Anesthesia & Analgesia

October 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

嗎啡誘導在體大鼠心臟的晚期心肌保護作用與阿片受體和核轉錄因數KappaB有關

(蘇殿三譯 陳傑 )

Morphine Induces Late Cardioprotection in Rat Hearts In Vivo: The Involvement of Opioid Receptors and Nuclear Transcription Factor B

Jan Frässdorf, Nina C. Weber, Detlef Obal, Octavian Toma, Jost Müllenheim, Georg Kojda, Benedikt Preckel, and Wolfgang Schlack

Anesth Analg 2005 101: 934-941

 

嗎啡增強異氟醚誘導的對抗心肌壞死的後效應:3磷酸肌醇和阿片類受體對兔子所起的作用。

(孫卓真譯 薛張綱校)

Morphine Enhances Isoflurane-Induced Postconditioning Against Myocardial Infarction: The Role of Phosphatidylinositol-3-Kinase and Opioid Receptors in Rabbits

Dorothee Weihrauch, John G. Krolikowski, Martin Bienengraeber, Judy R. Kersten, David C. Warltier, and Paul S. Pagel

Anesth Analg 2005 101: 942-949.

 

磷酸二酯酶-3抑制劑在離體人胃網膜動脈、乳內動脈及橈動脈之間不同的藥理學敏感性

(黃施偉 馬皓琳,李士通 )

Differential Pharmacologic Sensitivities of Phosphodiesterase-3 Inhibitors Among Human Isolated Gastroepiploic, Internal Mammary, and Radial Arteries

Masanori Onomoto, Isao Tsuneyoshi, Arata Yonetani, Shoich Suehiro, Kazuhisa Matsumoto, Ryuzo Sakata, and Yuichi Kanmura

Anesth Analg 2005 101: 950-956.

 

機械通氣對行胸部手術的患者肺免疫功能的影響

(彭中美 馬皓琳,李士通 )

The Pulmonary Immune Effects of Mechanical Ventilation in Patients Undergoing Thoracic Surgery

Thomas Schilling, Alf Kozian, Christof Huth, Frank Bühling, Moritz Kretzschmar, Tobias Welte, and Thomas Hachenberg

Anesth Analg 2005 101: 957-965.

 

無痛超聲吸出法肝切除(CUSA)增加了靜脈空氣栓塞(VAE)的發生率和危險性.

(孫卓真譯 薛張綱校)

Hepatic Resection by the Cavitron Ultrasonic Surgical Aspirator® Increases the Incidence and Severity of Venous Air Embolism

Bon N. Koo, Hae K. Kil, Jin-S Choi, Ji Y. Kim, Duk H. Chun, and Yong W. Hong

Anesth Analg 2005 101: 966-970.

 

麻醉恢復期西羅莫司塗抹冠脈支架內的血栓形成

(鄭擁軍譯 陳傑校)

Thrombosis of Sirolimus-Eluting Coronary Stent in the Postanesthesia Care Unit (Case Report)

J. Thomas Murphy and Brenda G. Fahy

Anesth Analg 2005 101: 971-973.

PEDIATRIC ANESTHESIA:

兒童頸部伸展時氣管長度伸長對氣管內導管安全的意義

(鄭擁軍譯 陳傑校)

Elongation of the Trachea During Neck Extension in Children: Implications of the Safety of Endotracheal Tubes

Kim Jin-Hee, Young-Jin Ro, Min Seong-Won, Kim Chong-Soo, Kim Seong-Deok, Jun Ho Lee, and Bahk Jae-Hyon

Anesth Analg 2005 101: 974-977

 

比較Vasotrac血壓儀和有創動脈血壓監測在行脊柱側突手術的青春期病人的橈動脈血壓測定

(王慧琳譯 薛張綱校)

A Comparison of Radial Artery Blood Pressure Determination Between the Vasotrac Device and Invasive Arterial Blood Pressure Monitoring in Adolescents Undergoing Scoliosis Surgery

Mary E. McCann, David Hill, Kristin C. Thomas, David Zurakowski, and Peter C. Laussen

Anesth Analg 2005 101: 978-985

 

糖尿病患兒外科圍手術期管理

(周志堅 馬皓琳,李士通 )

Perioperative Management of Pediatric Surgical Patients with Diabetes Mellitus (Medical Intelligence)

Erinn T. Rhodes, Lynne R. Ferrari, and Joseph I. Wolfsdorf

Anesth Analg 2005 101: 986-999.

AMBULATORY ANESTHESIA:

月經黃體期增加的黃體酮可減少麻醉藥物的需要量

(趙延華譯 陳傑校)

Increased Progesterone Production During the Luteal Phase of Menstruation May Decrease Anesthetic Requirement

Veysel Erden, Zehra Yangin, Kerem Erkalp, Hamdi Delatioglu, Feyza Bahçeci, and Ayse Seyhan

Anesth Analg 2005 101: 1007-1011

 

白內障手術的球下麻醉:需要多少劑量?

(王慧琳譯 薛張綱校)
Sub-Tenon’s Anesthetic Administration for Cataract Surgery: How Much Stays In?

Niall Patton, Tahira Y. Malik, and Tariq M. Aslam

Anesth Analg 2005 101: 1012-1014

ANESTHETIC PHARMACOLOGY:

七氟醚增強大鼠主動脈對硝酸甘油的耐藥:提示可能通過在血管平滑肌內附加產生超氧陰離子和/或氫氧根使可溶性鳥苷酸環化酶脫敏感化

(周雅春 馬皓琳,李士通 )

Sevoflurane Enhances Nitroglycerin Tolerance in Rat Aorta: Implications for the Desensitization of Soluble Guanylate Cyclase Possibly Through the Additive Generation of Su

Tetsuya Kakutani, Koji Ogawa, Shizue Iwahashi, Kazuhiro Mizumoto, and Yoshio Hatano

Anesth Analg 2005 101: 1015-1022.

 

不同效應部位半數平衡時間參數對預測效應部位七氟醚濃度的影響:一項模擬研究

(田婕 陳傑 )

The Effect of Using Different Values for the Effect-Site Equilibrium Half-Time on the Prediction of Effect-Site Sevoflurane Concentration: A Simulation Study

R. Ross Kennedy

Anesth Analg 2005 101: 1023-1028.

 

給予嗎啡的雪貂預注昂丹司瓊會減弱血漿抗利尿激素增加

(鍾靜譯,薛張綱校)

Pretreatment with Ondansetron Blunts Plasma Vasopressin Increases Associated with Morphine Administration in Ferrets

Eric P. Wilkens and Bill J. Yates

Anesth Analg 2005 101: 1029-1033.

 

在麻醉成人中用於拔除喉罩通氣道的最佳的七氟醚呼氣末濃度

(馬皓琳 李士通 )

Optimal End-Tidal Sevoflurane Concentration for the Removal of the Laryngeal Mask Airway in Anesthetized Adults

Yon Hee Shim, Cheung Soo Shin, Chul Ho Chang, and Yang-Sik Shin

Anesth Analg 2005 101: 1034-1037

 

長期使用氫離子拮抗劑治療的病人麻醉前使用質子泵抑制劑的有效性

(肖潔 陳傑 )

The Efficacy of Preanesthetic Proton Pump Inhibitor Treatment for Patients on Long-Term H2 Antagonist Therapy

Kazuyoshi Hirota, Mihoko Kudo, Hiroshi Hashimoto, and Tetsuya Kushikata

Anesth Analg 2005 101: 1038-1041

 

K2P通道――TRESK對麻藥和其他調節器反應存在種特異性差異

(鍾靜譯,薛張綱校)

Species-Specific Differences in Response to Anesthetics and Other Modulators by the K2P Channel TRESK

Bharat Keshavaprasad, Canhui Liu, John D. Au, Christoph H. Kindler, Joseph F. Cotten, and C. Spencer Yost

Anesth Analg 2005 101: 1042-1049.

 

選擇性磷酸二酯酶5抑制不減少健康志願者丙泊酚鎮靜需要量但影響恢復速度和血漿環鳥苷酸3',5'-單磷酸濃度

(顏濤 馬皓琳,李士通 )

Selective Phosphodiesterase 5 Inhibition Does Not Reduce Propofol Sedation Requirements but Affects Speed of Recovery and Plasma Cyclic Guanosine 3',5'-Monophosphate Concentrations in Healthy Volunteers

Thomas Engelhardt, Jamie MacDonald, Helen F. Galley, and Nigel R. Webster

Anesth Analg 2005 101: 1050-1053

 

靜脈麻醉劑對肥大細胞功能的抑制作用

(朱輝 陳傑 )

Inhibitory Effects of Intravenous Anesthetics on Mast Cell Function

Takahiro Fujimoto, Tomoki Nishiyama, and Kazuo Hanaoka

Anesth Analg 2005 101: 1054-1059

 

一項非脂化丙泊酚和含中鏈甘油三脂的丙泊酚乳劑所引起注射疼痛的比較研究

(齊波 陳傑 )

Pain on Injection of Lipid-Free Propofol and Propofol Emulsion Containing Medium-Chain Triglyceride: A Comparative Study (Brief Report)

Prakash K. Dubey and Arun Kumar

Anesth Analg 2005 101: 1060-1062.

 

乙醚或異氟醚麻醉對大鼠肝臟中細胞色素酶P450 2E1P450還原酶活性的影響

(陸文清譯 薛張綱校)

The Effect of Anesthesia by Diethyl Ether or Isoflurane on Activity of Cytochrome P450 2E1 and P450 Reductases in Rat Liver (Brief Report)

Andrea Y. A. Plate, Daune L. Crankshaw, and Daniel D. Gallaher

Anesth Analg 2005 101: 1063-1064

 

托特羅定預防導尿管相關膀胱不適的藥效:一項前瞻性、隨機、安慰劑-對照、雙盲研究

(黃佳佳 馬皓琳,李士通 )

The Efficacy of Tolterodine for Prevention of Catheter-Related Bladder Discomfort: A Prospective, Randomized, Placebo-Controlled, Double-Blind Study (Brief Report)

Anil Agarwal, Mehdi Raza, Vinay Singhal, Sanjay Dhiraaj, Rakesh Kapoor, Aneesh Srivastava, Devendra Gupta, Prabhat K. Singh, Chandra Kant Pandey, and Uttam Singh

Anesth Analg 2005 101: 1065-1067

TECHNOLOGY, COMPUTING, AND SIMULATION:

 

麻醉學中以類比為基礎的評估演示的可行性

(忻紀華 陳傑 )

The Feasibility of Sharing Simulation-Based Evaluation Scenarios in Anesthesiology

Haim Berkenstadt, Gareth S. Kantor, Yakov Yusim, Naomi Gafni, Azriel Perel, Tiberiu Ezri, and Amitai Ziv

Anesth Analg 2005 101: 1068-1074

 

在手術前對病人完成書面和電子調查的比較

(陸文清譯 薛張綱校)

A Comparison of Paper with Electronic Patient-Completed Questionnaires in a Preoperative Clinic

Elizabeth G. VanDenKerkhof, David H. Goldstein, William C. Blaine, and Michael J. Rimmer

Anesth Analg 2005 101: 1075-1080

 

通過持續上呼吸道二氧化碳監測來優化氣管內導管的套囊填充

(周荻譯 薛張綱校)

Optimization of Endotracheal Tube Cuff Filling by Continuous Upper Airway Carbon Dioxide Monitoring

Shai Efrati, Yuval Leonov, Amir Oron, Yariv Siman-Tov, Michael Averbukh, Alex Lavrushevich, and Ahuva Golik

Anesth Analg 2005 101: 1081-1088

 

評估葡萄糖初始分佈容積以評價液體衝擊中血漿容積

(黃麗娜 馬皓琳,李士通 )

An Evaluation of the Initial Distribution Volume of Glucose to Assess Plasma Volume During a Fluid Challenge (Technical Communication)

Laurence van Tulder, Burkhardt Michaeli, René Chioléro, Mette M. Berger, and Jean-Pierre Revelly

Anesth Analg 2005 101: 1089-1093

PAIN MEDICINE:

 

伊拉克戰爭中士兵受傷的表現,診斷,損傷機制和治療:在兩所軍事疼痛治療中心進行的一項流行病學研究

(殷文淵譯 陳傑 )

Presentation, Diagnoses, Mechanisms of Injury, and Treatment of Soldiers Injured in Operation Iraqi Freedom: An Epidemiological Study Conducted at Two Military Pain Management Centers

Steven P. Cohen, Scott Griffith, Thomas M. Larkin, Felipe Villena, and Ralph Larkin

Anesth Analg 2005 101: 1098-1103.

 

Etoricoxib對全膝或全髖替換術後病人的鎮痛效能:隨機,雙盲,安慰劑控制的研究

(周荻譯 薛張綱校)
Etoricoxib Provides Analgesic Efficacy to Patients After Knee or Hip Replacement Surgery: A Randomized, Double-Blind, Placebo-Controlled Study

G. Lynn Rasmussen, Kerstin Malmstrom, Michael H. Bourne, Maurice Jove, Steven M. Rhondeau, Paul Kotey, Jennifer Ang, Michelle Aversano, Alise S. Reicin for the Etoricoxib Postorthopedic Study Group

Anesth Analg 2005 101: 1104-1111

 

圍手術期疼痛管理技術對大鼠剖腹手術後食物消耗量和體重的影響

(張曦 馬皓琳,李士通 )

The Effects of Perioperative Pain Management Techniques on Food Consumption and Body Weight After Laparotomy in Rats

Yehuda Shavit, Gila Fish, Gilly Wolf, Eduard Mayburd, Ylia Meerson, Raz Yirmiya, and Benzion Beilin

Anesth Analg 2005 101: 1112-1116

 

嗎啡能夠誘導免疫抑制性淋巴細胞凋亡:真的嗎?

(潘志英 陳傑 )

Immunosuppression by Morphine-Induced Lymphocyte Apoptosis: Is It a Real Issue?

Takeshi Ohara, Tsunetoshi Itoh, and Masahiko Takahashi

Anesth Analg 2005 101: 1117-1122.

CRITICAL CARE AND TRAUMA:

 

生物和化學緊急事件的準備-------美國麻醉住院醫生培訓的調查

(顧新宇譯 陳傑校)

Emergency Preparedness for Biological and Chemical Incidents: A Survey of Anesthesiology Residency Programs in the United States

Keith A. Candiotti, Aimee Kamat, Paul Barach, Fani Nhuch, David Lubarsky, and David J. Birnbach

Anesth Analg 2005 101: 1135-1140.

 

危重病人能否運用腦電圖分析法來確定鎮靜的水平?

(韓曉丹譯 薛張綱校)

Can Electroencephalographic Analysis Be Used to Determine Sedation Levels in Critically Ill Patients?

Jean-Paul Roustan, Sarah Valette, Pierre Aubas, Gérard Rondouin, and Xavier Capdevila

Anesth Analg 2005 101: 1141-1151.

 

七氟醚預處理可抑制大鼠內毒素誘發的休克

(趙雪蓮 馬皓琳,李士通 )

Sevoflurane Pretreatment Inhibits Endotoxin-Induced Shock in Rats

Yoko Kidani, Takumi Taniguchi, Hiroko Kanakura, Yasuhiro Takemoto, Kazunobu Tsuda, and Ken Yamamoto

Anesth Analg 2005 101: 1152-1156

NEUROSURGICAL ANESTHESIA:

 

損傷前或後應用利多卡因或硫賁妥鈉來減弱無氧-糖的大鼠海馬切片培養的細胞死亡

(範穎暉 陳傑 )

Pre- or Postinsult Administration of Lidocaine or Thiopental Attenuates Cell Death in Rat Hippocampal Slice Cultures Caused by Oxygen-Glucose Deprivation

Hong Cao, Ira S. Kass, James E. Cottrell, and Peter J. Bergold

Anesth Analg 2005 101: 1163-1169

 

經蝶骨的垂體手術病人在手術期間的管理

(韓曉丹譯,薛張綱校)

Perioperative Management of Patients Undergoing Transsphenoidal Pituitary Surgery (Review Article)

Edward C. Nemergut, Aaron S. Dumont, Usha T. Barry, and Edward R. Laws

Anesth Analg 2005 101: 1170-1181  

OBSTETRIC ANESTHESIA:

 

剖腹產病人優選的麻醉結果

( 馬皓琳,李士通 )

Patient Preferences for Anesthesia Outcomes Associated with Cesarean Delivery

Brendan Carvalho, Sheila E. Cohen, Steven S. Lipman, Andrea Fuller, Anbu D. Mathusamy, and Alex Macario

Anesth Analg 2005 101: 1182-1187.

REGIONAL ANESTHESIA:

單側坐骨神經阻滯時選擇大轉子旁不同距離的部位注射是否有差異?

(朱慧琛譯 陳傑校)

Does the Site of Injection Distal to the Greater Trochanter Make a Difference in Lateral Sciatic Nerve Blockade?

Manuel Taboada, Jaime Rodríguez, Sabela Del Rio, Juan Lagunilla, Javier Carceller, Julián Álvarez, and Peter G. Atanassoff

Anesth Analg 2005 101: 1188-1191

 

使用刺激性導管持續坐骨神經阻滯較之傳統的非刺激性導管縮短達到手術所需阻滯要求的起始時間並使拇趾外翻修複後的鎮痛藥物使用量減至最小

(徐麗穎譯 薛張綱校)

Using Stimulating Catheters for Continuous Sciatic Nerve Block Shortens Onset Time of Surgical Block and Minimizes Postoperative Consumption of Pain Medication After Halux Valgus Repair as Compared with Conventional Nonstimulating Catheters

Andrea Casati, Guido Fanelli, Zbigniew Koscielniak-Nielsen, Gianluca Cappelleri, Giorgio Aldegheri, Giorgio Danelli, Régis Fuzier, and François Singelyn

Anesth Analg 2005 101: 1192-1197.

 

鎖骨臂叢神經阻滯與肱骨入路麻醉時間與效果的比較

(邱鬱薇 馬皓琳,李士通 )

Infraclavicular Brachial Plexus Block Versus Humeral Approach: Comparison of Anesthetic Time and Efficacy

Vincent Minville, Roland Amathieu, N’Guyen Luc, Claude Gris, Olivier Fourcade, Kamran Samii, and Dan Benhamou

Anesth Analg 2005 101: 1198-1201

 

髖部術後神經阻滯的抗分解代謝作用

(範穎暉 陳傑 )

The Anticatabolic Effect of Neuraxial Blockade After Hip Surgery

Ralph Lattermann, Geesche Belohlavek, Sigrid Wittmann, Bernd Füchtmeier, and Michael Gruber

Anesth Analg 2005 101: 1202-1208

GENERAL ARTICLES:

 

髖部骨折修復術後蘇醒室中譫妄預示術後譫妄

(徐麗穎譯 薛張綱校)

Recovery Room Delirium Predicts Postoperative Delirium After Hip-Fracture Repair

Punita T. Sharma, Frederick E. Sieber, Khwaja J. Zakriya, Ronald W. Pauldine, Kevin B. Gerold, Jian Hang, and Timothy H. Smith

Anesth Analg 2005 101: 1215-1220.

 

側臥位的氣道管理:一項隨機對照實驗

(陳瑋 馬皓琳,李士通 審校)

Airway Management in the Lateral Position: A Randomized Controlled Trial

Conan L. McCaul, Donal Harney, Margaret Ryan, Ciaran Moran, Brian P. Kavanagh, and John F. Boylan

Anesth Analg 2005 101: 1221-1225

 

.經鼻腔氣管插管時導管尖端設計對鼻腔損傷的影響:Magill尖與Murphy尖之比較

(田婕 陳傑 )

The Influence of Endotracheal Tube Tip Design on Nasal Trauma During Nasotracheal Intubation: Magill-Tip Versus Murphy-Tip

Jong-Hwan Lee, Chang-Hee Kim, Jae-Hyon Bahk, and Kum-Suk Park

Anesth Analg 2005 101: 1226-1229.

 

評價valsalva動作在靜脈穿刺疼痛的作用:一項隨機前瞻研究。

(王麗珺譯,薛張綱校)

Evaluating the Efficacy of the Valsalva Maneuver on Venous Cannulation Pain: A Prospective, Randomized Study

Anil Agarwal, P. K. Sinha, Manish Tandon, Sanjay Dhiraaj, and Uttam Singh

Anesth Analg 2005 101: 1230-1232

 

中重度氣管插管困難病人McCoy氣囊喉鏡檢查的評估

(張瑩 馬皓琳,李士通 )

An Evaluation of McCoy Balloon Laryngoscopy in Patients With Moderate-to-Major Endotracheal Intubation Difficulty

Spyros D. Mentzelopoulos, Maria Tzoufi, Kostas Rellos, Argyris S. Michalopoulos, Elissavet Stamataki, Charris Roussos, and Spyros G. Zakynthinos

Anesth Analg 2005 101: 1233-1237.

 

嗎啡增強異氟醚誘導的對抗心肌壞死的後效應:3磷酸肌醇和阿片類受體對兔子所起的作用。

Morphine enhances isoflurane-induced postconditioning against myocardial infarction: the role of phosphatidylinositol-3-kinase and opioid receptors in rabbits.

Weihrauch D, Krolikowski JG, Bienengraeber M, Kersten JR, Warltier DC, Pagel PS.

Department of Anesthesiology, Medical College of Wisconsin and Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin 53226, USA.

Anesth Analg. 2005 Oct;101(4):942-9.

 

異氟醚能啟動3磷酸肌醇(PI3K)信號從而減少早期再灌注時心急損傷的面積。我們測試了這樣一個假說:嗎啡能增強心肌對再灌注損傷的自我保護作用同時減少了脫噬作用從而保護了心機的活性。將兔子(n = 108)的冠狀動脈阻斷30分鐘後給於3小時生理鹽水的再灌注,在阻斷冠狀動脈前3分鐘和再灌注後2分鐘時用或不用異氟醚(0.5 or 1.0 MAC)、嗎啡(0.05 or 0.1 mg/kg)或兩者聯合誘導,然後給與選擇性抑制劑(PI3K)渥曼青黴素(0.6 mg/kg)或非選擇性阿片類拮抗劑納洛酮(6 mg/kg)後測試兔子的血流動力學。心急損傷的面積和脫噬作用的評估則分別採用三苯四唑著色和細胞色素c易位和TUNEL對左室心肌細胞著色的方法。1.0 MAC的異氟醚和0.1 mg/kg的嗎啡能減少心肌的損傷面積(P < 0.05)0.5 MAC的異氟醚和0.05 mg/kg的嗎啡聯合應用也能減少心肌的損傷。渥曼青黴素和納洛酮的單獨使用並不影響損傷面積但阻斷了由異氟醚、嗎啡或兩者聯合應用所產生的心肌保護作用。異氟醚和嗎啡減少了細胞色素c易位和TUNEL的著色。研究的結果表明了在體外嗎啡通過啟動PI3K和阿片類受體增強了異氟醚誘導的後效應。異氟醚的後效應能減少死亡細胞的脫噬作用從而保護了心機的完整性。意義:研究的結果表明了在體外嗎啡通過啟動PI3K和阿片類受體增強了異氟醚誘導的後效應。異氟醚和嗎啡的後效應能減少死亡細胞的脫噬作用從而保護了心機的完整性。

(孫卓真譯 薛張綱校)

Isoflurane reduces myocardial infarct size during early reperfusion by activating phosphatidylinositol-3-kinase (PI3K) signaling. We tested the hypothesis that this cardioprotection against reperfusion injury is enhanced by morphine and that a decrease in apoptosis plays a role in preservation of myocardial viability. Rabbits (n = 108) instrumented for hemodynamic measurement and subjected to a 30-min coronary occlusion followed by 3 h reperfusion received 0.9% saline, the selective PI3K inhibitor wortmannin (0.6 mg/kg), or the nonselective opioid antagonist naloxone (6 mg/kg) before coronary occlusion in the presence or absence of isoflurane (0.5 or 1.0 MAC), morphine (0.05 or 0.1 mg/kg), or their combination administered for 3 min before and 2 min after reperfusion. Infarct size was determined using triphenyltetrazolium staining and apoptosis assessed using cytochrome c translocation and Terminal Deoxynucleotidyl Transferase-Mediated dUTP Nick End Labeling (TUNEL) staining of left ventricular myocardium in situ. Isoflurane (1.0 but not 0.5 MAC) and morphine (0.1 but not 0.05 mg/kg) reduced (P < 0.05) infarct size (mean +/- sd 21% +/- 4%, 44% +/- 6%, 19% +/- 4%, and 41% +/- 6% of left ventricular area at risk, respectively) as compared with control (41% +/- 4%). The combination of 0.5 MAC isoflurane and 0.05 mg/kg morphine also decreased infarct size (18% +/- 9%). Wortmannin and naloxone alone did not affect infarct size but blocked the protection produced by isoflurane, morphine, and their combination. Isoflurane and morphine reduced cytochrome c translocation and TUNEL staining. The results indicate that morphine enhances isoflurane-induced postconditioning by activating PI3K and opioid receptors in vivo. A reduction in apoptotic cell death contributes to preservation of myocardial integrity during postconditioning by isoflurane. IMPLICATIONS: The results of this study indicate that morphine enhances isoflurane-induced postconditioning by activating phosphatidylinositol-3-kinase and opioid receptors in vivo. A reduction in apoptotic cell death contributes to preservation of myocardial integrity during postconditioning by isoflurane and morphine.

 

 

 

無痛超聲吸出法肝切除(CUSA)增加了靜脈空氣栓塞(VAE)的發生率和危險性.

Hepatic resection by the Cavitron Ultrasonic Surgical Aspirator increases the incidence and severity of venous air embolism.

Koo BN, Kil HK, Choi JS, Kim JY, Chun DH, Hong YW.

Department of Anesthesia and Pain Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemun-Gu, C.P.O. Box 8044, Seoul 120-752, Korea.

Anesth Analg. 2005 Oct;101(4):966-70

 

CUSA 是一種切除肝實質的無創技術,可以減少術中及圍手術期出血發病率。本研究通過比較用鉗夾破碎法(CC)和CUSA兩種方法在肝切除過程中經食道超聲心動圖(TEE)測定VAE的發生率與嚴重程度。在麻醉誘導後,TEE探頭被插入患者的食管,一位獨立的麻醉醫生將通過TEE的四室視野對VAE作出評分。CUSA組中所有的病人都發生了VAE44%的病人的VAE半徑超過右心半徑。而在CC組中有68%的病人發生了VAE 且其半徑小於右心半徑。兩組之間無明顯的血液動力學或呼氣末二氧化碳分壓的差別。總之,用CUSA 進行肝切除會增加VAE的發生率和危險性。意義:本研究論證了用CUSA 方法進行肝切除更常發生VAE且更嚴重。雖然我們沒有發現血流動力學方面的證明,但VAE會增加肝硬化病人的反常栓子的危險性。

(孫卓真譯 薛張綱校)

The Cavitron Ultrasonic Surgical Aspirator (CUSA) is an innovative tool for resecting hepatic parenchyma, which reduces intraoperative blood loss and perioperative morbidity. We designed this study to compare the incidence and severity of venous air embolism (VAE) detected via transesophageal echocardiography (TEE) during hepatic resection by using either the clamp-crushing method or the CUSA method. Fifty patients scheduled for hepatic resection were randomly assigned to receive hepatic resection by the clamp-crushing method (CC group) or by CUSA (CUSA group). After the induction of anesthesia, the TEE probe was inserted into the patient's esophagus. An independent anesthesiologist graded VAE shown in the 4-chamber view of TEE. All patients in the CUSA group showed VAE during hepatic resection and 44% of the patients had air embolism filling more than half the right heart diameter. In CC group, 68% of the patients showed VAE, which filled less than half the right heart diameter. There were no significant differences in hemodynamics and end-tidal CO2 partial pressure between the two groups. In conclusion, hepatic resection by CUSA increases the incidence and severity of VAE. IMPLICATIONS: This study demonstrated that venous air embolism during hepatic resection was more frequent and severe when using the Cavitron Ultrasonic Surgical Aspirator. Although we found no evidence of hemodynamic compromise, increased venous air embolism may increase the risk of paradoxical embolism in patients with liver cirrhosis.

 

 

比較Vasotrac血壓儀和有創動脈血壓監測在行脊柱側突手術的青春期病人的橈動脈血壓測定

A comparison of radial artery blood pressure determination between the vasotrac device and invasive arterial blood pressure monitoring in adolescents undergoing scoliosis surgery

 

McCann ME,Hill D,Thomas KC,Zurakowski D,Laussen PC.

Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital, Harvard Medical School, USA.

Anesth Analg 2005 101: 978-985.

 

Vasotrac血壓儀可以在無創情況下進行動脈血壓和動脈波形的測定.我們在心監對實行了心臟手術後迴圈尚穩定的兒童進行了Vasotrac血壓儀監測和持續動脈內血壓監測,結果證實了這一點.為了在不同的生理情況下評估此儀器,我們對行脊柱側突手術的麻醉狀態下的青春期兒童在俯臥位,控制性降壓或非控制性降壓情況下對此儀器進行研究.11個因特發性脊柱側突而行手術的兒童參與了此次的研究.麻醉方法為氧化亞氮和靜脈注射拉貝洛爾控制性降溫.得到的資料通過相關性,均數誤差和Bland-Altman圖表進行分析.無創的Vasotrac監測結果與動脈內血壓監測很接近.兩種系統所顯示出來的波形也十分相似.兩鍾方法所測得的收縮壓,舒張壓及平均動脈壓的相關係數分別為0.82,0.830.90.我們因此總結出, 在俯臥位和藥物導致的低血壓麻醉狀態下用Vasotrac進行無創血壓監測的效果和持續動脈血壓監測很接近並且是可靠的.(因此說明: Vasotrac這種無創的動脈血壓監測儀,對於俯臥位和輕中度控制性降壓狀態下行脊柱側突手術的青春期患者的血壓監測是很有效的.)

(王慧琳譯 薛張綱校)

 

The Vasotrac device (Medwave, Arden Hills, MN) allows noninvasive measurement of arterial blood pressure (BP) and arterial waveform. We have previously demonstrated agreement between the Vasotrac and continuous intraarterial BP monitoring in children with a stable circulation after cardiac surgery in the cardiac intensive care unit. To assess this monitor during different physiologic conditions, we studied the Vasotrac in anesthetized adolescent children undergoing scoliosis surgery in the prone position, with or without controlled hypotension. Eleven children undergoing surgery for idiopathic scoliosis were enrolled in this study. The anesthetic consisted of primarily a nitrous oxide and narcotic technique with controlled hypotension obtained using IV labetalol. Data were analyzed using correlations, mean error, and Bland-Altman plots. Noninvasive BP measured by the Vasotrac correlated closely with intraarterial BP. Waveforms displayed by the two systems were qualitatively similar. Correlation between the two methods for systolic, diastolic and mean BP was r = 0.82, r = 0.83, and r = 0.90, respectively. We conclude that noninvasive BP measurement using the Vasotrac monitor enables near-continuous and reliable monitoring of BP during anesthesia in the prone position and pharmacologic-induced hypotension. IMPLICATIONS: The Vasotrac, a noninvasive arterial blood pressure monitor, performs well in the prone position in adolescent patients undergoing scoliosis surgery using a technique of mild-to-moderate induced hypotension.

 

 

白內障手術的球下麻醉:需要多少劑量?

Sub-Tenon’s Anesthetic Administration for Cataract Surgery:How Much Stays In?

Patton N,Malik TY,Aslam TM

Department of Ophthalmology, Princess Margaret Hospital, Dunfermline, Fife, United Kingdom.

Anesth analg 2005 101:1012-1014.

 

我們採用了前瞻性隨機實驗的方法對予球下注射3ml5ml麻藥後剩餘的溶解量進行評估.剩餘容量與運動阻滯相關(r = 0.72; P < 0.001).兩組經切口所丟失的容量占注射總容量的百分比是相似的,這便提示球下空間不限於5ml,並且可以注射更大量麻醉藥來增加運動阻滯.說明:麻醉藥在球下空間的溶解量同運動阻滯是相關聯的.丟失量占注射給藥的百分比與注射量無關,提示球下空間不限於5ml,並且可以注射更大量麻醉藥來增加運動阻滯.

(王慧琳譯 薛張綱校)

We performed a prospective, randomized trial assessing the "remaining" volume of anesthetic solution that stays within the sub-Tenon's space after administration of 2 different volumes: 3 mL and 5 mL. The remaining volume correlated with motor block (r = 0.72; P < 0.001). The volume lost through the incision as a percentage of total volume injected was similar in both groups, suggesting sub-Tenon's space is not limited to a finite injected volume less than 5 mL and may be capable of receiving larger volumes of anesthetic to improve motor block.

給予嗎啡的雪貂預注昂丹司瓊會減弱血漿抗利尿激素增加

Pretreatment with ondansetron blunts plasma vasopressin increases associated with morphine administration in ferrets.
Wilkens EP, Yates BJ.
Department of Anesthesia-6413 JCP, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, Iowa 52242, USA.

Anesth Analg. 2005 Oct;101(4):1029-33, table of contents.

 

術後噁心和嘔吐是一個很重要的問題。可以用血漿標記物的方法來測量麻醉的嘔吐域值,例如用精氨酸加壓素(AVP)。我們可以測量單獨使用嗎啡以及聯合使用嗎啡及昂丹司瓊兩種情況下AVP濃度的變化。數據是由植入導管的雪貂而來的。雪貂蘇醒後,給予單獨靜注嗎啡後者先注昂丹司瓊再注嗎啡。在注入嗎啡前先採集基線血標本,然後分別在嗎啡注入5, 10, 15, 30, 45, 60, 90分鐘後收集血標本。血標本中AVP的濃度用放射免疫學方法測得。單獨應用嗎啡,血漿AVP的濃度在注射嗎啡456090分鐘時與基線水平有顯著差別。單獨應用昂丹司瓊,血漿AVP濃度在注射20分鐘後無改變。在注射嗎啡前先預注昂丹司瓊血漿AVP濃度無顯著變化。雙向變數分析法證實:昂丹司瓊能顯著降低在注射嗎啡後6090分鐘血漿中AVP的增加。這些資料表明:血漿AVP濃度可能是噁心的精確標誌,並可能對指導治療有效。提示:止吐藥昂丹司瓊不僅對有臨床表現的嘔吐有效,對血漿AVP水平的調控也有效。

(鍾靜譯,薛張綱校)

Postoperative nausea and vomiting are significant problems. A method for measuring vomiting thresholds for anesthetics using plasma markers, such as arginine vasopressin (AVP), would be useful. We measured the change in AVP concentrations associated with morphine alone or in combination with ondansetron pretreatment. Data were collected from ferrets implanted with IV catheters. After recovery, the ferrets were administered IV morphine alone or with ondansetron pretreatment. Baseline blood samples were taken before morphine injection, and at 5, 10, 15, 30, 45, 60, and 90 min after morphine injection. Plasma AVP levels were measured using radioimmunoassay. Morphine alone was associated with a significant increase in plasma AVP concentrations from baseline at 45, 60, and 90 min (P < 0.05). Ondansetron alone did not change the plasma AVP concentration after 20 min (P > 0.46). There was no significant increase (P > 0.46) in AVP concentration in animals that were pretreated with ondansetron before administration of morphine. Two-way analysis of variance confirmed that ondansetron significantly decreased the increase in AVP by morphine at 60 and 90 min (P < 0.05). These data suggest that plasma AVP concentration may be an accurate marker for nausea, and may be useful to guide treatment for this condition. IMPLICATIONS: The antiemetic, ondansetron, has an effect not only on clinically perceived vomiting, but also on plasma vasopressin level.

K2P通道――TRESK對麻藥和其他調節器反應存在種特異性差異

Species-specific differences in response to anesthetics and other modulators by the K2P channel TRESK.
Keshavaprasad B, Liu C, Au JD, Kindler CH, Cotten JF, Yost CS.
Department of Anesthesia and Perioperative Care, University of California San Francisco, 513 Parnassus Ave., Room S-261, Box 0542, San Francisco, California 94143, USA.

Anesth Analg. 2005 Oct;101(4):1042-9, table of contents.

 

TRESKTWIK相關的脊柱鉀通道)是新近發現的鉀通道(K2P)家族中的一員。人類的TRESK被氟烷,異氟醚,七氟醚和地氟醚啟動,使其成為最敏感的被揮發性麻藥啟動的K2P通道。我們比較了齧齒類動物和人類TRESK對麻藥敏感性和藥理學調節的差異。我們給小鼠和老鼠通電流,TRESK被臨床濃度的異氟醚啟動,但其效能明顯低於人類的TRESK。和人類的TRESK不同,齧齒類動物的TRESK在生理範圍內被酸性的細胞外液所抑制。微克分子的鋅就能抑制齧齒類動物的TRESK傳導的電流,但對人類的TRESK無效。在活體具有立體選擇性麻藥效能的異氟醚的異構體對於離體的齧齒類動物的TRESKs有立體特異性的增強作用。抑制齧齒類動物TRESKs酰胺類局麻藥的濃度比抑制人類TRESKs的濃度低了10倍。這表明了TRESKs種間差異和藥理學的相似性。要進一步瞭解TRESK的表達模式就要理解TRESK在麻藥作用機制中的地位。提示:小鼠和老鼠的TRESKTWIK相關的脊柱鉀通道)和人類的TRESK相比有不同的藥效學反應機制。特別是我們發現齧齒類動物的TRESK對異氟醚有立體特異性差異,但人類卻沒有。TRESK可能是揮發性麻醉氣體發揮作用的靶位。

(鍾靜譯,薛張綱校)

TRESK (TWIK-related spinal cord K+ channel) is the most recently characterized member of the tandem-pore domain potassium channel (K2P) family. Human TRESK is potently activated by halothane, isoflurane, sevoflurane, and desflurane, making it the most sensitive volatile anesthetic-activated K2P channel yet described. Herein, we compare the anesthetic sensitivity and pharmacologic modulation of rodent versions of TRESK to their human orthologue. Currents passed by mouse and rat TRESK were enhanced by isoflurane at clinical concentrations but with significantly lower efficacy than human TRESK. Unlike human TRESK, the rodent TRESKs are strongly inhibited by acidic extracellular pH in the physiologic range. Zinc inhibited currents passed by both rodent TRESK in the low micromolar range but was without effect on human TRESK. Enantiomers of isoflurane that have stereoselective anesthetic potency in vivo produced stereospecific enhancement of the rodent TRESKs in vitro. Amide local anesthetics inhibited the rodent TRESKs at almost 10-fold smaller concentrations than that which inhibit human TRESK. These results identified interspecies differences and similarities in the pharmacology of TRESK. Further characterization of TRESK expression patterns is needed to understand their role in anesthetic mechanisms. IMPLICATIONS: Mouse and rat TRESK (TWIK-related spinal cord K+ channel) have different pharmacologic responses compared with human TRESK. In particular, we found stereospecific differences in response to isoflurane by the rodent TRESKs but not by human TRESK. TRESK may be a target site for the mechanism of action of volatile anesthetics.

乙醚或異氟醚麻醉對大鼠肝臟中細胞色素酶P450 2E1P450還原酶活性的影響

The Effect of Anesthesia by Diethyl Ether or Isoflurane on Activity of Cytochrome P450 2E1 and P450 Reductases in Rat Liver

Andrea Y. A. Plate, MSc, Daune L. Crankshaw, PhD, and Daniel D. Gallaher, PhD

Department of Food Science and Nutrition, University of Minnesota, St. Paul, Minnesota

Anesth Analg 2005;101:1063-1064.

 

通過這項研究,我們試圖去確定用乙醚或異氟醚麻醉是否影響肝臟細胞色素酶P450 2E1P450還原酶的活性。大鼠在用純淨的飼料餵養6周後,分別用二氧化碳、乙醚、異氟醚麻醉。然後檢測肝細胞微粒體中細胞色素酶P450 2E1P450還原酶的活性。在這三組中,酶的活性沒有明顯的差別。結果顯示致死劑量的乙醚和異氟醚也不會影響P450酶的活性。

(陸文清譯 薛張綱校)

In this study we sought to determine whether exposure to the anesthetics diethyl ether and isoflurane influences the activity of hepatic cytochrome P450 2E1 and P450 reductases in the rat. Rats were fed a purified diet for 6 wk before anesthesia with 1 of 3 anesthetics: carbon dioxide, diethyl ether, or isoflurane. Cytochrome P450 2E1 and P450 reductases were measured in liver microsomes. No significant differences in enzyme activities were found among the groups. These results indicate that diethyl ether and isoflurane can be used to kill rats without inducing P450 enzymes.

 

 

在手術前對病人完成書面和電子調查的比較

A Comparison of Paper with Electronic Patient-Completed Questionnaires in a Preoperative Clinic

Elizabeth G. VanDenKerkhof, RN, DrPH, David H. Goldstein, MB, BcH, MSc, FRCPC, William C. Blaine, MSc, and Michael J. Rimmer

Department of Anesthesiology, Queen’s University, Kingston, Ontario, Canada

Anesth Analg 2005;101:1075-1080.

 

在這個隨機非盲法的試驗中,我們比較電子自助與紙筆完成成人麻醉簽字前調查表(PAAQ)的不同,電子自助法使用觸摸屏技術。選擇的病人為在預評價門診中完成PAAQ的人。病人被隨機的分為四組來完成PAAQ,分別是紙、掌上電腦(PDA)、觸摸屏電腦(kiosk)和寫字板。病人同時也完成一個偏愛度和滿意度的調查。主要的結果指標是之前完成與現在完成PAAQ兩者一致性的百分比和完成時間。只有366個病人中的1/6拒絕參加。完成PAAQ時間的中間數,最短的為kiosk2.3min,最長的為PDA3.2min({chi}2 = 14.5; P = 0.002)。全部病人平均兩者的一致性大約是94%。參與者在完成PAAQ前後的滿意度,用電子組的從10%增加到了97%,而用紙張的從60%增加到了64 。觸摸屏技術對病人完成PAAQ是一種精確和有效的平臺。對於將來的調查,病人更希望使用電子技術而不是普通的紙張

(陸文清譯 薛張綱校)

In this unblinded randomized control trial we compared electronic self-administered Pre-Admission Adult Anesthetic Questionnaires (PAAQ) using touchscreen technology with pen and paper. Patients were recruited in the Preassessment Clinic if they had completed a PAAQ in the surgeon’s office. Patients were randomized to study PAAQ using paper, hand-held computer (PDA), touchscreen desktop computer (kiosk), or tablet. Patients also completed a preference and satisfaction survey. The main outcome measures were percent agreement between the prestudy and study PAAQ and time to completion. Only six of the 366 patients approached refused to participate. The median time to completion of the PAAQ was shortest on the kiosk (2.3 min) and longest on the PDA (3.2 min) ({chi}2 = 14.5; P = 0.002). The mean agreement between the prestudy and the study PAAQ was approximately 94% across all study arms. The proportion of participants expressing comfort before and after completing the PAAQ increased from 10% to 97% on the computerized arms and from 60% to 64% on the paper arm. Touchscreen computer technology is an accurate, efficient platform for patient-administered PAAQ. Patients expressed comfort using the technology and preference for computerized versus paper for future questionnaires.

 

通過持續上呼吸道二氧化碳監測來優化氣管內導管的套囊填充

Optimization of endotracheal tube cuff filling by continuous upper airway carbon dioxide monitoring

Efrati S, Leonov Y, Oron A, Siman-Tov Y, Averbukh M, Lavrushevich A, Golik A

Department of Medicine A, Assaf Harofeh Medical Center, Zerifin, 70300, Israel.

Anesth Analg.

2005 Oct;101(4):1081-8, table of contents.

 

不適當的管口套囊填充與使用氣管內導管(ETT)造成的不同的併發症有關。在本次研究中,我們評價一種客觀的,非創傷性的方法通過監測上呼吸道內的二氧化碳分壓PCO2)來持續評估ETT管口周圍的洩漏。PCO2)水平通過同時測量ETT管口和聲帶之間,喉部和鼻孔內的二氧化碳描記圖。管口套囊填充用電子控制器來調整產生最小的壓力防止CO2洩漏。這種方式的可行性在人類模擬器和小豬模型中評估。臨床功能在60個正在經歷手術的病人中評估,與標準的麻醉評估方法比較。在ETT管口壓力和人類模擬器(R2=0.954,P<0.0001)以及小豬模型(R2>0.98P<0.0001)的PCO2)水平中觀察到線型相關性。ETT管口的碘洩漏,在小豬模型中,僅發生在當PCO2)水平〉2mmHg時。在手術病人中,平均ETT管口壓力由麻醉師根據臨床決定,明顯高於由PCO2)評估的最佳管口壓力(分別為,25.2+/-3.6 18.2+/-7.8mmHg,P<0.001)。根據這些發現,最佳ETT管口套囊填充壓可以通過監測鼻孔或喉部的PCO2)來確定。意義:一種新的,客觀的,無創的,基於在上呼吸道監測二氧化碳水平的優化氣管內導管套囊填充的方法能用來確定最低的管口壓力消除洩漏和防止窒息。

(周荻譯 薛張綱校)

Inappropriate cuff filling is responsible for various complications related to the use of an endotracheal tube (ETT). In this study, we evaluated an objective, noninvasive method for continuous assessment of leak around the ETT cuff by monitoring carbon dioxide pressure (P(CO2) in the upper airway. P(CO2) levels were measured by capnography simultaneously between the ETT cuff and the vocal cords, at the oropharynx, and in the nares of the nose. Cuff filling was regulated by an electronic controller to achieve the minimal pressure needed to prevent CO2 leak. Feasibility of the method was assessed in a human simulator and in a porcine model. Clinical function was evaluated in 60 patients undergoing surgery, comparing the method to the standard anesthesiologist evaluation. Linear correlations were observed between the ETT cuff pressure and P(CO2) level in the human simulator (R2 = 0.954, P < 0.0001) and in the porcine model (R2 > 0.98, P < 0.0001). Iodine leak around the ETT cuff, in the porcine model, occurred only when P(CO2) levels were >2 mm Hg. In the surgery patients, the mean ETT cuff pressure determined clinically by the anesthesiologist was significantly higher than the optimal cuff pressure assessed by P(CO2) (25.2 +/- 3.6 versus 18.2 +/- 7.8 mm Hg, respectively; P < 0.001). According to these findings, optimal ETT cuff filling pressure can be identified by monitoring P(CO2) at the nares or the oropharynx. IMPLICATIONS: A new, objective, noninvasive method for optimizing endotracheal tube cuff filling based on monitoring carbon dioxide levels in the upper airways can be used to identify the minimal cuff pressure necessary to eliminate leak and prevent aspiration.

 

 

Etoricoxib對全膝或全髖替換術後病人的鎮痛效能:隨機,雙盲,安慰劑控制的研究

Etoricoxib provides analgesic efficacy to patients after knee or hip replacement surgery: a randomized, double-blind, placebo-controlled study.
Rasmussen GL, Malmstrom K, Bourne MH, Jove M, Rhondeau SM, Kotey P, Ang J, Aversano M, Reicin AS; Etoricoxib Postorthopedic Study Group.
Orthopedic Specialty Hospital, Murray, Utah, USA.

Anesth Analg 2005 101: 1104-1111.


在這個隨機,雙盲,安慰劑對照,多中心的研究中,我們評估etoricoxib(一種新的環氧酶-2抑制劑)在全膝或全髖術後病人的鎮痛效果。總共228名中至重度疼痛的病人在術後72小時內被隨機分配接受120mg etoricoxib,對照給於甲氧萘丙酸鈉1100mg,或安慰劑(111)第一天,接著etoricoxib和安慰劑(12)第二天到第七天。病人報告疼痛分數,減少(阿片類-結合)藥物的使用,和研究藥物的反應。第一天,etoricoxib提供的鎮痛效果優於安慰劑,與控制給予的甲氧萘丙酸鈉相似,證明全部疼痛緩解分數超過8小時,原始終點;最低平均分數分別為為11.011.5,和5.6P<0.001比安慰劑)。相似地,比那些接受安慰劑治療的病人,更大百分數的病人接受etoricoxib和甲氧萘丙酸鈉對研究藥物報告效果好到很好:分別為53%60%26%。第2-7天,etoricoxib證明明顯減少了藥物的使用,35%P<0.001比安慰劑)。減少的臨床相關性由全球病人評估確定(P<0.05比安慰劑)。接受etoricoxib的病人也經歷了更少的“嚴重的”和“中度的”疼痛,和那些使用安慰劑的病人相比。Etoricoxib在本試驗中有很好的耐受性;副反應的發生不常見,在治療組中相似。總的來說,etoricoxib提供鎮痛與對照給予的甲氧萘丙酸鈉在第一天相似,而且優於安慰劑,減少了超過7天的補充的阿片類使用。意義:在術後組中(膝和髖置換術),etoricoxib120mg 提供鎮痛優於安慰劑而且與對照給予的甲氧萘丙酸鈉1100mg相似。接受etoricoxib的病人與安慰劑病人相比經歷更少的疼痛,減少阿片類的藥物使用。

(周荻譯 薛張綱校)
In this randomized, double-blind, placebo-controlled, multicenter study we assessed the analgesic effect of etoricoxib (a new cyclooxygenase-2 inhibitor) in patients having had knee or hip replacement surgery. A total of 228 patients with moderate or severe pain were randomly allocated within 72 h after surgery to receive etoricoxib 120 mg, controlled-release naproxen sodium 1100 mg, or placebo (1:1:1) on day 1 followed by etoricoxib and placebo (1:2) on days 2 to 7. Patients reported pain scores, rescue (opioid-combination) medication use, and the response to study drug. On day 1, etoricoxib provided an analgesic effect superior to placebo and similar to controlled-release naproxen sodium as demonstrated by the total pain relief score over 8 h, the primary end-point; least-squares mean scores were 11.0, 11.5, and 5.6, respectively (P < 0.001 versus placebo). Similarly, a larger percentage of patients receiving etoricoxib and naproxen sodium than those receiving placebo reported good to excellent responses to study drug: 53%, 60%, and 26% respectively. On days 2-7, etoricoxib demonstrated a significant reduction of rescue medication use, 35% (P < 0.001 versus placebo). The clinical relevance of the decrease was confirmed by Patient's Global Evaluation (P < 0.05 versus placebo). Patients receiving etoricoxib also experienced significantly less "worst" and "average" pain than did those on placebo. Etoricoxib was generally well tolerated in this study; the incidence of adverse experiences was infrequent and similar across treatment groups. In summary, etoricoxib provided analgesia that was similar to controlled-release naproxen sodium on day 1 and superior to placebo with reduced supplemental opioid use over 7 days. IMPLICATIONS: In a postsurgery setting (knee and hip replacements), etoricoxib 120 mg provided analgesia superior to placebo and similar to controlled-release naproxen sodium 1100 mg. Patients receiving etoricoxib suffered less pain and took less opioid rescue medication compared with patients on placebo.

 

危重病人能否運用腦電圖分析法來確定鎮靜的水平?

Can electroencephalographic analysis be used to determine sedation levels in critically ill patients?
Roustan JP, Valette S, Aubas P, Rondouin G, Capdevila X.
Department of Anesthesiology and Intensive Care Medicine, Neurological Explorations Laboratory, Lapeyronie University Hospital, 295 Avenue du Doyen G Giraud, 34000 Montpellier, France.
Anesth Analg 2005 101: 1141-1151.


長時間地使用鎮靜藥物可頻繁地導致重症監護病人的過度鎮靜。在深度鎮靜的病人臨床評估的尺度是不可靠的。從腦電圖記錄的光譜和雙頻光譜分析中得來的參數已經組合起來產生了一個監測麻醉深度的指標(BIS)。對於ICU的病人這些參數在監測鎮靜深度方面的作用仍不確定。對於從腦電圖原有的記錄中得到的光譜和雙頻光譜的參數,我們設計了這個前瞻性的研究來重新定義和計算並且評估它們在ICU病人鎮靜不足或者過度鎮靜診斷方面的臨床相關性。連續服用咪達唑侖和嗎啡來鎮靜的四十歲以上病人也包括在內。我們獲取了167位病人鎮靜水平的臨床評估,運用了RamsayComfort標準,同時腦電圖記錄了300秒。我們計算了四個頻帶(beta, alpha, Theta, and delta)的六個光譜相關參數、SEF95SEF50、四個雙頻光譜參數、有效的三聯產物、雙頻光譜、雙結合因數和比率10,同時評估了這些參數的相關性以及它們在預測鎮靜不足(Ramsay 12)和鎮靜過度(Ramsay 56)水平時的組合。這些計算在完成前後除外了激動的病人(此時COMFORT4的分值在2以上)。在預測過度鎮靜(Ramsay 56) 和鎮靜不足(Ramsay 12)的水平時相關性最大的參數是比率10SEF95。它們的線性組合相關性在預測鎮靜水平時作了合適地改進。在除外了激動病人後結果是相似的。我們得出結論:不同的腦電圖描述性參數呈現出巨大的個體差異性。腦電圖的光譜和雙頻光譜參數之間有著很強的關聯性。雙頻光譜分析在區別ICU病人鎮靜不足或鎮靜過度水平的預測能力方面相對於單純光譜分析有了略微的改善。

結論:SEF95和比率10 是腦電圖在監測ICU病人鎮靜水平時相關性最大的指標,但是腦電圖的計算值呈現出巨大的個體差異性。腦電圖的雙頻光譜分析相對於單純光譜分析有了略微的改善。

(韓曉丹譯 薛張綱校)

Prolonged use of sedative drugs frequently leads to oversedation of intensive care patients. Clinical assessment scales are not reliable in deeply sedated patients. Parameters obtained from spectral and bispectral analysis of electroencephalogram (EEG) records have been combined to create an index (BIS) to monitor anesthesia depth. The role of such parameters in monitoring the depth of the sedation in intensive care unit (ICU) patients has yet to be determined. We designed the present prospective study to redefine and calculate available spectral and bispectral parameters from raw EEG records and estimate their clinical relevance for the diagnosis of under- or oversedation levels in ICU patients. Forty adult patients receiving continuous midazolam and morphine sedation were included. We obtained 167 clinical evaluations of sedation level using Ramsay and COMFORT scales along with an EEG record of 300 s. Six spectral parameters-relative power of 4 frequency bands (beta, alpha, Theta, and delta), 95th percentile of the power spectrum (SEF95), and 50th percentile of the power spectrum (SEF50) and four bispectral parameters, real triple product, bispectrum (Bispectrum), bicoherence, and ratio 10-were calculated. The relevance of each of these parameters and combinations in predicting too light (Ramsay 1 and 2) or deep (Ramsay 5 and 6) sedation levels was assessed. These calculations were performed before and after exclusion of the agitated patients, whose COMFORT 4 score was above 2. The most relevant parameters for predicting levels of deep sedation (Ramsay 5 and 6) were ratio 10 (area under the curve = 0.763; 95% confidence interval, 0.679-0.833) and SEF95 (area under the curve = 0.687; 95% confidence interval, 0.597-0.767). The most relevant parameters for predicting light levels of sedation (Ramsay 1 and 2) were also ratio 10 (area under the curve = 0.829; 95% confidence interval, 0.695-0.917) and SEF95 (area under the curve = 0.798; 95% confidence interval, 0.650-0.898). There is a modest improvement in relevance of their linear combination in predicting sedation level. Results were similar after exclusion of agitated patients. We conclude that various calculated EEG descriptive parameters exhibited large interindividual variability. There was a strong correlation between EEG spectral and bispectral parameters. Bispectral analysis slightly improves the predictive power of simple spectral analysis in distinguishing too light or deep sedation levels in ICU patients. IMPLICATIONS: Spectral edge frequency 95 and Ratio 10 are the most relevant electroencephalogram (EEG) indexes for monitoring the level of sedation in intensive care unit patients but calculated EEG values exhibited large interindividual variability. Bispectral analysis of EEG provides a slight improvement over simple spectral analysis.

 

經蝶骨的垂體手術病人在手術期間的管理

Perioperative management of patients undergoing transsphenoidal pituitary surgery.
Nemergut EC, Dumont AS, Barry UT, Laws ER.
Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, Virginia 22908-0710, USA.

Anesth Analg 2005 101: 1170-1181.

 

垂體腺瘤通常表現為激素分泌過多,雖然藥物治療對於大多數機能亢進的腺瘤是有效的,但是卻不能治癒。所以,經蝶骨的垂體手術已經成為神經外科的一種普遍的治療方法,但是卻將獨特的挑戰留給了麻醉科醫生,因為不同的腺瘤有不一樣的併發症存在。任何類型的垂體瘤都可能引起垂體功能減退和局部質量效應,這些是蝶鞍內逐漸擴大的腫塊引起的。這裏我們回顧一下外科摘除腺瘤和蝶鞍內減壓所涉及的手術期間的厲害關係。對於庫興綜合症(腎上腺皮質激素分泌型腺瘤引起的皮質醇增多症)、肢端肥大症(生長激素分泌型腺瘤引起的)和促甲狀腺腺瘤引起的甲狀腺機能亢進我們要給於特別地注意。我們會詳細地表述手術中的危險包括出血、尿崩症、不適當抗利尿激素綜合症和垂體機能減退症。瞭解術前評估、術中管理、潛在併發症以及它們的處理和避免策略是手術期間成功的病人保健和減少發病率、死亡率的基礎。

(韓曉丹譯,薛張綱校)

Pituitary adenomas often present with the symptoms of hormonal hypersecretion, and although medical therapy is available for most hyperfunctioning states, it is not curative. As a result, transsphenoidal pituitary surgery has become a commonly performed neurosurgical procedure with unique challenges for the anesthesiologist due to the distinct medical comorbidities associated with various adenomas. Any type of pituitary tumor may also produce hypopituitarism and local mass effects secondary to the expanding intrasellar mass. Here we review the perioperative concerns surrounding surgery to remove adenomas and decompress the sellar space. Special attention is given to Cushing's disease (hypercortisolism secondary to an adrenocorticotropic hormone-secreting adenoma), acromegaly (secondary to a growth hormone-secreting adenoma), and hyperthyroidism in the setting of thyrotropic adenomas. Operative risks, including bleeding, diabetes insipidus, the syndrome of inappropriate antidiuretic hormone secretion, and hypopituitarism, are addressed in detail. Understanding preoperative assessment, intraoperative management, potential complications, their management, and strategies for avoidance are fundamental to successful perioperative patient care and avoidance of morbidity and mortality.

 

使用刺激性導管持續坐骨神經阻滯較之傳統的非刺激性導管縮短達到手術所需阻滯要求的起始時間並使拇趾外翻修複後的鎮痛藥物使用量減至最小

Using stimulating catheters for continuous sciatic nerve block shortens onset time of surgical block and minimizes postoperative consumption of pain medication after halux valgus repair as compared with conventional nonstimulating catheters

Casati A, Fanelli G, Koscielniak-Nielsen Z, Cappelleri G, Aldegheri G, Danelli G, Fuzier R, Singelyn F.
Department of Anesthesiology and Pain Therapy, Azienda Ospedaliera di Parma, Via Gramsci 14-43100 Parma, Italy. acasati@ao.pr.it

Anesth Analg. 2005 Oct;101(4):1192-7

 

我們在隨機的110例擇期整形腳外科手術病人中前瞻性地檢驗了應用刺激性導管增強持續膕窩部坐骨神經阻滯功效的假設。在引發一個坐骨神經介導的< = 0.5 mA的神經刺激輸出的肌顫後,通過盲測(C; n = 50)或是經由導管刺激(S; n = 50),這種圍神經導管超過導引器尖端2-4 cm。一次大劑量25 mL 1.5%甲呱卡因,術後病人自控輸注0.2%羅呱卡因(背景輸注:3 mL/h,增補劑量:5 mL,鎖定時間:30 min)。每8小時丙帕他莫2 g IV,如需要可用阿片類藥物補救性鎮痛。導管置管在S組需要7 +/- 2分鐘,在C組需要5 +/- 2分鐘 (P = 0.056)。可以發現S組中感覺和運動阻滯的起始時間顯著縮短。組間靜息和運動期間疼痛緩解質量未發現有差異。術後48小時局麻藥消耗中值(範圍)在SC組分別為239 mL (175-519 mL)322 mL (184-508 mL) (P = 0.002)SC組分別有12 (25%)28 (58%)的病人需要阿片類藥補救性鎮痛(P = 0.002)。我們推斷使用刺激性導管能達到更短的膕窩部坐骨神經阻滯起始時間,減少術後局麻藥液消耗而達到類似的疼痛緩解和使用較少的阿片類藥補救性鎮痛。推論:此項前瞻性隨機盲法調查證明了與盲法導管置入相比,使用刺激性導管持續膕窩部坐骨神經阻滯能達到更短的感覺和運動阻滯起始時間,在擇期整形腳外科手術後具有較少的局麻藥消耗和補救性藥物鎮痛的需要。

(徐麗穎譯 薛張綱校)

We prospectively tested the hypothesis that the use of a stimulating catheter improves the efficacy of continuous posterior popliteal sciatic nerve block in 100 randomized patients scheduled for elective orthopedic foot surgery. After eliciting a sciatic mediated muscular twitch at < or = 0.5 mA nerve stimulation output, the perineural catheter was advanced 2-4 cm beyond the tip of the introducer either blindly (Group C; n = 50) or stimulating via the catheter (Group S; n = 50). A bolus dose of 25 mL of 1.5% mepivacaine was followed by a postoperative patient-controlled infusion of 0.2% ropivacaine (basal infusion: 3 mL/h; incremental dose: 5 mL; lockout time: 30 min). Propacetamol 2 g IV was administered every 8 h, and opioid rescue analgesia was available if required. Catheter placement required 7 +/- 2 min in Group S and 5 +/- 2 min in Group C (P = 0.056). A significantly shorter onset time of both sensory and motor blocks was noted in Group S. No difference in quality of pain relief at rest and during motion was reported between the groups. Median (range) local anesthetic consumption during the first 48 h after surgery was 239 mL (175-519 mL) and 322 mL (184-508 mL) in Groups S and C, respectively (P = 0.002). Rescue opioid analgesia was required by 12 (25%) and 28 (58%) patients in Groups S and C, respectively (P = 0.002). We conclude that the use of a stimulating catheter results in shorter onset time of posterior popliteal sciatic nerve block, similar pain relief with reduced postoperative consumption of local anesthetic solution, and less rescue opioid consumption. IMPLICATIONS: This prospective, randomized, blind investigation demonstrated that the use of a stimulating catheter for continuous posterior popliteal sciatic nerve block resulted in shorter onset time of sensory and motor blocks and less local anesthetic consumption and need for rescue pain medication after elective orthopedic foot surgery compared with blind catheter advancement.

 

髖部骨折修復術後蘇醒室中譫妄預示術後譫妄

Recovery room delirium predicts postoperative delirium after hip-fracture repair

Sharma PT, Sieber FE, Zakriya KJ, Pauldine RW, Gerold KB, Hang J, Smith TH
Department of Anesthesiology & Critical Care Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., Baltimore, Maryland 21224, USA. Anesth Analg. 2005 Oct;101(4):1215-20

 

在這項研究中,我們試圖確定全麻下行髖部骨折修復術的老年病人蘇醒室中譫妄的發生率,並探索蘇醒室中譫妄是否與持續的術後譫妄相關。在這項前瞻性研究中,病人在標準化的麻醉方案下接受髖部骨折修復。另外,在術後麻醉監護室和病房中的術後疼痛管理也是標準化的。譫妄的存在通過精神紊亂評估方法(CAM)評分來確定。蘇醒室中譫妄通過終止異氟醚吸入後60分鐘獲取一個CAM評分來評估。術後譫妄通過術後住院恢復期間獲取每日CAM評分來評估。50例病人同意加入研究,47例進入分析(誘導後手術取消n=1;未遵從方案n=2)。病人平均年齡為77 +/- 1 (mean +/- SE) (range, 56-98 )。研究中77%病人ASA評分III級或III級以上。蘇醒室中譫妄的發生率為45%。術後譫妄的發生率為36%。蘇醒室中譫妄預示術後譫妄(P < 0.001, Fisher的精確試驗)的敏感性為100%,特異性為85%。術後麻醉監護室和病房中鎮痛藥給藥劑量在有和無術後譫妄的病人中是相似的。此項研究結果表明,蘇醒室譫妄是術後譫妄的強烈預測因素。推論:在行髖部骨折修復術的病人中,在使用標準化全麻方案和術後疼痛管理下,蘇醒室中譫妄是術後譫妄的一個強烈預測因素。

(徐麗穎譯 薛張綱校)

In this study, we sought to determine the incidence of recovery room delirium in elderly patients having hip-fracture repair under general anesthesia and to discover whether recovery room delirium is associated with continuing postoperative delirium. In this prospective study, patients undergoing hip-fracture repair were anesthetized using a standardized protocol. In addition, postoperative pain management was standardized in both the postoperative anesthesia care unit and in the hospital ward. The presence of delirium was determined using the confusion assessment method (CAM) score. Recovery room delirium was assessed by obtaining a CAM score at 60 min after discontinuation of isoflurane. Postoperative delirium was assessed by obtaining a daily CAM score during the postoperative in-hospital recovery period. Fifty patients consented to the study and 47 patients were included in the analysis (surgery cancelled postinduction n = 1; nonadherence to protocol n = 2). Average patient age was 77 +/- 1 (mean +/- SE) yr (range, 56-98 yr). Seventy-seven percent of the study patients were ASA class III or more. The prevalence of recovery room delirium was 45%. The prevalence of postoperative delirium was 36%. Recovery room delirium predicted postoperative delirium (P < 0.001, Fisher's exact test) with a sensitivity of 100% and a specificity of 85%. Analgesic doses administered in the postoperative anesthesia care unit and ward were similar in patients with or without postoperative delirium. Results of this study show that recovery room delirium is a strong predictor of postoperative delirium. IMPLICATIONS: In patients undergoing hip-fracture repair, recovery room delirium is a strong predictor of postoperative delirium when using a standardized protocol for general anesthesia and postoperative pain management.

 

評價valsalva動作在靜脈穿刺疼痛的作用:一項隨機前瞻研究。

Evaluating the efficacy of the valsalva maneuver on venous cannulation pain: a prospective, randomized study.

Agarwal A, Sinha PK, Tandon M, Dhiraaj S, Singh U.

Department of Anesthesia, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Anesth Analg. 2005 Oct;101(4):1230-2

 

靜脈穿刺引起的疼痛是一種不適的症狀。我們評價了valsalva動作在靜脈穿刺引起的疼痛上的作用。研究物件為擇期手術的75名成人、 ASA III,性別不限。 病人隨機分成3組,每組25人。組IC):對照組;組IIV):病人向血壓計管道吹氣,使水銀柱上升至30 mm Hg,持續20秒;IIIB):病人擠壓橡皮球。20秒後進行外周靜脈穿刺。靜脈穿刺引起的疼痛採用4點評分:030=無疼痛,1=輕度疼痛,2=中度疼痛,3=重度疼痛,以及視覺類比評分:0-10,0=無疼痛,10=最重度無法忍受的疼痛。Valsalva組觀察到疼痛發生率的顯著下降:25名病人中18名(72%),而另外兩組疼痛發生率均為100(P< 0.001)。同樣,Valsalva組病人疼痛的程度、需要穿刺前顯露靜脈的人數及穿刺時間均顯著降低(P< 0.001)。結論:靜脈穿刺是安全實施麻醉必不可少的步驟;然而由此引起的疼痛有時非常不適。我們觀察到靜脈穿刺同時採用valsalva動作能大大減少這種疼痛。

(王麗珺譯,薛張綱校)

Pain associated with venous cannula is a distressing symptom. We evaluated the efficacy of the Valsalva maneuver on pain associated with venous cannulation. Seventy-five adults, ASA physical status I and II, either sex, undergoing elective surgery, were included in this study. Patients were randomized into 3 groups of 25 each. Group I (C): control; Group II (V): blew into sphygmomanometer tubing and raised the mercury column up to 30 mm Hg for 20 s; Group III (B): pressed a rubber ball. Twenty seconds later, peripheral venous cannulation was performed. Venous cannulation pain was graded using a 4-point scale: 0-3, where 0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain, and visual analog scale of 0-10, where 0 = no pain and 10 = worst imaginable pain. A significant reduction in the incidence of pain was observed in the Valsalva group: 18 of 25 (72%) patients, whereas 25 of 25 (100%) experienced pain in the other two groups (P < 0.001). A significant reduction in the severity of pain, number of patients in whom one needed to make the vein prominent before cannulation, and the time taken for the same were observed in the Valsalva group (P < 0.001). IMPLICATIONS: Venous cannulation is a necessary step for safe anesthesia administration; however, the pain associated with it is sometimes very distressing. We observed that the Valsalva maneuver performed at the time of venous cannulation greatly decreases this pain.

磷酸二酯酶-3抑制劑在離體人胃網膜動脈、乳內動脈及橈動脈之間不同的藥理學敏感性

Differential Pharmacologic Sensitivities of Phosphodiesterase-3 Inhibitors Among Human Isolated Gastroepiploic, Internal Mammary, and Radial Arteries

Masanori Onomoto, MD*, Isao Tsuneyoshi, MD*, Arata Yonetani, MD*, Shoich Suehiro, MD{dagger}, Kazuhisa Matsumoto, MD{dagger}, Ryuzo Sakata, MD{dagger}, and Yuichi Kanmura, MD*

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

Anesth Analg 2005;101:950-956

 

目前尚無針對磷酸二酯酶(PDE)-3抑制劑對不同部位的人血管組織作用的系統研究 。我們在總共134例行冠脈搭橋手術患者身上採集了人胃網膜動脈(n = 70)、乳內動脈(n = 72)和撓動脈(n = 70),並探討了特異性PDE3抑制劑(奧普力農、米力農和氨力農)對這些血管收縮的影響。所有的這些PDE3抑制劑都劑量依賴性地減輕了血管對10–6 mol/L去甲腎上腺素以及10–9 10–8 mol/L凝血烷A2相似體U46619的收縮反應。在介導血管舒張時,這些抑制劑在去甲腎上腺素收縮的血管環中的作用比U46619中更有效。此外,在與最大治療血漿濃度相近似的濃度中(10–7 mol/L的奧普力農、10–6 mol/L的米力農、10–5 mol/L的氨力農)時,奧普力農和米力農對胃網膜和撓動脈的舒張作用比氨力農強;而對乳內動脈,米力農的舒張作用比其他兩者更強。這些結果提示這三種PDE-3抑制劑對人體不同部位動脈存在不同活性,並對它們在血管重建中預防不同動脈移植物痙攣的有效性具有借鑒作用。

(黃施偉 馬皓琳,李士通 校)

Systematic investigations of the actions of phosphodiesterase (PDE)-3 inhibitors on different human vascular tissues have not been performed. We investigated the effects of specific PDE-3 inhibitors (olprinone, milrinone, and amrinone) on contracted human gastroepiploic arteries (n = 70), internal mammary arteries (n = 72), and radial arteries (n = 70) harvested from a total of 134 patients, all of whom were undergoing coronary artery bypass surgery. Each of these PDE-3 inhibitors dose-dependently diminished the contractile responses to 10–6 mol/L norepinephrine and to either 10–9 or 10–8 mol/L of the thromboxane A2 analog U46619. In inducing vasorelaxations, these inhibitors were significantly more potent in norepinephrine-contracted rings than in those contracted with U46619. Further, at concentrations similar to the maximum therapeutic plasma concentrations (10–7 mol/L olprinone; 10–6 mol/L milrinone; 10–5 mol/L amrinone) olprinone and milrinone were more potent at inducing relaxations than amrinone in gastroepiploic arteries and radial arteries, whereas in internal mammary arteries milrinone was more potent than the others. These results suggest different activities for the three PDE-3 inhibitors among human arteries located in different regions and may be informative about the effectiveness of these inhibitors in preventing spasms in the various arterial grafts used in revascularization.


機械通氣對行胸部手術的患者肺免疫功能的影響

The Pulmonary Immune Effects of Mechanical Ventilation in Patients Undergoing Thoracic Surgery

 

Thomas Schilling, MD, DEAA*, Alf Kozian, MD*, Christof Huth, MD{dagger}, Frank Bühling, MD{ddagger}, Moritz Kretzschmar, cand med*, Tobias Welte, MD§, and Thomas Hachenberg, MD, PhD*

*Department of Anesthesiology and Intensive Care Medicine, {dagger}Department of Cardiovascular and Thoracic Surgery, {ddagger}Institute of Immunology, and §Department of Cardiology, Angiology, and Pneumology, Otto-von-Guericke-University, Magdeburg, Germany

Anesth Analg 2005;101:957-965

 

機械通氣(MV)可誘發肺泡的炎性反應。有建議單肺通氣(OLV)仍用雙肺通氣時的潮氣量(Vt),但有可能增加單肺的機械壓力,並可能加重肺泡介質釋放。我們研究了用不同的潮氣量通氣是否改變肺免疫功能、血流動力學和氣體交換。選擇32例行開胸手術的患者,隨機分成兩組,一組Vt 10 mL/kg (n = 16) ,另一組Vt 5 mL/kg (n = 16),調整MV使單肺通氣時和單肺通氣後Paco2正常。通氣肺行纖維光學支氣管肺泡灌洗,灌洗液中測定細胞、蛋白質、腫瘤壞死因數(TNF)-α、白細胞介素(IL)-8、可溶性細胞間黏附分子(sICAM)-1IL-10和彈性蛋白酶。根據需要用參數或非參數檢驗分析資料。在所有患者中,都發現促進炎性的變數增加。單肺通氣後和術後肺泡內細胞、蛋白質、球蛋白、IL-8 彈性蛋白酶和 IL-10的時間過程在兩組間沒有差異。TNF-α(8.45.0 µg/mL)sICAM-1濃度(52.727.5 µg/mL)在用Vt = 5 mL/kg單肺通氣後明顯減小。這些結果表明MV可誘發上皮損傷及通氣肺的促炎反應。OLV時減小潮氣量可減低肺泡TNF-αsICAM-1濃度。

(彭中美 馬皓琳,李士通 校)

Mechanical ventilation (MV) may induce an inflammatory alveolar response. One-lung ventilation (OLV) with tidal volumes (Vt) as used during two-lung ventilation is a suggested algorithm but may impose mechanical stress of the dependent lung and potentially aggravate alveolar mediator release. We studied whether ventilation with different Vt modifies pulmonary immune function, hemodynamics, and gas exchange. Thirty-two patients undergoing open thoracic surgery were randomized to receive either MV with Vt = 10 mL/kg (n = 16) or Vt = 5 mL/kg (n = 16) adjusted to normal Paco2 during and after OLV. Fiberoptic bronchoalveolar lavage of the ventilated lung was performed, and cells, protein, tumor necrosis factor (TNF)-{alpha}, interleukin (IL)-8, soluble intercellular adhesion molecule (sICAM)-1, IL-10, and elastase were determined in the bronchoalveolar lavage. Data were analyzed by parametric or nonparametric tests, as indicated. In all patients, an increase of proinflammatory variables was found. The time courses of intra-alveolar cells, protein, albumin, IL-8, elastase, and IL-10 did not differ between the groups after OLV and postoperatively. TNF-{alpha} (8.4 versus 5.0 µg/mL) and sICAM-1 (52.7 versus 27.5 µg/mL) concentrations were significantly smaller after OLV with Vt = 5 mL/kg. These results indicate that MV may induce epithelial damage and a proinflammatory response in the ventilated lung. Reduction of tidal volume during OLV may reduce alveolar concentrations of TNF-{alpha} and of sICAM-1.

 

 

糖尿病患兒外科圍手術期管理

Perioperative Management of Pediatric Surgical Patients with Diabetes Mellitus

Erinn T. Rhodes, MD, MPH*{ddagger}, Lynne R. Ferrari, MD{dagger}§, and Joseph I. Wolfsdorf, MB, BCh*{ddagger}

*Division of Endocrinology and {dagger}Department of Anesthesiology, Perioperative, and Pain Medicine, Children’s Hospital Boston; {ddagger}Departments of Pediatrics and §Anesthesia, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2005;101:986-999

 

目前對糖尿病患兒的管理策略日益複雜。為了優化這類病人的圍術期管理,兒科麻醉醫師必須認真考慮疾病的病理生理學、針對性的治療方法、血糖控制狀態和計畫手術的類型。兒科方面包括身體大小、青春期發育及耐受禁食的能力都是必須考慮的重要問題。為保持糖尿病治療的連貫性,圍術期的計畫應在參考兒童內分泌醫師的意見下制定。我們給出了波士頓兒童醫院對擬行計畫手術麻醉的1型或2型糖尿病患兒在手術和全麻的管理策略。這一兒科麻醉和內分泌治療之間的合作性成果,代表了必須促進醫療和改善管理的此類病人的標準化方法實例。文章突出了與之前發表的建議的不同之處,這些都是兒童糖尿病治療的持續發展所帶來的預期改變。

(周志堅 馬皓琳,李士通 校)

Pediatric patients with diabetes are managed with increasingly complex regimens. To optimally manage these patients during the perioperative period, pediatric anesthesiologists must carefully consider the pathophysiology of the disease, patient-specific methods of treatment, status of glycemic control, and the type of surgery proposed. Important pediatric issues, including body size, pubertal development, and ability to tolerate nil per os status, must be considered. To keep pace with the array of options for treating diabetes in children, the perioperative plan should be developed in consultation with a pediatric endocrinologist. We present an algorithm that was developed at Children’s Hospital Boston for the management of pediatric patients with either type 1 or type 2 diabetes mellitus presenting for surgery and general anesthesia. This collaborative effort between the pediatric anesthesia and endocrine services represents one example of a standardized approach to these patients that should facilitate care and improve management. Differences from previously published recommendations are highlighted, as are expected changes caused by the continued evolution of pediatric diabetes care.

 

 

七氟醚增強大鼠主動脈對硝酸甘油的耐藥:提示可能通過在血管平滑肌內附加產生超氧陰離子和/或氫氧根使可溶性鳥苷酸環化酶脫敏感化

Sevoflurane Enhances Nitroglycerin Tolerance in Rat Aorta: Implications for the Desensitization of Soluble Guanylate Cyclase Possibly Through the Additive Generation of Superoxide Anions and/or Hydroxyl Radicals Within Vascular Smooth Muscle

Tetsuya Kakutani, MD, Koji Ogawa, MD, Shizue Iwahashi, MD, Kazuhiro Mizumoto, MD, and Yoshio Hatano, MD

Department of Anesthesiology, Wakayama, Medical University, Wakayama, Japan.

Anesth Analg 2005;101:1015-1022

 

近來有證據表明: 硝酸甘油(TNG)耐藥,即硝酸甘油的血管舒張作用減弱,和活性基團的產生增加有關。我們設計本研究以探究介導TNG耐藥的機制並比較七氟醚和異氟醚對TNG耐藥形成的影響。記錄大鼠去內皮主動脈環張力的變化。評估由去氧腎上腺素引起收縮的動脈環對TNG (10–8–10–5 M)的累積舒張效應。然後在每種麻醉藥(1 to 3 MAC)存在或不存在的情況下將動脈環在含TNG (10–5 M)的浴液中孵育30min以誘導產生TNG耐藥。洗脫TNG和麻醉藥後獲得動脈環第二次對TNG的反應。一些動脈環預先給予氧基清除劑或巰基補充劑。比較前後兩次動脈環對TNG的舒張反應。3MAC七氟醚,而不是更小濃度的七氟醚或異氟醚,在同時給予TNG時促進TNG耐藥。單獨給予七氟醚對TNG耐藥沒有影響。氧基清除劑或低氧濃度(25%)可抑制共同給予七氟醚和TNG增強的TNG耐藥。3MAC七氟醚在高氧環境下可能通過在血管平滑肌內附加產生超氧陰離子或氫氧根來增強TNG耐藥形成。

(周雅春 馬皓琳,李士通 校)

Nitroglycerin (TNG) tolerance, defined as an impaired vasodilation response to TNG, has been recently demonstrated to be associated with increased production of reactive species. We designed this study to investigate the mechanisms that mediate TNG tolerance and to compare the effects of sevoflurane and isoflurane on the development of TNG tolerance. Tension changes in rat aortic rings without endothelium were recorded. The cumulative relaxant responses to TNG (10–8–10–5 M) were assessed in phenylephrine-contracted rings. To induce TNG tolerance, the rings were then incubated in the bathing solution containing TNG (10–5 M) for 30 min in the presence or absence of each anesthetic (1 to 3 MAC). After washout of TNG and anesthetic, the second response to TNG was obtained. Some rings were pretreated with oxygen radical scavengers or sulfhydryl supplements. The first and the second responses to TNG were compared. Sevoflurane at 3 MAC, but not sevoflurane at smaller concentrations or isoflurane, enhanced TNG tolerance when administered in combination with TNG. Sevoflurane alone had no effect on TNG tolerance. The enhancement of TNG tolerance in the case of a combined sevoflurane and TNG treatment was inhibited in the presence of oxygen radical scavengers or at a smaller oxygen concentration (25%). Sevoflurane at a concentration of 3 MAC in hyperoxic condition enhances the development of TNG tolerance, possibly by additive generation of superoxide anions or hydroxyl radicals within vascular smooth muscle.


在麻醉成人中用於拔除喉罩通氣道的最佳的七氟醚呼氣末濃度

Optimal End-Tidal Sevoflurane Concentration for the Removal of the Laryngeal Mask Airway in Anesthetized Adults

Yon Hee Shim, MD, Cheung Soo Shin, MD, Chul Ho Chang, MD, and Yang-Sik Shin, MD

Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea

Anesth Analg 2005;101:1034-1037

 

七氟醚提供平穩且快速的麻醉,在麻醉成人中拔除喉罩通氣道(LMA)時可用七氟醚。我們試圖確定在麻醉成人中用於拔除LMA所需的最佳七氟醚呼氣末濃度。我們研究了3522-64歲、ASA III級、進行會陰手術的成年患者。全身麻醉誘導用硫噴妥鈉,然後插入LMA。用七氟醚、氧氣和空氣維持麻醉。手術後維持靶濃度至少10 min,然後拔除LMA。用Dixon上下序貫方法(每步增減0.1%)預先確定拔除時的每個靶濃度,開始用1.7%的七氟醚呼氣末濃度。當拔除過程中或拔除後1 min內無咳嗽、牙關緊閉或有目的的大體動,且如果拔除後無屏氣、喉痙攣或氧飽和度下降,則認為LMA拔除成功。在50%的成人中達到成功拔除LMA的七氟醚呼氣末濃度為0.99% ± 0.09%(平均值±標準差),在95%的成人中為1.18%95%可信限1.07%–1.79%)。結論,我們已經確定七氟醚濃度為0.99%1.18%時,在50%95%的麻醉成人中可達到安全的LMA拔除,且無咳嗽、體動或任何其他氣道併發症。

(馬皓琳 李士通 校)

Sevoflurane provides smooth and rapid emergence from anesthesia and can be used when the removal of a laryngeal mask airway (LMA) is required in anesthetized patients. We sought to determine the optimal end-tidal concentrations of sevoflurane required for the removal of LMA in anesthetized adults. We studied 35 adults, aged 22–64 years old with an ASA physical status I or II, who were undergoing perineal surgery. General anesthesia was induced with thiopental, and the LMA was then inserted. Anesthesia was maintained with sevoflurane, oxygen, and air. After the surgery, the target concentration was maintained for at least 10 min, and then the LMA was removed. Each target concentration at the time of removal was predetermined by the Dixon up-down method (with 0.1% as a step size) starting at 1.7% end-tidal concentra-tion of sevoflurane. The LMA removal was considered successful when there was no coughing, clenching of teeth, or gross purposeful movements during or within 1 min after removal and also if there was no breath holding, laryngospasm, or desaturation after removal. The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of adults was 0.99% ± 0.09% (mean ± sd) and in 95% of adults was 1.18% (95% confidence limits, 1.07%–1.79%). In conclusion, we have determined that LMA removal in 50% and 95% of anesthetized adults can be safely accomplished without coughing, moving, or any other airway complications at 0.99% and 1.18% end-tidal concentrations of sevoflurane.


選擇性磷酸二酯酶5抑制不減少健康志願者丙泊酚鎮靜需要量但影響恢復速度和血漿環鳥苷酸3',5'-單磷酸濃度

Selective Phosphodiesterase 5 Inhibition Does Not Reduce Propofol Sedation Requirements but Affects Speed of Recovery and Plasma Cyclic Guanosine 3',5'-Monophosphate Concentrations in Healthy Volunteers

Thomas Engelhardt, MD, PhD, FRCA, Jamie MacDonald, FRCA MBChB, Helen F. Galley, PhD FIMLS, and Nigel R. Webster, PhD, FRCA, FRCP

Academic Unit of Anaesthesia and Intensive Care, Institute of Medical Sciences, University of Aberdeen, Aberdeen, Scotland, United Kingdom

Anesth Analg 2005;101:1050-1053

 

麻醉效應的調節涉及環鳥苷-3',5'單磷酸(cGMP)。我們假設通過選擇性抑制磷酸二酯酶限制cGMP的分解會影響丙泊酚的鎮靜需要量和血漿cGMP濃度。在這項安慰劑對照、雙盲、隨機交叉的預試驗中,10名志願者口服西地那非(sildenafil100mg或者安慰劑。通過使用丙泊酚靶控輸注系統直至達到無法語言交流(LVC)的鎮靜效果。測定血漿cGMP的基礎值、達到LVC時和達到LVC30分鐘後的濃度。與安慰劑處理者相比,口服西地那非的志願者的丙泊酚用量、預測的血漿濃度和鎮靜時間均無差異。服用西地那非後,恢復自發性語言交流的時間較短(4 [3–5] min vs 6 [3–8] min, 中位數[範圍], P = 0.019)。在安慰劑組,在丙泊酚鎮靜期間的cGMP濃度較基礎值降低(P < 0.004)。與安慰劑組相比,西地那非組在達到LVC時的血漿cGMP濃度較高(P = 0.004)。我們已證明,選擇性抑制磷酸二酯酶5能縮短丙泊酚鎮靜的恢復時間但不影響用量。在安慰劑組丙泊酚鎮靜期間血漿cGMP濃度的降低提示cGMP在丙泊酚對人類的麻醉中具有潛在的作用。

(顏濤 馬皓琳,李士通 校)

Cyclic guanosine 3',5'-monophosphate (cyclic GMP) has been implicated in modulating the effects of anesthesia. We hypothesized that limiting the breakdown of cyclic GMP through selective phosphodiesterase inhibition would influence propofol sedation requirements and plasma cyclic GMP concentrations. Ten volunteers received 100 mg of sildenafil or placebo orally in this placebo-controlled, double-blind, randomized crossover pilot study. Propofol sedation was achieved using a target-controlled infusion system until loss of verbal contact (LVC). Plasma cyclic GMP concentrations were determined at baseline, LVC, and 30 min after LVC. There was no difference in the amount of propofol used, predicted plasma concentration, or duration of sedation in volunteers after sildenafil compared with placebo treatment. Return of spontaneous verbal contact was faster after sildenafil (4 [3–8] min versus 6 [3–5] min, median [range], P = 0.019). Cyclic GMP concentrations were reduced during propofol sedation in the placebo group compared with baseline (P < 0.004). The plasma cyclic GMP concentrations were larger (P = 0.004) at LVC in the sildenafil group compared with placebo. We have shown that selective phosphodiesterase 5 inhibition decreases recovery time from propofol sedation without affecting propofol requirements. The decrease of plasma cyclic GMP concentrations during propofol sedation in the placebo group indicates a potential role of cyclic GMP in propofol anesthesia in humans.


托特羅定預防導尿管相關膀胱不適的藥效:一項前瞻性、隨機、安慰劑-對照、雙盲研究

The Efficacy of Tolterodine for Prevention of Catheter-Related Bladder Discomfort: A Prospective, Randomized, Placebo-Controlled, Double-Blind Study

Anil Agarwal, MD*, Mehdi Raza, MD*, Vinay Singhal, MD*, Sanjay Dhiraaj, MD*, Rakesh Kapoor, MS, McH{dagger}, Aneesh Srivastava, MS, McH{dagger}, Devendra Gupta, MD*, Prabhat K. Singh, MD*, Chandra Kant Pandey, MD*, and Uttam Singh, PhD{ddagger}

Departments of *Anesthesia, {dagger}Surgical Urology, and {ddagger}Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2005;101:1065-1067

 

留置導尿管繼發的膀胱不適是非常難受的,尤其對於麻醉蘇醒的病人。我們希望研究術中插入導尿管病人膀胱不適的發生率和嚴重程度,並衡量托特羅定――一種純膽鹼能受體拮抗劑在預防此不適方面的藥效。連續250ASAIII級、性別不限、接受需要插入導尿管的泌尿外科手術的成年病人參與了此項研究。C組(對照組n=165)接受安慰劑,T組(托特羅定組 n=50)接受託特羅定2mg。藥物在術前一小時口服。麻醉誘導以後,病人插上16F的氣囊導尿管,並用10mL生理鹽水充氣囊。在麻醉後復蘇室評估到達時(0)、到達後126小時的膀胱不適感及其嚴重程度,後者分為“輕,中和重”三個等級。在對照組觀察到的膀胱不適發生率為55%(165個病人中出現91個)。托特羅定組的膀胱不適發生率降低到36%(50個病人中出現18個),嚴重程度也比對照組有所減輕(P<0.05)。

(黃佳佳 馬皓琳,李士通 校)

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05).


評估葡萄糖初始分佈容積以評價液體衝擊中血漿容積

An Evaluation of the Initial Distribution Volume of Glucose to Assess Plasma Volume During a Fluid Challenge

Laurence van Tulder, MD, Burkhardt Michaeli, MD, René Chioléro, MD, Mette M. Berger, MD, PhD, and Jean-Pierre Revelly, MD

Surgical Intensive Care Unit, University Hospital, 1011 Lausanne, Switzerland

Anesth Analg 2005;101:1089-1093

 

迴圈血容量可以用葡萄糖初始分佈體積(IDVG)的方法來估計。在一個前瞻性觀察實驗中,我們評價了液體衝擊在個體病人中對IDVG的影響。在13個心臟手術後的病人中,分別在輸注羥乙基澱粉前和輸注7 mL/kg 30分鐘後測定IDVG11名不需要液體衝擊的病人作為對照組。運用單室指數模型,用5g葡萄糖靜注前和靜注後34567分鐘的血漿葡萄糖濃度,計算出IDVG。對照組的IDVG重複測定三次。IDVG在液體衝擊後並沒有變化(85±14 mL/kg93±14 mL/kgP = 0.08)。當P=0.05時可比度是0.25。葡萄糖指數冪對時間的回歸係數在澱粉輸注前是0.96±0.03,之後是0.95±0.04(沒有顯著性差異)。在對照組,IDVG90 ± 18 mL/kg,平均個體變異係數是0.15 ± 0.08IDVG看起來似乎不足以評價液體療法的個體反應。這個局限性可能與IDVG的可重複性差有關。

 (黃麗娜 馬皓琳,李士通 )

Circulation blood volume can be estimated with the initial distribution volume of glucose (IDVG) method. In a prospective, observational study, we evaluated the effect of a fluid challenge on IDVG in individual patients. In 13 patients after cardiac surgery, IDVG was determined before and after the infusion of 7 mL/kg hydroxyethyl starch over 30 min. Eleven patients not requiring a fluid challenge served as control. IDVG was computed with a one-compartment exponential model, using plasma glucose concentrations at baseline and 3, 4, 5, 6, and 7 min after 5 g of glucose IV bolus. IDVG was repeated 3 times in the control group. IDVG did not change after a fluid challenge (85 ± 14 versus 93 ± 14 mL/kg, P = 0.08), and the power of the comparison was 0.25 for a P value of 0.05. The regression coefficient of the exponential fit of glucose versus time was 0.96 ± 0.03 before, and 0.95 ± 0.04 after starch infusion (not significant). In the control group, IDVG was 90 ± 18 mL/kg, and the average individual coefficient of variation was 0.15 ± 0.08. IDVG seems inadequate to assess individual response to fluid therapy. This limitation may be related to the weak reproducibility of IDVG.


圍手術期疼痛管理技術對大鼠剖腹手術後食物消耗量和體重的影響

The Effects of Perioperative Pain Management Techniques on Food Consumption and Body Weight After Laparotomy in Rats

Yehuda Shavit, PhD*, Gila Fish, MSc*, Gilly Wolf, PhD C*, Eduard Mayburd, MD{dagger}, Ylia Meerson, MD{dagger}, Raz Yirmiya, PhD*, and Benzion Beilin, MD{dagger}

*Department of Psychology, Hebrew University, Jerusalem; and {dagger}Department of Anesthesiology, Rabin Medical Center, Golda–Hasharon Campus, Petah Tiqva, affiliated with the Sackler School of Medicine, Tel-Aviv University, Israel

Anesth Analg 2005;101:1112-1116

 

我們通過評估體重(BW)和食物消耗量(FC)來檢驗兩個圍手術期疼痛管理技術對剖腹手術後恢復的效應。所有大鼠術前鞘內給予嗎啡和布比卡因混合液,並且給予下列兩者之一:(a)術畢注射緩釋嗎啡或者(b)一種抗炎藥白介素-1受體拮抗劑(IL-1ra)聯合術前混合液。剖腹手術顯著減少FCBW。兩個鎮痛方法導致FCBW恢復較快。這種有益的作用在術前鎮痛聯合IL-1ra的組中更明顯。

(張曦 馬皓琳,李士通 校)

We examined the effects of two perioperative pain management techniques on recovery after laparotomy, as assessed by body weight (BW) and food consumption (FC). All rats received a preoperative intrathecal mixture of morphine plus bupivacaine combined with one of two treatments: (a) injection of slow-release morphine at the end of the surgery or (b) an antiinflammatory drug, interleukin-1 receptor antagonist (IL-1ra), combined with the preoperative mixture. Laparotomy significantly decreased FC and BW. Both analgesic treatments resulted in a faster recovery of FC and BW. This beneficial effect was more pronounced in the group receiving preoperative analgesics combined with IL-1ra.

 

 

七氟醚預處理可抑制大鼠內毒素誘發的休克

Sevoflurane Pretreatment Inhibits Endotoxin-Induced Shock in Rats

Yoko Kidani, MD*, Takumi Taniguchi, MD{dagger}, Hiroko Kanakura, MD*, Yasuhiro Takemoto, MD*, Kazunobu Tsuda, MD*, and Ken Yamamoto, MD*

Departments of *Anesthesiology and Intensive Care Medicine and {dagger}Emergency and Critical Care Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan

Anesth Analg 2005;101:1152-1156

 

作者觀察七氟醚預處理對內毒素致休克時死亡率和炎性反應的作用。將大鼠隨機分為4組(每組12只):內毒素組(靜脈注射大腸桿菌內毒素15 mg/kg 注射時間2 min);生理鹽水對照組(注射0.9%鹽水1.0 mL/kg);單用七氟醚組(在注射生理鹽水前吸入2.4%七氟醚30 min);七氟醚預處理組(在注射內毒素前吸入2.4%七氟醚30 min)。測定血流動力學參數、動脈血氣、血漿腫瘤壞死因數-a和白介素-6的濃度。觀察8小時死亡率。在注射內毒素前七氟醚預處理組,收縮壓和酸堿平衡得到改善。內毒素血症組、生理鹽水對照組、單用七氟醚組和七氟醚預處理組在注射內毒素後8小時的死亡率分別為83%8%0%25%。內毒素組的血漿細胞因數濃度明顯高於其他組。大鼠注射內毒素時七氟醚預處理可以抑制炎症反應和降低死亡率。

(趙雪蓮 馬皓琳,李士通 )

We examined the effects of sevoflurane pretreatment on mortality and inflammatory responses during endotoxin-induced shock. Rats were allocated randomly to 1 of 4 groups (n = 12 per group): an endotoxemia group, receiving IV Escherichia coli endotoxin (15 mg/kg over 2 min); a saline control group, receiving 0.9% saline (1.0 mL/kg); a sevoflurane-only group, receiving 2.4% sevoflurane for 30 min immediately before injection of 0.9% saline; and a sevoflurane pretreatment group, receiving 2.4% sevoflurane for 30 min immediately before injection of endotoxin. Hemodynamic variables, arterial blood gases, and plasma concentrations of tumor necrosis factor-{alpha} and interleukin-6 were measured. The 8-h mortality rate was determined. Systolic arterial blood pressure and acid-base balance improved with sevoflurane pretreatment before induction of endotoxemia. Mortality rates 8 h after endotoxin injection were 83%, 8%, 0%, and 25% for the endotoxemia, saline control, sevoflurane-only, and sevoflurane pretreatment groups, respectively. Plasma cytokine concentrations were significantly larger in the endotoxemia group than in the other groups. Sevoflurane pretreatment inhibited inflammatory responses and decreased mortality in rats exposed to endotoxin.


剖腹產病人優選的麻醉結果

Patient Preferences for Anesthesia Outcomes Associated with Cesarean Delivery

Brendan Carvalho, MBBCh, FRCA*, Sheila E. Cohen, MB, ChB, FRCA*, Steven S. Lipman, MD*, Andrea Fuller, MD*, Anbu D. Mathusamy, MD{dagger}, and Alex Macario, MD*

*Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and {dagger}Bronx-Lebanon Hospital, Bronx, New York

Anesth Analg 2005;101:1182-1187

 

當決定在區域麻醉下剖腹產(CS)使用椎管內給藥(如蛛網膜下腔阿片類藥物)時,麻醉醫生需要權衡減輕疼痛和副作用風險增加可能性來做出處理決定。以前沒有人研究產科病人的麻醉喜好。研究者向參加我們機構的准父母班的懷孕婦女進行了100份書面調查。我們用優先順序等級和相對值評分測定了特殊的術中和術後麻醉重要後果的病人喜好,同時研究病人對剖腹產及鎮痛藥的恐懼、關注和耐受度。100份調查中返回了82份進行分析。剖腹產過程中和其後的疼痛是最受關注的,其次是嘔吐、噁心、抽筋、瘙癢和顫抖。優先順序等級和相對值評分高度相關(R2 = 0.7)。病人在她們接受的鎮痛藥可能對她們的嬰兒有作用前能忍受視覺類比疼痛評分(0–100 mm56 ± 22的疼痛。與早先一般的外科手術群體噁心和嘔吐是最受關注的調查不同,我們發現剖腹產術中術後的疼痛是產婦最關心的。一般的副作用如瘙癢和顫抖只引起中度關注。這個資訊應該被用來指導麻醉選擇,如包括蛛網膜下腔阿片類藥物的足量應用。

(朱 馬皓琳,李士通 校)

When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients’ anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions’ expectant parent class. We determined patients’ preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients’ fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0–100 mm) of 56 ± 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients’ most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses.


鎖骨臂叢神經阻滯與肱骨入路麻醉時間與效果的比較

Infraclavicular Brachial Plexus Block Versus Humeral Approach: Comparison of Anesthetic Time and Efficacy

Vincent Minville, MD*, Roland Amathieu, MD*, N’Guyen Luc, MD*, Claude Gris, MD*, Olivier Fourcade, MD, PhD*, Kamran Samii, MD*, and Dan Benhamou, MD{dagger}

*Department of Anesthesiology and Intensive Care, Toulouse University Hospital, Paul Sabatier University, Toulouse, France; {dagger}Department of Anesthesiology and Intensive Care, Bicêtre University Hospital, Le Kremlin-Bicêtre, France

Anesth Analg 2005;101:1198-1201

 

大多數上臂的區域麻醉技術都是很成功的,其效力的區別並不能指導麻醉技術的選擇。本研究擬比較肱骨入路阻滯(HB)與鎖骨下臂叢神經阻滯(ICB),用麻醉時間(如操作時間+起效時間)作為主要的效果評估手段。手臂的四個主要神經達到完全感覺阻滯即說明此項阻滯是成功的。記錄下達到完全阻滯的時間。行上肢整形外科手術的病人入選此項前瞻隨機研究,分為ICB (In = 60例病人) HB (Hn = 60例病人)ICB組總的麻醉需要時間為19.5min(95%可信區間[CI], 17.4—21.6 min)HB組為20.8 min (95% CI, 18.7--22.9 min)。(無顯著性差異)。實施阻滯的時間,ICB組為4.5 min (95% CI, 4-5 min)HB 組為9.8 min (95% CI, 8.9-10.7 min) (P < 0.05)。起效時間,ICB組為15 min (95% CI, 13-17 min)HB 組為11 min (95% CI, 9--13 min) (P < 0.05)。成功率,ICB組為92%HB組為95%(無顯著性差異)。每組都有1例自限血管穿破。HB組起效時間更快,但是使用雙刺激的ICB組操作時間更快。兩組麻醉維持時間相似。

(邱鬱薇 馬皓琳,李士通 校)

Most upper arm regional anesthesia techniques are successful and differences in efficacy should not dictate the choice of technique. In the present study, we compared humeral block (HB) and infraclavicular brachial plexus block (ICB) using anesthetic time (i.e., duration of the procedure + onset time) as the primary outcome measure. The block was successful when a complete sensory block was obtained in the four major nerves of the arm, and the time to complete block was recorded. Patients undergoing orthopedic surgery of the upper limb were included in a prospective randomized study and received ICB (group I, n = 60 patients) or HB (group H, n = 60 patients). Total anesthetic time was 19.5 min (95% confidence interval [CI], 17.4—21.6 min) for ICB and 20.8 min (95% CI, 18.7--22.9 min) for HB (not significant). Time to perform the block was 4.5 min (95% CI, 4-5 min) for ICB and 9.8 min (95% CI, 8.9--10.7 min) for HB (P < 0.05). The onset time was 15 min (95% CI, 13-17 min) for ICB and 11 min (95% CI, 9--13 min) for HB (P < 0.05). The success rate was 92% for ICB and 95% for HB (not significant). One self-limited vascular puncture was made in each group. HB had a faster onset time but ICB using a double-stimulation technique was faster to perform. Anesthetic time was similar with the two techniques.


側臥位的氣道管理:一項隨機對照實驗

Airway Management in the Lateral Position: A Randomized Controlled Trial

Conan L. McCaul, FFARCSI*, Donal Harney, FCARCSI*, Margaret Ryan, FFARCSI*, Ciaran Moran, FFARCSI{dagger}, Brian P. Kavanagh, FRCPC{ddagger}, and John F. Boylan, FRCPC*

*Department of Anaesthesia and Intensive Care Medicine, St. Vincent’s University Hospital, Dublin, Ireland; {dagger}The Robert Jones Agnes Hunt Orthopedic Hospital, Oswestry, United Kingdom; and {ddagger}Division of Critical Care, Hospital for Sick Children, Toronto, Ontario, Canada

Anesth Analg 2005;101:1221-1225

 

在一些情況下可能需要確保側臥位元時氣道通暢。我們進行了一項前瞻性隨機臨床研究,研究左側臥位對氣道解剖和隨後的氣道管理的影響。對麻醉患者在仰臥位和左側臥位、環狀軟骨加壓或不加壓時用喉鏡檢查氣道。患者隨機分成氣管內插管和喉罩通氣道(LMA)氣道管理兩組。左側臥位使35%的患者喉鏡觀察到的氣道情況變差而無一例有改善。在側臥位時,氣管內插管與LMA相比,氣道管理失敗發生更多(8/391/30; P = 0.03),成功完成氣道管理的平均時間更長(39 ± 19 s26 ± 12 s; P = 0.002)。側臥位元時應用LMA進行氣道控制比氣管內插管更可靠。在該體位開始進行氣道管理時應把LMA作為首選的通氣道裝備。

(陳瑋 馬皓琳,李士通 審校)

It may be required to ensure patency of the airway in the lateral position in certain circumstances. We performed a prospective randomized clinical trial investigating the effects of left lateral patient positioning on airway anatomy and subsequent airway management. Laryngoscopic airway examination was performed in anesthetized patients, in the supine and left lateral positions, and in the presence and absence of cricoid pressure. Patients were randomized to airway management via an endotracheal tube or laryngeal mask airway (LMA). The left lateral position resulted in a deterioration of laryngoscopic view in 35% of patients and improvement in none. In the lateral position, failure of airway management occurred in more patients with the endotracheal tube versus LMA (8 of 39 versus 1 of 30; P = 0.03), and the mean time to successful completion of airway management was longer with tracheal intubation compared with the LMA (39 ± 19 s versus 26 ± 12 s; P = 0.002). LMA use results in more reliable airway control compared to tracheal intubation in the lateral position. The LMA should be considered as the primary airway device when instituting airway management in this position.


中重度氣管插管困難病人McCoy氣囊喉鏡檢查的評估

An Evaluation of McCoy Balloon Laryngoscopy in Patients With Moderate-to-Major Endotracheal Intubation Difficulty

Spyros D. Mentzelopoulos, MD, PhD, DEAA, Maria Tzoufi, MD, DEAA, Kostas Rellos, MD, PhD, Argyris S. Michalopoulos, MD, FCCM, FCCP, Elissavet Stamataki, MD, PhD, DEAA, Charris Roussos, MD, PhD, and Spyros G. Zakynthinos, MD, PhD

Departments of Intensive Care Medicine Henry Dunant General Hospital and Evaggelismos General Hospital, Athens, Greece.

Anesth Analg 2005;101:1233-1237

 

我們假設McCoy-氣囊複合喉鏡檢查較單獨的McCoy或氣囊喉鏡檢查使氣道管理更為便捷。10例實施了麻醉和肌松,先前插管困難評分大於5分的病人,McCoy複合氣囊喉鏡檢查較傳統/氣囊/McCoy喉鏡檢查使喉部的暴露面積更大(2.3 ± 0.60.6 ± 0.2/1.4 ± 0.4/1.5 ± 0.6 cm2),插管困難評分更低 (0.00 (0.00–0.00)6.00 (6.00–8.25)/1.50(0.00–4.00)/2.00(0.75–5.00),插管確認的時間要短9%–74% (所有的P < 0.05–0.001)。氣囊和McCoy喉鏡檢查較傳統的喉鏡檢查暴露和插管的條件均有提高。在中重度傳統氣道管理困難的病人中,McCoy複合氣囊喉鏡檢查進一步提高了喉鏡檢查暴露和插管的條件。

(張瑩 馬皓琳,李士通 校)

We hypothesized that combined McCoy-balloon laryngoscopy may facilitate airway management relative to McCoy or balloon laryngoscopy. In 10 anesthetized/paralyzed patients with prior intubation difficulty scale scores of >5, McCoy-balloon laryngoscopy versus conventional/balloon/McCoy laryngoscopies resulted in greater laryngeal aperture exposure (2.3 ± 0.6 versus 0.6 ± 0.2/1.4 ± 0.4/1.5 ± 0.6 cm2, respectively), lower intubation difficulty scale score (0.00 (0.00–0.00) versus 6.00 (6.00–8.25)/1.50(0.00–4.00)/2.00(0.75–5.00), respectively, median [interquartile range]), and 9%–74% shorter time to intubation confirmation (P < 0.05–0.001 for all). Balloon and McCoy laryngoscopies improved laryngoscopic/intubating conditions relative to conventional laryngoscopy. In patients with moderate-to-major conventional airway management difficulty, McCoy-balloon laryngoscopy further improves laryngoscopic/intubating conditions.

 

嗎啡誘導在體大鼠心臟的晚期心肌保護作用與阿片受體和核轉錄因數KappaB有關

Morphine Induces Late Cardioprotection in Rat Hearts In Vivo: The Involvement of Opioid Receptors and Nuclear Transcription Factor {kappa}B

Jan Frässdorf, MD, Nina C. Weber, PhD, Detlef Obal, MD, Octavian Toma, MD, Jost Müllenheim, MD, DEAA, Georg Kojda, MD, PharmD, Benedikt Preckel, MD, DEAA, and Wolfgang Schlack, MD, DEAA

Department of Anesthesiology, University Hospital of Düsseldorf, Düsseldorf, Germany

Anesth Analg 2005 101: 934-941.

 

Delta1阿片受體激動劑早期或者晚期預處理可以誘導明顯的心肌保護作用。在急性冠脈綜合症時嗎啡是最常用的鎮痛藥,因此在本研究中,作者研究了嗎啡晚期預處理是否能夠誘導心肌保護作用,同時觀察了這種作用是否與核轉錄因數KappaBNF-kappaB)的信號轉導有關。研究者分別用生理鹽水(NaCl0.9%5ml)、大腸桿菌脂多糖(LPS; 1 mg/kg)和嗎啡(MO,3 mg/kg)預處理,然後心肌局部缺血25min再灌注2小時。脂多糖是晚期預處理的觸發物,作為陽性對照組。納洛酮(NAL)用來觀察晚期預處理中阿片受體的作用,在生理鹽水,脂多糖或者嗎啡應用之前或者缺血再灌注前給藥。研究結果表明,在NaCl, NAL-NaCl,NaCl-NAL組梗死灶範圍分別為59% ± 9%, 51% ± 6%, 53%± 10%。嗎啡預處理後24h梗死灶範圍減少到20%± 6%MO-24H,並且這一作用可以被納洛酮取消(NAL-MO, 53% ± 14%MO-NAL, 60% ± 8%)。LPS預處理後梗死灶範圍縮至23% ± 8%。納洛酮在LPS應用前給藥不能拮抗LPS的作用(NAL-LPS 30% ± 16%),但是在缺血再灌注前給藥則能夠拮抗LPS的作用(LPS-NAL 54% ± 8%)。本研究同時應用Western blot電泳遷移率變動分析觀察了NF-kappaB在這其中的作用。結果發現嗎啡和LPS均可以提高抑制性蛋白kappaB的磷酸化,從而提高NF-kappaB的活性。總之,嗎啡誘導的晚期預處理與LPS相似,其心肌保護作用至少一部分是啟動了NK-kappaB。阿片受體在嗎啡和LPS誘導的晚期預處理中都有作用,但是只有在嗎啡誘導的晚期預處理中具有觸發的作用。

蘇殿三譯 陳傑 校)

{delta}1-opioid receptor agonists can induce cardioprotection by early and late preconditioning (LPC). Morphine (MO) is commonly used for pain treatment during acute coronary syndromes. We investigated whether MO can induce myocardial protection by LPC and whether a nuclear transcription factor {kappa}B (NF-{kappa}B)-dependent intracellular signaling pathway is involved. Rats were subjected to 25 min of regional ischemia and 2 h of reperfusion 24 h after treatment with saline (NaCl; 0.9% 5 mL), lipopolysaccharide of Escherichia coli (LPS; 1 mg/kg), or MO (3 mg/kg). LPS is a trigger of LPC and served as positive control. Naloxone (NAL) was used to investigate the role of opioid receptors in LPC and was given before NaCl, LPS, or MO application (trigger phase) or before ischemia-reperfusion (mediator phase). Infarct size (percentage area at risk) was 59% ± 9%, 51% ± 6%, or 53% ± 10% in the NaCl, NAL-NaCl, and NaCl-NAL groups, respectively. Pretreatment with MO reduced infarct size to 20% ± 6% after 24 h (MO-24h), and this effect was abolished by NAL in the trigger (NAL-MO, 53% ± 14%) and in the mediator (MO-NAL, 60% ± 8%) phases. Pretreatment with LPS reduced infarct size to 23% ± 8%. NAL administration in the trigger phase had no effect on infarct size (NAL-LPS 30% ± 16%), whereas NAL during the mediator phase of LPC abolished the LPS-induced cardioprotection (LPS-NAL 54% ± 8%). The role of NF-{kappa}B in morphine-induced LPC was investigated by Western blot and electrophoretic mobility shift assay. Morphine and LPS treatment increased phosphorylation of the inhibitory protein {kappa}B, leading to an increased activity of NF-{kappa}B. Thus, MO induces LPC similarly to LPS and it is likely that this cardioprotection is mediated at least in part by activation of NF-{kappa}B. Opioid receptors are involved as mediators in both MO- and LPS-induced LPC but as triggers only in MO-induced LPC.

 

麻醉恢復期西羅莫司塗抹冠脈支架內的血栓形成

Thrombosis of Sirolimus-Eluting Coronary Stent in the Postanesthesia Care Unit

J. Thomas Murphy, MD, FRCPC, and Brenda G. Fahy, MD

Department of Anesthesiology, University of Kentucky College of Medicine Lexington, Kentucky

Anesth Analg 2005 101: 971-973.

一名44歲的婦女在放置藥物塗抹冠脈支架後兩周行子宮切除術,結果在麻醉復蘇階段突發生心肌梗死,最終不治身亡。她在術前僅僅停服了一次阿司匹林和氯吡格雷。如能早期發現亞急性冠脈支架血栓並緊急行經皮冠脈處理,也許能避免她的死亡。在本例報導中,作者主要強調圍術期冠脈支架應用中的問題及其可能造成的影響。

(鄭擁軍譯 陳傑校)

A 44-yr-old woman with a drug-eluting coronary stent placement two weeks before surgery suffered a myocardial infarction in the postanesthesia care unit immediately after hysterectomy. She had missed only one dose of aspirin and clopidogrel preoperatively. Early recognition of subacute stent thrombosis and urgent percutaneous coronary intervention probably prevented her death. In this case report, we highlight perioperative coronary stent issues and discuss their implications.

 

兒童頸部伸展時氣管長度伸長對氣管內導管安全的意義

Elongation of the Trachea During Neck Extension in Children: Implications of the Safety of Endotracheal Tubes

Kim Jin-Hee, MD*, Young-Jin Ro, MD{dagger}, Min Seong-Won, MD{dagger}, Kim Chong-Soo, MD{dagger}, Kim Seong-Deok, MD*, Jun Ho Lee, MD{ddagger}, and Bahk Jae-Hyon, MD*

*Department of Anesthesiology, Seoul National University Medical College; {dagger}Departments of Anesthesiology and {ddagger}Otolaryngology, Seoul City Boramae Hospital, Korea

Anesth Analg 2005 101: 974-977.

 

兒童頸部伸展時,因為氣管的延長,氣管導管頭部(ETT)與氣管隆突之間距離的變化不等同於ETT與聲帶之間距離的變化。上述距離的變化與氣管導管脫出的危險性之間具有密切關係。本研究以25名兒童(年齡在2-8歲)為研究物件,全麻期間保持其頭位於中位,頸部充分伸展,應用纖維支氣管鏡測量ETT頭部與聲帶之間的距離。纖維支氣管鏡分別測量兒童頭部位於中位和頸部充分伸展兩種狀態下氣管導管長度變化。氣管長度減去ETT頭部和隆突之間的距離得到聲帶和ETT頭部之間的距離。頸部充分伸展後,氣管的平均長度為(7.97 ± 0.85 cm),平均增加0.95 ± 0.43 cm,聲帶和ETT頭部之間的距離變化為–1.08 ± 0.47 cm,然而ETT頭部和隆突之間的距離變化為2.02 ± 0.58 cm。上述結果表明頸部的充分伸展確實可改變ETT尖端與聲帶之間的相對位置,從而增加較年長兒童氣管導管脫出的危險性,但ETT尖端到聲帶實際移位由於氣管的延長而減少。

(鄭擁軍譯 陳傑校)

During neck extension, the changes in distance between endotracheal tube (ETT) tip and carina may not be equal to the changes in distance between vocal cords and ETT tip because of tracheal elongation. These distances are directly related to extubation risk. Using a fiberoptic bronchoscope, the distance between ETT tip and carina was measured in the neutral position after full extension of the neck in 25 children (2–8 yr old) scheduled for elective surgery under general anesthesia. The tracheal length was then measured in the neutral position and after full extension. The distance between vocal cords and ETT tip was calculated as the tracheal length minus the distance between ETT tip and carina. After full extension, the tracheal length (7.97 ± 0.85 cm) was increased by 0.95 ± 0.43 cm, and the change in distance between vocal cords and ETT tip was –1.08 ± 0.47 cm, whereas the change in distance between ETT tip and carina was 2.02 ± 0.58 cm. These results suggest that neck extension actually displaces the ETT tip to the vocal cords, increasing the risk of tracheal extubation in older children, although the actual displacement of ETT tip to vocal cords is reduced by tracheal lengthening.

 

月經黃體期增加的黃體酮可減少麻醉藥物的需要量

Increased Progesterone Production During the Luteal Phase of Menstruation May Decrease Anesthetic Requirement

Veysel Erden, MD*, Zehra Yangin, MD*, Kerem Erkalp, MD*, Hamdi Delatioglu, MD*, Feyza Bahçeci, MD*, and Ayse Seyhan, MD{dagger}

*Departments of Anesthesiology and {dagger}Obstetrics/Gynecology, SSK Vakif Gureba Hospital, Istanbul, Turkey

Anesth Analg 2005 101: 1007-1011

..

黃體酮除了具有重要的激素作用,對大腦還具有鎮靜和催眠效應。在該研究中,作者就黃體酮水平較低的卵泡期的婦女和黃體酮水平較高的黃體期的婦女對麻醉藥物的需要量進行了比較。該研究包括處於月經週期第1-10天(卵泡期)和第18-24天(黃體期)的病人各20名。麻醉誘導用芬太尼和硫噴妥,羅庫溴銨保證肌松,NO2 2L/minO2 2L/min和七氟醚維持麻醉,調節七氟醚濃度使兩組病人的腦電雙頻指數平均數值均維持在46。術前所有病人均抽取血液以測定黃體酮水平。作者發現卵泡組和黃體組的黃體酮水平分別為0.86 ± 0.30 ng/mL7.48 ±3.86 ng/mL。七氟醚的最低肺泡濃度(MAC-h在卵泡組(1.55 ± 0.18 MAC-h)顯著大於黃體組(1.3 ± 0.13 MAC-h) (P < 0.0001)。卵泡組的麻醉維持期七氟醚需要量較大。結論:黃體期較高的黃體酮水平可能是麻醉藥用量較少的原因。

(趙延華譯 陳傑校)

Besides having important hormonal effects, progesterone has depressant and hypnotic effects on the brain. In this study, we compared women in the follicular phase with low progesterone levels and in the luteal phase with high progesterone levels regarding their anesthetic requirements. Twenty patients with menstrual cycle days from 1 to 10 (follicular group) and 20 patients with menstrual cycle days from 18 to 24 (luteal group) were included in the study. Anesthesia was induced with fentanyl and thiopental; relaxation was secured with rocuronium, and anesthesia was maintained with a mixture of nitrous oxide 2 L/min and oxygen 2 L/min plus sevoflurane. The delivered sevoflurane concentration was adjusted to sustain a constant bispectral index value that averaged 46 in both groups. To determine the progesterone levels, blood samples were taken from all patients before surgery. We found that progesterone levels were 0.86 ± 0.30 ng/mL in the follicular group and 7.48 ± 3.86 ng/mL in the luteal group. The minimum alveolar anesthetic concentration (MAC)-hour (MAC-h) value of sevoflurane in the follicular group (1.55 ± 0.18 MAC-h) was significantly larger than in the luteal group (1.3 ± 0.13 MAC-h) (P < 0.0001). The sevoflurane requirements were larger in the follicular group during the maintenance phase of anesthesia. In conclusion, high progesterone levels during the luteal phase might be the cause of decreased anesthetic requirement.



不同效應部位半數平衡時間參數對預測效應部位七氟醚濃度的影響:一項模擬研究

The Effect of Using Different Values for the Effect-Site Equilibrium Half-Time on the Prediction of Effect-Site Sevoflurane Concentration: A Simulation Study

R. Ross Kennedy, MB, ChB, PhD FANZCA

Department of Anaesthesia, Christchurch Hospital & Christchurch School of Medicine and Health Sciences, Christchurch, New Zealand

Anesth Analg 2005 101: 1023-1028.

 

作者實驗室的一項預測性研究中曾將吸入麻醉藥的效應部位濃度(Ceff)作為吸入治療的靶目標。Ceff是由血漿效應部位半數平衡時間[t1/21/2ke0]決定的。在該項預測性研究中,t1/2ke0)是固定的,與患者的實際值有偏差。本研究的目的旨在探討這種偏差對Ceff預期值的影響。應用電腦類比模型,調整新鮮氣流量及揮發罐設置,使t1/2ke0)分別為2.53.55分鐘,以達到數個不同預期的Ceff值。應用每次類比的呼氣末參數和t1/2ke0),重新計算Ceff值。分別計算預測點的最大偏離度,總體吻合度,及復蘇延遲時間。當預測性研究中t1/2ke0)為3.5分鐘時,Ceff的最大偏離度為0.18vol%,發生在洗入階段,並在2-3分鐘內消失。Ceff1.0降至0.7vol%的時間差異為1.3分鐘。當顯示出的t1/2ke0)為2.5分鐘,模擬出的患者t1/2ke0)為5分鐘,或前者為5分鐘,後者為2.5分鐘時,Ceff結果近似相差兩倍。這些結果提示,Cefft1/2ke0)的較大偏離(50%-100%)時相對不敏感。

(田婕 陳傑 校)

We have developed a predictive display that allows effect-site concentration (Ceff) to be used as a target for administration of inhaled anesthesia. Ceff is dependent on the half-time for plasma effect-site equilibrium [t1/21/2(ke0)]. The t1/2(ke0) used in the predictive display is fixed and may differ from that in the patient. We wished to explore the effect of this difference on predictions of Ceff. In a computer simulation, fresh gas flow and vaporizer settings required to achieve a predefined time profile for Ceff were determined for t1/2(ke0) of 2.5, 3.5, and 5 min. The end-tidal values for each simulation were used to recalculate Ceff with each t1/2(ke0). The maximal deviation at predetermined points, measures of global fit, and the delay in "recovery" were calculated. With a predictive display t1/2(ke0) of 3.5 min, the maximal error in Ceff was 0.18 vol%, occurring during the wash-in phase and disappearing within 2–3 min. The difference in time for Ceff to decrease from 1.0 to 0.7 vol% was 1.3 min. Results with a display t1/2(ke0) of 2.5 min or 5 min and simulated patient t1/2(ke0) of 5 min or 2.5 min were approximately twice as large. These results suggest that Ceff is relatively insensitive to large (50%–100%) variations in t1/2(ke0).

 

長期使用氫離子拮抗劑治療的病人麻醉前使用質子泵抑制劑的有效性

The Efficacy of Preanesthetic Proton Pump Inhibitor Treatment for Patients on Long-Term H2 Antagonist Therapy

Kazuyoshi Hirota, MD, Mihoko Kudo, MD, Hiroshi Hashimoto, MD, and Tetsuya Kushikata, MD

Department of Anesthesiology, University of Hirosaki School of Medicine, Japan

Anesth Analg 2005 101: 1038-1041

.

作者曾報導了長期使用氫離子拮抗劑(療程大於4周)的病人,麻醉前使用氫離子拮抗劑耐受。本次研究,作者評價了長期規則使用氫離子拮抗劑(口服法莫替丁,療程大於4周)治療的病人,麻醉前使用質子泵抑制劑(PPI;口服雷貝拉唑)的有效性。48位擇期手術的病人假設能夠完全耐受氫離子拮抗劑,隨機分為兩組,一組接受PPI(口服雷貝拉唑20mgn24),另一組接受質子泵抑制劑(口服羅沙替丁75mgn24),服藥時間分別為,術前一天晚上9點和麻醉誘導前2小時。於麻醉誘導後,分別測量胃內容量和PH值。PPI組的胃內PH值為(5.38±2.42)較氫離子拮抗劑組(3.27±1.98P<0.01)明顯增高。PPI組的胃內容量為(8.6±1.5mL)較氫離子拮抗劑組(15.4±2.8mLP<0.05cf.PPI)明顯少。氫離子拮抗劑組有14位病人有產生酸性吸入性肺炎的危險(胃內PH<2.5或容量>25mL),而PPI組僅有4位病人存在此風險(P<0.05)。這些資料表明長期使用氫離子拮抗劑(療程大於4周)的病人,預防酸性吸入性肺炎應包括麻醉前使用PPI

(肖潔 陳傑 校)

We previously reported that H2-antagonist medication given for longer than 4 wk may produce complete tolerance to preanesthetic H2 antagonist therapy. In this study, we evaluated the efficacy of preanesthetic proton pump inhibitor (PPI; oral rabeprazol) use in patients receiving regular H2-antagonist (oral famotidine) therapy for more than 4 wk. Forty-eight patients with assumed complete tolerance to H2 antagonists undergoing elective surgery were recruited and randomly assigned to receive either a preanesthetic PPI (rabeprazol 20 mg; n = 24) or H2-antagonist (H2 group; roxatidine 75 mg; n = 24) at 9:00 pm on the day before surgery and 2 h before the induction of anesthesia. Volume of gastric contents and pH values were measured after the induction of anesthesia. Gastric pH value in the PPI group (5.38 ± 2.42) was significantly higher than in the H2 group (3.27 ± 1.98; P < 0.01). Gastric volume in the PPI group (8.6 ± 1.5 mL) was significantly smaller than in the H2 group (15.4 ± 2.8 mL; P < 0.05; cf. PPI). Fourteen patients in the H2 group were at risk of acid aspiration pneumonia (gastric pH <2.5 or volume >25 mL), whereas only four patients in the PPI group (P < 0.05) were at risk. These data suggest that in patients receiving H2-antagonist therapy for longer than 4 wk, prophylaxis for acid aspiration pneumonia should include preanesthetic PPI medication.

 

靜脈麻醉劑對肥大細胞功能的抑制作用

Inhibitory Effects of Intravenous Anesthetics on Mast Cell Function

Takahiro Fujimoto, MD, PhD, Tomoki Nishiyama, MD, PhD, and Kazuo Hanaoka, MD, PhD

Department of Anesthesiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Anesth Analg 2005 101: 1054-1059.

 

肥大細胞在炎症和自身組織損傷中起保護作用。肥大細胞功能受損可能會影響機體對感染的防禦機制。本文研究四種靜脈麻醉劑(硫噴妥鈉,咪唑安定,氯胺酮,異丙酚)對肥大細胞趨化性和胞吐作用的影響。利用P物質100μg/ml作為刺激物,通過博伊登技術測定犬肥大細胞的趨化性。利用P物質或伽瑪單體的IgG介導的交聯作為刺激物通過測定肥大細胞釋放的組胺評估肥大細胞的胞吐作用。硫噴妥鈉,咪唑安定和異丙酚對肥大細胞的趨化性產生劑量依賴的抑制作用。氯胺酮,咪唑安定和異丙酚對肥大細胞的胞吐作用產生劑量依賴的抑制作用。總之,咪唑安定和異丙酚對肥大細胞的趨化性和胞吐作用都有抑制作用,而硫噴妥鈉僅抑制肥大細胞的趨化性,氯胺酮僅抑制肥大細胞的胞吐作用。

(朱輝 陳傑 校)

Mast cells play a protective role in the inflammation and auto-tissue injury. The impairment of mast cell function may influence defense against infection. We investigated the effect of four IV anesthetics (thiopental, midazolam, ketamine, and propofol) on the chemotaxis and exocytosis of mast cells. Canine mast cell chemotaxis was measured by the Boyden's blindwell chamber technique using 100 µg/mL of substance P as a stimulator. We measured mast cell exocytosis by measuring released histamine from mast cells using substance P or gamma-monomeric IgG-mediated crosslinking as a stimulator. Thiopental, midazolam, and propofol exerted a dose-dependent inhibitory effect on mast cell chemotaxis. Ketamine, midazolam, and propofol had a dose-dependent inhibitory effect on mast cell exocytosis. In conclusion, midazolam and propofol inhibited both chemotaxis and exocytosis of mast cells, while thiopental only inhibited chemotaxis, and ketamine only inhibited exocytosis.

 

一項非脂化丙泊酚和含中鏈甘油三脂的丙泊酚乳劑所引起注射疼痛的比較研究

Pain on Injection of Lipid-Free Propofol and Propofol Emulsion Containing Medium-Chain Triglyceride: A Comparative Study

Prakash K. Dubey, MD, and Arun Kumar, MD

Department of Anesthesiology & Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, India

Anesth Analg 2005 101: 1060-1062.

丙泊酚引起的注射疼痛一直是麻醉醫生關注的問題。目前,在印度市場上,非脂化丙泊酚和含中鏈甘油三脂的丙泊酚乳劑均可供選擇。本研究的目的是對含中鏈甘油三脂的丙泊酚乳劑和非脂化丙泊酚所引起的注射疼痛進行評估。130名成年病人被隨機分為兩組:組I病人給予含中鏈甘油三脂的丙泊酚乳劑;組II病人給予非脂化丙泊酚。計算所得的總的誘導劑量的四分之一經病人手背最大的靜脈注射完成,注射時間超過5s。注射疼痛的評估主要是根據病人的言語反應和行為特徵。結果兩種製劑的丙泊酚均可引起注射疼痛。然而,與含中鏈甘油三脂的丙泊酚乳劑(40%)相比,非脂化丙泊酚所引起的注射疼痛更常見(89%)、更嚴重。

(齊波 陳傑 校)

Pain on injection of propofol continues to be a problem for anesthesiologists. A lipid-free formulation of propofol and a propofol emulsion containing medium-chain triglyceride have become available in the Indian market. We performed this study to assess the pain on injection of propofol emulsion containing medium-chain triglyceride as the lipid carrier and lipid-free propofol formulation. One-hundred-thirty adult patients were randomly assigned to one of two groups: Group I received propofol emulsion containing medium-chain triglyceride and Group II received lipid-free propofol. One fourth of the total calculated induction dose was injected over 5 s in the largest vein on the dorsum of a hand. Pain was assessed using verbal response and behavioral signs. Both formulations caused pain on injection. However, the lipid-free propofol solution produced frequent (89%) and severe pain on injection compared with the emulsion containing medium-chain triglyceride (40%).

 

麻醉學中以類比為基礎的評估演示的可行性

The Feasibility of Sharing Simulation-Based Evaluation Scenarios in Anesthesiology

Haim Berkenstadt, MD*{dagger}, Gareth S. Kantor, MD{ddagger}, Yakov Yusim, MD{dagger}, Naomi Gafni, PhD§, Azriel Perel, MD{dagger}, Tiberiu Ezri, MD||¶, and Amitai Ziv, MD

*The Israel Center for Medical Simulation (M.S.R.,1); {dagger}Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Hashomer, Israel; {ddagger}Department of Anesthesiology, University Hospitals of Cleveland, Cleveland, Ohio; §The National Institution for Testing and Evaluation, Jerusalem, Israel; ||Department of Anesthesiology, Edith Wolfson Medical Center, Holon, Israel; and ¶Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel

Anesth Analg 2005 101: 1068-1074.

 

儘管存在語言、教育和麻醉實踐背景的不同,作者在以色列,應用美國多學會聯合組織驗證體系,前瞻性評估以模擬實驗為基礎的評估方法在全球應用的可行性。31名以色列的低年資住院醫生進行了4次類比演示。培訓期被錄影,並且以兩名獨立的等級評定人運用兩個有效的評分系統對他們的表現進行評估。長表格的得分範圍從379570±12),總分為108,短表格的得分從18 35( 28±4.5),總分為4061%的參與者評分大於總分的70%,而原先US 的研究僅為5%80%的參與者認為演練的等級評定是符合實際的(1-4 級中為4 級)。通過長表格0.66的可信區間和短表格0.75的可信區間原先評價手段的可信度被證實。先前研究的值在長表格為0.72-0.76 ,短表格為0.71-0.75。當修訂的以色列的翻譯版本被應用時,結果仍是可信的。Pearson 集合的相互作用的可信度分析在長表格為0.91,短表格為0.96p<0.01)。對演示的高分解釋和與先前評估方法的相似性都說明在美國和以色列得到改進的以模擬為基礎的評估方法的可行性。以色列住院醫生的高分可能與以色列住院醫生多為先前受過麻醉培訓的移民有關。

(忻紀華 陳傑 校)

We prospectively assessed the feasibility of international sharing of simulation-based evaluation tools despite differences in language, education, and anesthesia practice, in an Israeli study, using validated scenarios from a multi-institutional United States (US) study. Thirty-one Israeli junior anesthesia residents performed four simulation scenarios. Training sessions were videotaped and performance was assessed using two validated scoring systems (Long and Short Forms) by two independent raters. Subjects scored from 37 to 95 (70 ± 12) of 108 possible points with the "Long Form" and "Short Form" scores ranging from 18 to 35 (28.2 ± 4.5) of 40 possible points. Scores >70% of the maximal score were achieved by 61% of participants in comparison to only 5% in the original US study. The scenarios were rated as very realistic by 80% of the participants (grade 4 on a 1–4 scale). Reliability of the original assessment tools was demonstrated by internal consistencies of 0.66 for the Long and 0.75 for the Short Form (Cronbach {alpha}statistic). Values in the original study were 0.72–0.76 for the Long and 0.71–0.75 for the Short Form. The reliability did not change when a revised Israeli version of the scoring was used. Interrater reliability measured by Pearson correlation was 0.91 for the Long and 0.96 for the Short Form (P < 0.01). The high scores for plausibility given to the scenarios and the similar reliability of the original assessment tool support the feasibility of using simulation-based evaluation tools, developed in the US, in Israel. The higher scores achieved by Israeli residents may be related to the fact that most Israeli residents are immigrants with previous training in anesthesia.

 

伊拉克戰爭中士兵受傷的表現,診斷,損傷機制和治療:在兩所軍事疼痛治療中心進行的一項流行病學研究

Presentation, Diagnoses, Mechanisms of Injury, and Treatment of Soldiers Injured in Operation Iraqi Freedom: An Epidemiological Study Conducted at Two Military Pain Management Centers

LTC Steven P. Cohen, MD*{ddagger}, MAJ Scott Griffith, MD{dagger}{ddagger}, LTC Thomas M. Larkin, MD{dagger}{ddagger},, MAJ Felipe Villena, DO§, and Ralph Larkin, PhD

*Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore; {dagger}Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, Maryland; {ddagger}Department of Anesthesiology, Walter Reed Army Medical Center, Washington, DC; §Pain Management Center, Landstuhl Regional Army Medical Center, Landstuhl, Germany; and ¶John Jay College of Criminal Justice of the City University of New York

Anesth Analg 2005 101: 1098-1103.

在近期的軍事衝突中,士兵減員的主要原因不是戰鬥損傷,大多數常見的原因卻與發生在國內生活中的相類似。為瞭解戰時影響士兵的疼痛原因,作者對162名士兵進行了觀察性研究,這些人都是由於身體原因而從伊拉克戰場上撤離的,在遠離戰爭威脅的兩大軍事疼痛治療中心進行治療。53%的士兵存在根性的(n=49)或軸性的(n=37)下背部疼痛,腰椎間盤突出是最常見的原因(24%)。兩種最多見的發病原因是以前手術治療後病情惡化 (15%)和摩托車事故(12%)。僅有17%的病人是在戰鬥中受傷的。72%的士兵至少接受了一次神經阻滯/注射,最多的是腰硬膜外類固醇激素治療(22%)。56%的病人服用非甾體類抗炎藥,49%的病人服用阿片類藥物,17%的病人接受了其他形式的治療。在49名可獲得資料的病人中,僅有2%回到了伊拉克服役。排除戰爭相關損傷,現代戰爭期間疼痛原因與發生在國內的相類似。為了提高好轉後返回服役的比例,建議前線部署的醫療機構進行更好的預防和更積極的治療。

(殷文淵譯 陳傑 校)

In recent military conflicts the major source of soldier attrition has not been battle injuries but more mundane causes similar to those encountered in civilian life. In an effort to determine the pain conditions affecting soldiers during wartime, we conducted an observational study among 162 soldiers medically evacuated from Operation Iraqi Freedom who were referred to 2 large pain treatment centers located outside the theaters of combat. Fifty-three percent of soldiers presented with either radicular (n = 49) or axial (n = 37) low back pain, with lumbar herniated disk being the most frequently diagnosed condition (24%). The two most implicated etiologies were exacerbation of a previous pain condition treated with surgery (15%) and motor vehicle accidents(12%). Only 17% of patients were injured during battle. Seventy-two percent of soldiers received at least one nerve block/injection, the most common of which was lumbar epidural steroid administration (22%). Nonsteroidal antiinflammatory drugs were prescribed to 56% of patients, opioids to 49%, and some form of alternative therapy to 17%. Among the 49 patients in whom data were available, only 2% returned to combat duty in Iraq. With the exception of battle-related injuries, the pain conditions suffered during modern warfare seem to be similar to those encountered in civilian pain clinics. To improve the return-to-duty rate, better preventive measures and more aggressive treatment conducted in forward-deployed medical units are recommended.

 

嗎啡能夠誘導免疫抑制性淋巴細胞凋亡:真的嗎?

Immunosuppression by Morphine-Induced Lymphocyte Apoptosis: Is It a Real Issue?

Takeshi Ohara, MD*, Tsunetoshi Itoh, MD{dagger}, and Masahiko Takahashi, MD{ddagger}

*Division of Pain Control, Department of Anesthesiology and Emergency Medicine, and {dagger}Division of Immunology and Embryology, Department of Cell Biology, Tohoku University Graduate School of Medicine, and {ddagger}Division of Dento-oral Anesthesiology, Department of Oral Medicine and Surgery, Tohoku University Graduate School of Dentistry, Sendai, Japan

Anesth Analg 2005 101: 1117-1122.

 

嗎啡是治療癌痛的良好藥物,然而最近不少文獻報導嗎啡會引起外周血淋巴細胞(PBLs)的凋亡,引起廣泛的關注。在本研究中作者評估嗎啡是否會引起體外培養的PBLs凋亡。通過流式細胞檢測分析表面磷脂酰絲氨酸和核碎片來檢測凋亡,並在流式細胞儀器的光散射基礎上分析Fas, Bcl-2, Caspase-3 活性。從健康機體分離出外周血單核細胞並且以鬼臼乙叉甙、嗎啡或培養基培養48小時。在和鬼臼乙叉甙共同培養過程中,PBLs中顯著誘導出凋亡過程,細胞存活沒有超過48小時。與之相比,在整個培育期間嗎啡沒有對凋亡過程產生顯著影響。此外,在嗎啡和Fas-特異抗體共同培養沒有增加凋亡細胞率。實驗結果未證明嗎啡引起免疫抑制導致淋巴細胞凋亡。在沒有更多的研究證明之前,作者認為嗎啡仍然是一種理想的止痛劑。

(潘志英 陳傑 校)

Morphine has been an optimal choice for cancer pain management. However, several recent studies suggested that morphine induces apoptosis in human peripheral blood lymphocytes (PBLs), raising a serious concern about the use of opioid-based analgesic strategies. In this study, therefore, we aimed to evaluate whether morphine induced apoptosis in cultured human PBLs. Apoptotic events were assessed by flow-cytometrical detection of surface phosphatidylserine and nuclear fragmentation, as well as Fas, Bcl-2, and Caspase-3 activity in PBLs gated on a light-scatter basis. Peripheral blood mononuclear cells isolated from healthy subjects were cultured with etoposide, morphine, or vehicle (medium) for 48 h. During co-culture with etoposide, apo-ptosis was significantly induced in PBLs, and the cells did not survive for 48 h. In comparison, morphine had no effect on the expression rate of any of the detected molecules, suggesting that no apparent apoptotic processes were induced during the incubation. Furthermore, co-incubation with a Fas-specific antibody did not increase apoptotic cell rates in the morphine cultures. These results do not support the hypothesis that morphine directly modulates PBL apoptosis resulting in immunosuppression. We believe that the choice of opioids for optimal pain relief should not be discouraged until further studies clarify this issue.

 

 

生物和化學緊急事件的準備-------美國麻醉住院醫生培訓的調查

Emergency Preparedness for Biological and Chemical Incidents: A Survey of Anesthesiology Residency Programs in the United States

Keith A. Candiotti, MD, Aimee Kamat, MD, Paul Barach, MD, MPH, Fani Nhuch, MD, David Lubarsky, MD, MBA, and David J. Birnbach, MD

Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami School of Medicine, Miami, Florida

Anesth Analg 2005 101: 1135-1140.

作者調查了專業醫務人員處理病人暴露于危險物品時臨床處理問題,包括大規模毀滅性武器(WMD)。對WMD的訓練被認為是公共健康政策和準備狀態的一個重要部分。儘管這些情況罕見,但一旦發生,將造成大規模傷亡。在許多大規模傷亡處理的例子中,麻醉醫生有責任在病人到達醫院後立即處理。作者調查了美國麻醉住院醫生培訓規劃提供的麻醉醫生對WMD的保護性調整及病人處理的訓練程度。資訊是通過所有培訓點的主管及主席的聯機線上調查獲得的。調查135家麻醉培訓所,其中90家(67%)作出回答。其中只有37%有一些培訓形式,而且其中最初的培訓之後不再重複訓練。密西西比河以東地區28%的培訓點有一些訓練形式,以西地區則只有17%提供培訓。根據調查顯示大多數美國麻醉住院醫生培訓中提供處理WMD下病人的訓練很少甚至沒有。

(顧新宇譯 陳傑校)

We surveyed health care professionals about their preparations to manage the clinical problems associated with patients exposed to hazardous substances, including weapons of mass destruction (WMD). Training for WMD is considered a key part of public health policy and preparedness. Although such events are rare, when they do occur, they can cause mass casualties. In many models of mass casualty management, anesthesiology personnel are responsible for treating patients immediately on arrival at the hospital. We studied the extent of training offered to anesthesiology personnel in the use of WMD protective gear and patient management in United States (US) anesthesiology residency programs. Information was obtained via an online survey to all program directors and chairpersons of anesthesiology programs. We polled all of the 135 US anesthesiology programs of which 90 (67%) responded. Only 37% had any form of training, and many of them did not repeat training after initial sessions. Twenty-eight percent of programs east of the Mississippi River reported some form of training whereas only 17% of programs west of it reported training available. The majority of anesthesia residency programs in the US that responded to our survey provided little or no training in the management of patients exposed to WMD.

 

損傷前或後應用利多卡因或硫賁妥鈉來減弱無氧-糖的大鼠海馬切片培養的細胞死亡

Pre- or Postinsult Administration of Lidocaine or Thiopental Attenuates Cell Death in Rat Hippocampal Slice Cultures Caused by Oxygen-Glucose Deprivation

Hong Cao, MD*{ddagger}§, Ira S. Kass, PhD*{dagger}{ddagger}, James E. Cottrell, MD*, and Peter J. Bergold, PhD{dagger}

Departments of *Anesthesiology and {dagger}Physiology & Pharmacology, State University of New York Downstate Medical Center, Brooklyn, New York; {ddagger}Department of Anesthesiology, Xuzhou Medical College, Jiangsu Province; and §Anesthesiology Department, Second Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang Province, People’s Republic of China

Anesth Analg 2005 101: 1163-1169.

在低氧和缺血期間應用利多卡因或硫賁妥鈉能改善恢復;但損傷前或後的治療效應尚不得而知。作者在20天齡的大鼠無氧-糖(OGD)損傷前或後10分鐘的海馬培養切片中給予利多卡因或硫賁妥鈉。用PI螢光作為OGD7天內神經元死亡的觀測指標。在海馬CA1區和齒狀回區OGD誘導的神經元死亡,均在缺血後一天達到高峰。損傷前給利多卡因(10100µM)或硫賁妥鈉(250, 600µM)顯著減弱OGD12天的損傷;這兩個藥物同樣顯著降低兩側大腦OGD後每日的 PI。損傷後給藥顯著降低OGD後一天的PI,同樣也減弱了總計日常OGDPI。這些資料提示,OGD之前或之後給予利多卡因或硫賁妥鈉,能在這種腦缺血離體模型減弱神經元的損傷。缺血後給藥往往是治療的第一先機。

(範穎暉 陳傑 校)

Lidocaine and thiopental improve recovery when administrated during hypoxia and ischemia; however, the effect of pre- or postinsult treatment alone is unknown. We applied either lidocaine or thiopental to hippocampal slice cultures from 20-day-old rats either before or after 10 min of oxygen-glucose deprivation (OGD). Propidium iodide (PI) fluorescence was used as an indicator of neuronal death for 7 days after OGD. OGD-induced neuronal death, in both the Cornus Ammonis 1 (CA1) and the dentate gyrus regions, peaked the first day after ischemia. Preinsult administration of either lidocaine (10, 100 µM) or thiopental (250, 600 µM) significantly reduced the damage measured on the first and second days after OGD; these drugs also significantly decreased the summed daily post-OGD PI fluorescence in both regions. Postinsult administration of lidocaine (10, 100 µM) or thiopental (250, 600 µM) significantly decreased the PI fluorescence on the first day after OGD; postinsult administration of these drugs also attenuated the summed daily post-OGD PI. These data indicate that the administration of lidocaine or thiopental either before or directly after OGD reduced neuronal damage in this in vitro model of cerebral ischemia. Postischemic administration is frequently the first opportunity for treatment.

 

單側坐骨神經阻滯時選擇大轉子旁不同距離的部位注射是否有差異?

Does the Site of Injection Distal to the Greater Trochanter Make a Difference in Lateral Sciatic Nerve Blockade?

Manuel Taboada, MD*, Jaime Rodríguez, MD, PhD*, Sabela Del Rio, MD*, Juan Lagunilla, MD*, Javier Carceller, MD*, Julián Álvarez, MD, PhD*, and Peter G. Atanassoff, MD{dagger}

*Department of Anesthesiology, Hospital Clínico Universitario de Santiago, Spain; and {dagger}Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2005 101: 1188-1191

 

坐骨神經的兩個不同分支在下肢的走行路線相距甚遠,如果使用單次注射技術進行小容量局部阻滯麻醉時可能產生臨床差異。在這次前瞻性、隨機、雙盲實驗中,作者比較了兩種不同的注射部位(距大轉子20cm30cm)分別單次注入1.5%甲呱卡因20mL後,坐骨神經阻滯的起效時間及成功率的差別。50個接受足部手術的患者隨機分配至任一組中進行單側坐骨神經阻滯:距大轉子20cm(近側端組;n=25),距大轉子30cm(遠側端組;n=25)。在彎曲的足部對<0.5mA的刺激有反應後注入1.5%甲呱卡因20mL,記錄足部感覺和運動阻滯的起效時間。成功率是指坐骨神經所有分佈區的感覺和運動阻滯完全,達到無痛手術。近側端組感覺和運動完全阻滯的時間(12+7min15+8min)比遠側端組(19+9min23+9minP<0.05)快,而且近側端組較遠側端組成功率更高(分別為88%56%P<0.05)。結論:進行單次小容量的單側坐骨神經阻滯時,選擇坐骨神經近側端作為注射部位可使起效時間縮短,同時提高阻滯成功率。

(朱慧琛譯 陳傑校)

The two components of the sciatic nerve become more distant from one another in their course down the lower limb. This may have clinical implications if a small volume of local anesthetic is used with a single injection technique. In this prospective, randomized, double-blind study, we compared two different injection sites, 20 cm and 30 cm distal to the greater trochanter, in terms of onset time and success rate of sciatic nerve blockade after a single injection of 20 mL of 1.5% mepivacaine. Fifty patients undergoing foot surgery were randomly allocated to receive a lateral sciatic nerve blockade using one of 2 levels: 20 cm distal to the greater trochanter (group proximal; n = 25) and 30 cm distal to the greater trochanter (group distal; n = 25). Twenty milliliters of 1.5% mepivacaine was injected after a flexion plantar response was obtained at <0.5 mA. Time required for onset of sensory and motor blockade of the foot was recorded. Success rate was defined as complete sensory and motor blockade in all sciatic nerve distributions associated with a pain-free surgery. Onset of complete sensory and motor blockade was faster in group proximal (12 ± 7 min and 15 ± 8 min, respectively) compared with group distal (19 ± 9 min and 23 ± 9 min; P < 0.05). Group proximal also had a more frequent success rate compared with group distal (88% versus 56%, respectively; P < 0.05). It is concluded that in lateral sciatic nerve blockade, a more proximal approach to the sciatic nerve predicts a shorter onset time and more frequent success than a more distal injection site when a single injection and a small volume of local anesthetic is used.

 

髖部術後神經阻滯的抗分解代謝作用

The Anticatabolic Effect of Neuraxial Blockade After Hip Surgery

Ralph Lattermann, MD, MSc*, Geesche Belohlavek, MD*, Sigrid Wittmann, MD*, Bernd Füchtmeier, MD{dagger}, and Michael Gruber, PhD*

Departments of *Anesthesia and {dagger}Trauma Surgery, University of Regensburg, Germany

Anesth Analg 2005 101: 1202-1208.

 

儘管已成功建立腹部手術後神經阻滯的蛋白質損耗減少效應,但神經阻滯後對下肢手術後的代謝影響仍不清楚。本研究作者對硬脊聯合阻滯(CSE)抑制髖部術後氨基酸氧化這一假說進行了驗證。16位將行全髖置換手術的病人進行全身麻醉繼以用氰苯雙呱酰胺行靜脈內病人自控鎮痛(對照組;n8),或用0.5%布比卡因行腰麻、用0.2%羅呱卡因和0.5ug/ml舒芬太尼行術後硬膜外鎮痛(CSEn8)。術前一天和術後一天的糖和蛋白代謝通過穩定同位素示蹤技術(66-2H2糖,L-1-13C 亮氨酸)測定。同時測定糖、乳酸、自由脂肪酸、皮質醇、高血糖素和胰島素的血漿濃度。CSE阻斷了術中和術後當時血糖濃度的升高(切皮後60分鐘:CSE4.9±0.7與對照組6.2±0.7mmol/LP<0.05)。CSE組術中皮質醇血漿濃度稍低於對照組。術後一天兩組間的血糖濃度、糖代謝產物、和糖清除率相當。CSE抑制了術後亮氨酸氧化率的升高(CSE 30 ± 12 對照組 43 ± 8 µmol·kg–1·h–1; P < 0.05)。兩組間蛋白分解、蛋白合成、和血漿乳酸、自由脂肪酸、胰島素、胰高血糖素無顯著差別。結論:CSE能預防髖部手術期間的高血糖,並抑制隨後蛋白分解代謝。

(範穎暉 陳傑 校)

Although the protein-sparing effect of neuraxial blockade after abdominal surgery is well established, its metabolic effect after operations on the lower extremities remains unclear. In this study, we tested the hypothesis that combined spinal and epidural blockade (CSE) inhibits amino acid oxidation after hip surgery. Sixteen patients undergoing hip replacement surgery received either general anesthesia followed by IV patient-controlled analgesia with piritramide (control; n = 8) or CSE using bupivacaine 0.5% for spinal anesthesia and ropivacaine 0.2% with 0.5 µg/mL of sufentanil for postoperative epidural analgesia (CSE; n = 8). Glucose and protein kinetics were assessed by stable isotope tracer technique ([6,6-2H2]glucose, L-[1-13C]leucine) on the day before and one day after surgery. Plasma concentrations of glucose, lactate, free fatty acids, cortisol, glucagon, and insulin were also determined. CSE prevented the increase in plasma glucose concentration during and immediately after the operation (60 min after skin incision: CSE 4.9 ± 0.7 versus control 6.2 ± 0.7 mmol/L; P < 0.05; postanesthesia care unit: CSE 5.0 ± 0.9 versus control 7.3 ± 1.1 mmol/L; P < 0.05). Intraoperative cortisol plasma concentrations were smaller in the CSE group than in the control group. One day after the operation, however, glucose plasma concentration, glucose production, and glucose clearance were comparable in both groups. CSE inhibited the postoperative increase in leucine oxidation rate (CSE 30 ± 12 versus control 43 ± 8 µmol·kg–1·h–1; P < 0.05). There were no differences between the groups in protein breakdown, whole body protein synthesis, and plasma concentrations of lactate, free fatty acids, insulin, and glucagon. In conclusion, CSE prevents hyperglycemia during hip surgery and inhibits protein catabolism thereafter.

 

.經鼻腔氣管插管時導管尖端設計對鼻腔損傷的影響:Magill尖與Murphy尖之比較

The Influence of Endotracheal Tube Tip Design on Nasal Trauma During Nasotracheal Intubation: Magill-Tip Versus Murphy-Tip

Jong-Hwan Lee, MD*, Chang-Hee Kim, MD{dagger}, Jae-Hyon Bahk, MD*, and Kum-Suk Park, MD*

Departments of *Anesthesiology and {dagger}Otolaryngology, Seoul National University Hospital, Seoul National University College of Medicine, Korea

Anesth Analg 2005 101: 1226-1229.

 

本研究應用傳統氯化多聚乙烯氣管導管(ETT),旨在探討經鼻腔氣管插管時不同尖端設計的ETTMagill尖與Murphy尖)對鼻腔損傷的影響。患者隨機分為四組(每組25人):經加熱軟化處理的Magill尖和Murphy尖,以及未經處理的Magill尖和Murphy尖。ETT在盲探下插入鼻咽部,在直接喉鏡暴露下插入氣管。通過吸痰管中血液的容積來評估鼻衄的嚴重程度。未經加熱軟化處理時,MurphyETTMagillETT鼻衄損傷更嚴重(P<0.05)。加熱軟化處理在兩種尖端設計ETT中均明顯降低鼻衄嚴重程度(P<0.05)。然而,未經加熱軟化處理的MagillETT與加熱軟化處理的MurphyETT相比,鼻衄嚴重程度,鼻腔損傷和疼痛的發生率無明顯差異。加熱軟化處理能夠降低經鼻腔氣管插管時損傷發生率,是值得推薦使用的措施。在使用正常導管的情況下,MagillETTMurphyETT損傷更小。

(田婕 陳傑 校)

We performed this study to assess the influence of endotracheal tube (ETT) tip design (Murphy-tip versus Magill-tip) on nasal trauma during nasotracheal intubation with a conventional polyvinyl chloride ETT. Patients were randomly allocated to one of four groups (n = 25 each): Magill-tipped ETT and Murphy-tipped ETT with or without thermosoftening. After preparation with a vasoconstrictor, the selected, well-lubricated ETT was advanced blindly into the nasopharynx, and intubation was completed under direct laryngoscopy. The severity of epistaxis was estimated based on the distance that blood had traveled up the suction catheter and tubing. Without thermosoftening, the Murphy-tipped ETT produced more severe epistaxis than the Magill-tipped ETT (P < 0.05). Thermosoftening effectively reduced the severity of epistaxis for both conventional types of ETT (P < 0.05). However, there was no difference in the severity of epistaxis and the incidence of nasal injury and pain between the Magill-tipped, nonthermosoftened ETT and Murphy-tipped, thermosoftened ETT. Thermosoftening is recommended because it decreases the trauma during nasotracheal intubation. However, if one chooses to use a normal ETT, the Magill-tipped ETT will cause fewer traumas than the Murphy-tipped ETT.