Anesthesia & Analgesia

September 2005

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

全麻誘導後發生低血壓的預測因素

( 路譯 薛張綱校)

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.

 

羥乙基澱粉130/0.4與改良明膠液體相比對心臟手術病人的容量擴張作用:對圍術期出血及輸血需求的影響

(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:

 

兒童自然睡眠期間雙頻指數的分析

(朱輝 陳傑 )

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.

 

兒童患者依託咪酯麻醉誘導時的血流動力學反應

(周志堅 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.

 

異氟醚介導的神經元變性:一項對海馬組織切片培養的評估

(王麗珺 薛張綱 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:

 

甲呱卡因脊麻後一過性神經系統症狀的發生率

(黃麗娜 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.

 

指壓按摩法和術前雙親焦慮症:試驗性研究

(孫敏莉 薛張綱 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:

 

延長注射時間以及少量吸煙可以降低芬太尼誘發嗆咳的發生率

(黃佳佳 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.

 

靜脈注射兩種不同異丙酚製劑引起疼痛的比較

( 薛張綱 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.

 

應用壓力容量環測定布比卡因、左旋布比卡因、羅呱卡因的心肌和血管效應

(範穎輝 陳傑 )

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.

 

隨時間減量使用吸入麻醉藥的指導意義

(齊波 陳傑 )

Tutorial: Context-Sensitive Decrement Times for Inhaled Anesthetics

Edmond I. Eger, II and Steven L. Shafer

Anesth Analg 2005 101: 688-696

 

丙泊酚對小鼠敏感神經潛在基因的微序列分析

(忻紀華 陳傑 )

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.

 

硫酸鎂預處理減少依託咪酯誘導後的肌痙攣

(邱鬱薇 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

 

持續量和單次量的四氯三乙基苯的體外人骨骼肌攣縮實驗在惡性高熱診斷中的正面與負面作用

(孫卓真 薛張綱 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-羥色胺3A受體拮抗劑類止吐藥可抑制肌肉的煙鹼樣乙酰膽鹼受體

(趙延華 陳傑 )

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

 

阿片受體內吞及ß-Arrestins在產生阿片類藥物耐受中的作用

(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:

 

通過電子聽診器及電腦分析呼吸音來判斷氣管內導管位置錯誤

(周曉敏 薛張綱 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

 

連續監測腹部大手術老年病人的腦氧飽和度能夠減輕腦組織潛在的低氧損傷

(蘇殿三 陳傑 )

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.

 

氫氧化鋇石灰乾燥後變黃色

( 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,異氟烷,和七氟烷在乾燥的鈉石灰中降解時鈉石灰的溫度

(周荻 薛張綱 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.

 

緊閉環路肌松控制系統的評價

(鄭擁軍 陳傑 )

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.

 

不同條件會導致腦電雙頻指數提示不正確的麻醉狀態

(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:

 

能增強布比卡因和嗎啡硬膜外鎮痛的氯胺酮血漿濃度

(王慧琳 薛張綱 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.

酯類酮咯酸的新型長效製劑具有長效抗傷害和抗炎效應

(殷文淵 陳傑 )

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.

 

神經調理素®對脊神經結紮大鼠的抗痛覺超敏和抗痛覺過敏作用

(張瑩 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

 

奧凱西平在大鼠模型中神經性疼痛機械和冷異常的抑制作用

(孫志榮 薛張綱 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

 

局部或全身應用帕瑞考昔聯合利多卡因/可樂定靜脈區域鎮痛用於上肢I型複雜區域疼痛綜合征的抗傷害性效應

(潘志英 陳傑 )

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

 

嗎啡和右美托咪啶單次應用後其抗疼痛強度的長期變化

(顏濤 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:

 

在美國羅庫溴銨的過敏反應的風險性與維庫溴銨相近似:對食品和藥品管理局的不良事件報告的分析

( 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:

給因感染假單胞菌而導致膿毒症的羊輸注0.9%的生理鹽水後不會使血容量擴張

(鍾靜 薛張綱 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

 

噴霧沙丁胺醇、外源性呼氣末正壓通氣、或兩者合用對患有慢性梗阻性肺部疾病病人機械通氣時的呼吸力學、血流動力學和氣體交換的作用

(肖潔 陳傑 )

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:

減少腦血流量能延長頸動脈內注射硫噴妥鈉引起的腦電圖靜息的時程

(吳儉 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:  

 

脊麻與硬膜外麻醉在嚴重先兆子癇剖宮產術中的比較:一項前瞻性的隨機多中心研究

(許文妍 薛張綱 )

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.

 

脊麻引起的低血壓------嚴重子癇前期患者與健康剖腹產孕婦的風險比較

(顧新宇 陳傑 )

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

 

硬膜外嗎啡用於產後輸卵管結紮術後的鎮痛

(陳瑋 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減少腰硬聯合麻醉時硬膜穿刺的反應

(陸文清 薛張綱 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:

超聲引導的鎖骨下阻滯與鎖骨上阻滯的比較

(鄭麗 陳傑 )

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.

 

全膝關節成形術後股神經阻滯聯合硬膜外鎮痛的作用

(黃施偉 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.

 

連續術中和術後胸段硬膜外鎮痛削弱腹部大手術後腦尿鈉肽釋放

(徐麗穎 薛張綱 )

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

 

脊麻中使用氯胺酮鎮靜能減少膝關節鏡手術中缺血再灌注損傷標誌物

(張宇 陳傑 )

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:

 

頸椎運動:在X線透視下比較應用光索導芯、視頻喉鏡和麥金托什喉鏡插管

(趙雪蓮 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

兒童自然睡眠期間雙頻指數的分析

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.

 

雙頻指數(BIS)是一項用於評估鎮靜水平的指標。一些研究者最近分析了成人在自然睡眠期間BIS的變化並發現當睡眠變得更深時BIS就明顯降低。睡眠中兒童的BIS指數的變化還沒有人開展研究。這項研究的目的是評估一組兒童在睡眠各階段的BIS趨勢並對有限的病例作描述性分析。筆者選擇了15名既往有癲癇發作史的兒童作隨訪,當前臨床指標陰性且腦電圖(EEG)正常,記錄清醒狀態、各個睡眠階段以及再醒時的BISEEG,計算每個階段BIS的範圍值、平均值和標準差。結果顯示隨睡眠變深時BIS逐漸降低。睡眠階段與BIS顯著相關。當再醒時,BIS緩慢增高。

(朱輝 陳傑 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.

 

應用壓力容量環測定布比卡因、左旋布比卡因、羅呱卡因的心肌和血管效應

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

.

羅呱卡因和左旋布比卡因研製和發展用以降低布比卡因偶然過量導致的致命風險。這些藥物在亞致死量時潛在心肌抑制作用尚不得而知。壓力容量環可用於區別心肌和血管效應。本實驗分組為布比卡因組、左旋布比卡因組、羅呱卡因組和生理鹽水對照組,分別用7只麻醉、開胸新西蘭大白兔,獲得了量-效曲線。同時插入一根連接的壓力導管獲得腔靜脈阻斷期間高度精確的左室壓力和容量資料。測量收縮力(V100),舒張功能(γ和舒張末期壓力容量關係),每次增加劑量後測量血管阻力。按0.1250.2的比率注射左旋布比卡因和布比卡因/羅呱卡因,來模擬臨床劑量,採用log28步)劑量遞增方案。40分鐘後,總藥量為2.66/4.25mg/kg。當劑量超過4.25mg/kg時,左旋布比卡因(p0.013)和布比卡因(p0.019)顯著降低收縮力,而羅呱卡因在4.25mg/kg時與生理鹽水對照組無顯著差異。布比卡因可降低射血分數和心指數,增加血管阻力。左旋布比卡因可降低射血分數和心指數,並證實具有雙重血管作用,在較大劑量時增加血管阻力。羅呱卡因增加血管阻力,降低射血分數,但對收縮力無影響。平均動脈壓和舒張功能在各組均無顯著變化。在臨床常規劑量下,與生理鹽水對照組相比較,布比卡因組和左旋布比卡因組均有收縮力顯著降低,而羅呱卡因組無顯著差異。

(範穎輝 陳傑 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.

隨時間減量使用吸入麻醉藥的指導意義

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.

 

隨時間減量使用吸入麻醉藥包含兩個含義:a) 麻醉的維持(通常指在一個穩定的肺泡氣濃度)-持續穩定;b)隨時間按某種比例降低肺泡和重要臟器(腦、心、腎和肝,統稱為血供豐富的組織)藥物濃度。從麻醉開始到按比例非線性降低麻醉藥濃度的時間延長,可能延長了麻醉恢復時間。在這個實驗中,研究人員應用了商業提供的類比程式(Gas Man) ®來證實和擴展這些概念。在這個模型中,對於異氟醚來說,延長麻醉持續時間可以明顯地延長其麻醉恢復時間。與異氟醚相比,七氟醚的蘇醒延遲較少。而對於地氟醚,僅僅通過增加麻醉時間或減少麻醉相關遞減時間95%和更多可以延長麻醉恢復時間。這些變化是因為每一種麻醉藥在血液和組織中的相對溶解度的不同所造成的。另外心輸出量的增加也會延遲清醒。

(齊波 陳傑 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.

 

丙泊酚對小鼠敏感神經潛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.

確立全麻藥物分子水平上作用機制是件困難的事,因為相關的全麻藥是多靶點的。,因此要在進行評價。天生睡眠時間短(ISS)和睡眠時間長(ILS)的小鼠對酒精和鎮靜催眠類藥物反應的敏感性是不同的,並且只含有一個單一的數量特徵性位元點(Lorpl),該位點導致小鼠對丙泊酚的翻正反射消失(LOPR)的基因變異。本研究中,作者應用高密度的寡核苷酸微序列證實大腦基因表達和候選基因在Lorpl 區域的不同表達來闡述LOPR時的分子機制。應用Affymetrix MG-U74 Av2 Genecphips®來進行微序列的分析,並通過半數逆轉錄多聚酶鏈反應來選擇不同的表達基因。ILSISS的小鼠大腦顯示共有3423組基因明確表達,其中有139組(4%)基因的表達不同。Lorpl 區域內的基因分析顯示有26組基因明確表達,其中2組(7%)基因的表達不同。這些基因編碼AWP 1蛋白(與蛋白激酶1相關)和“BTZPOZdomain containing 1”,這些蛋白的功能大多仍不知道。Lorpl 區域外的不同基因表達包括7組原來具有神經功能的基因,因此能作為另外的候選基因介導ISSILS中敏感神經差異。

(忻紀華 陳傑 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-羥色胺3A受體拮抗劑類止吐藥可抑制肌肉的煙鹼樣乙酰膽鹼受體

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-羥色胺能5-羥色胺3A受體(5-HT(3A)R)和肌肉的煙鹼樣膽鹼能受體(nAChR)的拮抗劑在麻醉中廣泛應用。5-HT(3A)RnAChR都是配體門控離子通道,其某些激動劑和拮抗劑具有已知的藥理共性。作者利用表達在非洲爪蟾(Xenopus Laevis)未成熟卵細胞上的哺乳類動物的5-HT(3A)R和肌肉nAChR,來研究臨床上應用的5-HT(3A)R拮抗劑-止吐藥和非去極化肌松藥對受體啟動後離子電流的作用。用全細胞的兩個電極的電壓鉗技術來記錄電流。朵拉司瓊、昂丹司瓊和格拉司瓊在鈉摩爾濃度(nM)可逆性地抑制5-HT(3A)R受體功能,其50%抑制濃度(IC(50))分別為11.8nM6.4 nM0.2 nM。朵拉司瓊的主要代謝物氫化朵拉司瓊(hydrodolasetron)對5-HT(3A)R的作用較其強40(IC(50) = 0.29 nM)。非去極化肌松藥d-筒箭毒堿對5-HT(3A)R 的阻滯強度與止吐藥相似,明顯強于萬可松和rapacuronium(IC(50) = 11.4 nM, 18.9 muM, 60.5 muM)。反過來,昂丹司瓊、朵拉司瓊和格拉司瓊也以劑量依賴性方式可逆性地抑制nAChR電流,對成熟nAChRIC(50)分別為14.2 muM7.8 muM 4.4 muM,對胚胎nAChRIC(50)分別為16.0 muM18.6 muM 13.9 muM。而且,氫化朵拉司瓊對成熟nAChR抑制作用明顯強于朵拉司瓊10倍之多。這些結果顯示作用於特異性的配體門控離子通道的藥物也可能影響其他類型的離子通路。

(趙延華 陳傑 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.

連續監測腹部大手術老年病人的腦氧飽和度能夠減輕腦組織潛在的低氧損傷

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.

 

隨著年齡的增長老年病人生理儲備下降,因此比年輕人更容易發生腦氧去飽和。為了評價腦氧飽和度監測(rSO2)是否能夠減輕手術期間腦氧去飽和,作者對122名全麻下行腹部大手術的老年病人進行了rSO2監測。病人隨機分配到兩組,處理組(rSO2監測可見,術中保持在誘導前的75%以上,n56)和對照組(rSO2監測不可見,根據常規進行麻醉,n66)。研究結果發現,在處理組有11名,對照組有15名病人rSO2低於術前的75%p0.82)。rSO2的均數(95%可信區間)在處理組(66%[64%-68%])高於對照組(61%[64%68%]p0.002),低於基礎值75%的曲線下面積在處理組(0.4min%[0.10.8min%])低於對照組(80min[2144min%]p0.017)。術後第7天的MMSE神經功能量表評分在對照組低於處理組(26[25-30] VS 28[2630],P=0.02)。研究還發現,低於基礎值75%的曲線下面積與術後MMSE量表評分較術前下降的幅度之間存在著明顯的相關性(r20.25p0.01)。對照組中術中出現腦氧去飽和的病人與處理組相比在PACU和醫院的停留時間都明顯延長(PACU:對照組47min[13-56min],處理組25min[15-35min],p0.01;醫院停留時間:對照組24[7-53];10[7-23]p0.007)。總之,研究者總結認為:rSO2監測下對老年行腹部大手術的病人進行麻醉管理可以減少病人腦組織可能出現的低氧,並且能夠減輕其對認知功能的影響,縮短在PACU和醫院的停留時間。

(蘇殿三 陳傑 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.

 

緊閉環路肌松控制系統的評價

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.

 

麻醉過程中如能實現肌松自動調控,則能在很大程度上減輕麻醉醫生的工作強度,從而使他們有精力兼顧其他病人。因此,本研究擬通過應用臨床常用的羅庫溴銨和四個成串刺激(TOF)計數,構建肌松控制系統,實現肌松自動調控。肌松控制系統由肌松監測儀(TOF Watch SX),主機和肌松藥微泵三部分組成。肌松監測儀將監測到的肌松信號輸入主機,主機通過相應程式調節微泵,控制肌松藥用量。肌松控制系統的演算法採用比例-積分(PI)演算法和查找表原件,以避免現有控制器的技術限制。控制器採用客觀方法以實現最優化,同時也能避免控制器演算法手工漂移所造成的系統運行不穩定。本試驗設定的適宜肌松控制目標為TOF計數保持在12的水平,並且通過15例病人驗證控制效果。在39小時的緊閉環路肌松控制試驗中,所記錄到的肌顫搐中96.1%在適宜的調控範圍內。本研究中羅庫溴銨平均用量為0.36 mg·kg–1·h–1 (sd 0.18 mg·kg–1·h–1)。本研究還表明,即使存在干擾的情況下,該控制系統仍具有良好的穩定性。該肌松控制器能維持TOF目標值,可以作為臨床條件下肌松控制閉合回路的硬體設計基礎以及用戶介面。

(鄭擁軍 陳傑 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.

 

酯類酮咯酸的新型長效製劑具有長效抗傷害和抗炎效應

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.

 

在臨床上沒有長效非甾體類抗炎藥可用於治療疼痛。在這個研究中,作者評估了幾種酯類酮咯酸的新製劑的抗傷害、抗炎效應和作用持續時間,例如,丙基酯,戊基酯,庚基酯和葵酯酮咯酸,觀察他們是否長效。在Sprague-Dawley鼠中進行了四個研究。在研究1-3中,評估了IM酮咯酸氨丁三醇和它的原製劑和丙基酯的抗傷害和抗炎效應。在研究4中,評估了其他幾種酯類酮咯酸的抗傷害和抗炎效應。作者發現酮咯酸氨丁三醇2480240µmol/kg(在生理鹽水中)產生顯著的鎮痛和抗炎效應,其持續時間大約為6-8小時。四種酮咯酸酯類使用的劑量為240µmol/kg(在油中)產生顯著的長效抗傷害和抗炎效應,其持續時間大約為52-76小時。作者認為酯類酮咯酸的靜脈新製劑在鼠中產生長效抗傷害和抗炎效應,為長於傳統的酮咯酸氨丁三醇製劑的6.5-9.5倍。

(殷文淵 陳傑 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.

 

局部或全身應用帕瑞考昔聯合利多卡因/可樂定靜脈區域鎮痛用於上肢I型複雜區域疼痛綜合征的抗傷害性效應

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應用帕瑞考昔(環氧酶-2抑制藥)聯合利多卡因/可樂定靜脈區域鎮痛應用於上肢I系型複雜區域疼痛綜合征(CRPS)的療效。30ICRPS病人分為3組。對照組(CG):在健康一側肢體靜脈注射生理鹽水,並且局部靜脈注射1 mg/kg利多卡因+30ug可樂定(以生理鹽水稀釋到10ml)。全身應用帕瑞考昔組(SPG):局部阻滯同CG,但是全身用藥帕瑞考昔20mg。局部靜脈注射帕瑞考昔組(IVRAPG):與CG組相比另外局部注射帕瑞考昔5mg。鎮痛每週一次,連續3周。鎮痛效果以VAS評分和止痛劑的用量來評估。與其他兩組相比,IVRAPG在第二周和第三周布洛芬每天的用量顯著減少(P < 0.05)IVRAPG3周布洛芬的用量也顯著小於前兩周 (P < 0.05)。前兩周各組VAS評分相似, IVRAPG第三周表現了較小的VAS評分(P < 0.05)。作者認為:靜脈注射帕瑞考昔5mg並聯合應用利多卡因/可樂定聯合靜脈區域鎮痛治療ICRPS具有良好的抗炎效果。

(潘志英 陳傑 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.

 

噴霧沙丁胺醇、外源性呼氣末正壓通氣、或兩者合用對患有慢性梗阻性肺部疾病病人機械通氣時的呼吸力學、血流動力學和氣體交換的作用

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.

作者假設沙丁胺醇噴霧與外部呼氣末正壓通氣(PEEPe)兩者合用時對防止慢性梗阻性肺病(COPD)惡化有獲益作用。10位對支氣管擴張藥敏感的COPD病人,在麻醉機械通氣時呈現出適度的內源性PEEP(PEEPi),本研究評價了以下各種情況下病人的呼吸系統(rs)力學、血流動力學和氣體交換:(a)基礎值(PEEP0[ZEEPe]),(b)吸入5mg沙丁胺醇噴霧30分鐘後(ZEEPe-S)(c)PEEPe設置為內源性PEEPi水平30分鐘(PEEPe),(d)保持PEEPe的水平不變,吸入5mg沙丁胺醇噴霧30分鐘後(PEEPe-S)。在PEEPe使用前先確定變數值已回復為基礎值。與ZEEPe相比,(a)ZEEP-S 時,PEEPi分別為(4.8±0.77.0±1.1cmH2O),功能性殘氣量為(115.6±23.1202.1±46.0mL),最小氣道阻力為(9.3±1.411.8±2.2cm H2OL-1s-1),附加氣道阻力有所減低(5.2±1.47.2±1.3cm H2OL-1s-1)(P<0.01),血流動力學有所改善;(b)PEEPe時,PEEPi減低(3.7±1.3cmH2O)(P<0.01),氣體交換有所改善; (c)PEEPe-S時,PEEPi最小(2.0±1.2cmH2O),而且呼吸力學(包括呼吸系統靜電回彈力)、血流動力學和氣體交換都有所改善。結論:在精心預選的COPD病人中,使用支氣管擴張藥/PEEPe取得有益作用。

(肖潔 陳傑 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.

 

脊麻引起的低血壓------嚴重子癇前期患者與健康剖腹產孕婦的風險比較

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,與健康足月臨產孕婦相比,嚴重先兆子癇患者脊麻後低血壓的發生率較低,且較不嚴重,麻黃素的需要量較少。在本研究中,作者假設上述發現受先兆子癇有關因素的影響要勝於較小子宮質量因素。比較先兆子癇患者組(n=65)與早產孕婦組(n=71)脊麻下(0.5%布比卡因、舒芬太尼、嗎啡)行剖腹產術中低血壓發生率及嚴重程度,低血壓定義:需要麻黃素處理(胎兒娩出前收縮壓〈100mmHg或平均動脈壓下降30%),同時研究Apgar評分與臍動脈血PH值。結果顯示,兩組中新生兒及胎盤的重量相似,但先兆子癇組的低血壓發生率比早產孕婦組低(分別為24.6%40.8%p=0.044)。儘管收縮壓、舒張壓、平均動脈壓下降程度相似,先兆子癇組血壓回復到基線水平時麻黃素的需要量比早產孕婦組更少(分別為9.8+4.6mg15.8+6.2mgp=0.031)。先兆子癇組患者的低血壓風險要比早產孕婦組低2倍(相對風險=0.06395%可信度0.3621.003p=0.044)。Apgar評分的影響很小而子宮動脈血PH值沒有什麼影響。結論:先兆子癇因素比較小子宮質量因素更能說明先兆子癇病人脊麻後低血壓的低發生率。

(顧新宇 陳傑 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.

 

超聲引導的鎖骨下阻滯與鎖骨上阻滯的比較

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.

 

在這項前瞻性研究中作者比較了超聲引導(USG)下的鎖骨上阻滯與鎖骨下阻滯的操作時間和阻滯質量。作者假設鎖骨下阻滯可以在較短的操作時間內完成並有與鎖骨上阻滯相同的阻滯質量。80個病人隨機的分為兩組:I(鎖骨下組)S組(鎖骨上組)。所有的阻滯都用7.5-MHZ超聲波探測定位和神經刺激。麻醉混合液為0.5%布比卡因5ml/kg2%鹽酸利多卡因(容積比1:3)加上120萬的腎上腺素組成的。感覺阻滯,運動阻滯和添藥率評估肌皮神經、正中、橈神經、尺神經等阻滯情況。不需加藥麻醉I80%,S87%(P=0.39)。 只有橈側阻滯添藥率有顯著差異: I18%,S0%(P0.006)。兩組間阻滯操作時間無顯著差異(I4分鐘,S4.65分鐘)。技術相關性疼痛指數組間無顯著差異(I:2.0,S:2.0,P=1.00)。結論:USG鎖骨下阻滯至少與USG鎖骨上阻滯一樣迅速完成並且產生相似的不需加藥的麻醉效果。

(鄭麗 陳傑 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.

 

脊麻中使用氯胺酮鎮靜能減少膝關節鏡手術中缺血再灌注損傷標誌物

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.

 

作者通過觀測血液和組織丙二醛(MDA)和次黃嘌呤(HPX)水平來研究膝關節鏡手術時,氯胺酮鎮靜對止血帶引起的氧化應激的影響。30ASA分級I-II級行膝關節鏡手術的病人,接受布比卡因12.5mg脊髓麻醉,隨機分成兩組。氯胺酮組,給予咪唑安定0.01mg/kg後連續注入氯胺酮0.5mg/kg·h,維持至術畢。安慰劑組,注入同量的安慰劑。Ramsey鎮靜評分(RSS)用來評定鎮靜程度。在注入氯胺酮前、止血帶缺血30min及解除止血帶後5min分別採集靜脈血和關節滑膜組織以測定MDAHPX水平。結果氯胺酮組MDAHPX水平顯著低於對照組,RSS分值較高且無副作用。結論:氯胺酮鎮靜減少了膝關節鏡手術中止血帶所致脂質過氧化標誌物的產生。

(張宇 陳傑 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.

 

羥乙基澱粉130/0.4與改良明膠液體相比對心臟手術病人的容量擴張作用:對圍術期出血及輸血需求的影響

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

 

在這項前瞻性、隨機、開放、對照研究中,我們選擇了行冠脈手術的患者,比較了6%羥乙基澱粉130/0.4(HES:n=64)3%改良液體明膠(GEL:n=68)作血管容量補充對紅細胞淨丟失量的作用。血液的丟失量可以從迴圈血容量的判定及術前術後血球壓積的測量來計算。允許輸入的膠體液的量控制在50 ml/kg。如果需要追加液體,使用晶體平衡液。麻醉及手術方法均標準化。兩組的人口統計學及術中變數均相似。整項研究中的用量:HES48.9±17.2 mL/mgGEL48.9±14.6 mL/kg。血紅細胞丟失總量,HES組為544±305 mLGEL組為504±327 mL。測量到的兩組失血量也相似(HES, 19.4 ± 12.3 mL/kg; GEL, 19.2 ± 14.5 mL/kg)。兩組使用的同種異體血製品量相似。在目前的研究條件中,在心臟手術中及術後用於擴張血漿容量,HES 130/0.4可有效替代改良液體明膠,用量可達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.

 

兒童患者依託咪酯麻醉誘導時的血流動力學反應

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

 

依託咪酯常被用以血流動力學儲備差的病人的麻醉誘導。我們運用有創性血流動力學監測研究了兒童病人麻醉誘導時注射依託咪酯後的短期效應。研究物件為12例進行心導管手術的兒童(平均年齡9.2±4.8歲;平均體重33.4±15.4kg);心導管操作包括房間隔缺損堵閉(n = 7)和室上性心動過速射頻導管消融(n = 5)。經靜脈鎮靜後,將尖端帶有氣囊的肺動脈導管置入,以測量心內及肺動脈的壓力和氧飽和度。記錄基礎值,靜脈注射依託咪酯0.3 mg/kg後再次記錄測量值。在所有分組中,注射依託咪酯後,所測右房、主動脈或肺動脈壓力和氧飽和度、計算的Qp:Qs之比或全身或肺血管阻力均沒有顯著性變化。使用依託咪酯後不引起有臨床意義的血流動力學改變,這一結果支持我們的臨床印象,即依託咪酯對兒童是安全的。而對於新生兒及嚴重心室功能不良和肺動脈高壓患兒,需要進一步研究以確定依託咪酯的血流動力學影響。

(周志堅 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.

 

甲呱卡因脊麻後一過性神經系統症狀的發生率

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

 

我們前瞻性地評估了1273例接受 1.5%甲呱卡因(純的,沒有葡萄糖)的脊麻(或腰硬聯合麻醉〔CSE〕)門診外科手術病人。假設對大量病人的分析會證實先前的發現即等比重的1.5%甲呱卡因並不總是併發一過性的神經系統症狀(TNS)。麻醉後1–4天中和6–9天中我們分別隨訪病人兩次。1210名病人術後成功隨訪(95%的隨訪率)。沒有一例病人因為麻醉藥的關係而產生持久的神經系統後遺症。372CSE麻醉中沒有一例麻醉藥不足以應付手術。838例脊麻中有14例(占1.7%)的麻醉藥是不足的。有78名病人發生了TNS(6.4%; 95% 可信區間為 5.1%–8%)TNS定義為新起病的背痛,這種背痛可放射到雙側臀部或遠側。患上TNS的病人平均年齡(48 ± 14 yr)較未患TNS的病人(41 ± 16 yr)(P < 0.001)更年老些。TNS不受性別和術中病人的體位的影響。較高的成功率和諸如TNS及硬膜穿破後頭痛這種併發症罕見的發生率,提示用甲呱卡因脊麻對門診手術病人來說是一種安全有效的麻醉藥物。

(黃麗娜 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.

 

延長注射時間以及少量吸煙可以降低芬太尼誘發嗆咳的發生率

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

 

我們設計這個實驗來評估注射時間以及吸煙對於芬太尼誘發嗆咳的影響。450ASAI–II級、1880歲、4090kg擇期手術病人入選。所有病人都通過前臂外周靜脈通路的近側端注射芬太尼(為便於臨床應用,體重4069kg的注射100µg7090kg的注射150 µg)。病人隨機分配至三個小組,每組150人。第一組病人在2s內注射完芬太尼,第二和第三組的病人以恒定的速度分別在15s30s內注射完芬太尼。我們記錄在芬太尼注射過程中以及注射完30s後每個病人的嗆咳次數。三組的嗆咳發生率分別為18%、8%及1.3%,長時間注射時明顯降低(P < 0.05)。最近吸煙者比不吸煙者的嗆咳發生率低,不過這種影響僅僅在少量吸煙者中比較明顯(每天小於10支或煙齡少於10年或小於10年包)。我們可以得出結論,延長注射時間降低芬太尼誘發嗆咳的發生率,少量吸煙可能是防止芬太尼誘發嗆咳的一個保護因素。

(黃佳佳 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.

 

 

硫酸鎂預處理減少依託咪酯誘導後的肌痙攣

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

 

依託咪酯用於麻醉誘導時經常會發生肌肉痙攣和注射部位疼痛。本研究擬觀察使用鎂及兩種劑量的氯胺酮預處理對於依託咪酯誘發的肌痙攣和注射部位疼痛的影響。本研究採用前瞻雙盲法,100ASAI–III級的病人隨機分為四組:氯胺酮0.2 mg/kg組、氯胺酮0.5mg/kg組、硫酸鎂(Mg2.48mmol組和生理鹽水組。預處理後90秒,採用依託咪酯0.2mg/kg行麻醉誘導,肌松藥用維庫溴銨0.1mg/kg。由一名不知道分組的麻醉醫生記錄肌痙攣、注射部位疼痛和等級0-3的鎮靜程度。硫酸鎂預處理組中,在給予依託咪酯後19例(76%)病人未發生肌痙攣,氯胺酮0.5mg/kg組中18例(72%),氯胺酮0.2mg/kg16例(64%),生理鹽水組中有1872%)例病人發生了肌痙攣(P<0.05)。我們得出結論,使用依託咪酯行麻醉誘導前90秒給予Mg2.48mmol能有效減輕依託咪酯誘發肌痙攣的程度,而氯胺酮並不降低肌痙攣的發生率。

(邱鬱薇 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.

 

 

阿片受體內吞及ß-Arrestins在產生阿片類藥物耐受中的作用

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

 

阿片類藥物耐受是一個重要的臨床問題,其特點為在重複給予阿片類藥物後同樣劑量的阿片類藥物所能獲得的鎮痛效果減小。傳統理論把阿片類藥物耐受的發生歸咎為受體脫敏感和內吞以及受體後適應。儘管常用阿片類藥物嗎啡可誘發耐受,但是嗎啡卻不能有效誘導阿片受體脫敏感和內吞。近期研究發現內吞的阿片受體在去磷酸化後可成為有效的受體並再迴圈至細胞膜表面。故受體內吞可能是減少阿片類藥物耐受的途徑之一。多項研究提示在阿片受體脫敏感、內吞及阿片類藥物耐受中ß-arrestins起到了關鍵的作用。儘管ß-arrestin 1ß-arrestin 2在高內在效能的阿片類藥物如埃托啡和芬太尼所誘發的上述現象中起到重要的作用,嗎啡耐受可能主要由ß-arrestin 2介導。通過影響阿片受體和ß-arrestins的相互作用調製阿片受體內吞可能是減少阿片類藥物耐受的治療靶位之一。

(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.


氫氧化鋇石灰乾燥後變黃色

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

 

在二氧化碳吸收劑裏常加入乙基紫來作為吸收飽和的指示劑。我們在麻醉藥分解的一些早期研究過程中,注意到(但未發表)氫氧化鋇石灰(BL)乾燥後會變黃,而鈉石灰不會。我們假設乾燥的BL中的乙基紫發生了化學反應產生了一種黃色著色劑。我們定性研究了用氧氣乾燥這些吸收劑的過程中產生黃色的進展過程。這種黃色著色劑可用二乙醚從乾燥的吸收劑中萃取,經過色譜分離,再進行核磁共振及聯合氣相色譜和質譜分析。BL接近完全乾燥時黃色顯現。我們成功地識別出BL乾燥時乙基紫分解成黃色的著色劑4,4’-二(乙氨基)苯甲酮。這種顏色並不明顯,不能用來識別吸收劑輕度乾燥,而且很難透過帶色彩的吸收罐觀察。BL可能充分乾燥後會使麻醉藥化學分解,但仍不顯示黃色。然而,一旦出現黃色,應該認為它已經乾燥。

(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.


不同條件會導致腦電雙頻指數提示不正確的麻醉狀態

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

 

腦電雙頻指數(BIS)自從1996年出現後,已經在日常麻醉工作中越來越流行了。然而,許多文獻報導有矛盾性的BIS值改變和讀數不精確。本綜述的目的是通過檢查各種發表報導中的BIS值與臨床判斷的鎮靜-麻醉狀態的不一致,是否起因於腦電描記(EEG)的腦功能的基礎病理生理學,還是因為BIS監測儀性能和設計上的缺點,來估價BIS監測的效用。高肌電活性和電器的干擾會引起複雜的干擾信號污染,但不會必然地顯示為干擾。這會被BIS演算曲解為腦電活性,並得出偽性的高BIS值。許多對EEG腦功能有直接作用的臨床情況也會直接影響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.

 

 

神經調理素®對脊神經結紮大鼠的抗痛覺超敏和抗痛覺過敏作用

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

 

雖然神經調理素® (NTP)作為一種鎮痛藥物在日本已經臨床使用很多年了,但是它在動物模型中對神經性疼痛的作用仍未被詳細研究。已有研究顯示NTP的主要作用是啟動下行單胺能疼痛抑制系統。我們以脊神經結紮小鼠為物件,研究了NTP對神經性疼痛的影響。NTP呈濃度依賴地抑制觸覺性痛感以及機械和溫度刺激的痛覺過敏。鞘內給予神經毒素耗竭脊髓單胺遞質後檢查NTP的作用時,去除5羥色胺能神經支配後NTP的抗觸覺性痛感和抗痛覺過敏作用仍然存在,但是去除去甲腎上腺素能神經支配後則消失。此外,腦室內給予NTP可提高疼痛回縮閾值,並延長潛伏期,但是鞘內或局部給藥則沒有這種作用。這些結果提示NTP對脊神經結紮導致神經性疼痛的抗痛覺超敏和抗痛覺過敏作用主要是脊髓上作用和去甲腎上腺素能系統的啟動介導的,可能是通過下行抑制通路起作用。

(張瑩 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.

 

 

嗎啡和右美托咪啶單次應用後其抗疼痛強度的長期變化

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

 

急性耐受發生于單次使用阿片或α2-腎上腺素能激動劑後,但是延遲型急性耐受的特性在急性和炎性熱痛試驗中尚未得到分析。我們研究了腹腔內注射嗎啡(10mg/kg)和α2-腎上腺素能激動劑右美托咪啶(150μg/kg)對急性熱痛(甩尾試驗)敏感性以及角叉菜膠導致的炎症性熱痛覺過敏(縮爪試驗)的抗疼痛作用強度,並且在7天後再次注射嗎啡和右美托咪啶,觀察其效應的長期變化。在兩個試驗組,首次處理並不影響第8天的基礎值。在甩尾試驗組,嗎啡而非右美托咪啶的抗疼痛作用強度在重複注射後明顯減弱,提示延遲型嗎啡急性耐受。相反,在重複注射嗎啡後其對縮爪試驗的抗痛覺過敏作用並無改變,而右美托咪啶的作用強度在第8天增強了。在第1天,炎症側和非炎症側之間有顯著差別,但是在第8天沒有明顯差別,提示藥物對炎症側的效應增強了。在這兩組疼痛試驗中,未發現兩種藥物有交叉耐受現象。這些資料顯示了在不同的熱痛試驗模型上,單次注射嗎啡或右美托咪啶後其抗疼痛作用強度的長期變化。

(顏濤 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.

 

 

在美國羅庫溴銨的過敏反應的風險性與維庫溴銨相近似:對食品和藥品管理局的不良事件報告的分析

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

 

法國和挪威公開的報告提示羅庫溴銨過敏反應的發生率較高,並且提升了對其安全性的關注。我們假設食品和藥品管理局不良事件報告系統可用於證實是否美國存在羅庫溴銨過敏事件的不尋常發生率、是否美國和國外的報告模式不同。我們查詢了食品和藥品管理局不良事件報告系統從1999年到2002第一季度的羅庫溴銨和維庫溴銨的所有不良事件,用專用軟體搜索代表可能存在過敏性反應的術語。我們比較了資料中這些術語在羅庫溴銨和維庫溴銨出現的頻率。我們接著評估在美國的和美國之外的報告中過敏性反應相關術語報導的發生率。羅庫溴銨的資料包含311個報導,166個國內的和145個國外的。50%的國外報告包含過敏性反應的術語,相對的,國內報告中為20%(P < 0.001)。在維庫溴銨的243個報告中的可比較數字為17%19%(沒有統計學差異)。在美國,維庫溴銨和羅庫溴銨包含過敏性反應術語的報告的發生率沒有差別,但是國外的報告有顯著差異(P < 0.001)。這些資料證實美國麻醉操作者沒有觀察到兩個常用的中效肌松藥的過敏反應有顯著差異,並且表明過敏性反應報導頻率可能受到報告來源地區的顯著影響。

(張 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.


減少腦血流量能延長頸動脈內注射硫噴妥鈉引起的腦電圖靜息的時程

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

 

由於輸送更多的藥物至腦部,腦血流量(CBF)的增加可增強靜脈麻醉藥的作用。相反地,數學模擬提示腦血流量減少通過增加局部藥物攝取和減少藥物洗出,能增強動脈內藥物的效能。我們假設在腦低灌注期間頸動脈內注射麻醉藥將顯著延長腦電圖(EEG)靜息的時程。我們用新西蘭大白兔檢驗了自己的假設。在第一組7個動物,我們觀察到降低CBF可削弱EEG活性近70%,但未消除EEG。隨後9個動物序貫地接受33 mg硫噴妥鈉注射(硫噴妥鈉-1,硫噴妥鈉+低灌注,和硫噴妥鈉-2)。第一和第三次在生理情況下注射。第二次在腦低灌注期間注射藥物。與注射硫噴妥鈉-1-2時比較,硫噴妥鈉+低灌注時EEG靜息顯著延長(分別從45 ± 567 ± 27秒,至206 ± 46秒,n = 9, P < 0.0001)。EEG恢復特徵在所有三次硫噴妥鈉測試中相似。本研究表明調節CBF是加強動脈內藥物輸送到腦的重要工具。

(吳儉 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.

 

 

硬膜外嗎啡用於產後輸卵管結紮術後的鎮痛

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

 

產後輸卵管結紮術後(PPTL)的婦女往往要經歷嚴重疼痛。我們假定硬膜外嗎啡,作為多模式鎮痛方案的一部分,能減輕PPTL的術後疼痛,減少全身性鎮痛藥物的需要量。在一項雙盲的研究中,PPTL硬膜外麻醉後的患者被隨機分為硬膜外生理鹽水組、硬膜外嗎啡2mg組、3mg組和4mg組。術後布洛芬600mg6小時給藥一次,同時患者可請求給予對乙酰氨基酚325mg/水化氫可酮10mg。主要評價參數為第一次要求追加鎮痛藥的時間。24小時記錄疼痛口頭等級評分和副作用的發生率及嚴重程度。與生理鹽水組相比,嗎啡各組需要追加鎮痛藥的時間較晚,所需的劑量較小。硬膜外嗎啡與生理鹽水比較,疼痛描記的頂峰和切口疼痛的口頭等級評分的峰值較低,以及描述疼痛的疼痛口頭等級評分-時間曲線下的面積也較小,但是,在嗎啡各組之間沒有差別。噁心、嘔吐和瘙癢在所有嗎啡組的患者更常見,在接受嗎啡4mg鎮痛治療的患者和接受生理鹽水、2mg嗎啡組的患者相比,需要對這些副作用進行治療的情形更常見。結論,硬膜外2mg嗎啡作為多模式鎮痛治療方案的一部分能加強鎮痛作用,降低PPTL後追加鎮痛藥的需求。與口服對乙酰氨基酚/阿片類藥物/非甾體抗炎類鎮痛藥相比,嗎啡2 mg副作用治療的需要並沒增加。

(陳瑋 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.


全膝關節成形術後股神經阻滯聯合硬膜外鎮痛的作用

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

 

硬膜外鎮痛或股神經阻滯都可以改善全膝關節成形術後的鎮痛和康復。尚未有研究去評估股神經阻滯和硬膜外鎮痛的聯合應用。在本項前瞻性、隨機、盲法研究中,我們探討了股神經阻滯和硬膜外鎮痛的聯合應用。41例病人接受單次注射0.375%布比卡因加5 µg/mL腎上腺素行股神經阻滯;39例病人作為對照。所有的病人接受腰-硬聯合麻醉和用0.06%布比卡因和10 µg/mL氫嗎啡酮進行病人自控硬膜外鎮痛。硬膜外鎮痛的平均時間為2天。所有病人都接受了相同的標準化的體療干預。與對照組相比,接受股神經阻滯的患者2天內接受體療時的視覺類比評分(VAS)的中位數值明顯較低:3 4 (術後第1)2.5 4 (2)P < 0.05。在第1天和第2天中,兩組病人在靜息時VAS疼痛評分的中位數都是0。術後第2天運動功能的屈曲範圍有改善(70°63°; P < 0.05)。沒有周圍神經病變發生。我們得出結論:硬膜外鎮痛的同時加上股神經阻滯可以顯著改善全膝成形術後頭2天內的鎮痛效果。

(黃施偉 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.

 

 

頸椎運動:在X線透視下比較應用光索導芯、視頻喉鏡和麥金托什喉鏡插管

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

 

對可能有頸椎損傷的患者如何選擇最佳插管方法還尚無定論。本研究應用X線透視攝像對比使用麥金托什喉鏡3型、視頻喉鏡®和光纖插管導芯(一般稱為光索或者光導芯)時頸椎運動的情況。36例健康患者隨機交叉使用光索或者視頻喉鏡和麥金托什喉鏡以保證線性穩定。檢查氣囊-面罩手控呼吸、喉鏡檢查和插管時枕骨-C1關節、C12關節、C25運動節段和C5-胸運動節段的運動情況。同時測定插管所需時間。氣囊-面罩手控呼吸時頸椎四個運動節段的運動要比應用麥金托什喉鏡時少82(P < 0.001)。應用光索的頸椎四個運動節段的運動比用麥金托什喉鏡平均輕57(P < 0.03)。應用光索和麥金托什喉鏡相比,插管需用時間沒有明顯差異。應用視頻喉鏡時,C25節段的運動減少50%P < 0.04,而其他節段無變化。應用視頻喉鏡要比麥金托什喉鏡時間長62(P < 0.01)。因此,與麥金托什喉鏡相比,光索(插管光纖)能減輕氣管內插管時頸椎的運動。

(趙雪蓮 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.

 

全麻誘導後發生低血壓的預測因素

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.

在全麻誘導後發生低血壓是一個普遍現象。在當前的研究中,我們試圖找出能夠預測在全麻誘導後發生有顯著臨床意義的低血壓的因素。將4096個全麻病人的麻醉記錄中的動脈血壓、人口學資料、術前用藥和麻醉誘導方式等採用電腦處理。平均血壓採用麻醉誘導前和誘導後0–5分鐘、5–10分鐘的血壓。低血壓的確定標準為:當平均動脈壓(MAP)高於70mmHgMAP降低超過40%,或者MAP低於60mmHg。總體而言,有9%的病人在全麻誘導後0–10分鐘內發生嚴重低血壓。在全麻誘導後0–10分鐘時間間隔裏,後半時發生低血壓更為常見(P < 0.001)。在2406個發生誘導後低血壓的病人中,其術後恢復延遲和死亡的發生率與沒有發生誘導後低血壓的病人相比更為常見(分別為13.3%8.6%,多元分析P < 0.02)。在統計學上有意義的麻醉誘導後0–10分鐘發生低血壓的多元預測因素包括:ASA III–V級,基礎MAP <70 mm Hg,年齡大於50歲,使用丙泊酚進行麻醉誘導,以及增加誘導時芬太尼用量。減少丙泊酚、依託咪酯和硫噴妥鈉的用量與減少低血壓的發生之間沒有關係。為了避免嚴重低血壓的發生,在年齡大於50歲且ASA評分3級的病人,可考慮使用其他藥物(如依託米酯)取代丙泊酚進行全麻誘導。我們認為對於基礎MAP<70mmHg的病人避免使用丙泊酚進行全麻誘導是明智的選擇。

( 路譯 薛張綱校)

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.

 

異氟醚介導的神經元變性:一項對海馬組織切片培養的評估

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

出生後七天的豚鼠持續暴露於麻醉劑下,通過拮抗N-甲基-d-天冬氨酸和/或加強γ-氨基丁酸,引起神經元變性和持續的行為缺陷。我們進行體外試驗並觀察是否試驗豚鼠的年齡或麻醉劑暴露時間會影響神經元變性的結果。從生後4714天並在體外培養了714天的豚鼠上獲得海馬組織切片(OHSs)。這些切片暴露於1.5%的異氟醚或新鮮空氣135小時。3天後評價海馬CA1CA3和齒狀回神經元的存活情況。從生後七天的豚鼠上獲得的OHSs,神經細胞死亡最多(P < 0.001),且在暴露於異氟醚5小時後最明顯(P < 0.001)。除外血流動力學、營養狀態、氧合情況及CO2清除率等變數,該體外研究表明:1.5%異氟醚暴露和圍產期神經元死亡與年齡及暴露時間均有關。

(王麗珺 薛張綱 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.

 

指壓按摩法和術前雙親焦慮症:試驗性研究
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,

 

在這項隨機對照研究中,在小兒外科手術前的術前等候區,我們檢測了指壓按摩的抗焦慮和鎮靜作用對其父母影響。六十一位父母接受了印堂穴(兩眉間的中間點)或假穴位的指壓按摩。在實驗干涉前後,分別測得焦慮(通過the Stait-Trait Anxiety Inventory測定)、動脈血氣,以及心率,而且腦電雙頻指數監測儀持續監測催眠鎮靜水平。重複測定方差分析顯示,與對照組父母相比,在干涉20分鐘後指壓按摩組的父母有顯著的焦慮減輕(37 +/- 10 45 +/- 13, P = 0.03)。然而,兩個試驗組的腦電雙頻指數、心率、動脈血氣沒有不同(P=沒有顯著差異)。我們得出結論,在印堂穴指壓按摩可以作為術前雙親焦慮症的治療方法。進一步的研究需要量化抗焦慮作用的強度和持續時間。

(孫敏莉 薛張綱 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.

 

靜脈注射兩種不同異丙酚製劑引起疼痛的比較

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.

 

異丙酚常由於鎮靜、麻醉誘導和維持。然而,其常引起注射部位疼痛。Lipuro®異丙酚為油相,可以溶解更多的異丙酚,因此,似乎可以減少疼痛。但關於此的調查研究存在方法學限制。我們進行了一項隨機、雙盲、交叉研究,用於比較亞麻醉劑量的兩種異丙酚製劑(Diprivan®Lipuro®)引起注射部位疼痛的強度。共有60位健康患者接受了這項研究,在同一個注射部位注射兩種異丙酚製劑,每種10min,中間用0.9%生理鹽水沖洗,兩種異丙酚製劑的順序是隨機的。在注射過程中及注射後1min,用言語等級評分表(VRS)進行疼痛評估。分析每一位患者不同時間點使用兩種不同異丙酚製劑的VRS差。先使用Diprivan®後使用Lipuro®異丙酚的患者(D-P組),使用Lipuro®時疼痛減輕,在注射初期(VRS差的中位數是2[四分位區間為0-2]P=0.002)與注射後1min3[0-4]P<0.001)差異都很明顯。先使用Lipuro®後使用Diprivan®異丙酚的患者(P- D組)VRS無明顯差異。與Diprivan®相比,Lipuro®異丙酚可以減少注射部位疼痛,當先使用時,也可以減少後續注射的Diprivan®異丙酚引起的疼痛。機制不明,目前認為可能與降低水相中異丙酚的濃度有關。

(金 薛張綱 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.

 

 

持續量和單次量的四氯三乙基苯的體外人骨骼肌攣縮實驗在惡性高熱診斷中的正面與負面作用

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

 

本研究評估了12.5-200mmol/L 的持續量或75100mmol/L單次劑量的四氯三乙基苯(CEP)在體外對易患惡性高熱(MH)者和不易患惡性高熱者的肌肉標本的不同作用。在從25100mmol/L各種濃度持續量CEP的體外實驗中,易患MH 者的肌肉標本較之不易患MH者的有更為明顯的攣縮。並且當CEP75mmol/L時,診斷組中沒有交迭現象,因此以本試驗來診斷MH是可行的。然而兩種單次劑量的實驗沒有診斷意義,因為它們診斷組中都發生了交迭現象。

(孫卓真 薛張綱 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.

 

通過電子聽診器及電腦分析呼吸音來判斷氣管內導管位置錯誤

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.

 

氣管內導管誤入主支氣管或食管可能導致低氧血症。目前判斷氣管內導管位置正確的方法包括聽診、X線攝片和支氣管鏡檢查,可被接受的標準方法是使用二氧化碳分析儀或比色法ETCO2監測儀等設備監測呼氣末二氧化碳(ETCO2)。但是,二氧化碳分析儀在院外、急診或低心輸出量的情況下可能無法獲得或不可靠,而且它不能檢出支氣管內導管。本研究的目的是在雙側胸部及上腹部放置電子聽診器量化和評測呼吸音特性來明確其檢測氣管內導管位置錯誤的能力。我們記錄了19個健康、非肥胖的成年人在全麻前的呼吸音。氣管插管後,通過支氣管鏡放置氣管內導管於隆凸上3 cm,然後予3500 mL的呼吸並記錄其呼吸音。第二根氣管內導管置入食管,予行相同的呼吸並記錄呼吸音。最後將氣管內的導管置入右主支氣管並記錄呼吸音。通過電腦分析,呼吸音被數位化並過濾掉選擇性頻率,在3個位置均記錄聽覺信號和能量比。使用帶通濾波器濾過聽覺信號得到的總能量比精確地識別出所有食管內和支氣管內導管(P < 0.001)。這些初步結果提示:這個電子聽診器組合設備在ETCO2無法檢測或不可靠的情況下可成為檢測成人氣管內導管位置錯誤的精確而便攜的裝置。

(周曉敏 薛張綱 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,異氟烷,和七氟烷在乾燥的鈉石灰中降解時鈉石灰的溫度

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.

 

罕見的,七氟烷在乾燥的鋇石灰中降解導致燃燒和病人損傷。現在的研究意於找尋是否七氟烷在乾燥的鈉石灰中使用也會引起高溫。我們用10L/min流量的氧氣直接通過新的吸收劑來吹幹鈉石灰。使用1140+/-30g(平均+/-標準誤)這種乾燥的吸收劑,填充於放置在標準的麻醉回路中的單個標準吸收罐中,回路中是6L/min流量的氧氣和1.5個最低肺泡濃度(MAC)的地氟烷或七氟烷,或者是三個MAC的地氟烷,異氟烷或者七氟烷(伴有或不伴有200ml/min流量的二氧化碳)。附加實驗中,使用兩個填有乾燥的吸收劑的吸收罐(而不是單個的吸收罐)和3.0MAC的七氟烷。一個3L的貯氣囊作為模肺,使這個肺以每分鐘通氣量10L/min通氣。使用1.53.0MAC的地氟烷或3.0MAC的異氟烷,在20-40分鐘內峰溫度由30攝氏度升高到45攝氏度然後降低。使用1.53.0MAC的七氟烷,溫度上升至大約90攝氏度,然後下降。二氧化碳和七氟烷共同使用不會升高達到的峰濃度。用兩個吸收罐延長了溫度升高的持續時間但不會升高3.0MAC的七氟烷達到的峰溫度。沒有一種麻醉藥的降解引起燃燒。

(周荻 薛張綱 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.

能增強布比卡因和嗎啡硬膜外鎮痛的氯胺酮血漿濃度

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)受體拮抗劑能夠增強阿片類藥物的鎮痛效果。氯胺酮是一種NMDA受體拮抗劑,它能夠增強嗎啡和布比卡因硬膜外鎮痛作用的血漿濃度尚不知道。我們採用安慰劑對照,雙盲的方法測試了24個患有肺癌或轉移性肺腫瘤的病人在行開胸手術麻醉恢復後4小時的鎮痛效果。在關閉皮膚後給予嗎啡+氯胺酮組(8個)和嗎啡+安慰劑組(8個)5ml2.5mg嗎啡和0.25%布比卡因,安慰劑+氯胺酮組(8個)5ml鹽水和0.25%布比卡因於硬膜外鎮痛。在此後4小時內嗎啡+氯胺酮組和安慰劑和氯胺酮組中,氯胺酮通過TCI泵給藥,成功地維持在血漿濃度為0,10,20,30,40,50ng/ml,病人通過100mm的視覺類比刻度(VAS)來評價靜息,咳嗽,嗜睡和噁心時的疼痛程度。在嗎啡+安慰劑組中,安慰劑(鹽水)幾乎可以替代氯胺酮。而在嗎啡+氯胺酮組當氯胺酮濃度達20ng/ml或更大時,病人靜息和咳嗽時的VAS評分與各自的基線相比可大大降低(P<0.05)。在安慰劑+氯胺酮組,相比較嗎啡+安慰劑組,任何氯胺酮血漿濃度對於靜息和咳嗽時的VAS評分並無太大影響。在嗎啡+氯胺酮組中,氯胺酮血漿濃度>20ng/ml時並不能進一步降低靜息和咳嗽時的VAS評分。嗜睡時的三組VAS評分在任何氯胺酮血漿濃度都是接近的。氯胺酮血漿濃度在20ng/ml或更大時可增強嗎啡和布比卡因的硬膜外鎮痛效果。作為嗎啡和布比卡因硬膜外鎮痛的輔助用藥和基於小劑量安全性的考慮,靜脈給予氯胺酮的最小血漿濃度應接近20ng/ml

(王慧琳 薛張綱 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.

 

奧凱西平在大鼠模型中神經性疼痛機械和冷異常的抑制作用

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.

 

奧凱西平(OCBZ)是一種類似卡馬西平的酮類(CBZ),並和CBZ有類似的鎮痛作用,但對它在神經性疼痛作用方面的研究很少。這項研究,我們評估了OCBZ在大鼠神經性疼痛模型中的鎮痛作用。每只sprague-dawley雄鼠左邊的L5L6脊神經都緊緊結紮以產生神經性疼痛。60只神經性疼痛的老鼠隨機分配到6,每組各自於腹膜裏放置生理鹽水, 媒介物(聚乙烯乙二醇400), OCBZ (10 mg/kg,20mg/kg,30mg/kg,50mg/kg)。於給藥前、給藥後15306090120150180分鐘記錄機械和冷異常,且經常用von frey細絲和100%丙酮分別刺激量化測量停藥後反應。在檢測藥物誘發的副作用時觀察到了眩暈表現。在OCBZ治療組,經常用機械和冷刺激的停藥顯著降低了劑量依賴方式(P<0.05)。只有在OCBZ的最大劑量才降眩暈表現次數。結果表明OCBZ對神經性疼痛異常和痛覺過敏是一種可行性治療。

(孫志榮 薛張綱 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


給因感染假單胞菌而導致膿毒症的羊輸注0.9%的生理鹽水後不會使血容量擴張

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

 

臨床醫師通常認為膿毒症患者的體液往往不能穩定地在血管中迴圈,常常會在組織間隙中蓄積。我們常假設:給患因感染高活力細菌而導致膿毒症並長期被儀器監測的清醒的羊輸注0.9%的生理鹽水會比給清醒的沒有患膿毒症的羊輸注0.9%的生理鹽水血容量的擴張少而組織間液的擴張大。給六隻意識清醒的成年羊以超過20分鐘(1.25ml/kg/min)的速度按25ml/kg靜脈滴注0.9%的生理鹽水,這些羊依次經歷沒有患膿毒症,患膿毒症的早期和晚期三個階段(早期和晚期分別是感染了銅綠假單胞菌後的4小時和24小時)。這些輸注液體的分佈和消除用質量守恆定律(即檢測血漿中偶氮藍燃料的量)以及容量動力學的方法分析。根據質量守恆分析的結果顯示:沒有患膿毒症以及膿毒症早期和晚期的羊,它們的血容量擴張的時程並沒有很大的變化。液體輸注結束後,平均給羊輸了1050/-125ml的液體,羊的平均體重是42/5kg,血容量擴張的平均值分別是:沒有患膿毒症的羊:312/-50ml,膿毒症早期的羊:386/-34,膿毒症晚期的羊400/51。三種羊的容量動力學分析結果是相似的。無論是患膿毒症還是沒有患膿毒症的羊,在輸注了0.9%的生理鹽水後血容量擴張的高峰和消退時程(都是3小時)還有動力學參數都是相似的。由此可見,與我們的臨床印象和假設相反,給這種動物模型輸注0.9%的生理鹽水後體液的分佈並沒有因感染銅綠假單胞菌導致的菌血症而改變。

(鍾靜 薛張綱 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.

脊麻與硬膜外麻醉在嚴重先兆子癇剖宮產術中的比較:一項前瞻性的隨機多中心研究

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.

 

在這項隨機多中心的研究中,我們比較脊麻和硬膜外麻醉在嚴重先兆子癇剖宮產術中的血流動力學上的效應。硬膜外組(n=47)被給予混合有1400000腎上腺素的2%利多卡因1823毫升,並在術後給予3毫克嗎啡。脊麻組(n=53)被給予2.2毫升0.5%的重比重布比卡因及0.2毫克嗎啡。我們假設在手術期間最低的平均動脈壓至少在脊麻組下降10毫米汞柱才可認為有臨床意義。研究發現兩組平均動脈壓在統計學上有顯著的差別:相對於硬膜外組,脊麻組有更多的患者出現了低血壓(P<0.001)。雖然低血壓(收縮壓<100毫米汞柱)的發生率脊麻組較之硬膜外組更為頻繁(51%比上23%),嚴重低血壓(收縮壓<=100毫米汞柱)的持續時間在兩組中都是很短暫的(<=1分鐘)。麻黃素的使用脊麻組較硬膜外組要來得多(中位數,6比上0毫克),但是所有患者的低血壓都是非常容易處理的。新生兒的Apgar評分及臍血血氣分析結果顯示兩組相似。不良的新生兒事件(五分鐘Apgar評分<7分及臍血PH<7.20)僅有二例,皆為早產新生兒(體重<1500克),且出生時母體沒有因區域麻醉而發生低血壓。本次大樣本的前瞻性研究結果支持脊麻在嚴重子癇患者的剖宮產中的應用。

(許文妍 薛張綱 )

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減少腰硬聯合麻醉時硬膜穿刺的反應

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.

 

在腰硬聯合麻醉(CSEA)置針的時候,病人可能會體驗到疼痛、壓迫感、感覺異常,或者在表面和深部注射局麻藥時,在針穿刺到骨膜時,在腰麻針穿破硬膜時,在硬膜外置管時感覺到不適。我們調查在穿刺針通過硬脊膜及軟脊膜時不適感和不自主的口頭及身體反應的發生率,同時調查在置腰麻針前硬膜外注射利多卡因對這些反應的影響。我們調查43位在CSEA時感覺很好的病人。通過阻力消失法將17Tuohy針置入硬膜外後,注入3ml不含防腐劑的生理鹽水,或是3ml 1200000腎上腺素的2%利多卡因置硬膜外腔。在1分鐘後用27號鉛筆尖樣Whitacre針用針套針的方法行硬脊膜穿刺。在硬脊膜穿刺時,注射利多卡因的有2人(9%)感覺很痛,而注射生理鹽水的有17人(81%)(P<0.05),這17人中對硬脊膜穿刺的反應有不自主的運動(33%),不自主的發聲(76%),或者承認在穿刺時有感覺(76%)。這項研究揭示通過阻力消失法將Tuohy針置入硬膜外,再用27號鉛筆尖樣Whitacre針行硬脊膜穿刺行CSEA時,會導致病人不自主的運動,不自主的發聲,即使感覺很好的病人也有大部分在穿刺時有感覺異常。而在置腰麻針前硬膜外注射利多卡因可以明顯的減少這些反應和感覺異常。

(陸文清 薛張綱 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.

 

連續術中和術後胸段硬膜外鎮痛削弱腹部大手術後腦尿鈉肽釋放

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.

 

我們研究了利用連續術中和術後胸段硬膜外鎮痛(TEA)阻斷痛覺傳入是否能降低有冠心病危險因素或已患冠心病的手術病人的腦尿鈉肽(BNP)的血漿濃度。28位進行腹部大手術的病人接受了全麻聯合1.25 mg/mL布比卡因和1 microg/mL舒芬太尼連續胸段硬膜外輸注(n = 14; TEA)或全麻後續患者自控靜脈鎮痛(n = 14; IV PCA)。在術前,切皮後90分鐘,送達重症監護室時,和術後第一、二、三天早晨連續進行痛覺視覺類比評分,測定血液動力學,血漿兒茶酚胺,心肌鈣蛋白T,心房尿鈉肽(ANP)BNP。動態視覺類比評分在TEA組中明顯要低。TEA降低術後心率而不影響其他的血流動力學參數。圍手術期血漿腎上腺素在兩個組中都增加,但在TEA組中顯然增加較少。兩組的ANPBNP基線濃度相似(分別為TEA 3.4 +/- 1.8 27.0 +/- 12.3 pg/mL; IV PCA 3.1 +/- 2.0 25.9 +/- 13.0 pg/mL)。圍術期ANPBNP兩組都增加,而TEA組病人術後BNP水平明顯較低(TEA 92.1 +/- 31.9 pg/mL; IV PCA 161.2 +/- 44.7 pg/mL)。並未觀察到血漿ANP濃度有類似的差別。兩組的血漿心肌鈣蛋白T始終都在正常範圍內。我們推斷,圍術期應用局麻藥和阿片類藥連續TEA削弱接受腹部大手術的冠心病危險人群和冠心病患者的BNP釋放。

(徐麗穎 薛張綱 )

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.