Anesthesia & Analgesia

March 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

七氟醚而非異丙酚在微創直接冠脈搭橋手術中具有保護心肌功能的作用

(王柯 薛張綱 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.

 

有和無氣腹時的肝門阻斷的血液動力學影響:一項超聲心動圖研究

(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.

 

簡化鎖骨下靜脈置管的解剖標誌:三角肌粗隆

(齊波 譯 陳傑 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.

右旋美托咪定對離體大鼠心臟缺氧-再充氧性左室功能不全的效能

(王麗珺 薛張綱 )

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.

血管緊張素抑制劑在普外科手術人群中的運用

(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.

 

術中血液回收:補液的計算

(齊波 譯 陳傑 校)

Intraoperative Blood Salvage: Fluid Replacement Calculations (Special Article)

John C. Drummond and Charise T. Petrovitch

Anesth Analg 2005 100: 645-649.

PEDIATRIC ANESTHESIA:

小兒麻醉術中知曉: 一組前瞻性研究

( 薛張綱 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.

 

兒童患者鞘內絕緣針電刺激的閾值電流探討

(周志堅  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.  

 

糖尿病治療的新進展:麻醉方面的意義

(朱慧琛 譯 陳傑 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:

術前靜脈液體療法減少高危病人術後噁心和疼痛

(周曉敏 薛張綱 )

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:

右旋美托咪定減少布比卡因和左旋布比卡因對大鼠的致驚厥潛能:{alpha}2-腎上腺素受體涉及控制驚厥

( 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.

 

地氟醚麻醉後的氣道反射恢復比七氟醚麻醉更迅速

(朱慧琛 譯 陳傑 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 -一種水溶性的異丙酚前體對志願者進行TCI輸注產生鎮靜作用

(許文妍 薛張綱 )

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.

 

心臟毒性濃度的布比卡因和羅呱卡因對冠狀血管阻力的對映體選擇性作用

(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.

 

一種新的具有外周阿片特性的藥物氟雷法胺和嗎啡、安慰劑對靜息通氣影響的比較研究

(顧漪聞 譯 陳傑 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.

 

拇內收肌監測神經肌阻滯方法中主利手不改變肌電圖監測結果

(蔡美華 薛張綱 )

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間硬膜外羅呱卡因麻醉降低雙譜指數

(馬皓琳 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.

 

七氟醚麻醉時短效β1受體拮抗藥艾司洛爾和蘭地洛爾抑制氣管插管時的雙頻指數反應

(顧漪聞 譯 陳傑 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.

 

三種手術用消毒鋪巾的表皮熱量損失,一種為密封而潮濕鋪巾

(孫志榮譯 薛張綱校)

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.

 

靜脈搏動對前額脈搏血氧波形的影響是Spo2計算錯誤的可能原因 

(張曦 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.

 

對麻醉狗使用主動脈流量探測儀檢測新型超聲多普勒心排量監測儀(USCOM)的可靠性

(朱輝 譯 陳傑 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:

 

超前鎮痛對急性術後鎮痛的療效:一項薈萃分析

(王麗珺譯 薛張綱校)

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.

 

大鼠術後疼痛模型中在神經周圍應用Resiniferatoxin預防痛覺過敏

(黃施偉 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.

 

口服小劑量可樂定對腹式子宮切除術病人圍術期結果的臨床效應

(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:

利用先進的模擬方法識別和糾正院前外傷病人氣道和呼吸處理技能中的缺陷

(朱輝 譯 陳傑 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.

 

內毒素血症患者使用異丙酚減弱急性肺損傷

( 薛張綱 )

Attenuation of Acute Lung Injury with Propofol in Endotoxemia

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

Anesth Analg 2005 100: 810-816.

 

創傷和缺血對倉鼠皮瓣組織糖代謝的影響

(軒泓 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.

 

膿毒血症階段非去極化肌松藥對鼠離體膈肌作用削弱的依賴性和差異性

(殷文淵 陳傑 )

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.

 

局部單純應用重組人鹼性成纖維細胞生長因數可加速家兔耳室創傷癒合期間初期血管生成

(孫敏莉 薛張綱 )

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:

異丙酚或七氟醚對估計腦灌注壓和零流動壓的影響

(趙雪蓮 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.

 

大鼠局灶性腦缺血模型中一氧化氮合成酶抑制劑對依託咪酯不良反應的作用

(殷文淵 陳傑 )

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.

 

大鼠脊髓缺血後白質損傷的評估:與灰質損傷的比較

(沈洪 薛張綱 )

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:

神經軸麻醉時心搏驟停:發生率和生存影響因素

(張瑩 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.

 

持續股神經阻滯時負荷量及術後所用的藥液中加入可樂定可延遲全膝關節成形術後運動功能的恢復

(趙延華 陳傑 )

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.

 

可樂定靜脈給藥而非神經周圍給藥途徑能延長腰大肌間隙阻滯髖部骨折術後鎮痛效果

(吳德華 薛張綱 )

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線圖形

(陳瑋    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.

 

氣道峰壓增加是氣管導管部分阻塞的晚期報警信號而呼氣流速的變化是早期報警信號

(趙延華 陳傑 )

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.

 

七氟醚而非異丙酚在微創直接冠脈搭橋手術中具有保護心肌功能的作用

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.

 

在實驗研究和臨床研究中,揮發性麻醉藥具有心肌保護的特性。我們設計了這次研究來評價在無心肺轉流的微創直接冠脈搭橋(MIDCAB)手術中七氟醚對於左心室功能的保護作用。我們隨機地把52位要進行MIDCAB手術的患者分成異丙酚組和七氟醚組。除了這些使用的麻醉藥,手術和麻醉管理在2組並無不同。我們測定了心肌肌鈣蛋白T、肌酸肌酶、肌酸肌酶MB、心電圖(ECG)和心超參數(心肌作功指數和早期心房充盈速率),之後夾閉冠狀動脈左前降支直至左內乳動脈吻合完成。在左前降支阻斷和再灌注期間,我們重複了心超測量、抽取血樣一直到72小時。左前降支阻斷之後,異丙酚組的心肌作功指數和早期心房充盈速率明顯惡化,分別從0.40 ± 0.12 1.29 ± 0.35 變成 0.49 ± 0.10 1.13 ± 0.22,而七氟醚組卻無此改變。異丙酚組在再灌注之後心肌作功指數仍較基線有明顯的升高(0.47 ± 0.11)。心電圖和實驗室檢查結果在2組之間無明顯異常。總之,在患者行MIDCAB手術短期缺血期間,七氟醚較異丙酚有更好的心肌保護作用。

(王柯 薛張綱 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.

 

右旋美托咪定對離體大鼠心臟缺氧-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

在睡眠呼吸暫停的病人中,由於呼吸暫停導致的缺氧是心臟病的一個重要因素。我們設計了這一研究來驗證對於那些缺乏系統的血流動力學和體液影響,而是由於缺氧-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護作用。離體大鼠心臟暴露於60分鐘的缺氧狀態,隨後10分鐘再充氧。第一個試驗,在缺氧狀態前給予010100nM的右旋美托咪定(每組n=7),第二個試驗(n=7),缺氧後給予100nM右旋美托咪定,第三個試驗(n=7, 100nM右旋美托咪定聯合或不聯合育亨賓(一種α2受體拮抗劑)在缺氧後給予。結果表明,缺氧狀態之前而非之後給予右旋美托咪定,顯著提高了再充氧後左室壓力的恢復(缺氧前給予010100nM的右旋美托咪定或缺氧後給予100nM右旋美托咪定的壓力值分別為53 ± 6, 64 ± 9, 78 ± 13, o 62 ± 12 mm Hg [均數±標準差]),聯合育亨賓後的壓力值是58 ± 8 mm Hg。我們推斷:右旋美托咪定對由於缺氧-再充氧性左室功能不全的直接保護作用主要是通過缺氧前和缺氧時對α2腎上腺受體的激動作用來實現的。

(王麗珺 薛張綱 )

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.

 

小兒麻醉術中知曉: 一組前瞻性研究

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.

 

在常規的成人麻醉中,術中知曉的發生率為0.1%-0.2%。近期沒有關於在兒童手術中麻醉中知曉發生率的研究的相關報導。由於藥理過程和麻醉技術的不同,提示麻醉中知曉在兒童中的發生率可能不同于成年人。在本次同年齡組前瞻性研究中,探明了麻醉中知曉在兒童中的發生率。有864名在皇家兒童醫院接受全麻的5-12歲的兒童,在三種不同的場合接受了精神檢查,以測定麻醉中知曉的發生情況。關於麻醉中知曉的評估隱含在一個更大規模的關於麻醉後行為改變的研究中。被懷疑有麻醉中知曉的報告分送四位獨立的專家審查。四位元專家意見一致的病例被確認為發生了麻醉中知曉。有28份報告被懷疑發生了麻醉中知曉,其中7例被確認,發生率0.8%95%可信限為0.3%-0.7%)。在發生麻醉中知曉的兒童中只有一位使用了肌松藥,而在沒有發生麻醉中知曉的病例中有12%使用了肌松藥。在發生了麻醉中知曉的兒童中沒有感到痛苦的報導。在發生麻醉中知曉的兒童中有20%發生了行為改變,在沒有發生麻醉中知曉的兒童中有16%發生了行為改變,兩者無顯著差別。本資料中有證據表明,和成人一樣,兒童也有發生術中知曉的風險。雖然原因仍不清楚,但麻醉醫師對兒童發生麻醉中知曉的可能性應引起警覺。

(金 薛張綱 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.

 

術前靜脈液體療法減少高危病人術後噁心和疼痛

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.

 

術前靜脈液體療法減少行不臥床手術的病人的術後噁心嘔吐(PONV)和疼痛的作用程度仍存在爭議。本研究擬明確使用平衡溶液行術前靜脈液體療法是否可以減少高危病人術後噁心嘔吐的發生率。八十個ASA I-III級、擬行婦科腹腔鏡手術的病人隨機分為兩組,術前分別接受大容量(2 mL/kg/h快速輸注)和小容量(3 mL/kg)複合乳酸鈉溶液靜脈輸注20分鐘以上。使用一種標準化、作用平穩的麻醉藥。術後0.5h1h4h,術後第1天和第3天由盲法調查員評估術後噁心嘔吐和疼痛發生率及嚴重程度、需要追加止吐藥和鎮痛治療的發生率及嚴重程度,大容量輸注組在所有時間點的PONV的發生率(對照組87%、大容量組59%)及嚴重程度均有顯著減少。大容量輸注組還減小術後疼痛評分及減少追加鎮痛藥的需要量。在行不臥床手術的病人,術前糾正血容量不足可有效減少這些高危病人的術後噁心嘔吐和疼痛。我們建議術前給予行不臥床手術的病人(PONV風險增加)2 mL/kg/h的複合乳酸鈉溶液。

(周曉敏 薛張綱 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 -一種水溶性的異丙酚前體對志願者進行TCI輸注產生鎮靜作用                           

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 是第一個用於人體研究的水溶性異丙酚前體。現今的異丙酚乳劑中存在一些不如人意的成分,比如;注射過程中的疼痛以及不斷增加的甘油三酯濃度。我們研究是否 GPI 15715能夠達到並維持2小時的鎮靜作用。6位男性和6位女性志願者接受了一次GPI 15715 TCI輸注,初始濃度在1.8ug/ml並在1小時後調整一次靶濃度;同時監測BIS 指數以及用改良的MOAA/S量表進行評估。在第一個小時內,MOAA/S的中值為4 ,到輸注的第二個小時則為3。在7位受試者中,異丙酚靶濃度調整為2.4ug/ml;還有2位受試者調整至3.0ug/ml。當異丙酚的濃度維持在1.9ug/ml時最有可能使MOAA/S的評分為3,並維持中度的鎮靜。在此過程中,我們沒有發現嚴重的副作用,並得出如下結論:GPI 15715可以產生理想的鎮靜作用。

(許文妍 薛張綱 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.

 

拇內收肌監測神經肌阻滯方法中主利手不改變肌電圖監測結果

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

肌音描記法(PMG)是一種新的監測神經肌阻滯(NMB)的方法有很高的敏感 性而且適用於所有肌肉。長久以來以拇內收肌為參照進行神經肌監測測運 用於研究和臨床實踐 。我們通過比較同一病人雙手的PMG信號(四個成串 刺激比值和T1/T2的值)來研究神經肌監測中主利手的影響。在14位病人 中,雙手大魚際裝有小型壓電麥克風,用此來記錄PMG。麻醉誘導後,雙 側尺神經每隔12秒有超強的TOF刺激。5秒內給予米庫氯銨0.2mg/kg。然後 比較雙手拇內收肌在藥物起效,最大效應,NMB發生反應情況。受試者為 12名右利手和2名左利手。在主利手和非主利手的信號中沒有顯示統計差 異。相關性很好(r=0.95).一致性很好,-0.57%的偏倚和區間-17.9%到 16.7%(主利手-非主利手)。此研究揭示NMB方法監測拇內收肌反應在 主利手和非主利手之間很小的偏倚、良好的相關性、沒有統計學差異。在 由拇內收肌監測NMB效應雙手可以交替運用。

(蔡美華 薛張綱 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.

 

三種手術用消毒鋪巾的表皮熱量損失,一種為密封而潮濕鋪巾

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.

 

一種新的密封而潮濕手術用消毒鋪巾估計可降低熱量的蒸發。比較了覆蓋這種和另2種傳統鋪巾的表皮熱量喪失和皮膚溫度。對八個志願者通過十五面積熱量對流傳導器計算了表皮熱量喪失和皮膚表面溫度。隨機順序,每個鋪巾通過幹的和濕的傳導器評估(模擬潮濕皮膚)。20分鐘無鋪巾覆蓋後,志願者頸下部分鋪巾覆蓋40分鐘。資料連續記錄,每10分鐘一次。 結果:在乾燥或者潮濕的環境下3種鋪巾效果類似。在乾燥條件下,熱量損失為82 ± 14 W,覆蓋手術用鋪巾組下降30%P < 0.001)。潮濕條件下,熱量損失基線為231 ± 45 W,覆蓋手術鋪巾組下降29%(P < 0.001)。濕性皮膚增加熱量損失282% (P < 0.001)。對覆蓋鋪巾的幹性或者濕性皮膚,皮膚溫度臨床上無重要區別。濕性皮膚熱量損失增加近3倍,覆蓋鋪巾後無區別。密封和傳統鋪巾熱量損失相似,不管濕性還是幹性皮膚。

(孫志榮譯 薛張綱校)

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.

 

超前鎮痛對急性術後鎮痛的療效:一項薈萃分析
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,

對於急性術後疼痛,超前鎮痛干預是否比傳統治療更加有效還存在爭議。我們搜集了相關的隨機對照試驗,特異地比較術前鎮痛和類似的術後鎮痛。回收的報告根據5種鎮痛方法分層:硬膜外鎮痛、傷口局麻藥浸潤、N-甲基-d-天冬氨酸拮抗劑(NMDA)、非甾體類抗炎藥(NSAIDs)和阿片類鎮痛藥的使用。主要分析的測試結果是疼痛強度評分、附加鎮痛藥的消耗及首次鎮痛藥消耗的時間。66個研究分析了從3261名病人中得到的資料。這些資料由同一效能模型聯繫起來,效能指數(ES)是標準化的均數差異。當所有3項測試結果都綜合分析後,硬膜外鎮痛 (ES, 0.38; 95% 可信區間 [CI], 0.28-0.47),傷口局麻藥浸潤(ES, 0.29; 95% CI, 0.17-0.40)和非甾體類抗炎藥(ES, 0.39; 95% CI, 0.27-0.48) 的效能指數最高。其中,超前硬膜外鎮痛的效果對所有3項測試指標都是一致的,而傷口局麻藥浸潤和非甾體類抗炎藥的使用能改善鎮痛藥的消耗及首次鎮痛所需的時間,但對術後疼痛評分影響不大。效能證據最少的是N-甲基-d-天冬氨酸拮抗劑(ES, 0.09; 95% CI, -0.03 to 0.22)和阿片類鎮痛藥(ES, -0.10; 95% CI, -0.26 to 0.07),結論尚有不明確之處。

(王麗珺譯 薛張綱校)

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.

 

內毒素血症患者使用異丙酚減弱急性肺損傷

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.

 

通過炎性介質和免疫反應,內毒素可以引起急性肺損傷(ALI)。而異丙酚是一種抗炎和免疫抑制藥物。我們進行此項研究的目的就是證明異丙酚是否能夠減弱與內毒素血症相關的急性肺損傷。我們將32只麻醉了的試驗兔隨機分為4組,每組8只。通過靜脈緩慢注射(大於30min5 mg/kg內毒素在其中3個組製造了急性肺損傷模型。在使用內毒素之前15min,一個ALI組接受單次劑量為2 mg/kg的異丙酚,隨後以4 mg · kg–1 · h–1的速度持續輸注;另一ALI組接受的異丙酚劑量分別為5 mg/kg15 mg · kg–1 · h–1;第三個ALI組則接受大豆油乳劑作為對照。無肺損傷的對照組接受以上兩種液體的輸注。在使用內毒素之後,給試驗兔吸入40%的氧氣並進行機械通氣達6h4組之間血流動力學沒有差異。大劑量的異丙酚可以減少肺部的白細胞沉積、肺水腫(通過肺的濕/幹重量比得出)和肺部高滲透性(通過支氣管肺泡灌洗液中白蛋白水平得出),從而改善氧合、肺通氣與氣體交換。低劑量的異丙酚達不到這樣的效果。通過研究我們認為,大劑量的異丙酚可以在生理、生物化學和組織學上減弱內毒素血症引起的急性肺損傷。

(金 薛張綱 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.

 

局部單純應用重組人鹼性成纖維細胞生長因數可加速家兔耳室創傷癒合期間初期血管生成

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.


局部血管生成治療使用重組人鹼性成纖維細胞生長因數(rhbFGF),這項技術已經應用到促進傷口癒合中。為了獲得血管生成治療過程最佳時機的有用資訊,我們按時間地觀察活家兔耳室皮下血管床,評估局部單純應用rhbFGF對於家兔耳室模型傷口癒合時血管生成的影響。創傷癒合過程,用5周時間肉眼觀察及顯微鏡評估新血管形成。每只家兔耳室接受單一劑量6杯(mug)的 rhbFGF(治療組 B1 n=13),或18杯(mug)的 rhbFGF(治療組 B2 n=16),或接受生理鹽水作為對照組(n=13)。一周時,最新生成的血管區組B1B2顯著大於對照組。兩周時,血管生成區組B1B2與對照組相似。五周時,完成血管化的家兔的比例組B1明顯多於對照組。五周時,毛細血管密度三組相似。這些結果提示局部應用rhbFGF,在家兔創傷癒合早期,可加速血管生成。然而,這種作用是短暫的,而且在血管化作用完成時對毛細血管密度沒有增加。

(孫敏莉 薛張綱 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.

 

大鼠脊髓缺血後白質損傷的評估:與灰質損傷的比較

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.

 

我們定量評估了大鼠脊髓缺血後白質和灰質損傷以及白質和灰質損傷程度之間的關係,25只雄性大鼠用異氟醚麻醉,應用低血壓和主動脈內球囊阻塞法使脊髓缺血。這些大鼠隨機分為以下三組:脊髓缺血缺血時間12分鐘組(SCI-12組,數量8例),脊髓缺血時間15分鐘組(SCI-15組,數量9例),假手術組(數量8例)。再灌注後24小時應用Basso-Beattie-BresnahanBBB)評分法評估後腿運動功能。根據腹角內正常神經元的數目評估灰質損傷程度,而白質損傷則根據空泡形成的程度以及腹內和腹外側白質的澱粉樣前質蛋白免疫原性來評估。在SCI-15組正常的神經元要比SCI12和假手術組的正常神經元顯著減少(P<0.05)。BBB評分和正常神經元數成顯著正相關。空泡區域比例在SCI-15組比在SCI-12組要顯著大(30% +/- 10% 9% +/- 7%, 0% +/- 0%, P < 0.05)。免疫組織化學分析顯示在腫脹的軸突中澱粉樣前質蛋白增加,在SCI-15組尤其明顯。正常神經元數目與空泡區域比例成顯著負相關。結果表明大鼠脊髓缺血後白質和灰質都會受到損傷而且白質的損傷程度與相對短時間恢復後灰質損傷的嚴重度相關聯。

 

(沈洪 薛張綱 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.

 

可樂定靜脈給藥而非神經周圍給藥途徑能延長腰大肌間隙阻滯髖部骨折術後鎮痛效果

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.

 

作者評估了可樂定輔助于左旋布比卡因腰大肌間隙阻滯(PCB)時全身給藥和局部給藥的效果。採取隨機、雙盲、前瞻性研究,選擇36例髖部骨折在PCB合併全麻下行外科手術治療的病人,隨機分為三組。每組病人給0.5%左旋布比卡因0.4mL/kg行腰大肌間隙阻滯(PCB)。

對照組(L組)靜脈注射生理鹽水,全身給藥組(IC組)靜脈注射可樂定1mug/kg,以及神經周圍給藥組(C組)同時給以靜脈注射生理鹽水和可樂定1mug/kg腰大肌間隙阻滯(PCB)。比較三組中從PCB注射完成到第一次追加鎮痛藥的間隔,IC組的時間間隔比L組要長(mean+/-sd 13.4+/-6.1 versus 7.3+/-3.6hP=0.03)。C組和L組之間無顯著差別(10.3+/-5.9 versus 7.3+/-3.6h P>0.05)。嗎啡和對乙酰氨基酚的24h用量在各組中相近。術後副反應(心動過緩,低血壓,鎮靜和噁心)在各組中亦無明顯差別。我們得出的結論是靜脈注射途徑給予可樂定(1microg/kg)能延長PCB術後鎮痛效果,同時不增加其副反應的發生率,而神經周圍給藥途徑卻無此作用。

(吳德華 薛張綱 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.

 

簡化鎖骨下靜脈置管的解剖標誌: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.

 

鎖骨下靜脈常用於中心靜脈置管的通道。一般通過幾個解剖標誌來決定穿刺點和穿刺角度,但利用這些標誌可能增加操作和解剖測量。本實驗研究利用位於鎖骨側面的三角肌粗隆作為解剖標誌進行定位的可行性。利用三角肌粗隆不需要這些操作和測量,從而方便鎖骨下靜脈穿刺。為系統地研究這個解剖標誌,作者將本研究分為四個階段:1) 雙盲檢查100個乾燥的鎖骨測量其三角肌粗隆內側緣至鎖骨側面末端的距離;2) 在20具新鮮的屍體上以三角肌粗隆和胸骨上切跡為標誌進行鎖骨下靜脈穿刺;3) 利用CT所獲取的資料資料對10個病人的鎖骨下動脈和靜脈以及周圍結構進行三維重建,測量兩側以三角肌粗隆為標誌的虛擬鎖骨下靜脈置管路徑的長度;4) 選擇60例病人以標準路徑或三角肌粗隆為標誌進行鎖骨下靜脈穿刺的前瞻性隨機試驗研究。在第一階段檢查者之間的測量差異為3 ± 1毫米;在第二階段,20個病例中有19個鎖骨下靜脈穿刺成功,而另外一例誤穿入鎖骨下動脈。在第三階段,左側和右側皮膚至靜脈距離無明顯差異,分別為4.9 ± 0.5 cm4.7 ± 0.6 cm。在第四個階段,所有病人均可完成鎖骨下靜脈穿刺,但穿刺時間三角肌粗隆組明顯快於標準路徑組(23 ± 16 34 ± 14 s) (P < 0.01)。作者認為三角肌粗隆可以作為一個可供選擇的解剖標誌,從而減少操作和解剖測量來簡化鎖骨下靜脈置管。

(齊波 譯 陳傑 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.

 

術中血液回收:補液的計算

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.

 

由於脊柱外科手術時間長、難度增加以及總失血量的增多,術中血液回收(IBS)裝置常被作為附加手段用於血液保存。作者利用現有關於IBS裝置性能和效率的資訊以及晶體液和膠體液分佈的資訊,提供給臨床醫生通過所給的IBS裝置回收容量預測總失血量的指導原則。同時制訂出當通過等滲晶體液和等滲膠體液來進行容量替代治療時,如何估計合適替代容量的指導原則。當血液丟失過程中平均紅細胞壓積在25%30%之間時,總失血量將達到IBS回收血液容量的3.44.0倍。如果通過晶體和膠體液來進行容量替代治療,則合適的替代容量將分別約為2.58.0倍的IBS回收容量。這些容量可能要大於目前一些臨床醫生所使用的容量。

(齊波 譯 陳傑 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.

 

 

糖尿病治療的新進展:麻醉方面的意義

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.

過去的20年對於I型糖尿病的治療取得了很大的進展。不僅研發了很多新的給藥途徑如持續皮下胰島素泵的使用,同時通過對藥物動力學和藥效學的預測研製了更多更穩定的胰島素類型。現在又發明了人造胰腺,這對於現今的糖尿病患者圍術期的處理產生了很大的影響。

(朱慧琛 譯 陳傑 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.

 

地氟醚麻醉後的氣道反射恢復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.

 

吸入溶解度較高的麻醉藥的病人通常較吸入溶解度較低的麻醉藥的病人從麻醉到蘇醒的時間延長。本研究的目的主要是測試蘇醒延遲的同時是否伴隨保護性氣道反射恢復延遲。患者隨機分為兩組,分別通過喉罩通氣道吸入地氟醚(n=31)或七氟醚(n=30)。兩組的人口統計學無差別。儘管七氟醚組有較多的患者同時接受局部麻醉(七氟醚組17例、地氟醚組8例),兩組的平均最小肺泡麻醉濃度分數均為0.62,平均最小肺泡麻醉濃度時間地氟醚組為1.00 ± 0.68,七氟醚組為0.95 ± 0.5。從停止麻醉到患者能對指令作出適當反應的時間七氟醚組相對更長(七氟醚組5.5 ± 3.1min,地氟醚組 3.4 ± 1.9 min; P < 0.01)。此外七氟醚組患者從第一次應答指令至無嗆咳及吞咽20ml水無外溢的時間也較長。產生應答反應2分鐘後,地氟醚組的患者均能進行無嗆咳及無外溢的吞咽動作,而55%的七氟醚組患者會產生喝水嗆咳和外溢症狀(P < 0.001)。產生應答反應後6分鐘,七氟醚組的患者仍無法進行無嗆咳的吞咽動作(P < 0.05)。結論:使用地氟醚後保護性氣道反射的恢復更迅速。

(朱慧琛 譯 陳傑 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.

 

一種新的具有外周阿片特性的藥物氟雷法胺和嗎啡、安慰劑對靜息通氣影響的比較研究

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.

 

在動物模型中,氟雷法胺(FF)是一種強效的鎮痛藥,它是作用于外周的選擇性μ-受體激動劑。本文選擇12例健康男性進行一項雙盲、隨機、雙對照、四方交叉研究。分別觀察FF、兩種劑量的嗎啡和安慰劑對靜息通氣的影響。每種藥物都是6h注射一次。按藥物和劑量分為FF1.22mg/kg)組 、大劑量(0.43mg/kg)嗎啡組 、小劑量(0.11mg/kg)嗎啡組、安慰劑組(Nacl 9mg/mL)。用呼吸速度描記儀和流線二氧化碳描記圖測量呼吸。採集各組的血漿測量藥物以及代謝產物的濃度。在注射FF15min後,所有病例均訴暫時肌痛,30min後消失。而通氣情況(335min),每組病人的潮氣量沒有差異。但是,兩個嗎啡組與另外兩組比較呼吸次數均變慢(最小劑量組P<0.05,最大劑量組P<0.001)。每分通氣量嗎啡大劑量組較FF組以及安慰劑組明顯減少(P<0.01)。這種差異也表現在大劑量的嗎啡組的Etco2升高(P<0.01)。結論:在靜息通氣時,和嗎啡不同,FF不會導致中樞性的呼吸抑制。這意味FF是一種外周的選擇性μ-受體激動劑。

(顧漪聞 譯 陳傑 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.

 

七氟醚麻醉時短效β1受體拮抗藥艾司洛爾和蘭地洛爾抑制氣管插管時的雙頻指數反應

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.

 

在一項隨機、雙盲、對照研究中,作者驗證了一項假設——在單用七氟醚麻醉時,短效β1受體拮抗藥艾司洛爾、蘭地洛爾能抑制氣管插管時血流動力學的改變以及雙頻指數的增加。選擇45例患者,隨機分為對照組、艾司洛爾組、蘭地洛爾組,每組15人。麻醉誘導選用七氟醚,呼氣末的肺泡濃度達到1MAC。麻醉誘導後5min,對照組注射生理鹽水,艾司洛爾組(負荷量1mg/kg,然後0.25 mg/kg/min)、蘭地洛爾組(負荷量0.125mg/kg,然後0.04 mg/kg/min)。在麻醉誘導後12min氣管插管。三組的平均動脈壓無明顯差異,氣管插管後的15min,所有組的心率均增加,但是艾司洛爾組和蘭地洛爾組心率的增加沒有對照組明顯(P<0.05)。所有病人的BIS基線為9698,在誘導後均下降,在插入喉鏡前,三組也沒有差異(對照組39±5、艾司洛爾組39±5、蘭地洛爾組38±4)。在插管後1min,對照組的BIS明顯增高(54±10P<0.05),但是另兩組沒有明顯改變(45±1041±6)。結論:1MAC的七氟醚麻醉時,艾司洛爾和蘭地洛爾能夠抑制氣管插管時的雙頻指數和心率的增加。

(顧漪聞 譯 陳傑 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.

 

對麻醉狗使用主動脈流量探測儀檢測新型超聲多普勒心排量監測儀(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.

 

作者利用動物模型來檢測一種新型攜帶型連續超聲多普勒心排量檢測儀(USCOM)的可靠性。六條麻醉犬,在升主動脈安裝一個高精度時間轉換超聲流量檢測儀(流量儀)來檢測心排量。輸入多巴胺(0-15ug∙kg-1·min-1)逐步提高犬的心排量。同步用流量儀和USCOM檢測心排量。每條犬收集至少64對資料。這些資料通過Bland-Altman繪圖法和Lin氏整合相關係數進行比較。一共收集了319對資料。心排量平均值是2.62±1.04L/min,數值的範圍是0.795.73 L/min。兩組資料間的平均偏差是-0.01L/min95%的可信區間是-0.340.31L/min。誤差±13%。有5/6犬,兩種方法測定的資料表現高度的相關,相關係數>0.9USCOM能提供可靠的心排量檢測。在人體上仍需進行臨床實驗來驗證這種儀器的可靠性。

(朱輝 譯 陳傑 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.

 

利用先進的模擬方法識別和糾正院前外傷病人氣道和呼吸處理技能中的缺陷

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.

在這項前瞻性的研究中,作者使用兩個全面的院前創傷急救方案(嚴重的胸外傷和腦外傷)和特定動作檢查表,反映安全處理並獲得最後成功的一系列處理步驟,這些用來評估畢業於高級創傷生命支持(ATLS)課程的醫生的實習操作。在第一批的36個參與者中,模擬訓練安排在氣道和呼吸處理的基本訓練之後,然而在下一批的36個參與者中,利用太空人模型做氣道處理45分的模擬訓練加到操作的前面。其訓練內容是基於第一批普遍存在的錯誤操作。通過訓練改變後,參與者中沒有實施環狀軟骨按壓或在插管中沒有用藥的人數分別從55%降到8%和從42%降到11%。在固定氣管導管前沒有穩妥持管的人數從28%降到了0%。在嚴重的腦外傷急救方案中,每個組有15/36個參與者,在首次插管後的第二次氣道或呼吸處理的錯誤發生率從60%降到了0%。目前的研究正如ATLS所指出的一樣,院前創傷處理的問題尤顯重要。ATLS的畢業生也許能從基於氣道和呼吸處理的模擬訓練中受益。然而基於模擬的臨床意義還有待評估。

(朱輝 譯 陳傑 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.

 

膿毒血症階段非去極化肌松藥對鼠離體膈肌作用削弱的依賴性和差異性

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.

作者使用盲腸結紮和刺破的膿毒血症鼠模型研究早期和晚期膿毒血症時非去極化肌松藥作用的變化。評估0.1Hz超強電流間接刺激膈神經引出的神經半膈肌等長顫搐張力。羅庫溴銨,潘庫溴銨和d-筒箭毒堿在無膿毒血症,早期膿毒血症和晚期膿毒血症時產生劑量依賴性地膈肌顫搐張力變化(P < 0.01 )。非膿毒血症期、早期膿毒血症到晚期膿毒血症濃度顫搐張力曲線逐漸右移,抑制濃度值增加50%。潘庫溴銨早期和晚期膿毒血症標準化右移最多,羅庫溴銨次之,d-筒箭毒堿最小。膿毒血症導致的IC50 值並不隨曲線的下降而減小。這個結果說明膿毒血症導致非去極化肌松藥敏感性降低,其程度依賴於膿毒血症的的分期和肌松藥種類。

(殷文淵 陳傑 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.

 

大鼠局灶性腦缺血模型中一氧化氮合成酶抑制劑對依託咪酯不良反應的作用

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.

 

作者評估了NG-硝基-l-精氨酸甲酯(l-NAME, 一種一氧化氮合成酶[NOS] 抑制劑)1 -精氨酸(一氧化氮底物)在自發性高血壓鼠氟烷或依託咪酯麻醉期間短暫大腦中動脈阻塞(MCAo)後大腦線粒體失功(下指損傷)的影響。大腦中動脈阻塞前60分鐘大鼠隨機分到五組中的一組(每組8只):氟烷/對照組,吸入氟烷1.2 MAC;氟烷/l-NAME組,氟烷1.2 MACl-NAME(30 mg/kg);依託咪酯組,心電圖顯示抑制劑量的依託咪酯;依託咪酯/l-NAME組,心電圖顯示抑制劑量的依託咪酯和l-NAME(30 mg/kg);或依託咪酯/l-NAME/精氨酸組,心電圖顯示抑制劑量的依託咪酯和l-NAME(30 mg/kg)1-精氨酸(負荷劑量300 mg/kg,隨後35 mg · kg–1 · min–1的速度靜注)。依託咪酯/l-NAME/精氨酸組和氟烷/對照組的損傷程度沒有差異,但略小於依託咪酯組或依託咪酯/l-NAME組。這些資料再次應證了作者過去的觀察:以氟烷為對照,依託咪酯在大腦中動脈暫時缺血狀態下對缺血損傷會產生有害影響。預先用l-NAME阻滯NOS對氟烷和依託咪酯兩組的損傷程度沒有差別(162 ± 17 155 ± 26)。使用大劑量1-精氨酸能防止依託咪酯的有害影響。但資料僅取了再灌注2小時後的資料,因此不能解釋具有代表性的神經方面預後。但這還是提示依託咪酯在大腦中動脈缺血早期通過部分抑制NOS對線粒體功能有不良影響。

(殷文淵 陳傑 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.

 

持續股神經阻滯時負荷量及術後所用的藥液中加入可樂定可延遲全膝關節成形術後運動功能的恢復

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.

作者評價了持續外周神經阻滯時加入可樂定的效果。60名病人進行全膝關節成形術,單次注藥阻滯坐骨神經和持續給藥阻滯股神經。病人隨機分為三組,第一組為先用0.75%布比卡因單次阻滯,然後持續用0.2%羅呱卡因(對照組,n20),第二組為先用0.75%布比卡因和1μg/kg可樂定,然後用0.2%羅呱卡因(可樂定負荷組,n20),第三組為先用0.75%布比卡因和1μg/kg可樂定,然後用0.2%羅呱卡因和1μg/mL可樂定(可樂定持續組,n20)。術後用病人自控的輸注泵進行持續股神經給藥(背景輸注速度為6mL/h,追加劑量為2ml,鎖定時間為15min)。三組的神經阻滯平均起效時間(起效時間範圍)分別為15min5-30min)、10min5-35min)、10min5-30min)。用視覺類比尺規測定病人的疼痛程度,三組沒有區別。24h局麻藥的總用藥量分別為170ml144-200ml)、156ml144-233ml)、150ml144-210ml)(P0.48)。三組的血流動力學指標和鎮靜程度相似。可樂定持續組48h後運動功能受損的發生率為27%,而前兩組只有6%(P0.05)。結論:可樂定1μg/ml加入到局麻藥中進行股神經阻滯,沒有更好地緩解疼痛,反而有可能引起運動功能恢復的延遲。

(趙延華 陳傑 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.

 

氣道峰壓增加是氣管導管部分阻塞的晚期報警信號而呼氣流速的變化是早期報警信號

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.

氣管導管(ETT)長時間留置時分泌物會不為察覺地進入氣道而阻塞導管,吸氣峰壓(Ppeak)被常用於監測氣道明顯而進行性的阻塞。Ppeak的增加不僅與氣道狹窄的程度有關,與吸氣流速也有關。氣道狹窄對慢的吸氣氣流的影響很小,但對快的呼氣氣流的減速效應明顯,因此易於監測。將被動呼氣的容量-流速曲線分為連續的五個部分,計算它們的時間常數(TE),用於分析氣道部分阻塞時呼氣氣流是否並且如何受阻。用九頭幼豬進行容量控制通氣,通過外力夾閉氣管導管產生三種不同程度阻塞。在所有的動物中,氣道阻塞使TE增加(曲線第一部分的平均值,在未阻塞氣道為550ms1度阻塞為661ms2度阻塞為877ms2度阻塞為1563ms),2度和3度阻塞時明顯。而Ppeak沒有明顯增加(基礎值、1度和2度氣道阻塞分別為131415cmH2O),最嚴重的氣道阻塞即3度阻塞時Ppeak才有所增加(20 cmH2O)。結論:呼氣流速能可靠地監測氣管導管(ETT)部分阻塞,對需要呼吸機的病人吸入氣流可監測ETT的狹窄情況。

(趙延華 陳傑 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.

 

有和無氣腹時的肝門阻斷的血液動力學影響:一項超聲心動圖研究

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

 

以前只通過右心插管已研究得出有和無氣腹時肝門阻斷(PTC)期間都有心臟指數下降。為了更好地瞭解這種心臟指數的下降,我們用經食管超聲心動圖來研究充足的前負荷和針對後負荷增加的心臟泵血能力之間的平衡。選擇10例在腹腔鏡檢查下施行PTC10例剖腹施行PTC的病人。PTC5分鐘,測定每搏量、左室(LV)面積變化率(FAC)和LV收縮末期室壁張力(LVESWS)作為常規的血液動力學的指標。同時記錄局部室壁運動異常(RWMA)。在剖腹術組,LV舒張末期面積下降,LVESWS沒有明顯增加。FAC保持穩定,一個病人發生RWMA。在腹腔鏡檢查組,LV舒張末期面積保持穩定,LVESWS增加。FAC明顯下降,有5個病人發生RWMA。在剖腹術組的主要的改變是前負荷下降,而腹腔鏡檢查組證明LV功能下降可能是LV前負荷下降和LV後負荷增加的結果。然而,對這些沒有心臟疾病的研究病人,這些變化並沒有必要停止或放棄肝門阻斷。

(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.


血管緊張素抑制劑在普外科手術人群中的運用

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

 

我們研究了普外科手術病人長效血管緊張素轉換酶抑制劑(ACEI)及血管緊張素II受體1亞型拮抗劑(ARA) 的停藥時間與全麻誘導後低血壓發生的關係。我們回顧研究了267個接受長效 ACEI/ARA治療並在全麻下行擇期非心臟手術的高血壓患者。在術前訪視病人時,要求病人術晨繼續服用或在術前24小時停用ACEI/ARA。並在術前記錄最後一次服用ACEI/ARA距手術的小時數。在電子病歷及麻醉記錄上回顧伴發疾病、所用麻醉藥的類型及劑量、術中血流動力學、靜脈補液、圍術期血管收縮藥的使用情況和嚴重術後併發症的發生率。記錄誘導後60 min時間內的動脈壓(BP)及心率,並將低血壓分類為中度(收縮壓 85 mm Hg)及重度(收縮壓 65 mm Hg)。我們將所有病人的資料分為兩組來分析:最後一次服用ACEI/ARA在術前<10 h10 h。在麻醉誘導後的最初30min時間內,最後一次服用ACEI/ARA在誘導前<10 h組的病人中度低血壓的發生率(60%)較10 h組的(46%)(P = 0.02)。最後一次服用ACEI/ARA在術前<10 h組的病人中度低血壓發生的校正差異比為1.7495%可信區間,1.03–2.93(P = 0.04)。兩組病人在重度低血壓的發生率及血管收縮藥的使用方面無差異。在誘導後的31-60min時間內兩組中度低血壓的發生率(P = 0.43)和重度低血壓的發生率(P = 0.97)均相似。兩組病人術後併發症的發生無差別。結論,至少在麻醉前10h 中斷使用ACEI/ARA治療與減少誘導後即刻發生低血壓的危險性有關。

(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.


兒童患者鞘內絕緣針電刺激的閾值電流探討

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

 

以往提示在給予鞘內電刺激時,閾電流值<1 mA便足以產生運動反應。我們設計本試驗的目的是確定絕緣針在鞘內誘發運動反應所需要的電流閾值。徵募20例年齡7.3 ± 3.9歲擬行腰椎穿刺術的兒童患者。用丙泊酚鎮靜後,患者被置於側臥位,18號或20號引導針置於L4-5水平,通過引導管針插入絕緣的24Pajunck單極針(帶有Sprotte針尖及針芯)。當進針至感覺出現“噗”的時候,提示已進入鞘內。此時以神經刺激儀連接到絕緣針上,逐步提高電流量,直至出現明顯的運動反應。然後檢查針座是否有腦脊液流出。如無腦脊液流出,則繼續進針,直至出現腦脊液,重新測定閾電流值。測得鞘內誘發運動反應所需的平均電流為0.6 ± 0.3 mA(範圍為0.1–1 mA)19例病人顫搐反應出現在L4-5肌節,1例出現在L219例兒童的顫搐為單側性,僅1例為雙側。這一結果證實了鞘內閾電流值為<1 mA的假設,這和報導的硬膜外電刺激閾電流值有顯著不同。

(周志堅  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.

 

 

右旋美托咪定減少布比卡因和左旋布比卡因對大鼠的致驚厥潛能:{alpha}2-腎上腺素受體涉及控制驚厥

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

 

右旋美托咪定是高選擇性的{alpha}2-腎上腺素受體激動劑,是局部麻醉時用來鎮靜和鎮痛的合併用藥。我們檢驗了這樣一個假設,即在清醒、有自發呼吸的大鼠中用於鎮靜的右美托咪定能改變外消旋布比卡因和左旋布比卡因的致驚厥潛能。第一個實驗中,雄性SD大鼠隨機分為六組:不用右旋美托咪定的布比卡因組(布比卡因對照組,BC)、用小劑量右旋美托咪定的布比卡因組(BS)、用大劑量右旋美托咪定的布比卡因組(BL),不用右旋美托咪定的左旋布比卡因組(左旋布比卡因對照組 LC),用小劑量右旋美托咪定的左旋布比卡因組(LS),用大劑量右旋美托咪定的左旋布比卡因組(LL)(每組n = 10)。右旋美托咪定一次注射(BC組和LC, 0 µg/kg; BS組和 LS, 0.5 µg/kg; BL組和LL, 1.5 µg/kg) 後開始持續輸注(BC組和LC , 0 µg · kg–1 · h–1; BS組和 LS, 3.6 µg · kg–1 · h–1; BL組和LL, 10.8 µg · kg–1 · h–1)右旋美托咪定輸注開始後15分鐘,開始以1 mg · kg–1 · min–1的速度持續輸注布比卡因(BC組、BS組和BL)或左旋布比卡因(LC組、LS組和LL)直至強直性/陣攣性驚厥出現。右旋美托咪定在BCBSBL組以及LCLSLL組達到的鎮靜水平是明顯不同的(P < 0.05)BLLL組布比卡因和左旋布比卡因的驚厥劑量分別明顯大於BC LC(P < 0.01)BLLL組開始驚厥時布比卡因和左旋布比卡因在血漿和腦中的濃度也大於BC LC(P < 0.01)。第二個實驗中,在右旋美托咪定輸注前10分鐘和輸注後5分鐘時給予育亨賓(1 mg/kg)來完全逆轉右旋美托咪定的鎮靜效果(首劑1.5 µg/kg,隨後10.8 µg · kg–1 · h–1)。給予育亨賓和右旋美托咪定的大鼠布比卡因和左旋布比卡因的驚厥劑量和驚厥開始時血漿和腦中的濃度明顯小於僅給予右旋美托咪定的大鼠(P < 0.05),並且與不用右旋美托咪定和育亨賓的大鼠相似。我們得出結論,用於鎮靜的右旋美托咪定減少布比卡因和左旋布比卡因對大鼠的致驚厥潛能。{alpha}2-腎上腺素受體激動劑可能涉及這個抗驚厥作用。

(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.

 

心臟毒性濃度的布比卡因和羅呱卡因對冠狀血管阻力的對映體選擇性作用

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

 

長效局麻藥布比卡因和羅呱卡因在運用中最主要的顧慮就是不慎注入靜脈,從而使心臟暴露於藥物的毒性濃度。我們檢驗了這樣一個假設,即這些手性(有構型對映性)麻醉藥對冠狀血管張力的作用有對映體選擇性,其調控機制並不包括對於電壓門控的Na+通道。在恒流主動脈灌注的離體心臟上連續測定冠狀動脈灌注壓(CPP)。這種方法對完整心臟的冠狀血管阻力提供敏感的分析。在並行試驗中,我們檢測了布比卡因和羅呱卡因對冠狀動脈內皮細胞上細胞內[Ca2+]的影響。此外,用離體的心室心肌細胞分析布比卡因對線粒體膜電位的影響。消旋布比卡因和右旋布比卡因產生類似的劑量依賴的CPP降低。然而左旋布比卡因、左旋羅呱卡因以及右旋羅呱卡因增加了CPP。同三磷酸腺苷相反,消旋布比卡因和左旋羅呱卡因都不改變內皮細胞內的[Ca2+],提示這些臨床上使用的藥物並不影響內皮細胞中一氧化氮合成酶。我們同樣發現可能的解聯體布比卡因並不使完整的心室心肌細胞中的線粒體去極化。結論,長效局麻藥對冠狀阻力血管的作用有對映體選擇性。消旋布比卡因和右旋布比卡因使得冠狀動脈擴張,反之左旋布比卡因和左旋羅呱卡因都導致冠狀動脈收縮,右旋羅呱卡因使冠狀動脈收縮的程度較小。

(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間硬膜外羅呱卡因麻醉降低雙譜指數

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

 

無揮發性和IV麻醉時硬膜外麻醉的鎮靜作用及對硬膜外麻醉引起的鎮靜的程度定量尚無研究。在本研究中我們評價了在清醒和在全麻期間硬膜外麻醉對雙譜指數(BIS)的影響。置入硬膜外導管後,隨機將患者分入2組,硬膜外給予生理鹽水 5 mL(組S)或等容量的0.75%羅呱卡因(組R)。在硬膜外注射後712131422 23 min進行清醒相期間的BIS測定。然後用異丙酚和維庫溴銨誘導全麻,並用0.75%七氟醚維持。從氣管插管約10 min後的10 min裏,每間隔1 min進行BIS測定。在清醒相期間組RBIS顯著低於組SP < 0.05)。在全麻期間組RBIS顯著低於組SP < 0.0001)。在清醒相期間和在全麻期間硬膜外麻醉降低BIS。與硬膜外麻醉有關聯的BIS的降低在全麻期間比在清醒相期間更顯著。

(馬皓琳 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.

 

 

靜脈搏動對前額脈搏血氧波形的影響是Spo2計算錯誤的可能原因 

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

 

反射型前額脈搏血氧感測器最近已被介紹到臨床實踐。據報導其優點在於反應時間更短,並能免受血管收縮的影響。人們關心的是這些新感測器中部分產生的信號不穩定和錯誤的低Spo2值的報導。在一項多部位(手指、耳朵和前額)波形體積描記法的研究中,注意到一些病例中前額的波形的結構變得出乎意料地複雜。從25個全身麻醉病例中得到的體積描記的信號顯示5個病例的複雜的前額波形。我們假設,複雜波形是下面的靜脈信號造成的。在感測器上用壓力敷裹使體積描記的波形恢復正常已被確定。進一步測試複雜的前額波形顯示,其與有心房波、瓣膜波和靜脈波的中心靜脈描記線在形態學上一致。我們推測,靜脈信號的存在是產生所報導的前額感測器問題的來源。我們相信,靜脈波形是探頭粘貼方法的結果,而不是應用反射型體積描記法感測器的結果。

(張曦 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.


大鼠術後疼痛模型中在神經周圍應用Resiniferatoxin預防痛覺過敏

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)是一種活性範圍單一的vanilloid激動劑。Vanilloid結合到暫態受體電位離子通道亞型1,後者是一種非選擇性的陽離子載體,在整合不同傷害信號時起重要作用。Vanilloid激動劑選擇性地降低對傷害刺激的敏感性。本研究中,我們試圖在一個切割性疼痛模型上判定神經周圍應用RTX是否能預防痛覺過敏。在一個大鼠模型中,在切割足背前將RTX經皮注射至坐骨神經和隱神經。在RTX注射前及注射後8天內的不同時段測定對von Frey細絲刺激的退縮反應、對壓掌的掙扎反應以及基於負重的疼痛評分。經皮注射RTX(0.0003%)到坐骨神經(0.1 mL)和隱神經(0.05 mL)可以完全預防切割時的痛覺過敏。切割後2小時,退縮閾值在不用RTX和用RTX組分別為51 mN456 mN P < 0.0001)。RTX還可預防由切割引起的掙扎閾值降低,並消除了與負重相關的疼痛行為。我們得出結論:RTX可以產生一種神經阻滯,此時可以消除術後疼痛並保留非疼痛性感覺和運動功能。

(黃施偉 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.

 

 

口服小劑量可樂定對腹式子宮切除術病人圍術期結果的臨床效應

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

 

我們在腹式子宮切除術病人中評估小劑量可樂定的對抗焦慮、鎮痛及血流動力學穩定的效應。61ASA I–II病人隨機在術前和術後24小時口服可樂定100 µg (n = 29)或接受安慰劑(n = 32)。雖然接受可樂定病人在術後開始6小時內較對照組病人更易嗜睡,但可樂定在術後72小時內具有抗焦慮及鎮痛作用。在中等至嚴重術後疼痛病人中,需治療病例數(防止1例嚴重焦慮發生而需要接受預防的病例數)是395%可信區間[CI]1.72–9.42),相比之下在無或僅輕度疼痛的病人中,需治療病例數為40例病人(95% CI, 18.79–99.68)。可樂定組中68%病人在術中的平均心率低於70 bpm,而安慰劑組21.40%(需治療病例數為295% CI, 1.29–2.80)。接受可樂定的病人術中需要更少量羅呱卡因,但PCA嗎啡用量並不減少。發現可樂定在圍術期具有臨床相關的抗焦慮效應,提示除了其他術前鎮靜藥,可樂定也可能是一有用的治療選擇。

(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.


創傷和缺血對倉鼠皮瓣組織糖代謝的影響

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

 

為觀察創傷性危重病患周圍組織的低灌注,我們用微透析法檢測了創傷的和缺血的倉鼠皮瓣組織中的葡萄糖、丙酮酸鹽和乳酸鹽的濃度。解剖學血供受阻使缺血部分的皮瓣的微循環血流量(鐳射多普勒血流量法)和局部組織氧張力(螢光染色淬滅法)明顯下降(P值均 < 0.01)。創傷區域的血流量、氧張力和丙酮酸水平在實驗期間均與正常對照組織相似,而缺血組織的丙酮酸水平明顯下降(與基礎值和其他組織相比,P值均 < 0.05)。兩部分皮瓣的乳酸水平均有上升(其中缺血組與基礎值和其他組相比,P值均 < 0.01,創傷組的上升則無顯著意義)。發覺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)。區分創傷相關性變化與缺血的特異性,乳酸是71% L/P比值是 70% (無明顯區別)。我們的結果提示:與乳酸相比,L/P比值能更準確地監測創傷後的缺血相關性缺氧。然而,在灌注正常但有創傷的組織產生的L/P比值和乳酸水平上升的發生率均較高。

(軒泓 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.

 

 

異丙酚或七氟醚對估計腦灌注壓和零流動壓的影響

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

 

零流動壓是(ZFP)指通過血管床的血流停止時的壓力。我們採用經顱多普勒超聲來觀察異丙酚或七氟醚對腦迴圈中的ZFP和估計的腦灌注壓(eCPP)的影響。研究了23例在全身麻醉下行非神經外科手術的健康患者。應用異丙酚麻醉誘導後,用輸注異丙酚(n = 13)或吸入七氟醚(n = 10)維持麻醉。記錄清醒時(作為基礎值)以及碳酸濃度正常(呼末二氧化碳分壓在基礎值水平)和低碳酸血症(低於基礎值1 kPa)時穩態麻醉下的腦中動脈血流速、無創動脈血壓和呼末二氧化碳分壓。用已建立的公式計算eCPP ZFP。結果表明,兩組的平均動脈壓都降低。異丙酚組的eCPP明顯降低(均數從5841mmHg),但七氟醚組沒有變化(從6062mmHg)。相對地,異丙酚組的ZFP明顯增高(從2533 mmHg)而在七氟醚組則明顯下降(從277mm Hg)。低碳酸血症對異丙酚組的eCPP ZFP無明顯影響,而在七氟醚組能明顯降低eCPP 且增高 ZFP

(趙雪蓮 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.


神經軸麻醉時心搏驟停:發生率和生存影響因素

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

 

椎管內麻醉時心搏驟停的發生率和影響因素目前尚不清楚,其生存結果的資料存在爭議。在這個回顧性研究中,我們評估了1983年至2002年,椎管內麻醉時心搏驟停的發生率,以及麻醉前的醫療情況和心搏驟停發生前後的事件與心搏驟停後生存率之間的關係。為了評估椎管內麻醉對比全身麻醉時心搏驟停的病人心搏驟停後生存率是否存在差異,還收集了同樣時間段內在全身麻醉下實施相同手術時發生心搏驟停病人的資料。在Mayo 醫院20年的研究時期內,椎管內阻滯時發生26例心搏驟停,全身麻醉時發生29例。1998年至2002年,椎管內麻醉時心搏驟停的總發生率是每10,000例病人發生1.8例,其中脊麻病人心搏驟停的發生率高於硬膜外麻醉 (10,000例病人中2.9例比0.9; P = 0.041)。椎管內麻醉時發生心搏驟停的26例病人中有14(54%),是麻醉直接導致了心搏驟停 (高位交感神經阻斷或給予鎮靜藥後呼吸抑制),而在另外12(46%)心搏驟停與特殊的外科事件(接合劑成分的粘接、精索操作、股骨鉸除和羊膜破裂)有關。全身麻醉時發生心搏驟停病人的ASA分級要高於椎管內麻醉時發生心搏驟停的病人(P = 0.031)。椎管內麻醉時心搏驟停病人的醫院倖存率高於全身麻醉病人(65% 31%; P = 0.013)。除外ASA分級和急症手術,校準化所有病人和手術特徵,椎管內麻醉時心搏驟停復蘇病人的存活率仍有統計學意義上顯著的改善。我們認為椎管內麻醉時心搏驟停病人的存活率大於或等於全身麻醉時心搏驟停的病人。

(張瑩 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線圖形

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

 

小範圍的初步研究顯示阻塞性肺疾病(OD)的二氧化碳曲線圖表現出特徵性的波形,而且該波形可能與第一秒用力呼氣量(FEV1)的變化有關。我們評估OD患者與正常肺功能和限制性肺疾病(RD)患者二氧化碳曲線圖和肺活量的相關性,用肺功能實驗室262名患者的常規樣本以前瞻性非隨機的方式進行研究。在肺功能測定前記錄二氧化碳曲線圖。OD患者的二氧化碳曲線圖與正常肺功能或 RD患者的有顯著性差別。這些差別隨疾病的嚴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% 可信區間[CI]: 4.0, 10.4)。中度OD平臺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二氧化碳曲線圖與正常肺和RD二氧化碳曲線圖之間的區別與FEV1變化有關,該差別的程度足以說明二氧化碳曲線圖可用於區別OD和正常肺。

(陳瑋    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.