Anesthesia & Analgesia

August 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

監測啟動凝血時間用於聯合應用肝素和抑肽酶:用SONOCLOT體外評估一種新的抑肽酶不敏感試驗

(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.

七氟醚對血管緊張素II誘導、p44/42促分裂原活化蛋白激酶介導的大鼠主動脈平滑肌收縮的抑制作用

(王麗珺譯 薛張綱校)

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:

兒童超聲介導下置入硬膜外導管

(曹瑜 陳傑 校)

Ultrasound-Guided Epidural Catheter Insertion in Children

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

Anesth Analg 2005 101: 333-339.

取小豬模型研究低溫低流量心肺轉流對初生腦的損傷類型

(王麗珺譯 薛張綱校)

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.

七氟醚預處理限制新生兒缺血的心肌細胞內/線粒體內鈣離子

(周志堅 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.

靜脈內使用樞複寧和安慰劑對全麻下手術的124月小兒預防術後嘔吐一項雙盲比較試驗

(顧漪聞 陳傑 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:

體外震波碎石時單用瑞芬太尼的鎮痛效果和副作用在不同輸注劑量時的比較

(金 薛張綱 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:

不同劑量異氟醚-芬太尼組合對麻醉後早期恢復及術後不良反應的影響

(黃佳佳 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.

性別對七氟醚或丙泊酚意識消失作用的影響

(張美榮 陳傑 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.

靜脈誘導全身麻醉中出現呵欠是否是短暫覺醒改變的表現

(金 路譯 薛張綱校)

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.

改良溶液引起的遊離異丙酚濃度的變化

(黃麗娜 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.

術前“芬太尼激發”做為一評估長期使用阿片類藥物患者術後阿片類使用劑量的工具

(張宇 陳傑 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.

地氟醚吸入濃度的快速增加不伴有癲癇樣腦電圖
(孫志榮 薛張綱 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-亞單位控制重組g-氨基丁酸A型受體對非制動劑1,2-二氯六氟環丁烷(F6, 2N)阻斷作用的敏感性

(黃施偉 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.

煙鹼受體的抑制在氯胺酮誘導的行為變化中的作用

(顧新宇 陳傑 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受體並非異氟烷產生遺忘和抑制作用的主要目標

(許文妍 薛張綱 )

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-瑞芬太尼麻醉期間NarcotrendBIS的監測:與標準方法的比較

(蘇殿三 陳傑 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.

麻醉和清醒狀態下聽覺刺激對AEP監測/2起源合成聽覺誘發電位指數的影響

(蔡美華譯 薛張綱校)

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.

連續經氣管混合靜脈血氧飽和度監測的初步研究

(邱鬱薇 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:

大鼠神經損傷後神經性疼痛增強可能與飲食中omegaω-3脂肪酸有關

(趙延華 陳傑 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.

疼痛相關和眼急動相關腦啟動之間相互作用的交叉模型:通過事件相關的功能性磁共振成像的初步研究

(孫敏莉譯 薛張綱校)

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.

對慢性縮窄性神經損傷沙鼠的丙酮噴霧測試的行為學和藥理學確認

(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)抑制劑在敗血症中的作用

(範穎輝 陳傑 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:

瑞芬太尼複合異丙酚全麻行清醒功能性腦地形圖監測前顱骨切開術的回顧性分析

(金琳 薛張綱 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.

七氟醚削弱大鼠腦血流的自體調節:被非選擇性一氧化氮合酶抑制劑逆轉

(張曦 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

七氟醚和過度通氣對頑固性癲癇患者腦棘波活動的影響

(朱輝 陳傑 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.

糾正觀念:氯胺酮能否應用與腦神經損傷病人?

(沈 薛張綱 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穿刺針用於無痛分娩腰-硬聯合方法的比較

(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內注射的神經毒性比較

(鄭擁軍 陳傑 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.

布比卡因和羅呱卡因用於連續周圍神經阻滯後對肌肉的遠期毒性作用

(吳德華譯 薛張綱校)

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.

腰骶段腦脊液容量對高比重布比卡因脊麻時麻醉平面和作用時間的影響:坐位和側臥位注射的比較

(張瑩 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.

大鼠星狀神經節阻滯試驗的新方法

(殷文淵 陳傑 校)

A Novel Technique for Experimental Stellate Ganglion Block in Rats

Salahadin Abdi and Zongqi Yang

Anesth Analg 2005 101: 561-565.

結腸手術病人鞘內應用可樂定的短期鎮痛和長期抗痛覺過敏的效果

(周曉敏 薛張綱 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.

關節鏡下輔助的前交叉韌帶重建術後關節腔內患者自控區域麻醉:羅呱卡因/嗎啡/酮咯酸合液與羅呱卡因/嗎啡合液的對比

(趙雪蓮 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:

麻醉恢復室中術後尿儲留的預測因素

(鄭麗 陳傑 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.

體位改變對未禁食者胃食管反流及屏障壓的影響

(孫少瀟譯 薛張綱校)

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.

術中液體限制改善大的擇期胃腸道手術的預後

(馬皓琳 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.

 

七氟醚對血管緊張素II誘導、p44/42促分裂原活化蛋白激酶介導的大鼠主動脈平滑肌收縮的抑制作用

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

七氟醚以劑量依賴方式擴張血管,降低動脈血壓。血管緊張素II(Ang II)是調節血管張力和動脈血壓的主要因素之一,而p44/42促分裂原活化蛋白激酶(p44/42 MAPK)AngII介導的血管平滑肌收縮相關。我們設計了這一試驗來研究七氟醚對血管緊張素II誘導、p44/42促分裂原活化蛋白激酶介導的大鼠主動脈平滑肌收縮的作用。我們採用等容測量法和蛋白印記分析分別檢驗了p44/42 MAPK激酶抑制劑, 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%)對於Ang II介導的收縮及p44/42 MAPK磷酸化在大鼠主動脈平滑肌上的作用。Ang II介導了短暫的收縮反應以及p44/42 MAPK的磷酸化,而後者又主要被PD 098059拮抗 (P < 0.05–0.01)。七氟醚以劑量依賴方式抑制了血管緊張素II介導的收縮反應(3.4% 5.1% 的七氟醚分別為P<0.050.01),七氟醚也降低了血管緊張素II誘發的p44/42 MAPK磷酸化(3.4%5.1% 的七氟醚均為P<0.05)。這一結果表明:七氟醚對於血管緊張素II介導的血管收縮的抑制作用,至少部分是由於對p44/42 MAPK介導的信號通道的抑制引起。

(王麗珺譯 薛張綱校)

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.

 

取小豬模型研究低溫低流量心肺轉流對初生腦的損傷類型

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

低流量心肺轉流(LF-CPB)是新生兒心臟手術中廣泛應用的一種模式。在方便手術修補的同時,也增加了由於低灌注引起神經損傷的危險性。在該試驗中,我們用小豬低溫LF-CPB模型研究了損傷類型及影響因素。小豬被麻醉、氣管插管、輔助通氣,並準備好心肺復蘇(CPR)。當LF-CPB 150分鐘後,pH固定計測定大腦溫度為22°C,試驗動物允許存活29天。每日評價神經狀態並做磁共振。大腦從組織學上評價。我們發現,CPR 1天、2天、9天後的神經功能損傷率分別為64%, 30%, 0%。所有試驗動物都有組織學上的腦損傷,主要累及新大腦皮層和海馬,基底節、丘腦、白質及小腦也有受累。細胞死亡作為選擇性的神經壞死出現在新大腦皮層深部和海馬的14區。即使採用pH固定計測量,新大腦皮層和海馬的損傷僅有很小部分與動脈高CO2有關。海馬損傷很少與高血糖有關。神經功能和基底節損傷很少與術後高紅細胞比容有關。

(王麗珺譯 薛張綱校)

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.

 

體外震波碎石時單用瑞芬太尼的鎮痛效果和副作用在不同輸注劑量時的比較

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.

該隨機雙盲研究被設計用來評價腎結石病人行體外震波碎石(ESWL)時採用兩種不同瑞芬太尼輸注速率時的鎮痛效果和副作用。該研究包括200個病人,分別給予瑞芬太尼0.05 μg · kg–1 · min–1 (n = 100)0.1 μg · kg–1 · min–1 (n = 100),都通過病人自控鎮痛(PCA)裝置需要時加用10μg單次給藥劑量。不另用其他鎮靜劑。對PCA的所需次數和輸注量進行記錄。整個操作過程中記錄動脈血壓、氧飽和度和呼吸頻率;治療結束後記錄術後噁心嘔吐(PONV)、眩暈、瘙癢、煩躁和呼吸抑制發生率。在術前、術後即刻、術後30分分別記錄疼痛的視覺類比評分值。結果顯示,在PCA需要次數、PCA給藥量及圍術期VAS評分方面沒有顯著的統計學差異。而術後即刻和30分鐘時PONV程度和眩暈、瘙癢發生例數在小劑量組有明顯減少。我們可以得出結論,瑞芬太尼0.05 μg · kg–1 · min–1維持量加10μg單次給藥劑量優於0.1 μg · kg–1 · min–1維持量加單次給藥劑量。因為在兩組病人之間疼痛視覺類比評分記錄上沒有顯著差別,而在接受ESWL治療的病人中,小劑量組有較低的副作用的發生率。

(金 薛張綱 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.

 

靜脈誘導全身麻醉中出現呵欠是否是短暫覺醒改變的表現

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.

 

雖然呵欠在靜脈誘導的全身麻醉中經常發生,但這種反應的意義仍然不為人所知。在本研究中,我們對30個手術病人採用硫噴妥鈉4mg/kg靜脈注射誘導,30個手術病人採用異丙酚2mg/kg靜脈注射誘導。然後,對呵欠發生的情況進行連續地評估一分鐘,作為唯一的臨床終點。整個觀察過程中採用腦電雙頻譜指數監測。以持續低水平的腦電雙頻譜指數的短暫增大作為覺醒反應的標準。以此標準為基礎,用呵欠反應作為覺醒徵象的靈敏度為77%,特異度為80%。如果某一病人有呵欠反應,則其覺醒的概率為84%(陽性預測值)。而沒有呵欠反應時,則無覺醒的概率為71%(陰性預測值)。根據簡單邏輯回歸分析,呵欠反應作為短暫覺醒反應的預測指標的優勢比為13.595%可信區間:3.8-48P<0.001)。在靜脈誘導中出現呵欠反應可以作為在進一步意識消失過程中出現短暫蘇醒改變的臨床指標。

(金 路譯 薛張綱校)

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.

 

地氟醚吸入濃度的快速增加不伴有癲癇樣腦電圖
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.

 

麻醉面罩誘導時吸入高濃度七氟醚可誘發癲癇樣腦電圖和心動過速。當地氟醚濃度突然增加時也可出現心動過速。還不清楚是否類似七氟醚伴有癲癇樣腦電圖。我們對31個女性麻醉誘導後快速增加七氟醚或者地氟醚濃度時腦電圖和心率進行了研究。麻醉誘導使用異丙酚和瑞米芬太尼進行氣管插管。患者誘導後隨機分配到小劑量七氟醚或者地氟醚複合笑氣和氧氣維持。10分鐘後,七氟醚或者地氟醚揮發罐調節到最高刻度(七氟醚7%,地氟醚18%)5分鐘。記錄心率和腦電圖。癲癇樣腦電圖在七氟醚組15個病人中記錄到8個人,但地氟醚組未記錄到一個(P<0.05)。2組心率都增加。在七氟醚組,HR逐漸的增加,而最高HR數值出現在七氟醚濃度增加後5分鐘。在地氟醚組,HR增加到93bpm於地氟醚濃度增加後2分鐘(沒有顯著的區別,七氟醚和地氟醚比較)。七氟醚快速的增加濃度在通氣正常時經常可誘發癲癇樣腦電圖。地氟醚濃度增加時伴有心動過速不伴有癲癇樣腦電圖。結論:七氟醚快速增加濃度可誘發癲癇樣腦電圖伴心動過速。快速增加地氟醚濃度誘發心動過速不伴有癲癇樣腦電圖。

(孫志榮 薛張綱 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受體並非異氟烷產生遺忘和抑制作用的主要目標

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受體ß3單體上N265M點突變的老鼠對很多種麻醉藥效存在著抵抗,如異丙酚、依託咪酯。相對與野生型鼠而言,它們需要多16%的安氟醚或多21%濃度的氟烷才能抑制撤回反射。我們通過巴甫洛夫試驗來測定是否需要用更多濃度的異氟烷來抑制這一突變種類的條件反射。試驗發現,和野生型鼠相比,異氟烷的濃度沒有顯著意義地上升。我們亦測定了最低肺泡有效濃度(MAC)(能夠抑制50%的突變鼠對傷害性刺激作出反應的最低肺泡有效濃度)。異氟烷對突變鼠的最低肺泡有效濃度(1.93% ± 0.003%; n = 14)較野生型鼠多17.0%(1.65 ± 0.04; n = 14; P < 0.001)。相同地,環丙烷對突變鼠的最低肺泡有效濃度(27.6% ± 0.55%; n = 16)較野生型鼠多13.6%(24.3 ± 0.46; n = 8; P< 0.01)。環丙烷對突變鼠最低肺泡有效濃度的增加出乎我們的意料,因為外界報導在α1β2γ2 γ-氨基丁酸A受體這一異氟烷作用最強的地方,環丙烷只有極微弱的作用。 與先前在α1β2γ2 γ-氨基丁酸A受體所得到的相符,我們發現在爪蟾卵上,5倍的環丙烷最低肺泡有效濃度增加了γ-氨基丁酸在α1β2γ2 γ-氨基丁酸A受體上的作用僅76%,在α1β3γ2 γ-氨基丁酸A受體及α6β3γ2 γ-氨基丁酸A受體上的加強作用也幾乎一致。大相徑庭的是, 非常低濃度的異氟烷(1 MAC)在這些受體上能夠產生160%到310%增效作用。如果,相對於異氟烷而言,環丙烷在任何γ-氨基丁酸A受體的亞體上都是極微弱地增加γ-氨基丁酸介導氯電子流的作用,那麼現在關於MAC的資料就和γ-氨基丁酸A受體不是吸入性麻醉藥產生的抑制作用的介導者這一概念一致。

(許文妍 薛張綱 )

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.

 

麻醉和清醒狀態下聽覺刺激對AEP監測/2起源合成聽覺誘發電位指數的影響

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合成指數(AAITM)從AEP計算得來,但是在低信號質量下全憑自發EEG得來。我們給16名麻醉和清醒狀態下的病人佩戴位置正確的耳機給予聽覺刺激然和取下耳機,來研究聽覺刺激對AAI的影響。AAIAarcotrend&reg;指數(NI),另一種以腦電波為基礎監測鎮靜深度的方法,同步記錄。麻醉和清醒狀態下AAI值正確配對耳機時比不佩戴耳機時要高(p<0.05)但還是在生產商認定的鎮靜狀態的範圍內。在麻醉狀態並正確佩戴耳機的情況下,我們發現AAI頻繁的波動與AEP來源和EEG來源,但病人取下耳機後AAI值完全以EEG為基礎。聽覺刺激對Narcotrend&reg和指數沒有影響。儘管不會誤認為病人鎮靜狀態是AAIAEP來源變為EEG來源,增加這兩種指數方法的協調性是需要的。

(蔡美華譯 薛張綱校)

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.

 

疼痛相關和眼急動相關腦啟動之間相互作用的交叉模型:通過事件相關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關腦啟動顯示較少一致信號,與常規任務相關啟動比較,其信號衰退較早。這可以是由認知或血流動力學相互作用介導的疼痛從上而下抑制而引起的,認知或血流動力學相互作用可以通過其他形式影響啟動。使用事件相關磁共振機能成像,我們通過眼急動這樣的交叉模型相互作用來檢測是否疼痛影響腦啟動。六名右利手志願者右前臂接受50℃的熱疼痛刺激(Pn = 6),並在3.0T核磁共振成像掃描器上進行全腦回波平面成像,執行視覺上介導的眼急動任務(Vn = 6),審查同時發生的疼痛加眼急動的例子(PVn = 5)。綜合平均機能啟動圖並且信號時程在啟動簇被分析。P啟動雙側第二驅體感覺皮層(S2)V啟動額部後方增補的眼區以及視覺區。PV增強了S2的啟動而且啟動了附加疼痛相關區域,包括雙側運動前區、右側腦島、前面及後面的扣帶回皮質。相反地,在PVV相關啟動被減弱。我們提出在眼球運動活動時疼痛使得交叉模型抑制,而且通過觸發對疼痛的注意力眼球運動任務增強疼痛相關啟動。提示:由於對疼痛的注意,疼痛相關腦啟動被增強。在不相關眼急動的神經網路之外,它可以參與自上而下的抑制。

(孫敏莉譯 薛張綱校)

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.

 

瑞芬太尼複合異丙酚全麻行清醒功能性腦地形圖監測前顱骨切開術的回顧性分析

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

這項研究總結了為進行清醒功能性腦地形圖而行顱骨切開術患者,採取靜脈全麻技術的藥物劑量、生理反應及麻醉併發症。回顧分析了98例操作,發現瑞芬太尼的靜脈最快輸注速率為0.050.05–0.09 µg · kg–1 · min–1;異丙酚為115100–150 µg · kg–1 · min–1。輸注的持續時間為7858-98 min。術中全麻蘇醒時間為停止靜脈用藥以便進行腦電地形圖分析後9 (6–13) min,與麻醉藥物輸注持續時間及腦電地形圖分析前顱骨切開的時間無關。用藥過程中,自主呼吸保持良好,Sao2 = 95% (92%–98%) Paco2 = 50 (47–55) mm Hg。但是,也發現在96位患者中,有69人出現至少一次30s的呼吸暫停。用藥期間,動脈收縮壓的最高值為150 (139–175) mm Hg,最低值為100 (70–150) mm Hg3位患者出現術中癲癇發作。2位元患者無法耐受清醒狀態,要求重新進行全麻誘導。沒有患者要求氣管插管或終止手術。對於為進行清醒功能性腦地形圖而行顱骨切開術患者,這種全麻技術是有效的,成為持續清醒或其他靜脈鎮靜技術的替代品之一。

(金琳 薛張綱 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.

 

 

糾正觀念:氯胺酮能否應用與腦神經損傷病人?

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

我們評估了圍手術期和監護設計關於氯胺酮對並有神經損傷或有其危險病人大腦影響的隨機臨床研究報告。我們也回顧了其他關於藥物對人大腦影響的文獻以及檢驗氯胺酮對大腦損傷的實驗性報告。在臨床設計中,循證II級證據表明在合用γ-氨基丁酸受體激動劑、不使用笑氣、應用控制性通氣情況下氯胺酮並不增加顱內壓。因此,氯胺酮可以安全地應用於顱腦神經損傷病人。與其他麻醉藥、鎮靜劑相比,循證IIIII級證據表明氯胺酮引起的血液動力學興奮可以增加腦的灌注,顱腦損傷病人應用鎮靜時使用氯胺酮也是一個不錯的選擇。實驗室研究表明,氯胺酮具有神經保護作用,S(+)氯胺酮有神經再生作用,甚至在腦損傷的當時給藥也有及作用。然而,這些良好結果的報告只是短期恢復期的研究。在生長期動物以及腦部特定區域沒有損傷的成年大鼠,大劑量氯胺酮才引起神經毒性,這可以被聯合應用γ-氨基丁酸受體激動劑預防。結論:氯胺酮可以安全的應用於神經系統損傷的病人,但是要控制呼吸以及聯合應用γ-氨基丁酸受體激動劑並且避免使用笑氣。它有利的迴圈效應以及前期資料顯示的腦保護作用值得進一步實驗和臨床研究。

(沈 薛張綱 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.

 

布比卡因和羅呱卡因用於連續周圍神經阻滯後對肌肉的遠期毒性作用

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.

 

羅比卡因相對布比卡因而言具有更少的肌肉毒性作用。因此,在與臨床相關的背景下作者研究比較布比卡因和羅呱卡因對肌肉的遠期毒性作用。在麻醉後的豬股神經旁放置導管,一組注入5mg/mL的布比卡因20ml,另一組注入7.5mg/mL的羅呱卡因20ml。隨後分別2.5mg/ml的布比卡因和3.75mg/ml的羅呱卡因以8ml/h連續注射6h以上。對照組給予相應容量的生理鹽水。每一組分別在第7天和28天時間點取注射部位的肌肉組織,其組織形態的損傷通過盲評分來計分(從0=無損害 3=明顯受損或肌肉壞死)。對照組中未見形態學改變。實驗期間,兩組局麻藥組中都可見到同樣的鈣化樣肌肉壞死,瘢痕組織形成及明顯的纖維組織增生。而且,布比卡因的肌肉損害作用顯示出了較羅呱卡因更明顯。本研究表明在模擬臨床背景中布比卡因和羅呱卡因都可引起不可逆的骨骼肌肌肉的損害,同時也證實了布比卡因具有更嚴重的肌肉毒性作用。然而,臨床上這兩種局麻藥的遠期肌肉毒性作用仍然需要進一步的評估。結果,兩種長效局麻藥運用于外周神經阻滯後4周,都產生了鈣化樣肌肉壞死,表明有不可逆的骨骼肌損害。然而相對羅呱卡因而言,布比卡因引起的肌肉損害程度更明顯。

(吳德華譯 薛張綱校)

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.

 

結腸手術病人鞘內應用可樂定的短期鎮痛和長期抗痛覺過敏的效果

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,我們調查了可樂定的術後抗痛覺過敏效果。60個行右半結腸切除術的病人進入本研究。病人被隨機化分成三組,全麻前在鞘內分別注入2毫升的可樂定(300毫克)、鹽水或布比卡因(10毫克)。使用靶控輸注異丙酚維持全麻,腦電雙頻指數進行監測。通過病人自控鎮痛裝置予靜注嗎啡行術後鎮痛。通過術後72小時內病人在休息、咳嗽和活動時的嗎啡需要量及視覺類比疼痛評分評估術後鎮痛。通過von Frey細絲測定機械性的痛覺過敏。詢問病人2周、1個月、6個月和12個月後的遺留疼痛情況。在鞘內注射可樂定組病人自控鎮痛的嗎啡需要量顯著減少(術後72小時可樂定組、鹽水組和布比卡因組分別為31.5 +/- 12 mg91 +/- 25.5 mg43 +/- 15 mgP < 0.05)。術後72小時可樂定組、鹽水組和布比卡因組痛覺過敏的面積分別為3 +/- 5 cm(2)90 +/- 30 cm(2)35 +/- 20 cm(2) (P < 0.05)。術後6個月時,可樂定組較鹽水組有更少的病人感覺到殘餘的疼痛(20人中有0個對比20人中有6個,P < 0.05)。我們認為術中鞘內應用可樂定和布比卡因均能提高術後即時的鎮痛效果,但是可樂定比布比卡因能更有效地減少術後繼發性的痛覺過敏。結論:鞘內應用可樂定有助於減少腹部手術病人恢復時繼發性的痛覺過敏。

(周曉敏 薛張綱 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.

 

 

體位改變對未禁食者胃食管反流及屏障壓的影響

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.

 

對於清醒的非禁食患者以最佳體位元(如,頭高位,頭低位元)將胃食管反流造成的胃內容物肺吸入的風險降到最小一直存在爭議。在目前的研究中,我們通過多通道管腔內阻抗測量法和胃內-食管壓力測定法對隨機行20度頭高仰臥位,或20度頭低位的清醒非禁食志願者進行測量,以研究胃食管反流和胃食管屏障壓。在不同體位間,平均每人胃食管反流發作次數(0/1/1)或胃-食管屏障壓(15.6/19.6/19.4 mmHg)並無顯著差異。我們的結論為特殊體位對清醒的非禁食患者預防胃-食管返流無效。提示:在清醒的非禁食患者傾斜至頭高位或頭低位元用以防止胃內容物返流時,其對胃食管返流的發生頻率無影響。

(孫少瀟譯 薛張綱校)

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.

 

兒童超聲介導下置入硬膜外導管

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.

 

硬膜外置管經常應用于病兒術中和術後疼痛的解除。在全身麻醉下細小的解剖結構和導管的置入使得硬膜外置管比較困難也難以避免損害。在這項研究中,作者研究了超聲在兒童硬膜外導管置入和安放中探查神經軸索結構的作用。本次研究物件為ASAI-II級、選擇性手術進行全身麻醉聯合硬膜外麻醉的兒童。病人使用的是平衡麻醉,七氟醚、阿片類藥、羅庫溴胺。在置管前,進行單側超聲檢查來確定神經軸索結構。記錄該結構的影像、部位和深度。用一個無菌藥盒來固定超聲探頭在準確位置,置入硬膜外導管,使用阻力消失技術,同時硬膜外導管在超聲引導下進入理想的深度。25名兒童中有23名參與了評估。硬膜外間隙,黃韌帶,硬膜結構能清晰辨別,並記錄所有病人距離皮膚的深度。經腰部硬膜外途徑穿刺的所有病人有阻力消失。超聲測量深度和阻力消失深度的相關係數是0.8823名病人中有8名在導管置入過程中能顯示硬膜外導管。另外11名病人中通過另一個超聲平面顯示導管。在新生兒和兒童中,超聲是很好的神經軸索結構辨別方法。椎體的大小和不完全骨化能很好地顯示和定位硬膜外間隙的深度,阻力消失以及相關的神經軸索結構。

(曹瑜 陳傑 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.

 

靜脈內使用樞複寧和安慰劑對全麻下手術的124月小兒預防術後嘔吐一項雙盲比較試驗

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.

 

為了瞭解術前預防性注射樞複寧(0.1mg/kg IV)對防治術後噁心嘔吐(POV)的有效性和安全性,作者進行一項雙盲,安慰劑對照研究。選擇670例全麻醉下行手術的小兒(1-24個月)患者, 每組335例(樞複寧組VS安慰劑組)。樞複寧噁心嘔吐情況和提早中斷試驗的發生率明顯少於安慰劑組(樞複寧組, 11%;安慰劑組, 28%;幾率比 = 0.33; P < 0.0001)。需另外加用樞複寧奧坦西隆預防性治療POV的人數大約為6 。樞複寧組較安慰劑組相比,需要急救措施或在術後早期必須採取補救措施的患者更少(樞複寧組, 5%; 安慰劑組, 10%);在使用了補救措施後,樞複寧組的術後嘔吐較少(6個中為0),而安慰劑組較多(21例中發生7例)。年齡為1-12月和13-24月的患者相比,POV的發生率和樞複寧抗嘔吐的作用相似。在小兒是否使用阿片類藥物作為麻醉或鎮痛措施方面,樞複寧組可以較好地耐受,相關的副作用和安慰劑組相似(樞複寧組為1.8% 安慰劑組為1.5%)

(顧漪聞 陳傑 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%).

 

性別對七氟醚或丙泊酚意識消失作用的影響

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.

既往研究顯示性別可能對全麻或緊急催眠藥需要量產生影響。本文作者研究揮發性麻醉藥(七氟醚)或靜脈麻醉藥(丙泊酚)下性別對催眠藥意識消失作用(LOC)中所需劑量的影響。115例未使用術前藥、ASA I-II級、年齡在18-40歲之間的病人,面罩吸入呼吸末濃度事先確定的七氟醚,或在自主呼吸時靶控注入丙泊酚,在足夠的時間使藥物均衡後,用輕度針刺激的反應來評價意識消失。Dixon的上- 下法用於確定50%效應時的催眠劑量(LOC50)。七氟醚麻醉時男性和女性的LOC50無明顯統計學意義(分別為0.83% ± 0.1% 0.92% ± 0.09% ET)。男性需要丙泊酚的劑量明顯多於女性(分別為2.9 ± 0.2 2.7 ± 0.1 µg/mL,)。然而,男性或女性用任何一種催眠藥物時其在LOC狀態下的雙頻指數(BIS)無明顯差別。調查證明男性或女性應用丙泊酚麻醉時,在LOC50狀態下所需劑量有一個小的、統計學有意義的差別異,而在七氟醚麻醉時沒有。正如BIS定義,在LOC50時男性和女性有相同的催眠狀態。表明性別在催眠 所需劑量是無明顯臨床意義。然而,BISLOC50時七氟醚和丙泊酚組有明顯差別,表明這些麻醉藥對神經生理學的效果可能不同。

(張美榮 陳傑 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.

 

術前“芬太尼激發”做為一評估長期使用阿片類藥物患者術後阿片類使用劑量的工具

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

阿片類藥物用於術後鎮痛,它產生的痛覺喪失和呼吸抑制與劑量有密切關係。作者研究了20例脊柱融合手術後長期使用阿片類藥物的病人。每個病人術前給予2ug/kg/min的芬太尼直到其呼吸頻率小於5/min。藥物動力學模型用於評估產生呼吸抑制的效應點和預定一個使30%病人產生呼吸抑制的PCA的設定值。術後PCA調整為每小時2-3個需要劑量。在恒定的PCA速率下,測定動脈血氣和血漿中芬太尼的水平。16位元病人不需要任何調整或只調整1PCA兩。動脈血氣中PCO2的平均水平為41mmHg,在39-46mmHg中波動。血漿中的芬太尼水平顯示術前的芬太尼激發對於芬太尼的效應點劑量和呼吸抑制之間有重要的關係。術前芬太尼激發的藥物動力學模型可能成為一種有用的工具,來個體化指導長期使用阿片類鎮痛劑的患者術後芬太尼用量。

(張宇 陳傑 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.

 

煙鹼受體的抑制在氯胺酮誘導的行為變化中的作用

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.

有一些麻醉藥如氯胺酮和一些揮發性麻醉藥在麻醉或亞麻醉時是煙鹼受體拮抗劑。而異丙酚並不抑制煙鹼受體。為確定氯胺酮抑制煙鹼所引起的潛在的行為變化,作者測定有或沒有某些煙鹼配位基時氯胺酮產生不動、翻正反射抑制和痛覺缺失所需的劑量,並以異丙酚為對照。當用單一麻醉藥時,氯胺酮產生無動和影響翻正反射時腹腔內用藥劑量(IP)分別為383±22mg/kg180±17mg/kg,而異丙酚用量分別為371±34mg/kg199mg/kg。煙鹼受體拮抗劑對異丙酚和氯胺酮劑量沒有什麼影響。當測定亞催眠狀態時傷害性反應,異丙酚不能分辨傷害性刺激前和抗傷害性刺激期間,而氯胺酮劑量大於60mg/kgIP時產生鎮痛作用。廣譜煙鹼受體拮抗劑美加明可以增強氯胺酮的鎮痛作用。上述發現與揮發性麻醉藥作用不同,後者煙鹼受體抑制作用被認為是抗傷害性刺激的原因。總之,氯胺酮拮抗N-甲基-d-天門冬氨酸而產生鎮痛這一作用機制還不明了。

(顧新宇 陳傑 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-瑞芬太尼麻醉期間NarcotrendBIS的監測:與標準方法的比較

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.

 

雙頻指數(BIS) (Aspect Medical Systems, Newton, MA)Narcotrend (MonitorTechnik, Bad Bramstedt, Germany)是兩種不同的麻醉深度監測方法。研究表明以BISNarcotrend監測麻醉深度指導全憑靜脈麻醉時,給藥的劑量和恢復的時間相當,但是目前還缺乏這兩種監測方法指導吸入麻醉的臨床資料。因此研究者設計了本項隨機雙盲的前瞻性研究,對BISNarcotrend監測麻醉深度指導地氟醚-瑞芬太尼麻醉與標準全身麻醉方法進行了比較研究。120名擬行較小整形外科手術的成年患者均接受地氟醚-瑞芬太尼麻醉,隨機分配到三組,分別由NarcotrendBIS和單純依靠臨床徵象調整麻醉深度。應用瑞芬太尼0.4 µg · kg–1 · min–1和丙泊酚2 mg/kg誘導。氣管插管後瑞芬太尼以恒定的速度注射(0.2 µg · kg–1 · min–1),地氟醚的濃度則根據臨床徵象或者兩種監護儀的監測目標(Narcotrend:“D0;BIS:“50”)進行調整,在手術中止前15min調整為"C1" (Narcotrend) "60" (BIS)。在標準全麻組,地氟醚的流量完全依靠臨床徵象進行調整,包括:心率、動脈血壓和體動等。稱量麻醉前後地氟醚揮發罐的重量計算每分鐘消耗量。資料用均數±標準差表示。研究結果發現,各組之間的人口學資料、麻醉時間、平均瑞芬太尼用量沒有顯著差異。與標準全麻操作組相比,應用BISNarcotrend作為指導後地氟醚的用量明顯減少(標準全麻組 443 ± 71 mg/min, Narcotrend 374 ± 124 mg/min, BIS 416 ± 99 mg/min [ P < 0.05])。但是三組間蘇醒時間沒有顯著性差異,睜眼時間分別為:4.7 ± 2.2 VS 3.7 ± 2.0 VS 4.2 ± 2.1 min。在地氟醚-瑞芬太尼麻醉中與標準全麻相比應用BISNarcotrend作為麻醉深度監測的指導效果相似。BISNarcotrend監測使地氟醚的消耗量輕度減少,但是對蘇醒時間的影響甚微。

(蘇殿三 陳傑 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.

 

大鼠神經損傷後神經性疼痛增強可能與飲食中omegaω-3脂肪酸有關

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.

 

飲食中某些蛋白質和油脂可降低坐骨神經部分結紮損傷後的慢性疼痛水平。作者通過實驗,首次研究了飲食中多不飽和脂肪酸在抑制坐骨神經部分結紮後神經性疼痛方面的作用。六組雄性Wistar大鼠部分結紮坐骨神經前後各一周,均用不含脂肪的酪蛋白飼料進行餵養。另外,分別用ω-3ω-6多不飽和脂肪酸含量明顯不同的芥花籽油、玉米油、大麻油、大豆油、葵花油或水進行強飼,每天1ml。記錄手術前後大鼠對觸摸和傷害性熱刺激的反應,並計算部分結紮坐骨神經前後的差值。各組對熱刺激的痛覺反應有顯著差別(P = 0.005),而對觸覺沒有差別。餵養大麻油的大鼠對熱刺激痛覺過敏,反應最強烈,顯著大於反應最輕的餵養玉米油的大鼠(差值分別為24.3 +/- 4.1分和6.1 +/- 3.1分,P < 0.001)。這兩種油的ω-6多不飽和脂肪酸的含量相似(大麻油為60%,玉米油為58%)。但ω-3的含量相差28倍(分別為20%0.7%)。飼料中ω-3的水平,而不是ω-6ω-3/ω-6比值與痛覺過敏顯著相關(P = 0.006)。因此得出結論,飲食中的油類可能會預測神經性疼痛的程度,這種影響可能與ω-3的含量有關。結論:作者發現某些常用的油類對部分神經損傷引起的持續疼痛有顯著的鎮痛效應。該效應可能與攝入的ω-3脂肪酸總量有關。

(趙延華 陳傑 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)抑制劑在敗血症中的作用

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在膿毒血症性休克的病理生理學中的作用具有爭議。其血管舒張作用眾所周知,但它同時還具有促炎和抗炎作用,在抗微生物宿主反應中起到至關重要的作用,它具有氧化和抗氧化作用,被稱作免疫與炎症網路的“致命毒藥”。大劑量NO和過氧化亞硝酸鹽與高血壓、血管麻痹、細胞窒息、細胞凋亡、乳酸酸中毒、以及多器官衰竭有關。因此,研製了一氧化氮合成酶(NOS)抑制劑,用以逆轉NO的有害作用。應用這些合劑的研究尚未獲得一致的成果,但是,一組研究中應用非選擇性NOS抑制劑N-甲基-1-鹽酸精氨酸被提前終止,因為雖然休克治療有效率上升,但死亡率也有所增加。因此,NOS抑制劑在敗血症中的應用尚有爭議。有文章強調了關於臨床適用範圍的差異,其資料獲取自在齧齒類動物、未復蘇、低動力模型應用提前處理,與在高級物種、復蘇、高動力模型應用滯後處理的對比研究。因此,當前的研究著眼於臨床相關大動物內毒素的研究,或與日常復蘇治療標準相結合的活細菌誘導、高動力敗血症模型的研究。

(範穎輝 陳傑 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.


七氟醚和過度通氣對頑固性癲癇患者腦棘波活動的影響

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.

 

本文研究了術中七氟醚和過度通氣對13名頑固性癲癇患者腦電圖棘波活動的影響。在大腦表面放上柵極並對以下這三種情況作腦電圖記錄:10.5 MAC的七氟醚,21.5MAC的七氟醚,和31.5MAC七氟醚伴過度通氣。評估各種情況下每5分鐘腦棘波的數量和有棘波發放的電極的百分數。用0.5MAC1.5MAC七氟醚麻醉的患者與4名長期植入硬膜下電極的患者在清醒狀態下當癲癇剛發作時和發作期間的棘波作比較。1.5MAC七氟醚麻醉的患者棘波數量和有棘波發放的電極的百分數明顯多於0.5MAC組的患者(P<0.05)。過度通氣的介入顯著增加了棘波的數量和有棘波發放的電極的百分數(P<0.05)。0.5MAC組的患者,棘波與那些清醒狀態下癲癇剛發作的相似,而1.5MAC組的患者,棘波與那些清醒狀態下癲癇正在發作的相似。這些結果表明七氟醚和過度通氣能影響頑固性癲癇患者腦棘波活動的頻率和幅度。因此當術中使用腦電圖定位癲癇的損害時,應密切注意七氟醚的濃度和通氣的狀態。

(朱輝 陳傑 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內注射的神經毒性比較

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.

 

諸多研究對利多卡因和其他局部麻醉藥的神經毒性進行了深入的研究,但結果差異很大。目前動物在體實驗研究不同麻醉藥物神經毒性尚未得到令人信服的結論。因此,本研究以神經系統感覺損傷和組織病理學損傷為觀察指標,比較等量利多卡因和布比卡因鞘內注射在神經毒性上的差異。首先,本實驗比較利多卡因和布比卡因的相對麻醉效能。大鼠分別給予生理鹽水20μL、利多卡因(濃度分別為0.625%、1.25%、2.5%和5%),或者布比卡因(濃度分別為0.125%0.25%、0.5%、1%),以大鼠甩尾試驗作為觀察指標,觀察時間為90min。結果發現利多卡因與布比卡因的相對麻醉效能為14.7095%的可信區間為3.65-6.07)。本實驗又以45只大鼠作為研究物件,觀察鞘內注射生理鹽水20μL2.13%布比卡因(約1.5mg/kg)或10%利多卡因(約6.9mg/kg)對於神經系統功能和形態的持續影響。結果表明鞘內注射利多卡因4天後,大鼠甩尾試驗潛伏期以及神經系統的病理損傷明顯高於生理鹽水組和布比卡因組。綜上所述,雖然本實驗中所用利多卡因和布比卡因的劑量高於臨床使用劑量,本實驗研究顯示大鼠利多卡因鞘內注射,其神經毒性高於相同濃度的布比卡因,。

(鄭擁軍 陳傑 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.

 

大鼠星狀神經節阻滯試驗的新方法

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.

 

星狀神經節阻滯在臨床上常規用於治療交感神經導致的疼痛綜合症。可是,星狀神經節阻滯對心血管的影響尚未很好的闡明。這個研究的目的是建立一個新的鼠星狀神經節阻滯模型技術。新技術是後路經皮方法,使用C7棘突軟骨作為標記。26Sprague-Dawley雌鼠分為六組。組Ⅰ(n=4)接受右側星狀神經節阻滯,組Ⅱ(n=5)接受左側星狀神經節阻滯,組Ⅲ(n=5)接受雙側星狀神經節阻滯,均使用0.25%的布比卡因。另外三個假組(每組n=4)分別作為三個治療組對照。所有接受星狀神經節阻滯的動物都可以觀察到上瞼下垂。與對照組相比,雙側星狀神經節阻滯組45分鐘內心率顯著下降。但單側星狀神經節阻滯的鼠中心率並沒改變。在另外9只鼠中,通過對左側(n = 3),右側(n = 3)和雙側星狀神經節阻滯(n = 3) 時使用甲基蘭進行染色,從而準確評估的星狀神經節阻滯。屍解顯示12個星狀神經節的11個被注射了甲基蘭染色。結論:後路經皮星狀神經節阻滯是一個可用於今後研究的可靠技術。

(殷文淵 陳傑 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.

 

麻醉恢復室中術後尿儲留的預測因素

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.

尿瀦留是一種很常見的術後併發症,並與膀胱過度膨脹和永久排尿損害的風險有關。這項研究的目的是確定麻醉恢復室內術後早期尿瀦留的預測因素。作者前瞻性地收集313個成人病人各種因數的差異,包括年齡,性別,泌尿系統的一些潛在的既往史,外科手術和麻醉的類型,圍術期使用抗膽鹼藥,體液總量,靜注嗎啡和進入麻醉監護室時的膀胱容量。每個病人在進入恢復室和離開恢復室時通過超聲測量膀胱容量。尿瀦留定義為膀胱容量大於600毫升且在30分鐘內不能排空。預測因素是通過多元分析法確定。在麻醉恢復室中尿瀦留發生率為16%。經多元分析顯示術中輸液(750mlP0.02,概率比=2.3),年齡(≥50P=0.008,概率比=2.4),和進入監護室的膀胱容量(≥270mlP=0.0001,概率比=4.8) 為尿瀦留獨立相關危險因數。考慮到未被診斷的術後尿瀦留對臨床的影響,上述結果顯示PACU內應使用攜帶型超聲系統評估膀胱的容量,尤其是有危險因數的病人。

(鄭麗 陳傑 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.

 

監測啟動凝血時間用於聯合應用肝素和抑肽酶:用SONOCLOT體外評估一種新的抑肽酶不敏感試驗

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

 

白陶土啟動凝血時間(ACT)通常用於監測心肺旁路期間單獨應用肝素的抗凝作用和肝素聯合抑肽酶後的抗凝作用。然而抑肽酶延長ACT的測定值。近來開發了一種新的用SONOCLOT分析儀監測,稱為“抑肽酶不敏感性”的ACT試驗(SaiACT)。在本研究中我們評價和比較了這一體外用SONOCLOT分析儀的新試驗和已確立的用HEMOCHRON分析儀的白陶土啟動凝血時間(HkACT)。25例行擇期瓣膜手術的病人,在麻醉誘導後采血80ml。血液放在枸櫞酸試管內,處理後分析肝素 (0123 U · mL–1)、抑肽酶(0200 kIU · mL–1)和用無鈣乳酸林格氏液稀釋25%ACT值的影響。總共分析了400個血液樣本,每份分兩份分別用SaiACTHkACT在廣泛的臨床上相關的範圍內測定ACT值。抑肽酶加入肝素化血液樣本不引起SaiACT值的明顯改變。相反,HkACT值明顯升高:抑肽酶分別延長肝素化血液樣本的HkACT20% ± 37%(2 U · mL–1)24% ± 18%(3 U · mL–1),體外血液稀釋增強這一作用。

(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.

 

 

七氟醚預處理限制新生兒缺血的心肌細胞內/線粒體內鈣離子

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

 

在成人心臟,七氟醚預處理(SPC)可減少心肌缺血/再灌注(I/R)損傷,效應機制可能是預處理減少了缺血和再灌注時細胞內Ca2+ ([Ca2+]i)/或線粒體內Ca2+([Ca2+]m)的積聚。鑒於新生兒在生理學、藥理學及代謝反應方面不同于成人,我們檢驗了這樣一個設想,即SPC通過KATP通道依賴機制限制了[Ca2+]i[Ca2+]m,從而保護新生兒心肌。在Langendorff 離體灌注的4-7日齡的兔心上,用螢光光譜分析和核磁共振光譜分析測量[Ca2+]i[Ca2+]m及三磷酸腺苷(ATP)。實驗分三組,研究SPC[Ca2+]m/[Ca2+]iATP及血流動力學和缺血損傷的效應。在SPC心臟,使用線粒體KATP通道阻滯劑5-羥癸酸評價線粒體KATP通道的作用。研究結果表明,SPC顯著減少了缺血/再灌注期的[Ca2+]i[Ca2+]m,同時減少再灌注時的肌酸激酶釋放,並使ATP濃度增高。而5-羥癸酸則可阻斷SPC[Ca2+]、血流動力學、ATP和肌酸激酶釋放的這些效應。結論,七氟醚預處理時[Ca2+]i[Ca2+]m的減少,與較多的ATP濃度恢復及較輕的細胞損傷相關。而線粒體KATP 通道的阻滯則削弱了SPC對缺血/再灌注的保護效應,提示這類通道參與了新生兒預處理保護機制。

(周志堅 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.


不同劑量異氟醚-芬太尼組合對麻醉後早期恢復及術後不良反應的影響

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

 

我們評估了不同劑量芬太尼-異氟醚組合對80例腹腔鏡膽囊切除術成年病人麻醉後早期恢復的影響。用芬太尼2 μg/kg和硫噴妥鈉5 mg/kg進行麻醉誘導,不使用笑氣。病人隨機分配到四組:第一組(n=20)接受0.6%呼氣末異氟醚複合芬太尼,第二組(n=20)接受1.2%呼氣末異氟醚複合芬太尼,第三組(n=20)接受1.8%呼氣末異氟醚複合芬太尼,第四組(n=20)僅接受異氟醚。在前三組,異氟醚濃度維持恒定,必要時應用芬太尼以使平均動脈壓維持在病房裏測得的最低平均動脈壓的± 10%範圍內。在第四組,異氟醚濃度根據上述平均動脈壓的標準進行調整。在縫皮結束時關閉異氟醚,並記錄自主呼吸產生時間(TSB),拔管時間(TE)及睜眼時間(TEO)。在麻醉後監護室的第一個小時內,每15分鐘評估病人的鎮靜程度、呼吸頻率、脈搏氧飽和度、嘔吐、疼痛和嗎啡用量。以後每半小時評估一次,直至送出監護室。前三組芬太尼的用量分別為8.3 ± 4.5 μg/kg (均數±標準差)、3.8 ± 1.3 μg/kg3.0 ± 0.7 μg/kg(P < 0.001),第四組平均呼氣末異氟醚濃度為2.0% ± 0.4%。儘管所有組平均TSB<5.5 min,但是TE從第一組的7.3 ± 5.1 min增加至第四組的20.6 ± 10.7 min(P < 0.001)TEO從第一組的7.4 ± 5.1 min增加至第四組的25.8 ± 9.4 min(P < 0.001)。在麻醉後監護室內的觀測指標在各組間均沒有差異。本研究表明低濃度的異氟醚複合相對大劑量的芬太尼比高濃度異氟醚複合相對小劑量芬太尼的麻醉後恢復快。

(黃佳佳 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.

 

 

改良溶液引起的遊離異丙酚濃度的變化

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

 

因為一般認為遊離異丙酚引起注射部位疼痛,我們通過改變異丙酚產品的兩種溶劑,調查研究了在中長鏈甘油三酯乳劑和長鏈甘油三酯乳劑中,遊離異丙酚濃度的變化。該研究中的技術是: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)改變溫度到20°36°C。異丙酚製品經過了24小時的透析,用高效液相色譜法分析受體媒介。中長鏈脂肪乳劑中游離異丙酚的濃度比長鏈脂肪乳劑中的明顯小30%。混合利多卡因及冷卻均不會降低兩種產品中的遊離異丙酚濃度。然而pH的下降和溫度升高均會降低其濃度。因為混合利多卡因會導致異丙酚乳劑的不穩定,而加溫會誘發微生物快速生長,所以推薦異丙酚給藥前注射利多卡因以減少注射區域疼痛。在本研究的任何情況下,中長鏈脂肪乳劑中游離異丙酚濃度明顯低於長鏈脂肪乳劑中的濃度(約30%–45%)。

(黃麗娜 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-亞單位控制重組g-氨基丁酸A型受體對非制動劑1,2-二氯六氟環丁烷(F6, 2N)阻斷作用的敏感性

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

 

為確定麻醉藥產生的複合麻醉的不同成分的效應,一些所謂的非麻醉劑/非制動劑類化合物被引入。由於負性的g-氨基丁酸A(GABAA)受體在全麻藥調製中樞神經系統(CNS)的效應中起重要作用,而其對不同藥物調節作用的敏感性依賴於亞單位的組成,我們對非制動劑1,2-二氯六氟環丁烷(F6){alpha}1ß2{alpha}1ß2{gamma}2s亞單位轉染的人胚腎293細胞上所表達的GABAA受體的效應進行了比較。使用快速灌流和全細胞記錄技術,我們發現:與異氟醚相似,F6阻斷了GABA引起的通過{alpha}1ß2受體的電流;但是,與異氟醚不同的是,{gamma}2s亞單位的存在則完全抵消了F6的阻斷作用。同樣,與異氟醚相反,F6對在這兩類受體中GABA引起的電流的失活動力學都無影響。我們得出結論:對{alpha}ß{gamma}受體的調節在F6的作用機制中幾乎不起作用,但是阻斷{alpha}ß受體可以促進F6CNS的作用。

(黃施偉 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.


連續經氣管混合靜脈血氧飽和度監測的初步研究

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

 

本研究旨在探討經氣管混合靜脈血氧飽和度(Svo2)監測的可行性和精確性。選取10例行胸外科手術的病人,將一次性兒童脈搏氧飽和感測器連接到主氣管和支氣管套囊之間的雙腔管上。全麻誘導後,插入雙腔管,並調整雙腔管在氣管中的合適位置。手術中的15min裏每隔3min採取一次肺動脈血以測量Svo2。在每次經肺動脈采血測量Svo2的同時,記錄測量的經氣管肺脈搏氧飽和度 (Sto2)。使用BlandAltman方法分析Sto2Svo2之間測量一致性的水平。在資料收集階段中,Sto2Svo2的均數±標準差(範圍)分別為82.0% ± 4.9%(72%91%)82.2% ± 5.5%(71%91%)Sto2Svo2之間的回歸分析線性相關係數為0.934(P < 0.05)Sto2Svo2絕對差值的95%可信區間為1.58%2.09%BlandAltman表中,Sto2Svo2差的均數±2倍標準差為0.12% ± 3.97%。我們得出結論,用經氣管肺血氧飽和度測量技術來連續監測肺動脈氧飽和度是可行而且是相當精確的。

(邱鬱薇 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.

 

 

對慢性縮窄性神經損傷沙鼠的丙酮噴霧測試的行為學和藥理學確認

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

 

冷刺激和機械刺激所致的痛覺過敏是神經痛患者的重要症狀。動物試驗中研究冷刺激所致痛覺過敏有助於我們理解神經性疼痛的基礎病理生理學機制及驗證藥物效果。評估慢性坐骨神經縮窄性損傷沙鼠在製冷板上對冷刺激的痛覺過敏並不一定穩定。本研究開發了一種通過Eppendorf®多等級細管以一種特定噴霧技術應用丙酮的新方法。在整個測試時段內機械刺激和丙酮噴霧可誘發慢性坐骨神經縮窄性損傷沙鼠長時程超敏反應,假手術組不出現此種現象。丙酮噴霧測試體現了一種不同于直接冷刺激的多模式刺激。對丙酮噴霧的反應在時程和強度上不僅與沙鼠對機械刺激所致痛覺過敏的反應一致,還和在其他物種上所觀察到的機械刺激及熱刺激所致的痛覺過敏一致。此外還運用不同的參考化合物對丙酮噴霧測試進行了藥理學驗證。對齧齒類動物神經性疼痛模型有效的不同化合物對急性和慢性給予丙酮噴霧所致的超敏反應也有影響。本研究表明多模式丙酮噴霧測試在齧齒類神經性疼痛的研究中是一個有價值的工具。

(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.


七氟醚削弱大鼠腦血流的自體調節:被非選擇性一氧化氮合酶抑制劑逆轉

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,我們觀察了應用非選擇性一氧化氮(NO)合酶抑制劑前後,1.02.0最小肺泡濃度(MAC)的七氟醚對大鼠的腦血流(CBF)自體調節的影響。大鼠被隨機分組如下:組1(n = 8)1.0 MAC七氟醚;組23(每組n = 8)2.0 MAC七氟醚。在給予左旋精氨酸甲酯(l-NAME30 mg/kg IV,組1和組2)前後或在低碳酸血症期間,通過分級出血來評估在140-160mmHg的平均動脈壓範圍內的自體調節能力。在附加的10個動物中,測量1.02.0MAC七氟醚時的腦組織NO2濃度。在1.0MAC七氟醚時(組1),不管NO合酶狀態如何都能維持CBF的自體調節能力,表明CBF的自體調節可能和NO存在無關。七氟醚劑量依賴性地增加腦組織的NO2濃度和削弱CBF自體調節。應用l-NAME (2)恢復CBF自體調節,但低碳酸血症(3) 沒有此作用。這表明七氟醚削弱自體調節能力繼發于血管周圍NO的增加,並且質疑腦血管的基礎張力(血管舒張能力)在低血壓時的重要性。

(張曦 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穿刺針用於無痛分娩腰-硬聯合方法的比較

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

 

當無痛分娩使用套針進行腰-硬聯合阻滯(CSE)方法時,不能發現腦脊液(CSF)、異感以及導管在鞘內移動或置入血管內等這些問題是常被關注的。硬膜外穿刺針附帶腰麻針孔,如背孔式Espocan®穿刺針可以減少這些危險。我們比較了改良的硬膜外針(ES)和傳統的Tuohy針用於CSE的效果和不良事件。100名臨產要求行無痛分娩(CSE)的產婦隨機分為2組:50名用ES 18號改良硬膜外穿刺針複合27Pencan®防損傷腰麻針,50名用傳統的18Tuohy針複合27Gertie Marx防損傷腰麻針。獲得關於鞘內或血管內置管、腰麻針進入時異感、硬膜外針置入後通過腰麻針不能得到CSF、無意刺破硬膜以及硬膜外導管功能的資訊。兩組都未發生鞘內置管。血管內置管和無意刺破硬膜的幾率兩組相仿。有顯著差異的是腰麻針引起的異感(ES14%Tuohy42%, P = 0.009)和首次穿刺時不能得到CSFES8%Tuohy28%, P < 0.02)。使用ES針用於CSE可明顯減少置入腰麻針時的異感,且更易首次穿刺就成功置入腰麻針。

(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.


腰骶段腦脊液容量對高比重布比卡因脊麻時麻醉平面和作用時間的影響:坐位和側臥位注射的比較

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

 

我們設計了本研究以比較病人側臥位或坐位注藥時,腰骶段腦脊液容量對高比重布比卡因脊麻擴散和作用時間的影響。74例脊麻下行表淺的整形外科手術或泌尿科手術病人列入研究範圍。從椎管磁共振影像計算出腰骶段腦脊液容量。病人被隨機分入兩組:側臥位組(L)和坐位組(S)(每組n = 37)。使用25號鉛筆型穿刺針行脊麻穿刺(3 mL高比重0.5%布比卡因),針孔朝向頭側,側臥位組病人非手術部位位於上側(L),或者病人在坐位下穿刺(S)。病人脊麻注射後立即轉為平臥位(L),或脊麻注射後再坐2分鐘(S)。採用Spearman等級相關法估計統計相關係數({rho})。腦脊液的容量和感覺阻滯峰平面在L(ρ= –0.69, P < 0.0001)S(ρ= –0.68, P < 0.0001)均呈負相關。S組中,腦脊液容量與感覺阻滯峰平面出現的時間(ρ= –0.48, P = 0.004)、平面消退到L1–4所需的時間(P < 0.05–0.01)明顯相關,但L組並不如此。我們得出結論,不管病人在何種體位下行脊麻注射,腦脊液的容量都會影響高比重布比卡因脊麻的擴散。病人處於坐位時,腦脊液的容量影響脊麻感覺阻滯的時間,但病人側臥位注射時則沒有明顯影響。

(張瑩 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.

 

 

關節鏡下輔助的前交叉韌帶重建術後關節腔內患者自控區域麻醉:羅呱卡因/嗎啡/酮咯酸合液與羅呱卡因/嗎啡合液的對比

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

 

前交叉韌帶重建(ACLR)術後有中等到重度的疼痛。我們比較了在脊麻下行前交叉韌帶重建術後的患者,採用羅呱卡因、嗎啡、有或無酮咯酸的藥液關節腔內鎮痛,觀察靜息和運動時的效果及另需IV嗎啡的用量。39名患者行關節腔內患者自控區域鎮痛,單次量10ml,鎖定間隔60分鐘。將病人隨機分為3組:RM組接受0.25%羅呱卡因和0.2mg/mL嗎啡合液;RMK組接受0.25%羅呱卡因、0.2mg/mL嗎啡以及1mg/mL的酮咯酸合液;P組接受生理鹽水。鎮痛藥混合液在100mL袋中配備,並編碼。如需要則自控靜脈追加2mg嗎啡,鎖定間隔為10分鐘。分別評估患者靜息和運動時的疼痛評分和滿意度。三組患者的疼痛評分和滿意度沒有顯著性差異。RMK組的日均嗎啡消耗量(8 ± 8 mg)小於RM(23 ± 20 mg;P = 0.002)。兩組嗎啡消耗量均小於P(46 ± 21 mg; P < 0.001)。結論:患者關節腔內自控區域鎮痛可有效緩解前交叉韌重建術後的疼痛。關節腔內複合應用羅呱卡因、嗎啡和酮咯酸的效果好於安慰劑組和羅呱卡因和嗎啡合液組。

(趙雪蓮 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.


術中液體限制改善大的擇期胃腸道手術的預後

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

 

液體治療是圍術期處理中最有爭議的話題之一。關於在擇期大手術中液體復蘇的質量和類型一直有爭議。但是圍術期血容量過多使術後發病率和死亡率升高的報導越來越多。最近的證據提示明智的圍術期液體治療改善大的擇期胃腸道手術的預後。觀察到的益處可能不只是歸因於晶體的限制,還歸因於膠體的應用。基於在本綜述中所討論的研究的一些臨床上有用的指南包括避免深全麻及消除接受硬膜外鎮痛的病人的預負荷。一般推薦一個液體處理的均衡辦法,即給予膠體以提供血流動力學的穩定性和維持排尿0.5 mL · kg–1 · h–1,給予晶體只用於維持。另外,可以用膠體以量對量原則補充失血量。而且,建議補充第三間隙丟失和利尿丟失的預定運算法則是不必要的。僅僅通過避免補充第三間隙丟失和預負荷就可達到晶體量的顯著減少,而不會面臨術中血流動力學不穩定或排尿減少(即< 0.5 mL · kg–1 · h–1)。最後,仍然需要有良好對照、在特定的病人人群中、有明確標準或研究目標的研究,來探討圍術期液體治療。

(馬皓琳 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.