Anesthesia & Analgesia

May 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

雷米芬太尼用於心臟手術病人的術後鎮痛

(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.

在日本非心臟手術期間心血管事件的發生率和美國及歐洲相同嗎?

(殷文淵 陳傑 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.

膝上和膝下截肢術對糖尿病和非糖尿病患者圍術期和長期致病率、致死率的研究

(吳德華譯 薛張綱校)

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.

回顧抑肽酶在原位肝移植中的應用:它的有害作用會抵消它的有益作用嗎?

(陳瑋 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:

在小兒心臟手術中常規使用經食道超聲心動圖的費用-效益比:10年經驗

(殷文淵 陳傑 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.

評估新生兒體外迴圈中標準肝素的劑量對凝血酶作用的影響

(吳德華譯 薛張綱校)

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.

行心臟手術的嬰幼兒脊麻後的術後鎮痛

(周志堅 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.

小兒心臟外科手術後應用Vasotrac測壓和有創動脈血壓監測的比較

(齊波 陳傑 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發揮劑量依賴而非年齡依賴的抗傷害性疼痛作用及年齡依賴性催眠作用

(王麗珺譯 薛張綱校)

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:

帕瑞考昔鈉和丙帕他莫用於成年患者腹股溝疝修復術後的腸道外術後鎮痛的隨機雙盲比較

(黃麗娜  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:

單次和多次口服環氧化酶2抑制劑羅非考昔時腦脊液和血漿中的藥代動力學

(齊波 陳傑 )

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

全麻在自主壓力反射指數上的濃度依賴性效應及兩者的藥理學增效關係

(王麗珺譯 薛張綱校)

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

腎上腺素的應用並不提高用異氟醚或地氟醚麻醉的大鼠對音調的恐懼學習

(黃麗娜 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.

老年患者髖骨骨折手術時靶控輸注異丙酚,手動控制輸注異丙酚和依託咪脂/地氟醚麻醉的比較

(顧漪聞 陳傑 )

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.

氧化亞氮對羅庫溴銨劑量回應關係的影響

(孫志榮譯 薛張綱校)

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.

紅黴素和氟伏沙明對靜脈利多卡因藥代動力學的影響

(顧漪聞 陳傑 )

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:

異丙酚和阿芬太尼維持的麻醉中腦電圖監測: 第二頻譜的作用

(蔡美華譯 薛張綱校)

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.

笑氣和七氟醚麻醉下的病人進行腹內沖洗時雙頻指數的改變

(張曦 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.

一項評估模擬團隊訓練在改善交流技能效果的方法

(朱輝 陳傑 )

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:

胸段硬膜外麻醉及鎮痛聯合切皮前美沙芬的應用對腸切除術後疼痛及腸功能恢復的改善作用#Preincisional_Dextromethorphan_Combined

(許文妍 薛張綱 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.

術前抑制脊髓環氧化酶-1可減輕術後疼痛

(張瑩 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.

術前加巴噴丁減少焦慮和提高膝手術後的早期功能恢復

(朱輝 陳傑 )

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.

曲馬多及其代謝產物對蟾蜍屬卵母細胞氨基乙酸γ-氨基丁酸N-甲基天冬氨酸受體表達的作用

(沈洪 薛張剛 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.

在神經性痛的大鼠模型中,鞘內注射的5-羥色胺去甲腎上腺素再攝取抑制劑米那普倫由單胺介導的Antiallodynic作用

(陳瑋 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:

成人採用吸入還是靜脈誘導?術前病人選擇調查

(潘志英 陳傑 )

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.

在不確定未來工作量的情況下使用一定財政支出進行選擇性手術室資源擴張的策略

(金琳 譯, 薛張綱校)

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:

一項評估長期保存紅細胞的臨床效能的試點試驗

(黃施偉 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.

無法插管-無法正常通氣(CICV)病人和困難插管策略:加拿大全國性調查

(潘志英 陳傑 )

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產物試驗(Gastrotest)與腸內營養相關胃腸併發症之間的關係

(孫敏莉譯,薛張綱校)

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-乙酰半胱氨酸減弱人全血內毒素誘發的粘附分子的表達

(張瑩 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:

 

犬選擇性腦低溫可抑制傷害性刺激引起的體動

(趙延華 陳傑 )

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.

異氟烷吸入時低碳酸血症對腦血流量自身調節的影響

(孫少瀟譯 薛張綱校)

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:

鞘內注射嗎啡後口唇單純皰疹復發:一項對產科病人的前瞻性隨機試驗

(邱鬱薇 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.

腰麻下行剖腹產時經皮電刺激是否可代替外科刺激?

(趙延華 陳傑 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:

美國局部麻醉協會最新指南中關於對預先低分子量肝素化行較大型矯形手術的病人進行脊神經麻醉的建議

(孫少瀟譯 薛張綱校)

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.

/上臂手術行斜角肌肌間溝臂叢神經阻滯後的神經後遺症:患者因素、麻醉因素和手術因素與發病率和臨床病程之間的關係

(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.

肩部手術後行病人自控斜角肌內鎮痛:後路留置導管

(周曉敏 薛張綱 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.

單次鞘內注射高比重布比卡因的半數有效劑量高於腰硬聯合方法的半數有效劑量

(趙雪蓮 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經導管置管可改善導管放置的位置嗎?一項隨機對照單盲試驗

(忻紀華 陳傑 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.

在膝以下部位手術中坐骨神經阻滯是否能耐受大腿部止血帶反應?

(費敏譯 薛張綱校)

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:

腎移植術中給以乳酸林格氏液或0.9% NaCl的隨機雙盲比較

(周志堅 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

術前焦慮評分是否有助於預測術後噁心和嘔吐的發生?

(忻紀華 陳傑 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.

-聲帶長度的評估

(吳德華譯 薛張綱校)

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:

腹腔手術後病人自控靜脈阿片類鎮痛與持續硬膜外鎮痛的效果比較

(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.

 

膝上和膝下截肢術對糖尿病和非糖尿病患者圍術期和長期致病率、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

 

我們通過回顧性研究了血管外科質量保障病史來評估膝上(AKAn=234)和膝下截肢術(BKA,n=720)在圍術期和長期的致病率和致死率,並研究了糖尿病(DM)在其中的影響(AKA 181BKA 606 )。本文研究了1990-2001年所有AKABKA患者,評估AKABKA圍術期30天內心臟病發生率和致死率,及術後3年和10年病死率。通過多元回歸分析圍術期30天內DM對心輸出量的影響,通過Cox 回歸分析評估DM對其術後長期生存的影響。AKA圍術期心臟事件(心臟猝死或非致命性心梗)發生率6.8%,而BKA3.6%。中期生存率AKA20月)明顯低於BKA52月)(P < 0.001)。DM不是圍術期30天致死率或術後3年生存率的顯著預測因素(分別odds ratio, 0.76 [0.39-1.49]; P = 0.43Hazard ratio, 1.03 [0.86-1.24]; P = 0.72),但可預測術後10年生存率(Hazard ratio, 1.34 [1.04-1.73]; P = 0.026)。截肢術的部位和腎功能不全史是圍術期30天死亡率的顯著預測因素(分別odds ratio, 4.35 [2.56-7.14]; P < 0.001odds ratio, 2.15 [1.13-4.08]; P = 0.019)。因此,AKA被認為是高風險手術,BKA是中風險手術。無論是否有糖尿病,AKABKA長期生存率都是低的。

(吳德華譯 薛張綱校)

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.

 

評估新生兒體外迴圈中標準肝素的劑量對凝血酶作用的影響

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

 

作者通過測量肝素的活性,凝血酶形成和凝血酶活性來對比新生兒和兒童CPB時肝素化的充分程度。選擇需行CPB10個新生兒和10個兒童,CPB前給予400U/kg肝素。測量基點, CPB開始後30minCPB停止後即刻,CPB停止後3h24h肝素抗-Xa活性,凝血酶原片段1.2F1.2),血小板因數AFPA)。新生兒組中,CPB期間和CPB後即刻肝素抗-Xa活性明顯下降;F1.2 FPA水平在基點時較高,CPB開始後降低,並且增加到大於兒童CPB後水平。資料表明,用標準肝素劑量,新生兒顯示CPB期間更低的肝素抗-Ka 活性,而其高的F1.2FPA基點水平表明術前他們具有比兒童更高的凝血活性。新生兒CPB開始後起初F1.2FPA有降低,可能是血液稀釋作用,但隨後增加則表明CPB期間和CPB後顯著更高的凝血酶形成和凝血酶活性。結果揭示了新生兒400U/kg肝素可能在CPB期間抑制凝血酶形成和活性是不充分的。

(吳德華譯 薛張綱校)

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發揮劑量依賴而非年齡依賴的抗傷害性疼痛作用及年齡依賴性催眠作用

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,一種{alpha}2腎上腺素能受體激動劑,是成人有效的鎮痛和鎮靜劑,但它對兒童是否有效卻鮮有報導。有些麻醉劑具有年齡依賴性的鎮痛作用,例如,笑氣對於新生仔鼠是相對無效的。我們研究了右旋美托咪啶的鎮痛和催眠作用,選擇年齡分別為7天、15天、19天、23天和29天的幼鼠及成年大鼠共6組,使其暴露於右旋美托咪啶(1050µg/kg)或生理鹽水。用福馬林蹠肌試驗模擬炎性疼痛,用免疫組化和行為方法來評價效果。右旋美托咪啶的催眠作用以正向反射喪失來評價。福馬林給藥途徑在每一年齡組均引起典型的傷害性疼痛反應;這種傷害性疼痛反應在所有應用右旋美托咪啶50µg/kg的年齡組有顯著減弱(P < 0.05),而應用右旋美托咪啶10µg/kg效果甚微。新生仔鼠顯示了對右旋美托咪啶最好的催眠敏感性(P < 0.05)

(王麗珺譯 薛張綱校)

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).

 

全麻在自主壓力反射指數上的濃度依賴性效應及兩者的藥理學增效關係

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.

 

心率和動脈血壓自發產生的波動提供了對心臟迷走神經功能的無創判定。但關於全麻對自主壓力反射(SBR)指數的影想所知甚少。我們研究了(a)七氟醚在SBR指數、心率變異性(HRV)、血壓變異性(b)方面的濃度依賴性效能以及在七氟醚麻醉過程中,藥理學壓力反射增效和SBR指數之間的一致性和相互關係。我們對9名健康志願者用七氟醚實施麻醉,在麻醉前、麻醉中及麻醉後3小時持續進行心電圖和有創動脈血壓監測,七氟醚的潮氣末濃度按隨機序列維持在0.7%1.4%2.0%。我們計算了三項SBR指數(順序方法、α-指數及低頻傳遞函數)並通過藥理學方法把它們與加壓及降壓試驗的增效相比較,心率變異性(HRV)和血壓變異性用清醒和麻醉條件下的固定呼吸頻率(12/分)分析。除了低頻傳遞函數,與清醒時的基線值相比,應用七氟醚不僅使SBR指數在麻醉過程中有所降低,在蘇醒後的30分鐘內也仍然降低。心率變異的自主順序指數和高頻、低頻效能顯示了濃度-依賴性的衰減。藥理學增效和SBR指數在麻醉期間總體來說具有很好的相關性,但是Bland-Altman分析揭示了SBR指數和壓力反射增效本身一樣具有一致性方面的限制。這些資料表明在七氟醚麻醉中,自發的指數是對藥理學壓力反射增效不恰當的評價,兩者之間存在矛盾。

(王麗珺譯 薛張綱校)

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.

 

氧化亞氮對羅庫溴銨劑量回應關係的影響

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

 

普遍認為氧化亞氮(N2O)增強非去極化肌松藥的作用極弱。最近很多證據表明N2O複合全靜脈麻醉(TIVA)下藥物潛能更強烈。我們對35個患者接受N2O-異丙酚-阿片類複合麻醉和接受TIVA作為對照組測量了羅庫溴銨50%的有效劑量。羅庫溴銨每個病人給單次劑量,每個人的藥物潛能通過HILL方程計算,假定logdose/4.52個組,麻醉誘導後15分鐘給肌松藥。神經肌肉功能通過單次0.10Hz刺激用肌電描記法測量。我們測得50%有效劑量TIVA中為0.209+/-0.051mg/kg,在N2O麻醉中為0.166+/-0.041mg/kg,降低了20(P<0.001)。該結果的臨床重要性必須適度考慮,然而, N2O麻醉中所獲得的潛能的評估可能低估麻醉誘導期間藥物需求。

(孫志榮譯 薛張綱校)

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.

 

異丙酚和阿芬太尼維持的麻醉中腦電圖監測: 第二頻譜的作用

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.

腦電(EEG)雙頻譜指數已用於麻醉監測。在二 階係數微小的情況下,也就是僅僅是獨立於頻 率的常數,二階係數的估計允許我們判斷是否 給定時間代表了一個線性隨機過程。這個研究 中,我們調查了在異丙酚和阿芬太尼維持的外 科手術麻醉中非微小二階係數的EEG點所占比 例來作為EEG非線性的程度。重複分析了記錄 下的來自20位行Hinich操作的腹部手術患者90 小時EEG,進行了統計分析,基於如下假設: EEG是線性隨機序列。在幾乎90%去偽相的固 EEG點,發現二階係數接近零或僅是常數。 在這些情況下,EEG可以認為是線性隨機序列 。我們的發現提示麻醉狀態下EEG監測取得的 頻率域中的頻譜資訊已大大的包含了信號的功 率譜。這對EEG雙頻譜指數在麻醉監測中的作 用提出了疑問。

(蔡美華譯 薛張綱校)

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.

 

胸段硬膜外麻醉及鎮痛聯合切皮前美沙芬的應用對腸切除術後疼痛及腸功能恢復的改善作用

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

 

腸切除術後的劇痛及腸梗阻延長了患者的出院時間. 在先前的研究中,我們已經證明消炎痛(IM)和美沙芬(DM)能夠提供超前鎮痛並改善術後疼痛. 而胸段硬膜外麻醉(PEA)及術後胸段硬膜外鎮痛(PCEA)的優點已經得到廣泛的證實. 故此次研究的目的是瞭解術中PEA PCEA 與切皮前IM DM 聯合應用對腸切除術後疼痛及腸功能恢復的效果. 病人被隨機分為三等組分別接受: 1)撲爾敏(CPM)20mg 及全身麻醉(GA)(CPM-GA ); 2)CPM 20mgTEA(CPM-TEA); 3)DM 40mg(CPM 20mg) GA並聯合TEA(DM-TEA). 在切皮前30 分鐘行全麻誘導,後給予CPM, DM(肌注), 及用利多卡因的TEA,並且所有的患者術後都接受PCEA鎮痛. 我們使用直觀類比標度對連續72 小時術後休息或是活動的效果進行評估,這些指標是: 第一次使用PCEA的時間; PCEA的總消耗量; 及第一次排氣的時間. 術後疼痛及腸啊功能的改善以如下順序排列,並且這種改善在統計學上有者明顯的意義: DM-TEA > CPM-TEA > CPM-GA . CPM-TEA相比DM-TEA 在疼痛評估上平均少了1.6個百分點; 在第一次使用PCEA時間上長了40分鐘; 72小時總量消耗少了15.8ml; 並且排氣時間提前了14.7小時(所有的P 值都小於0.01). 我們於是得出了切皮前DM(40 mg 肌注),術中TEA及術後PCEA可以加強鎮痛,並能促進腸功能的恢復. 提出可能存在的協同作用能減少利多卡因及阿片類藥物的用量.

(許文妍 薛張綱 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

曲馬多及其代謝產物對蟾蜍屬卵母細胞氨基乙酸γ-氨基丁酸N-甲基天冬氨酸受體表達的作用

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

 

我們評估了中樞性鎮痛藥曲馬多及其代謝產物對神經遞質門控離子通道的作用。 曲馬多抑制μ受體,但是親和力弱,能阻止中樞神經系統單胺的再攝取.這些作用使其具有抗疼痛作用。然而對於曲馬多其他作用卻知之甚少。我們檢測了曲馬多及其代謝產物(0.1-100 muM)對人重組神經遞質門控離子通道包括氨基乙酸、γ-氨基丁酸(GABA(A))N-甲基天冬氨酸(NMDA)受體在蟾蜍屬卵母細胞表達的作用。曲馬多及其代謝產物對氨基乙酸受體無任何作用,γ-氨基丁酸(GABA(A))受體只有高濃度(100 muM)時才顯著抑制,N-甲基天冬氨酸受體抑制則呈濃度依賴性。曲馬多及其代謝產物能夠有效抑制谷氨酸鹽-濃度反應曲線而不改變其最大半數有效濃度和Hill係數,這表明是非競爭性抑制。這項研究表明氨基乙酸受體不參與曲馬多的鎮痛效應而高濃度抑制γ-氨基丁酸受體可能與驚厥相關。抑制N-甲基天冬氨酸受體可能與相對高濃度的曲馬多鎮痛效應有關。

(沈洪 薛張剛 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.

 

在不確定未來工作量的情況下使用一定財政支出進行選擇性手術室資源擴張的策略

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.

 

若決定增加手術室的數目,各個手術室的時間分配是很容易的。手術室的時間分配要分兩步走:第一步是長期的統籌安排,第二步是短期的手術安排。統籌安排要考慮到最近一年的發展情況,還需要哪些特殊的儀器和專家。這些考慮都是基於對未來一年各專科和外科醫生的手術量的估計得出的。有一些外科醫生可以排出在外,比如那些需要ICU床位的醫生和同樣使用手術室一小時,創造的利潤最低的醫生。根據餘下外科醫生實際情況,估計未來手術室使用時間的上限和下限。因此,在只瞭解部分未來手術量資訊的情況下,就可以完成最初的手術室分配。當新手術室啟用後,根據實際情況調整手術室使用時間和人員分配,原則是使手術室利用率更高。對於那些在第一階段安排中沒有得到額外時間的外科醫生來說,根據他們實際工作量情況進行調整,適當增加手術室使用時間。一個三級醫院的病例報導指出,今後手術醫生需要量估計只有目前的15%,因此這一種手術室分配決策是有可行性的。

(金琳 譯, 薛張綱校)

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產物試驗(Gastrotest)與腸內營養相關胃腸併發症之間的關係

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

 

胃腸營養相關併發症(GICs)在危重病人中多見。不幸的是病人存在GICs危險因素是不容易被明確的。因此,我們對20個病人進行了一項明確五肽胃泌素刺激胃腔酸性產物試驗與GICs之間的關係的前瞻性研究。在予以胃腸營養之前,皮下注射五肽胃泌素(Gastrotest)胃液pH值的相應變化被測得。每個病人在重症監護室(ICU)治療期間,我們記錄了GICs與胃腸營養量的比值。對19個病人的資料進行分析以及9個病人(47%)有1 GIC,包括胃大部殘留,26%;腹脹,26%;以及嘔吐,21%。有GICs的病人在ICU停留較長時間(平均21.3,範圍5-45相比平均10.1,範圍3-32P < 0.05)。在開始腸內營養之前有Gastrotest反應的9個病人(47%)存在明顯較大的容量比值(P = 0.01)和較少的GICs1 [11%]相比8 [80%]P<0.05)。腹脹僅在無Gastrotest反應的病人發生。這次試驗陽性和陰性預測值對 GICs的預測能力分別80%88.9% 認為五肽胃泌素刺激胃腔酸性產物試驗與較大容量腸內營養攝入相關與GICs相關聯較少。

(孫敏莉譯,薛張綱校)

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.

 

異氟烷吸入時低碳酸血症對腦血流量自身調節的影響

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

 

異氟烷對腦血流量自身調節的抑制作用呈劑量依賴。過去的一些研究顯示在其他條件下受抑制的自身調節可經過度通氣恢復。我們假設低碳酸血症可以使受異氟烷麻醉而抑制的腦血流量自身調節恢復。我們對預先選定的年齡在21-59歲之間行非神經外科手術而無其他疾病的患者予異氟烷加純氧吸入。根據個體情況控制呼氣末異氟烷濃度,使其低於能引起短週期等電位腦電圖濃度0.1% 0.2% 。這使呼氣末異氟烷濃度控制在1.6% +/- 0.2% ,相當於最小肺泡麻醉濃度的1.4倍。根據需要靜注瑞芬太尼使平均動脈壓降至80 mm 。靜注新福林使平均動脈壓保持在100 mm Hg ,通過經顱多普勒超聲波檢查監測大腦中動脈血流速度以評價腦血流量的自身調節功能。流速的改變被用來計算自身調節指數。自身調節指數變動在01之間,且指數小於等於0.4 表示有明顯的自身調節抑制。自身調節隨即測試兩次。分別于正常二氧化碳血(Paco238-43 mm Hg)和低碳酸血症期 (Paco227-34 mm Hg)。在正常二氧化碳血時自身調節指數的中位數為0.29 (0.23-0.64) 而低碳酸血症期為 0.77 (0.70-0.78) (P < 0.005). 在正常二氧化碳血時12 個樣本中有8人的腦血流量自身調節被明顯抑制,低碳酸血症期則無人被抑制 (P = 0.001)。低碳酸血症可以恢復由於異氟烷引起的腦血流量自身調節的抑制。

(孫少瀟譯 薛張綱校)

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.

 

美國局部麻醉協會最新指南中關於對預先低分子量肝素化行較大型矯形手術的病人進行脊神經麻醉的建議
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,第二屆美國局部麻醉協會協商會就局部麻醉的連續安全性問題發表了聲明特別對於的有預先低分子量肝素化的病人行較大型矯形手術進行脊神經麻醉。2003年的會議報告明確表達對預先低分子量肝素化的病人進行局部麻醉可能是安全的。依靠根據局部麻醉的時間和期間的管理而對低分子量肝素化的首劑和後續劑量的給予時間和日最大劑量做出相應的調整將會使病人的安全性得到優化。因為對有預先低分子量肝素化預防血栓的病人給予局部麻醉是一次臨床上的挑戰,所以麻醉科醫師應該盡可能保證實施手術的每一個人員對相關的最新文獻和實踐指南如目前美國局部麻醉協會指南有一個理解。

(孫少瀟譯 薛張綱校)

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.

 

肩部手術後行病人自控斜角肌內鎮痛:後路留置導管

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.

 

通過側路或前路方法置入並維持斜角肌內導管具有技術挑戰性。我們在120個行肩部手術的病人中介紹另一項技術:通過套管針技術從頸後部置管並予48小時輸注0.1%羅呱卡因(5 mL初始劑量後5 mL/h,鎖定間隔時間20分鐘)來提供持續臂叢神經阻滯。所有導管均成功置入,無技術上的併發症(如置管失敗、誤入血管、硬膜外或蛛網膜下腔),無導管脫出或鎮痛藥液滲漏。12個病人出現聲音嘶啞,4個出現霍納氏綜合症,1個出現呼吸困難。1個病人主訴有輕微的感覺異常,可自行緩解。3個病人主訴頸部疼痛。疼痛評分及羅呱卡因需要量(通過病人自控鎮痛裝置給予)均較低。但仍需大樣本研究評估急性和非急性併發症來比較本方法和現有技術的效果及安全性。

(周曉敏 薛張綱 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.

在膝以下部位手術中坐骨神經阻滯是否能耐受大腿部止血帶反應?

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.

 

在這個前瞻性、隨機、盲法的研究中,我們評估Labat’s或膕窩後進路的坐骨神經阻滯在膝以下部位手術中大腿部止血帶反應的耐受性。120名患者分為2組每組60人。膕窩後路(Group 1)或Labat’s(Group 2)坐骨神經阻滯用25ml1%的甲呱卡因加1:200000的腎上腺素完成。每組都達到股神經阻滯。患者在阻滯過程中的舒適度、感覺阻滯、成功率以及大腿部止血帶反應的耐受性都做記錄。Group 1在阻滯過程的舒適度明顯優於Group 2(P < 0.01)t30 min. 時阻滯的完全性以及成功率兩組相似。兩組患者大腿部止血帶疼痛都隨時間而加劇,沒有顯著差異。我們認為儘管在91%的患者中股後皮神經感覺阻滯完全,但是Labat’s進路的坐骨神經阻滯較膕窩部進路不能更好地耐受大腿止血帶反應。膕窩進路可以達到同樣阻滯效果且患者感覺更舒適,是膝部以下手術的首選麻醉方法。

(費敏譯 薛張綱校)

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.

 

-聲帶長度的評估

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

 

經鼻插管常是纖支鏡插管的首選。經鼻放置一根塗有潤滑油的氣管導管能引導纖支鏡到達喉部,如果能預測鼻-聲帶的長度(NV長度),並放置氣管導管使其頂端能接近聲帶,有利於纖支鏡經過氣管導管最清晰地顯示聲帶。本研究我們測量了鼻-聲帶的長度,及其與體表標誌的關係。選擇50例男,45例女病人,在全麻下行選擇性外科手術,用纖支鏡測量他們鼻-聲帶長度。同時測量患者兩邊鼻兩側到耳屏的距離(NE 距離)和鼻到下頜角的距離(NM距離),並記錄患者的年齡、身高和體重。測量結果是NV長度男性為18.3 +/- 0.8 cm,女性為16.3 +/- 0.7 cmNV長度與身高和NE距離具有顯著相關性,而與NM距離沒有顯示相關性。因此,NV長度能通過身高或NE距離來預測。

(吳德華譯 薛張綱校)

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.

 

在日本非心臟手術期間心血管事件的發生率和美國及歐洲相同嗎?

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,術前評估伴有缺血性心臟疾病病人中一直存在的一個問題是:這樣的評估是建立在西方的資料上的,卻被作為判斷日本病人術中風險的根據。為了解決這個問題,1997年建立了心臟缺血和麻醉研究委員會,來指導日本非心臟手術中併發症的研究。在1997年的兩個回顧性研究中,伴有缺血性心臟疾病的病人比率為3.9%3.1%,約為美國和歐洲報導的十分之一。伴有缺血性心臟疾病的病人術中心血管併發症的發生率為16.4%13.2%,與美國和歐洲報導的發生率沒有很大差異。為了研究術中併發症的基本特徵,作者設計了一個前瞻性研究,物件是237名根據美國心臟學院/美國心臟協會指南中的非心臟手術的術中心血管評估表評定為中度術中心臟併發症風險的病人。作者發現術中心臟併發症的首要因素是高血壓(優勢比= 2.911)。術後心臟併發症的因素為反射性冠脈病變的嚴重程度和心功能不全 (心衰史, 優勢比= 6.884 冠心病危險指數分級,優勢比= 2.884;治療史; 優勢比= 4.774).(殷文淵 陳傑 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).

 

在小兒心臟手術中常規使用經食道超聲心動圖的費用-效益比:10年經驗

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.

在內科和手術治療先天性心臟病兒童過程中使用經食道超聲心動圖的益處已被公認。然而,它的費用-效益比沒有深入研究。作者分析了從19941月至200312月期間50817歲以下需要接受先天性心臟手術的病人常規行TEE檢查的報告。排除術後立即死亡的病例後,判定33名(5.7%)有明確指征需要再次體外迴圈,例如再手術,通過TEE發現而受益的病人。通過對所有固定和不固定費用分析顯示每名兒童可節約8502655瑞士法郎(CHF)。這些數字低估了術中常規進行TEE的真正費用-效益比,較低估計了受益而較大地估計了花費。TEE在血流動力學監測和內科處理,在降低術後死亡率以及在提高生活質量方面的潛在益處是無形的。雖然受益和花費會隨市場條件、病人數量、外科技術和TEE的技術而變化,作者認為他們的分析顯示在兒科心臟手術期間常規進行TEE的真正費用效益關係。

(殷文淵 陳傑 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.

 

小兒心臟外科手術後應用Vasotrac測壓和有創動脈血壓監測的比較

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是一個可提供近似連續血壓監測的無創動脈血壓監測裝置,並可能成為直接動脈內測壓的替代選擇。此裝置應用于成年病人已進行過評估,但有關兒科病人應用的資料卻非常有限。本研究的目的主要是評估兒科病人分別通過 Vasotrac和動脈導管監測動脈血壓和心率時是否具備一致性。選擇實施心臟矯治手術的兒童為研究物件,在術後同時通過Vasotrac和動脈導管監測動脈血壓。在研究過程中通過構建Bland-Altman曲線來評估二種測壓方式之間的一致性。並對研究所得資料進行配對相關分析、偏倚分析和精確度計算。研究物件共16名病人,平均年齡為10.1 ± 2.3歲,平均體重為34.6 ± 11.9 kg。研究中共採集到4102對資料。研究結果發現Vasotrac無創動脈血壓監測與動脈導管血壓監測之間在收縮壓、舒張壓和平均動脈壓的Pearson r值分別為0.900.800.91(P < 0.001)。兩種測壓方式之間存在良好的一致性。收縮壓、舒張壓和平均動脈壓進行混合模型回歸分析,其95%可信區間的絕對平均差分別為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,兒科病人應用Vasotrac測量動脈血壓與有創動脈血壓監測之間具備良好的一致性。

(齊波 陳傑 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.

 

單次和多次口服環氧化酶2抑制劑羅非考昔時腦脊液和血漿中的藥代動力學

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.

單次或多次口服環氧化酶2抑制劑時的腦脊液(CSF)藥代動力學與臨床效應相關,其原因可能因為這些藥物的鎮痛效應。作者選擇9個受試者鞘內植入導管作研究。口服50mg羅非考昔後,發現CSF藥物濃度緩緩地逐漸小於其血漿藥物濃度。CSF24小時藥物濃度曲線下面積(AUC)與血漿24小時AUC的比率為0.142。在連續給予羅非考昔50mg/d 9天後,發現第9天的血漿和CSF藥物濃度要大於第1天,第9天的血漿和CSF 24小時AUC均是第1AUC2倍。在連續給予羅非考昔9天後,AUCCSF/AUCplasma0.159。本研究的重要發現CSF羅非考昔水平約為其血漿水平的15%,並且通過每天重複給藥,其CSF AUC可超過原水平的兩倍。

(齊波 陳傑 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.

 

老年患者髖骨骨折手術時靶控輸注異丙酚,手動控制輸注異丙酚和依託咪脂/地氟醚麻醉的比較

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.

 

麻醉期間,藥物的副作用對老年患者具有更高的危險性,尤其是麻醉對心血管功能的影響。在這項前瞻性、隨機的研究中,作者選擇接受髖骨骨折手術的老年患者,分為三組,分別給予依託咪脂/地氟醚麻醉(ETO/DES組),靶控輸注異丙酚麻醉(TCI組),和手動控制輸注異丙酚麻醉(MAN組),記錄其誘導質量,血液動力學變化和恢復的情況。16個患者先給予依託咪脂(0.4mg/kg),然後吸入地氟醚,從初始呼氣末濃度為2.5%逐步增加。18個患者接受靶控異丙酚麻醉,從初始濃度1ug/mL開始逐漸增加,每次增加0.5ug/mL15個患者在60秒內用異丙酚1mg/kg快速誘導,然後泵注異丙酚5mg/kg/h 所有患者都泵注阿芬太尼0.4ug/kg/h,總量為20ug/kg。根據血流動力學變化,吸入地氟醚的濃度或異丙酚(TCI組)和異丙酚輸注速度(MAN組)的每次調節劑量分別為20%和50%。在TCIETO/DES組中,使平均動脈壓維持在基線水平的15%和30%間時間,分別佔用了總麻醉時間的60%和80%。而在MAN組中,使平均動脈壓維持在基線水平的15%和30%間時間,為總麻醉時間的30%和60%。在MAN組中,麻醉藥物的調節次數較多,為6.4±2.8,而ETO/DES組為2.5±1.2TCI組為2.6±1。作者認為對於老年患者TCI模式麻醉能改善異丙酚對血流動力學的影響。

(顧漪聞 陳傑 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.

 

紅黴素和氟伏沙明對靜脈利多卡因藥代動力學的影響

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(細胞色素P450 3A4)的抑制劑對利多卡因藥代動力學有輕微的影響。作者通過一項雙盲,隨機,三方交叉的實驗來研究同時使用抗抑鬱藥物氟伏沙明(CYP1A2抑制劑)和抗菌藥物紅黴素(CYP3A4抑制劑)對利多卡因藥代動力學的影響。9個志願者5天內分別每天服用100mg的氟伏沙明和安慰劑,或100mg氟伏沙明和1500mg紅黴素,或相應的安慰劑。在第六天,靜脈內給予利多卡因1.5mg/kg超過60分鐘。10小時後測量利多卡因及其主要代謝產物一乙基甘油二甲基苯胺的濃度。單獨給予氟伏沙明時,降低了41%利多卡因清除率(p0.001),並且延長了它的清除半衰期,從2.6小時到3.5小時(p0.01)。聯合使用氟伏沙明和紅黴素時,利多卡因的清除率比對照組小53%,比單用氟伏沙明組小21%(p0.05)。在聯合使用組中,利多卡因的半衰期(4.3h)比對照組(2.6h; p0.001)或單用氟伏沙明組(3.5hp0.01=)長。作者認為CYP1A2抑制劑(氟伏沙明)可能減少利多卡因的清除,因此可能會增加利多卡因的毒性。如果同時使用氟伏沙明和CYP3A4制劑如紅黴素,更可能通過減少利多卡因的清除來增加利多卡因的血漿濃度。

(顧漪聞 陳傑 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.

 

一項評估模擬團隊訓練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.

 

團隊行為和協調性,尤其是交流或團隊資訊共用,對於優化團隊工作至關重要。但在醫學研究中通常不能提供合理的方法來評估團隊資訊共用。在一對照的模擬設置中,作者用一項技術,測定參加為期一天的麻醉危機處理課程的受訓人員的臨床資訊,並作為整個團隊資訊共用的一項指標。儘管團隊的資訊共用的程度低,用訓練中所測量的團隊資訊共用的變化與自我評定變化的相關性來論證該方法學的準確性。儘管這門課程將對受訓人員的理論和實踐有用,但訓練中團隊資訊共用始終沒有統計學上的差別。

(朱輝 陳傑 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.

 

術前加巴噴丁減少焦慮和提高膝手術後的早期功能恢復

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.

 

加巴噴丁具有抗痛覺過敏和抗焦慮的作用。作者假設全麻下行關節內窺鏡下膝前十字韌帶修補術的病人術前服用加巴噴丁可減少焦慮,提高術後鎮痛和早期膝關節的運動,並驗證此假設。40例病人術前1~2小時隨機口服1200mg加巴噴丁或安慰劑,標準化麻醉。手術結束前30分鐘給予嗎啡0.1mg/kg,術後採用病人自控鎮痛。記錄48小時內疼痛評分和嗎啡用量。每天2次的理療,記錄膝關節的主動和被動曲伸度。術後焦慮值加巴噴丁組小於對照組(視覺類比評分範圍28±16mm66±15mmp0.001)。加巴噴丁組嗎啡需求量少於對照組(29±22mg69±40mgp0.001)。加巴噴丁組在休息和活動後的視覺類比刻度疼痛分值明顯降低。加巴噴丁組在2448小時的首次和最大膝關節屈曲度比對照組大。總之,關節內窺鏡下膝前十字韌帶修補術的病人術前服用加巴噴丁1200mg能減少術前焦慮,改善術後鎮痛和早期膝關節的運動。

(朱輝 陳傑 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.

 

成人採用吸入還是靜脈誘導?術前病人選擇調查

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.

如果讓病人選擇,他們願意選擇吸入還是靜脈麻醉誘導?經過倫理委員會批准後,作者調查240例外科門診手術病人:212例病人(88%)有麻醉史,其中203(96%)採用靜脈誘導,5 (2%)採用吸入誘導,4(2%)無麻醉誘導記錄。調查顯示78例病人(33%)願意選擇靜脈誘導,120 例病人(50%)選擇吸入麻醉誘導,42 (17%)未作選擇。七氟醚成功地用於154例自己選擇麻醉的病人。在美國,傳統的觀點認為大多數病人厭惡麻醉面罩,但研究結果似乎和以往觀點矛盾,並且顯示更多的人對靜脈穿刺持恐懼態度。在有足夠的人力和設備力量條件下,沒有返流和氣道管理困難,建議成年病人術前諮詢其選擇麻醉誘導方式。

(潘志英 陳傑 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.

 

無法插管-無法正常通氣(CICV)病人和困難插管策略:加拿大全國性調查

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

.

本研究目的是調查加拿大麻醉醫生如何處理插管困難和無法插管-無法正常通氣(CICV)病人。通過信件調查,作者諮詢麻醉醫生喜歡採用下列何種處理方案及使用滿意度:(a)在困難插管時更換氣管插管設備;(b)在CICV情況下採用聲門下氣道通氣。統計學處理採用卡方分析和t檢驗。2066例調查中971例得到反饋。在困難插管病人中首選的更換工具是光導管(45%),纖維光學支氣管鏡(26%),喉罩(20%)57%的回應者遇到CICV的情況。在CICV狀況下,首選聲門下通氣,常採用靜脈套管針環甲膜穿刺術(51%),經皮環甲膜切開術(28%),氣管切開(14%)。麻醉科醫生沒有通過手術進行聲門下氣道通氣經驗,但可在人體模型上練習後勝任聲門下氣道通氣(P < 0.001)。綜上所述,在困難氣管插管情況下,光導管是首選的更換設備。在CICV狀況下,靜脈套管針環甲膜穿刺術為首選,隨後是經皮環甲膜切開術、氣管切開術。在人體模型上練習有助於提高聲門下氣道通氣的技能。

(潘志英 陳傑 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.

 

犬選擇性腦低溫可抑制傷害性刺激引起的體動

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.

全身低溫可抑制傷害性刺激引起的體動,但是作用的主要部位尚不清楚。作者通過選擇性降低腦部溫度,研究腦部低溫對傷害性刺激引起體動的影響。16只實驗犬用異氟醚/氧氣進行麻醉,隨機分為兩組。在深度麻醉後,對犬肺行人工通氣,置入幾個主要的管道以進行灌注和監測。右椎動脈灌注冷的乳酸林格液,對腦部進行降溫,同時維持軀幹的溫度相對較高。當腦部溫度降低到20℃或25℃,停止吸入異氟醚,此時軀幹溫度分別約為34.7℃和34.6℃。呼氣末異氟醚濃度為0%時,用兩根25G的針電刺激尾部,腦溫20℃組對刺激均無反應,而腦溫25℃組8條犬中的7條對刺激有反應。這些結果提示對實驗犬進行選擇性腦部低溫(20)可抑制傷害性刺激引起的體動。

(趙延華 陳傑 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.

 

腰麻下行剖腹產時經皮電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.

 

有幾項實驗已經應用經皮電刺激(TES)研究腰麻時阻滯程度的差別。這些TES刺激被認為可代替外科刺激來反映阻滯程度,但是沒有研究顯示區域阻滯時TES是否可代替外科刺激。作者研究剖腹產手術病人是否能耐受無痛性TES20名婦女在腰麻下行選擇性剖腹產,應用無痛性TES10mA50Hz,持續1s)對五個不同區域的皮膚進行刺激。這些病人在手術過程中均不感到疼痛,但是對TES感覺阻滯的水平有差異,30%的病人能感知T10及以下水平的TES刺激。對T6或更高水準刺激的感知是一致的。無痛性TES刺激能夠在直接傳遞手術刺激的皮膚感覺區域被感知,此時病人完全感覺不到疼痛,這一事實提示在測試區域內TES代替手術刺激來反映阻滯程度並沒有實際應用的價值。

(趙延華 陳傑 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經導管置管可改善導管放置的位置嗎?一項隨機對照單盲試驗

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.

 

膝關節大手術後外周神經的連續阻滯可以提供長時的術後鎮痛並且加速功能的恢復。傳統的神經定位由神經刺激針定位後置入外周神經導管。通過鎮痛效果的試驗來糾正導管的位置。在導管放置過程中刺激導管有利於糾正位置,使其靠近神經處。本隨機實驗的目的是應用具有刺激功能的股神經導管置管,觀察感覺和運動神經阻滯的起效時間及是否有利於術後鎮痛和功能的恢復。在膝關節大手術的81位病人中,作者比較了用連續刺激置入股神經導管和傳統盲探法股神經導管置管方法的差異。導管放入時間相似:傳統組為4分鐘(3/7.3;中位數,百分位數第25比第75值),刺激導管組為5分鐘(4/8.8)。兩組中第一次放置有42%的導管位置準確(髕骨的運動反應電流0.5mA)。刺激組中22位病人(58%)的導管被重新改變方向1-20次,包括2例在20分鐘內未被準確放置。兩組運動和感覺神經阻滯的起效時間相似。術後5天內靜脈用阿片類藥物的用量,靜息和運動時的視覺鎮痛評分,膝關節的最大彎曲和伸展沒有差異。結論:連續刺激法神經阻滯和傳統的盲探法神經阻滯在感覺和運動神經阻滯的起效時間,術後鎮痛和功能恢復上沒有差異。

 

(忻紀華 陳傑 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.

 

術前焦慮評分是否有助於預測術後噁心和嘔吐的發生?

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.

術前焦慮曾被認為可預示術後噁心和嘔吐(PONV)的發生,但缺乏資料支援。作者對1389例各類手術病人,量化術前焦慮預測值,用logistic多因素回歸分析來建立PONV的預測模型。研究的預測指標包括有PONV史或運動系統疾病,吸煙,性別,年齡,種族,體重指數,ASA分級,手術類別,麻醉時間,麻醉方法及術後阿片類藥物鎮痛史。通過Spielberger State-Trait焦慮分級和阿姆斯特丹術前焦慮和資訊評分來評價焦慮程度。PONV的發生在術後的第一個24小時。logistic多因素回歸分析模型中特徵性曲線下的面積為0.7295%的可信區間,0.70-0.74),包括性別,年齡,吸煙,PONV史或運動系統疾病,手術類別和麻醉方法。焦慮和PONV相關但相關性弱,加入焦慮因素的模型接受機操作特徵曲線下的面積並沒有增加。所以,常規的術前焦慮評分並不見得有用,另外一些預示因素已被考慮。

(忻紀華 陳傑 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.

 

雷米芬太尼用於心臟手術病人的術後鎮痛

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

 

雷米芬太尼是一種短效的阿片類藥物,常用於心臟手術的麻醉。本研究試圖在心臟手術後氣管導管拔除病人中證實疼痛治療的可行性及確定雷米芬太尼提供足夠鎮痛的必需劑量。本研究包括30例擇期行心臟手術的病人。術後,一開始將術中使用的雷米芬太尼繼續維持在0.05 µg · kg–1 · min–1。氣管導管拔除前,使用非甾體類抗炎藥,並將雷米芬太尼減少至0.035 µg · kg–1 · min–1。氣管導管拔除後使用視覺類比量表(VAS)作疼痛評分:10 min內每2min一次,以後每10 min一次至第一小時結束,再以後的5 h裏每30min一次。當一個VAS評分30或呼吸頻率<10/分時,分別將雷米芬太尼的劑量增加或減少0.005 µg · kg–1 · min–1。第一個10min為快速劑量適應,增加雷米芬太尼0.005 µg · kg–1 · min–1兩次,然後增加0.01 µg · kg–1 · min–13次。30 min後,雷米芬太尼的平均劑量為0.051 µg · kg–1 · min–1VAS評分降低至26 ± 14。當雷米芬太尼的劑量在0.03 0.09 µg · kg–1 · min–1範圍內時,病人能得到充分的鎮痛。4h後雷米芬太尼的最大平均劑量達0.057 µg · kg–1 · min–1。氣管導管拔除後30min,使用雷米芬太尼複合非甾體類抗炎藥能為73%的病人提供足夠的鎮痛。在最初的10 min50%的病人必需快速劑量滴定。增加雷米芬太尼的初始劑量能縮短滴定期,但可能引起呼吸併發症。

(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.

回顧抑肽酶在原位肝移植中的應用:它的有害作用會抵消它的有益作用嗎?

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

 

輸血會對原位肝移植(OLT)患者的預後和移植肝的生存產生不良影響。從這一方面考慮,預防性應用抑肽酶能減少進行OLT的患者的失血量、輸血的需求量及移植肝再灌注時的血流動力學改變。然而,資料表明應限制抑肽酶在OLT中的應用:(a)在慢性肝疾病或進行OLT的患者中記錄的臨床、生物學、超聲心動圖及屍檢發現表明在這些患者中存在持續的前凝血狀態。抑肽酶治療對纖維蛋白溶解的抑制作用是否會使一些患者發展到不適當的血栓形成仍是有疑問的;(b)抑肽酶似乎不能改變進行OLT的患者的術後結果;(c)抑肽酶只在手術有明顯的失血時能減少輸血需求。而目前OLT仍需要2-5U紅血球的中等輸血量。

(陳瑋 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.


行心臟手術的嬰幼兒脊麻後的術後鎮痛

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

 

本項前瞻性、隨機、對照臨床試驗的目的是為了探討兒童以雷米芬太尼(REMI)或雷米芬太尼加脊麻(SAB+REMI)麻醉下行開心手術後阿片類鎮痛藥的需求量。我們以心臟手術後擬於手術室內氣管拔管的45例患兒為研究物件。排除標準為小於3個月和大於6歲、肺動脈高壓、充血性心力衰竭、SAB禁忌者以及未獲得知情同意者。所有病人以七氟醚吸入誘導,以雷米芬太尼和異氟醚(呼氣末濃度0.3%)維持麻醉。另外,分入SAB+REMI組的病人給以SAB 0.5–2.0 mg/kg丁卡因和7 µg/kg嗎啡。于手術室氣管拔管後,病人可以自控鎮痛方式每10分鐘靜脈注射0.3 µg/kg芬太尼,維持疼痛評分為4分。以後每小時記錄疼痛評分和芬太尼量,直至滿24小時或病人準備出ICU。結果SAB+REMI組患兒的疼痛評分(第一個8小時內P = 0.046;24小時內 P =0.05)和接受的IV芬太尼量(第一個8小時內P = 0.003; 24小時內P = 0.004)顯著低於REMI組。兩組間不良反應無差異,包括低血壓、心動過緩、最高PaCO2值、最低pH值、氧飽和度下降、搔癢和嘔吐。

(周志堅 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.


帕瑞考昔鈉和丙帕他莫用於成年患者腹股溝疝修復術後的腸道外術後鎮痛的隨機雙盲比較

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

 

新的環氧化酶-2選擇性的非甾體類抗炎藥注射劑(帕瑞考昔)從未與丙帕他莫(對乙酰氨基酚的腸胃外劑型)作過比較。在這個前瞻性的、隨機、雙盲、雙偽研究中,我們將182名預定于全麻下行初次腹股溝疝修補術的病人,在手術後12個小時內隨機單次注射了40 mg帕瑞考昔或兩次注射2g丙帕他莫。該研究的變數是嗎啡的消耗量、靜息時的疼痛程度與咳嗽時疼痛程度以及在手術後12個小時內病人的滿意程度。我們應用了Student’s t檢驗、{chi}2以及協方差分析進行了統計學分析。總的嗎啡消耗量在兩組之間沒有什麼差別。靜息時疼痛在帕瑞考昔組中較輕(P0.035)而兩組咳嗽時疼痛並無差別。副反應的發生率是相近的。帕瑞考昔組中有顯著更多的病人評價他們的疼痛處理為良或優的(87%對丙帕他莫組的70%,P=0.001)。在成年病人腹股溝疝修補術後的最初12個小時內,單次注射帕瑞考昔40mg與兩次注射丙帕他莫2g相比是相當的。

(黃麗娜  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.


腎上腺素的應用並不提高用異氟醚或地氟醚麻醉的大鼠對音調的恐懼學習

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

 

以前的報告表明腎上腺素的應用會提高大鼠在巴比妥鹽複合水合氯醛深麻醉過程中的學習,而並不提高兔在0.4%的異氟醚麻醉中的學習。我們以大鼠對音調的恐懼條件作用作為學習和記憶的實驗模型,,並以異氟醚和地氟醚作為麻醉劑來重新探討了這個問題。用能防止50%大鼠動反應的最小肺泡濃度(MAC)的一個分數來表示的遺忘音調恐懼的50%有效劑量ED50),在吸入異氟醚且腹膜內(i.p.)注射鹽水的對照大鼠中是0.32 ± 0.03 MAC(平均值±標準差),i.p.注射0.01 mg/kg腎上腺素的大鼠為0.37 ± 0.06 MAC,在i.p.注射0.1mg/kg腎上腺素的大鼠為0.38 ± 0.03 MAC。對於地氟醚,i.p.注射鹽水的對照大鼠遺忘恐懼的ED500.32 ± 0.05 MAC,在i.p.注射腎上腺素0.1mg/kg的大鼠是0.36 ± 0.04MAC。通過用大鼠對音調的恐懼條件作用進行評價,我們得出結論,外源性的腎上腺素並不降低因吸入異氟醚或地氟醚所產生的記憶缺失。

(黃麗娜 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.


在接受米庫氯銨的麻醉患者中用穩定的肌松/穩定的輸注速度方法證明的四個成串刺激“2個計數”與強直後“2個計數”之間的定量區別

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

 

在本研究中我們用穩定肌松/穩定輸注速度方法定量地評價了兩個標準化肌松水平――四個成串刺激(TOF)計數為2個反應與強直後計數(PTC)為2――之間的差異。10ASA分級I–II預定行擇期手術的已獲取同意的成年患者行麻醉(蘇芬太尼/異丙酚)、氣管插管、用混合O2/空氣正常機械通氣,且保持正常體溫;口咽和魚際溫度分別維持在36°32.5°C以上。從200 µg/kg米庫氯銨(MIV)部分恢復後,通過人為調節含MIV的輸注泵,使拇內收肌達到穩定的觸覺TOFPTC計數為2的肌松水平。一旦肌松水平和輸注速度在間隔5 min的連續4個時間點維持不變,就認為肌松水平和輸注速度是穩定的。觀察到的輸注速度為:TOF計數2–6 (2–11)PTC 2–17 (3–18) µg · kg–1 · min–1P < 0.001Wilcoxon’s配對比較試驗)。在當前情況下,達到和維持2PTC需要MIV輸注速度遠遠超過文獻中有關MIV輸注管理的“標準”建議。

(馬皓琳 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.


笑氣和七氟醚麻醉下的病人進行腹內沖洗時雙頻指數的改變

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

 

手術一般刺激導致腦電圖活躍。在一些情況下,麻醉不充分時的疼痛刺激導致腦電圖的抑制。這種現象被稱為反常激發。在我們日常的實踐中,我們注意到在腹部手術中用生理鹽水沖洗腹腔時雙頻指數(BIS)顯著減小伴隨有大的δ波動。在這項研究中,我們尋求評估腹腔內沖洗時BIS的改變。18ASA評級I~II級擇期行腹部手術的病人入選本研究,隨機分在對照組(組C)或者芬太尼組(組F)。麻醉誘導用3 mg/kg硫苯妥鈉,用50%的笑氣和七氟醚維持麻醉。用BIS監測儀記錄BIS95%邊緣頻率(SEF95)和爆發-抑制比。在手術將近結束時,但在腹腔沖洗之前,組F靜脈給予1.5 µg/kg芬太尼。組F病人在隨後的腹腔沖洗過程中,BISSEF95沒有顯著改變。相反,組C 的病人在開始沖洗後BISSEF95顯著下降。這些資料顯示,發生在腹腔內沖洗過程中的刺激可能導致一個矛盾的激發反應,證據是處理過的腦電圖參數下降。用芬太尼預處理抑制這種變化。麻醉學者應當知道這種矛盾的激發反應,以避免在這種情況下不恰當地減少麻醉劑濃度。

(張曦 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.


術前抑制脊髓環氧化酶-1可減輕術後疼痛

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

 

在切割傷術後疼痛模型中,術後第一天鞘內給予特異性環氧化酶(COX)-1 抑制劑具有鎮痛作用,而非COX-2抑制劑。我們在這個模型中研究了術前鞘內給予COX抑制劑的作用。手術前15分鐘,給予大鼠鞘內注射COX-1非特異性抑制劑(ketorolac)COX-1特異性抑制劑(SC-560)COX-2抑制劑(NS-398)或溶劑。然後在雄性大鼠左爪的掌底面上做一1釐米長的縱向切口,切開皮膚、筋膜和肌肉。測定2小時、4小時直至5天後大鼠對von Frey細絲的退縮反應閾值。KetorolacSC-560提高大鼠對機械刺激的退縮反應閾值,但NS-398沒有明顯作用。這些結果表明COX-1在術後脊髓疼痛處理和致敏中起到重要作用,術前鞘內給予特異性COX-1抑制劑對治療術後疼痛可能是有用的。

 (張瑩 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.


在神經性痛的大鼠模型中,鞘內注射的5-羥色胺去甲腎上腺素再攝取抑制劑米那普倫由單胺介導的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

 

抗抑鬱藥經常用於神經性疼痛的治療。在本研究中,我們測定了神經性疼痛的大鼠模型中選擇性單胺再攝取抑制劑在脊髓部位的antiallodynic作用。通過緊綁左L5 L6脊神經產生機械的allodynia,並用von Frey細絲刺激左後爪來測定之。通過長期置入的導管鞘內注射5-羥色胺去甲腎上腺素再攝取抑制劑米那普倫、選擇性5-羥色胺再攝取抑制劑帕羅西汀或選擇性去甲腎上腺素再攝取抑制劑馬普替林。米那普倫在3 µg100 µg之間的劑量產生劑量依賴性的antiallodynic作用。注射100 µg後該效應持續7小時(P < 0.05)30 µg米那普倫的antiallodynic作用可被鞘內同時給予的30 µg α2腎上腺素能受體拮抗劑育亨賓、30 µg5-羥色胺受體拮抗劑二甲麥角新堿或30 mug毒蕈堿型膽鹼受體拮抗劑阿托品所削弱(各自的P < 0.01)。米那普倫腹膜內給藥在劑量從3 30 mg/kg時沒有antiallodynic作用。鞘內應用帕羅西汀(10100 µg)和馬普替林(10100 µg)不產生antiallodynic作用。這些結果表明同時抑制脊髓5-羥色胺和去甲腎上腺素再攝取在介導antiallodynic作用時是必需的。米那普倫可能有效抑制神經性疼痛。

(陳瑋 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.


圍術期輸血與髖關節置換術後傷口癒合延遲:對住院時間的影響

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

 

整形外科手術後接受異體輸血的病人的住院時間相對較長,這一現象無法用輸血病人的感染發生率較高來解釋。為探討異體輸血是否會影響傷口癒合從而延長住院時間,本試驗連續觀察了444例擇期行髖關節手術的病人。術中選取5個時點收集輸血量、傷口情況和感染三個變數。在所觀察的444例病人中,有92例病人在圍術期接受了異體輸血。31%的輸血病人傷口癒合延遲,而未輸血病人傷口癒合延遲發生率只有18%(P<0.05)。異體輸血是較小的傷口癒合不良的唯一重要的預測因數。輸血病人住院時間相對延長(12.39.8天),這種現象可以用4個重要變數來預測:需要輸血(增加 2.7 ±0.5天)、發生傷口癒合不良(增加1.3 ±0.5天)、手術時間 (增加0.2±0.1/10 min)和病人年齡(增加 0.9 ±0.2 /10 yr)。這些資料表明異體輸血使術後傷口癒合不良發生率增高,因此,防止異體輸血可能會縮短擇期行整形外科手術病人的住院時間。

(邱鬱薇 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.

 

 

一項評估長期保存紅細胞的臨床效能的試點試驗

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

 

目前尚未確定長期保存的紅細胞的臨床後果。在本次試點試驗中,我們對持續供給儲存時間<8天的紅細胞的合理性進行了評估。此外,我們還在66例危重病人和心臟外科手術病人中對“新鮮血”的可能益處與標準紅細胞進行了比較。9例病人發放了紅細胞但沒有輸注。在其餘57例病人中,試驗組平均輸注5.5 ± 8.43 單位的紅細胞,而標準組為3.3 ± 3.27單位(P=0.25)。試驗組使用紅細胞的儲存時間的中位數為4天,而標準組為19天(差值為15天;四分位數差值範圍為1216天;P<0.001)。總體而言,73%的病人輸注了儲存時間相應於超過儲存時間90%的治療安排的紅細胞。輸注儲存<8天紅細胞組病人的年齡平均起來有較大的趨勢(68 ± 8.54 yr 63 ± 15.30 yr; P = 0.13),合併症也有較多的趨勢(85% 65%; P = 0.09)。總體上,試驗組中27%的病人死亡或有危及生命的併發症,而標準組為13%(P=0.31)。隨機化之後組間在長期呼吸、心血管和腎臟支持方面均無差異(P > 0.05)。根據已獲得的有限的資料,組織一項比較紅細胞儲存時間的大型臨床試驗是可行和應當的。

(黃施偉 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-乙酰半胱氨酸減弱人全血內毒素誘發的粘附分子的表達

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

 

白細胞粘附于血管內皮細胞在內毒素性休克早期起關鍵作用。減弱白細胞對內毒素的反應可能有助於預防進一步的器官損傷。近來有研究認為N-乙酰半胱氨酸(NAC)可減弱內毒素誘發的病理生理性變化。我們研究了NAC對內毒素刺激的人全血中的CD11bCD62L表達的影響。結果表明 NAC (>10 mM)呈濃度依賴地明顯抑制脂多糖(LPS)誘發的CD11b上調。但是NAC並不影響LPS誘發的CD62L 下調。我們還分析了NAC對白介素-8 (IL-8)誘發的人全血中CD11b表達的影響,IL-8 (10 ng/mL)明顯上調CD11b的表達, NAC (>10 mM)呈劑量依賴地明顯減弱這種作用。我們認為NAC減弱LPSIL-8誘發的人全血中增高的CD11b表達。

(張瑩 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.

 

 

 

鞘內注射嗎啡後口唇單純皰疹復發:一項對產科病人的前瞻性隨機試驗

 

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

 

至今尚沒有證據表明硬膜外注射嗎啡與口唇單純皰疹(HSL)復發有關。也沒有研究決定性地顯示HSL與鞘內注射嗎啡之間的關係。為探討這種關係,我們隨機、前瞻性地研究了100例有HSL史並在脊麻下行剖宮產手術的產科病人。一組病人鞘內注射嗎啡加經病人自控鎮痛IV給予嗎啡(ITM+PCA組)用於術後鎮痛;第二組病人僅經病人自控鎮痛IV給予嗎啡用於術後鎮痛(單獨PCA組)。所有病人均隨訪30天。ITM+PCA組中19例(38%)病人HSL復發,而單獨嗎啡PCA組有8例(6.6%)(P = 0.028)。 ITM+PCA組術後早期搔癢的發生率也較高。本試驗資料表明,HSLITM+PCA組和單純PCA組均有復發,而ITM+PCA組發生率較高。

(邱鬱薇 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.

 

 

/上臂手術行斜角肌肌間溝臂叢神經阻滯後的神經後遺症:患者因素、麻醉因素和手術因素與發病率和臨床病程之間的關係

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

 

連續隨訪 693名接受肩或(和)上臂手術的患者,在單次注射含1:200,000腎上腺素的0.625%左旋布比卡因行肌間溝臂叢神經阻滯(ISB)後測定患者神經後遺症的發病率、分佈和症狀解除及其與麻醉、手術和患者因素之間的關係。在一次標準化ISB24小時、48小時、2周和4周評估感覺缺失、感覺減退、感覺異常,疼痛/感覺遲鈍和肌力減退。對有症狀的患者監護至症狀解除為止。對報告疼痛或不適分值大於3(總分10)的受試者和有運動性或延伸感覺症狀的受試者進行診斷性評估。660名患者完成了4周的隨訪。56名患者報告了58項神經後遺症。除2例為肌力減退的症狀(經鑒定病變遠離行ISB的部位)外,其餘都為感覺性症狀。29名患者報告的31項後遺症可能與ISB相關,其中14項在行ISB的部位,9項在拇指/示指的遠節指骨,7項涉及耳後神經,及一例臨床臂叢病變。27名患者報告的後遺症可能與ISB沒有關係,這些症狀有正中神經(n9)和尺神經(n4)症狀、手術性神經失用(n12)和肌力減退(n2)。除2名出現肌力減退的患者和1名出現臨床臂叢病變的患者接受了治療干預外,其餘患者的症狀都自發緩解(中位數4周, 範圍2-16周)。定義為與ISB可能相關的神經後遺症的獨立預報因數的變數有:插入針頭時的感覺異常和24小時時行ISB部位的疼痛和淤傷。與之相反,患者坐位接受手術和行ISB部位的淤傷可作為可能與ISB無關的神經後遺症的預報因數。總之,用含腎上腺素的局麻藥單次注射行ISB之後的神經後遺症主要包括短暫輕微的感覺性症狀。

(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.

 

 

單次鞘內注射高比重布比卡因的半數有效劑量高於腰硬聯合方法的半數有效劑量

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

 

腰硬聯合方法(CSE)與單次鞘內注射(SSS)相比,其能延遲運動神經的恢復且低血壓更常見。我們採用上下連續分配方法測定CSESSS中鞘內高比重布比卡因的半數有效劑量(MED)。將60名男性患者隨機分為CSESSS組。所有的病人均選在L34間隙穿刺。在SSS組,通過27Whitacre脊麻穿刺針注入9.5mg高比重布比卡因。在CSE組,以充滿4ml空氣的17Tuohy針來定位於硬膜外腔,通過穿刺針導入27Whitacre脊髓穿刺針,注入7mg高比重布比卡因。劑量調整為0.5mg。“成功”的結果定義為感覺平面達T6T6以上並持續60分鐘。“成功”一例後將下一例病人劑量減小0.5mg,而“失敗”一例後則增大0.5mg。兩組中共有13例成功。CSE組的布比卡因的MED9.18 mg (95%可信區間為 8.89–9.47 mg) ,而SSS組布比卡因的MED11.37 mg (95%可信區間為 10.88–11.86 mg) (P < 0.001)。為達到定義的臨床目標,CSE組所需要的局麻藥較SSS組少19.3% (95% 可信區間 14.9%–23.6%)。我們發現兩組之間高比重布比卡因的MED明顯不同。在同樣臨床條件下,只要CSE取代SSS就可保證減少20%布比卡因的用量。

(趙雪蓮 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.

 

 

腎移植術中給以乳酸林格氏液或0.9% NaCl的隨機雙盲比較

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

 

腎移植手術補液常滴注生理鹽水(NS0.9% NaCl),以避免輸入過多含鉀液體而致高鉀血症。而最近的證據提示,NS可能產生在滴注平衡液如乳酸林格氏液(LR)時並不多見的不良反應。我們假設,NS對腎移植受體的腎功能有害。對行腎移植術的成人進行了前瞻性、隨機雙盲臨床試驗,比較用於術中IV輸液治療的NSLR。主要觀察指標為術後第三天肌酐濃度。在中期分析51例病人的資料後由於安全原因而終止研究。其中48例病人為接受活體腎移植,3例為屍體腎移植。26例滴注了NS25例為LR。兩組在主要指標上無差異。NS組有5(19%)(P = 0.05)患者因血鉀濃度超過了6 mEq/L進行高鉀血症治療,8(31%) (P = 0.004)因代謝性酸中毒而治療;而LR組無一例出現上述情況。故NS對腎臟功能無不良影響。與NS相比,LR較少出現高鉀血症和代謝性酸中毒。LR可能是一個對腎移植手術病人IV液體治療安全的選擇。

(周志堅 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.


腹腔手術後病人自控靜脈阿片類鎮痛與持續硬膜外鎮痛的效果比較

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:腹腔手術後鎮痛有兩種常用的方式:病人自控靜脈阿片類藥物鎮痛(PCA)和持續硬膜外鎮痛(CEA)。尚未確定哪種方式能更有效地鎮痛且副作用更少。

目的:本綜述的目的是通過對相關試驗的後分析比較腹腔手術後PCA阿片類鎮痛和CEA鎮痛的鎮痛效能、副作用、病人滿意度和手術結果

搜索策略:我們搜索了CENTRAL (Cochrane2002年第4)MEDLINE (19661月到200210)EMBASE (19881月到200210)以及論文的參考文獻列表。我們還聯繫了這方面的研究者。

入選標準:在腹腔手術後的成年病人從鎮痛效能和副作用兩方面來比較兩種鎮痛方法的隨機對照試驗。PCA鎮痛組的病人應能自己操作機器。持續硬膜外鎮痛組沒有PCA機器。

資料收集和分析:兩名綜述者獨立評價試驗質量和收集的資料。聯繫研究作者以提供補充資訊。從試驗中收集副作用資訊。

主要結果:共有含711例參與者的9個研究。PCA組視覺類比疼痛評分在62472小時都比CEA組高。靜息時疼痛的加權平均差和95%可靠區間分別是1.74 (95% CI 1.302.19) 0.99 (95% CI 0.651.33)0.63 (95% CI 0.241.01)。除PCA組瘙癢發生率較低,其讓步比值為0.27 (95% CI 0.110.64)外,住院時間和其他副作用均無統計學差異。

綜述者結論:腹腔手術病人在減輕術後72小時內疼痛上,CEA方式比阿片PCA方式更好,但使瘙癢發生率較高。比較這兩種鎮痛方法的其他優缺點還缺乏足夠證據。

(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.