Anesthesia & Analgesia

May 2006

Table of Content

CARDIOVASCULAR ANESTHESIA:

腹膜內CO2充氣主動脈手術時心功能:一項經食道超聲心動圖研究

(曹瑜 陳傑 校)

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

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

Anesth Analg 2006 102: 1304-1310

緊急肺栓子切除術全麻誘導後的急性血流動力惡化

(孫敏莉譯 薛張綱校)

Acute Hemodynamic Collapse After Induction of General Anesthesia for Emergent Pulmonary Embolectomy

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

Anesth Analg 2006 102: 1311-1315

用凝血彈力圖® Ecarin凝血時間化驗測定患者的比伐盧定血漿水平:與標準啟動凝血時間的比較

(彭中美 馬皓琳 李士通 )

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

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

Anesth Analg 2006 102: 1316-1319

小劑量重組活性因數Ⅶ(NovoSeven®)用於心臟手術

(肖潔 陳傑 校)

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

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

Anesth Analg 2006 102: 1320-1326.

頸內靜脈中心靜脈導管中心界標的準確性

(金琳 薛張綱校)

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

Anesth Analg 2006 102: 1327-1332.

在豬的麻醉及手術過程中測定自主神經系統的活性:對不同方法的評價

(裘毅敏 馬皓琳 李士通 校)

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

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

Anesth Analg 2006 102: 1333-1340.

七氟醚麻醉預處理對小鼠脊髓缺血再灌注損傷無保護作用。

(吳德華譯 薛張綱校)

Anesthetic Preconditioning with Sevoflurane Does Not Protect the Spinal Cord After an Ischemic-Reperfusion Injury in the Rat

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

Anesth Analg 2006 102: 1341-1347.

糖原合成酶激酶的抑制增強異氟醚誘導的早期再灌注期間抗心肌梗塞的保護作用

(潘志英 陳傑 校)

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

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

Anesth Analg 2006 102: 1348-1354.

一種抗凋亡的線粒體通透性轉換調節因數——B細胞淋巴瘤-2蛋白在兔對異氟醚誘導和缺血後處理的影響

(黃施偉 馬皓琳 李士通 校)

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

Anesth Analg 2006 102: 1355-1360

PEDIATRIC ANESTHESIA:

小兒外科軟組織或畸形矯正手術使用撲熱息痛、優布芬或二者聯合時的鎮痛效能

(韓曉丹譯 薛張綱校)

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

Anesth Analg 2006 102: 1365-1371

吹氣球對減輕患兒靜脈穿刺痛的有效性評價:前瞻性隨機對照研究

(趙延華 陳傑 校)

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

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

Anesth Analg 2006 102: 1372-1375.

對小兒患者重要的術後結果是什麼?

(黃佳佳 馬皓琳 李士通 校)

What Postoperative Outcomes Matter to Pediatric Patients?

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

Anesth Analg 2006 102: 1376-1382

七氟烷麻醉的小兒增殖腺切除術後托烷司瓊或可樂定對激惹發生的預防

(周荻譯 薛張綱校)

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.

AMBULATORY ANESTHESIA:

腹腔鏡手術病人口服格拉司瓊和靜注昂丹司瓊預防嘔吐作用的對比:嘔吐症狀和恢復質量

(李啟芳 陳傑 校)

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

Anesth Analg 2006 102: 1387-1393

成年病人催眠有利於減少術前焦慮

(薑旭暉 馬皓琳 李士通 校)

Hypnosis Reduces Preoperative Anxiety in Adult Patients

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

Anesth Analg 2006 102: 1394-1396.

ANESTHETIC PHARMACOLOGY:

常規麻醉藥和芳香族麻醉藥通過N-甲基-D-天門冬氨酸受體(NMDA)介導的肌松作用的研究

(陸文清譯 薛張綱校)

Contrasting Roles of the N-Methyl-d-Aspartate Receptor in the Production of Immobilization by Conventional and Aromatic Anesthetics

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

Anesth Analg 2006 102: 1397-1406

不同結構全麻藥物對人體NMDA受體的不同調節

(範穎輝 陳傑 校)

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

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

Anesth Analg 2006 102: 1407-1411

N-甲基d-天冬氨酸受體是否介導吸入麻醉藥抑制最低肺泡氣有效濃度時間疊加效應?

(周雅春 馬皓琳 李士通 校)

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

Anesth Analg 2006 102: 1412-1418

大鼠中2-, 3-, 4-醇和酮的最低肺泡麻醉劑濃度:與麻醉機制的相關性

(徐麗穎譯 薛張綱校)

The Minimum Alveolar Anesthetic Concentration of 2-, 3-, and 4-Alcohols and Ketones in Rats: Relevance to Anesthetic Mechanisms

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 Anesth

Analg 2006 102: 1419-1426.

接受異丙酚+瑞芬太尼和七氟醚+瑞芬太尼的麻醉病人支氣管粘液移動速率的比較

(鄭麗 陳傑 校)

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

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

Anesth Analg 2006 102: 1427-1430

異氟醚可調控大鼠杏仁核中染色體的表達

(趙雪蓮 馬皓琳 李士通 校)

Isoflurane Modulates Genomic Expression in Rat Amygdala

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

Anesth Analg 2006 102: 1431-1438.

快速阿片類藥物解毒中應用S()氯胺酮可減弱腦電描記儀上腦電活動的增加及感覺誘發電位的幅度

( 靜譯 薛張綱校)

S(+)-Ketamine Attenuates Increase in Electroencephalograph Activity and Amplitude Height of Sensory-Evoked Potentials During Rapid Opioid Detoxification

Enno Freye, Leo Latasch, and Joseph Victor Levy

Anesth Analg 2006 102: 1439-1444.

新型丁丙諾啡前體的長效製劑具有長時間的抗傷害作用

(忻紀華 陳傑 校)

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

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

Anesth Analg 2006 102: 1445-1451.

TECHNOLOGY, COMPUTING, AND SIMULATION:

熵指數與雙頻指數作為測量異丙酚腦電圖效應的手段

(黃麗娜 馬皓琳 李士通 )

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

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

Anesth Analg 2006 102: 1456-1462

以衛星通訊和國際互聯網來實現遠端麻醉監控

(孫卓真譯 薛張綱校)

Remote Anesthetic Monitoring Using Satellite Telecommunications and the Internet

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

Anesth Analg 2006 102: 1463-1467

PAIN MEDICINE:

生活質量和情緒療法對神經性疼痛的影響:疼痛減輕效應如何?

(顧新宇 陳傑 校)

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

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

Anesth Analg 2006 102: 1473-1479.

腹腔鏡對比剖腹肌瘤切除術:一個評估術後疼痛的雙盲研究

( 馬皓琳 李士通 校)

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

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

Anesth Analg 2006 102: 1480-1484

細胞鈣穩態對化療所致的疼痛性周圍神經病的異常調節

(王慧琳譯 薛張綱校)

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

Chiang Siau and Gary J. Bennett

Anesth Analg 2006 102: 1485-1490

CRITICAL CARE AND TRAUMA:

肺萎陷的選擇性復原方法對肺功能及血液動力學的影響:一項豬的實驗研究

(宋金超 陳傑 校)

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

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

Anesth Analg 2006 102: 1504-1510.

重症患者潮氣量對液體反應的動力學參數的影響

(顏濤 馬皓琳 李士通 校)

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

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

Anesth Analg 2006 102: 1511-1517.

己酮可哥堿全身或局部灌注對失血後高滲的復蘇的協同作用

( 薛張綱校)

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

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

Anesth Analg 2006 102: 1518-1524

NEUROSURGICAL ANESTHESIA:

應用體感誘發電位判斷脊髓手術中病人體位元與可能發生的上肢神經損傷之間的關係:一項回顧性研究

(蘇殿三 陳傑 校)

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

Anesth Analg 2006 102: 1538-1542.

開顱手術中用於探測靜脈氣體栓塞的心前區多普勒探頭最佳放置方法

(張瑩 馬皓琳 李士通 校)

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

Armin Schubert, Anupa Deogaonkar, and John C. Drummond

Anesth Analg 2006 102: 1543-1547

異氟醚和半胱天冬酶8抑制劑合用對局部腦缺血的大鼠有持久的神經保護作用

(王麗珺譯 薛張綱校)

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

Anesth Analg 2006 102: 1548-1555

REGIONAL ANESTHESIA:

老年病人髖部骨折修復術使用單次小劑量和導管連續注射布比卡因行脊麻的比較

(殷文淵 陳傑 校)

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

Vincent Minville, Olivier Fourcade, David Grousset, Clément Chassery, Luc Nguyen, Karim Asehnoune, Aline Colombani, Lounès Goulmamine, and Kamran Samii
Anesth Analg 2006 102: 1559-1563.

刺激後束提高鎖骨下臂叢神經阻滯的成功率

(邱鬱薇 馬皓琳 李士通 校)

Stimulation of the Posterior Cord Predicts Successful Infraclavicular Block

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

Anesth Analg 2006 102: 1564-1568.

GENERAL ARTICLES:                   

麻醉醫師和同一醫院的非麻醉醫師淋巴細胞姐妹染色體交換的比較

(王麗珺譯 薛張綱校)

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

Ahmet Eroglu, Figen Celep, and Nesrin Erciyes

Anesth Analg 2006 102: 1573-1577.

用四個成串刺激(TOF)、雙短強直刺激(DBS)、50Hz強直刺激、100Hz強直刺激和加速度儀(ACC)對手或手腕進行刺激監測可感知肌力衰減

(張美榮 陳傑 校)

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

Anesth Analg 2006 102: 1578-1584

 

緊急肺栓子切除術全麻誘導後的急性血流動力惡化

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

 

患者行肺栓子切除術,在全麻誘導時,常面臨血流動力學惡化。因此,我們研究在全麻誘導期間血流動力學惡化的發生率和可能的危險因素。我們收集了52名在我們機構行緊急肺栓子切除術的患者。在全麻誘導後血流動力學崩潰定義為使用血管升壓藥及inotrope後依然難以控制的低血壓,或需經緊急心肺轉流(CPB)的心肺復蘇及液體管理。人口統計學變數、共存疾病、栓子的特殊位置、術前心肌收縮力的支持治療,以及全麻誘導時麻醉藥物的使用,作為可能的危險因素被評估。全麻誘導後,19%的病人發生血流動力學崩潰(n=10)。然而,血流動力學不穩定的發生不能通過任何已評估的危險因素來預測。另外,住院期間,血流動力學穩定與不穩定患者的死亡率發生沒有不同(分別為10%4/42 10%1/10)。結論為,緊急肺栓子切除術全麻誘導後,血流動力學惡化經常發生。 以我們這項研究經驗為基礎結合血流動力學惡化的不可預測性,我們建議行肺栓子切除術的患者在全麻誘導前應該準備並且消毒鋪巾,心臟外科醫生根據需要應立即可到,進行心肺轉流術。

(孫敏莉譯 薛張綱校)

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.

 

頸內靜脈中心靜脈導管中心界標的準確性

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.

 

我們使用中心界標模擬進針通路,進行頸內靜脈中心靜脈導管穿刺置管。107位元受試者置於頭低腳高位,頭低30-35度,我們對他們進行超聲影像檢查,以定量測量界標的準確性(精密度和偏倚)。與此同時,我們測定發生動脈穿刺的頻率。使用中心界標模擬進針通路,與頸內靜脈導管中心80%的位置不符的受試者有34%(95%的可信限[CI]25%44%),橫跨過頸動脈的受試者有26%(95CI18%35%)。發生上述兩種情況的受試者占20%(95CI13%29%)。界標中央偏倚的平均值為3.7mm95CI2.74.8);相對來說,使用中心界標行右頸內靜脈置管更容易置於中心位置(104為受試者中有77位)(P<0.001)。肥胖患者使用界標更容易錯過頸內靜脈(比值比,3.11P<0.016),更容易發生動脈穿刺(比值比,3.03P<0.024)。由於中心界標的不準確性和偏倚,使用其進行穿刺指導,在不損傷頸動脈的情況下一針穿刺成功的可能性不高。當使用中心界標輔助進行中心靜脈置管時需考慮到測量偏倚。

(金琳 薛張綱校)

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.

 

 

七氟醚麻醉預處理對小鼠脊髓缺血再灌注損傷無保護作用。

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.

 

麻醉預處理(APC)是一種保護性機制,因此給予吸入麻醉藥可以對隨後產生的缺血性損傷有抵抗作用。我們設想用七氟醚進行脊髓預處理能降低缺血再灌注後神經的損傷。小鼠隨機分成15組。缺血預處理組(IPC組,n14)給予3minIPC30min再灌注,12min缺血。慢性麻醉預處理組(cSEVO組,n14)在缺血前2天給予1h3.5%七氟醚。急性APC組(aSEVO組,n14)在缺血前給予1h3.5%七氟醚及隨後的1h洗出。IPC組能降低缺血再灌注損傷,而aSEVOcSEVO組沒有顯示出比控制組更好的結果。脊髓組織學顯示除了IPC組和假裝手術的小鼠外,在所有組都顯示了嚴重的神經損害。七氟醚APC不能降低小鼠脊髓缺血模型的神經損害。傳統的缺血預處理對神經具有很好的保護作用。

(吳德華譯 薛張綱校)

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.

 

 

小兒外科軟組織或畸形矯正手術使用撲熱息痛、優布芬或二者聯合時的鎮痛效能

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.

 

幾項成人研究顯示撲熱息痛和一種非甾體類抗炎藥聯合用於術後鎮痛的效果要好於單獨使用其中的任何一種藥。然而,目前雖有撲熱息痛的推薦劑量在使用,但是還沒有關於小兒的這方面研究。在這項雙盲、安慰劑對照試驗中,我們隨機抽取了120個一至九歲的行軟組織或畸形矯正手術兒童,將他們分成三組,一組為經直腸給撲熱息痛60 mg/kg或口服給藥40 mg/kg,一組為靜脈給優布芬2 mg/kg(一天兩次),另一組為聯合給藥。在麻醉誘導時給予藥物的首劑量,第二個劑量在其後的八小時給予。術中麻醉使用七氟烷和持續輸注的雷米芬太尼。術後疼痛是通過行為客觀疼痛評分(09分)來評估24小時。病人復蘇時使用嗎啡0.05 mg/kg靜脈輸注。主要的變數是嗎啡消耗量。研究中我們使用了統計分析、變數分析、chi2實驗和卡普蘭-邁耶曲線。

(韓曉丹譯 薛張綱校)

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

 

七氟烷麻醉的小兒增殖腺切除術後托烷司瓊或可樂定對激惹發生的預防

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.

 

 

 

在七氟烷麻醉後兒童的術後激惹是一個常見的問題。在本項研究中,我們評估托烷司瓊或可樂定是否能降低小兒增殖腺切除術後的激惹發生率。我們將751-7歲的未術前用藥的小兒隨機分組,在麻醉誘導後分別接受安慰劑,托烷司瓊(0.1mg/kg)或可樂定(1.5µg/kg)。麻醉誘導和維持使用七氟烷。患者同時接受阿芬太尼(20µg/kg)和diclofenac1mg/kg)。術後鎮痛使用IV羥考酮(0.05mg/kg)。記錄完成標準的時間。用改良的疼痛/不適量表來評估術後行為。術後激惹的發生率托烷司瓊組顯著減少(32%8/25病人)與對照組相比(62%16/26病人,P<0.05)。可樂定不能預防激惹(發生率54%13/24)。研究中無副反應報導。出現時間組間相似(平均8099分鐘)。總結,托烷司瓊0.1mg/kg顯著減少七氟烷麻醉後激惹的發生率,可樂定1.5 µg/kg對術後激惹預防作用與安慰劑無差異。

(周荻譯 薛張綱校)

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 1–7 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.

 

 

常規麻醉藥和芳香族麻醉藥通過N-甲基-D-天門冬氨酸受體(NMDA)介導的肌松作用的研究
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

我們假設吸入麻醉藥的肌松作用部分或是完全由NMDA受體介導的,也有可能激動某些有害的反應。在離體試驗中,這直接和吸入麻醉藥阻斷    NMDA受體有關。為了驗證這個假說,我們檢測靜脈注射NMDA阻滯劑MK-801CPP來降低8種常規吸入麻醉藥(環丙烷,地氟醚,安氟醚,氟烷,異氟醚,一氧化二氮,七氟醚和氙)和8種芳香族化合物(苯,氟苯,鄰二氟苯, 對二氟苯, 1,2,4-三氟苯, 1,3,5-三氟苯, 五氟苯和六氟苯)MAC值,依託咪酯作為對照組。我們假設注射的MK-801CPP通過阻斷NMDA受體會成反比的降低這些吸入麻醉藥的MAC值。這個觀點在芳香族化合物被驗證是正確的,但在常規的吸入麻醉藥中沒有得到驗證。注入最大劑量的MK-80132ug/kg·min)降低常規吸入麻醉藥MAC值的59.4 +/- 3.4%,注入8ug/kg·min降低MAC值的45.5 +/- 4.2%,這和注入EC50的依託咪酯降低MAC51.4 +/- 19.0%沒有明顯的差異。依託咪酯通過加強GABA的作用起到麻醉作用。我們得出結論,某些芳香族化合物通過阻斷NMDA受體上的谷氨酸產生肌松作用,同時激動某些有害的反應,而常規的吸入麻醉藥並沒有這種作用。

(陸文清譯 薛張綱校)

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劑濃度:與麻醉機制的相關性

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假說提出麻醉劑效能與親脂性呈負相關;如常用吸入麻醉藥的MAC乘以油/氣分配係數等於一個常數,約1.82 +/- 0.56 atm (mean +/- sd)MAC是消除50%的個體對傷害性刺激體動所需的麻醉劑最低肺泡濃度。與常用吸入麻醉藥相比,從甲醇到辛醇的常規醇類的MAC乘以油/氣分配係數所得的常數為其十分之一。醇(C-OH)基使醇對水有很大的親和力,並且C-OH可將醇限制在麻醉劑起作用的疏水-親水介面。我們假設C-OH基的位置決定效能,可能通過最大範圍的調節使得分子酰基部分能伸入疏水層。採用相同推理,我們增加了在C=O基和末端甲基間具有相似碳原子數的酮的研究。醇和酮的研究結果都顯示了預計的相關性,但此相關性與相同碳鏈長度而氧原子位置不同時幾乎相等。油/氣分配係數對效能的預計與鏈長或氧原子位置相同或更佳。水/氣分配係數代表的親水性似乎也影響效能。

(徐麗穎譯 薛張綱校)

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.

 

快速阿片類藥物解毒中應用S()氯胺酮可減弱腦電描記儀上腦電活動的增加及感覺誘發電位的幅度

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.


麻醉輔助阿片類藥物解毒為常規無法解毒的患者提供了機會。很少有人知道發生在中樞神經系統中的興奮性效應。因為快速解毒是通過N-甲基-D-()冬氨酸(NMDA)受體啟動完成的,我通過實驗看非特異性NMDA拮抗劑S(+)氯胺酮是否能減少中樞神經系統的高活性。31個曾濫用阿片類藥物的患者在用異丙酚/可樂定麻醉機械通氣的過程中很快脫離納曲酮。腦電圖能譜和正中神經誘發體感電位SSEP由以下決定:在解毒前,異丙酚/可樂定麻醉,納曲酮注射後30分鐘,S(+)氯胺酮注射後560分鐘。和麻醉相比,納曲酮的腦電圖低delta減少了270%,快delta增加了110%,theta-(3-7 Hz) alpha-(7-13 Hz)改變不大。同時,SSEPlate N(100)的平均幅度從3.3 muV 增加到10.5 muV。可由S(+)氯胺酮減弱。心血管系統的改變不是快速戒斷症狀和決定快速阿片類藥物解毒終點的可靠指數。所以,腦電圖能譜和SSEP是更有效的指標。S(+)氯胺酮是麻醉中的有效輔助藥,因為它能減弱在快速阿片類藥物解毒中的中樞神經系統高活性。

(鍾 靜譯 薛張綱校)

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.

 

以衛星通訊和國際互聯網來實現遠端麻醉監控

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.

 

遠端實施麻醉需要相當大量的生理和影音資料在一資料平臺上進行合理地整合。一個厄瓜多爾與美國之間的低速寬帶就可以支持一次有效的遠端麻醉包括手術計畫的制定、氣道的評估、術中和蘇醒的判斷。用一個速度為64-Kbps的衛星電話可實現厄瓜多爾的MacasSucua Ecuador與美國的Richmond Virginia之間進行包括術前病人評估、氣管插管的影像資料、心電圖波形、脈搏氧飽和度測定、動脈壓力監測、二氧化碳監測和呼吸音聽診等資料的資料交換。

(孫卓真譯 薛張綱校)

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

 

 

細胞鈣穩態對化療所致的疼痛性周圍神經病的異常調節

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.


化療藥物紫衫醇和長春新堿常會引起長時間的疼痛性周圍神經病。我們通過使用藥物降低細胞內外鈣離子來研究鈣調節受損是否會導致化療相關的神經疼痛綜合征。為同抗HIV核苷23-雙去氧胞嘧啶(ddC)比較,我們將小鼠的神經損傷做成疼痛性周圍神經病。正常組(無神經病),用紫衫醇治療組,用長春新堿治療組分別進行以下鞘內注射:TMB-8 (46 nmol), Quin-2 (1.8 nmol), EGTA (0.1 micromol), EGTA-am (0.1 micromol)。注射TMB-8Quin-2後小鼠有慢性萎縮性損傷(CCI)。注射ddC後損傷出現在注射TMB-8之後。在每次注射後評估機械性疼痛和機械性感覺過敏。在CCI小鼠中可以看到藥物的溫度敏感作用。四種減少鈣離子的藥物能顯著抑制接受紫衫醇、長春新堿和ddC治療的小鼠的機械性疼痛和機械性感覺過敏,但對CCI和正常組無作用。我們因此得出結論:用紫衫醇、長春新堿和ddC治療造成的疼痛歸咎於細胞鈣穩態的異常,但細胞鈣穩態的異常與創傷後疼痛性周圍神經病無關。

(王慧琳譯 薛張綱校)

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.

 

 

己酮可哥堿全身或局部灌注對失血後高滲的復蘇的協同作用

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.

 

小容量的高滲鹽溶液([HS] 7.5% NaCl)對失血動物的全身情況和微循環都有好處。在失血性休克後給予己酮可哥堿(PTX)可獲有益的效果。因此我們假設在對失血性休克開始治療時即聯合應用HSPTX可對改善血流動力學獲得協同作用,並對此做了檢驗。二十四隻狗經放血至目標動脈血壓40mmHg後隨機分為三組:乳酸鈉林格氏液組(33 mL/kgn = 6)、HS組(7.5% NaCl 4 mL/kgn = 9)和HS+PTX組(7.5% NaCl 4 mL/kg + PTX 15 mg/kgn = 9)。通過Swan-Ganz導管和動脈置管監測全身血流動力學。同時計算胃粘膜-動脈Pco2梯度(Dg-aPco2;氣體張力測量儀)、門靜脈血流(超聲流量探頭)和全身及局部O2含量改變。HS可導致動脈平均壓、心輸出量和門靜脈血流量一定程度的升高。在HS+PTX組,我們觀察到比HS單獨使用時顯著但短暫的全身氧輸送的增加(180 ± 17 141 ± 13 mL/min)。與單獨輸注HSDg-aPco2減少(48.2 ± 6.4 39.4 ± 5.5 mm Hg)相比,在高滲的復蘇過程中注PTX可促使Dg-aPco2顯著減少(41.8 ± 4.8 25.7 ± 3.9 mm Hg)。我們認為,PTX在高滲的復蘇時作為輔助藥可以改善心血管狀態和胃粘膜氧供。

(金 薛張綱校)

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 Ringer’s 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.

 

 

異氟醚和半胱天冬酶8抑制劑合用對局部腦缺血的大鼠有持久的神經保護作用

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.

 

儘管在缺血後短期恢復期間,異氟醚可減少缺血性神經損傷,但我們實驗室的資料證實,這種神經保護作用並非是持久的,而神經細胞的調亡,部分是由半胱天冬酶介導,從而使梗死灶逐漸擴大。我們假設如果應用z-IETD-fmk,一種特殊的半胱天冬酶8抑制劑,異氟醚的神經保護作用將被延長。大鼠用異氟醚麻醉並隨機分為清醒染色劑組、異氟醚染色劑組、清醒IETD組和異氟醚-IETD組(每組25只)。我們阻斷大腦中動脈(MCAO)使大鼠處於60分鐘的局部腦缺血。每天在缺血前,通過植入的導管腦室內注射z-IETD-fmk或染色劑,直到阻斷大腦中動脈後14天。缺血後14天評價神經系統功能,同時測定腦梗面積及皮質腦梗灶周圍完整神經元的數量。異氟醚-IETD組的總梗死面積小於其他三組。清醒IETD組的腦梗面積比清醒染色劑組小。和其他各組相比,清醒染色劑組的皮質腦梗灶周圍完整神經元數量顯著減少。MCAO14異氟醚-IETD組的神經保護作用由於各染色劑組。結果表明:異氟醚和半胱天冬酶8抑制劑合用,其神經保護作用即使在14天恢復期後,依然是顯著的。兩者合用比單用任何一種效果都好。這些結果與之前觀點一致,即在腦梗恢復期,由於細胞調亡使梗死面積擴大,而它的抑制劑具有持久的神經保護作用。

(王麗珺譯 薛張綱校)

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

 

 

麻醉醫師和同一醫院的非麻醉醫師淋巴細胞姐妹染色體交換的比較

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.

 

已有報導,在暴露於麻醉性氣體的手術室工作人員中,外周淋巴細胞姐妹染色體交換(SCEs)的發生率有所上升。我們研究了麻醉醫師SCEs的上升是否可逆。25名暴露於麻醉性氣體如七氟醚和笑氣的麻醉醫師和同一醫院的內科醫師比較。測定手術室的七氟醚和笑氣的濃度。通過淋巴細胞培養,分別測定麻醉醫師在離開手術室之前及之後兩個月的SCE發生。這些SCE和非暴露組的內科醫師的SCE比較。職業性暴露於手術室的七氟醚和笑氣的SCE值高於閾值。麻醉醫師和內科醫師的SCE值有顯著差異(11.9 +/- 4.4 vs 4.2 +/- 1.1, P < 0.001)。離開手術室兩個月後,麻醉醫師的SCE值明顯低於手術室內測定值(分別是4.8 +/- 1.8 11.9 +/- 4.4, P < 0.001)。我們推斷:如果離開暴露環境兩個月,暴露於麻醉性氣體如七氟醚和笑氣中麻醉醫師SCE的上升是可逆的。

(王麗珺譯 薛張綱校)

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.

 

腹膜內CO2充氣主動脈手術時心功能:一項經食道超聲心動圖研究

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.

 

腹腔鏡對心功能的影響仍有爭議。作者假設在擇期行腹主動脈修復術的病人中心功能不全主要用於後負荷增加引起。為了證明這一假設,作者在15名擇期行腹腔鏡主動脈手術的病人中進行了一項經食道超聲心動圖的研究。系統測量左室和右室功能。首先測定病人仰臥位沒有氣腹和氣腹腹內壓為14mmHg時心功能。然後體位改為右側臥位,測定不用氣腹、腹內壓上升到7mmHg14mmHg時心功能。氣腹使動脈壓上升了25%,左室收縮期室壁應力上升了38%。左室射血分數下降25%,左室每搏量下降了18%。同時伴有左室收縮末期容量的增加。左室收縮功能的受損並不伴有左室收縮末期容量的變化。沒有觀察到上腔靜脈管徑隨呼吸的變化,表明容量狀態仍是理想的。隨腹內壓增加和體位的改變,右室每搏量隨呼吸變化增加,提示右室後負荷的增加。結論:擇期行腹腔鏡主動脈手術病人腹膜內CO2充氣使左室和右室收縮功能受損,主要由於後負荷增加所致。

(曹瑜 陳傑 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.

 

小劑量重組活性因數Ⅶ(NovoSeven®)用於心臟手術

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.

不同劑量的重組活性因數Ⅶ(rFa)曾用於心臟手術病人。作者檢測小劑量rFa用於治療心臟手術後的病人發生難治性出血有效性。研究組包括了15名存在難治性出血的心臟手術病人,按事先確定輸液方案一步步輸液治療末期靜脈緩注小劑量的(1.2mgrFa15名病情匹配患者進行用rFa使用前同樣的液體治療作為對照組。在輸液治療後的失血量是最主要的結果。25th75th24小時失血量中位數分別為研究組16851590-1770mL和對照組31702700-3850mLP0.0004)。研究組和對照組的輸血,輸冰凍血漿和血小板分別為:74-8U1812-21UP0.001);7.56-11U119-15UP0.003);00-4U96-13UP0.001)。另外,在研究組和對照組之間凝血酶原時間(P0.015),國際規範比(P=0.006,部分活化凝血酶原時間(P0.01),血小板記數(P=0.003),以上所有結果均有顯著改善。最後,接受rFa治療的病人在ICU停留時間明顯縮短(Х215.9P0.0001),再次手術探查的發生率降低(Х216.2P<0.0001)。小劑量的rFa緩慢注射用於存在難治性出血的心臟病人的療效是滿意的。目前還需要進一步的隨機研究來證實作者的研究結果。

(肖潔 陳傑 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, 25th–75th 24-h blood loss percentiles were 1685 (1590–1770) mL versus 3170 (2700–3850) 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 (4–8) U versus 18 (12–21) U (P = 0.001); 7.5 (6–11) U versus 11 (9–15) U (P = 0.003); 0 (0–4) U versus 9 (6–13) 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強異氟醚誘導的早期再灌注期間抗心肌梗塞的保護作用

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-再灌注損傷作用。冠狀動脈阻塞後再灌注前和再灌注中異氟醚短時間處理,也可產生抗心肌梗死作用。糖原合成酶激酶-β是否媒介這中作用仍不清楚。作者驗證以下設想:GSK抑制能增強異氟醚誘導的缺血預處理作用。兔子(n88;每組67只)冠狀動脈閉塞30min,然後以生理鹽水灌注3h,在灌注前和灌注後2min吸入異氟醚(0.5 1.0 MAC) 3 min,選擇性的GSK抑制劑SB216763 (SB21; 0.2 0.6 mg/kg), 0.5 MAC異氟醚加上SB210.2 mg/kg。其他組的兔子以磷脂酰肌醇-3(PI3K)抑制劑渥曼青黴素(0.6 mg/kg), 70-kDa核糖體蛋白s6 激酶 (p70s6K) 抑制劑雷怕黴素(0.25 mg/kg)預處理,或線粒體通透性轉變孔(mitochondrial permeability transition pore,mPTP) 開啟器蒼術苷 (5 mg/kg) 0.6 mg/kg SB21 0.5 MAC 異氟醚 0.2 mg/kg SB21 。另外的組用mPTP抑制劑環孢黴素A (5 mg/kg), 加上 0.2 mg/kg SB21用或不用蒼術苷預處理。與對照組相比(42% ±6%),異氟醚(1.0 MAC而不是0.5 MAC)SB21 (0.6 mg/kg而不是0.2 mg/kg)減少梗塞面積(分別為21% ±5%, 44% ±7%, 23% ± 4%, and 46% ± 2%, 均數+/- 標準差; 氯化三苯四唑染色)。異氟醚(0.5 MAC) 加上0.2 mg/kg SB21 和環孢黴素A 0.2 mg/kg SB21產生相似的保護作用(分別為24% ± 4% 27% ± 6%),蒼術苷而不是渥曼青黴素或雷怕黴素阻止了0.6 mg/kg SB21 0.5 MAC 異氟醚 0.2 mg/kg SB21的心肌保護作用。因此GSK抑制可以增強由mPTP-依賴的異氟醚誘導抗早期再灌注損傷作用。

(潘志英 陳傑 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.

 

吹氣球對減輕患兒靜脈穿刺痛的有效性評價:前瞻性隨機對照研究

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.

 

靜脈穿刺對住院患兒來說是最常見的痛苦。作者評價了吹氣球對緩解患兒靜脈穿刺痛的有效性。該項前瞻性隨機研究包括756-12歲患兒,ASA I-II級,男女均有,行擇期手術。患兒隨機平均分為三組,每組25名:組I(對照組)、組II(娛樂組)拍橡皮球、組III(氣球組)吹氣球。紮緊前臂的靜脈後,用22G靜脈導管進行靜脈穿刺。通過疼痛面部表情尺規來反映疼痛,該尺規的背面是長度為10cm的視覺類比尺規(VAS),0= “無痛10 =“最痛VAS評分1-3分為輕度疼痛,4-6分為中度疼痛,>6為嚴重疼痛。氣球組VAS評分的中值(四分位距)為13),分別低於娛樂組的2 (2)和對照組的4 (2) (P < 0.000)。同時觀察到氣球組的靜脈穿刺痛發生率和嚴重程度,與其他兩組相比顯著減少(P < 0.05)

(趙延華 陳傑 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 6–12 yr, ASA physical status I–II, 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, 4–6 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).

 

腹腔鏡手術病人口服格拉司瓊和靜注昂丹司瓊預防嘔吐作用的對比:嘔吐症狀和恢復質量

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.

通過對接受致吐性化療病人的對比研究, 人們認為格拉司瓊比昂丹司瓊對斷藥後噁心嘔吐(PDNY)效果更佳, 但迄今為止尚無此兩種HT3拮抗劑對PDNY和恢復質量的直接對比報導。 本文隨機、雙盲研究腹腔鏡手術病人口服格拉司瓊(1mg)或常規靜注昂丹司瓊(4 mg)的止吐作用。兩個醫學中心全麻行腹腔鏡手術病人220,對照(昂丹司瓊):術前1h口服安慰劑, 術後昂丹司瓊(4 mg) 靜注, 格拉司瓊組: 術前1h口服格拉司瓊(1mg), 術後2ml生理鹽水靜注。 隨後的48小時記錄病人的復蘇狀態,止吐劑的需求,PDNY的發生及藥物副作用。術後通過11點語言評級對噁心嘔吐程度評級,術後48h記錄復蘇質量及病人滿意度評分。兩組病人的人口學特徵,病人定向力的恢復時間,口服量和住院時間無差異, 兩組病人的PDNY發生率,對止吐劑的需求及復蘇質量也無差異。格拉司瓊和昂丹司瓊取得一致的止吐滿意分別花費26.6547.05美元。因此,在門診和住院病人的腹腔鏡手術,常規地預防性止吐, 昂丹司瓊(4 mg i.v.) 的花費-收益比格拉司瓊更佳。

(李啟芳 陳傑 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.

 

不同結構全麻藥物對人體NMDA受體的不同調節

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受體被認為是傷害性疼痛刺激的興奮性突觸遞質。儘管先前的研究已發現吸入麻醉劑在臨床相關濃度抑制NMDA受體通路,但採用不同的實驗設計,受體亞型,和/或組織來源會混淆吸入麻醉劑對NMDA受體抑制效應的定量比較。本研究致力於填補這一空白,採用雙電極電壓鉗技術,不同臨床芳香族吸入麻醉劑抑制人NMDA受體在非洲蟾蜍光滑卵母細胞表達的NR1/NR2B亞型,在1個最小肺泡有效濃度,麻醉成分可逆性抑制NMDA受體從12±6%到74±6%。這些結果證實相同麻醉濃度的吸入麻醉劑對NMDA受體的抑制程度不同。這些不同也許對確定這些受體在全麻藥的作用有意義。

(範穎輝 陳傑 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.

 

接受異丙酚+瑞芬太尼和七氟醚+瑞芬太尼的麻醉病人支氣管粘液移動速率的比較

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.

 

在離體試驗中顯示揮發性麻醉藥降低了纖毛的運動頻率。曾有報導支氣管纖毛運輸速度(BTV)的受損與肺部合併症的增高顯著相關。在這項研究中,作者旨在通過在體研究比較瑞芬太尼+異丙酚的全憑靜脈麻醉(TIVA)和七氟醚+瑞芬太尼時BTV的差異。擇期22名普外科手術病人隨機分為兩組:全憑靜脈麻醉組(異丙酚+瑞芬太尼),七氟醚組(七氟醚+瑞芬太尼)。氣管插管後30分鐘,通過纖支鏡觀察右主支氣管表面亞甲蘭染料移動獲取BTV。相對于全憑靜脈麻醉組,七氟醚組BTV顯著降低(七氟醚組1.5±0.70-2.3mm/min ,全憑靜脈麻醉組4.8±2.12.3-8.8mm/minP <0.0001)。與全憑靜脈麻醉比較,七氟醚麻醉可以導致支氣管纖毛的清潔作用顯著受損。這可能與圍術期肺部併發症相關聯,尤其是肺部合併症高危的病人。

(鄭麗 陳傑 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 [0–2.3] versus 4.8 ± 2.1 [2.3–8.8] 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.

 

新型丁丙諾啡前體的長效製劑具有長時間的抗傷害作用

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.

對於伴有長期疼痛的病人可能需要的是一種長時間作用的鎮痛藥物。本研究中,作者比較了在大鼠中肌注三種新型的丁丙諾啡前體的長效製劑:丙酸丁丙諾啡,庚酸丁丙諾啡和葵酸丁丙諾啡的抗傷害作用和作用維持時間。同時比較了肌注後三種製劑的藥代過程。以蹠肌反應評估抗傷害作用。以高性能液態色譜儀測定丁丙諾啡的血藥濃度。作者發現傳統的鹽酸製劑的抗傷害作用具有劑量依賴性。鹽酸丁丙諾啡(0.6umol/kg)產生長達5小時的抗傷害作用。而同等劑量的堿基丁丙諾啡,丙酸丁丙諾啡,庚酸丁丙諾啡和葵酸丁丙諾啡具有分別長達26285270小時的抗傷害作用。藥代動力學研究證實所有類型的丁丙諾啡鹽製劑均為丁丙諾啡的前體物質。結論:新型丁丙諾啡前體的長效製劑―― 丙酸丁丙諾啡,庚酸丁丙諾啡和葵酸丁丙諾啡都具有長時間的抗傷害作用。

(忻紀華 陳傑 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.

 

生活質量和情緒療法對神經性疼痛的影響:疼痛減輕效應如何?

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.

情緒和生活質量對神經性疼痛試驗結果改變很大,這可能是不穩定的鎮痛和其他治療效應的結果。作者通過嗎啡、加巴噴丁、嗎啡聯合加巴噴丁的試驗檢測疼痛、副作用、生活質量和情緒,以此評估神經性疼痛中疼痛減少與情緒、生活質量之間的關係。生活質量基線是根據健康生存得分簡表,情緒基線則根據可比較的正常人群情緒狀態評分。三種試驗處理有效的疼痛減少與生活質量的提高相關。嗎啡組、加巴噴丁組的疼痛減少與情緒改善有關,嗎啡聯合加巴噴丁使疼痛減少,而情緒狀態範圍內的任意一項改善就能使嗎啡聯合加巴噴丁組的疼痛減少。治療中鎮靜、便秘、口幹的嚴重性與情緒、生活質量改變無關。這些結果暗示更大的止痛治療效果是來自於實際生活質量和/或情緒的改善。儘管如此,其他有益或不利的治療相關副作用也可能影響情緒和生活質量。因此,今後的研究需要評估鎮痛試驗中治療相關副作用對情緒/生活質量的影響。

(顧新宇 陳傑 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.

 

肺萎陷的選擇性復原方法對肺功能及血液動力學的影響:一項豬的實驗研究

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:研究人為肺萎陷的選擇性復原方法是否比全肺復原方法更會增加肺氧合和肺容量,並有較小的迴圈副作用。方法:10只麻醉狀態的豬進行人工通氣,支氣管的阻滯物嵌入右下葉,選擇性灌洗以製備實驗性肺萎陷模型。將10只豬隨機分成兩組:一組是先選擇性復原方法(維持40cmH2O氣道壓30s)隨後全肺復原,另一組則相反。結果:選擇性肺復原方法的呼氣末肺容量中位數和PaO2中位數顯著增加,分別增加了100mL16kPa左右,在兩種模式之間沒有顯著的差異。在選擇性肺復原方法無迴圈(血液動力學)的改變,但是在全肺復原方法中,平均動脈壓顯著下降(中位數36mmHg, 25百分位數值和第75百分位數值為21, 41mmHg)心輸出量下降了2.11.6, 2.5L/min,左心室舒張末期的面積4.4 (3.5, 4.5)cm2.結論:選擇性肺復原方法與全肺復原方法相比具有相同的肺功能改善但沒有迴圈副作用。

(宋金超 陳傑 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.

 

應用體感誘發電位判斷脊髓手術中病人體位元與可能發生的上肢神經損傷之間的關係:一項回顧性研究

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.

體感誘發電位(SSEP)監測可以用於預防脊髓手術中的神經損傷並能檢查上肢神經的功能變化。SSEP傳導的變化可以顯示上肢可能的神經損傷。作者對1000例行脊髓手術的病人進行了SSEP監測以觀察手術體位對上肢神經功能的影響。研究結果發現絕大部分(92%)患者上肢SSEP改變可以通過改變手臂的位置得到改善,因此都歸類為體位相關。對這種體位相關的SSEP改變進行計算,並且比較了五種不同的體位:仰臥伸手位、仰臥卷手位、側臥位、俯臥卷手位、俯臥“超人”位。體位元相關SSEP改變的總發生率為6.1%。與其他體位相比,側臥位(7.5%)和俯臥超人位(7.0%)上肢SSEP改變的發生率明顯高於其他體位(1.8-3.2%)。沒有病人因為術中出現可以逆轉SSEP改變而造成術後功能缺陷的。總之,研究者認為,SSEP監測是一種很有價值的發現和轉變可能發生的上肢位元周神經損傷的手段。

(蘇殿三 陳傑 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.

 

老年病人髖部骨折修復術使用單次小劑量和導管連續注射布比卡因行脊麻的比較

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.

 

衰老和疾病會使老年病人在行脊麻期間易發生低血壓。作者根據持續脊麻(CSA)和小劑量單次注射脊麻(SA)的低血壓概率比較兩者的血流動力學影響。74名75歲以上接受髖部骨折修復手術的患者隨機分為兩組,每組37人。CSA組使用每15min給一次2.5mg等比重布比卡因,而SA組則單次注射7.5mg異布比卡因行脊麻。兩組的無創自動血壓在基線水平和CSA或SA後的總體變化都沒有顯著的統計學差異。在SA組,68%的患者都經歷了至少一次低血壓(收縮壓比基線值下降大於20%),CSA組只有31%的患者(P=0.005)。在SA組,51%的患者都經歷了至少一次嚴重的低血壓(收縮壓比基線值下降大於30%),CSA組只有8% (P<0.0001)。在CSA組中,麻黃素用量為4.5±2mg,SA組麻黃素用量為11±2mg的(P=0.005)。在CSA組中,麻醉劑用量為5mg(2.5-10mg),SA組用量為7.5mg(P<0.0001)。結論:對於接受髖部骨折手術修復的病人,與單次脊髓內注射7.5mg布比卡因相比,CSA較少發生低血壓和較嚴重低血壓事件。

(殷文淵 陳傑 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 (2.5–10) 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.

 

用四個成串刺激(TOF)、雙短強直刺激(DBS)、50Hz強直刺激、100Hz強直刺激和加速度儀(ACC)對手或手腕進行刺激監測可感知肌力衰減

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.

殘餘肌松可通過ACC,TOF,DBS, 50Hz強直刺激(TS)或100Hz強直刺激(TS)來評估。神經刺激可以在手或手腕上進行。作者在這兩個部位比較了以上所有的神經-肌肉刺激方法。32個病人在七氟醚麻醉下給予羅庫溴銨。測量遠端拇收肌肌動描記TOF比率。另外,隨機選擇手或手腕刺激,測量ACCTOF比率。在恢復期間,以盲法評估可感知肌力衰減。應用ACC TOF比率為0.31±0.15時,不能觀察到可感知肌力衰減。用DBS,閾值是0.76±0.1150Hz強直刺激閾值為0.31±0.15100Hz強直刺激閾值是0.88±0.18,範圍是0.14-1.00。這些反應對於手和手腕是一致的。當ACCTOF比率達到1.0時,肌動描記 TOF比率是0.89±0.06。刺激手時,ACCTOF比率超過1.0的情況比手腕的刺激出現的少。為了排除殘餘肌松,TOF, DBS, 50Hz強直刺激是不合適的,100Hz強直刺激不可靠的,而ACC效果最好。

(張美榮 陳傑 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 0.14–1.00. 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.

 

用凝血彈力圖® Ecarin凝血時間化驗測定患者的比伐盧定血漿水平:與標準啟動凝血時間的比較

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

 

標準啟動凝血時間(ACT)試驗與比伐盧定水平相關性較差,導致經皮冠脈介入治療患者的充分抗凝方面不確定。我們用來自于比伐盧定抗凝的80例行介入治療心臟病學手術患者的血液來檢驗血栓彈性描記儀®TEG®ecarin凝血時間(ECT)對比伐盧定的敏感性。這與用含矽藻土的標準凝血時間ACT分析比較。用TEG®分析時,直接凝血酶啟動劑-ecarin被用來發動凝結,並作為反應時間來測定。在獨立血液學的實驗室裏用顯色分析來評價血漿樣本中的比伐盧定。標準ACT對比伐盧定 水平線形回歸的r2 = 0.306 TEG® ECT對比伐盧定 水平的r2 = 0.746 (兩者 P < 0.0001)。證明TEG® ECT相對於標準ACT更有利於監測臨床治療範圍內的比伐盧定抗凝作用。

注:比伐盧定為短效可逆性抗凝血藥物

(彭中美 馬皓琳 李士通 )

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.

 

 

在豬的麻醉及手術過程中測定自主神經系統的活性:對不同方法的評價

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

 

在這項研究中,我們評價了對10只在七氟醚麻醉下行腹部手術的豬測定自主神經系統(ANS)活性的不同方法:ANSiscopeTM指數、心率變異性的譜分析、血流動力學變數及血漿兒茶酚胺及皮質醇水平。動物在120min麻醉下完成單側卵巢切除術。監測心血管及呼吸反應。ANSiscopeTM指數(交感指數ANSindexTM,副交感指數ANSindexTM及平衡指數balANSindexTM)用於監測ANS活性。使用參數方法自動回歸模型進行譜分析。使用低頻(LF)及高頻(HF)成分來分析短時程內心電圖(ECGs)功率譜密度。LF/(LF+HF)反映了交感活性,HF/(LF+HF)顯示了副交感活性,LF/HF比值大小反映了哪個系統佔優勢地位。監測不同時間點的血漿腎上腺素、去甲腎上腺素及皮質醇濃度。發現balANSindexTM與腎上腺素水平之間、LF/HF比值與血漿腎上腺素濃度之間存在相關性(P < 0.01)。而且,發現balANSindexTMLF/HF比值之間有顯著的相關性(P < 0.01)。然而,在登記的ANSiscope指數與血流動力學變數之間沒有發現相關性。本研究中發現的相關性提示balANSindexTM可作為麻醉及手術中監測ANS活性的有效工具。

(裘毅敏 馬皓琳 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.

 

 

一種抗凋亡的線粒體通透性轉換調節因數——B細胞淋巴瘤-2蛋白在兔對異氟醚誘導和缺血後處理的影響

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

 

冠狀動脈長時間堵塞後再灌注早期短暫給予異氟醚或反復、短暫的缺血可通過抑制線粒體通透性轉換孔道(mPTP)來保護心肌防止發生梗塞。延遲的缺血預處理過程中發生mPTP的抑制,同時伴有抗凋亡蛋白B細胞淋巴瘤-2Bcl-2)的表達增強。我們假設Bcl-2介導了再灌注期異氟醚或短暫缺血事件的心肌保護作用。對兔(n = 91)冠狀動脈左前降支阻斷30min之後再灌注3h,對此假設進行驗證。兔分別接受0.9%鹽水、再灌注之前3min和之後2min異氟醚(0.51.0MAC)、再灌注早期3個迴圈的缺血後處理(每次10s20s)、0.5MAC的異氟醚加3個迴圈的缺血後處理(10s)、或在有或無選擇性Bcl-2抑制劑HA14-12 mg/kg, i.p.)的情況下使用mPTP的直接抑制劑環孢黴素ACsA, 10 mg/kg)。異氟醚(1.0而不是0.5MAC)和缺血後處理(20s而不是10s)明顯(P < 0.05)減少梗塞範圍(分別占左室危險部位的21% ± 4%43% ± 7%19% ± 7% 39% ± 11%,平均值±標準差),而對照組為44% ± 4%0.5MAC的異氟醚加10s的缺血後處理和單獨使用CsA也有保護作用。單獨使用HA14-1並不影響梗塞面積也不阻斷由CsA產生的保護作用,卻取消了由1.0MAC異氟醚、20s的缺血後處理以及0.5MAC的異氟醚加10s的缺血後處理所產生的縮小梗塞面積的作用。這些結果提示在體內Bcl-2通過間接調製mPTP的活性來介導異氟醚誘導的和缺血後處理。

(黃施偉 馬皓琳 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.

 

 

對小兒患者重要的術後結果是什麼?

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 Children’s Hospital of Philadelphia; and {dagger}Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia

Anesth Analg 2006;102:1376-1382

 

在兒童醫療問題的決定上,經常由父母親代理,而將兒童自身排除在外。這樣的方法沒有考慮到父母和兒童在小兒健康問題上可能持有不同的觀點。在這項研究中,我們評估了與術後疼痛處理有關的兒童決定過程。研究了45例接受前交叉韌帶修補術或雞胸手術。用一個標準賭博方法評估兒童對於一種假想治療方法的效用的看法。假設這種方法在術後可以提供完美的疼痛控制,但有不同的嘔吐風險。所有患兒願意接受的將疼痛水平減小到零的最大嘔吐風險為32% ± 24%。女孩願意接受的嘔吐風險(41% ± 24%)要顯著高於男孩(25% ± 22%)(P = 0.02)。在被提問之前實際有嘔吐經歷的兒童願意接受的嘔吐風險(46% ± 26%)比無經歷者(23% ± 17%)(P = 0.035)。兒童們可以表達對他們首選的術後結果的看法,並且可以提供關於他們治療方案的有用資訊。看來與男孩相比,女孩認識到術後嘔吐的重要性低於疼痛控制。

(黃佳佳 馬皓琳 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 child’s health. In this study, we assessed children’s 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 children’s 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.

 

 

成年病人催眠有利於減少術前焦慮

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

 

在本次研究中我們檢查了催眠對術前焦慮的影響。我們將病人隨機分成三組,接受健康暗示的催眠組(n = 26)、接受注意傾聽和支持而無特殊催眠暗示的注意力控制組(n = 26)和“標準治療”對照組(n = 24)。我們測量了干預前後和進入手術室時的焦慮程度。我們發現催眠組干預後的焦慮程度顯著低於注意力控制組和對照組(運用方差分析,31±837±941±11P=0.008)。另外,在進入手術室時催眠組的焦慮水平顯著下降56%,而注意力控制組增加10%,對照組增加47%P=0.001)。總之我們發現催眠顯著減輕了術前焦慮程度。需要進一步的研究來檢查術前催眠對術後結果的影響。

(薑旭暉 馬皓琳 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-天冬氨酸受體是否介導吸入麻醉藥抑制最低肺泡氣有效濃度時間疊加效應?

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)受體可顯著降低吸入麻醉藥的最低肺泡氣有效濃度(MAC)。為了評估抑制MAC時間疊加效應中NMDA受體的重要性,我們採用不同刺激間期(ISIs)的成串電脈衝刺激大鼠尾部,並測定在不同ISIs可抑制大鼠體動的吸入麻醉藥濃度(交叉濃度)。交叉濃度與ISIs斜率之比可反映每種吸入麻醉藥時間疊加效應。我們研究了五種在離體實驗中阻斷NMDA受體能力差異很大的吸入麻醉藥。為了阻斷NMBA受體傳遞和揭示NMDA受體成分,在每個麻醉藥期間分別加入NMDA受體拮抗劑MK801。氟烷、異氟醚和六氟苯未抑制參與時間疊加效應的NMDA受體作用,該部占MAC21%到29%(每種麻醉藥 P< 0.05)。氙氣和o-二氟聯苯分別抑制NMDA受體對MAC作用至8%到0%(二者均無統計學意義),與它們在離體實驗中較強的NMDA受體阻斷作用一致。離體實驗中NMDA受體阻斷可影響強效抑制NMDA受體(而不是影響作用有限)的吸入麻醉藥產生的MAC

(周雅春 馬皓琳 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.

 

 

異氟醚可調控大鼠杏仁核中染色體的表達

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產生遺忘和無反應。儘管麻醉藥對神經離子載體蛋白聯合體有很多調控作用,但尚不清楚其導致的電生理改變的結果是否是臨床麻醉作用的唯一機制。環境改變會導致細胞發生多方面的變化,包括 DNA轉錄改變使細胞蛋白也發生變化。我們試圖通過研究大腦基因表達的變化情況,尋找可能的目標,涉及麻醉藥引起遺忘過程及全身麻醉的持續長時間不良反應,包括噁心和術後認知減退。本實驗應用SD大鼠(對照組為10只,異氟醚組為6只)通過採用Affymetrix基因晶片,給予大鼠2% (1.4 MAC)異氟醚15 min6 h,觀察大鼠杏仁核基底的完整表達基因的表達變化。給予異氟醚使管理各種功能的269特殊基因表達發生改變。受影響的基因與DNA轉錄、蛋白合成、代謝、信號級聯放大、細胞支架結構蛋白和神經特異性蛋白等等有關。即使短暫給予異氟醚也可在給藥後6 h導致杏仁核基因控制的廣泛改變。基因表達是一個動力學改變,也許可以解釋麻醉的一些長時間影響,且用特殊分子治療可潛在調節其中一些影響。

(趙雪蓮 馬皓琳 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.

 

 

熵指數與雙頻指數作為測量異丙酚腦電圖效應的手段

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介紹了熵模組TM來衡量麻醉深度。以腦電圖Shannon熵為基礎,計算出狀態熵(SE)和反應熵(RE)。我們調查了異丙酚麻醉中SERE的量效關係,並與腦電雙頻指數TMBIS)作了對比。我們研究了20名沒有外科手術刺激的患者。麻醉誘導經由前臂大靜脈以2000 mg/h (451 ± 77 µg·min–1·kg–1)的不變速度輸注異丙酚。輸注異丙酚,直至真正的爆發性抑制發生(超過50%)或平均動脈壓降至低於60 mm Hg。此後,在BIS值升至60以前,停止輸注異丙酚。接著,重新開始以2000 mg/h的不變速度輸注異丙酚以提高麻醉深度,當BIS值在4060之間時,再次停止輸注異丙酚。計算出決定係數(R2)和預測可能性(PK)以評價SEREBIS對於預測異丙酚效應部位濃度改變的性能。SEREBISR2值相似,分別為0.88 ± 0.080.89 ± 0.070.92 ± 0.06。然而,計算出的PK值卻顯示出了SEREBIS值的明顯差異, PK值分別為0.77 ± 0.090.76 ± 0.100.84 ± 0.06。當用PK測量 而不是用R2測量時,與SERE值相比,BIS值顯示出了在預測異丙酚效應部位濃度方面的微小優勢。

(黃麗娜 馬皓琳 李士通 )

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·min–1·kg–1) 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 40–60. 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.

 

 

腹腔鏡對比剖腹肌瘤切除術:一個評估術後疼痛的雙盲研究

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

 

腹腔鏡對比剖腹手術的優點在非盲研究方法中已有引證。我們的前瞻雙盲方法比較了進行腹腔鏡或者剖腹肌瘤切除術的病人,手術後72小時時疼痛評分。研究包括40個涉及保守的肌瘤切除術的女病人。在對肌瘤大小、數量和手術醫生分層後,病人被隨機分在腹腔鏡組(n = 19)或剖腹組(n = 21),並且接受標準化的麻醉和術後24小時的病人自控鎮痛。應用相同的傷口敷料覆蓋傷口來使病人和觀察者不知手術方法。手術後244872小時,用視覺類比評分 (VAS; 0 =不痛 10 = 不能忍受的疼痛) 記錄手術後疼痛評分。作為主要的結果變數,我們計算這些時點所有VAS-評分平均值。P < 0.05 (t-核對總和協方差分析)被認為有統計學差異。組間病人的情況沒有差異。腹腔鏡組所有244872小時的VAS評分平均值在統計學上顯著低於剖腹組 (2.28 ± 1.38 4.03 ± 1.63; P < 0.01)。我們第一次用雙盲方法得出的資料表明,腹腔鏡肌瘤切除術比剖腹手術減少手術後72小時的疼痛。

(張 馬皓琳 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.

 

 

重症患者潮氣量對液體反應的動力學參數的影響

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 d’Anesthésie-Réanimation et Unité Propre de Recherche de l’Enseignement Supérieur-Equipe d’Accueil (UPRES-EA 3540); Laboratoire de Biochimie Générale; Laboratoire d’Explorations Fonctionnelles Cardiorespiratoires; Université de Paris Sud, Hôpital de Bicêtre (APHP), Le Kremlin Bicêtre, France

Anesth Analg 2006;102:1511-1517

 

有人提議用心臟搏出量和動脈脈壓中的呼吸相關變異度({Delta}%Pp)來預測液體反應性。我們研究了行機械通氣的病人潮氣量(Vt)和腎上腺能張力對這些變數的影響。在血管內容量擴張之前和之後同時測定主動脈流速-時間積分({Delta}%VTIAo,超聲心動圖)和{Delta}%Pp(導管)的週期變化,並隨機改變Vt使之高於或低於基礎值。使用羥乙基澱粉(100ml 60秒)進行血管內擴容。以{Delta}%VTIAo{Delta}%Pp和左室橫截面舒張末面積(超聲心動圖)生成接受者操作特徵曲線,認為血管內容量擴張後心搏出量的變化(≥15%)為反應標準。使用協方差分析檢驗Vt{Delta}%VTIAo {Delta}%Pp的影響。這項前瞻性研究共包括21位病人;9人(43%)對血管內容量擴張有反應。有反應者的{Delta}%VTIAo {Delta}%Pp較無反應者高。當潮氣量處於適當水平時,{Delta}%VTIAo {Delta}%Pp的預測值相似(閾值分別為20.4% 10.0%),且較左室橫截面舒張末期面積的預測值高。{Delta}%Pp略微與去甲腎上腺素劑量相關。{Delta}%Pp在血管內容量擴張前和擴張後均隨著Vt水平的增加而增加,但{Delta}%VTIAo意外地保持穩定。結論,{Delta}%VTIAo{Delta}%Pp都是血管內液體反應性的良好預測指標,但是當Vt增加時兩者發展趨勢不同,這需要進一步的解釋。

(顏濤 馬皓琳 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 velocity–time 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.

 

 

開顱手術中用於探測靜脈氣體栓塞的心前區多普勒探頭最佳放置方法

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

 

確認合適的前胸壁心前區多普勒探頭的位置對早期發現靜脈氣體栓塞至關重要。我們研究了選擇性開顱手術中在不同探頭部位對生理鹽水(NS)或二氧化碳(CO2)試驗注射的反應。所有病人均接受4次注射(10mL生理鹽水和1mL二氧化碳,通過中心和外周靜脈導管)。用兩個分開的探頭同時記錄多普勒聲。在A組,探頭放置在胸骨左緣和右緣。在B組,左側探頭被故意放置在錯誤的部位,遠遠地側于左心前區,但與聲音信號一致。A(n=23)23例病人左側胸骨旁多普勒信號均可很容易地收集到,而23例中18例可以收集到右側胸骨旁信號(P < 0.05)。B組病人(n=17)中中心靜脈內注射CO2產生的右側胸骨旁陽性反應率88%,而離左心前區較遠的反應率為29%(P <0.015),,中心靜脈注射生理鹽水的反應率是76%(與中心靜脈CO2相比P<0.015)。左側胸骨旁放置探頭對臨床靜脈氣體栓塞的敏感性至少與右側胸骨旁放置探頭相仿。外周靜脈注射生理鹽水表現了另一個可供選擇的可行方法(反應率為83%)。但是在中心靜脈快速注射10mL生理鹽水會在心前區左側放置的探頭可能產生假陽性的確認。

(張瑩 馬皓琳 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.

 

 

刺激後束提高鎖骨下臂叢神經阻滯的成功率

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

 

常常在臂從神經鞘內定位某一神經束並將所有局麻藥溶液注射到此定位點來實行鎖骨下臂叢神經(IC)阻滯。我們假設刺激後束能提高鎖骨下臂叢神經(IC)阻滯的成功可能性。我們選取369例擇期行前臂或手部手術的病人,進行前瞻性非隨機觀察試驗。所有進行的IC阻滯均採用標準方法,並記錄給藥前即刻刺激的神經束。注射後15分鐘評估運動和感覺神經功能。與刺激側束和中間束相比,刺激後束使更多的神經中運動阻滯起效快,阻滯失敗的可能性下降(運動和感覺阻滯不足以進行手術)。失敗率刺激後束為5.8%,側束為28.3%P<0.05,中間束為15.4P<0.05)。為了多種混淆因素(例如性別、體重指數、切口部位及個人操作阻滯的技術水平)調整時,三組之間差異高度顯著。(P<0.001,側束與後束比較;P=0.003,中間束與後束比較)。同時刺激多束能減少失敗率(P<0.05)。我們得出結論,在後束定位或者同時在多束神經定位後注藥能提高IC阻滯的成功率。

(邱鬱薇 馬皓琳 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.