Anesthesia & Analgesia

March 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

七氟醚而非异丙酚在微创直接冠脉搭桥手术中具有保护心肌功能的作用

(王柯 薛张纲 校)

Sevoflurane but Not Propofol Preserves Myocardial Function During Minimally Invasive Direct Coronary Artery Bypass Surgery

Berthold Bein, Jochen Renner, Dorothee Caliebe, Jens Scholz, Andrea Paris, Sandra Fraund, Wiebke Zaehle, and Peter H. Tonner

Anesth Analg 2005 100: 610-616.

 

有和无气腹时的肝门阻断的血液动力学影响:一项超声心动图研究

(彭中美 李士通 )

Hemodynamic Effects of Portal Triad Clamping With and Without Pneumoperitoneum: An Echocardiographic Study

François Decailliot, Birgit Streich, Yves Heurtematte, Philippe Duvaldestin, Daniel Cherqui, and François Stéphan

Anesth Analg 2005 100: 617-622.

 

简化锁骨下静脉置管的解剖标志:三角肌粗隆

(齐波 译 陈杰 校)

An Anatomic Landmark to Simplify Subclavian Vein Cannulation: The "Deltoid Tuberosity" (Technical Communication)

Achim von Goedecke, Christian Keller, Bernhard Moriggl, Volker Wenzel, Reto Bale, Martina Deibl, Patrizia Moser, and Philipp Lirk

Anesth Analg 2005 100: 623-628.

右旋美托咪定对离体大鼠心脏缺氧-再充氧性左室功能不全的效能

(王丽珺 薛张纲 )

The Effects of Dexmedetomidine on Left Ventricular Function During Hypoxia and Reoxygenation in Isolated Rat Hearts

Huan Guo, Shunji Takahashi, Sungsam Cho, Tetsuya Hara, Shiro Tomiyasu, and Koji Sumikawa

Anesth Analg 2005 100: 629-635.

血管紧张素抑制剂在普外科手术人群中的运用

(裘毅敏 李士通 )

Angiotensin System Inhibitors in a General Surgical Population

Thomas Comfere, Juraj Sprung, Matthew M. Kumar, Myongsu Draper, Diana P. Wilson, Brent A. Williams, David R. Danielson, Lavonne Liedl, and David O. Warner

Anesth Analg 2005 100: 636-644.

 

术中血液回收:补液的计算

(齐波 译 陈杰 校)

Intraoperative Blood Salvage: Fluid Replacement Calculations (Special Article)

John C. Drummond and Charise T. Petrovitch

Anesth Analg 2005 100: 645-649.

PEDIATRIC ANESTHESIA:

小儿麻醉术中知晓: 一组前瞻性研究

( 薛张纲 校)

Awareness During Anesthesia in Children: A Prospective Cohort Study

Andrew J. Davidson, Grace H. Huang, Caroline Czarnecki, Margaret A. Gibson, Stephanie A. Stewart, Kris Jamsen, and Robyn Stargatt

Anesth Analg 2005 100: 653-661.

 

儿童患者鞘内绝缘针电刺激的阈值电流探讨

(周志坚  李士通 )

Threshold Current of an Insulated Needle in the Intrathecal Space in Pediatric Patients

Ban C.H. Tsui, Alese M. Wagner, Kirsten Cunningham, Shirley Perry, Sunil Desai, and Robert Seal

Anesth Analg 2005 100: 662-665.  

 

糖尿病治疗的新进展:麻醉方面的意义

(朱慧琛 译 陈杰 校)

Advances in Diabetic Management: Implications for Anesthesia (Review Article)

Zulfiqar Ahmed, Charles H. Lockhart, Molly Weiner, and Georgiana Klingensmith

Anesth Analg 2005 100: 666-669.  

AMBULATORY ANESTHESIA:

术前静脉液体疗法减少高危病人术后恶心和疼痛

(周晓敏 薛张纲 )

Preoperative Intravenous Fluid Therapy Decreases Postoperative Nausea and Pain in High Risk Patients

C. H. Maharaj, S. R. Kallam, A. Malik, P. Hassett, D. Grady, and J. G. Laffey

Anesth Analg 2005 100: 675-682.

ANESTHETIC PHARMACOLOGY:

右旋美托咪定减少布比卡因和左旋布比卡因对大鼠的致惊厥潜能:{alpha}2-肾上腺素受体涉及控制惊厥

( 李士通 校)

Dexmedetomidine Decreases the Convulsive Potency of Bupivacaine and Levobupivacaine in Rats: Involvement of {alpha}2-Adrenoceptor for Controlling Convulsions

Katsuaki Tanaka, Yutaka Oda, Tomoharu Funao, Ryota Takahashi, Naoya Hamaoka, and Akira Asada

Anesth Analg 2005 100: 687-696.

 

地氟醚麻醉后的气道反射恢复比七氟醚麻醉更迅速

(朱慧琛 译 陈杰 校)

Airway Reflexes Return More Rapidly After Desflurane Anesthesia Than After Sevoflurane Anesthesia

Rachel Eshima Mckay, Mary Jane C. Large, Michel C. Balea, and Warren R. Mckay

Anesth Analg 2005 100: 697-700.

 

GPI 15715 -一种水溶性的异丙酚前体对志愿者进行TCI输注产生镇静作用

(许文妍 薛张纲 )

Sedation with GPI 15715, a Water-Soluble Prodrug of Propofol, Using Target-Controlled Infusion in Volunteers

Jörg Fechner, Harald Ihmsen, Christine Schiessl, Christian Jeleazcov, James J. Vornov, Helmut Schwilden, and Jürgen Schüttler

Anesth Analg 2005 100: 701-706.

 

心脏毒性浓度的布比卡因和罗哌卡因对冠状血管阻力的对映体选择性作用

(沈浩 李士通 校)

Enantioselective Actions of Bupivacaine and Ropivacaine on Coronary Vascular Resistance at Cardiotoxic Concentrations

Marko D. Burmester, Klaus-Dieter Schlüter, Jürgen Daut, and Peter J. Hanley

Anesth Analg 2005 100: 707-712.

 

一种新的具有外周阿片特性的药物氟雷法胺和吗啡、安慰剂对静息通气影响的比较研究

(顾漪闻 译 陈杰 校)

A Novel Molecule (Frakefamide) with Peripheral Opioid Properties: The Effects on Resting Ventilation Compared with Morphine and Placebo

Åsa Österlund Modalen, Hans Quiding, Joana Frey, Lars Westman, and Sten Lindahl

Anesth Analg 2005 100: 713-717.

 

拇内收肌监测神经肌阻滞方法中主利手不改变肌电图监测结果

(蔡美华 薛张纲 )

Dominance of the Hand Does Not Change the Phonomyographic Measurement of Neuromuscular Block at the Adductor Pollicis Muscle (Technical Communication)

Guillaume Michaud, Guillaume Trager, Stéphane Deschamps, and Thomas M. Hemmerling

Anesth Analg 2005 100: 718-721.

TECHNOLOGY, COMPUTING, AND SIMULATION:

在清醒相和七氟醚全麻期间硬膜外罗哌卡因麻醉降低双谱指数

(马皓琳 李士通 校)

Epidural Ropivacaine Anesthesia Decreases the Bispectral Index During the Awake Phase and Sevoflurane General Anesthesia

Tadahiko Ishiyama, Satoshi Kashimoto, Takeshi Oguchi, Toshiaki Yamaguchi, Katsumi Okuyama, and Teruo Kumazawa

Anesth Analg 2005 100: 728-732.

 

七氟醚麻醉时短效β1受体拮抗药艾司洛尔和兰地洛尔抑制气管插管时的双频指数反应

(顾漪闻 译 陈杰 校)

The Short-Acting ß1-Adrenoceptor Antagonists Esmolol and Landiolol Suppress the Bispectral Index Response to Tracheal Intubation During Sevoflurane Anesthesia

Yutaka Oda, Kiyonobu Nishikawa, Ichiro Hase, and Akira Asada

Anesth Analg 2005 100: 733-737.

 

三种手术用消毒铺巾的表皮热量损失,一种为密封而潮湿铺巾

(孙志荣译 薛张纲校)

Cutaneous Heat Loss with Three Surgical Drapes, One Impervious to Moisture

Paul E. Maglinger, Daniel I. Sessler, and Rainer Lenhardt

Anesth Analg 2005 100: 738-742.

 

静脉搏动对前额脉搏血氧波形的影响是Spo2计算错误的可能原因 

(张曦 李士通 校)

The Effect of Venous Pulsation on the Forehead Pulse Oximeter Wave Form as a Possible Source of Error in Spo2 Calculation

Kirk H. Shelley, Doris Tamai, Denis Jablonka, Michael Gesquiere, Robert G. Stout, and David G. Silverman

Anesth Analg 2005 100: 743-747.

 

对麻醉狗使用主动脉流量探测仪检测新型超声多普勒心排量监测仪(USCOM)的可靠性

(朱辉 译 陈杰 校)

Testing the Reliability of a New Ultrasonic Cardiac Output Monitor, the USCOM, by Using Aortic Flowprobes in Anesthetized Dogs

Lester A. Critchley, Zhi Y. Peng, Benny S. Fok, Anna Lee, and Robert A. Phillips

Anesth Analg 2005 100: 748-753.

PAIN MEDICINE:

 

超前镇痛对急性术后镇痛的疗效:一项荟萃分析

(王丽珺译 薛张纲校)

The Efficacy of Preemptive Analgesia for Acute Postoperative Pain Management: A Meta-Analysis (Editorial)

Cliff K.-S. Ong, Philipp Lirk, Robin A. Seymour, and Brian J. Jenkins

Anesth Analg 2005 100: 757-773.

 

大鼠术后疼痛模型中在神经周围应用Resiniferatoxin预防痛觉过敏

(黄施伟 李士通 校)

Perineural Resiniferatoxin Prevents Hyperalgesia in a Rat Model of Postoperative Pain (Editorial)

Igor Kissin, Natasha Davison, and Edwin L. Bradley, Jr

Anesth Analg 2005 100: 774-780.

 

口服小剂量可乐定对腹式子宫切除术病人围术期结果的临床效应

(王立中 李士通 校)

The Clinical Effect of Small Oral Clonidine Doses on Perioperative Outcomes in Patients Undergoing Abdominal Hysterectomy

Maria Paz Loayza Hidalgo, Jorge Alberto Szimanski Auzani, Leandro Carpenedo Rumpel, Nívio Lemos Moreira, Jr, Arthur Werneck Costa Cursino, and Wolnei Caumo

Anesth Analg 2005 100: 795-802.

CRITICAL CARE AND TRAUMA:

利用先进的模拟方法识别和纠正院前外伤病人气道和呼吸处理技能中的缺陷

(朱辉 译 陈杰 校)

Using Advanced Simulation for Recognition and Correction of Gaps in Airway and Breathing Management Skills in Prehospital Trauma Care

Daphna Barsuk, Amitai Ziv, Guy Lin, Amir Blumenfeld, Orit Rubin, Ilan Keidan, Yaron Munz, and Haim Berkenstadt

Anesth Analg 2005 100: 803-809.

 

内毒素血症患者使用异丙酚减弱急性肺损伤

( 薛张纲 )

Attenuation of Acute Lung Injury with Propofol in Endotoxemia

Yumiko Takao, Katsuya Mikawa, Kahoru Nishina, and Hidefumi Obara

Anesth Analg 2005 100: 810-816.

 

创伤和缺血对仓鼠皮瓣组织糖代谢的影响

(轩泓 李士通 校)

The Influence of Trauma and Ischemia on Carbohydrate Metabolites Monitored in Hamster Flap Tissue

Claudio Contaldo, Jan Plock, Valentin Djonov, Michael Leunig, Andrej Banic, and Dominique Erni

Anesth Analg 2005 100: 817-822.

 

脓毒血症阶段非去极化肌松药对鼠离体膈肌作用削弱的依赖性和差异性

(殷文渊 陈杰 )

Sepsis Stage Dependently and Differentially Attenuates the Effects of Nondepolarizing Neuromuscular Blockers on the Rat Diaphragm In Vitro

Eichi Narimatsu, Tomohisa Niiya, Mikito Kawamata, and Akiyoshi Namiki

Anesth Analg 2005 100: 823-829.

 

局部单纯应用重组人碱性成纤维细胞生长因子可加速家兔耳室创伤愈合期间初期血管生成

(孙敏莉 薛张纲 )

A Single Local Application of Recombinant Human Basic Fibroblast Growth Factor Accelerates Initial Angiogenesis During Wound Healing in Rabbit Ear Chamber

Makiko Komori, Yasuko Tomizawa, Katsumi Takada, and Makoto Ozaki

Anesth Analg 2005 100: 830-834.

NEUROSURGICAL ANESTHESIA:

异丙酚或七氟醚对估计脑灌注压和零流动压的影响

(赵雪莲 李士通 校)

The Effects of Propofol or Sevoflurane on the Estimated Cerebral Perfusion Pressure and Zero Flow Pressure

Paul D. Marval, Mandy E. Perrin, Sally M. Hancock, and Ravi P. Mahajan

Anesth Analg 2005 100: 835-840.

 

大鼠局灶性脑缺血模型中一氧化氮合成酶抑制剂对依托咪酯不良反应的作用

(殷文渊 陈杰 )

The Role of Nitric Oxide Synthase Inhibition in the Adverse Effects of Etomidate in the Setting of Focal Cerebral Ischemia in Rats

John C. Drummond, Lorne D. McKay, Daniel J. Cole, and Piyush M. Patel

Anesth Analg 2005 100: 841-846.

 

大鼠脊髓缺血后白质损伤的评估:与灰质损伤的比较

(沈洪 薛张纲 )

An Evaluation of White Matter Injury After Spinal Cord Ischemia in Rats: A Comparison with Gray Matter Injury

Naoko Kurita, Masahiko Kawaguchi, Toshinori Horiuchi, Satoki Inoue, Takanori Sakamoto, Mitsutoshi Nakamura, Noboru Konishi, and Hitoshi Furuya

Anesth Analg 2005 100: 847-854.

REGIONAL ANESTHESIA:

神经轴麻醉时心搏骤停:发生率和生存影响因素

(张莹 李士通 校)

Cardiac Arrest During Neuraxial Anesthesia: Frequency and Predisposing Factors Associated with Survival

Sandra L. Kopp, Terese T. Horlocker, Mary Ellen Warner, James R. Hebl, Claude A. Vachon, Darrell R. Schroeder, Allan B. Gould, Jr, and Juraj Sprung

Anesth Analg 2005 100: 855-865.

 

持续股神经阻滞时负荷量及术后所用的药液中加入可乐定可延迟全膝关节成形术后运动功能的恢复

(赵延华 陈杰 )

Adding Clonidine to the Induction Bolus and Postoperative Infusion During Continuous Femoral Nerve Block Delays Recovery of Motor Function After Total Knee Arthroplasty

Andrea Casati, Federico Vinciguerra, Gianluca Cappelleri, Giorgio Aldegheri, Guido Fanelli, Marta Putzu, and Jacques E. Chelly

Anesth Analg 2005 100: 866-872.

 

可乐定静脉给药而非神经周围给药途径能延长腰大肌间隙阻滞髋部骨折术后镇痛效果

(吴德华 薛张纲 )

Intravenous but Not Perineural Clonidine Prolongs Postoperative Analgesia After Psoas Compartment Block with 0.5% Levobupivacaine for Hip Fracture Surgery

Stephen Mannion, Ivan Hayes, Frank Loughnane, Damian B. Murphy, and George D. Shorten

Anesth Analg 2005 100: 873-878.

GENERAL ARTICLES:

阻塞性肺疾病的二氧化碳曲线图形

(陈玮    李士通 校)

Capnogram Shape in Obstructive Lung Disease

Baruch Krauss, Aaron Deykin, Alexander Lam, Joan J. Ryoo, David R. Hampton, Paul W. Schmitt, and Jay L. Falk

Anesth Analg 2005 100: 884-888.

 

气道峰压增加是气管导管部分阻塞的晚期报警信号而呼气流速的变化是早期报警信号

(赵延华 陈杰 )

Peak Airway Pressure Increase Is a Late Warning Sign of Partial Endotracheal Tube Obstruction Whereas Change in Expiratory Flow Is an Early Warning Sign

Rafael Kawati, Marco Lattuada, Ulf Sjöstrand, Josef Guttmann, Göran Hedenstierna, Alois Helmer, and Michael Lichtwarck-Aschoff

Anesth Analg 2005 100: 889-893.

 

七氟醚而非异丙酚在微创直接冠脉搭桥手术中具有保护心肌功能的作用

Sevoflurane but Not Propofol Preserves Myocardial Function During Minimally Invasive Direct Coronary Artery Bypass Surgery

Berthold Bein, MD, Jochen Renner, MD, Dorothee Caliebe, MD, Jens Scholz, MD, Andrea Paris, MD, Sandra Fraund, MD, Wiebke Zaehle, and Peter H. Tonner, MD

Department of Anaesthesiology and Intensive Care Medicine and Department of Cardiothoracic and Vascular Surgery University Hospital Schleswig-Holstein, Campus Kiel, Germany

Anesth Analg 2005 100:610-616.

 

在实验研究和临床研究中,挥发性麻醉药具有心肌保护的特性。我们设计了这次研究来评价在无心肺转流的微创直接冠脉搭桥(MIDCAB)手术中七氟醚对于左心室功能的保护作用。我们随机地把52位要进行MIDCAB手术的患者分成异丙酚组和七氟醚组。除了这些使用的麻醉药,手术和麻醉管理在2组并无不同。我们测定了心肌肌钙蛋白T、肌酸肌酶、肌酸肌酶MB、心电图(ECG)和心超参数(心肌作功指数和早期心房充盈速率),之后夹闭冠状动脉左前降支直至左内乳动脉吻合完成。在左前降支阻断和再灌注期间,我们重复了心超测量、抽取血样一直到72小时。左前降支阻断之后,异丙酚组的心肌作功指数和早期心房充盈速率明显恶化,分别从0.40 ± 0.12 1.29 ± 0.35 变成 0.49 ± 0.10 1.13 ± 0.22,而七氟醚组却无此改变。异丙酚组在再灌注之后心肌作功指数仍较基线有明显的升高(0.47 ± 0.11)。心电图和实验室检查结果在2组之间无明显异常。总之,在患者行MIDCAB手术短期缺血期间,七氟醚较异丙酚有更好的心肌保护作用。

(王柯 薛张纲 校)

Volatile anesthetics exert cardioprotective properties in experimental and clinical studies. We designed this study to investigate the effects of sevoflurane on left ventricular (LV) performance during minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass. Fifty-two patients scheduled for MIDCAB surgery were randomly assigned to a propofol or a sevoflurane group. Apart from the anesthetics used, there was no difference in surgical and anesthetic management. After determination of cardiac troponin T, creatine kinase, and creatine kinase MB, electrocardiographic (ECG) data and echocardiography variables (myocardial performance index and early to atrial filling velocity ratio) the left anterior descending coronary artery (LAD) was clamped until anastomosis with the left internal mammary artery was completed. During LAD occlusion and during reperfusion, echocardiography measurements were repeated. Blood samples were obtained repeatedly for up to 72 h. After LAD occlusion, myocardial performance index and early to atrial filling velocity ratio in the propofol group deteriorated significantly from 0.40 ± 0.12 and 1.29 ± 0.35 to 0.49 ± 0.10 and 1.13 ± 0.22, respectively, whereas there was no change in the sevoflurane group. In the propofol group myocardial performance index remained increased (0.47 ± 0.11) compared with baseline during reperfusion. There were no significant differences in ECG and laboratory values between groups. In conclusion, during a brief period of ischemia in patients undergoing MIDCAB surgery, sevoflurane preserved myocardial function better than propofol.

 

右旋美托咪定对离体大鼠心脏缺氧-再充氧性左室功能不全的效能
The Effects of Dexmedetomidine on Left Ventricular Function During Hypoxia and Reoxygenation in Isolated Rat Hearts
Huan Guo, MD, Shunji Takahashi, MD, Sungsam Cho, MD, Tetsuya Hara, MD, Shiro Tomiyasu, MD, and Koji Sumikawa, MD
Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki, Japan
Address correspondence and reprint requests to Sungsam Cho, MD, Department of Anesthesiology, Nagasaki University School of Medicine, 1–7–1 Sakamoto, Nagasaki 852–8501, Japan.
Anesth Analg. 2005 Mar;100(3):629-35

在睡眠呼吸暂停的病人中,由于呼吸暂停导致的缺氧是心脏病的一个重要因素。我们设计了这一研究来验证对于那些缺乏系统的血流动力学和体液影响,而是由于缺氧-再充氧引起的左室功能不全,右旋美托咪定是否具有直接的保护作用。离体大鼠心脏暴露于60分钟的缺氧状态,随后10分钟再充氧。第一个试验,在缺氧状态前给予010100nM的右旋美托咪定(每组n=7),第二个试验(n=7),缺氧后给予100nM右旋美托咪定,第三个试验(n=7, 100nM右旋美托咪定联合或不联合育亨宾(一种α2受体拮抗剂)在缺氧后给予。结果表明,缺氧状态之前而非之后给予右旋美托咪定,显著提高了再充氧后左室压力的恢复(缺氧前给予010100nM的右旋美托咪定或缺氧后给予100nM右旋美托咪定的压力值分别为53 ± 6, 64 ± 9, 78 ± 13, o 62 ± 12 mm Hg [均数±标准差]),联合育亨宾后的压力值是58 ± 8 mm Hg。我们推断:右旋美托咪定对由于缺氧-再充氧性左室功能不全的直接保护作用主要是通过缺氧前和缺氧时对α2肾上腺受体的激动作用来实现的。

(王丽珺 薛张纲 )

Hypoxia resulting from apnea in patients with sleep apnea is an important factor in heart disease. We designed the present study to determine whether dexmedetomidine (DEX) has a direct protective effect against hypoxia-reoxygenation-induced left ventricular dysfunction without systemic hemodynamic and humoral effects. Isolated rat hearts were exposed to 60-min hypoxia followed by 30-min reoxygenation with 0, 10, or 100 nM DEX prehypoxia administration (n = 7 each group). In a second experiment (n = 7), 100 nM DEX was administered posthypoxia. In a third experiment (n = 7 each group), an 2 antagonist, yohimbine was given with and without 100 nM DEX prehypoxia administration. DEX prehypoxia, but not posthypoxia, administration significantly improved the recovery of left ventricular developed pressure after reoxygenation (0, 10, 100 nM DEX prehypoxia or 100 nM DEX posthypoxia values were 53 ± 6, 64 ± 9, 78 ± 13, or 62 ± 12 mm Hg [mean ± sd]) and reversed by yohimbine, 58 ± 8 mm Hg, respectively. We conclude that DEX exerts the direct protective effect on the left ventricular dysfunction caused by hypoxia-reoxygenation through mainly 2-adrenergic stimulation before and during the hypoxic period.

 

小儿麻醉术中知晓: 一组前瞻性研究

Awareness During Anesthesia in Children: A Prospective Cohort Study

Andrew J. Davidson, MBBS, GradDipEpiBiostats, FANZCA1.2, Grace H. Huang, BmedSci1, Caroline Czarnecki, BMedSci1, Margaret A. Gibson, BN, RN1, Stephanie A. Stewart, BN, RN1, Kris Jamsen, BSc, PGDip(Stats)3, and Robyn Stargatt, PhD, MAPS4

1.Department of Anaesthesia and Pain Management, The Royal Children’s Hospital, Parkville, Victoria, Australia; 2.Department of Pharmacology, University of Melbourne, Melbourne, Victoria, Australia; 3.Clinical Epidemiology and Biostatistics Unit, The Royal Children’s Hospital, Parkville, Victoria, Australia; 4.Department of Psychology, The Royal Children’s Hospital, Parkville, Victoria, Australia

Anesth Analg 2005 100: 629-635.

 

在常规的成人麻醉中,术中知晓的发生率为0.1%-0.2%。近期没有关于在儿童手术中麻醉中知晓发生率的研究的相关报道。由于药理过程和麻醉技术的不同,提示麻醉中知晓在儿童中的发生率可能不同于成年人。在本次同年龄组前瞻性研究中,探明了麻醉中知晓在儿童中的发生率。有864名在皇家儿童医院接受全麻的5-12岁的儿童,在三种不同的场合接受了精神检查,以测定麻醉中知晓的发生情况。关于麻醉中知晓的评估隐含在一个更大规模的关于麻醉后行为改变的研究中。被怀疑有麻醉中知晓的报告分送四位独立的专家审查。四位专家意见一致的病例被确认为发生了麻醉中知晓。有28份报告被怀疑发生了麻醉中知晓,其中7例被确认,发生率0.8%95%可信限为0.3%-0.7%)。在发生麻醉中知晓的儿童中只有一位使用了肌松药,而在没有发生麻醉中知晓的病例中有12%使用了肌松药。在发生了麻醉中知晓的儿童中没有感到痛苦的报道。在发生麻醉中知晓的儿童中有20%发生了行为改变,在没有发生麻醉中知晓的儿童中有16%发生了行为改变,两者无显著差别。本资料中有证据表明,和成人一样,儿童也有发生术中知晓的风险。虽然原因仍不清楚,但麻醉医师对儿童发生麻醉中知晓的可能性应引起警觉。

(金 薛张纲 校)

During routine adult anesthesia, the risk of awareness is 0.1%–0.2%. No recent studies have reported the incidence in children. Altered pharmacology and differing anesthesia techniques suggest that the incidence may differ in children. In this prospective cohort study, we determined the incidence of awareness during anesthesia in children. Eight-hundred-sixty-four children aged 5–12 yr who had undergone general anesthesia at The Royal Children’s Hospital were interviewed on 3 occasions to determine the incidence of awareness. The awareness assessment was nested within a larger study of behavior change after anesthesia. Reports of suspected awareness were sent to four independent adjudicators. If they all agreed, a case was classified as true awareness. Twenty-eight reports were generated. There were 7 cases of true awareness, for an incidence of 0.8% (95% confidence interval, 0.3%–1.7%). Only one aware child received neuromuscular blockers, compared with 12% in the nonaware group. No aware child reported distress, and no substantial difference was detected in behavior disturbance between aware (20%) and nonaware (16%) children. The data provide some evidence that, like adults, children are also at risk of intraoperative awareness. Although the cause remains unclear, anesthesiologists should be alerted to the possibility of awareness in children.

 

术前静脉液体疗法减少高危病人术后恶心和疼痛

Preoperative intravenous fluid therapy decreases postoperative nausea and pain in high risk patients.

Maharaj CH, Kallam SR, Malik A, Hassett P, Grady D, Laffey JG.

Department of Anaesthesia and Intensive Care Medicine, University College Hospital, Galway, Ireland.

Anesth Analg. 2005 Mar;100(3):675-82.

 

术前静脉液体疗法减少行不卧床手术的病人的术后恶心呕吐(PONV)和疼痛的作用程度仍存在争议。本研究拟明确使用平衡溶液行术前静脉液体疗法是否可以减少高危病人术后恶心呕吐的发生率。八十个ASA I-III级、拟行妇科腹腔镜手术的病人随机分为两组,术前分别接受大容量(2 mL/kg/h快速输注)和小容量(3 mL/kg)复合乳酸钠溶液静脉输注20分钟以上。使用一种标准化、作用平稳的麻醉药。术后0.5h1h4h,术后第1天和第3天由盲法调查员评估术后恶心呕吐和疼痛发生率及严重程度、需要追加止吐药和镇痛治疗的发生率及严重程度,大容量输注组在所有时间点的PONV的发生率(对照组87%、大容量组59%)及严重程度均有显著减少。大容量输注组还减小术后疼痛评分及减少追加镇痛药的需要量。在行不卧床手术的病人,术前纠正血容量不足可有效减少这些高危病人的术后恶心呕吐和疼痛。我们建议术前给予行不卧床手术的病人(PONV风险增加)2 mL/kg/h的复合乳酸钠溶液。

(周晓敏 薛张纲 校)

The potential for preoperative IV rehydration to reduce postoperative nausea and vomiting (PONV) and pain in patients undergoing ambulatory surgery remains unclear, with conflicting results reported. We sought to determine whether preoperative IV rehydration with a balanced salt solution would decrease the incidence of PONV in patients at increased risk for these symptoms. Eighty ASA grade I-III patients presenting for gynecologic laparoscopy were randomized to receive large (2 mL/kg per hour fasting) or small (3 mL/kg) volume infusions of compound sodium lactate solution over 20 min preoperatively. A standardized balanced anesthetic was used. The incidence and severity of PONV and pain, and need for supplemental antiemetic and analgesic therapy, were assessed by a blinded investigator at 0.5, 1, and 4 h postoperatively, and on the first and third postoperative days. The incidence (control 87% versus large volume 59%) and severity of PONV were significantly reduced in the large volume infusion group at all time intervals. The large volume infusion group also had decreased postoperative pain scores and required less supplemental analgesia. Preoperative correction of intravascular volume deficits effectively reduces PONV and postoperative pain in high risk patients presenting for ambulatory surgery. We recommend the preoperative administration of 2 mL/kg of compound sodium lactate for every hour of fasting to patients with an increased PONV risk presenting for ambulatory surgery.

 

GPI 15715 -一种水溶性的异丙酚前体对志愿者进行TCI输注产生镇静作用                           

Sedation with GPI 15715, a Water-Soluble Prodrug of Propofol, Using Target-Controlled Infusion in Volunteers.

Fechner, Jorg ; Ihmsen, Harald ; Schiessl, Christine ; Jeleazcov, Christian ; Vornov, James J. ; Schwilden, Helmut ; Schuttler, Jurgen

Department of Anesthesiology, University of Erlangen-Nuremberg, Erlangen, Germany; and +Guilford Pharmaceuticals Inc., Baltimore, Maryland

Anesthesia & Analgesia. 100(3):701-706, March 2005.

 

GPI 15715 是第一个用于人体研究的水溶性异丙酚前体。现今的异丙酚乳剂中存在一些不如人意的成分,比如;注射过程中的疼痛以及不断增加的甘油三酯浓度。我们研究是否 GPI 15715能够达到并维持2小时的镇静作用。6位男性和6位女性志愿者接受了一次GPI 15715 TCI输注,初始浓度在1.8ug/ml并在1小时后调整一次靶浓度;同时监测BIS 指数以及用改良的MOAA/S量表进行评估。在第一个小时内,MOAA/S的中值为4 ,到输注的第二个小时则为3。在7位受试者中,异丙酚靶浓度调整为2.4ug/ml;还有2位受试者调整至3.0ug/ml。当异丙酚的浓度维持在1.9ug/ml时最有可能使MOAA/S的评分为3,并维持中度的镇静。在此过程中,我们没有发现严重的副作用,并得出如下结论:GPI 15715可以产生理想的镇静作用。

(许文妍 薛张纲 校)

GPI 15715 is the first water-soluble propofol prodrug that has been studied in humans. Present propofol lipid formulations have well known undesirable properties, for example, pain on injection and increased triglyceride concentrations. We investigated whether GPI 15715 is suitable to achieve and maintain moderate sedation for 2 h. Six male and six female volunteers received a target-controlled infusion of GPI 15715, with an initial propofol target concentration of 1.8 [mu]g/mL and the possibility to adjust the propofol target once after 1 h. Propofol concentrations, the bispectral index, and modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) scores were monitored. The median MOAA/S score was 4 during the first hour and was 3 during the second hour of infusion. The propofol target had to be changed to 2.4 [mu]g/mL in seven volunteers and to 3.0 [mu]g/mL in two volunteers. A propofol concentration of 1.9 [mu]g/mL had the highest probability to result in an MOAA/S score of 3, which corresponds with moderate sedation. We observed no serious side effects. We conclude that GPI 15715 produces excellent sedation.

 

拇内收肌监测神经肌阻滞方法中主利手不改变肌电图监测结果

Dominance of the Hand Does Not Change the Phonomyographic Measurement of NeuromuscularBlock at the Adductor Pollicis Muscle

Guillaume Michaud, Guillaume Trager, MSc, Stéphane Deschamps, MSc, and Thomas M. Hemmerling, MD, DEAA From the Neuromuscular Research Group (NRG), Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal (CHUM) Hôtel-Dieu, Université de Montréal, Montréal, Canada Address correspondence and reprint requests to T. M. Hemmerling, MD, DEAA, Department of Anesthesiology, Université de Montréal, Hôtel-Dieu, 3580, rue St-Urbain, Montréal (Québec) H2W 1T8, Canada.

Anesth Analg 2005;100:718-721

肌音描记法(PMG)是一种新的监测神经肌阻滞(NMB)的方法有很高的敏感 性而且适用于所有肌肉。长久以来以拇内收肌为参照进行神经肌监测测运 用于研究和临床实践 。我们通过比较同一病人双手的PMG信号(四个成串 刺激比值和T1/T2的值)来研究神经肌监测中主利手的影响。在14位病人 中,双手大鱼际装有小型压电麦克风,用此来记录PMG。麻醉诱导后,双 侧尺神经每隔12秒有超强的TOF刺激。5秒内给予米库氯铵0.2mg/kg。然后 比较双手拇内收肌在药物起效,最大效应,NMB发生反应情况。受试者为 12名右利手和2名左利手。在主利手和非主利手的信号中没有显示统计差 异。相关性很好(r=0.95).一致性很好,-0.57%的偏倚和区间-17.9%到 16.7%(主利手-非主利手)。此研究揭示NMB方法监测拇内收肌反应在 主利手和非主利手之间很小的偏倚、良好的相关性、没有统计学差异。在 由拇内收肌监测NMB效应双手可以交替运用。

(蔡美华 薛张纲 校)

Phonomyography (PMG) is a novel method to determine neuromuscular blockade (NMB) with high sensitivity and applicability at all muscles. The adductor pollicis muscle has long been used in research and clinical practice as reference for neuromuscular monitoring. The goal of our study was to compare PMG signals (train-of-four [TOF] ratios and T1/T0 values) from both hands of the same patient to investigate the influence of hand dominance on neuromuscular monitoring. In 14 patients, PMG was recorded via small piezoelectric microphones taped over the thenar mass of both hands. After induction of anesthesia, both ulnar nerves were stimulated supramaximally using TOF stimulation every 12 s. Mivacurium 0.2 mg/kg was administered within 5 s. Onset, maximum effect, and offset of NMB were compared between both adductor pollicis muscles. Twelve patients were right-handed and two patients were left-handed. No statistical difference was found between the signals from the dominant or nondominant hand. Correlation was very good (r = 0.95). Agreement was excellent with a bias of –0.57% and limits of agreement of –17.9% to 16.7% (dominant – nondominant hand). This study shows minimal bias, good correlation and no statistical difference when NMB is monitored at both the dominant and nondominant adductor pollicis muscles. Both hands could be used interchangeably to assess NMB at the adductor pollicis muscle.

 

三种手术用消毒铺巾的表皮热量损失,一种为密封而潮湿铺巾

Cutaneous Heat Loss with Three Surgical Drapes, One Impervious to Moisture

Maglinger PE, Sessler DI, Lenhardt R.

The Outcomes ResearchTM Institute and the Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, Kentucky

Address correspondence and reprint requests to Daniel I. Sessler, MD, Outcomes ResearchTM Institute, 501 East Broadway, Suite 210, Louisville, KY 40202.

Anesth Analg 2005 100: 738-742.

 

一种新的密封而潮湿手术用消毒铺巾估计可降低热量的蒸发。比较了覆盖这种和另2种传统铺巾的表皮热量丧失和皮肤温度。对八个志愿者通过十五面积热量对流传导器计算了表皮热量丧失和皮肤表面温度。随机顺序,每个铺巾通过干的和湿的传导器评估(模拟潮湿皮肤)。20分钟无铺巾覆盖后,志愿者颈下部分铺巾覆盖40分钟。数据连续记录,每10分钟一次。 结果:在干燥或者潮湿的环境下3种铺巾效果类似。在干燥条件下,热量损失为82 ± 14 W,覆盖手术用铺巾组下降30%P < 0.001)。潮湿条件下,热量损失基线为231 ± 45 W,覆盖手术铺巾组下降29%(P < 0.001)。湿性皮肤增加热量损失282% (P < 0.001)。对覆盖铺巾的干性或者湿性皮肤,皮肤温度临床上无重要区别。湿性皮肤热量损失增加近3倍,覆盖铺巾后无区别。密封和传统铺巾热量损失相似,不管湿性还是干性皮肤。

(孙志荣译 薛张纲校)

A new surgical drape that is impervious to moisture presumably reduces evaporative heat loss. We compared cutaneous heat loss and skin temperature in volunteers covered with this drape to two conventional surgical drapes (Large Surgical Drape and Medline Proxima). We calculated cutaneous heat loss and skin-surface temperatures from 15 area-weighted thermal flux transducers in eight volunteers. In random order, each of the drapes was evaluated with dry transducers and moistened transducers (simulating wet skin). After a 20-min uncovered control period, volunteers were covered from the neck down for 40 min. Data were recorded continuously and averaged over 10 min. Results were similar for all three drapes for dry or moist conditions. Under dry conditions, baseline heat loss was 82 +/- 14 W and decreased 30% with a surgical drape (P < 0.001). Under moist conditions, baseline heat loss was 231 +/- 45 W and decreased 29% with a drape covering (P < 0.001). Moist skin increased heat loss 282% (P < 0.001). There were no clinically important differences in skin temperature among the covers with dry or moist skin. Moist skin increased heat loss nearly three-fold, but there were no differences among the drapes. We conclude that loss is comparable with impervious and conventional drapes with either moist or dry skin.

 

超前镇痛对急性术后镇痛的疗效:一项荟萃分析
The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis.
Ong CK, Lirk P, Seymour RA, Jenkins BJ.
Department of Oral & Maxillofacial Surgery, Faculty of Dentistry, National University of Singapore.
Anesth Analg. 2005 Mar;100(3):757-73,

对于急性术后疼痛,超前镇痛干预是否比传统治疗更加有效还存在争议。我们搜集了相关的随机对照试验,特异地比较术前镇痛和类似的术后镇痛。回收的报告根据5种镇痛方法分层:硬膜外镇痛、伤口局麻药浸润、N-甲基-d-天冬氨酸拮抗剂(NMDA)、非甾体类抗炎药(NSAIDs)和阿片类镇痛药的使用。主要分析的测试结果是疼痛强度评分、附加镇痛药的消耗及首次镇痛药消耗的时间。66个研究分析了从3261名病人中得到的数据。这些数据由同一效能模型联系起来,效能指数(ES)是标准化的均数差异。当所有3项测试结果都综合分析后,硬膜外镇痛 (ES, 0.38; 95% 可信区间 [CI], 0.28-0.47),伤口局麻药浸润(ES, 0.29; 95% CI, 0.17-0.40)和非甾体类抗炎药(ES, 0.39; 95% CI, 0.27-0.48) 的效能指数最高。其中,超前硬膜外镇痛的效果对所有3项测试指标都是一致的,而伤口局麻药浸润和非甾体类抗炎药的使用能改善镇痛药的消耗及首次镇痛所需的时间,但对术后疼痛评分影响不大。效能证据最少的是N-甲基-d-天冬氨酸拮抗剂(ES, 0.09; 95% CI, -0.03 to 0.22)和阿片类镇痛药(ES, -0.10; 95% CI, -0.26 to 0.07),结论尚有不明确之处。

(王丽珺译 薛张纲校)

Whether preemptive analgesic interventions are more effective than conventional regimens in managing acute postoperative pain remains controversial. We systematically searched for randomized controlled trials that specifically compared preoperative analgesic interventions with similar postoperative analgesic interventions via the same route. The retrieved reports were stratified according to five types of analgesic interventions: epidural analgesia, local anesthetic wound infiltration, systemic N-methyl-d-aspartic acid (NMDA) receptor antagonists, systemic nonsteroidal antiinflammatory drugs (NSAIDs), and systemic opioids. The primary outcome measures analyzed were the pain intensity scores, supplemental analgesic consumption, and time to first analgesic consumption. Sixty-six studies with data from 3261 patients were analyzed. Data were combined by using a fixed-effect model, and the effect size index (ES) used was the standardized mean difference. When the data from all three outcome measures were combined, the ES was most pronounced for preemptive administration of epidural analgesia (ES, 0.38; 95% confidence interval [CI], 0.28-0.47), local anesthetic wound infiltration (ES, 0.29; 95% CI, 0.17-0.40), and NSAID administration (ES, 0.39; 95% CI, 0.27-0.48). Whereas preemptive epidural analgesia resulted in consistent improvements in all three outcome variables, preemptive local anesthetic wound infiltration and NSAID administration improved analgesic consumption and time to first rescue analgesic request, but not postoperative pain scores. The least proof of efficacy was found in the case of systemic NMDA antagonist (ES, 0.09; 95% CI, -0.03 to 0.22) and opioid (ES, -0.10; 95% CI, -0.26 to 0.07) administration, and the results remain equivocal.

 

内毒素血症患者使用异丙酚减弱急性肺损伤

Attenuation of Acute Lung Injury with Propofol in Endotoxemia

Yumiko Takao, MD, Katsuya Mikawa, MD, Kahoru Nishina, MD, and Hidefumi Obara, MD

Department of Anesthesia & Perioperative Medicine, Faculty of Medical Sciences, Kobe University Graduate School of Medicine, Kobe, Japan

Anesth Analg. 2005 Feb;100(3):810-816.

 

通过炎性介质和免疫反应,内毒素可以引起急性肺损伤(ALI)。而异丙酚是一种抗炎和免疫抑制药物。我们进行此项研究的目的就是证明异丙酚是否能够减弱与内毒素血症相关的急性肺损伤。我们将32只麻醉了的试验兔随机分为4组,每组8只。通过静脉缓慢注射(大于30min5 mg/kg内毒素在其中3个组制造了急性肺损伤模型。在使用内毒素之前15min,一个ALI组接受单次剂量为2 mg/kg的异丙酚,随后以4 mg · kg–1 · h–1的速度持续输注;另一ALI组接受的异丙酚剂量分别为5 mg/kg15 mg · kg–1 · h–1;第三个ALI组则接受大豆油乳剂作为对照。无肺损伤的对照组接受以上两种液体的输注。在使用内毒素之后,给试验兔吸入40%的氧气并进行机械通气达6h4组之间血流动力学没有差异。大剂量的异丙酚可以减少肺部的白细胞沉积、肺水肿(通过肺的湿/干重量比得出)和肺部高渗透性(通过支气管肺泡灌洗液中白蛋白水平得出),从而改善氧合、肺通气与气体交换。低剂量的异丙酚达不到这样的效果。通过研究我们认为,大剂量的异丙酚可以在生理、生物化学和组织学上减弱内毒素血症引起的急性肺损伤。

(金 薛张纲 校)

Endotoxin causes acute lung injury (ALI) through many mediators of inflammatory and immune responses. Propofol is an antiinflammatory and immunosuppressive drug. We conducted this study to evaluate whether propofol attenuates ALI associated with endotoxemia. Thirty-two anesthetized rabbits were randomly divided into four groups (n = 8 each). ALI was induced by IV endotoxin 5 mg/kg over 30 min in 3 groups. In 2 of the ALI groups, IV administration of propofol (2 or 5 mg/kg as a bolus followed by continuous infusion at 4 or 15 mg · kg–1 · h–1) was started 15 min before endotoxin. The other ALI group received soybean-oil emulsion. The nonlung injury control group received infusion of both vehicles. The lungs were mechanically ventilated with 40% oxygen for 6 h after endotoxin. Hemodynamics did not differ among groups. The large dose of propofol attenuated lung leukosequestration, pulmonary edema (as assessed by lung wet/dry weight ratio), and pulmonary hyperpermeability (as assessed by albumin levels in bronchoalveolar lavage fluid) and resulted in better oxygenation, lung mechanics, and histological change. The small dose of propofol failed to do so. Our findings suggest that a large dose of propofol successfully mitigates physiological, biochemical, and histological deterioration in ALI in endotoxemia.

 

局部单纯应用重组人碱性成纤维细胞生长因子可加速家兔耳室创伤愈合期间初期血管生成

A single local application of recombinant human basic fibroblast growth factor accelerates initial angiogenesis during wound healing in rabbit ear chamber.

Komori M, Tomizawa Y, Takada K, Ozaki M.

Anesth Analg. 2005 Mar;100(3):830-4.


局部血管生成治疗使用重组人碱性成纤维细胞生长因子(rhbFGF),这项技术已经应用到促进伤口愈合中。为了获得血管生成治疗过程最佳时机的有用信息,我们按时间地观察活家兔耳室皮下血管床,评估局部单纯应用rhbFGF对于家兔耳室模型伤口愈合时血管生成的影响。创伤愈合过程,用5周时间肉眼观察及显微镜评估新血管形成。每只家兔耳室接受单一剂量6杯(mug)的 rhbFGF(治疗组 B1 n=13),或18杯(mug)的 rhbFGF(治疗组 B2 n=16),或接受生理盐水作为对照组(n=13)。一周时,最新生成的血管区组B1B2显著大于对照组。两周时,血管生成区组B1B2与对照组相似。五周时,完成血管化的家兔的比例组B1明显多于对照组。五周时,毛细血管密度三组相似。这些结果提示局部应用rhbFGF,在家兔创伤愈合早期,可加速血管生成。然而,这种作用是短暂的,而且在血管化作用完成时对毛细血管密度没有增加。

(孙敏莉 薛张纲 校)

Local angiogenic therapy with recombinant human basic fibroblast growth factor (rhbFGF) has been used to promote wound healing. To obtain useful information for the development of optimal angiogenic therapy, we chronologically evaluated the effects of a single local application of rhbFGF on angiogenesis in a rabbit ear chamber model of wound healing by observing the subcutaneous vessel bed intravitally. New vessel formation during wound healing was macroscopically and microscopically evaluated for 5 wk. Each rabbit ear chamber received a single dose of 6 mug rhbFGF (treatment B1: n = 13), 18 mug rhbFGF (treatment B2: n = 16), or physiological saline as control (n = 13). At 1 wk the newly vascularized area was significantly larger in groups B1 and B2 than in control. At 2 wk, the vascularized areas in groups B1, B2, and control were similar. At 5 wk, the percentage of rabbits with complete vascularization was significantly larger in group B1 than in control. Capillary density at 5 wk was similar among the three groups. These results suggest that locally applied rhbFGF accelerated angiogenesis during early wound healing in rabbits; however, this effect was transient and no increase in capillary density occurred at the completion of vascularization.

 

大鼠脊髓缺血后白质损伤的评估:与灰质损伤的比较

An evaluation of white matter injury after spinal cord ischemia in rats: a comparison with gray matter injury.

Kurita N, Kawaguchi M, Horiuchi T, Inoue S, Sakamoto T, Nakamura M, Konishi N, Furuya H.

Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Nara, Japan.

Anesth Analg. 2005 Mar;100(3):847-54.

 

我们定量评估了大鼠脊髓缺血后白质和灰质损伤以及白质和灰质损伤程度之间的关系,25只雄性大鼠用异氟醚麻醉,应用低血压和主动脉内球囊阻塞法使脊髓缺血。这些大鼠随机分为以下三组:脊髓缺血缺血时间12分钟组(SCI-12组,数量8例),脊髓缺血时间15分钟组(SCI-15组,数量9例),假手术组(数量8例)。再灌注后24小时应用Basso-Beattie-BresnahanBBB)评分法评估后腿运动功能。根据腹角内正常神经元的数目评估灰质损伤程度,而白质损伤则根据空泡形成的程度以及腹内和腹外侧白质的淀粉样前质蛋白免疫原性来评估。在SCI-15组正常的神经元要比SCI12和假手术组的正常神经元显著减少(P<0.05)。BBB评分和正常神经元数成显著正相关。空泡区域比例在SCI-15组比在SCI-12组要显著大(30% +/- 10% 9% +/- 7%, 0% +/- 0%, P < 0.05)。免疫组织化学分析显示在肿胀的轴突中淀粉样前质蛋白增加,在SCI-15组尤其明显。正常神经元数目与空泡区域比例成显著负相关。结果表明大鼠脊髓缺血后白质和灰质都会受到损伤而且白质的损伤程度与相对短时间恢复后灰质损伤的严重度相关联。

 

(沈洪 薛张纲 校)

We quantitatively assessed both gray and white matter injury after spinal cord ischemia in rats, and the relationship between the magnitude of gray and white matter injury was determined. Twenty-five male rats were anesthetized with isoflurane, and spinal cord ischemia (SCI) was induced by balloon intraaortic occlusion combined with hypotension. The animals were randomly allocated to one of the following three groups: animals with SCI for 12 min (SCI-12; n = 8), 15 min (SCI-15; n = 9), or those with sham operation (n = 8). Twenty-four hours after reperfusion, hindlimb motor function was assessed using the Basso-Beattie-Bresnahan scale scoring. Gray matter damage was assessed on the basis of the number of normal neurons in the ventral horn. White matter damage was assessed on the basis of the extent of vacuolation and amyloid precursor protein immunoreactivity in the ventral and ventrolateral white matter. There were significantly less normal neurons in the SCI-15 group compared with those in the SCI-12 and sham groups (P < 0.05). There was a significant positive correlation between the Basso-Beattie-Bresnahan scores and the number of normal neurons. The percentages of vacuolation areas in the SCI-15 group were significantly larger compared with those in the SCI-12 and sham groups (30% +/- 10% versus 9% +/- 7%, 0% +/- 0%, P < 0.05). Immunohistochemical analysis revealed increased amyloid precursor protein immunoreactivity in the swollen axons, especially in the SCI-15 group. There was a significant negative correlation between the number of normal neurons and percentages of vacuolation areas. These results indicate that both gray and white matter were injured after SCI in rats and the degree of white mater injury was correlated with the severity of gray matter injury after a relatively short recovery period.

 

可乐定静脉给药而非神经周围给药途径能延长腰大肌间隙阻滞髋部骨折术后镇痛效果

Intravenous but not perineural clonidine prolongs postoperative analgesia after psoas compartment block with 0.5% levobupivacaine for hip fracture surgery.

Mannion S, Hayes I, Loughnane F, Murphy DB, Shorten GD.
Department of Anaesthesia and Intensive Care, Cork University Hospital, Cork, Ireland.

Anesth Analg. 2005 Mar;100(3):873-8.

 

作者评估了可乐定辅助于左旋布比卡因腰大肌间隙阻滞(PCB)时全身给药和局部给药的效果。采取随机、双盲、前瞻性研究,选择36例髋部骨折在PCB合并全麻下行外科手术治疗的病人,随机分为三组。每组病人给0.5%左旋布比卡因0.4mL/kg行腰大肌间隙阻滞(PCB)。

对照组(L组)静脉注射生理盐水,全身给药组(IC组)静脉注射可乐定1mug/kg,以及神经周围给药组(C组)同时给以静脉注射生理盐水和可乐定1mug/kg腰大肌间隙阻滞(PCB)。比较三组中从PCB注射完成到第一次追加镇痛药的间隔,IC组的时间间隔比L组要长(mean+/-sd 13.4+/-6.1 versus 7.3+/-3.6hP=0.03)。C组和L组之间无显著差别(10.3+/-5.9 versus 7.3+/-3.6h P>0.05)。吗啡和对乙酰氨基酚的24h用量在各组中相近。术后副反应(心动过缓,低血压,镇静和恶心)在各组中亦无明显差别。我们得出的结论是静脉注射途径给予可乐定(1microg/kg)能延长PCB术后镇痛效果,同时不增加其副反应的发生率,而神经周围给药途径却无此作用。

(吴德华 薛张纲 校)

We evaluated the systemic and local effects of clonidine as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. In a randomized, prospective, double-blind trial, 36 patients requiring hip fracture surgery received PCB and general anesthesia. Patients were randomized into three groups. Each patient received PCB with 0.4 mL/kg of levobupivacaine 0.5%. The control group (group L) received IV saline, the systemic clonidine group (group IC) received IV clonidine 1 mug/kg, and the peripheral clonidine group (group C) received IV saline and PCB with clonidine 1 microg/kg. The interval from time of completion of block injection to first supplementary analgesic administration was longer in group IC compared with group L (mean +/- sd, 13.4 +/- 6.1 versus 7.3 +/- 3.6 h; P = 0.03). There was no difference between group C and group L (10.3 +/- 5.9 versus 7.3 +/- 3.6 h; P > 0.05). The groups were similar in terms of 24 h cumulative morphine and acetaminophen consumption. There were no significant differences among groups regarding postoperative adverse effects (bradycardia, hypotension, sedation, and nausea). We conclude that IV but not perineural clonidine (1 microg/kg) prolongs analgesia after PCB without increasing the incidence of adverse effects.

 

简化锁骨下静脉置管的解剖标志:三角肌粗隆

An Anatomic Landmark to Simplify Subclavian Vein Cannulation: The "Deltoid Tuberosity"

Achim von Goedecke, MD*, Christian Keller, MD*, Bernhard Moriggl, MD{dagger}, Volker Wenzel, MD*, Reto Bale, MD||, Martina Deibl, PhD{ddagger}, Patrizia Moser, MD§, and Philipp Lirk, MD*

*Department of Anesthesiology and Critical Care Medicine; {dagger}Institute of Anatomy, Histology, and Embryology; {ddagger}Department of Biostatistics and Documentation; §Department of Pathology; ||Department of Radiology I (Interdisciplinary Stereotactic Intervention and Planning Laboratory), Medical University of Innsbruck, Innsbruck, Austria

Anesth Analg 2005 100: 623-628.

 

锁骨下静脉常用于中心静脉置管的通道。一般通过几个解剖标志来决定穿刺点和穿刺角度,但利用这些标志可能增加操作和解剖测量。本实验研究利用位于锁骨侧面的三角肌粗隆作为解剖标志进行定位的可行性。利用三角肌粗隆不需要这些操作和测量,从而方便锁骨下静脉穿刺。为系统地研究这个解剖标志,作者将本研究分为四个阶段:1) 双盲检查100个干燥的锁骨测量其三角肌粗隆内侧缘至锁骨侧面末端的距离;2) 在20具新鲜的尸体上以三角肌粗隆和胸骨上切迹为标志进行锁骨下静脉穿刺;3) 利用CT所获取的数据资料对10个病人的锁骨下动脉和静脉以及周围结构进行三维重建,测量两侧以三角肌粗隆为标志的虚拟锁骨下静脉置管路径的长度;4) 选择60例病人以标准路径或三角肌粗隆为标志进行锁骨下静脉穿刺的前瞻性随机试验研究。在第一阶段检查者之间的测量差异为3 ± 1毫米;在第二阶段,20个病例中有19个锁骨下静脉穿刺成功,而另外一例误穿入锁骨下动脉。在第三阶段,左侧和右侧皮肤至静脉距离无明显差异,分别为4.9 ± 0.5 cm4.7 ± 0.6 cm。在第四个阶段,所有病人均可完成锁骨下静脉穿刺,但穿刺时间三角肌粗隆组明显快于标准路径组(23 ± 16 34 ± 14 s) (P < 0.01)。作者认为三角肌粗隆可以作为一个可供选择的解剖标志,从而减少操作和解剖测量来简化锁骨下静脉置管。

(齐波 译 陈杰 校)

The subclavian vein is frequently used to obtain central venous access. Several landmarks exist to determine the puncture site and angle, but they may require patient manipulation and anatomic measurements. We studied the feasibility of using the deltoid tuberosity, located on the lateral aspect of the clavicle, as an anatomic landmark. This would not necessitate these maneuvers and could therefore facilitate subclavian vein access. To systematically investigate this landmark, we conducted a study in four phases: 1) Two blindfolded examiners determined the distance between the tuberosity's medial border and the clavicle's lateral end in 100 dried clavicles and then 2) performed subclavian vein cannulation in 20 fresh human cadavers using the tuberosity and the suprasternal notch as landmarks. 3) Three-dimensional reconstructions of the subclavian artery and vein and surrounding structures were derived from computed tomography datasets of 10 patients. The length of the path of a virtual subclavian vein cannulation with the deltoid tuberosity landmark was measured bilaterally. 4) In a prospective, randomized trial, subclavian vein cannulation was performed in 60 patients with a standard approach or with the deltoid tuberosity as landmark. Interobserver difference between measurements in phase 1 was 3 ± 1 mm (mean ± sd); subclavian vein cannulation was achieved in 19 of 20 cases, whereas the subclavian artery was cannulated in one case (phase 2). In phase 3, there was no significant difference in skin-vein distance between the left (4.9 ± 0.5 cm) and right (4.7 ± 0.6 cm) sides. In phase 4, subclavian vein cannulation could be performed in all patients; moreover, subclavian vein cannulation was significantly (P < 0.01) faster in the deltoid tuberosity group versus the standard approach group (23 ± 16 versus 34 ± 14 s). We conclude that the clavicle's tuberosity may reflect an alternative anatomic landmark to simplify subclavian vein cannulation by minimizing patient manipulation and anatomic measurements.

 

术中血液回收:补液的计算

Intraoperative Blood Salvage: Fluid Replacement Calculations

John C. Drummond, MD, FRCPC, and Charise T. Petrovitch, M.D

Department of Anesthesia of the University of California, San Diego; the Veterans Affairs Medical Center, San Diego; and Providence Hospital, Washington, DC

Anesth Analg 2005 100: 645-649.

 

由于脊柱外科手术时间长、难度增加以及总失血量的增多,术中血液回收(IBS)装置常被作为附加手段用于血液保存。作者利用现有关于IBS装置性能和效率的信息以及晶体液和胶体液分布的信息,提供给临床医生通过所给的IBS装置回收容量预测总失血量的指导原则。同时制订出当通过等渗晶体液和等渗胶体液来进行容量替代治疗时,如何估计合适替代容量的指导原则。当血液丢失过程中平均红细胞压积在25%30%之间时,总失血量将达到IBS回收血液容量的3.44.0倍。如果通过晶体和胶体液来进行容量替代治疗,则合适的替代容量将分别约为2.58.0倍的IBS回收容量。这些容量可能要大于目前一些临床医生所使用的容量。

(齐波 译 陈杰 校)

Intraoperative blood salvage (IBS) devices are used as adjuncts to blood conservation in spinal surgical procedures of increasing duration, complexity, and total blood loss. We applied existing information about the performance and efficiency of IBS devices together with existing information regarding the distribution of crystalloids and colloids to provide clinicians with guidelines for the prediction of the total blood loss implications of a given volume of IBS return. We also developed guidelines for estimation of the appropriate replacement volumes for the acellular component of blood loss when replacement is undertaken with either isotonic-iso-oncotic colloid or isotonic crystalloid solutions. When average hematocrit during blood loss is between 25% and 30%, total blood loss will be 3.4–4.0 times the volume of the IBS recovery. When replacement is undertaken with colloids or crystalloids, the appropriate replacement volume will be approximately 2.5 and 8.0 (respectively) times the volume of the IBS recovery. These volumes may be larger than have been appreciated by some clinicians.

 

 

糖尿病治疗的新进展:麻醉方面的意义

Advances in Diabetic Management: Implications for Anesthesia

Zulfiqar Ahmed, MD*, Charles H. Lockhart, MD, Molly Weiner, RN{dagger}, and Georgiana Klingensmith, MD{ddagger}

*Children's Hospital of Michigan, Detroit, Michigan; {dagger}Barbara Davis Center for Childhood Diabetes; {ddagger}Department of Endocrinology, Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center; and ¶Department of Anesthesiology, The Children's Hospital, University of Colorado Health Sciences Center, Denver, Colorado

Anesth Analg 2005 100: 666-669.

过去的20年对于I型糖尿病的治疗取得了很大的进展。不仅研发了很多新的给药途径如持续皮下胰岛素泵的使用,同时通过对药物动力学和药效学的预测研制了更多更稳定的胰岛素类型。现在又发明了人造胰腺,这对于现今的糖尿病患者围术期的处理产生了很大的影响。

(朱慧琛 译 陈杰 校)

The past 20 yr have seen an explosion in advances for the management of Type I diabetes mellitus. Not only new delivery systems, such as the continuous subcutaneous insulin pump, but also better and more stable types of insulin with predictable pharmacokinetics and pharmacodynamics have been developed. An artificial pancreas is now on the horizon. This progress has had a significant impact on modern perioperative care of the diabetic patient.

 

地氟醚麻醉后的气道反射恢复比七氟醚麻醉更迅速

Airway Reflexes Return More Rapidly After Desflurane Anesthesia Than After Sevoflurane Anesthesia

Rachel Eshima Mckay, MD*, Mary Jane C. Large, RN, BSN{dagger}, Michel C. Balea, MS*, and Warren R. Mckay, MD*

Departments of *Anesthesia and Perioperative Care, and {dagger}Nursing, University of California, San Francisco, California

Anesth Analg 2005 100: 697-700.

 

吸入溶解度较高的麻醉药的病人通常较吸入溶解度较低的麻醉药的病人从麻醉到苏醒的时间延长。本研究的目的主要是测试苏醒延迟的同时是否伴随保护性气道反射恢复延迟。患者随机分为两组,分别通过喉罩通气道吸入地氟醚(n=31)或七氟醚(n=30)。两组的人口统计学无差别。尽管七氟醚组有较多的患者同时接受局部麻醉(七氟醚组17例、地氟醚组8例),两组的平均最小肺泡麻醉浓度分数均为0.62,平均最小肺泡麻醉浓度时间地氟醚组为1.00 ± 0.68,七氟醚组为0.95 ± 0.5。从停止麻醉到患者能对指令作出适当反应的时间七氟醚组相对更长(七氟醚组5.5 ± 3.1min,地氟醚组 3.4 ± 1.9 min; P < 0.01)。此外七氟醚组患者从第一次应答指令至无呛咳及吞咽20ml水无外溢的时间也较长。产生应答反应2分钟后,地氟醚组的患者均能进行无呛咳及无外溢的吞咽动作,而55%的七氟醚组患者会产生喝水呛咳和外溢症状(P < 0.001)。产生应答反应后6分钟,七氟醚组的患者仍无法进行无呛咳的吞咽动作(P < 0.05)。结论:使用地氟醚后保护性气道反射的恢复更迅速。

(朱慧琛 译 陈杰 校)

Patients given a more soluble inhaled anesthetic usually take longer to awaken from anesthesia than do patients given a less soluble anesthetic. In the present study, we tested whether such a delay in awakening was also associated with a delay in restoration of protective airway reflexes. Patients were randomly assigned to receive desflurane (n = 31) or sevoflurane (n = 33) via a laryngeal mask airway. Demographics did not differ between groups. The average minimum alveolar anesthetic concentration fraction for both groups was 0.62, and the mean (±sd) minimum alveolar anesthetic concentration hours was 1.00 ± 0.68 for desflurane versus 0.95 ± 0.57 for sevoflurane, although more patients given sevoflurane also received regional anesthesia (17 for sevoflurane and 8 for desflurane). The time from stopping anesthetic administration to appropriate response to command was longer after sevoflurane (5.5 ± 3.1 versus 3.4 ± 1.9 min; P < 0.01). In addition, the time from first response to command to ability to swallow 20 mL of water without coughing or drooling was longer after sevoflurane. At 2 min after responding to command, all patients given desflurane were able to swallow without coughing or drooling, whereas 55% of patients given sevoflurane coughed and/or drooled (P < 0.001). At 6 min after responding to command, 18% of patients given sevoflurane still could not swallow without coughing or drooling (P < 0.05). We conclude that desflurane allows an earlier return of protective airway reflexes.

 

一种新的具有外周阿片特性的药物氟雷法胺和吗啡、安慰剂对静息通气影响的比较研究

A Novel Molecule (Frakefamide) with Peripheral Opioid Properties: The Effects on Resting Ventilation Compared with Morphine and Placebo

Åsa Österlund Modalen, MD, Hans Quiding, PhD, Joana Frey, MD, Lars Westman, MD, PhD, and Sten Lindahl, MD, PhD

Departments of Anesthesiology and Intensive Care, Danderyds Hospital and Karolinska Institute, Stockholm

Anesth Analg 2005 100: 713-717.

 

在动物模型中,氟雷法胺(FF)是一种强效的镇痛药,它是作用于外周的选择性μ-受体激动剂。本文选择12例健康男性进行一项双盲、随机、双对照、四方交叉研究。分别观察FF、两种剂量的吗啡和安慰剂对静息通气的影响。每种药物都是6h注射一次。按药物和剂量分为FF1.22mg/kg)组 、大剂量(0.43mg/kg)吗啡组 、小剂量(0.11mg/kg)吗啡组、安慰剂组(Nacl 9mg/mL)。用呼吸速度描记仪和流线二氧化碳描记图测量呼吸。采集各组的血浆测量药物以及代谢产物的浓度。在注射FF15min后,所有病例均诉暂时肌痛,30min后消失。而通气情况(335min),每组病人的潮气量没有差异。但是,两个吗啡组与另外两组比较呼吸次数均变慢(最小剂量组P<0.05,最大剂量组P<0.001)。每分通气量吗啡大剂量组较FF组以及安慰剂组明显减少(P<0.01)。这种差异也表现在大剂量的吗啡组的Etco2升高(P<0.01)。结论:在静息通气时,和吗啡不同,FF不会导致中枢性的呼吸抑制。这意味FF是一种外周的选择性μ-受体激动剂。

(顾漪闻 译 陈杰 校)

In animal models frakefamide (FF) is a potent analgesic that acts as a peripheral active µ-selective receptor agonist. In this double-blind, randomized, double dummy four-way crossover study in 12 healthy male subjects, we investigated the effects on resting ventilation of FF and 2 dose levels of morphine compared with placebo. Each drug was infused for 6 h. The subjects received 1.22 mg/kg FF, 0.43 mg/kg morphine (M-large), and 0.11 mg/kg morphine (M-small). Sodium chloride 9 mg/mL was used as placebo. Ventilation was measured by pneumotachography and inline capnography. Blood was collected and plasma concentrations of FF and morphine and its metabolites were analyzed. Within 15 min after administration of FF all subjects complained of a transient myalgia, which disappeared within 30 min. At target measurement (335 min), there were no differences in tidal volume among the groups. Respiratory rates were, however, slower in the two M-groups (P < 0.05 in M-small and P < 0.001 in M-large) compared with FF and placebo. Minute volume was significantly less in the M-large group compared with the FF (P < 0.01) and placebo (P < 0.01) groups. This difference was reflected by an elevated ETco2 in the M-large group (P < 0.01). We conclude that, during resting ventilation, FF, unlike morphine, did not cause central respiratory depression. This suggests that FF has only peripheral µ-opioid agonist activity in humans.

 

七氟醚麻醉时短效β1受体拮抗药艾司洛尔和兰地洛尔抑制气管插管时的双频指数反应

The Short-Acting ß1-Adrenoceptor Antagonists Esmolol and Landiolol Suppress the Bispectral Index Response to Tracheal Intubation During Sevoflurane Anesthesia

Yutaka Oda, MD, PhD, Kiyonobu Nishikawa, MD, PhD, Ichiro Hase, MD, PhD, and Akira Asada, MD, PhD

Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan

Anesth Analg 2005 100: 733-737.

 

在一项随机、双盲、对照研究中,作者验证了一项假设——在单用七氟醚麻醉时,短效β1受体拮抗药艾司洛尔、兰地洛尔能抑制气管插管时血流动力学的改变以及双频指数的增加。选择45例患者,随机分为对照组、艾司洛尔组、兰地洛尔组,每组15人。麻醉诱导选用七氟醚,呼气末的肺泡浓度达到1MAC。麻醉诱导后5min,对照组注射生理盐水,艾司洛尔组(负荷量1mg/kg,然后0.25 mg/kg/min)、兰地洛尔组(负荷量0.125mg/kg,然后0.04 mg/kg/min)。在麻醉诱导后12min气管插管。三组的平均动脉压无明显差异,气管插管后的15min,所有组的心率均增加,但是艾司洛尔组和兰地洛尔组心率的增加没有对照组明显(P<0.05)。所有病人的BIS基线为9698,在诱导后均下降,在插入喉镜前,三组也没有差异(对照组39±5、艾司洛尔组39±5、兰地洛尔组38±4)。在插管后1min,对照组的BIS明显增高(54±10P<0.05),但是另两组没有明显改变(45±1041±6)。结论:1MAC的七氟醚麻醉时,艾司洛尔和兰地洛尔能够抑制气管插管时的双频指数和心率的增加。

(顾漪闻 译 陈杰 校)

In this randomized, double-blind, controlled study, we tested the hypothesis that the short-acting ß1-adrenoceptor antagonists esmolol and landiolol suppress hemodynamic changes and bispectral index (BIS) increases, both of which are induced by tracheal intubation under general anesthesia with sevoflurane alone. Forty-five patients were randomly assigned to the control, esmolol, and landiolol groups (n = 15 each). Anesthesia was induced with sevoflurane in oxygen, with an end-tidal concentration maintained at 1 minimum alveolar anesthetic concentration (MAC). Infusion of saline (control group), esmolol (bolus of 1 mg/kg and then 0.25 mg · kg–1 · min–1; esmolol group), or landiolol (bolus of 0.125 mg/kg and then 0.04 mg · kg–1 · min–1; landiolol group) was started 5 min after the induction of anesthesia and was continued throughout the study. Tracheal intubation was performed 12 min after anesthesia induction. There were no differences in overall changes of mean arterial blood pressure among the three groups, whereas, at 1–5 min after tracheal intubation, heart rate increased in all groups but was significantly slower in the esmolol and landiolol groups than in the control group (P < 0.05). BIS was between 96 and 98 for all patients at baseline and decreased during the induction of anesthesia. There were no differences in BIS among the three groups before laryngoscopy (39 ± 5, 39 ± 5, and 38 ± 4 in the control, esmolol, and landiolol groups, respectively). BIS increased significantly in the control group (54 ± 10; P < 0.05) 1 min after intubation, whereas it remained unchanged in the esmolol and landiolol groups (45 ± 10 and 41 ± 6, respectively). In conclusion, the increase in both heart rate and BIS after tracheal intubation under 1 MAC sevoflurane anesthesia was suppressed by the concomitant administration of either esmolol or landiolol.

 

对麻醉狗使用主动脉流量探测仪检测新型超声多普勒心排量监测仪(USCOM)的可靠性

Testing the Reliability of a New Ultrasonic Cardiac Output Monitor, the USCOM, by Using Aortic Flowprobes in Anesthetized Dogs

Lester A. Critchley, MD, FFARCSI*, Zhi Y. Peng, MD, PhD*, Benny S. Fok, BSc*, Anna Lee, PhD, MPH*, and Robert A. Phillips, FIR, DMU, AMS{dagger}

*Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China; and {dagger}School of Medicine, University of Queensland, Brisbane, Queensland, Australia

Anesth Analg 2005 100: 748-753.

 

作者利用动物模型来检测一种新型便携式连续超声多普勒心排量检测仪(USCOM)的可靠性。六条麻醉犬,在升主动脉安装一个高精度时间转换超声流量检测仪(流量仪)来检测心排量。输入多巴胺(0-15ug∙kg-1·min-1)逐步提高犬的心排量。同步用流量仪和USCOM检测心排量。每条犬收集至少64对数据。这些数据通过Bland-Altman绘图法和Lin氏整合相关系数进行比较。一共收集了319对数据。心排量平均值是2.62±1.04L/min,数值的范围是0.795.73 L/min。两组数据间的平均偏差是-0.01L/min95%的可信区间是-0.340.31L/min。误差±13%。有5/6犬,两种方法测定的数据表现高度的相关,相关系数>0.9USCOM能提供可靠的心排量检测。在人体上仍需进行临床实验来验证这种仪器的可靠性。

(朱辉 译 陈杰 校)

We have used an animal model to test the reliability of a new portable continuous-wave Doppler ultrasonic cardiac output monitor, the USCOM. In six anesthetized dogs, cardiac output was measured with a high-precision transit time ultrasonic flowprobe placed on the ascending aorta. The dogs’ cardiac output was increased with a dopamine infusion (0–15 µg · kg–1 · min–1). Simultaneous flowprobe and USCOM cardiac output measurements were made. Up to 64 pairs of readings were collected from each dog. Data were compared by using the Bland and Altman plot method and Lin’s concordance correlation coefficient. A total of 319 sets of paired readings were collected. The mean (±sd) cardiac output was 2.62 ± 1.04 L/min, and readings ranged from 0.79 to 5.73 L/min. The mean bias between the 2 sets of readings was –0.0l L/min, with limits of agreement (95% confidence intervals) of –0.34 to 0.31 L/min. This represents a ±13% error. In five of six dogs, there was a high degree of concordance, or agreement, between the 2 methods, with coefficients >0.9. The USCOM provided reliable measurements of cardiac output over a wide range of values. Clinical trials are needed to validate the device in humans.

 

利用先进的模拟方法识别和纠正院前外伤病人气道和呼吸处理技能中的缺陷

Using Advanced Simulation for Recognition and Correction of Gaps in Airway and Breathing Management Skills in Prehospital Trauma Care

Daphna Barsuk, MD*{dagger}, Amitai Ziv, MD{dagger}, Guy Lin, MD§, Amir Blumenfeld, MD§, Orit Rubin{dagger}||, Ilan Keidan, MD{ddagger}, Yaron Munz, MD{dagger}, and Haim Berkenstadt, MD{dagger}{ddagger}

*Department of General Surgery C, {dagger}The Israel Center for Medical Simulation, and {ddagger}Department of Anesthesiology and Intensive care, Sheba Medical Center, Tel Hashomer; §Sackler School of Medicine, Tel Aviv University, The Israel Defense Forces Medical Corps; and ||The National Institution for Test & Evaluation, Jerusalem, Israel

Anesth Analg 2005 100: 803-809.

在这项前瞻性的研究中,作者使用两个全面的院前创伤急救方案(严重的胸外伤和脑外伤)和特定动作检查表,反映安全处理并获得最后成功的一系列处理步骤,这些用来评估毕业于高级创伤生命支持(ATLS)课程的医生的实习操作。在第一批的36个参与者中,模拟训练安排在气道和呼吸处理的基本训练之后,然而在下一批的36个参与者中,利用太空人模型做气道处理45分的模拟训练加到操作的前面。其训练内容是基于第一批普遍存在的错误操作。通过训练改变后,参与者中没有实施环状软骨按压或在插管中没有用药的人数分别从55%降到8%和从42%降到11%。在固定气管导管前没有稳妥持管的人数从28%降到了0%。在严重的脑外伤急救方案中,每个组有15/36个参与者,在首次插管后的第二次气道或呼吸处理的错误发生率从60%降到了0%。目前的研究正如ATLS所指出的一样,院前创伤处理的问题尤显重要。ATLS的毕业生也许能从基于气道和呼吸处理的模拟训练中受益。然而基于模拟的临床意义还有待评估。

(朱辉 译 陈杰 校)

In this prospective study, we used two full-scale prehospital trauma scenarios (severe chest injury and severe head injury) and checklists of specific actions, reflecting essential actions for a safe treatment and successful outcome, were used to assess performance of postinternship physician graduates of the Advanced Trauma Life Support (ATLS) course. In the first 36 participants, simulated training followed basic training in airway and breathing management, whereas in the next 36 participants, 45 min of simulative training in airway management using the Air-Man simulator (Laerdal, Norway) were added before performing the study scenarios. The content of training was based on common mistakes performed by participants of the first group. After the change in training, the number of participants not performing cricoid pressure or not using medication during intubation decreased from 55% (20 of 36) to 8% (3 of 36) and from 42% (15 of 36) to 11% (4 of 36), respectively (P < 0.05). The number of participants not holding the tube properly before fixation decreased from 28% (10 of 36) to 0% (0 of 36) (P < 0.05). In the severe head trauma scenario, performed by 15 of 36 participants in each group, the incidence of mistakes in the management of secondary airway or breathing problems after initial intubation decreased from 60% (9 of 15) to 0% (0 of 15) (P < 0.05). The present study highlights problems in prehospital trauma management, as provided by the ATLS course. It seems that graduates may benefit from simulation-based airway and breathing training. However, clinical benefits from simulation-based training need to be evaluated.

 

脓毒血症阶段非去极化肌松药对鼠离体膈肌作用削弱的依赖性和差异性

Sepsis Stage Dependently and Differentially Attenuates the Effects of Nondepolarizing Neuromuscular Blockers on the Rat Diaphragm In Vitro

Eichi Narimatsu, MD, PhD*{dagger}, Tomohisa Niiya, MD*, Mikito Kawamata, MD, PhD*, and Akiyoshi Namiki, MD, PhD*

Departments of *Anesthesiology and {dagger}Critical Care Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan

Anesth Analg 2005 100: 823-829.

作者使用盲肠结扎和刺破的脓毒血症鼠模型研究早期和晚期脓毒血症时非去极化肌松药作用的变化。评估0.1Hz超强电流间接刺激膈神经引出的神经半膈肌等长颤搐张力。罗库溴铵,潘库溴铵和d-筒箭毒碱在无脓毒血症,早期脓毒血症和晚期脓毒血症时产生剂量依赖性地膈肌颤搐张力变化(P < 0.01 )。非脓毒血症期、早期脓毒血症到晚期脓毒血症浓度颤搐张力曲线逐渐右移,抑制浓度值增加50%。潘库溴铵早期和晚期脓毒血症标准化右移最多,罗库溴铵次之,d-筒箭毒碱最小。脓毒血症导致的IC50 值并不随曲线的下降而减小。这个结果说明脓毒血症导致非去极化肌松药敏感性降低,其程度依赖于脓毒血症的的分期和肌松药种类。

(殷文渊 陈杰 校)

We investigated the effects of early and late sepsis on the actions of nondepolarizing neuromuscular blockers by using a rat sepsis model induced by cecal ligation and puncture. Isometric twitch tensions of nerve-hemidiaphragm preparations elicited by indirect (phrenic nerve) supramaximal stimulation at 0.1 Hz were evaluated. Rocuronium, pancuronium, and d-tubocurarine dose-dependently decreased the twitch tensions of the nonseptic, early septic, and late septic diaphragms (P < 0.01 each by analysis of variance [ANOVA]). Late sepsis shifted the concentration-twitch tension curves rightward from those of nonsepsis to larger degrees than did early sepsis, as indicated by increases in 50% inhibitory concentration (IC50) values (P < 0.01 each by ANOVA and P < 0.01 or 0.05 by the Scheffé F test). The standardized rightward shifts in early and late sepsis were largest for pancuronium, second largest for rocuronium, and smallest for d-tubocurarine (5.741, 2.979, and 1.660 times in late sepsis, respectively; P < 0.01 each by ANOVA and the Scheffé F test). Sepsis-induced increases in IC50 values did not accompany the decreases in slopes. The results indicate that sepsis induces hyposensitivities to nondepolarizing neuromuscular blockers, the degree of which depends on the stage of sepsis and on the kind of neuromuscular blocker.

 

大鼠局灶性脑缺血模型中一氧化氮合成酶抑制剂对依托咪酯不良反应的作用

The Role of Nitric Oxide Synthase Inhibition in the Adverse Effects of Etomidate in the Setting of Focal Cerebral Ischemia in Rats

John C. Drummond, MD*{dagger}, Lorne D. McKay, MD{ddagger}, Daniel J. Cole, MD§, and Piyush M. Patel, MD*{dagger}

*Departments of Anesthesiology, University of California, San Diego, La Jolla; {dagger}VA Medical Center, San Diego; {ddagger}Loma Linda University, Loma Linda, California; and §Mayo Clinic College of Medicine, Rochester, Minnesota

Anesth Analg 2005 100: 841-846.

 

作者评估了NG-硝基-l-精氨酸甲酯(l-NAME, 一种一氧化氮合成酶[NOS] 抑制剂)1 -精氨酸(一氧化氮底物)在自发性高血压鼠氟烷或依托咪酯麻醉期间短暂大脑中动脉阻塞(MCAo)后大脑线粒体失功(下指损伤)的影响。大脑中动脉阻塞前60分钟大鼠随机分到五组中的一组(每组8只):氟烷/对照组,吸入氟烷1.2 MAC;氟烷/l-NAME组,氟烷1.2 MACl-NAME(30 mg/kg);依托咪酯组,心电图显示抑制剂量的依托咪酯;依托咪酯/l-NAME组,心电图显示抑制剂量的依托咪酯和l-NAME(30 mg/kg);或依托咪酯/l-NAME/精氨酸组,心电图显示抑制剂量的依托咪酯和l-NAME(30 mg/kg)1-精氨酸(负荷剂量300 mg/kg,随后35 mg · kg–1 · min–1的速度静注)。依托咪酯/l-NAME/精氨酸组和氟烷/对照组的损伤程度没有差异,但略小于依托咪酯组或依托咪酯/l-NAME组。这些数据再次应证了作者过去的观察:以氟烷为对照,依托咪酯在大脑中动脉暂时缺血状态下对缺血损伤会产生有害影响。预先用l-NAME阻滞NOS对氟烷和依托咪酯两组的损伤程度没有差别(162 ± 17 155 ± 26)。使用大剂量1-精氨酸能防止依托咪酯的有害影响。但数据仅取了再灌注2小时后的数据,因此不能解释具有代表性的神经方面预后。但这还是提示依托咪酯在大脑中动脉缺血早期通过部分抑制NOS对线粒体功能有不良影响。

(殷文渊 陈杰 校)

We evaluated the effect of NG-nitro-l-arginine-methyl-ester (l-NAME, a nitric oxide synthase [NOS] inhibitor) and l-arginine (nitric oxide substrate) on cerebral mitochondrial dysfunction (hereafter referred to as "injury") after temporary middle cerebral artery occlusion (MCAo) during halothane or etomidate anesthesia in spontaneously hypertensive rats. Sixty minutes before MCAo, rats were randomized to 1 of 5 regimens (n = 8 per group): h/control, 1.2 minimum alveolar anesthetic concentration of halothane; h/l-NAME, 1.2 minimum alveolar anesthetic concentration of halothane and l-NAME (30 mg/kg); etomidate, an electroencephalographic (EEG) burst suppression dose of etomidate; e/l-NAME, an EEG burst suppression dose of etomidate and l-NAME (30 mg/kg); or e/l-NAME/arg, an EEG burst suppression dose of etomidate, l-NAME (30 mg/kg), and l-arginine (bolus of 300 mg/kg with an infusion at 35 mg · kg–1 · min–1). After 180 min of MCAo and 120 min of reperfusion, volume of injury was determined using 2,3,5-triphenytetrazolium stain. Injury volume (mm3, mean ± sd) was larger in the etomidate group (153 ± 17) than the halothane anesthetized h/control group (93 ± 16) (P < 0.05) but did not differ between the e/l-NAME (162 ± 17) and h/l-NAME groups (155 ± 26). Injury volume in the e/l-NAME/arg group (88 ± 15) was not different from the h/control group (93 ± 16) and was less than that in either the etomidate or the e/l-NAME groups (P < 0.05). The data reproduce our previous observation that, relative to a halothane-anesthetized control state, etomidate has an adverse effect on ischemic injury in the setting of temporary focal cerebral ischemia. Prior inhibition of NOS with l-NAME resulted in no difference in the volume of injury between groups receiving etomidate or halothane (162 ± 17 versus 155 ± 26). Administration of a large dose of l-arginine prevented the adverse effect of etomidate. The data were obtained after only 2 h of reperfusion and therefore cannot be construed as representative of final neurologic outcome. They nonetheless suggest that etomidate produces an adverse effect on mitochondrial function early in the course of focal cerebral ischemia, in part, by inhibition of NOS.

 

持续股神经阻滞时负荷量及术后所用的药液中加入可乐定可延迟全膝关节成形术后运动功能的恢复

Adding Clonidine to the Induction Bolus and Postoperative Infusion During Continuous Femoral Nerve Block Delays Recovery of Motor Function After Total Knee Arthroplasty

Andrea Casati, MD*, Federico Vinciguerra, MD{dagger}, Gianluca Cappelleri, MD{dagger}, Giorgio Aldegheri, MD{dagger}, Guido Fanelli, MD*, Marta Putzu, MD*, and Jacques E. Chelly, MD{ddagger}

*Department of Anesthesiology, University of Parma, Parma, Italy; {dagger}Department of Anesthesiology, Vita-Salute University of Milano, Milano, Italy; and {ddagger}Department of Anesthesiology, University School of Medicine, Pittsburgh, Pennsylvania

Anesth Analg 2005 100: 866-872.

作者评价了持续外周神经阻滞时加入可乐定的效果。60名病人进行全膝关节成形术,单次注药阻滞坐骨神经和持续给药阻滞股神经。病人随机分为三组,第一组为先用0.75%布比卡因单次阻滞,然后持续用0.2%罗哌卡因(对照组,n20),第二组为先用0.75%布比卡因和1μg/kg可乐定,然后用0.2%罗哌卡因(可乐定负荷组,n20),第三组为先用0.75%布比卡因和1μg/kg可乐定,然后用0.2%罗哌卡因和1μg/mL可乐定(可乐定持续组,n20)。术后用病人自控的输注泵进行持续股神经给药(背景输注速度为6mL/h,追加剂量为2ml,锁定时间为15min)。三组的神经阻滞平均起效时间(起效时间范围)分别为15min5-30min)、10min5-35min)、10min5-30min)。用视觉模拟标尺测定病人的疼痛程度,三组没有区别。24h局麻药的总用药量分别为170ml144-200ml)、156ml144-233ml)、150ml144-210ml)(P0.48)。三组的血流动力学指标和镇静程度相似。可乐定持续组48h后运动功能受损的发生率为27%,而前两组只有6%(P0.05)。结论:可乐定1μg/ml加入到局麻药中进行股神经阻滞,没有更好地缓解疼痛,反而有可能引起运动功能恢复的延迟。

(赵延华 陈杰 校)

We evaluated the effects of adding clonidine for continuous peripheral nerve infusions. Sixty patients undergoing total knee arthroplasty under combined single-injection sciatic block and continuous femoral infusion were randomly allocated to three groups: block induction with 0.75% ropivacaine followed by 0.2% ropivacaine (group control; n = 20); block induction with 0.75% ropivacaine and 1 µg/kg clonidine followed by 0.2% ropivacaine (group cloni-bolus; n = 20), and block induction with 0.75% ropivacaine and 1 µg/kg clonidine followed by 0.2% ropivacaine with 1 µg/mL clonidine (group cloni-infusion; n = 20). After surgery, continuous femoral infusion was provided with a patient-controlled infusion pump (basal infusion rate, 6 mL/h; incremental dose, 2 mL; lockout time, 15 min). The median (range) onset time of surgical block was 15 min (5–30 min) in group control, 10 min (5–35 min) in group cloni-bolus, and 10 min (5–30 min) in group cloni-infusion (P = 0.07). No differences were reported among groups in the degree of pain measured with the visual analog scale. The total consumption of local anesthetic solution after a 24-h infusion was 170 mL (144–220 mL) in group control, 169 mL (144–260 mL) in group cloni-bolus, and 164 mL (144–248 mL) in group cloni-infusion (P = 0.51); after the second day of infusion, total consumption was 168 mL (144–200 mL) in group control, 156 mL (144–288 mL) in group cloni-bolus, and 150 mL (144–210 mL) in group cloni-infusion (P = 0.48). Hemodynamic profiles and sedation were similar in the three groups. Motor function impairment after 48 h of infusion was observed in 27% of cloni-infusion patients but in only 6% of both the control and cloni-bolus groups (P = 0.05). We conclude that adding clonidine 1 µg/mL to local anesthetic for continuous femoral nerve block does not improve the quality of pain relief but has the potential for delaying recovery of motor function.

 

气道峰压增加是气管导管部分阻塞的晚期报警信号而呼气流速的变化是早期报警信号

Peak Airway Pressure Increase Is a Late Warning Sign of Partial Endotracheal Tube Obstruction Whereas Change in Expiratory Flow Is an Early Warning Sign

Rafael Kawati, MD*, Marco Lattuada, MD{dagger}, Ulf Sjöstrand, MD, PhD*, Josef Guttmann, PhD{ddagger}, Göran Hedenstierna, MD, PhD{dagger}, Alois Helmer, MD§, and Michael Lichtwarck-Aschoff, MD, PhD*§

From the Departments of *Surgical, and {dagger}Medical Sciences, University Hospital, Uppsala, Sweden, {ddagger}Department of Anesthesiology and Critical Care Medicine, University Hospital Freiburg, Germany, §Department of Anesthesiology and Critical Care Medicine, Klinikum Augsburg, Augsburg, Germany

Anesth Analg 2005 100: 889-893.

气管导管(ETT)长时间留置时分泌物会不为察觉地进入气道而阻塞导管,吸气峰压(Ppeak)被常用于监测气道明显而进行性的阻塞。Ppeak的增加不仅与气道狭窄的程度有关,与吸气流速也有关。气道狭窄对慢的吸气气流的影响很小,但对快的呼气气流的减速效应明显,因此易于监测。将被动呼气的容量-流速曲线分为连续的五个部分,计算它们的时间常数(TE),用于分析气道部分阻塞时呼气气流是否并且如何受阻。用九头幼猪进行容量控制通气,通过外力夹闭气管导管产生三种不同程度阻塞。在所有的动物中,气道阻塞使TE增加(曲线第一部分的平均值,在未阻塞气道为550ms1度阻塞为661ms2度阻塞为877ms2度阻塞为1563ms),2度和3度阻塞时明显。而Ppeak没有明显增加(基础值、1度和2度气道阻塞分别为131415cmH2O),最严重的气道阻塞即3度阻塞时Ppeak才有所增加(20 cmH2O)。结论:呼气流速能可靠地监测气管导管(ETT)部分阻塞,对需要呼吸机的病人吸入气流可监测ETT的狭窄情况。

(赵延华 陈杰 校)

If peak inspiratory airway pressure (Ppeak) is used to monitor airway patency, progressive obstruction of the endotracheal tube (ETT) resulting from secretions can go undetected for a prolonged period. The reason is that any increase in Ppeak depends not only on the degree of narrowing but also on the inspiratory flow (V) rate. Although the impact of narrowing on low inspiratory Vis small, its decelerating effect on the high expiratory Vis pronounced and, hence, easily detectable. Dividing the volume-flow curve of a passive expiration into five consecutive segments (slices) and calculating the time constants ({tau}E) of these slices allows for analyzing whether and how expiratory Vis impeded by a partial obstruction. In nine piglets, during volume-controlled ventilation, three grades of ETT obstruction were created with an external clamp. In all animals the {tau}E increased with ETT obstruction (mean for the first slice: 550 ms with unobstructed ETT; grade 1: 661; grade 2: 877; and grade 3: 1563 ms, respectively) and this increase was significant with grade 2 and 3 obstruction. Ppeak, by contrast, did not increase significantly (base: 13, grade 1: 14, grade 2: 15 cm H2O) until the most severe (grade 3: 20 cm H2O) obstruction was created. We conclude that partial obstruction of the ETT can be reliably monitored with the expiratory Vsignal and has the potential of monitoring ETT narrowing in ventilator-dependent patients independent of the inspiratory Vpattern applied.

 

有和无气腹时的肝门阻断的血液动力学影响:一项超声心动图研究

Hemodynamic Effects of Portal Triad Clamping With and Without Pneumoperitoneum: An Echocardiographic Study

François Decailliot, MD*, Birgit Streich, MD*, Yves Heurtematte, MD*, Philippe Duvaldestin, MD*, Daniel Cherqui, MD{dagger}, and François Stéphan, MD, PhD*

*Service d’Anesthésie-Réanimation Chirurgicale and {dagger}Service de Chirurgie Digestive, Assistance Publique-Hôpitaux de Paris Hôpital Henri Mondor and Université Paris XII, Créteil, France

Anesth Analg 2005;100:617-622

 

以前只通过右心插管已研究得出有和无气腹时肝门阻断(PTC)期间都有心脏指数下降。为了更好地了解这种心脏指数的下降,我们用经食管超声心动图来研究充足的前负荷和针对后负荷增加的心脏泵血能力之间的平衡。选择10例在腹腔镜检查下施行PTC10例剖腹施行PTC的病人。PTC5分钟,测定每搏量、左室(LV)面积变化率(FAC)和LV收缩末期室壁张力(LVESWS)作为常规的血液动力学的指标。同时记录局部室壁运动异常(RWMA)。在剖腹术组,LV舒张末期面积下降,LVESWS没有明显增加。FAC保持稳定,一个病人发生RWMA。在腹腔镜检查组,LV舒张末期面积保持稳定,LVESWS增加。FAC明显下降,有5个病人发生RWMA。在剖腹术组的主要的改变是前负荷下降,而腹腔镜检查组证明LV功能下降可能是LV前负荷下降和LV后负荷增加的结果。然而,对这些没有心脏疾病的研究病人,这些变化并没有必要停止或放弃肝门阻断。

(彭中美 李士通 校)

The decrease of cardiac index observed during portal triad clamping (PTC) with and without pneumoperitoneum has been studied only with right heart catheterization. To better understand this decrease of cardiac index, we investigated the balance between the adequacy of preload and the ability of the heart to pump against an increased afterload, by using transesophageal echocardiography. Ten patients with PTC performed during laparoscopy and 10 with PTC performed during laparotomy were studied. Five minutes after PTC, the stroke volume, the left ventricular (LV) fractional area change (FAC), and the LV end-systolic wall stress (LVESWS) were measured as the conventional hemodynamic variables. Regional wall motion abnormalities (RWMA) were also recorded. In the laparotomy group, LV end-diastolic area decreased, and LVESWS did not increase significantly. FAC remained stable, and one patient developed RWMA. In the laparoscopic group, LV end-diastolic area remained stable, and LVESWS increased. FAC decreased significantly, and five patients developed RWMA. A decrease in preload was the main important change in the laparotomy group, and in the laparoscopic group a decrease in LV function was demonstrated that was likely a consequence of decreased LV preload and increased LV afterload. However, these did not necessitate stopping the procedure or releasing PTC in these study patients without cardiac disease.


血管紧张素抑制剂在普外科手术人群中的运用

Angiotensin System Inhibitors in a General Surgical Population

Thomas Comfere, MD*, Juraj Sprung, MD, PhD*, Matthew M. Kumar, MD*, Myongsu Draper, BSN*, Diana P. Wilson, BSN*, Brent A. Williams, MS{dagger}, David R. Danielson, MD*, Lavonne Liedl, RRT*, and David O. Warner, MD*

*Department of Anesthesiology and {dagger}Division of Biostatistics, Mayo Clinic College of Medicine, Rochester, Minnesota

Anesth Analg 2005;100:636-644

 

我们研究了普外科手术病人长效血管紧张素转换酶抑制剂(ACEI)及血管紧张素II受体1亚型拮抗剂(ARA) 的停药时间与全麻诱导后低血压发生的关系。我们回顾研究了267个接受长效 ACEI/ARA治疗并在全麻下行择期非心脏手术的高血压患者。在术前访视病人时,要求病人术晨继续服用或在术前24小时停用ACEI/ARA。并在术前记录最后一次服用ACEI/ARA距手术的小时数。在电子病历及麻醉记录上回顾伴发疾病、所用麻醉药的类型及剂量、术中血流动力学、静脉补液、围术期血管收缩药的使用情况和严重术后并发症的发生率。记录诱导后60 min时间内的动脉压(BP)及心率,并将低血压分类为中度(收缩压 85 mm Hg)及重度(收缩压 65 mm Hg)。我们将所有病人的数据分为两组来分析:最后一次服用ACEI/ARA在术前<10 h及≥10 h。在麻醉诱导后的最初30min时间内,最后一次服用ACEI/ARA在诱导前<10 h组的病人中度低血压的发生率(60%)较≥10 h组的(46%)(P = 0.02)。最后一次服用ACEI/ARA在术前<10 h组的病人中度低血压发生的校正差异比为1.7495%可信区间,1.03–2.93(P = 0.04)。两组病人在重度低血压的发生率及血管收缩药的使用方面无差异。在诱导后的31-60min时间内两组中度低血压的发生率(P = 0.43)和重度低血压的发生率(P = 0.97)均相似。两组病人术后并发症的发生无差别。结论,至少在麻醉前10h 中断使用ACEI/ARA治疗与减少诱导后即刻发生低血压的危险性有关。

(裘毅敏 李士通 校)

We studied the relationship between the timing of discontinuing chronic angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor subtype 1 antagonists (ARA) and hypotension after the induction of general anesthesia in a general surgical population. We retrospectively studied 267 hypertensive patients receiving chronic ACEI/ARA therapy undergoing elective noncardiac surgery under general anesthesia. During preoperative visits, patients were asked to either take their last ACEI/ARA therapy on the morning of surgery or withhold it up to 24 h before surgery. The number of hours from the last ACEI/ARA dose to surgery was recorded during the preoperative interview. Electronic medical and anesthesia records were reviewed for comorbidities, type and dose of anesthetics used, intraoperative hemodynamics, IV fluids, perioperative vasopressor administration, and rate of severe postoperative complications. Arterial blood pressure (BP) and heart rate were recorded during the 60-min postinduction period, and hypotension was classified as moderate (systolic BP ≤85 mm Hg) and severe (systolic BP ≤65 mm Hg). We analyzed all variables separately for patients who took their last ACEI/ARA therapy <10 h and ≥10 h before surgery. During the first 30 min after anesthetic induction, moderate hypotension was more frequent in patients whose most recent ACEI/ARA therapy was taken <10 h (60%) compared with those who stopped it ≥10 h (46%) before induction (P = 0.02). The adjusted odds ratio for moderate hypotension was 1.74 (95% confidence interval, 1.03–2.93) for those who took their ACEI/ARA therapy <10 h before surgery (P = 0.04). There were no differences between groups in the incidence of severe hypotension, nor was there a difference in the use of vasopressors. During the 31–60 min after induction, the incidence of either moderate (P = 0.43) or severe (P = 0.97) hypotension was similar in the two groups. No differences in postoperative complications were found between groups. In conclusion, discontinuation of ACEI/ARA therapy at least 10 h before anesthesia was associated with a reduced risk of immediate postinduction hypotension.


儿童患者鞘内绝缘针电刺激的阈值电流探讨

Threshold Current of an Insulated Needle in the Intrathecal Space in Pediatric Patients

Ban C.H. Tsui, MD MSc FRCP(C)*, Alese M. Wagner, BSc*, Kirsten Cunningham, MB, ChB*, Shirley Perry, MScN{dagger}, Sunil Desai, MB, ChB, FRCP(C){dagger}, and Robert Seal, MD, FRCP(C)*

*Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada; and {dagger}Department of Pediatric Oncology, Stollery Children's Hospital, Edmonton, Alberta, Canada

Anesth Analg 2005;100:662-665

 

以往提示在给予鞘内电刺激时,阈电流值<1 mA便足以产生运动反应。我们设计本试验的目的是确定绝缘针在鞘内诱发运动反应所需要的电流阈值。征募20例年龄7.3 ± 3.9岁拟行腰椎穿刺术的儿童患者。用丙泊酚镇静后,患者被置于侧卧位,18号或20号引导针置于L4-5水平,通过引导管针插入绝缘的24Pajunck单极针(带有Sprotte针尖及针芯)。当进针至感觉出现“噗”的时候,提示已进入鞘内。此时以神经刺激仪连接到绝缘针上,逐步提高电流量,直至出现明显的运动反应。然后检查针座是否有脑脊液流出。如无脑脊液流出,则继续进针,直至出现脑脊液,重新测定阈电流值。测得鞘内诱发运动反应所需的平均电流为0.6 ± 0.3 mA(范围为0.1–1 mA)19例病人颤搐反应出现在L4-5肌节,1例出现在L219例儿童的颤搐为单侧性,仅1例为双侧。这一结果证实了鞘内阈电流值为<1 mA的假设,这和报道的硬膜外电刺激阈电流值有显著不同。

(周志坚  李士通 )

A threshold current of <1 mA has been suggested to be sufficient to produce a motor response to electrical stimulation in the intrathecal space. We designed this study to determine the threshold current needed to elicit motor activity for an insulated needle in the intrathecal space. Twenty pediatric patients aged 7.3 ± 3.9 yr scheduled for lumbar puncture were recruited. After sedation with propofol, patients were turned to the lateral position and an 18-gauge or 20-gauge introducer needle was placed at the L4-5 level through which an insulated 24-gauge Pajunck unipolar needle (with a Sprotte tip and stylet) was inserted. The needle was advanced into the intrathecal space as suggested by the presence of a "pop." At this point, a nerve stimulator was attached to the insulated needle and the current was gradually increased until motor activity was evident. The needle hub was checked for cerebrospinal fluid. If cerebrospinal fluid was not present, the needle was advanced further until cerebrospinal fluid was present. The threshold current was retested. The mean current in the intrathecal space required to elicit a motor response was 0.6 ± 0.3 mA (range, 0.1–1 mA). In 19 patients, the twitches were observed at the L4-5 myotomes and 1 patient had twitches at L2. Twitches were observed unilaterally in 19 children and bilaterally in one child. This confirms the hypothesis that the threshold current in the intrathecal space is <1 mA and that it differs significantly from the threshold currents reported for electrical stimulation in the epidural space.

 

 

右旋美托咪定减少布比卡因和左旋布比卡因对大鼠的致惊厥潜能:{alpha}2-肾上腺素受体涉及控制惊厥

Dexmedetomidine Decreases the Convulsive Potency of Bupivacaine and Levobupivacaine in Rats: Involvement of {alpha}2-Adrenoceptor for Controlling Convulsions

Katsuaki Tanaka, MD, Yutaka Oda, MD, PhD, Tomoharu Funao, MD, PhD, Ryota Takahashi, MD, Naoya Hamaoka, MD, PhD, and Akira Asada, MD, PhD

Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan

Anesth Analg 2005;100:687-696

 

右旋美托咪定是高选择性的{alpha}2-肾上腺素受体激动剂,是局部麻醉时用来镇静和镇痛的合并用药。我们检验了这样一个假设,即在清醒、有自发呼吸的大鼠中用于镇静的右美托咪定能改变外消旋布比卡因和左旋布比卡因的致惊厥潜能。第一个实验中,雄性SD大鼠随机分为六组:不用右旋美托咪定的布比卡因组(布比卡因对照组,BC)、用小剂量右旋美托咪定的布比卡因组(BS)、用大剂量右旋美托咪定的布比卡因组(BL),不用右旋美托咪定的左旋布比卡因组(左旋布比卡因对照组 LC),用小剂量右旋美托咪定的左旋布比卡因组(LS),用大剂量右旋美托咪定的左旋布比卡因组(LL)(每组n = 10)。右旋美托咪定一次注射(BC组和LC, 0 µg/kg; BS组和 LS, 0.5 µg/kg; BL组和LL, 1.5 µg/kg) 后开始持续输注(BC组和LC , 0 µg · kg–1 · h–1; BS组和 LS, 3.6 µg · kg–1 · h–1; BL组和LL, 10.8 µg · kg–1 · h–1)右旋美托咪定输注开始后15分钟,开始以1 mg · kg–1 · min–1的速度持续输注布比卡因(BC组、BS组和BL)或左旋布比卡因(LC组、LS组和LL)直至强直性/阵挛性惊厥出现。右旋美托咪定在BCBSBL组以及LCLSLL组达到的镇静水平是明显不同的(P < 0.05)BLLL组布比卡因和左旋布比卡因的惊厥剂量分别明显大于BC LC(P < 0.01)BLLL组开始惊厥时布比卡因和左旋布比卡因在血浆和脑中的浓度也大于BC LC(P < 0.01)。第二个实验中,在右旋美托咪定输注前10分钟和输注后5分钟时给予育亨宾(1 mg/kg)来完全逆转右旋美托咪定的镇静效果(首剂1.5 µg/kg,随后10.8 µg · kg–1 · h–1)。给予育亨宾和右旋美托咪定的大鼠布比卡因和左旋布比卡因的惊厥剂量和惊厥开始时血浆和脑中的浓度明显小于仅给予右旋美托咪定的大鼠(P < 0.05),并且与不用右旋美托咪定和育亨宾的大鼠相似。我们得出结论,用于镇静的右旋美托咪定减少布比卡因和左旋布比卡因对大鼠的致惊厥潜能。{alpha}2-肾上腺素受体激动剂可能涉及这个抗惊厥作用。

(朱 李士通 校)

Dexmedetomidine, a highly selective {alpha}2-adrenoceptor agonist, is used in combination with local anesthetics for sedation and analgesia. We tested the hypothesis that dexmedetomidine used for sedation alters the convulsive potency of racemic bupivacaine and levobupivacaine in awake, spontaneously breathing rats. In the first experiments, male Sprague-Dawley rats were randomly divided into six groups: bupivacaine with no dexmedetomidine (bupivacaine control; BC), bupivacaine with small-dose dexmedetomidine (BS), bupivacaine with large-dose dexmedetomidine (BL), levobupivacaine with no dexmedetomidine (levobupivacaine control; LC), levobupivacaine with small-dose dexmedetomidine (LS), and levobupivacaine with large-dose dexmedetomidine (LL) (n = 10 for each group). Continuous infusion of dexmedetomidine (Groups BC and LC, 0 µg · kg–1 · h–1; Groups BS and LS, 3.6 µg · kg–1 · h–1; and Groups BL and LL, 10.8 µg · kg–1 · h–1) was started after bolus injection (Groups BC and LC, 0 µg/kg; Groups BS and LS, 0.5 µg/kg; and Groups BL and LL, 1.5 µg/kg). Fifteen minutes after the start of the dexmedetomidine infusion, continuous infusion of bupivacaine (Groups BC, BS, and BL) or levobupivacaine (Groups LC, LS, and LL) at 1 mg · kg–1 · min–1 was started and continued until tonic/clonic convulsions occurred. Dexmedetomidine achieved significantly different sedation levels both in Groups BC, BS, and BL and in Groups LC, LS, and LL (P < 0.05). Convulsive doses of bupivacaine and levobupivacaine were significantly larger in Groups BL and LL than in Groups BC and LC, respectively (P < 0.01 for both). Concentrations of bupivacaine and levobupivacaine in plasma and in brain at the onset of convulsions were also larger in Groups BL and LL than in Groups BC and LC (P < 0.01 for both). In the second experiment, yohimbine (1 mg/kg) administered 10 min before and 5 min after the start of dexmedetomidine infusion completely reversed the sedative effect of dexmedetomidine (bolus 1.5 µg/kg, followed by 10.8 µg · kg–1 · h–1). Convulsive doses and plasma and brain concentrations of bupivacaine and levobupivacaine at the onset of convulsions in rats receiving yohimbine and dexmedetomidine were significantly smaller than in those receiving only dexmedetomidine (P < 0.05 for all) and were similar to those without dexmedetomidine or yohimbine. We conclude that dexmedetomidine used for sedation decreases the convulsive potency of both bupivacaine and levobupivacaine in rats. {alpha}2-Adrenoceptor agonism may be involved in this anticonvulsant potency.

 

心脏毒性浓度的布比卡因和罗哌卡因对冠状血管阻力的对映体选择性作用

Enantioselective Actions of Bupivacaine and Ropivacaine on Coronary Vascular Resistance at Cardiotoxic Concentrations

Marko D. Burmester, Klaus-Dieter Schlüter, PhD, Jürgen Daut, MD, DPhil, and Peter J. Hanley, MBChB, PhD

Institut für Normale und Pathologische Physiologie, Universität Marburg, Marburg, Germany; Department of Physiology, Physiologisches Institut, Justus-Liebig-Universität, Giessen, Germany

Anesth Analg 2005;100:707-712

 

长效局麻药布比卡因和罗哌卡因在运用中最主要的顾虑就是不慎注入静脉,从而使心脏暴露于药物的毒性浓度。我们检验了这样一个假设,即这些手性(有构型对映性)麻醉药对冠状血管张力的作用有对映体选择性,其调控机制并不包括对于电压门控的Na+通道。在恒流主动脉灌注的离体心脏上连续测定冠状动脉灌注压(CPP)。这种方法对完整心脏的冠状血管阻力提供敏感的分析。在并行试验中,我们检测了布比卡因和罗哌卡因对冠状动脉内皮细胞上细胞内[Ca2+]的影响。此外,用离体的心室心肌细胞分析布比卡因对线粒体膜电位的影响。消旋布比卡因和右旋布比卡因产生类似的剂量依赖的CPP降低。然而左旋布比卡因、左旋罗哌卡因以及右旋罗哌卡因增加了CPP。同三磷酸腺苷相反,消旋布比卡因和左旋罗哌卡因都不改变内皮细胞内的[Ca2+],提示这些临床上使用的药物并不影响内皮细胞中一氧化氮合成酶。我们同样发现可能的解联体布比卡因并不使完整的心室心肌细胞中的线粒体去极化。结论,长效局麻药对冠状阻力血管的作用有对映体选择性。消旋布比卡因和右旋布比卡因使得冠状动脉扩张,反之左旋布比卡因和左旋罗哌卡因都导致冠状动脉收缩,右旋罗哌卡因使冠状动脉收缩的程度较小。

(沈浩 李士通 校)

 

The main concern with the use of the long-acting local anesthetics bupivacaine and ropivacaine is inadvertent IV injection, which exposes the heart to toxic drug concentrations. We tested the hypothesis that these chiral anesthetics exert enantioselective actions on coronary vascular tone, the regulation of which does not involve voltage-gated Na+ channels. Coronary perfusion pressure (CPP) was continuously measured in isolated hearts perfused via the aorta at a constant flow rate. This method provides a sensitive assay of coronary vascular resistance in the intact heart. In parallel experiments, we examined the effects of bupivacaine and ropivacaine on intracellular [Ca2+] in coronary endothelial cells. In addition, the effect of bupivacaine on mitochondrial membrane potential was assessed using isolated ventricular myocytes. Racemic bupivacaine and R(+)-bupivacaine produced similar dose-dependent decreases in CPP. However, S(-)-bupivacaine, S(-)-ropivacaine and R(+)-ropivacaine increased CPP. In contrast to adenosine triphosphate, neither racemic bupivacaine nor S(-)-ropivacaine changed endothelial intracellular [Ca2+], suggesting that these clinically used drugs do not modulate endothelial nitric oxide synthase. We also showed that the putative uncoupler bupivacaine did not depolarize mitochondria in intact ventricular myocytes. In conclusion, the long-acting local anesthetics have enantioselective actions on coronary resistance vessels. Racemic bupivacaine and R(+)-bupivacaine are coronary vasodilators, whereas S(-)-bupivacaine, S(-)-ropivacaine and, to a lesser extent, R(+)-ropivacaine all induce coronary vasoconstriction.


在清醒相和七氟醚全麻期间硬膜外罗哌卡因麻醉降低双谱指数

Epidural Ropivacaine Anesthesia Decreases the Bispectral Index During the Awake Phase and Sevoflurane General Anesthesia

 

Tadahiko Ishiyama, MD, PhD, Satoshi Kashimoto, MD, PhD, Takeshi Oguchi, MD, PhD, Toshiaki Yamaguchi, MD, PhD, Katsumi Okuyama, MD, and Teruo Kumazawa, MD, PhD

Department of Anesthesiology, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan

Anesth Analg 2005;100:728-732

 

无挥发性和IV麻醉时硬膜外麻醉的镇静作用及对硬膜外麻醉引起的镇静的程度定量尚无研究。在本研究中我们评价了在清醒和在全麻期间硬膜外麻醉对双谱指数(BIS)的影响。置入硬膜外导管后,随机将患者分入2组,硬膜外给予生理盐水 5 mL(组S)或等容量的0.75%罗哌卡因(组R)。在硬膜外注射后712131422 23 min进行清醒相期间的BIS测定。然后用异丙酚和维库溴铵诱导全麻,并用0.75%七氟醚维持。从气管插管约10 min后的10 min里,每间隔1 min进行BIS测定。在清醒相期间组RBIS显著低于组SP < 0.05)。在全麻期间组RBIS显著低于组SP < 0.0001)。在清醒相期间和在全麻期间硬膜外麻醉降低BIS。与硬膜外麻醉有关联的BIS的降低在全麻期间比在清醒相期间更显著。

(马皓琳 李士通 校)

The sedative effects of epidural anesthesia without volatile and IV anesthetics and quantification of the degree of epidural anesthesia-induced sedation have not been investigated. In the current study we evaluated the effects of epidural anesthesia on the bispectral index (BIS) during the awake phase and during general anesthesia. After placing the epidural catheter, the patients were randomly allocated to 2 groups receiving either 5 mL of epidural saline (group S) or the same volume of 0.75% ropivacaine (group R). The BIS measurements during the awake phase were performed at 7, 12, 13, 14, 22, and 23 min after the epidural injection. General anesthesia was then induced with propofol and vecuronium and maintained with 0.75% sevoflurane. From approximately 10 min after tracheal intubation, the BIS measurements were made at 1-min intervals for 10 min. The BIS during the awake phase was significantly lower in group R than in group S (P < 0.05). The BIS during general anesthesia was significantly lower in group R than in group S (P < 0.0001). Epidural anesthesia decreased the BIS during the awake phase and during general anesthesia. The decrease of the BIS associated with epidural anesthesia was more prominent during general anesthesia than during the awake phase.

 

 

静脉搏动对前额脉搏血氧波形的影响是Spo2计算错误的可能原因 

The Effect of Venous Pulsation on the Forehead Pulse Oximeter Wave Form as a Possible Source of Error in Spo2 Calculation

 

Kirk H. Shelley, MD, PhD, Doris Tamai, DO, Denis Jablonka, MD, Michael Gesquiere, MD, Robert G. Stout, MD, and David G. Silverman, MD

Department of Anesthesiology, Yale University, New Haven, Connecticut

Anesth Analg 2005;100:743-747

 

反射型前额脉搏血氧传感器最近已被介绍到临床实践。据报道其优点在于反应时间更短,并能免受血管收缩的影响。人们关心的是这些新传感器中部分产生的信号不稳定和错误的低Spo2值的报道。在一项多部位(手指、耳朵和前额)波形体积描记法的研究中,注意到一些病例中前额的波形的结构变得出乎意料地复杂。从25个全身麻醉病例中得到的体积描记的信号显示5个病例的复杂的前额波形。我们假设,复杂波形是下面的静脉信号造成的。在传感器上用压力敷裹使体积描记的波形恢复正常已被确定。进一步测试复杂的前额波形显示,其与有心房波、瓣膜波和静脉波的中心静脉描记线在形态学上一致。我们推测,静脉信号的存在是产生所报道的前额传感器问题的来源。我们相信,静脉波形是探头粘贴方法的结果,而不是应用反射型体积描记法传感器的结果。

(张曦 李士通 校)

 Reflective forehead pulse oximeter sensors have recently been introduced into clinical practice. They reportedly have the advantage of faster response times and immunity to the effects of vasoconstriction. Of concern are reports of signal instability and erroneously low Spo2 values with some of these new sensors. During a study of the plethysmographic wave forms from various sites (finger, ear, and forehead) it was noted that in some cases the forehead wave form became unexpectedly complex in configuration. The plethysmographic signals from 25 general anesthetic cases were obtained, which revealed the complex forehead wave form during 5 cases. We hypothesized that the complex wave form was attributable to an underlying venous signal. It was determined that the use of a pressure dressing over the sensor resulted in a return of a normal plethysmographic wave form. Further examination of the complex forehead wave form reveal a morphology consistent with a central venous trace with atrial, cuspidal, and venous waves. It is speculated that the presence of the venous signal is the source of the problems reported with the forehead sensors. It is believed that the venous wave form is a result of the method of attachment rather than the use of reflective plethysmographic sensors.


大鼠术后疼痛模型中在神经周围应用Resiniferatoxin预防痛觉过敏

Perineural Resiniferatoxin Prevents Hyperalgesia in a Rat Model of Postoperative Pain

Igor Kissin, MD, PhD*, Natasha Davison, BS*, and Edwin L. Bradley, Jr, PhD{dagger}

*Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and {dagger}Department of Biostatistics, University of Alabama at Birmingham

Anesth Analg 2005;100:774-780

 

ResiniferatoxinRTX)是一种活性范围单一的vanilloid激动剂。Vanilloid结合到瞬时受体电位离子通道亚型1,后者是一种非选择性的阳离子载体,在整合不同伤害信号时起重要作用。Vanilloid激动剂选择性地降低对伤害刺激的敏感性。本研究中,我们试图在一个切割性疼痛模型上判定神经周围应用RTX是否能预防痛觉过敏。在一个大鼠模型中,在切割足背前将RTX经皮注射至坐骨神经和隐神经。在RTX注射前及注射后8天内的不同时段测定对von Frey细丝刺激的退缩反应、对压掌的挣扎反应以及基于负重的疼痛评分。经皮注射RTX(0.0003%)到坐骨神经(0.1 mL)和隐神经(0.05 mL)可以完全预防切割时的痛觉过敏。切割后2小时,退缩阈值在不用RTX和用RTX组分别为51 mN456 mN P < 0.0001)。RTX还可预防由切割引起的挣扎阈值降低,并消除了与负重相关的疼痛行为。我们得出结论:RTX可以产生一种神经阻滞,此时可以消除术后疼痛并保留非疼痛性感觉和运动功能。

(黄施伟 李士通 校)

Resiniferatoxin (RTX) is a vanilloid agonist with a unique spectrum of activities. Vanilloids bind to the transient receptor potential ion channel subtype 1, a nonselective cation ionophore important in the integration of different noxious signals. Vanilloid agonists selectively decrease sensitivity to noxious stimuli. In this study, we sought to determine whether perineural RTX prevents hyperalgesia in a model of incisional pain. In a rat model, RTX was administered percutaneously to the sciatic and saphenous nerves before the plantar incision. The withdrawal response to von Frey filaments, the struggle response to pressure on the paw, and pain scoring based on weight bearing were measured before RTX and at various intervals for 8 days after RTX. A percutaneous injection of RTX (0.0003%) to the sciatic (0.1 mL) and saphenous (0.05 mL) nerves completely prevented incisional hyperalgesia. Two hours after incision, the withdrawal threshold was 51 mN without and 456 mN with RTX (P < 0.0001). RTX also prevented the incision-induced decrease in struggle threshold and abolished the pain behavior associated with weight bearing. We conclude that RTX provides a type of neural blockade when postoperative pain is abolished and that nonpainful sensations and motor functions are preserved.

 

 

口服小剂量可乐定对腹式子宫切除术病人围术期结果的临床效应

The Clinical Effect of Small Oral Clonidine Doses on Perioperative Outcomes in Patients Undergoing Abdominal Hysterectomy

 

Maria Paz Loayza Hidalgo, MD, PhD*{dagger}, Jorge Alberto Szimanski Auzani, MD{dagger}, Leandro Carpenedo Rumpel, MD{dagger}, Nívio Lemos Moreira, Jr, MD{dagger}, Arthur Werneck Costa Cursino, MD{dagger}, and Wolnei Caumo, MD, PhD{dagger}{ddagger}§

*Psychiatric Service, Hospital Materno Infantil Presidente Vargas; {dagger}Anesthesia Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; {ddagger}Universidade Federal do Rio Grande do Sul; and §Pharmacology Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil

Anesth Analg 2005;100:795-802

 

我们在腹式子宫切除术病人中评估小剂量可乐定的对抗焦虑、镇痛及血流动力学稳定的效应。61ASA I–II病人随机在术前和术后24小时口服可乐定100 µg (n = 29)或接受安慰剂(n = 32)。虽然接受可乐定病人在术后开始6小时内较对照组病人更易嗜睡,但可乐定在术后72小时内具有抗焦虑及镇痛作用。在中等至严重术后疼痛病人中,需治疗病例数(防止1例严重焦虑发生而需要接受预防的病例数)是395%可信区间[CI]1.72–9.42),相比之下在无或仅轻度疼痛的病人中,需治疗病例数为40例病人(95% CI, 18.79–99.68)。可乐定组中68%病人在术中的平均心率低于70 bpm,而安慰剂组21.40%(需治疗病例数为295% CI, 1.29–2.80)。接受可乐定的病人术中需要更少量罗哌卡因,但PCA吗啡用量并不减少。发现可乐定在围术期具有临床相关的抗焦虑效应,提示除了其它术前镇静药,可乐定也可能是一有用的治疗选择。

(王立中 李士通 校)

We assessed the effect of small clonidine doses on anxiolysis, analgesia, and hemodynamic stability in patients undergoing abdominal hysterectomy. A total of 61 patients, ASA status I–II, were randomly assigned to receive either oral clonidine 100 µg (n = 29) or placebo (n = 32) before surgery and 24 h after surgery. The use of clonidine resulted in anxiolysis and analgesia throughout the 72 h after surgery, although the subjects who received clonidine were sleepier than the control group for the first 6 h after surgery. The number needed to treat was 3 (95% confidence interval [CI], 1.72–9.42) to prevent intense anxiety in patients with moderate to intense postoperative pain, compared with 40 (95% CI, 18.79–99.68) in the absence of pain or with mild pain. In the treated patients, 68% had an average heart rate less than 70 bpm during surgery, compared with 21.40% in the placebo group (number needed to treat, 2; 95% CI, 1.29–2.80). The clonidine patients required small ropivacaine doses during the surgery but not less morphine by patient-controlled analgesia. A clinically relevant anxiolytic effect was found in patients who received oral clonidine in the perioperative period, and this suggests that clonidine might be a useful therapeutic alternative to other preoperative sedatives.


创伤和缺血对仓鼠皮瓣组织糖代谢的影响

The Influence of Trauma and Ischemia on Carbohydrate Metabolites Monitored in Hamster Flap Tissue

Claudio Contaldo, MD*, Jan Plock, MD*, Valentin Djonov, MD{dagger}, Michael Leunig, MD*, Andrej Banic, MD, PhD*, and Dominique Erni, MD*

*Department of Orthopedic, Plastic and Hand Surgery, Inselspital, University Hospital, CH-3010 Berne, Switzerland; {dagger}Institute of Anatomy, University of Berne, CH-3011 Berne, Switzerland

Anesth Analg 2005;100:817-822

 

为观察创伤性危重病患周围组织的低灌注,我们用微透析法检测了创伤的和缺血的仓鼠皮瓣组织中的葡萄糖、丙酮酸盐和乳酸盐的浓度。解剖学血供受阻使缺血部分的皮瓣的微循环血流量(激光多普勒血流量法)和局部组织氧张力(荧光染色淬灭法)明显下降(P值均 < 0.01)。创伤区域的血流量、氧张力和丙酮酸水平在实验期间均与正常对照组织相似,而缺血组织的丙酮酸水平明显下降(与基础值和其它组织相比,P值均 < 0.05)。两部分皮瓣的乳酸水平均有上升(其中缺血组与基础值和其它组相比,P值均 < 0.01,创伤组的上升则无显著意义)。发觉缺血性缺氧的敏感性,乳酸是62%,乳酸/丙酮酸比值 (L/P比值) 93%( P < 0.01)。区分创伤相关性变化与缺血的特异性,乳酸是71% L/P比值是 70% (无明显区别)。我们的结果提示:与乳酸相比,L/P比值能更准确地监测创伤后的缺血相关性缺氧。然而,在灌注正常但有创伤的组织产生的L/P比值和乳酸水平上升的发生率均较高。

(轩泓 李士通 校)

To monitor hypoperfusion of the peripheral tissues in critical illness caused by injury, we measured the concentrations of glucose, pyruvate, and lactate in traumatized and ischemic hamster flap tissue with the use of microdialysis. The interruption of the anatomic blood supply led to a drastic decrease in microvascular blood flow (laser Doppler flowmetry) and partial tissue oxygen tension (dye fluorescence quenching technique) in the ischemic part of the flap (both P < 0.01). In the traumatized area, blood flow, oxygen tension, and pyruvate were similar to the healthy control tissue throughout the experiments, whereas pyruvate was reduced in the ischemic tissue (P < 0.05 versus baseline and other tissues). Lactate was increased in both parts of the flap (P < 0.01 versus baseline and other groups for ischemic, not significant for traumatized). The sensitivity to detect ischemic hypoxia was 62% for lactate and 93% for lactate/pyruvate ratio (L/P) (P < 0.01). The specificity to discern ischemia-related from trauma-related changes was 71% for lactate and 70% for L/P (not significant). Our results suggest that L/P is more accurate than lactate for monitoring ischemia-related hypoxia after trauma. However, the rate of increased values originating from normally perfused but traumatized tissue was high for both markers.

 

 

异丙酚或七氟醚对估计脑灌注压和零流动压的影响

The Effects of Propofol or Sevoflurane on the Estimated Cerebral Perfusion Pressure and Zero Flow Pressure

Paul D. Marval, FRCA, Mandy E. Perrin, FRCA, Sally M. Hancock, FRCA, and Ravi P. Mahajan, FRCA, DM

University Departments of Anesthesia and Intensive Care, Queens Medical Centre and City Hospital NHS Trust, Nottingham, United Kingdom

Anesth Analg 2005;100:835-840

 

零流动压是(ZFP)指通过血管床的血流停止时的压力。我们采用经颅多普勒超声来观察异丙酚或七氟醚对脑循环中的ZFP和估计的脑灌注压(eCPP)的影响。研究了23例在全身麻醉下行非神经外科手术的健康患者。应用异丙酚麻醉诱导后,用输注异丙酚(n = 13)或吸入七氟醚(n = 10)维持麻醉。记录清醒时(作为基础值)以及碳酸浓度正常(呼末二氧化碳分压在基础值水平)和低碳酸血症(低于基础值1 kPa)时稳态麻醉下的脑中动脉血流速、无创动脉血压和呼末二氧化碳分压。用已建立的公式计算eCPP ZFP。结果表明,两组的平均动脉压都降低。异丙酚组的eCPP明显降低(均数从5841mmHg),但七氟醚组没有变化(从6062mmHg)。相对地,异丙酚组的ZFP明显增高(从2533 mmHg)而在七氟醚组则明显下降(从277mm Hg)。低碳酸血症对异丙酚组的eCPP ZFP无明显影响,而在七氟醚组能明显降低eCPP 且增高 ZFP

(赵雪莲 李士通 校)

The zero flow pressure (ZFP) is the pressure at which blood flow ceases through a vascular bed. Using transcranial Doppler ultrasonography, we investigated the effects of propofol or sevoflurane on the estimated cerebral perfusion pressure (eCPP) and ZFP in the cerebral circulation. Twenty-three healthy patients undergoing nonneurosurgical procedures under general anesthesia were studied. After induction of anesthesia using propofol, the anesthesia was maintained with either propofol infusion (n = 13) or sevoflurane (n = 10). Middle cerebral artery flow velocity, noninvasive arterial blood pressure, and end-tidal carbon dioxide partial pressure were recorded awake as a baseline, and during steady-state anesthesia at normocapnia (baseline end-tidal carbon dioxide partial pressure) and hypocapnia (1 kPa below baseline). The eCPP and ZFP were calculated using an established formula. The mean arterial blood pressure decreased in both groups. The eCPP decreased significantly in the propofol group (median, from 58 to 41 mm Hg) but not in the sevoflurane group (from 60 to 62 mm Hg). Correspondingly, ZFP increased significantly in the propofol group (from 25 to 33 mm Hg) and it decreased significantly in the sevoflurane group (from 27 to 7 mm Hg). Hypocapnia did not change eCPP or ZFP in the propofol group, but it significantly decreased eCPP and increased ZFP in the sevoflurane group.


神经轴麻醉时心搏骤停:发生率和生存影响因素

Cardiac Arrest During Neuraxial Anesthesia: Frequency and Predisposing Factors Associated with Survival

 

Sandra L. Kopp, MD*, Terese T. Horlocker, MD*, Mary Ellen Warner, MD*, James R. Hebl, MD*, Claude A. Vachon, MD*, Darrell R. Schroeder, MS{dagger}, Allan B. Gould, Jr, MD*, and Juraj Sprung, MD, PhD*

Departments of *Anesthesiology and {dagger}Health Sciences Research, Mayo Clinic, Rochester, Minnesota

Anesth Analg 2005;100:855-865

 

椎管内麻醉时心搏骤停的发生率和影响因素目前尚不清楚,其生存结果的资料存在争议。在这个回顾性研究中,我们评估了1983年至2002年,椎管内麻醉时心搏骤停的发生率,以及麻醉前的医疗情况和心搏骤停发生前后的事件与心搏骤停后生存率之间的关系。为了评估椎管内麻醉对比全身麻醉时心搏骤停的病人心搏骤停后生存率是否存在差异,还收集了同样时间段内在全身麻醉下实施相同手术时发生心搏骤停病人的资料。在Mayo 医院20年的研究时期内,椎管内阻滞时发生26例心搏骤停,全身麻醉时发生29例。1998年至2002年,椎管内麻醉时心搏骤停的总发生率是每10,000例病人发生1.8例,其中脊麻病人心搏骤停的发生率高于硬膜外麻醉 (10,000例病人中2.9例比0.9; P = 0.041)。椎管内麻醉时发生心搏骤停的26例病人中有14(54%),是麻醉直接导致了心搏骤停 (高位交感神经阻断或给予镇静药后呼吸抑制),而在另外12(46%)心搏骤停与特殊的外科事件(接合剂成分的粘接、精索操作、股骨铰除和羊膜破裂)有关。全身麻醉时发生心搏骤停病人的ASA分级要高于椎管内麻醉时发生心搏骤停的病人(P = 0.031)。椎管内麻醉时心搏骤停病人的医院幸存率高于全身麻醉病人(65% 31%; P = 0.013)。除外ASA分级和急症手术,校准化所有病人和手术特征,椎管内麻醉时心搏骤停复苏病人的存活率仍有统计学意义上显著的改善。我们认为椎管内麻醉时心搏骤停病人的存活率大于或等于全身麻醉时心搏骤停的病人。

(张莹 李士通 校)

The frequency and predisposing factors associated with cardiac arrest during neuraxial anesthesia remain undefined, and the survival outcome data are contradictory. In this retrospective study, we evaluated the frequency of cardiac arrest, as well as the association of preexisting medical conditions and periarrest events with survival after cardiac arrest during neuraxial anesthesia between 1983 and 2002. To assess whether survival after cardiac arrest differs for patients who arrest during neuraxial versus general anesthesia, data were also obtained for patients who experienced cardiac arrest under general anesthesia during similar surgical procedures during the same time interval. Over the 20-yr study period at the Mayo Clinic, there were 26 cardiac arrests during neuraxial blockade and 29 during general anesthesia. The overall frequency of cardiac arrest during neuraxial anesthesia for 1988 to 2002 was 1.8 per 10,000 patients, with more arrests in patients receiving spinal versus epidural anesthesia (2.9 versus 0.9 per 10,000; P = 0.041). In 14 (54%) of the 26 patients who arrested during a neuraxial technique, the anesthetic contributed directly to the arrest (high sympathectomy or respiratory depression after sedative administration), whereas in 12 (46%) patients, the arrest was associated with a specific surgical event (cementing of joint components, spermatic cord manipulation, reaming of the femur, and rupture of amniotic membranes). Patients who arrested during general anesthesia had a higher ASA classification than those who arrested during a neuraxial block (P = 0.031). Hospital survival was significantly improved for patients who arrested during neuraxial anesthesia versus general anesthesia (65% vs 31%; P = 0.013). The association of improved survival with neuraxial anesthesia remained statistically significant after adjusting for all patient/procedural characteristics, with the exception of ASA classification and emergency procedures. We conclude that a cardiac arrest during neuraxial anesthesia is associated with an equal or better likelihood of survival than a cardiac arrest during general anesthesia.

 

 

阻塞性肺疾病的二氧化碳曲线图形

Capnogram Shape in Obstructive Lung Disease

Baruch Krauss, MD, EdM*{ddagger}, Aaron Deykin, MD{dagger}{ddagger}, Alexander Lam{ddagger}, Joan J. Ryoo{ddagger}, David R. Hampton, PhD§, Paul W. Schmitt, PhD§, and Jay L. Falk, MD||

*Division of Emergency Medicine, Children’s Hospital-Boston; {dagger}Respiratory Division, Brigham and Women’s Hospital; {ddagger}Harvard Medical School, Boston, Massachusetts; §Research Division, Medtronic, Redmond, Washington; and ||Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida

Anesth Analg 2005;100:884-888

 

小范围的初步研究显示阻塞性肺疾病(OD)的二氧化碳曲线图表现出特征性的波形,而且该波形可能与第一秒用力呼气量(FEV1)的变化有关。我们评估OD患者与正常肺功能和限制性肺疾病(RD)患者二氧化碳曲线图和肺活量的相关性,用肺功能实验室262名患者的常规样本以前瞻性非随机的方式进行研究。在肺功能测定前记录二氧化碳曲线图。OD患者的二氧化碳曲线图与正常肺功能或 RD患者的有显著性差别。这些差别随疾病的严重程度的加深逐步加大。重度OD上升相的平均升起角度比正常肺小7.2度(95% 可信区间[CI]: 4.0, 10.4)。中度OD平台相平均肺泡仰角比正常肺大0.8 95% CI: 0.14, 1.4),而重度OD的平均仰角比正常肺大3.6度(95% CI: 2.9, 4.3)。OD二氧化碳曲线图与正常肺和RD二氧化碳曲线图之间的区别与FEV1变化有关,该差别的程度足以说明二氧化碳曲线图可用于区别OD和正常肺。

(陈玮    李士通 校)

Small, preliminary studies have suggested that capnograms of obstructive lung disease (OD) exhibit a characteristic shape and that this shape may be correlated to changes in forced expiratory volume in 1 s (FEV1). We evaluated the association between capnograms and spirometry from subjects with OD with normal and restrictive lung disease (RD) subjects. The study was conducted in a prospective, nonrandomized manner using a convenience sample of 262 subjects presenting to a pulmonary function laboratory. Capnograms were recorded before pulmonary function testing. Subjects with OD had capnograms that were significantly different from normal and RD subjects. These differences were progressive, increasing with disease severity. The average take-off angle of the ascending phase for severe OD was 7.2 degrees less (95% confidence interval [CI]: 4.0, 10.4) than for normals. The average alveolar plateau elevation angle was 0.8 degrees more (95% CI: 0.14, 1.4) for moderate OD than for normals, whereas the average elevation angle was 3.6 degrees more (95% CI: 2.9, 4.3) for severe OD than for normals. Differences between OD capnograms and normal and RD capnograms, correlating to changes in FEV1, were sufficiently large enough to suggest that the capnogram could be used to discriminate between OD and normal.