Anesthesia & Analgesia

 

August 2006

Table of Content

 

CARDIOVASCULAR ANESTHESIA:

兔異氟醚延遲性預處理的性別特異性:內皮一氧化氮合成酶的潛在作用

(孫敏莉譯 薛張綱校)

Gender-Specificity of Delayed Preconditioning by Isoflurane in Rabbits: Potential Role of Endothelial Nitric Oxide Synthase

Chen Wang, Pascal C. Chiari, Dorothee Weihrauch, John G. Krolikowski, David C. Warltier, Judy R. Kersten, Phillip F. Pratt, Jr, and Paul S. Pagel

Anesth Analg 2006 103: 274-280

 

細胞外信號調節的激酶觸發異氟醚預處理伴隨大鼠低氧可誘導因數-和血管內皮生長因數表達的上調

(黃施偉 譯,馬皓琳 李士通 )

Extracellular Signal-Regulated Kinases Trigger Isoflurane Preconditioning Concomitant with Upregulation of Hypoxia-Inducible Factor-1{alpha} and Vascular Endothelial Growth Factor Expression in Rats

Chen Wang, Dorothee Weihrauch, David A. Schwabe, Martin Bienengraeber, David C. Warltier, Judy R. Kersten, Phillip F. Pratt, Jr, and Paul S. Pagel

Anesth Analg 2006 103: 281-288.

 

七氟醚對體外迴圈下主動脈瓣置換手術病人的心肌保護作用

(宋翠俠 陳傑 校)

Cardioprotective Properties of Sevoflurane in Patients Undergoing Aortic Valve Replacement with Cardiopulmonary Bypass

Stefanie Cromheecke, Veronik Pepermans, Ellen Hendrickx, Sur Lorsomradee, Pieter W. ten Broecke, Bernard A. Stockman, Inez E. Rodrigus, and Stefan G. De Hert

Anesth Analg 2006 103: 289-296

 

可樂定可降低局麻下行頸動脈內膜剝脫術患者的應激反應:前瞻、隨機、雙盲、安慰劑對照臨床研究

(金琳 薛張綱 審校)

Clonidine Decreases Stress Response in Patients Undergoing Carotid Endarterectomy Under Regional Anesthesia: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

Christine E. Schneemilch, Holger Bachmann, Anke Ulrich, Regine Elwert, Zuhir Halloul, and Thomas Hachenberg

Anesth Analg 2006 103: 297-302.

PEDIATRIC ANESTHESIA:

異丙酚/異氟烷麻醉下兒童的年齡對運動激發電位的影響

(唐李雋 馬皓琳  李士通 )

The Effect of Age on Motor Evoked Potentials in Children Under Propofol/Isoflurane Anesthesia

Jeremy A. Lieberman, Russ Lyon, John Feiner, Mohammad Diab, and George A. Gregory

Anesth Analg 2006 103: 316-321

 

兒童行Nuss術時硬膜外使用布比卡因-芬太尼和布比卡因-可樂定的比較

(曹瑜 陳傑 )

A Comparison of Epidural Bupivacaine-Fentanyl and Bupivacaine-Clonidine in Children Undergoing the Nuss Procedure

Giovanni Cucchiaro, Scott N. Adzick, John B. Rose, Lynne Maxwell, and Mehernoor Watcha

Anesth Analg 2006 103: 322-327

 

超聲指導下神經刺激穿刺導管運用于小兒臀下肌坐骨神經阻滯:一項敍述性研究

(吳德華譯 薛張綱校)

Ultrasound-Guided Subgluteal Sciatic Nerve Blocks with Stimulating Catheters in Children: A Descriptive Study

Geert Jan van Geffen and Mathieu Gielen

Anesth Analg 2006 103: 328-333.

ANESTHETIC PHARMACOLOGY:

大鼠術後疼痛模型中腦脊液和外周前列腺素E2水準上調

(周雅春 馬皓琳 李士通校)

Upregulation of Cerebrospinal Fluid and Peripheral Prostaglandin E2 in a Rat Postoperative Pain Model

Jeffrey S. Kroin, Asokumar Buvanendran, Daniel E. Watts, Chiranjeev Saha, and Kenneth J. Tuman

Anesth Analg 2006 103: 334-343.

 

健康志願者應用新型經鼻咪達唑侖製劑的藥代動力學和藥效動力學

(肖潔 陳傑 )

Pharmacokinetics and Pharmacodynamics of a New Intranasal Midazolam Formulation in Healthy Volunteers

Daniel P. Wermeling, Kenneth A. Record, Thomas H. Kelly, Sanford M. Archer, Thomas Clinch, and Anita C. Rudy

Anesth Analg 2006 103: 344-349.

 

異氟烷抑制羊失血後補償性血管內容量擴張

( 路譯 薛張綱校)

Isoflurane Inhibits Compensatory Intravascular Volume Expansion After Hemorrhage in Sheep

Robert G. Hahn, Lance Brauer, Peter Rodhe, Christer H. Svensén, and Donald S. Prough

Anesth Analg 2006 103: 350-358

 

機械通氣的家兔對異丙酚鎮靜作用的耐受性

 (黃麗娜    馬皓琳 李士通 )

Tolerance to Propofol’s Sedative Effect in Mechanically Ventilated Rabbits

Petros Ypsilantis, Dimitrios Mikroulis, Maria Politou, Heleni Tsoukali, Michail Pitiakoudis, Vasilios Didilis, Georgios Theodoridis, Georgios Bougioukas, and Constantinos Simopoulos

Anesth Analg 2006 103: 359-365

 

超臨床劑量的曲馬多立體選擇性削弱離體大鼠主動脈內皮細胞依賴性血管擴張

(趙延華 陳傑 校)

A Supraclinical Dose of Tramadol Stereoselectively Attenuates Endothelium-Dependent Relaxation in Isolated Rat Aorta

Il-Woo Shin, Ju-Tae Sohn, Kyeong-Eon Park, Ki Churl Chang, Ju-Young Choi, Heon-Keun Lee, and Young-Kyun Chung

Anesth Analg 2006 103: 366-371.

TECHNOLOGY, COMPUTING, AND SIMULATION:

評價通氣對脈搏氧飽和度儀影響的最佳位置是什麼?

(王麗珺譯,薛張綱校)

What Is the Best Site for Measuring the Effect of Ventilation on the Pulse Oximeter Waveform?

Kirk H. Shelley, Denis H. Jablonka, Aymen A. Awad, Robert G. Stout, Hoda Rezkanna, and David G. Silverman

Anesth Analg 2006 103: 372-377.

 

比較介入放射治療中雙譜指數(BIS)指導的和臨床上指導的雷米芬太尼/異丙酚的鎮痛/鎮靜水準:觀察者單盲隨機研究

(黃佳佳譯,馬皓琳 李士通 )

Bispectral-Index-Guided Versus Clinically Guided Remifentanil/Propofol Analgesia/Sedation for Interventional Radiological Procedures: An Observer-Blinded Randomized Study

Ashraf A. Dahaba, Ulrike Lischnig, Robert Kronthaler, Helmar Bornemann, Vassil Georgiev, Peter H. Rehak, and Helfried Metzler

Anesth Analg 2006 103: 378-384.

 

0.5%布比卡因硬膜外阻滯複合氧化亞氮鎮靜的麻醉中BIS指數與OAA/S評分沒有明顯的相關性

(劉哲 陳傑 校)

Bispectral Index Does Not Correlate with Observer Assessment of Alertness and Sedation Scores During 0.5% Bupivacaine Epidural Anesthesia with Nitrous Oxide Sedation

Kyung Soo Park, Eun Jin Hur, Kyung Woo Han, Ho Yeong Kil, and Tae Hyung Han

Anesth Analg 2006 103: 385-389.

CRITICAL CARE AND TRAUMA:

氯胺酮改善燒傷後膿毒血症的大鼠的生存率

(陸文清譯 薛張綱校)

Ketamine Improves Survival in Burn Injury Followed by Sepsis in Rats

Reuven Gurfinkel, David Czeiger, Amos Douvdevani, Yoram Shapira, Alan A. Artru, Yuval Sufaro, Julia Mazar, and Gad Shaked

Anesth Analg 2006 103: 396-402.

 

在植入心內除顫複律器過程中重複短暫心臟停搏後的神經元損傷伴隨認知功能障礙

(顏濤 譯, 馬皓琳 李士通 )

Neuronal Injury After Repeated Brief Cardiac Arrests During Internal Cardioverter Defibrillator Implantation Is Associated With Deterioration of Cognitive Function

Manuela Weigl, Andrea Moritz, Barbara Steinlechner, Isabella Schmatzer, Bruno Mora, Richard Fakin, Daniel Zimpfer, Hendrik J. Ankersmit, Cesar Khazen, and Martin Dworschak

Anesth Analg 2006 103: 403-409

NEUROSURGICAL ANESTHESIA:

異氟醚對大鼠重度前腦缺血預後呈劑量依賴效應

(潘志英 陳傑 )

The Dose-Dependent Effects of Isoflurane on Outcome from Severe Forebrain Ischemia in the Rat

Ikuko Nasu, Noriko Yokoo, Seiji Takaoka, Kosuke Takata, Tamie Hoshikawa, Masayuki Okada, and Yoshihide Miura

Anesth Analg 2006 103: 413-418.

 

吸入麻醉藥異氟醚在缺氧期間增強皮質神經元中Ca2+-依賴性存活信號表達並調節MAP激酶,凋亡蛋白和轉錄因數

(徐麗穎譯 薛張綱校)

The Inhaled Anesthetic, Isoflurane, Enhances Ca2+-Dependent Survival Signaling in Cortical Neurons and Modulates MAP Kinases, Apoptosis Proteins and Transcription Factors During Hypoxia

Philip E. Bickler and Christian S. Fahlman

Anesth Analg 2006 103: 419-429.

 

Sigma 1受體激動劑通過抑制可誘導的一氧化氮合酶起神經保護藥物的作用

(姜旭暉譯,馬晧琳 李士通 )

Sigma 1 Receptor Agonists Act as Neuroprotective Drugs Through Inhibition of Inducible Nitric Oxide Synthase

Kamila Vagnerova, Patricia D. Hurn, Anish Bhardwaj, and Jeffrey R. Kirsch

Anesth Analg 2006 103: 430-434.

OBSTETRIC ANESTHESIA:

低氧性胎盤血管收縮:人胎盤對低氧反應是漸進性的

(蘇殿三 陳傑 )

Hypoxemic Fetoplacental Vasoconstriction: A Graduated Response to Reduced Oxygen Conditions in the Human Placenta

Ramiah Ramasubramanian, Raymond F. Johnson, John W. Downing, Beth H. Minzter, and Ray L. Paschall

Anesth Analg 2006 103: 439-442.

 

揮發性麻醉藥對離體的人懷孕子宮肌自發性收縮的作用:七氟烷,地氟烷,異氟烷和氟烷的比較

(周荻譯 薛張綱校)

The Effects of Volatile Anesthetics on Spontaneous Contractility of Isolated Human Pregnant Uterine Muscle: A Comparison Among Sevoflurane, Desflurane, Isoflurane, and Halothane

Kyung Y. Yoo, Jun C. Lee, Myung H. Yoon, Min-HO Shin, Seok J. Kim, Yoon H. Kim, Tae B. Song, and JongUn Lee

Anesth Analg 2006 103: 443-447

GENERAL ARTICLES:

腹部大手術後國際標準化比值延長與血管內液體大平衡相關

(邱鬱薇 馬皓琳 李士通 )

Prolonged International Normalized Ratio Correlates with a Large Intravascular Fluid Balance After Major Abdominal Surgery

Michal Barak, Oded Jurim, Ronit Tal, and Yeshayahu Katz

Anesth Analg 2006 103: 448-452

 

喉罩在導絲擴張式氣管造口術中的應用

(印傑敏譯 陳傑 )

The Use of the Laryngeal Mask Airway During Guidewire Dilating Forceps Tracheostomy

Davide Cattano, Steven Abramson, Stefano Buzzigoli, Candido Zoppi, Ettore Melai, Francesco Giunta, and Carin Hagberg

Anesth Analg 2006 103: 453-457

 

對於只接受了基本訓練的第一個月的麻醉住院醫生,導引下放置喉罩優於傳統的氣管插管

(王慧琳譯 薛張綱校)

Guided Insertion of the ProSeal Laryngeal Mask Airway Is Superior to Conventional Tracheal Intubation by First-Month Anesthesia Residents After Brief Manikin-Only Training

Matthias Hohlrieder, Joseph Brimacombe, Achim von Goedecke, and Christian Keller

Anesth Analg 2006 103: 458-462.

PAIN MEDICINE:

多慮平漱口:對癌症治療導致口腔粘膜炎患者的鎮痛作用和疼痛減輕持續時間

(張瑩 譯 馬皓琳 李士通 校)

Oral Doxepin Rinse: The Analgesic Effect and Duration of Pain Reduction in Patients with Oral Mucositis Due to Cancer Therapy

Joel B. Epstein, Joshua D. Epstein, Matthew S. Epstein, Hal Oien, and Edmond L. Truelove

Anesth Analg 2006 103: 465-470.

 

{alpha}-1 {alpha}-2 腎上腺素受體在周圍咪唑啉和腎上腺素受體激動劑誘導的傷害感受中的發揮作用

(宋金超 陳傑 )

The Contribution of Alpha-1 and Alpha-2 Adrenoceptors in Peripheral Imidazoline and Adrenoceptor Agonist-Induced Nociception

Ahmet Dogrul, Ilke Coskun, and Tayfun Uzbay

Anesth Analg 2006 103: 471-477

 

異丙酚對γ氨基酸受體(A)β3亞單位突變的老鼠橋腦內注射福馬林後感受受傷的行為以及脊髓c-fos的表達的影響

(鐘靜譯,薛張綱校)

Propofol’s Effects on Nociceptive Behavior and Spinal C-Fos Expression After Intraplantar Formalin Injection in Mice with a Mutation in the Gamma-Aminobutyric Acid-TypeA Receptor ß3 Subunit

Austin W. Merrill, Linda S. Barter, Uwe Rudolph, Edmond I. Eger, II, Joseph F. Antognini, Mirela Iodi Carstens, and E. Carstens

Anesth Analg 2006 103: 478-483

兔異氟醚延遲性預處理的性別特異性:內皮一氧化氮合成酶的潛在作用Gender-Specificity of Delayed Preconditioning by Isoflurane in Rabbits: Potential Role of Endothelial Nitric Oxide Synthase

Chen Wang, Pascal C. Chiari, Dorothee Weihrauch, John G. Krolikowski, David C. Warltier, Judy R. Kersten, Phillip F. Pratt, Jr, and Paul S. Pagel .

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

Anesth Analg 2006 103: 274-280.

 

參照於心臟保護,雌性動物抵抗缺血再灌注損傷,部分是由於雌激素通過內皮一氧化氮合成酶(eNOS)增加一氧化氮產物。是否在雌性動物發生缺血預處理依然存在爭論。在雄性家兔,異氟醚的延遲性心肌預適應通過eNOS來調節,但在雌性動物,異氟醚是否有相似的保護作用還不清楚。我們已試驗了這樣的假說,在雌性家兔心肌梗死面積為性別特異性減少,但是這種內在的心臟保護作用破壞進一步異氟醚誘導延遲性預處理的有益效應。方法:家兔(n=115)經歷30分鐘的冠狀動脈閉塞和3小時再灌注,在試驗前一天有或無的吸入異氟醚1.0最低肺泡有效濃度2小時。家兔接受生理鹽水或非選擇性、選擇性誘導,或選擇性接受二乙基溴乙醯胺NOS抑制劑[N-硝基-L-精氨酸甲酯(L-NAME, 10mg/kg),氨基胍(AG, 300mg/kg),或7-硝基吲唑(7-NI, 50mg/kg),分別地]。結果:相對生理鹽水(45 ± 2%),在雄性動物異氟醚減少梗塞面積(平均值 ± sd,左心室區域危險度的26 ± 5%)。在雄性家兔L-NAME,但不是AG7-NI,破壞異氟醚誘導的保護作用(分別為41 ± 9, 24 ± 4 22 ± 2%)。雌性家兔與雄性相比,梗塞面積減少而且eNOS蛋白表達增多。有或無異氟醚預處理,梗塞面積在雌性家兔無改變(分別為27 ± 9 27 ± 10%)。在雌性家兔有或無異氟醚預處理,L-NAME,但不是AG7-NI,增加梗塞面積。結論:雌性性別誘導減少梗塞面積通過eNOS介導,但是在活體,在缺血和再灌注之前暴露於異氟醚(1.0MAC)不能產生額外的心臟保護作用。

(孫敏莉譯 薛張綱校)

INTRODUCTION: Female gender confers cardioprotection against ischemia-reperfusion injury, in part because estrogen enhances nitric oxide production by endothelial nitric oxide synthase (eNOS). Whether ischemic preconditioning occurs in females remains controversial. Delayed myocardial preconditioning by isoflurane is mediated by eNOS in male rabbits, but whether females are similarly protected by isoflurane is unknown. We tested the hypothesis that gender-specific reductions in myocardial infarct size occur in female rabbits, but that this inherent cardioprotection abrogates further beneficial effects of isoflurane-induced delayed preconditioning.

METHODS: Rabbits (n = 115) underwent a 30 min coronary artery occlusion and 3 h reperfusion with or without a 2 h administration of 1.0 minimum alveolar concentration isoflurane one day before experimentation. Rabbits received saline or a nonselective, selective inducible, or selective neuronal NOS inhibitor [N-nitro-L-arginine methyl ester (L-NAME, 10 mg/kg), aminoguanidine (AG, 300 mg/kg), or 7-nitroindazole (7-NI, 50 mg/kg), respectively].

RESULTS: Isoflurane reduced infarct size in males (mean± sd, 26 ± 5% of the left ventricular area at risk) versus saline (45 ± 2%). L-NAME, but not AG or 7-NI, abolished isoflurane-induced protection in males (41 ± 9, 24 ± 4 and 22 ± 2%, respectively). Infarct size was reduced, and eNOS protein expression was greater, in female versus male rabbits. Infarct size was unchanged in female rabbits with, versus without, isoflurane pretreatment (27 ± 9 and 27 ± 10%, respectively). L-NAME, but not AG or 7-NI, increased infarct size with or without isoflurane pretreatment in females.

CONCLUSIONS: Female gender-induced reductions in infarct size are mediated by eNOS, but remote isoflurane exposure (1.0 MAC) before ischemia and reperfusion does not produce additional cardioprotection in vivo.

 

可樂定可降低局麻下行頸動脈內膜剝脫術患者的應激反應:前瞻、隨機、雙盲、安慰劑對照臨床研究

Clonidine Decreases Stress Response in Patients Undergoing Carotid Endarterectomy Under Regional Anesthesia: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study

Christine E. Schneemilch, Holger Bachmann, Anke Ulrich, Regine Elwert, Zuhir Halloul, and Thomas Hachenberg

From the *Department of Anesthesiology and Intensive Care Medicine and {dagger}Department of Surgery, Otto-von-Guericke-University, Magdeburg, Germany.

Anesth Analg 2006 103: 297-302.

 

不充分的鎮痛或焦慮會增加局麻(RA)下行頸動脈內膜剝脫術(CEA)患者的應激反應。中樞α2腎上腺素受體激動劑有顯著的鎮靜和鎮痛作用,可能可以減弱CEA過程中交感腎上腺活性,而提高RA的品質。我們研究了80位患者,隨機分為2組,每組40人。一組RA加安慰劑;另一組RA加可樂定,初始劑量為1 µg/kg,維持劑量為1 µg ·kg–1 ·h–1RA均採用頸深叢複合頸淺叢阻滯。測量CEA前、中、後血流動力學和神經系統變數。在特定的時間點采動脈血樣測量血漿腎上腺素、去甲腎上腺素、皮質醇、肌酸酶和CKMB濃度。在這項研究中,所有的患者均配合進行神經系統評估。兩組間鉗夾前和鉗夾過程中的平均動脈壓和心率無明顯差異。但是可樂定組患者縫皮和術後ICU中平均動脈壓明顯較低(P < 0.01)。安慰劑組患者皮質醇、腎上腺素、去甲腎上腺素的血漿濃度明顯升高(P < 0.05),並且有更多的患者需要使用抗高血壓治療(P < 0.01)。可樂定組患者術後高血壓的發生率(P < 0.01)和神經系統缺陷的發生率(P < 0.05)明顯減少。我們認為,1 µg ·kg–1 ·h–1可樂定在CEA手術中可抑制高腎上腺素反應,而不增加血流動力學和臨床神經系統監測的副作用。

(金琳 薛張綱 審校)

Inadequate analgesia or anxiety may induce an increased stress response in patients undergoing carotid endarterectomy (CEA) under regional anesthesia (RA). Central {alpha}2 adrenoceptor agonists have significant sedative and analgesic properties, which may attenuate sympathoadrenal activation during CEA and improve the quality of RA. We randomly assigned 80 patients to 2 groups receiving either RA plus placebo (n = 40) or RA plus clonidine 1 µg/kg as the initial loading dose followed by 1 µg ·kg–1 ·h–1 (n = 40). RA was performed as combined deep and superficial cervical plexus blockade. Hemodynamic and neurological variables were assessed before, during, and after CEA. Arterial blood samples were collected at defined time points for the determination of plasma concentrations of epinephrine, norepinephrine, cortisol, and creatinine kinase and creatinine kinase-MB. Throughout the study, all patients responded easily to neurological evaluations. Before and during clamping mean arterial blood pressure and heart rate were not different between the groups, but mean arterial blood pressure was lower in the clonidine group (P < 0.01) at skin closure and postoperatively in the intensive care unit. In the placebo group, cortisol, epinephrine, and norepinephrine plasma concentrations were increased significantly (P < 0.05) and more patients required antihypertensive treatment (P < 0.01). Postoperatively the incidence of hypertension (P < 0.001) and development of neurological deficits (P < 0.05) was significantly decreased in the clonidine group. We conclude that 1 µg ·kg–1 ·h–1 clonidine suppresses the hyperadrenergic response to CEA without adverse effects on hemodynamics or clinical neurological monitoring.

 

 

超聲指導下神經刺激穿刺導管運用于小兒臀下肌坐骨神經阻滯:一項敍述性研究

Ultrasound-guided subgluteal sciatic nerve blocks with stimulating catheters in children: a descriptive study.

van Geffen GJ, Gielen M.

Institute for Anesthesiology, Medical Centre, Radboud University, PO Box 9101, 6500 HB Nijmegen, The Netherlands.

Anesth Analg. 2006 Aug;103(2):328-33, table of contents

 

我們描述了在小兒聯合運用超聲和神經刺激指導臀下肌坐骨神經穿刺放置導管的臨床經驗。選擇10例準備行下肢手術的患兒,為了術中麻醉和術後鎮痛行全身麻醉和臀下肌坐骨神經穿刺放置導管。在超聲指導下,通過17G50mm的連續外周神經阻滯針和19G的刺激導管放置坐骨神經導管。在患兒中,用於刺激穿刺針和導管獲得肌肉收縮的最小電流有很大的不同。在注射局麻藥進入導管期間,通過可視的局麻藥阻滯範圍,來預測坐骨神經阻滯的成功。所有的導管都被成功的放置,並且提供了完善的術後鎮痛,未見併發症。

(吳德華譯 薛張綱校)

We describe our clinical experience of combining ultrasound guidance and nerve stimulation for the insertion of subgluteal sciatic catheters in children. Ten children scheduled for lower limb surgery with a combined general anesthetic and a subgluteal sciatic catheter placement for both operative anesthesia and postoperative pain relief were studied. Under ultrasonographic guidance the sciatic catheter was placed using an 17-gauge 50-mm Arrow continuous peripheral nerve block needle and a 19-gauge stimulating catheter (Stimucath). The minimal electrical current required for muscle contraction on the stimulating needle and catheter differed widely among patients. Based on the visualization of the spread of local anesthetic during injection through the catheter, a successful prediction for the sciatic block was made in all patients. All catheters were successfully placed and provided excellent postoperative pain relief without complications.

 

 

異氟烷抑制羊失血後補償性血管內容量擴張

Isoflurane Inhibits Compensatory Intravascular Volume Expansion After Hemorrhage in Sheep

Robert G. Hahn, MD, PhD*, Lance Brauer, MD{dagger}, Peter Rodhe*, Christer H. Svensén, MD, PhD{ddagger}, and Donald S. Prough, MD§

From the *Karolinska Institute, Stockholm, Sweden; {dagger}Anesthesia Investigational Intensive Care Unit, {ddagger}Department of Anesthesiology, §Professor and Rebecca Terry White Distinguished Chair of Anesthesiology, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, Texas.

Address correspondence to Robert G. Hahn, MD, PhD, Department of Anesthesiology, Karolinska Institute at Soder Hospital, 118 83 Stockholm, Sweden.

Anesth Analg 2006 103: 350-358.

 

在失血後,通過跨毛細血管壁再充盈,血容量可以得到部分的恢復,我們認為這一自發性補償性血管內容量擴張過程會被麻醉所抑制。六隻模型羊在清醒或異氟烷麻醉狀態下進行四個隨機安排的實驗。用靛青綠測定血容量後,將15%45%的血容量抽出。假定跨毛細管壁再充盈會稀釋血紅蛋白濃度,用品質平衡和動態計算反復測量血紅蛋白濃度來量化跨毛細管壁再充盈程度。在失血15%的情況下,清醒和異氟烷麻醉下的羊的平均動脈壓都保持平穩(正常血壓出血),但在出血45%的情況下,平均動脈壓都降低(低血壓出血)。在正常血壓出血和低血壓出血後前40分鐘內的跨毛細血管再充盈遠較其後的140分鐘內迅速(P < 0.001)。在清醒的羊,出血後180分鐘時,正常血壓出血的57%容量恢復,低血壓出血的42%容量恢復,相應的異氟烷麻醉下的羊分別只有13%27%血容量的恢復(P < 0.001)。這一新的動態模型提示血流動力學因素導致早期快速跨毛細血管壁再充盈,而隨後的血漿滲透壓降低使得再充盈減慢。我們得出結論,異氟烷麻醉抑制羊正常血壓出血和低血壓出血後的跨毛細血管壁再充盈。

(金 路譯 薛張綱校)

After hemorrhage, blood volume is partially restored by transcapillary refill, a process of spontaneous compensatory intravascular volume expansion that we hypothesized would be inhibited by anesthesia. Six chronically instrumented sheep were subjected to four randomly ordered experiments while conscious or during anesthesia with isoflurane. After plasma volume measurement (indocyanine green), 15% or 45% of the blood volume was withdrawn. To quantify transcapillary refill, mass balance and kinetic calculations utilized repeated measurements of hemoglobin concentration, assuming that transcapillary refill would dilute hemoglobin concentration. After 15% hemorrhage, mean arterial blood pressure remained stable in both conscious and isoflurane-anesthetized sheep (normotensive hemorrhage) but decreased after 45% hemorrhage (hypotensive hemorrhage). After either normotensive or hypotensive hemorrhage, transcapillary refill occurred more rapidly during the first 40 min than during the next 140 min (P < 0.001). In conscious sheep, at 180 min, 57% and 42% of the bled volume had been restored after normotensive and hypotensive hemorrhage, respectively, in contrast to only 13% and 27% (P < 0.001) in isoflurane-anesthetized sheep. A novel kinetic model implicated hemodynamic factors in rapid, early transcapillary refill and decreased plasma oncotic pressure in subsequent slower filling. We conclude that isoflurane inhibits transcapillary refill after both normotensive and hypotensive hemorrhage in sheep.

 

評價通氣對脈搏氧飽和度儀影響的最佳位置是什麼?

What Is the Best Site for Measuring the Effect of Ventilation on the Pulse Oximeter Waveform?

Kirk H. Shelley, Denis H. Jablonka, Aymen A. Awad, Robert G. Stout, Hoda Rezkanna, and David G. Silverman

Department of Anesthesiology, Yale University, New Haven, Connecticut, USA.

Anesth Analg 2006 103: 372-377.

 

心搏是脈搏氧飽和度儀波形的主要特徵。通氣對於波形的影響尚不明確。已有學者研究了通氣對波形的影響以確定呼吸頻率、潮氣量和血容量。該試驗選擇三個不同位置:手指、耳垂和前額,測定了通氣對反射性體積描計波形影響的相對強度。體積描計波形來自18名術中接受正壓通氣的病人和10名腎臟透析時自主呼吸的病人。光譜分析顯示,呼吸信號和波形是獨立的。前額和手指相比,前者脈搏氧飽和度波形中呼吸信號的強度是後者的10倍以上。在正壓通氣和自主呼吸的病人中均是如此。耳垂測得的體積描計數據證實了術中估計失血量和通氣的影響具有顯著的相關性(r(s) = 0.624, P = 0.006)

(王麗珺譯,薛張綱校)

The cardiac pulse is the predominant feature of the pulse oximeter (plethysmographic) waveform. Less obvious is the effect of ventilation on the waveform. There have been efforts to measure the effect of ventilation on the waveform to determine respiratory rate, tidal volume, and blood volume. We measured the relative strength of the effect of ventilation on the reflective plethysmographic waveform at three different sites: the finger, ear, and forehead. The plethysmographic waveforms from 18 patients undergoing positive pressure ventilation during surgery and 10 patients spontaneously breathing during renal dialysis were collected. The respiratory signal was isolated from the waveform using spectral analysis. It was found that the respiratory signal in the pulse oximeter waveform was more than 10 times stronger in the region of the head when compared with the finger. This was true with both controlled positive pressure ventilation and spontaneous breathing. A significant correlation was demonstrated between the estimated blood loss from surgical procedures and the impact of ventilation on ear plethysmographic data (r(s) = 0.624, P = 0.006).

 

 

氯胺酮改善燒傷後膿毒血症的大鼠的生存率

Ketamine improves survival in burn injury followed by sepsis in rats

Gurfinkel R, Czeiger D, Douvdevani A, Shapira Y, Artru AA, Sufaro Y, Mazar J, Shaked G

Department of Plastic Surgery, Soroka Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 84101, Israel.

Anesth Analg. 2006 Aug;103(2):396-402

 

曾經有報導,氯氨酮可以減少細胞因數的產物和改善大腸桿菌引起的膿毒血症的生存率。我們檢驗是否氯氨酮減少白介素(IL)6以及是否改善1)燒傷或2)燒傷合併膿毒血症24小時的生存率。氯氨酮(10 mg/kg)或生理鹽水在燒傷後1小時給予(1, 2, 5, 6),在燒傷後24小時給予( 3, 4)或在大腸桿菌接種時給予(7, 8)。記錄7天的死亡率,檢測血清中的IL-6在燒傷後6小時( 1-2),燒傷後30小時(3-4),或是在膿毒血症後6小時( 5-8)。單純燒傷:氯氨酮在燒傷後1小時馬上給予的而不是24小時給予的,減少燒傷引起的IL-6但不增加生存率。燒傷+膿毒血症:氯氨酮在燒傷後馬上給予的並不改善生存率和明顯減少膿毒血症誘導的IL-6的增加。相對的,氯氨酮在膿毒血症後馬上給予明顯改善生存率(46.1% vs 13.3%, P = 0.008)和減少IL-6 (72,640 +/- 40,990 vs 332,300 +/- 32,300 pg/mL, P = 0.008)。我們認為氯氨酮治療可以改善燒傷伴膿毒血症的生存率。這種有益的作用可能是通過干擾了炎症反應鏈,因為有證據表明促炎標記IL-6的減少。

(陸文清譯 薛張綱校)

Ketamine was reported to decrease cytokine production and improve survival after Escherichia coli-induced sepsis. We examined whether ketamine decreased interleukin (IL)-6 production and improved survival after 1) burn injury or 2) burn injury combined with sepsis (E. coli) at 24 h. Ketamine (10 mg/kg) or saline was given at 1 h after burn injury (G 1, 2, 5, 6), 24 h after burn injury (G 3, 4), or at E. coli inoculation (G 7, 8). Mortality was recorded for 7 days and IL-6 was measured in serum at 6 h after burn (G 1-2), 30 h after burn (G 3-4), or 6 h after sepsis (30 h after burn) (G 5-8).Burn injury only: Ketamine given immediately (1 h) after burn injury but not 24 h after, decreased the burn-induced increase of IL-6 but did not improve survival. Burn injury + sepsis: Ketamine given immediately after burn injury did not significantly decrease the sepsis-induced increase of IL-6 or improve survival. In contrast, ketamine given immediately after sepsis significantly improved survival (46.1% versus 13.3%, P = 0.008) and decreased IL-6 production (72,640 +/- 40,990 vs 332,300 +/- 32,300 pg/mL, P = 0.008). We conclude that ketamine therapy improves survival in burn injury followed by sepsis. This beneficial effect is probably achieved through interference with the inflammatory cascade, as evidenced by attenuation of the proinflammatory marker IL-6.

 

 

吸入麻醉藥異氟醚在缺氧期間增強皮質神經元中Ca2+-依賴性存活信號表達並調節MAP激酶,凋亡蛋白和轉錄因數

The inhaled anesthetic, isoflurane, enhances Ca2+-dependent survival signaling in cortical neurons and modulates MAP kinases, apoptosis proteins and transcription factors during hypoxia

Bickler PE, Fahlman CS.

Severinghaus-Radiometer Research Laboratories, Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, California 94143-0542, USA. bicklerp@anesthesia.ucsf.edu

Anesth Analg. 2006 Aug;103(2):419-29, table of contents

 

我們檢驗了吸入麻醉藥異氟醚對缺氧神經元的保護是否與MAP激酶和凋亡抑制因數的Ca2+依賴性磷酸化相關。在鼠皮質神經元培養中我們測定了缺氧或缺氧聯合異氟醚(1%氣相)後Ca2+依賴性和非Ca2+依賴性MAP激酶,轉錄因數和凋亡因數的磷酸化的改變。在缺氧神經元中,異氟醚減少>80%的細胞死亡和TUNEL著色。異氟醚釋放細胞內儲存的Ca2+,在氧化神經元中增加[Ca2+]i20%。神經元保護與缺氧神經元中[Ca2+]i的輕度增加相關,且需要IP3受體和磷脂酶C。在缺氧神經元中,異氟醚增加了Ca2+依賴性MAP激酶Pyk2 p42/44 (ERK)的磷酸化。非Ca2+依賴性MAP激酶p38途徑顯示了異氟醚而不是Ca2+載體ionomycin的磷酸化作用。異氟醚存在下缺氧神經元中JNK被磷酸化,轉錄因數c-Jun亦然;SP600125所致的JNK抑制可阻止c-Jun的磷酸化和神經元保護。異氟醚減少促凋亡因數Bad p90RSK的磷酸化並增加Akt磷酸化。然而,除了c-Jun,轉錄因數(Elk-1, GSK-3, Forkhead, p90RSK)減少或保持不變。可以推斷,異氟醚對缺氧皮質神經元的保護涉及的信號包括細胞內Ca2+調節,多種MAP激酶途徑和凋亡因數的調節的改變。

(徐麗穎譯 薛張綱校)

We tested whether the protection of hypoxic neurons by the inhaled anesthetic isoflurane is related to the Ca2+-dependent phosphorylation of MAP kinases and anti-apoptotic co-factors. In cultures of mouse cortical neurons we measured changes in the phosphorylation of Ca2+-dependent and Ca2+-independent MAP kinases, transcription factors, and apoptosis regulators after hypoxia or hypoxia combined with isoflurane (1% in gas phase). In hypoxic neurons, isoflurane reduced cell death and TUNEL staining by >80%. Isoflurane released Ca2+ from intracellular stores, increasing [Ca2+]i in oxygenated neurons by approximately 20%. Neuroprotection was associated with a smaller increase in [Ca2+]i in hypoxic neurons and required IP3 receptors and phospholipase C. In hypoxic neurons, isoflurane increased the phosphorylation of the Ca2+-dependent MAP kinases Pyk2 and p42/44 (ERK). The Ca2+-independent MAP kinase p38 pathway showed increased phosphorylation with isoflurane but not with ionomycin, a Ca2+ ionophore. JNK was phosphorylated in hypoxic neurons in the presence of isoflurane, as was the transcription factor c-Jun; JNK inhibition with SP600125 prevented both phosphorylation of c-Jun and neuroprotection. Isoflurane decreased phosphorylation of the pro-apoptotic cofactors Bad and p90RSK and increased Akt phosphorylation. However, with the exception of c-Jun, transcription factors (Elk-1, GSK-3, Forkhead, p90RSK) decreased or remained unchanged. We conclude that isoflurane's protection of hypoxic cortical neurons involves signaling that includes changes in intracellular Ca2+ regulation, several MAP kinase pathways and modulation of apoptosis regulators.

 

 

揮發性麻醉藥對離體的人懷孕子宮肌自發性收縮的作用:七氟烷,地氟烷,異氟烷和氟烷的比較

The Effects of Volatile Anesthetics on Spontaneous Contractility of Isolated Human Pregnant Uterine Muscle: A Comparison Among Sevoflurane, Desflurane, Isoflurane, and Halothane

Kyung Y. Yoo, Jun C. Lee, Myung H. Yoon, Min-HO Shin, Seok J. Kim, Yoon H. Kim, Tae B. Song, and JongUn Lee

Department of Anesthesiology, Chonnam National University Medical School, 5 Hak-dong, Gwangju 501-746, Korea.

Anesth Analg 2006 103: 443-447.

 

我們檢測了等效濃度七氟烷,地氟烷,異氟烷和氟烷對離體人類子宮肌自發性收縮的作用。我們也探討了是否他們的作用與鉀通道有關。子宮樣本取自正常足月的行擇期下腹部剖腹產的懷孕婦女。縱行肌束垂直包埋在組織腔內。記錄它們暴露於0.5-3MAC揮發性麻醉藥下,在沒有或有高電導的鈣啟動的鉀通道阻滯劑,四乙銨,或三磷酸腺苷敏感的鉀通道(K(ATP))阻滯劑,格列本尿素情況下的等長張力。麻醉藥產生了劑量依賴性的收縮抑制。七氟烷和地氟烷的抑制效能是相似的,異氟烷較弱,氟烷最弱。產生抑制50%收縮幅度的濃度(ED(50))分別是1.72, 1.44, 2.351.66 MAC (P < 0.05)四乙銨和格列本脲不影響子宮對麻醉藥的反應,除了格列本脲會消除對異氟烷的反應。這些結果顯示揮發性麻醉藥對人類子宮收縮有抑制作用。異氟烷的抑制作用可能有一部分是通過啟動K(ATP) 通道產生的。

(周荻譯 薛張綱校)

We examined the effects of equianesthetic concentrations of sevoflurane, desflurane, isoflurane, and halothane on the spontaneous contractility of isolated human pregnant uterine muscles. We also determined if their action was related to potassium channels. Uterine specimens were obtained from normal full-term pregnant women undergoing elective lower-segment cesarean delivery. Longitudinal muscle strips were mounted vertically in tissue chambers. Their isometric tension was recorded while they were exposed to 0.5-3 minimum alveolar concentration (MAC) of volatile anesthetics in the absence and presence of the high conductance calcium-activated potassium channel blocker, tetraethylammonium, or the adenosine triphosphate-sensitive potassium channel (K(ATP))-blocker, glibenclamide. The anesthetics examined produced a dose-dependent depression of contractility. The inhibitory potency of sevoflurane and desflurane was comparable to, whereas that of isoflurane was smaller than, that of halothane: concentrations causing 50% inhibition of the contractile amplitude (ED(50)) were 1.72, 1.44, 2.35, and 1.66 MAC (P < 0.05), respectively. Tetraethylammonium and glibenclamide did not affect the uterine response to the anesthetics, except for glibenclamide, which attenuated the response to isoflurane. These results indicate that the volatile anesthetics have inhibitory effects on the contractility of the human uterus. The inhibitory effect of isoflurane may in part be mediated through activation of K(ATP) channels.

 

 

對於只接受了基本訓練的第一個月的麻醉住院醫生,導引下放置喉罩優於傳統的氣管插管

Guided Insertion of the ProSeal Laryngeal Mask Airway Is Superior to Conventional Tracheal Intubation by First-Month Anesthesia Residents After Brief Manikin-Only Training

Matthias Hohlrieder, Joseph Brimacombe, Achim von Goedecke, and Christian Keller

Department of Anaesthesia and Intensive Care Medicine, Medical University Innsbruck, Austria.

Anesth Analg 2006 103: 458-462.

 

在以下的研究中,我們通過只接受了基本訓練的第一個月的麻醉住院醫生來比較兩種插管方式,即傳統的喉鏡暴露下氣管插管和喉鏡暴露、彈性橡膠探條導引下喉罩放置。五名無氣道管理經驗的第一個月的麻醉住院醫生,但要用上述方法完成200ASA12級的成人患者的插管和喉罩的放置。每位醫生要完成40例病人,每種方式20例,按隨機化原則分配。記錄下插管嘗試次數、有效氣道時間、壓力控制在12cm水柱時的通氣量、氣道損傷和技巧的獲得。資料經非盲觀察者採集。探條導引喉罩放置組在插管成功率(100%65%)和有效氣道時間(41+/-24秒比89+/62)上要優於喉鏡插管組(兩組P<0.0001)。在控制壓力通氣下探條導引喉罩放置組的呼氣量較大(730+/-170ml560+/-140ml),呼末CO2較低(33+/-4mmHg37+/-5mmHg)(兩組P<0.0001)。喉鏡插管組中喉鏡更易沾血(24%2%,P,0.0001)。有證據表明兩組在技術上均有收穫。我們得出結論:對於只接受過基本訓練的第一個月的麻醉住院醫生,喉鏡暴露、橡膠彈性探條導引下放置喉罩的方法在插管成功率、呼氣量和氣道損傷方面要優於傳統的喉鏡暴露下氣管插管法。心肺復蘇時,非專業人員在傳統插管失敗後可採用探條導引下放置喉罩。

王慧琳譯 薛張綱校)

In the following pilot study, we compared conventional laryngoscope-guided tracheal intubation (tracheal intubation) and laryngoscope-guided, gum elastic bougie-guided ProSeal laryngeal mask airway insertion (guided ProSeal) for airway management by first-month anesthesia residents after brief manikin-only training. Five first-month residents with no practical experience of airway management were observed performing these techniques in 200 ASA I-II anesthetized, paralyzed adults. Each resident managed 40 patients, 20 in each group, in random order. The number of insertion attempts, effective airway time, ventilatory capability during pressure-controlled ventilation set at 15 cm H2O, airway trauma, and skill acquisition were studied. Data were collected by unblinded observers. Insertion was more frequently successful (100% versus 65%) and effective airway time was shorter (41 +/- 24 s versus 89 +/- 62 s) in the guided ProSeal group (both P < 0.0001). Expired tidal volume was larger (730 +/- 170 mL versus 560 +/- 140 mL) and end-tidal CO(2) lower (33 +/- 4 mm Hg versus 37 +/- 5 mm Hg) in the guided ProSeal group during pressure controlled ventilation (both P < 0.0001). Blood staining was more frequent on the laryngoscope (24% versus 2%; P < 0.0001) in the tracheal intubation group. There was evidence for skill acquisition in both groups. We conclude that laryngoscope-guided, gum elastic bougie-guided insertion of the ProSeal laryngeal mask airway is superior to conventional laryngoscope-guided tracheal intubation for airway management in terms of insertion success, expired tidal volume, and airway trauma by first-month anesthesia residents after brief manikin-only training. The guided ProSeal technique has potential for cardiopulmonary resuscitation by novices when conventional intubation fails.

 

 

異丙酚對γ氨基酸受體(A)β3亞單位突變的老鼠橋腦內注射福馬林後感受受傷的行為以及脊髓c-fos的表達的影響

Propofol's effects on nociceptive behavior and spinal c-fos expression after intraplantar formalin injection in mice with a mutation in the gamma-aminobutyric acid-type(A) receptor beta3 subunit.

Austin W. Merrill, Linda S. Barter, Uwe Rudolph, Edmond I. Eger, II, Joseph F. Antognini, Mirela Iodi Carstens, and E. Carstens

Section of Neurobiology, Physiology and Behavior, University of California, Davis, Davis, California 95616, USA.

Anesth Analg 2006 103: 478-483

 

我們研究了異丙酚是否影響野生型老鼠和突變型老鼠(γ氨基酸受體(A)點突變,使得這些老鼠對異丙酚耐藥)在橋腦內注射福馬林後腰骶部脊髓感受受傷行為及fos樣免疫反應(FLI)。和橋腦內注射脂類藥物聯合福馬林的野生型老鼠相比,單注射異丙酚(30mg/kg IV)減少了福馬林引發的一期行為的最初2-3分鐘但不能改變2其行為或者脊髓FLI(64 +/- 19 細胞/)。對於橋腦內福馬林注射,大部分FLI被限制在同側脊髓淺表背角。接受60分鐘的異丙酚注射的野生型老鼠被麻醉了且不顯示出感受受傷的行為但FLI (58 +/- 11 細胞/節段)和其他野生型老鼠並沒有多大區別。接受30mg/kg異丙酚注射和橋腦內注射福馬林的突變型的老鼠沒有被麻醉且表現出感受受傷的行為。總的脊髓中的FLI47 +/- 29 細胞/節段。這些資料表明儘管異丙酚能產生麻醉作用,它不能抑制FLI(和感受受傷性行為相關),這和異丙酚沒有鎮痛作用這一特性相一致。

(鐘靜譯,薛張綱校)

We investigated whether propofol affected nociceptive behavior and fos-like immunoreactivity (FLI) in the lumbo-sacral spinal cord after intraplantar formalin injection in wild-type (WT) mice and in mutant mice harboring a point mutation of the gamma-aminobutyric acid type(A) receptor, which renders them resistant to propofol. Bolus injection of propofol (30 mg/kg IV) in WT mice reduced phase 1 formalin-evoked behavior over the initial 2-3 min but did not alter phase 2 behavior or spinal FLI (64 +/- 19 cells/section) compared with WT mice receiving intralipid vehicle plus intraplantar formalin (57 +/- 19 cells/section). Most FLI was restricted to superficial dorsal horn laminae ipsilateral to the formalin injection. WT mice receiving a 60-min propofol infusion were anesthetized throughout and did not display nociceptive behavior but had FLI (58 +/- 11 cells/section) that did not differ significantly from the other WT groups. Mutant mice receiving bolus injection of propofol (30 mg/kg) and intraplantar formalin were not anesthetized and exhibited nociceptive behavior. The total FLI in the spinal cord was 47 +/- 29 cells/section. These data indicate that although propofol produces anesthesia, it does not prevent the FLI that is associated with nociception, a finding consistent with propofol lacking analgesic properties.

 

七氟醚對體外迴圈下主動脈瓣置換手術病人的心肌保護作用

Cardioprotective Properties of Sevoflurane in Patients Undergoing Aortic Valve Replacement with Cardiopulmonary Bypass

Stefanie Cromheecke, MD*, Veronik Pepermans, MD*, Ellen Hendrickx, MD*, Sur Lorsomradee, MD*, Pieter W. ten Broecke, MD*, Bernard A. Stockman, MD{dagger}, Inez E. Rodrigus, MD, PhD{dagger}, and Stefan G. De Hert, MD, PhD*

From the Departments of *Anesthesiology and {dagger}Cardiac Surgery, University Hospital Antwerp, Belgium.

Anesth Analg 2006 103: 289-296.

冠脈手術患者吸入揮發性麻醉藥七氟醚有利於術後心肌功能的恢復,並減少肌鈣蛋白的釋放。作者研究七氟醚在主動脈狹窄患者行換瓣術(AVR)中是否有相同的心肌保護作用。30AVR手術病人隨機分成2組,一組靶控輸入異丙酚,另一組吸入七氟醚。圍術期通過肺動脈導管評估心臟功能。在左心室放置一個高度精密的壓力導管,用於連續48小時監測心臟的肌鈣蛋白濃度。七氟醚組體外迴圈後病人的每搏量和左室內壓上升最大速率顯著增加。在體外迴圈前後,七氟醚組增加心臟負荷對左室內壓上升最大速率的影響相似(體外迴圈前為1.3% ±8.6%,體外迴圈後1.0% ±5.4%);但是在異丙酚組,增加心臟負荷對左室內壓上升最大速率有明顯的抑制(體外迴圈前為0.1% ±4.9%,體外迴圈後為-8.2%+-4.4%)。異丙酚組,體外迴圈後心室舒張速率也明顯減慢,七氟醚組術後肌鈣蛋白水準較低。結果表明在AVR手術中吸入麻醉具有較好的心肌保護功能並減少肌鈣蛋白的釋放。

(宋翠俠 陳傑 校)

In coronary surgery patients the use of a volatile anesthetic regimen with sevoflurane was associated with a better recovery of myocardial function and less postoperative release of troponin I. In the present study we investigated whether these cardioprotective properties were also apparent in the cardiac surgical setting of aortic valve replacement (AVR) surgery for the correction of aortic stenosis. Thirty AVR surgery patients were randomly assigned to receive either target-controlled infusion of propofol or inhaled anesthesia with sevoflurane. Cardiac function was assessed perioperatively using a pulmonary artery catheter. Perioperatively, a high-fidelity pressure catheter was positioned in the left ventricle. Postoperative concentrations of cardiac troponin I were followed for 48 h. After cardiopulmonary bypass (CPB), stroke volume and dP/dtmax were significantly higher in the patients with sevoflurane. Post-CPB, the effects of an increase in cardiac load on dP/dtmax were similar to pre-CPB in the sevoflurane group (1.0 % ± 5.4% post-CPB versus 1.3% ± 8.6% pre-CPB) but more depressed in the propofol group (–8.2% ± 4.4% post-CPB versus 0.1% ± 4.9% pre-CPB). The rate of relaxation was significantly slower post-CPB in the propofol group. Postoperative levels of troponin I were significantly lower in the sevoflurane group. Our data indicate that the use of a volatile anesthetic regimen in AVR surgery was associated with better preservation of myocardial function and a reduced postoperative release of troponin I.

 

兒童行Nuss術時硬膜外使用布比卡因-芬太尼和布比卡因-可樂定的比較

A Comparison of Epidural Bupivacaine-Fentanyl and Bupivacaine-Clonidine in Children Undergoing the Nuss Procedure

Giovanni Cucchiaro, MD, Scott N. Adzick, MD, John B. Rose, MD, Lynne Maxwell, MD, and Mehernoor Watcha, MD From the Department of Anesthesiology and Critical Care Medicine and Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Anesth Analg 2006 103: 322-327.

 

硬膜外注入阿片類藥物雖然能產生有效的鎮痛,但多數患者有嚴重的副反應。目前可樂定是否能取代阿片類藥物並產生較少的副作用仍不清楚。在這項隨機試驗中,作者比較了硬膜外注入三種不同組合的布比卡因、芬太尼和可樂定(布比卡因+芬太尼,布比卡因+可樂定,布比卡因+芬太尼+可樂定)在行Nuss術的過程中,嘔吐和瘙癢的發生率以及鎮痛效果的差異。與布比卡因+芬太尼組(92%)和布比卡因+芬太尼+可樂定組(74%)相比,布比卡因+可樂定組副反應的發生率明顯較低(33%)(P0.004)。三組的術後鎮痛品質相似。沒有觀察到嚴重的併發症。結論:可樂定是一種有效而安全的硬膜外阿片類藥物的替代品。

(曹瑜 陳傑 校)

The administration of epidural opioids, though effective for producing analgesia, has severe side effects in most patients. It is unknown whether clonidine can effectively replace opioids and cause fewer side effects. We compared, in this randomized trial, the incidence of vomiting and pruritus as well as the analgesic profile of three different combinations of bupivacaine, fentanyl, and clonidine administered epidurally in patients undergoing the Nuss procedure: bupivacaine + fentanyl, bupivacaine + clonidine, bupivacaine + fentanyl + clonidine. The incidence of side effects was significantly less in the bupivacaine + clonidine group (33%) compared with the bupivacaine + fentanyl (92%) and bupivacaine + fentanyl + clonidine (73%) groups (P = 0.004). Quality of postoperative analgesia was similar in the three groups. No significant complications were observed. In conclusion, clonidine is an effective and safe alternative to epidural opioids.

 

健康志願者應用新型經鼻咪達唑侖製劑的藥代動力學和藥效動力學

Pharmacokinetics and Pharmacodynamics of a New Intranasal Midazolam Formulation in Healthy Volunteers

Daniel P. Wermeling, PharmD, FASHP*, Kenneth A. Record, PharmD*, Thomas H. Kelly, PhD{dagger}, Sanford M. Archer, MD{ddagger}, Thomas Clinch§, and Anita C. Rudy, PhD§

From the *University of Kentucky College of Pharmacy; {dagger}University of Kentucky College of Medicine; {ddagger}Division of Otolaryngology – Head & Neck Surgery, University of Kentucky A. B. Chandler Medical Center; §Intranasal Therapeutics, Inc., Lexington, Kentucky.

Anesth Analg 2006 103: 344-349.

本文作者對12名健康志願者進行標籤開放、隨機、三元交叉研究,評估單一劑量5mg的咪達唑侖在三種不同給藥方式下,即新式經鼻內給藥(IN)、肌注(IM)和靜脈內注射(IV)時藥代動力學和藥效動力學。IN給藥以噴霧方式用0.1mL單位劑量將藥物噴入兩側鼻孔。在每次給藥後的0-12小時內連續采血。使用高效液相技術和質譜法技術檢測咪達唑侖的血漿濃度。用無房室法分析藥代動力學參數。INIM咪達唑侖的平均生物利用度和百分比變異係數分別為72.512)和93.412)。IN時血藥濃度達到峰值的平均時間為10分鐘。不同給藥方式的不良事件很少,但是經鼻噴霧給藥有鼻咽部刺激,眼睛流淚和味道較差等不良報告。結果顯示咪達唑侖經鼻噴霧劑需進一步的研製。

(肖潔 陳傑 校)

We evaluated the pharmacokinetics and pharmacodynamics of single 5-mg doses of midazolam after administration of a novel intranasal (IN) formula, IM, and IV midazolam in an open-label, randomized, 3-way cross-over study in 12 healthy volunteers. IN doses were delivered as 0.1-mL unit-dose sprays of a novel formulation into both naris. Blood samples were taken serially from 0 to 12 h after each dose. Plasma midazolam concentrations were determined by liquid chromatography/mass spectrometry/mass spectrometry. Noncompartmental analysis was used to estimate pharmacokinetic parameters. The mean midazolam bioavailabilities and % coefficient of variation were 72.5 (12) and 93.4 (12) after the IN and IM doses, respectively. Median time to maximum concentration was 10 min for IN doses. Adverse events were minimal with all routes of administration, but nasopharyngeal irritation, eyes watering, and a bad taste were reported after IN doses. Our results support further development of this novel midazolam nasal spray.

 

超臨床劑量的曲馬多立體選擇性削弱離體大鼠主動脈內皮細胞依賴性血管擴張

A Supraclinical Dose of Tramadol Stereoselectively Attenuates Endothelium-Dependent Relaxation in Isolated Rat Aorta

Il-Woo Shin, MD*, Ju-Tae Sohn, MD*{dagger}, Kyeong-Eon Park, MD*, Ki Churl Chang, PhD{dagger}{ddagger}, Ju-Young Choi, MD*, Heon-Keun Lee, MD*, and Young-Kyun Chung, MD*

From the *Department of Anesthesia and Pain Medicine, Gyeongsang National University College of Medicine; {dagger}Institutes of Health Sciences, Gyeongsang National University; and {ddagger}Department of Pharmacology, Gyeongsang National University College of Medicine, Gyeongnam, Republic of Korea

Anesth Analg 2006 103: 366-371.

曲馬多是R(-)S(+)對映體的化合物,可抑制乙醯膽鹼介導的毒蕈堿受體反應和毒蕈堿引起的環鳥苷酸聚積。作者在離體實驗中利用大鼠主動脈研究曲馬多對乙醯膽鹼引起的內皮細胞依賴性血管擴張的效應,並確定曲馬多的這種效應是否具有立體選擇性,闡明其相關的細胞機制。在有或無納洛酮的情況下,用苯腎上腺素對內皮細胞完整的血管環進行預處理。然後在有或無曲馬多(外消旋、R(-)S(+))的情況下,繪製乙醯膽鹼、組胺和鈣離子載體A23187的劑量反應曲線。在有或無外消旋曲馬多的情況下,繪製硝普鈉的劑量反應曲線。不管有或無納洛酮,外消旋曲馬多(5×10–5 10–4 M)削弱乙醯膽鹼引起的血管環擴張。R(-)曲馬多5 x 10–5 M削弱乙醯膽鹼引起的血管環擴張,但S(+)曲馬多5 x 10–5 M沒有這種作用。外消旋曲馬多對鈣離子載體A23187或硝普鈉的劑量反應曲線沒有影響。上述結果顯示超臨床劑量(5 x 10–5 M)的曲馬多,通過在涉及非特異性內皮細胞活化的一個通路上接近於一氧化氮合酶啟動水準的抑制作用,可立體特異性地削弱內皮細胞依賴性血管擴張。

(趙延華 陳傑 校)

Tramadol, a combination of R(–) and S(+) enantiomers, inhibits both the acetylcholine-mediated response of muscarinic receptors and the muscarine-induced accumulation of cyclic guanosine monophosphate. Our goals in this in vitro study were to investigate the effects of tramadol on endothelium-dependent relaxation induced by acetylcholine, to determine whether this effect of tramadol is stereoselective, and to elucidate the associated cellular mechanism in rat aorta. In endothelium-intact rings precontracted with phenylephrine with or without naloxone, dose-response curves for acetylcholine, histamine, and calcium ionophore A23187 were generated in the presence and absence of tramadol (racemic, R(–) and S(+)). Sodium nitroprusside dose-response curves were generated in the presence and absence of racemic tramadol. Racemic tramadol (5 x 10–5 10–4 M) attenuated acetylcholine-induced relaxation in the rings with or without naloxone. R(–) tramadol, 5 x 10–5 M, attenuated acetylcholine-induced relaxation, whereas S(+) tramadol, 5 x 10–5 M, did not. Racemic tramadol (10–4 M) had no effect on dose-response curves for calcium ionophore A23187 or sodium nitroprusside. Taken together, these results indicate that tramadol, at a supraclinical dose (5 x 10–5 M), stereoselectively attenuates endothelium-dependent relaxation via an inhibitory effect at levels proximal to nitric oxide synthase activation on a pathway involving nonspecific endothelial receptor activation.

 

0.5%布比卡因硬膜外阻滯複合氧化亞氮鎮靜的麻醉中BIS指數與OAA/S評分沒有明顯的相關性

Bispectral Index Does Not Correlate with Observer Assessment of Alertness and Sedation Scores During 0.5% Bupivacaine Epidural Anesthesia with Nitrous Oxide Sedation

Kyung Soo Park, PhD, MD*, Eun Jin Hur, BS*, Kyung Woo Han{dagger}, Ho Yeong Kil, MD, PhD{dagger}, and Tae Hyung Han, MD, PhD, FAAFP{dagger}

From the Department of Pharmacology, Yonsei University College of Medicine, Seoul, Korea; {dagger}Department of Anesthesiology and Pain Medicine, Hangang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea.

Anesth Analg 2006 103: 385-389.

BIS指數被用作監測靜脈鎮靜催眠藥、強效揮發性麻醉劑的鎮靜程度和催眠水準。作者在實施區域阻滯的患者中,評價提高氧化亞氮的濃度對BIS的影響,並將它與OAA/S比較。隨機選擇48ASA-Ⅱ級,在腰部硬膜外麻醉下行下肢手術的成人患者。氧化亞氮與氧氣同時給予,通過緊扣的面罩使氧化亞氮潮氣末濃度逐漸增加至33%50%67% ,且每種濃度維持20分鐘。在每次增加氧化亞氮前獲取BIS指數和OAA/S的資料。48名患者中40人完成了實驗。增加氧化亞氮的濃度,BIS值沒有變化,但是氧化亞氮濃度在50%67%OAA/S評分明顯下降。用Somer dx.y計算的預測BISOAA/S的概率分別是0.600.84。麻醉醫師應該警惕,在單獨利用氧化亞氮鎮靜時BIS監測並不能敏感地測量鎮靜和催眠的深度。利用臨床監測鎮靜方法(如OAA/S評分)可能更好地確定麻醉藥需要的劑量和足夠的鎮靜和催眠的深度。

(劉哲 陳傑 校)

The bispectral index (BIS) has been used as a measure of the degree of sedation and level of hypnosis for IV hypnotics and sedatives, potent volatile anesthetics. We evaluated the effect of increasing concentrations of nitrous oxide (N2O) on BIS and compared it with the Observer's Assessment of Alertness and Sedation (OAA/S) scale in patients undergoing regional anesthesia. We studied 48 unpremedicated, ASA physical status I–II adult patients scheduled for lower extremity surgery under lumbar epidural anesthesia. N2O was given in oxygen to achieve measured end-tidal concentrations of 33%, 50%, and 67% N2O by a tight-fitting facemask, and each N2O concentration was maintained for 20 min. Paired measurements of BIS and OAA/S scores were obtained just before each increase in N2O concentration. Forty of the 48 subjects completed the study. Increasing N2O concentrations produced no changes in BIS despite a significant decrease in OAA/S scores at 50% and 67% N2O concentrations. The prediction probability for BIS and OAA/S calculated by Somers' dx · y were 0.60 and 0.84, respectively. Anesthesiologists should be aware that the BIS monitor may not be sensitive enough to provide an adequate measure of the depth of sedation and hypnosis when using N2O alone for sedation. It may be better to monitor sedation clinically (e.g., with the OAA/S scale) to determine the dose requirement and the adequacy of depth of sedation and hypnosis.

 

異氟醚對大鼠重度前腦缺血預後呈劑量依賴效應

The Dose-Dependent Effects of Isoflurane on Outcome from Severe Forebrain Ischemia in the Rat

Ikuko Nasu, MD*, Noriko Yokoo, MD, PhD*, Seiji Takaoka, MD, PhD*, Kosuke Takata, MD*, Tamie Hoshikawa, MD*, Masayuki Okada, MD*, and Yoshihide Miura, MD, PhD{dagger}

From the *Department of Anesthesiology, Yamagata University School of Medicine, Yamagata, Japan; and the {dagger}Department of Dental Anesthesiology, Health Sciences University of Hokkaido, Japan.

Anesth Analg 2006 103: 413-418.

異氟醚改善大鼠腦缺血預後,但其最佳的腦保護濃度尚未闡明。作者研究了大鼠重度前腦缺血模型中不同濃度異氟醚對預後的影響。禁食大鼠在進行雙側頸動脈閉塞加全身低血壓時分別吸入0.5, 1.0, 1.5, 2.0, 2.5 MAC的異氟醚。動脈血壓無須藥物處理。缺血後,麻醉以芬太尼/NO2維持2h。在實驗期間顱骨膜的溫度維持正常。缺血5天后評估神經運動評分,海馬CA1神經元死亡百分比,皮層的損傷。在缺血前,動脈血壓隨著MAC的增加而降低。吸入>1.0 MAC異氟醚的動物在缺血後頻發癲癇並且有較高的死亡率。CA1神經元死亡百分比沒有顯著差異(93 ~95%)。吸入0.5 MAC 1.0 MAC異氟醚的皮層神經元的壞死顯著低於>1.0 MAC的組。在1.0 MAC異氟醚的組,神經肌肉評分優於2.5 MAC組。在重度前腦缺血模型中,缺血前異氟醚預處理呈現顯著的組織學和行為學劑量依賴效應。小於1.5MAC劑量的異氟醚腦保護作用優於大劑量異氟醚。

(潘志英 陳傑 校)

Isoflurane improves outcome against cerebral ischemia in the rat. However, the optimal neuroprotective concentration has not been defined. We examined the effects of different isoflurane concentrations on outcome from severe forebrain ischemia in the rat. Fasted rats were subjected to 0.5, 1.0, 1.5, 2.0, or 2.5 minimum alveolar concentration (MAC) isoflurane during 10 min bilateral carotid occlusion plus systemic hypotension. Each isoflurane concentration was administered only before ischemia. Arterial blood pressure was not pharmacologically manipulated. After ischemia, the anesthetic regimen was changed to fentanyl/nitrous oxide and maintained for 2 h. Pericranial temperature was maintained normothermic during the experiment. Neuromotor score, % dead hippocampal CA1 neurons, and cortical injury were measured 5 days postischemia. Preischemic arterial blood pressure decreased as MAC was increased. Animals administered >1.0 MAC frequently exhibited postischemic seizures resulting in increased mortality. There was no difference among MAC conditions for % dead CA1 neurons (93 ~95%). In the cortex, neuronal necrosis was less severe with 0.5 MAC and 1.0 MAC isoflurane relative to >1.0 MAC values. The neuromotor score in the 1.0 MAC isoflurane group was superior to the 2.5 MAC group. Dose-dependent effects of preischemic administration of isoflurane on histologic and behavioral outcome after severe forebrain ischemia were observed. Isoflurane MAC values <1.5 provided superior overall outcome relative to larger isoflurane concentrations.

 

低氧性胎盤血管收縮:人胎盤對低氧反應是漸進性的

Hypoxemic Fetoplacental Vasoconstriction: A Graduated Response to Reduced Oxygen Conditions in the Human Placenta

Ramiah Ramasubramanian, MD, Raymond F. Johnson, BS, John W. Downing, MD, Beth H. Minzter, MD, and Ray L. Paschall, MD

From the *Department of Anesthesiology, Providence Milwaukie Hospital, Milwaukie, Oregon; {dagger}Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee; and {ddagger}Department of Anesthesiology, Columbia University, New York, New York.

Anesth Analg 2006 103: 439-442.

本文作者研究離體、雙重灌注的人胚胎絨毛的低氧性胎盤血管收縮(HFPV)的特性。將四個胎盤母面絨毛小葉應用21%O25%CO2N2(對照組)進行平衡,然後用含有5% CO2N2平衡30min,在此過程中監測其血壓的變化。結果發現血壓從69.8 (±6.4) mm Hg 升高至 105 (±3.0) mm Hg (P < 0.05),這肯定了HFPV在人胎盤中的作用。另外8個胎盤母面絨毛小葉分別依次應用對照氣體和混合氣體平衡15min,混合氣體包括15%, 12%, 5%0% O2,含有5% CO2N2 。結果發現胎盤血壓在15% O2平衡時從68.7 (± 3.7) mm Hg 升高到 70.5 (±3.3) mm Hg,在12% O2平衡時從69.3 (±3.8) mm Hg 升高到72.4 (±4.3) mm Hg,在0% O2平衡時從69.7 (± 3.4) mm Hg升高到77.9 (± 5.9) mm Hg。這說明,HFPV在人胎盤對低氧反應為漸進性。

(蘇殿三 陳傑 校)

We investigated the characteristics of hypoxemic fetoplacental vasoconstriction (HFPV) in the dual perfused, single isolated human placental cotyledon. Fetal arterial blood pressures (FAP) were measured in four cotyledons (Group 1) equilibrated with 21% oxygen (O2), 5% carbon dioxide (CO2), and nitrogen (N2) [control] followed by 5% CO2 in N2 for 30 min. FAP (mean ± sd) increased from 69.8 (± 6.4) to 105 (± 3.0) mm Hg (P < 0.05), confirming the utility of HFPV in the human placenta. Eight more cotyledons (Group 2) were exposed sequentially and alternately at 15-min intervals to the control gases and to gas blends containing 15%, 12%, 5%, and 0% O2 with 5% CO2 and N2. FAP increased significantly (P < 0.05) in a stepwise fashion from 68.7 (± 3.7) to 70.5 (± 3.3) mm Hg with 15% O2; from 69.3 (± 3.8) to 72.4 (± 4.3) mm Hg with 12% O2; from 67.8 (± 3.2) to 74.5 (± 3.4) mm Hg with 5% O2; and from 69.7 (± 3.4) to 77.9 (± 5.9) mm Hg with 0% O2, suggesting that HFPV is a graduated response to reduced O2 conditions in the human placenta.

 

喉罩在導絲擴張式氣管造口術中的應用

The Use of the Laryngeal Mask Airway During Guidewire Dilating Forceps Tracheostomy

Davide Cattano, MD*{dagger}, Steven Abramson, MD{ddagger}, Stefano Buzzigoli, MD{dagger}, Candido Zoppi, MD{dagger}, Ettore Melai, MD*, Francesco Giunta, MD*, and Carin Hagberg, MD{ddagger}

From the *Department of Surgery, Division of Anesthesiology and Intensive Care, University of Pisa, Pisa, Italy; {dagger}Department of Intensive Care, Anaesthesia and Analgesia, Versilia Hospital, Lidodi Camaiore, Italy; and {ddagger}Department of Anesthesiology, The University of Texas Medical School, Houston, Texas.

Anesth Analg 2006 103: 453-457.

 

經皮氣管造口因使用便捷,耗費較低,並能降低氣管造口術後併發症的發生率,已越來越多地替代了經典的開放式氣管造口。作者回顧了ICU中採用氣管內插管下行導絲擴張式經皮氣管造口術,並與使用經典的喉罩下進行操作的病例作比較。1998年至2004年間,有274名病人施行過氣管造口,其中254人(92.7%)使用了導絲擴張式氣管造口術,20人(7.3%)行外科開放式氣管造口。在使用導絲擴張式氣管造口的一組中,188人(74%)應用了經喉罩支氣管內鏡技術,66人(26%)則行氣管內插管下完成操作。作者認為經喉罩內窺鏡技術的視野優於氣管導管。氣管導管所引起的急性併發症較喉罩常見(6/66對比4/188P=0.022 Fisher’s精確測驗,優勢比=4.6)。兩者在急性併發症(10/2546/20P<0.001,優勢比=10.5)和長期合併症(0/254對比4/20P<0.001)的發生率上亦有顯著差異。無換氣功能障礙和胃內容物誤吸的報告。因此選擇性病人行導絲擴張式氣管造口,喉罩較氣管導管提供了更為安全和有效的氣道管理。

(印傑敏譯 陳傑 校)

Percutaneous tracheostomy has become a common alternative to the classical open tracheostomy because of its convenience, cost effectiveness, and decreased complication rates. We retrospectively reviewed our intensive care practice using a guidewire dilatating forceps percutaneous tracheostomy technique with an endotracheal tube, as compared with the Classic Laryngeal Mask Airway (LMA) for these procedures. From 1998 to 2004, 274 patients underwent a tracheostomy procedure. Two-hundred-fifty-four (92.7%) of these patients underwent a guidewire dilatating forceps tracheostomy and 20 (7.3%) underwent a surgical tracheostomy. In the guidewire dilatating forceps group, 188 (74%) were performed by endoscopy via LMA-guided bronchoscopy, and 66 (26%) were performed through an endotracheal tube. Endoscopic views obtained via the LMA were subjectively better than those obtained with the endotracheal tube. Acute complications were significantly more frequent when using an endotracheal tube as compared with the LMA (6 of 66 versus 4 of 188; P = 0.022 Fisher's exact test, odds ratio = 4.6). There was a significant difference in terms of acute (10 of 254 versus 6 of 20; P < 0.001, odds ratio = 10.5) and chronic (0 of 254 versus 4 of 20; P < 0.001) complications between the 2 groups. There were no ventilatory complications or reports of gastric aspiration. The LMA provides a safe and effective alternative to an endotracheal tube for airway management during guidewire dilatating forceps tracheostomies in selected patients.

 

{alpha}-1 {alpha}-2 腎上腺素受體在周圍咪唑啉和腎上腺素受體激動劑誘導的傷害感受中的發揮作用

The Contribution of Alpha-1 and Alpha-2 Adrenoceptors in Peripheral Imidazoline and Adrenoceptor Agonist-Induced Nociception

Ahmet Dogrul, MD, Ilke Coskun, and Tayfun Uzbay

From the Gülhane Military Medical Academy, Faculty of Medicine, Department of Medical Pharmacology, Psychopharmacology Research Unit, Ankara, Turkey.

Anesth Analg 2006 103: 471-477

作者用輕彈鼠尾試驗研究了大鼠外周腎上腺素受體和咪唑啉受體對傷害性感受啟動的影響以及{alpha}-1 {alpha}-2 腎上腺素受體在激動劑誘導的傷害感受中的作用。在鼠尾皮內注射10 µL的可樂定({alpha}-2腎上腺素受體激動劑), 胍丁胺(咪唑啉受體和{alpha}-2腎上腺素受體激動劑),去甲腎上腺素({alpha}-1{alpha}-2腎上腺素受體激動劑),苯腎上腺素({alpha}-1腎上腺素受體激動劑), 0.9%生理鹽水。皮內注射可樂定(1, 3, 10 µg) 或胍丁胺(3, 30, 50 µg) 可產生劑量依賴性的抗-傷害感受, 而皮內注射去甲腎上腺素(1, 10, and 30 µg)或苯腎上腺素(1, 10 30 µg) 可產生劑量依賴性的熱痛覺過敏。可樂定(10 µg)和胍丁胺(50 µg)導致的外周性的抗-傷害感受作用被預給育亨賓(一種選擇性的{alpha}-2腎上腺素拮抗劑)(2.5 mg/kg IP) 拮抗,而不能被呱唑唪(一種選擇性的{alpha}-1腎上腺素拮抗劑)(1 mg/kg IP) 拮抗。去甲腎上腺素(30 µg) 和苯腎上腺素 (30 µg)引起的熱的痛覺過敏可以被呱唑唪(1 mg/kg IP)拮抗,而不能被育亨賓(2.5 mg/kg IP) 拮抗。結果表明去甲腎上腺素和苯腎上腺素對局部的熱痛覺過敏的影響與{alpha}-1 腎上腺素受體有關,可樂定和胍丁胺的外周性抗-傷害感受作用與{alpha}-2 腎上腺素受體有關。

(宋金超 陳傑 校)

We evaluated the effects of activation of peripheral adrenoceptors (AR) and imidazoline receptors on nociception and the contribution of {alpha}-1 and {alpha}-2 AR receptors in agonist-induced nociception by using the tail-flick test in mice. Clonidine ({alpha}-2 AR agonist), agmatine (imidazoline receptor and {alpha}-2 AR agonist), noradrenaline (mixed {alpha}-1 and {alpha}-2 AR agonist), phenylephrine ({alpha}-1 AR agonist), or 0.9% saline was given by intradermal injection (10 µL) into the tail. The intradermal injection of clonidine (1, 3, and 10 µg) and agmatine (3, 30, and 50 µg) produced dose-dependent antinociception, whereas noradrenaline (1, 10, and 30 µg) and phenylephrine (1, 10 and 30 µg) produced dose-dependent thermal hyperalgesia. Clonidine (10 µg) and agmatine (50 µg)-induced peripheral antinociception were antagonized by pretreatment with yohimbine (2.5 mg/kg IP), a selective {alpha}-2 AR antagonist, but not by prazosin (1 mg/kg IP), a selective {alpha}-1 AR antagonist. Noradrenaline (30 µg) and phenylephrine (30 µg)-induced thermal hyperalgesia were antagonized by prazosin (1 mg/kg IP) but not by yohimbine (2.5 mg/kg IP). Our results suggest that local thermal hyperalgesic effects of noradrenaline and phenylephrine are linked to {alpha}-1 AR and the peripheral antinociceptive action of clonidine and agmatine are linked to {alpha}-2 AR.

 

細胞外信號調節的激酶觸發異氟醚預處理伴隨大鼠低氧可誘導因數-和血管內皮生長因數表達的上調

Extracellular Signal-Regulated Kinases Trigger Isoflurane Preconditioning Concomitant with Upregulation of Hypoxia-Inducible Factor-1{alpha} and Vascular Endothelial Growth Factor Expression in Rats

Chen Wang, MD, Dorothee Weihrauch, DVM, PhD, David A. Schwabe, BSEE, Martin Bienengraeber, PhD, David C. Warltier, MD, PhD, Judy R. Kersten, MD, Phillip F. Pratt, Jr, PhD, and Paul S. Pagel, MD, PhD

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

Anesth Analg 2006;103:281-288

 

引言:細胞外信號相關激酶12Erk1/2)是與麻醉藥預處理相關的線粒體啟動的蛋白激酶;不過Erk1/2究竟是觸發還是介導了此有益效應以及其產生心肌保護的機制尚屬未知。我們驗證了以下假設:大鼠接受冠脈阻斷30min再灌注2h,通過血流動力學測定提示異氟醚預處理是由Erk1/2觸發並伴有低氧可誘導因數HIF)及血管內皮生長因數(VEGF)表達上調。

方法:大鼠隨機接受靜注生理鹽水(對照)或異氟醚(冠脈阻斷之前吸入1MAC 30min,停止15min〔記憶期〕),並分別給予或不給予選擇性Erk1/2抑制劑PD 0980591mg/kg溶於二甲基亞碸,分別於吸入異氟醚〔觸發劑〕前3min或停止藥物〔介導劑〕後3min)。另外有兔單用二甲基亞碸預處理。從額外的各組大鼠按選定時點分別採集左心室組織標本用來對磷酸化-Erk1/2HIFVEGF的蛋白表達進行Western免疫印跡分析。

結果:和對照組相比,異氟醚明顯減少了梗死面積(左室危險部位面積的41±8vs 59% ± 4%P < 0.05,氯三苯四唑染色)。在異氟醚使用之前而不是之後使用PD 098059取消了心肌保護作用(分別為61% ± 5% 42% ± 9%)。異氟醚引起的磷酸化-Erk1/2HIFVEGF的表達增加也被PD 098059預處理所抑制。

結論:結果提示體內Erk1/2觸發了異氟醚預處理伴隨HIFVEGF的上調。

(黃施偉 譯,馬皓琳 李士通 校)

INTRODUCTION: Extracellular signal-related kinases 1 and 2 (Erk1/2) are mitogen-activated protein kinases that have been implicated in anesthetic preconditioning; but whether Erk1/2 triggers or mediates this beneficial effect and the mechanisms by which Erk1/2 produces cardioprotection are unknown. We tested the hypothesis that isoflurane preconditioning is triggered by Erk1/2 concomitant with upregulation of hypoxia-inducible factor 1{alpha} (HIF-1{alpha}) and vascular endothelial growth factor (VEGF) expression in rats instrumented for hemodynamic measurement and subjected to a 30-min coronary artery occlusion and 2-h reperfusion.

METHODS: Rats randomly received IV 0.9% saline (control) or isoflurane (1.0 minimum alveolar concentration administered for 30 min and discontinued 15 min [memory period] before coronary occlusion) in the absence or presence of the selective Erk1/2 inhibitor PD 098059 (1 mg/kg in dimethylsulfoxide administered IV either 3 min before exposure to isoflurane [trigger] or 3 min after discontinuation of the drug [mediator]). Additional rabbits were pretreated with dimethylsulfoxide alone. Left ventricular tissue samples were obtained at selected intervals from additional groups of rats for Western immunoblot analysis of phospho-Erk1/2, HIF-1{alpha}, and VEGF protein expression.

RESULTS: Isoflurane significantly (P < 0.05) reduced infarct size (41% ± 8% of the left ventricular area at risk; triphenyltetrazolium chloride staining) as compared with control (59% ± 4%). PD 098059 administered before, but not after, isoflurane abolished this cardioprotection (61% ± 5% and 42% ± 9%, respectively). Isoflurane-induced increases in phospho-Erk1/2, HIF-1{alpha}, and VEGF expression were also inhibited by PD 098059 pretreatment.

CONCLUSIONS: The results indicate that Erk1/2 triggers isoflurane preconditioning concomitant with HIF-1{alpha} and VEGF upregulation in vivo.

 

 

異丙酚/異氟烷麻醉下兒童的年齡對運動激發電位的影響

The Effect of Age on Motor Evoked Potentials in Children Under Propofol/Isoflurane Anesthesia

Jeremy A. Lieberman, MD*, Russ Lyon, MS, DABNM{ddagger}, John Feiner, MD*, Mohammad Diab, MD{dagger}, and George A. Gregory, MD*

From the *Department of Anesthesia and Perioperative Care, {dagger}Department of Orthopedic Surgery, {ddagger}Division of Perioperative Services, University of California, San Francisco, San Francisco, California.

Anesth Analg 2006;103:316-321

 

術中經顱運動激發電位(MEP)監測有助於預防脊柱手術期間的神經損傷。對於兒科群體來說,在常規麻醉條件下,此種監測可能有困難。我們回顧性地研究了56個年齡在218歲,欲在MEP監測下 行先天性脊柱側凸矯正手術的兒童的數據。在異氟烷-異丙酚複合全身麻醉下,我們在切皮前檢測出達到50微伏或更大MEP反應幅度所需的最小刺激閾電壓。年齡越小,引起足夠MEP反應所需的閾電壓越大。此外,年齡較小者的刺激脈衝系列較長並且更需要調整頭皮刺激電極。體表面積、身高、體重、體重指數亦是重要的因素,但經年齡標化後,並不能成為獨立的評估指標。給予年齡較小的兒童接受的異氟烷水準低於年齡較大的兒童,異丙酚的劑量相近。年幼患者需要更強的刺激方能產生MEP反應,可能是因為其中樞神經系統,尤其是下行皮質脊髓運動束的傳導欠成熟在最優化生理變異、限制麻醉鎮靜藥和選擇最適用于兒童(尤其是年齡<10歲)的刺激條件這些方面尚需加強關注。

唐李雋 馬皓琳  李士通 校)

Intraoperative transcranial motor evoked potential (MEP) monitoring may help prevent neurologic injury during spine surgery. This type of monitoring may be difficult in the pediatric population under general anesthesia. We retrospectively reviewed data from 56 children, aged 2 to 18 yr, who were to undergo surgical correction of idiopathic scoliosis with MEP monitoring. Under combined isoflurane-propofol general anesthesia, before incision, we examined the minimum stimulating threshold voltage required to achieve a 50-microvolt or greater MEP response amplitude. Younger age was associated with an increase in the threshold voltage needed to elicit a sufficient MEP response. In addition, younger age was associated with longer stimulating pulse trains and greater need to adjust stimulating scalp electrodes. Body surface area, height, weight, and body mass index were also significant factors, but they were not independent predictors, after adjusting for age. Younger children received significantly lower levels of isoflurane and comparable doses of propofol, compared with older patients. Stronger stimulation needed to produce MEP responses in younger patients may reflect immaturity of their central nervous system, specifically conduction by the descending corticospinal motor tracts. Greater attention must be given to optimizing physiologic variables, limiting depressant anesthetics, and selecting the most favorable stimulating conditions in children, especially those <10 yr old.

 

 

大鼠術後疼痛模型中腦脊液和外周前列腺素E2水準上調

Upregulation of Cerebrospinal Fluid and Peripheral Prostaglandin E2 in a Rat Postoperative Pain Model

Jeffrey S. Kroin, PhD, Asokumar Buvanendran, MD, Daniel E. Watts, BS, Chiranjeev Saha, MD, and Kenneth J. Tuman, MD

From the Department of Anesthesiology, Rush Medical College, Chicago, Illinois.

Anesth Analg 2006;103:334-343

 

胸外科手術術後疼痛治療一直以來是臨床的一個難題。在本研究中,我們採用胸肌切口模型顯示疼痛相關的行為特點和胸段腦脊液(CSF)及切口部位組織前列腺素E2 (PGE2)水準的變化。 用異氟醚、丙泊酚或蛛網膜下腔內注射布比卡因麻醉的大鼠左胸部行一深部肌肉切口。用微透析環路導管監測6小時內胸段腦脊液和切口部位組織的PGE2濃度。通過記錄探索性運動動作評估術後疼痛相關行為學改變。胸部肌肉手術使大鼠術後後腿直立動作和行走動作減少。口服酮咯酸或羅非考昔3mg/kg可使大鼠恢復正常的後腿直立動作和行走動作。接受脊麻的大鼠術後CSFPGE2濃度升高幅度最高(3倍),而接受丙泊酚麻醉的大鼠CSFPGE2濃度沒有變化。對於接受異氟醚麻醉或蛛網膜下腔注射布比卡因麻醉的大鼠,術前口服酮咯酸或羅非考昔3mg/kg可降低這些大鼠術後CSF和切口組織PGE2水準。鞘內注射酮咯酸(4 µg)可降低術後CSFPGE2水準而對切口組織PGE2水準沒有影響。但是鞘內注射L-745,337 (80 µg)不能降低CSFPGE2水準。胸外科手術傷口增加疼痛相關的行為學改變和腦脊液及切口組織PGE2水準,口服環氧合酶抑制劑可削弱此種變化。

(周雅春 馬皓琳 李士通校)

Analgesic management of postoperative pain associated with thoracic surgery remains a difficult clinical challenge. In the present study we used a thoracic muscle incision model to characterize pain-related behavior and changes in prostaglandin E2 (PGE2) in both thoracic cerebrospinal fluid (CSF) and incision site tissues. A deep muscle incision was made in the left thoracic region of rats anesthetized with isoflurane, propofol, or spinal bupivacaine. Thoracic CSF and incision site tissue concentrations of PGE2 were monitored for 6 h using microdialysis loop catheters. Postoperative pain-related behavior was assessed by recording exploratory locomotive activity. Thoracic muscle surgery decreased rearing and ambulation. Oral ketorolac or rofecoxib 3 mg/kg restored normal rearing and ambulation. Postoperative CSF PGE2 concentration increased most (threefold) with spinal anesthesia, and not at all with propofol. With surgery under isoflurane or spinal bupivacaine, presurgical oral administration of ketorolac or rofecoxib 3 mg/kg reduced postsurgical CSF PGE2 levels and tissue PGE2 levels. Intrathecal ketorolac (4 µg) reduced CSF PGE2 after surgery without affecting tissue PGE2 levels, whereas intrathecal L-745,337 (80 µg) did not reduce CSF PGE2. Thoracic surgical wounds increase pain-related behavior and CSF and tissue PGE2 levels, all of which can be attenuated by oral cyclooxygenase inhibitors.

 

 

機械通氣的家兔對異丙酚鎮靜作用的耐受性

Tolerance to Propofol’s Sedative Effect in Mechanically Ventilated Rabbits

Petros Ypsilantis, DVM, PhD*, Dimitrios Mikroulis, MD, PhD{dagger}, Maria Politou, MD*, Heleni Tsoukali, PhD{ddagger}, Michail Pitiakoudis, MD, PhD*, Vasilios Didilis, MD, PhD{dagger}, Georgios Theodoridis, PhD§, Georgios Bougioukas, MD, PhD{dagger}, and Constantinos Simopoulos, MD, PhD*

From the *Laboratory of Experimental Surgery and Surgical Research and {dagger}Thoracic and Cardiac Surgery Clinic, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece; {ddagger}Laboratory of Forensic Medicine and Toxicology, Medical School, and §Laboratory of Analytical Chemistry, Department of Chemistry, Aristotle University of Thessaloniki, Thessaloniki, Greece.

Anesth Analg 2006;103:359-365

 

異丙酚常用於對機械通氣的危重病人的鎮靜。在長期輸注過程中,這些病人可能會產生耐受。這裏,我們描述了長期機械通氣的家兔對異丙酚鎮靜效應耐藥的發展過程。六隻健康的雄性新西蘭大白兔進行了氣管內插管,持續靜脈輸注異丙酚48小時以維持鎮靜。調節異丙酚輸注速率(IR)以維持想達到的鎮靜水準。每30分鐘或者如果有清醒的體征可以更早些,評定一次鎮靜深度。每次調整輸注速率後,假設鎮靜水準足夠,均抽取一次動脈血,用高效液相色譜分析測定異丙酚濃度,並且計算出全身清除率。死亡率是100%,生存期30.8 ± 6.0 小時(均數±標準差)。輸注速率的調整過程遵循一個5相模式:1)穩定的輸注速率(持續時間的均數±標準差,1.2 ± 0.6 小時)2)增加輸注速率(9.4 ± 5.5 小時)3)穩定的高輸注速率(9.4 ± 5.5 小時)4)降低輸注速率(13.7 ± 1.9 小時)5)穩定的低輸注速率(5.0 ± 2.7 小時)。試驗中與異丙酚輸注速率相關的異丙酚濃度的變化過程遵循3相模式:1)隨著輸注速率的增加維持穩定的濃度(6.0 ± 2.7 小時),2)隨著輸注速率增加濃度增加(5.8 ± 2.5 小時),3)隨著輸注速率降低濃度增加(18.8 ± 3.3 小時)。異丙酚全身清除率在6.0 ± 2.7 小時裏逐漸增加,接著在24.6 ± 4.7小時裏逐漸下降。總而言之,所有家兔在異丙酚最初的輸注中對其鎮靜效應均發生了耐藥,與該種藥物的代謝清除率的變化有關。

 (黃麗娜    馬皓琳 李士通 )

Propofol is commonly used for the sedation of critically ill patients undergoing mechanical ventilation. These patients may develop tolerance during long-term administration. Here, we describe the development of tolerance to propofol’s sedative effect in rabbits during prolonged mechanical ventilation. Six healthy male New Zealand White rabbits were endotracheally intubated and received propofol by continuous IV infusion to maintain sedation for 48 h. The propofol infusion rate (IR) was adjusted to maintain the desired level of sedation. Assessments of the sedation level were made every 30 min or earlier if there were signs of awakening. Propofol concentrations were measured in arterial plasma after every other IR adjustment, provided there was an adequate level of sedation, using high performance liquid chromatography, and calculations of systemic clearance rates were made. The mortality rate was 100% with a survival period of 30.8 ± 6.0 h (mean ± sd). The course of IR adjustments followed a 5-phase pattern: 1) steady IR (mean ± sd duration; 1.2 ± 0.6 h), 2) increasing IR (9.4 ± 5.5 h), 3) steady high-IR (2.3 ± 1.2 h), 4) decreasing IR (13.7 ± 1.9 h), and 5) steady low-IR (5.0 ± 2.7 h). The course of propofol concentrations during the experiment in relation to propofol IR followed a 3-phase pattern: 1) steady concentration with increasing IRs (6.0 ± 2.7 h), 2) increasing concentrations with increasing IR (5.8 ± 2.5 h), and 3) increasing concentrations with decreasing IR (18.8 ± 3.3 h). Propofol systemic clearance rates were progressively increased for 6.0 ± 2.7 h and then gradually decreased for 24.6 ± 4.7 h. In conclusion, all rabbits developed tolerance to propofol’s sedative effect within the first hours of administration related to changes to the drug’s metabolic clearance.

 

 

比較介入放射治療中雙譜指數(BIS)指導的和臨床上指導的雷米芬太尼/異丙酚的鎮痛/鎮靜水準:觀察者單盲隨機研究

Bispectral-Index-Guided Versus Clinically Guided Remifentanil/Propofol Analgesia/Sedation for Interventional Radiological Procedures: An Observer-Blinded Randomized Study

Ashraf A. Dahaba, MD, MSc, PhD*, Ulrike Lischnig, MD*, Robert Kronthaler, MD*, Helmar Bornemann, MD*, Vassil Georgiev, MD*, Peter H. Rehak, PhD{dagger}, and Helfried Metzler, MD*

From the *Department of Anaesthesiology and Intensive Care Medicine, and {dagger}Biomedical Engineering and Computing Unit of the Department of Surgery, Graz Medical University, Graz, Austria.

Anesth Analg 2006;103:378-384

 

接受潛在疼痛的放射介入治療的病人一般需要複合鎮痛和鎮靜。這種鎮痛/鎮靜應該使病人在保持平靜的狀態下具有交流能力。雙譜指數(BIS)監測在這方面是非常有用的。我們研究的主要目的是在54位元隨機的病人中比較BIS指導的雷米芬太尼/異丙酚麻醉方法和臨床上指導的麻醉方法最佳鎮靜(定義為鎮靜興奮分級〔SAS 4級)的時間百分比。BIS組最佳鎮靜的時間百分比均數±標準差, (76.6% ± 14.7%)SAS(63.8% ± 16.4%)顯著延長(P = 0.004)BIS組雷米芬太尼(P = 0.0067)和異丙酚(P = 0.0075)的每公斤體重平均注速度(0.066 ± 0.027 μg · kg–1 · min–1 1.59 ± 0.44 mg · kg–1 · h–1)SAS(0.091 ± 0.036 μg · kg–1 · min–1 1.92 ± 0.43 mg · kg–1 · h–1)間均有顯著差異。BIS值和SAS分數 間存在著一個短期的相關性(r2 = 0.72)。結論,由BIS指導的比SAS指導的方法更有效。BIS的應用可以減少雷米芬太尼和異丙酚的用量。BIS靶範圍在8085可以提供足夠的鎮靜功能性水準。

(黃佳佳譯,馬皓琳 李士通

Patients undergoing potentially painful interventional radiological procedures generally require a combination of analgesia and sedation. This sedation/analgesia should allow the patient to communicate while also remaining calm. Bispectral index (BIS) monitoring could be useful in achieving this. The primary end-point of our study was to compare the percentage time with optimal sedation, defined as Sedation Agitation Scale (SAS) grade 4, between a BIS-guided remifentanil/propofol regimen and a clinically guided regimen in 54 randomly allocated patients. The mean ± sd percentage time with optimal sedation was significantly longer (P = 0.004) in the BIS group (76.6% ± 14.7%) than in the SAS group (63.8% ± 16.4%). There was a significant difference in the weighted mean infusion rates of remifentanil (P = 0.0067) and propofol (P = 0.0075) in the BIS group (0.066 ± 0.027 µg · kg–1 · min–1 1.59 ± 0.44 mg · kg–1 · h–1) compared with the SAS group (0.091 ± 0.036 µg · kg–1 · min–1 1.92 ± 0.43 mg · kg–1 · h–1), respectively. BIS values exhibited a temporal correlation to SAS scores (r2 = 0.72). In conclusion, a BIS-guided regimen was more effective than a SAS-guided regimen. The use of BIS resulted in fewer remifentanil and propofol doses. The targeted BIS range of 80–85 provided a sufficient functional level of sedation.

 

 

在植入心內除顫複律器過程中重複短暫心臟停搏後的神經元損傷伴隨認知功能障礙

Neuronal Injury After Repeated Brief Cardiac Arrests During Internal Cardioverter Defibrillator Implantation Is Associated With Deterioration of Cognitive Function

Manuela Weigl, MD*, Andrea Moritz, MD*, Barbara Steinlechner, MD*, Isabella Schmatzer, cand. med.*, Bruno Mora, MD*, Richard Fakin, cand. med.*, Daniel Zimpfer, MD{dagger}, Hendrik J. Ankersmit, MD{dagger}, Cesar Khazen, MD{dagger}, and Martin Dworschak, MD*

From the *Department of Anesthesiology and General Intensive Care, Division of Cardiothoracic and Vascular Anesthesia and Intensive Care; {dagger}Department of Surgery, Division of Cardiothoracic Surgery, University Hospital Vienna, Austria.

Anesth Analg 2006;103:403-409

 

為了確定在植入心內除顫複律器(ICD)後神經認知功能障礙的程度及其與神經元損傷範圍的關係,我們研究了42位施行ICDn=21)或起搏器(PM)(對照病人,n=21)植入術的病人。在術前和術後進行簡易智慧量表、追蹤試驗ATrailmaking A test)、向前及向後數字距離測驗和P300潛伏期測定。在術前、手術結束時以及術後2624小時測定血漿神經元特異性烯醇酶(NSE)。在術前,PM組病人的向後數字距離測驗評分和追蹤試驗得分較差,P300潛伏期延長。在術後,只有ICD植入病人的向後數字距離評分下降,NSE水準升高(P ≤ 0.05)。術前和術後向後數字距離測驗評分的差值與血漿NSE水準的升高相關(r2 = 0.3, P ≤0.05)。此外,在17ICD植入病人中13P300潛伏期延長,但是在10PM植入病人中7P300潛伏期縮短(P ≤0.05)。PM植入病人的追蹤試驗得分甚至得到改善(P ≤0.05)。看來即使短暫大腦缺血導致的神經元損傷也伴隨神經認知功能損害。

(顏濤 譯, 馬皓琳 李士通 校)

To determine the degree of neurocognitive dysfunction after placement of internal cardioverter defibrillators (ICD) and its relationship to the extent of neuronal injury, we studied 42 patients undergoing ICD (n = 21) or pacemaker (PM) insertion (control patients, n = 21). The Mini Mental State Examination, the Trailmaking A test and the forward and backward Digit Span tests were used and P300 latencies were determined preoperatively and postoperatively. Serum neuron-specific enolase (NSE) was determined before and at the end of, as well as 2, 6, and 24 h after surgery. Preoperatively, PM patients scored worse in the Digit Span backward and the Trailmaking tests and showed prolonged P300 latencies. Postoperatively, the Digit Span backward scores declined and NSE levels increased only in the ICD group (P ≤0.05). The difference between preoperative and postoperative Digit Span backward scores correlated with the increase in serum NSE levels (r2 = 0.3, P ≤0.05). Moreover, P300 latencies increased in 13 of 17 ICD patients, but decreased in 7 of 10 PM patients (P ≤0.05). PM patients even improved in the Trailmaking test (P ≤0.05). Neuronal injury from even brief periods of global brain ischemia seems to be associated with deteriorating neurocognitive function.

 

 

Sigma 1受體激動劑通過抑制可誘導的一氧化氮合酶起神經保護藥物的作用

Sigma 1 Receptor Agonists Act as Neuroprotective Drugs Through Inhibition of Inducible Nitric Oxide Synthase

Kamila Vagnerova, MD, Patricia D. Hurn, PhD, Anish Bhardwaj, MD, and Jeffrey R. Kirsch, MD

From the Department of Anesthesiology and Peri-Operative Medicine, Oregon Health and Science University, Portland, Oregon.

Anesth Analg 2006;103:430-434

 

缺血後給予sigma-1受體激動劑可以減少缺血性腦損傷,但是其中的機制還不清楚。我們假設sigma-1受體激動劑噴他左辛的右旋構體(P(+))可以通過部分改善可誘導的一氧化氮合酶(iNOS)介導的細胞死亡,從而減少損傷,其左旋構體(P(-))則缺少這種功能。我們比較了噴他左辛的右旋構體合用或不合用iNOS抑制劑氨基胍(AG)的治療效果以及噴他左辛的右旋構體對缺乏iNOSiNOSKO)的小鼠的效果。神經保護的一個可能機制是抑制iNOS的表達。雄性C57/Bl6小鼠被短暫夾閉中腦動脈(90 min),再灌注時給予藥物:1)噴他左辛的右旋構體+氨基胍,2)噴他左辛的右旋構體,3)噴他左辛的左旋構體,4)氨基胍,或5)安慰劑。可誘導一氧化氮合酶缺乏的小鼠用噴他左辛的右旋構體或安慰劑治療。用噴他左辛的右旋構體治療後梗死(氯化三苯四唑組織學,72 h)和安慰劑相比在紋狀體方面減少44%,在新大腦皮質方面減少23%(P<0.05),其減少與氨基胍作用相近。噴他左辛的左旋構體並不減少腦損傷。同時給予噴他左辛的右旋構體+氨基胍和單獨給予噴他左辛的右旋構體在神經保護水準方面沒有區別。噴他左辛的右旋構體在缺乏可誘導的一氧化氮合酶小鼠身上沒有進一步的神經保護作用。我們總結得出缺血後給予噴他左辛的右旋構體可以減少小鼠的梗死面積。由於氨基胍沒有促進噴他左辛的右旋構體的保護作用,且噴他左辛的右旋構體對可誘導的一氧化氮合酶缺乏小鼠不起作用,所以我們推測噴他左辛的右旋構體通過抑制iNOS毒性作用導致的細胞死亡起作用。

(姜旭暉譯,馬晧琳 李士通 校)

Postischemic administration of the sigma-1 agonists reduces ischemic brain injury; however, the mechanism is unclear. We hypothesized that the sigma-1 agonist (+)isoform of pentazocine (P(+)) reduces damage in part by ameliorating cell death mediated via inducible nitric oxide synthase (iNOS) and that the (–)isoform (P(–)) lacks this effect. We compared treatment with P(+) with or without the iNOS inhibitor aminoguanidine (AG) and also the effects of P(+) in iNOS deficient (iNOSKO) mice. A possible mechanism of neuroprotection is inhibition of iNOS expression. Male C57/Bl6 mice were subjected to transient middle cerebral artery occlusion (90 min) and drugs were administered with reperfusion: 1) P(+) with AG (P+/AG), 2) P(+), 3) P(–), 4) AG, or 5) placebo. iNOSKOs were treated with either P(+) or placebo. Infarction (triphenyltetrazolium chloride histology, 72 h) was reduced by P(+) treatment in striatum by 44% and in neocortex by 23% versus placebo (P < 0.05), a reduction comparable to AG effect. P(–) did not attenuate brain injury. There was no difference in P(+)/AG treatment compared with showed the same level of neuroprotection as P(+) alone. P(+) also did not provide further neuroprotection for iNOSKOs. We conclude that postischemic administration of P(+) reduces infarct volume in mice. Because AG provides no additional benefit to P(+) treatment and iNOSKOs do not benefit from P(+), we speculate that P(+) acts by suppressing cell death resulting from iNOS toxicity.

 

 

腹部大手術後國際標準化比值延長與血管內液體大平衡相關

Prolonged International Normalized Ratio Correlates with a Large Intravascular Fluid Balance After Major Abdominal Surgery

Michal Barak, MD, Oded Jurim, MD{ddagger}, Ronit Tal, MD{dagger}, and Yeshayahu Katz, MD, DSc§

From the Departments of *Anesthesiology and {dagger}Surgery B, Rambam Medical Center; {ddagger}Department of Surgery A, Carmel Medical Center; ¶Laboratory for Anesthesia, Pain and Neural Research, Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa; §Department of Anesthesiology, Haemek Medical Center, Afula, Israel.

Anesth Analg 2006;103:448-452

 

我們對32例已行胰十二指腸切除術且術中和術後未輸血的病人進行前瞻性隨機研究。根據病人術後早期液體平衡情況將其前瞻性地分為2組,組114例)維持血管內正液體平衡0-1000ml;組218例)維持血管內正液體平衡1000-2000ml。取3個時間點比較全血細胞計數、凝血試驗(國際標準化比值)和部分活化凝血酶原時間(aPTT):術前一天、到麻醉後恢復室即刻及離開麻醉後恢復室即刻(16h後)。兩組在麻醉後恢復室時國際標準化比值變差,組間有顯著性差異,但aPTT值之間無顯著性差異。液體正平衡的量與國際標準化比值延長之間存在正相關,與aPTT無相關性。結果顯示,限制性血管內液體平衡有助於保護病人腹部大手術後的凝血功能。

(邱鬱薇 馬皓琳 李士通 校)

We performed a prospective randomized study of 32 patients who had undergone pancreaticoduodenectomy and did not receive blood during and after surgery. The patients were prospectively assigned to two groups related to fluid balance in the immediate postoperative period. Group 1 (14 patients) were maintained at a positive intravascular fluid balance of 0–1000 mL; Group 2 (18 patients) were maintained at a positive balance of 1000–2000 mL. Complete blood counts and coagulation tests (International Normalized Ratio) and activated partial thromboplastin time (aPTT) were performed at three time points: the day before surgery, on arrival at the postanesthesia care unit, and on leaving the postanesthesia care unit (16 h later). There were significant differences in International Normalized Ratio values between the groups with deterioration during the time they were in the postanesthesia care unit but not in aPTT values. Positive correlation was found between the amount of positive fluid balance and International Normalized Ratio prolongation, but not with aPTT, suggesting that restricted intravascular fluid balance is beneficial for preservation of coagulation after major abdominal surgery.

 

 

多慮平漱口:對癌症治療導致口腔粘膜炎患者的鎮痛作用和疼痛減輕持續時間

Oral Doxepin Rinse: The Analgesic Effect and Duration of Pain Reduction in Patients with Oral Mucositis Due to Cancer Therapy

 

Joel B. Epstein, DMD, MSD*, Joshua D. Epstein, MA{dagger}, Matthew S. Epstein, BS{ddagger}, Hal Oien, DDS§, and Edmond L. Truelove, DDS, MSD

From the *Department of Oral Medicine and Diagnostic Sciences, College of Dentistry, and Chicago Cancer Center, College of Medicine, University of Illinois, Chicago, Illinois; {dagger}Department of Pharmaceutical Economics and Policy, University of Southern California, Los Angeles, California; {ddagger}Fred Hutchinson Cancer Research Center, Seattle; §Private General Dental Practice, Beaverton, Oregon; and ¶Department of Oral Medicine, University of Washington, Seattle, Washington.

Anesth Analg 2006;103:465-470

 

在以往的研究中,我們評估了癌症和癌症治療導致口腔粘膜炎患者局部多慮平漱口後減輕疼痛的作用,這個研究就是我們以往研究的延伸。我們的研究物件繼續仍限於僅僅因為癌症治療導致疼痛性口腔粘膜炎的病人,我們進一步分析了疼痛減輕的持續時間。共有51例口腔粘膜炎病人參與到實驗中。在多慮平(5mg/mL)漱口前和漱口後的4小時裏定期間隔時間,我們對口腔粘膜炎進行評分,對口腔疼痛用視覺類比評分進行評估。那些報告疼痛減輕的病人中,有95%在多慮平漱口後15分鐘內疼痛減輕。在總的樣本中,一般的病人認為疼痛最大減輕70%(P<0.0001)。疼痛再次出現較緩慢,研究結束時有19例病人(37%)仍報告疼痛較基礎值輕。我們使用Cox風險比例分析檢驗了這些資料,來判斷是哪些變數對疼痛減輕持續時間延長最有影響。我們最後的模型分析可以得出這樣的結論,基礎疼痛越嚴重,粘膜紅斑分數越差,或者相對疼痛最大減輕越明顯,與漱口後疼痛再次出現越慢相關(P<0.01)

(張瑩 譯 馬皓琳 李士通 校)

This research expands on our prior study, in which we assessed pain reduction after topical doxepin rinse in patients with oral mucositis resulting from cancer and cancer therapy. We continued to enroll patients with painful oral mucositis attributable solely to cancer therapy and performed further analysis on the duration of pain reduction. Fifty-one patients with oral mucositis were enrolled. Mucositis was scored and oral pain was assessed with a visual analog scale before doxepin oral rinse (5 mg/mL) and at regular intervals up to 4 h after rinsing. Of those who reported pain reduction, 95% did so within 15 min of rinsing with doxepin. In the total sample, the average patient reported a 70% maximum decrease in pain (P < 0.0001). Recurrence of pain was slow and at the conclusion of the study 19 patients (37%) still reported a reduction from baseline pain. With this censored data we used Cox-proportional hazards to determine what variables best explained longer duration of pain reduction. Our final model determined that more severe baseline pain, worse mucosal erythema score, or a larger relative maximum reduction in pain were all associated with a slower rate of pain recurrence after oral rinsing (all P < 0.01).