Anesthesia & Analgesia

July 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

應用米力農可改善合併二尖瓣返流病人在行非體外迴圈冠狀動脈旁路吻合術時血流動力學改變

(金 路譯 薛張綱校)

Hemodynamic Changes During Off-Pump Coronary Artery Bypass Anastomosis in Patients with Coexisting Mitral Regurgitation: Improvement with Milrinone

Takeshi Omae, Yasuyuki Kakihana, Akira Mastunaga, Isao Tsuneyoshi, Kouichi Kawasaki, Yuichi Kanmura, and Ryuzo Sakata

Anesth Analg 2005 101: 2-8.

米力農及考福新減弱兔腹主動脈阻斷松夾後軟腦膜小動脈的持續收縮

(裘毅敏 李士通 校)

Both Milrinone and Colforsin Daropate Attenuate the Sustained Pial Arteriolar Constriction Seen After Unclamping of an Abdominal Aortic Cross-Clamp in Rabbits

Masayoshi Uchida, Hiroki Iida, Mami Iida, Masahiko Kumazawa, Kazuyuki Sumi, Motoyasu Takenaka, and Shuji Dohi

Anesth Analg 2005 101: 9-16.

心臟手術/心肺轉流後房顫與單核細胞啟動有關

(朱輝 陳傑 )

Atrial Fibrillation After Cardiac Surgery/Cardiopulmonary Bypass Is Associated with Monocyte Activation

Manuel L. Fontes, Joseph P. Mathew, Henry M. Rinder, Daniel Zelterman, Brian R. Smith, Christine S. Rinder, and the Multicenter Study of Perioperative Ischemia (McSPI) Reasearch Group

Anesth Analg 2005 101: 17-23.

二尖瓣手術中伴隨射頻消融和手術方式(修補術對置換術)對心臟生物標誌物釋放的影響

(金 薛張綱 校)

The Effect of Concomitant Radiofrequency Ablation and Surgical Technique (Repair Versus Replacement) on Release of Cardiac Biomarkers During Mitral Valve Surgery

Alberto Zangrillo, Giuseppe Crescenzi, Giovanni Landoni, Stefano Benussi, Martina Crivellari, Federico Pappalardo, Enrica Dorigo, Carlo Pappone, and Ottavio Alfieri

Anesth Analg 2005 101: 24-29.

比較活體供肝和屍體供肝移植的輸液需要量:與終末期肝病評分模型和基礎凝血狀態的關係

(馬皓琳 李士通 校)

A Comparison of Transfusion Requirements Between Living Donation and Cadaveric Donation Liver Transplantation: Relationship to Model of End-Stage Liver Disease Score and Baseline Coagulation Status

Peter E. Frasco, Karl A. Poterack, Joseph G. Hentz, and David C. Mulligan

Anesth Analg 2005 101: 30-37.

PEDIATRIC ANESTHESIA:

小兒鎮靜狀態下評估系統安全和潛在失誤的方法

(朱輝 陳傑 校)

A Method for Measuring System Safety and Latent Errors Associated with Pediatric Procedural Sedation

George T. Blike, Klaus Christoffersen, Joseph P. Cravero, Steven K. Andeweg, and Jens Jensen
Anesth Analg 2005 101: 48-58.

昂丹司瓊口服片:在接受增殖腺扁桃體切除術的患兒中的可行性及有效性

(王麗珺譯 薛張綱校)

Ondansetron Oral Disintegrating Tablets: Acceptability and Efficacy in Children Undergoing Adenotonsillectomy

Ira Todd Cohen, Denise Joffe, Kelly Hummer, and Alice Soluri

Anesth Analg 2005 101: 59-63.

糖溶液的鎮痛:葡萄糖對表達的阿片類μ受體的作用

(周志堅 李士通 校)

Sugar Solution Analgesia: The Effects of Glucose on Expressed Mu Opioid Receptors

George R. Kracke, Katherine A. Uthoff, and Joseph D. Tobias

Anesth Analg 2005 101: 64-68.

小兒骶管麻醉時咪唑安定、氯胺酮和新斯的明與布比卡因聯合應用的比較

(趙延華 陳傑 校)

Caudal Additives in Pediatrics: A Comparison Among Midazolam, Ketamine, and Neostigmine Coadministered with Bupivacaine

P. Kumar, A. Rudra, A. K. Pan, and A. Acharya

Anesth Analg 2005 101: 69-73.

AMBULATORY ANESTHESIA:

高比重左布比卡因和羅呱卡因腰麻在門診膝關節鏡的應用:一項前瞻、隨機、雙盲試驗

(王麗珺譯 薛張綱校)

Spinal Anesthesia with Hyperbaric Levobupivacaine and Ropivacaine for Outpatient Knee Arthroscopy: A Prospective, Randomized, Double-Blind Study

Gianluca Cappelleri, Giorgio Aldegheri, Giorgio Danelli, Chiara Marchetti, Massimiliano Nuzzi, Gabriella Iannandrea, and Andrea Casati

Anesth Analg 2005 101: 77-82.

圍手術期羅非考西複合局麻藥區域阻滯可減少門診腹股溝疝修補術病人的疼痛及恢復時間

(黃佳佳 李士通 校)

Perioperative Rofecoxib Plus Local Anesthetic Field Block Diminishes Pain and Recovery Time After Outpatient Inguinal Hernia Repair

Dorothy J. Pavlin, Edward G. Pavlin, Karen D. Horvath, Laurie B. Amundsen, David R. Flum, and Kristine Roesen

Anesth Analg 2005 101: 83-89.

與藥物前體丙帕他莫(propacetamol)相比,對乙酰氨基酚(撲熱息痛)經靜脈用於第三磨牙手術後疼痛有同樣的鎮痛效能,但安全性更好

(趙延華 陳傑 校)

Intravenous Acetaminophen (Paracetamol): Comparable Analgesic Efficacy, but Better Local Safety than Its Prodrug, Propacetamol, for Postoperative Pain After Third Molar Surgery

Philip Lange Moller, Gitte Irene Juhl, Catherine Payen-Champenois, and Lasse Ansgar Skoglund

Anesth Analg 2005 101: 90-96.

靜脈注射異丙酚與咪達唑侖鎮靜對血流動力學及心率變異的不同影響

(金 琳譯 薛張綱校)

The Different Effects of Intravenous Propofol and Midazolam Sedation on Hemodynamic and Heart Rate Variability

Ni Ni Win, Haruhisa Fukayama, Hikaru Kohase, and Masahiro Umino

Anesth Analg 2005 101: 97-102.

ANESTHETIC PHARMACOLOGY:

兔神經根進入區十分容易受鞘內丁卡因的損害

(黃施偉 李士通 校)

The Nerve Root Entry Zone Is Highly Vulnerable to Intrathecal Tetracaine in Rabbits

Shuichi Kaneko, Mishiya Matsumoto, Shunsuke Tsuruta, Takao Hirata, Toshikazu Gondo, and Takefumi Sakabe

Anesth Analg 2005 101: 107-114.

昔多芬(商品名:偉哥)對肺栓塞導致的氧化應激和肺高壓的影響

(忻紀華 陳傑 校)

The Effect of Sildenafil on Pulmonary Embolism-Induced Oxidative Stress and Pulmonary Hypertension

Carlos A. Dias-Junior, Debora C. Souza-Costa, Talita Zerbini, Joao B. T. da Rocha, Raquel F. Gerlach, and Jose E. Tanus-Santos

Anesth Analg 2005 101: 115-120.

體外可樂定和新斯的明的抗菌活性

(孫敏莉譯 薛張綱校)

Antibacterial Activity of Clonidine and Neostigmine In Vitro

Emmanuel Boselli, Marion Guillier, Jean Freney, Marie-Andrée Mazoyer, Emmanuelle Casoli, François R. N. Renaud, Thomas Rimmelé, Dominique Chassard, and Bernard Allaouchiche

Anesth Analg 2005 101: 121-124.

雙頻指數指導下的異丙酚麻醉中雷米芬太尼抑制氣管插管和切皮時的心血管反應的效應部位濃度

(張曦 李士通 校)

The Effect-Site Concentration of Remifentanil Blunting Cardiovascular Responses to Tracheal Intubation and Skin Incision During Bispectral Index-Guided Propofol Anesthesia

Andrea Albertin, Andrea Casati, Lombardo Federica, Valeri Roberto, Vittorino Travaglini, Piercarlo Bergonzi, and Giorgio Torri

Anesth Analg 2005 101: 125-130.

右旋依託咪酯和光活性右旋Azietomidate在野生型鼠麻醉中的作用比較和降低γ-氨基丁酸受體β3亞單位上N265M位元點突變體的比較

(忻紀華 陳傑 校)

R (+) Etomidate and the Photoactivable R (+) Azietomidate Have Comparable Anesthetic Activity in Wild-Type Mice and Comparably Decreased Activity in Mice with a N265M Point Mutation in the Gamma-Aminobutyric Acid Receptor ß3 Subunit

Mark Liao, James M. Sonner, S. Shaukat Husain, Keith W. Miller, Rachel Jurd, Uwe Rudolph, and Edmond I. Eger, II

Anesth Analg 2005 101: 131-135 receptors.

異氟醚對FisherLewis大鼠氣道平滑肌連接橋動力的影響

(沈 洪譯 薛張綱 校)

The Effects of Isoflurane on Airway Smooth Muscle Crossbridge Kinetics in Fisher and Lewis Rats

Caroline Duracher, François-Xavier Blanc, Pierre-Yves Gueugniaud, Jean Stéphane David, Bruno Riou, Yves Lecarpentier, and Catherine Coirault

Anesth Analg 2005 101: 136-142.

三種吸入麻醉藥對GluR6(海人藻酸) 受體基因突變小鼠的作用

(周雅春 李士通 校)

The Effect of Three Inhaled Anesthetics in Mice Harboring Mutations in the GluR6 (Kainate) Receptor Gene

James M. Sonner, Bryce Vissel, Gordon Royle, Anya Maurer, Diane Gong, Nicole V. Baron, Neil Harrison, Michael Fanselow, and Edmond I. Eger, II

Anesth Analg 2005 101: 143-148.

TECHNOLOGY, COMPUTING, AND SIMULATION:

Ohmeda 7810 呼吸機風箱漏氣對室內空氣污染、吸入氧濃度、氣道壓和潮氣量的影響

(吳德華譯 薛張綱校)

The Effect of a Bellows Leak in an Ohmeda 7810 Ventilator on Room Contamination, Inspired Oxygen, Airway Pressure, and Tidal Volume

Samsun Lampotang, Justin C. Sanchez, BaiXi Chen, and Nikolaus Gravenstein

Anesth Analg 2005 101: 151-154.

大鼠胸段蛛網膜下腔置管術的改良步驟

(黃麗娜    李士通  校)

An Improved Procedure for Catheterization of the Thoracic Spinal Subarachnoid Space in the Rat

Y. Y. Poon, Alice Y. W. Chang, S. F. Ko, and Samuel H. H. Chan

Anesth Analg 2005 101: 155-160.

先進的病人監測顯示器:連續資訊的工具

(殷文淵 陳傑 校)

Advanced Patient Monitoring Displays: Tools for Continuous Informing (Medical Intelligence)

Penelope M. Sanderson, Marcus O. Watson, and W. John Russell

Anesth Analg 2005 101: 161-168.

PAIN MEDICINE:

通過中線徑路進行枕部神經電刺激和手術皮下置電極來治療嚴重枕部神經痛:一項初步研究

(殷文淵 陳傑 校)

Occipital Nerve Electrical Stimulation via the Midline Approach and Subcutaneous Surgical Leads for Treatment of Severe Occipital Neuralgia: A Pilot Study

Leonardo Kapural, Nagy Mekhail, Salim M. Hayek, Michael Stanton-Hicks, and Osama Malak

Anesth Analg 2005 101: 171-174.

大鼠神經損傷後不同時間鎮痛藥藥效測試

(孫志榮譯 薛張綱校)

The Effect of Antinociceptive Drugs Tested at Different Times After Nerve Injury in Rats

Aldric T. Hama and David Borsook

Anesth Analg 2005 101: 175-179.

曲馬多代謝物O-去甲基曲馬多在表達 M1 M3克隆受體的蟾蜍卵母細胞中對 毒蕈堿受體引起的反應的影響

(邱鬱薇 李士通 校)

The Effects of the Tramadol Metabolite O-Desmethyl Tramadol on Muscarinic Receptor-Induced Responses in Xenopus Oocytes Expressing Cloned M1 or M3 Receptors

Motohiro Nakamura, Kouichiro Minami, Yasuhito Uezono, Takafumi Horishita, Junichi Ogata, Munehiro Shiraishi, Takashi Okamoto, Tadanori Terada, and Takeyoshi Sata

Anesth Analg 2005 101: 180-186.

CRITICAL CARE AND TRAUMA:

由單個職業醫療人員進行的頭上方心肺復蘇可改善基礎生命支持的效果:一項模擬研究

(朱玫娟 陳傑 校)

Over-the-Head Cardiopulmonary Resuscitation Improves Efficacy in Basic Life Support Performed by Professional Medical Personnel with a Single Rescuer: A Simulation Study

Michael Hüpfl, Andreas Duma, Thomas Uray, Christina Maier, Nikolaus Fiegl, Norbert Bogner, and Peter Nagele

Anesth Analg 2005 101: 200-205.

床旁運用標準監測儀器估測功能殘氣量:吸入氧濃度小改變下的改良的氮氣洗出洗入技術

(蔡美華譯 薛張綱校)

Estimation of Functional Residual Capacity at the Bedside Using Standard Monitoring Equipment: A Modified Nitrogen Washout/Washin Technique Requiring a Small Change of the Inspired Oxygen Fraction

Cecilia Olegård, Sören Söndergaard, Erik Houltz, Stefan Lundin, and Ola Stenqvist

Anesth Analg 2005 101: 206-212.

絲氨酸蛋白酶抑制劑在酸誤吸和高氧後維持固有超氧化物歧化酶水平,但不能減少肺損傷

(朱慧 李士通 校)

Serine Antiproteinase Administration Preserves Innate Superoxide Dismutase Levels After Acid Aspiration and Hyperoxia but Does Not Decrease Lung Injury

Nader D. Nader, Bruce A. Davidson, Alan R. Tait, Bruce A. Holm, and Paul R. Knight

Anesth Analg 2005 101: 213-219.

加巴噴丁與卡馬西平對重症監護室格林-巴厘(Guillain-Barre)綜合征患者鎮痛治療的比較性評估

(朱玫娟 陳傑 校)

The Comparative Evaluation of Gabapentin and Carbamazepine for Pain Management in Guillain-Barré Syndrome Patients in the Intensive Care Unit

Chandra Kant Pandey, Mehdi Raza, Mukesh Tripathi, Deepa V. Navkar, Abhishek Kumar, and Uttam K. Singh

Anesth Analg 2005 101: 220-225.

兒茶酚胺加強誘導性的NO合酶的產生涉及到CAT-1CAT-2

(吳德華譯 薛張綱校)

Catecholamines' Enhancement of Inducible Nitric Oxide Synthase-Induced Nitric Oxide Biosynthesis Involves CAT-1 and CAT-2A

Wen-Chou Lin, Pei-Shan Tsai, and Chun-Jen Huang

Anesth Analg 2005 101: 226-232. T-2A but not CAT-2 or CAT-2B.

NEUROSURGICAL ANESTHESIA:

在單側腦半球功能抑制中的雙側雙譜指數監測

(黃佳佳 李士通 校)

Bilateral Bispectral Index Monitoring During Suppression of Unilateral Hemispheric Function

Haren Heller, Raheleh Hatami, Paul Mullin, Robert R. Sciacca, Alexander G. Khandji, Marla Hamberger, Ronald Emerson, and Eric J. Heyer

Anesth Analg 2005 101: 235-341.

異氟醚麻醉期間靜脈注射咪唑安定導致的脊髓血流改變

(顧漪聞 陳傑 校)

Spinal Cord Blood Flow Change by Intravenous Midazolam During Isoflurane Anesthesia

Tomoki Nishiyama

Anesth Analg 2005 101: 242-245.

OBSTETRIC ANESTHESIA:

麻醉中的過失與疏忽:一項使用試驗性檢查目錄的實驗性研究

(周曉敏 薛張綱 校)

Errors and Omissions in Anesthesia: A Pilot Study Using a Pilot’s Checklist

Elaine M. Hart and Harry Owen

Anesth Analg 2005 101: 246-250.

瑞芬太尼在腔鏡手術中用於胎兒制動及母親鎮靜的作用:與安定比較的隨機、雙盲實驗

(張瑩 李士通 校)

Remifentanil for Fetal Immobilization and Maternal Sedation During Fetoscopic Surgery: A Randomized, Double-Blind Comparison with Diazepam

Marc Van de Velde, Dominique Van Schoubroeck, Liesbeth E. Lewi, Marco A.E. Marcus, Jacques C. Jani, Carlo Missant, An Teunkens, and Jan A. Deprest

Anesth Analg 2005 101: 251-258.

REGIONAL ANESTHESIA:

採用新方法,排除舊方法?兩種腰大肌阻滯方法的比較

(顧漪聞 陳傑 校)

In with the New, Out with the Old? Comparison of Two Approaches for Psoas Compartment Block

Stephen Mannion, Sheila O'Callaghan, Mary Walsh, Damian B. Murphy, and George D. Shorten

Anesth Analg 2005 101: 259-264 occurs more frequently after psoas compartment block than previously reported.

兔硬膜外止痛法預防內毒素誘導的腸粘膜損傷

(孫少瀟譯 薛張綱校)

Epidural Analgesia Prevents Endotoxin-Induced Gut Mucosal Injury in Rabbits
Shizuko Kosugi, Hiroshi Morisaki, Tomoyuki Satoh, Kimiaki Ai, Michiko Yamamoto, Junko Soejima, Ryohei Serita, Yoshifumi Kotake, Akitoshi Ishizaka, and Junzo Takeda

Anesth Analg 2005 101: 265-272.

垂直鎖骨下臂叢神經阻滯:應用磁共振成像技術的模擬研究

(趙雪蓮 莊心良 )

The Vertical Infraclavicular Brachial Plexus Block: A Simulation Study Using Magnetic Resonance Imaging

Øivind Klaastad, Örjan Smedby, Trygve Kjelstrup, and Hans-Jørgen Smith

Anesth Analg 2005 101: 273-278.

GENERAL ARTICLES:

Mallampti分級相比,上唇咬診實驗預測困難喉鏡檢查的可靠性和有效性:一個客觀的前瞻性評估

(齊波 陳傑 校)

The Reliability and Validity of the Upper Lip Bite Test Compared with the Mallampati Classification to Predict Difficult Laryngoscopy: An External Prospective Evaluation

Leopold H. J. Eberhart, Christian Arndt, Thomas Cierpka, Judith Schwanekamp, Hinnerk Wulf, and Caroline Putzke

Anesth Analg 2005 101: 284-289.

磺酸甘葡環烴鈉漱口減少氣管插管引起的術後咽喉潰瘍

(孫少瀟譯 薛張綱校)

Gargling with Sodium Azulene Sulfonate Reduces the Postoperative Sore Throat After Intubation of the Trachea

Junchi Ogata, Kouichiro Minami, Takafumi Horishita, Munehiro Shiraishi, Takashi Okamoto, Tadanori Terada, and Takeyoshi Sata

Anesth Analg 2005 101: 290-293.

心臟手術/心肺轉流後房顫與單核細胞啟動有關

Atrial Fibrillation After Cardiac Surgery/Cardiopulmonary Bypass Is Associated with Monocyte Activation

Manuel L. Fontes, MD{dagger}, Joseph P. Mathew, MD{dagger}, Henry M. Rinder, MD*, Daniel Zelterman, PhD{ddagger}, Brian R. Smith, MD*, Christine S. Rinder, MD*{dagger}, and the Multicenter Study of Perioperative Ischemia (McSPI) Reasearch Group

Department of *Laboratory Medicine, {dagger}Anesthesiology, and {ddagger}Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2005 101: 17-23.

心肺轉流的心臟手術患者術後1/3患者發生房顫並引起相應的發病率和死亡率。最近的資料顯示心肌的炎性浸潤可能是造成房顫的原因。於是作者設計了這項研究以確定圍術期心肺轉流(CPB)引起的白細胞炎症反應是否與術後房顫有關。72名心臟手術/心肺轉流的患者,術前均為竇性心律。圍術期在單核細胞和中性粒細胞中測量白細胞啟動情況(CD11b上調因數),術前測定反映炎症情況的C反應蛋白(CRP)和監測圍術期中性粒細胞過氧化酶(MPO)以及測定反映心肌損傷的肌鈣蛋白。評估術後發生房顫患者與術後正常竇性心律的患者之間各方面的差異。72名患者都完成了該研究,其中26名患者發生了房顫(36%)。發生房顫的患者圍術期單核細胞CD11b上調因數顯著增加(P0.01),但PMN CD11b的增加與房顫無明顯相關(P=0.057)。主動脈夾閉鉗開放後單核細胞和中性粒細胞兩者計數增加與術後房顫顯著相關(分別為P=0.007P=0.005)。相反,房顫和正常心律患者之間術前CRP和圍術期MPO無差異。同樣地,肌鈣蛋白峰值在組間也無差異。在這項心臟手術/心肺轉流患者的研究中,圍術期單核細胞粘附受體CD11b上調以及迴圈中的單核細胞和中性粒細胞增加與術後房顫相關,顯示心臟手術/心肺轉流期間細胞炎症的介入可能促成這個病理生理學變化。

(朱輝 陳傑 )

Atrial fibrillation (AF) contributes significantly to morbidity and mortality in as many as one-third of patients after cardiac surgery that requires cardiopulmonary bypass (CPB). Recent data suggest that inflammatory infiltration of the myocardium may predispose to AF. We conducted an exploratory pilot study to determine if there was an association between the perioperative leukocyte inflammatory response to cardiac surgery/CPB and postoperative AF. We enrolled 72 patients undergoing cardiac surgery with CPB; all patients were in sinus rhythm before surgery. Leukocyte activation (CD11b upregulation) was perioperatively measured in monocytes and neutrophils (PMN). Preoperative C-reactive protein (CRP) and perioperative neutrophil myeloperoxidase (MPO) were also monitored for inflammation, and troponin I was assayed for perioperative cardiac muscle damage. All markers were evaluated for differences between the subset of patients who developed AF versus those who remained in normal sinus rhythm after surgery. All 72 patients completed the study. Postoperative AF developed in 26 (36%) patients. Perioperative monocyte CD11b upregulation was significantly increased in patients who developed AF (P = 0.01), but increases in PMN CD11b were not significantly associated with AF (P = 0.057). The increase in both monocyte and PMN counts after aortic cross-clamp release was significantly associated with postoperative AF (P = 0.007 and P = 0.005, respectively). By contrast, preoperative CRP and perioperative MPO did not differ between AF and normal rhythm patients. Similarly, the peak value of troponin I did not differ between groups. In this pilot study of cardiac surgery/CPB patients, perioperative upregulation of the monocyte adhesion receptor, CD11b, and higher circulating monocyte and PMN numbers were associated with postoperative AF, suggesting that the induction of cellular inflammation during cardiac surgery/CPB may contribute to this pathophysiology.

 

小兒鎮靜狀態下評估系統安全和潛在失誤的方法

A Method for Measuring System Safety and Latent Errors Associated with Pediatric Procedural Sedation

George T. Blike, MD, Klaus Christoffersen, PhD, Joseph P. Cravero, MD, Steven K. Andeweg, MD, and Jens Jensen, MS

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

Anesth Analg 2005 101: 48-58.

 

在醫院內對於鎮靜患者的診斷和治療過程中可能會發生危及生命的呼吸抑制。作者通過一類比的實驗發現潛在的系統錯誤。這個模擬事件可重複並有逼真的生理學過程且如果無干預措施將隨時間消耗逐漸遞減而給予適當治療可改善。觀察在理想場所,放射科,急診科處理模擬事件的狀況,並用攝像機錄製下來。類比的生理學資料每隔5秒被自動保存下來。通過錄影標記的設置評估對類比事件的發現,診斷,治療與“最好實踐”的偏差。類比資料的保存檔被用來計算超出範圍的緊急情況的時間。在放射科和急診科低氧和低血壓持續時間分別為4.55.5分鐘,而在金標準場所為0分鐘。許多潛在的失誤可在錄影重播中被發現。這項研究提示在實際的鎮靜護理場所利用人作為快速的試驗模型能更客觀地量化急救系統實施的可行性。這項試驗說明儘管已對鎮靜護理要求作了相應的處理但對於患者本人和護理系統仍易受傷害。

(朱輝 陳傑 校)

The practice of sedating patients in the hospital for diagnostic and therapeutic procedures may be associated with life-threatening respiratory depression. We describe a method that uses a simulated event to identify latent system failures. A simulated scenario was developed that was reproducible with realistic physiology that degraded over time if no interventions occurred and improved when treated appropriately. Management of the scenario was observed in an ideal setting, a radiology department, and an emergency department. Event management was videotaped. The simulator’s physiological data were saved automatically at 5-s intervals. Deviations from "best practice" were measured by using a set of video markers for event detection, diagnosis, and treatment. The simulator data files were used to calculate time out of range for critical variables. Hypoxia and hypotension lasted 4.5 and 5.5 min in the radiology and emergency departments, respectively, compared with 0 min in the gold standard setting. Many latent failures were identified by reviewing the video. This study supports the feasibility of using available human simulation as a crash-test dummy to more objectively quantify rescue system performance in actual sedation care settings. This method revealed vulnerabilities in personnel and in care systems even though sedation care regulatory requirements were met.

 

小兒骶管麻醉時咪唑安定、氯胺酮和新斯的明與布比卡因聯合應用的比較
Caudal Additives in Pediatrics: A Comparison Among Midazolam, Ketamine, and Neostigmine Coadministered with Bupivacaine

P. Kumar, MBBS, A. Rudra, MD, FAMS, A. K. Pan, DA, MD, and A. Acharya, DA, MD

Department of Anaesthesiology, Calcutta National Medical College, Kolkata, India

Anesth Analg 2005 101: 69-73.

 

小兒骶管麻醉時單次注射布比卡因的作用持續時間僅為4-8h,因此逐漸不再普遍應用。在一項前瞻性隨機雙盲臨床試驗中,比較並評價了氯胺酮、咪唑安定和新斯的明與布比卡因聯合應用于骶管硬膜外腔後術中和術後鎮痛效果。80名年齡為5-10歲需行腹股溝疝修補術病人(ASA I級),隨機平均分為4組(每組n20),未用術前藥,標準全麻誘導後行骶管注射,藥液為0.25%布比卡因(1ml/kg),有或無氯胺酮(0.5mg/kg)、咪唑安定(50 µg /kg)和新斯的明(2 µg /kg)。對分組情況不清楚的麻醉醫生負責監測疼痛、鎮靜、術後噁心/嘔吐、頭昏和瘙癢情況。在布比卡因-新斯的明組和布比卡因-咪唑安定組,首次給鎮痛藥(撲熱息痛糖漿)的時間晚於其他組(P < 0.05)。不適反應如嘔吐、瘙癢和頭昏,在各組相似。但是,布比卡因-氯胺酮組的幻覺發生率高於其他組。該研究顯示了單次骶管內注射布比卡因-新斯的明和布比卡因-咪唑安定與延長術後鎮痛時間有關。

(趙延華 陳傑 校)

Single-shot "kiddie caudal" with bupivacaine alone is losing popularity because of its duration of 4–8 h. In a prospective randomized double-blind clinical study, we assessed and compared the efficacy of ketamine, midazolam, and neostigmine coadministered with bupivacaine in a caudal epidural to provide intraoperative and postoperative pain relief. Eighty children (ASA status I) aged 5–10 yr undergoing unilateral inguinal herniotomy were allocated randomly in equal numbers (n = 20) into 4 groups to receive a caudal injection of 0.25% bupivacaine (1 mL/kg) with or without ketamine (0.5 mg/kg), midazolam (50 µg/kg), and neostig-mine (2 µg/kg), after the induction of standardized general anesthesia without premedication. Monitoring for pain, sedation, postoperative nausea/vomiting, dizziness, and pruritus was performed by anesthesiologists blinded to the study allocation. The time to first analgesic administration (paracetamol syrup) was longer (P < 0.05) in the bupivacaine-neostigmine group and the bupivacaine-midazolam group than in the other groups. Undesirable effects, such as emesis, pruritus, and dizziness, were comparable in all groups. However, the incidence of hallucination was more frequent in the bupivacaine-ketamine group compared with the other groups. This study shows that single-shot caudal coadministration of bupivacaine-neostigmine and bupivacaine-midazolam was associated with an extended duration of postoperative pain relief.

與藥物前體丙帕他莫(propacetamol)相比,對乙酰氨基酚(撲熱息痛)經靜脈用於第三磨牙手術後疼痛有同樣的鎮痛效能,但安全性更好
Intravenous Acetaminophen (Paracetamol): Comparable Analgesic Efficacy, but Better Local Safety than Its Prodrug, Propacetamol, for Postoperative Pain After Third Molar Surgery

Philip Lange Moller, MD, Gitte Irene Juhl, MD, Catherine Payen-Champenois, MD, and Lasse Ansgar Skoglund, DDS, DSci

Department of Anaesthesia, University Hospital of Aarhus, Aarhus, Denmark; Neurosciences Department, Bristol-Myers Squibb, France; and the Section of Dental Pharmacology and Pharmacotherapy, University of Oslo, Oslo, Norway

Address correspondence and reprint requests to Philip Lange Moller, MD, Department of Anesthesia, University Hospital of Aarhus, Norrebrogade 44, DK-8000 Aarhus, Denmark. .

Anesth Analg 2005 101: 90-96.

 

作者利用隨機對照雙盲平行分組研究,比較對乙酰氨基酚(撲熱息痛)1gn51)和其前體丙帕他莫2gn51)以及安慰劑(n50)用於第三磨牙手術後中重度疼痛病人的效果。藥物經靜脈注射,時間為15min。注藥開始後即在室內評價其治療效果,時間為6h。根據100mm視覺類比評分尺規和分類尺規評定疼痛強度,與安慰劑相比,兩個治療組有明顯的疼痛緩解作用(p< 0.01,除了丙帕他莫6h時作用不明顯)。除1h外,兩個治療組組間沒有顯著差別。6h的初步評價顯示兩個治療組與安慰劑組相比有顯著的治療效果(P < 0.0001),而兩個治療組之間沒有差別。治療組疼痛開始出現緩解的平均時間是開始輸注後6-8min,兩個治療組的效果相似,與安慰劑組相比鎮痛時間更長和整體評價更好。病人主訴注射部位疼痛的情況,對乙酰氨基酚組或安慰劑組(0%)明顯少於丙帕他莫組(49%)。結論:1g對乙酰氨基酚和2g丙帕他莫的鎮痛效果強於安慰劑,丙帕他莫輸注部位局部疼痛發生率更高。

(趙延華 陳傑 校)

We compared an acetaminophen (paracetamol) 1 g (n = 51) formulation for infusion with propacetamol 2 g (n = 51) and placebo (n = 50) in a randomized, controlled, double-blind, parallel group trial in patients with moderate-to-severe pain after third molar surgery. Treatment efficacy was assessed in house for 6 h after starting the 15-min infusion. Significant effects versus placebo (P < 0.01) were obtained with both active treatments on pain relief, pain intensity difference on a 100-mm visual analog scale, and on a categorical scale (except for propacetamol at 6 h). No significant differences were noted between active groups except at 1 h. Six-hour weighted sums of primary assessments showed significantly better efficacy than placebo (P < 0.0001) and no difference between active treatments. Median stopwatch time to onset of pain relief for active treatment was 6–8 min after infusion start. Active treatments showed comparable efficacy with a significantly longer duration of analgesia and better patients’ global evaluation compared with placebo. The incidence of patients reporting local pain at the infusion site was significantly less frequent after IV acetaminophen or placebo (0%) in comparison with propacetamol (49%). In conclusion, acetaminophen 1 g and propacetamol 2 g were superior to placebo regarding analgesic efficacy, with a more frequent incidence of local pain at the infusion site for propacetamol.

 

昔多芬(商品名:偉哥)對肺栓塞導致的氧化應激和肺高壓的影響

The Effect of Sildenafil on Pulmonary Embolism-Induced Oxidative Stress and Pulmonary Hypertension

Carlos A. Dias-Junior, Pharm D, Debora C. Souza-Costa, Pharm D, MS, Talita Zerbini, Joao B. T. da Rocha, BS, PhD, Raquel F. Gerlach, DDS, PhD, and Jose E. Tanus-Santos, MD, PhD

Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Sao Paulo, Brazil

Anesth Analg 2005 101: 115-120.

急性肺栓塞(APE)是肺高壓和死亡的主要原因。作者測試了昔多芬對麻醉中的犬發生急性肺栓塞時的血流動力學影響。假手術的犬僅接受生理鹽水(n3)。以靜脈注射300um的微球逐步造成肺栓塞使肺動脈壓升高20mmHg。在基礎狀態、APE誘導發生後和昔多芬0.25mg/kgn8),或昔多芬 1mg/kg0.3mg/kg/hn8)或生理鹽水(n9)注射開始後測定血流動力學改變。相同的實驗在小鼠單肺灌注準備時進行。血漿丙二酰磺尿酸相互作用也同時在兩個研究中進行以測定氧化應激。兩種劑量的昔多芬都可降低犬的肺動脈壓8-16mmHgp<0.05),並減少APE後的氧化應激。兩種劑量的昔多芬均未使動脈血壓發生改變。昔多芬在單肺灌注肺的小鼠中產生同樣的作用。這些發現指出靜脈注射昔多芬可以選擇性的減少APE後的肺平均動脈壓,可能通過抗氧化機制。

(忻紀華 陳傑 校)

Acute pulmonary embolism (APE) is a major cause of pulmonary hypertension and death. We examined the effects of sildenafil on the hemodynamic changes caused by APE in anesthetized dogs. Sham-operated dogs (n = 3) received only saline. APE was induced by stepwise IV injections of 300 µm microspheres in amounts adjusted to increase mean pulmonary artery pressures by 20 mm Hg. Hemodynamic evaluation was performed at baseline, after APE was induced, and then after sildenafil 0.25 mg/kg (n = 8), or sildenafil 1 mg/kg + 0.3 mg · kg–1 · h–1 (n = 8) or saline (n = 9) infusions were started. Similar experiments were conducted to examine the effects of sildenafil in rat isolated perfused lung preparation. Plasma thiobarbituric acid reactive species were also determined in both studies to measure oxidative stress. Both doses of sildenafil reduced mean pulmonary artery pressures in dogs by approximately 8 to 16 mm Hg (both P < 0.05) and attenuated the increase in oxidative stress after APE. Mean arterial blood pressure remained unaltered after both doses of sildenafil. Sildenafil produced similar effects after APE in rat isolated perfused lung preparation. These findings indicate that IV sildenafil can selectively attenuate the increases in mean pulmonary artery pressures after APE, possibly through antioxidant mechanisms.

 

右旋依託咪酯和光活性右旋Azietomidate在野生型鼠麻醉中的作用比較和降低γ-氨基丁酸受體β3亞單位上N265M位元點突變體的比較

R (+) Etomidate and the Photoactivable R (+) Azietomidate Have Comparable Anesthetic Activity in Wild-Type Mice and Comparably Decreased Activity in Mice with a N265M Point Mutation in the Gamma-Aminobutyric Acid Receptor ß3 Subunit

Mark Liao, BS, James M. Sonner, MD, S. Shaukat Husain, DPhil*, Keith W. Miller, DPhil*, Rachel Jurd, PhD{dagger}, Uwe Rudolph, MD{dagger}, and Edmond I. Eger, II, MD

Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; *Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts; and {dagger}Institute of Pharmacology and Toxicology, University of Zurich, Zurich, Switzerland

Anesth Analg 2005 101: 131-135.

 

衍生于依託米酯,Azietomidate光活化性的diazirine,具有很多依託米酯的作用,包括消除蝌蚪的正位反射和增加γ-氨基丁酸誘導的電流。應用Azietomidate來研究麻醉機制是基於它和依託米酯有共同作用位點的假設。在γ-氨基丁酸受體β3亞單位上具有N265M位點突變體的小鼠使用一定劑量的依託米酯可以顯著降低正位反射缺失的敏感性。因此,本試驗作者靜脈注射一定劑量Azietomidate後測量了野生型鼠和突變鼠對正位反射的恢復時間。Azietomidate7.5mg/kg)的平均恢復時間分別為:野生型鼠10.0±0.9min,突變型鼠3.0±1.6min。依託米酯(7.5mg/kg)的平均恢復時間分別為:野生型鼠12.0±1.3min,突變型鼠4.0±0.7min。所以,此劑量下的γ-氨基丁酸受體β3亞單位上N265M單一位點突變體,幾乎將依託米酯和Azietomidate的正位反射恢復時間分為兩半(分別為7.6±1.5min7.2 ±1.8min),強烈顯示上述兩藥的殘餘結構貢獻于Azietomidate對行為的影響。

(忻紀華 陳傑 校)

A photoactivable diazirine derivative of etomidate, azietomidate, shares many actions of etomidate, including a capacity to abolish the righting reflexes in tadpoles and enhance gamma-aminobutyric acid (GABA)-induced currents. Azietomidate’s usefulness in studies of mechanisms of anesthesia depends on the assumption that it shares a site of action with etomidate. Mice bearing an N265M ß3 subunit point mutation in GABAA receptors have a markedly decreased sensitivity to loss of righting reflexes induced by etomidate over a range of doses. Accordingly, in the present study we measured the time to recovery of righting reflexes of wild type and mutant mice as a function of dose given as an IV bolus. Analysis of the data for azietomidate yielded mean times to recovery of righting reflexes at a dose of 7.5 mg/kg of 10.0 ± 0.9 min and 3.0 ± 1.6 min for wild type and mutant mice, respectively (mean ± sd). A similar analysis for etomidate yielded mean times to recovery of righting reflexes at a dose of 7.5 mg/kg of 12.0 ± 1.3 min and 4.0 ± 0.7 min for wild type and mutant mice respectively. Thus, at this dose a single mutation, N265M on the ß3 subunit of the GABAA receptor, approximately halved the time to recovery of righting reflexes for both etomidate and azietomidate (by 7.6 ± 1.5 min and 7.2 ± 1.8 min, respectively), emphasizing the contribution of this residue as a determinant of a behavioral response of azietomidate in mice.

 

先進的病人監測顯示器:連續資訊的工具

Advanced Patient Monitoring Displays: Tools for Continuous Informing

Penelope M. Sanderson, PhD, FASSA*, Marcus O. Watson, PhD*, and W. John Russell, MBBS, DPhil, DIC, FRCA, FANZCA{dagger}

*ARC Key Centre for Human Factors and Applied Cognitive Psychology, The University of Queensland, St Lucia; and {dagger}Department of Anaesthesia and Intensive Care, Royal Adelaide Hospital, Adelaide, Australia

Address correspondence to Penelope M. Sanderson, PhD, ARC Key Centre for Human Factors and Applied Cognitive Psychology, The University of Queensland, St Lucia, Australia 4072. .

Anesth Analg 2005 101: 161-168.

作者回顧了在麻醉監測中運用的先進顯示技術情況。研究者調查了能整合各種資訊,某些情況下可以提供給麻醉醫師連續結果的顯示器。整合後可視顯示器提供了更高等級的病人狀態和對事件的反應速度,但是這樣精密的定時儲存的資訊的益處不得而知。懸掛式顯示器似乎可以縮短對變化的反應時間,但它們對週邊認知和注意的影響不得而知。持續音頻顯示器將血氧飽和度的功能擴展,看上去似乎可以縮短反應時間和改善其他定時監測任務的功能,但將它們整合入這個已經嘈雜的手術環境中效果仍需測試。作者回顧了這三種方法的利弊,吸取了其他方面的發明,例如航空學,提出在麻醉背景下獲得的結果。證明先進的監測顯示器提高病人的預後是有難度的,更實際的目標大概是證明這種顯示器可以提高環境的認知,更早的反應,和更少的工作負擔,所有這些都是有利於保證麻醉的安全。

(殷文淵 陳傑 校)

We reviewed the use of advanced display technologies for monitoring in anesthesia. Researchers are investigating displays that integrate information and that, in some cases, also deliver the results continuously to the anesthesiologist. Integrated visual displays reveal higher-order properties of patient state and speed in responding to events, but their benefits under an intensely timeshared load is unknown. Head-mounted displays seem to shorten the time to respond to changes, but their impact on peripheral awareness and attention is unknown. Continuous auditory displays extending pulse oximetry seem to shorten response times and improve the ability to timeshare other tasks, but their integration into the already noisy operative environment still needs to be tested. We reviewed the advantages and disadvantages of the three approaches, drawing on findings from other fields, such as aviation, to suggest outcomes where there are still no results for the anesthesia context. Proving that advanced patient monitoring displays improve patient outcomes is difficult, and a more realistic goal is probably to prove that such displays lead to better situational awareness, earlier responding, and less workload, all of which keep anesthesia practice away from the outer boundaries of safe operation.

 

通過中線徑路進行枕部神經電刺激和手術皮下置電極來治療嚴重枕部神經痛:一項初步研究

Occipital Nerve Electrical Stimulation via the Midline Approach and Subcutaneous Surgical Leads for Treatment of Severe Occipital Neuralgia: A Pilot Study

Leonardo Kapural, MD, PhD, Nagy Mekhail, MD, PhD, Salim M. Hayek, MD, PhD, Michael Stanton-Hicks, MB, BS, and Osama Malak, MD

Pain Management Department, The Cleveland Clinic Foundation, Cleveland, Ohio

Address correspondence and reprint requests to Leonardo Kapural, MD, PhD, Pain Management Center, The Cleveland Clinic Foundation, 9500 Euclid Ave., Desk C25, Cleveland, OH 44195. .

Anesth Analg 2005 101: 171-174.

 

持續枕部神經痛可以產生嚴重的頭痛,不易通過保守或手術方法來控制。作者描述了一組6名平均具有4.9年慢性頭痛史的病人,這些病人通過改良中間徑路接受枕部神經電刺激導線的植入的枕部神經痛治療效果。這些病人過去接受過保守和手術治療,包括口服抗抑鬱藥,膜穩定劑,阿片類藥物,枕部神經阻滯和射頻消融術。在枕部刺激試驗期間和植入後的三個月疼痛視覺類比評分顯著下降、功能顯著改善。VAS平均評分從8.66±1.0下降至2.5±1.3;疼痛致殘指數從49.8±15.9改善至14.0±7.4。中線徑路與乳突下徑路相比有幾處優點。中線徑路方法在頸部上方僅有一個小小的切口,僅當屈曲時拉緊導線,在側曲和旋轉時張力最小,從而使這個系統非常穩定。

(殷文淵 陳傑 校)

Persistent occipital neuralgia can produce severe headaches that may not be controllable by conservative or surgical approaches. We describe a case series of 6 patients who had chronic headaches over an average of 4.9 yr who underwent occipital nerve electrical stimulation lead implantation using a modified midline approach. The patients had received conservative and surgical therapies in the past including oral antidepressants, membrane stabilizers, opioids, occipital nerve blocks, and radiofrequency ablations. Significant decreases in pain visual analog scale (VAS) scores and drastic improvement in functional capacity were observed during the occipital stimulation trial and during the 3-mo follow-up after implantation. The mean VAS score changed from 8.66 ± 1.0 to 2.5 ± 1.3 whereas pain disability index improved from 49.8 ± 15.9 to 14.0 ± 7.4. Our midline approach has several advantages compared with the submastoid approach used elsewhere. There is only one small midline incision over the upper neck and the strain on the lead extension occurs only with flexion and is minimal with lateral flexion and rotation, which contributes to overall stability of this system.

由單個職業醫療人員進行的頭上方心肺復蘇可改善基礎生命支持的效果:一項模擬研究

Over-the-Head Cardiopulmonary Resuscitation Improves Efficacy in Basic Life Support Performed by Professional Medical Personnel with a Single Rescuer: A Simulation Study

Michael Hüpfl, MD*{dagger}, Andreas Duma, MD*{dagger}, Thomas Uray, MD{dagger}, Christina Maier{dagger}, Nikolaus Fiegl{dagger}, Norbert Bogner{dagger}, and Peter Nagele, MD*{ddagger}

*Department of Anesthesia and General Intensive Care, Medical University; {dagger}St. John's Ambulance, Vienna, Austria; and {ddagger}Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri

Anesth Analg 2005 101: 200-205.

 

雙人心肺復蘇被認為是專業基礎生命支持的最好辦法。然而,對於許多院前心跳停止的情況來說,當別的救護員進行其他工作時,單個救護員必需要開始進行單人心肺復蘇。理論上,在此情況時,頭上方心肺復蘇是一個合適的選擇,此方法的附加優勢是使單個救護員可以使用簡易呼吸器進行通氣。 在此試驗中,作者對在人體模型上進行的標準單人心肺復蘇和單人頭上方心肺復蘇進行了比較。此試驗採用隨機、交叉研究設計,每一個參與者都掌握這兩種心肺復蘇技術。由分析軟體收集每個方法進行的2分鐘心肺復蘇試驗中通氣和胸部按壓的資料。67個急救醫學學生參與了此試驗。與標準心肺復蘇相比,頭上方心肺復蘇有更高的通氣率(正確通氣的數目為330/760279/779p0.002)。兩組中胸部按壓的質量沒有區別(正確胸部按壓:4293/63044313/6395,p=0.44)。總之,當單個職業醫療人員要進行單人心肺復蘇時,頭上方心肺復蘇是一種有效的選擇,與標準基本生命支持相比,頭上方心肺復蘇的通氣率和胸部按壓的質量更高。

(朱玫娟 陳傑 校)

Two-rescuer cardiopulmonary resuscitation (CPR) is considered the best method for professional basic life support (BLS). However, in many prehospital cardiac arrest situations, one rescuer has to begin CPR alone while the other performs additional tasks. In theory, over-the-head CPR is a suitable alternative in this situation, with the added benefit of allowing the single rescuer to use a self-inflating bag for ventilation. In this trial, we compared standard single-rescuer CPR with over-the-head CPR in manikins. We planned this study using a crossover study design where each participant administered both CPR techniques in a randomized order. Ventilation and chest compression data were collected with analysis software during a 2-min CPR test for each technique. Sixty-seven emergency medical technician students participated in this trial. Over-the-head CPR allowed for superior ventilation compared to standard CPR (number of correct ventilations: 330 of 760 versus 279 of 779; P = 0.002). The quality of delivered chest compressions did not differ between the two groups (correct chest compressions: 4293 of 6304 versus 4313 of 6395; P = 0.44). In conclusion, our study has shown that over-the-head CPR may be an effective alternative BLS technique when a single professional rescuer has to perform CPR, likely offering superior ventilation and comparable chest compression quality compared with standard BLS.

 

加巴噴丁與卡馬西平對重症監護室格林-巴厘(Guillain-Barre)綜合征患者鎮痛治療的比較性評估

The Comparative Evaluation of Gabapentin and Carbamazepine for Pain Management in Guillain-Barré Syndrome Patients in the Intensive Care Unit

Chandra Kant Pandey, MD*, Mehdi Raza, MD*, Mukesh Tripathi, MD*, Deepa V. Navkar, MD*, Abhishek Kumar, MD*, and Uttam K. Singh, PhD{dagger}

*Departments of Anaesthesiology and {dagger}Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2005 101: 220-225.

 

作者比較了36Guillain-Barre綜合症患者使用加巴噴丁與卡馬西平後疼痛緩解的效果。患者隨機分為加巴噴丁組(7天,每天3次,每次300mg)、卡馬西平組(7天,每天3次,每次100mg)和安慰劑組(7天,每天3次)。當患者需要時,使用芬太尼2ug/kg作為輔助鎮痛藥。在用藥以前和研究過程中每隔6小時,用010分疼痛評定量表對疼痛進行評分,用1-6Ramsay鎮靜評分對鎮靜進行評分。記錄每個患者每天總芬太尼消耗量。研究結果顯示與對照組(6.06.06.06.06.06.0)和卡馬西平組(6.06.05.04.04.03.53.0)相比,加巴噴丁組的平均疼痛評分更低(p<0.05),分別為3.52.52.02.02.02.02.0)。加巴噴丁組和卡馬西平組治療第一天芬太尼消耗量沒有明顯差別(分別為340.1±34.3ug347.5±38.0ug),但與對照組(590.4±35.0ug)相比,這兩組芬太尼消耗量有明顯減少(p<0.05)。在研究的其餘階段,3組間芬太尼消耗量有明顯差別,加巴噴丁組最少(p<0.05)。結論:在緩解疼痛和芬太尼消耗上,加巴噴丁比卡馬西平更有效。

(朱玫娟 陳傑 校)

We evaluated the effects of gabapentin and carbamazepine for pain relief in 36 Guillain-Barré syndrome patients. Patients were randomly assigned to receive gabapentin 300 mg, carbamazepine 100 mg, or matching placebo 3 times a day for 7 days. Fentanyl 2 µg/kg was used as a supplementary analgesic on patient demand. The pain score was recorded by using a numeric pain rating scale of 0–10, and sedation was recorded with a Ramsay sedation scale of 1–6 before medications were given and then at 6-h intervals throughout the study period. Total daily fentanyl consumption was recorded each day for each patient. The results of the study demonstrated that patients in the gabapentin group had significantly lower (P < 0.05) median numeric pain rating scale scores (3.5, 2.5, 2.0, 2.0, 2.0, 2.0, and 2.0) compared with patients in the placebo group (6.0, 6.0, 6.0, 6.0, 6.0, 6.0, and 6.0) and the carbamazepine group (6.0, 6.0, 5.0, 4.0, 4.0, 3.5, and 3.0). There was no significant difference in fentanyl consumption between the gabapentin and carbamazepine groups on Day 1 (340.1 ± 34.3 µg and 347.5 ± 38.0 µg, respectively), but consumption was significantly less in these 2 groups compared with the placebo group (590.4 ± 35.0 µg) (P < 0.05). For the rest of the study period, there was a significant difference in fentanyl consumption among all treatment groups, and it was minimal in the gabapentin group (P < 0.05). We conclude that gabapentin is more effective than carbamazepine for decreasing pain and fentanyl consumption.

 

異氟醚麻醉期間靜脈注射咪唑安定導致的脊髓血流改變

Spinal Cord Blood Flow Change by Intravenous Midazolam During Isoflurane Anesthesia

Tomoki Nishiyama, MD, PhD

Department of Anesthesiology, University of Tokyo, Japan

Anesth Analg 2005 101: 242-245.

作者研究了靜脈注射咪唑安定對異氟醚麻醉下的貓脊髓血流改變的影響。貓行椎板切除,並暴露腰脊髓。在立體定位下,在L2水平的中線側,將鉑金電極插入脊髓12mm深度。在靜脈注射負荷劑量的咪唑安定(將0124mg/kg的咪唑安定5ml;每組n8)後,分別記錄515306090以及90min貓的動脈血壓,心率,和脊髓血流(用氫清除法)。01mg/kg的咪唑安定組30min對動脈血壓沒有影響,但注射24mg/kg咪唑安定30min後動脈血壓下降。心率沒有改變。注射咪唑安定1mg/kg90min,和2mg/kg15min後脊髓血流增加,但是4mg/kg沒有改變。結論:咪唑安定(1mg/kg)增加了貓的脊髓血流而不改變動脈血壓。大劑量的咪唑安定(4mg/kg)不能改變脊髓的血流,但是可減低異氟醚麻醉下的貓的動脈血壓。

(顧漪聞 陳傑 校)

We investigated the effects of IV midazolam on spinal cord blood flow in 32 cats anesthetized with isoflurane. Cats underwent laminectomy, and the lumbar spinal cord was exposed. A platinum electrode was inserted stereotaxically into the spinal cord to a depth of 1 mm—2 mm lateral to midline at L2. Arterial blood pressure, heart rate, and spinal cord blood flow (using the hydrogen clearance method) were measured before and at 5, 15, 30, 60, 90, and 120 min after an IV bolus of midazolam (0, 1, 2, or 4 mg/kg in saline 5 mL; n = 8 cats per dose). Arterial blood pressure was not affected by 0 or 1 mg/kg of midazolam but was decreased for 30 min by 2 or 4 mg/kg of midazolam. Heart rate did not change. Spinal cord blood flow was increased for 90 min by midazolam 1 mg/kg and for 15 min by midazolam 2 mg/kg but was not changed by midazolam 4 mg/kg. In conclusion, 1 mg/kg of midazolam increased feline spinal cord blood flow without changing arterial blood pressure. In contrast, a larger dose of midazolam (4 mg/kg) did not change spinal cord blood flow but substantially decreased arterial blood pressure during isoflurane anesthesia.

 

採用新方法,排除舊方法?兩種腰大肌阻滯方法的比較

In with the New, Out with the Old? Comparison of Two Approaches for Psoas Compartment Block

Stephen Mannion, MRCPI, FCARCSI, Sheila O'Callaghan, FCARCSI, Mary Walsh, FCARCSI, Damian B. Murphy, FCARCSI, MD, and George D. Shorten, FCARCSI, PhD

Department of Anaesthesia and Intensive Care, Cork University Hospital; St. Mary's Orthopaedic Hospital; and University College, Cork, Ireland

Anesth Analg 2005 101: 259-264.

作者比較了WinnieCapdevila兩種腰大肌阻滯方法(PCB)。操作均由一個醫生完成,比較組間的對側擴散,腰叢阻滯,和術後鎮痛效果。前瞻性、雙盲研究60名大關節成形術(髖或膝)患者,均行PCB0.5%左旋布比卡因0.4ml/kg,)隨後行蛛網膜下腔阻滯。患者隨機分為兩組,一組採用Capdevila法(組Cn30),另一組採用改良Winnie法(組Wn30)。評估PCB153045min時向對側擴散和腰叢阻滯效果。通過感覺測試來評價對側擴散(雙側T4S5)和股和股外側皮神經阻滯的情況,並評價閉孔肌運動阻滯情況。在組C10個患者發生雙側麻醉,組W則為12例(P0.8)。股神經,股外側皮神經,和閉孔神經的阻滯情況:組C90%,93%,80%;組W分別為93%,97%,90%P>0.05)。因此,在PCB的過程中,疼痛評分,24h嗎啡消耗,或第一次嗎啡鎮痛時間,兩組沒有差異。

(顧漪聞 陳傑 校)

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.

 

Mallampti分級相比,上唇咬診實驗預測困難喉鏡檢查的可靠性和有效性:一個客觀的前瞻性評估

The Reliability and Validity of the Upper Lip Bite Test Compared with the Mallampati Classification to Predict Difficult Laryngoscopy: An External Prospective Evaluation

Leopold H. J. Eberhart, MD, Christian Arndt, MD, Thomas Cierpka, MD, Judith Schwanekamp, MD, Hinnerk Wulf, MD, and Caroline Putzke, MD

Department of Anesthesiology and Critical Care Medicine, Philipps-University Marburg, Germany

Anesth Analg 2005 101: 284-289.

 

最近,一項新的用於預測困難喉鏡檢查發生率的床旁篩查實驗被應用,從而作為Mallampti分級的替代選擇。上唇咬診實驗(ULBT)是測試病人能否用下切牙咬住上唇或能否完全咬住上唇。一般來講,一個新的預測工具在應用于臨床之前應進行客觀性的評估。因此,本研究就這個預測方法,評估其可靠性,判別能力,並與Mallampti評分進行比較(應用SamsoonYoung氏校正)。結果發現有12%的病人不能應用ULBT(Mallampti評分法只有<1%)。用ULBT可靠性較好(к=0.79к=0.59)。對1425個連續的病人評估預測病人是否有困難喉鏡檢查。實驗由兩個經過特殊訓練的完全獨立的觀察者在這些病人中同時進行評估。麻醉誘導後,由主治麻醉醫生應用CormackLehane分級評估喉鏡檢查視野。I級或II級稱為簡單喉鏡檢查,III級或IV級為困難喉鏡檢查。兩種預測方法的判別能力較低(ULBT0.60[95%可信區間,0.57-0.63]Mallampti評分為0.66[0.57-0.63]),表明了它們作為單一篩查工具應用時不能很好的進行預測。

(齊波 陳傑 校)

Recently, a new bedside screening test to predict the occurrence of a difficult laryngoscopy has been developed as a substitute for the Mallampati classification. The Upper-Lip-Bite test (ULBT) evaluated the patient’s ability to reach or completely cover the upper lip with the lower incisors. It is often accepted that new predictive tools should undergo an external evaluation before the tool is used in clinical practice. Thus, we evaluated this test with respect to applicability, interobserver reliability, and discriminating power and compared it with the Mallampati-score (using Samsoon and Young’s modification). The ULBT could not be applied in 12% of all patients (Mallampati score, <1%). However, the interobserver reliability was better for the ULBT ({kappa} = 0.79 versus {kappa}= 0.59). The discriminating power to predict a patient with difficult laryngoscopy was evaluated in 1425 consecutive patients. Both tests were assessed simultaneously in these patients by two specially trained independent observers. After the induction of anesthesia, the laryngoscopic view was assessed by the attending anesthesiologist using the classification of Cormack and Lehane. A grade I or II was called easy laryngoscopy and grade III and IV difficult laryngoscopy. The discriminating power for both tests was low (0.60 for the ULBT [95% confidence interval, 0.57–0.63] and 0.66 [0.63–0.69]) for the Mallampati score), indicating that both tests are poor predictors as single screening tests.

 

應用米力農可改善合併二尖瓣返流病人在行非體外迴圈冠狀動脈旁路吻合術時血流動力學改變

Hemodynamic Changes During Off-Pump Coronary Artery Bypass Anastomosis in Patients with Coexisting Mitral Regurgitation: Improvement with Milrinone

Takeshi Omae, MD*, Yasuyuki Kakihana, MD*, Akira Mastunaga, MD*, Isao Tsuneyoshi, MD*, Kouichi Kawasaki, MD*, Yuichi Kanmura, MD*, and Ryuzo Sakata, MD.

*Department of Anesthesiology and Critical Care Medicine and {dagger}Second Department of Surgery, Faculty of Medicine, Kagoshima University, Japan.

Anesth Analg 2005 101: 2-8.

 

一般認為,合併二尖瓣返流病人在行非體外迴圈冠狀動脈旁路(OPCAB)吻合術時,會有二尖瓣(MR)加重、心臟指數(CI)下降和平均肺動脈壓(MPAP)增高,而米力農可以改善發生在OPCAB吻合術時的MF增加。本研究包括140名選擇OPCAB的病人分成3組:無MR[MR-)組,n57]MR[MR+)組,n41]MR米力農治療組[M+MR+)組,n42]。本研究只包含MR1+2+級病人,MR3+4+級病人不在研究之列。血流動力學參數在麻醉誘導之後以及吻合術術中測量。M+MR+)組在麻醉誘導後即給予米力農0.5 µg·kg–1·min–1靜脈注射。在左冠狀動脈吻合術中,MR+)組較MR-)組CI顯著減小(P < 0.0001)MPAPMR顯著增加(P < 0.001)。同樣在左冠狀動脈吻合術中,M+MR(+)組較MR+)組CI顯著增大(P < 0.001)MPAPMR顯著降低(P < 0.05)。合併MR的病人,左冠狀動脈分支吻合術和CI減少及回流和MPAP增加相關。同樣在這些病人中,採用米力農治療有助於在吻合術中保持血流動力學穩定。

(金 路譯 薛張綱校)

We hypothesized that mitral regurgitation (MR) would be exacerbated, cardiac index (CI) decreased, and mean pulmonary artery pressure (MPAP) increased in patients with coexisting MR during off-pump coronary artery bypass (OPCAB) anastomosis, and that milrinone could ameliorate increases in MR that occur during OPCAB anastomosis. Subjects comprised 140 patients scheduled for elective OPCAB divided into three groups: patients without MR (MR(-) group; n = 57), patients with MR (MR(+) group; n = 41), and patients with MR who received milrinone (M+MR(+) group; n = 42). Patients with grade 1+ or 2+ MR were included, whereas those with grade 3+ or 4+ MR were excluded. Hemodynamic variables were measured after the induction of anesthesia and during anastomosis. IV infusion of milrinone (0.5 µg · kg–1 · min–1) started immediately after the induction of anesthesia in the M+MR(+) group. CI was significantly decreased (P < 0.0001), and MPAP and MR were significantly increased (P < 0.001) during left coronary anastomosis in the MR(+) group compared with the MR(-) group. CI was significantly higher (P < 0.001), and neither MPAP nor MR were increased (P < 0.05) during left coronary artery anastomosis in the M+MR(+) group compared to the MR(+) group. In patients with MR, anastomosis of the left coronary artery branches was associated with decreased CI and increased regurgitation and MPAP. In such patients, treatment with milrinone helps to stabilize hemodynamics during anastomosis.

 

二尖瓣手術中伴隨射頻消融和手術方式(修補術對置換術)對心臟生物標誌物釋放的影響

The Effect of Concomitant Radiofrequency Ablation and Surgical Technique (Repair Versus Replacement) on Release of Cardiac Biomarkers During Mitral Valve Surgery

Alberto Zangrillo, MD*, Giuseppe Crescenzi, MD*, Giovanni Landoni, MD*, Stefano Benussi, MD{dagger}, Martina Crivellari, MD*, Federico Pappalardo, MD*, Enrica Dorigo, MD{dagger}, Carlo Pappone, MD, PhD{ddagger}, and Ottavio Alfieri, MD{dagger} .

*Departments of Cardiovascular Anesthesia, {dagger}Cardiac Surgery, and {ddagger}Cardiology, IRCCS San Raffaele Hospital, Milan, Italy .

Address correspondence and reprint requests to Giovanni Landoni, MD, Department of Cardiovascular Anesthesia, IRCCS San Raffaele Hospital, Milan, Italy, Via Olgettina 60, 20132 Milano Italy.

Anesth Analg 2005 101: 24-29.

 

所有施行心臟手術的病人都會有一定程度的可通過心臟生物標誌物釋放的測定證實的非特異心肌損害,並伴隨心輸出量的減少。我們研究了在71例二尖瓣手術伴左房消融術病人中行房顫單極射頻消融術對心臟生物標誌物的釋放的作用,並採用71例單純二尖瓣手術病人作為病例對照。本研究可檢測3 ng/mL的差別。兩組間在心肌肌鈣蛋白I10± 5.3 12 ± 10.4 ng/mL; P = 0.7)和CK-MB50 ± 21.8 57 ± 62.0 ng/mL; P = 0.5)的釋放上沒有差別。根據單變數分析,術後心肌肌鈣蛋白I峰值水平與心肺轉流(P = 0.002)及大動脈鉗閉(P = 0.001)的持續時間呈線性相關,也和手術方式(二尖瓣置換術15 ± 12 ng/mL 二尖瓣修補術9 ± 4.8 ng/mL P = 0.0007)呈線性相關。在多變數分析中,二尖瓣置換術是術後心肌肌鈣蛋白I峰值釋放的唯一的獨立預測因素(P = 0.005)。和單純二尖瓣手術相比,房顫射頻消融並不引起心臟生物標誌物釋放的顯著增加;和二尖瓣置換術相比,二尖瓣修補術所致心臟生物標誌物的釋放相對較少。

(金 薛張綱 校)

All patients undergoing heart surgery experience a certain amount of nonspecific myocardial injury documented by the release of cardiac biomarkers and associated with poor outcome. We investigated the role of unipolar radiofrequency ablation of atrial fibrillation on the release of cardiac biomarkers in 71 patients undergoing mitral valve surgery and concomitant left atrial ablation case-matched with 71 patients undergoing isolated mitral surgery. The study was powered to detect a 3 ng/mL difference. There was no difference between the 2 groups in terms of cardiac troponin I (10 ± 5.3 versus 12 + 10.4 ng/mL; P = 0.7) or creatine kinase-MB (50 ± 21.8 versus 57 ± 62.0 ng/mL; P = 0.5) release. Postoperative peak cardiac troponin I levels had univariate associations with the duration of cardiopulmonary bypass (P = 0.002) and aortic cross-clamping (P = 0.001) and with the surgical technique (15 ± 12 ng/mL for mitral valve replacement versus 9 ± 4.8 for mitral valve repair; P = 0.0007) at univariate analysis. Mitral valve replacement was the only independent predictor of postoperative peak release of cardiac troponin I identified with multivariate analysis (P = 0.005). Radiofrequency ablation of atrial fibrillation does not significantly increase cardiac biomarker release compared with isolated mitral surgery; mitral valve repair is associated with less release of cardiac biomarkers compared with mitral valve replacement.

昂丹司瓊口服片:在接受增殖腺扁桃體切除術的患兒中的可行性及有效性

Ondansetron Oral Disintegrating Tablets: Acceptability and Efficacy in Children Undergoing Adenotonsillectomy

Ira Todd Cohen, MD, Denise Joffe, MD, Kelly Hummer, BSN, and Alice Soluri, BSN

Department of Anesthesiology, Children's National Medical Center, and George Washington University School of Medicine, Washington, DC.

Anesth Analg 2005 101: 59-63.

術後噁心嘔吐(PONV)是兒科手術的一大併發症,靜注及口服昂丹司瓊對之有效。由於這些方法不一定可行,我們研究了昂丹司瓊口服片(ODT)的可行性和有效性。在該隨機、雙盲、安慰劑對照試驗中,62511歲接受增殖腺扁桃體切除術的患兒術前口服ODT4mg)或安慰劑。患兒通過味覺或感覺評價藥物。麻醉由七氟醚誘導、地氟醚維持,以及芬太尼2.5 µg/kg和地塞米松0.5 mg/kg(最大劑量 12mg)。由一位與治療無關的觀測者評價患兒的疼痛、躁動及術後噁心嘔吐情況。術後處理包括芬太尼1 µg/kg治療疼痛與躁動、胃複安0.15 mg/kg(最大劑量 10mg)治療PONV。試驗各組間的年齡、體重、恢復時間、躁動或疼痛沒有顯著差異。大約90%的受試對象覺得ODT味道不錯。沒有受試物件拒絕該試驗藥物,但我們發現,含昂丹司瓊的藥片沒有安慰劑口感好。服用昂丹司瓊組的嘔吐發生率顯著減少。

(王麗珺譯 薛張綱校)

Postoperative nausea and vomiting (PONV), a major complication in children, is responsive to IV and oral ondansetron. Because these routes are not always available, we studied the acceptability and efficacy of ondansetron oral disintegrating tablets (ODT). In this double-blind, randomized, placebo-controlled study, 62 patients undergoing adenotonsillectomy, aged 5 to 11 years, preoperatively received ODT (4 mg) or placebo. Patients assessed the medication for taste and sensation. Anesthesia was induced with sevoflurane, maintained with desflurane, and supplemented with fentanyl 2.5 µg/kg and dexamethasone 0.5 mg/kg (maximum dose, 12 mg). An observer blinded to treat-ment evaluated patients for pain, agitation, and PONV. Postoperative treatment consisted of fentanyl 1 µg/kg for pain and agitation and metoclopramide 0.15 mg/kg (maximum dose, 10 mg) for PONV. There were no significant differences between study groups with regard to age, weight, recovery time, agitation, or pain. Approximately 90% of the subjects found the ODT to taste good. No subject rejected the study medication, but the ondansetron-containing tablets were found to be less palatable than the placebo. The incidence of vomiting was significantly less in the ondansetron-medicated group.

 

高比重左布比卡因和羅呱卡因腰麻在門診膝關節鏡的應用:一項前瞻、隨機、雙盲試驗。

Spinal Anesthesia with Hyperbaric Levobupivacaine and Ropivacaine for Outpatient Knee Arthroscopy: A Prospective, Randomized, Double-Blind Study

Gianluca Cappelleri, MD*, Giorgio Aldegheri, MD*, Giorgio Danelli, MD{dagger}, Chiara Marchetti, MD*, Massimiliano Nuzzi, MD{dagger}, Gabriella Iannandrea, MD{dagger}, and Andrea Casati, MD{dagger} .

Department of Anesthesiology, Vita-Salute University of Milan, IRCCS H. San Raffaele, Milan, Italy; {dagger}Department of Anesthesiology, University of Parma, Azienda Ospedaliera di Parma, Parma, Italy.

Anesth Analg 2005 101: 77-82.

為比較用小劑量高比重羅呱卡因和2種劑量的高比重左布比卡因實施單側脊髓阻滯,我們隨機選取了91ASA I-II的門診膝關節鏡手術病人,分別接受0.5%高比重羅呱卡因7.5mg(羅呱卡因組-7.5,n=31)或0.5%高比重左布比卡因7.5mg(左布比卡因組-7.5n=30)5mg(左布比卡因組-5,n=31)。採用25Whitacre脊麻針在34腰椎間隙實施腰麻。患者在注射後15分鐘內保持側臥位。30分鐘後,羅呱卡因組-7.5、左布比卡因組-7.5 及左布比卡因組-5分別有73%, 50%,61%的病人出現了絕對單側感覺阻滯(P = 0.40)94%, 93%83%的病人出現了單側運動阻滯(P = 0.31)。羅呱卡因組-7.5的一名病人需改全麻以完成手術,羅呱卡因組-7.5的一名病人(3%)及左布比卡因組-5的一名病人(3%)需用芬太尼補充給藥法(P = 0.42)。羅呱卡因組-7.5的腰麻平均時間(時間範圍)(135[126-154]分鐘)短于左布比卡因組-7.5135[126-154]分鐘),出院時間也是羅呱卡因組-7.5(197 [177–218] 分鐘)和左布比卡因組-5(197 [187–251] 分鐘)短于左布比卡因組-7.5(238 [219–277] 分鐘)P分別為0.02 0.04)。我們推論:0.5%高比重羅呱卡7.5mg0.5%高比重左布比卡因5mg為門診膝關節鏡手術提供了良好的腰麻,較之0.5%高比重左布比卡因7.5mg,其出院時間更快。

(王麗珺譯 薛張綱校)

To compare unilateral spinal block produced with small doses of hyperbaric ropivacaine with that produced by 2 doses of hyperbaric levobupivacaine, we randomly allocated 91 ASA physical status I–II outpatients undergoing knee arthroscopy to receive unilateral spinal anesthesia with 7.5 mg of hyperbaric ropivacaine 0.5% (group Ropi-7.5, n = 31) or either 7.5 mg (group Levo-7.5, n = 30) or 5 mg (group Levo-5, n = 30) of hyperbaric levobupivacaine 0.5%. Spinal anesthesia was performed at the L3-4 interspace using a 25-gauge Whitacre spinal needle. The lateral decubitus position was maintained for 15 min after injection. Strictly unilateral sensory block was present in 73%, 50%, and 61% of cases in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively, 30 min after injection (P = 0.40), and unilateral motor block was observed in 94%, 93%, and 83% in groups Ropi-7.5, Levo-7.5, and Levo-5, respectively (P = 0.31). One patient of group Ropi-7.5 required general anesthesia to complete surgery, and fentanyl supplementation was required in one patient of group Ropi-7.5 (3%) and one patient of group Levo-5 (3%) (P = 0.42). The median (range) time for spinal block resolution was shorter in group Ropi-7.5 (135 [126–154] min] than in group Levo-7.5 (162 [148–201] min) (P = 0.04); whereas home discharge was shorter in groups Ropi-7.5 (197 [177–218] min) and Levo-5 (197 [187–251] min) as compared with group Levo-7.5 (238 [219–277] min) (P = 0.02 and P = 0.04, respectively). We conclude that 7.5 mg of 0.5% hyperbaric ropivacaine and 5 mg of 0.5% hyperbaric levobupivacaine provide adequate spinal block for outpatient knee arthroscopy, with a faster home discharge as compared with 7.5 mg of 0.5% hyperbaric levobupivacaine.

 

靜脈注射異丙酚與咪達唑侖鎮靜對血流動力學及心率變異的不同影響

The Different Effects of Intravenous Propofol and Midazolam Sedation on Hemodynamic and Heart Rate Variability

Ni Ni Win, Haruhisa Fukayama, Hikaru Kohase, Masahiro Umino.

Anesthesiology and Clinical Physiology, Department of Oral Restitution, Division of Oral Health Sciences, Graduate School, Tokyo Medical and Dental University, 1–5–45, Yushima, Bunkyou-ku, Tokyo, Japan, 113–8549.

Anesth Analg 2005 101: 97-102.

 

在使用異丙酚與咪達唑侖對患者進行鎮靜的過程中,有報導心率和血壓會發生變化。一種可能的解釋是二者通過影響心臟自主神經系統而影響心率和血壓。通過心率變異性分析,有兩種特別的假說得到檢驗:1)異丙酚使負交感神經活性佔優勢,引起心率和血壓下降;2)咪達唑侖增加交感神經活性,引起心率增快,血壓下降。一個前瞻性、隨機試驗研究了30位行牙科手術的患者,在清醒、鎮靜和恢復期監測他們的心率、血壓、低頻指數(LF)、高頻指數(HF)及熵,並使用OAA/S評分(the Observer’s Assessment of Alertness/Sedation score)評估患者鎮靜水平。鎮靜期與基線相比,異丙酚使總強度及LF/HF比值明顯下降(分別為503 ± 209 ms2/Hz 162 ± 92 ms2/Hz2.5 ± 1.2 1.0 ± 0.4),但心率並沒有任何改變。咪達唑侖使鎮靜期正常的HF值降低(34 ± 10% 10 ± 4%),但卻不會使LF/HF比值明顯改變(2.3±1.1 2.2±1.4),心率則有所增加。在蘇醒期,異丙酚使HF正常基線升高(34 ± 11%44 ± 12%),心率明顯下降,而咪達唑侖則增加LF/HF比值(2.3 ± 1.13.7 ± 1.8),不改變心率。這些結果作用說明,在同一時期,異丙酚副交感作用佔優勢,而咪達唑侖的交感優勢作用。在鎮靜麻醉中,特別是當非住院患者心血管併發症發生率高時,這些研究結果十分重要。

(金 琳譯 薛張綱校)

Heart rate (HR) and arterial blood pressure (BP) changes have been reported during conscious sedation with propofol and midazolam. One potential mechanism to explain these changes is that propofol and midazolam affect HR and BP via changes in the cardiac autonomic nervous system. Two specific hypotheses were tested by HR variability analysis: 1) propofol induces predominance of parasympathetic activity, leading to decreased HR and BP, and 2) midazolam induces predominance of sympathetic activity, leading to increased HR and decreased BP. Thirty dental patients were included in a prospective, randomized study. HR, BP, low frequency (LF), high frequency (HF), and entropy were monitored during the awake, sedation, and recovery periods and depth of sedation was assessed using the Observer’s Assessment of Alertness/Sedation score. Propofol induced a significant decrease in total power (503 ± 209 ms2/Hz versus 162 ± 92 ms2/Hz) and LF/HF ratio (2.5 ± 1.2 versus 1.0 ± 0.4), despite the absence of any change in HR during the sedation period compared with baseline. Midazolam decreased normalized HF (34 ± 10% versus 10 ± 4%) but did not significantly change LF/HF ratio (2.3 ± 1.1 versus 2.2 ± 1.4) and increased HR in the sedation period. Compared with baseline, propofol was associated with a significant increase in normalized HF in the recovery period (34 ± 11% versus 44 ± 12%) and a significant decrease in HR, whereas midazolam was associated with an increase in LF/HF ratio (2.3 ± 1.1 versus 3.7 ± 1.8) with no change in HR. These results indicated a dominant parasympathetic effect of propofol and a dominant sympathetic effect of midazolam in both periods. These results should be considered during conscious sedation, especially in patients at risk of cardiovascular complications.

 

體外可樂定和新斯的明的抗菌活性

Antibacterial activity of clonidine and neostigmine in vitro.
Boselli E, Guillier M, Freney J, Mazoyer MA, Casoli E, Renaud FR, Rimmele T, Chassard D, Allaouchiche B.
Service d'Anesthesie-Reanimation, Department of Anesthesiology, Hopital Edouard Herriot, 5 place d'Arsonval, 69437 Lyon cedex 03, France.

Anesth Analg. 2005 Jul;101(1):121-4.

 

當區域麻醉後出現感染併發症,我們進行體外試驗,研究可樂定和新斯的明對一般微生物的抗菌活性。37℃時,金黃葡萄球菌、表皮葡萄球菌及大腸埃希菌的懸液與濃度為37.575150mg/ml的可樂定及125250500mg/ml新斯的明在13624小時共同孵育。經3724小時孵育後,我們使用兩因素方差分析來比較菌落計數。隨著可樂定濃度的增高(P < 0.05),金葡菌平均菌落計數顯著下降,在6小時最大濃度(150mg/ml)幾乎100%滅菌,介於中間濃度(75mg/ml24小時幾乎100%滅菌。對於表皮葡萄球菌,我們觀察到了類似的結果,在6小時最大濃度(75150mg/ml)幾乎100%滅菌。可樂定對大腸埃希菌無殺菌活性,新斯的明對所測試的任何菌屬均無殺菌活性。在本次實驗的環境下,在體外可樂定,而非新斯的明,表現出對區域麻醉後感染併發症最多見的微生物的抗菌活性呈現濃度和時間依賴性。

(孫敏莉譯 薛張綱校)

We conducted an in vitro study to investigate the antibacterial activity of clonidine and neostigmine on common microorganisms encountered during infectious complications after regional anesthesia. Standardized suspensions of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli were incubated during 1, 3, 6, and 24 h at 37 degrees C with concentrations of 37.5, 75, and 150 microg/mL of clonidine and 125, 250, and 500 microg/mL of neostigmine. After 24 h incubation at 37 degrees C, the colony counts were compared by two-way analysis of variance. The mean colony counts for S. aureus decreased significantly from control as the exposure to clonidine increased (P < 0.05), with a approximately 100% kill at 6 h for the largest concentration (150 microg/mL) and at 24 h for the intermediate concentration (75 microg/mL). Similar results were observed for S. epidermidis, with a approximately 100% kill at 6 h for the largest concentrations (75 and 150 microg/mL). No bactericidal activity of clonidine was observed for E. coli and no bactericidal activity of neostigmine was observed for any of the tested strains. In the conditions of this experiment, clonidine, but not neostigmine, exhibited a concentration-dependent and time-dependent bactericidal activity in vitro on the microorganisms most frequently encountered in infectious complications after regional anesthesia.

 

異氟醚對FisherLewis大鼠氣道平滑肌連接橋動力的影響

The effects of isoflurane on airway smooth muscle crossbridge kinetics in Fisher and Lewis rats.

Duracher C, Blanc FX, Gueugniaud PY, David JS, Riou B, Lecarpentier Y, Coirault C.

Laboratory of Pathophysiologie cellulaire et moleculaire de l'insuffisance cardiaque, Institut National de la Sante et de la Recherche Medicale INSERM U572 Centre Hospitalo-Universitaire Lariboisiere, Assistance Publique-Hopitaux de Paris, France.

Anesth Analg. 2005 Jul;101(1):136-42.

 

我們的目的是研究異氟醚如何改變連接橋的數目和其動力學以及比較其對Fisher Lewis 大鼠的不同作用,這兩株大鼠的氣道反應性不同。應用乙酰甲膽鹼(10(-6) M)引起收縮後,觀察異氟醚(2 MAC)對氣管平滑肌帶等張和等長收縮的作用。連接橋的力學和動力學用適合氣道平滑肌的Huxley's方程分析。應用異氟醚後,在Lewis大鼠最大速度沒有改變,而在Fisher大鼠(氣道反應最強的株)顯著減少,大約只有基礎值的25%。異氟醚完全改變了乙酰甲膽鹼引起的Lewis大鼠活性連接橋數目的增長(乙酰甲膽鹼比異氟醚為2.4 +/- 0.5 1.8 +/- 0.4 10(9)/mm(2),而只是部分使Fisher大鼠發生了改變。(乙酰甲膽鹼比異氟醚為2.7 +/- 0.4 versus 2.1 +/- 0.3 10(9)/mm(2)。異氟醚使兩種大鼠收縮期的連接橋數目增加了40%,與基礎值相比Lewis大鼠連接橋的數目在連接橋迴圈中幾乎增加了兩倍。在分離期異氟醚引起的連接橋的增加,Lewis大鼠要比Fisher大鼠要少(P < 0.05)。我們得出結論:異氟醚改變離體大鼠平滑肌連接橋的數目以及連接橋迴圈的程度的不同取決於氣道反應水平。

(沈 洪譯 薛張綱 校)

Our aim was to determine how isoflurane modified crossbridge (CB) number and kinetics in airway smooth muscle (ASM) and to compare its effects in Fisher and Lewis rats, two strains with differences in airway responsiveness. The effects of isoflurane (2 MAC) on isotonic and isometric contractility in tracheal ASM strips were investigated after methacholine (10(-6) M)-induced contraction. CB mechanics and kinetics were analyzed using the formalism of Huxley's equations adapted to ASM. After isoflurane, maximum velocity did not differ from baseline in Lewis rats, whereas it was significantly less than baseline in Fisher rats ( approximately 25%), the most reactive strain. Isoflurane totally reversed methacholine-induced increase in active CB number in Lewis rats (2.4 +/- 0.5 versus 1.8 +/- 0.4 10(9)/mm(2) after methacholine and isoflurane, respectively) whereas reversal was only partial in Fisher rats (2.7 +/- 0.4 versus 2.1 +/- 0.3 10(9)/mm(2) after methacholine and isoflurane, respectively). Isoflurane induced a 40% increase in attachment step duration in both strains and an almost twofold increase in the CB cycle duration compared with baseline in Lewis rats. The isoflurane-induced increase in detachment step duration was less in Lewis than in Fisher rats (P < 0.05). We concluded that isoflurane modulated CB number and CB cycling rates of isolated rat ASM differently depending on the level of airway responsiveness.

 

Ohmeda 7810 呼吸機風箱漏氣對室內空氣污染、吸入氧濃度、氣道壓和潮氣量的影響。
The effect of a bellows leak in an Ohmeda 7810 ventilator on room contamination, inspired oxygen, airway pressure, and tidal volume.

Lampotang S, Sanchez JC, Chen B, Gravenstein N.
Department of Anesthesiology, University of Florida, Gainesville, FL, USA.

Anesth Analg. 2005 Jul;101(1):151-4

 

作者利用氧驅動式麻醉呼吸機(Ohmeda 7810, Madison, WI)研究了呼吸機少量風箱漏氣對吸入氧濃度(FiO2)、呼出氣潮氣量(Vt)、氣道壓和室內空氣污染的影響。利用能產生CO2的模擬肺進行機械通氣,分為有和沒有風箱漏氣兩組,設置呼吸頻率8bpm,吸/呼比12。測量呼吸閥CO2濃度、FiO2Vt和氣道壓力。設置潮氣量分別為400600800ml。新鮮氣體流量(FGF)分別為0.3L/min O2和(a5.0L/min 空氣,(b2.0L/min 空氣和(c0.2L/min 氮氣。在有或沒有風箱氣體漏氣組中以及所有FGFVt設置組中,FiO2VtPIP(吸氣峰壓)和PEEP(呼吸末正壓)均無臨床差別。而在漏氣組中呼吸閥CO2濃度始終不能歸零,表明載有CO2的循環氣體通過風箱漏氣污染風箱中的氣體。Ohmeda 78104mm漏氣口可使麻醉氣體污染周圍空氣,但對FiO2VtPIP(吸氣峰壓)和PEEP(呼吸末正壓)無明顯影響。

(吳德華譯 薛張綱校)

We investigated the effect of a small bellows leak (bellows full at end-expiration) on inspired oxygen fraction (Fio(2)), exhaled tidal volume (Vt), airway pressure, and room contamination in an oxygen-driven anesthesia ventilator (Ohmeda 7810, Madison, WI). CO(2) concentration at the ventilator exhalation valve, Fio(2), Vt, and airway pressure were measured (n = 3) while ventilating a CO(2)-producing test lung at 8 breaths/min and an inspiratory/expiratory ratio of 1:2, with and without a bellows leak (4-mm-long tear). Set Vt was 400, 600, 800, and 1000 mL. Fresh gas flow (FGF) was 0.3 L/min O(2) and (a) 5.0 L/min air, (b) 2.0 L/min air, and (c) 0.2 L/min nitrogen. There was no clinical difference in Fio(2), Vt, PIP (peak inspiratory pressure) and PEEP (positive end-expiratory pressure), with and without a 4-mm bellows tear, at all FGFs and Vt settings. CO(2) at the ventilator exhalation valve was always nonzero with a bellows leak, indicating that CO(2)-laden circuit gas was contaminating the drive gas via the bellows leak. A 4-mm bellows tear in an Ohmeda 7810 ventilator allows anesthetic gases to contaminate ambient air but does not cause clinically significant changes in Fio(2), exhaled Vt, PIP, or PEEP.

 

大鼠神經損傷後不同時間鎮痛藥藥效測試

The effect of antinociceptive drugs tested at different times after nerve injury in rats

Hama AT, Borsook D.
Descartes Therapeutics, Inc., Waltham, Massachusetts, USA.

Anesth Analg 2005 101: 175-179.

 

假設涉及神經性頭痛發展的神經系統解剖和功能發生改變,在神經性頭痛患者藥物療效不一致時這在損傷後不同時間點是可能的。現在的研究,我們評估了兩種神經性頭痛臨床治療的一線藥物在老鼠周圍神經損傷後不同時間段行為效應,即抗驚厥藥加巴噴丁 和抗抑鬱藥丙咪嗪。剩下神經已損傷的老鼠在受傷後2,4,8周時對無傷害的機械刺激下有反應(von Frey filament) 加巴噴丁在任何一個時間點呈 劑量依賴性抑止機械刺激敏感性,但是加巴噴丁 損傷後4周的藥效是損傷後28周的3倍。相反的,丙咪嗪損傷後28周缺少重要的效應,但在損傷後4周稍微削弱機械高敏感性。結果表明藥物效應在神經性狀態下隨時間改變,在評估藥物在動物疼痛模型臨床應用前期和作為暫時臨床治療方法時這應該被充分考慮。

(孫志榮譯 薛張綱校)

Given the evolving nature of anatomical and functional changes in the nervous system that are involved in the development of neuropathic pain, it is possible that the differing time course after injury underlies the inconsistent efficacy of drugs in neuropathic pain patients. In the current study, we evaluated the behavioral effects of two standard drugs used clinically for neuropathic pain, the anticonvulsant gabapentin and antidepressant imipramine, in rats at different times after peripheral nerve injury. Rats that underwent the spared nerve injury procedure responded to an innocuous mechanical stimulus (von Frey filament) 2, 4, and 8 wk after injury. Gabapentin dose-dependently suppressed mechanical sensitivity at all time points tested but the potency of gabapentin was three-fold less 4 wk postinjury (135 mg/kg) compared with 2 and 8 wk postinjury (41 and 44 mg/kg, respectively). In contrast, imipramine lacked significant efficacy at 2 and 8 wk postinjury but slightly attenuated mechanical hypersensitivity at 4 wk postinjury. The results show that drug effects may change over time in the neuropathic state, which should be an important consideration in the evaluation of drugs in preclinical animal pain models and has implications for temporal approaches to therapy in the clinic.

 

床旁運用標準監測儀器估測功能殘氣量:吸入氧濃度小改變下的改良的氮氣洗出洗入技術

Estimation of Functional Residual Capacity at the Bedside Using Standard Monitoring Equipment: A Modified Nitrogen Washout/Washin Technique Requiring a Small Change of the Inspired Oxygen Fraction

Cecilia Oleg?rd, MD*, S?ren S?ndergaard, MD, PhD*, Erik Houltz, MD, PhD, Stefan Lundin, MD, PhD*, and Ola Stenqvist, MD, PhD*.

*Department of Anesthesiology and Intensive Care and Department of Thoracic Anesthesiology, Sahlgrenska University Hospital, Gothenburg, Sweden .

Anesth Analg 2005 101: 206-212.

 

我們以吸入和呼氣末氣體濃度的標準監測為基礎設計改良了氮氣洗出洗進技術測量急性呼吸衰竭(ARF)的功能殘氣量(FRC)。我們用氧濃度在0.31.0的通氣的氧消耗肺模型來驗證這項設計。肺模型的呼吸商介於0.71.0。改變吸入氧濃度在0.10.20.3進行測量。28ARF的病人分別進行兩次測量。在肺模型中,0.1的吸入氧濃度變化引起肺模型的參考FRC值有103 ± 5% 的數值變化,在吸入氧濃度達1.0時精度也一樣好其值為103 ± 7%。在病人中,雙次測量有-5mL的偏倚95%的可信區間為[38; 29 mL ]。吸入氧濃度分別為0.10.3表現出-9mL的偏倚,限制區間為[365; 347 mL]。這個實驗顯示了用常規監測儀吸入氧濃度只在0.1的變化下FRC的測量有良好的精度。在吸入氧濃度1.0的條件下測量方法也有一樣好的精度。

(蔡美華譯 薛張綱校)

We developed a modified nitrogen washin/washout technique based on standard monitors using inspiratory and end-tidal gas concentration values for functional residual capacity (FRC) measurements in patients with acute respiratory failure (ARF). For validation we used an oxygen-consuming lung model ventilated with an inspiratory oxygen fraction (Fio2) between 0.3 and 1.0. The respiratory quotient of the lung model was varied between 0.7 and 1.0. Measurements were performed changing Fio2 with fractions of 0.1, 0.2, and 0.3. In 28 patients with ARF, duplicate measurements were performed. In the lung model, an Fio2 change of 0.1 resulted in a value of 103 ± 5% of the reference FRC value of the lung model, and the precision was equally good up to an Fio2 of 1.0 with a value of 103 ± 7%. In the patients, duplicate measurements showed a bias of –5 mL with a 95% confidence interval [–38; 29 mL ]. A comparison of a change in Fio2 of 0.1 with 0.3 showed a bias of –9 mL and limits of agreement of [–365; 347 mL]. This study shows good precision of FRC measurements with standard monitors using a change in Fio2 of only 0.1. Measurements can be performed with equal precision up to an Fio2 of 1.0.

 

兒茶酚胺加強誘導性的NO合酶的產生涉及到CAT-1CAT-2

Catecholamines' enhancement of inducible nitric oxide synthase-induced nitric oxide biosynthesis involves CAT-1 and CAT-2A.

Lin WC, Tsai PS, Huang CJ.
Department of Urology, Mackay Memorial Hospital, 92 s. 2 Chung San N. Rd., Taipei 104, Taiwan, Republic of China.
Anesth Analg. 2005 Jul;101(1):226-32.

 

LPS刺激的巨噬細胞中,兒茶酚胺能增加誘導性一氧化氮合酶,使NO產生過量。由陽離子氨基酸運載體(包括CAT-1,CAT-2,CAT-2ACAT-2B)調節的L-精氨酸轉運在iNOS合成中起關鍵性作用。我們在受刺激的巨噬細胞中研究了兒茶酚胺對L-精氨酸轉運和CAT同工酶的表達。匯合RAW264.7細胞和LPS一起同兒茶酚氨或不給予兒茶酚胺(腎上腺素或去甲腎上腺素,5*10-6M)進行培養18小時。檢測NO生成量,L-精氨酸轉運和酶的表達。資料顯示LPS同時誘導iNOSCAT-2CAT-2B的表達,而CAT-1CAT-2表達不受影響。受刺激的巨噬細胞中也發現NO產量和L-精氨酸轉運也明顯的增加(分別約為8倍和3倍)。兒茶酚胺明顯地增加了受刺激巨噬細胞中NO合成和L-精氨酸的轉運(分別幾乎30%20%)。在LPS刺激的巨噬細胞中,兒茶酚胺也增加了iNOSCAT-1CAT-2A的表達,但不影響CAT-2CAT-2B的表達。此外,兒茶酚胺的這種作用能被地塞米松或心得安抑制。我們提供的首要證據表明在受刺激的巨噬細胞中,L-精氨酸轉運能被兒茶酚胺加強。而且,這種作用可能涉及到CAT-1CAT-2A,但與CAT-2CAT-2B無關。

(吳德華譯 薛張綱校)

Catecholamines enhance inducible nitric oxide synthase (iNOS) expression that results in nitric oxide (NO) overproduction in lipopolysaccharide (LPS)-stimulated macrophages. L-arginine transport mediated by cationic amino acid transporters (including CAT-1, CAT-2, CAT-2A, and CAT-2B) is crucial in regulating iNOS activity. We sought to assess the effects of catecholamines on L-arginine transport and CAT isozyme expression in stimulated macrophages. Confluent RAW264.7 cells were cultured with LPS with or without catecholamines (epinephrine or norepinephrine, 5 x 10(-6) M) for 18 h. NO production, L-arginine transport, and enzyme expression were determined. Our data revealed that LPS co-induced iNOS, CAT-2, and CAT-2B expression, whereas CAT-1 and CAT-2A expression remained unaffected. Significant increases in NO production and L-arginine transport (approximately eight-fold and three-fold increases, respectively) were found in activated macrophages. Catecholamines significantly enhanced NO production and L-arginine transport (approximately 30% and 20% increases, respectively) in activated macrophages. Catecholamines also enhanced the expression of iNOS, CAT-1, and CAT-2A but not CAT-2 or CAT-2B in LPS-stimulated macrophages. Furthermore, the enhancement effects of catecholamines were inhibited by either dexamethasone or propranolol. We provide the first evidence to indicate that L-arginine transport in activated macrophages could be enhanced by catecholamines. Furthermore, this catecholamine-enhanced L-arginine transport might involve CAT-1 and CAT-2A but not CAT-2 or CAT-2B.

 

麻醉中的過失與疏忽:一項使用試驗性檢查目錄的實驗性研究

Errors and omissions in anesthesia: a pilot study using a pilot's checklist.

Hart EM, Owen H.

Flinders Clinical Skills and Simulation Unit, Flinders University Department of Anesthesia and Intensive Care, Flinders Medical Centre, Bedford Park, SA 5042, Australia.

Anesth Analg. 2005 Jul;101(1):246-50

 

近來麻醉醫師在為剖腹產分娩實施全麻時變得更不熟練成為關注的焦點。我們考慮一項口頭的檢查目錄是否有助於其準備工作。根據專家的建議,我們為剖腹產分娩實施全麻建立了一個需要檢查的專案目錄。這一目錄被放入一個帶有聲音提醒的電子檢查目錄系統中, 20個麻醉醫師通過一個高度靈敏的麻醉模擬器進行試驗。在40個檢查項目中,參與者忽視檢查的項目平均達13個(範圍為7-23個)。通常忽視的專案包括沒有檢查用於困難插管的推車是否備好及沒有使病人的頭處於最合適的位置。多數(95%)參與者感覺此檢查目錄是有用的,80%的參與者願意在模擬試驗中使用它;60%的參與者選擇書面的檢查目錄而40%選擇口頭目錄。準備為剖腹產分娩實施全麻時一些重要的檢查可能會被遺忘,而使用一個檢查目錄可能會提高病人的安全性。

(周曉敏 薛張綱 校)

There are recent concerns that anesthesiologists are becoming less skilled in providing general anesthesia for Cesarean delivery. We considered whether a verbal checklist would help in the preparation for this event. We created a list of items to be checked when preparing to administer general anesthesia for a Cesarean delivery using expert opinion. This list was loaded onto an electronic checklist system with voice prompts and tested on 20 anesthesiologists using a high-fidelity anesthesia simulator. Participants omitted to check a median of 13 (range, 7-23) of 40 items. Common omissions included not checking that the difficult intubation trolley was available and not optimizing the patient's head position. Most (95%) participants felt that the checklist was useful and 80% would like to use it for practicing simulated scenarios; 60% preferred a written checklist and 40% preferred the verbal checklist. Important checks may be forgotten when preparing to give a general anesthetic for Cesarean delivery, and the use of a checklist could improve patient safety.

 

兔硬膜外止痛法預防內毒素誘導的腸粘膜損傷

Epidural analgesia prevents endotoxin-induced gut mucosal injury in rabbits.
Kosugi S, Morisaki H, Satoh T, Ai K, Yamamoto M, Soejima J, Serita R, Kotake Y, Ishizaka A, Takeda J.
Department of Anesthesiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
Anesth Analg. 2005 Jul;101(1):265-72.


通過此研究,我們評價在兔身上實施硬膜外止痛法而改變腸道對內毒素屏障作用。放置硬膜外導管後,通過硬膜外導管,28只雄兔被隨機注射0.5% 的利多卡因(E組)或生理鹽水(C組)。總量為0.4 mL/kg ,以0.1 mL . kg(-1) . h(-1)持續輸注。在以15 microg . kg(-1) . h(-1) 連續輸注脂多糖時,測定平均動脈壓、粘膜內PH值及血漿血栓調節素濃度。在4小時內,平均動脈壓下降(P < 0.05), 粘膜內PH值增高(P < 0.01), E組與C組相比,血液被極大的稀釋 (P < 0.05) ,而兩組的血栓調節素水平上升程度相似。隨著回腸濕幹比的下降,E組的腸粘膜組織病理學損傷痕跡明顯小於重C (P < 0.01)。在一系列獨立的實驗中(每組N>10E組的粘膜通透性明顯小於重C (P < 0.05)。綜上所述,雖然灌注壓和動脈血氧含量顯著下降,但硬膜外止痛法使內毒素誘導的腸粘膜組織和功能損傷降到最小,可能的機制為內皮獨立機制。

(孫少瀟譯 薛張綱校)

In the present study, we evaluated the effect of epidural analgesia on the alterations of gut barrier function elicited by endotoxin in rabbits. After the placement of an epidural catheter, 28 male rabbits were randomized into either 0.5% lidocaine (group E) or saline (group C) group. The solutions (0.4 mL/kg) were epidurally injected, followed by continuous infusion (0.1 mL . kg(-1) . h(-1)) throughout the study period. Under a continuous infusion of lipopolysaccharide (15 microg . kg(-1) . h(-1)), mean arterial blood pressure, intramucosal pH, and plasma thrombomodulin concentrations were measured. At 4 h, mean arterial blood pressure was lower (P < 0.05), intramucosal pH was higher (P < 0.01), and the progression of hemodilution more profound (P < 0.05) in group E versus group C, whereas plasma thrombomodulin levels were increased to a similar extent between the groups. With less wet-to-dry weight ratio of ileum, histopathological injury scores of gut mucosa were significantly less in group E versus group C (P < 0.01). In a separate series of experiments (n = 10 each group), mucosal permeability in group E was significantly less compared with group C (P < 0.05). Collectively, these studies showed that despite a significant decrease of perfusion pressure and arterial oxygen content, epidural analgesia minimized endotoxin-induced functional and structural injury of gut mucosa possibly through endothelium-independent mechanisms.

 

磺酸甘葡環烴鈉漱口減少氣管插管引起的術後咽喉潰瘍

Gargling with sodium azulene sulfonate reduces the postoperative sore throat after intubation of the trachea.
Ogata J
, Minami K, Horishita T, Shiraishi M, Okamoto T, Terada T, Sata T.
Department of Anesthesiology, University of Occupational and Environmental Health School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu, Fukuoka 807-8555, Japan.
Anesth Analg. 2005 Jul;101(1):290-3.

 

術後咽喉潰瘍是一項仍未解決的氣管插管術後併發症。在此試驗中,我們研究了磺酸甘葡環烴鈉對減少氣管插管術後咽喉潰瘍的作用。40個行全麻的擇期術後病人被隨機分配到甘葡環烴組和對照組。在甘葡環烴組,病人用40 microg/mL 的甘葡環烴稀釋液100 mL漱口。在對照組,病人用自來水100 mL漱口。計數全麻後出現的術後咽喉潰瘍,並用口述類比疼痛尺規法進行評價。兩組的年齡、身高、體重、性別、麻醉和手術時間沒有明顯區別。在對照組,13個病人(65%) 主訴有術後咽喉潰瘍,其中9(45%)持續24小時。在甘葡環烴組,5(25%) 主訴有術後咽喉潰瘍,但都於24小時後消失。甘葡環烴組的術後咽喉潰瘍發生率和口述類比疼痛尺規法評分明顯低於對照組。我們證實甘葡環烴漱口是減輕術後咽喉潰瘍病有效而無副作用的方法。

(孫少瀟譯 薛張綱校)

Postoperative sore throat (POST) is a complication that remains to be resolved in patients undergoing endotracheal intubation. In this study, we investigated whether preoperative gargling with sodium 1,4-dimethyl-7-isopropylazulene-3-sulfonate monohydrate (sodium azulene sulfonate, Azunol) reduces POST after endotracheal intubation. Forty patients scheduled for elective surgery under general anesthesia were randomized into Azunol and control groups. In the Azunol group, patients gargled with 4 mg Azunol diluted with 100 mL tap water (40 microg/mL). In the control group, patients gargled with 100 mL of tap water. After emergence from general anesthesia, the patients with POST were counted and POST was evaluated using a verbal analog pain scale. There were no significant differences between the two groups by age, height, body weight, gender distribution, or duration of anesthesia and surgery. In the control group, 13 patients (65%) complained of POST, which remained 24 h later in nine patients (45%). In the Azunol group, five patients (25%) also complained of POST, which completely disappeared by 24 h later. The incidence of POST and verbal analog pain scale scores in the Azunol group decreased significantly compared with the control group. We demonstrated that gargling with Azunol effectively attenuated POST with no adverse reactions.

米力農及考福新減弱兔腹主動脈阻斷松夾後軟腦膜小動脈的持續收縮

Both Milrinone and Colforsin Daropate Attenuate the Sustained Pial Arteriolar Constriction Seen After Unclamping of an Abdominal Aortic Cross-Clamp in Rabbits

Masayoshi Uchida, MD*, Hiroki Iida, MD{dagger}, Mami Iida, MD{ddagger}, Masahiko Kumazawa, MD{dagger}, Kazuyuki Sumi, MD{dagger}, Motoyasu Takenaka, MD{dagger}, and Shuji Dohi, MD{dagger}

* Department of Anesthesia, Chubu Rosai Hospital; {dagger}Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine; {ddagger}Department of Cardiology, Gifu University Graduate School of Medicine, and Department of Nutrition and Food Science, Faculty of Economics, Gifu Women’s University, Gifu, Japan

Anesth Analg 2005;101:9-16

 

以前我們曾報導了腹主動脈阻斷鉗松夾可引起軟腦膜內動脈先擴張隨後持續收縮。米力農及考福新均有血管擴張作用,並且都已用於如腹主動脈瘤切除術這些危重的情況。我們事先在兔的頭顱上準備好一個封閉的顱骨窗,在靜脈開始輸注0.9%鹽水(對照組)、米力農或考福新(0.050.5 µg · kg–1 · min–1)之前(基線)及輸注開始後15 min(主動脈夾閉前)、主動脈夾閉後即刻、夾閉後20 min、及松夾後060 min的時候監測軟腦膜小動脈的直徑。在對照組,松夾後動脈直徑明顯變小,持續至少60min(與基礎值相比,最大的變化,大動脈比基礎值下降15%,小動脈下降26%)。這些數值在注入兩個劑量的米力農及大劑量的考福新後明顯減小(在 60 min時分別與基礎值相比,–5% –8%, 10% 12%, –2% –5%)。在第二個實驗中,顱內局部血流及組織氧分壓的變化反映了血管參數的變化。因此,IV米力農及考福新可減弱由腹主動脈阻斷松夾引起的軟腦膜小動脈的持續性收縮

(裘毅敏 李士通 校)

We previously reported that unclamping of an abdominal aortic cross-clamp causes initial dilation of pial arteries followed by sustained constriction. Both milrinone and colforsin daropate have a vasodilator action, and both have been used in such critical conditions as abdominal aortic aneurysmectomy. We measured cerebral pial arteriolar diameters using a rabbit closed cranial window preparation before (baseline) and 15 min after the start of an IV infusion of 0.9% saline (control group), milrinone, or colforsin daropate (0.05 and 0.5 µg · /kg–1 · min–1) (pre-clamp), just after aortic clamping, 20 min after clamping, and at 0 to 60 min after unclamping. In the control group, a significant decrease in diameter persisted for at least 60 min after unclamping (maximum, –15% for large and –26% for small arterioles versus baseline). These values were significantly smaller after both doses of milrinone and the larger dose of colforsin daropate (–5% and –8%, 10% and 12%, and –2% and –5%, respectively vs baseline, at 60 min). In a second experiment, changes in regional cerebral blood flow and tissue oxygen tension reflected changes in vascular variables. Thus, sustained cerebral pial arteriolar constriction induced by aortic unclamping can be attenuated by IV milrinone or colforsin daropate.


比較活體供肝和屍體供肝移植的輸液需要量:與終末期肝病評分模型和基礎凝血狀態的關係

A Comparison of Transfusion Requirements Between Living Donation and Cadaveric Donation Liver Transplantation: Relationship to Model of End-Stage Liver Disease Score and Baseline Coagulation Status

Peter E. Frasco, MD, Karl A. Poterack, MD, Joseph G. Hentz, MS, and David C. Mulligan, MD

Departments of Anesthesiology and Transplant Surgery, Mayo Clinic College of Medicine, Mayo Clinic Scottsdale, Arizona

Anesth Analg 2005;101:30-37

 

用活體供肝對需要肝移植的患者來說是一項重要的選擇。我們回顧了3年的時間裏(2001-200427例活的供肝移植和69例屍體供肝移植病人術前終末期肝病模型(MELD)評分、基礎凝血實驗室結果及術中紅血球和血液成分治療的輸注。與接受屍體供肝移植的患者相比,接受活體供肝移植的患者的MELD評分顯著較低,凝血功能好(P<0.001)。活供肝移植患者接受的紅血球和血成分治療的輸注也顯著少於屍體供肝移植患者(P<0.001)。合併屍體供肝移植和活供肝移植的所有患者進行分析發現,MELD評分和術前凝血試驗(P<0.001)與術中紅細胞和血液成分治療的輸注之間的相關性顯著。認為MELD評分和術前纖維蛋白原濃度是需要輸血的獨立預計因素。結論,我們發現移植時的疾病嚴重程度、凝血功能受損程度和輸紅血球和血液成分治療的需要量在接受活供肝移植的患者與接受屍體供肝移植的患者之間有顯著差異。

(馬皓琳 李士通 校)

The use of living donation is an important option for patients in need of liver transplant. We retrospectively reviewed the preoperative Model for End-Stage Liver Disease (MELD) score, baseline coagulation laboratory results, and intraoperative transfusion of red blood cells and component therapy for 27 living donation transplants and 69 cadaveric donation transplants during a 3-yr period (2001–2004). Patients undergoing living donation transplantation had significantly lower MELD scores and preserved coagulation function compared with cadaveric donation transplantation recipients (P < 0.001). The living donation transplant patients also received significantly fewer transfusions of red blood cells and component therapy compared with the cadaveric donation transplant patients (P < 0.001). For the combined population of both cadaveric donation transplant and living donation transplant patients, there were significant associations between MELD score and preoperative coagulation tests (P < 0.001) and intraoperative transfusion of blood and component therapy. MELD score and preoperative fibrinogen concentration were identified as independent predictors of transfusion exposure. In conclusion, we detected significant differences in severity of disease at time of transplantation, degree of impairment of coagulation function, and need for transfusion of red blood cells and component therapy between patients undergoing living donation transplantation compared with patients undergoing cadaveric donation transplantation.

 

 

糖溶液的鎮痛:葡萄糖對表達的阿片類μ受體的作用

Sugar Solution Analgesia: The Effects of Glucose on Expressed Mu Opioid Receptors

George R. Kracke, PhD*, Katherine A. Uthoff, BS*, and Joseph D. Tobias, MD*{dagger}

Departments of *Anesthesiology and Perioperative Medicine and {dagger}Child Health, University of Missouri School of Medicine, Columbia

Anesth Analg 2005;101:64-68

 

口服葡萄糖或蔗糖溶液對新生兒手術疼痛提供有效的鎮痛作用。鑒於阿片受體拮抗劑可削弱糖溶液的這一鎮痛作用,我們檢驗了葡萄糖能直接激動阿片受體的假設。將μ受體(MOR-1)表達於蟾蜍卵母細胞這一公認的表達系統,然後檢驗葡萄糖對受體可能的激動、拮抗和調節作用。結果為對照實驗中, 10 nM Tyr-D-Ala-Gly-Me-Phe-Gly-ol (DAMGO)(一種人工合成的腦啡肽,為μ受體特異性激動劑)可激動MOR-1;而20 mM的葡萄糖卻並沒有作用。並且,葡萄糖對DAMGO激動 MOR-1的效應無任何影響。最後,葡萄糖對DAMGO所致的急性受體脫敏感也不產生任何調節作用。我們得出結論,在體外表達系統中,葡萄糖對阿片類μ受體不產生直接作用;葡萄糖和阿片系統之間所表現的相互關係可能是涉及內源性阿片類釋放的間接作用。

(周志堅 李士通 校)

Glucose or sucrose solutions administered orally provide effective analgesia for procedural pain in neonates. Because analgesia with sugar solutions can be decreased by opioid receptor antagonists, we tested the hypothesis that glucose directly activates opioid receptors. Mu opioid receptors (MOR-1) were expressed in Xenopus oocytes, a well recognized expression system, and glucose was tested for possible agonist, antagonist, and modulatory effects on the receptor. In control experiments, 10 nM of Tyr-D-Ala-Gly-Me-Phe-Gly-ol (DAMGO), a synthetic enkephalin and specific mu agonist, activated the MOR-1, whereas 20 mM of glucose had no effect. In addition, glucose had no effect on the activation of the mu receptor by DAMGO. Finally, glucose did not modulate acute receptor desensitization induced by DAMGO. We conclude that glucose does not directly interact with MOR-1 in an in vitro expression system and that the purported interaction between glucose and the opioid system may be an indirect one, involving release of endogenous opioids.

 

圍手術期羅非考西複合局麻藥區域阻滯可減少門診腹股溝疝修補術病人的疼痛及恢復時間

Perioperative Rofecoxib Plus Local Anesthetic Field Block Diminishes Pain and Recovery Time After Outpatient Inguinal Hernia Repair

Dorothy J. Pavlin, MD, Edward G. Pavlin, MD, Karen D. Horvath, MD, Laurie B. Amundsen, MD, David R. Flum, MD, MPH, and Kristine Roesen, BA

Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington

Anesth Analg 2005;101:83-89

 

在這項研究中,我們比較了三組腹股溝疝修補術後病人的疼痛評分:實驗組在切皮前行局麻藥區域阻滯(PL)或PL複合圍術期羅非考西;對照組接受常規標準化治療。75例在全麻下行腹股溝疝修補術的病人隨機分配至三組,第一組在術前及術後五天服用安慰劑藥丸(CONT組),第二組在術前行布比卡因區域阻滯和圍術期服用安慰劑(PL組),第三組在術前行區域阻滯加上術前及術後五天口服羅非考西50mgPLR組)。所有病人關腹時均在傷口處給予布比卡因局部浸潤,並在術後靜脈注射芬太尼和撲熱息痛/羥考酮。用方差分析比較出院時間、疼痛評分(010),止痛劑的使用量及滿意度評分(16)。和CONT組相比,PLR組病人在麻醉後監護病房裏(3.75.3, P = 0.02)及術後24小時時(5.36.8, P = 0.03)的最高疼痛評分(最痛)都比較低,並且早38分鐘出院(P = 0.01),出院後024小時期間羥考酮的用量也減少28%。PL組的疼痛30分鐘內比CONT組要輕。手術24小時以後三組間無顯著差異。我們可以得出結論:圍手術期羅非考西複合PL可減少住院恢復時間,減少疼痛評分及阿片類藥物的使用,並能提高術後24小時內的滿意度評分。

(黃佳佳 李士通 校)

In this study, we compared pain scores after inguinal herniorrhaphy in patients treated by preincisional local anesthetic field block (PL), or PL combined with perioperative rofecoxib, with controls who received standard care. Seventy-five patients having herniorrhaphy under general anesthesia were randomly assigned to receive a placebo pill preoperatively, and for 5 days postoperatively (CONT); preoperative bupivacaine field block and perioperative placebo (PL); preoperative field block plus rofecoxib, 50 mg preoperatively and for 5 days postoperatively (PLR). Bupivacaine infiltration in the wound at closure, IV fentanyl and acetaminophen/oxycodone were administered postoperatively to all. Discharge time, pain scores (0–10), analgesic use, and satisfaction scores (1–6) were compared using analysis of variance. PLR patients had lower maximum pain scores (worst pain) in the postanesthesia care unit (3.7 versus 5.3, P = 0.02) and at 24 h (5.3 versus 6.8, P = 0.03), were discharged 38 min sooner (P = 0.01), required 28% less oxycodone 0–24 h after discharge (P = 0.04), and reported higher satisfaction scores compared with CONT. Pain in PL was less than CONT for 30 min. There were no differences among the 3 groups after 24 h postoperatively. We conclude that perioperative rofecoxib with PL reduces in-hospital recovery time, decreases pain scores and opioid use, and improves satisfaction scores in the first 24 h after surgery.

 

兔神經根進入區十分容易受鞘內丁卡因的損害

The Nerve Root Entry Zone Is Highly Vulnerable to Intrathecal Tetracaine in Rabbits

Shuichi Kaneko, MD, Mishiya Matsumoto, MD, Shunsuke Tsuruta, MD, Takao Hirata, MD, Toshikazu Gondo, MD, and Takefumi Sakabe, MD

Departments of Anesthesiology-Resuscitology and Surgical Pathology, Yamaguchi University School of Medicine, Yamaguchi, Japan

Anesth Analg 2005;101:107-114

 

據推測,脊髓的神經根進入區(也稱為Obersteiner-Redlich區)可能對鞘內使用的高濃度局麻藥更敏感。不過,尚無此方面形態學的依據。本研究中,我們在給兔鞘內使用丁卡因後檢查了神經根進入區神經纖維的形態學變化。兔被分為4組(每組6只),分別接受鞘內注射0.3mL的生理鹽水(對照)或1%、2%或4%的丁卡因。用藥後1周時進行神經學和組織病理學的評估。1%丁卡因組儘管不能檢測到神經學上的功能障礙,但選擇性地損傷位於腹側和背側神經根的進入區由少突膠質細胞組成的髓鞘。應用2%和4%的丁卡因,組織病理的損傷延伸至背側纖維、神經根的末梢部分及馬尾;同時神經學的功能障礙變得明顯。這些結果證實神經根進入區由少突膠質細胞組成的髓鞘十分容易受到鞘內使用的高濃度丁卡因的損害。

(黃施偉 李士通 校)

It has been speculated that the nerve root entry zone in the spinal cord, known as the Obersteiner-Redlich zone, may be more sensitive to large concentrations of local anesthetics administered intrathecally. However, there has been no morphological evidence for this. In the present study, we examined morphological changes of nerve fibers at the nerve root entry zone after administration of intrathecal tetracaine in rabbits. Rabbits were assigned to 4 groups (n = 6 in each) and received intrathecal 0.3 mL saline (control), or 1%, 2%, or 4% tetracaine. Neurological and histopathological assessments were performed 1 wk after the administration. Tetracaine 1% selectively injured the myelin sheaths made by oligodendrocytes at the nerve root entry zones of both ventral and dorsal roots, although neurological dysfunction could not be detected. With tetracaine 2% and 4%, histopathological damage extended to the dorsal funiculus, distal part of roots, and cauda equina and neurological dysfunction became apparent. These results demonstrate that the myelin sheaths made by oligodendrocytes at the nerve root entry zone are highly vulnerable to large concentrations of tetracaine given intrathecally.

 

雙頻指數指導下的異丙酚麻醉中雷米芬太尼抑制氣管插管和切皮時的心血管反應的效應部位濃度

The Effect-Site Concentration of Remifentanil Blunting Cardiovascular Responses to Tracheal Intubation and Skin Incision During Bispectral Index-Guided Propofol Anesthesia

Andrea Albertin, MD, Andrea Casati, MD, Lombardo Federica, MD, Valeri Roberto, MD, Vittorino Travaglini, MD, Piercarlo Bergonzi, MD, and Giorgio Torri, MD

Department of Anesthesiology-IRCCS H. San Raffaele, Vita-Salute University of Milano, Milan, Italy

Anesth Analg 2005;101:125-130

 

我們在雙頻指數(BIS)指導下的異丙酚麻醉時,測定雷米芬太尼抑制氣管插管和切皮時的交感神經反應的效應部位濃度。41例進行腹部大手術、ASA I-II級、年齡20-65歲的病人,隨機分成兩組:氣管插管組(組TIn = 20)和切皮組(組 SI, n = 21)。所有的病人接受靶控輸注異丙酚4 µg/mL,調節輸注速度使BIS維持在40-50範圍之間。用上下序貫試驗法測定雷米芬太尼阻斷50%病例對氣管插管和切皮的交感神經反應的效應部位濃度(Ce50)TI組的雷米芬太尼Ce50平均值(95%可信區間[CI]) 5.0 ng/mL (95% CI, 4.7–5.4 ng/mL)SI 組是2.1 ng/mL(95% CI, 1.4–2.8 ng/mL)。此項研究顯示,合併使用BIS指導下的靶控輸注異丙酚時,5 ng/mL2 ng/mL的雷米芬太尼效應部位濃度能有效抑制50%病人對氣管插管和切皮的交感神經反應。

(張曦 李士通 校)

We sought to determine the effect-site concentration of remifentanil blunting sympathetic responses to tracheal intubation and skin incision during bispectral index (BIS)-guided propofol anesthesia. Forty-one ASA physical status I–II patients, aged 20–65 yr and undergoing major abdominal surgery, were randomly assigned to one of two groups: tracheal intubation (group TI, n = 20) or skin incision (group SI, n = 21). All patients received a target-controlled infusion of propofol of 4 µg/mL, which was then adjusted to maintain a BIS value ranging between 40 and 50. The effect-site concentration of remifentanil blocking the sympathetic responses to tracheal intubation and skin incision in 50% of cases (Ce50) was determined using an up-and-down sequential allocation method. The mean (95% confidence interval [CI]) Ce50 of remifentanil was 5.0 ng/mL for TI (95% CI, 4.7–5.4 ng/mL) and 2.1 ng/mL for SI (95% CI, 1.4–2.8 ng/mL). This study shows that effect-site concentrations of remifentanil of 5 ng/mL and 2 ng/mL are effective in blunting sympathetic responses to tracheal intubation and skin incision in 50% of patients when combined with a BIS-guided target controlled infusion of propofol.


三種吸入麻醉藥對GluR6(海人藻酸) 受體基因突變小鼠的作用

The Effect of Three Inhaled Anesthetics in Mice Harboring Mutations in the GluR6 (Kainate) Receptor Gene

James M. Sonner, MD, Bryce Vissel, PhD, Gordon Royle, PhD, Anya Maurer, BS, Diane Gong, BS, Nicole V. Baron, MD, Neil Harrison, PhD, Michael Fanselow, PhD, and Edmond I. Eger, II, MD

Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; The Garvan Institute of Medical Research, Sydney, Australia; Molecular Neurobiology Laboratory, The Salk Institute for Biological Studies, La Jolla, California; Department of Anesthesiology, C.V Starr Laboratory for Molecular Neuropharmacology, Weill Medical College of Cornell University, New York, New York; and Psychology Department, University of California, Los Angeles, California

Anesth Analg 2005;101:143-148

 

GluR5-GluR7KA1 KA2亞單位共同組成海人藻酸受體——離子型興奮性谷氨酸受體的一種亞型。 異氟醚可增強表達於卵母細胞上含GluR6亞單位的海人藻酸受體的作用。為驗證GluR6亞單位基因改變是否會影響吸入麻醉藥的在體作用,本實驗選取敲除GluR6的小鼠(即缺乏海人藻酸受體亞單位GluR6的小鼠)和GluR6修飾突變株小鼠(此種小鼠在GluR6受體膜2區存在顯性的谷氨酸/精氨酸陰性的修飾突變(O/R突變),此種突變增加含GluR6Q的海人藻酸受體鈣離子的通透性),測定兩組小鼠地氟醚、異氟醚和氟烷的最小肺泡濃度。同時測定異氟醚干擾對音調和伴存恐嚇的巴甫洛夫條件反射的能力。缺乏GluR6亞單位不改變異氟醚、地氟醚或氟烷的最小肺泡濃度。這可能是由於構成海人藻酸受體的其他海人藻酸受體亞單位代償了缺乏的GluR6的作用,故最小肺泡濃度仍正常。O/R突變明顯影響含GluR6亞單位的海人藻酸受體,可增加小鼠異氟醚的最小肺泡濃度(增加12%;P < 0.01,減少地氟醚的最小肺泡濃度(減少18%;P < 0.001),但並不改變氟烷的最小肺泡濃度(P0.25)。這些資料可以表明含GluR6Q亞單位的海人藻酸受體直接或間接有差別地調節吸入麻醉藥制動的機制。研究表明GluR6基因突變不影響異氟醚干擾驚恐條件反射的能力。

(周雅春 李士通 校)

Combinations of GluR5-GluR7, KA1, and KA2 subunits form kainate receptors, a subtype of excitatory ionotropic glutamate receptors. Isoflurane enhances the action of kainate receptors comprising GluR6 subunits expressed in oocytes. To test whether alterations of the GluR6 subunit gene affect the actions of inhaled anesthetics in vivo, we measured the minimum alveolar concentration of desflurane, isoflurane, and halothane in mice lacking the kainate receptor subunit GluR6 (GluR6 knockout mice) and mice with a dominant negative glutamine/arginine (Q/R) editing mutation in membrane domain 2 of the GluR6 receptor (GluR6 editing mutants), which increases the calcium permeability of kainate receptors containing GluR6Q. We also measured the capacity of isoflurane to interfere with Pavlovian fear conditioning to a tone and to context. Absence of the GluR6 subunit did not change the minimum alveolar concentration of isoflurane, desflurane, or halothane. Possibly, kainate receptors assembled from the remaining kainate receptor subunits compensate for the absent subunits and thereby produce a normal minimum alveolar concentration. A Q/R mutation that dominantly affects kainate receptors containing the GluR6 subunit in mice increased isoflurane minimum alveolar concentration (by 12%; P < 0.01), decreased desflurane minimum alveolar concentration (by 18%; P < 0.001), and did not change halothane minimum alveolar concentration (P = 0.25). These data may indicate that kainate receptors containing GluR6Q subunits differently modulate, directly or indirectly, the mechanism by which inhaled anesthetics cause immobility. The mutations of GluR6 that were studied did not affect the capacity of isoflurane to interfere with fear conditioning.


大鼠胸段蛛網膜下腔置管術的改良步驟

An Improved Procedure for Catheterization of the Thoracic Spinal Subarachnoid Space in the Rat

Y. Y. Poon, MD*{dagger}{ddagger}, Alice Y. W. Chang, PhD{dagger}, S. F. Ko, MD§, and Samuel H. H. Chan, PhD{dagger}

*Graduate Institute of Clinical Medicine and Science, Chang Gung University, Kaohsiung; {dagger}Center for Neuroscience, National Sun Yat-sen University, Kaohsiung; and Departments of {ddagger}Anesthesiology and §Radiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, Republic of China

Anesth Analg 2005;101:155-160

 

蛛網膜下腔置管為動物實驗中脊髓給藥或是收集腦脊液提供了一個便利的途徑,並且已經有助於我們理解為麻醉、鎮痛以及心血管調節提供理論基礎的脊髓機制。這些年得到的經驗揭示了這項技術的幾個缺點。我們報導的這種置管術包括了大鼠胸脊髓段直接蛛網膜下腔置管的益處,而摒棄了已知的缺陷。鞘內導管是一端有一個小矽珠子的PE10導管,與作為引導的4/0 縫線一起插入。用縫線引導器的L形鉤作為固定物,進導管入蛛網膜下腔,直到矽珠嵌進T13椎骨椎板上的鑽孔(2 x 2 mm)。我們改良過的大鼠胸段蛛網膜下腔置管術與以往報導過的方法相比較:手術創傷較少,導管放置得更精確且固定得更穩固,腦脊液漏較少,發病率或病死率最低。

(黃麗娜    李士通  校)

Catheterization of the subarachnoid space provides a convenient means to deliver drugs to, or collect cerebrospinal fluid from, the spinal cord in animal experiments, and has been instrumental to our understanding of spinal mechanisms that underlie anesthesia, analgesia, or cardiovascular regulation. Experience gained over the years has revealed several shortcomings of this technique. We report a procedure that encompasses the benefits of direct subarachnoid catheterization of the rat thoracic spinal cord but circumvents the known shortcomings. An intrathecal catheter was fabricated with a small silicon bead at one end of a PE-10 catheter, which was cannulated with a 4/0 suture that served as a guide. Using the L-shape hook of the suture guide as an anchorage, the catheter was advanced into the subarachnoid space until the silicon bead was lodged on a drilled hole (2 x 2 mm) over the lamina proper on the T13 vertebrae. With less surgical trauma, greater precision of placement and firmer anchorage of the catheter, less leakage of cerebrospinal fluid, and minimal mortality or morbidity, our modified procedure for catheterization of the thoracic spinal subarachnoid space in the rat compared favorably to previously reported methods.


曲馬多代謝物O-去甲基曲馬多在表達 M1 M3克隆受體的蟾蜍卵母細胞中對 毒蕈堿受體引起的反應的影響

The Effects of the Tramadol Metabolite O-Desmethyl Tramadol on Muscarinic Receptor-Induced Responses in Xenopus Oocytes Expressing Cloned M1 or M3 Receptors

Motohiro Nakamura, MD*, Kouichiro Minami, MD, PhD*, Yasuhito Uezono, MD, PhD{dagger}, Takafumi Horishita, MD, PhD*, Junichi Ogata, MD, PhD*, Munehiro Shiraishi, MD, PhD*, Takashi Okamoto, MD*, Tadanori Terada, MD*, and Takeyoshi Sata, MD, PhD*

*Department of Anesthesiology, University of Occupational and Environmental Health School of Medicine, Kitakyushu, Japan; and {dagger}Department of Pharmacology, Nagasaki University Graduate School of Biomedical Sciences, Japan

Anesth Analg 2005;101:180-186

 

O-去甲基曲馬多是曲馬多的一種主要代謝物。它已廣泛應用於臨床,有鎮痛效應。毒蕈堿受體參與腦和自主神經系統中的神經元功能,人們對這些受體作為鎮痛藥在中樞神經系統內的靶位元給予了廣泛關注。我們已報導曲馬多抑制1型毒蕈堿(M1 受體和3型毒蕈堿(M3 受體的功能,提示毒蕈堿受體是曲馬多的作用位點。可是O-去甲基曲馬多對毒蕈堿受體功能的作用至今還沒有詳細研究。本研究使用蟾蜍卵母細胞表達系統觀察了O-去甲基曲馬多對M1 受體和M3 受體功能的影響。O-去甲基曲馬多(0.1100  µM)抑制表達M1 受體的卵母細胞中乙酰膽鹼(Ach)引起的電流(半量最大抑制濃度為[IC50] = 2 ± 0.6 µM),而它不抑制表達M3 受體的卵母細胞中Ach引起的電流。儘管蛋白激酶C抑制劑GF109203X能增加Ach引起的電流,但它對O-去甲基曲馬多抑制表達M1 受體電流的卵母細胞中Ach引起的電流的作用幾乎無影響。當Ach濃度增高時O-去甲基曲馬多對M1 受體的抑制作用被克服(O-去甲基曲馬多的KD= 0.3 µM)。O-去甲基曲馬多抑制[3H] 二苯乙醇酸奎寧環酯([3H]QNB)與卵母細胞上表達的M1 受體的特異結合(IC50 = 10.1 ± 0.1 µM),而不抑制[3H]QNB與卵母細胞上表達的M3 受體的特異結合。根據上述結果,O-去甲基曲馬多抑制M1 受體的功能,而對M3 受體的功能影響甚微。本研究顯示了O-去甲基曲馬多對受體分子水平的作用,這將有助於解釋它的神經系統作用。

(邱鬱薇 李士通 校)

 

O-desmethyl tramadol is one of the main metabolites of tramadol. It has been widely used clinically and has analgesic activity. Muscarinic receptors are involved in neuronal functions in the brain and autonomic nervous system, and much attention has been paid to these receptors as targets for analgesic drugs in the central nervous system. We have reported that tramadol inhibits the function of type-1 muscarinic (M1) receptors and type-3 muscarinic (M3) receptors, suggesting that muscarinic receptors are sites of action of tramadol. However, the effects of O-desmethyl tramadol on muscarinic receptor functions have not been studied in detail. In this study, we investigated the effects of O-desmethyl tramadol on M1 and M3 receptors, using the Xenopus oocyte expression system. O-desmethyl tramadol (0.1–100 µM) inhibited acetylcholine (ACh)-induced currents in oocytes expressing the M1 receptors (half-maximal inhibitory concentration [IC50] = 2 ± 0.6 µM), whereas it did not suppress ACh-induced currents in oocytes expressing the M3 receptor. Although GF109203X, a protein kinase C inhibitor, increased the ACh-induced current, it had little effect on the inhibition of ACh-induced currents by O-desmethyl tramadol in oocytes expressing M1 receptors. The inhibitory effect of O-desmethyl tramadol on M1 receptor was overcome when the concentration of ACh was increased (KD with O-desmethyl tramadol = 0.3 µM). O-desmethyl tramadol inhibited the specific binding of [3H]quinuclidinyl benzilate ([3H]QNB) to the oocytes expressed M1 receptors (IC50 = 10.1 ± 0.1 µM), whereas it did not suppress the specific binding of [3H]QNB to the oocytes expressed M3 receptors. Based on these results, O-desmethyl tramadol inhibits functions of M1 receptors but has little effect on those of M3 receptors. This study demonstrates the molecular action of O-desmethyl tramadol on the receptors and may help to explain its neural function.

 

 

絲氨酸蛋白酶抑制劑在酸誤吸和高氧後維持固有超氧化物歧化酶水平,但不能減少肺損傷

Serine Antiproteinase Administration Preserves Innate Superoxide Dismutase Levels After Acid Aspiration and Hyperoxia but Does Not Decrease Lung Injury

 

Nader D. Nader, MD, PhD*, Bruce A. Davidson, BS*, Alan R. Tait, PhD§, Bruce A. Holm, PhD{ddagger}, and Paul R. Knight, MD, PhD*{dagger}

Departments of *Anesthesiology, {dagger}Microbiology, and {ddagger}Pharmacology, State University of New York at Buffalo; and §Department of Anesthesiology, University of Michigan, Ann Arbor

Anesth Analg 2005;101:213-219

 

酸誤吸和周圍環境氧過多後的急性肺損傷導致肺顯著的氧化損害。肺的抗氧化劑水平也下降了。由於氣道中絲氨酸蛋白酶水平急劇增加,我們猜測這些酶對肺抗氧化劑的分解起重要作用。在周圍氧增多(氧過多)環境中大鼠肺誤吸酸前注入絲氨酸蛋白酶抑制劑抑肽酶。測定肺Cu/Zn Mn 超氧化物歧化酶(SOD)活性(用比色測定)及Cu/Zn SOD免疫活性蛋白(酶聯反應免疫吸收劑測定)。同時評定蛋白酶抑制劑處理對急性肺損傷的影響。總SODCu/Zn SOD Cu/Zn SOD 抗原蛋白水平在動物誤吸酸和氧過多後均減少 。然而,Mn SOD活性沒有改變。動物體內Cu/Zn SOD的下降由於絲氨酸蛋白酶活性被抑制而被削弱。但通過測定肺部滲入的放射性同位素白蛋白(滲透性指數)、動脈血氣和急性炎症指標(肺髓過氧化物酶活性、替代的嗜中性細胞標記和炎性細胞因數)顯示蛋白酶抑制劑處理並不減少急性肺損傷。我們得出結論絲氨酸蛋白酶的產生在減少Cu/Zn SOD中起主要作用,從而減少了肺抗氧化劑水平。但它在急性肺損傷的發病機理中的作用仍不清楚。

(朱慧 李士通 校)

Acute lung injury after acid aspiration and increased ambient oxygen result in significant oxidative damage to the lungs. Lung antioxidant levels are also reduced. Because levels of serine proteinases in the airspaces are also dramatically increased, we hypothesized that these enzymes play a role in degrading lung antioxidants. Rats were treated with a serine proteinase inhibitor, aprotinin, before pulmonary aspiration of acid in the presence of increased ambient oxygen (hyperoxia). Lung Cu/Zn and Mn superoxide dismutase (SOD) activity (by colorimetric assay) and Cu/Zn SOD immune reactive protein (enzyme-linked immunosorbent assay) were assayed. The effects of antiproteinase treatment on acute lung injury were also assessed. Total SOD, Cu/Zn SOD, and Cu/Zn SOD antigenic protein levels were decreased in animals after acid aspiration and hyperoxia. However, Mn SOD activity was unchanged. The decrease in Cu/Zn SOD was attenuated in animals, where serine proteinase activity was inhibited. However, antiproteinase treatment did not decrease acute pulmonary injury, as assessed by leakage of radiolabeled albumin into the lung (permeability index), arterial blood gases, and markers of acute inflammation (pulmonary myeloperoxidase activity, a surrogate neutrophilic marker, and inflammatory cytokine profiles). We conclude that production of serine proteinases play a major role in degrading Cu/Zn SOD, thereby decreasing pulmonary antioxidant capacity. However, the role this plays in the pathogenesis of the acute lung injury is not clear.


在單側腦半球功能抑制中的雙側雙譜指數監測

Bilateral Bispectral Index Monitoring During Suppression of Unilateral Hemispheric Function

Haren Heller, MD*, Raheleh Hatami, BA*, Paul Mullin, MD{dagger}, Robert R. Sciacca, EngScD{ddagger}, Alexander G. Khandji, MD§, Marla Hamberger, PhD{dagger}, Ronald Emerson, MD{dagger}, and Eric J. Heyer, MD, PhD*{dagger}

Departments of *Anesthesiology, {dagger}Neurology, {ddagger}Medicine, and §Radiology, The New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York

Anesth Analg 2005;101:235-341

 

雙譜指數(BIS)已被用於監測基於腦電圖(EEG)的“鎮靜”水平。篩選是否行癲癇手術時病人要進行Wada試驗,即通過注射短效巴比妥類藥物使一側腦半球功能性失活。我們推測BIS指數能反映這些功能的變化。8名癲癇患者參與了此項研究。完整安置21EEG電極以及2BIS XPQuatro)條帶電極置於雙側頭皮的額葉區域。持續記錄EEG。記錄每分鐘的雙側腦半球BIS值。通過雙側頸內動脈插入導管進行血管造影。一直注射異戊巴比妥或美索比妥直到病人出現輕偏癱。EEG證實了巴比妥類對單側大腦皮層的顯著影響。用重複方差分析來分析從置於頭部左側和右側的監測電極帶得到的BIS 值(左BIS和右BIS)的差異以及在每次注射巴比妥類藥物之前和之後左和 BIS 值間的差異。注射巴比妥類藥物到左側和右側頸內動脈都會引起21導聯EEG的顯著變化。然而,雙側的BIS 值並無顯著性差異(P=0.84)。重複注射巴比妥類藥物,一些病人出現了鎮靜作用。這時,左右兩側的BIS 值在注射巴比妥後均出現了下降。除非病人在鎮靜狀態下,否則BIS 監測儀無法區別顯著的腦半球EEG和臨床功能的改變。

(黃佳佳 李士通 校)

Bispectral Index (BIS) has been used to monitor level of "sedation" based on the electroencephalogram (EEG). Patients evaluated for surgery to control a seizure disorder undergo Wada testing, during which one hemisphere is rendered functionally inactive after injecting a short-acting barbiturate. We surmised that the BIS values would reflect these functional changes. Eight epileptic patients were enrolled. A full array of 21 EEG electrodes and 2 BIS XP (Quatro) strips over each frontal region of the scalp were applied. The EEG was continuously recorded. BIS values from each hemisphere were recorded every minute. Angiography was performed by advancing a catheter into each internal carotid artery. Amobarbital or methohexital was injected until the patient developed a hemiparesis. The EEG confirmed a significant lateralized cortical effect of the barbiturate. Repeated measures analysis of variance was used to analyze the differences between the BIS values from monitor electrode strips placed on the left (left BIS) and the right (right BIS) sides of the head as well as the differences in the left and right BIS values before and after each injection of the barbiturate. Injection of barbiturate into either the left or right internal carotid artery produced a significant change on the 21-electrode EEG. However, there was no difference between left BIS to right BIS values (P = 0.84). With repeated injections of barbiturates, some patients became sedated. At these times, both left BIS and right BIS values decreased together before and after injection of barbiturate. The BIS monitor was unable to distinguish significant hemispheric EEG and clinical functional changes except when the patient became sedated.


瑞芬太尼在腔鏡手術中用於胎兒制動及母親鎮靜的作用:與安定比較的隨機、雙盲實驗

Remifentanil for Fetal Immobilization and Maternal Sedation During Fetoscopic Surgery: A Randomized, Double-Blind Comparison with Diazepam

Marc Van de Velde, MD, PhD, Dominique Van Schoubroeck, MD, Liesbeth E. Lewi, MD, Marco A.E. Marcus, MD, PhD, Jacques C. Jani, MD, Carlo Missant, MD, An Teunkens, MD, and Jan A. Deprest, MD, PhD

Departments of Anaesthesiology and Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium, and the Department of Anaesthesiology, University of Maastricht, The Netherlands

Anesth Analg 2005;101:251-258

 

我們醫院常規使用產科內窺鏡手術治療單絨毛膜腔雙胎胎兒的某些疾病。我們選擇在脊硬聯合麻醉加母親鎮靜下實行手術。由於沒有進行全麻,胎兒不會停止活動。我們假設瑞芬太尼可以使母親達到足夠的鎮靜,並使胎兒停止活動,此作用等同或優於安定。54例孕中期孕婦被列入這個隨機雙盲試驗。實施脊硬聯合麻醉後,開始用間斷推注安定或持續輸注瑞芬太尼使母親鎮靜。分別于術前、術中和術後60分鐘內評價母親的鎮靜程度、血流動力學、不良反應以及胎兒的血流動力學和制動情況。瑞芬太尼使母親產生足夠的鎮靜效果,有輕微的、但並無臨床意義的呼吸抑制作用(手術開始後40分鐘時,母親的呼吸頻率為13 ± 4/分,Pco2 38.6 ± 4 mm Hg),而安定對母親的鎮靜作用更明顯,但沒有呼吸抑制作用(手術開始後40分鐘時,母親的呼吸頻率為18 ± 3/分,Pco2 32.7 ± 3 mm Hg)。與安定比較,瑞芬太尼使胎兒制動的作用出現早,且更加明顯,從而改善了手術條件;手術開始40分鐘內,胎兒總體和肢體活動次數,安定為12 ± 4,瑞芬太尼為2 ± 1。因此,使用瑞芬太尼麻醉的病人,其平均手術時間(範圍)明顯較安定組的病人短,瑞芬太尼麻醉組為60 (54–71)分鐘,安定麻醉組為80 (60–90)分鐘。 我們得出結論,瑞芬太尼可改善胎兒的制動,母親產生足夠的鎮靜,僅對母親呼吸有輕微影響。

(張瑩 李士通 校)

Obstetric endoscopy procedures are routinely performed at our institution to treat selected complications of monochorionic twin gestation. We perform these procedures under combined spinal epidural anesthesia plus maternal sedation. In the absence of general anesthesia, fetal immobilization is not achieved. We hypothesized that remifentanil would induce adequate maternal sedation and provide fetal immobilization, which is equal or superior to that induced by diazepam. Fifty-four second trimester pregnant women were included in this randomized, double-blind trial. After combined spinal epidural anesthesia, maternal sedation was initiated using either incremental doses of diazepam or a continuous infusion of remifentanil. Maternal sedation, hemodynamics, side effects, and fetal hemodynamics and immobilization were evaluated before, during, and for 60 min after surgery. Remifentanil produced adequate maternal sedation with mild but clinically irrelevant respiratory depression (respiratory rate 13 ± 4 breaths/min and Pco2 38.6 ± 4 mm Hg at 40 min of surgery), whereas diazepam resulted in a more pronounced maternal sedation but no respiratory depression (respiratory rate 18 ± 3 breaths/min and Pco2 32.7 ± 3 mm Hg at 40 min of surgery). Compared with diazepam, fetal immobilization with remifentanil occurred faster and was more pronounced, resulting in improved surgical conditions; the number of gross body and limb movements was 12 ± 4 (diazepam) versus 2 ± 1 (remifentanil) at 40 min of surgery. Because of this, the mean (range) duration of surgery was significantly shorter in the remifentanil-treated patients, 60 (54–71) min versus 80 (60–90) min in the diazepam group. We conclude that remifentanil produces improved fetal immobilization with good maternal sedation and only minimal effects on maternal respiration.

 

 

垂直鎖骨下臂叢神經阻滯:應用磁共振成像技術的模擬研究

The Vertical Infraclavicular Brachial Plexus Block: A Simulation Study Using Magnetic Resonance Imaging

Øivind Klaastad, DMSc*, Örjan Smedby, DrMedSci{dagger}, Trygve Kjelstrup, MD{ddagger}, and Hans-Jørgen Smith, DMSc§

*Department of Anesthesiology and The Interventional Centre, {ddagger}Department of Anesthesiology, and §Department of Radiology, Rikshospitalet University Hospital, Oslo, Norway; and {dagger}Department of Radiology, University Hospital Linköping, Linköping, Sweden

Anesth Analg 2005;101:273-278

 

推薦的垂直鎖骨下臂叢神經阻滯進針軌跡是前後位,針尾朝向鎖骨中點。作者採用磁共振成像技術研究在20例成年志願者中氣胸和穿破鎖骨下血管的風險性和這種方法的精確性。進針指向肺的有6例,其中5人為女性。然而在所有研究物件中通過碰到鎖骨下血管、神經叢或第一肋骨後停止進針就可避免刺破胸膜。3例進針軌跡碰到鎖骨下靜脈,5例遇到鎖骨下動脈。進針軌跡與神經叢之間的距離(最靠近的方位)中位數為1 mm(範圍0–9 mm9例碰到神經。總之,施行垂直鎖骨下臂叢神經阻滯時,針穿破胸膜有很小的可能性,尤其在女性,但碰到鎖骨下靜脈和動脈的機會較大。儘管進針方向貼近神經叢,任何內側偏斜在其他深度可導致刺破胸膜和鎖骨下血管的危險。 臨床上確定進針點的精確度是很關鍵的。

(趙雪蓮 莊心良 )

The recommended needle trajectory for the vertical infraclavicular brachial plexus block is anteroposterior, caudad to the middle of the clavicle. We studied the risk of pneumothorax and subclavian vessel puncture and the precision of this method by using magnetic resonance imaging in 20 adult volunteers. The trajectory aimed at the lung in six subjects, five of whom were women. However, pleural contact could be avoided in all subjects by halting needle advancement after contact with the subclavian vessels, plexus, or first rib. The subclavian vein was reached by the trajectory in three and the subclavian artery in five subjects. The trajectory had a median distance to the plexus (closest aspect) of 1 mm (range, 0–9 mm) and contacted the nerves in 9 subjects. In conclusion, there is a small probability that the needle may reach the pleura when a vertical infraclavicular brachial plexus block is performed, particularly in women, and a high probability that it will contact the subclavian vein or artery. Although the trajectory is close to the plexus, any medial deviation carries the risk of pleural or subclavian vessel contact at other depths. Clinical accuracy in defining the insertion point is critical.