Anesthesia & Analgesia

April 2006

Table of Content

 

 

CARDIOVASCULAR ANESTHESIA:

七氟醚产生的延迟性心肌保护作用在吸入后48小时时较24小时时更显著

(齐波 陈杰 校)

Inhaled Sevoflurane Produces Better Delayed Myocardial Protection at 48 Versus 24 Hours After Exposure

Marc Lutz and Hong Liu

Anesth Analg 2006 102: 984-990.

预测急性等容血液稀释对分离自体全血血液成分的影响

(孙敏莉译 薛张纲校)

Prediction of the Effect of Acute Normovolemic Hemodilution on the Hematological Constituents of Sequestered Autologous Whole Blood

Paul G. Loubser and Anthony Chan

Anesth Analg 2006 102: 991-997

明胶和羟乙基淀粉而不是白蛋白破坏心脏手术后的凝血功能 

(彭中美 马皓琳 李士通 校)

Gelatin and Hydroxyethyl Starch, but Not Albumin, Impair Hemostasis After Cardiac Surgery

Tomi T. Niemi, Raili T. Suojaranta-Ylinen, Sinikka I. Kukkonen, and Anne H. Kuitunen

Anesth Analg 2006 102: 998-1006.

抗凝血酶(抗纤维蛋白酶)能调节腹主动脉瘤修补手术中凝血、细胞因子的产生、以及粘附分子表达

(宋金超 陈杰 校)

Antithrombin Can Modulate Coagulation, Cytokine Production, and Expression of Adhesion Molecules in Abdominal Aortic Aneurysm Repair Surgery

Tomoki Nishiyama

Anesth Analg 2006 102: 1007-1011.

首次心脏手术大量出血、输血与再次手术大量出血、输血相关

(金琳 薛张纲校)

Excessive Bleeding and Transfusion in a Prior Cardiac Surgery is Associated with Excessive Bleeding and Transfusion in the Next Surgery

Gregory A. Nuttall, Nicole Henderson, Michael Quinn, Clay Blair, Layne Summers, Brent A. Williams, William C. Oliver, and Paula J. Santrach

Anesth Analg 2006 102: 1012-1017.

大鼠中低温体外循环后海马Bcl-2Bax表达及神经元凋亡

(黄施伟 译,马皓琳 李士通 校)

Hippocampus bcl-2 and bax Expression and Neuronal Apoptosis After Moderate Hypothermic Cardiopulmonary Bypass in Rats

Ting-Jie Zhang, Jian Hang, Da-Xiang Wen, Yan-Nan Hang, and Frederick E. Sieber

Anesth Analg 2006 102: 1018-1025.

冠状动脉搭桥术后长期心率动力学变化

(忻纪华 陈杰 校)

Long-Term Alterations of Heart Rate Dynamics After Coronary Artery Bypass Graft Surgery

Timo T. Laitio, Heikki V. Huikuri, Juha Koskenvuo, Jouko Jalonen, Timo H. Mäkikallio, Hans Helenius, Erkki S.H. Kentala, Jaakko Hartiala, and Harry Scheinin

Anesth Analg 2006 102: 1026-1031.

在犬左心室非依赖Starling机制的lusitropism指数:逻辑时间常数(logistic time constant)。

(吴德华译 薛张纲校)

Starling-Effect-Independent Lusitropism Index in Canine Left Ventricle: Logistic Time Constant

Ju Mizuno, Satoshi Mohri, Juichiro Shimizu, Shunsuke Suzuki, Takeshi Mikane, Junichi Araki, Hiromi Matsubara, Terumasa Morita, Kazuo Hanaoka, and Hiroyuki Suga

Anesth Analg 2006 102: 1032-1039.

PEDIATRIC ANESTHESIA:

阿片类药物依赖的重症监护小儿患者停用阿片药物的前瞻性评估

(黄佳佳译,马皓琳 李士通校)

A Prospective Evaluation of Opioid Weaning in Opioid-Dependent Pediatric Critical Care Patients

Richard J. Berens, Michael T. Meyer, Theresa A. Mikhailov, Krista D. Colpaert, Michelle L. Czarnecki, Nancy S. Ghanayem, George M. Hoffman, Deborah J. Soetenga, Thomas J. Nelson, and Steven J. Weisman

Anesth Analg 2006 102: 1045-1050.

通过短暂充血反应评估七氟醚对小儿脑血管自动调节功能的影响

(苏殿三 陈杰 校)

The Effect of Sevoflurane on Cerebral Autoregulation in Young Children as Assessed by the Transient Hyperemic Response

Gordon T. Wong, Igor Luginbuehl, Cengiz Karsli, and Bruno Bissonnette

Anesth Analg 2006 102: 1051-1055.

小儿脑MRI检查时七氟醚麻醉结束前给予小剂量氯胺酮或Nalbuphine可减少清醒时躁动

( 路译 薛张纲校)

Prevention of Emergence Agitation After Sevoflurane Anesthesia for Pediatric Cerebral Magnetic Resonance Imaging by Small Doses of Ketamine or Nalbuphine Administered Just Before Discontinuing Anesthesia

Bernard J. Dalens, Anne Marie Pinard, Dany-Roch Létourneau, Natalie T. Albert, and René J. Y. Truchon

Anesth Analg 2006 102: 1056-1061.

I期重建术的左心发育不良综合征新生儿中米力农群体药代动力学

(周志坚 马皓琳 李士通 校)

Population Pharmacokinetics of Milrinone in Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage I Reconstruction

Athena F. Zuppa, Susan C. Nicolson, Peter C. Adamson, Gil Wernovsky, John T. Mondick, Nancy Burnham, Timothy M. Hoffman, J. William Gaynor, Lauren A. Davis, William J. Greeley, Thomas L. Spray, and Jeffrey S. Barrett

Anesth Analg 2006 102: 1062-1069.

AMBULATORY ANESTHESIA:

斜疝修补术病人使用椎旁阻滞可比全麻提供更好的当天恢复

(殷文渊 陈杰 校)

Paravertebral Blocks Provide Superior Same-Day Recovery over General Anesthesia for Patients Undergoing Inguinal Hernia Repair

Admir Hadzic, Beklen Kerimoglu, Dan Loreio, Pelin Emine Karaca, Richard E. Claudio, Marina Yufa, Ray Wedderburn, Alan C. Santos, and Daniel M. Thys

Anesth Analg 2006 102: 1076-1081.

全麻下行视网膜脱离手术的病人围术期进行眼球周围阻滞:一项随机双盲试验

(王丽珺译 薛张纲校)

Preoperative Peribulbar Block in Patients Undergoing Retinal Detachment Surgery Under General Anesthesia: A Randomized Double-Blind Study

Jérôme Morel, Jean Pascal, David Charier, Véronique De Pasquale, Philippe Gain, Christian Auboyer, and Serge Molliex

Anesth Analg 2006 102: 1082-1087.

ANESTHETIC PHARMACOLOGY:

异氟醚、七氟醚麻醉期间气管插管后N2O引起异常脑电改变

(顾新宇 陈杰 校)

异丙酚麻醉中对指令的反应消失时对笑气以及麻醉药的需要量

(黄丽娜   马皓琳 李士通  )

Nitrous Oxide and Anesthetic Requirement for Loss of Response to Command During Propofol Anesthesia

Dharshi Karalapillai, Kate Leslie, Abhay Umranikar, and Andrew R. Bjorksten

Anesth Analg 2006 102: 1088-1093.

利多卡因通过对人舌癌细胞表皮生长因子受体的抑制起到抑制增殖的作用

(陆文清译 薛张纲校)

The Antiproliferative Effect of Lidocaine on Human Tongue Cancer Cells with Inhibition of the Activity of Epidermal Growth Factor Receptor

Masahiro Sakaguchi, Yoshihiro Kuroda, and Munetaka Hirose

Anesth Analg 2006 102: 1103-1107.

局麻药对脂多糖所致内皮细胞损伤的保护作用:线粒体三磷酸腺苷敏感性钾离子通道的作用

(周雅春 马皓琳 李士通 校)

Local Anesthetic-Induced Protection Against Lipopolysaccharide-Induced Injury in Endothelial Cells: The Role of Mitochondrial Adenosine Triphosphate-Sensitive Potassium Channels

Manuela J. M. de Klaver, Gregory S. Weingart, Tom G. Obrig, and George F. Rich

Anesth Analg 2006 102: 1108-1113.

硫喷妥钠能调节大鼠脊髓背角神经元中γ-氨基丁酸A受体功能

(田婕 陈杰 校)

Modulation of Gamma-Aminobutyric AcidA Receptor Function by Thiopental in the Rat Spinal Dorsal Horn Neurons

Chuan-Xiu Yang, Han Xu, Ke-Qing Zhou, Meng-Ya Wang, and Tian-Le Xu

Anesth Analg 2006 102: 1114-1120.

抗胆碱酯酶药通过Rho-激酶途径刺激大鼠气管平滑肌收缩

(周荻 薛张纲校)

Anticholinesterase Drugs Stimulate Smooth Muscle Contraction of the Rat Trachea Through the Rho-Kinase Pathway

Osamu Shibata, Masataka Saito, Maki Yoshimura, Masakazu Yamaguchi, Kenji Nishioka, Tetsuji Makita, and Koji Sumikawa

Anesth Analg 2006 102: 1121-1126.

格拉斯琼和多拉斯琼预防术后恶心呕吐与CYP2D6的基因型有关

(颜涛 马皓琳 李士通 校)

Prevention of Postoperative Nausea and Vomiting with Granisetron and Dolasetron in Relation to CYP2D6 Genotype

Piotr K. Janicki, H. Gregg Schuler, Tomasz M. Jarzembowski, and Malina Rossi, II

Anesth Analg 2006 102: 1127-1133.

异氟醚保护遭受中度缺氧的成年小鼠的空间立体记忆

(郑丽 陈杰 校)

Isoflurane Preserves Spatial Working Memory in Adult Mice After Moderate Hypoxia

Alex Bekker, Romin Shah, David Quartermain, Yong-Sheng Li, and Thomas Blanck

Anesth Analg 2006 102: 1134-1138

TECHNOLOGY, COMPUTING, AND SIMULATION:

听觉诱发电位、脑电双频指数和估计效应室浓度对临床麻醉终末的预测

(王慧琳译 薛张纲校)

A-Line, Bispectral Index, and Estimated Effect-Site Concentrations: A Prediction of Clinical End-Points of Anesthesia

Sascha Kreuer, Jörgen Bruhn, Reinhard Larsen, Heiko Buchinger, and Wolfram Wilhelm

Anesth Analg 2006 102: 1141-1146.

患者持续静脉输注给药:通过模型预测受流速和输注系统死腔影响的潜在药物剂量波动

(赵雪莲 马皓琳 李士通 校)

The Delivery of Drugs to Patients by Continuous Intravenous Infusion: Modeling Predicts Potential Dose Fluctuations Depending on Flow Rates and Infusion System Dead Volume

Mark A. Lovich, M. Ellen Kinnealley, Nathanial M. Sims, and Robert A. Peterfreund

Anesth Analg 2006 102: 1147-1153.

PAIN MEDICINE:

鞘内使用吗啡以缓解肝切除术后疼痛:与硬膜外镇痛的比较

(曹瑜 陈杰 校)

The Use of Intrathecal Morphine for Postoperative Pain Relief After Liver Resection: A Comparison with Epidural Analgesia

Lesley De Pietri, Antonio Siniscalchi, Alexia Reggiani, Michele Masetti, Bruno Begliomini, Matteo Gazzi, Giorgio E. Gerunda, and Alberto Pasetto

Anesth Analg 2006 102: 1157-1163.

磁共振光谱法发现慢性腰痛相关的脑部生化改变:一项初步报告

(徐丽颖译 薛张纲校)

Magnetic Resonance Spectroscopy Detects Biochemical Changes in the Brain Associated with Chronic Low Back Pain: A Preliminary Report

Philip J. Siddall, Peter Stanwell, Annie Woodhouse, Ray L. Somorjai, Brion Dolenko, Alexander Nikulin, Roger Bourne, Uwe Himmelreich, Cynthia Lean, Michael J. Cousins, and Carolyn E. Mountford

Anesth Analg 2006 102: 1164-1168.

依托咪酯抑制大鼠腰背角神经元对伤害性温度刺激的反应

(张莹 马皓琳 李士通 校)

Etomidate Depresses Lumbar Dorsal Horn Neuronal Responses to Noxious Thermal Stimulation in Rats

Toshihiko Mitsuyo, Joseph F. Antognini, and Earl Carstens

Anesth Analg 2006 102: 1169-1173.

CRITICAL CARE AND TRAUMA:

不同程度的多脏器功能不全患者的局部微血管功能和血管反应性

(朱辉 陈杰 校)

Regional Microvascular Function and Vascular Reactivity in Patients with Different Degrees of Multiple Organ Dysfunction Syndrome

Hans Knotzer, Werner Pajk, Martin W. Dünser, Stephan Maier, Andreas J. Mayr, Nicole Ritsch, Barbara Friesenecker, and Walter R. Hasibeder

Anesth Analg 2006 102: 1187-1193

在体外实验中由生理盐水引起的稀释性凝血功能障碍可被纤维蛋白原浓缩剂逆转而由6%羟乙基淀粉引起的则不能

(孙卓真译 薛张纲校)

Fibrinogen Concentrate Reverses Dilutional Coagulopathy Induced In Vitro by Saline but Not by Hydroxyethyl Starch 6%

Claudia De Lorenzo, Andreas Calatzis, Ulrich Welsch, and Bernhard Heindl

Anesth Analg 2006 102: 1194-1200.

部分辅助通气过程中兔子呼吸肌的局部血流

(张曦 马皓琳 李士通 校)

Regional Blood Flow in Respiratory Muscles During Partial Ventilatory Assistance in Rabbits

Akinori Uchiyama, Yuji Fujino, Kikumi Hosotsubo, Eriko Miyoshi, Takashi Mashimo, and Masaji Nishimura

Anesth Analg 2006 102: 1201-1206.  

NEUROSURGICAL ANESTHESIA:

大鼠脊髓短暂非损伤性缺血后鞘内注射尼可地尔和小剂量吗啡可导致痉挛性截瘫

(肖洁 陈杰 校)

Intrathecal Nicorandil and Small-Dose Morphine Can Induce Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in the Rat

Tatsuya Fuchigami, Manabu Kakinohana, Seiya Nakamura, Kenji Murata, and Kazuhiro Sugahara

Anesth Analg 2006 102: 1217-1222.

脊髓损伤病人接受损伤平面以下手术时的麻醉需求和应激激素反应

(韩晓丹译 薛张纲校)

Anesthetic Requirements and Stress Hormone Responses in Spinal Cord-Injured Patients Undergoing Surgery Below the Level of Injury

KyungYeon Yoo, JaeHa Hwang, SungTae Jeong, SeokJai Kim, HongBeom Bae, JeongIl Choi, SungSu Chung, and JongUn Lee

Anesth Analg 2006 102: 1223-1228.

REGIONAL ANESTHESIA:

在现有临床环境下比较全膝关节整形术后单次注射的股神经阻滞及持续性股神经阻滞作用对患者住院时间及长时程功能恢复的影响

(裘毅敏 马皓琳 李士通校)

The Effect of Single-Injection Femoral Nerve Block Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty on Hospital Length of Stay and Long-Term Functional Recovery Within an Established Clinical Pathway

Francis V. Salinas, Spencer S. Liu, and Michael F. Mulroy
Anesth Analg 2006 102: 1234-1239.

全膝关节置换术后硬膜外镇痛和连续股神经-坐骨神经联合阻滞的比较

(张美荣 陈杰 校)

A Comparison of Epidural Analgesia With Combined Continuous Femoral-Sciatic Nerve Blocks After Total Knee Replacement

Dusanka Zaric, Klavs Boysen, Christian Christiansen, Jadwiga Christiansen, Snorre Stephensen, and Bodil Christensen

Anesth Analg 2006 102: 1240-1246.

局麻中下肢的皮肤温度

( 静译 薛张纲校)

Skin Temperature During Regional Anesthesia of the Lower Extremity

Markus F. Stevens, Robert Werdehausen, Henning Hermanns, and Peter Lipfert

Anesth Analg 2006 102: 1247-1251.

GENERAL ARTICLES:

术后谵妄:疼痛和疼痛治疗的重要性

(潘志英 陈杰 校)

Postoperative Delirium: The Importance of Pain and Pain Management

Linnea E. Vaurio, Laura P. Sands, Yun Wang, E. Ann Mullen, and Jacqueline M. Leung

Anesth Analg 2006 102: 1267-1273.

比较静脉输注盐水、平衡液、胶体对凝血在体外的影响

(钟静译 薛张纲校)

A Head-to-Head Comparison of the In Vitro Coagulation Effects of Saline-Based and Balanced Electrolyte Crystalloid and Colloid Intravenous Fluids

Anthony M. Roche, Michael F. M. James, Elliott Bennett-Guerrero, and Michael G. Mythen

Anesth Analg 2006 102: 1274-1279.

测试温度和存储温度对血小板凝集的影响:一次体外的全血试验

(姜旭晖 马皓琳 李士通 校)

The Effects of Test Temperature and Storage Temperature on Platelet Aggregation: A Whole Blood In Vitro Study

Gisela Scharbert, Madeleine Kalb, Corinna Marschalek, and Sibylle A. Kozek-Langenecker

Anesth Analg 2006 102: 1280-1284.

预测急性等容血液稀释对分离自体全血血液成分的影响

Prediction of the effect of acute normovolemic hemodilution on the hematological constituents of sequestered autologous whole blood.
Loubser PG, Chan A.
Research Division, Hematicus Limited Partnership, Sugar Land, TX 77478, USA.

Anesth Analg. 2006 Apr;102(4):991-7

 

当进行急性等容血液稀释(ANH)时,自体全血收集在含有抗凝剂的采集袋中。对于血液稀释后,分离全血血液成分的影响从来没有进行过检测。当ANH时,我们建立一个数学模型来预测全血袋成分是如何改变的,阐明ANH效能的理论基础。公式被衍生用来计算ANH[X]的影响,[X]指血液成分的益处。指数包络被确定,当最初的血容量和全血袋容量(WB(ANH))经过处理,于是ANH对每种成分的影响可以被计算。通过与标准同种异体血制品相比较,自体全血血红蛋白、血小板,以及纤维蛋白原的等价被确定。我们明确在收集血([X](n))的特定单位中血液成分X浓度是作为最初浓度([X](0))的一部分被提供。当WB(ANH)增加与估计血容量相关联,[X](n)的递减在后续采集血袋中增加。无论最初血容量多少,450ml自体全血分别地相当于13.3 g/dL1U浓缩红细胞和123× 103/微升的全血衍生血小板浓缩液。用这种模式ANH对自体全血成分的影响可以精确的预测。WB(ANH)变成等价的自体血产品可以提供有效的方法比较不同ANH研究的结果。指数包络可以用来评价麻醉师执行的实际ANH技术,其依次可影响质量保证标准。

(孙敏莉译 薛张纲校)

During acute normovolemic hemodilution (ANH), autologous whole blood is collected in a series of collection bags containing anticoagulant. The effect of hemodilution on the actual hematological constituents of this sequestered whole blood product has never been examined. We developed a mathematical model that predicts how whole blood bag constituents change during ANH to elucidate the theoretical basis for ANH efficacy. Formulas were derived to calculate the effect of ANH on [X], the blood constituent of interest. An exponential envelope was defined so that the projected impact of ANH on each constituent could be computed while initial blood volume and whole blood bag volume (WB(ANH)) were manipulated. Equivalency of autologous whole blood hemoglobin, platelets, and fibrinogen were determined by comparison with standard allogeneic blood products. We determined that the concentration of blood constituent X in a particular unit of collected blood ([X](n)) is provided as a fraction of the initial concentration ([X](0)). As WB(ANH) increases relative to estimated blood volume, the decrement in [X](n) increases in successive blood collection bags. Irrespective of initial blood volume, the equivalence of a 450-mL autologous whole blood bag to 1 U of packed red cells and 1 U of whole blood-derived platelet concentrate is 13.3 g/dL and 123 x 10(3)/microL, respectively. The impact of ANH on autologous whole blood constituents may be accurately predicted using this model. Conversion of WB(ANH) into equivalent allogeneic blood products could provide a useful method of comparing outcome in various ANH studies. The exponential envelope may be used to assess the actual ANH technique performed by the anesthesiologist, which in turn may impact quality assurance standards.

 

首次心脏手术大量出血、输血与再次手术大量出血、输血相关

Excessive Bleeding and Transfusion in a Prior Cardiac Surgery is Associated with Excessive Bleeding and Transfusion in the Next Surgery

Gregory A. Nuttall, MD*, Nicole Henderson, MS**, Michael Quinn, CRNA{dagger}, Clay Blair, CRNA{dagger}, Layne Summers, CRNA{dagger}, Brent A. Williams, MS{ddagger}, William C. Oliver, MD*, and Paula J. Santrach, MD***.

Department of Anesthesilogy, Mayo Clinic, Rochester, Minnesota.

Anesth Analg 2006 102: 1012-1017.

 

若存在大量出血的遗传倾向,那么多次心脏手术大量出血之间必有关联。为此,我们进行了一次回顾性调查,分析了从1990119日至2002625日之间的174位患者,他们均在体外循环下进行了2次心脏手术,研究2次手术间大量出血的联系。必须符合以下两条才定义为大量出血:1)术后24小时胸管内出血大于或等于750mL(胸管引流量[CTD]750);2)输注任意一种非红细胞(RBC)血制品。使用Logist回归分析第一次和第二次心脏手术大量出血之间的关系。第二次手术CTD750Logist回归模型表明,第一次手术CTD750CTD750比较,未校准的比值比为2.18P0.03),使用年龄、性别、体表面积、术前使用抗凝剂、体外循环时间及第二次手术方式校准后的比值比为2.42P0.03)。第二次手术使用任何非红细胞血制品的Logist回归模型表明第一次手术使用任何非红细胞血制品与未使用者比较,未校准的比值比为2.32P0.02),使用年龄、性别、体表面积、术前使用抗凝剂、体外循环时间及第二次手术方式校准后的比值比为2.55P0.02)。因此,我们认为第一次手术的大量出血史使第二次手术大量出血的危险因素升高两倍以上。

(金琳 薛张纲校)

If there is a genetic predisposition to excessive bleeding, there should be an association in excessive blood loss between multiple cardiac surgeries. We retrospectively determined in 174 patients the association of excessive bleeding between 2 cardiac surgeries with cardiopulmonary bypass between January 19, 1990 and June 25, 2002. Excessive bleeding was defined by 2 criteria: (a) postoperating room chest tube blood loss over 24 h more than or equal to 750 mL (chest tube drainage [CTD] ≥750) and (b) transfusion of any non-red blood cell (RBC) blood products. Logistic regression was used to estimate the association between excessive bleeding at the first and second cardiac procedures. The logistic regression models for CTD ≥750 in the second surgery determined that CTD ≥750 in the first surgery compared to CTD < 750 had an unadjusted odds ratio of 2.18 (P = 0.03) and an odds ratio of 2.42 (P = 0.03) when adjusted for age, sex, body surface area, preoperative anticoagulant use, cardiopulmonary bypass duration, and procedure type at second surgery. The logistic regression model for any non-RBC use in the second surgery determined that any non-RBC use in the first surgery compared with no non-RBC use had an unadjusted odds ratio of 2.32 (P = 0.02) and an odds ratio of 2.55 (P = 0.02) when adjusted for age, sex, body surface area, preoperative anticoagulant use, cardiopulmonary bypass duration, and procedure type at second surgery. We conclude that a history of excessive bleeding during the first operation is associated with more than two times increased risk for excessive bleeding in the second surgery.

 

在犬左心室非依赖Starling机制的lusitropism指数:逻辑时间常数(logistic time constant)。

Starling-effect-independent lusitropism index in canine left ventricle: logistic time constant.

Mizuno J. Mohri S. Shimizu J. Suzuki S. Mikane T. Araki J. Matsubara H. Morita T. Hanaoka K. Suga H.

Department of Cardiovascular Physiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.

Anesthesia & Analgesia. 102(4):1032-9, 2006 .

 

逻辑时间常数(logistic time constant, tau(L))被认为是一个传统单指数时间常数(tau(E))更好的左心室舒张率或lusitropism指数。然而,Frank-Starling效应是否或者怎样影响tau(L)仍有待阐明。我们比较了左室容量(LVV)对tau(L)和单指数时间常数的影响。利用8离体相互循环的心脏形成的4个不同容积(10121416mL),在3个不同的终点分析来自最大的负压力时间速率(-dP/dt(max))形成的左室等容舒张压力曲线。我们发现,在所有的左室容积和各终点,tau(L)都优于单指数时间常数。左室容量负荷不影响tau(L)但可轻微影响tau(E)。虽然更进一步的终点增加tau(L) tau(E),但对tau(L)的增加明显小于tau(E)。而且它的常数振幅和非零渐进线的变化对tau(L)明显更小。我们的结论,tau(L)是一个更可靠的lusitropism指数,他不依赖于左室容积负荷的变化和Frank-Starling机制的影响。

(吴德华译 薛张纲校)

The logistic time constant (tau(L)) has been proposed as a better index of the rate of left ventricular (LV) relaxation or lusitropism than the conventional monoexponential time constant (tau(E)). However, whether and how the Frank-Starling effect influences tau(L) remains to be elucidated. We compared the effect of LV volume (LVV) loading on both logistic and monoexponential fittings. The isovolumic LV relaxation pressure curves from the maximum negative time derivative of pressure (-dP/dt(max)) were analyzed at 3 different end-points at 4 LVVs of 10, 12, 14, and 16 mL in 8 excised, cross-circulated canine hearts. We found that the logistic fitting was superior to the monoexponential fitting at all LVVs and end-points. LVV loading did not affect tau(L) but affected tau(E) slightly. Although the advancing end-point increased both tau(L) and tau(E), the increases were significantly smaller for tau(L) than for tau(E) at all LVVs. Moreover, the changes in both the amplitude constants and nonzero asymptotes with the advancing end-point were significantly smaller for the logistic fitting than for the monoexponential fitting. We conclude that tau(L) served as a more reliable index of lusitropism that is independent of the change in LVV loading or the Frank-Starling effect.

 

小儿脑MRI检查时七氟醚麻醉结束前给予小剂量氯胺酮或Nalbuphine可减少清醒时躁动

Prevention of Emergence Agitation After Sevoflurane Anesthesia for Pediatric Cerebral Magnetic Resonance Imaging by Small Doses of Ketamine or Nalbuphine Administered Just Before Discontinuing Anesthesia

Bernard J. Dalens, MD, PhD, Anne Marie Pinard, MD, Dany-Roch Létourneau, MD, Natalie T. Albert, MD, and René J. Y. Truchon, MD

Department of Anesthesiology, CHUL du Centre Hospitalier Universitaire de Québec, Québec, Canada

Address correspondence to Bernard J. Dalens, Department of Anesthesiology, CHUL du Centre Hospitalier Universitaire de Québec, 2705, boul. Laurier - Local 2206, Sainte-Foy, Québec, Canada, G1V 4G2.

Anesth Analg 2006 102: 1056-1061.

 

MRI检查要求长时间制动,在儿科病人通常只能采用全麻达成目的。七氟醚可以提供足够的麻醉深度,但很多病人出现清醒时躁动。小剂量的氯胺酮和nalbuphine可以提供适度的镇静,但在苏醒期效果较差。我们猜测,将它们推迟至检查结束时使用,既可有效防止清醒时躁动,又不延长患者苏醒和出苏醒室时间。我们进行了一项双盲研究,9068岁患者随机分为三组,在七氟醚全麻下MRI检查终期分别给予生理盐水(S组)、氯胺酮(0.25 mg/kg)K组)和nalbuphine (0.1 mg/kg)N组)。我们评价了30分钟内时苏醒情况,镇静/躁动状况,达到出室标准情况。三组病人在年龄、性别比例、身体状况和合并内科疾病等可比。清醒条件无显著差别。S组在所有时间的躁动情况明显较多,5分钟和10分钟时迟钝的患者在K组和N组较多。所有患者在30分钟时都达到了出室标准,但K组、N组患者清醒并安静的人数明显较多。总之,在七氟醚麻醉下行MRI检查时使用小剂量氯胺酮或nalbuphine可以减少清醒时躁动而又不延迟出室。应用Nalbuphine比氯胺酮效果更好。

(金 路译 薛张纲校)

Magnetic resonance imaging (MRI) requires long-lasting immobilization that frequently can only be provided by general anesthesia in pediatric patients. Sevoflurane provides adequate anesthesia but many patients experience emergence agitation. Small doses of ketamine and nalbuphine provide moderate sedation but their benefits have subsided at the time of emergence. We hypothesized that delaying their administration until the end of the procedure would prevent emergence agitation without prolonging patient wake-up and discharge times from the postanesthesia care unit. We performed a double-blind study involving 90 patients (aged 6 mo to 8 yr) randomly allocated to 1 of 3 groups receiving either saline (S-group), ketamine (0.25 mg/kg) (K-group), or nalbuphine (0.1 mg/kg) (N-group) at the end of an MRI procedure under sevoflurane anesthesia. We evaluated emergence conditions, sedation/agitation status and completion of discharge criteria at 30 min. The three groups were comparable in age, sex ratio, physical status, and associated medical disorders. Emergence conditions did not differ significantly. There were significantly more agitated children, at all times, in the S-group and more obtunded patients at early times (5 and 10 min) in both K- and N-groups. All patients met discharge criteria at 30 min but significantly more children were awake and quiet in the K-group and still more in the N-group. In conclusion, small doses of ketamine or nalbuphine administered at the end of an MRI procedure under sevoflurane anesthesia reduce emergence agitation without delaying discharge. Nalbuphine provided better results than ketamine.

 

全麻下行视网膜脱离手术的病人围术期进行眼球周围阻滞:一项随机双盲试验

Preoperative Peribulbar Block in Patients Undergoing Retinal Detachment Surgery Under General Anesthesia: A Randomized Double-Blind Study

Jérôme Morel, MD, Jean Pascal, MD, David Charier, MD, Véronique De Pasquale, MD, Philippe Gain, MD, PhD, Christian Auboyer, MD, and Serge Molliex, MD, PhD

Département d’Anesthésie-Réanimation, Service d’Ophtalmologie, Hôpital Bellevue, Saint-Etienne, France

Anesth Analg 2006;102:1082-1087.

成人的视网膜脱离手术通常和严重的术后疼痛及呕吐相关。该项随机双盲对照试验是为了证明1%罗哌卡因眼球周围阻滞(PB)联合全麻,较眼睑下方生理盐水皮下注射联合全麻,不但能改善手术条件,而且能减轻术后疼痛。每组包括31名病人。麻醉用异丙酚靶控输注、瑞芬太尼持续输注,维持脑室双频指数(BIS)在4050之间。术后镇痛包括静脉输入恒定剂量的丙帕他莫,以及通过病人自控装置输入奈福泮。曲马多作为补救药静脉给予。各组间的人口数据具有可比性,BIS保持在目标水平。在PB组,很少有病人出现眼心反射(6 vs 17P < 0.01);术野出血减少(1 vs 11P < 0.01);首次需要奈福泮的时间更长(148 ± 99 46 ± 58分钟;P < 0.01);拔管后的前6小时奈福泮的用量下降(18.9 ± 13.9 vs 28.5 ± 14.7 mg; P < 0.05);术后即时疼痛评分降低;更少的病人需要补救药物(5 vs 23; P < 0.01)。术后恶心呕吐的发生率两组相似。综上所述,PB联合全麻改善了手术条件,减轻了术后疼痛。

(王丽珺译 薛张纲校)

Retinal detachment surgery is frequently associated with significant postoperative pain and emesis in adults. In this randomized, double-blind, controlled study we sought to demonstrate that 1% ropivacaine peribulbar (PB) block in conjunction with general anesthesia (GA) improves operative conditions and postoperative analgesia compared with GA combined with subcutaneous normal saline injection into the inferior eyelid. Thirty-one patients were included in each group. Anesthesia was performed with target-controlled infusion propofol and continuous remifentanil infusion adjusted to maintain bispectral index values between 40 and 50. Postoperative analgesia included fixed-dose IV infusion of propacetamol and IV injection of nefopam via a patient-controlled analgesia device. Tramadol was infused IV as rescue medication. Demographic data were comparable between the groups and bispectral index values were maintained at the objective target. In the PB group, fewer patients presented an oculocardiac reflex (6 versus 17; P < 0.01); bleeding interfering with the surgical field was reduced (1 versus 11 patients; P < 0.01); mean time to first nefopam request was longer (148 ± 99 versus 46 ± 58 min; P < 0.01); mean nefopam consumption was diminished during the first 6 h after tracheal extubation (18.9 ± 13.9 versus 28.5 ± 14.7 mg; P < 0.05); immediate postoperative pain scores were lower; and fewer patients required rescue medication (5 versus 23; P < 0.01). The two groups were similar with respect to the incidence of postoperative nausea and vomiting. Overall, PB block combined with GA improved operating conditions and postoperative analgesia in retinal detachment surgery.

 

利多卡因通过对人舌癌细胞表皮生长因子受体的抑制起到抑制增殖的作用

The Antiproliferative Effect of Lidocaine on Human Tongue Cancer Cells with Inhibition of the Activity of Epidermal Growth Factor Receptor

Masahiro Sakaguchi, MD*, Yoshihiro Kuroda, PhD, and Munetaka Hirose, MD*

*Department of Anesthesiology, Kyoto Prefectural University of Medicine; and Graduate School of Pharmaceutical Sciences, Kyoto University, Japan

Anesth Analg 2006;102:1103-1107.

 

局部麻醉药可以抑制多种癌细胞的增殖,但其机制尚未知晓。我们之前的研究表明,利多卡因在局部给药时的组织浓度就可以直接抑制表皮生长因子受体(EGFR),而这正是一个潜在的目标来抑制癌细胞的增殖。因此,我们假设利多卡因可以通过抑制EGFR的活性来抑制癌细胞的增殖。我们研究利多卡因(40–4000 µM)对人类舌癌细胞CAL27增殖的作用,这种细胞表达有较高水平的EGFR。同时也研究利多卡因对已经激动的EGF(磷酸化的EGFR)的作用。一个临床的利多卡因浓度(400 µM)在没有产生细胞毒性下可以同时抑制血清介导和EGF介导的CAL27细胞的增殖,也抑制            EGF激活的酪氨酸激酶的活性。较大浓度的利多卡因(4000 µM)在抑制增殖的同时有细胞毒性。我们觉得对激动的EGF的抑制是利多卡因对CAL27细胞抑制增殖的机制之一。传统用于止痛的利多卡因口腔给药会抑制人舌癌细胞的增殖。

(陆文清译 薛张纲校)

Local anesthetics suppress proliferation in several cancer cells. The mechanism of the suppression, however, is unknown. Our previous study shows that lidocaine, at the level of tissue concentration under topical or local administration, has a direct inhibitory effect on the activity of epidermal growth factor receptor (EGFR), which is a potential target for antiproliferation in cancer cells. Therefore, we hypothesized that lidocaine would suppress the proliferation of cancer cells through the inhibition of EGFR activity. We investigated the effects of lidocaine (40–4000 µM) on proliferation of a human tongue cancer cell line, CAL27, which has a high level of EGFR expression, and also examined the effect of lidocaine on epidermal growth factor (EGF)-stimulated autophosphorylation of EGFR in CAL27 cells.A clinical concentration of lidocaine (400 µM) suppressed both serum-induced and EGF-induced proliferation of CAL27 cells and inhibited EGF-stimulated tyrosine kinase activity of EGFR without cytotoxicity. A larger concentration of lidocaine (4000 µM) showed cytotoxicity with an antiproliferative effect. We suggest that the inhibition of EGF-stimulated EGFR activity is one of the mechanisms of the antiproliferative effect of lidocaine on CAL27 cells. Lidocaine administered topically within the oral cavity for cancer pain relief may suppress the proliferation of human tongue cancer cells

           

抗胆碱酯酶药通过Rho-激酶途径刺激大鼠气管平滑肌收缩

Anticholinesterase Drugs Stimulate Smooth Muscle Contraction of the Rat Trachea Through the Rho-Kinase Pathway

Osamu Shibata, MD, Masataka Saito, MD, Maki Yoshimura, MD, Masakazu Yamaguchi, MD, Kenji Nishioka, MD, Tetsuji Makita, MD, and Koji Sumikawa, MD

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

Address correspondence and reprint requests to Osamu Shibata, MD, Department of Anesthesiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan. Address e-mail to opshiba@net.nagasaki-u.ac.jp .

Anesth Analg 2006;102:1121-1126.

 

此项研究是为了确定Rho激酶抑制剂,Y-27632和法舒地尔,在抗胆碱酯酶药(抗-ChE)介导的大鼠气管收缩和纤维醇磷脂酰化反应中的效果。在体外相等张力和[3H]纤维醇单磷酸(IP1)的测量是由大鼠的气管环或切片来获得的。新斯的明-和溴吡斯的明介导的收缩几乎可以完全被30 µM Y-27632和法舒地尔抑制。然而,在各自100µM的剂量下,乙酰胆碱介导的收缩抑制不完全,即,Y-27632抑制56%,法舒地尔抑制51%。法舒地尔对新斯的明和乙酰胆碱介导的收缩抑制效果可以被calyculin-A,一种肌球蛋白磷酸化抑制剂所完全逆转。新斯的明介导的IP1积聚被100µM的法舒地尔削弱。这些结果显示抗胆碱酯酶药部分通过激活Rho激酶途径引起气道平滑肌收缩。

(周荻 薛张纲校)

We performed this study to determine the effects of Rho-kinase inhibitors, Y-27632 and fasudil, on the anticholinesterase (anti-ChE)-induced contractile and phosphatidylinositol responses of the rat trachea. In vitro measurements of isometric tension and [3H] inositol monophosphate that was formed were conducted by using rat tracheal rings or slices. Neostigmine- and pyridostigmine-induced contractions were almost completely inhibited by Y-27632 and fasudil at 30 µM each, whereas acetylcholine-induced contraction was inhibited incompletely, i.e., by 56% by Y-27632 and by 51% by fasudil, at 100 µM for each, respectively. The inhibitory effects of fasudil on neostigmine- and acetylcholine-induced contractions were completely reversed by calyculin-A, a myosin phosphatase inhibitor. Neostigmine-induced IP1 accumulation was attenuated by fasudil at 100 µM. The results suggest that anti-ChEs cause airway smooth muscle contraction, in part, through activation of the Rho-kinase pathway.

 

听觉诱发电位、脑电双频指数和估计效应室浓度对临床麻醉终末的预测

A-Line, Bispectral Index, and Estimated Effect-Site Concentrations: A Prediction of Clinical End-Points of Anesthesia

Sascha Kreuer, Jörgen Bruhn, Reinhard Larsen, Heiko Buchinger, and Wolfram Wilhelm

Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Germany.

Anesth Analg 2006 102: 1141-1146.

 

中潜伏期听觉诱发电位已用于麻醉深度的监测。我们调查研究了地氟醚的剂量反应关系和听觉诱发电位指数(AAI)及脑电双频指数(BIS)对于苏醒的预测价值。选择了20个行根治性前列腺切除术的成年男性。为了尽可能地减小阿片类药物的作用,我们选择了硬膜外复合全麻。给受试者耳机听觉刺激并进行AAIBIS监测。麻醉诱导采用异丙酚和瑞芬太尼。而维持仅用地氟醚。同AAIBIS监测参数相比,地氟醚和异丙酚分布及效应室浓度的药代动力学模型被用来预测临床终末的深度(预测概率)。病人在AAI值为47+/-20BIS值为77+/-14时睁眼,睁眼时AAIBIS及地氟醚的效应室浓度的预测概率分别为0.810.890.91。睁眼的最佳预测是通过计算地氟醚的效应室浓度。地氟醚的效应室浓度和AAIBIS的预测关系通过非线性回归分析计算(AAI的相关度为0.75BIS的相关度为0.80)BIS和临床终点浓度或地氟醚的效应室浓度的预测相关性要优于AAI

(王慧琳译 薛张纲校)

Autoregressive modeling with exogenous input of middle-latency auditory evoked potentials (A-Line AEP index, AAI) has been developed for monitoring depth of anesthesia. We investigated the prediction of recovery and dose-response relationship of desflurane and AAI or bispectral index (BIS) values. Twenty adult men scheduled for radical prostatectomy were recruited. To minimize opioid effects, analgesia was provided by a concurrent epidural in addition to the general anesthetic. Electrodes for AAI and BIS monitoring and a headphone for auditory stimuli were applied. Propofol and remifentanil were used for anesthetic induction. Maintenance of anesthesia was with desflurane only. For comparison to AAI and BIS monitor parameters, pharmacokinetic models for desflurane and propofol distribution and effect-site concentrations were used to predict clinical end-points (Prediction probability P(K)). Patients opened their eyes at an AAI value of 47 +/- 20 and a BIS value of 77 +/- 14 (mean +/- sd), and the prediction probability for eye opening was P(K) = 0.81 for AAI, P(K) = 0.89 for BIS, and P(K) = 0.91 for desflurane effect-site concentration. The opening of eyes was best predicted by the calculated desflurane effect-site concentration. The relationship between predicted desflurane effect-site concentration versus AAI and BIS was calculated by nonlinear regression analysis (r = 0.75 for AAI and r = 0.80 for BIS). The correlation between BIS and clinical end-points of anesthesia or the desflurane effect-compartment concentration is better than for the AAI.

 

磁共振光谱法发现慢性腰痛相关的脑部生化改变:一项初步报告

Magnetic Resonance Spectroscopy Detects Biochemical Changes in the Brain Associated with Chronic Low Back Pain: A Preliminary Report

Siddall PJ, Stanwell P, Woodhouse A, Somorjai RL, Dolenko B, Nikulin A, Bourne R, Himmelreich U, Lean C, Cousins MJ, Mountford CE

Pain Management Research Institute, University of Sydney, Royal North Shore Hospital, St. Leonards NSW, Australia.

Anesth Analg 2006 102: 1164-1168

 

磁共振(MR)光谱法是一项可用于探测脑部和其他器官中代谢产物和神经递质浓度的非侵入性技术。我们采用在体(1)H MR光谱法在腰痛组与对照组中进行比较以观察与疼痛处理相关的三个脑区的生化改变。一种模式识别方法用于确定基于MR光谱法是否能够正确区别腰痛对象与对照组。在32个腰痛对象和33个无痛对照者的前额叶皮质、前扣带回皮质和丘脑获取MR光谱。采用一种模式识别方法(统计分类策略)在组间分析比较光谱。采用这种方法,能够用前扣带回皮质、丘脑和前额叶皮质的光谱区别腰痛对象和对照组,精确度分别为100%, 99%, 97%。结果证明,运用MR光谱法结合适当的模式识别方法能够以高精确度发现慢性疼痛的脑部生化改变。

(徐丽颖译 薛张纲校)

Magnetic resonance (MR) spectroscopy is a noninvasive technique that can be used to detect and measure the concentration of metabolites and neurotransmitters in the brain and other organs. We used in vivo (1)H MR spectroscopy in subjects with low back pain compared with control subjects to detect alterations in biochemistry in three brain regions associated with pain processing. A pattern recognition approach was used to determine whether it was possible to discriminate accurately subjects with low back pain from control subjects based on MR spectroscopy. MR spectra were obtained from the prefrontal cortex, anterior cingulate cortex, and thalamus of 32 subjects with low back pain and 33 control subjects without pain. Spectra were analyzed and compared between groups using a pattern recognition method (Statistical Classification Strategy). Using this approach, it was possible to discriminate between subjects with low back pain and control subjects with accuracies of 100%, 99%, and 97% using spectra obtained from the anterior cingulate cortex, thalamus, and prefrontal cortex, respectively. These results demonstrate that MR spectroscopy, in combination with an appropriate pattern recognition approach, is able to detect brain biochemical changes associated with chronic pain with a high degree of accuracy.

 

在体外实验中由生理盐水引起的稀释性凝血功能障碍可被纤维蛋白原浓缩剂逆转而由6%羟乙基淀粉引起的则不能

Fibrinogen concentrate reverses dilutional coagulopathy induced in vitro by saline but not by hydroxyethyl starch 6%.

De Lorenzo C, Calatzis A, Welsch U, Heindl B.

Department of Anesthesiology, Ludwig Maximilians University, Munich, Germany.

Anesth Analg. 2006 Apr;102(4):1194-200.


严重的出血通过大量地丢失、消耗、稀释各种凝血因子和血小板从而导致凝血功能障碍。本次体外实验的目的是研究由生理盐水或6%羟乙基淀粉(HES)所引起的渐进性血液稀释在血块形成方面所起的作用并且分析替代性纤维蛋白原和血小板对稀释性凝血功能障碍的影响。由8名志愿者提供的全血标本分别被以上两种稀释剂稀释到占整个样本容量的20%80%。血块形成由血栓弹力图来描记。直到稀释剂占整个样本容量的60%之前替代性纤维蛋白原和血小板都不会被加入样本中。实验表明当6%羟乙基淀粉稀释剂占整个样本容量的40%时血块形成出现严重障碍而用0.9%生理盐水则要直到60%时才出现。在血小板功能被阻断的情况下,用6%羟乙基淀粉稀释剂稀释到占整个样本容量的20%时纤维蛋白单体的聚合功能严重受损,相对的用0.9%生理盐水则要到稀释剂占整个样本容量的80%才会出现同样的现象。添加替代性纤维蛋白原和血小板在用0.9%生理盐水作稀释剂时能使血块形成功能复原而6%羟乙基淀粉作为稀释剂时则不能。在临床相关事件上单独使用血小板或添加血小板对血块形成所起的作用不大。在体外实验中由类晶体所引起的稀释性凝血功能障碍可被添加替代性纤维蛋白原所逆转。相反地,由于羟乙基淀粉分子干扰了纤维蛋白单体的聚合功能,因此添加替代性纤维蛋白原和血小板对由6%羟乙基淀粉所引起的稀释性凝血功能障碍所起的作用很小。

(孙卓真译 薛张纲校)

Severe bleeding often induces coagulopathy via loss, consumption, and dilution of clotting factors and platelets. The aims of our in vitro study were to characterize the influence of progressive hemodilution with either NaCl 0.9% or hydroxyethyl starch (HES) 6% on blood clot formation and to analyze the effect of substitution of fibrinogen and platelets on dilutional coagulopathy. Whole blood samples drawn from 8 volunteers were diluted from 20% to 80% of the sample volume with both diluents separately. Clot formation was measured by thrombelastography. At a 60% dilution, either fibrinogen and/or platelets were added to the samples. Clot firmness became critical after 40% dilution with HES 6% but not until 60% dilution with NaCl 0.9%. When platelet function was blocked, fibrin polymerization was severely impaired after 20% dilution with HES 6%, whereas such an effect was only seen after 80% dilution with NaCl 0.9%. The addition of fibrinogen reconstituted the clot firmness in the presence of NaCl 0.9%, but this had only a minor effect after dilution with HES 6%. Platelets alone or in addition were not able to improve clot firmness to a clinically relevant extent. Dilutional coagulopathy induced by crystalloids can, in vitro, be effectively reversed by supplementation of fibrinogen. In contrast, HES molecules interfere with fibrin polymerization and, thus, administration of fibrinogen after dilution with HES 6% failed to significantly improve clot firmness.

 

脊髓损伤病人接受损伤平面以下手术时的麻醉需求和应激激素反应

Anesthetic requirements and stress hormone responses in spinal cord-injured patients undergoing surgery below the level of injury.
Yoo K, Hwang J, Jeong S, Kim S, Bae H, Choi J, Chung S, Lee J.
Department of Anesthesiology, Chonnam National University Medical School, 8 Hak-dong, Gwangju 501-190, South Korea.
Anesth Analg 2006 102: 1223-1228.

脊髓麻醉降低最小肺泡浓度。我们研究了脊髓损伤对于七氟醚用量和应激激素的影响。在此项研究中一组是22个慢性脊髓损伤并将接受损伤平面以下手术的病人,另一组是15个没有脊髓损伤的对照病人。病人的BIS值为4050。监测包括呼气末七氟醚浓度、动脉血压、心率、血浆儿茶酚胺和皮质醇的浓度。术中,两组病人的动脉血压、心率和BIS值是相互比较的。SCI组病人的呼气末七氟醚的浓度明显比对照组的低。对照组的血浆儿茶酚胺和皮质醇的浓度在术中和术后1小时相对于苏醒时的基线值有明显升高。SCI组病人的交感肾上腺素和皮质醇反应被抑制了。我们得出结论:SCI组病人接受损伤平面以下手术时的麻醉药用量减少20%--39%,同时交感肾上腺素和皮质醇反应被抑制。

(韩晓丹译 薛张纲校)

Neuraxial anesthesia decreases the minimum alveolar concentration. We determined the effects of spinal cord injury (SCI) on sevoflurane requirements and stress hormone response. Twenty-two chronic SCI patients undergoing surgery below the level of the injury were enrolled in the study, and 15 patients without cord injury served as control patients. Bispectral index score was maintained at 40-50. Measurements included end-tidal sevoflurane concentrations, systolic arterial blood pressure, heart rate, and plasma catecholamine and cortisol concentrations. During surgery, systolic arterial blood pressure, heart rate, and Bispectral index were comparable between SCI and control groups. However, end-tidal sevoflurane concentration was significantly smaller in the SCI (0.81%-1.06%) versus control (1.28%-1.31%) patients. In the control group, plasma norepinephrine and cortisol concentrations were significantly increased during and 1 h after surgery compared with awake baseline values. In the SCI group, the sympathoadrenal and cortisol responses were virtually abolished. We conclude that SCI reduces the anesthetic requirement by 20%-39% during surgery below the level of injury, in association with blunted sympathoadrenal and cortisol response.

 

局麻中下肢的皮肤温度

Skin temperature during regional anesthesia of the lower extremity.
Stevens MF, Werdehausen R, Hermanns H, Lipfert P.
Department of Anesthesiology, University of Dusseldorf, Dusseldorf, Germany. markus.

Anesth Analg 2006 102:


在轴索神经阻滞的早期皮肤温度会升高。但是,用皮温改变来预期外周神经阻滞是否成功仍不确切。因此,我们研究是否皮温升高超过1℃预期着股骨和坐骨神经阻滞,硬膜外麻醉后感觉受损。我们进行了一项非随机化的试验,测试了33名股神经和坐骨阻滞阻滞以及10名硬膜外麻醉病人的皮温变化。每5分钟测试病人的感觉和运动功能。皮温变化超过1度,硬膜外阻滞比股神经和坐骨神经阻滞早出现。股神经支配的皮肤温度变化小于1度。6.6%的坐骨阻滞成功的病人中皮温改变早于感觉消失。我们得出的结论是:皮温改变是坐骨神经阻滞成功的可靠依据。临床价值不高。

(钟 静译 薛张纲校)

Increase in skin temperature (Ts) occurs early during neuraxial blocks. However, the reliability of Ts to predict successful peripheral block is unknown. Therefore, we investigated whether an increase in Ts more than 1 degrees C precedes or follows an impairment of sensation after combined femoral and sciatic nerve block as well as after epidural anesthesia. In this prospective, nonrandomized study we determined Ts changes in 33 patients undergoing knee or foot surgery under femoral and sciatic nerve block and 10 patients undergoing epidural anesthesia. Perception and motor function were assessed every 5 min. An increase in Ts (> or =1 degrees C) at the foot occurred later after sciatic nerve block than after epidural anesthesia (10.3 +/- 2.8 versus 5.0 min; P < 0.01). Alterations of Ts at skin innervated by the femoral nerve were <1 degrees C. Ts increase preceded sensory block after sciatic nerve block in 6.6% of patients but indicated a successful block (sensitivity, specificity, and accuracy = 100%). We conclude that an increase of Ts is a reliable, but late, sign of successful sciatic nerve block. Therefore it is of limited clinical value. Ts changes after femoral nerve block are negligible and late.

 

比较静脉输注盐水、平衡液、胶体对凝血在体外的影响

A head-to-head comparison of the in vitro coagulation effects of saline-based and balanced electrolyte crystalloid and colloid intravenous fluids.
Roche AM, James MF, Bennett-Guerrero E, Mythen MG.
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.

Anesth Analg 2006 102: 1274-1279.

羟乙基淀粉和盐水、平衡液都可能影响凝血。我们对10名健康的志愿者进行试验,用血栓弹性描记器示凝血差异,溶液稀释分为20%,40%,60%。输20%-40%乳酸林格液,血液高凝。输60%羟乙基淀粉,喷他淀粉,白蛋白,都为低凝。输40%羟乙基淀粉也能造成低凝。大分子淀粉比中分子淀粉对凝血的影响更大。平衡液对凝血的影响较小。喷他淀粉中加入平衡液能减少胶体对凝血功能的影响,当其稀释浓度较低时,血液呈高凝,60%时稀释时对凝血影响很小。这些数据支持低分子羟乙基淀粉配入盐水中比高分子对凝血影响更小这一理论,并可由血栓弹性描记器验证。

(钟静译 薛张纲校)

Both fluid composition (e.g., type of hydroxyethyl starch) and formulation (e.g., saline or balanced salt carrier solution) may alter whole blood coagulation. We therefore enrolled 10 healthy volunteers to test ex vivo, thrombelastograph-based blood coagulation differences of eight crystalloid and colloid solutions at 20%, 40%, and 60% dilutions. Saline and lactated Ringer's solution produced a hypercoagulable state at 20%-40% dilutions. Saline, hetastarch in saline, pentastarch in saline, tetrastarch in saline, and human albumin solutions all produced a hypocoagulable state at 60% dilution. Hetastarch in saline also produced a hypocoagulable state at 40% dilution. The larger molecular weight starches produced more intense coagulation abnormalities than the medium molecular weight compounds formulated similarly (i.e., suspended in saline or balanced salt solution). The balanced salt solutions caused fewer coagulation abnormalities, especially pentastarch in balanced salt solution. This balanced salt pentastarch preparation produced the least derangement of coagulation of the colloid solutions at all dilutions, causing hypercoagulability at the lower dilutions and minimal coagulation derangement at 60% dilution. These data support the theory that smaller molecular weight hydroxyethyl starches and colloids suspended in balanced salt solutions preserve coagulation better than large molecular weight starches and saline-based colloids, as judged by thrombelastography.

抗凝血酶(抗纤维蛋白酶)能调节腹主动脉瘤修补手术中凝血、细胞因子的产生、以及粘附分子表达

Antithrombin Can Modulate Coagulation, Cytokine Production, and Expression of Adhesion Molecules in Abdominal Aortic Aneurysm Repair Surgery

Tomoki Nishiyama, MD, PhD

Department of Anesthesiology, The University of Tokyo, Faculty of Medicine, Tokyo Department fund was used for this study.

Anesth Analg 2006 102: 1007-1011

.

本文作者研究了抗凝血酶在腹主动脉瘤修补手术中对凝血、纤溶、以及细胞因子和粘附分子产生的影响。16个行Y-型移植置换术的腹主动脉瘤患者分成抗凝血酶组和对照组。抗凝血酶组在肝素化前和肝素化24小时后于30分钟内分别注入3000单位的抗凝血酶。在手术前, 手术结束时,术后第1、第2天分别进行白细胞计数、血小板计数,测定凝血酶原时间、抗凝血酶、多形核白细胞的白细胞弹性蛋白酶、白介素(IL)-1ß IL-6 IL-8 肿瘤坏死因子-{alpha}和粘附分子的血浆浓度,以及凝血、纤溶的变化。结果:对照组抗凝血酶的浓度下降,而抗凝血酶组中升高,组间比较有显著性差异。凝血酶原时间, d-二聚体、凝血酶-抗凝血酶复合物和细胞间的粘附分子-1 的浓度仅在对照组升高;而多形核白细胞的白细胞弹性蛋白酶、白介素IL-6、肿瘤坏死因子-{alpha}和血管的细胞粘附分子-1在两组中都升高。抗凝血酶组除细胞间的粘附分子-1以外均小于对照组。结论:抗凝血酶能在腹主动脉瘤手术中降低高凝和炎症的激活,可能降低不良事件的发生。

(宋金超 陈杰 校)

We investigated the effects of antithrombin on coagulation, fibrinolysis, and production of cytokines and adhesion molecules in abdominal aortic aneurysm repair surgery. Sixteen patients for Y-shaped graft replacement of abdominal aortic aneurysm were divided into an antithrombin group and a control group. In the antithrombin group, 3000 U antithrombin was infused over 30 min before heparin administration and 24 h later. White blood cell counts, platelet counts, prothrombin time ratio, and serum concentrations of antithrombin, polymorphonuclear leukocyte elastase, interleukin (IL)-1ß, IL-6, IL-8, tumor necrosis factor-{alpha}, and adhesion molecules, and variables of coagulation and fibrinolysis were measured before surgery, at the end of surgery, and 1 and 2 days after surgery. The antithrombin concentration decreased in the control group, whereas it increased in the antithrombin group with significant differences between the groups. Prothrombin time ratio, concentrations of d-dimer, thrombin-antithrombin complex, and intercellular adhesion molecule-1 increased only in the control group and polymorphonuclear leukocyte elastase, IL-6, tumor necrosis factor-{alpha}, and vascular cell adhesion molecule-1 increased in both groups. They were significantly less in the antithrombin group except for intercellular adhesion molecule-1. In conclusion, antithrombin could decrease hypercoagulation and inflammatory activation during abdominal aortic aneurysm surgery, which may decrease adverse events.

 

七氟醚产生的延迟性心肌保护作用在吸入后48小时时较24小时时更显著

Inhaled Sevoflurane Produces Better Delayed Myocardial Protection at 48 Versus 24 Hours After Exposure

Marc Lutz, DO, and Hong Liu, MD

Department of Anesthesiology and Pain Medicine, University of California, Davis

Anesth Analg 2006 102: 984-990.

缺血预处理对继后心脏缺血和再灌注损伤可产生延迟性的保护作用。有关吸入麻醉药产生类似的心脏保护作用有相互矛盾的报道。本研究的目的是观察吸入麻醉药七氟醚是否产生类似的延迟性麻醉预处理作用,并比较吸入后24小时和48小时时保护作用的差异。选择2-4月大的雄性Fischer344只,吸入七氟醚(2.5% 维持 60 分钟)24小时或48小时后,游离大鼠心脏并灌注约30分钟(平均),灌注后先进行25分钟的缺血处理,再进行60分钟的再灌注。对照组心脏在缺血处理前没有进行任何处理。研究中测定左心(LV)功能,肌酸激酶(CK)梗塞面积(IS)。并通过核磁共振测定Na+i[Ca2+]i,和 pHi.。与对照组相比,七氟醚组吸入后24小时和48小时大鼠的LV功能增强,ISCK明显降低。与24小时组相比,48小时组大鼠的LV功能恢复更加明显,ISCK也明显降低。与对照组相比,24小时组和48小时组有显著的三磷酸腺苷保存作用,且酸中毒、[Ca2+]iNa+i明显降低。因此,七氟醚可以产生延迟的预处理效果,产生在吸入后24小时以后渐达最大的保护效应。

(齐波 陈杰 校)

Ischemia preconditioning produces a delayed window of cardioprotection against subsequent ischemia and reperfusion injury. Contradictory results have been reported regarding the ability of inhaled anesthetics to produce similar effects. Our investigation was designed to test whether inhaled sevoflurane is capable of producing a delayed window of anesthetic preconditioning and to compare the differences at 24 and 48 h after exposure. Male Fischer-344 rats, 2–4 mo old, were exposed to sevoflurane (2.5% for 60 min). Twenty-four or 48 h after exposure, the hearts were isolated and perfused for 30 min (equilibration) followed by 25 min of ischemia and then 60 min of reperfusion. Control hearts received no treatment before ischemia. Left ventricular (LV) function, creatine kinase (CK), and infarct size (IS) were measured. Nuclear magnetic resonance was used to measure Na+i, [Ca2+]i, and pHi. There was improved LV function and significant reduction in IS and CK and in both the 24- and 48-h delayed groups compared with the controls. There was also a significant recovery of LV function and reduction in IS and CK in the 48-h group when compared with the 24-h group. There was significant adenosine triphosphate preservation in both the 24- and 48-h groups, as well as a significant reduction in acidosis, [Ca2+]I, and Na+i in response to ischemia in both the groups versus the control. Sevoflurane is capable of producing a delayed window of preconditioning, and it takes more than 24 h to produce maximal protective effects.

 

冠状动脉搭桥术后长期心率动力学变化

Long-Term Alterations of Heart Rate Dynamics After Coronary Artery Bypass Graft Surgery

Timo T. Laitio, MD*, Heikki V. Huikuri, MD§, Juha Koskenvuo, MD{dagger}, Jouko Jalonen, MD*, Timo H. Mäkikallio, MD§, Hans Helenius, MSc{ddagger}, Erkki S.H. Kentala, MD*, Jaakko Hartiala, MD{dagger}, and Harry Scheinin, MD

Departments of *Anesthesiology and Intensive Care and {dagger}Clinical Physiology, Turku University Hospital; Departments of {ddagger}Biostatistics and ¶Pharmacology and Clinical Pharmacology, Turku PET Centre, University of Turku; and §Division of Cardiology, Department of Medicine, Oulu University Hospital, Finland

Anesth Analg 2006 102: 1026-1031

.

本研究的目的是为了验证冠状动脉搭桥术后出现长久整体心率变异性和部分心率形态改变。在各种病人中心率变异性的降低常预示死亡率增高。选择25例择期行冠状动脉搭桥手术的病人,在手术一周前,六周后和六月后连续24小时监测心电图变化。其中17例病人还监测了术后12月的心电图变化。主要评估心率变异的时间和频率,同时测量短期的鳞状排列指数(α1),近似熵指数,和乘幕-规则与间歇变异的相关危险的关系( β-slope)。术后乃至术后6周,6月和12月的高,低,极低和超低频率指数均较术前显著降低(P=0.001,P<0.001,P<0.001,P<0.001)。鳞状排列指数(α1)在6周时显著降低,但在术后6月时恢复术前水平。β-slope较稳定,但所有的复杂度(近似熵指数)在研究期间均表现为降低(一年后P<0.01)。短时和长期的心率变异性改变对冠状动脉搭桥术后病人预后的长期影响尚不清楚。

(忻纪华 陈杰 校)

We tested the hypothesis that there may be long-term alterations in overall heart rate (HR) variability and in fractal HR behavior after coronary artery bypass graft (CABG) surgery. Reduced HR variability predicts morbidity in various patient populations. Continuous 24-h electrocardiograph recordings were performed in 25 elective CABG surgery patients 1 wk before the operation and 6 wk and 6 mo after. Seventeen of the patients also had recordings 12 mo after CABG. Time and frequency domain measures of HR variability were assessed, along with measurement of short-term fractal scaling exponent ({alpha}1), approximate entropy, and power-law relationship of relative risk interval variability (ß-slope). The high, low, very low, and ultra low frequency powers decreased significantly after the operation and remained at a significantly decreased level 6 wk and 6 and 12 mo after the operation than before (P = 0.01, P < 0.001, P < 0.001, and P < 0.001 for overall difference between the time points, respectively). The fractal scaling exponent {alpha}1 was at significantly more decreased 6 wk after (P < 0.05) CABG than before surgery but recovered to the preoperative level 6 mo after the operation. Long-term fractal organization (ß-slope) remained stable, but the overall complexity (approximate entropy) decreased toward more predictable HR dynamics during the study period (P < 0.01 after 1 yr). The predictive value of temporary and persistent long-term changes of the HR dynamics after CABG surgery for long-term outcome is not clear.

 

通过短暂充血反应评估七氟醚对小儿脑血管自动调节功能的影响

The Effect of Sevoflurane on Cerebral Autoregulation in Young Children as Assessed by the Transient Hyperemic Response

Gordon T. Wong, FANZCA, Igor Luginbuehl, MD, Cengiz Karsli, FRCPC, and Bruno Bissonnette, FRCPC

Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada

Anesth Analg 2006 102: 1051-1055.

应用经颅多普勒技术作短暂充血反应(THR)试验评估脑血管自动调节功能,是一种简单的无创检测技术。然而有关小儿THR的研究未见报导。在本研究中,作者应用该项技术评估七氟醚全麻小儿的反应情况。20ASA I级,接受泌尿外科手术的小儿随机接受0.5, 1.01.5 MAC七氟醚麻醉。骶管麻醉提供镇痛作用。在压迫右侧颈动脉前(F1)、中(F2)和后(F3)三个时间点分别检测同侧大脑中动脉的脑血流速度,压迫时间为10秒。研究结果表明,THR率(THRR)在0.5MAC1.0MAC,和1.5MAC分别是1.24 +/- 0.11, 1.16 +/- 0.09, 1.13 +/- 0.07THRR0.5MAC组与1.0MAC1.5MAC组相比存在着明显差异(P<0.05)。但是在1.01.5MAC;两组间没有明显差异。以往认为,THRR超过1.09是阳性反应低限。本研究结果表明,1.5MAC以下七氟醚麻醉时THR呈剂量依赖性变化。这说明,小儿以七氟醚进行麻醉时,只要不超过1.5MAC,脑血管的自动调节功能依然存在。

(苏殿三 陈杰 校)

The transient hyperemic response (THR) test is a simple, noninvasive technique to evaluate cerebral autoregulation using transcranial Doppler. It has not yet been used in studies involving children. In this study we evaluated this response in children undergoing general anesthesia using sevoflurane. Twenty ASA physical status I children undergoing elective urological surgery sequentially received sevoflurane at 0.5, 1.0, and 1.5 MAC in a randomized order. Analgesia was solely provided by caudal anesthesia. The right middle cerebral artery flow velocities before (F1), during (F2), and after (F3) a 10-s ipsilateral carotid artery compression were recorded. The THR ratios (THRR) (± sd) for 0.5 MAC, 1.0 MAC, and 1.5 MAC were 1.24 ± 0.11, 1.16 ± 0.09, and 1.13 ± 0.07, respectively. The THRR was significantly different between 0.5 MAC versus 1.0 and 1.5 MAC, respectively (P < 0.05). However, no difference was detected between 1.0 and 1.5 MAC. A THRR of more than 1.09 has previously been accepted as the lower limit of a positive response. The results in this study suggest that THR is affected by sevoflurane in a dose-dependent fashion but is maintained at up to 1.5 MAC. This suggests cerebral autoregulation is preserved in children anesthetized with up to 1.5 MAC sevoflurane.

 

斜疝修补术病人使用椎旁阻滞可比全麻提供更好的当天恢复

Paravertebral Blocks Provide Superior Same-Day Recovery over General Anesthesia for Patients Undergoing Inguinal Hernia Repair

Admir Hadzic, MD, PhD, Beklen Kerimoglu, MD, Dan Loreio, MD, Pelin Emine Karaca, MD, Richard E. Claudio, BS, Marina Yufa, MD, Ray Wedderburn, MD, Alan C. Santos, MD, MPH, and Daniel M. Thys, MD

The Department of Anesthesiology, St. Luke’s-Roosevelt Hospital Center, College of Physicians and Surgeons of Columbia University, New York, New York

Anesth Analg 2006 102: 1076-1081.

 

斜疝修补术通常在神经阻滞或局部或全身麻醉下作为门诊手术进行的。作者假设使用椎旁阻滞(PVB)作为单独麻醉技术能使病人在较短时间内出院回家,比快通道全麻(GA)更好的当天恢复。50名病人随机接受PVB或GA。PVB 0.75% 罗哌卡因,随后使用丙泊酚镇静; GA 多拉司琼 12.5 mg, 丙泊酚诱导,罗库溴胺插管,地氟醚,0.25%布比卡因行区域阻滞。记录不需进入麻醉后恢复室的病人数、术后开始疼痛时间、行动、出院和不良事件发生率。大多数PVB组的病人符合不进入PACU的标准(71%),而全麻组只有8%病人(P < 0.001)。PVB组的病人仅有3名(13%)在医院时需要镇痛治疗,尽管同时使用了局部麻醉,全麻组有12(50%)名病人需要镇痛治疗(P = 0.005)。PVB组病人能较早开始活动(102 ± 55 min),全麻组病人较迟(213 ± 108 min; P < 0.001)。PVB组的病人准备出院和离院时间(156 ± 60 253 ± 37 min)较全麻组病人(203 ± 91 218 ± 93 min)(P < 0.001)。接受PVB的病人在第一个24小时内不良事件(例如恶心,呕吐和喉痛)和疼痛需要治疗率小于全麻病人。因此,在接受斜疝修补术的门诊病人中,PVB病人比GA病人较快出院、不良事件的发生减少且具有较好的术后镇痛。

(殷文渊 陈杰 校)

Inguinal herniorrhaphy is commonly performed on an outpatient basis under nerve blocks or local or general anesthesia (GA). Our hypothesis is that use of paravertebral blocks (PVB) as the sole anesthetic technique will result in shorter time to achieve home readiness and improved same-day recovery over a ‘fast-track‘ GA. Fifty patients were randomly assigned to receive either PVB or GA under standardized protocols (PVB = 0.75% ropivacaine, followed by propofol sedation; GA = dolasetron 12.5 mg, propofol induction, rocuronium, endotracheal intubation; desflurane; bupivacaine 0.25% for field block). Eligibility for postanesthetic care unit (PACU) bypass and data on time-to-postoperative pain, ambulation, home readiness, and incidence of adverse events were collected. More patients in the PVB group (71%) met the criteria to bypass the postanesthetic care unit compared with patients in the GA group (8%; P < 0.001). Only 3 (13%) of patients in the PVB group requested treatment for pain while in the hospital, compared with 12 (50%) patients in the GA group, despite infiltration with local anesthetic (P = 0.005). Patients in the PVB group were able to ambulate earlier (102 ± 55 minutes) than those in the GA group (213 ± 108 minutes; P < 0.001). Time-to-home readiness and discharge times were shorter for patients in the PVB group (156 ± 60 and 253 ± 37 minutes) compared with those in the GA group (203 ± 91 and 218 ± 93 minutes) (P < 0.001). Adverse events (e.g., nausea, vomiting, sore throat) and pain requiring treatment in the first 24 hours occurred less frequently in patients who had received PVB than in those who had received GA. In outpatients undergoing inguinal herniorrhaphy, PVB resulted in faster time to home readiness and was associated with fewer adverse events and better analgesia before discharge than GA.

 

异氟醚、七氟醚麻醉期间气管插管后N2O引起异常脑电改变

Nitrous Oxide Induces Paradoxical Electroencephalographic Changes After Tracheal Intubation During Isoflurane and Sevoflurane Anesthesia

Yutaka Oda, MD, PhD, Katsuaki Tanaka, MD, PhD, Tadashi Matsuura, MD, Ichiro Hase, MD, PhD, Kiyonobu Nishikawa, MD, PhD, and Akira Asada, MD, PhD

Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan; Department of Anesthesiology, Hoshigaoka Koseinenkin Hospital, Hirakata, Japan

Anesth Analg 2006 102: 1094-1102.

在一项随机双盲对照研究中,作者验证如下假设:在异氟醚、七氟醚麻醉气管插管后N2O能影响双频指数(BIS)和95%边缘频率(SEF95)。在实验1中,90ASA I级的患者随机分成6组(每组n=15)。异氟醚,七氟醚麻醉复合0%33%66%N2O,异氟醚七氟醚的浓度是逐渐升高,其呼末浓度分别维持在1.1%1.7%。麻醉诱导后12分钟行气管插管。与喉镜置入前单纯接受异氟醚或七氟醚的患者相比,气管插管后1分钟BIS明显增加(分别为P0.0010.007)。接受66% N2O-异氟醚或66% N2O-七氟醚的患者气管插管后BIS,SEF95均明显降低,较接受异氟醚或七氟醚的患者明显低(两者P<0.01)。在实验2,静注芬太尼3ug/kg能完全消除66% N2O-异氟醚或66% N2O-七氟醚气管插管后BISSEF95的降低。结论:66% N2O可引起异氟醚和七氟醚麻醉气管插管后异常的BIS降低。

(顾新宇 陈杰 校)

In this randomized, double-blind, controlled study, we tested the hypothesis that nitrous oxide (N2O) affects bispectral index (BIS) and 95% spectral edge frequency (SEF95) in response to tracheal intubation during anesthesia with isoflurane and sevoflurane. In protocol 1, we randomly allocated 90 ASA physical status I patients to 6 groups (n = 15 each). Anesthesia was induced with isoflurane or sevoflurane with 0%, 33%, or 66% N2O. The concentration of isoflurane and sevoflurane was gradually increased and end-tidal concentrations were maintained at 1.1% and 1.7%, respectively. Tracheal intubation was performed 12 min after induction of anesthesia. BIS was significantly increased 1 min after tracheal intubation compared before laryngoscopy in patients receiving only isoflurane or sevoflurane (P = 0.001 and 0.007, respectively). In patients receiving 66% N2O-isoflurane or 66% N2O-sevoflurane, both BIS and SEF95 were significantly decreased after tracheal intubation and significantly lower than in those patients receiving only isoflurane or sevoflurane, respectively (P < 0.01 for both). In protocol 2, 3 µg/kg of IV fentanyl completely abolished the decrease of BIS and SEF95 after tracheal intubation during anesthesia with 66% N2O-isoflurane and 66% N2O-sevoflurane (n = 10). We conclude that 66% N2O induced a paradoxical decrease of BIS in response to tracheal intubation during anesthesia with isoflurane and sevoflurane.

 

硫喷妥钠能调节大鼠脊髓背角神经元中γ-氨基丁酸A受体功能

Modulation of Gamma-Aminobutyric AcidA Receptor Function by Thiopental in the Rat Spinal Dorsal Horn Neurons

Chuan-Xiu Yang, MS*{dagger}{ddagger}, Han Xu, PhD*{dagger}, Ke-Qing Zhou*, Meng-Ya Wang, PhD{ddagger}, and Tian-Le Xu, PhD, MD*{dagger}

*School of Life Sciences, University of Science and Technology of China, Hefei; {dagger}Institute of Neuroscience and Key Laboratory of Neurobiology, Chinese Academy of Sciences, Shanghai; and {ddagger}Laboratory of Cell Electrophysiology, Wannan Medical College, Wuhu, China

Anesth Analg 2006 102: 1114-1120.

为检测硫喷妥钠在脊髓背角水平的作用,作者在机械分离的大鼠脊髓背角神经元中应用全细胞膜片钳技术对该药进行研究。高浓度的硫喷妥钠通过激活氯通道产生电流(IThio),其阈浓度约为50uMIThioγ-氨基丁酸(GABAA受体拮抗剂荷包牡丹碱敏感,而对甘氨酸受体拮抗剂士的宁不敏感。临床浓度(30uM)的硫喷妥钠显著增强亚饱和GABA诱导的电流(IGABA),但对饱和GABA诱导电流无明显作用。并且硫喷妥钠能够延长IGABA的失敏和失活时间。浓度达到300uM时,硫喷妥钠能够抑制IGABA的峰值,推测这一作用与开放通道被阻滞有关。另外,30uM的硫喷妥钠能够延长GABA能微小抑制性突触后电流的时程,降低其频率。本研究结果显示硫喷妥钠对GABA能抑制性传导有增强作用,提示脊髓上的GABA A 受体可能是硫喷妥钠抑制运动,降低机体对伤害性刺激的反应的潜在作用位点。

(田婕 陈杰 校)

To assess the actions of thiopental at the spinal dorsal horn level, we examined the effects of thiopental using the whole cell patch-clamp technique on mechanically dissociated rat spinal dorsal horn neurons. Thiopental, at large concentrations, elicited a current (IThio) through activation of chloride conductance, and its threshold concentration was approximately 50 µM. IThio was sensitive to bicuculline, a {gamma}-aminobutyric acid (GABA)A receptor antagonist, but not to strychnine, a glycine receptor antagonist. At a clinically relevant concentration (30 µM), thiopental markedly enhanced the peak amplitude of a subsaturating GABA-induced current (IGABA) but not that of a saturating GABA-induced cur-rent. Furthermore, thiopental prolonged the time constants of both desensitization and deactivation of IGABA. At a large concentration (300 µM), it inhibited the peak amplitude of IGABA, which may be the result of open-channel blockade. In addition, at 30 µM, thiopental increased the duration and decreased the frequency of GABAergic miniature inhibitory postsynaptic currents. These results indicate that thiopental enhances GABAergic inhibitory transmission and suggest that GABAA receptors in the spinal cord are a potential target through which thiopental causes immobility and depresses the response to noxious stimuli.

 

异氟醚保护遭受中度缺氧的成年小鼠的空间立体记忆

Isoflurane Preserves Spatial Working Memory in Adult Mice After Moderate Hypoxia

Alex Bekker, MD, PhD, Romin Shah, MD, David Quartermain, PhD, Yong-Sheng Li, MD, and Thomas Blanck, MD, PhD

Department of Anesthesiology, Department of Neurology, New York University Medical Center, New York, New York

Anesth Analg 2006 102: 1134-1138.

 

围术期缺氧可导致术后认知的损害。然而麻醉对缺氧相关的中枢神经系统损害的方面是起加剧作用还是保护作用仍未阐明。本文作者研究缺氧或联合异氟醚是否会影响小鼠的记忆功能。成年小鼠随机分为四组并维持一个小时:21%氧气组,21%氧气+1.2%异氟醚组,8%氧气组,8%氧气+异氟醚1.2%。实验中维持自主呼吸。将其体温维持在37+0.5ºC。小鼠复苏24小时以避免残留麻醉药物对神经行为表现的影响。小鼠记忆力通过Y迷宫来评估。实验中,首先关闭一端,允许小鼠在Y形迷宫2个开放端间奔跑15分钟,并观察其活动。1小时后,开放Y形迷宫所有开口。用照相机和相关软件自动记录通过Y形迷宫每个出口的时间。小鼠在麻醉后的147天被测试。每次实验有差异的开口作为新的开口。用差异可重复测量分析行为,随后用简单主因分析合适时用Newman-Keuls 测验比较。P <0.05认为差异有意义。遭受缺氧的动物(8%氧气1小时)在损伤后1天在新出口处花的时间显著减少。然而这种损害作用是暂时的。缺氧小鼠的行为在缺氧后4天恢复到对照组水平。小鼠遭受缺氧合并使用异氟醚时未显示损害作用,且与对照组所有时间点上相当。缺氧对立体空间记忆功能有短暂的损害表现。异氟醚对此缺氧引起的有害影响起了保护作用。

(郑丽 陈杰 校)

Perioperative hypoxia may contribute to postoperative cognitive impairment. It is unknown, however, whether anesthetics exacerbate or protect against hypoxia-related central nervous system impairment. We sought to determine whether hypoxia alone or in combination with isoflurane disrupts working memory in mice. To this extent, we assigned adult mice to one of four treatments for 1 h: oxygen 21%, oxygen 21% + isoflurane 1.2%, oxygen 8%, or oxygen 8% + isoflurane 1.2%. Mice breathed spontaneously throughout the experiment. Body temperature was maintained at 37°C + 0.5°C. Mice were allowed to recover for 24 h to avoid the confounding influence of residual anesthetics on neurobehavioral performance. Working memory was assessed by use of a Y maze modified for mice. For the training trial, entry to one arm was blocked and mice were permitted to run between the two open arms for 15 min and inspect the objects outside. For the test trial, carried out 1 h later, all arms were open. Time spent in each arm was automatically recorded by a camera and associated software. Mice were tested 1, 4, and 7 days after anesthesia. A different arm was used as the novel arm for each test. Performance was analyzed with repeated-measurements analysis of variance, followed by analysis of simple main effects and by post hoc comparison using Newman-Keuls test when appropriate. P values <0.05 were considered significant. Animals subjected to hypoxia (8% oxygen for 1 h) spent significantly less time in the novel arm 1 day after the insult. The impairment, however, was transient. Hypoxic mice performance improved to the level of the control animals on the fourth post-treatment day. Mice subjected to hypoxia plus isoflurane exhibited no impairment and were comparable to the control group at all time points. Hypoxia transiently impairs performance in a spatial memory task. It appears that isoflurane protects against this deleterious effect of hypoxia.

 

鞘内使用吗啡以缓解肝切除术后疼痛:与硬膜外镇痛的比较

The Use of Intrathecal Morphine for Postoperative Pain Relief After Liver Resection: A Comparison with Epidural Analgesia

Lesley De Pietri, MD*, Antonio Siniscalchi, MD*, Alexia Reggiani, MD*, Michele Masetti, MD{dagger}, Bruno Begliomini, MD*, Matteo Gazzi, MD*, Giorgio E. Gerunda, MD{dagger}, and Alberto Pasetto, MD*

*Division of Anesthesiology and {dagger}Liver and Multivisceral Transplant Center, University of Modena and Reggio Emilia, Italy

Anesth Analg 2006 102: 1157-1163.

在一些医疗机构中常使用硬膜外导管进行肝脏手术后镇痛。但是,麻醉医生可能对硬膜外留置导管感到不满意,主要是考虑到这些病人肝功能受损可能会引起凝血障碍和出血的并发症。在本项研究中,作者用单次鞘内注射吗啡技术并与肝脏手术后连续硬膜外输注吗啡镇痛效果相比较。50位病人随机分入硬膜外镇痛组(EP组,n25)和鞘内镇痛组(IN组,n25)。镇痛效果用VAS评分来表示,同时记录副反应,其它静脉镇痛药的需求量。没有观察到任何脊髓受压现象。EP组距离首次静脉镇痛药物需要的时间比IN组长(25±18.5h相对于12±10.3hp<0.05)。两组病人术后48小时期间VAS评分均低于30mmIN组病人自控镇痛设备消耗的静脉吗啡量大于EP组(12.0±5.54mg相对于3.1±2.6mgP <0.01)。两组呕吐发生率均为4%,而IN组瘙痒(16%相对于0%)、恶心(16%相对于4%)的发生更常见。没有发生椎管内注射后疼痛和脊髓血肿。在肝脏切除后,单次鞘内注射吗啡复合病人自控静脉吗啡镇痛能提供满意的术后镇痛。根据VAS评分,这种方法的效果在术后48小时并不比连续硬膜外镇痛效果差。

(曹瑜 陈杰 校)

An epidural catheter is used in some institutions for postoperative analgesia after liver surgery. However, anesthesiologists may not feel comfortable leaving a catheter in the epidural space because of concern about coagulation disturbances and possible bleeding complications caused by impaired liver function. In this study, we tested a single-shot intrathecal morphine technique and compared it to a continuous epidural naropine infusion for postoperative analgesia in liver surgery. Fifty patients were randomly assigned to an epidural analgesia group (EP group; n = 25) and an intrathecal analgesia group (IN group; n = 25). The quality of analgesia assessed by a visual analog scale (VAS), the side effects, and the additional IV analgesic requirements were recorded. We did not observe any signs of cord compression. Time to first pain drug requirement was longer in the EP group compared to the IN group (25 ± 18.5 h versus 12 ± 10.3 h; P < 0.05). In both groups, the VAS remained less than 30 mm throughout the 48-h follow-up period. Consumption of IV morphine with a patient-controlled analgesia device in the IN group was larger (mostly from 24 to 48 h after surgery) than the EP group (12.0 ± 5.54 mg versus 3.1 ± 2.6 mg, respectively; P < 0.01). The incidence of vomiting was 4% in both groups, whereas the incidence of pruritus (16% versus 0%) and nausea (16% versus 4%) was more frequent in the IN group. No postdural puncture headache and no spinal hematoma occurred. After liver resection, a single dose of intrathecal morphine followed by patient-controlled morphine analgesia can provide satisfactory postoperative pain relief. The quality of this treatment, according to the VAS, is not inferior to continuous epidural analgesia up to 48 h after surgery.

 

不同程度的多脏器功能不全患者的局部微血管功能和血管反应性

Regional Microvascular Function and Vascular Reactivity in Patients with Different Degrees of Multiple Organ Dysfunction Syndrome

Hans Knotzer, MD*, Werner Pajk, MD*, Martin W. Dünser, MD*, Stephan Maier, MD*, Andreas J. Mayr, MD*, Nicole Ritsch, MD*, Barbara Friesenecker, MD*, and Walter R. Hasibeder, MD{dagger}

*Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck; and {dagger}Department of Anesthesiology and Critical Care Medicine, Krankenhaus der Barmherzigen Schwestern, Ried, Austria

Anesth Analg 2006 102: 1187-1193.

多脏器功能不全(MODS)的病理生理常被认为与微血管功能障碍有关。研究者假定在重症患者中MODS的严重性取决于所测量的局部微血管功能的参数和血管反应性。因此,研究者对血流动力学稳定的中度(n15)和重度(n15MODS患者通过三方面进行了比较:(a)在前臂通过经皮PO2/PCO2电极测定充血反应和激光多普勒速度测量,(b)在大腿通过渗出体积描记法评估微血管渗透性以及(c)胃张力测定的数据。中度MODS患者死亡率为20%,而重度MODS的患者死亡率为60%(P=0.025)。重度MODS患者动脉血乳酸值(3.81±2.7mmol/L)明显高于中度MODS患者(1.66±0.82mmol/LP=0.006)。中重度MODS患者之间胃PHi,胃局部-动脉血PCO2差,毛细血管滤过系数,等容积静脉压力以及皮肤充血反应无明显差异。本研究显示,一旦被确定为MODS,局部微血管功能和血管反应性的变化不能反映脏器功能障碍的严重程度。

(朱辉 陈杰 校)

The pathophysiology of multiple organ dysfunction syndrome (MODS) is believed to be related to that of microcirculatory dysfunction. We hypothesized that the severity of MODS is determined by measuring regional variables of microvascular function and vascular reactivity in critically ill patients. Therefore, we compared (a) reactive hyperemia response in the forearm using transcutaneous Po2/Pco2 electrodes and laser Doppler velocimetry, (b) microvascular permeability assessed by strain-gauge plethysmography in legs, and (c) variables derived from gastric tonometry in hemodynamically stable patients with moderate (n = 15) and severe (n = 15) MODS. There were no differences in systemic oxygen delivery, consumption, and oxygen extraction ratio between the groups. Mortality was 20% in patients with moderate MODS and 60% in patients with severe MODS (P = 0.025). Patients with a high MODS score had significantly larger arterial lactate concentrations (3.81 ± 2.7 mmol/L) than patients with moderate MODS (1.66 ± 0.82 mmol/L; P = 0.006). No significant differences in gastric pHi, gastric regional-to-arterial Pco2 difference, capillary filtration coefficient, isovolumetric venous pressure, and skin reactive hyperemia response were observed between patients with moderate and severe MODS. Once MODS is established, regional variables of microvascular function and vascular reactivity measured in this study do not reflect severity of organ dysfunction.

 

大鼠脊髓短暂非损伤性缺血后鞘内注射尼可地尔和小剂量吗啡可导致痉挛性截瘫

Intrathecal Nicorandil and Small-Dose Morphine Can Induce Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in the Rat

Tatsuya Fuchigami, MD, PhD, Manabu Kakinohana, MD, PhD, Seiya Nakamura, MD, PhD, Kenji Murata, MD, PhD, and Kazuhiro Sugahara, MD, PhD

Department of Anesthesiology, University of the Ryukyus; Division of Anesthesiology, Okinawa Prefectural Nanbu Hospital, Okinawa, Japan

Anesth Analg 2006 102: 1217-1222.

 

作者研究了脊髓短暂非损伤性缺血的大鼠在鞘内注射尼可地尔(K离子ATP通道激动剂)和吗啡后药物的相互作用和大鼠的运动功能。实验动物为Sprague-Dawley大鼠,用带有球囊的导管人为造成动脉阻塞6min,完成脊髓缺血模型。所有实验动物均在缺血1小时后,鞘内注射(IT)吗啡(1-60μg),除了鞘内注射吗啡外,M组(对照组),MN组(同时注射吗啡和尼可地尔),MNG组(同时注射吗啡、尼可地尔和格列本脲)分别于再灌注后150min鞘内注射生理盐水,尼可地尔(10μg),格列本脲(10μg)和尼可地尔(10μg)。通过量子生物测定法计算再灌注后3小时50%实验动物发生截瘫的有效剂量(ED50),评价鞘内注射吗啡对脊髓缺血后神经功能的影响。M组和MN组的ED50分别为15.1±4.9μg2.9±1.0μgP<0.05)。在MNG组,剂量效应曲线右移,导致截瘫的ED5011.6±4.7μg。目前的实验结果证明大鼠脊髓短暂非损伤性缺血后鞘内注射小剂量的吗啡合并尼可地尔可以导致痉挛性截瘫。

(肖洁 陈杰 校)

We investigated the interaction between nicorandil, a K+ATP channel opener, and morphine on motor function after a noninjurious interval of spinal cord ischemia in the rat. Spinal ischemia was induced by aortic occlusion for 6 min with a balloon catheter in Sprague-Dawley rats. All animals received intrathecal (IT) injection of morphine (1–60 µg) 1 h after ischemia. In addition to IT injection of morphine, group M (control), group MN (combination of morphine and nicorandil), and group MNG (combination of morphine, nicorandil, and glibenclamide) received IT saline, nicorandil (10 µg), and both glibenclamide (10 µg) and nicorandil (10 µg) after 150 min of reperfusion, respectively. A quantal bioassay for the effect of IT morphine on neurological function after ischemia was performed to calculate 50% effective dose values (ED50) for inducing paraparesis at 3 h of reperfusion. The ED50 in group M and group MN was 15.1 ± 4.9 µg and 2.9 ± 1.0 µg of IT morphine, respectively (P < 0.05). In Group MNG, the dose-response curve shifted back to the right and the ED50 for inducing paraparesis was 11.6 ± 4.7 µg of IT morphine. The present study demonstrates that IT small-dose morphine combined with nicorandil induces spastic paraparesis after noninjurious interval of spinal cord ischemia in the rat.

 

全膝关节置换术后硬膜外镇痛和连续股神经-坐骨神经联合阻滞的比较

A Comparison of Epidural Analgesia With Combined Continuous Femoral-Sciatic Nerve Blocks After Total Knee Replacement

Dusanka Zaric, MD, PhD, Klavs Boysen, MD, Christian Christiansen, MD, Jadwiga Christiansen, MD, Snorre Stephensen, MD, and Bodil Christensen, RN

Departments of Anesthesiology and Orthopedic Surgery, Frederiksberg Hospital, University of Copenhagen, Denmark

Anesth Analg 2006 102: 1240-1246.

 

全膝置换术后硬膜外镇痛法一直是疼痛缓解的金标准。然而,周围神经阻滞由于副作用发生率可能减少而被广泛应用。本文作者研究该假设的正确性。60名病人随机分组分别接受硬膜外镇痛或股神经和坐骨神经联合阻滞。硬膜外和股神经导管内泵入罗哌卡因2mg/mL加上舒芬太尼1ug/mL,坐骨神经泵入罗哌卡因0.5mg/mL(输送速度5mL/h,维持55h)。主要观察总的副作用发生率(术后第一天发生尿潴留和剧烈的头晕、瘙痒、镇静和恶心/呕吐)。记录术后72小时内运动神经阻滞的程度,静息时和运动时的疼痛和恢复指数。术后第一天,硬膜外组87%病人发生一个或多个副作用,而神经阻滞组只有35%病人(p0.0002)。在手术当天和术后第一天,周围神经阻滞组病人手术侧肢体的运动神经阻滞较强(p0.001),在手术当天,硬膜外组病人未手术肢体阻滞较强(p0.0003)。所有的病人在运动时疼痛被很好的控制且住院时间无区别。恢复指数也相似。研究结果表明:在术后第一天,股神经/ 坐骨神经阻滞组副作用的发生率比硬膜外组低。

(张美荣 陈杰 校)

Epidural analgesia remains the "gold standard" of pain relief after total knee replacement. However, peripheral nerve block is gaining popularity because the incidence of side effects may be reduced. Our study tests this postulate. Sixty patients were prospectively randomized to receive either epidural infusion or combined continuous femoral and sciatic nerve blocks. Ropivacaine 2 mg/mL plus sufentanil 1 µg/mL was given either epidurally or through the femoral nerve catheter, and ropivacaine 0.5 mg/mL was given through the sciatic nerve catheter using elastomeric infusers (delivering 5 mL/h for 55 h). The primary outcome measure was the total incidence of side effects (urinary retention and moderate to severe degrees of dizziness, pruritus, sedation, and nausea/vomiting on the first postoperative day). Intensity of motor blockade, pain at rest and on mobilization, and rehabilitation indices were also registered for 72 h. One or more side effects were present in 87% of patients in the epidural group whereas only 35% of patients in the femoral and sciatic block groups were affected on the first postoperative day (P = 0.0002). Motor blockade was more intense in the operated limb on the day of surgery and the first postoperative day in the peripheral nerve block group (P = 0.001), whereas the non-operated limb was more blocked in the epidural group on the day of surgery (P = 0.0003). Pain on mobilization was well controlled in both groups and there were no differences in the length of hospital stay. Rehabilitation indices were similar. The results demonstrate a reduced incidence of side effects in the femoral/sciatic nerve block group than in the epidural group on the first postoperative day.

 

术后谵妄:疼痛和疼痛治疗的重要性

Postoperative Delirium: The Importance of Pain and Pain Management

Linnea E. Vaurio, BA*, Laura P. Sands, PhD{dagger}, Yun Wang, PhD{ddagger}, E. Ann Mullen, BSc*, and Jacqueline M. Leung, MD, MPH*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco; and {dagger}School of Nursing, Center on Aging and the Life Course and {ddagger}Department of Statistics, Purdue University, West Lafayette, Indiana Current position for Y.W.: Staff statistician, Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15213

Anesth Analg 2006 102: 1267-1273.

 

术后谵妄是老年病人常见的并发症,很少有研究调查导致术后谵妄的原因。作者假设术后谵妄和术后疼痛以及疼痛治疗方法有关。选择大于65岁的非心脏手术病人作为研究对象。术前制定一份精神检查表,术后用精神紊乱评估方法测定第一个3天的谵妄程度,收集术后镇痛的方法以及术前和术后给药方法。以视觉模似评分法记录术前和术后静息痛以及运动痛。研究对象为333例病人,年龄74 ± 6岁。手术后46%的病人产生术后谵妄。通过多元回归分析,年龄(OR, 2.5; 95% CI 1.5 to 4.2),中等程度术前静息痛 (OR, 2.2; 95% CI 1.2 to 4.0) 和重度术前静息痛(OR, 3.7; 95% CI 1.5 to 9.0),以及疼痛从基础值上升到术后第一天(OR, 1.1; 95% CI 1.01 to 1.2)是术后谵妄独立危险因子。相反,与静脉鸦片类镇痛药病人自控镇痛相比那些单独使用口服阿片镇痛的病人术后谵妄的发生率显著降低(OR, 0.4; 95% CI 0.2 to 0.7)。上述结果证明作者的假设:疼痛和疼痛治疗策略是老年病人术后谵妄的重要因素。

(潘志英 陈杰 校)

Postoperative delirium is common in geriatric patients. Few studies have examined events in the postoperative period that may contribute to the occurrence of postoperative delirium. We hypothesized that postoperative delirium is related to postoperative pain and/or pain management strategy. Patients aged ≥65 years who were scheduled for major noncardiac surgery were studied. A structured interview was conducted preoperatively and for the first 3 postoperative days to determine the presence of delirium using the Confusion Assessment Method. The method of postoperative pain management, as well as pre- and postoperative medications for the first 3 days, was collected. Pre- and postoperative pain at rest and with movement was recorded using the Visual Analog Scale. Three hundred thirty-three patients, with a mean age of 74 ± 6 years, were studied. After surgery, 46% of patients developed postoperative delirium. By multivariate logistic regression, age (odds ratio [OR], 2.5; 95% confidence interval [CI] 1.5 to 4.2), moderate (OR, 2.2; 95% CI 1.2 to 4.0) and severe (OR, 3.7; 95% CI 1.5 to 9.0) preoperative resting pain, and increase in level of pain from baseline to postoperative day one (OR, 1.1; 95% CI 1.01 to 1.2) were independently associated with a greater risk for the development of postoperative delirium. In contrast, patients who used oral opioid analgesics as their sole means of postoperative pain control were at decreased risk of developing delirium in comparison with those who used opioid analgesics via IV patient-controlled analgesia technique (OR, 0.4; 95% CI 0.2 to 0.7). These results validate our hypothesis that pain and pain management strategies are important factors related to the development of postoperative delirium in elderly patients.

明胶和羟乙基淀粉而不是白蛋白破坏心脏手术后的凝血功能 

Gelatin and Hydroxyethyl Starch, but Not Albumin, Impair Hemostasis After Cardiac Surgery

Tomi T. Niemi, MD, PhD, Raili T. Suojaranta-Ylinen, MD, PhD, Sinikka I. Kukkonen, MD, PhD, and Anne H. Kuitunen, MD, PhD

Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Meilahti Hospital, Helsinki, Finland

Anesth Analg 2006;102:998-1006

 

我们研究了45例患者心脏手术术后应用胶体对凝血功能的影响。患者随机应用4%白蛋白、4%琥珀酰明胶或6%羟乙基淀粉 (分子量 200 kDa/取代级0.5)15 mL kg–1做短期输注。输注完成后即刻在明胶和羟乙基淀粉组的凝血弹力描记图中最大凝块固度明显下降,而在白蛋白组的这些值保持不变。凝块强度破坏持续时间达2小时,尽管数值有部分恢复。术后出血与人造胶体的汇聚数据中凝块强度呈负相关。纤维蛋白形成(凝块形成时间,α角)和纤维蛋白原依赖性凝块强度(最大凝块固度和切应力弹性系数)在羟乙基淀粉组比明胶组干扰更大。我们得出结论,心肺旁路手术后明胶和羟乙基淀粉都破坏凝块强度和纤维蛋白建立,从而使患者失血增加。应用羟乙基淀粉后见凝血功能破坏最大,而白蛋白对凝血功能参数的影响较小。

(彭中美 马皓琳 李士通 校)

We investigated the effect of postoperative administration of colloids on hemostasis in 45 patients after cardiac surgery. Patients were randomized to receive 15 mL kg–1 of either 4% albumin, 4% succinylated gelatin, or 6% hydroxyethyl starch (molecular weight of 200 kDa/degree of substitution 0.5) as a short-term infusion. There was a comparable decrease in maximum clot firmness of thromboelastometry tracings in gelatin and hydroxyethyl starch groups immediately after completion of the infusion, whereas these values remained unchanged in the albumin group. The impairment in clot strength persisted up to 2 h, although the values partly recovered. Postoperative bleeding correlated inversely with the clot strength in pooled data of the artificial colloids. Fibrin formation (clot formation time, {alpha}-angle) and fibrinogen-dependent clot strength (maximum clot firmness and shear elastic modulus) were more disturbed in the hydroxyethyl starch group than in the gelatin group. We conclude that after cardiopulmonary bypass surgery, both gelatin and hydroxyethyl starch impair clot strength and fibrin buildup, which may predispose patients to increased blood loss. The greatest impairment in hemostasis was seen after hydroxyethyl starch administration, whereas albumin appeared to have the least effect on hemostatic variables.

 

大鼠中低温体外循环后海马Bcl-2Bax表达及神经元凋亡

Hippocampus bcl-2 and bax Expression and Neuronal Apoptosis After Moderate Hypothermic Cardiopulmonary Bypass in Rats

Ting-Jie Zhang, MD, PhD*, Jian Hang, MD, PhD{dagger}, Da-Xiang Wen, MD, PhD*, Yan-Nan Hang, MD*, and Frederick E. Sieber, MD{dagger}

*Department of Anesthesiology, Ren Ji Hospital, Shanghai Second Medicine University, China; and {dagger}Department of Anesthesiology, Johns Hopkins Bayview Medical Center, Johns Hopkins Medical Institutions, Baltimore, Maryland

Anesth Analg 2006;102:1018-1025

 

我们采用大鼠中低温(26°C–28°C)伴血液稀释的体外循环(CPB)模型,研究了CPB后直至6h的海马凋亡基因表达和神经元凋亡。雄性大鼠(380400g)在异氟醚和芬太尼全麻下行CPB。行右心房和尾动脉置管,蠕动泵和膜氧合器用于CPB。研究分为2组:组1大鼠(n = 15)禁食后行60min中低温非搏动性CPB;组2由假手术大鼠组成(n = 15)。CPB1h,每组6只大鼠的海马被处理用逆转录酶聚合酶链反应来检测凋亡基因(bcl-2bax)的mRNA,并用bcl-2bax PCR产物和β-actin基因的比值判定mRNA的表达。CPB6h,用免疫组化来测定每组6只大鼠中bcl-2bax蛋白的海马表达,并用TUNEL测定神经元的凋亡。CPB6h,用电子显微镜检测每组3只大鼠的海马CA1区神经元超结构的变化。CPB1h,组1bcl-2/β-actinbax/β-actinbax/bcl-2mRNA比值增加(组1比组2bcl-2/β-actin0.82 ± 0.140.63 ± 0.07 P = 0.03bax/β-actin1.04 ± 0.140.56 ± 0.03P = 0.00bax/bcl-21.31 ± 0.120.84 ± 0.09 P = 0.02)。CPB6h,组1大鼠海马CA1bcl-2bax的蛋白表达增加(组1比组2bcl-20.18 ± 0.050.09 ± 0.01P = 0.02bax0.20 ± 0.060.04 ± 0.02P = 0.01)。CPB6h1大鼠海马CA1区的TUNEL染色增加(组1比组20.14 ± 0.020.03 ± 0.01P = 0.00)。组1大鼠海马CA1区神经元发生符合凋亡的超结构变化。大鼠行中低温伴血液稀释的CPB后的恢复期早期可发生海马CA1baxbcl-2基因表达和神经元凋亡。

(黄施伟 译,马皓琳 李士通 校)

Using a rat model of moderate hypothermic (26°C–28°C) cardiopulmonary bypass (CPB) with hemodilution, we investigated hippocampal apoptotic gene expression and neuronal apoptosis up to 6 h after CPB. The CPB was performed on male rats (380–400 g) under general anesthesia with isoflurane and fentanyl. The right atrium and tail artery were cannulated, and a peristaltic pump and membrane oxygenator were used for CPB. Two groups were studied: Group 1 consisted of fasted rats (n = 15) subjected to 60 min of moderate hypothermic nonpulsatile CPB; Group 2 consisted of sham-operated rats (n = 15). At 1 h after CPB, in 6 rats per group, hippocampus was processed for the apoptotic gene (bcl-2 and bax) messenger RNAs detection by reverse transcriptase polymerase chain reaction, and messenger RNA expression was determined by the ratio of the polymerase chain reaction product of bcl-2 or bax to the ß-actin gene. At 6 h after CPB, in 6 rats per group, hippocampus expression of Bcl-2 and bax protein was determined by immunohistochemistry, and neuronal apoptosis was detected by TUNEL. At 6 h after CPB, in three rats per group, changes in hippocampal CA1 neuronal ultra structure were determined with electron microscopy. Group 1 had increased ratios of bcl-2/ß-actin, bax/ß-actin, and bax/bcl-2 mRNA at 1 h after CPB (bcl-2/ß-actin, 0.82 ± 0.14 versus 0.63 ± 0.07; P = 0.03; bax/ß-actin, 1.04 ± 0.14 versus 0.56 ± 0.03; P = 0.00; bax/bcl-2, 1.31 ± 0.12 versus 0.84 ± 0.09; P = 0.02; Group 1 versus Group 2, respectively). Group 1 had increased bcl-2 and bax protein expression in hippocampal CA1 region at 6 h after CPB (bcl-2, 0.18 ± 0.05 versus 0.09 ± 0.01; P = 0.02; bax, 0.20 ± 0.06 versus 0.04 ± 0.02; P = 0.01; Group 1 versus Group 2, respectively). Group 1 had increased TUNEL staining in hippocampus CA1 at 6 h after CPB (0.14 ± 0.02 versus 0.03 ± 0.01; P = 0.00; Group 1 versus Group 2, respectively). In Group 1 CA1 hippocampus neurons, ultra-structural changes consistent with apoptosis occurred. In rats, moderate hypothermic CPB with hemodilution is associated with CA1 hippocampus bax and bcl-2 gene expression and neuronal apoptosis during the early post-CPB recovery period.

 

 

阿片类药物依赖的重症监护小儿患者停用阿片药物的前瞻性评估

A Prospective Evaluation of Opioid Weaning in Opioid-Dependent Pediatric Critical Care Patients

Richard J. Berens, MD, Michael T. Meyer, MD, Theresa A. Mikhailov, MD, Krista D. Colpaert, RN, Michelle L. Czarnecki, RN, MSN, CPNP, Nancy S. Ghanayem, MD, George M. Hoffman, Deborah J. Soetenga, RN, MSN, CNS, Thomas J. Nelson, RPh, and Steven J. Weisman, MD

Departments of Anesthesiology and Pediatrics, Medical College of Wisconsin, Children’s Hospital of Wisconsin; National Outcomes Center, Children’s Hospital and Health System; Jane B. Pettit Pain and Palliative Care Center, Children’s Hospital of Wisconsin; Department of Nursing, Children’s Hospital of Wisconsin; Department of Pharmacy, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin

Anesth Analg 2006;102:1045-1050

 

我们会在长期的儿科重症监护中应用阿片类药物以试图减少危重病儿的应激和缓解疼痛。这种治疗方法使得儿童冒有阿片依赖的风险。一旦出现依赖,患儿就需要停药,或者面临突然停药引起戒断综合征的风险。我们对几位阿片依赖的患儿进行了一个前瞻随机的研究,比较用口服美沙酮取代阿片类药物5天和10天。平均使用阿片类药物三周时间的两组患儿在需要阿片类药物解救的激惹事件(每两小时连续测量3次婴儿戒断评分>8)数量上没有显著性差异。在两组患儿中,大部分需要解救的事件都发生在停药的第五天和第六天。一旦转为口服美沙酮,患儿就可以在五天以内成功地戒断,并需要停药后的随访期来观察延迟性的戒断综合征。

(黄佳佳译,马皓琳 李士通校)

Critically ill children are treated with opioid medication in an attempt to decrease stress and alleviate pain during prolonged pediatric intensive care. This treatment plan places children at risk for opioid dependency. Once dependent, children need to be weaned or risk development of a withdrawal syndrome on abrupt cessation of medication. We enrolled opioid-dependent children into a prospective, randomized trial of 5- versus 10-day opioid weaning using oral methadone. Children exposed to opioids for an average of 3 wk showed no difference in the number of agitation events requiring opioid rescue (3 consecutive neonatal abstinence scores >8 every 2 h) in either wean group. Most of the events requiring rescue occurred on day 5 and 6 of the wean in both treatment groups. Patients may be able to be weaned successfully in 5 days once converted to oral methadone, with a follow-up period after medication wean to observe for a delayed withdrawal syndrome.

 

 

I期重建术的左心发育不良综合征新生儿中米力农群体药代动力学

Population Pharmacokinetics of Milrinone in Neonates with Hypoplastic Left Heart Syndrome Undergoing Stage I Reconstruction

Athena F. Zuppa, MD MSCE, Susan C. Nicolson, MD, Peter C. Adamson, MD, Gil Wernovsky, MD, John T. Mondick, Nancy Burnham, RN, MSN, Timothy M. Hoffman, MD, J. William Gaynor, MD, Lauren A. Davis, BS, William J. Greeley, MD, MBA, Thomas L. Spray, MD, and Jeffrey S. Barrett, PhD

Division of Clinical Pharmacology and Therapeutics, Department of Pediatrics, Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Division of Cardiology, Department of Pediatrics, Division of Cardiothoracic Surgery, Department of Surgery, Abramson Research Center, Philadelphia, Pennsylvania

Anesth Analg 2006;102:1062-1069

 

我们对16例因左心发育不良而行期重建术的新生儿进行了对米力农的随机、盲法药代动力学研究,来观察心肺转流和改良超滤时对药物分布的影响,并确定术后持续IV输注过程中的药物暴露情况。当新生儿开始复温时,在心肺转流回路内给以首量米力农100 250 μg/kg。术后,根据临床需要输注米力农。在心肺转流、改良超滤期间和术后,用NONMEM运算法则的混合效应模式计算米力农的药代动力学特性。尽管改良超滤的药物清除率为3.3 mL·kg1·min1,本研究中的所有病人均表现出超滤浓缩效应。在手术后即刻,本研究中的婴儿表现为肾脏清除功能损害。在给以0.5μg·kg1·min1持续输注的最初12小时内,药物出现蓄积现象。术后,米力农的清除功能显著受损 (0.4 mL · kg· min1),术后第12小时改善, 术后第4天后达到稳态清除率(2.6 mL · kg· min1)。在术后肾功能显著受损的阶段,应该考虑的输注速度为0.2 μ· kg· min1 

(周志坚 马皓琳 李士通 校)

We performed a blinded, randomized pharmacokinetic study of milrinone in 16 neonates with hypoplastic left heart undergoing stage I reconstruction to determine the impact of cardiopulmonary bypass and modified ultrafiltration on drug disposition and to define the drug exposure during a continuous IV infusion of drug postoperatively. Neonates received an initial dose of either a 100 or 250 µg/kg of milrinone into the cardiopulmonary bypass circuit at the start of rewarming. Postoperatively, milrinone was infused to clinical needs. A mixed-effect modeling approach was used to characterize milrinone pharmacokinetics during cardiopulmonary bypass, modified ultrafiltration, and postoperatively using the NONMEM algorithm. All patients in this study demonstrated a modified ultrafiltration concentrating effect that occurred despite a modified ultrafiltration drug clearance of 3.3 mL · kg–1 · min–1. The infants in this study demonstrated an impaired renal clearance during the immediate postoperative period. A constant infusion of 0.5 µg · kg–1 · min–1 resulted in drug accumulation during the initial 12 h of drug administration. Postoperatively, milrinone clearance was significantly impaired (0.4 mL · kg–1 · min–1), improved by the 12th postoperative hour, and approached steady-state clearance (2.6 mL · kg–1 · min–1) by postoperative day 4. In the postoperative setting of markedly impaired renal function, an infusion rate of 0.2 µg · kg–1 · min–1 should be considered.

 

 

异丙酚麻醉中对指令的反应消失时对笑气以及麻醉药的需要量

Nitrous Oxide and Anesthetic Requirement for Loss of Response to Command During Propofol Anesthesia

Dharshi Karalapillai, MBBS*, Kate Leslie, MBBS, MD, MEpi, FANZCA{dagger}{ddagger}, Abhay Umranikar, MBBS, FANZCA*, and Andrew R. Bjorksten, BS (Hons), PhD{dagger}

*Department of Anaesthesia, Ballarat Base Hospital; {dagger}Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; and {ddagger}Department of Pharmacology, University of Melbourne, Australia

Anesth Analg 2006;102:1088-1093

 

与令50%病人对指令的反应消失(LOR)有关的血药浓度(CP50LOR)是衡量麻醉强度的重要指标。因此,我们对401860岁用单纯异丙酚或复合用异丙酚和67%笑气(N2O)进行麻醉的健康外科病人测定了CP50LOR。将病人随机分为经面罩吸入纯氧或吸入67%笑气和氧气的混合气体。3分钟后,开始靶控输注异丙酚,浓度由同一组前一例病人的反应决定。15分钟后,由不知分组的观察者评定对指令的反应。抽取动脉血样本以测定异丙酚浓度,并连续监测脑电双频指数(BIS)。在测定指令反应时,单纯用异丙酚组异丙酚测定浓度和靶浓度均显著大于异丙酚复合笑气组,而BIS值前者明显小于后者。单纯用异丙酚组的异丙酚CP50LOR 4.58 µg/mL95%可信区间[CI]1.1415.36),而异丙酚复合笑气组为2.67 µg/mL95CI2.28–3.17)。50%病人对指令有反应的BIS值,在单纯用异丙酚组为6095CI55–65),在异丙酚复合笑气组为75 (95%CI73–83)

  (黄丽娜   马皓琳 李士通  )

The blood concentration associated with loss of response (LOR) to command in 50% of subjects (CP50LOR) is an important measure of anesthetic potency. We therefore determined the CP50LOR in 40 healthy surgical patients, aged 18–60 yr old, receiving propofol alone or propofol with 67% nitrous oxide (N2O). Patients were randomized to receive 100% oxygen or 67% N2O in oxygen via facemask. Three minutes later, a target-controlled propofol infusion was commenced at a concentration determined by the response of the previous patient in the same group. Fifteen minutes later, response to command was assessed by a blinded observer. Arterial blood samples were taken for propofol assay, and the bispectral index (BIS) was monitored continuously. At testing for response to command, both the measured and target propofol concentrations were significantly larger and BIS values significantly smaller in the propofol-alone group compared with the propofol-N2O group. The CP50LOR of propofol in the propofol-alone group was 4.58 µg/mL (95% confidence interval [CI], 1.14–15.36) and 2.67 µg/mL (95% CI, 2.28–3.17) in the propofol-N2O group. The BIS value when 50% of patients responded to command was 60 (95% CI, 55–65) in the propofol-alone group and 75 (95% CI, 73–83) in the propofol-N2O group.

 

 

局麻药对脂多糖所致内皮细胞损伤的保护作用:线粒体三磷酸腺苷敏感性钾离子通道的作用

Local Anesthetic-Induced Protection Against Lipopolysaccharide-Induced Injury in Endothelial Cells: The Role of Mitochondrial Adenosine Triphosphate-Sensitive Potassium Channels

Manuela J. M. de Klaver, MD, Gregory S. Weingart, BS, Tom G. Obrig, PhD, and George F. Rich, MD, PhD

Department of Anesthesiology, Department of Medicine, Nephrology Division, Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia

Anesth Analg 2006;102:1108-1113

 

利多卡因可减轻缺血再灌注和炎症反应所致的细胞损伤,尽管其保护机制至今不明。我们假设利多卡因和其他酰胺类局麻药可通过激活线粒体三磷酸腺苷敏感性钾通道(mitoKATP)对内皮细胞损伤产生保护作用。我们观察酰胺类局麻药(利多卡因、罗哌卡因和布比卡因)、酯类局麻药(丁卡因和普鲁卡因)、一种酰胺类局麻药类似物(YWI)和两种非酰胺类局麻药类似物(JDAICM)在存在或不存在mitoKATP通道阻断剂5-羟癸酸的两种情况下对应用脂多糖(LPS)的人微血管内皮细胞生存能力的影响。用黄素蛋白荧光观察局麻药对二氮嗪诱导的mitoKATP通道激活效应的影响。利多卡因、罗哌卡因、布比卡因、YWIJDAICM可缓解LPS所致的细胞生存能力下降60%到70%。5羟癸酸可抑制酰胺类局麻药和YWI的保护作用,但不影响JDAICM引起的保护作用。丁卡因和普鲁卡因对脂多糖所致的损伤没有保护作用。酰胺类局麻药及其类似物(YWI)可使二氮嗪激发的黄素蛋白荧光增强5%到20%,而酯类局麻药可使二氮嗪激发的黄素蛋白荧光减弱5%到60%,非酯类局麻药类似物无影响。综上所述,酰胺类局麻药及其类似物(YWI)部分通过激活mitoKATP 通道来减轻LPS所致细胞损伤。相反,丁卡因和普鲁卡因没有保护作用,并且抑制mitoKATP 通道的激活。非酰胺类局麻药类似物也可产生保护作用,但其机制不依赖于mitoKATP 通道。

(周雅春 马皓琳 李士通 校)

Lidocaine attenuates cell injury induced by ischemic-reperfusion and inflammation, although the protective mechanisms are not understood. We hypothesized that lidocaine and other amide local anesthetics protect against endothelial cell injury through activation of the mitochondrial adenosine triphosphate-sensitive potassium (mitoKATP) channels. We determined the effects of amide local anesthetics (lidocaine, ropivacaine, and bupivacaine), ester local anesthetics (tetracaine and procaine), one amide analog (YWI), and two non-amide local anesthetic analogs (JDA and ICM) on viability of human microvascular endothelial cells after exposure to lipopolysaccharide (LPS) in the absence or presence of the mitoKATP channel antagonist 5-hydroxydecaonate. Flavoprotein fluorescence was used to investigate the effects of local anesthetics on diazoxide-induced activation of mitoKATP channels. Lidocaine, ropivacaine, bupivicaine, YWI, JDA, and ICM attenuated by 60% to 70% the decrease in cell viability caused by LPS. Amide local anesthetics and YWI protection was inhibited by 5-hydroxydecaonate, whereas the protection induced by JDA and ICM was not. Tetracaine and procaine did not protect against LPS-induced injury. The amide local anesthetics and the amide analog (YWI) enhanced diazoxide-induced flavoprotein fluorescence by 5% to 20%, whereas ester local anesthetics decreased diazoxide-induced flavoprotein fluorescence by 5% to 60% and the non-amide local anesthetic analogs had no effect. In conclusion, amide local anesthetics and the amide analog (YWI) attenuate LPS-induced cell injury, in part, through activation of mitoKATP channels. In contrast, tetracaine and procaine had no protective effects and inhibited activation of mitoKATP channels. The non-amide local anesthetic analogs induced protection but through mechanisms independent of mitoKATP channels.

 

 

格拉斯琼和多拉斯琼预防术后恶心呕吐与CYP2D6的基因型有关

Prevention of Postoperative Nausea and Vomiting with Granisetron and Dolasetron in Relation to CYP2D6 Genotype

Piotr K. Janicki, MD, PhD, H. Gregg Schuler, MSc, CCRC, Tomasz M. Jarzembowski, MD, and Malina Rossi, II, MS

Department of Anesthesiology, Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA

Anesth Analg 2006;102:1127-1133

 

我们研究了格拉斯琼和多拉斯琼预防术后恶心呕如的有效性。由于各种用于止吐的5-羟色胺35-HT3)拮抗剂的代谢涉及不同异构的肝细胞色素P450系统,我们检验了这些药物的临床有效性和多态的细胞色素P450 2D6CYP2D6)的基因型之间的关系。这项前瞻性的随机、双盲研究共涉及150位具有术后恶心呕吐中到高度危险的病人。所有观察对象均在麻醉诱导时接受了地塞米松,然后给予12.5mg 多拉斯琼或者1mg格拉斯琼。我们分析了在术后第一个24小时内完全有效(指无呕吐或者未使用救援药物)的病人数。采用TaqMan实时聚合酶链反应法测定CYP2D6的基因型。格拉斯琼组完全有效(54.7%)较多拉斯琼组多(38.7%, P < 0.05)。在接受多拉斯琼的病人中,预计超速代谢状态的CYP2D6等位基因副本携带者发生呕吐事件的频率高于格拉斯琼组病人(P < 0.05)。故假设两种被研究的5-HT3受体拮抗剂抗呕吐效果的差异与CYP2D6等位基因副本携带状态的不同有关。

(颜涛 马皓琳 李士通 校)

We investigated the efficacy of granisetron and dolasetron in preventing postoperative nausea and vomiting. Because the metabolism of the various antiemetic 5-hydroxytryptamine type 3 (5-HT3) antagonists involves different isoforms of the hepatic cytochrome P450 system, we examined the relationship between the clinical efficacy of these drugs and polymorphic cytochrome P450 2D6 (CYP2D6) genotype. This prospective, randomized, double-blind study involved 150 adult patients with a moderate to high risk for postoperative nausea and vomiting. All subjects received dexamethasone at induction of anesthesia followed by either 12.5 mg of dolasetron or 1 mg of granisetron. We analyzed the number of complete responders (no vomiting or rescue medication) during the first 24 hours after surgery. CYP2D6 genotyping was performed using a TaqMan real-time polymerase chain reaction. A complete response was more frequent in the granisetron group (54.7%) compared with the dolasetron group (38.7%, P < 0.05). In subjects receiving dolasetron, carriers of the duplication of the CYP2D6 allele predicting ultrarapid metabolizer status had more frequent vomiting episodes (P < 0.05) than patients in the granisetron group. It is postulated that the difference in the antiemetic efficacy between two investigated 5-HT3 receptor antagonists may be associated with differences in the carrier status for the duplication of the CYP2D6 allele.

 

 

患者持续静脉输注给药:通过模型预测受流速和输注系统死腔影响的潜在药物剂量波动

The Delivery of Drugs to Patients by Continuous Intravenous Infusion: Modeling Predicts Potential Dose Fluctuations Depending on Flow Rates and Infusion System Dead Volume

Mark A. Lovich, MD, PhD*, M. Ellen Kinnealley, RN{dagger}, Nathanial M. Sims, MD*{dagger}, and Robert A. Peterfreund, MD, PhD*

Departments of *Anesthesia and Critical Care and {dagger}Biomedical Engineering, Massachusetts General Hospital, Boston

Anesth Analg 2006;102:1147-1153

 

静脉输注药物有潜在的剂量误差,这是由携带药物的液体流速和输液器死腔之间的复杂相互作用而引起。我们以苯肾上腺素作为模型化合物,用计算机计算输液器死腔中存储的药物稳态量 。死腔中的药量随原药浓度和拟给剂量增加而增加,却随流速增加而减少。我们还模拟突然中断携带液体时药物传送的动力学扰动。如果原先的携带液体很快,一旦该输液中止则药物的进入速率降低很多。药物输注速率快可导致药物进入体内更快恢复。最后,在改变药物输注或输注液体速度后达到新稳态的时间可计算得到。原型药浓度大、死腔较大和最后的携带液体速度较慢时这个时间最长。这些计算结果表明a)死腔中可能包含很多药物剂量有时不小心可能造成相当于单次误注 b)停止携带液体能明显降低药物给入;c)改变携带液体流速或药物剂量后药物达到新稳态给入速度前可能有明显滞后。尽管只用计算苯肾上腺素的模型,但这些观念很普遍且对任何通过静脉输注给予的药物均有效。

(赵雪莲 马皓琳 李士通 校)

IV drug infusion has the potential for dosing errors, which arise from complex interactions between carrier flows and the infusion set dead volume. We computed the steady-state mass of drug stored in the infusion set dead volume, using phenylephrine as a model compound. The mass of drug in the dead volume increases with stock drug concentration and desired dose but decreases with carrier flow rate. We also modeled the dynamic perturbations in drug delivery when a carrier is abruptly stopped. Rapid initial carrier flow rates lead to greater depression in drug delivery rate after carrier flow ceases. Rapid drug infusion rates lead to faster restoration of desired drug delivery. Finally, the time to reach a new steady-state after a change in drug delivery or carrier rate was computed. This time is longest for large stock-drug concentrations, larger dead volumes, and slower final carrier rates. These computations illustrate that (a) the dead volume may contain a large mass of drug available for inadvertent bolus, (b) cessation of carrier flow can profoundly reduce drug delivery, and (c) after a change in carrier flow or drug dosing, a significant lag is possible before drug delivery achieves steady state. Although computed for phenylephrine, the concepts are generic and valid for any drug administered by IV infusion.

 

 

依托咪酯抑制大鼠腰背角神经元对伤害性温度刺激的反应

Etomidate Depresses Lumbar Dorsal Horn Neuronal Responses to Noxious Thermal Stimulation in Rats

Toshihiko Mitsuyo, MD{ddagger}, Joseph F. Antognini, MD*{dagger}, and Earl Carstens, PhD{dagger}

*Department of Anesthesiology and Pain Medicine, University of California, Davis, {dagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis, {ddagger}Department of Anesthesiology, Ehime University, Matsuyama, Japan

Anesth Analg 2006;102:1169-1173

 

依托咪酯是一种广泛应用的静脉麻醉药,但对其镇痛作用,尤其是其对脊髓神经元对伤害性刺激的反应的影响,几乎不知。我们假设依托咪酯可能会抑制腰段神经元对伤害性热刺激的反应。使用异氟醚(1.2%)麻醉大鼠(n = 15),行椎板切除以记录单个单元的活动。依托咪酯给药前和给药后每2分钟(直到注射后13分钟)记录大鼠腰神经元对后爪伤害性热刺激(52°C, 12s)的反应。给予0.1250.250.512 mg/kg依托咪酯后,依托咪酯峰作用时的反应(对照反应的百分比)分别为63% ± 16%63% ± 16%38% ± 25%36% ± 30%41% ± 26%。这种反应可以很快恢复,通常是在注射后10分钟内。在去大脑、给予依托咪酯未用异氟醚的大鼠或给予异丙酚的异氟醚麻醉大鼠,也可以记录到相似的反应。这些数据表明依托咪酯抑制脊髓神经元对伤害性刺激的反应,其机制可能与依托咪酯的镇痛作用有关。

(张莹 马皓琳 李士通 校)

Etomidate is a widely used IV anesthetic, but little is known about its analgesic properties, in particular, its effects on spinal cord neuronal responses to noxious stimuli. We hypothesized that etomidate would depress lumbar neuronal responses to noxious heat. Rats (n = 15) were anesthetized with isoflurane (1.2%) and laminectomy was performed to record single unit activity. Lumbar neuronal responses to noxious thermal (52°C, 12 s) stimulation of the hindpaw were recorded before and every 2 min (up to 13 min postinjection) after administration of etomidate. The responses at peak effect of etomidate (as a percentage of the control response) were 63% ± 16%, 63% ± 16%, 38% ± 25%, 36% ± 30%, and 41% ± 26% for the 0.125, 0.25, 0.5, 1 and 2 mg/kg doses, respectively. The responses quickly recovered, usually by the 10-min period postinjection. Similar responses were obtained in decerebrate, isoflurane-free rats administered etomidate and in isoflurane-anesthetized rats administered propofol. These data demonstrate that etomidate depresses spinal cord neuronal responses to noxious stimulation and is a possible mechanism by which this drug might produce analgesia.

 

 

部分辅助通气过程中兔子呼吸肌的局部血流

Regional Blood Flow in Respiratory Muscles During Partial Ventilatory Assistance in Rabbits

Akinori Uchiyama*, Yuji Fujino*, Kikumi Hosotsubo*, Eriko Miyoshi*, Takashi Mashimo*, and Masaji Nishimura{dagger}

*Osaka University Hospital Intensive Care Unit, Yamadaoka, Suita; and {dagger}Department of Emergency and Critical Care Medicine, University of Tokushima Graduate School, Kuramotocho, Tokushima, Japan

Anesth Analg 2006;102:1201-1206

 

我们验证这样一个假设,即部分辅助通气对呼吸肌的血流的减少与机械控制通气(CMV)期间发现的影响水平相似。在10只兔子中比较三个水平的压力支持通气(PSV)和2CMV设置。在持续正压模式下给予PSV 0612 cm H2O,接着在用肌肉松弛药的情况下给予每个CMV设置636次呼吸/分钟)和12cm H2O18次呼吸/分钟)的压力控制通气(PCV)值。我们用有色微球测量呼吸肌肉、下肢端、肾脏和肝脏的局部组织血流。PSV6PCV6PCV12期间在膈肌处局部组织血流均低于PSV0。膈底血流PSV12PCV12多,和PSV0相似。然而,PSV6膈膜跨压是–0.8 ± 1.6 cm H2OPSV12–3.1 ± 2.4 cm H2O。在PSV12观察到由无效的触发努力引起的吸气不协调。通气设置不影响下肢、肝脏和肾脏血流。结论,通气设置影响膈膜血流。在某些PSV设置,膈膜的血流是最小的。

(张曦 马皓琳 李士通 校)

We tested the hypothesis that even partial ventilatory assistance would reduce respiratory muscle blood flow to levels similar to those found during control mechanical ventilation (CMV). Three levels of pressure support ventilation (PSV) and 2 CMV settings were compared in 10 rabbits. PSV 0, 6, and 12 cm H2O, under continuous positive airway pressure mode, were applied, and then pressure control ventilation (PCV) values of 6 (36 breaths/min) and 12 cm H2O (18 per breaths/min) were applied to each CMV setting with a muscle relaxant. Using colored microspheres, we measured regional tissue blood flow in respiratory muscles, lower extremities, kidney, and liver. Regional tissue blood flow in the diaphragm during PSV6, PCV6, and PCV12 were less than those during PSV0. During PSV12, blood flow in the crural diaphragm was more than that during PCV12 and similar to that during PSV0. Whereas the transdiaphragmatic pressure of PSV6 was –0.8 ± 1.6 cm H2O, that of PSV12 was –3.1 ± 2.4 cm H2O. Inspiratory asynchrony, arising from an ineffective triggering effort, was observed in PSV12. The ventilatory settings did not affect blood flow of the lower extremities, liver, and kidney. In conclusion, ventilatory settings affected blood flow in the diaphragm. At certain PSV settings, blood flow in the diaphragm was minimal.

 

 

在现有临床环境下比较全膝关节整形术后单次注射的股神经阻滞及持续性股神经阻滞作用对患者住院时间及长时程功能恢复的影响

The Effect of Single-Injection Femoral Nerve Block Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty on Hospital Length of Stay and Long-Term Functional Recovery Within an Established Clinical Pathway

Francis V. Salinas, MD, Spencer S. Liu, MD, and Michael F. Mulroy, MD

Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington; and Department of Anesthesiology, University of Washington, Seattle

Anesth Analg 2006;102:1234-1239

 

全膝关节整形术(TKA)可导致严重的疼痛,已证明单次注射的股神经阻滞(SFNB)产生的镇痛时程是有限的。持续性的股神经阻滞(CFNB)可以延长SFNB的镇痛时程。我们前瞻性地将36个行TKA的病人随机分成CFNB组对SFNB组,评价它们在标准临床途径中对住院时间长短(LOS)的影响,以此作为主要研究结果。次要的研究结果包括视觉模拟法(VAS)的疼痛评分、阿片类药物的消耗量及在12周时的长时程功能恢复情况。CFNB组的平均VAS静息评分明显低于SFNB组:术后第一天(1.7 3.3 [P = 0.002])及第二天(0.9 3.2 [P < 0.0001])CFNB组在理疗期间的平均最大VAS评分也明显低于SFNB组:术后第一天(4.7 6.3 [P = 0.01]) 第二天 (3.9 6.1 [P = 0.0005])CFNB组的平均氧可酮消耗量也明显低于SFNB组:术后第一天15 mg 40 mg (P = < 0.0001); 术后第二天20 mg 43 mg (P = 0.0004)。两组间的住院时间LOS(3.8 3.9 )或长期的功能恢复(12周时膝关节能弯曲117° 113° )没有明显差别。在当代美国的医疗保健环境中,CFNB产生的镇痛时程延长提供的影响缺乏对住院时间及长时期的功能恢复可能仅有很小的作用。

(裘毅敏 马皓琳 李士通校)

Total knee arthroplasty (TKA) may result in severe pain, and single-injection femoral nerve blocks (SFNB) have been demonstrated to have a limited duration of analgesia. Continuous femoral nerve blocks (CFNB) can prolong the analgesic duration of SFNB. We prospectively randomized 36 patients undergoing TKA to CFNB versus SFNB and evaluated the effect on hospital length of stay (LOS) as the primary outcome within a standardized clinical pathway. Secondary outcomes included visual analog scale (VAS) pain scores, opioid consumption, and long-term functional recovery at 12 wk. Mean VAS resting scores were significantly lower among patients who received CFNB versus SFNB: first day (1.7 vs 3.3 [P = 0.002]) and second day (0.9 vs 3.2 [P < 0.0001]) after surgery. Mean maximal VAS scores during physical therapy were significantly lower among patients who received CFNB versus SFNB: first day (4.7 vs 6.3 [P = 0.01]) and second day (3.9 vs 6.1 [P = 0.0005]) after surgery. Mean oxycodone consumption was significantly lower among patients who received CFNB versus SFNB: 15 mg versus 40 mg (P = < 0.0001) on the first day after surgery; 20 mg versus 43 mg (P = 0.0004) on the second day after surgery. There was no difference in hospital LOS (3.8 vs 3.9 days) or long-term functional recovery (117° versus 113° knee flexion at 12 wk) between the two groups. The lack of effect provided by increased duration of analgesia (from CFNB) after TKA may now have minimal impact on hospital LOS and long-term functional recovery in the contemporary healthcare environment within the United States.


术后镇痛对老年病人谵妄与认知功能下降的影响:系统综述

The Role of Postoperative Analgesia in Delirium and Cognitive Decline in Elderly Patients: A Systematic Review

Harold K. Fong, MD, Laura P. Sands, PhD, and Jacqueline M. Leung, MD, MPH

School of Medicine, Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; Purdue University, West Lafayette, Indiana

Anesth Analg 2006;102:1255-1266

 

术后谵妄与认知功能下降是老年病人经常会发生的不良反应。病人术前并存的因素、用药、术中及术后发生的各种原因均与术后谵妄与认知功能下降的发展有关。尽管以往研究证实术后疼痛是风险因素,但至今还鲜有临床研究比较术后常用镇痛技术(静脉镇痛和硬膜外镇痛)及阿片类镇痛药对术后认知功能的影响。对PubmedCINAHL数据库的一项系统性搜索确定了关于比较不同阿片类镇痛药对术后谵妄与认知功能下降的影响的六项研究,及五项比较静脉镇痛与硬膜外镇痛的不同镇痛途径的研究。哌替啶始终使老年病人术后谵妄的风险增高,但目前的证据表明其他术后较常用的阿片类药如吗啡,芬太尼或二氢吗啡酮对术后谵妄和认知功能下降影响无显著区别。而目前的研究还证实静脉镇痛和硬膜外镇痛对术后认知功能障碍的影响无显著性差异。但是未来还尚需足够大规模的研究样本量以及定义研究结果的更加标准化的方法来进一步证实目前发现。

(邱郁薇 马皓琳 李士通 校)

Postoperative delirium and cognitive decline are adverse events that occur frequently in elderly patients. Preexisting patient factors, medications, and various intraoperative and postoperative causes have been implicated in the development of postoperative delirium and cognitive decline. Despite previous studies identifying postoperative pain as a risk factor, relatively few clinical studies have compared the effect of common postoperative pain management techniques (IV and epidural) or opioid analgesics on postoperative cognitive status. A systematic search of the PubMed and CINAHL databases identified six studies comparing different opioid analgesics on postoperative delirium and cognitive decline and five studies comparing IV and epidural routes of administering analgesia. Meperidine was consistently associated with an increased risk of delirium in elderly surgical patients, but the current evidence has not shown a significant difference in postoperative delirium or cognitive decline among other more frequently used postoperative opioids such as morphine, fentanyl, or hydromorphone. The available studies also suggest that IV or epidural techniques do not influence cognitive function differently. However, future investigations of sufficient study size and more standardized methods of defining outcomes are necessary to confirm the current findings.

 

 

测试温度和存储温度对血小板凝集的影响:一次体外的全血试验

The Effects of Test Temperature and Storage Temperature on Platelet Aggregation: A Whole Blood In Vitro Study

Gisela Scharbert, MD, Madeleine Kalb, Corinna Marschalek, and Sibylle A. Kozek-Langenecker, MD

Department of General Anesthesiology and Intensive Care (B), Vienna Medical University, Vienna, Austria

Anesth Analg 2006;102:1280-1284

 

我们用流式细胞计量术和阻抗集合度测定系统地评估了测试温度和存储温度对血小板凝集的影响。27名健康成年男性志愿者的一部分含枸橼酸盐的全血储存在37°C22°C的条件下。一部分用作在22°C34°C37°C40°C下测定对胶原、二磷酸腺苷、瑞斯西丁素和花生四烯酸反应中的阻抗集合度测试。用PAC-1荧光染色法和全血细胞流式计量术在22°C 37°C测定由二磷酸腺苷激活的血小板上激活的纤维蛋白原受体表达。测试温度34°C37°C时通过胶原、瑞斯西丁素和花生四烯酸诱导的聚集反应没有显著差别,但是在22°C时的反应显著减弱。相反,二磷酸腺苷诱导的聚集反应在测试温度为34°C22°C时都显著增强。高温是唯一可以减弱胶原诱导的凝集反应的情况。存储温度22°C相较37°C而言是唯一可以增强二磷酸腺苷和胶原诱导的凝集反应。在测试温度低于37°CPAC-1的结合增强。通过预加热抗体超过22°C则时结合显著减少。我们的结果提示浅低温测试条件下没有相关的影响,而深度低温诱发粘合、血栓素的生成和激活受损。在浅低温和深低温时对二磷酸腺苷的反应均增强的病理机制还不清楚。存储温度很大程度上影响了对激动剂二磷酸腺苷和胶原的聚集反应,但是对瑞斯西丁素和花生四烯酸没有影响。采用了温度易变化的抗体PAC-1的流式细胞仪不能评定温度对血小板集合力的影响。

(姜旭晖 马皓琳 李士通 校)

We systematically evaluated the effects of test temperature and storage temperature on platelet aggregation using flow cytometry and impedance aggregometry. Aliquots of citrated whole blood from 27 healthy adult male volunteers were stored at 37°C and 22°C. Aliquots were subjected to impedance aggregometry in response to collagen, adenosine diphosphate, ristocetin, and arachidonic acid performed at 22°C, 34°C, 37°C, and 40°C. The expression of activated fibrinogen receptor was determined on adenosine diphosphate-activated platelets at 22°C and 37°C by whole blood flow cytometry using PAC-1 for fluorescent staining. Aggregation induced by collagen, ristocetin, and arachidonic acid was not significantly different at the test temperatures of 34°C and 37°C but was significantly impaired at 22°C. In contrast, adenosine diphosphate-induced aggregation was significantly increased at both 34°C and 22°C. Hyperthermia exclusively impaired collagen-induced aggregation. Storage temperature of 22°C exclusively enhanced adenosine diphosphate- and collagen-induced aggregation compared with storage at 37°C. The binding of PAC-1 was enhanced at test temperatures below 37°C. Prewarming the antibody above 22°C significantly decreased binding. Our results suggest that mild hypothermic test conditions have no relevant effect, whereas profound hypothermia induces defects in adhesion, thromboxane generation, and activation. The pathomechanism for the increased response to adenosine diphosphate at mild and profound hypothermia remains unclear. Storage temperature considerably affects the aggregation response to the agonists adenosine diphosphate and collagen but not to arachidonic acid and ristocetin. Flow cytometry using the temperature-labile antibody PAC-1 fails to assess temperature effects on platelet aggregability.