Anesthesia & Analgesia

May 2006

Table of Content

CARDIOVASCULAR ANESTHESIA:

Pascal Alfonsi, Antoine Vieillard-Baron, Marc Coggia, Bruno Guignard, Olivier Goeau-Brissonniere, François Jardin, and Marcel Chauvin

Cardiac Function During Intraperitoneal CO2 Insufflation for Aortic Surgery: A Transesophageal Echocardiographic Study
Anesth Analg 2006 102: 1304-1310. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Left ventricular dysfunction during a 14 mm Hg pneumoperitoneum in patients scheduled for abdominal aortic repair in the supine or lateral position is more likely a consequence of a cardiac workload increase than of a venous return impairment.

Peter Rosenberger, Stanton K. Shernan, Prem S. Shekar, Jayshree K. Tuli, Thomas Weissmüller, Sary F. Aranki, and Holger K. Eltzschig

Acute Hemodynamic Collapse After Induction of General Anesthesia for Emergent Pulmonary Embolectomy
Anesth Analg 2006 102: 1311-1315. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: In patients undergoing pulmonary embolectomy, severe hypotension after anesthesia induction, which requires emergent institution of cardiopulmonary bypass, occurs frequently (19%) and is unpredictable. Therefore, we recommend preparing and draping patients before induction of general anesthesia for surgical pulmonary embolectomy.

Roger C. Carroll, Jack J. Chavez, Jeffery W. Simmons, Carolyn C. Snider, Dale C. Wortham, Stuart J. Bresee, and Eli Cohen

Measurement of Patients' Bivalirudin Plasma Levels by a Thrombelastograph® Ecarin Clotting Time Assay: A Comparison to a Standard Activated Clotting Time
Anesth Analg 2006 102: 1316-1319. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We evaluated a Thrombelastograph(R) ecarin clotting time assay and found that it correlated better than a standard activated clotting time test with plasma bivalirudin levels.

Stefano Romagnoli, Sergio Bevilacqua, Sandro Gelsomino, Silvia Pradella, Lorenzo Ghilli, Carlo Rostagno, Gian Franco Gensini, and Carlo Sorbara

Small-Dose Recombinant Activated Factor VII (NovoSeven®) in Cardiac Surgery
Anesth Analg 2006 102: 1320-1326. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Recombinant FVIIa reduced postoperative bleeding, transfusion of red blood cells, fresh-frozen plasma, and platelet transfusion, as well as intensive care unit stay and re-exploration rate.

Peter L. Bailey, Emmett E. Whitaker, Linda S. Palmer, and Laurent G. Glance

The Accuracy of the Central Landmark Used for Central Venous Catheterization of the Internal Jugular Vein
Anesth Analg 2006 102: 1327-1332. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Ultrasound evaluation indicates that use of the central landmark approach for right internal jugular catheterization results in more medial needle insertion than desired, with risk of carotid puncture or failure to catheterize the jugular vein.

María F. Martín Cancho, María S. Carrasco-Jiménez, Juan R. Lima, Laura Luis, Verónica Crisóstomo, and Jesús Usón-Gargallo

The Measurement of Neurovegetative Activity During Anesthesia and Surgery in Swine: An Evaluation of Different Techniques
Anesth Analg 2006 102: 1333-1340. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This pilot study performed in sevoflurane-anesthetized pigs suggests that the ANSiscopeTM monitor may be useful for representing and measuring neurovegetative activity during general inhaled anesthesia.

David A. Zvara, Andrew J. Bryant, Dwight D. Deal, Mario P. DeMarco, Kevin M. Campos, Carol M. Mansfield, and Michael Tytell

Anesthetic Preconditioning with Sevoflurane Does Not Protect the Spinal Cord After an Ischemic-Reperfusion Injury in the Rat
Anesth Analg 2006 102: 1341-1347. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Paraplegia remains a devastating consequence of descending and thoracoabdominal aortic operations that have a period of obligate spinal cord ischemia. This research demonstrated no benefit of anesthetic preconditioning in attenuating this type of injury.

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

Inhibition of Glycogen Synthase Kinase Enhances Isoflurane-Induced Protection Against Myocardial Infarction During Early Reperfusion In Vivo
Anesth Analg 2006 102: 1348-1354. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Inhibition of the regulatory protein, glycogen synthase kinase, enhances protection against myocardial infarction by isoflurane administered immediately before and during early reperfusion after prolonged coronary artery occlusion via a mitochondrial permeability transition pore-dependent mechanism.

Chen Wang, Donald A. Neff, John G. Krolikowski, Dorothee Weihrauch, Martin Bienengraeber, David C. Warltier, Judy R. Kersten, and Paul S. Pagel

The Influence of B-Cell Lymphoma 2 Protein, an Antiapoptotic Regulator of Mitochondrial Permeability Transition, on Isoflurane-Induced and Ischemic Postconditioning in Rabbits
Anesth Analg 2006 102: 1355-1360. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Inhibition of the antiapoptotic regulatory protein Bcl-2 abolishes myocardial protection produced by brief exposure to isoflurane or repetitive, transient ischemic episodes during early reperfusion in rabbits. In contrast, inhibition of Bcl-2 did not affect protection afforded by cyclosporin A, a direct mitochondrial permeability transition pore (mPTP) antagonist. The results suggest that Bcl-2 mediates isoflurane-induced and ischemic postconditioning by indirectly modulating mPTP activity in vivo.

Jessica L. Willert, Douglas Shook, and Michael N. D'Ambra

3D Transesophageal Echocardiography: Systolic Anterior Motion with Hypertrophic Obstructive Cardiomyopathy (Echo Rounds)
Anesth Analg 2006 102: 1361-1362. [Full Text] [PDF]
 

Thomas F. Kindl, Ali M. Hassan, Robert L. Booth, Jr, Samuel J. Durham, and Thomas J. Papadimos

A Primary High-Grade Pleomorphic Pericardial Liposarcoma Presenting as Syncope and Angina (Echo Rounds)
Anesth Analg 2006 102: 1363-1364. [Full Text] [PDF] [Data Supplement]
   

PEDIATRIC ANESTHESIA:

Arja Hiller, Olli A. Meretoja, Reijo Korpela, Satu Piiparinen, and Tomi Taivainen

The Analgesic Efficacy of Acetaminophen, Ketoprofen, or Their Combination for Pediatric Surgical Patients Having Soft Tissue or Orthopedic Procedures
Anesth Analg 2006 102: 1365-1371. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We compared the analgesic efficacy of the combination of acetaminophen 60 mg/kg rectally plus 40 mg/kg orally per 24 h and ketoprofen (a traditional nonsteroidal antiinflammatory drug) 4 mg/kg per 24 h IV with the single drugs in pediatric surgical inpatients. The combination produced better pain treatment than either single drug when evaluated by 24-h morphine requirement or objective pain scores.

Devendra Gupta, Anil Agarwal, Sanjay Dhiraaj, Manish Tandon, Mukesh Kumar, Ravi Shankar Singh, Prabhat K. Singh, and Uttam Singh

An Evaluation of Efficacy of Balloon Inflation on Venous Cannulation Pain in Children: A Prospective, Randomized, Controlled Study
Anesth Analg 2006 102: 1372-1375. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Venipuncture is the most common painful event for hospitalized children. We observed that 20 s of forced exhalation during balloon inflation reduced both the incidence and severity of venipuncture pain. This reduction in venipuncture pain may be the combined effect of distraction and Valsalva.

Giovanni Cucchiaro, John T. Farrar, Jessica W. Guite, and Yuelin Li

What Postoperative Outcomes Matter to Pediatric Patients?
Anesth Analg 2006 102: 1376-1382. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We investigated, for the first time, which postoperative outcome is most important to pediatric patients using standard gamble techniques. The results suggest a difference between boys and girls, as well as a difference between children's and adults' preferences.

Ulla Lankinen, Risto Avela, and Pekka Tarkkila

The Prevention of Emergence Agitation With Tropisetron or Clonidine After Sevoflurane Anesthesia in Small Children Undergoing Adenoidectomy
Anesth Analg 2006 102: 1383-1386. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Preoperative tropisetron 0.1 mg/kg could effectively reduce the incidence of postoperative agitation after sevoflurane anesthesia for day-case adenoidectomy in small children. The effect of clonidine 1.5 {micro}g/kg did not differ from placebo.

AMBULATORY ANESTHESIA:

Paul F. White, Jun Tang, Mohamed A. Hamza, Babatunde Ogunnaike, Monica Lo, Ronald H. Wender, Robert Naruse, Alexander Sloninsky, Robert Kariger, Scott Cunneen, and Ted Khalili

The Use of Oral Granisetron Versus Intravenous Ondansetron for Antiemetic Prophylaxis in Patients Undergoing Laparoscopic Surgery: The Effect on Emetic Symptoms and Quality of Recovery
Anesth Analg 2006 102: 1387-1393. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Preoperative administration of granisetron, 1 mg per os, was not significantly different from ondansetron, 4 mg IV, in preventing emetic symptoms and improving recovery after laparoscopic surgery. However, ondansetron was more cost-effective than granisetron for routine prophylaxis as a result of its lower cost and comparable antiemetic efficacy and patient satisfaction.

Haleh Saadat, Jacqueline Drummond-Lewis, Inna Maranets, Deborah Kaplan, Anusha Saadat, Shu-Ming Wang, and Zeev N. Kain

Hypnosis Reduces Preoperative Anxiety in Adult Patients
Anesth Analg 2006 102: 1394-1396. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Hypnosis given before surgery will significantly reduce the anxiety and fear of adult patients.

ANESTHETIC PHARMACOLOGY:

Edmond I. Eger, II, Mark Liao, Michael J. Laster, Albert Won, John Popovich, Douglas E. Raines, Ken Solt, Robert C. Dutton, Franklin V. Cobos, II, and James M. Sonner

Contrasting Roles of the N-Methyl-d-Aspartate Receptor in the Production of Immobilization by Conventional and Aromatic Anesthetics
Anesth Analg 2006 102: 1397-1406. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Blockade of N-methyl-d-aspartate (NMDA) receptors by conventional inhaled anesthetics does not mediate the capacity of such anesthetics to produce immobility in the face of noxious stimulation. In contrast, for aromatic anesthetics, NMDA receptors mediate production of immobility in proportion to the capacity of such anesthetics to block the NMDA receptor.

Ken Solt, Edmond I. Eger, II, and Douglas E. Raines

Differential Modulation of Human N-Methyl-d-Aspartate Receptors by Structurally Diverse General Anesthetics
Anesth Analg 2006 102: 1407-1411. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We found that equianesthetic concentrations (1 minimum alveolar anesthetic concentration [MAC]) of 15 structurally diverse inhaled anesthetics produced a sixfold range of inhibition of the human N-methyl-d-aspartate (NMDA) receptor, a finding that may be useful in a determination of the contribution of NMDA receptor inhibition to the MAC of inhaled anesthetics.

Robert C. Dutton, Michael J. Laster, Yilei Xing, James M. Sonner, Douglas E. Raines, Ken Solt, and Edmond I. Eger, II

Do N-Methyl-d-Aspartate Receptors Mediate the Capacity of Inhaled Anesthetics to Suppress the Temporal Summation that Contributes to Minimum Alveolar Concentration?
Anesth Analg 2006 102: 1412-1418. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Blockade of N-methyl-d-aspartate receptors may explain the action of a few inhaled anesthetics, as defined by MAC, but may have minimal relevance for immobilization produced by most commonly used inhaled anesthetics.

Albert Won, Irene Oh, Mark Liao, James M. Sonner, R. Adron Harris, Michael J. Laster, Robert Brosnan, James R. Trudell, and Edmond I. Eger, II

The Minimum Alveolar Anesthetic Concentration of 2-, 3-, and 4-Alcohols and Ketones in Rats: Relevance to Anesthetic Mechanisms
Anesth Analg 2006 102: 1419-1426. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: The position of the C-OH group of an alcohol or the C=O group of a ketone (that is, the length of the acyl carbon chain extending from the C-OH or C=O group) is not a better predictor of anesthetic potency than the total length of the carbon chain or the affinity of the alcohol or ketone to a lipid (olive oil) phase.

Thomas Ledowski, Michael J. Paech, Bhavesh Patel, and Stephan A. Schug

Bronchial Mucus Transport Velocity in Patients Receiving Propofol and Remifentanil Versus Sevoflurane and Remifentanil Anesthesia
Anesth Analg 2006 102: 1427-1430. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Anesthetic drugs may depress bronchial clearance. Using an in vivo method, we demonstrated significantly more depression of bronchial clearance in patients anesthetized with sevoflurane compared with propofol. This might have an impact on the use of these drugs in patients at high risk for pulmonary complications.

Ira J. Rampil, Daryn H. Moller, and Achim H. Bell

Isoflurane Modulates Genomic Expression in Rat Amygdala
Anesth Analg 2006 102: 1431-1438. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Isoflurane causes widespread alterations in which genes are expressed in the central nervous system. This article uses GeneChip technology to describe these changes and the implications for understanding a more complete picture of clinical anesthetic effect.

Enno Freye, Leo Latasch, and Joseph Victor Levy

S(+)-Ketamine Attenuates Increase in Electroencephalograph Activity and Amplitude Height of Sensory-Evoked Potentials During Rapid Opioid Detoxification
Anesth Analg 2006 102: 1439-1444. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We monitored central nervous system variables during rapid opiate detoxification for excitatory effects and their attenuation by the additional administration of the nonspecific N-methyl-d-aspartic acid-antagonist S(+)-ketamine.

Kuo-Sheng Liu, Jann-Inn Tzeng, Yu-Wen Chen, Kuo-Lun Huang, Chun-Hsiung Kuei, and Jhi-Joung Wang

Novel Depots of Buprenorphine Prodrugs Have a Long-Acting Antinociceptive Effect
Anesth Analg 2006 102: 1445-1451. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: The antinociceptive effects of three novel depots of buprenorphine esters were evaluated. We found that the novel depots of buprenorphine esters buprenorphine propionate, enanthate, and decanoate had a long duration of antinociceptive effect after IM injections in rats. This result is valuable for the development of long-acting analgesia for pain management.

Mark Liao, Michael J. Laster, Edmond I. Eger, II, Michael Tang, and James M. Sonner

Naloxone Does Not Increase the Minimum Alveolar Anesthetic Concentration of Sevoflurane in Mice (Brief Report)
Anesth Analg 2006 102: 1452-1455. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: The opioid antagonist naloxone does not increase the minimum alveolar anesthetic concentration of sevoflurane in mice. Opioid receptors do not mediate the capacity of inhaled anesthetics to suppress movement in response to noxious stimulation.

TECHNOLOGY, COMPUTING, AND SIMULATION:

Richard Klaus Ellerkmann, Martin Soehle, Thorsten Michael Alves, Vidal-Markus Liermann, Ingobert Wenningmann, Heiko Roepcke, Sascha Kreuer, Andreas Hoeft, and Jörgen Bruhn

Spectral Entropy and Bispectral Index as Measures of the Electroencephalographic Effects of Propofol
Anesth Analg 2006 102: 1456-1462. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Bispectral index seems to show slight advantages discriminating between anesthetic propofol effect-site concentrations in comparison with spectral entropy.

Stephen W. Cone, Lynne Gehr, Russell Hummel, and Ronald C. Merrell

Remote Anesthetic Monitoring Using Satellite Telecommunications and the Internet
Anesth Analg 2006 102: 1463-1467. [Abstract] [Full Text] [PDF]
 

Implications: To provide even remote areas with skilled, experienced anesthesiologists, an application of telemedicine resources was developed to transmit monitored patient data during anesthesia for consultation from a distance to improve patient outcome during anesthesia.

Bryan Harris and Matthew B. Weinger

An Insidious Failure of an Oxygen Analyzer (Case Report)
Anesth Analg 2006 102: 1468-1472. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This case serves to illustrate the implications of monitor design and the potential impact of device failure in the absence of redundant monitoring of critical functionality.

PAIN MEDICINE:

Maneesh A. Deshpande, Ronald R. Holden, and Ian Gilron

The Impact of Therapy on Quality of Life and Mood in Neuropathic Pain: What Is the Effect of Pain Reduction?
Anesth Analg 2006 102: 1473-1479. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We evaluated the relationship between analgesia and mood/quality of life using outcomes from a recent clinical trial. Treatment-induced analgesia was shown to correlate with improvement in mood and quality of life. These results suggest that greater analgesic efficacy may lead to larger improvements in mood/quality of life.

A. Holzer, S. T. Jirecek, U. M. Illievich, J. Huber, and R. J. Wenzl

Laparoscopic Versus Open Myomectomy: A Double-Blind Study to Evaluate Postoperative Pain
Anesth Analg 2006 102: 1480-1484. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: In a double-blind setting, laparoscopic surgery reduced postoperative pain and analgesic demand after myomectomy during the first 3 days after surgery compared with open surgery.

Chiang Siau and Gary J. Bennett

Dysregulation of Cellular Calcium Homeostasis in Chemotherapy-Evoked Painful Peripheral Neuropathy
Anesth Analg 2006 102: 1485-1490. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Paclitaxel and vincristine often produce a pain syndrome that compromises their usefulness as anticancer drugs. The experiments described here suggest that the pain may be caused by an impairment of neuronal or glial ability to properly regulate intracellular Ca2+. A possible underlying pathology could be impaired mitochondrial Ca2+ regulation.

ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH:

Franklin Dexter, Jack C. Yue, and Angella J. Dow

Predicting Anesthesia Times for Diagnostic and Interventional Radiological Procedures
Anesth Analg 2006 102: 1491-1500. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Anesthesia times for individual diagnostic radiological procedures (e.g., magnetic resonance imaging) can be based on systematic rules from the facility's experts. In contrast, a series of interventional radiological procedures performed on the same day can be scheduled consecutively up to a calculated time (e.g., 4 pm), assuring that the anesthesia team usually finishes before the end of the workday (6 pm).

Ira Todd Cohen and Kantilal Patel

Peer Review Interrater Concordance of Scientific Abstracts: A Study of Anesthesiology Subspecialty and Component Societies (Brief Report)
Anesth Analg 2006 102: 1501-1503. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: We evaluated the selection process for subspecialty meeting abstracts. There was poor to moderate agreement among reviewers. We suggest that the review process can be improved by using clear evaluation criteria and scoring abstracts using interval scales.

CRITICAL CARE AND TRAUMA:

Lars Kjærsgaard Hansen, Erik Sloth, Jonas Nielsen, Jacob Koefoed-Nielsen, Per Lambert, Søren Lunde, and Anders Larsson

Selective Recruitment Maneuvers for Lobar Atelectasis: Effects on Lung Function and Central Hemodynamics: An Experimental Study in Pigs
Anesth Analg 2006 102: 1504-1510. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Lobar lung collapse is common after anesthesia and surgery. A standard, general (global) lung inflation maneuver is usually effective in improving lung function but may cause significant cardiovascular depression. This experimental study shows that selective inflation of a collapsed lobe via a balloon catheter is effective and has no significant circulatory side effects.

Cyril Charron, Christine Fessenmeyer, Claudine Cosson, Jean-Xavier Mazoit, Jean-Louis Hebert, Dan Benhamou, and Alain R. Edouard

The Influence of Tidal Volume on the Dynamic Variables of Fluid Responsiveness in Critically Ill Patients
Anesth Analg 2006 102: 1511-1517. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: The respiratory-related changes in stroke volume and arterial pulse pressure have the same predictive value for cardiac responsiveness to intravascular fluid administration in mechanically ventilated patients. The influence of tidal volume on pulse pressure variability may increase the sensitivity of the test.

Ruy J. Cruz, Jr, Margareth M. Yada-Langui, Luiz F. Poli de Figueiredo, Sueli Sinosaki, and Mauricio Rocha e Silva

The Synergistic Effects of Pentoxifylline on Systemic and Regional Perfusion After Hemorrhage and Hypertonic Resuscitation
Anesth Analg 2006 102: 1518-1524. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Pentoxifylline (PTX) has beneficial effects when administrated after hemorrhagic shock, restoring cardiac output and improving splanchnic perfusion. We tested the hypothesis that a combination of small volumes of hypertonic saline solution and PTX in the initial treatment of hemorrhagic shock provides synergistic hemodynamic benefits.

Michael Imhoff and Silvia Kuhls

Alarm Algorithms in Critical Care Monitoring (Review Article)
Anesth Analg 2006 102: 1525-1537. [Abstract] [Full Text] [PDF]
 

NEUROSURGICAL ANESTHESIA:

Ihab R. Kamel, Elizabeth T. Drum, Stephen A. Koch, Joseph A. Whitten, John P. Gaughan, Rodger E. Barnette, and Woodrow W. Wendling

The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Patient Positioning and Impending Upper Extremity Nerve Injury During Spine Surgery: A Retrospective Analysis
Anesth Analg 2006 102: 1538-1542. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: The lateral decubitus and prone "superman" positions were identified as high-risk positions for upper extremity somatosensory evoked potential changes in spine surgery. Somatosensory evoked potential changes were reversible by upper extremity position modification and were not associated with postoperative neurological deficits.

Armin Schubert, Anupa Deogaonkar, and John C. Drummond

Precordial Doppler Probe Placement for Optimal Detection of Venous Air Embolism During Craniotomy
Anesth Analg 2006 102: 1543-1547. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: For early detection of venous air embolism, accurate precordial Doppler probe verification with test injections is crucial. Left parasternal Doppler probe placement was at least as sensitive to test injections as right parasternal placement. Vigorous central test injection may result in false positive verification of laterally placed precordial Doppler probes.

Satoki Inoue, Daniel P. Davis, John C. Drummond, Daniel J. Cole, and Piyush M. Patel

The Combination of Isoflurane and Caspase 8 Inhibition Results in Sustained Neuroprotection in Rats Subject to Focal Cerebral Ischemia
Anesth Analg 2006 102: 1548-1555. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This study investigates the combined efficacy of an anti-excitotoxic and an anti-apoptotic drug in preventing ischemic neuronal death in a rat model. The role of the extrinsic caspase pathway in ischemia is explored using IETD, a specific caspase 8 inhibitor.

Thomas A. Moore, II, James M. Markert, and Robert C. Knowlton

Dexmedetomidine as Rescue Drug During Awake Craniotomy for Cortical Motor Mapping and Tumor Resection (Case Report)
Anesth Analg 2006 102: 1556-1558. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: In this report, we discuss the use of dexmedetomidine as a rescue drug during an awake craniotomy for cortical motor mapping and tumor resection. The procedure was begun using a combination of continuous infusions of propofol and remifentanil, our prior standard regimen for these procedures.

REGIONAL ANESTHESIA:

Vincent Minville, Olivier Fourcade, David Grousset, Clément Chassery, Luc Nguyen, Karim Asehnoune, Aline Colombani, Lounès Goulmamine, and Kamran Samii

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients
Anesth Analg 2006 102: 1559-1563. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This study showed that continuous spinal anesthesia provided fewer episodes of hypotension than single injection with 7.5 mg isobaric bupivacaine for surgical repair of hip fracture in elderly patients.

Harish Lecamwasam, James Mayfield, Laura Rosow, Yuchiao Chang, Christopher Carter, and Carl Rosow

Stimulation of the Posterior Cord Predicts Successful Infraclavicular Block
Anesth Analg 2006 102: 1564-1568. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: Peripheral nerve stimulation was used to guide placement of local anesthetic during infraclavicular block of the brachial plexus. The fastest onset of motor block and the greatest clinical success occurred when the posterior cord was located before injection.

Catherine Marcucci, Neil B. Sandson, Eric M. Thorn, and Denis L. Bourke

Unrecognized Drug-Drug Interactions: A Cause of Intraoperative Cardiac Arrest? (Case Report)
Anesth Analg 2006 102: 1569-1572. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This case report uses the emerging literature on the hepatic CYP450 enzyme system to provide an analysis of how multiple drug-drug interactions had a catastrophic effect in a patient receiving an otherwise uncomplicated anesthetic. We believe that evaluations in the field of anesthetic pharmacology will increasingly be based on this type of analysis.

GENERAL ARTICLES:             

Ahmet Eroglu, Figen Celep, and Nesrin Erciyes

A Comparison of Sister Chromatid Exchanges in Lymphocytes of Anesthesiologists to Nonanesthesiologists in the Same Hospital
Anesth Analg 2006 102: 1573-1577. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: This prospective study demonstrates that the incidence of sister chromatid exchanges in anesthesiologists exposed to waste anesthetic gases such as sevoflurane and nitrous oxide is more frequent in unexposed physicians in the same hospital. The increase of sister chromatid exchanges in anesthesiologists is reversible if they work free from exposure for 2 mo.

Florent Capron, Louis-Philippe Fortier, Sébastien Racine, and François Donati

Tactile Fade Detection with Hand or Wrist Stimulation Using Train-of-Four, Double-Burst Stimulation, 50-Hertz Tetanus, 100-Hertz Tetanus, and Acceleromyography
Anesth Analg 2006 102: 1578-1584. [Abstract] [Full Text] [PDF]
 

IMPLICATIONS: To detect residual neuromuscular blockade, tactile evaluation of 50-Hz tetanic, train-of-four (TOF), or double-burst fade lacks sensitivity. Fade after a 100-Hz tetanus is unreliable. An acceleromyographic TOF ratio of 1.0 is recommended to exclude residual paralysis. Stimulation at the hand and the wrist yields similar results for tactile evaluation.

紧急肺栓子切除术全麻诱导后的急性血流动力恶化

Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy.
Rosenberger P, Shernan SK, Shekar PS, Tuli JK, Weissmuller T, Aranki SF, Eltzschig HK.
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Anesth Analg.2006 102(5):1311-5

 

患者行肺栓子切除术,在全麻诱导时,常面临血流动力学恶化。因此,我们研究在全麻诱导期间血流动力学恶化的发生率和可能的危险因素。我们收集了52名在我们机构行紧急肺栓子切除术的患者。在全麻诱导后血流动力学崩溃定义为使用血管升压药及inotrope后依然难以控制的低血压,或需经紧急心肺转流(CPB)的心肺复苏及液体管理。人口统计学变量、共存疾病、栓子的特殊位置、术前心肌收缩力的支持治疗,以及全麻诱导时麻醉药物的使用,作为可能的危险因素被评估。全麻诱导后,19%的病人发生血流动力学崩溃(n=10)。然而,血流动力学不稳定的发生不能通过任何已评估的危险因素来预测。另外,住院期间,血流动力学稳定与不稳定患者的死亡率发生没有不同(分别为10%4/42 10%1/10)。结论为,紧急肺栓子切除术全麻诱导后,血流动力学恶化经常发生。 以我们这项研究经验为基础结合血流动力学恶化的不可预测性,我们建议行肺栓子切除术的患者在全麻诱导前应该准备并且消毒铺巾,心脏外科医生根据需要应立即可到,进行心肺转流术。

(孙敏莉译 薛张纲校)

Patients undergoing pulmonary embolectomy often experience hemodynamic deterioration during induction of general anesthesia (GA). Therefore, we studied the incidence and possible risk factors for hemodynamic deterioration during GA induction. Fifty-two consecutive patients undergoing emergent pulmonary embolectomy at our institution were included. Hemodynamic collapse after GA induction was defined as hypotension refractory to vasopressor, inotrope, or fluid administration, requiring cardiopulmonary resuscitation followed by urgent institution of cardiopulmonary bypass (CPB). Demographic variables, comorbidities, specific location of thromboemboli, preoperative inotropic support, and anesthetic drugs used for GA induction were evaluated as possible risk factors. After GA induction, hemodynamic collapse occurred in 19% of patients (n = 10). However, the occurrence of hemodynamic instability was not predicted by any of the evaluated risk factors. In addition, the incidence of in-hospital mortality did not differ between hemodynamically stable or unstable patients (10%; 4 of 42 versus 10%; 1 of 10 patients, respectively). In conclusion, hemodynamic deterioration after GA induction develops frequently during emergent pulmonary embolectomy. On the basis of our experience from this study and the unpredictable nature of hemodynamic deterioration, we suggest that patients undergoing pulmonary embolectomy should be prepared and draped before GA induction, and a cardiac surgical team should immediately be available for emergent institution of cardiopulmonary bypass.

 

颈内静脉中心静脉导管中心界标的准确性

The Accuracy of the Central Landmark Used for Central Venous Catheterization of the Internal Jugular Vein

Peter L. Bailey, Emmett E. Whitaker, Linda S. Palmer, and Laurent G. Glance

Department of Anesthesiology, University of Rochester, Rochester, New York

Anesth Analg 2006 102: 1327-1332.

 

我们使用中心界标模拟进针通路,进行颈内静脉中心静脉导管穿刺置管。107位受试者置于头低脚高位,头低30-35度,我们对他们进行超声影像检查,以定量测量界标的准确性(精密度和偏倚)。与此同时,我们测定发生动脉穿刺的频率。使用中心界标模拟进针通路,与颈内静脉导管中心80%的位置不符的受试者有34%(95%的可信限[CI]25%44%),横跨过颈动脉的受试者有26%(95CI18%35%)。发生上述两种情况的受试者占20%(95CI13%29%)。界标中央偏倚的平均值为3.7mm95CI2.74.8);相对来说,使用中心界标行右颈内静脉置管更容易置于中心位置(104为受试者中有77位)(P<0.001)。肥胖患者使用界标更容易错过颈内静脉(比值比,3.11P<0.016),更容易发生动脉穿刺(比值比,3.03P<0.024)。由于中心界标的不准确性和偏倚,使用其进行穿刺指导,在不损伤颈动脉的情况下一针穿刺成功的可能性不高。当使用中心界标辅助进行中心静脉置管时需考虑到测量偏倚。

(金琳 译 薛张纲校)

We simulated needle paths based on the central landmark used for central venous catheterization of the internal jugular vein. We obtained ultrasound images to quantify the landmark's accuracy (precision and bias) in 107 subjects placed in Trendelenburg position with their heads turned 30-35 degrees. We also determined the frequency of simulated carotid artery puncture. The simulated needle path missed the middle 80% of the lumen of the internal jugular vein in 34% of subjects (95% confidence interval [CI], 25% to 44%) and traversed the carotid artery in 26% of subjects (95% CI, 18% to 35%). Both events occurred in 20% of subjects (95% CI, 13%29%). The landmark had a medial bias of 3.7 mm (95% CI, 2.7 to 4.8); it was more often (77 of 104 subjects) medial to the center of the right internal jugular vein (P < 0.001). The landmark was more likely to miss the internal jugular vein (odds ratio, 3.11; P < 0.016) and intersect the carotid (odds ratio, 3.03; P < 0.024) in obese patients. The central landmark should not be expected to yield frequent success on first needle pass without risk of carotid puncture because of its imprecision and bias. The measured bias should be considered when the central landmark is used for central venous catheterization.

 

 

七氟醚麻醉预处理对小鼠脊髓缺血再灌注损伤无保护作用。

Anesthetic preconditioning with sevoflurane does not protect the spinal cord after an ischemic-reperfusion injury in the rat.

Zvara DA. Bryant AJ. Deal DD. DeMarco MP. Campos KM. Mansfield CM. Tytell M.

Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27127-1009, USA.

Anesthesia & Analgesia. 102(5):1341-7, 2006 May.

 

麻醉预处理(APC)是一种保护性机制,因此给予吸入麻醉药可以对随后产生的缺血性损伤有抵抗作用。我们设想用七氟醚进行脊髓预处理能降低缺血再灌注后神经的损伤。小鼠随机分成15组。缺血预处理组(IPC组,n14)给予3minIPC30min再灌注,12min缺血。慢性麻醉预处理组(cSEVO组,n14)在缺血前2天给予1h3.5%七氟醚。急性APC组(aSEVO组,n14)在缺血前给予1h3.5%七氟醚及随后的1h洗出。IPC组能降低缺血再灌注损伤,而aSEVOcSEVO组没有显示出比控制组更好的结果。脊髓组织学显示除了IPC组和假装手术的小鼠外,在所有组都显示了严重的神经损害。七氟醚APC不能降低小鼠脊髓缺血模型的神经损害。传统的缺血预处理对神经具有很好的保护作用。

(吴德华译 薛张纲校)

Anesthetic preconditioning (APC) is a protective mechanism, whereby exposure to a volatile anesthetic renders a tissue resistant to a subsequent ischemic insult. We hypothesized that APC of the rat spinal cord with sevoflurane would reduce neurologic deficit after an ischemic-reperfusion injury. Rats were randomly assigned to 1 of 5 groups. The ischemic preconditioning (IPC) group (n = 14) had 3 min of IPC, 30 min of reperfusion, and 12 min of ischemia. The chronic APC (cSEVO) group (n = 14) had 1 h of APC with 3.5% sevoflurane on each of 2 days before ischemia. The acute APC (aSEVO) group (n = 14) had 1 h of APC with 3.5% sevoflurane followed by a 1-h washout period before the induction of ischemia. The controls (n = 14) underwent no preconditioning before ischemia. IPC attenuated the ischemia-reperfusion injury, whereas aSEVO and cSEVO groups were no better than control animals. Histologic evaluation of the spinal cord showed severe neurologic damage in all groups except for the IPC group and sham-operated rats. APC with sevoflurane did not reduce neurologic injury in a rat model of spinal cord ischemia. Traditional ischemic preconditioning had a strong protective benefit on neurologic outcome.

 

 

小儿外科软组织或畸形矫正手术使用扑热息痛、优布芬或二者联合时的镇痛效能

The Analgesic Efficacy of Acetaminophen, Ketoprofen, or Their Combination for Pediatric Surgical Patients Having Soft Tissue or Orthopedic Procedures

Arja Hiller, Olli A. Meretoja, Reijo Korpela, Satu Piiparinen, and Tomi Taivainen

Department of Anesthesia, Hospital for Children and Adolescents, University of Helsinki, Finland

Anesth Analg 2006 102: 1365-1371.

 

几项成人研究显示扑热息痛和一种非甾体类抗炎药联合用于术后镇痛的效果要好于单独使用其中的任何一种药。然而,目前虽有扑热息痛的推荐剂量在使用,但是还没有关于小儿的这方面研究。在这项双盲、安慰剂对照试验中,我们随机抽取了120个一至九岁的行软组织或畸形矫正手术儿童,将他们分成三组,一组为经直肠给扑热息痛60 mg/kg或口服给药40 mg/kg,一组为静脉给优布芬2 mg/kg(一天两次),另一组为联合给药。在麻醉诱导时给予药物的首剂量,第二个剂量在其后的八小时给予。术中麻醉使用七氟烷和持续输注的雷米芬太尼。术后疼痛是通过行为客观疼痛评分(0-9分)来评估24小时。病人复苏时使用吗啡0.05 mg/kg静脉输注。主要的变量是吗啡消耗量。研究中我们使用了统计分析、变量分析、chi2实验和卡普兰-迈耶曲线。

(韩晓丹译 薛张纲校)

The combined use of acetaminophen and a nonsteroidal antiinflammatory drug has been shown to provide better postoperative analgesia than either drug alone in several adult studies. However, there are no pediatric studies analyzing similar effects when the currently recommended doses of acetaminophen are used. In a double-blind, placebo-controlled design we randomized 120 children, aged 1-9 yr, undergoing orthopedic or soft tissue surgery, into 3 groups to receive either acetaminophen 60 mg/kg rectally and 40 mg/kg orally, ketoprofen 2 mg/kg IV twice, or the combination of the active drugs. The first drug doses were given at anesthetic induction and the second doses 8 h thereafter. During anesthesia all children received sevoflurane and a continuous infusion of remifentanil. Postoperative pain was evaluated by the behavioral objective pain scale (0-9) for 24 h. The rescue medication was morphine 0.05 mg/kg IV. The primary outcome variable was morphine consumption. For statistical analysis, analysis of variance, chi2 test and Kaplan-Meier survival analysis were used. Morphine requirement was less in th

 

七氟烷麻醉的小儿增殖腺切除术后托烷司琼或可乐定对激惹发生的预防

The Prevention of Emergence Agitation With Tropisetron or Clonidine After Sevoflurane Anesthesia in Small Children Undergoing Adenoidectomy

Ulla Lankinen, MD, Risto Avela, MD, and Pekka Tarkkila, MD, PhD

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

Anesth Analg 2006 102: 1383-1386.

 

 

 

在七氟烷麻醉后儿童的术后激惹是一个常见的问题。在本项研究中,我们评估托烷司琼或可乐定是否能降低小儿增殖腺切除术后的激惹发生率。我们将751-7岁的未术前用药的小儿随机分组,在麻醉诱导后分别接受安慰剂,托烷司琼(0.1mg/kg)或可乐定(1.5µg/kg)。麻醉诱导和维持使用七氟烷。患者同时接受阿芬太尼(20µg/kg)和diclofenac1mg/kg)。术后镇痛使用IV羟考酮(0.05mg/kg)。记录完成标准的时间。用改良的疼痛/不适量表来评估术后行为。术后激惹的发生率托烷司琼组显著减少(32%8/25病人)与对照组相比(62%16/26病人,P<0.05)。可乐定不能预防激惹(发生率54%13/24)。研究中无副反应报道。出现时间组间相似(平均8099分钟)。总结,托烷司琼0.1mg/kg显著减少七氟烷麻醉后激惹的发生率,可乐定1.5 µg/kg对术后激惹预防作用与安慰剂无差异。

(周荻译 薛张纲校)

Postoperative agitation is a common problem after sevoflurane anesthesia in children. In the present study, we evaluated if tropisetron or clonidine could reduce the incidence of postoperative agitation after day case adenoidectomy in small children. We included 75 unpremedicated children aged 17 yr who were randomly assigned to receive either placebo, tropisetron (0.1 mg/kg) or clonidine (1.5 µg/kg) after anesthesia induction. Anesthesia was induced and maintained with sevoflurane. Patients also received alfentanil (20 µg/kg) and diclofenac (1 mg/kg). Postoperative pain was treated with IV oxycodone (0.05 mg/kg). Time to achieve discharge criteria was recorded. Modified pain/discomfort scale was used assess the postoperative behavior. The incidence of postoperative agitation was significantly less (32%, 8/25 patients) in the tropisetron group compared with placebo (62%, 16/26 patients), P < 0.05). Clonidine could not prevent agitation (incidence 54%, 13/24). No adverse effects were noted during the study. Discharge times were similar between the groups (between 80 and 99 min on average). In conclusion, tropisetron 0.1 mg/kg significantly reduced the incidence of postoperative agitation after sevoflurane anesthesia. Clonidine 1.5 µg/kg did not differ from placebo with respect to postoperative agitation.

 

 

常规麻醉药和芳香族麻醉药通过N-甲基-D-天门冬氨酸受体(NMDA)介导的肌松作用的研究
Contrasting roles of the N-methyl-d-aspartate receptor in the production of immobilization by conventional and aromatic anesthetics.

Eger EI 2nd, Liao M, Laster MJ, Won A, Popovich J, Raines DE, Solt K, Dutton RC, Cobos FV 2nd, Sonner JM.
Department of Anesthesia and Perioperative Care, University of California, San Francisco, California 94143-0464, USA.

Anesth Analg 2006102(5):1397-406

我们假设吸入麻醉药的肌松作用部分或是完全由NMDA受体介导的,也有可能激动某些有害的反应。在离体试验中,这直接和吸入麻醉药阻断         NMDA受体有关。为了验证这个假说,我们检测静脉注射NMDA阻滞剂MK-801CPP来降低8种常规吸入麻醉药(环丙烷,地氟醚,安氟醚,氟烷,异氟醚,一氧化二氮,七氟醚和氙)和8种芳香族化合物(苯,氟苯,邻二氟苯, 对二氟苯, 1,2,4-三氟苯, 1,3,5-三氟苯, 五氟苯和六氟苯)MAC值,依托咪酯作为对照组。我们假设注射的MK-801CPP通过阻断NMDA受体会成反比的降低这些吸入麻醉药的MAC值。这个观点在芳香族化合物被验证是正确的,但在常规的吸入麻醉药中没有得到验证。注入最大剂量的MK-80132ug/kg·min)降低常规吸入麻醉药MAC值的59.4 +/- 3.4%,注入8ug/kg·min降低MAC值的45.5 +/- 4.2%,这和注入EC50的依托咪酯降低MAC51.4 +/- 19.0%没有明显的差异。依托咪酯通过加强GABA的作用起到麻醉作用。我们得出结论,某些芳香族化合物通过阻断NMDA受体上的谷氨酸产生肌松作用,同时激动某些有害的反应,而常规的吸入麻醉药并没有这种作用。

(陆文清译 薛张纲校)

We hypothesized that N-methyl-d-aspartate (NMDA) receptors mediate some or all of the capacity of inhaled anesthetics to prevent movement in the face of noxious stimulation, and that this capacity to prevent movement correlates directly with the invitro capacity of such anesthetics to block the NMDA receptor. To test this hypothesis, we measured the effect of IV infusion of the NMDA blockers dizocilpine (MK-801) and (R)-4-(3-phosphonopropyl) piperazine-2-carboxylic acid (CPP) to decrease the MAC (the minimum alveolar concentration of anesthetic that prevents movement in 50% of subjects given a noxious stimulation) of 8 conventional anesthetics (cyclopropane, desflurane, enflurane, halothane, isoflurane, nitrous oxide, sevoflurane, and xenon) and 8 aromatic compounds (benzene, fluorobenzene, o-difluorobenzene, p-difluorobenzene, 1,2,4-trifluorobenzene, 1,3,5-trifluorobenzene, pentafluorobenzene, and hexafluorobenzene) and, for comparison, etomidate.We postulated that MK-801 or CPP infusions would decrease MAC in inverse proportion to the in vitro capacity of these anesthetics to block the NMDA receptor. This notion proved correct for the aromatic inhaled anesthetics, but not for the conventional anesthetics. At the greatest infusion of MK-801 (32 microg x kg(-1) x min(-1)) the MACs of conventional anesthetics decreased by 59.4 +/- 3.4% (mean +/- sd) and at 8 microg x kg(-1) x min(-1) by 45.5 +/- 4.2%, a decrease not significantly different from a 51.4 +/- 19.0% decrease produced in the EC50 for etomidate, an anesthetic that acts solely by enhancing gamma-amino butyric acid (GABA) receptors. We conclude that some aromatic anesthetics may produce immobility in the face of noxious stimulation by blocking the action of glutamate on NMDA receptors but that conventional inhaled anesthetics do not.

 

 

大鼠中2-, 3-, 4-醇和酮的最低肺泡麻醉剂浓度:与麻醉机制的相关性

The minimum alveolar anesthetic concentration of 2-, 3-, and 4-alcohols and ketones in rats: relevance to anesthetic mechanisms.
Won A, Oh I, Liao M, Sonner JM, Harris RA, Laster MJ, Brosnan R, Trudell JR, Eger EI 2nd.

Department of Anesthesia and Perioperative Care, University of California, San Francisco, California 94143-0464, USA.

Anesth Analg. 2006102(5):1419-26

Meyer-Overton假说提出麻醉剂效能与亲脂性呈负相关;如常用吸入麻醉药的MAC乘以油/气分配系数等于一个常数,约1.82 +/- 0.56 atm (mean +/- sd)MAC是消除50%的个体对伤害性刺激体动所需的麻醉剂最低肺泡浓度。与常用吸入麻醉药相比,从甲醇到辛醇的常规醇类的MAC乘以油/气分配系数所得的常数为其十分之一。醇(C-OH)基使醇对水有很大的亲和力,并且C-OH可将醇限制在麻醉剂起作用的疏水-亲水界面。我们假设C-OH基的位置决定效能,可能通过最大范围的调节使得分子酰基部分能伸入疏水层。采用相同推理,我们增加了在C=O基和末端甲基间具有相似碳原子数的酮的研究。醇和酮的研究结果都显示了预计的相关性,但此相关性与相同碳链长度而氧原子位置不同时几乎相等。油/气分配系数对效能的预计与链长或氧原子位置相同或更佳。水/气分配系数代表的亲水性似乎也影响效能。

(徐丽颖译 薛张纲校)

The Meyer-Overton hypothesis predicts that anesthetic potency correlates inversely with lipophilicity; e.g., MAC times the olive oil/gas partition coefficient equals a constant of approximately 1.82 +/- 0.56 atm (mean +/- sd) for conventional inhaled anesthetics. MAC is the minimum alveolar concentration of anesthetic required to eliminate movement in response to a noxious stimulus in 50% of subjects. In contrast to conventional inhaled anesthetics, MAC times the olive oil/gas partition coefficient for normal alcohols from methanol through octanol equals a constant one tenth as large as that for conventional inhaled anesthetics. The alcohol (C-OH) group causes a great affinity of alcohols to water, and the C-OH may tether the alcohol at the hydrophobic-hydrophilic interface where anesthetics are thought to act. We hypothesized that the position of the C-OH group determined potency, perhaps by governing the maximum extent to which the acyl portion of the molecule might extend into a hydrophobic phase. Using the same reasoning, we added studies of ketones with similar numbers of carbon atoms between the C=O group and the terminal methyl group. The results for both alcohols and ketones showed the predicted correlation, but the correlation was no better than that with carbon chain length regardless of the placement of the oxygen. The oil/gas partition coefficient predicted potency as well as, or better than, either chain length or oxygen placement. Hydrophilicity, as indicated by the saline/gas partition coefficient, also seemed to influence potency.

 

快速阿片类药物解毒中应用S()氯胺酮可减弱脑电描记仪上脑电活动的增加及感觉诱发电位的幅度

S(+)-ketamine attenuates increase in electroencephalograph activity and amplitude height of sensory-evoked potentials during rapid opioid detoxification.
Freye E, Latasch L, Levy JV.
Clinics of Vascular Surgery and Renal Transplantation, Heinrich-Heine-University Dusseldorf, Germany.

Anesth Analg 2006 102: 1439-1444.


麻醉辅助阿片类药物解毒为常规无法解毒的患者提供了机会。很少有人知道发生在中枢神经系统中的兴奋性效应。因为快速解毒是通过N-甲基-D-()冬氨酸(NMDA)受体激活完成的,我通过实验看非特异性NMDA拮抗剂S(+)氯胺酮是否能减少中枢神经系统的高活性。31个曾滥用阿片类药物的患者在用异丙酚/可乐定麻醉机械通气的过程中很快脱离纳曲酮。脑电图能谱和正中神经诱发体感电位SSEP由以下决定:在解毒前,异丙酚/可乐定麻醉,纳曲酮注射后30分钟,S(+)氯胺酮注射后560分钟。和麻醉相比,纳曲酮的脑电图低delta减少了270%,快delta增加了110%,theta-(3-7 Hz) alpha-(7-13 Hz)改变不大。同时,SSEPlate N(100)的平均幅度从3.3 muV 增加到10.5 muV。可由S(+)氯胺酮减弱。心血管系统的改变不是快速戒断症状和决定快速阿片类药物解毒终点的可靠指数。所以,脑电图能谱和SSEP是更有效的指标。S(+)氯胺酮是麻醉中的有效辅助药,因为它能减弱在快速阿片类药物解毒中的中枢神经系统高活性。

(钟 静译 薛张纲校)

Anesthesia-assisted opioid detoxification offers an opportunity for patients who have undergone unsuccessful conventional detoxifications. Little is known of excitatory effects taking place in the central nervous system during this procedure. Because acute withdrawal is accompanied by N-methyl-d-aspartic acid (NMDA)-receptor activation we tested whether the administration of the nonspecific N-methyl-d-aspartic acid antagonist S(+)-ketamine results in a reduction of hyperactivity in the central nervous system. Thirty-one patients with a long history of opioid abuse were acutely withdrawn with naltrexone during propofol/clonidine anesthesia and mechanical ventilation. Electroencephalogram (EEG) power spectra as well as median nerve-evoked somatosensory potentials (SSEP) were determined at the following times: evening before detoxification (control), steady-state propofol/clonidine-anesthesia, 30 min after naltrexone administration, and 5 min and 60 min after additional S(+)-ketamine (1.5 mg/kg). Compared to steady-state anesthesia, naltrexone induced a decrease by 270% in the low delta (0.5-3 Hz) and an increase by 110% in the fast beta (13-30 Hz) domain of the EEG with only minor changes in the theta-(3-7 Hz) and alpha-(7-13 Hz) band. Simultaneously, mean amplitude of the late N(100) peak of the SSEP increased from 3.3 muV to 10.5 muV. The changes could be attenuated by the additional administration of S(+)-ketamine, 5 min and 60 min after injection. Cardiovascular changes were not a reliable index for monitoring acute withdrawal symptoms and determining termination of rapid opioid detoxification. In this regard, EEG power spectra and SSEP were more consistent and clinically useful variables. S(+)-ketamine is a valuable adjunct in the anesthetic regimen, since it attenuates hyperactivity of the central nervous system during rapid opioid detoxification.

 

以卫星通讯和国际互联网来实现远程麻醉监控

Remote anesthetic monitoring using satellite telecommunications and the Internet.

Cone SW, Gehr L, Hummel R, Merrell RC

Medical Informatics and Technology Applications Consortium, Virginia Commonwealth University, Richmond, Virginia 23298, USA.

Anesth Analg. 2006102(5):1463-7.

 

远程实施麻醉需要相当大量的生理和影音数据在一数据平台上进行合理地整合。一个厄瓜多尔与美国之间的低速宽带就可以支持一次有效的远程麻醉包括手术计划的制定、气道的评估、术中和苏醒的判断。用一个速度为64-Kbps的卫星电话可实现厄瓜多尔的MacasSucua Ecuador与美国的Richmond Virginia之间进行包括术前病人评估、气管插管的影象资料、心电图波形、脉搏氧饱和度测定、动脉压力监测、二氧化碳监测和呼吸音听诊等资料的数据交换。

(孙卓真译 薛张纲校)

Remote collaboration for anesthesia requires considerable sharing of physiologic data, audio, and images on a consistent data platform. A low-bandwidth connection between Ecuador and the United States supported effective joint management of operative plan, airway, intraoperative decisions, and recovery. Transmission with a 64-Kbps InMarSat satellite telephone (Thrane & Thrane, Denmark) connection from hospitals in Macas and Sucua, Ecuador, to Richmond, Virginia, included preoperative patient evaluations, video of endotracheal intubations, electrocardiogram waveforms, pulse oximetry measurements, arterial blood pressure readings, capnography readings, and auscultation of breath sounds

 

 

细胞钙稳态对化疗所致的疼痛性周围神经病的异常调节

Dysregulation of Cellular Calcium Homeostasis in Chemotherapy-Evoked Painful Peripheral Neuropathy

Chiang Siau and Gary J. Bennett

Department of Anesthesia, McGill University, Montreal, Quebec, Canada.

Anesth Analg 2006 102: 1485-1490.


化疗药物紫衫醇和长春新碱常会引起长时间的疼痛性周围神经病。我们通过使用药物降低细胞内外钙离子来研究钙调节受损是否会导致化疗相关的神经疼痛综合征。为同抗HIV核苷23-双脱氧胞嘧啶(ddC)比较,我们将小鼠的神经损伤做成疼痛性周围神经病。正常组(无神经病),用紫衫醇治疗组,用长春新碱治疗组分别进行以下鞘内注射:TMB-8 (46 nmol), Quin-2 (1.8 nmol), EGTA (0.1 micromol), EGTA-am (0.1 micromol)。注射TMB-8Quin-2后小鼠有慢性萎缩性损伤(CCI)。注射ddC后损伤出现在注射TMB-8之后。在每次注射后评估机械性疼痛和机械性感觉过敏。在CCI小鼠中可以看到药物的温度敏感作用。四种减少钙离子的药物能显著抑制接受紫衫醇、长春新碱和ddC治疗的小鼠的机械性疼痛和机械性感觉过敏,但对CCI和正常组无作用。我们因此得出结论:用紫衫醇、长春新碱和ddC治疗造成的疼痛归咎于细胞钙稳态的异常,但细胞钙稳态的异常与创伤后疼痛性周围神经病无关。

(王慧琳译 薛张纲校)

Paclitaxel and vincristine are chemotherapeutic drugs that often evoke a long-lasting painful peripheral neuropathy. Using drugs that reduce intracellular or extracellular calcium ions (Ca2+), we investigated the hypothesis that impaired Ca2+ regulation contributes to the chemotherapy-evoked neuropathic pain syndrome. For comparison, we also tested rats with painful peripheral neuropathy caused by nerve trauma and to the anti-human immunodeficiency virus nucleoside analog 2',3'-dideoxycytidine (ddC). Normal naive (without neuropathy), paclitaxel-treated, and vincristine-treated rats received the following intrathecal injections: TMB-8 (46 nmol), Quin-2 (1.8 nmol), EGTA (0.1 micromol), EGTA-am (0.1 micromol), and their vehicle controls. Chronic constriction injury (CCI) rats were examined after TMB-8 and Quin-2 injections, and ddC-treated rats were examined after receiving TMB-8. Mechano-allodynia and mechano-hyperalgesia were evaluated after each injection. Drug effects on heat hyperalgesia were also tested in CCI rats. All four Ca2+-reducing drugs significantly inhibited mechano-allodynia and mechano-hyperalgesia in the rats treated with paclitaxel, vincristine, or ddC, but no effects were seen in the CCI or naive rats. We conclude that a similar abnormality of cellular Ca2+ homeostasis contributes to the pain caused by paclitaxel, vincristine, and ddC, but not posttraumatic painful peripheral neuropathy.

 

 

己酮可可碱全身或局部灌注对失血后高渗的复苏的协同作用

The Synergistic Effects of Pentoxifylline on Systemic and Regional Perfusion After Hemorrhage and Hypertonic Resuscitation

Ruy J. Cruz, Jr, MD, PhD*, Margareth M. Yada-Langui, PhD, Luiz F. Poli de Figueiredo, MD, PhD*, Sueli Sinosaki, MSc, and Mauricio Rocha e Silva, MD, PhD*

Research Division, Heart Institute, *InCor and LIM-11, University of São Paulo School of Medicine, Brazil

Anesth Analg 2000 102: 1518-1524.

 

小容量的高渗盐溶液([HS] 7.5% NaCl)对失血动物的全身情况和微循环都有好处。在失血性休克后给予己酮可可碱(PTX)可获有益的效果。因此我们假设在对失血性休克开始治疗时即联合应用HSPTX可对改善血流动力学获得协同作用,并对此做了检验。二十四只狗经放血至目标动脉血压40mmHg后随机分为三组:乳酸钠林格氏液组(33 mL/kgn = 6)、HS组(7.5% NaCl 4 mL/kgn = 9)和HS+PTX组(7.5% NaCl 4 mL/kg + PTX 15 mg/kgn = 9)。通过Swan-Ganz导管和动脉置管监测全身血流动力学。同时计算胃粘膜-动脉Pco2梯度(Dg-aPco2;气体张力测量仪)、门静脉血流(超声流量探头)和全身及局部O2含量改变。HS可导致动脉平均压、心输出量和门静脉血流量一定程度的升高。在HS+PTX组,我们观察到比HS单独使用时显著但短暂的全身氧输送的增加(180 ± 17 141 ± 13 mL/min)。与单独输注HSDg-aPco2减少(48.2 ± 6.4 39.4 ± 5.5 mm Hg)相比,在高渗的复苏过程中注PTX可促使Dg-aPco2显著减少(41.8 ± 4.8 25.7 ± 3.9 mm Hg)。我们认为,PTX在高渗的复苏时作为辅助药可以改善心血管状态和胃粘膜氧供。

(金 路 译 薛张纲校)

Small volumes of hypertonic saline solution ([HS] 7.5% NaCl) produce systemic and microcirculatory benefits in hemorrhaged animals. Pentoxifylline (PTX) has beneficial effects when administrated after hemorrhagic shock. We tested the hypothesis that the combination of HS and PTX in the initial treatment of hemorrhagic shock provides synergistic hemodynamic benefits. Twenty-four dogs were bled to a target arterial blood pressure of 40 mm Hg and randomized into 3 groups: lactated Ringers solution (33 mL/kg; n = 6); HS (7.5% NaCl 4 mL/kg; n = 9); and HS+PTX (7.5% NaCl 4 mL/kg + PTX 15 mg/kg; n = 9). Systemic hemodynamics were measured by Swan-Ganz and arterial catheters. Gastric mucosal-arterial Pco2 gradient (Dg-aPco2; gas tonometry), portal vein blood flow (ultrasonic flowprobe), and systemic and regional O2-derived variables were also evaluated. HS induced a partial increase in mean arterial blood pressure, cardiac output, and portal vein blood flow. In the HS+PTX group, we observed a significant, but transitory, increase in systemic oxygen delivery (180 ± 17 versus 141 ± 13 mL/min) in comparison to HS alone. PTX infusion during hypertonic resuscitation promoted a significant reduction in Dg-aPco2 (41.8 ± 4.8 to 25.7 ± 3.9 mm Hg) when compared with isolated HS infusion (48.2 ± 6.4 to 39.4 ± 5.5 mm Hg). We conclude that PTX as an adjunct drug during hypertonic resuscitation improves cardiovascular performance and gastric mucosal oxygenation.

 

 

异氟醚和半胱天冬酶8抑制剂合用对局部脑缺血的大鼠有持久的神经保护作用

The Combination of Isoflurane and Caspase 8 Inhibition Results in Sustained Neuroprotection in Rats Subject to Focal Cerebral Ischemia

Satoki Inoue, Daniel P. Davis, John C. Drummond, Daniel J. Cole, and Piyush M. Patel

Department of Anesthesiology, VA Medical Center and UC San Diego, San Diego, California 92103-8676, USA.

Anesth Analg 2006 102: 1548-1555.

 

尽管在缺血后短期恢复期间,异氟醚可减少缺血性神经损伤,但我们实验室的资料证实,这种神经保护作用并非是持久的,而神经细胞的调亡,部分是由半胱天冬酶介导,从而使梗死灶逐渐扩大。我们假设如果应用z-IETD-fmk,一种特殊的半胱天冬酶8抑制剂,异氟醚的神经保护作用将被延长。大鼠用异氟醚麻醉并随机分为清醒染色剂组、异氟醚染色剂组、清醒IETD组和异氟醚-IETD组(每组25只)。我们阻断大脑中动脉(MCAO)使大鼠处于60分钟的局部脑缺血。每天在缺血前,通过植入的导管脑室内注射z-IETD-fmk或染色剂,直到阻断大脑中动脉后14天。缺血后14天评价神经系统功能,同时测定脑梗面积及皮质脑梗灶周围完整神经元的数量。异氟醚-IETD组的总梗死面积小于其他三组。清醒IETD组的脑梗面积比清醒染色剂组小。和其他各组相比,清醒染色剂组的皮质脑梗灶周围完整神经元数量显著减少。MCAO14异氟醚-IETD组的神经保护作用由于各染色剂组。结果表明:异氟醚和半胱天冬酶8抑制剂合用,其神经保护作用即使在14天恢复期后,依然是显著的。两者合用比单用任何一种效果都好。这些结果与之前观点一致,即在脑梗恢复期,由于细胞调亡使梗死面积扩大,而它的抑制剂具有持久的神经保护作用。

(王丽珺译 薛张纲校)

Although isoflurane can reduce ischemic neuronal injury after short postischemic recovery intervals, data from our laboratory have demonstrated that this neuroprotection is not sustained and that delayed apoptotic neuronal death, mediated in part by activation of caspases, contributes to the gradual increase in the size of the infarction. We tested the hypothesis that the neuroprotective efficacy of isoflurane can be prolonged with the administration of z-IETD-fmk, a specific inhibitor of caspase 8. Fasted Wister rats were anesthetized with isoflurane and randomly allocated to awake-vehicle, isoflurane-vehicle, awake-IETD, or isoflurane-IETD groups (n = 25 per group). Animals were subjected to 60 min focal ischemia by filament occlusion of the middle cerebral artery (MCAO). Daily intracerebroventricular injections of z-IETD-fmk or vehicle were administered via an implanted cannula starting before ischemia and continuing until 14 days post-MCAO. Neurological assessment was performed 14 days after ischemia after which the volume of cerebral infarction and number of intact neurons in the peri-infarct cortex were determined. Total infarction volume was less in the isoflurane-IETD group than in awake-vehicle, isoflurane-vehicle, and awake-IETD groups. Infarction volume was also less in the awake-IETD group versus the awake-vehicle group. The number of intact neurons within the peri-infarct cortex was significantly less in the awake-vehicle group in comparison with the other three experimental groups. The isoflurane-IETD group had better neurologic outcomes than both vehicle-treated groups at 14 days post-MCAO. These results suggest that a combination of isoflurane and a caspase 8 inhibitor can produce neuroprotection that is evident even after a recovery period of 14 days. This combination demonstrated greater efficacy than the administration of either isoflurane or z-IETD-fmk alone. These results are consistent with the premise that continuing apoptosis contributes to the enlargement of cerebral infarction during the recovery period and that its inhibition can provide sustained neuroprotection

 

 

麻醉医师和同一医院的非麻醉医师淋巴细胞姐妹染色体交换的比较

A Comparison of Sister Chromatid Exchanges in Lymphocytes of Anesthesiologists to Nonanesthesiologists in the Same Hospital

Ahmet Eroglu, Figen Celep, and Nesrin Erciyes

Department of Anesthesiology, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey.

Anesth Analg 2006 102: 1573-1577.

 

已有报道,在暴露于麻醉性气体的手术室工作人员中,外周淋巴细胞姐妹染色体交换(SCEs)的发生率有所上升。我们研究了麻醉医师SCEs的上升是否可逆。25名暴露于麻醉性气体如七氟醚和笑气的麻醉医师和同一医院的内科医师比较。测定手术室的七氟醚和笑气的浓度。通过淋巴细胞培养,分别测定麻醉医师在离开手术室之前及之后两个月的SCE发生。这些SCE和非暴露组的内科医师的SCE比较。职业性暴露于手术室的七氟醚和笑气的SCE值高于阈值。麻醉医师和内科医师的SCE值有显著差异(11.9 +/- 4.4 vs 4.2 +/- 1.1, P < 0.001)。离开手术室两个月后,麻醉医师的SCE值明显低于手术室内测定值(分别是4.8 +/- 1.8 11.9 +/- 4.4, P < 0.001)。我们推断:如果离开暴露环境两个月,暴露于麻醉性气体如七氟醚和笑气中麻醉医师SCE的上升是可逆的。

(王丽珺译 薛张纲校)

An increased incidence of sister chromatid exchanges (SCEs) in peripheral lymphocytes of operating room personnel exposed to waste anesthetic gases has been reported. We investigated whether the increase of SCEs in anesthesiologists was reversible. Twenty-five anesthesiologists exposed to waste anesthetic gases such as sevoflurane and nitrous oxide were compared with nonexposed internists working in the same hospital. The concentrations of sevoflurane and nitrous oxide in the operating rooms were measured. The incidence of SCE was measured in lymphocytes cultures of anesthesiologists before and after a 2-mo leave from the operating room. These values of SCE were compared with those of nonexposed physicians. Occupational exposure to sevoflurane and nitrous oxide in the operating rooms were above the threshold values. There was a significant difference in SCE values of the anesthesiologists compared with the nonexposed physicians (11.9 +/- 4.4 versus 4.2 +/- 1.1, P < 0.001). After a 2-mo leave from the operating room, the SCE values of the anesthesiologists were significantly lower compared with those taken before the leave (4.8 +/- 1.8 and 11.9 +/- 4.4, respectively, P < 0.001). We conclude that the increase of SCE in anesthesiologists exposed to increased environmental concentrations of waste anesthetics gases, such as sevoflurane and nitrous oxide, are reversible if they work free from exposure for 2 mo.

 

腹膜内CO2充气主动脉手术时心功能:一项经食道超声心动图研究

Cardiac Function During Intraperitoneal CO2 Insufflation for Aortic Surgery: A Transesophageal Echocardiographic Study

Pascal Alfonsi, MD, Antoine Vieillard-Baron, MD, PhD, Marc Coggia, MD, Bruno Guignard, MD, Olivier Goeau-Brissonniere, MD, François Jardin, MD, and Marcel Chauvin, MD

Departments of Anesthesiology, Vascular Surgery, and Intensive Care Unit, Ambroise Paré University Hospital, Assistance Publique Hôpitaux de Paris, Boulogne, Cedex, France

Anesth Analg 2006 102: 1304-1310.

 

腹腔镜对心功能的影响仍有争议。作者假设在择期行腹主动脉修复术的病人中心功能不全主要用于后负荷增加引起。为了证明这一假设,作者在15名择期行腹腔镜主动脉手术的病人中进行了一项经食道超声心动图的研究。系统测量左室和右室功能。首先测定病人仰卧位没有气腹和气腹腹内压为14mmHg时心功能。然后体位改为右侧卧位,测定不用气腹、腹内压上升到7mmHg和14mmHg时心功能。气腹使动脉压上升了25%,左室收缩期室壁应力上升了38%。左室射血分数下降25%,左室每搏量下降了18%。同时伴有左室收缩末期容量的增加。左室收缩功能的受损并不伴有左室收缩末期容量的变化。没有观察到上腔静脉管径随呼吸的变化,表明容量状态仍是理想的。随腹内压增加和体位的改变,右室每搏量随呼吸变化增加,提示右室后负荷的增加。结论:择期行腹腔镜主动脉手术病人腹膜内CO2充气使左室和右室收缩功能受损,主要由于后负荷增加所致。

(曹瑜 译 陈杰 校)

The effect of laparoscopy on cardiac function is controversial. We hypothesized that cardiac dysfunction related to increased afterload could be predominant in patients undergoing elective abdominal aortic repair. To test this hypothesis, we conducted a transesophageal echocardiographic study in 15 patients during laparoscopic aortic surgery. We systematically assessed left ventricular (LV) and right ventricular (RV) functions. Measurements were obtained in the supine position without pneumoperitoneum and with an intraabdominal pressure of 14 mm Hg. Then, patients were turned to the right lateral position without pneumoperitoneum and intraabdominal pressure was increased to 7 mm Hg and to 14 mm Hg. Pneumoperitoneum induced a 25% arterial blood pressure increase and a 38% increase in LV systolic wall stress. A 25% decrease in LV ejection fraction and an 18% decrease in LV stroke volume were observed, associated with an increase in LV end-systolic volume. LV diastolic function impairment was observed without change in LV end-diastolic volume. Respiratory alterations in superior vena cava diameter were never observed, suggesting that volume status remained optimal. Respiratory changes in RV stroke volume were increased according to intraabdominal pressure and body position, reflecting an increase in RV afterload. In conclusion, peritoneal CO2 insufflation in patients scheduled for laparoscopic aortic surgery could impair LV and RV systolic functions as a consequence of increased afterload.

 

小剂量重组活性因子Ⅶ(NovoSeven®)用于心脏手术

Small-Dose Recombinant Activated Factor VII (NovoSeven®) in Cardiac Surgery

Stefano Romagnoli, MD, Sergio Bevilacqua, MD*, Sandro Gelsomino, MD{dagger}, Silvia Pradella, MD, Lorenzo Ghilli, MD{ddagger}, Carlo Rostagno, MD{ddagger}, Gian Franco Gensini, MD, and Carlo Sorbara, MD

*Department of Cardiac Surgery; Careggi Hospital, Florence, Italy; {dagger}Department of Radiology; University of Florence, Florence, Italy; {ddagger}Department of Internal Medicine and Cardiology; University of Florence, Florence, Italy.

Anesth Analg 2006 102: 1320-1326.

不同剂量的重组活性因子Ⅶ(rFa)曾用于心脏手术病人。作者检测小剂量rFa用于治疗心脏手术后的病人发生难治性出血有效性。研究组包括了15名存在难治性出血的心脏手术病人,按事先确定输液方案一步步输液治疗末期静脉缓注小剂量的(1.2mgrFa15名病情匹配患者进行用rFa使用前同样的液体治疗作为对照组。在输液治疗后的失血量是最主要的结果。25th75th24小时失血量中位数分别为研究组16851590-1770mL和对照组31702700-3850mLP0.0004)。研究组和对照组的输血,输冰冻血浆和血小板分别为:74-8U1812-21UP0.001);7.56-11U119-15UP0.003);00-4U96-13UP0.001)。另外,在研究组和对照组之间凝血酶原时间(P0.015),国际规范比(P=0.006,部分活化凝血酶原时间(P0.01),血小板记数(P=0.003),以上所有结果均有显著改善。最后,接受rFa治疗的病人在ICU停留时间明显缩短(Х215.9P0.0001),再次手术探查的发生率降低(Х216.2P<0.0001)。小剂量的rFa缓慢注射用于存在难治性出血的心脏病人的疗效是满意的。目前还需要进一步的随机研究来证实作者的研究结果。

(肖洁 译 陈杰 校)

Recombinant activated factor VII (rFVIIa) has been used at different doses in cardiac surgery patients. We tested the efficacy of small-dose rFVIIa in patients with intractable bleeding after cardiac surgery. The study group comprised 15 cardiac surgery patients with intractable bleeding treated with small-dose (1.2 mg) rFVIIa as a slow IV bolus at the end of complete step-by step transfusion protocol. Fifteen matched patients undergoing the same transfusion protocol in the pre-rFVIIa era represented the control group. Blood loss at the end of the transfusion protocol was a primary outcome. Median, 25th75th 24-h blood loss percentiles were 1685 (15901770) mL versus 3170 (27003850) mL in study group and controls, respectively (P = 0.0004). Transfused red blood cells, fresh-frozen plasma, and platelets in the study group and controls were as follows: 7 (48) U versus 18 (1221) U (P = 0.001); 7.5 (611) U versus 11 (915) U (P = 0.003); 0 (04) U versus 9 (613) U (P = 0.001). In addition, significant improvements of prothrombin time (P = 0.015), international normalized ratio (P = 0.006), activated partial prothrombin time (P = 0.01), and platelet count (P = 0.003) were detected in the study group versus controls. Finally, patients receiving rFVIIa showed a reduced intensive care unit length of stay ({chi}2 = 15.9, P = 0.0001) and had infrequent surgical re-exploration ({chi}2 = 16.2,P < 0.0001). Small-dose rFVIIa showed satisfactory results in cardiac patients with intractable bleeding. Further randomized studies are necessary to confirm our findings.

 

糖原合成酶激酶的抑制增强异氟醚诱导的早期再灌注期间抗心肌梗塞的保护作用

Inhibition of Glycogen Synthase Kinase Enhances Isoflurane-Induced Protection Against Myocardial Infarction During Early Reperfusion In Vivo

Paul S. Pagel, MD, PhD, John G. Krolikowski, BA, Donald A. Neff, BS, Dorothee Weihrauch, DVM, PhD, Martin Bienengraeber, PhD, Judy R. Kersten, MD, and David C. Warltier, MD, PhD

Departments of Anesthesiology, Pharmacology and Toxicology, and Medicine (Division of Cardiovascular Diseases), the Medical College of Wisconsin and the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin

Anesth Analg 2006 102: 1348-1354.

抑制糖原合成酶激酶(GSK)-β有抗缺血-再灌注损伤作用。冠状动脉阻塞后再灌注前和再灌注中异氟醚短时间处理,也可产生抗心肌梗死作用。糖原合成酶激酶-β是否媒介这中作用仍不清楚。作者验证以下设想:GSK抑制能增强异氟醚诱导的缺血预处理作用。兔子(n=88;每组6或7只)冠状动脉闭塞30min,然后以生理盐水灌注3h,在灌注前和灌注后2min吸入异氟醚(0.5 1.0 MAC) 3 min,选择性的GSK抑制剂SB216763 (SB21; 0.2 0.6 mg/kg), 0.5 MAC异氟醚加上SB210.2 mg/kg。其他组的兔子以磷脂酰肌醇-3(PI3K)抑制剂渥曼青霉素(0.6 mg/kg), 70-kDa核糖体蛋白s6 激酶 (p70s6K) 抑制剂雷怕霉素(0.25 mg/kg)预处理,或线粒体通透性转变孔(mitochondrial permeability transition pore,mPTP) 开启器苍术苷 (5 mg/kg) 0.6 mg/kg SB21 0.5 MAC 异氟醚 加 0.2 mg/kg SB21 。另外的组用mPTP抑制剂环孢霉素A (5 mg/kg), 加上 0.2 mg/kg SB21用或不用苍术苷预处理。与对照组相比(42% ±6%),异氟醚(1.0 MAC而不是0.5 MAC)SB21 (0.6 mg/kg而不是0.2 mg/kg)减少梗塞面积(分别为21% ±5%, 44% ±7%, 23% ± 4%, and 46% ± 2%, 均数+/- 标准差; 氯化三苯四唑染色)。异氟醚(0.5 MAC) 加上0.2 mg/kg SB21 和环孢霉素A 0.2 mg/kg SB21产生相似的保护作用(分别为24% ± 4% 27% ± 6%),苍术苷而不是渥曼青霉素或雷怕霉素阻止了0.6 mg/kg SB21 0.5 MAC 异氟醚 加 0.2 mg/kg SB21的心肌保护作用。因此GSK抑制可以增强由mPTP-依赖的异氟醚诱导抗早期再灌注损伤作用。

(潘志英 译 陈杰 校)

Inhibition of glycogen synthase kinase (GSK)-ß protects against ischemia-reperfusion injury. Brief exposure to isoflurane before and during early reperfusion after coronary artery occlusion also protects against infarction. Whether GSK-ß mediates this action is unknown. We tested the hypothesis that GSK inhibition enhances isoflurane-induced postconditioning. Rabbits (n = 88; 6 to 7 per group) subjected to a 30-min coronary occlusion followed by 3 h reperfusion received saline, isoflurane (0.5 or 1.0 minimum alveolar concentration [MAC]) administered for 3 min before and 2 min after reperfusion, the selective GSK inhibitor SB216763 (SB21; 0.2 or 0.6 mg/kg), or 0.5 MAC isoflurane plus 0.2 mg/kg SB21. Other groups of rabbits pretreated with phosphatidylinositol-3 kinase (PI3K) inhibitor wortmannin (0.6 mg/kg), 70-kDa ribosomal protein s6 kinase (p70s6K) inhibitor rapamycin (0.25 mg/kg), or mitochondrial permeability transition pore (mPTP) opener atractyloside (5 mg/kg) received 0.6 mg/kg SB21 or 0.5 MAC isoflurane plus 0.2 mg/kg SB21. Additional groups received the mPTP inhibitor, cyclosporin A (5 mg/kg), plus 0.2 mg/kg SB21 with or without atractyloside pretreatment. Isoflurane (1.0 but not 0.5 MAC) and SB21 (0.6 but not 0.2 mg/kg) reduced (P < 0.05) infarct size (21% ± 5%, 44% ± 7%, 23% ± 4%, and 46% ± 2%, respectively, of left ventricular area at risk, mean± sd; triphenyltetrazolium staining) as compared with control (42% ± 6%). Isoflurane (0.5 MAC) plus 0.2 mg/kg SB21 and cyclosporin A plus 0.2 mg/kg SB21 produced similar degrees of protection (24% ± 4% and 27% ± 6%, respectively). Atractyloside but not wortmannin or rapamycin abolished protection produced by 0.6 mg/kg SB21 and 0.5 MAC isoflurane plus 0.2 mg/kg SB21. Thus, GSK inhibition enhances isoflurane-induced protection against infarction during early reperfusion via a mPTP-dependent mechanism.

 

吹气球对减轻患儿静脉穿刺痛的有效性评价:前瞻性随机对照研究

An Evaluation of Efficacy of Balloon Inflation on Venous Cannulation Pain in Children: A Prospective, Randomized, Controlled Study

Devendra Gupta, MD, Anil Agarwal, MD, Sanjay Dhiraaj, MD, Manish Tandon, MD, Mukesh Kumar, MD, Ravi Shankar Singh, MBBS, Prabhat K. Singh, MD, and Uttam Singh, PhD

Department of Anesthesia and Biostatistics, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India

Anesth Analg 2006 102: 1372-1375.

 

静脉穿刺对住院患儿来说是最常见的痛苦。作者评价了吹气球对缓解患儿静脉穿刺痛的有效性。该项前瞻性随机研究包括756-12岁患儿,ASA I-II级,男女均有,行择期手术。患儿随机平均分为三组,每组25名:组I(对照组)、组II(娱乐组)拍橡皮球、组III(气球组)吹气球。扎紧前臂的静脉后,用22G静脉导管进行静脉穿刺。通过疼痛面部表情标尺来反映疼痛,该标尺的背面是长度为10cm的视觉模拟标尺(VAS),0= 无痛10 =最痛VAS评分1-3分为轻度疼痛,4-6分为中度疼痛,>6为严重疼痛。气球组VAS评分的中值(四分位距)为13),分别低于娱乐组的2 (2)和对照组的4 (2) (P < 0.000)。同时观察到气球组的静脉穿刺痛发生率和严重程度,与其他两组相比显著减少(P < 0.05)

(赵延华 译 陈杰 校)

Venipuncture is the most common painful event for a hospitalized child. We evaluated the efficacy of balloon inflation for attenuating venipuncture pain in children. Seventy-five pediatric patients aged 612 yr, ASA physical status III, of either sex, undergoing elective surgery were included in this prospective and randomized study. Patients were randomly divided into 3 equal groups of 25 each; Group I (control), Group II (distraction) pressed a rubber ball, and Group III (balloon) inflated a balloon. A manual venous occlusion was applied on the forearm and venipuncture was performed with a 22-gauge venous cannula. Pain was self-reported by a pain face scale with a 10-cm visual analog scale (VAS) placed at its back, where 0 = "no pain" and 10 = "worst imaginable pain." VAS scores of 1-3 were rated as mild, 46 as moderate, and >6 as severe. Median (interquartile range) VAS score in the balloon group was 1 (3), which was reduced as compared with 2 (2) and 4 (2) observed in the distraction and control groups, respectively (P < 0.000). Significant reduction in the incidence and severity of venipuncture pain was also observed in the balloon group compared with the other 2 groups (P < 0.05).

 

腹腔镜手术病人口服格拉司琼和静注昂丹司琼预防呕吐作用的对比:呕吐症状和恢复质量

The Use of Oral Granisetron Versus Intravenous Ondansetron for Antiemetic Prophylaxis in Patients Undergoing Laparoscopic Surgery: The Effect on Emetic Symptoms and Quality of Recovery

Paul F. White, PhD, MD*, Jun Tang, MD{dagger}, Mohamed A. Hamza, MD*, Babatunde Ogunnaike, MD*, Monica Lo*, Ronald H. Wender, MD{dagger}, Robert Naruse, MD{dagger}, Alexander Sloninsky, MD{dagger}, Robert Kariger, MD{dagger}, Scott Cunneen, MD{dagger}, and Ted Khalili, MD{ddagger}

*Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas; {dagger}Department of Anesthesiology, Department of Surgery, {ddagger}Cedars-Sinai Medical Center, Los Angeles, California

Anesth Analg 2006 102: 1387-1393.

通过对接受致吐性化疗病人的对比研究, 人们认为格拉司琼比昂丹司琼对断药后恶心呕吐(PDNY)效果更佳, 但迄今为止尚无此两种HT3拮抗剂对PDNY和恢复质量的直接对比报道。 本文随机、双盲研究腹腔镜手术病人口服格拉司琼(1mg)或常规静注昂丹司琼(4 mg)的止吐作用。两个医学中心全麻行腹腔镜手术病人220,对照(昂丹司琼):术前1h口服安慰剂, 术后昂丹司琼(4 mg) 静注, 格拉司琼组: 术前1h口服格拉司琼(1mg), 术后2ml生理盐水静注。 随后的48小时记录病人的复苏状态,止吐剂的需求,PDNY的发生及药物副作用。术后通过11点语言评级对恶心呕吐程度评级,术后48h记录复苏质量及病人满意度评分。两组病人的人口学特征,病人定向力的恢复时间,口服量和住院时间无差异, 两组病人的PDNY发生率,对止吐剂的需求及复苏质量也无差异。格拉司琼和昂丹司琼取得一致的止吐满意分别花费26.6547.05美元。因此,在门诊和住院病人的腹腔镜手术,常规地预防性止吐, 昂丹司琼(4 mg i.v.) 的花费-收益比格拉司琼更佳。

(李启芳 译 陈杰 校)

Based on comparative studies in patients receiving emetogenic chemotherapy, it has been suggested that granisetron would be more effective than ondansetron for the prevention of postdischarge nausea and vomiting (PDNV). However, there have been no direct comparisons of these two popular 5-HT3 antagonists with respect to PDNV and quality of recovery. We designed this randomized, double-blind study to compare the antiemetic efficacy of oral granisetron (1 mg) to a standard IV dose of ondansetron (4 mg) when administered for antiemetic prophylaxis as part of a multimodal regimen in a laparoscopic surgical population. A total of 220 patients undergoing laparoscopic surgery with a standardized general anesthetic technique were enrolled in this prospective study at two major medical centers. Patients were randomly assigned to one of two prophylactic treatment groups: the control (ondansetron) group received an oral placebo 1 h before surgery and ondansetron, 4 mg IV, at the end of the surgery, and the granisetron group received granisetron, 1 mg per os, 1 h before surgery, and normal saline, 2 mL IV, at the end of the surgery. The early recovery profiles, requirement for rescue antiemetics, incidence of PDNV, and the side effects were recorded over the 48 h study period. In addition, nausea scores were assessed using an 11-point verbal rating scale at specific intervals in the postoperative period. The quality of recovery and patient satisfaction scores were recorded at 48 h after surgery. The demographic characteristics were similar in the two prophylaxis treatment groups, as well as the recovery times to patient orientation, oral intake, and hospital discharge. The incidences of PDNV, requirements for rescue antiemetics, and quality of recovery did not differ between the two study groups. The antiemetic drug acquisition costs to achieve comparable patient satisfaction with ondansetron and granisetron were US $25.65 and $47.05, respectively. Therefore, ondansetron (4 mg IV) was more cost-effective than granisetron (1 mg per os) for routine antiemetic prophylaxis as part of a multimodal regimen in patients undergoing either outpatient or inpatient laparoscopic surgery.

 

不同结构全麻药物对人体NMDA受体的不同调节

Differential Modulation of Human N-Methyl-d-Aspartate Receptors by Structurally Diverse General Anesthetics

Ken Solt, MD*, Edmond I. Eger, II, MD{dagger}, and Douglas E. Raines, MD*

*Department of Anesthesia and Critical Care, Massachusetts General Hospital, and Department of Anaesthesia, Harvard Medical School, Boston Massachusetts; and {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, California

Anesth Analg 2006 102: 1407-1411.

NMDA受体被认为是伤害性疼痛刺激的兴奋性突触递质。尽管先前的研究已发现吸入麻醉剂在临床相关浓度抑制NMDA受体通路,但采用不同的实验设计,受体亚型,和/或组织来源会混淆吸入麻醉剂对NMDA受体抑制效应的定量比较。本研究致力于填补这一空白,采用双电极电压钳技术,不同临床芳香族吸入麻醉剂抑制人NMDA受体在非洲蟾蜍光滑卵母细胞表达的NR1/NR2B亚型,在1个最小肺泡有效浓度,麻醉成分可逆性抑制NMDA受体从12±6%到74±6%。这些结果证实相同麻醉浓度的吸入麻醉剂对NMDA受体的抑制程度不同。这些不同也许对确定这些受体在全麻药的作用有意义。

(范颖辉 译 陈杰 校)

N-Methyl-d-aspartate (NMDA) receptors have a presumed role in excitatory synaptic transmission and nociceptive pathways. Although previous studies have found that inhaled anesthetics inhibit NMDA receptor-mediated currents at clinically relevant concentrations, the use of different experimental protocols, receptor subtypes, and/or tissue sources confounds quantitative comparisons of the NMDA receptor inhibitory potencies of inhaled anesthetics. In the present study, we sought to fill this void by defining, using the two-electrode voltage-clamp technique, the extent to which diverse clinical and aromatic inhaled anesthetics inhibit the NR1/NR2B subtype of the human NMDA receptor expressed in Xenopus laevis oocytes. At 1 minimum alveolar anesthetic concentration (MAC), anesthetic compounds reversibly inhibited NMDA receptor currents by 12 ± 6% to 74 ± 6%. These results demonstrate that equianesthetic concentrations of inhaled anesthetics can differ considerably in the extent to which they inhibit NMDA receptors. Such differences may be useful for defining the role that this receptor plays in producing the in vivo actions of general anesthetics.

 

接受异丙酚+瑞芬太尼和七氟醚+瑞芬太尼的麻醉病人支气管粘液移动速率的比较

Bronchial Mucus Transport Velocity in Patients Receiving Propofol and Remifentanil Versus Sevoflurane and Remifentanil Anesthesia

Thomas Ledowski, MD,DEAA*, Michael J. Paech, DM, FANZCA*{dagger}, Bhavesh Patel, MBBS,FRCA*, and Stephan A. Schug, FANZCA, FFPMANZCA*{dagger}

*Department of Anaesthesia and Pain Medicine, Royal Perth Hospital; and {dagger}School of Medicine and Pharmacology, The University of Western Australia, Perth, Australia

Anesth Analg 2006 102: 1427-1430.

 

在离体试验中显示挥发性麻醉药降低了纤毛的运动频率。曾有报道支气管纤毛运输速度(BTV)的受损与肺部合并症的增高显著相关。在这项研究中,作者旨在通过在体研究比较瑞芬太尼+异丙酚的全凭静脉麻醉(TIVA)和七氟醚+瑞芬太尼时BTV的差异。择期22名普外科手术病人随机分为两组:全凭静脉麻醉组(异丙酚+瑞芬太尼),七氟醚组(七氟醚+瑞芬太尼)。气管插管后30分钟,通过纤支镜观察右主支气管表面亚甲兰染料移动获取BTV。相对于全凭静脉麻醉组,七氟醚组BTV显著降低(七氟醚组1.5±0.70-2.3mm/min ,全凭静脉麻醉组4.8±2.12.3-8.8mm/minP <0.0001)。与全凭静脉麻醉比较,七氟醚麻醉可以导致支气管纤毛的清洁作用显著受损。这可能与围术期肺部并发症相关联,尤其是肺部合并症高危的病人。

(郑丽 译 陈杰 校)

Volatile anesthetics reduce ciliary beat frequency in vitro. It has been reported that impaired bronchial mucus transport velocity (BTV) is associated with significantly increased pulmonary complications. In this study, we sought to determine in vivo differences in BTV, comparing patients having total IV anesthesia (TIVA) with propofol and remifentanil to anesthesia with sevoflurane and remifentanil. Twenty-two patients scheduled for elective general surgery were randomized to one of two groups: TIVA (propofol/remifentanil) or SEVO (sevoflurane/remifentanil). Thirty minutes after tracheal intubation, BTV was assessed by fiberoptic observation of the movement of methylene blue dye applied to the dorsal surface of the right main bronchus. BTV was significantly reduced in the SEVO group compared with the TIVA group (mean, 1.5 ± 0.7 [02.3] versus 4.8 ± 2.1 [2.38.8] mm/min; P < 0.0001). Anesthesia with sevoflurane may lead to significantly impaired bronchociliary clearance in comparison to TIVA. This could have implications for perioperative pulmonary complications, in particular in patients at risk for pulmonary complications.

 

新型丁丙诺啡前体的长效制剂具有长时间的抗伤害作用

Novel Depots of Buprenorphine Prodrugs Have a Long-Acting Antinociceptive Effect

Kuo-Sheng Liu, MS* {dagger}, Jann-Inn Tzeng, MD, MS*, Yu-Wen Chen, MS*, Kuo-Lun Huang, MS*, Chun-Hsiung Kuei, PhD{dagger}, and Jhi-Joung Wang, MD, PhD*

*Departments of Anesthesiology and Medical Research, Chi-Mei Medical Center; {dagger}Department of Chemistry, National Cheng-Kung University, Tainan, Taiwan

Anesth Analg 2006 102: 1445-1451.

对于伴有长期疼痛的病人可能需要的是一种长时间作用的镇痛药物。本研究中,作者比较了在大鼠中肌注三种新型的丁丙诺啡前体的长效制剂:丙酸丁丙诺啡,庚酸丁丙诺啡和葵酸丁丙诺啡的抗伤害作用和作用维持时间。同时比较了肌注后三种制剂的药代过程。以跖肌反应评估抗伤害作用。以高性能液态色谱仪测定丁丙诺啡的血药浓度。作者发现传统的盐酸制剂的抗伤害作用具有剂量依赖性。盐酸丁丙诺啡(0.6umol/kg)产生长达5小时的抗伤害作用。而同等剂量的碱基丁丙诺啡,丙酸丁丙诺啡,庚酸丁丙诺啡和葵酸丁丙诺啡具有分别长达26285270小时的抗伤害作用。药代动力学研究证实所有类型的丁丙诺啡盐制剂均为丁丙诺啡的前体物质。结论:新型丁丙诺啡前体的长效制剂―― 丙酸丁丙诺啡,庚酸丁丙诺啡和葵酸丁丙诺啡都具有长时间的抗伤害作用。

(忻纪华 译 陈杰 校)

An analgesic with a prolonged duration may be desirable in patients with long-lasting pain. In this study, we evaluated the antinociceptive effects and durations of action of three novel depots of buprenorphine esters buprenorphine propionate, enanthate, and decanoate given by IM injection, in rats. The pharmacokinetic profiles of buprenorphine in blood after IM injection of these depots were also evaluated. Antinociception was evaluated using the plantar test. Buprenorphine concentrations in blood were assayed using high-performance liquid chromatography. We found that the traditional form of buprenorphine HCl (in saline) produced a dose-related antinociceptive effect. A dose of 0.6 µmol/kg buprenorphine HCl (in saline) produced a significant antinociceptive effect lasting 5 h. The same dose of buprenorphine base, propionate, enanthate, and decanoate (in oil) also produced a significant antinociceptive effect with longer durations of action of 26, 28, 52, and 70 h, respectively. The pharmacokinetic studies demonstrated that all the buprenorphine esters were prodrugs of buprenorphine. We conclude that the novel depots of buprenorphine prodrugs: buprenorphine propionate, enanthate, and decanoate produced a long-acting antinociceptive effect after IM injection in rats.

 

生活质量和情绪疗法对神经性疼痛的影响:疼痛减轻效应如何?

The Impact of Therapy on Quality of Life and Mood in Neuropathic Pain: What Is the Effect of Pain Reduction?

Maneesh A. Deshpande, MSc, Ronald R. Holden, PhD, and Ian Gilron, MD, MSc, FRCPC

Department of Anesthesiology, Queen's University and Kingston General Hospital, Kingston, Ontario, Canada

Anesth Analg 2006 102: 1473-1479.

情绪和生活质量对神经性疼痛试验结果改变很大,这可能是不稳定的镇痛和其它治疗效应的结果。作者通过吗啡、加巴喷丁、吗啡联合加巴喷丁的试验检测疼痛、副作用、生活质量和情绪,以此评估神经性疼痛中疼痛减少与情绪、生活质量之间的关系。生活质量基线是根据健康生存得分简表,情绪基线则根据可比较的正常人群情绪状态评分。三种试验处理有效的疼痛减少与生活质量的提高相关。吗啡组、加巴喷丁组的疼痛减少与情绪改善有关,吗啡联合加巴喷丁使疼痛减少,而情绪状态范围内的任意一项改善就能使吗啡联合加巴喷丁组的疼痛减少。治疗中镇静、便秘、口干的严重性与情绪、生活质量改变无关。这些结果暗示更大的止痛治疗效果是来自于实际生活质量和/或情绪的改善。尽管如此,其它有益或不利的治疗相关副作用也可能影响情绪和生活质量。因此,今后的研究需要评估镇痛试验中治疗相关副作用对情绪/生活质量的影响。

(顾新宇 译 陈杰 校)

Mood and quality of life (QOL) outcomes vary widely in neuropathic pain trials. This may be a result of variable analgesia and other treatment effects. We evaluated the relationship between pain reduction and mood/QOL in neuropathic pain. Pain, side effects, QOL, and mood from a trial of morphine, gabapentin, and a morphine-gabapentin combination were examined. Baseline QOL was impaired according to Short Form Health Survey (SF-36) scores. Baseline mood, according to Profile of Mood States scores, was comparable to that of a nondepressed population. Pain reduction with all three active trial treatments correlated with improved QOL. Pain reduction with morphine and with gabapentin correlated with improved mood. Pain reduction with a morphine-gabapentin combination correlated with improvement in only one of several domains of the Profile of Mood States. Severity of sedation, constipation, and dry mouth during any treatment did not correlate with mood/QOL changes. These results can be interpreted to imply that larger analgesic treatment effect sizes lead to more substantial improvements in QOL and/or mood. However, other beneficial or adverse treatment-related side effects may also affect mood/QOL. Therefore, future studies are needed to also evaluate the impact of treatment-related side effects on mood/QOL in analgesic trials.

 

肺萎陷的选择性复原方法对肺功能及血液动力学的影响:一项猪的实验研究

Selective Recruitment Maneuvers for Lobar Atelectasis: Effects on Lung Function and Central Hemodynamics: An Experimental Study in Pigs

Lars Kjærsgaard Hansen, MD*, Erik Sloth, MD, PhD{dagger}{ddagger}, Jonas Nielsen, MD§, Jacob Koefoed-Nielsen, MD*{dagger}, Per Lambert, MD*, Søren Lunde, MS{dagger}{ddagger}, and Anders Larsson, MD, PhD*{dagger}

*Department of Anesthesia and Intensive Care Medicine, Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospitals, Aalborg, Denmark; {dagger}Clinical Institute, Aarhus University, Århus, Denmark; {ddagger}Department of Anesthesia and Intensive Care Medicine, Skejby Hospital, Aarhus University Hospitals, Århus, Denmark; and §Department of Anaesthesia and Intensive Care Medicine, Copenhagen University Hospital Gentofte, Hellerup, Denmark

Anesth Analg 2006 102: 1504-1510. [

 

目的:研究人为肺萎陷的选择性复原方法是否比全肺复原方法更会增加肺氧合和肺容量,并有较小的循环副作用。方法:10只麻醉状态的猪进行人工通气,支气管的阻滞物嵌入右下叶,选择性灌洗以制备实验性肺萎陷模型。将10只猪随机分成两组:一组是先选择性复原方法(维持40cmH2O气道压30s)随后全肺复原,另一组则相反。结果:选择性肺复原方法的呼气末肺容量中位数和PaO2中位数显著增加,分别增加了100mL16kPa左右,在两种模式之间没有显著的差异。在选择性肺复原方法无循环(血液动力学)的改变,但是在全肺复原方法中,平均动脉压显著下降(中位数36mmHg, 25百分位数值和第75百分位数值为21, 41mmHg)心输出量下降了2.11.6, 2.5L/min,左心室舒张末期的面积4.4 (3.5, 4.5)cm2.结论:选择性肺复原方法与全肺复原方法相比具有相同的肺功能改善但没有循环副作用。

(宋金超 译 陈杰 校)

We investigated whether selective lung recruitment of a lobar collapse would improve oxygenation and lung volume as well as a general (global) lung recruitment maneuver, with fewer circulatory side effects. In 10 ventilated, anesthetized pigs, a bronchial blocker was inserted in the right lower lobe, which was selectively lavaged to create a dense lobar collapse. The pigs were randomized into two orders of lung recruitment maneuvers (40 cm H2O airway pressure for 30 s): either a selective lung recruitment maneuver (using the inner lumen of the bronchial blocker) followed by a general lung recruitment maneuver, or vice versa. Median end-expiratory lung volume and median Pao2 increased significantly by approximately 100 mL and 16 kPa, respectively, with no significant differences between the two recruitment methods. There were no circulatory changes during the selective lung recruitment maneuver, but during the general lung recruitment maneuver, mean arterial blood pressure decreased significantly by 36 (21, 41) mm Hg (median, 25th and 75th percentiles), cardiac output by 2.1 (1.6, 2.5) L/min and left ventricular end-diastolic area by 4.4 (3.5, 4.5) cm2. In conclusion, a selective recruitment maneuver improved lung function similar to a general lung recruitment maneuver but without any circulatory side effects.

 

应用体感诱发电位判断脊髓手术中病人体位与可能发生的上肢神经损伤之间的关系:一项回顾性研究

The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Patient Positioning and Impending Upper Extremity Nerve Injury During Spine Surgery: A Retrospective Analysis

Ihab R. Kamel, MD*, Elizabeth T. Drum, MD, FAAP*, Stephen A. Koch, BS{dagger}, Joseph A. Whitten, BA, MBS*, John P. Gaughan, PhD{ddagger}, Rodger E. Barnette, MD, FCCM*, and Woodrow W. Wendling, MD, PhD*

Departments of *Anesthesiology, {dagger}Neuromonitoring, and {ddagger}Biostatistics, Temple University Hospital and School of Medicine, Philadelphia, Pennsylvania

Anesth Analg 2006 102: 1538-1542.

体感诱发电位(SSEP)监测可以用于预防脊髓手术中的神经损伤并能检查上肢神经的功能变化。SSEP传导的变化可以显示上肢可能的神经损伤。作者对1000例行脊髓手术的病人进行了SSEP监测以观察手术体位对上肢神经功能的影响。研究结果发现绝大部分(92%)患者上肢SSEP改变可以通过改变手臂的位置得到改善,因此都归类为体位相关。对这种体位相关的SSEP改变进行计算,并且比较了五种不同的体位:仰卧伸手位、仰卧卷手位、侧卧位、俯卧卷手位、俯卧“超人”位。体位相关SSEP改变的总发生率为6.1%。与其它体位相比,侧卧位(7.5%)和俯卧超人位(7.0%)上肢SSEP改变的发生率明显高于其它体位(1.8-3.2%)。没有病人因为术中出现可以逆转SSEP改变而造成术后功能缺陷的。总之,研究者认为,SSEP监测是一种很有价值的发现和转变可能发生的上肢位周神经损伤的手段。

(苏殿三 译 陈杰 校)

Somatosensory evoked potential (SSEP) monitoring is used to prevent nerve damage in spine surgery and to detect changes in upper extremity nerve function. Upper extremity SSEP conduction changes may indicate impending nerve injury. We investigated the effect of operative positioning on upper extremity nerve function retrospectively in 1000 consecutive spine surgeries that used SSEP monitoring. The vast majority (92%) of upper extremity SSEP changes were reversed by modifying the arm position and were therefore classified as position-related. The incidence of position-related upper extremity SSEP changes was calculated and compared for five different surgical positions: supine arms out, supine arms tucked, lateral decubitus position, prone arms tucked, and the prone "superman" position. The overall incidence of position-related upper extremity SSEP changes was 6.1%. The lateral decubitus position (7.5%) and prone superman position (7.0%) had a significantly more frequent incidence of position-related upper extremity SSEP changes (P < 0.0001, Z-test for Poisson counts) compared with other positions (1.8%3.2%). No patient with a reversible SSEP change developed a new postoperative deficit in the affected extremity. SSEP monitoring is of value in identifying and reversing impending upper extremity peripheral nerve injury.

 

老年病人髋部骨折修复术使用单次小剂量和导管连续注射布比卡因行脊麻的比较

Spinal Anesthesia Using Single Injection Small-Dose Bupivacaine Versus Continuous Catheter Injection Techniques for Surgical Repair of Hip Fracture in Elderly Patients

Vincent Minville, MD, Olivier Fourcade, MD, PhD, David Grousset, MD, Clément Chassery, MD, Luc Nguyen, MD, Karim Asehnoune, MD, Aline Colombani, MD, Lounès Goulmamine, MD, and Kamran Samii, MD

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

Anesth Analg 2006 102: 1559-1563.

 

衰老和疾病会使老年病人在行脊麻期间易发生低血压。作者根据持续脊麻(CSA)和小剂量单次注射脊麻(SA)的低血压概率比较两者的血流动力学影响。74名75岁以上接受髋部骨折修复手术的患者随机分为两组,每组37人。CSA组使用每15min给一次2.5mg等比重布比卡因,而SA组则单次注射7.5mg异布比卡因行脊麻。两组的无创自动血压在基线水平和CSA或SA后的总体变化都没有显著的统计学差异。在SA组,68%的患者都经历了至少一次低血压(收缩压比基线值下降大于20%),CSA组只有31%的患者(P=0.005)。在SA组,51%的患者都经历了至少一次严重的低血压(收缩压比基线值下降大于30%),CSA组只有8% (P<0.0001)。在CSA组中,麻黄素用量为4.5±2mg,SA组麻黄素用量为11±2mg的(P=0.005)。在CSA组中,麻醉剂用量为5mg(2.5-10mg),SA组用量为7.5mg(P<0.0001)。结论:对于接受髋部骨折手术修复的病人,与单次脊髓内注射7.5mg布比卡因相比,CSA较少发生低血压和较严重低血压事件。

(殷文渊 译 陈杰 校)

Aging and disease may make elderly patients particularly susceptible to hypotension during spinal anesthesia. We compared the hemodynamic effect of continuous spinal anesthesia (CSA) and small dose single injection spinal anesthesia (SA) regarding the incidence of hypotension. Seventy-four patients aged >75 yr undergoing surgical repair of hip fracture were randomized into 2 groups of 37 patients each. Group CSA received a continuous spinal anesthetic with a titration of 2.5 mg boluses every 15 min of isobaric bupivacaine, while group SA received a single injection spinal anesthetic with 7.5 mg of isobaric bupivacaine. The overall variations in noninvasive automated arterial blood pressure were not statistically significantly different in the 2 groups at baseline and after CSA or SA (not significant). In the SA group, 68% of patients experienced at least one episode of hypotension (decrease in systolic arterial blood pressure greater than 20% of baseline value) versus 31% of patients in the CSA group (P = 0.005). In the SA group, 51% of patients experienced at least one episode of severe hypotension (decrease in systolic arterial blood pressure more than 30% of baseline value) versus 8% of patients in the CSA group (P < 0.0001). In the CSA group, 4.5 ± 2 mg of ephedrine was injected versus 11 ± 2 mg in the SA group (P = 0.005). In the CSA group, 5 mg (2.510) of anesthetic solution was required versus 7.5 mg in the SA group (P < 0.0001). We conclude that, in elderly patients undergoing hip fracture repair, CSA provides fewer episodes of hypotension and severe hypotension compared with a single intrathecal injection of 7.5 mg bupivacaine.

 

用四个成串刺激(TOF)、双短强直刺激(DBS)、50Hz强直刺激、100Hz强直刺激和加速度仪(ACC)对手或手腕进行刺激监测可感知肌力衰减

Tactile Fade Detection with Hand or Wrist Stimulation Using Train-of-Four, Double-Burst Stimulation, 50-Hertz Tetanus, 100-Hertz Tetanus, and Acceleromyography

Florent Capron, MD, Louis-Philippe Fortier, MSc, MD, FRCPC, Sébastien Racine, MSc, and François Donati, PhD, MD, FRCPC

Department of Anesthesiology, Hôpital Maisonneuve-Rosemont and Université de Montréal, Québec, Canada

Anesth Analg 2006 102: 1578-1584.

残余肌松可通过ACC,TOF,DBS, 50Hz强直刺激(TS)或100Hz强直刺激(TS)来评估。神经刺激可以在手或手腕上进行。作者在这两个部位比较了以上所有的神经-肌肉刺激方法。32个病人在七氟醚麻醉下给予罗库溴铵。测量远端拇收肌肌动描记TOF比率。另外,随机选择手或手腕刺激,测量ACCTOF比率。在恢复期间,以盲法评估可感知肌力衰减。应用ACC TOF比率为0.31±0.15时,不能观察到可感知肌力衰减。用DBS,阈值是0.76±0.1150Hz强直刺激阈值为0.31±0.15100Hz强直刺激阈值是0.88±0.18,范围是0.14-1.00。这些反应对于手和手腕是一致的。当ACCTOF比率达到1.0时,肌动描记 TOF比率是0.89±0.06。刺激手时,ACCTOF比率超过1.0的情况比手腕的刺激出现的少。为了排除残余肌松,TOF, DBS, 50Hz强直刺激是不合适的,100Hz强直刺激不可靠的,而ACC效果最好。

(张美荣 译 陈杰 校)

Residual neuromuscular blockade can be evaluated using acceleromyography, tactile assessment of train-of-four (TOF), double-burst stimulation (DBS), 50-Hz tetanus, or 100-Hz tetanus. Nerve stimulation can be at the hand or the wrist. We compared all these tests at both sites of stimulation. Rocuronium was given to 32 patients under sevoflurane anesthesia. The mechanomyographic adductor pollicis TOF ratio was measured at one extremity. In the other, stimulation was at the hand or the wrist, by random allocation, and the acceleromyographic TOF ratio was measured. During recovery, a blinded observer estimated tactile fade. The TOF fade became undetectable when mechanomyographic TOF ratio was (mean ± sd) 0.31 ± 0.15. For DBS, this threshold was 0.76 ± 0.11. For 50-Hz tetanus, it was 0.31 ± 0.15. For 100-Hz tetanus, it was 0.88 ± 0.18, with a range of 0.141.00. These tactile responses were the same for hand and wrist stimulation. When acceleromyographic TOF ratio reached 1.0, the mechanomyographic TOF ratio was 0.89 ± 0.06. With stimulation in the hand, acceleromyographic TOF ratio >1.0 was less frequent than at the wrist. To exclude residual paralysis, TOF, DBS, and 50-Hz tetanus are inadequate, 100-Hz tetanus is unreliable, and acceleromyography performs best.

 

用凝血弹力图® Ecarin凝血时间化验测定患者的比伐卢定血浆水平:与标准激活凝血时间的比较

Measurement of Patients' Bivalirudin Plasma Levels by a Thrombelastograph® Ecarin Clotting Time Assay: A Comparison to a Standard Activated Clotting Time

Roger C. Carroll, PhD, Jack J. Chavez, MD, Jeffery W. Simmons, MD, Carolyn C. Snider, MT, Dale C. Wortham, MD, Stuart J. Bresee, MD, and Eli Cohen, PhD

Departments of Anesthesiology and Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee; Haemoscope Corporation, Niles, Illinois

Anesth Analg 2006;102:1316-1319

 

标准激活凝血时间(ACT)试验与比伐卢定水平相关性较差,导致经皮冠脉介入治疗患者的充分抗凝方面不确定。我们用来自于比伐卢定抗凝的80例行介入治疗心脏病学手术患者的血液来检验血栓弹性描记仪®TEG®ecarin凝血时间(ECT)对比伐卢定的敏感性。这与用含硅藻土的标准凝血时间ACT分析比较。用TEG®分析时,直接凝血酶激活剂-ecarin被用来发动凝结,并作为反应时间来测定。在独立血液学的实验室里用显色分析来评价血浆样本中的比伐卢定。标准ACT对比伐卢定 水平线形回归的r2 = 0.306 TEG® ECT对比伐卢定 水平的r2 = 0.746 (两者 P < 0.0001)。证明TEG® ECT相对于标准ACT更有利于监测临床治疗范围内的比伐卢定抗凝作用。

注:比伐卢定为短效可逆性抗凝血药物

(彭中美 译 马皓琳 李士通 校)

Standard activated clotting time (ACT) tests have a poor correlation to bivalirudin levels, leading to uncertainty regarding adequate anticoagulation in percutaneous coronary intervention patients. We tested a Thrombelastograph® (TEG®) ecarin clotting time (ECT) assay for sensitivity to bivalirudin using blood from 80 patients undergoing interventional cardiology procedures with bivalirudin anticoagulation. This was compared to a standard Hemochron ACT assay using diatomaceous earth. With the TEG® assay, the direct thrombin activator, ecarin, was used to initiate coagulation and measured as the reaction time. Plasma samples were evaluated for bivalirudin by a chromogenic assay at an independent hematological laboratory. Linear regression of the standard ACT versus bivalirudin level gave an r2 = 0.306 whereas the TEG® ECT gave a much higher r2 = 0.746 (both P < 0.0001). The TEG® ECT should prove more useful than the standard ACT for monitoring bivalirudin anticoagulation across the clinically therapeutic range.

 

 

在猪的麻醉及手术过程中测定自主神经系统的活性:对不同方法的评价

The Measurement of Neurovegetative Activity During Anesthesia and Surgery in Swine: An Evaluation of Different Techniques

María F. Martín Cancho, PD, PhD, María S. Carrasco-Jiménez, MD, PhD, Juan R. Lima, DVM, Laura Luis, DVM, PhD, Verónica Crisóstomo, DVM, PhD, and Jesús Usón-Gargallo, DVM, PhD

Minimally Invasive Surgery Centre, Avda/ Universidad s/n, Cáceres, Spain; the Department of Anesthesiology, Medical School, Hospital Universitario de Puerto Real, Cádiz University, Cadiz, Spain

Anesth Analg 2006;102:1333-1340

 

在这项研究中,我们评价了对10只在七氟醚麻醉下行腹部手术的猪测定自主神经系统(ANS)活性的不同方法:ANSiscopeTM指数、心率变异性的谱分析、血流动力学变量及血浆儿茶酚胺及皮质醇水平。动物在120min麻醉下完成单侧卵巢切除术。监测心血管及呼吸反应。ANSiscopeTM指数(交感指数ANSindexTM,副交感指数ANSindexTM及平衡指数balANSindexTM)用于监测ANS活性。使用参数方法自动回归模型进行谱分析。使用低频(LF)及高频(HF)成分来分析短时程内心电图(ECGs)功率谱密度。LF/(LF+HF)反映了交感活性,HF/(LF+HF)显示了副交感活性,LF/HF比值大小反映了哪个系统占优势地位。监测不同时间点的血浆肾上腺素、去甲肾上腺素及皮质醇浓度。发现balANSindexTM与肾上腺素水平之间、LF/HF比值与血浆肾上腺素浓度之间存在相关性(P < 0.01)。而且,发现balANSindexTMLF/HF比值之间有显著的相关性(P < 0.01)。然而,在登记的ANSiscope指数与血流动力学变量之间没有发现相关性。本研究中发现的相关性提示balANSindexTM可作为麻醉及手术中监测ANS活性的有效工具。

(裘毅敏 译 马皓琳 李士通 校)

In this study we evaluated, in 10 sevoflurane-anesthetized pigs undergoing abdominal surgery, different techniques for measuring autonomic nervous system (ANS) activity: ANSiscopeTM index, spectral analysis of heart-rate variability, hemodynamic variables, and plasma catecholamines and cortisol levels. Animals underwent a 120-min anesthesia during which unilateral ovariectomy was performed. Cardiovascular and respiratory responses were monitored. ANSiscopeTM indices (ANSindexTM sympathetic, ANSindexTM parasympathetic and balANSindexTM) were used to monitor ANS activity. Spectral analysis was performed using an autoregressive model with a parametric method. The low frequency (LF) and high frequency (HF) components were used to interpret the power spectral density of short-term electrocardiograms (ECGs). The relationship LF/(LF+HF) reflects sympathetic activity, HF/(LF+HF) indicates parasympathetic activity, and the LF/HF ratio gives the predominance of the system. Plasma concentrations of adrenaline, noradrenaline, and cortisol were determined at different times. Correlation (P < 0.01) was found between the balANSindexTM and adrenaline levels and between LF/HF ratio and plasma adrenaline concentrations. Moreover, a significant (P < 0.01) correlation was found between the balANSindexTM and LF/HF ratio. However, no correlation was seen between the registered ANSiscope indices and hemodynamic variables. The correlation seen in this study suggests that the balANSindexTM could be a useful tool to monitor ANS activity during anesthesia and surgery.

 

 

一种抗凋亡的线粒体通透性转换调节因子——B细胞淋巴瘤-2蛋白在兔对异氟醚诱导和缺血后处理的影响

The Influence of B-Cell Lymphoma 2 Protein, an Antiapoptotic Regulator of Mitochondrial Permeability Transition, on Isoflurane-Induced and Ischemic Postconditioning in Rabbits

Chen Wang, MD, Donald A. Neff, BS, John G. Krolikowski, BA, Dorothee Weihrauch, DVM, PhD, Martin Bienengraeber, PhD, David C. Warltier, MD, PhD, Judy R. Kersten, MD, and Paul S. Pagel, MD, PhD

Departments of Anesthesiology, Pharmacology and Toxicology, and Medicine (Division of Cardiovascular Diseases), the Medical College of Wisconsin; the Clement J. Zablocki Veterans Affairs Medical Center; Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin

Anesth Analg 2006;102:1355-1360

 

冠状动脉长时间堵塞后再灌注早期短暂给予异氟醚或反复、短暂的缺血可通过抑制线粒体通透性转换孔道(mPTP)来保护心肌防止发生梗塞。延迟的缺血预处理过程中发生mPTP的抑制,同时伴有抗凋亡蛋白B细胞淋巴瘤-2Bcl-2)的表达增强。我们假设Bcl-2介导了再灌注期异氟醚或短暂缺血事件的心肌保护作用。对兔(n = 91)冠状动脉左前降支阻断30min之后再灌注3h,对此假设进行验证。兔分别接受0.9%盐水、再灌注之前3min和之后2min异氟醚(0.51.0MAC)、再灌注早期3个循环的缺血后处理(每次10s20s)、0.5MAC的异氟醚加3个循环的缺血后处理(10s)、或在有或无选择性Bcl-2抑制剂HA14-12 mg/kg, i.p.)的情况下使用mPTP的直接抑制剂环孢霉素ACsA, 10 mg/kg)。异氟醚(1.0而不是0.5MAC)和缺血后处理(20s而不是10s)明显(P < 0.05)减少梗塞范围(分别占左室危险部位的21% ± 4%43% ± 7%19% ± 7% 39% ± 11%,平均值±标准差),而对照组为44% ± 4%0.5MAC的异氟醚加10s的缺血后处理和单独使用CsA也有保护作用。单独使用HA14-1并不影响梗塞面积也不阻断由CsA产生的保护作用,却取消了由1.0MAC异氟醚、20s的缺血后处理以及0.5MAC的异氟醚加10s的缺血后处理所产生的缩小梗塞面积的作用。这些结果提示在体内Bcl-2通过间接调制mPTP的活性来介导异氟醚诱导的和缺血后处理。

(黄施伟 译 马皓琳 李士通 校)

Brief exposure to isoflurane or repetitive, transient ischemia during early reperfusion after prolonged coronary artery occlusion protects against myocardial infarction by inhibiting the mitochondrial permeability transition pore (mPTP). Inhibition of mPTP during delayed ischemic preconditioning occurred concomitant with enhanced expression of the antiapoptotic protein B cell lymphoma-2 (Bcl-2). We tested the hypothesis that Bcl-2 mediates myocardial protection by isoflurane or brief ischemic episodes during reperfusion in rabbits (n = 91) subjected to a 30-min left anterior descending coronary artery occlusion followed by 3 h reperfusion. Rabbits received 0.9% saline, isoflurane (0.5 or 1.0 minimum alveolar concentration, MAC) administered for 3 min before and 2 min after reperfusion, 3 cycles of postconditioning ischemia (10 or 20 s each) during early reperfusion, 0.5 MAC isoflurane plus 3 cycles of postconditioning ischemia (10 s), or the direct mPTP inhibitor cyclosporin A (CsA, 10 mg/kg) in the presence or absence of the selective Bcl-2 inhibitor HA14-1 (2 mg/kg, i.p.). Isoflurane (1.0, but not 0.5, MAC) and postconditioning ischemia (20 s but not 10 s) significantly (P < 0.05) reduced infarct size (mean ± sd, 21% ± 4%, 43% ± 7%, 19% ± 7%, and 39% ± 11%, respectively, of left ventricular area at risk) as compared with control (44% ± 4%). Isoflurane (0.5 MAC) plus 10 s postconditioning ischemia and CsA alone also exerted protection. HA14-1 alone did not affect infarct size nor block protection produced by CsA but abolished reductions in infarct size caused by 1.0 MAC isoflurane, 20 s postconditioning ischemia, and 0.5 MAC isoflurane plus 10 s postconditioning ischemia. The results suggest that Bcl-2 mediates isoflurane-induced and ischemic postconditioning by indirectly modulating mPTP activity in vivo.

 

 

对小儿患者重要的术后结果是什么?

What Postoperative Outcomes Matter to Pediatric Patients?

 

Giovanni Cucchiaro, MD*, John T. Farrar, MD, PhD{dagger}, Jessica W. Guite, PhD*, and Yuelin Li, PhD*

*Department of Anesthesia and Critical Care Medicine, The Childrens Hospital of Philadelphia; and {dagger}Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia

Anesth Analg 2006;102:1376-1382

 

在儿童医疗问题的决定上,经常由父母亲代理,而将儿童自身排除在外。这样的方法没有考虑到父母和儿童在小儿健康问题上可能持有不同的观点。在这项研究中,我们评估了与术后疼痛处理有关的儿童决定过程。研究了45例接受前交叉韧带修补术或鸡胸手术。用一个标准赌博方法评估儿童对于一种假想治疗方法的效用的看法。假设这种方法在术后可以提供完美的疼痛控制,但有不同的呕吐风险。所有患儿愿意接受的将疼痛水平减小到零的最大呕吐风险为32% ± 24%。女孩愿意接受的呕吐风险(41% ± 24%)要显著高于男孩(25% ± 22%)(P = 0.02)。在被提问之前实际有呕吐经历的儿童愿意接受的呕吐风险(46% ± 26%)比无经历者(23% ± 17%)(P = 0.035)。儿童们可以表达对他们首选的术后结果的看法,并且可以提供关于他们治疗方案的有用信息。看来与男孩相比,女孩认识到术后呕吐的重要性低于疼痛控制。

(黄佳佳 译 马皓琳 李士通 校)

Children are often excluded from making decisions related to their medical treatment, and parents proxy reports are often used. This approach fails to consider that parents and children may differ in their perception of the childs health. In this study, we assessed childrens decision-making processes related to postoperative pain management. Forty-five children who underwent an anterior cruciate ligament repair or Nuss procedure for pectus excavatum repair were studied. A standard gamble technique was used to assess childrens perceptions of the utility of a hypothetical treatment that would provide them with perfect pain control, with respect to different rates of risk for vomiting during the postoperative period. The maximum risk of vomiting that the overall study population was willing to accept to decrease the pain level to zero was 32% ± 24%. Girls were willing to take a significantly higher risk (41% ± 24%) compared to boys (25% ± 22%) (P = 0.02). Children who actually experienced vomiting before they were questioned were willing to take a higher risk (46% ± 26%) compared to those who did not (23% ± 17%) (P = 0.035). Children can express opinions about preferred postoperative outcomes and provide useful input about their care. Girls, more than boys, seem to perceive vomiting as less important than improved pain control in the postoperative period.

 

 

成年病人催眠有利于减少术前焦虑

Hypnosis Reduces Preoperative Anxiety in Adult Patients

Haleh Saadat, MD, Jacqueline Drummond-Lewis, MD, Inna Maranets, MD, Deborah Kaplan, Anusha Saadat, Shu-Ming Wang, MD, and Zeev N. Kain, MD

Center for the Advancement of Perioperative Health, Departments of Anesthesiology, Pediatrics, and Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Anesth Analg 2006;102:1394-1396

 

在本次研究中我们检查了催眠对术前焦虑的影响。我们将病人随机分成三组,接受健康暗示的催眠组(n = 26)、接受注意倾听和支持而无特殊催眠暗示的注意力控制组(n = 26)和“标准治疗”对照组(n = 24)。我们测量了干预前后和进入手术室时的焦虑程度。我们发现催眠组干预后的焦虑程度显著低于注意力控制组和对照组(运用方差分析,31±837±941±11P=0.008)。另外,在进入手术室时催眠组的焦虑水平显著下降56%,而注意力控制组增加10%,对照组增加47%P=0.001)。总之我们发现催眠显著减轻了术前焦虑程度。需要进一步的研究来检查术前催眠对术后结果的影响。

(姜旭晖 译 马皓琳 李士通 校)

In this study we examined the effect of hypnosis on preoperative anxiety. Subjects were randomized into 3 groups, a hypnosis group (n = 26) who received suggestions of well-being; an attention-control group (n = 26) who received attentive listening and support without any specific hypnotic suggestions and a "standard of care" control group (n = 24). Anxiety was measured pre- and postintervention as well as on entrance to the operating rooms. We found that patients in the hypnosis group were significantly less anxious postintervention as compared with patients in the attention-control group and the control group (31 ± 8 versus 37 ± 9 versus 41 ± 11, analysis of variance, P = 0.008). Moreover, on entrance to the operating rooms, the hypnosis group reported a significant decrease of 56% in their anxiety level whereas the attention-control group reported an increase of 10% in anxiety and the control group reported an increase of 47% in their anxiety (P = 0.001). In conclusion, we found that hypnosis significantly alleviates preoperative anxiety. Future studies are indicated to examine the effects of preoperative hypnosis on postoperative outcomes.

 

 

N-甲基d-天冬氨酸受体是否介导吸入麻醉药抑制最低肺泡气有效浓度时间叠加效应?

Do N-Methyl-d-Aspartate Receptors Mediate the Capacity of Inhaled Anesthetics to Suppress the Temporal Summation that Contributes to Minimum Alveolar Concentration?

Robert C. Dutton, MD*, Michael J. Laster, DVM*, Yilei Xing, MD*, James M. Sonner, MD*, Douglas E. Raines, MD{dagger}, Ken Solt, MD{dagger}, and Edmond I. Eger, II, MD*

*Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California; {dagger}Department of Anaesthesia and Critical Care, Massachusetts General Hospital, and Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts

Anesth Analg 2006;102:1412-1418

 

拮抗N-甲基d-天冬氨酸(NMDA)受体可显著降低吸入麻醉药的最低肺泡气有效浓度(MAC)。为了评估抑制MAC时间叠加效应中NMDA受体的重要性,我们采用不同刺激间期(ISIs)的成串电脉冲刺激大鼠尾部,并测定在不同ISIs可抑制大鼠体动的吸入麻醉药浓度(交叉浓度)。交叉浓度与ISIs斜率之比可反映每种吸入麻醉药时间叠加效应。我们研究了五种在离体实验中阻断NMDA受体能力差异很大的吸入麻醉药。为了阻断NMBA受体传递和揭示NMDA受体成分,在每个麻醉药期间分别加入NMDA受体拮抗剂MK801。氟烷、异氟醚和六氟苯未抑制参与时间叠加效应的NMDA受体作用,该部占MAC21%到29%(每种麻醉药 P< 0.05)。氙气和o-二氟联苯分别抑制NMDA受体对MAC作用至8%到0%(二者均无统计学意义),与它们在离体实验中较强的NMDA受体阻断作用一致。离体实验中NMDA受体阻断可影响强效抑制NMDA受体(而不是影响作用有限)的吸入麻醉药产生的MAC

(周雅春 译 马皓琳 李士通 校)

Antagonism of N-methyl-d-aspartate (NMDA) receptors markedly decreases the minimum alveolar concentration (MAC) of inhaled anesthetics. To assess the importance of suppression of the temporal summation NMDA receptor component of MAC, we stimulated the tail of rats with trains of electrical pulses of varying interstimulus intervals (ISIs) and determined the inhaled anesthetic concentrations (crossover concentrations) that suppressed movement at different ISIs. The slopes of crossover concentrations versus ISIs provided a measure of temporal summation for each anesthetic. We studied five anesthetics that differ widely in their in vitro capacity to block NMDA receptors. To block NMDA receptor transmission and reveal the NMDA receptor component, the NMDA receptor antagonist, MK801, was separately added during each anesthetic. Halothane, isoflurane, and hexafluorobenzene did not appreciably suppress the NMDA receptor components of temporal summation, which contributed to 21% to 29% of MAC (P < 0.05 for each). Xenon and o-difluorobenzene suppressed these components to 8% to 0%, respectively, of MAC (neither significant), consistent with their greater NMDA receptor blocking action in vitro. NMDA receptor blockade may contribute to the MAC produced by inhaled anesthetics that potently inhibit NMDA receptors in vitro but not those that have a limited in vitro effect.

 

 

异氟醚可调控大鼠杏仁核中染色体的表达

Isoflurane Modulates Genomic Expression in Rat Amygdala

Ira J. Rampil, MS, MD, Daryn H. Moller, MD, and Achim H. Bell, PhD

Department of Anesthesiology and Neurological Surgery, State University of New York at Stony Brook, HSC University Hospital, Stony Brook, New York

Anesth Analg 2006;102:1431-1438

 

最小量的全身麻醉可产生遗忘和无反应。尽管麻醉药对神经离子载体蛋白联合体有很多调控作用,但尚不清楚其导致的电生理改变的结果是否是临床麻醉作用的唯一机制。环境改变会导致细胞发生多方面的变化,包括 DNA转录改变使细胞蛋白也发生变化。我们试图通过研究大脑基因表达的变化情况,寻找可能的目标,涉及麻醉药引起遗忘过程及全身麻醉的持续长时间不良反应,包括恶心和术后认知减退。本实验应用SD大鼠(对照组为10只,异氟醚组为6只)通过采用Affymetrix基因芯片,给予大鼠2% (1.4 MAC)异氟醚15 min6 h,观察大鼠杏仁核基底的完整表达基因的表达变化。给予异氟醚使管理各种功能的269特殊基因表达发生改变。受影响的基因与DNA转录、蛋白合成、代谢、信号级联放大、细胞支架结构蛋白和神经特异性蛋白等等有关。即使短暂给予异氟醚也可在给药后6 h导致杏仁核基因控制的广泛改变。基因表达是一个动力学改变,也许可以解释麻醉的一些长时间影响,且用特殊分子治疗可潜在调节其中一些影响。

(赵雪莲 译 马皓琳 李士通 校)

General anesthesia, at a minimum, provides amnesia and unresponsiveness. Although anesthetics have many modulatory effects on neuronal ionophore protein complexes, it is not clear that the resulting electrophysiologic changes are the sole mechanisms of clinical anesthetic action. Cells respond to environmental changes in several ways, including alterations in DNA transcription leading to changes in the cell's proteins. We sought to expose the changes in global genomic expression, seeking potential targets involved in the processes of anesthetic-induced amnesia, and persistent long-term side effects of general anesthesia, including nausea and postoperative cognitive decline. Using Affymetrix GeneChips, we surveyed changes in expression across the entire expressed genome of Sprague-Dawley rat (n = 10 baseline, n = 6 isoflurane) basolateral amygdala 6 h after exposure to 15 min of 2% (1.4 MAC) isoflurane. Isoflurane administration was associated with altered expression in 269 unique genes possessing functional annotation. Affected genes were related to DNA transcription, protein synthesis, metabolism, signaling cascades, cytoskeletal structural proteins, and neural-specific proteins, among others. Even brief exposure to isoflurane leads to widespread changes in the genetic control in the amygdala 6 h after exposure. Gene expression is a dynamic process that may explain some long-term effects of anesthesia and that has the potential to modulate some of those effects using specific molecular therapeutics.

 

 

熵指数与双频指数作为测量异丙酚脑电图效应的手段

Spectral Entropy and Bispectral Index as Measures of the Electroencephalographic Effects of Propofol

Richard Klaus Ellerkmann, MD*, Martin Soehle, MD*, Thorsten Michael Alves*, Vidal-Markus Liermann*, Ingobert Wenningmann, MD*, Heiko Roepcke, MD*, Sascha Kreuer, MD{dagger}, Andreas Hoeft, MD, PhD*, and Jörgen Bruhn, MD*

*Department of Anesthesiology and Intensive Care Medicine, University of Bonn; and {dagger}Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Germany

Anesth Analg 2006;102:1456-1462

 

最近,Datex-Ohmeda介绍了熵模块TM来衡量麻醉深度。以脑电图Shannon熵为基础,计算出状态熵(SE)和反应熵(RE)。我们调查了异丙酚麻醉中SERE的量效关系,并与脑电双频指数TMBIS)作了对比。我们研究了20名没有外科手术刺激的患者。麻醉诱导经由前臂大静脉以2000 mg/h (451 ± 77 µg·min1·kg1)的不变速度输注异丙酚。输注异丙酚,直至真正的爆发性抑制发生(超过50%)或平均动脉压降至低于60 mm Hg。此后,在BIS值升至60以前,停止输注异丙酚。接着,重新开始以2000 mg/h的不变速度输注异丙酚以提高麻醉深度,当BIS值在4060之间时,再次停止输注异丙酚。计算出决定系数(R2)和预测可能性(PK)以评价SE、RE和BIS对于预测异丙酚效应部位浓度改变的性能。SE、RE和BIS的R2值相似,分别为0.88 ± 0.080.89 ± 0.070.92 ± 0.06。然而,计算出的PK值却显示出了SEREBIS值的明显差异, PK值分别为0.77 ± 0.090.76 ± 0.100.84 ± 0.06。当用PK测量 而不是用R2测量时,与SERE值相比,BIS值显示出了在预测异丙酚效应部位浓度方面的微小优势。

(黄丽娜 译 马皓琳 李士通 校)

Recently, Datex-Ohmeda introduced the Entropy ModuleTM for measuring depth of anesthesia. Based on the Shannon entropy of the electroencephalogram, state entropy (SE) and response entropy (RE) are computed. We investigated the dose-response relationship of SE and RE during propofol anesthesia in comparison with the Bispectral IndexTM (BIS). Twenty patients were studied without surgical stimulus. Anesthesia was induced by a constant propofol infusion of 2000 mg/h (451 ± 77 µg·min1·kg1) via a large forearm vein. Propofol was infused until substantial burst suppression occurred (more than 50%) or mean arterial blood pressure decreased to <60 mm Hg. Hereafter, infusions were stopped until recovery of BIS values up to 60 was reached. Subsequently, the constant propofol infusion of 2000 mg/h was restarted to increase depth of anesthesia and again decreased (infusion was stopped) within the BIS value range of 4060. The coefficient of determination (R2) and the prediction probability (PK) were calculated to evaluate the performance of SE, RE, and BIS to predict changing propofol effect-site concentrations. R2 values for SE, RE, and BIS of 0.88 ± 0.08, 0.89 ± 0.07, and 0.92 ± 0.06, respectively, were similar. The calculated PK values, however, revealed a significant difference between SE and RE compared with BIS, with PK = 0.77 ± 0.09, 0.76 ± 0.10, and 0.84 ± 0.06, respectively. BIS seems to show slight advantages in predicting propofol effect-site concentrations compared with SE and RE, as measured by PK but not as measured by R2.

 

 

腹腔镜对比剖腹肌瘤切除术:一个评估术后疼痛的双盲研究

Laparoscopic Versus Open Myomectomy: A Double-Blind Study to Evaluate Postoperative Pain

A. Holzer, MD*, S. T. Jirecek, MD{dagger}, U. M. Illievich, MD*, J. Huber, MD{dagger}, and R. J. Wenzl, MD{dagger}

Departments of *Anaesthesiology and General Intensive Care Medicine and {dagger}Obstetrics and Gynecology; Medical University of Vienna, Austria

Anesth Analg 2006;102:1480-1484

 

腹腔镜对比剖腹手术的优点在非盲研究方法中已有引证。我们的前瞻双盲方法比较了进行腹腔镜或者剖腹肌瘤切除术的病人,手术后72小时时疼痛评分。研究包括40个涉及保守的肌瘤切除术的女病人。在对肌瘤大小、数量和手术医生分层后,病人被随机分在腹腔镜组(n = 19)或剖腹组(n = 21),并且接受标准化的麻醉和术后24小时的病人自控镇痛。应用相同的伤口敷料覆盖伤口来使病人和观察者不知手术方法。手术后244872小时,用视觉模拟评分 (VAS; 0 =不痛 和 10 = 不能忍受的疼痛) 记录手术后疼痛评分。作为主要的结果变量,我们计算这些时点所有VAS-评分平均值。P < 0.05 (t-检验和协方差分析)被认为有统计学差异。组间病人的情况没有差异。腹腔镜组所有244872小时的VAS评分平均值在统计学上显著低于剖腹组 (2.28 ± 1.38 4.03 ± 1.63; P < 0.01)。我们第一次用双盲方法得出的数据表明,腹腔镜肌瘤切除术比剖腹手术减少手术后72小时的疼痛。

(张 曦 译 马皓琳 李士通 校)

The advantages of laparoscopic over open surgery have been documented in nonblinded settings. Our prospective, double-blind setting evaluated pain scores 72 h after surgery by comparing patients who underwent laparoscopic myomectomy or with laparotomy. Forty women referred for conservative myomectomy were included in the study. After stratification (myoma size, number of myomas, and surgeon), patients were randomized to either laparoscopy (n = 19) or laparotomy (n = 21) and received a standardized anesthesia and patient-controlled analgesia for 24 h after surgery. Identical wound dressings were applied to blind the patient and the observer to the surgical approach. The postoperative pain scores were documented on a visual analog scale (VAS; 0 = no and 10 = unbearable pain) at 24, 48, and 72 h after surgery. As the primary outcome variable, we calculated the mean overall VAS-score at these time points. P < 0.05 (t-test and analysis of covariance) was considered statistically significant. There were no differences in patient characteristics among the groups. The mean overall VAS score at 24, 48, and72 h was statistically significantly lower in the laparoscopic group compared with the laparotomy group (2.28 ± 1.38 versus 4.03 ± 1.63; P < 0.01). Our data demonstrate, for the first time in a double-blind setting, that laparoscopic myomectomy reduces postoperative pain for 72 h after surgery compared with laparotomy.

 

 

重症患者潮气量对液体反应的动力学参数的影响

The Influence of Tidal Volume on the Dynamic Variables of Fluid Responsiveness in Critically Ill Patients

Cyril Charron, MD, Christine Fessenmeyer, MD, Claudine Cosson, PhD, Jean-Xavier Mazoit, MD, PhD, Jean-Louis Hebert, MD, PhD, Dan Benhamou, MD, and Alain R. Edouard, MD, PhD

Service dAnesthésie-Réanimation et Unité Propre de Recherche de lEnseignement Supérieur-Equipe dAccueil (UPRES-EA 3540); Laboratoire de Biochimie Générale; Laboratoire dExplorations Fonctionnelles Cardiorespiratoires; Université de Paris Sud, Hôpital de Bicêtre (APHP), Le Kremlin Bicêtre, France

Anesth Analg 2006;102:1511-1517

 

有人提议用心脏搏出量和动脉脉压中的呼吸相关变异度({Delta}%Pp)来预测液体反应性。我们研究了行机械通气的病人潮气量(Vt)和肾上腺能张力对这些变量的影响。在血管内容量扩张之前和之后同时测定主动脉流速-时间积分({Delta}%VTIAo,超声心动图)和{Delta}%Pp(导管)的周期变化,并随机改变Vt使之高于或低于基础值。使用羟乙基淀粉(100ml 60秒)进行血管内扩容。以{Delta}%VTIAo{Delta}%Pp和左室横截面舒张末面积(超声心动图)生成接受者操作特征曲线,认为血管内容量扩张后心搏出量的变化(≥15%)为反应标准。使用协方差分析检验Vt{Delta}%VTIAo {Delta}%Pp的影响。这项前瞻性研究共包括21位病人;9人(43%)对血管内容量扩张有反应。有反应者的{Delta}%VTIAo {Delta}%Pp较无反应者高。当潮气量处于适当水平时,{Delta}%VTIAo {Delta}%Pp的预测值相似(阈值分别为20.4% 10.0%),且较左室横截面舒张末期面积的预测值高。{Delta}%Pp略微与去甲肾上腺素剂量相关。{Delta}%Pp在血管内容量扩张前和扩张后均随着Vt水平的增加而增加,但{Delta}%VTIAo意外地保持稳定。结论,{Delta}%VTIAo{Delta}%Pp都是血管内液体反应性的良好预测指标,但是当Vt增加时两者发展趋势不同,这需要进一步的解释。

(颜涛 译 马皓琳 李士通 校)

Respiratory-related variabilities in stroke volume and arterial pulse pressure ({Delta}%Pp) are proposed to predict fluid responsiveness. We investigated the influence of tidal volume (Vt) and adrenergic tone on these variables in mechanically ventilated patients. Cyclic changes in aortic velocitytime integrals ({Delta}%VTIAo, echocardiography) and {Delta}%Pp (catheter) were measured simultaneously before and after intravascular volume expansion, and Vt was randomly varied below and above its basal value. Intravascular volume expansion was performed by hydroxyethyl starch (100 mL, 60 s). Receiver operating characteristic curves were generated for {Delta}%VTIAo, {Delta}%Pp and left ventricle cross-sectional end-diastolic area (echocardiography), considering the change in stroke volume after intravascular volume expansion (≥15%) as the response criterion. Covariance analysis was used to test the influence of Vt on {Delta}%VTIAo and {Delta}%Pp. Twenty-one patients were prospectively included; 9 patients (43%) were responders to intravascular volume expansion. {Delta}%VTIAo and {Delta}%Pp were higher in responders compared with nonresponders. Predictive values of {Delta}%VTIAo and {Delta}%Pp were similar (threshold: 20.4% and 10.0%, respectively) and higher than that of left ventricle cross-sectional end-diastolic area at the appropriate level of Vt. {Delta}%Pp was slightly correlated with norepinephrine dosage. {Delta}%Pp increased with the increase in the level of Vt both before and after intravascular volume expansion, contrasting with an unexpected stability of {Delta}%VTIAo. In conclusion, {Delta}%VTIAo and {Delta}%Pp are good predictors of intravascular fluid responsiveness but the divergent evolution of these two variables when Vt was increased needs further explanation.

 

 

开颅手术中用于探测静脉气体栓塞的心前区多普勒探头最佳放置方法

Precordial Doppler Probe Placement for Optimal Detection of Venous Air Embolism During Craniotomy

Armin Schubert, MD, MBA*{dagger}, Anupa Deogaonkar, MD, MPhil{ddagger}, and John C. Drummond, MD, FRCPC§

*Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH; {dagger}Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH; {ddagger}Division of Anesthesiology and Critical Care, Cleveland Clinic Foundation, Cleveland, OH; §Department of Anesthesiology, University of California, San Diego; and Department of Anesthesiology, VA Medical Center, San Diego, CA

Anesth Analg 2006;102:1543-1547

 

确认合适的前胸壁心前区多普勒探头的位置对早期发现静脉气体栓塞至关重要。我们研究了选择性开颅手术中在不同探头部位对生理盐水(NS)或二氧化碳(CO2)试验注射的反应。所有病人均接受4次注射(10mL生理盐水和1mL二氧化碳,通过中心和外周静脉导管)。用两个分开的探头同时记录多普勒声。在A组,探头放置在胸骨左缘和右缘。在B组,左侧探头被故意放置在错误的部位,远远地侧于左心前区,但与声音信号一致。A(n=23)23例病人左侧胸骨旁多普勒信号均可很容易地收集到,而23例中18例可以收集到右侧胸骨旁信号(P < 0.05)。B组病人(n=17)中中心静脉内注射CO2产生的右侧胸骨旁阳性反应率88%,而离左心前区较远的反应率为29%(P <0.015),,中心静脉注射生理盐水的反应率是76%(与中心静脉CO2相比P<0.015)。左侧胸骨旁放置探头对临床静脉气体栓塞的敏感性至少与右侧胸骨旁放置探头相仿。外周静脉注射生理盐水表现了另一个可供选择的可行方法(反应率为83%)。但是在中心静脉快速注射10mL生理盐水会在心前区左侧放置的探头可能产生假阳性的确认。

(张莹 译 马皓琳 李士通 校)

Verification of appropriate precordial Doppler probe position over the anterior chest wall is crucial for early detection of venous air embolism. We studied responses to normal saline (NS) and carbon dioxide (CO2) test injections at various probe locations during elective craniotomy. All patients received four IV injections (10 mL of NS and 1 mL of CO2 via central and peripheral venous catheters). Doppler sounds were simultaneously recorded with two separate probes. In Group A, probes were placed in left and right parasternal positions. In Group B, the left probe was intentionally malpositioned as far laterally over the left precordium as was compatible with an audible signal. In Group A (n = 23), a left parasternal Doppler signal was easily obtainable in 23 of 23 patients, versus 18 of 23 patients for the right parasternal probe (P < 0.05). In Group B (n = 17), central CO2 injection yielded a positive right parasternal response rate of 88% compared with 29% over the far left precordium (P < 0.015), where central NS injections yielded a 76% response rate (P < 0.015 versus central CO2 injection). Left parasternal placement is at least as sensitive to clinical venous air embolism events as right parasternal placement. Peripheral saline injection represents a viable alternative (83% response rate). Vigorous central injection of 10 mL of NS however, risks false positive verification of left lateral precordial probe placement.

 

 

刺激后束提高锁骨下臂丛神经阻滞的成功率

Stimulation of the Posterior Cord Predicts Successful Infraclavicular Block

Harish Lecamwasam, MD, James Mayfield, MD, Laura Rosow, BA, Yuchiao Chang, PhD, Christopher Carter, MD, and Carl Rosow, MD, PhD

Department of Anesthesia and Critical Care, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts; Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta, Georgia

Anesth Analg 2006;102:1564-1568

 

常常在臂从神经鞘内定位某一神经束并将所有局麻药溶液注射到此定位点来实行锁骨下臂丛神经(IC)阻滞。我们假设刺激后束能提高锁骨下臂丛神经(IC)阻滞的成功可能性。我们选取369例择期行前臂或手部手术的病人,进行前瞻性非随机观察试验。所有进行的IC阻滞均采用标准方法,并记录给药前即刻刺激的神经束。注射后15分钟评估运动和感觉神经功能。与刺激侧束和中间束相比,刺激后束使更多的神经中运动阻滞起效快,阻滞失败的可能性下降(运动和感觉阻滞不足以进行手术)。失败率刺激后束为5.8%,侧束为28.3%P<0.05,中间束为15.4P<0.05)。为了多种混淆因素(例如性别、体重指数、切口部位及个人操作阻滞的技术水平)调整时,三组之间差异高度显著。(P<0.001,侧束与后束比较;P=0.003,中间束与后束比较)。同时刺激多束能减少失败率(P<0.05)。我们得出结论,在后束定位或者同时在多束神经定位后注药能提高IC阻滞的成功率。

(邱郁薇 译 马皓琳 李士通 校)

Infraclavicular (IC) block is often performed by localizing one cord within the brachial plexus sheath and placing all the local anesthetic solution at that location. We hypothesized that posterior cord stimulation would be associated with a greater likelihood of IC block success. We enrolled 369 patients scheduled for surgery to the lower arm or hand in a prospective, nonrandomized observational trial. All underwent IC blocks using a standard technique, and the cord stimulated immediately before drug injection was recorded. Motor and sensory functioning were evaluated 15 min after injection. Compared with stimulation of either the lateral or medial cord, stimulation of the posterior cord was associated with rapid onset of motor block in significantly more nerves, as well as a decreased likelihood of block failure (motor and sensory block inadequate to perform surgery). Failure rates were 5.8% for posterior cord, 28.3% for lateral (P < 0.05), and 15.4% for medial (P < 0.05). The differences were highly significant when adjusted for multiple possible confounders, such as gender, body mass index, location of the incision, and level of training of the individual performing the block (P < 0.001, lateral versus posterior; P = 0.003, medial versus posterior). A low failure rate was also predicted by stimulation of more than one cord simultaneously (P < 0.05). We conclude that injection after locating the posterior cord or multiple cords predicts successful IC block.