Anesthesia & Analgesia

 

July 2006

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

心肺轉流術開始時使用亞甲藍的血流動力學效應

(孫敏莉譯 薛張綱校)

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.

在紅細胞灌注的離體兔心中雷米芬太尼和舒芬太尼對冠脈和心肌的作用

(馬皓琳 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.

輸注紅細胞的保存時間與再次心臟手術後患病率和死亡率的相關性

(趙延華 陳傑 )

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

心肺轉流管理和神經系統預後:對目前實踐一項循證醫學評估

(金琳 薛張綱校)

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:

右美托咪定在兒科心臟手術中的應用

(裘毅敏譯,馬皓琳 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.

右旋美托咪啶作兒科CT檢查時鎮靜的研究

(王震虹 陳傑 )

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

比較右旋美托咪定和異丙芬用於小兒磁共振檢查時鎮靜、血流動力學和呼吸的影響

(吳德華譯 薛張綱校)

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:

近期的吸煙行為與術後噁心和嘔吐

(彭中美    馬皓琳 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.

一種嚴重抑鬱症新方法-磁驚厥療法的麻醉思考

(顧新宇 陳傑 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:

麻醉空間螺旋特性I:仲醇對映體的最低肺泡氣濃度

( 路譯 薛張綱校)

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.

分子手性與麻醉II:仲醇對映體對離子通道功能作用的立體選擇性

(顏濤 譯, 馬皓琳 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.

異氟醚降低小鼠海馬細胞外5-羥色胺

(李啟芳 陳傑 校)

Isoflurane Decreases Extracellular Serotonin in the Mouse Hippocampus

Robert A. Whittington and László Virág

Anesth Analg 2006 103: 92-98.

長期蛛網膜下腔應用1-對氯苯酚-5甲氧基-2甲基-1H-吲哚-3醋酸(吲哚美辛):一項在動物模型中對神經毒性作用的評價

(王麗珺譯 薛張綱校)

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.

對正常或高反應性氣道的家兔注射肌松藥後的支氣管痙攣的發生

(黃麗娜     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.

小劑量過氧化氫可增強TNF-{alpha}誘導細胞凋亡的毒性且被丙泊酚逆轉

(鄭擁軍 陳傑 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天冬氨酸受體ε1亞型敲除小鼠中乙醇誘導的催眠耐受缺乏。

(吳德華譯 薛張綱校)

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:

一個先進的麻醉學專業培訓計畫:專為社區麻醉醫師設計的臨床教育

(張瑩 譯 馬皓琳 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.

應用麻醉資訊系統和應答自動反饋時增強醫療檔的及時性的醫療法律重要性

(肖潔 陳傑 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.

住院醫生和麻醉醫師對基礎科學的態度

(徐麗穎譯 薛張綱校)

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:強離子酸中毒中的一種?

 (張曦   馬皓琳 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.

羥乙基澱粉在大鼠內毒素性腸中具有抗炎作用

(鄭麗 陳傑校

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.

硫酸嗎啡減輕失血性休克引起的通透性增高

(周 荻譯 薛張綱校)

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:

經蝶骨手術術後噁心嘔吐與疼痛:一項877例病人的資料回顧

(邱鬱薇 馬皓琳 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.

比較糖尿病病人在七氟醚和異氟醚麻醉下腦血管對二氧化碳的反應性

(潘志英 陳傑 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.

七氟醚對大鼠大腦缺血再灌注神經元損傷和細胞凋亡因數表達的長期作用

(陸文清譯 薛張綱校)

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:

腎上腺素對左旋布比卡因聯合舒芬太尼硬膜外分娩鎮痛的影響

(黃佳佳譯, 馬皓琳,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-硬膜外聯合麻醉下行剖腹產時重比重布比卡因對產婦血液動力學的劑量依賴效應

(宋金超 陳傑 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:

老年病人在腹部手術中以白蛋白為基礎的靜脈擴容治療的價值

( 靜譯 薛張綱校)

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:

運用核磁共振機能成像技術測量嗎啡對首次使用阿片類藥物的健康志願者的中樞神經系統回路的影響

(姜旭暉譯 馬皓琳,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.

非阿片類鎮痛藥帕瑞考昔(Parecoxib),撲熱息痛(Paracetamol),安乃近(Metamizol)對緩解腰椎間盤摘除術後疼痛的療效

(殷文淵 陳傑 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:

中樞神經系統疾病患者的椎管內麻醉及鎮痛

(王慧琳譯 薛張綱校)

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.

持續性膕神經阻滯的可行性和併發症:1001例病例的調查研究

(唐李雋 馬皓琳 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.

鞘內注射2-氯普魯卡因進行門診病人下肢手術的隨機、雙盲對照的臨床研究

(蘇殿三 陳傑 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.

外周搏動指數是一種可靠而又早期的評價局部阻滯效果的監測手段

(孫卓真譯 薛張綱校)

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.

 

輸注紅細胞的保存時間與再次心臟手術後患病率和死亡率的相關性

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.

 

紅細胞在保存過程中發生許多變化,但是與其相關的損害在臨床上並不明確。作者假定再次胸骨切開行心臟手術患者的死亡率與輸注紅細胞的保存時間有關,因為這些病人需要輸血和出現不良預後的風險高。作者回顧性分析了再次胸骨正中切開行冠狀動脈搭橋或瓣膜手術並接受異體紅細胞的患者434名,其中321名(74%)患者符合標準。在調整了混淆因素和紅細胞輸注總量的影響後,研究發現紅細胞的保存時間與住院死亡率(相關風險比(HR)=1.151P < 0.0001)和院外死亡率(HR = 1.116; P < 0.0001)相關。輸注紅細胞的平均保存時間也是住院死亡率的獨立預測指標(HR = 1.036; P < 0.0001)。該研究同時觀察了保存時間和急性腎功能障礙、監護室及住院時間的獨立相關性。保存時間與再次胸骨切開行心臟手術後不良預後有關。該發現的臨床意義應該在大樣本隨機盲態的臨床試驗中進行研究。

(趙延華 陳傑 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.

 

右旋美托咪啶作兒科CT檢查時鎮靜的研究

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.

 

右旋美托咪定作為兒科鎮靜的經驗有限。本研究首次對右美托咪定在兒科放射檢查中具有鎮靜作用作了前瞻性評估。在20055月,作者醫院鎮靜委員會推薦以右美托咪定取代在CT檢查中的常規藥戊巴比妥而作為標準用藥。詳細質量保證(QA)資料單收集每個患者的相關資訊,將這些資料記錄到電腦化的鎮靜資料庫裏。經過IRB同意後可取得所有QA資料。62個患者平均年齡2.8歲(SD=1.8,範圍0.5~9.7),靜注右旋美托咪啶,負荷量為2mcg/kg維持10min。之後重複注射,劑量為2mcg/kg維持10min直到Ramsay鎮靜評估分值為4RSS)。繼續以1mcg/kg/hr維持注射直至拍攝結束。重復資料方差分析顯示和鎮靜前比較,心率和平均動脈壓在注射,恢復期平均值降低了15%P<0.01)。呼吸頻率和呼氣末CO2並沒有顯著改變。平均恢復時間為32±18分鐘。基於上述研究結果,右旋美托咪啶可能提供可靠的有效的鎮靜。

(王震虹 陳傑 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.

 

一種嚴重抑鬱症新方法-磁驚厥療法的麻醉思考

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.

電驚厥療法(ECT)是嚴重抑鬱症一種非常有效的治療方法。然而,它的應用與治療後認知損傷顯著相關。磁驚厥療法(MST)作為一種選擇性治療方法可以減少驚厥後副作用,可能通過更多的局灶性發作所致。在開放平行研究中,作者比較20例匹配病例接受一系列ECTMST,研究其麻醉藥、肌松藥、心血管藥物的需要量和心血管效應、BIS指數、早期復蘇時間等。結果顯示:與ECT相比,MST與定向時間減少更相關(4±118±5分鐘,P0.01)。為了減少MST後殘餘肌松,琥珀膽鹼的需要量更少(38±1797±2mgP0.01〉。MSTBIS值較ECT組在刺激前更高,刺激後更低。兩治療組漢密頓抑鬱量表值都顯著低於基線值,但ECT組治療後更低(14± 10P0.05)。結論:MST在誘導驚厥後比ECT肌松藥的需要量減少,BIS值的變異性減少,認知功能的恢復更快。在大腦刺激可比的水平上,MSTECT抗抑鬱效應還需更深入的研究。

(顧新宇 陳傑 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.


異氟醚降低小鼠海馬細胞外5-羥色胺

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-羥色胺能系統在全麻中可能發揮一定作用,且海馬5-羥色胺能遞質的改變與抑鬱,焦慮,認知,聽覺的改變有關。目前吸入麻醉劑對海馬5-羥色胺水平的影響知之甚少。本實驗檢測異氟醚對小鼠海馬5-羥色胺的影響。成年雄性129/SvEv小鼠在吸入40%O2 1.01.5MAC的異氟醚,對照組僅吸入40%O2,持續80min。海馬5-羥色胺水平採用微量滲析和高效液相色譜檢測。20-40min後,1MAC1.5MAC的異氟醚均顯著降低海馬5-羥色胺水平(分別為基礎水平的41.5%+11.0%36.4%+13.9%),且在1.5MAC組,微量滲析發現麻醉結束後幾小時仍有5-羥色胺的降低,為了明確異氟醚降低5-羥色胺是否由5-羥色胺轉移子(SERT)所致,C57BL/6 野生型小鼠 (SERT +/+)和純合型 SERT 基因敲除小鼠SERT-/-)的小鼠在吸入40%O2 1 MAC異氟醚或僅吸入40%O2,微量滲析發現異氟醚在SERT+/+)和SERT-/-)的小鼠中均有5-羥色胺的降低,SERT-/-)降低更明顯(22.4%+8.5%V.S.50.2%+17.4%)。本實驗表明異氟醚降低小鼠海馬5-羥色胺且不依賴SERT的功能。

(李啟芳 陳傑 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.

 

小劑量過氧化氫可增強TNF-{alpha}誘導細胞凋亡的毒性且被丙泊酚逆轉

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.

 

本研究基於人血管內皮細胞ECV304模型,探討H2O2可增加TNF-{alpha}致細胞凋亡的毒性,且這一毒性增強作用可被具有抗氧化作用的丙泊酚所逆轉。本研究取人血管內皮細胞ECV304經培養後分為以下幾組:對照組、過氧化氫預處理組、TNF- {alpha}預處理組,TNF-{alpha}複合H2O2預處理組、丙泊酚複合H2O2預處理組。研究共進行24h並觀察以下指標: LDH檢測細胞活性;流式細胞儀和TUNEL法檢測細胞凋亡;免疫組化法檢測凋亡相關基因BCL-2Bax的表達。研究結果表明:ECV304細胞經TNF-{alpha}預處理後,細胞凋亡數明顯增加,同時Bax表達和LDH釋放明顯增加;BCL-2表達明顯降低,過氧化物歧化酶和谷胱甘肽氧化酶含量的明顯降低。與對照組相比,H2O2 10 µM不會引起細胞明顯的脂質過氧化(對照組MDA含量為0.70 ± 0.04 nmol/mg H2O2組為0.75 ± 0.03 nmol/mg) (P > 0.05)。但是H2O2會進一步增加TNF-a所誘導的脂質過氧化,同時上調Bax蛋白表達,下調Bcl-2的蛋白表達以及增加TNF-a誘導的細胞凋亡(P < 0.05)。丙泊酚50 µM可減輕TNF-{alpha}H2O2誘導的細胞凋亡,減少LDHMDA的生成,上調Bcl-2的表達。因而本研究表明H2O2可增強TNF-{alpha}的細胞毒性,丙泊酚可逆轉這一作用從而產生保護效應。

(鄭擁軍 陳傑 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.


應用麻醉資訊系統和應答自動反饋時增強醫療檔的及時性的醫療法律重要性

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.

 

理想的檔應該是在完成操作時及時完成。雖然電子記錄系統一般不會將病史中每個記錄條相應的時間都打在旁邊,但麻醉自動化記錄系統可以適時存儲所有麻醉中發生的相應事件並與時間一致。當越來越多的律師開始意識到這個事實並要求審查這些記錄,前矚性記錄表格的完整性可能被因醫療事件成被告的麻醉團體所破壞,這帶來嚴重的醫療法律後果。作者在過去的大量的實踐基礎上,逐步通過三步改變目前的記錄系統。在兩個月教育培訓期間,記錄發生緊急事件時準確時間的比例從25%升到60%。自動郵件回饋系統將準確記錄時間的比例又提升到70%。當與部分記賬部門的個人接觸和郵件拷貝通知相結合時,比例又升至>99.5%。這種行動的改變幾乎見於所有的個體。在研究的最後階段95%的住院醫生不及時的紀錄病例數<2/月。一旦習慣養成,在以後的9個月內幾乎不需要補充輸入。這就證明醫生的行為與工作流程相關,並非與病人相關,且容易持久。

(肖潔 陳傑 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.

 

羥乙基澱粉在大鼠內毒素性腸中具有抗炎作用

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.

 

作者用大鼠在體研究HES(羥乙基澱粉)對內毒素血症致腸道炎症中炎症間質和轉錄因數啟動的作用。大鼠靜注脂多糖(LPS5mg/kg誘導內毒素血症並用靜脈滴注HES16ml/kg,IV)或生理鹽水(64ml/kg,IV)治療。在LPS靜注後的236小時,分別收集大鼠的回腸組織。回腸中各種不同的炎症間質水平(腫瘤壞死因數-a 白介素—6,細胞因數介導中性粒細胞誘導因數--1,白介素—10),炎症誘導mRNAs(mRNAs),核因數(NF--{kappa}B,蛋白啟動因數(AP--1,以及回腸髓過氧化酶陽性細胞。HES顯著降低了腫瘤壞死因數-a,IL-6, 中性粒細胞誘導因數—1, 炎症誘導mRNAs(mRNAs) 在大鼠回腸部表達水平的增高。相似地,HES可以降低由LPS產生的回腸髓過氧化酶陽性細胞表達,並且可以抑制回腸部NF-{kappa}BAP-1的啟動。結果顯示HES可以下調腸道炎症因數的產生,且這種抗炎作用是通過抑制NF-{kappa}B以及AP-1的啟動來實現的。

(鄭麗 陳傑校

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.

 

比較糖尿病病人在七氟醚和異氟醚麻醉下腦血管對二氧化碳的反應性

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.

 

已有報導使用揮發麻醉藥會影響腦血管的二氧化碳反應性。作者研究了40例糖尿病病人,比較七氟醚和異氟醚麻醉腦血管對二氧化碳的反應性。麻醉用1.0 MAC的七氟醚或異氟醚並複合33%氧和67%笑氣。2.5-MHz的經顱多普勒超聲探頭緊貼病人右顳部連續測量大腦中動脈平均血流速度。測定大腦中動脈平均血流速度基礎值和心血管血液動力學參數後,通過減少呼吸頻率來增加呼末CO2,並重複測試。用以上的資料來計算絕對和相對的CO2反應性。與那些口服降糖藥和飲食療法的病人相比,無論用異氟醚還是七氟醚,絕對的CO2反應性都比用胰島素處理過的病人低(七氟醚組: 飲食療法 = 2.6 ± 0.6; 口服降糖藥 = 2.5 ± 0.8; 胰島素 = 1.6 ± 0.8*; 異氟醚組: 飲食療法= 3.3 ± i0.7; 口服降糖藥= 3.4 ± 0.7; 胰島素 = 1.9 ± 0.7* cm · s–1 · mm Hg–1; *P < 0.05)。相對CO2反應性顯示口服降糖藥和飲食療法的病人相同的模式,相對和絕對的二氧化碳的反應性七氟醚組要低於異氟醚組。因此作者推斷:無論在七氟醚還是異氟醚下,胰島素依賴病人腦血管的二氧化碳的反應性是受損害的。

(潘志英 陳傑 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-硬膜外聯合麻醉下行剖腹產時重比重布比卡因對產婦血液動力學的劑量依賴效應

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.

 

血壓下降是脊麻下剖腹產的一個重要的副作用。有證據表明降低脊麻藥的劑量對維持產婦血液動力學的穩定有明顯的作用。作者設計了隨機試驗以驗證這一假設——降低局部麻醉的脊麻藥的劑量可以產生相等的麻醉強度同時減輕產婦的低血壓。 50個待產婦隨機分配到兩個試驗組。在高劑量脊麻-硬膜外聯合麻醉組使用9.5 mg重比重布比卡因複合 2.5 µg蘇芬太尼;在低劑量脊麻-硬膜外聯合麻醉組使用6.5 mg重比重布比卡因複合 2.5 µg蘇芬太尼。收集人口統計學資料、產科資料、疼痛視覺類比評分、對疼痛進行藥物干預的次數,血液動力學等資料。與低劑量組相比,高劑量組病人經歷較為顯著且較長的低血壓期。平均最低收縮壓低劑量組高於高劑量組 (102 ± 16 88 ± 16; P < 0.05). 與低劑量組相比,在高劑量組中較多病人經歷低血壓期(68%16%; P < 0.05)。在高劑量組15個病人因為血壓過低需要藥物治療,而低劑量組只有5個。高劑量組病人的有效麻醉效果 (冷覺阻滯平面達T3或以上) 的時間比低劑量組的較長 (95 ± 25 min68 ± 18 min, P < 0.05)。結論:小劑量的脊麻藥用量 (6.5 mg重比重布比卡因複合蘇芬太尼)有利於維持產婦血流動力學的穩定,且具有相等的麻醉強度,只是縮短了藥物的作用時間。

(宋金超 陳傑 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.


非阿片類鎮痛藥帕瑞考昔(Parecoxib),撲熱息痛(Paracetamol),安乃近(Metamizol)對緩解腰椎間盤摘除術後疼痛的療效

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.

 

在這項前瞻性,雙盲,隨機,安慰劑對照的研究中,作者比較了三種靜脈非阿片類鎮痛藥緩解腰椎間盤摘除術後疼痛的療效。80名健康病人隨機分為四個治療組(n=20),分別在手術結束前45分鐘靜脈注射帕瑞考昔40mg,撲熱息痛1g,安乃近1g或安慰劑。在麻醉後監護室(PACU)中病人均使用呱腈米特進行病人自控鎮痛治療。安乃近組到達PACU的鎮痛評分顯著低於帕瑞考昔,撲熱息痛和安慰劑組。此外,安乃近組中需要額外PCA的病人數明顯少於其他三組。可是,根據在PACU中所記錄的PCA資料推算,在這四組中需要額外PCA的病人中,無論是首次需要呱腈米特的時間還是累計消耗呱腈米特量沒有顯著差別。在所有組中的副反應發生率很少。這些結果說明在接受椎間盤摘除術的病人中,緩解術後疼痛安乃近優於帕瑞考昔,撲熱息痛和安慰劑,且副反應最小。

(殷文淵 陳傑 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.

 

鞘內注射2-氯普魯卡因進行門診病人下肢手術的隨機、雙盲對照的臨床研究

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-氯普魯卡因腰麻下行擇期下肢手術的門診病人的劑量相關性。分別採用不含防腐劑的1%2-氯普魯卡因30mg30mg組,n15),40mg40mg組,n15),和50mg50mg組,n15)。研究結果發現,三組病人的麻醉起效時間相同。所有的病人均沒有改為全身麻醉完成手術。由於腰麻阻滯時間不足術中需要追加鎮痛藥的在30mg組有5例(35%),40mg組有2例(13%)(p0.014)。需要追加鎮痛藥的時間為30-60min,中數為40min。脊髓阻滯效果消失和運動恢復的時間在30mg組較快,為60[41-98]min85[45-123]min40mg組為85[46-141]min180[72-281]min50mg組為97[60-169]min185[90-355]minp0.001p0.003)。三組病人術後回家的時間沒有顯著差異,分別為30mg組:182[120-267]min40mg組為198 [123-271] min50mg組為203 [102-394] minP = 0.155)。在術後24小時和7天的隨訪過程中沒有發現一過性的神經症狀。總之作者認為,2-氯普魯卡因40mg50mg對於門診手術病人可以提供長達45-60min的足夠的脊髓麻醉時間,30mg脊髓麻醉的時間往往不足。

(蘇殿三 陳傑 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.


在紅細胞灌注的離體兔心中雷米芬太尼和舒芬太尼對冠脈和心肌的作用

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壓可能與心肌缺血的不良事件有關聯。儘管這些事件可很容易地歸結於冠脈灌注壓力的下降,我們還是檢驗了雷米芬太尼可直接影響冠脈血管收縮張力的假設。因此,我們評價了雷米芬太尼在離體兔心Langendorff模型上對冠脈和心肌的直接作用,並與濃度相近似的舒芬太尼引起之作用相比較。在全身麻醉下,快速分離新西蘭兔的心臟,建立紅細胞灌注的離體心臟模型。然後將心臟暴露于逐漸增量濃度(10-1000 nM)的雷米芬太尼(n = 10)或舒芬太尼(n = 8)。在每個濃度之間,將心臟恢復到基礎值狀態。記錄兩藥每個濃度的最大冠脈和心肌作用。兩組冠脈血流和心肌功能的基礎值相近似。雷米芬太尼和舒芬太尼均不引起顯著的冠脈和心肌作用。這些結果提示雷米芬太尼引起血流動力學紊亂時發生的心肌缺血,尤其在心臟病人,僅僅與外周血流動力學變化引起的冠脈灌注壓降低有關。

(馬皓琳 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.

 

 

右美托咪定在兒科心臟手術中的應用

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

 

我們檢驗了鹽酸右美托咪定(一種α2受體激動劑)在小兒心臟手術中減慢心率、降低動脈壓及降低神經內分泌反應的能力。在一項隨機安慰劑對照的研究中,將30個行開心手術的患兒隨機平分到兩組中。對照組接受生理鹽水,而治療組(DEX組)在10 min的時間內接受一個鹽酸右美托咪定初始的推注劑量(0.5 µg/kg),緊接著以0.5 µg · kg–1 · h–1的速度持續靜脈輸注。監測動脈壓、心率及迴圈中可的松、腎上腺素、去甲腎上腺素及血糖的連續濃度。與基礎值相比,輸注鹽酸右美托咪定後,切皮時動脈壓及心率明顯下降。在對照組中,從切皮到體外迴圈結束,患者的心率及動脈壓增加(P < 0.05)。與基礎值相比,兩組患者在劈胸骨後及體外迴圈後血漿中的可的松、腎上腺素、去甲腎上腺素及血糖濃度均明顯升高(P < 0.05)。然而,與DEX組相比,對照組中的數值明顯更高(P < 0.05)。結論:對於先心患兒的心臟矯治手術,術中輸注鹽酸右美托咪定能減輕血流動力學及神經內分泌對手術創傷及體外迴圈的反應。

(裘毅敏譯,馬皓琳 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.

 

 

近期的吸煙行為與術後噁心和嘔吐

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

 

 吸煙者通過未知的機制減少術後噁心和嘔吐(PONV)的風險性。如果保護與煙成分的急性影響有關,近期吸煙者將會受到最好的保護。我們試驗了這一假說,在吸煙者中,術後噁心與用呼出一氧化碳(CO)濃度來定量的最近吸煙相關。在這一觀察性研究中,140女性吸煙者術前測定呼出CO水平。在術後24小時評估PONV。術前CO和出恢復室時噁心評分之間沒有相關性(用Spearman等級相關評定)。發現術後24小時噁心和PONV史或者運動病史、術中止吐藥預防應用、麻醉的持續時間和麻醉後恢復室中阿片類的使用顯著相關。然而,術前CO水平和術後24小時的噁心之間沒有相關性。這些初步的資料提示吸煙減少PONV的作用與術前呼出CO水平沒有直接關係。

(彭中美    馬皓琳 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.

 

 

分子手性與麻醉II:仲醇對映體對離子通道功能作用的立體選擇性

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

 

 分子手性已經被提出作為鑒別相關分子靶作用和不相關分子靶作用的一個手段,但是對於揮發性麻醉藥這種檢驗方法的敏感性和特異性尚屬未知。我們使用了兩種麻醉效果(防止50%動物體動的MAC)具有結構選擇性的手性醇類麻醉藥(2-丁醇和2-戊醇)的對映體和對蛙卵母細胞作用無結構選擇性的己醇。每一個蛙卵母細胞表達三種麻醉敏感性離子通道之一: Twik相關脊髓鉀離子(TRESK)通道;γ氨基丁酸A型(GABAA)受體和N-甲基-d-天冬氨酸(NMDA)受體。我們採用電壓鉗技術,發現2-丁醇對任何通道的作用都不具有結構選擇性(例如,16 mM 2-丁醇R-)和S-)對映體分別減少通過NMDA受體的電流44% ± 3% [均數 ± 標準誤]37% ± 4%);2-戊醇對一種通道作用有結構選擇性(GABAA受體,兩種異構體分別使電流增加277% ± 20% 141% ± 30%);2-己醇對GABAANMDA受體的作用都具有結構選擇性(例如,分別可以使通過NMDA受體的電流減少19% ± 3% 43% ± 5%)。我們計算了在下列兩種情況下應用手性來檢驗麻醉藥物的相關性方法的敏感性和特異性:1)所有三個通道是MAC的有關調停者;2)沒有一個通道是MAC的調停者。由於在受體和整個動物實驗結果間沒有一致的相關性,這些敏感性和特異性的計算結果都很差。我們不建議採用手性結構作為吸入麻醉藥靶點的效應相關性的檢驗方法。

(顏濤 譯, 馬皓琳 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.

 

 

對正常或高反應性氣道的家兔注射肌松藥後的支氣管痙攣的發生

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

 

肌松藥會誘發術中的支氣管痙攣。我們描述了注射肌松藥後正常或高反應性氣道收縮的強度和短暫表現的特徵。在沒有處理過的家兔和已經對卵清蛋白的變應原致敏家兔,連續測定呼吸暫停的90s內的呼吸系統的氣道阻抗(Zrs)。開始記錄Zrs15秒後,按隨機順序分別注射司可林、美維庫銨或呱庫溴銨。然後在外源性組胺注射劑量逐漸增大時也分別測定Zrs。為了監測這些操作過程中的氣道力學變化,每2s的時間窗平均一次Zrs值,並且用模型裝置來測定氣道阻力(Raw)。致敏的家兔的氣道阻力的增加明顯大於未處理過的家兔。司可林組氣道阻力升高的最大幅度和最大變化速率分別是146% ± 29% 0.80 ± 0.12 cm H2O/L,美維庫銨組80% ± 25% 0.71 ± 0.13 cm H2O/L,呱庫溴銨變化最小(40% ± 12% 0.41 ± 0.04 cm H2O/L)。注射司可林或美維庫銨後,變應性致敏會引起嚴重的且迅速發展的支氣管痙攣。當存在支氣管高反應性時,注射司可林或美維庫銨時,應該考慮到這些有害的副作用。

(黃麗娜     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.

 

 

一個先進的麻醉學專業培訓計畫:專為社區麻醉醫師設計的臨床教育

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

 

我們為社區麻醉醫師設立了一個計畫,目的是評估他們的臨床水平,以及在最新的麻醉技術方面對他們進行額外的培訓。這個教育計畫針對的是先前已經接受過培訓者為進修目的、或有相當長時間沒有在臨床工作的需要進一步培養的麻醉醫師。所有的受訓人員都有有效的沒有限制的加利福尼亞行醫執照醫療事故保險。接近有一半的受訓人員在入會時在臨床工作,其他的人離開臨床工作1-9年不等。最初24個畢業生花了平均9周時間(範圍3–24周)的時間學習課程,以達到其個人設定的目標。完成課程之後平均15個月,我們跟蹤調查了畢業生。所有的回答者都指出他們將再次參加這樣的培訓,80%的人認為他們學到了新的技術上的技能,73%的聲明這個課程讓他們瞭解了更多種不同的藥物,50%的人認為這個課程讓他們改變了治療病人的方式。這個計畫可以作為任何一種醫學訓練的模式,尤其是在要求從業者需要很強的技術技能的那些領域。

(張瑩 譯 馬皓琳 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:強離子酸中毒中的一種?

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

 

血漿碳酸氫鹽減少與高氯性酸中毒及乳酸性酸中毒有關。根據Stewart推論的酸堿生理,強離子差調整血漿碳酸氫鹽,氯化物和乳酸鹽是臨床化學中唯獨常規測得的強離子。我們假設,不管有或者沒有乳酸,血漿強離子差都比單獨的血漿氯化物與血漿碳酸氫鹽更有關。我們用了300個重症病人的血漿酸堿數據。與碳酸氫鹽的相關性逐漸減弱(P<0.001):所有檢測的強離子,r = 0.60;檢測強離子沒有檢測乳酸鹽,r = 0.42;單獨氯化物,r = –0.27。在有傳統的高氯性酸中毒(BE < –2mmol/L,陰離子間隙<17 mmol/L) 26個病人的一個亞群裏,檢測的強離子差(沒有乳酸鹽),比起氯化物與碳酸氫鹽有較強的相關性(P < 0.001)r = 0.85r =–0.60。結論,高氯性酸中毒和乳酸性酸中毒都是強離子酸中毒。應該認為高氯血症與血漿強陽離子有關。現實的結論是,通過靜脈液體治療來管理和預防酸堿紊亂都包括了調節血漿強離子,尤其是鈉和氯離子。

 (張曦   馬皓琳 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.

 

 

經蝶骨手術術後噁心嘔吐與疼痛:一項877例病人的資料回顧

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

 

儘管大量研究已評價了經幕上和幕下途徑行顱骨切除術術後噁心嘔吐及疼痛,但對於經蝶骨路徑有關的術後噁心嘔吐及疼痛,還鮮有資料報導。因此,我們回顧了同一術者經蝶骨手術的877例病人的圍術期記錄。術後嘔吐的總發生率為7.5%,明顯低於大多數研究得出的神經外科病人發生率。術中腦脊液的滲漏及隨後的脂肪移植術、腰穿針的應用及行顱咽管瘤切除的病人,術後嘔吐發生率均明顯增加(分別為11.4%、17.1%和18%)。有趣的是,預防性應用止吐藥並不能減少總的或任一群病人的嘔吐發生率;但氟呱利多和恩丹西酮都能減少術後恢復室(PACU)內病人噁心的發生率。關於疼痛及嗎啡消耗量方面,後來發展為尿崩症的病人在PACU對嗎啡的需要量明顯增加。尚無其他疾病狀態與PACU內病人疼痛及嗎啡消耗量增加相關。

(邱鬱薇 馬皓琳 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.

 

腎上腺素對左旋布比卡因聯合舒芬太尼硬膜外分娩鎮痛的影響

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

 

在這個前瞻隨機雙盲實驗中,我們研究了腎上腺素是否增高左旋布比卡因聯合舒芬太尼硬膜外分娩鎮痛的功效。70位分娩期產婦接受硬膜外含或不含1:800,000腎上腺素的 0.125%布比卡因聯合0.75 μg/mL 舒芬太尼注射,10ml起始劑量後啟動病人自控鎮痛泵。比較兩組間每小時及總用藥量、VAS疼痛評分、感覺及運動神經阻滯、分娩持續時間、.生命體征、母嬰結果及副作用。如果產婦在研究過程中沒有得到足夠鎮痛,即使10ml補救劑量後,則排除於進一步研究並給予10ml1:800,000腎上腺素的 0.125%布比卡因聯合0.75 μg/mL 舒芬太尼混合液。腎上腺素組15分鐘及20分鐘時的每小時用藥量、補救劑量及疼痛評分均較低。腎上腺素組運動神經阻滯發生率和第二產程持續時間有較高趨勢,且與1分鐘及5分鐘時較低的Apgar評分相關。這些發現提示加入腎上腺素加強硬膜外左旋布比卡因聯合舒芬太尼的作用,但可引起更多運動神經阻滯。

(黃佳佳譯, 馬皓琳,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.

 

 

運用核磁共振機能成像技術測量嗎啡對首次使用阿片類藥物的健康志願者的中樞神經系統回路的影響

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

 

在這個初步研究中,我們運用核磁共振機能成像技術(fMRI)來研究嗎啡對8位首次使用阿片類藥物的健康志願者的作用。在核磁共振機能成像的掃描下靜脈內給予志願者小劑量的嗎啡(4 mg/70 kg)或生理鹽水。給予嗎啡而非鹽水引發了輕微的欣快感而沒有令人厭惡的症狀,而且在包括伏核、通過近雙凸透鏡延展開的杏仁核、眶額皮質和海馬區在內的反饋結構引發了正性的信號改變。在伏核出現的正性信號與以前報導的由傷害性刺激引起的信號相反。嗎啡在皮質區通過與鎮靜催眠藥物諸如異丙酚或咪唑安定類似的方式產生了一個有所減弱的信號。在中腦導水管周圍灰質、帶狀前回(減弱的信號)和丘腦下部(增強的信號)觀察到內源性鎮痛區域的啟動作用。反饋回路中的啟動模式與報導的濫用使人欣快藥物相似,提供了評價嗎啡對涉及成癮的中樞神經系統回路成分的最初作用的一個模型。在皮質區相對於皮質下區域觀察到一個分離的fMRI反應,提示了來自感覺-運動和認知功能的反饋的分離。啟動模式與以前在µ拮抗劑納洛酮觀察到的相反。

(姜旭暉譯 馬皓琳,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.

 

 

持續性膕神經阻滯的可行性和併發症:1001例病例的調查研究

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

 

神經周圍導管被越來越廣泛地應用於整形外科術後疼痛的治療。與留置神經周圍導管有關的遠期併發症尚研究甚少。我們調查了持續性膕神經阻滯的功效和與其相關的急、慢性併發症。預期性評估1001例行踝或足部擇期性手術並預定接受持續性膕神經阻滯的患者。所有患者經導管給予初始推注劑量的0.5%羅呱卡因40ml。在給予初始推注劑量後6小時開始連續輸注0.3%羅呱卡因前24小時,然後減量到0.2%直至研究階段結束。記錄成功率和急性併發症。總成功率為97.5%。最高的成功率與頭低腳高位有關。急性併發症包括神經定位時的皮膚感覺異常(0.5%)、局部麻醉藥使用時的疼痛(0.8%)和血液抽吸(0.4%)。未發生中樞神經系統毒性和心臟毒性。術後10天和3周時檢查慢性併發症,包括兩例穿刺部位炎症。未觀察到感染和神經病。持續性膕神經阻滯應用於踝或足部手術有較高的成功率和極少的急、慢性併發症。

(唐李雋 馬皓琳 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.

 

心肺轉流術開始時使用亞甲藍的血流動力學效應

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

 

心肺轉流術(CPB)時發生低血壓,部分因為炎性反應的介導,氧化亞氮和鳥苷酸環化酶起重要作用。在這項研究中,我們驗證亞甲藍(MB)的血液動力學效應,鳥苷酸環化酶抑制劑,在心肺轉流術(CPB)時給使用了血管緊張素轉換酶抑制劑的患者使用。30名行心臟外科手術的患者在CPB 和心臟麻痹停搏後隨機分配接受MB(3 mg/kg)或生理鹽水(S)。在所用受試患者中CPB的處理相似。血液動力學資料在CPB之前、CPB時和CPB之後被收集。記錄所使用的血管加壓藥物。在CPB開始和心臟麻痹停搏時,所有受試患者平均動脈壓(MAP)和體循環血管阻力(SVR)有著相似的下降。MB增加MAPSVR,而且這種效應持續40分鐘。生理鹽水組在CPB整個過程MAPSVR持續下降。在CPB時生理鹽水組接受較多次數的苯腎上腺素,而且在CPB之後需要較多的去甲腎上腺素來維持所需的MAP。儘管相同或較高MAPSVRMB組血清乳酸鹽水平明顯較低。結論為,服用血管緊張素轉換酶抑制劑的患者在CPB後使用MB可以增加MAPSVR及減少血管加壓藥物的需求。此外,血清乳酸鹽水平在MB患者中較低,提示有更多有效地組織灌注。

(孫敏莉譯 薛張綱校)

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.

 

心肺轉流管理和神經系統預後:對目前實踐一項循證醫學評估

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.

 

高齡患者心臟手術後發生神經系統併發症已越來越重要。在這篇綜述裏,我們對目前CPB方案與神經系統併發症的發生之間的關係做了嚴格的分析。除了使用20-40µm的動脈導管濾膜和膜氧發生器,基本CPB儀的新型改進版或使用特殊裝置或方案(包括低溫和“嚴格”血糖控制)對神經系統的預後沒有更多的優勢。主動脈外超聲檢查可以用在升主動脈操作時,以避免動脈粥樣硬化產生的不良後果。雖然現有的臨床試驗認為這種操作價值有限。目前在CPB中控制血流、動脈壓和pH的措施得到了很多臨床觀察資料的支援。雖然有些資料證明一些阻滯興奮性氨基酸信號傳導通路和炎症反應藥物的優勢,目前沒有藥物被推薦用於CPB中進行神經保護。總之,這篇綜述的資料強調在CPB過程中指導醫生照顧患者的現有理論基礎存在缺陷。多中心臨床研究表明需要循證方案的發展以降低神經系統併發症,以避免患者發病率和死亡率的增加。

(金琳 薛張綱校)

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.

 

比較右旋美托咪定和異丙芬用於小兒磁共振檢查時鎮靜、血流動力學和呼吸的影響

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

 

我們比較了右旋美托咪定和異丙芬在小兒行磁共振時鎮靜、血流動力學和呼吸的影響。60個小兒隨機分成2組:右美托咪定組(D)給予1ug/kg初始劑量,隨後0.5ugkgh-1劑量連續輸注;異丙芬組(P)初始劑量3mg/kg,隨後100ugkgh-1連續輸注。磁共振檢查過程中,小兒體動導致很難完成磁共振檢查被認為是鎮靜不充分。研究過程中記錄平均動脈壓(MAP),心率,外周氧飽和度和呼吸頻率。在P組中,鎮靜起效時間,蘇醒時間和出院時間明顯短於D組。兩組MAP,心率和RR都低於基礎值。鎮靜過程中P組中MAPRR明顯低D組。P組中有4個小兒被發現氧飽和度降低。在大多數小兒中右旋美托咪定和異丙芬能提供充分的鎮靜。雖然異丙芬可產生快速的麻醉誘導和蘇醒,但它可能導致低血壓和去氧飽和度。因此,右旋美托咪定可能是又一可靠的鎮靜藥選擇。

(吳德華譯 薛張綱校)

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.

 

麻醉空間螺旋特性I:仲醇對映體的最低肺泡氣濃度

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.

 

既往許多關於吸入麻醉作用中空間螺旋特性研究都採用異氟烷對映結構。這些對映結構價格昂貴且數量稀少,這就限制了研究,例如對麻醉作用的分子靶標的初步證明之類的研究才能採用這些異構體來進行。我們假設仲醇(如含-CH2-CHOH-CH3基團的化合物)這一類的實驗性麻醉劑也可表現出對映結構選擇性。為驗證這個假設,我們測定了小鼠體內2-醇類(從2-丁醇到2-庚醇)同源系列對映結構的最低肺泡氣濃度(MAC)。因為這些醇類在實驗過程中部分地代謝為2-酮類(如含有-CH2-CO-CH3基團),我們分別測定這些2-酮類的MAC。假設酮類的MAC增加是由於醇類所致,在小鼠實驗中通過酮類的麻醉劑效應可以近似的測定醇類的MAC。我們發現2-丁醇和2-戊醇的異構體具有對映結構選擇性。S-(+)-2-丁醇的MAC值比它的R-(-)-對映體要高17%,而S-(+)-2-戊醇的MAC值比它的出R-(-)-對映體高出38%。在2-己醇和2-庚醇中沒有觀察到立體結構選擇性。這些發現使得對麻醉空間螺旋特性研究採用較便宜的揮發性化合物變得可行,特別是在體內環境下沒有代謝改變時更是如此。

(金 路譯 薛張綱校)

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.

 

長期蛛網膜下腔應用1-對氯苯酚-5甲氧基-2甲基-1H-吲哚-3醋酸(吲哚美辛):一項在動物模型中對神經毒性作用的評價

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.

 

軸索應用非甾體類抗炎藥被認為是治療頑固性疼痛的一種方法,但很少有證據表明,這樣應用吲哚美辛是否具有神經毒性作用。在該試驗中,我們評價了蛛網膜下腔給予吲哚美辛是否會對幾內亞豬造成組織學上的神經毒性。需要驗證的假設是“蛛網膜下腔給予吲哚美辛會損傷幾內亞豬的脊髓嗎?”10只雄性幾內亞豬被麻醉,聚酰胺導管和蛛網膜下腔的微量泵相聯,後者置於L2-3水平。試驗動物隨機分為2組,每組5只。連續14天持續注入吲哚美辛或生理鹽水(0.5 mL/h)。神經毒性由脊髓生理學測定。任何一組都沒有證據表明存在組織學毒性。這些資料指出,蛛網膜下腔注射該劑量的吲哚美辛不會造成脊髓典型的神經毒性。我們推論:硬膜外腔應用吲哚美辛可能是疼痛治療的另一可行方法,雖然其安全性還

有待證實。

(王麗珺譯 薛張綱校)

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天冬氨酸受體ε1亞型敲除小鼠中乙醇誘導的催眠耐受缺乏。

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

 

近來的藥理學研究顯示了N-甲基-D天冬氨酸受體(NMDA)在成癮性藥物(阿片類,安非他明和可卡因)發展的神經適應性過程中發揮著重要的作用。本實驗中,我們研究了NMDA受體對乙醇誘導的催眠耐受所起的作用。採用NMDA受體ε1亞型敲除小鼠。給單一劑量33.54g/kg乙醇注射後催眠敏感性在野生型小鼠和NMDA受體ε1亞型敲除小鼠之間沒有顯著的差別。雖然野生型小鼠在連續4天重複注射4g/kg乙醇後顯示催眠耐受,但與NMDA受體ε1亞型敲除小鼠在催眠持續時間上沒有明顯區別。在連續4天注射後兩組小鼠之間,體內乙醇清除也沒有明顯區別。我們的結果顯示,含有NMDA受體的ε1亞型可能涉及乙醇誘導的催眠耐受形成有關。

(吳德華譯 薛張綱校)

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.

 

住院醫生和麻醉醫師對基礎科學的態度

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,

 

標題事件的已知適用性在於對成人學習來說是一個必要的條件。態度是指影響學習者對個人行為選擇,從而決定學習行為發生可能性的內在狀態。這項研究的目的是描述和比較住院醫生和麻醉師對基礎科學和臨床實踐相關性的態度。給予105名住院醫師和142名麻醉醫師一個8項問卷調查。電子化收集資料。回答按5Likert量表評分。對住院醫生和麻醉醫師的回答做比較。儘管兩組中都觀察到了基礎科學與臨床實踐公認的相關性這一普遍模式,但麻醉醫師的等級要顯著高於住院醫生。兩組都深入強調在臨床實踐前對基礎科學的正規學習,但麻醉主治醫生的評分要顯著高於住院醫生。儘管評分中值低於量表的中位數,但住院醫生相比麻醉醫師來說大多贊成學習大體概念的淺顯途徑。兩組對教授基礎科學期間,在住院醫生令人興奮的好奇心中講師角色的評分都為量表的中值。兩組對他們的在職教育經歷都給予高度評價。

(徐麗穎譯 薛張綱校)

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.

 

硫酸嗎啡減輕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

 

硫酸嗎啡常用於那些需要手術干預來控制出血的病人。最近的資料顯示嗎啡作為一種免疫制約劑影響白細胞,增加感染率。此外,嗎啡釋放組胺——一種增加微血管通透性的炎性介質。嗎啡的這兩種作用均加重失血性休克後的炎症過程。本項研究中,我們評估了硫酸嗎啡在微血管通透性中的作用和它在失血性休克後的白細胞聚集作用。在一段對照期後,在烏拉坦麻醉的SD大鼠中把血分離出來降低平均動脈壓到40mmHg一小時。檢查小腸的透照節段腸系膜後毛細血管靜脈來定量通透性和白細胞聚集的改變。在控制期,大鼠接受了靜脈注射的用異硫氰酸螢光素標記的牛白蛋白。從異硫氰酸螢光素標記的牛白蛋白釋放出的螢光強度用數字顯微鏡在微血管腔內記錄,並與同時的腔外光強度比較。這些圖像下載到電腦化的圖像分析程式來定量估計光強度的變化。這些光強度的變化代表白蛋白的外滲。此外,明視野圖像記錄到壓縮光碟來重播以測定白細胞聚集。在100微米片斷的靜脈中穩態停留超過30秒認為白細胞聚集。我們的結果證明了異硫氰酸螢光素標記的牛白蛋白血管外漏明顯增加,白細胞在後毛細血管內皮的聚集增加。在休克期前給予硫酸嗎啡10 µg/kg減少失血性休克後的高通透性(P < 0.05)並增加白細胞聚集(P < 0.05)。這些結果說明與失血性休克後的加重的炎性反應不同,嗎啡能提供微血管的保護。

(周 荻譯 薛張綱校)

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.

七氟醚對大鼠大腦缺血再灌注神經元損傷和細胞凋亡因數表達的長期作用

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

我們觀察七氟醚對缺血再灌注大鼠大腦組織病理學損傷和凋亡關鍵蛋白的長期作用。64只雄性Sprague-Dawley大鼠被隨機的分為組1(芬太尼和N2O/O2,對照)和組22%七氟醚和O2/空氣)。缺血(45分鐘)是由阻塞單側的頸總動脈和出血性低血壓(平均動脈壓40 mm Hg)造成的。大鼠在1, 3, 7, and 28天後殺掉。大腦切片在蘇木精和曙紅染色下計數海馬的嗜曙紅細胞。啟動的激酶3和凋亡調控蛋白Bax, Bcl-2, Mdm-2 p53通過免疫染色來分析。在整個階段,七氟醚麻醉的大鼠中沒有發現嗜曙紅神經元,而在對照組發現了9%-38%的海馬神經元(128天)。在第1和第3天,對照組的Bax濃度比七氟醚組的大140%-200%。前3天對照組的Bcl-2濃度低100%。啟動的激酶在兩組中都存在(0.75%-2.2%)。這些資料都支援在大腦缺血再灌注損傷時七氟醚的神經保護作用。

(陸文清譯 薛張綱校)

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.

 

老年病人在腹部手術中以白蛋白為基礎的靜脈擴容治療的價值

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)治療低血容量的價值是有爭議的。其他相對較為便宜的選擇如羥乙基澱粉(HES)因為其副作用有時是不能使用的。我們選擇了50例病人,年齡均大於70歲,進行腹部手術,隨即輸5%HA,或者6%HES130/0.4),當平均動脈壓<60mmHg,中心靜脈壓<10mmHg時。血流動力學、炎症因數(IL-6)、內皮啟動分子(黏附分子)、凝血功能(血栓彈力圖)以及腎功能(相關蛋白)在誘導後、手術後、在ICU5h和術後第一天監測。HA組病人輸了3960+/-590mlHA,5070+/-1030ml林格氏液,HES組病人輸了3500+/-530HES4550+/-880ml林格氏液。總蛋白只有在HA組病人是正常的。兩組病人的血流動力學、凝血、腎功能無顯著差別。IL-6和黏附分子HA組顯著高於HES組。我們總結出HA在行腹部手術的老年病人中的應用可以被HES替代。由於降低的炎症反應和內皮啟動損傷,HES130/0.4是比較合適的。

(鍾 靜譯 薛張綱校)

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.

 

中樞神經系統疾病患者的椎管內麻醉及鎮痛

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.

 

椎管內麻醉技術在已患中樞神經系統疾病患者中的應用歷來被認為是相對禁忌的。除了機械性創傷,局麻藥的毒性反應及中樞神經缺血以外,害怕實施麻醉後神經病變加重也時常報導。我們調查了已患中樞神經系統疾病患者在接受了椎管內麻醉後的新的或進行性併發症的發生率。我們對Mayo診所從19882000年間的已患中樞神經系統疾病患者之後接受了椎管內麻醉或鎮痛的臨床病例進行回顧性分析。139位病人被納入此項研究。病人平均年齡為60+/-17歲。性別分佈為8662%)位男性比5338%)位女性。在實施麻醉時患者明確診斷有中樞神經系統疾病的平均年數為23+/-23年,有7453%)位病人是有神經症狀的。7554%)位病人接受了腰麻,5842%)位病人接受了硬膜外麻醉或鎮痛,43%)位病人接受了持續腰麻,21%)位病人接受了腰硬聯合麻醉。布比卡因是所有局麻藥中應用最多的。7252%)位病人的局麻藥中加入了腎上腺素。有1511%)例出現了併發症,主要是無意地導致了感覺過度和穿刺針導致的創傷。13698%)位病人的阻滯是滿意的。與術前相比較,術後未發現新的或加重的併發症(0.0%; 95%的可信區間, 0.0%-0.3%)。我們得出以下結論:椎管內麻醉或鎮痛相關的併發症在已患中樞神經系統疾病患者中的發生率並不如以前認為的那樣高,不應將椎管內麻醉作為此類患者的絕對禁忌症。

(王慧琳譯 薛張綱校)

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.

外周搏動指數是一種可靠而又早期的評價局部阻滯效果的監測手段

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

 

我們研究表明,用標準的手指氧飽和度探頭來監測外周搏動指數(PFI)可以作為一種早期而又有效的評價局部阻滯效果的監測手段。66名四肢手術病人,麻醉為臂叢或坐骨神經阻滯,用藥均為1.5%的甲呱卡因。所謂PFI就是在實施阻滯前10分鐘到阻滯後30分鐘採用氧飽和度探頭監測外周血管的搏動與非搏動之間的比值。而未被阻滯的四肢將同樣記錄PFI。當阻滯後30分鐘每間隔5分鐘測試病人的針刺覺和溫度感覺。我們發現當臂叢阻滯後10分鐘,坐骨神經阻滯後12分鐘 PFI值上升1.55,提示阻滯成功。PFI對於提示臂叢阻滯效果的敏感性和特異性為100%、陽性預測值與陰性預測值分別為95%93%。而對於坐骨神經阻滯而言,其敏感性和特異性分別為90%100%12分鐘時的陽性預測值與陰性預測值分別為94%92%。在15分鐘時臂叢阻滯對痛覺和溫度覺刺激的PFI的敏感性和特異性均為71%100%。而坐骨神經阻滯對溫度刺激的PFI的敏感性和特異性為77%100%、對痛覺刺激的PFI的敏感性和特異性分別為20%100%。我們由此得到的結論是PFI是一種簡單、早期而又客觀的對局部阻滯效果評價的手段。

(孫卓真譯 薛張綱校)

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.