Anesthesia & Analgesia

February 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

開胸或內鏡技術行微創冠狀動脈旁路移植術時心肌壁節段性運動

(王 薛張綱 校)

Segmental Myocardial Wall Motion During Minimally Invasive Coronary Artery Bypass Grafting Using Open and Endoscopic Surgical Techniques

S. Mierdl, C. Byhahn, V. Lischke, T. Aybek, G. Wimmer-Greinecker, S. Dogan, S. Viehmeyer, P. Kessler, and Klaus Westphal

Anesth Analg 2005 100: 306-314

心臟手術期間傷口乾燥能防止嗎? 一項實驗性研究

(朱慧琛 譯 陳傑 校)

Can Wound Desiccation Be Averted During Cardiac Surgery? An Experimental Study

Mikael Persson and Jan van der Linden

Anesth Analg 2005 100: 315-320

持續胃減壓治療冠脈搭橋術後的噁心嘔吐

(彭中美 李士通 校)

Continuous Gastric Decompression for Postoperative Nausea and Vomiting After Coronary Revascularization Surgery

Crina L. Burlacu, David Healy, Donal J. Buggy, Ciaran Twomey, David Veerasingam, Andrew Tierney, and Denis C. Moriarty

Anesth Analg 2005 100: 321-326.

氙或笑氣麻醉對豬單肺通氣的全身氧合和肺灌注的影響

(朱慧琛 譯 陳傑 校)

The Effects of Xenon or Nitrous Oxide Supplementation on Systemic Oxygenation and Pulmonary Perfusion During One-Lung Ventilation in Pigs

Konrad Schwarzkopf, Torsten Schreiber, Elke Gaser, Niels-Peter Preussler, Lars Hueter, Harald Schubert, Helga Rek, and Waheedullah Karzai

Anesth Analg 2005 100: 335-339.

經食道超聲心動圖評估腹腔鏡手術中二氧化碳氣腹對肝血流的影響

(張俊傑 李士通 校)

The Effects of Intraabdominally Insufflated Carbon Dioxide on Hepatic Blood Flow During Laparoscopic Surgery Assessed by Transesophageal Echocardiography

Rainer Meierhenrich, Albrecht Gauss, Peter Vandenesch, Michael Georgieff, Bertram Poch, and Wolfram Schütz

Anesth Analg 2005 100: 340-347.

非損傷性脊髓缺血後使用嗎啡所致脊髓運動神經元變性可能來源於脊髓N-甲基天冬氨酸受體的啟動

(王 薛張綱 校)

The Effect of Volatile Anesthetics on Respiratory System Resistance in Patients with Chronic Obstructive Pulmonary Disease

揮發性麻醉藥對慢性阻塞性肺患者呼吸道阻力的影響

(王 薛張綱 校)

C. A. Volta, V. Alvisi, S. Petrini, S. Zardi, E. Marangoni, R. Ragazzi, M. Capuzzo, and R. Alvisi

Anesth Analg 2005 100: 348-353.

PEDIATRIC ANESTHESIA:

ProSealTM喉罩時壓力支持通氣與持續氣道正壓通氣的比較:小兒麻醉時的隨機交叉研究

(趙延華 譯 陳傑 校)

Pressure Support Ventilation Versus Continuous Positive Airway Pressure Ventilation with the ProSealTM Laryngeal Mask Airway: A Randomized Crossover Study of Anesthetized Pediatric Patients

A. von Goedecke, J. Brimacombe, C. Hörmann, H. -C. Jeske, A. Kleinsasser, and C. Keller

Anesth Analg 2005 100: 357-360.

AMBULATORY ANESTHESIA:

最佳時機針刺刺激輔助樞複寧預防整形手術病人的嘔吐

(裘毅敏 李士通 校)

Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery

Paul F. White, Mohamed A. Hamza, Alejandro Recart, Jayne E. Coleman, Amy R. Macaluso, Lyndsey Cox, Omar Jaffer, Dajun Song, and Rod Rohrich

Anesth Analg 2005 100: 367-372.

道拉西酮和樞複寧治療術後噁心嘔吐的比較

(金 薛張剛 校)

Dolasetron Versus Ondansetron for the Treatment of Postoperative Nausea and Vomiting

Tricia A. Meyer, Charles R. Roberson, Mohammed H. Rajab, Jad Davis, and Charles H. McLeskey

Anesth Analg 2005 100: 373-377

ANESTHETIC PHARMACOLOGY:

急性大劑量接觸有機磷時的保護性藥物:小鼠中應用甲氧氯普胺、泰必利與解磷定的比較

(忻紀華 陳傑 校)

Protective Drugs in Acute Large-Dose Exposure to Organophosphates: A Comparison of Metoclopramide and Tiapride with Pralidoxime in Rats
Georg A. Petroianu, Mohammed Y. Hasan, Syed M. Nurulain, Kholoud Arafat, Rajan Sheen, Ayman Saleh, and Andrea Schmitt

Anesth Analg 2005 100: 382-386.

針刺刺激的時間並不影響麻醉藥的需要量

(沈浩譯,李士通校)

The Timing of Acupuncture Stimulation Does Not Influence Anesthetic Requirement

Grigory Chernyak, Papiya Sengupta, Rainer Lenhardt, Edwin Liem, Anthony G. Doufas, Daniel I. Sessler, and Ozan Akça

Anesth Analg 2005 100: 387-392.

順式阿曲庫銨在眼咽肌營養不良患者的藥效動力學

(金 薛張剛 校)

Cisatracurium Pharmacodynamics in Patients with Oculopharyngeal Muscular Dystrophy

Marie-Josée Caron, François Girard, Dominique C. Girard, Daniel Boudreault, Bernard Brais, Edgard Nassif, Philippe Chouinard, Monique Ruel, and André Duranceau

Anesth Analg 2005 100: 393-397.

異氟醚麻醉期間CO2通過中樞而非外周途徑抑制F

(殷文淵 譯 陳傑 校)

Carbon Dioxide Depresses the F Wave by a Central, Not Peripheral, Mechanism During Isoflurane Anesthesia

Carmen Dominguez, Earl Carstens, and Joseph F. Antognini

Anesth Analg 2005 100: 398-403.

高濃度笑氣能減弱大鼠由嗎啡產生的異氟醚最小肺泡濃度的節省效應

(張曦 李士通 校)

Large Concentrations of Nitrous Oxide Decrease the Isoflurane Minimum Alveolar Concentration Sparing Effect of Morphine in the Rat

Martín Santos, Viviana Kuncar, Fernando Martínez-Taboada, and Francisco J. Tendillo

Anesth Analg 2005 100: 404-408.

利多卡因使活性內皮IL-1betaIL-6IL-8濃度降低及ICAM-1表達的削弱

(金 薛張剛 校)

Activated Endothelial Interleukin-1ß, -6, and -8 Concentrations and Intercellular Adhesion Molecule-1 Expression Are Attenuated by Lidocaine

Wei Lan, Dominic C. Harmon, Jiang H. Wang, George D. Shorten, and Paul H. Redmond

Anesth Analg 2005 100: 409-412.

離體脊髓的吸入麻醉藥洗出過程中高反應性與乙醇清除的比較

(趙延華 譯 陳傑 校)

Hyperresponsiveness on Washout of Volatile Anesthetics from Isolated Spinal Cord Compared to Withdrawal from Ethanol

Shirley M.E. Wong, Sarah M. Sweitzer, Michael C. Peters, and Joan J. Kendig

Anesth Analg 2005 100: 413-436.

ATP敏感鉀通道參與培養的人主動脈內皮細胞膜電位對髙滲的反應

(黃施偉 李士通 校)

Involvement of Adenosine Triphosphate-Sensitive Potassium Channels in the Response of Membrane Potential to Hyperosmolality in Cultured Human Aorta Endothelial Cells

Mikiyo Yamaguchi, Yoshinobu Tomiyama, Toshiko Katayama, Hiroshi Kitahata, and Shuzo Oshita

Anesth Analg 2005 100: 419-426.

TECHNOLOGY, COMPUTING, AND SIMULATION:

揮發性和氣體麻醉藥在體外輸入系統中吸附性丟失的研究

(吳德華 薛張剛 校)

Sorptive Loss of Volatile and Gaseous Anesthetics from In Vitro Drug Application Systems

Takahiro Suzuki, Ichiro Uchida, and Takashi Mashimo

Anesth Analg 2005 100: 427-430

血紅蛋白氧載體(Oxyglobin®Hemopure®HemolinkTM)對乳酸測定的干擾

(朱輝 譯 陳傑 校)

Lactate Measurement Interference by Hemoglobin-Based Oxygen Carriers (Oxyglobin®, Hemopure®, and HemolinkTM)

Jonathan S. Jahr, Stephen Osgood, Stephen J. Rothenberg, Qiao-Ling Li, Anthony W. Butch, Robert Gunther, Anthony Cheung, and Bernd Driessen

Anesth Analg 2005 100: 431-436.

氧化血紅蛋白為基質的攜氧分子(血紅蛋白 Glutamer-200)產生的高鐵血紅蛋白干擾乳酸測定 (YSI 2700 SELECTTM生化分析儀)嗎?

(軒泓 李士通 校)

Does Methemoglobin from Oxidized Hemoglobin-Based Oxygen Carrier (Hemoglobin Glutamer-200) Interfere with Lactate Measurement (YSI 2700 SELECTTM Biochemistry Analyzer)?

Stephen L. Osgood, Jonathan S. Jahr, Poonam Desai, Jessica Tsukamoto, and Bernd Driessen

Anesth Analg 2005 100: 437-439.

刺激模式和異丙酚血漿濃度對運動誘發電位的修飾效應

(廖慶武 薛張綱 校)

The Modifying Effects of Stimulation Pattern and Propofol Plasma Concentration on Motor-Evoked Potentials

Kai M. Scheufler, Peter C. Reinacher, Winfried Blumrich, Josef Zentner, and Hans-Joachim Priebe

Anesth Analg 2005 100: 440-447.

PAIN MEDICINE:

圍術期聯合使用右美沙芬和靜脈利多卡因對腹腔鏡膽囊手術後疼痛的緩解和腸功能恢復的影響

(朱輝 譯 陳傑 校)

The Interaction Effect of Perioperative Cotreatment with Dextromethorphan and Intravenous Lidocaine on Pain Relief and Recovery of Bowel Function After Laparoscopic Cholecystectomy

Ching-Tang Wu, Cecil O Borel, Meei-Shyuan Lee, Jyh-Cherng Yu, Hang-Seng Liou, Haun-De Yi, and Chih-Ping Yang

Anesth Analg 2005 100: 448-453.

環加氧酶-2抑制劑帕瑞考昔鈉治療婦產科剖腹手術後疼痛與肌注嗎啡12 mg一樣有效

(趙雪蓮 李士通 校)

The Cyclooxygenase-2-Specific Inhibitor Parecoxib Sodium Is as Effective as 12 mg of Morphine Administered Intramuscularly for Treating Pain After Gynecologic Laparotomy Surgery

T. Philip Malan, Jr, Stephen Gordon, Richard Hubbard, and Michael Snabes

Anesth Analg 2005 100: 454-460

嗎啡能加強神經結紮損傷大鼠模型椎管內注射N(6)-2-苯基-腺苷-右異構體(R-PIA)的鎮痛效果

(沈 薛張剛 校)

Morphine Can Enhance the Antiallodynic Effect of Intrathecal R-PIA in Rats with Nerve Ligation Injury

Jai-Hyun Hwang, Gyu-Sam Hwang, Sung-Kang Cho, and Sung-Min Han

Anesth Analg 2005 100: 461-468.

術後患者使用曲馬多和嗎啡的半數有效量:一項相互作用的研究

(朱玫娟 譯 陳傑 校)

The Median Effective Dose of Tramadol and Morphine for Postoperative Patients: A Study of Interactions

Thi Aurore Marcou, Sophie Marque, Jean-Xavier Mazoit, and Dan Benhamou

Anesth Analg 2005 100: 469-474.

注射小劑量氯胺酮可改善全膝關節成形術後鎮痛及康復

(周雅春 李士通 校)

Small-Dose Ketamine Infusion Improves Postoperative Analgesia and Rehabilitation After Total Knee Arthroplasty

Frédéric Adam, Marcel Chauvin, Bertrand Du Manoir, Mathieu Langlois, Daniel I. Sessler, and Dominique Fletcher

Anesth Analg 2005 100: 475-480.

異丙酚對熱痛覺的影響

(孫志榮 薛張綱 )

The Effect of Propofol on Thermal Pain Perception

Michael A. Frölich, Donald D. Price, Michael E. Robinson, Jonathan J. Shuster, Douglas W. Theriaque, and Marc W. Heft

Anesth Analg 2005 100: 481-486.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

一個作為資料收集平臺面向多中心研究的網站

(朱玫娟 譯 陳傑 校)

An Internet Web Site as a Data Collection Platform for Multicenter Research

Alexander Avidan, Charles Weissman, and Charles L. Sprung

Anesth Analg 2005 100: 506-511.

CRITICAL CARE AND TRAUMA:

環周性調整超聲探頭位置以確定穿刺頸內靜脈的最佳徑路:對成人無創性幾何研究

(王立中 李士通 校)

Circumferential Adjustment of Ultrasound Probe Position to Determine the Optimal Approach to the Internal Jugular Vein: A Noninvasive Geometric Study in Adults

James M. Riopelle, Darren P. Ruiz, John P. Hunt, Mark R. Mitchell, J. Carlos Mena, Jason A. Rigol, Bruno C. Jubelin, Arthur J. Riopelle, Valeriy V. Kozmenko, and Matthew K. Miller

Anesth Analg 2005 100: 512-519.

腎上腺素加強全血中血小板與白細胞粘著力的體外實驗

許文妍 薛張綱 )

Epinephrine Enhances Platelet-Neutrophil Adhesion in Whole Blood In Vitro

Nicola A. Horn, Denisa M. Anastase, Klaus E. Hecker, Jan H. Baumert, Tilo Robitzsch, and Rolf Rossaint

Anesth Analg 2005 100: 520-526.

危重病中指導營養支持實驗的實際方法學質量的回顧:有待提高

殷文淵 陳傑 校)

A Review of the True Methodological Quality of Nutritional Support Trials Conducted in the Critically Ill: Time for Improvement

Gordon S. Doig, Fiona Simpson, and Anthony Delaney

Anesth Analg 2005 100: 527-533.

NEUROSURGICAL ANESTHESIA:

神經外科手術患者長期應用苯妥英或卡馬西平治療影響順式阿曲庫銨引起的神經肌肉阻滯作用

(陳瑋    李士通 校)

Cisatracurium-Induced Neuromuscular Blockade Is Affected by Chronic Phenytoin or Carbamazepine Treatment in Neurosurgical Patients

Anouk Richard, François Girard, Dominique C. Girard, Daniel Boudreault, Philippe Chouinard, Robert Moumdjian, Alain Bouthilier, Monique Ruel, Johanne Couture, and France Varin

Anesth Analg 2005 100: 538-544.

REGIONAL ANESTHESIA:

脊麻手術中應用2-氯普魯卡因初始十個月的經驗

(蔡美華 薛張剛 校)

Spinal 2-Chloroprocaine for Surgery: An Initial 10-Month Experience

Jessica R. Yoos and Dan J. Kopacz

Anesth Analg 2005 100: 553-558.

\2-氯普魯卡因脊髓麻醉:複合可樂定的效果

(齊波 譯 陳傑 校)

Spinal 2-Chloroprocaine: The Effect of Added Clonidine

Brad R. Davis and Dan J. Kopacz

Anesth Analg 2005 100: 559-565.

2-氯普魯卡因脊麻:在志願者中與小劑量布比卡因比較

(周志堅 李士通 )

Spinal 2-Chloroprocaine: A Comparison with Small-Dose Bupivacaine in Volunteers

Jessica R. Yoos and Dan J. Kopacz

Anesth Analg 2005 100: 566-572.

脊麻2-氯普魯卡因:志願者中與普魯卡因比較

(費 薛張剛 校)

Spinal 2-Chloroprocaine: A Comparison with Procaine in Volunteers

Aaron F. Gonter and Dan J. Kopacz

Anesth Analg 2005 100: 573-579.

GENERAL ARTICLES:

全麻誘導期間應用呼吸末正壓通氣可增加病態肥胖病人呼吸暫停而無低氧的持續時間

(齊波 譯 陳傑 校)

Positive End-Expiratory Pressure During Induction of General Anesthesia Increases Duration of Nonhypoxic Apnea in Morbidly Obese Patients
Sylvain Gander, Philippe Frascarolo, Michel Suter, Donat R. Spahn, and Lennart Magnusson

Anesth Analg 2005 100: 580-584

成人頸深部感染的氣道管理:病例系列和文獻回顧

(張瑩 李士通 校)

Airway Management in Adult Patients with Deep Neck Infections: A Case Series and Review of the Literature

Andranik Ovassapian, Meltem Tuncbilek, Erik K. Weitzel, and Chandrashekhar W. Joshi

Anesth Analg 2005 100: 585-589.

與經典喉罩比較Proseal喉罩壽命較短

(孫敏莉 薛張綱 校)

The ProSealTM Has a Shorter Life-Span than the ClassicTM Laryngeal Mask Airway

Sarah Doneley, Joseph Brimacombe, Christian Keller, and Achim von Goedecke

Anesth Analg 2005 100: 590-593.

 

心臟手術期間傷口乾燥能防止嗎? 一項實驗性研究

Can Wound Desiccation Be Averted During Cardiac Surgery? An Experimental Study

Mikael Persson, PhD, and Jan van der Linden, MD PhD

Division of Medical Engineering, Department of Laboratory Medicine, and Department of Cardiothoracic Surgery & Anesthesiology; Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2005 100: 315-320.

 

心臟手術中傷口暴露而乾燥,尤其是手術室使用空氣流通裝置及吹入乾燥的CO2時。本文作者比較了心胸傷口體外模型中在上述情況和吹入潮濕CO2的情況下的氣體濕度和乾燥率。為評價流速的影響,CO210l/min的流速經過一個標準末端開口的管子或一個低流量的氣體霧化器。並與沒有吸入的對照組相比較。當通過末端開口的管子時,無論吸入乾燥或濕化的CO2,兩組的濕度基本相同。然而,總的乾燥率比對照組高(P<0.001),尤其是在暴露處與氣體噴射的地方,這些地方的乾燥率要比對照組高3倍(P<0.001)。使用氣體霧化器時,乾燥CO2導致零濕度,與對照組的乾燥率相同。CO2濕化的吸入組與對照組相比增加了濕度(P<0.001),降低乾燥率90%P<0.001)。濕化的CO2可被用來防止心胸外科傷口的乾燥。潮濕的氣體只有經過低流量的出口裝置時才有效。

(朱慧琛 譯 陳傑 校)

During cardiac surgery the wound is exposed to desiccation, especially as a result of operating room ventilation and the insufflation of dry carbon dioxide (CO2) for de-airing. We compared the gas humidity and desiccation rates in an in vitro model of a cardiothoracic wound during these conditions and during insufflation of humidified CO2. To assess the influence of flow velocity, CO2 was insufflated at 10 L/min via two devices, a standard open-ended tube and a low-velocity gas diffuser. The treatment arms were compared with a control without insufflation. When insufflated via the open-ended tube the humidity in the model was almost equal to the control, both with dry and humidified CO2. However, the total desiccation rate was more rapid than the control (P < 0.001), especially in the area exposed to the gas jet where the desiccation rate was three times more rapid (P < 0.001). With the gas diffuser, dry CO2 caused almost zero humidity and a desiccation rate that was almost equal to the control. Humidified CO2 increased humidity in comparison with the control (P < 0.001) and decreased the desiccation rate by >90% (P < 0.001). Humidified CO2 may be used to avert desiccation of the cardiothoracic wound. The humidified gas is effective only when delivered via a low-velocity outlet device.

 

氙或笑氣麻醉對豬單肺通氣的全身氧合和肺灌注的影響

The Effects of Xenon or Nitrous Oxide Supplementation on Systemic Oxygenation and Pulmonary Perfusion During One-Lung Ventilation in Pigs

Konrad Schwarzkopf, MD*, Torsten Schreiber, MD*, Elke Gaser, MD*, Niels-Peter Preussler, MD*, Lars Hueter, MD*, Harald Schubert, DVM{dagger}, Helga Rek*, and Waheedullah Karzai, MD{ddagger}

*Department of Anesthesiology and Intensive Care Medicine and {dagger}Institute for Experimental Animals, University of Jena; and {ddagger}Department of Anesthesiology and Intensive Care Medicine, Zentralklinik Bad Berka, Germany

Anesth Analg 2005 100: 335-339.

 

在單肺通氣(OLV)過程中,不同的麻醉方式可影響全身血流動力學狀態、肺灌注和氧合。本文作者研究了豬單肺通氣模型中異丙酚複合氙氣(Xe)或笑氣麻醉時對氧合、肺灌注和全身及肺血流動力學的影響。九隻豬施行麻醉、氣管插管和機械通氣。在置入動脈導管和肺動脈導管後,通過氣管切開處置入左雙腔氣管導管。異丙酚靜脈持續滴注並隨機複合N2O/O26040)或Xe/ O26040)或N2/O26040)。所有檢測均在吸入濃度穩定後進行。使用染色微滴法監測肺灌注的微小差別。單肺通氣時氧合(N2/O2, N2O/O2, Xe/ O2Pa O2分別為90+1795+2094+20mmHg)、左肺灌注(N2/O2, N2O/O2, Xe/ O2組分別為16%+5%14%+6%18.8%)組間無明顯差別。但N2O/O2組平均動脈壓(N2/O2, N2O/O2, Xe/ O2組分別為78+2562+2366+23mmHg)和混合靜脈飽和度(N2/O2, N2O/O2, Xe/ O2組分別為55%+12%48%+12%50%+12%)低於對照組(N2/O2)。因此,在實驗性單肺通氣時靜脈麻醉複合XeN2O不會影響氧合及肺灌注。

(朱慧琛 譯 陳傑 校)

During experimental one-lung ventilation (OLV), the type of anesthesia may alter systemic hemodynamics, lung perfusion, and oxygenation. We studied whether xenon (Xe) or nitrous oxide (N2O) added to propofol anesthesia would affect oxygenation, lung perfusion, and systemic and pulmonary hemodynamics during OLV in a pig model. Nine pigs were anesthetized, tracheally intubated, and mechanically ventilated. After placement of arterial and pulmonary artery catheters, a left-sided double-lumen tube was placed via tracheotomy. IV anesthesia with propofol was supplemented in random order with N2O/O2 60:40 or Xe/O2 60:40 or N2/O2 60:40. All measurements were made after stabilization at each concentration. Differential lung perfusion was measured with colored microspheres. Oxygenation (Pao2: 90 ± 17, 95 ± 20, and 94 ± 20 mm Hg for N2/O2, N2O/O2, and Xe/O2) and left lung perfusion (16% ± 5%, 14% ± 6%, and 18.8% for N2/O2, N2O/O2, and Xe/O2) during OLV did not differ among the 3 groups. However, mean arterial blood pressure (78 ± 25, 62 ± 23, and 66 ± 23 mm Hg for N2/O2, N2O/O2, and Xe/O2) and mixed venous saturation (55% ± 12%, 48% ± 12%, and 50% ± 12% for N2/O2, N2O/O2, and Xe/O2) were reduced during N2O/O2 as compared with the control group (N2/O2). Supplementation of IV anesthesia with Xe or N2O does not impair oxygenation nor alter lung perfusion during experimental OLV.

 

ProSealTM喉罩時壓力支持通氣與持續氣道正壓通氣的比較:小兒麻醉時的隨機交叉研究

Pressure Support Ventilation Versus Continuous Positive Airway Pressure Ventilation with the ProSealTM Laryngeal Mask Airway: A Randomized Crossover Study of Anesthetized Pediatric Patients

A. von Goedecke, MD*, J. Brimacombe, MB, ChB, FRCA, MD{dagger}, C. Hörmann, MD*, H. -C. Jeske, MD*, A. Kleinsasser, MD*, and C. Keller, MD*

*Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria; and {dagger}James Cook University, Cairns Base Hospital, Australia

Anesth Analg 2005 100: 357-360.

 

對成人的研究發現,持續氣道正壓通氣(CPAP)和壓力支持通氣(PSV)可改善氣體交換,但是關於兒童的研究很少。作者比較了兒童麻醉下利用ProSealTM喉罩通氣時PSVCPAP的有效性。病人隨機分為兩組,術前獲得相關資料。在第一組,病人按順序進行CPAPPSVCPAP。在第二組,病人按順序進行PSVCPAPPSVPSV時呼氣末正壓(PEEP3cmH2O、壓力支持設定為高於PEEP水平10cmH2OCPAP設定為3cmH2O。每一種通氣模式維持5min,在此過程中記錄以下資料,包括呼氣末CO2(PETCO2)SpO2、潮氣量、氣道峰壓、呼吸功(WOB)、 食道壓的變化、壓力時間乘積、呼吸驅動力、吸入時間分數、呼吸頻率、無創平均動脈壓和心率。在第一組,PSV前後進行CPAP,測定值相同。在第二組,CPAP前後進行PSV,測定值相同。CPAPPETCO2、呼吸頻率、WOB、壓力時間乘積、食道壓的變化、吸入時間分數分別為52±7mmHg30±6/min0.95 ±0.72 JL150 ±90cmH2O·s-1·min-114.1±8.9 cmH2O34% ±5%PSV的相應指標分別為46±6mmHg24±6/min0.54±0.54JL94±88 cmH2O·s-1·min-110.6±7.4cmH2O29%±3%,均小於CPAPP < 0.0010.05)。PSV的潮氣量為179 ±50mL,高於CPAP129 ±44 mLP < 0.001)。SpO2、呼吸驅動力、平均動脈壓和心率在兩種通氣模式沒有區別。結論:對ASA I級的1-7歲兒童利用ProSealTM喉罩進行麻醉時,與CPAP相比PSV能改善氣體交換並減少呼吸功(WOB)。

(趙延華 譯 陳傑 校)

Continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) improve gas exchange in adults, but there are little published data regarding children. We compared the efficacy of PSV with CPAP in anesthetized children managed with the ProSealTM laryngeal mask airway. Patients were randomized into two equal-sized crossover groups and data were collected before surgery. In Group 1, patients underwent CPAP, PSV, and CPAP in sequence. In Group 2, patients underwent PSV, CPAP, and PSV in sequence. PSV comprised positive end-expiratory pressure set at 3 cm H2O and inspiratory pressure support set at 10 cm H2O above positive end-expiratory pressure. CPAP was set at 3 cm H2O. Each ventilatory mode was maintained for 5 min. The following data were recorded at each ventilatory mode: ETco2, Spo2, expired tidal volume, peak airway pressure, work of breathing patient (WOB), {delta}esophageal pressure, pressure time product, respiratory drive, inspiratory time fraction, respiratory rate, noninvasive mean arterial blood pressure, and heart rate. In Group 1, measurements for CPAP were similar before and after PSV. In Group 2, measurements for PSV were similar before and after CPAP. When compared with CPAP, PSV had lower ETco2 (46 ± 6 versus 52 ± 7 mm Hg; P < 0.001), slower respiratory rate (24 ± 6 versus 30 ± 6 min–1; P < 0.001), lower WOB (0.54 ± 0.54 versus 0.95 ± 0.72 JL–1; P < 0.05), lower pressure time product (94 ± 88 versus 150 ± 90 cm H2O s–1min–1; P < 0.001), lower {delta}esophageal pressure (10.6 ± 7.4 versus 14.1 ± 8.9 cm H2O; P < 0.05), lower inspiratory time fraction (29% ± 3% versus 34% ± 5%; P < 0.001), and higher expired tidal volume (179 ± 50 versus 129 ± 44 mL; P < 0.001). There were no differences in Spo2, respiratory drive, mean arterial blood pressure, and heart rate. We conclude that PSV improves gas exchange and reduces WOB during ProSealTM laryngeal mask airway anesthesia compared with CPAP in ASA physical status I children aged 1–7 yr.

 

急性大劑量接觸有機磷時的保護性藥物:小鼠中應用甲氧氯普胺、泰必利與解磷定的比較

Protective Drugs in Acute Large-Dose Exposure to Organophosphates: A Comparison of Metoclopramide and Tiapride with Pralidoxime in Rats

Georg A. Petroianu, MD, PhD, FCP*, Mohammed Y. Hasan, PhD, DABT*, Syed M. Nurulain, Mphil*, Kholoud Arafat, MSc*, Rajan Sheen, MSc*, Ayman Saleh, PhD{dagger}, and Andrea Schmitt, MD{ddagger}

Departments of *Pharmacology and {dagger}Biochemistry, Faculty of Medicine & Health Sciences, UAE University, Al-Ain, United Arab Emirates; and {ddagger}Central Institute of Mental Health, Mannheim, Germany

Anesth Analg 2005 100: 382-386.

 

作用微弱的可逆性膽鹼酯酶抑制劑與作用強烈的抑制劑如有機磷酸鹽合用時,可以產生保護性作用。慢性小劑量接觸有機磷後,體內和體外實驗研究顯示苯甲酰胺化合物、甲氧氯普胺在膽鹼酯酶拮抗對氧磷時可產生保護作用(假定通過該機制)。泰必利是相關的苯甲酰胺類藥物。本研究中作者用治療金標準”——解磷定比較了甲氧氯普胺和泰必利對急性大劑量接觸有機磷類藥對氧磷的保護作用。組1接受1umol的對氧磷(約為75%的致死劑量),組2 接受50umol的甲氧氯普胺,組3 接受50umol的泰必利,組4 接受50umol的解磷定,組5 接受1umol的對氧磷和50umol的甲氧氯普胺,組6 接受1umol的對氧磷和50umol的泰必利,組7 接受1umol的對氧磷和50umol的解磷定。所有藥物均以外周靜脈用藥。所有動物均觀察48小時,記錄30分鐘,12342448小時的死亡率。分別於基礎狀態,30分鐘,24小時和48小時抽血測紅細胞乙酰膽鹼酯酶。除了第7組死亡出現較晚,其餘組死亡主要集中在對氧磷用藥後30分鐘,而此後變化甚小。甲氧氯普胺,泰必利和解磷定組30分鐘時的死亡率幾乎為0,對氧磷組為73±20,對氧磷和甲氧氯普胺組為65±15,對氧磷和泰必利組為38±14,對氧磷和解磷定組為13±1948小時時,死亡率在對氧磷組為75±18,對氧磷和甲氧氯普胺組為67±17,對氧磷和泰必利組為42±16,對氧磷和解磷定組為27±24。在急性大劑量對氧磷中毒後,甲氧氯普胺對死亡率無明顯影響。泰必利與解磷定均能明顯降低死亡率。30分鐘時泰必利的保護作用較解磷定弱,但在48小時時兩者無顯著差異。

(忻紀華 陳傑 校)

Weak and reversible inhibitors of cholinesterase(s), when coadministered in excess with a more potent inhibitor such as organophosphates, can act in a protective manner. The benzamide compound, metoclopramide, confers some protection (putatively via this mechanism) for cholinesterases against inhibition by paraoxon both in vitro and in vivo, after chronic small-dose exposure. Tiapride is a related benzamide. In this study, we compared the protection by metoclopramide and tiapride in rats acutely exposed to large doses of paraoxon with the therapeutic "gold standard," pralidoxime. Group 1 received 1 µmol paraoxon (approximately 75% lethal dose), Group 2 received 50 µmol metoclopramide, Group 3 received 50 µmol tiapride, Group 4 received 50 µmol pralidoxime, Group 5 received 1 µmol paraoxon + 50 µmol metoclopramide, Group 6 1 µmol paraoxon + 50 µmol tiapride, and Group 7 1 µmol paraoxon + 50 µmol pralidoxime. All substances were administered intraperitoneally. The animals were monitored for 48 h and mortality was recorded at 30 min, 1, 2, 3, 4, 24, and 48 h. Blood was taken for red blood cell acetylcholinesterase measurements at baseline, 30 min, 24, and 48 h. With the exception of Group 7, in which some late mortality was observed, mortality occurred mainly in the first 30 min after paraoxon administration with minimal changes occurring thereafter. Mortality at 30 min was 0% in the metoclopramide, tiapride, and pralidoxime groups and 73 ± 20 (paraoxon), 65 ± 15 (paraoxon + metoclopramide), 38 ± 14 (paraoxon + tiapride), and 13 ± 19 (paraoxon + pralidoxime). Mortality at 48 h was 75 ± 18 (paraoxon), 67 ± 17 (paraoxon + metoclopramide), 42 ± 16 (paraoxon + tiapride), and 27 ± 24 (paraoxon + pralidoxime). Metoclopramide does not significantly influence mortality after acute large-dose paraoxon exposure. Both tiapride and pralidoxime significantly decreased mortality in our model. The protection conferred by tiapride was significantly less than that conferred by pralidoxime at 30 min, but was not significantly different at 24 and 48 h.

 

異氟醚麻醉期間CO2通過中樞而非外周途徑抑制F

Carbon Dioxide Depresses the F Wave by a Central, Not Peripheral, Mechanism During Isoflurane Anesthesia

Carmen Dominguez, MD*, Earl Carstens, PhD{dagger}, and Joseph F. Antognini, MD*{dagger}

*Department of Anesthesiology and Pain Medicine and {dagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis

Anesth Analg 2005 100: 398-403.

 

二氧化碳(CO2)具有麻醉特性並有報導稱抑制誘發肌電圖的F波,F波被認為代表運動神經元的興奮性。麻醉藥如異氟醚也會抑制F波。因為CO2能抑制肌肉收縮功能和脊髓神經元,現在還不清楚CO2抑制F波是通過中樞途徑還是外周途徑。作者使用異氟醚(1.4%)麻醉兔子,準備後肢轉流(使用膜性氧合器),籍此獲得後肢肌肉和軀幹的CO2分壓可以單獨調整。記錄後肢和軀幹的CO2均正常時,下肢或軀幹CO2升高({approx}90 mm Hg)時,下肢和軀幹CO2都升高時({approx}90 mm Hg)腳底肌肉的F波。結果顯示只有後肢CO2的升高時對F波的振幅沒有顯著影響,而軀幹CO2的升高會使F波降低52%±32%。當軀幹低碳酸血症時增加後肢的CO2並不會導致額外的F波降低。因此,CO2抑制F波是通過中樞而非外周途徑,但確切機制仍不清楚。

(殷文淵 譯 陳傑 校)

Carbon dioxide (CO2) has anesthetic properties and has been reported to depress the F wave of the evoked electromyogram; the F wave is thought to reflect motoneuron excitability. Anesthetics such as isoflurane also depress the F wave. Because CO2 can depress muscle contractile function, as well as spinal cord neurons, it is unclear whether CO2 depresses the F wave via a central or peripheral mechanism. We anesthetized rabbits with isoflurane (1.4%) and prepared for hindlimb bypass (with a membrane oxygenator) whereby the partial pressures of CO2 in the hindlimb muscle and torso could be independently adjusted. The F wave was recorded from the hindlimb plantar muscles when the CO2 was normal to the hindlimb and torso, and when it was increased (to {approx}90 mm Hg) in the hindlimb, the torso, or both. Increasing the CO2 to just the hindlimb had no significant effect on the F-wave amplitude, but increasing the CO2 to the torso depressed the F wave to 52% ± 32% of control; adding CO2 to the hindlimb during torso hypercarbia did not result in any additional depression of the F wave. CO2 depressed the F wave via a central, not peripheral, mechanism, although the precise mechanism is unknown.

 

離體脊髓的吸入麻醉藥洗出過程中高反應性與乙醇清除的比較

Hyperresponsiveness on Washout of Volatile Anesthetics from Isolated Spinal Cord Compared to Withdrawal from Ethanol

Shirley M.E. Wong, MSc, Sarah M. Sweitzer, PhD{dagger}, Michael C. Peters, BS, and Joan J. Kendig, PhD

Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2005 100: 413-436.

 

作者用新生鼠游離的脊髓進行實驗,研究吸入麻醉藥氟烷和異氟烷(1MAC)的清除過程中觀察到的群集興奮性誘發電位(pEPSP)與麻醉濃度的乙醇相比反應性較高的機制。暴露於每一種麻醉藥30min並洗出,pEPSP面積增加,顯著高於對照水平(P < 0.01-0.001)。相同時間內持續暴露於極小濃度(0.025MAC)的異氟烷,pEPSP增大程度相似 (P < 0.05)。提示這種現象是洗出過程中低濃度麻醉藥引起的直接興奮效應,不同於乙醇的真正清除過程。異氟烷而不是氟烷能顯著增加鉀刺激引起的興奮性神經遞質谷氨酸、天冬氨酸和P物質的釋放,提示對該藥物的高反應性是突觸前介導的遞質釋放增加的結果。一種廣譜的特殊蛋白激酶C抑制劑GF109203X阻斷乙醇清除過程中的高反應性,但不能阻斷氟烷洗出過程的高反應性。如果麻醉後行為症狀的出現是以類似於脊髓觀察到的興奮性為基礎,這些結果就顯示它們反映直接興奮作用,而不是清除過程。是由於對離子通道或受體的直接作用,而不是蛋白激酶C介導的間接效應。

(趙延華 譯 陳傑 校)

We performed experiments in spinal cords isolated from neonatal rats to probe the mechanisms responsible for hyperresponsiveness of the population excitatory evoked potential (pEPSP) observed on washout of the volatile anesthetics halothane and isoflurane (1 minimal alveolar anesthetic concentration equivalent, MAC) compared with that observed after an anesthetic concentration of ethanol. After 30 min exposure to each anesthetic and washout, pEPSP area increased to levels significantly more than control (P < 0.01–0.001). Exposure to a very small (0.025 MAC) concentration of isoflurane over the same period itself produced a similarly exaggerated pEPSP (P < 0.05) in the continued presence of the drug, suggesting that the phenomenon is a direct excitatory effect of the small concentrations of anesthetic on washout, unlike the true withdrawal observed with ethanol. Isoflurane, but not halothane, significantly increased the amount of potassium-stimulated release of the excitatory neurotransmitters glutamate, aspartate, and substance P, suggesting the hyperresponsiveness for that drug is the result of a presynaptically mediated increase in transmitter release. A broad spectrum specific protein kinase C inhibitor, GF109203X, blocked ethanol withdrawal hyperresponsiveness but not hyperresponsiveness after halothane. If the behavioral symptoms of emergence from anesthesia are based on excitatory actions similar to those observed in the spinal cord, the results show that they represent direct excitatory actions rather than withdrawal and are attributable to direct actions on ion channels or receptors, rather than indirect effects mediated by protein kinase C.

 

血紅蛋白氧載體(Oxyglobin®Hemopure®HemolinkTM)對乳酸測定的干擾

Lactate Measurement Interference by Hemoglobin-Based Oxygen Carriers (Oxyglobin®, Hemopure®, and HemolinkTM)

Jonathan S. Jahr, MD, Stephen Osgood, MD, Stephen J. Rothenberg, PhD, Qiao-Ling Li, MD, PhD, Anthony W. Butch, PhD, Robert Gunther, PhD, Anthony Cheung, PhD, and Bernd Driessen, DVM, PhD

Departments of Anesthesiology and Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, and Department of Anesthesiology, Charles R. Drew University of Medicine and Science, Martin Luther King, Jr./Drew Medical Center, Los Angeles, California; Johns Hopkins University School of Medicine, Baltimore, Maryland; National Institute of Public Health, Cuernavaca, Mexico; Departments of Surgery and Medical Pathology, UC Davis School of Medicine; and Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania

Anesth Analg 2005 100: 431-436

 

作者研究血紅蛋白氧載體(HBOCs)、小牛血紅蛋白-200(HBOC-200Oxyglobin®)、小牛血紅蛋白-250HBOC-201, Hemopure®)和hemolinktTM是否干擾乳酸鹽測定的準確性。濃縮的左旋乳酸鹽溶液、HBOC 和全血或是加了PlasmaLYte-ATM 血漿的混合物加到樣管裏做成濃度線性而持續增加的連續乳酸鹽濃縮液樣品。乳酸鹽樣品濃度範圍在5~110mg/dl(0.6-12mm)〔生理參考範圍:5-20mg/ml0.56-2.2mm) ]。將乳酸鹽濃度的儀器測量值與計算值做比較。小牛血紅蛋白-250乳酸鹽濃度的測量值與計算值之間平均相差-5.1mg/dl(-0.51mm)(LX-20),乳酸鹽濃度越高的時候兩個值相差越大。hemolinktTM組測量值與計算值之間平均相差-2.2mg/dl(-0.24mm)(LX-20)。獸醫產品,小牛血紅蛋白-200在三台分析儀(LX-20YSI 1500YSI 2300)上檢測。YSI1500測得的值減去計算值的差值平均是+1.3mg/dl,相對於YSI2300 (差值為-2.6mg/dl)LX-20l(差值為-8.4mg/d)來說最精確。這項研究的臨床意義在於隨著血漿中HBOC水平的增加,乳酸鹽濃度的判斷將變得不準確,尤其是在乳酸鹽濃度較高的時候,這將導致低估乳酸鹽測量價值和對病人的處理不足。因此,當血漿中混有HBOC時解釋乳酸鹽濃度測量值時需慎重。

(朱輝 譯 陳傑 校)

We sought to determine whether hemoglobin-based oxygen carriers (HBOCs), hemoglobin glutamer-200 [bovine] (HBOC-200, Oxyglobin®), hemoglobin glutamer-250 [bovine] (HBOC-201, Hemopure®), and hemoglobin raffimer (HemolinkTM) interfere with the accuracy of lactate measurements. Combinations of concentrated L-lactate solution, HBOC, and blood or plasma with added PlasmaLyte-ATM were added to sample tubes to make a linear and constant increase in lactate concentration in consecutive samples. Sample lactate concentrations ranged from 5–110 mg/dL (0.6–12 mm) (physiological reference range: 5–20 mg/dL [0.56–2.2 mm]). Comparisons were made between machine measured lactate concentrations and calculated lactate concentrations. For Hb glutamer-250, the average difference between measured and calculated lactate concentrations was –5.1 mg/dL (–0.57 mm) (LX-20®), with greater underestimation at larger lactate concentrations. For Hb raffimer, the average difference was –2.2 mg/dL (–0.24 mm) (LX-20®). The veterinary product, Hb glutamer-200, was tested on 3 analyzers (LX-20®, YSI 1500, and YSI 2300). The YSI 1500 was the most accurate instrument with the mean difference between measured minus calculated lactate being +1.3 mg/dL versus –2.6 mg/dL (YSI 2300) and –8.4 mg/dL (LX-20®). The clinical implications of this study are that with increasing levels of an HBOC in plasma, lactate interpretation may become inaccurate, especially at larger lactate concentrations, causing underestimation of measured lactate values and possible under-treatment of the patient. Therefore, caution must be exercised when interpreting lactate results when a HBOC is present in plasma.

 

圍術期聯合使用右美沙芬和靜脈利多卡因對腹腔鏡膽囊手術後疼痛的緩解和腸功能恢復的影響

The Interaction Effect of Perioperative Cotreatment with Dextromethorphan and Intravenous Lidocaine on Pain Relief and Recovery of Bowel Function After Laparoscopic Cholecystectomy

Ching-Tang Wu, MD*, Cecil O Borel, MD, Meei-Shyuan Lee, MPH{ddagger}, Jyh-Cherng Yu, MD{dagger}, Hang-Seng Liou, MD§, Haun-De Yi, MD||, and Chih-Ping Yang, MD||

Department of *Anesthesiology and {dagger}General Surgery, Tri-Service General Hospital; {ddagger}Department of Public Health, National Defense Medical Center, National Defense University, Taipei; Division of §Obstetrics and Gynecology and ||Anesthesiology, Armed Forces Taoyuan General Hospital, Taiwan, Republic of China; and ¶Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2005 100: 448-453.

 

右美沙芬(DM)和利多卡因都可改善術後疼痛。在這項研究中,作者評估了腹腔鏡膽囊手術(LC)後使用右美沙芬和靜注利多卡因鎮痛的相互作用。100ASAⅠ-Ⅱ級擇期行LC的患者隨機分成四組:(a)肌注馬來酸撲爾敏(CPM20mg和靜注正常生理鹽水(C組);(b) 肌注DM40mg和靜注正常生理鹽水(DM)(c) 肌注CPM20mg和靜注利多卡因3mg·kg-1·h-1L組)(d) 肌注DM40mg和靜注利多卡因(DM+L組)。所有的注藥都在切皮前30分鐘進行。根據休息和咳嗽時視覺疼痛評分,使用度冷丁的次數和劑量以及術後第一次排氣的時間等指標評估鎮痛效果。結果DM+L組的患者鎮痛效果最好,腸功能恢復最快。DML組的患者緩解疼痛的效果明顯好於C組的患者。結果表明腹腔鏡膽囊手術後聯合使用DM和靜注利多卡因可增強鎮痛效果並對腸功能恢復有協同作用。

(朱輝 譯 陳傑 校)

Both dextromethorphan (DM) and IV lidocaine improve postoperative pain relief. In the present study, we evaluated the interaction of DM and IV lidocaine on pain management after laparoscopic cholecystectomy (LC). One-hundred ASA physical status I or II patients scheduled for LC were randomized into four equal groups to receive either: (a) chlorpheniramine maleate (CPM) intramuscular injection (IM) 20 mg and IV normal saline (N/S) (group C); (b) DM 40 mg IM and IV N/S (group DM); (c) CPM 20 mg IM and IV lidocaine 3 mg · kg–1 · h–1 (group L); or (d) DM 40 mg IM and IV lidocaine (group DM+L). All treatments were administered 30 min before skin incision. Analgesic effects were evaluated using visual analog scale pain scores at rest and during coughing, time to meperidine request, total meperidine consumption, and the time to first passage of flatus after surgery. Patients of the DM+L group exhibited the best pain relief and fastest recovery of bowel function among groups. Patients in the DM and L groups had significantly better pain relief than those in the C group. The results showed an additional effect on pain relief and a synergistic effect on recovery of bowel function when DM was combined with IV lidocaine after LC.

 

術後患者使用曲馬多和嗎啡的半數有效量:一項相互作用的研究

The Median Effective Dose of Tramadol and Morphine for Postoperative Patients: A Study of Interactions

Thi Aurore Marcou, MD, Sophie Marque, MD, Jean-Xavier Mazoit, MD, PhD, and Dan Benhamou, MD

Department of Anesthesiology, Hôpital Bicętre, Assistance Publique-Hôpitaux de Paris, F-94275 Le Kremlin-Bicętre and Anesthesia Laboratory UPRES EA 3540, Faculté de Médecine du Kremlin-Bicętre, Université de Paris-Sud, F-94276 Le Kremlin-Bicętre, France

Anesth Analg 2005 100: 469-474.

 

曲馬多是一中樞性止痛劑。在一項採用含小量嗎啡的有效平衡鎮痛技術的研究中,作者使用等輻射分析法研究曲馬多、嗎啡和聯合使用的半數有效量(ED50 ),以此來判定其交互作用。這項雙盲、隨機、兩階段的前瞻性研究中,90個術後患者分為3組。每一個患者使用的曲馬多和嗎啡的劑量由上下分配技術決定。在曲馬多組和嗎啡組的起始劑量分別為100mg5mg,每次增加的劑量分別為10mg1mg。在第二階段,曲馬多和嗎啡的使用劑量的比例為403。疼痛評分(010)小於或等於3為有效鎮痛的閾值。然後使用等輻射分析法。曲馬多和嗎啡的ED50分別為86 mg 5.7 mg95%的可信區間分別為57–115 mg4.2–7.2 mg 。聯合使用時曲馬多的ED5072 mg95%的可信區間為6282mg,嗎啡的ED505.4 mg95%的可信區間為46.2mg。聯合使用曲馬多和嗎啡的效果弱於其相加作用,因此不建議用於術後鎮痛。

(朱玫娟 譯 陳傑 校)

Tramadol is a centrally-acting analgesic drug. In a search of an effective balanced analgesia technique with a morphine-sparing component, we studied the median effective analgesic doses (ED50) of tramadol, morphine, and their combination to determine the nature of their interaction using an isobolographic analysis. In this double-blind, randomized, two-stage prospective study, 90 postoperative patients were enrolled in one of three groups. The dose of tramadol and morphine received by a particular patient was determined using an up-down allocation technique. Initial doses and increments were, respectively, 100 mg and 10 mg in the tramadol group and 5 mg and 1 mg in the morphine group. In the second part, a 40:3 tramadol:morphine dosing ratio was used. The threshold of effective analgesia was defined as 3 or less on a numerical pain score (0–10). Isobolographic analysis was subsequently applied. The ED50 values (95% confidence interval) of tramadol and morphine were, respectively, 86 mg (57–115 mg) and 5.7 mg (4.2–7.2 mg). The ED50 of the combination was 72 mg (62–82 mg) for tramadol and 5.4 mg (4–6.6.2 mg) for morphine. The combination of tramadol and morphine was infra-additive and thus not recommended for postoperative analgesia.

 

一個作為資料收集平臺面向多中心研究的網站

An Internet Web Site as a Data Collection Platform for Multicenter Research

Alexander Avidan, MD, Charles Weissman, MD, and Charles L. Sprung, MD

Department of Anesthesiology and Critical Care Medicine, Hadassah - Hebrew University Medical Center, Jerusalem, Ein Karem, POB 12000, Jerusalem, 91120, Israel

Anesth Analg 2005 100: 506-511.

對於多中心的研究來說,互聯網是一個有效的資料收集的選擇。相比傳統的諸如使用紙張或傳統信件的方式來說,具有很大的優勢。作者創建了一個網站,為多中心的有關倫理決策研究收集資料。這個網站採用Microsoft FrontPage做為編輯工具。採用Microsoft Access處理資料庫。在網站設計上,安全性問題是最受到關心的。歐洲37個中心近一年半中4248個患者使用這個網站。利用網站收集資料是非常高效的,調查者不需要接受訓練就可以使用。使用者的總體滿意率較高。除了安全性問題以外,可交互性與用戶友善的設計是這個系統獲得成功的基石。

(朱玫娟 譯 陳傑 校)

The Internet can be an effective alternative for data collection for multicenter studies. It has major advantages over the "classical" method of using paper and traditional ("snail") mail. We developed an Internet site and implemented collection of data for a multicenter study of ethical decision-making. The Web site was built with Microsoft FrontPage as the authoring tool. Database management was performed with Microsoft Access. Security issues were the major concerns for the web design. Thirty-seven European centers enrolled 4248 patients during 1.5 yr using the Internet site. The use of this Internet site for data acquisition was highly effective, and the investigators were able to use the system without training. Overall satisfaction of the investigators was high. After security issues, interactivity and user-friendly design are the main cornerstones for the success of such a system.

 

危重病中指導營養支持實驗的實際方法學質量的回顧:有待提高

A Review of the True Methodological Quality of Nutritional Support Trials Conducted in the Critically Ill: Time for Improvement

Gordon S. Doig, PhD, Fiona Simpson, MSc, and Anthony Delaney, MBBS

From the Northern Clinical School, University of Sydney, Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia, the Department of Nutrition, Royal North Shore Hospital, Sydney, Australia and Foothills Medical Centre, Calgary, Alberta, Canada

Anesth Analg 2005 100: 527-533.

 

在這個綜述中,作者試圖評價危重症病人中進行的營養支持實驗的實際方法的質量,並將這些結果同膿毒血症試驗的方法相比較。大範圍的文獻檢索顯示有111篇危重病人中進行營養支持干預對臨床預後影響的隨機、對照實驗文獻。與膿毒血症試驗相比較,營養支援試驗似乎較少使用盲法(營養支援實驗35 /111;膿毒血症試驗32 / 40, P < 0.001)或缺少意向治療分析((營養支援實驗64 /111;膿毒血症試驗37 / 40, P < 0.001)。較少使用隨機方法(營養支援實驗19 / 111;膿毒血症試驗12 / 40 versus, P = 0.010),而眾所周知這可以保持分配的隱密性。雖然1996年公佈配對聲明後營養支持研究中使用盲法有所增加(公佈前9 /47 ;公佈後 26 / 64, P = 0.023),但在其他關鍵領域中並沒有改善。先前的聲明中描述所有的膿毒血症試驗的方法質量為。但營養支持研究在方法質量上所有方面都顯著差於膿毒血症試驗,且隨著時間的推移鮮有改善。 如果試圖在危重病醫學發現具有富有意義的臨床預後的差異,未來研究的方法質量必須改進。

殷文淵 陳傑 校)

In this review we sought to appraise the true methodological quality of nutritional support studies conducted in critically ill patients and to compare these findings to the methodological quality of sepsis trials. An extensive literature search revealed 111 randomized controlled trials conducted in critically ill patients evaluating the impact of nutritional support interventions on clinically meaningful outcomes. Compared with sepsis trials, nutritional support studies were significantly less likely to use blinding (32 of 40 versus 35 of 111, P < 0.001) or present an intention-to-treat analysis (37 of 40 versus 64 of 111, P < 0.001). There was a trend toward the less frequent use of randomization methods that are known to maintain allocation concealment (12 of 40 versus 19 of 111, P = 0.10). Although nutritional support studies demonstrated a significant increase in the use of blinding after the publication of the CONSORT statement in 1996 (9 of 47 versus 26 of 64 post-CONSORT, P = 0.023), there were no improvements in other key areas. Previous publications have described the overall methodological quality of sepsis trials as "poor." Nutritional support studies were significantly worse than sepsis trials in all aspects of methodological quality, and there were few improvements noted over time. To detect important differences in clinically meaningful outcomes in critical care, the methodological quality of future studies must be improved.

\2-氯普魯卡因脊髓麻醉:複合可樂定的效果

Spinal 2-Chloroprocaine: The Effect of Added Clonidine

Brad R. Davis, MD, and Dan J. Kopacz, MD

Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington

Anesth Analg 2005 100: 559-565

 

2-氯普魯卡因(2CP)是一種短效的脊髓麻醉藥。可樂定能夠增加布比卡因和羅呱卡因的麻醉效果,但在常規劑量(12ug/Kg)下可產生全身副反應。目前,還沒有關於2-氯普魯卡因複合可樂定的試驗研究。在這個隨機雙盲交叉試驗研究中,作者選擇8個志願者,比較2-氯普魯卡因(30mg)複合可樂定(15ug)和單獨應用2-氯普魯卡因(30mg)的麻醉效果。在研究中對志願者進行針刺疼痛,運動力量,對電刺激和大腿止血帶耐受性以及行走恢復時間的評估。2CP組和2CP複合可樂定組的最高阻滯平面相似,分別為T8(阻滯範圍為T6L2)和T8(阻滯範圍為T4T11)(P0.57)。複合可樂定組L1感覺阻滯時間延長(51 ± 23 分鐘比 76 ± 11 分鐘;P = 0.002),感覺阻滯完全衰退時間延長(99 ± 18 分鐘比131 ± 15 分鐘;P = 0.001)。複合可樂定組下肢運動阻滯時間增加(恢復至Bromage評分基線水平的時間:65 ± 13 min 79 ± 19 min, P = 0.004;腓腸肌力量恢復 90% P = 0.003)。可樂定增加志願者對止血帶耐受時間從33分鐘增加至45分鐘(P = 0.06),志願者恢復行走的時間,自主排泄和出院的時間也相應延長(均為99 ± 18 分鐘比 131 ± 15 分鐘; P = 0.001),兩組志願者在血流動力學改變上無明顯差異,且均無暫時的局部神經主訴症狀出現。本研究認為小劑量可樂定可增加2CP脊髓麻醉阻滯時間和麻醉效果且無全身副反應。

(齊波 譯 陳傑 校)

Preservative-free 2-chloroprocaine (2-CP) is being investigated for short-acting spinal anesthesia. Clonidine improves the quality of spinal bupivacaine and ropivacaine, but in traditional doses (1–2 µg/kg) it produces systemic side effects. It has not been studied in combination with 2-CP. In this double-blind, randomized crossover study, we compared spinal 2-CP (30 mg) with and without clonidine (15 µg) in eight volunteers. Pinprick anesthesia, motor strength, tolerance to electrical stimulation and thigh tourniquet, and time to ambulation were assessed. Peak block height was similar between 2-CP (T8 [range, T6 to L2]) and 2-CP with clonidine (T8 [range, T4 to T11]) (P = 0.57). Sensory anesthesia was prolonged with clonidine at L1 (51 ± 23 min versus 76 ± 11 min; P = 0.002), as was complete block regression (99 ± 18 min versus 131 ± 15 min; P = 0.001). Lower extremity motor blockade was increased with clonidine (return to baseline Bromage score: 65 ± 13 min versus 79 ± 19 min, P = 0.004; return to 90% gastrocnemius strength: P = 0.003). Clonidine increased tourniquet tolerance from 33 to 45 min (P = 0.06) and increased time to ambulation, spontaneous voiding, and discharge (99 ± 18 min versus 131 ± 15 min for all; P = 0.001). There were no differences in hemodynamic measurements, and no subject reported transient neurologic symptoms. We conclude that small-dose clonidine increases the duration and improves the quality of 2-CP spinal anesthesia without systemic side effects.

 

全麻誘導期間應用呼吸末正壓通氣可增加病態肥胖病人呼吸暫停而無低氧的持續時間

Positive End-Expiratory Pressure During Induction of General Anesthesia Increases Duration of Nonhypoxic Apnea in Morbidly Obese Patients

Sylvain Gander, MD*, Philippe Frascarolo, PhD*, Michel Suter, MD{dagger}, Donat R. Spahn, MD*, and Lennart Magnusson, MD, PhD*

Departments of *Anesthesiology and {dagger}Surgery, University Hospital, Lausanne, Switzerland Anesth Analg 2005 100: 580-584.

 

在全麻誘導期間應用呼吸末正壓通氣(PEEP)可以防止肺不張形成,並增加非肥胖病人呼吸暫停而無低氧的持續時間。PEEP也可以防止病態肥胖病人的肺不張。因為病態肥胖病人發生困難氣道處理的機會更多,且動脈血去氧飽和發展更迅速。本研究的目的是研究麻醉誘導過程中應用PEEP的臨床優點。三十名病態肥胖病人隨機分為兩組。PEEP組,病人先通過一個持續正壓氣道壓力裝置(10cmH­2O)吸入100%純氧,注入麻醉誘導藥物後,通過呼吸機給予PEEP10cmH­2O5分鐘至氣管插管。對照組誘導順序相同,但在誘導過程中不給予持續氣道正壓或PEEP。研究中測定病人SpO2下降到90%時的呼吸暫停持續時間,並在呼吸暫停前和Spo292%時進行動脈血氣分析。結果發現PEEP組病人無低氧情況的呼吸暫停時間較對照組延長(188 ± 46 127 ± 43 s P = 0.002)。PEEP組病人呼吸暫停前的PaO2較高(P = 0.038)。研究表明在全麻醉誘導過程中應用正壓通氣可將病態肥胖病人呼吸暫停而無低氧的持續時間增加50%

(齊波 譯 陳傑 校)

Positive end-expiratory pressure (PEEP) applied during induction of anesthesia prevents atelectasis formation and increases the duration of nonhypoxic apnea in nonobese patients. PEEP also prevents atelectasis formation in morbidly obese patients. Because morbidly obese patients have difficult airway management more often and because arterial desaturation develops rapidly, we studied the clinical benefit of PEEP applied during anesthesia induction. Thirty morbidly obese patients were randomly allocated to one of two groups. In the PEEP group, patients breathed 100% O2 through a continuous positive airway pressure device (10 cm H2O) for 5 min. After induction of anesthesia, they were mechanically ventilated with PEEP (10 cm H2O) for another 5 min until tracheal intubation. In the control group, the sequence was the same but without any continuous positive airway pressure or PEEP. We measured apnea duration until Spo2 reached 90% and we performed arterial blood gases analyses just before apnea and at 92% Spo2. Nonhypoxic apnea duration was longer in the PEEP group compared with the control group (188 ± 46 versus 127 ± 43 s; P = 0.002). Pao2 was higher before apnea in the PEEP group (P = 0.038). Application of positive airway pressure during induction of general anesthesia in morbidly obese patients increases nonhypoxic apnea duration by 50%.

開胸或內鏡技術行微創冠狀動脈旁路移植術時心肌壁節段性運動

Segmental Myocardial Wall Motion During Minimally Invasive Coronary Artery Bypass Grafting Using Open and Endoscopic Surgical Techniques

S. Mierdl, MD, C. Byhahn, MD, V. Lischke, MD, T. Aybek, MD, G. Wimmer-Greinecker, MD, S. Dogan, MD{dagger}, S. Viehmeyer, P. Kessler, MD, and Klaus Westphal, MD

Department of Anesthesiology, Intensive Care Medicine and Pain Control, Department of Thoracic and Cardiovascular Surgery, J.W. Goethe-University Hospital, Frankfurt, Germany

Anesth Analg 2005 Feb 100(2): 306-314.

 

目前對於單支冠狀動脈病變行微創外科治療的方法包括保持心跳、不用心肺轉流的微創開胸手術(MIDCAB)和使用心肺轉流、完全內鏡下機器人輔助的手術(TECAB)。在血運重建之前,這兩類手術中都可能存在潛在的引起心肌應激的因素,比如單肺通氣、暫時的冠脈阻斷、心臟脫位、胸內吹入CO2、長時間的心肺轉流和手術。在本次超聲心動圖的研究中我們通過評價節段性心肌運動的異常程度來分析微創開胸手術和內鏡下機器人輔助手術中的影響因素。我們研究了46個患有單支冠脈病變的病人,其中16位患者接受了微創開胸手術而其餘30位則行內鏡下機器人輔助手術。對這2組患者整個手術過程中間我們進行了持續的經食道超聲心動圖的監測,同時獲得了血流動力學和氧合的資料。在這2組病人手術中我們都可以觀察到輕微但是明顯的異常的節段性心肌壁運動,這種異常變化在內鏡下機器人輔助手術組尤為明顯。與手術的時間無關的是這些變化在血運重建後均完全消失,沒有觀察到明顯的血流動力學損害。因此我們認為微創開胸手術和內鏡下機器人輔助手術和圍手術期顯著的節段性異常心肌壁運動有關。與開胸組不同,內鏡下機器人輔助手術組病人出現了更加有意義的異常心肌壁運動,因為2組都使用了單肺通氣技術,所以這可能是胸內吹入CO2所致。2組患者都未出現永久性的異常心肌壁運動或心肺轉流後的異常心肌壁運動。內鏡下機器人輔助手術組出現了更加廣泛的異常心室壁運動,這一現象提示我們使用這種方法時可能存在更大的右心功能不全的風險。

(王 薛張綱 校)

Current options for minimally invasive surgical treatment of single-vessel coronary artery disease include beating heart procedures without cardiopulmonary bypass (CPB) via mini-thoracotomy (MIDCAB) and totally endoscopic robot-assisted techniques (TECAB) with CPB. Both procedures are associated with potential myocardial stress before revascularization, such as single-lung ventilation (SLV), temporary coronary artery occlusion, cardiac luxation, intrathoracic carbon dioxide insufflation, and extended CPB and operating time. In this echocardiographic study we sought to evaluate the extent of intraoperative segmental wall motion abnormalities (SWMA) during MIDCAB and TECAB surgery and to identify factors affecting SWMA. Forty-six patients with single-vessel coronary artery disease were studied. Sixteen patients were operated using the MIDCAB technique and 30 patients with TECAB. In both groups sequential transesophageal echocardiograms were recorded during the entire procedure. Hemodynamic data and oxygenation variables were acquired simultaneously. In both groups, mild but obvious perioperative SWMA were identified and noted to increase during the course of the operation. These SWMA were more pronounced in the TECAB group. Independent of operating time, these changes disappeared completely after revascularization. No significant hemodynamic compromise was observed. We conclude that MIDCAB and TECAB techniques are associated with significant perioperative SWMA. The appearance of more profound SWMA in the TECAB group compared with the MIDCAB patients might have been the result of intrathoracic CO2 insufflation, as SLV was used in both groups. No persistent SWMA or post-CPB SWMA were apparent in either group. More extensive intraoperative ventricular SWMA was detected in the TECAB group, suggesting that a more frequent risk for right ventricular dysfunction may exist during TECAB procedures.

 

非損傷性脊髓缺血後使用嗎啡所致脊髓運動神經元變性可能來源於脊髓N-甲基天冬氨酸受體的啟動

The Effect of Volatile Anesthetics on Respiratory System Resistance in Patients with Chronic Obstructive Pulmonary Disease

Manabu Kakinohana, MD, PhD*, Osamu Kakinohana, PhD{dagger}, Jong Hun Jun, MD, PhD{ddagger}, Martin Marsala, MD{dagger}, Kenneth J. Davison, MD§, and Kazuhiro Sugahara, MD, PhD*

*Department of Anesthesiology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan; {dagger}Department of Anesthesiology, University of California, San Diego, California; {ddagger}Department of Anesthesiology, Hanyang University College of Medicine, Seoul, Korea; and §Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts

Anesth Analg 2005 Feb 1002: 327-334.

 

我們研究了阻斷大鼠主動脈後神經軸索使用嗎啡引起的脊髓運動神經元變性和N-甲基天冬氨酸受體(NMDA)的啟動的關係。我們使用帶氣囊的導管阻斷主動脈6分鐘造成脊髓缺血。在微透析研究中,再灌注後30分鐘我們鞘內注射生理鹽水10µL(c組;n=8)和嗎啡30µg(M組;n=8),在假手術後30分鐘嗎啡30µg(SM組;n=8)和生理鹽水10µL(SC組;n=8)同樣被注射入鞘內。我們在缺血前、鞘內注射前和再灌注後2、4、8、24和48小時(鞘內注射後)收集了微透析樣本。第二,我們研究了嗎啡引起的痙攣性下肢癱瘓後鞘內注射MK-80130 µg)後的脊髓組織病理學改變。M組鞘內注射嗎啡後與基線和C組相比腦脊液中的谷氨酸鹽濃度升高(P<0.05),這一濃度升高持續了8小時。嗎啡引起的痙攣性下肢癱瘓後鞘內注射MK-801與注射生理鹽水相比減少了暗染的{alpha}-運動神經元的數量。這些資料表明鞘內注射嗎啡可導致痙攣性下肢癱瘓同時伴有腦脊液中谷氨酸鹽的濃度升高,後者參與了NMDA受體的啟動。因此我們認為在脊髓缺血的情況下嗎啡可以通過啟動NMDA受體產生神經毒性。

(王 薛張綱 校)

We investigated the relationship between the degeneration of spinal motor neurons and activation of N-methyl-d-aspartate (NMDA) receptors after neuraxial morphine following a noninjurious interval of aortic occlusion in rats. Spinal cord ischemia was induced by aortic occlusion for 6 min with a balloon catheter. In a microdialysis study, 10 µL of saline (group C; n = 8) or 30 µg of morphine (group M; n = 8) was injected intrathecally (IT) 0.5 h after reflow, and 30 µg of morphine (group SM; n = 8) or 10 µL of saline (group SC; n = 8) was injected IT 0.5 h after sham operation. Microdialysis samples were collected preischemia, before IT injection, and at 2, 4, 8, 24, and 48 h of reperfusion (after IT injection). Second, we investigated the effect of IT MK-801 (30 µg) on the histopathologic changes in the spinal cord after morphine-induced spastic paraparesis. After IT morphine, the cerebrospinal fluid (CSF) glutamate concentration was increased in group M relative to both baseline and group C (P < 0.05). This increase persisted for 8 hrs. IT MK-801 significantly reduced the number of dark-stained {alpha}-motoneurons after morphine-induced spastic paraparesis compared with the saline group. These data indicate that IT morphine induces spastic paraparesis with a concomitant increase in CSF glutamate, which is involved in NMDA receptor activation. We suggest that opioids may be neurotoxic in the setting of spinal cord ischemia via NMDA receptor activation.

 

揮發性麻醉藥對慢性阻塞性肺患者呼吸道阻力的影響

The Effect of Volatile Anesthetics on Respiratory System Resistance in Patients with Chronic Obstructive Pulmonary Disease

C. A. Volta, MD, V. Alvisi, MD, S. Petrini, MD, S. Zardi, MD, E. Marangoni, MD, R. Ragazzi, MD, M. Capuzzo, MD, and R. Alvisi, MD

Department of Surgical, Anesthesiological and Radiological Science, Section of Anesthesia and Intensive Care, S. Anna Hospital, University of Ferrara, Ferrara, Italy

Address correspondence and reprint requests to Carlo Alberto Volta, MD, Department of Surgical, Anesthesiological and Radiological Science, Section of Anesthesia and Intensive Care, S. Anna Hospital, University of Ferrara, Corso Giovecca 203, 44100

Anesth Analg 2005 Feb 1002: 348-353.

 

我們研究了異氟烷和七氟醚對於慢性阻塞性肺病(COPD)患者呼吸道阻力(Rmin,rs)的影響,COPD的診斷依靠呼吸道存在阻塞,這種阻塞在使用支氣管擴張藥物治療後僅是部分可逆的。我們連續選擇接受胸外科手術的周圍型肺癌的96位患者。這些患者被分成2組:術前第一秒用力肺活量/用力肺活量<70%>70%。在麻醉維持5分鐘和10分鐘後,我們使用持續氣流/快速阻斷的方法來測量呼吸道的阻力。麻醉維持隨機使用硫賁妥鈉0.30 mg.kg–1.min–1或者呼氣末1.1MAC的異氟烷或七氟醚。11位患者被排除在研究之外:其中2位誤用異丙酚誘導,9位患者因為氣管導管位置不當。使用揮發性麻醉藥維持麻醉的病例能夠降低COPD患者的氣道阻力而硫賁妥鈉卻不能。COPD患者中對於揮發性麻醉藥無反應的百分比也較正常人要大。因此我們的結論是:異氟烷或七氟醚能夠對COPD患者產生支氣管擴張作用。

(王 薛張綱 校)

We examined the effect of isoflurane and sevoflurane on respiratory system resistance (Rmin,rs) in patients with chronic obstructive pulmonary disease (COPD). The diagnosis of COPD rests on the presence of airway obstruction, which is only partially reversible after bronchodilator treatment. Ninety-six consecutive patients undergoing thoracic surgery for peripheral lung cancer were enrolled. They were divided into two groups: preoperative forced expiratory volume in 1 s/forced vital capacity ratio <70% or >70%. Rmin,rs was measured after 5 and 10 min of maintenance anesthesia by using the constant flow/rapid occlusion method. Maintenance of anesthesia was randomized to thiopental 0.30 mg · kg–1 · min–1 or 1.1 minimum alveolar anesthetic concentration end-tidal isoflurane or sevoflurane. Eleven patients were excluded: two because anesthesia was erroneously induced with propofol and nine because of an incorrect tube position. Maintenance with thiopental failed to decrease Rmin,rs, whereas both volatile anesthetics were able to decrease Rmin,rs in patients with COPD. The percentage of patients who did not respond to volatile anesthetics was larger in those with COPD as well. In conclusion, we have demonstrated that isoflurane and sevoflurane produce bronchodilation in patients with COPD.

 

道拉西酮和樞複寧治療術後噁心嘔吐的比較

Dolasetron versus ondansetron for the treatment of postoperative nausea and vomiting.

Meyer TA, Roberson CR, Rajab MH, Davis J, McLeskey CH.
Department of Pharmacy, Scott & White Memorial Hospital, 2401 S. 31st Street, Temple, TX 76508, USA.

Anesth Analg. 2005 Feb;100(2):373-7

 

術後噁心嘔吐(PONV)仍是難以處理的問題。儘管預防性給予止吐藥,(術後)劇烈的噁心嘔吐仍然經常發生。目前,還沒有有關道拉西酮和樞複寧治療術後噁心嘔吐的療效比較的研究公開發表。這是一個對成年門診手術病人進行的前瞻性的隨機雙盲的對照研究。我們從連續559名成年手術病人中篩選92名,隨機給予道拉西酮和樞複寧。本研究的目的:1) 探明對於白天手術的病人,給予樞複寧4 mg或道拉西酮12.5 mg靜脈注射,哪一種治療PONV的療效更好;2)比較兩種藥物治療PONV的成本。使用樞複寧的47名病人中,有33人(70%)需要追加藥物,而使用道拉西酮的45名病人中,只有18人(40%)需要追加藥物(P<0.004)。使用道拉西酮比使用樞複寧要便宜近40%,而且,在追加使用止吐藥產生的費用中,使用道拉西酮的病人要比使用樞複甯的病人節約30%。由於較少需要追加用藥,可認為道拉西酮具有更好的止吐治療效果。因為在本醫院追加用藥的較少和藥物較便宜,使用道拉西酮組的病人所需費用比使用樞複甯組的病人要少。

(金 薛張剛 校)

The management of postoperative nausea and vomiting (PONV) remains a persistent problem. Despite the use of prophylactic antiemetics, breakthrough nausea and vomiting still frequently occur. There have been no published studies comparing dolasetron and ondansetron for the treatment of PONV. This was a prospective, randomized, double-blind, active-controlled study in adult outpatient surgery patients. We screened 559 consecutive adult surgery patients, with 92 patients randomized to either ondansetron or dolasetron. The objectives of the study were 1) to determine whether treatment of PONV with ondansetron 4 mg IV or dolasetron 12.5 mg IV would result in better outcomes in patients undergoing day surgery and 2) to compare the cost of drugs used for treating PONV. Thirty-three (70%) of 47 patients given ondansetron required rescue medication, compared with 18 (40%) of 45 patients given dolasetron (P < 0.004). Dolasetron was approximately 40% less expensive than ondansetron, and the costs of the study drug plus rescue antiemetics were 30% less in the dolasetron group than in the ondansetron group. Dolasetron provided greater efficacy for antiemetic treatment because of the need for less rescue therapy. Because of the decreased use of rescue antiemetics and acquisition cost at our hospital, costs in the dolasetron group were less than costs in the ondansetron group.

 

順式阿曲庫銨在眼咽肌營養不良患者的藥效動力學

Cisatracurium pharmacodynamics in patients with oculopharyngeal muscular dystrophy.

Caron MJ, Girard F, Girard DC, Boudreault D, Brais B, Nassif E, Chouinard P, Ruel M, Duranceau A.
Department of Anesthesiology, Centre Hospitalier de l'Universite de Montreal, Hopital Notre-Dame, 1560 Sherbrooke E., Montreal, Quebec, Canada H2L 4M1.
Anesth Analg. 2005 Feb;100(2):393-7.

 

肌松藥在眼咽型肌營養不良症(OPMD)患者體內的藥效動力學尚未有專門研究。我們設計了本研究,比較順式阿曲庫銨在OPMD患者和對照組中的藥效動力學。選取40名病人:20名需在全麻下行咽肌環形切開術的病人和20名手術時間和失血量相仿、年齡相近的對照病人。麻醉方式標準化,每組病人都推注0.1mg/kg的順式阿曲庫銨。每組病人記錄起效時間、至T1恢復10%時間以及T1恢復10%-25%25%-75%的間隔時間。對OPMD患者按疾病不同嚴重程度進一步作分析,統計結果和手術過程中的資料都相似。和對照組相比,OPMD患者用藥後的起效時間明顯延長(4.6+/-1.5 min3.4 +/- 1.0 minP = 0.001)。在不同組別之間,儘管疾病的嚴重程度不同,恢復時間或指數沒有差異。結論,在OPMD患者和對照組中,順式阿曲庫銨產生的神經肌肉阻滯過程沒有差別,在OPMD患者中藥物起效延遲可能存在。

(金 薛張剛 校)

The pharmacodynamics of muscle relaxants in patients with oculopharyngeal muscular dystrophy (OPMD) have never been studied. We designed this study to compare the pharmacodynamics of cisatracurium in OPMD patients versus a control group. Forty patients were enrolled: 20 OPMD patients requiring general anesthesia for cricopharyngeal myotomy and 20 age-matched controls undergoing an operation of similar duration and expected blood loss. Anesthesia was standardized, and both groups received a bolus of cisatracurium 0.1 mg/kg. Onset time, time to 10% T1 recovery, and the intervals 10%-25% and 25%-75% were calculated for both groups. A subgroup analysis was performed in patients with a more severe form of OPMD. Demographic and intraoperative data were similar. Onset time was significantly longer in OPMD patients compared with the control group (4.6 +/- 1.5 min versus 3.4 +/- 1.0 min; P = 0.001). There was no difference in recovery times or indices between groups, regardless of the severity of the disease. In conclusion, there was no difference in the duration of a cisatracurium-induced neuromuscular block between OPMD patients and a control group. A delayed onset of action of the drug may occur.

 

利多卡因使活性內皮IL-1betaIL-6IL-8濃度降低及ICAM-1表達的削弱

Activated endothelial interleukin-1beta, -6, and -8 concentrations and intercellular adhesion molecule-1 expression are attenuated by lidocaine.

Lan W, Harmon DC, Wang JH, Shorten GD, Redmond PH.
Academic Department of Surgery, Cork University Hospital, University College, Cork, Ireland.

Anesth Analg. 2005 Feb;100(2):409-12

 

內皮細胞在缺血再灌注損傷中起了重要的作用。我們研究了利多卡因對活性臍血管內皮細胞(HUVEC)白介素(IL)-1betaIL-6IL-8濃度以及細胞間粘附分子-1ICAM-1)表達的影響。HUVECs用不同濃度的利多卡因(0 to 0.5 mg/ml)預處理60分鐘後,再加入2.5 ng/ml濃度的腫瘤壞死因數- alpha,經4小時孵化後提取上清液,用酶聯免疫吸附試驗測定細胞因數濃度。內皮性ICAM-1表達用流式血細胞計數方法測定。根據不同資料採用卡方檢驗或post hoc不配對資料t-檢驗進行分析。0.5mg/ml利多卡因使HUVECs內白介素(IL)濃度降低,和臨床治療量血漿濃度近似的利多卡因(0.005 mg/ml)處理後的HUVECs相比,IL-1beta1.89+/-0.11pg/ml4.16 +/- 1.27pg/ml; P = 0.009),IL-6 65.5 +/- 5.14 pg/ml162 +/- 11.5pg/ml; P < 0.001),IL-83869 +/- 785pg/ml14,961 +/- 406pg/ml ; P < 0.001)。用0.05 mg/ml利多卡因處理過的HUVECs,其ICAM-1的表達要低於對照組(198 +/- 52.7 298 +/- 50.3; Mean Channel Fluorescence; P < 0.001)。高於臨床治療濃度的高濃度利多卡因使活性內皮性IL-1betaIL-6IL-8濃度降低,使ICAM-1表達削弱。

(金 薛張剛 校)

Endothelial cells play a key role in ischemia reperfusion injury. We investigated the effects of lidocaine on activated human umbilical vein endothelial cell (HUVEC) interleukin (IL)-1beta, IL-6, and IL-8 concentrations and intercellular adhesion molecule-1 (ICAM-1) expression. HUVECs were pretreated with different concentrations of lidocaine (0 to 0.5 mg/mL) for 60 min, thereafter tumor necrosis factor-alpha was added at a concentration of 2.5 ng/mL and the cells incubated for 4 h. Supernatants were harvested, and cytokine concentrations were analyzed by enzyme-linked immunosorbent assay. Endothelial ICAM-1 expression was analyzed by using flow cytometry. Differences were assessed using analysis of variance and post hoc unpaired Student's t-test where appropriate. Lidocaine (0.5 mg/mL) decreased IL-1beta (1.89 +/- 0.11 versus 4.16 +/- 1.27 pg/mL; P = 0.009), IL-6 (65.5 +/- 5.14 versus 162 +/- 11.5 pg/mL; P < 0.001), and IL-8 (3869 +/- 785 versus 14,961 +/- 406 pg/mL; P < 0.001) concentrations compared with the control. IL-1beta, IL-6, and IL-8 concentrations in HUVECs treated with clinically relevant plasma concentrations of lidocaine (0.005 mg/mL) were similar to control. ICAM-1 expression on lidocaine-treated (0.05 mg/mL) HUVECs was less than on controls (198 +/- 52.7 versus 298 +/- 50.3; Mean Channel Fluorescence; P < 0.001). Activated endothelial IL-1beta, IL-6, and IL-8 concentrations and ICAM-1 expression are attenuated only by lidocaine at concentrations larger than clinically relevant concentrations.

 

揮發性和氣體麻醉藥在體外輸入系統中吸附性丟失的研究

Sorptive loss of volatile and gaseous anesthetics from in vitro drug application systems.

Suzuki T, Uchida I, Mashimo T.

Department of Anesthesiology, Osaka University Medical School, 2-2 Yamadaoka, Suita, Osaka, Japan 565-0871.

Anesth Analg. 2005 Feb;100(2):427-30.

 

在體外藥理學實驗中,各種麻醉藥的效應濃度值的確定取決於生理狀態下濃解的藥物確切濃度。由於麻醉藥在輸入過程中,特別在管道系統中,存在吸附、吸收和其他的丟失,實際麻醉藥濃度可能不同於預期濃度。作者檢測了這種假設:當麻醉藥溶液通過實驗管道時,其遞送濃度將降低,並通過檢測兩種揮發性麻醉藥(七氟醚和異氟醚)以及兩種氣體麻醉藥(N2O和疝氣)來研究其丟失的量。作者分別測定了由5種不同物質[玻璃、聚四氟乙烯、聚乙烯(PE)、聚氯乙烯(PVC)和矽膠]組成的管道(1m*2mm*ID*4mmOD)中的溶液。當麻醉藥分別通過PVC和矽膠管時,其輸出濃度顯著減少,分別為>33%和>43%。而當麻醉藥分別通過玻璃管、聚四氟乙烯或矽膠管時其輸出麻醉藥濃度沒有降低,當七氟醚溶液流經PVC和矽膠管時,從溶液流動開始到麻醉藥丟失忽略不計時所需時間分別為2030分鐘。研究結果表明儘管PVC和矽膠管柔軟易使,但在吸入麻醉藥藥理學實驗中頻繁使用PVC和矽膠管顯示出很大不足。

(吳德華 薛張剛 校)

In in vitro pharmacological experiments, determination of effective concentration values for various anesthetics depends on understanding the exact concentration of the drugs dissolved in physiological solutions. Actual anesthetic concentration may differ from expectations because of drug adsorption, absorption or other loss, especially in tubing. We tested the hypothesis that delivered concentrations of anesthetics decrease when solutions pass through laboratory tubing and investigated such loss by measuring the entering and exiting dissolved concentrations of two volatile (sevoflurane and isoflurane) and two gaseous (nitrous oxide and xenon) anesthetics. We tested solutions passed through tubes (1 m x 2 mm ID x 4 mm OD) made of five different materials (glass, Teflon, polyethylene (PE), polyvinyl chloride (PVC), and silicon rubber). Exiting concentrations of anesthetics were significantly reduced when they were passed through PVC (>33%) and silicon (>43%) tubes. There were no decreases in anesthetic concentrations with glass, Teflon, or PE tubes. When sevoflurane solution flowed through PVC and silicon tubes, it took 20 and 30 min, respectively, after start of flow until the anesthetic loss became negligible. These results indicate that frequently used PVC and silicon tubes, whereas flexible and easy to handle, have serious drawbacks when used in inhaled anesthetic pharmacology experiments.

 

 

刺激模式和異丙酚血漿濃度對運動誘發電位的修飾效應

The modifying effects of stimulation pattern and propofol plasma concentration on motor-evoked potentials.

Scheufler KM, Reinacher PC, Blumrich W, Zentner J, Priebe HJ.

Abt. Allgemeine Neurochirurgie, Universitatsklinikum Freiburg, Breisacher Strasse 64, D-79106 Freiburg, Germany.

Anesth Analg. 2005 Feb;100(2):440-7

 

手術中運動誘發電位(MEPs)的特性極大的依賴於刺激模式和麻醉技術。術中MEP記錄進一步的改善需要有每個這些因素修飾效應的精確知識。因此,我們設計的這項研究為了描述不同異丙酚靶血漿濃度時不同刺激模式的修飾效應的特徵,在手術期經顱記錄電MEPs12名患者進行了開顱術,刺激模式(300-500v100-1000Hz 1-5刺激)在不同的PTPCs24,和6mg/ml)隨機不同。瑞芬太尼予0.2mg/kgmin保持不變。MEPs被記錄從大魚際肌到小魚際肌。分析MEPs不考慮PTPC。三向方差分析揭示了增加刺激強度、頻率及刺激的數目顯著影響MEP波幅(P<0.05)。MEP最大的波幅和記錄成功的頻率在1000Hz150V3或更多刺激下被觀測到。PTPC2 4 6mg/ml)對MEP波幅的顯著地主要影響僅在大魚際肌記錄點觀測到。波幅率是由兩倍或四倍刺激誘發相應的MEPs計算而得來的,其證明MEPsPTPC改變不敏感。因此,在刺激模式變化時,MEP特徵表現為顯著不同,而在PTPC變化時,則較少改變。

(廖慶武 薛張綱 校)

The quality of intraoperative motor-evoked potentials (MEPs) largely depends on the stimulation pattern and anesthetic technique. Further improvement in intraoperative MEP recording requires exact knowledge of the modifying effects of each of these factors. Accordingly, we designed this study to characterize the modifying effect of different stimulation patterns during different propofol target plasma concentrations (PTPCs) on intraoperatively recorded transcranial electrical MEPs. In 12 patients undergoing craniotomy, stimulation patterns (300-500 V; 100-1000 Hz; 1-5 stimuli) were varied randomly at different PTPCs (2, 4, and 6 microg/mL). Remifentanil was administered unchanged at 0.2 microg . kg(-1) . min(-1). MEPs were recorded from the thenar and hypothenar muscles. Analysis of MEPs was blinded to the PTPC. Three-way analysis of variance revealed significant main effects of increasing stimulation intensity, frequency, and number of stimuli on MEP amplitude (P < 0.05). Maximum MEP amplitudes and recording success rates were observed with three or more stimuli delivered at 1000 Hz and > or =150 V. A significant main effect of PTPC (2 vs 4 and 6 microg/mL) on MEP amplitude was observed at the thenar recording site only (P < 0.05). An amplitude ratio calculated from corresponding MEPs evoked by double and quadruple stimulation proved to be insensitive to changes in PTPC. In conclusion, MEP characteristics varied significantly in response to changes in stimulation pattern and less to changes in PTPC.

 

嗎啡能加強神經結紮損傷大鼠模型椎管內注射N(6)-2-苯基-腺苷-右異構體(R-PIA)的鎮痛效果

Morphine can enhance the antiallodynic effect of intrathecal R-PIA in rats with nerve ligation injury

Hwang JH, Hwang GS, Cho SK, Han SM

Department of Anesthesia and Pain Medicine, University of Ulsan, College of Medicine, Asan Medical Center, 388-1 Pungnap-Dong, Songpa-Gu, Seoul 138-736Korea.

Anesth Analg. 2005 Feb;100(2):461-8.

 

神經結紮損傷可以產生可觸知的異常疼痛。椎管內注射腺苷受體激動劑或嗎啡具有鎮痛效應。在這項研究中,我們觀察了神經結紮損傷老鼠模型由腺苷A1受體激動劑N(6)-2-苯基-腺苷-右異構體(R-PIA)所致鎮痛背景下椎管內注射嗎啡的效應。大鼠模型為左側L5-6脊神經結紮並在椎管內置管。應用足底纖維測試方法(von Frey filaments)對受損的後腿進行疼痛監測。將退縮反應作為閾值。給予嗎啡和R-PIA以獲得劑量-反應曲線和半數有效量(ED50)。ED50的部分同時建立聯合用藥的ED50。應用等幅射分析方法來分析藥物的相互作用。椎管內注射8-環戊基-13二丙基黃嘌呤(DPCPX一種A1受體拮抗劑)以及納洛酮以觀測鎮痛效應的逆轉。同時觀察副作用。結果:椎管內注射嗎啡和R-PIA以及它們的混合物都能夠產生劑量依賴性的鎮痛效果而沒有嚴重的副作用。當聯合用藥時椎管內注射嗎啡能夠加強R-PIA的鎮痛作用並且DPCPX能夠逆轉其最大效應。結果表明可觸知的異常疼痛在脊髓水平μ-阿片以及A1受體的啟動是相互促進的。

(沈 薛張剛 校)

Nerve ligation injury may produce a tactile allodynia. Intrathecal adenosine receptor agonists or morphine have an antiallodynic effect. In this study, we examined the effect of intrathecal morphine on the antiallodynic state induced by the adenosine A1 receptor agonist, N(6)-(2-phenylisopropyl)-adenosine R-(-)isomer (R-PIA), in a rat model of nerve ligation injury. Rats were prepared with ligation of left L5-6 spinal nerves and intrathecal catheter implantation. Tactile allodynia was measured by applying von Frey filaments to the lesioned hindpaw. Thresholds for withdrawal response were assessed. Morphine and R-PIA were administered to obtain the dose-response curve and the 50% effective dose (ED(50)). Fractions of ED(50)s were administered concurrently to establish the ED(50) of the drug combination. The drug interaction was analyzed using the isobolographic method. Intrathecal 8-cyclopentyl-1,3-dipropylxanthine (DPCPX), an A1 receptor antagonist, and naloxone were administered to examine the reversal of the antiallodynic effect. Side effects were also observed. Intrathecal morphine and R-PIA and their combination produced a dose-dependent antagonism without severe side effects. Intrathecal morphine synergistically enhanced the antiallodynic effect of R-PIA when coadministered. Intrathecal naloxone and DPCPX reversed the maximal antiallodynic effect in the combination group. These results suggest that activation of mu-opioid and A1 receptors at the spinal level is required for the synergistic interaction on tactile allodynia.

 

異丙酚對熱痛覺的影響

The Effect of Propofol on Thermal Pain Perception

Michael A. Froplich, MD, MS, Donald D. Price, PhD, Michael E. Robinson, PhD, Jonathan J. Shuster, PhD, Douglas W. Theriaque, MS, and Marc W. Heft, DMD, PhD

Department of Anesthesiology, University of Alabama at Birmingham, 619 South 19th Street, Birmingham, AL 35249-6810, USA.

Anesth Analg 2005 Feb;1002: 481-486.

 

研究廣泛使用的鎮靜催眠藥propofol對疼痛感知的影響。18個病例平衡而隨機的分成兩組,propofol兩個不同鎮靜濃度組。推薦疼痛刺激溫度(45攝氏度,47攝氏度,49攝氏度)任意順序,31攝氏度無疼痛刺激交替試驗。使用目標靶控注射,效應室濃度0.5mug/ml為溫和鎮靜,1.0mug/ml為適度鎮靜。應用視覺類比評分,分為疼痛強度和更不愉快的痛苦。平均疼痛強度于安慰時為28/100,溫和鎮靜時35/100,適度鎮靜40/100。更不愉快痛苦安慰時23/100,溫和鎮靜時29/100,適度鎮靜時33/100。這種影響對於不同疼痛經歷和鎮痛感知水平的患者有所差別。propofol鎮靜的患者需給予適當鎮痛。

(孫志榮 薛張綱 )

We studied the effect of propofol, a widely used sedative-hypnotic drug, on pain perception. Eighteen subjects received propofol in two sedative concentrations that were balanced and randomized in order. Painful (45 degrees C, 47 degrees C, and 49 degrees C) stimulation temperatures were presented in random order, and nonpainful 31 degrees C stimuli were presented on alternate trials. We used a target-controlled infusion and chose effect site concentrations of 0.5 mug/mL for mild sedation and 1.0 mug/mL for moderate sedation. Using a visual analog scale, subjects rated both pain intensity and unpleasantness higher when sedated with propofol. The average pain intensity was 28/100 for placebo, 35/100 for mild, and 40/100 for moderate sedation. Pain unpleasantness was 23/100 for placebo, 29/100 for mild, and 33/100 for moderate sedation. This effect was unexpected and may be explained by a difference of subjective pain experience by a patient and the perceived level of analgesia by a health care provider in sedated patients. This finding calls further attention to the need for adequate analgesia in patients sedated with propofol.

 

腎上腺素加強全血中血小板與白細胞粘著力的體外實驗

Epinephrine Enhances Platelet-Neutrophil Adhesion in Whole Blood In Vitro

Horn, Nicola A. MD *; Anastase, Denisa M. MD +; Hecker, Klaus E. MD *;

Baumert, Jan H. MD *; Robitzsch, Tilo MD ++; Rossaint, Rolf MD, PhD *

*Department of Anesthesiology, Rheinisch-Westfalische Technische Hochschule,

Aachen, Germany; +Department of Anesthesiology, Spitalul Clinic de Ortopedie

Foisor, Bucuresti, Romania; and ++Institute of Transfusion Medicine,

Rheinisch-Westfalische Technische Hochschule, Aachen, Germany

Anesth Analg 2005 Feb;1002: 520-526.

 

先前的研究表明:兒茶酚胺對α或β腎上腺素能受體的啟動可以影響中性粒細胞的功能、細胞因數的釋放以及血小板的聚集能力。由此我們來研究是否通過腎上腺素對腎上腺素能受體的啟動也能改變血小板與中性粒細胞的粘著力。這項研究對某些嚴重的疾病可能帶來特別的價值,因為血小板和中性粒細胞間聯繫的增強是炎症和血栓形成的關鍵。基於這個意圖,不同腎上腺素濃度的全血(10納摩爾、100納摩爾以及1微摩爾)被用來作為培養基。為了區別受體特異性的反應,我們取樣本的一部分在用腎上腺素培養前先加入普萘洛爾(10微摩爾)或酚妥拉明(10微摩爾)培養。之後,另外一部分樣本由100納摩爾末端甲酰-甲硫氨酰-亮氨酰-苯丙氨酸啟動。所有的樣本均染色,且血小板和中性粒細胞的黏著和CD45以及L-選擇蛋白、CD11bP-選擇蛋白糖蛋白配位基、糖蛋白IIb/IIIa、和P-選擇蛋白的表達由雙色的流式細胞計量數來測量。腎上腺素主要加強血小板與中性粒細胞的聚集以及P-選擇蛋白與糖蛋白IIb/IIIa在血小板上的表達。CD11bL-選擇蛋白在未受啟動的中性粒細胞上表達不變,而在末端甲酰-甲硫氨酰-亮氨酰-苯丙氨酸啟動的培養基裏,C

D11b的表達上調並且L-選擇蛋白受腎上腺素抑止而表達下調。在用腎上腺素培養前使用β腎上腺素能受體阻斷劑增強了血小板與中性粒細胞的聚集並進一步地促進了黏附因數(CD11bP-選擇蛋白和糖蛋白IIb/IIIa)的表達。這些結果表示腎上腺素加強了血小板和中性粒細胞的粘著力。由α腎上腺素能受體介導的P-選擇蛋白和糖蛋白IIb/IIIa的表達增加從本質上有助於這一反應。我們的研究顯示:收縮性的因素加強了血小板和中性粒細胞的粘著力--對某些嚴重疾病的患者而言可這能是決定性的因素。

(許文妍 薛張綱 )

Previous studies showed that [alpha]- or [beta]-adrenoceptor stimulation by catecholamines influenced neutrophil function, cytokine liberation, and platelet aggregability. We investigated whether adrenergic stimulation with epinephrine also alters platelet-neutrophil adhesion. This might be of specific interest in the critically ill, because the increased association of platelets and neutrophils has been shown to be of key importance in inflammation and thrombosis. For this purpose, whole blood was incubated with increasing concentrations of epinephrine (10 nM, 100 nM, and 1 [mu]M). To distinguish receptor-specific effects, a subset of samples was incubated with propranolol (10 [mu]M) or phentolamine (10 [mu]M) before exposure to epinephrine. After incubation, another subset of samples was also stimulated with 100 nM of N-formyl-methionyl-leucyl-phenylalanine. All samples were stained, and platelet-neutrophil adhesion and CD45, L-selectin, CD11b, P-selectin glycoprotein ligand-1, glycoprotein IIb/IIIa, and P-selectin expression were measured by two-color flow cytometry. Epinephrine significantly enhanced platelet-neutrophil adhesion and P-selectin and glycoprotein IIb/IIIa expression on platelets. CD11b and L-selectin expression on unstimulated neutrophils remained unchanged, whereas N-formyl-methionyl-leucyl-phenylalanine-induced upregulation of CD11b and downregulation of L-selectin were suppressed by epinephrine. [beta]-Adrenergic blockade before incubation with epinephrine increased platelet-neutrophil aggregates and adhesion molecule expression (CD11b, P-selectin, and glycoprotein IIb/IIIa) even further. These results demonstrate that epinephrine enhances platelet-neutrophil adhesion. The [alpha]-adrenergic receptor-mediated increase in P-selectin and glycoprotein IIb/IIIa expression on platelets may contribute substantially to this effect. Our study shows that inotropic support enhances the platelet-neutrophil interaction, which might be crucial for critically ill patients.

 

脊麻手術中應用2-氯普魯卡因初始十個月的經驗

Spinal 2-Chloroprocaine for Surgery: An Initial 10-Month Experience

Jessica R. Yoos, MD, and Dan J. Kopacz, MD

Department of Anesthesiology, Virginia Mason Clinic, Seattle, Washington

Anesth Analg 2005 Feb;1002: 553-558.

 

由於利多卡因經常在外科患者中引起短暫神經病變綜合征(TNS),目前開始了2-氯普魯卡因(2-CP)作為短效局麻藥利多卡因的替代藥物的研究。在志願者中應用劑量30-60mg2-CP能夠提供理想的麻醉平面而且未有TNS事件發生的報導。我們回顧研究了本機構初次在外科病人脊麻中應用2-CP的十個月臨床經驗。多數應用在急診手術中,其中39例為整形外科,30例普外科,18例婦產科,34例泌尿外科。常同劑量為2-CP 30-40mg92%的病例中再添加10-20ug的芬太尼。中位阻滯最高平面在T6-T8。手術時間為32.3±18.4分鐘。麻醉開始到手術結束時間為53.1± 20.7分鐘。入院至開始手術時間和入院至出院時間分別為155.1 ± 34.7分鐘和207.9 ± 69.4 分鐘。2-CP可預測阻滯範圍消退時間,所以在歷時一小時的外科手術中可以安全有效地作為利多卡因和普魯卡因的替代藥物。手術之後未有TNS報導。

(蔡美華 薛張剛 校)

Spinal 2-chloroprocaine (2-CP) is currently being investigated as a short-acting alternative to lidocaine, which frequently causes transient neurologic symptoms (TNS) in surgical patients. TNS has not been reported with 2-CP in volunteers in doses ranging from 30 to 60 mg and appears to provide an excellent level of surgical anesthesia. In this retrospective study, we describe the experience with spinal 2-CP in surgical patients during its first 10 mo of clinical use at our institution. Most patients had ambulatory surgery, including 39 orthopedic, 30 general surgical, 18 gynecologic, and 34 genitourinary procedures. Chloroprocaine 30 or 40 mg, with or without fentanyl (10–20 &micro;g), was the most common (92%) dose combination used. Mean peak block height averaged T6 to T8. The surgical procedure time was 32.3 ± 18.4 min. Time from placement of the block to the end of the surgical procedure was 53.1 ± 20.7 min. Times to ambulation and discharge were 155.1 ± 34.7 min and 207.9 ± 69.4 min, respectively. 2-CP spinal anesthesia has proven to be a safe and effective alternative to lidocaine and procaine for ambulatory surgical procedures of 1 h, with a predictable regression of block height. No patients reported TNS after surgery.

 

脊麻2-氯普魯卡因:志願者中與普魯卡因比較

Spinal 2-Chloroprocaine: A Comparison with Procaine in Volunteers

Aaron F. Gonter, MD, and Dan J. Kopacz, MD

Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington

Anesth Analg 2005 Feb;1002: 573-579.

 

近期將不含防腐劑的2-氯普魯卡因(2CP)用於脊麻的研究顯示它是一種能提供與利多卡因相似麻醉效應的可靠短效藥。在這個隨機雙盲交叉研究中,我們在8名志願者中比較脊麻2CP30mg)和普魯卡因(80mg)的效應以決定哪種藥物產生的脊麻效應對於門診手術的患者是理想的。通過針刺感覺、經皮電刺激、對腿部止血帶的耐受性以及運動阻代替手術效應,2CP與普魯卡因是相似的。峰阻滯高度(T9[範圍,T6T12]T6[T4T8];P=0.0796),消退2個節段的時間(51 ± 17 分鐘 53 ± 10 分鐘; P = 0.7434),止血帶耐受時間(37 ± 16 分鐘 49 ± 17分鐘; P = 0.1755),肌力恢復時間(Bromage分期: 54 ± 23 分鐘較 55 ± 44 分鐘, P = 0.9366; 四頭肌恢復 90 %: 78 ± 9分鐘 versus 98 ± 30 分鐘; P = 0.0721),都是相似的。普魯卡因作用維持較長的感覺阻滯 (P = 0.0011)和運動阻滯在腓腸肌(P = 0.0004)和四頭肌(P = 0.0146);感覺阻滯結束時間(103 ± 12 分鐘較151 ± 26 分鐘; P = 0.0003),移動時間(103 ± 12 分鐘 151 ± 26 分鐘; P = 0.0003),排尿時間(103 ± 12 分鐘 156 ± 23 分鐘; P < 0.0001),用普魯卡因者均延長。結論,劑量試驗,脊麻2CP (30 mg)可能是短小門診手術的更佳選擇,因為它能提供與普魯卡因(80mg)類似的麻醉效應,而達到消退標準更快。

(費 薛張剛 校)

Recent studies using preservative-free 2-chloroprocaine (2-CP) for spinal anesthesia have shown it to be a reliable short-acting drug that provides similar anesthesia to lidocaine. In this randomized, double-blind, crossover study, we compared the characteristics of spinal 2-CP (30 mg) with those of procaine (80 mg) in eight volunteers to determine whether either drug produces spinal anesthetic characteristics ideal for outpatient surgery. By using sensation to pinprick, transcutaneous electrical stimulation, tolerance to thigh tourniquet, and motor blockade as surrogates for surgical efficacy, 2-CP compared similarly to procaine. Peak block height (T9 [range, T6 to T12] versus T6 [T4 to T8]; P = 0.0796), time to two-segment regression (51 ± 17 min versus 53 ± 10 min; P = 0.7434), tourniquet time tolerance (37 ± 16 versus 49 min ± 17 min; P = 0.1755), and time to return of motor strength (Bromage scale: 54 ± 23 min versus 55 ± 44 min, P = 0.9366; return of 90% quadriceps strength: 78 ± 9 min versus 98 ± 30 min; P = 0.0721) were all similar. Procaine did produce overall longer sensory blockade (P = 0.0011) and motor blockade at the gastrocnemius (P = 0.0004) and quadriceps (P = 0.0146) muscles. Times until the resolution of sensory blockade (103 ± 12 min versus 151 ± 26 min; P = 0.0003), ambulation (103 ± 12 min versus 151 ± 26 min; P = 0.0003), and micturition (103 ± 12 min versus 156 ± 23 min; P < 0.0001) were all prolonged after procaine. In conclusion, at the doses tested, spinal 2-CP (30 mg) may be a better choice for short outpatient procedures because it provides anesthesia with similar efficacy as procaine (80 mg) but with more rapid fulfillment of discharge criteria.

與經典喉罩比較Proseal喉罩壽命較短

The ProSeal has a shorter life-span than the Classic laryngeal mask airway.

Doneley S, Brimacombe J, Keller C, von Goedecke A.
Department of Anaesthesia, Cairns Base Hospital, The Esplanade, Cairns 4870, Australia.

Anesth Analg. 2005 Feb;100(2):590-3

 

我們測試了這樣的假設:ProSeal喉罩(LMA)比經典喉罩的壽命短。我們也比較了使用時殘留氣囊的容量、彈性的改變以及其通透性。六個新的4ProSeal喉罩和六個新的4號經典喉罩被測試。每個喉罩都經歷模擬的臨床使用週期,直到該喉罩不能通過使用前檢查,而停止使用。模擬的臨床使用週期包括:1)使氣囊膨脹至推薦的最大容量一小時;2)浸入含酶溶液中3分鐘;3)清洗內、外表面;4)自動清洗14分鐘(85℃);5)乾燥30分鐘(75℃);6)在134℃,206kPa下高壓滅菌4分鐘。在第一個週期和後來的每10個週期之前,氣囊內充進40ml的空氣,分別立刻及3小時後測氣囊內壓力。最初氣囊內壓測得通過彈性或阻力使其變形的方法,氣囊內壓改變的測量是利用通透性的方法而測得。殘留氣囊容量的測量是由10個經典和10ProSeal4號喉罩用氣體稀釋技術測得。經典喉罩和ProSeal喉罩的壽命分別為(均值±標準差,範圍)82±2345-109)及133±3576-176)。ProSeal喉罩與經典喉罩相比壽命較短(P=0.01)。對於ProSeal喉罩,使用時不存在彈性及通透性的改變。對於經典喉罩,有彈性的減退(P<0.0001)和通透性的增加(P<0.0001)。經典喉罩殘留氣囊容量較ProSeal喉罩高(2.6±1.3ml1.5±0.9mlP=0.04)。我們推斷ProSeal喉罩壽命較經典喉罩短,但是使用次數都超過了商家推薦的40次。我們推薦重複使用喉罩,直到其不能通過使用前檢測再丟棄該喉罩,而不是在使用了特定的次數後。

(孫敏莉 薛張綱 校)

We tested the hypothesis that the life-span of the ProSeal laryngeal mask airway (LMA) is shorter than the Classic LMA. We also compared residual cuff volumes and changes in elastance and permeability with use. Six new size 4 ProSeal LMAs and 6 new size 4 Classic LMAs were tested. Each LMA underwent a simulated clinical use cycle until it failed the pre-use check tests. The simulated clinical use cycle comprised: i) inflating the cuff to the maximum recommended volume for 1 h; ii) immersion in an enzymatic solution for 3 min; iii) washing the external and internal surfaces; iv) automatic washing for 14 min (< or =85 degrees C); v) drying for 30 min (< or =75 degrees C); and vi) autoclaving at 134 degrees C for 4 min at 206 kPa. Before the first cycle and every 10 subsequent cycles, the cuff was inflated with 40 mL air and the intracuff pressure was measured immediately and 3 h later. The initial intracuff pressure was taken to be an inverse measure of the elastance or resistance to deformation, and the intracuff pressure change were taken as a measure of the permeability. The residual cuff volume was determined for 10 Classic and 10 ProSeal size 4 LMAs using a gas dilution technique. The mean +/- sd (range) longevity for the ProSeal LMA and Classic LMA was 82 +/- 23 (45-109) uses and 133 +/- 35 (76-176) uses, respectively. The ProSeal LMA has a shorter life-span than the Classic LMA (P = 0.01). For the ProSeal LMA, there was no change in elastance or permeability with use. For the Classic LMA, there was a decrease in elastance (P < 0.0001) and an increase in permeability (P < 0.0001) with use. The residual cuff volume was higher for the ProSeal LMA (2.6 +/- 1.3 mL versus 1.5 +/- 0.9, P = 0.04). We conclude that the life-span of the ProSeal LMA is shorter than the Classic LMA, but both exceed the manufacturer's recommendations of 40 uses. We recommend that reusable LMA devices be discarded when they fail the pre-use check tests, rather than after a specific number of uses.

持續胃減壓治療冠脈搭橋術後的噁心嘔吐

Continuous Gastric Decompression for Postoperative Nausea and Vomiting After Coronary Revascularization Surgery

Crina L. Burlacu, FCAI*, David Healy, MRCSI{dagger}, Donal J. Buggy, MD, MSc, DME, FRCPI, FCAI, FRCA*{ddagger}, Ciaran Twomey, FCAI*, David Veerasingam, FRCSI{dagger}, Andrew Tierney, FCAI*, and Denis C. Moriarty, FCAI, FRCA*

* Department of Anaesthesia and Intensive Care Medicine, and {dagger}Department of Cardiothoracic Surgery, Mater Misericordiae University Hospital, Dublin, Ireland, and {ddagger}Outcomes Research InstituteTM, University of Louisville, Louisville, Kentucky

Anesth Analg 2005;100:321-326

 

心臟手術後常見噁心、嘔吐,並可能導致嚴重的併發症發病率。而麻醉期間胃減壓對預防較短時間的非心臟手術後的噁心、嘔吐,有相矛盾的結果。我們檢驗了這樣一個假設,即對在體外迴圈下行擇期冠脈血管搭橋術中進行胃減壓,持續到術後氣管導管拔除後,可降低嘔吐或幹嘔和噁心的發生率。在這一前瞻的、隨機的群組研究中, 104例術後噁心和嘔吐的Apfel風險因素至少2級的病人分為2組,一組在麻醉誘導後插入靠重力自然引流的胃管(n = 52),另一組為對照組(n = 52)。在術後氣管導管拔除時同時拔除胃管。主要監測嘔吐或幹嘔的發生率。次要的監測結果包括用視覺類比評分法評估噁心的發生率和嚴重程度。有胃減壓的病人嘔吐或幹嘔的發生率為13.4%,對照組為11.5% (P = 0.7)。相同地,兩組之間在噁心的發生率 (32.7%25.0%, P = 0.6),在12小時時用視覺類比評分法評估的噁心嚴重程度中位值 (25; 範圍0–55 mm30; 範圍 0–60 mm, P = 0.4), 及止吐藥應用(38.5%28.8%, P = 0.3) 上沒有明顯統計學差異。在冠脈血管搭橋術中和術後直到拔除氣管導管期間持續胃減壓不能降低這些病人嘔吐或幹嘔的發生率及噁心的發生率和嚴重程度。

(彭中美 李士通 校)

Postoperative nausea and vomiting is common after cardiac surgery and may contribute to significant morbidity. Gastric decompression during anesthesia has been used for postoperative nausea and vomiting prophylaxis in shorter duration noncardiac surgery with conflicting results. We tested the hypothesis that gastric decompression during elective coronary revascularization surgery with cardiopulmonary bypass and continued afterwards until tracheal extubation would reduce the incidence of vomiting or retching and nausea. In a prospective, randomized, cohort study, 104 patients with at least 2 Apfel’s risk factors for postoperative nausea and vomiting were allocated to receive a gastric tube on free gravity drainage after induction of anesthesia (n = 52) or to a control group (n = 52). The gastric tube was removed simultaneously with tracheal extubation postoperatively. The primary outcome measure was the incidence of vomiting or retching. Secondary outcomes included the incidence and severity of nausea measured on a visual analog scale. The incidence of vomiting or retching was 13.4% in patients with gastric decompression, compared with 11.5% in the control group (P = 0.7). Similarly, there was no statistically significant difference between the two groups in the incidence of nausea (32.7% versus 25.0%, P = 0.6), median severity of nausea on a visual analog scale at 12 h (25; range, 0–55 mm versus 30; range, 0–60 mm, P = 0.4), or antiemetics administration (38.5% versus 28.8%, P = 0.3). Continuous gastric decompression during coronary revascularization surgery and afterwards until tracheal extubation did not reduce the incidence of vomiting or retching or the incidence and severity of nausea in these patients.

 

經食道超聲心動圖評估腹腔鏡手術中二氧化碳氣腹對肝血流的影響

The Effects of Intraabdominally Insufflated Carbon Dioxide on Hepatic Blood Flow During Laparoscopic Surgery Assessed by Transesophageal Echocardiography

Rainer Meierhenrich, MD, Albrecht Gauss, MD, Peter Vandenesch, MD, Michael Georgieff, MD, Bertram Poch, MD*, and Wolfram Schütz, MD

Departments of Anesthesiology and *General Surgery, University of Ulm, Germany

Anesth Analg 2005;100:340-347

 

二氧化碳(CO2)氣腹對內臟和肝臟灌注的影響以往有不同的結果報導。一些實驗室研究認為氣腹可以引起與腹內壓相關的肝血流量減少,而其他的研究者則認為當腹內壓(IAP)低於16 mm Hg時肝血流量是增加的。本實驗的目的是為了觀察在健康成人行腹腔鏡手術時充入CO2對肝血流量的影響。我們採用經食道多普勒超聲心動圖的方法,測定了24例行腹腔鏡手術患者的肝中和肝右靜脈血流量。分別在氣腹前、氣腹後第5102030 40分鐘以及放氣第15分鐘測定肝靜脈血流量。12例行常規疝修補術的患者作為對照組。在氣腹形成過程中,肝中和右肝靜脈血流明顯增加。在充入CO25分鐘後右肝平均血流指數從196 mL/min/m2 (95% 可信區間(CI), 140–261 mL/min/m2) 增加至392 mL/min/m2 (CI, 263–551 mL/min/m2) (P < 0.05),並在整個氣腹過程中一直維持。肝中靜脈血流指數在充氣20分鐘後從105 mL/min/m2 (CI, 71–136 mL/min/m2) 增加至159 mL/min/m2 (CI, 103–236 mL/min/m2)。放氣後兩條肝靜脈血流量都回復到基礎值。相反的是對照組肝血流量在整個研究過程中未發生改變。我們作出結論健康成人在CO2氣腹形成IAP 12 mm Hg時肝臟灌注增加。

(張俊傑 李士通 校)

Conflicting results have been published about the effects of carbon dioxide (CO2) pneumoperitoneum on splanchnic and liver perfusion. Several experimental studies described a pressure-related reduction in hepatic blood flow, whereas other investigators reported an increase as long as the intraabdominal pressure (IAP) remained less than 16 mm Hg. Our goal in the present study was to investigate the effects of insufflated CO2 on hepatic blood flow during laparoscopic surgery in healthy adults. Blood flow in the right and middle hepatic veins was assessed in 24 patients undergoing laparoscopic surgery by use of transesophageal Doppler echocardiography. Hepatic venous blood flow was recorded before and after 5, 10, 20, 30, and 40 min of pneumoperitoneum, as well as 1 and 5 min after deflation. Twelve patients undergoing conventional hernia repair served as the control group. The induction of pneumoperitoneum produced a significant increase in blood flow of the right and middle hepatic veins. Five minutes after insufflation of CO2 the median right hepatic blood flow index increased from 196 mL/min/m2 (95% confidence interval (CI), 140–261 mL/min/m2) to 392 mL/min/m2 (CI, 263–551 mL/min/m2) (P < 0.05) and persisted during maintenance of pneumoperitoneum. In the middle hepatic vein the blood flow index increased from 105 mL/min/m2 (CI, 71–136 mL/min/m2) to 159 mL/min/m2 (CI, 103–236 mL/min/m2) 20 min after insufflation of CO2. After deflation blood flow returned to baseline values in both hepatic veins. Conversely, in the control group hepatic blood flow remained unchanged over the entire study period. We conclude that induction of CO2 pneumoperitoneum with an IAP of 12 mm Hg is associated with an increase in hepatic perfusion in healthy adults.

 

最佳時機針刺刺激輔助樞複寧預防整形手術病人的嘔吐

Optimal Timing of Acustimulation for Antiemetic Prophylaxis as an Adjunct to Ondansetron in Patients Undergoing Plastic Surgery

 

Paul F. White, MD, PhD*, Mohamed A. Hamza, MD*, Alejandro Recart, MD*, Jayne E. Coleman, MD*, Amy R. Macaluso, MD*, Lyndsey Cox, MS*, Omar Jaffer, MS*, Dajun Song, MD, PhD*, and Rod Rohrich, MD{dagger}

Departments of *Anesthesiology & Pain Management and {dagger}Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

Anesth Analg 2005;100:367-372

 

我們設計這項研究,以評估在整形手術前、後、或前後都使用經皮電針穴位刺激,同時合併使用樞複寧止吐療效。使用隨機、雙盲、假性裝置對照的研究設計比較三種預防性針刺刺激的治療方案:術前組術前使用有活性的裝置30 min,術後使用假性裝置72 h;術後組術前使用假性裝置30 min,術後使用有活性的裝置72 h;圍術期組術前使用有活性的裝置30 min,術後使用有活性的裝置72 h(每組n = 35)。所有的病人均接受標準化全麻,術畢靜脈注射4 mg樞複寧。在術後72 h裏的特定時間間隔測定嘔吐/幹嘔的發生率及對額外止吐藥的需求。用11點的口頭等級評定量表來記錄噁心評分。評定的其他結果參數包括:出院時間(對於門診病人)、正常日常生活活動的恢復、完全的止吐反應率及病人對止吐治療及恢復質量的滿意度。圍術期使用ReliefBand®的完全有效率(68%)比只在術前使用該裝置(43%)明顯增加。在圍術期及術後治療組(與術前組相比)術後噁心的評分中位值明顯降低。最終,在一個從0 ( 最壞) 100( 最好)的任意標度上,圍術期或術後接受針刺刺激組(相對術前組)的病人對恢復質量的滿意度(83 ± 16 85 ± 13 72 ± 18)及對止吐處理的滿意度(96 ± 994 ± 10 86 ± 13)明顯較高。對手術當日出院的病人,圍術期給予針刺刺激(相對術前而言),可以回家的時間明顯提前(114 ± 41 min164 ± 50 min; P < 0.05)。結論,在術後使用ReliefBand®給予針刺刺激進行止吐治療能最有效地減少術後噁心嘔吐及改善病人的滿意度。

(裘毅敏 李士通 校)

We designed this study to evaluate the antiemetic efficacy of transcutaneous electrical acupoint stimulation in combination with ondansetron when applied before, after, or both before and after plastic surgery. A randomized, double-blind, sham-controlled study design was used to compare three prophylactic acustimulation treatment schedules: preoperative—an active device was applied for 30 min before and a sham device for 72 h after surgery; postoperative—a sham device was applied for 30 min before and an active device for 72 h after surgery; and perioperative—an active device was applied for 30 min before and 72 h after surgery (n = 35 per group). All patients received a standardized general anesthetic, and ondansetron 4 mg IV was administered at the end of surgery. The incidence of vomiting/retching and the need for rescue antiemetics were determined at specific time intervals for up to 72 h after surgery. Nausea scores were recorded with an 11-point verbal rating scale. Other outcome variables assessed included discharge times (for outpatients), resumption of normal activities of daily living, complete antiemetic response rate, and patient satisfaction with antiemetic therapy and quality of recovery. Perioperative use of the ReliefBand® significantly increased complete responses (68%) compared with use of the device before surgery only (43%). Median postoperative nausea scores were significantly reduced in the peri- and postoperative (versus preoperative) treatment groups. Finally, patient satisfaction with the quality of recovery (83 ± 16 and 85 ± 13 vs 72 ± 18) and antiemetic management (96 ± 9 and 94 ± 10 vs 86 ± 13) on an arbitrary scale from 0 = worst to 100 = best was significantly higher in the groups receiving peri- or postoperative (versus preoperative) acustimulation therapy. For patients discharged on the day of surgery, the time to home readiness was significantly reduced (114 ± 41 min versus 164 ± 50 min; P < 0.05) when acustimulation was administered perioperatively (versus preoperatively). In conclusion, acustimulation with the ReliefBand® was most effective in reducing postoperative nausea and vomiting and improving patients’ satisfaction with their antiemetic therapy when it was administered after surgery.

 

針刺刺激的時間並不影響麻醉藥的需要量

The Timing of Acupuncture Stimulation Does Not Influence Anesthetic Requirement

Grigory Chernyak, MD*, Papiya Sengupta, MD, Rainer Lenhardt, MD*, Edwin Liem, MD*, Anthony G. Doufas, MD, PhD*, Daniel I. Sessler, MD*, and Ozan Akça, MD*

*Department of Anesthesiology and Perioperative Medicine and Outcomes ResearchTM Institute, University of Louisville, Kentucky

Anesth Analg 2005;100:387-392

 

有研究提示在麻醉誘導前進行針刺比在其後進行更有效果。我們通過實驗希望證明,在誘導前30min開始給予電針刺激比在誘導後開始,能更明顯地減少麻醉藥用量。7名志願者在3天中以地氟醚進行麻醉實驗。首先選擇四個可以產生上腹部區域鎮痛效果、同時也產生一定的非特異性的鎮靜和鎮痛效果穴位針刺,分別為:足三裏 (St36),三陰交 (Sp6), 列缺 (Sp34), 合穀 (LI4)。分別用2Hz10Hz電刺激以2秒的時程交替進行針刺。三天實驗第一天內容為針刺在誘導前(誘導前組),志願者以麻醉誘導前進行30min的電針刺激,並維持到整個過程中。第二天實驗內容為針刺在誘導中(誘導組),針頭在誘導前安置在皮膚上,但是電刺激直到誘導後才給予。第三天實驗中(實驗組),電極被放置到針刺點鄰近,但是並不在皮膚上放置針灸針。測痛用的傷害性電刺激通過25G的針在上腹部給予(70 mA; 100 Hz; 10 s)。在病人因為疼痛發生體動時地氟醚的濃度增加0.5%,在不發生體動時減少0.5%。這種連續上下調節,使志願者從體動到無體動的變化連續反復四次,以LOGISTIC回歸P50分析方法來分析地氟醚的需要量。在三組實驗組中地氟醚的需求量基本相近,分別為實驗組(mean ± sd; 5.2% ± 0.6%), 誘導前組 (5.0% ± 0.8%), 和誘導組 (4.7% ± 0.3%; P = 0.125) 。我們認為這種形式的針刺並不能影響全麻效能或減少全麻藥物的需求量。

(沈浩譯,李士通校)

Studies suggest that acupuncture is more effective when induced before the induction of general anesthesia than afterwards. We tested the hypothesis that electro-acupuncture initiated 30 min before the induction reduces anesthetic requirement more than acupuncture initiated after the induction. Seven volunteers were each anesthetized with desflurane on 3 study days. Needles were inserted percutaneously at four acupuncture points thought to produce analgesia in the upper abdominal area and provide generalized sedative and analgesic effects: Zusanli (St36), Sanyinjiao (Sp6), Liangqiu (Sp34), and Hegu (LI4). Needles were stimulated at 2 Hz and 10 Hz, with frequencies alternating at 2-s intervals. On Preinduction day, electro-acupuncture was started 30 min before the induction of anesthesia and maintained throughout the study. On At-induction day, needles were positioned before the induction of anesthesia, but electro-acupuncture stimulation was not initiated until after the induction. On Control day, electrodes were positioned near the acupoints, but needles were not inserted. Noxious electrical stimulation was administered via 25-gauge needles on the upper abdomen (70 mA; 100 Hz; 10 s). The desflurane concentration was increased 0.5% when movement occurred and decreased 0.5% when it did not. These up-and-down sequences continued until volunteers crossed from movement to no movement four times. The P50 of logistic regression identified desflurane requirement. Desflurane requirement was similar on the Control (mean ± sd; 5.2% ± 0.6%), Preinduction (5.0% ± 0.8%), and At-induction (4.7% ± 0.3%; P = 0.125) days. This type of acupuncture is thus unlikely to facilitate general anesthesia or decrease the requirement for anesthetic drugs.

 

高濃度笑氣能減弱大鼠由嗎啡產生的異氟醚最小肺泡濃度的節省效應

Large Concentrations of Nitrous Oxide Decrease the Isoflurane Minimum Alveolar Concentration Sparing Effect of Morphine in the Rat

Martín Santos, DVM, PhD*{dagger}, Viviana Kuncar, DVM*, Fernando Martínez-Taboada, DVM*, and Francisco J. Tendillo, DVM, PhD, DipECVA*{dagger}

*Department of Experimental Surgery, University Hospital Puerta de Hierro; and {dagger}Department of Anesthesiology, Complutense University Veterinary School, Madrid, Spain

Anesth Analg 2005;100:404-408

 

當與揮發性麻醉劑複合應用時,已證實許多輔助藥有節省揮發性麻醉劑的特性 。笑氣複合應用揮發性麻醉劑,減少了揮發性麻醉劑產生麻醉作用所需的濃度。阿片類麻醉劑的鎮痛劑量明顯減少人和實驗動物的吸入麻醉劑需要量。我們實施此研究來確定,複合應用笑氣和嗎啡能否進一步減少鼠異氟醚最小肺泡有效濃度(MAC)58只母鼠被分在8組:在4個可能的笑氣濃度下(0%30%50%70%)給於異氟醚和生理鹽水或者嗎啡(1 mg/kg)。然後在夾尾時從肺泡氣體樣本測定異氟醚的MAC (MACISO)。在不同笑氣濃度下異氟醚的MAC明顯不同,增加笑氣濃度減少異氟醚的需求。在0%30%笑氣濃度時應用嗎啡減少MACISO。嗎啡減少MACISO的作用在50%笑氣濃度時減少,在70%笑氣濃度時不存在。無論如何,有嗎啡存在時,MACISO30%–70%的笑氣濃度範圍不依賴於笑氣濃度。

(張曦 李士通 校)

Many adjuvant drugs have demonstrated anesthetic-sparing properties when combined with volatile anesthetics. Nitrous oxide is combined with volatile anesthetics to reduce the concentrations of volatile anesthetics required to produce anesthesia. Analgesic doses of opioids clearly reduce the requirement for inhaled anesthetics in both human patients and experimental animals. We performed this study to determine whether the combination of nitrous oxide and morphine decreased isoflurane minimum alveolar anesthetic concentration (MAC) even further in the rat. Fifty-eight female rats were used. The rats were divided into 8 groups: isoflurane in 4 possible nitrous oxide concentrations (0%, 30%, 50%, or 70%) with saline or morphine (1 mg/kg). Then the MAC of isoflurane (MACISO)was determined from alveolar gas samples at the time of tail clamp. The MAC of isoflurane was significantly different at each nitrous oxide concentration, and increasing nitrous oxide concentrations reduced anesthetic requirements for isoflurane. The administration of morphine reduced the MACISO when used with 0% or 30% nitrous oxide. This MACISO by morphine reduction was less with 50% nitrous oxide and nonexistent at 70% nitrous oxide. However, with morphine present the MACISO was independent of the nitrous oxide concentration in the 30%–70% range.

 

ATP敏感鉀通道參與培養的人主動脈內皮細胞膜電位對髙滲的反應

Involvement of Adenosine Triphosphate-Sensitive Potassium Channels in the Response of Membrane Potential to Hyperosmolality in Cultured Human Aorta Endothelial Cells

Mikiyo Yamaguchi, MD, Yoshinobu Tomiyama, MD, Toshiko Katayama, MD, Hiroshi Kitahata, MD, and Shuzo Oshita, MD

Department of Anesthesiology, Tokushima University School of Medicine, Tokushima, Japan

Anesth Analg 2005;100:419-426

 

內皮細胞的膜電位是內皮功能包括血管張力調節的一項重要決定因素。我們研究了ATP敏感鉀通道(KATP)是否參與培養的人主動脈內皮細胞膜電位對髙滲的反應。用電壓敏感的螢光染料bis-(1,3-diethylthiobarbiturate)trimethine oxonol來對膜電位的相對變化進行半定量評估。為了探討甘露醇、蔗糖和NaCl引起的髙滲對膜電位的影響,細胞用含200 nM bis-(1,3-diethylthiobarbiturate)trimethine oxonolEarle’s平衡鹽溶液(285 mOsm/kg H2O)持續灌流,並在有或無1 µM格列苯脲(一種公認的KATP通道阻滯劑)的情況下接觸315345 mOsm/kg H2O的髙滲媒介。髙滲的甘露醇明顯地引起內皮細胞的超極化,1 µM的格列苯脲可以預防(n6)。估計的膜電位變化在315345 mOsm/kg H2O時分別為13 ± 8 21 ± 8 mV。髙張的蔗糖引起相似的變化。然而,儘管髙張的鹽水也可以顯著地引起內皮細胞的超極化(n6),這一變化卻並不為1 µM 格列苯脲所預防。結論,在培養的人主動脈內皮細胞上,KATP通道可能參與了由髙滲甘露醇和蔗糖引起的超極化,其並未參與由髙張鹽水引起的超極化。

(黃施偉 李士通 校)

The membrane potential of endothelial cells is an important determinant of endothelial functions, including regulation of vascular tone. We investigated whether adenosine triphosphate-sensitive potassium (KATP) channels were involved in the response of membrane potential to hyperosmolality in cultured human aorta endothelial cells. The voltage-sensitive fluorescent dye, bis-(1,3-diethylthiobarbiturate)trimethine oxonol, was used to assess relative changes in membrane potential semiquantitatively. To investigate the effect of mannitol-, sucrose-, and NaCl-induced hyperosmolality on membrane potential, cells were continuously perfused with Earle’s balanced salt solution (285 mOsm/kg H2O) containing 200 nM bis-(1,3-diethylthiobarbiturate)trimethine oxonol and exposed to 315 and 345 mOsm/kg H2O hyperosmotic medium sequentially in the presence and absence of 1 µM glibenclamide, a well-known KATP channel blocker. Hyperosmotic mannitol significantly induced hyperpolarization of the endothelial cells, which was prevented by 1 µM glibenclamide (n = 6). Estimated changes of membrane potential at 315 and 345 mOsm/kg H2O were 13 ± 8 and 21 ± 8 mV, respectively. Hypertonic sucrose induced similar changes. However, although hypertonic saline also significantly induced hyperpolarization of the endothelial cells (n = 6), the hyperpolarization was not prevented by 1 µM glibenclamide. In conclusion, KATP channels may participate in hyperosmotic mannitol- and sucrose-induced hyperpolarization, but not in hypertonic saline-induced hyperpolarization in cultured human aorta endothelial cells.

 

氧化血紅蛋白為基質的攜氧分子(血紅蛋白 Glutamer-200)產生的高鐵血紅蛋白干擾乳酸測定 (YSI 2700 SELECTTM生化分析儀)嗎?

Does Methemoglobin from Oxidized Hemoglobin-Based Oxygen Carrier (Hemoglobin Glutamer-200) Interfere with Lactate Measurement (YSI 2700 SELECTTM Biochemistry Analyzer)?

Stephen L. Osgood, MD*, Jonathan S. Jahr, MD*{dagger}, Poonam Desai*, Jessica Tsukamoto*, and Bernd Driessen, DVM, PhD*{ddagger}

*Department of Anesthesiology, David Geffen School of Medicine at University of California Los Angeles; {dagger}Charles R. Drew University of Medicine and Science, Martin Luther King Jr./Drew Medical Center, Los Angeles, California; and {ddagger}Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, Philadelphia

Anesth Analg 2005;100:437-439

 

在本研究中,我們驗證了當氧化血紅蛋白源性的攜氧物質――血紅蛋白 Glutamer-200Oxyglobin®Biopure 公司)產生的高鐵血紅蛋白(Met-HBOC)存在時, YSI 2700 SELECTTM 葡萄糖/乳酸分析儀測定乳酸的準確性。不同濃度組合的濃縮左旋乳酸溶液、庫存狗血漿和Plasmalyte ATM 加入四種樣本組(1%10%20%40% Met-HBOC [1.3 g/dL])中,使連貫樣本中的乳酸濃度線性增加。乳酸濃度測量值和計算值之間的平均差異分別是–5.1 mg/dL (1% Met-HBOC)–5.8 mg/dL (10% Met-HBOC)–4.6 mg (20% Met-HBOC)–8.5 mg/dL (40% Met-HBOC)。均方根誤差分別是6.5 mg/dL7.4 mg/dL6.8 mg/dL10.3 mg/dLBland-Altman 相關係數(r)分別是 r = –0.94 (P = 0.01) r = –0.91 (P < 0.001) r = –0.90 (P < 0.001)r = –0.94 (P < 0.001)(當測量值和計算值完全一致時 r = 0 )。結果提示當Met-HBOC存在時,用YSI 2700分析儀測量的乳酸濃度偏低,其偏差與Met-HBOC的含量無關。當患者血漿中存在HBOC時,所測乳酸濃度會偏低,其偏差與高鐵血紅蛋白的濃度無關。

(軒泓 李士通 校)

In this study, we validated the accuracy of lactate measurements (YSI 2700 SELECTTM glucose/lactate analyzer) in the presence of methemoglobin from an oxidized bag of hemoglobin-based oxygen carrier (Met-HBOC), hemoglobin glutamer-200 (Oxyglobin®; Biopure Corp). Different combinations of concentrated l-lactate solution, pooled canine plasma, and Plasmalyte ATM were added to 4 sample groups (1%, 10%, 20%, and 40% Met-HBOC [1.3 g/dL]) to yield linear increases in lactate concentration in consecutive samples. The mean difference between measured and calculated lactate was –5.1 mg/dL (1% Met-HBOC), –5.8 mg/dL (10% Met-HBOC), –4.6 mg (20% Met-HBOC), and –8.5 mg/dL (40% Met-HBOC). The root mean square error was 6.5 mg/dL, 7.4 mg/dL, 6.8 mg/dL, and 10.3 mg/dL, respectively. The Bland-Altman correlation (r) was r = –0.94 (P = 0.01), r = –0.91 (P < 0.001), r = –0.90 (P < 0.001), and r = –0.94 (P < 0.001), respectively, where r = 0 for perfect agreement between measured and calculated values. Results indicate that true lactate levels in the presence of Met-HBOC are underestimated when measured by an YSI 2700 analyzer independent of the amount of Met-HBOC present. When interpreting lactate concentrations from a patient with a HBOC present in plasma, underestimation of true lactate levels may occur unrelated to methemoglobin concentrations.

 

環加氧酶-2抑制劑帕瑞考昔鈉治療婦產科剖腹手術後疼痛與肌注嗎啡12 mg一樣有效

The Cyclooxygenase-2-Specific Inhibitor Parecoxib Sodium Is as Effective as 12 mg of Morphine Administered Intramuscularly for Treating Pain After Gynecologic Laparotomy Surgery

T. Philip Malan, Jr, MD, PhD*, Stephen Gordon, MD{dagger}, Richard Hubbard, MD{ddagger}, and Michael Snabes, MD{ddagger}

*Department of Anesthesiology, The University of Arizona, Tucson, Arizona; {dagger}Comprehensive NeuroScience Inc., Atlanta, Georgia; and {ddagger}Pfizer Global Pharmaceuticals, Skokie, Illinois

Anesth Analg 2005;100:454-460

 

帕瑞考昔鈉為選擇性環加氧酶-2抑制劑,也是伐地昔布可注射的前驅藥物,它能有效的緩解術後疼痛。在此隨機、雙盲、安慰劑對照的研究中,我們對單次肌注40 mg帕瑞考昔鈉和單次肌注6 mg12 mg嗎啡控制婦產科剖腹手術後疼痛的效果進行了對比。根據幾乎所有的功效測定值(包括總體疼痛緩解度和患者對此研究性治療的總體評估),肌注40 mg帕瑞考昔鈉能緩解疼痛並降低疼痛的強度,其效果與肌注12 mg嗎啡相比無統計學差異,並明顯優於肌注6 mg嗎啡。相較於兩種劑量的嗎啡,肌注40 mg帕瑞考昔鈉處理的病人追加鎮痛藥物的時間較晚,且此劑量能持續緩解疼痛達12小時。各治療組的不良反應發生率同安慰劑組相同。上述結果顯示40 mg帕瑞考昔鈉同臨床上有關劑量的嗎啡在控制婦產科剖腹手術術後疼痛上同樣有效。

(趙雪蓮 李士通 校)

Parecoxib sodium, the injectable prodrug of valdecoxib, is a cyclooxygenase-2-specific inhibitor that is effective in the treatment of postoperative pain. In this randomized, double-blind, placebo-controlled study, we compared the efficacy of a single dose of parecoxib sodium 40 mg IM with single doses of morphine 6 and 12 mg IM in treating postoperative pain after gynecologic surgery requiring a laparotomy incision. By nearly all efficacy measures (including total pain relief and patient's global evaluation of study medication), parecoxib sodium 40 mg IM demonstrated pain relief and a decrease in pain intensity that was statistically similar to that with morphine 12 mg IM and superior to that with morphine 6 mg IM. Parecoxib sodium 40 mg IM-treated patients also demonstrated a longer time to use of rescue medication than patients treated with both morphine doses, and this dose provided sustained pain relief over the 12-h study period. The incidence of adverse events in the active treatment groups was similar to that observed with placebo. Parecoxib sodium, 40 mg IM, has been shown to be as effective as clinically relevant doses of morphine in patients after gynecologic laparotomy surgery.


注射小劑量氯胺酮可改善全膝關節成形術後鎮痛及康復

Small-Dose Ketamine Infusion Improves Postoperative Analgesia and Rehabilitation After Total Knee Arthroplasty

 

Frédéric Adam, MD, Marcel Chauvin, MD, Bertrand Du Manoir, MD, Mathieu Langlois, MD, Daniel I. Sessler, MD, and Dominique Fletcher, MD

Departments of Anesthesia and INSERM E 332, Hôpital Ambroise Pare, Assistance Publique-Hôpitaux de Paris, 92100 Boulogne, France; Hôpital Raymond Poincaré, Assistance Publique Hôpitaux de Paris, 92428 Garches, France; and the Outcomes ResearchTM Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Anesth Analg 2005;100:475-480

 

我們設計該試驗以評估靜脈注射小劑量氯胺酮複合持續股神經阻滯對於全膝關節成形術後疼痛和康復的作用。術前以0.3 mL/kg 0.75%羅呱卡因行股神經阻滯,術後在外科病房繼以0.2%羅呱卡因以0.1 mL · kg–1 · h–1速度行持續股神經阻滯48小時。病人隨機分為兩組,一組在術中靜脈注射0.5 mg/kg初始劑量的氯胺酮後繼以3 µg · kg–1 · min–1速度靜脈持續輸注氯胺酮,術後以1.5 µg · kg–1 · min–1速度持續輸注氯胺酮48小時(氯胺酮組);另一組給予同樣容量的生理鹽水(對照組)。術後病人自控靜脈輸注嗎啡以提供附加的術後鎮痛。記錄48小時裏的疼痛評分和嗎啡用量。每天記錄病人膝關節主動屈曲可忍受的最大幅度直至病人出院。手術後6周和3個月對病人進行隨訪。氯胺酮組嗎啡需求量少於對照組(45 ± 20 mg69 ± 30mgP < 0.02)。氯胺酮組病人比對照組更快達到膝關節可主動屈曲90°(兩組中位數7天對12天;25--75%可信限5—11天對8—15; P < 0.03)。術後6周和3個月的預後兩組相似。以上結果證實氯胺酮是圍手術期多方式鎮痛中的有效輔助鎮痛用藥,且對於膝蓋早期活動有積極作用。兩組病人均未報告出現鎮靜、幻覺、噩夢或複視,且兩組間噁心和嘔吐的發生率也無顯著差異。

(周雅春 李士通 校)

We designed this study to evaluate the effect of small-dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty. Continuous femoral nerve block was started with 0.3 mL/kg of 0.75% ropivacaine before surgery and continued in the surgical ward for 48 h with 0.2% ropivacaine at a rate of 0.1 mL · kg–1 · h–1. Patients were randomly assigned to receive an initial bolus of 0.5 mg/kg ketamine followed by a continuous infusion of 3 µg · kg–1 · min–1 during surgery and 1.5 µg · kg–1 · min–1 for 48 h (ketamine group) or an equal volume of saline (control group). Additional postoperative analgesia was provided by patient-controlled IV morphine. Pain scores and morphine consumption were recorded over 48 h. The maximal degree of active knee flexion tolerated was recorded daily until hospital discharge. Follow-up was performed 6 wk and 3 mo after surgery. The ketamine group required significantly less morphine than the control group (45 ± 20 mg versus 69 ± 30 mg; P < 0.02). Patients in the ketamine group reached 90° of active knee flexion more rapidly than those in the control group (at 7 [5–11] versus 12 [8–45] days, median [25%–75% interquartile range]; P < 0.03). Outcomes at 6 wk and 3 mo were similar in each group. These results confirm that ketamine is a useful analgesic adjuvant in perioperative multimodal analgesia with a positive impact on early knee mobilization. No patient in either group reported sedation, hallucinations, nightmares, or diplopia, and no differences were noted in the incidence of nausea and vomiting between the two groups.

 

環周性調整超聲探頭位置以確定穿刺頸內靜脈的最佳徑路:對成人無創性幾何研究

Circumferential Adjustment of Ultrasound Probe Position to Determine the Optimal Approach to the Internal Jugular Vein: A Noninvasive Geometric Study in Adults

 

James M. Riopelle, MD*, Darren P. Ruiz, MD*, John P. Hunt, MD{dagger}, Mark R. Mitchell, MD*, J. Carlos Mena, MD, Jason A. Rigol, MD*, Bruno C. Jubelin, PhD{ddagger}, Arthur J. Riopelle, PhD§, Valeriy V. Kozmenko, MD*, and Matthew K. Miller, MD*

Departments of *Anesthesiology, {dagger}Surgery, ¶Radiology, and {ddagger}Medicine, Louisiana State University Health Sciences Center at New Orleans, New Orleans, Louisiana; and §Department of Psychology, Louisiana State University, Baton Rouge, Louisiana

Anesth Analg 2005;100:512-519

 

 環頸部調整二維超聲(US)探頭位置常被推薦作為一種在頸內靜脈(IJV)置管時減少誤穿頸總動脈機率的方法。我們獲得並分析了107個成人的雙側頸部高分辨US多重圖像,以確定利用該方法來辨認從皮膚至IJV的徑路,使頸部動靜脈重疊最少而靜脈目標(角的)寬度最大。該方法在確定穿刺IJV徑路方面始終優於四種常用的利用表面解剖標誌確定穿刺徑路方法(“盲法”),並且在用US指導的下列情況更有效:1)調整頭部轉動程度,2)在高和低的途徑之間選擇及3)在左與右IJV間選擇。利用高解析度超聲圖像儀也有助於辯認可能與選擇最佳穿刺IJV通路有關的其他頸部解剖結構(非目標的靜脈、淋巴結和甲狀腺)的精確邊界。

(王立中 李士通 校)

Circumferential adjustment of the position of a two-dimensional ultrasound (US) probe around the neck has been recommended as a strategy for reducing the potential for unintentional common carotid artery puncture during internal jugular venous (IJV) cannulation. We obtained multiple high-resolution US images bilaterally from the necks of 107 adult subjects and analyzed these to determine the degree to which this strategy permits identification of a pathway from the skin to the IJV that minimizes venoarterial overlap while maximizing venous target (angular) width. The method consistently permitted identification of an approach to the IJV superior to that obtainable with any one of four popular surface anatomy-based ("blind") approaches and was even more powerful if used in concert with a US-guided 1) adjustment of the degree of head rotation, 2) choice between a high and low approach, and 3) choice between the right and left IJV. Use of a high-resolution US imaging device also permitted identification of the precise boundaries of additional cervical anatomic structures (nontarget vessels, lymph nodes, and the thyroid gland) potentially relevant to selection of an optimal approach to the IJV.


神經外科手術患者長期應用苯妥英或卡馬西平治療影響順式阿曲庫銨引起的神經肌肉阻滯作用

Cisatracurium-Induced Neuromuscular Blockade Is Affected by Chronic Phenytoin or Carbamazepine Treatment in Neurosurgical Patients

Anouk Richard, MD, FRCPC*, François Girard, MD, FRCPC*, Dominique C. Girard, MD, FRCPC*, Daniel Boudreault, MD, FRCPC*, Philippe Chouinard, MD, FRCPC*, Robert Moumdjian, MD, FRCS{dagger}, Alain Bouthilier, MD, FRCS{dagger}, Monique Ruel, RN, CCRP*, Johanne Couture, RT{ddagger}, and France Varin, Bpharm, PhD{ddagger}

*Department of Anesthesiology and {dagger}Neurosurgery Division, CHUM, Hôpital Notre-Dame; and {ddagger}Faculty of Pharmacy, Université de Montréal, Montréal, Canada

Anesth Analg 2005;100:538-544

 

慢性抗驚厥治療(CAT)對順式阿曲庫銨的神經肌肉阻滯作用的維持和恢復的影響還未被充分地研究。在本研究中,我們比較應用或不應用CAT的患者長時間輸注順式阿曲庫銨的藥代動力學和藥效動力學。30位進行顱內手術的患者入選本研究:15位元患者應用CAT(卡馬西平和苯妥英,A組)和15位患者作為對照不進行抗驚厥治療(C組)。麻醉標準化,兩組均給予一個劑量的順式阿曲庫銨然後持續輸注保持肌顫搐抑制95%。獲得穩態後再持續輸注兩小時。然後使神經肌肉阻滯自然恢復。測量順式阿曲庫銨血漿濃度的血樣在穩態期間(Cp ss 95)和恢復的不同時間採集。兩組人口統計學資料和術中情況相似。CAT使第一個肌顫搐恢復到25%75%更快。保持肌顫搐抑制95%的穩態所需的順式阿曲庫銨的輸注速率在A組要快44% P < 0.001)。與C組相比A組順式阿曲庫銨的清除明顯要快(7.12 ± 1.87 vs 5.72 ± 0.70 L · kg –1 · min –1P = 0.01)。Cpss95A組也明顯要高(191 ± 45 vs 159 ± 36 ng/mLP = 0.04)。另外,應用CAT的患者順式阿曲庫銨的清除增加20%,從而使肌松藥輸注後神經肌肉阻滯的恢復更快。同樣,應用CAT的患者Cpss95增加20%,表明對順式阿曲庫銨作用的耐藥性增加。

(陳瑋    李士通 校)

The effect of chronic anticonvulsant therapy (CAT) on the maintenance and recovery profiles of cisatracurium-induced neuromuscular blockade has not been adequately studied. In this study, we compared the pharmacokinetics and pharmacodynamics of cisatracurium after a prolonged infusion in patients with or without CAT. Thirty patients undergoing intracranial surgery were enrolled in the study: 15 patients under CAT (carbamazepine and phenytoin, Group A) and 15 controls receiving no anticonvulsant therapy (Group C). Anesthesia was standardized and both groups received a bolus of cisatracurium followed by an infusion to maintain a 95% twitch depression. A steady-state was obtained and the infusion was kept constant for 2 additional hours. Neuromuscular blockade was then allowed to spontaneously recover. Blood samples were taken for measurement of cisatracurium plasma concentration during the steady-state period (Cpss95) and at various times during recovery. Demographic and intraoperative data were similar. CAT resulted in faster 25% and 75% recovery of the first twitch. The rate of infusion of cisatracurium needed to maintain a 95% twitch depression at steady-state was 44% faster in Group A (P < 0.001). The clearance of cisatracurium was significantly faster in Group A when compared with Group C (7.12 ± 1.87 versus 5.72 ± 0.70 L · kg–1 · min–1, P = 0.01). The Cpss95 was also significantly larger in Group A (191 ± 45 versus 159 ± 36 ng/mL, P = 0.04). In addition, patients receiving CAT had a 20% increase in the clearance of cisatracurium that, in turn, resulted in a faster recovery of neuromuscular blockade after an infusion of the drug. Also, patients under CAT had a 20% increase in their Cpss95, indicating an increased resistance to the effect of cisatracurium.

 

2-氯普魯卡因脊麻:在志願者中與小劑量布比卡因比較

Spinal 2-Chloroprocaine: A Comparison with Small-Dose Bupivacaine in Volunteers

Jessica R. Yoos, MD, and Dan J. Kopacz, MD

Department of Anesthesiology, Virginia Mason Clinic, Seattle, Washington

Anesth Analg 2005;100:566-572

 

在全國範圍內,門診手術量呈持續上升 。由於利多卡因脊麻存在與之相關的一過性神經症狀,因此許多臨床醫師在門診手術時轉而選用小劑量布比卡因進行脊麻。然而,布比卡因常常不能提供充分的手術麻醉效果,時效也很難預料。所以,不含防腐劑的2-氯普魯卡因(2-CP)又再度成為門診脊麻的選擇之一。我們設計了這個雙盲、隨機、交叉、志願者試驗來比較2-CP 40mg和小劑量布比卡因7.5mg的脊麻效果。觀察指標為針刺麻醉水平、運動肌力、對止血帶和電刺激的耐受性以及模擬出院標準。兩組之間,阻滯的峰平面(2-CP平均到T7 [範圍T3–10]; 布比卡因平均到T9 [範圍T4–L1])、消退到L1的時間 (2-CP 64 ± 10 min對布比卡因 87 ± 41 min)及止血帶耐受時間(2-CP 52 ± 11 min對布比卡因60 ± 27 min)沒有顯著差異(P 值分別為 0.150.120.40)。然而,布比卡因組的模擬出院時間(包括阻滯完全消退時間、下床活動時間和自然排便時間)顯著較長(2-CP113 ± 14min, 布比卡因191 ± 30 min, P = 0.0009)。受試者中未見一過性神經症狀表現和其他副反應。我們得出結論,與7.5mg布比卡因相比,使用2-CP進行門診手術脊麻可以提供充分的麻醉時效和阻滯深度,而且阻滯消退及恢復到離床活動顯著加快。

(周志堅 李士通 )

Ambulatory surgery continues to increase nationwide. Because spinal lidocaine is associated with transient neurologic symptoms, many clinicians have switched to small-dose bupivacaine for outpatient spinal anesthesia. However, bupivacaine often produces inadequate surgical anesthesia and has an unpredictable duration. Preservative-free 2-chloroprocaine (2-CP) has reemerged as an alternative for outpatient spinal anesthesia. We designed this double-blind, randomized, crossover, volunteer study to compare 40 mg of 2-CP with small-dose (7.5 mg) bupivacaine with measures of pinprick anesthesia, motor strength, tolerance to tourniquet and electrical stimulation, and simulated discharge criteria. Peak block height (2-CP average T7 [range T3–10]; bupivacaine average T9 [range T4–L1]), regression to L1 (2-CP 64 ± 10 versus bupivacaine 87 ± 41 min), and tourniquet tolerance (2-CP 52 ± 11 versus bupivacaine 60 ± 27 min) did not differ between drugs (P = 0.15, 0.12, and 0.40, respectively). However, time to simulated discharge (including time to complete block regression, ambulation, and spontaneous voiding) was significantly longer with bupivacaine (2-CP 113 ± 14, bupivacaine 191 ± 30 min, P = 0.0009). No subjects reported transient neurologic symptoms or other side effects. We conclude that spinal 2-CP provides adequate duration and density of block for ambulatory surgical procedures, and has significantly faster resolution of block and return to ambulation compared with 7.5 mg of bupivacaine.

 

成人頸深部感染的氣道管理:病例系列和文獻回顧

Airway Management in Adult Patients with Deep Neck Infections: A Case Series and Review of the Literature

Andranik Ovassapian, MD*, Meltem Tuncbilek, MD{dagger}, Erik K. Weitzel, MD{ddagger}, and Chandrashekhar W. Joshi, MD{dagger}

*Department of Anesthesia and Critical Care, the University of Chicago, Chicago Illinois; {dagger}Department of Anesthesiology, Northwestern University, Chicago, Illinois, and {ddagger}Department of Otolaryngology and Communication Sciences, Baylor College of Medicine, Houston, Texas

Anesth Analg 2005;100:585-589

 

患有頸深部感染的病人,尤其是那些有路德維格咽痛的病人,很可能死於氣道管理失誤。這些病人非常需要熟練的氣道管理,但是現在仍未建立一種安全的控制氣道的方法。我們對患頸深部感染的病人通過表面麻醉行纖維支氣管鏡引導氣管插管,以提供全身麻醉用於手術干預。用專門的資料收集表格記錄病人的特點和插管方法。26例病人中,17例患路德維格咽痛,其餘9例患其他類型頸深部感染。3例病人在坐位,2例在福勒氏體位,21例在仰臥頭抬高10°–15°行氣管插管。25例病人氣管插管成功:19例經鼻,6例經口。手術後7例病人保留氣管導管,5例病人實施氣管切開。併發症限於3例輕微鼻衄、4例鎮靜過度伴短暫低氧血症。12例病人知曉部分手術情況,其中2例認為是不愉快的。表面麻醉後纖維支氣管鏡引導氣管插管用於患頸深部感染的成年病人是非常成功的。如果不能使用纖維支氣管鏡、臨床醫生沒有熟練掌握清醒纖維支氣管鏡引導氣管插管、或者插管失敗,建議局麻下行氣管切開術。

(張瑩 李士通 校)

Patients with deep neck infections, especially those with Ludwig’s angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig’s angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler’s position, and 21 in the supine position with the head up 10°–15°. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.