Anesthesia & Analgesia

August 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

监测激活凝血时间用于联合应用肝素和抑肽酶:用SONOCLOT体外评估一种新的抑肽酶不敏感试验

(彭中美 李士通 校)

Monitoring Activated Clotting Time for Combined Heparin and Aprotinin Application: An In Vitro Evaluation of a New Aprotinin-Insensitive Test Using SONOCLOT

Michael T. Ganter, Seraina Dalbert, Kirk Graves, Richard Klaghofer, Andreas Zollinger, and Christoph K. Hofer

Anesth Analg 2005 101: 308-314.

七氟醚对血管紧张素II诱导、p44/42促分裂原活化蛋白激酶介导的大鼠主动脉平滑肌收缩的抑制作用

(王丽珺译 薛张纲校)

The Inhibitory Effects of Sevoflurane on Angiotensin II- Induced, p44/42 Mitogen-Activated Protein Kinase-Mediated Contraction of Rat Aortic Smooth Muscle

Jingui Yu, Kazuhiro Mizumoto, Yasuyuki Tokinaga, Koji Ogawa, and Yoshio Hatano

Anesth Analg 2005 101: 315-321.

PEDIATRIC ANESTHESIA:

儿童超声介导下置入硬膜外导管

(曹瑜 陈杰 校)

Ultrasound-Guided Epidural Catheter Insertion in Children

Hans-Jürgen Rapp, A. Folger, and T. Grau

Anesth Analg 2005 101: 333-339.

取小猪模型研究低温低流量心肺转流对初生脑的损伤类型

(王丽珺译 薛张纲校)

Injury Pattern of the Neonatal Brain After Hypothermic Low-Flow Cardiopulmonary Bypass in a Piglet Model

Andreas W. Loepke, Jeffrey A. Golden, John C. McCann, and C. Dean Kurth

Anesth Analg 2005 101: 340-348.

七氟醚预处理限制新生儿缺血的心肌细胞内/线粒体内钙离子

(周志坚 李士通 校)

Sevoflurane Preconditioning Limits Intracellular/Mitochondrial Ca2+ in Ischemic Newborn Myocardium

Hong Liu, Lianguo Wang, Matt Eaton, and Saul Schaefer

Anesth Analg 2005 101: 349-355.

静脉内使用枢复宁和安慰剂对全麻下手术的124月小儿预防术后呕吐一项双盲比较试验

(顾漪闻 陈杰 校)

A Double-Blind Comparison of Intravenous Ondansetron and Placebo for Preventing Postoperative Emesis in 1- to 24-Month-Old Pediatric Patients After Surgery Under General Anesthesia

Samia N. Khalil, Andrew G. Roth, Ira T. Cohen, Eli Simhi, J. Mark Ansermino, Mariana E. Bolos, Charles J. Coté, Raafat S. Hannallah, Peter J. Davis, Peter B. Brooks, Mark W. Russo, Gaya C. Anschuetz, and Linda M. Blackburn

Anesth Analg 2005 101: 356-361.

AMBULATORY ANESTHESIA:

体外震波碎石时单用瑞芬太尼的镇痛效果和副作用在不同输注剂量时的比较

(金 薛张纲 校)

Remifentanil as a Single Drug for Extracorporeal Shock Wave Lithotripsy: A Comparison of Infusion Doses in Terms of Analgesic Potency and Side Effects

Hector J. Medina, Eilish M. Galvin, Maaike Dirckx, Preveen Banwarie, Johannes F. H. Ubben, Freek J. Zijlstra, Jan Klein, and Serge J. C. Verbrugge

Anesth Analg 2005 101: 365-370.

ANESTHETIC PHARMACOLOGY:

不同剂量异氟醚-芬太尼组合对麻醉后早期恢复及术后不良反应的影响

(黄佳佳 李士通

The Effect of Different Isoflurane-Fentanyl Dose Combinations on Early Recovery from Anesthesia and Postoperative Adverse Effects

Hernán R. Muñoz, Fernando R. Altermatt, Julio A. González, and Paula J. León

Anesth Analg 2005 101: 371-376.

性别对七氟醚或丙泊酚意识消失作用的影响

(张美荣 陈杰 校)

The Influence of Gender on Loss of Consciousness with Sevoflurane or Propofol

Mitsuharu Kodaka, Jay W. Johansen, and Peter S. Sebel

Anesth Analg 2005 101: 377-381.

静脉诱导全身麻醉中出现呵欠是否是短暂觉醒改变的表现

(金 路译 薛张纲校)

Does Yawning Represent a Transient Arousal-Shift During Intravenous Induction of General Anesthesia?

Yoshiko Kasuya, Tatsuo Murakami, Tsutomu Oshima, and Shuji Dohi

Anesth Analg 2005 101: 382-384.

改良溶液引起的游离异丙酚浓度的变化

(黄丽娜 李士通 )

Changes in Concentrations of Free Propofol by Modification of the Solution

Michiaki Yamakage, Sohshi Iwasaki, Jun-Ichi Satoh, and Akiyoshi Namiki

Anesth Analg 2005 101: 385-388.

术前“芬太尼激发”做为一评估长期使用阿片类药物患者术后阿片类使用剂量的工具

(张宇 陈杰 校)

Preoperative "Fentanyl Challenge" as a Tool to Estimate Postoperative Opioid Dosing in Chronic Opioid-Consuming Patients

Jennifer J. Davis, Jeffrey D. Swenson, Robert H. Hall, Jeffrey D. Dillon, Ken B. Johnson, Talmage D. Egan, Nathan L. Pace, and Su-Yi Niu

Anesth Analg 2005 101: 389-395.

地氟醚吸入浓度的快速增加不伴有癫痫样脑电图
(孙志荣 薛张纲 校)
A Rapid Increase in the Inspired Concentration of Desflurane Is Not Associated with Epileptiform Encephalogram

Anne P. Vakkuri, Elina R. Seitsonen, Ville H. Jäntti, Mika Särkelä, Kari T. Korttila, Markku P.J. Paloheimo, and Arvi M. Yli-Hankala

Anesth Analg 2005 101: 396-400

g-亚单位控制重组g-氨基丁酸A型受体对非制动剂1,2-二氯六氟环丁烷(F6, 2N)阻断作用的敏感性

(黄施伟 李士通 校)

The {gamma}-Subunit Governs the Susceptibility of Recombinant {gamma}-Aminobutyric Acid Type A Receptors to Block by the Nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6, 2N)

Ewa D. Zarnowska, Robert A. Pearce, Abdallah A. Saad, and Misha Perouansky

Anesth Analg 2005 101: 401-406.

烟碱受体的抑制在氯胺酮诱导的行为变化中的作用

(顾新宇 陈杰 校)

The Role of Nicotinic Inhibition in Ketamine-Induced Behavior

Julia O. Udesky, Nicole Z. Spence, Ron Achiel, Chrisitane Lee, and Pamela Flood

Anesth Analg 2005 101: 407-411.

含有β3的γ-氨基丁酸A受体并非异氟烷产生遗忘和抑制作用的主要目标

(许文妍 薛张纲 )

ß3-Containing Gamma-Aminobutyric AcidA Receptors Are Not Major Targets for the Amnesic and Immobilizing Actions of Isoflurane

Mark Liao, James M. Sonner, Rachel Jurd, Uwe Rudolph, Cecilia M. Borghese, R. Adron Harris, Michael J. Laster, and Edmond I. Eger, II

Anesth Analg 2005 101: 412-418.

TECHNOLOGY, COMPUTING, AND SIMULATION:

地氟醚-瑞芬太尼麻醉期间NarcotrendBIS的监测:与标准方法的比较

(苏殿三 陈杰 校)

Narcotrend or Bispectral Index Monitoring During Desflurane-Remifentanil Anesthesia: A Comparison with a Standard Practice Protocol

Sascha Kreuer, Jörgen Bruhn, Christian Stracke, Luc Aniset, Malte Silomon, Reinhard Larsen, and Wolfram Wilhelm

Anesth Analg 2005 101: 427-434.

麻醉和清醒状态下听觉刺激对AEP监测/2起源合成听觉诱发电位指数的影响

(蔡美华译 薛张纲校)

The Impact of Acoustic Stimulation on the AEP Monitor/2 Derived Composite Auditory Evoked Potential Index Under Awake and Anesthetized Conditions

Frank Weber, Markus Zimmermann, and Thomas Bein

Anesth Analg 2005 101: 435-439.

连续经气管混合静脉血氧饱和度监测的初步研究

(邱郁薇 李士通 校)

A Pilot Study of Continuous Transtracheal Mixed Venous Oxygen Saturation Monitoring

Wei Wei, Zhaoqiong Zhu, Lunxu Liu, Yunxia Zuo, Min Gong, Fushan Xue, and Jin Liu

Anesth Analg 2005 101: 440-443.

PAIN MEDICINE:

大鼠神经损伤后神经性疼痛增强可能与饮食中omegaω-3脂肪酸有关

(赵延华 陈杰 校)

Dietary Omega-3 Fatty Acids May Be Associated with Increased Neuropathic Pain in Nerve-Injured Rats

Jordi Pérez, Mark A. Ware, Stephanie Chevalier, Rejeanne Gougeon, and Yoram Shir

Anesth Analg 2005 101: 444-448.

疼痛相关和眼急动相关脑激活之间相互作用的交叉模型:通过事件相关的功能性磁共振成像的初步研究

(孙敏莉译 薛张纲校)

The Cross-Modal Interaction Between Pain-Related and Saccade-Related Cerebral Activation: A Preliminary Study by Event-Related Functional Magnetic Resonance Imaging

Jiro Kurata, Keith R. Thulborn, and Leonard L. Firestone

Anesth Analg 2005 101: 449-456.

对慢性缩窄性神经损伤沙鼠的丙酮喷雾测试的行为学和药理学确认

(周雅春 李士通 校)

A Behavioral and Pharmacological Validation of the Acetone Spray Test in Gerbils with a Chronic Constriction Injury

Kris Vissers and Theo Meert

Anesth Analg 2005 101: 457-464.

CRITICAL CARE AND TRAUMA:

一氧化氮合成酶(NOS)抑制剂在败血症中的作用

(范颖辉 陈杰 校)

Nitric Oxide Synthase Inhibition in Sepsis? Lessons Learned from Large-Animal Studies (Review Article)

Balázs Hauser, Hendrik Bracht, Martin Matejovic, Peter Radermacher, and Balasubramanian Venkatesh

Anesth Analg 2005 101: 488-498.

NEUROSURGICAL ANESTHESIA:

瑞芬太尼复合异丙酚全麻行清醒功能性脑地形图监测前颅骨切开术的回顾性分析

(金琳 薛张纲 校)

A Retrospective Analysis of a Remifentanil/Propofol General Anesthetic for Craniotomy Before Awake Functional Brain Mapping

John C. Keifer, Dimitar Dentchev, Kenneth Little, David S. Warner, Allan H. Friedman, and Cecil O. Borel

Anesth Analg 2005 101: 502-508.

七氟醚削弱大鼠脑血流的自体调节:被非选择性一氧化氮合酶抑制剂逆转

(张曦 李士通 校)

Sevoflurane Impairs Cerebral Blood Flow Autoregulation in Rats: Reversal by Nonselective Nitric Oxide Synthase Inhibition

Christian Werner, Hong Lu, Kristin Engelhard, Nikolaus Unbehaun, and Eberhard Kochs

Anesth Analg 2005 101: 509-516

七氟醚和过度通气对顽固性癫痫患者脑棘波活动的影响

(朱辉 陈杰 校)

The Effects of Sevoflurane and Hyperventilation on Electrocorticogram Spike Activity in Patients with Refractory Epilepsy

Naoko Kurita, Masahiko Kawaguchi, Tohru Hoshida, Hiroyuki Nakase, Toshisuke Sakaki, and Hitoshi Furuya

Anesth Analg 2005 101: 517-523.

纠正观念:氯胺酮能否应用与脑神经损伤病人?

(沈 薛张纲 校)

Revising a Dogma: Ketamine for Patients with Neurological Injury? (Medical Intelligence)

Sabine Himmelseher and Marcel E. Durieux

Anesth Analg 2005 101: 524-534.

OBSTETRIC ANESTHESIA:

Espocan®Tuohy穿刺针用于无痛分娩腰-硬联合方法的比较

(朱 李士通 校)

A Comparison of Espocan® and Tuohy Needles for the Combined Spinal-Epidural Technique for Labor Analgesia

Ingrid M. Browne, David J. Birnbach, Deborah J. Stein, David A. O'Gorman, and Maxine Kuroda

Anesth Analg 2005 101: 535-540.

REGIONAL ANESTHESIA:

大鼠利多卡因和布比卡因鞘内注射的神经毒性比较

(郑拥军 陈杰 校)

The Comparative Neurotoxicity of Intrathecal Lidocaine and Bupivacaine in Rats

Shinichi Sakura, Yumiko Kirihara, Tomoko Muguruma, Tomomune Kishimoto, and Yoji Saito

Anesth Analg 2005 101: 541-547.

布比卡因和罗哌卡因用于连续周围神经阻滞后对肌肉的远期毒性作用

(吴德华译 薛张纲校)

The Long Term Myotoxic Effects of Bupivacaine and Ropivacaine After Continuous Peripheral Nerve Blocks

Wolfgang Zink, Jürgen R. E. Bohl, Nicola Hacke, Barbara Sinner, Eike Martin, and Bernhard M. Graf

Anesth Analg 2005 101: 548-554.

腰骶段脑脊液容量对高比重布比卡因脊麻时麻醉平面和作用时间的影响:坐位和侧卧位注射的比较

(张莹 李士通 校)

The Influence of Lumbosacral Cerebrospinal Fluid Volume on Extent and Duration of Hyperbaric Bupivacaine Spinal Anesthesia: A Comparison Between Seated and Lateral Decubitus Injection Positions

Hideyuki Higuchi, Yushi Adachi, and Tomiei Kazama

Anesth Analg 2005 101: 555-560.

大鼠星状神经节阻滞试验的新方法

(殷文渊 陈杰 校)

A Novel Technique for Experimental Stellate Ganglion Block in Rats

Salahadin Abdi and Zongqi Yang

Anesth Analg 2005 101: 561-565.

结肠手术病人鞘内应用可乐定的短期镇痛和长期抗痛觉过敏的效果

(周晓敏 薛张纲 校)

The Short-Lasting Analgesia and Long-Term Antihyperalgesic Effect of Intrathecal Clonidine in Patients Undergoing Colonic Surgery

Marc De Kock, Patricia Lavand’homme, and Hilde Waterloos

Anesth Analg 2005 101: 566-572.

关节镜下辅助的前交叉韧带重建术后关节腔内患者自控区域麻醉:罗哌卡因/吗啡/酮咯酸合液与罗哌卡因/吗啡合液的对比

(赵雪莲 李士通 校)

Intraarticular Patient-Controlled Regional Anesthesia After Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction: Ropivacaine/Morphine/Ketorolac Versus Ropivacaine/Morphine

Neli Vintar, Narinder Rawal, and Matjaz Veselko

Anesth Analg 2005 101: 573-578..

GENERAL ARTICLES:

麻醉恢复室中术后尿储留的预测因素

(郑丽 陈杰 校)

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit

Hawa Keita, Elisabeth Diouf, Florence Tubach, Tammo Brouwer, Souhayl Dahmani, Jean Mantz, and Jean-Marie Desmonts

Anesth Analg 2005 101: 592-596.

体位改变对未禁食者胃食管反流及屏障压的影响

(孙少潇译 薛张纲校)

The Influence of Postural Changes on Gastroesophageal Reflux and Barrier Pressure in Nonfasting Individuals

Hans-Christian Jeske, Jan Borovicka, Achim von Goedecke, Christa Meyenberger, Thomas Heidegger, and Arnulf Benzer

Anesth Analg 2005 101: 597-600.

术中液体限制改善大的择期胃肠道手术的预后

(马皓琳 李士通 校)

Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery (Medical Intelligence)

Girish P. Joshi

Anesth Analg 2005 101: 601-605.

 

七氟醚对血管紧张素II诱导、p44/42促分裂原活化蛋白激酶介导的大鼠主动脉平滑肌收缩的抑制作用

The Inhibitory Effects of Sevoflurane on Angiotensin II- Induced, p44/42 Mitogen-Activated Protein Kinase-Mediated Contraction of Rat Aortic Smooth Muscle

Jingui Yu, MD*, Kazuhiro Mizumoto, MD*, Yasuyuki Tokinaga, MD*, Koji Ogawa, MD{dagger}, and Yoshio Hatano, MD*

*Department of Anesthesiology and {dagger}Surgical Operating Center, Wakayama Medical University, Wakayama City, Japan

Address correspondence and reprint requests to Yoshio Hatano, MD, Department of Anesthesiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, 641-0012, Japan.

Anesth Analg 2005;101:315-321

七氟醚以剂量依赖方式扩张血管,降低动脉血压。血管紧张素II(Ang II)是调节血管张力和动脉血压的主要因素之一,而p44/42促分裂原活化蛋白激酶(p44/42 MAPK)AngII介导的血管平滑肌收缩相关。我们设计了这一试验来研究七氟醚对血管紧张素II诱导、p44/42促分裂原活化蛋白激酶介导的大鼠主动脉平滑肌收缩的作用。我们采用等容测量法和蛋白印记分析分别检验了p44/42 MAPK激酶抑制剂, PD 098059(10–5 mol [M], 5 x 10–5 M and 10–4 M),和七氟醚(1.7%, 3.4%, and 5.1%)对于Ang II介导的收缩及p44/42 MAPK磷酸化在大鼠主动脉平滑肌上的作用。Ang II介导了短暂的收缩反应以及p44/42 MAPK的磷酸化,而后者又主要被PD 098059拮抗 (P < 0.05–0.01)。七氟醚以剂量依赖方式抑制了血管紧张素II介导的收缩反应(3.4% 5.1% 的七氟醚分别为P<0.050.01),七氟醚也降低了血管紧张素II诱发的p44/42 MAPK磷酸化(3.4%5.1% 的七氟醚均为P<0.05)。这一结果表明:七氟醚对于血管紧张素II介导的血管收缩的抑制作用,至少部分是由于对p44/42 MAPK介导的信号通道的抑制引起。

(王丽珺译 薛张纲校)

Sevoflurane dilates blood vessels and reduces arterial blood pressure in a dose-dependent manner. Angiotensin II (Ang II) is one of the primary regulators of vascular tension and arterial blood pressure, and the p44/42 mitogen-activated protein kinases (p44/42 MAPK) are involved in Ang II-mediated vascular smooth muscle contraction. We designed this study to examine the effects of sevoflurane on Ang II-induced, p44/42 MAPK-mediated contraction of rat aortic smooth muscle. The effects of the p44/42 MAPK kinase (MEK1/2) inhibitor, PD 098059 (10–5 molar [M], 5 x 10–5 M and 10–4 M), and sevoflurane (1.7%, 3.4%, and 5.1%) on Ang II-induced contraction and p44/42 MAPK phosphorylation were tested in rat aortic smooth muscle, using isometric force measurement and Western blot analysis, respectively. Ang II induced both a transient contractile response and phosphorylation of p44/42 MAPK, which were significantly attenuated by PD 098059 (P < 0.05–0.01). Sevoflurane inhibited Ang II-induced contractile response in a dose-dependent manner (P < 0.05 and 0.01 in response to 3.4% and 5.1% sevoflurane, respectively). Sevoflurane also dose-dependently depressed Ang II-elicited p44/42 MAPK phosphorylation (P < 0.01 in response to 3.4% and 5.1% sevoflurane). These results suggest that the inhibitory effect of sevoflurane on Ang II-induced vasoconstriction is, at least in part, caused by the inhibition of the p44/42 MAPK-mediated signaling pathway.

 

取小猪模型研究低温低流量心肺转流对初生脑的损伤类型

Injury Pattern of the Neonatal Brain After Hypothermic Low-Flow Cardiopulmonary Bypass in a Piglet Model

Andreas W. Loepke, MD, PhD*, Jeffrey A. Golden, MD{dagger}, John C. McCann, BS*, and C. Dean Kurth, MD*

Department of Anesthesia, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, and Institute of Pediatric Anesthesia, Cincinnati Children’s Hospital Research Foundation, Cincinnati, Ohio; and {dagger}Department of Pathology, Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

Anesth Analg 2005;101:340-348

低流量心肺转流(LF-CPB)是新生儿心脏手术中广泛应用的一种模式。在方便手术修补的同时,也增加了由于低灌注引起神经损伤的危险性。在该试验中,我们用小猪低温LF-CPB模型研究了损伤类型及影响因素。小猪被麻醉、气管插管、辅助通气,并准备好心肺复苏(CPR)。当LF-CPB 150分钟后,pH固定计测定大脑温度为22°C,试验动物允许存活29天。每日评价神经状态并做磁共振。大脑从组织学上评价。我们发现,CPR 1天、2天、9天后的神经功能损伤率分别为64%, 30%, 0%。所有试验动物都有组织学上的脑损伤,主要累及新大脑皮层和海马,基底节、丘脑、白质及小脑也有受累。细胞死亡作为选择性的神经坏死出现在新大脑皮层深部和海马的14区。即使采用pH固定计测量,新大脑皮层和海马的损伤仅有很小部分与动脉高CO2有关。海马损伤很少与高血糖有关。神经功能和基底节损伤很少与术后高红细胞比容有关。

(王丽珺译 薛张纲校)

Low-flow cardiopulmonary bypass (LF-CPB) is a widely used modality in neonatal heart surgery. While facilitating surgical repair, it poses a risk of neurological injury caused by hypoperfusion. In the present study, we characterize the injury pattern and influencing factors in a piglet hypothermic LF-CPB model. Piglets were anesthetized, tracheally intubated, ventilated, and prepared for CPB. After LF-CPB for 150 min at 22°C (brain) using pH-stat strategy, animals were allowed to survive for 2 or 9 days. Neurological status was assessed daily and magnetic resonance imaging scans were performed. Brains were assessed histologically. Functional neurological impairment was seen in 64%, 30%, and 0% of animals 1, 2, and 9 days after CPB, respectively. All animals showed histological brain damage, predominantly in neocortex and hippocampus, less so in basal ganglia, thalamus, white matter, and cerebellum. Cell death appeared as selective neuronal necrosis in the deeper layers in neocortex and CA1–4 sections in hippocampus. Even in a pH-stat strategy, less neocortical and hippocampal damage correlated with higher arterial partial pressure for carbon dioxide. Less hippocampal damage was associated with higher blood glucose levels. Less functional neurological impairment and basal ganglia damage correlated with higher postoperative hematocrit.

 

体外震波碎石时单用瑞芬太尼的镇痛效果和副作用在不同输注剂量时的比较

Remifentanil as a Single Drug for Extracorporeal Shock Wave Lithotripsy: A Comparison of Infusion Doses in Terms of Analgesic Potency and Side Effects

Hector J. Medina, MD, Eilish M. Galvin, MB, FCARCSI, Maaike Dirckx, MD, Preveen Banwarie, MSc, Johannes F. H. Ubben, MSc, Freek J. Zijlstra, PhD, Jan Klein, MD, PhD, and Serge J. C. Verbrugge, MD, PhD

Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands

Address correspondence and reprint requests to Eilish Galvin, MB, FCARCSI, Department of Anesthesiology, Erasmus University Medical Center, P.O. Box 2040, 3015 GD Rotterdam, The Netherlands.

Anesth Analg 2005 101: 365-370.

该随机双盲研究被设计用来评价肾结石病人行体外震波碎石(ESWL)时采用两种不同瑞芬太尼输注速率时的镇痛效果和副作用。该研究包括200个病人,分别给予瑞芬太尼0.05 μg · kg–1 · min–1 (n = 100)0.1 μg · kg–1 · min–1 (n = 100),都通过病人自控镇痛(PCA)装置需要时加用10μg单次给药剂量。不另用其它镇静剂。对PCA的所需次数和输注量进行记录。整个操作过程中记录动脉血压、氧饱和度和呼吸频率;治疗结束后记录术后恶心呕吐(PONV)、眩晕、瘙痒、烦躁和呼吸抑制发生率。在术前、术后即刻、术后30分分别记录疼痛的视觉模拟评分值。结果显示,在PCA需要次数、PCA给药量及围术期VAS评分方面没有显著的统计学差异。而术后即刻和30分钟时PONV程度和眩晕、瘙痒发生例数在小剂量组有明显减少。我们可以得出结论,瑞芬太尼0.05 μg · kg–1 · min–1维持量加10μg单次给药剂量优于0.1 μg · kg–1 · min–1维持量加单次给药剂量。因为在两组病人之间疼痛视觉模拟评分记录上没有显著差别,而在接受ESWL治疗的病人中,小剂量组有较低的副作用的发生率。

(金 薛张纲 校)

This randomized, double-blind study was designed to evaluate analgesic effectiveness and side effects of two remifentanil infusion rates in patients undergoing extracorporeal shock wave lithotripsy (ESWL) for renal stones. We included 200 patients who were administered remifentanil either 0.05 μg · kg–1 · min–1 (n = 100) or 0.1 μg · kg–1 · min–1 (n = 100) plus demand bolus of 10 μg of remifentanil via a patient-controlled analgesia (PCA) device. No other sedating drugs were given. The frequencies of PCA demands and deliveries were recorded. Arterial blood pressure, oxygen saturation, and respiratory rate were recorded throughout the procedure; postoperative nausea and vomiting (PONV), dizziness, itching, agitation, and respiratory depression were measured posttreatment. Visual analog scale (VAS) scores were taken preoperatively, directly postoperatively, and 30 min after finishing the procedure. There were no statistically significant differences in the frequency of PCA demands and delivered boluses or among perioperative VAS scores. The extent of PONV and frequency of dizziness and itching immediately after and dizziness 30 min after the end of treatment were significantly reduced in the smaller dose group. We conclude that a remifentanil regimen of 0.05 μg · kg–1 · min–1 plus 10 μg demands is superior to 0.1 μg · kg–1 · min–1 plus demands, as there was no difference in the VAS scores recorded between groups and it has a less frequent incidence of side effects in patients receiving ESWL.

 

静脉诱导全身麻醉中出现呵欠是否是短暂觉醒改变的表现

Does Yawning Represent a Transient Arousal-Shift During Intravenous Induction of General Anesthesia?

Yoshiko Kasuya, MD*, Tatsuo Murakami, MD*, Tsutomu Oshima, MD__, and Shuji Dohi, MD__

*Division of Anesthesia, Gifu Red Cross Hospital; and __Department of Anesthesiology, Gifu University Graduate School of Medicine, Gifu-City, Japan

Address correspondence and reprint requests to Tsutomu Oshima, MD, Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, 1-1

Yanagido, Gifu City, Gifu 501-1194, Japan.

Anesth Analg 2005 101: 382-384.

 

虽然呵欠在静脉诱导的全身麻醉中经常发生,但这种反应的意义仍然不为人所知。在本研究中,我们对30个手术病人采用硫喷妥钠4mg/kg静脉注射诱导,30个手术病人采用异丙酚2mg/kg静脉注射诱导。然后,对呵欠发生的情况进行连续地评估一分钟,作为唯一的临床终点。整个观察过程中采用脑电双频谱指数监测。以持续低水平的脑电双频谱指数的短暂增大作为觉醒反应的标准。以此标准为基础,用呵欠反应作为觉醒征象的灵敏度为77%,特异度为80%。如果某一病人有呵欠反应,则其觉醒的概率为84%(阳性预测值)。而没有呵欠反应时,则无觉醒的概率为71%(阴性预测值)。根据简单逻辑回归分析,呵欠反应作为短暂觉醒反应的预测指标的优势比为13.595%可信区间:3.8-48P<0.001)。在静脉诱导中出现呵欠反应可以作为在进一步意识消失过程中出现短暂苏醒改变的临床指标。

(金 路译 薛张纲校)

Although yawning occurs frequently during the IV induction of general anesthesia, the significance of this response remains unknown. In this study, we induced 30 surgical patients with 4 mg/kg thiopental IV, and 30 patients with 2 mg/kg propofol IV. Thereafter, the occurrence of yawning was continuously assessed, as the only clinical end-point, for 1 min. The electroencephalographic bispectral index was monitored throughout the observation period. The criterion for an arousal response was a transient increase during a continuing decrease in the bispectral index value. On the basis of this criterion, the sensitivity and specificity of the yawning response as an arousal sign were 77% and 80%, respectively. If a patient exhibited a yawning response, the chance of arousal was 84% (positive predictive value). With no yawning response, the chance of nonarousal was 71% (negative predictive value). According to simple logistic regression, the yawning response was predictive of a transient arousal-shift with an odds ratio of 13.5 (95% confidence interval: 3.8–48; P < 0.001). The occurrence of a yawning response during IV induction may be a clinical indicator of a transient arousal-shift during progressive loss of consciousness.

 

地氟醚吸入浓度的快速增加不伴有癫痫样脑电图
A rapid increase in the inspired concentration of desflurane is not associated with epileptiform encephalogram.
Vakkuri AP, Seitsonen ER, Jantti VH, Sarkela M, Korttila KT, Paloheimo MP, Yli-Hankala AM.
Department of Anesthesia and Intensive Care, Helsinki University Hospital, Helsinki, Finland.

Anesth Analg 2005 101: 396-400.

 

麻醉面罩诱导时吸入高浓度七氟醚可诱发癫痫样脑电图和心动过速。当地氟醚浓度突然增加时也可出现心动过速。还不清楚是否类似七氟醚伴有癫痫样脑电图。我们对31个女性麻醉诱导后快速增加七氟醚或者地氟醚浓度时脑电图和心率进行了研究。麻醉诱导使用异丙酚和瑞米芬太尼进行气管插管。患者诱导后随机分配到小剂量七氟醚或者地氟醚复合笑气和氧气维持。10分钟后,七氟醚或者地氟醚挥发罐调节到最高刻度(七氟醚7%,地氟醚18%)5分钟。记录心率和脑电图。癫痫样脑电图在七氟醚组15个病人中记录到8个人,但地氟醚组未记录到一个(P<0.05)。2组心率都增加。在七氟醚组,HR逐渐的增加,而最高HR数值出现在七氟醚浓度增加后5分钟。在地氟醚组,HR增加到93bpm于地氟醚浓度增加后2分钟(没有显著的区别,七氟醚和地氟醚比较)。七氟醚快速的增加浓度在通气正常时经常可诱发癫痫样脑电图。地氟醚浓度增加时伴有心动过速不伴有癫痫样脑电图。结论:七氟醚快速增加浓度可诱发癫痫样脑电图伴心动过速。快速增加地氟醚浓度诱发心动过速不伴有癫痫样脑电图。

(孙志荣 薛张纲 校)
The large inspired concentration of sevoflurane (S) during mask induction of anesthesia can induce epileptiform electroencephalogram (EEG) associated with tachycardia. Tachycardia is also seen when the concentration of desflurane (D) is abruptly increased. It is not known whether this is associated with epileptiform EEG similar to S. We studied EEG and heart rate (HR) during rapidly increased concentrations of S or D in 31 females during the postintubation period of anesthesia. Anesthesia was induced with propofol and remifentanil, and the tracheas were intubated. Patients were randomized to receive either S or D in nitrous oxide-oxygen mixture after intubation, at a small dose first. After 10 min, S or D vaporizer was advanced to the highest reading of the vaporizer (7% for S, 18% for D) for 5 min. HR and EEG were recorded. Epileptiform EEG activity was recorded in eight of 15 patients in group S and in none in group D (P < 0.05). HR increased in both groups. In group S, HR increased gradually and the highest HR value was 84 bpm at 5 min after the increase in sevoflurane concentration. In group D, HR increased to 93 bpm 2 min after the increase in desflurane concentration (no significant difference, S versus D). A rapid increase in the concentration of S frequently induces epileptiform EEG during normoventilation. Tachycardia during increasing concentrations of D is not associated with epileptiform EEG. IMPLICATIONS: A rapid increase in the concentration of sevoflurane induces epileptiform encephalogram (EEG) with tachycardia. A rapid increase in the concentration of desflurane also induces tachycardia but is not associated with epileptiform EEG.

 

含有β3的γ-氨基丁酸A受体并非异氟烷产生遗忘和抑制作用的主要目标

ß3-Containing Gamma-Aminobutyric AcidA Receptors Are Not Major Targets for the Amnesic and Immobilizing Actions of Isoflurane

Mark Liao, BS*, James M. Sonner, MD*, Rachel Jurd, PhD, Uwe Rudolph, MD, Cecilia M. Borghese, PhD, R. Adron Harris, PhD, Michael J. Laster, DVM*, and Edmond I. Eger, II, MD* .

Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; Institute of Pharmacology and Toxicology, University of Zurich, Zurich, Switzerland; and Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, Texas.

Anesth Analg 2005 101: 412-418.

 

在γ-氨基丁酸A受体ß3单体上N265M点突变的老鼠对很多种麻醉药效存在着抵抗,如异丙酚、依托咪酯。相对与野生型鼠而言,它们需要多16%的安氟醚或多21%浓度的氟烷才能抑制撤回反射。我们通过巴甫洛夫试验来测定是否需要用更多浓度的异氟烷来抑制这一突变种类的条件反射。试验发现,和野生型鼠相比,异氟烷的浓度没有显著意义地上升。我们亦测定了最低肺泡有效浓度(MAC)(能够抑制50%的突变鼠对伤害性刺激作出反应的最低肺泡有效浓度)。异氟烷对突变鼠的最低肺泡有效浓度(1.93% ± 0.003%; n = 14)较野生型鼠多17.0%(1.65 ± 0.04; n = 14; P < 0.001)。相同地,环丙烷对突变鼠的最低肺泡有效浓度(27.6% ± 0.55%; n = 16)较野生型鼠多13.6%(24.3 ± 0.46; n = 8; P< 0.01)。环丙烷对突变鼠最低肺泡有效浓度的增加出乎我们的意料,因为外界报道在α1β2γ2 γ-氨基丁酸A受体这一异氟烷作用最强的地方,环丙烷只有极微弱的作用。 与先前在α1β2γ2 γ-氨基丁酸A受体所得到的相符,我们发现在爪蟾卵上,5倍的环丙烷最低肺泡有效浓度增加了γ-氨基丁酸在α1β2γ2 γ-氨基丁酸A受体上的作用仅76%,在α1β3γ2 γ-氨基丁酸A受体及α6β3γ2 γ-氨基丁酸A受体上的加强作用也几乎一致。大相径庭的是, 非常低浓度的异氟烷(1 MAC)在这些受体上能够产生160%到310%增效作用。如果,相对于异氟烷而言,环丙烷在任何γ-氨基丁酸A受体的亚体上都是极微弱地增加γ-氨基丁酸介导氯电子流的作用,那么现在关于MAC的数据就和γ-氨基丁酸A受体不是吸入性麻醉药产生的抑制作用的介导者这一概念一致。

(许文妍 薛张纲 )

Mice bearing an N265M point mutation in the gamma-aminobutyric acid (GABA)A receptor ß3 subunit resist various anesthetic effects of propofol and etomidate. They also require a 16% larger concentration of enflurane and a 21% larger concentration of halothane to abolish the withdrawal reflex than do wild-type mice. Using a Pavlovian test, we measured whether this mutation increased the concentration of isoflurane required to impair learning and memory relative to wild-type mice. We found that the concentration was not significantly increased. We also measured MAC (the minimum alveolar concentration required to eliminate movement in response to noxious stimulation in 50% of subjects). Isoflurane MAC for mutant mice (1.93% ± 0.0.03%; mean ± se; n = 14) was 17.0% larger than MAC for wild-type mice (1.65 ± 0.04; n = 14; P < 0.001). Similarly, the cyclopropane MAC for mutant mice (27.6% ± 0.55%; n = 16) was 13.6% larger than MAC for wild-type mice (24.3 ± 0.46; n = 8; P < 0.01). The increase in MAC for cyclopropane was unexpected, because published reports find only minimal actions at 1ß22 GABAA receptors whereas isoflurane provides a large enhancement. Consistent with previous work on 1ß22 GABAA receptors, we found in Xenopus oocytes that 5 MAC cyclopropane enhanced the effect of GABA on 1ß22 GABAA receptors by only 76%, and by a nearly identical enhancement in 1ß32, and 6ß32 receptors. In contrast, a much smaller concentration of isoflurane (1 MAC) produced a 160% to 310% enhancement in these receptors. If, relative to isoflurane, cyclopropane minimally increases GABA-induced chloride currents at any GABAA receptor subtype, the present data for MAC are consistent with the notion that GABAA receptors do not mediate the immobility produced by inhaled anesthetics.

 

麻醉和清醒状态下听觉刺激对AEP监测/2起源合成听觉诱发电位指数的影响

The Impact of Acoustic Stimulation on the AEP Monitor/2 Derived Composite

Auditory Evoked Potential Index Under Awake and Anesthetized Conditions

Frank Weber, MD, Markus Zimmermann, MD, and Thomas Bein, MD

Department of Anesthesiology, University Hospital Regensburg, Germany

Address correspondence and reprint requests to Frank Weber, MD, Department of

Anesthesiology, University Hospital Regensburg, Franz-Josef-Strau&szlig;-Allee 11, D-93053 Regensburg, Germany.

Anesth Analg 2005;101:435-439.

 

AEP合成指数(AAITM)从AEP计算得来,但是在低信号质量下全凭自发EEG得来。我们给16名麻醉和清醒状态下的病人佩戴位置正确的耳机给予听觉刺激然和取下耳机,来研究听觉刺激对AAI的影响。AAIAarcotrend&reg;指数(NI),另一种以脑电波为基础监测镇静深度的方法,同步记录。麻醉和清醒状态下AAI值正确配对耳机时比不佩戴耳机时要高(p<0.05)但还是在生产商认定的镇静状态的范围内。在麻醉状态并正确佩戴耳机的情况下,我们发现AAI频繁的波动与AEP来源和EEG来源,但病人取下耳机后AAI值完全以EEG为基础。听觉刺激对Narcotrend&reg和指数没有影响。尽管不会误认为病人镇静状态是AAIAEP来源变为EEG来源,增加这两种指数方法的协调性是需要的。

(蔡美华译 薛张纲校)

The composite AEP index (AAITM) is preferably calculated from the AEP, but in

case of low signal quality it is based entirely on the spontaneous EEG. We

investigated the impact of auditory input on the AAI in 16 patients with

correctly positioned headphones for acoustic stimulation and headphones

disconnected from the patient’s ears under awake and anesthetized conditions.

The AAI and the Narcotrend&reg; Index (NI), another EEG-based measure of hypnotic depth, were recorded simultaneously. AAI values under awake and anesthetized conditions were higher with correctly positioned headphones than with headphones disconnected from the patient’s ears (P < 0.05) but remained within the range indicating the patient’s actual hypnotic state as given by the manufacturer of

the monitor. Under awake conditions with correctly positioned headphones we

observed frequent fluctuations between AEP-derived and EEG-derived AAI, whereas

with headphones disconnected from the patient’s ears the AAI calculation was

completely EEG based. Acoustic stimulation had no impact on the Narcotrend&reg;

Index. Although relevant misinterpretations of the patient’s hypnotic state as a

consequence of a turnover from AEP-derived to EEG-derived AAI values should not

occur, an improved harmonization of the two methods of indexing would be

desirable.

 

疼痛相关和眼急动相关脑激活之间相互作用的交叉模型:通过事件相关的功能性磁共振成像的初步研究

The cross-modal interaction between pain-related and saccade-related cerebral activation: a preliminary study by event-related functional magnetic resonance imaging.

Kurata J, Thulborn KR, Firestone LL.
Department of Anesthesiology and Critical Care Medicine,University of Pittsburgh, Pittsburgh, PA, USA.

Anesth Analg. 2005 Aug;101(2):449-56.

 

功能性磁共振成像中疼痛相关脑激活显示较少一致信号,与常规任务相关激活比较,其信号衰退较早。这可以是由认知或血流动力学相互作用介导的疼痛从上而下抑制而引起的,认知或血流动力学相互作用可以通过其他形式影响激活。使用事件相关磁共振机能成像,我们通过眼急动这样的交叉模型相互作用来检测是否疼痛影响脑激活。六名右利手志愿者右前臂接受50℃的热疼痛刺激(Pn = 6),并在3.0T核磁共振成像扫描器上进行全脑回波平面成像,执行视觉上介导的眼急动任务(Vn = 6),审查同时发生的疼痛加眼急动的例子(PVn = 5)。综合平均机能激活图并且信号时程在激活簇被分析。P激活双侧第二驱体感觉皮层(S2)V激活额部后方增补的眼区以及视觉区。PV增强了S2的激活而且激活了附加疼痛相关区域,包括双侧运动前区、右侧脑岛、前面及后面的扣带回皮质。相反地,在PVV相关激活被减弱。我们提出在眼球运动活动时疼痛使得交叉模型抑制,而且通过触发对疼痛的注意力眼球运动任务增强疼痛相关激活。提示:由于对疼痛的注意,疼痛相关脑激活被增强。在不相关眼急动的神经网络之外,它可以参与自上而下的抑制。

(孙敏莉译 薛张纲校)

Pain-related cerebral activation in functional magnetic resonance imaging shows less consistent signals that decay earlier than in conventional task-related activation. This may result from pain's top-down inhibition mediated by cognitive or hemodynamic interaction that could affect activation by other modalities. Using event-related functional magnetic resonance imaging, we examined whether pain affects cerebral activation by a saccade task through such cross-modal interaction. Six right-handed volunteers underwent whole-brain echo-planar imaging on a 3.0 T magnetic resonance imaging scanner while they received thermal pain stimulus at 50 degrees C on the right forearm (P; n = 6), performed a visually guided saccade task (V; n = 6), and went through a simultaneous pain-plus-saccade paradigm (PV; n = 5). Averaged functional activation maps were synthesized and signal time courses were analyzed at activation clusters. P activated the bilateral secondary somatosensory cortex (S2). V activated the posterior, supplementary, frontal eye fields, and visual areas. PV enhanced the S2 activation and activated additional pain-related areas, including the bilateral premotor area, right insula, anterior, and posterior cingulate cortices. In contrast, V-related activation was attenuated in PV. We propose that pain caused cross-modal suppression on the oculomotor activity and that an oculomotor task enhanced pain-related activation by triggering attention toward pain. IMPLICATIONS: Pain-related cerebral activation is enhanced by attention toward pain. It may involve top-down suppression over the unrelated neural networks of saccade.

 

瑞芬太尼复合异丙酚全麻行清醒功能性脑地形图监测前颅骨切开术的回顾性分析

A Retrospective Analysis of a Remifentanil/Propofol General Anesthetic for Craniotomy Before Awake Functional Brain Mapping

John C. Keifer, MD, Dimitar Dentchev, MD, Kenneth Little, MD, David S. Warner, MD, Allan H. Friedman, MD, and Cecil O. Borel, MD.

Departments of Anesthesiology (Neuroanesthesia) and Surgery (Neurosurgery) Duke University Medical Center .

Anesth Analg 2005;101:502-508

这项研究总结了为进行清醒功能性脑地形图而行颅骨切开术患者,采取静脉全麻技术的药物剂量、生理反应及麻醉并发症。回顾分析了98例操作,发现瑞芬太尼的静脉最快输注速率为0.050.05–0.09 µg · kg–1 · min–1;异丙酚为115100–150 µg · kg–1 · min–1。输注的持续时间为7858-98 min。术中全麻苏醒时间为停止静脉用药以便进行脑电地形图分析后9 (6–13) min,与麻醉药物输注持续时间及脑电地形图分析前颅骨切开的时间无关。用药过程中,自主呼吸保持良好,Sao2 = 95% (92%–98%) Paco2 = 50 (47–55) mm Hg。但是,也发现在96位患者中,有69人出现至少一次30s的呼吸暂停。用药期间,动脉收缩压的最高值为150 (139–175) mm Hg,最低值为100 (70–150) mm Hg3位患者出现术中癫痫发作。2位患者无法耐受清醒状态,要求重新进行全麻诱导。没有患者要求气管插管或终止手术。对于为进行清醒功能性脑地形图而行颅骨切开术患者,这种全麻技术是有效的,成为持续清醒或其他静脉镇静技术的替代品之一。

(金琳 薛张纲 校)

We performed this study to summarize drug dosing, physiologic responses, and anesthetic complications from an IV general anesthetic technique for patients undergoing craniotomy for awake functional brain mapping. Review of 98 procedures revealed "most rapid" IV infusion rates for remifentanil 0.05, 0.05–0.09 µg · kg–1 · min–1 and propofol 115, 100–150 µg · kg–1 · min–1. The infusions lasted for 78, 58-98 min. Intraoperative emergence from general anesthesia was 9 (6–13) min after discontinuing IV infusions to allow for brain mapping and was independent of infusion duration and duration of craniotomy befo re mapping. Spontaneous ventilation was generally satisfactory during drug infusion, as evidenced by Sao2 = 95% (92%–98%) and Paco2 = 50 (47–55) mm Hg. However, we recorded at least one 30-s epoch of apnea in 69 of 96 patients. Maximum systolic arterial blood pressure was 150 (139–175) mm Hg and minimal systolic arterial blood pressure was 100 (70–150) mm Hg during drug infusion. Three patients experienced intraoperative seizures. Two patients did not tolerate the awake state and required reinduction of general anesthesia. No patients required endotracheal intubation or discontinuation of surgery. This general anesthetic technique is effective for craniotomy with awake functional brain mapping and offers an alternative to continuous wakefulness or other IV sedation techniques.

 

 

纠正观念:氯胺酮能否应用与脑神经损伤病人?

Revising a dogma: ketamine for patients with neurological injury?

Himmelseher S, Durieux ME.

Klinik fuer Anaesthesiologie, Klinikum rechts der Isar, Technische Universitat, Munchen, Germany.
Anesth Analg. 2005 Aug;101(2):524-34

我们评估了围手术期和监护设计关于氯胺酮对并有神经损伤或有其危险病人大脑影响的随机临床研究报告。我们也回顾了其它关于药物对人大脑影响的文献以及检验氯胺酮对大脑损伤的实验性报告。在临床设计中,循证II级证据表明在合用γ-氨基丁酸受体激动剂、不使用笑气、应用控制性通气情况下氯胺酮并不增加颅内压。因此,氯胺酮可以安全地应用于颅脑神经损伤病人。与其他麻醉药、镇静剂相比,循证IIIII级证据表明氯胺酮引起的血液动力学兴奋可以增加脑的灌注,颅脑损伤病人应用镇静时使用氯胺酮也是一个不错的选择。实验室研究表明,氯胺酮具有神经保护作用,S(+)氯胺酮有神经再生作用,甚至在脑损伤的当时给药也有及作用。然而,这些良好结果的报告只是短期恢复期的研究。在生长期动物以及脑部特定区域没有损伤的成年大鼠,大剂量氯胺酮才引起神经毒性,这可以被联合应用γ-氨基丁酸受体激动剂预防。结论:氯胺酮可以安全的应用于神经系统损伤的病人,但是要控制呼吸以及联合应用γ-氨基丁酸受体激动剂并且避免使用笑气。它有利的循环效应以及前期资料显示的脑保护作用值得进一步实验和临床研究。

(沈 薛张纲 校)

We evaluated reports of randomized clinical trials in the perioperative and intensive care setting concerning ketamine's effects on the brain in patients with, or at risk for, neurological injury. We also reviewed other studies in humans on the drug's effects on the brain, and reports that examined ketamine in experimental brain injury. In the clinical setting, level II evidence indicates that ketamine does not increase intracranial pressure when used under conditions of controlled ventilation, coadministration of a gamma-aminobutyric acid (GABA) receptor agonist, and without nitrous oxide. Ketamine may thus safely be used in neurologically impaired patients. Compared with other anesthetics or sedatives, level II and III evidence indicates that hemodynamic stimulation induced by ketamine may improve cerebral perfusion; this could make the drug a preferred choice in sedative regimes after brain injury. In the laboratory, ketamine has neuroprotective, and S(+)-ketamine additional neuroregenerative effects, even when administered after onset of a cerebral insult. However, improved outcomes were only reported in studies with brief recovery observation intervals. In developing animals, and in certain brain areas of adult rats without cerebral injury, neurotoxic effects were noted after large-dose ketamine. These were prevented by coadministration of GABA receptor agonists. IMPLICATIONS: Ketamine can be used safely in neurologically impaired patients under conditions of controlled ventilation, coadministration of a {gamma}-aminobutyric acid receptor agonist, and avoidance of nitrous oxide. Its beneficial circulatory effects and preclinical data demonstrating neuroprotection merit further animal and patient investigation.

 

布比卡因和罗哌卡因用于连续周围神经阻滞后对肌肉的远期毒性作用

The long term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blocks.

Zink W, Bohl JR, Hacke N, Sinner B, Martin E, Graf BM.
Department of Anesthesiology, University of Heidelberg, Germany.

Anesth Analg. 2005 Aug;101(2):548-54.

 

罗比卡因相对布比卡因而言具有更少的肌肉毒性作用。因此,在与临床相关的背景下作者研究比较布比卡因和罗哌卡因对肌肉的远期毒性作用。在麻醉后的猪股神经旁放置导管,一组注入5mg/mL的布比卡因20ml,另一组注入7.5mg/mL的罗哌卡因20ml。随后分别2.5mg/ml的布比卡因和3.75mg/ml的罗哌卡因以8ml/h连续注射6h以上。对照组给予相应容量的生理盐水。每一组分别在第7天和28天时间点取注射部位的肌肉组织,其组织形态的损伤通过盲评分来计分(从0=无损害 3=明显受损或肌肉坏死)。对照组中未见形态学改变。实验期间,两组局麻药组中都可见到同样的钙化样肌肉坏死,瘢痕组织形成及明显的纤维组织增生。而且,布比卡因的肌肉损害作用显示出了较罗哌卡因更明显。本研究表明在模拟临床背景中布比卡因和罗哌卡因都可引起不可逆的骨骼肌肌肉的损害,同时也证实了布比卡因具有更严重的肌肉毒性作用。然而,临床上这两种局麻药的远期肌肉毒性作用仍然需要进一步的评估。结果,两种长效局麻药运用于外周神经阻滞后4周,都产生了钙化样肌肉坏死,表明有不可逆的骨骼肌损害。然而相对罗哌卡因而言,布比卡因引起的肌肉损害程度更明显。

(吴德华译 薛张纲校)

Compared with bupivacaine, acute myotoxicity of ropivacaine is less severe. Thus, in this study we compared the long term myotoxic effects of both drugs in a clinically relevant setting. Femoral nerve catheters were inserted in anesthetized pigs, and either 20 mL of bupivacaine (5 mg/mL) or ropivacaine (7.5 mg/mL) was injected. Subsequently, bupivacaine (2.5 mg/mL) and ropivacaine (3.75 mg/mL) were continuously infused (8 mL/h) over 6 h. Control animals were treated with corresponding volumes of normal saline. After 7 and 28 days, respectively, muscle samples were dissected at the former injection sites, and histological patterns of muscle damage were blindly scored (0 = no damage to 3 = marked lesions/myonecrosis) and compared. No morphological tissue changes were detected in control animals. In the observed period, both local anesthetics induced morphologically identical patterns of calcific myonecrosis, formation of scar tissue, and a marked rate of fiber regeneration. However, bupivacaine's effects were constantly more pronounced than those of ropivacaine. These data show that both drugs induce irreversible skeletal muscle damage in a clinically relevant model, and confirm the exceeding rate of myotoxicity of bupivacaine. However, the clinical impact of these long term myotoxic effects still has to be assessed. IMPLICATIONS: In a period of 4 wk after peripheral nerve block, both long-acting local anesthetics, bupivacaine and ropivacaine, produced calcific myonecrosis suggestive of irreversible skeletal muscle damage. In comparison with ropivacaine, however, the extent of bupivacaine-induced muscle lesions was significantly larger.

 

结肠手术病人鞘内应用可乐定的短期镇痛和长期抗痛觉过敏的效果

The short-lasting analgesia and long-term antihyperalgesic effect of intrathecal clonidine in patients undergoing colonic surgery.
De Kock M, Lavand'homme P, Waterloos H.
Department of Anesthesiology, University of Louvain, St. Luc Hospital, Brussels, Belgium.

Anesth Analg. 2005 Aug;101(2):566-72, table of contents.

 

在本研究中,我们调查了可乐定的术后抗痛觉过敏效果。60个行右半结肠切除术的病人进入本研究。病人被随机化分成三组,全麻前在鞘内分别注入2毫升的可乐定(300毫克)、盐水或布比卡因(10毫克)。使用靶控输注异丙酚维持全麻,脑电双频指数进行监测。通过病人自控镇痛装置予静注吗啡行术后镇痛。通过术后72小时内病人在休息、咳嗽和活动时的吗啡需要量及视觉模拟疼痛评分评估术后镇痛。通过von Frey细丝测定机械性的痛觉过敏。询问病人2周、1个月、6个月和12个月后的遗留疼痛情况。在鞘内注射可乐定组病人自控镇痛的吗啡需要量显著减少(术后72小时可乐定组、盐水组和布比卡因组分别为31.5 +/- 12 mg91 +/- 25.5 mg43 +/- 15 mgP < 0.05)。术后72小时可乐定组、盐水组和布比卡因组痛觉过敏的面积分别为3 +/- 5 cm(2)90 +/- 30 cm(2)35 +/- 20 cm(2) (P < 0.05)。术后6个月时,可乐定组较盐水组有更少的病人感觉到残余的疼痛(20人中有0个对比20人中有6个,P < 0.05)。我们认为术中鞘内应用可乐定和布比卡因均能提高术后即时的镇痛效果,但是可乐定比布比卡因能更有效地减少术后继发性的痛觉过敏。结论:鞘内应用可乐定有助于减少腹部手术病人恢复时继发性的痛觉过敏。

(周晓敏 薛张纲 校)

In this study, we investigated the antihyperalgesic effect of clonidine after surgery. Sixty patients undergoing right colic resection were studied. Patients were randomized to receive prior to general anesthesia a 2-mL intrathecal (IT) injection of 300 microg of clonidine or saline, or 10 mg of bupivacaine. General anesthesia was achieved using a target concentration propofol infusion and monitored using bispectral index. Postoperative analgesia was provided by morphine IV given through a patient-controlled analgesia device. Postoperative analgesia was assessed by morphine requirements and visual analog scale pain scores at rest, cough, and movement during the first 72 h. Mechanical hyperalgesia was measured by von Frey filaments. Patients were questioned regarding residual pain at 2 wk,1, 6, and 12 mo. The patient-controlled analgesia morphine requirements were significantly smaller in the IT clonidine group (31.5 +/- 12 versus 91 +/- 25.5 and 43 +/- 15 mg, respectively, in groups clonidine, saline, and bupivacaine: P < 0.05 at 72 postoperative hours). The area of hyperalgesia at 72 h was 3 +/- 5 cm(2) in the clonidine group versus 90 +/- 30 and 35 +/- 20 cm(2) in the saline and bupivacaine groups (P < 0.05). At 6 mo, fewer patients in the clonidine group experienced residual pain than in the saline group (0 of 20 versus 6 of 20, P < 0.05). We conclude that both intraoperative spinal clonidine and bupivacaine improve immediate postoperative analgesia. IT clonidine was, however, more potent than IT bupivacaine to reduce postoperative secondary hyperalgesia. IMPLICATIONS: Spinal clonidine contributes to the reduction of secondary hyperalgesia in patients recovering from abdominal surgery.

 

 

体位改变对未禁食者胃食管反流及屏障压的影响

The influence of postural changes on gastroesophageal reflux and barrier pressure in nonfasting individuals.
Jeske HC, Borovicka J, Von Goedecke A, Mevenberger C, Heidegger T, Benzer A.
Department of Gastroenterology, Kantonsspital St. Gallen, CH-9000 St. Gallen, Switzerland.
Anesth Analg. 2005 Aug;101(2):597-600, table of contents.

 

对于清醒的非禁食患者以最佳体位(如,头高位,头低位)将胃食管反流造成的胃内容物肺吸入的风险降到最小一直存在争议。在目前的研究中,我们通过多通道管腔内阻抗测量法和胃内-食管压力测定法对随机行20度头高仰卧位,或20度头低位的清醒非禁食志愿者进行测量,以研究胃食管反流和胃食管屏障压。在不同体位间,平均每人胃食管反流发作次数(0/1/1)或胃-食管屏障压(15.6/19.6/19.4 mmHg)并无显著差异。我们的结论为特殊体位对清醒的非禁食患者预防胃-食管返流无效。提示:在清醒的非禁食患者倾斜至头高位或头低位用以防止胃内容物返流时,其对胃食管返流的发生频率无影响。

(孙少潇译 薛张纲校)

There is controversy regarding optimal body positioning (i.e., head-up, head-down) in awake nonfasting individuals to minimize the risk for pulmonary aspiration of gastric contents as the result of gastroesophageal reflux (GER). In the present study, we investigated GER and intragastric-esophageal barrier pressure by means of multichannel intraluminal impedance measurement and intragastric-esophageal manometry in awake, nonfasting volunteers randomly positioned in a 20 degrees head-up position, the supine position, and a 20 degrees head-down position. No significant difference among positions was found with respect to number of GER episodes per person (0/1/1) or intragastric-esophageal barrier pressure (15.6/19.6/19.4 mm Hg). We conclude that specific body positioning is useless in the prophylaxis of GER in awake nonfasting individuals. IMPLICATIONS: Tilting of nonfasting individuals to the head-up or head-down position recommended for prevention of regurgitation of gastric contents does not influence the frequency of gastroesophageal reflux.

 

儿童超声介导下置入硬膜外导管

Ultrasound-Guided Epidural Catheter Insertion in Children

Hans-Jürgen Rapp, MD*, A. Folger, MD*, and T. Grau, MD, PhD{dagger}

*Department of Anesthesiology and Intensive Care, University Hospital Mannheim and {dagger}Department of Anesthesiology University Hospital Heidelberg, Faculties of the Ruprecht-Karls-University, Heidelberg, Germany

Anesth Analg 2005 101: 333-339.

 

硬膜外置管经常应用于病儿术中和术后疼痛的解除。在全身麻醉下细小的解剖结构和导管的置入使得硬膜外置管比较困难也难以避免损害。在这项研究中,作者研究了超声在儿童硬膜外导管置入和安放中探查神经轴索结构的作用。本次研究对象为ASAI-II级、选择性手术进行全身麻醉联合硬膜外麻醉的儿童。病人使用的是平衡麻醉,七氟醚、阿片类药、罗库溴胺。在置管前,进行单侧超声检查来确定神经轴索结构。记录该结构的影像、部位和深度。用一个无菌药盒来固定超声探头在准确位置,置入硬膜外导管,使用阻力消失技术,同时硬膜外导管在超声引导下进入理想的深度。25名儿童中有23名参与了评估。硬膜外间隙,黄韧带,硬膜结构能清晰辨别,并记录所有病人距离皮肤的深度。经腰部硬膜外途径穿刺的所有病人有阻力消失。超声测量深度和阻力消失深度的相关系数是0.8823名病人中有8名在导管置入过程中能显示硬膜外导管。另外11名病人中通过另一个超声平面显示导管。在新生儿和儿童中,超声是很好的神经轴索结构辨别方法。椎体的大小和不完全骨化能很好地显示和定位硬膜外间隙的深度,阻力消失以及相关的神经轴索结构。

(曹瑜 陈杰 校)

Epidural catheters (EC) are often used in pediatric patients for intraoperative and postoperative pain relief. The small anatomical structures and catheter insertion under general anesthesia make it more difficult to perform EC and to prevent damage. In this study we investigated the use of ultrasound (US) in detecting neuraxial structures during insertion and placement of EC in children. ASA I–II children scheduled for elective surgery under combined general and epidural anesthesia were studied. Patients received balanced anesthesia using sevoflurane, opioids and rocuronium. Before EC insertion US examination in a lateral position was done to visualize and identify neuraxial structures. Quality of visualization and site and depth of structures were recorded. Using a sterile kit to hold the US probe in position and enable the visualization of the neuraxial structures, an epidural cannula was inserted, using the loss of resistance technique, as the EC passed under US control to the desired level. Of 25 children, 23 were evaluated. Epidural space, ligamentum flavum, and dural structures were clearly identified and the depth to skin level estimated in all patients. Loss of resistance was visualized in all patients with a lumbar epidural approach. Correlation of US measured depth and depth of loss of resistance was 0.88. In eight of 23 patients EC could be visualized during insertion and in 11 others it could be visualized with additional US planes. US is an excellent tool to identify neuraxial structures in both infants and children. The size and the incomplete ossification of the vertebra allow exact visualization and localization of the depth of the epidural space, the loss of resistance, and all relevant neuraxial structures.

 

静脉内使用枢复宁和安慰剂对全麻下手术的124月小儿预防术后呕吐一项双盲比较试验

A Double-Blind Comparison of Intravenous Ondansetron and Placebo for Preventing Postoperative Emesis in 1- to 24-Month-Old Pediatric Patients After Surgery Under General Anesthesia

Samia N. Khalil, MD*, Andrew G. Roth, MD{dagger}, Ira T. Cohen, MD{ddagger}, Eli Simhi, MD||, J. Mark Ansermino, MBChB§, Mariana E. Bolos, MD*, Charles J. Coté, MD{dagger}, Raafat S. Hannallah, MD{ddagger}, Peter J. Davis, MD||, Peter B. Brooks, MBChB§, Mark W. Russo, MD, PhD, Gaya C. Anschuetz, MS, and Linda M. Blackburn, RN, MS

*Department of Anesthesiology, University of Texas Health Science Center, Houston; {dagger}Department of Pediatric Anesthesiology, Children’s Memorial Hospital, the Feinberg School of Medicine at Northwestern University, Chicago, Illinois; {ddagger}Department of Anesthesiology, Children’s National Medical Center, Washington, DC; §Department of Anesthesia, British Columbia’s Children’s Hospital, Vancouver; ||Department of Anesthesiology, Children’s Hospital of Pittsburgh; and ¶GlaxoSmithKline, Upper Providence, Pennsylvania

Anesth Analg 2005 101: 356-361.

 

为了了解术前预防性注射枢复宁(0.1mg/kg IV)对防治术后恶心呕吐(POV)的有效性和安全性,作者进行一项双盲,安慰剂对照研究。选择670例全麻醉下行手术的小儿(1-24个月)患者, 每组335例(枢复宁组VS安慰剂组)。枢复宁恶心呕吐情况和提早中断试验的发生率明显少于安慰剂组(枢复宁组, 11%;安慰剂组, 28%;几率比 = 0.33; P < 0.0001)。需另外加用枢复宁奥坦西隆预防性治疗POV的人数大约为6 。枢复宁组较安慰剂组相比,需要急救措施或在术后早期必须采取补救措施的患者更少(枢复宁组, 5%; 安慰剂组, 10%);在使用了补救措施后,枢复宁组的术后呕吐较少(6个中为0),而安慰剂组较多(21例中发生7例)。年龄为1-12月和13-24月的患者相比,POV的发生率和枢复宁抗呕吐的作用相似。在小儿是否使用阿片类药物作为麻醉或镇痛措施方面,枢复宁组可以较好地耐受,相关的副作用和安慰剂组相似(枢复宁组为1.8% 安慰剂组为1.5%)

(顾漪闻 陈杰 校)

We assessed the efficacy and safety of ondansetron (0.1 mg/kg IV) prophylactically administered before surgery for prevention of postoperative vomiting (POV) in a double-blind, placebo-controlled study of 670 pediatric patients, 1- to 24-mo-old, undergoing elective surgery under general anesthesia. The study enrolled 335 children in each treatment group (ondansetron versus placebo). Significantly fewer children treated with ondansetron exhibited emesis or discontinued the study prematurely after surgery (ondansetron, 11%; placebo, 28%; odds ratio = 0.33; P < 0.0001). The number required to treat prophylactically with ondansetron to prevent POV was approximately six. Ondansetron treatment also resulted in fewer patients requiring rescue medication or assumed to have had rescue upon early discontinuation from the study during the postoperative period (ondansetron, 5%; placebo, 10%) and less emesis (0 of 6) after rescue medication when compared with placebo (7 of 21). The incidence of POV and other antiemetic effects of ondansetron were similar in children aged 1–12 mo and 13–24 mo and in children prospectively expected or not expected to require opioids as part of their anesthetic or analgesic management. Ondansetron was well tolerated; the incidence of adverse events considered possibly related to study drug was similar between treatment groups (ondansetron, 1.8%; placebo, 1.5%).

 

性别对七氟醚或丙泊酚意识消失作用的影响

The Influence of Gender on Loss of Consciousness with Sevoflurane or Propofol

Mitsuharu Kodaka, MD, PhD, Jay W. Johansen, MD, PhD, and Peter S. Sebel, MB, BS, PhD, MBA

Department of Anesthesiology, Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia

Anesth Analg 2005 101: 377-381.

既往研究显示性别可能对全麻或紧急催眠药需要量产生影响。本文作者研究挥发性麻醉药(七氟醚)或静脉麻醉药(丙泊酚)下性别对催眠药意识消失作用(LOC)中所需剂量的影响。115例未使用术前药、ASA I-II级、年龄在18-40岁之间的病人,面罩吸入呼吸末浓度事先确定的七氟醚,或在自主呼吸时靶控注入丙泊酚,在足够的时间使药物均衡后,用轻度针刺激的反应来评价意识消失。Dixon的上- 下法用于确定50%效应时的催眠剂量(LOC50)。七氟醚麻醉时男性和女性的LOC50无明显统计学意义(分别为0.83% ± 0.1% 0.92% ± 0.09% ET)。男性需要丙泊酚的剂量明显多于女性(分别为2.9 ± 0.2 2.7 ± 0.1 µg/mL,)。然而,男性或女性用任何一种催眠药物时其在LOC状态下的双频指数(BIS)无明显差别。调查证明男性或女性应用丙泊酚麻醉时,在LOC50状态下所需剂量有一个小的、统计学有意义的差别异,而在七氟醚麻醉时没有。正如BIS定义,在LOC50时男性和女性有相同的催眠状态。表明性别在催眠 所需剂量是无明显临床意义。然而,BISLOC50时七氟醚和丙泊酚组有明显差别,表明这些麻醉药对神经生理学的效果可能不同。

(张美荣 陈杰 校)

Studies have suggested that hypnotic requirements for general anesthesia and emergence may be influenced by gender. In this study, we examined the effect of gender on the hypnotic requirement for loss of consciousness (LOC) using either a volatile (sevoflurane) or an IV (propofol) anesthetic. One-hundred-fifteen unpremedicated, ASA physical status I–II patients, aged 18–40 yr old, received either sevoflurane by mask to a predetermined end-tidal concentration (%ETsevo) or propofol by target-controlled infusion (effect site) while breathing spontaneously. After sufficient time for equilibration, LOC was assessed by lack of response to mild prodding. The up-down method of Dixon was used to determine the hypnotic target concentration at 50% response (LOC50). No statistically significant difference in LOC50 was noted between men and women for sevoflurane (0.83% ± 0.1% and 0.92% ± 0.09% ET, respectively). Men required significantly more propofol than women (2.9 ± 0.2 versus 2.7 ± 0.1 µg/mL, respectively). However, there was no difference in the bispectral index (BIS) at LOC for men or women with either hypnotic anesthetic. This investigation identified a small, statistically significant difference in hypnotic requirement at LOC50 between men and women with propofol but not with sevoflurane. As defined by BIS, men and women had equivalent hypnotic states at LOC50, indicating that gender had no clinically significant effect on hypnotic requirements. However, BIS at a defined clinical end-point (LOC50) was significantly different between the sevoflurane and propofol groups, suggesting that neurophysiological effects of these anesthetics may be different.

 

术前“芬太尼激发”做为一评估长期使用阿片类药物患者术后阿片类使用剂量的工具

Preoperative "Fentanyl Challenge" as a Tool to Estimate Postoperative Opioid Dosing in Chronic Opioid-Consuming Patients

Jennifer J. Davis, MD, Jeffrey D. Swenson, MD, Robert H. Hall, BS, Jeffrey D. Dillon, MD, Ken B. Johnson, MD, Talmage D. Egan, MD, Nathan L. Pace, MD, MStat, and Su-Yi Niu, PhD

Department of Anesthesiology at the Universit

阿片类药物用于术后镇痛,它产生的痛觉丧失和呼吸抑制与剂量有密切关系。作者研究了20例脊柱融合手术后长期使用阿片类药物的病人。每个病人术前给予2ug/kg/min的芬太尼直到其呼吸频率小于5/min。药物动力学模型用于评估产生呼吸抑制的效应点和预定一个使30%病人产生呼吸抑制的PCA的设定值。术后PCA调整为每小时2-3个需要剂量。在恒定的PCA速率下,测定动脉血气和血浆中芬太尼的水平。16位病人不需要任何调整或只调整1PCA两。动脉血气中PCO2的平均水平为41mmHg,在39-46mmHg中波动。血浆中的芬太尼水平显示术前的芬太尼激发对于芬太尼的效应点剂量和呼吸抑制之间有重要的关系。术前芬太尼激发的药物动力学模型可能成为一种有用的工具,来个体化指导长期使用阿片类镇痛剂的患者术后芬太尼用量。

(张宇 陈杰 校)

When opioids are used for postoperative pain control, it is useful to define the dose-response relationship for analgesia and respiratory depression. We studied 20 chronically opioid-consuming patients having elective multilevel spine fusion. Preoperatively, each patient received a fentanyl infusion of 2 µg · kg–1 · min–1 until the respiratory rate was <5 breaths/min. Pharmacokinetic simulations were used to estimate the effect site concentration at the time of respiratory depression and to predict the patient-controlled analgesia settings that would provide an effect-site fentanyl concentration that was 30% of the concentration associated with respiratory depression. Postoperatively, patient-controlled analgesia settings were adjusted to achieve 2–3 demand doses per hour. At steady-state patient-controlled analgesia settings, arterial blood gases and plasma fentanyl levels were measured. Sixteen patients required no adjustment or one patient-controlled analgesia adjustment. The median arterial Pco2 level was 41 mm Hg and the interquartile range was 39–46 mm Hg. Plasma fentanyl levels demonstrated a significant correlation to the estimated effect-site concentration associated with respiratory depression determined during the preoperative fentanyl challenge. A preoperative fentanyl challenge used with pharmacokinetic simulations may be a useful tool to individualize the administration of analgesics to chronically opioid-consuming patients.

 

烟碱受体的抑制在氯胺酮诱导的行为变化中的作用

The Role of Nicotinic Inhibition in Ketamine-Induced Behavior

Julia O. Udesky, Nicole Z. Spence, Ron Achiel, Chrisitane Lee, and Pamela Flood, MD

Department of Anesthesiology, Columbia University, New York, New York

Anesth Analg 2005 101: 407-411.

有一些麻醉药如氯胺酮和一些挥发性麻醉药在麻醉或亚麻醉时是烟碱受体拮抗剂。而异丙酚并不抑制烟碱受体。为确定氯胺酮抑制烟碱所引起的潜在的行为变化,作者测定有或没有某些烟碱配位基时氯胺酮产生不动、翻正反射抑制和痛觉缺失所需的剂量,并以异丙酚为对照。当用单一麻醉药时,氯胺酮产生无动和影响翻正反射时腹腔内用药剂量(IP)分别为383±22mg/kg180±17mg/kg,而异丙酚用量分别为371±34mg/kg199mg/kg。烟碱受体拮抗剂对异丙酚和氯胺酮剂量没有什么影响。当测定亚催眠状态时伤害性反应,异丙酚不能分辨伤害性刺激前和抗伤害性刺激期间,而氯胺酮剂量大于60mg/kgIP时产生镇痛作用。广谱烟碱受体拮抗剂美加明可以增强氯胺酮的镇痛作用。上述发现与挥发性麻醉药作用不同,后者烟碱受体抑制作用被认为是抗伤害性刺激的原因。总之,氯胺酮拮抗N-甲基-d-天门冬氨酸而产生镇痛这一作用机制还不明了。

(顾新宇 陈杰 校)

Several anesthetic drugs are nicotinic antagonists at or below levels used for anesthesia, including ketamine and volatile anesthetics. In contrast, propofol does not inhibit nicotinic receptors. To determine the potential behavioral ramifications of nicotinic inhibition by ketamine, we determined the doses of ketamine required to induce immobility, impair the righting reflex, and cause analgesia in the absence and presence of several nicotinic ligands. Propofol was used as a control in similar experiments. When used as a sole anesthetic drug, 383 ± 22 mg/kg ketamine intraperitoneally (IP) was required for immobility and 180 ± 17 mg/kg IP impaired righting reflex. Propofol, 371 ± 34 mg/kg IP, induced immobility whereas 199 mg/kg IP inhibited the righting reflex. Nicotinic antagonists had no effect on the dose of propofol or ketamine required for either end-point. When nociceptive responses were tested at subhypnotic doses, no pronociceptive or antinociceptive phase was identified for propofol, whereas analgesia was induced at ketamine doses larger than 60 mg/kg IP. The broad-spectrum nicotinic antagonist mecamylamine enhanced the analgesic action of ketamine. These findings are different than those seen with volatile anesthetics, where nicotinic inhibition is thought to be responsible for a pronociceptive action. Such a phase is possibly obscured by analgesia induced as a result of N-methyl-d-aspartic acid antagonism by ketamine.

 

地氟醚-瑞芬太尼麻醉期间NarcotrendBIS的监测:与标准方法的比较

Narcotrend or Bispectral Index Monitoring During Desflurane-Remifentanil Anesthesia: A Comparison with a Standard Practice Protocol

Sascha Kreuer, MD*, Jörgen Bruhn, MD{dagger}, Christian Stracke, MD*, Luc Aniset*, Malte Silomon, MD*, Reinhard Larsen, MD*, and Wolfram Wilhelm, MD, DEAA{ddagger}

Department of Anesthesiology and Intensive Care Medicine, *University of Saarland, Homburg/Saar; {dagger}University of Bonn, Bonn; and {ddagger}St.-Marien-Hospital, Lünen, Germany

Anesth Analg 2005 101: 427-434.

 

双频指数(BIS) (Aspect Medical Systems, Newton, MA)Narcotrend (MonitorTechnik, Bad Bramstedt, Germany)是两种不同的麻醉深度监测方法。研究表明以BISNarcotrend监测麻醉深度指导全凭静脉麻醉时,给药的剂量和恢复的时间相当,但是目前还缺乏这两种监测方法指导吸入麻醉的临床资料。因此研究者设计了本项随机双盲的前瞻性研究,对BISNarcotrend监测麻醉深度指导地氟醚-瑞芬太尼麻醉与标准全身麻醉方法进行了比较研究。120名拟行较小整形外科手术的成年患者均接受地氟醚-瑞芬太尼麻醉,随机分配到三组,分别由NarcotrendBIS和单纯依靠临床征象调整麻醉深度。应用瑞芬太尼0.4 µg · kg–1 · min–1和丙泊酚2 mg/kg诱导。气管插管后瑞芬太尼以恒定的速度注射(0.2 µg · kg–1 · min–1),地氟醚的浓度则根据临床征象或者两种监护仪的监测目标(Narcotrend:“D0;BIS:“50”)进行调整,在手术中止前15min调整为"C1" (Narcotrend) "60" (BIS)。在标准全麻组,地氟醚的流量完全依靠临床征象进行调整,包括:心率、动脉血压和体动等。称量麻醉前后地氟醚挥发罐的重量计算每分钟消耗量。数据用均数±标准差表示。研究结果发现,各组之间的人口学数据、麻醉时间、平均瑞芬太尼用量没有显著差异。与标准全麻操作组相比,应用BISNarcotrend作为指导后地氟醚的用量明显减少(标准全麻组 443 ± 71 mg/min, Narcotrend 374 ± 124 mg/min, BIS 416 ± 99 mg/min [ P < 0.05])。但是三组间苏醒时间没有显著性差异,睁眼时间分别为:4.7 ± 2.2 VS 3.7 ± 2.0 VS 4.2 ± 2.1 min。在地氟醚-瑞芬太尼麻醉中与标准全麻相比应用BISNarcotrend作为麻醉深度监测的指导效果相似。BISNarcotrend监测使地氟醚的消耗量轻度减少,但是对苏醒时间的影响甚微。

(苏殿三 陈杰 校)

Bispectral Index (BIS) (Aspect Medical Systems, Newton, MA) and Narcotrend (MonitorTechnik, Bad Bramstedt, Germany) are monitoring devices that were, as others, designed to assess the depth of anesthesia. Meanwhile, a number of studies indicate that with total IV anesthesia, BIS and Narcotrend have comparable effects on drug consumption and recovery times whereas comparative clinical data for volatile anesthetics are still missing. Therefore, we designed the present prospective, randomized, and double-blinded study to compare the effects of BIS and Narcotrend monitoring during desflurane-remifentanil anesthesia and versus a standard anesthetic practice protocol. One-hundred-twenty adult patients scheduled for minor orthopedic surgery were randomized to receive a desflurane-remifentanil anesthetic controlled either by Narcotrend or by BIS or solely by clinical variables. Anesthesia was induced with 0.4 µg · kg–1 · min–1 remifentanil and 2 mg/kg propofol. After tracheal intubation, remifentanil was infused at a constant rate of 0.2 µg · kg–1 · min–1 whereas desflurane in 1.5 L/min O2/air was adjusted according to clinical variables or the following target values: during maintenance of anesthesia to a value of "D0" (Narcotrend) or "50" (BIS), 15 min before the end of surgery to "C1" (Narcotrend) or "60" (BIS), whereas in the standard protocol group, desflurane was controlled according to clinical variables, e.g., heart rate, arterial blood pressure, movements. Recovery times and desflurane consumption were recorded by a blinded investigator. The desflurane vaporizer was weighed before and after anesthesia and consumption per minute was calculated. Data are mean ± sd. The groups were comparable for demographic data, duration of anesthesia, and mean remifentanil dosages. Compared with standard practice, patients with Narcotrend or BIS monitoring needed significantly less desflurane (standard practice 443 ± 71 mg/min, Narcotrend 374 ± 124 mg/min, BIS monitoring 416 ± 99 mg/min desflurane [both P < 0.05]). However, recovery times were not significantly different between the groups, e.g., opening of eyes 4.7 ± 2.2 versus 3.7 ± 2.0 versus 4.2 ± 2.1 min. During desflurane-remifentanil anesthesia, Narcotrend and BIS monitoring seem to be equally effective compared with standard anesthetic practice: BIS and Narcotrend allow for a small reduction of desflurane consumption whereas recovery times are only slightly reduced.

 

大鼠神经损伤后神经性疼痛增强可能与饮食中omegaω-3脂肪酸有关

Dietary Omega-3 Fatty Acids May Be Associated with Increased Neuropathic Pain in Nerve-Injured Rats

Jordi Pérez, MD*{dagger}, Mark A. Ware, MBBS{dagger}{ddagger}, Stephanie Chevalier, PhD§, Rejeanne Gougeon, PhD§, and Yoram Shir, MD*{dagger}{ddagger}

*Anesthesia Research Unit and {dagger}Pain Centre, Department of Anesthesia, {ddagger}Centre for Research on Pain and §the Nutrition and Food Science Centre, McGill University Health Centre, Montreal, Canada

Anesth Analg 2005 101: 444-448.

 

饮食中某些蛋白质和油脂可降低坐骨神经部分结扎损伤后的慢性疼痛水平。作者通过实验,首次研究了饮食中多不饱和脂肪酸在抑制坐骨神经部分结扎后神经性疼痛方面的作用。六组雄性Wistar大鼠部分结扎坐骨神经前后各一周,均用不含脂肪的酪蛋白饲料进行喂养。另外,分别用ω-3ω-6多不饱和脂肪酸含量明显不同的芥花籽油、玉米油、大麻油、大豆油、葵花油或水进行强饲,每天1ml。记录手术前后大鼠对触摸和伤害性热刺激的反应,并计算部分结扎坐骨神经前后的差值。各组对热刺激的痛觉反应有显著差别(P = 0.005),而对触觉没有差别。喂养大麻油的大鼠对热刺激痛觉过敏,反应最强烈,显著大于反应最轻的喂养玉米油的大鼠(差值分别为24.3 +/- 4.1分和6.1 +/- 3.1分,P < 0.001)。这两种油的ω-6多不饱和脂肪酸的含量相似(大麻油为60%,玉米油为58%)。但ω-3的含量相差28倍(分别为20%0.7%)。饲料中ω-3的水平,而不是ω-6ω-3/ω-6比值与痛觉过敏显著相关(P = 0.006)。因此得出结论,饮食中的油类可能会预测神经性疼痛的程度,这种影响可能与ω-3的含量有关。结论:作者发现某些常用的油类对部分神经损伤引起的持续疼痛有显著的镇痛效应。该效应可能与摄入的ω-3脂肪酸总量有关。

(赵延华 陈杰 校)

certain dietary proteins and oils are capable of decreasing chronic neuropathic pain levels in rats after partial sciatic nerve ligation injury. We tested, for the first time, the role of dietary polyunsaturated fatty acids in suppressing pain in partial sciatic nerve ligation-injured rats. Six groups of male Wistar rats were fed an identical casein-based, fat-free diet for 1 wk preceding partial sciatic nerve ligation injury and for 1 wk thereafter. In addition, rats received, via gavage, 1 mL/day of pure canola, corn, hemp, soy, or sunflower oil, differing significantly in their {omega}-3 and {omega}-6 polyunsaturated fatty acid content, or 1 mL of plain water. Responses to tactile and noxious heat stimuli were recorded before and after surgery and a difference score was calculated for each group by subtracting the preoperative from the post-partial sciatic nerve ligation values. Heat hyperalgesia, but not tactile allodynia, was significantly different among the dietary groups (P = 0.005). Heat hyperalgesia of rats fed hemp oil, developing the most robust response, was significantly larger compared with rats fed corn oil, developing the least pain model (difference score: 24.3 ± 4.1 s versus 6.1 ± 3.1 s, respectively; P < 0.001). These oils contain similar levels of {omega}-6 polyunsaturated fatty acids (hemp, 60%; corn, 58%) but their {omega}-3 levels are 28-fold different (20% versus 0.7%, respectively). A significant correlation was found among dietary levels of {omega}-3, but not {omega}-6 or the {omega}-3/{omega}-6 ratio, of the six dietary groups and heat hyperalgesia (P = 0.006). We conclude that dietary oil might predict levels of neuropathic pain in rats and that this effect may be associated with dietary {omega}-3 levels.

 

一氧化氮合成酶(NOS)抑制剂在败血症中的作用

Nitric Oxide Synthase Inhibition in Sepsis? Lessons Learned from Large-Animal Studies

Balázs Hauser, MD*{dagger}, Hendrik Bracht, MD*, Martin Matejovic, MD, PhD{ddagger}, Peter Radermacher, MD*, and Balasubramanian Venkatesh, MBBS, MD, FRCA, FFARCSI, FJFICM, MD§

*Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Germany; {dagger}Aneszteziológiai és Intenzív Terápiás Klinika, Semmelweis Egyetem, Budapest, Hungary; {ddagger}IPS, I. Interní Kliniky, Karlova Universita, Plzen, Czech Republic; and §Princess Alexandra & Wesley Hospitals, University of Queensland, Brisbane, Australia

Anesth Analg 2005 101: 488-498.

NO在脓毒血症性休克的病理生理学中的作用具有争议。其血管舒张作用众所周知,但它同时还具有促炎和抗炎作用,在抗微生物宿主反应中起到至关重要的作用,它具有氧化和抗氧化作用,被称作免疫与炎症网络的“致命毒药”。大剂量NO和过氧化亚硝酸盐与高血压、血管麻痹、细胞窒息、细胞凋亡、乳酸酸中毒、以及多器官衰竭有关。因此,研制了一氧化氮合成酶(NOS)抑制剂,用以逆转NO的有害作用。应用这些合剂的研究尚未获得一致的成果,但是,一组研究中应用非选择性NOS抑制剂N-甲基-1-盐酸精氨酸被提前终止,因为虽然休克治疗有效率上升,但死亡率也有所增加。因此,NOS抑制剂在败血症中的应用尚有争议。有文章强调了关于临床适用范围的差异,其数据获取自在啮齿类动物、未复苏、低动力模型应用提前处理,与在高级物种、复苏、高动力模型应用滞后处理的对比研究。因此,当前的研究着眼于临床相关大动物内毒素的研究,或与日常复苏治疗标准相结合的活细菌诱导、高动力败血症模型的研究。

(范颖辉 陈杰 校)

Nitric Oxide (NO) plays a controversial role in the pathophysiology of sepsis and septic shock. Its vasodilatory effects are well known, but it also has pro- and antiinflammatory properties, assumes crucial importance in antimicrobial host defense, may act as an oxidant as well as an antioxidant, and is said to be a "vital poison" for the immune and inflammatory network. Large amounts of NO and peroxynitrite are responsible for hypotension, vasoplegia, cellular suffocation, apoptosis, lactic acidosis, and ultimately multiorgan failure. Therefore, NO synthase (NOS) inhibitors were developed to reverse the deleterious effects of NO. Studies using these compounds have not met with uniform success however, and a trial using the nonselective NOS inhibitor NG-methyl-l-arginine hydrochloride was terminated prematurely because of increased mortality in the treatment arm despite improved shock resolution. Thus, the issue of NOS inhibition in sepsis remains a matter of debate. Several publications have emphasized the differences concerning clinical applicability of data obtained from unresuscitated, hypodynamic rodent models using a pretreatment approach versus resuscitated, hyperdynamic models in high-order species using posttreatment approaches. Therefore, the present review focuses on clinically relevant large-animal studies of endotoxin or living bacteria-induced, hyperdynamic models of sepsis that integrate standard day-to-day care resuscitative measures.


七氟醚和过度通气对顽固性癫痫患者脑棘波活动的影响

The Effects of Sevoflurane and Hyperventilation on Electrocorticogram Spike Activity in Patients with Refractory Epilepsy

Naoko Kurita, MD*, Masahiko Kawaguchi, MD*, Tohru Hoshida, MD{ddagger}, Hiroyuki Nakase, MD{dagger}, Toshisuke Sakaki, MD{dagger}, and Hitoshi Furuya, MD*

Departments of *Anesthesiology and {dagger}Neurosurgery, Nara Medical University, Kashihara; {ddagger}Department of Neurosurgery, Nara Prefectural Nara Hospital, Nara, Japan

Anesth Analg 2005 101: 517-523.

 

本文研究了术中七氟醚和过度通气对13名顽固性癫痫患者脑电图棘波活动的影响。在大脑表面放上栅极并对以下这三种情况作脑电图记录:10.5 MAC的七氟醚,21.5MAC的七氟醚,和31.5MAC七氟醚伴过度通气。评估各种情况下每5分钟脑棘波的数量和有棘波发放的电极的百分数。用0.5MAC1.5MAC七氟醚麻醉的患者与4名长期植入硬膜下电极的患者在清醒状态下当癫痫刚发作时和发作期间的棘波作比较。1.5MAC七氟醚麻醉的患者棘波数量和有棘波发放的电极的百分数明显多于0.5MAC组的患者(P<0.05)。过度通气的介入显著增加了棘波的数量和有棘波发放的电极的百分数(P<0.05)。0.5MAC组的患者,棘波与那些清醒状态下癫痫刚发作的相似,而1.5MAC组的患者,棘波与那些清醒状态下癫痫正在发作的相似。这些结果表明七氟醚和过度通气能影响顽固性癫痫患者脑棘波活动的频率和幅度。因此当术中使用脑电图定位癫痫的损害时,应密切注意七氟醚的浓度和通气的状态。

(朱辉 陈杰 校)

We investigated the effects of sevoflurane and hyperventilation on intraoperative electrocorticogram (ECoG) spike activity in 13 patients with intractable epilepsy. Grid electrodes were placed on the brain surface and ECoG was recorded under the following conditions: 1) 0.5 minimal alveolar anesthetic concentration (MAC) sevoflurane, 2) 1.5 MAC sevoflurane, and 3) 1.5 MAC sevoflurane with hyperventilation. The number of spikes per 5 min and the percentage of leads with spikes were assessed in each condition. In 4 patients with chronically implanted-subdural electrodes, the leads with seizure onset and with spikes during the interictal periods in the awake state were compared with those during sevoflurane anesthesia at 0.5 MAC and 1.5 MAC. The number of spikes and the percentage of leads with spikes were significantly more under 1.5 MAC sevoflurane anesthesia compared with those under 0.5 MAC sevoflurane (P < 0.05). The induction of hyperventilation significantly increased the number of spikes and percentage of leads with spikes (P < 0.05). With 0.5 MAC sevoflurane, the leads with spikes were similar to those at seizure onset in the awake state, whereas with 1.5 MAC sevoflurane, spikes were similar to those occurring during interictal periods in the awake state. These results indicate that sevoflurane and hyperventilation can affect the frequency and extent of ECoG spike activity in patients with intractable epilepsy. Careful attention should be paid to the concentration of sevoflurane used and ventilatory status when intraoperative EcoG is used to localize epileptic lesions.

 

大鼠利多卡因和布比卡因鞘内注射的神经毒性比较

The Comparative Neurotoxicity of Intrathecal Lidocaine and Bupivacaine in Rats

Shinichi Sakura, MD*, Yumiko Kirihara, DVM{dagger}, Tomoko Muguruma, MD*, Tomomune Kishimoto, MD*, and Yoji Saito, MD*

Departments of *Anesthesiology and {dagger}Experimental Animals, Shimane University School of Medicine, Izumo City, Japan

Anesth Analg 2005 101: 541-547.

 

诸多研究对利多卡因和其他局部麻醉药的神经毒性进行了深入的研究,但结果差异很大。目前动物在体实验研究不同麻醉药物神经毒性尚未得到令人信服的结论。因此,本研究以神经系统感觉损伤和组织病理学损伤为观察指标,比较等量利多卡因和布比卡因鞘内注射在神经毒性上的差异。首先,本实验比较利多卡因和布比卡因的相对麻醉效能。大鼠分别给予生理盐水20μL、利多卡因(浓度分别为0.625%、1.25%、2.5%和5%),或者布比卡因(浓度分别为0.125%0.25%、0.5%、1%),以大鼠甩尾试验作为观察指标,观察时间为90min。结果发现利多卡因与布比卡因的相对麻醉效能为14.7095%的可信区间为3.65-6.07)。本实验又以45只大鼠作为研究对象,观察鞘内注射生理盐水20μL2.13%布比卡因(约1.5mg/kg)或10%利多卡因(约6.9mg/kg)对于神经系统功能和形态的持续影响。结果表明鞘内注射利多卡因4天后,大鼠甩尾试验潜伏期以及神经系统的病理损伤明显高于生理盐水组和布比卡因组。综上所述,虽然本实验中所用利多卡因和布比卡因的剂量高于临床使用剂量,本实验研究显示大鼠利多卡因鞘内注射,其神经毒性高于相同浓度的布比卡因,。

(郑拥军 陈杰 校)

There is a considerable difference in the number of reports of neurologic injury in the literature between lidocaine and other local anesthetics. Few in vivo animal studies have produced convincing results showing a difference in neurotoxicity among anesthetics. We investigated whether lidocaine and bupivacaine differ with respect to sensory impairment and histologic damage when equipotent doses of the two are administered intrathecally in rats. First, to determine relative anesthetic potency, rats intrathecally received 20 µL of saline, 0.625%, 1.25%, 2.5%, or 5% lidocaine, or 0.125%, 0.25%, 0.5%, or 1.0% bupivacaine, and were examined with the tail-flick test for 90 min. The potency ratio calculated was approximately 1:4.70 (95% confidence interval, 3.65–6.07) for lidocaine/bupivacaine. In the next experiment, 45 rats intrathecally received 20 µL of saline, 2.13% bupivacaine (approximately 1.5 mg/kg), or 10% lidocaine (approximately 6.9 mg/kg), and were examined for persistent functional impairment and morphologic damage. Rats given lidocaine developed significantly more prolonged tail-flick latencies than those in other groups 4 days after injection and incurred more morphologic damage than those given saline or bupivacaine. In conclusion, although the doses of anesthetics administered were larger than those used clinically, the present results suggest that bupivacaine is less neurotoxic than lidocaine when administered intrathecally at equipotent concentrations in the rat model.

 

大鼠星状神经节阻滞试验的新方法

A Novel Technique for Experimental Stellate Ganglion Block in Rats

Salahadin Abdi, MD, PhD, and Zongqi Yang, MD, PhD

Division of Pain Medicine, Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital/University of Miami, Miami, Florida

Anesth Analg 2005 101: 561-565.

 

星状神经节阻滞在临床上常规用于治疗交感神经导致的疼痛综合症。可是,星状神经节阻滞对心血管的影响尚未很好的阐明。这个研究的目的是建立一个新的鼠星状神经节阻滞模型技术。新技术是后路经皮方法,使用C7棘突软骨作为标记。26Sprague-Dawley雌鼠分为六组。组Ⅰ(n=4)接受右侧星状神经节阻滞,组Ⅱ(n=5)接受左侧星状神经节阻滞,组Ⅲ(n=5)接受双侧星状神经节阻滞,均使用0.25%的布比卡因。另外三个假组(每组n=4)分别作为三个治疗组对照。所有接受星状神经节阻滞的动物都可以观察到上睑下垂。与对照组相比,双侧星状神经节阻滞组45分钟内心率显著下降。但单侧星状神经节阻滞的鼠中心率并没改变。在另外9只鼠中,通过对左侧(n = 3),右侧(n = 3)和双侧星状神经节阻滞(n = 3) 时使用甲基兰进行染色,从而准确评估的星状神经节阻滞。尸解显示12个星状神经节的11个被注射了甲基兰染色。结论:后路经皮星状神经节阻滞是一个可用于今后研究的可靠技术。

(殷文渊 陈杰 校)

A stellate ganglion block (SGB) is routinely performed in a clinical setting for the treatment of sympathetically maintained pain syndromes. However, the cardiovascular effects of SGB have not been well defined. The purpose of the present study was to develop a new technique of SGB in a rat model. Our new technique of SGB is a posterior percutaneous approach and uses the cartilaginous process of the C7 spinous process as a landmark. Twenty-six Sprague-Dawley female rats were divided into six groups. Group I (n = 4) underwent right sided SGB, Group II (n = 5) underwent left-sided SGB, and Group III (n = 5) underwent bilateral SGB using bupivacaine 0.25%. Three additional sham groups (n = 4 in each group) served as controls to each of the three treatment groups. Ipsilateral eyelid droop (ptosis) was observed in all animals that underwent SGB with bupivacaine. Heart rate decreased significantly for up to 45 min after bilateral SGB compared with control groups. However, this value did not change in rats after unilateral SGB. In 9 additional rats, we evaluated the accuracy of SGB by injecting methylene blue to stain the right (n = 3), left (n = 3), and bilateral SGB (n = 3). At autopsy, 11 of 12 SG were stained post-methylene blue injection. We conclude from our study that our new approach, posterior percutaneous SGB is a reliable technique that can be used for further studies.

 

麻醉恢复室中术后尿储留的预测因素

Predictive Factors of Early Postoperative Urinary Retention in the Postanesthesia Care Unit

Hawa Keita, MD, PhD, Elisabeth Diouf, MD, Florence Tubach, MD, Tammo Brouwer, MD, Souhayl Dahmani, MD, Jean Mantz, MD, PhD, and Jean-Marie Desmonts, MD

Department of Anesthesiology and Intensive Care, Hospital Bichat-Claude Bernard, Paris, France

Anesth Analg 2005 101: 592-596.

尿潴留是一种很常见的术后并发症,并与膀胱过度膨胀和永久排尿损害的风险有关。这项研究的目的是确定麻醉恢复室内术后早期尿潴留的预测因素。作者前瞻性地收集313个成人病人各种因子的差异,包括年龄,性别,泌尿系统的一些潜在的既往史,外科手术和麻醉的类型,围术期使用抗胆碱药,体液总量,静注吗啡和进入麻醉监护室时的膀胱容量。每个病人在进入恢复室和离开恢复室时通过超声测量膀胱容量。尿潴留定义为膀胱容量大于600毫升且在30分钟内不能排空。预测因素是通过多元分析法确定。在麻醉恢复室中尿潴留发生率为16%。经多元分析显示术中输液(≥750mlP0.02,概率比=2.3),年龄(≥50P=0.008,概率比=2.4),和进入监护室的膀胱容量(≥270mlP=0.0001,概率比=4.8) 为尿潴留独立相关危险因子。考虑到未被诊断的术后尿潴留对临床的影响,上述结果显示PACU内应使用便携式超声系统评估膀胱的容量,尤其是有危险因数的病人。

(郑丽 陈杰 校)

Urinary retention is a common postoperative complication associated with bladder overdistension and the risk of permanent detrusor damage. The goal of this study was to determine predictive factors of early postoperative urinary retention in the postanesthesia care unit (PACU). We prospectively collected, in 313 adult patients, variables including age, gender, previous history of urinary tract symptoms, type of surgery and anesthesia, intraoperative administration of anticholinergics, amount of intraoperative fluids, IV morphine titration, and bladder volume on entry to the PACU. For each patient, bladder volume was measured by ultrasound on entry and before discharge from the PACU. Urinary retention was defined as a bladder volume larger than 600 mL with an inability to void within 30 min. Predictive factors were identified by multivariate analysis. The incidence of urinary retention in the PACU was 16%. In the multivariate analysis only the amount of intraoperative fluids (≥750 mL; P = 0.02; odds ratio = 2.3), age (≥50 yr; P = 0.008; odds ratio = 2.4), and bladder volume on entry to PACU (≥270 mL; P = 0.0001; odds ratio = 4.8) were found to independently increase the risk of urinary retention. Considering the clinical impact of undiagnosed postoperative urinary retention, these results suggest systematic evaluation of bladder volume with a portable ultrasound device in the PACU, especially in patients with risk factors.

 

监测激活凝血时间用于联合应用肝素和抑肽酶:用SONOCLOT体外评估一种新的抑肽酶不敏感试验

Monitoring Activated Clotting Time for Combined Heparin and Aprotinin Application: An In Vitro Evaluation of a New Aprotinin-Insensitive Test Using SONOCLOT

Michael T. Ganter, MD, DEAA*, Seraina Dalbert{dagger}, Kirk Graves, ECCP{ddagger}, Richard Klaghofer, PhD§, Andreas Zollinger, MD{dagger}, and Christoph K. Hofer, MD, DEAA{dagger}

*Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA; {dagger}Institute of Anesthesiology and Intensive Care Medicine and {ddagger}Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland; and §Department of Psychosocial Medicine, University Hospital Zurich, Zurich, Switzerland

Anesth Analg 2005;101:308-314

 

白陶土激活凝血时间(ACT)通常用于监测心肺旁路期间单独应用肝素的抗凝作用和肝素联合抑肽酶后的抗凝作用。然而抑肽酶延长ACT的测定值。近来开发了一种新的用SONOCLOT分析仪监测,称为“抑肽酶不敏感性”的ACT试验(SaiACT)。在本研究中我们评价和比较了这一体外用SONOCLOT分析仪的新试验和已确立的用HEMOCHRON分析仪的白陶土激活凝血时间(HkACT)。25例行择期瓣膜手术的病人,在麻醉诱导后采血80ml。血液放在枸橼酸试管内,处理后分析肝素 (0123 U · mL–1)、抑肽酶(0200 kIU · mL–1)和用无钙乳酸林格氏液稀释25%ACT值的影响。总共分析了400个血液样本,每份分两份分别用SaiACTHkACT在广泛的临床上相关的范围内测定ACT值。抑肽酶加入肝素化血液样本不引起SaiACT值的明显改变。相反,HkACT值明显升高:抑肽酶分别延长肝素化血液样本的HkACT20% ± 37%(2 U · mL–1)24% ± 18%(3 U · mL–1),体外血液稀释增强这一作用。

(彭中美 李士通 校)

The kaolin-based activated clotting time (ACT) is commonly used for monitoring heparin-induced anticoagulation alone and combined with aprotinin during cardiopulmonary bypass. However, aprotinin prolongs ACT measurements. Recently, a new so-called ‘aprotinin-insensitive‘ ACT test (SaiACT) has been developed for the SONOCLOT analyzer. In this study we evaluated and compared this new test for the SONOCLOT analyzer in vitro with an established kaolin-based ACT from HEMOCHRON (HkACT). Twenty-five patients undergoing elective valve surgery donated 80 mL of blood after induction of anesthesia. The blood was withdrawn in citrated tubes and processed to analyze effects of heparin (0, 1, 2, and 3 U · mL–1), aprotinin (0, 200 kIU · mL–1), and 25% hemodilution with calcium-free lactated Ringer’s solution on ACT measurements. A total of 400 blood samples were analyzed and ACT was measured in a wide, clinically relevant range in duplicate with SaiACT and HkACT. Addition of aprotinin to heparinized blood samples induced no significant changes of SaiACT measurements. By contrast, HkACT readings increased significantly: aprotinin prolonged HkACT in heparinized blood samples by 20% ± 37% (2 U · mL–1) and 24% ± 18% (3 U · mL–1), respectively, and in vitro hemodilution increased this effect.

 

 

七氟醚预处理限制新生儿缺血的心肌细胞内/线粒体内钙离子

Sevoflurane Preconditioning Limits Intracellular/Mitochondrial Ca2+ in Ischemic Newborn Myocardium

Hong Liu, MD*, Lianguo Wang, MD{dagger}, Matt Eaton, BS{dagger}, and Saul Schaefer, MD{dagger}

*Department of Anesthesiology and Pain Medicine; and {dagger}Department of Internal Medicine, Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California

Anesth Analg 2005;101:349-355

 

在成人心脏,七氟醚预处理(SPC)可减少心肌缺血/再灌注(I/R)损伤,效应机制可能是预处理减少了缺血和再灌注时细胞内Ca2+ ([Ca2+]i)/或线粒体内Ca2+([Ca2+]m)的积聚。鉴于新生儿在生理学、药理学及代谢反应方面不同于成人,我们检验了这样一个设想,即SPC通过KATP通道依赖机制限制了[Ca2+]i[Ca2+]m,从而保护新生儿心肌。在Langendorff 离体灌注的4-7日龄的兔心上,用荧光光谱分析和核磁共振光谱分析测量[Ca2+]i[Ca2+]m及三磷酸腺苷(ATP)。实验分三组,研究SPC[Ca2+]m/[Ca2+]iATP及血流动力学和缺血损伤的效应。在SPC心脏,使用线粒体KATP通道阻滞剂5-羟癸酸评价线粒体KATP通道的作用。研究结果表明,SPC显著减少了缺血/再灌注期的[Ca2+]i[Ca2+]m,同时减少再灌注时的肌酸激酶释放,并使ATP浓度增高。而5-羟癸酸则可阻断SPC[Ca2+]、血流动力学、ATP和肌酸激酶释放的这些效应。结论,七氟醚预处理时[Ca2+]i[Ca2+]m的减少,与较多的ATP浓度恢复及较轻的细胞损伤相关。而线粒体KATP 通道的阻滞则削弱了SPC对缺血/再灌注的保护效应,提示这类通道参与了新生儿预处理保护机制。

(周志坚 李士通 校)

Sevoflurane preconditioning (SPC) in adult hearts reduces myocardial ischemia/reperfusion (I/R) injury, an effect that may be mediated by reductions in intracellular Ca2+ ([Ca2+]i) and/or mitochondrial Ca2+ ([Ca2+]m) accumulation during ischemia and reperfusion. Because the physiology, pharmacology, and metabolic responses of the newborn differ from adults, we tested the hypothesis that SPC protects newborn myocardium by limiting [Ca2+]i and [Ca2+]m by a KATP channel-dependent mechanism. Fluorescence spectrofluorometry and nuclear magnetic resonance spectroscopy were used to measure [Ca2+]i, [Ca2+]m, and adenosine triphosphate (ATP) in 4- to 7-day-old Langendorff-perfused rabbit hearts. Three experimental groups were used to study the effect of SPC on [Ca2+]m/[Ca2+]i, ATP, as well as hemodynamics and ischemic injury. The role of mitochondrial KATP channels was assessed by exposing the SPC hearts to the mitochondrial KATP channel blocker 5-hydroxydecanoic acid. Our results show that SPC significantly decreased [Ca2+]i and [Ca2+]m during I/R, as well as decreased creatine kinase release during reperfusion and resulted in higher ATP. 5-Hydroxydecanoic acid abolished the effect of SPC on [Ca2+], hemodynamics, ATP, and creatine kinase release. In conclusion, decreased [Ca2+]i and [Ca2+]m observed with SPC is associated with greater ATP recovery as well as diminished cell injury. Mitochondrial KATP channel blockade attenuates the SPC effect during I/R, suggesting that these channels are involved in the protective effects of SPC in the newborn.


不同剂量异氟醚-芬太尼组合对麻醉后早期恢复及术后不良反应的影响

The Effect of Different Isoflurane-Fentanyl Dose Combinations on Early Recovery from Anesthesia and Postoperative Adverse Effects

Hernán R. Muñoz, MD, MSc, Fernando R. Altermatt, MD, Julio A. González, MD, and Paula J. León, MD

Departamento de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile. Santiago, Chile

Anesth Analg 2005;101:371-376

 

我们评估了不同剂量芬太尼-异氟醚组合对80例腹腔镜胆囊切除术成年病人麻醉后早期恢复的影响。用芬太尼2 μg/kg和硫喷妥钠5 mg/kg进行麻醉诱导,不使用笑气。病人随机分配到四组:第一组(n=20)接受0.6%呼气末异氟醚复合芬太尼,第二组(n=20)接受1.2%呼气末异氟醚复合芬太尼,第三组(n=20)接受1.8%呼气末异氟醚复合芬太尼,第四组(n=20)仅接受异氟醚。在前三组,异氟醚浓度维持恒定,必要时应用芬太尼以使平均动脉压维持在病房里测得的最低平均动脉压的± 10%范围内。在第四组,异氟醚浓度根据上述平均动脉压的标准进行调整。在缝皮结束时关闭异氟醚,并记录自主呼吸产生时间(TSB),拔管时间(TE)及睁眼时间(TEO)。在麻醉后监护室的第一个小时内,每15分钟评估病人的镇静程度、呼吸频率、脉搏氧饱和度、呕吐、疼痛和吗啡用量。以后每半小时评估一次,直至送出监护室。前三组芬太尼的用量分别为8.3 ± 4.5 μg/kg (均数±标准差)、3.8 ± 1.3 μg/kg3.0 ± 0.7 μg/kg(P < 0.001),第四组平均呼气末异氟醚浓度为2.0% ± 0.4%。尽管所有组平均TSB<5.5 min,但是TE从第一组的7.3 ± 5.1 min增加至第四组的20.6 ± 10.7 min(P < 0.001)TEO从第一组的7.4 ± 5.1 min增加至第四组的25.8 ± 9.4 min(P < 0.001)。在麻醉后监护室内的观测指标在各组间均没有差异。本研究表明低浓度的异氟醚复合相对大剂量的芬太尼比高浓度异氟醚复合相对小剂量芬太尼的麻醉后恢复快。

(黄佳佳 李士通

We evaluated the effect of different combinations of fentanyl-isoflurane on early recovery from anesthesia in 80 adult patients undergoing laparoscopic cholecystectomy. Anesthesia was induced with fentanyl 2 µg/kg and thiopental 5 mg/kg. Nitrous oxide was not used and patients were randomly assigned to one of four groups: Group 1 (n = 20) received 0.6% end-tidal isoflurane plus fentanyl, Group 2 (n = 20) received 1.2% end-tidal isoflurane plus fentanyl, Group 3 (n = 20) received 1.8% end-tidal isoflurane plus fentanyl, and Group 4 (n = 20) received only isoflurane. In Groups 1, 2 and 3 isoflurane concentration was kept constant and fentanyl was given as necessary to maintain the mean arterial blood pressure within ± 10% of the minimum mean arterial blood pressure measured in the ward. In Group 4, isoflurane concentration was adjusted to maintain mean arterial blood pressure as above. At the end of skin closure isoflurane was discontinued and the time to spontaneous breathing (TSB), time to extubation (TE) and time to eye opening (TEO) were recorded. In the postanesthesia care unit, the degree of sedation, respiratory rate, Spo2, emesis, pain, and morphine consumption were evaluated every 15 min for 1 h, and thereafter every 30 min until discharge. Fentanyl requirements were 8.3 ± 4.5 µg/kg (mean ± sd) in Group 1, 3.8 ± 1.3 µg/kg in Group 2, and 3.0 ± 0.7 µg/kg in Group 3 (P < 0.001), whereas in Group 4 the mean end-tidal concentration of isoflurane was 2.0% ± 0.4%. Although the mean TSB was <5.5 min in all groups, TE increased from 7.3 ± 5.1 min in Group 1 to 20.6 ± 10.7 min in Group 4 (P < 0.001), and TEO increased from 7.4 ± 5.1 min in Group 1 to 25.8 ± 9.4 min in Group 4 (P < 0.001). There were no differences among the groups in any of the variables measured in the postanesthesia care unit. This study shows that the combination of a small concentration of isoflurane and a relatively larger dose of fentanyl results in a faster recovery from anesthesia than the inverse combination of doses.

 

 

改良溶液引起的游离异丙酚浓度的变化

Changes in Concentrations of Free Propofol by Modification of the Solution

Michiaki Yamakage, MD, PhD, Sohshi Iwasaki, MD, Jun-Ichi Satoh, MD, and Akiyoshi Namiki, MD, PhD

Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Hokkaido, Japan

Anesth Analg 2005;101:385-388

 

因为一般认为游离异丙酚引起注射部位疼痛,我们通过改变异丙酚产品的两种溶剂,调查研究了在中长链甘油三酯乳剂和长链甘油三酯乳剂中,游离异丙酚浓度的变化。该研究中的技术是:1)混和2%利多卡因(10:1)2)5%葡萄糖混和在醋酸化的Ringer’s液中以降低pH(10:1),3)改变温度到20°36°C。异丙酚制品经过了24小时的透析,用高效液相色谱法分析受体媒介。中长链脂肪乳剂中游离异丙酚的浓度比长链脂肪乳剂中的明显小30%。混合利多卡因及冷却均不会降低两种产品中的游离异丙酚浓度。然而pH的下降和温度升高均会降低其浓度。因为混合利多卡因会导致异丙酚乳剂的不稳定,而加温会诱发微生物快速生长,所以推荐异丙酚给药前注射利多卡因以减少注射区域疼痛。在本研究的任何情况下,中长链脂肪乳剂中游离异丙酚浓度明显低于长链脂肪乳剂中的浓度(约30%–45%)。

(黄丽娜 李士通 )

Because free propofol is thought to be responsible for pain on injection, we investigated the changes in concentrations of free propofol by modifying two kinds of propofol products in a medium- and long-chain triglyceride (MCT/LCT) emulsion and in an LCT emulsion. The techniques used in this study were 1) mixing 2% lidocaine (10:1), 2) mixing 5% dextrose in acetated Ringer’s solution to reduce pH (10:1), and 3) changing the temperature to 4°, 20°, and 36°C. The propofol preparations were dialyzed for 24 h, and the receptor medium was analyzed using high-performance liquid chromatography. The concentration of free propofol in propofol MCT/LCT was significantly smaller by 30% than that in propofol LCT. Neither mixing lidocaine nor cooling reduced the concentrations of free propofol in both products, but the concentrations were reduced by a decrease in pH and by an increase in temperature. Because mixing lidocaine can induce instability in an emulsion of propofol and warming can rapidly induce microbial growth, injection of lidocaine before propofol administration is recommended to reduce the pain on injection. The concentrations of free propofol in propofol MCT/LCT were significantly smaller (by approximately 30%–45%) than those in propofol LCT during any situation in this study.

 

 

g-亚单位控制重组g-氨基丁酸A型受体对非制动剂1,2-二氯六氟环丁烷(F6, 2N)阻断作用的敏感性

The {gamma}-Subunit Governs the Susceptibility of Recombinant {gamma}-Aminobutyric Acid Type A Receptors to Block by the Nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6, 2N)

Ewa D. Zarnowska, PhD, Robert A. Pearce, MD, PhD, Abdallah A. Saad, BS, and Misha Perouansky, MD

Department of Anesthesiology, University of Wisconsin, Madison

Anesth Analg 2005;101:401-406

 

为确定麻醉药产生的复合麻醉的不同成分的效应,一些所谓的非麻醉剂/非制动剂类化合物被引入。由于负性的g-氨基丁酸A(GABAA)受体在全麻药调制中枢神经系统(CNS)的效应中起重要作用,而其对不同药物调节作用的敏感性依赖于亚单位的组成,我们对非制动剂1,2-二氯六氟环丁烷(F6){alpha}1ß2{alpha}1ß2{gamma}2s亚单位转染的人胚肾293细胞上所表达的GABAA受体的效应进行了比较。使用快速灌流和全细胞记录技术,我们发现:与异氟醚相似,F6阻断了GABA引起的通过{alpha}1ß2受体的电流;但是,与异氟醚不同的是,{gamma}2s亚单位的存在则完全抵消了F6的阻断作用。同样,与异氟醚相反,F6对在这两类受体中GABA引起的电流的失活动力学都无影响。我们得出结论:对{alpha}ß{gamma}受体的调节在F6的作用机制中几乎不起作用,但是阻断{alpha}ß受体可以促进F6CNS的作用。

(黄施伟 李士通 校)

To identify anesthetic effects that produce the different components of the complex anesthetic state, the so-called nonanesthetics/nonimmobilizer classes of compounds have been introduced. Because ionotropic {gamma}-aminobutyric acid type A (GABAA) receptors play an important role in the mediation of the central nervous system (CNS) effects of general anesthetics, and their susceptibility to modulation by various drugs depends on subunit composition, we have compared the effect of the nonimmobilizer 1,2-dichlorohexafluorocyclobutane (F6) on GABAA receptors expressed in human embryonic kidney 293 cells transfected with {alpha}1ß2 versus {alpha}1ß2{gamma}2s subunits. Using rapid perfusion and whole-cell recording techniques, we found that, like isoflurane, F6 blocked GABA-induced currents through {alpha}1ß2 receptors but, unlike isoflurane, the presence of the {gamma}2s subunit conferred complete resistance to block by F6. Also, in contrast to isoflurane, F6 had no effect on deactivation kinetics of GABA-induced currents in either type of receptor. We conclude that modulation of {alpha}ß{gamma} receptors plays little or no role in the actions of F6, but the block of {alpha}ß receptors may contribute to its effects on the CNS.


连续经气管混合静脉血氧饱和度监测的初步研究

A Pilot Study of Continuous Transtracheal Mixed Venous Oxygen Saturation Monitoring

Wei Wei, MM, Zhaoqiong Zhu, MB, Lunxu Liu, MD, Yunxia Zuo, MM, PhD, Min Gong, PhD, Fushan Xue, MD, and Jin Liu, MD

Departments of Anesthesiology and Cardiothoracic Surgery, West China Hospital, Sichuan University; Department of Physics, Sichuan University, Chengdu, Sichuan, P. R. China; and the Department of Anesthesia, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Beijing, P. R. China.

Anesth Analg 2005;101:440-443

 

本研究旨在探讨经气管混合静脉血氧饱和度(Svo2)监测的可行性和精确性。选取10例行胸外科手术的病人,将一次性儿童脉搏氧饱和传感器连接到主气管和支气管套囊之间的双腔管上。全麻诱导后,插入双腔管,并调整双腔管在气管中的合适位置。手术中的15min里每隔3min采取一次肺动脉血以测量Svo2。在每次经肺动脉采血测量Svo2的同时,记录测量的经气管肺脉搏氧饱和度 (Sto2)。使用BlandAltman方法分析Sto2Svo2之间测量一致性的水平。在数据收集阶段中,Sto2Svo2的均数±标准差(范围)分别为82.0% ± 4.9%(72%91%)82.2% ± 5.5%(71%91%)Sto2Svo2之间的回归分析线性相关系数为0.934(P < 0.05)Sto2Svo2绝对差值的95%可信区间为1.58%2.09%BlandAltman表中,Sto2Svo2差的均数±2倍标准差为0.12% ± 3.97%。我们得出结论,用经气管肺血氧饱和度测量技术来连续监测肺动脉氧饱和度是可行而且是相当精确的。

(邱郁薇 李士通 校)

In this study, we investigated the feasibility and the accuracy of transtracheal mixed venous oxygen saturation (Svo2) monitoring. Ten patients undergoing thoracic surgery were included in this study. A single-use pediatric pulse oximetry sensor was attached to the double-lumen tube between the tracheal and bronchial cuff. After anesthesia was induced, the double-lumen tube was inserted into the trachea and adjusted to the proper position. During surgery, the pulmonary arterial blood was sampled every 3 min for 15 min to measure the Svo2. The measurements made by the transtracheal pulmonary pulse oximeter (Sto2) were recorded at the same time that blood was sampled from the pulmonary artery for Svo2 measurements. The levels of measurement agreement between the Sto2 and the Svo2 were analyzed using the Bland and Altman method. The mean ± sd (range) oxygen saturation values during the data collecting period were 82.0% ± 4.9% (72%–91%) for the Sto2 and 82.2% ± 5.5% (71%–91%) for the Svo2, respectively. The linear correlation coefficient of the regression analysis between the Sto2 and the Svo2 was 0.934 (P < 0.05). A 95% confidence interval for absolute difference between the Sto2 and the Svo2 was 1.58%–2.09%. The mean ± 2 sd difference between the Sto2 and the Svo2 was 0.12% ± 3.97% on the Bland and Altman graph. We conclude that it is feasible to monitor the pulmonary artery oxygen saturation continuously by a transtracheal pulse oximetry technique and that it can be done so accurately.

 

 

对慢性缩窄性神经损伤沙鼠的丙酮喷雾测试的行为学和药理学确认

A Behavioral and Pharmacological Validation of the Acetone Spray Test in Gerbils with a Chronic Constriction Injury

Kris Vissers, MD, PhD*, and Theo Meert, PhD, PhD{dagger}

*Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium; {dagger}J&J PRD, a division of Janssen Pharmaceutica, Beerse, Belgium

Anesth Analg 2005;101:457-464

 

冷刺激和机械刺激所致的痛觉过敏是神经痛患者的重要症状。动物试验中研究冷刺激所致痛觉过敏有助于我们理解神经性疼痛的基础病理生理学机制及验证药物效果。评估慢性坐骨神经缩窄性损伤沙鼠在制冷板上对冷刺激的痛觉过敏并不一定稳定。本研究开发了一种通过Eppendorf®多等级细管以一种特定喷雾技术应用丙酮的新方法。在整个测试时段内机械刺激和丙酮喷雾可诱发慢性坐骨神经缩窄性损伤沙鼠长时程超敏反应,假手术组不出现此种现象。丙酮喷雾测试体现了一种不同于直接冷刺激的多模式刺激。对丙酮喷雾的反应在时程和强度上不仅与沙鼠对机械刺激所致痛觉过敏的反应一致,还和在其他物种上所观察到的机械刺激及热刺激所致的痛觉过敏一致。此外还运用不同的参考化合物对丙酮喷雾测试进行了药理学验证。对啮齿类动物神经性疼痛模型有效的不同化合物对急性和慢性给予丙酮喷雾所致的超敏反应也有影响。本研究表明多模式丙酮喷雾测试在啮齿类神经性疼痛的研究中是一个有价值的工具。

(周雅春 李士通 校)

Cold and mechanical allodynia are important symptoms in patients with neuropathic pain. The study of cold allodynia in animals can help us to understand the underlying pathophysiological mechanisms of neuropathic pain and to validate drugs. The evaluation of cold allodynia in gerbils with a chronic constriction injury of the sciatic nerve on the cold plate is not always stable. We developed a new application method of acetone using a specific spray technique with an Eppendorf® multistepper pipette. The chronic constriction injury of the sciatic nerve in gerbils resulted in a long-lasting mechanical and acetone spray-induced hyperreactivity throughout the testing period, which is clearly different from what was seen in sham-operated animals. The acetone spray test incorporates a multimodal stimulus different from direct cold stimulation. The reactivity to the acetone spray coincides in time and strength with the reactivity observed in mechanical allodynia in gerbils and with mechanical and thermal allodynia in other species. Furthermore, a pharmacological validation of the acetone spray test by different reference compounds was performed. Different compounds effective in neuropathic pain models in rodents influence the hyperreactivity to the acetone spray after acute and chronic administration. This study indicates that the multimodal acetone spray test is a valuable tool in the study of neuropathic pain in rodents.


七氟醚削弱大鼠脑血流的自体调节:被非选择性一氧化氮合酶抑制剂逆转

Sevoflurane Impairs Cerebral Blood Flow Autoregulation in Rats: Reversal by Nonselective Nitric Oxide Synthase Inhibition

Christian Werner, MD*, Hong Lu, MD{dagger}, Kristin Engelhard, MD*, Nikolaus Unbehaun, MD{ddagger}, and Eberhard Kochs, MD{dagger}

*Klinik für Anästhesiologie, Johannes Gutenberg-Universität, Mainz; {dagger}Klinik für Anaesthesiologie and {ddagger}Chirurgische Klinik und Poliklinik, Technische Universität, München, Germany

Anesth Analg 2005;101:509-516

 

在此研究中,我们观察了应用非选择性一氧化氮(NO)合酶抑制剂前后,1.02.0最小肺泡浓度(MAC)的七氟醚对大鼠的脑血流(CBF)自体调节的影响。大鼠被随机分组如下:组1(n = 8)1.0 MAC七氟醚;组23(每组n = 8)2.0 MAC七氟醚。在给予左旋精氨酸甲酯(l-NAME30 mg/kg IV,组1和组2)前后或在低碳酸血症期间,通过分级出血来评估在140-160mmHg的平均动脉压范围内的自体调节能力。在附加的10个动物中,测量1.02.0MAC七氟醚时的脑组织NO2浓度。在1.0MAC七氟醚时(组1),不管NO合酶状态如何都能维持CBF的自体调节能力,表明CBF的自体调节可能和NO存在无关。七氟醚剂量依赖性地增加脑组织的NO2浓度和削弱CBF自体调节。应用l-NAME (2)恢复CBF自体调节,但低碳酸血症(3) 没有此作用。这表明七氟醚削弱自体调节能力继发于血管周围NO的增加,并且质疑脑血管的基础张力(血管舒张能力)在低血压时的重要性。

(张曦 李士通 校)

In this study, we investigated the effects of 1.0 and 2.0 minimum alveolar anesthetic concentration (MAC) sevoflurane on cerebral blood flow (CBF) autoregulation before and after nonselective inhibition of nitric oxide (NO) synthase in rats. Rats were randomly assigned as follows: Group 1 (n = 8): 1.0 MAC sevoflurane; Groups 2 and 3 (n = 8 per group): 2.0 MAC sevoflurane. Assessment of autoregulation within a mean arterial blood pressure range of 140–60 mm Hg was performed by graded hemorrhage before and after administration of l-arginine methyl ester (l-NAME, 30 mg/kg IV, Groups 1 and 2) or during hypocapnia (Group 3). In 10 additional animals, brain tissue NO2 concentrations were measured at 1.0 and 2.0 MAC sevoflurane. CBF autoregulation was maintained with 1.0 MAC sevoflurane (Group 1) regardless of NO synthase status indicating that CBF autoregulation might not be related to NO availability. Sevoflurane dose-dependently increased brain tissue NO2 and impaired CBF autoregulation. Administration of l-NAME (Group 2) but not hypocapnia (Group 3) restored CBF autoregulation. This suggests that sevoflurane impairs the autoregulatory capacity secondary to an increase of the perivascular NO availability and questions the importance of basal cerebrovascular tone in terms of vasodilatory capacity during hypotensive challenges.


Espocan®Tuohy穿刺针用于无痛分娩腰-硬联合方法的比较

A Comparison of Espocan® and Tuohy Needles for the Combined Spinal-Epidural Technique for Labor Analgesia

Ingrid M. Browne, MB, BCh, BAO, FFARCSI, David J. Birnbach, MD, Deborah J. Stein, MD, David A. O'Gorman, MD, FFARCSI, and Maxine Kuroda, MPH, PhD

Departments of Anesthesiology, University of Miami School of Medicine, Miami, Florida; and St. Luke's-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York

Anesth Analg 2005;101:535-540

 

当无痛分娩使用套针进行腰-硬联合阻滞(CSE)方法时,不能发现脑脊液(CSF)、异感以及导管在鞘内移动或置入血管内等这些问题是常被关注的。硬膜外穿刺针附带腰麻针孔,如背孔式Espocan®穿刺针可以减少这些危险。我们比较了改良的硬膜外针(ES)和传统的Tuohy针用于CSE的效果和不良事件。100名临产要求行无痛分娩(CSE)的产妇随机分为2组:50名用ES 18号改良硬膜外穿刺针复合27Pencan®防损伤腰麻针,50名用传统的18Tuohy针复合27Gertie Marx防损伤腰麻针。获得关于鞘内或血管内置管、腰麻针进入时异感、硬膜外针置入后通过腰麻针不能得到CSF、无意刺破硬膜以及硬膜外导管功能的信息。两组都未发生鞘内置管。血管内置管和无意刺破硬膜的几率两组相仿。有显著差异的是腰麻针引起的异感(ES14%Tuohy42%, P = 0.009)和首次穿刺时不能得到CSFES8%Tuohy28%, P < 0.02)。使用ES针用于CSE可明显减少置入腰麻针时的异感,且更易首次穿刺就成功置入腰麻针。

(朱 李士通 校)

When using the needle-through-needle combined spinal-epidural (CSE) technique for labor analgesia, failure to obtain cerebrospinal fluid (CSF), paresthesias, and intrathecal or intravascular migration of the catheter are of concern. Epidural needles with spinal needle apertures, such as the back-hole Espocan® (ES) needles, are available and may reduce these risks. We describe the efficacy and adverse events associated with a modified epidural needle (ES) versus a conventional Tuohy needle for CSE. One-hundred parturients requesting labor analgesia (CSE) were randomized into 2 groups: 50—ES 18-gauge modified epidural needle with 27-gauge Pencan® atraumatic spinal needle, 50—conventional 18-gauge Tuohy needle with 27-gauge Gertie Marx atraumatic spinal needle. Information on intrathecal or intravascular catheter placement, paresthesia on introduction of spinal needle, failure to obtain CSF through the spinal needle after placement of epidural needle, unintentional dural puncture, and epidural catheter function was obtained. No intrathecal catheter placement occurred in either group. Rates of intravascular catheter placement and unintentional dural puncture were similar between the groups. Significant differences were noted regarding spinal needle-induced paresthesia (14% ES versus 42% Tuohy needles, P = 0.009) and failure to obtain CSF on first attempt (8% ES versus 28% Tuohy needles, P < 0.02). Use of ES needles for CSE significantly reduces paresthesia associated with the insertion of the spinal needle and is associated with more frequent successful spinal needle placement on the first attempt.


腰骶段脑脊液容量对高比重布比卡因脊麻时麻醉平面和作用时间的影响:坐位和侧卧位注射的比较

The Influence of Lumbosacral Cerebrospinal Fluid Volume on Extent and Duration of Hyperbaric Bupivacaine Spinal Anesthesia: A Comparison Between Seated and Lateral Decubitus Injection Positions

Hideyuki Higuchi, MD*, Yushi Adachi, MD{dagger}, and Tomiei Kazama, MD{dagger}

*Department of Anesthesia, Self Defense Force Hanshin Hospital, Hyogo; and {dagger}Department of Anesthesiology, National Defense Medical College, Saitama, Japan

Anesth Analg 2005;101:555-560

 

我们设计了本研究以比较病人侧卧位或坐位注药时,腰骶段脑脊液容量对高比重布比卡因脊麻扩散和作用时间的影响。74例脊麻下行表浅的整形外科手术或泌尿科手术病人列入研究范围。从椎管磁共振影像计算出腰骶段脑脊液容量。病人被随机分入两组:侧卧位组(L)和坐位组(S)(每组n = 37)。使用25号铅笔型穿刺针行脊麻穿刺(3 mL高比重0.5%布比卡因),针孔朝向头侧,侧卧位组病人非手术部位位于上侧(L),或者病人在坐位下穿刺(S)。病人脊麻注射后立即转为平卧位(L),或脊麻注射后再坐2分钟(S)。采用Spearman等级相关法估计统计相关系数({rho})。脑脊液的容量和感觉阻滞峰平面在L(ρ= –0.69, P < 0.0001)S(ρ= –0.68, P < 0.0001)均呈负相关。S组中,脑脊液容量与感觉阻滞峰平面出现的时间(ρ= –0.48, P = 0.004)、平面消退到L1–4所需的时间(P < 0.05–0.01)明显相关,但L组并不如此。我们得出结论,不管病人在何种体位下行脊麻注射,脑脊液的容量都会影响高比重布比卡因脊麻的扩散。病人处于坐位时,脑脊液的容量影响脊麻感觉阻滞的时间,但病人侧卧位注射时则没有明显影响。

(张莹 李士通 校)

We designed the present study to examine the influence of lumbosacral cerebrospinal fluid (CSF) volume on the spread and duration of hyperbaric bupivacaine spinal anesthesia when the injection is made with the patient in the lateral position compared with that when the patient is in a seated position. Seventy-four patients undergoing peripheral orthopedic or urogenital surgery with spinal block were enrolled. Lumbosacral CSF volumes were calculated from axial magnetic resonance images. Patients were randomly assigned to 1 of 2 groups: the lateral (L) and seated (S) groups (n = 37 each). Spinal anesthesia (3 mL hyperbaric 0.5% bupivacaine) was administered using a 25-gauge pencil-type needle with the needle aperture directed cephalad and the patient in the lateral decubitus position with the non-operated side up (L group) or with the patient in a seated position (S group). Patients were turned supine immediately after spinal injection (L group) or after remaining seated for 2 min (S group). Statistical correlation coefficients ({rho}) were assessed using Spearman’s rank correlation. There were negative correlations between CSF volume and peak sensory block level in both the L ({rho} = –0.69, P < 0.0001) and S groups ({rho} = –0.68, P < 0.0001). In the S group, but not in the L group, CSF volume significantly correlated with onset time of peak sensory block level ({rho} = –0.48, P = 0.004), and time required for regression to L1–4 (P < 0.05–0.01). We conclude that CSF volume influences the spread of spinal anesthesia with hyperbaric bupivacaine regardless of patient position when the spinal injection is made. CSF volume influenced the duration of spinal sensory anesthesia when the injection was made with the patient in a seated position, but not in the lateral position.

 

 

关节镜下辅助的前交叉韧带重建术后关节腔内患者自控区域麻醉:罗哌卡因/吗啡/酮咯酸合液与罗哌卡因/吗啡合液的对比

Intraarticular Patient-Controlled Regional Anesthesia After Arthroscopically Assisted Anterior Cruciate Ligament Reconstruction: Ropivacaine/Morphine/Ketorolac Versus Ropivacaine/Morphine

Neli Vintar, MD*, Narinder Rawal, MD, PhD{dagger}, and Matjaz Veselko, MD{ddagger}

*Department of Anesthesiology and Intensive Care, {dagger}Department of Traumatology, University Medical Center Ljubljana, Slovenia, {ddagger}Department of Anesthesiology, University Hospital Orebro, Sweden

Anesth Analg 2005;101:573-578

 

前交叉韧带重建(ACLR)术后有中等到重度的疼痛。我们比较了在脊麻下行前交叉韧带重建术后的患者,采用罗哌卡因、吗啡、有或无酮咯酸的药液关节腔内镇痛,观察静息和运动时的效果及另需IV吗啡的用量。39名患者行关节腔内患者自控区域镇痛,单次量10ml,锁定间隔60分钟。将病人随机分为3组:RM组接受0.25%罗哌卡因和0.2mg/mL吗啡合液;RMK组接受0.25%罗哌卡因、0.2mg/mL吗啡以及1mg/mL的酮咯酸合液;P组接受生理盐水。镇痛药混合液在100mL袋中配备,并编码。如需要则自控静脉追加2mg吗啡,锁定间隔为10分钟。分别评估患者静息和运动时的疼痛评分和满意度。三组患者的疼痛评分和满意度没有显著性差异。RMK组的日均吗啡消耗量(8 ± 8 mg)小于RM(23 ± 20 mg;P = 0.002)。两组吗啡消耗量均小于P(46 ± 21 mg; P < 0.001)。结论:患者关节腔内自控区域镇痛可有效缓解前交叉韧重建术后的疼痛。关节腔内复合应用罗哌卡因、吗啡和酮咯酸的效果好于安慰剂组和罗哌卡因和吗啡合液组。

(赵雪莲 李士通 校)

Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe postoperative pain. We compared the intraarticular analgesic effects of ropivacaine and morphine with or without ketorolac and the need for rescue IV morphine at rest and during movement in patients undergoing anterior cruciate ligament reconstruction during spinal anesthesia. Thirty-nine patients receiving intraarticular patient-controlled regional analgesia with a 10-mL bolus and a 60-min lockout interval were randomized into 3 groups: the RM group received 0.25% ropivacaine and morphine 0.2 mg/mL; the RMK group received 0.25% ropivacaine, morphine 0.2 mg/mL and ketorolac 1 mg/mL; the P group received saline. Analgesic mixtures were prepared in 100-mL bags and coded. If needed, rescue morphine 2 mg was self-administered IV with 10-min lockout intervals. Pain scores and patient satisfaction were assessed at rest and during movement. There were no significant differences among the groups in pain scores and patient satisfaction. Daily morphine consumption was significantly smaller in the RMK group (8 ± 8 mg) compared with the RM group (23 ± 20 mg; P = 0.002) and in both groups compared with control (46 ± 21 mg; P < 0.001). We conclude that intraarticular patient-controlled regional analgesia provides effective pain relief after anterior cruciate ligament reconstruction. The combination of intraarticular ropivacaine, morphine, and ketorolac was superior to control or to a combination of ropivacaine and morphine.


术中液体限制改善大的择期胃肠道手术的预后

Intraoperative Fluid Restriction Improves Outcome After Major Elective Gastrointestinal Surgery

Girish P. Joshi, MB, BS, MD, FFARCSI

Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center

Anesth Analg 2005;101:601-605

 

液体治疗是围术期处理中最有争议的话题之一。关于在择期大手术中液体复苏的质量和类型一直有争议。但是围术期血容量过多使术后发病率和死亡率升高的报导越来越多。最近的证据提示明智的围术期液体治疗改善大的择期胃肠道手术的预后。观察到的益处可能不只是归因于晶体的限制,还归因于胶体的应用。基于在本综述中所讨论的研究的一些临床上有用的指南包括避免深全麻及消除接受硬膜外镇痛的病人的预负荷。一般推荐一个液体处理的均衡办法,即给予胶体以提供血流动力学的稳定性和维持排尿0.5 mL · kg–1 · h–1,给予晶体只用于维持。另外,可以用胶体以量对量原则补充失血量。而且,建议补充第三间隙丢失和利尿丢失的预定运算法则是不必要的。仅仅通过避免补充第三间隙丢失和预负荷就可达到晶体量的显著减少,而不会面临术中血流动力学不稳定或排尿减少(即< 0.5 mL · kg–1 · h–1)。最后,仍然需要有良好对照、在特定的病人人群中、有明确标准或研究目标的研究,来探讨围术期液体治疗。

(马皓琳 李士通 校)

Fluid therapy is one of the most controversial topics in perioperative management. There is continuing debate with regard to the quantity and the type of fluid resuscitation during elective major surgery. However, there are increasing reports of perioperative excessive intravascular volume leading to increased postoperative morbidity and mortality. Recent evidence suggests that judicious perioperative fluid therapy improves outcome after major elective gastrointestinal surgery. The observed benefits may not be solely attributable to crystalloid restriction but also to the use of colloids instead. Some clinically useful guidelines based on the studies discussed in this review include avoidance of deep general anesthesia and elimination of preload for patients who receive epidural analgesia. A balanced approach to fluid management is recommended, with colloids administered to provide hemodynamic stability and maintain urine output of 0.5 mL · kg–1 · h–1 and crystalloids administered only for maintenance. In addition, blood loss may be replaced with colloid on a volume-to-volume basis. Furthermore, predetermined algorithms that suggest replacement of third space losses and losses through diuresis are unnecessary. Significant reduction in crystalloid volume can be achieved without encountering intraoperative hemodynamic instability or reduced (i.e., < 0.5 mL · kg–1 · h–1) urinary output just by avoiding replacement of third space losses and preloading. Finally, there is a need for well-controlled studies in a well-defined patient population using clear criteria or end-points for perioperative fluid therapy.