Anesthesia & Analgesia

April 2006

Table of Content

 

 

CARDIOVASCULAR ANESTHESIA:

七氟醚產生的延遲性心肌保護作用在吸入後48小時時較24小時時更顯著

(齊波 陳傑 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.

預測急性等容血液稀釋對分離自體全血血液成分的影響

(孫敏莉譯 薛張綱校)

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

明膠和羥乙基澱粉而不是白蛋白破壞心臟手術後的凝血功能 

(彭中美 馬皓琳 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(抗纖維蛋白酶)能調節腹主動脈瘤修補手術中凝血、細胞因數的產生、以及粘附分子表達

(宋金超 陳傑 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.

首次心臟手術大量出血、輸血與再次手術大量出血、輸血相關

(金琳 薛張綱校)

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.

大鼠中低溫體外迴圈後海馬Bcl-2Bax表達及神經元凋亡

(黃施偉 譯,馬皓琳 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.

冠狀動脈搭橋術後長期心率動力學變化

(忻紀華 陳傑 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.

在犬左心室非依賴Starling機制的lusitropism指數:邏輯時間常數(logistic time constant)。

(吳德華譯 薛張綱校)

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:

阿片類藥物依賴的重症監護小兒患者停用阿片藥物的前瞻性評估

(黃佳佳譯,馬皓琳 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.

通過短暫充血反應評估七氟醚對小兒腦血管自動調節功能的影響

(蘇殿三 陳傑 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.

小兒腦MRI檢查時七氟醚麻醉結束前給予小劑量氯胺酮或Nalbuphine可減少清醒時躁動

( 路譯 薛張綱校)

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期重建術的左心發育不良綜合征新生兒中米力農群體藥代動力學

(周志堅 馬皓琳 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:

斜疝修補術病人使用椎旁阻滯可比全麻提供更好的當天恢復

(殷文淵 陳傑 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.

全麻下行視網膜脫離手術的病人圍術期進行眼球周圍阻滯:一項隨機雙盲試驗

(王麗珺譯 薛張綱校)

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:

異氟醚、七氟醚麻醉期間氣管插管後N2O引起異常腦電改變

(顧新宇 陳傑 校)

異丙酚麻醉中對指令的反應消失時對笑氣以及麻醉藥的需要量

(黃麗娜   馬皓琳 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.

利多卡因通過對人舌癌細胞表皮生長因數受體的抑制起到抑制增殖的作用

(陸文清譯 薛張綱校)

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.

局麻藥對脂多糖所致內皮細胞損傷的保護作用:線粒體三磷酸腺苷敏感性鉀離子通道的作用

(周雅春 馬皓琳 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.

硫噴妥鈉能調節大鼠脊髓背角神經元中γ-氨基丁酸A受體功能

(田婕 陳傑 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.

抗膽鹼酯酶藥通過Rho-激酶途徑刺激大鼠氣管平滑肌收縮

(周荻 薛張綱校)

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.

格拉斯瓊和朵拉斯瓊預防術後噁心嘔吐與CYP2D6的基因型有關

(顏濤 馬皓琳 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.

異氟醚保護遭受中度缺氧的成年小鼠的空間立體記憶

(鄭麗 陳傑 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:

聽覺誘發電位、腦電雙頻指數和估計效應室濃度對臨床麻醉終末的預測

(王慧琳譯 薛張綱校)

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.

患者持續靜脈輸注給藥:通過模型預測受流速和輸注系統死腔影響的潛在藥物劑量波動

(趙雪蓮 馬皓琳 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:

鞘內使用嗎啡以緩解肝切除術後疼痛:與硬膜外鎮痛的比較

(曹瑜 陳傑 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.

磁共振光譜法發現慢性腰痛相關的腦部生化改變:一項初步報告

(徐麗穎譯 薛張綱校)

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.

依託咪酯抑制大鼠腰背角神經元對傷害性溫度刺激的反應

(張瑩 馬皓琳 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:

不同程度的多臟器功能不全患者的局部微血管功能和血管反應性

(朱輝 陳傑 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

在體外實驗中由生理鹽水引起的稀釋性凝血功能障礙可被纖維蛋白原濃縮劑逆轉而由6%羥乙基澱粉引起的則不能

(孫卓真譯 薛張綱校)

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.

部分輔助通氣過程中兔子呼吸肌的局部血流

(張曦 馬皓琳 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:

大鼠脊髓短暫非損傷性缺血後鞘內注射尼可地爾和小劑量嗎啡可導致痙攣性截癱

(肖潔 陳傑 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.

脊髓損傷病人接受損傷平面以下手術時的麻醉需求和應激激素反應

(韓曉丹譯 薛張綱校)

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:

在現有臨床環境下比較全膝關節整形術後單次注射的股神經阻滯及持續性股神經阻滯作用對患者住院時間及長時程功能恢復的影響

(裘毅敏 馬皓琳 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.

全膝關節置換術後硬膜外鎮痛和連續股神經-坐骨神經聯合阻滯的比較

(張美榮 陳傑 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.

局麻中下肢的皮膚溫度

( 靜譯 薛張綱校)

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:

術後譫妄:疼痛和疼痛治療的重要性

(潘志英 陳傑 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.

比較靜脈輸注鹽水、平衡液、膠體對凝血在體外的影響

(鍾靜譯 薛張綱校)

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.

測試溫度和存儲溫度對血小板凝集的影響:一次體外的全血試驗

(薑旭暉 馬皓琳 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.

預測急性等容血液稀釋對分離自體全血血液成分的影響

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

 

當進行急性等容血液稀釋(ANH)時,自體全血收集在含有抗凝劑的採集袋中。對於血液稀釋後,分離全血血液成分的影響從來沒有進行過檢測。當ANH時,我們建立一個數學模型來預測全血袋成分是如何改變的,闡明ANH效能的理論基礎。公式被衍生用來計算ANH[X]的影響,[X]指血液成分的益處。指數包絡被確定,當最初的血容量和全血袋容量(WB(ANH))經過處理,於是ANH對每種成分的影響可以被計算。通過與標準同種異體血製品相比較,自體全血血紅蛋白、血小板,以及纖維蛋白原的等價被確定。我們明確在收集血([X](n))的特定單位中血液成分X濃度是作為最初濃度([X](0))的一部分被提供。當WB(ANH)增加與估計血容量相關聯,[X](n)的遞減在後續採集血袋中增加。無論最初血容量多少,450ml自體全血分別地相當於13.3 g/dL1U濃縮紅細胞和123× 103/微升的全血衍生血小板濃縮液。用這種模式ANH對自體全血成分的影響可以精確的預測。WB(ANH)變成等價的自體血產品可以提供有效的方法比較不同ANH研究的結果。指數包絡可以用來評價麻醉師執行的實際ANH技術,其依次可影響質量保證標準。

(孫敏莉譯 薛張綱校)

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.

 

首次心臟手術大量出血、輸血與再次手術大量出血、輸血相關

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.

 

若存在大量出血的遺傳傾向,那麼多次心臟手術大量出血之間必有關聯。為此,我們進行了一次回顧性調查,分析了從1990119日至2002625日之間的174位患者,他們均在體外迴圈下進行了2次心臟手術,研究2次手術間大量出血的聯繫。必須符合以下兩條才定義為大量出血:1)術後24小時胸管內出血大於或等於750mL(胸管引流量[CTD]750);2)輸注任意一種非紅細胞(RBC)血製品。使用Logist回歸分析第一次和第二次心臟手術大量出血之間的關係。第二次手術CTD750Logist回歸模型表明,第一次手術CTD750CTD750比較,未校準的比值比為2.18P0.03),使用年齡、性別、體表面積、術前使用抗凝劑、體外迴圈時間及第二次手術方式校準後的比值比為2.42P0.03)。第二次手術使用任何非紅細胞血製品的Logist回歸模型表明第一次手術使用任何非紅細胞血製品與未使用者比較,未校準的比值比為2.32P0.02),使用年齡、性別、體表面積、術前使用抗凝劑、體外迴圈時間及第二次手術方式校準後的比值比為2.55P0.02)。因此,我們認為第一次手術的大量出血史使第二次手術大量出血的危險因素升高兩倍以上。

(金琳 薛張綱校)

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.

 

在犬左心室非依賴Starling機制的lusitropism指數:邏輯時間常數(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 .

 

邏輯時間常數(logistic time constant, tau(L))被認為是一個傳統單指數時間常數(tau(E))更好的左心室舒張率或lusitropism指數。然而,Frank-Starling效應是否或者怎樣影響tau(L)仍有待闡明。我們比較了左室容量(LVV)對tau(L)和單指數時間常數的影響。利用8離體相互迴圈的心臟形成的4個不同容積(10121416mL),在3個不同的終點分析來自最大的負壓力時間速率(-dP/dt(max))形成的左室等容舒張壓力曲線。我們發現,在所有的左室容積和各終點,tau(L)都優於單指數時間常數。左室容量負荷不影響tau(L)但可輕微影響tau(E)。雖然更進一步的終點增加tau(L) tau(E),但對tau(L)的增加明顯小於tau(E)。而且它的常數振幅和非零漸進線的變化對tau(L)明顯更小。我們的結論,tau(L)是一個更可靠的lusitropism指數,他不依賴于左室容積負荷的變化和Frank-Starling機制的影響。

(吳德華譯 薛張綱校)

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.

 

小兒腦MRI檢查時七氟醚麻醉結束前給予小劑量氯胺酮或Nalbuphine可減少清醒時躁動

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檢查要求長時間制動,在兒科病人通常只能採用全麻達成目的。七氟醚可以提供足夠的麻醉深度,但很多病人出現清醒時躁動。小劑量的氯胺酮和nalbuphine可以提供適度的鎮靜,但在蘇醒期效果較差。我們猜測,將它們推遲至檢查結束時使用,既可有效防止清醒時躁動,又不延長患者蘇醒和出蘇醒室時間。我們進行了一項雙盲研究,9068歲患者隨機分為三組,在七氟醚全麻下MRI檢查終期分別給予生理鹽水(S組)、氯胺酮(0.25 mg/kg)K組)和nalbuphine (0.1 mg/kg)N組)。我們評價了30分鐘內時蘇醒情況,鎮靜/躁動狀況,達到出室標準情況。三組病人在年齡、性別比例、身體狀況和合併內科疾病等可比。清醒條件無顯著差別。S組在所有時間的躁動情況明顯較多,5分鐘和10分鐘時遲鈍的患者在K組和N組較多。所有患者在30分鐘時都達到了出室標準,但K組、N組患者清醒並安靜的人數明顯較多。總之,在七氟醚麻醉下行MRI檢查時使用小劑量氯胺酮或nalbuphine可以減少清醒時躁動而又不延遲出室。應用Nalbuphine比氯胺酮效果更好。

(金 路譯 薛張綱校)

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.

 

全麻下行視網膜脫離手術的病人圍術期進行眼球周圍阻滯:一項隨機雙盲試驗

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.

成人的視網膜脫離手術通常和嚴重的術後疼痛及嘔吐相關。該項隨機雙盲對照試驗是為了證明1%羅呱卡因眼球周圍阻滯(PB)聯合全麻,較眼瞼下方生理鹽水皮下注射聯合全麻,不但能改善手術條件,而且能減輕術後疼痛。每組包括31名病人。麻醉用異丙酚靶控輸注、瑞芬太尼持續輸注,維持腦室雙頻指數(BIS)在4050之間。術後鎮痛包括靜脈輸入恒定劑量的丙帕他莫,以及通過病人自控裝置輸入奈福泮。曲馬多作為補救藥靜脈給予。各組間的人口資料具有可比性,BIS保持在目標水平。在PB組,很少有病人出現眼心反射(6 vs 17P < 0.01);術野出血減少(1 vs 11P < 0.01);首次需要奈福泮的時間更長(148 ± 99 46 ± 58分鐘;P < 0.01);拔管後的前6小時奈福泮的用量下降(18.9 ± 13.9 vs 28.5 ± 14.7 mg; P < 0.05);術後即時疼痛評分降低;更少的病人需要補救藥物(5 vs 23; P < 0.01)。術後噁心嘔吐的發生率兩組相似。綜上所述,PB聯合全麻改善了手術條件,減輕了術後疼痛。

(王麗珺譯 薛張綱校)

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.

 

利多卡因通過對人舌癌細胞表皮生長因數受體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.

 

局部麻醉藥可以抑制多種癌細胞的增殖,但其機制尚未知曉。我們之前的研究表明,利多卡因在局部給藥時的組織濃度就可以直接抑制表皮生長因數受體(EGFR),而這正是一個潛在的目標來抑制癌細胞的增殖。因此,我們假設利多卡因可以通過抑制EGFR的活性來抑制癌細胞的增殖。我們研究利多卡因(40–4000 µM)對人類舌癌細胞CAL27增殖的作用,這種細胞表達有較高水準的EGFR。同時也研究利多卡因對已經激動的EGF(磷酸化的EGFR)的作用。一個臨床的利多卡因濃度(400 µM)在沒有產生細胞毒性下可以同時抑制血清介導和EGF介導的CAL27細胞的增殖,也抑制            EGF啟動的酪氨酸激酶的活性。較大濃度的利多卡因(4000 µM)在抑制增殖的同時有細胞毒性。我們覺得對激動的EGF的抑制是利多卡因對CAL27細胞抑制增殖的機制之一。傳統用於止痛的利多卡因口腔給藥會抑制人舌癌細胞的增殖。

(陸文清譯 薛張綱校)

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

           

抗膽鹼酯酶藥通過Rho-激酶途徑刺激大鼠氣管平滑肌收縮

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.

 

此項研究是為了確定Rho激酶抑制劑,Y-27632和法舒地爾,在抗膽鹼酯酶藥(抗-ChE)介導的大鼠氣管收縮和纖維醇磷脂酰化反應中的效果。在體外相等張力和[3H]纖維醇單磷酸(IP1)的測量是由大鼠的氣管環或切片來獲得的。新斯的明-和溴吡斯的明介導的收縮幾乎可以完全被30 µM Y-27632和法舒地爾抑制。然而,在各自100µM的劑量下,乙酰膽鹼介導的收縮抑制不完全,即,Y-27632抑制56%,法舒地爾抑制51%。法舒地爾對新斯的明和乙酰膽鹼介導的收縮抑制效果可以被calyculin-A,一種肌球蛋白磷酸化抑制劑所完全逆轉。新斯的明介導的IP1積聚被100µM的法舒地爾削弱。這些結果顯示抗膽鹼酯酶藥部分通過啟動Rho激酶途徑引起氣道平滑肌收縮。

(周荻 薛張綱校)

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.

 

聽覺誘發電位、腦電雙頻指數和估計效應室濃度對臨床麻醉終末的預測

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.

 

中潛伏期聽覺誘發電位已用於麻醉深度的監測。我們調查研究了地氟醚的劑量反應關係和聽覺誘發電位指數(AAI)及腦電雙頻指數(BIS)對於蘇醒的預測價值。選擇了20個行根治性前列腺切除術的成年男性。為了盡可能地減小阿片類藥物的作用,我們選擇了硬膜外複合全麻。給受試者耳機聽覺刺激並進行AAIBIS監測。麻醉誘導採用異丙酚和瑞芬太尼。而維持僅用地氟醚。同AAIBIS監測參數相比,地氟醚和異丙酚分佈及效應室濃度的藥代動力學模型被用來預測臨床終末的深度(預測概率)。病人在AAI值為47+/-20BIS值為77+/-14時睜眼,睜眼時AAIBIS及地氟醚的效應室濃度的預測概率分別為0.810.890.91。睜眼的最佳預測是通過計算地氟醚的效應室濃度。地氟醚的效應室濃度和AAIBIS的預測關係通過非線性回歸分析計算(AAI的相關度為0.75BIS的相關度為0.80)BIS和臨床終點濃度或地氟醚的效應室濃度的預測相關性要優於AAI

(王慧琳譯 薛張綱校)

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.

 

磁共振光譜法發現慢性腰痛相關的腦部生化改變:一項初步報告

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)光譜法是一項可用於探測腦部和其他器官中代謝產物和神經遞質濃度的非侵入性技術。我們採用在體(1)H MR光譜法在腰痛組與對照組中進行比較以觀察與疼痛處理相關的三個腦區的生化改變。一種模式識別方法用於確定基於MR光譜法是否能夠正確區別腰痛物件與對照組。在32個腰痛對象和33個無痛對照者的前額葉皮質、前扣帶回皮質和丘腦獲取MR光譜。採用一種模式識別方法(統計分類策略)在組間分析比較光譜。採用這種方法,能夠用前扣帶回皮質、丘腦和前額葉皮質的光譜區別腰痛物件和對照組,精確度分別為100%, 99%, 97%。結果證明,運用MR光譜法結合適當的模式識別方法能夠以高精確度發現慢性疼痛的腦部生化改變。

(徐麗穎譯 薛張綱校)

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.

 

在體外實驗中由生理鹽水引起的稀釋性凝血功能障礙可被纖維蛋白原濃縮劑逆轉而由6%羥乙基澱粉引起的則不能

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.


嚴重的出血通過大量地丟失、消耗、稀釋各種凝血因數和血小板從而導致凝血功能障礙。本次體外實驗的目的是研究由生理鹽水或6%羥乙基澱粉(HES)所引起的漸進性血液稀釋在血塊形成方面所起的作用並且分析替代性纖維蛋白原和血小板對稀釋性凝血功能障礙的影響。由8名志願者提供的全血標本分別被以上兩種稀釋劑稀釋到占整個樣本容量的20%80%。血塊形成由血栓彈力圖來描記。直到稀釋劑占整個樣本容量的60%之前替代性纖維蛋白原和血小板都不會被加入樣本中。實驗表明當6%羥乙基澱粉稀釋劑占整個樣本容量的40%時血塊形成出現嚴重障礙而用0.9%生理鹽水則要直到60%時才出現。在血小板功能被阻斷的情況下,用6%羥乙基澱粉稀釋劑稀釋到占整個樣本容量的20%時纖維蛋白單體的聚合功能嚴重受損,相對的用0.9%生理鹽水則要到稀釋劑占整個樣本容量的80%才會出現同樣的現象。添加替代性纖維蛋白原和血小板在用0.9%生理鹽水作稀釋劑時能使血塊形成功能復原而6%羥乙基澱粉作為稀釋劑時則不能。在臨床相關事件上單獨使用血小板或添加血小板對血塊形成所起的作用不大。在體外實驗中由類晶體所引起的稀釋性凝血功能障礙可被添加替代性纖維蛋白原所逆轉。相反地,由於羥乙基澱粉分子干擾了纖維蛋白單體的聚合功能,因此添加替代性纖維蛋白原和血小板對由6%羥乙基澱粉所引起的稀釋性凝血功能障礙所起的作用很小。

(孫卓真譯 薛張綱校)

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.

 

脊髓損傷病人接受損傷平面以下手術時的麻醉需求和應激激素反應

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濃度。我們研究了脊髓損傷對於七氟醚用量和應激激素的影響。在此項研究中一組是22個慢性脊髓損傷並將接受損傷平面以下手術的病人,另一組是15個沒有脊髓損傷的對照病人。病人的BIS值為4050。監測包括呼氣末七氟醚濃度、動脈血壓、心率、血漿兒茶酚胺和皮質醇的濃度。術中,兩組病人的動脈血壓、心率和BIS值是相互比較的。SCI組病人的呼氣末七氟醚的濃度明顯比對照組的低。對照組的血漿兒茶酚胺和皮質醇的濃度在術中和術後1小時相對于蘇醒時的基線值有明顯升高。SCI組病人的交感腎上腺素和皮質醇反應被抑制了。我們得出結論:SCI組病人接受損傷平面以下手術時的麻醉藥用量減少20%--39%,同時交感腎上腺素和皮質醇反應被抑制。

(韓曉丹譯 薛張綱校)

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.

 

局麻中下肢的皮膚溫度

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:


在軸索神經阻滯的早期皮膚溫度會升高。但是,用皮溫改變來預期外周神經阻滯是否成功仍不確切。因此,我們研究是否皮溫升高超過1℃預期著股骨和坐骨神經阻滯,硬膜外麻醉後感覺受損。我們進行了一項非隨機化的試驗,測試了33名股神經和坐骨阻滯阻滯以及10名硬膜外麻醉病人的皮溫變化。每5分鐘測試病人的感覺和運動功能。皮溫變化超過1度,硬膜外阻滯比股神經和坐骨神經阻滯早出現。股神經支配的皮膚溫度變化小於1度。6.6%的坐骨阻滯成功的病人中皮溫改變早於感覺消失。我們得出的結論是:皮溫改變是坐骨神經阻滯成功的可靠依據。臨床價值不高。

(鍾 靜譯 薛張綱校)

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.

 

比較靜脈輸注鹽水、平衡液、膠體對凝血在體外的影響

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.

羥乙基澱粉和鹽水、平衡液都可能影響凝血。我們對10名健康的志願者進行試驗,用血栓彈性描記器示凝血差異,溶液稀釋分為20%,40%,60%。輸20%-40%乳酸林格液,血液高凝。輸60%羥乙基澱粉,噴他澱粉,白蛋白,都為低凝。輸40%羥乙基澱粉也能造成低凝。大分子澱粉比中分子澱粉對凝血的影響更大。平衡液對凝血的影響較小。噴他澱粉中加入平衡液能減少膠體對凝血功能的影響,當其稀釋濃度較低時,血液呈高凝,60%時稀釋時對凝血影響很小。這些資料支援低分子羥乙基澱粉配入鹽水中比高分子對凝血影響更小這一理論,並可由血栓彈性描記器驗證。

(鍾靜譯 薛張綱校)

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(抗纖維蛋白酶)能調節腹主動脈瘤修補手術中凝血、細胞因數的產生、以及粘附分子表達

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動脈瘤修補手術中對凝血、纖溶、以及細胞因數和粘附分子產生的影響。16個行Y-型移植置換術的腹主動脈瘤患者分成抗凝血酶組和對照組。抗凝血酶組在肝素化前和肝素化24小時後於30分鐘內分別注入3000單位的抗凝血酶。在手術前, 手術結束時,術後第1、第2天分別進行白細胞計數、血小板計數,測定凝血酶原時間、抗凝血酶、多形核白細胞的白細胞彈性蛋白酶、白介素(IL)-1ß IL-6 IL-8 腫瘤壞死因數-{alpha}和粘附分子的血漿濃度,以及凝血、纖溶的變化。結果:對照組抗凝血酶的濃度下降,而抗凝血酶組中升高,組間比較有顯著性差異。凝血酶原時間, d-二聚體、凝血酶-抗凝血酶複合物和細胞間的粘附分子-1 的濃度僅在對照組升高;而多形核白細胞的白細胞彈性蛋白酶、白介素IL-6、腫瘤壞死因數-{alpha}和血管的細胞粘附分子-1在兩組中都升高。抗凝血酶組除細胞間的粘附分子-1以外均小於對照組。結論:抗凝血酶能在腹主動脈瘤手術中降低高凝和炎症的啟動,可能降低不良事件的發生。

(宋金超 陳傑 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.

 

七氟醚產生的延遲性心肌保護作用在吸入後48小時時較24小時時更顯著

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.

缺血預處理對繼後心臟缺血和再灌注損傷可產生延遲性的保護作用。有關吸入麻醉藥產生類似的心臟保護作用有相互矛盾的報導。本研究的目的是觀察吸入麻醉藥七氟醚是否產生類似的延遲性麻醉預處理作用,並比較吸入後24小時和48小時時保護作用的差異。選擇2-4月大的雄性Fischer344只,吸入七氟醚(2.5% 維持 60 分鐘)24小時或48小時後,游離大鼠心臟並灌注約30分鐘(平均),灌注後先進行25分鐘的缺血處理,再進行60分鐘的再灌注。對照組心臟在缺血處理前沒有進行任何處理。研究中測定左心(LV)功能,肌酸激酶(CK)梗塞面積(IS)。並通過核磁共振測定Na+i[Ca2+]i,和 pHi.。與對照組相比,七氟醚組吸入後24小時和48小時大鼠的LV功能增強,ISCK明顯降低。與24小時組相比,48小時組大鼠的LV功能恢復更加明顯,ISCK也明顯降低。與對照組相比,24小時組和48小時組有顯著的三磷酸腺苷保存作用,且酸中毒、[Ca2+]iNa+i明顯降低。因此,七氟醚可以產生延遲的預處理效果,產生在吸入後24小時以後漸達最大的保護效應。

(齊波 陳傑 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.

 

冠狀動脈搭橋術後長期心率動力學變化

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

.

本研究的目的是為了驗證冠狀動脈搭橋術後出現長久整體心率變異性和部分心率形態改變。在各種病人中心率變異性的降低常預示死亡率增高。選擇25例擇期行冠狀動脈搭橋手術的病人,在手術一周前,六周後和六月後連續24小時監測心電圖變化。其中17例病人還監測了術後12月的心電圖變化。主要評估心率變異的時間和頻率,同時測量短期的鱗狀排列指數(α1),近似熵指數,和乘幕-規則與間歇變異的相關危險的關係( β-slope)。術後乃至術後6周,6月和12月的高,低,極低和超低頻率指數均較術前顯著降低(P=0.001,P<0.001,P<0.001,P<0.001)。鱗狀排列指數(α1)在6周時顯著降低,但在術後6月時恢復術前水平。β-slope較穩定,但所有的複雜度(近似熵指數)在研究期間均表現為降低(一年後P<0.01)。短時和長期的心率變異性改變對冠狀動脈搭橋術後病人預後的長期影響尚不清楚。

(忻紀華 陳傑 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.

 

通過短暫充血反應評估七氟醚對小兒腦血管自動調節功能的影響

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.

應用經顱多普勒技術作短暫充血反應(THR)試驗評估腦血管自動調節功能,是一種簡單的無創檢測技術。然而有關小兒THR的研究未見報導。在本研究中,作者應用該項技術評估七氟醚全麻小兒的反應情況。20ASA I級,接受泌尿外科手術的小兒隨機接受0.5, 1.01.5 MAC七氟醚麻醉。骶管麻醉提供鎮痛作用。在壓迫右側頸動脈前(F1)、中(F2)和後(F3)三個時間點分別檢測同側大腦中動脈的腦血流速度,壓迫時間為10秒。研究結果表明,THR率(THRR)在0.5MAC1.0MAC,和1.5MAC分別是1.24 +/- 0.11, 1.16 +/- 0.09, 1.13 +/- 0.07THRR0.5MAC組與1.0MAC1.5MAC組相比存在著明顯差異(P<0.05)。但是在1.01.5MAC;兩組間沒有明顯差異。以往認為,THRR超過1.09是陽性反應低限。本研究結果表明,1.5MAC以下七氟醚麻醉時THR呈劑量依賴性變化。這說明,小兒以七氟醚進行麻醉時,只要不超過1.5MAC,腦血管的自動調節功能依然存在。

(蘇殿三 陳傑 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.

 

斜疝修補術病人使用椎旁阻滯可比全麻提供更好的當天恢復

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.

 

斜疝修補術通常在神經阻滯或局部或全身麻醉下作為門診手術進行的。作者假設使用椎旁阻滯(PVB)作為單獨麻醉技術能使病人在較短時間內出院回家,比快通道全麻(GA)更好的當天恢復。50名病人隨機接受PVB或GA。PVB 0.75% 羅呱卡因,隨後使用丙泊酚鎮靜; GA 朵拉司瓊 12.5 mg, 丙泊酚誘導,羅庫溴胺插管,地氟醚,0.25%布比卡因行區域阻滯。記錄不需進入麻醉後恢復室的病人數、術後開始疼痛時間、行動、出院和不良事件發生率。大多數PVB組的病人符合不進入PACU的標準(71%),而全麻組只有8%病人(P < 0.001)。PVB組的病人僅有3名(13%)在醫院時需要鎮痛治療,儘管同時使用了局部麻醉,全麻組有12(50%)名病人需要鎮痛治療(P = 0.005)。PVB組病人能較早開始活動(102 ± 55 min),全麻組病人較遲(213 ± 108 min; P < 0.001)。PVB組的病人準備出院和離院時間(156 ± 60 253 ± 37 min)較全麻組病人(203 ± 91 218 ± 93 min)(P < 0.001)。接受PVB的病人在第一個24小時內不良事件(例如噁心,嘔吐和喉痛)和疼痛需要治療率小於全麻病人。因此,在接受斜疝修補術的門診病人中,PVB病人比GA病人較快出院、不良事件的發生減少且具有較好的術後鎮痛。

(殷文淵 陳傑 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.

 

異氟醚、七氟醚麻醉期間氣管插管後N2O引起異常腦電改變

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.

在一項隨機雙盲對照研究中,作者驗證如下假設:在異氟醚、七氟醚麻醉氣管插管後N2O能影響雙頻指數(BIS)和95%邊緣頻率(SEF95)。在實驗1中,90ASA I級的患者隨機分成6組(每組n=15)。異氟醚,七氟醚麻醉複合0%33%66%N2O,異氟醚七氟醚的濃度是逐漸升高,其呼末濃度分別維持在1.1%1.7%。麻醉誘導後12分鐘行氣管插管。與喉鏡置入前單純接受異氟醚或七氟醚的患者相比,氣管插管後1分鐘BIS明顯增加(分別為P0.0010.007)。接受66% N2O-異氟醚或66% N2O-七氟醚的患者氣管插管後BIS,SEF95均明顯降低,較接受異氟醚或七氟醚的患者明顯低(兩者P<0.01)。在實驗2,靜注芬太尼3ug/kg能完全消除66% N2O-異氟醚或66% N2O-七氟醚氣管插管後BISSEF95的降低。結論:66% N2O可引起異氟醚和七氟醚麻醉氣管插管後異常的BIS降低。

(顧新宇 陳傑 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.

 

硫噴妥鈉能調節大鼠脊髓背角神經元中γ-氨基丁酸A受體功能

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.

為檢測硫噴妥鈉在脊髓背角水平的作用,作者在機械分離的大鼠脊髓背角神經元中應用全細胞膜片鉗技術對該藥進行研究。高濃度的硫噴妥鈉通過啟動氯通道產生電流(IThio),其閾濃度約為50uMIThioγ-氨基丁酸(GABAA受體拮抗劑荷包牡丹堿敏感,而對甘氨酸受體拮抗劑士的寧不敏感。臨床濃度(30uM)的硫噴妥鈉顯著增強亞飽和GABA誘導的電流(IGABA),但對飽和GABA誘導電流無明顯作用。並且硫噴妥鈉能夠延長IGABA的失敏和失活時間。濃度達到300uM時,硫噴妥鈉能夠抑制IGABA的峰值,推測這一作用與開放通道被阻滯有關。另外,30uM的硫噴妥鈉能夠延長GABA能微小抑制性突觸後電流的時程,降低其頻率。本研究結果顯示硫噴妥鈉對GABA能抑制性傳導有增強作用,提示脊髓上的GABA A 受體可能是硫噴妥鈉抑制運動,降低機體對傷害性刺激的反應的潛在作用位點。

(田婕 陳傑 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.

 

異氟醚保護遭受中度缺氧的成年小鼠的空間立體記憶

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.

 

圍術期缺氧可導致術後認知的損害。然而麻醉對缺氧相關的中樞神經系統損害的方面是起加劇作用還是保護作用仍未闡明。本文作者研究缺氧或聯合異氟醚是否會影響小鼠的記憶功能。成年小鼠隨機分為四組並維持一個小時:21%氧氣組,21%氧氣+1.2%異氟醚組,8%氧氣組,8%氧氣+異氟醚1.2%。實驗中維持自主呼吸。將其體溫維持在37+0.5ºC。小鼠復蘇24小時以避免殘留麻醉藥物對神經行為表現的影響。小鼠記憶力通過Y迷宮來評估。實驗中,首先關閉一端,允許小鼠在Y形迷宮2個開放端間奔跑15分鐘,並觀察其活動。1小時後,開放Y形迷宮所有開口。用照相機和相關軟體自動記錄通過Y形迷宮每個出口的時間。小鼠在麻醉後的147天被測試。每次實驗有差異的開口作為新的開口。用差異可重複測量分析行為,隨後用簡單主因分析合適時用Newman-Keuls 測驗比較。P <0.05認為差異有意義。遭受缺氧的動物(8%氧氣1小時)在損傷後1天在新出口處花的時間顯著減少。然而這種損害作用是暫時的。缺氧小鼠的行為在缺氧後4天恢復到對照組水平。小鼠遭受缺氧合併使用異氟醚時未顯示損害作用,且與對照組所有時間點上相當。缺氧對立體空間記憶功能有短暫的損害表現。異氟醚對此缺氧引起的有害影響起了保護作用。

(鄭麗 陳傑 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.

 

鞘內使用嗎啡以緩解肝切除術後疼痛:與硬膜外鎮痛的比較

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.

在一些醫療機構中常使用硬膜外導管進行肝臟手術後鎮痛。但是,麻醉醫生可能對硬膜外留置導管感到不滿意,主要是考慮到這些病人肝功能受損可能會引起凝血障礙和出血的併發症。在本項研究中,作者用單次鞘內注射嗎啡技術並與肝臟手術後連續硬膜外輸注嗎啡鎮痛效果相比較。50位病人隨機分入硬膜外鎮痛組(EP組,n25)和鞘內鎮痛組(IN組,n25)。鎮痛效果用VAS評分來表示,同時記錄副反應,其他靜脈鎮痛藥的需求量。沒有觀察到任何脊髓受壓現象。EP組距離首次靜脈鎮痛藥物需要的時間比IN組長(25±18.5h相對於12±10.3hp<0.05)。兩組病人術後48小時期間VAS評分均低於30mmIN組病人自控鎮痛設備消耗的靜脈嗎啡量大於EP組(12.0±5.54mg相對於3.1±2.6mgP <0.01)。兩組嘔吐發生率均為4%,而IN組瘙癢(16%相對於0%)、噁心(16%相對於4%)的發生更常見。沒有發生椎管內注射後疼痛和脊髓血腫。在肝臟切除後,單次鞘內注射嗎啡複合病人自控靜脈嗎啡鎮痛能提供滿意的術後鎮痛。根據VAS評分,這種方法的效果在術後48小時並不比連續硬膜外鎮痛效果差。

(曹瑜 陳傑 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.

 

不同程度的多臟器功能不全患者的局部微血管功能和血管反應性

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.

多臟器功能不全(MODS)的病理生理常被認為與微血管功能障礙有關。研究者假定在重症患者中MODS的嚴重性取決於所測量的局部微血管功能的參數和血管反應性。因此,研究者對血流動力學穩定的中度(n15)和重度(n15MODS患者通過三方面進行了比較:(a)在前臂通過經皮PO2/PCO2電極測定充血反應和鐳射多普勒速度測量,(b)在大腿通過滲出體積描記法評估微血管滲透性以及(c)胃張力測定的資料。中度MODS患者死亡率為20%,而重度MODS的患者死亡率為60%(P=0.025)。重度MODS患者動脈血乳酸值(3.81±2.7mmol/L)明顯高於中度MODS患者(1.66±0.82mmol/LP=0.006)。中重度MODS患者之間胃PHi,胃局部-動脈血PCO2差,毛細血管濾過係數,等容積靜脈壓力以及皮膚充血反應無明顯差異。本研究顯示,一旦被確定為MODS,局部微血管功能和血管反應性的變化不能反映臟器功能障礙的嚴重程度。

(朱輝 陳傑 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.

 

大鼠脊髓短暫非損傷性缺血後鞘內注射尼可地爾和小劑量嗎啡可導致痙攣性截癱

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.

 

作者研究了脊髓短暫非損傷性缺血的大鼠在鞘內注射尼可地爾(K離子ATP通道激動劑)和嗎啡後藥物的相互作用和大鼠的運動功能。實驗動物為Sprague-Dawley大鼠,用帶有球囊的導管人為造成動脈阻塞6min,完成脊髓缺血模型。所有實驗動物均在缺血1小時後,鞘內注射(IT)嗎啡(1-60μg),除了鞘內注射嗎啡外,M組(對照組),MN組(同時注射嗎啡和尼可地爾),MNG組(同時注射嗎啡、尼可地爾和格列本脲)分別於再灌注後150min鞘內注射生理鹽水,尼可地爾(10μg),格列本脲(10μg)和尼可地爾(10μg)。通過量子生物測定法計算再灌注後3小時50%實驗動物發生截癱的有效劑量(ED50),評價鞘內注射嗎啡對脊髓缺血後神經功能的影響。M組和MN組的ED50分別為15.1±4.9μg2.9±1.0μgP<0.05)。在MNG組,劑量效應曲線右移,導致截癱的ED5011.6±4.7μg。目前的實驗結果證明大鼠脊髓短暫非損傷性缺血後鞘內注射小劑量的嗎啡合併尼可地爾可以導致痙攣性截癱。

(肖潔 陳傑 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.

 

全膝關節置換術後硬膜外鎮痛和連續股神經-坐骨神經聯合阻滯的比較

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.

 

全膝置換術後硬膜外鎮痛法一直是疼痛緩解的金標準。然而,周圍神經阻滯由於副作用發生率可能減少而被廣泛應用。本文作者研究該假設的正確性。60名病人隨機分組分別接受硬膜外鎮痛或股神經和坐骨神經聯合阻滯。硬膜外和股神經導管內泵入羅呱卡因2mg/mL加上舒芬太尼1ug/mL,坐骨神經泵入羅呱卡因0.5mg/mL(輸送速度5mL/h,維持55h)。主要觀察總的副作用發生率(術後第一天發生尿瀦留和劇烈的頭暈、瘙癢、鎮靜和噁心/嘔吐)。記錄術後72小時內運動神經阻滯的程度,靜息時和運動時的疼痛和恢復指數。術後第一天,硬膜外組87%病人發生一個或多個副作用,而神經阻滯組只有35%病人(p0.0002)。在手術當天和術後第一天,周圍神經阻滯組病人手術側肢體的運動神經阻滯較強(p0.001),在手術當天,硬膜外組病人未手術肢體阻滯較強(p0.0003)。所有的病人在運動時疼痛被很好的控制且住院時間無區別。恢復指數也相似。研究結果表明:在術後第一天,股神經/ 坐骨神經阻滯組副作用的發生率比硬膜外組低。

(張美榮 陳傑 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.

 

術後譫妄:疼痛和疼痛治療的重要性

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.

 

術後譫妄是老年病人常見的併發症,很少有研究調查導致術後譫妄的原因。作者假設術後譫妄和術後疼痛以及疼痛治療方法有關。選擇大於65歲的非心臟手術病人作為研究物件。術前制定一份精神檢查表,術後用精神紊亂評估方法測定第一個3天的譫妄程度,收集術後鎮痛的方法以及術前和術後給藥方法。以視覺模似評分法記錄術前和術後靜息痛以及運動痛。研究物件為333例病人,年齡74 ± 6歲。手術後46%的病人產生術後譫妄。通過多元回歸分析,年齡(OR, 2.5; 95% CI 1.5 to 4.2),中等程度術前靜息痛 (OR, 2.2; 95% CI 1.2 to 4.0) 和重度術前靜息痛(OR, 3.7; 95% CI 1.5 to 9.0),以及疼痛從基礎值上升到術後第一天(OR, 1.1; 95% CI 1.01 to 1.2)是術後譫妄獨立危險因數。相反,與靜脈鴉片類鎮痛藥病人自控鎮痛相比那些單獨使用口服阿片鎮痛的病人術後譫妄的發生率顯著降低(OR, 0.4; 95% CI 0.2 to 0.7)。上述結果證明作者的假設:疼痛和疼痛治療策略是老年病人術後譫妄的重要因素。

(潘志英 陳傑 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.

明膠和羥乙基澱粉而不是白蛋白破壞心臟手術後的凝血功能 

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

 

我們研究了45例患者心臟手術術後應用膠體對凝血功能的影響。患者隨機應用4%白蛋白、4%琥珀酰明膠或6%羥乙基澱粉 (分子量 200 kDa/取代級0.5)15 mL kg–1做短期輸注。輸注完成後即刻在明膠和羥乙基澱粉組的凝血彈力描記圖中最大凝塊固度明顯下降,而在白蛋白組的這些值保持不變。凝塊強度破壞持續時間達2小時,儘管數值有部分恢復。術後出血與人造膠體的彙聚資料中凝塊強度呈負相關。纖維蛋白形成(凝塊形成時間,α角)和纖維蛋白原依賴性凝塊強度(最大凝塊固度和切應力彈性係數)在羥乙基澱粉組比明膠組干擾更大。我們得出結論,心肺旁路手術後明膠和羥乙基澱粉都破壞凝塊強度和纖維蛋白建立,從而使患者失血增加。應用羥乙基澱粉後見凝血功能破壞最大,而白蛋白對凝血功能參數的影響較小。

(彭中美 馬皓琳 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.

 

大鼠中低溫體外迴圈後海馬Bcl-2Bax表達及神經元凋亡

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

 

我們採用大鼠中低溫(26°C–28°C)伴血液稀釋的體外迴圈(CPB)模型,研究了CPB後直至6h的海馬凋亡基因表達和神經元凋亡。雄性大鼠(380400g)在異氟醚和芬太尼全麻下行CPB。行右心房和尾動脈置管,蠕動泵和膜氧合器用於CPB。研究分為2組:組1大鼠(n = 15)禁食後行60min中低溫非搏動性CPB;組2由假手術大鼠組成(n = 15)。CPB1h,每組6只大鼠的海馬被處理用逆轉錄酶聚合酶鏈反應來檢測凋亡基因(bcl-2bax)的mRNA,並用bcl-2bax PCR產物和β-actin基因的比值判定mRNA的表達。CPB6h,用免疫組化來測定每組6只大鼠中bcl-2bax蛋白的海馬表達,並用TUNEL測定神經元的凋亡。CPB6h,用電子顯微鏡檢測每組3只大鼠的海馬CA1區神經元超結構的變化。CPB1h,組1bcl-2/β-actinbax/β-actinbax/bcl-2mRNA比值增加(組1比組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,組1大鼠海馬CA1bcl-2bax的蛋白表達增加(組1比組2bcl-20.18 ± 0.050.09 ± 0.01P = 0.02bax0.20 ± 0.060.04 ± 0.02P = 0.01)。CPB6h1大鼠海馬CA1區的TUNEL染色增加(組1比組20.14 ± 0.020.03 ± 0.01P = 0.00)。組1大鼠海馬CA1區神經元發生符合凋亡的超結構變化。大鼠行中低溫伴血液稀釋的CPB後的恢復期早期可發生海馬CA1baxbcl-2基因表達和神經元凋亡。

(黃施偉 譯,馬皓琳 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.

 

 

阿片類藥物依賴的重症監護小兒患者停用阿片藥物的前瞻性評估

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

 

我們會在長期的兒科重症監護中應用阿片類藥物以試圖減少危重病兒的應激和緩解疼痛。這種治療方法使得兒童冒有阿片依賴的風險。一旦出現依賴,患兒就需要停藥,或者面臨突然停藥引起戒斷綜合征的風險。我們對幾位阿片依賴的患兒進行了一個前瞻隨機的研究,比較用口服美沙酮取代阿片類藥物5天和10天。平均使用阿片類藥物三周時間的兩組患兒在需要阿片類藥物解救的激惹事件(每兩小時連續測量3次嬰兒戒斷評分>8)數量上沒有顯著性差異。在兩組患兒中,大部分需要解救的事件都發生在停藥的第五天和第六天。一旦轉為口服美沙酮,患兒就可以在五天以內成功地戒斷,並需要停藥後的隨訪期來觀察延遲性的戒斷綜合征。

(黃佳佳譯,馬皓琳 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期重建術的左心發育不良綜合征新生兒中米力農群體藥代動力學

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

 

我們對16例因左心發育不良而行期重建術的新生兒進行了對米力農的隨機、盲法藥代動力學研究,來觀察心肺轉流和改良超濾時對藥物分佈的影響,並確定術後持續IV輸注過程中的藥物暴露情況。當新生兒開始複溫時,在心肺轉流回路內給以首量米力農100 250 μg/kg。術後,根據臨床需要輸注米力農。在心肺轉流、改良超濾期間和術後,用NONMEM運算法則的混合效應模式計算米力農的藥代動力學特性。儘管改良超濾的藥物清除率為3.3 mL·kg1·min1,本研究中的所有病人均表現出超濾濃縮效應。在手術後即刻,本研究中的嬰兒表現為腎臟清除功能損害。在給以0.5μg·kg1·min1持續輸注的最初12小時內,藥物出現蓄積現象。術後,米力農的清除功能顯著受損 (0.4 mL · kg· min1),術後第12小時改善, 術後第4天後達到穩態清除率(2.6 mL · kg· min1)。在術後腎功能顯著受損的階段,應該考慮的輸注速度為0.2 μ· kg· min1 

(周志堅 馬皓琳 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.

 

 

異丙酚麻醉中對指令的反應消失時對笑氣以及麻醉藥的需要量

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

 

與令50%病人對指令的反應消失(LOR)有關的血藥濃度(CP50LOR)是衡量麻醉強度的重要指標。因此,我們對401860歲用單純異丙酚或複合用異丙酚和67%笑氣(N2O)進行麻醉的健康外科病人測定了CP50LOR。將病人隨機分為經面罩吸入純氧或吸入67%笑氣和氧氣的混合氣體。3分鐘後,開始靶控輸注異丙酚,濃度由同一組前一例病人的反應決定。15分鐘後,由不知分組的觀察者評定對指令的反應。抽取動脈血樣本以測定異丙酚濃度,並連續監測腦電雙頻指數(BIS)。在測定指令反應時,單純用異丙酚組異丙酚測定濃度和靶濃度均顯著大於異丙酚複合笑氣組,而BIS值前者明顯小於後者。單純用異丙酚組的異丙酚CP50LOR 4.58 µg/mL95%可信區間[CI]1.1415.36),而異丙酚複合笑氣組為2.67 µg/mL95CI2.28–3.17)。50%病人對指令有反應的BIS值,在單純用異丙酚組為6095CI55–65),在異丙酚複合笑氣組為75 (95%CI73–83)

  (黃麗娜   馬皓琳 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.

 

 

局麻藥對脂多糖所致內皮細胞損傷的保護作用:線粒體三磷酸腺苷敏感性鉀離子通道的作用

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

 

利多卡因可減輕缺血再灌注和炎症反應所致的細胞損傷,儘管其保護機制至今不明。我們假設利多卡因和其他酰胺類局麻藥可通過啟動線粒體三磷酸腺苷敏感性鉀通道(mitoKATP)對內皮細胞損傷產生保護作用。我們觀察酰胺類局麻藥(利多卡因、羅呱卡因和布比卡因)、酯類局麻藥(丁卡因和普魯卡因)、一種酰胺類局麻藥類似物(YWI)和兩種非酰胺類局麻藥類似物(JDAICM)在存在或不存在mitoKATP通道阻斷劑5-羥癸酸的兩種情況下對應用脂多糖(LPS)的人微血管內皮細胞生存能力的影響。用黃素蛋白螢光觀察局麻藥對二氮嗪誘導的mitoKATP通道啟動效應的影響。利多卡因、羅呱卡因、布比卡因、YWIJDAICM可緩解LPS所致的細胞生存能力下降60%到70%。5羥癸酸可抑制酰胺類局麻藥和YWI的保護作用,但不影響JDAICM引起的保護作用。丁卡因和普魯卡因對脂多糖所致的損傷沒有保護作用。酰胺類局麻藥及其類似物(YWI)可使二氮嗪激發的黃素蛋白螢光增強5%到20%,而酯類局麻藥可使二氮嗪激發的黃素蛋白螢光減弱5%到60%,非酯類局麻藥類似物無影響。綜上所述,酰胺類局麻藥及其類似物(YWI)部分通過啟動mitoKATP 通道來減輕LPS所致細胞損傷。相反,丁卡因和普魯卡因沒有保護作用,並且抑制mitoKATP 通道的啟動。非酰胺類局麻藥類似物也可產生保護作用,但其機制不依賴於mitoKATP 通道。

(周雅春 馬皓琳 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.

 

 

格拉斯瓊和朵拉斯瓊預防術後噁心嘔吐與CYP2D6的基因型有關

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

 

我們研究了格拉斯瓊和朵拉斯瓊預防術後噁心嘔如的有效性。由於各種用於止吐的5-羥色胺35-HT3)拮抗劑的代謝涉及不同異構的肝細胞色素P450系統,我們檢驗了這些藥物的臨床有效性和多態的細胞色素P450 2D6CYP2D6)的基因型之間的關係。這項前瞻性的隨機、雙盲研究共涉及150位具有術後噁心嘔吐中到高度危險的病人。所有觀察物件均在麻醉誘導時接受了地塞米松,然後給予12.5mg 朵拉斯瓊或者1mg格拉斯瓊。我們分析了在術後第一個24小時內完全有效(指無嘔吐或者未使用救援藥物)的病人數。採用TaqMan即時聚合酶鏈反應法測定CYP2D6的基因型。格拉斯瓊組完全有效(54.7%)較多拉斯瓊組多(38.7%, P < 0.05)。在接受朵拉斯瓊的病人中,預計超速代謝狀態的CYP2D6等位元基因副本攜帶者發生嘔吐事件的頻率高於格拉斯瓊組病人(P < 0.05)。故假設兩種被研究的5-HT3受體拮抗劑抗嘔吐效果的差異與CYP2D6等位元基因副本攜帶狀態的不同有關。

(顏濤 馬皓琳 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.

 

 

患者持續靜脈輸注給藥:通過模型預測受流速和輸注系統死腔影響的潛在藥物劑量波動

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

 

靜脈輸注藥物有潛在的劑量誤差,這是由攜帶藥物的液體流速和輸液器死腔之間的複雜相互作用而引起。我們以苯腎上腺素作為模型化合物,用電腦計算輸液器死腔中存儲的藥物穩態量 。死腔中的藥量隨原藥濃度和擬給劑量增加而增加,卻隨流速增加而減少。我們還模擬突然中斷攜帶液體時藥物傳送的動力學擾動。如果原先的攜帶液體很快,一旦該輸液中止則藥物的進入速率降低很多。藥物輸注速率快可導致藥物進入體內更快恢復。最後,在改變藥物輸注或輸注液體速度後達到新穩態的時間可計算得到。原型藥濃度大、死腔較大和最後的攜帶液體速度較慢時這個時間最長。這些計算結果表明a)死腔中可能包含很多藥物劑量有時不小心可能造成相當於單次誤注 b)停止攜帶液體能明顯降低藥物給入;c)改變攜帶液體流速或藥物劑量後藥物達到新穩態給入速度前可能有明顯滯後。儘管只用計算苯腎上腺素的模型,但這些觀念很普遍且對任何通過靜脈輸注給予的藥物均有效。

(趙雪蓮 馬皓琳 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.

 

 

依託咪酯抑制大鼠腰背角神經元對傷害性溫度刺激的反應

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

 

依託咪酯是一種廣泛應用的靜脈麻醉藥,但對其鎮痛作用,尤其是其對脊髓神經元對傷害性刺激的反應的影響,幾乎不知。我們假設依託咪酯可能會抑制腰段神經元對傷害性熱刺激的反應。使用異氟醚(1.2%)麻醉大鼠(n = 15),行椎板切除以記錄單個單元的活動。依託咪酯給藥前和給藥後每2分鐘(直到注射後13分鐘)記錄大鼠腰神經元對後爪傷害性熱刺激(52°C, 12s)的反應。給予0.1250.250.512 mg/kg依託咪酯後,依託咪酯峰作用時的反應(對照反應的百分比)分別為63% ± 16%63% ± 16%38% ± 25%36% ± 30%41% ± 26%。這種反應可以很快恢復,通常是在注射後10分鐘內。在去大腦、給予依託咪酯未用異氟醚的大鼠或給予異丙酚的異氟醚麻醉大鼠,也可以記錄到相似的反應。這些資料表明依託咪酯抑制脊髓神經元對傷害性刺激的反應,其機制可能與依託咪酯的鎮痛作用有關。

(張瑩 馬皓琳 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.

 

 

部分輔助通氣過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

 

我們驗證這樣一個假設,即部分輔助通氣對呼吸肌的血流的減少與機械控制通氣(CMV)期間發現的影響水平相似。在10只兔子中比較三個水平的壓力支持通氣(PSV)和2CMV設置。在持續正壓模式下給予PSV 0612 cm H2O,接著在用肌肉鬆弛藥的情況下給予每個CMV設置636次呼吸/分鐘)和12cm H2O18次呼吸/分鐘)的壓力控制通氣(PCV)值。我們用有色微球測量呼吸肌肉、下肢端、腎臟和肝臟的局部組織血流。PSV6PCV6PCV12期間在膈肌處局部組織血流均低於PSV0。膈底血流PSV12PCV12多,和PSV0相似。然而,PSV6膈膜跨壓是–0.8 ± 1.6 cm H2OPSV12–3.1 ± 2.4 cm H2O。在PSV12觀察到由無效的觸發努力引起的吸氣不協調。通氣設置不影響下肢、肝臟和腎臟血流。結論,通氣設置影響膈膜血流。在某些PSV設置,膈膜的血流是最小的。

(張曦 馬皓琳 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.

 

 

在現有臨床環境下比較全膝關節整形術後單次注射的股神經阻滯及持續性股神經阻滯作用對患者住院時間及長時程功能恢復的影響

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

 

全膝關節整形術(TKA)可導致嚴重的疼痛,已證明單次注射的股神經阻滯(SFNB)產生的鎮痛時程是有限的。持續性的股神經阻滯(CFNB)可以延長SFNB的鎮痛時程。我們前瞻性地將36個行TKA的病人隨機分成CFNB組對SFNB組,評價它們在標準臨床途徑中對住院時間長短(LOS)的影響,以此作為主要研究結果。次要的研究結果包括視覺類比法(VAS)的疼痛評分、阿片類藥物的消耗量及在12周時的長時程功能恢復情況。CFNB組的平均VAS靜息評分明顯低於SFNB組:術後第一天(1.7 3.3 [P = 0.002])及第二天(0.9 3.2 [P < 0.0001])CFNB組在理療期間的平均最大VAS評分也明顯低於SFNB組:術後第一天(4.7 6.3 [P = 0.01]) 第二天 (3.9 6.1 [P = 0.0005])CFNB組的平均氧可酮消耗量也明顯低於SFNB組:術後第一天15 mg 40 mg (P = < 0.0001); 術後第二天20 mg 43 mg (P = 0.0004)。兩組間的住院時間LOS(3.8 3.9 )或長期的功能恢復(12周時膝關節能彎曲117° 113° )沒有明顯差別。在當代美國的醫療保健環境中,CFNB產生的鎮痛時程延長提供的影響缺乏對住院時間及長時期的功能恢復可能僅有很小的作用。

(裘毅敏 馬皓琳 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.


術後鎮痛對老年病人譫妄與認知功能下降的影響:系統綜述

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

 

術後譫妄與認知功能下降是老年病人經常會發生的不良反應。病人術前並存的因素、用藥、術中及術後發生的各種原因均與術後譫妄與認知功能下降的發展有關。儘管以往研究證實術後疼痛是風險因素,但至今還鮮有臨床研究比較術後常用鎮痛技術(靜脈鎮痛和硬膜外鎮痛)及阿片類鎮痛藥對術後認知功能的影響。對PubmedCINAHL資料庫的一項系統性搜索確定了關於比較不同阿片類鎮痛藥對術後譫妄與認知功能下降的影響的六項研究,及五項比較靜脈鎮痛與硬膜外鎮痛的不同鎮痛途徑的研究。呱替啶始終使老年病人術後譫妄的風險增高,但目前的證據表明其他術後較常用的阿片類藥如嗎啡,芬太尼或二氫嗎啡酮對術後譫妄和認知功能下降影響無顯著區別。而目前的研究還證實靜脈鎮痛和硬膜外鎮痛對術後認知功能障礙的影響無顯著性差異。但是未來還尚需足夠大規模的研究樣本量以及定義研究結果的更加標準化的方法來進一步證實目前發現。

(邱鬱薇 馬皓琳 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.

 

 

測試溫度和存儲溫度對血小板凝集的影響:一次體外的全血試驗

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

 

我們用流式細胞計量術和阻抗集合度測定系統地評估了測試溫度和存儲溫度對血小板凝集的影響。27名健康成年男性志願者的一部分含枸櫞酸鹽的全血儲存在37°C22°C的條件下。一部分用作在22°C34°C37°C40°C下測定對膠原、二磷酸腺苷、瑞斯西丁素和花生四烯酸反應中的阻抗集合度測試。用PAC-1螢光染色法和全血細胞流式計量術在22°C 37°C測定由二磷酸腺苷啟動的血小板上啟動的纖維蛋白原受體表達。測試溫度34°C37°C時通過膠原、瑞斯西丁素和花生四烯酸誘導的聚集反應沒有顯著差別,但是在22°C時的反應顯著減弱。相反,二磷酸腺苷誘導的聚集反應在測試溫度為34°C22°C時都顯著增強。高溫是唯一可以減弱膠原誘導的凝集反應的情況。存儲溫度22°C相較37°C而言是唯一可以增強二磷酸腺苷和膠原誘導的凝集反應。在測試溫度低於37°CPAC-1的結合增強。通過預加熱抗體超過22°C則時結合顯著減少。我們的結果提示淺低溫測試條件下沒有相關的影響,而深度低溫誘發粘合、血栓素的生成和啟動受損。在淺低溫和深低溫時對二磷酸腺苷的反應均增強的病理機制還不清楚。存儲溫度很大程度上影響了對激動劑二磷酸腺苷和膠原的聚集反應,但是對瑞斯西丁素和花生四烯酸沒有影響。採用了溫度易變化的抗體PAC-1的流式細胞儀不能評定溫度對血小板集合力的影響。

(薑旭暉 馬皓琳 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.