Anesthesia & Analgesia

May 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

雷米芬太尼用于心脏手术病人的术后镇痛

(裘毅敏 李士通 校)

Postoperative Analgesia with Remifentanil in Patients Undergoing Cardiac Surgery

Barbara Steinlechner, Herbert Koinig, Georg Grubhofer, Martin Ponschab, Silvia Eislmeir, Martin Dworschak, and Angela Rajek

Anesth Analg 2005 100: 1230-1235.

在日本非心脏手术期间心血管事件的发生率和美国及欧洲相同吗?

(殷文渊 陈杰 校)

Are the Incidences of Cardiac Events During Noncardiac Surgery in Japan the Same as in the United States and Europe?

Makoto Seki, Satoshi Kashimoto, Osamu Nagata, Hitoshi Yoshioka, Toshihiko Ishiguro, Kinya Nishimura, Osamu Honda, Atsuhiro Sakamoto, Akibumi Omi, Yukihiko Ogihara, Keiko Fujimoto, Motoyo Iwade, Tatsuya Yamada, Minoru Nomura, and Junzo Takeda

Anesth Analg 2005 100: 1236-1240.

膝上和膝下截肢术对糖尿病和非糖尿病患者围术期和长期致病率、致死率的研究

(吴德华译 薛张纲校)

Perioperative and Long-Term Morbidity and Mortality After Above-Knee and Below-Knee Amputations in Diabetics and Nondiabetics

Balachundhar Subramaniam, Frank Pomposelli, Daniel Talmor, and Kyung W. Park

Anesth Analg 2005 100: 1241-1247.

回顾抑肽酶在原位肝移植中的应用:它的有害作用会抵消它的有益作用吗?

(陈玮 李士通 校)

A Review of Aprotinin in Orthotopic Liver Transplantation: Can Its Harmful Effects Offset Its Beneficial Effects? (Review Article)

Claude Lentschener, Karine Roche, and Yves Ozier

PEDIATRIC ANESTHESIA:

在小儿心脏手术中常规使用经食道超声心动图的费用-效益比:10年经验

(殷文渊 陈杰 校)

Cost-Effectiveness of Routine Intraoperative Transesophageal Echocardiography in Pediatric Cardiac Surgery: A 10-Year Experience

Dominique A. Bettex, René Prêtre, Rolf Jenni, and Edith R. Schmid

Anesth Analg 2005 100: 1271-1275.

评估新生儿体外循环中标准肝素的剂量对凝血酶作用的影响

(吴德华译 薛张纲校)

An Evaluation of the Effects of a Standard Heparin Dose on Thrombin Inhibition During Cardiopulmonary Bypass in Neonates

Nina A. Guzzetta, Bruce E. Miller, Kathy Todd, Fania Szlam, Renee H. Moore, and Steven R. Tosone

Anesth Analg 2005 100: 1276-1282.

行心脏手术的婴幼儿脊麻后的术后镇痛

(周志坚 李士通 校)

Postoperative Analgesia After Spinal Blockade in Infants and Children Undergoing Cardiac Surgery

Gregory B. Hammer, Chandra Ramamoorthy, Hong Cao, Glyn D. Williams, M. Gail Boltz, Komal Kamra, and David R. Drover

Anesth Analg 2005 100: 1283-1288.

小儿心脏外科手术后应用Vasotrac测压和有创动脉血压监测的比较

(齐波 陈杰 校)

A Comparison of the Vasotrac with Invasive Arterial Blood Pressure Monitoring in Children After Pediatric Cardiac Surgery

Clifford L. Cua, Kristi Thomas, David Zurakowski, and Peter C. Laussen

Anesth Analg 2005 100: 1289-1294.

右旋美托咪啶在大鼠中发挥剂量依赖而非年龄依赖的抗伤害性疼痛作用及年龄依赖性催眠作用

(王丽珺译 薛张纲校)

Dexmedetomidine Exerts Dose-Dependent Age-Independent Antinociception but Age-Dependent Hypnosis in Fischer Rats

Robert D. Sanders, Mariangella Giombini, Daqing Ma, Yoko Ohashi, Mahmuda Hossain, Masahiko Fujinaga, and Mervyn Maze

Anesth Analg 2005 100: 1295-1302. encountered in the very young.

AMBULATORY ANESTHESIA:

帕瑞考昔钠和丙帕他莫用于成年患者腹股沟疝修复术后的肠道外术后镇痛的随机双盲比较

(黄丽娜  李士通  )

A Randomized, Double-Blind Comparison Between Parecoxib Sodium and Propacetamol for Parenteral Postoperative Analgesia After Inguinal Hernia Repair in Adult Patients

M. Beaussier, H. Weickmans, C. Paugam, S. Lavazais, J. P. Baechle, P. Goater, A. Buffin, J. F. Loriferne, J. F. Perier, J. P. Didelot, A. Mosbah, R. Said, and A. Lienhart

Anesth Analg 2005 100: 1309-1315.

ANESTHETIC PHARMACOLOGY:

单次和多次口服环氧化酶2抑制剂罗非考昔时脑脊液和血浆中的药代动力学

(齐波 陈杰 )

Cerebrospinal Fluid and Plasma Pharmacokinetics of the Cyclooxygenase 2 Inhibitor Rofecoxib in Humans: Single and Multiple Oral Drug Administration
Asokumar Buvanendran, Jeffrey S. Kroin, Kenneth J. Tuman, Timothy R. Lubenow, Dalia Elmofty, and Pauline Luk

Anesth Analg 2005 100: 1320-1324

全麻在自主压力反射指数上的浓度依赖性效应及两者的药理学增效关系

(王丽珺译 薛张纲校)

The Concentration-Dependent Effects of General Anesthesia on Spontaneous Baroreflex Indices and Their Correlations with Pharmacological Gains
Makoto Tanaka and Toshiaki Nishikawa

Anesth Analg 2005 100: 1325-1332

肾上腺素的应用并不提高用异氟醚或地氟醚麻醉的大鼠对音调的恐惧学习

(黄丽娜 李士通  校)

Administration of Epinephrine Does Not Increase Learning of Fear to Tone in Rats Anesthetized with Isoflurane or Desflurane

James M. Sonner, Yilei Xing, Yi Zhang, Anya Maurer, Michael S. Fanselow, Robert C. Dutton, and Edmond I. Eger, II

Anesth Analg 2005 100: 1333-1337.

老年患者髋骨骨折手术时靶控输注异丙酚,手动控制输注异丙酚和依托咪脂/地氟醚麻醉的比较

(顾漪闻 陈杰 )

A Comparison of Target- and Manually Controlled Infusion Propofol and Etomidate/Desflurane Anesthesia in Elderly Patients Undergoing Hip Fracture Surgery

Sylvie Passot, Frédérique Servin, Jean Pascal, Françoise Charret, Christian Auboyer, and Serge Molliex

Anesth Analg 2005 100: 1338-1342.

氧化亚氮对罗库溴铵剂量响应关系的影响

(孙志荣译 薛张纲校)

The Effect of Nitrous Oxide on the Dose-Response Relationship of Rocuronium

Aaron F. Kopman, Wanda A. Chin, Jimmy Moe, and Rawshan Malik

Anesth Analg 2005 100: 1343-1347.

红霉素和氟伏沙明对静脉利多卡因药代动力学的影响

(顾漪闻 陈杰 )

The Effect of Erythromycin and Fluvoxamine on the Pharmacokinetics of Intravenous Lidocaine

Klaus T. Olkkola, Mika H. Isohanni, Katri Hamunen, and Pertti J. Neuvonen

Anesth Analg 2005 100: 1352-1356

TECHNOLOGY, COMPUTING, AND SIMULATION:

异丙酚和阿芬太尼维持的麻醉中脑电图监测: 第二频谱的作用

(蔡美华译 薛张纲校)

Electroencephalogram Monitoring During Anesthesia with Propofol and Alfentanil: The Impact of Second Order Spectral Analysis

Christian Jeleazcov, Jörg Fechner, and Helmut Schwilden

Anesth Analg 2005 100: 1365-1369.

笑气和七氟醚麻醉下的病人进行腹内冲洗时双频指数的改变

(张曦 李士通 校)

Changes in the Bispectral Index During Intraabdominal Irrigation in Patients Anesthetized with Nitrous Oxide and Sevoflurane

Yasuhiro Morimoto, Akiko Matsumoto, Yumika Koizumi, Toru Gohara, Takefumi Sakabe, and Satoshi Hagihira

Anesth Analg 2005 100: 1370-1374.

一项评估模拟团队训练在改善交流技能效果的方法

(朱辉 陈杰 )

A Method for Measuring the Effectiveness of Simulation-Based Team Training for Improving Communication Skills
Richard H. Blum, Daniel B. Raemer, John S. Carroll, Ronald L. Dufresne, and Jeffrey B. Cooper

Anesth Analg 2005 100: 1375-1380

PAIN MEDICINE:

胸段硬膜外麻醉及镇痛联合切皮前美沙芬的应用对肠切除术后疼痛及肠功能恢复的改善作用#Preincisional_Dextromethorphan_Combined

(许文妍 薛张纲 校)

Preincisional Dextromethorphan Combined with Thoracic Epidural Anesthesia and Analgesia Improves Postoperative Pain and Bowel Function in Patients Undergoing Colonic Surgery

Chun-Chang Yeh, Shu-Wen Jao, Billy K. Huh, Chih-Shung Wong, Chih-Ping Yang, William D. White, and Ching-Tang Wu

Anesth Analg 2005 100: 1384-1389.

术前抑制脊髓环氧化酶-1可减轻术后疼痛

(张莹 李士通 校)

Preoperative Inhibition of Cyclooxygenase-1 in the Spinal Cord Reduces Postoperative Pain

Xiaoying Zhu, Dawn R. Conklin, and James C. Eisenach

Anesth Analg 2005 100: 1390-1393.

术前加巴喷丁减少焦虑和提高膝手术后的早期功能恢复

(朱辉 陈杰 )

Preoperative Gabapentin Decreases Anxiety and Improves Early Functional Recovery from Knee Surgery

Christophe Ménigaux, Frédéric Adam, Bruno Guignard, Daniel I. Sessler, and Marcel Chauvin

Anesth Analg 2005 100: 1394-1399.

曲马多及其代谢产物对蟾蜍属卵母细胞氨基乙酸γ-氨基丁酸N-甲基天冬氨酸受体表达的作用

(沈洪 薛张刚 校)

The Effects of Tramadol and Its Metabolite on Glycine, {gamma}-Aminobutyric AcidA, and N-Methyl-d-Aspartate Receptors Expressed in Xenopus Oocytes
Koji Hara, Kouichiro Minami, and Takeyoshi Sata

Anesth Analg 2005 100: 1400-1405.

在神经性痛的大鼠模型中,鞘内注射的5-羟色胺去甲肾上腺素再摄取抑制剂米那普伦由单胺介导的Antiallodynic作用

(陈玮 李士通 校)

The Monoamine-Mediated Antiallodynic Effects of Intrathecally Administered Milnacipran, a Serotonin Noradrenaline Reuptake Inhibitor, in a Rat Model of Neuropathic Pain

Hideaki Obata, Shigeru Saito, Shiro Koizuka, Koichi Nishikawa, and Fumio Goto

Anesth Analg 2005 100: 1406-1410.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

成人采用吸入还是静脉诱导?术前病人选择调查

(潘志英 陈杰 )

Intravenous or Inhaled Induction of Anesthesia in Adults? An Audit of Preoperative Patient Preferences

Anton A. van den Berg, Dudley A. Chitty, Ramoun D. Jones, Mir S. Sohel, and Ali Shahen

Anesth Analg 2005 100: 1422-1424.

在不确定未来工作量的情况下使用一定财政支出进行选择性手术室资源扩张的策略

(金琳 译, 薛张纲校)

Tactical Decision Making for Selective Expansion of Operating Room Resources Incorporating Financial Criteria and Uncertainty in Subspecialties' Future Workloads

Franklin Dexter, Johannes Ledolter, and Ruth E. Wachtel

Anesth Analg 2005 100: 1425-1432

CRITICAL CARE AND TRAUMA:

一项评估长期保存红细胞的临床效能的试点试验

(黄施伟 李士通 校)

A Pilot Trial Evaluating the Clinical Effects of Prolonged Storage of Red Cells

Paul C. Hébert, Ian Chin-Yee, Dean Fergusson, Morris Blajchman, Raymond Martineau, Jennifer Clinch, Bernhard Olberg, and the Canadian Critical Care Trials Group

Anesth Analg 2005 100: 1433-1458.

无法插管-无法正常通气(CICV)病人和困难插管策略:加拿大全国性调查

(潘志英 陈杰 )

Cannot Intubate–Cannot Ventilate and Difficult Intubation Strategies: Results of a Canadian National Survey

David T. Wong, Kevin Lai, Frances F. Chung, and Ranee Y. Ho

Anesth Analg 2005 100: 1439-1446

危重病人五肽胃泌素刺激胃腔酸性产物试验(Gastrotest)与肠内营养相关胃肠并发症之间的关系

(孙敏莉译,薛张纲校)

The Relationship Between a Pentagastrin-Stimulated Gastric Luminal Acid Production Test (Gastrotest) and Enteral Feeding-Related Gastrointestinal Complications in Critically Ill Patients

Mark A. Hamilton, Miriam V. Chapman, Maj Mutch, Elliott Bennett-Guerrero, and Monty G. Mythen

Anesth Analg 2005 100: 1447-1452.

N-乙酰半胱氨酸减弱人全血内毒素诱发的粘附分子的表达

(张莹 李士通 校)

N-Acetyl-Cysteine Attenuates Endotoxin-Induced Adhesion Molecule Expression in Human Whole Blood

Koichiroh Nandate, Masanori Ogata, Hitomi Tamura, Takashi Kawasaki, Takeyoshi Sata, and Akio Shigematsu

Anesth Analg 2005 100: 1453-1457.

 

NEUROSURGICAL ANESTHESIA:

 

犬选择性脑低温可抑制伤害性刺激引起的体动

(赵延华 陈杰 )

Selective Brain Hypothermia Suppresses Noxious-Evoked Movement in Canines

Ryukichi Takayama, Rumiko Uda, Naofumi Isono, Motomasa Furuse, Tomio Ohta, Toshihiko Kuroiwa, and Hidemaro Mori

Anesth Analg 2005 100: 1458-1462.

异氟烷吸入时低碳酸血症对脑血流量自身调节的影响

(孙少潇译 薛张纲校)

The Effect of Hypocapnia on the Autoregulation of Cerebral Blood Flow During Administration of Isoflurane

Timothy J. McCulloch, Tillman W. Boesel, and Arthur M. Lam

Anesth Analg 2005 100: 1463-1467.

OBSTETRIC ANESTHESIA:

鞘内注射吗啡后口唇单纯疱疹复发:一项对产科病人的前瞻性随机试验

(邱郁薇 李士通 校)

Oral Herpes Simplex Reactivation After Intrathecal Morphine: A Prospective Randomized Trial in an Obstetric Population

Paul W. Davies, Manuel C. Vallejo, Kelly T. Shannon, Antonio J. Amortegui, and Sivam Ramanathan

Anesth Analg 2005 100: 1472-1476.

腰麻下行剖腹产时经皮电刺激是否可代替外科刺激?

(赵延华 陈杰 校)

Is Transcutaneous Electrical Stimulation a Realistic Surrogate for Genuine Surgical Stimulation During Spinal Anesthesia for Cesarean Delivery?

Asif S. H. Zaidi and Ian F. Russell

Anesth Analg 2005 100: 1477-1481

REGIONAL ANESTHESIA:

美国局部麻醉协会最新指南中关于对预先低分子量肝素化行较大型矫形手术的病人进行脊神经麻醉的建议

(孙少潇译 薛张纲校)

Neuraxial Anesthesia and Low-Molecular-Weight Heparin Prophylaxis in Major Orthopedic Surgery in the Wake of the Latest American Society of Regional Anesthesia Guidelines (Medical Intelligence)

John C. Rowlingson and Peter B. Hanson

Anesth Analg 2005 100: 1482-1488.

/上臂手术行斜角肌肌间沟臂丛神经阻滞后的神经后遗症:患者因素、麻醉因素和手术因素与发病率和临床病程之间的关系

(周雅春 李士通 校)

Neurologic Sequelae After Interscalene Brachial Plexus Block for Shoulder/Upper Arm Surgery: The Association of Patient, Anesthetic, and Surgical Factors to the Incidence and Clinical Course (Medical Intelligence)

Kenneth D. Candido, Radha Sukhani, Robert Doty, Jr, Antoun Nader, Mark C. Kendall, Edward Yaghmour, Tripti C. Kataria, and Robert McCarthy

Anesth Analg 2005 100: 1489-1495.

肩部手术后行病人自控斜角肌内镇痛:后路留置导管

(周晓敏 薛张纲 校)

Patient-Controlled Interscalene Analgesia After Shoulder Surgery: Catheter Insertion by the Posterior Approach (Medical Intelligence)

Ignace Sandefo, J.-M. Bernard, Van Elstraete, T. Lebrun, B. Polin, F. Alla, C. Poey, and L. Savorit

Anesth Analg 2005 100: 1496-1498.

单次鞘内注射高比重布比卡因的半数有效剂量高于腰硬联合方法的半数有效剂量

(赵雪莲 李士通 校)

The Median Effective Dose of Intrathecal Hyperbaric Bupivacaine Is Larger in the Single-Shot Spinal as Compared with the Combined Spinal-Epidural Technique (Medical Intelligence)

Raymond Wee-Lip Goy, Yoong Chee-Seng, Alex Tiong-Heng Sia, Koay Choo-Kok, and Shen Liang

Anesth Analg 2005 100: 1499-1502.

用具有刺激功能的股神经导管置管可改善导管放置的位置吗?一项随机对照单盲试验

(忻纪华 译 陈杰 校)

Does Femoral Nerve Catheter Placement with Stimulating Catheters Improve Effective Placement? A Randomized, Controlled, and Observer-Blinded Trial (Medical Intelligence)

Astrid M. Morin, Leopold H. J. Eberhart, Hagen K. E. Behnke, Stefanie Wagner, Tilo Koch, Udo Wolf, Walter Nau, Clemens Kill, Götz Geldner, and Hinnerk Wulf

Anesth Analg 2005 100: 1503-1510.

在膝以下部位手术中坐骨神经阻滞是否能耐受大腿部止血带反应?

(费敏译 薛张纲校)

Does the Sciatic Nerve Approach Influence Thigh Tourniquet Tolerance During Below-Knee Surgery? (Medical Intelligence)

Régis Fuzier, Pierre Hoffreumont, Sophie Bringuier-Branchereau, Xavier Capdevila, and François Singelyn

Anesth Analg 2005 100: 1511-1514

GENERAL ARTICLES:

肾移植术中给以乳酸林格氏液或0.9% NaCl的随机双盲比较

(周志坚 李士通 )

A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation

Catherine M. N. O’Malley, Robert J. Frumento, Mark A. Hardy, Alan I. Benvenisty, Tricia E. Brentjens, John S. Mercer, and Elliott Bennett-Guerrero

Anesth Analg 2005 100: 1518-1524

术前焦虑评分是否有助于预测术后恶心和呕吐的发生?

(忻纪华 译 陈杰 校)

Does Measurement of Preoperative Anxiety Have Added Value for Predicting Postoperative Nausea and Vomiting?

Jolanda E. Van den Bosch, Karel G. Moons, Gouke J. Bonsel, and Cor J. Kalkman

Anesth Analg 2005 100: 1525-1532.

-声带长度的评估

(吴德华译 薛张纲校)

Estimation of the Length of the Nares-Vocal Cord

Dong Woo Han, Yon Hee Shim, Cheung Soo Shin, Youn-Woo Lee, Jong Seok Lee, and So Woon Ahn

Anesth Analg 2005 100: 1533-1535.

COCHRANE CORNER:

腹腔手术后病人自控静脉阿片类镇痛与持续硬膜外镇痛的效果比较

(朱慧 李士通 校)

Patient Controlled Intravenous Opioid Analgesia Versus Continuous Epidural Analgesia for Pain After Intra-Abdominal Surgery

T. Werawatganon and S. Charuluxananan

Anesth Analg 2005 100: 1536.

 

膝上和膝下截肢术对糖尿病和非糖尿病患者围术期和长期致病率、致死率的研究

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics.

Subramaniam B, Pomposelli F, Talmor D, Park KW

Department of Anesthesiology and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.

Anesth Analg. 2005;100(5):1241-7

 

我们通过回顾性研究了血管外科质量保障病史来评估膝上(AKAn=234)和膝下截肢术(BKA,n=720)在围术期和长期的致病率和致死率,并研究了糖尿病(DM)在其中的影响(AKA 181BKA 606 )。本文研究了1990-2001年所有AKABKA患者,评估AKABKA围术期30天内心脏病发生率和致死率,及术后3年和10年病死率。通过多元回归分析围术期30天内DM对心输出量的影响,通过Cox 回归分析评估DM对其术后长期生存的影响。AKA围术期心脏事件(心脏猝死或非致命性心梗)发生率≥6.8%,而BKA为≥3.6%。中期生存率AKA20月)明显低于BKA52月)(P < 0.001)。DM不是围术期30天致死率或术后3年生存率的显著预测因素(分别odds ratio, 0.76 [0.39-1.49]; P = 0.43Hazard ratio, 1.03 [0.86-1.24]; P = 0.72),但可预测术后10年生存率(Hazard ratio, 1.34 [1.04-1.73]; P = 0.026)。截肢术的部位和肾功能不全史是围术期30天死亡率的显著预测因素(分别odds ratio, 4.35 [2.56-7.14]; P < 0.001odds ratio, 2.15 [1.13-4.08]; P = 0.019)。因此,AKA被认为是高风险手术,BKA是中风险手术。无论是否有糖尿病,AKABKA长期生存率都是低的。

(吴德华译 薛张纲校)

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.

 

评估新生儿体外循环中标准肝素的剂量对凝血酶作用的影响

An evaluation of the effects of a standard heparin dose on thrombin inhibition during cardiopulmonary bypass in neonates.
Guzzetta NA, Miller BE, Todd K, Szlam F, Moore RH, Tosone SR.

Department of Anesthesiology, Children's Healthcare of Atlanta at Egleston, 1405 Clifton Road NE, Atlanta, GA 30322, USA.

Anesth Analg. 2005 ;100(5):1276-82

 

作者通过测量肝素的活性,凝血酶形成和凝血酶活性来对比新生儿和儿童CPB时肝素化的充分程度。选择需行CPB10个新生儿和10个儿童,CPB前给予400U/kg肝素。测量基点, CPB开始后30minCPB停止后即刻,CPB停止后3h24h肝素抗-Xa活性,凝血酶原片段1.2F1.2),血小板因子AFPA)。新生儿组中,CPB期间和CPB后即刻肝素抗-Xa活性明显下降;F1.2 FPA水平在基点时较高,CPB开始后降低,并且增加到大于儿童CPB后水平。数据表明,用标准肝素剂量,新生儿显示CPB期间更低的肝素抗-Ka 活性,而其高的F1.2FPA基点水平表明术前他们具有比儿童更高的凝血活性。新生儿CPB开始后起初F1.2FPA有降低,可能是血液稀释作用,但随后增加则表明CPB期间和CPB后显著更高的凝血酶形成和凝血酶活性。结果揭示了新生儿400U/kg肝素可能在CPB期间抑制凝血酶形成和活性是不充分的。

(吴德华译 薛张纲校)

We compared the adequacy of heparinization in neonates and older children undergoing cardiopulmonary bypass (CPB) by measuring heparin activity, thrombin formation, and thrombin activity. Ten neonates and 10 older children were administered 400 U/kg of heparin before CPB. Heparin anti-Xa activity, prothrombin fragment 1.2 (F1.2), and fibrinopeptide A (FPA) were measured at baseline, after 30 min on CPB, immediately post-CPB, and 3 and 24 h post-CPB. Heparin anti-Xa activity was significantly decreased during and immediately post-CPB in the neonatal group. F1.2 and FPA levels in neonates were significantly higher at baseline, decreased with the commencement of CPB, and increased to levels higher than those in older children after CPB. Our data show that with standard heparin doses, neonates exhibit less heparin anti-Xa activity during CPB. Higher baseline levels of F1.2 and FPA present in neonates indicate preoperative activation of their coagulation systems as compared with older children. Although F1.2 and FPA levels initially decrease with the commencement of CPB, probably representing hemodilution, the subsequent increase in these markers indicates significantly more thrombin formation and activity during and after CPB. These results raise the concern that 400 U/kg of heparin may not adequately suppress thrombin formation and activity in neonates undergoing CPB.

 

右旋美托咪啶在大鼠中发挥剂量依赖而非年龄依赖的抗伤害性疼痛作用及年龄依赖性催眠作用

Dexmedetomidine Exerts Dose-Dependent Age-Independent Antinociception but Age-Dependent Hypnosis in Fischer Rats

Robert D. Sanders, MBBS, Mariangella Giombini, MD, Daqing Ma, MD, PhD, Yoko Ohashi, MD, Mahmuda Hossain, PhD, Masahiko Fujinaga, MD, PhD, and Mervyn Maze, FRCP, FRCA, FMedSci

Departments of Anaesthetics and Intensive Care and Biological Sciences, Imperial College London

Address correspondence and reprint requests to Mervyn Maze, MB, ChB, FRCP, FRC, Sir Ivan Magill Professor of Anesthetics, Imperial College, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH.

Anesth Analg 2005;100:1295-1302

右旋美托咪啶,一种{alpha}2肾上腺素能受体激动剂,是成人有效的镇痛和镇静剂,但它对儿童是否有效却鲜有报道。有些麻醉剂具有年龄依赖性的镇痛作用,例如,笑气对于新生仔鼠是相对无效的。我们研究了右旋美托咪啶的镇痛和催眠作用,选择年龄分别为7天、15天、19天、23天和29天的幼鼠及成年大鼠共6组,使其暴露于右旋美托咪啶(1050µg/kg)或生理盐水。用福尔马林跖肌试验模拟炎性疼痛,用免疫组化和行为方法来评价效果。右旋美托咪啶的催眠作用以正向反射丧失来评价。福尔马林给药途径在每一年龄组均引起典型的伤害性疼痛反应;这种伤害性疼痛反应在所有应用右旋美托咪啶50µg/kg的年龄组有显著减弱(P < 0.05),而应用右旋美托咪啶10µg/kg效果甚微。新生仔鼠显示了对右旋美托咪啶最好的催眠敏感性(P < 0.05)

(王丽珺译 薛张纲校)

Dexmedetomidine (Dex), an {alpha}2-adrenoceptor agonist, is an effective analgesic and sedative drug in adults; however, little information is available about its efficacy in pediatric populations. Some anesthetics exhibit an age-dependent analgesic effect, e.g., nitrous oxide, being relatively ineffective in newborn rats. We investigated the analgesic and hypnotic efficacy of Dex using 6 cohorts of Fischer rats aged 7, 15, 19, 23, and 29 days and adults exposed to either Dex (10 or 50 µg/kg) or saline subcutaneously. Formalin plantar testing was used to mimic inflammatory pain, and its effect was assessed using immunohistochemical (c-Fos staining) and behavioral methods. The hypnotic action of Dex was assessed by loss of righting reflex. Formalin administration produced a typical nociceptive response in each age group; these nociceptive responses were significantly attenuated by Dex 50 µg/kg at all ages (P < 0.05), whereas Dex 10 µg/kg had little effect. Neonatal rats showed the greatest hypnotic sensitivity to Dex (P < 0.05).

 

全麻在自主压力反射指数上的浓度依赖性效应及两者的药理学增效关系

The concentration-dependent effects of general anesthesia on spontaneous baroreflex indices and their correlations with pharmacological gains.

Tanaka M, Nishikawa T.
Department of Anesthesia, Akita University School of Medicine, Hondo 1-1-1, Akita-city 010-8543, Japan.
Anesth Analg. 2005 ;100(5):1325-32.

 

心率和动脉血压自发产生的波动提供了对心脏迷走神经功能的无创判定。但关于全麻对自主压力反射(SBR)指数的影想所知甚少。我们研究了(a)七氟醚在SBR指数、心率变异性(HRV)、血压变异性(b)方面的浓度依赖性效能以及在七氟醚麻醉过程中,药理学压力反射增效和SBR指数之间的一致性和相互关系。我们对9名健康志愿者用七氟醚实施麻醉,在麻醉前、麻醉中及麻醉后3小时持续进行心电图和有创动脉血压监测,七氟醚的潮气末浓度按随机序列维持在0.7%1.4%2.0%。我们计算了三项SBR指数(顺序方法、α-指数及低频传递函数)并通过药理学方法把它们与加压及降压试验的增效相比较,心率变异性(HRV)和血压变异性用清醒和麻醉条件下的固定呼吸频率(12/分)分析。除了低频传递函数,与清醒时的基线值相比,应用七氟醚不仅使SBR指数在麻醉过程中有所降低,在苏醒后的30分钟内也仍然降低。心率变异的自主顺序指数和高频、低频效能显示了浓度-依赖性的衰减。药理学增效和SBR指数在麻醉期间总体来说具有很好的相关性,但是Bland-Altman分析揭示了SBR指数和压力反射增效本身一样具有一致性方面的限制。这些数据表明在七氟醚麻醉中,自发的指数是对药理学压力反射增效不恰当的评价,两者之间存在矛盾。

(王丽珺译 薛张纲校)

Beat-to-beat assessment of spontaneously occurring fluctuations in heart rate and arterial blood pressure allows noninvasive determination of cardiovagal function, but little is known regarding the effects of general anesthesia on spontaneous baroreflex (SBR) indices. We examined (a) concentration-dependent effects of sevoflurane on SBR indices, heart rate variability (HRV), and blood pressure variability and (b) correlation and agreement between pharmacological baroreflex gains and SBR indices during sevoflurane anesthesia. Continuous electrocardiogram and invasive arterial blood pressure were monitored in nine healthy volunteers before, during, and for 3 h after sevoflurane anesthesia, during which end-tidal sevoflurane was maintained at 0.7%, 1.4%, and 2.0% in random sequences. We derived three SBR indices (sequence method, alpha-index, and low-frequency transfer function) and compared them with pressor and depressor test gains by the pharmacological method. HRV and blood pressure variability were analyzed at a fixed respiratory rate (12 breaths/min) in awake and anesthetized conditions. Except for low-frequency transfer function, SBR indices were depressed by sevoflurane and remained depressed for 30 min after emergence from anesthesia, compared with the conscious baseline value. Spontaneous sequence indices and high- and low-frequency powers of HRV demonstrated concentration-dependent depression. Pharmacological gains and SBR indices during anesthesia generally correlated well, but Bland-Altman analysis revealed that SBR indices had limits of agreement as large as the baroreflex gain itself. These data suggest that spontaneous indices are inadequate estimates of, and are inconsistent with, the pharmacological baroreflex gain during sevoflurane anesthesia.

 

氧化亚氮对罗库溴铵剂量响应关系的影响

The effect of nitrous oxide on the dose-response relationship of rocuronium.
Kopman AF, Chin WA, Moe J, Malik R.

Department of Anesthesiology, Room N.R. 408, St. Vincent's Hospital Manhattan, 170 West 12th St., New York City, NY 10011, USA.

Anesth Analg. 2005 ;100(5) 1343-1347

 

普遍认为氧化亚氮(N2O)增强非去极化肌松药的作用极弱。最近很多证据表明N2O复合全静脉麻醉(TIVA)下药物潜能更强烈。我们对35个患者接受N2O-异丙酚-阿片类复合麻醉和接受TIVA作为对照组测量了罗库溴铵50%的有效剂量。罗库溴铵每个病人给单次剂量,每个人的药物潜能通过HILL方程计算,假定logdose/4.52个组,麻醉诱导后15分钟给肌松药。神经肌肉功能通过单次0.10Hz刺激用肌电描记法测量。我们测得50%有效剂量TIVA中为0.209+/-0.051mg/kg,在N2O麻醉中为0.166+/-0.041mg/kg,降低了20(P<0.001)。该结果的临床重要性必须适度考虑,然而, N2O麻醉中所获得的潜能的评估可能低估麻醉诱导期间药物需求。

(孙志荣译 薛张纲校)

It has been generally assumed that nitrous oxide (N(2)O) enhances the effects of nondepolarizing muscle relaxants only weakly if at all. More recent evidence suggests that drug potency may be more intense under N(2)O anesthesia compared with total IV anesthesia (TIVA). However, the magnitude of this effect has not been well defined. We measured the 50% effective dose of rocuronium in 35 patients receiving N(2)O-propofol-opioid anesthesia and a comparable group receiving TIVA. A single dose of rocuronium was given to each patient and drug potency was calculated for each individual from the Hill equation assuming a log-dose/logit slope of 4.5. In both groups, the relaxant was administered 15 min after induction of anesthesia. Neuromuscular function was measured using electromyography with single stimuli at 0.10 Hz. We measured a 50% effective dose of 0.209 +/- 0.051 mg/kg during TIVA and of 0.166 +/- 0.041 mg/kg during N(2)O anesthesia, a decrease of 20% (P < 0.001). The clinical importance of this effect must be considered modest; however, estimates of potency that are usually obtained during N(2)O anesthesia may underestimate drug requirements at the time of induction of anesthesia.

 

异丙酚和阿芬太尼维持的麻醉中脑电图监测: 第二频谱的作用

Electroencephalogram Monitoring During Anesthesia with Propofol and Alfentanil: The Impact of Second Order Spectral Analysis

Christian Jeleazcov, J&ouml;rg Fechner, and Helmut Schwilden

Department of Anesthesiology, University of Erlangen-Nuremberg, Germany

Anesth Analg 2005 100: 1365-1369.

脑电(EEG)双频谱指数已用于麻醉监测。在二 阶系数微小的情况下,也就是仅仅是独立于频 率的常数,二阶系数的估计允许我们判断是否 给定时间代表了一个线性随机过程。这个研究 中,我们调查了在异丙酚和阿芬太尼维持的外 科手术麻醉中非微小二阶系数的EEG点所占比 例来作为EEG非线性的程度。重复分析了记录 下的来自20位行Hinich操作的腹部手术患者90 小时EEG,进行了统计分析,基于如下假设: EEG是线性随机序列。在几乎90%去伪相的固 EEG点,发现二阶系数接近零或仅是常数。 在这些情况下,EEG可以认为是线性随机序列 。我们的发现提示麻醉状态下EEG监测取得的 频率域中的频谱信息已大大的包含了信号的功 率谱。这对EEG双频谱指数在麻醉监测中的作 用提出了疑问。

(蔡美华译 薛张纲校)

Bispectral analysis of the electroencephalogram (EEG) has been used for monitoring anesthesia. The estimation of bicoherence allows us to determine whether a given time series represents a linear random process in cases where the bicoherence is trivial, i.e., a mere constant independent of frequency. In this study, we investigated the proportion of EEG epochs with nontrivial bicoherence during surgical anesthesia with propofol and alfentanil as an indicator for the degree of nonlinearity in the EEG. We reanalyzed 90 h of EEG recorded from 20 patients undergoing abdominal surgery using the Hinich procedure, which provides a statistical test for the following hypothesis: the EEG is a linear random process. In approximately 90% of all artifact-free, stationary EEG epochs, the bicoherence was found to be zero or a mere constant. Under these conditions, the EEG can be considered as a linear random process. Our findings suggest that the spectral information in the frequency domain delivered by the EEG monitoring during anesthesia is largely contained in the power spectrum of the signal. This calls into question the benefit of EEG bispectral analysis for monitoring anesthesia effect.

 

胸段硬膜外麻醉及镇痛联合切皮前美沙芬的应用对肠切除术后疼痛及肠功能恢复的改善作用

Preincisional Dextromethorphan Combined with Thoracic Epidural Anesthesia and Analgesia Improves Postoperative Pain and Bowel Function in Patients Undergoing Colonic Surgery

Yeh, Chun-Chang MD *; Jao, Shu-Wen MD +; Huh, Billy K. MD, PhD ++; Wong, Chih-Shung MD, PhD *; Yang, Chih-Ping MD *; White, William D. MPH ++; Wu, Ching-Tang MD *

Departments of *Anesthesiology and +Surgery, Tri-Service General Hospital, and National Defense Medical Center, Taipei, Taiwan, Republic of China; and ++Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg. 2005;100(5). 1384-1389

 

肠切除术后的剧痛及肠梗阻延长了患者的出院时间. 在先前的研究中,我们已经证明消炎痛(IM)和美沙芬(DM)能够提供超前镇痛并改善术后疼痛. 而胸段硬膜外麻醉(PEA)及术后胸段硬膜外镇痛(PCEA)的优点已经得到广泛的证实. 故此次研究的目的是了解术中PEA PCEA 与切皮前IM DM 联合应用对肠切除术后疼痛及肠功能恢复的效果. 病人被随机分为三等组分别接受: 1)扑尔敏(CPM)20mg 及全身麻醉(GA)(CPM-GA ); 2)CPM 20mgTEA(CPM-TEA); 3)DM 40mg(CPM 20mg) GA并联合TEA(DM-TEA). 在切皮前30 分钟行全麻诱导,后给予CPM, DM(肌注), 及用利多卡因的TEA,并且所有的患者术后都接受PCEA镇痛. 我们使用直观类比标度对连续72 小时术后休息或是活动的效果进行评估,这些指标是: 第一次使用PCEA的时间; PCEA的总消耗量; 及第一次排气的时间. 术后疼痛及肠啊功能的改善以如下顺序排列,并且这种改善在统计学上有者明显的意义: DM-TEA > CPM-TEA > CPM-GA . CPM-TEA相比DM-TEA 在疼痛评估上平均少了1.6个百分点; 在第一次使用PCEA时间上长了40分钟; 72小时总量消耗少了15.8ml; 并且排气时间提前了14.7小时(所有的P 值都小于0.01). 我们于是得出了切皮前DM(40 mg 肌注),术中TEA及术后PCEA可以加强镇痛,并能促进肠功能的恢复. 提出可能存在的协同作用能减少利多卡因及阿片类药物的用量.

(许文妍 薛张纲 校)

Colonic surgery is associated with severe postoperative pain and postoperative ileus, which contribute to delayed hospital discharge. In previous studies, we demonstrated that IM dextromethorphan (DM) provided preemptive analgesia and improved postoperative pain. The benefit of thoracic epidural anesthesia (TEA) and postoperative epidural analgesia on postoperative pain was well demonstrated. The goal of this study was to investigate the effect of preincisional IM DM combined with intraoperative TEA and postoperative patient-controlled epidural analgesia (PCEA) on pain and bowel function after colonic surgery. Patients were randomized into 3 equal groups to receive: 1) chlorpheniramine maleate (CPM) 20 mg and general anesthesia (CPM-GA); 2) CPM 20 mg and GA combined with TEA (CPM-TEA); or 3) DM 40 mg (containing 20 mg of CPM) and GA combined with TEA (DM-TEA). The CPM, DM, and TEA with lidocaine were administered after GA induction via an IM injection and 30 min before the skin incision. All patients received postoperative PCEA for pain control. Analgesic effects were evaluated for 72 h after surgery using visual analog scale pain scores at rest and moving, time to first PCEA request for pain relief, total PCEA consumption, and the time to first passage of flatus. Statistically significant improvement of postoperative pain and bowel function was observed in the following order: DM-TEA > CPM-TEA > CPM-GA. Compared with the CPM-TEA group, the DM-TEA group averaged 1.6 points lower on first-hour pain scores, 40 min longer to first PCEA request, 15.8 mL less PCEA drug over 72 h, and 14.7 h earlier bowel function (all P < 0.01). We conclude that the combination of preincisional DM (40 mg IM), intraoperative TEA, and postoperative PCEA enhances analgesia and facilitates recovery of bowel function, suggesting possible synergistic interaction with local anesthetics and opioids.

 

The Effects of Tramadol and Its Metabolite on Glycine, {gamma}-Aminobutyric AcidA, and N-Methyl-d-Aspartate Receptors Expressed in Xenopus Oocytes

曲马多及其代谢产物对蟾蜍属卵母细胞氨基乙酸γ-氨基丁酸N-甲基天冬氨酸受体表达的作用

Hara K, Minami K, Sata T.

Department of Anesthesiology, University of Occupational and Environmental Health School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan.

Anesth Analg. 2005 May;100(5):1400-1405

 

我们评估了中枢性镇痛药曲马多及其代谢产物对神经递质门控离子通道的作用。 曲马多抑制μ受体,但是亲和力弱,能阻止中枢神经系统单胺的再摄取.这些作用使其具有抗疼痛作用。然而对于曲马多其它作用却知之甚少。我们检测了曲马多及其代谢产物(0.1-100 muM)对人重组神经递质门控离子通道包括氨基乙酸、γ-氨基丁酸(GABA(A))N-甲基天冬氨酸(NMDA)受体在蟾蜍属卵母细胞表达的作用。曲马多及其代谢产物对氨基乙酸受体无任何作用,γ-氨基丁酸(GABA(A))受体只有高浓度(100 muM)时才显著抑制,N-甲基天冬氨酸受体抑制则呈浓度依赖性。曲马多及其代谢产物能够有效抑制谷氨酸盐-浓度反应曲线而不改变其最大半数有效浓度和Hill系数,这表明是非竞争性抑制。这项研究表明氨基乙酸受体不参与曲马多的镇痛效应而高浓度抑制γ-氨基丁酸受体可能与惊厥相关。抑制N-甲基天冬氨酸受体可能与相对高浓度的曲马多镇痛效应有关。

(沈洪 薛张刚 校)

We assessed the effects of tramadol, a centrally acting analgesic, and its major metabolite, on neurotransmitter-gated ion channels. Tramadol binds to mu-opioid receptors with low affinity and inhibits reuptake of monoamines in the central nervous system. These actions are believed to primarily contribute to its antinociceptive effects. However, little is known about other sites of tramadol's action. We tested the effects of tramadol and its M1 metabolite (0.1-100 muM) on human recombinant neurotransmitter-gated ion channels, including glycine, gamma-aminobutyric acid(A) (GABA(A)), and N-methyl-d-aspartate (NMDA) receptors, expressed in Xenopus oocytes. Tramadol and M1 metabolite did not have any effects on glycine receptors. GABA(A) receptors were significantly inhibited only at large concentrations (100 muM). NMDA receptors were inhibited in a concentration-dependent manner. Tramadol and M1 metabolite inhibited the glutamate-concentration response curve without changing the half-maximal effective concentration or the Hill coefficient, indicating a noncompetitive inhibition. This study suggests that glycine receptors do not provide the antinociceptive effect of tramadol and that the inhibition of GABA(A) receptors at large concentration might correlate with convulsions. The inhibitory effect on NMDA receptors may contribute to the antinociceptive effect of tramadol at relatively large concentrations.

 

在不确定未来工作量的情况下使用一定财政支出进行选择性手术室资源扩张的策略

Tactical Decision Making for Selective Expansion of Operating Room Resources Incorporating Financial Criteria and Uncertainty in Subspecialties' Future Workloads

Franklin Dexter, Johannes Ledolter, Ruth E. Wachtel

Division of Management Consulting, Departments of Anesthesia and Health Management & Policy, Department of Management Sciences, College of Business, and Department of Anesthesia, University of Iowa

Anesth Analg 2005; 100(5): 1425-1432.

 

若决定增加手术室的数目,各个手术室的时间分配是很容易的。手术室的时间分配要分两步走:第一步是长期的统筹安排,第二步是短期的手术安排。统筹安排要考虑到最近一年的发展情况,还需要哪些特殊的仪器和专家。这些考虑都是基于对未来一年各专科和外科医生的手术量的估计得出的。有一些外科医生可以排出在外,比如那些需要ICU床位的医生和同样使用手术室一小时,创造的利润最低的医生。根据余下外科医生实际情况,估计未来手术室使用时间的上限和下限。因此,在只了解部分未来手术量信息的情况下,就可以完成最初的手术室分配。当新手术室启用后,根据实际情况调整手术室使用时间和人员分配,原则是使手术室利用率更高。对于那些在第一阶段安排中没有得到额外时间的外科医生来说,根据他们实际工作量情况进行调整,适当增加手术室使用时间。一个三级医院的病例报道指出,今后手术医生需要量估计只有目前的15%,因此这一种手术室分配决策是有可行性的。

(金琳 译, 薛张纲校)

We considered the allocation of operating room (OR) time at facilities where the strategic decision had been made to increase the number of ORs. Allocation occurs in two stages: a long-term tactical stage followed by short-term operational stage. Tactical decisions, approximately 1 yr in advance, determine what specialized equipment and expertise will be needed. Tactical decisions are based on estimates of future OR workload for each subspecialty or surgeon. We show that groups of surgeons can be excluded from consideration at this tactical stage (e.g., surgeons who need intensive care beds or those with below average contribution margins per OR hour). Lower and upper limits are estimated for the future demand of OR time by the remaining surgeons. Thus, initial OR allocations can be accomplished with only partial information on future OR workload. Once the new ORs open, operational decision-making based on OR efficiency is used to fill the OR time and adjust staffing. Surgeons who were not allocated additional time at the tactical stage are provided increased OR time through operational adjustments based on their actual workload. In a case study from a tertiary hospital, future demand estimates were needed for only 15% of surgeons, illustrating the practicality of these methods for use in tactical OR allocation decisions.

 

危重病人五肽胃泌素刺激胃腔酸性产物试验(Gastrotest)与肠内营养相关胃肠并发症之间的关系

The relationship between a pentagastrin-stimulated gastric luminal acid production test (Gastrotest) and enteral feeding-related gastrointestinal complications in critically ill patients

Hamilton MA, Chapman MV, Mutch M, Bennett-Guerrero E, Mythen MG.
Duke Clinical Research Institute, Duke University (Anesthesiology-Box 3094), Durham, NC 27710, USA.
Anesth Analg. 2005 May;100(5):1447-52

 

胃肠营养相关并发症(GICs)在危重病人中多见。不幸的是病人存在GICs危险因素是不容易被明确的。因此,我们对20个病人进行了一项明确五肽胃泌素刺激胃腔酸性产物试验与GICs之间的关系的前瞻性研究。在予以胃肠营养之前,皮下注射五肽胃泌素(Gastrotest)胃液pH值的相应变化被测得。每个病人在重症监护室(ICU)治疗期间,我们记录了GICs与胃肠营养量的比值。对19个病人的数据进行分析以及9个病人(47%)有≥1 GIC,包括胃大部残留,26%;腹胀,26%;以及呕吐,21%。有GICs的病人在ICU停留较长时间(平均21.3,范围5-45相比平均10.1,范围3-32P < 0.05)。在开始肠内营养之前有Gastrotest反应的9个病人(47%)存在明显较大的容量比值(P = 0.01)和较少的GICs1 [11%]相比8 [80%]P<0.05)。腹胀仅在无Gastrotest反应的病人发生。这次试验阳性和阴性预测值对 GICs的预测能力分别80%88.9% 认为五肽胃泌素刺激胃腔酸性产物试验与较大容量肠内营养摄入相关与GICs相关联较少。

(孙敏莉译,薛张纲校)

Gastrointestinal feeding-related complications (GICs) are common in critically ill patients. Unfortunately, patients at risk for GICs cannot be easily identified. Therefore, we performed a prospective study of 20 critically ill patients to determine the association between a pentagastrin-stimulated gastric acid production test and GICs. Before feeding, the change in the pH of gastric juice was measured in response to a subcutaneous injection of pentagastrin (Gastrotest). We recorded GICs and the feeding volume ratio during each patient's intensive care unit (ICU) stay. Nineteen patients' data were analyzed and 9 patients (47%) developed > or =1 GIC, including large gastric residuals, 26%; abdominal distension, 26%; and vomiting, 21%. Patients with GICs had a longer length of ICU stay (mean 21.3, range 5-45 versus 10.1, range 3-32; P < 0.05). The 9 patients (47%) who were Gastrotest responders before starting enteral feeding exhibited a significantly larger volume ratio (P = 0.01) and fewer GICs (1 [11%] versus 8 [80%]; P < 0.05). Abdominal distension was seen in only nonresponders. The positive and negative predictive values for this test's ability to predict GICs were 80% and 88.9%, respectively. Responding to a pentagastrin-stimulated gastric luminal acid production test is associated with the administration of larger volumes of enteral feed and fewer GICs.

 

异氟烷吸入时低碳酸血症对脑血流量自身调节的影响

The effect of hypocapnia on the autoregulation of cerebral blood flow during administration of isoflurane

McCulloch TJ, Boesel TW, Lam AM.
Department of Anaesthetics, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.

Anesth Analg. 2005 May;100(5):1463-1467

 

异氟烷对脑血流量自身调节的抑制作用呈剂量依赖。过去的一些研究显示在其他条件下受抑制的自身调节可经过度通气恢复。我们假设低碳酸血症可以使受异氟烷麻醉而抑制的脑血流量自身调节恢复。我们对预先选定的年龄在21-59岁之间行非神经外科手术而无其他疾病的患者予异氟烷加纯氧吸入。根据个体情况控制呼气末异氟烷浓度,使其低于能引起短周期等电位脑电图浓度0.1% 0.2% 。这使呼气末异氟烷浓度控制在1.6% +/- 0.2% ,相当于最小肺泡麻醉浓度的1.4倍。根据需要静注瑞芬太尼使平均动脉压降至80 mm 。静注新福林使平均动脉压保持在100 mm Hg ,通过经颅多普勒超声波检查监测大脑中动脉血流速度以评价脑血流量的自身调节功能。流速的改变被用来计算自身调节指数。自身调节指数变动在01之间,且指数小于等于0.4 表示有明显的自身调节抑制。自身调节随即测试两次。分别于正常二氧化碳血(Paco238-43 mm Hg)和低碳酸血症期 (Paco227-34 mm Hg)。在正常二氧化碳血时自身调节指数的中位数为0.29 (0.23-0.64) 而低碳酸血症期为 0.77 (0.70-0.78) (P < 0.005). 在正常二氧化碳血时12 个样本中有8人的脑血流量自身调节被明显抑制,低碳酸血症期则无人被抑制 (P = 0.001)。低碳酸血症可以恢复由于异氟烷引起的脑血流量自身调节的抑制。

(孙少潇译 薛张纲校)

Isoflurane impairs autoregulation of cerebral blood flow in a dose-related manner. Previous investigations in several other conditions have demonstrated that impaired autoregulation can be restored by hyperventilation. We hypothesized that hypocapnia may restore cerebral autoregulation impaired by isoflurane anesthesia. We administered isoflurane in 100% oxygen to 12 healthy patients aged 21-59 yr scheduled for elective nonneurological surgery. Isoflurane end-tidal concentration was individualized at 0.1% to 0.2% less than that required to induce short periods of isoelectric electroencephalogram. This resulted in an end-tidal isoflurane concentration of 1.6% +/- 0.2% (mean +/- sd) corresponding to an age-adjusted minimum alveolar anesthetic concentration multiple of 1.4. Mean arterial blood pressure was reduced to <80 mm Hg, by infusion of remifentanil if required. Cerebral autoregulation was assessed by infusing phenylephrine to increase mean arterial blood pressure to 100 mm Hg while monitoring middle cerebral artery blood flow velocity with transcranial Doppler ultrasonography. The change in flow velocity was used to calculate the autoregulation index (ARI). The ARI ranges between 0 and 1 and an ARI < or =0.4 indicates significantly impaired autoregulation. Autoregulation was tested twice in randomized order: once during normocapnia (Paco(2) 38-43 mm Hg) and once during hypocapnia (Paco(2) 27-34 mm Hg). The median (interquartile range) ARI was 0.29 (0.23-0.64) during normocapnia and 0.77 (0.70-0.78) during hypocapnia (P < 0.005). Of the 12 subjects, autoregulation was significantly impaired in 8 subjects during normocapnia and none during hypocapnia (P = 0.001). Hypocapnia restored cerebral autoregulation in normal subjects during isoflurane-induced impairment of autoregulation.

 

美国局部麻醉协会最新指南中关于对预先低分子量肝素化行较大型矫形手术的病人进行脊神经麻醉的建议
Neuraxial anesthesia and low-molecular-weight heparin prophylaxis in major orthopedic surgery in the wake of the latest American Society of Regional Anesthesia guidelines Rowlingson JC, Hanson PB.
Rowlingson JC, Hanson PB.
Department of Anesthesiology, University of Virginia, UVA Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA. JCR3T@virginia.edu
Anesth Analg. 2005 May;100(5):1482-1488,

 

20035月,第二届美国局部麻醉协会协商会就局部麻醉的连续安全性问题发表了声明特别对于的有预先低分子量肝素化的病人行较大型矫形手术进行脊神经麻醉。2003年的会议报告明确表达对预先低分子量肝素化的病人进行局部麻醉可能是安全的。依靠根据局部麻醉的时间和期间的管理而对低分子量肝素化的首剂和后续剂量的给予时间和日最大剂量做出相应的调整将会使病人的安全性得到优化。因为对有预先低分子量肝素化预防血栓的病人给予局部麻醉是一次临床上的挑战,所以麻醉科医师应该尽可能保证实施手术的每一个人员对相关的最新文献和实践指南如目前美国局部麻醉协会指南有一个理解。

(孙少潇译 薛张纲校)

In May 2003, the Second American Society of Regional Anesthesia Consensus Conference statement was issued partly in response to continued safety concerns over the use of regional anesthesia--in particular, neuraxial techniques--with low-molecular-weight heparin (LMWH) prophylaxis in major orthopedic surgery. As the 2003 Consensus statement makes clear, regional anesthesia may be used safely with LMWH prophylaxis. The key to optimizing patient safety, however, depends on a careful calibration of the total daily dose and the timing of the first and subsequent doses of the LMWH drug with the timing and management of the regional anesthetic procedure. Because the challenge of successfully providing regional anesthesia in the presence of LMWH thromboprophylaxis is a clinical one, anesthesiologists should do what they can to ensure that every member of the surgical team has an understanding of current literature and practice guidelines such as those recently published by the American Society of Regional Anesthesia.

 

肩部手术后行病人自控斜角肌内镇痛:后路留置导管

Patient-controlled interscalene analgesia after shoulder surgery: catheter insertion by the posterior approach.
Sandefo I, Bernard JM, Elstraete V, Lebrun T, Polin B, Alla F, Poey C, Savorit L.
Clinique Saint Paul, 97200 Fort de France, France.

Anesth Analg. 2005 May;100(5):1496-8.

 

通过侧路或前路方法置入并维持斜角肌内导管具有技术挑战性。我们在120个行肩部手术的病人中介绍另一项技术:通过套管针技术从颈后部置管并予48小时输注0.1%罗哌卡因(5 mL初始剂量后5 mL/h,锁定间隔时间20分钟)来提供持续臂丛神经阻滞。所有导管均成功置入,无技术上的并发症(如置管失败、误入血管、硬膜外或蛛网膜下腔),无导管脱出或镇痛药液渗漏。12个病人出现声音嘶哑,4个出现霍纳氏综合症,1个出现呼吸困难。1个病人主诉有轻微的感觉异常,可自行缓解。3个病人主诉颈部疼痛。疼痛评分及罗哌卡因需要量(通过病人自控镇痛装置给予)均较低。但仍需大样本研究评估急性和非急性并发症来比较本方法和现有技术的效果及安全性。

(周晓敏 薛张纲 校)

Insertion and maintenance of an interscalene catheter is technically challenging using lateral or anterior approaches. We report a technique to provide continuous brachial plexus blockade through a 48-h infusion of ropivacaine 0.1% (5 mL/h with a 5 mL bolus dose, 20-min lockout interval) using a catheter inserted with cannula-over-needle technique on the posterior side of the neck in 120 patients undergoing shoulder surgery. All catheters were successfully placed. There were no technical complications (impossibility to thread catheter, accidental vascular, epidural or subarachnoid location), catheter dislodgment, or analgesic solution leakage. Dysphonia, Horner's syndrome, and difficulty breathing were observed in 12 patients, four patients, and one patient, respectively. One patient complained of minor paresthesia that spontaneously resolved. Three patients complained of cervical pain. Pain scores as well as ropivacaine requirement via a patient-controlled analgesia device were low. Evaluation of acute and nonacute complications in a large-size study is needed to compare efficacy and safety of this approach with existing techniques.

在膝以下部位手术中坐骨神经阻滞是否能耐受大腿部止血带反应?

Does the Sciatic Nerve Approach Influence Thigh Tourniquet Tolerance During Below-Knee Surgery?

 

Régis Fuzier, MD*, Pierre Hoffreumont, MD{dagger}, Sophie Bringuier-Branchereau, PharmD{ddagger}, Xavier Capdevila, MD, PhD{ddagger}, and François Singelyn, MD, PhD*

*Department of Anesthesiology, Université Catholique de Louvain School of Medicine, Brussels, Belgium; {dagger}Clinique Saint Pierre, Ottignies, Belgium; {ddagger}Department of Anesthesiology, Hôpital Lapeyronie, Montpellier, France

Anesth Analg 2005 100: 1511-1514.

 

在这个前瞻性、随机、盲法的研究中,我们评估Labat’s或腘窝后进路的坐骨神经阻滞在膝以下部位手术中大腿部止血带反应的耐受性。120名患者分为2组每组60人。腘窝后路(Group 1)或Labat’s(Group 2)坐骨神经阻滞用25ml1%的甲哌卡因加1:200000的肾上腺素完成。每组都达到股神经阻滞。患者在阻滞过程中的舒适度、感觉阻滞、成功率以及大腿部止血带反应的耐受性都做记录。Group 1在阻滞过程的舒适度明显优于Group 2(P < 0.01)t30 min. 时阻滞的完全性以及成功率两组相似。两组患者大腿部止血带疼痛都随时间而加剧,没有显著差异。我们认为尽管在91%的患者中股后皮神经感觉阻滞完全,但是Labat’s进路的坐骨神经阻滞较腘窝部进路不能更好地耐受大腿止血带反应。腘窝进路可以达到同样阻滞效果且患者感觉更舒适,是膝部以下手术的首选麻醉方法。

(费敏译 薛张纲校)

In this prospective, randomized, blinded study we assessed thigh tourniquet tolerance when a Labat’s or a posterior popliteal approach of the sciatic nerve was used for below-knee surgery. One-hundred-twenty patients were divided into two groups of 60. A posterior popliteal (Group 1) or a Labat’s (Group 2) sciatic nerve block was performed with 25 mL 1% mepivacaine + epinephrine 1:200,000. In both groups, a femoral nerve block was achieved. Patient comfort during block performance, sensory block, success rate, and thigh tourniquet tolerance were recorded. Performance of the block was significantly more comfortable in Group 1 than in Group 2 (P < 0.01). Completeness of the block at t30 min. and success rate were comparable in both groups. Thigh tourniquet pain increased with time in both groups. No statistically significant difference was observed between groups. We conclude that despite a complete sensory blockade of the posterior femoral cutaneous nerve in 91% of the patients, Labat’s approach of the sciatic nerve provides no better thigh tourniquet tolerance than the popliteal approach. The popliteal approach is as efficient but more comfortable for the patient and is the preferred technique for below-knee surgery.

 

-声带长度的评估

Estimation of the length of the nares-vocal cord.

Han DW, Shim YH, Shin CS, Lee YW, Lee JS, Ahn SW.
Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, CPO Box 8044, Seoul 120-752, Korea.

Anesth Analg. 2005;100(5):1533-5

 

经鼻插管常是纤支镜插管的首选。经鼻放置一根涂有润滑油的气管导管能引导纤支镜到达喉部,如果能预测鼻-声带的长度(NV长度),并放置气管导管使其顶端能接近声带,有利于纤支镜经过气管导管最清晰地显示声带。本研究我们测量了鼻-声带的长度,及其与体表标志的关系。选择50例男,45例女病人,在全麻下行选择性外科手术,用纤支镜测量他们鼻-声带长度。同时测量患者两边鼻两侧到耳屏的距离(NE 距离)和鼻到下颌角的距离(NM距离),并记录患者的年龄、身高和体重。测量结果是NV长度男性为18.3 +/- 0.8 cm,女性为16.3 +/- 0.7 cmNV长度与身高和NE距离具有显著相关性,而与NM距离没有显示相关性。因此,NV长度能通过身高或NE距离来预测。

(吴德华译 薛张纲校)

The nasal route is preferred for fiberoptic intubation. Placing a lubricated endotracheal tube through the nostril can guide the fiberoptic scope towards the larynx. It would be helpful for optimal visualization of the vocal cord when the scope is passed through the endotracheal tube if the length of nares-vocal cord (NV length) could be predicted and the tip of the endotracheal tube could be placed close to the vocal cord. In this study we measured the NV length and examined the relationship between the NV length and various external measurements. Using a fiberoptic scope, the NV lengths were measured in 50 male and 45 female patients scheduled to undergo elective surgery under general anesthesia. In addition, the distances from the lateral border of the nares to tragus of the ear (NE distance) and to the angle of the mandible (NM distance) were measured. The age, height, and weight of all the patients were recorded. The NV length of the males was 18.3 +/- 0.8 cm, and that of the females was 16.3 +/- 0.7 cm. The relationship between the NV length and body height (P < 0.001, r = 0.755) and the NE distance (P < 0.001, r = 0.636) showed a significant correlation but NM distance did not (P = 0.075). The length of the NV cord can be predicted using the body height or the NE distance.

 

在日本非心脏手术期间心血管事件的发生率和美国及欧洲相同吗?

Are the Incidences of Cardiac Events During Noncardiac Surgery in Japan the Same as in the United States and Europe?

Makoto Seki, MD, Satoshi Kashimoto, MD, Osamu Nagata, MD, Hitoshi Yoshioka, MD, Toshihiko Ishiguro, MD, Kinya Nishimura, MD, Osamu Honda, MD, Atsuhiro Sakamoto, MD, Akibumi Omi, MD, Yukihiko Ogihara, MD, Keiko Fujimoto, MD, Motoyo Iwade, MD, Tatsuya Yamada, MD, Minoru Nomura, MD, and Junzo Takeda, MD Department of Anesthesiology, Cancer Institute Hospital; Department of Anesthesiology, Faculty of Medicine, University of Yamanashi; Department of Anesthesiology, Tokyo Women’s Medical University; Department of Anesthesiology, Tokyo Metropolitan Toshima Hospital; Department of Anesthesiology, Juntendo University School of Medicine; Department of Anesthesiology, Division of Critical Care, National Cancer Center Hospital; Department of Anesthesiology, Nippon Medical School; Department of Anesthesiology, Tokyo Medical University, Hachioji Medical Center; Department of Anesthesiology, Yokohama City University School of Medicine; Department of Anesthesiology, School of Medicine, Keio University, Tokyo, Japan

Anesth Analg 2005 100: 1236-1240.

 

在日本,术前评估伴有缺血性心脏疾病病人中一直存在的一个问题是:这样的评估是建立在西方的数据上的,却被作为判断日本病人术中风险的根据。为了解决这个问题,1997年建立了心脏缺血和麻醉研究委员会,来指导日本非心脏手术中并发症的研究。在1997年的两个回顾性研究中,伴有缺血性心脏疾病的病人比率为3.9%3.1%,约为美国和欧洲报道的十分之一。伴有缺血性心脏疾病的病人术中心血管并发症的发生率为16.4%13.2%,与美国和欧洲报道的发生率没有很大差异。为了研究术中并发症的基本特征,作者设计了一个前瞻性研究,对象是237名根据美国心脏学院/美国心脏协会指南中的非心脏手术的术中心血管评估表评定为中度术中心脏并发症风险的病人。作者发现术中心脏并发症的首要因素是高血压(优势比= 2.911)。术后心脏并发症的因素为反射性冠脉病变的严重程度和心功能不全 (心衰史, 优势比= 6.884 冠心病危险指数分级,优势比= 2.884;治疗史; 优势比= 4.774).(殷文渊 陈杰 校)

In Japan, an ever-present problem in the preoperative evaluation of patients with ischemic heart disease is that although such evaluations are based on Western data, these data serve as the basis for determining perioperative risk in Japanese patients. To remedy this problem, the Cardiac Ischemia and Anesthesia Research Committee was formed in 1997 and has conducted studies of perioperative complications in noncardiac surgery in Japan. In two retrospective studies in 1997, the proportions of patients with ischemic heart disease were 3.9% and 3.1%, approximately one tenth the rates reported in Europe and the United States. The incidences of perioperative cardiac complications in patients with ischemic heart disease were 16.4% and 13.2%, not widely divergent from rates reported in Europe and the United States. To investigate the baseline characteristics involved in perioperative complications, we conducted a prospective study of 237 patients classified as having intermediate risk for perioperative cardiac complications according to the American College of Cardiology/American Heart Association Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. We found that the prominent factor in intraoperative cardiac complications was the presence of hypertension (odds ratio = 2.911). Factors contributing to postoperative cardiac complications included those reflecting coronary lesion severity and cardiac dysfunction (history of heart failure; odds ratio = 6.884, coronary risk index grade; odds ratio = 2.884, and a history of intervention; odds ratio = 4.774).

 

在小儿心脏手术中常规使用经食道超声心动图的费用-效益比:10年经验

Cost-Effectiveness of Routine Intraoperative Transesophageal Echocardiography in Pediatric Cardiac Surgery: A 10-Year Experience

Dominique A. Bettex, MD, René Prêtre, MD, Rolf Jenni, MD, MSEE, and Edith R. Schmid, MD

Division of Cardiovascular Anesthesia, Clinic of Cardiovascular Surgery, and Division of Cardiology, University Hospital of Zurich, Zurich, Switzerland

Anesth Analg 2005 100: 1271-1275.

在内科和手术治疗先天性心脏病儿童过程中使用经食道超声心动图的益处已被公认。然而,它的费用-效益比没有深入研究。作者分析了从19941月至200312月期间50817岁以下需要接受先天性心脏手术的病人常规行TEE检查的报告。排除术后立即死亡的病例后,判定33名(5.7%)有明确指征需要再次体外循环,例如再手术,通过TEE发现而受益的病人。通过对所有固定和不固定费用分析显示每名儿童可节约8502655瑞士法郎(CHF)。这些数字低估了术中常规进行TEE的真正费用-效益比,较低估计了受益而较大地估计了花费。TEE在血流动力学监测和内科处理,在降低术后死亡率以及在提高生活质量方面的潜在益处是无形的。虽然受益和花费会随市场条件、病人数量、外科技术和TEE的技术而变化,作者认为他们的分析显示在儿科心脏手术期间常规进行TEE的真正费用效益关系。

(殷文渊 陈杰 校)

The beneficial effect of transesophageal echocardiography (TEE) on medical and surgical treatment of children with congenital heart disease has been established. Its cost-effectiveness, however, has not been extensively studied. We analyzed reports of 580 routine TEE examinations performed in our institution between January 1994 and December 2003 in patients younger than 17 yr who required congenital cardiac surgery. After excluding patients who died immediately postoperatively, we identified 33 patients (5.7%) who required a second bypass run on clear-cut indication, i.e., surgical reoperation, and who clearly benefited from TEE findings. An estimate of both fixed and variable costs revealed a savings of 850 to 2655 Swiss francs (CHF) ($690 to $2130 US) per child. This figure undoubtedly underestimates the true cost-effectiveness of routine intraoperative TEE in this setting because we used mostly conservative estimates of the benefits and liberal estimates of the costs. The potential benefits of TEE in hemodynamic monitoring and medical management, in reduction of postoperative morbidity, and in improvement in the quality of life are intangible and were not considered. Although benefits and costs vary according to market conditions, patient populations, surgical practice, and technical expertise with TEE, our analysis demonstrates substantial cost-effectiveness in the use of routine TEE during pediatric cardiac surgery.

 

小儿心脏外科手术后应用Vasotrac测压和有创动脉血压监测的比较

A Comparison of the Vasotrac with Invasive Arterial Blood Pressure Monitoring in Children After Pediatric Cardiac Surgery

Clifford L. Cua, MD, Kristi Thomas, RN, David Zurakowski, PhD, and Peter C. Laussen, MBBS

Departments of Cardiology and Orthopaedic Surgery, Children’s Hospital Boston, Boston, Massachusetts

Anesth Analg 2005 100: 1289-1294.

Vasotrac是一个可提供近似连续血压监测的无创动脉血压监测装置,并可能成为直接动脉内测压的替代选择。此装置应用于成年病人已进行过评估,但有关儿科病人应用的资料却非常有限。本研究的目的主要是评估儿科病人分别通过 Vasotrac和动脉导管监测动脉血压和心率时是否具备一致性。选择实施心脏矫治手术的儿童为研究对象,在术后同时通过Vasotrac和动脉导管监测动脉血压。在研究过程中通过构建Bland-Altman曲线来评估二种测压方式之间的一致性。并对研究所得数据进行配对相关分析、偏倚分析和精确度计算。研究对象共16名病人,平均年龄为10.1 ± 2.3岁,平均体重为34.6 ± 11.9 kg。研究中共采集到4102对数据。研究结果发现Vasotrac无创动脉血压监测与动脉导管血压监测之间在收缩压、舒张压和平均动脉压的Pearson r值分别为0.900.800.91(P < 0.001)。两种测压方式之间存在良好的一致性。收缩压、舒张压和平均动脉压进行混合模型回归分析,其95%可信区间的绝对平均差分别为4.0 mm Hg (3.0–5.0 mm Hg), 4.3 mm Hg (3.1–5.5 mm Hg), 3.5 mm Hg (2.5–4.0 mm Hg)。因此,儿科病人应用Vasotrac测量动脉血压与有创动脉血压监测之间具备良好的一致性。

(齐波 陈杰 校)

The Vasotrac is a device that provides near-continuous and noninvasive arterial blood pressure monitoring and may be an alternative to direct intraarterial measurement. It has been evaluated in adult patients, but minimal information is available for pediatric patients. We evaluated agreement between measurements of arterial blood pressure and heart rate obtained from the Vasotrac versus an arterial catheter in a pediatric population. Children undergoing corrective cardiac surgery were enrolled. Simultaneous arterial blood pressure measurements were obtained postoperatively from the Vasotrac unit and an arterial catheter. Bland-Altman plots were constructed to assess agreement. Paired correlation analysis, bias, and precision calculations were performed. Sixteen patients, mean age 10.1 ± 2.3 yr and weight 34.6 ± 11.9 kg, were enrolled. Four-thousand-one- hundred- two paired measurements were obtained. Arterial blood pressures measured noninvasively correlated with catheter measurements with Pearson r values of 0.90, 0.80, and 0.91 for systolic, diastolic, and mean arterial blood pressures, respectively (all P < 0.001). There was excellent agreement between arterial blood pressure measurement methods. Absolute mean differences based on mixed-model regression with 95% confidence intervals were 4.0 mm Hg (3.0–5.0 mm Hg), 4.3 mm Hg (3.1–5.5 mm Hg), and 3.5 mm Hg (2.5–4.0 mm Hg) for systolic blood pressure, diastolic blood pressure, and mean blood pressure, respectively. Arterial blood pressure measurements obtained from the Vasotrac agreed well with invasive arterial monitoring in pediatric patients.

 

单次和多次口服环氧化酶2抑制剂罗非考昔时脑脊液和血浆中的药代动力学

Cerebrospinal Fluid and Plasma Pharmacokinetics of the Cyclooxygenase 2 Inhibitor Rofecoxib in Humans: Single and Multiple Oral Drug Administration

Asokumar Buvanendran, MD*, Jeffrey S. Kroin, PhD*, Kenneth J. Tuman, MD*, Timothy R. Lubenow, MD*, Dalia Elmofty, MD*, and Pauline Luk, BS{dagger}

*Department of Anesthesiology, Rush Medical College at Rush University Medical Center, Chicago, Illinois; and {dagger}Merck Frosst Canada, Kirkland, Quebec, Canada

Anesth Analg 2005 100: 1320-1324.

单次或多次口服环氧化酶2抑制剂时的脑脊液(CSF)药代动力学与临床效应相关,其原因可能因为这些药物的镇痛效应。作者选择9个受试者鞘内植入导管作研究。口服50mg罗非考昔后,发现CSF药物浓度缓缓地逐渐小于其血浆药物浓度。CSF24小时药物浓度曲线下面积(AUC)与血浆24小时AUC的比率为0.142。在连续给予罗非考昔50mg/d 9天后,发现第9天的血浆和CSF药物浓度要大于第1天,第9天的血浆和CSF 24小时AUC均是第1AUC2倍。在连续给予罗非考昔9天后,AUCCSF/AUCplasma0.159。本研究的重要发现CSF罗非考昔水平约为其血浆水平的15%,并且通过每天重复给药,其CSF AUC可超过原水平的两倍。

(齐波 陈杰 校)

Cerebrospinal fluid (CSF) pharmacokinetics of orally administered cyclooxygenase 2 inhibitors, with single or multiple dosing, is of clinical relevance because it may relate to the analgesic efficacy of these drugs. We enrolled 9 subjects with implanted intrathecal catheters in the study. After 50-mg oral rofecoxib administration, the CSF drug concentration lagged slightly behind the plasma drug concentration. The ratio of the 24-h area under the drug-concentration curve (AUC) in CSF to plasma was 0.142. After daily dosing of rofecoxib 50 mg/d for 9 days, rofecoxib concentrations in plasma and CSF were larger on Day 9 than on Day 1, with the 24-h AUC on Day 9 more than twice the Day 1 AUC for both plasma and CSF. After nine consecutive daily doses of rofecoxib, the AUCCSF/AUCplasma ratio was 0.159. The important findings of this study are that CSF rofecoxib levels are approximately 15% of plasma levels and that repeated daily dosing more than doubles the AUC in CSF.

 

老年患者髋骨骨折手术时靶控输注异丙酚,手动控制输注异丙酚和依托咪脂/地氟醚麻醉的比较

A Comparison of Target- and Manually Controlled Infusion Propofol and Etomidate/Desflurane Anesthesia in Elderly Patients Undergoing Hip Fracture Surgery

Sylvie Passot, MD, Frédérique Servin, MD*, Jean Pascal, MD, Françoise Charret, MD, Christian Auboyer, MD, and Serge Molliex, MD, PhD

Département d'Anesthésie-Réanimation, Hôpital Bellevue, Saint-Etienne, France; *Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Bichat, Paris, France

Anesth Analg 2005 100: 1338-1342.

 

麻醉期间,药物的副作用对老年患者具有更高的危险性,尤其是麻醉对心血管功能的影响。在这项前瞻性、随机的研究中,作者选择接受髋骨骨折手术的老年患者,分为三组,分别给予依托咪脂/地氟醚麻醉(ETO/DES组),靶控输注异丙酚麻醉(TCI组),和手动控制输注异丙酚麻醉(MAN组),记录其诱导质量,血液动力学变化和恢复的情况。16个患者先给予依托咪脂(0.4mg/kg),然后吸入地氟醚,从初始呼气末浓度为2.5%逐步增加。18个患者接受靶控异丙酚麻醉,从初始浓度1ug/mL开始逐渐增加,每次增加0.5ug/mL15个患者在60秒内用异丙酚1mg/kg快速诱导,然后泵注异丙酚5mg/kg/h 所有患者都泵注阿芬太尼0.4ug/kg/h,总量为20ug/kg。根据血流动力学变化,吸入地氟醚的浓度或异丙酚(TCI组)和异丙酚输注速度(MAN组)的每次调节剂量分别为20%和50%。在TCIETO/DES组中,使平均动脉压维持在基线水平的15%和30%间时间,分别占用了总麻醉时间的60%和80%。而在MAN组中,使平均动脉压维持在基线水平的15%和30%间时间,为总麻醉时间的30%和60%。在MAN组中,麻醉药物的调节次数较多,为6.4±2.8,而ETO/DES组为2.5±1.2TCI组为2.6±1。作者认为对于老年患者TCI模式麻醉能改善异丙酚对血流动力学的影响。

(顾漪闻 陈杰 校)

Elderly patients have a higher risk of developing adverse drug reactions during anesthesia, especially anesthesia affecting cardiovascular performance. In this prospective randomized study we compared quality of induction, hemodynamics, and recovery in elderly patients scheduled for hip fracture surgery and receiving either etomidate/desflurane (ETO/DES) or target-controlled (TCI) or manually controlled (MAN) propofol infusion for anesthesia. Sixteen patients were anesthetized with ETO (0.4 mg/kg) followed by DES titrated from an initial end-tidal concentration of 2.5%. Eighteen patients received propofol TCI at an initial plasma concentration of 1 µg/mL and titrated upwards by 0.5-µg/mL steps. Fifteen patients received a bolus induction of propofol 1 mg/kg over 60 s followed by an infusion initially set at 5 mg · kg–1 · h–1. All received a bolus (20 µg/kg) followed by an infusion of 0.4 µg · kg–1 · min–1 alfentanil. According to hemodynamics, concentrations of DES or propofol (TCI group) and propofol infusion rate (MAN group) were respectively adjusted by a step of 20% and 50%. In the TCI and ETO/DES groups, the time spent at a mean arterial blood pressure within 15% and 30% of baseline values was more than 60% and 80% of anesthesia time, whereas in the MAN group it was <30% and 60%, respectively. In the MAN group more anesthetic drug adjustments were recorded (6.4 ± 2.8 versus 2.5 ± 1.2 [ETO/DES] and 2.6 ± 1 [TCI]). TCI improves the time course of propofol's hemodynamic effects in elderly patients.

 

红霉素和氟伏沙明对静脉利多卡因药代动力学的影响

The Effect of Erythromycin and Fluvoxamine on the Pharmacokinetics of Intravenous Lidocaine

Klaus T. Olkkola, MD, PhD*, Mika H. Isohanni, MD{dagger}{ddagger}, Katri Hamunen, MD, PhD§, and Pertti J. Neuvonen, MD, PhD{ddagger} *Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland; {dagger}Department of Anaesthesia, Deaconess Hospital, Helsinki, Finland; and the {ddagger}Department of Clinical Pharmacology and §Department of Anaesthesiology and Intensive Care Medicine, University of Helsinki, Helsinki, Finland

Anesth Analg 2005 100: 1352-1356.

 

CYP3A4(细胞色素P450 3A4)的抑制剂对利多卡因药代动力学有轻微的影响。作者通过一项双盲,随机,三方交叉的实验来研究同时使用抗抑郁药物氟伏沙明(CYP1A2抑制剂)和抗菌药物红霉素(CYP3A4抑制剂)对利多卡因药代动力学的影响。9个志愿者5天内分别每天服用100mg的氟伏沙明和安慰剂,或100mg氟伏沙明和1500mg红霉素,或相应的安慰剂。在第六天,静脉内给予利多卡因1.5mg/kg超过60分钟。10小时后测量利多卡因及其主要代谢产物一乙基甘油二甲基苯胺的浓度。单独给予氟伏沙明时,降低了41%利多卡因清除率(p0.001),并且延长了它的清除半衰期,从2.6小时到3.5小时(p0.01)。联合使用氟伏沙明和红霉素时,利多卡因的清除率比对照组小53%,比单用氟伏沙明组小21%(p0.05)。在联合使用组中,利多卡因的半衰期(4.3h)比对照组(2.6h; p0.001)或单用氟伏沙明组(3.5hp0.01=)长。作者认为CYP1A2抑制剂(氟伏沙明)可能减少利多卡因的清除,因此可能会增加利多卡因的毒性。如果同时使用氟伏沙明和CYP3A4制剂如红霉素,更可能通过减少利多卡因的清除来增加利多卡因的血浆浓度。

(顾漪闻 陈杰 校)

Inhibitors of CYP3A4 (cytochrome P450 3A4) have a minor effect on lidocaine pharmacokinetics. We studied the effect of coadministration of the antidepressant fluvoxamine (CYP1A2 inhibitor) and antimicrobial drug erythromycin (CYP3A4 inhibitor) on lidocaine pharmacokinetics in a double-blind, randomized, three-way crossover study. Nine volunteers ingested daily 100 mg fluvoxamine and placebo, 100 mg fluvoxamine and 1500 mg erythromycin, or their corresponding placebos for 5 days. On day 6, 1.5 mg/kg lidocaine was administered IV over 60 min. Concentrations of lidocaine and its major metabolite monoethylglycinexylidide were measured for 10 h. Fluvoxamine alone decreased the clearance of lidocaine by 41% (P < 0.001) and prolonged its elimination half-life from 2.6 to 3.5 h (P < 0.01). During the combination of fluvoxamine and erythromycin, lidocaine clearance was 53% smaller than during placebo (P < 0.001) and 21% smaller than during fluvoxamine alone (P < 0.05). During the combination phase the half-life of lidocaine (4.3 h) was longer than during the placebo (2.6 h; P < 0.001) or fluvoxamine (3.5 h; P < 0.01). We conclude that inhibition of CYP1A2 by fluvoxamine considerably reduces elimination of lidocaine and may increase the risk of lidocaine toxicity. Concomitant use of both fluvoxamine and a CYP3A4 inhibitor such as erythromycin can further increase plasma lidocaine concentrations by decreasing its clearance.

 

一项评估模拟团队训练在改善交流技能效果的方法

A Method for Measuring the Effectiveness of Simulation-Based Team Training for Improving Communication Skills

Richard H. Blum, MD, MSE*||, Daniel B. Raemer, PhD{dagger}||, John S. Carroll, PhD{ddagger}||, Ronald L. Dufresne§||, and Jeffrey B. Cooper, PhD{dagger}||

*Department of Anesthesia, Perioperative and Pain Medicine, Children’s Hospital Boston; {dagger}Department of Anesthesia and Critical Care, Massachusetts General Hospital; {ddagger}Sloan School of Management, Massachusetts Institute of Technology; §The Carroll School of Management, Boston College, Boston; and ||Center for Medical Simulation, Cambridge, Massachusetts

Anesth Analg 2005 100: 1375-1380.

 

团队行为和协调性,尤其是交流或团队信息共享,对于优化团队工作至关重要。但在医学研究中通常不能提供合理的方法来评估团队信息共享。在一对照的模拟设置中,作者用一项技术,测定参加为期一天的麻醉危机处理课程的受训人员的临床信息,并作为整个团队信息共享的一项指标。尽管团队的信息共享的程度低,用训练中所测量的团队信息共享的变化与自我评定变化的相关性来论证该方法学的准确性。尽管这门课程将对受训人员的理论和实践有用,但训练中团队信息共享始终没有统计学上的差别。

(朱辉 陈杰 校)

Team behavior and coordination, particularly communication or team information-sharing, are critical for optimizing team performance; research in medicine generally provides no accepted method for measurement of team information-sharing. In a controlled simulator setting, we developed a technique for placing clinical information (probes) with members of a team of trainees participating in a 1-day Anesthesia Crisis Resource Management course and later tested the teams for knowledge of the probes as an indicator of overall team information-sharing. Despite the low level of team information-sharing, we demonstrated construct validity of the probe methodology by the correlation of measured change in team information-sharing from beginning to end of training with self-rated change. There was no statistical difference in "group sharing" from beginning to end of training, despite trainees’ survey responses that the course would be useful for their education and practice.

 

术前加巴喷丁减少焦虑和提高膝手术后的早期功能恢复

Preoperative Gabapentin Decreases Anxiety and Improves Early Functional Recovery from Knee Surgery

Christophe Ménigaux, MD*, Frédéric Adam, MD*, Bruno Guignard, MD*, Daniel I. Sessler, MD{dagger}, and Marcel Chauvin, MD*

*Department of Anesthesia, Hôpital Ambroise Paré, Assistance Publique Hôpitaux de Paris, Paris, France; {dagger}Outcomes ResearchTM Institute, Department of Anesthesiology, University of Louisville, Louisville, Kentucky

Anesth Analg 2005 100: 1394-1399.

 

加巴喷丁具有抗痛觉过敏和抗焦虑的作用。作者假设全麻下行关节内窥镜下膝前十字韧带修补术的病人术前服用加巴喷丁可减少焦虑,提高术后镇痛和早期膝关节的运动,并验证此假设。40例病人术前1~2小时随机口服1200mg加巴喷丁或安慰剂,标准化麻醉。手术结束前30分钟给予吗啡0.1mg/kg,术后采用病人自控镇痛。记录48小时内疼痛评分和吗啡用量。每天2次的理疗,记录膝关节的主动和被动曲伸度。术后焦虑值加巴喷丁组小于对照组(视觉模拟评分范围28±16mm66±15mmp0.001)。加巴喷丁组吗啡需求量少于对照组(29±22mg69±40mgp0.001)。加巴喷丁组在休息和活动后的视觉模拟刻度疼痛分值明显降低。加巴喷丁组在2448小时的首次和最大膝关节屈曲度比对照组大。总之,关节内窥镜下膝前十字韧带修补术的病人术前服用加巴喷丁1200mg能减少术前焦虑,改善术后镇痛和早期膝关节的运动。

(朱辉 陈杰 校)

Gabapentin has antihyperalgesic and anxiolytic properties. We thus tested the hypothesis that premedication with gabapentin would decrease preoperative anxiety and improve postoperative analgesia and early postoperative knee mobilization in patients undergoing arthroscopic anterior cruciate ligament repair under general anesthesia. Forty patients were randomly assigned to receive 1200 mg oral gabapentin or placebo 1–2 h before surgery; anesthesia was standardized. Patients received morphine, 0.1 mg/kg, 30 min before the end of surgery and postoperatively via a patient-controlled pump. Pain scores and morphine consumption were recorded over 48 h. Degrees of active and passive knee flexion and extension were recorded during physiotherapy on days 1 and 2. Preoperative anxiety scores were less in the gabapentin than control group (visual analog scale scores of 28 ± 16 mm versus 66 ± 15 mm, respectively; P < 0.001). The gabapentin group required less morphine than the control group (29 ± 22 mg versus 69 ± 40 mg, respectively; P < 0.001). Visual analog scale pain scores at rest and after mobilization were significantly reduced in the gabapentin group. First and maximal passive and active knee flexions at 24 and 48 h were significantly more extensive in the gabapentin than in the control group. In conclusion, premedication with 1200 mg gabapentin improved preoperative anxiolysis, postoperative analgesia, and early knee mobilization after arthroscopic anterior cruciate ligament repair.

 

成人采用吸入还是静脉诱导?术前病人选择调查

Intravenous or Inhaled Induction of Anesthesia in Adults? An Audit of Preoperative Patient Preferences

Anton A. van den Berg, FRCA, Dudley A. Chitty, MD, Ramoun D. Jones, MD, Mir S. Sohel, MD, and Ali Shahen, MD

Department of Anesthesiology MSB 5.020, Medical School, University of Texas, Houston

Anesth Analg 2005 100: 1422-1424.

如果让病人选择,他们愿意选择吸入还是静脉麻醉诱导?经过伦理委员会批准后,作者调查240例外科门诊手术病人:212例病人(88%)有麻醉史,其中203(96%)采用静脉诱导,5 (2%)采用吸入诱导,4(2%)无麻醉诱导记录。调查显示78例病人(33%)愿意选择静脉诱导,120 例病人(50%)选择吸入麻醉诱导,42 (17%)未作选择。七氟醚成功地用于154例自己选择麻醉的病人。在美国,传统的观点认为大多数病人厌恶麻醉面罩,但研究结果似乎和以往观点矛盾,并且显示更多的人对静脉穿刺持恐惧态度。在有足够的人力和设备力量条件下,没有返流和气道管理困难,建议成年病人术前咨询其选择麻醉诱导方式。

(潘志英 陈杰 校)

If given a choice, would patients prefer an inhaled or IV method of inducing anesthesia? We investigated the choice between inhaled and IV induction of anesthesia of adult patients presenting to an academic institution for ambulatory surgery. Of 240 patients audited at the preoperative visit, 212 (88%) reported anesthetic histories in which anesthesia had been induced IV and by inhalation in 203 (96%) and 5 (2%) patients, respectively, with the remaining 4 (2%) having no recall of route of the induction of anesthesia. Seventy-eight (33%) patients selected IV induction, 120 (50%) chose inhaled induction, and 42 (17%) patients were undecided. Sevoflurane was used successfully for induction in 154 patients to whom it was offered. These findings seem to contradict the concept that most adult patients have an aversion to anesthesia masks and suggest that a fear of needle stick may be more prevalent among some populations of American adults. Where manpower and facilities permit and in the absence of risk of regurgitation or airway difficulty, it is suggested that enquiry be made of healthy adults presenting for elective ambulatory surgery as to their preferred route for the induction of anesthesia.

 

无法插管-无法正常通气(CICV)病人和困难插管策略:加拿大全国性调查

Cannot Intubate–Cannot Ventilate and Difficult Intubation Strategies: Results of a Canadian National Survey

David T. Wong, MD*, Kevin Lai, BSc{dagger}, Frances F. Chung, FRCPC*, and Ranee Y. Ho{ddagger}

*Department of Anesthesiology, {dagger}University of Toronto, Ontario, Canada; and {ddagger}McMaster University, Hamilton, Ontario, Canada

Anesth Analg 2005 100: 1439-1446

.

本研究目的是调查加拿大麻醉医生如何处理插管困难和无法插管-无法正常通气(CICV)病人。通过信件调查,作者咨询麻醉医生喜欢采用下列何种处理方案及使用满意度:(a)在困难插管时更换气管插管设备;(b)在CICV情况下采用声门下气道通气。统计学处理采用卡方分析和t检验。2066例调查中971例得到反馈。在困难插管病人中首选的更换工具是光导管(45%),纤维光学支气管镜(26%),喉罩(20%)57%的回应者遇到CICV的情况。在CICV状况下,首选声门下通气,常采用静脉套管针环甲膜穿刺术(51%),经皮环甲膜切开术(28%),气管切开(14%)。麻醉科医生没有通过手术进行声门下气道通气经验,但可在人体模型上练习后胜任声门下气道通气(P < 0.001)。综上所述,在困难气管插管情况下,光导管是首选的更换设备。在CICV状况下,静脉套管针环甲膜穿刺术为首选,随后是经皮环甲膜切开术、气管切开术。在人体模型上练习有助于提高声门下气道通气的技能。

(潘志英 陈杰 校)

The purpose of this study was to determine the preferences of Canadian anesthesiologists in difficult intubation and cannot intubatecannot ventilate (CICV) situations. Using a mailed survey, we asked anesthesiologists their preferences for and comfort level in using (a) alternative airway devices in a difficult intubation scenario and (b) infraglottic airway in a CICV scenario. Chi-square analysis and Student’s t-test were used for categorical and continuous variables. Nine-hundred-seventy-one of 2066 surveys were returned. In the difficult intubation scenario, the preferred alternative airway devices were lighted stylet (45%), fiberoptic bronchoscope (26%), and intubating laryngeal mask airway (20%). Only 57% of respondents had encountered a CICV situation in real life. In the CICV scenario, preferred infraglottic airways were cricothyroidotomy by IV catheter (51%), percutaneous cricothyroidotomy (28%), and tracheostomy by surgeon (14%). Anesthesiologists had little experience and were uncomfortable with open surgical infraglottic airways. Anesthesiologists with experience using infraglottic airways on mannequins were more comfortable using them in patients (P < 0.001). In conclusion, in a difficult intubation scenario, the lighted stylet has emerged as the preferred alternative airway device. In a CICV scenario, respondents preferred cricothyroidotomy by IV catheter, followed by percutaneous cricothyroidotomy and tracheostomy by surgeon. Practice on mannequins was associated with improved comfort in using infraglottic airways in patients.

 

犬选择性脑低温可抑制伤害性刺激引起的体动

Selective Brain Hypothermia Suppresses Noxious-Evoked Movement in Canines

Ryukichi Takayama, MD*, Rumiko Uda, MD*, Naofumi Isono, MD{dagger}, Motomasa Furuse, MD{dagger}, Tomio Ohta, MD{dagger}, Toshihiko Kuroiwa, MD{dagger}, and Hidemaro Mori, MD*

Department of *Anesthesiology and {dagger}Neurosurgery, Osaka Medical College, Japan

Anesth Analg 2005 100: 1458-1462.

全身低温可抑制伤害性刺激引起的体动,但是作用的主要部位尚不清楚。作者通过选择性降低脑部温度,研究脑部低温对伤害性刺激引起体动的影响。16只实验犬用异氟醚/氧气进行麻醉,随机分为两组。在深度麻醉后,对犬肺行人工通气,置入几个主要的管道以进行灌注和监测。右椎动脉灌注冷的乳酸林格液,对脑部进行降温,同时维持躯干的温度相对较高。当脑部温度降低到20℃或25℃,停止吸入异氟醚,此时躯干温度分别约为34.7℃和34.6℃。呼气末异氟醚浓度为0%时,用两根25G的针电刺激尾部,脑温20℃组对刺激均无反应,而脑温25℃组8条犬中的7条对刺激有反应。这些结果提示对实验犬进行选择性脑部低温(20)可抑制伤害性刺激引起的体动。

(赵延华 陈杰 校)

Systemic hypothermia suppresses noxious-evoked movement, but its main site of action is unknown. We examined the effect of hypothermia in the brain on noxious-evoked movement by selectively cooling the brain. Sixteen beagles were randomly divided into two groups and anesthetized with isoflurane/oxygen. After being deeply anesthetized, the dogs’ lungs were artificially ventilated, and several major vessels were cannulated for perfusion and monitoring. Cold lactate Ringer’s solution was infused into the right vertebral artery to cool the brain while maintaining the trunk temperature relatively warmer. When the brain temperature decreased to 20°C or 25°C, isoflurane administration was discontinued; the trunk temperatures at this stage were approximately 34.7°C and 34.6°C, respectively. After the end-tidal isoflurane concentration reached 0%, the base of the tail was stimulated with an electric current through 2 25-gauge needles. None of the dogs reacted to tail stimulation when the brain temperature was at 20°C, whereas 7 of 8 reacted at 25°C. These results indicate that selective brain hypothermia (20°C) results in suppressing noxious-evoked movement in canines.

 

腰麻下行剖腹产时经皮电刺激是否可代替外科刺激?

Is Transcutaneous Electrical Stimulation a Realistic Surrogate for Genuine Surgical Stimulation During Spinal Anesthesia for Cesarean Delivery?

Asif S. H. Zaidi, FCPS, and Ian F. Russell, FRCA

Department of Anesthetics, Hull Royal Infirmary, Hull, United Kingdom

Anesth Analg 2005 100: 1477-1481.

 

有几项实验已经应用经皮电刺激(TES)研究腰麻时阻滞程度的差别。这些TES刺激被认为可代替外科刺激来反映阻滞程度,但是没有研究显示区域阻滞时TES是否可代替外科刺激。作者研究剖腹产手术病人是否能耐受无痛性TES20名妇女在腰麻下行选择性剖腹产,应用无痛性TES10mA50Hz,持续1s)对五个不同区域的皮肤进行刺激。这些病人在手术过程中均不感到疼痛,但是对TES感觉阻滞的水平有差异,30%的病人能感知T10及以下水平的TES刺激。对T6或更高水平刺激的感知是一致的。无痛性TES刺激能够在直接传递手术刺激的皮肤感觉区域被感知,此时病人完全感觉不到疼痛,这一事实提示在测试区域内TES代替手术刺激来反映阻滞程度并没有实际应用的价值。

(赵延华 陈杰 校)

Several studies have investigated differential block during spinal anesthesia using transcutaneous electrical stimulation (TES) applied to patients skin. These TES stimuli are claimed to be a surrogate for surgical stimulation, but TES has never been shown to be a realistic surrogate for a surgical stimulus during regional anesthesia. We investigated whether patients could appreciate nonpainful TES at the same time as they were undergoing painless cesarean delivery surgery. We applied a nonpainful TES (10 mA, 50 Hz, 1-s duration) to the skin, at 5 different dermatomal levels, in 20 women undergoing elective cesarean delivery during spinal anesthesia. During surgery, all the women were totally pain free but we noted that the level of block to TES was variable: in 30% of women, TES could be felt at the T10 dermatome or more caudally. The first appreciation of touch was consistently at T6 or above. The fact that a nonpainful TES stimulus could be appreciated within the dermatomes directly involved in transmitting surgical stimuli, at a time when the patients were totally pain free, suggests that TES at the tested levels is of little value as a surrogate surgical stimulus.

 

用具有刺激功能的股神经导管置管可改善导管放置的位置吗?一项随机对照单盲试验

Does Femoral Nerve Catheter Placement with Stimulating Catheters Improve Effective Placement? A Randomized, Controlled, and Observer-Blinded Trial

Astrid M. Morin, MD, DEAA*, Leopold H. J. Eberhart, MD*, Hagen K. E. Behnke, MD*, Stefanie Wagner*, Tilo Koch, RN*, Udo Wolf, PT{dagger}, Walter Nau, PT{dagger}, Clemens Kill, MD*, Götz Geldner, MD, DEAA*, and Hinnerk Wulf, MD*

Departments of *Anesthesiology and Critical Care Medicine, and {dagger}Physical Therapy, Philipps-University Marburg, Marburg, Germany

Anesth Analg 2005 100: 1503-1510.

 

膝关节大手术后外周神经的连续阻滞可以提供长时的术后镇痛并且加速功能的恢复。传统的神经定位由神经刺激针定位后置入外周神经导管。通过镇痛效果的试验来纠正导管的位置。在导管放置过程中刺激导管有利于纠正位置,使其靠近神经处。本随机实验的目的是应用具有刺激功能的股神经导管置管,观察感觉和运动神经阻滞的起效时间及是否有利于术后镇痛和功能的恢复。在膝关节大手术的81位病人中,作者比较了用连续刺激置入股神经导管和传统盲探法股神经导管置管方法的差异。导管放入时间相似:传统组为4分钟(3/7.3;中位数,百分位数第25比第75值),刺激导管组为5分钟(4/8.8)。两组中第一次放置有42%的导管位置准确(髌骨的运动反应电流≤0.5mA)。刺激组中22位病人(58%)的导管被重新改变方向1-20次,包括2例在20分钟内未被准确放置。两组运动和感觉神经阻滞的起效时间相似。术后5天内静脉用阿片类药物的用量,静息和运动时的视觉镇痛评分,膝关节的最大弯曲和伸展没有差异。结论:连续刺激法神经阻滞和传统的盲探法神经阻滞在感觉和运动神经阻滞的起效时间,术后镇痛和功能恢复上没有差异。

 

(忻纪华 译 陈杰 校)

Continuous peripheral nerve blocks offer the benefit of extended postoperative analgesia and accelerated functional recovery after major knee surgery. Conventional nerve localization is performed over a stimulating needle followed by blind insertion of the peripheral catheter. Correct catheter placement is confirmed by testing for satisfactory analgesia. Stimulating catheters offer the advantage of verifying correct placement close to the nerve during catheter placement. The aim of this randomized trial was to determine whether accurate catheter positioning under continuous stimulation accelerates the onset of sensory and motor block, improves the quality of postoperative analgesia, and enhances functional recovery. We compared femoral nerve catheters inserted under continuous stimulation with catheters that were placed using the conventional technique of blind advancement in 81 patients undergoing major knee surgery. Time of catheter placement was similar in both groups with 4 min (3/7.3; median, 25th/75th percentile) in the conventional group and 5 min (4/8.8) in the stimulating catheter group. In both groups, 42% of the catheters could be correctly placed (motor response of the patella with a current ≤0.5 mA) at first attempt. In 22 patients (58%) of the stimulating catheter group, the catheter had to be redirected 1–20 times, including 2 that could not be correctly placed within 20 min. The onset time of sensory and motor block was almost similar in both groups. There were no differences in the postoperative IV opioid consumption, and visual analog scale pain scores at rest and movement, or maximal bending and stretching of the knee joint during the 5 days after surgery. We conclude that with continuous femoral nerve blocks, blind catheter advancement is as effective as the stimulating catheter technique with respect to onset time of sensory and motor block as well as for postoperative pain reduction and functional outcome.

 

术前焦虑评分是否有助于预测术后恶心和呕吐的发生?

Does Measurement of Preoperative Anxiety Have Added Value for Predicting Postoperative Nausea and Vomiting?

Jolanda E. Van den Bosch, MSc{dagger}, Karel G. Moons, PhD*, Gouke J. Bonsel, PhD{ddagger}, and Cor J. Kalkman, MD, PhD*

*Department of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; {dagger}Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands; and {ddagger}Department of Public Health, University Medical Center Amsterdam, Amsterdam, The Netherlands

Anesth Analg 2005 100: 1525-1532.

术前焦虑曾被认为可预示术后恶心和呕吐(PONV)的发生,但缺乏数据支持。作者对1389例各类手术病人,量化术前焦虑预测值,用logistic多因素回归分析来建立PONV的预测模型。研究的预测指标包括有PONV史或运动系统疾病,吸烟,性别,年龄,种族,体重指数,ASA分级,手术类别,麻醉时间,麻醉方法及术后阿片类药物镇痛史。通过Spielberger State-Trait焦虑分级和阿姆斯特丹术前焦虑和信息评分来评价焦虑程度。PONV的发生在术后的第一个24小时。logistic多因素回归分析模型中特征性曲线下的面积为0.7295%的可信区间,0.70-0.74),包括性别,年龄,吸烟,PONV史或运动系统疾病,手术类别和麻醉方法。焦虑和PONV相关但相关性弱,加入焦虑因素的模型接受机操作特征曲线下的面积并没有增加。所以,常规的术前焦虑评分并不见得有用,另外一些预示因素已被考虑。

(忻纪华 译 陈杰 校)

 

Preoperative anxiety has been suggested as a predictor of postoperative nausea and vomiting (PONV), but supporting data are lacking. We quantified the added predictive value of preoperative anxiety to established predictors of PONV in 1389 surgical inpatients undergoing various procedures, by using multivariate logistic regression analysis. Investigated predictors were a history of PONV or motion sickness, smoking, sex, age, ethnicity, body mass index, ASA physical status, surgery type, duration of anesthesia, anesthetic technique, and postoperative opioid analgesia. Anxiety was measured by the Spielberger State-Trait Anxiety Inventory and the Amsterdam Preoperative Anxiety and Information Scale. The outcome was the occurrence of PONV in the first 24 h after surgery. The area under the receiver operating characteristic curve of a multivariate (logistic regression) model including sex, age, smoking, history of PONV or motion sickness, surgery type, and anesthetic technique was 0.72 (95% confidence interval, 0.70–0.74). There was a weak but significant association of anxiety with PONV, but the addition of anxiety to the model did not further increase the area under the receiver operating characteristic curve. Therefore, routine preoperative measurement of anxiety does not seem warranted, provided that the other predictors are already considered.

 

雷米芬太尼用于心脏手术病人的术后镇痛

Postoperative Analgesia with Remifentanil in Patients Undergoing Cardiac Surgery

Barbara Steinlechner, MD, Herbert Koinig, MD, Georg Grubhofer, MD, Martin Ponschab, MD, Silvia Eislmeir, MD, Martin Dworschak, MD, and Angela Rajek, MD

Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, University Hospital of Vienna, Austria

Anesth Analg 2005;100:1230-1235

 

雷米芬太尼是一种短效的阿片类药物,常用于心脏手术的麻醉。本研究试图在心脏手术后气管导管拔除病人中证实疼痛治疗的可行性及确定雷米芬太尼提供足够镇痛的必需剂量。本研究包括30例择期行心脏手术的病人。术后,一开始将术中使用的雷米芬太尼继续维持在0.05 µg · kg–1 · min–1。气管导管拔除前,使用非甾体类抗炎药,并将雷米芬太尼减少至0.035 µg · kg–1 · min–1。气管导管拔除后使用视觉模拟量表(VAS)作疼痛评分:10 min内每2min一次,以后每10 min一次至第一小时结束,再以后的5 h里每30min一次。当一个VAS评分≥30或呼吸频率<10/分时,分别将雷米芬太尼的剂量增加或减少0.005 µg · kg–1 · min–1。第一个10min为快速剂量适应,增加雷米芬太尼0.005 µg · kg–1 · min–1两次,然后增加0.01 µg · kg–1 · min–13次。30 min后,雷米芬太尼的平均剂量为0.051 µg · kg–1 · min–1VAS评分降低至26 ± 14。当雷米芬太尼的剂量在0.03 0.09 µg · kg–1 · min–1范围内时,病人能得到充分的镇痛。4h后雷米芬太尼的最大平均剂量达0.057 µg · kg–1 · min–1。气管导管拔除后30min,使用雷米芬太尼复合非甾体类抗炎药能为73%的病人提供足够的镇痛。在最初的10 min50%的病人必需快速剂量滴定。增加雷米芬太尼的初始剂量能缩短滴定期,但可能引起呼吸并发症。

(裘毅敏 李士通 校)

Remifentanil, a short-acting opioid, is commonly used in cardiac anesthesia. In this study we sought to demonstrate the feasibility of pain treatment and to determine the remifentanil dose necessary for adequate analgesia in tracheally extubated patients after cardiac surgery. Thirty patients undergoing elective cardiac surgery were included in this study. After surgery, the intraoperatively administered remifentanil was initially continued at 0.05 µg · kg–1 · min–1. Before tracheal extubation, a nonsteroidal antiinflammatory drug was administered and remifentanil was reduced to 0.035 µg · kg–1 · min–1. Pain assessment using a visual analog scale (VAS) was performed after tracheal extubation, in 2-min intervals for 10 min, every 10 min until the end of the first hour and every 30 min during the ensuing 5 h. A VAS score ≥30 or a respiratory rate <10 breaths/min was followed by an increase or decrease in the remifentanil dose by 0.005 µg · kg–1 · min–1, respectively. For rapid dose adaptation during the first 10 min, remifentanil was increased twice by 0.005 µg · kg–1 · min–1 and then 3 times by 0.01 µg · kg–1 · min–1. With a mean remifentanil dose of 0.051 µg · kg–1 · min–1 VAS decreased to 26 ± 14 after 30 min. Sufficient analgesia was achieved with remifentanil doses ranging from 0.03 to 0.09 µg · kg–1 · min–1. A maximum mean remifentanil dose of 0.057 µg · kg–1 · min–1 was reached after 4 h. The combination of remifentanil with a nonsteroidal antiinflammatory drug provided adequate analgesia in 73% of patients 30 min after tracheal extubation. Rapid dose titration was necessary during the first 10 min in 50% of patients. Increasing the initial remifentanil dose could shorten the titration period but may be associated with respiratory complications.

回顾抑肽酶在原位肝移植中的应用:它的有害作用会抵消它的有益作用吗?

A Review of Aprotinin in Orthotopic Liver Transplantation: Can Its Harmful Effects Offset Its Beneficial Effects?

Claude Lentschener, MD, Karine Roche, and Yves Ozier, MD

Department of Anesthesia and Critical Care, Université Paris V – René Descartes, Hôpital Cochin, Assistance publique – Hôpitaux de Paris, Paris, France

Anesth Analg 2005;100:1248-1255

 

输血会对原位肝移植(OLT)患者的预后和移植肝的生存产生不良影响。从这一方面考虑,预防性应用抑肽酶能减少进行OLT的患者的失血量、输血的需求量及移植肝再灌注时的血流动力学改变。然而,数据表明应限制抑肽酶在OLT中的应用:(a)在慢性肝疾病或进行OLT的患者中记录的临床、生物学、超声心动图及尸检发现表明在这些患者中存在持续的前凝血状态。抑肽酶治疗对纤维蛋白溶解的抑制作用是否会使一些患者发展到不适当的血栓形成仍是有疑问的;(b)抑肽酶似乎不能改变进行OLT的患者的术后结果;(c)抑肽酶只在手术有明显的失血时能减少输血需求。而目前OLT仍需要2-5U红血球的中等输血量。

(陈玮 李士通 校)

Blood transfusion can adversely affect patient outcome and graft survival in orthotopic liver transplantation (OLT). With this respect, prophylactic aprotinin administration decreases blood loss, transfusion requirements, and the hemodynamic changes associated with graft reperfusion in patients undergoing OLT. However, data indicate limiting the use of aprotinin in OLT: (a) clinical, biological, echocardiographic, and postmortem findings recorded in patients with chronic liver disease or undergoing OLT suggest that a continuous prothrombotic state exists in these patients. Whether the inhibition of fibrinolysis associated with aprotinin therapy will expose some patients to untoward thrombosis is questionable; (b) aprotinin does not appear to alter postoperative outcome in patients undergoing OLT; (c) aprotinin decreases blood transfusion requirements only when surgery is associated with significant blood loss. However, at the present time, median transfusion requirements of 2 to 5 red blood cell units are required in OLT.


行心脏手术的婴幼儿脊麻后的术后镇痛

Postoperative Analgesia After Spinal Blockade in Infants and Children Undergoing Cardiac Surgery

Gregory B. Hammer, MD*§, Chandra Ramamoorthy, MBBS*, Hong Cao, MD*, Glyn D. Williams, MD*, M. Gail Boltz, MD*, Komal Kamra, MBBS*, and David R. Drover, MD*

Departments of *Anesthesia and §Pediatrics, Stanford University Medical Center, California

Anesth Analg 2005;100:1283-1288

 

本项前瞻性、随机、对照临床试验的目的是为了探讨儿童以雷米芬太尼(REMI)或雷米芬太尼加脊麻(SAB+REMI)麻醉下行开心手术后阿片类镇痛药的需求量。我们以心脏手术后拟于手术室内气管拔管的45例患儿为研究对象。排除标准为小于3个月和大于6岁、肺动脉高压、充血性心力衰竭、SAB禁忌者以及未获得知情同意者。所有病人以七氟醚吸入诱导,以雷米芬太尼和异氟醚(呼气末浓度0.3%)维持麻醉。另外,分入SAB+REMI组的病人给以SAB 0.5–2.0 mg/kg丁卡因和7 µg/kg吗啡。于手术室气管拔管后,病人可以自控镇痛方式每10分钟静脉注射0.3 µg/kg芬太尼,维持疼痛评分为4分。以后每小时记录疼痛评分和芬太尼量,直至满24小时或病人准备出ICU。结果SAB+REMI组患儿的疼痛评分(第一个8小时内P = 0.046;24小时内 P =0.05)和接受的IV芬太尼量(第一个8小时内P = 0.003; 24小时内P = 0.004)显著低于REMI组。两组间不良反应无差异,包括低血压、心动过缓、最高PaCO2值、最低pH值、氧饱和度下降、搔痒和呕吐。

(周志坚 李士通 校)

The aim of this prospective, randomized, controlled clinical trial was to define the opioid analgesic requirement after a remifentanil (REMI)-based anesthetic with spinal anesthetic blockade (SAB+REMI) or without (REMI) spinal blockade for open-heart surgery in children. We enrolled 45 patients who were candidates for tracheal extubation in the operating room after cardiac surgery. Exclusion criteria included age <3 mo and >6 yr, pulmonary hypertension, congestive heart failure, contraindication to SAB, and failure to obtain informed consent. All patients had an inhaled induction with sevoflurane and maintenance of anesthesia with REMI and isoflurane (0.3% end-tidal). In addition, patients assigned to the SAB+REMI group received SAB with tetracaine (0.5–2.0 mg/kg) and morphine (7 µg/kg). After tracheal extubation in the operating room, patients received fentanyl 0.3 µg/kg IV every 10 min by patient-controlled analgesia for pain score = 4. Pain scores and fentanyl doses were recorded every hour for 24 h or until the patient was ready for discharge from the intensive care unit. Patients in the SAB+REMI group had significantly lower pain scores (P = 0.046 for the first 8 h; P =0.05 for 24 h) and received less IV fentanyl (P = 0.003 for the first 8 h; P = 0.004 for 24 h) than those in the REMI group. There were no intergroup differences in adverse effects, including hypotension, bradycardia, highest PaCO2, lowest pH, episodes of oxygen desaturation, pruritus, and vomiting.


帕瑞考昔钠和丙帕他莫用于成年患者腹股沟疝修复术后的肠道外术后镇痛的随机双盲比较

A Randomized, Double-Blind Comparison Between Parecoxib Sodium and Propacetamol for Parenteral Postoperative Analgesia After Inguinal Hernia Repair in Adult Patients

M. Beaussier, MD*, H. Weickmans, MD*, C. Paugam, MD*, S. Lavazais, MD{dagger}, J. P. Baechle, MD{ddagger}, P. Goater, MD§, A. Buffin, MD||, J. F. Loriferne, MD, J. F. Perier, MD#, J. P. Didelot, MD**, A. Mosbah, MD{dagger}{dagger}, R. Said, MD{dagger}{dagger}, and A. Lienhart, MD, PhD*

*CHU St. Antoine, Paris, France; {dagger}CHU Poitiers, France; {ddagger}Clinique de la Sauvegarde, Lyon, France; §HIA Val de Grâce, Paris, France; ||CHU Annecy, France; ¶Hôpital Ste Camille, Bry sur Marne, France; #CHU Tenon, Paris, France; **CHU Brabois, Vandoeuvre, les Nancy, France; and {dagger}{dagger}CHU Sahloul, Sousse, Tunisie

Anesth Analg 2005;100:1309-1315

 

新的环氧化酶-2选择性的非甾体类抗炎药注射剂(帕瑞考昔)从未与丙帕他莫(对乙酰氨基酚的肠胃外剂型)作过比较。在这个前瞻性的、随机、双盲、双伪研究中,我们将182名预定于全麻下行初次腹股沟疝修补术的病人,在手术后12个小时内随机单次注射了40 mg帕瑞考昔或两次注射2g丙帕他莫。该研究的变量是吗啡的消耗量、静息时的疼痛程度与咳嗽时疼痛程度以及在手术后12个小时内病人的满意程度。我们应用了Student’s t检验、{chi}2以及协方差分析进行了统计学分析。总的吗啡消耗量在两组之间没有什么差别。静息时疼痛在帕瑞考昔组中较轻(P0.035)而两组咳嗽时疼痛并无差别。副反应的发生率是相近的。帕瑞考昔组中有显著更多的病人评价他们的疼痛处理为良或优的(87%对丙帕他莫组的70%,P=0.001)。在成年病人腹股沟疝修补术后的最初12个小时内,单次注射帕瑞考昔40mg与两次注射丙帕他莫2g相比是相当的。

(黄丽娜  李士通  )

The newly injectable cyclooxygenase-2 selective nonsteroidal antiinflammatory drug, parecoxib, has never been compared with propacetamol, a parenteral formulation of acetaminophen. In this prospective, randomized, double-blind, double-dummy study, we randomly assigned 182 patients scheduled for initial inguinal hernia repair under general anesthesia to receive a single injection of 40 mg parecoxib or 2 injections of 2 g propacetamol within the first 12 h after surgery. The study variables were morphine consumption, pain at rest and while coughing, and patient satisfaction throughout the first 12 h postoperatively. For statistical analysis, we used the Student’s t-test, {chi}2, and covariance analysis. Total morphine consumption did not differ between the two groups. Pain was less intense in the parecoxib group at rest (P = 0.035) but did not differ for pain while coughing. The incidence of side effects was similar. Significantly more patients in the parecoxib group rated their pain management as good or excellent (87% versus 70% in the propacetamol group, P = 0.001). Within the first 12 h after inguinal hernia repair in adult patients, a single injection of parecoxib 40 mg compares favorably with 2 injections of propacetamol 2 g.


肾上腺素的应用并不提高用异氟醚或地氟醚麻醉的大鼠对音调的恐惧学习

Administration of Epinephrine Does Not Increase Learning of Fear to Tone in Rats Anesthetized with Isoflurane or Desflurane

James M. Sonner, MD*, Yilei Xing, MD*, Yi Zhang, MD*, Anya Maurer, BS*, Michael S. Fanselow, PhD, MD{dagger}, Robert C. Dutton, MD*, and Edmond I. Eger, II, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; and {dagger}Department of Psychology, University of California, Los Angeles

Anesth Analg 2005;100:1333-1337

 

以前的报告表明肾上腺素的应用会提高大鼠在巴比妥盐复合水合氯醛深麻醉过程中的学习,而并不提高兔在0.4%的异氟醚麻醉中的学习。我们以大鼠对音调的恐惧条件作用作为学习和记忆的实验模型,,并以异氟醚和地氟醚作为麻醉剂来重新探讨了这个问题。用能防止50%大鼠动反应的最小肺泡浓度(MAC)的一个分数来表示的遗忘音调恐惧的50%有效剂量ED50),在吸入异氟醚且腹膜内(i.p.)注射盐水的对照大鼠中是0.32 ± 0.03 MAC(平均值±标准差),i.p.注射0.01 mg/kg肾上腺素的大鼠为0.37 ± 0.06 MAC,在i.p.注射0.1mg/kg肾上腺素的大鼠为0.38 ± 0.03 MAC。对于地氟醚,i.p.注射盐水的对照大鼠遗忘恐惧的ED500.32 ± 0.05 MAC,在i.p.注射肾上腺素0.1mg/kg的大鼠是0.36 ± 0.04MAC。通过用大鼠对音调的恐惧条件作用进行评价,我们得出结论,外源性的肾上腺素并不降低因吸入异氟醚或地氟醚所产生的记忆缺失。

(黄丽娜 李士通  校)

Previous reports suggest that the administration of epinephrine increases learning during deep barbiturate-chloral hydrate anesthesia in rats but not during anesthesia with 0.4% isoflurane in rabbits. We revisited this issue, using fear conditioning to a tone in rats as our experimental model for learning and memory and isoflurane and desflurane as our anesthetics. Expressed as a fraction of the minimum alveolar anesthetic concentration (MAC) preventing movement in 50% of rats, the amnestic 50% effective dose (ED50) for fear to tone in control rats inhaling isoflurane and injected with saline intraperitoneally (i.p.) was 0.32 ± 0.03 MAC (mean ± se) compared with 0.37 ± 0.06 MAC in rats injected with 0.01 mg/kg of epinephrine i.p. and 0.38 ± 0.03 MAC in rats injected with 0.1 mg/kg of epinephrine i.p. For desflurane, the amnestic ED50 were 0.32 ± 0.05 MAC in control rats receiving a saline injection i.p. versus 0.36 ± 0.04 MAC in rats injected with 0.1 mg/kg of epinephrine i.p. We conclude that exogenous epinephrine does not decrease amnesia produced by inhaled isoflurane or desflurane, as assessed by fear conditioning to a tone in rats.


在接受米库氯铵的麻醉患者中用稳定的肌松/稳定的输注速度方法证明的四个成串刺激“2个计数”与强直后“2个计数”之间的定量区别

The Quantitative Distinction Between Train-of-Four "Counts of 2" and Posttetanic "Counts of 2" Evidenced by a Stable Paralysis/Stable Infusion Rate Method in Anesthetized Patients Receiving Mivacurium

A. A. d’Hollander, MD, PhD, A. V. Pytel, MD, B. M. Merzouga, MD, and C.-E. Klopfenstein, MD

Service d’ Anesthésiologie, Hôpital Universitaire de Genève, Genève, Switzerland

Anesth Analg 2005;100:1348-1351

 

在本研究中我们用稳定肌松/稳定输注速度方法定量地评价了两个标准化肌松水平――四个成串刺激(TOF)计数为2个反应与强直后计数(PTC)为2――之间的差异。10ASA分级I–II预定行择期手术的已获取同意的成年患者行麻醉(苏芬太尼/异丙酚)、气管插管、用混合O2/空气正常机械通气,且保持正常体温;口咽和鱼际温度分别维持在36°32.5°C以上。从200 µg/kg米库氯铵(MIV)部分恢复后,通过人为调节含MIV的输注泵,使拇内收肌达到稳定的触觉TOFPTC计数为2的肌松水平。一旦肌松水平和输注速度在间隔5 min的连续4个时间点维持不变,就认为肌松水平和输注速度是稳定的。观察到的输注速度为:TOF计数2–6 (2–11)PTC 2–17 (3–18) µg · kg–1 · min–1P < 0.001Wilcoxon’s配对比较试验)。在当前情况下,达到和维持2PTC需要MIV输注速度远远超过文献中有关MIV输注管理的“标准”建议。

(马皓琳 李士通 校)

In this study we quantitatively evaluated, by a stable paralysis/stable infusion rate method, the difference between two standardized paralysis levels—train-of-four (TOF) count of 2 responses and posttetanic count (PTC) of 2. Ten ASA physical status I–II consenting adult patients scheduled for elective surgery were anesthetized (sufentanil/propofol), tracheally intubated, mechanically normoventilated with a fixed O2/air mixture, and normothermic; oropharynx and thenar temperatures were maintained above 36° and 32.5°C, respectively. After partial recovery from 200 µg/kg mivacurium (MIV), stable tactile TOF and PTC counts of 2 paralysis levels were induced on the adductor pollicis muscle by manual adjustments of an infusion pump containing MIV. The paralysis levels and the infusion rates were considered as stable once they remained constant at 4 consecutive time points separated by 5 min each. Infusion rates observed were: TOF count 2–6 (2–11) and PTC 2–17 (3–18) µg · kg–1 · min–1 (P < 0.001; Wilcoxon’s paired comparison test). Under the present conditions, obtaining and maintaining a PTC of 2 requires MIV infusion rates far in excess of the "standard" recommendations mentioned in the literature for MIV infusion management.


笑气和七氟醚麻醉下的病人进行腹内冲洗时双频指数的改变

Changes in the Bispectral Index During Intraabdominal Irrigation in Patients Anesthetized with Nitrous Oxide and Sevoflurane

Yasuhiro Morimoto, MD, Akiko Matsumoto, MD, Yumika Koizumi, MD, Toru Gohara, MD, Takefumi Sakabe, MD, and Satoshi Hagihira, MD*

Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Yamaguchi, Japan; *Department of Anesthesiology, Osaka University Graduate School of Medicine, Osaka, Japan

Anesth Analg 2005;100:1370-1374

 

手术一般刺激导致脑电图活跃。在一些情况下,麻醉不充分时的疼痛刺激导致脑电图的抑制。这种现象被称为反常激发。在我们日常的实践中,我们注意到在腹部手术中用生理盐水冲洗腹腔时双频指数(BIS)显著减小伴随有大的δ波动。在这项研究中,我们寻求评估腹腔内冲洗时BIS的改变。18ASA评级I~II级择期行腹部手术的病人入选本研究,随机分在对照组(组C)或者芬太尼组(组F)。麻醉诱导用3 mg/kg硫苯妥钠,用50%的笑气和七氟醚维持麻醉。用BIS监测仪记录BIS95%边缘频率(SEF95)和爆发-抑制比。在手术将近结束时,但在腹腔冲洗之前,组F静脉给予1.5 µg/kg芬太尼。组F病人在随后的腹腔冲洗过程中,BISSEF95没有显著改变。相反,组C 的病人在开始冲洗后BISSEF95显著下降。这些数据显示,发生在腹腔内冲洗过程中的刺激可能导致一个矛盾的激发反应,证据是处理过的脑电图参数下降。用芬太尼预处理抑制这种变化。麻醉学者应当知道这种矛盾的激发反应,以避免在这种情况下不恰当地减少麻醉剂浓度。

(张曦 李士通 校)

Surgical stimulation typically results in an activation of electroencephalographic activity. In some instances, painful stimulation in the presence of inadequate anesthesia results in a suppression of the electroencephalogram. This phenomenon has been referred to as a "paradoxical arousal." In our daily practice, we have noted a marked decrease in the bispectral index (BIS) with large {delta}waves during abdominal surgery when the abdominal cavity was irrigated with normal saline. In the present study, we sought to evaluate changes in BIS during intraabdominal irrigation. Eighteen ASA physical status I–II patients scheduled for elective abdominal surgery were enrolled in the study and allocated randomly to the control group (group C) or the fentanyl group (group F). Anesthesia was induced with 3 mg/kg of thiopental and was maintained with sevoflurane and 50% nitrous oxide. BIS, 95% spectral edge frequency (SEF95), and burst-suppression ratio were recorded using a BIS monitor. Near the end of the procedure, but before irrigation of the abdominal cavity, 1.5 µg/kg fentanyl was given IV to group F. There was no significant change in BIS or SEF95 in group F patients during subsequent irrigation of the abdominal cavity. In contrast, BIS and SEF95 decreased significantly after start of irrigation in group C patients. These data show that the stimulation occurring during intraabdominal irrigation might cause a paradoxical arousal response, as evidenced by a decrease in processed electroencephalographic parameters. Pretreatment with fentanyl suppressed these changes. Anesthesiologists should be aware of this paradoxical arousal response to avoid an inappropriate decrease in the anesthetic concentration in such situations.


术前抑制脊髓环氧化酶-1可减轻术后疼痛

Preoperative Inhibition of Cyclooxygenase-1 in the Spinal Cord Reduces Postoperative Pain

Xiaoying Zhu, MD, Dawn R. Conklin, BS, and James C. Eisenach, MD

Program of Neuroscience, Department of Anesthesiology and Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Anesth Analg 2005;100:1390-1393

 

在切割伤术后疼痛模型中,术后第一天鞘内给予特异性环氧化酶(COX)-1 抑制剂具有镇痛作用,而非COX-2抑制剂。我们在这个模型中研究了术前鞘内给予COX抑制剂的作用。手术前15分钟,给予大鼠鞘内注射COX-1非特异性抑制剂(ketorolac)COX-1特异性抑制剂(SC-560)COX-2抑制剂(NS-398)或溶剂。然后在雄性大鼠左爪的掌底面上做一1厘米长的纵向切口,切开皮肤、筋膜和肌肉。测定2小时、4小时直至5天后大鼠对von Frey细丝的退缩反应阈值。KetorolacSC-560提高大鼠对机械刺激的退缩反应阈值,但NS-398没有明显作用。这些结果表明COX-1在术后脊髓疼痛处理和致敏中起到重要作用,术前鞘内给予特异性COX-1抑制剂对治疗术后疼痛可能是有用的。

 (张莹 李士通 校)

Intrathecal administration of cyclooxygenase (COX)-1, but not COX-2, specific inhibitors given on postoperative day 1 has analgesic effects in an incisional model of postoperative pain. We investigated the effects of preoperative administration of intrathecal COX inhibitors in this model. Fifteen minutes before surgery, rats received intrathecally the COX-1 preferring inhibitor, ketorolac, the specific COX-1 inhibitor, SC-560, the COX-2 inhibitor, NS-398, or vehicle. A 1-cm longitudinal incision was then made through skin, fascia, and muscles of the plantar aspect of a left paw in male rats. Withdrawal threshold to von Frey filaments was measured at 2 h, 4 h, and at intervals up to 5 days later. Ketorolac and SC-560 increased withdrawal threshold to mechanical stimulation, but NS-398 had no significant effect. These results suggest that COX-1 plays an important role in spinal cord pain processing and sensitization after surgery and that preoperative intrathecal administration of specific COX-1 inhibitors may be useful to treat postoperative pain.


在神经性痛的大鼠模型中,鞘内注射的5-羟色胺去甲肾上腺素再摄取抑制剂米那普伦由单胺介导的Antiallodynic作用

The Monoamine-Mediated Antiallodynic Effects of Intrathecally Administered Milnacipran, a Serotonin Noradrenaline Reuptake Inhibitor, in a Rat Model of Neuropathic Pain

Hideaki Obata, MD, Shigeru Saito, MD, Shiro Koizuka, MD, Koichi Nishikawa, MD, and Fumio Goto, MD

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

Anesth Analg 2005;100:1406-1410

 

抗抑郁药经常用于神经性疼痛的治疗。在本研究中,我们测定了神经性疼痛的大鼠模型中选择性单胺再摄取抑制剂在脊髓部位的antiallodynic作用。通过紧绑左L5 L6脊神经产生机械的allodynia,并用von Frey细丝刺激左后爪来测定之。通过长期置入的导管鞘内注射5-羟色胺去甲肾上腺素再摄取抑制剂米那普伦、选择性5-羟色胺再摄取抑制剂帕罗西汀或选择性去甲肾上腺素再摄取抑制剂马普替林。米那普伦在3 µg100 µg之间的剂量产生剂量依赖性的antiallodynic作用。注射100 µg后该效应持续7小时(P < 0.05)30 µg米那普伦的antiallodynic作用可被鞘内同时给予的30 µg α2肾上腺素能受体拮抗剂育亨宾、30 µg5-羟色胺受体拮抗剂二甲麦角新碱或30 mug毒蕈碱型胆碱受体拮抗剂阿托品所削弱(各自的P < 0.01)。米那普伦腹膜内给药在剂量从3 30 mg/kg时没有antiallodynic作用。鞘内应用帕罗西汀(10100 µg)和马普替林(10100 µg)不产生antiallodynic作用。这些结果表明同时抑制脊髓5-羟色胺和去甲肾上腺素再摄取在介导antiallodynic作用时是必需的。米那普伦可能有效抑制神经性疼痛。

(陈玮 李士通 校)

Antidepressants are often used to treat neuropathic pain. In the present study, we determined the antiallodynic effects of selective monoamine reuptake inhibitors in the spinal cord in a rat model of neuropathic pain. Mechanical allodynia was produced by tight ligation of the left L5 and L6 spinal nerves and determined by applying von Frey filaments to the left hindpaw. A serotonin noradrenaline reuptake inhibitor, milnacipran, a selective serotonin reuptake inhibitor, paroxetine, or a selective noradrenaline reuptake inhibitor, maprotiline, was administered intrathecally via a chronically implanted catheter. Milnacipran produced dose-dependent antiallodynic effects at doses between 3 µg and 100 µg. The effect lasted for 7 h after injection of 100 µg (P < 0.05). The antiallodynic effect of 30 µg of milnacipran was attenuated by intrathecal coadministration of 30 µg of yohimbine, an {alpha}2-adrenoceptor antagonist, 30 µg of methysergide, a serotonin receptor antagonist, or 30 µg of atropine, a muscarinic receptor antagonist (P < 0.01, respectively). Intraperitoneal administration of milnacipran had no antiallodynic effects at doses of 3 to 30 mg/kg. Antiallodynic effects were not produced by intrathecal administration of paroxetine (10 to 100 µg) or maprotiline (10 to 100 µg). These findings suggest that simultaneous inhibition of serotonin and noradrenaline reuptake in the spinal cord is essential to mediate antiallodynic effects. Milnacipran might be effective for suppression of neuropathic pain.


围术期输血与髋关节置换术后伤口愈合延迟:对住院时间的影响

Perioperative Blood Transfusions and Delayed Wound Healing After Hip Replacement Surgery: Effects on Duration of Hospitalization

Eric W. G. Weber, MD*, Robert Slappendel, MD, PhD{dagger}, Martin H. Prins, MD, PhD{ddagger}, Dick B. van der Schaaf, MD§, Marcel E. Durieux, MD, PhD*||, and Danja Strümper, MD

Departments of *Anesthesiology and {ddagger}Clinical Epidemiology, University Hospital Maastricht, Maastricht, The Netherlands; Departments of {dagger}Anesthesiology and §Orthopedic Surgery, St. Maartens Hospital, Nijmegen, The Netherlands; ||Department of Anesthesiology, University of Virginia, Charlottesville, Virginia; and ¶Department of Anesthesiology, University Hospital Münster, Münster, Germany

Anesth Analg 2005;100:1416-1421

 

整形外科手术后接受异体输血的病人的住院时间相对较长,这一现象无法用输血病人的感染发生率较高来解释。为探讨异体输血是否会影响伤口愈合从而延长住院时间,本试验连续观察了444例择期行髋关节手术的病人。术中选取5个时点收集输血量、伤口情况和感染三个变量。在所观察的444例病人中,有92例病人在围术期接受了异体输血。31%的输血病人伤口愈合延迟,而未输血病人伤口愈合延迟发生率只有18%(P<0.05)。异体输血是较小的伤口愈合不良的唯一重要的预测因子。输血病人住院时间相对延长(12.39.8天),这种现象可以用4个重要变量来预测:需要输血(增加 2.7 ±0.5天)、发生伤口愈合不良(增加1.3 ±0.5天)、手术时间 (增加0.2±0.1/10 min)和病人年龄(增加 0.9 ±0.2 /10 yr)。这些数据表明异体输血使术后伤口愈合不良发生率增高,因此,防止异体输血可能会缩短择期行整形外科手术病人的住院时间。

(邱郁薇 李士通 校)

Patients who receive allogeneic blood transfusions after orthopedic surgery have a longer duration of hospitalization, and this cannot be explained by a more frequent incidence of infections in transfused patients. To determine whether transfusion of allogeneic blood interferes with wound healing and therefore increases the duration of hospitalization, we performed an observational study in 444 consecutive patients scheduled for elective primary hip surgery. Transfusion, wound, and infection variables were collected at five time points during treatment. Of the 444 consecutive patients studied, 92 received blood transfusions during their perioperative course. Thirty-one percent of transfused patients developed wound-healing disturbances versus 18% of the nontransfused group (P < 0.05); allogeneic blood transfusion was the only significant predictor for development of minor wound-healing disturbances. Duration of hospitalization was prolonged in transfused patients (12.3 versus 9.8 days) and could be predicted by 4 significant variables: requirement for blood transfusion (adds 2.7 ± 0.5 days), presence of wound-healing disturbances (adds 1.3 ± 0.5 days), duration of surgery (adds 0.2 ± 0.1 days/10 min), and patient's age (adds 0.9 ± 0.2 days/10 yr). These data suggest that allogeneic blood transfusion is associated with an increased incidence of wound-healing disturbances and that prevention of allogeneic blood transfusion may be relevant in limiting the duration of admission after elective orthopedic surgery.

 

 

一项评估长期保存红细胞的临床效能的试点试验

A Pilot Trial Evaluating the Clinical Effects of Prolonged Storage of Red Cells

Paul C. Hébert, MD*, Ian Chin-Yee, MD{dagger}, Dean Fergusson, PhD*, Morris Blajchman, MD{ddagger}, Raymond Martineau, MD§, Jennifer Clinch, BSc, MA*, Bernhard Olberg, MD||, and the Canadian Critical Care Trials Group

*University of Ottawa Centre for Transfusion Research, Ottawa Hospital Research Institute, Clinical Epidemiology Unit; {dagger}Division of Hematology, London Health Sciences Centre, Ontario; {ddagger}Department of Laboratory Medicine, McMaster University Health Centre; §Division of Cardiovascular Anaesthesiology, Institut de Cardiologie de Montreal; and ||Department of Pathology, Ottawa Hospital, Canada

Anesth Analg 2005;100:1433-1458

 

目前尚未确定长期保存的红细胞的临床后果。在本次试点试验中,我们对持续供给储存时间<8天的红细胞的合理性进行了评估。此外,我们还在66例危重病人和心脏外科手术病人中对“新鲜血”的可能益处与标准红细胞进行了比较。9例病人发放了红细胞但没有输注。在其余57例病人中,试验组平均输注5.5 ± 8.43 单位的红细胞,而标准组为3.3 ± 3.27单位(P=0.25)。试验组使用红细胞的储存时间的中位数为4天,而标准组为19天(差值为15天;四分位数差值范围为1216天;P<0.001)。总体而言,73%的病人输注了储存时间相应于超过储存时间90%的治疗安排的红细胞。输注储存<8天红细胞组病人的年龄平均起来有较大的趋势(68 ± 8.54 yr 63 ± 15.30 yr; P = 0.13),合并症也有较多的趋势(85% 65%; P = 0.09)。总体上,试验组中27%的病人死亡或有危及生命的并发症,而标准组为13%(P=0.31)。随机化之后组间在长期呼吸、心血管和肾脏支持方面均无差异(P > 0.05)。根据已获得的有限的资料,组织一项比较红细胞储存时间的大型临床试验是可行和应当的。

(黄施伟 李士通 校)

The clinical consequences of prolonged storage of red cells have not been established. In this pilot study, we evaluated whether it would be feasible to provide a continuous supply of red cells stored <8 days. In addition, we examined the potential benefits attributed to "fresh" as compared to standard red cells in 66 critically ill and cardiac surgical patients. Nine patients were issued red cells but were not transfused. From the 57 remaining patients, the number of units transfused averaged 5.5 ± 8.43 red cell units in the experimental group compared to 3.3 ± 3.27 red cell units in the standard group (P = 0.25). The median storage time was 4 days in the experimental group compared to 19 days in the standard group (difference of 15 days; interquartile range of 12–16 days; P < 0.001). Overall, 73% of patients received red cells with storage times that corresponded to the treatment allocation more than 90% of the time. The group receiving red cells <8 days old tended to be older on average (68 ± 8.54 yr versus 63 ± 15.30 yr; P = 0.13) and have more comorbid illnesses (85% versus 65%; P = 0.09). In total, 27% of patients in the experimental group died or had a life-threatening complication as compared to 13% in the standard group (P = 0.31). There were no differences in prolonged respiratory, cardiovascular, or renal support after randomization (P > 0.05). A large clinical trial comparing red cell storage times is feasible and warranted given the limited available evidence.


N-乙酰半胱氨酸减弱人全血内毒素诱发的粘附分子的表达

N-Acetyl-Cysteine Attenuates Endotoxin-Induced Adhesion Molecule Expression in Human Whole Blood

Koichiroh Nandate, MD*, Masanori Ogata, MD{dagger}, Hitomi Tamura, MD{dagger}, Takashi Kawasaki, MD{dagger}, Takeyoshi Sata, MD{dagger}, and Akio Shigematsu, MD{dagger}

*Division of Critical and Emergency Care Medicine and {dagger}Department of Anesthesiology, University of Occupational and Environmental Health, Kitakyushu, Japan

Anesth Analg 2005;100:1453-1457

 

白细胞粘附于血管内皮细胞在内毒素性休克早期起关键作用。减弱白细胞对内毒素的反应可能有助于预防进一步的器官损伤。近来有研究认为N-乙酰半胱氨酸(NAC)可减弱内毒素诱发的病理生理性变化。我们研究了NAC对内毒素刺激的人全血中的CD11bCD62L表达的影响。结果表明 NAC (>10 mM)呈浓度依赖地明显抑制脂多糖(LPS)诱发的CD11b上调。但是NAC并不影响LPS诱发的CD62L 下调。我们还分析了NAC对白介素-8 (IL-8)诱发的人全血中CD11b表达的影响,IL-8 (10 ng/mL)明显上调CD11b的表达, NAC (>10 mM)呈剂量依赖地明显减弱这种作用。我们认为NAC减弱LPSIL-8诱发的人全血中增高的CD11b表达。

(张莹 李士通 校)

Leukocyte adhesion to endothelial cells plays a pivotal role in the early stage of endotoxin shock. The attenuation of the leukocyte response to endotoxin may contribute to the prevention of further organ dysfunction. Recent evidence implies that N-acetyl-cysteine (NAC) attenuates endotoxin-induced pathophysiological changes. We investigated the effect of NAC on the expression of CD11b and CD62L in endotoxin-stimulated human whole blood. NAC (>10 mM) significantly inhibited the lipopolysaccharide (LPS)-induced upregulation of CD11b in a concentration-dependent manner. However, NAC did not affect the LPS-induced downregulation of CD62L. We also analyzed the effect of NAC on interleukin-8 (IL-8)-induced expression of CD11b in human whole blood. IL-8 (10 ng/mL) significantly upregulated the expression of CD11b, and the IL-8-induced upregulation was significantly attenuated by NAC (>10 mM) in a dose-dependent manner. We conclude that NAC attenuates the increased expression of CD11b in either LPS or IL-8-stimulated human whole blood.

 

 

 

鞘内注射吗啡后口唇单纯疱疹复发:一项对产科病人的前瞻性随机试验

 

Oral Herpes Simplex Reactivation After Intrathecal Morphine: A Prospective Randomized Trial in an Obstetric Population

Paul W. Davies, MD, Manuel C. Vallejo, MD, Kelly T. Shannon, MD, Antonio J. Amortegui, MD, and Sivam Ramanathan, MD

University of Pittsburgh School of Medicine, Department of Anesthesiology, Magee-Womens Hospital, Pittsburgh, Pennsylvania

Anesth Analg 2005;100:1472-1476

 

至今尚没有证据表明硬膜外注射吗啡与口唇单纯疱疹(HSL)复发有关。也没有研究决定性地显示HSL与鞘内注射吗啡之间的关系。为探讨这种关系,我们随机、前瞻性地研究了100例有HSL史并在脊麻下行剖宫产手术的产科病人。一组病人鞘内注射吗啡加经病人自控镇痛IV给予吗啡(ITM+PCA组)用于术后镇痛;第二组病人仅经病人自控镇痛IV给予吗啡用于术后镇痛(单独PCA组)。所有病人均随访30天。ITM+PCA组中19例(38%)病人HSL复发,而单独吗啡PCA组有8例(6.6%)(P = 0.028)。 ITM+PCA组术后早期搔痒的发生率也较高。本试验数据表明,HSLITM+PCA组和单纯PCA组均有复发,而ITM+PCA组发生率较高。

(邱郁薇 李士通 校)

There is now evidence for an association between the use of epidural morphine and reactivation of herpes simplex labialis (HSL). There are no studies that definitively demonstrate the relationship between HSL reactivation and spinal intrathecal morphine. To investigate this relationship, we randomized and prospectively studied 100 obstetric patients with a history of HSL undergoing cesarean delivery under spinal anesthesia. One group received intrathecal morphine plus IV morphine via patient-controlled analgesia (ITM+PCA group) for postoperative analgesia, and a second group received only IV morphine via patient-controlled analgesia for postoperative analgesia (PCA-only group). Patients were followed for a 30-day period. In the ITM+PCA group 19 (38%) patients had HSL reactivation whereas eight (16.6%) had HSL reactivation in the morphine PCA-only group (P = 0.028). The incidence of pruritus in the ITM+PCA group was also more frequent in the early postoperative period. Our data show HSL reactivation in both the ITM+PCA group and PCA-only morphine group, with a more frequent incidence in the ITM+PCA group.

 

 

/上臂手术行斜角肌肌间沟臂丛神经阻滞后的神经后遗症:患者因素、麻醉因素和手术因素与发病率和临床病程之间的关系

Neurologic Sequelae After Interscalene Brachial Plexus Block for Shoulder/Upper Arm Surgery: The Association of Patient, Anesthetic, and Surgical Factors to the Incidence and Clinical Course

Kenneth D. Candido, MD, Radha Sukhani, MD, Robert Doty, Jr, MD, Antoun Nader, MD, Mark C. Kendall, MD, Edward Yaghmour, MD, Tripti C. Kataria, MPH, MD, and Robert McCarthy, PharmD

Department of Anesthesiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2005;100:1489-1495

 

连续随访 693名接受肩或(和)上臂手术的患者,在单次注射含1:200,000肾上腺素的0.625%左旋布比卡因行肌间沟臂丛神经阻滞(ISB)后测定患者神经后遗症的发病率、分布和症状解除及其与麻醉、手术和患者因素之间的关系。在一次标准化ISB24小时、48小时、2周和4周评估感觉缺失、感觉减退、感觉异常,疼痛/感觉迟钝和肌力减退。对有症状的患者监护至症状解除为止。对报告疼痛或不适分值大于3(总分10)的受试者和有运动性或延伸感觉症状的受试者进行诊断性评估。660名患者完成了4周的随访。56名患者报告了58项神经后遗症。除2例为肌力减退的症状(经鉴定病变远离行ISB的部位)外,其余都为感觉性症状。29名患者报告的31项后遗症可能与ISB相关,其中14项在行ISB的部位,9项在拇指/示指的远节指骨,7项涉及耳后神经,及一例临床臂丛病变。27名患者报告的后遗症可能与ISB没有关系,这些症状有正中神经(n9)和尺神经(n4)症状、手术性神经失用(n12)和肌力减退(n2)。除2名出现肌力减退的患者和1名出现临床臂丛病变的患者接受了治疗干预外,其余患者的症状都自发缓解(中位数4周, 范围2-16周)。定义为与ISB可能相关的神经后遗症的独立预报因子的变量有:插入针头时的感觉异常和24小时时行ISB部位的疼痛和淤伤。与之相反,患者坐位接受手术和行ISB部位的淤伤可作为可能与ISB无关的神经后遗症的预报因子。总之,用含肾上腺素的局麻药单次注射行ISB之后的神经后遗症主要包括短暂轻微的感觉性症状。

(周雅春 李士通 校)

We determined the incidence, distribution, and resolution of neurologic sequelae and the association with anesthetic, surgical, and patient factors after single-injection interscalene block (ISB) using levobupivacaine 0.625% with epinephrine 1:200,000 in subjects undergoing shoulder or upper arm surgery, or both, in 693 consecutive adult patients. After a standardized ISB, assessments were made at 24 and 48 h and at 2 and 4 wk for anesthesia, hypesthesia, paresthesias, pain/dysesthesias, and motor weakness. Symptomatic patients were monitored until resolution. Subjects reporting pain or discomfort >3 of 10 and those with motor or extending sensory symptoms received diagnostic assessment. Six-hundred-sixty subjects completed 4 wk of follow-up. Fifty-eight neurologic sequelae were reported by 56 subjects. Symptoms were sensory except for two cases of motor weakness (lesions identified distant from the ISB site). Thirty-one sequelae with likely ISB association were reported by 29 subjects, including 14 at the ISB site, 9 at the distal phalanx of thumb/index finger, 7 involving the posterior auricular nerve, and 1 clinical brachial plexopathy. Sequelae not likely associated with the ISB were reported by 27 subjects with symptoms reported in the median (n = 9) and ulnar (n = 4) nerves, surgical neuropraxias (n = 12), and motor weakness (n = 2). Symptoms resolved spontaneously (median 4 wk; range, 2–16 wk) except in the two patients with motor weaknesses and the patient with clinical brachial plexopathy, who received therapeutic interventions. Variables identified as independent predictors of neurologic sequelae likely related to ISB were paresthesia at needle insertion and ISB site pain or bruising at 24 h. In contrast, surgery preformed in the sitting position, as well as ISB site bruising, was identified as a predictor of neurologic sequelae not likely related to ISB. In conclusion, neurologic sequelae after single-injection ISB using epinephrine mainly involve transient minor sensory symptoms.

 

 

单次鞘内注射高比重布比卡因的半数有效剂量高于腰硬联合方法的半数有效剂量

The Median Effective Dose of Intrathecal Hyperbaric Bupivacaine Is Larger in the Single-Shot Spinal as Compared with the Combined Spinal-Epidural Technique

Raymond Wee-Lip Goy, MMed Anesthesia, FANZCA, Yoong Chee-Seng, MMed Anesthesia, FAMS, Alex Tiong-Heng Sia, MMed Anesthesia, Koay Choo-Kok, MMed Anesthesia, FANZCA, FAMS, and Shen Liang, MSc

Department of Anesthesia and Intensive Care, Changi General Hospital, Singapore

Anesth Analg 2005;100:1499-1502

 

腰硬联合方法(CSE)与单次鞘内注射(SSS)相比,其能延迟运动神经的恢复且低血压更常见。我们采用上下连续分配方法测定CSESSS中鞘内高比重布比卡因的半数有效剂量(MED)。将60名男性患者随机分为CSESSS组。所有的病人均选在L34间隙穿刺。在SSS组,通过27Whitacre脊麻穿刺针注入9.5mg高比重布比卡因。在CSE组,以充满4ml空气的17Tuohy针来定位于硬膜外腔,通过穿刺针导入27Whitacre脊髓穿刺针,注入7mg高比重布比卡因。剂量调整为0.5mg。“成功”的结果定义为感觉平面达T6T6以上并持续60分钟。“成功”一例后将下一例病人剂量减小0.5mg,而“失败”一例后则增大0.5mg。两组中共有13例成功。CSE组的布比卡因的MED9.18 mg (95%可信区间为 8.89–9.47 mg) ,而SSS组布比卡因的MED11.37 mg (95%可信区间为 10.88–11.86 mg) (P < 0.001)。为达到定义的临床目标,CSE组所需要的局麻药较SSS组少19.3% (95% 可信区间 14.9%–23.6%)。我们发现两组之间高比重布比卡因的MED明显不同。在同样临床条件下,只要CSE取代SSS就可保证减少20%布比卡因的用量。

(赵雪莲 李士通 校)

The combined spinal-epidural technique (CSE) has been associated with prolonged motor recovery and more frequent arterial hypotension as compared with a single-shot spinal (SSS) technique. We determined the median effective dose (MED) of intrathecal hyperbaric bupivacaine for CSE and SSS by using the up-down sequential allocation technique. Sixty male patients were randomly allocated to receive intrathecal administration through an SSS or CSE technique. Needle insertion occurred at the L3-4 interspace in all patients. In SSS, 9.5 mg of hyperbaric bupivacaine was administered through a 27-gauge Whitacre spinal needle. In CSE, a 17-gauge Tuohy needle with 4 mL of air was used to locate the epidural space, through which a 27-gauge Whitacre spinal needle was introduced and 7.0 mg of hyperbaric bupivacaine was administered. The dosing adjustment was 0.5 mg. A "successful" outcome was arbitrarily defined as sensory anesthesia at or above the T6 dermatome lasting for 60 min. A "success" resulted in a 0.5-mg decrement, whereas a "failure" resulted in a 0.5-mg increment in the next patient. There were 13 successes in both groups. The MED of bupivacaine was 9.18 mg (95% confidence interval, 8.89–9.47 mg) for CSE as compared with 11.37 mg (95% confidence interval, 10.88–11.86 mg) for SSS (P < 0.001). CSE required 19.3% (95% confidence interval, 14.9%–23.6%) less local anesthetic to achieve the defined clinical target. We found significant discrepancies in the MED of hyperbaric bupivacaine between the two techniques. Under similar clinical conditions, a 20% decrement in the dose of bupivacaine may be warranted whenever CSE is intended in place of SSS.

 

 

肾移植术中给以乳酸林格氏液或0.9% NaCl的随机双盲比较

A Randomized, Double-Blind Comparison of Lactated Ringer’s Solution and 0.9% NaCl During Renal Transplantation

Catherine M. N. O’Malley, FFARCSI*, Robert J. Frumento, MPH*, Mark A. Hardy, MD{dagger}, Alan I. Benvenisty, MD{dagger}, Tricia E. Brentjens, MD*, John S. Mercer, MD, and Elliott Bennett-Guerrero, MD*

Departments of *Anesthesiology and {dagger}Surgery, Columbia University, College of Physicians & Surgeons, New York

Anesth Analg 2005;100:1518-1524

 

肾移植手术补液常滴注生理盐水(NS0.9% NaCl),以避免输入过多含钾液体而致高钾血症。而最近的证据提示,NS可能产生在滴注平衡液如乳酸林格氏液(LR)时并不多见的不良反应。我们假设,NS对肾移植受体的肾功能有害。对行肾移植术的成人进行了前瞻性、随机双盲临床试验,比较用于术中IV输液治疗的NSLR。主要观察指标为术后第三天肌酐浓度。在中期分析51例病人的数据后由于安全原因而终止研究。其中48例病人为接受活体肾移植,3例为尸体肾移植。26例滴注了NS25例为LR。两组在主要指标上无差异。NS组有5(19%)(P = 0.05)患者因血钾浓度超过了6 mEq/L进行高钾血症治疗,8(31%) (P = 0.004)因代谢性酸中毒而治疗;而LR组无一例出现上述情况。故NS对肾脏功能无不良影响。与NS相比,LR较少出现高钾血症和代谢性酸中毒。LR可能是一个对肾移植手术病人IV液体治疗安全的选择。

(周志坚 李士通 )

Normal saline (NS; 0.9% NaCl) is administered during kidney transplantation to avoid the risk of hyperkalemia associated with potassium-containing fluids. Recent evidence suggests that NS may be associated with adverse effects that are not seen with balanced-salt fluids, e.g., lactated Ringer’s solution (LR). We hypothesized that NS is detrimental to renal function in kidney transplant recipients. Adults undergoing kidney transplantation were enrolled in a prospective, randomized, double-blind clinical trial of NS versus LR for intraoperative IV fluid therapy. The primary outcome measure was creatinine concentration on postoperative Day 3. The study was terminated for safety reasons after interim analysis of data from 51 patients. Forty-eight patients underwent living donor kidney transplants, and three patients underwent cadaveric donor transplants. Twenty-six patients received NS, and 25 patients received LR. There was no difference between groups in the primary outcome measure. Five (19%) patients in the NS group versus zero (0%) patients in the LR group had potassium concentrations >6 mEq/L and were treated for hyperkalemia (P = 0.05). Eight (31%) patients in the NS group versus zero (0%) patients in the LR group were treated for metabolic acidosis (P = 0.004). NS did not adversely affect renal function. LR was associated with less hyperkalemia and acidosis compared with NS. LR may be a safe choice for IV fluid therapy in patients undergoing kidney transplantation.


腹腔手术后病人自控静脉阿片类镇痛与持续硬膜外镇痛的效果比较

Patient Controlled Intravenous Opioid Analgesia Versus Continuous Epidural Analgesia for Pain After Intra-Abdominal Surgery

Werawatganon, T; Charuluxananan, S

Anesth Analg 2005;100:1536

 

背景:腹腔手术后镇痛有两种常用的方式:病人自控静脉阿片类药物镇痛(PCA)和持续硬膜外镇痛(CEA)。尚未确定哪种方式能更有效地镇痛且副作用更少。

目的:本综述的目的是通过对相关试验的后分析比较腹腔手术后PCA阿片类镇痛和CEA镇痛的镇痛效能、副作用、病人满意度和手术结果

搜索策略:我们搜索了CENTRAL (Cochrane2002年第4)MEDLINE (19661月到200210)EMBASE (19881月到200210)以及论文的参考文献列表。我们还联系了这方面的研究者。

入选标准:在腹腔手术后的成年病人从镇痛效能和副作用两方面来比较两种镇痛方法的随机对照试验。PCA镇痛组的病人应能自己操作机器。持续硬膜外镇痛组没有PCA机器。

数据收集和分析:两名综述者独立评价试验质量和收集的数据。联系研究作者以提供补充信息。从试验中收集副作用信息。

主要结果:共有含711例参与者的9个研究。PCA组视觉模拟疼痛评分在62472小时都比CEA组高。静息时疼痛的加权平均差和95%可靠区间分别是1.74 (95% CI 1.302.19) 0.99 (95% CI 0.651.33)0.63 (95% CI 0.241.01)。除PCA组瘙痒发生率较低,其让步比值为0.27 (95% CI 0.110.64)外,住院时间和其他副作用均无统计学差异。

综述者结论:腹腔手术病人在减轻术后72小时内疼痛上,CEA方式比阿片PCA方式更好,但使瘙痒发生率较高。比较这两种镇痛方法的其他优缺点还缺乏足够证据。

(朱慧 李士通 校)

 

Background: There are two common techniques for postoperative pain control after intra-abdominal surgery: patient-controlled analgesia (PCA) with IV opioids and continuous epidural analgesia (CEA). It is uncertain which method has better pain control and fewer adverse effects.

Objectives: The objective of this review was to compare PCA opioid therapy with CEA for pain control after intra-abdominal surgery in terms of analgesic efficacy, side effects, patient satisfaction and surgical outcome by meta-analysis of the relevant trials.

Search strategy: We searched CENTRAL (The Cochrane Library, Issue 4, 2002), MEDLINE (January 1966 to October 2002), EMBASE (January 1988 to October 2002), and reference lists of articles. We also contacted researchers in the field.

Selection criteria: Randomized controlled trials of adult patients after intra-abdominal surgery comparing the effect of two pain control regimens in terms of analgesic efficacy and side effects. In the patient-controlled analgesia (PCA) group the patient should be able to operate the device himself. In the continuous epidural analgesia group there was no PCA device.

Data collection and analysis: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials.

Main results: Nine studies involving 711 participants were included. The PCA group had a higher pain visual analog scale than the CEA group during 6, 24 and 72 h periods. The weighted mean difference and 95% confidence interval of resting pain was 1.74 (95% CI 1.30 to 2.19), 0.99 (95% CI 0.65 to 1.33), and 0.63 (95% CI 0.24 to 1.01), respectively. The length of hospital stay and other adverse effects were not statistically different except that the incidence of pruritus was lower in the PCA group, odds ratio of 0.27 (95% CI 0.11 to 0.64).

Reviewers’ conclusions: CEA is superior to opioid PCA in relieving postoperative pain for up to 72 h in patients undergoing intra-abdominal surgery, but it is associated with a higher incidence of pruritus. There is insufficient evidence to draw comparisons about the other advantages and disadvantages of these two methods of pain relief.