Anesthesia & Analgesia

January 2005

Table of Content

 

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

麻醉管理與非心臟手術術後一年死亡率

沈洪 薛張剛

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:

急性等容血液稀釋在單肺通氣時對氧合作用的影響

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.

 

經皮血管造影下顯示導引鋼絲J型頭端的方向是鎖骨下靜脈導管位置不正確的顯著影響因素:一項隨機,對照研究

朱輝 譯 陳傑 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.

 

地氟醚麻醉心臟手術後應用左布比卡因胸骨旁阻滯和浸潤對術後疼痛、肺功能以及拔管時間的影響

沈洪 薛張剛

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.

 

繼發於中樞神經系統中一氧化氮增加的交感傳出減少導致肝素後魚精蛋白產生的低血壓

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公式導出的即時估算混合靜脈血異氟醚濃度的方法

殷文淵 譯 陳傑 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

 

麻醉藥預處理:自由基在幾內亞豬離體心臟由七氟醚介導的減弱線粒體電子傳導中的作用

沈洪 薛張剛

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:

麻醉對上呼吸道感染的患兒:還困難嗎?

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.

 

等比重羅呱卡因(5 mg/ml)在兒童脊麻中的應用

殷文淵 譯 陳傑 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

 

異丙酚和七氟醚對兒童QT間期及複極化跨膜彌散的影響

孫敏莉 薛張綱

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.

 

容量減少性濃縮血小板中的血小板功能完整性

周志堅 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:

一般患者和醫療保健專職人員對術後恢復和術後噁心嘔吐處理方面的比較

顧漪聞 譯 陳傑 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.

 

眼球周圍麻醉:小劑量麻醉劑經皮注射技術

孫敏莉 薛張綱

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:

對貓靜脈給予利多卡因對異氟醚肺泡最低濃度的影響

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腎上腺素能受體在呱替啶對小鼠體溫調節中樞的影響

顧漪聞 譯 陳傑 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.

 

在意識喪失和清醒時異丙酚個體效應點濃度是類似的

孫敏莉 薛張綱

在意識喪失及喚醒時丙泊酚的個體作用部位濃度相似

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.


三磷酸腺苷對維庫溴銨神經肌肉阻滯的影響

朱慧琛 譯 陳傑 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.

 

對乙酰氨基酚、阿司匹林和安乃近對幾內亞豬離體小腸蠕動的影響

吳德華 薛張剛

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.

 

硫噴妥鈉在大鼠身上產生制動主要通過脊髓上位作用

黃施偉 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:

異丙酚誘導意識喪失和SNAP指數之間的關係

孫敏莉 薛張綱

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.

用於拇內收肌神經肌肉監測的四個成串刺激可置於腕部或手上

馬皓琳 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:

醫療保健鑒定聯合委員會對疼痛圍術期阿片類藥物需求量和恢復室停留時間的影響

朱慧琛 譯 陳傑 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.

 

奈福泮與氯氨酮在增強術後鎮痛中的比較

金琳 薛張綱

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.

 

利多卡因興奮重組椎實螺(Lymnaea stagnalis呼吸模式發生器的突觸前及後神經元

王立中 譯,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:

術後胃腸道功能紊亂

金琳 薛張綱

Postoperative Gastrointestinal Tract Dysfunction

Michael G. Mythen

Anesth Analg 2005 100: 196-204.

 

心臟手術後拔除胸腔引流管三種鎮痛方法的隨機比較

軒泓 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.

 

氣管損傷的保守治療

齊波 譯 陳傑 校

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

Anesth Analg 2005 100: 210-214.

NEUROSURGICAL ANESTHESIA:

對海馬切片培養標本有神經保護作用的是輕度低溫,而不是異丙酚

金琳 薛張綱

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.

 

可樂定在神經外科手術中的應用

張俊傑 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:一種新的分娩全身鎮痛藥

齊波 譯 陳傑 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.

 

鞘內注射嗎啡用於產後雙側輸卵管結紮後的鎮痛

廖慶武 薛張綱校

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:

用區域麻醉和鎮痛抑制乳房癌手術應激反應並不影響血管內皮生長因數和前列腺素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.

 

拉氏坐骨神經阻滯時足蹠曲比背曲更具可信度:一個前瞻性、隨機對比

趙雪蓮 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.

 

清醒大鼠持續胸段硬膜外麻醉引起節段性交感神經阻滯

趙延華 譯 陳傑 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:

胸腔內視鏡交感神經切斷術時外周皮膚血流量和溫度的比較

廖慶武 薛張綱

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.

 

內窺鏡交感神經切除術全程中手掌皮膚血流和溫度反應

  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.

 

經喉罩插入常規的氣管導管

趙延華 譯 陳傑 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.

 

 

麻醉管理與非心臟手術術後一年死亡率

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.

 

麻醉管理對長期效果的影響人們還知之甚少。我們設計了一個前瞻性觀測研究:研究成人在全麻下非心臟手術術後一年內死亡率是否與人口統計學、術前臨床狀況、外科手術、以及術中情況等變數有關。在所有病人(N1064)中一年死亡率是5.5%65歲(包括65歲)以上病人(N=243)死亡率是10.3%。多變異Cox回歸分析比例轉機模型表明這三個變數具有顯著的獨立預測作用:病人合併症(相對危險=16.116P<0.0001,累計深度麻醉時間(雙頻譜指數<45)(相對危險=1.224/h;P0.0121),術中低血壓(相對危險=1.036/minP0.0125)。術後一年的死亡率主要與先前的疾病史有關。然而累計深度麻醉時間以及術中低血壓同樣是死亡率增加的顯著的獨立預測因素。這種關聯表明術中麻醉管理對手術結果的影響可能比預期時間要長。

(沈洪 薛張剛 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.

 

地氟醚麻醉心臟手術後應用左布比卡因胸骨旁阻滯和浸潤對術後疼痛、肺功能以及拔管時間的影響

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.

早期拔管在心臟術後已很常見。達到這一目標麻醉技術面臨早期術後鎮痛的挑戰。我們採取隨機,安慰劑對照,雙盲研究術後胸骨旁阻滯對鎮痛,呼吸功能以及拔管時間的影響。我們選擇了20例胸骨正中切口的心臟手術病人;17例完成了研究。麻醉過程以地氟醚為基礎,應用小劑量阿片類維持。在胸骨金屬絲放置前,胸外科醫生進行胸骨旁阻滯以及切口和放置引流管處局部浸潤。應用含有1400000腎上腺素0.25%的左布比卡因54ml,或以54ml的生理鹽水為安慰劑。24小時內觀察鎮痛效果以及肺功能。左布比卡因組病人在術後第一個4小時應用嗎啡量比對照組明顯要少(20.8 +/- 6.2 mg 33.2 +/- 10.9 mgP0.013);而且在拔管過程中有更好的氧合。對照組9個人中有4個人需要疼痛救助,而左布比卡因組8個人中無人需要疼痛救助(P0.08)。所有病人血漿左布比卡因濃度均低於潛在毒性水平(0.64 +/- 0.43 microg/mL;範圍:0.24-1.64 microg/mL)。應用左布比卡因胸骨旁阻滯以及傷口和放置引流管處局部浸潤對於早期想拔除氣管導管的心臟病人是很有效的。

(沈洪 薛張剛 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.

 

麻醉藥預處理:自由基在幾內亞豬離體心臟由七氟醚介導的減弱線粒體電子傳導中的作用

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.

 

心臟保護的麻醉預處理作用可以被一氧化氮合成酶抑制劑或活性氧物質(ROS)清除劑消除。我們以前報導過七氟醚預處理中線粒體電子傳遞(ET)減弱以及活性氧物質的增加是激發心臟保護的麻醉預處理機制。我們假定是一氧化氮和活性氧物質參與了麻醉藥介導的減弱電子傳遞(ET)的作用。線上檢測68Langendorff灌流的幾內亞豬離體心臟的心功能和減少的煙酰胺腺嘌呤二核苷酸(NADH)螢光,這是線粒體電子傳遞指標。所有心臟都經過30分鐘完全缺血和120分鐘的再灌注。在缺血前,無論是否給以1.3mM的七氟醚進行心臟保護的預處理,所有心臟都臨時給予超氧化物歧化酶、過氧化氫酶、谷光甘肽以清除ROSL-NG-硝基精氨酸甲酯(L-NAME)來阻止一氧化氮合成酶。心臟保護的麻醉預處理能夠暫時增加缺血前的NADH,換言之,能夠減弱線粒體的電子傳遞。這種NADH的增加以及麻醉預處理對再灌注的心臟保護作用都可以被超氧化物歧化酶、過氧化氫酶、谷光甘肽、L-NG-硝基精氨酸甲酯所阻斷。因此,活性氧物質和一氧化氮或包括過(氧化)亞硝鹽等反應產物都參與了七氟醚介導的減弱電子傳遞作用。這可能導致正反饋機制使活性氧物質增加繼發改變線粒體功能從而啟動麻醉預處理的心臟保護作用。

(沈洪 薛張剛 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.

 

異丙酚和七氟醚對兒童QT間期及複極化跨膜彌散的影響

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間期延長與尖端扭轉型室性心動過速(TdP)相關,特別是在有長QT綜合症的兒童和青年中。TdP的敏感性起源於穿透心肌細胞壁的複極化跨膜彌散(TDR)增加。幾種麻醉藥物可以延長QT間期,但是對於TDR的影響尚不清楚。TDR可以在心電圖上被測量(ECG),即T波波峰和T波終點(Tp-e)之間的時間間隔。我們隨機抽取了50ASA體格狀態III級,年齡在116歲的兒童,隨機接受異丙酚(組P)或七氟醚(組S),調查異丙酚和七氟醚對校正QTQTc)及Tp-e的影響。十二導聯心電圖在術前及術中被記錄。七氟醚顯著延長術前QTc;而異丙酚卻無。兩者對於術前Tp-e沒有任何顯著影響。在兒童,七氟醚較異丙酚極大延長了心肌複極化持續時間,但是對於複極化彌散度無影響,因此兩種麻醉劑的TdP的危險性有可能是很小的。

(孫敏莉 薛張綱 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.

 

眼球周圍麻醉:小劑量麻醉劑經皮注射技術.

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

 

我們評估使用小劑量麻醉劑注射技術用於眼球周圍麻醉的效能及安全性。我們收集了接受各種眼科操作的857名患者。麻醉包括經皮注射5-6.5ml2%利多卡因。2分鐘時,85.6%的患者出現至少50%的運動阻滯;5分鐘時,78.6%患者有>80%的運動阻滯;5分鐘以後100%的患者有了充足的外科麻醉。所有患者沒有嚴重阻滯相關併發症。對於經典技術,本文所描述的技術是一項簡單而令人滿意的選擇。

(孫敏莉 薛張綱 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.

 

在意識喪失和清醒時異丙酚個體效應點濃度是類似的

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.

 

關於異丙酚在意識喪失和意識恢復的效應點濃度的報導很大程度上不同。因此,沒有以總體均數為依據的單一濃度來證明對於個體患者最佳濃度。所以我們測試的假說:在意識喪失和恢復期個體異丙酚效應點濃度是類似的。在20名成年志願者中,通過靶控輸注系統評估在意識喪失和恢復時異丙酚效應點濃度。異丙酚效應點濃度逐步升高直到志願者喪失意識(對聲音刺激無反應);無意識狀態維持15分鐘,志願者漸清醒。這樣的實驗在每個者願者重複3次。我們主要的結果是濃度產生無意識及評估的意識喪失和恢復的效應點濃度之間的關係。靶效應點異丙酚濃度在意識喪失時是2.0±0.9,意識恢復時是1.8±0.7(P <0.001)。平均個體效應點濃度在意識恢復與喪失之間差僅為0.17±0.32 微克/mL95%的可信區間差為0.09-0.25 微克/mL)。我們的結果提示,意識喪失濃度個體滴定可基於平均總體需要量定量異丙酚劑量是一種選擇。

(孫敏莉 薛張綱 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.

對乙酰氨基酚、阿司匹林和安乃近對幾內亞豬離體小腸蠕動的影響

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.

 

小腸蠕動受抑制是阿片類鎮痛藥的一個主要副作用。而非阿片類鎮痛藥,如對乙酰氨基酚,阿司匹林和安乃近,是否對小腸蠕動有影響仍不知。本研究中,我們探討了這些非阿片類鎮痛藥對小腸蠕動的影響,並分析了其中的一些機理。在幾內亞豬小腸多個離體段內通過灌注誘導增加小腸管腔內壓力來激發小腸蠕動。小腸蠕動壓力閾值(小腸蠕動被激發的壓力,PPT)被用來量化藥物對小腸的作用。把媒介液(Tyrode’s 溶液),對乙酰氨基酚(0.01-100uM),阿司匹林(100-300uM),安乃近(10-100uM)加入浸泡小腸的容器中,當對乙酰氨基酚濃度達10uM時,在6個腸段中有4個腸段對對乙酰氨基酚產生濃度依賴性地增加了PPT,小腸蠕動受抑制。當達到100uM時,所有腸段PPT增加,腸蠕動受抑制(EC50=6.0uM)。當濃度達到3uM時,對乙酰氨基酚對PPT的增加能被納絡酮及蜂毒明肽減輕,但L-硝基精氨酸甲酯(L-NAME),D-硝基精氨酸甲酯(D-NAME;與L-NAME對應的無活性右旋結構),阿司匹林,二甲麥角新堿及曲匹西隆不具此減輕作用。乙酰水楊酸以及安乃近不影響小腸蠕動。此結果首次顯示對乙酰氨基酚對小腸蠕動抑制的影響具有濃度依賴性,而阿司匹林和安乃近無此作用。 對乙酰氨基酚對小腸蠕動的抑制作用涉及一些Ca2+依賴性K+通道的信號傳導,內源性阿片類途徑,可能還與環氧化酶-3受抑制有關。

(吳德華 薛張剛 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.

 

異丙酚誘導意識喪失和SNAP指數之間的關係

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是經處理的腦電圖監測儀,其運作基於低和高頻光譜元件的運算法則,從而衍生出SNAP指數。在本項研究中,我們力求明確SNAP指數與接受異丙酚推注受試者意識喪失之間的關係。隨機抽取的受試者隨機接受11種靜脈推注異丙酚劑量中的1種(00.60.8, 1.0, 1.2, 1.4, 1.6, 1.8, 2.0, 2.2, 2.4 mg/kg; n=20/組)。當受試者開始意識喪失時(終點)或在接受注射後160秒,SNAP指數被記錄。65%受試者到達終點(定義為接受試者停止注射時間)。50%異丙酚有效劑量是0.97 mg/kg (95%可信區間[CI], 0.86-1.07 mg/kg)SNAP指數清醒中位數為92(範圍為78-99),而且在達到終點和沒有達到終點的受試者之間沒有不同。停止注射的受試者其終點SNAP指數低於基線,中位數為76 (範圍為57-94),其劑量>=1.0 mg/kg,但在不同劑量之間沒有不同。在160秒受試者沒有到達終點,指數沒有不同於基線。二元邏輯回歸模式預測SNAP指數95%意識喪失有效劑量71 (95% CI, 63-74) 19 (95% CI, 16-22) SNAP指數不同於基線。這些模型在接受操作器特徵曲線下面積為0.837 0.864SNAP指數與異丙酚誘導意識喪失相關聯。SNAP指數是意識喪是有用的顯示器,而且可以作為麻醉深度監測,進行進一步的研究。

(孫敏莉 薛張綱 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.

 

奈福泮與氯氨酮在增強術後鎮痛中的比較

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

 

單獨使用阿片類藥物有時會引起術後鎮痛不完全,而聯合用藥可能可以減少阿片類藥物的用量,增加療效。有部分患者術後單獨使用嗎啡只能減輕部分疼痛,因此我們提出了一個假說,將奈福泮或氯氨酮用於此類患者,是否可以減少後續需要使用的阿片類藥物的藥量,並且產生適當的鎮痛效果。我們通過實驗驗證了這個假說。經歷了大手術的患者(n77)每人靜注9mg嗎啡,將那些仍然感覺到疼痛的患者隨機分為3組,使用盲法給予1)等張鹽水(對照組,n = 21),2)10mg氯氨酮(氯氨酮組,n = 23),3)20mg奈福泮(奈福泮組,n = 22)。隨後每隔5min給予3mg嗎啡直到達到合適的鎮痛效果,或者給試驗性藥物後60min,或者出現通氣不足(呼吸頻率<10/分或脈搏氧飽和度<95%)。在使用試驗性藥物之後追加的嗎啡的量對照組(平均值±標準差;17 ± 10 mg)明顯大於奈福泮組(10 ± 5 mgP < 0.005),與氯氨酮組(9 ± 5 mgP < 0.001)。嗎啡成功使用於所有奈福泮與氯氨酮組的患者,而對照組的4位患者沒有能夠耐受嗎啡(2位出現呼吸抑制,2位持續疼痛)。奈福泮組的患者較多地出現心悸和多汗症狀,氯氨酮組的患者的鎮靜程度更深。並沒有發現奈福泮與氯氨酮組在其他潛在併發症上有所不同。

(金琳 薛張綱 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.

 

術後胃腸道功能紊亂

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

 

術後胃腸道(GI)功能紊亂(PGID)是一個十分常見的問題,增加患者的痛苦,並且使醫療費用提高。PGID的發病機理非常複雜,而且是多因素的。對PGID傳統的治療措施包括使用促進胃腸道動力的藥物、放置鼻胃管及避免術後早期進食進水。這些措施旨在降低PGID的發生率,但是顯然沒有什麼效果。隨機臨床試驗表明,靜脈使用大量的液體治療,以達到預定的增加心輸出量的目的,可以改善內臟灌注,從而降低PGID的發病率。包括限制手術切口的大小,選擇區域阻滯的麻醉方法,早期活動和腸內營養在內的綜合治療措施可以顯著地降低術後併發症的發生,減少PGID,縮短住院時間。然而,這些治療方法都沒有經過充分有力的多中心前瞻性隨機對照試驗性研究證實。

(金琳 薛張綱 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.

 

對海馬切片培養標本有神經保護作用的是輕度低溫,而不是異丙酚

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

 

麻醉藥物的神經保護潛能尚未明確,比如異丙酚和輕度低溫。因此,比較兩種臨床常用濃度的異丙酚和輕度低溫防止海馬切片培養標本(HSC)遲發性神經元死亡的效率就顯得非常有必要。我們將標本分為4組,37℃不加異丙酚組、37℃加用10µM異丙酚組、37℃加用100µM異丙酚組、35℃不加異丙酚組(輕度低溫組)。將這4組切片標本處於1h缺氧缺糖(OGD)狀態,然後觀察細胞存活情況。在23天之後神經元仍存活則定義為存活。我們使用碘化丙啶螢光來判斷每一個海馬薄層切片CA1CA3及齒狀神經元是否死亡。結果表示,輕度低溫能夠阻止CA1CA3及齒狀神經元的死亡,而異丙酚只有在10µM的濃度下才能夠保護齒狀神經元。無論是10µM還是100µM的異丙酚,對CA1CA3神經元的缺血缺氧損傷均無保護作用。通過薄層切片培養發現,100µM異丙酚並不會減少100µM N甲基D天門冬氨酸(NMDA)、500µM谷氨酸及20µM α氨基5甲基4異唑丙酸(AMPA)的毒性。異丙酚的神經保護作用可能包括γ氨基丁酸介導的對谷氨酸受體(GluRs)的間接抑制作用,而谷氨酸受體激動劑可以導致鈣離子內流。我們在海馬切片培養標本中的CA1神經元、分離的CA1神經元和大腦皮層切片中的CA1神經元中研究了異丙酚對谷氨酸受體活性的影響。在分離的CA1神經元內,異丙酚(100µM200µM,接近爆發抑制的濃度)可以減少谷氨酸介導的[Ca2+]i的升高({Delta}[Ca2+]i)反應達25%–35%;在新鮮海馬薄層切片和培養標本中,可以降低谷氨酸和NMDA介導的{Delta}[Ca2+]i35%–50%。不論是在CA1神經元還是在皮質切片標本,使用苦味素阻滯GABAA受體都可以充分減少對GluRs的抑制作用。通過研究,我們得出:輕度低溫對海馬切片培養標本中缺氧缺葡萄糖的CA1CA3神經元有保護作用,而異丙酚沒有這樣的作用。異丙酚在可以減少皮質和海馬神經元谷氨酸和NMDA受體反應能力的濃度並沒有神經保護作用。

(金琳 薛張綱 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.

 

鞘內注射嗎啡用於產後雙側輸卵管結紮後的鎮痛

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

 

產後雙側輸卵管結紮(PPBTL)會導致術後疼痛。我們設計此研究是為了判定鞘內注射50 µg嗎啡用於PPBTL後的鎮痛效果。對65位婦女實施腰麻,分別使用12.75mg重比重布比卡因和20µg芬太尼並加50µg嗎啡(嗎啡組)或者0.05ml生理鹽水(對照組)。術後常規根據需要使用500mg萘普生和5mg氧可酮/325mg對乙酰氨基酚混合物進行鎮痛。在所有病例中,嗎啡組具有最高的滿意度(P = 0.003)、靜息時(P = 0.008)和運動時(P < 0.0001)最低的疼痛程度。噁心、瘙癢和鎮靜評分在所有病例中沒有顯著差別,但嗎啡組嘔吐的發生頻率更加高(21.4% 3.5%; P = 0.052)。在均值間的兩兩比較中,和對照組比較,嗎啡組4h時靜息(P = 0.006)和運動(P = 0.002)時的疼痛、12h時運動時(P = 0.0004)的疼痛顯著降低,12h瘙癢發生的頻率(P = 0.002)顯著增高,5mg氧可酮/325mg對乙酰氨基酚混合物的使用顯著減少(P = 0.006),術後至第一次使用鎮痛藥物的時間顯著延長(P = 0.006)。因此我們認為鞘內注射重比重布比卡因和芬太尼並加用50µg嗎啡能為接受PPBTL的婦女提供更好的術後鎮痛。

(廖慶武 薛張綱校)

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.

 

胸腔內視鏡交感神經切斷術時外周皮膚血流量和溫度的比較

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.

 

在外科手術治療多汗症中,評價上肢的去交感神經對於術後效果的預測是必需的,特別是對於胸腔內視鏡交感神經鏈切斷術,一個最近認為損傷最小,術後代償性多汗發生最少的技術。皮膚血流量(SkBF;鐳射多普勒流量計)比溫度提供了一個更加快速和可靠的去神經指標,因此為檢驗這個假說,我們前瞻性地比較了10個進行胸腔內視鏡交感神經鏈切斷術的特發性多汗症患者的手掌SkBF和指尖溫度。從基線到峰值,左右手手掌SkBF(平均值±標準差)分別增加了273.3 ± 24.7 任意單位 and 252.4 ± 30.1任意單位,而溫度分別增加了0.9°C ± 0.3°C and 1.5°C ± 0.6°C。在有效的右側胸交感神經鏈切斷術中,到達SkBF峰值的時間是43 ± 13 s,而到達溫度峰值的時間是277 ± 53 s (P < 0.001)。在左側,到達SkBF峰值的時間是81 ± 14 s,而到達溫度峰值的時間是305 ± 34 s (P < 0.001)。所有患者均被認為交感神經切斷成功。因此我們認為交感神經切斷術中評價去神經,鐳射多普勒SkBF時間解析度上優於溫度,故能提供一個優質和定量的評價去神經的附加措施。

廖慶武 薛張綱 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.

 

 

經皮血管造影下顯示導引鋼絲J型頭端的方向是鎖骨下靜脈導管位置不正確的顯著影響因素:一項隨機,對照研究

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.

 

中心靜脈導管位置不準確導致導管功能減弱如不能抽血的情況常見於鎖骨下靜脈穿刺方法。在這項前瞻性研究中作者旨在確定右鎖骨下靜脈穿刺時導引鋼絲J型頭端的方向是否影響靜脈導管頭端的位置。在這項隨機雙盲臨床研究中,作者觀察了右鎖骨下靜脈穿刺時J型頭端朝向尾端(第一組,n=147)或頭端 (第二組,n=148)的靜脈導管的位置。兩組患者多數(97%57%)導管進入了鎖骨下或右心房(P < 0.05)。第一組和第二組患者導管誤入同側頸內靜脈的發生率分別為2%40%P < 0.01)。在隨後的血管模型的試驗性中也證實即使在血管之間急性成角的地方如鎖骨下靜脈,頸內靜脈和上腔靜脈匯合處中J型頭端方向與引導鋼絲進入血管的方向一致。結論:在右鎖骨下靜脈穿刺時只有保持導引鋼絲J型頭端方向朝尾部才能使中心靜脈導管更準確地進入右心房。

(朱輝 譯 陳傑 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公式導出的即時估算混合靜脈血異氟醚濃度的方法

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藥有效血濃度概念的公式,以便不直接抽取血樣而計算混合靜脈血(MVBC)的吸入麻醉藥濃度。在這個研究中,作者調查了心臟手術病人在異氟醚麻醉期間計算濃度和實測血樣濃度之間的關聯關係。16名病人(試驗1)在不同的時間點,通過肺動脈導管收集肺動脈血樣本進行氣體色譜/光譜分析,這些樣本代表真實濃度。通過氣體監測儀測量吸入和呼出氣異氟醚濃度以計算MVBC。並使用林氏有效血濃度計算方法,得到的結果與MVBC相比較。另外11名病人(試驗2)進行了研究以驗證試驗1得出的結論。結果顯示麻醉期間MVBC和真實血濃度具有相似的動力模型,並高度相關。作者推斷MVBC可以代表心臟手術期間真實肺動脈異氟醚濃度。結果表明MVBC可以作為一種有用的即時估計肺動脈異氟醚濃度的方法,但臨床有效性和重要性值得進一步研究。

(殷文淵 譯 陳傑 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.

 

等比重羅呱卡因(5 mg/ml)在兒童脊麻中的應用

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.

 

本研究作者評估了羅呱卡因在兒童脊麻中的效果。9317歲接受選擇性下腹部或下肢手術的兒童進行了這一開放性、前瞻性研究。病人側臥位,選擇L3-4L4-5為穿刺間隙,使用羅呱卡因濃度為5 mg/ml,使用劑量為0.5mg/kg(最大量20 mg)。注射後,病人仰臥位。記錄感覺阻滯的起效和持續時間以及運動阻滯的程度。93名兒童中92名獲得了滿意的麻醉效果。三名兒童接受了全麻,一名兒童脊麻失敗,兩例手術超過感覺阻滯時間。四名兒童在切皮時追加鎮痛藥。平均最高感覺阻滯平面為T6(範圍,T2T12),感覺阻滯平面衰退至T10的平均時間為96分鐘(範圍為34210分鐘)。一名兒童出現暫時性心動過速,一名出現低血壓。出院後四名兒童出現輕度的暫時性放射性神經刺激症狀,一名出現持續性體位性頭痛而進行硬膜外自體血修補治療。作者認為兒童(>1歲)鞘內使用等比重羅呱卡因能取得與成人相似的阻滯效果,但大劑量使用的安全性還需進一步研究。

(殷文淵 譯 陳傑 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.

 

一般患者和醫療保健專職人員對術後恢復和術後噁心嘔吐處理方面的比較

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與醫療保健專職人員對在術後恢復和術後噁心嘔吐(PONV)處理方面的異同的。依照主要的不同點制定包括14項內容的調查表,內容有:術後恢復期症狀(PONV,鎮靜,疼痛等),以及術後PONV的處理(預防,鎮吐藥效和額外支出等)。選擇52位醫療保健專職人員(麻醉醫生,恢復室護士)以及200位擇期婦科手術患者(應答率97%)進行研究。根據一般患者和醫療保健專職人員的反應,結合分析顯示,對術後恢復的最關注點是減少PONV的發生。醫療保健專職人員對術後鎮靜方面比一般患者顯得更為重視,比一般患者更關注鎮吐藥的花費,但針對術後嘔吐的有效治療和常規預防方面,未顯示出明顯的偏愛。這項研究顯示一般患者和醫療保健專職人員在術後疼痛,鎮靜,鎮吐藥效果和治療的花費方面只有很小的差異。

(顧漪聞 譯 陳傑 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腎上腺素能受體在呱替啶對小鼠體溫調節中樞的影響

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.

呱替啶具有很強的抗寒顫作用,其潛在的機制尚未完全闡明。最近的研究顯示其可能與α2腎上腺素能受體有關。作者對小鼠的體溫調節中樞模型做了一項研究,觀察呱替啶對非寒戰生熱作用的效應。對安置于樹脂玻璃房中的小鼠進行腹腔注射藥物,按藥物的不同分為四組:生理鹽水組(0.1mg/kg);呱替啶組(20mg/kg; 特異α2腎上腺素能受體拮抗劑阿替美唑(2mg/kg)加生理鹽水組;阿替美唑(2mg/kg)加呱替啶組。小鼠身體變涼而誘發體溫調節中樞反應後測量其直腸溫度和混合呼出氣二氧化碳濃度。當呼出二氧化碳不斷增加時的溫度,就認為是非寒顫的產熱作用的最大反應強度和非寒顫產熱作用的體溫調節的開始。呱替啶的非寒顫產熱作用體溫調節開始的溫度明顯下降(36.6oC±0.7 oC),生理鹽水組為(37.9 oC ± 0.6 oC, 阿替美唑加生理鹽水為(37.8 oC±0.4 oC;P<0.01)。在注射了阿替美唑加呱替啶後,其呱替啶的抗寒戰的效果消失(37.7 oC ±0.6 oC; P<0.05)。呱替啶沒有減少非寒戰產熱作用的最大強度。研究結果顯示α2腎上腺素能受體在呱替啶對小鼠的體溫調節中樞抑制中起了主要的作用。

(顧漪聞 譯 陳傑 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.

 

三磷酸腺苷對維庫溴銨神經肌肉阻滯的影響

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.

 

術中持續靜脈注射三磷酸腺苷可起到鎮痛和血管擴張作用。由於三磷酸腺苷可抑制神經肌肉傳導,作者研究了持續靜脈注射三磷酸腺苷是否會增強維庫溴銨的神經肌肉阻滯作用。29位接受選擇性小手術的患者隨機持續靜注三磷酸腺苷0.1mg ∙ kg-1 ∙ min-10.9NaCl。使用肌電儀行尺神經TOF刺激並記錄姆內收肌的神經肌肉活動。維庫溴銨劑量為253040μg/kg,記錄滯後時間、起效時間和最大阻滯時間。每組應用最小平方線性回歸分析計算ED50ED95。三磷酸腺苷組ED50ED95分別為29μg/kg44μg/kg,對照組為26μg/kg46μg/kg。組間滯後時間、起效時間和神經肌肉反應無明顯區別。三磷酸腺苷組的大部分患者出現了低血壓(收縮壓<80mm Hg)。結論:三磷酸腺苷0.1mg ∙ kg -1∙ min-1不增強維庫溴銨的神經肌肉阻滯作用。

(朱慧琛 譯 陳傑 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.

 

醫療保健鑒定聯合委員會對疼痛圍術期阿片類藥物需求量和恢復室停留時間的影響

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.

 

醫療保健鑒定聯合委員會(JCAHO)要求重視住院患者的疼痛治療,在疼痛開始時應用相應的圍術期服務可很快取得許多改變。200210月作者在術後恢復室(PACU)開始實行疼痛評分方案。在PACU中應用此評分評價患者對鎮痛治療的反應。同時制定離開PACU的適度疼痛評分指標。作者評估了1082位接受一般手術、整形外科、神經外科、泌尿外科和婦產科手術的患者對疼痛治療的反應。作者發現與2000年相比,2002年患者阿片類藥物(換算為嗎啡劑量)的平均需求量明顯提高(從40.4+13.2mg 上升到46.6+20.4mgP<0.001。在PACU中阿片類藥物需求量提高更為明顯(從6.5+7.3mg上升到10.5+10.4mgP<0.001)。阿片類藥物用量的增加並不延長住院時間、不提高鈉絡酮的需求量及不增加術後噁心嘔吐的發生率。作者認為術後短時間的阿片類藥物用量的增加不會提升阿片類藥物相關副作用的發生率。

(朱慧琛 譯 陳傑 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.

 

氣管損傷的保守治療

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.

 

無論什麼原因的氣管損傷,均可能威脅病人的生命安全。治療上可以選擇外科手術修補,目前還沒有其他治療方式與之相比較。作者假定可以通過人造氣管架橋的方式進行保守治療。選擇5例氣管損傷的病人,2例是因外傷和氣管插管造成的氣管上三分之一損傷,另外3例是因經皮氣管切開而造成的氣管中三分之一損傷。在支氣管鏡引導下置入氣管內或氣管造口導管,並將導管末端氣囊充氣以堵塞氣管損傷處來完成氣管架橋。架橋完成後空氣洩漏迅速停止,所有氣管缺損沒有進一步發展。無一例病例發生氣管狹窄或縱膈炎。結果表明通過在支氣管鏡引導下置入人造氣管對氣管損傷進行保守治療是有效的,並使那些因保守治療失敗而需要二期外科手術治療的病人處於較為有利的狀態。

(齊波 譯 陳傑 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:一種新的分娩全身鎮痛藥

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.

作者通過一個隨機雙盲對照臨床試驗來比較產婦分娩時採用雷米芬太尼自控鎮痛(PCIA)和靜脈用杜冷丁的鎮痛效果。選擇88名要求靜脈分娩鎮痛的健康產婦,隨機分為兩組,一組(n=43)接受雷米芬太尼PCIA,藥物劑量漸增(0.27-0.93ug/Kg);另一組(n45)採用杜冷丁150mg靜脈注射(用藥範圍為75200mg)。結果雷米芬太尼PCIA分娩鎮痛較靜脈用杜冷丁更為有效,雷米芬太尼組病人視覺疼痛評分較低(35.2±10.258.8±12.8P0.001,病人滿意評分較高(3.9±0.61.9±0.4P0.001);病人較弱的鎮靜作用(1.2±0.12.9±0.1P0.001)。另外雷米芬太尼使病人血紅蛋白去飽和作用較低(97.5%±1.094.2%±1.5P0.007)。雷米芬太尼組病人鎮痛失敗率(從靜脈鎮痛轉為硬膜外鎮痛)較杜冷丁組病人低(10.8%38.8%P0.007),兩組產婦的分娩方式或新生兒情況無明顯差異。與杜冷丁鎮痛組比,雷米芬太尼組新生兒異常胎心率的發生較少(P < 0.001)。研究表明,通過PCIA給予產婦重複小劑量且間斷遞增的雷米芬太尼可以保證其在分娩過程中有效且可靠的鎮痛。

(齊波 譯 陳傑 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.

 

清醒大鼠持續胸段硬膜外麻醉引起節段性交感神經阻滯

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)在危重病治療中的應用增加,主要是進行心臟、腸道的交感神經阻滯。作者對清醒大鼠實施一種新的持續TEA方法,評價心臟、呼吸功能和交感神經活性。13只實驗大鼠經硬膜外注射生理鹽水(CON組)作為對照組或0.5%布比卡因(EPI組)作為實驗組,注射速度為15μl/h,持續2h,注射時間為第一天和第三天。記錄平均動脈壓、心率、呼吸頻率、PaO2和運動評分的基礎值以及給藥306090120min的數值。分別被記錄前爪、胸部上中下部分、後爪和前後尾部的皮膚溫度。交感神經活性的變化通過皮膚溫度的變化(ΔT)來評價。給藥組血流動力學和呼吸維持不變,只是有輕度的運動受限。胸部上中下部分的ΔT均高於生理鹽水組的相應數值(P<0.001)。給藥組尾後部溫度降低(6090120minP<0.05),如90minΔT-0.86 ± 0.25°C,而生理鹽水組ΔT0.4 ± 0.12°C。第三天和第一天的ΔT相當。在清醒大鼠TEA穩定地節段性阻滯交感神經,不會引起心血管呼吸功能和運動系統的副作用。這項新技術可用於嚴重疾病的長期模型。

(趙延華 譯 陳傑 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.

 

經喉罩插入常規的氣管導管

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.

 

可通過喉罩(laryngeal mask airwayLMA)的FastrachTM矽樹脂加固的氣管導管(FTST),是特別為插入式LMAintubating LMAILMA)而設計,以通過該喉罩進行氣管插管。常規的氣管導管已經被成功應用,以完成氣管插管。作者通過研究評價了經過ILMA盲插FTST導管、Rusch聚氯乙烯導管(polyvinyl chloride tubePVCT)和Rusch乳膠導管(latex armored tubeLAT)的成功率。150ASAⅠ~Ⅱ健康成人,全麻下行選擇性手術,隨機分為三組,即FTST組(n=50)、管道經過預熱的PVCT組(n=50)和LVT組(n=50),行氣管插管。記錄插管的難易程度、插管所需時間、試插次數、插管輔助手法的使用次數。另外,記錄插管失敗次數和拔除ILMA所需時間。記錄術後病人出現創傷、咽喉酸痛和聲嘶等情況。PVCTFTST插管的成功率為96%,顯著高於LAT82%)(P<0.05)。PVCTLAT第一次插管的成功率相似(86%),顯著高於LAT52%)(P<0.05)。LAT插管誤入食道的發生率(29.7%)顯著高於PVCT(1.8%)FTST7.4%)(P<0.05)。結論:PVCT經預熱後可像FTST那樣經喉罩盲插,但LAT插管失敗率高且容易誤入食道。

(趙延華 譯 陳傑 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.

 

急性等容血液稀釋在單肺通氣時對氧合作用的影響

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

 

有關等容血液稀釋(IH)在單肺通氣(OLV)時對氧化作用的影響的資料很少。我們研究了47例血紅蛋白均>14 g/dL的擇期肺部手術患者(17例肺功能正常[NL]17例慢性阻塞性肺疾病[COPD][COPD]13COPD患者作為時間/麻醉效應對照[CTRL])。麻醉標準化,雙腔管插入氣管。通氣參數設定及吸入氧濃度保持不變。研究在手術開始前進行,患者處於仰臥位。先OLV15分鐘,再建立雙肺通氣,並且進行IH500 mL),給予同等容量的羥乙基澱粉。隨後再進行OLV 15分鐘。CTRL組,按同樣的次序給予OLV,不進行IH。每次OLV期末,記錄肺部力學參數和血氣。用方差分析對資料進行分析(均數±標準差)。NL組和CTRL組的動脈氧分壓保持不變,而COPD組從IH前的119 ± 21 mm Hg下降到IH後的86 ± 16 mm HgP <0.01)。輕度的IHOLV時損害COPD患者的氣體交換,但是對肺功能正常的患者無影響。

(陳 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.

 

繼發於中樞神經系統中一氧化氮增加的交感傳出減少導致肝素後魚精蛋白產生的低血壓

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

 

為了闡明魚精蛋白導致的低血壓、一氧化氮 (NO)與交感活性間是否有聯繫,我們先給予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),作為壓力感受器去神經支配的兔子的預處理,然後給予300 U/kg肝素,再給予3 mg/kg魚精蛋白。比較血流動力學參數和腎交感神經活性(RSNA)。在D-NAME組,心率(HR)、平均動脈壓(MAP)RSNA分別顯著減少至93.7% ± 0.7% 75.0% ± 5.1%65.2% ± 4.6%(mean ± SE)。在L-NAME組,L-NAME的預處理顯著抑制了魚精蛋白對這些參數的抑制作用。由於動物是完全地壓力感受器去神經支配,RSNA的下降可歸因於魚精蛋白的中樞抑制作用,交感傳出的減少可能導致HRMAP的下降。預先給予L-NAME,一個NO合酶抑制劑,可以抑制魚精蛋白對交感傳出的抑制作用,提示了,繼發於魚精蛋白導致的中樞神經系統中NO濃度增加的交感傳出的減少可能促成了魚精蛋白導致的心血管抑制。

(張 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.

 

麻醉對上呼吸道感染的患兒:還困難嗎?

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

 

小兒麻醉中最有爭論的問題之一圍繞著對有上呼吸道感染(URI)的患兒是否繼續進行麻醉與手術的決策。過去,有URI的患兒原則上應推遲手術日期直至症狀消失。該措施主要基於以往的經驗支持的前提:麻醉會增加嚴重併發症的危險性及患兒術後病程的複雜性。儘管最近的臨床資料證實:一些患有URI的患兒圍術期併發症有增加的危險,對於大部分患兒而言可以預期、認識及治療這些併發症。儘管對有URI的患兒麻醉仍是一種挑戰,但對於評價及處理這些患兒,目前麻醉醫生現已處於一個更好的位置能作出更明智的決定,而取消手術的做法已成為過去。

(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.

 

容量減少性濃縮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

 

為治療早產及低出生體重嬰兒的血小板減少症,通常需要輸注小容量血小板。同時,進行開心手術及體外迴圈並危及心臟功能的嬰兒又面臨著血容量過多的風險。可以從標準單個供者的一個濃縮血小板(PC)單位中分出一部分來得到小容量的血小板替代品。或者有PCs的容量減少的適應證以在最可能小的容量中輸注最多數量的血小板。我們在20份聯貫的單個供者提取的PCs中,測定容量減少前後血小板自發和誘導活化。平均儲存2天後,用離心方法去除PCs的血漿成分。用流式細胞儀測定血小板自發的、二磷酸腺苷(ADP)誘導的和膠原誘導的活性。進一步測定經ADP和膠原誘導的聚合物。結果為,標準PCs中共有33.8%的血小板有自發活性。PCs容量減少使血小板自發活性輕度但顯著升高(43.2%)。另外,容量減少使ADP誘導的血小板聚合性受影響,但對膠原誘導的血小板活性無影響。輸注容量減少的PCs是血容量過多風險高的患者用標準PCs的另一有效選擇,因為相同容量可以有效增加兩倍數目的血小板。

(周志堅 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.

 

對貓靜脈給予利多卡因對異氟醚肺泡最低濃度的影響

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藥的最小肺泡濃度(MAC),臨床上可用於減少其他麻醉藥的用量。在本研究中,我們探討了利多卡因對貓MAC的影響。研究了6只貓。在實驗1,測定異氟醚的MAC。靜脈一次給利多卡因2mg/kg,測定靜脈血漿利多卡因濃度以確定其藥代動力學值。在實驗2,給予利多卡因,使之血漿靶濃度在1-11µg/mL,測定每一個利多卡因血漿濃度時的異氟醚的MAC。利多卡因血漿靶濃度為1357911 µg/mL時,實際利多卡因血漿濃度分別為1.06 ± 0.122.83 ± 0.39 4.93 ± 0.64 6.86 ± 0.97 8.86 ± 2.109.84 ± 1.34 µg/mL。利多卡因靶濃度為01357911 µg/mL時,研究中異氟醚的MAC分別為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%。在利多卡因血漿靶濃度為1357911 µg/mL時,利多卡因線性地降低異氟醚的MAC分別為–6%6%7%28%19%35%28%45%29%53%44%59%。我們作出結論:利多卡因降低異氟醚的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.

 

在意識喪失及喚醒時丙泊酚的個體作用部位濃度相似

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

 

已有報導的丙泊酚意識喪失時和意識恢復時的作用部位濃度範圍很大。因此任何一個基於人群平均值的濃度對於個體病人來說未必是最理想的濃度。所以我們來驗證這樣一個假設:個體在意識喪失和恢復時其丙泊酚作用部位濃度是相近的。在20名成年人中以靶控輸注系統估算志願者在意識喪失和恢復時丙泊酚的作用部位濃度。逐漸增加丙泊酚的作用部位濃度直至志願者喪失意識(對於語言刺激無反應);維持志願者意識喪失狀態15分鐘,隨後喚醒志願者。此過程在每個志願者重複3次。我們得到的主要結果是丙泊酚使意識喪失的濃度及估算的意識喪失時的作用部位濃度與意識恢復時的作用部位濃度之間的關係。丙泊酚的靶作用部位濃度在意識喪失時為2.0 ± 0.9 意識恢復時為 1.8 ± 0.7 (P < 0.001)。個體意識喪失和恢復時丙泊酚作用部位濃度差的平均值僅為0.17 ± 0.32 µg/mL(差的95%可信限為 0.09–0.25 µg/mL)。因此我們的結果提示丙泊酚個體滴定至意識消失是除了在人群平均需要量的基礎上定量給予以外的另一選擇。

(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.

 

硫噴妥鈉在大鼠身上產生制動主要通過脊髓上位作用

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

 

脊索介導了吸入麻醉藥絕大部分的制動作用。本研究中我們在大鼠身上探討了到底是脊髓還是脊髓以上部位介導了硫噴妥鈉的制動作用。硫噴妥鈉通過IV、椎管內(IT)、腦室內(ICV)或ITICV同時給藥。只有IV輸注產生麻醉作用,即對夾尾無體動反應(換言之,相當於最小肺泡濃度,MAC 。因此,用硫噴妥鈉的MAC-節省效應(針對異氟醚)來評估ITICV輸注硫噴妥鈉的制動作用。在全腦、脊索和遠離輸注部位的大腦皮層的一個薄片中測定硫噴妥鈉的濃度。這些濃度與輸注硫噴妥鈉的MAC-節省效應之間以一種多元回歸的模式相關。為了評估硫噴妥鈉滲入脊索的速率,大鼠脊索在體外用硫噴妥鈉浸浴至平衡,然後測定脊索中的硫噴妥鈉濃度以作為平衡穩定時間的函數。在體內通過行為研究的時間跨度進行IT輸注硫噴妥鈉來重複了這個研究。我們發現,ITICV輸注硫噴妥鈉25 µg/min減少異氟醚的MAC<25%。與IV輸注一定劑量可以在無異氟醚時產生麻醉作用的硫噴妥鈉時相比, IT輸注或ICV輸注硫噴妥鈉25 µg/min之後,相應的脊索和全腦中的硫噴妥鈉濃度分別超過500%和680%。異氟醚MAC減少的百分比主要和腦組織中硫噴妥鈉的濃度相關而與腦室中濃度無關。脊索輸注可以減少約20%的MAC。在體外IT硫噴妥鈉很容易彌散入脊索,時間常數約1h。我們得出結論:與吸入麻醉藥不同,硫噴妥鈉的制動作用主要是脊髓上位的。大腦中除了靠近第三和第四腦室外的中樞部位起了最主要的作用。

(黃施偉 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.

 

用於拇內收肌神經肌肉監測的四個成串刺激可置於腕部或手上

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

 

在腕部的尺神經刺激拇內收肌是監測神經肌肉功能的標準方法。一般認為在肌肉上刺激直接引起肌肉收縮,但是其證據不足。在本研究中,我們試圖確定手上的拇內收肌刺激過程中發生的直接肌肉刺激以及其反應是否與在腕部刺激時觀察到的相似。在20例七氟醚麻醉的患者中,一部分刺激電極置於腕部尺神經,第二部分置於手背部第一掌骨與第二掌骨之間。監測肌加速度反應。給予羅庫溴銨0.6 mg/kg。在腕部實施四個成串(TOF)刺激,直到最大阻滯。然後,在手部實施刺激。在恢復過程中,交替監測兩部位。注射羅庫溴銨後,20例患者中的17例在兩部位刺激均無顫搐反應,1例在兩個部位刺激均有反應,2例患者僅在腕部刺激有反應。在恢復過程中手上的TOF比率與腕部相比較,用BlandAltman分析顯示,偏差為0.5%,一致限度±11.8%。在手上刺激不引起直接的肌肉刺激,因為其反應並不大於在腕部刺激所產生的反應。刺激兩部位產生的TOF比率相近。

(馬皓琳 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.

 

心臟手術後拔除胸腔引流管三種鎮痛方法的隨機比較

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位患者行冠脈搭橋手術和/或瓣膜手術,術後拔除胸腔引流管時進行鎮痛,前瞻隨機地研究三種鎮痛方法的效果。患者隨機接受0.1 mg/kg嗎啡靜脈注射、0.5%布比卡因20 mL皮下注射或通過活瓣吸入50%笑氣50%氧氣混合氣體(Entonox)。拔管前、拔管時用視覺類比評分(visual analog scaleVAS)來評估疼痛水平。拔管時布比卡因組、Entonox組和嗎啡組的VAS中位數(第25百分位數、第75百分位數)分別是:9.5 mm (318 mm)37.0 mm (1356 mm) 15.0 mm (727 mm)Entonox組的疼痛評分高於布比卡因組(P = 0.005)和嗎啡組(P = 0.047)。三組疼痛評分基礎值與拔管值的差異分別是:–0.5 mm (–137 mm)+10 mm (129 mm)–3.0 mm (–1112 mm)。三組間動脈壓、心率、PaCO2、血氧飽和度和鎮靜水平無顯著差異。拔除胸腔引流管時布比卡因和嗎啡的鎮痛效果較好,但Entonox的鎮痛效果不好。

(軒泓 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.

 

 

可樂定在神經外科手術中的應用

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

 

本研究目的包括兩部分:確定顱內手術患者預防淺低溫後的術後寒戰的可樂定劑量和評估可樂定對患者麻醉恢復的影響。48例擇期行顱內手術患者分成兩組。在第一部分研究 (n = 14)中,我們使用Dixon’s 上下法確定可樂定預防淺低溫(35°C)後的術後寒戰的ED50。首個患者可樂定的劑量是3 µg/kg。隨後患者的劑量以1 µg/kg的增量調整。術後一小時評估寒戰的發生情況。第二部分研究(n = 34)為評估3 µg/kg可樂定對麻醉恢復的影響的前瞻、隨機、盲法、安慰劑對照研究,。開始縫硬腦膜時,隨機給予患者可樂定或生理鹽水輸注15分鐘。研究麻醉結束後2小時內的恢復參數。對手術結束時靶中心溫度為35°C的神經外科患者,可樂定預防寒戰的ED501.1 ± 1.5 µg/kg。相比生理鹽水,麻醉結束前1小時給予神經外科患者3 µg/kg可樂定既不會延遲麻醉恢復,也不會有臨床上顯著的鎮靜或血流動力學作用。我們的研究提示可樂定可用于神經外科患者來預防淺低溫後的術後寒戰。

(張俊傑 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.

 

用區域麻醉和鎮痛抑制乳房癌手術應激反應並不影響血管內皮生長因數和前列腺素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轉移的基礎,這一增生受血管生長因數和前列腺素E2介導。我們假設血清中血管內皮生長因數和前列腺素E2的水平在乳腺癌手術應激刺激下會有所增加,而可被椎旁阻滯麻醉和鎮痛所抑制。30例乳房切除手術婦女入選這個前瞻性研究中,被隨機分入為:用全麻進行手術並在術後以阿片類藥物鎮痛(嗎啡0.1mg/kg單次和PCA注射);全麻複合椎旁麻醉(72小時注射)兩組。所有的病人都接受直腸二氯芬酸肛栓。在術前以及在術後424小時採集靜脈血液樣本,檢測血清中血糖、皮質醇、C-反應蛋白、VEGF以及PEGE2。結果:PVAA可抑制手術的應激反應,使作為應激反應水平的血漿中血糖、皮質醇和C反應蛋白明顯的減低。但是VEGFPGE2的水平在兩組中並沒有明顯的差異。在用PVAA複合全麻以及單獨用全麻的病人中424小時VEGF變化的百分比是3% ± 44%9% ± 80% P = 0.29。以及5% ± 43% –10% ± 63%, P = 0.41。兩組PEGE2在術後424小時改變為0% ± 17% 11% ± 69%, P = 0.29 and 34% ± 19% 47% ± 18%, P = 0.15.。結論:我們認為儘管抑制了手術的應激刺激,PVAA並不能影響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.

 

 

拉氏坐骨神經阻滯時足蹠曲比背曲更具可信度:一個前瞻性、隨機對比

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

 

 傳統的拉氏坐骨神經阻滯法已不能展示足部的哪一運動反應提供了更高概率的完全感覺和運動阻滯。在本前瞻性、隨機的、雙盲研究中,我們對比足蹠曲和背曲之間以傳統方法阻滯坐骨神經的起效時間和功效。共80例行拇趾外翻手術的患者隨機分為引出足蹠曲後(n = 40)或足背曲(n = 40)後坐骨神經阻滯。以<0.5 mA電流激發運動反應後,給予0.75%羅呱卡因20ml。成功率定義為所有坐骨神經支配區域完全感覺和運動阻滯且手術不痛。記錄足部感覺和運動阻滯的起效時間。引出足蹠曲後的成功率(87.5%)明顯高於足背曲(55%; P < 0.05)。引出足蹠曲後完全感覺和運動阻滯的起效 (分別為10 ± 10 min13 ± 10 min)較足背曲快 (20 ± 11 min24 ± 12 min; P < 0.05)。我們得出結論,足蹠曲預示的拉氏經典後路坐骨神經阻滯的比足背曲預示的起效時間短並且成功率高。

(趙雪蓮 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.

 

內窺鏡交感神經切除術全程中手掌皮膚血流和溫度反應

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

 

胸外科交感神經切除術常用于治療原發性手掌和腋窩多汗症。手掌皮膚溫度的升高是鑒定手術成功與否的常用方法。由於手掌溫度的改變繼發於皮膚血流的改變,本研究的目的是證明這樣一個假設,即監測手掌皮膚血流較監測手掌皮膚溫度更能時時清晰反映手術效果。在11個患手掌和/或腋窩多汗症病人行交感神經切斷術全程,我們測量了手掌皮膚溫度和血流(使用鐳射多普勒流量計)。最初燒灼5分鐘後,皮膚血流從48 ± 7灌流單位提高到121 ± 17灌流單位(P < 0.001),而皮膚溫度卻沒有明顯變化(31.0°C ± 0.5°C31.3°C ± 0.5°CP > 0.05)。達到皮膚血流峰值所需的時間(22 ± 3 min)明顯較達到皮膚溫度峰值的時間短(34 ± 0.3 min; P < 0.001)。開始燒灼交感神經51015分鐘後,皮膚血流的升高占總皮膚血流升高的較大部分,與皮膚溫度升高不同(所有的P < 0.006)。這些資料說明胸部交感神經切斷術中,監測皮膚血流較監測皮膚溫度更加時時和清晰。但是,最初燒灼胸壁上的神經節可能在物理破壞神經節前就已導致皮膚血流的升高,。這可能限制了監測皮膚血流來鑒別手術成功與否的實際應用。

(張  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.

 

利多卡因興奮重組椎實螺(Lymnaea stagnalis呼吸模式發生器的突觸前及後神經元

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興奮中樞神經系統包括呼吸模式的兩方面作用。過量局麻藥引起的興奮作用常認為是由於早期阻斷皮層抑制性通路之故。為澄清利多卡因對抑制性突觸的突觸前及後神經元的效應,我們利用蝸牛Lymnaea stagnalis的二個神經元在體外重組而構建培養軀體-軀體呼吸模式發生器模型。首先我們觀察了利多卡因對單個突觸前(RPeD1)或突觸後(VD4)神經元的影響。在同時記錄RPeD1VD4時,分別比較了利多卡因給予前及後(0.01, 0.1, and 1 mM)的動作電位數量、膜電位和動作電位的波長。結果利多卡因能增加動作電位的數量及單個動作電位的波長,並以劑量依賴方式使RPeD1VD4神經元的靜息膜電位去極化。此外利多卡因能減低外向性鉀電流。在軀體-軀體神經對中,0.01 mM 利多卡因引起RPeD1興奮而抑制VD40.11 mM 利多卡因則導致RPeD1VD4神經元的興奮。總之利多卡因能減低突觸前和後神經元的突觸傳遞和神經元一般興奮性。

(王立中 譯,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.