Anesthesia & Analgesia

 

July 2006

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

心肺转流术开始时使用亚甲蓝的血流动力学效应

(孙敏莉译 薛张纲校)

The Hemodynamic Effects of Methylene Blue When Administered at the Onset of Cardiopulmonary Bypass

Andrew D. Maslow, Gary Stearns, Parag Batula, Carl S. Schwartz, Jeffrey Gough, and Arun K. Singh

Anesth Analg 2006 103: 2-8.

在红细胞灌注的离体兔心中雷米芬太尼和舒芬太尼对冠脉和心肌的作用

(马皓琳 李士通 校)

The Coronary and Myocardial Effects of Remifentanil and Sufentanil in the Erythrocyte-Perfused Isolated Rabbit Heart

Patrick Lecomte, Alexandre Ouattara, Yannick Le Manach, Marc Landi, Pierre Coriat, and Bruno Riou

Anesth Analg 2006 103: 9-14. ed hemodynamic instability, especially in cardiac patients, does not involve direct changes in coronary vasomotor tone.

输注红细胞的保存时间与再次心脏手术后患病率和死亡率的相关性

(赵延华 陈杰 )

The Association Between Duration of Storage of Transfused Red Blood Cells and Morbidity and Mortality After Reoperative Cardiac Surgery

Sukhjeewan Basran, Robert J. Frumento, Allison Cohen, Samuel Lee, Yuling Du, Ervant Nishanian, Harold S. Kaplan, Mark Stafford-Smith, and Elliott Bennett-Guerrero

Anesth Analg 2006 103: 15-20

心肺转流管理和神经系统预后:对目前实践一项循证医学评估

(金琳 薛张纲校)

Cardiopulmonary Bypass Management and Neurologic Outcomes: An Evidence-Based Appraisal of Current Practices (Review Article)

Charles W. Hogue, Jr, Christopher A. Palin, and Joseph E. Arrowsmith

Anesth Analg 2006 103: 21-37.

PEDIATRIC ANESTHESIA:

右美托咪定在儿科心脏手术中的应用

(裘毅敏译,马皓琳 李士通校)

The Use of Dexmedetomidine in Pediatric Cardiac Surgery (Editorial)

Ahmed M. Mukhtar, Eman M. Obayah, and Amira M. Hassona

Anesth Analg 2006 103: 52-56.

右旋美托咪啶作儿科CT检查时镇静的研究

(王震虹 陈杰 )

Dexmedetomidine for Pediatric Sedation for Computed Tomography Imaging Studies (Editorial)

Keira P. Mason, Steven E. Zgleszewski, Jennifer L. Dearden, Raymond S. Dumont, Michele A. Pirich, Cynthia D. Stark, Peggy D'Angelo, Shann MacPherson, Paulette J. Fontaine, Linda Connor, and David Zurakowski

Anesth Analg 2006 103: 57-62

比较右旋美托咪定和异丙芬用于小儿磁共振检查时镇静、血流动力学和呼吸的影响

(吴德华译 薛张纲校)

A Comparison of the Sedative, Hemodynamic, and Respiratory Effects of Dexmedetomidine and Propofol in Children Undergoing Magnetic Resonance Imaging (Editorial)

Ahmet Koroglu, Huseyin Teksan, Ozlem Sagir, Aytaç Yucel, Huseyin I. Toprak, and Ozcan M. Ersoy

Anesth Analg 2006 103: 63-67.

AMBULATORY ANESTHESIA:

近期的吸烟行为与术后恶心和呕吐

(彭中美    马皓琳 李士通  校)

Recent Smoking Behavior and Postoperative Nausea and Vomiting

Francis Whalen, Juraj Sprung, Christopher M. Burkle, Darrell R. Schroeder, and David O. Warner

Anesth Analg 2006 103: 70-75.

一种严重抑郁症新方法-磁惊厥疗法的麻醉思考

(顾新宇 陈杰 校)

Anesthetic Considerations for Magnetic Seizure Therapy: A Novel Therapy for Severe Depression

Paul F. White, Quinlan Amos, Yunan Zhang, Louis Stool, Mustafa M. Husain, Larry Thornton, Michael Downing, Shawn McClintock, and Sarah H. Lisanby

Anesth Analg 2006 103: 76-80.

ANESTHETIC PHARMACOLOGY:

麻醉空间螺旋特性I:仲醇对映体的最低肺泡气浓度

( 路译 薛张纲校)

Chirality in Anesthesia I: Minimum Alveolar Concentration of Secondary Alcohol Enantiomers

Albert Won, Irene Oh, Michael J. Laster, John Popovich, Edmond I. Eger, II, and James M. Sonner

Anesth Analg 2006 103: 81-84.

分子手性与麻醉II:仲醇对映体对离子通道功能作用的立体选择性

(颜涛 译, 马皓琳 李士通 校)

Chirality in Anesthesia II: Stereoselective Modulation of Ion Channel Function by Secondary Alcohol Enantiomers

Robert Brosnan, Diane Gong, Joseph Cotten, Bharat Keshavaprasad, C. Spencer Yost, Edmond I. Eger, II, and James M. Sonner

Anesth Analg 2006 103: 86-91.

异氟醚降低小鼠海马细胞外5-羟色胺

(李启芳 陈杰 校)

Isoflurane Decreases Extracellular Serotonin in the Mouse Hippocampus

Robert A. Whittington and László Virág

Anesth Analg 2006 103: 92-98.

长期蛛网膜下腔应用1-对氯苯酚-5甲氧基-2甲基-1H-吲哚-3醋酸(吲哚美辛):一项在动物模型中对神经毒性作用的评价

(王丽珺译 薛张纲校)

Chronic Subarachnoid Administration of 1-(4chlorobenzoyl)-5methoxy-2methyl-1H-indole-3 Acetic Acid (Indomethacin): An Evaluation of Its Neurotoxic Effects in an Animal Model

Uriah Guevara-López, Alfredo Covarrubias-Gómez, Hilario Gutierrez-Acar, J. Antonio Aldrete, Francisco J. López-Muñoz, and Braulio Martínez-Benítez

Anesth Analg 2006 103: 99-102.

对正常或高反应性气道的家兔注射肌松药后的支气管痉挛的发生

(黄丽娜     李士通  校)

Development of Bronchoconstriction After Administration of Muscle Relaxants in Rabbits with Normal or Hyperreactive Airways

Ferenc Peták, Zoltán Hantos, Ágnes Adamicza, Hristifor Gálity, and Walid Habre

Anesth Analg 2006 103: 103-109.

小剂量过氧化氢可增强TNF-{alpha}诱导细胞凋亡的毒性且被丙泊酚逆转

(郑拥军 陈杰 校)

A Small Dose of Hydrogen Peroxide Enhances Tumor Necrosis Factor-Alpha Toxicity in Inducing Human Vascular Endothelial Cell Apoptosis: Reversal with Propofol

Tao Luo and Zhengyuan Xia

Anesth Analg 2006 103: 110-116.

N-甲基-D天冬氨酸受体ε1亚型敲除小鼠中乙醇诱导的催眠耐受缺乏。

(吴德华译 薛张纲校)

Ethanol-Induced Hypnotic Tolerance Is Absent in N-Methyl-d-Aspartate Receptor {varepsilon}1 Subunit Knockout Mice

Yuki Sato, Norimasa Seo, and Eiji Kobayashi

Anesth Analg 2006 103: 117-120.

ECONOMICS, EDUCATION, AND POLICY:

一个先进的麻醉学专业培训计划:专为社区麻醉医师设计的临床教育

(张莹 译 马皓琳 李士通 校)

An Advanced Specialty Training Program in Anesthesiology: A Special Educational Fellowship Designed to Return Community Anesthesiologists to Clinical Practice (Special Article)

C. Philip Larson, Jr and Randolph H. Steadman

Anesth Analg 2006 103: 126-130.

应用麻醉信息系统和应答自动反馈时增强医疗文件的及时性的医疗法律重要性

(肖洁 陈杰 校)

The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice

Michael M. Vigoda and David A. Lubarsky

Anesth Analg 2006 103: 131-136.

住院医生和麻醉医师对基础科学的态度

(徐丽颖译 薛张纲校)

Attitudes of Residents and Anesthesiologists Toward Basic Sciences

Getúlio Rodrigues de Oliveira Filho and Leonardo Schonhorst

Anesth Analg 2006 103: 137-143.

CRITICAL CARE AND TRAUMA:

重症患者的高氯性酸中毒:强离子酸中毒中的一种?

 (张曦   马皓琳 李士通  校)

Hyperchloremic Acidosis in the Critically Ill: One of the Strong-Ion Acidoses?

David A. Story, Hiroshi Morimatsu, and Rinaldo Bellomo

Anesth Analg 2006 103: 144-148.

羟乙基淀粉在大鼠内毒素性肠中具有抗炎作用

(郑丽 陈杰校

Hydroxyethyl Starch Exhibits Antiinflammatory Effects in the Intestines of Endotoxemic Rats

Ran Lv, Zhi-Qiang Zhou, Hai-Wei Wu, Yi Jin, Wei Zhou, and Jian-Guo Xu

Anesth Analg 2006 103: 149-155.

硫酸吗啡减轻失血性休克引起的通透性增高

(周 荻译 薛张纲校)

Morphine Sulfate Attenuates Hemorrhagic Shock- Induced Hyperpermeability

Craig Charleston, Rudolph Puana, Russell K. McAllister, Felicia A. Hunter, and Ed W. Childs

Anesth Analg 2006 103: 156-161.

NEUROSURGICAL ANESTHESIA:

经蝶骨手术术后恶心呕吐与疼痛:一项877例病人的资料回顾

(邱郁薇 马皓琳 李士通 校)

Postoperative Nausea and Vomiting and Pain After Transsphenoidal Surgery: A Review of 877 Patients

Brigid C. Flynn and Edward C. Nemergut

Anesth Analg 2006 103: 162-167.

比较糖尿病病人在七氟醚和异氟醚麻醉下脑血管对二氧化碳的反应性

(潘志英 陈杰 校)

The Comparative Effects of Sevoflurane Versus Isoflurane on Cerebrovascular Carbon Dioxide Reactivity in Patients with Diabetes Mellitus

Yuji Kadoi, Ken-ichiro Takahashi, Shigeru Saito, and Fumio Goto

Anesth Analg 2006 103: 168-172.

七氟醚对大鼠大脑缺血再灌注神经元损伤和细胞凋亡因子表达的长期作用

(陆文清译 薛张纲校)

The Long-Term Effect of Sevoflurane on Neuronal Cell Damage and Expression of Apoptotic Factors After Cerebral Ischemia and Reperfusion in Rats

Monika Pape, Kristin Engelhard, Eva Eberspächer, Regina Hollweck, Kristine Kellermann, Susanne Zintner, Peter Hutzler, and Christian Werner

Anesth Analg 2006 103: 173-179.

OBSTETRIC ANESTHESIA:

肾上腺素对左旋布比卡因联合舒芬太尼硬膜外分娩镇痛的影响

(黄佳佳译, 马皓琳,李士通校)

Levobupivacaine-Sufentanil With or Without Epinephrine During Epidural Labor Analgesia

Filiep M. Soetens, Maurits A. Soetens, and Marcel P. Vercauteren

Anesth Analg 2006 103: 182-186.

脊麻-硬膜外联合麻醉下行剖腹产时重比重布比卡因对产妇血液动力学的剂量依赖效应

(宋金超 陈杰 校)

Combined Spinal-Epidural Anesthesia for Cesarean Delivery: Dose-Dependent Effects of Hyperbaric Bupivacaine on Maternal Hemodynamics

Marc Van de Velde, Dominique Van Schoubroeck, Jacques Jani, An Teunkens, Carlo Missant, and J. Deprest

Anesth Analg 2006 103: 187-190.

GENERAL ARTICLES:

老年病人在腹部手术中以白蛋白为基础的静脉扩容治疗的价值

( 静译 薛张纲校)

The Value of an Albumin-Based Intravascular Volume Replacement Strategy in Elderly Patients Undergoing Major Abdominal Surgery

Joachim Boldt, Thilo Schölhorn, Jochen Mayer, Sven Piper, and Stefan Suttner

Anesth Analg 2006 103: 191-199.

PAIN MEDICINE:

运用核磁共振机能成像技术测量吗啡对首次使用阿片类药物的健康志愿者的中枢神经系统回路的影响

(姜旭晖译 马皓琳,李士通校)

Functional Magnetic Resonance Imaging Measures of the Effects of Morphine on Central Nervous System Circuitry in Opioid-Naive Healthy Volunteers

Lino Becerra, Kim Harter, R. Gilberto Gonzalez, and David Borsook

Anesth Analg 2006 103: 208-216.

非阿片类镇痛药帕瑞考昔(Parecoxib),扑热息痛(Paracetamol),安乃近(Metamizol)对缓解腰椎间盘摘除术后疼痛的疗效

(殷文渊 陈杰 校)

The Efficacy of the Non-Opioid Analgesics Parecoxib, Paracetamol and Metamizol for Postoperative Pain Relief After Lumbar Microdiscectomy

Ulrich Grundmann, Clemens Wörnle, Andreas Biedler, Sascha Kreuer, Marc Wrobel, and Wolfram Wilhelm

Anesth Analg 2006 103: 217-222.

REGIONAL ANESTHESIA:

中枢神经系统疾病患者的椎管内麻醉及镇痛

(王慧琳译 薛张纲校)

Neuraxial Anesthesia and Analgesia in Patients with Preexisting Central Nervous System Disorders

James R. Hebl, Terese T. Horlocker, and Darrell R. Schroeder

Anesth Analg 2006 103: 223-228.

持续性腘神经阻滞的可行性和并发症:1001例病例的调查研究

(唐李隽 马皓琳 李士通 校)

The Feasibility and Complications of the Continuous Popliteal Nerve Block: A 1001-Case Survey

Alain Borgeat, Stephan Blumenthal, Maud Lambert, Panagiotis Theodorou, and Patrick Vienne

Anesth Analg 2006 103: 229-233.

鞘内注射2-氯普鲁卡因进行门诊病人下肢手术的随机、双盲对照的临床研究

(苏殿三 陈杰 校)

Intrathecal 2-Chloroprocaine for Lower Limb Outpatient Surgery: A Prospective, Randomized, Double-Blind, Clinical Evaluation

Andrea Casati, Giorgio Danelli, Marco Berti, Augusto Fioro, Andrea Fanelli, Cristina Benassi, Gioacchino Petronella, and Guido Fanelli

Anesth Analg 2006 103: 234-238.

外周搏动指数是一种可靠而又早期的评价局部阻滞效果的监测手段

(孙卓真译 薛张纲校)

Peripheral Flow Index Is a Reliable and Early Indicator of Regional Block Success

Eilish M. Galvin, Sjoerd Niehof, Serge JC Verbrugge, Iscandar Maissan, Alexander Jahn, Jan Klein, and Jasper van Bommel

Anesth Analg 2006 103: 239-243.

 

输注红细胞的保存时间与再次心脏手术后患病率和死亡率的相关性

The Association Between Duration of Storage of Transfused Red Blood Cells and Morbidity and Mortality After Reoperative Cardiac Surgery

Sukhjeewan Basran, MD, Robert J. Frumento, MS, MPH, Allison Cohen, BS, Samuel Lee, MD, Yuling Du, PhD, Ervant Nishanian, MD, PhD, Harold S. Kaplan, MD, Mark Stafford-Smith, FRCPC, and Elliott Bennett-Guerrero, MD

Anesth Analg 2006 103: 15-20.

 

红细胞在保存过程中发生许多变化,但是与其相关的损害在临床上并不明确。作者假定再次胸骨切开行心脏手术患者的死亡率与输注红细胞的保存时间有关,因为这些病人需要输血和出现不良预后的风险高。作者回顾性分析了再次胸骨正中切开行冠状动脉搭桥或瓣膜手术并接受异体红细胞的患者434名,其中321名(74%)患者符合标准。在调整了混淆因素和红细胞输注总量的影响后,研究发现红细胞的保存时间与住院死亡率(相关风险比(HR)=1.151P < 0.0001)和院外死亡率(HR = 1.116; P < 0.0001)相关。输注红细胞的平均保存时间也是住院死亡率的独立预测指标(HR = 1.036; P < 0.0001)。该研究同时观察了保存时间和急性肾功能障碍、监护室及住院时间的独立相关性。保存时间与再次胸骨切开行心脏手术后不良预后有关。该发现的临床意义应该在大样本随机盲态的临床试验中进行研究。

(赵延华 陈杰 校)

Red blood cells (RBCs) undergo numerous changes during storage; however, the clinical relevance of these storage "lesions" is unclear. We hypothesized that the duration of storage of transfused RBCs is associated with mortality after repeat sternotomy for cardiac surgery, because these patients are at high risk for both RBC transfusion and adverse outcome. We retrospectively analyzed 434 patients who underwent repeat median sternotomy for coronary artery bypass graft or valve surgery and who received allogeneic RBCs. Three-hundred-twenty-one (74%) patients met the criteria for eligibility. After adjusting for the effects of confounders and the total number of RBC transfusions, the duration of storage of the oldest RBC unit transfused was found to be associated with both in-hospital mortality (Cox proportional hazard ratio (HR) = 1.151; P < 0.0001) and out-of-hospital mortality (HR = 1.116; P < 0.0001). The mean duration of storage of transfused RBCs was also an independent predictor of in-hospital mortality (HR = 1.036; P < 0.0001). Independent associations between the duration of storage of transfused RBCs and acute renal dysfunction and intensive care unit and hospital length of stay were also observed. The duration of storage of RBCs is associated with adverse outcome after repeat sternotomy for cardiac surgery. The clinical significance of this finding should be investigated in a large, randomized, blinded clinical trial.

 

右旋美托咪啶作儿科CT检查时镇静的研究

Dexmedetomidine for Pediatric Sedation for Computed Tomography Imaging Studies

Keira P. Mason, MD*{dagger}, Steven E. Zgleszewski, MD*, Jennifer L. Dearden, MD*, Raymond S. Dumont, MD*, Michele A. Pirich, RN, BSN{dagger}, Cynthia D. Stark, RN, CPNP{dagger}, Peggy D'Angelo, BSN, RN{dagger}, Shann MacPherson, BSN, RN{dagger}, Paulette J. Fontaine, BS{dagger}, Linda Connor, RN{dagger}, and David Zurakowski, PhD*{ddagger}

Anesth Analg 2006 103: 57-62.

 

右旋美托咪定作为儿科镇静的经验有限。本研究首次对右美托咪定在儿科放射检查中具有镇静作用作了前瞻性评估。在20055月,作者医院镇静委员会推荐以右美托咪定取代在CT检查中的常规药戊巴比妥而作为标准用药。详细质量保证(QA)数据单收集每个患者的相关信息,将这些数据记录到计算机化的镇静数据库里。经过IRB同意后可取得所有QA数据。62个患者平均年龄2.8岁(SD=1.8,范围0.5~9.7),静注右旋美托咪啶,负荷量为2mcg/kg维持10min。之后重复注射,剂量为2mcg/kg维持10min直到Ramsay镇静评估分值为4RSS)。继续以1mcg/kg/hr维持注射直至拍摄结束。重复数据方差分析显示和镇静前比较,心率和平均动脉压在注射,恢复期平均值降低了15%P<0.01)。呼吸频率和呼气末CO2并没有显著改变。平均恢复时间为32±18分钟。基于上述研究结果,右旋美托咪啶可能提供可靠的有效的镇静。

(王震虹 陈杰 校)

Dexmedetomidine is a sedative with limited experience in the pediatric population. This is the first study that prospectively evaluates the sedation profile of a dexmedetomidine pilot program for pediatric sedation for radiological imaging studies. In March 2005, our hospital sedation committee approved the replacement of IV pentobarbital with dexmedetomidine as the standard of care for CT imaging. Detailed Quality Assurance (QA) data sheets collect relevant information on each patient, which is then logged into a computerized sedation database. After IRB approval, all QA data was accessed. Sixty-two patients with a mean age of 2.8 years (SD = 1.8, range 0.5–9.7) received IV (IV) dexmedetomidine administered as a 2 mcg/kg loading dose over 10 minutes, followed by repeat boluses of 2 mcg/kg over 10 minutes until target of Ramsay Sedation Score 4 (RSS) achieved. Patients were then maintained on 1 mcg/kg/hr infusion until imaging is completed. Repeated-measures ANOVA indicated that compared to pre-sedation values, the heart rate and mean arterial blood pressure decreased an average of 15% during bolus, infusion and recovery (P < 0.01). No significant changes were observed in respiratory rate or end-tidal CO2. Mean recovery time was 32 ± 18 minutes. Based on our pilot results, dexmedetomidine may provide a reliable and effective method of providing sedation.

 

一种严重抑郁症新方法-磁惊厥疗法的麻醉思考

Anesthetic Considerations for Magnetic Seizure Therapy: A Novel Therapy for Severe Depression

Paul F. White, PhD, MD, FANZCA*, Quinlan Amos, MD*, Yunan Zhang, MD*, Louis Stool, MD*, Mustafa M. Husain, MD{dagger}, Larry Thornton, MD{dagger}, Michael Downing, MD{dagger}, Shawn McClintock, PhD*, and Sarah H. Lisanby, MD{ddagger}

From the Departments of *Anesthesiology and Pain Management and {dagger}Psychiatry, University of Texas Southwestern Medical Center, Dallas; and {ddagger}Department of Neuroscience, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York.

Anesth Analg 2006 103: 76-80.

电惊厥疗法(ECT)是严重抑郁症一种非常有效的治疗方法。然而,它的应用与治疗后认知损伤显著相关。磁惊厥疗法(MST)作为一种选择性治疗方法可以减少惊厥后副作用,可能通过更多的局灶性发作所致。在开放平行研究中,作者比较20例匹配病例接受一系列ECTMST,研究其麻醉药、肌松药、心血管药物的需要量和心血管效应、BIS指数、早期复苏时间等。结果显示:与ECT相比,MST与定向时间减少更相关(4±118±5分钟,P0.01)。为了减少MST后残余肌松,琥珀胆碱的需要量更少(38±1797±2mgP0.01〉。MSTBIS值较ECT组在刺激前更高,刺激后更低。两治疗组汉密顿抑郁量表值都显著低于基线值,但ECT组治疗后更低(14± 10P0.05)。结论:MST在诱导惊厥后比ECT肌松药的需要量减少,BIS值的变异性减少,认知功能的恢复更快。在大脑刺激可比的水平上,MSTECT抗抑郁效应还需更深入的研究。

(顾新宇 陈杰 校)

Electroconvulsive therapy (ECT) is a highly effective treatment for severe depression. However, its use is associated with significant posttreatment cognitive impairment. Magnetic seizure therapy (MST) was developed as an alternative therapy that could reduce postseizure side effects through the induction of more "focal" seizure activity. Using an open-parallel study design, we compared 20 case-matched patients undergoing a series of either ECT or MST procedures with respect to their anesthetic, muscle relaxant, and cardiovascular drug requirements, effects on cardiovascular and electroencephalographic bispectral index (BIS) values, and early recovery times. We found that MST was associated with a reduced time to orientation (4 ± 1 versus 18 ± 5 min; P < 0.01) compared with ECT. To minimize residual muscle paralysis after MST, a reduction in the succinylcholine dosage (38 ± 17 versus 97 ± 2 mg; P < 0.01) was required. The BIS values were higher before, and lower immediately after, the stimulus was applied in the MST (versus ECT) group. The Hamilton depression rating scale score was significantly reduced from the baseline value in both treatment groups; however, the posttreatment score was lower after the series of ECT treatments (6 ± 6 versus 14 ± 10; P < 0.05). We conclude that MST was associated with a decreased requirement for muscle relaxants, reduced variability in the BIS values after seizure induction, and a more rapid recovery of cognitive function compared with ECT. Further studies are required to evaluate the antidepressant efficacy of MST versus ECT when they are administered at comparable levels of cerebral stimulation.


异氟醚降低小鼠海马细胞外5-羟色胺

Isoflurane Decreases Extracellular Serotonin in the Mouse Hippocampus

Robert A. Whittington, MD, and László Virág, MS

From the Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York.

Anesth Analg 2006 103: 92-98.

5-羟色胺能系统在全麻中可能发挥一定作用,且海马5-羟色胺能递质的改变与抑郁,焦虑,认知,听觉的改变有关。目前吸入麻醉剂对海马5-羟色胺水平的影响知之甚少。本实验检测异氟醚对小鼠海马5-羟色胺的影响。成年雄性129/SvEv小鼠在吸入40%O2 1.01.5MAC的异氟醚,对照组仅吸入40%O2,持续80min。海马5-羟色胺水平采用微量渗析和高效液相色谱检测。20-40min后,1MAC1.5MAC的异氟醚均显著降低海马5-羟色胺水平(分别为基础水平的41.5%+11.0%36.4%+13.9%),且在1.5MAC组,微量渗析发现麻醉结束后几小时仍有5-羟色胺的降低,为了明确异氟醚降低5-羟色胺是否由5-羟色胺转移子(SERT)所致,C57BL/6 野生型小鼠 (SERT +/+)和纯合型 SERT 基因敲除小鼠SERT-/-)的小鼠在吸入40%O2 1 MAC异氟醚或仅吸入40%O2,微量渗析发现异氟醚在SERT+/+)和SERT-/-)的小鼠中均有5-羟色胺的降低,SERT-/-)降低更明显(22.4%+8.5%V.S.50.2%+17.4%)。本实验表明异氟醚降低小鼠海马5-羟色胺且不依赖SERT的功能。

(李启芳 陈杰 校)

The serotonergic system may play a role during general anesthesia. Furthermore, alterations in serotonergic neurotransmission in the hippocampus have been linked to depression and anxiety as well as to changes in arousal and cognition. Little is known about the effects of volatile anesthetics on hippocampal serotonin (5-HT) levels. In this study we examined the effects of isoflurane on hippocampal 5-HT levels in mice. Adult male 129/SvEv mice were exposed to either isoflurane 1 or 1.5 minimum alveolar concentration (MAC) both in 40% O2 in air or to 40% O2 in air alone (control) for a period of 80 min, and hippocampal 5-HT levels were measured by microdialysis coupled with high performance liquid chromatography. Within 20–40 min of administration, both doses of isoflurane similarly produced a significant decrease in hippocampal 5-HT to 41.5% ± 11.0% and 36.4% ± 13.9% of the baseline level in the isoflurane 1 MAC and 1.5 MAC groups, respectively. Furthermore, when additional dialysates were obtained on termination of anesthesia in the isoflurane 1.5 MAC group, the decrease in extracellular 5-HT levels persisted for several hours. To determine if isoflurane-induced changes in extracellular 5-HT involve the serotonin transporter (SERT), similar microdialysis studies were performed in C57BL/6 wild-type (SERT +/+) and homozygous SERT knockout (SERT –/–) mice exposed to either 1 MAC isoflurane in 40% O2 in air or to 40% O2 in air alone for a period of 80 min. Isoflurane produced a significant decrease in hippocampal 5-HT in SERT +/+ and SERT –/–, and this decrease was larger in SERT –/– compared with SERT +/+: to 22.4% ± 8.5% versus 50.2% ± 17.4% of the baseline 5-HT level, respectively. These data suggest that isoflurane produces a decrease in hippocampal 5-HT, independent of SERT function.

 

小剂量过氧化氢可增强TNF-{alpha}诱导细胞凋亡的毒性且被丙泊酚逆转

A Small Dose of Hydrogen Peroxide Enhances Tumor Necrosis Factor-Alpha Toxicity in Inducing Human Vascular Endothelial Cell Apoptosis: Reversal with Propofol

Tao Luo, MD, and Zhengyuan Xia, MD, PhD

From the Department of Anesthesiology, Anesthesiology Research Laboratories, Renmin Hospital of Wuhan University, People's Republic of China.

Anesth Analg 2006 103: 110-116.

 

本研究基于人血管内皮细胞ECV304模型,探讨H2O2可增加TNF-{alpha}致细胞凋亡的毒性,且这一毒性增强作用可被具有抗氧化作用的丙泊酚所逆转。本研究取人血管内皮细胞ECV304经培养后分为以下几组:对照组、过氧化氢预处理组、TNF- {alpha}预处理组,TNF-{alpha}复合H2O2预处理组、丙泊酚复合H2O2预处理组。研究共进行24h并观察以下指标: LDH检测细胞活性;流式细胞仪和TUNEL法检测细胞凋亡;免疫组化法检测凋亡相关基因BCL-2Bax的表达。研究结果表明:ECV304细胞经TNF-{alpha}预处理后,细胞凋亡数明显增加,同时Bax表达和LDH释放明显增加;BCL-2表达明显降低,过氧化物歧化酶和谷胱甘肽氧化酶含量的明显降低。与对照组相比,H2O2 10 µM不会引起细胞明显的脂质过氧化(对照组MDA含量为0.70 ± 0.04 nmol/mg H2O2组为0.75 ± 0.03 nmol/mg) (P > 0.05)。但是H2O2会进一步增加TNF-a所诱导的脂质过氧化,同时上调Bax蛋白表达,下调Bcl-2的蛋白表达以及增加TNF-a诱导的细胞凋亡(P < 0.05)。丙泊酚50 µM可减轻TNF-{alpha}H2O2诱导的细胞凋亡,减少LDHMDA的生成,上调Bcl-2的表达。因而本研究表明H2O2可增强TNF-{alpha}的细胞毒性,丙泊酚可逆转这一作用从而产生保护效应。

(郑拥军 陈杰 校)

We designed the present study to test the hypothesis that oxygen free radicals can enhance tumor necrosis factor (TNF)-{alpha} cellular toxicity, which might be reversed by propofol, an anesthetic with antioxidant properties, in human vascular endothelial cell line ECV304. Cultured ECV304 were either not treated, treated with 10 µM of hydrogen peroxide (H2O2), treated with TNF-{alpha} (40 ng/mL) alone, TNF-{alpha} in the presence of 10 µM of H2O2 (H+T), or propofol plus H2O2 for 24 h. Cell viability was measured by lactate dehydrogenate (LDH) assay. Cell apoptosis was assessed by flow cytometry and terminal deoxynucleotidyl transferase (TdT)-mediated deoxyuridine triphosphate (dUTP) nick end-labeling. The antiapoptotic Bcl-2 and pro-apoptotic Bax protein expressions were measured by immunocytochemical analysis. Increases in apoptosis, Bax, lipid peroxidation product malondialdehyde, LDH, and decreases in Bcl-2, superoxide dismutase, and glutathione peroxidase were observed in TNF-{alpha}–treated cells. H2O2 10 µM did not cause significant lipid peroxidation (0.75 ± 0.03 nmol/mg of malondialdehyde protein) as compared with control (0.70 ± 0.04 nmol/mg of malondialdehyde protein) (P > 0.05) but further enhanced TNF-{alpha}–induced lipid peroxidation, upregulated Bax, and down-regulated Bcl-2 expression and enhanced TNF-{alpha}–induced cell apoptosis (P < 0.05). Propofol 50 µM attenuated TNF-{alpha} and H2O2-induced cell apoptosis, accompanied by decreases in malondialdehyde and LDH production and restoration of Bcl-2 expression. Propofol exerts protective effects against H2O2-enhanced TNF-{alpha} cell toxicity by reducing oxidative injury.


应用麻醉信息系统和应答自动反馈时增强医疗文件的及时性的医疗法律重要性

The Medicolegal Importance of Enhancing Timeliness of Documentation When Using an Anesthesia Information System and the Response to Automated Feedback in an Academic Practice

Michael M. Vigoda, MD, MBA, and David A. Lubarsky, MD, MBA

From the Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, University of Miami School of Business, Miami, Florida.

Anesth Analg 2006 103: 131-136.

 

理想的文件应该是在完成操作时及时完成。虽然电子记录系统一般不会将病史中每个记录条相应的时间都打在旁边,但麻醉自动化记录系统可以适时存储所有麻醉中发生的相应事件并与时间一致。当越来越多的律师开始意识到这个事实并要求审查这些记录,前瞩性记录表格的完整性可能被因医疗事件成被告的麻醉团体所破坏,这带来严重的医疗法律后果。作者在过去的大量的实践基础上,逐步通过三步改变目前的记录系统。在两个月教育培训期间,记录发生紧急事件时准确时间的比例从25%升到60%。自动邮件回馈系统将准确记录时间的比例又提升到70%。当与部分记账部门的个人接触和邮件拷贝通知相结合时,比例又升至>99.5%。这种行动的改变几乎见于所有的个体。在研究的最后阶段95%的住院医生不及时的纪录病例数<2/月。一旦习惯养成,在以后的9个月内几乎不需要补充输入。这就证明医生的行为与工作流程相关,并非与病人相关,且容易持久。

(肖洁 陈杰 校)

Documentation should ideally occur in real time immediately after completion of a service. Although electronic records often do not print the time that documentation notes were entered on the medical record, automated anesthesia record keeping systems store an audit trail that time stamps events entered by all anesthesia providers. As more lawyers become aware of this fact and requisition audit trails, prospective charting of necessary documentation may undermine the integrity of an anesthesia care team accused of malpractice, with potentially significant medicolegal consequences. We changed existing documentation practices of a large academic practice via a three-step process. Educational sessions increased the percentage of cases with correct timing of emergence documentation from 25% to 60% over a 2-mo period. Automated email performance feedback further increased correct note timing to 70%. When combined with personal contact by a member of the billing office and email copy notification of the chair, the percentage increased to >99.5%. The behavioral change was seen in all individuals, as 95% of attendings had ≤2 records/mo with untimely documentation at the end of the study period. Once the habits were ingrained, further input was rarely necessary over the next 9 mo. This suggests physician behavioral change related to work process flow, unlike that related to patient care, is easily sustained.

 

羟乙基淀粉在大鼠内毒素性肠中具有抗炎作用

Hydroxyethyl Starch Exhibits Antiinflammatory Effects in the Intestines of Endotoxemic Rats

Ran Lv, MD, Zhi-Qiang Zhou, MD, Hai-Wei Wu, MD, Yi Jin, MS, Wei Zhou, MD, and Jian-Guo Xu, MD

From the Department of Anesthesiology, Department of Cardiosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China; Department of General Surgery, the Affiliated Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.

Anesth Analg 2006 103: 149-155.

 

作者用大鼠在体研究HES(羟乙基淀粉)对内毒素血症致肠道炎症中炎症间质和转录因子激活的作用。大鼠静注脂多糖(LPS5mg/kg诱导内毒素血症并用静脉滴注HES16ml/kg,IV)或生理盐水(64ml/kg,IV)治疗。在LPS静注后的236小时,分别收集大鼠的回肠组织。回肠中各种不同的炎症间质水平(肿瘤坏死因子-a 白介素—6,细胞因子介导中性粒细胞诱导因子--1,白介素—10),炎症诱导mRNAs(mRNAs),核因子(NF--{kappa}B,蛋白激活因子(AP--1,以及回肠髓过氧化酶阳性细胞。HES显著降低了肿瘤坏死因子-a,IL-6, 中性粒细胞诱导因子—1, 炎症诱导mRNAs(mRNAs) 在大鼠回肠部表达水平的增高。相似地,HES可以降低由LPS产生的回肠髓过氧化酶阳性细胞表达,并且可以抑制回肠部NF-{kappa}BAP-1的激活。结果显示HES可以下调肠道炎症因子的产生,且这种抗炎作用是通过抑制NF-{kappa}B以及AP-1的激活来实现的。

(郑丽 陈杰校

We performed the present in vivo study to investigate the effect of hydroxyethyl starch (HES) on intestinal production of inflammatory mediators and activation of transcription factors during endotoxemia. Rats with endotoxemia induced by lipopolysaccharide (LPS) (5 mg/kg, IV) were treated with HES (16 mL/kg, IV) or saline (64 mL/kg, IV). At 2, 3, or 6 h after the LPS challenge, the rat ileal tissues were collected. Various ileal inflammatory mediator levels (tumor necrosis factor-{alpha}, interleukin [IL]-6, cytokine-induced neutrophil chemoattractant-1, and IL-10), inflammatory mediator messenger RNAs (mRNAs), activities of nuclear factor (NF)-{kappa}B and activator protein (AP)-1, and ileal myeloperoxidase-positive cells were determined in each group. HES significantly reduced the increased intestinal levels of tumor necrosis factor-{alpha}, IL-6, cytokine-induced neutrophil chemoattractant-1, and the mRNAs in the endotoxemic rats. Similarly, HES could decrease the myeloperoxidase-positive cells induced by LPS and also inhibit ileal NF-{kappa}B and AP-1 activations. Our results suggest that during endotoxemia HES may down-regulate intestinal inflammatory mediator production, and this antiinflammatory effect of HES may act through suppression of NF-{kappa}B and AP-1 activations.

 

比较糖尿病病人在七氟醚和异氟醚麻醉下脑血管对二氧化碳的反应性

The Comparative Effects of Sevoflurane Versus Isoflurane on Cerebrovascular Carbon Dioxide Reactivity in Patients with Diabetes Mellitus

Yuji Kadoi, MD, Ken-ichiro Takahashi, MD, Shigeru Saito, MD, and Fumio Goto, MD

From the Department of Anesthesiology, Gunma University, Graduate School of Medicine, Japan.

Anesth Analg 2006 103: 168-172.

 

已有报道使用挥发麻醉药会影响脑血管的二氧化碳反应性。作者研究了40例糖尿病病人,比较七氟醚和异氟醚麻醉脑血管对二氧化碳的反应性。麻醉用1.0 MAC的七氟醚或异氟醚并复合33%氧和67%笑气。2.5-MHz的经颅多普勒超声探头紧贴病人右颞部连续测量大脑中动脉平均血流速度。测定大脑中动脉平均血流速度基础值和心血管血液动力学参数后,通过减少呼吸频率来增加呼末CO2,并重复测试。用以上的数据来计算绝对和相对的CO2反应性。与那些口服降糖药和饮食疗法的病人相比,无论用异氟醚还是七氟醚,绝对的CO2反应性都比用胰岛素处理过的病人低(七氟醚组: 饮食疗法 = 2.6 ± 0.6; 口服降糖药 = 2.5 ± 0.8; 胰岛素 = 1.6 ± 0.8*; 异氟醚组: 饮食疗法= 3.3 ± i0.7; 口服降糖药= 3.4 ± 0.7; 胰岛素 = 1.9 ± 0.7* cm · s–1 · mm Hg–1; *P < 0.05)。相对CO2反应性显示口服降糖药和饮食疗法的病人相同的模式,相对和绝对的二氧化碳的反应性七氟醚组要低于异氟醚组。因此作者推断:无论在七氟醚还是异氟醚下,胰岛素依赖病人脑血管的二氧化碳的反应性是受损害的。

(潘志英 陈杰 校)

The use of volatile anesthetics has been reported to alter cerebrovascular carbon dioxide (CO2) reactivity. We examined the comparative effects of sevoflurane versus isoflurane on cerebrovascular CO2 reactivity in 40 patients with diabetes mellitus. Anesthesia was maintained with either 1.0 minimum alveolar anesthetic concentration of sevoflurane or 1.0 minimum alveolar anesthetic concentration of isoflurane in 33% oxygen and 67% nitrous oxide. A 2.5-MHz pulsed transcranial Doppler probe was attached to the patient's head at the right temporal window for continuous measurement of mean blood flow velocity in the middle cerebral artery. After establishing baseline middle cerebral artery velocity values and cardiovascular hemodynamics, we increased end-tidal CO2 by decreasing ventilatory frequency by 2–5 breaths/min and repeated the measurements. These were then used to calculate absolute and relative CO2 reactivity. Absolute CO2 reactivity was less in insulin-treated patients with either sevoflurane or isoflurane compared with those patients on oral antidiabetic drugs or dietary therapy (sevoflurane group: diet = 2.6 ± 0.6; oral antidiabetic drug = 2.5 ± 0.8; insulin = 1.6 ± 0.8*; isoflurane group: diet = 3.3 ± i0.7; oral antidiabetic drug = 3.4 ± 0.7; insulin = 1.9 ± 0.7* cm · s–1 · mm Hg–1; *P < 0.05, respectively). Relative CO2 reactivity showed a similar pattern in the diet-controlled and oral antidiabetic groups, absolute and relative CO2 reactivities were lower with sevoflurane versus isoflurane. Hence, we conclude that cerebrovascular CO2 reactivity in insulin-dependent patients is impaired under both sevoflurane and isoflurane anesthesia.

 

脊麻-硬膜外联合麻醉下行剖腹产时重比重布比卡因对产妇血液动力学的剂量依赖效应

Combined Spinal-Epidural Anesthesia for Cesarean Delivery: Dose-Dependent Effects of Hyperbaric Bupivacaine on Maternal Hemodynamics

Marc Van de Velde, MD, PhD, Dominique Van Schoubroeck, MD, Jacques Jani, MD, An Teunkens, MD, Carlo Missant, MD, and J. Deprest, MD, PhD

Anesth Analg 2006 103: 187-190.

 

血压下降是脊麻下剖腹产的一个重要的副作用。有证据表明降低脊麻药的剂量对维持产妇血液动力学的稳定有明显的作用。作者设计了随机试验以验证这一假设——降低局部麻醉的脊麻药的剂量可以产生相等的麻醉强度同时减轻产妇的低血压。 50个待产妇随机分配到两个试验组。在高剂量脊麻-硬膜外联合麻醉组使用9.5 mg重比重布比卡因复合 2.5 µg苏芬太尼;在低剂量脊麻-硬膜外联合麻醉组使用6.5 mg重比重布比卡因复合 2.5 µg苏芬太尼。收集人口统计学资料、产科资料、疼痛视觉模拟评分、对疼痛进行药物干预的次数,血液动力学等资料。与低剂量组相比,高剂量组病人经历较为显著且较长的低血压期。平均最低收缩压低剂量组高于高剂量组 (102 ± 16 88 ± 16; P < 0.05). 与低剂量组相比,在高剂量组中较多病人经历低血压期(68%16%; P < 0.05)。在高剂量组15个病人因为血压过低需要药物治疗,而低剂量组只有5个。高剂量组病人的有效麻醉效果 (冷觉阻滞平面达T3或以上) 的时间比低剂量组的较长 (95 ± 25 min68 ± 18 min, P < 0.05)。结论:小剂量的脊麻药用量 (6.5 mg重比重布比卡因复合苏芬太尼)有利于维持产妇血流动力学的稳定,且具有相等的麻醉强度,只是缩短了药物的作用时间。

(宋金超 陈杰 校)

Hypotension remains an important side effect of spinal anesthesia for cesarean delivery. There is limited evidence that reducing the spinal dose has a favorable effect on maternal hemodynamic stability. We designed the present randomized trial to test the hypothesis that reducing the spinal dose of local anesthetics results in equally effective anesthesia and less maternal hypotension. Fifty term pregnant patients were randomly assigned to two study groups. In the HIGH-group combined spinal-epidural anesthesia was performed using 9.5 mg hyperbaric bupivacaine combined with 2.5 µg sufentanil. In the LOW-group combined spinal-epidural anesthesia was performed using 6.5 mg hyperbaric bupivacaine combined with 2.5 µg sufentanil. Demographic data, obstetrical data, visual analog scale score for pain, number of medical interventions for pain, maternal hemodynamics, and neonatal outcome were recorded. Patients in the HIGH-group experienced more pronounced and longer hypotensive periods as compared with the LOW-group. The mean lowest recorded systolic blood pressure was higher in the LOW-group (102 ± 16 versus 88 ± 16 in the HIGH-group; P < 0.05). More patients in the HIGH-group experienced hypotension compared with the LOW-group (68% versus 16%; P < 0.05). In the HIGH-group 15 patients required pharmacological treatment for hypotension compared with 5 in the LOW-group. Duration of effective anesthesia (block to cold sensation above or at T3) was longer in the HIGH-group as compared with the LOW-group (95 ± 25 versus 68 ± 18 min, respectively, P < 0.05). We conclude that small-dose spinal anesthesia (6.5 mg hyperbaric bupivacaine combined with sufentanil) better preserves maternal hemodynamic stability with equally effective anesthesia that is of shorter duration.


非阿片类镇痛药帕瑞考昔(Parecoxib),扑热息痛(Paracetamol),安乃近(Metamizol)对缓解腰椎间盘摘除术后疼痛的疗效

The Efficacy of the Non-Opioid Analgesics Parecoxib, Paracetamol and Metamizol for Postoperative Pain Relief After Lumbar Microdiscectomy

Ulrich Grundmann, MD*, Clemens Wörnle, MD*, Andreas Biedler, MD*, Sascha Kreuer, MD*, Marc Wrobel, MD*, and Wolfram Wilhelm, MD{dagger}

From the *Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Germany; and {dagger}Department of Anesthesiology and Intensive Care Medicine, St.-Marien-Hospital Lünen, Lünen, Germany.

Address correspondence and reprint requests to Ulrich Grundmann, MD, Department of Anesthesiology and Intensive Care Medicine, University of Saarland, D-66421 Homburg/Saar, Germany.

Anesth Analg 2006 103: 217-222.

 

在这项前瞻性,双盲,随机,安慰剂对照的研究中,作者比较了三种静脉非阿片类镇痛药缓解腰椎间盘摘除术后疼痛的疗效。80名健康病人随机分为四个治疗组(n=20),分别在手术结束前45分钟静脉注射帕瑞考昔40mg,扑热息痛1g,安乃近1g或安慰剂。在麻醉后监护室(PACU)中病人均使用哌腈米特进行病人自控镇痛治疗。安乃近组到达PACU的镇痛评分显著低于帕瑞考昔,扑热息痛和安慰剂组。此外,安乃近组中需要额外PCA的病人数明显少于其它三组。可是,根据在PACU中所记录的PCA数据推算,在这四组中需要额外PCA的病人中,无论是首次需要哌腈米特的时间还是累计消耗哌腈米特量没有显著差别。在所有组中的副反应发生率很少。这些结果说明在接受椎间盘摘除术的病人中,缓解术后疼痛安乃近优于帕瑞考昔,扑热息痛和安慰剂,且副反应最小。

(殷文渊 陈杰 校)

In this prospective, double-blind, randomized, placebo-controlled study we compared the efficacy of three IV non-opioid analgesics for postoperative pain relief after lumbar microdiscectomy. Eighty healthy patients were randomly divided into 4 treatment groups (n = 20 each) to receive either parecoxib 40 mg, paracetamol 1 g, metamizol 1 g, or placebo IV 45 min before the end of surgery. In the postanesthesia care unit (PACU) patients were treated using patient-controlled analgesia (PCA) with piritramide. In the metamizol group the pain score at arrival in the PACU was significantly lower compared with the paracetamol, parecoxib, and placebo groups. In addition, in the metamizol group significantly fewer patients required additional PCA compared with the other groups studied. However, in those patients who required additional pain therapy in the four treatment groups, there was no significant difference in time to first request for piritramide and cumulative consumption of piritramide as assessed by the PCA data in the PACU. The incidence of adverse side effects was infrequent in all groups. These results suggest that in patients undergoing lumbar microdiscectomy, metamizol is superior to parecoxib, paracetamol, and placebo for immediate postoperative pain relief with minimal side effects.

 

鞘内注射2-氯普鲁卡因进行门诊病人下肢手术的随机、双盲对照的临床研究

Intrathecal 2-Chloroprocaine for Lower Limb Outpatient Surgery: A Prospective, Randomized, Double-Blind, Clinical Evaluation

Andrea Casati, Giorgio Danelli, Marco Berti, Augusto Fioro, Andrea Fanelli, Cristina Benassi, Gioacchino Petronella, and Guido Fanelli

Anesth Analg 2006 103: 234-238.

作者研究了45ASAI-II2-氯普鲁卡因腰麻下行择期下肢手术的门诊病人的剂量相关性。分别采用不含防腐剂的1%2-氯普鲁卡因30mg30mg组,n15),40mg40mg组,n15),和50mg50mg组,n15)。研究结果发现,三组病人的麻醉起效时间相同。所有的病人均没有改为全身麻醉完成手术。由于腰麻阻滞时间不足术中需要追加镇痛药的在30mg组有5例(35%),40mg组有2例(13%)(p0.014)。需要追加镇痛药的时间为30-60min,中数为40min。脊髓阻滞效果消失和运动恢复的时间在30mg组较快,为60[41-98]min85[45-123]min40mg组为85[46-141]min180[72-281]min50mg组为97[60-169]min185[90-355]minp0.001p0.003)。三组病人术后回家的时间没有显著差异,分别为30mg组:182[120-267]min40mg组为198 [123-271] min50mg组为203 [102-394] minP = 0.155)。在术后24小时和7天的随访过程中没有发现一过性的神经症状。总之作者认为,2-氯普鲁卡因40mg50mg对于门诊手术病人可以提供长达45-60min的足够的脊髓麻醉时间,30mg脊髓麻醉的时间往往不足。

(苏殿三 陈杰 校)

e evaluated the dose-response relationship of 2-chloroprocaine for lower limb outpatient procedure in 45 ASA physical status I-II outpatients undergoing elective lower limb surgery under spinal anesthesia, with 30 mg (group Chlor-30, n = 15), 40 mg (group Chlor-40, n = 15), or 50 mg (group Chlor-50, n = 15) of 1% preservative free 2-chloroprocaine. Onset time was similar in the three groups. General anesthesia was never required to complete surgery. Intraoperative analgesic supplementation as a result of insufficient duration of spinal block was required in 5 patients of group Chlor-30 (35%) and 2 patients of group Chlor-40 (13%) (P = 0.014), with a median (range) time for supplementation request of 40 (30–60) min. Spinal block resolution and recovery of ambulation were faster in group Chlor-30 (60 [41–98] min and 85 [45–123] min) than in groups Chlor-40 (85 [46–141] min and 180 [72–281] min) and Chlor-50 (97 [60–169] min and 185 [90–355] min) (P = 0.001 and P = 0.003, respectively), with no differences in home discharge time (182 [120–267] min in group Chlor-30, 198 [123–271] min in group Chlor-40, and 203 [102–394] min in group Chlor-50; P = 0.155). No transient neurologic symptoms were reported at 24-h and 7-day follow-up. We conclude that although 40 and 50 mg of 2-chloroprocaine provide adequate spinal anesthesia for outpatient procedures lasting 45–60 min, 30 mg produces a spinal block of insufficient duration.


在红细胞灌注的离体兔心中雷米芬太尼和舒芬太尼对冠脉和心肌的作用

The Coronary and Myocardial Effects of Remifentanil and Sufentanil in the Erythrocyte-Perfused Isolated Rabbit Heart

Patrick Lecomte, MD, Alexandre Ouattara, MD, Yannick Le Manach, MD, Marc Landi, MD, Pierre Coriat, MD, and Bruno Riou, MD, PhD

From the Laboratory of Anesthesiology, Department of Anesthesia and Critical Care and Department of Emergency Medicine and Surgery, Centre Hospitalier Universitaire Pitié-Salpêtrière, Assistance-Publique-Hôpitaux de Paris, Université Pierre et Marie Curie (Paris 6), Paris, France.

Anesth Analg 2006;103:9-14

 

雷米芬太尼引起的低血压可能与心肌缺血的不良事件有关联。尽管这些事件可很容易地归结于冠脉灌注压力的下降,我们还是检验了雷米芬太尼可直接影响冠脉血管收缩张力的假设。因此,我们评价了雷米芬太尼在离体兔心Langendorff模型上对冠脉和心肌的直接作用,并与浓度相近似的舒芬太尼引起之作用相比较。在全身麻醉下,快速分离新西兰兔的心脏,建立红细胞灌注的离体心脏模型。然后将心脏暴露于逐渐增量浓度(10-1000 nM)的雷米芬太尼(n = 10)或舒芬太尼(n = 8)。在每个浓度之间,将心脏恢复到基础值状态。记录两药每个浓度的最大冠脉和心肌作用。两组冠脉血流和心肌功能的基础值相近似。雷米芬太尼和舒芬太尼均不引起显著的冠脉和心肌作用。这些结果提示雷米芬太尼引起血流动力学紊乱时发生的心肌缺血,尤其在心脏病人,仅仅与外周血流动力学变化引起的冠脉灌注压降低有关。

(马皓琳 李士通 校)

Remifentanil-induced hypotension may be associated with adverse ischemic myocardial events. Although these events can be easily attributed to a decrease in coronary pressure perfusion, we tested the hypothesis that remifentanil could directly affect coronary vasomotor tone. Therefore, we assessed intrinsic coronary and myocardial in vitro effects of remifentanil on a Langendorff’s rabbit model and compared these effects with those provoked by similar intracoronary concentrations of sufentanil. Under general anesthesia, hearts from New Zealand rabbits were rapidly excised and mounted on an erythrocyte-perfused and isolated heart preparation. The hearts were then exposed to increasing concentrations (10-1000 nM) of either remifentanil (n = 10) or sufentanil (n = 8). Between each concentration, hearts were allowed to return to baseline status. The maximal coronary and myocardial effects of each concentration of both drugs were noted. Baseline values of coronary blood flow and myocardial performances were comparable between groups. Neither remifentanil nor sufentanil induced significant coronary and myocardial effects. These results suggest that myocardial ischemia, which may occur during remifentanil-induced hemodynamic disturbances, especially in cardiac patients, is only related to a decrease in coronary perfusion pressure provoked by peripheral hemodynamic changes.

 

 

右美托咪定在儿科心脏手术中的应用

The Use of Dexmedetomidine in Pediatric Cardiac Surgery

Ahmed M. Mukhtar, MD*, Eman M. Obayah, MD{dagger}, and Amira M. Hassona{dagger}

From the Departments of Anesthesia and Intensive Care and Biochemitry, Cairo Uniersity, Egypt.

Anesth Analg 2006;103:52-56

 

我们检验了盐酸右美托咪定(一种α2受体激动剂)在小儿心脏手术中减慢心率、降低动脉压及降低神经内分泌反应的能力。在一项随机安慰剂对照的研究中,将30个行开心手术的患儿随机平分到两组中。对照组接受生理盐水,而治疗组(DEX组)在10 min的时间内接受一个盐酸右美托咪定初始的推注剂量(0.5 µg/kg),紧接着以0.5 µg · kg–1 · h–1的速度持续静脉输注。监测动脉压、心率及循环中可的松、肾上腺素、去甲肾上腺素及血糖的连续浓度。与基础值相比,输注盐酸右美托咪定后,切皮时动脉压及心率明显下降。在对照组中,从切皮到体外循环结束,患者的心率及动脉压增加(P < 0.05)。与基础值相比,两组患者在劈胸骨后及体外循环后血浆中的可的松、肾上腺素、去甲肾上腺素及血糖浓度均明显升高(P < 0.05)。然而,与DEX组相比,对照组中的数值明显更高(P < 0.05)。结论:对于先心患儿的心脏矫治手术,术中输注盐酸右美托咪定能减轻血流动力学及神经内分泌对手术创伤及体外循环的反应。

(裘毅敏译,马皓琳 李士通校)

We tested dexmedetomidine, an {alpha}2 agonist, for its ability to decrease heart rate, arterial blood pressure, and neuroendocrinal responses during pediatric cardiac surgery. In a randomized, placebo-controlled study, 30 pediatric patients undergoing open heart surgery were randomly assigned to one of two equal groups. The control group received saline, whereas the treatment group (DEX group) received an initial bolus dose of dexmedetomidine (0.5 µg/kg) over 10 min, followed immediately by a continuous infusion of 0.5 µg · kg–1 · h–1. Arterial blood pressure, heart rate, and sequential concentrations of circulating cortisol, epinephrine, norepinephrine, and blood glucose were measured. Relative to baseline, arterial blood pressure and heart rate decreased significantly after the administration of dexmedetomidine through skin incision. In the control group, patients' heart rate and arterial blood pressure measures increased after skin incision until the end of bypass (P < 0.05). In both groups, plasma cortisol, epinephrine, norepinephrine, and blood glucose increased significantly relative to baseline, after sternotomy, and after bypass. However, the values were significantly higher in the control group compared with the DEX group (P < 0.05). In conclusion, intraoperative dexmedetomidine infusion attenuated the hemodynamic and neuroendocrinal response to surgical trauma and cardiopulmonary bypass in pediatric patients undergoing corrective surgery for congenital heart disease.

 

 

近期的吸烟行为与术后恶心和呕吐

Recent Smoking Behavior and Postoperative Nausea and Vomiting

Francis Whalen, MD, Juraj Sprung, MD, Christopher M. Burkle, MD, Darrell R. Schroeder, MS, and David O. Warner, MD

From the Anesthesia Clinical Research Unit, Departments of Anesthesiology and Health Sciences Research, Mayo Clinic, Rochester, Minnesota.

Anesth Analg 2006;103:70-75

 

 吸烟者通过未知的机制减少术后恶心和呕吐(PONV)的风险性。如果保护与烟成分的急性影响有关,近期吸烟者将会受到最好的保护。我们试验了这一假说,在吸烟者中,术后恶心与用呼出一氧化碳(CO)浓度来定量的最近吸烟相关。在这一观察性研究中,140女性吸烟者术前测定呼出CO水平。在术后24小时评估PONV。术前CO和出恢复室时恶心评分之间没有相关性(用Spearman等级相关评定)。发现术后24小时恶心和PONV史或者运动病史、术中止吐药预防应用、麻醉的持续时间和麻醉后恢复室中阿片类的使用显著相关。然而,术前CO水平和术后24小时的恶心之间没有相关性。这些初步的资料提示吸烟减少PONV的作用与术前呼出CO水平没有直接关系。

(彭中美    马皓琳 李士通  校)

The risk of postoperative nausea and vomiting (PONV) is reduced in cigarette smokers by unknown mechanisms. If protection is related to an acute effect of smoke constituents, smokers with the most recent exposure to cigarette smoke would be most protected. We tested the hypothesis that in cigarette smokers, postoperative nausea is correlated with recent exposure to cigarette smoke as quantified by exhaled carbon monoxide (CO) concentrations. In this observational study, exhaled CO levels were measured in 140 female smokers preoperatively. PONV was assessed over the first 24 h after surgery. There was no correlation (assessed with Spearman rank correlation) between preoperative CO and nausea scores at recovery room discharge. Significant correlations were found between nausea assessed over the first 24 h postoperatively and a history of PONV or motion sickness, the use of intraoperative antiemetic prophylaxis, duration of anesthesia, and use of opioids in the postanesthesia care unit. However, there was no correlation between preoperative CO and nausea over the first 24 h. These preliminary data suggest that the effect of smoking in reduced PONV is not directly related to preoperative exhaled CO levels.

 

 

分子手性与麻醉II:仲醇对映体对离子通道功能作用的立体选择性

Chirality in Anesthesia II: Stereoselective Modulation of Ion Channel Function by Secondary Alcohol Enantiomers

Robert Brosnan, DVM, PhD*, Diane Gong, PharmD{dagger}, Joseph Cotten, MD, PhD{ddagger}, Bharat Keshavaprasad, MD§, C. Spencer Yost, MD§, Edmond I. Eger, II, MD§, and James M. Sonner, MD§

From the *Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis; {dagger}The University of Texas at Austin, Waggoner Center for Alcohol and Addiction Research; {ddagger}The Department of Anesthesia and Critical Care Massachusetts General Hospital and §The Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2006;103:86-91

 

 分子手性已经被提出作为鉴别相关分子靶作用和不相关分子靶作用的一个手段,但是对于挥发性麻醉药这种检验方法的敏感性和特异性尚属未知。我们使用了两种麻醉效果(防止50%动物体动的MAC)具有结构选择性的手性醇类麻醉药(2-丁醇和2-戊醇)的对映体和对蛙卵母细胞作用无结构选择性的己醇。每一个蛙卵母细胞表达三种麻醉敏感性离子通道之一: Twik相关脊髓钾离子(TRESK)通道;γ氨基丁酸A型(GABAA)受体和N-甲基-d-天冬氨酸(NMDA)受体。我们采用电压钳技术,发现2-丁醇对任何通道的作用都不具有结构选择性(例如,16 mM 2-丁醇R-)和S-)对映体分别减少通过NMDA受体的电流44% ± 3% [均数 ± 标准误]37% ± 4%);2-戊醇对一种通道作用有结构选择性(GABAA受体,两种异构体分别使电流增加277% ± 20% 141% ± 30%);2-己醇对GABAANMDA受体的作用都具有结构选择性(例如,分别可以使通过NMDA受体的电流减少19% ± 3% 43% ± 5%)。我们计算了在下列两种情况下应用手性来检验麻醉药物的相关性方法的敏感性和特异性:1)所有三个通道是MAC的有关调停者;2)没有一个通道是MAC的调停者。由于在受体和整个动物实验结果间没有一致的相关性,这些敏感性和特异性的计算结果都很差。我们不建议采用手性结构作为吸入麻醉药靶点的效应相关性的检验方法。

(颜涛 译, 马皓琳 李士通 校)

Chirality has been proposed as a means for distinguishing relevant from irrelevant molecular targets of action, but the sensitivity and specificity of this test is unknown for volatile anesthetics. We applied enantiomers of two chiral anesthetic alcohols (2-butanol and 2-pentanol) that are enantioselective for the minimum alveolar concentration (MAC) preventing movement in 50% of animals and one (2-hexanol) that was not to frog oocytes. Each oocyte expressed one of three anesthetic-sensitive ion channels: a Twik-related-spinal cord K+ (TRESK) channel, a {gamma}-amino butyric acid type A (GABAA) receptor and an N-methyl-d-aspartate (NMDA) receptor. Using voltage-clamp techniques, we found that 2-butanol was not enantioselective for any channel (e.g., 16 mM 2-butanol R(–) and S(–) enantiomers decreased current through an NMDA receptors by 44% ± 3% [mean ± se] and 37% ± 4%, respectively); 2-pentanol was enantioselective for one channel (the GABAA receptor, the enantiomers increasing current by 277% ± 20% and 141% ± 30%); 2-hexanol was enantioselective for both GABAA and NMDA receptors (e.g., decreasing current through the NMDA receptor by 19% ± 3% and 43% ± 5%). We calculated the sensitivity and specificity of chirality as a test of anesthetic relevance under two scenarios: 1) all three channels were relevant mediators of MAC and 2) no channel was a mediator of MAC. These sensitivities and specificities were poor because there is no consistent correspondence between receptor and whole animal results. We recommend that enantioselectivity not be used as a test of relevance for inhaled anesthetic targets.

 

 

对正常或高反应性气道的家兔注射肌松药后的支气管痉挛的发生

Development of Bronchoconstriction After Administration of Muscle Relaxants in Rabbits with Normal or Hyperreactive Airways

Ferenc Peták, PhD*, Zoltán Hantos, PhD, DSc*, Ágnes Adamicza, PhD{dagger}, Hristifor Gálity*, and Walid Habre, MD, PhD{ddagger}

From the *Department of Medical Informatics and {dagger}Institute of Surgical Research, University of Szeged, Hungary; and {ddagger}Pediatric Anesthesia Unit, Geneva Children's Hospital, Switzerland.

Anesth Analg 2006;103:103-109

 

肌松药会诱发术中的支气管痉挛。我们描述了注射肌松药后正常或高反应性气道收缩的强度和短暂表现的特征。在没有处理过的家兔和已经对卵清蛋白的变应原致敏家兔,连续测定呼吸暂停的90s内的呼吸系统的气道阻抗(Zrs)。开始记录Zrs15秒后,按随机顺序分别注射司可林、美维库铵或哌库溴铵。然后在外源性组胺注射剂量逐渐增大时也分别测定Zrs。为了监测这些操作过程中的气道力学变化,每2s的时间窗平均一次Zrs值,并且用模型装置来测定气道阻力(Raw)。致敏的家兔的气道阻力的增加明显大于未处理过的家兔。司可林组气道阻力升高的最大幅度和最大变化速率分别是146% ± 29% 0.80 ± 0.12 cm H2O/L,美维库铵组80% ± 25% 0.71 ± 0.13 cm H2O/L,哌库溴铵变化最小(40% ± 12% 0.41 ± 0.04 cm H2O/L)。注射司可林或美维库铵后,变应性致敏会引起严重的且迅速发展的支气管痉挛。当存在支气管高反应性时,注射司可林或美维库铵时,应该考虑到这些有害的副作用。

(黄丽娜     李士通  校)

Neuromuscular blocking drugs can induce intraoperative bronchospasm. We characterized the magnitude and the temporal profile of the constriction in normal or in hyperresponsive airways after injections of neuromuscular blocking drugs. Respiratory system impedance (Zrs) was measured continuously over a 90-s apneic period in naïve and rabbits sensitized to allergens by ovalbumin. Fifteen s after the start of Zrs recordings, succinylcholine, mivacurium, or pipecuronium was administered in random order. Zrs was then also recorded during the administration of increasing doses of exogenous histamine. To monitor the changes in the airway mechanics during these maneuvers, Zrs was averaged for 2-s time windows, and the airway resistance (Raw) was determined by model fitting. The increases in Raw were significantly larger in the sensitized rabbits than in the naïve animals. The largest increases in Raw and the maximum rate of change in Raw were obtained for succinylcholine (146% ± 29% and 0.80 ± 0.12 cm H2O/L, respectively) and mivacurium (80% ± 25% and 0.71 ± 0.13 cm H2O/L) and the smallest were obtained for pipecuronium (40% ± 12% and 0.41 ± 0.04 cm H2O/L). Allergic sensitization leads to severe and rapidly developing bronchospasm after administrations of mivacurium or succinylcholine. These deleterious side effects should be considered when succinylcholine or mivacurium is administered in the presence of bronchial hyperreactivity.

 

 

一个先进的麻醉学专业培训计划:专为社区麻醉医师设计的临床教育

An Advanced Specialty Training Program in Anesthesiology: A Special Educational Fellowship Designed to Return Community Anesthesiologists to Clinical Practice

C. Philip Larson, Jr, MD, and Randolph H. Steadman, MD

From the Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California.

Anesth Analg 2006;103:126-130

 

我们为社区麻醉医师设立了一个计划,目的是评估他们的临床水平,以及在最新的麻醉技术方面对他们进行额外的培训。这个教育计划针对的是先前已经接受过培训者为进修目的、或有相当长时间没有在临床工作的需要进一步培养的麻醉医师。所有的受训人员都有有效的没有限制的加利福尼亚行医执照医疗事故保险。接近有一半的受训人员在入会时在临床工作,其他的人离开临床工作1-9年不等。最初24个毕业生花了平均9周时间(范围3–24周)的时间学习课程,以达到其个人设定的目标。完成课程之后平均15个月,我们跟踪调查了毕业生。所有的回答者都指出他们将再次参加这样的培训,80%的人认为他们学到了新的技术上的技能,73%的声明这个课程让他们了解了更多种不同的药物,50%的人认为这个课程让他们改变了治疗病人的方式。这个计划可以作为任何一种医学训练的模式,尤其是在要求从业者需要很强的技术技能的那些领域。

(张莹 译 马皓琳 李士通 校)

We describe a program for community anesthesiologists designed to evaluate clinical skills and provide additional training in the latest technologies in anesthesiology. This educational program was established for previously trained anesthesiologists who require additional training for either remedial purposes or because of a prolonged absence from practice. All enrollees had an active, unrestricted California medical license and malpractice insurance. Approximately half of the participants had been in active practice at the time of enrollment; the remainder had been away from practice from 1 to 9 yr. The first 24 graduates of the fellowship spent an average of 9 wk (range, 3–24 wk) in the program to meet their individualized goals. Graduates were surveyed an average of 15 mo after completion of the fellowship. All respondents indicated that they would enroll in the program again; 80% indicated they learned new technical skills, 73% stated that the fellowship introduced them to a greater variety of drugs, and 50% indicated that the fellowship changed their approach to patient care. This program may serve as a model for any discipline of medicine and is particularly relevant for those with a substantial component of technical skills expected of its practitioners.

 

 

重症患者的高氯性酸中毒:强离子酸中毒中的一种?

Hyperchloremic Acidosis in the Critically Ill: One of the Strong-Ion Acidoses?

David A. Story, MD, FANZCA*{ddagger}, Hiroshi Morimatsu, MD{dagger}, and Rinaldo Bellomo, MD, FJFICM{dagger}

From the Departments of *Anaesthesia and {dagger}Intensive Care, Austin Health, and {ddagger}Department of Surgery, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia.

Anesth Analg 2006;103:144-148

 

血浆碳酸氢盐减少与高氯性酸中毒及乳酸性酸中毒有关。根据Stewart推论的酸碱生理,强离子差调整血浆碳酸氢盐,氯化物和乳酸盐是临床化学中唯独常规测得的强离子。我们假设,不管有或者没有乳酸,血浆强离子差都比单独的血浆氯化物与血浆碳酸氢盐更有关。我们用了300个重症病人的血浆酸碱数据。与碳酸氢盐的相关性逐渐减弱(P<0.001):所有检测的强离子,r = 0.60;检测强离子没有检测乳酸盐,r = 0.42;单独氯化物,r = –0.27。在有传统的高氯性酸中毒(BE < –2mmol/L,阴离子间隙<17 mmol/L) 26个病人的一个亚群里,检测的强离子差(没有乳酸盐),比起氯化物与碳酸氢盐有较强的相关性(P < 0.001)r = 0.85r =–0.60。结论,高氯性酸中毒和乳酸性酸中毒都是强离子酸中毒。应该认为高氯血症与血浆强阳离子有关。现实的结论是,通过静脉液体治疗来管理和预防酸碱紊乱都包括了调节血浆强离子,尤其是钠和氯离子。

 (张曦   马皓琳 李士通  校)

 Decreases in plasma bicarbonate are associated with hyperchloremic acidosis and lactic acidosis. According to the Stewart approach to acid-base physiology, the strong-ion difference regulates plasma bicarbonate, with chloride and lactate being the only strong anions routinely measured in clinical chemistry. We hypothesized that the plasma strong-ion difference, both with and without lactate, would have a stronger association with plasma bicarbonate than plasma chloride alone would have with bicarbonate. We used plasma acid-base data from 300 critically ill patients. The correlation with bicarbonate became progressively weaker (P < 0.001): all measured strong ions, r = 0.60; measured strong ions without lactate, r = 0.42; chloride alone, r = –0.27. In a subgroup of 26 patients with traditional hyperchloremic acidosis (base excess < –2mmol/L and anion gap <17 mmol/L), the measured strong-ion difference (without lactate) had a stronger correlation (P < 0.001) with bicarbonate than chloride had: r = 0.85 versus r = –0.60. We conclude that hyperchloremic acidosis and lactic acidosis are strong-ion acidoses. Hyperchloremia should be viewed relative to the plasma strong cations. A practical conclusion is that both managing and preventing acid-base disorders with IV fluid therapy involves manipulating each of the plasma strong ions, particularly sodium and chloride.

 

 

经蝶骨手术术后恶心呕吐与疼痛:一项877例病人的资料回顾

Postoperative Nausea and Vomiting and Pain After Transsphenoidal Surgery: A Review of 877 Patients

Brigid C. Flynn, MD*, and Edward C. Nemergut, MD*{dagger}

From the Departments of *Anesthesiology and {dagger}Neurosurgery, University of Virginia Health System, Charlottesville.

Anesth Analg 2006;103:162-167

 

尽管大量研究已评价了经幕上和幕下途径行颅骨切除术术后恶心呕吐及疼痛,但对于经蝶骨路径有关的术后恶心呕吐及疼痛,还鲜有资料报道。因此,我们回顾了同一术者经蝶骨手术的877例病人的围术期记录。术后呕吐的总发生率为7.5%,明显低于大多数研究得出的神经外科病人发生率。术中脑脊液的渗漏及随后的脂肪移植术、腰穿针的应用及行颅咽管瘤切除的病人,术后呕吐发生率均明显增加(分别为11.4%、17.1%和18%)。有趣的是,预防性应用止吐药并不能减少总的或任一群病人的呕吐发生率;但氟哌利多和恩丹西酮都能减少术后恢复室(PACU)内病人恶心的发生率。关于疼痛及吗啡消耗量方面,后来发展为尿崩症的病人在PACU对吗啡的需要量明显增加。尚无其他疾病状态与PACU内病人疼痛及吗啡消耗量增加相关。

(邱郁薇 马皓琳 李士通 校)

Although postoperative nausea and vomiting and pain after supra- and infratentorial craniotomy have been evaluated in multiple studies, there are few data regarding pain or postoperative nausea and vomiting after transsphenoidal procedures. Therefore, we reviewed the perioperative records of 877 patients undergoing transsphenoidal surgery by the same surgeon. The overall incidence of postoperative emesis was 7.5%, significantly less than most studies of neurosurgical patients. An intraoperative cerebrospinal fluid leak and subsequent fat grafting, the use of lumbar intrathecal catheter, and patients presenting for the resection of a craniopharyngiomas all had a significantly increased incidence of postoperative emesis (11.4%, 17.1%, and 18%, respectively). Interestingly, antiemetic prophylaxis did not decrease the risk of vomiting overall or in any cohort of patients; however, both droperidol and ondansetron decreased the incidence of nausea in the postanesthesia care unit (PACU). Regarding pain and morphine consumption, patients who later developed diabetes insipidus had a significant increase in morphine requirements in the PACU. No other disease state was associated with increased pain or morphine consumption in the PACU.

 

肾上腺素对左旋布比卡因联合舒芬太尼硬膜外分娩镇痛的影响

Levobupivacaine-Sufentanil With or Without Epinephrine During Epidural Labor Analgesia

Filiep M. Soetens, MD*, Maurits A. Soetens, MD*, and Marcel P. Vercauteren, MD, PhD{dagger}

From the *Department of Anesthesiology, Sint-Elisabeth Hospital, Turnhout, Belgium; and {dagger}Department of Anesthesiology, University Hospital Antwerp, Edegem, Belgium.

Anesth Analg 2006;103:182-186

 

在这个前瞻随机双盲实验中,我们研究了肾上腺素是否增高左旋布比卡因联合舒芬太尼硬膜外分娩镇痛的功效。70位分娩期产妇接受硬膜外含或不含1:800,000肾上腺素的 0.125%布比卡因联合0.75 μg/mL 舒芬太尼注射,10ml起始剂量后启动病人自控镇痛泵。比较两组间每小时及总用药量、VAS疼痛评分、感觉及运动神经阻滞、分娩持续时间、.生命体征、母婴结果及副作用。如果产妇在研究过程中没有得到足够镇痛,即使10ml补救剂量后,则排除于进一步研究并给予10ml1:800,000肾上腺素的 0.125%布比卡因联合0.75 μg/mL 舒芬太尼混合液。肾上腺素组15分钟及20分钟时的每小时用药量、补救剂量及疼痛评分均较低。肾上腺素组运动神经阻滞发生率和第二产程持续时间有较高趋势,且与1分钟及5分钟时较低的Apgar评分相关。这些发现提示加入肾上腺素加强硬膜外左旋布比卡因联合舒芬太尼的作用,但可引起更多运动神经阻滞。

(黄佳佳译, 马皓琳,李士通校)

In a prospective, randomized, double-blind study, we investigated whether epinephrine increased the efficacy of levobupivacaine and sufentanil during epidural labor analgesia. Seventy term parturients received an epidural injection of levobupivacaine 0.125% and sufentanil 0.75 µg/mL with or without 1:800,000 epinephrine. After an initial dose of 10 mL, a patient-controlled analgesia pump was started. Total and hourly drug consumption, pain scores using the visual analog scale, sensory and motor block, duration of labor, vital variables, maternal and neonatal outcome, and side effects were compared. If the parturients experienced insufficient pain relief during the study, even after a rescue dose of 10 mL, they were excluded from further study and received 10 mL of bupivacaine 0.125% and sufentanil 0.75 µg/mL with 1:800,000 epinephrine. Hourly drug consumption, rescue dosing, and pain scores at 15 min and 20 min were lower in the epinephrine group. The incidence of motor block and duration of the second stage of labor tended to be higher in the epinephrine group and were associated with lower Apgar scores at 1 and 5 min. These findings suggest that the addition of epinephrine intensifies the effects of epidural levobupivacaine and sufentanil but may cause more motor block.

 

 

运用核磁共振机能成像技术测量吗啡对首次使用阿片类药物的健康志愿者的中枢神经系统回路的影响

Functional Magnetic Resonance Imaging Measures of the Effects of Morphine on Central Nervous System Circuitry in Opioid-Naive Healthy Volunteers

Lino Becerra, PhD*{dagger}{ddagger}§, Kim Harter, BA{ddagger}, R. Gilberto Gonzalez, MD, PhD{ddagger}§, and David Borsook, MD, PhD*{dagger}{ddagger}§

From the *P.A.I.N. Group, Brain Imaging Center; {dagger}Department of Psychiatry, McLean Hospital; and Departments of {ddagger}Radiology and §Neuroradiology, Massachusetts General Hospital – Athinoula Martinos Biomedical Imaging Center, and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2006;103:208-216

 

在这个初步研究中,我们运用核磁共振机能成像技术(fMRI)来研究吗啡对8位首次使用阿片类药物的健康志愿者的作用。在核磁共振机能成像的扫描下静脉内给予志愿者小剂量的吗啡(4 mg/70 kg)或生理盐水。给予吗啡而非盐水引发了轻微的欣快感而没有令人厌恶的症状,而且在包括伏核、通过近双凸透镜延展开的杏仁核、眶额皮质和海马区在内的反馈结构引发了正性的信号改变。在伏核出现的正性信号与以前报道的由伤害性刺激引起的信号相反。吗啡在皮质区通过与镇静催眠药物诸如异丙酚或咪唑安定类似的方式产生了一个有所减弱的信号。在中脑导水管周围灰质、带状前回(减弱的信号)和丘脑下部(增强的信号)观察到内源性镇痛区域的激活作用。反馈回路中的激活模式与报道的滥用使人欣快药物相似,提供了评价吗啡对涉及成瘾的中枢神经系统回路成分的最初作用的一个模型。在皮质区相对于皮质下区域观察到一个分离的fMRI反应,提示了来自感觉-运动和认知功能的反馈的分离。激活模式与以前在µ拮抗剂纳洛酮观察到的相反。

(姜旭晖译 马皓琳,李士通校)

In this pilot study, we used functional magnetic resonance imaging (fMRI) to study the effects of morphine in 8 healthy, opioid-naïve volunteers. Intravenous small-dose morphine (4 mg/70 kg) or saline was administered to volunteers undergoing a fMRI scan. Infusion of morphine, but not saline, elicited mild euphoria without aversive symptoms and resulted in positive signal changes in reward structures including the nucleus accumbens, sublenticular extended amygdala, orbitofrontal cortex, and hippocampus. The positive signal in the accumbens was opposite to the signal previously reported for noxious stimuli. Morphine produces a decreased signal in cortical areas in a similar manner to sedative-hypnotic drugs such as propofol or midazolam. Activation in endogenous analgesic regions was observed in the periaqueductal gray, the anterior cingulate gyrus (decreased signal), and hypothalamus (increased signals). The pattern of activation in reward circuitry was similar to that reported for euphoric drugs of abuse, providing a model to evaluate the initial effects of morphine on the central nervous system components of the circuitry involved in addiction. The segregation of fMRI response that was observed in cortical versus subcortical regions suggests a dissociation of reward from sensory-motor and cognitive functions. Activation patterns were opposite to those previously observed for the µ antagonist, naloxone.

 

 

持续性腘神经阻滞的可行性和并发症:1001例病例的调查研究

The Feasibility and Complications of the Continuous Popliteal Nerve Block: A 1001-Case Survey

Alain Borgeat, MD, Stephan Blumenthal, MD, Maud Lambert, MD, Panagiotis Theodorou, MD, and Patrick Vienne, MD

From the Department of Anesthesiology, Orthopedic University Hospital Balgrist, Zurich, Switzerland.

Anesth Analg 2006;103:229-233

 

神经周围导管被越来越广泛地应用于整形外科术后疼痛的治疗。与留置神经周围导管有关的远期并发症尚研究甚少。我们调查了持续性腘神经阻滞的功效和与其相关的急、慢性并发症。预期性评估1001例行踝或足部择期性手术并预定接受持续性腘神经阻滞的患者。所有患者经导管给予初始推注剂量的0.5%罗哌卡因40ml。在给予初始推注剂量后6小时开始连续输注0.3%罗哌卡因前24小时,然后减量到0.2%直至研究阶段结束。记录成功率和急性并发症。总成功率为97.5%。最高的成功率与头低脚高位有关。急性并发症包括神经定位时的皮肤感觉异常(0.5%)、局部麻醉药使用时的疼痛(0.8%)和血液抽吸(0.4%)。未发生中枢神经系统毒性和心脏毒性。术后10天和3周时检查慢性并发症,包括两例穿刺部位炎症。未观察到感染和神经病。持续性腘神经阻滞应用于踝或足部手术有较高的成功率和极少的急、慢性并发症。

(唐李隽 马皓琳 李士通 校)

Perineural catheters are increasingly used worldwide for the treatment of postoperative pain in orthopedics. Long-term complications associated with the placement of a perineural catheter remain largely unstudied. We investigated the efficacy and the acute and late complications associated with the continuous popliteal nerve block. One-thousand-one patients undergoing elective surgery of the ankle or foot and scheduled to have a continuous popliteal nerve block were prospectively evaluated. All patients received an initial bolus of 40 mL ropivacaine 0.5% through the catheter. A continuous infusion of ropivacaine 0.3% initiated 6 h after the initial bolus was administered for the first 24 h and then decreased to ropivacaine 0.2% until the end of the study period. The success rate and acute complications were recorded. The overall success rate was 97.5%. The highest success rate was associated with foot inversion. Acute complications consisted of paresthesias during nerve localization (0.5%), pain during local anesthetic application (0.8%), and blood aspiration (0.4%). No central nervous system toxicity or cardiotoxicity occurred. Late complications were checked at 10 days and 3 mo after surgery. These included two cases of inflammation at the puncture site. No infection or neuropathy was observed. The use of continuous popliteal nerve block for ankle or foot surgery is associated with frequent success and few acute and late complications.

 

心肺转流术开始时使用亚甲蓝的血流动力学效应

The Hemodynamic Effects of Methylene Blue When Administered at the Onset of Cardiopulmonary Bypass

Andrew D. Maslow, MD*, Gary Stearns, CCP{dagger}, Parag Batula, BMS§, Carl S. Schwartz, MD*, Jeffrey Gough, CCP, and Arun K. Singh, MD{ddagger}

From the Departments of *Anesthesiology, {dagger}Perfusion Therapy, and {ddagger}Cardiac Surgery, §Brown Medical School, Rhode Island Hospital, Providence Rhode Island.

Address correspondence and reprint requests to Andrew Maslow MD, 63 Prince St, Needham Ma, 02492.

Anesth Analg 2006 103: 2-8

 

心肺转流术(CPB)时发生低血压,部分因为炎性反应的介导,氧化亚氮和鸟苷酸环化酶起重要作用。在这项研究中,我们验证亚甲蓝(MB)的血液动力学效应,鸟苷酸环化酶抑制剂,在心肺转流术(CPB)时给使用了血管紧张素转换酶抑制剂的患者使用。30名行心脏外科手术的患者在CPB 和心脏麻痹停搏后随机分配接受MB(3 mg/kg)或生理盐水(S)。在所用受试患者中CPB的处理相似。血液动力学数据在CPB之前、CPB时和CPB之后被收集。记录所使用的血管加压药物。在CPB开始和心脏麻痹停搏时,所有受试患者平均动脉压(MAP)和体循环血管阻力(SVR)有着相似的下降。MB增加MAPSVR,而且这种效应持续40分钟。生理盐水组在CPB整个过程MAPSVR持续下降。在CPB时生理盐水组接受较多次数的苯肾上腺素,而且在CPB之后需要较多的去甲肾上腺素来维持所需的MAP。尽管相同或较高MAPSVRMB组血清乳酸盐水平明显较低。结论为,服用血管紧张素转换酶抑制剂的患者在CPB后使用MB可以增加MAPSVR及减少血管加压药物的需求。此外,血清乳酸盐水平在MB患者中较低,提示有更多有效地组织灌注。

(孙敏莉译 薛张纲校)

Hypotension occurs during cardiopulmonary bypass (CPB), in part because of induction of the inflammatory response, for which nitric oxide and guanylate cyclase play a central role. In this study we examined the hemodynamic effects of methylene blue (MB), an inhibitor of guanylate cyclase, administered during cardiopulmonary bypass (CPB) to patients taking angiotensin-converting enzyme inhibitors. Thirty patients undergoing cardiac surgery were randomized to receive either MB (3 mg/kg) or saline (S) after institution of CPB and cardioplegic arrest. CPB was managed similarly for all study patients. Hemodynamic data were assessed before, during, and after CPB. The use of vasopressors was recorded. All study patients experienced a similar reduction in mean arterial blood pressure (MAP) and systemic vascular resistance (SVR) with the onset of CPB and cardioplegic arrest. MB increased MAP and SVR and this effect lasted for 40 minutes. The saline group demonstrated a persistently reduced MAP and SVR throughout CPB. The saline group received phenylephrine more frequently during CPB, and more norepinephrine after CPB to maintain a desirable MAP. The MB group recorded significantly lower serum lactate levels despite equal or greater MAP and SVR. In conclusion, administration of MB after institution of CPB for patients taking angiotensin-converting enzyme inhibitors increased MAP and SVR and reduced the need for vasopressors. Furthermore, serum lactate levels were lower in MB patients, suggesting more favorable tissue perfusion.

 

心肺转流管理和神经系统预后:对目前实践一项循证医学评估

Cardiopulmonary Bypass Management and Neurologic Outcomes: An Evidence-Based Appraisal of Current Practices

Charles W. Hogue, Jr, Christopher A. Palin, and Joseph E. Arrowsmith

From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University Medical School, Baltimore, MD; Department of Anaesthesia, St. Mary’s Hospital, London, UK; Department of Anaesthesia, Papworth Hospital, Cambridge, UK.

Anesth Analg 2006 103: 21-37.

 

高龄患者心脏手术后发生神经系统并发症已越来越重要。在这篇综述里,我们对目前CPB方案与神经系统并发症的发生之间的关系做了严格的分析。除了使用20-40µm的动脉导管滤膜和膜氧发生器,基本CPB仪的新型改进版或使用特殊装置或方案(包括低温和“严格”血糖控制)对神经系统的预后没有更多的优势。主动脉外超声检查可以用在升主动脉操作时,以避免动脉粥样硬化产生的不良后果。虽然现有的临床试验认为这种操作价值有限。目前在CPB中控制血流、动脉压和pH的措施得到了很多临床观察数据的支持。虽然有些数据证明一些阻滞兴奋性氨基酸信号传导通路和炎症反应药物的优势,目前没有药物被推荐用于CPB中进行神经保护。总之,这篇综述的数据强调在CPB过程中指导医生照顾患者的现有理论基础存在缺陷。多中心临床研究表明需要循证方案的发展以降低神经系统并发症,以避免患者发病率和死亡率的增加。

(金琳 薛张纲校)

Neurologic complications after cardiac surgery are of growing importance for an aging surgical population. In this review, we provide a critical appraisal of the impact of current cardiopulmonary bypass (CPB) management strategies on neurologic complications. Other than the use of 20–40 µm arterial line filters and membrane oxygenators, newer modifications of the basic CPB apparatus or the use of specialized equipment or procedures (including hypothermia and "tight" glucose control) have unproven benefit on neurologic outcomes. Epiaortic ultrasound can be considered for ascending aorta manipulations to avoid atheroma, although available clinical trials assessing this maneuver are limited. Current approaches for managing flow, arterial blood pressure, and pH during CPB are supported by data from clinical investigations, but these studies included few elderly or high-risk patients and predated many other contemporary practices. Although there are promising data on the benefits of some drugs blocking excitatory amino acid signaling pathways and inflammation, there are currently no drugs that can be recommended for neuroprotection during CPB. Together, the reviewed data highlight the deficiencies of the current knowledge base that physicians are dependent on to guide patient care during CPB. Multicenter clinical trials assessing measures to reduce the frequency of neurologic complications are needed to develop evidence-based strategies to avoid increasing patient morbidity and mortality.

 

比较右旋美托咪定和异丙芬用于小儿磁共振检查时镇静、血流动力学和呼吸的影响

A Comparison of the Sedative, Hemodynamic, and Respiratory Effects of Dexmedetomidine and Propofol in Children Undergoing Magnetic Resonance Imaging

Ahmet Koroglu, MD* Huseyin Teksan, MD† Ozlem Sagýr, MD* Aytac¸ Yucel, MD* Huseyin I. Toprak, MD* Ozcan M. Ersoy, MD*

*Department of Anesthesiology and Reanimation, Inonu University, Medical Faculty, Malatya, Turkey; †Group of Vatan’s Hospital, Clinic of Anesthesiology, Karabuk, Turkey.

Anesth Analg 2006;103:63–7

 

我们比较了右旋美托咪定和异丙芬在小儿行磁共振时镇静、血流动力学和呼吸的影响。60个小儿随机分成2组:右美托咪定组(D)给予1ug/kg初始剂量,随后0.5ugkgh-1剂量连续输注;异丙芬组(P)初始剂量3mg/kg,随后100ugkgh-1连续输注。磁共振检查过程中,小儿体动导致很难完成磁共振检查被认为是镇静不充分。研究过程中记录平均动脉压(MAP),心率,外周氧饱和度和呼吸频率。在P组中,镇静起效时间,苏醒时间和出院时间明显短于D组。两组MAP,心率和RR都低于基础值。镇静过程中P组中MAPRR明显低D组。P组中有4个小儿被发现氧饱和度降低。在大多数小儿中右旋美托咪定和异丙芬能提供充分的镇静。虽然异丙芬可产生快速的麻醉诱导和苏醒,但它可能导致低血压和去氧饱和度。因此,右旋美托咪定可能是又一可靠的镇静药选择。

(吴德华译 薛张纲校)

We compared the sedative, hemodynamic, and respiratory effects of dexmedetomidine and propofol in children undergoing magnetic resonance imaging procedures. Sixty children were randomly distributed into two groups: The dexmedetomidine (D) group received 1 _g/kg initial dose followed by continuous infusion of 0.5 _g · kg_1 · h_1 and a propofol group (P) received 3 mg/kg initial dose followed by a continuous infusion of 100 _g · kg_1 · min_1. Inadequate sedation was defined as difficulty in completing the procedure because of the child’s movement during

magnetic resonance imaging. Mean arterial pressure (MAP), heart rate, peripheral oxygen saturation, and respiratory rate (RR) were recorded during the study. The onset of sedation, recovery, and discharge time were significantly shorter in group P than in group D. MAP, heart rate, and RR decreased during sedation from the

baseline values in both groups. MAP and RR were significantly lower in group P than in group D during sedation. Desaturation was observed in four children of group P. Dexmedetomidine and propofol provided adequate sedation in most of the children. We conclude that although propofol provided faster anesthetic

induction and recovery times, it caused hypotension and desaturation. Thus, dexmedetomidine could be an alternative reliable sedative drug to propofol in selected patients.

 

麻醉空间螺旋特性I:仲醇对映体的最低肺泡气浓度

Chirality in Anesthesia I: Minimum Alveolar Concentration of Secondary Alcohol Enantiomers

Albert Won, BS, Irene Oh, BS, Michael J. Laster, DVM, John Popovich, BS, Edmond I. Eger, II, MD, and James M. Sonner, MD

From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Address correspondence to James M. Sonner, MD, Department of Anesthesia, S-455, University of California, San Francisco, CA 94143-0464.

Anesth Analg 2006 103: 81-84.

 

既往许多关于吸入麻醉作用中空间螺旋特性研究都采用异氟烷对映结构。这些对映结构价格昂贵且数量稀少,这就限制了研究,例如对麻醉作用的分子靶标的初步证明之类的研究才能采用这些异构体来进行。我们假设仲醇(如含-CH2-CHOH-CH3基团的化合物)这一类的实验性麻醉剂也可表现出对映结构选择性。为验证这个假设,我们测定了小鼠体内2-醇类(从2-丁醇到2-庚醇)同源系列对映结构的最低肺泡气浓度(MAC)。因为这些醇类在实验过程中部分地代谢为2-酮类(如含有-CH2-CO-CH3基团),我们分别测定这些2-酮类的MAC。假设酮类的MAC增加是由于醇类所致,在小鼠实验中通过酮类的麻醉剂效应可以近似的测定醇类的MAC。我们发现2-丁醇和2-戊醇的异构体具有对映结构选择性。S-(+)-2-丁醇的MAC值比它的R-(-)-对映体要高17%,而S-(+)-2-戊醇的MAC值比它的出R-(-)-对映体高出38%。在2-己醇和2-庚醇中没有观察到立体结构选择性。这些发现使得对麻醉空间螺旋特性研究采用较便宜的挥发性化合物变得可行,特别是在体内环境下没有代谢改变时更是如此。

(金 路译 薛张纲校)

Most studies of chirality in inhaled anesthetic action have used the enantiomers of isoflurane. These enantiomers are expensive and scarce, which limits studies, such as the preliminary identification of molecular targets of anesthetic action, that can be performed with these isomers. We hypothesized that secondary alcohols (i.e., compounds having a -CH2-CHOH-CH3 group) that are experimental anesthetics would show enantioselectivity. To test this hypothesis, we determined the minimum alveolar anesthetic concentration (MAC) of the enantiomers of the homologous series of 2-alcohols from 2-butanol to 2-heptanol in rats. Because these alcohols are partially metabolized to 2-ketones during the course of study (i.e., having a -CH2-CO-CH3 group), we independently measured the MAC of the 2-ketones. Assuming additivity of MAC of the ketones with the alcohols, we corrected for the anesthetic effect of the ketones in rats to determine the MAC of the alcohols. We found that the 2-butanol and 2-pentanol isomers were enantioselective. S-(+)-2-butanol had a MAC that was 17% larger than for the R-(-)-enantiomer, whereas S-(+)-2-pentanol had a MAC that was 38% larger than the R-(-)- enantiomer. No stereoselectivity was observed for 2-hexanol and 2-heptanol. These findings may permit studies of chirality in anesthesia, particularly in in vitro systems where metabolism does not occur, using inexpensive volatile compounds.

 

长期蛛网膜下腔应用1-对氯苯酚-5甲氧基-2甲基-1H-吲哚-3醋酸(吲哚美辛):一项在动物模型中对神经毒性作用的评价

Chronic Subarachnoid Administration of 1-(4chlorobenzoyl)-5methoxy-2methyl-1H-indole-3 Acetic Acid (Indomethacin): An Evaluation of Its Neurotoxic Effects in an Animal Model

Uriah Guevara-López, Alfredo Covarrubias-Gómez, Hilario Gutierrez-Acar, J. Antonio Aldrete, Francisco J. López-Muñoz, and Braulio Martínez-Benítez

Department of Pain and Palliative Medicine, National Institute for Medical Sciences and Nutrition Salvador Zubirán, DF

Anesth Analg 2006 103: 99-102.

 

轴索应用非甾体类抗炎药被认为是治疗顽固性疼痛的一种方法,但很少有证据表明,这样应用吲哚美辛是否具有神经毒性作用。在该试验中,我们评价了蛛网膜下腔给予吲哚美辛是否会对几内亚猪造成组织学上的神经毒性。需要验证的假设是“蛛网膜下腔给予吲哚美辛会损伤几内亚猪的脊髓吗?”10只雄性几内亚猪被麻醉,聚酰胺导管和蛛网膜下腔的微量泵相联,后者置于L2-3水平。试验动物随机分为2组,每组5只。连续14天持续注入吲哚美辛或生理盐水(0.5 mL/h)。神经毒性由脊髓生理学测定。任何一组都没有证据表明存在组织学毒性。这些数据指出,蛛网膜下腔注射该剂量的吲哚美辛不会造成脊髓典型的神经毒性。我们推论:硬膜外腔应用吲哚美辛可能是疼痛治疗的另一可行方法,虽然其安全性还

有待证实。

(王丽珺译 薛张纲校)

Neuraxial administration of nonsteroid antiinflammatory drugs has been suggested as an alternative in the management of intractable pain, but there is little evidence that the neurotoxic effects of indomethacin by this route of administration have been evaluated. In this study, we evaluated histological neurotoxicity of indomethacin after its subarachnoid administration in guinea pigs. The hypothesis tested was "Does subarachnoid administration of indomethacin produce damage in the spinal cord of guinea pigs?" Ten male guinea pigs were anesthetized, and a polyamide catheter connected to a subcutaneous osmotic micro-pump was implanted at the L2-3 level. Animals were randomly assigned in 2 groups of 5 animals each. Indomethacin or saline solution was administered by continuous infusion (0.5 microL/h) for 14 days. Neurotoxicity was determined by spinal cord histopathology. There was no evidence of toxicity in the histological examinations of either group. These data suggest that subarachnoid administration of indomethacin infusion, at these doses, did not produce lesions typical of neurotoxicity in the spinal cord. We have concluded that epidural administration of indomethacin may be considered an alternative for application in human pain management, although more studies to determine its safety are required.

 

N-甲基-D天冬氨酸受体ε1亚型敲除小鼠中乙醇诱导的催眠耐受缺乏。

Ethanol-induced hypnotic tolerance is absent in N-methyl-D-aspartate receptor epsilon1 subunit knockout mice.

Sato Y. Seo N. Kobayashi E.

Department of Anesthesiology, Division of Organ Replacement Research, Center for Molecular Medicine, Jichi Medical School, Kawachi, Tochigi, Japan.

Anesth & Analg 2006 103:117-20

 

近来的药理学研究显示了N-甲基-D天冬氨酸受体(NMDA)在成瘾性药物(阿片类,安非他明和可卡因)发展的神经适应性过程中发挥着重要的作用。本实验中,我们研究了NMDA受体对乙醇诱导的催眠耐受所起的作用。采用NMDA受体ε1亚型敲除小鼠。给单一剂量33.54g/kg乙醇注射后催眠敏感性在野生型小鼠和NMDA受体ε1亚型敲除小鼠之间没有显著的差别。虽然野生型小鼠在连续4天重复注射4g/kg乙醇后显示催眠耐受,但与NMDA受体ε1亚型敲除小鼠在催眠持续时间上没有明显区别。在连续4天注射后两组小鼠之间,体内乙醇清除也没有明显区别。我们的结果显示,含有NMDA受体的ε1亚型可能涉及乙醇诱导的催眠耐受形成有关。

(吴德华译 薛张纲校)

Recent pharmacological studies suggest that N-methyl-D-aspartate (NMDA) receptors play an important role in neuroadaptive processes in the development of tolerance to addictive drugs, such as opioids, amphetamine, and cocaine. In the present study, we investigated the contribution of the NMDA receptor to ethanol-induced hypnotic tolerance using NMDA receptor epsilon1 subunit knockout mice. Hypnotic sensitivity to a single injection of 3, 3.5, and 4 g/kg ethanol was not significantly different between wild-type mice and NMDA receptor epsilon1 subunit knockout mice. In contrast, although wild-type mice displayed hypnotic tolerance after repeated administration of 4 g/kg ethanol for 4 consecutive days, no change in the duration of hypnosis was observed in knockout mice. No significant differences were observed in blood ethanol clearance between wild-type and knockout mice on day 4. Our results indicate epsilon1 subunit containing the NMDA receptor might be involved in the development of ethanol-induced hypnotic tolerance.

 

住院医生和麻醉医师对基础科学的态度

Attitudes of residents and anesthesiologists toward basic sciences
Filho GR, Schonhorst L.
Nucleus for Teaching and Research in Medical Education, Department of Anesthesiology, Hospital Governador Celso Ramos, Florianopolis, SC, Brazil.

Anesth Analg. 2006 103:137-43,

 

标题事件的已知适用性在于对成人学习来说是一个必要的条件。态度是指影响学习者对个人行为选择,从而决定学习行为发生可能性的内在状态。这项研究的目的是描述和比较住院医生和麻醉师对基础科学和临床实践相关性的态度。给予105名住院医师和142名麻醉医师一个8项问卷调查。电子化收集数据。回答按5Likert量表评分。对住院医生和麻醉医师的回答做比较。尽管两组中都观察到了基础科学与临床实践公认的相关性这一普遍模式,但麻醉医师的等级要显著高于住院医生。两组都深入强调在临床实践前对基础科学的正规学习,但麻醉主治医生的评分要显著高于住院医生。尽管评分中值低于量表的中位数,但住院医生相比麻醉医师来说大多赞成学习大体概念的浅显途径。两组对教授基础科学期间,在住院医生令人兴奋的好奇心中讲师角色的评分都为量表的中值。两组对他们的在职教育经历都给予高度评价。

(徐丽颖译 薛张纲校)

The perceived relevance of the subject matter is an essential condition for adult learning. Attitudes refer to internal states that influence learner's choices of personal action, which determine the probability of learning behaviors. Our objectives in this study were to describe and compare attitudes of residents and anesthesiologists towards the relevance of basic sciences to clinical practice. An 8-item questionnaire was given to 105 residents and 142 anesthesiologists. Data were electronically collected. Responses were graded on 5-level scales. Comparisons were made between responses of residents and anesthesiologists. Although a general pattern of acknowledged relevance of basic sciences to clinical practice was observed in both groups, anesthesiologists' ratings were significantly higher than residents' ratings. Both groups emphasized in-depth formal learning of basic sciences before their clinical application, but attending anesthesiologists' scores were significantly higher than residents' scores. Residents were more favorable to a more superficial approach represented by learning general concepts than anesthesiologists, although median scores were below the center of the scale (neutral). In both groups median ratings of the role of instructors in exciting residents' curiosity through the teaching of basic sciences were located in the center of the respective scales. Both groups rated their in-training educational experiences high.

 

硫酸吗啡减轻失血性休克引起的通透性增高

Morphine Sulfate Attenuates Hemorrhagic Shock- Induced Hyperpermeability

Craig Charleston, MD*, Rudolph Puana, MD*, Russell K. McAllister, MD*, Felicia A. Hunter*, and Ed W. Childs, MD{dagger}

From the Departments of *Anesthesiology and {dagger}Surgery, Scott and White Clinic and Memorial Hospital, Scott, Sherwood and Brindley Foundation, Texas A&M University System Health Science Center College of Medicine, Temple, Texas.

Address correspondence and reprint requests to Ed W. Childs, MD, Scott and White Clinic and Memorial Hospital, Department of Surgery, 2401 South 31st St., Temple, Texas 76508.

Anesth Analg 2006;103:156-161

 

硫酸吗啡常用于那些需要手术干预来控制出血的病人。最近的数据显示吗啡作为一种免疫制约剂影响白细胞,增加感染率。此外,吗啡释放组胺——一种增加微血管通透性的炎性介质。吗啡的这两种作用均加重失血性休克后的炎症过程。本项研究中,我们评估了硫酸吗啡在微血管通透性中的作用和它在失血性休克后的白细胞聚集作用。在一段对照期后,在乌拉坦麻醉的SD大鼠中把血分离出来降低平均动脉压到40mmHg一小时。检查小肠的透照节段肠系膜后毛细血管静脉来定量通透性和白细胞聚集的改变。在控制期,大鼠接受了静脉注射的用异硫氰酸荧光素标记的牛白蛋白。从异硫氰酸荧光素标记的牛白蛋白释放出的荧光强度用数字显微镜在微血管腔内记录,并与同时的腔外光强度比较。这些图像下载到计算机化的图像分析程序来定量估计光强度的变化。这些光强度的变化代表白蛋白的外渗。此外,明视野图像记录到压缩光盘来回放以测定白细胞聚集。在100微米片断的静脉中稳态停留超过30秒认为白细胞聚集。我们的结果证明了异硫氰酸荧光素标记的牛白蛋白血管外漏明显增加,白细胞在后毛细血管内皮的聚集增加。在休克期前给予硫酸吗啡10 µg/kg减少失血性休克后的高通透性(P < 0.05)并增加白细胞聚集(P < 0.05)。这些结果说明与失血性休克后的加重的炎性反应不同,吗啡能提供微血管的保护。

(周 荻译 薛张纲校)

Morphine sulfate is often administered for patients requiring surgical intervention for the control of hemorrhage. Recent data implicate morphine as an immune modulator that affects white blood cells and increases infection rates. In addition, morphine releases histamine, an inflammatory mediator that increases microvascular permeability. Both of these actions of morphine could aggravate the inflammatory progress after hemorrhagic shock. In this study, we evaluated the role of morphine sulfate on microvascular permeability and its effects on leukocyte adherence after hemorrhagic shock. After a control period, blood was withdrawn to reduce the mean arterial blood pressure to 40 mm Hg for 1 h in urethane-anesthetized Sprague-Dawley rats. Mesenteric postcapillary venules in a transilluminated segment of small intestine were examined to quantify changes in permeability and leukocyte adherence. The rats received an IV injection of fluorescein isothiocyanate-bovine albumin during the control period. The fluorescent light intensity emitted from the fluorescein isothiocyanate-bovine albumin was recorded with digital microscopy within the lumen of the microvasculature and compared with the intensity of light in the extraluminal space over time. These images were downloaded to a computerized image analysis program that quantitates changes in light intensity. This change in light intensity represents albumin extravasation. In addition, bright-field images were recorded on compact disk for playback to determine leukocyte adherence. Leukocytes stationary for more than 30 s or longer in a 100-micron segment of venule was considered adherent. Our results demonstrated a marked increase in fluorescein isothiocyanate-bovine albumin leakage into the extravascular an increase in leukocytes adhering to the postcapillary venular endothelium. Morphine sulfate 10 µg/kg given before the shock period, attenuated both the hyperpermeability (P < 0.05) and the increase in leukocyte adherence (P < 0.05) after hemorrhagic shock. These results suggest that instead of aggravating the inflammatory response after hemorrhagic shock, morphine may provide protection to the microvasculature.

七氟醚对大鼠大脑缺血再灌注神经元损伤和细胞凋亡因子表达的长期作用

The long-term effect of sevoflurane on neuronal cell damage and expression of apoptotic factors after cerebral ischemia and reperfusion in rats.

Pape M, Engelhard K, Eberspacher E, Hollweck R, Kellermann K, Zintner S, Hutzler P, Werner C.
Klinik fur Anasthesiolgie Klinikum der Johannes Gutenberg-Universitat, Langenbeckstrasse 1, 55131 Mainz, Germany.

Anesth Analg. 2006 103:173-9

我们观察七氟醚对缺血再灌注大鼠大脑组织病理学损伤和凋亡关键蛋白的长期作用。64只雄性Sprague-Dawley大鼠被随机的分为组1(芬太尼和N2O/O2,对照)和组22%七氟醚和O2/空气)。缺血(45分钟)是由阻塞单侧的颈总动脉和出血性低血压(平均动脉压40 mm Hg)造成的。大鼠在1, 3, 7, and 28天后杀掉。大脑切片在苏木精和曙红染色下计数海马的嗜曙红细胞。激活的激酶3和凋亡调控蛋白Bax, Bcl-2, Mdm-2 p53通过免疫染色来分析。在整个阶段,七氟醚麻醉的大鼠中没有发现嗜曙红神经元,而在对照组发现了9%-38%的海马神经元(128天)。在第1和第3天,对照组的Bax浓度比七氟醚组的大140%-200%。前3天对照组的Bcl-2浓度低100%。激活的激酶在两组中都存在(0.75%-2.2%)。这些数据都支持在大脑缺血再灌注损伤时七氟醚的神经保护作用。

(陆文清译 薛张纲校)

We investigated the long-term effects of sevoflurane on histopathologic injury and key proteins of apoptosis in a rat hemispheric ischemia/reperfusion model. Sixty-four male Sprague-Dawley rats were randomly assigned to Group 1 (fentanyl and N2O/O2; control) and Group 2 (2.0 vol% sevoflurane and O2/air). Ischemia (45 min) was produced by unilateral common carotid artery occlusion plus hemorrhagic hypotension (mean arterial blood pressure 40 mm Hg). Animals were killed after 1, 3, 7, and 28 days. In hematoxylin and eosin-stained brain sections eosinophilic hippocampal neurons were counted. Activated caspase-3 and the apoptosis-regulating proteins Bax, Bcl-2, Mdm-2, and p53 were analyzed by immunostaining.No eosinophilic neurons were detected in sevoflurane-anesthetized rats over time, whereas 9%-38% of the hippocampal neurons were eosinophilic (days 1-28) in control animals. On days 1 and 3, the concentration of Bax was 140%-200% larger in fentanyl/N2O-anesthetized animals compared with sevoflurane. Bcl-2 was 100% less in control animals during the first 3 days. Activated caspase-3 was detected in neurons of both groups (0.75%-2.2%). These data support a sustained neuroprotective potency of sevoflurane related to reduced eosinophilic injury after cerebral ischemia/reperfusion.

 

老年病人在腹部手术中以白蛋白为基础的静脉扩容治疗的价值

The value of an albumin-based intravascular volume replacement strategy in elderly patients undergoing major abdominal surgery.
Boldt J, Scholhorn T, Mayer J, Piper S, Suttner S.
Clinic of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Bremserstr 79, D-67063 Ludwigshafen, Germany.

Anesth Analg 2006 103: 191-199.

 

用人白蛋白(HA)治疗低血容量的价值是有争议的。其他相对较为便宜的选择如羟乙基淀粉(HES)因为其副作用有时是不能使用的。我们选择了50例病人,年龄均大于70岁,进行腹部手术,随即输5%HA,或者6%HES130/0.4),当平均动脉压<60mmHg,中心静脉压<10mmHg时。血流动力学、炎症因子(IL-6)、内皮激活分子(黏附分子)、凝血功能(血栓弹力图)以及肾功能(相关蛋白)在诱导后、手术后、在ICU5h和术后第一天监测。HA组病人输了3960+/-590mlHA,5070+/-1030ml林格氏液,HES组病人输了3500+/-530HES4550+/-880ml林格氏液。总蛋白只有在HA组病人是正常的。两组病人的血流动力学、凝血、肾功能无显著差别。IL-6和黏附分子HA组显著高于HES组。我们总结出HA在行腹部手术的老年病人中的应用可以被HES替代。由于降低的炎症反应和内皮激活损伤,HES130/0.4是比较合适的。

(钟 静译 薛张纲校)

The value of human albumin (HA) for treating hypovolemia is controversial. Less expensive alternatives such as hydroxyethyl starch (HES) are sometimes refused because of unwanted side effects. We prospectively randomized 50 patients older than 70 years old undergoing major abdominal surgery to receive either 5% HA (n = 25) or a third generation HES preparation (6% HES 130/0.4; n = 25) when mean arterial blood pressure was <60 mm Hg and central venous pressure was <10 mm Hg. Hemodynamics, inflammation (interleukin-6), endothelial activation-integrity (adhesion molecules), coagulation (thrombelastography), and renal function (including kidney-specific proteins) were monitored after the induction of anesthesia, after surgery, 5 h in the intensive care unit, and on the first postoperative day. HA patients received 3960 +/- 590 mL of HA and 5070 +/- 1030 mL of Ringer's lactate solution, and HES patients received 3500 +/- 530 mL of HES and 4550 +/- 880 mL of Ringer's lactate solution. Total protein remained normal only in the HA-treated patients. No significant differences (P > 0.1) between the groups were seen with regard to hemodynamics, coagulation, and kidney function. Plasma levels of interleukin-6 and soluble adhesion molecules were significantly (P < 0.05) higher in the HA- than in the HES-treated patients. We conclude that HA in elderly patients undergoing major abdominal surgery can easily be replaced by a modern HES preparation. Because of the decreased inflammatory response and endothelial activation-injury, HES 130/0.4 seems to be the more appropriate fluid strategy for these patients.

 

中枢神经系统疾病患者的椎管内麻醉及镇痛

Neuraxial Anesthesia and Analgesia in Patients with Preexisting Central Nervous System Disorders

James R. Hebl, Terese T. Horlocker, and Darrell R. Schroeder

Department of Anesthesiology, Mayo Clinic College of Medicine, 200 First Street, S.W., Rochester, Minnesota 55905, USA.

Anesth Analg 2006 103: 223-228.

 

椎管内麻醉技术在已患中枢神经系统疾病患者中的应用历来被认为是相对禁忌的。除了机械性创伤,局麻药的毒性反应及中枢神经缺血以外,害怕实施麻醉后神经病变加重也时常报道。我们调查了已患中枢神经系统疾病患者在接受了椎管内麻醉后的新的或进行性并发症的发生率。我们对Mayo诊所从19882000年间的已患中枢神经系统疾病患者之后接受了椎管内麻醉或镇痛的临床病例进行回顾性分析。139位病人被纳入此项研究。病人平均年龄为60+/-17岁。性别分布为8662%)位男性比5338%)位女性。在实施麻醉时患者明确诊断有中枢神经系统疾病的平均年数为23+/-23年,有7453%)位病人是有神经症状的。7554%)位病人接受了腰麻,5842%)位病人接受了硬膜外麻醉或镇痛,43%)位病人接受了持续腰麻,21%)位病人接受了腰硬联合麻醉。布比卡因是所有局麻药中应用最多的。7252%)位病人的局麻药中加入了肾上腺素。有1511%)例出现了并发症,主要是无意地导致了感觉过度和穿刺针导致的创伤。13698%)位病人的阻滞是满意的。与术前相比较,术后未发现新的或加重的并发症(0.0%; 95%的可信区间, 0.0%-0.3%)。我们得出以下结论:椎管内麻醉或镇痛相关的并发症在已患中枢神经系统疾病患者中的发生率并不如以前认为的那样高,不应将椎管内麻醉作为此类患者的绝对禁忌症。

(王慧琳译 薛张纲校)

Historically, the use of regional anesthetic techniques in patients with preexisting central nervous system (CNS) disorders has been considered relatively contraindicated. The fear of worsening neurologic outcome secondary to mechanical trauma, local anesthetic toxicity, or neural ischemia is commonly reported. We examined the frequency of new or progressive neurologic complications in patients with preexisting CNS disorders who subsequently underwent neuraxial blockade. The medical records of all patients at the Mayo Clinic from the period 1988 to 2000 with a history of a CNS disorder who subsequently received neuraxial anesthesia or analgesia were retrospectively reviewed. One-hundred-thirty-nine (n = 139) patients were identified for study inclusion. Mean patient age was 60 +/- 17 yr. Gender distribution was 86 (62%) males and 53 (38%) females. An established CNS disorder diagnosis was present a mean of 23 +/- 23 yr at the time of surgical anesthesia, with 74 (53%) patients reporting active neurologic symptoms. Spinal anesthesia was performed in 75 (54%) patients, epidural anesthesia or analgesia in 58 (42%) patients, continuous spinal anesthesia in 4 (3%) patients, and a combined spinal-epidural technique in 2 (1%) patients. Bupivacaine was the local anesthetic most commonly used in all techniques. Epinephrine was added to the injectate in 72 (52%) patients. There were 15 (11%) technical complications, with the unintentional elicitation of a paresthesia and traumatic needle placement occurring most frequently. A satisfactory block was reported in 136 (98%) patients. No new or worsening postoperative neurologic deficits occurred when compared to preoperative findings(0.0%; 95% confidence interval, 0.0%-0.3%). We conclude that the risks commonly associated with neuraxial anesthesia and analgesia in patients with preexisting CNS disorders may not be as frequent as once thought and that neuraxial blockade should not be considered an absolute contraindication within this patient population.

外周搏动指数是一种可靠而又早期的评价局部阻滞效果的监测手段

Peripheral flow index is a reliable and early indicator of regional block success.
Galvin EM
, Niehof S, Verbrugge SJ, Maissan I, Jahn A, Klein J, van Bommel J.
Department of Anesthesiology, Erasmus University Medical Center, 3015 GD, Rotterdam, The Netherlands.

Anesth Analg. 2006 103:239-43, table of contents

 

我们研究表明,用标准的手指氧饱和度探头来监测外周搏动指数(PFI)可以作为一种早期而又有效的评价局部阻滞效果的监测手段。66名四肢手术病人,麻醉为臂丛或坐骨神经阻滞,用药均为1.5%的甲哌卡因。所谓PFI就是在实施阻滞前10分钟到阻滞后30分钟采用氧饱和度探头监测外周血管的搏动与非搏动之间的比值。而未被阻滞的四肢将同样记录PFI。当阻滞后30分钟每间隔5分钟测试病人的针刺觉和温度感觉。我们发现当臂丛阻滞后10分钟,坐骨神经阻滞后12分钟 PFI值上升1.55,提示阻滞成功。PFI对于提示臂丛阻滞效果的敏感性和特异性为100%、阳性预测值与阴性预测值分别为95%93%。而对于坐骨神经阻滞而言,其敏感性和特异性分别为90%100%12分钟时的阳性预测值与阴性预测值分别为94%92%。在15分钟时臂丛阻滞对痛觉和温度觉刺激的PFI的敏感性和特异性均为71%100%。而坐骨神经阻滞对温度刺激的PFI的敏感性和特异性为77%100%、对痛觉刺激的PFI的敏感性和特异性分别为20%100%。我们由此得到的结论是PFI是一种简单、早期而又客观的对局部阻滞效果评价的手段。

(孙卓真译 薛张纲校)

We investigated the usefulness of peripheral flow index (PFI) measurement using a standard pulse oximetry digit probe for early prediction of successful regional blocks. Sixty-six patients scheduled for limb surgery underwent either axillary or sciatic block using a nerve stimulator technique with mepivacaine 1.5%. PFI, which is the ratio of the pulsatile versus the nonpulsatile component of the pulse oximetry signal, was recorded from 10 min before block insertion until 30 min afterwards. PFI recordings of the unblocked limb were similarly recorded. Pinprick and cold sensation were assessed at 5-min intervals until 30 min after blockade. An increase in PFI by a factor of 1.55 at 10 min after axillary block placement (P = 0.006), and 12 min after sciatic block placement (P = 0.001) was required to predict a successful block. The sensitivity and specificity of PFI was 100% for predicting axillary block outcomes at this time. Positive predictive value was 95% and negative predictive value was 93%. For sciatic blocks, sensitivity and specificity were 90% and 100%, respectively. The calculated positive predictive value at time 12 min for sciatic blocks was 94% and negative predictive value was 92%. At 15 min after block placement, cold and pinprick sensations had the same calculated values for sensitivity and specificity at 71% and 100%, respectively, for axillary blocks. For sciatic blocks, cold sensation had a sensitivity of 77% and a specificity of 100%, whereas pinprick had a sensitivity of just 20% with a specificity of 100%. We conclude that PFI provides a simple, early, and objective assessment of the success and failure of nerve blocks.