Anesthesia & Analgesia

December 2005

Table of Content

CARDIOVASCULAR ANESTHESIA:

增大的心臟和年齡削弱豚鼠離體心臟的麻醉預處理

(周荻 譯 薛張綱 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.

缺血預適應改善肥胖大鼠肝移植的能量狀態和提高存活率

擁軍 陳傑 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

異氟醚通過抑制蛋白激酶、JNKERK來保護腎功能免受缺血再灌注的損害

(裘毅敏 馬皓琳,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

在早期再灌注時對線粒體滲透轉運的抑制可以加強異氟醚的心臟保護作用:線粒體KATP通道的作用
(陸文清譯 薛張綱校)

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變化時應用經食管多普勒測定心輸出量的精確度低於溫度稀釋法

(齊波 陳傑 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術中的應用:一項隨機對照試驗系統性綜述

(彭中美 馬皓琳, 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:

七氟醚全身麻醉下兒童喉部滴入蒸餾水引起氣道保護性反射的研究

(朱輝 陳傑 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.

可樂定用於小兒七氟醚麻醉後躁動的治療

(黃佳佳 馬皓琳,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.

由代理人控制兒童腫瘤患者自控鎮痛的安全性

(周志堅 馬皓琳,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:

比較局部和全身麻醉在門診手術的優缺點: 隨機對照試驗的薈萃分析

(王慧琳譯,薛張綱校)

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.

門診外科術後出院綜合征:首周發生率,強度和風險因素

(範穎暉 陳傑 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.

比較雷芬太尼或硫酸鎂與安慰劑在減小電驚厥療法的血流動力學反應

(黃麗娜 馬皓琳,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.

日間行前列腺近距離放療中全麻和脊麻技術的評價

(徐麗穎譯 薛張綱校)

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.

門診外科的周圍神經阻滯技術

(張美榮 陳傑 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:

舒芬太尼在人體的血管擴張作用

(邱鬱薇 馬皓琳,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-天冬氨酸受體調整非腎上腺素能非膽鹼能食道下段括約肌的鬆弛作用

(孫卓真 譯,薛張綱 審校)

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.

大鼠中樞咪唑啉受體亞型調控氟烷-腎上腺素性心律失常

(忻紀華 陳傑 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.

成人丹曲林的分室藥代動力學:惡性高熱協會的劑量指導方針有用嗎?

(張瑩 馬皓琳,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.

神經內分泌應激反應和心率變異性:全憑靜脈麻醉與複合麻醉的比較

(孫敏莉譯,薛張綱校)

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:

瑞芬太尼和丙泊酚誘導的意識消失期間肌松藥對雙頻指數和Datex-Ohmeda熵值的影響

(鄭麗 陳傑 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.

振動-觸覺顯示器樣機用於生理監測的評估

(周雅春 馬皓琳,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型鈣通道阻滯劑消除阿片類藥物引起的感覺過敏和抗傷害性刺激作用的耐藥性

(金琳 譯,薛張綱 審校)

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. 

全身使用局麻藥緩解神經性疼痛:系統回顧和薈萃分析

(肖潔 陳傑 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.

大鼠鞘內單次注射嗎啡引起長時間痛覺過敏:預先注射氯胺酮的保護作用

(趙雪蓮 馬皓琳,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.

內皮素對坐骨神經慢性收縮性損害後神經病理性疼痛的影響

(吳德華譯 薛張綱校)

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.

 

雙酯瑞因對炎性和神經病理性傷害性刺激小鼠模型中機械性痛覺過敏的影響

(田婕 陳傑 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、碘苯六醇和鈉稀釋測定細胞外液量的大小

(馬皓琳 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.

危重病人中心靜脈導管的菌落:比較標準導管和兩種含抗菌劑導管的前瞻性隨機對照研究

(金 薛張綱 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.

早期膠體替換治療在亞致死性出血性休克模型中的應用

(朱慧琛 陳傑 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.

單次促腎上腺皮質激素刺激試驗不能揭示膿毒症休克時的腎上腺功能不足

(顏濤 馬皓琳,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-核糖合成酶抑制劑在大鼠內臟動脈缺血再灌注損傷後改善肺動脈對內皮依賴性血管擴張劑的舒張作用

(王麗珺譯 薛張綱校)

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:

迴圈中成熟腎上腺髓質素(adrenomedullin)與足月妊娠血容量有關

(趙延華 陳傑 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:

全膝關節置換後持續股神經阻滯或者硬膜外鎮痛:前瞻性隨機對照試驗

(張 馬皓琳,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.

確定術後鎮痛的硬膜外導管位置的兩種非直接方法的比較性研究

(鍾靜譯 薛張綱校)

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羅呱卡因阻滯時感覺和運動神經阻滯的起效時間

(蘇殿三 陳傑 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.

三環類抗抑鬱藥用作局麻藥引起的組織損傷

(黃施偉 馬皓琳,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:

手術後顫抖的獨立危險因素
(陸文清譯 薛張綱校)

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.

擇期手術患者貧血的發現、評估與處理

(顧新宇 陳傑 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應用的多中心研究

(陳瑋 馬皓琳,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.

異氟醚通過抑制蛋白激酶、JNKERK來保護腎功能免受缺血再灌注的損害

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

 

異氟醚有對抗心、腦缺血的藥物預處理作用,但對腎臟是否也存在同樣的作用,尚不明了。在本研究中,我們通過大鼠的腎臟研究異氟醚的藥物預處理作用。在異氟醚預處理組(在腎缺血前予1.5%異氟醚20min)再灌注後2448h時的血清肌酐(1.2±0.71.1±0.2mg/dL)及血尿素氮(99±29 187±31mg/dL)明顯小於非預處理組(肌酐;2.4±1.22.9±0.9mg/dL,尿素氮;62±19 79±20mg/dL)。我們同時研究了異氟醚腎臟預處理所涉及到的細胞內信號傳導問題。腎臟預處理組中的應激蛋白激酶、JNKERK,而非p38,明顯小於非預處理組(P0.05=。我們得到結論,異氟醚在缺血前給予有對抗腎臟缺血再灌注損傷的預處理作用。異氟醚預處理的機制可能涉及蛋白激酶、JNKERK的抑制。

(裘毅敏 馬皓琳,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術中的應用:一項隨機對照試驗系統性綜述

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

 

抑肽酶治療是一種減少出血和輸血的較有希望的方法。然而整形外科手術中使用抑肽酶的有效性和安全性,尚存在爭議。我們在電子資料庫中檢索有關抑肽酶在整形外科手術中的有效和安全性的隨機對照試驗。分析了包括總共506例行較大整形外科手術病人的13個試驗。手術中和圍手術期血液丟失在抑肽酶治療病人明顯少於對照病人(手術中血液丟失的加權均數差 [WMD] = –229 mL, 95% 可信區間[CI] = –367 –91 mL, P = 0.0011;圍手術期血液丟失的WMD = –557 mL; 95% CI = –860–254 mL; P < 0.0001)。抑肽酶處理的病人術中和圍術期輸注的庫存紅細胞(RBC)單位(U)顯著少於對照病人(術中RBC UWMD= –1.1 U95% CI = –1.7–0.4 UP = 0.0001 圍術期RBC UWMD = –1.1 U; 95% CI = –1.7–0.5 U; P < 0.0001。抑肽酶與深靜脈血栓的發生率升高無關(幾率= 0.39; 95% CI = 0.141.05, P = 0.061)。作者得出結論,抑肽酶減少手術中和圍手術期血液丟失和輸異體血的需要量,整形外科大手術病人用藥物或機械性預防時,抑肽酶與深靜脈血栓的危險性增加可能並沒有關係。

(彭中美 馬皓琳, 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.


可樂定用於小兒七氟醚麻醉後躁動的治療

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

 

可樂定可有效治療兒童七氟醚引起的麻醉後躁動。我們對兒科門診手術診所收入的169名兒童進行研究,以對可樂定減少躁動風險定量。將接受七氟醚全麻附加區域或中樞阻滯的受試兒童在麻醉前隨機分配到兩個組:可樂定2 μg/kg及安慰劑組。由不瞭解麻醉方法的觀察者評估恢復指標及躁動的存在。疼痛和不適評分在可樂定組顯著下降,躁動以及嚴重躁動的幾率分別下降了57% (P = 0.029)67%(P = 0.064)。發生躁動及嚴重躁動的相對危險度分別為0.43 (95% 可信區間, 0.24–0.78)0.32 (0.09–1.17)。可樂定可顯著降低兒童七氟醚麻醉後躁動發生率。

(黃佳佳 馬皓琳,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.


由代理人控制兒童腫瘤患者自控鎮痛的安全性

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,我們通過評價497224h時段的PCA使用(其中576個由患兒代理人控制PCA),研究1011例兒童和青年癌症患者用患者自控鎮痛(PCA)來控制疼痛的情況。選擇由代理人控制PCA的條件是低年齡組、有神經肌肉功能缺陷、預計反復對病人進行疼痛性操作及終末期疾病者。我們測定了與使用PCA有關的呼吸和神經學併發症的發生率。在497224-h時段中,70個時段觀察到了重要的併發症,其中28/4972(0.56%)為呼吸系統併發症,35/4972(0.7%)為神經學併發症,7/4972(0.14%)為呼吸、神經系統同時累及的併發症。在由代理人控制的PCA組中,觀察到呼吸和神經系統併發症各2例。需要使用納絡酮來逆轉呼吸或神經系統阿片樣反應的情況有3例,標準PCA2例及代理人PCA1例。因此對確保持續的安全性的建議包括,謹慎選擇病人、代理人的使用培訓、適當的操作檔說明及制度上指南的制定。

(周志堅 馬皓琳,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.


比較雷芬太尼或硫酸鎂與安慰劑在減小電驚厥療法的血流動力學反應

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

 

在這一前瞻性的隨機雙盲安慰劑對照交叉研究中,我們比較了雷芬太尼或硫酸鎂與安慰劑在減小電驚厥療法交感反應方面的效應。20名成人經歷了總共115次麻醉下治療性電驚厥療法。病人們隨機分組兩次,分入三組中的其中一組:安慰劑對照組、硫酸鎂30 mg/kg組或雷芬太尼1.0 µg/kg組。建立靜脈通路之前,記錄收縮期和舒張期動脈血壓、心率及血氧飽和度。用硫噴妥鈉4 mg/kg進行麻醉誘導。隨後給予試用藥物,在電驚厥療法實施之前,給予司可林0.5 mg/kg進行神經肌肉阻滯。在驚厥結束後即刻、1分鐘、3分鐘和10分鐘重複所有測量。雷芬太尼和硫酸鎂在減輕驚厥後即刻、1分鐘和3分鐘時收縮期動脈血壓的升高上有顯著的統計學意義(P < 0.05)。雷芬太尼可以減輕驚厥後1分鐘和3分鐘時的心率增快,而對心率峰值沒有作用。而硫酸鎂及安慰劑沒有這種作用。雷米芬太尼可以延長呼吸暫停的持續時間(平均90 s),但沒有其他不良的呼吸系統反應。平均驚厥活動持續時間為33 (± 14) s,各組間沒有差異。結論,雷芬太尼1.0 µg/kg硫酸鎂30 mg/kg可以減弱收縮期動脈血壓對電驚厥療法的反應,而並不減少驚厥活動的持續時間。由於硫酸鎂對心率的作用較小,其對電驚厥療法後存在心動過緩風險的病人可能較雷芬太尼更為有利。

(黃麗娜 馬皓琳,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.


舒芬太尼在人體的血管擴張作用

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

 

舒芬太尼是一種強效阿片類藥物,有時會引起低血壓的發生。其發生低血壓的機制目前還不清楚。我們假設舒芬太尼對血管平滑肌有直接作用從而引起血管擴張。10例年輕健康志願者,以0.0830.1670.3330.833 µg/min的速度肱動脈輸注舒芬太尼。試驗組和對照組均採用靜脈閉塞體積描計術測量前臂血流量。輸注手臂的前臂血流量呈劑量依賴性增加,從每100mL 組織3.2增加到5.2 mL/min,而對照(未輸注)手臂的前臂血流未增加。在輸注過程中,心率和平均動脈壓沒有明顯改變。而且在任一輸注水平呼吸頻率無明顯改變,鎮靜也沒有發生。因此,這些資料支援舒芬太尼並未發生“溢出”到體循環產生顯著的全身作用。我們得出結論,舒芬太尼對人體血管組織有直接的血管舒張作用,而這一作用似乎不依賴於神經性的和全身機制。

(邱鬱薇 馬皓琳,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.


成人丹曲林的分室藥代動力學:惡性高熱協會的劑量指導方針有用嗎?

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

 

丹曲林是唯一被證實能有效預防和治療惡性高熱的藥物。近來其建議使用的劑量是基於非分室分析,且很大程度上憑經驗。它們之間還有分歧,表現為來自美國惡性高熱協會(MHAUS)和歐洲原始資料的建議不同。我們測定了丹曲林的分室藥代動力學,模擬基於近來建議劑量的濃度時間過程,並提出了一個理想的給藥方式。9名志願者(55–89 kg)接受靜脈輸注丹曲林(5mg/kg30分鐘後給予0.05mg · kg–1 · h–15h)。間斷抽取靜脈血,直到給藥後60小時,使用反相高效液相色譜測定丹曲林血漿濃度。採用一室、二室和三室模型式擬和資料,並使用協變分析。用NONMEM及總體方法進行所有的計算。兩室模型能適當地描述這些資料,典型的變數值如下(中位數± 標準誤):分佈容積V1 = 3.24 ± 0.61 LV2 = 22.9 ± 1.53 L;血漿清除率CLel = 0.03 ± 0.003 L/min;分佈清除率CLdist = 1.24 ± 0.22 L/min。所有參數均與體重呈線性比例關係。模擬歐洲治療惡性高熱的建議使血漿濃度在24小時內集中於14–18 mg/L。模擬MHAUS的指導用法(間斷注射),使藥物血漿濃度峰值和穀值範圍為6.7–22.6 mg/L。以我們的發現為根據,我們提議應根據控制症狀所需的最初單次注射的劑量調整以後的輸注量。這種策略可以維持個體化的治療濃度,並提高藥物血漿濃度的穩定性。

(張瑩 馬皓琳,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.


振動-觸覺顯示器樣機用於生理監測的評估

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

 

在手術室裏採用視覺顯示器和聽覺報警器傳遞生理參數資訊。但是,生理參數專案的高速增長和高錯誤報警率大大地增加了對臨床醫師注意力的要求。我們擴展了現有觸覺技術以改善情況識別能力,並製造了一種實用的臨床報警設備。該振動-觸覺顯示器用2個振動馬達貼在前臂掌側表面,在模擬臨床環境中與聽覺報警器比較。該振動-觸覺顯示器同聽覺報警器一樣易於學習使用並且在單一使用或與聽覺報警器合用時有更高的辨識率。儘管振動-觸覺報警器樣機會給使用者帶來一些不適,但是大多數使用者更願意選擇使用該報警器。此外,同單用振動-觸覺報警器相比,振動-觸覺和聽覺聯合報警器的精確性有所降低。此種振動-觸覺設備模型雖然顯示了可觀的臨床應用價值,但是仍需要進一步的臨床測試和改進,特別是使用者舒適性方面的改進。

(周雅春 馬皓琳,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.


大鼠鞘內單次注射嗎啡引起長時間痛覺過敏:預先注射氯胺酮的保護作用

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

 

給予阿片肽可引起包括NMDA受體啟動在內的活性傷害過程,導致阿片肽引起的痛覺敏感。對大鼠的實驗室觀察已報導長期鞘內應用阿片肽後可降低基礎的傷害閾值。在本研究中我們試圖確定單次鞘內應用嗎啡是否可使無傷害大鼠產生痛覺增敏,以及評估預先使用NMDA拮抗劑氯胺酮對傷害感受閾值的影響。雄性Sprague-Dawley大鼠快速鞘內給予嗎啡(5μg10μg)後幾天用壓爪實驗測定對傷害刺激的敏感性。同時評價在鞘內給予嗎啡前,皮下注射NMBA拮抗劑氯胺酮(10mg/kg)的作用。鞘內單次注射嗎啡產生雙相傷害感受。早期無痛與傷害感受閾值持續提高35h有關,隨後緩發的痛覺過敏則與傷害感受閾值持續降低12天有關。皮下注射氯胺酮對鞘內給予嗎啡後的早期無痛期沒有顯著調節作用,但幾乎可完全預防延遲傷害感受閾值的降低。大鼠鞘內單次注射嗎啡產生延遲和持續的痛覺增敏,引起阿片肽痛覺敏感的發生。

(趙雪蓮 馬皓琳,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、碘苯六醇和鈉稀釋測定細胞外液量的大小

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

 

有必要尋找不涉及放射性描記法來評價細胞外液(ECF)容積的方法。因為此目的,我們在10例男性志願者(平均年齡34 yr)中用了3個方法來測定ECF容積。靜脈內輸注等滲甘露醇1 L後,穩態血漿溴化物濃度(對照)與血漿碘苯六醇動力學分析的結果及血清鈉稀釋的動力學分析相比較。用這些描記法的分佈容積來顯示ECF容積。結果揭示了所有3個方法的結果之間有統計學意義的相關性,雖然平均鈉稀釋顯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個方法都顯著與體重相關。各方法顯示的細胞外液占體重百分比分別為鈉18.3%3.1%)、碘苯六醇19.6%1.0%)及溴化物20.5%1.1%)。我們得出結論:鈉稀釋可在床旁進行,而碘苯六醇和溴化物顯示個體之間的差異較小。碘苯六醇同時測定腎小球濾過率,如果醫院用這個描記法來進行腎功能的常規評價,那麼它應該是個臨床可行的選擇。

(馬皓琳 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.


單次促腎上腺皮質激素刺激試驗不能揭示膿毒症休克時的腎上腺功能不足

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

 

對危重病人的腎上腺皮質功能不足的診斷是複雜的。在重症監護病房,促腎上腺皮質激素(ACTH)刺激試驗是一種被廣泛接受的評價腎上腺功能是否足夠的方法。但是,在短時間裏對該試驗的反應可能具有很大的個體差異。在這項前瞻性研究中,我們研究了ACTH刺激試驗在20位患有膿毒症、20位患有膿毒症休克和20位病情危重但是無膿毒症患者的可重複性。在患者進入重症監護病房後或者開始發生膿毒症時,在24小時內連續進行兩次ACTH刺激試驗。在沒有膿毒症的病人中,第1天和第2天對ACTH的反應具有良好的相關性(Pearson相關係數0.689p=0.001)。相反,在患有膿毒症休克的病人中,兩次ACTH反應沒有相關性(Pearson相關係數0.401p=0.080)。我們的結論是,對於患有膿毒症休克的病人,ACTH刺激試驗結果的可重複性很差。對於這些病人來說,單次ACTH刺激試驗不可能是診斷腎上腺功能不足的最好方法。

(顏濤 馬皓琳,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.


全膝關節置換後持續股神經阻滯或者硬膜外鎮痛:前瞻性隨機對照試驗

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

 

由於全膝關節置換(TKR)術後疼痛劇烈,我們在前瞻隨機試驗中比較TKR術後持續股神經阻滯(CRNB)和持續硬膜外鎮痛(CEA)的鎮痛效果。在脊麻下進行TKR的病人,隨機接受股神經注射0.2%布比卡因(中位元注射速率9.3mL/h))(n=53),或者硬膜外注射0.2%羅呱卡因複合4µg/mL的芬太尼(中位元注射速率7.6mL/h))(n=55)。輔助鎮痛是口服羅非昔布和氧可酮及靜脈注射嗎啡。術後評估疼痛、噁心嘔吐、低血壓發作、運動神經阻滯、膝關節運動的範圍以及康復的標誌點。兩組的疼痛評分、移動範圍和康復相同。CFNB組的噁心和嘔吐的發生顯著減少(P < 0.002)。相比CEA組,CFNB組需使用更多羅非昔布(P < 0.04)和氧可酮(P < 0.005)。兩組中直到48小時,手術肢體比非手術肢體在髖部水平和膝關節水平顯示更多運動阻滯(P < 0.05, Mann-Whitney U-test),但是兩組間非手術肢體沒有差異。CFNBTKR後多種鎮痛策略中的一個有效的區域性組成。

(張 馬皓琳,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.


三環類抗抑鬱藥用作局麻藥引起的組織損傷

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

 

三環類抗抑鬱藥(TCAs)用作局麻藥時的神經毒性已有報導。我們對TCAs引起組織損傷尤其是與許多局麻藥一樣可以引起肌肉毒性的假設進行了驗證。向動物的坐骨神經注射080mM的多慮平、阿米替林或布比卡因(1.5mL用作組織學研究,0.3mL用作神經行為研究)。注射後四天,TCAs引起了缺血性組織損傷。皮下組織顯示腫脹變硬,伴出血並與表面皮膚粘連。肌肉呈廣泛性蒼白。組織病理學顯示肌肉及其周圍軟組織凝固性壞死,伴累及區域附近血管內血栓形成。這些現象在布比卡因組明顯減少。TCA注射和布比卡因注射的動物還產生了典型的局麻藥肌肉毒性。阿米替林作為局麻藥其效價低於布比卡因:產生100min神經阻滯所需的濃度分別為20mM3mM。一些接受高濃度阿米替林的動物產生了自發性的神經阻滯的復發或有不可逆性的神經阻滯,兩者都反映了神經的損傷。這兩個發現在注射布比卡因的動物中均未發生。TCAs並未顯示有任何超過常規局麻藥的優點,卻可能冒毒性顯著增加的危險。

(黃施偉 馬皓琳,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應用的多中心研究

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

 

我們設計這個多中心試驗的目的是為了評估一種新型的一次性使用在聲門上區的氣道設備Ambu®喉罩在擇期手術患者中的性能及其安全性。118名未用肌松(ASA分級I-II級,年齡18-65歲,體重指數18-30 kg/m-2)接受全憑靜脈麻醉的患者入選該研究。喉罩置入後,氣囊內壓力在60 cm H2O時纖維鏡確定位置和測定口咽部的洩漏壓。通氣的難易程度通過潮氣量設定在6 mL/kg控制通氣來確定。注意並記錄所有的併發症。經過一次或兩次嘗試後(分別為92.4% 7.6%)所有的患者都被成功地置入喉罩,置入時間(從面罩拿掉開始到進行第一次通氣)是44.9 ± 37.91 s。所有患者都能獲得足夠的通氣,91.5%的患者纖維內鏡檢查能看到聲帶,口咽部的洩漏壓為24.1 ± 5.44 cm H2O8.5%的患者在喉罩上發現血跡。併發症和患者的抱怨很少並很快消除。在計畫行擇期手術未用肌松藥的患者中,Ambu喉罩能容易並快速置入,同時在正壓通氣時能夠提供安全有效的密閉。

(陳瑋 馬皓琳,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.

 

缺血預適應改善肥胖大鼠肝移植的能量狀態和提高存活率

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.

 

肥胖供體的肝常存在脂肪浸潤,易遭受缺血再灌注損傷,導致移植物失功並摘除。本研究中作者觀察在冷缺血過程中,缺血預適應(10min缺血,隨後10min再灌注)能否提高肥胖大鼠供體肝臟的能量儲備,減輕肝臟缺血再灌注損傷。本研究在冷缺血不同時點,分別採集肥胖大鼠和瘦型大鼠(對照組)的肝臟樣本,採用磁共振光譜(magnetic resonance spectroscopy)分析肝細胞的能量代謝狀況,以觀察是否缺血預適應能否改善供體肝的細胞代謝。結果發現與對照組相比,冷缺血第一個小時,缺血預適應可顯著改善肥胖鼠肝的能量代謝。冷缺血四小時,肥胖鼠肝與對照組之間無明顯差異。再灌注8小時,缺血預適應可明顯提高對照組鼠肝的能量儲備,而對肥胖鼠肝的保護效應消失。後續研究中作者發現,冷缺血前四小時進行缺血預適應,可明顯提高肝移植鼠移植後24小時的存活率(從25%提高到88%)。

(鄭擁軍 陳傑 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變化時應用經食管多普勒測定心輸出量的精確度低於溫度稀釋法

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

.

經食管多普勒是根據降主動脈血流量來測定心輸出量(CO)的。因為腦血流量受Paco2的影響,Paco2升高可引起腦血流量增加,從而導致CO的增加。本研究選擇30例實施不停跳冠狀動脈搭橋手術的病人。術中當Paco2維持在30 mm Hg40 mm Hg時,採用經食管多普勒和溫度稀釋法測定病人CO。結果發現應用溫度稀釋法在Paco2 40 mm Hg時測定的CO(4.17 ± 0.94 L/min)明顯高於Paco2 30 mm Hg時所測的結果(3.78 ± 0.85 L/min)。而應用經食管多普勒所測結果無明顯差異,在Paco2 40 mm Hg30 mm Hg時分別為3.85 ± 0.76 L/min3.77 ± 0.74 L/min。應用Bland-Altman分析研究結果的偏差和精度發現,在Paco240 mm Hg時分別為–0.32 0.49 L/min,在Paco230 mm Hg時為–0.01 0.34 L/min。結果提示兩種CO的測量方法在Paco230 mm Hg時一致性較好,但在Paco240 mm Hg時溫度稀釋法所測值較高。

(齊波 陳傑 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.

 

 

七氟醚全身麻醉下兒童喉部滴入蒸餾水引起氣道保護性反射的研究

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.

為研究全身麻醉的兒童七氟醚如何抑制氣道的保護性反射,作者選擇12歲以下的兒童作為研究物件。吸入七氟醚和氧實施麻醉。患者使用喉罩並保留自主呼吸。根據麻醉深度分成組1和組2(七氟醚呼氣末濃度分別為1%和2%)。主要通過喉部纖維鏡成像以及呼吸流速和食道壓評估喉部變化。通過纖維鏡的管道滴入小劑量蒸餾水0.02ml/kg(最小量為0.2ml)引起氣道的保護性反射。喉部的反應分為被動(喉頭關閉,喉痙攣,呼吸暫停)和主動(咳嗽,呼氣反射,吞咽反射)兩類。每組有10名研究物件。在兩組患者中,最初的反應都是被動的;然而,在組1中,有8名患者有主動反射;組2病人沒有主動反射(P<0.01)。結論:在兒童中,七氟醚全身麻醉的麻醉深度改變氣道的保護性反射。

(朱輝 陳傑 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.

 

門診外科術後出院綜合征:首周發生率,強度和風險因素

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.

輕微的後遺症,比如疼痛,噁心和嗜睡在外科術後出院早期時有發生。在這項前瞻性觀察研究中作者描繪了外科術後早期幾種症狀的發生率和強度,並研究發病率的預測因素。在兩個相似的普通門診外科單元,3910例病人接受了問卷調查,採用四點模型為上述的症狀逐日分級。用多元邏輯回歸來分析風險因素,成人與兒童分為不同的組。在這些病人中,有275470%)有回應。在門診外科術後一周病人經歷了很多輕微後遺征。術後第一天的症狀很普遍(高達86%的病人),至術後724%的成年患者仍有不適。在成人,疼痛是最普遍的症狀,與其他症狀相比,常為中等或嚴重。嗜睡則在兒童更常見。青年,大孩子,和女性更易合併輕微併發症。較長時間的外科手術導致所有病人的疼痛和噁心增加,在成人中增加其他幾種症狀的風險。

(範穎暉 陳傑 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.

 

門診外科的周圍神經阻滯技術

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.

在門診外科手術麻醉中,周圍神經阻滯(PNBs)顯得越來越重要。其具有許多理想門診手術麻醉的特點:外科麻醉,較長的術後鎮痛,易出院。適當的技術對於評估其潛在的作用和支援的論據是必不可少的。與全身麻醉相比,PNBs用於上肢手術時阿片類藥物的應用顯著減少,相關副作用也顯著減少。上述優點在緊靠圍術期已被證明,但在出院後未進行廣泛的調查。下肢手術PNBs對可致較大組織創傷的操作有獨特的益處,其良好的鎮痛被誇大了,這一點被少量的再入院所證明。當前大多數的研究並不支持此種觀點,因為當病人回到家中麻醉消退以後,很難處理疼痛。門診病人持續PNBs的最初研究證明:止痛效果好于單次靜脈注射,並提供持續的術後止痛。這些令人鼓舞的研究不得不考慮家中處理導管的安全性問題。儘管這些研究都支持PNBs,但是大部分研究,或是對於一系列研究或者是相當小的前瞻性研究,很少關注鎮痛,阿片類藥物的應用以及其副作用。歸根結底,具有更大規模的前瞻性資料顯示更為廣泛結果益處,以便更有說服力促使麻醉科醫師使用PNBs,此技術仍然面對很多技術上的挑戰。

(張美榮 陳傑 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.

 

大鼠中樞咪唑啉受體亞型調控氟烷-腎上腺素性心律失常

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.

 

先前作者曾報導有關中樞神經系統的咪唑啉受體參與調節氟烷-腎上腺素性心律失常。這些受體分為I1 I2 亞型,但仍未確定究竟是哪一亞型參與氟烷-腎上腺素性心律失常的調控。本研究的目的是研究調控的亞型。大鼠氟烷麻醉,並連續監測動脈壓和室性早搏。致心律失常的腎上腺素定義為15s內出現3個或以上室性早搏的最小劑量的腎上腺素。在氟烷麻醉期間,腦池內的莫索他定出現劑量相關性抑制腎上腺素誘導的心律失常。腦池內的依法克生,一種選擇性的I1 受體的拮抗劑,對I2 受體幾乎無親和力,而α-育亨賓是I2 受體的拮抗劑,阻斷莫索他定的抗心律失常作用。腦池內的BU224 2-BFI為選擇性的I2配體同樣能抑制腎上腺素導致的心律失常。這些作用可被依法克生所消除。結論:中樞性I1受體,而不是I2受體在氟烷-腎上腺素性心律失常的抑制中起重要作用。

(忻紀華 陳傑 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.

 

瑞芬太尼和丙泊酚誘導的意識消失期間肌松藥對雙頻指數和Datex-Ohmeda熵值的影響

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.

有關肌松藥對雙頻指數的影響的研究有相互矛盾的結果。前瞻性、隨機、雙盲的試驗中,病人接受了目標濃度的瑞芬太尼合併丙泊酚的輸注直到病人意識消失。意識消失後的兩分鐘,試驗組給予單次阿曲庫銨,而對照組給予安慰劑。記錄以下變數:雙頻指數,邊緣頻率,肌電活動,以及用Datex-Ohneda熵監測儀監測狀態熵和反應熵。在意識消失時的兩組間結果相似。病人意識消失後安慰組用藥後較意識消失時的雙頻指數(P < 0.002),邊緣頻率 P <0.05, 肌電活動(P <0.002),狀態熵(P <0.05),反應熵(P <0.01)均下降。試驗組在雙頻指數(P <0.0001),邊緣頻率 P <0.01),肌電活動(P <0.0001),狀態熵(P <0.0001),反應熵(P <0.0001)下降。試驗組在雙頻指數(P <0.05, 肌電活動(P <0.0001)和 反應熵(P <0.01)方面的下降較安慰劑組顯著。淺麻醉病人給予肌松劑時雙頻指數和反應熵下降,但狀態熵則無太大變化。

(鄭麗 陳傑 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.


全身使用局麻藥緩解神經性疼痛:系統回顧和薈萃分析

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.

 

作者回顧性研究了隨機對照試驗,評價全身使用局麻藥、空白對照藥或其他有效藥治療神經性疼痛的療效和安全性。共41項研究中,系統回顧包括了不同品質的27項試驗。10項利多卡因研究和9項美西律研究適合Meta分析(共有n=706位病人)。神經性疼痛治療使用利多卡因(用法為每30-60分鐘,靜脈推注5mg/kg)、美西律(平均劑量,600mg/天)和空白對照藥(0-100mm疼痛VAS評分的加權平均差=-10.6095%可信區間:-14.52-6.68P<0.00001)合併用嗎啡,加巴噴丁,阿米替林和金剛烷胺(加權平均差=-0.6095%可信區間:-6.965.75)。該治療方法的優點是對外周神經痛(外傷,糖尿病)和中樞性疼痛的持續性療效。利多卡因和美西律最主要的副作用為困倦、疲勞、噁心和頭暈。全身使用局麻藥的副反應發生率較空白對照組高,但與嗎啡,阿米替林,加巴噴丁的副反應發生率相似(優勢比:1.2395%可信區間:0.226.90)。在臨床試驗過程中利多卡因和美西律沒有明顯的副作用,較空白對照組更能緩解神經性疼痛,並與其他用於該情況下的麻醉鎮痛藥療效相似。

(肖潔 陳傑 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.

 

雙酯瑞因對炎性和神經病理性傷害性刺激小鼠模型中機械性痛覺過敏的影響

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.

本實驗旨在研究雙酯瑞因,一種治療骨性關節炎的藥物,在炎性和神經病理性傷害性刺激小鼠模型中全身性抗痛覺過敏的作用,並將雙酯瑞因的效應與臨床常用的神經病理性疼痛的治療藥物加巴噴丁做比較。與加巴噴丁相似,雙酯瑞因能夠明顯逆轉角叉菜膠引起的機械性痛覺過敏。當雙酯瑞因的給藥途徑由腳掌內注射變為鞘內注射時,它同樣能明顯降低角叉菜膠引起的傷害性刺激雙酯瑞因和加巴噴丁也能明顯抑制弗氏完全佐劑(CFA),或部分性坐骨神經結紮(PLSN)造成的機械性痛覺過敏。本實驗劑量的雙酯瑞因和加巴噴丁對小鼠的運動能力,運動的協調性,及體溫均無影響。本研究結果表明,雙酯瑞因在角叉菜膠,CFA引起的傷害性刺激模型中,及PLSN造成的神經病理性疼痛中,均具有與加巴噴丁相似的顯著性抗痛覺過敏作用。雙酯瑞因有望成為治療炎性和神經病理性疼痛的一種有意義的藥物。

(田婕 陳傑 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.

 

早期膠體替換治療在亞致死性出血性休克模型中的應用

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.

 

已有數個研究評估液體治療的時間、速度及方式在對照性、實驗性、低血壓出血性休克模型的療效。在一個亞致死性的實驗模型中,作者評估了兩種不同溶液的液體復蘇治療對血流動力學和代謝的影響。實驗中,30頭年幼的大白豬隨機分為三個組:組I(對照組,n=10)無出血;組II(羥乙基澱粉,HESn=10, 接受控制性放血使平均動脈壓(MAP)在30mmHg,血乳酸>10mM/L,復蘇時先使用7mL/kgHES130/0.46%,隨後使用33mL/kg的乳酸林格氏液(LR)和自體血回輸;組IIILRn=10),接受控制性放血使平均動脈壓維持在30mmHg血乳酸>10mM/L,復蘇時先使用40mL/kgLR,然後應用自體血回輸。研究證實使用HES130/0.4優於LR,主要表現在血流動力學和灌注的差異上。儘管組織灌注提高,但MAP仍然不能完全恢復至基礎水平。結論:與輸注相同容量的晶體液相比早期輸注膠體可更好地促進組織灌注的恢復。

(朱慧琛 陳傑 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.

 

迴圈中成熟腎上腺髓質素(adrenomedullin)與足月妊娠血容量有關

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.

在妊娠過程中,血漿中腎上腺髓質素的濃度增加。作者測定了血容量、血漿和腦脊液中成熟腎上腺髓質素濃度,檢測了血漿和腦脊液中髓質素是否與妊娠期血容量增加有關。該研究中包括47名在腰麻下行手術的婦女。作者首先對需行整形外科手術的非妊娠婦女、妊娠15-18周行婦科手術的婦女和足月妊娠行剖宮產的婦女,測定了血漿和腦脊液中成熟髓質素的濃度。第二部分研究包括20名健康和足月妊娠臨產需行剖宮產的婦女。作者應用靛氰綠通過無創的脈搏分光光度法測定了動脈血壓和血容量。血漿中成熟的髓質素濃度在非妊娠、妊娠早期和足月妊娠組分別為1.24 +/- 0.982.79 +/- 1.23 4.79 +/- 2.61 fmol/mL (mean +/- sd)。但腦脊液中成熟髓質素並沒有顯著增加。而且,血漿(而不是腦脊液)中成熟髓質素與每單位體重的血容量有顯著的相關性(r2= 0.46; P = 0.0009)。這些發現提示血漿中成熟髓質素濃度增加,而且增加的髓質素與妊娠期間血容量增加有關。

(趙延華 陳傑 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羅呱卡因阻滯時感覺和運動神經阻滯的起效時間

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.

 

作者研究了羅呱卡因硬膜外阻滯時在麻醉藥液中添加和不添加芬太尼對感覺和運動阻滯起效時間的差異。45名接受膝關節鏡手術的年輕男性病人隨機分配到三組,每組15名:硬膜外芬太尼組(EF,硬膜外給予1%的羅呱卡因15ml+芬太尼100µg然後靜脈注射2ml生理鹽水);靜脈芬太尼組(IF,硬膜外給予1%的羅呱卡因15ml+生理鹽水2ml,然後靜脈注射芬太尼100µg);對照組(硬膜外給予1%的羅呱卡因15ml+生理鹽水2ml,然後靜脈注射生理鹽水2ml)。應用針刺法檢測感覺神經阻滯,應用改良Bromage評分檢測運動神經阻滯。同時記錄血流動力學變化、硬膜外阻滯後寒顫和硬膜外芬太尼相關副作用。研究結果表明,EF組感覺神經阻滯平面達到T10的時間(13.0 ± 3.0 min)IF(16.2 ± 3.5 min)和對照組 (17.7 ± 3.6 min) 相比明顯縮短(P < 0.05)。運動神經阻滯的Bromage評分達到12分的時間在EF(11.9 ± 4.6 24.4 ± 5.9 min)明顯短於IF組(16.9 ± 4.7 30.8 ± 5.6 min, P < 0.05)和對照組(18.3 ± 4.9 32.7 ± 5.7 min, P < 0.05)。硬膜外阻滯後寒顫的發生率在三組間沒有明顯差異。在EF組有3個病人出現瘙癢症狀,在IF組只有1名患者出現瘙癢。沒有病人出現噁心、嘔吐、呼吸抑制、尿瀦留或者低血壓等副作用。總之,研究者認為,在1%的羅呱卡因中混合100µg芬太尼進行硬膜外阻滯能夠加速感覺和運動神經阻滯的起始時間,且無芬太尼相關併發症。

(蘇殿三 陳傑 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.

 

擇期手術患者貧血的發現、評估與處理

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,擇期手術患者貧血的流行率可能高達75%。一項全國性統計表明35%的擇期行關節置換術患者其入院前檢測血色素水平<13g/dl。擇期手術前3—7天進行包括標準檢測在內的檢查,預防並有效地評價與處理患者未料的貧血。因此,術前貧血的發現、評價、處理的標準方法被認為是一項不足的醫學需要。為了彌補這一知識缺陷,作者召集了許多內科醫生就貧血的處理來研究其臨床監測方法。擇期手術患者術前接受至少30天的血色素監測。因為貧血的鑒別和評價有利於快速診斷和處理潛在的並存症,改善患者的預後。所以不能解釋的貧血 (女性Hgb<12g/dl,男性Hgb<13g/dl)應延期手術,直至準確評估。

(顧新宇 陳傑 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.

 

增大的心臟和年齡削弱豚鼠離體心臟的麻醉預處理

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

 

麻醉預處理(APC)減少心肌缺血/再灌注損傷。最近的調查報導高齡心臟對麻醉預處理不敏感。我們研究在年幼豚鼠中,增大的心臟和年齡增長是否決定對麻醉預處理的敏感性。將用Langendorff離體心臟灌流機準備過的不同重量(1.1-2.2g)和年齡(2-7周)的豚鼠心臟暴露於1.3mM的七氟烷15分鐘,接著洗脫30分鐘(APCn=20),然後整體缺血30分鐘並再灌注120分鐘。對照組心臟(n=20)不進行麻醉預處理。等體積下測量左心室壓力,心肌梗塞面積由三苯基四氮唑著色決定。實驗初期兩組間功能資料並無不同,與心臟重量和年齡也無相關性。經過120分鐘再灌注,麻醉預處理組中左心室壓力,冠狀動脈血流和組織生存能力顯示出與增大的心臟重量和年齡明顯的負相關,在對照組中沒有。即,麻醉預處理對體積小/年齡小的心臟功能改善和梗塞面積減少優於對體積大/年齡大的心臟。因此,即使在年幼的豚鼠中,增大的年齡和心臟尺寸削弱了對麻醉預處理的敏感性。這可能對將來的基礎科學研究和麻醉預處理在人類臨床中應用的可能性具有重要的指示。

(周荻 薛張綱 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.

 

在早期再灌注時對線粒體滲透轉運的抑制可以加強異氟醚的心臟保護作用:線粒體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


在冠狀動脈延長梗阻後早期再灌注的缺血期,對線粒體滲透轉運孔(mPTP)的抑制可以產生一種短暫的可重複的保護作用。在早期再灌注之前和同時,短暫的暴露於異氟醚也可產生心臟保護作用,但是,mPTP是否與這個有益的效應有關還不得而知。我們檢驗mPTP是異氟醚起效的條件這個假說,同時也驗證線粒體KATP (mKATP)通道在這個過程中的作用。大鼠(n=102)先梗阻冠脈30分鐘,然後再灌注3小時生理鹽水(對照),在再灌注前3分鐘到再灌注後2分鐘分給予異氟醚(0.5 or 1.0 MAC),或者給予mPTP抑制劑cyclosporin A (CsA, 5 or 10 mg/kg),或者給予mPTP激動劑atractyloside (5 mg/kg),或者給予選擇性mKATP通道拮抗劑5-hydroxydecanoate (5-HD; 10 mg/kg)。其他大鼠給予0.5 MAC異氟醚加5 mg/kg CsA,而沒有atractyloside 5-HD。異氟醚(1.0MAC)和CsA(10mg/kg)產生(P < 0.05)梗死面積(21% +/- 4%, 44% +/- 6%, 24% +/- 3%, and 43% +/- 6%, 各自的, 平均值 +/- 標準差, 左室面積; triphenyltetrazolium 染色),以及作為對照的梗死面積(42% +/- 7%)。異氟醚(0.5MAC)加CsA(5mg/kg)也是有保護作用的(27% +/- 4%)atractyloside 5-HD都不單獨影響梗死面積,但這些藥物抑制了1.0 MAC異氟醚加 10 mg/kg CsA0.5 MAC異氟醚加 5 mg/kg CsA的保護作用。這個結果表明mPTP的抑制加強異氟醚的作用,而mPTP開放抑制異氟醚的作用。在活體,異氟醚介導的對線粒體滲透轉運的抑制依賴線粒體KATP通道的啟動。

(陸文清譯 薛張綱校)

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.

 

比較局部和全身麻醉在門診手術的優缺點: 隨機對照試驗的薈萃分析

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薦成為門診手術最佳的麻醉方法。我們在MEDLINE和其他資料庫查找採用薈萃分析,隨機對照試驗的方法比較局部麻醉和全身麻醉用於門診手術病人的不同之處。只有在主要傳導阻滯時考慮用局部麻醉。局部麻醉可進一步分為中樞神經阻滯和外周神經阻滯。15組(1003病人)和7組(359病人)試驗分別用中樞神經阻滯和外周神經阻滯,並用薈萃分析進行處理 。中樞神經阻滯和外周神經阻滯與增加誘導時間,降低疼痛,縮短麻醉後蘇醒時間相關。然而,中樞神經阻滯不能縮短麻醉後蘇醒時間,也不能減輕噁心反應,儘管減少了鎮痛藥的用量,且它增加了整個門診手術的時間,大約35分鐘。相比之下,外周神經阻滯能縮短麻醉後蘇醒時間,也能減輕噁心,但同樣不能縮短門診手術的總的時間。此薈萃分析說明局部麻醉有它強大的優勢,諸如降低了麻醉後蘇醒室的利用,減輕了噁心反應及術後疼痛。儘管這些因素被認為可以縮短在門診手術室的時間,但中樞神經阻滯和外周神經阻滯都不能縮短門診手術時間。另外一些因素,如不適當的標準和薈萃分析的局限性或許可以解釋這種差異。

(王慧琳譯,薛張綱校)

\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

 

日間行前列腺近距離放療中全麻和脊麻技術的評價

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

 

我們評價了日間經會陰前列腺近距離放療中的四種麻醉技術:單獨芬太尼或異丙酚全憑靜脈麻醉(TIVA),或芬太尼、硫噴妥鈉和異氟醚(F-P-I)聯合全麻,與5mg 0.5%大劑量高比重布比卡因(LDS)2.5mg 0.5%高比重布比卡因聯合芬太尼25mug小劑量(SDS)椎管內阻滯比較。全麻組手術時間較短。TIVA組病人結束時間(103 +/- 41 min)F-P-I組病人(131 +/- 65 min), SDS (126 +/- 55 min), LDS 病人(169 +/- 65 min)早(TIVA相對所有其他組和脊麻組間P < 0.05)。TIVA組病人離院時間(119 +/- 42 min)F-P-I 組病人(160 +/- 69 min) SDS組或LDS 組病人 (分別為132 +/- 53 and 186 +/- 72 min)早(TIVA對其他組和脊麻組間P < 0.05)。至於術後噁心嘔吐、疼痛評分、在家中正常功能的恢復和總體滿意度沒有組間差異。儘管四種技術都適用於此手術,但TIVA提供了最早的手術結束時間及之後的離院時間。在脊麻技術組間,SDS技術需要更多的術中鎮靜,但能達到更快的術畢和離院時間。TIVA,異氟醚和芬太尼聯合全麻,和兩種脊麻技術(5 mg 0.5% 布比卡因,或 2.5 mg 0.5% 布比卡因聯合 25 mug 芬太尼)都適用於日間經會陰近距離放療。TIVA能提供最早的術畢及之後的離院歸家時間。2.5 mg布比卡因聯合 25 ug 芬太尼椎管阻滯比單用5 mg布比卡因能提供更早的術畢和離院時間。

(徐麗穎譯 薛張綱校)

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-天冬氨酸受體調整非腎上腺素能非膽鹼能食道下段括約肌的鬆弛作用

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

 

我們研究外周N-甲基- D-天冬氨酸(NMDA)受體在腸肌從通過非腎上腺素能非膽鹼(NANC)能鬆弛食道下段括約肌(LES)的作用。我們測量從日本白鼠上取得的LES等長收縮。用KCl、阿托品和胍乙啶產生肌肉鬆弛作用。用放射核素的方法測定3',5'-環磷酸鳥苷(cGMP)的濃度。肌肉被暴露在二乙基二硫代氨基酸中使Cu/Zn過氧化物歧化酶失活。MK801以濃度依賴性方式抑制了NANC的鬆弛作用,並伴隨3',5'-環磷酸鳥苷產生的下降。NMDA引起了濃度依賴性的鬆弛,該種鬆弛被MK801拮抗。NMDA刺激cGMP產生,而cGMP則被NG-硝基-L-精氨酸,N-硝基-L-精氨酸所抑制。過)氧化物歧化酶(100 U/mL)使由MK801介導的對NANC肌松作用的抑制的濃度依賴曲線右移,反之過氧化氫酶則相反。DETCA使連苯三酚-、氯胺酮-MK801介導的對NANC肌松作用的抑制的濃度依賴曲線左移。這些結果表明外周NMDA受體介導NANC使肌肉鬆弛,並能通過產生細胞外超氧負離子部分調節NMDA的作用,因此可清除由笑氣產生的肌松作用。

(孫卓真 譯,薛張綱 審校)

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

 

 

神經內分泌應激反應和心率變異性:全憑靜脈麻醉與複合麻醉的比較
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

 

削弱術中應激反應是改善預後的關鍵因素。在複合麻醉(BLA)和全憑靜脈麻醉(TIVA)中,我們比較了神經內分泌改變和心率變異性(HRV)。43個病人隨機接受BLA(七氟醚/瑞芬太尼)或TIVA(丙泊酚/瑞芬太尼)。麻醉深度通過腦電雙頻指數來監測。應激反應激素水平在7個點測定(P1=基線;P2=氣管插管;P3=切皮;P4=最大手術創傷;P5=外科手術結束;P6=氣管拔管;P7=氣管拔管後15分鐘)。HRV通過功率譜分析:極低頻率(VLF),低頻率(LF),高頻率(HF),LF/HF比率,總能量(TP)。在TIVA的P6,LF/HF較高,在TIVA的P3-7,TP值較高(P3: 412.694.2; P4: 266.7114.6; P5: 290.3111.9; P6: 1523.7658.1; P7: 1225.6 342.6 ms2)) BAL表現較高的腎上腺素水平(P7: 100.554 pg/mL),去甲腎上腺素水平(P3: 221119.5P4: 194130.5 pg/mL),促腎上腺皮質激素水平(P210.57.7P5: 5.33.6P6:10.95.3P7: 20.5 7.1 pg/mL)和皮質醇水平(P7:6.93.9 微克/dL)。這顯示,與TIVA相比,在耳鼻喉外科手術應用BAL有較高的交感活性。

(孫敏莉譯,薛張綱校)

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型鈣通道阻滯劑消除阿片類藥物引起的感覺過敏和抗傷害性刺激作用的耐藥性

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.

 

近期的研究發現長期使用嗎啡可引起反常的疼痛加劇,這種嗎啡抗傷害性刺激作用的耐藥性可以解釋疼痛加劇的狀態。雖然引起阿片類藥物介導疼痛異常的機理還不清除,很多證據表明刺激誘導興奮性遞質增加,從而支援發生這種情況的可能性。L型鈣通道是興奮性神經遞質釋放的關鍵,我們假設阻滯L型鈣通道可以改變阿片類藥物引起的感覺過敏和抗傷害性刺激作用的耐藥性。使用Swiss-Webster雄性小鼠,分兩組,一組鞘內注射嗎啡(10µg)一組鞘內注射嗎啡(10µg)宇阿洛地平(10µg)的混合液,一日兩次,共注射八周。重複注射嗎啡組小鼠對觸覺和溫度覺刺激反應增強。同時使用假定的選擇性L型鈣通道阻滯劑阿洛地平可以預防這種超敏的發生。此外,連續注射嗎啡8周的小鼠,其嗎啡抗傷害性刺激劑量-效應曲線明顯右移,表明出現抗傷害性刺激的耐藥性。而同時注射阿洛地平的小鼠並未出現耐藥性。這些研究結果表明,L型鈣通道阻滯劑,如阿洛地平,可以預防鞘內使用嗎啡引起的阿片類藥物介導的痛覺過敏及抗傷害性刺激的耐藥性,其原理可能是降低了刺激誘導的興奮性神經遞質的釋放。

(金琳 譯,薛張綱 審校)

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.

 

內皮素對坐骨神經慢性收縮性損害後神經病理性疼痛的影響

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

 

本研究目的是內皮素對神經病理性疼痛的影響。內皮素(ET)是個家族性成員,包括ET-1ET-2ET-3,是控制血管張力的廣泛分佈的多肽類物質。ET-1通過啟動ETA受體導致激烈痛,ETA是通過ETB受體啟動啟動疼痛信號而被調節。利用小鼠坐骨神經慢性收縮性損害模型,我們發現,ETA受體拮抗藥能快速地明顯地降低損傷5天後熱和機械的過敏性痛覺反應。而且,ET-1ETA受體能在慢性收縮性損傷部位局限性上調信號和蛋白水平,表明ET-1可能參與損傷後疼痛的產生。資料顯示ET-1作為一個全身的疼痛調節的重要因數,同時顯示ETA拮抗劑作為一個治療神經病理性疼痛的潛在的新的方法值得研究。

(吳德華譯 薛張綱校)  

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.

 

危重病人中心靜脈導管的菌落:比較標準導管和兩種含抗菌劑導管的前瞻性隨機對照研究

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.

 

在這個非盲的、隨機對照的前瞻性研究中,我們比較了標準的無預充劑的中心靜脈導管(CVC)和銀塗層及預充洗必太磺胺嘧啶銀(CH-SS)兩種中心靜脈導管(CVC)的菌落率。病人特徵,CVC穿刺部位,留置時間以及採用半定量和定量微生物技術檢測菌落作為資料記錄下來。275名危重病人被納入研究佇列。共放置了160個標準導管、160個銀塗層導管和165個預充CH-SS導管。CVC菌落在各研究組間有顯著差異(P = 0.029)。在菌落率和1000導管日菌落方面,標準導管與銀塗層導管之間差異無顯著性(P = 0.564; P = 0.24),與CH-SS導管相比亦然(P= 0.795; P = 0.639)。當兩比較抗菌效果時,CH-SS導管菌落率顯著低於銀塗層導管(16.9% 7.3%; P = 0.01; 1000導管日18.2% 7.5%; P = 0.003; 相對危險度 0.43; 95% 可信區間 0.21–0.85)。然而,標準導管和銀塗層導管首次菌落分別發生在置管後23天,CH-SS導管在7天後才有菌落。總之,由於重症監護時導管菌落發生率很低,且留置時間常超過10天,與標準聚氨酯導管相比,含抗菌劑導管並不能有效防止導管菌落的發生。

(金 薛張綱 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-核糖合成酶抑制劑在大鼠內臟動脈缺血再灌注損傷後改善肺動脈對內皮依賴性血管擴張劑的舒張作用

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)在內臟動脈缺血再灌注損傷(IR)後調節肺動脈收縮及舒張反應的機制尚未明確。我們用PARS的抑制劑—三氨苯酰胺研究這一反應。鉗夾大鼠腸系膜上動脈60分鐘,再開放60分鐘,建立IR模型。在2組治療組,再灌注前10分鐘分別靜脈予5 10 mg/kg三氨苯酰胺的單次劑量,隨後再灌注過程中分別以5 10 mg.kg(-1).h(-1)靜脈維持(IR + PARS抑制劑510組),在非治療組,不給予三氨苯酰胺,僅靜滴生理鹽水(IR組)。在對照組,雖實施手術,但腸系膜上動脈未閉塞(偽組)。分離肺動脈並在試管內評價藥物作用。IR組顯示:肺動脈對新福林的收縮作用並未減弱,但較對照組,其對內皮依賴性血管擴張劑、乙酰膽鹼和光輝黴素的舒張作用明顯受到抑制。IR + PARS抑制劑510組較IR組,對內皮依賴性血管擴張劑的舒張反應有所增強。我們推斷:IR減弱了肺動脈對內皮依賴性血管擴張劑的舒張反應,而PARS抑制劑能夠改善舒張作用。

(王麗珺譯 薛張綱校)

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

 

確定術後鎮痛的硬膜外導管位置的兩種非直接方法的比較性研究

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.

 

我們隨機地用兩種非直接地方法確定218名手術病人硬膜外導管位置,分別是硬膜外刺激實驗,硬膜外壓力波形分析。硬膜外隙是通過落空感確定的。導管置入硬膜外隙5cm,預充09%生理鹽水5ml。這兩種方法的陽性預測值和特異性都很高,但敏感性不高(80EST,81%EPWA),陰性預測值都比較低(16EST,17%EPWA)。兩種方法結合起來敏感性增加(97%),陰性預測值(57%)。如果對小於10mA的刺激不僅包括運動反應還包括感覺的話,EST的敏感性要增加到87%。我們建議加入感覺反應的測試到比較的標準中。老年病人的EPWA的敏感性更高:大於80歲的病人的敏感性是94%,小於40歲是63%,4060歲是73%,6080歲是85%。我們的結論是兩種方法在確定硬膜外導管位置上是相當的。

(鍾靜譯 薛張綱校)
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.

 

手術後顫抖的獨立危險因素
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.

 

手術後顫抖(PAS)對病人的是不舒服的,也是有潛在風險的。在這個觀察性試驗中,我們試圖確定全麻後PAS的獨立危險因素。通過1340個連續的病人,PAS潛在的危險因數被記錄。記錄顫抖,外周和中心體溫,以及在PACU的加溫。資料被分為評估組(n = 1000)和確認組(n = 340)。第一組被用來確定PAS的獨立危險因素和確定風險大小用於backward-elimination logistic regression 分析。用確定組通過ROC曲線分析和線性回歸在預測的和實際發生的PAS之間來驗證假設的模型的區別度和刻度。PAS的發生率是11.6%有三個主要的危險因素:年輕,內部修復手術,中心體溫低,年齡是最重要得。風險的分數來自一個有合理區分力的分析,在ROC曲線下面積為0.6995%可信區間,0.60-0.78; P < 0.0001)而且,刻度曲線的方程(y = 0.69x + 6; R2= 0.82; P < 0.05) 在預測的和實際的PAS發生率之間有一個很好的,統計學上的重要一致。在目前的研究,術後顫抖可以在滿意的精確性下用四個危險因素預測。這個模型可以作為一個臨床工具來指導臨床工作者合理的使用防顫抖藥物。

(陸文清譯 薛張綱校)

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.