Anesthesia & Analgesia

April 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

 

對輸注庫存血和血紅蛋白氧載體所致血液稀釋的全身反應

(王麗珺譯 薛張綱校)

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術中使用硬膜外麻醉與單獨使用全麻相比不減少心肌損害的生化標誌

(朱玫娟 譯 陳傑 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

異丙酚減輕缺血再灌注和氧化應激引起的肺血管內皮損傷

(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:

氣道操作與側臥位在腺樣體扁桃體肥大兒童的麻醉實施、氣道開放過程中的內鏡測量效能

(王麗珺譯 薛張綱校)

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

小劑量納洛酮對兒童和青少年PCIA時阿片類藥物導致的副作用和鎮痛效果的影響:一項雙盲、前瞻、隨機和對照的研究

(朱玫娟 譯 陳傑 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、笑氣和七氟醚麻醉下兒科腫瘤短小手術操作後恢復的比較

(周志堅 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、表面活性物質及其聯合應用在改善嬰兒式氣管內酸化導致的急性肺損傷的效果

(金 薛張綱 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:

門診關節鏡手術,周圍神經阻滯較全麻恢復更好

(朱玫娟 譯 陳傑 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:

預防注射羅庫溴銨時的退縮反應:比較芬太尼與利多卡因

(馬皓琳 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

揮發性麻醉藥導致痛覺增強中腎上腺素能和類膽鹼能傳輸的作用

(金 薛張綱 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.

輕度低溫對幼豬血漿芬太尼濃度和生物轉化的影響

(朱玫娟 譯 陳傑 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.

牛的白質、皮層灰質、丘腦、海馬和下丘腦區域中揮發性麻醉藥的溶解度

(張瑩 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.

地氟醚預處理對內皮粘附分子和mRNA的體外效應

(蔡美華譯 薛張綱校)

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.

犬急性等容血液稀釋時吸入氟烷、異氟烷和七氟烷的比較性評估
(齊波 譯 陳傑 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.

圖解吸入麻醉藥的攝取,包括出入脂肪組織的彌散

(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:阿片類藥信號傳導和耐受機制領域的新角色

(許文妍譯 薛張綱校)

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:

健康志願者麻醉中12導聯高頻QRS心電圖

(齊波 譯 陳傑 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.

載體流速和輸注系統死腔容量對靜脈內藥物傳輸動力學的影響

(軒泓 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

非零基本氧流量對麻醉機呼吸回路漏氣檢驗的危害

(孫志榮譯 薛張綱校)

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,一種新型單劑量緩釋硬膜外嗎啡與標準硬膜外嗎啡對緩解下腹部手術後疼痛的比較研究

(殷文淵 譯 陳傑 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.

兔鞘內給予新斯的明預防鞘內可樂定的減輕高碳酸血症腦血管擴張的作用

(王立中譯,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.

布比卡因對角叉菜膠引起小鼠炎症反應的作用: 體外刺激後白細胞產生細胞因數

(沈洪 薛張綱 )

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.

脊髓阿片樣受體1激動劑,而非N-甲基-D-天門冬氨酸拮抗劑,逆轉大鼠皮內注射辣椒素引起的繼發性機械性異常性疼痛

(殷文淵 譯 陳傑 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:

成人圍手術期液體管理及其臨床結果

(黃麗娜  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:

硝酸甘油對胃重建食管術後微循環灌注和氧合影響的研究

(吳德華譯 薛張綱校)

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

手動膨脹肺時呼氣末正壓水平對呼氣流速峰值的影響

(趙延華 譯 陳傑 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.

比較肝素化和非肝素化溶液用於維持圍術期橈動脈導管暢通的功效及併發的阻塞

(邱鬱薇      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.

全氟己烷對家兔離體肺相對血流分佈僅有微小影響

(金琳 薛張綱校)

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:

鞘內預注射酮咯酸能減少大鼠脊髓缺血性損傷

(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.

家兔急性閉合性頭顱窗中軟膜動脈對局部應用維拉帕米反應

(孫敏莉譯 薛張綱校)

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:

單次給藥、持續釋放的硬膜外嗎啡處理擇期剖腹產術後疼痛:多中心隨機對照研究結果

(朱輝 譯 陳傑 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.

體位和比重對擇期剖腹產鞘內布比卡因擴散的影響

(趙雪蓮 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:

慢性腎衰患者用布比卡因和羅呱卡因行肌間溝臂叢神經阻滯:膈肌移動和肺功能改變

(費敏譯 薛張綱 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.

連續肌間溝神經周圍注射羅呱卡因中加入可樂定可改善術後鎮痛:一項隨機、雙盲、對照研究

(朱輝 譯 陳傑 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.

可樂定加入甲呱卡因用於腋路臂叢阻滯下甲溝炎手術的效果

(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

一項鎖骨下區域的磁共振成像(MRI)分析:進針前能估計臂叢深度嗎?

(周曉敏 薛張綱 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.

利多卡因複合硫酸鎂行局部靜脈麻醉

(顧漪聞 譯 陳傑 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.

缺血性視神經病變患者中星狀神經節阻滯對視覺誘發電位和眼動脈與頸內動脈血流的影響

(陳瑋     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:

環狀軟骨按壓與瑞芬太尼、丙泊酚對食管運動及食道下端括約肌的作用

(孫少瀟譯 薛張綱校)

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.

七氟醚複合異丙酚和七氟醚、異丙酚分別用於成人喉罩通氣道置入的比較

(顧漪聞 譯 陳傑 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術中使用硬膜外麻醉與單獨使用全麻相比不減少心肌損害的生化標誌

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.

 

冠脈搭橋手術(CABG)中使用高位胸段硬膜外麻醉/鎮痛(HTEA)可能具有心肌保護作用。在這項前瞻、隨機、對照研究中,作者研究了選擇性CABG時,HTEA對肌鈣蛋白I釋放、氣管拔管時間和鎮痛等的作用。120位患者隨機分為全麻組(GA)和全麻加高位胸段硬膜外麻醉組(HTEA組)。GA組接受芬太尼(715ug/kg)和嗎啡。HTEA組接受芬太尼(57ug/kg)和硬膜外注射0.2%羅呱卡因+芬太尼(2ug/ml)直到術後第三天。結果:肌鈣蛋白I水平組間沒有區別。HTEA組中,拔管時間[中位數]為15min10320 min),GA組為430 min284590 min)。與GA組相比,HTEA組鎮痛顯著。在ICUHTEA組術後平均動脈血壓和系統血管阻力較低。結論:在CABG中使用硬膜外麻醉不影響肌鈣蛋白I的釋放,但能改善術後鎮痛,並縮短拔管時間。

(朱玫娟 譯 陳傑 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.

 

小劑量納洛酮對兒童和青少年PCIA時阿片類藥物導致的副作用和鎮痛效果的影響:一項雙盲、前瞻、隨機和對照的研究

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.

 

阿片類藥物常伴隨噁心、嘔吐和瘙癢等副作用。作者假設預防性、持續使用小劑量納洛酮可以減少阿片類藥物導致副作用的發病率,且不影響鎮痛藥物或阿片類藥物的使用量。在這項前瞻、雙盲、隨機和對照的研究中,46名術後患者(男21,女25),平均年齡為14±2.5歲,平均體重為53±17kg,使用嗎啡PCIA。患者隨機分為對照組(注射生理鹽水,n26)和納洛酮組(納洛酮0.25ug/kg/hn20)。結果:與納洛酮組相比,對照組的瘙癢和噁心發生率和嚴重性明顯增加,發生率分別為77%比20%,P0.0570%比35%,P0.05。嗎啡使用量(1.02±0.41mg/kg/d1.28±0.61mg/kg/d),靜息時疼痛評分(4±23±2),以及咳嗽狀態時評分(6±26±2)沒有明顯區別。結論:在兒童和青少年中,小劑量注射納洛酮(0.25ug/kg/h)可以明顯減輕阿片類藥物導致的副作用,而不影響阿片類藥物的鎮痛作用。當患者自控靜脈嗎啡鎮痛治療中重度疼痛時,臨床醫生可考慮同時使用小劑量的納洛酮輸注。

(朱玫娟 譯 陳傑 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.

 

門診關節鏡手術,周圍神經阻滯較全麻恢復更好

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.

通常認為門診手術中使用周圍神經阻滯(PNBs)具有潛在的優勢。但沒有針對門診關節鏡手術患者使用短效局麻藥周圍神經阻滯和全麻的比較研究。作者假設使用短效局麻藥聯合腰叢和骶神經阻滯與全麻相比能縮短出院時間。計畫接受關節鏡手術患者隨機分為全麻組和腰叢/骶神經組,全麻組使用咪唑安定、芬太尼、異丙酚,通過喉罩使用N2O/O2/地氟醚,腰叢/骶神經組使用氯普魯卡因。為控制術後疼痛,接受全麻的患者關節腔內注射0.25%的布比卡因20ml。周圍神經阻滯組患者在阻滯前給予咪唑安定(最多為4mg)和阿芬太尼(500750ug),術中使用異丙酚3050ug/kg/min鎮靜。比較兩組患者的圍術期時間,未入麻醉後監護病房比率,疼痛的和併發症的發生率。50例患者,全麻組和腰叢/骶神經組各為25例。兩組總手術室時間沒有顯著差異(97±37min91±42min)。周圍神經阻滯組中,72%患者未入麻醉後監護病房,全麻組中只有24%(P0.002)。在周圍神經阻滯組中手術結束到達到出院回家標準的時間、和實際出院時間與全麻組相比明顯縮短(分別為131±62min205±94min162±71min226±96min)。結論:對於門診關節鏡手術,使用3%2-氯普魯卡因聯合進行腰叢和骶神經阻滯較全麻恢復更好。

(朱玫娟 譯 陳傑 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.

 

輕度低溫對幼豬血漿芬太尼濃度和生物轉化的影響

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.

[

治療性低溫可以改變鎮痛和鎮靜藥物的需要劑量,但尚無資料顯示持續、長時使用芬太尼時,輕度低溫對其血漿濃度的影響。因此,作者利用豬模型來評估連續33小時使用芬太尼時,持續低溫對芬太尼濃度的影響。7頭雌性小豬(平均重量:11.8±1.1kg)靜脈使用芬太尼(15ug/kg/h)和咪唑安定(1.0mg/kg/h)進行麻醉。在準備和穩定後(12h以後),這些動物被降溫到中心溫度為31.6℃±0.2℃,保持6h,然後複溫,並保持在正常溫度37.7℃±0.36h。通過放免測定法測定血漿內芬太尼濃度,用熱稀釋法測心指數,通過染色酶技術測腎動脈、脾動脈、胰動脈、胃動脈、腸動脈和肝動脈血流。此外,4只小豬中,通過N-脫甲基乙基嗎啡離體檢測肝微粒體細胞色素P450 3A4CYP3A4)溫度依賴性。在低溫狀態,血漿芬太尼濃度增加25±11%(P0.05),並且在複溫後血藥濃度持續上升至少6h。低溫降低心指數(41±15%,P0.05),同時減少除肝動脈以外所有器官的血流量。低溫時CYP 3A4具有顯著的溫度依賴性(P0.01)。輕度低溫可以導致血漿芬太尼濃度的分佈和/或清除依賴性的增加,並且在複溫後可以持續增加幾個小時。結論:為了恰當的鎮痛和鎮靜應當預見到治療性低溫期間及結束後早期血漿芬太尼濃度會持續地增加。

(朱玫娟 譯 陳傑 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.

 

犬急性等容血液稀釋時吸入氟烷、異氟烷和七氟烷的比較性評估
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.

 

急性等容血液稀釋(ANH)的血流動力學反應受麻醉藥的影響。作者隨機研究18只雜種犬,在用三種不同的吸入麻醉藥氟烷、異氟烷或七氟烷下進行ANH。在抽血前、血液稀釋結束時、血液稀釋結束後3060min時分別測定血流動力學、氧運輸和胃pH。除了七氟烷組心率偏快外,組間血流動力學指標的基礎值相似。血液稀釋後30min,氟烷、異氟烷和七氟烷三組CI分別增加88%、86%和157%,但氟烷組動-靜脈氧差和氧耗更大。用張力計獲得的胃pH並沒有變化,組間無差異。因為對ANH的血流動力學反應並不削弱,三種麻醉藥均可安全用於麻醉維持。

(齊波 譯 陳傑 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.

 

健康志願者麻醉中12導聯高頻QRS心電圖

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綜合波高頻(HF)成分的分析,已被顯示是心肌缺血和梗死的指標,與手術室外常規ST段分析相比更為敏感。在該研究中,作者記錄了全麻對健康志願者QRS高頻分析的影響,以此確定這項技術對麻醉病人監測的潛在價值。記錄30名健康個體麻醉前後全部12導聯HFQRS心電圖(ECGs)。與誘導前比較,誘導後多導聯(原先描述的正常限)HF QRS的多個變數有顯著變化。為瞭解這項技術監測麻醉病人心肌缺血的價值,尚需進一步的研究。

(齊波 譯 陳傑 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,一種新型單劑量緩釋硬膜外嗎啡與標準硬膜外嗎啡對緩解下腹部手術後疼痛的比較研究

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.

 

在這個隨機、對照、不同劑量的研究中,作者評估了一種新型單劑量緩釋硬膜外嗎啡(DepodurTM)在接受下腹部手術病人中的鎮痛效果。541名病人在手術前約30分鐘隨機分至6個硬膜外治療組中的一組。6組是:5mg標準硬膜外硫酸嗎啡;5mg單次劑量緩釋硬膜外嗎啡(EREM);和10152025mg單次劑量EREM。主要研究目的是評估單次劑量EREM10152025mg與單次劑量EREM5mg相比對處理術後疼痛的效果。通過繪製一條劑量-反應關係直線來評估術後48小時內病人自控鎮痛追加芬太尼的用量。隨後通過安全和效率分析將單次劑量EREM10152025mg與單次劑量EREM5mg進行比較並與5mg硫酸嗎啡組進行比較。就像劑量-反應關係所顯示的那樣,術後靜脈芬太尼的用量相應減少。102025mg單次劑量EREM病人與5mg硫酸嗎啡相比靜脈芬太尼用量顯著減少。在48小時內,與標準嗎啡病人相比,更多的單次劑量EREM病人不需要靜脈使用芬太尼。雖然所有治療組都通過術後鎮痛中的芬太尼來評估,但硫酸嗎啡組的術後鎮痛芬太尼使用頻率顯著增多,152025mg單次劑量EREM的病人疼痛強度評分較低且對疼痛緩解滿意。總之,單次劑量EREM耐受性良好,97%的不良事件被評定為輕微或中等。正如所預料的那樣,所報導的不良事件與其他硬膜外阿片類藥一樣。總之,這個隨機、對照研究說明單次劑量EREM可以在術後鎮痛的48小時內起作用,但許多病人由於疼痛仍需追加藥物。實驗中,單次劑量EREM的副作用是可接受和可預測的。

(殷文淵 譯 陳傑 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.

 

脊髓阿片樣受體1激動劑,而非N-甲基-D-天門冬氨酸拮抗劑,逆轉大鼠皮內注射辣椒素引起的繼發性機械性異常性疼痛

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

皮內注射辣椒素引起的繼發性機械性異常性疼痛被廣泛用於探索組織損傷導致機械性異常性疼痛的內在機制。可是,辣椒素濃度與繼發性機械性異常性疼痛發生的相關性和辣椒素誘導機械性異常性疼痛發生和維持的內在機制以及引起的繼發性機械性異常性疼痛知之甚少。在這個實驗中,作者研究皮內注射辣椒素與繼發性機械性異常性疼痛的相關性和脊髓阿片受體相關1受體激動劑(ORL1)和N-甲基-D-天門冬氨酸受體在皮內注射引起的繼發性機械性異常性疼痛的發生和維持中的作用。0.03%的辣椒素50uL導致最強的異常性疼痛。鞘內注射痛敏肽,一種脊髓阿片受體相關1受體激動劑,削弱繼發性機械性痛覺過敏的持續時間,但對繼發機械性痛覺過敏的產生沒有影響。鞘內注射MK801,一種N-甲基-D-天門冬氨酸拮抗劑,對繼發性機械性痛覺過敏的產生沒有影響。這些發現支援ORL1受體應該為治療組織損傷引起的繼發性機械性異常性疼痛的研究方向。

(殷文淵 譯 陳傑 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.

 

手動膨脹肺時呼氣末正壓水平對呼氣流速峰值的影響

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.

對機械通氣病人進行手動膨脹肺(MHI)時,使用人工復蘇氣囊(MRB)時呼氣末正壓(PEEP)可能導致MHI分泌物移動技術無效。在這項研究中,作者旨在研究MHI時增加PEEP或降低順應性對呼氣流速(PEF)峰值的影響。該研究為盲態隨機,讓10名在MHI和重症監護治療方面具有豐富經驗的理療師對模擬肺進行操作。PEEP水平為0-15 cmH2O,順應性為0.050.02 L/cmH2O,隨機選擇MRB類型。Mapleson-C MRB氣囊與Laerdal MRB氣囊相比,不管在何種水平的PEEP均可顯著提高PEF(P < 0.01, d = 2.72)。順應性正常時(0.05 L/cmH2O),Mapleson-C環路內PEEP大於10 cmH2OPEF顯著降低(P < 0.01, d = 1.45)Laerdal MRB氣囊內PEEP大於10 cmH2O時,並沒有達到理論上能產生雙相氣液流動從而使肺內分泌物移動的PEF水平。如果粘液阻塞為MHI使用指征,Mapleson-C MRB可能是分泌物移動的最有效方法。

(趙延華 譯 陳傑 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.

單次給藥、持續釋放的硬膜外嗎啡處理擇期剖腹產術後疼痛:多中心隨機對照研究結果

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.

 

在這項多中心、隨機、對照研究中,作者比較了一種新型單次給藥持續釋放的硬膜外嗎啡(EREMDepoDurTM)在擇期剖腹產術後48小時的鎮痛效果和安全性,並與硬膜外硫酸嗎啡做比較。ASAI~II的臨產婦採用腰麻和硬膜外的聯合麻醉技術。腰麻劑量為布比卡因12~15mg+芬太尼10ug,通過硬膜外導管給予標準嗎啡5mg51015mg EREM作術後鎮痛。與標準嗎啡5mg組比較, EREM 1015mg組阿片類藥物追加總量明顯減少,而且術後48小時的功能評分提高。與標準嗎啡組比較, EREM 1015mg組休息時視覺疼痛評分和術後24~48小時活動評分較好。但EREM 5mg組和標準嗎啡組之間沒有明顯的差別。單次給藥EREM具有很好的耐受性,不良反應強度較弱。剖腹產術後鎮痛中使用EREM具有一定優勢,術後24~48小時鎮痛效果明顯優於標準嗎啡。

(朱輝 譯 陳傑 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.

 

連續肌間溝神經周圍注射羅呱卡因中加入可樂定可改善術後鎮痛:一項隨機、雙盲、對照研究

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.

儘管在神經阻滯單次用藥中加入可樂定能延長局麻藥的作用時間和術後鎮痛時間,但這一方法並不能提高連續神經阻滯時局麻藥效果。在這項研究中,作者使用較大劑量的可樂定以期提高鎮痛效果。選擇術後具有中等程度疼痛的肩部整形外科手術病人20例,術前行肌間溝臂叢神經阻滯(1.5%甲呱卡因,腎上腺素2.5ug/ml,可樂定50ug混合液40ml)和神經周圍置管。術後通過導管給予0.2%羅呱卡因或0.2%羅呱卡因+2ug/ml可樂定的混合液(背景速度5ml/h; 單次追加量5ml,鎖定時間1小時)。隨機、雙盲分組。主要記錄術後強烈疼痛的變化。其次記錄疼痛評分,病人自我追加劑量,口服鎮痛藥的使用,睡眠質量和注射引起的併發症。結果顯示組間變數沒有顯著的統計學差異。結論:羅呱卡因肌間溝神經周圍注射用藥中加入2ug/ml可樂定並不能減少術後第一天疼痛強度。這項陰性結果僅提示缺乏效果,將來需要進一步研究證實。

(朱輝 譯 陳傑 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.

 

利多卡因複合硫酸鎂行局部靜脈麻醉

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.

 

作者在本研究中將鎂加入利多卡因用於評估局部靜脈麻醉(IVRA)對止血帶所引起的疼痛的作用。選擇性手部手術的患者30 例,均行IVRA,隨機分為2組,組C採用10ml的生理鹽水加0.5%的利多卡因3mg/kg預充至40ml,組M採用10ml 15%的硫酸鎂(12.4mmol)加0.5%的利多卡因3mg/kg預充至40ml。分別記錄注射痛程度、感覺和運動阻滯的起效和恢復時間、止血帶引起的疼痛和麻醉效果。術後當疼痛視覺評分VAS>4分時,則給患者肌肉注射75mg雙氯芬酸,並且記錄鎮痛藥需要時間和量。組M的感覺和運動阻滯起效快,而消失慢(P<0.05),並且在術中1520304050min,止血帶所引起的VAS評分低(P<0.001)。麻醉醫師和手術醫師均認為組M的效果優於組CP<0.05)。術後患者第一次需要術後鎮痛的時間,組C95±29min,組M155±38minP<0.05)。術後6hVAS評分,組C高於組MP<0.05),而雙氯芬酸的需要量組C130±55mg)也高於組M50±35mg)(P<0.05)。作者認為利多卡因複合硫酸鎂可以提高IVRA的麻醉和鎮痛效果。

(顧漪聞 譯 陳傑 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.

 

七氟醚複合異丙酚和七氟醚、異丙酚分別用於成人喉罩通氣道置入的比較

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.

 

在一項前瞻性、隨機研究中,作者比較了七氟醚-異丙酚、七氟醚、異丙酚麻醉誘導用於成人喉罩通氣道置入(LMA)的第一次的成功率及副作用。選擇83例無術前用藥、ASAⅠ-Ⅱ患者,麻醉誘導用單次肺活量呼吸(VCB)法,分為三組,分別為複合組:吸入8%七氟醚+靜脈注射1.5mg/kg異丙酚;七氟醚組:單用8%七氟醚;異丙酚組:單用異丙酚3mg/kg。結果發現,複合組用藥誘導時,LMA第一次成功率(93.5%)比單獨用七氟醚組(46%)或異丙酚組(61.5%)要高(P<0.001)。異丙酚組誘導LMA速度最快,而術後噁心嘔吐幾率最低。但是這個優點被其注射時所引起的注射痛(69%)和LMA置入時患者身體活動的發生率高所抵消(異丙酚組為50%,複合組為19%,七氟醚組為26%,P<0.05)。此外異丙酚組的呼吸暫停的發生率更高(異丙酚組為84%,複合組為16%,七氟醚組為7%,P<0.001)。結果顯示,七氟醚複合異丙酚誘導麻醉置入喉罩,第一次喉罩置入的成功率高,呼吸抑制的發生率低。

(顧漪聞 譯 陳傑 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.

 

 

對輸注庫存血和血紅蛋白氧載體所致血液稀釋的全身反應

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

我們評價了嚴格氧轉運條件下,與血液或血色素raffimer進行交換的系統效能。我們比較了接受血紅蛋白氧載體(HBOC)、新鮮血液(採集時間<24小時)或庫存血(10天)進行血液稀釋的動物中的氧轉運情況。大鼠隨機接受血液或HBOC的等容量交換。氧的消耗用呼出氣體及血液樣本來測量,而整個體內的氧轉運由心排量和動脈氧含量來計算。交換後,大鼠服從逐步的等容量血液稀釋。同時測量血壓、血氣、酸堿狀態、血糖、血紅蛋白氧飽和度、心率和整個外周阻力。我們發現:1)接受HBOC的大鼠在血液稀釋過程中平均動脈壓和整個外周阻力均升高;2)用呼出氣體和血液來計算的氧轉運結果相同;3)氧轉運在接受血液和HBOC的大鼠中並無差別;4)最終血紅蛋白濃度(1.8 ± 0.1 g/dL)和氧轉運情況(5 ± 1 mL · min–1 · kg–1)在所有動物中是類似的;5)在血液稀釋過程中,大部分氧轉運和生化變化是類似的。這些資料表明,如果自體50%的血紅蛋白被庫存血中的血紅蛋白替代的話,對氧轉運的耐受性不會改變。

(王麗珺譯 薛張綱校)

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.

 

氣道操作與側臥位在腺樣體扁桃體肥大兒童的麻醉實施、氣道開放過程中的內鏡測量效能

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

 

在腺樣體扁桃體肥大且自主呼吸的兒童中實施全麻,上呼吸道阻塞對於麻醉醫師而言是一大挑戰。側臥位是治療阻塞性睡眠呼吸暫停的一種簡單方法。在該研究中,我們檢驗了體位改變與常規氣道操作如在氣道開放過程中抬高下頦或托下頜(內鏡檢查喉鳴情況或上呼吸道範圍)對擇期行腺樣體扁桃體切除術的兒童實施麻醉過程中的效能。18111歲的兒童用七氟醚麻醉。在用5%七氟醚和100%氧氣進行自主呼吸的過程中,記錄上呼吸道範圍和喉鳴情況。記錄到基線後,仰臥位和側臥位均抬高下頦及托下頜。抬高下頦、托下頜、側臥位增加了氣管暴露範圍、改善了喉鳴情況。更重要的是,側臥位提高了這些氣道操作在開放氣道過程中的效能。我們推斷:側臥位聯合氣道操作為腺樣體扁桃體肥大兒童的麻醉實施提供了更好的氣道開放。

(王麗珺譯 薛張綱校)

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、表面活性物質及其聯合應用在改善嬰兒式氣管內酸化導致的急性肺損傷的效果

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

 

我們開展此項研究旨在比較局部液體灌洗通氣(PLV)、肺泡表面活性物質(PSF)、以及兩者的聯合應用在改善嬰兒式酸化誘導所致急性肺損傷(ALI)的通氣的作用。在第一部分的研究中,42只接受設定呼期末正壓10cmH2O的容量控制通氣的兔子被隨機分配到六組(無創組、單純氣體通氣組GViPLVi PSFi PLVi->PSFi PSFi->PLVi)。各組都經過了嬰兒式氣管內酸化(2 mL/kg, pH 1.8)處理。GVi不經PLVPS治療。在嬰兒式酸化30 min ,PLVi接受氣管內碳氟化合物15 mL/kg治療, PSFi接受表面活性物質100 mg/kg治療. PLVi->PSFiPSFi->PLVi同時接受兩種措施間隔30 min順序治療。在第二部分研究中,六組接受與第一部分研究相同藥物治療的42只兔子給予壓力控制通氣。在產生ALI150 min,切下肺做生化和組織學檢查評定損傷程度。在這兩部分研究中,PSF、碳氟化合物以及兩者的聯合應用,可以減輕肺內白細胞浸潤、水腫,並使中性粒細胞產生過氧化物減少,從而改善氧合、肺通氣功能和組織學改變。在PSF之後使用碳氟化合物可以產生最好的治療效果,而在碳氟化合物之後使用PSF的效果最差,且這種差別與通氣模式無關。

(金 薛張綱 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.

 

揮發性麻醉藥導致痛覺增強中腎上腺素能和類膽鹼能傳輸的作用

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

 

揮發性麻醉藥在痛覺傳導方面有兩階段的作用效果。在非常低濃度的情況下,它們增加痛覺敏感度;反之,在較大的亞麻醉濃度下,它們可以起到鎮痛作用。以前的研究提示,膽鹼能抑制劑可以調節異氟醚的早期痛覺作用。而且,膽鹼能受體的活化有助於脊索的去甲腎上腺素的釋放。我們猜測脊索去甲腎上腺素釋放的膽鹼調製能調節異氟醚的早期痛覺作用。我們用小鼠後爪回縮反應時間作為使用腎上腺素活性抑制劑或膽鹼處理後痛覺靈敏度的測量指標。異氟醚在疼痛方面的作用隨濃度而改變。異氟醚使痛覺增強的50%有效濃度為0.16%,而起鎮痛作用的50%有效濃度為0.8%。神經毒素DSP-4所致全身去甲腎上腺素損耗促使基線回縮反應時間減少,阻止異氟醚早期痛覺。基線回縮反應時間也可因鞘內育亨賓的作用而減少。在用育亨賓治療後,異氟醚不再具有早期痛覺作用。尼古丁經腦室內注射後增強基線反應時間但不阻止異氟醚的早期痛覺。相反,尼古丁鞘內給藥導致輕度基線反應時間減少並阻止異氟醚早期痛覺作用。我們推斷,似乎脊髓去甲腎上腺素傳輸是發生異氟醚早期痛覺的必要因素。異氟醚也許通過抑制活性膽鹼能受體而起到調節脊髓內去甲腎上腺素釋放的作用。

(金 薛張綱 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.

 

地氟醚預處理對內皮粘附分子和mRNA的體外效應

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.

 

細胞間粘附分子-1ICAM-1)、血管粘附分子-1VCAM-)E選擇蛋白的低表達可能是削弱缺血再灌注區域中性粒細胞粘附于血管內皮細胞的原因。地氟醚減少了缺血再灌注損傷。於是,我們假設地氟醚能影響經過腫瘤壞死因數(TNF)刺激的人臍靜脈血內皮細胞(HUVEC)表達ICAM-1E選擇蛋白和ICAM-1VCAM-1mRNA表達。HUVEC在一個最低肺泡有效濃度的地氟醚下60分鐘的預處理後經過TNF的刺激。HUVECICAM-1E選擇蛋白的蛋白表達通過免疫生化技術結合細胞形象計數技術評價。HUVECVCAM-1ICAM-1mRNA表達通過逆轉錄多聚酶鏈技術獲得。地氟醚不僅減少了HUVECICAM-1E選擇蛋白而且減少了HUVECICAM-1VCAM-1mRNA表達。中性粒細胞粘附於地氟醚預處理的HUVEC的速度減慢。地氟醚預處理的HUVEC減少的中性粒細胞粘附這一表現和減少的粘附分子表達有很好的相關性。這些結果提示地氟醚影響細胞粘附分子表達作用在牽涉到中性粒細胞的再聚集的多個階段。地氟醚相關的缺血再灌注損傷減少和其抑制ICAM-1VCAM-1E選擇蛋白表達以及抑制介導中性粒細胞轉位形成血管內皮細胞的緊密連接。

(蔡美華譯 薛張綱校)

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:阿片類藥信號傳導和耐受機制領域的新角色

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.

 

本文回顧了G信使蛋白調控子(GRS) 白在阿片類藥信號機制和阿片類藥耐受中重要作用的 進展。阿片類藥發揮生理作用通過複雜的G蛋白耦聯受 體信號機制,已知RGS蛋白緊密調控了G蛋白信號通路 RGS蛋白包含GTP酶通過內在RGS結構域和其他多種 信號相關受體的功能結構域來加速蛋白活動。文獻中 報導了超過20中的RGS蛋白,提示有多種RGS蛋白負調 G蛋白介導阿片信號,使阿片信號脫敏內化,影響阿 片類藥耐受發生速度。未來藥物治療將RGS蛋白作為靶 目標指向于調節阿片類藥在急性和慢性疼痛效力可能 是疼痛治療的重要進展。

(許文妍譯 薛張綱校)

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.

 

非零基本氧流量對麻醉機呼吸回路漏氣檢驗的危害

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.

 

麻醉機非零基本氧流量被設定來補充氧代謝需要。然而,沒有科學證據證明這是必需的。本研究我們試圖闡明非零基本流量在麻醉前檢查是否對察覺漏氣有影響。25個參與者對麻醉機進行了漏氣檢驗以發現呼吸回路漏氣。人工漏氣產生裝置造成0~1L/min漏氣。調查人隨機選擇漏氣裝置並連到呼吸回路上。參與者對現場和漏氣產生裝置都不清楚,並檢驗呼吸回路以發現漏氣。對無和有基本流量進行了常規呼吸系統漏氣檢驗。每個漏氣過程中察覺漏氣的結果都進行了統計學分析。有基本流量的漏氣檢驗發現漏氣的速度小於非基本流量組(P<0.01)。我們證明非零基本氧流量降低察覺漏氣速度並妨礙漏氣察覺,特別小漏氣。因此,我們推薦呼吸漏氣檢驗應於無基本氧流量下進行。

(孫志榮譯 薛張綱校)

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.

 

布比卡因對角叉菜膠引起小鼠炎症反應的作用: 體外刺激後白細胞產生細胞因數

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.

 

我們目的是研究布比卡因對足底注射角叉菜膠引起系統反應的作用。我們研究了角叉菜膠、布比卡因或二者對脂多糖(LPS)和熱處理後金黃色葡萄球菌Cowan 株(SAC)培養的全血а-腫瘤壞死因數(TNF-α)、白介素(IL-1β,IL-10產生的作用。小鼠給予後爪注射角叉菜膠合並或不合併對側加壓肌注布比卡因。全血標本在15小時後取出並且應用LPSSAC培養。測量超浮游物內α-腫瘤壞死因數、白介素-1β、以及IL-10的含量。在LPSSAC培養基中,致炎因數(TNF-α和白介素-1β)在給予角叉菜膠後增加。布比卡因能夠防止這種炎症反應: LPS刺激後TNF-α的產生 992 +/- 1022146 +/- 338 919 +/- 116 pg/mL(布比卡因+角叉菜膠比角叉菜膠比對照組)。這種布比卡因的作用在SAC刺激下有所減低。然而,對於單純給以布比卡因治療,IL-10在阻止炎症反應的細胞因數中並不出現。這些實驗表明角叉菜膠引起小鼠後爪炎症反應改變了血細胞對LPSSAC的反應,布比卡因調節了角叉菜膠引起系統炎症反應。而且,IL-10似乎不是由布比卡因引起的抗炎症反應因數。布比卡因的這種精確機制需進一步闡明。

(沈洪 薛張綱 )

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.

 

硝酸甘油對胃重建食管術後微循環灌注和氧合影響的研究

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.


食管切除後胃重建食管術是食道癌病人的一種外科治療選擇。與頸部吻合口有關的併發症是胃底部微循環血流(MBF)的損害和缺血。本研究的目的在於區別MBF降低是否與動脈供血不足有關或者與靜脈瘀血有關。

因此我們同時監測了胃重建食管術不同階段的MBF,微循環血紅蛋白氧飽和度(muHbSo(2))和微循環血紅蛋白濃度(muHbcon)。14例食管切除後胃重建食管術病人,通過鐳射多普勒偵測儀監測MBF,通過反射性分光光度測定法監測muHbSo(2)muHbcon。並且吻合結束後在胃底部使用硝酸甘油。我們觀察到這些病人中胃幽門部的MBF沒有明顯改變,但胃底部的MBF在手術期間卻有進行性降低,從正常210±18 Arbitrary Units 降低到胃重建食管術完成後的52±9 Arbitrary Units (均值±標準差 P<0.05)。胃重建食管期間muHbSo(2) muHbcon 沒有明顯改變。而硝酸甘油使用後MBF增加一倍。我們得出的結論是胃重建食管期間MBF降低,而muHbSo(2) muHbcon 沒有明顯改變。其MBF降低可能與靜脈淤血有關,且能部分被硝酸甘油抵消。

(吳德華譯 薛張綱校)

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.

 

全氟己烷對家兔離體肺相對血流分佈僅有微小影響

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

 

本試驗的目的是證明使用全氟己烷(PFH)對家兔離體肺相對血流(Qrel)分佈無顯著影響。用Krebs-Henseleit緩衝液對14個家兔離體肺標本進行灌注處理,速度為150 mL/min。肺血流後負荷保持在3mmHg水平。使用小型動物呼吸機進行機械通氣,吸入氣為室內空氣,混有4% CO2,呼吸頻率為30/分,潮氣量為1212 mL/kgPEEP2 cm H2O。當達到穩態時,其中9個離體肺吸入18 vol. % PFH蒸氣30min,另外5個離體肺作為對照組。通過螢光標記小體評估Qrel分佈的改變。組間使用不配對Student's t檢驗進行分析,組內使用配對Student's t檢驗、單樣本Student's t檢驗、Anderson-Hauck均衡核對總和Pearson相關分析進行統計學分析。PFH組的平均相關係數為0.564 ± 0.182,對照組為0.502 ± 0.295。不同時間段或兩組間均未見Qrel分佈的顯著性差異。PFH組可以見到Qrel向下肺再分佈的趨勢。我們的結論是,PFH對家兔離體肺Qrel再分佈無顯著影響。

(金琳 薛張綱校)

 

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.

 

家兔急性閉合性頭顱窗中軟膜動脈對局部應用維拉帕米反應

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,我們已經觀察到動脈血內的維拉帕米可以增加腦血流量,然而一氧化氮供體,例如硝酸甘油卻沒有此作用。在臨床上,維拉帕米和硝酸甘油都有擴張腦大動脈的作用。因此,我們假設維拉帕米局部給藥即可以擴張腦近端大動脈,也可以擴張腦遠端小動脈,而硝酸甘油僅優先擴張腦近端大動脈。我們測試我們的假設在10只新西蘭白兔的急性頭顱窗中。在給藥之前測得資料之後,我們每5分鐘往頭顱窗內傾注硝酸甘油或維拉帕米4種漸增的濃度[10-8)、10-6)、10-4)和10-3M]。增加最大的直徑以百分率的形式表達,與用藥前直徑相比。在使用兩種藥物時,兩種藥物的時間間隔為30分鐘。局部維拉帕米給藥增加近端腦大動脈(>60毫米)為32% +/- 18%,及遠端小動脈(<60毫米)為62% +/- 42%。在局部給予硝酸甘油後我們觀察到動脈直徑有11% +/- 11%的適度增加,僅在近端大動脈顯著。在10(-8) to 10(-3) M範圍內,與硝酸甘油相比較,局部應用維拉帕米證明維拉帕米是有效的腦血管擴張劑以及作用腦遠端軟膜小動脈更強有力的血管擴張劑。

(孫敏莉譯 薛張綱校)

 

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.

 

慢性腎衰患者用布比卡因和羅呱卡因行肌間溝臂叢神經阻滯:膈肌移動和肺功能改變

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.

 

在這個隨機雙盲研究中,我們比較慢性腎衰患者用0.33%布比卡因和0.33%羅呱卡因行肌間溝臂叢神經阻滯(IBP)的麻醉特性和肺功能的改變。42名患者因創建動靜脈瘺行IBP,隨機分成2組接受0.33%布比卡因(Group B)或0.33%羅呱卡因(Group R30ml。評估阻滯起效時間、膈肌移動(超聲評估),以及布比卡因和羅呱卡因的血漿濃度。同側膈肌反向運動或固定以及正向運動減少>10mm定義為膈肌輕癱。肺功能參數用床旁肺量儀測量。7名患者需要補充局麻,1名全脊麻;這些患者排除在研究之外。成功率為80.9%。兩組阻滯效果相似。兩組同側膈肌移動均較基礎值減少(P<0.05)。膈肌輕癱在Group B16人中有10人發生,Group R18人中有8人發生(P> 0.05.兩組患者的肺功能較基礎值均顯著降低(Group B組用力肺活量(FVC30%,第一秒用力呼氣量(FEV1 32%,呼氣峰流量(PEF) 31%Group RFVC 17%, FEV1 17%, and PEF 5% (P < 0.001)Group B組減少比Group R顯著(P < 0.05)Group B 組的3名患者和Group R組的1名患者有輕度的呼吸問題(P > 0.05)。布比卡因和羅呱卡因的濃度都低於中毒水平而非“正常範圍”。我們認為0.33%的布比卡因在IBP後肺功能降低比0.33%的羅呱卡因更顯著。

(費敏譯 薛張綱 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.

 

一項鎖骨下區域的磁共振成像(MRI)分析:進針前能估計臂叢深度嗎?

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,通過簡便的體表標誌如喙突(CP)和鎖骨(CL),我們檢查鎖骨下區域的解剖來評估實施鎖骨下阻滯前估計臂叢深度的可能性。我們研究了21MRI,每份含四個通過鎖骨下區域的矢狀面圖像。測量包括從前胸壁皮膚到臂叢的距離、臂叢與鎖骨的位置關係及鎖骨寬度。在矢狀面臂叢正好位於鎖骨下,平均距喙突1cm。如果在這個平面下沿喙突移至中點下進針,那麼接下來就可以估計臂叢深度。總的來說,如果真正地按計劃的點進針,指向鎖骨頂部,那麼從針尖到鎖骨中點的距離等於從進針點到臂叢的距離。此外,不僅在這個矢狀面通常沒有肺臟,而且即使有也位於臂叢後面。在鎖骨下區域估計臂叢深度或“測量深度”是可行的,而且有應用潛能。此發現有待在臨床工作中行進一步研究。

(周曉敏 薛張綱 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.

 

環狀軟骨按壓與瑞芬太尼、丙泊酚對食管運動及食道下端括約肌的作用

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.

 

環狀軟骨按壓術在可能發生胃內容物誤吸的麻醉誘導時常作為金標準。然而,在麻醉誘導的整個過程中不同階段環狀軟骨按壓術的效果並未被研究。這一研究的目的是為了查證環狀軟骨按壓與瑞芬太尼、丙泊酚對食管的能動性及食道下端括約肌的作用。我們通過牙套裝置記錄了10個健康支援者食道下端括約肌壓力並計算出屏障壓。對清醒支援者以30牛的壓力進行環狀軟骨按壓時,食道下端括約肌壓力和屏障壓可顯著降低(P<0.05)。但是,當以每公斤體重每分鐘0.2微克瑞芬太尼靜注時,並未出現這一結果。單用瑞芬太尼或合併1 mg/kg初始劑量的丙泊酚靜脈注射不產生任何食道下端括約肌壓力或屏障壓的有統計學意義的改變。瑞芬太尼可以抑制自發的食管的能動性並能徹底消除環狀軟骨按壓術所導致的不適體驗。總而言之,對清醒支援者以30牛的壓力進行環狀軟骨按壓可使食道下端括約肌壓力和屏障壓降低。但在瑞芬太尼注射時無效。這顯示了在快速誘導中選擇施用環狀軟骨按壓術的時機的重要。

(孫少瀟譯 薛張綱校)

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.

異丙酚減輕缺血再灌注和氧化應激引起的肺血管內皮損傷

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

 

心肺轉流和肺移植後氧化劑介導的細胞損傷導致肺功能不全。以前,我們觀察血管緊張素轉換酶(ACE)從內皮細胞表面的分泌是一比肺濕-幹重量比更敏感且更早的氧化肺內皮損傷的標記。這一研究的目的是通過測定ACE分泌來評價有抗氧化劑特性的麻醉劑異丙酚防止氧化肺損傷的潛能。ACE在缺血再灌注(I/R)後從離體的鼠灌注肺釋放明顯增多。異丙酚能明顯降低I/R誘導的ACE釋放23.4% (P < 0.05)。用0.75 mM H2O2灌注也引起ACE從肺微血管釋放,異丙酚同樣可減輕它。異丙酚對H2O2誘導的ACE釋放的保護作用,在體外通過用中國鼠卵巢細胞過量表達人體ACE來證實。因而,通過測定在急性肺損傷I/RH2O2模型中ACE釋放,發現異丙酚能減輕肺內皮的氧化損傷。

(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、笑氣和七氟醚麻醉下兒科腫瘤短小手術操作後恢復的比較

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

 

對患兒施行疼痛的短小腫瘤手術操作時,麻醉方法的要求是恢復迅速而沒有副反應。我們比較分析了以丙泊酚、笑氣和七氟醚麻醉或丙泊酚和雷米芬太尼全靜脈麻醉這兩種麻醉方法的恢復特點。將21例擬于兩周內進行兩次疼痛相似的操作的患兒實行單盲法比較。麻醉方法的次序隨機化。丙泊酚和雷米芬太尼麻醉包括單次給以丙泊酚3–5 mg/kg和雷米芬太尼 1–4 µg/kg。丙泊酚、七氟醚和笑氣麻醉包括丙泊酚 3–5 mg/kg 同時吸入 2%–8% 七氟醚和70%笑氣。主要的結果參數為達到恢復出院標準所需的時間,同時觀察其他恢復特徵。患兒的平均年齡為6.5 (範圍為 2.5–9.8)。其中19例為淋巴性白血病,2例為淋巴瘤。所有患兒進行鞘內化療術,有一例進行骨髓吸取術。大部分操作的時間短於4分鐘。丙泊酚和雷米芬太尼麻醉後達到出院標準的平均時間比以丙泊酚、七氟醚和笑氣麻醉者短將近19分鐘(P = 0.001)。所有的其他時間比較有相似的趨勢和統計學差異。7例患兒父母表示偏愛丙泊酚和雷米芬太尼麻醉,僅1例父母表示更喜歡丙泊酚、七氟醚和笑氣麻醉。在進行操作過程中,小兒均出現呼吸暫停,需要麻醉醫生輔助呼吸。丙泊酚和雷米芬太尼麻醉後達到出恢復室標準的時間比丙泊酚、七氟醚、笑氣複合麻醉平均早19分鐘。更多的父母喜歡丙泊酚和雷米芬太尼麻醉。

(周志堅 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.


預防注射羅庫溴銨時的退縮反應:比較芬太尼與利多卡因

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

 

我們比較了IV芬太尼與IV利多卡因作為預防注射羅庫溴銨退縮反應的預處理的效果。對於這個前瞻性、隨機、安慰劑對照、雙盲研究,我們收入了9018-65歲、ASA分級為III的進行擇期手術需要全麻和正壓通氣的患者。患者隨機分入3組中的1組:組F IV 50 µg/mL的芬太尼2 mL100 µg),組L 2%無防腐劑的利多卡因2 mL40 mg),組P(安慰劑)生理鹽水2 mL。安慰劑組、利多卡因組和芬太尼組在羅庫溴銨後的退縮反應的發生率分別為57%30%7%。我們發現與安慰劑組相比較,芬太尼組和利多卡因組退縮反應的發生率均顯著降低(P < 0.05),其中芬太尼組最有效(P < 0.05)。得出結論,芬太尼和利多卡因都是可用以減輕注射羅庫溴銨時退縮反應的有效臨床處理,其中芬太尼最有效。

(馬皓琳 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.


牛的白質、皮層灰質、丘腦、海馬和下丘腦區域中揮發性麻醉藥的溶解度

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

 

雖然整個腦中現代揮發性麻醉藥的溶解度是已知的,但特殊腦區域中這些藥物的溶解度仍缺乏資料。由於不同區域脂質含量不同,而強效揮發性麻醉藥又是脂溶性的,因此揮發性麻醉藥在腦某些區域的溶解度與其他區域可能不同(例如灰質對白質)。在這一報告中,我們在牛腦中研究了這一問題,發現白質/氣體分配係數比灰質/氣體分配係數大1.6 (地氟醚) 2.4 (氟烷) ,異氟醚和七氟醚的這個值介於兩者之間,是1.9倍。丘腦/氣體、下丘腦/氣體和海馬/氣體的分配係數介於灰質/氣體和白質/氣體之間。這些資料可能有助於明確麻醉恢復過程中涉及意識恢復的腦的部位。

(張瑩 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.

 

圖解吸入麻醉藥的攝取,包括出入脂肪組織的彌散

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

 

儘管已有人設計了一些模擬吸入麻醉藥藥代動力學的數學和電腦模型,但是這些模型的複雜性有時限制了影響藥代動力學的因素所產生的互相作用的直覺評價。本篇論文通過考慮到麻醉藥由通氣輸送至肺以及通過迴圈彌散至組織蓄積的圖樣,闡明了影響吸入麻醉藥藥代動力學的決定因素。圖解具體表現了血流量和血液溶解度的效應均為影響彌散程度的決定因素。它們具體表現了組織容量和溶解度為影響組織蓄積能力的決定因素。用代表特殊組織的區域面積大小表示該組織蓄積(攝取)麻醉藥能力的大小,用進出這些區域的箭頭長度和寬度表示麻醉藥移動的程度。這些圖解具體表現了對藥代動力學越來越顯得重要的因素,如肥胖。肥胖加劇麻醉藥的蓄積量,其中包括通過組織間彌散到達脂肪的麻醉藥。這些蓄積的麻醉藥回到迴圈中使得健康的肥胖病人恢復延遲,對於溶解度大的麻醉藥,此種情況更為顯著。不過,在脂肪中麻醉藥增多發生於較低的分壓,故本質上可能並不會影響蘇醒。我們希望這些圖解能使麻醉執業醫師瞭解影響吸入麻醉藥藥代動力學的決定因素間的相互作用。

(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.

 

載體流速和輸注系統死腔容量對靜脈內藥物傳輸動力學的影響

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

 

連接到靜脈注射晶體液通路的藥物輸注,可能造成IV藥物傳輸的動力學很複雜,其取決於輸注系統的死腔容量、藥物流速和載體流速。死腔的概念是直觀的,對死腔與載體和藥物流速間的相互作用缺乏正確理解,將導致強效藥物傳輸速度的個體差異很大,從而引起出乎意料的臨床效果。我們自數學模型來定量分析這種相互作用。用亞甲基藍輸注的實驗模擬來檢驗這個預言。該模型預言對載體或藥物的流量變化的反應有時間上的滯後,這一滯後與死腔容量成正比例,與總流量成反比。增加載體流速能提供一個類似推注劑量。暫時減慢或停止載體流量則可能使藥物傳輸速度減慢,有時影響很久。再恢復載體速度,則又產生一次推注量。輸注系統與載體間的連接方法及系統的使用歷史會影響藥物傳輸動力學。因此,儘管輸注系統的結構及載體和藥物流速變化的影響是複雜的,但仍然是可預測的。上述定量研究可能有助於靜脈藥物輸注系統的安全使用。

(軒泓 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.

 

兔鞘內給予新斯的明預防鞘內可樂定的減輕高碳酸血症腦血管擴張的作用

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

 

以前我們證明腰部鞘內給予α2激動劑能緩解高碳酸血症引起的腦血管擴張。鞘內聯合給予新斯的明和可樂定可用於鎮痛。聯合應用對於大腦血管反應性的效應尚未清楚。我們用戊巴比妥麻醉兔,分成二組:(a)可樂定組(腰部鞘內給予生理鹽水30min後給予可樂定2mg/kgn = 6;(b)新斯的明預處理組(腰部鞘內新斯的明2mg/kg 30min給予可樂定2mg/kgn = 6)。我們以封閉顱骨窗技術評估二組兔的軟膜小動脈直徑在高碳酸血症情況下的變化。可樂定組軟膜小動脈對高碳酸血症的擴張反應明顯減輕(給藥前及後30, 60, and 90 min時分別為14%±4%4%±4%6%±6%5%±7%)。單獨生理鹽水或新斯的明均不能改變腦血管對高碳酸血的反應。預先給予新斯的明則能完全預防鞘內給予可樂定所具有的緩解高碳酸血症所致的腦血管擴張(分別為16%±7%15%±6%12%±6%16%±8%)。

(王立中譯,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).


成人圍手術期液體管理及其臨床結果

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

 

靜脈內液體可以避免脫水、維持有效的迴圈容量、預防組織灌注不足,應該將其同圍手術期麻醉實施的核心要素(維持催眠、鎮痛和肌松)同等考慮。近年來,對不同液體的作用的認識已經增加了。通過對各種可用的晶體或膠體液的理化以及生物特性的理解,可以合理地指導我們在不同的臨床情況中選擇液體類型。然而,卻鮮有有用的臨床結果資料能指導這個選擇。決定給多少液體在歷史上比選擇用何種液體更有爭議。許多臨床研究都支持這一概念,通過補液以達到最大的左室搏出量(同時避免補液過量以及隨之發生的左室功能損害)的方法可能會改善結果。在這篇文章裏,我們回顧了可用的液體類型以及補液策略並討論一下它們與成年人的臨床結果的聯繫。

(黃麗娜  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.

 

比較肝素化和非肝素化溶液用於維持圍術期橈動脈導管暢通的功效及併發的阻塞

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

 

本試驗採用隨機雙盲對照的方法,比較肝素化和非肝素化注射液輸注用於維持圍術期橈動脈導管的通暢及併發的橈動脈阻塞發生率。200名病人被隨機分為肝素化沖洗液組(H組,n = 100)和非肝素化沖洗液組(S組,n=100)。由同一試驗者使用多普勒超聲探頭和脈搏血氧測量法評估拔管前、拔管後即刻及拔管後24小時橈動脈和尺動脈血流。檢查穿刺置管點有無血腫、神經損傷及感染。導管平均置留時間在H組為378 ± 159.0 min,在S組為332 ± 154.6 min。由壓力波減幅導致的糾正干預均數(位置改變的均數[S, 1.5 ± 2.0; H, 1.4 ± 3.8];手動沖洗均數[S組,1.3 ± 1.7H組,1.2 ± 1.2])在兩組無顯著性差異。拔除套管後,H組有20例病人發生部分或完全性阻塞,S組為16例(無差異)。阻塞發生率與拔管後穿刺點有血腫(P = 0.013)、套管置留時間長(P = 0.04)及年齡小於65(P = 0.009)相關。總之,肝素化和非肝素化沖洗液對於維持圍術期橈動脈導管的通暢沒有顯著性差異.

(邱鬱薇      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.


鞘內預注射酮咯酸能減少大鼠脊髓缺血性損傷

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

 

脊髓缺血性損傷造成的截癱是胸腹主動脈瘤手術修復的一個潛在的併發症。研究指出環氧合酶(COX)參與缺血性神經損傷,且COX抑制劑可能減少損傷。在這個實驗中,我們觀察鞘內預注射酮咯酸――一種非選擇性COX抑制劑,是否對大鼠缺血性脊髓損傷有保護作用。大鼠被隨機分組,在脊髓缺血(主動脈內氣囊堵塞,維持近端動脈低血壓11分鐘)前1小時給予鞘內注射生理鹽水、酮咯酸30 µg酮咯酸60 µg (每組n = 6只大鼠)。另有6只大鼠作為假裝手術的對照。根據缺血損傷後24小時的下肢運動功能和腰椎脊髓的組織病理學改變來評定缺血性損傷。在第二個試驗中用另外20只大鼠(每組n = 10)來評價這些藥物的安全性。再灌注後28天記錄大鼠的存活率。鞘內預注射酮咯酸60 µg明顯減少神經細胞的死亡,改善下肢運動功能,長期存活率與對照組相似。結果顯示鞘內預注射酮咯酸可能有預防胸腹主動脈手術期間的脊髓缺血性損傷的治療潛能。

(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.


體位和比重對擇期剖腹產鞘內布比卡因擴散的影響

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

 

 脊麻誘導時的體位和藥液的比重被認為是決定藥物在腦脊液中擴散的重要影響因素。本實驗為雙盲和前瞻性研究,將150例行擇期剖腹產患者隨機分坐位或右側臥位誘導、脊麻鞘內給予重比重、等比重或輕比重布比卡因溶液10mg。麻醉時用聯合腰麻方法鞘內注射後,將患者置於仰臥楔形位。應用DMA-450密度儀和以前生效的公式測定計算三種鞘內用液體的密度。資料獲取包括感覺平面、運動阻滯、低血壓發生情況及麻黃素使用情況。統計學分析包括方差分析和Cuzick非參數趨勢統計。與坐位相比較,在側臥位時比重對布比卡因感覺平面的擴散無影響。但輕比重溶液的擴散顯著不同,產生的鎮痛平面高於重比重溶液(P = 0.002)。然而,在最大擴散的總差別不同只有一節段,重比重溶液達到最大感覺平面的中位數T3,而等比重和輕比重溶液達到T2。隨著比重增高運動阻滯明顯減輕(P = 0.029),這個趨勢只在側臥位有統計學差異 (P = 0.033)。隨著比重降低,低血壓的發生率和麻黃素使用都增加(P = 0.003 P=0.004 )。在輕比重坐位組低血壓的發生率最高(76%),頸段阻滯的發生率也最高(24%; P = 0.032)

(趙雪蓮 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).


可樂定加入甲呱卡因用於腋路臂叢阻滯下甲溝炎手術的效果

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

 

我們假設在腋路臂叢阻滯(ABPB)後在同樣的神經分佈內,受感染組織的感覺阻滯起效較健康組織有所延遲,而可樂定加入甲呱卡因將加強麻醉及術後鎮痛作用。將41例在ABPB下行拇指/食指甲溝炎手術的門診病人以雙盲方式隨機給予400mg甲呱卡因加100 µg可樂定(可樂定組, n = 21)或加2 mL 生理鹽水 (安慰劑組, n = 20)。在安慰劑組,同樣的神經分佈的受感染區域的感覺阻滯起效較健康區域有所延遲(24.7 ± 5.5 min對正中神經21.3 ± 7.2 P = 0.02 及橈神經21.6 ± 7.8 min P = 0.04 )。在可樂定組,與安慰劑組相比,1) 正中神經及橈神經範圍感覺阻滯的起效均加速了(11.1 ± 5.610.5 ± 5.2分別對21.3 ± 7.221.6 ± 7.8 min, P < 0.001) 2)感染區域的感覺阻滯起效加速(9.1 ± 1.9 24.7 ± 5.5 min; P < 0.001)3) 麻醉持續時間(275 ± 75163 ± 57; P = 0.04)及首次需要鎮痛藥的時間(279 ± 87197 ± 84 min; P = 0.002)延長,這時的視覺類比評分降低(30 ± 18 70 ± 24; P < 0.001)4)術後24小時和48小時的口頭數值等級評分降低(1.7 ± 2.2 4.1 ± 3.0; P = 0.0020.1 ± 0.5 1.5 ± 2.4; P = 0.01) 。我們的發現提示在ABPB下對末梢感染組織進行手術,在同樣的神經分佈區域,受感染的組織較健康組織對麻醉有耐藥,將可樂定加入甲呱卡因可加強麻醉及術後鎮痛效果。

(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.

 

缺血性視神經病變患者中星狀神經節阻滯對視覺誘發電位和眼動脈與頸內動脈血流的影響

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,缺血性視神經病變(ION)是會引起視覺喪失的常見疾病。我們用星狀神經節阻滯(SGB)治療ION,研究其對圖片視覺誘發電位(P-VEP)和視動脈(OA)與頸內動脈(ICA)血流的影響。在本研究中研究了由同一位眼科醫生作出診斷的12例患者的12只缺血性眼睛,每天用2%利多卡因2-3 mL對所有患者的病側進行SGB,治療期10-15天。與健康的眼睛相比,SGB前的ION眼睛P-VEP P100的潛伏期延長(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後,潛伏期和振幅恢復到正常水平(103 ± 6 ms98 ± 3 ms10.43 ± 4.88 µV10.26 ± 4.09 µV P > 0.05)。治療前,缺血側OAICA血流速度很慢,血流阻抗指數很高,但SGB減少了這些改變。SGB不影響正常側的OAICA。結論是SGB改善了ION眼睛的P-VEPOAICA的血流。還需更多的研究去證實SGB是治療ION一種有效的方法。

(陳瑋     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.