Anesthesia & Analgesia

 

September 2006

Table of Content

CARDIOVASCULAR ANESTHESIA:

與異氟醚相比,體外迴圈過程中使用大量異丙酚可減少冠狀動脈手術患者心肌損傷的生化標誌物

(  琳譯  薛張綱 校)

Large-Dose Propofol During Cardiopulmonary Bypass Decreases Biochemical Markers of Myocardial Injury in Coronary Surgery Patients: A Comparison with Isoflurane

Zhengyuan Xia, Zhiyong Huang, and David M. Ansley

Anesth Analg 2006 103: 527-532.

頸動脈內膜剝離術中頸深淺叢複合神經阻滯後心血管自主調節能的化

(衛紅 陳傑 )

Altered Autonomic Cardiovascular Regulation After Combined Deep and Superficial Cervical Plexus Blockade for Carotid Endarterectomy

Young-Kug Kim, Gyu-Sam Hwang, In-Young Huh, Jai-Hyun Hwang, Jong-Yeon Park, Sung-Lyang Chung, Tae-Won Kwon, and Sung-Min Han

Anesth Analg 2006 103: 533-539

比伐盧定在不停跳冠脈再造術中提供快速、有效且可靠的凝作用:"EVOLUTION OFF"試驗的結果

(裘毅敏 譯,馬皓琳 李士通 校)

Bivalirudin Provides Rapid, Effective, and Reliable Anticoagulation During Off-Pump Coronary Revascularization: Results of the "EVOLUTION OFF" Trial

Andreas Koster, Bruce Spiess, Michael Jurmann, Cornelius M. Dyke, Nicholas G. Smedira, Sol Aronson, and Michael A. Lincoff

Anesth Analg 2006 103: 540-544

糖尿病弱離子通道阻斷的心律失常作用

(孫敏莉譯 薛張綱校)

Diabetes Mellitus Reduces the Antiarrhythmic Effect of Ion Channel Blockers

Isao Ito, Yukio Hayashi, Yusuke Kawai, Mitsuo Iwasaki, Koji Takada, Takahiko Kamibayashi, Atsushi Yamatodani, and Takashi Mashimo

Anesth Analg 2006 103: 545-550.

模擬麻醉危象中認知輔方法的應用

(詹慧 陳傑 校)

Use of Cognitive Aids in a Simulated Anesthetic Crisis

T. Kyle Harrison, Tanja Manser, Steven K. Howard, and David M. Gaba
Anesth Analg 2006 103: 551-556.

慢性心衰的圍手術期處理

(彭中美 馬皓琳 李士通校)

Perioperative Management of Chronic Heart Failure (Review Article)

Leanne Groban and John Butterworth

Anesth Analg 2006 103: 557-575.

PEDIATRIC ANESTHESIA:

小兒肝移植術中低鉀血症:發生率與風險因素

(吳德華譯 薛張綱校)

Intraoperative Hypokalemia in Pediatric Liver Transplantation: Incidence and Risk Factors

Victor W. Xia, Bin Du, Albert Tran, Luke Liu, Ke-Qin Hu, Jonathan R. Hiatt, Ronald W. Busuttil, and Randolph H. Steadman

Anesth Analg 2006 103: 587-593.

ANESTHETIC PHARMACOLOGY:

異丙酚減弱致敏大鼠氣管卵清蛋白誘導的支氣管平滑肌收縮:制5-羥色胺和乙醯膽鹼信號轉導

(丁震敏 陳傑 校)

Propofol Attenuates Ovalbumin-Induced Smooth Muscle Contraction of the Sensitized Rat Trachea: Inhibition of Serotonergic and Cholinergic Signaling

Masakazu Yamaguchi, Osamu Shibata, Kenji Nishioka, Tetsuji Makita, and Koji Sumikawa

Anesth Analg 2006 103: 594-600.

大鼠氣管內注射維庫溴與靜脈給藥和肌注的效能比較

(黃麗娜 馬皓琳 李士通 較)

The Efficacy of Intratracheal Administration of Vecuronium in Rats, Compared with Intravenous and Intramuscular Administration

Hiroshi Sunaga, Masahisa Kaneko, and Yoshikiyo Amaki

Anesth Analg 2006 103: 601-607.

低濃度的地卡因延緩神經生長,並不損害神經突和生長錐

(吳德華譯 薛張綱校)

Tetracaine at a Small Concentration Delayed Nerve Growth Without Destroying Neurites and Growth Cones

Kenichi Sekimoto, Shigeru Saito, and Fumio Goto

Anesth Analg 2006 103: 608-614.

局部麻醉對家兔眼睛初級感覺神經和副交感神經的制作用

(李惟一 陳傑 校)

The Inhibitory Effects of Local Anesthetics on Primary Sensory Nerve and Parasympathetic Nerve in Rabbit Eye

Ko Takakura, Maki Mizogami, Shigeru Morishima, and Ikunobu Muramatsu

Anesth Analg 2006 103: 615-619.

經皮血氣二氧化碳監測小鼠誘導性通氣制

(邱鬱薇 馬皓琳 李士通 校)

Transcutaneous Blood Gas CO2 Monitoring of Induced Ventilatory Depression in Mice

Peyman Sahbaie, Shohreh Madanlou, Parham Gharagozlou, J. David Clark, Jelveh Lameh, and Timothy M. Delorey

Anesth Analg 2006 103: 620-625.

TECHNOLOGY, COMPUTING, AND SIMULATION:

 海豚的單側大腦球的BIS 監測

(孫卓真譯 薛張綱校)

Bispectral Index Monitoring of Unihemispheric Effects in Dolphins

Red S. Howard, James J. Finneran, and Sam H. Ridgway

Anesth Analg 2006 103: 626-632.

用雙頻指數評估麻醉深度與術後認知能障礙和恢復有關嗎?

(肖潔 陳傑 校)

Is Depth of Anesthesia, as Assessed by the Bispectral Index, Related to Postoperative Cognitive Dysfunction and Recovery?

Ehab Farag, Gordon J. Chelune, Armin Schubert, and Edward J. Mascha

Anesth Analg 2006 103: 633-640.

七氟醚複合靜脈太尼麻醉時腦電圖 Bicoherence的化

(張曦   馬皓琳 李士通  校)

Changes in Electroencephalographic Bicoherence During Sevoflurane Anesthesia Combined with Intravenous Fentanyl

Yasuhiro Morimoto, Satoshi Hagihira, Satoshi Yamashita, Yasuhiko Iida, Mishiya Matsumoto, Syunsuke Tsuruta, and Takefumi Sakabe

Anesth Analg 2006 103: 641-645

CRITICAL CARE AND TRAUMA:

 壓控制通氣模式中氣管內插管部分梗阻的呼氣流量改檢測

(  荻譯 薛張綱校)

Change in Expiratory Flow Detects Partial Endotracheal Tube Obstruction in Pressure-Controlled Ventilation

Rafael Kawati, Laszlo Vimlati, Josef Guttmann, Göran Hedenstierna, Ulf Sjöstrand, Stefan Schumann, and Michael Lichtwarck-Aschoff

Anesth Analg 2006 103: 650-657.

NEUROSURGICAL ANESTHESIA:

β-受體阻滯減輕大鼠大腦暫時性局部缺血後損傷

(周懿之 陳傑 校)

ß-Adrenoreceptor Antagonists Attenuate Brain Injury After Transient Focal Ischemia in Rats

Toru Goyagi, Tetsu Kimura, Toshiaki Nishikawa, Yoshitsugu Tobe, and Yoko Masaki

Anesth Analg 2006 103: 658-663.

OBSTETRIC ANESTHESIA:

伐地考昔用於剖宮產術後鎮痛:一個隨機、雙盲、安慰對照研究

(黃佳佳譯,李士通 馬皓琳校)

Valdecoxib for Postoperative Pain Management After Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Study

Brendan Carvalho, Larry Chu, Andrea Fuller, Sheila E. Cohen, and Edward T. Riley

Anesth Analg 2006 103: 664-670.

GENERAL ARTICLES:

開腹手術期間的血管內補液管理與血流動學的化

(胡湘 馬皓琳 李士通 校)

Intravascular Fluid Administration and Hemodynamic Performance During Open Abdominal Surgery

Christer H. Svensén, Joel Olsson, and Robert G. Hahn

Anesth Analg 2006 103: 671-676.

高碳酸血症可以改善病態肥胖手術病人的組織氧供

(陸文清譯 薛張綱校)

Hypercapnia Improves Tissue Oxygenation in Morbidly Obese Surgical Patients

Helmut Hager, Dayakar Reddy, Goutham Mandadi, Debra Pulley, J. Chris Eagon, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2006 103: 677-681.

腹膜內局麻在腹腔鏡下膽切除術中的作用:系統回顧與薈萃分析

(印傑敏 陳傑 校)

The Effect of Intraperitoneal Local Anesthesia in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Alexander P. Boddy, Samir Mehta, and Michael Rhodes

Anesth Analg 2006 103: 682-688.

ANALGESIA:

鞘內注射環氧化酶-1制而非環氧化酶-2制能夠逆轉剖腹手術對大鼠探索行為的影響

(顏濤 馬皓琳 李士通 校)

Intrathecal Administration of a Cylcooxygenase-1, but Not a Cyclooxygenase-2 Inhibitor, Reverses the Effects of Laparotomy on Exploratory Activity in Rats

Thomas J. Martin, Nancy L. Buechler, and James C. Eisenach

Anesth Analg 2006 103: 690-695.

 靜脈應用酮洛來克對辣椒素誘發的深部組織痛覺過敏的作用

(徐麗穎譯 薛張綱校)

The Effect of Intravenous Ketorolac on Capsaicin-Induced Deep Tissue Hyperalgesia

Keeran Kumar, Greg R. Polston, and Mark S. Wallace

Anesth Analg 2006 103: 696-702.

乳腺手術前行椎旁神經阻滯(PVB)可減少術後慢性疼痛的發生

(趙延華 陳傑 校)

Preincisional Paravertebral Block Reduces the Prevalence of Chronic Pain After Breast Surgery

Pekka M. Kairaluoma, Martina S. Bachmann, Per H. Rosenberg, and Pertti J. Pere

Anesth Analg 2006 103: 703-708.

腹式全子宮切除術後足三裏穴應用辣椒素貼的鎮痛作用

(周雅春 馬皓琳 李士通 校)

The Analgesic Effects of Capsicum Plaster at the Zusanli Point After Abdominal Hysterectomy

Kyo S. Kim and Yu M. Nam

Anesth Analg 2006 103: 709-713.  

給大鼠間歇性腰穿:一種新的實驗方法用於研究阿片類藥物的耐受性

(王慧琳譯 薛張綱校)

Intermittent Lumbar Puncture in Rats: A Novel Method for the Experimental Study of Opioid Tolerance (Technical Communication)

Jijun J. Xu, Brittan C. Walla, Miguel F. Diaz, Gregory N. Fuller, and Howard B. Gutstein

Anesth Analg 2006 103: 714-720.

疼痛記憶:外周神經樹脂毒素的作用

(宋翠俠 陳傑 校)

Memory of Pain: The Effect of Perineural Resiniferatoxin

Igor Kissin, Cristina F. Freitas, and Edwin L. Bradley, Jr

Anesth Analg 2006 103: 721-728.

通過亞麻醉量的右旋氯胺酮來調節疼痛成像

(薑旭暉 馬皓琳 李士通校)

Imaging Pain Modulation by Subanesthetic S-(+)-Ketamine

Till Sprenger, Michael Valet, Ralph Woltmann, Claus Zimmer, Rainer Freynhagen, Eberhard F. Kochs, Thomas R. Tölle, and Klaus J. Wagner

Anesth Analg 2006 103: 729-737.

 痛敏肽受體在笑氣的痛敏反應中的作用

(鐘靜譯 薛張綱校)

The Involvement of the Nociceptin Receptor in the Antinociceptive Action of Nitrous Oxide

Shugaku Himukashi, Hiroshi Takeshima, Sahoko Koyanagi, Tsutomu Shichino, and Kazuhiko Fukuda

Anesth Analg 2006 103: 738-741.

 

樞複寧在P-糖蛋白制作用過程中的傷害性疼痛效應

(宋金超 陳傑 校)

The Pronociceptive Effect of Ondansetron in the Setting of P-Glycoprotein Inhibition

Jason A. Scott, Margaret Wood, and Pamela Flood

Anesth Analg 2006 103: 742-746.

嗎啡對人類5-HT 3A受體的影響

(張瑩 馬皓琳 李士通校)

The Effects of Morphine on Human 5-HT3A Receptors

Maria Wittmann, I. Peters, T. Schaaf, H. C. Wartenberg, S. Wirz, J. Nadstawek, B. W. Urban, and M. Barann

Anesth Analg 2006 103: 747-752.

 氟烷和異氟醚對非麻醉下去大腦大鼠背角神經元的不同作用

(王麗珺譯 薛張綱校)

The Differential Effects of Halothane and Isoflurane on Windup of Dorsal Horn Neurons Selected in Unanesthetized Decerebrated Rats

Toshihiko Mitsuyo, Robert C. Dutton, Joseph F. Antognini, and Earl Carstens

Anesth Analg 2006 103: 753-760.

肌間溝臂叢阻滯的神經定位術:機械異感法和神經刺激法的一項前瞻性、隨機比較研究

(曹瑜 陳傑 校)

Nerve Localization Techniques for Interscalene Brachial Plexus Blockade: A Prospective, Randomized Comparison of Mechanical Paresthesia Versus Electrical Stimulation

Gregory A. Liguori, Victor M. Zayas, Jacques T. YaDeau, Richard L. Kahn, Leonardo Paroli, Valeria Buschiazzo, and Anita Wu

Anesth Analg 2006 103: 761-767.

坐骨神經和股神經聯合阻滯下全膝關節成形術中的羅呱卡因和布比卡因的藥效動學

(唐李雋   馬皓琳 李士通 校)

The Pharmacodynamics of Ropivacaine and Bupivacaine in Combined Sciatic and Femoral Nerve Blocks for Total Knee Arthroplasty

Pierre Beaulieu, Denis Babin, and Thomas Hemmerling

Anesth Analg 2006 103: 768-774.

 

頸動脈內膜剝離術中頸深淺叢複合神經阻滯後心血管自主調節能的化

Altered Autonomic Cardiovascular Regulation After Combined Deep and Superficial Cervical Plexus Blockade for Carotid Endarterectomy

Young-Kug Kim, MD*, Gyu-Sam Hwang, MD*, In-Young Huh, MD*, Jai-Hyun Hwang, MD*, Jong-Yeon Park, MD*, Sung-Lyang Chung, MD*, Tae-Won Kwon, MD{dagger}, and Sung-Min Han, MD*

From the *Department of Anesthesiology and Pain Medicine and {dagger}Division of Vascular Surgery, Department of Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.

Anesth Analg 2006 103: 533-539.

失調的心臟自主調節會導致心血管能亂。作者研究了頸動脈內膜剝離術(CEA)中頸深淺叢複合神經阻滯(CP)是否對心血管自主調節能產生影響。為評估頸深淺叢複合神經阻滯前後心血管自主調節作用,22例行CEA的病人參與了此項研究。作者對其心率(HR)異性,收縮期血壓(SBP)異性,以壓反射靈敏度等指標進行了監測和分析。結果顯示在行頸深淺叢複合神經阻滯(CP)後,SBP (157±28mmHg vs 191±38mmHg)和HR (68±10bpm vs 84±9bpm)均有所增。心率異性的高頻率(3.7±0.9 vs 2.2±1.2In/ms²)下降(副交感降低);而收縮期血壓異性的低頻率(5.5±4.7mmHg vs 8.6±9.4mmHg²)增(交感增強);壓反射靈敏度降低,而且這種減少與SBP的增呈負相關的(r=-0.455)。目前的研究結果提示頸深淺叢複合神經阻滯(CP)破壞了心血管自主調節系統的動態平衡。因此,在行CEA的高危心臟病人中,頸深淺叢複合神經阻滯(CP)與術中和術後的不利的心血管事件是否有一定的相關,有待進一步研究證實。

(衛紅 陳傑 校)

Compromised cardiac autonomic modulation can produce cardiovascular disturbances. We investigated whether combined deep and superficial cervical plexus (CP) blockade for carotid endarterectomy (CEA) produces changes in autonomic cardiovascular regulation. To estimate alterations in cardiovascular autonomic control before and after combined CP blockade in 22 patients undergoing CEA, the heart rate (HR) variability, systolic blood pressure (SBP) variability, and baroreflex sensitivity were analyzed. We found that SBP (157 ± 28 mm Hg versus 191 ± 38 mm Hg before and after combined CP blockade, respectively) and HR (68 ± 10 bpm versus 84 ± 9 bpm) increased after combined CP blockade. The high frequency power of HR variability (3.7 ± 0.9 versus 2.2 ± 1.2 ln/ms2) decreased (decrease in parasympathetic drive), whereas the low frequency power of SBP variability (5.5 ± 4.7 versus 8.6 ± 9.4 mm Hg2) increased (increase in vascular sympathetic outflow). Baroreflex sensitivity decreased, and this decrease was negatively correlated with a SBP increase (r = –0.455). The present results suggest that combined CP blockade impairs autonomic cardiovascular homeostasis and suggests an association between combined CP blockade and intraoperative or postoperative adverse cardiovascular events in high-risk cardiac patients undergoing CEA that merits further studies.

 

模擬麻醉危象中認知輔方法的應用

Use of Cognitive Aids in a Simulated Anesthetic Crisis

T. Kyle Harrison, MD, Tanja Manser, PhD, Steven K. Howard, MD, and David M. Gaba, MD

From the Patient Simulation Center of Innovation at VA Palo Alto Health Care System and the Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2006 103: 551-556.

 

作者憑經驗地評估了在高保真模擬惡性高熱事件中,使用認知輔方法是否促進惡性高熱的準確、時地治療。48例模擬噁心高熱的成人病例,其中24例為CA1組,24例為CA2組。在CA1組中,24個病例中有19例使用了認知輔方法(79%),19例中8例是經常或廣泛使用認知輔方法。而在CA2組中,23例中有18例使用了認知輔方法(78%),18個病例中僅6例經常或廣泛地使用認知輔方法。在CA1CA2組中,認知輔方法使用頻率與惡性高熱治療的有效性顯著相關,CA 1 r0.59P<0.01),CA 2 r0.68P<0.001)。治療惡性高熱最佳的團經常使用認知輔方法。儘管這種現象在CA2的佇列中並不十分顯著,但是認知輔方法的使用與惡性高熱的治療仍有顯著相關性。作者認為認知輔方法與惡性高熱正確治療之間存在顯著相關。

(詹慧 陳傑 校)

We evaluated empirically the extent to which the use of a cognitive aid during a high-fidelity simulation of a malignant hyperthermia (MH) event facilitated the correct and prompt treatment of MH. We reviewed the management of 48 simulated adult MH scenarios; 24 involving CA 1 and 24 involving CA 2 residents. In the CA 1 group, 19 of the 24 teams (79%) used a cognitive aid, but only 8 of the 19 teams used it frequently or extensively. In the CA 2 group, 18 of the 23 teams (78%) used a cognitive aid but only 6 of them used it frequently or extensively. The frequency of cognitive aid use correlated significantly with the MH treatment score for the CA 1 group (Spearman r = 0.59, P < 0.01) and CA 2 group (Spearman r = 0.68, P < 0.001). The teams that performed the best in treating MH used a cognitive aid extensively throughout the simulation. Although the effect was less pronounced in the more experienced CA 2 cohort, there was still a strong correlation between performance and cognitive aid use. We were able to show a strong correlation between the use of a cognitive aid and the correct treatment of MH.

 

異丙酚減弱致敏大鼠氣管卵清蛋白誘導的支氣管平滑肌收縮:制5-羥色胺和乙醯膽鹼信號轉導

Propofol Attenuates Ovalbumin-Induced Smooth Muscle Contraction of the Sensitized Rat Trachea: Inhibition of Serotonergic and Cholinergic Signaling

Masakazu Yamaguchi, MD, Osamu Shibata, MD, Kenji Nishioka, MD, Tetsuji Makita, MD, and Koji Sumikawa, MD

From the Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki, Japan.

Anesth Analg 2006 103: 594-600.

異丙酚被認為適合於支氣管哮喘病人的麻醉誘導。然而,它作用於支氣管的機制尚未完全闡明。作者研究了異丙酚對卵清蛋白(OA)誘導的致敏鼠支氣管收縮作用的效應。雄性Wistar鼠,用卵清蛋白10ug混合鋁氫氧化合物10mg單次腹腔內注射以致敏。14天后,用支氣管環作試驗研究。觀察凱坦生(5-HT2受體拮)和阿托品對卵清蛋白誘導的收縮作用的影響。然後觀察異丙酚對卵清蛋白,5羥色胺,乙醯膽鹼電刺激誘發的收縮效應的影響。凱坦生和阿托品混合減弱卵清蛋白誘發的收縮效應90%。異丙酚量依賴性減弱卵清蛋白誘發的收縮作用。異丙酚可消除5羥色胺誘發的收縮效應,減弱乙醯膽鹼的收縮作用,幾乎完全減弱由電刺激區域5羥色胺引起收縮增強作用。這些結果提示異丙酚減弱卵清蛋白誘導的收縮作用的機制是制5羥色胺。異丙酚在免疫球蛋白E相關的哮喘病人應是一個有用的麻醉藥。

(丁震敏 陳傑 校)

Propofol is considered suitable for induction of anesthesia in patients with bronchial asthma. However, the mechanisms of its action on bronchi are not fully understood. We examined the effects of propofol on ovalbumin (OA)-induced contraction of OA-sensitized rat trachea. Male Wistar rats were sensitized by a single intraperitoneal injection of OA 10 µg mixed with aluminum hydroxide, 10 mg, as adjuvant. Fourteen days later, the experiment was performed using the tracheal rings. We observed the effects of ketanserin, a 5-HT2 receptor antagonist, and atropine on OA-induced contraction. Next, the effects of propofol on OA-, serotonin (5-HT)-, acetylcholine-, or electrical field stimulation-induced contractions were observed. OA-induced contraction was 90% attenuated by the combination of ketanserin and atropine. Propofol significantly attenuated OA-induced contraction in a dose-dependent manner. Propofol abolished 5-HT-induced contraction, attenuated acetylcholine-induced contraction, and also almost completely attenuated the enhancement by 5-HT of electrical field stimulation-induced contraction. These results suggest that the mechanism involved in the attenuation by propofol of OA-induced contraction is inhibition of the actions of 5-HT. Propofol should be a useful anesthetic in patients with immunoglobulin E-related asthma.

 

局部麻醉對家兔眼睛初級感覺神經和副交感神經的制作用

The Inhibitory Effects of Local Anesthetics on Primary Sensory Nerve and Parasympathetic Nerve in Rabbit Eye

Ko Takakura, MD, PhD*, Maki Mizogami, MD, PhD*, Shigeru Morishima, MD, PhD{dagger}, and Ikunobu Muramatsu, PhD{dagger}

From the *Department of Anesthesiology, Asahi University School of Dentistry, Hozumi, Mizuho, Gifu; and {dagger}Division of Pharmacology, Department of Biochemistry and Bioinformative Sciences, School of Medicine, University of Fukui, Matsuoka, Japan.

Anesth Analg 2006 103: 615-619.

初級感覺神經同時向外周神經系統和中樞神經系統傳遞資,並且通過在外周釋放諸如速激肽之類的神經遞質來調節神經源性炎症。因為局部麻醉在神經源性炎症中的作用仍有爭議,作者通過對比局部麻醉在家兔的虹膜括約肌中對於速激肽類神經遞質和膽鹼類神經遞質的直接作用進行相關的研究。家兔虹膜括約肌受三叉神經速激肽類和副交感膽鹼類神經的支配,經粘膜電刺激可以產生速激肽類和膽鹼類神經支配引發的收縮。可卡因和利多卡因(1-300uM)以濃度和刺激頻率依賴性的方式消弱由電刺激所引發的速激肽類和膽鹼類收縮。然而,局部麻醉對於速激肽類神經作用的敏感度要比在膽鹼類中的更高,這種差異輕微但有顯著意義。外源性神經激肽A和氯化氨甲醯膽鹼所產生的收縮不受100uM的可卡因和利多卡因影響。述研究結果顯示局部麻醉對三叉神經感覺支中的速激肽類神經遞質有直接的制作用,而且這種作用較之在同一神經的副交感支的作用更為顯著。提示局部麻醉可能由外周感覺神經傳導的制而產生神經炎症的作用。

(李惟一 陳傑 校)

Primary sensory nerves transmit information to both the periphery and central nervous systems, and they mediate neurogenic inflammation by release of neurotransmitters, such as tachykinins, in the periphery. Because the effect of local anesthetics on neurogenic inflammation is a subject of controversy, we investigated the direct effect of local anesthetics on tachykininergic neurotransmission, comparing it with cholinergic neurotransmission in the rabbit iris sphincter muscle. Rabbit iris sphincter muscle is innervated by trigeminal tachykininergic and parasympathetic cholinergic nerves, and the electrical transmural stimulation produces tachykininergic and cholinergic contractions. Cocaine and lidocaine (1–300 µM) attenuated tachykininergic and cholinergic contractions induced by electrical transmural stimulation in concentration- and stimulus frequency-dependent manner. However, the sensitivity to both local anesthetics was slightly, but significantly, higher in tachykininergic than in cholinergic responses. Exogenous neurokinin A and carbachol produced contractions that were not inhibited by 100 µM of cocaine and lidocaine. These results show that local anesthetics have a direct inhibitory effect on tachykininergic neurotransmission of the trigeminal sensory nerve, and the effect on this nerve is more potent than on the parasympathetic nerve and suggests that local anesthetics may have antineurogenic inflammatory effects via the inhibitory effects on the peripheral transmission of primary sensory nerve.

 

用雙頻指數評估麻醉深度與術後認知能障礙和恢復有關嗎?

Is Depth of Anesthesia, as Assessed by the Bispectral Index, Related to Postoperative Cognitive Dysfunction and Recovery?

Ehab Farag, MD, FRCA*, Gordon J. Chelune, PhD{dagger}, Armin Schubert, MD, MBA*, and Edward J. Mascha, PhD

From the *Department of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio; {dagger}Department of Neurology, Center for Alzheimer’s Care, Imaging, and Research, University of Utah, Salt Lake City, Utah; and {ddagger}Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2006 103: 633-640.

[

作者將74位手術患者隨機分成手術過程中低BIS組(平均BIS值,38.9)和高BIS組(平均BIS值,50.7)。分別在術前和術後4-6周,用認知的一套試驗包括運算速度指數(processing speed index)、工作記憶指數(working memory index)和語言記憶指數(verbal memory index)對患者的認知狀態進行評估。低BIS組運算速度指數為113.7±1.5,高BIS組為107.9±1.4P0.006)。在另外兩項試驗中無差異。因此,較深的麻醉深度與術後4-6周認知能較好有一定的相關性,特別表現在資運算能等方面。

(肖潔 陳傑 校)

We randomized 74 patients to either a lower Bispectral Index (BIS) regimen (median BIS, 38.9) or a higher BIS regimen (mean BIS, 50.7) during the surgical procedure. Preoperatively and 4–6 wk after surgery, the patients’ cognitive status was assessed with a cognitive test battery consisting of processing speed index, working memory index, and verbal memory index. Processing speed index was 113.7 ± 1.5 (mean ± se) in the lower BIS group versus 107.9 ± 1.4 in the higher BIS group (P = 0.006). No difference was observed in the other two test battery components. Somewhat deeper levels of anesthesia were therefore associated with better cognitive function 4–6 wk postoperatively, particularly with respect to the ability to process information.

 

β-受體阻滯減輕大鼠大腦暫時性局部缺血後損傷

ß-Adrenoreceptor Antagonists Attenuate Brain Injury After Transient Focal Ischemia in Rats

Toru Goyagi, MD, Tetsu Kimura, MD, Toshiaki Nishikawa, MD, Yoshitsugu Tobe, and Yoko Masaki, PhD

From the Department of Anesthesia and Intensive Care Medicine, Akita University School of Medicine, Akita, Japan.

Anesth Analg 2006 103: 658-663.

 

實驗發現β-受體阻滯可以減輕心臟和腎臟缺血後的損傷,用於臨治療心梗和嚴重燒傷。此外,在實驗條件下β-受體阻滯對大腦暫時性局部缺血後起到神經能保護作用。作者設計了這個實驗來比較幾種不同的β-受體阻滯對大鼠大腦暫時性局部缺血後的神經保護作用。氟烷麻醉下體溫正常的成年雄性SpragueDawley大鼠大腦中動脈阻斷2小時(管腔內的縫合線借並用鐳射多普勒血流測量儀驗證)。一部分大鼠接受靜脈輸注(IV)生理鹽水0.5mL/h,普萘洛爾100ug·kg1·min1,卡維地洛4 ug·kg1·min1,艾司洛爾200 ug·kg1·min1或者蘭地洛爾50 ug·kg1·min1(每組n6),大腦中動脈阻斷前30分鐘開始靜脈注射並持續24小時。按照同樣的實驗設計,另一部分大鼠接受鞘內(IT)枕大池注射艾司洛爾50 ug·kg1·min1或者蘭地洛爾10 ug·kg1·min1n5每組)。再灌注22小時後進行神經病學的損傷評估,取出腦組織用氯化三苯四唑固定後測定梗塞灶體積。另一部分大鼠接受靜脈注射saline,艾司洛爾和蘭地洛爾(n6每組),存活七天后測定梗塞灶的大小。神經病學的評估發現給予普萘洛爾(IV),卡維地洛(IV),艾司洛爾(IV),蘭地洛爾(IV),艾司洛爾(IT),蘭地洛爾(IT)的大鼠較給予saline的大鼠損傷輕(P<0.05)。接受靜脈內或鞘內注射β-受體阻滯的大鼠大腦皮質和紋狀體的梗塞灶體積較給予生理鹽水的大鼠小(P<0.05)。作者推斷β-受體阻滯可以改善大鼠大腦暫時性局部缺血後的神經學和組織學結果,並且與給藥途徑無關。

(周懿之 陳傑 校)

ß-adrenoreceptor antagonists experimentally reduce cardiac and renal injury after ischemia and are also clinically useful for myocardial infarction and severe burns. In addition, ß-adrenoreceptor antagonists provide neuroprotective effects after focal cerebral ischemia in experimental settings. We conducted the present study to compare the neuroprotective effects of several ß-adrenoreceptor antagonists in rat transient focal cerebral ischemia. Halothane-anesthetized normothermic adult male Sprague-Dawley rats were subjected to 2 h of middle cerebral artery occlusion using the intraluminal suture technique confirmed by laser Doppler flowmetry. Rats received an IV infusion of saline 0.5 mL/h, propranolol 100 µg · kg–1 · min–1, carvedilol 4 µg · kg–1 · min–1, esmolol 200 µg · kg–1 · min–1, or landiolol 50 µg · kg–1 · min–1 (n = 6 in each group). Infusion was initiated 30 min before middle cerebral artery occlusion and continued for 24 h. Additional rats received esmolol 50 µg · kg–1 · min–1 or landiolol 10 µg · kg–1 · min–1 intrathecally (IT) via the cisterna magna (n = 5 in each group), according to the same experimental protocol. The neurological deficit score was evaluated at 22 h after reperfusion, and the brains were removed and stained with triphenyltetrazolium chloride for evaluation of infarct volume. Additional rats that received saline, esmolol, and landiolol IV (n = 6 in each group) were allowed to survive for 7 days followed by measurement of infarct size. Neurological deficit scores were smaller in rats treated with propranolol-IV, carvedilol-IV, esmolol-IV, landiolol-IV, esmolol-IT, and landiolol-IT compared with saline-treated rats (P < 0.05). Cortical and striatum infarct volumes were less in the rats receiving ß-adrenoreceptor antagonists via either IV or IT than in saline-treated rats (P < 0.05). We conclude that ß-adrenoreceptor antagonists improve neurological and histological outcomes after transient focal cerebral ischemia in rats independent of administration route.

 

腹膜內局麻在腹腔鏡下膽切除術中的作用:系統回顧與薈萃分析

The Effect of Intraperitoneal Local Anesthesia in Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis

Alexander P. Boddy, BM, BCh, Samir Mehta, BM, BCh, and Michael Rhodes, MD

From the Department of General Surgery, Norfolk and Norwich University Hospital, United Kingdom.

Anesth Analg 2006 103: 682-688.

 

腹膜內給藥局部麻醉常被用於強腹腔鏡下膽切除術後鎮痛效果。作者進行了一系列綜合性分析從而確立這一術在減輕術後腹部疼痛的效能。系統文獻檢索顯示了24個隨機對比實驗評估腹膜內局麻在符合實驗標準的腹腔鏡下膽切除術中的應用效果。其中,16個研究報導了充分的資料從而可以進行組合定量分析。手術後4小時視覺類比評分平均數(WMD)使用隨機的效應模型以混合。總體說,腹膜內局麻可以顯著降低術後4小時的痛覺評分(WMD,-9mm95%CI〕,-13至-5)。亞組分析提示這種局部麻醉在手術開始時即進行與在手術結束時注藥相比(WMD,-6mm95(CI),-10至-2)其效果會更強(WMD,-13mm95(CI),-19至-7)。沒有發現關於發生局麻藥毒性反應的負面事例的報導。結論:腹膜內局麻是安全的,並顯著減輕了術後早期的腹部疼痛。

(印傑敏 陳傑 校)

Intraperitoneal administration of local anesthesia is often used to improve pain relief after laparoscopic cholecystectomy. We have conducted a meta-analysis to establish the efficacy of this technique in reducing early postoperative abdominal pain. A systematic literature search revealed 24 randomized, controlled trials assessing intraperitoneal local anesthetic use in laparoscopic cholecystectomy that met inclusion criteria. Of these, 16 studies reported sufficient data to allow pooled quantitative analysis. The weighted mean differences (WMD) in visual analog pain score at 4 h after surgery were pooled using a random effects model. Overall, the use of intraperitoneal local anesthesia resulted in a significantly reduced pain score at 4 h (WMD, –9 mm; 95% confidence interval [CI], –13 to –5). Subgroup analysis suggested that the effect was greater when the local anesthetic was given at the start of the operation (WMD, –13 mm; 95% CI, –19 to –7) compared with instillation at the end (WMD, –6 mm; 95% CI, –10 to –2). No adverse events related to local anesthetic toxicity were reported. We conclude that the use of intraperitoneal local anesthesia is safe, and it results in a statistically significant reduction in early postoperative abdominal pain.

 

乳腺手術前行椎旁神經阻滯(PVB)可減少術後慢性疼痛的發生

Preincisional Paravertebral Block Reduces the Prevalence of Chronic Pain After Breast Surgery

Pekka M. Kairaluoma, MD, Martina S. Bachmann, MD, PhD, Per H. Rosenberg, MD, PhD, and Pertti J. Pere, MD, PhD

From the Department of Anesthesia and Intensive Care Medicine, Helsinki University Hospital, Finland.

Anesth Analg 2006 103: 703-708.

作者早先曾報導過,乳腺腫瘤手術前行椎旁神經阻滯(PVB)可提供明顯而迅速的術後鎮痛。作者對這些病人(n60)又進行了為期一年的隨訪,以觀察PVB是否也能減少術後慢性疼痛的發生。該隨訪包括14天的症狀記錄和術後1個月、6個月、12個月時通過電話詢問病人情況。30PVB患者和30名對照者的14天鎮痛藥用量是相同的。但是,術後1個月後運動相關性疼痛的強度在PVB組較低(P = 0.005)。術後6個月後,任何疼痛症狀的發生情況在PVB組均較低(P = 0.029)。最後,術後12個月後,除了疼痛症狀的發生率較低(P = 0.003)和運動相關性疼痛程度較輕(P = 0.003)外,PVB組靜息性疼痛的強度也較輕(P = 0.011)。這些結果與術中有無切開臂叢神經無關。神經病理性疼痛的發生率低(PVB組和對照組分別為2例和3例)。乳腺腫瘤手術前PVB除了能緩解術後急性疼痛,也能減輕術後1年時間內慢性疼痛的發生。

(趙延華 陳傑 校)

We reported earlier that preincisional paravertebral block (PVB) provides significant immediate postoperative analgesia after breast cancer surgery. In the same patients (n = 60), a 1-yr follow-up was performed to find out whether PVB could also reduce the prevalence of postoperative chronic pain. The follow-up consisted of a 14-day symptom diary and telephone interviews 1, 6, and 12 mo after surgery. The 14-day consumption of analgesics was similar in the 30 PVB and the 30 control patients. However, 1 mo after surgery, the intensity of motion-related pain was lower (P = 0.005) in the PVB group. Six months after surgery, the prevalence of any pain symptoms (P = 0.029) was lower in the PVB group. Finally, at 12 mo after surgery, in addition to the prevalence of pain symptoms (P = 0.003) and the intensity of motion-related pain (P = 0.003), the intensity of pain at rest (P = 0.011) was lower in the PVB group. These findings were independent of whether or not axillary dissection had been performed. The incidence of neuropathic pain was low (two and three patients in the PVB and control groups, respectively). In addition to providing acute postoperative pain relief, preoperative PVB seems to reduce the prevalence of chronic pain 1 yr after breast cancer surgery.


疼痛記憶:外周神經樹脂毒素的作用

Memory of Pain: The Effect of Perineural Resiniferatoxin

Igor Kissin, MD, PhD*, Cristina F. Freitas, BA*, and Edwin L. Bradley, Jr, PhD{dagger}

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and {dagger}Department of Biostatistics, University of Alabama at Birmingham.

Anesth Analg 2006 103: 721-728.

中樞神經系統對於急性疼痛的持久記憶可能導致向慢性疼痛轉化。據報導,長時增強於中樞敏感性均可作為突觸可塑性的形式,並且可以通過刺激C類神經纖維所誘發。目前的研究中,作者通過在角叉藻聚糖反復的誘發炎症反應中測定遠端的痛覺增敏情況來評估對傷害性疼痛的記憶,這種方法用於判斷是否選擇性阻斷C類神經纖維可以制持久的疼痛記憶的發生。在大鼠實驗中,於坐骨神經和隱神經處經皮給予樹脂毒素,然後分別在後爪通過交叉的2只置入器注射角叉藻聚糖,觀察2周,在這2次炎症反應中,於各個不同的時間間隔測定指標:對傷害性壓的反應,後爪的溫度以體積的化。試驗表明:初次炎症反應誘發的痛覺增敏恢復後,反復的炎症反應可以導致遠端的痛覺增敏,而在初次炎症反應是不出現的。第二次注射角叉藻聚糖後,遠端痛覺增敏的最大值(對側的後爪傷害性壓的閾值從141±23g下降為96±19gp< 0.0001)達到24h。在反復的炎症反應中初次注射角叉藻聚糖之前給予外周神經樹脂毒素(0.001%)後遠端的痛覺增敏可以完全制(p<0.0002)。述結果顯示傷害性神經纖維的選擇性阻滯能預防中樞神經系統長時程痛覺高敏相關的印跡的形成。因此,疼痛記憶能通過選擇性、長時C-纖維預製。

(宋翠俠 陳傑 校)

The long-lasting imprint of acute pain in the central nervous system may contribute to the transition of acute pain to chronicity. The long-term potentiation (which is proposed as a mechanism of memory) and central sensitization were each reported as a form of synaptic plasticity, and both can be initiated by stimulation of C fibers. In the current study, we assessed nociceptive memory regarding hyperalgesia by measuring distant hyperalgesia after repeated carrageenan-induced inflammation. This approach was used to determine whether selective blockade of C fibers can prevent the development of a long-lasting imprint of hyperalgesia. In rat experiments, resiniferatoxin was administered percutaneously at the sciatic and saphenous nerves, and two crossover intraplantar injections of carrageenan into the hindpaws were performed 2 wk apart. Responses to noxious pressure and heat and changes in paw volumes were measured at various intervals during two carrageenan-induced inflammations. The experiments demonstrated that after recovery of hyperalgesia induced by the initial inflammation, repeated inflammation led to the development of a distant hyperalgesia that was absent during the initial inflammation. The maximum of distant hyperalgesia (decrease of noxious pressure threshold in the contralateral hindpaw from 141 ± 23 g to 96 ± 19 g; P < 0.0001) was reached 24 h after the second injection of carrageenan. The development of distant hyperalgesia during the repeated inflammation was completely prevented (P < 0.0002) by perineural resiniferatoxin (0.001%) administered before the initial injection of carrageenan. These results indicate that selective blockade of nociceptive fibers prevents formation of long-term hyperalgesia-related imprint in the central nervous system. Thus, pain memory can be preempted by selective and prolonged blockade of C-fibers.


樞複寧在P-糖蛋白制作用過程中的傷害性疼痛效應

The Pronociceptive Effect of Ondansetron in the Setting of P-Glycoprotein Inhibition

Jason A. Scott, MD, Margaret Wood, MD, and Pamela Flood, MD

From the Department of Anesthesiology, Columbia University, New York, New York.

Anesth Analg 2006 103: 742-746

.

樞複甯是一種強效的止吐藥,它通過制5HT3受體起效。異氟醚的肺泡最低有效濃度 (MAC)不受外周血裏樞複寧的影響;然而,樞複寧是P-糖蛋白(一種表達在血腦屏障的轉運泵)的酶作用底物。因此作者假設中樞神經系統的樞複寧的濃度可能被P-糖蛋白所消減。作為一直強的P-糖蛋白制,在臨試驗中用來促進化療藥或菌()素進入中樞神經系統,作者研究了P-糖蛋白缺如時樞複寧的影響。給予正常大鼠腰部鞘內注射樞複寧賦型。P-糖蛋白敲除的大鼠野生型對照大鼠無論是否臨使用P-糖蛋白制物都給予外周樞複寧處理。傷害感受性用熱刺激退縮等待時間來評估,無體動時的異氟醚濃度作為異氟醚的MAC。在大鼠鞘內注射樞複寧 (20 g )增熱疼痛敏感性20.0% ± 5.8% (P < 0.01)。在P-糖蛋白敲除的大鼠中外周樞複寧 (2 mg/kg) 增了熱疼痛敏感性,但是在野生型對照大鼠中沒有作用 (P < 0.01)。外周 樞複寧對經P-糖蛋白制物奎尼丁處理以後的野生型大鼠有小的但有統計意義的傷害感受性的影響,但是對經環孢黴素 A或維拉帕米處理的野生型大鼠無影響。在P-糖蛋白敲除的大鼠中異氟醚的MAC沒有因鞘內注射樞複甯或外周給予樞複寧而改。鞘內注射樞複寧可以提高熱疼痛敏感性。在P-糖蛋白缺如時, 樞複寧可以達到足夠的濃度以增疼痛敏感。即使直接髓給藥, 樞複寧也沒有改異氟醚的MAC值,結果支持了5HT3 對全身麻醉藥制動作用不起作用的觀點。

(宋金超 陳傑 校)

Ondansetron is a potent antiemetic drug that acts through inhibition of the 5HT3 receptors for serotonin. Minimum alveolar concentration (MAC) for isoflurane is not affected by systemic ondansetron; however ondansetron is a substrate of P-glycoprotein, a transport pump expressed in the blood-brain barrier. Thus, we hypothesized that central nervous system concentrations of ondansetron might be reduced by the P-gp protein. As potent inhibitors of P-gp are in clinical trials to improve access of desirable chemotherapeutic and antibiotic drugs to the central nervous system, we studied the effect of ondansetron in the absence of extrusion by P-gp. Normal rats were given lumbar intrathecal ondansetron or vehicle. P-gp knockout mice and wild-type controls were treated with systemic ondansetron in the presence and absence of clinically used P-gp inhibitors. Nociception was assessed as thermal hindpaw withdrawal latency and immobility was assessed as isoflurane MAC. In rats, intrathecal ondansetron (20 g) increased thermal pain sensitivity by 20.0% ± 5.8% (P < 0.01). Systemic ondansetron (2 mg/kg) increased pain sensitivity in P-gp knockout mice but had no effect in wild-type mice (P < 0.01). Systemic ondansetron had a small but statistically significant pronociceptive effect after treatment of wild-type mice with the P-gp inhibitor quinidine but not with cyclosporine or verapamil. Isoflurane MAC was not changed by intrathecal ondansetron in rats or systemically administered ondansetron in P-gp knockout mice. Intrathecal ondansetron can enhance thermal pain sensitivity. In the absence of P-gp protein, ondansetron can reach concentrations sufficient to increase pain sensitivity. Even with direct spinal application, ondansetron does not alter isoflurane MAC, supporting the idea that 5HT3 modulation does not play a role in general anesthetic immobility.


肌間溝臂叢阻滯的神經定位術:機械異感法和神經刺激法的一項前瞻性、隨機比較研究

Nerve Localization Techniques for Interscalene Brachial Plexus Blockade: A Prospective, Randomized Comparison of Mechanical Paresthesia Versus Electrical Stimulation

Gregory A. Liguori, MD, Victor M. Zayas, MD, Jacques T. YaDeau, MD, PhD, Richard L. Kahn, MD, Leonardo Paroli, MD, PhD, Valeria Buschiazzo, and Anita Wu, MD

From the Hospital for Special Surgery, Department of Anesthesiology Weill Medical College of Cornell University, New York, New York.

Anesth Analg 2006 103: 761-767.

術後神經症狀(PONS)在行外周神經阻滯的肢整形手術後是比較常見的。在這項研究中,作者前瞻性地比較了肩部手術使用電刺激法(ES)和機械異感法(MP)進行神經定位的肌間溝阻滯後PONS的發生率。在隨機選入MP組的中,一根1英寸長,23號的長斜面針置入肌間溝來誘導肩、手臂、肘、腕或手的麻痹感。ES組的病人,一根5cm22號的短斜面絕緣針置入肌間溝來誘導運動反應,包括肘、腕或手指的屈曲或伸展,或是三角肌的刺激反應,刺激強度0.2-0.5mA之間。每個肌間溝阻滯都使用1.5%甲呱卡因(另130萬腎腺素,0.1meq/L碳酸氫納)5060ml 218個病人隨機分入兩組。一個病人脫落。ES25個病人(23%)在針刺入時產生麻痹感。ESPONS的發生率是10.1%(11/109),而MP組的發生率是9.3%(10/108)(兩組差異不顯著)。PONS平均持續兩個月,所有患者的症狀在12個月內完全消失。成率、起效時間和病人滿意率兩組相同。結論:選擇神經定位的方法可以基於患者和麻醉醫師的舒適度和喜好,而不必考慮PONS的發生。

(曹瑜 陳傑 校)

Postoperative neurologic symptoms (PONS) are relatively common after upper extremity orthopedic surgery performed under peripheral neural blockade. In this study, we prospectively compared the incidence of PONS after shoulder surgery under interscalene (IS) block using the electrical stimulation (ES) or mechanical paresthesia (MP) techniques of nerve localization. For patients randomized to the MP group, a 1-in, 23-g long-beveled needle was placed into the IS groove to elicit a paresthesia to the shoulder, arm, elbow, wrist, or hand. For patients randomized to the ES group, a 5-cm, 22-g short-beveled insulated needle was placed into the IS groove to elicit a motor response including flexion or extension of the elbow, wrist, or fingers or deltoid muscle stimulation at a current between 0.2 and 0.5 mA. Each IS block was performed with 50–60 mL of 1.5% mepivacaine containing 1:300,000 epinephrine and 0.1meq/L sodium bicarbonate. Two-hundred-eighteen patients were randomized between the two groups. One patient was lost to follow-up. Twenty-five patients (23%) in the ES group experienced paresthesia during needle insertion. The incidence of PONS using the ES technique was 10.1% (11/109), whereas the incidence with the MP technique was 9.3% (10/108) (not significant). The PONS lasted a median duration of 2 mo, and symptoms in all patients resolved within 12 mo. The success rate, onset time, and patient satisfaction were also comparable between groups. We conclude that the choice of nerve localization technique can be made based on the patient’s and anesthesiologist’s comfort and preferences and not on concern for the development of PONS.


比伐盧定在不停跳冠脈再造術中提供快速、有效且可靠的凝作用:"EVOLUTION OFF"試驗的結果

Bivalirudin Provides Rapid, Effective, and Reliable Anticoagulation During Off-Pump Coronary Revascularization: Results of the "EVOLUTION OFF" Trial

Andreas Koster, MD*, Bruce Spiess, MD{ddagger}, Michael Jurmann, MD{dagger}, Cornelius M. Dyke, MD, Nicholas G. Smedira, MD, Sol Aronson, MD#, and Michael A. Lincoff, MD||

From the Departments of *Anesthesia and {dagger}Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum, Berlin, Germany; {ddagger}Department of Cardiothoracic Anesthesia, Virginia Commonwealth University, Richmond; Departments of Cardiothoracic Surgery and ||Cardiovascular Medicine, The Cleveland Clinic Foundation, Ohio; ¶Gaston Memorial Hospital, Gastonia; and #Department of Anesthesiology, Duke University, Durham, North Carolina.

Anesth Analg 2006;103:540-544

 

EVOLUTION OFF試驗中,我們評估了比伐盧定在不停跳冠脈搭橋術中與肝素-魚精蛋白相比的安全性效。在這項用比伐盧定處理的患者的EVOLUTION OFF資料分析中,我們評估了比伐盧定的藥代動學(PK)其凝的有效性,即達到活化凝血時間(ACT)目標值。分析的資料來自于101位元病人。在搭橋手術過程中,在推注0.75 mg/kg比伐盧定後,以1.75 mg · kg–1 · h–1的速率持續輸注。目標是ACT+>300 s。在4位患者身獲得了比伐盧定的PK資料。僅在例外情況中需要重複推注部分的藥量或增輸注速率。PK資料的分析顯示了初量推注後的比伐盧定的平均濃度為11.0 ± 0.53 µg/mL,輸注中的平均濃度為11.2 ± 2.32 µg/mL。比伐盧定濃度與ACT+值之間的Pearson相關度為0.92。比伐盧定的PK資料始終都超過6.5 µg/mL,該值已證實是經皮冠脈手術的有效濃度。比伐盧定濃度與ACT+值之間的相關度是好的,且目標ACT+值幾乎都能達到。這些結果提示:倘若按照目前的方案,比伐盧定在不停跳冠脈搭橋術中可提供可靠有效的凝作用。

(裘毅敏 譯,馬皓琳 李士通 校)

In the EVOLUTION OFF trial, we evaluated the safety and efficacy of bivalirudin during off-pump coronary artery bypass grafting as compared with heparin-protamine. In this subanalysis of EVOLUTION OFF data of bivalirudin-treated patients, we assessed the pharmacokinetics (PK) and effectiveness of bivalirudin anticoagulation to achieve target activated clotting time (ACT)+ values. Data from 101 patients were assessed. A bolus of 0.75 mg/kg of bivalirudin was followed by a continuous infusion of 1.75 mg · kg–1 · h–1 during the grafting procedure. An ACT+ value of >300 s was the target. In four patients, PK data for bivalirudin were obtained. Only in exceptional cases were repeat fractional boluses or an increase of the infusion rate required. Assessment of the PK data showed a mean concentration of bivalirudin after the initial bolus of 11.0 ± 0.53 µg/mL and a mean concentration during infusion of 11.2 ± 2.32 µg/mL. Pearson’s correlation between bivalirudin concentrations and ACT+ values was 0.92. Bivalirudin PK data consistently exceeded concentrations of 6.5 µg/mL, which have been evaluated as effective during percutaneous coronary intervention. The correlation between bivalirudin levels and ACT+ values was good, and the target ACT+ values were almost always achieved. These results suggest that bivalirudin, given according to the current protocol, provides reliable and effective anticoagulation during off-pump coronary artery bypass graft surgery.

 

慢性心衰的圍手術期處理

Perioperative Management of Chronic Heart Failure

Leanne Groban, MD*, and John Butterworth, MD{dagger}

From the *Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina; {dagger}Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.

Anesth Analg 2006;103:557-575

 

心衰是正在增多的一些心臟情況之一。儘管對激素和其他信號系統的病理生理基礎有較好的瞭解,儘管通過藥物治療改善預後,許多心衰病人還是沒有接受有效的治療。心衰病人通常在手術室和ICU裏需要醫學診斷和處理;那麼,麻醉醫師應掌握最新的門診病人(慢性)的醫學治療進展和住院病人的急性心衰病情惡化的處理。因此,我們回顧了血管張素轉換酶制、血管張素受體阻滯、ß-腎腺素受體阻滯和醛固酮拮,因為這些藥物延長生命,也在當前的慢性心衰臨實踐指導中經常應用。我們還回顧了慢性心衰病人行手術和麻醉的併發症,並討論了對急性症狀惡化(例如由血管內容量過多、不恰當的藥物“假期”或者潛在的心臟疾病的惡化引起)如何最好地提供強治療。

(彭中美 馬皓琳 李士通校)

Heart failure (HF) is one of the few cardiac conditions that is increasing. Despite a better understanding of how hormones and other signaling systems underlie the pathophysiology, and despite improved outcomes from pharmacologic therapy, many HF patients receive no effective treatment. Patients with HF commonly require medical diagnosis and management in operating rooms and critical care units; thus anesthesiologists are obliged to remain up-to-date both with advances in outpatient (chronic) medical management and with inpatient treatments for acute exacerbations of HF. Accordingly, we reviewed angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, ß-adrenergic receptor blockers, and aldosterone antagonists because these drugs prolong life and are included in current clinical practice guidelines for treating patients with chronic HF. We also reviewed the implications of chronic HF for patients undergoing surgery and anesthesia and discuss how best to provide intensive treatment for acute exacerbations of symptoms, such as might be caused by excessive intravascular volume, inappropriate drug "holidays," or worsening of the underlying cardiac disease.

 

大鼠氣管內注射維庫溴與靜脈給藥和肌注的效能比較

The Efficacy of Intratracheal Administration of Vecuronium in Rats, Compared with Intravenous and Intramuscular Administration

Hiroshi Sunaga, MD*, Masahisa Kaneko, PhD{dagger}, and Yoshikiyo Amaki, MD*

From the *Department of Anesthesiology, Jikei University School of Medicine Tokyo, Japan; and {dagger}Medical Museum, Graduate School of Medicine and Faculty of Medicine, University of Tokyo, Tokyo, Japan.

Anesth Analg 2006;103:601-607

 

氣管內給藥將成為注射維庫溴的一個可選擇的途徑,為了研究其適當與否,我們比較了三組大鼠分別經氣管內、肌肉和靜脈注射維庫溴的藥效動學參數。同時也研究了三組中維庫溴的藥代動學。經氣管內、靜脈和肌注的量分別設在1.500.302.25mg/kg。氣管內給藥組起效(127 ± 17s)明顯早於肌注組(267 ± 62s),明顯晚於靜脈組(18 ± 7s(經方差分析和Tukey-Kramer 分析P < 0.05)。氣管內給藥組的作用時間(794 ± 162 s)明顯長於靜脈給藥組(93 ± 30 s),但與肌注組(743 ± 131 s)沒有明顯差異。氣管內給藥組的恢復指數(134 ± 30 s)明顯短於肌注組(222 ± 47 s),明顯長於靜脈給藥組(32 ± 12 s)。儘管氣管內給予維庫溴仍慢於靜脈注射,但倘若其較肌注組吸收快、起效快,看來仍較有優勢。

(黃麗娜 馬皓琳 李士通 較)

To investigate the suitability of the intratracheal (IT) route as an alternative route for the administration of vecuronium, we compared the pharmacodynamic parameters for neuromuscular block in three groups of rats given vecuronium via the IT, IM, and IV routes. We also examined the pharmacokinetics of vecuronium in the three groups. The doses for the IT, IV, and IM groups were set at 1.50, 0.300, and 2.25 mg/kg, respectively. The onset of action in the IT group (127 ± 17 s) was significantly earlier than that in the IM group (267 ± 62 s), and significantly later than that in the IV group (18 ± 7 s) (P < 0.05 by analysis of variance and the Tukey-Kramer analysis). The duration of action in the IT group (794 ± 162 s) was significantly longer than that in the IV group (93 ± 30 s) but not significantly different from that in the IM group (743 ± 131 s). The recovery index in the IT group (134 ± 30 s) was significantly shorter than that in the IM group (222 ± 47 s) and significantly longer than that in the IV group (32 ± 12 s). Although IT administration of vecuronium is still slower than IV administration, it appears to be more advantageous as compared with IM administration, given the more rapid absorption and faster onset of action.

 

經皮血氣二氧化碳監測小鼠誘導性通氣制

Transcutaneous Blood Gas CO2 Monitoring of Induced Ventilatory Depression in Mice

Peyman Sahbaie, MD*, Shohreh Madanlou, MD*, Parham Gharagozlou, MD*, J. David Clark, MD, PhD{dagger}, Jelveh Lameh, PhD*, and Timothy M. Delorey, PhD*

From the *Molecular Research Institute, Mountain View, California; {dagger}VA Palo Alto Health Care System and Stanford University Department of Anesthesiology, Palo Alto, California.

Anesth Analg 2006;103:620-625

 

我們評估了在小鼠監測經皮二氧化碳分壓(Ptcco2)這項簡便非創傷性術以確定其是否能夠精確可重複的評估小鼠的通氣制。為了達到此目標,異氟醚吸入麻醉的雄性C57Bl/6小鼠吸入不同百分比的二氧化碳或太尼(已知的呼吸制藥物),監測Ptcco2 Paco2 (動脈血二氧化碳分壓)。所有量的太尼都會使Ptcco2 20分鐘內顯著增,並且Ptcco2 值在生理鹽水組與太尼組間的差異具有統計學意義(P < 0.0001)。Paco2 值與Ptcco2 值之間具有很好的相關性(r2 = 0.91)。Bland-Altman分析也發現在小鼠身Ptcco2 能準確可靠地反映Paco2。因此發現,在一定條件下,Ptcco2 測量值能可靠地反映小鼠的Paco2。因此在不同條件下較大樣本量的小鼠模型,Ptcco2 術可以用作為快速定量的評估廣譜藥物呼吸制特性的一個手段。

(邱鬱薇 馬皓琳 李士通 校)

We assessed a simple, noninvasive method of monitoring transcutaneous partial pressure of CO2 (Ptcco2) in mice to determine whether it would provide an accurate and reproducible method to assess ventilatory depression in mice. To this end, Ptcco2 and Paco2 (partial pressure of arterial CO2) measurements were performed on isoflurane-anesthetized male C57Bl/6 mice breathing differing percentages of CO2 or fentanyl, a known ventilatory depressive drug. All doses of fentanyl produced a sharp increase in Ptcco2 values within 20 min with difference in Ptcco2 values between saline and all fentanyl groups being statistically significant (P < 0.0001). A good correlation between Paco2 and Ptcco2 values was established (r2 = 0.91). A Bland-Altman analysis likewise found that Ptcco2 measurements in the mice reliably and accurately reflected their Paco2 values. Therefore, under controlled conditions, Ptcco2 measurements were found to reliably reflect Paco2 values in mice. Consequently, the Ptcco2 method can be used as a means to rapidly and quantitatively assess the ventilatory depressive properties of a wide spectrum of drugs, under varying conditions in numerous mouse models.

 

七氟醚複合靜脈太尼麻醉時腦電圖 Bicoherence的化

Changes in Electroencephalographic Bicoherence During Sevoflurane Anesthesia Combined with Intravenous Fentanyl

Yasuhiro Morimoto, MD, Satoshi Hagihira, MD*, Satoshi Yamashita, MD, Yasuhiko Iida, MD, Mishiya Matsumoto, MD, Syunsuke Tsuruta, MD, and Takefumi Sakabe, MD

From the Department of Anesthesiology-Resuscitology, Yamaguchi University School of Medicine, Yamaguchi, Japan; and *Department of Anesthesiology, Osaka University Graduate School of Medicine.

Anesth Analg 2006;103:641-645

 

隨著介紹雙頻指數(BIS)作為度量全麻中病人的鎮靜程度,注意已被集中於腦電圖(EEG)的雙頻譜分析。在本研究中,我們評估了EEG bicoherence和七氟醚濃度之間的關係。16個預定擇期腹部手術的ASA I–II級病人入選研究。用5%七氟醚麻醉誘導,七氟醚和氧氣(50%)維持麻醉。手術開始前,靜脈注射太尼(2 µg/kg),然後持續輸注(2 µg · kg–1 · h–1)。應用我們建立的軟體,在呼氣末七氟醚濃度分別為0.5%0.8%1.1%1.4%1.7%2.0%2.3%時,記錄EEG bicoherenceBIS95%緣頻率(SEF95)。在淺麻醉下,EEG bicoherence值低,隨著七氟醚濃度的增,bicoherence的兩個峰沿對角線出現(f1 = f2)。當七氟醚濃度增到1.4%,第一個(4 Hz附近)和第二個(10 Hz附近)峰都高(分別為37.7% ± 7.5%35.1% ± 9.0%)。但是當七氟醚濃度繼續增,第一個峰平而第二個峰趨向於輕微下降。在七氟醚濃度增高時BIS值減小,在1.4%和更高七氟醚濃度時,BIS值平穩。在七氟醚濃度增到2.3%SEF95也減少。因此,兩個bicoherence峰的分佈模式可能比BIS監測術中七氟醚的麻醉效應更好。

(張曦   馬皓琳 李士通  校)

With the introduction of bispectral index (BIS) as a measure of a patient’s sedation during general anesthesia, attention has been directed toward bispectral analysis of electroencephalography (EEG). In the present study we evaluated the relationship between EEG bicoherence and sevoflurane concentration. Sixteen ASA physical status I–II patients scheduled for elective abdominal surgery were enrolled in the study. Anesthesia was induced with 5% sevoflurane and maintained with sevoflurane and oxygen (50%). Just before surgery, IV fentanyl (2 µg/kg) was given and then continuously infused (2 µg · kg–1 · h–1). Using software we developed, EEG bicoherence, BIS, and 95% spectral edge frequency (SEF95) were recorded at end-tidal sevoflurane concentrations of 0.5%, 0.8%, 1.1%, 1.4%, 1.7%, 2.0%, and 2.3%. Under light anesthesia, EEG bicoherence values were low. With increasing sevoflurane concentrations, 2 peaks of bicoherence emerged along the diagonal line (f1 = f2). Both the first (at around 4 Hz) and second (at around 10 Hz) grew higher (37.7% ± 7.5% and 35.1% ± 9.0%, respectively) as the sevoflurane concentration increased to 1.4%. However, the first peak leveled off whereas the second tended to decrease slightly with further increases in sevoflurane concentration. The BIS value decreased as the sevoflurane concentration increased and leveled off at 1.4% and higher concentrations of sevoflurane. The SEF 95 also decreased as the sevoflurane concentration increased up to 2.3%. Thus the distribution pattern of the two bicoherence peaks is likely to be better than BIS of the anesthetic effect of sevoflurane during surgery.

 

伐地考昔用於剖宮產術後鎮痛:一個隨機、雙盲、安慰對照研究

Valdecoxib for Postoperative Pain Management After Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Study

Brendan Carvalho, MBBCh, FRCA*, Larry Chu, MD, MS*, Andrea Fuller, MD{dagger}, Sheila E. Cohen, MB, ChB*, and Edward T. Riley, MD*

From the *Department of Anesthesia, Stanford University School of Medicine Stanford, California; {dagger}Northern Colorado Anesthesia Professional Consultants, Fort Collins, Colorado.

Anesth Analg 2006;103:664-670

 

儘管非甾體類炎藥可改善剖宮產術後疼痛緩解,但是它們具有出血等潛在的副作用。圍術期環氧化酶(COX-2 制在很多手術模型中顯示出了與非甾體類炎藥相似的鎮痛作用,但在剖宮產術後尚無研究。我們設計這個隨機雙盲實驗以研究伐地考昔在剖宮產術後的鎮痛效應其減少阿片用量的作用。麻下擇期剖宮產的健康產婦隨機分成兩組,術後72小時內每12小時口服伐地考昔20mg或安慰。在研究進行期間,由於COX-2制的安全問題日明顯,評估48位病人後中止了此次研究。我們發現,在伐地考昔組和安慰組之間總的麻醉性鎮痛藥用量無差異(換算成嗎啡等效量分別為121 ± 70 mg 143 ± 77 mg; P = 0.26)。兩組間靜息活動疼痛近似,儘管此後的檢驗效率足已發現有臨意義的差異。靜脈嗎啡用量、首次要求鎮痛藥時間、病人滿意度、副作用、母乳餵成能性活動也均無顯著性差異。所有病人術後疼痛都控制較好。直到現在還不支持鞘內入嗎啡的麻下剖宮產術後用伐地考昔。

(黃佳佳譯,李士通 馬皓琳校)

Although nonsteroidal antiinflammatory drugs (NSAIDs) improve postoperative pain relief after cesarean delivery, they carry potential side effects (e.g., bleeding). Perioperative cyclooxygenase (COX)-2 inhibitors show similar analgesic efficacy to nonsteroidal antiinflammatory drugs in many surgical models but have not been studied after cesarean delivery. We designed this randomized double-blind study to determine the analgesic efficacy and opioid-sparing effects of valdecoxib after cesarean delivery. Healthy patients undergoing elective cesarean delivery under spinal anesthesia were randomized to receive oral valdecoxib 20 mg or placebo every 12 h for 72 h postoperatively. As a result of cyclooxygenase-2 inhibitors safety concerns that became apparent during this study, the study was terminated early after evaluating 48 patients. We found no differences in total analgesic consumption between the valdecoxib and placebo groups (121 ± 70 versus 143 ± 77 morphine mg-equivalents, respectively; P = 0.26). Pain at rest and during activity were similar between the groups despite adequate post hoc power to have detected a clinically significant difference. There were also no differences in IV morphine requirements, time to first analgesic request, patient satisfaction, side effects, breast-feeding success, or functional activity. Postoperative pain was generally well controlled. Adding valdecoxib after cesarean delivery under spinal anesthesia with intrathecal morphine is not supported at this time.

 

開腹手術期間的血管內補液管理與血流動學的化

Intravascular Fluid Administration and Hemodynamic Performance During Open Abdominal Surgery

Christer H. Svensén, MD, PhD, DEAA*, Joel Olsson, MD, PhD, DEAA*, and Robert G. Hahn, MD, PhD{dagger}

From the *Department of Anesthesiology, University of Texas Medical Branch, Galveston; {dagger}Karolinska Institute, Stockholm, Sweden.

Anesth Analg 2006;103:671-676

 

我們對十位接受腹部開放性手術的病人研究了是否能將肺動脈導管測量到的中心血流動學表示補液治療的藥效學。我們檢測了病人在45 min裏靜滴乳酸林格氏溶液25 mL/kg,輸液期時與輸液後血漿稀釋度(血漿稀釋度常作為一項血容量擴充的指標)與血流動學化的相關程度。肺動脈楔壓與中心靜脈壓升高對靜脈輸液有反應,與相應的血漿稀釋度相關。十位病人中的六位表現為心排出量的下降,有可能是繼發于周圍血管的阻增(無效者),而其餘的則表現為心排出量的增(有效者)。容量動學分析提示有效的病人中有54%的輸注液體在輸注結束時存在於中央液腔,研究結束時為25%,無效者則分別為25%3%。結論:一的接受腹部開放性手術的病人對晶體液的反應是心排出量下降。肺動脈楔壓與中心靜脈壓對不同程度的血漿稀釋有較連貫的反映,可以用來類比應用容量動學計算的液體治療方案。

(胡湘 馬皓琳 李士通 校)

We studied whether central hemodynamics measured by a pulmonary artery catheter can serve as a pharmacodynamic expression of fluid therapy in 10 patients undergoing open abdominal surgery. We examined how closely hemodynamic variables follow plasma dilution, which is an index of plasma volume expansion, during and after an IV infusion of 25 mL/kg of lactated Ringer’s solution over 45 min. Pulmonary artery wedge pressure and central venous pressure responded to IV fluid with an increase that correlated with accompanying plasma dilution. Six of 10 patients showed a decrease in cardiac output that was probably secondary to an increase in peripheral vascular resistance (nonresponders), whereas the rest increased cardiac output (responders). Volume kinetic analysis suggested that 54% of the infused fluid resided in the central fluid space at the end of the infusion and 25% at the end of the study in the responders compared with 25% and 3%, respectively, in nonresponders. In conclusion, half of the patients undergoing open abdominal surgery responded to crystalloid fluid with a decrease in cardiac output. Pulmonary artery wedge pressure and central venous pressure responded more consistently to different degrees of plasma dilution, which can be simulated for various fluid regimens using volume kinetics.

 

鞘內注射環氧化酶-1制而非環氧化酶-2制能夠逆轉剖腹手術對大鼠探索行為的影響

Intrathecal Administration of a Cylcooxygenase-1, but Not a Cyclooxygenase-2 Inhibitor, Reverses the Effects of Laparotomy on Exploratory Activity in Rats

Thomas J. Martin, PhD*, Nancy L. Buechler, BS*, and James C. Eisenach, MD{dagger}

From the Departments of *Physiology and Pharmacology and {dagger}Anesthesiology, the Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2006;103:690-695

 

切開性手術後對機械性刺激超敏感的研究提示,髓內環氧化酶(COX-1而非COX-2參與了術後疼痛。在本研究中,我們想通過研究自主探索行為而非撤退反射來確定COX同酶在剖腹手術後的作用。成年雄性SD大鼠於異氟烷麻醉下行肋下剖腹術或僅接受麻醉未手術。在術後第一天,鞘內注射二甲基亞碸(溶)或COX-1SC560或者COX-2NS-398後,監測大鼠的探索性運動行為。在鞘內未放置導管組和鞘內注射溶的對照組,剖腹術使動物的移動、豎立以快速小幅運動(刻板動作)行為減少的幅度相同。SC-560能夠量相關性地使動物恢復到正常的探索行為,當SC-560量達到20µg或更高時,動物的探索行為可以完全恢復。相反,直至50µgNS-398均不能增動物的探索行為。探索行為和剖腹手術的這些資料與切開手術後的反射性退縮反應相一致,並且顯示COX-1制減少術後的疼痛反應。髓COX-1制使探索行為(包括伸長腹肌的後腿站立行為)完全恢復。這些資料提示髓中的靶COX-1可產生術後鎮痛。

(顏濤 馬皓琳 李士通 校)

Studies of hypersensitivity to mechanical stimuli after incisional surgery suggest that cyclooxygenase (COX)-1, but not COX-2, in the spinal cord participates in postoperative pain. In the current study, we sought to determine the role of COX isoenzymes after laparotomy, examining spontaneous exploratory behavior rather than withdrawal reflexes. Adult male Sprague-Dawley rats underwent subcostal laparotomy surgery under isoflurane anesthesia or received anesthesia without surgery. Exploratory locomotor activity was measured on the first postoperative day after intrathecal injection of dimethyl sulfoxide (vehicle) or COX-1 (SC-560) or COX-2 (NS-398) inhibitors. Laparotomy reduced ambulation, rearing, and rapid small movements (stereotypy) similarly in animals without intrathecal catheters and those receiving intrathecal vehicle control. SC-560 produced a dose-related return to normal exploratory behavior with complete return at doses of 20 µg and larger. In contrast, NS-398 in doses up to 50 µg failed to increase exploratory behavior. These data with exploratory behavior and laparotomy agree with studies with reflexive withdrawal responses after incisional surgery and indicate that COX-1 inhibition reduces pain responses after surgery. Spinal COX-1 inhibition completely restores exploratory activity, including rearing behavior that stretches the abdominal muscles. These data suggest that targeting COX-1 in the spinal cord may produce postoperative analgesia.

 

腹式全子宮切除術後足三裏穴應用辣椒素貼的鎮痛作用

The Analgesic Effects of Capsicum Plaster at the Zusanli Point After Abdominal Hysterectomy

Kyo S. Kim, MD, PhD, and Yu M. Nam, MD

From the Department of Anesthesiology, Hanyang University Hospital, Seoul, Korea.

Anesth Analg 2006;103:709-713

 

背景:針灸已被用作阿片類鎮痛術後疼痛治療的補充療法。我們設計了這個雙盲、假治療-對照研究來評價辣椒素貼(PAS)用於足三裏(ST-36)穴對於術後阿片類鎮痛藥需求量、副作用和恢復特性的影響。

方法:90例接受腹式全子宮切除手術的女性患者隨機分為3個治療組(每組30人):足三裏組患者足三裏穴使用PAS,假治療組患者在肩膀非穴位處使用PAS,對照組在足三裏穴使用安慰貼帶。麻醉誘導前術後3天每天8個小時使用PAS

結果:足三裏組術後24小時嗎啡用量(31.5 ± 6.8 mL)顯著小於對照組(44.3 ± 10.1 mL)和假治療組(44.6 ± 10.4 mL) (P < 0.01)。足三裏組術後72小時副作用發生率治療性止吐藥使用率均低於其他兩組(P < 0.01)

結論:足三裏穴使用PAS可減少腹式全子宮切除術後患者阿片類藥物的需求量與阿片類藥物相關的副作用。

(周雅春 馬皓琳 李士通 校)

BACKGROUND: Acupuncture has been used to supplement opioid analgesics for postoperative pain control. We designed this double-blind, sham-controlled study to assess the effectiveness of capsicum plaster (PAS) at Zusanli (ST-36) acupoints on postoperative opioid analgesic requirement, side effects, and recovery profile.

METHODS: Ninety women undergoing total abdominal hysterectomy were randomly assigned to 3 treatment regimens (n = 30 each): group Zusanli = PAS at Zusanli acupoints, group sham = PAS at the nonacupoints on the shoulders, and group control = placebo tape at Zusanli acupoints. The PAS was applied before induction of anesthesia and maintained for 8 h per day for 3 postoperative days.

RESULTS: The total amount of morphine administered in the first 24 h after the operation was significantly decreased in group Zusanli (31.5 ± 6.8 mL) compared with groups control (44.3 ± 10.1 mL) and sham (44.6 ± 10.4 mL) (P < 0.01). The incidence of postoperative side effects and the use of rescue antiemetics during the 72 h after surgery were significantly reduced in group Zusanli compared with other groups (P < 0.01).

CONCLUSION: PAS at Zusanli points decreased the postoperative opioid requirement and opioid-related side effects of patients undergoing abdominal hysterectomy.

 

通過亞麻醉量的右旋氯胺酮來調節疼痛成像

Imaging Pain Modulation by Subanesthetic S-(+)-Ketamine

Till Sprenger, MD*, Michael Valet, MD*, Ralph Woltmann, MD*, Claus Zimmer, MD{ddagger}, Rainer Freynhagen, MD, DEAA, Eberhard F. Kochs, MD{dagger}, Thomas R. Tölle, MD, PhD*, and Klaus J. Wagner, MD{dagger}

From the *Neurologische Klinik und Poliklinik, Technische Universität München; {dagger}Klinik für Anaesthesiologie, Technische Universität München; {ddagger}Institut für Röntgendiagnostik, Technische Universität München; Klinik für Anaesthesiologie, Universität Düsseldorf, Germany.

Anesth Analg 2006;103:729-737

 

小量右旋氯胺酮對大腦處理疼痛的影響知道得很少。我們調查了靜脈注射亞麻醉量的右旋氯胺酮對實驗性疼痛熱刺激的感知的影響。對健康的志願者在分別給予安慰或量逐漸增的氯胺酮輸注(0.050.10.15 mg · kg–1 · h–1)和疼痛刺激時用磁共振能成像以評估。監測生命指標,並對所有實驗物件均在數位等級尺規進行疼痛強度和不愉快事件的等級評定。用精神行為問卷來評定意識的改。隨著氯胺酮用量的增,疼痛不愉快事件減少(0.15 mg · kg–1 · h–1的氯胺酮和安慰相比下降 55.1%)。疼痛強度的等級也隨氯胺酮量增相應減少,但程度較低(下降23.1%)。給予安慰時,觀察到了典型的疼痛刺激系統(丘腦、島葉、扣帶束和額前皮質)啟動,而給予氯胺酮時的疼痛影像表現為量依賴性的疼痛引起的大腦啟動減弱。分析量依賴性的氯胺酮對疼痛的作用顯示第二級體感性皮層(S2)、島葉和前扣帶回皮質的啟動減弱。前扣帶回皮質的這個部分(中扣帶束皮質)和情感疼痛成分相關,氯胺酮可有效調節疼痛的情感過程。

(薑旭暉 馬皓琳 李士通校)

Little is known about the effects of low-dose S-(+)-ketamine on the cerebral processing of pain. We investigated the effects of subanesthetic IV S-(+)-ketamine doses on the perception of experimental painful heat stimuli. Healthy volunteers were evaluated with functional magnetic resonance imaging (fMRI) while receiving the painful stimuli in conjunction with placebo and increasing doses (0.05, 0.1, 0.15 mg · kg–1 · h–1) of ketamine infusion. Vital variables were monitored and all subjects rated pain intensity and unpleasantness on a numerical rating scale. Alterations in consciousness were measured using a psycho-behavioral questionnaire. Pain unpleasantness declined as ketamine dosage was increased (55.1% decrease, placebo versus 0.15 mg · kg–1 · h–1 ketamine). Pain intensity ratings also decreased with increasing ketamine dosage but to a lesser extent (23.1% decrease). During placebo administration, a typical pain activation network (thalamus, insula, cingulate, and prefrontal cortex) was found, whereas decreased pain perception with ketamine was associated with a dose-dependent reduction of pain-induced cerebral activations. Analysis of the dose-dependent ketamine effects on pain processing showed a decreasing activation of the secondary somatosensory cortex (S2), insula and anterior cingulate cortex. This part of the anterior cingulate cortex (midcingulate cortex) has been linked with the affective pain component that underlines the potency of ketamine in modulating affective pain processing.

 

嗎啡對人類5-HT 3A受體的影響

The Effects of Morphine on Human 5-HT3A Receptors

Maria Wittmann, MD, I. Peters, MS, T. Schaaf, MS, H. C. Wartenberg, MD, S. Wirz, MD, J. Nadstawek, MD, B. W. Urban, PhD, and M. Barann, PhD

From the Klink und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätskliniken Bonn, Bonn, Germany.

Anesth Analg 2006;103:747-752

 

5-HT 3受體是配體門控離子通道,參與嘔吐和疼痛的調控。在本實驗中,我們研究了阿片類鎮痛藥嗎啡是否對人類5-HT 3受體有特的作用。將人類5-HT 3A受體的cDNA穩態轉染入HEK-293細胞的全細胞碎片,使用膜片鉗術觀察嗎啡對5-HT誘發的細胞電流的影響。細胞膜電位為負值時,5-HT呈濃度依賴地誘發內向電流。5-HT 3受體拮昂丹司(0.3 nM)呈可逆地制5-HT誘發的信號。嗎啡可逆地制5-HT誘發電流的峰值,IC501.1 µMHill 係數 1.2。隨著5-HT濃度的增高,嗎啡的制作用逐步減弱,說明兩者具有競爭作用。此外,嗎啡存在時電流的啟動和失活動學明顯減慢。嗎啡的拮納洛酮,也可制5-HT誘發的電流 (例如,3 µM納洛酮可制17%的電流)。嗎啡和納洛酮的作用不呈相。嗎啡的效能競爭性制作用說明了嗎啡作用於某一受體部位的機制,而非對細胞膜的非特異性作用。

(張瑩 馬皓琳 李士通校)

5-HT3 receptors are ligand-gated ion channels that are involved in the modulation of emesis and pain. In this study, we investigated whether the opioid analgesic, morphine, exerts specific effects on human 5-HT3 receptors. Whole-cell patches from HEK-293 cells stably transfected with the human 5-HT3A receptor cDNA were used to determine the effects of morphine on the 5-HT-induced currents using the patch clamp technique. At negative membrane potentials, 5-HT induced inward currents in a concentration-dependent manner. The 5-HT3 receptor antagonist, ondansetron, (0.3 nM) reversibly inhibited the 5-HT-induced signals. Morphine reversibly suppressed 5-HT-induced peak currents as a function of concentration (IC50 = 1.1 µM, Hill coefficient = 1.2). The block by morphine decreased with increasing 5-HT concentrations, suggesting a competitive effect. In addition, the activation, as well as the inactivation, kinetics of the currents were significantly slowed in the presence of morphine. The morphine antagonist, naloxone, also inhibited 5-HT-induced currents (e.g., at 3 µM by 17%). The effects of morphine and naloxone were not additive. The potency of morphine and the competitivity of the blocking effect points to a specific mechanism at a receptor site rather than an unspecific membrane effect.

 

坐骨神經和股神經聯合阻滯下全膝關節成形術中的羅呱卡因和布比卡因的藥效動學

The Pharmacodynamics of Ropivacaine and Bupivacaine in Combined Sciatic and Femoral Nerve Blocks for Total Knee Arthroplasty

Pierre Beaulieu, MD, PhD, FRCA, Denis Babin, MSc, and Thomas Hemmerling, MD, DEAA

From the Department of Anesthesiology, CHUM Hôtel-Dieu, Montreal, Quebec, Canada.

Anesth Analg 2006;103:768-774

 

與布比卡因相比羅呱卡因在區域麻醉中的效價仍有爭議。因此,我們比較了相同濃度的布比卡因和羅呱卡因在實行坐骨神經和股神經聯合阻滯的膝關節成形術患者的藥效動學。麻醉誘導前五十名患者分別在坐骨神經(15 mL)和股神經(25 mL)處注射0.5%布比卡因(n = 25) 0.5% 羅呱卡因(n = 25)。記錄股神經、隱神經、腓總神經、脛神經分配區域的感覺缺失和恢復(以對側為對照的冷覺的%)以運動能(無收縮或正常肌)。並且評估48小時裏的疼痛評分和嗎啡消耗量。在感覺和運動阻滯起效方面布比卡因和羅呱卡因沒有差異。然而,感覺和運動的恢復羅呱卡因組則較快,但僅在坐骨神經和感覺恢復在2428小時、運動能在1220小時的情況下較顯著。總體,疼痛評分和嗎啡消耗量很接近。綜所述,在坐骨神經和股神經聯合阻滯的消退期布比卡因和羅呱卡因是有差異的。一種評估坐骨神經和股神經阻滯的全新的系統方法由此提出。
(唐李雋   馬皓琳 李士通 校)

The potency of ropivacaine compared with bupivacaine in regional anesthesia remains controversial. Therefore, we compared the pharmacodynamics of equal concentrations of bupivacaine and ropivacaine in combined sciatic and femoral nerve blocks for patients undergoing knee arthroplasty. Fifty patients received 40 mL of either 0.5% bupivacaine (n = 25) or 0.5% ropivacaine (n = 25) divided between the sciatic (15 mL) and the femoral (25 mL) nerves before induction of anesthesia. Loss and recovery of sensory (% of cold sensation compared to opposite side) and motor (no contraction or normal muscle force) functions were recorded in the distribution of the femoral, saphenous, common peroneal, and tibial nerves. Pain scores and morphine consumption over 48 h were also evaluated. There were no difference between bupivacaine and ropivacaine in terms of onset of sensory and motor blockade. However, resolution of sensory and motor function was faster in the ropivacaine group but only significantly so for the sciatic nerve and between 24 to 28 h for sensory resolution and 12 to 20 h for motor function. Overall, pain scores and morphine consumption were similar. In conclusion, we showed that block resolution is different between bupivacaine and ropivacaine when administered for combined sciatic and femoral nerve blocks. A new systematic method to assess sciatic and femoral nerve blockade is proposed.

 

與異氟醚相比,體外迴圈過程中使用大量異丙酚可減少冠狀動脈手術患者心肌損傷的生化標誌物

Large-Dose Propofol During Cardiopulmonary Bypass Decreases Biochemical Markers of Myocardial Injury in Coronary Surgery Patients: A Comparison with Isoflurane

Zhengyuan Xia, Zhiyong Huang, and David M. Ansley

From the *Anesthesiology Research Laboratory, Department of Anesthesiology, Renmin Hospital of Wuhan University; Shenzhen Sun Yat-sen Cardiovascular Hospital, China; and Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver, Canada.

Anesth Analg 2006,103: 527-532

 

我們觀察到若在體外迴圈(CPB)過程中大異丙酚的用量以增強其氧化作用可起到心臟保護作用。54位冠狀動脈旁路手術的患者隨機分為異丙酚低量組(P組,n18)、異丙酚高量組(HiP組,n18)、異氟醚組(I組,n18)。誘導插管後使用異氟醚(I組,吸入濃度為1%-3.5%)或異丙酚持續輸注(P組,60µg · kg–1 · min–1)維持麻醉。在HiP組,CPB開始前10min至動脈開放後15min這一段時間內,異丙酚的維持量增高至120 µg · kg–1 · min–1,隨後降至60µg · kg–1 · min–1直至手術結束。組P、組HiP、組I動脈鉗閉的時間分別為83 ± 2488 ± 2281 ± 20分鐘(P > 0.1)。與組P和組I相比,組HiPCPB8小時一種氧化應激的標誌物——丙酮醛產物(malondialdehydeMDA)明顯減少,CPB24小時cTnI明顯減少(P < 0.05)。與組I相比,組HiP的患者脫離CPB時需要使用的正性肌藥物明顯減少;術後全身血管阻明顯減小。組HiPCPB24小時的平均心臟指數較組I、組P明顯增高(組I、組P、組HiP分別為2.2 ± 0.12.3 ± 0.22.8 ± 0.3 L · min–1 · m–2)。與組I相比,組HiP患者ICU的停留時間明顯縮短。我們認為,與異氟醚和小量異丙酚相比,在CPB中使用大量異丙酚可以減少術後心肌細胞損傷。

(金  琳譯  薛張綱 校)

 We investigated if increasing propofol's dosage to augment its antioxidant capacity during cardiopulmonary bypass (CPB) could confer cardiac protection. Fifty-four coronary artery bypass graft surgery patients were randomly assigned to small-dose propofol (Group P; n = 18), large-dose propofol (Group HiP; n = 18), or isoflurane Group (Group I; n = 18). After the induction, anesthesia was maintained with an inspired concentration of isoflurane 1%–3.5% (Group I) or a continuous infusion of propofol 60 µg · kg–1 · min–1 (Group P) throughout the surgery. In Group HiP, this dose of propofol was increased to 120 µg · kg–1 · min–1 for 10 min before the onset of CPB until 15 min after aortic unclamping and then decreased to 60 µg · kg–1 · min–1 until the end of surgery. The duration of aortic cross-clamping was 83 ± 24, 88 ± 22, and 81 ± 20 min in Group P, Group HiP, and Group I, respectively (P > 0.1). Plasma malondialdehyde, a marker of oxidative stress, was significantly lower at 8 h after CPB, and Troponin I was lower at 24 h after CPB in Group HiP compared with Group P and Group I (P < 0.05). There was a significant reduction in inotropic requirements for separation from CPB in Group HiP compared with Group I. Postoperative systemic vascular resistance was significantly reduced in Group HiP as compared with Group I. Mean cardiac index was significantly higher at 24 h after CPB in Group HiP compared with Group P and Group I (P < 0.05) (Group I, 2.2 ± 0.1; Group P, 2.3 ± 0.2; and Group HiP, 2.8 ± 0.3 L · min–1 · m–2, respectively). The duration of intensive care unit stay was significantly shorter in Group Hi-P compared with Group I. We conclude that administration of a large dose of propofol during CPB attenuates postoperative myocardial cellular damage as compared with isoflurane or small-dose propofol anesthesia.

 

 糖尿病弱離子通道阻斷的心律失常作用

Diabetes Mellitus Reduces the Antiarrhythmic Effect of Ion Channel Blockers

Isao Ito, Yukio Hayashi, Yusuke Kawai, Mitsuo Iwasaki, Koji Takada, Takahiko Kamibayashi, Atsushi Yamatodani, and Takashi Mashimo

Department of Anesthesiology, School of Allied Health Sciences, Osaka University Faculty of Medicine, Osaka , Japan .

Anesth Analg 2006 103: 545-550

 

我們設計的實驗研究是檢測是否在糖尿病鼠糖尿病可以影響氟卡胺,鈉通道阻滯;E-4031,鉀通道阻滯;和維拉帕米,鈣通道阻滯的心律失常作用。實驗是在經鏈唑黴素處理後在246周無損傷的糖尿病鼠身進行。鼠經氟烷麻醉,同時監測其持續動脈血壓和心室早期收縮。通過在15秒內誘導3次或更多的心室早期收縮的腎腺素最小量作為致心律失常腎腺素量。應用氟卡胺的鼠致心律失常腎腺素量為8.2 +/- 2.2微克/kg (平均值 +/- sd),經鏈唑黴素處理後,246周無損傷糖尿病鼠分別7.4 +/- 6.1, 5.5 +/- 2.8,和2.0 +/- 0.5 微克/kg。相似的,E-40317.7 +/- 2.6, 2.3 +/- 0.7, 2.0 +/- 0.7, 1.2 +/- 0.5微克/kg,維拉帕米是8.2 +/- 2.1, 3.1 +/- 1.2, 2.3 +/- 0.9,和1.5 +/- 0.5微克/kg。胰島素部分的逆轉阻斷的心律失常作用。我們推斷糖尿病弱氟卡胺、E-4031和維拉帕米的心律失常作用。

(孫敏莉譯 薛張綱校)

We designed the present study to examine whether diabetes mellitus affects the antiarrhythmic effect of flecainide, a sodium channel blocker, E-4031, a potassium channel blocker, and verapamil, a calcium channel blocker, in diabetic rats. The experiments were performed in intact and diabetic rats 2, 4, and 6 wk after administration of streptozotocin. Rats were anesthetized with halothane and monitored continuously for arterial blood pressure and premature ventricular contractions. The arrhythmogenic dose of epinephrine was defined as the smallest dose producing 3 or more premature ventricular contractions within a 15-s period. The arrhythmogenic doses of epinephrine in the presence of flecainide were 8.2 +/- 2.2 (mean +/- sd), 7.4 +/- 6.1, 5.5 +/- 2.8, and 2.0 +/- 0.5 microg/kg in intact and diabetic rats 2, 4, and 6 wk after streptozotocin administration, respectively. Similarly, the arrhythmogenic doses of epinephrine in the presence of E-4031 were 7.7 +/- 2.6, 2.3 +/- 0.7, 2.0 +/- 0.7, and 1.2 +/- 0.5 microg/kg, and those in the presence of verapamil were 8.2 +/- 2.1, 3.1 +/- 1.2, 2.3 +/- 0.9, and 1.5 +/- 0.5 microg/kg. Insulin partially recovered the antiarrhythmic effect of the blockers. We concluded that diabetes mellitus reduces the antiarrhythmic effects of flecainide, E-4031, and verapamil.

                                                           

 小兒肝移植術中低鉀血症:發生率與風險因素

Intraoperative Hypokalemia in Pediatric Liver Transplantation: Incidence and Risk Factors

 Victor W. Xia, Bin Du, Albert Tran, Luke Liu, Ke-Qin Hu, Jonathan R. Hiatt, Ronald W. Busuttil, and Randolph H. Steadman

the Departments of *Anesthesiology and †Surgery, David Geffen School of Medicine, University of California , Los Angeles ,

Los Angeles, California ; ‡Division of Gastroenterology, University of California , Irvine Medical Center , Orange , California ; §Department of Anesthesiology, 2nd Affiliated Hospital, Kunming Medical College , Kunming , China .

Anesth Analg 2006 103: 587-593.

 

回顧性研究268例肝移植患兒,我們研究了術中鉀亂的發生和開放前開放後低鉀血症的風險因素。總體,低鉀血症是小兒患者肝移植期主要的亂,發生率72.0%。低鉀血症在開放後比開放前更常見。高鉀血症雖然是明確的常見的併發症,但在小兒肝移植期間並不常見。通過邏輯斯諦回歸分析,開放前基礎血鉀水準3.5 mmol/L、基礎K+5mmol/L和肌酐0.5mg/dL是低鉀血症的預測因素;體重15kg K+3.5 mmol/L,新鮮冰凍血漿輸注大於90mL/kg和術前存在腹水是開放後低鉀血症的獨立預測因素。這些研究支持使用K+替代治療維持血鉀正常,避免小兒肝移植低鉀血症相關的潛在的併發症,特別是有低鉀血症高風險的小兒。

(吳德華譯 薛張綱校)

 In this retrospective study of 268 children undergoing liver transplantation, we investigated the incidence of intraoperative potassium (K_) disturbances and the risk factors for hypokalemia in the preperfusion and postreperfusion periods. Overall, hypokalemia was the predominant disturbance, occurring in 72.0% of pediatric patients during liver transplantation. Hypokalemia was more common during the postreperfusion period than the prereperfusion period. Hyperkalemia, though a commonly cited complication, was infrequent during pediatric liver

transplantation. Using multivariate logistic regression analysis, baseline serum K_ 3.5 mmol/L, base excess5 mmol/L, and creatinine0.5 mg/dL were found to be predictors for hypokalemia in the prereperfusion period; and body weight15 kg, K_3.5 mmol/L, fresh-frozen plasma transfusion>90 mL/kg, and absence of ascites at surgery were independent predictors for hypokalemia in the postreperfusion period. These findings support the use of K_ replacement to maintain normokalemia and avoid the potential complications related to hypokalemia in pediatric liver transplantation, especially in children with the risk factors for hypokalemia.

 

 低濃度的地卡因延緩神經生長,並不損害神經突和生長錐

Tetracaine at a small concentration delayed nerve growth without destroying neurites and growth cones.

 

Sekimoto K, Saito S, Goto F.

Department of Anesthesiology, Gunma University Graduate School of Medicine, Showa-machi, Maebashi , Japan .

Anesth Analg. 2006 ,103:608-14

 

局麻藥高濃度應用于神經元時有直接的神經毒害作用和誘導生長錐崩潰作用。能而,長時間暴露在低濃度的局麻藥對神經元的影響未見報道。本研究檢測了低濃度地卡因對雞胚胎根部神經突生長是否有減慢減慢作用。地卡因對神經元的影響通過顯微鏡、神經突生長率、量化形態學分析、生長錐崩潰分析和Western blot 分析來評價。大於5uM的高濃度局麻藥實施24h48h後,神經突生長明顯減慢。10uM20uM的地卡因應用後24h48h,生長錐絲狀偽足縮短數量明顯減少。神經元細胞體內肌動蛋白數量增,其與對神經突和生長錐的影響相反——分別給予51020uM地卡因後48h其肌動蛋白數量減少。結論,連續暴露在低濃度地卡因可延緩神經突生長,降低絲狀偽足的數量和減少神經突肌動蛋白數量。

 (吳德華譯 薛張綱校)

Local anesthetics have direct neurotoxicity and induce growth cone collapse when applied to neurons at large concentrations. However, the effects of prolonged exposure to local anesthetics at a small concentration have never been studied. We examined whether neurite growth was slowed by tetracaine at small concentrations in chick embryo dorsal root ganglions. The effects of tetracaine were examined microscopically and by a neurite growth rate assay, quantitative morphologic assay, growth cone collapse assay, and Western blot assay. Neurite growth 24 and 48 h after application was delayed significantly when tetracaine was applied at a concentration larger than 5 microM. Filopodia of growth cones retracted, and their number was significantly decreased 24 and 48 h after the application of 10 and 20 microM of tetracaine. The quantity of actin in cell bodies increased, contrary to the effect on neurites and growth cones, where actin decreased 48 h after the application of 5, 10, and 20 microM of tetracaine. In conclusion, continuous exposure to tetracaine at small concentrations delayed neurite growth, reduced the number of filopodia, and decreased actin content.

 

 海豚的單側大腦球的BIS 監測

Bispectral Index Monitoring of Unihemispheric Effects in Dolphins

 Howard RS, Finneran JJ, Ridgway SH.

Department of Anesthesiology, Naval Medical Center , San Diego , California 92134-5000 , USA .

Anesth Analg. 2006 Sep;103(3):626-32

 

在海豚入睡時,它們的腦電活動的改僅在一側的大腦球顯示,換而言之就是海豚的左腦與右腦可以輪替地休息。在寬吻海豚屬中,我們用BIS監測可以發現兩個球之間腦電活動的不平衡。我們在海豚大腦的兩同步放置BIS感測器,通常但不總是發現兩BIS值的巨大差異(左60而右90)。這種情況不僅發生在不使用藥物的海豚身,在使用了異丙酚、阿托品和或地西泮的動物身也可發現。觀測通常在海豚于水中休息後持續3小時左右。單側球效應在海豚身是可以通過藥物誘導出現的。海豚以其接近於人類的大腦向我們提供了一個用於研究人類大腦單側球效應的動物模型。

(孫卓真譯 薛張綱校)

When dolphins sleepTheir electroencephalographic activity may change in only one cerebral hemisphere; i.e., the left and right brain hemispheres can take turns sleeping. We demonstrate that the bispectral index (BIS) monitor can detect interhemispheric asymmetry in the dolphin species Tursiops truncatus. Using two BIS sensors placed simultaneously over each side of the dolphin's head, we often, but not always, found significant differences between the two BIS values (e.g., left side 60 and right side 90) in non-medicated animals and in animals given propofol, atropine, and/or diazepam. Observations were each made over a period of approximately 3 h on dolphins resting out of the water. Unihemispheric effects may be inducible pharmacologically in dolphins. The dolphin, with its human-sized brain, may provide an animal model for study of unihemispheric effects in humans.

 

 壓控制通氣模式中氣管內插管部分梗阻的呼氣流量改檢測

Change in Expiratory Flow Detects Partial Endotracheal Tube Obstruction in Pressure-Controlled Ventilation

 Rafael Kawati, MD, PhD*, Laszlo Vimlati, MD*, Josef Guttmann, PhD , Göran Hedenstierna, MD, PhD , Ulf Sjöstrand, MD, PhD*, Stefan Schumann, PhD ,and Michael Lichtwarck-Aschoff, MD, PhD

From the Departments of *Surgical, and Medical Sci ences, University Hospital, Uppsala, Sweden; Department of Anesthesiology and Critical Care Medicine, University Hospital, Freiburg, Germany; Department of Anesthesiology and Critical Care Medicine, Klinikum Augsburg, Augsburg, Germany.

Anesth Analg 2006;103:650-657


在壓控制通氣模式(PCV)中,只有極端程度的氣管內導管(ETT)狹窄才能通過監測潮氣量(VT)發現。為了評估PCV中的氣管內導管梗阻程度並與VT監測比較,我們製造了三種不同程度的部分氣管內導管梗阻,在11只麻醉狀態下的健康小豬中使用4種不同內直徑(ID 9.08.07.06.0mm )的氣管導管。描繪出呼氣流量溢量( e–V)曲線,計算15%呼氣時間(Te)的時間常量( e)。我們還計算了第一個15%呼氣時間所占的呼氣量分數(Vex fract,15)並比較了三種梗阻程度的化與完整呼氣潮氣量。潮氣量監測無法發現氣管內導管狹窄。相反,Vex fract,15下降和 e增與氣管內導管的狹窄增顯著相關(IDs9.08.07.06.0,平均Vex fract,15分別為195, 180, 146, and 134 mLIDs9.08.07.06.0的平均 e分別為380, 491, 635, 794 ms)。我們總結當彈性回縮使 e適當得到考慮, e Vex fract,15分析可在PCV模式中監測氣管內導管部分梗阻。

(周  荻譯 薛張綱校)

Only extreme degrees of endotracheal tube (ETT) narrowing can be detected with monitoring of tidal volume (VT) during pressure-controlled ventilation (PCV). To assess the degree of ETT obstruction in PCV and to compare it to VT monitoring, we produced 3 levels of partial ETT obstruction in 11 healthy anesthetized piglets using ETTs of 4 different inner diameters (IDs 9.0, 8.0, 7.0, and 6.0 mm ). An expiratory flow over volume ( e–V) curve was plotted and the time constant ( e) at 15% of expiration time (Te) was calculated. We also calculated the fractional volume expired during the first 15% of Te (Vex fract,15) and compared those variables to full expiratory VT for each of the 3 obstructions. VT monitoring failed to detect ETT narrowing. By contrast, Vex fract,15 decreased and e increased significantly with increasing ETT narrowing (for IDs 9.0, 8.0, 7.0, and 6.0, mean Vex fract,15 was 195, 180, 146, and 134 mL respectively and mean e was 380, 491, 635, 794 ms for IDs 9.0, 8.0, 7.0, and 6.0 respectively). We conclude that when the elastic recoil that drives e is appropriately considered, analysis of e and Vex fract,15 detects partial ETT obstruction during PCV.

                                                          

 高碳酸血症可以改善病態肥胖手術病人的組織氧供

Hypercapnia Improves Tissue Oxygenation in Morbidly Obese Surgical Patients

 Helmut Hager, MD* , Dayakar Reddy, MD*, Goutham Mandadi, MD*, Debra Pulley, MD , J. Chris Eagon, MD , Daniel I. Sessler, MD||, and Andrea Kurz, MD¶

Address correspondence to Helmut Hager, MD, Department of Anesthesiology and General Intensive Care Medicine, Medical University Vienna, Austria.

Anesth Analg 2006;103:677-681

 

在病態肥胖的手術病人中,傷口感染的發生率增,部分是因為這些病人的組織氧合處在緣狀態。不像瘦的病人,在病態肥胖的病人中,增吸入氧濃度(Fio2)只能輕微的改善組織氧合。輕微的高碳酸血症可以改善瘦的病人的組織氧合,但在病態肥胖的病人中還沒有被評價。因此我們假設,在Fio2 80%的腹部手術病態肥胖的病人中,輕微的高碳酸血症可以明顯改善組織氧合。三十位擇期行開腹胃切除的病態肥胖(體重指數61.5 ± 17 kg /m2)的病人被隨機分為正常碳酸血症(n15,呼末二氧化碳35 mm Hg)或高碳酸血症(n15,呼末二氧化碳50 mm Hg);Fio280%。麻醉管理和其他影響因素被控制。組織氧合通過極譜分析探針在臂皮下測量。人口統計學特性、心血管指標和動脈血氧分壓(正常碳酸血症222 ± 48 對高碳酸血症230 ± 68 mm HgP = 0.705)組間無差異。但是組織氧合高碳酸血症高於正常碳酸血症(78 ± 31 56 ± 13 mm Hg; P = 0.029)。所以,輕微的高碳酸血症改善組織氧合在臨是有價值的,並且可以減少病態肥胖病人的傷口感染率。

(陸文清譯 薛張綱校)

Risk of wound infection is increased in morbidly obese surgical patients, in part because a major determinant of wound infection risk, tissue oxygenation, is marginal. Unlike in lean patients, supplemental inspired oxygen (Fio2) only slightly improves tissue oxygenation in obese patients. Mild hypercapnia improves tissue oxygenation in lean patients but has not been evaluated in obese patients. We thus tested the hypothesis that mild hypercapnia markedly improves tissue oxygenation in morbidly obese patients given Fio2 80% during major abdominal surgery.Thirty obese patients (body mass index 61.5 ± 17 kg /m2) scheduled for open gastric bypass were randomly assigned to normocapnia (n = 15, end-tidal Pco2 35 mm Hg) or hypercapnia (n = 15, end-tidal Pco2 50 mm Hg); Fio2 was 80%. Anesthetic management and other confounding factors were controlled. Tissue oxygen tension was measured subcutaneously at the upper arm using a polarographic probe in a silastic tonometer.Demographic characteristics, cardiovascular measurements, and Pao2 (222 ± 48 versus 230 ± 68 mm Hg in normocapnic versus hypercapnic; mean ± sd; P = 0.705) were comparable in the groups. Tissue oxygen tension, however, was greater in hypercapnic than in normocapnic patients (78 ± 31 versus 56 ± 13 mm Hg; P = 0.029). Mild hypercapnia increased tissue oxygenation by an amount believed to be clinically important and could potentially reduce the risk of surgical wound infection in morbidly obese patients.

 

 靜脈應用酮洛來克對辣椒素誘發的深部組織痛覺過敏的作用

The Effect of Intravenous Ketorolac on Capsaicin-Induced Deep Tissue Hyperalgesia

 Kumar, Keeran MD; Polston, Greg R. MD; Wallace, Mark S. MD

the Department of Anesthesiology, University of California San Diego , San Diego , California

Anesth Analg 2006,103:696-702,

 

臨前期和臨試驗已強調小量持續傳入衝動可導致中樞易化,可經系統給予NSAIDS藥物予以弱。然而,這些研究採用的都是經皮痛覺過敏模型。在這項研究中,我們評估了靜注酮洛來克對肌注辣椒素導致深部組織痛覺過敏的試驗模型的效應。我們採用了雙盲對照佇列設計。研究物件在間隔一周的兩部分試驗中分別接受60mg酮洛來克或安慰。隨後在尺側腕屈肌注射辣椒素(100 [mu]g in 10 [mu]L)。注射後0, 5, 10, 15, 20, 25分鐘後記錄自發痛覺評分、按壓痛覺評分、顯著疼痛、痛覺分佈區域和疼痛性質。然後標記皮膚知覺,測定熱和機械閾值。肌注辣椒素可產生可靠的疼痛主訴、痛覺過敏和牽涉痛。酮洛來克對辣椒素導致的自發痛、誘發痛、痛覺分佈或繼發痛覺過敏沒有作用。這項研究的發現支持了採用肌注辣椒素痛覺模型進行進一步藥理研究的可行性。

(徐麗穎譯 薛張綱校)

 Preclinical and clinical studies have emphasized that persistent small afferent input will induce a state of central facilitation that can be attenuated by systemically administered nonsteroidal antiinflammatory drugs. However, these studies have been performed using cutaneous models of hyperalgesia. In this study we evaluated the effects of IV ketorolac on an experimental model of deep tissue hyperalgesia using IM capsaicin. We used a double-blind, placebo-controlled, crossover design. Ten subjects received 60 mg of ketorolac or placebo in 2 sessions separated by 1 wk. Capsaicin (100 [mu]g in 10 [mu]L) was then injected into the flexor carpi ulnaris muscle of the left forearm. After injection, spontaneous pain scores, pressure pain scores, gripping pain, pain distribution, and pain quality were recorded at 0, 5, 10, 15, 20, and 25 min. Cutaneous allodynia and dysesthesia were then mapped and thermal and mechanical thresholds were measured. The IM injection of capsaicin resulted in a reliable report of pain, hyperalgesia, and referred pain. Ketorolac had no effect on spontaneous pain, elicited pain, pain distribution, or secondary hyperalgesia induced by capsaicin. The findings of this study support the feasibility of further pharmacological studies using the IM capsaicin pain model.

 

 給大鼠間歇性腰穿:一種新的實驗方法用於研究阿片類藥物的耐受性

Intermittent Lumbar Puncture in Rats: A Novel Method for the Experimental Study of Opioid Tolerance (Technical Communication)

 Jijun J. Xu, Brittan C. Walla, Miguel F. Diaz, Gregory N. Fuller, and Howard B. Gutstein

Department of Anesthesiology and Molecular Genetics, Program in Genes and Development, Graduate School of Biomedical Sciences, University of Texas , M.D. Anderson Cancer Center , Houston , TX 77030 , USA .

Anesth Analg 2006 103: 714-720.

 

給大鼠蛛網膜下腔注入阿片類藥物已成為研究阿片類藥物藥理學的重要方法,包括其無痛和耐受性。蛛網膜下腔置管,無論是通過頸椎還是腰段,已成為往髓內給予阿片藥物的主要方法。然而,這類方法會導致諸多併發症。為了避免這些問題,我們發明了一種方法來研究用阿片藥物進行麻,即給大鼠間歇性行腰穿。此法避免了置管相關的合併症。我們已證實了此法可用于研究阿片藥物用於麻的耐受性且不會引起合併症。間歇性腰穿應被證實是一種有效的研究阿片藥物用於麻的無痛性和耐受性的方法。

 (王慧琳譯 薛張綱校)

 Spinal subarachnoid opioid administration in rats has been a very important method for studying the pharmacological effects of opioids, including analgesia and tolerance. Intrathecal catheterization, either through the cervical or lumbar approach, has been the predominant method used to deliver opioids spinally. However, these methods have potential undesirable complications. To help mitigate these problems, we have developed a method of intermittent lumbar puncture in rats to study the effects of chronic spinal opioid administration. This method avoids cat heter-associated morbidity. We demonstrate that this method can be readily used to induce spinal opioid tolerance without causing morbidity. Intermittent lumbar puncture should prove to be a useful technique for investigating mechanisms of spinal opioid analgesia and opioid tolerance development.

 

 痛敏肽受體在笑氣的痛敏反應中的作用

The involvemenr of the nociceptin receptor in the antinociceptive action of nitrous oxide

 Himukashi S, Takeshima H, Koyanagi S, Shichino T, Fukuda K.

Department of Anesthesia, Kyoto University Hospital , Kyoto , Japan .

Anesth Analg 2006 103: 738-741.

 

痛敏肽和它的受體廣泛分佈於中樞神經系統,參與痛敏的調節。我們曾報導過揮發性麻醉藥的MAC在痛敏肽受體剔除(NOP-/-)的小鼠和野生型小鼠無差別。最近的研究中我們研究了痛敏肽系統是否參與了笑氣的痛敏反應。我們發現笑氣對NOP-/-型小鼠的麻醉作用低於NOP+/+。而且,用氟烷和笑氣複合麻醉,腹腔內注射酸性物質,NOP-/-小鼠會出現血漿促腎腺皮質激素升高,而NOP+/+沒有。一項免疫組織化學研究表明笑氣可以使NOP+/+小鼠的c-Fos表達,但NOP-/-沒有。這些結果顯示笑氣的痛敏反應至少部分是由痛敏肽介導的。

(鐘靜譯 薛張綱校)

Nociceptin and its receptor are widely expressed in the central nervous system and are involved in the modulation of nociception. We have previously reported that the minimum anesthetic alveolar concentrations for volatile anesthetics do not differ between nociceptin receptor knockout (NOP-/-) mice and wild-type (NOP+/+) mice. In the present study, we investigated whether the nociceptin system is involved in the antinociceptive action of nitrous oxide. Using the acetic acid-induced writhing test, we showed that nitrous oxide had significantly less analgesic action in NOP-/- mice than in NOP+/+ mice. Furthermore, when anesthetized with a mixture of halothane and nitrous oxide (70%), intraperitoneal injection of acetic acid resulted in an increase of plasma adrenocorticotropic hormone concentrations in NOP-/- mice but not in NOP+/+ mice. An immunohistochemical study showed that nitrous oxide exposure induced c-Fos _expression in the spinal cords of NOP+/+ mice but not in those of NOP-/- mice. These results together suggest that the antinociceptive action of nitrous oxide is, at least partly, mediated by the nociceptin system.

 

 氟烷和異氟醚對非麻醉下去大腦大鼠背角神經元的不同作用

The Differential Effects of Halothane and Isoflurane on Windup of Dorsal Horn Neurons Selected in Unanesthetized Decerebrated Rats

 Toshihiko Mitsuyo, Robert C. Dutton, Joseph F. Antognini, and Earl Carstens

San Francisco; and Department of Anesthesiology and Pain Medicine and Section of Neurobiology, Physiology, and Behavior, University of California , Davis .

Anesth Analg 2006 103: 753-760.

 

氟烷和異氟醚,在圍最小肺泡氣有效濃度(MAC)的範圍內,對髓傷害性神經元產生不同作用。為什麼氟烷在0.81.2MAC的範圍內,進一步降低了它們的反應,而異氟醚卻沒有類似作用呢?我們研究了在01.2MAC的範圍內,這些麻醉氣體是否對終末產生不同作用,是否進一步提高神經元對重複傷害性刺激的反應。在去大腦大鼠,從背角神經元終末到201HzC纖維的電刺激,記錄單個單位的資料。應用平行交叉試驗來測定氟烷和異氟醚(0, 0.4, 0.8 1.2 MAC)。隨著氟烷和異氟醚的濃度從0增到1.2MAC,制首次刺激反應的作用增,還增了對所有刺激反應總和的制(分別到34% ± 8% 50% ± 8%, P < 0.05)。從00.8MAC,兩種麻醉氣體都可制終末(即總反應-20×首次反應),但只有氟烷能在1.2MAC時使之進一步降低。0MAC時的神經元反應在0.8MAC時,只是部分,而非全部受制。量依賴性終末制與時間疼痛的減少相一致。氟烷1.2MAC時有進一步的制,異氟醚卻沒有,提示了兩者固定作用的位點不同。固定性看來並非是由麻醉氣體對傷害性神經元這一亞群的制介導的。

(王麗珺譯 薛張綱校)

Halothane and isoflurane, in the peri-minimum alveolar anesthetic concentration (MAC) range, exert differential effects on spinal nociceptive neurons, whereby halothane further depresses their  responses from 0.8 to 1.2 MAC, whereas isoflurane does not. We presently investigated if these anesthetics differentially affect windup, the progressive increase in neuronal responses to repetitive noxious stimuli, over a broad concentration range from 0 to 1.2 MAC. In decerebrated rats, single-unit recordings were made from dorsal horn neurons exhibiting windup to 20 1-Hz C-fiber strength electrical stimuli. Halothane and isoflurane (0, 0.4, 0.8, and 1.2 MAC) were tested in a counterbalanced crossover protocol. Increasing halothane and isoflurane from 0 to 1.2 MAC progressively suppressed the response to the first stimulus, as well as summed responses to all stimuli (to 34% ± 8% and 50% ± 8%, respectively; P < 0.05). Absolute windup (summed response minus 20x the first response) was suppressed by both anesthetics from 0 to 0.8 MAC, with further depression by halothane but not isoflurane at 1.2 MAC. Responses of neurons isolated at 0 MAC were partially, but never totally, depressed at 0.8 MAC. The dose-dependent suppression of windup is consistent with reduced temporal summation of pain. Further depression at 1.2 MAC halothane, but not isoflurane, suggests different sites of immobilizing action for these two anesthetics. Immobility seems to not be mediated by severe anesthetic depression of a subpopulation of nociceptive neurons.