Anesthesia & Analgesia

December 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

增大的心脏和年龄削弱豚鼠离体心脏的麻醉预处理

(周荻 薛张纲 校)

Increasing Heart Size and Age Attenuate Anesthetic Preconditioning in Guinea Pig Isolated Hearts

Matthias L. Riess, Amadou K. S. Camara, Samhita S. Rhodes, Joseph McCormick, Ming T. Jiang, and David F. Stowe

Anesth Analg 2005 101: 1572-1576.

缺血预适应改善肥胖大鼠肝移植的能量状态和提高存活率

(郑拥军 陈杰 校)

Ischemic Preconditioning Improves Energy State and Transplantation Survival in Obese Zucker Rat Livers

Claus U. Niemann, Ryutaro Hirose, Tao Liu, Matthias Behrends, Jaimi L. Brown, Douglas F. Kominsky, John P. Roberts, and Natalie Serkova

Anesth Analg 2005 101: 1577-1583

异氟醚通过抑制蛋白激酶、JNKERK来保护肾功能免受缺血再灌注的损害

(裘毅敏 马皓琳,李士通 )

Isoflurane Protects Renal Function Against Ischemia and Reperfusion Through Inhibition of Protein Kinases, JNK and ERK

Hideo Hashiguchi, Hiroaki Morooka, Hiroshi Miyoshi, Masanori Matsumoto, Takehiko Koji, and Koji Sumikawa

Anesth Analg 2005 101: 1584-1589

在早期再灌注时对线粒体渗透转运的抑制可以加强异氟醚的心脏保护作用:线粒体KATP通道的作用
(陆文清译 薛张纲校)

Inhibition of Mitochondrial Permeability Transition Enhances Isoflurane-Induced Cardioprotection During Early Reperfusion: The Role of Mitochondrial KATP Channels

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

Anesth Analg 2005 101: 1590-1596.

Paco2变化时应用经食管多普勒测定心输出量的精确度低于温度稀释法

(齐波 陈杰 校)

Cardiac Output Measurement Using the Transesophageal Doppler Method Is Less Accurate Than the Thermodilution Method When Changing Paco2

Toshiyuki Sawai, Toshihiro Nohmi, Yoshihiko Ohnishi, Yuji Takauchi, and Masakazu Kuro

Anesth Analg 2005 101: 1597-1601.

抑肽酶在整形外科大手术中的应用:一项随机对照试验系统性综述

(彭中美 马皓琳, 李士通 校)

Aprotinin in Major Orthopedic Surgery: A Systematic Review of Randomized Controlled Trials

Toshiya Shiga, Zen’ichiro Wajima, Tetsuo Inoue, and Atsuhiro Sakamoto

Anesth Analg 2005 101: 1602-1607

PEDIATRIC ANESTHESIA:

七氟醚全身麻醉下儿童喉部滴入蒸馏水引起气道保护性反射的研究

(朱辉 陈杰 校)

Airway Protective Reflexes Evoked by Laryngeal Instillation of Distilled Water Under Sevoflurane General Anesthesia in Children

Teruhiko Ishikawa, Shiroh Isono, Atsuko Tanaka, Yugo Tagaito, and Takashi Nishino

Anesth Analg 2005 101: 1615-1618.

可乐定用于小儿七氟醚麻醉后躁动的治疗

(黄佳佳 马皓琳,李士通 校)

Clonidine Treatment for Agitation in Children After Sevoflurane Anesthesia

Simonetta Tesoro, Daniele Mezzetti, Laura Marchesini, and Vito Aldo Peduto

Anesth Analg 2005 101: 1619-1622.

由代理人控制儿童肿瘤患者自控镇痛的安全性

(周志坚 马皓琳,李士通 )

The Safety of Patient-Controlled Analgesia by Proxy in Pediatric Oncology Patients

Doralina L. Anghelescu, Laura L. Burgoyne, Linda L. Oakes, and Debora A. Wallace

Anesth Analg 2005 101: 1623-1627.

AMBULATORY ANESTHESIA:

比较局部和全身麻醉在门诊手术的优缺点: 随机对照试验的荟萃分析

(王慧琳译,薛张纲校)

A Comparison of Regional Versus General Anesthesia for Ambulatory Anesthesia: A Meta-Analysis of Randomized Controlled Trials

Spencer S. Liu, Wyndam M. Strodtbeck, Jeffrey M. Richman, and Christopher L. Wu

Anesth Analg 2005 101: 1634-1642.

门诊外科术后出院综合征:首周发生率,强度和风险因素

(范颖晖 陈杰 校)

Postdischarge Symptoms After Ambulatory Surgery: First-Week Incidence, Intensity, and Risk Factors

Kristiina Mattila, Juhani Toivonen, Leena Janhunen, Per H. Rosenberg, and Markku Hynynen

Anesth Analg 2005 101: 1643-1650.

比较雷芬太尼或硫酸镁与安慰剂在减小电惊厥疗法的血流动力学反应

(黄丽娜 马皓琳,李士通 )

The Comparative Effects of Remifentanil or Magnesium Sulfate Versus Placebo on Attenuating the Hemodynamic Responses After Electroconvulsive Therapy

Dirk H. van Zijl, Peter C. Gordon, and Michael F. James

Anesth Analg 2005 101: 1651-1655.

日间行前列腺近距离放疗中全麻和脊麻技术的评价

(徐丽颖译 薛张纲校)

An Evaluation of General and Spinal Anesthesia Techniques for Prostate Brachytherapy in a Day Surgery Setting (Brief Report)

Ron Flaishon, Perla Ekstein, Haim Matzkin, and Avi A. Weinbroum

Anesth Analg 2005 101: 1656-1658. ss.

门诊外科的周围神经阻滞技术

(张美荣 陈杰 校)

Peripheral Nerve Block Techniques for Ambulatory Surgery (Review Article)

Stephen M. Klein, Holly Evans, Karen C. Nielsen, Marcy S. Tucker, David S. Warner, and Susan M. Steele

Anesth Analg 2005 101: 1663-1676.

ANESTHETIC PHARMACOLOGY:

舒芬太尼在人体的血管扩张作用

(邱郁薇 马皓琳,李士通 校)

Vasodilation from Sufentanil in Humans

Thomas J. Ebert, David J. Ficke, Shahbaz R. Arain, Melissa N. Holtz, and Hariharan Shankar

Anesth Analg 2005 101: 1677-1680.

兔的外周N-甲基- D-天冬氨酸受体调整非肾上腺素能非胆碱能食道下段括约肌的松弛作用

(孙卓真 译,薛张纲 审校)

Peripheral N-Methyl-d-Aspartate Receptors Modulate Nonadrenergic Noncholinergic Lower Esophageal Sphincter Relaxation in Rabbits

Atsushi Kohjitani, Makoto Funahashi, Takuya Miyawaki, Motohiko Hanazaki, Ryuji Matsuo, and Masahiko Shimada

Anesth Analg 2005 101: 1681-1688.

大鼠中枢咪唑啉受体亚型调控氟烷-肾上腺素性心律失常

(忻纪华 陈杰 校)

Identification of the Central Imidazoline Receptor Subtype Involved in Modulation of Halothane-Epinephrine Arrhythmias in Rats

Kiyokazu Kagawa, Yukio Hayashi, Isao Itoh, Mitsuo Iwasaki, Koji Takada, Takahiko Kamibayashi, Atsushi Yamatodani, and Takashi Mashimo

Anesth Analg 2005 101: 1689-1694.

成人丹曲林的分室药代动力学:恶性高热协会的剂量指导方针有用吗?

(张莹 马皓琳,李士通 校)

Compartmental Pharmacokinetics of Dantrolene in Adults: Do Malignant Hyperthermia Association Dosing Guidelines Work?

Tobias Podranski, Thomas Bouillon, Peter M. Schumacher, Akikio Taguchi, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2005 101: 1695-1699.

神经内分泌应激反应和心率变异性:全凭静脉麻醉与复合麻醉的比较

(孙敏莉译,薛张纲校)

Neuroendocrine Stress Response and Heart Rate Variability: A Comparison of Total Intravenous Versus Balanced Anesthesia

Thomas Ledowski, Berthold Bein, Robert Hanss, Andrea Paris, Wolfgang Fudickar, Jens Scholz, and Peter H. Tonner

Anesth Analg 2005 101: 1700-1705.

TECHNOLOGY, COMPUTING, AND SIMULATION:

瑞芬太尼和丙泊酚诱导的意识消失期间肌松药对双频指数和Datex-Ohmeda熵值的影响

(郑丽 陈杰 校)

The Influence of a Muscle Relaxant Bolus on Bispectral and Datex-Ohmeda Entropy Values During Propofol-Remifentanil Induced Loss of Consciousness

Ngai Liu, Thierry Chazot, Isabelle Huybrechts, Jean-Dominique Law-Koune, Luc Barvais, and Marc Fischler

Anesth Analg 2005 101: 1713-1718.

振动-触觉显示器样机用于生理监测的评估

(周雅春 马皓琳,李士通 校)

An Evaluation of a Vibro-Tactile Display Prototype for Physiological Monitoring

Jessie Y. C. Ng, Jo C. F. Man, Sidney Fels, Guy Dumont, and J. Mark Ansermino

Anesth Analg 2005 101: 1719-1724.

PAIN MEDICINE:

脊柱L型钙通道阻滞剂消除阿片类药物引起的感觉过敏和抗伤害性刺激作用的耐药性

(金琳 译,薛张纲 审校)

Spinal L-Type Calcium Channel Blockade Abolishes Opioid-Induced Sensory Hypersensitivity and Antinociceptive Tolerance

Ahmet Dogrul, Edward J. Bilsky, Michael H. Ossipov, Josephine Lai, and Frank Porreca

Anesth Analg 2005 101: 1730-1735. 

全身使用局麻药缓解神经性疼痛:系统回顾和荟萃分析

(肖洁 陈杰 校)

Systemic Administration of Local Anesthetics to Relieve Neuropathic Pain: A Systematic Review and Meta-Analysis

Ivo W. Tremont-Lukats, Vidya Challapalli, Ewan D. McNicol, Joseph Lau, and Daniel B. Carr

Anesth Analg 2005 101: 1738-1749.

大鼠鞘内单次注射吗啡引起长时间痛觉过敏:预先注射氯胺酮的保护作用

(赵雪莲 马皓琳,李士通 校)

A Single Dose of Intrathecal Morphine in Rats Induces Long-Lasting Hyperalgesia: The Protective Effect of Prior Administration of Ketamine

Alain C. Van Elstraete, Philippe Sitbon, Fabien Trabold, Jean-Xavier Mazoit, and Dan Benhamou

Anesth Analg 2005 101: 1750-1756.

内皮素对坐骨神经慢性收缩性损害后神经病理性疼痛的影响

(吴德华译 薛张纲校)

A Role for Endothelin in Neuropathic Pain After Chronic Constriction Injury of the Sciatic Nerve

Markus Klass, Allen Hord, Melissa Wilcox, Don Denson, and Marie Csete

Anesth Analg 2005 101: 1757-1762.

 

双酯瑞因对炎性和神经病理性伤害性刺激小鼠模型中机械性痛觉过敏的影响

(田婕 陈杰 校)

The Effects of Diacerhein on Mechanical Allodynia in Inflammatory and Neuropathic Models of Nociception in Mice

Nara L. M. Quintão, Rodrigo Medeiros, Adair R.S. Santos, Maria M. Campos, and João B. Calixto

Anesth Analg 2005 101: 1763-1769.

CRITICAL CARE AND TRAUMA:

用溴化物、碘苯六醇和钠稀释测定细胞外液量的大小

(马皓琳 李士通 校)

Measuring the Size of the Extracellular Fluid Space Using Bromide, Iohexol, and Sodium Dilution

Joachim H. Zdolsek, Björn Lisander, and Robert G. Hahn

Anesth Analg 2005 101: 1770-1777.

危重病人中心静脉导管的菌落:比较标准导管和两种含抗菌剂导管的前瞻性随机对照研究

(金 薛张纲 校)

Central Venous Catheter Colonization in Critically Ill Patients: A Prospective, Randomized, Controlled Study Comparing Standard with Two Antiseptic-Impregnated Catheters

Martin W. Dünser, Andreas J. Mayr, Guido Hinterberger, Cornelia Lass Flörl, Hanno Ulmer, Stefan Schmid, Barbara Friesenecker, Ingo Lorenz, and Walter R. Hasibeder

Anesth Analg 2005 101: 1778-1784.

早期胶体替换治疗在亚致死性出血性休克模型中的应用

(朱慧琛 陈杰 校)

Early Colloid Replacement Therapy in a Near-Fatal Model of Hemorrhagic Shock

Evandro L.A. Ferreira, Renato G.G. Terzi, William A. Silva, and Ana C. de Moraes

Anesth Analg 2005 101: 1785-1791.

单次促肾上腺皮质激素刺激试验不能揭示脓毒症休克时的肾上腺功能不足

(颜涛 马皓琳,李士通 校)

A Single Adrenocorticotropic Hormone Stimulation Test Does Not Reveal Adrenal Insufficiency in Septic Shock

Pekka Loisa, Ari Uusaro, and Esko Ruokonen

Anesth Analg 2005 101: 1792-1798.

ADP-核糖合成酶抑制剂在大鼠内脏动脉缺血再灌注损伤后改善肺动脉对内皮依赖性血管扩张剂的舒张作用

(王丽珺译 薛张纲校)

Inhibition of Poly (ADP-ribose) Synthetase Improves Pulmonary Arterial Endothelium-Dependent Relaxation After Ischemic-Reperfusion Injury of Splanchnic Artery in Rats

Hirofumi Nagata, Takashi Horiguchi, Keiji Enzan, Toshiaki Nishikawa, and Kenji Suzuki

Anesth Analg 2005 101: 1799-1804.

OBSTETRIC ANESTHESIA:

循环中成熟肾上腺髓质素(adrenomedullin)与足月妊娠血容量有关

(赵延华 陈杰 校)

Circulating Mature Adrenomedullin Is Related to Blood Volume in Full-Term Pregnancy

Yukio Hayashi, Hiroshi Ueyama, Takashi Mashimo, Kenji Kangawa, and Naoto Minamino

Anesth Analg 2005 101: 1816-1820.

REGIONAL ANESTHESIA:

全膝关节置换后持续股神经阻滞或者硬膜外镇痛:前瞻性随机对照试验

(张 马皓琳,李士通 校)

Continuous Femoral Nerve Blockade or Epidural Analgesia After Total Knee Replacement: A Prospective Randomized Controlled Trial

Michael J. Barrington, David Olive, Keng Low, David A. Scott, Jennifer Brittain, and Peter Choong

Anesth Analg 2005 101: 1824-1829.

确定术后镇痛的硬膜外导管位置的两种非直接方法的比较性研究

(钟静译 薛张纲校)

A Prospective Comparative Study of Two Indirect Methods for Confirming the Localization of an Epidural Catheter for Postoperative Analgesia

Etienne de Medicis, Jean-Pierre Tetrault, Rene Martin, Remi Robichaud, and Lucie Laroche

Anesth Analg 2005 101: 1830-1833.

芬太尼硬膜外注射可加快罗哌卡因阻滞时感觉和运动神经阻滞的起效时间

(苏殿三 陈杰 校)

Epidural Fentanyl Speeds the Onset of Sensory and Motor Blocks During Epidural Ropivacaine Anesthesia

Chen-Hwan Cherng, Chih-Ping Yang, and Chih-Shung Wong

Anesth Analg 2005 101: 1834-1837.

三环类抗抑郁药用作局麻药引起的组织损伤

(黄施伟 马皓琳,李士通 校)

Tissue Injury from Tricyclic Antidepressants Used as Local Anesthetics

Caryn S. Barnet, David N. Louis, and Daniel S. Kohane

Anesth Analg 2005 101: 1838-1843.

GENERAL ARTICLES:

手术后颤抖的独立危险因素
(陆文清译 薛张纲校)

Independent Risk Factors for Postoperative Shivering

Leopold H. J. Eberhart, Friederike Döderlein, Gudrun Eisenhardt, Peter Kranke, Daniel I. Sessler, Alexander Torossian, Hinnerk Wulf, and Astrid M. Morin

Anesth Analg 2005 101: 1849-1857.

择期手术患者贫血的发现、评估与处理

(顾新宇 陈杰 校)

Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient

Lawrence T. Goodnough, Aryeh Shander, Jerry L. Spivak, Jonathan H. Waters, Arnold J. Friedman, Jeffrey L. Carson, E. Michael Keating, Thomas Maddox, and Richard Spence

Anesth Analg 2005 101: 1858-1861.

 

Ambu®喉罩在未用肌松的麻醉患者中应用的多中心研究

(陈玮 马皓琳,李士通 校)

A Multicenter Study of the Ambu® Laryngeal Mask in Nonparalyzed, Anesthetized Patients

Carin A. Hagberg, Frank Samsoe Jensen, Harald V. Genzwuerker, Renée Krivosic-Horber, Bettina U. Schmitz, Jochen Hinkelbein, Marius Contzen, Herve Menu, and Karim Bourzoufi

Anesth Analg 2005 101: 1862-1866.

异氟醚通过抑制蛋白激酶、JNKERK来保护肾功能免受缺血再灌注的损害

Isoflurane Protects Renal Function Against Ischemia and Reperfusion Through Inhibition of Protein Kinases, JNK and ERK

Hideo Hashiguchi, MD, Hiroaki Morooka, MD, Hiroshi Miyoshi, MD, Masanori Matsumoto, MD, Takehiko Koji, MD, and Koji Sumikawa, MD

Department of Anesthesiology, Department of Histology, Nagasaki University School of Medicine, Nagasaki, Japan

Anesth Analg 2005;101:1584-1589

 

异氟醚有对抗心、脑缺血的药物预处理作用,但对肾脏是否也存在同样的作用,尚不明了。在本研究中,我们通过大鼠的肾脏研究异氟醚的药物预处理作用。在异氟醚预处理组(在肾缺血前予1.5%异氟醚20min)再灌注后2448h时的血清肌酐(1.2±0.71.1±0.2mg/dL)及血尿素氮(99±29 187±31mg/dL)明显小于非预处理组(肌酐;2.4±1.22.9±0.9mg/dL,尿素氮;62±19 79±20mg/dL)。我们同时研究了异氟醚肾脏预处理所涉及到的细胞内信号传导问题。肾脏预处理组中的应激蛋白激酶、JNKERK,而非p38,明显小于非预处理组(P0.05=。我们得到结论,异氟醚在缺血前给予有对抗肾脏缺血再灌注损伤的预处理作用。异氟醚预处理的机制可能涉及蛋白激酶、JNKERK的抑制。

(裘毅敏 马皓琳,李士通 校)

Isoflurane has a pharmacological preconditioning effect against ischemia in the heart and brain, but whether this also occurs in the kidney is unclear. In this study, we investigated pharmacological preconditioning by isoflurane in the rat kidney. In the isoflurane preconditioning group (1.5% isoflurane for 20 min before renal ischemia) serum creatinine (1.2 ± 0.7 and 1.1 ± 0.2 mg/dL) and blood urea nitrogen (99 ± 29 and 187 ± 31 mg/dL) were significantly smaller at 24 and 48 h after reperfusion than in the nonpreconditioning group (creatinine; 2.4 ± 1.2 and 2.9 ± 0.9 mg/dL, urea; 62 ± 19 and 79 ± 20 mg/dL). We also investigated the intracellular signal transduction involved in isoflurane preconditioning in the kidney. The activities of the stress protein kinases, JNK and ERK but not p38, were significantly less in the kidneys of the preconditioning group than in those of the nonpreconditioning group (P < 0.05). We conclude that isoflurane has a preconditioning effect against renal ischemia/reperfusion injury when administered before ischemia. Inhibition of the protein kinases, JNK and ERK, might be involved in the mechanisms of isoflurane preconditioning.

 

 

抑肽酶在整形外科大手术中的应用:一项随机对照试验系统性综述

Aprotinin in Major Orthopedic Surgery: A Systematic Review of Randomized Controlled Trials

Toshiya Shiga, MD, PhD, Zen’ichiro Wajima, MD, PhD, Tetsuo Inoue, MD, PhD, and Atsuhiro Sakamoto, MD, PhD

Department of Anesthesia, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan; Department of Anesthesiology, Nippon Medical School Hospital, Tokyo, Japan

Anesth Analg 2005;101:1602-1607

 

抑肽酶治疗是一种减少出血和输血的较有希望的方法。然而整形外科手术中使用抑肽酶的有效性和安全性,尚存在争议。我们在电子数据库中检索有关抑肽酶在整形外科手术中的有效和安全性的随机对照试验。分析了包括总共506例行较大整形外科手术病人的13个试验。手术中和围手术期血液丢失在抑肽酶治疗病人明显少于对照病人(手术中血液丢失的加权均数差 [WMD] = –229 mL, 95% 可信区间[CI] = –367 –91 mL, P = 0.0011;围手术期血液丢失的WMD = –557 mL; 95% CI = –860–254 mL; P < 0.0001)。抑肽酶处理的病人术中和围术期输注的库存红细胞(RBC)单位(U)显著少于对照病人(术中RBC UWMD= –1.1 U95% CI = –1.7–0.4 UP = 0.0001 围术期RBC UWMD = –1.1 U; 95% CI = –1.7–0.5 U; P < 0.0001。抑肽酶与深静脉血栓的发生率升高无关(几率= 0.39; 95% CI = 0.141.05, P = 0.061)。作者得出结论,抑肽酶减少手术中和围手术期血液丢失和输异体血的需要量,整形外科大手术病人用药物或机械性预防时,抑肽酶与深静脉血栓的危险性增加可能并没有关系。

(彭中美 马皓琳, 李士通 校)

Aprotinin therapy is a promising strategy for reducing blood loss and blood transfusion requirements. The efficacy and safety of aprotinin in orthopedic surgery, however, remain controversial. We searched electronic databases for randomized controlled trials on the efficacy and safety of the use of aprotinin in orthopedic surgery. Thirteen trials that included a total of 506 patients who underwent major orthopedic surgery were analyzed. The pooled intraoperative and perioperative blood loss was significantly less in the aprotinin-treated patients than in the control patients (weighted mean difference [WMD] for intraoperative blood loss = –229 mL, 95% confidence interval [CI] = –367 to –91 mL, P = 0.0011; WMD for perioperative blood loss = –557 mL; 95% CI = –860 to –254 mL; P < 0.0001). The pooled amounts of red blood cell (RBC) units (U) transfused intraoperatively and perioperatively were significantly less in the aprotinin-treated patients than in the control patients (WMD for intraoperative RBC U = –1.1 U; 95% CI = –1.7 to –0.4 U; P = 0.0001; WMD for perioperative RBC U = –1.1 U; 95% CI = –1.7 to –0.5 U; P < 0.0001). Aprotinin was not associated with an increased incidence of deep vein thrombosis (odds ratio = 0.39; 95% CI = 0.14 to 1.05, P = 0.061). The authors conclude that aprotinin reduces the intraoperative and perioperative blood loss and allogeneic blood transfusion requirement and may not be associated with increased risk of deep vein thrombosis in the presence of pharmacological or mechanical prophylaxis in patients undergoing major orthopedic surgery.


可乐定用于小儿七氟醚麻醉后躁动的治疗

Clonidine Treatment for Agitation in Children After Sevoflurane Anesthesia

Simonetta Tesoro, Daniele Mezzetti, Laura Marchesini, and Vito Aldo Peduto

Section of Anesthesia, Analgesia and Intensive Care, Department of Clinical and Experimental Medicine, University of Perugia, Italy

Anesth Analg 2005;101:1619-1622

 

可乐定可有效治疗儿童七氟醚引起的麻醉后躁动。我们对儿科门诊手术诊所收入的169名儿童进行研究,以对可乐定减少躁动风险定量。将接受七氟醚全麻附加区域或中枢阻滞的受试儿童在麻醉前随机分配到两个组:可乐定2 μg/kg及安慰剂组。由不了解麻醉方法的观察者评估恢复指标及躁动的存在。疼痛和不适评分在可乐定组显著下降,躁动以及严重躁动的几率分别下降了57% (P = 0.029)67%(P = 0.064)。发生躁动及严重躁动的相对危险度分别为0.43 (95% 可信区间, 0.24–0.78)0.32 (0.09–1.17)。可乐定可显著降低儿童七氟醚麻醉后躁动发生率。

(黄佳佳 马皓琳,李士通 校)

Clonidine is effective in treating sevoflurane-induced postanesthesia agitation in children. We conducted a study on 169 children to quantify the risk reduction of clonidine agitation in patients admitted to our day-surgery pediatric clinic. Children were randomly allocated to receive clonidine 2 µg/kg or placebo before general anesthesia with sevoflurane that was also supplemented with a regional or central block. An observer blinded to the anesthetic technique assessed recovery variables and the presence of agitation. Pain and discomfort scores were significantly decreased in the clonidine group; the incidence of agitation was reduced by 57% (P = 0.029) and the incidence of severe agitation by 67% (P = 0.064). Relative risks for developing agitation and severe agitation were 0.43 (95% confidence interval, 0.24–0.78) and 0.32 (0.09–1.17), respectively. Clonidine produces a substantial reduction in the risk of postsevoflurane agitation in children.


由代理人控制儿童肿瘤患者自控镇痛的安全性

The Safety of Patient-Controlled Analgesia by Proxy in Pediatric Oncology Patients

Doralina L. Anghelescu, MD*, Laura L. Burgoyne, BM, BS, FANZCA*, Linda L. Oakes, RN, MSN, CCNS{dagger}, and Debora A. Wallace, RN, BSN*

Division of *Anesthesia and {dagger}Nursing Research and Patient Care Services, St. Jude Children’s Research Hospital, Memphis, Tennessee

Anesth Analg 2005;101:1623-1627

 

1999年二月至2003年十二月,我们通过评价497224h时段的PCA使用(其中576个由患儿代理人控制PCA),研究1011例儿童和青年癌症患者用患者自控镇痛(PCA)来控制疼痛的情况。选择由代理人控制PCA的条件是低年龄组、有神经肌肉功能缺陷、预计反复对病人进行疼痛性操作及终末期疾病者。我们测定了与使用PCA有关的呼吸和神经学并发症的发生率。在497224-h时段中,70个时段观察到了重要的并发症,其中28/4972(0.56%)为呼吸系统并发症,35/4972(0.7%)为神经学并发症,7/4972(0.14%)为呼吸、神经系统同时累及的并发症。在由代理人控制的PCA组中,观察到呼吸和神经系统并发症各2例。需要使用纳络酮来逆转呼吸或神经系统阿片样反应的情况有3例,标准PCA2例及代理人PCA1例。因此对确保持续的安全性的建议包括,谨慎选择病人、代理人的使用培训、适当的操作文件说明及制度上指南的制定。

(周志坚 马皓琳,李士通 )

Between February 1999 and December 2003, we studied the use of patient-controlled analgesia (PCA) to control pain in 1011 children and young adults with cancer, by evaluating 4972 24-h periods of PCA usage, 576 of which involved PCA by proxy. Selection of patients for PCA by proxy was based on younger age group, neuromuscular limitation, expectation of repeated painful procedures, and terminal disease. We measured the incidence of respiratory and neurological complications related to the use of PCA. Major complications were observed during 70 of the 4972 24-h observations, with 28 of 4972, or 0.56%, involving respiratory complications, 35 of 4972, or 0.7%, involving neurological complications, and 7 of 4972 24-h observations, or 0.14%, involving both respiratory and neurological complications. In the PCA by proxy group, two respiratory complications and two neurological complications were observed. Reversal of opioid-related respiratory or neurological effects with naloxone was required in three instances, two in the standard PCA group and one in the PCA by proxy group. Recommendations to ensure continuing safety include careful patient selection, education of proxy users, appropriate documentation, and institutional guidelines.


比较雷芬太尼或硫酸镁与安慰剂在减小电惊厥疗法的血流动力学反应

The Comparative Effects of Remifentanil or Magnesium Sulfate Versus Placebo on Attenuating the Hemodynamic Responses After Electroconvulsive Therapy

Dirk H. van Zijl, MBChB, FCA, Peter C. Gordon, MBChB, BSc, FCA, and Michael F. James, MBChB, FFARCS, PhD

Department of Anaesthesia, Groote Schuur Hospital, Valkenberg Hospital and the University of Cape Town, South Africa

Anesth Analg 2005;101:1651-1655

 

在这一前瞻性的随机双盲安慰剂对照交叉研究中,我们比较了雷芬太尼或硫酸镁与安慰剂在减小电惊厥疗法交感反应方面的效应。20名成人经历了总共115次麻醉下治疗性电惊厥疗法。病人们随机分组两次,分入三组中的其中一组:安慰剂对照组、硫酸镁30 mg/kg组或雷芬太尼1.0 µg/kg组。建立静脉通路之前,记录收缩期和舒张期动脉血压、心率及血氧饱和度。用硫喷妥钠4 mg/kg进行麻醉诱导。随后给予试用药物,在电惊厥疗法实施之前,给予司可林0.5 mg/kg进行神经肌肉阻滞。在惊厥结束后即刻、1分钟、3分钟和10分钟重复所有测量。雷芬太尼和硫酸镁在减轻惊厥后即刻、1分钟和3分钟时收缩期动脉血压的升高上有显著的统计学意义(P < 0.05)。雷芬太尼可以减轻惊厥后1分钟和3分钟时的心率增快,而对心率峰值没有作用。而硫酸镁及安慰剂没有这种作用。雷米芬太尼可以延长呼吸暂停的持续时间(平均90 s),但没有其他不良的呼吸系统反应。平均惊厥活动持续时间为33 (± 14) s,各组间没有差异。结论,雷芬太尼1.0 µg/kg硫酸镁30 mg/kg可以减弱收缩期动脉血压对电惊厥疗法的反应,而并不减少惊厥活动的持续时间。由于硫酸镁对心率的作用较小,其对电惊厥疗法后存在心动过缓风险的病人可能较雷芬太尼更为有利。

(黄丽娜 马皓琳,李士通 )

In this prospective, randomized, double-blind, placebo-controlled, crossover study we compared the effects of remifentanil or magnesium sulfate (MgSO4) versus placebo in attenuating the sympathetic response to electroconvulsive therapy. Twenty adults underwent a total of 115 anesthetics for therapeutic electroconvulsive therapy. Patients were randomly allocated twice into each of the three test groups: placebo control, MgSO4 30 mg/kg, or remifentanil 1.0 µg/kg. Systolic and diastolic arterial blood pressures, heart rate, and oxygen saturations were recorded before IV access was established. Anesthesia was induced with thiopental 4 mg/kg. The trial drug was then administered and neuromuscular blockade was followed with succinylcholine 0.5 mg/kg before electroconvulsive therapy was performed. All measurements were repeated at 0, 1, 3 and 10 min after the seizure ended. Remifentanil and MgSO4 produced a statistically significant attenuation of the increase in systolic arterial blood pressure at 0, 1, and 3 min (P < 0.05). Remifentanil, but not MgSO4 or placebo, attenuated the increase in heart rate at 1 and 3 min but not the peak rate. Remifentanil increased the duration of apnea (mean 90 s), with no other adverse respiratory effects. Mean seizure duration time was 33 (± 14) s, with no difference among the groups. In conclusion, remifentanil 1.0 µg/kg and MgSO4 30 mg/kg attenuated the systolic arterial blood pressure response to electroconvulsive therapy without reducing the duration of seizure activity. Because MgSO4 has less effect on HR, it might offer advantages over remifentanil in patients at risk for post-electroconvulsive therapy bradycardia.


舒芬太尼在人体的血管扩张作用

Vasodilation from Sufentanil in Humans

Thomas J. Ebert, MD, PhD, David J. Ficke, BS, Shahbaz R. Arain, MD, Melissa N. Holtz, BS, and Hariharan Shankar, MD

Department of Anesthesiology, Medical College of Wisconsin and VA Medical Center, Milwaukee, Wisconsin

Anesth Analg 2005;101:1677-1680

 

舒芬太尼是一种强效阿片类药物,有时会引起低血压的发生。其发生低血压的机制目前还不清楚。我们假设舒芬太尼对血管平滑肌有直接作用从而引起血管扩张。10例年轻健康志愿者,以0.0830.1670.3330.833 µg/min的速度肱动脉输注舒芬太尼。试验组和对照组均采用静脉闭塞体积描计术测量前臂血流量。输注手臂的前臂血流量呈剂量依赖性增加,从每100mL 组织3.2增加到5.2 mL/min,而对照(未输注)手臂的前臂血流未增加。在输注过程中,心率和平均动脉压没有明显改变。而且在任一输注水平呼吸频率无明显改变,镇静也没有发生。因此,这些数据支持舒芬太尼并未发生“溢出”到体循环产生显著的全身作用。我们得出结论,舒芬太尼对人体血管组织有直接的血管舒张作用,而这一作用似乎不依赖于神经性的和全身机制。

(邱郁薇 马皓琳,李士通 校)

 

Sufentanil is a potent opioid that occasionally has been associated with hypotension. The mechanism behind this hypotension is unclear. We hypothesized that sufentanil had a direct effect on vascular smooth muscle to cause vasodilation. Sufentanil was infused into the brachial artery of 10 young, healthy volunteers at rates of 0.083, 0.167, 0.333, and 0.833 µg/min. Forearm blood flow was measured in both the experimental and control arms with venous occlusion plethysmography. The forearm blood flow in the infused arm increased in a dose-dependent fashion from 3.2 to 5.2 mL/min per 100 mL of tissue whereas simultaneous measurements in the control (non-infused) arm did not increase. Heart rate and mean arterial blood pressure were unchanged during the infusions. Furthermore, respiratory rate did not change at any infusion level and sedation did not occur. Thus, the data support that significant systemic "spillover" of sufentanil did not occur. We conclude that sufentanil has a direct, vasodilatory effect on human vascular tissue that is likely independent of a neurogenic or systemic mechanism.


成人丹曲林的分室药代动力学:恶性高热协会的剂量指导方针有用吗?

Compartmental Pharmacokinetics of Dantrolene in Adults: Do Malignant Hyperthermia Association Dosing Guidelines Work?

Tobias Podranski, MD*, Thomas Bouillon, MD*, Peter M. Schumacher, MS, PhD*, Akikio Taguchi, MD{dagger}, Daniel I. Sessler, MD{ddagger}, and Andrea Kurz, MD*{ddagger}

*Department of Anesthesiology, University of Bern, Switzerland; {dagger}Department of Anesthesia, Washington University, St. Louis, Missouri; {ddagger}Outcomes ResearchTM Institute, University of Louisville, Kentucky

Anesth Analg 2005;101:1695-1699

 

丹曲林是唯一被证实能有效预防和治疗恶性高热的药物。近来其建议使用的剂量是基于非分室分析,且很大程度上凭经验。它们之间还有分歧,表现为来自美国恶性高热协会(MHAUS)和欧洲原始资料的建议不同。我们测定了丹曲林的分室药代动力学,模拟基于近来建议剂量的浓度时间过程,并提出了一个理想的给药方式。9名志愿者(55–89 kg)接受静脉输注丹曲林(5mg/kg30分钟后给予0.05mg · kg–1 · h–15h)。间断抽取静脉血,直到给药后60小时,使用反相高效液相色谱测定丹曲林血浆浓度。采用一室、二室和三室模型式拟和数据,并使用协变分析。用NONMEM及总体方法进行所有的计算。两室模型能适当地描述这些数据,典型的变量值如下(中位数± 标准误):分布容积V1 = 3.24 ± 0.61 LV2 = 22.9 ± 1.53 L;血浆清除率CLel = 0.03 ± 0.003 L/min;分布清除率CLdist = 1.24 ± 0.22 L/min。所有参数均与体重呈线性比例关系。模拟欧洲治疗恶性高热的建议使血浆浓度在24小时内集中于14–18 mg/L。模拟MHAUS的指导用法(间断注射),使药物血浆浓度峰值和谷值范围为6.7–22.6 mg/L。以我们的发现为根据,我们提议应根据控制症状所需的最初单次注射的剂量调整以后的输注量。这种策略可以维持个体化的治疗浓度,并提高药物血浆浓度的稳定性。

(张莹 马皓琳,李士通 校)

 

Dantrolene is the only drug proven effective for prevention and treatment of malignant hyperthermia (MH). Current dosing recommendations are based on noncompartmental analyses and are largely empiric. They are also divergent, as evidenced by differing recommendations from the Malignant Hyperthermia Association of the United States (MHAUS) and European Sources. We determined the compartmental pharmacokinetics of dantrolene, simulated the concentration time course based on currently recommended dosing, and suggest an optimal regimen. Nine volunteers (55–89 kg) received IV infusions of dantrolene (5 mg/kg over 30 min followed by 0.05 mg · kg–1 · h–1 for 5 h). Venous blood samples were drawn for up to 60 h, and dantrolene plasma concentrations were determined by reverse phase, high-performance liquid chromatography. One, two, and three compartmental models were fitted to the data, and a covariate analysis was performed. All calculations were performed with NONMEM using the population approach. The data were adequately described by a two-compartment model with the following typical variable values (median ± se): volumes of distribution V1 = 3.24 ± 0.61 L; V2 = 22.9 ± 1.53 L; plasma clearance CLel = 0.03 ± 0.003 L/min; and distributional clearance CLdist = 1.24 ± 0.22 L/min. All parameters were scaled linearly with weight. Simulations of European recommendations for treatment of MH lead to plasma concentrations converging to 14–18 mg/L within 24 h. Simulating MHAUS guidelines (intermittent bolus administration) yielded peak and trough plasma concentrations ranging from 6.7–22.6 mg/L. Based on our findings, we propose an infusion regimen adjusted to the initial bolus dose(s) required to control symptoms. This strategy maintains the individualized therapeutic concentrations and improves stability of plasma concentrations.


振动-触觉显示器样机用于生理监测的评估

An Evaluation of a Vibro-Tactile Display Prototype for Physiological Monitoring

Jessie Y. C. Ng, MASc*, Jo C. F. Man, MASc*, Sidney Fels, PhD, PEng*, Guy Dumont, PhD*, and J. Mark Ansermino, MBBCh, MSc (Inf), FFA{dagger}

*Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, Canada; {dagger}Department of Anesthesia, University of British Columbia, Vancouver, Canada

Anesth Analg 2005;101:1719-1724

 

在手术室里采用视觉显示器和听觉报警器传递生理参数信息。但是,生理参数项目的高速增长和高错误报警率大大地增加了对临床医师注意力的要求。我们扩展了现有触觉技术以改善情况识别能力,并制造了一种实用的临床报警设备。该振动-触觉显示器用2个振动马达贴在前臂掌侧表面,在模拟临床环境中与听觉报警器比较。该振动-触觉显示器同听觉报警器一样易于学习使用并且在单一使用或与听觉报警器合用时有更高的辨识率。尽管振动-触觉报警器样机会给使用者带来一些不适,但是大多数使用者更愿意选择使用该报警器。此外,同单用振动-触觉报警器相比,振动-触觉和听觉联合报警器的精确性有所降低。此种振动-触觉设备模型虽然显示了可观的临床应用价值,但是仍需要进一步的临床测试和改进,特别是使用者舒适性方面的改进。

(周雅春 马皓琳,李士通 校)

Visual displays and auditory alarms are used to convey information on physiological variables in an operating room. However, the exponential growth in the number of physiological variables and the high probability of false alarms has amplified demands on the clinician’s attention. We have extended existing tactile technology to improve situational awareness and produce a practical clinical advisory device. A vibro-tactile display, using two vibrating motors applied to the volar surface of the forearm, was compared to an auditory alarm in a simulated clinical environment. Compared with auditory alarms, the vibro-tactile alarm was as easy to learn and had a better identification rate when used alone or combined with the auditory alarm. Most users preferred the vibro-tactile alarm although the prototype caused some discomfort. Furthermore, a combined vibro-tactile and auditory alarm had reduced accuracy when compared with the vibro-tactile alarm alone. The vibro-tactile modality shows considerable promise for clinical practice but will require further clinical testing and refinement, especially with regard to user comfort.


大鼠鞘内单次注射吗啡引起长时间痛觉过敏:预先注射氯胺酮的保护作用

A Single Dose of Intrathecal Morphine in Rats Induces Long-Lasting Hyperalgesia: The Protective Effect of Prior Administration of Ketamine

Alain C. Van Elstraete, MD, Philippe Sitbon, MD, Fabien Trabold, MD, Jean-Xavier Mazoit, MD, PhD, and Dan Benhamou, MD

Department of Anesthesiology, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris and the Anesthesia Laboratory UPRES-EA 3540, Faculté de Médecine du Kremlin-Bicêtre Université Paris-Sud, Le Kremlin-Bicêtre, France

Anesth Analg 2005;101:1750-1756

 

给予阿片肽可引起包括NMDA受体激活在内的活性伤害过程,导致阿片肽引起的痛觉敏感。对大鼠的实验室观察已报道长期鞘内应用阿片肽后可降低基础的伤害阈值。在本研究中我们试图确定单次鞘内应用吗啡是否可使无伤害大鼠产生痛觉增敏,以及评估预先使用NMDA拮抗剂氯胺酮对伤害感受阈值的影响。雄性Sprague-Dawley大鼠快速鞘内给予吗啡(5μg10μg)后几天用压爪实验测定对伤害刺激的敏感性。同时评价在鞘内给予吗啡前,皮下注射NMBA拮抗剂氯胺酮(10mg/kg)的作用。鞘内单次注射吗啡产生双相伤害感受。早期无痛与伤害感受阈值持续提高35h有关,随后缓发的痛觉过敏则与伤害感受阈值持续降低12天有关。皮下注射氯胺酮对鞘内给予吗啡后的早期无痛期没有显著调节作用,但几乎可完全预防延迟伤害感受阈值的降低。大鼠鞘内单次注射吗啡产生延迟和持续的痛觉增敏,引起阿片肽痛觉敏感的发生。

(赵雪莲 马皓琳,李士通 校)

An active pronociceptive process involving N-methyl-d-aspartate (NMDA) receptor activation is initiated by opioid administration, leading to opioid-induced pain sensitivity. Experimental observations in rats have reported reduction of baseline nociceptive threshold after prolonged spinal opioid administration. In this study we sought to determine whether a single dose of intrathecal morphine can induce hyperalgesia in uninjured rats and to assess the effects of pretreatment with the NMDA-antagonist ketamine on nociceptive thresholds. Sensitivity to nociceptive stimuli (paw pressure test) was assessed for several days after an acute intrathecal injection of morphine (5 µg and 10 µg) in male Sprague-Dawley rats. The effects of subcutaneously administered NMDA-receptor antagonist ketamine (10 mg/kg) before intrathecally administered morphine were also evaluated. A single intrathecal injection of morphine led to a biphasic effect on nociception; early analgesia associated with an increase in the nociceptive threshold lasting 3-5 h was followed by delayed hyperalgesia associated with a decrease in the nociceptive threshold lasting 1-2 days. Subcutaneous ketamine did not significantly modify the early analgesic component but almost completely prevented the delayed decrease in nociceptive threshold after intrathecal administration of morphine. A single intrathecal injection of morphine in rats produces a delayed and sustained hyperalgesia linked to the development of opioid-induced pain sensitivity.


用溴化物、碘苯六醇和钠稀释测定细胞外液量的大小

Measuring the Size of the Extracellular Fluid Space Using Bromide, Iohexol, and Sodium Dilution

Joachim H. Zdolsek, MD, PhD*, Björn Lisander, MD, PhD*, and Robert G. Hahn, MD, PhD{dagger}

*Department of Anesthesiology, University Hospital, Linköping, Sweden; {dagger}Department of Anesthesiology, Karolinska Institute, Stockholm, Sweden

Anesth Analg 2005;101:1770-1777

 

有必要寻找不涉及放射性描记法来评价细胞外液(ECF)容积的方法。因为此目的,我们在10例男性志愿者(平均年龄34 yr)中用了3个方法来测定ECF容积。静脉内输注等渗甘露醇1 L后,稳态血浆溴化物浓度(对照)与血浆碘苯六醇动力学分析的结果及血清钠稀释的动力学分析相比较。用这些描记法的分布容积来显示ECF容积。结果揭示了所有3个方法的结果之间有统计学意义的相关性,虽然平均钠稀释显示的比碘苯六醇的值小0.7 L,比溴化物的值小1.4 L。所有3个方法都显著与体重相关。各方法显示的细胞外液占体重百分比分别为钠18.3%3.1%)、碘苯六醇19.6%1.0%)及溴化物20.5%1.1%)。我们得出结论:钠稀释可在床旁进行,而碘苯六醇和溴化物显示个体之间的差异较小。碘苯六醇同时测定肾小球滤过率,如果医院用这个描记法来进行肾功能的常规评价,那么它应该是个临床可行的选择。

(马皓琳 李士通 校)

There is a need to find methods to assess the size of the extracellular fluid (ECF) volume without involving radioactive tracers. For this purpose, we applied 3 methods for measuring the ECF volume in 10 male volunteers (mean age, 34 yr). Steady-state plasma bromide concentration (control) was compared to the results of kinetic analysis of plasma iohexol and to kinetic analysis of the dilution of serum sodium after IV infusion of 1 L of isotonic mannitol. The volume of distribution of these tracers was used to indicate the ECF volume. The results disclosed statistically significant correlations between the results of all 3 methods, although the average sodium dilution showed 0.7 L lower values than iohexol and 1.4 L lower than bromide. All three methods correlated significantly with body weight. The percentage of the body weight indicated by the methods was 18.3% (3.1%) for sodium, 19.6% (1.0%) for iohexol, and 20.5% (1.1%) for bromide. We conclude that sodium dilution may be performed at bedside but iohexol and bromide showed less intersubject variability. Iohexol simultaneously measures the glomerular filtration rate and should be a viable clinical option if the hospital performs routine assessments of kidney function using this tracer.


单次促肾上腺皮质激素刺激试验不能揭示脓毒症休克时的肾上腺功能不足

A Single Adrenocorticotropic Hormone Stimulation Test Does Not Reveal Adrenal Insufficiency in Septic Shock

Pekka Loisa, MD*, Ari Uusaro, MD{dagger}, and Esko Ruokonen, MD{ddagger}

*Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland; {dagger}Department of Intensive Care, Kuopio University Hospital, Kuopio, Finland; {ddagger}Department of Intensive Care, Tampere University Hospital, Tampere, Finland

Anesth Analg 2005;101:1792-1798

 

对危重病人的肾上腺皮质功能不足的诊断是复杂的。在重症监护病房,促肾上腺皮质激素(ACTH)刺激试验是一种被广泛接受的评价肾上腺功能是否足够的方法。但是,在短时间里对该试验的反应可能具有很大的个体差异。在这项前瞻性研究中,我们研究了ACTH刺激试验在20位患有脓毒症、20位患有脓毒症休克和20位病情危重但是无脓毒症患者的可重复性。在患者进入重症监护病房后或者开始发生脓毒症时,在24小时内连续进行两次ACTH刺激试验。在没有脓毒症的病人中,第1天和第2天对ACTH的反应具有良好的相关性(Pearson相关系数0.689p=0.001)。相反,在患有脓毒症休克的病人中,两次ACTH反应没有相关性(Pearson相关系数0.401p=0.080)。我们的结论是,对于患有脓毒症休克的病人,ACTH刺激试验结果的可重复性很差。对于这些病人来说,单次ACTH刺激试验不可能是诊断肾上腺功能不足的最好方法。

(颜涛 马皓琳,李士通 校)

The diagnosis of adrenocortical insufficiency in critically ill patients is complex. The adrenocorticotropic hormone (ACTH) stimulation test is a widely accepted method for assessing the adequacy of adrenal function in intensive care units, but it is possible that there may be wide variations in responses to the test over a short period of time. In this prospective study, we investigated the reproducibility of the ACTH stimulation test in 20 patients with sepsis, in 20 patients with septic shock, and in 20 critically ill patients without sepsis. Two consecutive ACTH stimulation tests were performed within 24 h after intensive care unit admission or at the onset of sepsis. In patients without sepsis there was good correlation between ACTH responses on days 1 and 2 (Pearson's correlation coefficient, 0.689; P = 0.001). In contrast, in patients with septic shock no correlation was observed between the two ACTH responses (Pearson's correlation coefficient, 0.401; P = 0.080). We conclude that the results of the ACTH stimulation tests are poorly reproducible in septic shock and a single ACTH stimulation test may not be the best method to diagnose adrenal insufficiency in these patients.


全膝关节置换后持续股神经阻滞或者硬膜外镇痛:前瞻性随机对照试验

Continuous Femoral Nerve Blockade or Epidural Analgesia After Total Knee Replacement: A Prospective Randomized Controlled Trial

Michael J. Barrington, FANZCA, David Olive, FANZCA, Keng Low, FANZCA, David A. Scott, PhD, FANZCA, Jennifer Brittain, MBA, BScPT, and Peter Choong, MD, FRACS

Department of Anaesthesia, Department of Physiotherapy, Department of Orthopaedic Surgery, St Vincent’s Hospital, Melbourne, Australia

Anesth Analg 2005;101:1824-1829

 

由于全膝关节置换(TKR)术后疼痛剧烈,我们在前瞻随机试验中比较TKR术后持续股神经阻滞(CRNB)和持续硬膜外镇痛(CEA)的镇痛效果。在脊麻下进行TKR的病人,随机接受股神经注射0.2%布比卡因(中位注射速率9.3mL/h))(n=53),或者硬膜外注射0.2%罗哌卡因复合4µg/mL的芬太尼(中位注射速率7.6mL/h))(n=55)。辅助镇痛是口服罗非昔布和氧可酮及静脉注射吗啡。术后评估疼痛、恶心呕吐、低血压发作、运动神经阻滞、膝关节运动的范围以及康复的标志点。两组的疼痛评分、移动范围和康复相同。CFNB组的恶心和呕吐的发生显著减少(P < 0.002)。相比CEA组,CFNB组需使用更多罗非昔布(P < 0.04)和氧可酮(P < 0.005)。两组中直到48小时,手术肢体比非手术肢体在髋部水平和膝关节水平显示更多运动阻滞(P < 0.05, Mann-Whitney U-test),但是两组间非手术肢体没有差异。CFNBTKR后多种镇痛策略中的一个有效的区域性组成。

(张 马皓琳,李士通 校)

Because postoperative pain after total knee replacement (TKR) can be severe, we compared the analgesic efficacy of continuous femoral nerve blockade (CFNB) and continuous epidural analgesia (CEA) after TKR in this prospective randomized trial. Patients undergoing TKR under spinal anesthesia were randomized to receive either a femoral infusion of bupivacaine 0.2% (median infusion rate 9.3 mL/h) (n = 53) or an epidural infusion of ropivacaine 0.2% with fentanyl 4 µg/mL (median infusion rate 7.6 mL/h) (n = 55). Adjuvant analgesics were oral rofecoxib and oxycodone and IV morphine. Pain, nausea and vomiting, hypotensive episodes, motor block, range of knee movement, and rehabilitation milestones were assessed postoperatively. There were equivalent pain scores, range of movement, and rehabilitation in both groups. There was significantly less nausea and vomiting in the CFNB group (P < 0.002). The CFNB group received more rofecoxib (P < 0.04) and oxycodone (P < 0.005) than the CEA group. The operative limb displayed more motor block than the nonoperative limb in both groups at the level of the hip and knee for up to 48 h (P < 0.05, Mann-Whitney U-test), but there was no difference between groups in the nonoperative limb. CFNB is an effective regional component of a multimodal analgesic strategy after TKR.


三环类抗抑郁药用作局麻药引起的组织损伤

Tissue Injury from Tricyclic Antidepressants Used as Local Anesthetics

Caryn S. Barnet, BA, David N. Louis, MD, and Daniel S. Kohane, MD, PhD

Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts; Department of Pathology and Neurosurgical Service, and Pediatric Intensive Care Unit, Massachusetts General Hospital and Harvard Medical School, Boston Massachusetts

Anesth Analg 2005;101:1838-1843

 

三环类抗抑郁药(TCAs)用作局麻药时的神经毒性已有报导。我们对TCAs引起组织损伤尤其是与许多局麻药一样可以引起肌肉毒性的假设进行了验证。向动物的坐骨神经注射080mM的多虑平、阿米替林或布比卡因(1.5mL用作组织学研究,0.3mL用作神经行为研究)。注射后四天,TCAs引起了缺血性组织损伤。皮下组织显示肿胀变硬,伴出血并与表面皮肤粘连。肌肉呈广泛性苍白。组织病理学显示肌肉及其周围软组织凝固性坏死,伴累及区域附近血管内血栓形成。这些现象在布比卡因组明显减少。TCA注射和布比卡因注射的动物还产生了典型的局麻药肌肉毒性。阿米替林作为局麻药其效价低于布比卡因:产生100min神经阻滞所需的浓度分别为20mM3mM。一些接受高浓度阿米替林的动物产生了自发性的神经阻滞的复发或有不可逆性的神经阻滞,两者都反映了神经的损伤。这两个发现在注射布比卡因的动物中均未发生。TCAs并未显示有任何超过常规局麻药的优点,却可能冒毒性显著增加的危险。

(黄施伟 马皓琳,李士通 校)

Neurotoxicity has been reported with tricyclic antidepressants (TCAs) used as local anesthetics. We examined the hypothesis that TCAs cause tissue injury, particularly myotoxicity, as occurs with many local anesthetics. Animals were given sciatic nerve injections with 0–80 mM doxepin, amitriptyline, or bupivacaine (1.5 mL for histological studies, 0.3 mL for neurobehavioral studies). Four days after injection, the TCAs caused ischemic tissue injury. Subcutaneous tissue showed expansion and hardening, with hemorrhage and adhesion to overlying skin. Muscle was diffusely pale. Histopathology showed coagulative necrosis of muscle and surrounding soft tissues, with thrombus formation in vasculature near affected areas. These findings were much reduced with bupivacaine. TCA-injected and bupivacaine-injected animals also developed characteristic local anesthetic myotoxicity. Amitriptyline proved less potent than bupivacaine as a local anesthetic: the concentrations required to provide 100 min of nerve block were 20 mM and 3 mM, respectively. Some animals receiving large concentrations of amitriptyline developed spontaneous recrudescence of nerve blockade or had irreversible nerve blockade, both of which may reflect nerve injury. Neither finding occurred in animals injected with bupivacaine. TCAs do not appear to offer any advantages over conventional local anesthetics and do appear to risk substantially increased toxicity.


Ambu®喉罩在未用肌松的麻醉患者中应用的多中心研究

A Multicenter Study of the Ambu® Laryngeal Mask in Nonparalyzed, Anesthetized Patients

Carin A. Hagberg, MD*, Frank Samsoe Jensen, MD, PhD, Harald V. Genzwuerker, MD, Renée Krivosic-Horber, MD§, Bettina U. Schmitz, MD*, Jochen Hinkelbein, MD, Marius Contzen, MD, Herve Menu, MD§, and Karim Bourzoufi, MD§

*Department of Anesthesiology, University of Texas Medical School at Houston, Houston, Texas; Department of Anaesthesiology, Gentofte University Hospital, Hellerup, Denmark; University Hospital Mannheim, Institute of Anesthesiology and Intensive Care Medicine, Mannheim, Germany; §Hôpital Jeanne de Flandre, Clinique d’Anesthésie Réanimation, Lille Cedex, France

Anesth Analg 2005;101:1862-1866

 

我们设计这个多中心试验的目的是为了评估一种新型的一次性使用在声门上区的气道设备Ambu®喉罩在择期手术患者中的性能及其安全性。118名未用肌松(ASA分级I-II级,年龄18-65岁,体重指数18-30 kg/m-2)接受全凭静脉麻醉的患者入选该研究。喉罩置入后,气囊内压力在60 cm H2O时纤维镜确定位置和测定口咽部的泄漏压。通气的难易程度通过潮气量设定在6 mL/kg控制通气来确定。注意并记录所有的并发症。经过一次或两次尝试后(分别为92.4% 7.6%)所有的患者都被成功地置入喉罩,置入时间(从面罩拿掉开始到进行第一次通气)是44.9 ± 37.91 s。所有患者都能获得足够的通气,91.5%的患者纤维内镜检查能看到声带,口咽部的泄漏压为24.1 ± 5.44 cm H2O8.5%的患者在喉罩上发现血迹。并发症和患者的抱怨很少并很快消除。在计划行择期手术未用肌松药的患者中,Ambu喉罩能容易并快速置入,同时在正压通气时能够提供安全有效的密闭。

(陈玮 马皓琳,李士通 校)

We designed this multicenter trial to evaluate the performance and safety of the Ambu® laryngeal mask, a new disposable supraglottic airway device, in patients scheduled for elective surgery. One-hundred-eighteen nonparalyzed, anesthetized patients (ASA physical status I–II, age, 18–65 yr, body mass index, 18–30 kg/m–2) receiving total IV anesthesia were included in this study. After device insertion, fiberoptic position and oropharyngeal leak pressure were determined at an intracuff pressure of 60 cm H2O. Ease of ventilation was determined by controlling ventilation at 6 mL/kg tidal volume. Any complications were noted and recorded. Device placement was successful in all patients on the first or second attempt (92.4% or 7.6%, respectively) with an insertion time (removal of face mask until first tidal volume) of 44.9 ± 37.91 s. Adequate ventilation was achieved in all patients and the vocal cords could be visualized by fiberoptic endoscopy in 91.5% of patients. Oropharyngeal leak pressures were 24.1 ± 5.44 cm H2O. Blood was detected on the device in 8.5% of patients. Complications and patient complaints were minor and quickly resolved. The Ambu laryngeal mask is easy and quick to insert and provides a safe and efficient seal during positive pressure ventilation in nonparalyzed patients scheduled for elective surgery.

 

缺血预适应改善肥胖大鼠肝移植的能量状态和提高存活率

Ischemic Preconditioning Improves Energy State and Transplantation Survival in Obese Zucker Rat Livers

Claus U. Niemann, MD*, Ryutaro Hirose, MD{dagger}, Tao Liu, MD{dagger}, Matthias Behrends, MD{ddagger}, Jaimi L. Brown, BS§, Douglas F. Kominsky, PhD§, John P. Roberts, MD{dagger}, and Natalie Serkova, PhD§

*Department of Anesthesia and Perioperative Care, {dagger}Department of Surgery, Division of Transplantation, University of California, San Francisco, California; {ddagger}Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany; §Department of Anesthesiology, Biomedical MRI/MRS, University of Colorado Health Sciences Center, Denver, Colorado

Anesth Analg 2005 101: 1577-1583.

 

肥胖供体的肝常存在脂肪浸润,易遭受缺血再灌注损伤,导致移植物失功并摘除。本研究中作者观察在冷缺血过程中,缺血预适应(10min缺血,随后10min再灌注)能否提高肥胖大鼠供体肝脏的能量储备,减轻肝脏缺血再灌注损伤。本研究在冷缺血不同时点,分别采集肥胖大鼠和瘦型大鼠(对照组)的肝脏样本,采用磁共振光谱(magnetic resonance spectroscopy)分析肝细胞的能量代谢状况,以观察是否缺血预适应能否改善供体肝的细胞代谢。结果发现与对照组相比,冷缺血第一个小时,缺血预适应可显著改善肥胖鼠肝的能量代谢。冷缺血四小时,肥胖鼠肝与对照组之间无明显差异。再灌注8小时,缺血预适应可明显提高对照组鼠肝的能量储备,而对肥胖鼠肝的保护效应消失。后续研究中作者发现,冷缺血前四小时进行缺血预适应,可明显提高肝移植鼠移植后24小时的存活率(从25%提高到88%)。

(郑拥军 陈杰 校)

Livers from obese donors often have fatty infiltrates and are more susceptible to ischemia-reperfusion injury and subsequent graft dysfunction. This often leads to the exclusion of organs from obese donors. We investigated whether ischemic preconditioning (IP, 10 min ischemia, 10 min reperfusion) preserves cellular metabolism in livers from obese Zucker rats during cold ischemia. Liver samples (–IP and +IP) were collected from obese and control lean rats at different time points of cold ischemia (CI) and analyzed by magnetic resonance spectroscopy (1H- and 31P-MRS) to assess whether IP improves hepatic cellular metabolism. IP significantly improved high energy metabolism in IP livers from obese rats when compared with obese controls during the first hours of CI. At 4 h of cold storage, obese IP livers were not different from control lean non-IP livers. The beneficial metabolic effect of IP on livers form obese rats, however, was absent at 8 h of reperfusion. In contrast, in livers from lean rats, IP resulted in improved high-energy metabolism during the entire observation period of 8 h. In a later part of the study, IP of liver grafts from obese rats before 4 h of cold storage improved recipient survival after graft transplantation. IP of liver grafts from obese rats before 4 h of CI increases 24-h survival of recipient animals from 25% to 88%.

 

Paco2变化时应用经食管多普勒测定心输出量的精确度低于温度稀释法

Cardiac Output Measurement Using the Transesophageal Doppler Method Is Less Accurate Than the Thermodilution Method When Changing Paco2

Toshiyuki Sawai, MD, Toshihiro Nohmi, MD, Yoshihiko Ohnishi, MD, Yuji Takauchi, MD, and Masakazu Kuro, MD, PhD

Department of Anesthesiology, Osaka Medical College, Takatsuki, Japan; Department of Anesthesia, National Cardiovascular Center, Suita, Japan

Anesth Analg 2005 101: 1597-1601

.

经食管多普勒是根据降主动脉血流量来测定心输出量(CO)的。因为脑血流量受Paco2的影响,Paco2升高可引起脑血流量增加,从而导致CO的增加。本研究选择30例实施不停跳冠状动脉搭桥手术的病人。术中当Paco2维持在30 mm Hg40 mm Hg时,采用经食管多普勒和温度稀释法测定病人CO。结果发现应用温度稀释法在Paco2 40 mm Hg时测定的CO(4.17 ± 0.94 L/min)明显高于Paco2 30 mm Hg时所测的结果(3.78 ± 0.85 L/min)。而应用经食管多普勒所测结果无明显差异,在Paco2 40 mm Hg30 mm Hg时分别为3.85 ± 0.76 L/min3.77 ± 0.74 L/min。应用Bland-Altman分析研究结果的偏差和精度发现,在Paco240 mm Hg时分别为–0.32 0.49 L/min,在Paco230 mm Hg时为–0.01 0.34 L/min。结果提示两种CO的测量方法在Paco230 mm Hg时一致性较好,但在Paco240 mm Hg时温度稀释法所测值较高。

(齐波 陈杰 校)

Cardiac output (CO) determination using transesophageal Doppler is based on the measurement of descending aortic blood flow. Because cerebral blood flow is dependent on Paco2, an increase in Paco2 would result in an increase of CO because of the increase in cerebral blood flow and vice versa. We enrolled 30 patients undergoing off-pump coronary artery graft surgery in the study. The CO was determined by both transesophageal Doppler and thermodilution while Paco2 was maintained at either 30 mm Hg or 40 mm Hg in random order. The CO by thermodilution was significantly higher at Paco2 of 40 mm Hg (4.17 ± 0.94 L/min) than at 30 mm Hg (3.78 ± 0.85 L/min). On the other hand, there were no significant differences in CO by transesophageal Doppler: 3.85 ± 0.76 L/min at Paco2 of 40 mm Hg and 3.77 ± 0.74 at 30 mm Hg. Bland-Altman analysis yielded bias and precision of –0.32 and 0.49 L/min at Paco2 of 40 mm Hg, and –0.01 and 0.34 L/min at 30 mm Hg. These results indicate that both methods of CO measurement are in agreement at 30 mm Hg of Paco2, but the thermodilution method provides higher values at 40 mm Hg of Paco2.

 

 

七氟醚全身麻醉下儿童喉部滴入蒸馏水引起气道保护性反射的研究

Airway Protective Reflexes Evoked by Laryngeal Instillation of Distilled Water Under Sevoflurane General Anesthesia in Children

Teruhiko Ishikawa, MD, Shiroh Isono, MD, Atsuko Tanaka, MD, Yugo Tagaito, MD, and Takashi Nishino, MD

Department of Anesthesiology (B1), Chiba University Graduate School of Medicine, Tokyo, Japan

Anesth Analg 2005 101: 1615-1618.

为研究全身麻醉的儿童七氟醚如何抑制气道的保护性反射,作者选择12岁以下的儿童作为研究对象。吸入七氟醚和氧实施麻醉。患者使用喉罩并保留自主呼吸。根据麻醉深度分成组1和组2(七氟醚呼气末浓度分别为1%和2%)。主要通过喉部纤维镜成像以及呼吸流速和食道压评估喉部变化。通过纤维镜的管道滴入小剂量蒸馏水0.02ml/kg(最小量为0.2ml)引起气道的保护性反射。喉部的反应分为被动(喉头关闭,喉痉挛,呼吸暂停)和主动(咳嗽,呼气反射,吞咽反射)两类。每组有10名研究对象。在两组患者中,最初的反应都是被动的;然而,在组1中,有8名患者有主动反射;组2病人没有主动反射(P<0.01)。结论:在儿童中,七氟醚全身麻醉的麻醉深度改变气道的保护性反射。

(朱辉 陈杰 校)

To investigate how sevoflurane modifies airway protective reflexes in anesthetized children, we recruited patients younger than 12-yr-old for our study. Anesthesia was induced with inhaled sevoflurane in oxygen. The airway was managed with a laryngeal mask airway and the patient breathing spontaneously. Depending on the depth of anesthesia, the subjects were divided into two groups: Group 1 and Group 2 (1% and 2% of end-tidal sevoflurane concentration, respectively). Behaviors of the larynx were assessed mainly by the fiberscopic images of the larynx as well as respiratory flow and esophageal pressure. A small dose, 0.02 mL/kg of distilled water (minimum 0.2 mL) was instilled to the larynx through a channel of the scope to evoke an airway protective reflex from the larynx. The responses were categorized into passive (laryngeal closure, laryngospasm, and apnea) and active (cough, expiration reflex, and swallowing reflex) responses. Ten subjects were included in each group. In both groups, the primary responses were passive; however, in Group 1, active reflexes were also observed in 8 of 10 subjects; no subjects in Group 2 had active reflexes (P < 0.01). We concluded that, in children, the depth of general anesthesia with sevoflurane modified airway protective reflexes.

 

门诊外科术后出院综合征:首周发生率,强度和风险因素

Postdischarge Symptoms After Ambulatory Surgery: First-Week Incidence, Intensity, and Risk Factors

Kristiina Mattila, MD*, Juhani Toivonen, MD, PhD{ddagger}, Leena Janhunen, MD*, Per H. Rosenberg, MD, PhD{dagger}, and Markku Hynynen, MD, PhD*

*Department of Anesthesiology and Intensive Care Medicine, Jorvi Hospital, Helsinki University Central Hospital, Espoo, Finland; {dagger}Department of Anesthesiology and Intensive Care Medicine, Meilahti Hospital, Helsinki University Central Hospital, Helsinki, Finland; and {ddagger}Department of Anesthesiology, South Carelian Central Hospital, Lappeenranta, Helsinki, Finland

Anesth Analg 2005 101: 1643-1650.

轻微的后遗症,比如疼痛,恶心和嗜睡在外科术后出院早期时有发生。在这项前瞻性观察研究中作者描绘了外科术后早期几种症状的发生率和强度,并研究发病率的预测因素。在两个相似的普通门诊外科单元,3910例病人接受了问卷调查,采用四点模型为上述的症状逐日分级。用多元逻辑回归来分析风险因素,成人与儿童分为不同的组。在这些病人中,有275470%)有回应。在门诊外科术后一周病人经历了很多轻微后遗征。术后第一天的症状很普遍(高达86%的病人),至术后724%的成年患者仍有不适。在成人,疼痛是最普遍的症状,与其它症状相比,常为中等或严重。嗜睡则在儿童更常见。青年,大孩子,和女性更易合并轻微并发症。较长时间的外科手术导致所有病人的疼痛和恶心增加,在成人中增加其它几种症状的风险。

(范颖晖 陈杰 校)

Minor sequelae, such as pain, nausea, and drowsiness, often occur in surgical outpatients in the immediate postdischarge period. In this prospective, observational study was defined the daily incidence and intensity of several symptoms during the first week after surgery and determined predictive factors of minor morbidity. In two similar mixed ambulatory surgery units, 3910 patients received a questionnaire to grade daily the intensity of predefined symptoms on a 4-point scale. Multinomial logistic regression was used to analyze risk factors, with adults and children as separate groups. Of these patients, 2754 (70%) responded. Patients experienced numerous minor sequelae during the first week after ambulatory surgery. Symptoms were common (up to 86% of all patients) on the initial days after surgery and were still reported by 24% of adults on the postoperative Day 7. In adults, pain was the most common symptom and, in comparison with other symptoms, was more often moderate or severe. Drowsiness was most common in children. Younger adults, older children, and women were more prone to experience minor morbidity. Longer duration of surgery led to increased likelihood of pain and nausea in all patients and increased the risk of several other symptoms in adults.

 

门诊外科的周围神经阻滞技术

Peripheral Nerve Block Techniques for Ambulatory Surgery

Stephen M. Klein, MD, Holly Evans, MD, FRCP(C), Karen C. Nielsen, MD, Marcy S. Tucker, MD, PhD, David S. Warner, MD, and Susan M. Steele, MD

Division of Ambulatory Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina

Anesth Analg 2005 101: 1663-1676.

在门诊外科手术麻醉中,周围神经阻滞(PNBs)显得越来越重要。其具有许多理想门诊手术麻醉的特点:外科麻醉,较长的术后镇痛,易出院。适当的技术对于评估其潜在的作用和支持的论据是必不可少的。与全身麻醉相比,PNBs用于上肢手术时阿片类药物的应用显著减少,相关副作用也显著减少。上述优点在紧靠围术期已被证明,但在出院后未进行广泛的调查。下肢手术PNBs对可致较大组织创伤的操作有独特的益处,其良好的镇痛被夸大了,这一点被少量的再入院所证明。当前大多数的研究并不支持此种观点,因为当病人回到家中麻醉消退以后,很难处理疼痛。门诊病人持续PNBs的最初研究证明:止痛效果好于单次静脉注射,并提供持续的术后止痛。这些令人鼓舞的研究不得不考虑家中处理导管的安全性问题。尽管这些研究都支持PNBs,但是大部分研究,或是对于一系列研究或者是相当小的前瞻性研究,很少关注镇痛,阿片类药物的应用以及其副作用。归根结底,具有更大规模的前瞻性资料显示更为广泛结果益处,以便更有说服力促使麻醉科医师使用PNBs,此技术仍然面对很多技术上的挑战。

(张美荣 陈杰 校)

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

 

大鼠中枢咪唑啉受体亚型调控氟烷-肾上腺素性心律失常

Identification of the Central Imidazoline Receptor Subtype Involved in Modulation of Halothane-Epinephrine Arrhythmias in Rats

Kiyokazu Kagawa, MD*, Yukio Hayashi, MD*, Isao Itoh, MD*, Mitsuo Iwasaki, MD*, Koji Takada, MD*, Takahiko Kamibayashi, MD*, Atsushi Yamatodani, MD{dagger}, and Takashi Mashimo, MD*

Department of *Anesthesiology and {dagger}Medical Physics School of Allied Health Sciences, Osaka University Faculty of Medicine, Japan

Anesth Analg 2005 101: 1689-1694.

 

先前作者曾报道有关中枢神经系统的咪唑啉受体参与调节氟烷-肾上腺素性心律失常。这些受体分为I1 I2 亚型,但仍未确定究竟是哪一亚型参与氟烷-肾上腺素性心律失常的调控。本研究的目的是研究调控的亚型。大鼠氟烷麻醉,并连续监测动脉压和室性早搏。致心律失常的肾上腺素定义为15s内出现3个或以上室性早搏的最小剂量的肾上腺素。在氟烷麻醉期间,脑池内的莫索他定出现剂量相关性抑制肾上腺素诱导的心律失常。脑池内的依法克生,一种选择性的I1 受体的拮抗剂,对I2 受体几乎无亲和力,而α-育亨宾是I2 受体的拮抗剂,阻断莫索他定的抗心律失常作用。脑池内的BU224 2-BFI为选择性的I2配体同样能抑制肾上腺素导致的心律失常。这些作用可被依法克生所消除。结论:中枢性I1受体,而不是I2受体在氟烷-肾上腺素性心律失常的抑制中起重要作用。

(忻纪华 陈杰 校)

We previously reported that imidazoline receptors in the central nervous system are involved in modulation of halothane-epinephrine arrhythmias. These receptors have been subclassified as I1 and I2 subtypes, but it is not known which receptor subtype is involved in halothane-epinephrine-induced arrhythmias. We designed the present study to clarify the involvement of central imidazoline receptor subtype in the modulation of halothane-epinephrine-induced arrhythmias. Rats were anesthetized with halothane and monitored continuously for systemic arterial blood pressure and premature ventricular contractions. The arrhythmogenic dose of epinephrine was defined as the smallest dose that produces three or more premature ventricular contractions within a 15-s period. Intracisternal moxonidine dose-dependently inhibited the epinephrine-induced arrhythmias during halothane anesthesia. Intracisternal efaroxan, a selective I1 antagonist with little affinity for I2 subtype, but not rauwolscine, an {alpha}2 antagonist without affinity for imidazoline receptors, blocked the antiarrhythmic effect of moxonidine. Intracisternal BU 224 and 2-BFI, selective I2 ligands, also inhibited the epinephrine-induced arrhythmias dose-dependently; however, these effects were abolished by efaroxan. We conclude that central I1, but not I2, receptors play an important role in inhibition of halothane-epinephrine arrhythmia.

 

瑞芬太尼和丙泊酚诱导的意识消失期间肌松药对双频指数和Datex-Ohmeda熵值的影响

The Influence of a Muscle Relaxant Bolus on Bispectral and Datex-Ohmeda Entropy Values During Propofol-Remifentanil Induced Loss of Consciousness

Ngai Liu, MD*, Thierry Chazot, MD*, Isabelle Huybrechts, MD{dagger}, Jean-Dominique Law-Koune, MD*, Luc Barvais, MD{dagger}, and Marc Fischler, MD*

*Department of Anesthesiology, Hôpital Foch, Suresnes, France; {dagger}Department of Anesthesiology, Hôpital Erasme, ULB, Brussels, Belgium

Anesth Analg 2005 101: 1713-1718.

有关肌松药对双频指数的影响的研究有相互矛盾的结果。前瞻性、随机、双盲的试验中,病人接受了目标浓度的瑞芬太尼合并丙泊酚的输注直到病人意识消失。意识消失后的两分钟,试验组给予单次阿曲库铵,而对照组给予安慰剂。记录以下变量:双频指数,边缘频率,肌电活动,以及用Datex-Ohneda熵监测仪监测状态熵和反应熵。在意识消失时的两组间结果相似。病人意识消失后安慰组用药后较意识消失时的双频指数(P < 0.002),边缘频率 P <0.05, 肌电活动(P <0.002),状态熵(P <0.05),反应熵(P <0.01)均下降。试验组在双频指数(P <0.0001),边缘频率 P <0.01),肌电活动(P <0.0001),状态熵(P <0.0001),反应熵(P <0.0001)下降。试验组在双频指数(P <0.05, 肌电活动(P <0.0001)和 反应熵(P <0.01)方面的下降较安慰剂组显著。浅麻醉病人给予肌松剂时双频指数和反应熵下降,但状态熵则无太大变化。

(郑丽 陈杰 校)

Studies investigating the influence of muscle relaxants on the bispectral index have yielded contradictory results. In our prospective, randomized, double-blind experiments, patients received a fixed target concentration of remifentanil along with a target-controlled infusion of propofol, titrated until loss of consciousness. Two minutes after loss of consciousness, the study group received a bolus injection of atracurium, whereas the control group received a placebo. The following variables were recorded: bispectral index, spectral edge frequency, electromyographic activity, state entropy, and response entropy provided by the Datex-Ohmeda Entropy monitor. Similar values were obtained in both groups at loss of consciousness. Placebo administration induced a decrease in bispectral index (P < 0.002), spectral edge frequency (P < 0.05), electromyographic activ-ity (P < 0.02), state entropy (P < 0.05), and response entropy (P < 0.01) compared with the values measured at loss of consciousness. Atracurium administration induced a decrease in bispectral index (P < 0.0001), spectral edge frequency (P < 0.01), electromyographic activity (P < 0.0001), state entropy (P < 0.0001), and response entropy (P < 0.0001) values. Decreases in bispectral index (P < 0.05), electromyographic activity (P < 0.0001), and response entropy (P < 0.01) were larger after atracurium than placebo injection. In lightly anesthetized patients, myorelaxant administration decreases bispectral index and response entropy, but not state entropy values.


全身使用局麻药缓解神经性疼痛:系统回顾和荟萃分析

Systemic Administration of Local Anesthetics to Relieve Neuropathic Pain: A Systematic Review and Meta-Analysis

Ivo W. Tremont-Lukats, MD*, Vidya Challapalli, MD{dagger}, Ewan D. McNicol, RPh, MS{ddagger}, Joseph Lau, MD§, and Daniel B. Carr, MD{ddagger}§

*Department of Neurology, Medical University of South Carolina, Charleston, SC; {dagger}Department of Anesthesiology and Critical Care, University of Chicago Hospitals, Chicago, IL; {ddagger}Department of Anesthesiology, and §Institute for Clinical Research and Health Policy Studies Tufts-New England Medical Center, Boston, MA

Anesth Analg 2005 101: 1738-1749.

 

作者回顾性研究了随机对照试验,评价全身使用局麻药、空白对照药或其他有效药治疗神经性疼痛的疗效和安全性。共41项研究中,系统回顾包括了不同品质的27项试验。10项利多卡因研究和9项美西律研究适合Meta分析(共有n=706位病人)。神经性疼痛治疗使用利多卡因(用法为每30-60分钟,静脉推注5mg/kg)、美西律(平均剂量,600mg/天)和空白对照药(0-100mm疼痛VAS评分的加权平均差=-10.6095%可信区间:-14.52-6.68P<0.00001)合并用吗啡,加巴喷丁,阿米替林和金刚烷胺(加权平均差=-0.6095%可信区间:-6.965.75)。该治疗方法的优点是对外周神经痛(外伤,糖尿病)和中枢性疼痛的持续性疗效。利多卡因和美西律最主要的副作用为困倦、疲劳、恶心和头晕。全身使用局麻药的副反应发生率较空白对照组高,但与吗啡,阿米替林,加巴喷丁的副反应发生率相似(优势比:1.2395%可信区间:0.226.90)。在临床试验过程中利多卡因和美西律没有明显的副作用,较空白对照组更能缓解神经性疼痛,并与其他用于该情况下的麻醉镇痛药疗效相似。

(肖洁 陈杰 校)

We reviewed randomized controlled trials to determine the efficacy and safety of systemically administered local anesthetics compared with placebo or active drugs. Of 41 retrieved studies, 27 trials of diverse quality were included in the systematic review. Ten lidocaine and nine mexiletine trials had data suitable for meta-analysis (n = 706 patients total). Lidocaine (most commonly 5 mg/kg IV over 30-60 min) and mexiletine (median dose, 600 mg daily) were superior to placebo (weighted mean difference on a 0-100 mm pain intensity visual analog scale = –10.60; 95% confidence interval: –14.52 to –6.68; P < 0.00001) and equal to morphine, gabapentin, amitriptyline, and amantadine (weighted mean difference = –0.60; 95% confidence interval: –6.96 to 5.75) for neuropathic pain. The therapeutic benefit was more consistent for peripheral pain (trauma, diabetes) and central pain. The most common adverse effects of lidocaine and mexiletine were drowsiness, fatigue, nausea, and dizziness. The adverse event rate for systemically administered local anesthetics was more than for placebo but equivalent to morphine, amitriptyline, or gabapentin (odds ratio: 1.23; 95% confidence interval: 0.22 to 6.90). Lidocaine and mexiletine produced no major adverse events in controlled clinical trials, were superior to placebo to relieve neuropathic pain, and were as effective as other analgesics used for this condition.

 

双酯瑞因对炎性和神经病理性伤害性刺激小鼠模型中机械性痛觉过敏的影响

The Effects of Diacerhein on Mechanical Allodynia in Inflammatory and Neuropathic Models of Nociception in Mice

Nara L. M. Quintão, MSc, Rodrigo Medeiros, MSc, Adair R.S. Santos, PhD, Maria M. Campos, PhD, and João B. Calixto, PhD

Departments of Pharmacology and Physiology, Center of Biological Sciences, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil

Anesth Analg 2005 101: 1763-1769.

本实验旨在研究双酯瑞因,一种治疗骨性关节炎的药物,在炎性和神经病理性伤害性刺激小鼠模型中全身性抗痛觉过敏的作用,并将双酯瑞因的效应与临床常用的神经病理性疼痛的治疗药物加巴喷丁做比较。与加巴喷丁相似,双酯瑞因能够明显逆转角叉菜胶引起的机械性痛觉过敏。当双酯瑞因的给药途径由脚掌内注射变为鞘内注射时,它同样能明显降低角叉菜胶引起的伤害性刺激双酯瑞因和加巴喷丁也能明显抑制弗氏完全佐剂(CFA),或部分性坐骨神经结扎(PLSN)造成的机械性痛觉过敏。本实验剂量的双酯瑞因和加巴喷丁对小鼠的运动能力,运动的协调性,及体温均无影响。本研究结果表明,双酯瑞因在角叉菜胶,CFA引起的伤害性刺激模型中,及PLSN造成的神经病理性疼痛中,均具有与加巴喷丁相似的显著性抗痛觉过敏作用。双酯瑞因有望成为治疗炎性和神经病理性疼痛的一种有意义的药物。

(田婕 陈杰 校)

In this study we analyzed the systemic antiallodynic properties of diacerhein, a drug used to treat osteoarthritis, in inflammatory and neuropathic models of nociception in mice. The effects of diacerhein were compared with those of gabapentin, a drug used clinically for the management of neuropathic pain. Similar to gabapentin, diacerhein was able to significantly reverse the mechanical allodynia induced by carrageenan. A significant inhibition of carrageenan-induced nociception was also observed when diacerhein was administered by the intrathecal but not by the intraplantar route. The treatment with diacerhein or with gabapentin also inhibited the mechanical allodynia induced by complete Freund’s adjuvant (CFA) or after the partial ligation of the sciatic nerve (PLSN). In the same range of doses, diacerhein or gabapentin did not affect the locomotor activity, motor coordination, or body temperature of the animals. The present results indicate that diacerhein produces marked antiallodynic effects in carrageenan and CFA nociception models and also inhibits the neuropathic pain after PLSN, with an efficacy similar to that observed for gabapentin. Diacerhein may be a potentially interesting tool for the management of inflammatory and neuropathic pain.

 

早期胶体替换治疗在亚致死性出血性休克模型中的应用

Early Colloid Replacement Therapy in a Near-Fatal Model of Hemorrhagic Shock

Evandro L.A. Ferreira, MD, Renato G.G. Terzi, William A. Silva, and Ana C. de Moraes

Departamento de Cirurgia, Núcleo de Medicina e Cirurgia Experimental, Faculdade de Ciências Médicas – FCM, Universidade Estadual de Campinas - UNICAMP, Campinas, São Paulo, Brazil

Anesth Analg 2005 101: 1785-1791.

 

已有数个研究评估液体治疗的时间、速度及方式在对照性、实验性、低血压出血性休克模型的疗效。在一个亚致死性的实验模型中,作者评估了两种不同溶液的液体复苏治疗对血流动力学和代谢的影响。实验中,30头年幼的大白猪随机分为三个组:组I(对照组,n=10)无出血;组II(羟乙基淀粉,HESn=10, 接受控制性放血使平均动脉压(MAP)在30mmHg,血乳酸>10mM/L,复苏时先使用7mL/kgHES130/0.46%,随后使用33mL/kg的乳酸林格氏液(LR)和自体血回输;组IIILRn=10),接受控制性放血使平均动脉压维持在30mmHg血乳酸>10mM/L,复苏时先使用40mL/kgLR,然后应用自体血回输。研究证实使用HES130/0.4优于LR,主要表现在血流动力学和灌注的差异上。尽管组织灌注提高,但MAP仍然不能完全恢复至基础水平。结论:与输注相同容量的晶体液相比早期输注胶体可更好地促进组织灌注的恢复。

(朱慧琛 陈杰 校)

Several controlled, experimental, hypotensive models of hemorrhagic shock have evaluated the effects of timing, rate, and types of fluid replacement. In a near-fatal experimental model we evaluated the hemodynamic and metabolic effects of two types of solutions for fluid resuscitation. In this study, 30 young Large-White pigs were randomly assigned to three groups: Group I (control, n= 10), not bled; Group II (hydroxyethyl starch, HES, n = 10), submitted to controlled hemorrhage to a mean arterial blood pressure (MAP) of 30 mm Hg and blood lactate >10 mM/L, at which time resuscitation was initiated with 7 mL/kg of HES 130/0.4 6% followed by 33 mL/kg of lactated Ringer's solution (LR) and retransfusion; Group III (LR, n = 10), submitted to controlled hemorrhage to a MAP of 30 mm Hg and blood lactate >10 mM/L, at which time resuscitation was initiated with 40 mL/kg of LR followed by retransfusion. The resuscitation with HES 130/0.4 proved to be superior to LR, expressed by hemodynamic and perfusion variables. Despite improvement in tissue perfusion, MAP did not totally return to baseline values. In conclusion, early colloid infusion resulted in prompt recovery of tissue perfusion when compared with infusion with an equal volume of crystalloid.

 

循环中成熟肾上腺髓质素(adrenomedullin)与足月妊娠血容量有关

Circulating Mature Adrenomedullin Is Related to Blood Volume in Full-Term Pregnancy

Yukio Hayashi, MD*, Hiroshi Ueyama, MD*, Takashi Mashimo, MD*, Kenji Kangawa, PhD{dagger}, and Naoto Minamino, PhD{dagger}

*Department of Anesthesiology, Osaka University Faculty of Medicine; and {dagger}Japan and Research Institute, National Cardiovascular Center, Suita, Osaka, Japan

Anesth Analg 2005 101: 1816-1820.

在妊娠过程中,血浆中肾上腺髓质素的浓度增加。作者测定了血容量、血浆和脑脊液中成熟肾上腺髓质素浓度,检测了血浆和脑脊液中髓质素是否与妊娠期血容量增加有关。该研究中包括47名在腰麻下行手术的妇女。作者首先对需行整形外科手术的非妊娠妇女、妊娠15-18周行妇科手术的妇女和足月妊娠行剖宫产的妇女,测定了血浆和脑脊液中成熟髓质素的浓度。第二部分研究包括20名健康和足月妊娠临产需行剖宫产的妇女。作者应用靛氰绿通过无创的脉搏分光光度法测定了动脉血压和血容量。血浆中成熟的髓质素浓度在非妊娠、妊娠早期和足月妊娠组分别为1.24 +/- 0.982.79 +/- 1.23 4.79 +/- 2.61 fmol/mL (mean +/- sd)。但脑脊液中成熟髓质素并没有显著增加。而且,血浆(而不是脑脊液)中成熟髓质素与每单位体重的血容量有显著的相关性(r2= 0.46; P = 0.0009)。这些发现提示血浆中成熟髓质素浓度增加,而且增加的髓质素与妊娠期间血容量增加有关。

(赵延华 陈杰 校)

Plasma adrenomedullin concentration increases during pregnancy. We measured blood volume and mature adrenomedullin concentration in plasma and cerebrospinal fluid and examined whether mature adrenomedullin in plasma and cerebrospinal fluid was associated with increasing blood volume during pregnancy. We enrolled 47 women undergoing surgery with spinal anesthesia in this study. We first measured mature adrenomedullin concentration in plasma and cerebrospinal fluid of nonpregnant women undergoing orthopedic surgery, pregnant women between 15 and 18 wk of gestation undergoing gynecological surgery, and pregnant women at full-term undergoing cesarean delivery. The second study included 20 healthy and full-term parturients scheduled for cesarean delivery. We measured arterial blood pressure and blood volume by noninvasive pulse spectrophotometry using indocyanine green. Plasma-mature adrenomedullin concentration was 1.24 ± 0.98, 2.79 ± 1.23, 4.79 ± 2.61 fmol/mL (mean ± sd) in the nonpregnant, the early gestation, and the full-term groups, respectively. But in cerebrospinal fluid, mature adrenomedullin did not significantly increase. Furthermore, mature adrenomedullin in plasma, but not cerebrospinal fluid, had a significant correlation with blood volume per unit body weight (r2 = 0.46; P = 0.0009). These findings demonstrate that plasma-mature adrenomedullin concentration increased and that increased plasma-mature adrenomedullin is associated with increased blood volume during pregnancy.

 

芬太尼硬膜外注射可加快罗哌卡因阻滞时感觉和运动神经阻滞的起效时间

Epidural Fentanyl Speeds the Onset of Sensory and Motor Blocks During Epidural Ropivacaine Anesthesia

Chen-Hwan Cherng, MD, DMSc, Chih-Ping Yang, MD*, and Chih-Shung Wong, MD, PhD

Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; *Division of Anesthesiology, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan

Anesth Analg 2005 101: 1834-1837.

 

作者研究了罗哌卡因硬膜外阻滞时在麻醉药液中添加和不添加芬太尼对感觉和运动阻滞起效时间的差异。45名接受膝关节镜手术的年轻男性病人随机分配到三组,每组15名:硬膜外芬太尼组(EF,硬膜外给予1%的罗哌卡因15ml+芬太尼100µg然后静脉注射2ml生理盐水);静脉芬太尼组(IF,硬膜外给予1%的罗哌卡因15ml+生理盐水2ml,然后静脉注射芬太尼100µg);对照组(硬膜外给予1%的罗哌卡因15ml+生理盐水2ml,然后静脉注射生理盐水2ml)。应用针刺法检测感觉神经阻滞,应用改良Bromage评分检测运动神经阻滞。同时记录血流动力学变化、硬膜外阻滞后寒颤和硬膜外芬太尼相关副作用。研究结果表明,EF组感觉神经阻滞平面达到T10的时间(13.0 ± 3.0 min)IF(16.2 ± 3.5 min)和对照组 (17.7 ± 3.6 min) 相比明显缩短(P < 0.05)。运动神经阻滞的Bromage评分达到12分的时间在EF(11.9 ± 4.6 24.4 ± 5.9 min)明显短于IF组(16.9 ± 4.7 30.8 ± 5.6 min, P < 0.05)和对照组(18.3 ± 4.9 32.7 ± 5.7 min, P < 0.05)。硬膜外阻滞后寒颤的发生率在三组间没有明显差异。在EF组有3个病人出现瘙痒症状,在IF组只有1名患者出现瘙痒。没有病人出现恶心、呕吐、呼吸抑制、尿潴留或者低血压等副作用。总之,研究者认为,在1%的罗哌卡因中混合100µg芬太尼进行硬膜外阻滞能够加速感觉和运动神经阻滞的起始时间,且无芬太尼相关并发症。

(苏殿三 陈杰 校)

In this study we examined the onset times of sensory and motor block during epidural ropivacaine anesthesia with and without the addition of fentanyl to the epidural solution. Forty-five young male patients undergoing knee arthroscopic surgery were randomly allocated into 3 groups of 15 patients each: epidural fentanyl (EF; epidural administration of 15 mL of 1% ropivacaine plus 100 µg fentanyl followed by IV injection of 2 mL of normal saline); IV fentanyl (IF; epidural administration of 15 mL of 1% ropivacaine plus 2 mL of normal saline followed by IV injection of 100 µg fentanyl); and control (C; epidural administration of 15 mL of 1% ropivacaine plus 2 mL of normal saline followed by IV injection of 2 mL of normal saline). The sensory and motor blocks were assessed by pinprick and modified Bromage scale, respectively. The hemodynamic changes, postepidural shivering, and side effects of epidural fentanyl were also recorded. There was no difference in the distribution of age, weight, and height among the 3 groups. The onset time of sensory block to the T10 dermatome was significantly more rapid in the EF group (13.0 ± 3.0 min) than in the IF group (16.2 ± 3.5 min, P < 0.05) or C group (17.7 ± 3.6 min, P < 0.05). The onset times of motor block up to Bromage scale 1 and 2 were significantly more rapid in the EF group (11.9 ± 4.6 and 24.4 ± 5.9 min) than in the IF group (16.9 ± 4.7 and 30.8 ± 5.6 min, P < 0.05) or C group (18.3 ± 4.9 and 32.7 ± 5.7 min, P < 0.05). There was no difference in the incidence of shivering among the three groups. Pruritus was observed in three patients of the EF group and one patient of the IF group. No nausea, vomiting, respiratory depression, urinary retention, or hypotension was observed in any patient. We conclude that epidural administration of the mixture of 100 µg fentanyl and 1% ropivacaine solution accelerated the onset of sensory and motor blocks during epidural ropivacaine anesthesia without significant fentanyl-related side effects.

 

择期手术患者贫血的发现、评估与处理

Detection, Evaluation, and Management of Anemia in the Elective Surgical Patient

Lawrence T. Goodnough, MD, Aryeh Shander, MD, Jerry L. Spivak, MD, Jonathan H. Waters, MD, Arnold J. Friedman, MD, Jeffrey L. Carson, MD, E. Michael Keating, MD, Thomas Maddox, MD, and Richard Spence, MD

Departments of Pathology and Medicine, Stanford University, Stanford, California; Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey; Mount Sinai School of Medicine, Mount Sinai Hospital; Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Anesthesiology, Magee Women’s Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Obstetrics and Gynecology, Beth Israel Medical Center, New York, New York; Division of General Internal Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey; Center for Hip and Knee Surgery, St. Francis Hospital, Mooresville, Indiana; Department of Family Practice, St. Luke’s Hospital of Kansas City, Kansas City, Missouri; Department of Surgery, St. Agnes HealthCare, Baltimore, Maryland

Anesth Analg 2005 101: 1858-1861.

在特定人群中,择期手术患者贫血的流行率可能高达75%。一项全国性统计表明35%的择期行关节置换术患者其入院前检测血色素水平<13g/dl。择期手术前3—7天进行包括标准检测在内的检查,预防并有效地评价与处理患者未料的贫血。因此,术前贫血的发现、评价、处理的标准方法被认为是一项不足的医学需要。为了弥补这一知识缺陷,作者召集了许多内科医生就贫血的处理来研究其临床监测方法。择期手术患者术前接受至少30天的血色素监测。因为贫血的鉴别和评价有利于快速诊断和处理潜在的并存症,改善患者的预后。所以不能解释的贫血 (女性Hgb<12g/dl,男性Hgb<13g/dl)应延期手术,直至准确评估。

(顾新宇 陈杰 校)

The prevalence of anemia in elective surgical patients may be as frequent as 75% in certain populations. A national audit demonstrated that 35% of patients scheduled for joint replacement therapy have a hemoglobin <13 g/dL on preadmission testing. Standard practice currently consists of preadmission testing 3 to 7 days before an elective operative procedure, precluding the opportunity to effectively evaluate and manage a patient with unexpected anemia. Therefore, a standardized approach for the detection, evaluation, and management of anemia in the preoperative surgical setting was identified as an unmet medical need. To address this knowledge gap, we convened a panel of physicians to develop a clinical care pathway for anemia management in this setting. Elective surgery patients should receive a hemoglobin (Hgb) determination a minimum of 30 days before the scheduled surgical procedure. Because the identification and evaluation of anemia in this setting will assist in expedited diagnosis and treatment of underlying comorbidities and will improve patient outcomes, unexplained anemia (Hgb <12g/dL for females and <13g/dL for males) should cause elective surgery to be deferred until an evaluation can be performed.

 

增大的心脏和年龄削弱豚鼠离体心脏的麻醉预处理

Increasing heart size and age attenuate anesthetic preconditioning in guinea pig isolated hearts.

Riess ML, Camara AK, Rhodes SS, McCormick J, Jiang MT, Stowe DF

Department of Anesthesiology and Physiology, Cardiovascular Research Center, Medical College of Wisconsin, Milwaukee, WI 53226, USA. mriess@mcw.edu

Anesth Analg. 2005 Dec;101(6):1572-6

 

麻醉预处理(APC)减少心肌缺血/再灌注损伤。最近的调查报导高龄心脏对麻醉预处理不敏感。我们研究在年幼豚鼠中,增大的心脏和年龄增长是否决定对麻醉预处理的敏感性。将用Langendorff离体心脏灌流机准备过的不同重量(1.1-2.2g)和年龄(2-7周)的豚鼠心脏暴露于1.3mM的七氟烷15分钟,接着洗脱30分钟(APCn=20),然后整体缺血30分钟并再灌注120分钟。对照组心脏(n=20)不进行麻醉预处理。等体积下测量左心室压力,心肌梗塞面积由三苯基四氮唑着色决定。实验初期两组间功能数据并无不同,与心脏重量和年龄也无相关性。经过120分钟再灌注,麻醉预处理组中左心室压力,冠状动脉血流和组织生存能力显示出与增大的心脏重量和年龄明显的负相关,在对照组中没有。即,麻醉预处理对体积小/年龄小的心脏功能改善和梗塞面积减少优于对体积大/年龄大的心脏。因此,即使在年幼的豚鼠中,增大的年龄和心脏尺寸削弱了对麻醉预处理的敏感性。这可能对将来的基础科学研究和麻醉预处理在人类临床中应用的可能性具有重要的指示。

(周荻 薛张纲 校)

Anesthetic preconditioning (APC) reduces myocardial ischemia/reperfusion injury. Recent investigations have reported that older hearts are not susceptible to APC. We investigated if increasing heart size with age determines the susceptibility to APC in young guinea pigs. Langendorff-prepared guinea pig hearts of different weights (1.1-2.2 g) and ages (2-7 wks) were exposed to 1.3 mM sevoflurane for 15 min followed by 30 min washout (APC; n = 20) before 30 min global ischemia and 120 min reperfusion. Control hearts (n = 20) were not subject to APC. Left ventricular pressure was measured isovolumetrically and infarct size was determined by triphenyltetrazolium staining. Functional data were not different between groups at the beginning of the experiments nor did they correlate with heart weight or age. At 120 min reperfusion, left ventricular pressure, coronary flow, and tissue viability showed significant negative correlations with increasing heart weight and age in APC but not in control hearts; i.e., APC improved function and attenuated infarct size better in smaller/younger hearts than in larger/older hearts. Thus, increasing age and heart size attenuate the susceptibility for APC even in younger guinea pigs. This may have important implications for further basic science research and the possible clinical applicability of APC in humans.

 

在早期再灌注时对线粒体渗透转运的抑制可以加强异氟醚的心脏保护作用:线粒体KATP通道的作用
Inhibition of mitochondrial permeability transition enhances isoflurane-induced cardioprotection during early reperfusion: the role of mitochondrial KATP channels.

Krolikowski JG, Bienengraeber M, Weihrauch D, Warltier DC, Kersten JR, Pagel PS.
Departments of Anesthesiology, Pharmacology and Toxicology, and Medicine (Division of Cardiovascular Diseases), the Medical College of Wisconsin, Milwaukee, WI 53226, USA.
Anesth Analg. 2005 Dec;101(6):1590-6


在冠状动脉延长梗阻后早期再灌注的缺血期,对线粒体渗透转运孔(mPTP)的抑制可以产生一种短暂的可重复的保护作用。在早期再灌注之前和同时,短暂的暴露于异氟醚也可产生心脏保护作用,但是,mPTP是否与这个有益的效应有关还不得而知。我们检验mPTP是异氟醚起效的条件这个假说,同时也验证线粒体KATP (mKATP)通道在这个过程中的作用。大鼠(n=102)先梗阻冠脉30分钟,然后再灌注3小时生理盐水(对照),在再灌注前3分钟到再灌注后2分钟分给予异氟醚(0.5 or 1.0 MAC),或者给予mPTP抑制剂cyclosporin A (CsA, 5 or 10 mg/kg),或者给予mPTP激动剂atractyloside (5 mg/kg),或者给予选择性mKATP通道拮抗剂5-hydroxydecanoate (5-HD; 10 mg/kg)。其他大鼠给予0.5 MAC异氟醚加5 mg/kg CsA,而没有atractyloside 5-HD。异氟醚(1.0MAC)和CsA(10mg/kg)产生(P < 0.05)梗死面积(21% +/- 4%, 44% +/- 6%, 24% +/- 3%, and 43% +/- 6%, 各自的, 平均值 +/- 标准差, 左室面积; triphenyltetrazolium 染色),以及作为对照的梗死面积(42% +/- 7%)。异氟醚(0.5MAC)加CsA(5mg/kg)也是有保护作用的(27% +/- 4%)atractyloside 5-HD都不单独影响梗死面积,但这些药物抑制了1.0 MAC异氟醚加 10 mg/kg CsA0.5 MAC异氟醚加 5 mg/kg CsA的保护作用。这个结果表明mPTP的抑制加强异氟醚的作用,而mPTP开放抑制异氟醚的作用。在活体,异氟醚介导的对线粒体渗透转运的抑制依赖线粒体KATP通道的激活。

(陆文清译 薛张纲校)

Inhibition of the mitochondrial permeability transition pore (mPTP) mediates the protective effects of brief, repetitive ischemic episodes during early reperfusion after prolonged coronary artery occlusion. Brief exposure to isoflurane immediately before and during early reperfusion also produces cardioprotection, but whether mPTP is involved in this beneficial effect is unknown. We tested the hypothesis that mPTP mediates isoflurane-induced postconditioning and also examined the role of mitochondrial KATP (mKATP) channels in this process. Rabbits (n = 102) subjected to a 30-min coronary occlusion followed by 3 h reperfusion received 0.9% saline (control), isoflurane (0.5 or 1.0 MAC) administered for 3 min before and 2 min after reperfusion, or the mPTP inhibitor cyclosporin A (CsA, 5 or 10 mg/kg) in the presence or absence of the mPTP opener atractyloside (5 mg/kg) or the selective mK(ATP) channel antagonist 5-hydroxydecanoate (5-HD; 10 mg/kg). Other rabbits received 0.5 MAC isoflurane plus 5 mg/kg CsA in the presence and absence of atractyloside or 5-HD. Isoflurane (1.0 but not 0.5 MAC) and CsA (10 but not 5 mg/kg) reduced (P < 0.05) infarct size (21% +/- 4%, 44% +/- 6%, 24% +/- 3%, and 43% +/- 6%, respectively, mean +/- sd of left ventricular area at risk; triphenyltetrazolium staining) as compared with control (42% +/- 7%). Isoflurane (0.5 MAC) plus CsA (5 mg/kg) was also protective (27% +/- 4%). Neither atractyloside nor 5-HD alone affected infarct size, but these drugs abolished protection by 1.0 MAC isoflurane, 10 mg/kg CsA, and 0.5 MAC isoflurane plus 5 mg/kg CsA. The results indicate that mPTP inhibition enhances, whereas opening abolishes, isoflurane-induced postconditioning. This isoflurane-induced inhibition of mitochondrial permeability transition is dependent on activation of mitochondrial KATP channels in vivo.

 

比较局部和全身麻醉在门诊手术的优缺点: 随机对照试验的荟萃分析

A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials.

Liu SS, Strodtbeck WM, Richman JM, Wu CL.
Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA 98111, USA.

Anesth Analg. 2005 Dec;101(6):1634-42.

 

局部麻醉和全身麻醉都已被推荐成为门诊手术最佳的麻醉方法。我们在MEDLINE和其他数据库查找采用荟萃分析,随机对照试验的方法比较局部麻醉和全身麻醉用于门诊手术病人的不同之处。只有在主要传导阻滞时考虑用局部麻醉。局部麻醉可进一步分为中枢神经阻滞和外周神经阻滞。15组(1003病人)和7组(359病人)试验分别用中枢神经阻滞和外周神经阻滞,并用荟萃分析进行处理 。中枢神经阻滞和外周神经阻滞与增加诱导时间,降低疼痛,缩短麻醉后苏醒时间相关。然而,中枢神经阻滞不能缩短麻醉后苏醒时间,也不能减轻恶心反应,尽管减少了镇痛药的用量,且它增加了整个门诊手术的时间,大约35分钟。相比之下,外周神经阻滞能缩短麻醉后苏醒时间,也能减轻恶心,但同样不能缩短门诊手术的总的时间。此荟萃分析说明局部麻醉有它强大的优势,诸如降低了麻醉后苏醒室的利用,减轻了恶心反应及术后疼痛。尽管这些因素被认为可以缩短在门诊手术室的时间,但中枢神经阻滞和外周神经阻滞都不能缩短门诊手术时间。另外一些因素,如不适当的标准和荟萃分析的局限性或许可以解释这种差异。

(王慧琳译,薛张纲校)

\Both regional anesthesia and general anesthesia have been proposed to provide optimal ambulatory anesthesia. We searched MEDLINE and other databases for randomized controlled trials comparing regional anesthesia and general anesthesia in ambulatory surgery patients for meta-analysis. Only major conduction blocks were considered to be regional anesthesia. Regional anesthesia was further separated into central neuraxial block and peripheral nerve block. Fifteen (1003 patients) and 7 (359 patients) trials for central neuraxial block and peripheral nerve block were included in the meta-analysis. Both central neuraxial block and peripheral nerve block were associated with increased induction time, reduced pain scores, and decreased need for postanesthesia care unit analgesics. However, central neuraxial block was not associated with decreased postanesthesia care unit bypass or time or reduced nausea despite reduced analgesics, and it was associated with a 35-min increase in total ambulatory surgery unit time. In contrast, peripheral nerve block was associated with decreased postanesthesia care unit need and decreased nausea but, again, not with decreased ambulatory surgery unit time. This meta-analysis indicates potential advantages for regional anesthesia, such as decreased postanesthesia care unit use, nausea, and postoperative pain. Although these factors have been proposed to reduce ambulatory surgery unit stay, neither central neuraxial block nor peripheral nerve block were associated with reduced ambulatory surgery unit time. Other factors, such as unsuitable discharge criteria and limitations of meta-analysis, may explain this discrepancy

 

日间行前列腺近距离放疗中全麻和脊麻技术的评价

An evaluation of general and spinal anesthesia techniques for prostate brachytherapy in a day surgery setting

Flaishon R, Ekstein P, Matzkin H, Weinbroum AA.
Department of Anesthesiology, Tel Aviv Sourasky Medical Center 6, Weizmann St., Tel Aviv 64239, Israel.

Anesth Analg. 2005 Dec;101(6):1656-8

 

我们评价了日间经会阴前列腺近距离放疗中的四种麻醉技术:单独芬太尼或异丙酚全凭静脉麻醉(TIVA),或芬太尼、硫喷妥钠和异氟醚(F-P-I)联合全麻,与5mg 0.5%大剂量高比重布比卡因(LDS)2.5mg 0.5%高比重布比卡因联合芬太尼25mug小剂量(SDS)椎管内阻滞比较。全麻组手术时间较短。TIVA组病人结束时间(103 +/- 41 min)F-P-I组病人(131 +/- 65 min), SDS (126 +/- 55 min), LDS 病人(169 +/- 65 min)早(TIVA相对所有其他组和脊麻组间P < 0.05)。TIVA组病人离院时间(119 +/- 42 min)F-P-I 组病人(160 +/- 69 min) SDS组或LDS 组病人 (分别为132 +/- 53 and 186 +/- 72 min)早(TIVA对其他组和脊麻组间P < 0.05)。至于术后恶心呕吐、疼痛评分、在家中正常功能的恢复和总体满意度没有组间差异。尽管四种技术都适用于此手术,但TIVA提供了最早的手术结束时间及之后的离院时间。在脊麻技术组间,SDS技术需要更多的术中镇静,但能达到更快的术毕和离院时间。TIVA,异氟醚和芬太尼联合全麻,和两种脊麻技术(5 mg 0.5% 布比卡因,或 2.5 mg 0.5% 布比卡因联合 25 mug 芬太尼)都适用于日间经会阴近距离放疗。TIVA能提供最早的术毕及之后的离院归家时间。2.5 mg布比卡因联合 25 ug 芬太尼椎管阻滞比单用5 mg布比卡因能提供更早的术毕和离院时间。

(徐丽颖译 薛张纲校)

We evaluated four anesthetic techniques for transperineal brachytherapy of the prostate in a day-surgery setting: general anesthesia with either fentanyl and propofol total IV anesthesia (TIVA) or with fentanyl, thiopental, and isoflurane (F-P-I), versus spinal block using 5 mg of 0.5% large-dose spinal hyperbaric bupivacaine (LDS) or 2.5 mg of 0.5% hyperbaric bupivacaine plus fentanyl 25 mug small-dose spinal (SDS). Operating room time was shorter in the general anesthesia groups. TIVA patients voided earlier (103 +/- 41 min) than F-P-I patients (131 +/- 65 min), SDS (126 +/- 55 min), and LDS patients (169 +/- 65 min; P < 0.05 TIVA versus all groups and between spinal groups). TIVA patients were discharged earlier (119 +/- 42 min) than F-P-I patients (160 +/- 69 min) and SDS or LDS patients (132 +/- 53 and 186 +/- 72 min, respectively; P < 0.05 versus all groups and between the spinal groups). There were no intergroup differences regarding postanesthesia nausea or vomiting, pain score, return to normal function at home, or overall satisfaction. Whereas all four techniques are suitable for this procedure, TIVA provides the earliest voiding and consequently fastest discharge. Between spinal techniques, the SDS technique requires more intraoperative sedation but provides earlier voiding and consequently earlier discharge. TIVA, general anesthesia with isoflurane and fentanyl, and two spinal techniques (5 mg of bupivacaine 0.5% or 2.5 mg of bupivacaine 0.5% plus 25 mug of fentanyl) are suitable techniques for transperineal brachytherapy in the day-surgery setting. TIVA allows for earliest voiding and therefore fastest discharge home. Spinal block with 2.5 mg of bupivacaine plus 25 mug of fentanyl provides earlier voiding and consequently earlier discharge than 5 mg of bupivacaine alone.

 

 

兔的外周N-甲基- D-天冬氨酸受体调整非肾上腺素能非胆碱能食道下段括约肌的松弛作用

Peripheral N-methyl-D-aspartate receptors modulate nonadrenergic noncholinergic lower esophageal sphincter relaxation in rabbits.

Kohjitani A, Funahashi M, Miyawaki T, Hanazaki M, Matsuo R, Shimada M.

Department of Dental Anesthesiology, Okayama University Hospital of Medicine and Dentistry, 2-5-1 Shikata-cho, Okayama 700-8525, Japan.

Anesth Analg. 2005 Dec;101(6):1681-8

 

我们研究外周N-甲基- D-天冬氨酸(NMDA)受体在肠肌从通过非肾上腺素能非胆碱(NANC)能松弛食道下段括约肌(LES)的作用。我们测量从日本白鼠上取得的LES等长收缩。用KCl、阿托品和胍乙啶产生肌肉松弛作用。用放射核素的方法测定3',5'-环磷酸鸟苷(cGMP)的浓度。肌肉被暴露在二乙基二硫代氨基酸中使Cu/Zn过氧化物歧化酶失活。MK801以浓度依赖性方式抑制了NANC的松弛作用,并伴随3',5'-环磷酸鸟苷产生的下降。NMDA引起了浓度依赖性的松弛,该种松弛被MK801拮抗。NMDA刺激cGMP产生,而cGMP则被NG-硝基-L-精氨酸,N-硝基-L-精氨酸所抑制。过)氧化物歧化酶(100 U/mL)使由MK801介导的对NANC肌松作用的抑制的浓度依赖曲线右移,反之过氧化氢酶则相反。DETCA使连苯三酚-、氯胺酮-MK801介导的对NANC肌松作用的抑制的浓度依赖曲线左移。这些结果表明外周NMDA受体介导NANC使肌肉松弛,并能通过产生细胞外超氧负离子部分调节NMDA的作用,因此可清除由笑气产生的肌松作用。

(孙卓真 译,薛张纲 审校)

We investigated the role of peripheral N-methyl-D-aspartate (NMDA) receptors in the myenteric plexus in mediating nonadrenergic noncholinergic (NANC) nitrergic relaxation of the lower esophageal sphincter (LES). Isometric contraction of LES strips from Japanese White rabbits was measured. relaxation was induced by KCl (30 mM) in the presence of atropine and guanethidine. The concentration of 3',5'-cyclic guanosine monophosphate (cGMP) was measured using a radioimmunoassay. The muscle strips were exposed to diethyldithiocarbamic acid (DETCA; 3 mM) to inactivate Cu/Zn superoxide dismutase. MK801 (5-methyl-10,11-dihydroxy-5H-dibenzo(a,d)cyclohepten-5,10-imine) inhibited NANC relaxation in a concentration-dependent manner (EC50 = 1.5 x 10(-5) M), accompanied by a decrease in cGMP production. NMDA induced a concentration-dependent relaxation, which was antagonized by MK801. NMDA stimulated cGMP production, which was inhibited by N(G)-nitro-L-arginine. Superoxide dismutase (100 U/mL) shifted the concentration-response relationship of MK801-mediated inhibition of NANC relaxation to the right (EC50 = 3.4 x 10(-5) M), whereas catalase did not. Treatment with DETCA shifted the concentration-response relationships of pyrogallol-, ketamine- and MK801-mediated inhibition of NANC relaxation to the left. These findings suggest that the peripheral NMDA receptors mediate NANC smooth muscle relaxation, and modulate it, in part, through extracellular production of superoxide anions, thus eliminating the relaxant effect of endogenous nitric oxide

 

 

神经内分泌应激反应和心率变异性:全凭静脉麻醉与复合麻醉的比较
Neuroendocrine stress response and heart rate variability: a comparison of total intravenous versus balanced anesthesia.

Ledowski T, Bein B, Hanss R, Paris A, Fudickar W, Scholz J, Tonner PH.
Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Wellington Street Campus, Perth WA 6000.

Anesth Analg. 2005 Dec;101(6):1700-5

 

削弱术中应激反应是改善预后的关键因素。在复合麻醉(BLA)和全凭静脉麻醉(TIVA)中,我们比较了神经内分泌改变和心率变异性(HRV)。43个病人随机接受BLA(七氟醚/瑞芬太尼)或TIVA(丙泊酚/瑞芬太尼)。麻醉深度通过脑电双频指数来监测。应激反应激素水平在7个点测定(P1=基线;P2=气管插管;P3=切皮;P4=最大手术创伤;P5=外科手术结束;P6=气管拔管;P7=气管拔管后15分钟)。HRV通过功率谱分析:极低频率(VLF),低频率(LF),高频率(HF),LF/HF比率,总能量(TP)。在TIVA的P6,LF/HF较高,在TIVA的P3-7,TP值较高(P3: 412.694.2; P4: 266.7114.6; P5: 290.3111.9; P6: 1523.7658.1; P7: 1225.6 342.6 ms2)) BAL表现较高的肾上腺素水平(P7: 100.554 pg/mL),去甲肾上腺素水平(P3: 221119.5P4: 194130.5 pg/mL),促肾上腺皮质激素水平(P210.57.7P5: 5.33.6P6:10.95.3P7: 20.5 7.1 pg/mL)和皮质醇水平(P7:6.93.9 微克/dL)。这显示,与TIVA相比,在耳鼻喉外科手术应用BAL有较高的交感活性。

(孙敏莉译,薛张纲校)

Attenuating intraoperative stress is a key factor in improving outcome. We compared neuroendocrine changes and heart rate variability (HRV) during balanced anesthesia (BAL) versus total IV anesthesia (TIVA). Forty-three patients randomly received either BAL (sevoflurane/remifentanil) or TIVA (propofol/remifentanil). Depth of anesthesia was monitored by bispectral index. Stress hormones were measured at 7 time points (P1 = baseline; P2 = tracheal intubation; P3 = skin incision; P4 = maximum operative trauma; P5 = end of surgery; P6 = tracheal extubation; P7 = 15 min after tracheal extubation). HRV was analyzed by power spectrum analysis: very low frequency (VLF), low frequency (LF), high frequency (HF), LF/HF ratio, and total power (TP). LF/HF was higher in TIVA at P6 and TP was higher in TIVA at P3-7 (P3: 412.6 versus 94.2; P4: 266.7 versus 114.6; P5: 290.3 versus 111.9; P6: 1523.7 versus 658.1; P7: 1225.6 versus 342.6 ms2)). BAL showed higher levels of epinephrine (P7: 100.5 versus 54 pg/mL), norepinephrine (P3: 221 versus 119.5; P4: 194 versus 130.5 pg/mL), adrenocorticotropic hormone (P2 10.5 versus 7.7; P5: 5.3 versus 3.6; P6: 10.9 versus 5.3; P7: 20.5 versus 7.1 pg/mL) and cortisol (P7: 6.9 versus 3.9 microg/dL). This indicates a higher sympathetic outflow using BAL versus TIVA during ear-nose-throat surgery.

 

脊柱L型钙通道阻滞剂消除阿片类药物引起的感觉过敏和抗伤害性刺激作用的耐药性

Spinal L-Type Calcium Channel Blockade Abolishes Opioid-Induced Sensory Hypersensitivity and Antinociceptive Tolerance

Ahmet Dogrul, Edward J. Bilsky, Michael H. Ossipov, Josephine Lai, and Frank Porreca

Address correspondence and reprint requests to Frank Porreca, PhD, Department of Pharmacology, College of Medicine, University of Arizona, AHSC, 1501 North Campbell Ave., Tucson, AZ 85724.

Anesth Analg 2005 101: 1730-1735.

 

近期的研究发现长期使用吗啡可引起反常的疼痛加剧,这种吗啡抗伤害性刺激作用的耐药性可以解释疼痛加剧的状态。虽然引起阿片类药物介导疼痛异常的机理还不清除,很多证据表明刺激诱导兴奋性递质增加,从而支持发生这种情况的可能性。L型钙通道是兴奋性神经递质释放的关键,我们假设阻滞L型钙通道可以改变阿片类药物引起的感觉过敏和抗伤害性刺激作用的耐药性。使用Swiss-Webster雄性小鼠,分两组,一组鞘内注射吗啡(10µg)一组鞘内注射吗啡(10µg)宇阿洛地平(10µg)的混合液,一日两次,共注射八周。重复注射吗啡组小鼠对触觉和温度觉刺激反应增强。同时使用假定的选择性L型钙通道阻滞剂阿洛地平可以预防这种超敏的发生。此外,连续注射吗啡8周的小鼠,其吗啡抗伤害性刺激剂量-效应曲线明显右移,表明出现抗伤害性刺激的耐药性。而同时注射阿洛地平的小鼠并未出现耐药性。这些研究结果表明,L型钙通道阻滞剂,如阿洛地平,可以预防鞘内使用吗啡引起的阿片类药物介导的痛觉过敏及抗伤害性刺激的耐药性,其原理可能是降低了刺激诱导的兴奋性神经递质的释放。

(金琳 译,薛张纲 审校)

Recent studies have suggested that prolonged exposure to morphine results in the development of paradoxical, abnormal enhanced pain. It has also been suggested that this enhanced pain state may be interpreted as antinociceptive tolerance. Although the precise mechanisms that drive opioid-induced abnormal pain are not well known, considerable evidence suggests that this state may be supported by enhanced, stimulus-evoked excitatory transmission. We hypothesized that blockade of L-type calcium channels, which are critical for excitatory neurotransmitter release, would alter the development of opioid-induced hyperalgesia and antinociceptive tolerance. Male, Swiss-Webster mice received twice-daily intrathecal injections of morphine (10 g) alone or in combination with amlodipine (10 g) for 8 days. Mice receiving repeated morphine injections developed enhanced responses to tactile and thermal stimuli. These hypersensitivities were prevented by the coadministration of the putative selective L-type calcium channel blocker amlodipine. Moreover, mice receiving morphine for 8 days demonstrated a significant rightward shift of the morphine antinociceptive dose-response curve, indicative of antinociceptive tolerance, whereas those that also received amlodipine along with morphine did not demonstrate tolerance. These results suggest that blockade of the L-type calcium channels with amlodipine prevented opioid-induced hyperalgesia and the expression of antinociceptive tolerance to spinal morphine, presumably by reducing stimulus-induced excitatory neurotransmitter release.

 

内皮素对坐骨神经慢性收缩性损害后神经病理性疼痛的影响

A Role for Endothelin in Neuropathic Pain After Chronic Constriction Injury of the Sciatic Nerve

Markus Klass, MD, PhD, Allen Hord, MD, Melissa Wilcox, BA, Don Denson, PhD, and Marie Csete, MD, PhD

Departments of Anesthesiology and Cell Biology, Emory University School of Medicine, Atlanta, Georgia

Address correspondence and reprint requests to Marie Csete MD, PhD, Emory Anesthesiology Laboratories, 1462 Clifton Rd NE, Room 420, Atlanta GA 30322.

Anesth Analg 2005;101:1757-1762

 

本研究目的是内皮素对神经病理性疼痛的影响。内皮素(ET)是个家族性成员,包括ET-1ET-2ET-3,是控制血管张力的广泛分布的多肽类物质。ET-1通过激活ETA受体导致激烈痛,ETA是通过ETB受体激活启动疼痛信号而被调节。利用小鼠坐骨神经慢性收缩性损害模型,我们发现,ETA受体拮抗药能快速地明显地降低损伤5天后热和机械的过敏性痛觉反应。而且,ET-1ETA受体能在慢性收缩性损伤部位局限性上调信号和蛋白水平,表明ET-1可能参与损伤后疼痛的产生。数据显示ET-1作为一个全身的疼痛调节的重要因子,同时显示ETA拮抗剂作为一个治疗神经病理性疼痛的潜在的新的方法值得研究。

(吴德华译 薛张纲校)  

The purpose of this study was to explore the role of endothelin in neuropathic pain. Endothelins (ET) are a family (ET-1, ET-2, ET-3) of ubiquitously expressed peptides involved in control of vascular tone. Injected ET-1 causes intense pain via activation of ETA receptors, modulated by analgesic signals initiated by ETB receptor activation. Using a rat model of chronic constriction injury of the sciatic nerve, we found that pharmacologic ETA receptor antagonism acutely and significantly reduced thermal and mechanical hyperalgesic responses 5 days after injury. Furthermore, ET-1 and the ETA receptor are locally upregulated at the site of chronic constriction injury at both the message and the protein levels, suggesting that ET-1 may be involved in establishing pain after the injury. These data point to ET-1 as an important mediator of pain in general and suggest that ETA antagonism deserves study as a potential novel therapy for neuropathic pain.

 

危重病人中心静脉导管的菌落:比较标准导管和两种含抗菌剂导管的前瞻性随机对照研究

Central Venous Catheter Colonization in Critically Ill Patients: A Prospective, Randomized, Controlled Study Comparing Standard with Two Antiseptic-Impregnated Catheters

Martin W. Dünser, MD*, Andreas J. Mayr, MD*, Guido Hinterberger, PhD, Cornelia Lass Flörl, MD, Hanno Ulmer, PhD, Stefan Schmid, MD*, Barbara Friesenecker, MD*, Ingo Lorenz, MD*, and Walter R. Hasibeder, MD

*Division of General and Surgical Intensive Care Medicine, Department of Anesthesia and Critical Care Medicine, Institute for Hospital Hygienics and Social Medicine, and Institute for Medical Biostatistics, Innsbruck Medical University; Department of Anesthesia and Critical Care Medicine, Krankenhaus der Barmherzigen Schwestern, Ried I. Innkreis, Austria

Anesth Analg 2005 101: 1778-1784.

 

在这个非盲的、随机对照的前瞻性研究中,我们比较了标准的无预充剂的中心静脉导管(CVC)和银涂层及预充洗必太磺胺嘧啶银(CH-SS)两种中心静脉导管(CVC)的菌落率。病人特征,CVC穿刺部位,留置时间以及采用半定量和定量微生物技术检测菌落作为数据记录下来。275名危重病人被纳入研究队列。共放置了160个标准导管、160个银涂层导管和165个预充CH-SS导管。CVC菌落在各研究组间有显著差异(P = 0.029)。在菌落率和1000导管日菌落方面,标准导管与银涂层导管之间差异无显著性(P = 0.564; P = 0.24),与CH-SS导管相比亦然(P= 0.795; P = 0.639)。当两比较抗菌效果时,CH-SS导管菌落率显著低于银涂层导管(16.9% 7.3%; P = 0.01; 1000导管日18.2% 7.5%; P = 0.003; 相对危险度 0.43; 95% 可信区间 0.21–0.85)。然而,标准导管和银涂层导管首次菌落分别发生在置管后23天,CH-SS导管在7天后才有菌落。总之,由于重症监护时导管菌落发生率很低,且留置时间常超过10天,与标准聚氨酯导管相比,含抗菌剂导管并不能有效防止导管菌落的发生。

(金 薛张纲 校)

In this prospective, randomized, controlled, unblinded study, we compared colonization rates of a standard, unimpregnated central venous catheter (CVC) with rates for silver-coated and chlorhexidine-silversulfadiazine (CH-SS)-impregnated CVC. Patient characteristics, CVC insertion site, indwelling time, and colonization detected by semiquantitative and quantitative microbiologic techniques were documented. Two-hundred-seventy-five critically ill patients were included into the study protocol. One-hundred-sixty standard, 160 silver (S)-coated, and 165 externally impregnated CH-SS CVC were inserted. There was a significant difference in CVC colonization rates among study groups (P = 0.029). There was no difference in the colonization rate and the colonization per 1000 catheter days between standard and S-coated (P = 0.564; P = 0.24) or CH-SS-coated CVC (P= 0.795; P = 0.639). When comparing antiseptic CVC with each other, colonization rates were significantly less with CH-SS-impregnated than with S-coated CVC (16.9% versus 7.3%; P = 0.01; 18.2 versus 7.5 of 1000 catheter days; P = 0.003; relative risk, 0.43; 95% confidence interval, 0.21–0.85). Whereas standard and S-coated CVC were first colonized 2 and 3 days after insertion, respectively, CH-SS CVC were first colonized only after 7 days. In conclusion, antiseptic-impregnated CVC could not prevent catheter colonization when compared with standard polyurethane catheters in a critical care setting with infrequent catheter colonization rates and CVC left in place for >10 days.

 

ADP-核糖合成酶抑制剂在大鼠内脏动脉缺血再灌注损伤后改善肺动脉对内皮依赖性血管扩张剂的舒张作用

Inhibition of Poly (ADP-ribose) Synthetase Improves Pulmonary Arterial Endothelium-Dependent Relaxation After Ischemic-Reperfusion Injury of Splanchnic Artery in Rats

Hirofumi Nagata, Takashi Horiguchi, Keiji Enzan, Toshiaki Nishikawa, and Kenji Suzuki

Department of Anesthesia and Intensive Care, Akita University School of Medicine, Hondo 1-1-1, Akita City, Akita 010-8543, Japan.

Anesth Analg 2005 1016: 1799-1804.

 

聚二磷酸腺苷核糖合成酶(PARS)在内脏动脉缺血再灌注损伤(IR)后调节肺动脉收缩及舒张反应的机制尚未明确。我们用PARS的抑制剂—三氨苯酰胺研究这一反应。钳夹大鼠肠系膜上动脉60分钟,再开放60分钟,建立IR模型。在2组治疗组,再灌注前10分钟分别静脉予5 10 mg/kg三氨苯酰胺的单次剂量,随后再灌注过程中分别以5 10 mg.kg(-1).h(-1)静脉维持(IR + PARS抑制剂510组),在非治疗组,不给予三氨苯酰胺,仅静滴生理盐水(IR组)。在对照组,虽实施手术,但肠系膜上动脉未闭塞(伪组)。分离肺动脉并在试管内评价药物作用。IR组显示:肺动脉对新福林的收缩作用并未减弱,但较对照组,其对内皮依赖性血管扩张剂、乙酰胆碱和光辉霉素的舒张作用明显受到抑制。IR + PARS抑制剂510组较IR组,对内皮依赖性血管扩张剂的舒张反应有所增强。我们推断:IR减弱了肺动脉对内皮依赖性血管扩张剂的舒张反应,而PARS抑制剂能够改善舒张作用。

(王丽珺译 薛张纲校)

The role of poly (adenosine diphosphate-ribose) synthetase (PARS) in the contractile and relaxant responses of pulmonary arteries injured by ischemia and reperfusion (IR) of splanchnic artery has not been evaluated. We examined these responses by using 3-aminobenzamide, a pharmacological inhibitor of PARS. IR models in rats were induced by clamping the superior mesenteric artery for 60 min, followed by release of the clamp for 60 min. In the 2 treated groups, 5 or 10 mg/kg of 3-aminobenzamide was administered as an IV bolus at 10 min before reperfusion, followed by infusion rates of 5 and 10 mg.kg(-1).h(-1), respectively, during the period of reperfusion (IR + PARS inhibitor 5 and 10 groups). In the vehicle-treated group, 3-aminobenzamide was not given, but IV saline was administered (IR group). In the control group, surgery was performed, but the superior mesenteric artery was not occluded (sham group). The pulmonary arteries were isolated, and effects of drugs were evaluated in vitro. The IR group showed no attenuation of the contractile responses of the pulmonary artery to phenylephrine. The relaxant responses to endothelium-dependent vasodilators, acetylcholine, and A23187 in the IR group were significantly inhibited when compared with the sham group. The reduction in the relaxant response to endothelium-dependent vasodilators was improved in the IR + PARS inhibitor 5 and 10 groups when compared with the IR group. We concluded that IR attenuated the relaxant responses of the pulmonary artery to endothelium-dependent vasodilators and that PARS inhibitors ameliorate the reduction in the relaxant response

 

确定术后镇痛的硬膜外导管位置的两种非直接方法的比较性研究

A prospective comparative study of two indirect methods for confirming the localization of an epidural catheter for postoperative analgesia.
de Medicis E, Tetrault JP, Martin R, Robichaud R, Laroche L.
Departement d'Anesthesiologie Centre Hospitalier Universitaire de Sherbrooke 3001, 12 E. Avenue Nord Sherbrooke, Quebec, Canada J1H 5N4. estria1@globetrotter.net
Anesth Analg 2005 101: 1830-1833.

 

我们随机地用两种非直接地方法确定218名手术病人硬膜外导管位置,分别是硬膜外刺激实验,硬膜外压力波形分析。硬膜外隙是通过落空感确定的。导管置入硬膜外隙5cm,预充09%生理盐水5ml。这两种方法的阳性预测值和特异性都很高,但敏感性不高(80EST,81%EPWA),阴性预测值都比较低(16EST,17%EPWA)。两种方法结合起来敏感性增加(97%),阴性预测值(57%)。如果对小于10mA的刺激不仅包括运动反应还包括感觉的话,EST的敏感性要增加到87%。我们建议加入感觉反应的测试到比较的标准中。老年病人的EPWA的敏感性更高:大于80岁的病人的敏感性是94%,小于40岁是63%,4060岁是73%,6080岁是85%。我们的结论是两种方法在确定硬膜外导管位置上是相当的。

(钟静译 薛张纲校)
We prospectively evaluated, in randomized order, 2 indirect methods of confirming the localization of an epidural catheter for postoperative analgesia in 218 surgical patients: epidural stimulation test (EST) and epidural pressure waveform analysis (EPWA). The epidural space was localized by using a loss of resistance technique. All catheters were inserted 5 cm into the epidural space and primed with 5 mL of 0.9% normal saline. There were no differences between the methods: the positive predictive value and specificity were high (100% in both groups), but the sensitivity was moderate (80% for EST and 81% for EPWA) and the negative predictive value was low (16% for EST and 17% for EPWA). Combining both methods yielded better sensitivity (97%) and negative predictive value (57%) (P < 0.001). The sensitivity of EST was increased to 87% (P < 0.05) if sensory response was included as well as motor response for stimulation less than 10 mA. We suggest the inclusion of sensory response in the appropriate dermatome at a current <10 mA as a criterion for adequate epidural catheter localization for EST testing. EPWA sensitivity was significantly better with older patients: 94% for patients older than 80 yr compared with 63% for patients younger than 40, 73% for patients 40 to 60, and 85% for patients aged 60 to 80 yr (P = 0.03). We conclude that the two tests are comparable for confirming catheter placement.

 

手术后颤抖的独立危险因素
Independent risk factors for postoperative shivering.
Eberhart LH, Doderlein F, Eisenhardt G, Kranke P, Sessler DI, Torossian A, Wulf H, Morin AM.

Department of Anesthesiology and Critical Care, Philipps-University Marburg, Baldingerstr. 1, D-35033 Marburg, Germany. eberhart@mailer.uni-marburg.de
Anesth Analg. 2005 Dec;101(6):1849-57.

 

手术后颤抖(PAS)对病人的是不舒服的,也是有潜在风险的。在这个观察性试验中,我们试图确定全麻后PAS的独立危险因素。通过1340个连续的病人,PAS潜在的危险因子被记录。记录颤抖,外周和中心体温,以及在PACU的加温。数据被分为评估组(n = 1000)和确认组(n = 340)。第一组被用来确定PAS的独立危险因素和确定风险大小用于backward-elimination logistic regression 分析。用确定组通过ROC曲线分析和线性回归在预测的和实际发生的PAS之间来验证假设的模型的区别度和刻度。PAS的发生率是11.6%有三个主要的危险因素:年轻,内部修复手术,中心体温低,年龄是最重要得。风险的分数来自一个有合理区分力的分析,在ROC曲线下面积为0.6995%可信区间,0.60-0.78; P < 0.0001)而且,刻度曲线的方程(y = 0.69x + 6; R2= 0.82; P < 0.05) 在预测的和实际的PAS发生率之间有一个很好的,统计学上的重要一致。在目前的研究,术后颤抖可以在满意的精确性下用四个危险因素预测。这个模型可以作为一个临床工具来指导临床工作者合理的使用防颤抖药物。

(陆文清译 薛张纲校)

Postoperative shivering (PAS) is uncomfortable for patients and potentially risky. In this observational trial we sought to identify independent risk factors for PAS after general anesthesia. Potential risk factors for PAS were recorded in 1340 consecutive patients. Signs of shivering, peripheral and core temperature, and thermal comfort were recorded in the postanesthetic care unit. The data were split into an evaluation data set (n = 1000) and a validation data set (n = 340). The first was used to identify independent risk factors for PAS and to formulate a risk score using backward-elimination logistic regression analysis. The proposed model was subsequently tested for its discrimination and calibration properties using receiver operating characteristic (ROC)-curve analysis and linear correlation between the predicted and the actual incidences of PAS in the validation group. The incidence of PAS was 11.6%. There were three major risk factors: young age, endoprosthetic surgery, and core hypothermia, with age being the most important. The risk score derived from this analysis had a reasonable discriminating power, with an area under the ROC-curve of 0.69 (95% confidence interval, 0.60-0.78; P < 0.0001). Furthermore the equation of the calibration curve (y = 0.69x + 6; R2= 0.82; P < 0.05) indicated a good and statistically significant agreement between predicted and actual PAS incidence. Postoperative shivering can be predicted with acceptable accuracy using the four risk factors identified in the present study. The presented model may serve as a clinical tool to help clinicians to rationally administer prophylactic antishivering drugs.