 5 mg; P < 0.005) or ketamine (9 ± 5 mg; P < 0.001) groups. Morphine titration was successful in all ketamine and nefopam patients but failed in four control patients (two because of respiratory toxicity and two because of persistent pain). Tachycardia and profuse sweating were more frequent in patients given nefopam, and sedation was more intense with ketamine; however, the incidence of other potential complications did not differ among groups.

 

术后胃肠道功能紊乱

Postoperative Gastrointestinal Tract Dysfunction

Michael G. Mythen, MD, FRCA

Department of Anaesthesia and Critical Care, University College London, United Kingdom; and Portex Anaesthesia, Intensive Care and Respiratory Unit, Institute of Child Health, University College London, United Kingdom

Anesth Analg 2005;100(1):196-204

 

术后胃肠道(GI)功能紊乱(PGID)是一个十分常见的问题,增加患者的痛苦,并且使医疗费用提高。PGID的发病机理非常复杂,而且是多因素的。对PGID传统的治疗措施包括使用促进胃肠道动力的药物、放置鼻胃管及避免术后早期进食进水。这些措施旨在降低PGID的发生率,但是显然没有什么效果。随机临床试验表明,静脉使用大量的液体治疗,以达到预定的增加心输出量的目的,可以改善内脏灌注,从而降低PGID的发病率。包括限制手术切口的大小,选择区域阻滞的麻醉方法,早期活动和肠内营养在内的综合治疗措施可以显著地降低术后并发症的发生,减少PGID,缩短住院时间。然而,这些治疗方法都没有经过充分有力的多中心前瞻性随机对照试验性研究证实。

(金琳 薛张纲 校)

Postoperative gastrointestinal (GI) tract dysfunction (PGID) is common and is associated with increased patient suffering and cost of care. The pathogenesis of PGID is complex and multifactorial. Traditional measures intended to reduce the incidence of PGID, such as the use of prokinetic drugs, nasogastric tube drainage, and the avoidance of early fluid and/or food intake, are apparently not beneficial. The administration of larger volumes of IV fluids to achieve predetermined increases in cardiac output has been shown in randomized trials to improve gut perfusion and reduce the incidence of PGID. A multimodal approach that includes limited surgical incision, regional local anesthesia, early mobilization, and enteral feeding has been associated with a dramatic reduction in postoperative complications, PGID, and length of hospital stay. However, none of these approaches has been validated in adequately powered multicenter prospective randomized controlled trials.

 

对海马切片培养标本有神经保护作用的是轻度低温,而不是异丙酚

Mild Hypothermia, but Not Propofol, Is Neuroprotective in Organotypic Hippocampal Cultures

John R. Feiner, MD, Philip E. Bickler, MD, PhD, Sergio Estrada, BS, Paul H. Donohoe, PhD, Christian S. Fahlman, PhD, and Jennifer A. Schuyler, BS

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

Anesth Analg 2005;100(1): 215-225

 

麻醉药物的神经保护潜能尚未明确,比如异丙酚和轻度低温。因此,比较两种临床常用浓度的异丙酚和轻度低温防止海马切片培养标本(HSC)迟发性神经元死亡的效率就显得非常有必要。我们将标本分为4组,37℃不加异丙酚组、37℃加用10µM异丙酚组、37℃加用100µM异丙酚组、35℃不加异丙酚组(轻度低温组)。将这4组切片标本处于1h缺氧缺糖(OGD)状态,然后观察细胞存活情况。在23天之后神经元仍存活则定义为存活。我们使用碘化丙啶荧光来判断每一个海马薄层切片CA1CA3及齿状神经元是否死亡。结果表示,轻度低温能够阻止CA1CA3及齿状神经元的死亡,而异丙酚只有在10µM的浓度下才能够保护齿状神经元。无论是10µM还是100µM的异丙酚,对CA1CA3神经元的缺血缺氧损伤均无保护作用。通过薄层切片培养发现,100µM异丙酚并不会减少100µM N甲基D天门冬氨酸(NMDA)、500µM谷氨酸及20µM α氨基5甲基4异唑丙酸(AMPA)的毒性。异丙酚的神经保护作用可能包括γ氨基丁酸介导的对谷氨酸受体(GluRs)的间接抑制作用,而谷氨酸受体激动剂可以导致钙离子内流。我们在海马切片培养标本中的CA1神经元、分离的CA1神经元和大脑皮层切片中的CA1神经元中研究了异丙酚对谷氨酸受体活性的影响。在分离的CA1神经元内,异丙酚(100µM200µM,接近爆发抑制的浓度)可以减少谷氨酸介导的[Ca2+]i的升高({Delta}[Ca2+]i)反应达25%–35%;在新鲜海马薄层切片和培养标本中,可以降低谷氨酸和NMDA介导的{Delta}[Ca2+]i35%–50%。不论是在CA1神经元还是在皮质切片标本,使用苦味素阻滞GABAA受体都可以充分减少对GluRs的抑制作用。通过研究,我们得出:轻度低温对海马切片培养标本中缺氧缺葡萄糖的CA1CA3神经元有保护作用,而异丙酚没有这样的作用。异丙酚在可以减少皮质和海马神经元谷氨酸和NMDA受体反应能力的浓度并没有神经保护作用。

(金琳 薛张纲 校)

The neuroprotective potency of anesthetics such as propofol compared to mild hypothermia remains undefined. Therefore, we determined whether propofol at two clinically relevant concentrations is as effective as mild hypothermia in preventing delayed neuron death in hippocampal slice cultures (HSC). Survival of neurons was assessed 2 and 3 days after 1 h oxygen and glucose deprivation (OGD) either at 37°C (with or without 10 or 100 µM propofol) or at an average temperature of 35°C during OGD (mild hypothermia). Cell death in CA1, CA3, and dentate neurons in each slice was measured with propidium iodide fluorescence. Mild hypothermia eliminated death in CA1, CA3, and dentate neurons but propofol protected dentate neurons only at a concentration of 10 µM; the more ischemia vulnerable CA1 and CA3 neurons were not protected by either 10 µM or 100 µM propofol. In slice cultures, the toxicity of 100 µM N-methyl-D-aspartate (NMDA), 500 µM glutamate, and 20 µM {alpha}-amino-5-methyl-4-isoxazole propionic acid (AMPA) was not reduced by 100 µM propofol. Because propofol neuroprotection may involve gamma-aminobutyric acid (GABA)-mediated indirect inhibition of glutamate receptors (GluRs), the effects of propofol on GluR activity (calcium influx induced by GluR agonists) were studied in CA1 neurons in HSC, in isolated CA1 neurons, and in cortical brain slices. Propofol (100 and 200 µM, approximate burst suppression concentrations) decreased glutamate-mediated [Ca2+]i increases ({Delta}[Ca2+]i) responses by 25%–35% in isolated CA1 neurons and reduced glutamate and NMDA {Delta}[Ca2+]i in acute and cultured hippocampal slices by 35%–50%. In both CA1 neurons and cortical slices, blocking GABAA receptors with picrotoxin reduced the inhibition of GluRs substantially. We conclude that mild hypothermia, but not propofol, protects CA1 and CA3 neurons in hippocampal slice cultures subjected to oxygen and glucose deprivation. Propofol was not neuroprotective at concentrations that reduce glutamate and NMDA receptor responses in cortical and hippocampal neurons.

 

鞘内注射吗啡用于产后双侧输卵管结扎后的镇痛

Intrathecal Morphine for Analgesia After Postpartum Bilateral Tubal Ligation

Ashraf S. Habib, MBBCh, FRCA, Holly A. Muir, FRCPC, William D. White, MPH, Tede E. Spahn, CRNA, Adeyemi J. Olufolabi, FRCA, Terrance W. Breen, FRCPC, and The Duke Women’s Anesthesia Research Group

Department of Anesthesiology, Division of Women’s Anesthesia, Duke University Medical Center, Durham, North Carolina

Anesth Analg 20051;100:239-243

 

产后双侧输卵管结扎(PPBTL)会导致术后疼痛。我们设计此研究是为了判定鞘内注射50 µg吗啡用于PPBTL后的镇痛效果。对65位妇女实施腰麻,分别使用12.75mg重比重布比卡因和20µg芬太尼并加50µg吗啡(吗啡组)或者0.05ml生理盐水(对照组)。术后常规根据需要使用500mg萘普生和5mg氧可酮/325mg对乙酰氨基酚混合物进行镇痛。在所有病例中,吗啡组具有最高的满意度(P = 0.003)、静息时(P = 0.008)和运动时(P < 0.0001)最低的疼痛程度。恶心、瘙痒和镇静评分在所有病例中没有显著差别,但吗啡组呕吐的发生频率更加高(21.4% 3.5%; P = 0.052)。在均值间的两两比较中,和对照组比较,吗啡组4h时静息(P = 0.006)和运动(P = 0.002)时的疼痛、12h时运动时(P = 0.0004)的疼痛显著降低,12h瘙痒发生的频率(P = 0.002)显著增高,5mg氧可酮/325mg对乙酰氨基酚混合物的使用显著减少(P = 0.006),术后至第一次使用镇痛药物的时间显著延长(P = 0.006)。因此我们认为鞘内注射重比重布比卡因和芬太尼并加用50µg吗啡能为接受PPBTL的妇女提供更好的术后镇痛。

(廖庆武 薛张纲校)

Postpartum bilateral tubal ligation (PPBTL) causes postoperative pain. We designed this study to determine the efficacy of 50 µg intrathecal morphine for analgesia after PPBTL. Sixty-five women received spinal anesthesia with 12.75 mg hyperbaric bupivacaine, 20 µg of fentanyl, and either 50 µg of morphine (morphine group) or 0.05 mL of saline (control group). Postoperative analgesia was provided with regular naproxen 500 mg and oxycodone 5 mg/acetaminophen 325 mg mixture as needed. Overall, satisfaction was higher (P = 0.003) and pain was less intense at rest (P = 0.008) and on movement (P < 0.0001) in the morphine group. There was no significant overall difference in nausea, pruritus, or sedation scores, but vomiting occurred more frequently in the morphine group (21.4% versus 3.5%; P = 0.052). In post hoc comparisons, pain at rest within the morphine group was significantly less at 4 h (P = 0.006), pain on movement was significantly less at 4 h (P = 0.002) and 12 h (P = 0.0004), and pruritus was significantly more frequent at 12 h (P = 0.002) compared with the control group. Oxycodone 5 mg/acetaminophen 325 mg mixture consumption was significantly smaller (P = 0.006) and the time to first request of analgesia was significantly longer (P = 0.006) in the morphine group. We conclude that the addition of 50 µg of morphine to intrathecal hyperbaric bupivacaine and fentanyl provides improved postoperative analgesia in women undergoing PPBTL.

 

胸腔内视镜交感神经切断术时外周皮肤血流量和温度的比较

A Comparison of Peripheral Skin Blood Flow and Temperature During Endoscopic Thoracic Sympathotomy

John H. Eisenach, MD*, Tasha L. Pike*, Diane E. Wick*, Niki M. Dietz, MD*, Robert D. Fealey, MD, John L. D. Atkinson, MD, and Nisha Charkoudian, PhD

Departments of *Anesthesiology, {dagger}Neurology, {ddagger}Neurosurgery, and Physiology, Mayo Clinic College of Medicine, Rochester, Minnesota

Anesth Analg 2005 1001: 269-276.

 

在外科手术治疗多汗症中,评价上肢的去交感神经对于术后效果的预测是必需的,特别是对于胸腔内视镜交感神经链切断术,一个最近认为损伤最小,术后代偿性多汗发生最少的技术。皮肤血流量(SkBF;激光多普勒流量计)比温度提供了一个更加快速和可靠的去神经指标,因此为检验这个假说,我们前瞻性地比较了10个进行胸腔内视镜交感神经链切断术的特发性多汗症患者的手掌SkBF和指尖温度。从基线到峰值,左右手手掌SkBF(平均值±标准差)分别增加了273.3 ± 24.7 任意单位 and 252.4 ± 30.1任意单位,而温度分别增加了0.9°C ± 0.3°C and 1.5°C ± 0.6°C。在有效的右侧胸交感神经链切断术中,到达SkBF峰值的时间是43 ± 13 s,而到达温度峰值的时间是277 ± 53 s (P < 0.001)。在左侧,到达SkBF峰值的时间是81 ± 14 s,而到达温度峰值的时间是305 ± 34 s (P < 0.001)。所有患者均被认为交感神经切断成功。因此我们认为交感神经切断术中评价去神经,激光多普勒SkBF时间解析度上优于温度,故能提供一个优质和定量的评价去神经的附加措施。

廖庆武 薛张纲 校)

The assessment of sympathetic denervation to the upper extremities during surgery for hyperhidrosis is essential in predicting postoperative outcome, particularly for endoscopic thoracic chain sympathotomy, a recently described, minimally destructive technique that minimizes postoperative compensatory hyperhidrosis. To test the hypothesis that skin blood flow (SkBF; laser Doppler flowmetry) provides a faster and more reliable indication of denervation than temperature (temp), we prospectively compared palmar SkBF and fingertip temp in 10 patients undergoing endoscopic thoracic chain sympathotomy for essential hyperhidrosis. From baseline to peak values, palmar SkBF (mean ± SEM) increased 273.3 ± 24.7 arbitrary units and 252.4 ± 30.1 arbitrary units, whereas temp increased 0.9°C ± 0.3°C and 1.5°C ± 0.6°C on the right and left, respectively. Upon effective sympathotomy of the right thoracic chain, the time to peak SkBF was 43 ± 13 s, whereas the time to peak temp was 277 ± 53 s (P < 0.001). On the left, the time to peak SkBF was 81 ± 14 s, and time to peak temp was 305 ± 34 s (P < 0.001). All patients considered the sympathotomy successful. We conclude that laser Doppler SkBF is superior to temp in temporal resolution for assessment of denervation during sympathotomy and that it provides a superior qualitative and quantitative adjunct to monitoring denervation.

 

 

经皮血管造影下显示导引钢丝J型头端的方向是锁骨下静脉导管位置不正确的显著影响因素:一项随机,对照研究

Direction of the J-Tip of the Guidewire, in Seldinger Technique, Is a Significant Factor in Misplacement of Subclavian Vein Catheter: A Randomized, Controlled Study

Mukesh Tripathi, MD, MNAMS*, Prakash K. Dubey, MD{dagger}, and Sushil P. Ambesh, MD*

*Department of Anesthesiology; Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India; {dagger}Department of Anesthesiology; Indira Gandhi Institute of Medical Sciences, Patna, India.

Anesth Analg 2005 100: 21-24.

 

中心静脉导管位置不准确导致导管功能减弱如不能抽血的情况常见于锁骨下静脉穿刺方法。在这项前瞻性研究中作者旨在确定右锁骨下静脉穿刺时导引钢丝J型头端的方向是否影响静脉导管头端的位置。在这项随机双盲临床研究中,作者观察了右锁骨下静脉穿刺时J型头端朝向尾端(第一组,n=147)或头端 (第二组,n=148)的静脉导管的位置。两组患者多数(97%57%)导管进入了锁骨下或右心房(P < 0.05)。第一组和第二组患者导管误入同侧颈内静脉的发生率分别为2%40%P < 0.01)。在随后的血管模型的试验性中也证实即使在血管之间急性成角的地方如锁骨下静脉,颈内静脉和上腔静脉汇合处中J型头端方向与引导钢丝进入血管的方向一致。结论:在右锁骨下静脉穿刺时只有保持导引钢丝J型头端方向朝尾部才能使中心静脉导管更准确地进入右心房。

(朱辉 译 陈杰 校)

Misplacement of central venous catheters, predisposing to poor functioning including inability to aspirate blood, is common with the subclavian approach. In this prospective study we sought to determine whether the direction of the guidewire J-tip influenced the catheter tip placement during right subclavian catheterization. In this randomized, double-blind clinical study, we observed the placement of catheters via the right subclavian vein while keeping the J-tip directed either caudad in Group 1 (n = 147) or cephalad in Group 2 (n = 148) patients. The majority of catheters (97% and 57%) in Groups 1 and 2 respectively entered the superior vena cava/right atrium (P < 0.05). The incidence of catheter misplacement into the ipsilateral internal jugular vein was 2% and 40% in Groups 1 and 2, respectively (P = < 0.01). Subsequent experimental study confirmed that the direction of the J-tip was retained inside a model of vascular tubes and its tip led the guidewire into the tubing on the same side even at the acute angulation formed between tubings representing the subclavian, internal jugular, and superior vena cava junction complex. The authors conclude that the simple measure of keeping the guidewire J-tip directed caudad increased correct placement of central venous catheters towards the right atrium during right subclavian catheterization.

 

Fick’s公式导出的实时估算混合静脉血异氟醚浓度的方法

A Real-Time Method for Estimating the Concentrations of Isoflurane in Mixed Venous Blood by a Derived Fick’s Equation

Wai M. Ho, MD*,{dagger}, Nae C. Yang, MS*, K. C. Wong, MD, PhD*,{ddagger}, and Kai L. Hwang, MS§

*Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan; {dagger}Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan; {ddagger}Department of Anesthesiology, University of Utah, Salt Lake City, Utah; and §Department of Public Health, College of Health Care and Management, Chung Shan Medical University, Taichung, Taiwan

Anesth Analg 2005 100: 38-45.

 

本文作者提出了源自Fick’s原理和林氏吸入麻醉药有效血浓度概念的公式,以便不直接抽取血样而计算混合静脉血(MVBC)的吸入麻醉药浓度。在这个研究中,作者调查了心脏手术病人在异氟醚麻醉期间计算浓度和实测血样浓度之间的关联关系。16名病人(试验1)在不同的时间点,通过肺动脉导管收集肺动脉血样本进行气体色谱/光谱分析,这些样本代表真实浓度。通过气体监测仪测量吸入和呼出气异氟醚浓度以计算MVBC。并使用林氏有效血浓度计算方法,得到的结果与MVBC相比较。另外11名病人(试验2)进行了研究以验证试验1得出的结论。结果显示麻醉期间MVBC和真实血浓度具有相似的动力模型,并高度相关。作者推断MVBC可以代表心脏手术期间真实肺动脉异氟醚浓度。结果表明MVBC可以作为一种有用的实时估计肺动脉异氟醚浓度的方法,但临床有效性和重要性值得进一步研究。

(殷文渊 译 陈杰 校)

We propose an equation derived from Fick’s laws and Lin’s concept of effective blood concentration to calculate the blood concentration of inhaled anesthetics in mixed venous blood (MVBC) without direct blood sampling. We investigated the relationship between the calculated concentrations and the actual blood sample concentrations in mixed venous blood of patients undergoing cardiac surgery during isoflurane anesthesia in this study. Sixteen patients were recruited for Experiment 1. At different time points, pulmonary arterial blood samples were collected for gas chromatography/mass spectrometric determination via the pulmonary artery catheter: these samples represented the actual concentrations. The inspired and expired concentrations of isoflurane measured by a gas monitor were used for the MVBC calculations. Lin’s effective blood concentration method was also used, and the obtained results were then compared with MVBC. Studies were conducted on 11 additional patients (Experiment 2) to confirm the results obtained from Experiment 1. The MVBC and the actual blood concentrations showed a similar kinetic pattern and level during anesthesia and had high correlation coefficients within subjects. We have demonstrated that MVBC could represent the actual pulmonary blood concentrations of isoflurane during cardiac surgery. The results suggest that MVBC could be a useful method of estimating the real-time pulmonary blood concentration of isoflurane. The clinical significance and importance of the method merit further investigation.

 

等比重罗哌卡因(5 mg/ml)在儿童脊麻中的应用

Isobaric Ropivacaine 5 mg/mL for Spinal Anesthesia in Children

Hannu Kokki, MD, PhD, Paula Ylönen, BM, Merja Laisalmi, MD, Marja Heikkinen, MD, and Matti Reinikainen, MD

Department of Anesthesiology and Intensive Care, Department of Surgery, Kuopio University Hospital, Department of Pharmacology and Toxicology, University of Kuopio, Kuopio, Finland.

Anesth Analg 2005 100: 66-70.

 

本研究作者评估了罗哌卡因在儿童脊麻中的效果。9317岁接受选择性下腹部或下肢手术的儿童进行了这一开放性、前瞻性研究。病人侧卧位,选择L3-4L4-5为穿刺间隙,使用罗哌卡因浓度为5 mg/ml,使用剂量为0.5mg/kg(最大量20 mg)。注射后,病人仰卧位。记录感觉阻滞的起效和持续时间以及运动阻滞的程度。93名儿童中92名获得了满意的麻醉效果。三名儿童接受了全麻,一名儿童脊麻失败,两例手术超过感觉阻滞时间。四名儿童在切皮时追加镇痛药。平均最高感觉阻滞平面为T6(范围,T2T12),感觉阻滞平面衰退至T10的平均时间为96分钟(范围为34210分钟)。一名儿童出现暂时性心动过速,一名出现低血压。出院后四名儿童出现轻度的暂时性放射性神经刺激症状,一名出现持续性体位性头痛而进行硬膜外自体血修补治疗。作者认为儿童(>1岁)鞘内使用等比重罗哌卡因能取得与成人相似的阻滞效果,但大剂量使用的安全性还需进一步研究。

(殷文渊 译 陈杰 校)

In this clinical trial, we evaluated the clinical effects of ropivacaine for spinal anesthesia in children. An open, prospective study was performed on 93 children, aged 1–17 yr, undergoing elective lower abdominal or lower limb surgery. A plain solution of ropivacaine 5 mg/mL at a dose of 0.5 mg/kg body weight (up to 20 mg) was administered via the L3-4 or L4-5 interspace with the patient in the lateral decubitus position. After injection, the patients were placed supine. The spread and duration of sensory analgesia and the degree of motor block were recorded. Satisfactory surgical anesthesia was achieved in 92 of the 93 children. Three children received general anesthesia; in one child spinal anesthesia failed, and in two cases surgery outlasted the duration of the sensory block. Four children received supplemental analgesia for skin incision. The mean highest level of sensory block was T6 (range, T2 to T12), and the mean time to the regression of sensory block to T10 was 96 min (range, 34–210 min). One child developed transient bradycardia and one hypotension. After discharge four children developed mild transient radiating neurologic symptoms and one epidural blood patch was performed for persistent position-dependent headache. We conclude that the block performance of intrathecal isobaric ropivacaine in children (>1 yr) is similar to that obtained in adults but the safety of the larger dose used in children warrants further studies.

 

一般患者和医疗保健专职人员对术后恢复和术后恶心呕吐处理方面的比较

A Comparison of Patients’ and Health Care Professionals’ Preferences for Symptoms During Immediate Postoperative Recovery and the Management of Postoperative Nausea and Vomiting

Anna Lee, MPH, PhD, Tony Gin, MBChB, MD, FANZCA, FRCA, Angel S. C. Lau, BSN(Hons), Dip Epid Biostat, RN, and Floria F. Ng, BASc, RN

Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, China

Anesth Analg 2005 100: 87-93.

 

本文作者研究了一般患者与医疗保健专职人员对在术后恢复和术后恶心呕吐(PONV)处理方面的异同的。依照主要的不同点制定包括14项内容的调查表,内容有:术后恢复期症状(PONV,镇静,疼痛等),以及术后PONV的处理(预防,镇吐药效和额外支出等)。选择52位医疗保健专职人员(麻醉医生,恢复室护士)以及200位择期妇科手术患者(应答率97%)进行研究。根据一般患者和医疗保健专职人员的反应,结合分析显示,对术后恢复的最关注点是减少PONV的发生。医疗保健专职人员对术后镇静方面比一般患者显得更为重视,比一般患者更关注镇吐药的花费,但针对术后呕吐的有效治疗和常规预防方面,未显示出明显的偏爱。这项研究显示一般患者和医疗保健专职人员在术后疼痛,镇静,镇吐药效果和治疗的花费方面只有很小的差异。

(顾漪闻 译 陈杰 校)

In this study we sought to examine the differences in patients’ and health care professionals’ preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting (PONV). The key differences between symptoms during immediate postoperative recovery (PONV, sedation, and pain) and management of PONV (prophylaxis, efficacy of antiemetic, and extra cost) were used to develop 14 scenarios in a questionnaire. Fifty-two health care professionals (anesthesiologists and recovery room nurses) and 200 women undergoing elective gynecological surgery were recruited (overall response rate, 97%). From patients’ and health care professionals’ perspectives, conjoint analysis showed that the most important attribute for immediate postoperative recovery was a reduction in the risk of PONV. Health care professionals placed more importance on postoperative sedation than patients did. They were more concerned about the cost of the antiemetic to the patient than the patients were themselves. There was no preference for a policy of effective treatment versus routine prophylaxis. This study shows that there were small differences in the importance of pain, sedation, efficacy of the antiemetic, and extra cost of treatment between patients and health care professionals.

 

α2肾上腺素能受体在哌替啶对小鼠体温调节中枢的影响

The Effect of Meperidine on Thermoregulation in Mice: Involvement of {alpha}2-Adrenoceptors

Andrea Paris, MD, Christina Ohlendorf, MD, Michael Marquardt, Berthold Bein, MD, James M. Sonner, MD*, Jens Scholz, MD, and Peter H. Tonner, MD

Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany; *Department of Anesthesia, University of California, San Francisco, California

Anesth Analg 2005 100: 102-106.

哌替啶具有很强的抗寒颤作用,其潜在的机制尚未完全阐明。最近的研究显示其可能与α2肾上腺素能受体有关。作者对小鼠的体温调节中枢模型做了一项研究,观察哌替啶对非寒战生热作用的效应。对安置于树脂玻璃房中的小鼠进行腹腔注射药物,按药物的不同分为四组:生理盐水组(0.1mg/kg);哌替啶组(20mg/kg; 特异α2肾上腺素能受体拮抗剂阿替美唑(2mg/kg)加生理盐水组;阿替美唑(2mg/kg)加哌替啶组。小鼠身体变凉而诱发体温调节中枢反应后测量其直肠温度和混合呼出气二氧化碳浓度。当呼出二氧化碳不断增加时的温度,就认为是非寒颤的产热作用的最大反应强度和非寒颤产热作用的体温调节的开始。哌替啶的非寒颤产热作用体温调节开始的温度明显下降(36.6oC±0.7 oC),生理盐水组为(37.9 oC ± 0.6 oC, 阿替美唑加生理盐水为(37.8 oC±0.4 oC;P<0.01)。在注射了阿替美唑加哌替啶后,其哌替啶的抗寒战的效果消失(37.7 oC ±0.6 oC; P<0.05)。哌替啶没有减少非寒战产热作用的最大强度。研究结果显示α2肾上腺素能受体在哌替啶对小鼠的体温调节中枢抑制中起了主要的作用。

(顾漪闻 译 陈杰 校)

Meperidine has potent antishivering properties. The underlying mechanisms are not fully elucidated, but recent investigations suggest that {alpha}2-adrenoceptors are likely to be involved. We performed the current study to investigate the effects of meperidine on nonshivering thermogenesis in a model of thermoregulation in mice. After injection (0.1 mL/kg intraperitoneally) of saline, meperidine (20 mg/kg), the specific {alpha}2-adrenoceptor antagonist atipamezole (2 mg/kg), plus saline or atipamezole plus meperidine, respectively, mice were positioned in a Plexiglas chamber. Rectal temperature and mixed expired carbon dioxide were measured after provoking thermoregulatory effects by whole body cooling. Maximum response intensity of nonshivering thermogenesis and the thermoregulatory threshold for nonshivering thermogenesis, which was defined as the temperature at which a sustained increase in expiratory carbon dioxide can be measured, were investigated. Meperidine significantly decreased the threshold of nonshivering thermogenesis (36.6°C ± 0.7°C) versus saline (37.9°C ± 0.6°C) and versus atipamezole plus saline (37.8°C ± 0.4°C; P < 0.01). This effect was abolished after administration of meperidine combined with atipamezole (37.7°C ± 0.6°C; P < 0.05). Meperidine did not decrease the maximum intensity of nonshivering thermogenesis. The results suggest a major role of {alpha}2-adrenoceptors in the inhibition of thermoregulation by meperidine in mice.

 

三磷酸腺苷对维库溴铵神经肌肉阻滞的影响

The Effect of Adenosine Triphosphate on Vecuronium-Induced Neuromuscular Block

Keiichi Nitahara, MD, PhD, Shinjiro Shono, MD, Takamitsu Hamada, MD, Hideyuki Higuchi, MD, PhD, Tadakazu Sakuragi, MD, PhD, and Kazuo Higa, MD, PhD

Department of Anesthesiology, Fukuoka University School of Medicine, Fukuoka, Japan.

Anesth Analg 2005 100: 116-119.

 

术中持续静脉注射三磷酸腺苷可起到镇痛和血管扩张作用。由于三磷酸腺苷可抑制神经肌肉传导,作者研究了持续静脉注射三磷酸腺苷是否会增强维库溴铵的神经肌肉阻滞作用。29位接受选择性小手术的患者随机持续静注三磷酸腺苷0.1mg ∙ kg-1 ∙ min-10.9NaCl。使用肌电仪行尺神经TOF刺激并记录姆内收肌的神经肌肉活动。维库溴铵剂量为253040μg/kg,记录滞后时间、起效时间和最大阻滞时间。每组应用最小平方线性回归分析计算ED50ED95。三磷酸腺苷组ED50ED95分别为29μg/kg44μg/kg,对照组为26μg/kg46μg/kg。组间滞后时间、起效时间和神经肌肉反应无明显区别。三磷酸腺苷组的大部分患者出现了低血压(收缩压<80mm Hg)。结论:三磷酸腺苷0.1mg ∙ kg -1∙ min-1不增强维库溴铵的神经肌肉阻滞作用。

(朱慧琛 译 陈杰 校)

Continuous IV adenosine triphosphate administration has been used during surgery in the expectation of analgesic and vasodilative effects. Because adenosine triphosphate inhibits neuromuscular transmission, we investigated whether the neuromuscular effect of vecuronium was enhanced by IV adenosine triphosphate in 29 patients randomly given either continuous IV adenosine triphosphate 0.1 mg · kg–1 · min–1 or 0.9% NaCl when undergoing elective minor surgery. Anesthesia was induced and maintained with propofol. Neuromuscular monitoring was recorded from the adductor pollicis muscle using electromyography with train-of-four stimulation of the ulnar nerve. Vecuronium 25, 30, or 40 µg/kg was given and lag time, onset time, and maximum block were recorded. ED50 and ED95 values for each group were derived from least squares linear regression analysis. ED50 and ED95 values were 29 µg/kg and 44 µg/kg, respectively, for the adenosine triphosphate group and 26 µg/kg and 46 µg/kg, respectively, for the controls. Differences in lag time, onset time, and neuromuscular responses between the two groups were not statistically significant. A significantly larger number of patients in the adenosine triphosphate group showed hypotension (systolic blood pressure <80 mm Hg). Our results demonstrated that adenosine triphosphate 0.1 mg · kg–1 · min–1 did not enhance the neuromuscular block induced by vecuronium.

 

医疗保健鉴定联合委员会对疼痛围术期阿片类药物需求量和恢复室停留时间的影响

The Impact of the Joint Commission for Accreditation of Healthcare Organizations Pain Initiative on Perioperative Opiate Consumption and Recovery Room Length of Stay

Peter E. Frasco, MD, Juraj Sprung, MD, PhD, and Terrence L. Trentman, MD

Departments of Anesthesiology, Mayo Clinic College of Medicine, Mayo Clinic, Scottsdale, Arizona and Rochester, Minnesota

Anesth Analg 2005 100: 162-168.

 

医疗保健鉴定联合委员会(JCAHO)要求重视住院患者的疼痛治疗,在疼痛开始时应用相应的围术期服务可很快取得许多改变。200210月作者在术后恢复室(PACU)开始实行疼痛评分方案。在PACU中应用此评分评价患者对镇痛治疗的反应。同时制定离开PACU的适度疼痛评分指标。作者评估了1082位接受一般手术、整形外科、神经外科、泌尿外科和妇产科手术的患者对疼痛治疗的反应。作者发现与2000年相比,2002年患者阿片类药物(换算为吗啡剂量)的平均需求量明显提高(从40.4+13.2mg 上升到46.6+20.4mgP<0.001。在PACU中阿片类药物需求量提高更为明显(从6.5+7.3mg上升到10.5+10.4mgP<0.001)。阿片类药物用量的增加并不延长住院时间、不提高钠络酮的需求量及不增加术后恶心呕吐的发生率。作者认为术后短时间的阿片类药物用量的增加不会提升阿片类药物相关副作用的发生率。

(朱慧琛 译 陈杰 校)

The enhanced organizational emphasis on the management of pain in hospitalized patients mandated by the Joint Commission for Accreditation of Health Care Organizations (JCAHO) pain initiative precipitated a number of changes by the perioperative services at our facility. In October 2002, a numeric pain scale became mandatory in our postanesthesia care unit (PACU). Response to analgesia in the PACU was recorded using this scale. In addition, an acceptable pain score was required for discharge from the PACU. We evaluated the effects of these changes in the pain management of 1082 patients undergoing general, orthopedic, neurosurgical, urologic, and gynecologic surgeries. We detected an overall increase in the average consumption of opiates (morphine equivalents) in 2002 compared with 2000 (46.6 ± 20.4 mg versus 40.4 ± 13.2 mg, P < 0.001). This increase was most significant in the PACU (10.5 ± 10.4 mg versus 6.5 ± 7.3 mg, P < 0.001 between the 2 periods, respectively). This increase in opiate use was not associated with an increased length of stay, an increase in the requirement for naloxone, or an increase in treatment for postoperative nausea and vomiting. We conclude that the increase in opiate use, which could be explained by compliance with the JCAHO pain initiative, was not associated with additional opiate-induced morbidity in the immediate postoperative period.

 

气管损伤的保守治疗

Conservative Treatment of Tracheal Injuries

Martin Beiderlinden, MD, Michael Adamzik, MD, and Jürgen Peters, MD

Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany

Anesth Analg 2005 100: 210-214.

 

无论什么原因的气管损伤,均可能威胁病人的生命安全。治疗上可以选择外科手术修补,目前还没有其它治疗方式与之相比较。作者假定可以通过人造气管架桥的方式进行保守治疗。选择5例气管损伤的病人,2例是因外伤和气管插管造成的气管上三分之一损伤,另外3例是因经皮气管切开而造成的气管中三分之一损伤。在支气管镜引导下置入气管内或气管造口导管,并将导管末端气囊充气以堵塞气管损伤处来完成气管架桥。架桥完成后空气泄漏迅速停止,所有气管缺损没有进一步发展。无一例病例发生气管狭窄或纵膈炎。结果表明通过在支气管镜引导下置入人造气管对气管损伤进行保守治疗是有效的,并使那些因保守治疗失败而需要二期外科手术治疗的病人处于较为有利的状态。

(齐波 译 陈杰 校)

Tracheal injuries, independent of their origin, may be life-threatening. Surgical repair is regarded as the treatment of choice but has not been compared with other approaches. We hypothesized that defects bridgeable by an artificial airway may enable conservative treatment. We report on five patients with tracheal injuries, two in the trachea’s upper third resulting from trauma and intubation and three in its middle third after percutaneous dilational tracheostomy. Tracheal defects were bridged by endotracheal or tracheostomy tubes under bronchoscopic guidance and the cuff was inflated distal to the lesion. Air leakage stopped immediately and all tracheal defects healed without further interventions. No case of stenosis or mediastinitis was observed. These results suggest that treating tracheal injuries conservatively by placing an artificial airway under bronchoscopic guidance may be effective and offers a convenient starting position for secondary surgical repair in selected patients when conservative treatment fails.

 

雷米芬太尼:一种新的分娩全身镇痛药

Remifentanil: A Novel Systemic Analgesic for Labor Pain

Shmuel Evron, MD*,{dagger}, Marek Glezerman, MD{ddagger}, Oskar Sadan, MD{ddagger}, Mona Boaz, PhD§, and Tiberiu Ezri, MD*,{dagger}

Anesth Analg 2005 100: 233-238.

作者通过一个随机双盲对照临床试验来比较产妇分娩时采用雷米芬太尼自控镇痛(PCIA)和静脉用杜冷丁的镇痛效果。选择88名要求静脉分娩镇痛的健康产妇,随机分为两组,一组(n=43)接受雷米芬太尼PCIA,药物剂量渐增(0.27-0.93ug/Kg);另一组(n45)采用杜冷丁150mg静脉注射(用药范围为75200mg)。结果雷米芬太尼PCIA分娩镇痛较静脉用杜冷丁更为有效,雷米芬太尼组病人视觉疼痛评分较低(35.2±10.258.8±12.8P0.001,病人满意评分较高(3.9±0.61.9±0.4P0.001);病人较弱的镇静作用(1.2±0.12.9±0.1P0.001)。另外雷米芬太尼使病人血红蛋白去饱和作用较低(97.5%±1.094.2%±1.5P0.007)。雷米芬太尼组病人镇痛失败率(从静脉镇痛转为硬膜外镇痛)较杜冷丁组病人低(10.8%38.8%P0.007),两组产妇的分娩方式或新生儿情况无明显差异。与杜冷丁镇痛组比,雷米芬太尼组新生儿异常胎心率的发生较少(P < 0.001)。研究表明,通过PCIA给予产妇重复小剂量且间断递增的雷米芬太尼可以保证其在分娩过程中有效且可靠的镇痛。

(齐波 译 陈杰 校)

In a double-blind, randomized, controlled clinical trial, we compared the analgesic effect of remifentanil in patient-controlled IV analgesia (PCIA) during labor and delivery with the effect of an IV infusion of meperidine. Eighty-eight healthy term parturients who requested IV analgesia for labor pain were enrolled in the study and were randomly assigned to receive either increasing doses (0.27–0.93 µg/kg per bolus) of PCIA remifentanil (n = 43) or an IV infusion of meperidine 150 mg (range, 75–200 mg) per patient (n = 45). Remifentanil by the PCIA device was more effective and reliable analgesia for labor and delivery than IV infusion of meperidine. The visual analog score was lower (35.8 ± 10.2 versus 58.8 ± 12.8; P < 0.001) and the patient satisfaction score higher (3.9 ± 0.6 versus 1.9 ± 0.4; P < 0.001), with less of a sedative effect (1.2 ± 0.1 versus 2.9 ± 0.1; P < 0.001) and less hemoglobin desaturation (97.5% ± 1.0 versus 94.2% ± 1.5; P < 0.007). The percentage of analgesia failure (the rate of crossover from opiate to epidural analgesia) was less for remifentanil compared with meperidine (10.8% versus 38.8%; P < 0.007). There were no significant differences between groups in the mode of delivery or neonatal outcome. There were fewer nonreassuring abnormal fetal heart rate patterns, i.e., higher variability and reactivity with fewer decelerations, under remifentanil therapy as compared with meperidine (P < 0.001). In conclusion, an intermittent incremental regimen with repeated small-dose PCIA boluses of remifentanil provided effective and reliable analgesia during labor and delivery.

 

清醒大鼠持续胸段硬膜外麻醉引起节段性交感神经阻滞

Continuous Thoracic Epidural Anesthesia Induces Segmental Sympathetic Block in the Awake Rat

Hendrik Freise, MD, Sören Anthonsen, Lars G. Fischer, MD, Hugo K. Van Aken, MD, and Andreas W. Sielenkämper, MD

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Muenster, Muenster, Germany

Anesth Analg 2005 100: 255-262.

胸段硬膜外麻醉(EA)在危重病治疗中的应用增加,主要是进行心脏、肠道的交感神经阻滞。作者对清醒大鼠实施一种新的持续TEA方法,评价心脏、呼吸功能和交感神经活性。13只实验大鼠经硬膜外注射生理盐水(CON组)作为对照组或0.5%布比卡因(EPI组)作为实验组,注射速度为15μl/h,持续2h,注射时间为第一天和第三天。记录平均动脉压、心率、呼吸频率、PaO2和运动评分的基础值以及给药306090120min的数值。分别被记录前爪、胸部上中下部分、后爪和前后尾部的皮肤温度。交感神经活性的变化通过皮肤温度的变化(ΔT)来评价。给药组血流动力学和呼吸维持不变,只是有轻度的运动受限。胸部上中下部分的ΔT均高于生理盐水组的相应数值(P<0.001)。给药组尾后部温度降低(6090120minP<0.05),如90minΔT-0.86 ± 0.25°C,而生理盐水组ΔT0.4 ± 0.12°C。第三天和第一天的ΔT相当。在清醒大鼠TEA稳定地节段性阻滞交感神经,不会引起心血管呼吸功能和运动系统的副作用。这项新技术可用于严重疾病的长期模型。

(赵延华 译 陈杰 校)

Thoracic epidural anesthesia (TEA) is used increasingly in critical care, especially for cardiac and intestinal sympathetic block. In this study we evaluated cardiorespiratory function and sympathetic activity in a new model of continuous TEA in awake rats. Thirteen rats received epidural saline control (CON) or bupivacaine 0.5% epidural infusion (EPI) at 15 µl/h for 2 h on day 1 and day 3. Mean arterial blood pressure, heart rate, respiration rate, arterial PCO2, and motor score were recorded at baseline and after 30, 60, 90, and 120 min. Skin temperature was measured at front paws, high-thoracic, mid-thoracic, and low-thoracic, hind paws, and the proximal and distal tail. Changes in sympathetic activity were assessed by skin temperature changes from baseline ({Delta}T). In the EPI group, hemodynamics and respiration remained unchanged and only mild motor deficits occurred. {Delta}T in thoracic segments was higher in the EPI than in the CON group (P < 0.001 at all times at high-thoracic, mid-thoracic, and low-thoracic segments). Skin temperature decreased in the distal tail in the EPI group, e.g., after 90 min {Delta}T = –0.86 ± 0.25°C (EPI) versus 0.4 ± 0.12°C (CON) (P < 0.05 at 60, 90, and 120 min). {Delta}T on day 3 was comparable to day 1. TEA induced stable segmental sympathetic block without cardiorespiratory and motor side effects in awake rats. This new technique may be applied in prolonged models of critical illness.

 

经喉罩插入常规的气管导管

Conventional Tracheal Tubes for Intubation Through the Intubating Laryngeal Mask Airway

Pankaj Kundra, MD, MAMS, FIMSA, N. Sujata, MD, and M. Ravishankar, DA, MD

Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India

Anesth Analg 2005 100: 284-288.

 

可通过喉罩(laryngeal mask airwayLMA)的FastrachTM硅树脂加固的气管导管(FTST),是特别为插入式LMAintubating LMAILMA)而设计,以通过该喉罩进行气管插管。常规的气管导管已经被成功应用,以完成气管插管。作者通过研究评价了经过ILMA盲插FTST导管、Rusch聚氯乙烯导管(polyvinyl chloride tubePVCT)和Rusch乳胶导管(latex armored tubeLAT)的成功率。150ASAⅠ健康成人,全麻下行选择性手术,随机分为三组,即FTST组(n=50)、管道经过预热的PVCT组(n=50)和LVT组(n=50),行气管插管。记录插管的难易程度、插管所需时间、试插次数、插管辅助手法的使用次数。另外,记录插管失败次数和拔除ILMA所需时间。记录术后病人出现创伤、咽喉酸痛和声嘶等情况。PVCTFTST插管的成功率为96%,显著高于LAT82%)(P<0.05)。PVCTLAT第一次插管的成功率相似(86%),显著高于LAT52%)(P<0.05)。LAT插管误入食道的发生率(29.7%)显著高于PVCT(1.8%)FTST7.4%)(P<0.05)。结论:PVCT经预热后可像FTST那样经喉罩盲插,但LAT插管失败率高且容易误入食道。

(赵延华 译 陈杰 校)

 

The laryngeal mask airway (LMA)-FastrachTM silicone wire-reinforced tracheal tube (FTST) was specially designed for tracheal intubation through the intubating LMA (ILMA). However, conventional tracheal tubes have been successfully used to accomplish tracheal intubation. We designed this study to evaluate the success rate of blind tracheal intubation through the ILMA by using the FTST, the Rusch polyvinyl chloride tube (PVCT), and the Rusch latex armored tube (LAT). One-hundred-fifty healthy adults of ASA physical status I and II who were undergoing elective surgery under general anesthesia were randomly allocated into three groups. FTST (n = 50), prewarmed PVCT (n = 50), and LAT (n = 50) were used for tracheal intubation. Ease of tracheal intubation was assessed by the time taken, the number of attempts, and the number of maneuvers required for success. In addition, numbers of failed intubation attempts and times taken for ILMA removal were also recorded. After surgery, the incidence of trauma, sore throat, and hoarseness was noted. Significantly more frequent success in tracheal intubation was achieved with the PVCT and FTST (96%) compared with the LAT (82%) (P < 0.05). Tracheal intubation on the first attempt was similar with the PVCT and FTST (86%) and was significantly more frequent than with the LAT (52%) (P < 0.05). Esophageal placement was significantly more frequent with the LAT (29.7%) when compared with the PVCT and FTST (1.8% and 7.4%, respectively) (P < 0.05). The authors conclude that a prewarmed PVCT can be used as successfully as the FTST for blind tracheal intubation through the ILMA, whereas the LAT is associated with more frequent failure and esophageal intubation.

 

急性等容血液稀释在单肺通气时对氧合作用的影响

The Effects of Acute Isovolemic Hemodilution on Oxygenation During One-Lung Ventilation

Laszlo L. Szegedi, MD*, Philippe Van der Linden, MD, PhD{dagger}, Anne Ducart, MD{ddagger}, Pieter Cosaert, MD*, Jan Poelaert, MD, PhD§, Frank Vermassen, MD, PhD||, Eric P. Mortier, MD, DSc*, and Alain A. d’Hollander, MD, PhD

*Department of Anesthesiology, Gent University Hospital, Gent, Belgium; {dagger}Department of Anesthesiology, Brugmann University Hospital, Brussels, Belgium; {ddagger}Department of Anesthesiology, Erasme University Hospital, Brussels, Belgium; §Department of Cardiac Anesthesia and Intensive Care, Gent University Hospital, Gent, Belgium; ||Department of Thoracic and Vascular Surgery, Gent University Hospital, Gent, Belgium; and ¶Department of Anesthesiology, Geneva University Hospital, Geneva, Switzerland

Anesth Analg 2005;100:15-20

 

有关等容血液稀释(IH)在单肺通气(OLV)时对氧化作用的影响的资料很少。我们研究了47例血红蛋白均>14 g/dL的择期肺部手术患者(17例肺功能正常[NL]17例慢性阻塞性肺疾病[COPD][COPD]13COPD患者作为时间/麻醉效应对照[CTRL])。麻醉标准化,双腔管插入气管。通气参数设定及吸入氧浓度保持不变。研究在手术开始前进行,患者处于仰卧位。先OLV15分钟,再建立双肺通气,并且进行IH500 mL),给予同等容量的羟乙基淀粉。随后再进行OLV 15分钟。CTRL组,按同样的次序给予OLV,不进行IH。每次OLV期末,记录肺部力学参数和血气。用方差分析对数据进行分析(均数±标准差)。NL组和CTRL组的动脉氧分压保持不变,而COPD组从IH前的119 ± 21 mm Hg下降到IH后的86 ± 16 mm HgP <0.01)。轻度的IHOLV时损害COPD患者的气体交换,但是对肺功能正常的患者无影响。

(陈 李士通 校)

Data on the effects of isovolemic hemodilution (IH) on oxygenation during one-lung ventilation (OLV) are lacking. We studied 47 patients with hemoglobin >14 g/dL who were scheduled for lung surgery (17 with normal lung function [group NL], 17 with chronic obstructive pulmonary disease [COPD] [group COPD], and 13 with COPD as control for time/anesthesia effects [group CTRL]). Anesthesia was standardized. The tracheas were intubated with a double-lumen tube. Ventilatory settings and fraction of inspired oxygen remained constant. The study was performed with patients in the supine position before surgery. OLV was initiated for 15 min. Two-lung ventilation was reinstituted, and IH was performed (500 mL); an identical volume of hydroxyethyl starch was administered. Subsequently, OLV was again performed for 15 min. In group CTRL, the same sequences of OLV were performed without IH. At the end of each period of OLV, pulmonary mechanics and blood gases were recorded. Data were analyzed by analysis of variance (mean ± SD). In group NL and group CTRL, the arterial oxygen partial pressure remained constant, whereas it decreased in group COPD from 119 ± 21 mm Hg before IH to 86 ± 16 mm Hg after IH (P < 0.01). Mild IH impairs gas exchange during OLV in COPD patients, but not in patients with normal lung function.

 

继发于中枢神经系统中一氧化氮增加的交感传出减少导致肝素后鱼精蛋白产生的低血压

Protamine After Heparin Produces Hypotension Resulting from Decreased Sympathetic Outflow Secondary to Increased Nitric Oxide in the Central Nervous System

Yoshikazu Hamada, MD*, Yoshiyuki Kameyama, MD*, Hideyuki Narita, MD*, Kirk T. Benson, MD{dagger}, and Hiroshi Goto, MD{dagger}

*Department of Anesthesiology, Tokyo Medical University, Shinjuku, Tokyo, Japan; {dagger}Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas.

Anesth Analg 2005;100:33-37

 

为了阐明鱼精蛋白导致的低血压、一氧化氮 (NO)与交感活性间是否有联系,我们先给予20 mg/kg NG-硝基-D-精氨酸甲酯(D-NAME)或者NG-硝基-L-精氨酸甲酯 (L-NAME),作为压力感受器去神经支配的兔子的预处理,然后给予300 U/kg肝素,再给予3 mg/kg鱼精蛋白。比较血流动力学参数和肾交感神经活性(RSNA)。在D-NAME组,心率(HR)、平均动脉压(MAP)RSNA分别显著减少至93.7% ± 0.7% 75.0% ± 5.1%65.2% ± 4.6%(mean ± SE)。在L-NAME组,L-NAME的预处理显著抑制了鱼精蛋白对这些参数的抑制作用。由于动物是完全地压力感受器去神经支配,RSNA的下降可归因于鱼精蛋白的中枢抑制作用,交感传出的减少可能导致HRMAP的下降。预先给予L-NAME,一个NO合酶抑制剂,可以抑制鱼精蛋白对交感传出的抑制作用,提示了,继发于鱼精蛋白导致的中枢神经系统中NO浓度增加的交感传出的减少可能促成了鱼精蛋白导致的心血管抑制。

(张 李士通 校)

To elucidate whether there are linkages among protamine-induced hypotension, nitric oxide (NO), and sympathetic nerve activity, we administered 3 mg/kg protamine sulfate after 300 U/kg heparin after 20 mg/kg of NG-nitro-D-arginine methyl ester (D-NAME) or NG-nitro-L-arginine methyl ester (L-NAME) as a pretreatment to baroreceptor-denervated rabbits and compared changes in hemodynamic variables and renal sympathetic nerve activity (RSNA). In the D-NAME group, heart rate (HR), mean arterial blood pressure (MAP), and RSNA significantly decreased to 93.7% ± 0.7%, 75.0% ± 5.1% and 65.2% ± 4.6% (mean ± SE), respectively. In the L-NAME group, the pretreatment of L-NAME significantly inhibited the depressant effects of protamine on these variables. Because the animals were totally baroreceptor-denervated, decreased RSNA was attributable to the central depressant effect of protamine, and decreased sympathetic outflow could have contributed to the reduction of HR and MAP. The depressant effect of protamine on sympathetic outflow was inhibited by the pretreatment with L-NAME, a NO synthase inhibitor, suggesting that decreased sympathetic outflow secondary to a protamine-induced increase in NO concentration in the central nervous system may contribute to protamine-induced cardiovascular depression.

 

麻醉对上呼吸道感染的患儿:还困难吗?

Anesthesia for the Child with an Upper Respiratory Tract Infection: Still a Dilemma?

Alan R. Tait, PhD, and Shobha Malviya, MD

Department of Anesthesiology, University of Michigan Health Systems, Ann Arbor, Michigan

Anesth Analg 2005;100:59-65

 

小儿麻醉中最有争论的问题之一围绕着对有上呼吸道感染(URI)的患儿是否继续进行麻醉与手术的决策。过去,有URI的患儿原则上应推迟手术日期直至症状消失。该措施主要基于以往的经验支持的前提:麻醉会增加严重并发症的危险性及患儿术后病程的复杂性。尽管最近的临床数据证实:一些患有URI的患儿围术期并发症有增加的危险,对于大部分患儿而言可以预期、认识及治疗这些并发症。尽管对有URI的患儿麻醉仍是一种挑战,但对于评价及处理这些患儿,目前麻醉医生现已处于一个更好的位置能作出更明智的决定,而取消手术的做法已成为过去。

(裘毅敏 李士通 校)

One of the most controversial issues in pediatric anesthesia has revolved around the decision to proceed with anesthesia and surgery for the child who presents with an upper respiratory tract infection (URI). In the past, doctrine dictated that children with URIs have their surgery postponed until the child was symptom free. This practice was based on the empirically supported premise that anesthesia increased the risk of serious complications and complicated the child’s postoperative course. Although recent clinical data confirm that some children with URIs are at increased risk of perioperative complications, these complications can, for the most part, be anticipated, recognized, and treated. Although the child with a URI still presents a challenge, anesthesiologists are now in a better position to make informed decisions regarding the assessment and management of these children, such that blanket cancellation has now become a thing of the past.

 

容量减少性浓缩血小板中的血小板功能完整性

The Functional Integrity of Platelets in Volume-Reduced Platelet Concentrates

Helge Schoenfeld, MD*,{dagger}, Manfred Muhm, MD*,{ddagger}, Ulrich R. Doepfmer, MD, FRCA{dagger}, Wolfgang J. Kox, MD, PhD, FRCP{dagger}, Claudia Spies, MD{dagger}, and Hartmut Radtke, MD§

*Department of Anesthesiology, Inselspital, University Hospital of Bern, Bern, Switzerland; {dagger}Department of Anesthesiology and Intensive Care Medicine, Charité, University Medicine Berlin, Campus Charité Mitte, Berlin, Germany; {ddagger}Department of Cardiothoracic Anesthesia and Intensive Care Medicine, University of Vienna, and Department of Anesthesiology and Intensive Care Medicine, Hospital of Oberpullendorf, Austria; and §Institute of Transfusion Medicine, Charité, University Medicine Berlin, Campus Charité Mitte, Berlin, Germany

Anesth Analg 2005;100:78-81

 

为治疗早产及低出生体重婴儿的血小板减少症,通常需要输注小容量血小板。同时,进行开心手术及体外循环并危及心脏功能的婴儿又面临着血容量过多的风险。可以从标准单个供者的一个浓缩血小板(PC)单位中分出一部分来得到小容量的血小板替代品。或者有PCs的容量减少的适应证以在最可能小的容量中输注最多数量的血小板。我们在20份联贯的单个供者提取的PCs中,测定容量减少前后血小板自发和诱导活化。平均储存2天后,用离心方法去除PCs的血浆成分。用流式细胞仪测定血小板自发的、二磷酸腺苷(ADP)诱导的和胶原诱导的活性。进一步测定经ADP和胶原诱导的聚合物。结果为,标准PCs中共有33.8%的血小板有自发活性。PCs容量减少使血小板自发活性轻度但显著升高(43.2%)。另外,容量减少使ADP诱导的血小板聚合性受影响,但对胶原诱导的血小板活性无影响。输注容量减少的PCs是血容量过多风险高的患者用标准PCs的另一有效选择,因为相同容量可以有效增加两倍数目的血小板。

(周志坚 李士通 校) 

Premature and low-birth-weight infants usually require small-volume platelet transfusions to treat thrombocytopenia. Also, infants undergoing open-heart surgery with extracorporeal circulation and with compromised cardiac function are at risk for excessive intravascular volume. The small-volume platelet substitution can be achieved by dispensing an aliquot from the unit of a standard single-donor platelet concentrate (PC). Alternatively, there is an indication for volume reduction of PCs to maximize the number of platelets transfused in the smallest possible volume. We determined the spontaneous and induced activation of platelets before and after volume reduction in 20 consecutive single-donor-apheresis PCs. After a mean storage time of 2 days, the PCs were plasma-depleted by centrifugation. Spontaneous, adenosine diphosphate (ADP)-induced, and collagen-induced activation were determined by flow cytometry. Furthermore, ADP- and collagen-induced aggregation were measured. A total of 33.8% of platelets in standard PCs were activated spontaneously. Volume reduction of PCs led to a mild but significant increase of spontaneous activation of platelets (43.2%). Additionally, volume reduction resulted in an impaired ADP-induced aggregability of platelets, whereas collagen induction was unaffected. Transfusion of volume-reduced PCs is an effective alternative to use of standard PCs in patients at frequent risk for excessive intravascular volume, because equal volumes increase the platelet count twice as effectively.

 

对猫静脉给予利多卡因对异氟醚肺泡最低浓度的影响

The Effects of Intravenous Lidocaine Administration on the Minimum Alveolar Concentration of Isoflurane in Cats

Bruno H. Pypendop, DrMedVet, DrVetSci, and Jan E. Ilkiw, BVSc, PhD

Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis

Anesth Analg 2005;100:97-101

 

利多卡因降低吸入麻醉药的最小肺泡浓度(MAC),临床上可用于减少其他麻醉药的用量。在本研究中,我们探讨了利多卡因对猫MAC的影响。研究了6只猫。在实验1,测定异氟醚的MAC。静脉一次给利多卡因2mg/kg,测定静脉血浆利多卡因浓度以确定其药代动力学值。在实验2,给予利多卡因,使之血浆靶浓度在1-11µg/mL,测定每一个利多卡因血浆浓度时的异氟醚的MAC。利多卡因血浆靶浓度为1357911 µg/mL时,实际利多卡因血浆浓度分别为1.06 ± 0.122.83 ± 0.39 4.93 ± 0.64 6.86 ± 0.97 8.86 ± 2.109.84 ± 1.34 µg/mL。利多卡因靶浓度为01357911 µg/mL时,研究中异氟醚的MAC分别为2.21% ± 0.17%2.14% ± 0.14%1.88% ± 0.18%1.66% ± 0.16%1.47% ± 0.13%1.33% ± 0.23%1.06% ± 0.19%。在利多卡因血浆靶浓度为1357911 µg/mL时,利多卡因线性地降低异氟醚的MAC分别为–6%6%7%28%19%35%28%45%29%53%44%59%。我们作出结论:利多卡因降低异氟醚的MAC

(彭中美 李士通 校)

Lidocaine decreases the minimum alveolar concentration (MAC) of inhaled anesthetics and has been used clinically to reduce the requirements for other anesthetic drugs. In this study we examined the effects of lidocaine on isoflurane MAC in cats. Six cats were studied. In Experiment 1, the MAC of isoflurane was determined. An IV bolus of lidocaine 2 mg/kg was then administrated and venous plasma lidocaine concentrations were measured to determine pharmacokinetic values. In Experiment 2, lidocaine was administered to achieve target plasma concentrations between 1 and 11 µg/mL and the MAC of isoflurane was determined at each lidocaine plasma concentration. Actual lidocaine plasma concentrations were 1.06 ± 0.12, 2.83 ± 0.39, 4.93 ± 0.64, 6.86 ± 0.97, 8.86 ± 2.10, and 9.84 ± 1.34 µg/mL for the target concentrations of 1, 3, 5, 7, 9, and 11 µg/mL, respectively. The MAC of isoflurane in this study was 2.21% ± 0.17%, 2.14% ± 0.14%, 1.88% ± 0.18%, 1.66% ± 0.16%, 1.47% ± 0.13%, 1.33% ± 0.23%, and 1.06% ± 0.19% at lidocaine target plasma concentrations of 0, 1, 3, 5, 7, 9, and 11 µg/mL, respectively. Lidocaine, at target plasma concentrations of 1, 3, 5, 7, 9, and 11 µg/mL, linearly decreased isoflurane MAC by –6% to 6%, 7% to 28%, 19% to 35%, 28% to 45%, 29% to 53%, and 44% to 59%, respectively. We conclude that lidocaine decreases the MAC of isoflurane.

 

在意识丧失及唤醒时丙泊酚的个体作用部位浓度相似

Individual Effect-Site Concentrations of Propofol Are Similar at Loss of Consciousness and at Awakening

Hiroko Iwakiri, MD, Noboru Nishihara, DDS, PhD, Osamu Nagata, MD, Takashi Matsukawa, MD, Makoto Ozaki, MD, and Daniel I. Sessler, MD

Department of Anesthesiology, Tokyo Women’s Medical University, Tokyo, Japan; Department of Anesthesiology, University of Yamanashi, Faculty of Medicine, Yamanashi, Japan; and Outcomes ResearchTM Institute and Departments of Anesthesiology and Perioperative Medicine and Pharmacology, University of Louisville, Louisville, Kentucky.

Anesth Analg 2005;100:107-110

 

已有报道的丙泊酚意识丧失时和意识恢复时的作用部位浓度范围很大。因此任何一个基于人群平均值的浓度对于个体病人来说未必是最理想的浓度。所以我们来验证这样一个假设:个体在意识丧失和恢复时其丙泊酚作用部位浓度是相近的。在20名成年人中以靶控输注系统估算志愿者在意识丧失和恢复时丙泊酚的作用部位浓度。逐渐增加丙泊酚的作用部位浓度直至志愿者丧失意识(对于语言刺激无反应);维持志愿者意识丧失状态15分钟,随后唤醒志愿者。此过程在每个志愿者重复3次。我们得到的主要结果是丙泊酚使意识丧失的浓度及估算的意识丧失时的作用部位浓度与意识恢复时的作用部位浓度之间的关系。丙泊酚的靶作用部位浓度在意识丧失时为2.0 ± 0.9 意识恢复时为 1.8 ± 0.7 (P < 0.001)。个体意识丧失和恢复时丙泊酚作用部位浓度差的平均值仅为0.17 ± 0.32 µg/mL(差的95%可信限为 0.09–0.25 µg/mL)。因此我们的结果提示丙泊酚个体滴定至意识消失是除了在人群平均需要量的基础上定量给予以外的另一选择。

(周雅春   李士通 校)

Reported effect-site concentrations of propofol at loss of consciousness and recovery of consciousness vary widely. Thus, no single concentration based on a population average will prove optimal for individual patients. We therefore tested the hypothesis that individual propofol effect-site concentrations at loss and return of consciousness are similar. Propofol effect-site concentrations at loss and recovery of consciousness were estimated with a target-control infusion system in 20 adults. Propofol effect-site concentrations were gradually increased until the volunteers lost consciousness (no response to verbal stimuli); unconsciousness was maintained for 15 min, and the volunteers were then awakened. This protocol was repeated three times in each volunteer. Our major outcomes were the concentration producing unconsciousness and the relationship between the estimated effect-site concentrations at loss and recovery of consciousness. The target effect-site propofol concentration was 2.0 ± 0.9 at loss of consciousness and 1.8 ± 0.7 at return of consciousness (P < 0.001). The average difference between individual effect-site concentrations at return and loss of consciousness was only 0.17 ± 0.32 µg/mL (95% confidence interval for the difference 0.09–0.25 µg/mL). Our results thus suggest that individual titration to loss of consciousness is an alternative to dosing propofol on the basis of average population requirements.

 

硫喷妥钠在大鼠身上产生制动主要通过脊髓上位作用

Thiopental Produces Immobility Primarily by Supraspinal Actions in Rats

Caroline Stabernack, MD, Yi Zhang, MD, James M. Sonner, MD, Michael Laster, DVM, and Edmond I Eger, II, MD

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

Anesth Analg 2005;100:128-136

 

脊索介导了吸入麻醉药绝大部分的制动作用。本研究中我们在大鼠身上探讨了到底是脊髓还是脊髓以上部位介导了硫喷妥钠的制动作用。硫喷妥钠通过IV、椎管内(IT)、脑室内(ICV)或ITICV同时给药。只有IV输注产生麻醉作用,即对夹尾无体动反应(换言之,相当于最小肺泡浓度,MAC 。因此,用硫喷妥钠的MAC-节省效应(针对异氟醚)来评估ITICV输注硫喷妥钠的制动作用。在全脑、脊索和远离输注部位的大脑皮层的一个薄片中测定硫喷妥钠的浓度。这些浓度与输注硫喷妥钠的MAC-节省效应之间以一种多元回归的模式相关。为了评估硫喷妥钠渗入脊索的速率,大鼠脊索在体外用硫喷妥钠浸浴至平衡,然后测定脊索中的硫喷妥钠浓度以作为平衡稳定时间的函数。在体内通过行为研究的时间跨度进行IT输注硫喷妥钠来重复了这个研究。我们发现,ITICV输注硫喷妥钠25 µg/min减少异氟醚的MAC<25%。与IV输注一定剂量可以在无异氟醚时产生麻醉作用的硫喷妥钠时相比, IT输注或ICV输注硫喷妥钠25 µg/min之后,相应的脊索和全脑中的硫喷妥钠浓度分别超过500%和680%。异氟醚MAC减少的百分比主要和脑组织中硫喷妥钠的浓度相关而与脑室中浓度无关。脊索输注可以减少约20%的MAC。在体外IT硫喷妥钠很容易弥散入脊索,时间常数约1h。我们得出结论:与吸入麻醉药不同,硫喷妥钠的制动作用主要是脊髓上位的。大脑中除了靠近第三和第四脑室外的中枢部位起了最主要的作用。

(黄施伟 李士通 校)

The spinal cord mediates most of the immobilizing action of inhaled anesthetics. In the present study we investigated whether spinal or supraspinal sites mediate the immobilizing action of thiopental in rats. Thiopental was administered IV, intrathecally (IT), intracerebroventricularly (ICV), or simultaneously IT and ICV. Only the IV infusion produced anesthesia, defined as immobility in response to application of a tail clamp (i.e., the equivalent of minimum alveolar concentration, MAC). Consequently, the MAC-sparing effect (for isoflurane) of thiopental was used to assess the immobilizing contribution of IT and ICV infusions of thiopental. Thiopental concentrations were determined in whole brain, spinal cord, and a slice of cerebral cortex distant from the infusion sites. These concentrations were correlated with the MAC-sparing effect of the thiopental infusions in a multiple regression model. To assess the rate at which thiopental penetrates the cord, rat spinal cords were equilibrated in a bath of thiopental ex vivo and the concentration of thiopental in the cord was measured as a function of equilibration time. This was repeated in vivo with IT infusions of thiopental spanning the time of the behavioral studies. We found that IT or ICV infusion of thiopental 25 µg/min decreased isoflurane MAC <25%. The associated thiopental concentrations in the spinal cord after IT infusion, and in the whole brain after ICV infusion of 25 µg/min thiopental, exceeded by 500% and 680%, respectively, the concentrations found in the spinal cord and in the whole brain after IV infusion of thiopental in a dose that produced anesthesia in the absence of isoflurane. The percentage decrease in the MAC of isoflurane correlated primarily with the concentration of thiopental found in cerebral tissue not in contact with the cerebral ventricles. The spinal cord infusion produced an approximately 20% decrease in MAC. Ex vivo IT thiopental readily diffused into the spinal cord, with a time constant of approximately 1 h. We conclude that, unlike inhaled anesthetics, the immobilizing action of thiopental is largely supraspinal. Centers in the brain other than those near the third and fourth ventricles produce the greatest effect.

 

用于拇内收肌神经肌肉监测的四个成串刺激可置于腕部或手上

Train-of-Four Stimulation for Adductor Pollicis Neuromuscular Monitoring Can Be Applied at the Wrist or Over the Hand

Marie-Eve Nepveu, MD, François Donati, MD, PhD, FRCPC, and Louis-Philippe Fortier, MSC, MD, FRCPC

Department of Anesthesiology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada

Anesth Analg 2005;100:149-154

 

在腕部的尺神经刺激拇内收肌是监测神经肌肉功能的标准方法。一般认为在肌肉上刺激直接引起肌肉收缩,但是其证据不足。在本研究中,我们试图确定手上的拇内收肌刺激过程中发生的直接肌肉刺激以及其反应是否与在腕部刺激时观察到的相似。在20例七氟醚麻醉的患者中,一部分刺激电极置于腕部尺神经,第二部分置于手背部第一掌骨与第二掌骨之间。监测肌加速度反应。给予罗库溴铵0.6 mg/kg。在腕部实施四个成串(TOF)刺激,直到最大阻滞。然后,在手部实施刺激。在恢复过程中,交替监测两部位。注射罗库溴铵后,20例患者中的17例在两部位刺激均无颤搐反应,1例在两个部位刺激均有反应,2例患者仅在腕部刺激有反应。在恢复过程中手上的TOF比率与腕部相比较,用BlandAltman分析显示,偏差为0.5%,一致限度±11.8%。在手上刺激不引起直接的肌肉刺激,因为其反应并不大于在腕部刺激所产生的反应。刺激两部位产生的TOF比率相近。

(马皓琳 李士通 校)

Adductor pollicis stimulation over the ulnar nerve at the wrist is the standard method of monitoring neuromuscular function. Stimulation over a muscle is believed to cause direct muscle contraction, but evidence for this is lacking. In this study we sought to determine whether direct muscle stimulation occurred during stimulation of the adductor pollicis in the hand and whether the responses were comparable to those observed with stimulation at the wrist. In 20 patients anesthetized with sevoflurane, 1 pair of stimulating electrodes was positioned over the ulnar nerve at the wrist. A second pair was placed between the first and second metacarpals on the palmar and dorsal aspects of the hand. The acceleromyographic response was monitored. Rocuronium 0.6 mg/kg was administered. Train-of-four (TOF) stimulations were applied at the wrist site until maximal blockade. Then, stimulation was applied to the hand site. During recovery, both sites were monitored alternately. After injection of rocuronium, 17 of 20 patients showed no twitch response at either site. One patient had a response at both stimulation sites, and two patients had responses only at the wrist site. With a Bland and Altman analysis, TOF ratios during recovery at the hand showed a bias of 0.5% and limits of agreement of ±11.8% as compared with the wrist. Stimulation in the hand causes no direct muscle stimulation because the response is no more than that produced by stimulation at the wrist. Both sites yield comparable TOF ratios.

 

心脏手术后拔除胸腔引流管三种镇痛方法的随机比较

A Randomized Comparison of Three Methods of Analgesia for Chest Drain Removal in Postcardiac Surgical Patients

Maria Akrofi, FRCA, Scott Miller, FRCA, Steve Colfar, Peter R. Corry, FRCA, Brian M. Fabri, FRCS, Mark D. Pullan, FRCS, Glenn N. Russell, FRCA, and Mark A. Fox, FRCA

Cardiothoracic Centre National Health Service Trust, Thomas Drive, Liverpool, United Kingdom

Anesth Analg 2005;100:205-209

 

 66位患者行冠脉搭桥手术和/或瓣膜手术,术后拔除胸腔引流管时进行镇痛,前瞻随机地研究三种镇痛方法的效果。患者随机接受0.1 mg/kg吗啡静脉注射、0.5%布比卡因20 mL皮下注射或通过活瓣吸入50%笑气50%氧气混合气体(Entonox)。拔管前、拔管时用视觉模拟评分(visual analog scaleVAS)来评估疼痛水平。拔管时布比卡因组、Entonox组和吗啡组的VAS中位数(第25百分位数、第75百分位数)分别是:9.5 mm (318 mm)37.0 mm (1356 mm) 15.0 mm (727 mm)Entonox组的疼痛评分高于布比卡因组(P = 0.005)和吗啡组(P = 0.047)。三组疼痛评分基础值与拔管值的差异分别是:–0.5 mm (–137 mm)+10 mm (129 mm)–3.0 mm (–1112 mm)。三组间动脉压、心率、PaCO2、血氧饱和度和镇静水平无显著差异。拔除胸腔引流管时布比卡因和吗啡的镇痛效果较好,但Entonox的镇痛效果不好。

(轩泓 李士通 校)

Sixty-six patients scheduled for coronary artery bypass graft and/or valve surgery were recruited in a prospective, randomized study designed to compare the effectiveness of three analgesic regimens for chest drain removal. Patients were randomized to receive 0.1 mg/kg IV morphine, 20 mL of 0.5% bupivacaine infiltrated subcutaneously, or inhaled 50% nitrous oxide in oxygen (Entonox) via a demand valve. We assessed pain by measuring visual analog scale pain scores before and during drain removal. Median (25th, 75th centile) visual analog scale pain scores associated with drain removal in the bupivacaine, Entonox, and morphine groups were 9.5 mm (3, 18 mm), 37.0 mm (13, 56 mm), and 15.0 mm (7, 27 mm), respectively. The pain scores were higher in the Entonox group compared with the bupivacaine group (P = 0.005) and the morphine group (P = 0.047). Differences between baseline and drain-removal scores were –0.5 mm (–13, 7 mm), +10 mm (1, 29 mm), and –3.0 mm (–11, 12 mm), respectively. There was no difference among groups in arterial blood pressure, heart rate, PaCO2, oxygenation, or sedation. Bupivacaine and morphine, unlike Entonox, produce lower pain scores associated with drain removal.

 

 

可乐定在神经外科手术中的应用

Intraoperative Clonidine Administration to Neurosurgical Patients

Claudia Stapelfeldt, MD, Errol P. Lobo, MD, PhD, Ronald Brown, BS, and Pekka O. Talke, MD

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

Anesth Analg 2005;100:226-232

 

本研究目的包括两部分:确定颅内手术患者预防浅低温后的术后寒战的可乐定剂量和评估可乐定对患者麻醉恢复的影响。48例择期行颅内手术患者分成两组。在第一部分研究 (n = 14)中,我们使用Dixon’s 上下法确定可乐定预防浅低温(35°C)后的术后寒战的ED50。首个患者可乐定的剂量是3 µg/kg。随后患者的剂量以1 µg/kg的增量调整。术后一小时评估寒战的发生情况。第二部分研究(n = 34)为评估3 µg/kg可乐定对麻醉恢复的影响的前瞻、随机、盲法、安慰剂对照研究,。开始缝硬脑膜时,随机给予患者可乐定或生理盐水输注15分钟。研究麻醉结束后2小时内的恢复参数。对手术结束时靶中心温度为35°C的神经外科患者,可乐定预防寒战的ED501.1 ± 1.5 µg/kg。相比生理盐水,麻醉结束前1小时给予神经外科患者3 µg/kg可乐定既不会延迟麻醉恢复,也不会有临床上显著的镇静或血流动力学作用。我们的研究提示可乐定可用于神经外科患者来预防浅低温后的术后寒战。

(张俊杰 李士通 校)

The goals of this two-part study were to determine the dose of clonidine to prevent postoperative shivering after mild hypothermia and to evaluate the effect of clonidine on recovery from anesthesia in patients undergoing surgery for intracranial lesions. We enrolled 48 patients undergoing elective supratentorial neurosurgical procedures into one of two studies. In study 1 (n = 14) we determined the ED50 of clonidine to prevent postoperative shivering after mild hypothermia (35°C) using Dixon’s up-and-down method. Clonidine dose for the first study patient was 3 µg/kg. The dose was then adjusted in 1-µg/kg increments for the following patients. Shivering was assessed for 1 h postoperatively. Study 2 (n = 34) was a prospective, randomized, double-blind, placebo controlled study to evaluate the effect of 3 µg/kg clonidine on recovery from anesthesia. At the beginning of dural closure, patients randomly received a 15-min infusion of either clonidine or normal saline. Recovery variables were studied for 2 h after the end of anesthesia. The ED50 of clonidine to prevent shivering was 1.1 ± 1.5 µg/kg in neurosurgical patients whose target core temperature was 35°C at the end of surgery. Compared with saline, 3 µg/kg of clonidine administered to neurosurgical patients 1 h before the end of anesthesia did not delay emergence from anesthesia nor did it have clinically significant sedative or hemodynamic effects. Our results imply that clonidine may be used in neurosurgical patients to prevent postoperative shivering after mild hypothermia.

 

用区域麻醉和镇痛抑制乳房癌手术应激反应并不影响血管内皮生长因子和前列腺素E2

Inhibition of the Stress Response to Breast Cancer Surgery by Regional Anesthesia and Analgesia Does Not Affect Vascular Endothelial Growth Factor and Prostaglandin E2

S. C. O’Riain, FCARCSI*, D. J. Buggy, MD, MSc, DME, FRCPI, FCARCSI, FRCA*,{dagger},{ddagger}, M. J. Kerin, MCh, FRCSI, FRCSGen{dagger},{ddagger}, R. W. G. Watson, PhD{dagger}, and D. C. Moriarty, FCARCSI*,{ddagger}

*Department of Anaesthesia and Intensive Care Medicine, Mater Misericordiae University Hospital; {dagger}Conway Institute of Biomolecular and Biomedical Research, University College Dublin; and the {ddagger}National Breast Screening Programme, Dublin, Ireland

Anesth Analg 2005;100:244-249

 

血管增生是乳腺癌症转移的基础,这一增生受血管生长因子和前列腺素E2介导。我们假设血清中血管内皮生长因子和前列腺素E2的水平在乳腺癌手术应激刺激下会有所增加,而可被椎旁阻滞麻醉和镇痛所抑制。30例乳房切除手术妇女入选这个前瞻性研究中,被随机分入为:用全麻进行手术并在术后以阿片类药物镇痛(吗啡0.1mg/kg单次和PCA注射);全麻复合椎旁麻醉(72小时注射)两组。所有的病人都接受直肠二氯芬酸肛栓。在术前以及在术后424小时采集静脉血液样本,检测血清中血糖、皮质醇、C-反应蛋白、VEGF以及PEGE2。结果:PVAA可抑制手术的应激反应,使作为应激反应水平的血浆中血糖、皮质醇和C反应蛋白明显的减低。但是VEGFPGE2的水平在两组中并没有明显的差异。在用PVAA复合全麻以及单独用全麻的病人中424小时VEGF变化的百分比是3% ± 44%9% ± 80% P = 0.29。以及5% ± 43% –10% ± 63%, P = 0.41。两组PEGE2在术后424小时改变为0% ± 17% 11% ± 69%, P = 0.29 and 34% ± 19% 47% ± 18%, P = 0.15.。结论:我们认为尽管抑制了手术的应激刺激,PVAA并不能影响乳房癌的血管再生因素VEGFPGE2

(沈浩 李士通 校)

Angiogenesis is essential for breast cancer metastases formation and is mediated by vascular endothelial growth factor (VEGF) and prostaglandin E2 (PGE2). We hypothesized that serum levels of VEGF and PGE2 are increased by the stress response to breast cancer surgery and attenuated by paravertebral anesthesia and analgesia (PVAA). Thirty women undergoing mastectomy were enrolled in this prospective, randomized study, to receive general anesthesia (GA) and postoperative opioid analgesia (morphine 0.1 mg/kg bolus and patient-controlled infusion) or GA and PVAA (72-h infusion). All patients received rectal diclofenac. Venous blood samples were taken preoperatively and at 4 and 24 h postoperatively for serum glucose, cortisol, C-reactive protein, VEGF, and PGE2. PVAA inhibited the surgical stress response, as indicated by significantly less plasma glucose, cortisol, and C-reactive protein. VEGF and PGE2 values did not differ significantly between the groups. Mean (SD) percentage change in VEGF at 4 and 24 h respectively were 3% ± 44% versus 9% ± 80%, P = 0.29 and 5% ± 43% versus –10% ± 63%, P = 0.41 for patients with combined general and PVAA and GA alone, respectively. Mean percentage change in postoperative PGE2 at 4 and 24 h respectively was 10% ± 17% versus 11% ± 69%, P = 0.29 and 34% ± 19% versus 47% ± 18%, P = 0.15. We conclude that despite inhibiting the surgical stress response, PVAA had no effect on serum levels of putative breast cancer angiogenic factors, VEGF and PGE2.

 

 

拉氏坐骨神经阻滞时足跖曲比背曲更具可信度:一个前瞻性、随机对比

Plantar Flexion Seems More Reliable than Dorsiflexion with Labat’s Sciatic Nerve Block: A Prospective, Randomized Comparison

Manuel Taboada, MD*, Peter G. Atanassoff, MD{dagger}, Jaime Rodríguez, MD, PhD*, Joaquín Cortés, MD, PhD*, Sabela Del Rio, MD*, Juan Lagunilla, MD*, Francisco Gude, MD*, and Julián Álvarez, MD, PhD*

*University of Santiago de Compostela, Department of Anesthesiology, Hospital Clínico Universitario de Santiago, Spain; and {dagger}Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2005;100:250-254

 

 传统的拉氏坐骨神经阻滞法已不能展示足部的哪一运动反应提供了更高概率的完全感觉和运动阻滞。在本前瞻性、随机的、双盲研究中,我们对比足跖曲和背曲之间以传统方法阻滞坐骨神经的起效时间和功效。共80例行拇趾外翻手术的患者随机分为引出足跖曲后(n = 40)或足背曲(n = 40)后坐骨神经阻滞。以<0.5 mA电流激发运动反应后,给予0.75%罗哌卡因20ml。成功率定义为所有坐骨神经支配区域完全感觉和运动阻滞且手术不痛。记录足部感觉和运动阻滞的起效时间。引出足跖曲后的成功率(87.5%)明显高于足背曲(55%; P < 0.05)。引出足跖曲后完全感觉和运动阻滞的起效 (分别为10 ± 10 min13 ± 10 min)较足背曲快 (20 ± 11 min24 ± 12 min; P < 0.05)。我们得出结论,足跖曲预示的拉氏经典后路坐骨神经阻滞的比足背曲预示的起效时间短并且成功率高。

(赵雪莲 李士通 校)

Labat’s classic approach to the sciatic nerve has not been able to show which motor response of the foot provides a more frequent rate of complete sensory and motor block. In this prospective, randomized, double-blind study, we compared plantar flexion with dorsiflexion with regard to onset time and efficacy of sciatic nerve block using the classic posterior approach. A total of 80 patients undergoing hallux valgus repair were randomly allocated to receive sciatic nerve block after evoked plantar flexion (n = 40) or dorsiflexion (n = 40). Twenty milliliters of 0.75% ropivacaine was injected after the motor response was elicited at <0.5 mA. Success rate was defined as complete sensory and motor block in all sciatic nerve distributions associated with a pain-free surgery. Time required for onset of sensory and motor block of the foot was recorded. Success was more frequent after elicited plantar flexion (87.5%) than dorsiflexion (55%; P < 0.05). Onset of complete sensory and motor block of the foot was faster after elicited plantar flexion (10 ± 10 min and 13 ± 10 min, respectively) compared with dorsiflexion (20 ± 11 min and 24 ± 12 min; P < 0.05). We conclude that plantar flexion of the foot predicts a shorter onset time and a more frequent success rate than dorsiflexion with Labat’s classic posterior sciatic nerve block.

 

内窥镜交感神经切除术全程中手掌皮肤血流和温度反应

Palmar Skin Blood Flow and Temperature Responses Throughout Endoscopic Sympathectomy

Craig G. Crandall, PhD*,{dagger}, Dan M. Meyer, MD{ddagger}, Scott L. Davis, PhD*,{dagger}, and Suzanne M. Dellaria, MD§

*Institute for Exercise and Environmental Medicine, Presbyterian Hospital of Dallas, Texas; and Departments of {dagger}Internal Medicine, {ddagger}Cardiothoracic Surgery, and §Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas

Anesth Analg 2005;100:277-283

 

胸外科交感神经切除术常用于治疗原发性手掌和腋窝多汗症。手掌皮肤温度的升高是鉴定手术成功与否的常用方法。由于手掌温度的改变继发于皮肤血流的改变,本研究的目的是证明这样一个假设,即监测手掌皮肤血流较监测手掌皮肤温度更能时时清晰反映手术效果。在11个患手掌和/或腋窝多汗症病人行交感神经切断术全程,我们测量了手掌皮肤温度和血流(使用激光多普勒流量计)。最初烧灼5分钟后,皮肤血流从48 ± 7灌流单位提高到121 ± 17灌流单位(P < 0.001),而皮肤温度却没有明显变化(31.0°C ± 0.5°C31.3°C ± 0.5°CP > 0.05)。达到皮肤血流峰值所需的时间(22 ± 3 min)明显较达到皮肤温度峰值的时间短(34 ± 0.3 min; P < 0.001)。开始烧灼交感神经51015分钟后,皮肤血流的升高占总皮肤血流升高的较大部分,与皮肤温度升高不同(所有的P < 0.006)。这些数据说明胸部交感神经切断术中,监测皮肤血流较监测皮肤温度更加时时和清晰。但是,最初烧灼胸壁上的神经节可能在物理破坏神经节前就已导致皮肤血流的升高,。这可能限制了监测皮肤血流来鉴别手术成功与否的实际应用。

(张  李士通 校)

Thoracic surgical sympathectomy is often performed to treat primary palmar and axillary hyperhidrosis. An increase in palmar skin temperature is frequently used to identify the success of the procedure. Because changes in palmar skin temperature occur secondary to changes in skin blood flow, the objective of this study was to test the hypothesis that monitoring palmar skin blood flow would provide greater temporal resolution relative to monitoring palmar skin temperature. In 11 patients with palmar and/or axillary hyperhidrosis, we measured palmar skin temperature and blood flow (via laser Doppler flowmetry) throughout the sympathectomy procedure. Five minutes after the initial cautery, skin blood flow increased from 48 ± 7 perfusion units to 121 ± 17 perfusion units (P < 0.001), whereas no significant change in temperature was observed (31.0°C ± 0.5°C to 31.3°C ± 0.5°C; P > 0.05). The time required to reach peak skin blood flow (22 ± 3 min) was significantly less than the time required to reach peak skin temperature (34 ± 0.3 min; P < 0.001). Finally at 5, 10, and 15 min after the initial cautery, skin blood flow increased to a larger percentage of the total increase in skin blood flow relative skin temperature (all P < 0.006). These data suggest that monitoring skin blood flow provides greater temporal resolution when compared with monitoring skin temperature during thoracic sympathectomy. However, the initial cautery of the parietal pleura over the ganglion may result in increases in skin blood flow before physical disruption of the ganglion. This occurrence may limit the utility of skin blood-flow measurements in identifying the success of the procedure.

 

利多卡因兴奋重组椎实螺(Lymnaea stagnalis呼吸模式发生器的突触前及后神经元

Lidocaine Excites Both Pre- and Postsynaptic Neurons of Reconstructed Respiratory Pattern Generator in Lymnaea stagnalis

 Shin Onizuka, MD, Toshiharu Kasaba, MD, Toshiro Hamakawa, MD, and Mayumi Takasaki, MD

Department of Anesthesiology, Miyazaki Medical College, University of Miyazaki, Kiyotake-Cho, Miyazaki, Japan

Anesth Analg 2005;100:175-182

利多卡因具有抑制和兴奋中枢神经系统包括呼吸模式的两方面作用。过量局麻药引起的兴奋作用常认为是由于早期阻断皮层抑制性通路之故。为澄清利多卡因对抑制性突触的突触前及后神经元的效应,我们利用蜗牛Lymnaea stagnalis的二个神经元在体外重组而构建培养躯体-躯体呼吸模式发生器模型。首先我们观察了利多卡因对单个突触前(RPeD1)或突触后(VD4)神经元的影响。在同时记录RPeD1VD4时,分别比较了利多卡因给予前及后(0.01, 0.1, and 1 mM)的动作电位数量、膜电位和动作电位的波长。结果利多卡因能增加动作电位的数量及单个动作电位的波长,并以剂量依赖方式使RPeD1VD4神经元的静息膜电位去极化。此外利多卡因能减低外向性钾电流。在躯体-躯体神经对中,0.01 mM 利多卡因引起RPeD1兴奋而抑制VD40.11 mM 利多卡因则导致RPeD1VD4神经元的兴奋。总之利多卡因能减低突触前和后神经元的突触传递和神经元一般兴奋性。

(王立中 译,李士通 校)

Lidocaine causes both inhibition and excitation in the central nervous system, including the respiratory pattern. The excitation induced by an excessive dose of local anesthetic is thought to be the result of an initial blockade of an inhibitory pathway in the cerebral cortex. To clarify the effect of lidocaine on the pre- and postsynaptic neurons of an inhibitory synapse, a cultured soma-soma respiratory pattern generator model consisting of two neurons from the snail Lymnaea stagnalis were reconstructed in vitro. First we investigated the effects of lidocaine on single presynaptic (RPeD1) or postsynaptic (VD4) neurons. While RPeD1 and VD4 were simultaneously recorded, the number of action potentials, the membrane potential, and the wavelength of the action potential were compared before and after lidocaine (0.01, 0.1, and 1 mM) administration. Lidocaine increased the number of action potentials and the wavelength of a single action potential, and it depolarized the resting membrane potential in both RPeD1 and VD4 neurons in a dose-dependent manner. Furthermore, lidocaine decreased outward potassium currents. In soma-soma pairs, RPeD1 excitation and VD4 suppression occurred in 0.01 mM lidocaine, whereas both RPeD1 and VD4 neurons were excited by 0.1 and 1 mM lidocaine. In conclusion, lidocaine causes a reduction in synaptic transmission and general neuronal excitation in both presynaptic and postsynaptic neurons.