Anesthesia & Analgesia

 

June 2006

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

心臟外科手術前婦女的預成認知損害以及它與C-反應蛋白濃度之間的關係

(孫敏莉譯 薛張綱校)

Preexisting Cognitive Impairment in Women Before Cardiac Surgery and Its Relationship with C-Reactive Protein Concentrations

Charles W. Hogue, Jr, Tamara Hershey, David Dixon, Robert Fucetola, Abdullah Nassief, Kenneth E. Freedland, Betsy Thomas, and Kenneth Schechtman

Anesth Analg 2006 102: 1602-1608.

心臟手術後早期活動時混合靜脈血氧飽和度顯著下降:體位或鍛煉的影響?

(趙延華 陳傑 校)

The Marked Reduction in Mixed Venous Oxygen Saturation During Early Mobilization After Cardiac Surgery: The Effect of Posture or Exercise?

Idar Kirkeby-Garstad, Ulrik Wisløff, Eirik Skogvoll, Tomas Stølen, Arnt-Erik Tjønna, Roar Stenseth, and Olav FM Sellevold

Anesth Analg 2006 102: 1609-1616.

體外迴圈期間人體空腸粘膜灌注的自身調節

(彭中美 馬皓琳 李士通 校)

Autoregulation of Human Jejunal Mucosal Perfusion During Cardiopulmonary Bypass

Andreas Nygren, Anders Thorén, Erik Houltz, and Sven-Erik Ricksten

Anesth Analg 2006 102: 1617-1622.

心臟手術後白介素-6升高預示感染的發生

(金琳 薛張綱 審校)

Increased Interleukin-6 After Cardiac Surgery Predicts Infection

Michael Sander, Christian von Heymann, Vera von Dossow, Corinna Spaethe, Wolfgang F. Konertz, Uday Jain, and Claudia D. Spies

Anesth Analg 2006 102: 1623-1629.

體外迴圈冠狀動脈手術病人術後血清改變內皮Ca2+的信號轉導

(殷文淵 陳傑 校)

Endothelial Ca2+ Signal Transduction Is Altered by Postoperative Serum from Patients Undergoing Coronary Surgery with Cardiopulmonary Bypass

Crispin Schneider and Thomas Volk

Anesth Analg 2006 102: 1630-1637.

N-乙酰半胱氨酸對腹主動脈手術中腎功能受損的預防作用:一個隨機、雙盲、安慰劑對照試驗

(裘毅敏 馬皓琳 李士通 校)

N-Acetylcysteine for the Prevention of Kidney Injury in Abdominal Aortic Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

Marja S. Hynninen, Tomi T. Niemi, Reino Pöyhiä, Elina I. Raininko, Markku T. Salmenperä, Mauri J. Lepäntalo, Mikael J. Railo, and Minna K. Tallgren

Anesth Analg 2006 102: 1638-1645.

比較三種磷酸二酯酶III抑制劑對豚鼠離體心臟機械和代謝功能的影響

(吳德華譯 薛張綱校)

A Comparison of Three Phosphodiesterase Type III Inhibitors on Mechanical and Metabolic Function in Guinea Pig Isolated Hearts

York A. Zausig, David F. Stowe, Wolfgang Zink, Christoph Grube, Eike Martin, and Bernhard M. Graf

Anesth Analg 2006 102: 1646-1652.

經食管超聲心動圖在非心臟手術心臟停搏併入中的應用

(劉哲 陳傑

The Usefulness of Transesophageal Echocardiography During Intraoperative Cardiac Arrest in Noncardiac Surgery

Stavros G. Memtsoudis, Peter Rosenberger, Michaela Loffler, Holger K. Eltzschig, Annette Mizuguchi, Stanton K. Shernan, and John A. Fox

Anesth Analg 2006 102: 1653-1657.

PEDIATRIC ANESTHESIA:

兒科脊柱側突手術中瑞芬太尼輸注過程中急性阿片類藥物耐受的發生

(薑旭暉 馬皓琳 李士通 校)

Development of Acute Opioid Tolerance During Infusion of Remifentanil for Pediatric Scoliosis Surgery

Mark W. Crawford, Chantal Hickey, Christian Zaarour, Andrew Howard, and Basem Naser

Anesth Analg 2006 102: 1662-1667.

與嗎啡相比術中使用曲馬多對兒童心臟手術後採用護士控制鎮痛可以較早蘇醒和較少使用鎮靜劑

(金 路譯 薛張綱校)

Intraoperative Administration of Tramadol for Postoperative Nurse-Controlled Analgesia Resulted in Earlier Awakening and Less Sedation than Morphine in Children After Cardiac Surgery

Ya-Chun Chu, Su-Man Lin, Ying-Chou Hsieh, Kwok-Hon Chan, and Mei-Yung Tsou

Anesth Analg 2006 102: 1668-1673.

腦部MRI掃描能升高鎮靜小兒的中心體溫

(蘇殿三 陳傑 校)

Brain Magnetic Resonance Imaging Increases Core Body Temperature in Sedated Children

Yvon F. Bryan, Thomas W. Templeton, Todd G. Nick, Martin Szafran, and Avery Tung

Anesth Analg 2006 102: 1674-1679.

在兒科麻醉中超聲波引導下的髂腹股溝/髂腹下神經阻滯:最佳容量是多少?

(姜旭暉譯,馬皓琳 李士通校)

Ultrasonographic-Guided Ilioinguinal/Iliohypogastric Nerve Block in Pediatric Anesthesia: What is the Optimal Volume?

H. Willschke, A. Bösenberg, P. Marhofer, S. Johnston, S. Kettner, U. Eichenberger, O. Wanzel, and S. Kapral

Anesth Analg 2006 102: 1680-1684

兒科病人通過喉周導氣管對聲門上氣道的可視定位

(王麗珺譯 薛張綱校)

Video Assessment of Supraglottic Airway Orientation Through the Perilaryngeal Airway in Pediatric Patients

David M. Polaner, Dheeraj Ahuja, Jeannie Zuk, and Zhaoxing Pan

Anesth Analg 2006 102: 1685-1688

ANESTHETIC PHARMACOLOGY:

全麻藥抑制培養的海馬切片的縫隙連接間的資訊傳遞

(李啟芳 陳傑 校)

General Anesthetics Inhibit Gap Junction Communication in Cultured Organotypic Hippocampal Slices

Kirsten Wentlandt, Marina Samoilova, Peter L. Carlen, and Hossam El Beheiry

Anesth Analg 2006 102: 1692-1698

年齡增長延長成年人七氟醚/笑氣誘導的起效時間

(張 譯,馬皓琳 李士通 校)

Onset Time for Sevoflurane/Nitrous Oxide Induction in Adults Is Prolonged with Increasing Age

Michael C. Lewis, Ricardo I. Gerenstein, and Gilbert Chidiac

Anesth Analg 2006 102: 1699-1702.

七氟烷對大鼠氣管上皮細胞纖毛活動的作用:與異氟烷和氟烷比較

(周荻 薛張綱 校)

The Effect of Sevoflurane on Ciliary Motility in Rat Cultured Tracheal Epithelial Cells: A Comparison with Isoflurane and Halothane

Shogo Matsuura, Gotaro Shirakami, Hiroko Iida, Keiji Tanimoto, and Kazuhiko Fukuda

Anesth Analg 2006 102: 1703-1708.

氟烷、異氟烷對微電流刺激網狀細胞時引起腦電反應的效應差異

(顧新宇 陳傑 校)

The Differential Effects of Halothane and Isoflurane on Electroencephalographic Responses to Electrical Microstimulation of the Reticular Formation

Mashawn Orth, Emigdio Bravo, Linda Barter, Earl Carstens, and Joseph F. Antognini

Anesth Analg 2006 102: 1709-1714.

氙氣對兔肌原性動作誘發電位的作用:與丙泊酚和異氟醚的比較

(周雅春 馬皓琳 李士通 校)

The Effects of Xenon on Myogenic Motor Evoked Potentials in Rabbits: A Comparison with Propofol and Isoflurane

Yuri Yamamoto, Masahiko Kawaguchi, Meiko Kakimoto, Masahiro Takahashi, Satoki Inoue, Takahisa Goto, and Hitoshi Furuya

Anesth Analg 2006 102: 1715-1721.

環孢黴素和胰島素對大鼠缺血性脊髓損傷的的作用

(陸文清譯 薛張綱校)

The Effects of Cyclosporin A and Insulin on Ischemic Spinal Cord Injury in Rabbits

Shunsuke Tsuruta, Mishiya Matsumoto, Shiro Fukuda, Atsuo Yamashita, Ying Jun Cui, Hiroya Wakamatsu, and Takefumi Sakabe

Anesth Analg 2006 102: 1722-1727.

阿米替林的神經毒性由細胞凋亡介導並被Caspase抑制劑阻斷

(王震虹 陳傑 校)

The Neurotoxic Effects of Amitriptyline Are Mediated by Apoptosis and are Effectively Blocked by Inhibition of Caspase Activity

Philipp Lirk, Ingrid Haller, Barbara Hausott, Shota Ingorokva, Martina Deibl, Peter Gerner, and Lars Klimaschewski

Anesth Analg 2006 102: 1728-1733.

使離體鼇蝦巨軸突傳導阻滯的利多卡因和布比卡因的細胞內濃度的比較

(顏濤 譯, 馬皓琳 李士通校)

A Comparison of Intracellular Lidocaine and Bupivacaine Concentrations Producing Nerve Conduction Block in the Giant Axon of Crayfish In Vitro

Takeshi Yano, Shoichiro Ibusuki, and Mayumi Takasaki

Anesth Analg 2006 102: 1734-1738.

利多卡因抑制誘生型一氧化氮合酶和陽離子氨基酸轉運蛋白2在有活性的鼠類巨噬細胞中的轉錄可能與電壓敏感性鈉通道有關

(韓曉丹譯 薛張綱校)

Lidocaine Inhibition of Inducible Nitric Oxide Synthase and Cationic Amino Acid Transporter-2 Transcription in Activated Murine Macrophages May Involve Voltage-Sensitive Na+ Channel

Yun-Fang Kai, Chen-Hsien Yang, and Chun-Jen Huang

Anesth Analg 2006 102: 1739-1744.

TECHNOLOGY, COMPUTING, AND SIMULATION:

腦電圖衰退和針灸

(鍾靜譯 薛張綱校)

Electroencephalogram-Entropy and Acupuncture

Gerhard Litscher

Anesth Analg 2006 102: 1745-1751.

一種優化充氣止血帶壓力測量動脈阻斷壓的新方法

(宋金超 陳傑 校)

New Method for Estimating Arterial Occlusion Pressure in Optimizing Pneumatic Tourniquet Inflation Pressure

Bahattin Tuncali, Ayse Karci, Binnur Erdalkiran Tuncali, Omur Mavioglu, Mustafa Ozkan, Abdul Kadir Bacakoglu, Hakan Baydur, Ahmet Ekin, and Zahide Elar

A Anesth Analg 2006 102: 1752-1757.

傳統動脈血氣分析研究動脈氧分壓波動的含義

(張瑩 馬皓琳 李士通 校)

The Implications of Arterial Po2 Oscillations for Conventional Arterial Blood Gas Analysis

Birgit Pfeiffer, Rebecca S. Syring, Klaus Markstaller, Cynthia M. Otto, and James E. Baumgardner

Anesth Analg 2006 102: 1758-1764.

PAIN MEDICINE:

嗎啡、可待因和美沙酮及其對映體在不同的大鼠疼痛模型的作用

(王慧琳譯 薛張綱校)

Morphine, Oxycodone, Methadone and Its Enantiomers in Different Models of Nociception in the Rat

Kim Lemberg, Vesa K. Kontinen, Kaarin Viljakka, Irene Kylänlahti, Jari Yli-Kauhaluoma, and Eija Kalso

Anesth Analg 2006 102: 1768-1774.

顱脊神經媒介大鼠經顱電刺激法中的抗傷害作用

(張美榮 陳傑 校)

The Role of the Craniospinal Nerves in Mediating the Antinociceptive Effect of Transcranial Electrostimulation in the Rat

Vladimir Nekhendzy, M. Frances Davies, Hendrikus J. M. Lemmens, and Mervyn Maze

Anesth Analg 2006 102: 1775-1780.

嗎啡-6-葡萄糖醛酸:用於術後鎮痛的嗎啡代替品

(黃佳佳譯 馬皓琳 李士通校)

Morphine-6-Glucuronide: Morphine's Successor for Postoperative Pain Relief? (Review Article)

Eveline L. A. van Dorp, Raymonda Romberg, Elise Sarton, James G. Bovill, and Albert Dahan

Anesth Analg 2006 102: 1789-1797.

CRITICAL CARE AND TRAUMA:

志願受試者急性疼痛期間乙琥紅黴素促進胃排空

(潘志英 陳傑 校)

Erythromycin Promotes Gastric Emptying During Acute Pain in Volunteers

Lionel Bouvet, Frédéric Duflo, Nathalie Bleyzac, François Mion, Emmanuel Boselli, Bernard Allaouchiche, and Dominique Chassard

Anesth Analg 2006 102: 1803-1808.

血漿N端-腦型利鈉肽原水平作為危重病人預後的一個標記

(黃施偉 譯,馬皓琳 李士通 校)

Plasma Level of N Terminal Pro-Brain Natriuretic Peptide as a Prognostic Marker in Critically Ill Patients

Yaniv Almog, Victor Novack, Rinat Megralishvili, Sergio Kobal, Leonid Barski, Daniel King, and Doron Zahger

Anesth Analg 2006 102: 1809-1815.

NEUROSURGICAL ANESTHESIA:

用腦電圖監測麻醉深度的實驗中證實:通過頸內靜脈單劑量多次注射法會影響維持麻醉深度的異丙酚的用量

(孫卓真譯 薛張綱校)

Bolus Configuration Affects Dose Requirements of Intracarotid Propofol for Electroencephalographic Silence

Shailendra Joshi, Mei Wang, Joshua J. Etu, and John Pile-Spellman

Anesth Analg 2006 102: 1816-1822.

吲哚美辛對有顱內高壓的綿羊接受異丙酚或異氟醚麻醉中對顱內壓和腦血流動力學的影響

(鄭麗 陳傑 校)

The Effects of Indomethacin on Intracranial Pressure and Cerebral Hemodynamics During Isoflurane or Propofol Anesthesia in Sheep with Intracranial Hypertension

Mads Rasmussen, Richard N. Upton, Cliff Grant, Allison M. Martinez, Georg E. Cold, and Guy Ludbrook

Anesth Analg 2006 102: 1823-1829.

地氟醚和七氟醚在穩態條件下對腦氧測定的影響

(邱鬱薇 馬皓琳 李士通 校)

The Effect of Desflurane and Sevoflurane on Cerebral Oximetry Under Steady-State Conditions

Argyro Fassoulaki, Helen Kaliontzi, George Petropoulos, and Athanassia Tsaroucha

Anesth Analg 2006 102: 1830-1835.

高滲鹽水在治療由外傷性腦損傷引起的顱內高壓中的作用

(孫卓真譯 薛張綱校)

The Use of Hypertonic Saline for Treating Intracranial Hypertension After Traumatic Brain Injury (Review Article)

Hayden White, David Cook, and Bala Venkatesh

Anesth Analg 2006 102: 1836-1846.

REGIONAL ANESTHESIA:

年齡對羅呱卡因硬膜外麻醉後運動阻滯中位有效濃度的影響

(曹瑜 陳傑 校)

The Effects of Age on the Median Effective Concentration of Ropivacaine for Motor Blockade After Epidural Anesthesia with Ropivacaine

Yuhong Li, Shengmei Zhu, Fangping Bao, Jianhong Xu, Xiang Yan, and Xudong Jin

Anesth Analg 2006 102: 1847-1850.

對比1%純利多卡因和由等量生理鹽水稀釋2%利多卡因後的1%利多卡因所產生的硬膜外阻滯

(趙雪蓮 馬皓琳 李士通 校)

A Comparison of Epidural Blockade Produced by Plain 1% Lidocaine and 1% Lidocaine Prepared by Dilution of 2% Lidocaine with the Same Volume of Saline

Akifumi Kanai and Sumio Hoka

Anesth Analg 2006 102: 1851-1855.

GENERAL ARTICLES:

Mallampati試驗預測困難氣道準確性的系統回顧 (meta分析)

(徐麗穎譯 薛張綱校)

A Systematic Review (Meta-Analysis) of the Accuracy of the Mallampati Tests to Predict the Difficult Airway

Anna Lee, Lawrence T. Y. Fan, Tony Gin, Manoj K. Karmakar, and Warwick D. Ngan Kee

Anesth Analg 2006 102: 1867-1878.

體位影響手靈巧度

肖潔 陳傑 校)

Body Position Affects Manual Dexterity

Charles W. Buffington, Stanley D. MacMurdo, and Christopher M. Ryan

Anesth Analg 2006 102: 1879-1883.

術後噁心嘔吐的危險因數

(黃麗娜     馬皓琳 李士通  )

Risk Factors for Postoperative Nausea and Vomiting (Review Article)

Tong J. Gan

Anesth Analg 2006 102: 1884-1898.

 

 

心臟外科手術前婦女的預成認知損害以及它與C-反應蛋白濃度之間的關係

Preexisting cognitive impairment in women before cardiac surgery and its relationship with C-reactive protein concentrations.
Hogue CW Jr, Hershey T, Dixon D, Fucetola R, Nassief A, Freedland KE, Thomas B, Schechtman K.
Department of Anesthesiology and Critical Care Med Johns Hopkins Hospital, 600 N. Wolfe St, Tower 711 Baltimore, MD 21287-8711, USA.

Anesth Analg 2006 102: 1602-1608.

當調查心臟外科手術對認知的影響時,發現術前認知狀態很少被重視。 在這項研究中,我們尋求明確擇期行心臟外科手術婦女認知損害的患病率,以非住院的志願者作為參照組,同時檢測C-反應蛋白水平與認知損害之間的關係。108名擇期行心臟外科手術絕經後的婦女和58名非住院作為對照的婦女進行了心理測試。在外科手術患者中,檢測到高靈敏度C-反應蛋白含量。與對照組相比,術前認知損害被定義為>2sd較低分值2個測試。108名患者中49位表現認知損害(45%)。與沒有出現認知損害的患者相比,認知損害患者的C-反應蛋白水平較高(中位數,8.1 mg/L 4.7 mg/L; P = 0.04)。基於多變數邏輯回歸分析,患者年齡、較低教育水平、2型糖尿病,以及心肌梗塞可作為認知損害的危險因素(P < 0.05),但是C-反應蛋白水平卻不是(P = 0.09)。結論是,在心臟外科手術之前婦女的認知損害是普遍的,處於這種狀態的婦女C-反應蛋白水平是增高的,但是這種炎性標記物和預成認知損害之間的關係可能是續發的急性期反應物,作為其他易發因素的標記物。

(孫敏莉譯 薛張綱校)

Preoperative cognitive state is seldom considered when investigating the effects of cardiac surgery on cognition. In this study we sought to determine the prevalence of cognitive impairment in women scheduled for cardiac surgery using nonhospitalized volunteers as a reference group and to examine the relationship between C-reactive protein levels and cognitive impairment. Psychometric testing was performed in 108 postmenopausal women scheduled for cardiac surgery and in 58 nonhospitalized control women. High sensitivity C-reactive protein levels were measured in the surgical patients. Preoperative cognitive impairment was defined as >2 sd lower scores on > or =2 tests compared with the controls. Cognitive impairment was present in 49 of 108 (45%) patients. C-reactive protein levels were higher for patients with compared with those without cognitive impairment (median, 8.1 mg/L versus 4.7 mg/L; P = 0.04). Based on multivariate logistic regression analysis, patient age, lower attained level of education, type 2 diabetes mellitus, and prior myocardial infarction identified risk for cognitive impairment (P < 0.05) but C-reactive protein levels did not (P = 0.09). In conclusion, cognitive impairment is prevalent in women before cardiac surgery. C-reactive protein levels are increased in women with this condition but the relationship between this inflammatory marker and preexisting cognitive impairment is likely secondary to the acute phase reactant serving as a marker for other predisposing conditions

 

 

 

心臟手術後白介素-6升高預示感染的發生

Increased Interleukin-6 After Cardiac Surgery Predicts Infection

Michael Sander, MD, Christian von Heymann, MD, Vera von Dossow, MD, Corinna Spaethe, MD, Wolfgang F. Konertz, MD, Uday Jain, MSIT, MD, PhD, and Claudia D. Spies, MD.

Departments of Anesthesiology and Intensive Care Medicine, and Cardiovascular Surgery, University Hospital Charité, Campus Charité Mitte/Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Germany; Department of Anesthesiology, St. Mary’s Medical Center, San Francisco, California

Anesth Analg 2006 102: 1623-1629.

 

使用體外迴圈(CPB)的心臟手術後感染的早期診斷和治療有利於改善預後。傳統的實驗室檢查如C反應蛋白、白細胞計數等不能分辨患者是感染的早期還是不伴有感染的全身炎症反應綜合症。CPB之後,機體釋放促炎和抗炎反應因數,包括腫瘤壞死因數α、白介素(IL-6IL-10。我們研究了這項因數對心臟手術術後感染的預示能力。46位元因左室射血分數受損(<60%)準備行心臟手術的患者進入研究。在術前1天、術前即刻、入ICU時、術後1天、3天、7天采血標本。感染的定義依照疾病預防和控制中心的標準。手術後有13位元患者發生感染。發生感染的患者平均在術後4天被證實,術後3天所有感染患者的IL-6IL-10均明顯升高,而腫瘤壞死因數α、白細胞、C反應蛋白並未升高。感染患者術後即刻的血糖明顯升高。CPBIL-6升高可以預示左心功能不全患者心臟手術後感染的發生。

(金琳 薛張綱 審校)

Early diagnosis and treatment of infection after cardiac surgery with cardiopulmonary bypass (CPB) improves outcome. Conventional laboratory tests, such as C-reactive protein and white blood cell count can not distinguish patients with early infection from those with systemic inflammatory response syndrome but without infection. After CPB, there is a systemic release of proinflammatory and antiinflammatory cytokines, including tumor necrosis factor-{alpha}, interleukin (IL)-6, and IL-10. We investigated the predictive ability of these variables for infection after cardiac surgery. Forty-six patients with impaired left ventricular ejection fraction (<60%), scheduled for cardiac surgery, were included. Plasma samples were drawn 1 day before and immediately before surgery, on admission to the intensive care unit, and on days 1, 3, and 7 after surgery. Infection was identified according to the criteria of the Centers for Disease Control and Prevention. After surgery 13 patients developed an infection. In patients with infection, confirmed a median of 4 days after surgery, all measurements of IL-6, and IL-10 on postoperative day 3 were significantly increased. Tumor necrosis factor-{alpha}, leukocytes, and C-reactive protein were not increased in these patients. Immediately after surgery blood glucose was significantly increased in patients with infection. Increased IL-6 after CPB is predictive of infection after cardiac surgery in patients with impaired left ventricular function.

 

 

比較三種磷酸二酯酶III抑制劑對豚鼠離體心臟機械和代謝功能的影響

A comparison of three phosphodiesterase type III inhibitors on mechanical and metabolic function in guinea pig isolated hearts.

Zausig YA. Stowe DF. Zink W. Grube C. Martin E. Graf BM.

University of Goettingen, Dept. of Anaesthesia, ZARI, Robert-Koch-Strasse 40, Goettingen, 37075, Germany.

Anesth Anal. 102(6):1646-52, 2006 Jun.

 

對外周迴圈無影響的磷酸二酯酶III抑制劑是否對心臟舒張和冠脈血管有影響仍知之甚少。我們假設磷酸二酯酶III抑制劑對心臟功能和代謝有不同的作用,以及其冠脈舒張作用僅僅依靠正性肌力作用後的自主調節。本研究目的是比較Langendorff灌注的豚鼠離體心臟中三種臨床常用磷酸二酯酶III抑制劑對電生理、機械、血管舒張和代謝的劑量反應性影響。我們發現,超過10-710-4M的範圍,安力農、銥諾昔酮和米力農都產生最大的濃度依賴性正性變時效應(12%,18%,26%)、變力效應(16%26%26%)和鬆弛效應(14%,21%,19%)。臨床濃度下,所有的三種藥都增加心率,但是只有米力農明顯增加心肌收縮性和舒張性(11%)。最高濃度下,每種磷酸二酯酶III抑制劑相似地增加心肌收縮力,同時氧耗增加,相應增加冠脈血流和氧輸送。每種藥物濃度達最高時,冠脈血流仍能保持,表明是由於代謝率增加導致冠脈血流增加。我們的結論,三種磷酸二酯酶III抑制劑不直接促進冠脈舒張,米力農在臨床濃度時有最強的心肌收縮性和舒張性。

(吳德華譯 薛張綱校)

Little is known about of the comparative cardiac lusitropic and coronary vasoactive effects of type III phosphodiesterase inhibitors independent of their systemic circulatory effects. We hypothesized that phosphodiesterase inhibitors have dissimilar concentration-dependent effects on cardiac function and metabolism and that their coronary vasodilatory effects are solely dependent on flow autoregulation secondary to positive inotropic effects. Our aim was to compare the dose-response electrophysiologic, mechanical, vasodilatory, and metabolic properties of three clinically available phosphodiesterase inhibitors in isolated Langendorff perfused guinea pig hearts. We found that, over a range from 10(-7) to 10(-4) M, amrinone, enoximone, and milrinone each produced maximal concentration-dependent positive chronotropic (12%, 18%, 26%), inotropic (16%, 26%, 26%), and lusitropic (14%, 21%, 19%) effects. At clinical concentrations, all phosphodiesterase inhibitors increased heart rate, but only milrinone significantly enhanced contractility and relaxation (11%). Each phosphodiesterase inhibitor similarly increased contractility at its highest concentration; this was accompanied by an increase in oxygen consumption, which was matched by comparable increases in coronary flow and oxygen delivery. Coronary flow reserve was preserved at the highest concentration of each drug, indicating that an increased metabolic rate was responsible for the increase in coronary flow by each drug at each concentration. Over the concentrations examined, we conclude that each of the phosphodiesterase inhibitors does not directly promote coronary vasodilation and that milrinone has the most prominent effects on contractility and relaxation at clinically relevant concentrations.

 

與嗎啡相比術中使用曲馬多對兒童心臟手術後採用護士控制鎮痛可以較早蘇醒和較少使用鎮靜劑

Intraoperative Administration of Tramadol for Postoperative Nurse-Controlled Analgesia Resulted in Earlier Awakening and Less Sedation than Morphine in Children After Cardiac Surgery

Ya-Chun Chu, MD, PhD, Su-Man Lin, MD, Ying-Chou Hsieh, MD, Kwok-Hon Chan, MD, and Mei-Yung Tsou, MD, PhD

Department of Anesthesiology Taipei Veterans General Hospital and National Yang-Ming University, School of Medicine, Taipei, Taiwan

Address correspondence and reprint requests to Mei-Yung Tsou, MD, PhD, Department of Anesthesiology, Taipei-Veterans General Hospital, 112, Taiwan.

Anesth Analg 2006 102: 1668-1673.

 

在成人,術中使用曲馬多與嗎啡相比可以較早蘇醒,較少使用鎮靜劑。在本隨機、對照、雙盲研究中,我們研究了術中初始劑量曲馬多是否可以獲得比嗎啡在全麻後更迅速的蘇醒、較少使用鎮靜劑和在小兒術後較早拔除氣管內導管。四十名16歲行房或室間隔缺損修補術後在兒科加強監護病房拔除氣管內導管的兒童,在胸骨關閉後隨機給予嗎啡(初始劑量0.2 mg/kg)或曲馬多(初始劑量2 mg/kg)後,再分別行單劑嗎啡0.02 mg/kg或曲馬多0.2 mg/kg、背景劑量嗎啡0.015 mg/kg·hr或曲馬多0.15mg/kg·hr的護士控制鎮痛。術後使用曲馬多的兒童從全麻中蘇醒較早(P = 0.02),術後第12小時較少使用鎮靜劑(分別為 P=0.03 P=0.01)。曲馬多組氣管內導管拔除較早(P = 0.01)。兩組之間在滯留在兒科加強監護病房內的時長方面無差別。同時兩組間護士控制鎮痛第一次劑量給予時間和48小時觀察期內客觀疼痛評分相當。脈搏氧飽和度降低和嘔吐發生率兩組間相似。所有患兒在術後第12天進食良好,且兩組間無差別。

(金 路譯 薛張綱校)

In adults, intraoperative administration of tramadol could result in earlier recovery and less sedation than morphine. In this controlled, randomized, double-blind study, we investigated whether an intraoperative initial dose of tramadol could cause more rapid awakening from general anesthesia, less sedation, and earlier tracheal extubation than morphine in children during the immediate postoperative period. Forty children aged 1–6 yr, scheduled for atrial or ventricular septal defect repair and tracheal extubation in the pediatric intensive care unit, were randomly allocated to receive morphine, initial dose 0.2 mg/kg, or tramadol 2 mg/kg given at the end of sternal closure, followed by nurse-controlled analgesia (bolus 0.02 mg/kg of morphine and 0.2 mg/kg of tramadol) with background infusions (0.015 mg · kg–1 · h–1 for morphine and 0.15 mg · kg–1 · h–1 for tramadol). Postoperatively, children receiving tramadol had earlier awakening from general anesthesia (P = 0.02) and were less sedated at 1 and 2 h postoperatively (P = 0.03 and P = 0.01, respectively). Tracheal extubation was earlier in the tramadol group (P = 0.01). Lengths of pediatric intensive care unit stay did not differ between groups. Times to first trigger of nurse-controlled analgesia bolus and objective pain scores during the 48 h observation period were comparable between groups. The incidence of desaturation and emesis were similar between groups. The patients ate well and did not differ on Day 1 or Day 2.

 

兒科病人通過喉周導氣管對聲門上氣道的可視定位

Video Assessment of Supraglottic Airway Orientation Through the Perilaryngeal Airway in Pediatric Patients

David M. Polaner, Dheeraj Ahuja, Jeannie Zuk, and Zhaoxing Pan

The Children's Hospital Department of Anesthesia, 1056 East 19th Avenue, B090, Denver, CO 80218, USA.

Anesth Analg 2006 102: 1685-1688.

 

COBRA喉周導氣管(PLA)是一種應用于兒童的新型聲門上的導氣管裝置。我們研究了45名嬰兒和兒童,通過纖支鏡定位,採用PLA來確定喉的位置。對喉的可視程度進行評分,並評價PLA和會厭的位置。所有受試物件都選用合適的導氣管,但在10kg及以下的病人中,76.9%的兒童喉頭部分或完全阻塞,在聲門開放時會厭蓋於聲門上。這在較大的兒童中是不常見的。幾乎在所有的受試物件中,PLA的裝置與會厭和聲門上結構相近。我們推測:1)PLA為嬰兒和兒童提供了一種可接受的氣道,但會厭的折疊及聲門開放時的阻塞在嬰兒中是常見的。2)在這一年齡組,格外警惕氣道的梗阻是必要的。3)PLA和聲門上結構的相近提示了較深的麻醉可能減少對喉頭的刺激。

(王麗珺譯 薛張綱校)

The COBRA perilaryngeal airway (PLA) is a new supraglottic airway device available for use in children. We studied the orientation of the larynx as viewed through the PLA using video obtained with a fiberoptic bronchoscope in 45 infants and children. Laryngeal view was scored, and position of the grill bars of the PLA and the epiglottis was assessed. An acceptable airway was obtained in all subjects, but the laryngeal view was nearly or completely obstructed in 76.9% of the patients 10 kg and less, with the epiglottis folded over the glottic opening. This was uncommon in larger children. The grill bars of the PLA were closely opposed to the epiglottis and supraglottic structures in nearly all subjects. We conclude that 1) the PLA provides an acceptable airway in infants and children, but infolding of the epiglottis with obstruction of the view of the glottic opening is common in infants, 2) extra vigilance for airway obstruction in this age group is necessary, and 3) the PLA's close opposition to the supraglottic structures suggests that removal in a deeper plane of anesthesia might minimize laryngeal stimulation.

 

七氟烷對大鼠氣管上皮細胞纖毛活動的作用:與異氟烷和氟烷比較

The Effect of Sevoflurane on Ciliary Motility in Rat Cultured Tracheal Epithelial Cells: A Comparison with Isoflurane and Halothane

Shogo Matsuura, Gotaro Shirakami, Hiroko Iida, Keiji Tanimoto, and Kazuhiko Fukuda

Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan

Address correspondence and reprint requests to Gotaro Shirakami, MD, Department of Anesthesia, Kyoto University Hospital, Kyoto 606-8507, Japan.

Anesth Analg 2006 102: 1703-1708.

 

氟烷和異氟烷有力地抑制了氣道纖毛活動度。我們用純化培養的大鼠氣管上皮細胞比較了七氟烷與氟烷和異氟烷對纖毛活動頻率(CBF)的影響。大鼠氣管上皮細胞從成年雄性SD大鼠中分離出來,建立氣液交界面。細胞的頂端表面暴露於含有潮濕和溫暖(25°C)空氣(媒介)的新鮮氣體中,含有或沒有七氟烷(0%–4%),氟烷(0%–2%),或異氟烷(0%–2%)。纖毛活動的圖像被記錄下來,用電腦分析CBFCBF基線(= 100%),計算暴露後30分鐘的CBF。暴露於媒介後30分鐘的CBF101% ± 4% (mean ± sd)。暴露於0.25%–2%七氟烷,CBF沒有顯著的改變,而暴露於0.25%–2%的氟烷和異氟烷中,CBF呈劑量依賴性降低。暴露於2%的七氟烷,氟烷和異氟烷30分鐘後的CBF分別是97% ± 9%, 56% ± 14%, and 47% ± 6%n=5)。這些結果說明在離體大鼠氣管上皮細胞中,七氟烷有直接的纖毛抑制作用但是作用要遠弱於氟烷和異氟烷。

(周荻 薛張綱 校)

Halothane and isoflurane potently depress airway ciliary motility. We compared the effect of sevoflurane on ciliary beat frequency (CBF) with that of halothane and isoflurane using purified and cultured rat tracheal epithelial cells. Rat tracheal epithelial cells were isolated from adult male Sprague-Dawley rats to establish an air-liquid interface culture. Apical surfaces of the cells were exposed to a fresh gas containing humidified and warmed (25°C) air (vehicle) with or without sevoflurane (0%–4%), halothane (0%–2%), or isoflurane (0%–2%). The images of motile cilia were videotaped and CBF was analyzed using a computer. Baseline CBF (= 100%) and CBF 30 min after the exposure were measured. CBF 30 min after vehicle exposure was 101% ± 4% (mean ± sd). Exposures to 0.25%–2% sevoflurane did not change CBF significantly, although exposures to 0.25%–2% halothane or isoflurane decreased CBF dose-dependently. CBFs 30 min after exposures to 2% of sevoflurane, halothane, and isoflurane were 97% ± 9%, 56% ± 14%, and 47% ± 6%, respectively (n = 5 each). Sevoflurane 4% reduced CBF significantly but slightly (84% ± 2%, n = 5). These results show that sevoflurane has a direct cilioinhibitory action but its action is much weaker than that of halothane and isoflurane in isolated rat tracheal epithelial cells.

 

環孢黴素和胰島素對大鼠缺血性脊髓損傷的的作用

The effects of cyclosporin a and insulin on ischemic spinal cord injury in rabbits.

Tsuruta S, Matsumoto M, Fukuda S, Yamashita A, Cui YJ, Wakamatsu H, Sakabe T.
Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi, 755-8505, Japan.

Anesth Analg. 2006 Jun;102(6):1722-7

通過這個研究,我們檢測環孢黴素(一種抑制線粒體滲透轉運的藥物)和胰島素對大鼠脊髓缺血性損傷的作用。我們將大鼠分為5(每組6),正常屏障組(sham BO),屏障開放組(BO),屏障開放環孢黴素組(BO-CsA),屏障開放胰島素組(BO-I),屏障開放環孢黴素胰島素組(BO-CsA-I)。第一天的時候打開血—脊髓屏障以便藥物更好的滲透。環孢黴素(10 mg/kg.d, IV)在第35天給藥(共30 mg/kg)。胰島素在缺血前30分鐘給藥。對於所有的組,缺血是在第5天阻斷腹主動脈13分鐘。神經學和組織病理學的評價在缺血後4天進行。在BO-CsA組,血糖水平明顯高於其他組,並且沒有觀察到保護作用。作為對照,BO-I 組和Bo-CsA-I組的下肢活動功能和BO-CsA-I組的組織病理學明顯好於sham BO, BO, and BO-CsA組。結果顯示,胰島素可以保護缺血性的脊髓損傷,而環孢黴素的作用是很小的。

(陸文清譯 薛張綱校)

We examined the effects of cyclosporin A (CsA), a drug that inhibits mitochondrial permeability transition pore, and insulin on ischemic spinal cord damage in rabbits. We assigned rabbits to 5 groups (n = 6 in each); sham barrier-opened group (sham BO), barrier-opened group (BO), barrier-opened-CsA group (BO-CsA), barrier-opened-insulin group (BO-I), and barrier-opened-CsA-insulin group (BO-CsA-I). The blood-spinal cord barrier was opened to facilitate drug penetration by a mild injury to the lumber spinal cord on day 1. CsA (10 mg/kg per day IV) was administered on day 3 to day 5 (total 30 mg/kg). Insulin was administered 30 min before ischemia. In all groups, spinal cord ischemia was produced on day 5 by occluding the abdominal aorta for 13 min.Neurological and histopathological evaluations were performed 4 days after ischemia. In group BO-CsA, blood glucose concentrations were significantly larger compared with the other four groups, and no protection was observed. In contrast, hindlimb motor function in groups BO-I and Bo-CsA-I and histopathology in group BO-CsA-I were significantly better than in groups sham BO, BO, and BO-CsA. The results indicate that insulin protects against ischemic spinal cord injury, whereas the effect of CsA is, at best, minimal.

 

利多卡因抑制誘生型一氧化氮合酶和陽離子氨基酸轉運蛋白2在有活性的鼠類巨噬細胞中的轉錄可能與電壓敏感性鈉通道有關

Lidocaine inhibition of inducible nitric oxide synthase and cationic amino Acid transporter-2 transcription in activated murine macrophages may involve voltage-sensitive na+ channel.

Huang YH, Tsai PS, Kai YF, Yang CH, Huang CJ.

Ya-Hsien Huang, Pei-Shan Tsai, Yun-Fang Kai, Chen-Hsien Yang, and Chun-Jen Huang

Departments of Anesthesiology and Medical Research, Mackay Memorial Hospital; Mackay Medicine, Nursing and Management College; College of Nursing and Graduate Institute of Medical Science, Taipei Medical University, Taipei, Taiwan

Anesth Analg 2006 102: 1739-1744.


有報導在有活性的鼠類巨噬細胞中利多卡因對NO的生成有抑制作用,但是誘生型一氧化氮合酶(iNOS)在其中的作用仍沒有探明。另外,2型陽離子氨基酸轉運蛋白(CAT-2)和鳥苷三磷酸環水解酶I (GTPCH)對於iNOS有調節作用。目前利多卡因對CAT-2 GTPCH的作用仍未知。為了研究它們之間的作用,連生的鼠類巨噬細胞(RAW264.7 細胞)將在收穫前18小時與脂多糖(LPS)或利多卡因(5, 50, or 500 muM)聯合孵化。我們也用了TTX和無定形藜蘆堿來闡明電壓敏感性鈉通道的可能作用。我們的資料表明在受刺激的巨噬細胞中LPS對於iNOS CAT-2的轉錄是正調節作用而GTPCH沒有此作用。在劑量依賴性的方法中,利多卡因可減弱LPS對於iNOS CAT-2的正調節作用。相反的,利多卡因可明顯增強LPS啟動的巨噬細胞中GTPCH的轉錄作用。TTX對於iNOS, CAT-2GTPCH的作用與利多卡因相似。另外,無定形藜蘆堿明顯減弱利多卡因和TTX的作用。我們得出結論:在LPS啟動的巨噬細胞中利多卡因明顯抑制iNOS CAT-2的轉錄,而增強GTPCH的轉錄,這可能與電壓敏感性鈉通道有關。

(韓曉丹譯 薛張綱校)
Lidocaine has been reported to inhibit nitric oxide (NO) production in activated murine macrophages, but the role of inducible NO synthase (iNOS) in lidocaine-induced inhibition of NO has not been explored. In addition, type-2 cationic amino acid transporter (CAT-2) and guanosine triphosphate cyclohydrolase I (GTPCH) also regulate iNOS activity. The effects of lidocaine on CAT-2 and GTPCH are unknown. To explore further these effects, confluent immortalized murine macrophages (RAW264.7 cells) were incubated with lipopolysaccharide (LPS) or in combination with lidocaine (5, 50, or 500 muM) for 18 h before harvesting. We also used tetrodotoxin (TTX) and veratridine to elucidate the possible role of voltage-sensitive Na(+) channel. Our data demonstrated that LPS significantly upregulated transcription of iNOS and CAT-2 but not GTPCH in stimulated macrophages. In a dose-dependent manner, lidocaine significantly attenuated the LPS-induced upregulation of iNOS and CAT-2. Conversely, lidocaine significantly increased GTPCH transcription in LPS-stimulated macrophages. The effects of TTX on iNOS, CAT-2, and GTPCH expression were comparable to those of lidocaine. In addition, veratridine significantly attenuated the effects of lidocaine and TTX. We therefore concluded that lidocaine significantly inhibits iNOS and CAT-2 and, in turn, enhances GTPCH transcription in LPS-stimulated macrophages via a mechanism that possibly involves the voltage-sensitive Na(+) channel.

 

腦電圖衰退和針灸

Electroencephalogram-entropy and acupuncture.
Litscher G.
MDsc, Research Unit of Biomedical Engineering, in Anesthesia and Intensive Care Medicine, Medical University Graz, Auenbruggerplatz 29, A-8036 Graz, Austria. gerhard.

Anesth Analg 2006 102: 1745-1751.


用電腦來評價鎮靜和催眠的深度是困難的。腦電圖被認為可能是一種方法。反應減退(RE)和狀態減退(SE)是多因素的腦電圖檢測新技術,我們用針灸來研究。這兩個參數都被用來反應鎮靜狀態的改變。在一項隨機交叉試驗中用兩種針灸方法對9名健康患者進行研究。在鎮靜穴位用針刺或用雷射針進行針灸能顯著降低RESE。相反,在"Qi-energy"點針灸不能降低這兩個參數。不同的針灸方法能產生不同的可重複的腦電圖的改變。因此,針灸的衰退測量的研究可能是有價值的。

(鍾靜譯 薛張綱校)

Computer-based measuring of the level of sedation and hypnosis is difficult and has proven to be challenging. The electroencephalogram (EEG) has been proposed as a potential method. Response entropy (RE) and state entropy (SE) are multifactor, dimensionless parameters of a new technology of EEG monitoring, and we investigated them for the first time in acupuncture research within this study. Both parameters have been alleged to reflect changes in the clinical state of sedation. Two different acupuncture schemes were tested in a randomized crossover trial with nine healthy volunteers (mean age +/- sd, 28.8 +/- 3.6 yr; 25-36 yr). Applying and stimulating acupuncture needles or performing laserneedle acupuncture at special sedation points decreased RE and SE significantly (P </= 0.01; paired t-test) compared with the reference interval before acupuncture. In contrast, acupuncture of points for increasing "Qi-energy" did not decrease parameters of entropy. Specific acupuncture schemes produce specific, reproducible, and quantifiable effects on entropy parameters in the EEG. Therefore, entropy measurements during acupuncture seem to be worthy of further evaluation with a larger series of subjects.

 

嗎啡、可待因和美沙酮及其對映體在不同的大鼠疼痛模型的作用

Morphine, Oxycodone, Methadone and Its Enantiomers in Different Models of Nociception in the Rat

Kim Lemberg, Vesa K. Kontinen, Kaarin Viljakka, Irene Kylänlahti, Jari Yli-Kauhaluoma, and Eija Kalso

Pain Clinic, Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital,

Anesth Analg 2006 102: 1768-1774.

 

我們研究常用的μ-阿片受體激動劑嗎啡、可待因和美沙酮及其對映體對於大鼠急性疼痛的熱和機械模型以及脊神經結紮的神經性疼痛模型的作用。蛛網膜下腔給予嗎啡、可待因和美沙酮及其對映體對於彈尾巴、燙板和壓爪試驗的抗疼痛成劑量依賴性。左旋美沙酮、外消旋美沙酮和可待因的劑量依賴性抗疼痛效果相似,而嗎啡的量效曲線較淺。在脊神經結紮的神經性疼痛模型中,蛛網膜下腔給予嗎啡、可待因、美沙酮和左旋美沙酮對於大鼠的機械性和冷疼痛模型有抗疼痛作用。並證實了左旋美沙酮的抗異常性疼痛作用最強。D-美沙酮在所有試驗中無活性。給予嗎啡5.0 mg/kg,可待因2.5 mg/kg和左旋美沙酮1.25 mg/kg30分鐘後可降低自主運動。結論:對於急性損傷,所有μ-受體激動劑都有抗損傷作用,其中嗎啡的作用最弱。對於神經損傷性疼痛,左旋美沙酮對於機械和冷所至的異常性疼痛的抗疼痛效果最好。阿片類藥物在不同的疼痛模型中的效果不同。應當研究左旋美沙酮在人的神經病性疼痛中的作用。

(王慧琳譯 薛張綱校)

We studied the effects of the commonly used mu-opioid receptor agonists morphine, oxycodone, methadone and the enantiomers of methadone in thermal and mechanical models of acute pain and in the spinal nerve ligation model of neuropathic pain in rats. Subcutaneous administration of morphine, oxycodone, and methadone produced a dose-dependent antinociceptive effect in the tail flick, hotplate, and paw pressure tests. l-methadone, racemic methadone, and oxycodone had a similar dose-dependent antinociceptive effect, whereas the dose-response curve of morphine was shallower. In the spinal nerve ligation model of neuropathic pain, subcutaneous administration of morphine, oxycodone, methadone and l-methadone had antiallodynic effects in tests of mechanical and cold allodynia. l-methadone showed the strongest antiallodynic effect of the tested drugs. d-methadone was inactive in all tests. Morphine 5.0 mg/kg, oxycodone 2.5 mg/kg, and l-methadone 1.25 mg/kg decreased spontaneous locomotion 30 min after drug administration. In conclusion, in acute nociception all mu-opioid receptor agonists produced antinociception, with morphine showing the weakest effect. In nerve injury pain, l-methadone showed the greatest antiallodynic potency in both mechanical and cold allodynia compared with the other opioids. Opioids seem to have different profiles in different pain models. l-methadone should be studied for neuropathic pain in humans.

 

高滲鹽水在治療由外傷性腦損傷引起的顱內高壓中的作用

The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury.

White H, Cook D, Venkatesh B.
QE II Hospital, Kessels Rd., Coopers Plains 33, Queensland 4108, Australia.

Anesth Analg. 2006 Jun;102(6):1836-46

 

過去的十年中我們見證了高滲鹽水在外傷性低容量復蘇治療中再次啟用。最初研究表明髙滲鹽水在外傷病人中對腦損傷有益,然而在最近的研究中這點並未得到證實。在動物與人的實驗中已證明了高滲鹽水在神經損傷病人的腦血流、顱內壓和炎症應答方面有臨床所希望的生理效應。由於腦外傷病人存活率低,因此在這方面的臨床研究很少。在本綜述中我將一起回顧與調查實驗與臨床中的有關髙滲鹽水在神經外傷中作為滲透療法藥物的知識。

(孫卓真譯 薛張綱校)

The past decade has witnessed a resurgence of interest in the use of hypertonic saline for low-volume resuscitation after trauma. Preliminary studies suggested that benefits are limited to a subgroup of trauma patients with brain injury, but a recent study of prehospital administration of hypertonic saline to patients with traumatic brain injury failed to confirm a benefit. Animal and human studies have demonstrated that hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure, and inflammatory responses in models of neurotrauma. There are few clinical studies in traumatic brain injury with patient survival as an end point. In this review, we examined the experimental and clinical knowledge of hypertonic saline as an osmotherapeutic agent in neurotrauma.

 

用腦電圖監測麻醉深度的實驗中證實:通過頸內靜脈單劑量多次注射法會影響維持麻醉深度的異丙酚的用量

Bolus configuration affects dose requirements of intracarotid propofol for electroencephalographic silence.

Joshi S, Wang M, Etu JJ, Pile-Spellman J.

Irving Assistant Department of Anesthesiology, P&S P Box 46, College of Physicians and Surgeons of Columbia University

Anesth Analg. 2006 Jun;102(6):1816-22.

 

我們假設通過頸內靜脈單劑量多次注射異丙酚來維持腦電圖穩定時所需要的用量比持續輸注法所需的用量小。並且保證每次異丙酚的單劑量都是一個有效劑量。我們以大鼠為實驗來比較了單劑量多次法與持續輸注法的異丙酚的用量。然後我們又比較了四組不同設定的單劑量(濃度或劑量)的異丙酚(0.33% x 0.1 mL, 0.33% x 0.3 mL, 1% x 0.1 mL, and 1% x 0.3 mL)在維持腦電圖穩定時的用量。我們發現同樣在維持腦電圖穩定的情況下持續輸注法所需異丙酚的用量是單劑量多次法的三倍,分別是22.8 +/- 11.9 vs 6.2 +/- 2.9 mL/h(n = 7, P < 0.004) 此外,在單劑量多次法中每次異丙酚的用量與濃度會影響其最終的整體作用,總劑量=3.6 + 29 x mg/, n = 32, r = 0.85。因此為了達到最大的效果我們應該調整好每次異丙酚的用量與濃度。

(孫卓真譯 薛張綱校)

We hypothesized that an intracarotid bolus injection of propofol to produce electroencephalographic (EEG) silence would require a smaller dose of the drug compared with the continuous infusion of the drug. Furthermore, the bolus propofol dose will be a function of the bolus characteristics in each bolus (mass/volume). We compared the dose requirements of intracarotid propofol needed to maintain EEG silence when delivered as bolus injections to continuous infusions in rabbits. Subsequently, we compared whether four different bolus characteristics (concentration and volume) of propofol (0.33% x 0.1 mL, 0.33% x 0.3 mL, 1% x 0.1 mL, and 1% x 0.3 mL) affected the dose required to produce EEG silence. We found that the infusion rate of propofol required to sustain EEG silence was three-fold larger than the dose required by bolus injections, 22.8 +/- 11.9 vs 6.2 +/- 2.9 mL/h for infusion versus bolus, respectively (n = 7, P < 0.004). Furthermore, during bolus injection, the doses of propofol required to produce EEG silence were a direct function of the bolus volume and the mass of drug in each bolus, total dose = 3.6 + 29 x mg/bolus, n = 32, r = 0.85. For maximum regional effects of the bolus intracarotid drug injection, the bolus characteristics (volume and drug concentration) have to be optimized.

 

Mallampati試驗預測困難氣道準確性的系統回顧 (meta分析)

A systematic review (meta-analysis) of the accuracy of the mallampati tests to predict the difficult airway.

Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.

MPH, Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong.

Anesth Analg. 2006 Jun;102(6):1867-78

 

最初的和改良的Mallampati試驗常常用以預測困難氣道,但關於其準確性存在爭議。我們在MEDLINE和其他的一些資料庫搜索了對全麻病人術前Mallampati 試驗結果與隨後的困難氣道發生率(困難喉鏡檢查,困難插管,或困難通氣作為參照試驗)進行比較的前瞻性研究。包括了42項研究34,513個病人。參照試驗的定義差異很大。預測困難喉鏡檢查,兩種Mallampati試驗準確性都很好(sROC曲線下面積分別為0.89 0.05 0.78 0.05)。預測困難插管,改良Mallampati試驗準確性較好(sROC曲線下面積=0.83 0.03),而最初的Mallampati試驗較差(sROC曲線下面積=0.58 0.12)Mallampati試驗對識別困難面罩通氣較差。未發現發表偏倚。單獨使用Mallampati試驗對預測困難氣道準確性有限,因而不是實用的篩選試驗。

(徐麗穎譯 薛張綱校)

The original and modified Mallampati tests are commonly used to predict the difficult airway, but there is controversy regarding their accuracy. We searched MEDLINE and other databases for prospective studies of patients undergoing general anesthesia in which the results of a preoperative Mallampati test were compared with the subsequent rate of difficult airway (difficult laryngoscopy, difficult intubation, or difficult ventilation as reference tests). Forty-two studies enrolling 34,513 patients were included. The definitions of the reference tests varied widely. For predicting difficult laryngoscopy, both versions of the Mallampati test had good accuracy (area under the summary receiver operating characteristic (sROC) curve = 0.89 0.05 and 0.78 0.05, respectively). For predicting difficult intubation, the modified Mallampati test had good accuracy (area under the sROC curve = 0.83 0.03) whereas the original Mallampati test was poor (area under the sROC curve = 0.58 0.12). The Mallampati tests were poor at identifying difficult mask ventilation. Publication bias was not detected. Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.

 

心臟手術後早期活動時混合靜脈血氧飽和度顯著下降:體位或鍛煉的影響?
The Marked Reduction in Mixed Venous Oxygen Saturation During Early Mobilization After Cardiac Surgery: The Effect of Posture or Exercise?

Idar Kirkeby-Garstad, MD, Ulrik Wisløff, PhD, Eirik Skogvoll, MD, PhD, Tomas Stølen, Arnt-Erik Tjønna, Roar Stenseth, MD, PhD, and Olav FM Sellevold, MD, PhD

Department of Cardiothoracic Anesthesia and Intensive Care, St Olav University Hospital, Department of Circulation and Medical Imaging, and Unit for Applied Clinical Research, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway

Anesth Analg 2006 102: 1609-1616.

心臟手術後早期活動可引起混合靜脈血氧飽和度(SvO2)的顯著下降。通過肺動脈導管和間接測熱法,作者研究了鍛煉和體位改變對冠狀動脈搭橋術前和術後首日上午心指數(CI)和SvO2的影響。16名射血分數>0.50的患者,在靜息狀態、仰臥腳踏車鍛煉和被動站立時接受研究。術前進行30W的仰臥蹬車可使CI增加1.5 ± 0.8 L·min-1·m-2,術後則使CI增加0.9 ± 0.7 L·min-1·m-2 (P < 0.05);但術前SvO2從靜息狀態的80%± 4%降低至63 ± 6% (P < 0.05),術後SvO2從靜息狀態的71% ± 5% 降低至46% ± 11% (P < 0.05)。術前被動站立時CI 降低0.8 ± 0.5 L·min-1·m-2,術後被動站立時CI降低0.3± 0.4 L·min-1·m-2(P < 0.05);術前SvO279% ± 5%降至64%± 7% (P < 0.05),術後從72% ± 6%降至60%± 6% (P < 0.05)。這種鍛煉顯示術後心血管反應發生改變,同樣的工作負荷可引起SvO2顯著降低。手術前後被動站立均可顯著降低SvO2,但是這種影響在術後相對較不明顯。術後對體位元改變和鍛煉的反應發生改變,可能都引起了術後活動中SvO2的降低。

(趙延華 陳傑 校)

Early mobilization after cardiac surgery induces a marked reduction in mixed venous oxygen saturation (Svo2). Using pulmonary artery catheters and indirect calorimetry, we investigated the effects of exercise and postural change on cardiac index (CI) and Svo2 before and on the first morning after coronary artery bypass surgery. Sixteen patients with an ejection fraction >0.50 were studied at rest, during supine bicycle exercise, and during passive standing. Supine cycling at 30 W increased CI by 1.5 ± 0.8 L · min–1 · m–2 before and 0.9 ± 0.7 L · min–1 · m–2 after surgery (P < 0.05), whereas Svo2 was reduced from 80% ± 4% at rest to 63 ± 6% preoperatively (P < 0.05) and from 71% ± 5% to 46% ± 11% postoperatively (P < 0.05). Passive standing reduced CI by 0.8 ± 0.5 L · min–1 · m–2 before and 0.3 ± 0.4 L · min–1 · m–2 after surgery (P < 0.05). Svo2 was reduced from 79% ± 5% to 64% ± 7% preoperatively (P < 0.05) and from 72% ± 6% to 60% ± 6% postoperatively (P < 0.05). The exercise challenge revealed an altered cardiovascular response after surgery, causing a larger reduction in Svo2 for the same workload. Passive standing significantly reduced Svo2 both days, but this effect was less pronounced after surgery. The response to postural change and exercise was altered after surgery and may both contribute to the reduction in Svo2 during postoperative mobilization.

 

體外迴圈冠狀動脈手術病人術後血清改變內皮Ca2+的信號轉導

Endothelial Ca2+ Signal Transduction Is Altered by Postoperative Serum from Patients Undergoing Coronary Surgery with Cardiopulmonary Bypass
Crispin Schneider, Cand. med., and Thomas Volk, MD

Department of Anesthesiology and Intensive Care Medicine, Charitè-Universitätsmedizin Berlin, Berlin, Germany

Anesth Analg 2006 102: 1630-1637.

術後內皮失功可能為內皮細胞內信號轉導性質改變所致。一般認為這種功能改變是全身性的,且和創傷大小有關。這促使作者假設血中存在某種介質所致。因此,作者研究了高侵襲性手術(體外迴圈冠狀動脈手術[CS])和較小侵襲手術(關節融合手術[TJA])病人圍術期血清對內皮信號細胞Ca2+反應的影響。採集26名接受CS病人和15名接受TJA病人術前和術後的血清,將主動脈內皮細胞放在其中培養。用ATP100 µM)誘發的FURA-2螢光改變方法測量細胞內的Ca2+。在CS樣本中,誘發[Ca2+]i信號被術後血清增強(高峰水平: 96 ± 41 FU 116 ± 45 FU; P < 0.05)TJA病人血清則無這種術後增強。使用硝苯地平對CS樣本進行預孵化阻斷電壓門控Ca2+通道不會改變這種效應,但缺乏細胞外Ca2+會終止暴露於CS血清所導致的反應性增高。利用Mn2+抑制可探測到Ca2+的內流,暴露於CS血漿的內皮細胞Ca2+內流增加,而Ca2+內流與術後迴圈內白介素-6水平相關(P < 0.007)。體外迴圈冠狀動脈手術病人術後內皮功能改變部分由存在於血漿內的全身因素導致,血漿可導致特異內皮Ca2+信號轉導增強。在離體情況下這一增強作用在接受未存在Ca2+內流增強的TJA病人的血清時消失。

(殷文淵 陳傑 校)

Endothelial dysfunction after surgery may be caused by alterations in the intracellular signaling properties of endothelial cells. Functional alterations are believed to be systemic and dependent on the amount of invasiveness. This led us to assume that there would be a mediator in the blood. Therefore, we investigated the influence of perioperative serum obtained from patients undergoing highly invasive surgical interventions (cardiac surgery [CS] with cardiopulmonary bypass) and less invasiveness (total joint arthroplasty [TJA]) on endothelial single cell Ca2+ responses. Aortic endothelial cells were incubated with preoperative and postoperative serum samples from 26 patients undergoing CS and from 15 patients undergoing TJA. Adenosine triphosphate (100 µM)-induced alterations in FURA-2 fluorescence was used to measure intracellular Ca2+ in single cells. In CS samples the induced [Ca2+]i signals were enhanced by postoperative serum (peak levels: 96 ± 41 FU versus 116 ± 45 FU; P < 0.05). These postoperative enhancements were absent in TJA patients serum. Preincubation of CS samples with nifedipine to block voltage gated Ca2+ channels did not alter this effect, but the absence of extracellular Ca2+ abolished the increased response from postoperative CS serum exposure. Ca2+ entry probed with Mn2+ quenching was increased in endothelial cells exposed with postoperative CS serum and Ca2+ entry correlated with postoperative circulating interleukin-6 levels (P < 0.007). Endothelial functional alterations after CS with cardiopulmonary bypass are attributable, in part, to systemic factors present in serum that lead to specific endothelial enhanced Ca2+-signaling. This enhancement can be separated in vitro as an increased Ca2+ entry not present in serum from patients recovering from TJA.

 

經食管超聲心動圖在非心臟手術心臟停搏併入中的應用

The Usefulness of Transesophageal Echocardiography During Intraoperative Cardiac Arrest in Noncardiac Surgery

Stavros G. Memtsoudis, MD, PhD, Peter Rosenberger, MD, Michaela Loffler, Holger K. Eltzschig, MD, Annette Mizuguchi, MD, PhD, Stanton K. Shernan, MD, and John A. Fox, MD

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Department of Anesthesiology and Intensive Care Medicine, Tübingen University Hospital, Tübingen, Germany

Anesth Analg 2006 102: 1653-1657.

根據美國麻醉協會和心血管麻醉協會指南,威脅生命的血流動力學紊亂是術中應用經食道超聲心動圖(TEE)Ⅰ類適應證。然而,TEE對術中心臟停搏診斷的用途以及它對病人處理的影響尚無嚴密的觀察。作者利用本科TEE資料庫,選取22例行非心臟手術且在全麻誘導與手術結束期間有意外的嚴重血流動力學衰竭需要加強心臟生命支援的病人。回顧TEE檢查結果、病程錄、具體的操作記錄、心輸出量等,來分析TEE在診斷血流動力學的效用,並評估其對其後處理的影響。在22例行TEE檢查的患者中,初步診斷19人存在潛在的病理學過程,包括9例有血栓栓子,6例急性心肌缺血,2例血容量減少,2例心包填塞。3例患者不能利用TEE確診。18例患者接受TEE指導下高級心臟生命支持方案以外的特殊處理,包括12例病人接受了外科處理。14例病人安全離開手術室,其中7例病人康復出院。因此,TEE可為術中心臟停搏病人提供另外的診斷資訊,並可以直接指導特殊的生命支援治療。

(劉哲 陳傑

According to guidelines established by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists, life-threatening hemodynamic disturbances are classified as a category I indication for the intraoperative use of transesophageal echocardiography (TEE). However, the usefulness of TEE during intraoperative cardiac arrest and its impact on patient management have not been rigorously investigated. Using our departmental TEE database, we identified a population of 22 patients who underwent noncardiac surgical procedures and experienced unexpected intraoperative hemodynamic collapse requiring the initiation of Advanced Cardiac Life Support procedures between the time of induction of general anesthesia and the termination of the surgical procedure. Results of TEE examinations, patient records, detailed operative records, and outcome of patients were reviewed for the utility of TEE to diagnose the etiology of the hemodynamic collapse. Furthermore, the impact on subsequent patient management was evaluated. A primary suspected diagnosis of the underlying pathological process was established in 19 of 22 patients with TEE, including 9 with thromboembolic events, 6 with acute myocardial ischemia, 2 with hypovolemia, and 2 patients with pericardial tamponade. A definitive diagnosis could not be made in 3 patients with TEE. In 18 patients, TEE guided specific management beyond implementation of Advanced Cardiac Life Support protocols, including the addition of surgical procedures in 12 patients. Fourteen patients survived to leave the operating room, and 7 of these patients were eventually discharged from the hospital. Thus, TEE may provide additional diagnostic information in patients with intraoperative cardiac arrest and may directly guide specific, potentially life-saving therapy.

 

腦部MRI掃描能升高鎮靜小兒的中心體溫

Brain Magnetic Resonance Imaging Increases Core Body Temperature in Sedated Children

Yvon F. Bryan, MD*, Thomas W. Templeton, MD{ddagger}, Todd G. Nick, PhD{dagger}, Martin Szafran, BS§, and Avery Tung, MD

*Department of Clinical Anesthesia and Clinical Pediatrics, {dagger}Department of Pediatrics, Center for Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center and University of Cincinnati, College of Medicine, Cincinnati, Ohio; {ddagger}Department of Pediatric Anesthesia and Critical Care, Wake Forest University School of Medicine, Winston-Salem, North Carolina; §Pritzker School of Medicine, ¶Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois

Anesth Analg 2006 102: 1674-1679.

 

目前,越來越多的兒童在麻醉鎮靜的狀態下接受核磁共振(MRI)檢查。MRI需要一個溫度較低的環境。由於兒童的體表面積/體重比較成人大,大多數保溫設備與MRI不相容,因此存在著由於熱量散失造成體溫下降的風險。但是由於患兒吸收掃描過程產生的輻射可以對抗這種熱量損失。為了研究輻射吸收對患兒體溫的影響,作者在MRI之前和之後測量了30名行MRI檢查的小兒的鼓膜溫度。這些患兒均在水合氯醛鎮靜下行MRI檢查,均穿醫院的服裝並蓋一條毯子。研究結果顯示,患兒的平均年齡為14.9±8.6月,體重為9.8±2.8kg。平均掃描時間為42±13min,在這期間鼓膜溫度升高了0.5攝氏度,從36.9±0.4℃升高到37.4±0.3℃(95%CI0.3-0.7℃,p<0.001)。研究結果表明,儘管沒有應用防止熱量散失和保暖措施,但是應用水合氯醛鎮靜的小兒行腦部MRI檢查時體溫非但沒有下降反而升高了。這一結果表明,在MRI檢查過程中積極進行保暖並不適合於所有病人。

(蘇殿三 陳傑 校)

An increasing number of children now undergo magnetic resonance imaging (MRI) under sedation. MRI requires a cool environment. Because children have a larger surface area to body weight ratio than adults and because active warming devices are not MRI compatible, hypothermia as a result of passive heat loss is a risk. Absorption of radiofrequency radiation generated by the scanning process, however, may partially offset this heat loss. To determine the effect of absorbed radiofrequency radiation on body temperature during MRI, we measured pre-MRI and post-MRI tympanic temperatures in 30 children who underwent brain MRI while sedated with chloral hydrate and covered with a hospital gown and blanket. The mean (± sd) age was 14.9 ± 8.6 mo, and weight was 9.8 ± 2.8 kg. During an average scan duration of 42 ± 13 min, mean tympanic temperatures increased 0.5°C from 36.9°C ± 0.4°C to 37.4°C ± 0.3°C; (95% CI difference, 0.3°C to 0.7°C; P < 0.001). Our findings suggest that children sedated with chloral hydrate for brain MRI did not become hypothermic but rather had increased body temperature despite minimal barriers to heat loss and no active warming. These results imply that aggressive measures to prevent passive heat loss during MRI studies may not be needed in all patients.

 

全麻藥抑制培養的海馬切片的縫隙連接間的資訊傳遞

General Anesthetics Inhibit Gap Junction Communication in Cultured Organotypic Hippocampal Slices

Kirsten Wentlandt, PhD, Marina Samoilova, PhD, Peter L. Carlen, MD, FRCPC, and Hossam El Beheiry, MBBCh, PhD, FRCPC

Division of Cellular and Molecular Biology, Toronto Western Research Institute, Departments of Anesthesia & Pain Management, Physiology and Medicine (Neurology), University of Toronto, University Health Network, Toronto, Ontario, Canada

Anesth Analg 2006 102: 1692-1698.

 

縫隙連接是連接相鄰細胞的通道蛋白,形成電突觸,促進神經元活動的同步活動。由此神經元活動引發和傳播形成的腦電波產生認知和意識。本實驗探討異丙酚,硫噴妥鈉,氟烷在培養的海馬切片中對縫隙連接間的資訊傳遞的影響。採用照相漂白後螢光恢復技術(FRAP)和心電生理檢測技術。FRAP 發現15m的異丙酚和10m硫噴妥鈉分別減低縫隙連接間的資訊傳遞達46.7±4.5%和48.8±5.5%。低劑量(5m異丙酚,2m硫酚妥鈉)則不影響縫隙連接耦聯。電生理檢測發現連續4次電刺激(50Hz2″)時,15m的異丙酚和10m硫噴妥鈉可減低海馬切片的自發放電及放電後第一次收縮。且0.64mM的氟烷(約2MAC)對縫隙連接間的資訊傳遞無影響。但2.8mM的氟烷阻斷FRAP70%。本研究表明麻醉劑量的異丙酚,硫噴妥鈉(除氟烷)可抑制培養海馬切片的縫隙連接間的資訊傳遞。縫隙連接間的資訊傳遞的抑制可能在麻醉機理中發揮一定的作用。

(李啟芳 陳傑 校)

Gap junctions are protein channels that directly connect the cytosol of neighboring cells, thus forming electrical synapses and promoting synchronous neuronal activities. Such activities lead to the initiation and propagation of electroencephalogram oscillations implicated in cognition and consciousness. In this study, we investigated the effects of propofol, thiopental, and halothane on gap junction communication in cultured organotypic hippocampal slices by recovery of fluorescence after photo bleaching (FRAP) technique and electrophysiological recordings. Propofol 15 µM and thiopental 10 µM attenuated gap junction communication in slice cultures by 46.7% ± 4.5% and 48.8% ± 5.5%, respectively, as measured by FRAP. Smaller concentrations of propofol 5 µM and thiopental 2 µM did not change gap junction coupling. Accompanying the decreased gap junction communication, hippocampus slice cultures exposed to propofol 15 µM and thiopental 10 µM were found to have reduced electrophysiologic spontaneous discharges and primary after discharges evoked by a tetanic train of 50 Hz for 2 s. On the other hand, halothane 0.64 mM, a concentration slightly larger than twice its minimum alveolar concentration had no effect on gap junction coupling while halothane 2.8 mM blocked FRAP by 70%. The current study illustrates that anesthetic concentrations of propofol and thiopental, but not halothane, attenuate gap junction communication in cultured hippocampal slices. Suppression of gap junction function could compound the mechanisms of anesthetic actions.

 

氟烷、異氟烷對微電流刺激網狀細胞時引起腦電反應的效應差異

The Differential Effects of Halothane and Isoflurane on Electroencephalographic Responses to Electrical Microstimulation of the Reticular Formation

Mashawn Orth, BS, Emigdio Bravo, BS, Linda Barter, MVSc, Earl Carstens, PhD, and Joseph F. Antognini, MD

Department of Anesthesiology and Pain Medicine, Section of Neurobiology, Physiology and Behavior, University of California, Davis, Davis, California

Anesth Analg 2006 102: 1709-1714.

異氟烷和氟烷在網狀細胞結構(決定意識狀態的關鍵之處)能產生腦電抑制和神經細胞抑制。作者假定異氟烷對微電流刺激網狀細胞結構引出的腦電活動的抑制要強於氟烷。用異氟烷、氟烷麻醉大鼠,並將刺激電極置於網狀細胞結構。在交叉實驗中,調整氟烷或異氟烷的濃度為0.8 1.2最小肺泡濃度(MAC),運用微電流刺激並記錄EEG反應。在0.8MAC氟烷-異氟烷和1.2MAC氟烷時,微刺激能增加邊緣頻譜和頻率中值範圍2-2.5HZ。在1.2MAC異氟烷時能產生爆發抑制,微刺激縮短等電位時限(24%±19%8%±7%;P<0.05),而並不 改變邊緣頻譜和頻率中值範圍。在需要制動的麻醉藥濃度下,從0.8MAC1.2MAC,雖然EEG反應被抑制,皮層對網狀細胞結構的微刺激仍然有反應。這些資料顯示皮層神經元在異氟烷和氟烷麻醉時對突觸輸入仍有反應。

(顧新宇 陳傑 校)

Isoflurane and halothane cause electroencephalographic (EEG) depression and neuronal depression in the reticular formation, a site critical to consciousness. We hypothesized that isoflurane, more than halothane, would depress EEG activation elicited by electrical microstimulation of the reticular formation. Rats were anesthetized with either halothane or isoflurane and stimulating electrodes were positioned in the reticular formation. In a crossover design, anesthetic concentration was adjusted to 0.8 and 1.2 minimum alveolar concentration (MAC) of halothane or isoflurane and electrical microstimulation was performed and the EEG responses were recorded. Microstimulation increased the spectral edge and median edge frequencies 2–2.5 Hz at 0.8 MAC for halothane and isoflurane and 1.2 MAC halothane. At 1.2 MAC isoflurane, burst suppression occurred and microstimulation decreased the period of isoelectricity (24% ± 19% to 8% ± 7%; P < 0.05), whereas the spectral edge and median edge frequencies were unchanged. At anesthetic concentrations required to produce immobility, the cortex remains responsive to electrical microstimulation of the reticular formation, although the EEG response is depressed in the transition from 0.8 to 1.2 MAC. These data indicate that cortical neurons remain responsive to synaptic input during isoflurane and halothane anesthesia.

 

阿米替林的神經毒性由細胞凋亡介導並被Caspase抑制劑阻斷

The Neurotoxic Effects of Amitriptyline Are Mediated by Apoptosis and are Effectively Blocked by Inhibition of Caspase Activity

Philipp Lirk, MD*, Ingrid Haller, MD*, Barbara Hausott, PhD#, Shota Ingorokva, MD#, Martina Deibl, MSc&, Peter Gerner, MD%, and Lars Klimaschewski, MD#

*Department of Anesthesiology and Critical Care Medicine, #Division of Neuroanatomy, and &Institute of Biostatistics, Computer Sciences, and Health Management, Innsbruck Medical University, Austria; %Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, USA

Anesth Analg 2006 102: 1728-1733.

 

口服三環抗抑鬱藥被廣泛的應用於慢性疼痛的治療,在體外用於阻斷鈉通道,在體內用於阻滯神經傳導。但是,已經發現在神經系統使用阿米替林後出現了毒性反應。因此作者研究了阿米替林的神經毒性的產生機制以及防止此毒性的可能方法。為了評估劑量依賴性的阿米替林的神經毒性作者用阿米替林培養了成年大鼠背根神經節的細胞,定量測定了神經存活數。此外,還研究了細胞凋亡的指標(線粒體膜電位,細胞質細胞色素C,和活化的caspase-3),阿米替林和caspase活性抑制劑z-vad-fmk共同培養細胞並對細胞的存活進行測定。作者發現阿米替林引起劑量依賴性毒性。用阿米替林培養的神經元線粒體膜電位的降低,細胞色素C的釋放至細胞質和caspase-3啟動。和z-vad-fmk一起進行孵育細胞可以顯著的改善細胞存活。總之,阿米替林引起的神經毒性是由細胞凋亡介導的, caspase活性抑制劑可以減輕毒性,這顯示了抑制凋亡途徑可能會減輕局麻藥的神經毒性。在體內試驗需要證實抗細胞凋亡藥和局麻藥聯合應用是否能夠減輕神經毒性的副作用。

(王震虹 陳傑 校)

Oral tricyclic antidepressants, widely used as adjuncts in the treatment of chronic pain, block sodium channels in vitro and nerve conduction in vivo. However, toxicity of amitriptyline has been observed after neural application. We therefore investigated the mechanism and possible prevention of amitriptyline neurotoxicity. To assess dose-dependent neurotoxicity of amitriptyline, we incubated neuron cultures from adult rat dorsal root ganglia with amitriptyline and quantified neuronal survival. Additionally, we investigated accepted markers of apoptosis (mitochondrial membrane potential, cytosolic cytochrome c, and activated caspase-3) and co-incubated amitriptyline with an inhibitor of caspase activity, z-vad-fmk, to assess the effect on cell survival. We found a dose-dependent neurotoxic effect of amitriptyline. Neurons incubated with amitriptyline exhibited loss of mitochondrial membrane potential, release of cytochrome c into the cytoplasm, and activation of caspase-3. Co-incubation with z-vad-fmk substantially improved neuronal survival in culture. In conclusion, amitriptyline-induced neurotoxicity is mediated by apoptosis and is attenuated by inhibition of caspase activity, suggesting that inhibition of apoptotic pathways may be efficient at alleviating local anesthetic–induced neurotoxicity. In vivo studies will have to corroborate whether the co-injection of anti-apoptotic drugs with local anesthetics decreases neurotoxic side effects.

 

一種優化充氣止血帶壓力測量動脈阻斷壓的新方法

A New Method for Estimating Arterial Occlusion Pressure in Optimizing Pneumatic Tourniquet Inflation Pressure

Bahattin Tuncali, MD, Ayse Karci, MD, Binnur Erdalkiran Tuncali, MD, Omur Mavioglu, MD, Mustafa Ozkan, Abdul Kadir Bacakoglu, Hakan Baydur, MD, Ahmet Ekin, and Zahide Elar

Department of Anesthesiology and Reanimation, Department of Orthopedics and Traumatology-Division of Hand Surgery, Department of Public Health, Dokuz Eylul University, Izmir, Turkey

Anesth Analg 2006 102: 1752-1757.

為了減輕在使用充氣止血帶過程中與壓力相關的損傷,常推薦使用最低有效的充氣壓。動脈阻斷壓(AOP)是一種測定用於維持無血術野的袖帶壓力。但是時間的控制是關鍵,它需要操作者的技巧,所以很少被廣泛使用。動脈阻斷壓的測量要通過皮下軟組織的壓力轉換才能實現。作者測量了30例麻醉狀態的成年病人的止血帶充氣壓力為100,200,300mmHg時的止血帶下最上層和最下層的組織壓力。所有病人均接受肌松全麻。Stryker壓力監測儀測量止血帶下組織壓力。所有病人的軟組織的壓力始終低於應用(設定)的止血帶充氣壓力。結果表明組織填料係數是20-75 cm。一種新的AOP的測量方法 [AOP=(systolic blood pressure+10)/Tissue padding coefficient] 這種新的AOP測量方法可能是一種簡單快速可供臨床選用的AOP測量方法。

(宋金超 陳傑 校)

To reduce pressure-related injuries resulting from pneumatic tourniquet use, the lowest possible inflation pressure is recommended. Arterial occlusion pressure (AOP) is a measure of the cuff pressure required to maintain a bloodless surgical field. However, its determination method is time consuming, requires operator skill, and is therefore seldom used in current practice. An AOP estimation can be made by knowing the pressure transmitted to the underlying soft tissues. We measured upper and lower extremity tissue pressures under the tourniquet cuff at 100, 200, and 300 mm Hg of tourniquet inflation pressures in 30 anesthetized living adult patients. All patients received general anesthesia with neuromuscular relaxation. A Stryker intra-compartmental pressure monitor was used to measure tissue pressures under the tourniquet cuff. In all patients, the soft tissue pressures were consistently lower than the applied tourniquet inflation pressures. Our results revealed tissue padding coefficients for extremities 20 to 75 cm in circumferences. An estimation method of AOP was developed [AOP = (systolic blood pressure + 10)/Tissue padding coefficient]. The new AOP estimation method may be a simple, rapid, and clinically practical alternative to the AOP determination method.


顱脊神經媒介大鼠經顱電刺激法中的抗傷害作用

The Role of the Craniospinal Nerves in Mediating the Antinociceptive Effect of Transcranial Electrostimulation in the Rat

Vladimir Nekhendzy, MD, M. Frances Davies, PhD, Hendrikus J. M. Lemmens, MD, PhD, and Mervyn Maze, MB, ChB, FRCP, FRCA

Department of Anesthesiology, Stanford University School of Medicine, Stanford, California; Department of Anaesthetics and Intensive Care, Imperial College, London and Chelsea and Westminster NHS Hospital Trust, London, UK

Anesth Analg 2006 102: 1775-1780.

 

已有報導顯示經顱電刺激療法(TES)具有顯著的鎮痛作用,但它的作用機制尚未闡明。從最近臨床上關於TES的鼠模型介紹中作者已驗證TES的抗傷害作用,提示鼠的頭皮感覺神經起間接作用。在這個研究中,作者試圖通過在TES的電極下行局部浸潤麻醉以阻斷TES的抗傷害作用來研究顱脊神經的作用。通過TES電極應用各種不同的經皮電神經刺激方式來比較TES的抗傷害作用的差異。用清醒的未限制活動的雄鼠進行實驗,在清醒狀態下用甩尾的潛伏期來測量傷害性疼痛的閾值以評估TES的抗傷害作用。資料用Bonferroni t-檢驗單變數檢驗分析。TES的抗傷害作用在局麻後明顯減少,給予100赫茲的經皮電神經刺激後能長時間產生相同深度的抗傷害作用。結論:顱脊神經在TES的間接抗傷害作用中起了重要的作用,也提供了這種作用的潛在機制的假設。

(張美榮 陳傑 校)

Transcranial electrostimulation (TES) has been reported to elicit significant analgesia, but its mechanism of action has not been elucidated. In a recently introduced clinically relevant rat model of TES we have validated and characterized the TES antinociceptive effect, suggesting involvement of the sensory nerves of the rat's scalp in mediating that effect. In this study, we have further investigated the role of the craniospinal nerves by attempting to block the TES antinociceptive effect with local anesthetic injected under the TES electrodes. We also applied different transcutaneous electrical nerve stimulation modalities through the TES electrodes and compared the elicited antinociceptive effect to that of TES. The antinociceptive effect was assessed by measuring nociceptive thresholds in the tail-flick latency test in awake, unrestrained male rats. Data were analyzed by one-way analysis of variance followed by the Bonferroni t-test. The TES antinociceptive effect was significantly reduced after local anesthetic injection, and administration of 100 Hz transcutaneous electrical nerve stimulation was, over time, capable of eliciting the same degree of antinociceptive effect as TES. We conclude that sensory craniospinal nerves play a critical role in mediating the TES antinociceptive action and offer a hypothesis on the underlying mechanism(s) responsible for this action.

 

志願受試者急性疼痛期間乙琥紅黴素促進胃排空

Erythromycin Promotes Gastric Emptying During Acute Pain in Volunteers

Lionel Bouvet, MD, Frédéric Duflo, MD, Nathalie Bleyzac, PharmD, François Mion, MD, PhD, Emmanuel Boselli, MD, Bernard Allaouchiche, MD, PhD, and Dominique Chassard, MD, PhD

Department of Anesthesiology and Intensive Care, and Laboratory of Pathophysiology in Anesthesiology and Intensive Care (EA 18/96), Hôpital de l'Hôtel-Dieu; Department of Pharmacy, Hôpital Debrousse; Department of Gastroenterology, Hôpital Edouard Herriot, Lyon, France

Anesth Analg 2006 102: 1803-1808. [

 

在本雙盲交叉研究中,作者假設使用乙琥紅黴素能作為一種促進胃動力藥來防治急性疼痛引起的胃輕癱。7名標準化急性疼痛的志願者來評估乙琥紅黴素對於胃排空(GE)的效應。辛酸呼吸實驗來測定固體的胃排空率。對乙酰氨基酚吸收試驗測定液體的胃排空率。攝入13C-標記的食物5min後,受試者隨機成為實驗組(安慰劑和乙琥紅黴素組)和對照刺激(對照組)包括每分鐘重複將手浸入4°C (實驗) or 37°C (對照) 水中,兩次間隔15S。當實驗開始,輸注250mL生理鹽水(對照組和安慰劑組)250mg乙琥紅黴素(乙琥紅黴素組)。以視覺評分來評估疼痛和應激狀態,實驗自始至終記錄標準的血液動力學參數。結果顯示急性應激降低固體的胃排空,但是和安慰劑組相比乙琥紅黴素可以顯著促進胃排空。液體的胃排空率3組相似。作者推斷乙琥紅黴素可以作為一種有效的促進胃運動的藥物來用於急性疼痛。

(潘志英 陳傑 校)

In this double-blind cross-over study, we assessed whether erythromycin infusion is effective as a prokinetic drug against gastroparesis from acute pain. The effect of erythromycin on gastric emptying (GE) was measured in seven volunteers subjected to a standardized acute painful stimulus. The GE rate for solids was measured using the octanoic acid breath test. An acetaminophen absorption test measured the GE rate for liquids. Five minutes after ingestion of a 13C-labeled meal, the subjects received in randomized order either a test (placebo and erythromycin groups) or a control (control group) stimulus consisting of repeated 1-min immersion of a hand into 4°C (test) or 37°C (control) water, with 15 s for recovery between immersions, for a total of 20 min. While the stimulus was applied, 250 mL saline (control and placebo groups) or 250 mg erythromycin (erythromycin group) was infused. Pain and stress were evaluated using visual analog scales, and standard hemodynamic values were recorded throughout the study. Our results show that acute stress decreased GE for solids, which was significantly accelerated in the erythromycin group in comparison with the placebo group. GE for liquids was similar in the three groups. We conclude that erythromycin is effective as a prokinetic drug for solids in acute painful situations.


吲哚美辛對有顱內高壓的綿羊接受異丙酚或異氟醚麻醉中對顱內壓和腦血流動力學的影響

The Effects of Indomethacin on Intracranial Pressure and Cerebral Hemodynamics During Isoflurane or Propofol Anesthesia in Sheep with Intracranial Hypertension

Mads Rasmussen, MD, PhD*{dagger}, Richard N. Upton, BSc, PhD*, Cliff Grant, MMedSc*, Allison M. Martinez*, Georg E. Cold, MD, PhD{dagger}, and Guy Ludbrook, MD, FANZCA, PhD*

*Department of Anesthesia and Intensive Care, Royal Adelaide Hospital/University of Adelaide, North Terrace, Australia; and {dagger}Department of Neuroanesthesia, Århus University Hospital, Denmark

Anesth Analg 2006 102: 1823-1829.

吲哚美辛降低顱內壓的作用或許取決於麻醉用藥。作者在有顱內高壓的綿羊在接受異丙酚或異氟醚麻醉時,吲哚美辛對顱內壓和腦血流的影響。六隻隨機接受異氟醚或異丙酚麻醉的綿羊用交叉設計方法進行研究。麻醉深度通過動物反應和狀態熵來測定。在靜脈注射吲哚美辛前後的特定的時間測定CBFICP,平均動脈壓,動靜脈氧分壓差,PaCO2。兩種麻醉中動物反應和狀態熵相似。在兩組麻醉中,異氟醚和異丙酚組CBF降低分別為11%34%。吲哚美辛在兩組麻醉用藥之後的15秒產生了ICP的下降作用,ICP的降低異氟醚組更為顯著(P = 0.009)。在兩組麻醉中,吲哚美辛導致平均動脈壓增加和CBF較用藥前降低17%(異氟醚組)和14%(異丙酚組)。異氟醚組在CBF上的降低作用要明顯大於異丙酚組。對ICP的影響,異氟醚更為明顯。作者認為吲哚美辛的作用部分通過自身調節反應產生的。

(鄭麗 陳傑 校)

The effect of indomethacin in reducing intracranial pressure (ICP) may be dependent on the choice of anesthetic regimen. We studied the effects of indomethacin on ICP and cerebral blood flow (CBF) during isoflurane or propofol anesthesia in a sheep model of intracranial hypertension. A crossover design was applied in which six sheep were anesthetized with isoflurane and propofol in a random order. Anesthetic depth was measured with response and state entropy. Changes in CBF, ICP, mean arterial blood pressure, arterio-venous oxygen difference, and Paco2 were measured at specific times before and after an IV indomethacin bolus (0.2 mg/kg). Response and state entropy values during anesthesia were similar in both groups. Isoflurane and propofol reduced CBF by 11% and 34%, respectively. Indomethacin caused a reduction in ICP within 15 s during both anesthetic regimens, with the decrease in ICP being significantly more pronounced during isoflurane (P = 0.009). In both anesthetic groups, indomethacin caused a simultaneous increase in mean arterial blood pressure and a further 17% versus 14% decrease in CBF from predrug values for isoflurane and propofol, respectively. The reduction in CBF was significantly more pronounced for propofol (P = 0.02). The effect on ICP, however, was most pronounced during isoflurane anesthesia. We suggest that the effect of indomethacin is partly mediated by an autoregulatory response.


年齡對羅呱卡因硬膜外麻醉後運動阻滯中位有效濃度的影響

The Effects of Age on the Median Effective Concentration of Ropivacaine for Motor Blockade After Epidural Anesthesia with Ropivacaine

Yuhong Li, PhD, Shengmei Zhu, PhD, Fangping Bao, MS, Jianhong Xu, MS, Xiang Yan, MS, and Xudong Jin, MS

Department of Anesthesiology, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, People’s Republic of China

Anesth Analg 2006 102: 1847-1850.

局麻藥最小鎮痛濃度定義為中位有效濃度(EC50)。在這項研究中,泌尿科或下肢小手術的病人中,作者致力於研究年齡對運動阻滯的影響並確定老年病人硬膜外注入羅呱卡因後運動阻滯的EC50。將ASA I-II級的病人分入兩個年齡組(組I70歲;組II<70歲)。每一組硬膜外注入15ml羅呱卡因,不加腎上腺素。每組的第一個病人使用0.425%的濃度。使用上下順序分配來決定後一個的使用濃度。試驗濃度間隔是0.025%。有效運動阻滯的標準是30分鐘內Bromage評分>0。羅呱卡因運動阻滯的EC50第一組是0.383%(95%可信區間,0.385%-0.409%),第二組是0.536%(95%可信區間,0.512%-0.556%)(p<0.01)。結論:年齡是羅呱卡因硬膜外麻醉運動阻滯EC50的一項決定因素。

(曹瑜 陳傑 校)

Minimal local analgesic concentrations have been defined as the median effective concentration (EC50). In this study, we sought to examine the effect of age on motor blockade and determine the motor block EC50 of elderly patients after epidural administration of ropivacaine in patients undergoing urological or minor lower limb surgery. ASA physical status I–II patients were enrolled in 1 of 2 age groups (Group 1: ≥70 yr; Group 2: <70 yr). Each received a 15-mL bolus of epidural ropivacaine without epinephrine. The first patient in each group received 0.425%. Up-down sequential allocation was used to determine subsequent concentrations at a testing interval of 0.025%. Effective motor blockade was defined as a modified Bromage score >0 within 30 min. The motor blockade EC50 of ropivacaine was 0.383% (95% confidence interval, 0.358%–0. 409%) in group 1 and 0.536% (95% confidence interval, 0.512%–0.556%) in group 2 (P < 0.01). We conclude that age is a determinant of motor blockade EC50 of ropivacaine with epidural administration.

 

體位影響手靈巧度
Body Position Affects Manual Dexterity

Charles W. Buffington, MD*, Stanley D. MacMurdo, MD*, and Christopher M. Ryan, PhD{dagger}

Departments of *Anesthesiology and {dagger}Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania

Anesth Analg 2006 102: 1879-1883.

 

為評估姿勢和精神運動功效兩者之間的關係,20例麻醉醫生參加了這項實驗。檢測每位醫生分別在坐著、跪著和站著腰部向前彎曲這三個體位時,體位對手靈巧度和眼-手協調性的影響。受試者在坐位時較其他體位的工作效率(用Grooved Pegboard Test評價)改善6-10%(P<0.005)。除了坐位外,其他體位元都會使受試者感到疼痛和不適。坐位改善手靈巧度在低分操作者較高分操作者更顯著。本研究表明受試者處於一個較為舒適的坐位時,可改善其手靈巧度。
(肖潔 陳傑 校)

To evaluate the relationship between posture and psychomotor efficiency, 20 anesthesia providers performed a test requiring manual dexterity and eye-hand coordination while seated, kneeling, and standing bent forward at the waist. Performance on the Grooved Pegboard Test improved 6%–10% (P < 0.005) when subjects were seated compared to kneeling and standing bent at the waist, positions that the subjects rated as more painful and less comfortable than sitting. Sitting improved manual dexterity more in subjects with poor scores than it did in subjects with good performance. This study demonstrates improved manual dexterity in subjects seated in a comfortable position.

 

體外迴圈期間人體空腸粘膜灌注的自身調節

Autoregulation of Human Jejunal Mucosal Perfusion During Cardiopulmonary Bypass

Andreas Nygren, MD, Anders Thorén, MD, PhD, Erik Houltz, MD, PhD, and Sven-Erik Ricksten, MD, PhD

Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg Sweden

Anesth Analg 2006;102:1617-1622

 

動物研究已提示小腸血流的自身調節在體外迴圈(CPB)期間遭到嚴重的損害。我們研究了10例行擇期心臟手術的患者非搏動血流CPB (34°C)期間空腸粘膜對灌注的自身調節功能。隨機改變CPB流速從2.4 L/min/m2 1.8或者 3.0 L/min/m2持續3分鐘,引起平均動脈壓(MAP)變化。用鐳射多普勒血流儀持續記錄空腸粘膜灌注(JMP)。在CPB期間所有患者都記錄到典型的流量變化(血管舒縮運動)模式。在平均動脈壓在50 ± 15 ~74 ± 16 mm Hg 範圍內,CPB流速的變化沒有引起平均JMP、空腸粘膜紅細胞壓積及紅細胞流速的顯著變化。血管運動頻率和幅度與CPB流速呈正相關。靜脈輸注環前列腺素(10 µg, Flolan®),儘管MAP 59 ± 12降至 45 ± 10 mm Hg (P < 0.05),但能抑制血管運動,並增加JMP192 ± 53 277 ± 70 (P < 0.05) 灌注單位。環前列腺素誘導的血管舒張導致粘膜自身調節(壓力依賴性灌注)減弱。我們得出結論,在人體CPB期間小腸粘膜灌注的自身調節能夠維持。

(彭中美 馬皓琳 李士通 校)

Animal studies have suggested that autoregulation of intestinal blood flow is severely impaired during cardiopulmonary bypass (CPB). We investigated the jejunal mucosal capacity to autoregulate perfusion during nonpulsatile CPB (34°C) in 10 patients undergoing elective cardiac surgery. Changes in mean arterial blood pressure (MAP) were induced by altering the CPB flow rate randomly for periods of 3 min from 2.4 L/min/m2 to either 1.8 or 3.0 L/min/m2. Jejunal mucosal perfusion (JMP) was continuously recorded by laser Doppler flowmetry. A typical pattern of flow motion (vasomotion) was recorded in all patients during CPB. Variations in CPB flow rates caused no significant changes in mean JMP, jejunal mucosal hematocrit, or red blood cell velocity within a range of MAP from 50 ± 15 to 74 ± 16 mm Hg. The vasomotion frequency and amplitude was positively correlated with CPB flow rate. IV injections of prostacyclin (10 µg, Flolan®) blunted vasomotion and increased JMP from 192 ± 53 to 277 ± 70 (P < 0.05) perfusion units despite a reduction in MAP from 59 ± 12 to 45 ± 10 mm Hg (P < 0.05). Prostacyclin-induced vasodilation resulted in loss of mucosal autoregulation (pressure-dependent perfusion). We conclude that autoregulation of intestinal mucosal perfusion is maintained during CPB in humans.

 

 

N-乙酰半胱氨酸對腹主動脈手術中腎功能受損的預防作用:一個隨機、雙盲、安慰劑對照試驗

N-Acetylcysteine for the Prevention of Kidney Injury in Abdominal Aortic Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial

Marja S. Hynninen, MD, PhD, Tomi T. Niemi, MD, PhD, Reino Pöyhiä, MD, PhD, Elina I. Raininko, MD, Markku T. Salmenperä, MD, PhD, Mauri J. Lepäntalo, MD, PhD, Mikael J. Railo, MD, PhD, and Minna K. Tallgren, MD, PhD

Department of Anesthesia and Intensive Care Medicine, Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland

Anesth Analg 2006;102:1638-1645

 

在這項前瞻性的、隨機、雙盲、安慰組對照的試驗中,我們研究了靜脈注射N-乙酰半胱氨酸對腹主動脈手術病人腎功能損傷的預防作用。70個無腎功能受損既往史的病人隨機分配接受N-乙酰半胱氨酸(150 mg/kg混合在250 mL 5%的葡萄糖中注射20 min,隨後150 mg/kg混合在250 mL 5%的葡萄糖中輸注24 h)或安慰劑。麻醉誘導後開始輸注。主要檢測結果為腎功能的損傷,通過測得的尿N-乙酰-ß-d-氨基葡糖苷酶 (NAG)/肌酐比(腎小管損傷的標誌)增加及尿白蛋白/肌酐比(腎小球損傷的標誌)增加來反映。通過測定血漿肌酐及血清半胱氨酸蛋白酶抑制劑Ccystatin C)濃度來評估腎功能。兩組病人從基礎值到腹主動脈夾閉前,尿NAG/肌酐比顯著增加,並持續升高至術後第5天。N-乙酰半胱氨酸組從基礎值到松夾後6 h尿白蛋白/肌酐比顯著增加。然而,兩組間NAG/肌酐比及白蛋白/肌酐比無明顯差別。在研究階段兩組的血漿肌酐及血清cystatin C值保持不變。結論,對於術前腎功能正常的病人,在擇期行大動脈手術期間N-乙酰半胱氨酸未能對腎功能提供任何明顯的保護作用,腎小管的某些程度損傷看來發生於大動脈夾閉前。

(裘毅敏 馬皓琳 李士通 校)

In this prospective, randomized, placebo-controlled, double-blind trial we studied the effects of IV N-acetylcysteine for prevention of renal injury in patients undergoing abdominal aortic surgery. Seventy patients without previously documented renal dysfunction were randomly allocated to receive either N-acetylcysteine (150 mg/kg mixed in 250 mL of 5% dextrose infused in 20 min, followed by an infusion of 150 mg/kg in 250 mL of 5% dextrose over 24 h) or placebo. The infusion was started after the induction of anesthesia. The primary outcome measure was renal injury as measured by the increases in urinary N-acetyl-ß-d-glucosaminidase (NAG)/creatinine ratio (indicator of renal tubular injury) and urinary albumin/creatinine ratio (indicator of glomerular injury). Renal function was assessed by measuring plasma creatinine and serum cystatin C concentrations. The urinary NAG/creatinine ratio increased significantly from baseline to before crossclamp and remained increased on day 5 in both groups. The urinary albumin/creatinine ratio increased significantly from baseline to 6 h after declamping in the N-acetylcysteine group. However, the changes in the NAG/creatinine ratio and the albumin/creatinine ratio were not significantly different between the two groups. Plasma creatinine and serum cystatin C values remained unchanged during the study period in both groups. In conclusion, N-acetylcysteine did not offer any significant protection from renal injury during elective aortic operation in patients with normal preoperative renal function, and some degree of tubular injury seems to occur before aortic crossclamp.

 

 

兒科脊柱側突手術中瑞芬太尼輸注過程中急性阿片類藥物耐受的發生

Development of Acute Opioid Tolerance During Infusion of Remifentanil for Pediatric Scoliosis Surgery

Mark W. Crawford, MBBS, FRCPC, Chantal Hickey, MD, FRCPC, Christian Zaarour, MD, Andrew Howard, MD, FRCSC, and Basem Naser, MBBS, FRCPC

Department of Anesthesia, Division of Orthopedic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada

Anesth Analg 2006;102:1662-1667

 

我們檢驗了在進行脊柱側突手術的青少年中連續術中輸注瑞芬太尼會造成臨床上相關的急性阿片類藥物耐受的假設。我們將三十個青少年病人隨機分成兩組接受不同的術中鎮痛方案,一組連續輸注瑞芬太尼,另一組只間斷給予嗎啡。用病人可以自己給予嗎啡的病人自控鎮痛裝置來評估術後鎮痛藥的消耗量。術後嗎啡的消耗累積總量、疼痛評分和鎮靜評分由一位元不知情的研究者記錄,術後最初四小時每小時記錄一次,以後的二十小時每四小時記錄一次。在術後24小時的每個時間點瑞芬太尼組的嗎啡累積消耗量均顯著超過嗎啡組(P<0.001)。術後24小時嗎啡的累積消耗量在瑞芬太尼組(1.65 ± 0.41 mg/kg)比嗎啡組(1.27 ± 0.32 mg/kg)30%(差異的95%可信區間為0.11~0.65 mg/kg)。兩組之間的疼痛評分和鎮靜評分的差異沒有統計學意義。這些資料提示了青少年在脊柱側突手術中連續輸注瑞芬太尼會造成臨床上相關的急性阿片類藥物耐受的發展。

(薑旭暉 馬皓琳 李士通 校)

We tested the hypothesis that continuous intraoperative infusion of remifentanil is associated with the development of clinically relevant acute opioid tolerance in adolescents undergoing scoliosis surgery. Thirty adolescents were randomly assigned to receive an intraoperative analgesic regimen consisting of continuous remifentanil infusion or intermittent morphine alone. Postoperative analgesic consumption was assessed with a patient-controlled analgesia device that was used to self-administer morphine. Cumulative postoperative morphine consumption, pain scores, and sedation scores were recorded by a blinded investigator every hour for the first 4 h postoperatively and then every 4 h for a total of 24 h. Cumulative morphine consumption in the remifentanil group was significantly more than that in the morphine group at each time point in the initial 24 h after surgery (P < 0.0001). At 24 h after surgery, cumulative morphine consumption was 30% greater in the remifentanil group (1.65 ± 0.41 mg/kg) than in the morphine group (1.27 ± 0.32 mg/kg) (95% confidence interval for the difference, 0.11 to 0.65 mg/kg). Differences in pain and sedation scores were not statistically significant. These data suggest that intraoperative infusion of remifentanil is associated with the development of clinically relevant acute opioid tolerance in adolescents undergoing scoliosis surgery.

 

 

在兒科麻醉中超聲波引導下的髂腹股溝/髂腹下神經阻滯:最佳容量是多少?

Ultrasonographic-Guided Ilioinguinal/Iliohypogastric Nerve Block in Pediatric Anesthesia: What is the Optimal Volume?

H. Willschke, MD*, A. Bösenberg, MBChB, FFA(SA){ddagger}, P. Marhofer, MD*, S. Johnston, MBChB, FCA(SA){ddagger}, S. Kettner, MD*, U. Eichenberger, MD§, O. Wanzel, MD{dagger}, and S. Kapral, MD*

*Department of Anesthesia and Intensive Care Medicine, Medical University of Vienna; {dagger}Division of Anesthesia and Intensive Care Medicine, Orthopedic Hospital Gersthof, Vienna, Austria; {ddagger}Department of Anesthesia, Red Cross Children's War Memorial Hospital, University Cape Town, South Africa; and §Department of Anaesthesia, Inselspital Bern, Switzerland

Anesth Analg 2006;102:1680-1684

 

最近我們的研究組已經證實了在小兒髂腹股溝/髂腹下神經阻滯中超聲波引導的有效性。因此我們設計了一個後續研究來評定用於這個區域麻醉技術的局麻藥最佳用量。每個研究組有十個小兒,在超聲波引導下進行髂腹股溝/髂腹下神經阻滯,用修正的上調下調方法,給予的開始劑量為0.25%左旋布比卡因0.2 mL/kg。在每組的10例後分析結果,如果所有的阻滯都滿意的話,我們就再增加10個小兒進行研究並將局麻藥用量減少50%。如果一組沒有達到100%的成功率,我們就將下一組的用量增加一半。用0.25%左旋布比卡因0.2 0.1 mL/kg時,成功率為100%。用量為 0.25%左旋布比卡因0.05mL/kg時,10個小兒中有4個因為阻滯不全需要追加鎮痛。因此,依據方案將用量增大到0.25%左旋布比卡因0.075mL/kg,這一次成功率又達到了100%。我們得出結論,用於小兒髂腹股溝/髂腹下神經阻滯的超聲波引導使局麻藥用量減少到0.075mL/kg

(姜旭暉譯,馬皓琳 李士通校)

Recently, our study group demonstrated the usefulness of ultrasonographic guidance in ilioinguinal/iliohypogastric nerve blocks in children. As a consequence, we designed a follow-up study to evaluate the optimal volume of local anesthetic for this regional anesthetic technique. Using a modified step-up-step-down approach, with 10 children in each study group, a starting dose of 0.2 mL/kg of 0.25% levobupivacaine was administered to perform an ilioinguinal/iliohypogastric nerve block under ultrasonographic guidance. After each group of 10 patients, the results were analyzed, and if all blocks were successful, the volume of local anesthetic was decreased by 50%, and a further 10 patients were enrolled into the study. Failure to achieve a 100% success rate within a group subjected patients to an automatic increase of half the previous volume reduction to be used in the subsequent group. Using 0.2 and 0.1 mL/kg of 0.25% levobupivacaine, the success rate was 100%. With a volume of 0.05 mL/kg of 0.25% levobupivacaine, 4 of 10 children received additional analgesia because of an inadequate block. Therefore, according to the protocol, the amount was increased to 0.075 mL/kg of 0.25% levobupivacaine, where the success rate was again 100%. We conclude that ultrasonographic guidance for ilioinguinal/iliohypogastric nerve blocks in children allowed a reduction of the volume of local anesthetic to 0.075 mL/kg.

 

 

年齡增長延長成年人七氟醚/笑氣誘導的起效時間

Onset Time for Sevoflurane/Nitrous Oxide Induction in Adults Is Prolonged with Increasing Age

Michael C. Lewis, MD, Ricardo I. Gerenstein, MD, and Gilbert Chidiac, MD

Department of Anesthesiology, University of Miami, Miami, Florida; Division of Anesthesiology, Cleveland Clinic Florida, Weston Florida

Anesth Analg 2006;102:1699-1702

 

吸入誘導麻醉偶爾應用于成人。我們用改良肺活量法七氟醚/笑氣吸入誘導,評估年齡增長對麻醉起效時間的影響。20個病人,年齡26-65歲,從預充有8%七氟醚/N2O/O2的麻醉環路中進行一個肺活量呼吸後,再行常規潮氣量呼吸。記錄以下參數:睫毛反射消失時間(LOER);雙頻指數60時間(BIS60);誘導時、LOER時和BIS60時七氟醚呼出濃度。LOER BIS60平均時間和95%可信區間分別為54 s(37-70 s)175 s(143-207 s),並顯著隨年齡增長而延長(r = 0.65; P = 0.002)。從回歸曲線可以預測60歲病人的LOERBIS60的時間比30歲的病人分別延長3.9倍和2倍。LOERBIS60時七氟醚呼出濃度隨著年齡增加而減少。我們得出結論,年齡增長顯著延長七氟醚/笑氣吸入誘導。

(張 譯,馬皓琳 李士通 校)

Inhaled induction of anesthesia is occasionally used in adults. Using a modified vital capacity sevoflurane/nitrous oxide (N2O) inhaled induction, we evaluated the effect of increasing age on the onset time of anesthesia. Twenty patients, aged 26-65 yr, performed a vital capacity breath followed by regular tidal breathing from an anesthesia circuit primed with sevoflurane 8%/N2O/O2. The following values were recorded: time to loss of eyelash reflex (LOER); time to bispectral index ≤60 (BIS ≤60); expired fraction of sevoflurane at the time of induction, LOER and BIS ≤60. The mean times and 95% confidence intervals to LOER and BIS ≤60 were 54 s (37-70 s) and 175 s (143-207 s), respectively, and were significantly prolonged by aging (r = 0.65; P = 0.002). Times to LOER and BIS ≤60, predicted from the regression line, were 3.9 and 2 times longer in a 60-yr-old than in a 30-yr-old patient. The expired fraction of sevoflurane measured at time to LOER and BIS ≤60 decreases with increase in age. We conclude that inhaled induction with sevoflurane/N2O is dramatically prolonged with increased age.

 

 

氙氣對兔肌原性動作誘發電位的作用:與丙泊酚和異氟醚的比較

The Effects of Xenon on Myogenic Motor Evoked Potentials in Rabbits: A Comparison with Propofol and Isoflurane

Yuri Yamamoto, MD, Masahiko Kawaguchi, MD, Meiko Kakimoto, MD, Masahiro Takahashi, MD, Satoki Inoue, MD, Takahisa Goto, MD, and Hitoshi Furuya, MD

Department of Anesthesiology, Nara Medical University, Nara, Japan; Department of Anesthesia, Teikyo University, School of Medicine, Tokyo, Japan

Anesth Analg 2006;102:1715-1721

 

本研究比較了氙氣、丙泊酚和異氟醚對氯胺酮/芬太尼麻醉下兔肌原性動作誘發電位(MEPs)的不同作用。30只實驗動物隨機分為3組(每組10只)。丙泊酚組動物給予丙泊酚0.4 mg·kg1·min1(小劑量組)和0.8 mg·kg1·min1 (大劑量組)。異氟醚組動物給予異氟醚0.8%(小劑量組)和1.6%(大劑量組)。氙氣組給予氙氣35%(小劑量組)和70%(大劑量組)。在每種麻醉給藥之前、給藥過程中(小劑量組和大劑量組)和給藥之後記錄單脈衝和5個成串脈衝刺激比目魚肌引起的肌原性MEPs。單脈衝刺激下,氙氣小劑量組和大劑量組分別有90%和50%動物的MEPs可被記錄到,且氙氣組和異氟醚組MEP振幅顯著低於丙泊酚組。在成串脈衝刺激下,氙氣小劑量組和大劑量組分別有100%和90%動物的MEPs可被記錄到,且氙氣組MEP振幅減小程度比丙泊酚組顯著,但小於異氟醚大劑量組。上述結果提示儘管氙氣對於肌原性MEPs具有抑制作用,氙氣麻醉時採用多脈衝刺激進行MEP記錄還是可行的。

(周雅春 馬皓琳 李士通 校)

We compared the effects of xenon on myogenic motor evoked potentials (MEPs) with those of propofol and isoflurane in rabbits under ketamine/fentanyl anesthesia. Thirty animals were randomly allocated to one of 3 groups (n = 10 in each group). In the propofol group, propofol was administered at a rate of 0.4 mg · kg–1 · min–1 (small) and 0.8 mg · kg–1 · min–1 (large). In the isoflurane group, isoflurane was administered at 0.8% (small) and 1.6% (large). In the xenon group, xenon was administered at 35% (small) and 70% (large). Myogenic MEPs in response to stimulation with single pulse and a train of 5 pulses were recorded from the soleus muscle before, during (at small and large doses), and after the administration of each anesthetic. With single-pulse stimulation, MEPs were recorded in 90% and 50% of animals at small and large doses of xenon, respectively, and MEP amplitudes in the xenon and isoflurane groups were significantly lower compared with those in the propofol group. With train pulse stimulation, MEPs were recorded in 100% and 90% of animals at small and large doses of xenon, respectively, and a reduction in MEP amplitudes by xenon was more prominent than by propofol but less than isoflurane at large doses. These results suggest that MEP recording may be feasible under xenon anesthesia if multipulse stimulation is used, although xenon has suppressive effects on myogenic MEPs.

 

 

使離體鼇蝦巨軸突傳導阻滯的利多卡因和布比卡因的細胞內濃度的比較

A Comparison of Intracellular Lidocaine and Bupivacaine Concentrations Producing Nerve Conduction Block in the Giant Axon of Crayfish In Vitro

Takeshi Yano, MD, Shoichiro Ibusuki, MD, and Mayumi Takasaki, MD

Department of Anesthesiology, Faculty of Medicine, University of Miyazaki, Kiyotake-Cho, Japan

Anesth Analg 2006;102:1734-1738

 

臨床上,利多卡因需要比布比卡因高的濃度才能阻滯神經。布比卡因比利多卡因的脂溶性高、組織穿透性好、對鈉通道的結合力更強,導致其麻醉強度更高。局麻藥需要從細胞內環境接近鈉通道。在本研究中,我們目的是確定利多可因和布比卡因在鼇蝦巨軸突產生神經阻滯時的細胞內濃度。使用利多卡因或者布比卡因溶液灌流,通過對強直或相位電刺激不產生誘發動作電位來確定神經阻滯。用利多卡因或者布比卡因敏感性玻璃微電極來測定細胞內利多卡因或布比卡因濃度。與利多卡因相比,較小濃度布比卡因產生相位阻滯更有效、更快。在神經傳導已經阻滯時,利多卡因的細胞內濃度和細胞內/胞外濃度比顯著高於布比卡因。這些發現說明布比卡因比利多卡因強度高,至少在離體鼇蝦巨軸突上如此。現有結果提示與利多卡因相比,布比卡因是更強的神經阻滯劑,且在較低濃度即可產生效用依賴性的(相位性)阻滯。

(顏濤 譯, 馬皓琳 李士通校)

Clinically, lidocaine requires a larger concentration than bupivacaine to block nerves. Bupivacaine has a higher lipid solubility, tissue permeability, and affinity for sodium channels than lidocaine, resulting in greater anesthetic potency. Local anesthetics require access to the sodium channel from the intracellular milieu. In this study, we sought to determine the intracellular concentration of lidocaine and bupivacaine when a nerve was blocked in the giant axon of a crayfish. A solution of lidocaine or bupivacaine was perfused, and a nerve block was determined as the absence of an evoked action potential after tonic or phasic electrical stimulation. The intracellular lidocaine or bupivacaine concentration was measured using a lidocaine- or bupivacaine-sensitive glass micro-electrode. A phasic block was more effectively and rapidly achieved with a smaller concentration of bupivacaine than with lidocaine. The intracellular concentration and intra- to extracellular ratios were significantly larger with lidocaine than with bupivacaine when nerve conduction was blocked. These findings suggest that bupivacaine has a higher potency than lidocaine, at least in the giant axon of a crayfish in vitro. The implications of the present results are that bupivacaine is a more potent nerve block and produces a use-dependent (phasic) block at smaller concentrations than lidocaine.

 

 

傳統動脈血氣分析研究動脈氧分壓波動的含義

The Implications of Arterial Po2 Oscillations for Conventional Arterial Blood Gas Analysis

Birgit Pfeiffer, MD, Rebecca S. Syring, DVM, Klaus Markstaller, MD, Cynthia M. Otto, DVM, PhD, and James E. Baumgardner, MD, PhD

Department of Anesthesia, Section of Critical Care, Department of Clinical Studies-Philadelphia, School of Veterinary Medicine, Center for Sleep and Respiratory Neurobiology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Anesthesiology, Johannes Gutenberg University, Mainz, Germany; SpectruMedix LLC, State College, Pennsylvania; Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University, Magdeburg, Germany

Anesth Analg 2006;102:1758-1764

 

在一個沒有肺泡表面活性物質的肺損傷模型,潮氣性的肺不張範圍波動和分流率變化可以導致動脈氧分壓(PaO2)產生很大的波動。我們以人工通氣的兔子為模型,採用不同採樣技術研究這種波動對傳統動脈血氣(ABG)分析結果的影響。每只兔子均給予了5種不同的通氣設置,2種是在鹽水灌洗肺損傷之前,3種是在鹽水灌洗之後。在一種頭臂動脈內快速反應探頭的指導下,根據要達到的PaO2幅度和平均值波動的5種不同目標,改變通氣機設置。在PaO2波動的峰頂和穀底,或者幾個呼吸週期定時採集血樣進行動脈血氣分析。在肺損傷之前,PaO2波動很小,採樣時間的選擇並不影響PaO2。在鹽水肺灌洗之後,動脈內氧探頭測得的氧分壓波動確認有肺不張潮氣性改善存在時,傳統動脈血氣的PaO2在改善峰頂(295 ± 130 mm Hg)明顯較穀底(74 ± 15 mm Hg)和平均值要高(125 ± 75 mm Hg)。鹽水灌洗後,早期輕微肺損傷,在呼吸週期的不同時間氧分壓變化即很大。在每次呼吸使肺不張膨脹時,由傳統血氣得出的分流率,在解釋其變化時應該考慮到呼吸因素對動脈氧分壓潛在的巨大的影響。

(張瑩 馬皓琳 李士通 校)

In a surfactant-depletion model of lung injury, tidal recruitment of atelectasis and changes in shunt fraction lead to large Pao2 oscillations. We investigated the effect of these oscillations on conventional arterial blood gas (ABG) results using different sampling techniques in ventilated rabbits. In each rabbit, 5 different ventilator settings were studied, 2 before saline lavage injury and 3 after lavage injury. Ventilator settings were altered according to 5 different goals for the amplitude and mean value of brachiocephalic Pao2 oscillations, as guided by a fast responding intraarterial probe. ABG collection was timed to obtain the sample at the peak or trough of the Pao2 oscillations, or over several respiratory cycles. Before lung injury, oscillations were small and sample timing did not influence Pao2. After saline lavage, when Po2 fluctuations measured by the indwelling arterial Po2 probe confirmed tidal recruitment, Pao2 by ABG was significantly higher at peak (295 ± 130 mm Hg) compared with trough (74 ± 15 mm Hg) or mean (125 ± 75 mm Hg). In early, mild lung injury after saline lavage, Pao2 can vary markedly during the respiratory cycle. When atelectasis is recruited with each breath, interpretation of changes in shunt fraction, based on conventional ABG analysis, should account for potentially large respiratory variations in arterial Po2.

 

 

嗎啡-6-葡萄糖醛酸:用於術後鎮痛的嗎啡代替品

Morphine-6-Glucuronide: Morphine's Successor for Postoperative Pain Relief?

Eveline L. A. van Dorp, MSc, Raymonda Romberg, MD, PhD, Elise Sarton, MD, PhD, James G. Bovill, MD, PhD, and Albert Dahan, MD, PhD

Department of Anesthesiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands

Anesth Analg 2006;102:1789-1797

 

在探索比嗎啡副作用少的鎮痛藥時,對嗎啡的活性代謝產物嗎啡-6-葡萄糖醛酸(M6G)的檢查顯示其可能就是這樣一個藥物。和嗎啡相反,M6G不經過代謝,但通過腎臟排泄,並且顯示出腸肝迴圈,因為它是存在於肝和腸中的多藥耐受傳遞蛋白的底物。M6G顯示出延遲性鎮痛效應(血-效應部位平衡半衰期48h),這部分與其通過血腦屏障及在腦室間分佈速度較慢有關。在人體,M6G的效價只有嗎啡的一半。在臨床研究中,M6G能被很好耐受並且可產生足夠且長效的術後鎮痛。在鎮痛劑量範圍內,M6G和等效鎮痛劑量嗎啡相比,可產生相似程度的二氧化碳通氣反應降低,但是對低氧通氣反應的抑制顯著較小。初步資料提示,M6G噁心嘔吐的發生率低於嗎啡,在術後及實驗環境中分別可減少50%和75%。儘管文獻資料的資料很有說服力,我們相信仍需要更多的研究以證明M6G在術後鎮痛方面優於嗎啡。

(黃佳佳譯 馬皓琳 李士通校)

In searching for an analgesic with fewer side effects than morphine, examination of morphine's active metabolite, morphine-6-glucuronide (M6G), suggests that M6G is possibly such a drug. In contrast to morphine, M6G is not metabolized but excreted via the kidneys and exhibits enterohepatic cycling, as it is a substrate for multidrug resistance transporter proteins in the liver and intestines. M6G exhibits a delay in its analgesic effect (blood-effect site equilibration half-life 4–8 h), which is partly related to slow passage through the blood-brain barrier and distribution within the brain compartment. In humans, M6G's potency is just half of that of morphine. In clinical studies, M6G is well tolerated and produces adequate and long lasting postoperative analgesia. At analgesic doses, M6G causes similar reduction of the ventilatory response to CO2 as an equianalgesic dose of morphine but significantly less depression of the hypoxic ventilatory response. Preliminary data indicate that M6G is associated less than morphine with nausea and vomiting, causing 50% and 75% less nausea in postoperative and experimental settings, respectively. Although the data from the literature are very promising, we believe that more studies are necessary before we may conclude that M6G is superior to morphine for postoperative analgesia.

 

 

血漿N端-腦型利鈉肽原水平作為危重病人預後的一個標記

Plasma Level of N Terminal Pro-Brain Natriuretic Peptide as a Prognostic Marker in Critically Ill Patients

Yaniv Almog, MD*, Victor Novack, MD{dagger}, Rinat Megralishvili, RN,CCRN*, Sergio Kobal, MD{ddagger}, Leonid Barski, MD{dagger}, Daniel King, MD{dagger}, and Doron Zahger, MD{ddagger}

*Medical Intensive Care Unit and the Departments of {dagger}Medicine and {ddagger}Cardiology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel

Anesth Analg 2006;102:1809-1815

 

我們對入住重症監護室時檢測的N端-腦型利鈉肽原(NT-pro BNP)是否能作為危重病人死亡率的獨立預測指標進行了研究。我們實施了一項前瞻性的觀察性群組研究,包括78APACHE II 評分大於12的患者。准入時對血清NT-pro BNP和心肌肌鈣蛋白T進行檢測,24h內行超聲心動圖檢查。主要觀察終點是30天死亡率。22例(28.2%)死亡患者的NT-pro BNP水平的中位數明顯高於存活者(83281016 pg/mL; P = 0.001)。NT-pro BNP水平大於1900 pg/mL的患者死亡率明顯增高(47.2%11.9%; P = 0.03),該組中到重度左室功能障礙的發生率(30.6%9.5%; P = 0.02)和心肌肌鈣蛋白T水平異常的發生率也較高(33.3%14.3%; P = 0.05)APACHE-II校正後的多變數分析顯示:NT-pro BNP水平高於1900 pg/mL是死亡率的一個獨立預測指標。

(黃施偉 譯,馬皓琳 李士通 校)

We studied whether N-terminal pro brain natriuretic peptide (NT-pro BNP) measured at intensive care unit admission is an independent predictor of mortality in critically ill patients. We conducted a prospective observational cohort study enrolling 78 patients with APACHE II scores more than 12. Serum NT-pro BNP and cardiac troponin T were measured at admission, and echocardiography was performed within 24 h. The primary end-point was 30-day mortality. The median NT-pro BNP levels of the 22 (28.2%) patients who died were significantly more frequent than that of those who survived (8328 versus 1016 pg/mL; P = 0.001). Patients with NT-pro BNP levels more than 1900 pg/mL had significantly more frequent mortality (47.2% versus 11.9%; P = 0.03). This group also had more frequent moderate to severe left ventricular dysfunction (30.6% versus 9.5%; P = 0.02) and abnormal cardiac troponin T levels (33.3% versus 14.3%; P = 0.05). Multivariate analyses adjusted for APACHE-II revealed that a NT-pro BNP level more than 1900 pg/mL is an independent predictor of mortality.

 

 

地氟醚和七氟醚在穩態條件下對腦氧測定的影響

The Effect of Desflurane and Sevoflurane on Cerebral Oximetry Under Steady-State Conditions

Argyro Fassoulaki, MD, PhD, DEAA, Helen Kaliontzi, MD, George Petropoulos, MD, and Athanassia Tsaroucha, MD

Department of Anesthesiology, Aretaieion Hospital, Athens, Greece

Anesth Analg 2006;102:1830-1835

 

我們研究了七氟醚和地氟醚對局域腦氧合(rSO2)的影響。22例行腹式子宮切除術的病人在穩態條件下以隨機交叉的方式間隔30 min吸入七氟醚和地氟醚各15min,以維持腦電雙頻指數(BIS)為4050。其餘22例進行相同麻醉和手術的病人,BIS維持在2030。在穩態狀態下吸入每個麻醉劑的15min內,每3min記錄rSO2 BIS、吸入和呼氣末麻醉劑濃度、呼氣末二氧化碳分壓、Spo2收縮壓和舒張壓及心率。當BIS值維持在40502030時,rSO2七氟醚與地氟醚之間無差異。維持BIS值在405020–30所需的地氟醚和七氟醚MACBIS值分別為1.01.2 (P = 0.004)1.6 1.8 (P < 0.001)。吸入1.6MAC地氟醚比1MAC地氟醚rSO2較高,分別為71 ± 1366 ± 10P < 0.001);吸入1.8MAC七氟醚比1.2MAC七氟醚rSO2較高,分別為72 ± 1166 ± 13P < 0.001)。結論,在BIS方面等效濃度的地氟醚和七氟醚具有相似的rSO2值,而兩個麻醉藥的較大麻醉劑濃度能提高rSO2值。

(邱鬱薇 馬皓琳 李士通 校)

We studied the effect of sevoflurane and desflurane on regional cerebral oxygenation (rSO2). Twenty-two patients undergoing abdominal hysterectomy received sevoflurane and desflurane for 15 min each and 30 min apart under steady-state conditions in a randomized, crossover manner to maintain a bispectral index (BIS) of 40–50. In another 22 patients undergoing the same anesthesia and surgery BIS was maintained at 20–30. During the 15-min administration of each anesthetic at steady-state conditions rSO2, BIS, inspired and end-tidal anesthetic concentrations, end-tidal CO2, Spo2, systolic and diastolic blood pressures, and heart rate were recorded every 3 min. The rSO2 did not differ between sevoflurane and desflurane when BIS values were maintained between 40–50 or 20–30. The MACBIS values required to maintain BIS at 40–50 and at 20–30 were 1.0 versus 1.2 (P = 0.004) and 1.6 versus 1.8 (P < 0.001) for desflurane and sevoflurane respectively. Higher rSO2 values were obtained by 1.6 MAC (71 ± 13) than by 1 MAC of desflurane (66 ± 10; P < 0.001) and by 1.8 MAC (72 ± 11) than by 1.2 MAC of sevoflurane (66 ± 13; P < 0.001). In conclusion, equipotent concentrations of desflurane or sevoflurane in terms of BIS are associated with similar rSO2 values, but larger anesthetic concentrations of both anesthetics increased the rSO2 values.

 

 

對比1%純利多卡因和由等量生理鹽水稀釋2%利多卡因後的1%利多卡因所產生的硬膜外阻滯

A Comparison of Epidural Blockade Produced by Plain 1% Lidocaine and 1% Lidocaine Prepared by Dilution of 2% Lidocaine with the Same Volume of Saline

Akifumi Kanai, MD, PhD, and Sumio Hoka, MD, PhD

Department of Anesthesiology, Kitasato University School of Medicine, Kitasato, Japan

Anesth Analg 2006;102:1851-1855

 

局部麻醉藥經常由生理鹽水稀釋,但是稀釋對硬膜外阻滯的影響還不清楚。作者選取40名行婦科腹部手術的患者,隨機分為兩組;應用商業上配備的純1%利多卡因組(P組)和用由等量生理鹽水稀釋2%利多卡因得到的1%利多卡因組(D組),都通過在L12的硬膜外導管硬膜外輸注。測定溶液pH值、鈉和氯離子的濃度。在硬膜外輸注後51015分鐘,監測感覺和運動阻滯、足部皮膚溫度、動脈血壓和心率。相較於D組,P組各評價時點的感覺阻滯平面擴散均顯著較廣。P組的足部溫度升高和平均動脈壓降低顯著快於D組。儘管兩溶液的平均pH值相似,稀釋溶液的鈉離子和氯離子濃度明顯高於純溶液。作者認為以等量生理鹽水稀釋2%利多卡因產生的硬膜外阻滯效能低於商業上配備的純1%利多卡因。

(趙雪蓮 馬皓琳 李士通 校)

Local anesthetics are commonly diluted with saline, but the influence of the dilution on the epidural anesthesia remains unclear. We randomized 40 patients scheduled for gynecological abdominal surgery under epidural anesthesia to one of two groups; those in group P received plain commercially prepared 1% lidocaine and those in group D received 1% lidocaine derived from 2% lidocaine and the same volume of saline was infused epidurally with an epidural catheter at L1-2. The pH and sodium and chloride ion concentrations of the solutions were measured. Sensory and motor blockade, foot skin temperature, arterial blood pressure, and heart rate were assessed at 5, 10, and 15 min after the epidural infusion. The spread of sensory blockade was significantly wider in group P at all assessment times than in group D. The increase of foot temperature and decrease of mean arterial blood pressure were significantly faster in group P than in group D. Although the mean pH values of the two solutions were similar, sodium and chloride ion concentrations of the diluted solution were significantly larger than those of the plain solution. We conclude that 2% lidocaine diluted with the same volume of saline produces less potent epidural blockade than commercially prepared plain 1% lidocaine.

 

 

術後噁心嘔吐的危險因數

Risk Factors for Postoperative Nausea and Vomiting

Tong J. Gan, MB, FRCA, FFARCSI

Department of Anesthesiology, Duke University Medical Center, Durham, NC

Anesth Analg 2006;102:1884-1898

 

對於術後噁心嘔吐(PONV)風險因素的認識可以幫助麻醉醫生完善使用預防性療法。現代PONV風險性研究始於20世紀90年代應用對數回歸分析來同時判別多重獨立的PONV預測因素的研究,以及薈萃分析及系統綜述的發表文獻。這些文獻認為,少壯期女性、非抽煙人群、有PONV或運動病的病史、嬰兒期後的兒童期和成年期早期、手術持續時間延長以及應用揮發性麻醉劑、笑氣、大劑量新斯的明或者術中或術後應用阿片類藥物,是已經確定的PONV危險因數。可能的危險因數包括,偏頭痛的病史、兒童的父母或同胞有PONV或運動病的病史、較好的ASA體格狀態、嚴重的術前焦慮某些種族或者手術類型、術期補液、給予的晶膠比值、較長的麻醉時間,全麻還是區域麻醉或鎮靜、平衡麻醉或全憑靜脈麻醉、以及長效還是短效阿片類藥的應用。月經早期、肥胖以及缺乏輔助供氧等證明不是危險因素。當前的風險評分系統對於預測哪些病人群體將遭受PONV55%~80%的準確性。對於分析遺傳性或調查不足的臨床病人特徵作為潛在的危險因數以及涉及門診病人及兒童的進一步研究,必將改善對PONV的預測系統。

 (黃麗娜     馬皓琳 李士通  )

Knowledge of postoperative nausea and vomiting (PONV) risk factors allows anesthesiologists to optimize the use of prophylactic regimens. Modern PONV risk research began in the 1990s with publication of studies using logistic regression analysis to simultaneously identify multiple independent PONV predictors and publication of meta-analyses and systematic reviews. This literature shows that female gender post-puberty, nonsmoking status, history of PONV or motion sickness, childhood after infancy and younger adulthood, increasing duration of surgery, and use of volatile anesthetics, nitrous oxide, large-dose neostigmine, or intraoperative or postoperative opioids are well established PONV risk factors. Possible risk factors include history of migraine, history of PONV or motion sickness in a child’s parent or sibling, better ASA physical status, intense preoperative anxiety, certain ethnicities or surgery types, decreased perioperative fluids, crystalloid versus colloid administration, increasing duration of anesthesia, general versus regional anesthesia or sedation, balanced versus total IV anesthesia, and use of longer-acting versus shorter-acting opioids. Early-phase menstruation, obesity and lack of supplemental oxygen are disproved risk factors. Current risk scoring systems have ~55%–80% accuracy in predicting which patient groups will suffer PONV. Further research examining genetic and under-investigated clinical patient characteristics as potential risk factors, and involving outpatients and children, should improve predictive systems.