Anesthesia & Analgesia

June 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

体外循环下心脏手术期间嗜中性粒细胞介导基质金属蛋白酶-9的分泌和激活

(殷文渊 陈杰 校)

Neutrophil-Mediated Secretion and Activation of Matrix Metalloproteinase-9 During Cardiac Surgery with Cardiopulmonary Bypass

Tso-Chou Lin, Chi-Yuan Li, Chien-Sung Tsai, Chih-Hung Ku, Ching-Tang Wu, Chih-Shung Wong, and Shung-Tai Ho

Anesth Analg 2005 100: 1554-1560.

高位胸段硬膜外麻醉对冠心病病人左心室收缩及舒张功能的影响

(裘毅敏 李士通 校)

The Effect of High Thoracic Epidural Anesthesia on Systolic and Diastolic Left Ventricular Function in Patients with Coronary Artery Disease

Christoph Schmidt, Frank Hinder, Hugo Van Aken, Gregor Theilmeier, Christian Bruch, Stefan P. Wirtz, Hartmut Bürkle, Tim Gühs, Markus Rothenburger, and Elmar Berendes

Anesth Analg 2005 100: 1561-1569.

马体内血红蛋白依赖性氧载体牛血红蛋白-200的药代动力学

(王丽珺译 薛张纲校)

The Pharmacokinetics of Hemoglobin-Based Oxygen Carrier Hemoglobin Glutamer-200 Bovine in the Horse

Lawrence R. Soma, Cornelius E. Uboh, Fuyu Guan, Yi Luo, Peter J. Moate, Raymond C. Boston, and Bernd Driessen

Anesth Analg 2005 100: 1570-1575.

血栓弹性描记法的最大振幅预测包括心肌梗死的术后血栓性并发症

(殷文渊 陈杰 校)

Thromboelastography Maximum Amplitude Predicts Postoperative Thrombotic Complications Including Myocardial Infarction

Douglas J. McCrath, Elisabetta Cerboni, Robert J. Frumento, Andrew L. Hirsh, and Elliott Bennett-Guerrero

Anesth Analg 2005 100: 1576-1583.

挥发性麻醉药的心脏保护作用:机制和临床意义

(马皓琳 李士通 校)

Cardioprotection with Volatile Anesthetics: Mechanisms and Clinical Implications (Review Article)

Stefan G. De Hert, Franco Turani, Sanjiv Mathur, and David F. Stowe

Anesth Analg 2005 100: 1584-1593.

PEDIATRIC ANESTHESIA:

瑞芬太尼在婴儿气管插管中的剂量效应

(王丽珺译 薛张纲校)

Dose-Response of Remifentanil for Tracheal Intubation in Infants

Mark W. Crawford, Jason Hayes, and Juliana M. Tan

Anesth Analg 2005 100: 1599-1604.

儿科病人使用21/2 ProSealTM喉罩通气与标准喉罩通气的随机交叉比较

(肖洁 陈杰 校)

A Randomized Crossover Comparison of the Size 21/2 Laryngeal Mask Airway ProSealTM Versus Laryngeal Mask Airway-ClassicTM in Pediatric Patients

Kai Goldmann and Christian Jakob

Anesth Analg 2005 100: 1605-1610.

在猪动物模型使用电刺激来监测硬膜外穿刺进针位置

 (张莹 李士通 校)

The Use of Electrical Stimulation to Monitor Epidural Needle Advancement in a Porcine Model

Ban C. H. Tsui, Derek Emery, Richard R. E. Uwiera, and Brendan Finucane

Anesth Analg 2005 100: 1611-1613.

达特茅斯手术条件标准的发展和确证

(金 薛张纲 校)

Development and Validation of the Dartmouth Operative Conditions Scale

Joseph P. Cravero, George T. Blike, Stephen D. Surgenor, and Jens Jensen

Anesth Analg 2005 100: 1614-1621.

预防性使用地塞米松以减少儿科斜视手术后恶心呕吐的发生:剂量范围和安全性评价研究

(肖洁 陈杰 校)

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

Rashmi Madan, Anuj Bhatia, Sajith Chakithandy, Rajeshwari Subramaniam, Gurram Rammohan, Shrinivas Deshpande, Manorama Singh, and H. L. Kaul

Anesth Analg 2005 100: 1622-1626.

AMBULATORY ANESTHESIA:

爱荷华麻醉满意量表是否可用于评价社区医院白内障治疗时局部麻醉和监护镇静下病人的满意程度?

(周志坚 李士通 校)

Can the Iowa Satisfaction with Anesthesia Scale Be Used to Measure Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation at a Community Hospital?
Donald Fung, Marsha Cohen, Susan Stewart, and Andy Davies

Anesth Analg 2005 100: 1637-1643.

在进行表面局部麻醉和监测下镇静时白内障护理的社区医院中决定病人满意度的是何种因素

( 薛张纲 )

What Determines Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation in a Community Hospital Setting?

Donald Fung, Marsha M. Cohen, Susan Stewart, and Andy Davies

Anesth Analg 2005 100: 1644-1650.

ANESTHETIC PHARMACOLOGY:

异丙酚剂量依赖性地通过影响Bcl2BAX表达和NO产生减少肿瘤坏死因子(TNFα)诱导的人脐静脉内皮细胞凋亡

(顾漪闻 陈杰 校)

Propofol Dose-Dependently Reduces Tumor Necrosis Factor-{alpha}-Induced Human Umbilical Vein Endothelial Cell Apoptosis: Effects on Bcl-2 and Bax Expression and Nitric Oxide Generation

Tao Luo, Zhengyuan Xia, David M. Ansley, Jingping Ouyang, David J. Granville, Yinping Li, Zhong-Yuan Xia, Qing-Shan Zhou, and Xian-Yi Liu

Anesth Analg 2005 100: 1653-1659.

 氯胺酮立体选择性抑制培养海马神经元的自发性钙振荡

(黄施伟 李士通 校)

Ketamine Stereoselectively Inhibits Spontaneous Ca2+-Oscillations in Cultured Hippocampal Neurons

Barbara Sinner, Oliver Friedrich, Wolfgang Zink, Eike Martin, Rainer H. A. Fink, and Bernhard M. Graf

Anesth Analg 2005 100: 1660-1666.

非制动剂12-二氯己氟环丁烷1,2-dichlorohexafluorocyclobutaneF62N))和异氟醚对突触外γ-氨基丁酸受体的不同效应

(沈洪译 薛张纲 校)

The Differential Effects of the Nonimmobilizer 1,2-Dichlorohexafluorocyclobutane (F6, 2N) and Isoflurane on Extrasynaptic Gamma-Aminobutyric AcidA Receptors

Misha Perouansky, Mathew I. Banks, and Robert A. Pearce

Anesth Analg 2005 100: 1667-1673.

局麻药n-丁基- p-氨基苯甲酸酯可完全阻滞鼠感觉神经元的N-型钙离子传导

(顾漪闻 陈杰 校)

The Block of Total and N-Type Calcium Conductance in Mouse Sensory Neurons by the Local Anesthetic n-Butyl-p-Aminobenzoate

Jeroen P. Beekwilder, Daniel L. B. Winkelman, Gertrudis Th. H. van Kempen, Rutgeris J. van den Berg, and Dirk L. Ypey

Anesth Analg 2005 100: 1674-1679.

异氟醚与肌膜上KATP通道蛋白激酶C激活剂的关系

(赵雪莲 李士通 )

The Interaction of Isoflurane and Protein Kinase C-Activators on Sarcolemmal KATP Channels

Lawrence A. Turner, Kazuhiro Fujimoto, Akihiro Suzuki, Anna Stadnicka, Zeljko J. Bosnjak, and Wai-Meng Kwok

Anesth Analg 2005 100: 1680-1686.

NR3B亚组不改变重组N-甲基D-门冬氨酸受体的麻醉敏感性

(孙敏莉译,薛张纲校)

The NR3B Subunit Does Not Alter the Anesthetic Sensitivities of Recombinant N-Methyl-d-Aspartate Receptors
Tomohiro Yamakura, Ahmed R. Askalany, Andrey B. Petrenko, Tatsuro Kohno, Hiroshi Baba, and Kenji Sakimura

Anesth Analg 2005 100: 1687-1692

TECHNOLOGY, COMPUTING, AND SIMULATION:

硬膜外导管的电特性:神经刺激引导仪要求什么?

(顾漪闻 陈杰 校)

The Electrical Properties of Epidural Catheters: What Are the Requirements for Nerve Stimulation Guidance?

Hisayoshi Tamai, Shigehito Sawamura, Hidenao Atarashi, Kenji Takeda, Kazuhiko Ohe, and Kazuo Hanaoka

Anesth Analg 2005 100: 1704-1707.

体循环阻力对麻醉犬阻抗心动描记法测量值的影响

(周雅春 李士通 校)

The Effect of Peripheral Resistance on Impedance Cardiography Measurements in the Anesthetized Dog

Lester A. H. Critchley, Zhi Y. Peng, Benny S. Fok, and Anthony E. James

Anesth Analg 2005 100: 1708-1712.

现场麻醉机机械通气时的氧气消耗

(陈玮 李士通 审校)

Oxygen Consumption with Mechanical Ventilation in a Field Anesthesia Machine (Technical Communication)

Dale F. Szpisjak, Charles L. Lamb, and Kenneth D. Klions

Anesth Analg 2005 100: 1713-1717.

颈外表面监测不能够评估喉部神经肌肉阻滞作用(经验交流)

(金琳 译,薛张纲 校)

An External Monitoring Site at the Neck Cannot Be Used to Measure Neuromuscular Blockade of the Larynx (Technical Communication)
Thomas M. Hemmerling, Guillaume Michaud, Stéphane Deschamps, and Guillaume Trager

Anesth Analg 2005 100: 1718-1722.

通过改良压力降低方式来检测单向活瓣功能不全

(顾漪闻 陈杰 校)

Detecting Unidirectional Valve Incompetence by the Modified Pressure Decline Method (Technical Communication)

Wade A. Weigel and W. Bosseau Murray

Anesth Analg 2005 100: 1723-1727

PAIN MEDICINE:

年龄对大鼠吗啡耐药性产生的影响

邱郁薇    李士通 校)

Age-Dependent Morphine Tolerance Development in the Rat

Yan Wang, James Mitchell, Kumi Moriyama, Ki-jun Kim, Manohar Sharma, Guo-xi Xie, and Pamela Pierce Palmer

Anesth Analg 2005 100: 1733-1739.

慢性疼痛病人对阿片类镇痛药量的增加呈年龄依赖性

(吴德华 薛张纲 校)

Age-Dependent Opioid Escalation in Chronic Pain Patients

Chante Buntin-Mushock, Lisa Phillip, Kumi Moriyama, and Pamela Pierce Palmer

Anesth Analg 2005 100: 1740-1745.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

麻醉前访视后病人的满意度和所获的信息:面对面会谈,宣传资料和录像三种方法的比较

(朱辉 陈杰 校)

Patient Satisfaction and Information Gain After the Preanesthetic Visit: A Comparison of Face-to-Face Interview, Brochure, and Video

Stephanie A. Snyder-Ramos, Henrik Seintsch, Bernd W. Böttiger, Johann Motsch, Eike Martin, and Martin Bauer

Anesth Analg 2005 100: 1753-1758.

主要麻醉学期刊中随机对照试验的质量

(黄丽娜    李士通  )

The Quality of Randomized Controlled Trials in Major Anesthesiology Journals

Mary Lou V. H. Greenfield, Andrew L. Rosenberg, Michael O’Reilly, Amy M. Shanks, Michelle J. Sliwinski, and Michael D. Nauss

Anesth Analg 2005 100: 1759-1764.

CRITICAL CARE AND TRAUMA:

高频通气相和传统通气对急性肺损伤和急性呼吸窘迫综合征治疗的比较:系统性回顾和cochrane分析

(孙志荣 ,薛张纲 )

High-Frequency Ventilation Versus Conventional Ventilation for the Treatment of Acute Lung Injury and Acute Respiratory Distress Syndrome: A Systematic Review and Cochrane Analysis

Hannah Wunsch, James Mapstone, and Jukka Takala

Anesth Analg 2005 100: 1765-1772

两种不同羟乙基淀粉溶液(6%贺斯130/0.4200/0.5)对血粘度的影响

(朱辉 陈杰 校)

The Influence of Two Different Hydroxyethyl Starch Solutions (6% HES 130/0.4 and 200/0.5) on Blood Viscosity

Thomas A. Neff, Lukas Fischler, Michael Mark, Reto Stocker, and Walter H. Reinhart

Anesth Analg 2005 100: 1773-1780.

在血栓弹性描记法中血小板计数对血块退缩和组织纤溶酶原活化剂介导的纤维蛋白溶解的影响

(张曦 李士通 校)

The Effects of Platelet Count on Clot Retraction and Tissue Plasminogen Activator-Induced Fibrinolysis on Thrombelastography

Nobuyuki Katori, Kenichi A. Tanaka, Fania Szlam, and Jerrold H. Levy

Anesth Analg 2005 100: 1781-1785.

单磷酰脂质A预处理后:危急的局部缺血组织的存活率

(许文妍 薛张纲 )

Preconditioning with Monophosphoryl Lipid A Improves Survival of Critically Ischemic Tissue
Yves Harder, Claudio Contaldo, Joachim Klenk, Andrej Banic, Stephan M. Jakob, and Dominique Erni

Anesth Analg 2005 100: 1786-1792.

NEUROSURGICAL ANESTHESIA:

在儿科脊柱侧弯手术中异氟醚和地氟醚逐步增加剂量脑双频指数维持在60时对皮层体感诱发电位的影响

(朱玫娟 陈杰 校)

The Effects of Isoflurane and Desflurane Titrated to a Bispectral Index of 60 on the Cortical Somatosensory Evoked Potential During Pediatric Scoliosis Surgery

James E. Fletcher, Albert R. Hinn, Christopher M. Heard, Linda S. Georges, Eugene B. Freid, Ann Keifer, Sandra D. Brooks, Ann G. Bailey, and Robert D. Valley

Anesth Analg 2005 100: 1797-1803.

REGIONAL ANESTHESIA:

比较用利多卡因和其他局麻药脊麻后的一过性神经症状:对随机对照试验的一个系统性回顾

(朱慧 李士通 校)

Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials

Dusanka Zaric, Christian Christiansen, Nathan L. Pace, and Yodying Punjasawadwong

Anesth Analg 2005 100: 1811-1816.

昂丹司琼全身性给药能拮抗椎管内利多卡因的感觉阻滞作用

(蔡美华 薛张纲 校)

Systemic Ondansetron Antagonizes the Sensory Block Produced by Intrathecal Lidocaine
Argyro Fassoulaki, A. Melemeni, Marianna Zotou, and Constantine Sarantopoulos

Anesth Analg 2005 100: 1817-1821.

家庭持续周围神经阻滞:综述

(朱玫娟 陈杰 校)

Continuous Peripheral Nerve Blocks at Home: A Review (Review Article)
Brian M. Ilfeld and F. Kayser Enneking

Anesth Analg 2005 100: 1822-1833.

GENERAL ARTICLES:

气管导管拔除时的残余肌松

(马皓琳 李士通 校)

Residual Paralysis at the Time of Tracheal Extubation

Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Mark Franklin, Michael J. Avram, and Jeffery S. Vender

Anesth Analg 2005 100: 1840-1845.

比较在整形外科大手术中大剂量10%羟乙基淀粉264/0.455%白蛋白对凝血功能的影响:一项三盲随机试验

(周晓敏 薛张纲 校)

A Triple-Blinded Randomized Trial Comparing the Hemostatic Effects of Large-Dose 10% Hydroxyethyl Starch 264/0.45 Versus 5% Albumin During Major Reconstructive Surgery

Ramiro Arellano, Bing Siang Gan, Mary Jane Salpeter, Erik Yeo, Stuart McCluskey, Ruxandra Pinto, Jonathan Irish, Douglas C. Ross, D. John Doyle, John Parkin, Dale Brown, Lorne Rotstein, Ian Witterick, Wayne Matthews, John Yoo, Peter C. Neligan, Pat Gullane, and Howard Lampe

Anesth Analg 2005 100: 1846-1853.

 

马体内血红蛋白依赖性氧载体牛血红蛋白-200的药代动力学

The Pharmacokinetics of Hemoglobin-Based Oxygen Carrier Hemoglobin Glutamer-200 Bovine in the Horse

Lawrence R. Soma, VMD*, Cornelius E. Uboh, PhD*{dagger}, Fuyu Guan, PhD*, Yi Luo, PhD*, Peter J. Moate, Magr, SC*, Raymond C. Boston, PhD*, and Bernd Driessen, DVM, PhD*{ddagger}

Department of Clinical Studies, School of Veterinary Medicine, University of Pennsylvania; {dagger}Department of Chemistry, Pennsylvania Equine Toxicology & Research Center, West Chester University; and {ddagger}Department of Anesthesiology, David Geffen School of Medicine, University of California-Los Angeles

Anesth Analg 2005;100:1570-1575

小牛血红蛋白-200(HBOC-200)是一种血红蛋白依赖性氧载体(HBOC)。它包含了聚合戊二醛牛血红蛋白。这项研究的目的在于研究在马体内静脉注入32.5HBOC-200溶液后,第一代HBOC的药代动力学。用我们实验室最近得出的方法对马血浆和尿中的HBOC-200进行定量。血浆清除以牛血红蛋白的容积分布为基础。HBOC-200血浆浓度-时间曲线的减退期由非互换2区划模型来描述,大小聚合物的消除半衰期分别为121.3小时,随着HBOC-200的注入,47.0%象小分子量聚合物那样消除,53%象大分子量聚合物那样消除。血浆浓度-时间曲线下的面积是5143.1 µg · h–1 · mL–1.,大小聚合物的分配容积分别为86.9 63.9 mL/kg,清除率是42.1 3.8 mL · kg–1 · h–1,总之,由于这些溶液的异质性,第一代HBOC的消除要比以往假定的复杂的多。哺乳动物用相同的机制去除血红蛋白,这并不是马体内唯一的代谢过程,这一研究的结论可以推广。

(王丽珺译 薛张纲校)

Hemoglobin-glutamer-200 (HBOC-200) is a hemoglobin (Hb)-based oxygen carrier (HBOC) comprising glutaraldehyde-polymerized bovine Hb. In this study, we sought to determine the pharmacokinetics of this first generation HBOC after IV infusion of 32.5 g of HBOC-200 solution in horses. Quantification of HBOC-200 in equine plasma and urine was performed using a method recently developed by our laboratory. The elimination from plasma was based on size distribution of the bovine Hb polymer. The decline of plasma concentration-time curve of HBOC-200 was described by a noninterchanging 2-compartmental model. The median elimination half-lives of the small and large aggregates were 1.3 and 12.0 h, respectively. Of the HBOC-200 infused, 47.0% was eliminated as the smaller molecular weight and 53% as the larger molecular weight polymers. The area under the plasma concentration-time curve was 5143.1 µg · h–1 · mL–1. The volumes of distribution of the small and large aggregates were 86.9 and 63.9 mL/kg and the clearances were 42.1 and 3.8 mL · kg–1 · h–1, respectively. In conclusion, elimination of first generation HBOCs was shown to be more complex than previously assumed because of the heterogeneous nature of these solutions. Mammalian species dispose of Hb using similar mechanisms, and there is no unique metabolic process in the horse that would not allow a logical extension of the general interpretation of this study.

 

瑞芬太尼在婴儿气管插管中的剂量效应

Dose-Response of Remifentanil for Tracheal Intubation in Infants

Mark W. Crawford, MBBS, FRCPC, Jason Hayes, MD, FRCPC, and Juliana M. Tan, MBBS, MMed (Anesth)

Department of Anaesthesia and the Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

Anesth Analg 2005;100:1599-1604

为了比较瑞芬太尼在婴儿和儿童气管插管中的剂量效应,32名足月儿和32名儿童分别用10 µg/kg的格隆溴铵和4.0 mg/kg的异丙酚实施麻醉,并给予四种剂量的瑞芬太尼(1.25, 1.50, 1.75, or 2.00 µg/kg)促进插管。我们采用logistic回归分析测定瑞芬太尼在50%98%病人的有效剂量(ED50ED98)。我们发现婴儿和儿童的logistic回归曲线是相似的(P = 0.38)。瑞芬太尼的ED50ED98分别为1.70 ± 0.1 µg/kg and 2.88 ± 0.5 µg/kg。在第二项双盲试验中,24名婴儿用异丙酚实施麻醉并随机接受3.0 µg/kg瑞芬太尼或2.0 mg/kg琥珀胆碱以促进气管插管。测定呼吸暂停时间、气管插管条件以及血流动力学改变。我们发现异丙酚/瑞芬太尼组和异丙酚/琥珀胆碱组的呼吸暂停时间及插管条件是相似的。心动过缓、低血压和胸壁强直并未发生。我们推断在婴儿和儿童的气管插管过程中使用瑞芬太尼的剂量效应是相似的。相比在婴儿中采用异丙酚/琥珀胆碱,异丙酚/瑞芬太尼提供了临床可接受的插管条件、稳定的血流动力学和一定时间的呼吸暂停。

(王丽珺译 薛张纲校)

To compare the dose-response of remifentanil for tracheal intubation in infants and children, 32 healthy full-term infants and 32 children were anesthetized with 10 µg/kg glycopyrrolate and 4.0 mg/kg propofol and administered 1 of 4 doses of remifentanil (1.25, 1.50, 1.75, or 2.00 µg/kg) to facilitate tracheal intubation. We determined the effective doses of remifentanil in 50% (ED50) and 98% (ED98) of patients by using logistic regression analysis. We found that logistic regression curves were similar for infants and children (P = 0.38). ED50 and ED98 values for remifentanil were 1.70 ± 0.1 µg/kg and 2.88 ± 0.5 µg/kg, respectively. In a second double-blind study, 24 infants were anesthetized with propofol and randomized to receive either 3.0 µg/kg remifentanil or 2.0 mg/kg succinylcholine to facilitate tracheal intubation. The duration of apnea, tracheal intubating conditions and hemodynamic changes were determined. We found that the duration of apnea and intubating conditions after propofol/remifentanil were similar to those after propofol/succinylcholine. Bradycardia, hypotension, and chest wall rigidity did not occur. We conclude that the dose-response of remifentanil for tracheal intubation is similar in infants and children. Propofol/remifentanil provides clinically acceptable intubating conditions, stable hemodynamics, and a duration of apnea comparable to that with propofol/succinylcholine in infants.

 

达特茅斯手术条件标准的发展和确证

Development and Validation of the Dartmouth Operative Conditions Scale

Joseph P. Cravero, MD, George T. Blike, MD, Stephen D. Surgenor, MD, and Jens Jensen, MS

Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire

Address correspondence and reprint requests to Joseph P. Cravero, Department of Anesthesiology, Dartmouth Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756.

Anesth Analg 2005;100: 1614-1621

关于小儿科镇静实施的研究由于没有客观的衡量标准很难进行。该标准应允许就在不同的操作者及技术条件下实施镇静时的效果和安全性进行比较。我们推荐达特茅斯手术条件标准(DOCS),它被设计作为一种研究工具用来将不同的镇静实施者的操作条件的合理性进行标化。起先,人们采用人性因素方法学建立了一种儿科镇静方法的模型,并详细说明了(DOCS)操作过程中衡量病人条件的标准。为了达到确证,从长达300小时的为测试或评级目的的操作过程录影带中选取70段录影剪辑(各长30秒)。通过比较10位不同的评价者间对各剪辑的打分,证实了其内部评价的可靠性。内部评价的可靠性通过各评价者一年后的再次测试进行评价。测验编制的正确性通过分析与时间相关的采取镇静操作的DOCS的评分改变得到证实。标准的有效性通过对比DOCS和一种修正的舒适度的评分得到验证。经过10位具有不同背景的卫生保健提供者在为期一年的研究后,DOCS取得了极好的内部评价(kappa = 0.84)和外部评价(kappa = 0.91)一致性。标准的有效性由于从20个相互独立的录影剪辑获得的DOCS和修正的舒适度评分之间密切的相关性(Spearman相关系数=0.98P<0.001)而得到验证。麻醉诱导20分钟后DOCS评分的分布显著低于镇静开始之前的评分,而镇静刚出现时的评分始终高于20分钟后的评分(p<0.001),因而确定了该标准的测验编制的正确性。在用于通过影像资料比较儿科镇静服务的有效性和安全性方面,DOCS是一个有效的研究工具,而无需考虑为减少焦虑或疼痛在操作过程中所采取的是何种技术。

(金 薛张纲 校)

Studies of pediatric sedation practice have suffered from the lack of an objective scale that would allow for a comparison of the effectiveness and safety of sedation provided by various providers and techniques. We present the Dartmouth Operative Conditions Scale (DOCS), which is designed as a research tool to codify the appropriateness of the procedural conditions provided by various sedation interventions. To begin, human factors methodology was used to develop a model of the pediatric sedation process and to define the criteria for measuring a patient’s condition during a procedure (DOCS). To accomplish validation, 70 video clips (30-s duration) were then selected from more than 300 h of procedural video tape for testing/grading purposes. Inter-rater reliability was tested by comparing the score for each video clip among 10 different raters. Intra-rater reliability was evaluated by retesting all of the raters 1 yr after their initial rating. Construct validity was confirmed by analyzing the change in DOCS score relative to the time that sedation intervention was undertaken. Criterion validity was tested by comparing the DOCS to a modified COMFORT® score. The DOCS was completed with excellent inter-rater (kappa = 0.84) and intra-rater (kappa = 0.91) agreement by 10 health care providers with various backgrounds during the 1-yr study period. Criterion validity was supported by the close correlation between the DOCS and the modified COMFORT® scores for 20 distinct video clips (Spearman correlation coefficient = 0.98; P < 0.001). The distribution of DOCS scores 20 min after the anesthetic induction was significantly lower than the scores before initiation of sedation, and scores after emergence were consistently higher than those 20 min after sedation (P < 0.001), thus confirming construct validity of the scale. The DOCS is a validated research tool when used with video data for comparing the effectiveness and safety of pediatric sedation service, regardless of technique used for decreasing anxiety or pain during a procedure.

 

在进行表面局部麻醉和监测下镇静时白内障护理的社区医院中决定病人满意度的是何种因素

What Determines Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation in a Community Hospital Setting?

Donald Fung, MD, MSc*, Marsha M. Cohen, MSc, MD{dagger}, Susan Stewart, BSc, MA{ddagger}, and Andy Davies, MD*

*North Bay General Hospital, North Bay, and Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto; {dagger}Centre for Research in Women’s Health, Sunnybrook & Women’s College Health Sciences Centre and the Department of Health Policy, Management & Evaluation, University of Toronto, Toronto; and {ddagger}North Shores District Health Council, North Bay, Ontario, Canada

Address correspondence and reprint requests to Donald Fung, North Bay General Hospital, 750 Scollard, North Bay, Ontario, Canada.

Anesth Analg 2005;100: 1644-1650.

 

爱荷华麻醉满意度标准(ISAS)是一种用来评价监测下麻醉护理时病人满意度的可靠而又有效的工具。我们用ISAS来探索在一所小规模社区医院中进行表面局部麻醉和监测下镇静时白内障护理的病人满意度决定因素。ISAS(评分1-6)在306例白内障手术后的病人中马上进行。所有病人均接受由麻醉医生实施的表面局麻和四级镇静。病人满意度较高:平均ISAS5.6(标准差:0.46;范围:3.3-6.0)。术中和术后疼痛发生率分别为13%37%;其它负反应发生率很低(<0.5%)。在多因素逻辑回归分析中,有意义的满意度预测因素为术后疼痛(优势比 [OR]: 4.84; 99% 可信限 [CI]: 2.21, 10.60),手术医生(OR: 0.21; 99% CI: 0.05, 0.91),以及术前焦虑(OR: 1.17; 99% CI: 1.03, 1.34)ISAS平均评分(OR = 0.28; 99% CI: 0.13, 0.59)和手术前焦虑(OR = 1.12; 99% CI: 0.99, 1.28)可作为体验这一低质量级别的有意义预测因素。我们的结果显示ISAS可用来跟踪监测下白内障护理的病人满意度。白内障手术中和术后疼痛很常见,这也是患者对白内障护理满意度低的一个主要原因。

( 薛张纲 )

The Iowa Satisfaction with Anesthesia Scale (ISAS) is a reliable and valid tool to measure patient satisfaction with monitored anesthesia care. We used the ISAS to discover determinants of patient satisfaction with cataract care under topical local anesthesia and monitored sedation in a small community hospital. The ISAS (scored 1 to 6) was administered to 306 patients immediately after cataract surgery. All patients received topical local anesthesia and IV sedation administered by an anesthesiologist. Patient satisfaction was high: mean ISAS was 5.6 (sd 0.46; range: 3.3–6.0). The incidence of intraoperative and postoperative pain was 13% and 37%; other adverse events were infrequent (<5%). In multivariable logistic regression, significant predictors of satisfaction were postoperative pain (odds ratio [OR]: 4.84; 99% confidence interval [CI]: 2.21, 10.60), surgeon (OR: 0.21; 99% CI: 0.05, 0.91), and preoperative anxiety (OR: 1.17; 99% CI: 1.03, 1.34). ISAS mean scores (OR = 0.28; 99% CI: 0.13, 0.59) and preoperative anxiety (OR = 1.12; 99% CI: 0.99, 1.28) emerged as significant predictors of low rating of quality of experience. Our results indicate that the ISAS can be used to track patient satisfaction with monitored cataract care. Pain during and after cataract surgery is common and is a major reason for lower patient satisfaction with their cataract care.

非制动剂12-二氯己氟环丁烷(1,2-dichlorohexafluorocyclobutaneF62N))和异氟醚对突触外γ-氨基丁酸受体的不同效应

The differential effects of the nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6, 2N) and isoflurane on extrasynaptic gamma-aminobutyric acid A receptors.

 

Perouansky M, Banks MI, Pearce RA.

Department of Anesthesiology, University of Wisconsin, Madison, WI 53792-3272, USA.

Anesth Analg. 2005 Jun;100 (6):1667-73.

 

非制动剂12-二氯己氟环丁烷(1,2-dichlorohexafluorocyclobutaneF6,也称为2N))能够分别在低于或高于预测浓度(MACpred)导致遗忘或惊厥。这些效应的细胞学以及分子学基础还不清楚。我们先前报道过F6对躯体海马锥体细胞突触的γ-氨基丁酸(GABA)A受体没有作用。然而,在海马神经元的突触下GABAA受体与位于突触外的这些受体有不同的药理学特性,这些不同的受体可能有不同的生理功能。因此我们研究了F6和异氟醚对通过暴露于短暂高浓度脉冲的γ-氨基丁酸的有核离体碎片,主要由从海马神经元获得的突触外GABAA受体介导的电流的影响。我们发现大多数神经元的突触外GABAA受体对110 microM浓度以下的F6不敏感,尽管从公认的中间神经元获得的受体可以被43 microM浓度的F6有效抑制。与此相反,异氟醚能够始终降低最大幅度以及减慢突触外受体介导电流的弱化,与其对突触受体作用相似。这些结果表明锥体神经元的突触外GABAA受体对异氟醚有选择性敏感,而对F6却没有。

(沈洪译 薛张纲 校)

The nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6; also known as 2N) causes amnesia and seizures at concentrations less than and more than, respectively, than that predicted to cause immobility (MACpred). The molecular and cellular basis of these effects is not known. We reported previously that F6 has no effect on synaptic gamma aminobutyric acid (GABA)A receptors located on the somata of hippocampal pyramidal cells. However, in hippocampal neurons, GABAA receptors that are located subsynaptically have different pharmacologic properties from those at extrasynaptic sites, and these classes of receptors may serve different physiologic functions. Therefore, we investigated the effects of F6 and isoflurane on currents mediated predominantly by extrasynaptic GABAA receptors harvested from hippocampal neurons by exposing nucleated excised patches to brief, high-concentration pulses of GABA. We found that extrasynaptic GABAA receptors in the majority of neurons located in the pyramidal cell layer are insensitive to F6 at concentrations up to 110 microM, although receptors harvested from one putative interneuron were potently inhibited by 43 microM of F6. By contrast, isoflurane consistently reduced the peak amplitude and slowed deactivation of currents mediated by extrasynaptic receptors, similar to its effect on synaptic receptors. These results demonstrate the selective sensitivity of extrasynaptic GABAA receptors on pyramidal neurons to isoflurane but not F6.

 

 

NR3B亚组不改变重组N-甲基D-门冬氨酸受体的麻醉敏感性

The NR3B subunit does not alter the anesthetic sensitivities of recombinant N-methyl-D-aspartate receptors.

Yamakura T, Askalany AR, Petrenko AB, Kohno T, Baba H, Sakimura K.
Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan.

Anesth Analg. 2005 ,100 (6):1687-92.

 

N-甲基D-门冬氨酸受体或配有NR1NR2NR3B亚组构成一个受体或具有明确的通道特性。在最近的研究中,我们研究了表达在非洲蟾蜍卵母细胞上的NR1/NR2通道NR3B亚组在NMDA受体的麻醉敏感性共同表达的效应。尽管NR3B亚组显著地减少NR1/NR2A-B通道的当前幅度,但通过NR3B亚组的复合表达,NR1/NR2A-B通道对Mg2+、胺碘酮、异氟醚、氧化氮及乙醇的敏感性不改变。这些结果提示NMDA受体的麻醉敏感性不依赖于NR3亚组的存在或缺乏。在NR3B亚组两个氨基酸残基的突变在同源的NR1NR2NN + 1位点,它们构成阻断Mg2+和胺碘酮的位点,但并不影响NR1/NR2B/NR3B通道对Mg2+、胺碘酮和异氟醚的敏感性。因而,NR3B亚组在NN + 1位点的氨基酸残基不太可能构成在NR1/NR2/NR3通道的阻断位点。

(孙敏莉译,薛张纲校)


The N-methyl-D-aspartate (NMDA) receptor NR3B subunit co-assembles with NR1 and NR2 subunits to form a receptor complex with distinct channel properties. In the present study, we investigated the effects of co-expression of the NR3B subunit on the anesthetic sensitivities of NMDA receptors for NR1/NR2 channels expressed in Xenopus oocytes. Although the NR3B subunit prominently reduced the current amplitude of NR1/NR2A-B channels, the sensitivities of NR1/NR2A-B channels to Mg2+, ketamine, isoflurane, nitrous oxide, and ethanol were not altered by coexpression of the NR3B subunit. These results suggest that the anesthetic sensitivities of NMDA receptors do not depend on the presence or absence of the NR3 subunit. Mutations of two amino acid residues in the NR3B subunit at positions homologous to the N and N + 1 sites in the NR1 and NR2 subunits, which constitute the blocking sites for Mg2+ and ketamine, did not affect the sensitivities of NR1/NR2B/NR3B channels to Mg2+, ketamine and isoflurane. Thus, the amino acid residues at the N and N + 1 sites in NR3 subunits are unlikely to be involved in the formation of channel blocking sites in NR1/NR2/NR3 channels.

 

颈外表面监测不能够评估喉部神经肌肉阻滞作用(经验交流)

An External Monitoring Site at the Neck Cannot Be Used to Measure Neuromuscular Blockade of the Larynx (Technical Communication)

Thomas M. Hemmerling, Guillaume Michaud, Stéphane Deschamps, and Guillaume Trager

Neuromuscular Research Group (NRG), Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal (CHUM) Hôtel-Dieu, Université de Montréal, Canada

Anesth Analg 2005(6) 100: 1718-1722.

 

肌音描计法是一种新型监测神经肌肉阻滞(NMB)的方法。在使用0.1mg/kg美维库铵后,我们将环杓侧肌(LCA)监测NMB与喉外监测NMB进行比较。我们收集了12位患者的数据资料,包括以上两个部位的肌音描计结果。麻醉诱导采用0.25–0.5 µg · kg–1 · min–1的瑞芬太尼、2–3 mg/kg异丙酚。将微型压电传声器置于声带侧方,在杓状软骨基底部插入肌肉层,以记录LCA收缩产生的声音信号。另外一个麦克风置于体外甲状软骨切迹下方的气管外侧。使用四个成串刺激(TOF)用最大强度连续刺激喉返神经12秒。NMB起始、详细记录起始期、峰效应及消失的数据并加以分析讨论。无论是峰效应、控制25%、75%及90%颤搐反应及TOF比值恢复至0.5-0.8,体外测量的值都明显延长。两组测量的起效时间没有显著性差别。我们将带有麦克风的肌音描计仪置于患者颈部,以评估在喉部进行体外NMB监测的可能性。与LCA监测相比,新法起效时间慢、有一个更为显著的峰效应。在体外上述部位记录到的声音信号似乎与喉肌收缩无关,而与颈部带肌的收缩有关。

(金琳 译,薛张纲 校)

Using phonomyography, a new monitoring technique of neuromuscular blockade (NMB), we compared NMB after mivacurium 0.1 mg/kg at the lateral cricoarytenoid muscle (LCA) with a possible external monitoring site of the larynx. In 12 patients, data were obtained at both sites using phonomyography. Anesthesia was induced with remifentanil 0.25–0.5 µg · kg–1 · min–1 followed by propofol 2–3 mg/kg. A small piezo-electric microphone was positioned beside the vocal cords into the muscular process at the base of the arytenoid cartilage to record acoustic signals from the contraction of the LCA. A second microphone was positioned at an external site, lateral to the trachea, just below the thyroid notch. The recurrent laryngeal nerve was stimulated supramaximally using train-of-four (TOF) stimulation every 12 s. Onset, maximum effect, and offset of NMB were measured and compared. Peak effect, time to reach (T) 25%, 75%, and 90% of control twitch response, and TOF recovery to TOF ratios 0.5–0.8 were significantly longer at the external site. The onset time was not significantly different between the two sites. We used phonomyography with a microphone placed at the neck to evaluate the possibility to externally monitor NMB at the larynx. When compared with LCA, we found a more pronounced peak effect and longer offset of NMB. The acoustic signals recorded at this external site are unlikely to stem from laryngeal muscle contraction but are rather a result of contraction of the strap muscles of the neck.

 

慢性疼痛病人对阿片类镇痛药量的增加呈年龄依赖性

Age-dependent opioid escalation in chronic pain patients.

Buntin-Mushock C, Phillip L, Moriyama K, Palmer PP.

University of California, San Francisco, Department of Anesthesia and Perioperative Care, 513 Parnassus Ave., Box 0464, Room S-455, San Francisco, CA 94143, USA.

Anesth Analg. 2005 Jun;10 (6):1740-5.

 

在一些每日用镇痛药治疗的病人中可观察到对阿片类镇痛药剂量需求的快速增加,尽管这些病人的可鉴别的临床特征还未知。此现象可能由对药物的耐受性导致。本文对206例患者进行回顾性研究,证明患者的年龄是否与阿片类镇痛药快速增加具有相关性。年轻患者和老年患者的初始剂量相似(< or =50 yr; 49 +/- 3 mg/d 口服吗啡等效剂量 VS > or =60 yr; 42 +/- 3 mg/d)。年轻患者在15+/-1.3个月后达到最大剂量为452+/-63mg/d,老年患者则为14.4+/-1.5个月、211+/-23mg/dP0.0001)。在最后的临床观察中,年轻患者平均剂量为365+/-61mg/d,老年患者为168+/-18mg/dP < 0.0001)。从初始服药到临床出院,只有老年患者显示了可观察的疼痛评分是降低的(6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01)。数据表明患者对阿片类镇痛药剂量需求增加因素中年龄是一个重要的变量。虽然也有除阿片类耐受之外的其他因素参与,但老年患者可能有更低的对阿片类镇痛药的耐受性。

(吴德华 薛张纲 校)

Rapid opioid dose escalation, possibly caused by tolerance, has been observed in some patients on daily opioid therapy, although clinically identifiable characteristics of these patients are unknown. In this retrospective chart review of 206 patients, we examined whether the age of the patient was related to opioid escalation. Initial starting doses of long-acting opioids were similar in younger patients (< or =50 yr; 49 +/- 3 mg/d oral morphine-equivalent dose) versus older patients (> or =60 yr; 42 +/- 3 mg/d). Younger patients reached a maximum dose of 452 +/- 63 mg/d over 15.0 +/- 1.3 mo, whereas older patients achieved a maximum dose of 211 +/- 23 mg/d over 14.4 +/- 1.5 mo (P < 0.0001). At the last clinic visit, younger-patient dosing averaged 365 +/- 61 mg/d, with older patients averaging 168 +/- 18 mg/d (P < 0.0001). Only older patients demonstrated a reduction in visual analog scale scores from start of opioid therapy until discharge from the clinic (6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01). These clinical data suggest that age is an important variable in opioid dose escalation. Although factors other than opioid tolerance can result in dose escalation, it is possible that older patients may have a reduced rate of tolerance development.

 

高频通气相和传统通气对急性肺损伤和急性呼吸窘迫综合征治疗的比较:系统性回顾和cochrane分析

High-frequency ventilation versus conventional ventilation for the treatment of acute lung injury and acute respiratory distress syndrome: a systematic review and cochrane analysis.

Wunsch H, Mapstone J, Takala J.
Department of Anesthesiology, Columbia Presbyterian Medical Center, 630 W. 168th St., New York, NY 10032, USA.

Anesth Analg. 2005 Jun;100(6).

 

这篇综述,我们检查了高频通气和传统通气对小儿和成人急性肺损伤和急性呼吸窘迫综合征的治疗结果.。我们以cochrane协作上的指导方针为根据进行了系统的文献搜索。两组试验引用包含标准;一组招募小儿(n=58),另一组招募成人(n=148)。两组都采用高频振动通气机和包含不同肺容量恢复策略的使用作为干预。干预组显示了较小的30天后死亡率趋势(小儿:相对危险[RR],0.83;95%信任时间间隔[CI],0.43-1.42;成人: RR,0.72;95%CI,0.50.-1.03),然而没有研究显示统计学上重要区别。同样,干预组和控制组呼吸机通气天数也没有统计学的重要区别。儿科研究(RR, 0.36; 95% CI, 0.14-0.93),在复位术危险时补充氧有统计学意义。总体上没有充分证据推断高频通气可以减低具有急性肺损伤或急性呼吸窘迫综合征患者的死亡率或长久的死亡率。 (这篇综述作为Cochrane 综述发表在The Cochrane Library 2004, Issue 3. Cochrane 综述作为新证据.注释.评论时常更新,而最新综述可在Cochrane Library查阅.)

(孙志荣 ,薛张纲 )

In this review, we examine outcomes from using high-frequency ventilation compared with conventional ventilation as therapy for acute lung injury and acute respiratory distress syndrome in children and adults. We conducted a systematic search of the literature based on the guidelines of the Cochrane Collaboration. Two trials met the inclusion criteria; one recruited children (n = 58), and the other recruited adults (n = 148). Both trials used a high-frequency oscillatory ventilator as the intervention and included variable use of lung-volume recruitment strategies. The intervention groups showed a trend toward less 30-day mortality (children: relative risk [RR], 0.83; 95% confidence interval [CI], 0.43-1.62; adults: RR, 0.72; 95% CI, 0.50-1.03), although neither study showed a statistically significant difference. Similarly, there was no statistically significant difference between the intervention and control groups for "total length of ventilator days." There was a statistically significant reduction in the risk of requiring supplemental oxygen among survivors at 30 days in the pediatric study (RR, 0.36; 95% CI, 0.14-0.93). Overall there is not enough evidence to conclude that high-frequency ventilation reduces mortality or long-term morbidity in patients with acute lung injury or acute respiratory distress syndrome. (This review is published as a Cochrane Review in The Cochrane Library 2004, Issue 3. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and The Cochrane Library should be consulted for the most recent version of the Review.).

 

单磷酰脂质A预处理后:危急的局部缺血组织的存活率

Preconditioning with Monophosphoryl Lipid A Improves Survival of Critically Ischemic Tissue.

Harder, Yves MD; Contaldo, Claudio MD; Klenk, Joachim MD; Banic, Andrej MD, PhD; Jakob, Stephan M. MD, PhD; Erni, Dominique MD

Department of Plastic Surgery and the Surgical Research Unit, Inselspital University Hospital, Berne, Switzerland

Anesth Analg. 2005;100(6):1786-1792

 

在这项试验中,我们评估用单磷酰脂质A预处理后的危急局部缺血创伤组织边缘的效果和全身及局部血流动力学改变以及使用挥发性麻醉药物与麻醉性镇痛药维持的麻醉过程中的氧合效果.20头大白猪在被切割臀肌前随机地接受了单磷酰脂质A(35微克每千克经静脉注射)或者Saline液体浸润24小时.这些动物在术中用异氟烷(呼吸末浓度为1.25%)维持并监测全身及局部臀肌皮瓣的血流动力学与氧合效应至6小时后.结果为:预处理过的样本心指数及氧供增加(两者P<0.05),并且中心静脉压及外周血压都有降低(两者P<0.01).在预处理过的皮瓣中微循环血流(使用激光多普勒血流仪监测)及局部组织的氧张力(使用微探针极谱描计术)与对照组相比增长了2.5(两者P<0.05);并且在术后14天里发生皮瓣坏死减少了20%P<0.05)。我们的结果表明:使用单次剂量单磷酰脂质A预处理能减少缺血相关的创伤愈合并发症,其机制可能与改善组织的灌注和氧合有关。此外,预处理在相对延长的异氟烷麻醉中有突出的对外周心血管的稳定作用。

(许文妍 薛张纲 )

In this study we sought to assess the effects of preconditioning with monophosphoryl lipid A on critically ischemic wound margins and on systemic and local hemodynamics and oxygenation during prolonged anesthesia with volatile anesthetics and narcotics. Twenty large white pigs were randomly assigned to receive either monophosphoryl lipid A 35 [mu]g/kg IV or saline 24 h before dissection of a buttock flap. The animals were anesthetized with isoflurane (end-tidal concentration approximately 1.25%) for surgery and subsequent monitoring of hemodynamics and oxygenation both systemically and in the flap tissue for 6 h. Preconditioning resulted in increased cardiac index and oxygen delivery (both P < 0.05) and in decreased central venous pressure and systemic vascular resistance (both P < 0.01). In the preconditioned flap tissue, microcirculatory blood flow (laser Doppler flowmetry) and partial tissue oxygen tension (polarographic microprobes) were up to 2.5-fold higher compared with control (both P < 0.05) and flap necrosis was reduced by 20% on postoperative day 14 (P < 0.05). Our results suggest that preconditioning with a single dose of monophosphoryl lipid A may attenuate ischemia-related wound healing complications, which may be related to an improvement in perfusion and oxygenation of this tissue. Furthermore, preconditioning exerted a systemic cardiovascular stabilization effect during prolonged isoflurane anesthesia.

昂丹司琼全身性给药能拮抗椎管内利多卡因的感觉阻滞作用

Systemic Ondansetron Antagonizes the Sensory Block Produced by Intrathecal Lidocaine

Argyro Fassoulaki, MD, PhD, DEAA*, A. Melemeni, MD, Marianna Zotou, MD, and Constantine Sarantopoulos, MD, MSc, PhD, DEAA

*Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens; Department of Anesthesiology, St Savas Hospital, Athens, Greece; and Department of Anesthesia, Medical College of Wisconsin, Milwaukee

Address correspondence and reprint requests to A. Fassoulaki, 57-59 Raftopoulou St., 11744 Athens, Greece.

Anesth Analg 2005 100: 1817-1821.

 

这次前瞻性随机对照双盲研究中,我们研究了昂丹司琼对于利多卡因蛛网膜下腔神经阻滞作用的影响。45例择期行腰麻下经尿道手术的男性病人在术前晚上口服4毫克昂丹司琼在腰麻前经静脉给予4毫克昂丹司琼(昂丹司琼组)或给予安慰剂(安慰剂组)。椎管内给予2毫升5%利多卡因。 椎管内给药202530分钟后测感觉阻滞平面, 306090分钟后测运动阻滞。由于技术原因2名对照组病人和5名昂丹司琼组病人未有感觉阻滞。在昂丹司琼组,30分钟后感觉阻滞效果有显著差别(p=0.048)。,蛛网膜下腔给予利多卡因15202530分钟后感觉阻滞平面在对照组为T11T12T12T12,在昂丹司琼组为T12T12T12L1,两组在30分钟后有差异(p=0.019)。在任何时间两组运动阻滞没有区别。在我们的研究条件下,得出昂丹司琼能拮抗利多卡因的感觉阻滞作用的结论。

(蔡美华 薛张纲 校)

In this prospective randomized, double-blind study, we investigated the effect of ondansetron on the lidocaine subarachnoid block. Fifty-four male patients scheduled for transurethral surgery under subarachnoid anesthesia received oral ondansetron 4 mg the evening before surgery and 4 mg IV 15 min before subarachnoid anesthesia (ondansetron group) or placebo (placebo group). Two milliliters of 5% hyperbaric lidocaine was administered intrathecally. Sensory block was assessed 20, 25, and 30 min and motor block 30, 60, and 90 min after lidocaine injection. In two patients in the control group and five in the ondansetron group, sensory block was not assessed for technical reasons. In the ondansetron group, sensory block values differed significantly over the 30-min period of assessments (P = 0.048). Fifteen, 20, 25, and 30 min after subarachnoid lidocaine, the level of sensory block was at T11, T12, T12, and T12 in the control group and T12, T12, T12, and L1 in the ondansetron group and differed between groups at 30 min (P = 0.019). Motor block did not differ between the two groups at any study time. We conclude that, under the conditions of our study, ondansetron antagonizes the sensory block produced by lidocaine.

 

比较在整形外科大手术中大剂量10%羟乙基淀粉264/0.455%白蛋白对凝血功能的影响:一项三盲随机试验

A triple-blinded randomized trial comparing the hemostatic effects of large-dose 10% hydroxyethyl starch 264/0.45 versus 5% albumin during major reconstructive surgery.

Arellano R, Gan BS, Salpeter MJ, Yeo E, McCluskey S, Pinto R, Irish J, Ross DC, Doyle DJ, Parkin J, Brown D, Rotstein L, Witterick I, Matthews W, Yoo J, Neligan PC, Gullane P, Lampe H.

Department of Anesthesia, Kingston General Hospital, 76 Stuart Street Kingston, Ontario, Canada K7L 2V7.

Anesth Analg. 2005 ;100(6):1846-53.

 

在加拿大,羟乙基淀粉264/0.45 (HES 264/0.45; 分子量 264 kDa, 取代级 0.45)已经在很大程度上取代了白蛋白成为围手术期血管内扩容的胶体液。HES 264/0.45的最大推荐剂量为28 mL/kg;然而,并没有临床数据支持这一限制量。在本研究中,我们比较了在头颈部整形外科大手术中HES 264/0.455%白蛋白高达45 mL/kg剂量、超过24小时时对凝血功能的影响。50个病人被随机分为HES 264/0.45组和5%白蛋白组,时间从麻醉诱导到24小时后。白蛋白和HES 264/0.45在围手术期和术后均能有效维持生理变量。在输注30 mL/kg 45 mL/kg后,HES 264/0.45组病人的部分凝血酶原时间和国际标准化比(INR)较白蛋白组有显著增高 (P < 0.05)。在输注15 mL/kg 30 mL/kg 45 mL/kg后,HES 264/0.45组的VIII因子和von Willebrand因子水平显著低于白蛋白组 (P < 0.05)HES 264/0.45组接受异体红细胞输注的病人明显较多 (P < 0.02)。我们认为HES 264/0.45输注大于30 mL/kg、超过24小时对凝血功能的损害在很大程度上高于白蛋白,并可能导致更多的异体血输注。

(周晓敏 薛张纲 校)

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.

体外循环下心脏手术期间嗜中性粒细胞介导基质金属蛋白酶-9的分泌和激活

Neutrophil-Mediated Secretion and Activation of Matrix Metalloproteinase-9 During Cardiac Surgery with Cardiopulmonary Bypass

Tso-Chou Lin, MD*, Chi-Yuan Li, MD, MS*, Chien-Sung Tsai, MD{dagger}, Chih-Hung Ku, MS, ScD{ddagger}, Ching-Tang Wu, MD*, Chih-Shung Wong, MD, PhD*, and Shung-Tai Ho, MD, MS*

*Department of Anesthesiology and {dagger}Surgery, Tri-Service General Hospital; and {ddagger}School of Public Heath, National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China

Anesth Analg 2005 100: 1554-1560.

 

体外循环(CPB)引起嗜中性粒细胞激活,脱颗粒和系统性炎症反应。基质金属蛋白酶-9MMP-9)存在于嗜中性粒细胞中,在其激活时释放。CPB的病人中可以观察到MMP-9的增高。作者设计了这个研究来确定CPB期间MMP-9是否来源于嗜中性粒细胞。研究包括了21名接受选择性CABG手术的病人,进行或没进行体外循环。采集血样分析MMP-9和组织金属蛋白酶抑制剂-1TIMP-1)。分离嗜中性粒细胞并检测MMP-9产物和m-RNA表达。CPB开始2-6小时后,血浆MMP-9水平和活性显著升高,而不停跳心脏手术的病人MMP-9水平没有升高。CPB开始后2小时,嗜中性粒细胞和m-RNA含量显著升高。6小时内血浆TIMP-1的水平逐渐升高,体外循环开始后2-4小时MMP-9/ TIMP-1比值增高。研究显示体外循环引起血浆MMP-9浓度和活性增高。相应的MMP-9表达和产物的增高提示MMP-9主要来源于嗜中性粒细胞并且会引起与体外循环有关的炎症反应。

(殷文渊 陈杰 校)

Cardiopulmonary bypass (CPB) induces neutrophil activation, degranulation, and a systemic inflammatory response. Matrix metalloproteinase (MMP)-9 exists in neutrophils and is released on neutrophil activation. Increased levels of MMP-9 have been observed in patients undergoing CPB. We designed the present study to determine whether MMP-9 is derived from neutrophils during CPB. Twenty-one patients undergoing elective coronary artery bypass grafting with or without CPB were included in this study. Blood was collected and analyzed for MMP-9 and tissue inhibitor of metalloproteinase (TIMP)-1. Neutrophils were also isolated and examined for MMP-9 production and mRNA expression. Plasma levels and activity of MMP-9 increased significantly 2–6 h after beginning CPB, whereas the MMP-9 levels in patients with off-pump cardiac surgery did not increase. The neutrophil content of MMP-9 and mRNA increased significantly 2 h after beginning CPB. The plasma levels of TIMP-1 increased gradually for 6 h, whereas the MMP-9/TIMP-1 ratios were increased 2–4 h after beginning CPB. The present study demonstrated that CPB causes an increase in the concentration and activity of plasma MMP-9. The corresponding increase in neutrophil MMP-9 expression and production suggests that MMP-9 is derived primarily from neutrophils and may contribute to the inflammatory response associated with CPB.

 

血栓弹性描记法的最大振幅预测包括心肌梗死的术后血栓性并发症

Thromboelastography Maximum Amplitude Predicts Postoperative Thrombotic Complications Including Myocardial Infarction

Douglas J. McCrath, MD, Elisabetta Cerboni, Robert J. Frumento, MS, MPH, Andrew L. Hirsh, BS, and Elliott Bennett-Guerrero, MD

Department of Anesthesiology, Columbia University College of Physicians & Surgeons, New York, New York

Anesth Analg 2005 100: 1576-1583.

术后血栓性并发症增加住院天数和费用。如果潜在的术后血栓并发症是由高凝状态所导致,作者想确定使用血栓弹性描记法进行术后血液分析是否能预测术后血栓形成性并发症的发生,包括心肌梗死(MI)。预先登记了240名接受各种手术的病人。使用校正Goldman风险指数对每名病人进行心脏风险评估。手术后即刻进行血栓弹性描记法测定并确定最大振幅(MA),以此表示凝结力。以不知情的观察者通过诊断性试验来确定术后血栓性并发症。12名发生术后血栓性并发症的病人中的10名(4.2%)遭受了损害。MA增高的病人(95人中的8人,8.4%)术后血栓性并发症发生的几率明显高于MA68的病人(145人中的2人,1.4%)。此外,在MA增高组(95人中的6人,6.3%)中术后MI的百分比要显著大于MA68组(145人中的0人,0 %)(P=0.0035)。在多元分析中,MA增高和Goldman风险评分都可以单独预测术后MI。在不同组手术病人中,术后凝血弹性描记法确定的高凝状态与包括MI在内的术后血栓性并发症相关。

(殷文渊 陈杰 校)

Postoperative thrombotic complications increase hospital length of stay and health care costs. Given the potential for thrombotic complications to result from hypercoagulable states, we sought to determine whether postoperative blood analysis using thromboelastography could predict the occurrence of thrombotic complications, including myocardial infarction (MI). We prospectively enrolled 240 patients undergoing a wide variety of surgical procedures. A cardiac risk score was assigned to each patient using the established revised Goldman risk index. Thromboelastography was performed immediately after surgery and maximum amplitude (MA), representing clot strength, was determined. Postoperative thrombotic complications requiring confirmation by a diagnostic test were assessed by a blinded observer. Ten patients (4.2%) suffered a total of 12 postoperative thrombotic complications. The incidence of thrombotic complications with increased MA (8 of 95 = 8.4%) was significantly (P = 0.0157) more frequent than that of patients with MA ≤68 (2 of 145 = 1.4%). Furthermore, the percentage suffering postoperative MI in the increased MA group (6 of 95 = 6.3%) was significantly larger than that in the MA ≤68 group (0 of 145 = 0%) (P = 0.0035). In a multivariate analysis, increased MA (P = 0.013; odds ratio, 1.16; 95% confidence interval, 1.03–1.20) and Goldman risk score (P = 0.046; odds ratio, 2.39; 95% confidence interval, 1.02–5.61) both independently predicted postoperative MI. A postoperative hypercoagulable state as determined by thromboelastography is associated with postoperative thrombotic complications, including MI, in a diverse group of surgical patients.

 

儿科病人使用21/2 ProSealTM喉罩通气与标准喉罩通气的随机交叉比较

A Randomized Crossover Comparison of the Size 21/2 Laryngeal Mask Airway ProSealTM Versus Laryngeal Mask Airway-ClassicTM in Pediatric Patients

Kai Goldmann, MD, DEAA, and Christian Jakob

Department of Anaesthesia and Intensive Care Therapy, Philipps University Marburg, Germany

Anesth Analg 2005 100: 1605-1610.

在成人麻醉中, ProSealTM喉罩通气(P-LMA)较标准喉罩通气(C-LMA) 的密封更为有效,且便于放置胃管。儿科病人尺寸的P-LMA最近新问世。作者选择了30例麻醉而无肌松的儿科病人,年龄7.7 ± 2岁,体重27 (20–35) kg,随机插入1/2P-LMAC-LMA。评价插入喉罩的难易度、喉罩插入开始时气道的特性、光纤导管定位的位置、气道漏气压力和最大潮气量。插入P-LMA的病人再评价胃管放置的影响。两种喉罩插入的难以程度相似。P-LMA组喉罩插入开始时气道的特性优于另一组(P = 0.01)。头正中位时气道漏气压为(22.618.5 mbarP = 0.003),最大屈曲时为(37 26.3mbarP < 0.001),最大伸展时为(15.2 13 mbar; P = 0.045),最大潮气量为(1088949 mLP = 0.002)P-LMA组均优于C-LMA组。C-LMA组有气体进入胃内,而P-LMA组未见此现象(P = 0.014)。所有病人都可以放置胃管。本研究显示可靠放置胃管和气道漏气压明显升高,意味儿科病人可使用1/2P-LMA行正压通气。

(肖洁 陈杰 校)

The laryngeal mask airway (LMA)-ProSealTM (P-LMA) forms a more effective seal than the LMA-ClassicTM (C-LMA) and facilitates gastric tube (g-tube) placement in adults. The first pediatric sizes of P-LMA recently became available. In 30 anesthetized, nonparalyzed children, aged 7.7 ± 2 yr and weighing 27 (20–35) kg, we inserted the size 1/2P-LMA and C-LMA in random order. Ease of insertion, quality of initial airway, fiberoptic position, airway leak pressure, and maximum tidal volume were determined. G-tube placement was assessed for the P-LMA. Ease of insertion was similar for both devices. The quality of the initial airway was better for the P-LMA (P = 0.01). Airway leak pressure in neutral head position (22.6 versus 18.5 mbar; P = 0.003), maximum flexion (37 versus 26.3 mbar; P < 0.001), maximum extension (15.2 versus 13 mbar; P = 0.045), and maximum tidal volume (1088 versus 949 mL; P = 0.002) were significantly better for the P-LMA. Air entry into the stomach occurred with the C-LMA but not with the P-LMA (P = 0.014). G-tube placement was possible in all patients. The reliability of g-tube placement and the significantly increased airway leak pressure found in this investigation might have important implications for use of the size 1/2P-LMA for positive pressure ventilation in children.

 

预防性使用地塞米松以减少儿科斜视手术后恶心呕吐的发生:剂量范围和安全性评价研究

Prophylactic Dexamethasone for Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Dose Ranging and Safety Evaluation Study

Rashmi Madan, MD*{dagger}, Anuj Bhatia, MD*{ddagger}, Sajith Chakithandy, MBBS*, Rajeshwari Subramaniam, MD*, Gurram Rammohan, MBBS*, Shrinivas Deshpande, MD*, Manorama Singh, MD*, and H. L. Kaul, MD*

*Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India; {dagger}Department of Anaesthetics, Queen Elizabeth Hospital, Norfolk; and {ddagger}Department of Anesthetics, Addenbrookes Hospital, Cambridge, United Kingdom

Anesth Analg 2005 100: 1622-1626.

 

在这项双盲、随机、对照性研究中,作者评价了预防性静脉内注射不同剂量的地塞米松治疗儿科病人斜视术后恶心呕吐(PONV)的有效性和安全性。168个病人,年龄(2–15)岁,全身麻醉诱导后接受静脉内注射地塞米松0.25 mg/kg (D 0.25),地塞米松(D 0.5) 0.5 mg/kg,地塞米松1.0 mg/kg (D 1)或生理盐水(S)。术后随访24小时,分别在术后0–2h2–6h6–24h评价病人恶心呕吐发生率。分别在术前和注射治疗药物后4h测量病人的血糖。术后一周评价病人伤口愈合和感染的情况。与地塞米松组相比,S组的大部分病人在术后的0–2h2–6h6–24h中发生呕吐(P = 0.001, P = 0.003, P = 0.04),而且需加用大剂量的止吐剂。与S组相比,地塞米松组中较少发生严重PONV(D0.256个,D0.53个,D16个,P = 0.001)。所有病人中,均未发现术后血糖升高,且伤口愈合满意。结果表明,儿科斜视矫治手术中,使用地塞米松0.25 mg/kg较生理盐水有更效地防治PONV,并与更大剂量的地塞米松有相等的作用。

(肖洁 陈杰 校)

In this double-blind, randomized, placebo-controlled study, we evaluated the efficacy and safety of different doses of prophylactic IV dexamethasone for postoperative nausea and vomiting (PONV) in 168 children (aged 2–15 yr) scheduled for strabismus surgery. Patients received IV dexamethasone 0.25 mg/kg (D 0.25), 0.5 mg/kg (D 0.5), 1.0 mg/kg (D 1), or saline (S) immediately after induction of general anesthesia. Patients were discharged 24 h after surgery. Nausea and vomiting were assessed at 0–2, 2–6, and 6–24 h after surgery. Blood glucose was measured preoperatively and at 4 h after study drug administration. Wound healing and were assessed after 1 wk. More patients in group S had vomiting at 0–2, 2–6, and 6–24 h (P = 0.001, P = 0.003, and P = 0.04, respectively) and required larger doses of rescue antiemetics compared with the dexamethasone groups. Fewer patients in the dexamethasone groups (6, 3, and 6 in D 0.25, D 0.5, and D 1, respectively) had severe PONV compared with group S (P = 0.001). No significant increase in postoperative blood glucose levels was observed and wound healing was satisfactory in all four groups. The results suggest that dexamethasone 0.25 mg/kg is more effective than saline and equally effective compared with larger doses for preventing PONV for pediatric strabismus surgery.

 

异丙酚剂量依赖性地通过影响Bcl2BAX表达和NO产生减少肿瘤坏死因子(TNFα)诱导的人脐静脉内皮细胞凋亡

Propofol Dose-Dependently Reduces Tumor Necrosis Factor-{alpha}-Induced Human Umbilical Vein Endothelial Cell Apoptosis: Effects on Bcl-2 and Bax Expression and Nitric Oxide Generation

Tao Luo, MD*, Zhengyuan Xia, MD, PhD*{ddagger}, David M. Ansley, MD, FRCP{ddagger}, Jingping Ouyang, MD{dagger}, David J. Granville, PhD§, Yinping Li, PhD{dagger}, Zhong-Yuan Xia, MD*, Qing-Shan Zhou, MD, PhD*, and Xian-Yi Liu, MD*

*Department of Anesthesiology, Renmin Hospital, Wuhan University; {dagger}Department of Pathophysiology, Faculty of Medicine, Wuhan University, Wuhan, People’s Republic of China; {ddagger}Centre for Anesthesia & Analgesia, Department of Pharmacology & Therapeutics, The University of British Columbia, Vancouver; and §The James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, The University of British Columbia, Vancouver, British Columbia, Canada

Anesth Analg 2005 100: 1653-1659.

作者研究了异丙酚是否能抑制肿瘤坏死因子(TNFα)诱导的人工培养的人脐静脉内皮细胞(HUVECs)凋亡。分离的HUVECs置于20%小牛血清的改进的Eagle培养基中培养。HUVECs未处理组和HUVECs异丙酚处理组均在37°C下培养24.5h。行TNF处理的HUVECs 组一开始先在含有TNF或者不同浓度异丙酚中分别培养30min,然后放置于加有40ng/mlTNF的培养基中24h。采用末端脱氧核苷酰酶酸转移酶介导的切口末端标记法(TUNEL)来检测凋亡,并用电镜技术验证。用免疫细胞化学分析法检测抗凋亡的Bc l2和前凋亡Bax蛋白表达。TNF刺激导致HUVECsBcl2/Bax比率的下降,并且增加了凋亡指数(AI:凋亡细胞的百分比)。异丙酚在浓度≥12μM时,明显减弱HUVECsBcl2/Bax比率的下降,并且增加了AIp<0.001),这种效果呈现剂量依赖性。同时伴随着NO的产生增加,与Bcl2/Bax比率和AI呈负相关(p=0.0009)。结果说明临床相关剂量的异丙酚可减少肿瘤坏死因子(TNFα)诱导的HUVECs凋亡。

(顾漪闻 陈杰 校)

We investigated whether propofol can inhibit tumor necrosis factor (TNF)-{alpha}-induced apoptosis in cultured human umbilical vein endothelial cells (HUVECs). Isolated HUVECs were cultured in Dulbecco’s modified Eagle medium supplemented with 20% bovine calf serum. HUVECs in untreated and propofol control groups were cultured at 37°C for 24.5 h. HUVECs in the TNF treatment groups were initially cultured for 30 min in the presence of TNF or various concentrations of propofol, respectively, which were then cultured for 24 h with the addition of TNF at 40 ng/mL in the medium. Apoptosis was detected using terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) and confirmed by electron microscopy. The antiapoptotic Bcl-2 and proapoptotic Bax protein expressions were measured by immunocytochemical analysis. TNF stimulation resulted in a reduced Bcl-2/Bax ratio and increased apoptotic index (AI: percentage of apoptotic cells) in HUVECs. Propofol, at concentrations ≥12 µM, significantly (P < 0.001) and dose-dependently attenuated TNF-induced increase in AI and decrease in Bcl-2/Bax ratio. This was accompanied by increases in nitric oxide production. There is an inverse correlation between the ratio of Bcl-2/Bax expression and AI (P = 0.0009). These results suggest that propofol, at clinical relevant concentrations, can reduce TNF-induced HUVEC apoptosis.

 

局麻药n-丁基- p-氨基苯甲酸酯可完全阻滞鼠感觉神经元的N-型钙离子传导

The Block of Total and N-Type Calcium Conductance in Mouse Sensory Neurons by the Local Anesthetic n-Butyl-p-Aminobenzoate

Jeroen P. Beekwilder, MSc, Daniel L. B. Winkelman, MSc, Gertrudis Th. H. van Kempen, BSc, Rutgeris J. van den Berg, PhD, and Dirk L. Ypey, PhD

Department of Neurophysiology, Leiden University Medical Center, Leiden, The Netherlands

Anesth Analg 2005 100: 1674-1679.

为了解硬膜外给予局麻药氨苯丁酯混悬液(BAB)所产生的选择性麻醉的机制,作者研究了溶解的BAB对于感觉神经元的钙离子通道的影响。取新生小鼠小直径脊根神经节,通过电压钳制刺激术检测其全细胞的钡或钙离子流。BAB抑制了这些细胞和电刺激相关的钡离子流, BAB呈浓度依赖性(50%的抑制浓度为207±14μMn40)。 BAB依赖剂量和药理学上独立全细胞钡离子流的N-型成分的浓度相似。在有BAB时,N-型离子流的灭活和失活时间稍短,因此,作者认为,离子运动改变可能和离子流被抑制有关。当钙离子流受到控制电势的刺激,产生动作电位峰时, BAB同样可以抑制全细胞钙离子流和它的N-型成分。可以认为BAB抑制钙离子流可能是硬膜外给予局麻药混悬液所产生局部麻醉的机制。

(顾漪闻 陈杰 校)

To contribute to the understanding of the mechanism underlying selective analgesia by epidural application of suspensions of the local anesthetic butamben (n-butyl-p-aminobenzoate; BAB), we investigated the effect of dissolved BAB on calcium channels in sensory neurons. Small-diameter dorsal root ganglion neurons from newborn mice were used to measure whole-cell barium or calcium currents through calcium channels upon voltage-clamp stimulation. BAB suppressed the voltage-step-evoked barium current of these cells in a concentration-dependent manner with a 50% inhibitory concentration of 207 ± 14 µM (n = 40). A similar concentration dependency was found for the pharmacologically isolated N-type component of the whole-cell barium current. The time constants of inactivation and deactivation of the N-type current became smaller in the presence of BAB, thus suggesting that kinetic changes are involved in the inhibition of this current. BAB caused a similar inhibition of the total calcium current and its N-type component when these currents were evoked by command potentials with the shape of an action potential. This inhibition of calcium currents by BAB should be considered in the search for the mechanism of selective analgesia by epidural suspensions of this local anesthetic.

 

硬膜外导管的电特性:神经刺激引导仪要求什么?

The Electrical Properties of Epidural Catheters: What Are the Requirements for Nerve Stimulation Guidance?

Hisayoshi Tamai, MD, Shigehito Sawamura, MD, PhD, Hidenao Atarashi, BS, Kenji Takeda, MD, Kazuhiko Ohe, MD, PhD, and Kazuo Hanaoka, MD, PhD

Department of Anesthesiology, The University of Tokyo, Tokyo, Japan

Anesth Analg 2005 100: 1704-1707.

作者设计本研究,目的是观测目前市场上常用的硬膜外导管的电阻抗,以寻找合适的产品用于引导神经刺激器的插入。选择四种硬膜外导管,两根是非金属线加强导管(19号和20号,尼龙),另两根是金属线加强导管(19号无管芯和20号有管芯)。导管的电阻抗通过串联电路中电压与固定阻抗比例来计算。在生理盐水中,非金属线加强导管的阻抗超过700kΩ,金属线加强导管无管芯和有管芯的分别为14.4±0.2 kΩ10.1±0.42kΩ。当管芯通过了20号的尼龙导管时,阻抗减少到49.2±1.96 kΩ。当导管用10%的高渗盐水处理过后,两根非金属线加强导管的阻抗和生理盐水处理过的比较,减少了1/3。这些试验的硬膜外导管,充满生理盐水后,其电阻抗都发生了改变。作者认为用于引导电刺激仪的硬膜外导管均应该有螺旋式的不锈钢金属线加强,或是有不锈钢的管芯。

(顾漪闻 陈杰 校)

We designed the present study to investigate the electrical resistance of commercially available epidural catheters and to search for products and procedures suitable for nerve stimulation-guided insertion. Four types of epidural catheters were evaluated: 2 nonwire-reinforced catheters (19-gauge and 20-gauge nylon) and 2 wire-reinforced catheters (19-gauge without stylet and 20-gauge with stylet). The resistance of a catheter was calculated from the voltage level proportional to the fixed resistance in series circuit. In case of physiologic saline, the resistance of nonreinforced catheters was more than 700 k{Omega}, whereas the wire-reinforced catheter was 14.4 ± 0.20 k{Omega} without stylet and 10.1 ± 0.42 k{Omega} with stylet. When the stylet was passed through a 20-gauge nylon catheter, the resistance decreased to 49.2 ± 1.96 k{Omega}. When catheters were primed with 10% hypertonic saline, the resistance of both nonreinforced catheters decreased by one third compared with physiologic saline. The electrical resistance of the saline-filled epidural catheters significantly differed among products tested. We conclude that epidural catheterization that is guided by electrical stimulation should be performed only with catheters equipped with spiral stainless steel wire reinforcement or with a stainless steel stylet.

 

通过改良压力降低方式来检测单向活瓣功能不全

Detecting Unidirectional Valve Incompetence by the Modified Pressure Decline Method

Wade A. Weigel, MD, and W. Bosseau Murray, MBChB, FRCA, MD

Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania

Anesth Analg 2005 100: 1723-1727.

 

1993FDA麻醉仪器调查委员会提供了一项指南,用于指导标准的麻醉仪器环路的检查。但是,作者认为,这项指南没能提供良好的检测单向活瓣(UDV)的方法,因此,作者用改良压力降低方式(MPDM)来检测单向活瓣功能不全。这个方法通过压力储气囊向UDV的顺流来检测活瓣的功能。用MPDM法检测了18个麻醉呼吸回路中的36个单向活瓣。一台DraegerDraeger医疗公司,TelfordPA)和一台OhmedaDatexOhmeda公司,MadisonWI)机器由于使用了功能不全活瓣盘而重新检测。在18个麻醉呼吸回路中的36个单向活瓣中有一个UDV功能不全(3%)。将功能不全的UDV放置在每个型号的麻醉机时,用MPDM法可以检测活瓣漏气(Draeger0.6L/min 流量漏气,Ohmeda0.9L/min 流量漏气)。MPDM用来检测单向活瓣功能不全是一种快速和有效的方法。

(顾漪闻 陈杰 校)

The 1993 Food and Drug Administration anesthesia apparatus checkout recommendation provides guidance for a standardized circle system checkout but, we believe, inadequately tests unidirectional valve (UDV) function. We developed the modified pressure decline method (MPDM) for checking UDVs. The test involves pressurizing reservoir bags downstream of the UDVs to check for competency. Thirty-six UDVs in 18 anesthesia circle systems were evaluated using the MPDM. One Draeger (Draeger Medical Inc., Telford, PA) and one Ohmeda (Datex-Ohmeda Inc., Madison, WI) machine were then retested using incompetent valve discs. One incompetent UDV (3%) was identified of the 36 valves tested in 18 anesthesia machines. The MPDM detected the valve leak (Draeger 0.6 L/min flow leak; Ohmeda 0.9 L/min flow leak) when the incompetent valve discs were intentionally introduced into each type of machine. MPDM provides a quick and effective way of identifying incompetent UDVs.

 

麻醉前访视后病人的满意度和所获的信息:面对面会谈,宣传资料和录像三种方法的比较

Patient Satisfaction and Information Gain After the Preanesthetic Visit: A Comparison of Face-to-Face Interview, Brochure, and Video

Stephanie A. Snyder-Ramos, MD*, Henrik Seintsch*, Bernd W. Böttiger, MD, DEAA*, Johann Motsch, MD*, Eike Martin, MD, FANZCA*, and Martin Bauer, MD, MPH*

*Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany; and {dagger}Department of Anesthesiology, Universities of Schleswig-Holstein, Campus Kiel, Kiel, Germany

Anesth Analg 2005 100: 1753-1758.

这项研究中作者比较了麻醉前访视的三种方法。按顺序研究197名接受全身麻醉的外科手术患者。病人随机分成常规麻醉前会谈,宣传资料加会谈或自制录像加会谈三组。麻醉前访视后,每种方法病人的满意度和所获信息量通过调查表量化。病人满意度的调查通过六点记分表评估,而所获信息量通过多项选择评估。录像加会谈组显示得最高分(患者满意度占可能最大点数总分的98%,所获信息量占93%)。相反,宣传资料加会谈组病人满意度和所获信息量分别为93%和80%,而标准会谈组为91%和72%。病人的满意度和所获信息量最大总分在会谈组和录像组间有显著差异,但会谈组和宣传资料组间无显著差异。因此,这些数据提示利用录像作为麻醉前访视的补充可提高患者的满意度并获得最大信息量。

(朱辉 陈杰 校)

In this study we compared 3 methods of conducting the preanesthetic visit. We prospectively studied 197 consecutive surgical patients who were to undergo general anesthesia. The patients were randomized to a routine preanesthetic interview, a brochure plus an interview, or a self-made documentary video plus an interview. After the preanesthetic visit, the degree of patient satisfaction and information gain was quantified by a questionnaire for each method. The questions on patient satisfaction were assessed on a six-point scale, and those on information gain were assessed on a multiple-choice basis. The video plus interview group showed the highest point scores (98% of the possible maximum sum point score in patient satisfaction and 93% of the maximum sum score in information gain). In contrast, the patients of the brochure plus interview group revealed 93% for patient satisfaction and 80% for information gain, and in the standard interview group, the corresponding figures were 91% and 72%, respectively. The maximum sum scores in patient satisfaction and information gain were significantly different between the interview and the video groups, but not between the interview and the brochure groups. Therefore, these data suggest that the use of a documentary video to supplement a preoperative interview may enhance patient satisfaction and maximize information gain.

 

两种不同羟乙基淀粉溶液(6%贺斯130/0.4200/0.5)对血粘度的影响

The Influence of Two Different Hydroxyethyl Starch Solutions (6% HES 130/0.4 and 200/0.5) on Blood Viscosity

Thomas A. Neff, MD, Lukas Fischler, MD, Michael Mark, MD, Reto Stocker, MD, and Walter H. Reinhart, MD

Department of Internal Medicine, Kantonsspital, Chur, Switzerland, and Division of Surgical Intensive Care, University Hospital, Zurich, Switzerland

Anesth Analg 2005 100: 1773-1780.

 

本研究观察两种不同羟乙基淀粉溶液即新型中分子贺斯130/0.46%)和贺斯200/0.56%)对严重脑外伤患者离体和在体的血浆和全血液粘度的影响。离体试验中,在血标本内不断加入6%贺斯130/0.46%贺斯200/0.5溶液以增加贺斯浓度(0%-50%)。测定高(94.5s-1)和低(0.1s-1)切变率时血浆粘度和全血粘度(血球压积45%)。两种贺斯溶液都增加血浆粘度但贺斯130/0.4增加程度不及贺斯200/0.5。而贺斯浓度在37.5%或更大时贺斯130/0.4全血粘度显著低于贺斯200/0.5。在体研究是通过31名严重脑外伤患者随机给以贺斯130/0.4或贺斯200/0.5几天治疗,融化冰冻血浆并测定血浆压积。输注正常红血球(O型,Rh阴性,压积45%)重新溶解配成原来浓度以测得全血粘度。整个过程中血浆和全血粘度有增加趋势但无统计学意义。尽管两种贺斯在体外试验中显著增加血粘度,而在体研究中不明显,但这可能反映出在重复、大剂量使用贺斯时真实的临床状况。因此,当大剂量使用时,贺斯130/0.4比传统的贺斯200/0.5更具有血液流变学优点。

(朱辉 陈杰 校)

We performed the current study to investigate the influence of 2 different hydroxyethyl starch (HES) solutions, the novel medium molecular weight HES 130/0.4 (6%) and HES 200/0.5 (6%), on plasma and whole blood viscosity in vitro and ex vivo in patients with severe head injury. For the in vitro experiments, blood was incubated with increasing concentrations (0%–50% vol/vol plasma) of either 6% HES 130/0.4 or 6% HES 200/0.5 solution. Plasma viscosity and whole blood viscosity (hematocrit [Hct] 45%) at high (94.5 s–1) and low (0.1 s–1) shear rates were determined. Both HES solutions increased plasma viscosity, but HES 130/0.4 to a lesser extent than HES 200/0.5. Whole blood viscosity was significantly less with HES 130/0.4 than with HES 200/0.5 at concentrations of 37.5% and larger. In the ex vivo study on 31 patients with severe cranio-cerebral trauma treated randomly with either HES 130/0.4 or HES 200/0.5 over several days, frozen plasma samples were thawed and plasma viscosity was determined. Blood was reconstituted with normal erythrocytes (0, Rh neg, Hct 45%) for whole blood viscosity measurements. In both groups plasma and blood viscosity tended to increase over time without statistical significance. Although the prominent effects found in vitro are not in keeping with the ex vivo data, they are likely to reflect the true clinical situation during repetitive, large-dose HES administration. We therefore conclude that HES 130/0.4 may have hemorheological advantages over conventional HES 200/0.5 when used in large quantities.

 

在儿科脊柱侧弯手术中异氟醚和地氟醚逐步增加剂量脑双频指数维持在60时对皮层体感诱发电位的影响

The Effects of Isoflurane and Desflurane Titrated to a Bispectral Index of 60 on the Cortical Somatosensory Evoked Potential During Pediatric Scoliosis Surgery

James E. Fletcher, MB BS, MRCP, FRCA*, Albert R. Hinn, MD*, Christopher M. Heard, MB ChB{dagger}, Linda S. Georges, MD*, Eugene B. Freid, MD*, Ann Keifer, MD*, Sandra D. Brooks, R.EEG/EPT, CNIM*, Ann G. Bailey, MD*, and Robert D. Valley, MD*

*Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and {dagger}Department of Anesthesiology, Children’s Hospital Buffalo, Buffalo, New York

Anesth Analg 2005 100: 1797-1803.

 

在这项研究中,作者在儿科原发性脊柱侧弯患者矫正手术中,比较异氟醚和地氟醚对通过头皮电极记录的胫后体感诱发电位的影响。研究中,镇静深度通过持续脑双频指数监测,维持在BIS60。患者吸入地氟醚和异氟醚时诱发的皮层振幅(N37-P45),分别为0.53 ± 0.3 µV 1.3 ± 0.8 µV (P = 0.014)。此外,比较交叉吸入地氟醚或异氟醚改成其它麻醉药时诱发电位的变化。结果也显示异氟醚诱发的皮层振幅比地氟醚诱发的振幅要大。异氟醚和地氟醚对皮层下(N31-P34)P37潜伏期振幅的作用无明显区别。

(朱玫娟 陈杰 校)

In this study, we compared the effect of isoflurane and desflurane on the posterior tibial somatosensory evoked potential recorded by scalp electrodes during correction of idiopathic scoliosis in pediatric patients. Depth of sedation was controlled by maintaining bispectral index (BIS) at 60 throughout the study. Comparison of patients breathing desflurane and isoflurane showed an evoked cortical amplitude (N37-P45) of 0.53 ± 0.3 µV versus 1.3 ± 0.8 µV (P = 0.014), respectively. In addition to this comparison, a crossover design was included whereby the desflurane or isoflurane received in the first part of the study was changed to the other anesthetic. Substituting one anesthetic for another confirmed our initial finding that the cortical evoked amplitude is greater with isoflurane than with desflurane. No differential effect was found between desflurane and isoflurane on the evoked subcortical (N31-P34) amplitude or the P37 latency.

 

家庭持续周围神经阻滞:综述

Continuous Peripheral Nerve Blocks at Home: A Review

Brian M. Ilfeld, MD, and F. Kayser Enneking, MD

From the Departments of Anesthesiology and Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida

Anesth Analg 2005 100: 1822-1833.

在单次局部神经阻滞后,术后镇痛的时间通常限制在1216小时或者更少。在初始注射局部阻滞药物后,可以通过神经周围置管来持续输注局麻药进行术后镇痛。通过近来介绍的那些可信赖和携带的输注泵,这项技术现在可以在门诊中开展。在这篇综述中,作者总结了与这项镇痛新技术有关的文献中的数据,特别是在患者家中进行持续神经周围输注相关的重要内容。内容包括持续输注的优点和风险,适应症和患者选择的原则,使用的导管、输注泵、给药配比、输注选择以及那些与家庭护理特别相关的内容。

(朱玫娟 陈杰 校)

Postoperative analgesia is generally limited to 12–16 h or less after single-injection regional nerve blocks. Postoperative analgesia may be provided with a local anesthetic infusion via a perineural catheter after initial regional block resolution. This technique may now be used in the outpatient setting with the relatively recent introduction of reliable, portable infusion pumps. In this review article, we summarize the available published data related to this new analgesic technique and highlight important issues related specifically to perineural infusion provided in patients’ own homes. Topics include infusion benefits and risks, indications and patient selection criteria, catheter, infusion pump, dosing regimen, and infusate selection, and issues related specifically to home-care.

 

异氟醚与肌膜上KATP通道蛋白激酶C激活剂的关系

The Interaction of Isoflurane and Protein Kinase C-Activators on Sarcolemmal KATP Channels

Lawrence A. Turner, MD*, Kazuhiro Fujimoto, MD, PhD*, Akihiro Suzuki, MD*, Anna Stadnicka, PhD*, Zeljko J. Bosnjak, PhD* , and Wai-Meng Kwok, PhD*{ddagger}

Departments of *Anesthesiology, {dagger}Physiology, and {ddagger}Pharmacology & Toxicology, Medical College of Wisconsin, Milwaukee

Anesth Analg 2005;100: 1680-1686

 

 蛋白激酶CPKC)相关的信号传导途径可能与麻醉药的记忆效应和缺血预适应有关,其可帮助心肌在随后的缺血或ATP耗竭时促进ATP敏感钾通道活化。应用膜片钳技术研究分离豚鼠心肌,发现给予巴豆油酯刺激PKC后,心肌给予1mM异氟醚,与电极内含1mMATP相较,电极内含0.5mMATP者的肌膜ATP通道(IKATP)电流更大(P <0.05)。其pA/pF分别为10 ± 5n5 2 ± 1n6)。PKC抑制剂bisindolylmaleinide能拮抗同等条件下第二次给予异氟醚引起的电流。电极内含有甘油二酯(PKC激动剂)能激发与其浓度相关的IKATP。单独给予0.5µM 甘油二酯激发的IKATP电流pA/pF均值为5 ± 3n9)。只对显微镜下肌细胞短暂给予异氟醚,随后冲洗掉,电极内含有同样的甘油二酯溶液能激发更大的(P <0.01) IKATP, 均值为 40 ± 9 pA/pF (n10),其在麻醉药处理后48 ± 2 min 出现。当细胞内ATP减少时,异氟醚能激发更大的IKATP是依赖于PKC以异氟醚预适应的肌细胞引起肌膜KATP持续改变,可加强甘油二酯诱导IKATP的作用。

赵雪莲 李士通

Protein kinase C (PKC)-dependent signaling pathways may be involved in the "memory" effect of anesthetic and ischemic preconditioning, which facilitates activation of cardioprotective adenosine triphosphate (ATP)-sensitive potassium channels during later ischemic challenge and ATP depletion. Using patch-clamp techniques, we found that exposure of isolated guinea pig cardiomyocytes to 1 mM of isoflurane after phorbol ester stimulation of PKC facilitates the induction of larger (P ≤0.05) sarcolemmal KATP channel currents (IKATP) during cell dialysis with 0.5, compared to 1.0, mM of ATP in the pipette (10 ± 5 versus 2 ± 1 pA/pF in five and six cells, respectively). A PKC inhibitor, bisindolylmaleimide, abolished the induction of IKATP by a second brief isoflurane exposure under these conditions. A diacylglycerol PKC activator applied via the pipette elicited concentration-related activation of IKATP. The diacylglycerol alone (0.5 µM) elicited IKATP, averaging 5 ± 3 pA/pF in nine cells. Briefly treating myocytes on the microscope stage with isoflurane, followed by washout and patching with the same diacylglycerol solution, elicited larger (P ≤0.01) IKATP, averaging 40 ± 9 pA/pF (10 cells), with an onset 48 ± 2 min after anesthetic pretreatment. Facilitation of IKATP by isoflurane during the reduction of intracellular ATP is dependent on PKC, whereas "preconditioning" myocytes with isoflurane causes persistent changes in sarcolemmal KATP channel function, which enhance the induction of IKATP by a diacylglycerol.

高位胸段硬膜外麻醉对冠心病病人左心室收缩及舒张功能的影响

The Effect of High Thoracic Epidural Anesthesia on Systolic and Diastolic Left Ventricular Function in Patients with Coronary Artery Disease

 

Christoph Schmidt, MD*, Frank Hinder, MD, PhD*, Hugo Van Aken, MD, PhD, FRCA, FANZCA*, Gregor Theilmeier, MD*, Christian Bruch, MD, PhD{dagger}, Stefan P. Wirtz, MD*, Hartmut Bürkle, MD, PhD*, Tim Gühs, MD*, Markus Rothenburger, MD, PhD{ddagger}, and Elmar Berendes, MD, PhD*

Departments of *Anesthesiology and Surgical Intensive-Care Medicine, {dagger}Cardiology, and {ddagger}Chest, Heart, and Vascular Surgery, University of Münster Hospital, Germany

Anesth Analg 2005;100:1561-1569

 

冠心病人通过交感神经系统的激活引起血管收缩。心外膜及微血管上的肾上腺α1及α2样的收缩作用是心肌缺血的潜在诱发因素。在高位胸段硬膜外麻醉(HTEA)抑制交感神经系统的活性时,已经观察到心肌缺血减轻。然而,仍存在一种争议的问题,即是否采用HTEA就能相应地改善左室(LV)功能。为了澄清这个问题,在HTEA之前和之后,使用一种新的综合整个LV收缩/舒张功能的参数(心肌活动指数[MPI])和更加明确地指示收缩功能(如分数区域变化)或舒张功能(如心室内流动传播速度)的附加参数来连续量化左心功能。对37位计划行冠脉手术病人置入高位胸段硬膜外导管,并对清醒病人施行HTEA。在HTEA开始前后记录超声心动图及血流动力学。HTEA能使LV舒张功能明显改善。(如,VP45.1±16.1上升至58.3±18.8cm/sP<0.001),而收缩功能的指数无明显改变。由于舒张特性的改变导致MPI0.51±0.13改善至0.35±0.13(P<0.001).结论:心功能的改善是源于舒张特性的改变。

(裘毅敏 李士通 校)

In patients with coronary artery disease, vasoconstriction is induced through activation of the sympathetic nervous system. Both {alpha}1- and {alpha}2-adrenergic epicardial and microvascular constriction are potent initiators of myocardial ischemia. Attenuation of ischemia has been observed when sympathetic nervous system activity is inhibited by high thoracic epidural anesthesia (HTEA). However, it is still a matter of controversy whether establishing HTEA may correspondingly translate into an improvement of left ventricular (LV) function. To clarify this issue, LV function was quantified serially before and after HTEA using a new combined systolic/diastolic variable of global LV function (myocardial performance index [MPI]) and additional variables that more specifically address systolic (e.g., fractional area change) or diastolic function (e.g., intraventricular flow propagation velocity [Vp]). High thoracic epidural catheters were inserted in 37 patients scheduled for coronary artery surgery, and HTEA was administered in the awake patients. Echocardiographic and hemodynamic measures were recorded before and after institution of HTEA. HTEA induced a significant improvement in diastolic LV function (e.g., Vp changed from 45.1 ± 16.1 to 53.8 ± 18.8 cm/s; P < 0.001), whereas indices of systolic function did not change. The change in the diastolic characteristics caused the MPI to improve from 0.51 ± 0.13 to 0.35 ± 0.13 (P < 0.001). We conclude that an improvement in cardiac function was due to improved diastolic characteristics.


挥发性麻醉药的心脏保护作用:机制和临床意义

Cardioprotection with Volatile Anesthetics: Mechanisms and Clinical Implications

Stefan G. De Hert, MD, PhD*, Franco Turani, MD{dagger}, Sanjiv Mathur, MD{ddagger}, and David F. Stowe, MD, PhD§

*Department of Anesthesiology, University Hospital Antwerp, Edegem, Belgium; {dagger}Department of Anesthesia and Intensive Care, European Hospital, University of Rome Tor Vergata, Rome, Italy; {ddagger}Department of Anesthesia and Critical Care, Sudbury Regional Hospital, Sudbury, Ontario, Canada; §Departments of Anesthesiology and Physiology, The Medical College of Wisconsin, Department of Biomedical Engineering, Marquette University; Research Service, Veterans Affairs Medical Center, Milwaukee, Wisconsin

Anesth Analg 2005;100: 1584-1593

 

心脏手术和一些非心脏手术伴有围术期心脏病事件的高风险。实验室数据提示挥发性全麻药的临床浓度保护心肌以免缺血和再灌注损伤,正如显示的梗塞面积较小且再灌注时收缩功能恢复较快。这些麻醉药也可介导对其它器官(如脑和肾脏)的保护作用。最近许多报导已提示这些实验室观察到的保护作用在心脏手术中也有临床意义。但是挥发性麻醉药对结果(如心脏和非心脏手术的术后死亡率和恢复)的影响尚未明确。

(马皓琳 李士通 校)

Cardiac surgery and some noncardiac procedures are associated with a significant risk of perioperative cardiac morbid events. Experimental data indicate that clinical concentrations of volatile general anesthetics protect the myocardium from ischemia and reperfusion injury, as shown by decreased infarct size and a more rapid recovery of contractile function on reperfusion. These anesthetics may also mediate protective effects in other organs, such as the brain and kidney. Recently, a number of reports have indicated that these experimentally observed protective effects may also have clinical implications in cardiac surgery. However, the impact of the use of volatile anesthetics on outcome measures, such as postoperative mortality and recovery in cardiac and noncardiac surgery, is yet to be determined.

 

在猪动物模型使用电刺激来监测硬膜外穿刺进针位置

The Use of Electrical Stimulation to Monitor Epidural Needle Advancement in a Porcine Model

Ban C. H. Tsui, MD, MSc, FRCP(C)*, Derek Emery, MD, FRCP(C){dagger}, Richard R. E. Uwiera, DVM, PhD{ddagger}, and Brendan Finucane, MB, ChB, FRCP(C)*

Departments of *Anesthesiology and Pain Medicine, {dagger}Radiology and Diagnostic Imaging, and {ddagger}Health Sciences Laboratory Animal Services, University of Alberta, Edmonton, Canada

Anesth Analg 2005;100: 1611-1613

 

在硬膜外穿刺过程中使用电刺激引发肌肉颤搐,可指示硬膜外穿刺针的位置。我们在猪动物模型中给予5 mA电流刺激,研究其是否能持续监测硬膜外穿刺的进针位置。在本研究中使用了520公斤重的猪。在每只猪20个不同的节段穿刺带有5 mA刺激电流的针。进针直到观察到有肌肉颤搐但没有阻力消失感,然后使用阻力消失法确定穿刺针的位置。试验结束后,进行解剖,以确认脊髓是否受到损伤。5只猪共有100次穿刺。硬膜外间隙中阈电流为3.6 ± 0.6 mA。在59次穿刺中,在最初观察到肌肉颤搐的深度没有达到阻力消失感。但再进针1-2 mm就达到阻力消失感。在其它41次穿刺中,未进一步进针就观察到了阻力消失感。解剖显示,所有猪都没有穿破硬膜和脊髓损伤。这些观察资料显示电刺激可用于提示硬膜外穿刺针已经或者即将进入硬膜外间隙。但是假阳性率高达59%,因此用这种方法来指导猪的硬膜外穿刺的准确路径是不切实际和不可靠的。

 (张莹 李士通 校)

Muscle twitches elicited with electrical stimulation (ES) during epidural insertion may indicate epidural needle location. We examined the potential application of ES at 5 mA as a continuous method of monitoring the response to epidural needle advancement in a porcine model. Five 20-kg pigs were used in this study. A needle with a stimulating current of 5 mA was inserted at 20 separate levels in each pig. The needle was advanced until a muscle twitch was observed without loss-of-resistance (LOR). The needle position was then assessed using LOR. At the end of the experiment, an autopsy was performed to assess the spinal cord for injury. A total of 100 needle insertions were performed in the 5 pigs. The threshold current in the epidural space was 3.6 ± 0.6 mA. In 59 of the needle insertions, LOR was not obtained at the depth at which a muscle twitch was initially observed. However, after advancing these 59 needles another 1–2 mm, LOR was obtained. In the other 41 insertions, LOR was observed without further advancement of the needle. Autopsies indicated there were no dural punctures or spinal cord damage in any of the pigs. These observations suggest that ES can be used to signal that the epidural needle is in or approaching the epidural space. However, the high false positive predictive value (59%) makes it impractical and unreliable to detect the precise entry of a needle into the epidural space in pigs.

 

 

爱荷华麻醉满意量表是否可用于评价社区医院白内障治疗时局部麻醉和监护镇静下病人的满意程度?

Can the Iowa Satisfaction with Anesthesia Scale Be Used to Measure Patient Satisfaction with Cataract Care Under Topical Local Anesthesia and Monitored Sedation at a Community Hospital?

Donald Fung, MD, MSc*, Marsha Cohen, MSc, MD{dagger}, Susan Stewart, MSc{ddagger}, and Andy Davies, MD*

*North Bay General Hospital, North Bay, and Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto; {dagger}Centre for Research in Women’s Health, Sunnybrook & Women’s College Health Sciences Centre and the Department of Health Policy, Management & Evaluation, University of Toronto, Toronto; and {ddagger}North Shores District Health Council, North Bay, Ontario, Canada

Anesth Analg 2005;100: 1637-1643

 

 病人满意度分级提供了评价和监督卫生保健质量的一种手段。在一个社区医院接受白内障治疗的病人中,我们检验了用爱荷华麻醉满意量表(ISAS)是否能评价对麻醉医生进行局部麻醉和监护镇静的满意度。对306例病人同时进行ISAS测量和其他卫生质量和病人满意度分级。所有问卷都得到了完全的回答。ISAS表明相当的可靠(Cronbach’s {alpha}α= 0.68; 检验-再检验 = 0.48–0.67)ISAS具有出色的结构有效性;给出质量等级较低(4.98 vs 5.64)、满意度视觉模拟评分较低(5.12 vs 5.65)、希望改变对他们的治疗(4.76 vs 5.67)、有改善服务的建议(5.08 vs 5.63)或希望更深的镇静程度(4.85vs 5.66)的病人的ISAS得分较低 (P < 0.0001)。我们的结果提示,ISAS问卷调查用于评价在局部麻醉和监护镇静下行白内障手术病人的满意度,是一种可行、可靠且有效的工具。

(周志坚 李士通 校)

Patient satisfaction ratings provide a means to evaluate and monitor quality of health care. We tested the ability of the Iowa Satisfaction with Anesthesia Scale (ISAS) to measure satisfaction with cataract care under topical local anesthesia and monitored sedation given by an anesthesiologist at a community hospital. Three hundred six patients were administered the ISAS along with alternate ratings of quality of care and patient satisfaction. There were no incomplete questionnaires. The ISAS demonstrated reasonable reliability (Cronbach’s {alpha}= 0.68; test-retest = 0.48–0.67). The ISAS had excellent construct validity; ISAS scores were lower in patients who gave lower ratings of quality (4.98 versus 5.64), who had lower satisfaction visual analog scale scores (5.12 versus 5.65), who wanted changes in their care (4.76 versus 5.67), who had suggestions to improve care (5.08 versus 5.63), or who preferred more sedation (4.85 versus 5.66) (P < 0.0001). Our results indicate that the ISAS questionnaire is a feasible, reliable, and valid tool to measure patient satisfaction in patients undergoing cataract surgery under topical anesthesia and monitored sedation.

 

 

氯胺酮立体选择性抑制培养海马神经元的自发性钙振荡

Ketamine Stereoselectively Inhibits Spontaneous Ca2-Oscillations in Cultured Hippocampal Neurons

Barbara Sinner, MD*{dagger}, Oliver Friedrich, MD, PhD{dagger}, Wolfgang Zink, MD*{dagger}, Eike Martin, MD*, Rainer H. A. Fink, PhD{dagger}, and Bernhard M. Graf, MD, PhD*{dagger}

*Department of Anesthesiology, and {dagger}Institute for Physiology and Pathophysiology, University of Heidelberg, Heidelberg, Germany

Anesth Analg 2005;100:1660-1666

 

自发性钙振荡是胞浆内钙周期性的增加和减少。在神经元中,它们被认为是具有整合的性能,因为振幅和频率影响轴突的外延、神经元生长的锥形移行以及在发育中的皮层里的远端接线。氯胺酮的立体异构体之间对NMDA受体的亲和力以及镇痛和麻醉效力有差别。通过钙离子敏感的染料fura2AM,采用双重激发钙离子比例测量荧光技术,我们检测了培养的海马神经元细胞中的自发性钙振荡。自发性钙振荡的发展依赖于细胞外的钙离子,而其振幅和频率在不含镁离子的溶液中会增加。钙离子的振荡依赖于谷氨酸盐,因为阻断了NMDA、α-氨基-3-羟基-5-甲基-4-恶唑丙酸或红藻氨酸受体会导致振荡完全中断。氯胺酮的立体异构体剂量依赖和可逆地抑制自发性钙振荡的幅度和频率。这种效应是高度立体选择性的,S()异构体差不多比R(–)镜像体效力强4倍。这些结果和立体异构体的临床麻醉和镇痛效价相符,因此我们的实验方法可以提供一个模型系统用来研究麻醉药对钙依赖的神经信息整合的作用机制。

 (黄施伟 李士通 校)

Spontaneous Ca2-oscillations are a result of periodic increases and decreases of cytosolic Ca2. In neurons, they are thought to possess integrative properties because amplitude and frequency influence axon outgrowth, neuronal growth cone migration, and long distant wiring within the developing cortex. Ketamine stereoisomers differ in their affinities for the N-methyl-d-aspartic acid receptor and analgesic and anesthetic effects. Using a dual-excitation Ca2 ratiometric fluorescence technique with the Ca2-sensitive dye fura-2 AM, we detected spontaneous Ca2-oscillations in neurons of hippocampal cell cultures. Spontaneous Ca2-oscillations development is dependent on external Ca2, and their amplitude and frequency increased in Mg2-free solution. Ca2-oscillations are glutamate dependent because blocking of the N-methyl-d-aspartic acid, {alpha}-amino-3-hydroxy-5-methyl-4-isoxazolepropionic, or kainate receptor resulted in a complete disruption of the oscillations. The ketamine stereoisomers dose-dependently and reversibly suppressed the amplitude and frequency of the spontaneous Ca2-oscillations. This effect was highly stereoselective with the S() isomer being nearly four times more potent than the R(–) enantiomer. These results correlate well with the clinical anesthetic and analgesic potency of the stereoisomers and therefore our experimental approach might represent a model system to study mechanisms of anesthetic action on Ca2-dependent integration of neuronal information.

 

体循环阻力对麻醉犬阻抗心动描记法测量值的影响

The Effect of Peripheral Resistance on Impedance Cardiography Measurements in the Anesthetized Dog

Lester A. H. Critchley, MD, FFARCSI*, Zhi Y. Peng, MB BS, MD*, Benny S. Fok, BSc*, and Anthony E. James, BVSc, MSc{dagger}

*Department of Anaesthesia and Intensive Care and {dagger}The Laboratory Animal Services Centre, The Chinese University of Hong Kong, Shatin, Hong Kong, China

Anesth Analg 2005;100: 1708-1712

 

对于血管扩张和脓毒血症的病人,测定心排量(CO)的阻抗法可能低估真实值。本研究旨在确定总体循环阻力(TPR)对阻抗CO COIC)测定值是否有影响。对八条进行麻醉及机械通气的犬,置高精度流量探头于升主动脉上直接测定COCO流量探头(COFP))。于股动脉处测定平均动脉压。同时测定 COIC。在12小时内通过输注去氧肾上腺素和肾上腺素及吸入氟烷改变TPR(平均动脉压×80/ COFP)。计算两种CO测量值之间的偏差(COIC – COFP),并通过相关回归分析与TPR比较。从8条犬TPR的变动中共收集了547CO测量值。在实验中COFP平均变动190%(范围,89%–425%),TPR平均变动266%(范围,94%–580%)。阻抗法测定的心排量值在TPR低时低于实际值,而当TPR高时则高于实际值。在CO偏差和TPR之间存在着对数关系。CO偏差和TPR之间的相关系数(r)变动范围为0.460.89P<0.0001)。每当TPR减半或翻倍时CO偏差变动0.62 ± 1.8 L/min34%。此发现可解释在涉及重症病人的正常研究中发现COIC和其他方法的CO测定值之间的吻合性差的原因。

(周雅春 李士通 校)

In the vasodilated and septic patient, the impedance method of measuring cardiac output (CO) may underestimate the true value. In this study, we sought to determine whether impedance CO (COIC) measurements are influenced by total peripheral resistance (TPR). In eight anesthetized and ventilated dogs, a high-precision flowprobe was placed on the ascending aorta, and direct CO was measured (CO flowprobe (COFP)). Mean arterial blood pressure was measured from the femoral artery. Simultaneous COIC measurements were made. TPR (mean arterial blood pressure x 80/COFP) was varied over 1–2 h by using infusions of phenylephrine and adrenaline and inhaled halothane. The bias between methods of CO measurement (COIC – COFP) was calculated and compared with TPR by using correlation and regression analysis. A total of 547 pairs of CO measurements were collected from the 8 dogs as TPR was varied. COFP changed by a mean of 190% (range, 89%–425%), and TPR changed by a mean of 266% (range, 94%–580%) during the experiment. The impedance method underestimated CO when TPR was low and overestimated CO when TPR was high. There was a logarithmic relationship between the CO bias and TPR. Correlation coefficients (r) between the CO bias and TPR ranged from 0.46 to 0.89 (P < 0.0001). The bias changed by 0.62 ± 1.8 L/min, or by 34%, every time TPR halved or doubled. This finding explains the poor agreement between COIC and other methods of CO measurement found in validation studies involving critically ill patients.

 

现场麻醉机机械通气时的氧气消耗

Oxygen Consumption with Mechanical Ventilation in a Field Anesthesia Machine

Dale F. Szpisjak, MD*,, Charles L. Lamb, MD{dagger}, and Kenneth D. Klions, MD{dagger}

*Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland, and the {dagger}Anesthesia Department, Fleet Hospital, Bremerton, Washington

Anesth Analg 2005;100: 1713-1717

 

配有气动式呼吸机的现场麻醉机(FAM)已逐渐用于可能没有中心供氧系统的偏远地区。这些呼吸机可能会快速耗尽氧气瓶中的氧气,尤其是在肺顺应性下降的患者中。本研究的目的是确定现代FAM在肺顺应性好(HC)和肺顺应性差(LC)不同模式时的氧耗率。氧耗率用D型氧气筒(初始压力1700 psig)和Narkomed® M FAM测定,FAM用一空气喷射器混入室内空气作为驱动气的一部分降低压缩气体的消耗。分别在HCLC模式下测定三种不同(500750,和1000 mL)潮气量(Vt)的氧耗率,新鲜气流量是1L/min。呼吸频率维持在10/分。氧气的消耗直接随Vt而变化,与顺应性呈反比。氧气的消耗从HC-500 mL Vt模式的4.8 ± 0.07 L/min增加到LC-1000 mL Vt模式的6.2 ± 0.05 L/minD型氧气筒持续的时间范围在56.8 ± 0.4 73.6 ± 1.0分钟。假设氧新鲜气流量是1 L/min,用最快的消耗率计算筒中氧气的持续时间会低估顺应性好和Vt较小模式下氧气的持续时间,但是增加了患者的安全界限。

(陈玮 李士通 审校)

Field anesthesia machines (FAM) with gas-powered ventilators have been developed for remote locations that may not have a central supply of oxygen. These ventilators may rapidly deplete oxygen cylinders, especially in patients with decreased pulmonary compliance. Our goal in this study was to determine oxygen consumption rates with a contemporary FAM in models of high (HC) and low (LC) pulmonary compliance. Oxygen consumption rates were tested using D cylinders (initial pressure 1700 psig) and the Narkomed® M FAM, which uses an air injector to decrease compressed gas consumption by entraining room air as part of the drive gas. Three different tidal volumes (Vt) were tested (500, 750, and 1000 mL) with HC and LC lung models, and the fresh gas flow rate was 1 L/min. Respiratory rate was constant at 10 breaths/min. Oxygen consumption varied directly with Vt and inversely with compliance, increasing from 4.8 ± 0.07 L/min with the HC-500 mL Vt model to 6.2 ± 0.05 L/min with the LC-1000 mL Vt model. D cylinder duration ranged from 56.8 ± 0.4 to 73.6 ± 1.0 minutes. Assuming oxygen fresh gas flow of 1 L/min, calculating tank duration with the fastest consumption rate underestimated the tank duration for more compliant and smaller Vt models but provided a greater margin of patient safety.

 

年龄对大鼠吗啡耐药性产生的影响

Age-Dependent Morphine Tolerance Development in the Rat

Yan Wang, MD, James Mitchell, MD, Kumi Moriyama, MD, Ki-jun Kim, MD, PhD, Manohar Sharma, PhD, Guo-xi Xie, MD, PhD, and Pamela Pierce Palmer, MD, PhD

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

Anesth Analg 2005;100: 1733-1739

 

在各个年龄组,用来治疗慢性疼痛的阿片类药物用量均有增加,而年龄对于阿片类药物耐受性的影响,至今还没有很全面的报道。在本研究中,我们观察了大鼠对于吗啡耐受性产生的年龄相关性差异。本研究选取出生3周、3个月、6个月和1年的大鼠作为研究对象。皮下注射吗啡(8mg/kg),每日两次。注射吗啡前5min和注射后30min分别给予热刺激,通过观察大鼠摆尾反应时间的变化以评估吗啡的镇痛效应。与第一天相比,吗啡引起的镇痛效应降低75%定义为对吗啡产生耐药性。出生 3周、3 个月、6个月和1年的的大鼠 分别在第4天、第10天、第14天和第22天时对吗啡产生耐药性。 吗啡及其代谢产物的血浆浓度表明,在各个年龄组吗啡药代动力学的差异与对吗啡产生耐受性无关。本研究表明,对吗啡的耐受性在年幼大鼠身上较年长大鼠发生得更迅速,而且不可能是药物代谢和药物清除存在差异的结果。年龄增长可能会影响参与吗啡耐受性产生的分子机制,这为研究如何延迟对阿片类药物产生耐受性提供了新的治疗方向。

邱郁薇    李士通 校)

In all age groups, the use of opioids to treat chronic pain conditions has increased, yet the impact of age on opioid tolerance development has not been comprehensively addressed. In this study, we investigated age-related differences in morphine tolerance development in rats. Rats aged 3 wk, 3 mo, 6 mo, and 1 yr were used in the study. Morphine (8 mg/kg) was injected subcutaneously twice each day and its analgesic effect assessed by the change in tail-flick latency using a thermal stimulus 5 min before and 30 min after dosing. Tolerance was defined as a 75% reduction in morphine-induced analgesia compared to Day 1. Rats aged 3 wk, 3 mo, 6 mo, and 1 yr developed tolerance on the 4th, 10th, 14th, and 22nd days of morphine treatment, respectively. Plasma levels of morphine and its metabolites showed that pharmacokinetic differences among the groups did not correlate with the differences in tolerance development. This study demonstrates that morphine tolerance occurs more rapidly in younger rats than older rats and is unlikely to be the result of differences in drug metabolism or clearance. Aging may impact molecular processes involved in tolerance development and provide insight into novel therapeutic targets to delay opioid tolerance development.

 

 

主要麻醉学期刊中随机对照试验的质量

The Quality of Randomized Controlled Trials in Major Anesthesiology Journals

Mary Lou V. H. Greenfield, MPH, MS, Andrew L. Rosenberg, MD, Michael O’Reilly, MS, MD, Amy M. Shanks, MS, Michelle J. Sliwinski, MS, and Michael D. Nauss, BS

Department of Anesthesiology, University of Michigan, Ann Arbor

Anesth Analg 2005;100: 1759-1764

 

人们越来越关注到随机对照试验的质量,以及它们是如何报道的。我们研究了主导的麻醉学杂志,以确定是否有特定的领域针对已出版的临床研究的设计及分析的改善。我们通过MEDLINE 检索重新得到到20001月至200012月期间发表在主导麻醉学期刊(麻醉学(Anesthesiology)、麻醉与镇痛(Anesthesia & Analgesia)、麻醉(Anaesthesia)和加拿大麻醉杂志(Canadian Journal of Anaesthesia)上的所有的随机对照试验。我们应用先前证明有效的评估工具,包括与研究质量有关的14个项目,为每篇文章的质量评分。总体平均质量得分是44% ± 16%。而选取适当对照的得分(77% ± 7%)及讨论副作用的 (67% ± 6%)的总体平均得分相对较高。随机盲法研究(5% ± 2%)、观察者对结果的盲态处理(1% ± 1%),post-beta评估的得分(16% ± 13%)则非常低。而所有研究中有32%缺少重要的处理前临床预测方法。随机对照试验中报告及实施中需要重要改进,并且需要集中在随机化的方法学、研究者的盲法和样本大小的评估。对文献重新评估会进一步促进采纳提高随机对照试验质量的指南。

(黄丽娜    李士通  )

Increased attention has been directed at the quality of randomized controlled trials (RCTs) and how they are being reported. We examined leading anesthesiology journals to identify if there were specific areas for improvement in the design and analysis of published clinical studies. All RCTs that appeared between January 2000 and December 2000 in leading anesthesiology journals (Anesthesiology,Anesthesia & Analgesia,Anaesthesia, and Canadian Journal of Anaesthesia) were retrieved by a MEDLINE search. We used a previously validated assessment tool, including 14 items associated with study quality, to determine a quality score for each article. The overall mean weighted quality score was 44% ± 16%. Overall average scores were relatively high for appropriate controls (77% ± 7%) and discussions of side effects (67% ± 6%). Scores were very low for randomization blinding (5% ± 2%), blinding observers to results (1% ± 1%), and post-beta estimates (16% ± 13%). Important pretreatment clinical predictors were absent in 32% of all studies. Significant improvement in the reporting and conduct of RCTs is required and should focus on randomization methodology, the blinding of investigators, and sample size estimates. Repeat assessments of the literature may improve the adoption of guidelines for the improvement of the quality of randomized controlled trials.

 

 

在血栓弹性描记法中血小板计数对血块退缩和组织纤溶酶原活化剂介导的纤维蛋白溶解的影响

The Effects of Platelet Count on Clot Retraction and Tissue Plasminogen Activator-Induced Fibrinolysis on Thrombelastography

Nobuyuki Katori, MD, Kenichi A. Tanaka, MD, Fania Szlam, MMS, and Jerrold H. Levy, MD

Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia

Anesth Analg 2005;100: 1781-1785

 

血块退缩和纤维蛋白溶解在血栓弹性描记法(TEG®)中可能呈现描记图幅度的减小。前者代表正常的或者过度活跃的血小板的功能,后者代表纤溶状态。区分纤溶与血块退缩是很重要的,因为两者的治疗是不同的。为了区别这两种现象,我们用缺乏血小板的血浆(PPP)和富含血小板的血浆(PRP)进行TEG®,逐步增加血小板数量(范围,50–1200 x 109/L),加入或者不加入abciximab。每个样本检测最大幅度(MA)MA30分钟和60分钟时幅度下降的百分率。加入组织纤溶酶原活化剂(tPA)的血样作为纤维蛋白溶解的阳性对照。同时检测血凝块形态学的改变和d-二聚体水平。随着血小板计数的增高,MA30分钟和60分钟时幅度下降的百分率显著增大,但是在加入abciximab的样本中无此结果。在PRP中血凝块的形态学改变显示了血块退缩,但是在PPP或者用abciximab预处理的PRP中不显示血块退缩。d-二聚体水平仅仅在加入tPA的样本中增加,但是在原本的PPP或者PRP样本中不增加。结论,我们表明在30分钟和60分钟时幅度的减小可能是由于血小板介导的血块退缩,且能够被abciximab预处理所削弱,abciximab妨碍了血小板-纤维蛋白(原)聚集。

(张曦 李士通 校)

Clot retraction and fibrinolysis may present as a decrease in amplitude on thrombelastography (TEG®). The former represents normal or hyperactive platelet function, and the latter represents a fibrinolytic state. It is important to distinguish clot retraction from fibrinolysis because the treatment of each condition is different. To distinguish between these phenomena, we performed TEG® with platelet-poor plasma (PPP) and platelet-rich plasma (PRP) with an increasing platelet count (range, 50–1200 x 109/L) with or without abciximab. Maximum amplitude (MA) and the percentage decrease of amplitude at 30 and 60 min after MA were examined for each sample. Blood samples to which tissue plasminogen activator (tPA) was added served as positive controls for fibrinolysis. Morphological changes of clots and d-dimer levels were also examined. With higher platelet counts, the percentage decrease of amplitude after MA increased significantly at 30 and 60 min, but not in the abciximab samples. Morphological changes of clots have shown clot retraction in PRP, but not in PPP or PRP pretreated with abciximab. d-Dimer levels increased only in samples to which tPA was added, but not in native PPP or PRP samples. In conclusion, we have shown that the decrease in amplitude at 30 and 60 min can be due to platelet-mediated clot retraction and can be attenuated by sample pretreatment with abciximab, which interrupts platelet-fibrin(ogen) binding.

 

 

比较用利多卡因和其他局麻药脊麻后的一过性神经症状:对随机对照试验的一个系统性回顾

Transient Neurologic Symptoms After Spinal Anesthesia with Lidocaine Versus Other Local Anesthetics: A Systematic Review of Randomized, Controlled Trials

Dusanka Zaric, MD, PhD*, Christian Christiansen, MD*, Nathan L. Pace, MD, MStat{dagger}, and Yodying Punjasawadwong, MD{ddagger}

*Department of Anesthesiology, Frederiksberg University Hospital, Frederiksberg, Denmark; {dagger}Department of Anesthesiology, University of Utah, Salt Lake City, Utah; and {ddagger}Department of Anesthesiology, Chiang Mai University, Chiang Mai, Thailand

Anesth Analg 2005;100: 1811-1816

 

1948年起利多卡因应用于脊麻,表面上看来没有引起关注。然而,近10年中,大量研究提示利多卡因可能是引起脊麻后神经并发症的一个可能原因。对接受无意外脊麻的病人随访显示一些病人有下肢疼痛--一过性神经症状(TNS)。在这项研究中,我们试图比较在用利多卡因和用其他局麻药脊麻醉后TNS和神经并发症的发生率。通过计算机检索Cochrane库、MEDLINELILACEMBASE并检查参考文献清单中的试验和综述文章来寻找已发表的研究。检索发现共14个试验报道了在1347例病人中有117例发生了TNS。这些病人中没有人显示有神经并发症的体征。利多卡因用于脊麻后发生TNS的相对危险性为4.3595%可信区间1.98-9.54)高于其他局麻药(布比卡因、丙胺卡因、普鲁卡因和甲哌卡因)。没有证据显示这些疼痛情况与神经病理学改变有关,所有病人的症状在术后10天自行消失。

(朱慧 李士通 校)

Lidocaine has been used for spinal anesthesia since 1948, seemingly without causing concern. However, during the last 10 years, a number of reports have appeared implicating lidocaine as a possible cause of neurologic complications after spinal anesthesia. Follow-up of patients who received uncomplicated spinal anesthesia revealed that some of them developed pain in the lower extremities—transient neurologic symptoms (TNS). In this study, we sought to compare the frequency of 1) TNS and 2) neurologic complications after spinal anesthesia with lidocaine with that after other local anesthetics. Published trials were identified by computerized searches of The Cochrane Library, MEDLINE, LILAC, and EMBASE and by checking the reference lists of trials and review articles. The search identified 14 trials reporting 1347 patients, 117 of whom developed TNS. None of these patients showed signs of neurologic complications. The relative risk for developing TNS after spinal anesthesia with lidocaine was higher than with other local anesthetics (bupivacaine, prilocaine, procaine, and mepivacaine), i.e., 4.35 (95% confidence interval, 1.98–9.54). There was no evidence that this painful condition was associated with any neurologic pathology; in all patients, the symptoms disappeared spontaneously by the 10th postoperative day.

 

气管导管拔除时的残余肌松

Residual Paralysis at the Time of Tracheal Extubation

Glenn S. Murphy, MD*, Joseph W. Szokol, MD*, Jesse H. Marymont, MD*, Mark Franklin, MD*, Michael J. Avram, PhD{dagger}, and Jeffery S. Vender, MD*

*Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Evanston, Illinois; and {dagger}Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Anesth Analg 2005;100: 1840-1845

 

神经肌肉阻滞很小时呼吸肌和喉肌功能仍受损。气管导管拔除时存在残余肌松可导致不良的呼吸事件。在本观察中,我们评估了气管导管拔除时残余神经肌肉阻滞的发生率和严重程度。选择120例行妇科或普外科手术的患者。用罗库溴铵维持神经肌肉阻滞(视觉四个成串计数为2),且所有患者在TOF计数为2-4时用新斯的明拮抗。在临床医生用标准临床指标(抬头5 s或举手、根据指令睁眼、可接受的吸气负力或肺活量呼吸值)和周围神经刺激(无TOF或强直刺激后衰减迹象)认为神经肌肉已完全恢复后,气管导管拔除前即刻、用肌加速度仪对TOF比定量。到达麻醉后恢复室时再测一次TOF比。气管导管拔除前即刻的TOF比平均值为0.67 ± 0.2120例患者中,70例(58%)的TOF<0.7105例(88%)的TOF<0.9。在麻醉恢复室中TOF<0.79例,8%)和<0.938例,32%)的患者显著少于手术室(P <0.001)。我们的结果提示气管导管拔除时很少存在完全的神经肌肉恢复。

(马皓琳 李士通 校)

Respiratory and pharyngeal muscle function are impaired during minimal neuromuscular blockade. Tracheal extubation in the presence of residual paresis may contribute to adverse respiratory events. In this investigation, we assessed the incidence and severity of residual neuromuscular block at the time of tracheal extubation. One-hundred-twenty patients presenting for gynecologic or general surgical procedures were enrolled. Neuromuscular blockade was maintained with rocuronium (visual train-of-four [TOF] count of 2) and all subjects were reversed with neostigmine at a TOF count of 2–4. TOF ratios were quantified using acceleromyography immediately before tracheal extubation, after clinicians had determined that complete neuromuscular recovery had occurred using standard clinical criteria (5-s head lift or hand grip, eye opening on command, acceptable negative inspiratory force or vital capacity breath values) and peripheral nerve stimulation (no evidence of fade with TOF or tetanic stimulation). TOF ratios were measured again on arrival to the postanesthesia care unit. Immediately before tracheal extubation, the mean TOF ratio was 0.67 ± 0.2; among the 120 patients, 70 (58%) had a TOF ratio <0.7 and 105 (88%) had a TOF ratio <0.9. Significantly fewer patients had TOF ratios <0.7 (9 subjects, 8%) and <0.9 (38 subjects, 32%) in the postanesthesia care unit compared with the operating room (P < 0.001). Our results suggest that complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation.