Anesthesia & Analgesia

September 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

全麻诱导后发生低血压的预测因素

( 路译 薛张纲校)

Predictors of Hypotension After Induction of General Anesthesia

David L. Reich, Sabera Hossain, Marina Krol, Bernard Baez, Puja Patel, Ariel Bernstein, and Carol A. Bodian

Anesth Analg 2005 101: 622-628.

 

羟乙基淀粉130/0.4与改良明胶液体相比对心脏手术病人的容量扩张作用:对围术期出血及输血需求的影响

(裘毅敏 李士通 )

Hydroxyethyl Starch 130/0.4 Versus Modified Fluid Gelatin for Volume Expansion in Cardiac Surgery Patients: The Effects on Perioperative Bleeding and Transfusion Needs

Philippe J. Van der Linden, Stefan G. De Hert, Dirk Deraedt, Stefanie Cromheecke, Koen De Decker, Rudi De Paep, Inez Rodrigus, Anne Daper, and Anne Trenchant

Anesth Analg 2005 101: 629-634

PEDIATRIC ANESTHESIA:

 

儿童自然睡眠期间双频指数的分析

(朱辉 陈杰 )

Analysis of the Bispectral Index During Natural Sleep in Children

Franca Benini, Manuela Trapanotto, Stefano Sartori, Anna Capretta, Daniela Gobber, Clementina Boniver, and Franco Zacchello

Anesth Analg 2005 101: 641-644.

 

儿童患者依托咪酯麻醉诱导时的血流动力学反应

(周志坚 李士通 )

Hemodynamic Responses to Etomidate on Induction of Anesthesia in Pediatric Patients

Molly Sarkar, Peter C. Laussen, David Zurakowski, Avinash Shukla, Barry Kussman, and Kirsten C. Odegard

Anesth Analg 2005 101: 645-650.

 

异氟醚介导的神经元变性:一项对海马组织切片培养的评估

(王丽珺 薛张纲 校)

Isoflurane-Induced Neuronal Degeneration: An Evaluation in Organotypic Hippocampal Slice Cultures

Lisa Wise-Faberowski, Haito Zhang, Richard Ing, Robert D. Pearlstein, and David S. Warner

Anesth Analg 2005 101: 651-657

AMBULATORY ANESTHESIA:

 

甲哌卡因脊麻后一过性神经系统症状的发生率

(黄丽娜 李士通 )

The Incidence of Transient Neurologic Symptoms After Spinal Anesthesia with Mepivacaine

Jacques T. YaDeau, Gregory A. Liguori, and Victor M. Zayas

Anesth Analg 2005 101: 661-665.

 

指压按摩法和术前双亲焦虑症:试验性研究

(孙敏莉 薛张纲 校)

Acupressure and Preoperative Parental Anxiety: A Pilot Study

Shu-Ming Wang, Dorothy Gaal, Inna Maranets, Alison Caldwell-Andrews, and Zeev N. Kain

Anesth Analg 2005 101: 666-669

ANESTHETIC PHARMACOLOGY:

 

延长注射时间以及少量吸烟可以降低芬太尼诱发呛咳的发生率

(黄佳佳 李士通 )

Prolonged Injection Time and Light Smoking Decrease the Incidence of Fentanyl-Induced Cough

Jui-An Lin, Chun-Chang Yeh, Meei-Shyuan Lee, Ching-Tang Wu, Shinn-Long Lin, and Chih-Shung Wong

Anesth Analg 2005 101: 670-674.

 

静脉注射两种不同异丙酚制剂引起疼痛的比较

( 薛张纲 校)

A Comparison of Pain on Intravenous Injection Between Two Preparations of Propofol

Nicholas C. H. Sun, Andrew Y. C. Wong, and Michael G. Irwin

Anesth Analg 2005 101: 675-678.

 

应用压力容量环测定布比卡因、左旋布比卡因、罗哌卡因的心肌和血管效应

(范颖辉 陈杰 )

The Myocardial and Vascular Effects of Bupivacaine, Levobupivacaine, and Ropivacaine Using Pressure Volume Loops

Colin F. Royse and Alistair G. Royse

Anesth Analg 2005 101: 679-687.

 

随时间减量使用吸入麻醉药的指导意义

(齐波 陈杰 )

Tutorial: Context-Sensitive Decrement Times for Inhaled Anesthetics

Edmond I. Eger, II and Steven L. Shafer

Anesth Analg 2005 101: 688-696

 

丙泊酚对小鼠敏感神经潜在基因的微序列分析

(忻纪华 陈杰 )

A Microarray Analysis of Potential Genes Underlying the Neurosensitivity of Mice to Propofol

Damon A. Lowes, Helen F. Galley, Peter R. Lowe, Brad A. Rikke, Thomas E. Johnson, and Nigel R. Webster

Anesth Analg 2005 101: 697-704.

 

硫酸镁预处理减少依托咪酯诱导后的肌痉挛

(邱郁薇 李士通 )

Magnesium Sulfate Pretreatment Reduces Myoclonus After Etomidate

Aygun Guler, Tulin Satilmis, Seda B. Akinci, Bilge Celebioglu, and Meral Kanbak

Anesth Analg 2005 101: 705-709

 

持续量和单次量的四氯三乙基苯的体外人骨骼肌挛缩实验在恶性高热诊断中的正面与负面作用

(孙卓真 薛张纲 校)

Cumulative and Bolus In Vitro Contracture Testing with 4-Chloro-3-Ethylphenol in Malignant Hyperthermia Positive and Negative Human Skeletal Muscles

Mark Ulrich Gerbershagen, Marko Fiege, Ralf Weisshorn, Kerstin Kolodzie, Jochen Schulte am Esch, and Frank Wappler

Anesth Analg 2005 101: 710-714

 

5-羟色胺3A受体拮抗剂类止吐药可抑制肌肉的烟碱样乙酰胆碱受体

(赵延华 陈杰 )

Antiemetics of the 5-Hydroxytryptamine 3A Antagonist Class Inhibit Muscle Nicotinic Acetylcholine Receptors

Matthias Paul, Robert Callahan, John Au, Christoph H. Kindler, and C. Spencer Yost

Anesth Analg 2005 101: 715-721

 

阿片受体内吞及ß-Arrestins在产生阿片类药物耐受中的作用

(周雅春 李士通 )

The Role of Opioid Receptor Internalization and ß-Arrestins in the Development of Opioid Tolerance (Medical Intelligence)

Zhiyi Zuo

Anesth Analg 2005 101: 728-734

TECHNOLOGY, COMPUTING, AND SIMULATION:

 

通过电子听诊器及计算机分析呼吸音来判断气管内导管位置错误

(周晓敏 薛张纲 校)

Identification of Endotracheal Tube Malpositions Using Computerized Analysis of Breath Sounds via Electronic Stethoscopes

Christopher J. O’Connor, Hansen Mansy, Robert A. Balk, Kenneth J. Tuman, and Richard H. Sandler

Anesth Analg 2005 101: 735-739

 

连续监测腹部大手术老年病人的脑氧饱和度能够减轻脑组织潜在的低氧损伤

(苏殿三 陈杰 )

Continuous Monitoring of Cerebral Oxygen Saturation in Elderly Patients Undergoing Major Abdominal Surgery Minimizes Brain Exposure to Potential Hypoxia

Andrea Casati, Guido Fanelli, Paolo Pietropaoli, Rodolfo Proietti, Rosalba Tufano, Giorgio Danelli, Giuseppe Fierro, Germano De Cosmo, Giovanni Servillo on behalf of the Collaborative Italian Study Group on Anesthesia in Elderly Patients

Anesth Analg 2005 101: 740-747.

 

氢氧化钡石灰干燥后变黄色

( 李士通 校)

Barium Hydroxide Lime Turns Yellow After Desiccation

Christofer D. Barth, Marshall B. Dunning, III, Lynn Bretscher, and Harvey J. Woehlck

Anesth Analg 2005 101: 748-752.

 

地氟烷,异氟烷,和七氟烷在干燥的钠石灰中降解时钠石灰的温度

(周荻 薛张纲 校)

Temperatures in Soda Lime During Degradation of Desflurane, Isoflurane, and Sevoflurane by Desiccated Soda Lime

Michael J. Laster and Edmond I. Eger, II

Anesth Analg 2005 101: 753-757.

 

紧闭环路肌松控制系统的评价

(郑拥军 陈杰 )

Evaluation of a Closed-Loop Muscle Relaxation Control System

Douglas J. Eleveld, Johannes H. Proost, and J. Mark K. H. Wierda

Anesth Analg 2005 101: 758-764.

 

不同条件会导致脑电双频指数提示不正确的麻醉状态

(彭中美 李士通 )

Different Conditions That Could Result in the Bispectral Index Indicating an Incorrect Hypnotic State (Review Article)

Ashraf A. Dahaba

Anesth Analg 2005 101: 765-773

PAIN MEDICINE:

 

能增强布比卡因和吗啡硬膜外镇痛的氯胺酮血浆浓度

(王慧琳 薛张纲 校)

Determining the Plasma Concentration of Ketamine That Enhances Epidural Bupivacaine-and-Morphine-Induced Analgesia

Manzo Suzuki, Takao Kinoshita, Takehiko Kikutani, Kenji Yokoyama, Toshiichiro Inagi, Kikuzo Sugimoto, Shuji Haraguchi, Takao Hisayoshi, and Yoichi Shimada

Anesth Analg 2005 101: 777-784.

酯类酮咯酸的新型长效制剂具有长效抗伤害和抗炎效应

(殷文渊 陈杰 )

Novel Depots of Ketorolac Esters Have Long-Acting Antinociceptive and Antiinflammatory Effects

Shyun-Yeu Liu, Ja-Ping Shieh, Jann-Inn Tzeng, Hou Chia-Hui, Yen-Ling Cheng, Kuo-Lun Huang, and Jhi-Joung Wang

Anesth Analg 2005 101: 785-792.

 

神经调理素®对脊神经结扎大鼠的抗痛觉超敏和抗痛觉过敏作用

(张莹 李士通 校)

The Antiallodynic and Antihyperalgesic Effects of Neurotropin® in Mice with Spinal Nerve Ligation

Takahiro Suzuki, Yong Hua Li, and Takashi Mashimo

Anesth Analg 2005 101: 793-799

 

奥卡西平在大鼠模型中神经性疼痛机械和冷异常的抑制作用

(孙志荣 薛张纲 校)
The Suppressive Effects of Oxcarbazepine on Mechanical and Cold Allodynia in a Rat Model of Neuropathic Pain

Yeon Jang, Eun S. Kim, Soo S. Park, Jaemin Lee, and Dong E. Moon

Anesth Analg 2005 101: 800-806

 

局部或全身应用帕瑞考昔联合利多卡因/可乐定静脉区域镇痛用于上肢I型复杂区域疼痛综合征的抗伤害性效应

(潘志英 陈杰 )

The Antinociceptive Effect of Local or Systemic Parecoxib Combined with Lidocaine/Clonidine Intravenous Regional Analgesia for Complex Regional Pain Syndrome Type I in the Arm

Luiz-Cleber P. Frade, Gabriela R. Lauretti, Izabel C.P.R. Lima, and Newton L. Pereira

Anesth Analg 2005 101: 807-811

 

吗啡和右美托咪啶单次应用后其抗疼痛强度的长期变化

(颜涛 李士通 校)

Long-Term Changes in the Antinociceptive Potency of Morphine or Dexmedetomidine After a Single Treatment

Gyongyi Horvath, Gabriella Kekesi, Ildiko Dobos, Walter Klimscha, and Gyorgy Benedek

Anesth Analg 2005 101: 812-818.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

 

在美国罗库溴铵的过敏反应的风险性与维库溴铵相近似:对食品和药品管理局的不良事件报告的分析

( 李士通 校)

The Risk of Anaphylactic Reactions to Rocuronium in the United States Is Comparable to That of Vecuronium: An Analysis of Food and Drug Administration Reporting of Adverse Events

Sanjay M. Bhananker, James T. O’Donnell, John R. Salemi, and Michael J. Bishop

Anesth Analg 2005 101: 819-822

CRITICAL CARE AND TRAUMA:

给因感染假单胞菌而导致脓毒症的羊输注0.9%的生理盐水后不会使血容量扩张

(钟静 薛张纲 校)

Sepsis Produced by Pseudomonas Bacteremia Does Not Alter Plasma Volume Expansion After 0.9% Saline Infusion in Sheep

Christer H. Svensén, Bryan Clifton, Kirk I. Brauer, Joel Olsson, Tatsuo Uchida, Lillian D. Traber, Daniel L. Traber, and Donald S. Prough

Anesth Analg 2005 101: 835-842

 

喷雾沙丁胺醇、外源性呼气末正压通气、或两者合用对患有慢性梗阻性肺部疾病病人机械通气时的呼吸力学、血流动力学和气体交换的作用

(肖洁 陈杰 )

The Effects of Nebulized Salbutamol, External Positive End-Expiratory Pressure, and Their Combination on Respiratory Mechanics, Hemodynamics, and Gas Exchange in Mechanically Ventilated Chronic Obstructive Pulmonary Disease Patients

Maria Tzoufi, Spyros D. Mentzelopoulos, Charis Roussos, and Apostolos Armaganidis

Anesth Analg 2005 101: 843-850.

NEUROSURGICAL ANESTHESIA:

减少脑血流量能延长颈动脉内注射硫喷妥钠引起的脑电图静息的时程

(吴俭 李士通 )

Reducing Cerebral Blood Flow Increases the Duration of Electroencephalographic Silence by Intracarotid Thiopental

Shailendra Joshi, Mei Wang, Joshua J. Etu, and John Pile-Spellman

Anesth Analg 2005 101: 851-858

OBSTETRIC ANESTHESIA:  

 

脊麻与硬膜外麻醉在严重先兆子痫剖宫产术中的比较:一项前瞻性的随机多中心研究

(许文妍 薛张纲 )

Spinal Versus Epidural Anesthesia for Cesarean Delivery in Severe Preeclampsia: A Prospective Randomized, Multicenter Study

Shusee Visalyaputra, Oraluxna Rodanant, Wanna Somboonviboon, Kamthorn Tantivitayatan, Somboon Thienthong, and Wanawimol Saengchote

Anesth Analg 2005 101: 862-868.

 

脊麻引起的低血压------严重子痫前期患者与健康剖腹产孕妇的风险比较

(顾新宇 陈杰 )

Spinal Anesthesia-Induced Hypotension: A Risk Comparison Between Patients with Severe Preeclampsia and Healthy Women Undergoing Preterm Cesarean Delivery

Antoine G. M. Aya, Nathalie Vialles, Issam Tanoubi, Roseline Mangin, Jean-Michel Ferrer, Colette Robert, Jacques Ripart, and Jean-Emmanuel de La Coussaye

Anesth Analg 2005 101: 869-875

 

硬膜外吗啡用于产后输卵管结扎术后的镇痛

(陈玮 李士通 校)

Postoperative Epidural Morphine for Postpartum Tubal Ligation Analgesia

R-Jay L. Marcus, Cynthia A. Wong, Amy Lehor, Robert J. McCarthy, Edward Yaghmour, and Meltem Yilmaz

Anesth Analg 2005 101: 876-881

 

硬膜外注射利多卡因减少腰硬联合麻醉时硬膜穿刺的反应

(陆文清 薛张纲 校)

Epidural Injection of Lidocaine Reduces the Response to Dural Puncture Accompanying Spinal Needle Insertion When Performing Combined Spinal-Epidural Anesthesia

Anton A. van den Berg, Monzer Sadek, Steven Swanson, and Satyajeet Ghatge

Anesth Analg 2005 101: 882-885

REGIONAL ANESTHESIA:

超声引导的锁骨下阻滞与锁骨上阻滞的比较

(郑丽 陈杰 )

Ultrasound-Guided Infraclavicular Versus Supraclavicular Block

Geneviève Arcand, Stephan R. Williams, Philippe Chouinard, Daniel Boudreault, Patrick Harris, Monique Ruel, and François Girard

Anesth Analg 2005 101: 886-890.

 

全膝关节成形术后股神经阻滞联合硬膜外镇痛的作用

(黄施伟 李士通 校)

The Effects of Femoral Nerve Blockade in Conjunction with Epidural Analgesia After Total Knee Arthroplasty

Jacques T. YaDeau, Janet B. Cahill, Mark W. Zawadsky, Nigel E. Sharrock, Friedrich Bottner, Christine M. Morelli, Richard L. Kahn, and Thomas P. Sculco

Anesth Analg 2005 101: 891-895.

 

连续术中和术后胸段硬膜外镇痛削弱腹部大手术后脑尿钠肽释放

(徐丽颖 薛张纲 )

Continuous Intra- and Postoperative Thoracic Epidural Analgesia Attenuates Brain Natriuretic Peptide Release After Major Abdominal Surgery

Stefan Suttner, Katrin Lang, Swen N. Piper, Harald Schultz, Kerstin D. Röhm, and Joachim Boldt

Anesth Analg 2005 101: 896-903

 

脊麻中使用氯胺酮镇静能减少膝关节镜手术中缺血再灌注损伤标志物

(张宇 陈杰 )

Ketamine Sedation During Spinal Anesthesia for Arthroscopic Knee Surgery Reduced the Ischemia-Reperfusion Injury Markers

Fatma Saricaoglu, Didem Dal, Akgün Ebru Salman, Mahmut Nedim Doral, Kamer Kilinç, and Ülkü Aypar

Anesth Analg 2005 101: 904-909

GENERAL ARTICLES:

 

颈椎运动:在X线透视下比较应用光索导芯、视频喉镜和麦金托什喉镜插管

(赵雪莲 李士通 校)

Cervical Spine Motion: A Fluoroscopic Comparison During Intubation with Lighted Stylet, GlideScope, and Macintosh Laryngoscope

Timothy P. Turkstra, Rosemary A. Craen, David M. Pelz, and Adrian W. Gelb

Anesth Analg 2005 101: 910-915

儿童自然睡眠期间双频指数的分析

Analysis of the Bispectral Index During Natural Sleep in Children

Franca Benini, MD, Manuela Trapanotto, MD, Stefano Sartori, MD, Anna Capretta, MD, Daniela Gobber, MD, Clementina Boniver, MD, and Franco Zacchello, PhD, MD

Department of Pediatrics, University of Padova, Padova, Italy

Anesth Analg 2005 101: 641-644.

 

双频指数(BIS)是一项用于评估镇静水平的指标。一些研究者最近分析了成人在自然睡眠期间BIS的变化并发现当睡眠变得更深时BIS就明显降低。睡眠中儿童的BIS指数的变化还没有人开展研究。这项研究的目的是评估一组儿童在睡眠各阶段的BIS趋势并对有限的病例作描述性分析。笔者选择了15名既往有癫痫发作史的儿童作随访,当前临床指标阴性且脑电图(EEG)正常,记录清醒状态、各个睡眠阶段以及再醒时的BISEEG,计算每个阶段BIS的范围值、平均值和标准差。结果显示随睡眠变深时BIS逐渐降低。睡眠阶段与BIS显著相关。当再醒时,BIS缓慢增高。

(朱辉 陈杰 校)

The Bispectral Index (BIS) is a system used to measure sedation levels. Some investigators recently analyzed changes in the BIS during natural sleep in adults and found that the BIS diminished considerably as sleep became deeper. No such studies have been undertaken to investigate changes in the BIS in sleeping children. The aim of this work was to assess the trend of the BIS in the various stages of sleep in a group of children, performing a descriptive analysis on a limited number of cases. We evaluated 15 children with negative clinical findings and a normal electroencephalogram (EEG) as part of their follow-up for prior episodes of epilepsy, recording the BIS and EEG in a waking state, in the various stages of sleep and on reawaking. For each stage, the mean value, the standard deviation, and the range of BIS values were calculated. The results showed that the BIS decreased progressively as sleep became deeper. The correlation between the stage of sleep and the BIS was significant. On reawaking, a slow increase was apparent in the BIS.

 

应用压力容量环测定布比卡因、左旋布比卡因、罗哌卡因的心肌和血管效应

The Myocardial and Vascular Effects of Bupivacaine, Levobupivacaine, and Ropivacaine Using Pressure Volume Loops

Colin F. Royse, MBBS, MD, FANZCA, and Alistair G. Royse, MBBS, MD, FRACS

Cardiovascular Therapeutics Unit, Department of Pharmacology, University of Melbourne, Victoria, Australia

Anesth Analg 2005 101: 679-687

.

罗哌卡因和左旋布比卡因研制和发展用以降低布比卡因偶然过量导致的致命风险。这些药物在亚致死量时潜在心肌抑制作用尚不得而知。压力容量环可用于区别心肌和血管效应。本实验分组为布比卡因组、左旋布比卡因组、罗哌卡因组和生理盐水对照组,分别用7只麻醉、开胸新西兰大白兔,获得了量-效曲线。同时插入一根连接的压力导管获得腔静脉阻断期间高度精确的左室压力和容量数据。测量收缩力(V100),舒张功能(γ和舒张末期压力容量关系),每次增加剂量后测量血管阻力。按0.1250.2的比率注射左旋布比卡因和布比卡因/罗哌卡因,来模拟临床剂量,采用log28步)剂量递增方案。40分钟后,总药量为2.66/4.25mg/kg。当剂量超过4.25mg/kg时,左旋布比卡因(p0.013)和布比卡因(p0.019)显著降低收缩力,而罗哌卡因在4.25mg/kg时与生理盐水对照组无显著差异。布比卡因可降低射血分数和心指数,增加血管阻力。左旋布比卡因可降低射血分数和心指数,并证实具有双重血管作用,在较大剂量时增加血管阻力。罗哌卡因增加血管阻力,降低射血分数,但对收缩力无影响。平均动脉压和舒张功能在各组均无显著变化。在临床常规剂量下,与生理盐水对照组相比较,布比卡因组和左旋布比卡因组均有收缩力显著降低,而罗哌卡因组无显著差异。

(范颖辉 陈杰 校)

Ropivacaine and levobupivacaine were developed to reduce the risk of fatal accidental overdose reported with bupivacaine. The myocardial depressant potential of these drugs in sublethal dosage is unknown. Pressure volume loops can be used to separate myocardial from vascular effects. We acquired dose-response curves to incremental infusions in seven anesthetized, open-chest New Zealand white rabbits in each of bupivacaine, levobupivacaine, ropivacaine, and saline control groups. Simultaneous high-fidelity left ventricular pressure and volume data were acquired during caval occlusion with a combined conductance-pressure catheter inserted via an apical stab. Measurements of contractility (V100), diastolic function ({tau} and end-diastolic pressure volume relation), and vascular resistance were performed after each dose increase. Drugs were infused at a ratio of 0.125:0.2 for levobupivacaine and bupivacaine/ropivacaine to simulate clinical usage, with a log2 (8 step) dose escalation protocol. Over 40 min, the accumulated doses were 2.66/4.25 mg/kg. Levobupivacaine (P = 0.013) and bupivacaine (P = 0.019) significantly impaired contractility at doses exceeding 1.32 mg/kg, whereas ropivacaine was not different from control at 4.25 mg/kg. Bupivacaine reduced ejection fraction (EF) and cardiac index, and increased vascular resistance. Levobupivacaine reduced EF and cardiac index and demonstrated a biphasic vascular response, increasing vascular resistance at larger dosage. Ropivacaine increased vascular resistance and reduced EF without effect on contractility. Mean arterial blood pressure and diastolic function were unchanged for all drugs. Significant decline in contractility from control occurs with bupivacaine and levobupivacaine, but not with ropivacaine, at doses achievable in routine clinical practice.

随时间减量使用吸入麻醉药的指导意义

Tutorial: Context-Sensitive Decrement Times for Inhaled Anesthetics

Edmond I. Eger, II, MD, and Steven L. Shafer, MD

Department of Anesthesia and Perioperative Care, University of California, Department of Biopharmaceutical Science, UCSF, San Francisco, California, and Department of Anesthesia, Stanford University, Stanford, California,

Anesth Analg 2005 101: 688-696.

 

随时间减量使用吸入麻醉药包含两个含义:a) 麻醉的维持(通常指在一个稳定的肺泡气浓度)-持续稳定;b)随时间按某种比例降低肺泡和重要脏器(脑、心、肾和肝,统称为血供丰富的组织)药物浓度。从麻醉开始到按比例非线性降低麻醉药浓度的时间延长,可能延长了麻醉恢复时间。在这个实验中,研究人员应用了商业提供的模拟程序(Gas Man) ®来证实和扩展这些概念。在这个模型中,对于异氟醚来说,延长麻醉持续时间可以明显地延长其麻醉恢复时间。与异氟醚相比,七氟醚的苏醒延迟较少。而对于地氟醚,仅仅通过增加麻醉时间或减少麻醉相关递减时间95%和更多可以延长麻醉恢复时间。这些变化是因为每一种麻醉药在血液和组织中的相对溶解度的不同所造成的。另外心输出量的增加也会延迟清醒。

(齐波 陈杰 校)

Context-sensitive decrement times for inhaled anesthetics connect two values: a) the duration of anesthesia (nominally at a constant alveolar concentration)—the "context" and b) the time to decrease the alveolar or vital tissue (e.g., brain, heart, kidney, and liver, collectively called the vessel-rich group of tissues) concentration by some fractional "decrement" of the starting concentration. Increasing duration of anesthesia increases the time to a given decrement in a nonlinear manner that may considerably delay recovery. In the present report we use a commercially available simulation program (Gas Man®) to confirm and enlarge on these concepts. In this simulation, increasing duration of anesthesia can markedly delay complete awakening for isoflurane. Increasing anesthesia duration imposes considerably less delay in awakening from sevoflurane compared with isoflurane. For desflurane, only prolonged anesthesia or decrements of 95% and more should delay awakening from anesthesia. These changes are shown to be the result of the relative solubility of each anesthetic in blood and tissue. An increase in cardiac output is also shown to delay awakening.

 

丙泊酚对小鼠敏感神经潜在基因的微序列分析

A Microarray Analysis of Potential Genes Underlying the Neurosensitivity of Mice to Propofol

Damon A. Lowes, PhD*, Helen F. Galley, PhD, FIMLS*, Peter R. Lowe, PhD*, Brad A. Rikke, PhD{dagger}, Thomas E. Johnson, PhD{dagger}, and Nigel R. Webster, PhD FRCP, FRCA*

*Academic Unit of Anaesthesia and Intensive Care, University of Aberdeen, Scotland, United Kingdom; and {dagger}Institute for Behavioral Genetics, University of Colorado at Boulder, Boulder, Colorado

Anesth Analg 2005 101: 697-704.

确立全麻药物分子水平上作用机制是件困难的事,因为相关的全麻药是多靶点的。,因此要在进行评价。天生睡眠时间短(ISS)和睡眠时间长(ILS)的小鼠对酒精和镇静催眠类药物反应的敏感性是不同的,并且只含有一个单一的数量特征性位点(Lorpl),该位点导致小鼠对丙泊酚的翻正反射消失(LOPR)的基因变异。本研究中,作者应用高密度的寡核苷酸微序列证实大脑基因表达和候选基因在Lorpl 区域的不同表达来阐述LOPR时的分子机制。应用Affymetrix MG-U74 Av2 Genecphips®来进行微序列的分析,并通过半数逆转录多聚酶链反应来选择不同的表达基因。ILSISS的小鼠大脑显示共有3423组基因明确表达,其中有139组(4%)基因的表达不同。Lorpl 区域内的基因分析显示有26组基因明确表达,其中2组(7%)基因的表达不同。这些基因编码AWP 1蛋白(与蛋白激酶1相关)和“BTZPOZdomain containing 1”,这些蛋白的功能大多仍不知道。Lorpl 区域外的不同基因表达包括7组原来具有神经功能的基因,因此能作为另外的候选基因介导ISSILS中敏感神经差异。

(忻纪华 陈杰 校)

Establishing the mechanism of action of general anesthetics at the molecular level is difficult because of the multiple targets with which these drugs are associated. Inbred short sleep (ISS) and long sleep (ILS) mice are differentially sensitive in response to ethanol and other sedative hypnotics and contain a single quantitative trait locus (Lorp1) that accounts for the genetic variance of loss-of-righting reflex in response to propofol (LORP). In this study, we used high-density oligonucleotide microarrays to identify global gene expression and candidate genes differentially expressed within the Lorp1 region that may give insight into the molecular mechanism underlying LORP. Microarray analysis was performed using Affymetrix MG-U74Av2 Genechips® and a selection of differentially expressed genes was confirmed by semiquantitative reverse transcription-polymerase chain reaction. Global expression in the brains of ILS and ISS mice revealed 3423 genes that were significantly expressed, of which 139 (4%) were differentially expressed. Analysis of genes located within the Lorp1 region showed that 26 genes were significantly expressed and that just 2 genes (7%) were differentially expressed. These genes encoded for the proteins AWP1 (associated with protein kinase 1) and "BTB (POZ) domain containing 1," whose functions are largely uncharacterized. Genes differentially expressed outside Lorp1 included seven genes with previously characterized neuronal functions and thus stand out as additional candidate genes that may be involved in mediating the neurosensitivity differences between ISS and ILS.

5-羟色胺3A受体拮抗剂类止吐药可抑制肌肉的烟碱样乙酰胆碱受体

Antiemetics of the 5-Hydroxytryptamine 3A Antagonist Class Inhibit Muscle Nicotinic Acetylcholine Receptors

Matthias Paul, MD, DEAA*, Robert Callahan, BS{dagger}, John Au, BS{dagger}, Christoph H. Kindler, MD, DEAA{ddagger}, and C. Spencer Yost, MD{dagger}

*Department of Anesthesia and Perioperative Care, University of Cologne, Cologne, Germany; {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California; and {ddagger}Department of Anesthesia, University Hospital, Basel, Switzerland

Anesth Analg 2005 101: 715-721.

5-羟色胺能5-羟色胺3A受体(5-HT(3A)R)和肌肉的烟碱样胆碱能受体(nAChR)的拮抗剂在麻醉中广泛应用。5-HT(3A)RnAChR都是配体门控离子通道,其某些激动剂和拮抗剂具有已知的药理共性。作者利用表达在非洲爪蟾(Xenopus Laevis)未成熟卵细胞上的哺乳类动物的5-HT(3A)R和肌肉nAChR,来研究临床上应用的5-HT(3A)R拮抗剂-止吐药和非去极化肌松药对受体激活后离子电流的作用。用全细胞的两个电极的电压钳技术来记录电流。多拉司琼、昂丹司琼和格拉司琼在钠摩尔浓度(nM)可逆性地抑制5-HT(3A)R受体功能,其50%抑制浓度(IC(50))分别为11.8nM6.4 nM0.2 nM。多拉司琼的主要代谢物氢化多拉司琼(hydrodolasetron)对5-HT(3A)R的作用较其强40(IC(50) = 0.29 nM)。非去极化肌松药d-筒箭毒碱对5-HT(3A)R 的阻滞强度与止吐药相似,明显强于万可松和rapacuronium(IC(50) = 11.4 nM, 18.9 muM, 60.5 muM)。反过来,昂丹司琼、多拉司琼和格拉司琼也以剂量依赖性方式可逆性地抑制nAChR电流,对成熟nAChRIC(50)分别为14.2 muM7.8 muM 4.4 muM,对胚胎nAChRIC(50)分别为16.0 muM18.6 muM 13.9 muM。而且,氢化多拉司琼对成熟nAChR抑制作用明显强于多拉司琼10倍之多。这些结果显示作用于特异性的配体门控离子通道的药物也可能影响其它类型的离子通路。

(赵延华 陈杰 校)

Antagonists of the serotonergic 5-hydroxytryptamine 3A receptor (5-HT3AR) and muscle nicotinic acetylcholine receptors (nAChR) are widely used in anesthesia practice. Both 5-HT3AR and nAChR are ligand-gated ion channels with known pharmacological overlap between some of their agonists and antagonists. We studied the actions of clinically used 5-HT3AR antagonist antiemetics and nondepolarizing muscle blockers on ionic currents elicited by the activation of mammalian 5-HT3AR and muscle nAChR, expressed in Xenopus laevis oocytes. Currents were recorded using a whole-cell two-electrode voltage clamp technique. Dolasetron, ondansetron, and granisetron reversibly inhibited 5-HT3AR function at nanomolar concentrations with 50% inhibitory concentrations (IC50) of 11.8, 6.4, and 0.2 nM; the rank order of inhibition correlated well with their clinical antiemetic potencies. The principal metabolite of dolasetron, hydrodolasetron, was 40 times more potent than the parent compound on 5-HT3AR (IC50 = 0.29 nM). The potency of the nondepolarizing muscle blocker d-tubocurarine in blocking 5-HT3AR was similar to that of the antiemetics and significantly more than vecuronium and rapacuronium (IC50 = 11.4 nM, 18.9 µM, 60.5 µM). Conversely, ondansetron, dolasetron, and granisetron also reversibly inhibited nAChR currents in a dose-dependent manner with IC50s of 14.2, 7.8, and 4.4 µM for the adult nAChR and 16.0, 18.6, and 13.9 µM for the embryonic nAChR. Again, hydrodolasetron showed significantly (10 times) more inhibitory potency on the adult nAChR than the parent compound dolasetron. These results indicate that drugs that target specific ligand-gated ion channels may also affect other ion channel types.

连续监测腹部大手术老年病人的脑氧饱和度能够减轻脑组织潜在的低氧损伤

Continuous Monitoring of Cerebral Oxygen Saturation in Elderly Patients Undergoing Major Abdominal Surgery Minimizes Brain Exposure to Potential Hypoxia

Andrea Casati, MD*, Guido Fanelli, MD*, Paolo Pietropaoli, MD{dagger}, Rodolfo Proietti, MD{ddagger}, Rosalba Tufano, MD§, Giorgio Danelli, MD*, Giuseppe Fierro, MD{dagger}, Germano De Cosmo, MD{ddagger}, Giovanni Servillo, MD§ on behalf of the Collaborative Italian Study Group on Anesthesia in Elderly Patients

*Department of Anesthesiology, Azienda Ospedaliera di Parma - Università degli Studi di Parma – Parma; {dagger}Department of Anesthesiology, Policlinico Universitario Umberto I–Università degli Studi di Roma – Roma; {ddagger}Department of Anesthesiology, Policlinico Gemelli, Università Cattolica di Roma – Roma; §Department of Anesthesiology, Policlinico Universitario Federico II di Napoli - Napoli

Anesth Analg 2005 101: 740-747.

 

随着年龄的增长老年病人生理储备下降,因此比年轻人更容易发生脑氧去饱和。为了评价脑氧饱和度监测(rSO2)是否能够减轻手术期间脑氧去饱和,作者对122名全麻下行腹部大手术的老年病人进行了rSO2监测。病人随机分配到两组,处理组(rSO2监测可见,术中保持在诱导前的75%以上,n56)和对照组(rSO2监测不可见,根据常规进行麻醉,n66)。研究结果发现,在处理组有11名,对照组有15名病人rSO2低于术前的75%p0.82)。rSO2的均数(95%可信区间)在处理组(66%[64%-68%])高于对照组(61%[64%68%]p0.002),低于基础值75%的曲线下面积在处理组(0.4min%[0.10.8min%])低于对照组(80min[2144min%]p0.017)。术后第7天的MMSE神经功能量表评分在对照组低于处理组(26[25-30] VS 28[2630],P=0.02)。研究还发现,低于基础值75%的曲线下面积与术后MMSE量表评分较术前下降的幅度之间存在着明显的相关性(r20.25p0.01)。对照组中术中出现脑氧去饱和的病人与处理组相比在PACU和医院的停留时间都明显延长(PACU:对照组47min[13-56min],处理组25min[15-35min],p0.01;医院停留时间:对照组24[7-53];10[7-23]p0.007)。总之,研究者总结认为:rSO2监测下对老年行腹部大手术的病人进行麻醉管理可以减少病人脑组织可能出现的低氧,并且能够减轻其对认知功能的影响,缩短在PACU和医院的停留时间。

(苏殿三 陈杰 校)

Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO2) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO2 in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO2 was maintained at ≥75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO2 reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO2 were higher (66% [64%–68%]) and the area under the curve below 75% of baseline (AUCrSO22< 75% of baseline) was lower (0.4 min% [0.1–0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%–63%] and 80 min% [2–144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25–30]) than in the treatment group (28 [26–30]) (P = 0.02), with a significant correlation between the AUCrSO2 < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r2= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13–56 min]) and longer hospital stay (24 days [7–53] days) compared with patients of the treatment group (25 min [15–35 min] and 10 days [7–23 days], respectively; P = 0.01 and P = 0.007). Using rSO2 monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.

 

紧闭环路肌松控制系统的评价

Evaluation of a Closed-Loop Muscle Relaxation Control System

Douglas J. Eleveld, MEng, Johannes H. Proost, PhD, and J. Mark K. H. Wierda, MD, PhD

Research Group for Experimental Anesthesiology and Clinical Pharmacology, Groningen, The Netherlands

Anesth Analg 2005 101: 758-764.

 

麻醉过程中如能实现肌松自动调控,则能在很大程度上减轻麻醉医生的工作强度,从而使他们有精力兼顾其他病人。因此,本研究拟通过应用临床常用的罗库溴铵和四个成串刺激(TOF)计数,构建肌松控制系统,实现肌松自动调控。肌松控制系统由肌松监测仪(TOF Watch SX),主机和肌松药微泵三部分组成。肌松监测仪将监测到的肌松信号输入主机,主机通过相应程序调节微泵,控制肌松药用量。肌松控制系统的算法采用比例-积分(PI)算法和查找表原件,以避免现有控制器的技术限制。控制器采用客观方法以实现最优化,同时也能避免控制器算法手工漂移所造成的系统运行不稳定。本试验设定的适宜肌松控制目标为TOF计数保持在12的水平,并且通过15例病人验证控制效果。在39小时的紧闭环路肌松控制试验中,所记录到的肌颤搐中96.1%在适宜的调控范围内。本研究中罗库溴铵平均用量为0.36 mg·kg–1·h–1 (sd 0.18 mg·kg–1·h–1)。本研究还表明,即使存在干扰的情况下,该控制系统仍具有良好的稳定性。该肌松控制器能维持TOF目标值,可以作为临床条件下肌松控制闭合回路的硬件设计基础以及用户接口。

(郑拥军 陈杰 校)

Automatic muscle relaxation control may reduce anesthesiologists’ workload freeing them for other patient care requirements. In this report we describe a muscle relaxation controller designed for routine clinical application using rocuronium and the train-of-four count. A muscle relaxation monitor (TOF Watch SX) was connected to a laptop computer running a controller algorithm program that communicates with a syringe pump to form a closed-loop muscle relaxation system. The control algorithm uses proportional-integral and lookup table components and is designed to avoid the usability restrictions of existing controllers. The controller is optimized using an objective method to avoid the uncertainties of ‘‘hand-crafted’’ controller algorithms. Controller target was train-of-four count 1 or 2 and controller performance was evaluated in 15 patients. During 39 hours of closed-loop control, 96.1% of all twitches recorded were in the target range. Average rocuronium infusion rate was 0.36 mg·kg–1·h–1 (sd 0.18 mg·kg–1·h–1). We show that the controller remains useful even in the presence of disturbances that can arise in routine clinical conditions. The muscle relaxation controller maintained the target train-of-four count values and may serve as a basis for the design of hardware and user interfaces for closed-loop muscle relaxation control in clinical conditions.

 

酯类酮咯酸的新型长效制剂具有长效抗伤害和抗炎效应

Novel Depots of Ketorolac Esters Have Long-Acting Antinociceptive and Antiinflammatory Effects

Shyun-Yeu Liu, DDS*{dagger}{ddagger}, Ja-Ping Shieh, MD, MS{ddagger}, Jann-Inn Tzeng, MD, MS{ddagger}, Hou Chia-Hui, BS{ddagger}, Yen-Ling Cheng, BS{ddagger}, Kuo-Lun Huang, MS{ddagger}, and Jhi-Joung Wang, MD, PhD{ddagger}

*Department of Oral and Maxillofacial Surgery, National Defense Medical Center, Taipei; {dagger}Department of Oral and Maxillofacial Surgery, Taipei Medical University, Taipei; and {ddagger}Departments of Anesthesiology and Medical Research, Chi-Mei Medical Center, Tainan (Yung-Kang and Liou-Ying), Taiwan

Anesth Analg 2005 101: 785-792.

 

在临床上没有长效非甾体类抗炎药可用于治疗疼痛。在这个研究中,作者评估了几种酯类酮咯酸的新制剂的抗伤害、抗炎效应和作用持续时间,例如,丙基酯,戊基酯,庚基酯和葵酯酮咯酸,观察他们是否长效。在Sprague-Dawley鼠中进行了四个研究。在研究1-3中,评估了IM酮咯酸氨丁三醇和它的原制剂和丙基酯的抗伤害和抗炎效应。在研究4中,评估了其他几种酯类酮咯酸的抗伤害和抗炎效应。作者发现酮咯酸氨丁三醇2480240µmol/kg(在生理盐水中)产生显著的镇痛和抗炎效应,其持续时间大约为6-8小时。四种酮咯酸酯类使用的剂量为240µmol/kg(在油中)产生显著的长效抗伤害和抗炎效应,其持续时间大约为52-76小时。作者认为酯类酮咯酸的静脉新制剂在鼠中产生长效抗伤害和抗炎效应,为长于传统的酮咯酸氨丁三醇制剂的6.5-9.5倍。

(殷文渊 陈杰 校)

No long-acting nonsteroidal antiinflammatory drug is clinically available for the treatment of pain. In this study, we evaluated the antinociceptive and antiinflammatory effects and duration of action of several novel depots of ketorolac esters, such as ketorolac propyl ester, pentyl ester, heptyl ester, and decyl ester, and observed whether they had a long-acting effect. Four studies in Sprague-Dawley rats were performed. In Studies 1–3, the antinociceptive and antiinflammatory effects of IM ketorolac tromethamine and its base and propyl ester were evaluated. In Study 4, the antinociceptive and antiinflammatory effects of several other ketorolac esters were evaluated. We found that ketorolac tromethamine 24, 80, and 240 µmol/kg (in saline) produced significant antinociceptive and antiinflammatory effects with duration of action of approximately 6–8 h. The four ketorolac esters at a dose of 240 µmol/kg (in oil) produced significant long-acting antinociceptive and antiinflammatory effects, with duration of action of approximately 52–76 h. We concluded that IM injection of novel depots of ketorolac esters in rats produce long-acting antinociceptive and antiinflammatory effects that are 6.5- to 9.5-fold longer than the traditional dosage form of ketorolac tromethamine.

 

局部或全身应用帕瑞考昔联合利多卡因/可乐定静脉区域镇痛用于上肢I型复杂区域疼痛综合征的抗伤害性效应

The Antinociceptive Effect of Local or Systemic Parecoxib Combined with Lidocaine/Clonidine Intravenous Regional Analgesia for Complex Regional Pain Syndrome Type I in the Arm

Luiz-Cleber P. Frade, MD, Gabriela R. Lauretti, MD, MSc, PhD, Izabel C.P.R. Lima, MD, MSc, PhD, and Newton L. Pereira, B Pharm, MSc, PhD

Pain Clinic, Teaching University Hospital of the Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil

Anesth Analg 2005 101: 807-811.

 

作者研究了局部或全身应用帕瑞考昔(环氧酶-2抑制药)联合利多卡因/可乐定静脉区域镇痛应用于上肢I系型复杂区域疼痛综合征(CRPS)的疗效。30ICRPS病人分为3组。对照组(CG):在健康一侧肢体静脉注射生理盐水,并且局部静脉注射1 mg/kg利多卡因+30ug可乐定(以生理盐水稀释到10ml)。全身应用帕瑞考昔组(SPG):局部阻滞同CG,但是全身用药帕瑞考昔20mg。局部静脉注射帕瑞考昔组(IVRAPG):与CG组相比另外局部注射帕瑞考昔5mg。镇痛每周一次,连续3周。镇痛效果以VAS评分和止痛剂的用量来评估。与其他两组相比,IVRAPG在第二周和第三周布洛芬每天的用量显著减少(P < 0.05)IVRAPG3周布洛芬的用量也显著小于前两周 (P < 0.05)。前两周各组VAS评分相似, IVRAPG第三周表现了较小的VAS评分(P < 0.05)。作者认为:静脉注射帕瑞考昔5mg并联合应用利多卡因/可乐定联合静脉区域镇痛治疗ICRPS具有良好的抗炎效果。

(潘志英 陈杰 校)

We evaluated the efficacy of local or systemic parecoxib combined with lidocaine/clonidine IV regional analgesia in complex regional pain syndrome (CRPS) type 1 in a dominant upper limb. Thirty patients with CRPS type 1 were divided into three groups. The control group (CG) received both IV saline in the healthy limb and IV loco-regional 1 mg/kg of lidocaine + 30 µg of clonidine, diluted to a 10-mL volume with saline. The systemic parecoxib group (SPG) received a regional block similar to that administered to the CG but with systemic 20 mg of parecoxib, whereas the IV regional anesthesia with parecoxib group (IVRAPG) received an extra IV 5 mg of loco-regional parecoxib compared with the CG. The block was performed once a week for 3 consecutive weeks. Analgesia was evaluated by the 10-cm visual analog scale (VAS) and rescue analgesic consumption. The IVRAPG showed less daily ketoprofen (milligrams) consumption in the second and third weeks compared with the other groups (P < 0.05). The IVRAPG also showed less ketoprofen consumption when comparing the first and second week with the third week (P < 0.05). The VAS score comparison among groups revealed that groups were similar during the first and second week observation, although the IVRAPG showed smaller VAS scores in the third week compared with both CG and SPG (P < 0.05). We conclude the IV 5 mg of parecoxib was an effective antiinflammatory drug combined with clonidine/lidocaine loco-regional block in CRPS type 1.

 

喷雾沙丁胺醇、外源性呼气末正压通气、或两者合用对患有慢性梗阻性肺部疾病病人机械通气时的呼吸力学、血流动力学和气体交换的作用

The Effects of Nebulized Salbutamol, External Positive End-Expiratory Pressure, and Their Combination on Respiratory Mechanics, Hemodynamics, and Gas Exchange in Mechanically Ventilated Chronic Obstructive Pulmonary Disease Patients

Maria Tzoufi, MD, DEAA*, Spyros D. Mentzelopoulos, MD, PhD, DEAA*{dagger}, Charis Roussos, MD, PhD{dagger}, and Apostolos Armaganidis, MD, PhD*

*Department of Intensive Care Medicine, Attikon University Hospital; and {dagger}Department of Intensive Care Medicine, Evaggelismos General Hospital, Athens, Greece

Anesth Analg 2005 101: 843-850.

作者假设沙丁胺醇喷雾与外部呼气末正压通气(PEEPe)两者合用时对防止慢性梗阻性肺病(COPD)恶化有获益作用。10位对支气管扩张药敏感的COPD病人,在麻醉机械通气时呈现出适度的内源性PEEP(PEEPi),本研究评价了以下各种情况下病人的呼吸系统(rs)力学、血流动力学和气体交换:(a)基础值(PEEP0[ZEEPe]),(b)吸入5mg沙丁胺醇喷雾30分钟后(ZEEPe-S)(c)PEEPe设置为内源性PEEPi水平30分钟(PEEPe),(d)保持PEEPe的水平不变,吸入5mg沙丁胺醇喷雾30分钟后(PEEPe-S)。在PEEPe使用前先确定变量值已回复为基础值。与ZEEPe相比,(a)ZEEP-S 时,PEEPi分别为(4.8±0.77.0±1.1cmH2O),功能性残气量为(115.6±23.1202.1±46.0mL),最小气道阻力为(9.3±1.411.8±2.2cm H2OL-1s-1),附加气道阻力有所减低(5.2±1.47.2±1.3cm H2OL-1s-1)(P<0.01),血流动力学有所改善;(b)PEEPe时,PEEPi减低(3.7±1.3cmH2O)(P<0.01),气体交换有所改善; (c)PEEPe-S时,PEEPi最小(2.0±1.2cmH2O),而且呼吸力学(包括呼吸系统静电回弹力)、血流动力学和气体交换都有所改善。结论:在精心预选的COPD病人中,使用支气管扩张药/PEEPe取得有益作用。

(肖洁 陈杰 校)

We hypothesized that combined salbutamol and external positive end-expiratory pressure (PEEPe) may present additive benefits in chronic obstructive pulmonary disease (COPD) exacerbation. In 10 anesthetized, mechanically ventilated, and bronchodilator-responsive COPD patients exhibiting moderate intrinsic PEEP (PEEPi), we assessed respiratory system (rs) mechanics, hemodynamics, and gas exchange at (a) baseline (zero PEEPe [ZEEPe]), (b) 30 min after 5 mg of nebulized salbutamol administration (ZEEPe-S), (c) 30 min after setting PEEPe at baseline PEEPi level (PEEPe), and (d) 30 min after 5 mg of nebulized salbutamol administration with PEEPe maintained unchanged (PEEPe-S). Return of determined variable values to baseline values was confirmed before PEEPe application. Relative to ZEEPe, (a) at ZEEP-S, PEEPi (4.8 ± 0.7 versus 7.0 ± 1.1 cm H2O), functional residual capacity change (115.6 ± 23.1 versus 202.1 ± 46.0 mL), minimal rs (airway) resistance (9.3 ± 1.4 versus 11.8 ± 2.2 cm H2O·L–1·s–1), and additional rs resistance (5.2 ± 1.4 versus 7.2 ± 1.3 cm H2O·L–1·s–1) were reduced (P < 0.01), and hemodynamics were improved; (b) at PEEPe, PEEPi (3.7 ± 1.3 cm H2O) was reduced (P < 0.01), and gas exchange was improved; and (c) at PEEPe-S, PEEPi (2.0 ± 1.2 cm H2O) was minimized, and rs mechanics (static rs elastance included), hemodynamics, and gas exchange were improved. Conclusively, in carefully preselected COPD patients, bronchodilation/PEEPe exhibits additive benefits.

 

脊麻引起的低血压------严重子痫前期患者与健康剖腹产孕妇的风险比较

Spinal Anesthesia-Induced Hypotension: A Risk Comparison Between Patients with Severe Preeclampsia and Healthy Women Undergoing Preterm Cesarean Delivery

Antoine G. M. Aya, MD, PhD, Nathalie Vialles, MD, Issam Tanoubi, MD, Roseline Mangin, MD, MSc, Jean-Michel Ferrer, MD, Colette Robert, MD, Jacques Ripart, MD, PhD, and Jean-Emmanuel de La Coussaye, MD, PhD

Division of Anesthesiology, Pain Management, Emergency and Critical Care Medicine, University Hospital, Nîmes, France

Anesth Analg 2005 101: 869-875.

 

作者既往研究表明,与健康足月临产孕妇相比,严重先兆子痫患者脊麻后低血压的发生率较低,且较不严重,麻黄素的需要量较少。在本研究中,作者假设上述发现受先兆子痫有关因素的影响要胜于较小子宫质量因素。比较先兆子痫患者组(n=65)与早产孕妇组(n=71)脊麻下(0.5%布比卡因、舒芬太尼、吗啡)行剖腹产术中低血压发生率及严重程度,低血压定义:需要麻黄素处理(胎儿娩出前收缩压〈100mmHg或平均动脉压下降30%),同时研究Apgar评分与脐动脉血PH值。结果显示,两组中新生儿及胎盘的重量相似,但先兆子痫组的低血压发生率比早产孕妇组低(分别为24.6%40.8%p=0.044)。尽管收缩压、舒张压、平均动脉压下降程度相似,先兆子痫组血压回复到基线水平时麻黄素的需要量比早产孕妇组更少(分别为9.8+4.6mg15.8+6.2mgp=0.031)。先兆子痫组患者的低血压风险要比早产孕妇组低2倍(相对风险=0.06395%可信度0.3621.003p=0.044)。Apgar评分的影响很小而子宫动脉血PH值没有什么影响。结论:先兆子痫因素比较小子宫质量因素更能说明先兆子痫病人脊麻后低血压的低发生率。

(顾新宇 陈杰 校)

We previously showed that, in comparison with term healthy parturients, patients with severe preeclampsia had a less frequent incidence of spinal hypotension, which was less severe and required less ephedrine. In the present study, we hypothesized that these findings were attributable to preeclampsia-associated factors rather than to a smaller uterine mass. The incidence and severity of hypotension were compared between severe preeclamptics (n = 65) and parturients with preterm pregnancies (n = 71), undergoing spinal anesthesia for cesarean delivery (0.5% bupivacaine, sufentanil, morphine). Hypotension was defined as the need for ephedrine (systolic blood pressure <100 mm Hg in parturients with preterm fetuses or 30% decrease in mean blood pressure in both groups). Apgar scores and umbilical arterial blood pH were also studied. Neonatal and placental weights were similar between the groups. Hypotension was less frequent in preeclamptic patients than in women with preterm pregnancies (24.6% versus 40.8%, respectively, P = 0.044). Although the magnitude of the decrease in systolic, diastolic, and mean arterial blood pressure was similar between groups, preeclamptic patients required less ephedrine than women in the preterm group to restore blood pressure to baseline levels (9.8 ± 4.6 mg versus 15.8 ± 6.2 mg, respectively, P = 0.031). The risk of hypotension in the preeclamptic group was almost 2 times less than that in the preterm group (relative risk = 0.603; 95% confidence interval, 0.362–1.003; P = 0.044). The impact of Apgar scores was minor, and umbilical arterial blood pH was not affected. We conclude that preeclampsia-associated factors, rather than a smaller uterine mass, account for the infrequent incidence of spinal hypotension in preeclamptic patients.

 

超声引导的锁骨下阻滞与锁骨上阻滞的比较

Ultrasound-Guided Infraclavicular Versus Supraclavicular Block

Geneviève Arcand, MD*, Stephan R. Williams, MD, PhD, FRCPC*, Philippe Chouinard, MD, FRCPC*, Daniel Boudreault, MD, FRCPC*, Patrick Harris, MD, FRCSC{dagger}, Monique Ruel, RN, CCRP*, and François Girard, MD, FRCPC*

Departments of *Anesthesiology and {dagger}Surgery, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Montréal, Canada

Address correspondence to Stephan Williams, MD, PhD, FRCPC, Department of Anesthesiology, CHUM, Hôpital Notre-Dame, 1560 Sherbrooke east, Montreal, Canada, H2L 4M1.

Anesth Analg 2005 101: 886-890.

 

在这项前瞻性研究中作者比较了超声引导(USG)下的锁骨上阻滞与锁骨下阻滞的操作时间和阻滞质量。作者假设锁骨下阻滞可以在较短的操作时间内完成并有与锁骨上阻滞相同的阻滞质量。80个病人随机的分为两组:I(锁骨下组)S组(锁骨上组)。所有的阻滞都用7.5-MHZ超声波探测定位和神经刺激。麻醉混合液为0.5%布比卡因5ml/kg2%盐酸利多卡因(容积比1:3)加上120万的肾上腺素组成的。感觉阻滞,运动阻滞和添药率评估肌皮神经、正中、桡神经、尺神经等阻滞情况。不需加药麻醉I80%,S87%(P=0.39)。 只有桡侧阻滞添药率有显著差异: I18%,S0%(P0.006)。两组间阻滞操作时间无显著差异(I4分钟,S4.65分钟)。技术相关性疼痛指数组间无显著差异(I:2.0,S:2.0,P=1.00)。结论:USG锁骨下阻滞至少与USG锁骨上阻滞一样迅速完成并且产生相似的不需加药的麻醉效果。

(郑丽 陈杰 校)

In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation.

 

脊麻中使用氯胺酮镇静能减少膝关节镜手术中缺血再灌注损伤标志物

Ketamine Sedation During Spinal Anesthesia for Arthroscopic Knee Surgery Reduced the Ischemia-Reperfusion Injury Markers

Fatma Saricaoglu, MD*, Didem Dal, MD*, Akgün Ebru Salman, MD*, Mahmut Nedim Doral, MD{dagger}, Kamer Kilinç, MD{ddagger}, and Ülkü Aypar, MD*

*Department of Anaesthesiology and Reanimation, {dagger}Department of Sports Medicine and Orthopaedics, and the {ddagger}Department of Biochemistry, Hacettepe University Faculty of Medicine, Ankara, Turkey

Anesth Analg 2005 101: 904-909.

 

作者通过观测血液和组织丙二醛(MDA)和次黄嘌呤(HPX)水平来研究膝关节镜手术时,氯胺酮镇静对止血带引起的氧化应激的影响。30ASA分级I-II级行膝关节镜手术的病人,接受布比卡因12.5mg脊髓麻醉,随机分成两组。氯胺酮组,给予咪唑安定0.01mg/kg后连续注入氯胺酮0.5mg/kg·h,维持至术毕。安慰剂组,注入同量的安慰剂。Ramsey镇静评分(RSS)用来评定镇静程度。在注入氯胺酮前、止血带缺血30min及解除止血带后5min分别采集静脉血和关节滑膜组织以测定MDAHPX水平。结果氯胺酮组MDAHPX水平显著低于对照组,RSS分值较高且无副作用。结论:氯胺酮镇静减少了膝关节镜手术中止血带所致脂质过氧化标志物的产生。

(张宇 陈杰 校)

We studied the effect of ketamine sedation on oxidative stress during arthroscopic knee surgery with tourniquet application by determining blood and tissue malonyldialdehyde (MDA) and hypoxanthine (HPX) levels. Thirty ASA I–II patients undergoing arthroscopic knee surgery with tourniquet were randomly divided into two groups. Spinal anesthesia induced with 12.5 mg bupivacaine was administered to all patients. In the ketamine group, after IV administration of 0.01 mg/kg midazolam, a continuous infusion of ketamine (0.5 mg · kg–1 · h–1) was used until the end of surgery whereas the placebo group received a volume-equivalent placebo infusion. Ramsey Sedation Scale (RSS) was used for assessing the sedation level. Venous blood and synovial membrane tissue samples were obtained before ketamine infusion, at 30 min of tourniquet ischemia, and at 5 min after tourniquet deflation for MDA and HPX measurements. Tissue MDA and HPX levels were significantly less in the ketamine group than the control group after reperfusion. RSS scores were higher in the ketamine group without any adverse effect. We conclude that ketamine sedation attenuates lipid peroxidation markers in arthroscopic knee surgery with tourniquet application.

 

羟乙基淀粉130/0.4与改良明胶液体相比对心脏手术病人的容量扩张作用:对围术期出血及输血需求的影响

Hydroxyethyl Starch 130/0.4 Versus Modified Fluid Gelatin for Volume Expansion in Cardiac Surgery Patients: The Effects on Perioperative Bleeding and Transfusion Needs

Philippe J. Van der Linden, MD, PhD*, Stefan G. De Hert, MD, PhD{dagger}, Dirk Deraedt, MD{ddagger}, Stefanie Cromheecke, MD{dagger}, Koen De Decker, MD{ddagger}, Rudi De Paep, MD{ddagger}, Inez Rodrigus, MD, PhD§, Anne Daper, MD*, and Anne Trenchant, MD*

*Department of Anesthesiology, CHU Charleroi, Belgium; {dagger}Department of Anesthesiology, {ddagger}Department of Intensive Care, §Department of Cardiac Surgery, University Hospital, Antwerp, Belgium

Anesth Analg 2005;101:629-634

 

在这项前瞻性、随机、开放、对照研究中,我们选择了行冠脉手术的患者,比较了6%羟乙基淀粉130/0.4(HES:n=64)3%改良液体明胶(GEL:n=68)作血管容量补充对红细胞净丢失量的作用。血液的丢失量可以从循环血容量的判定及术前术后血球压积的测量来计算。允许输入的胶体液的量控制在50 ml/kg。如果需要追加液体,使用晶体平衡液。麻醉及手术方法均标准化。两组的人口统计学及术中变量均相似。整项研究中的用量:HES48.9±17.2 mL/mgGEL48.9±14.6 mL/kg。血红细胞丢失总量,HES组为544±305 mLGEL组为504±327 mL。测量到的两组失血量也相似(HES, 19.4 ± 12.3 mL/kg; GEL, 19.2 ± 14.5 mL/kg)。两组使用的同种异体血制品量相似。在目前的研究条件中,在心脏手术中及术后用于扩张血浆容量,HES 130/0.4可有效替代改良液体明胶,用量可达50 mL/kg

(裘毅敏 李士通 校)

In this prospective, randomized, open controlled study we compared the effects on net red blood cell loss of 6% hydroxyethyl starch 130/0.4 (HES: n = 64) and 3% modified fluid gelatin (GEL: n = 68) administered for intravascular volume management in patients undergoing coronary surgery. Blood losses were calculated from determination of circulating blood volume and measurement of preoperative and postoperative hematocrit. Amount of colloids that could be administered was limited to 50 mL/kg. If additional fluids were required, balanced crystalloid solution was used. Anesthetic and surgical techniques were standardized. Both groups were similar with regard to demographic and intraoperative variables. Total study drug was 48.9 ± 17.2 mL/kg in the HES group and 48.9 ± 14.6 mL/kg in the GEL group. Total red blood cell loss was 544 ± 305 mL in the HES group and 504 ± 327 mL the GEL group. Measured blood losses were also similar in both groups (HES, 19.4 ± 12.3 mL/kg; GEL, 19.2 ± 14.5 mL/kg). Exposure to allogeneic blood product was comparable in both groups. In the conditions of the present study, HES 130/0.4 up to 50 mL/kg is a valuable alternative to modified fluid gelatin for plasma volume expansion during and after cardiac surgery.

 

儿童患者依托咪酯麻醉诱导时的血流动力学反应

Hemodynamic Responses to Etomidate on Induction of Anesthesia in Pediatric Patients

Molly Sarkar, MD, PhD*, Peter C. Laussen, MBBS*, David Zurakowski, PhD{dagger}, Avinash Shukla, MD*, Barry Kussman, MBBS*, and Kirsten C. Odegard, MD*

Departments of *Anesthesia and {dagger}Orthopaedic Surgery, Children’s Hospital, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2005;101:645-650

 

依托咪酯常被用以血流动力学储备差的病人的麻醉诱导。我们运用有创性血流动力学监测研究了儿童病人麻醉诱导时注射依托咪酯后的短期效应。研究对象为12例进行心导管手术的儿童(平均年龄9.2±4.8岁;平均体重33.4±15.4kg);心导管操作包括房间隔缺损堵闭(n = 7)和室上性心动过速射频导管消融(n = 5)。经静脉镇静后,将尖端带有气囊的肺动脉导管置入,以测量心内及肺动脉的压力和氧饱和度。记录基础值,静脉注射依托咪酯0.3 mg/kg后再次记录测量值。在所有分组中,注射依托咪酯后,所测右房、主动脉或肺动脉压力和氧饱和度、计算的Qp:Qs之比或全身或肺血管阻力均没有显著性变化。使用依托咪酯后不引起有临床意义的血流动力学改变,这一结果支持我们的临床印象,即依托咪酯对儿童是安全的。而对于新生儿及严重心室功能不良和肺动脉高压患儿,需要进一步研究以确定依托咪酯的血流动力学影响。

(周志坚 李士通 校)

Etomidate is often used for inducing anesthesia in patients who have limited hemodynamic reserve. Using invasive hemodynamic monitoring, we studied the acute effects of a bolus of etomidate during induction of anesthesia in children. Twelve children undergoing cardiac catheterization were studied (mean age, 9.2 ± 4.8 yr; mean weight, 33.4 ± 15.4 kg); catheterization procedures included device closure of secundum atrial septal defects (n = 7) and radiofrequency catheter ablation procedures for supraventricular tachycardia (n = 5). Using IV sedation, a balloon-tipped pulmonary artery catheter was placed to measure intracardiac and pulmonary artery pressures and oxygen saturations. Baseline measurements were recorded and then re-peated after a bolus of IV etomidate (0.3 mg/kg). For the entire group, no significant changes in right atrial, aortic, or pulmonary artery pressure, oxygen saturations, calculated Qp:Qs ratio or systemic or pulmonary vascular resistance were detected after the bolus dose of etomidate. The lack of clinically significant hemodynamic changes after etomidate administration supports the clinical impression that etomidate is safe in children. Further research is needed to determine the hemodynamic profile of etomidate in neonates and in pediatric patients with severe ventricular dysfunction and pulmonary hypertension.

 

甲哌卡因脊麻后一过性神经系统症状的发生率

The Incidence of Transient Neurologic Symptoms After Spinal Anesthesia with Mepivacaine

Jacques T. YaDeau, MD, PhD, Gregory A. Liguori, MD, and Victor M. Zayas, MD

Anesthesiology Department, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York

Anesth Analg 2005;101:661-665

 

我们前瞻性地评估了1273例接受 1.5%甲哌卡因(纯的,没有葡萄糖)的脊麻(或腰硬联合麻醉〔CSE〕)门诊外科手术病人。假设对大量病人的分析会证实先前的发现即等比重的1.5%甲哌卡因并不总是并发一过性的神经系统症状(TNS)。麻醉后1–4天中和6–9天中我们分别随访病人两次。1210名病人术后成功随访(95%的随访率)。没有一例病人因为麻醉药的关系而产生持久的神经系统后遗症。372CSE麻醉中没有一例麻醉药不足以应付手术。838例脊麻中有14例(占1.7%)的麻醉药是不足的。有78名病人发生了TNS(6.4%; 95% 可信区间为 5.1%–8%)TNS定义为新起病的背痛,这种背痛可放射到双侧臀部或远侧。患上TNS的病人平均年龄(48 ± 14 yr)较未患TNS的病人(41 ± 16 yr)(P < 0.001)更年老些。TNS不受性别和术中病人的体位的影响。较高的成功率和诸如TNS及硬膜穿破后头痛这种并发症罕见的发生率,提示用甲哌卡因脊麻对门诊手术病人来说是一种安全有效的麻醉药物。

(黄丽娜 李士通 )

We prospectively evaluated 1273 patients who received spinal (or combined spinal-epidural [CSE]) anesthesia with 1.5% mepivacaine (plain, no glucose) for ambulatory surgery. We hypothesized that analysis of a large series of patients would confirm previous findings that isobaric 1.5% mepivacaine is not frequently associated with transient neurologic symptoms (TNS). Patients were contacted twice after the anesthetic, at days 1–4 and days 6–9. One-thousand-two-hundred-ten patients were successfully contacted postoperatively (95% follow-up rate). None of the patients had permanent neurologic sequelae from the anesthetic. None of the 372 CSE anesthetics was inadequate for surgery. Fourteen of 838 (1.7%) of the spinal anesthetics were inadequate. TNS, defined as the new onset of back pain that radiated bilaterally to buttocks or distally, occurred in 78 patients (6.4%; 95% confidence intervals 5.1%–8%). The mean age of patients who developed TNS (48 ± 14 yr) was older than that of patients without TNS (41 ± 16 yr) (P < 0.001). TNS was not influenced by gender or intraoperative position. The frequent success rate and infrequent rates of complications such as TNS and postdural puncture headache suggest that spinal anesthesia with mepivacaine is likely to be a safe and effective anesthetic for ambulatory patients.

 

延长注射时间以及少量吸烟可以降低芬太尼诱发呛咳的发生率

Prolonged Injection Time and Light Smoking Decrease the Incidence of Fentanyl-Induced Cough

Jui-An Lin, MD, Chun-Chang Yeh, MD, Meei-Shyuan Lee, DPH, Ching-Tang Wu, MD, Shinn-Long Lin, MD, and Chih-Shung Wong, MD, PhD

Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, National Defense University, Taipei, Taiwan, Republic of China

Anesth Analg 2005;101:670-674

 

我们设计这个实验来评估注射时间以及吸烟对于芬太尼诱发呛咳的影响。450ASAI–II级、1880岁、4090kg择期手术病人入选。所有病人都通过前臂外周静脉通路的近侧端注射芬太尼(为便于临床应用,体重4069kg的注射100µg7090kg的注射150 µg)。病人随机分配至三个小组,每组150人。第一组病人在2s内注射完芬太尼,第二和第三组的病人以恒定的速度分别在15s30s内注射完芬太尼。我们记录在芬太尼注射过程中以及注射完30s后每个病人的呛咳次数。三组的呛咳发生率分别为18%、8%及1.3%,长时间注射时明显降低(P < 0.05)。最近吸烟者比不吸烟者的呛咳发生率低,不过这种影响仅仅在少量吸烟者中比较明显(每天小于10支或烟龄少于10年或小于10年包)。我们可以得出结论,延长注射时间降低芬太尼诱发呛咳的发生率,少量吸烟可能是防止芬太尼诱发呛咳的一个保护因素。

(黄佳佳 李士通 校)

We designed this study to evaluate the effect of injection time and smoking on fentanyl-induced cough. Four-hundred-fifty ASA class I–II patients, aged 18–80 yr and weighing 40–90 kg, scheduled for elective surgery were included. All patients received fentanyl (100 µg for patients weighing 40–69 kg and 150 µg for patients weighing 70–90 kg for clinical convenience) via the proximal port of a peripheral IV line on the forearm. Patients were randomly assigned to 3 groups of 150 patients each. Patients in Group I received fentanyl injection over 2 s, whereas for patients in Groups II and III the fentanyl was injected at a constant rate over 15 s and 30 s, respectively. We recorded the number of coughs of each patient during and 30 s after fentanyl injection. The incidence of cough was 18% in group I, 8% in Group II, and 1.3% in Group III, significantly less (P < 0.05) with a longer injection time. Current smokers had a less frequent incidence of cough than nonsmokers; however, this effect was only significant in light smokers (<10 cigarettes per day or <10 smoking years or <10 pack-years). In conclusion, a longer injection time reduces the incidence of fentanyl-induced cough, and light smoking may be a protective factor against fentanyl-induced cough.

 

 

硫酸镁预处理减少依托咪酯诱导后的肌痉挛

Magnesium Sulfate Pretreatment Reduces Myoclonus After Etomidate

Aygun Guler, MD, Tulin Satilmis, MD, Seda B. Akinci, MD, Bilge Celebioglu, MD, and Meral Kanbak, MD

Department of Anesthesiology and Reanimation, Hacettepe University, Sihhiye Ankara, Turkey

Anesth Analg 2005;101:705-709

 

依托咪酯用于麻醉诱导时经常会发生肌肉痉挛和注射部位疼痛。本研究拟观察使用镁及两种剂量的氯胺酮预处理对于依托咪酯诱发的肌痉挛和注射部位疼痛的影响。本研究采用前瞻双盲法,100ASAI–III级的病人随机分为四组:氯胺酮0.2 mg/kg组、氯胺酮0.5mg/kg组、硫酸镁(Mg2.48mmol组和生理盐水组。预处理后90秒,采用依托咪酯0.2mg/kg行麻醉诱导,肌松药用维库溴铵0.1mg/kg。由一名不知道分组的麻醉医生记录肌痉挛、注射部位疼痛和等级0-3的镇静程度。硫酸镁预处理组中,在给予依托咪酯后19例(76%)病人未发生肌痉挛,氯胺酮0.5mg/kg组中18例(72%),氯胺酮0.2mg/kg16例(64%),生理盐水组中有1872%)例病人发生了肌痉挛(P<0.05)。我们得出结论,使用依托咪酯行麻醉诱导前90秒给予Mg2.48mmol能有效减轻依托咪酯诱发肌痉挛的程度,而氯胺酮并不降低肌痉挛的发生率。

(邱郁薇 李士通 校)

Myoclonic movements and pain on injection are common problems during induction of anesthesia with etomidate. We investigated the influence of pretreatment with magnesium and two doses of ketamine on the incidence of etomidate-induced myoclonus and pain. A prospective double-blind study was performed on 100 ASA physical status I–III patients who were randomized into 4 groups according to the pretreatment drug: ketamine 0.2 mg/kg, ketamine 0.5 mg/kg, magnesium sulfate (Mg) 2.48 mmol, or normal saline. Ninety seconds after the pretreatment, anesthesia was induced with etomidate 0.2 mg/kg. Vecuronium 0.1 mg/kg was used as the muscle relaxant. An anesthesiologist, blinded to group allocation, recorded the myoclonic movements, pain, and sedation on a scale between 0–3. Nineteen of the 25 patients receiving Mg (76%) did not have myoclonic movements after the administration of etomidate, whereas 18 patients (72%) in the ketamine 0.5 mg/kg, 16 patients (64%) in the ketamine 0.2 mg/kg, and 18 patients (72%) in the control group experienced myoclonic movements (P < 0.05). We conclude that Mg 2.48 mmol administered 90 s before the induction of anesthesia with etomidate is effective in reducing the severity of etomidate-induced myoclonic muscle movements and that ketamine does not reduce the incidence of myoclonic movements.

 

 

阿片受体内吞及ß-Arrestins在产生阿片类药物耐受中的作用

The Role of Opioid Receptor Internalization and ß-Arrestins in the Development of Opioid Tolerance

Zhiyi Zuo, MD, PhD

Department of Anesthesiology, University of Virginia, Charlottesville, Virginia

Anesth Analg 2005;101:728-734

 

阿片类药物耐受是一个重要的临床问题,其特点为在重复给予阿片类药物后同样剂量的阿片类药物所能获得的镇痛效果减小。传统理论把阿片类药物耐受的发生归咎为受体脱敏感和内吞以及受体后适应。尽管常用阿片类药物吗啡可诱发耐受,但是吗啡却不能有效诱导阿片受体脱敏感和内吞。近期研究发现内吞的阿片受体在去磷酸化后可成为有效的受体并再循环至细胞膜表面。故受体内吞可能是减少阿片类药物耐受的途径之一。多项研究提示在阿片受体脱敏感、内吞及阿片类药物耐受中ß-arrestins起到了关键的作用。尽管ß-arrestin 1ß-arrestin 2在高内在效能的阿片类药物如埃托啡和芬太尼所诱发的上述现象中起到重要的作用,吗啡耐受可能主要由ß-arrestin 2介导。通过影响阿片受体和ß-arrestins的相互作用调制阿片受体内吞可能是减少阿片类药物耐受的治疗靶位之一。

(周雅春 李士通 )

Opioid tolerance, a phenomenon characterized by decreased analgesic effects obtained by the same dose of opioids after repeated use of the opioids, is a significant clinical problem. Traditional theory attributes receptor desensitization and internalization and post-receptor adaptation to the development of opioid tolerance. However, morphine, a commonly used opioid, induces tolerance but is not an effective drug to induce opioid receptor desensitization and internalization. Recent studies found that internalized opioid receptors can become competent receptors and recycle back to the cell surface membrane after dephosphorylation. Thus, receptor internalization may be a way to reduce opioid tolerance. Multiple studies have suggested a key role of ß-arrestins in opioid receptor desensitization and internalization and opioid tolerance. Although ß-arrestin 1 and ß-arrestin 2 are important for these effects induced by opioids with high intrinsic efficacy such as etorphine and fentanyl, morphine tolerance may be mediated mainly via ß-arrestin 2. Modification of opioid receptor internalization by affecting the interaction between opioid receptors and ß-arrestins may be a therapeutic target for reducing opioid tolerance.


氢氧化钡石灰干燥后变黄色

Barium Hydroxide Lime Turns Yellow After Desiccation

Christofer D. Barth, MD*, Marshall B. Dunning, III, PhD{dagger}, Lynn Bretscher, PhD{ddagger}, and Harvey J. Woehlck, MD§

*Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio; and {dagger}Division of Pulmonary/Critical Care Medicine and Departments of {ddagger}Biochemistry and §Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2005;101:748-752

 

在二氧化碳吸收剂里常加入乙基紫来作为吸收饱和的指示剂。我们在麻醉药分解的一些早期研究过程中,注意到(但未发表)氢氧化钡石灰(BL)干燥后会变黄,而钠石灰不会。我们假设干燥的BL中的乙基紫发生了化学反应产生了一种黄色着色剂。我们定性研究了用氧气干燥这些吸收剂的过程中产生黄色的进展过程。这种黄色着色剂可用二乙醚从干燥的吸收剂中萃取,经过色谱分离,再进行核磁共振及联合气相色谱和质谱分析。BL接近完全干燥时黄色显现。我们成功地识别出BL干燥时乙基紫分解成黄色的着色剂4,4’-二(乙氨基)苯甲酮。这种颜色并不明显,不能用来识别吸收剂轻度干燥,而且很难透过带色彩的吸收罐观察。BL可能充分干燥后会使麻醉药化学分解,但仍不显示黄色。然而,一旦出现黄色,应该认为它已经干燥。

(朱 李士通 校)

Ethyl violet is added to carbon dioxide absorbents and normally serves as an indicator of absorbent exhaustion. During the course of several prior studies of anesthetic breakdown, we noted (but did not publish) that barium hydroxide lime (BL), but not soda lime, turns yellow upon desiccation. We hypothesize that ethyl violet undergoes chemical reaction to produce a yellow colorant in desiccated BL. We qualitatively studied the time course of yellow color development during desiccation of these absorbents with dry oxygen. The yellow colorant was extracted from desiccated absorbent with diethyl ether, separated with chromatography, and analyzed with proton nuclear magnetic resonance and combined gas chromatography and mass spectrometry. The yellow color develops after BL has reached nearly complete desiccation. We successfully identified that ethyl violet decomposes into the yellow colorant 4,4'-bis(diethylamino)benzophenone upon desiccation of BL. The color is not intense, is not useful for identifying low levels of absorbent desiccation, and may be difficult to see through tinted canisters. It may be possible for BL to be sufficiently desiccated to allow chemical breakdown of anesthetics, but not yet show yellow coloration. However, if yellow coloration exists, one should assume that it has become desiccated.


不同条件会导致脑电双频指数提示不正确的麻醉状态

Different Conditions That Could Result in the Bispectral Index Indicating an Incorrect Hypnotic State

Ashraf A. Dahaba, MD, MSc, PhD

Department of Anaesthesiology and Intensive Care Medicine, Graz Medical University, Graz, Austria.

Anesth Analg 2005;101:765-773

 

脑电双频指数(BIS)自从1996年出现后,已经在日常麻醉工作中越来越流行了。然而,许多文献报道有矛盾性的BIS值改变和读数不精确。本综述的目的是通过检查各种发表报导中的BIS值与临床判断的镇静-麻醉状态的不一致,是否起因于脑电描记(EEG)的脑功能的基础病理生理学,还是因为BIS监测仪性能和设计上的缺点,来估价BIS监测的效用。高肌电活性和电器的干扰会引起复杂的干扰信号污染,但不会必然地显示为干扰。这会被BIS演算曲解为脑电活性,并得出伪性的高BIS值。许多对EEG脑功能有直接作用的临床情况也会直接影响BIS值。

(彭中美 李士通 校)

Since its introduction in 1996, the Bispectral Index (BIS) has gained increasing popularity in daily anesthesia practice. However, numerous reports have been appearing in the literature of paradoxical BIS changes and inaccurate readings. The purpose of this review is to assess the utility of BIS monitoring through examining the various published reports of all BIS values not coinciding with a clinically judged sedative-hypnotic state, whether arising from an underlying pathophysiology of electroencephalographic (EEG) cerebral function or because of shortcomings in the performance and design of the BIS monitor. High electromyographic activity and electric device interference could create subtle artifact signal pollution without their necessarily being displayed as artifacts. This would be misinterpreted by the BIS algorithm as EEG activity and assigned a spuriously increased BIS value. Numerous clinical conditions that have a direct effect on EEG cerebral function could also directly influence the BIS value.

 

 

神经调理素®对脊神经结扎大鼠的抗痛觉超敏和抗痛觉过敏作用

The Antiallodynic and Antihyperalgesic Effects of Neurotropin® in Mice with Spinal Nerve Ligation

Takahiro Suzuki, MD, Yong Hua Li, BS, and Takashi Mashimo, MD, PhD

Department of Anesthesiology, Osaka University Medical School, Osaka, Japan

Anesth Analg 2005;101:793-799

 

虽然神经调理素® (NTP)作为一种镇痛药物在日本已经临床使用很多年了,但是它在动物模型中对神经性疼痛的作用仍未被详细研究。已有研究显示NTP的主要作用是激活下行单胺能疼痛抑制系统。我们以脊神经结扎小鼠为对象,研究了NTP对神经性疼痛的影响。NTP呈浓度依赖地抑制触觉性痛感以及机械和温度刺激的痛觉过敏。鞘内给予神经毒素耗竭脊髓单胺递质后检查NTP的作用时,去除5羟色胺能神经支配后NTP的抗触觉性痛感和抗痛觉过敏作用仍然存在,但是去除去甲肾上腺素能神经支配后则消失。此外,脑室内给予NTP可提高疼痛回缩阈值,并延长潜伏期,但是鞘内或局部给药则没有这种作用。这些结果提示NTP对脊神经结扎导致神经性疼痛的抗痛觉超敏和抗痛觉过敏作用主要是脊髓上作用和去甲肾上腺素能系统的激活介导的,可能是通过下行抑制通路起作用。

(张莹 李士通 校)

Although Neurotropin® (NTP) has been used clinically as an analgesic in Japan for many years, its effect on neuropathic pain in animal models has not been examined in detail. Its main effect has been indicated to be activation of the descending monoaminergic pain inhibitory systems. To study the effect of NTP on neuropathic pain, we subjected mice to spinal nerve ligation. NTP inhibited both tactile allodynia and mechanical and thermal hyperalgesia in a dose-dependent manner. When the effect of NTP was examined after depletion of monoamines in the spinal cord by intrathecal neurotoxins, the antiallodynic and antihyperalgesic effects were still observed after serotonergic denervation, but not after noradrenergic denervation. In addition, intracerebroventricular NTP increased withdrawal threshold and latency although intrathecal or local administration of NTP did not. These results suggest that the antiallodynic and antihyperalgesic effect of NTP on neuropathic pain induced by spinal nerve ligation is mediated principally through the action at supraspinal sites and through activation of spinal noradrenergic systems, possibly via the descending inhibitory pathway.

 

 

吗啡和右美托咪啶单次应用后其抗疼痛强度的长期变化

Long-Term Changes in the Antinociceptive Potency of Morphine or Dexmedetomidine After a Single Treatment

Gyongyi Horvath, MD PhD*{dagger}, Gabriella Kekesi, PhD*, Ildiko Dobos*, Walter Klimscha, MD{ddagger}, and Gyorgy Benedek, MD, DSc*

Departments of *Physiology, Faculty of Medicine, and {dagger}Physiotherapy, Faculty of Health Sciences, University of Szeged, Hungary; and {ddagger}Department of Anesthesia and Intensive Care, Danube Hospital, Vienna, Austria

Anesth Analg 2005;101:812-818

 

急性耐受发生于单次使用阿片或α2-肾上腺素能激动剂后,但是延迟型急性耐受的特性在急性和炎性热痛试验中尚未得到分析。我们研究了腹腔内注射吗啡(10mg/kg)和α2-肾上腺素能激动剂右美托咪啶(150μg/kg)对急性热痛(甩尾试验)敏感性以及角叉菜胶导致的炎症性热痛觉过敏(缩爪试验)的抗疼痛作用强度,并且在7天后再次注射吗啡和右美托咪啶,观察其效应的长期变化。在两个试验组,首次处理并不影响第8天的基础值。在甩尾试验组,吗啡而非右美托咪啶的抗疼痛作用强度在重复注射后明显减弱,提示延迟型吗啡急性耐受。相反,在重复注射吗啡后其对缩爪试验的抗痛觉过敏作用并无改变,而右美托咪啶的作用强度在第8天增强了。在第1天,炎症侧和非炎症侧之间有显著差别,但是在第8天没有明显差别,提示药物对炎症侧的效应增强了。在这两组疼痛试验中,未发现两种药物有交叉耐受现象。这些数据显示了在不同的热痛试验模型上,单次注射吗啡或右美托咪啶后其抗疼痛作用强度的长期变化。

(颜涛 李士通 校)

Acute tolerance develops after a single administration of opiate or {alpha}2-adrenergic agonists, but the characteristics of the delayed type of acute tolerance have not been analyzed in acute and inflammatory thermal pain tests. We investigated the long-term changes in the antinociceptive potency of morphine (10 mg/kg) injected intraperitoneally and the {alpha}2-adrenoceptor agonist dexmedetomidine (150 µg/kg intraperitoneally) on acute heat pain (tail-flick test) sensitivity and on carrageenan-induced inflammatory thermal hyperalgesia (paw withdrawal test) after a second injection 7 days later. The first treatment did not influence the baseline values on Day 8 in either test. In the tail-flick test, the antinociceptive potency of morphine, but not that of dexmedetomidine, was significantly decreased after repeated administration, suggesting a delayed type of acute tolerance to morphine. In contrast, the antihyperalgesic effect of morphine in the paw withdrawal test did not change after repeated injection, whereas the potency of dexmedetomidine was increased on Day 8. There were significant differences between the inflamed and noninflamed sides on Day 1 but not on Day 8, revealing an increased potency of the drugs on the inflamed side. There was no sign of cross-tolerance between the two drugs in either pain test. These data indicate long-term changes in the antinociceptive potency of morphine or dexmedetomidine after single treatment in different heat pain tests.

 

 

在美国罗库溴铵的过敏反应的风险性与维库溴铵相近似:对食品和药品管理局的不良事件报告的分析

The Risk of Anaphylactic Reactions to Rocuronium in the United States Is Comparable to That of Vecuronium: An Analysis of Food and Drug Administration Reporting of Adverse Events

Sanjay M. Bhananker, MD, FRCA*, James T. O’Donnell, PharmD, FCP{dagger}, John R. Salemi, BS{ddagger}, and Michael J. Bishop, MD*

*Department of Anesthesiology, University of Washington School of Medicine, Seattle, WA; {dagger}Department of Pharmacology, Rush Medical College, Chicago, IL; {ddagger}Pharmaconsultant, Inc., Palatine, IL; and §Department of Veterans Affairs and the Departments of Anesthesiology and Medicine (adjunct, Pulmonary and Critical Care), University of Washington School of Medicine, Seattle, WA

Anesth Analg 2005;101:819-822

 

法国和挪威公开的报告提示罗库溴铵过敏反应的发生率较高,并且提升了对其安全性的关注。我们假设食品和药品管理局不良事件报告系统可用于证实是否美国存在罗库溴铵过敏事件的不寻常发生率、是否美国和国外的报告模式不同。我们查询了食品和药品管理局不良事件报告系统从1999年到2002第一季度的罗库溴铵和维库溴铵的所有不良事件,用专用软件搜索代表可能存在过敏性反应的术语。我们比较了资料中这些术语在罗库溴铵和维库溴铵出现的频率。我们接着评估在美国的和美国之外的报告中过敏性反应相关术语报导的发生率。罗库溴铵的资料包含311个报道,166个国内的和145个国外的。50%的国外报告包含过敏性反应的术语,相对的,国内报告中为20%(P < 0.001)。在维库溴铵的243个报告中的可比较数字为17%19%(没有统计学差异)。在美国,维库溴铵和罗库溴铵包含过敏性反应术语的报告的发生率没有差别,但是国外的报告有显著差异(P < 0.001)。这些资料证实美国麻醉操作者没有观察到两个常用的中效肌松药的过敏反应有显著差异,并且表明过敏性反应报道频率可能受到报告来源地区的显著影响。

(张 李士通 校)

Published reports from France and Norway suggest a frequent incidence of anaphylaxis to rocuronium and have raised concerns about its safety. We hypothesized that the Food and Drug Administration Adverse Event Reporting System could be used to confirm whether there has been an unusual incidence of anaphylactic events for rocuronium in the United States (U.S.) and whether the reporting patterns differ within and outside of the U.S.. We queried the Food and Drug Administration Adverse Event Reporting System for 1999 through the first quarter of 2002 for all adverse events for the drugs rocuronium and vecuronium and then searched on the terms considered to represent possible anaphylaxis using proprietary software. We compared the frequency of these terms in data both for rocuronium and vecuronium. We then assessed the occurrence of reports of anaphylaxis-related terms in reports from the U.S. compared with reports originating outside of the U.S.. For rocuronium, the database contained 311 reports, 166 domestic and 145 from foreign sources. Fifty percent of the foreign reports contained an anaphylaxis term versus 20% of the domestic reports (P < 0.001). For vecuronium, the comparable figures were 17% and 19% (not significant) and the total number of reports was 243. The incidence of the reports containing anaphylaxis terms did not differ between vecuronium and rocuronium in the U.S. but were significantly different for foreign reports (P < 0.001). These data confirm that U.S. anesthesia providers have not observed a significant difference in anaphylactic reactions between the two commonly used intermediate-acting muscle relaxants and suggest that frequency of reports of anaphylaxis may be significantly influenced by the area from which the reports originate.


减少脑血流量能延长颈动脉内注射硫喷妥钠引起的脑电图静息的时程

Reducing Cerebral Blood Flow Increases the Duration of Electroencephalographic Silence by Intracarotid Thiopental

Shailendra Joshi, MD*, Mei Wang, MS*, Joshua J. Etu, BA*, and John Pile-Spellman, MD{dagger}{ddagger}

Departments of *Anesthesiology, {dagger}Radiology, and {ddagger}Neurosurgery, College of Physicians and Surgeons of Columbia University, New York, New York

Anesth Analg 2005;101:851-858

 

由于输送更多的药物至脑部,脑血流量(CBF)的增加可增强静脉麻醉药的作用。相反地,数学模拟提示脑血流量减少通过增加局部药物摄取和减少药物洗出,能增强动脉内药物的效能。我们假设在脑低灌注期间颈动脉内注射麻醉药将显著延长脑电图(EEG)静息的时程。我们用新西兰大白兔检验了自己的假设。在第一组7个动物,我们观察到降低CBF可削弱EEG活性近70%,但未消除EEG。随后9个动物序贯地接受33 mg硫喷妥钠注射(硫喷妥钠-1,硫喷妥钠+低灌注,和硫喷妥钠-2)。第一和第三次在生理情况下注射。第二次在脑低灌注期间注射药物。与注射硫喷妥钠-1-2时比较,硫喷妥钠+低灌注时EEG静息显著延长(分别从45 ± 567 ± 27秒,至206 ± 46秒,n = 9, P < 0.0001)。EEG恢复特征在所有三次硫喷妥钠测试中相似。本研究表明调节CBF是加强动脉内药物输送到脑的重要工具。

(吴俭 李士通 )

The effects of IV anesthetics are enhanced by increased cerebral blood flow (CBF) because of a greater delivery of drugs to the brain. In contrast, mathematical simulations suggest that a decrease in CBF, by increasing regional drug uptake and decreasing drug washout, enhances the efficacy of intraarterial drugs. We hypothesized that administrating intracarotid anesthetics during cerebral hypoperfusion will significantly prolong the duration of electroencephalographic (EEG) silence. We tested our hypothesis on New Zealand White rabbits. In the first group of 7 animals, we observed that decreasing CBF by approximately 70% attenuated, but did not abolish, EEG activity. Subsequently, 9 animals received 3 intracarotid injections of 3 mg of thiopental (thiopental-1, thiopental + hypoperfusion, and thiopental-2). The first and third injections were made under physiological conditions. The second drug injection was made during cerebral hypoperfusion. Compared with injection of thiopental-1 and -2, thiopental + hypoperfusion resulted in a profound increase in EEG silence (from 45 ± 5 and 67 ± 27 s, to 206 ± 46 s, respectively, n = 9, P < 0.0001). The EEG recovery profile was similar during all three thiopental challenges. The study suggests that modulation of CBF is an important tool for enhancing intraarterial drug delivery to the brain.

 

 

硬膜外吗啡用于产后输卵管结扎术后的镇痛

Postoperative Epidural Morphine for Postpartum Tubal Ligation Analgesia

 

R-Jay L. Marcus, MD, Cynthia A. Wong, MD, Amy Lehor, RN, Robert J. McCarthy, PharmD, Edward Yaghmour, MD, and Meltem Yilmaz, MD

Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Anesth Analg 2005;101:876-881

 

产后输卵管结扎术后(PPTL)的妇女往往要经历严重疼痛。我们假定硬膜外吗啡,作为多模式镇痛方案的一部分,能减轻PPTL的术后疼痛,减少全身性镇痛药物的需要量。在一项双盲的研究中,PPTL硬膜外麻醉后的患者被随机分为硬膜外生理盐水组、硬膜外吗啡2mg组、3mg组和4mg组。术后布洛芬600mg6小时给药一次,同时患者可请求给予对乙酰氨基酚325mg/水化氢可酮10mg。主要评价参数为第一次要求追加镇痛药的时间。24小时记录疼痛口头等级评分和副作用的发生率及严重程度。与生理盐水组相比,吗啡各组需要追加镇痛药的时间较晚,所需的剂量较小。硬膜外吗啡与生理盐水比较,疼痛描记的顶峰和切口疼痛的口头等级评分的峰值较低,以及描述疼痛的疼痛口头等级评分-时间曲线下的面积也较小,但是,在吗啡各组之间没有差别。恶心、呕吐和瘙痒在所有吗啡组的患者更常见,在接受吗啡4mg镇痛治疗的患者和接受生理盐水、2mg吗啡组的患者相比,需要对这些副作用进行治疗的情形更常见。结论,硬膜外2mg吗啡作为多模式镇痛治疗方案的一部分能加强镇痛作用,降低PPTL后追加镇痛药的需求。与口服对乙酰氨基酚/阿片类药物/非甾体抗炎类镇痛药相比,吗啡2 mg副作用治疗的需要并没增加。

(陈玮 李士通 校)

Women undergoing postoperative postpartum tubal ligation (PPTL) often experience considerable pain. We hypothesized that epidural morphine, as part of a multi-modal analgesic regimen, would decrease postoperative pain and the need for systemic analgesia after PPTL. In a double-blinded study, patients were randomized to receive epidural saline or morphine 2 mg, 3 mg, or 4 mg after epidural anesthesia for PPTL. Postoperatively, ibuprofen 600 mg was administered every 6 h and patients could request acetaminophen 325 mg/hydrocodone 10 mg. The primary outcome variable was time to first request for supplemental analgesia. Verbal rating scores for pain and the incidence and severity of side effects were recorded for 24 h. Morphine group subjects requested supplemental analgesia later and received fewer doses compared with the saline group subjects. Peak cramping and incisional verbal rating scores for pain and the area under the verbal rating scores for pain x time curve for cramping pain were less after epidural morphine compared with saline, but there were no differences among morphine groups. Nausea, vomiting, and pruritus occurred more often in all morphine groups and subjects who received morphine 4 mg required treatment for these side effects more frequently than the saline or morphine 2 mg groups. In conclusion, epidural morphine 2 mg as part of a multi-modal analgesic regimen improved analgesia and decreased the need for supplemental analgesics after PPTL. The need to treat side effects with morphine 2 mg was not increased compared to a regimen of oral acetaminophen/opioid/nonsteroidal antiinflammatory analgesics.


全膝关节成形术后股神经阻滞联合硬膜外镇痛的作用

The Effects of Femoral Nerve Blockade in Conjunction with Epidural Analgesia After Total Knee Arthroplasty

Jacques T. YaDeau, MD, PhD*, Janet B. Cahill, PT{dagger}, Mark W. Zawadsky, MD{ddagger}, Nigel E. Sharrock, MBChB*, Friedrich Bottner, MD{ddagger}, Christine M. Morelli, BS*, Richard L. Kahn, MD*, and Thomas P. Sculco, MD{ddagger}

Departments of *Anesthesia, {dagger}Rehabilitation, and {ddagger}Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York

Anesth Analg 2005;101:891-895

 

硬膜外镇痛或股神经阻滞都可以改善全膝关节成形术后的镇痛和康复。尚未有研究去评估股神经阻滞和硬膜外镇痛的联合应用。在本项前瞻性、随机、盲法研究中,我们探讨了股神经阻滞和硬膜外镇痛的联合应用。41例病人接受单次注射0.375%布比卡因加5 µg/mL肾上腺素行股神经阻滞;39例病人作为对照。所有的病人接受腰-硬联合麻醉和用0.06%布比卡因和10 µg/mL氢吗啡酮进行病人自控硬膜外镇痛。硬膜外镇痛的平均时间为2天。所有病人都接受了相同的标准化的体疗干预。与对照组相比,接受股神经阻滞的患者2天内接受体疗时的视觉模拟评分(VAS)的中位数值明显较低:3 4 (术后第1)2.5 4 (2)P < 0.05。在第1天和第2天中,两组病人在静息时VAS疼痛评分的中位数都是0。术后第2天运动功能的屈曲范围有改善(70°63°; P < 0.05)。没有周围神经病变发生。我们得出结论:硬膜外镇痛的同时加上股神经阻滞可以显著改善全膝成形术后头2天内的镇痛效果。

(黄施伟 李士通 校)

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 µg/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 µg/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70° versus 63°; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.

 

 

颈椎运动:在X线透视下比较应用光索导芯、视频喉镜和麦金托什喉镜插管

Cervical Spine Motion: A Fluoroscopic Comparison During Intubation with Lighted Stylet, GlideScope, and Macintosh Laryngoscope

Timothy P. Turkstra, M Eng, P Eng, MD*, Rosemary A. Craen, MB, BS, FRCPC, FANZCA*, David M. Pelz, MD, FRCPC{dagger}, and Adrian W. Gelb, MB, ChB, FRCPC, FRCA*

Department of *Anesthesia and Perioperative Medicine and {dagger}Diagnostic Radiology and Nuclear Medicine, University of Western Ontario, Canada

Anesth Analg 2005;101:910-915

 

对可能有颈椎损伤的患者如何选择最佳插管方法还尚无定论。本研究应用X线透视摄像对比使用麦金托什喉镜3型、视频喉镜®和光纤插管导芯(一般称为光索或者光导芯)时颈椎运动的情况。36例健康患者随机交叉使用光索或者视频喉镜和麦金托什喉镜以保证线性稳定。检查气囊-面罩手控呼吸、喉镜检查和插管时枕骨-C1关节、C12关节、C25运动节段和C5-胸运动节段的运动情况。同时测定插管所需时间。气囊-面罩手控呼吸时颈椎四个运动节段的运动要比应用麦金托什喉镜时少82(P < 0.001)。应用光索的颈椎四个运动节段的运动比用麦金托什喉镜平均轻57(P < 0.03)。应用光索和麦金托什喉镜相比,插管需用时间没有明显差异。应用视频喉镜时,C25节段的运动减少50%P < 0.04,而其它节段无变化。应用视频喉镜要比麦金托什喉镜时间长62(P < 0.01)。因此,与麦金托什喉镜相比,光索(插管光纤)能减轻气管内插管时颈椎的运动。

(赵雪莲 李士通 校)

The question of which is the optimum technique to intubate the trachea in a patient who may have a cervical(C)-spine injury remains unresolved. We compared, using fluoroscopic video, C-spine motion during intubation for Macintosh 3 blade, GlideScope®, and Intubating Lighted Stylet, popularly known as the Lightwand or Trachlight®. Thirty-six healthy patients were randomized to participate in a crossover trial of either Lightwand or GlideScope to Macintosh laryngoscopy, with in-line stabilization. C-spine motion was examined at the Occiput-C1 junction, C1-2 junction, C2-5 motion segment, and C5-thoracic motion segment during manual ventilation via bag-mask, laryngoscopy, and intubation. Time to intubate was also measured. C-spine motion during bag-mask ventilation was 82% less at the four motion segments studied than during Macintosh laryngoscopy (P < 0.001). C-spine motion using the Lightwand was less than during Macintosh laryngoscopy, averaging 57% less at the four motion segments studied (P < 0.03). There was no significant difference in time to intubate between the Lightwand and the Macintosh blade. C-spine motion was reduced 50% at the C2-5 segment using the GlideScope (P < 0.04) but unchanged at the other segments. Laryngoscopy with GlideScope took 62% longer than with the Macintosh blade (P < 0.01). Thus, the Lightwand (Intubating Lighted Stylet) is associated with reduced C-spine movement during endotracheal intubation compared with the Macintosh laryngoscope.

 

全麻诱导后发生低血压的预测因素

Predictors of Hypotension After Induction of General Anesthesia

David L. Reich, MD, Sabera Hossain, MA, Marina Krol, PhD, Bernard Baez, MD, Puja Patel, Ariel Bernstein, and Carol A. Bodian, DrPH

Departments of Anesthesiology and Biomathematical Sciences, Mount Sinai School of Medicine, New York, New York

Address correspondence and reprint requests to David L. Reich, MD, Department of Anesthesiology, Mount Sinai Medical Center, Box 1010, One Gustave L. Levy Place, New York, NY 10029–6574.

Anesth Analg 2005 101: 622-628.

在全麻诱导后发生低血压是一个普遍现象。在当前的研究中,我们试图找出能够预测在全麻诱导后发生有显著临床意义的低血压的因素。将4096个全麻病人的麻醉记录中的动脉血压、人口学资料、术前用药和麻醉诱导方式等采用计算机处理。平均血压采用麻醉诱导前和诱导后0–5分钟、5–10分钟的血压。低血压的确定标准为:当平均动脉压(MAP)高于70mmHgMAP降低超过40%,或者MAP低于60mmHg。总体而言,有9%的病人在全麻诱导后0–10分钟内发生严重低血压。在全麻诱导后0–10分钟时间间隔里,后半时发生低血压更为常见(P < 0.001)。在2406个发生诱导后低血压的病人中,其术后恢复延迟和死亡的发生率与没有发生诱导后低血压的病人相比更为常见(分别为13.3%8.6%,多元分析P < 0.02)。在统计学上有意义的麻醉诱导后0–10分钟发生低血压的多元预测因素包括:ASA III–V级,基础MAP <70 mm Hg,年龄大于50岁,使用丙泊酚进行麻醉诱导,以及增加诱导时芬太尼用量。减少丙泊酚、依托咪酯和硫喷妥钠的用量与减少低血压的发生之间没有关系。为了避免严重低血压的发生,在年龄大于50岁且ASA评分3级的病人,可考虑使用其它药物(如依托米酯)取代丙泊酚进行全麻诱导。我们认为对于基础MAP<70mmHg的病人避免使用丙泊酚进行全麻诱导是明智的选择。

( 路译 薛张纲校)

Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0–5 and 5–10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0–10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0–10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0–10 min after anesthetic induction included: ASA III–V, baseline MAP <70 mm Hg, age 50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status 3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.

 

异氟醚介导的神经元变性:一项对海马组织切片培养的评估

Isoflurane-Induced Neuronal Degeneration: An Evaluation in Organotypic Hippocampal Slice Cultures

Lisa Wise-Faberowski, MD*, Haito Zhang, PhD§, Richard Ing, MB, BCh, FCA (SA)*, Robert D. Pearlstein, PhD{ddagger}, and David S. Warner, MD*{dagger}{ddagger}.

Departments of *Anesthesiology, {dagger}Neurobiology, and {ddagger}Surgery, Duke University Medical Center, Durham, North Carolina; and §Department of Neurobiology, Loma Linda University, Loma Linda, California.

Anesth Analg 2005;101:651-657

出生后七天的豚鼠持续暴露于麻醉剂下,通过拮抗N-甲基-d-天冬氨酸和/或加强γ-氨基丁酸,引起神经元变性和持续的行为缺陷。我们进行体外试验并观察是否试验豚鼠的年龄或麻醉剂暴露时间会影响神经元变性的结果。从生后4714天并在体外培养了714天的豚鼠上获得海马组织切片(OHSs)。这些切片暴露于1.5%的异氟醚或新鲜空气135小时。3天后评价海马CA1CA3和齿状回神经元的存活情况。从生后七天的豚鼠上获得的OHSs,神经细胞死亡最多(P < 0.001),且在暴露于异氟醚5小时后最明显(P < 0.001)。除外血流动力学、营养状态、氧合情况及CO2清除率等变量,该体外研究表明:1.5%异氟醚暴露和围产期神经元死亡与年龄及暴露时间均有关。

(王丽珺 薛张纲 校)

Prolonged exposure of postnatal day (PND) 7 rat pups to anesthetics, which act via N-methyl-d-aspartate antagonism and/or {gamma}-amino butyric acid enhancement, causes neurodegeneration and persistent behavioral deficits. We studied these findings in vitro and determined whether the age of rat pups used for study or duration of anesthetic exposure modulates resultant neurodegeneration. Organotypic hippocampal slices (OHSs) were prepared from rat pups on PNDs 4, 7, and 14 and cultured 7 or 14 days in vitro. The slices were exposed to 1.5% isoflurane or fresh gas for durations of 1, 3, or 5 h. Hippocampal CA1, CA3, and dentate gyrus neuronal survival was assessed 3 days later. Neuronal cell death was greatest in OHSs prepared from PND 7 rat pups (P < 0.001) and was most evident after 5 h exposure to isoflurane (P < 0.001). By eliminating variables such as hemodynamics, nutrition, oxygenation, and carbon dioxide elimination, this in vitro investigation supports both an age- and duration-dependent relationship between 1.5% isoflurane exposure and perinatal neuronal death.

 

指压按摩法和术前双亲焦虑症:试验性研究
Acupressure and preoperative parental anxiety: a pilot study.
Wang SM, Gaal D, Maranets I, Caldwell-Andrews A, Kain ZN.
Department of Anesthesiology, Yale University School of Medicine, PO Box 208051, 333 Cedar Street, New Haven, CT 06521, USA.

Anesth Analg. 2005 Sep;101(3):666-9,

 

在这项随机对照研究中,在小儿外科手术前的术前等候区,我们检测了指压按摩的抗焦虑和镇静作用对其父母影响。六十一位父母接受了印堂穴(两眉间的中间点)或假穴位的指压按摩。在实验干涉前后,分别测得焦虑(通过the Stait-Trait Anxiety Inventory测定)、动脉血气,以及心率,而且脑电双频指数监测仪持续监测催眠镇静水平。重复测定方差分析显示,与对照组父母相比,在干涉20分钟后指压按摩组的父母有显著的焦虑减轻(37 +/- 10 45 +/- 13, P = 0.03)。然而,两个试验组的脑电双频指数、心率、动脉血气没有不同(P=没有显著差异)。我们得出结论,在印堂穴指压按摩可以作为术前双亲焦虑症的治疗方法。进一步的研究需要量化抗焦虑作用的强度和持续时间。

(孙敏莉 薛张纲 校)

In this randomized sham-controlled study we examined the anxiolytic and sedative effects of acupressure on parents in the preoperative holding area before their children's surgery. Sixty-one parents received acupressure either at the Yintang point (midpoint between the two eyebrows) or at a sham point. Anxiety (as measured by the Stait-Trait Anxiety Inventory), arterial blood pressure, and heart rate were assessed before and after the intervention and a Bispectral Index monitor was used to continuously monitor hypnotic sedation levels. Repeated-measures analysis of variance showed that parents in the acupressure group reported significantly less anxiety at 20 min post-intervention as compared with parents in the sham group (37 +/- 10 versus 45 +/- 13, P = 0.03). Bispectral Index values, heart rate, and arterial blood pressure, however, did not differ between the two study groups (P = not significant). We conclude that acupressure at the Yintang point may be used as a treatment for parental preoperative anxiety. Future studies are needed to quantify the magnitude and duration of the anxiolytic effect.

 

静脉注射两种不同异丙酚制剂引起疼痛的比较

A Comparison of Pain on Intravenous Injection Between Two Preparations of Propofol

Nicholas C. H. Sun, MB BS*, Andrew Y. C. Wong, MB, ChB, FHKAM*, and Michael G. Irwin, MB, ChB, MD, DA, FRCA, FHKCA, FHKAM.

Department of Anaesthesiology, *Queen Mary Hospital; and {dagger}The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong.

 

异丙酚常由于镇静、麻醉诱导和维持。然而,其常引起注射部位疼痛。Lipuro®异丙酚为油相,可以溶解更多的异丙酚,因此,似乎可以减少疼痛。但关于此的调查研究存在方法学限制。我们进行了一项随机、双盲、交叉研究,用于比较亚麻醉剂量的两种异丙酚制剂(Diprivan®Lipuro®)引起注射部位疼痛的强度。共有60位健康患者接受了这项研究,在同一个注射部位注射两种异丙酚制剂,每种10min,中间用0.9%生理盐水冲洗,两种异丙酚制剂的顺序是随机的。在注射过程中及注射后1min,用言语等级评分表(VRS)进行疼痛评估。分析每一位患者不同时间点使用两种不同异丙酚制剂的VRS差。先使用Diprivan®后使用Lipuro®异丙酚的患者(D-P组),使用Lipuro®时疼痛减轻,在注射初期(VRS差的中位数是2[四分位区间为0-2]P=0.002)与注射后1min3[0-4]P<0.001)差异都很明显。先使用Lipuro®后使用Diprivan®异丙酚的患者(P- D组)VRS无明显差异。与Diprivan®相比,Lipuro®异丙酚可以减少注射部位疼痛,当先使用时,也可以减少后续注射的Diprivan®异丙酚引起的疼痛。机制不明,目前认为可能与降低水相中异丙酚的浓度有关。

(金 薛张纲 校)

Propofol is frequently used for sedation, induction, and maintenance of anesthesia. It is, however, associated with pain on injection. Propofol-Lipuro® has an oil phase that allows a larger proportion of propofol to be dissolved in it and, thereby, apparently reduces pain. However, studies investigating this have had methodological limitations. We devised a randomized, double-blind, crossover study comparing pain on injection between two preparations of propofol, Diprivan® and Propofol-Lipuro®, in subanesthetic doses. Sixty healthy patients received the drugs in random order via the same injection site separated by 10 min and a 0.9% saline flush. Pain was assessed using a verbal rating score (VRS) during and at 1-min time points after injection. Differences in VRS between the two propofol preparations at different time points in each patient were analyzed. In patients who were given Diprivan® first followed by Propofol-Lipuro® (group D-P), pain was significantly reduced with Propofol-Lipuro® compared with Diprivan® during initial injection (median difference in VRS = 2 [interquartile range 0–2], P = 0.002) and at 1 min (3 [0–4], P < 0.001). In patients who were given Propofol-Lipuro® first followed by Diprivan® (group P-D), no significant differences in VRS were shown. Propofol-Lipuro® is associated with reduced injection pain compared with Diprivan® and also seems to attenuate subsequent injection pain of Diprivan® when administered first. The mechanism is unknown, but may be related to a reduction in the concentration of propofol in the aqueous phase.

 

 

持续量和单次量的四氯三乙基苯的体外人骨骼肌挛缩实验在恶性高热诊断中的正面与负面作用

Cumulative and bolus in vitro contracture testing with 4-chloro-3-ethylphenol in malignant hyperthermia positive and negative human skeletal muscles.

Gerbershagen MU, Fiege M, Weisshorn R, Kolodzie K, Schulte am Esch J, Wappler F.

Department of Anesthesiology, Hospital Koln-Merheim, University Witten/Herdecke, Cologne, Germany.

Anesth Analg. 2005 Sep;101(3):710-4

 

本研究评估了12.5-200mmol/L 的持续量或75100mmol/L单次剂量的四氯三乙基苯(CEP)在体外对易患恶性高热(MH)者和不易患恶性高热者的肌肉标本的不同作用。在从25100mmol/L各种浓度持续量CEP的体外实验中,易患MH 者的肌肉标本较之不易患MH者的有更为明显的挛缩。并且当CEP75mmol/L时,诊断组中没有交迭现象,因此以本试验来诊断MH是可行的。然而两种单次剂量的实验没有诊断意义,因为它们诊断组中都发生了交迭现象。

(孙卓真 薛张纲 校)

In this study we evaluated the in vitro effects of 4-chloro-3-ethylphenol (CEP) using cumulative (12.5-200 micromol/L) or bolus (75 and 100 micromol/L) administrations, on muscle specimens from malignant hyperthermia (MH) susceptible and MH nonsusceptible patients, respectively. In the cumulative CEP in vitro contracture test, contractures were significantly greater in the MH susceptible compared with the MH nonsusceptible muscles in all concentrations between 25 and 100 micromol/L. There was no overlap between the diagnostic groups at 75 micromol/L of CEP, so this test appears to be feasible for diagnosis of MH susceptibility. The two bolus tests are not diagnostically useful, as overlaps between the diagnostic groups were observed.

 

通过电子听诊器及计算机分析呼吸音来判断气管内导管位置错误

Identification of endotracheal tube malpositions using computerized analysis of breath sounds via electronic stethoscopes.

O'Connor CJ, Mansy H, Balk RA, Tuman KJ, Sandler RH.
Department of Anesthesiology, Rush Medical College at Rush University Medical Center, 1653 W. Congress Parkway, Chicago, IL 60612, USA.

Anesth Analg. 2005 Sep;101(3):735-9.

 

气管内导管误入主支气管或食管可能导致低氧血症。目前判断气管内导管位置正确的方法包括听诊、X线摄片和支气管镜检查,可被接受的标准方法是使用二氧化碳分析仪或比色法ETCO2监测仪等设备监测呼气末二氧化碳(ETCO2)。但是,二氧化碳分析仪在院外、急诊或低心输出量的情况下可能无法获得或不可靠,而且它不能检出支气管内导管。本研究的目的是在双侧胸部及上腹部放置电子听诊器量化和评测呼吸音特性来明确其检测气管内导管位置错误的能力。我们记录了19个健康、非肥胖的成年人在全麻前的呼吸音。气管插管后,通过支气管镜放置气管内导管于隆凸上3 cm,然后予3500 mL的呼吸并记录其呼吸音。第二根气管内导管置入食管,予行相同的呼吸并记录呼吸音。最后将气管内的导管置入右主支气管并记录呼吸音。通过计算机分析,呼吸音被数字化并过滤掉选择性频率,在3个位置均记录听觉信号和能量比。使用带通滤波器滤过听觉信号得到的总能量比精确地识别出所有食管内和支气管内导管(P < 0.001)。这些初步结果提示:这个电子听诊器组合设备在ETCO2无法检测或不可靠的情况下可成为检测成人气管内导管位置错误的精确而便携的装置。

(周晓敏 薛张纲 校)

Endotracheal tube (ETT) malpositioning into a mainstem bronchus or the esophagus may result in significant hypoxemia. Current methods to determine correct ETT position include auscultation, radiography, and bronchoscopy, although the current acceptable standard procedure for proper endotracheal (versus esophageal) intubation is detection of end-tidal carbon dioxide (ETco(2)) by capnography, capnometry, or colorimetric ETco(2) devices. Unfortunately, capnography may be unavailable or unreliable in nonhospital/emergency settings or in low cardiac output states, and it does not detect endobronchial intubation. The purpose of this study was to quantify and assess breath sound characteristics using electronic stethoscopes placed over each hemithorax and epigastrium to determine their ability to detect ETT malposition. We recorded breath sounds in 19 healthy, non-obese adults before general surgical procedures. After intubation of the trachea, the ETT was bronchoscopically positioned 3 cm above the carina, after which 3 breaths of 500 mL were given and breath sounds were recorded. A second ETT was placed in the esophagus and the same series of breaths and recordings were performed. Finally, the tracheal ETT was advanced into the right mainstem bronchus and breath sounds were recorded. Using computerized analysis, breath sounds were digitized and filtered to remove selected frequencies, and acoustic signals and energy ratios were obtained for all 3 positions. Total energy ratios using band-pass filtering of the acoustic signals accurately identified all esophageal and endobronchial intubation (P < 0.001). These preliminary results suggest that this technique, when incorporated into a 3-component, electronic stethoscope-type device, may be an accurate, portable mechanism to reliably detect ETT malposition in adults when ETco(2) may be unavailable or unreliable.

 

地氟烷,异氟烷,和七氟烷在干燥的钠石灰中降解时钠石灰的温度

Temperatures in soda lime during degradation of desflurane, isoflurane, and sevoflurane by desiccated soda lime.

Michael J. Laster and Edmond I. Eger, II

Department of Anesthesia, S-455, University of California-San Francisco, CA 94143-0464, USA.

Anesth Analg 2005 101: 753-757.

 

罕见的,七氟烷在干燥的钡石灰中降解导致燃烧和病人损伤。现在的研究意于找寻是否七氟烷在干燥的钠石灰中使用也会引起高温。我们用10L/min流量的氧气直接通过新的吸收剂来吹干钠石灰。使用1140+/-30g(平均+/-标准误)这种干燥的吸收剂,填充于放置在标准的麻醉回路中的单个标准吸收罐中,回路中是6L/min流量的氧气和1.5个最低肺泡浓度(MAC)的地氟烷或七氟烷,或者是三个MAC的地氟烷,异氟烷或者七氟烷(伴有或不伴有200ml/min流量的二氧化碳)。附加实验中,使用两个填有干燥的吸收剂的吸收罐(而不是单个的吸收罐)和3.0MAC的七氟烷。一个3L的贮气囊作为模肺,使这个肺以每分钟通气量10L/min通气。使用1.53.0MAC的地氟烷或3.0MAC的异氟烷,在20-40分钟内峰温度由30摄氏度升高到45摄氏度然后降低。使用1.53.0MAC的七氟烷,温度上升至大约90摄氏度,然后下降。二氧化碳和七氟烷共同使用不会升高达到的峰浓度。用两个吸收罐延长了温度升高的持续时间但不会升高3.0MAC的七氟烷达到的峰温度。没有一种麻醉药的降解引起燃烧。

(周荻 薛张纲 校)

Rarely, fire and patient injury result from the degradation of sevoflurane by desiccated Baralyme. The present investigation sought to determine whether high temperatures also arose with sevoflurane use in the presence of desiccated soda lime. We desiccated soda lime by directing a 10 L/min flow of oxygen through fresh absorbent. Using 1140 +/- 30 g (mean +/- sd) of this desiccated absorbent, we filled a single standard absorber canister placed in a standard anesthetic circuit to which we directed a 6 L/min flow of oxygen containing 1.5 minimum alveolar concentration (MAC) desflurane or sevoflurane, or 3.0 MAC desflurane, isoflurane, or sevoflurane (with and without concurrent delivery of 200 mL/min carbon dioxide). In an additional test, 2 canisters (rather than a single canister) containing desiccated absorbent were used and 3.0 MAC sevoflurane was applied. A 3-L reservoir bag served as a surrogate lung, and we ventilated this lung with a minute ventilation of 10 L/min. With desflurane at 1.5 MAC or 3.0 MAC or isoflurane at 3.0 MAC temperatures increased in 20 to 40 min to a peak of 30 degrees C to 45 degrees C and then declined. With 1.5 or 3.0 MAC sevoflurane, temperatures increased to approximately 90 degrees C, after which temperatures declined. Concurrent delivery of carbon dioxide and sevoflurane did not increase the peak temperatures reached. The use of 2 canisters increased the duration but not the peak of increased temperature reached with 3.0 MAC sevoflurane. No fires resulted from degradation of any anesthetic.

能增强布比卡因和吗啡硬膜外镇痛的氯胺酮血浆浓度

Determining the plasma concentration of ketamine that enhances epidural bupivacaine-and-morphine-induced analgesia.
Suzuki M, Kinoshita T, Kikutani T, Yokoyama K, Inagi T, Sugimoto K, Haraguchi S, Hisayoshi T, Shimada Y.
Department of Anesthesiology, Second Hospital Nippon Medical School, Kanagawa 211-8533, Japan. manzo@nms.ac.jp
Anesth Analg 2005 101: 777-784

NMDA(N-甲基-D-天冬氨酸)受体拮抗剂能够增强阿片类药物的镇痛效果。氯胺酮是一种NMDA受体拮抗剂,它能够增强吗啡和布比卡因硬膜外镇痛作用的血浆浓度尚不知道。我们采用安慰剂对照,双盲的方法测试了24个患有肺癌或转移性肺肿瘤的病人在行开胸手术麻醉恢复后4小时的镇痛效果。在关闭皮肤后给予吗啡+氯胺酮组(8个)和吗啡+安慰剂组(8个)5ml2.5mg吗啡和0.25%布比卡因,安慰剂+氯胺酮组(8个)5ml盐水和0.25%布比卡因于硬膜外镇痛。在此后4小时内吗啡+氯胺酮组和安慰剂和氯胺酮组中,氯胺酮通过TCI泵给药,成功地维持在血浆浓度为0,10,20,30,40,50ng/ml,病人通过100mm的视觉模拟刻度(VAS)来评价静息,咳嗽,嗜睡和恶心时的疼痛程度。在吗啡+安慰剂组中,安慰剂(盐水)几乎可以替代氯胺酮。而在吗啡+氯胺酮组当氯胺酮浓度达20ng/ml或更大时,病人静息和咳嗽时的VAS评分与各自的基线相比可大大降低(P<0.05)。在安慰剂+氯胺酮组,相比较吗啡+安慰剂组,任何氯胺酮血浆浓度对于静息和咳嗽时的VAS评分并无太大影响。在吗啡+氯胺酮组中,氯胺酮血浆浓度>20ng/ml时并不能进一步降低静息和咳嗽时的VAS评分。嗜睡时的三组VAS评分在任何氯胺酮血浆浓度都是接近的。氯胺酮血浆浓度在20ng/ml或更大时可增强吗啡和布比卡因的硬膜外镇痛效果。作为吗啡和布比卡因硬膜外镇痛的辅助用药和基于小剂量安全性的考虑,静脉给予氯胺酮的最小血浆浓度应接近20ng/ml

(王慧琳 薛张纲 校)

N-methyl-D-aspartate (NMDA) receptor antagonists enhance opioid-induced analgesia. The plasma concentration of ketamine, an NMDA receptor antagonist that enhances epidural morphine-and-bupivacaine-induced analgesia, is not known. We examined 24 patients with lung carcinoma or metastatic lung tumor who underwent video-assisted thoracic surgery in a placebo-controlled, double-blind manner 4 h after emergence from anesthesia. The morphine + ketamine group (n = 8) and morphine + placebo group (n = 8) received 5 mL volume of 2.5 mg morphine and 0.25% bupivacaine and the placebo + ketamine group (n = 8) received 5 mL volume of saline and 0.25% bupivacaine epidurally at the end of skin closure. Four hours after this anesthesia, in the morphine + ketamine and placebo + ketamine groups, ketamine was administered to successively maintain a stable plasma ketamine concentration of 0, 10, 20, 30, 40, and 50 ng/mL by a target-controlled infusion device, and patients assessed the levels of pain at rest, pain on coughing, somnolence (drowsiness), and nausea using a 100-mm visual analog scale (VAS). In the morphine + placebo group, a placebo (saline) was similarly administered instead of ketamine. In the morphine + ketamine group, the VAS scores for pain at rest and pain on coughing significantly decreased on ketamine administration at a plasma concentration of 20 ng/mL or larger compared with the respective baseline VAS scores (P < 0.05 each). In the placebo + ketamine group, the VAS scores for pain at rest and pain on coughing did not significantly change at any plasma concentration of ketamine as compared to the morphine + placebo group. In the morphine + ketamine group, a plasma concentration of ketamine larger than 20 ng/mL did not further reduce VAS scores for pain at rest and pain on coughing. The VAS scores for drowsiness were comparable among the three groups at any plasma concentration of ketamine. Ketamine at a plasma concentration of 20 ng/mL or larger may enhance epidural morphine-and-bupivacaine-induced analgesia. As an adjunct with epidural morphine-and-bupivacaine and considering the safety of small doses, the minimal plasma concentration of ketamine given IV may be approximately 20 ng/mL.

 

奥卡西平在大鼠模型中神经性疼痛机械和冷异常的抑制作用

The suppressive effects of oxcarbazepine on mechanical and cold allodynia in a rat model of neuropathic pain.
Jang Y
, Kim ES, Park SS, Lee J, Moon DE.
Department of Anesthesiology, School of Medicine, The Catholic University of Korea, Kangnam Saint Mary's Hospital, 505 Banpo-Dong, Seocho-Gu, Seoul, Korea.
Anesth Analg 2005 101: 800-806.

 

奥卡西平(OCBZ)是一种类似卡马西平的酮类(CBZ),并和CBZ有类似的镇痛作用,但对它在神经性疼痛作用方面的研究很少。这项研究,我们评估了OCBZ在大鼠神经性疼痛模型中的镇痛作用。每只sprague-dawley雄鼠左边的L5L6脊神经都紧紧结扎以产生神经性疼痛。60只神经性疼痛的老鼠随机分配到6,每组各自于腹膜里放置生理盐水, 媒介物(聚乙烯乙二醇400), OCBZ (10 mg/kg,20mg/kg,30mg/kg,50mg/kg)。于给药前、给药后15306090120150180分钟记录机械和冷异常,且经常用von frey细丝和100%丙酮分别刺激量化测量停药后反应。在检测药物诱发的副作用时观察到了眩晕表现。在OCBZ治疗组,经常用机械和冷刺激的停药显著降低了剂量依赖方式(P<0.05)。只有在OCBZ的最大剂量才降眩晕表现次数。结果表明OCBZ对神经性疼痛异常和痛觉过敏是一种可行性治疗。

(孙志荣 薛张纲 校)
Oxcarbazepine (OCBZ) is a keto analog of carbamazepine (CBZ) and may have similar analgesic properties to CBZ, but studies on its effects in neuropathic pain conditions are rare. In this study, we evaluated the analgesic effects of OCBZ in a rat neuropathic pain model. Male Sprague-Dawley rats were prepared by tightly ligating the left L5 and L6 spinal nerves to produce neuropathic pain. Sixty neuropathic rats were randomly assigned into six groups, and normal saline, a vehicle (polyethylene glycol 400), and OCBZ (10 mg/kg, 20 mg/kg, 30 mg/kg, and 50 mg/kg) were intraperitoneally administered to these individual groups. Mechanical and cold allodynia were observed at preadministration and 15, 30, 60, 90, 120, 150, and 180 min after drug administration and were quantified by measuring withdrawal frequencies to stimuli with von Frey filaments and 100% acetone, respectively. Rotarod performance was measured to detect drug-induced adverse motor effects. In the OCBZ-treated groups, withdrawal frequencies to mechanical and cold stimuli were significantly reduced in a dose-dependent manner (P < 0.05). Only at the largest dose did OCBZ reduce rotarod performance time. These results suggest that OCBZ may be a possible therapeutic consideration in neuropathic pain conditions associated with allodynia and hyperalgesia


给因感染假单胞菌而导致脓毒症的羊输注0.9%的生理盐水后不会使血容量扩张

Sepsis produced by Pseudomonas bacteremia does not alter plasma volume expansion after 0.9% saline infusion in sheep.
Svensen CH
, Clifton B, Brauer KI, Olsson J, Uchida T, Traber LD, Traber DL, Prough DS.
Department of Anesthesiology, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0591, USA.

Anesth Analg 2005 101: 835-842

 

临床医师通常认为脓毒症患者的体液往往不能稳定地在血管中循环,常常会在组织间隙中蓄积。我们常假设:给患因感染高活力细菌而导致脓毒症并长期被仪器监测的清醒的羊输注0.9%的生理盐水会比给清醒的没有患脓毒症的羊输注0.9%的生理盐水血容量的扩张少而组织间液的扩张大。给六只意识清醒的成年羊以超过20分钟(1.25ml/kg/min)的速度按25ml/kg静脉滴注0.9%的生理盐水,这些羊依次经历没有患脓毒症,患脓毒症的早期和晚期三个阶段(早期和晚期分别是感染了铜绿假单胞菌后的4小时和24小时)。这些输注液体的分布和消除用质量守恒定律(即检测血浆中偶氮蓝燃料的量)以及容量动力学的方法分析。根据质量守恒分析的结果显示:没有患脓毒症以及脓毒症早期和晚期的羊,它们的血容量扩张的时程并没有很大的变化。液体输注结束后,平均给羊输了1050/-125ml的液体,羊的平均体重是42/5kg,血容量扩张的平均值分别是:没有患脓毒症的羊:312/-50ml,脓毒症早期的羊:386/-34,脓毒症晚期的羊400/51。三种羊的容量动力学分析结果是相似的。无论是患脓毒症还是没有患脓毒症的羊,在输注了0.9%的生理盐水后血容量扩张的高峰和消退时程(都是3小时)还有动力学参数都是相似的。由此可见,与我们的临床印象和假设相反,给这种动物模型输注0.9%的生理盐水后体液的分布并没有因感染铜绿假单胞菌导致的菌血症而改变。

(钟静 薛张纲 校)

Clinicians generally consider sepsis to be a state in which fluid is poorly retained within the vasculature and accumulates within the interstitium. We hypothesized that infusion of 0.9% saline in conscious, chronically instrumented sheep with hyperdynamic bacteremic sepsis would be associated with less plasma volume expansion (PVE) and greater interstitial fluid volume expansion than in conscious, nonseptic sheep. Six conscious adult sheep received an IV infusion of 25 mL/kg of 0.9% saline over 20 min (1.25 mL.kg(-1).min(-1)) in a control nonseptic state and during early and late sepsis (4 and 24 h, respectively, after initiation of a standard infusion of live Pseudomonas aeruginosa). The distribution and elimination of infused fluid were studied by mass balance (after measurement of plasma volume using Evans blue dye) and volume kinetic analysis. Mass balance demonstrated no significant differences in the time-course of PVE between control, early sepsis, and late sepsis. At the end of the infusions, which averaged 1050 +/- 125 mL in sheep weighing an average of 42 +/- 5 kg, calculated PVE was 312 +/- 50 mL, 386 +/- 34 mL, and 400 +/- 51, respectively. Volume kinetic analysis was similar in all three protocols. In both nonseptic and septic sheep, infusion of 0.9% saline resulted in similar peak PVE and resolution of PVE over a 3-h interval and similar kinetic parameters. Contrary to clinical impressions and to our hypothesis, the distribution of 0.9% saline in this animal model was not changed by bacteremia produced by infusion of Pseudomonas aeruginosa.

脊麻与硬膜外麻醉在严重先兆子痫剖宫产术中的比较:一项前瞻性的随机多中心研究

Spinal Versus Epidural Anesthesia for Cesarean Delivery in Severe Preeclampsia: A Prospective Randomized, Multicenter Study.

Visalyaputra, Shusee MD *; Rodanant, Oraluxna MD +; Somboonviboon, Wanna MD +; Tantivitayatan, Kamthorn MD ++; Thienthong, Somboon MD [S]; Saengchote, Wanawimol MD .

*Department of Anesthesiology, Siriraj Hospital, Faculty of Medicine, Mahidol University; +Department of Anesthesiology, Chulalongkorn University Hospital, Faculty of Medicine; ++Department of Anesthesiology, Rajvithi Hospital, Tertiary Care Center, Bangkok, Thailand; [S]Department of Anesthesiology, Faculty of Medicine, Khonkaen University, Khonkaen, Thailand; [//]Department of Anesthesiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

Anesthesia & Analgesia. 101(3):862-868, September 2005.

 

在这项随机多中心的研究中,我们比较脊麻和硬膜外麻醉在严重先兆子痫剖宫产术中的血流动力学上的效应。硬膜外组(n=47)被给予混合有1400000肾上腺素的2%利多卡因1823毫升,并在术后给予3毫克吗啡。脊麻组(n=53)被给予2.2毫升0.5%的重比重布比卡因及0.2毫克吗啡。我们假设在手术期间最低的平均动脉压至少在脊麻组下降10毫米汞柱才可认为有临床意义。研究发现两组平均动脉压在统计学上有显著的差别:相对于硬膜外组,脊麻组有更多的患者出现了低血压(P<0.001)。虽然低血压(收缩压<100毫米汞柱)的发生率脊麻组较之硬膜外组更为频繁(51%比上23%),严重低血压(收缩压<=100毫米汞柱)的持续时间在两组中都是很短暂的(<=1分钟)。麻黄素的使用脊麻组较硬膜外组要来得多(中位数,6比上0毫克),但是所有患者的低血压都是非常容易处理的。新生儿的Apgar评分及脐血血气分析结果显示两组相似。不良的新生儿事件(五分钟Apgar评分<7分及脐血PH<7.20)仅有二例,皆为早产新生儿(体重<1500克),且出生时母体没有因区域麻醉而发生低血压。本次大样本的前瞻性研究结果支持脊麻在严重子痫患者的剖宫产中的应用。

(许文妍 薛张纲 )

In this randomized, multicenter study we compared the hemodynamic effects of spinal and epidural anesthesia for cesarean delivery in severely preeclamptic patients. The epidural group (n = 47) received 2% lidocaine with epinephrine 1:400,000, 18-23 mL, followed by 3 mg of morphine after delivery. The spinal group (n = 53) received 2.2 mL of 0.5% hyperbaric bupivacaine plus 0.2 mg morphine. We hypothesized that the lowest MAP (mean arterial blood pressure, the primary outcome) during the delivery period would have to be at least 10 mm Hg less in the spinal group to be of clinical importance. We found that there was a statistically significant difference in MAP, with more patients in the spinal group exhibiting hypotension (P < 0.001). Although the incidence of hypotension (systolic arterial blood pressure, SAP <=100 mm Hg) was more frequent in the spinal group than in the epidural group (51% versus 23%), the duration of significant hypotension (SAP <=100 mm Hg) was short (<=1 min) in both groups. There was more use of ephedrine in the spinal group than in the epidural group (median, 6 versus 0 mg) but hypotension was easily treated in all patients. Neonatal outcomes assessed by Apgar scores and the umbilical arterial blood gas analysis were similar in both groups. Adverse neonatal outcomes (5-min Apgar score <7 and umbilical arterial blood pH <7.20) were found in only 2 premature newborns (weight <1500 g) who were born without maternal hypotension after regional anesthesia. We conclude that the results of this large prospective study support the use of spinal anesthesia for cesarean delivery in severely preeclamptic patients.

硬膜外注射利多卡因减少腰硬联合麻醉时硬膜穿刺的反应

Epidural injection of lidocaine reduces the response to dural puncture accompanying spinal needle insertion when performing combined spinal-epidural anesthesia.

van den Berg AA, Sadek M, Swanson S, Ghatge S.

The University of Texas Medical School at Houston, 6431 Fannin, MSB 5.020, Houston, TX 77030-1503, USA.

Anesth Analg. 2005 Sep;101(3):882-5.

 

在腰硬联合麻醉(CSEA)置针的时候,病人可能会体验到疼痛、压迫感、感觉异常,或者在表面和深部注射局麻药时,在针穿刺到骨膜时,在腰麻针穿破硬膜时,在硬膜外置管时感觉到不适。我们调查在穿刺针通过硬脊膜及软脊膜时不适感和不自主的口头及身体反应的发生率,同时调查在置腰麻针前硬膜外注射利多卡因对这些反应的影响。我们调查43位在CSEA时感觉很好的病人。通过阻力消失法将17Tuohy针置入硬膜外后,注入3ml不含防腐剂的生理盐水,或是3ml 1200000肾上腺素的2%利多卡因置硬膜外腔。在1分钟后用27号铅笔尖样Whitacre针用针套针的方法行硬脊膜穿刺。在硬脊膜穿刺时,注射利多卡因的有2人(9%)感觉很痛,而注射生理盐水的有17人(81%)(P<0.05),这17人中对硬脊膜穿刺的反应有不自主的运动(33%),不自主的发声(76%),或者承认在穿刺时有感觉(76%)。这项研究揭示通过阻力消失法将Tuohy针置入硬膜外,再用27号铅笔尖样Whitacre针行硬脊膜穿刺行CSEA时,会导致病人不自主的运动,不自主的发声,即使感觉很好的病人也有大部分在穿刺时有感觉异常。而在置腰麻针前硬膜外注射利多卡因可以明显的减少这些反应和感觉异常。

(陆文清 薛张纲 校)

During placement of needles for combined spinal-epidural anesthesia (CSEA), patients may experience pain, pressure, paresthesia, or discomfort during skin and deeper injection of local anesthetic, needle impingement on periosteum, dural puncture by the spinal needle, and insertion of the epidural catheter. We investigated the incidence of perception of and spontaneous verbal and motor responses to insertion of a spinal needle through the dura mater and pia mater and the effect of injecting lidocaine into the epidural space through the epidural needle before inserting the spinal needle through the meninges. Forty-three patients presenting for elective cesarean delivery under CSEA were studied.After localization of the epidural space using loss of resistance to air using a 17-gauge Tuohy needle, either 3 mL preservative free normal saline or 3 mL lidocaine 2% plus epinephrine 1:200,000 was injected through the Tuohy needle. "Needle through needle" dural puncture was performed 1 min later using a 27-gauge Whitacre pencil-point needle. At the moment of dural puncture, 2 (9%) parturients given lidocaine and 17 (81%) parturients given saline (P < 0.005) responded to dural puncture by spontaneously moving (33%), spontaneously vocalizing (62%), or, in response to direct questioning, by acknowledging (76%) having perceived sensation during thecal penetration. This study reveals that dural puncture by a Whitacre 27-gauge pencil-point needle inserted through a Tuohy epidural needle sited using loss of resistance to air causes involuntary movement, spontaneous vocalization, or is perceived by the majority of patients presenting for cesarean delivery under CSEA and that lidocaine injected into the epidural space before dural puncture largely eliminates these responses and sensations.

 

连续术中和术后胸段硬膜外镇痛削弱腹部大手术后脑尿钠肽释放

Continuous Intra- and Postoperative Thoracic Epidural Analgesia Attenuates Brain Natriuretic Peptide Release After Major Abdominal Surgery

Stefan Suttner, Katrin Lang, Swen N. Piper, Harald Schultz, Kerstin D. R&ouml;hm, and Joachim Boldt.

Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany.
Anesth Analg 2005 101: 896-903.

 

我们研究了利用连续术中和术后胸段硬膜外镇痛(TEA)阻断痛觉传入是否能降低有冠心病危险因素或已患冠心病的手术病人的脑尿钠肽(BNP)的血浆浓度。28位进行腹部大手术的病人接受了全麻联合1.25 mg/mL布比卡因和1 microg/mL舒芬太尼连续胸段硬膜外输注(n = 14; TEA)或全麻后续患者自控静脉镇痛(n = 14; IV PCA)。在术前,切皮后90分钟,送达重症监护室时,和术后第一、二、三天早晨连续进行痛觉视觉模拟评分,测定血液动力学,血浆儿茶酚胺,心肌钙蛋白T,心房尿钠肽(ANP)BNP。动态视觉模拟评分在TEA组中明显要低。TEA降低术后心率而不影响其他的血流动力学参数。围手术期血浆肾上腺素在两个组中都增加,但在TEA组中显然增加较少。两组的ANPBNP基线浓度相似(分别为TEA 3.4 +/- 1.8 27.0 +/- 12.3 pg/mL; IV PCA 3.1 +/- 2.0 25.9 +/- 13.0 pg/mL)。围术期ANPBNP两组都增加,而TEA组病人术后BNP水平明显较低(TEA 92.1 +/- 31.9 pg/mL; IV PCA 161.2 +/- 44.7 pg/mL)。并未观察到血浆ANP浓度有类似的差别。两组的血浆心肌钙蛋白T始终都在正常范围内。我们推断,围术期应用局麻药和阿片类药连续TEA削弱接受腹部大手术的冠心病危险人群和冠心病患者的BNP释放。

(徐丽颖 薛张纲 )

We investigated whether blocking afferent nociceptive inputs by continuous intra- and postoperative thoracic epidural analgesia (TEA) would decrease plasma concentrations of brain natriuretic peptide (BNP) in patients who were at risk for, or had, coronary artery disease. Twenty-eight patients undergoing major abdominal surgery received either general anesthesia supplemented with a continuous thoracic epidural infusion of 1.25 mg/mL bupivacaine and 1 microg/mL sufentanil (n = 14; TEA) or general anesthesia followed by IV patient-controlled analgesia (n = 14; IV PCA). Visual analog scale pain scores, hemodynamics, plasma catecholamines, cardiac troponin T, atrial natriuretic peptide (ANP), and BNP were serially measured preoperatively, 90 min after skin incision, at arrival in the intensive care unit, and in the morning of the first, second, and third postoperative day. Dynamic visual analog scale scores were significantly less in the TEA group. TEA reduced the postoperative heart rate without affecting other hemodynamic variables. Plasma epinephrine increased perioperatively in both groups but was significantly lower in the TEA group. Baseline ANP and BNP concentrations were similar between groups (TEA 3.4 +/- 1.8 and 27.0 +/- 12.3 pg/mL; IV PCA 3.1 +/- 2.0 and 25.9 +/- 13.0 pg/mL, respectively). ANP and BNP increased perioperatively in both groups, with significantly lower postoperative BNP levels in TEA patients (TEA 92.1 +/- 31.9 pg/mL; IV PCA 161.2 +/- 44.7 pg/mL). No such difference was observed in plasma ANP concentrations. Plasma cardiac troponin T concentrations were within normal limits in both groups at all times. We conclude that continuous perioperative TEA using local anesthetics and opioids attenuated the release of BNP in patients undergoing major abdominal surgery who were at risk for, or had, coronary artery disease.