Anesthesia & Analgesia

April 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

 

对输注库存血和血红蛋白氧载体所致血液稀释的全身反应

(王丽珺译 薛张纲校)

Systemic Responses to Hemodilution After Transfusion with Stored Blood and with a Hemoglobin-Based Oxygen Carrier
Ivo P. Torres Filho, Bruce D. Spiess, R. Wayne Barbee, Kevin R. Ward, John Oldenhof, and Roland N. Pittman

Anesth Analg 2005 100: 912-920.

CABG术中使用硬膜外麻醉与单独使用全麻相比不减少心肌损害的生化标志

(朱玫娟 译 陈杰 校)

Epidural Anesthesia for Coronary Artery Bypass Surgery Compared with General Anesthesia Alone Does Not Reduce Biochemical Markers of Myocardial Damage
Michael J. Barrington, Roman Kluger, Robert Watson, David A. Scott, and Karen J. Harris

Anesth Analg 2005 100: 921-928

异丙酚减轻缺血再灌注和氧化应激引起的肺血管内皮损伤

(彭中美 李士通 校)

Propofol Attenuates Lung Endothelial Injury Induced by Ischemia-Reperfusion and Oxidative Stress

Irina V. Balyasnikova, David J. Visintine, Helena B. Gunnerson, Chanannait Paisansathan, Verna L. Baughman, Richard D. Minshall, and Sergei M. Danilov

Anesth Analg 2005 100: 929-936.

PEDIATRIC ANESTHESIA:

气道操作与侧卧位在腺样体扁桃体肥大儿童的麻醉实施、气道开放过程中的内镜测量效能

(王丽珺译 薛张纲校)

The Endoscopically Measured Effects of Airway Maneuvers and the Lateral Position on Airway Patency in Anesthetized Children with Adenotonsillar Hypertrophy

Young-Chang P. Arai, Kayo Fukunaga, Wasa Ueda, Masashi Hamada, Hiroyuki Ikenaga, and Kei Fukushima

Anesth Analg 2005 100: 949-952

小剂量纳洛酮对儿童和青少年PCIA时阿片类药物导致的副作用和镇痛效果的影响:一项双盲、前瞻、随机和对照的研究

(朱玫娟 译 陈杰 校)

The Effects of a Small-Dose Naloxone Infusion on Opioid-Induced Side Effects and Analgesia in Children and Adolescents Treated with Intravenous Patient-Controlled Analgesia: A Double-Blind, Prospective, Randomized, Controlled Study

Lynne G. Maxwell, Sandra C. Kaufmann, Sally Bitzer, Eric V. Jackson, Jr, John McGready, Sabine Kost-Byerly, Lori Kozlowski, Sharon K. Rothman, and Myron Yaster

Anesth Analg 2005 100: 953-958

丙泊酚和雷米芬太尼麻醉或丙泊酚、笑气和七氟醚麻醉下儿科肿瘤短小手术操作后恢复的比较

(周志坚 李士通 校)

Recovery After Anesthesia for Short Pediatric Oncology Procedures: Propofol and Remifentanil Compared with Propofol, Nitrous Oxide, and Sevoflurane
Hilary R. Glaisyer and Michael R. J. Sury

Anesth Analg 2005 100: 959-963.

碳氟化合物、表面活性物质及其联合应用在改善婴儿式气管内酸化导致的急性肺损伤的效果

(金 薛张纲 校)

The Efficacy of Fluorocarbon, Surfactant, and Their Combination for Improving Acute Lung Injury Induced by Intratracheal Acidified Infant Formula
Kahoru Nishina, Katsuya Mikawa, Yumiko Takao, and Hidefumi Obara

Anesth Analg 2005 100: 964-971.

AMBULATORY ANESTHESIA:

门诊关节镜手术,周围神经阻滞较全麻恢复更好

(朱玫娟 译 陈杰 校)

Peripheral Nerve Blocks Result in Superior Recovery Profile Compared with General Anesthesia in Outpatient Knee Arthroscopy

Admir Hadzic, Pelin Emine Karaca, Paul Hobeika, George Unis, Jeffrey Dermksian, Marina Yufa, Richard Claudio, Jerry D. Vloka, Alan C. Santos, and Daniel M. Thys

Anesth Analg 2005 100: 976-981.

ANESTHETIC PHARMACOLOGY:

预防注射罗库溴铵时的退缩反应:比较芬太尼与利多卡因

(马皓琳 李士通 校)

Preventing the Withdrawal Response Associated with Rocuronium Injection: A Comparison of Fentanyl with Lidocaine

Norezalee Ahmad, Choy Yin Choy, Esa Ab Aris, and Subrahmanyam Balan

Anesth Analg 2005 100: 987-990

挥发性麻醉药导致痛觉增强中肾上腺素能和类胆碱能传输的作用

(金 薛张纲 校)

The Role of Adrenergic and Cholinergic Transmission in Volatile Anesthetic-Induced Pain Enhancement

Thomas J. Rowley, Danette Daniel, and Pamela Flood

Anesth Analg 2005 100: 991-995.

轻度低温对幼猪血浆芬太尼浓度和生物转化的影响

(朱玫娟 译 陈杰 校)

The Effect of Mild Hypothermia on Plasma Fentanyl Concentration and Biotransformation in Juvenile Pigs
Harald G. Fritz, Martin Holzmayr, Bernd Walter, Klaus-Uwe Moeritz, Amelie Lupp, and Reinhard Bauer

Anesth Analg 2005 100: 996-1002.

牛的白质、皮层灰质、丘脑、海马和下丘脑区域中挥发性麻醉药的溶解度

(张莹 李士通 校)

Solubility of Volatile Anesthetics in Bovine White Matter, Cortical Gray Matter, Thalamus, Hippocampus, and Hypothalamic Area

Mireille A. Neumann, Edmond I Eger, II, and Richard B. Weiskopf

Anesth Analg 2005 100: 1003-1006.

地氟醚预处理对内皮粘附分子和mRNA的体外效应

(蔡美华译 薛张纲校)

The In Vitro Effect of Desflurane Preconditioning on Endothelial Adhesion Molecules and mRNA Expression

Zhu Biao, Xue Zhanggang, Jiang Hao, Miao Changhong, and Cang Jing

Anesth Analg 2005 100: 1007-1013.

犬急性等容血液稀释时吸入氟烷、异氟烷和七氟烷的比较性评估
(齐波 译 陈杰 校)

A Comparative Evaluation of Inhaled Halothane, Isoflurane, and Sevoflurane During Acute Normovolemic Hemodilution in Dogs

Denise Tabacchi Fantoni, Denise Aya Otsuki, Aline Magalhães Ambrósio, Eunice Yuriko Tamura, and José Otávio Costa Auler, Jr

Anesth Analg 2005 100: 1014-1019.

图解吸入麻醉药的摄取,包括出入脂肪组织的弥散

(周雅春 李士通 校)

Illustrations of Inhaled Anesthetic Uptake, Including Intertissue Diffusion to and from Fat (Special Article)

Edmond I. Eger, II and Lawrence J. Saidman

Anesth Analg 2005 100: 1020-1033

RGS蛋白:阿片类药信号传导和耐受机制领域的新角色

(许文妍译 薛张纲校)

RGS Proteins: New Players in the Field of Opioid Signaling and Tolerance Mechanisms (Review Article)
Guo-xi Xie and Pamela Pierce Palmer

Anesth Analg 2005 100: 1034-1042. 

TECHNOLOGY, COMPUTING, AND SIMULATION:

健康志愿者麻醉中12导联高频QRS心电图

(齐波 译 陈杰 校)

Twelve-Lead High-Frequency QRS Electrocardiography During Anesthesia in Healthy Subjects
Thomas N. Spackman, Martin D. Abel, and Todd T. Schlegel

Anesth Analg 2005 100: 1043-1047.

载体流速和输注系统死腔容量对静脉内药物传输动力学的影响

(轩泓 李士通 校)

The Impact of Carrier Flow Rate and Infusion Set Dead-Volume on the Dynamics of Intravenous Drug Delivery

Mark A. Lovich, Jason Doles, and Robert A. Peterfreund

Anesth Analg 2005 100: 1048-1055

非零基本氧流量对麻醉机呼吸回路漏气检验的危害

(孙志荣译 薛张纲校)

Non-Zero Basal Oxygen Flow a Hazard to Anesthesia Breathing Circuit Leak Test

Joho Tokumine, Kazuhiro Sugahara, Kouji Gushiken, Minoru Ohta, Tomoaki Matsuyama, and Satoko Saikawa

Anesth Analg 2005 100: 1056-1058.

PAIN MEDICINE:

DepodurTM,一种新型单剂量缓释硬膜外吗啡与标准硬膜外吗啡对缓解下腹部手术后疼痛的比较研究

(殷文渊 译 陈杰 校)

A Comparison of DepodurTM, a Novel, Single-Dose Extended-Release Epidural Morphine, with Standard Epidural Morphine for Pain Relief After Lower Abdominal Surgery

David Gambling, Thomas Hughes, Gavin Martin, William Horton, Garen Manvelian for the Single-Dose EREM Study Group

Anesth Analg 2005 100: 1065-1074.

兔鞘内给予新斯的明预防鞘内可乐定的减轻高碳酸血症脑血管扩张的作用

(王立中译,李士通校)

Intrathecal Neostigmine Prevents Intrathecal Clonidine from Attenuating Hypercapnic Cerebral Vasodilation in Rabbits

Motoyasu Takenaka, Hiroki Iida, Mami Iida, Kazuyuki Sumi, Masahiko Kumazawa, Shigeaki Tanahashi, and Shuji Dohi

Anesth Analg 2005 100: 1075-1080.

布比卡因对角叉菜胶引起小鼠炎症反应的作用: 体外刺激后白细胞产生细胞因子

(沈洪 薛张纲 )

Bupivacaine’s Action on the Carrageenan-Induced Inflammatory Response in Mice: Cytokine Production by Leukocytes After Ex-Vivo Stimulation
Hélène Beloeil, Karim Asehnoune, Pierre Moine, Dan Benhamou, and Jean-Xavier Mazoit

Anesth Analg 2005 100: 1081-1086.

脊髓阿片样受体1激动剂,而非N-甲基-D-天门冬氨酸拮抗剂,逆转大鼠皮内注射辣椒素引起的继发性机械性异常性疼痛

(殷文渊 译 陈杰 校)

Spinal Opioid Receptor Like1 Receptor Agonist, but Not N-Methyl-D-Aspartic Acid Antagonist, Reverses the Secondary Mechanical Allodynia Induced by Intradermal Injection of Capsaicin in Rats

Natsuko Nozaki-Taguchi and Tatsuo Yamamoto

Anesth Analg 2005 100: 1087-1092.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

成人手术期液管理及其临床结果

(黄丽娜  李士通  )

Perioperative Fluid Management and Clinical Outcomes in Adults (Review Article)

Michael P. W. Grocott, Michael G. Mythen, and Tong J. Gan

Anesth Analg 2005 100: 1093-1106.

CRITICAL CARE AND TRAUMA:

硝酸甘油对胃重建食管术后微循环灌注和氧合影响的研究

(吴德华译 薛张纲校)

The Effect of Nitroglycerin on Microvascular Perfusion and Oxygenation During Gastric Tube Reconstruction

Marc P. Buise, Can Ince, Hugo W. Tilanus, Jan Klein, Diederik Gommers, and Jasper van Bommel

Anesth Analg 2005 100: 1107-1111

手动膨胀肺时呼气末正压水平对呼气流速峰值的影响

(赵延华 译 陈杰 校)

The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation
Camila Savian, Pamela Chan, and Jennifer Paratz

Anesth Analg 2005 100: 1112-1116.

比较肝素化和非肝素化溶液用于维持围术期桡动脉导管畅通的功效及并发的阻塞

(邱郁薇      李士通  校)

A Comparison of the Efficacy of Heparinized and Nonheparinized Solutions for Maintenance of Perioperative Radial Arterial Catheter Patency and Subsequent Occlusion
Binnur E. Tuncali, Buhar Kuvaki, Bahattin Tuncali, and Emine Capar

Anesth Analg 2005 100: 1117-1121.

全氟己烷对家兔离体肺相对血流分布仅有微小影响

(金琳 薛张纲校)

Perfluorohexane Vapor Has Only Minor Effects on Spatial Pulmonary Blood Flow Distribution in Isolated Rabbit Lungs

Matthias Hübler, Axel R. Heller, Jörg U. Bleyl, Marcelo Gama de Abreu, Tobias Kroll, Thomas Rössel, and Thea Koch

Anesth Analg 2005 100: 1122-1128.

NEUROSURGICAL ANESTHESIA:

鞘内预注射酮咯酸能减少大鼠脊髓缺血性损伤

(朱 李士通 校)

Intrathecal Ketorolac Pretreatment Reduced Spinal Cord Ischemic Injury in Rats
Ying-Chou Hsieh, Wen-Yi Liang, Shen-Kou Tsai, and Chih-Shung Wong

Anesth Analg 2005 100: 1134-1139.

家兔急性闭合性头颅窗中软膜动脉对局部应用维拉帕米反应

(孙敏莉译 薛张纲校)

Pial Arterial Response to Topical Verapamil in Acute Closed Cranial Windows in Rabbits

Roger Hartl, Shailendra Joshi, Sean Levine, Mei Wang, and Robert R. Sciacca

Anesth Analg 2005 100: 1140-1146.

OBSTETRIC ANESTHESIA:

单次给药、持续释放的硬膜外吗啡处理择期剖腹产术后疼痛:多中心随机对照研究结果

(朱辉 译 陈杰 校)

Single-Dose, Sustained-Release Epidural Morphine in the Management of Postoperative Pain After Elective Cesarean Delivery: Results of a Multicenter Randomized Controlled Study
Brendan Carvalho, Edward Riley, Sheila E. Cohen, David Gambling, Craig Palmer, H. Jane Huffnagle, Linda Polley, Holly Muir, Scott Segal, Christine Lihou, Garen Manvelian for the DepoDur Study Group

Anesth Analg 2005 100: 1150-1158.

体位和比重对择期剖腹产鞘内布比卡因扩散的影响

(赵雪莲 李士通 校)

The Effect of Posture and Baricity on the Spread of Intrathecal Bupivacaine for Elective Cesarean Delivery

Stephen P. Hallworth, Roshan Fernando, Malachy O. Columb, and Gary M. Stocks

Anesth Analg 2005 100: 1159-1165.

REGIONAL ANESTHESIA:

慢性肾衰患者用布比卡因和罗哌卡因行肌间沟臂丛神经阻滞:膈肌移动和肺功能改变

(费敏译 薛张纲 校)

Interscalene Brachial Plexus Block with Bupivacaine and Ropivacaine in Patients with Chronic Renal Failure: Diaphragmatic Excursion and Pulmonary Function Changes

Fatis Altintas, Funda Gumus, Guner Kaya, Ismail Mihmanli, Fatih Kantarci, Kamil Kaynak, and M. Serif Cansever

Anesth Analg 2005 100: 1166-1171.

连续肌间沟神经周围注射罗哌卡因中加入可乐定可改善术后镇痛:一项随机、双盲、对照研究

(朱辉 译 陈杰 校)

Clonidine Added to a Continuous Interscalene Ropivacaine Perineural Infusion to Improve Postoperative Analgesia: A Randomized, Double-Blind, Controlled Study

Brian M. Ilfeld, Timothy E. Morey, Lisa J. Thannikary, Thomas W. Wright, and F. Kayser Enneking

Anesth Analg 2005 100: 1172-1178.

可乐定加入甲哌卡因用于腋路臂丛阻滞下甲沟炎手术的效果

(裘毅敏 李士通 校)

The Effects of Clonidine Added to Mepivacaine for Paronychia Surgery Under Axillary Brachial Plexus Block
Gabriella Iohom, Adnane Machmachi, Désiré-Pascal Diarra, Mohammed Khatouf, Sylvie Boileau, François Dap, Stéphanie Boini, Paul-Michel Mertes, and Herve Bouaziz

Anesth Analg 2005 100: 1179-1183

一项锁骨下区域的磁共振成像(MRI)分析:进针前能估计臂丛深度吗?

(周晓敏 薛张纲 校)

A Magnetic Resonance Imaging Analysis of the Infraclavicular Region: Can Brachial Plexus Depth Be Estimated Before Needle Insertion?
Philip B. Cornish and Michael Nowitz

Anesth Analg 2005 100: 1184-1188.

利多卡因复合硫酸镁行局部静脉麻醉

(顾漪闻 译 陈杰 校)

Intravenous Regional Anesthesia Using Lidocaine and Magnesium

Alparslan Turan, Dilek Memis, Beyhan Karamanlioglu, Turhan Güler, and Zafer Pamukçu

Anesth Analg 2005 100: 1189-1192.

缺血性视神经病变患者中星状神经节阻滞对视觉诱发电位和眼动脉与颈内动脉血流的影响

(陈玮     李士通 校)

The Effects of Stellate Ganglion Block on Visual Evoked Potential and Blood Flow of the Ophthalmic and Internal Carotid Arteries in Patients with Ischemic Optic Neuropathy

Feng Liu, Guozhong Xu, Zheli Liu, Yan Zhao, Xiaojun Lv, and Junke Wang

Anesth Analg 2005 100: 1193-1196.

GENERAL ARTICLES:

环状软骨按压与瑞芬太尼、丙泊酚对食管运动及食道下端括约肌的作用

(孙少潇译 薛张纲校)

The Effects of Cricoid Pressure, Remifentanil, and Propofol on Esophageal Motility and the Lower Esophageal Sphincter
Kristian Thorn, Sven-Egron Thorn, and Magnus Wattwil

Anesth Analg 2005 100: 1200-1203.

七氟醚复合异丙酚和七氟醚、异丙酚分别用于成人喉罩通气道置入的比较

(顾漪闻 译 陈杰 校)

A Comparison of Sevoflurane-Propofol Versus Sevoflurane or Propofol for Laryngeal Mask Airway Insertion in Adults
Sahar M Siddik-Sayyid, Marie T. Aouad, Samar K. Taha, Dima G. Daaboul, Patricia G. Deeb, Faraj M. Massouh, Marie-Rose A. Muallem, and Anis S. Baraka

Anesth Analg 2005 100: 1204-1209

 

CABG术中使用硬膜外麻醉与单独使用全麻相比不减少心肌损害的生化标志

Epidural Anesthesia for Coronary Artery Bypass Surgery Compared with General Anesthesia Alone Does Not Reduce Biochemical Markers of Myocardial Damage

Michael J. Barrington, FANZCA, Roman Kluger, FANZCA, Robert Watson, FANZCA, David A. Scott, FANZCA, and Karen J. Harris, RN

Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Australia

Anesth Analg 2005 100: 921-928.

 

冠脉搭桥手术(CABG)中使用高位胸段硬膜外麻醉/镇痛(HTEA)可能具有心肌保护作用。在这项前瞻、随机、对照研究中,作者研究了选择性CABG时,HTEA对肌钙蛋白I释放、气管拔管时间和镇痛等的作用。120位患者随机分为全麻组(GA)和全麻加高位胸段硬膜外麻醉组(HTEA组)。GA组接受芬太尼(715ug/kg)和吗啡。HTEA组接受芬太尼(57ug/kg)和硬膜外注射0.2%罗哌卡因+芬太尼(2ug/ml)直到术后第三天。结果:肌钙蛋白I水平组间没有区别。HTEA组中,拔管时间[中位数]为15min10320 min),GA组为430 min284590 min)。与GA组相比,HTEA组镇痛显著。在ICUHTEA组术后平均动脉血压和系统血管阻力较低。结论:在CABG中使用硬膜外麻醉不影响肌钙蛋白I的释放,但能改善术后镇痛,并缩短拔管时间。

(朱玫娟 译 陈杰 校)

High thoracic epidural anesthesia/analgesia (HTEA) for coronary artery bypass grafting (CABG) surgery may have myocardial protective effects. In this prospective randomized controlled study, we investigated the effect of HTEA for elective CABG surgery on the release of troponin I, time to tracheal extubation, and analgesia. One-hundred-twenty patients were randomized to a general anesthesia (GA) group or a GA plus HTEA group. The GA group received fentanyl (7–15 µg/kg) and a morphine infusion. The HTEA group received fentanyl (5–7 µg/kg) and an epidural infusion of ropivacaine 0.2% and fentanyl 2 µg/mL until postoperative Day 3. There were no differences in troponin I levels between study groups. The time to tracheal extubation [median (inter quartile range)] in the HTEA group was 15 min (10–320 min), compared with 430 min (284–590 min) in the GA group (P < 0.0001). Analgesia was improved in the HTEA group compared with the GA group. Mean arterial blood pressure poststernotomy and systemic vascular resistance in the intensive care unit were lower in the HTEA group. We conclude that HTEA for CABG surgery had no effect on troponin release but improved postoperative analgesia and was associated with a reduced time to extubation.

 

小剂量纳洛酮对儿童和青少年PCIA时阿片类药物导致的副作用和镇痛效果的影响:一项双盲、前瞻、随机和对照的研究

The Effects of a Small-Dose Naloxone Infusion on Opioid-Induced Side Effects and Analgesia in Children and Adolescents Treated with Intravenous Patient-Controlled Analgesia: A Double-Blind, Prospective, Randomized, Controlled Study

Lynne G. Maxwell, MD*, Sandra C. Kaufmann, MD{dagger}, Sally Bitzer, MD{ddagger}, Eric V. Jackson, Jr, MD{ddagger}, John McGready, MS§, Sabine Kost-Byerly, MD{ddagger}, Lori Kozlowski, RN{ddagger}, Sharon K. Rothman, RN{ddagger}, and Myron Yaster, MD{ddagger}

*Department of Anesthesiology, The Children’s Hospital of Philadelphia, Pennsylvania; {dagger}Department of Anesthesiology, The Joe DiMaggio Children’s Hospital, Hollywood, Florida; {ddagger}Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, The Johns Hopkins Medical Institutions; and §Department of Biostatistics, The Johns Hopkins University School of Public Health, Baltimore, Maryland

Anesth Analg 2005 100: 953-958.

 

阿片类药物常伴随恶心、呕吐和瘙痒等副作用。作者假设预防性、持续使用小剂量纳洛酮可以减少阿片类药物导致副作用的发病率,且不影响镇痛药物或阿片类药物的使用量。在这项前瞻、双盲、随机和对照的研究中,46名术后患者(男21,女25),平均年龄为14±2.5岁,平均体重为53±17kg,使用吗啡PCIA。患者随机分为对照组(注射生理盐水,n26)和纳洛酮组(纳洛酮0.25ug/kg/hn20)。结果:与纳洛酮组相比,对照组的瘙痒和恶心发生率和严重性明显增加,发生率分别为77%比20%,P0.0570%比35%,P0.05。吗啡使用量(1.02±0.41mg/kg/d1.28±0.61mg/kg/d),静息时疼痛评分(4±23±2),以及咳嗽状态时评分(6±26±2)没有明显区别。结论:在儿童和青少年中,小剂量注射纳洛酮(0.25ug/kg/h)可以明显减轻阿片类药物导致的副作用,而不影响阿片类药物的镇痛作用。当患者自控静脉吗啡镇痛治疗中重度疼痛时,临床医生可考虑同时使用小剂量的纳洛酮输注。

(朱玫娟 译 陈杰 校)

Opioids are frequently associated with side effects such as nausea, vomiting, and pruritus. We hypothesized that a prophylactic, continuous small-dose naloxone infusion would reduce the incidence of opioid-induced side effects without affecting analgesia or opioid consumption. In this prospective, double-blind, randomized, controlled clinical trial, we studied 46 postoperative patients (M:F, 21:25), averaging 14 ± 2.5 yr and 53 ± 17 kg, at the start of morphine IV patient-controlled analgesia. Patients were randomized to either saline (control, n = 26) or naloxone 0.25 µg · kg–1 · h–1 (n = 20). We found that the incidence and severity of pruritus (77% versus 20%; P < 0.05) and nausea (70% versus 35%; P < 0.05) was significantly more frequent in the placebo group compared with the naloxone group. Morphine consumption (1.02 ± 0.41 mg · kg–1 · d–1 versus 1.28 ± 0.61 mg · kg–1 · d–1), pain scores at rest (4 ± 2 versus 3 ± 2), and pain scores with coughing (6 ± 2 versus 6 ± 2) were not different. We conclude that, in children and adolescents, a small-dose naloxone infusion (0.25 µg · kg–1 · h–1) can significantly reduce the incidence and severity of opioid-induced side effects without affecting opioid-induced analgesia. When initiating morphine IV patient-controlled analgesia for the treatment of moderate to severe pain, clinicians should strongly consider starting a concomitant small-dose naloxone infusion.

 

门诊关节镜手术,周围神经阻滞较全麻恢复更好

Peripheral Nerve Blocks Result in Superior Recovery Profile Compared with General Anesthesia in Outpatient Knee Arthroscopy

Admir Hadzic, MD, PhD, Pelin Emine Karaca, MD, Paul Hobeika, MD, George Unis, MD, Jeffrey Dermksian, MD, Marina Yufa, MD, Richard Claudio, BS, Jerry D. Vloka, MD, PhD, Alan C. Santos, MD, MPH, and Daniel M. Thys, MD

Department of Anesthesiology, St. Luke’s-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York

Anesth Analg 2005 100: 976-981.

通常认为门诊手术中使用周围神经阻滞(PNBs)具有潜在的优势。但没有针对门诊关节镜手术患者使用短效局麻药周围神经阻滞和全麻的比较研究。作者假设使用短效局麻药联合腰丛和骶神经阻滞与全麻相比能缩短出院时间。计划接受关节镜手术患者随机分为全麻组和腰丛/骶神经组,全麻组使用咪唑安定、芬太尼、异丙酚,通过喉罩使用N2O/O2/地氟醚,腰丛/骶神经组使用氯普鲁卡因。为控制术后疼痛,接受全麻的患者关节腔内注射0.25%的布比卡因20ml。周围神经阻滞组患者在阻滞前给予咪唑安定(最多为4mg)和阿芬太尼(500750ug),术中使用异丙酚3050ug/kg/min镇静。比较两组患者的围术期时间,未入麻醉后监护病房比率,疼痛的和并发症的发生率。50例患者,全麻组和腰丛/骶神经组各为25例。两组总手术室时间没有显著差异(97±37min91±42min)。周围神经阻滞组中,72%患者未入麻醉后监护病房,全麻组中只有24%(P0.002)。在周围神经阻滞组中手术结束到达到出院回家标准的时间、和实际出院时间与全麻组相比明显缩短(分别为131±62min205±94min162±71min226±96min)。结论:对于门诊关节镜手术,使用3%2-氯普鲁卡因联合进行腰丛和骶神经阻滞较全麻恢复更好。

(朱玫娟 译 陈杰 校)

It has been suggested that use of peripheral nerve blocks (PNBs) may have some potential benefits in the outpatient setting. There have been no studies specifically comparing PNBs performed with short-acting local anesthetics with general anesthesia (GA) in patients undergoing outpatient knee surgery. We hypothesized that a combination of lumbar plexus and sciatic blocks using a short-acting local anesthetic will result in shorter time-to-discharge-home as compared with GA. Patients scheduled to undergo knee arthroscopy were randomized to receive a GA (midazolam, fentanyl, propofol, N2O/O2/desflurane via laryngeal mask airway) or lumbar plexus/sciatic block (PNBs; 2-chloroprocaine). Patients given GA also received an intraarticular injection of 20 mL 0.25% bupivacaine for postoperative pain control. Patients in the PNB group were given midazolam (up to 4 mg) and alfentanil (500–750 µg) before block placement and propofol 30–50 µg · kg–1 · min–1 for intraoperative sedation. Relevant perioperative times, postanesthesia care unit bypass rate, severity of pain, and incidence of complications were compared between the two groups. Fifty patients were enrolled in the study; 25 patients each received GA or PNBs. Total operating room time did not differ significantly between the 2 groups (97 ± 37 versus 91 ± 42 min). Seventy-two percent of patients receiving PNB met criteria enabling them to bypass Phase I postanesthesia care unit compared with only 24% of those receiving GA (P < 0.002). Time to meet criteria for discharge home (home readiness) and time to actual discharge were significantly shorter for patients given PNBs than for patients given GA (131 ± 62 versus 205 ± 94 and 162 ± 71 versus 226 ± 96, respectively). Under the conditions of our study, the combination of lumbar plexus and sciatic blocks with 2-chloroprocaine 3% was associated with a superior recovery profile compared with GA in patients having outpatient knee arthroscopy.

 

轻度低温对幼猪血浆芬太尼浓度和生物转化的影响

The Effect of Mild Hypothermia on Plasma Fentanyl Concentration and Biotransformation in Juvenile Pigs

Harald G. Fritz, MD*, Martin Holzmayr{dagger}, Bernd Walter, MD{dagger}{ddagger}, Klaus-Uwe Moeritz, PhD||, Amelie Lupp, MD§, and Reinhard Bauer, MD, PhD{dagger}

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Pathobiochemistry, Institute for Pathophysiology and Pathobiochemistry, {ddagger}Department of Neurosurgery and §Institute for Pharmacology and Toxicology, Friedrich-Schiller-University, Jena; and || Institute of Pharmacology, Ernst Moritz Arndt University, Greifswald, Germany

Anesth Analg 2005 100: 996-1002.

[

治疗性低温可以改变镇痛和镇静药物的需要剂量,但尚无资料显示持续、长时使用芬太尼时,轻度低温对其血浆浓度的影响。因此,作者利用猪模型来评估连续33小时使用芬太尼时,持续低温对芬太尼浓度的影响。7头雌性小猪(平均重量:11.8±1.1kg)静脉使用芬太尼(15ug/kg/h)和咪唑安定(1.0mg/kg/h)进行麻醉。在准备和稳定后(12h以后),这些动物被降温到中心温度为31.6℃±0.2℃,保持6h,然后复温,并保持在正常温度37.7℃±0.3℃6h。通过放免测定法测定血浆内芬太尼浓度,用热稀释法测心指数,通过染色酶技术测肾动脉、脾动脉、胰动脉、胃动脉、肠动脉和肝动脉血流。此外,4只小猪中,通过N-脱甲基乙基吗啡离体检测肝微粒体细胞色素P450 3A4CYP3A4)温度依赖性。在低温状态,血浆芬太尼浓度增加25±11%(P0.05),并且在复温后血药浓度持续上升至少6h。低温降低心指数(41±15%,P0.05),同时减少除肝动脉以外所有器官的血流量。低温时CYP 3A4具有显著的温度依赖性(P0.01)。轻度低温可以导致血浆芬太尼浓度的分布和/或清除依赖性的增加,并且在复温后可以持续增加几个小时。结论:为了恰当的镇痛和镇静应当预见到治疗性低温期间及结束后早期血浆芬太尼浓度会持续地增加。

(朱玫娟 译 陈杰 校)

Therapeutic hypothermia may alter the required dosage of analgesics and sedatives, but no data are available on the effects of mild hypothermia on plasma fentanyl concentration during continuous, long-term administration. We therefore assessed in a porcine model the effect of prolonged hypothermia on plasma fentanyl concentration during 33 h of continuous fentanyl administration. Seven female piglets (weight: 11.8 ± 1.1 kg) were anesthetized by IV fentanyl (15 µg · kg–1 · h–1) and midazolam (1.0 mg · kg–1 · h–1). After preparation and stabilization (12 h), the animals were cooled to a core temperature of 31.6° ± 0.2°C for 6 h and were then rewarmed and kept normothermic at 37.7° ± 0.3°C for 6 more hours. Plasma fentanyl concentrations were measured by radioimmunoassay, cardiac index by thermodilution, and blood flows of the kidney, spleen, pancreas, stomach, gut, and hepatic artery by a colored microspheres technique. Furthermore, in an additional 4 pigs, temperature dependency of hepatic microsomal cytochrome P450 3A4 (CYP3A4) was determined in vitro by ethylmorphine N-demethylation. Plasma fentanyl concentration increased by 25% ± 11% (P < 0.05) during hypothermia and remained increased for at least 6 h after rewarming. Hypothermia reduced the cardiac index (41% ± 15%, P < 0.05), as well as all organ blood flows except the hepatic artery. A strong temperature dependency of CYP3A4 was found (P < 0.01). Mild hypothermia induced a distribution and/or elimination-dependent increase in plasma fentanyl concentration which remained increased for several hours after rewarming. Consequently, a prolonged increase of the plasma fentanyl concentration should be anticipated for appropriate control of the analgesia/sedatives during and early after therapeutic hypothermia.

 

犬急性等容血液稀释时吸入氟烷、异氟烷和七氟烷的比较性评估
A Comparative Evaluation of Inhaled Halothane, Isoflurane, and Sevoflurane During Acute Normovolemic Hemodilution in Dogs

Denise Tabacchi Fantoni, DVM, PhD*, Denise Aya Otsuki, DVM*, Aline Magalhães Ambrósio, DVM*, Eunice Yuriko Tamura*, and José Otávio Costa Auler, Jr, MD, PhD{dagger}

*Department of Surgery, School of Veterinary Medicine, University of São Paulo, São Paulo, Brazil; and {dagger}Department of Anesthesiology, School of Medicine, University of São Paulo, São Paulo, Brazil

Anesth Analg 2005 100: 1014-1019.

 

急性等容血液稀释(ANH)的血流动力学反应受麻醉药的影响。作者随机研究18只杂种犬,在用三种不同的吸入麻醉药氟烷、异氟烷或七氟烷下进行ANH。在抽血前、血液稀释结束时、血液稀释结束后3060min时分别测定血流动力学、氧运输和胃pH。除了七氟烷组心率偏快外,组间血流动力学指标的基础值相似。血液稀释后30min,氟烷、异氟烷和七氟烷三组CI分别增加88%、86%和157%,但氟烷组动-静脉氧差和氧耗更大。用张力计获得的胃pH并没有变化,组间无差异。因为对ANH的血流动力学反应并不削弱,三种麻醉药均可安全用于麻醉维持。

(齐波 译 陈杰 校)

The hemodynamic response to acute normovolemic hemodilution (ANH) can be affected by the anesthetics used. We randomized 18 mongrel dogs to undergo ANH with 3 different inhaled anesthetics: halothane, isoflurane, or sevoflurane. Hemodynamics, oxygen transport, and gastric pH were measured before blood withdrawal, at the end of hemodilution, and 30 and 60 min after the end of hemodilution. The baseline measurements of all hemodynamic variables were similar among groups, with the exception of heart rate, which was more rapid in the sevoflurane group. Thirty minutes after hemodilution, the cardiac index increased 88%, 86%, and 157% in the halothane, isoflurane, and sevoflurane groups, respectively, whereas arterial-venous oxygen differences and oxygen consumption were larger in the halothane group compared with the isoflurane and sevoflurane groups. Gastric pH obtained by tonometry did not change and was not different among groups. Because the hemodynamic response to ANH was not blunted, all three anesthetics may be safely used for the maintenance of anesthesia.

 

健康志愿者麻醉中12导联高频QRS心电图

Twelve-Lead High-Frequency QRS Electrocardiography During Anesthesia in Healthy Subjects

Thomas N. Spackman, MD*, Martin D. Abel, MBBCh*, and Todd T. Schlegel, MD{dagger}

*Division of Cardiovascular/Thoracic Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota; and {dagger}Neuro-Autonomic Laboratory, NASA Johnson Space Center, Houston, Texas

Anesth Analg 2005 100: 1043-1047.

 

QRS综合波高频(HF)成分的分析,已被显示是心肌缺血和梗死的指标,与手术室外常规ST段分析相比更为敏感。在该研究中,作者记录了全麻对健康志愿者QRS高频分析的影响,以此确定这项技术对麻醉病人监测的潜在价值。记录30名健康个体麻醉前后全部12导联HFQRS心电图(ECGs)。与诱导前比较,诱导后多导联(原先描述的正常限)HF QRS的多个变量有显著变化。为了解这项技术监测麻醉病人心肌缺血的价值,尚需进一步的研究。

(齐波 译 陈杰 校)

Analysis of the high-frequency (HF) components of the QRS complex has been shown to be a more sensitive indicator of myocardial ischemia and infarction than conventional ST segment analysis in settings outside of the operating room. In this study, we documented the effect of general anesthesia on HF QRS analysis in healthy patients as the first step in determining the potential of this technique for monitoring anesthetized patients. HF QRS electrocardiograms (ECGs) were obtained from all 12 ECG leads in 30 healthy subjects before and after the induction of anesthesia. When compared with preinduction values, there were significant postinduction changes in multiple variables of the HF QRS in many leads studied that were within previously described normal limits. Additional study is needed to understand the potential of this monitoring technique for enhancing detection of myocardial ischemia in the anesthetized population.

 

DepodurTM,一种新型单剂量缓释硬膜外吗啡与标准硬膜外吗啡对缓解下腹部手术后疼痛的比较研究

A Comparison of DepodurTM, a Novel, Single-Dose Extended-Release Epidural Morphine, with Standard Epidural Morphine for Pain Relief After Lower Abdominal Surgery

David Gambling, MB, BS, FRCPC*, Thomas Hughes, MD{dagger}, Gavin Martin, MD{ddagger}, William Horton, MD§, Garen Manvelian, MD|| for the Single-Dose EREM Study Group

*Sharp Mary Birch Hospital for Women, San Diego, California; {dagger}Woodland Memorial Hospital, Woodland, California; {ddagger}Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; §Progressive Research, LLC, Greenville, South Carolina; and ||SkyePharma, Inc., San Diego, California

Anesth Analg 2005 100: 1065-1074.

 

在这个随机、对照、不同剂量的研究中,作者评估了一种新型单剂量缓释硬膜外吗啡(DepodurTM)在接受下腹部手术病人中的镇痛效果。541名病人在手术前约30分钟随机分至6个硬膜外治疗组中的一组。6组是:5mg标准硬膜外硫酸吗啡;5mg单次剂量缓释硬膜外吗啡(EREM);和10152025mg单次剂量EREM。主要研究目的是评估单次剂量EREM10152025mg与单次剂量EREM5mg相比对处理术后疼痛的效果。通过绘制一条剂量-反应关系直线来评估术后48小时内病人自控镇痛追加芬太尼的用量。随后通过安全和效率分析将单次剂量EREM10152025mg与单次剂量EREM5mg进行比较并与5mg硫酸吗啡组进行比较。就像剂量-反应关系所显示的那样,术后静脉芬太尼的用量相应减少。102025mg单次剂量EREM病人与5mg硫酸吗啡相比静脉芬太尼用量显著减少。在48小时内,与标准吗啡病人相比,更多的单次剂量EREM病人不需要静脉使用芬太尼。虽然所有治疗组都通过术后镇痛中的芬太尼来评估,但硫酸吗啡组的术后镇痛芬太尼使用频率显著增多,152025mg单次剂量EREM的病人疼痛强度评分较低且对疼痛缓解满意。总之,单次剂量EREM耐受性良好,97%的不良事件被评定为轻微或中等。正如所预料的那样,所报道的不良事件与其他硬膜外阿片类药一样。总之,这个随机、对照研究说明单次剂量EREM可以在术后镇痛的48小时内起作用,但许多病人由于疼痛仍需追加药物。实验中,单次剂量EREM的副作用是可接受和可预测的。

(殷文渊 译 陈杰 校)

In this randomized, controlled, dose-ranging study, we evaluated the analgesic efficacy of a novel single-dose extended-release epidural morphine (DepodurTM) in patients undergoing lower abdominal surgery. Five-hundred-forty-one patients were randomly assigned to one of six epidural treatments administered approximately 30 min before surgery. The 6 treatments were 5 mg of standard epidural morphine sulfate (MS) (active comparator); 5 mg of single-dose extended-release epidural morphine (EREM) (dose control); and 10, 15, 20, and 25 mg of single-dose EREM. The main study objective was to assess the efficacy of single-dose EREM 10, 15, 20, or 25 mg versus single-dose EREM 5 mg for the management of postoperative pain. This was done by plotting a linear dose-response relationship to assess postoperative IV patient-controlled analgesia (PCA) fentanyl consumption for breakthrough pain for 48 h after surgery. Secondary safety and efficacy analyses compared the 10-, 15-, 20-, and 25-mg single-dose EREM groups with the 5-mg single-dose EREM group and compared each single-dose EREM group with 5 mg of MS. As shown by the dose-response relationship, there was a dose-related reduction in the use of postoperative IV fentanyl through 48 h (estimated slope, –22.2; P = 0.0002). Patients treated with 10, 20, and 25 mg of single-dose EREM used significantly less IV fentanyl (mean ± sd: 995 ± 987 µg, P = 0.0446; 972 ± 982 µg, P = 0.0221; and 683 ± 620 µg, P < 0.0001, respectively) through 48 h after surgery compared with the 5-mg single-dose EREM group (1218 ± 894 µg). At 48 h postdose, significantly more single-dose EREM patients (13%) than MS patients (2%) had required no IV fentanyl (P < 0.01). Although all treatment groups had access to PCA fentanyl and there was more frequent PCA fentanyl use in the MS group, patients in the single-dose EREM 15, 20, and 25 mg groups reported significantly lower pain-intensity scores and greater satisfaction with their pain relief. Overall, single-dose EREM was well tolerated, with 97% of adverse events rated as mild to moderate. As expected, the adverse events reported were consistent with those of other epidural opioids (i.e., nausea, vomiting, pruritus, and hypotension). In conclusion, this controlled study demonstrated that single-dose EREM can provide up to 48 h of postoperative analgesia, but supplementation for breakthrough pain is still required in most patients. Within the context of this study, the side effect profile of single-dose EREM was acceptable and predictable.

 

脊髓阿片样受体1激动剂,而非N-甲基-D-天门冬氨酸拮抗剂,逆转大鼠皮内注射辣椒素引起的继发性机械性异常性疼痛

Spinal Opioid Receptor Like1 Receptor Agonist, but Not N-Methyl-D-Aspartic Acid Antagonist, Reverses the Secondary Mechanical Allodynia Induced by Intradermal Injection of Capsaicin in Rats

Natsuko Nozaki-Taguchi, MD, and Tatsuo Yamamoto, MD

Department of Anesthesiology, Graduate School of Medicine, Chiba University, Japan

Anesth Analg 2005 100: 1087-1092

皮内注射辣椒素引起的继发性机械性异常性疼痛被广泛用于探索组织损伤导致机械性异常性疼痛的内在机制。可是,辣椒素浓度与继发性机械性异常性疼痛发生的相关性和辣椒素诱导机械性异常性疼痛发生和维持的内在机制以及引起的继发性机械性异常性疼痛知之甚少。在这个实验中,作者研究皮内注射辣椒素与继发性机械性异常性疼痛的相关性和脊髓阿片受体相关1受体激动剂(ORL1)和N-甲基-D-天门冬氨酸受体在皮内注射引起的继发性机械性异常性疼痛的发生和维持中的作用。0.03%的辣椒素50uL导致最强的异常性疼痛。鞘内注射痛敏肽,一种脊髓阿片受体相关1受体激动剂,削弱继发性机械性痛觉过敏的持续时间,但对继发机械性痛觉过敏的产生没有影响。鞘内注射MK801,一种N-甲基-D-天门冬氨酸拮抗剂,对继发性机械性痛觉过敏的产生没有影响。这些发现支持ORL1受体应该为治疗组织损伤引起的继发性机械性异常性疼痛的研究方向。

(殷文渊 译 陈杰 校)

Secondary mechanical allodynia induced by intradermal injection of capsaicin has been widely used to search for the underlying mechanisms of tissue injury induced mechanical allodynia. However, the capsaicin concentration dependency of the development of secondary mechanical allodynia and the underlying mechanisms of development and maintenance of capsaicin-induced mechanical allodynia are not fully understood. In the present study, we clarify the capsaicin concentration dependency for development and maintenance of secondary mechanical allodynia and the role of spinal opioid receptor like1 (ORL1) receptor and N-methyl-d-aspartate receptor in the development and maintenance of secondary mechanical allodynia induced by an intradermal capsaicin injection. Capsaicin 50 µL of 0.03% induced the most intense secondary mechanical allodynia. Intrathecal injection of nociceptin, an ORL1 receptor agonist, attenuated the maintenance of secondary mechanical allodynia but had no effect on the development of secondary mechanical allodynia. An intrathecal injection of MK801, an N-methyl-d-aspartate receptor antagonist, had no effect on the development and maintenance of secondary mechanical allodynia. These findings suggest that spinal ORL1 receptor should be the target of study for the treatment of secondary mechanical allodynia induced by tissue injury.

 

手动膨胀肺时呼气末正压水平对呼气流速峰值的影响

The Effect of Positive End-Expiratory Pressure Level on Peak Expiratory Flow During Manual Hyperinflation

Camila Savian, BPHty*, Pamela Chan, BPHty, MPHtyStud{dagger}{ddagger}, and Jennifer Paratz, MPHty, PhD, FACP*{ddagger}

*Alfred Hospital/La Trobe University, Melbourne, {dagger}Prince of Wales Hospital, Hong Kong, {ddagger}University of Queensland, Australia

Anesth Analg 2005 100: 1112-1116.

对机械通气病人进行手动膨胀肺(MHI)时,使用人工复苏气囊(MRB)时呼气末正压(PEEP)可能导致MHI分泌物移动技术无效。在这项研究中,作者旨在研究MHI时增加PEEP或降低顺应性对呼气流速(PEF)峰值的影响。该研究为盲态随机,让10名在MHI和重症监护治疗方面具有丰富经验的理疗师对模拟肺进行操作。PEEP水平为0-15 cmH2O,顺应性为0.050.02 L/cmH2O,随机选择MRB类型。Mapleson-C MRB气囊与Laerdal MRB气囊相比,不管在何种水平的PEEP均可显著提高PEF(P < 0.01, d = 2.72)。顺应性正常时(0.05 L/cmH2O),Mapleson-C环路内PEEP大于10 cmH2OPEF显著降低(P < 0.01, d = 1.45)Laerdal MRB气囊内PEEP大于10 cmH2O时,并没有达到理论上能产生双相气液流动从而使肺内分泌物移动的PEF水平。如果粘液阻塞为MHI使用指征,Mapleson-C MRB可能是分泌物移动的最有效方法。

(赵延华 译 陈杰 校)

Including positive end-expiratory pressure (PEEP) in the manual resuscitation bag (MRB) may render manual hyperinflation (MHI) ineffective as a secretion maneuver technique in mechanically ventilated patients. In this study we aimed to determine the effect of increased PEEP or decreased compliance on peak expiratory flow rate (PEF) during MHI. A blinded, randomized study was performed on a lung simulator by 10 physiotherapists experienced in MHI and intensive care practice. PEEP levels of 0–15 cm H2O, compliance levels of 0.05 and 0.02 L/cm H2O, and MRB type were randomized. The Mapleson-C MRB generated significantly higher PEF (P < 0.01, d = 2.72) when compared with the Laerdal MRB for all levels of PEEP. In normal compliance (0.05 L/cm H2O) there was a significant decrease in PEF (P < 0.01, d = 1.45) for a PEEP more than 10 cm H2O in the Mapleson-C circuit. The Laerdal MRB at PEEP levels of more than 10 cm H2O did not generate a PEF that is theoretically capable of producing two-phase gas-liquid flow and, consequently, mobilizing pulmonary secretions. If MHI is indicated as a result of mucous plugging, the Mapleson-C MRB may be the most effective method of secretion mobilization.

单次给药、持续释放的硬膜外吗啡处理择期剖腹产术后疼痛:多中心随机对照研究结果

Single-Dose, Sustained-Release Epidural Morphine in the Management of Postoperative Pain After Elective Cesarean Delivery: Results of a Multicenter Randomized Controlled Study

Brendan Carvalho, MBBCh, FRCA*, Edward Riley, MD*, Sheila E. Cohen, MBChB, FRCA*, David Gambling, MB, BS, FRCPC{dagger}, Craig Palmer, MD{ddagger}, H. Jane Huffnagle, DO§, Linda Polley, MD||, Holly Muir, MD, Scott Segal, MD#, Christine Lihou, CCRA**, Garen Manvelian, MD** for the DepoDur Study Group

*Department of Anesthesia, Stanford University School of Medicine, Stanford, California; {dagger}Sharp Mary Birch Hospital for Women, San Diego, California; {ddagger}Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, Arizona; §Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania; ||Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; ¶Department of Anesthesiology, Duke University, Durham, North Carolina; #Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; and **SkyePharma, Inc., San Diego, California

Anesth Analg 2005 100: 1150-1158.

 

在这项多中心、随机、对照研究中,作者比较了一种新型单次给药持续释放的硬膜外吗啡(EREMDepoDurTM)在择期剖腹产术后48小时的镇痛效果和安全性,并与硬膜外硫酸吗啡做比较。ASAI~II的临产妇采用腰麻和硬膜外的联合麻醉技术。腰麻剂量为布比卡因12~15mg+芬太尼10ug,通过硬膜外导管给予标准吗啡5mg51015mg EREM作术后镇痛。与标准吗啡5mg组比较, EREM 1015mg组阿片类药物追加总量明显减少,而且术后48小时的功能评分提高。与标准吗啡组比较, EREM 1015mg组休息时视觉疼痛评分和术后24~48小时活动评分较好。但EREM 5mg组和标准吗啡组之间没有明显的差别。单次给药EREM具有很好的耐受性,不良反应强度较弱。剖腹产术后镇痛中使用EREM具有一定优势,术后24~48小时镇痛效果明显优于标准吗啡。

(朱辉 译 陈杰 校)

In this multicenter, randomized, controlled study, we compared the analgesic efficacy and safety profile of a new single-dose extended-release epidural morphine (EREM) formulation (DepoDurTM) with that of epidural morphine sulfate for the management of postoperative pain for up to 48 h after elective cesarean delivery. ASA physical status I or II parturients (n = 75) were anesthetized with a combined spinal/epidural technique. Parturients received intrathecal bupivacaine 12–15 mg and fentanyl 10 µg for spinal anesthesia and a single epidural injection of either 5 mg of standard (conventional preservative-free) morphine or 5, 10, or 15 mg of extended-release morphine after cord clamping for postoperative pain control. Single-dose EREM 10 and 15 mg groups significantly decreased total supplemental opioid medication use and improved functional ability scores for 48 h after surgery compared with those receiving 5 mg of standard morphine. Visual analog scale pain scores at rest and with activity at 24 to 48 h after dosing were significantly better in the 10- and 15-mg single-dose EREM groups versus the standard morphine group. There were no significant differences between the two 5 mg (single-dose EREM and standard morphine) groups. Single-dose EREM was well tolerated, and most adverse events were mild to moderate in severity. Single-dose EREM is a potentially beneficial epidural analgesic for the management of post-cesarean delivery pain and has particular advantages over standard morphine for the period from 24 to 48 h after surgery.

 

连续肌间沟神经周围注射罗哌卡因中加入可乐定可改善术后镇痛:一项随机、双盲、对照研究

Clonidine Added to a Continuous Interscalene Ropivacaine Perineural Infusion to Improve Postoperative Analgesia: A Randomized, Double-Blind, Controlled Study

Brian M. Ilfeld, MD*, Timothy E. Morey, MD*, Lisa J. Thannikary, MD*, Thomas W. Wright, MD{dagger}, and F. Kayser Enneking, MD*{dagger}

*Anesthesiology and {dagger}Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida

Anesth Analg 2005 100: 1172-1178.

尽管在神经阻滞单次用药中加入可乐定能延长局麻药的作用时间和术后镇痛时间,但这一方法并不能提高连续神经阻滞时局麻药效果。在这项研究中,作者使用较大剂量的可乐定以期提高镇痛效果。选择术后具有中等程度疼痛的肩部整形外科手术病人20例,术前行肌间沟臂丛神经阻滞(1.5%甲哌卡因,肾上腺素2.5ug/ml,可乐定50ug混合液40ml)和神经周围置管。术后通过导管给予0.2%罗哌卡因或0.2%罗哌卡因+2ug/ml可乐定的混合液(背景速度5ml/h; 单次追加量5ml,锁定时间1小时)。随机、双盲分组。主要记录术后强烈疼痛的变化。其次记录疼痛评分,病人自我追加剂量,口服镇痛药的使用,睡眠质量和注射引起的并发症。结果显示组间变量没有显著的统计学差异。结论:罗哌卡因肌间沟神经周围注射用药中加入2ug/ml可乐定并不能减少术后第一天疼痛强度。这项阴性结果仅提示缺乏效果,将来需要进一步研究证实。

(朱辉 译 陈杰 校)

Although clonidine has been shown to increase the duration of local anesthetic action and prolong postoperative analgesia when included in single-injection nerve blocks, the only controlled investigation of the efficacy of this practice to improve analgesia for continuous perineural local anesthetic infusion failed to discern any clinically relevant benefits. For this study, we used a larger dose of clonidine in an attempt to improve analgesia. Patients (n = 20) undergoing moderately painful orthopedic surgery of the shoulder received an interscalene brachial plexus block (40 mL of mepivacaine 1.5%, epinephrine 2.5 µg/mL, and clonidine 50 µg) and a perineural catheter before surgery. After surgery, ropivacaine 0.2% or ropivacaine 0.2% plus clonidine 2 µg/mL was delivered via the catheter for 3 days (basal rate, 5 mL/h; patient-controlled bolus, 5 mL; lockout, 1 h). Investigators and patients were blind to random group assignment. The primary outcome variable was designated as the most intense pain during the day after surgery. Secondary end-points included additional pain scores, patient-controlled bolus doses, oral analgesic use, sleep quality, and catheter- or infusion-related complications. There were no statistically significant differences between groups for any of the variables investigated. We conclude that adding clonidine 2 µg/mL to a ropivacaine interscalene perineural infusion does not decrease breakthrough pain intensity the day after surgery. For the additional end-points, our negative findings are only suggestive of a lack of effect and require further study for verification.

 

利多卡因复合硫酸镁行局部静脉麻醉

Intravenous Regional Anesthesia Using Lidocaine and Magnesium

Alparslan Turan, MD, Dilek Memis, MD, Beyhan Karamanlioglu, MD, Turhan Güler, MD, and Zafer Pamukçu, MD

Department of Anaesthesiology and Reanimation, Medical Faculty, Trakya University, Edirne, Turkey

Anesth Analg 2005 100: 1189-1192.

 

作者在本研究中将镁加入利多卡因用于评估局部静脉麻醉(IVRA)对止血带所引起的疼痛的作用。选择性手部手术的患者30 例,均行IVRA,随机分为2组,组C采用10ml的生理盐水加0.5%的利多卡因3mg/kg预充至40ml,组M采用10ml 15%的硫酸镁(12.4mmol)加0.5%的利多卡因3mg/kg预充至40ml。分别记录注射痛程度、感觉和运动阻滞的起效和恢复时间、止血带引起的疼痛和麻醉效果。术后当疼痛视觉评分VAS>4分时,则给患者肌肉注射75mg双氯芬酸,并且记录镇痛药需要时间和量。组M的感觉和运动阻滞起效快,而消失慢(P<0.05),并且在术中1520304050min,止血带所引起的VAS评分低(P<0.001)。麻醉医师和手术医师均认为组M的效果优于组CP<0.05)。术后患者第一次需要术后镇痛的时间,组C95±29min,组M155±38minP<0.05)。术后6hVAS评分,组C高于组MP<0.05),而双氯芬酸的需要量组C130±55mg)也高于组M50±35mg)(P<0.05)。作者认为利多卡因复合硫酸镁可以提高IVRA的麻醉和镇痛效果。

(顾漪闻 译 陈杰 校)

We conducted this study to evaluate the effects of magnesium, when added to lidocaine for IV regional anesthesia (IVRA), on tourniquet pain. Thirty patients undergoing elective hand surgery during IVRA were randomly assigned to two groups. IVRA was achieved with 10 mL of saline plus 3 mg/kg lidocaine 0.5% diluted with saline to a total of 40 mL in group C or with 10 mL of 15% magnesium sulfate (12.4 mmol) plus 3 mg/kg lidocaine 0.5% diluted with saline to a total of 40 mL in group M. Injection pain, sensory and motor block onset and recovery time, tourniquet pain, and anesthesia quality were noted. Patients were instructed to receive 75 mg of IM diclofenac when the visual analog scale (VAS) score was >4, and analgesic requirements were recorded. Sensory and motor block onset times were shorter and recovery times were prolonged in group M (P < 0.05). VAS scores of tourniquet pain were lower in group M at 15, 20, 30, 40, and 50 min (P < 0.001). Anesthesia quality, as determined by the anesthesiologist and surgeon, was better in group M (P < 0.05). Time to the first postoperative analgesic request in group C was 95 ± 29 min and in group M was 155 ± 38 min (P < 0.05). Postoperative VAS scores were higher for the first postoperative 6 h in group C (P < 0.05). Diclofenac consumption was significantly less in group M (50 ± 35 mg) when compared with group C (130 + 55 mg) (P < 0.05). We conclude that magnesium as an adjunct to lidocaine improves the quality of anesthesia and analgesia in IVRA.

 

七氟醚复合异丙酚和七氟醚、异丙酚分别用于成人喉罩通气道置入的比较

A Comparison of Sevoflurane-Propofol Versus Sevoflurane or Propofol for Laryngeal Mask Airway Insertion in Adults

Sahar M Siddik-Sayyid, MD, FRCA, Marie T. Aouad, MD, Samar K. Taha, MD, Dima G. Daaboul, MD, Patricia G. Deeb, MD, Faraj M. Massouh, MD, Marie-Rose A. Muallem, MD, and Anis S. Baraka, MD, FRCA

Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.

Anesth Analg 2005 100: 1204-1209.

 

在一项前瞻性、随机研究中,作者比较了七氟醚-异丙酚、七氟醚、异丙酚麻醉诱导用于成人喉罩通气道置入(LMA)的第一次的成功率及副作用。选择83例无术前用药、ASAⅠ患者,麻醉诱导用单次肺活量呼吸(VCB)法,分为三组,分别为复合组:吸入8%七氟醚+静脉注射1.5mg/kg异丙酚;七氟醚组:单用8%七氟醚;异丙酚组:单用异丙酚3mg/kg。结果发现,复合组用药诱导时,LMA第一次成功率(93.5%)比单独用七氟醚组(46%)或异丙酚组(61.5%)要高(P<0.001)。异丙酚组诱导LMA速度最快,而术后恶心呕吐几率最低。但是这个优点被其注射时所引起的注射痛(69%)和LMA置入时患者身体活动的发生率高所抵消(异丙酚组为50%,复合组为19%,七氟醚组为26%,P<0.05)。此外异丙酚组的呼吸暂停的发生率更高(异丙酚组为84%,复合组为16%,七氟醚组为7%,P<0.001)。结果显示,七氟醚复合异丙酚诱导麻醉置入喉罩,第一次喉罩置入的成功率高,呼吸抑制的发生率低。

(顾漪闻 译 陈杰 校)

In a prospective, randomized study, we investigated the incidence of successful insertion of laryngeal mask airway (LMA) at the first attempt and the incidence of side effects after LMA insertion using the combination of sevoflurane and propofol as compared with either sevoflurane or propofol alone for induction of anesthesia. Eighty-three unpremedicated ASA physical status I–II patients were anesthetized with a single vital capacity breath (VCB) of sevoflurane 8% supplemented with IV propofol 1.5 mg/kg, a single VCB of sevoflurane 8%, or IV propofol 3 mg/kg. The coinduction technique was associated with the most frequent incidence of successful LMA insertion at the first attempt (93.5%) than either sevoflurane alone (46%) or propofol alone (61.5%) (P < 0.001). Propofol-induced induction of anesthesia allowed the fastest insertion of LMA and was associated with the least frequent incidence of postoperative nausea and vomiting. However, this advantage of propofol was offset by a frequent incidence of pain on injection (69%) and the occurrence of movements during insertion of the LMA (50% in the propofol group versus 19% and 26% in the sevoflurane and sevoflurane-propofol groups, respectively; P < 0.05), as well as a more frequent incidence of apnea (84% in the propofol group versus 7% and 16% in the sevoflurane and sevoflurane-propofol groups, respectively; P < 0.001). The report shows that induction of anesthesia with sevoflurane-propofol combined provides a frequent incidence of successful LMA insertion at the first attempt that is associated with an infrequent incidence of apnea.

 

 

对输注库存血和血红蛋白氧载体所致血液稀释的全身反应

Systemic Responses to Hemodilution After Transfusion with Stored Blood and with a Hemoglobin-Based Oxygen Carrier

Ivo P. Torres Filho, MD, PhD*{dagger}{ddagger}, Bruce D. Spiess, MD*{dagger}, R. Wayne Barbee, PhD{dagger}{ddagger}, Kevin R. Ward, MD{dagger}{ddagger}, John Oldenhof, PhD§, and Roland N. Pittman, PhD{dagger}{ddagger}

Departments of *Anesthesiology, {dagger}Emergency Medicine, and {ddagger}Physiology, Virginia Commonwealth University Reanimation Engineering Shock Center, Virginia Commonwealth University Medical Center, Richmond, Virginia; and §Hemosol Inc., Toronto, Ontario, Canada

Anesth Analg 2005;100:912-920

我们评价了严格氧转运条件下,与血液或血色素raffimer进行交换的系统效能。我们比较了接受血红蛋白氧载体(HBOC)、新鲜血液(采集时间<24小时)或库存血(10天)进行血液稀释的动物中的氧转运情况。大鼠随机接受血液或HBOC的等容量交换。氧的消耗用呼出气体及血液样本来测量,而整个体内的氧转运由心排量和动脉氧含量来计算。交换后,大鼠服从逐步的等容量血液稀释。同时测量血压、血气、酸碱状态、血糖、血红蛋白氧饱和度、心率和整个外周阻力。我们发现:1)接受HBOC的大鼠在血液稀释过程中平均动脉压和整个外周阻力均升高;2)用呼出气体和血液来计算的氧转运结果相同;3)氧转运在接受血液和HBOC的大鼠中并无差别;4)最终血红蛋白浓度(1.8 ± 0.1 g/dL)和氧转运情况(5 ± 1 mL · min–1 · kg–1)在所有动物中是类似的;5)在血液稀释过程中,大部分氧转运和生化变化是类似的。这些数据表明,如果自体50%的血红蛋白被库存血中的血红蛋白替代的话,对氧转运的耐受性不会改变。

(王丽珺译 薛张纲校)

We assessed the systemic effects of exchanges with blood or hemoglobin (Hb) raffimer under conditions of critical oxygen delivery (Do2crit). We compared Do2crit in animals receiving Hb-based oxygen carrier (HBOC; HemolinkTM), fresh blood (collected <24 h), or stored blood (10 days) before hemodilution. Rats were randomized to control, blood, or HBOC isovolemic exchange. Oxygen consumption was measured by using expired gas (Vo2a) and blood (Vo2b) samples, whereas whole-body oxygen delivery (Do2) was calculated from cardiac output and arterial oxygen content. After exchange, rats were subjected to stepwise isovolemic hemodilution. Blood pressure, gases, acid-base status, glucose, Hb oxygen saturation, heart rate, and total peripheral resistance were also measured. We found that 1) HBOC-treated rats showed an increased mean arterial blood pressure and total peripheral resistance throughout the hemodilution, 2) Do2crit calculated with Vo2a or Vo2b gave identical results, 3) Do2crit was not different between animals receiving blood and those receiving HBOC, 4) the terminal Hb concentration (1.8 ± 0.1 g/dL) and Do2 (5 ± 1 mL · min–1 · kg–1) were similar for all animals, and 5) most oxygen transport and biochemical variables changed similarly during hemodilution. The data suggest that tolerance to Do2crit is not altered by 50% replacement of native Hb by stored blood or Hb raffimer.

 

气道操作与侧卧位在腺样体扁桃体肥大儿童的麻醉实施、气道开放过程中的内镜测量效能

The Endoscopically Measured Effects of Airway Maneuvers and the Lateral Position on Airway Patency in Anesthetized Children with Adenotonsillar Hypertrophy

Young-Chang P. Arai, MD*, Kayo Fukunaga, MD*, Wasa Ueda, MD{dagger}, Masashi Hamada, MD{ddagger}, Hiroyuki Ikenaga, MD{ddagger}, and Kei Fukushima, MD{ddagger} Department of Anesthesiology, Kochi Medical School, Oko-Cho, Nankoku city, Kochi, Japan; {dagger}Departments of Anesthesiology, Clinical Physiology and Pharmacology, School of Nursing, {ddagger}Department of Otolaryngology, Kochi Medical School, Kochi, Japan

Anesth Analg 2005;100:949-952

 

在腺样体扁桃体肥大且自主呼吸的儿童中实施全麻,上呼吸道阻塞对于麻醉医师而言是一大挑战。侧卧位是治疗阻塞性睡眠呼吸暂停的一种简单方法。在该研究中,我们检验了体位改变与常规气道操作如在气道开放过程中抬高下颏或托下颌(内镜检查喉鸣情况或上呼吸道范围)对择期行腺样体扁桃体切除术的儿童实施麻醉过程中的效能。18111岁的儿童用七氟醚麻醉。在用5%七氟醚和100%氧气进行自主呼吸的过程中,记录上呼吸道范围和喉鸣情况。记录到基线后,仰卧位和侧卧位均抬高下颏及托下颌。抬高下颏、托下颌、侧卧位增加了气管暴露范围、改善了喉鸣情况。更重要的是,侧卧位提高了这些气道操作在开放气道过程中的效能。我们推断:侧卧位联合气道操作为腺样体扁桃体肥大儿童的麻醉实施提供了更好的气道开放。

(王丽珺译 薛张纲校)

Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing children with adenotonsillar hypertrophy. Lateral positioning is a simple treatment for obstructive sleep apnea. In this study, we examined the effects of body position shifting and common airway maneuvers such as chin lift and jaw thrust on airway patency (stridor score and upper airway dimensions by endoscopy) in anesthetized children scheduled for adenotonsillectomy. Eighteen children aged 1–11 yr were anesthetized with sevoflurane. During spontaneous breathing with 5% sevoflurane and 100% oxygen, upper airway dimensions and stridor score were recorded. After baseline recording, chin lift and jaw thrust were performed in both the supine and the lateral decubitus position. Chin lift, jaw thrust, and lateral position increased the airway dimensions and improved the stridor score. Moreover, lateral positioning enhanced the effects of these airway maneuvers on airway patency. We concluded that lateral positioning combined with airway maneuvers provided better airway patency for anesthetized children with adenotonsillar hypertrophy.

碳氟化合物、表面活性物质及其联合应用在改善婴儿式气管内酸化导致的急性肺损伤的效果

The Efficacy of Fluorocarbon, Surfactant, and Their Combination for Improving Acute Lung Injury Induced by Intratracheal Acidified Infant Formula

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

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

Address correspondence and reprint requests to Katsuya Mikawa, MD, Department of Anesthesia & Perioperative Medicine, Faculty of Medical Sciences, Kobe University Graduate School of Medicine, Kusunoki-cho 7, Chuo-ku, Kobe 650–0017, Japan.

Anesth Analg 2005 100:964-971

 

我们开展此项研究旨在比较局部液体灌洗通气(PLV)、肺泡表面活性物质(PSF)、以及两者的联合应用在改善婴儿式酸化诱导所致急性肺损伤(ALI)的通气的作用。在第一部分的研究中,42只接受设定呼期末正压10cmH2O的容量控制通气的兔子被随机分配到六组(无创组、单纯气体通气组GViPLVi PSFi PLVi->PSFi PSFi->PLVi)。各组都经过了婴儿式气管内酸化(2 mL/kg, pH 1.8)处理。GVi不经PLVPS治疗。在婴儿式酸化30 min ,PLVi接受气管内碳氟化合物15 mL/kg治疗, PSFi接受表面活性物质100 mg/kg治疗. PLVi->PSFiPSFi->PLVi同时接受两种措施间隔30 min顺序治疗。在第二部分研究中,六组接受与第一部分研究相同药物治疗的42只兔子给予压力控制通气。在产生ALI150 min,切下肺做生化和组织学检查评定损伤程度。在这两部分研究中,PSF、碳氟化合物以及两者的联合应用,可以减轻肺内白细胞浸润、水肿,并使中性粒细胞产生过氧化物减少,从而改善氧合、肺通气功能和组织学改变。在PSF之后使用碳氟化合物可以产生最好的治疗效果,而在碳氟化合物之后使用PSF的效果最差,且这种差别与通气模式无关。

(金 薛张纲 校)

We conducted the current study to compare the efficacy of partial liquid ventilation (PLV), pulmonary surfactant (PSF), and their combination in ameliorating the acidified infant-formula-induced acute lung injury (ALI). In the Part I study, 42 rabbits receiving volume-controlled ventilation with positive end-expiratory pressure 10 cm H2O were randomly divided into 6 groups (groups noninjuryi, gas ventilation [GVi], PLVi, PSFi, PLVi->PSFi, and PSFi->PLVi). ALI was induced by intratracheal acidified infant formula (2 mL/kg, pH 1.8). Group GVi received neither PLV nor PSF therapy. Groups PLV and PSF received intratracheal fluorocarbon 15 mL/kg or surfactant 100 mg/kg, respectively, 30 min after acidified infant formula. Groups PLVi->PSFi and PSFi->PLVi received both treatments at 30-min intervals. In Part II, 42 rabbits (in 6 groups) undergoing pressure-controlled ventilation received the same drug therapies as in Part I. The lungs were excised to assess biochemical and histological damage 150 min after induction of ALI. In Parts I and II, PSF, fluorocarbon, and their combination attenuated lung leukosequestration and edema and superoxide production of neutrophils, consequently improving oxygenation, lung mechanics, and pathological changes. Independent of ventilation mode, PSF followed by fluorocarbon provided the most beneficial effects and fluorocarbon followed by PSF produced the least efficacy.

 

挥发性麻醉药导致痛觉增强中肾上腺素能和类胆碱能传输的作用

The Role of Adrenergic and Cholinergic Transmission in Volatile Anesthetic-Induced Pain Enhancement

Thomas J. Rowley, B.S., Danette Daniel, M.D., and Pamela Flood, M.D.

Department of Anesthesiology, Columbia University, New York, New York Address correspondence and reprint requests to Pamela Flood, Department of Anesthesiology, Columbia University, 630 West 168th Street, NY, NY 10032.

Anesth Analg 2005 100:991-995

 

挥发性麻醉药在痛觉传导方面有两阶段的作用效果。在非常低浓度的情况下,它们增加痛觉敏感度;反之,在较大的亚麻醉浓度下,它们可以起到镇痛作用。以前的研究提示,胆碱能抑制剂可以调节异氟醚的早期痛觉作用。而且,胆碱能受体的活化有助于脊索的去甲肾上腺素的释放。我们猜测脊索去甲肾上腺素释放的胆碱调制能调节异氟醚的早期痛觉作用。我们用小鼠后爪回缩反应时间作为使用肾上腺素活性抑制剂或胆碱处理后痛觉灵敏度的测量指标。异氟醚在疼痛方面的作用随浓度而改变。异氟醚使痛觉增强的50%有效浓度为0.16%,而起镇痛作用的50%有效浓度为0.8%。神经毒素DSP-4所致全身去甲肾上腺素损耗促使基线回缩反应时间减少,阻止异氟醚早期痛觉。基线回缩反应时间也可因鞘内育亨宾的作用而减少。在用育亨宾治疗后,异氟醚不再具有早期痛觉作用。尼古丁经脑室内注射后增强基线反应时间但不阻止异氟醚的早期痛觉。相反,尼古丁鞘内给药导致轻度基线反应时间减少并阻止异氟醚早期痛觉作用。我们推断,似乎脊髓去甲肾上腺素传输是发生异氟醚早期痛觉的必要因素。异氟醚也许通过抑制活性胆碱能受体而起到调节脊髓内去甲肾上腺素释放的作用。

(金 薛张纲 校)

Volatile anesthetic drugs have a biphasic effect on pain transmission. At very small concentrations they enhance pain sensitivity whereas at larger subanesthetic concentrations they have an analgesic effect. Previous work has suggested that nicotinic inhibition could mediate the pronociceptive action of isoflurane. Furthermore, activation of nicotinic receptors facilitates the release of norepinephrine in the spinal cord. We hypothesize that nicotinic modulation of norepinephrine release in the spinal cord mediates isoflurane's pronociceptive action. We used hindpaw withdrawal latency as a measure of pain sensitivity after inhibition of adrenergic activity or treatment with nicotine in mice. Isoflurane's effect on pain is separable by concentration. The 50% effective concentration for pain enhancement is 0.16% isoflurane whereas the 50% effective concentration for the antinociceptive action of isoflurane is 0.8%. Depletion of systemic norepinephrine with the neurotoxin DSP-4 caused a reduction in baseline withdrawal latencies and prevented isoflurane pronociception. Baseline latency was also reduced by intrathecal yohimbine. After treatment with yohimbine, isoflurane had no additional pronociceptive effect. Nicotine administered through intracerebroventricular injection increased baseline latency but did not prevent isoflurane pronociception. Conversely, intrathecal applications of nicotine caused a slight reduction in baseline latency and prevented isoflurane's pronociceptive effect. We conclude that spinal noradrenergic transmission seems to be necessary for isoflurane pronociception to occur. Isoflurane may act by inhibiting tonically active nicotinic receptors that modulate the release of norepinephrine in the spinal cord.

 

地氟醚预处理对内皮粘附分子和mRNA的体外效应

The In Vitro Effect of Desflurane Preconditioning on Endothelial Adhesion Molecules and mRNA Expression

Zhu Biao, MD, PhD, Xue Zhanggang, MD, Jiang Hao, MD, Miao Changhong, MD, PhD, and Cang Jing, MD, PhD

Department of Anesthesiology and Intensive Care Unit, Zhongshan Hospital, Shanghan Medical College, FuDan University, Shanghai, China

Anesth Analg 2005 100: 1007-1013.

 

细胞间粘附分子-1ICAM-1)、血管粘附分子-1VCAM-)E选择蛋白的低表达可能是削弱缺血再灌注区域中性粒细胞粘附于血管内皮细胞的原因。地氟醚减少了缺血再灌注损伤。于是,我们假设地氟醚能影响经过肿瘤坏死因子(TNF)刺激的人脐静脉血内皮细胞(HUVEC)表达ICAM-1E选择蛋白和ICAM-1VCAM-1mRNA表达。HUVEC在一个最低肺泡有效浓度的地氟醚下60分钟的预处理后经过TNF的刺激。HUVECICAM-1E选择蛋白的蛋白表达通过免疫生化技术结合细胞形象计数技术评价。HUVECVCAM-1ICAM-1mRNA表达通过逆转录多聚酶链技术获得。地氟醚不仅减少了HUVECICAM-1E选择蛋白而且减少了HUVECICAM-1VCAM-1mRNA表达。中性粒细胞粘附于地氟醚预处理的HUVEC的速度减慢。地氟醚预处理的HUVEC减少的中性粒细胞粘附这一表现和减少的粘附分子表达有很好的相关性。这些结果提示地氟醚影响细胞粘附分子表达作用在牵涉到中性粒细胞的再聚集的多个阶段。地氟醚相关的缺血再灌注损伤减少和其抑制ICAM-1VCAM-1E选择蛋白表达以及抑制介导中性粒细胞转位形成血管内皮细胞的紧密连接。

(蔡美华译 薛张纲校)

Lower expression of intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), and E-selectin may be responsible for attenuated ischemic-reperfusion neutrophil adhesion to vascular endothelium. Desflurane reduces ischemia-reperfusion injury. Therefore, we assessed whether desflurane affects the protein expression of ICAM-1 and E-selectin and mRNA expression of ICAM-1 and VCAM-1 of human umbilical venous endothelial cells (HUVEC) stimulated with tumor necrosis factor- (TNF-). HUVEC were preconditioned for 60 min with 1 minimum alveolar concentration desflurane before stimulating with TNF-. Protein expression of adhesion molecules ICAM-1 and E-selectin of HUVEC were evaluated via immunocytochemical techniques combined with image cytometry. ICAM-1 and VCAM-1 mRNA expression of HUVEC were determined via reverse transcription-polymerase chain reaction. Desflurane not only reduced the protein expression of ICAM-1 and E-selectin but also ICAM-1 and VCAM-1 mRNA expression of the HUVEC. The adhesion rate of neutrophils with desflurane-treated HUVEC was slower. The decreased neutrophil adhesion on the desflurane-treated HUVEC correlated well with the decrease in adhesion molecule expression. These results show that desflurane affects the expression of adhesion molecules involved in the multistep process of neutrophil recruitment. Desflurane related ischemia-reperfusion injury reduction correlates well with expression inhibition of ICAM-1, VCAM-1, and E-selectin that mediates neutrophil rotation and firm adhesion on the vascular endothelium.

 

RGS蛋白:阿片类药信号传导和耐受机制领域的新角色

RGS Proteins: New Players in the Field of Opioid Signaling and Tolerance Mechanisms

Guo-xi Xie, MD, PhD, and Pamela Pierce Palmer, MD, PhD

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

Anesth Analg 2005 100: 1034-1042.

 

本文回顾了G信使蛋白调控子(GRS) 白在阿片类药信号机制和阿片类药耐受中重要作用的 进展。阿片类药发挥生理作用通过复杂的G蛋白耦联受 体信号机制,已知RGS蛋白紧密调控了G蛋白信号通路 RGS蛋白包含GTP酶通过内在RGS结构域和其他多种 信号相关受体的功能结构域来加速蛋白活动。文献中 报道了超过20中的RGS蛋白,提示有多种RGS蛋白负调 G蛋白介导阿片信号,使阿片信号脱敏内化,影响阿 片类药耐受发生速度。未来药物治疗将RGS蛋白作为靶 目标指向于调节阿片类药在急性和慢性疼痛效力可能 是疼痛治疗的重要进展。

(许文妍译 薛张纲校)

In this article we review recent advances in our understanding of the crucial role of the Regulator of G protein Signaling (RGS) proteins in opioid signaling mechanisms and opioid tolerance development. Opioids exert their physiologic effects via complex G protein-coupled receptor-signaling mechanisms, and RGS proteins are now known to tightly regulate the G protein signaling cycle. RGS proteins contain GTPase-accelerating protein activity within their characteristic RGS domain and various other receptor signaling-related properties of their other functional domains. There have been more than 20 RGS proteins reported in the literature, and multiple RGS proteins have been shown to negatively regulate G protein-mediated opioid signaling, facilitate opioid receptor desensitization and internalization, and affect the rate at which opioid tolerance develops. Using RGS proteins as targets for future drug therapy aimed at modulating opioid effectiveness in both acute and chronic pain settings may be an important advance in the treatment of pain.

 

非零基本氧流量对麻醉机呼吸回路漏气检验的危害

Non-zero basal oxygen flow a hazard to anesthesia breathing circuit leak test.

Tokumine J, Sugahara K, Gushiken K, Ohta M, Matsuyama T, Saikawa S.
Department of Anesthesiology, Faculty of Medicine, University of the Ryukyus, Japan.

Anesth Analg 2005 1001056-1058.

 

麻醉机非零基本氧流量被设定来补充氧代谢需要。然而,没有科学证据证明这是必需的。本研究我们试图阐明非零基本流量在麻醉前检查是否对察觉漏气有影响。25个参与者对麻醉机进行了漏气检验以发现呼吸回路漏气。人工漏气产生装置造成0~1L/min漏气。调查人随机选择漏气装置并连到呼吸回路上。参与者对现场和漏气产生装置都不清楚,并检验呼吸回路以发现漏气。对无和有基本流量进行了常规呼吸系统漏气检验。每个漏气过程中察觉漏气的结果都进行了统计学分析。有基本流量的漏气检验发现漏气的速度小于非基本流量组(P<0.01)。我们证明非零基本氧流量降低察觉漏气速度并妨碍漏气察觉,特别小漏气。因此,我们推荐呼吸漏气检验应于无基本氧流量下进行。

(孙志荣译 薛张纲校)

The non-zero basal flow (BF) of oxygen in anesthesia machines has been set to supply the basal metabolic requirement of oxygen. However, there is no scientific evidence of its necessity. In this study we sought to clarify whether non-zero BF affects leak detection during preanesthetic inspections. Twenty-five participants performed leak tests on anesthesia machines to detect breathing circuit leaks. Artificial leak-producing devices were used to create leaks from 0 to 1.0 L/min. The investigator randomly chose the leak device and connected it into the breathing circuit. Participants, blinded as to the presence or the type of leak producing device, then tested the breathing circuit for leaks. The conventional breathing system leak test was performed with and without BF. The results of leak detection in each leak procedure were analyzed statistically. The leak detection rate of leak test with BF was less than without BF (P < 0.01). We demonstrated that non-zero BF of oxygen decreases the leak detection rate and is an obstacle for leak detection, especially for small leaks. Therefore, we recommend that breathing circuit leak tests should be performed in the absence of BF of oxygen.

 

布比卡因对角叉菜胶引起小鼠炎症反应的作用: 体外刺激后白细胞产生细胞因子

Bupivacaine's action on the carrageenan-induced inflammatory response in mice: cytokine production by leukocytes after ex-vivo stimulation.

eloeil H, Asehnoune K, Moine P, Benhamou D, Mazoit JX.

Laboratoire d'anesthesie, Universite de Paris-Sud, Cedex, France.

Anesth Analg. 2005 Apr;100(4):1081-6.

 

我们目的是研究布比卡因对足底注射角叉菜胶引起系统反应的作用。我们研究了角叉菜胶、布比卡因或二者对脂多糖(LPS)和热处理后金黄色葡萄球菌Cowan 株(SAC)培养的全血а-肿瘤坏死因子(TNF-α)、白介素(IL-1β,IL-10产生的作用。小鼠给予后爪注射角叉菜胶合并或不合并对侧加压肌注布比卡因。全血标本在15小时后取出并且应用LPSSAC培养。测量超浮游物内α-肿瘤坏死因子、白介素-1β、以及IL-10的含量。在LPSSAC培养基中,致炎因子(TNF-α和白介素-1β)在给予角叉菜胶后增加。布比卡因能够防止这种炎症反应: LPS刺激后TNF-α的产生 992 +/- 1022146 +/- 338 919 +/- 116 pg/mL(布比卡因+角叉菜胶比角叉菜胶比对照组)。这种布比卡因的作用在SAC刺激下有所减低。然而,对于单纯给以布比卡因治疗,IL-10在阻止炎症反应的细胞因子中并不出现。这些实验表明角叉菜胶引起小鼠后爪炎症反应改变了血细胞对LPSSAC的反应,布比卡因调节了角叉菜胶引起系统炎症反应。而且,IL-10似乎不是由布比卡因引起的抗炎症反应因子。布比卡因的这种精确机制需进一步阐明。

(沈洪 薛张纲 )

We aimed to study the effect of bupivacaine on the systemic response elicited by intraplantar injection of carrageenan. To that purpose, we studied the effects of carrageenan, bupivacaine, or both on the production of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, and IL-10 by whole blood cultured in the presence of lipopolysaccharide (LPS) and of heat-killed Staphylococcus Aureus Cowan (SAC). Mice received a hindpaw injection of carrageenan with or without encapsulated IM bupivacaine given contralaterally. Whole blood was sampled 15 h later and cultured for 24 h with LPS or SAC. The amounts of TNF-alpha, IL-1beta, and IL-10 in the supernatants were measured. In the presence of LPS or SAC, proinflammatory cytokine (TNF-alpha and IL-1beta) production was increased after carrageenan. Bupivacaine prevented this inflammatory response: 992 +/- 102 versus 2146 +/- 338 versus 919 +/- 116 pg/mL for TNF-alpha (bupivacaine + carrageenan versus carrageenan versus control after LPS stimulation). This effect of bupivacaine was less after SAC stimulation. Moreover, IL-10 was not involved in the inhibition of proinflammatory cytokine production observed after treatment by bupivacaine alone. These experiments show that carrageenan-induced hindpaw inflammation modifies the blood cell reactivity to LPS and SAC and that bupivacaine regulates the systemic response elicited by carrageenan. Furthermore, IL-10 does not seem to be a factor of the antiinflammatory response induced by bupivacaine. The precise mechanism underlying this effect of bupivacaine remains to be clarified.

 

硝酸甘油对胃重建食管术后微循环灌注和氧合影响的研究

The effect of nitroglycerin on microvascular perfusion and oxygenation during gastric tube reconstruction.
Buise MP, Ince C, Tilanus HW, Klein J, Gommers D, van Bommel J.
Department of Anesthesiology, Erasmus Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands.

Anesth Analg. 2005 Apr;100(4):1107-11.


食管切除后胃重建食管术是食道癌病人的一种外科治疗选择。与颈部吻合口有关的并发症是胃底部微循环血流(MBF)的损害和缺血。本研究的目的在于区别MBF降低是否与动脉供血不足有关或者与静脉瘀血有关。

因此我们同时监测了胃重建食管术不同阶段的MBF,微循环血红蛋白氧饱和度(muHbSo(2))和微循环血红蛋白浓度(muHbcon)。14例食管切除后胃重建食管术病人,通过激光多普勒侦测仪监测MBF,通过反射性分光光度测定法监测muHbSo(2)muHbcon。并且吻合结束后在胃底部使用硝酸甘油。我们观察到这些病人中胃幽门部的MBF没有明显改变,但胃底部的MBF在手术期间却有进行性降低,从正常210±18 Arbitrary Units 降低到胃重建食管术完成后的52±9 Arbitrary Units (均值±标准差 P<0.05)。胃重建食管期间muHbSo(2) muHbcon 没有明显改变。而硝酸甘油使用后MBF增加一倍。我们得出的结论是胃重建食管期间MBF降低,而muHbSo(2) muHbcon 没有明显改变。其MBF降低可能与静脉淤血有关,且能部分被硝酸甘油抵消。

(吴德华译 薛张纲校)

Esophagectomy followed by gastric tube reconstruction is the surgical treatment of choice for patients with esophageal cancer. Complications of the cervical anastomosis are associated with impaired microvascular blood flow (MBF) and ischemia in the gastric fundus. The aim of the present study was to differentiate whether the decrease in MBF is a result of arterial insufficiency or of venous congestion. To do this we assessed MBF, microvascular hemoglobin oxygen saturation (muHbSo(2)), and microvascular hemoglobin concentration (muHbcon) simultaneously during different stages of gastric tube reconstruction. In 14 patients,MBF was determined with laser Doppler flowmetry, and muHbSo(2) and muHbcon were determined with reflectance spectro- photometry. After completion of the anastomosis, nitroglycerin was applied at the fundus. Although MBF did not change significantly in the pylorus, MBF decreased progressively during surgery in the fundus from 210 +/- 18 Arbitrary Units at baseline (normal stomach) to 52 +/- 9 Arbitrary Units after completion of reconstruction (mean +/- sem; P < 0.05). There was no change in muHbSo(2) and muHbcon during the reconstruction. After application of nitroglycerin, MBF doubled.We conclude that MBF decreases during gastric tube reconstruction but that muHbSo(2) and muHbcon do not. This decrease might be the result of venous congestion, which can partly be counteracted by application of nitroglycerin.

 

全氟己烷对家兔离体肺相对血流分布仅有微小影响

Perfluorohexane Vapor Has Only Minor Effects on Spatial Pulmonary Blood Flow Distribution in Isolated Rabbit Lungs

Matthias Hübler, Axel R. Heller, Jörg U. Bleyl, Marcelo Gama de Abreu, Tobias Kroll, Thomas Rössel, and Thea Koch

Address correspondence and reprint requests to Matthias Hübler, MD, DEAA, Department of Anesthesiology and Intensive Care Medicine, Carl Gustav Carus University Hospital, Fetscherstr. 74, 01307 Dresden, Germany.

Anesth Analg 2005 100(4): 1122-1128

 

本试验的目的是证明使用全氟己烷(PFH)对家兔离体肺相对血流(Qrel)分布无显著影响。用Krebs-Henseleit缓冲液对14个家兔离体肺标本进行灌注处理,速度为150 mL/min。肺血流后负荷保持在3mmHg水平。使用小型动物呼吸机进行机械通气,吸入气为室内空气,混有4% CO2,呼吸频率为30/分,潮气量为1212 mL/kgPEEP2 cm H2O。当达到稳态时,其中9个离体肺吸入18 vol. % PFH蒸气30min,另外5个离体肺作为对照组。通过荧光标记小体评估Qrel分布的改变。组间使用不配对Student's t检验进行分析,组内使用配对Student's t检验、单样本Student's t检验、Anderson-Hauck均衡检验和Pearson相关分析进行统计学分析。PFH组的平均相关系数为0.564 ± 0.182,对照组为0.502 ± 0.295。不同时间段或两组间均未见Qrel分布的显著性差异。PFH组可以见到Qrel向下肺再分布的趋势。我们的结论是,PFH对家兔离体肺Qrel再分布无显著影响。

(金琳 薛张纲校)

 

We tested the hypothesis that administration of perfluorohexane (PFH) vapor does not significantly affect the relative pulmonary blood flow (Qrel) distribution in isolated rabbit lungs. Fourteen isolated rabbit lungs were perfused with a Krebs-Henseleit buffer solution (flow 150 mL/min). Pulmonary afterload was set to 3 mm Hg. The lungs were ventilated with 4% CO2 in room air using a small animal ventilator (respiratory rate, 30 breaths/min; tidal volume, 12 mL/kg body weight; positive end-expiratory pressure, 2 cm H2O). After a steady-state period, 18 vol. % of PFH vapor was administered to 9 lungs for 30 min. In a second set of experiments five lungs served as controls. Change in Qrel distribution was assessed using fluorescent-labeled microspheres. The unpaired Student's t-test was used to compare variables between groups. The paired Student's t-test, the one-sample Student's t-test, the Anderson-Hauck test of equivalence, and Pearson correlation were used to analyze changes within groups. The mean correlation coefficients of Qrel were 0.564 ± 0.182 for the PFH group and 0.502 ± 0.295 for the control group, respectively. No significant changes in Qrel distribution over time and between groups were found. However, in the PFH group a tendency towards redistribution of Qrel to more ventral lung areas was noted. Our results suggest that PFH vapor has no significant effects on redistribution of Qrel in isolated rabbit lungs.

 

家兔急性闭合性头颅窗中软膜动脉对局部应用维拉帕米反应

Pial arterial response to topical verapamil in acute closed cranial windows in rabbits.
Hartl R, Joshi S, Levine S, Wang M, Sciacca RR.
Department of Neurosurgery, Weill Medical College, Cornell University, New York, New York, USA.

Anesth Analg. 2005 Apr;100(4):1140-6

之前,我们已经观察到动脉血内的维拉帕米可以增加脑血流量,然而一氧化氮供体,例如硝酸甘油却没有此作用。在临床上,维拉帕米和硝酸甘油都有扩张脑大动脉的作用。因此,我们假设维拉帕米局部给药即可以扩张脑近端大动脉,也可以扩张脑远端小动脉,而硝酸甘油仅优先扩张脑近端大动脉。我们测试我们的假设在10只新西兰白兔的急性头颅窗中。在给药之前测得数据之后,我们每5分钟往头颅窗内倾注硝酸甘油或维拉帕米4种渐增的浓度[10-8)、10-6)、10-4)和10-3M]。增加最大的直径以百分率的形式表达,与用药前直径相比。在使用两种药物时,两种药物的时间间隔为30分钟。局部维拉帕米给药增加近端脑大动脉(>60毫米)为32% +/- 18%,及远端小动脉(<60毫米)为62% +/- 42%。在局部给予硝酸甘油后我们观察到动脉直径有11% +/- 11%的适度增加,仅在近端大动脉显著。在10(-8) to 10(-3) M范围内,与硝酸甘油相比较,局部应用维拉帕米证明维拉帕米是有效的脑血管扩张剂以及作用脑远端软膜小动脉更强有力的血管扩张剂。

(孙敏莉译 薛张纲校)

 

We have previously observed that intraarterial verapamil increases cerebral blood flow, whereas nitric oxide donors, such as nitroglycerin, do not. Clinically, both verapamil and nitroglycerin dilate large cerebral arteries. Therefore, we hypothesized that topical verapamil would dilate both the large proximal and the small distal cerebral arteries, whereas nitroglycerin would preferentially dilate only the large proximal arteries. We tested our hypothesis in acute cranial windows implanted in 10 New Zealand White rabbits. After predrug measurements, we superfused 4 increasing concentrations of verapamil or nitroglycerin (10(-8), 10(-6), 10(-4), and 10(-3) M) in the cranial windows for 5 min each. The maximum increase in diameter was expressed as a percentage change from predrug diameters. There was a 30-min period of rest between the two drug challenges. Topical verapamil increased the arterial diameter of the larger proximal arterioles (>60 microm) by 32% +/- 18% and that of the smaller distal arterioles (<60 microm) by 62% +/- 42%. A modest increase in arterial diameters of 11% +/- 11% was observed after topical nitroglycerin that was significant only for the large-proximal arterioles. Within the 10(-8) to 10(-3) M range, topical verapamil, compared with nitroglycerin, proved to be a more potent cerebral vasodilator and had a more robust vasodilator effect on the distal small pial arteries.

 

慢性肾衰患者用布比卡因和罗哌卡因行肌间沟臂丛神经阻滞:膈肌移动和肺功能改变

Interscalene Brachial Plexus Block with Bupivacaine and Ropivacaine in Patients with Chronic Renal Failure: Diaphragmatic Excursion and Pulmonary Function Changes

Fatis Altintas, Funda Gumus, Guner Kaya, Ismail Mihmanli, Fatih Kantarci, Kamil Kaynak, and M. Serif Cansever

Departments of *Anesthesiology, {dagger}Radiology, {ddagger}Thoracic Surgery, and §Pediatrics, Metabolism Division Laboratory, Istanbul University Cerrahpasa Medical School, Istanbul, Turkey

Anesth Analg 2005 100: 1166-1171.

 

在这个随机双盲研究中,我们比较慢性肾衰患者用0.33%布比卡因和0.33%罗哌卡因行肌间沟臂丛神经阻滞(IBP)的麻醉特性和肺功能的改变。42名患者因创建动静脉瘘行IBP,随机分成2组接受0.33%布比卡因(Group B)或0.33%罗哌卡因(Group R30ml。评估阻滞起效时间、膈肌移动(超声评估),以及布比卡因和罗哌卡因的血浆浓度。同侧膈肌反向运动或固定以及正向运动减少>10mm定义为膈肌轻瘫。肺功能参数用床旁肺量仪测量。7名患者需要补充局麻,1名全脊麻;这些患者排除在研究之外。成功率为80.9%。两组阻滞效果相似。两组同侧膈肌移动均较基础值减少(P<0.05)。膈肌轻瘫在Group B16人中有10人发生,Group R18人中有8人发生(P> 0.05.两组患者的肺功能较基础值均显著降低(Group B组用力肺活量(FVC30%,第一秒用力呼气量(FEV1 32%,呼气峰流量(PEF) 31%Group RFVC 17%, FEV1 17%, and PEF 5% (P < 0.001)Group B组减少比Group R显著(P < 0.05)Group B 组的3名患者和Group R组的1名患者有轻度的呼吸问题(P > 0.05)。布比卡因和罗哌卡因的浓度都低于中毒水平而非“正常范围”。我们认为0.33%的布比卡因在IBP后肺功能降低比0.33%的罗哌卡因更显著。

(费敏译 薛张纲 校)

In this randomized, double-blind study, we compared the anesthetic characteristics and pulmonary function changes of 0.33% bupivacaine and 0.33% ropivacaine used for interscalene brachial plexus (IBP) anesthesia in patients with chronic renal failure. Forty-two patients undergoing IBP anesthesia for creation of arteriovenous fistulas were randomly allocated to receive either 30 mL of 0.33% bupivacaine (Group B) or 0.33% ropivacaine (Group R). Block onset time, diaphragmatic excursion (ultrasonographic evaluation), and free plasma concentrations of bupivacaine and ropivacaine were evaluated. Negative motion or immobility of the ipsilateral hemidiaphragm and a decrease of >10 mm in positive motion were defined as diaphragmatic paresis. The pulmonary function variables were measured by bedside spirometry equipment. Seven patients needed supplemental local anesthetic, one with total spinal block; these patients were excluded from the study. The success rate was 80.9%. Block quality was similar in the two groups. Ipsilateral hemidiaphragmatic excursion was decreased in both groups compared with baseline values (P < 0.05). Diaphragmatic paresis was identified in 10 of 16 patients and 8 of 18 patients in Groups B and R, respectively (P > 0.05). Pulmonary function significantly decreased from baseline in both groups (forced vital capacity (FVC) 30%, forced expiratory volume at 1 second (FEV1) 32%, and peak expiratory flow (PEF) 31% in Group B and FVC 17%, FEV1 17%, and PEF 5% in Group R) (P < 0.001). The decreases in Group B were larger than those in Group R (P < 0.05). Three patients in Group B and one in Group R had mild respiratory problems (P > 0.05). Concentrations of bupivacaine and ropivacaine were below toxic levels rather than "normal range." We conclude that pulmonary function decreased more after IBP with 0.33% bupivacaine than with 0.33% ropivacaine.

 

一项锁骨下区域的磁共振成像(MRI)分析:进针前能估计臂丛深度吗?

A magnetic resonance imaging analysis of the infraclavicular region: can brachial plexus depth be estimated before needle insertion?
Cornish PB, Nowitz M.
Department of Anaesthesia, Nelson Hospital, Nelson, New Zealand.

Anesth Analg. 2005 Apr;100(4):1184-8.

 

在本研究中,通过简便的体表标志如喙突(CP)和锁骨(CL),我们检查锁骨下区域的解剖来评估实施锁骨下阻滞前估计臂丛深度的可能性。我们研究了21MRI,每份含四个通过锁骨下区域的矢状面图像。测量包括从前胸壁皮肤到臂丛的距离、臂丛与锁骨的位置关系及锁骨宽度。在矢状面臂丛正好位于锁骨下,平均距喙突1cm。如果在这个平面下沿喙突移至中点下进针,那么接下来就可以估计臂丛深度。总的来说,如果真正地按计划的点进针,指向锁骨顶部,那么从针尖到锁骨中点的距离等于从进针点到臂丛的距离。此外,不仅在这个矢状面通常没有肺脏,而且即使有也位于臂丛后面。在锁骨下区域估计臂丛深度或“测量深度”是可行的,而且有应用潜能。此发现有待在临床工作中行进一步研究。

(周晓敏 薛张纲 校)

In this study we examined the anatomy of the infraclavicular region to assess the possibility of estimating brachial plexus depth before performing an infraclavicular block, by using readily identifiable landmarks such as the coracoid process (CP) and the clavicle (CL). Four parasagittal planes across the infraclavicular region were analyzed in 21 individual series of magnetic resonance imaging studies. Measurements included distance to the plexus from the skin of the anterior chest wall, position of the plexus relative to the CL, and clavicular width. The brachial plexus is located directly below the CL in the parasagittal plane 1 cm medial to the CP. If one inserts a needle in this same plane at a point in line with the inferomedial edge of the CP, then plexus depth can be estimated as follows. If the needle is raised, as a whole, straight up from the planned point of insertion to be level with the top of the CL, then the distance from the tip of the needle to a point midway across the width of the CL is equivalent to the distance from the insertion point to the plexus. Furthermore, not only is it uncommon to find the lung in this same parasagittal plane, but when it does appear, it is well behind the plexus. Estimating plexus depth, or "depth gauging," in the infraclavicular region is achievable and is a potentially useful strategy. Further study is required to confirm this finding in the clinical environment.

 

环状软骨按压与瑞芬太尼、丙泊酚对食管运动及食道下端括约肌的作用

The effects of cricoid pressure, remifentanil, and propofol on esophageal motility and the lower esophageal sphincter.

Thorn K, Thorn SE, Wattwil M.

Department of Anesthesiology and Intensive Care, Orebro University Hospital, 701 85 Orebro, Sweden.

Anesth Analg. 2005 Apr;100(4):1200-3.

 

环状软骨按压术在可能发生胃内容物误吸的麻醉诱导时常作为金标准。然而,在麻醉诱导的整个过程中不同阶段环状软骨按压术的效果并未被研究。这一研究的目的是为了查证环状软骨按压与瑞芬太尼、丙泊酚对食管的能动性及食道下端括约肌的作用。我们通过牙套装置记录了10个健康支援者食道下端括约肌压力并计算出屏障压。对清醒支援者以30牛的压力进行环状软骨按压时,食道下端括约肌压力和屏障压可显著降低(P<0.05)。但是,当以每公斤体重每分钟0.2微克瑞芬太尼静注时,并未出现这一结果。单用瑞芬太尼或合并1 mg/kg初始剂量的丙泊酚静脉注射不产生任何食道下端括约肌压力或屏障压的有统计学意义的改变。瑞芬太尼可以抑制自发的食管的能动性并能彻底消除环状软骨按压术所导致的不适体验。总而言之,对清醒支援者以30牛的压力进行环状软骨按压可使食道下端括约肌压力和屏障压降低。但在瑞芬太尼注射时无效。这显示了在快速诱导中选择施用环状软骨按压术的时机的重要。

(孙少潇译 薛张纲校)

Cricoid pressure is the gold standard during the induction of anesthesia when there is a risk of aspiration of gastric contents. However, the effect of cricoid pressure during the different steps of complete anesthesia induction has not been studied. The purpose of this study was to investigate the effects of cricoid pressure, remifentanil, and propofol on lower esophageal sphincter (LES) and esophageal motility. We recorded LES pressure (LESP) and calculated barrier pressure ([BrP] = LESP - gastric pressure) in 10 healthy volunteers using a Dent sleeve device. There was a significant decrease in LESP and BrP when a cricoid pressure of 30 N was performed in the awake volunteers (P < 0.05). However, this effect was not seen during the infusion of remifentanil 0.2 microg . kg(-1) . min(-1). Remifentanil per se or together with a bolus dose of propofol 1 mg/kg IV did not induce any statistical change in LESP or BrP. Remifentanil abolished spontaneous esophageal motility and completely eliminated the experience of discomfort induced by cricoid pressure. In conclusion, cricoid pressure of 30 N induced a decrease of LESP and BrP in awake volunteers. These effects were not seen during the remifentanil infusion. This shows the importance of when to apply cricoid pressure during rapid-sequence induction.

异丙酚减轻缺血再灌注和氧化应激引起的肺血管内皮损伤

Propofol Attenuates Lung Endothelial Injury Induced by Ischemia-Reperfusion and Oxidative Stress

Irina V. Balyasnikova, PhD, David J. Visintine, BA, Helena B. Gunnerson, MD, Chanannait Paisansathan, MD, Verna L. Baughman, MD, Richard D. Minshall, PhD, and Sergei M. Danilov, MD, PhD

Departments of Anesthesiology and Pharmacology, University of Illinois at Chicago, Chicago, Illinois

Anesth Analg 2005;100:929-936

 

心肺转流和肺移植后氧化剂介导的细胞损伤导致肺功能不全。以前,我们观察血管紧张素转换酶(ACE)从内皮细胞表面的分泌是一比肺湿-干重量比更敏感且更早的氧化肺内皮损伤的标记。这一研究的目的是通过测定ACE分泌来评价有抗氧化剂特性的麻醉剂异丙酚防止氧化肺损伤的潜能。ACE在缺血再灌注(I/R)后从离体的鼠灌注肺释放明显增多。异丙酚能明显降低I/R诱导的ACE释放23.4% (P < 0.05)。用0.75 mM H2O2灌注也引起ACE从肺微血管释放,异丙酚同样可减轻它。异丙酚对H2O2诱导的ACE释放的保护作用,在体外通过用中国鼠卵巢细胞过量表达人体ACE来证实。因而,通过测定在急性肺损伤I/RH2O2模型中ACE释放,发现异丙酚能减轻肺内皮的氧化损伤。

(彭中美 李士通 校)

Lung dysfunction after cardiopulmonary bypass and lung transplantation results from oxidant-mediated cellular damage. Previously, we observed the shedding of angiotensin-converting enzyme (ACE) from the endothelial cell surface to be a more sensitive and earlier marker of oxidative lung endothelial injury than lung wet-to-dry weight ratio. The aim of this study was to evaluate the potential of the anesthetic propofol, which has antioxidant properties, to prevent oxidative lung injury by measuring ACE shedding. ACE release from isolated perfused rat lungs increased significantly after ischemia-reperfusion (I/R). Propofol significantly decreased I/R-induced ACE release by 23.4% (P < 0.05). Perfusion with 0.75 mM H2O2 also caused ACE release from the lung microvasculature, which was similarly attenuated by propofol. The protective effect of propofol on H2O2-induced ACE shedding was confirmed in vitro using Chinese Hamster Ovary cells overexpressing human ACE. Thus, propofol can attenuate oxidative injury of the pulmonary endothelium as detected by ACE shedding in I/R and H2O2 models of acute lung injury.

 

丙泊酚和雷米芬太尼麻醉或丙泊酚、笑气和七氟醚麻醉下儿科肿瘤短小手术操作后恢复的比较

Recovery After Anesthesia for Short Pediatric Oncology Procedures: Propofol and Remifentanil Compared with Propofol, Nitrous Oxide, and Sevoflurane

Hilary R. Glaisyer, MRCP, FRCA, and Michael R. J. Sury, FRCA

Department of Anaesthesia, Great Ormond Street Hospital for Children NHS Trust, London, UK

Anesth Analg 2005;100:959-963

 

对患儿施行疼痛的短小肿瘤手术操作时,麻醉方法的要求是恢复迅速而没有副反应。我们比较分析了以丙泊酚、笑气和七氟醚麻醉或丙泊酚和雷米芬太尼全静脉麻醉这两种麻醉方法的恢复特点。将21例拟于两周内进行两次疼痛相似的操作的患儿实行单盲法比较。麻醉方法的次序随机化。丙泊酚和雷米芬太尼麻醉包括单次给以丙泊酚3–5 mg/kg和雷米芬太尼 1–4 µg/kg。丙泊酚、七氟醚和笑气麻醉包括丙泊酚 3–5 mg/kg 同时吸入 2%–8% 七氟醚和70%笑气。主要的结果参数为达到恢复出院标准所需的时间,同时观察其他恢复特征。患儿的平均年龄为6.5 (范围为 2.5–9.8)。其中19例为淋巴性白血病,2例为淋巴瘤。所有患儿进行鞘内化疗术,有一例进行骨髓吸取术。大部分操作的时间短于4分钟。丙泊酚和雷米芬太尼麻醉后达到出院标准的平均时间比以丙泊酚、七氟醚和笑气麻醉者短将近19分钟(P = 0.001)。所有的其他时间比较有相似的趋势和统计学差异。7例患儿父母表示偏爱丙泊酚和雷米芬太尼麻醉,仅1例父母表示更喜欢丙泊酚、七氟醚和笑气麻醉。在进行操作过程中,小儿均出现呼吸暂停,需要麻醉医生辅助呼吸。丙泊酚和雷米芬太尼麻醉后达到出恢复室标准的时间比丙泊酚、七氟醚、笑气复合麻醉平均早19分钟。更多的父母喜欢丙泊酚和雷米芬太尼麻醉。

(周志坚 李士通 校)

Anesthesia techniques in children undergoing short painful oncology procedures should allow rapid recovery without side effects. We compared the recovery characteristics of two anesthetic techniques: propofol with sevoflurane and nitrous oxide and a total IV technique using propofol and remifentanil. Twenty-one children, undergoing two similar painful procedures within 2 wk were studied in a single-blind manner within patient comparison. The order of the techniques was randomized. Propofol and remifentanil involved bolus doses of both propofol 3–5 mg/kg and remifentanil 1–4 µg/kg. Propofol with sevoflurane and nitrous oxide involved propofol 3–5 mg/kg with 2%–8% sevoflurane and 70% nitrous oxide. The primary outcome variable was the time taken to achieve recovery discharge criteria; other recovery characteristics were also noted. The mean age of the children was 6.5 yr (range, 2.5–9.8 yr). Nineteen had lymphoblastic leukemia and two had lymphoma. All children had intrathecal chemotherapy and one had bone marrow aspiration. Most procedures lasted <4 min. The mean time to achieve recovery discharge criteria was appreciably shorter after propofol and remifentanil than propofol with sevoflurane and nitrous oxide by nearly 19 min (P = 0.001). All other time comparisons had similar trends and statistical differences. Seven parents expressed a preference for the propofol and remifentanil technique compared with one preferring propofol with sevoflurane and nitrous oxide. Children are apneic during the procedure and require respiratory support from an anesthesiologist. Discharge readiness from the recovery ward was achieved on average 19 min earlier after propofol with remifentanil compared with the combination of propofol, sevoflurane and nitrous oxide. Parents more often preferred propofol with remifentanil.


预防注射罗库溴铵时的退缩反应:比较芬太尼与利多卡因

Preventing the Withdrawal Response Associated with Rocuronium Injection: A Comparison of Fentanyl with Lidocaine

Norezalee Ahmad, MBChB, MMed, Choy Yin Choy, MBChB, MMed, FANZCA, Esa Ab Aris, MD, MMed, and Subrahmanyam Balan, MBBS, MMed

Hospital Sultanah Aminah, Johor Bahru, Malaysia; Department of Anesthesiology & Intensive Care, Hospital Universiti Kebangsaan Malaysia, Malaysia

Anesth Analg 2005;100:987-990

 

我们比较了IV芬太尼与IV利多卡因作为预防注射罗库溴铵退缩反应的预处理的效果。对于这个前瞻性、随机、安慰剂对照、双盲研究,我们收入了9018-65岁、ASA分级为III的进行择期手术需要全麻和正压通气的患者。患者随机分入3组中的1组:组F IV 50 µg/mL的芬太尼2 mL100 µg),组L 2%无防腐剂的利多卡因2 mL40 mg),组P(安慰剂)生理盐水2 mL。安慰剂组、利多卡因组和芬太尼组在罗库溴铵后的退缩反应的发生率分别为57%30%7%。我们发现与安慰剂组相比较,芬太尼组和利多卡因组退缩反应的发生率均显著降低(P < 0.05),其中芬太尼组最有效(P < 0.05)。得出结论,芬太尼和利多卡因都是可用以减轻注射罗库溴铵时退缩反应的有效临床处理,其中芬太尼最有效。

(马皓琳 李士通 校)

We compared the efficacy of IV fentanyl with IV lidocaine as pretreatment for the prevention of withdrawal response after rocuronium injection. For this prospective, randomized, placebo-controlled, double-blind study we recruited 90 patients aged between 18 and 65 yr, ASA physical status I or II, who had undergone elective surgery requiring general anesthesia and positive pressure ventilation. Patients were randomly allocated to 1 of 3 groups: group F received 2 mL IV fentanyl 50 µg/mL (100 µg), group L received 2 mL of preservative-free lidocaine 2% (40 mg), and group P (placebo) received 2 mL of normal saline. The incidence of withdrawal response after rocuronium was 57%, 30%, and 7% in the placebo, lidocaine, and fentanyl groups, respectively. We found a significant reduction in incidence of withdrawal response in both the fentanyl and lidocaine groups when compared with the placebo group (P < 0.05), with the fentanyl group being most effective (P < 0.05). In conclusion, both fentanyl and lidocaine are effective clinical treatments to alleviate the withdrawal response associated with rocuronium injection, with fentanyl being more effective.


牛的白质、皮层灰质、丘脑、海马和下丘脑区域中挥发性麻醉药的溶解度

Solubility of Volatile Anesthetics in Bovine White Matter, Cortical Gray Matter, Thalamus, Hippocampus, and Hypothalamic Area

Mireille A. Neumann, MD, Edmond I Eger, II, MD, and Richard B. Weiskopf, MD

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

Anesth Analg 2005;100:1003-1006

 

虽然整个脑中现代挥发性麻醉药的溶解度是已知的,但特殊脑区域中这些药物的溶解度仍缺乏资料。由于不同区域脂质含量不同,而强效挥发性麻醉药又是脂溶性的,因此挥发性麻醉药在脑某些区域的溶解度与其它区域可能不同(例如灰质对白质)。在这一报告中,我们在牛脑中研究了这一问题,发现白质/气体分配系数比灰质/气体分配系数大1.6 (地氟醚) 2.4 (氟烷) ,异氟醚和七氟醚的这个值介于两者之间,是1.9倍。丘脑/气体、下丘脑/气体和海马/气体的分配系数介于灰质/气体和白质/气体之间。这些资料可能有助于明确麻醉恢复过程中涉及意识恢复的脑的部位。

(张莹 李士通 校)

Although known for whole brain, values are lacking for solubilities of modern volatile anesthetics in specific brain regions. Some regions should differ from others (e.g., gray matter versus white matter) because they differ in lipid content and because potent inhaled anesthetics are lipophilic. In the present report, we examined this issue in bovine brain, finding that white matter/gas partition coefficients are 1.6 (desflurane) to 2.4 (halothane) times larger than gray matter/gas partition coefficients, with values for isoflurane and sevoflurane lying between these at 1.9. Values for thalamus/gas, hypothalamic area/gas, and hippocampal/gas partition coefficients lie between those for gray and white matter. These data may be useful in defining the parts of the brain involved with return to consciousness during recovery from anesthesia.

 

图解吸入麻醉药的摄取,包括出入脂肪组织的弥散

Illustrations of Inhaled Anesthetic Uptake, Including Intertissue Diffusion to and from Fat

Edmond I. Eger, II, MD*, and Lawrence J. Saidman, MD

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; and †Department of Anesthesia, Stanford University, Stanford, California

Anesth Analg 2005;100:1020-1033

 

尽管已有人设计了一些模拟吸入麻醉药药代动力学的数学和计算机模型,但是这些模型的复杂性有时限制了影响药代动力学的因素所产生的互相作用的直觉评价。本篇论文通过考虑到麻醉药由通气输送至肺以及通过循环弥散至组织蓄积的图样,阐明了影响吸入麻醉药药代动力学的决定因素。图解具体表现了血流量和血液溶解度的效应均为影响弥散程度的决定因素。它们具体表现了组织容量和溶解度为影响组织蓄积能力的决定因素。用代表特殊组织的区域面积大小表示该组织蓄积(摄取)麻醉药能力的大小,用进出这些区域的箭头长度和宽度表示麻醉药移动的程度。这些图解具体表现了对药代动力学越来越显得重要的因素,如肥胖。肥胖加剧麻醉药的蓄积量,其中包括通过组织间弥散到达脂肪的麻醉药。这些蓄积的麻醉药回到循环中使得健康的肥胖病人恢复延迟,对于溶解度大的麻醉药,此种情况更为显著。不过,在脂肪中麻醉药增多发生于较低的分压,故本质上可能并不会影响苏醒。我们希望这些图解能使麻醉执业医师了解影响吸入麻醉药药代动力学的决定因素间的相互作用。

(周雅春 李士通 校)

Although several mathematical and computer simulations of inhaled anesthetic pharmacokinetics have been devised, their complexity sometimes limits an intuitive appreciation of the interactions produced by the determinants of kinetics. In this essay, we illustrate the factors that govern inhaled anesthetic pharmacokinetics with drawings that consider delivery of anesthetic by ventilation to the lungs and dispersion of the anesthetic to tissue depots by the circulation. The illustrations incorporate the effects of both blood flow and blood solubility as determinants of the extent of dispersion. They incorporate tissue volume and solubility as determinants of the capacity of the tissue depots. Capacity to hold (take up) anesthetic is depicted by areas representing specific tissues, and the extent of anesthetic movement is depicted by the length and breadth of arrows to and from the areas depicting capacity. The illustrations incorporate increasingly important elements to kinetics, such as obesity. Obesity increases the depots available for storage of anesthetic, including anesthetic that reaches fat by intertissue diffusion. Such anesthetic returns to the circulation to delay recovery in healthy and obese patients, particularly with more soluble anesthetics. However, the increased anesthetic in fat occurs at a lower partial pressure and thus might not influence emergence materially. We hope that these illustrations will allow anesthesia practitioners to appreciate the interactions of the factors that govern inhaled anesthetic pharmacokinetics.

 

载体流速和输注系统死腔容量对静脉内药物传输动力学的影响

The Impact of Carrier Flow Rate and Infusion Set Dead-Volume on the Dynamics of Intravenous Drug Delivery

Mark A. Lovich, MD, PhD, Jason Doles, and Robert A. Peterfreund, MD, PhD

Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston

Anesth Analg 2005;100:1048-1055

 

连接到静脉注射晶体液通路的药物输注,可能造成IV药物传输的动力学很复杂,其取决于输注系统的死腔容量、药物流速和载体流速。死腔的概念是直观的,对死腔与载体和药物流速间的相互作用缺乏正确理解,将导致强效药物传输速度的个体差异很大,从而引起出乎意料的临床效果。我们自数学模型来定量分析这种相互作用。用亚甲基蓝输注的实验模拟来检验这个预言。该模型预言对载体或药物的流量变化的反应有时间上的滞后,这一滞后与死腔容量成正比例,与总流量成反比。增加载体流速能提供一个类似推注剂量。暂时减慢或停止载体流量则可能使药物传输速度减慢,有时影响很久。再恢复载体速度,则又产生一次推注量。输注系统与载体间的连接方法及系统的使用历史会影响药物传输动力学。因此,尽管输注系统的结构及载体和药物流速变化的影响是复杂的,但仍然是可预测的。上述定量研究可能有助于静脉药物输注系统的安全使用。

(轩泓 李士通 校)

The dynamics of IV drug delivery resulting from drug infusions connected to main-line crystalloid carriers can be complex and depend on infusion set dead-volume, drug flow rate, and carrier flow rate. While the concept of dead-volume is intuitive, a lack of appreciation of the interaction with the carrier and drug flow rates can lead to unintended clinical effects resulting from large variations in the delivery rate of potent drugs. We derived mathematical models to quantify these interactions. Experimental simulation with methylene blue infusions tested these predictions. The models predict a lag in response time to changes in carrier or drug flow, which is proportional to the dead-volume and inversely related to the total flow rate. Increasing the carrier rate provides an acute drug bolus. Temporary reduction or cessation of carrier flow decreases the rate of drug delivery, potentially for prolonged periods. Furthermore, a drug bolus results from restoration of the carrier flow. The method of connecting an infusion to a carrier and the use history affects the dynamics of drug delivery. Thus, although complex, the impact of infusion set architecture and changes in carrier and drug flow rates are predictable. These quantitative studies may help optimize the safe use of IV drug infusion systems.

 

兔鞘内给予新斯的明预防鞘内可乐定的减轻高碳酸血症脑血管扩张的作用

Intrathecal Neostigmine Prevents Intrathecal Clonidine from Attenuating Hypercapnic Cerebral Vasodilation in Rabbits

Takenaka M, Iida H, Iida M, Sumi K, Kumazawa M, Tanahashi S, Dohi S.

Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu 501-1194, Japan.

Anesth Analg 2005;100:1075-1080

 

以前我们证明腰部鞘内给予α2激动剂能缓解高碳酸血症引起的脑血管扩张。鞘内联合给予新斯的明和可乐定可用于镇痛。联合应用对于大脑血管反应性的效应尚未清楚。我们用戊巴比妥麻醉兔,分成二组:(a)可乐定组(腰部鞘内给予生理盐水30min后给予可乐定2mg/kgn = 6;(b)新斯的明预处理组(腰部鞘内新斯的明2mg/kg 30min给予可乐定2mg/kgn = 6)。我们以封闭颅骨窗技术评估二组兔的软膜小动脉直径在高碳酸血症情况下的变化。可乐定组软膜小动脉对高碳酸血症的扩张反应明显减轻(给药前及后30, 60, and 90 min时分别为14%±4%4%±4%6%±6%5%±7%)。单独生理盐水或新斯的明均不能改变脑血管对高碳酸血的反应。预先给予新斯的明则能完全预防鞘内给予可乐定所具有的缓解高碳酸血症所致的脑血管扩张(分别为16%±7%15%±6%12%±6%16%±8%)。

(王立中译,李士通校)

We previously demonstrated that lumbar intrathecal α2 agonists attenuate hypercapnia-induced cerebral vasodilation. The combination of intrathecal clonidine and neostigmine is being investigated as pain therapy. The effects of their combination on cerebrovascular reactivity are unknown. We allocated rabbits anesthetized with pentobarbital to two groups: (a) clonidine (normal saline followed 30 min later by clonidine 2 µg/kg, both into the lumbar intrathecal space; n = 6), and (b) neostigmine-pretreatment (neostigmine 2 µg/kg followed 30 min later by clonidine 2 µg/kg, both into the lumbar intrathecal space; n = 6). We then evaluated the hypercapnia-induced changes in pial arteriolar diameter in these two groups using the closed cranial window preparation. The pial arteriolar dilator response to hypercapnia was significantly attenuated in the clonidine group (14% ± 4%, 4% ± 4%, 6% ± 6%, and 5% ± 7% for before and 30, 60, and 90 min, respectively). Neither normal saline nor neostigmine alone induced any change in the cerebral reactivity to hypercapnia. Pretreatment with neostigmine completely prevented the clonidine-induced attenuation of the hypercapnic cerebral vasodilation attenuated by intrathecal clonidine (16% ± 7%, 15% ± 6%, 12% ± 6%, and 16% ± 8%, respectively).


成人围手术期液体管理及其临床结果

Perioperative Fluid Management and Clinical Outcomes in Adults

Michael P. W. Grocott, BSc, MRCP, FRCA*, Michael G. Mythen, MD, FRCA*, and Tong J. Gan, MD, FRCA, FFARCS(I)

*Centre for Anaesthesia, University College London, London, United Kingdom; and †Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2005;100:1093-1106

 

静脉内液体可以避免脱水、维持有效的循环容量、预防组织灌注不足,应该将其同围手术期麻醉实施的核心要素(维持催眠、镇痛和肌松)同等考虑。近年来,对不同液体的作用的认识已经增加了。通过对各种可用的晶体或胶体液的理化以及生物特性的理解,可以合理地指导我们在不同的临床情况中选择液体类型。然而,却鲜有有用的临床结果数据能指导这个选择。决定给多少液体在历史上比选择用何种液体更有争议。许多临床研究都支持这一概念,通过补液以达到最大的左室搏出量(同时避免补液过量以及随之发生的左室功能损害)的方法可能会改善结果。在这篇文章里,我们回顾了可用的液体类型以及补液策略并讨论一下它们与成年人的临床结果的联系。

(黄丽娜  李士通  )

 

The administration of IV fluid to avoid dehydration, maintain an effective circulating volume, and prevent inadequate tissue perfusion should be considered, along with the maintenance of sleep, pain relief, and muscular relaxation, a core element of the perioperative practice of anesthesia. Knowledge of the effects of different fluids has increased in recent years, and the choice of fluid type in a variety of clinical situations can now be rationally guided by an understanding of the physicochemical and biological properties of the various crystalloid and colloid solutions available. However, there are few useful clinical outcome data to guide this decision. Deciding how much fluid to give has historically been more controversial than choosing which fluid to use. A number of clinical studies support the notion that an approach based on administering fluids to achieve maximal left ventricular stroke volume (while avoiding excess fluid administration and consequent impairment of left ventricular performance) may improve outcomes. In this article, we review the available fluid types and strategies of fluid administration and discuss their relationship to clinical outcomes in adults.

 

比较肝素化和非肝素化溶液用于维持围术期桡动脉导管畅通的功效及并发的阻塞

A Comparison of the Efficacy of Heparinized and Nonheparinized Solutions for Maintenance of Perioperative Radial Arterial Catheter Patency and Subsequent Occlusion

Binnur E. Tuncali, MD, Buhar Kuvaki, MD, Bahattin Tuncali, MD, and Emine Capar, MD

Department of Anesthesiology and Reanimation, Dokuz Eylul University, Izmir, Turkey

Anesth Analg 2005;100:1117-1121

 

本试验采用随机双盲对照的方法,比较肝素化和非肝素化注射液输注用于维持围术期桡动脉导管的通畅及并发的桡动脉阻塞发生率。200名病人被随机分为肝素化冲洗液组(H组,n = 100)和非肝素化冲洗液组(S组,n=100)。由同一试验者使用多普勒超声探头和脉搏血氧测量法评估拔管前、拔管后即刻及拔管后24小时桡动脉和尺动脉血流。检查穿刺置管点有无血肿、神经损伤及感染。导管平均置留时间在H组为378 ± 159.0 min,在S组为332 ± 154.6 min。由压力波减幅导致的纠正干预均数(位置改变的均数[S, 1.5 ± 2.0; H, 1.4 ± 3.8];手动冲洗均数[S组,1.3 ± 1.7H组,1.2 ± 1.2])在两组无显著性差异。拔除套管后,H组有20例病人发生部分或完全性阻塞,S组为16例(无差异)。阻塞发生率与拔管后穿刺点有血肿(P = 0.013)、套管置留时间长(P = 0.04)及年龄小于65(P = 0.009)相关。总之,肝素化和非肝素化冲洗液对于维持围术期桡动脉导管的通畅没有显著性差异.

(邱郁薇      李士通  校)

In a randomized, double-blind, controlled study, we compared heparinized and nonheparinized infusions for the maintenance of perioperative arterial catheter patency and the incidence of subsequent radial arterial occlusion. Two-hundred patients were randomized into 2 groups to receive heparinized (group H, n = 100) or nonheparinized (group S, n = 100) flush solutions. Radial and ulnar blood flows were assessed using Doppler probe and pulse oximetry before, just after, and 24 h after decannulation by the same investigator. The cannulation site was examined for complications such as hematoma, nerve injury, and infection. The mean duration of cannulations was 378 ± 159.0 min in group H and 332 ± 154.6 min in group S. The mean number of corrective interventions caused by dampening of the pressure wave (mean number of positional changes [group S, 1.5 ± 2.0; group H, 1.4 ± 3.8] and mean number of manual flushes [group S, 1.3 ± 1.7; group H, 1.2 ± 1.2]) was not significantly different in both groups. After decannulation, partial or total occlusion developed in 20 group H patients and 16 group S patients (not significant). The incidence of occlusion was correlated to the presence of hematoma at the puncture site after decannulation (P = 0.013), long duration of cannulation (P = 0.04), and age <65 yr (P = 0.009). In conclusion, there is no significant difference between heparinized and nonheparinized flush solutions for the maintenance of perioperative radial artery catheter patency.


鞘内预注射酮咯酸能减少大鼠脊髓缺血性损伤

Intrathecal Ketorolac Pretreatment Reduced Spinal Cord Ischemic Injury in Rats

Ying-Chou Hsieh*, Wen-Yi Liang§, Shen-Kou Tsai, and Chih-Shung Wong

*Graduate Institute of Medical Science, National Defense Medical Center; Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Neihu; and Departments of Anesthesiology and §Pathology, Veterans General Hospital, Shipai, Taipei, Taiwan

Anesth Analg 2005;100:1134-1139

 

脊髓缺血性损伤造成的截瘫是胸腹主动脉瘤手术修复的一个潜在的并发症。研究指出环氧合酶(COX)参与缺血性神经损伤,且COX抑制剂可能减少损伤。在这个实验中,我们观察鞘内预注射酮咯酸――一种非选择性COX抑制剂,是否对大鼠缺血性脊髓损伤有保护作用。大鼠被随机分组,在脊髓缺血(主动脉内气囊堵塞,维持近端动脉低血压11分钟)前1小时给予鞘内注射生理盐水、酮咯酸30 µg酮咯酸60 µg (每组n = 6只大鼠)。另有6只大鼠作为假装手术的对照。根据缺血损伤后24小时的下肢运动功能和腰椎脊髓的组织病理学改变来评定缺血性损伤。在第二个试验中用另外20只大鼠(每组n = 10)来评价这些药物的安全性。再灌注后28天记录大鼠的存活率。鞘内预注射酮咯酸60 µg明显减少神经细胞的死亡,改善下肢运动功能,长期存活率与对照组相似。结果显示鞘内预注射酮咯酸可能有预防胸腹主动脉手术期间的脊髓缺血性损伤的治疗潜能。

(朱 李士通 校)

Paraplegia caused by spinal cord ischemic injury remains a potential complication of surgical repair of thoracoabdominal aortic aneurysms. Studies suggest that cyclooxygenase (COX) contributes to ischemic neuronal damage and that COX inhibitors may reduce injury. In this study, we examined whether intrathecal pretreatment with ketorolac, a nonselective COX inhibitor, had a protective effect against ischemic spinal cord injury in rats. Rats were randomized to receive either intrathecal normal saline, ketorolac 30 µg, or ketorolac 60 µg (n = 6 rats per group) 1 h before spinal cord ischemia (intraaortic balloon occlusion combined with proximal arterial hypotension for 11 min). Another 6 rats served as the sham-operated controls. Ischemic injury was assessed by hindlimb motor function and by histopathological changes in the lumbar spinal cord at 24 h after the ischemic insult. The other 20 rats (n = 10 per group) were used in the second experiments to evaluate the safety of this drug. Survival of rats was recorded 28 days after reperfusion. Intrathecal pretreatment with 60 µg of ketorolac significantly reduced neuronal death and improved hindlimb motor function, and the long-term survival was similar to that in the control group. The results suggest that intrathecal ketorolac may be of therapeutic potential for preventing spinal cord ischemic injury during thoracoabdominal aortic surgery.


体位和比重对择期剖腹产鞘内布比卡因扩散的影响

The Effect of Posture and Baricity on the Spread of Intrathecal Bupivacaine for Elective Cesarean Delivery

Stephen P. Hallworth, FRCA*, Roshan Fernando, FRCA*, Malachy O. Columb, FRCA, and Gary M. Stocks, FRCA*

*Department of Anesthetics, Royal Free Hospital, London, and †Department of Anesthesia and Intensive Medicine, South Manchester University Hospital, Wythenshawe, United Kingdom

Anesth Analg 2005;100:1159-1165

 

 脊麻诱导时的体位和药液的比重被认为是决定药物在脑脊液中扩散的重要影响因素。本实验为双盲和前瞻性研究,将150例行择期剖腹产患者随机分坐位或右侧卧位诱导、脊麻鞘内给予重比重、等比重或轻比重布比卡因溶液10mg。麻醉时用联合腰麻方法鞘内注射后,将患者置于仰卧楔形位。应用DMA-450密度仪和以前生效的公式测定计算三种鞘内用液体的密度。数据采集包括感觉平面、运动阻滞、低血压发生情况及麻黄素使用情况。统计学分析包括方差分析和Cuzick非参数趋势统计。与坐位相比较,在侧卧位时比重对布比卡因感觉平面的扩散无影响。但轻比重溶液的扩散显著不同,产生的镇痛平面高于重比重溶液(P = 0.002)。然而,在最大扩散的总差别不同只有一节段,重比重溶液达到最大感觉平面的中位数T3,而等比重和轻比重溶液达到T2。随着比重增高运动阻滞明显减轻(P = 0.029),这个趋势只在侧卧位有统计学差异 (P = 0.033)。随着比重降低,低血压的发生率和麻黄素使用都增加(P = 0.003 P=0.004 )。在轻比重坐位组低血压的发生率最高(76%),颈段阻滞的发生率也最高(24%; P = 0.032)

(赵雪莲 李士通 校)

Posture and baricity during induction of spinal anesthesia with intrathecal drugs are believed to be important in determining spread within the cerebrospinal fluid. In this double-blind prospective study, 150 patients undergoing elective cesarean delivery were randomized to receive a hyperbaric, isobaric, or hypobaric intrathecal solution of 10 mg bupivacaine during spinal anesthesia induced in either the sitting or right lateral position. After an intrathecal injection using a combined-spinal technique patients were placed in the supine wedged position. We determined the densities of the three intrathecal solutions from a previously validated formula and measured using a DMA-450 density meter. Data collection included sensory level, motor block, episodes of hypotension, and ephedrine use. Statistical analysis included analysis of variance and Cuzick’s trend. In the lateral position, baricity had no effect on the spread of sensory levels for bupivacaine compared to the sitting position, where there was a statistically significant difference in spread with the hypobaric solution producing higher levels of analgesia than the hyperbaric solution (P = 0.002). However, the overall differences in maximal spread only differed by one dermatome, with the hyperbaric solution achieving a median maximum sensory level to T3 compared with T2 for the isobaric and hypobaric solutions. Motor block was significantly (P = 0.029) reduced with increasing baricity and this trend was significant (P = 0.033) for the lateral position only. Hypotension incidence and ephedrine use increased with decreasing baricity (P = 0.003 and 0.004 respectively), with the hypobaric sitting group having the most frequent incidence of hypotension (76%) as well as cervical blocks (24%; P = 0.032).


可乐定加入甲哌卡因用于腋路臂丛阻滞下甲沟炎手术的效果

The Effects of Clonidine Added to Mepivacaine for Paronychia Surgery Under Axillary Brachial Plexus Block

Gabriella Iohom, FCARCSI*, Adnane Machmachi, MD*, Désiré-Pascal Diarra, MD*, Mohammed Khatouf, MD*, Sylvie Boileau, MD*, François Dap, MD, Stéphanie Boini, MD, Paul-Michel Mertes, MD, PhD*, and Herve Bouaziz, MD, PhD*

*Department of Anesthesiology and Intensive Care Medicine, Nancy University Hospitals, Department of Plastic and Hand Surgery, Hôpital Jeanne d’Arc, Department of Clinical Epidemiology and Evaluation, Marin Hospital, Nancy, France

Anesth Analg 2005;100:1179-1183

 

我们假设在腋路臂丛阻滞(ABPB)后在同样的神经分布内,受感染组织的感觉阻滞起效较健康组织有所延迟,而可乐定加入甲哌卡因将加强麻醉及术后镇痛作用。将41例在ABPB下行拇指/食指甲沟炎手术的门诊病人以双盲方式随机给予400mg甲哌卡因加100 µg可乐定(可乐定组, n = 21)或加2 mL 生理盐水 (安慰剂组, n = 20)。在安慰剂组,同样的神经分布的受感染区域的感觉阻滞起效较健康区域有所延迟(24.7 ± 5.5 min对正中神经21.3 ± 7.2 P = 0.02 及桡神经21.6 ± 7.8 min P = 0.04 )。在可乐定组,与安慰剂组相比,1) 正中神经及桡神经范围感觉阻滞的起效均加速了(11.1 ± 5.610.5 ± 5.2分别对21.3 ± 7.221.6 ± 7.8 min, P < 0.001) 2)感染区域的感觉阻滞起效加速(9.1 ± 1.9 24.7 ± 5.5 min; P < 0.001)3) 麻醉持续时间(275 ± 75163 ± 57; P = 0.04)及首次需要镇痛药的时间(279 ± 87197 ± 84 min; P = 0.002)延长,这时的视觉模拟评分降低(30 ± 18 70 ± 24; P < 0.001)4)术后24小时和48小时的口头数值等级评分降低(1.7 ± 2.2 4.1 ± 3.0; P = 0.0020.1 ± 0.5 1.5 ± 2.4; P = 0.01) 。我们的发现提示在ABPB下对末梢感染组织进行手术,在同样的神经分布区域,受感染的组织较健康组织对麻醉有耐药,将可乐定加入甲哌卡因可加强麻醉及术后镇痛效果。

(裘毅敏 李士通 校)

We hypothesized that onset of sensory block is delayed in infected versus healthy tissues within the same nerve distribution after axillary brachial plexus block (ABPB) and that clonidine added to mepivacaine would enhance anesthesia and postoperative analgesia. Forty-one outpatients undergoing thumb/index paronychia surgery under ABPB were randomly assigned to receive in a double-blind fashion 400 mg mepivacaine plus either 100 µg clonidine (clonidine group, n = 21) or 2 mL saline (placebo group, n = 20). Onset of sensory block in the infected area was delayed compared with healthy areas of the same nerve distribution (24.7 ± 5.5 min versus 21.3 ± 7.2; P = 0.02 for median and 21.6 ± 7.8 min; P = 0.04 for radial) within the placebo group. In the clonidine group, when compared to placebo i) onset of sensory block in both the median and radial nerve territories was accelerated (11.1 ± 5.6 and 10.5 ± 5.2 versus 21.3 ± 7.2 and 21.6 ± 7.8 min, respectively; P < 0.001), ii) onset of sensory block in the region of infection was accelerated (9.1 ± 1.9 versus 24.7 ± 5.5 min; P < 0.001), iii) duration of anesthesia (275 ± 75 versus 163 ± 57; P = 0.04) and time to first analgesic requirement (279 ± 87 versus 197 ± 84 min; P = 0.002) were prolonged with decreased visual analog scale scores at this time (30 ± 18 versus 70 ± 24; P < 0.001), and iv) verbal numeric rating scores were decreased at 24 h (1.7 ± 2.2 versus 4.1 ± 3.0; P = 0.002) and 48 h (0.1 ± 0.5 versus 1.5 ± 2.4; P = 0.01) postoperatively. Our findings suggest that in the setting of distal infected tissue surgery under ABPB infected tissues are resistant to anesthesia compared with healthy areas within the same nerve distribution and clonidine added to mepivacaine enhances both anesthesia and postoperative analgesia.

 

缺血性视神经病变患者中星状神经节阻滞对视觉诱发电位和眼动脉与颈内动脉血流的影响

The Effects of Stellate Ganglion Block on Visual Evoked Potential and Blood Flow of the Ophthalmic and Internal Carotid Arteries in Patients with Ischemic Optic Neuropathy

 

Feng Liu, PhD*, Guozhong Xu, MB*, Zheli Liu, PhD†, Yan Zhao, MM‡, Xiaojun Lv, MM§, and Junke Wang, MM*

Departments of *Anesthesiology and Ophthalmology, The First Affiliated Hospital of China Medical University, Shenyang, China; and Departments of Stomach Surgery and §Internal Medicine, LiaoNing Cancer Hospital, Shenyang, China

Anesth Analg 2005;100:1193-1196

 

在老年人,缺血性视神经病变(ION)是会引起视觉丧失的常见疾病。我们用星状神经节阻滞(SGB)治疗ION,研究其对图片视觉诱发电位(P-VEP)和视动脉(OA)与颈内动脉(ICA)血流的影响。在本研究中研究了由同一位眼科医生作出诊断的12例患者的12只缺血性眼睛,每天用2%利多卡因2-3 mL对所有患者的病侧进行SGB,治疗期10-15天。与健康的眼睛相比,SGB前的ION眼睛P-VEP P100的潜伏期延长(123 ± 14 ms98 ± 3 ms P < 0.05),振幅降低(4.24 ± 1.76 µV10.26 ± 4.09 µVP < 0.05)。但SGB后,潜伏期和振幅恢复到正常水平(103 ± 6 ms98 ± 3 ms10.43 ± 4.88 µV10.26 ± 4.09 µV P > 0.05)。治疗前,缺血侧OAICA血流速度很慢,血流阻抗指数很高,但SGB减少了这些改变。SGB不影响正常侧的OAICA。结论是SGB改善了ION眼睛的P-VEPOAICA的血流。还需更多的研究去证实SGB是治疗ION一种有效的方法。

(陈玮     李士通 校)

Ischemic optic neuropathy (ION) is a common disease that can cause a loss of visual acuity in the elderly. We treated ION patients with stellate ganglion block (SGB) and investigated its effects on picture visual evoked potential (P-VEP) and blood flow in the ophthalmic artery (OA) and internal carotid artery (ICA). Twelve ischemic eyes in 12 patients diagnosed by the same ophthalmologist were investigated in this study. All patients were treated with daily SGB on the affected side with 2–3 mL of 2% lidocaine for a treatment period of 10–15 days. In ION eyes before SGB, compared with healthy eyes, the latency of P-VEP P100 was delayed (123 ± 14 ms versus 98 ± 3 ms; P < 0.05), and the amplitude was reduced (4.24 ± 1.76 µV versus 10.26 ± 4.09 µV; P < 0.05). After SGB, the latency and amplitude returned to normal (103 ± 6 ms versus 98 ± 3 ms; 10.43 ± 4.88 µV versus 10.26 ± 4.09 µV; P > 0.05). Before treatment, the blood flow velocities of the OA and the ICA on the ischemic side were slow and the resistance indexes were high, but SGB reduced these changes. SGB did not affect the OA and the ICA on the healthy side. We conclude that SGB improves P-VEP and OA and ICA blood flow in ION eyes. Further studies are needed to confirm that this is an effective method for the treatment of ION.