Anesthesia & Analgesia

 

October 2006

Table of Content

CARDIOVASCULAR ANESTHESIA:

性别对单纯主脉瓣置换手术后住院病人的死亡率和发病率的影响

彭中美 马皓琳 李士通

The Impact of Gender on In-Hospital Mortality and Morbidity After Isolated Aortic Valve Replacement

Andra Ibrahim Duncan, Jia Lin, Colleen G. Koch, A. Marc Gillinov, Meng Xu, and Norman J. Starr

Anesth Analg 2006 103: 800-808.

可乐定可减弱心脏手术后T细胞亚群的早期促炎症反应

张美荣 陈杰

Clonidine Attenuated Early Proinflammatory Response in T-Cell Subsets After Cardiac Surgery

Vera von Dossow, Nadine Baehr, Maryam Moshirzadeh, Christian von Heymann, Jan P. Braun, Ortrud V. Hein, Michael Sander, Klaus-D Wernecke, Wolfgang Konertz, and Claudia D. Spies

Anesth Analg 2006 103: 809-814.

太尼的心脏保作用包括中心和外周阿片受体的药理学证据

金琳 薛张纲校

Pharmacologic Evidence for the Involvement of Central and Peripheral Opioid Receptors in the Cardioprotective Effects of Fentanyl

Marcos A. Lessa and Eduardo Tibiriçá

Anesth Analg 2006 103: 815-821.

κ-阿片受体拮改善了长期仪器监测的心肌顿的恢复

黄施伟 译,马皓琳 李士通

{kappa}-Opioid Receptor Antagonism Improves Recovery from Myocardial Stunning in Chronically Instrumented Dogs

Maike A. Grosse Hartlage, Marc M. Theisen, Nelson P. Monteiro de Oliveira, Hugo Van Aken, Manfred Fobker, and Thomas P. Weber

Anesth Analg 2006 103: 822-832.

非诺多泮和多巴胺、硝普钠在腹主脉夹闭中的比较研究

王震虹 陈杰

A Comparison of Fenoldopam with Dopamine and Sodium Nitroprusside in Patients Undergoing Cross-Clamping of the Abdominal Aorta

William C. Oliver, Jr, Gregory A. Nuttall, Kenneth J. Cherry, Paul A. Decker, Thomas Bower, and Mark H. Ereth

Anesth Analg 2006 103: 833-840.

 组织因子通道制剂对由血栓弹图所确定的凝血学的影响

孙敏莉译 薛张纲校

The Impact of Tissue Factor Pathway Inhibitor on Coagulation Kinetics Determined by Thrombelastography

Paul Audu, Vance G. Nielsen, Valerie Armstead, Garry Powell, Jerry Kim, Larry Kim, and Munira Mehta

Anesth Analg 2006 103: 841-845.

缺血导致心肌非同步收缩模型的建立

黄佳佳译,李士通 马皓琳校

Modeling Ischemia-Induced Dyssynchronous Myocardial Contraction

David P. Strum and Michael R. Pinsky

Anesth Analg 2006 103: 846-853.

PEDIATRIC ANESTHESIA:

婴幼儿磁共振检查中的镇静和麻醉:实施者药理学方面的考虑

(印洁敏 陈杰 校)

Sedation and Anesthesia Protocols Used for Magnetic Resonance Imaging Studies in Infants: Provider and Pharmacologic Considerations

Priti G. Dalal, David Murray, Thomas Cox, John McAllister, and Rebecca Snider

Anesth Analg 2006 103: 863-868.

小儿颅脑外伤行急开颅减压术期间低血压的发生率和风险因素。

吴德华译 薛张纲校

The Incidence and Risk Factors for Hypotension During Emergent Decompressive Craniotomy in Children with Traumatic Brain Injury

Patrick Miller, Christopher D. Mack, Marla Sammer, Irene Rozet, Lorri A. Lee, Saipin Muangman, Marjorie Wang, Will Hollingworth, Arthur M. Lam, and Monica S. Vavilala

Anesth Analg 2006 103: 869-875.

ANESTHETIC PHARMACOLOGY:

硬膜外利多卡因导致大鼠剂量依赖性神经损伤

颜涛 译, 马皓琳 李士通

Epidural Lidocaine Induces Dose-Dependent Neurologic Injury in Rats

Tomoko Muguruma, Shinichi Sakura, and Yoji Saito

Anesth Analg 2006 103: 876-881.

异丙酚微乳剂用于的麻醉特性

宋翠侠 陈杰

Anesthetic Properties of a Propofol Microemulsion in Dogs

Timothy E. Morey, Jerome H. Modell, Dushyant Shekhawat, Dinesh O. Shah, Brian Klatt, George P. Thomas, Frank A. Kero, Matthew M. Booth, and Donn M. Dennis

Anesth Analg 2006 103: 882-887.

TECHNOLOGY, COMPUTING, AND SIMULATION:

支气管内插管的模型优化探测

  路译 薛张纲校

Model-Based Detection of Endobronchial Intubation

Rachana K. Visaria and Dwayne R. Westenskow

Anesth Analg 2006 103: 888-893.

自发脑电图和诱发电位的同步监测用于预测全麻的不同临态的判别能

唐李隽 马皓琳 李士通

The Discriminant Power of Simultaneous Monitoring of Spontaneous Electroencephalogram and Evoked Potentials as a Predictor of Different Clinical States of General Anesthesia

Christian Jeleazcov, Gerhard Schneider, Michael Daunderer, Bertram Scheller, Jürgen Schüttler, and Helmut Schwilden

Anesth Analg 2006 103: 894-901.

异丙酚静脉麻醉期间瑞太尼对中潜伏期听觉诱发电位的影响

郑丽 陈杰

The Contribution of Remifentanil to Middle Latency Auditory Evoked Potentials During Induction of Propofol Anesthesia

Stefan Schraag, Joachim Flaschar, Manuela Schleyer, Michael Georgieff, and Gavin N.C. Kenny

Anesth Analg 2006 103: 902-907.

  项提供 医师特异性反馈的麻醉信息系统改善了预防性应用生素的时机

王丽珺译 薛张纲校

An Anesthesia Information System Designed to Provide Physician-Specific Feedback Improves Timely Administration of Prophylactic Antibiotics

Michael O’Reilly, AkkeNeel Talsma, Sharon VanRiper, Sachin Kheterpal, and Richard Burney

Anesth Analg 2006 103: 908-912.

计算机评估负压手术室的通风性能

邱郁薇 马皓琳 李士通

A Computer Evaluation of Ventilation Performance in a Negative-Pressure Operating Theater

Tin-tai Chow, Anne Kwan, Zhang Lin, and Wei Bai

Anesth Analg 2006 103: 913-918.

ECONOMICS, EDUCATION, AND POLICY:

手术切皮前的操作分析: 1558例患者的观察性研究

詹琼慧 陈杰

Task Analysis of the Preincision Surgical Period: An Independent Observer-Based Study of 1558 Cases

Alejandro Escobar, Elizabeth A. Davis, Jan Ehrenwerth, Gail A. Watrous, Gene S. Fisch, Zeev N. Kain, and Paul G. Barash

Anesth Analg 2006 103: 922-927.

 儿科手术室中切皮前的工作分析:一项有关656次手术的独立观察研究

韩晓丹译 薛张纲校

Task Analysis of the Preincision Period in a Pediatric Operating Suite: An Independent Observer-Based Study of 656 Cases

Haleh Saadat, Alejandro Escobar, Elizabeth A. Davis, Jan Ehrenwerth, Gail Watrous, Gene S. Fisch, Zeev N. Kain, and Paul G. Barash

Anesth Analg 2006 103: 928-931. a surgical case.

住院医师培训和手术室时间表的关系:1558例基于独立观测者的研究

姜旭晖译,马皓琳,李士通校

Resident Teaching Versus the Operating Room Schedule: An Independent Observer-Based Study of 1558 Cases

Elizabeth A. Davis, Alejandro Escobar, Jan Ehrenwerth, Gail A. Watrous, Gene S. Fisch, Zeev N. Kain, and Paul G. Barash

Anesth Analg 2006 103: 932-937.

CRITICAL CARE AND TRAUMA:

大学附属医院的围术期肺误吸的发生率和预后: 一项持续4年的回顾性分析

杨卫红 陈杰

The Incidence and Outcome of Perioperative Pulmonary Aspiration in a University Hospital: A 4-Year Retrospective Analysis

Tetsuro Sakai, Raymond M. Planinsic, Joseph J. Quinlan, Linda J. Handley, Tae-Yop Kim, and Ibetsam A. Hilmi

Anesth Analg 2006 103: 941-947.

 微量渗析法用于由肝破裂引起的出血性休克中脑代谢的评估

孙卓真译 薛张纲校

Cerebral Metabolism Assessed with Microdialysis in Uncontrolled Hemorrhagic Shock After Penetrating Liver Trauma

Patrick Meybohm, Erol Cavus, Berthold Bein, Markus Steinfath, Philipp-Alexander Brand, Jens Scholz, and Volker Dörges

Anesth Analg 2006 103: 948-954.

NEUROSURGICAL ANESTHESIA:

右旋美托咪啶不会提高清醒颈脉内膜切除术病人的颈脉内分流的发生率

胡湘 马皓琳 李士通

Dexmedetomidine Does Not Increase the Incidence of Intracarotid Shunting in Patients Undergoing Awake Carotid Endarterectomy

Alex Bekker, Mark Gold, Raza Ahmed, Jung Kim, Caron Rockman, Glenn Jacobovitz, Thomas Riles, and Gene Fisch

Anesth Analg 2006 103: 955-958.

胸骨多普勒法测心输出量:剖宫产术应用标准的或持续腰硬联合麻醉的比较

丁震敏 陈杰

Suprasternal Doppler Estimation of Cardiac Output: Standard Versus Sequential Combined Spinal Epidural Anesthesia for Cesarean Delivery

Johanna K. Bray, Roshan Fernando, Nisa P. Patel, and Malachy O. Columb

Anesth Analg 2006 103: 959-964.

GENERAL ARTICLES:

 甲腺手术插管困难:神话还是现实?

荻译 薛张纲校

Difficult Intubation in Thyroid Surgery: Myth or Reality?

R. Amathieu, N. Smail, J. Catineau, M. P. Poloujadoff, K. Samii, and F. Adnet

Anesth Analg 2006 103: 965-968.

关于新鲜冰冻血浆融化程序和凝血因子活性的时间过程:一项对照性实验室研究

裘毅敏译,马皓琳 李士通校

Thawing Procedures and the Time Course of Clotting Factor Activity in Fresh-Frozen Plasma: A Controlled Laboratory Investigation

Christian von Heymann, Axel Pruss, Michael Sander, Anne Finkeldey, Sabine Ziemer, Ulrich Kalus, Holger Kiesewetter, Abdulgabar Salama, and Claudia Spies

Anesth Analg 2006 103: 969-974.

意识和麻醉的科学整合

曹瑜 陈杰

Integrating the Science of Consciousness and Anesthesia (Review Article)

George A. Mashour

Anesth Analg 2006 103: 975-982.

ANALGESIA:

鞘内注射吗啡或太尼联合病人自控镇痛与单独病人自控镇痛在肝切除术后镇痛效果的比较

陆文清译 薛张纲校

A Comparison of Intrathecal Morphine/Fentanyl and Patient-Controlled Analgesia with Patient-Controlled Analgesia Alone for Analgesia After Liver Resection

Jean-Denis Roy, Luc Massicotte, Marie-Pascale Sassine, Robert F. Seal, and André Roy

Anesth Analg 2006 103: 990-994.

乳房手术后恒定的一氧化氮产物的血浆浓度与术后早期疼痛慢性术后疼痛严重性的关系

黄丽娜 马皓琳 李士通

The Associations Between Severity of Early Postoperative Pain, Chronic Postsurgical Pain and Plasma Concentration of Stable Nitric Oxide Products After Breast Surgery

Gabriella Iohom, Hamza Abdalla, James O'Brien, Szilvia Szarvas, Vivienne Larney, Elisabeth Buckley, Mark Butler, and George Declan Shorten

Anesth Analg 2006 103: 995-1000.

消炎灵漱口水和阿司匹林漱口水在减弱术后咽喉痛方面的作用的评估:一个前瞻性,随机,单盲的研究

李唯一 陈杰

An Evaluation of the Efficacy of Aspirin and Benzydamine Hydrochloride Gargle for Attenuating Postoperative Sore Throat: A Prospective, Randomized, Single-Blind Study

Anil Agarwal, S. S. Nath, Debolina Goswami, Devendra Gupta, Sanjay Dhiraaj, and Prabhat K. Singh

Anesth Analg 2006 103: 1001-1003. incidence and the severity of postoperative sore throat.

 在急性伤害性疼痛家兔模型中静脉腺苷诱导伤害感受的特征:与瑞太尼的对照研究

徐丽颖译 薛张纲校

The Characteristics of Intravenous Adenosine-Induced Antinociception in a Rabbit Model of Acute Nociceptive Pain: A Comparative Study with Remifentanil

Masakazu Hayashida, Atsuo Fukunaga, Ken-ichi Fukuda, Satoru Sakurai, Hideki Mamiya, Tatsuya Ichinohe, Yuzuru Kaneko, and Kazuo Hanaoka

Anesth Analg 2006 103: 1004-1010.

急慢性疼痛病人人类µ阿片受体基因的能性A118G多态性的基因相关研究

张莹 马皓琳 李士通校

A Genetic Association Study of the Functional A118G Polymorphism of the Human µ-Opioid Receptor Gene in Patients with Acute and Chronic Pain

Piotr K. Janicki, Gregg Schuler, David Francis, Angela Bohr, Vitaly Gordin, Tomasz Jarzembowski, Victor Ruiz-Velasco, and Berend Mets

Anesth Analg 2006 103: 1011-1017.

神经轴阻滞和全麻下行选择性全髋置换(THR)的比较:一项Meta分析

周懿之 陈杰

A Comparison of Neuraxial Block Versus General Anesthesia for Elective Total Hip Replacement: A Meta-Analysis

William J. Mauermann, Ashley M. Shilling, and Zhiyi Zuo

Anesth Analg 2006 103: 1018-1025.

 通过硬膜外造影计算机体层摄影术对术后硬膜外镇痛失败的病例分析

王慧琳译 薛张纲校

An Analysis of Postoperative Epidural Analgesia Failure by Computed Tomography Epidurography

Cyrus Motamed, Fayezi Farhat, Francis Rémérand, Jean Stéphanazzi, Agnès Laplanche, and Christian Jayr

Anesth Analg 2006 103: 1026-1032.

太尼的心脏保作用包括中心和外周阿片受体的药理学证据

Pharmacologic Evidence for the Involvement of Central and Peripheral Opioid Receptors in the Cardioprotective Effects of Fentanyl

 Marcos A. Lessa, MD, PhD, and Eduardo Tibiriçá, MD, PhD

Address correspondence and reprint requests to Eduardo Tibiriçá, Department of Physiology and Pharmacodynamics, Oswaldo Cruz Institute, FIOCRUZ, Ave. Brasil 4365-Manguinhos, C. P. 926, 21045-900, Rio de Janeiro, RJ, Brazil.

Anesth Analg 2006 103: 815-821

 

背景:我们通过麻醉兔心肌缺血再灌注损伤模型观察包括中心和外周阿片受体(OR)在内的太尼心脏保作用(FENT)是否与交感过度兴奋的药理作用有关。方法:在35min冠脉闭塞、120min再灌注后,向家兔脑室内注射L谷氨酸达到刺激中枢交感神经的作用。使用FENT治疗(550 µg/kg,静脉注射)前5min,向家兔脑室内注射盐酸纳洛酮或静脉注射甲硫丁氨酸纳洛酮(一种四元化合物,不能透过血脑屏障)。结果:只有FENT 50组心脏梗塞的面积缩小(由51% ± 2% 降至 24% ± 2%)。当外周OR阻滞时,这种保作用消失(42% ± 4%),中枢OR阻滞时没有影响(32% ± 3%)。使用FENT 50时,缺血期间心室合成物前体数量降低(由54 ± 3降至19 ± 7),而当中枢OR阻滞时,这种保作用消失(40 ± 3), 外周OR阻滞时没有影响(18 ± 7)。在灌注期间,使用FENT 50时心室合成物前体数量降低(由134 ± 50降至9 ± 5),当中枢和外周OR阻滞时,这种保作用都减弱(分别为42 ± 420 ± 11)。使用FENT 50时,死亡率(50%)和室性心过速的发生率(55%)都降为零。结论:太尼减少心肌缺血再灌注损伤的作用是通过外周ORs介导的,而阿片类药物的心律失常作用是通过中枢OR介导的。

(金琳 薛张纲校)

 BACKGROUND: We investigated the involvement of central and peripheral opioid receptors (OR) in the cardioprotective effects of fentanyl (FENT) in a model of myocardial ischemia/reperfusion injury associated with pharmacologically induced sympathetic overactivity in anesthetized rabbits. METHODS: Central sympathetic stimulation was achieved through intracerebroventricular injection of l-glutamate in animals submitted to 35 min of coronary occlusion followed by 120 min of reperfusion. Rabbits received naloxone HCl intracerebroventricularly or naloxone methiodide IV, a quaternary compound that does not cross the blood–brain barrier, 5 min before FENT treatment (5 or 50 µg/kg, IV).RESULTS: Infarct area was reduced only by FENT 50 (from 51% ± 2% to 24% ± 2%). This protective effect was abolished by peripheral (42% ± 4%), but not central, OR blockade (32% ± 3%). The number of premature ventricular complexes during the ischemic period (54 ± 3) was reduced by FENT 50 (19 ± 7), an effect blunted by central (40 ± 3) but not peripheral (18 ± 7) blockade of OR. During reperfusion, the number of premature ventricular complexes (134 ± 50) was reduced to 9 ± 5 by FENT 50 and was prevented by central (42 ± 4) as well as peripheral (20 ± 11) OR blockade. The mortality rate (50%) and incidence of ventricular tachycardia (55%) were completely abolished by FENT 50.

CONCLUSIONS: We conclude that fentanyl's effects for limiting myocardial ischemic injury are mediated via peripheral ORs while opioid's antiarrhythmic actions are mediated via central OR agonism.

 

 组织因子通道制剂对由血栓弹图所确定的凝血学的影响

The impact of tissue factor pathway inhibitor on coagulation kinetics determinded by thrombelastography

 Audu P,Nielsen VG,Armstead V,Powell G,Kim J,Kim L,Mehta M.

Department of Anesthesiology, Thomas Jefferson University , Philadelphia , Pennsylvania , USA .

Anesth Analg. 2006 Oct;103(4):841-5

 

背景:组织因子通道制剂(TFPI)是40-kDa的内源性蛋白质,其可制组织因子(TF)结合活化因子X(FXa)启的凝结反应。TF/ FXa合成物随后与TF/活化因子VII(FVIIa)合成物结合,最终制凝血酶生成。使用肝素引起内皮放TFPI浓度为正常值的六倍。血栓弹图(TEG)经常用于监测围术期的凝血态,假定TFPI既制共同的和TF凝血通路,TFPI可能潜在影响基于TEG读数的断性解。因此,在这项研究中,我们通过TEG研究TFPI对凝血的影响。方法:在体外,全血、因子VII缺乏血浆,和正常血浆暴露不同的TFPI浓度后,其未变性时,操作硅藻土激活和TF-激活TEG。结果:在全血,需附87.5 ng/mL TFPI(两倍正常浓度)来延长血块增殖,附175 ng/mL的浓度其血块增殖和强度仅受轻微影响。因子VII缺乏血浆实验阐明在这些浓度TFPI-介导的凝血制是继发于FXa制。硅藻土激活显著的弱TFPI-介导的对凝血影响,然而TF激活强TFPI-介导的延长凝血启和TFPI-介导的血块增殖减少。结论:在包括肝素处理的情况中(例如,心肺转流术),TEG凝血监测时,TFPI-介导的凝血制应该考虑。

(孙敏莉译 薛张纲校)

 BACKGROUND: Tissue factor pathway inhibitor (TFPI) is a 40-kDa, endogenous protein that inhibits tissue factor (TF)-initiated coagulation by bonding with activated factor X (FXa). The TFPI/FXa complex then subsequently binds with TF/activated factor VII (FVIIa) complex, ultimately inhibiting thrombin generation. Heparin administration causes endothelial release of TFPI concentrations up to sixfold normal values. Thrombelastography (TEG) is often used to monitor hemostasis in the perioperative period, and TFPI could potentially affect the diagnostic interpretation of TEG-based data, given its inhibition of both common and TF coagulation pathways. Thus, in this study we characterized the effect of TFPI on coagulation kinetics via TEG. METHODS: Whole blood, Factor VII-deficient plasma, and normal plasma were exposed in vitro to various concentrations of TFPI, after which unmodified, celite-activated, and TF-activated TEG were performed. RESULTS: The addition of 87.5 ng/mL TFPI (twice normal concentration) was required to prolong clot propagation in whole blood, with propagation and strength only significantly affected by the addition of 175 ng/mL concentrations. Experiments with Factor VII-deficient plasma demonstrated that TFPI-mediated suppression of coagulation kinetics at these concentrations was secondary to FXa inhibition. Celite activation markedly attenuated TFPI-mediated effects on coagulation kinetics, whereas TF activation accentuated TFPI-mediated prolongation of clot initiation and diminution of propagation. CONCLUSIONS: In settings involving heparin administration (e.g., cardiopulmonary bypass), TFPI-mediated inhibition of coagulation should be considered during TEG-based hemostatic monitoring.

 

 小儿颅脑外伤行急开颅减压术期间低血压的发生率和风险因素

The incidence and risk factors for hypotension during emergent decompressive craniotomy in children with traumatic brain injury.

 Miller P, Mack CD, Sammer M, Rozet I, Lee LA, Muangman S,Wang M, Hollingworth W, Lam AM, Vavilala MS.

Department of Anesthesiology, University of Washington , Seattle , Washington , USA .

Anesth Analg. 2006 Oct;103(4):869-75 

 

我们回顾性研究了一家1级水平的小儿创伤中心一群13岁以下颅脑外伤(TBI)小儿行急开颅减压手术术中低血压(IH)的发生率和危险因素。1994-2004期间,108例患儿行因TBI行急开颅减压术。总体,5652%)例患儿有IHIH独立的危险因素为:每10ml估计失血量/kg体重(ARR 1.15 95%CI 1.08-1.22);颅脑CT中线移位每mmARR 1.04 95%CI 1.01-1.07);每10ml颅脑CT病灶容量(ARR 1.03 95%CI 1.01-1.05)和急科就存在低血压(5/5例急科低血压患儿有IH)。CT中线移位〉/= 4mm 预示IHARR 1.67 95% CI 1.06-2.63),失血量的独立因素。IH在急性小儿TBI开颅减压术中发生率高。急科低血压,失血量,CT病灶容积和CT中线移位预示IH。麻醉科医生能通过术前CT中线移位〉/= 4mm 来评估手术期间的低血压。

(吴德华译 薛张纲校)

 We conducted a retrospective cohort study in children <13 yr with traumatic brain injury (TBI) at a Level 1 pediatric trauma center to describe risk factors for intraoperative hypotension (IH) during emergent decompressive craniotomy. Between 1994 and 2004, 108 children underwent emergent decompressive craniotomy for TBI. Overall, 56 (52%) patients had IH. Independent risk factors for IH were each 10 mL estimated blood loss/kg (ARR 1.15 95% CI 1.08-1.22), each mm of computed tomography (CT) midline shift (ARR 1.04 95%CI 1.01-1.07), each 10 mL of CT lesion volume (ARR 1.03 95%CI 1.01-1.05), and emergency department (ED) hypotension (5/5 patients with ED hypotension had IH). CT midline shift > or = 4 mm predicted IH (ARR 1.67 95% CI 1.06-2.63), independent of blood loss. IH occurred frequently during emergent decompressive craniotomy in children with TBI. ED hypotension, blood loss, CT lesion volume, and CT midline shift predicted IH. Anesthesiologists can expect children with preoperative CT midline shift > or = 4 mm to have IH during this procedure.

 

支气管内插管的模型优化探测

Model-Based Detection of Endobronchial Intubation

 

Rachana K. Visaria, PhD , and Dwayne R. Westenskow, PhD*

From the Departments of *Anesthesiology and Bioengineering, University of Utah , Salt Lake City , Utah .

Anesth Analg 2006 103: 888-893.

 

我们开发了一种新式的自化的集总模型优化方法用来探测支气管内插管(EBI)。该模型以常规监测的气道压和气流作为输入参数。在探测支气管内插管时,这种方法的特征是当支气管内插管不到位时测试到胸壁僵硬(SCW)的发生。支气管内插管采用10只麻痹并且瘫痪的杂种狗进行,先行气管内插管机械通气,然后将导管插入右主支气管。在胸壁周围裹压气以造成胸壁僵硬的结果。在口部连续测量并记录气道压和气流,并通过这些信号估计呼吸阻。模型参数进行重复识别直到呼吸阻和模型预测阻间的均方根误差达到最小。对支气管插管期间模型参数相对于基线的改变进行分析。10例中的9例,在支气管内插管期间可以肯定的是,该模型的依从性成分(C1)降低≥50%,而模型的性成分(R2)的改变与基线相比≤10-fold。在40个胸壁僵硬案例中测试该标准,发现四个假阳性。在胸壁僵硬时,与基线相比有R1 R2明显升高同时C2明显降低。该项初步研究揭示了在支气管内插管的无创适时探测中,它朝向帮临医生进行决策迈出了有希望的一步。

(金  路译 薛张纲校)

 To detect endobronchial intubation (EBI) noninvasively in real time, we developed a novel, automated, lumped model-based approach. The model uses routinely monitored airway pressure and flow as inputs. The specificity of the method in detecting EBI was determined by testing events of stiff chest wall (SCW) in the absence of EBI. EBI was induced in 10 anesthetized, paralyzed, and mechanically ventilated mongrel dogs (19– 45 kg ) by advancing the endotracheal tube into the right mainstem bronchus. The event of SCW was created by wrapping a pressure cuff around the chest. Airway pressure and flow were continuously recorded at the mouth, and respiratory impedance was estimated from these signals. Model parameters were iteratively identified until the root mean square error between the respiratory and model-predicted impedance was minimum. The change in model parameters during EBI from baseline was analyzed. In nine of 10 cases, it was determined that during EBI, the model’s compliance element (C1) decreased 50% and model’s resistance element (R2) changed 10-fold from baseline. Testing this rule on 40 cases of SCW, four false positives were obtained. During SCW, R1 and R2 increased, whereas C2 decreased significantly from baseline. This preliminary study is a promising step toward noninvasive, real-time detection of EBI to aid clinicians in decision making.

 

  项提供 医师特异性反馈的麻醉信息系统改善了预防性应用生素的时机

 An Anesthesia Information System Designed to Provide Physician-Specific Feedback Improves Timely Administration of Prophylactic Antibiotics

 Michael O’Reilly, AkkeNeel Talsma, Sharon VanRiper, Sachin Kheterpal, and Richard Burney

Department of Anesthesiology, University of Michigan Health Systems, Ann Arbor , Michigan 48109-0048 , USA .

Anesth Analg 2006 103: 908-912.

 

手术区的感染是引起术后发病率和死亡率增的常见原因,并且显著增了治疗费用。全国外科感染预防计划(SIP)的一项内容就是确保预防性生素的时应用,这是降低术后感染的一个关键因素。我们麻醉科承担了适时预防性应用生素的责任,此外,我们还采用了多种方法来提醒 麻醉 医师应用预防性的生素。我们使用临麻醉信息系统为适时预防性应用生素提供实践指南,并从数据库生成反馈给每个医师,目的是为了能使病人在切口1小时内得到生素治疗。这一方案实施前,69%的适应病人在切口60分钟内接受了生素治疗。这一方案开始1年后,稳步增到92%。医师特异性反馈增了执行指南的依从性。麻醉信息系统希望制定和监测新的实践指南, 麻醉 医师要确保非麻醉直接相关治疗的适时应用,这在影响外科预后方面起着关键的作用。

(王丽珺译 薛张纲校)

 Surgical site infections are a frequent cause of morbidity and mortality and add significantly to the cost of care. One component of the national Surgical Infection Prevention (SIP) program is to ensure timely administration of prophylactic antibiotics, a key factor to reduce postoperative infection. Our anesthesia department decided to assume the responsibility for timing and administration of antibiotic prophylaxis and we initiated a multitiered approach to remind the anesthesiologist to administer the prophylactic antibiotics. We used our anesthesia clinical information system to implement practice guidelines for timely antibiotic administration and to generate reports from the database to provide specific feedback to individual care providers with the goal of ensuring that patients receive antibiotic prophylaxis within 1 h of incision. Before the initiation of this project, 69% of eligible patients received antibiotics within 60 min of the incision. After the program began, there was a steady increase in compliance to 92% 1 yr later. Provider -specific feedback increases compliance with practice guidelines related to timely administration of prophylactic antibiotics. Anesthesia information systems hold promise for implementing and monitoring new practice guidelines and the anesthesiologist may play a key role in influencing surgical outcomes by ensuring appropriate therapy that may not be directly related to anesthesia care.

 

 儿科手术室中切皮前的工作分析:一项有关656次手术的独立观察研究

Task Analysis of the Preincision Period in a Pediatric Operating Suite: An Independent Observer-Based Study of 656 Cases

Haleh Saadat, MD*, Alejandro Escobar, MD*, Elizabeth A. Davis, RDCS*, Jan Ehrenwerth, MD*, Gail Watrous, RN*, Gene S. Fisch, PhD , Zeev N. Kain, MD, MBA*, and Paul G. Barash, MD*

From the *Department of Anesthesiology, General Clinical Research Center, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut.

.Anesth Analg 2006 103: 928-931.

 

我们设计了交叉组合调查来评估麻醉实施时间ART)和小儿经历麻醉外科手术的外科准备时间(n=656)。数据由有经验的且独立的观察者收集,变量有年龄、ASA分级、麻醉器械和有创监测的位置。我们发现平均ART11.0 ± 9.7分钟,平均外科准备时间是11.1 ± 10.0分钟。ART的范围从7 ± 7分到52 ± 18分。ART占整个手术时间的15%± 7%,它的变异性很大,主要和整个手术时间长短有关。我们还发现ART有一个明显的变量,包括ASA分级和年龄。例如,年纪小的儿童要比年纪大的儿童ART长。主治麻醉医生和住院麻醉医生的房间覆盖率对ART的影响不大。我们得出结论:小儿手术的ART是多变的,最主要的相关因素有小儿的年龄和ASA分级。当安排外科手术时应考虑这些因素。

(韩晓丹译 薛张纲校)

 We designed this cross-sectional investigation to assess anesthesia release time (ART = patient-on-table until release for surgical preparation) and surgical preparation time (start of surgical preparation to incision) of children undergoing anesthesia and surgery (n = 656). Data collected by trained independent observers included variables such as age, ASA physical status, anesthetic technique, and placement of invasive monitoring. We found that mean ART was 11.0 ± 9.7 min and the mean surgical preparation time was 11.1 ± 10.0 min. Also, ART ranged from 7 ± 7 min (for mask anesthesia) to 52 ± 18 min (general anesthesia/endotracheal tube and invasive hemodynamic monitoring). The percentage of ART of the total case length was 15% ± 7%, with a wide variability depending on the total case length. We also found that there is a significant variability in ART as a function of the surgical service involved (analysis of variance; P = 0.0001), ASA physical status (P = 0.0001), and age. For example, younger children had a significantly longer ART as compared with older children (P = 0.001). Room coverage ratio by the attending anesthesiologist and training level of the anesthesia resident did not impact ART (P = not significant). We conclude that ART in children undergoing surgery is highly variable and is a function of factors such as the surgical service involved, age of the child, and ASA physical status of the child. These factors should be considered when scheduling a surgical case.

 

 微量渗析法用于由肝破裂引起的出血性休克中脑代谢的评估

Cerebral metabolism assessed with microdialysis in uncontrolled hemorrhagic shock after penetrating liver trauma.

 Meybohm P, Cavus E,Bein B,Steinfath M,Brand PA,Scholz J,Dorges V.

Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel , Germany .

Anesth Analg. 2006 Oct;103(4):948-54

 

我们在难以控制的出血性休克的猪的模型中,评价使用精氨酸压素(AVP)和高张的羟乙基淀粉溶液(HHS)进行容量复苏时的脑灌注压脑内微量渗析法测得的脑代谢。16只被麻醉的猪首先造成其由于肝出血而形成的血流学失代偿态。然后分成两组给与容量复苏,一组为普通溶液组(n = 8),一组为AVP/HHS(n = 8)。给药后30分钟,使用人工压迫控制出血,然后两组给与同样的晶体和胶体。观察研究存活下来的猪一小时后得到以下结论。在血流学失代偿后,普通溶液复苏组与AVP/HHS组相比脑灌注压升小(mean +/- sem; 24 +/- 5 vs 45 +/- 7 mm Hg; P < 0.01);溶液复苏后5分钟平均脑内血管氧分压与AVP/HHS组相比显著下降(36 +/- 3 vs 64 +/- 4 torr P < 0.01)。同时两组之间也比较了脑代谢的不同。结论是作为容量复苏的初始手段,如考虑到脑内灌注脑供氧时AVP/HHS被证明优于普通溶液;但如考虑脑代谢存活物的细胞二次损伤时与普通溶液无明显差异。

(孙卓真译 薛张纲校)

        In a porcine model of uncontrolled hemorrhagic shock, we evaluated the effects of fluid resuscitation versus arginine vasopressin (AVP) combined with hypertonic-hyperoncotic hydroxyethyl starch solution (HHS) on cerebral perfusion pressure (CPP) and on cerebral metabolism using intracerebral microdialysis. Sixteen anesthetized pigs were subjected to uncontrolled liver bleeding until hemodynamic decompensation, followed by resuscitation using either fluid (n = 8) or AVP/HHS (n = 8). Thirty minutes after drug administration, bleeding was controlled by manual compression, and colloid and crystalloid solutions were administered in both groups. All surviving animals were observed for one hour. After hemodynamic decompensation, fluid resuscitation resulted in a smaller increase of CPP than did AVP/HHS (mean +/- sem; 24 +/- 5 vs 45 +/- 7 mm Hg; P < 0.01). Mean (+/- sem) cerebral venous partial pressure of oxygen was significantly decreased (P < 0.01) 5 min after fluid compared with 5 min after AVP/HHS administration (36 +/- 3 vs 64 +/- 4 torr). Cerebral metabolism was comparable in both groups. In conclusion, AVP/HHS proved to be superior to fluid in the initial phase of therapy with respect to CPP and cerebral oxygenation, but was comparable to fluid regarding cerebral metabolism and secondary cell damage in surviving animals.

 

 甲腺手术插管困难:神话还是现实?

Difficult intubation in thyroid surgery: myth or reality?

Amathieu R, Smail N, Catineau J, Poloujadoff MP, Samii K, Adnet F.

SAMU 93, EA 3409, Hopital Avicenne, University Paris, Bobigny , France .

Anesth Analg 2006 103: 965-968.

 

甲腺手术被认为是困难气道管理的一个危险因素。我们前瞻性研究了连续324位行甲腺手术的病人,根据插管困难标尺来调查困难插管的发生率以其他特的预测性因素。困难插管的总发生率为11.1% (95% CI: 7.6-14.5)。中位插管困难标尺为0(25th-75th 百分位数: 0; 2.7)。在三个预定义组中(回波描记无甲腺肿块,临可触甲腺肿块,不可触的甲腺肿块),困难插管分别发生在10% (95% CI: 4.8-17.4), 13% (95% CI: 6.5-18.4) 11% (95% CI: 4.7-16.8)的病人,组间无统计学差异。特的预测标准(可触的肿块,胸内的肿块,气道变形,气道压迫或甲腺恶性肿瘤)与困难插管的发生率增高无关。经典的预测标准(张口度< 35mm Mallampati IIIIV,短颈,颈部活度<80度,甲颏距< 65mm 和下颌骨退缩)在单变量分析中是显著可靠的困难插管风险因素。

(周 荻译 薛张纲校)

 Thyroid surgery is considered to be a risk factor for difficult airway management. We prospectively studied 324 consecutive patients undergoing thyroid surgery to investigate the incidence of difficult intubation as evaluated by the intubation difficulty scale as well as other specific predictive factors. The overall incidence of difficult intubation was 11.1% (95% CI: 7.6-14.5). Median intubation difficulty scale was 0 (25th-75th percentile: 0; 2.7). In three predefined groups (no echographic goiter, clinically palpable goiter, and impalpable goiter), difficult intubation occurred in 10% (95% CI: 4.8-17.4), 13% (95% CI: 6.5-18.4), and 11% (95% CI: 4.7-16.8) of patients, respectively, with no statistical difference among the groups. Specific predictive criteria (palpable goiter, endothoracic goiter, airway deformation, airway compression, or thyroid malignancy) were not associated with an increased rate of difficult intubation. Classical predictive criteria (mouth opening < 35 mm , Mallampati III or IV, short neck, neck mobility <80 degrees , thyromental distance < 65 mm , and a retrognathic mandible) were significantly reliable in the univariate analysis as risk factors for difficult intubation.

 

 

鞘内注射吗啡或太尼联合病人自控镇痛与单独病人自控镇痛在肝切除术后镇痛效果的比较

A comparison of intrathecal morphine/fentanyl and patient-controlled analgesia with patient-controlled analgesia alone for analgesia after liver resection

 Roy JD, Massicotte L, Sassine MP, Seal RF, Roy A

Department ofAnesthesiology, Centre hospitalier de l'Universite de Montreal, Hopital St-Luc, Montreal , Quebec , Canada .

Anesth Analg. 2006 Oct;103(4):990-4

 

持续硬膜外麻醉和镇痛可以考虑用于肝切除手术,但是经常因为潜在的凝血能异常和可能发生硬膜外血肿而放弃使用。在这个前瞻、随机、双盲的研究中,我们比较两组肝切除术后病人自控镇痛的吗啡用量:一组术前鞘内注射吗啡(0.5mg)和太尼(15ug)(治疗组);一组术前鞘内注射安慰剂(安慰剂组)。四十个肝切除(≥2个段)的病人被挑选入组。主要监测指标是病人自控镇痛的吗啡用量。次要指标是评价休息和活时的疼痛,评分用可视疼痛量表,包括评估镇静、恶心、骚痒和呼吸频率。结果监测在髓麻醉后612182448小时。安慰剂组的病人每段时间吗啡的用量几乎是治疗组的三倍(在48小时:124 +/- 30 vs 47 +/- 21 mg, P < 0.0001)。在治疗组,前18小时的疼痛评分比较低。两组不良反应的发生率没有差异。所以,肝脏手术前鞘内注射吗啡(0.5mg)和太尼(15ug)可以明显减少术后吗啡的用量而不增不良反应。

(陆文清译 薛张纲校)

 Continuous epidural anesthesia and analgesia may be considered in liver resection, but is often avoided because of the potential development of coagulopathies and the risk of epidural hematoma. In this prospective, randomized, double-blind study we compared postoperative morphine consumption via patient-controlled analgesia after liver surgery between two groups of patients: patients receiving a preoperative dose of intrathecal morphine (0.5 mg) and fentanyl (15 microg) (treatment group) and patients receiving a sham intrathecal injection (placebo group).Forty patients scheduled for major liver resection (> or = two segments) were enrolled. The primary outcome measure was patient-controlled analgesia morphine consumption. Secondary outcomes were evaluation of pain at rest and with movement, scored on a visual analog scale with assessment of sedation, nausea, pruritus, and respiratory frequency. Outcome measures were recorded at 6, 12, 18, 24, and 48 h postspinal anesthesia or simulation. Patients in the placebo group consumed approximately three times more morphine during each time interval than patients in the treatment group (at 48 h: 124 +/- 30 vs 47 +/- 21 mg, P < 0.0001). Pain evaluation on the visual analog scale was lower for the first 18 h in the treatment group. There was no difference in the incidence of side effects in both groups. Intrathecal morphine (0.5 mg) and fentanyl (15 microg) given before liver surgery significantly decreased postoperative morphine consumption compared to placebo without any increase in side effects.

 

 在急性伤害性疼痛家兔模型中静脉腺苷诱导伤害感受的特征:与瑞太尼的对照研究

The Characteristics of Intravenous Adenosine-Induced Antinociception in a Rabbit Model of Acute Nociceptive Pain: A Comparative Study with Remifentanil

Hayashida M, Fukunaga A, Fukuda K, Sakurai S, Mamiya H, Ichinohe T, Kaneko Y, Hanaoka K

Surgical Center, Research Hospital, Institute of Medical Institute, The University of Tokyo, Tokyo, Japan.

Anesth Analg. 2006 Oct;103(4):1004-10.

 

背景:腺苷和瑞太尼是具有超短衰期的强效静脉镇痛药。静脉应用腺苷的伤害感受效应还未被清晰阐明。我们在用家兔比较腺苷和瑞太尼的效应。方法:16只家兔,放置在悬带允许适当的自由运,静脉应用腺苷(400 microg x kg(-1) x min(-1))或瑞太尼(0.4 microg x kg(-1) x min(-1)),持续240min。结果:通过评估对钳夹前脚无反应的物数量和出现逃避运的电刺激阈,两种药物都可产生深度伤害感受。用瑞太尼,伤害感受效应迅速增强,60min达峰,随后即使继续输注仍开始减弱。停止输注后,迅速减弱并且在30min内消失。静脉应用腺苷的扩血管效应即刻产生且持续时间极短。腺苷的伤害感受效应增强缓慢,但在输注期间逐渐增强,只在输注结束时达峰。在输注终止后360min内缓慢减弱。结论:瑞太尼起效迅速且作用时间短,很可能显示了耐受性的发展,而腺苷的伤害感受效应起效缓慢且持续时间长,但血浆衰期极短,具有即刻开-关特性的扩血管效应。

(徐丽颖译 薛张纲校)

 BACKGROUND: Adenosine and remifentanil are potent IV analgesics with ultrashort half-lives. The antinociceptive effect of IV adenosine has not been clearly characterized. We compared the antinociceptive effects of adenosine and remifentanil in rabbits. METHODS: Sixteen rabbits, placed on a sling allowing reasonably free movement, received IV adenosine (400 microg x kg(-1) x min(-1)) or remifentanil (0.4 microg x kg(-1) x min(-1)) over 240 min. RESULTS: Both drugs produced profound antinociception, as assessed by the number of animals unresponsive to clamping the forepaw and the electrical stimulation threshold of escape movement. With remifentanil, the antinociceptive effect increased rapidly, reaching its peak at 60 min, and then began to decline despite continued infusion. After stopping the infusion, it decreased rapidly and disappeared within 30 min. The vasodilating effect of IV adenosine was immediate in onset and ultrashort in duration. The antinociceptive effect of adenosine increased slowly but progressively during the infusion, reaching its peak only when the infusion ended. Then it decreased slowly over the following 360 min after terminating the infusion. CONCLUSION: Remifentanil had a rapid onset and short duration of action, and probably showed signs of tolerance development, whereas the antinocieptive effect of adenosine was slow in onset and long-lasting, despite its ultrashort plasma half-life and the immediate on-off profiles of its vasodilating effect.

 

 通过硬膜外造影计算机体层摄影术对术后硬膜外镇痛失败的病例分析

An Analysis of Postoperative Epidural Analgesia Failure by Computed Tomography Epidurography

 Cyrus Motamed, Fayezi Farhat, Francis Rémérand, Jean Stéphanazzi, Agnès Laplanche, and Christian Jayr

Department of Anesthesia, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif , Cedex , France .

Anesth Analg 2006 103: 1026-1032.

 

此项前瞻性研究共包括125例患者,我们通过硬膜外造影计算机体层摄影术对大型腹部外科手术术后硬膜外镇痛失败进行分析,比较两组患者即硬膜外镇痛成组和失败组的硬膜外导管移出和液体漏出硬膜外腔的发生率。我们设想导管移出和液体漏出的发生率在镇痛成组要低一些。我们在全麻前行胸段硬膜外导管放置。术中给药为0.25%布比卡因,术后48小时采用0.125%布比卡因(10ml/h)吗啡(0.25mg/h)持续硬膜外镇痛。镇痛失败定义为:在静息态下直观类比标度疼痛评分大于30mm /48小时之内任何原因的硬膜外镇痛中断。当出现镇痛失败,且不是导管扭结或不良事件(n=11,我们就注射造影剂行CT扫描。镇痛满意的患者(即成组)也行CT扫描。镇痛失败的发生率为24.8%n31),失败组行CT扫描(n=20)示有7位患者的硬膜外导管不在硬膜外腔,9位患者的导管位置正常,1位患者的导管位置偏于一侧,3位患者的镇痛液从硬膜外腔漏出。成组中,CT扫描(n=19)示11位患者的导管位置正常,5位患者导管偏于一侧,3位患者镇痛液有漏出。我们得出结论:硬膜外镇痛失败的主要原因是导管移出。CT扫描是较常用的发现液体漏出的方法,提示可能是早期导管移出。

(王慧琳译 薛张纲校)

 In this prospective study involving 125 patients, we analyzed epidural analgesia failure after major abdominal surgery using computed tomography (CT) epidurographies to compare the incidence of dislodgement of epidural catheters and leakage of solution from the epidural space between two groups of patients: patients with successful or failed epidural analgesia. Our hypothesis was that the incidence of dislodgement and leakage should be low when epidural analgesia is successful. A thoracic epidural catheter was inserted before general anesthesia and secured by subcutaneous tunneling. Bupivacaine (0.25%) was administered during surgery followed by continuous epidural analgesia with 0.125% bupivacaine (10 mL/h) and morphine (0.25 mg/h) for 48 h. Failure was defined as a visual analog scale pain score at rest more than 30 mm and/or interruption of epidural analgesia before 48 h for any reason. When failure was not due to unintentionally withdrawn, kinked catheters or adverse events (n = 11), a CT scan with contrast injection was performed. Control CT scans were also performed in patients with adequate analgesia (i.e., the success group). The incidence of failure was 24.8% (n = 31). CT scans in the failure group (n = 20) showed seven patients with catheters outside the epidural space, nine with normal distribution, one with unilateral spread, and three with leakage of solution outside the epidural space. In the success group, CT scans (n = 19) showed 11 patients with normal distribution, five with unilateral spread, and three with leakage. We conclude that the major cause of epidural analgesia failure was dislodgment of the catheter. CT scans were mostly useful for detecting leakage of injectate, which may be the early phase of dislodgment.

 

 

可乐定可减弱心脏手术后T细胞亚群的早期促炎症反应

Clonidine Attenuated Early Proinflammatory Response in T-Cell Subsets After Cardiac Surgery

Vera von Dossow, MD*, Nadine Baehr, Cand Med*, Maryam Moshirzadeh, MD*, Christian von Heymann, MD*, Jan P. Braun, MD*, Ortrud V. Hein, MD*, Michael Sander, MD*, Klaus-D Wernecke, PhD{dagger}, Wolfgang Konertz, MD{ddagger}, and Claudia D. Spies, MD*

From the *Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charité; {dagger}Institute of Medical Biometry, Campus Charité Mitte, Charité; {ddagger}Department of Cardiovascular Surgery, Campus Charité Mitte, Charité, Universitaetsmedizin Berlin, Berlin, Germany.

Anesth Analg 2006 103: 809-814.

 

T细胞对损伤的免疫反应起主导的作用。心脏手术后发生全身炎症反应综合征的风险高并诱导促炎症反应细胞因子不平衡。可乐定通过减少交感神经活性而具有免疫调作用,本研究对冠脉旁路移植手术的病人的术后早期进行T淋巴细胞的能分析。40名心脏手术病人随机分为两组:可乐定组(可乐定1ug /kg/h n=20)和对照组(n=20)。从麻醉诱导后开始用药直到手术后6小时。术前、入ICU、手术后6小时、12小时、手术后第一天和第二天的早晨分别取血测定Th1Th2细胞和细胞毒性淋巴细胞(Tc1Tc2细胞)。可乐定组,手术后6小时Th1/Th2Tc1/Tc2的比率较对照组显著降低(p<0.05)。可乐定改变了外周血T细胞亚型的比例增强促炎症反应,这一点可能有利于维持术后免疫平衡。

(张美荣 陈杰 校)

T-cells play a central role in the immune response to injury. Cardiac surgery is associated with significant risk of systemic inflammatory response syndrome and subsequent unbalanced induction of proinflammatory cytokines. As clonidine has immunomodulating properties via reducing sympathetic activity, this study involved the analysis of T-cell function in the early postoperative period in patients undergoing coronary artery bypass graft surgery. Forty patients undergoing cardiac surgery were randomly allocated to one of the following groups: clonidine group (n = 20) [clonidine 1 µg kg–1 h–1] and placebo group (n = 20). Study medication was started after induction of anesthesia and maintained until 6 h after surgery. Blood samples to determine Th1 and Th2 cells and cytotoxic lymphocytes (Tc1 and Tc2 cells) were drawn preoperatively, on admission to the intensive care unit, 6 and 12 h postoperatively as well as on the morning of days 1 and 2 after surgery. In the clonidine group significantly lower levels of Th1/Th2 ratios as well as Tc1/Tc2 ratios were found 6 h postoperatively compared to the placebo group (P < 0.05). Clonidine changed the ratio of T-lymphocyte subpopulations in peripheral blood in favor of a proinflammatory response, which might be favorable for maintaining immune balance after surgery.

 

非诺多泮和多巴胺、硝普钠在腹主脉夹闭中的比较研究

A Comparison of Fenoldopam with Dopamine and Sodium Nitroprusside in Patients Undergoing Cross-Clamping of the Abdominal Aorta

William C. Oliver, Jr, MD*, Gregory A. Nuttall, MD*, Kenneth J. Cherry, MD{dagger}, Paul A. Decker, MSc{ddagger}, Thomas Bower, MD, and Mark H. Ereth, MD*

From the *Department of Anesthesiology; {dagger}Department of Surgery, Emeritus Staff; {ddagger}Division of Biostatistics; and Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota.

Anesth Analg 2006 103: 833-840

.

非诺多泮为选择性多巴胺受体激剂,可以迅速降低脉压,其作用时间和硝普钠相似,但与硝普钠不同,可以增肾血流量。作者比较了腹主脉夹闭手术中使用非诺多泮、多巴胺、硝普钠的血流学和肾血管效应。随机选择60名患者术前双盲注射非诺多泮或多巴胺(2µg.kg.min-1)和硝普钠。开腹前,脉夹闭即刻,松解后5min和术毕时分别记录血流学变化。术中和术后测定尿量,血清肌酐和肌酐清除率。采用双样本等级检验比较组间持续变量,Fisher’s 检验比较分离变量。严重高血压的发生率,最高收缩压和使用高血压药物的情况各组间无差异。术中最多的血流学变化和所有肾能的指标没有差异。因此非诺多泮和其他治疗药物相比在大血管手术包括脉夹闭的过程中没有显著优。

(王震虹 陈杰 校)

Fenoldopam, a selective dopamine-1-receptor agonist, decreases arterial blood pressure rapidly, with a brief duration of action similar to sodium nitroprusside (SNP), but in contrast to SNP, it increases renal blood flow. We compared the hemodynamic and renal effects of fenoldopam in patients undergoing abdominal aortic surgery requiring cross-clamping of the aorta with another therapeutic option, dopamine and SNP. Fenoldopam or 2 mcg · kg–1 · min–1 of dopamine and SNP was infused before incision in 60 randomly selected patients in a double-blind fashion. Hemodynamic variables were recorded before incision, immediately before clamping the aorta, 5 min after cross-clamp release and upon completion of surgery. Urine output, serum creatinine, and creatinine clearance were measured intraoperatively and postoperatively. Characteristics were compared between groups using two-sample rank sum test for continuous variables and Fisher’s exact test for discrete variables. The occurrence of severe hypotension, maximum systolic blood pressure, and need for additional antihypertensive drugs were not different between the groups. Most intraoperative hemodynamic variables and all indices of renal function did not differ according to treatment. Therefore, fenoldopam has no therapeutic advantage compared with similar therapies in patients undergoing major vascular surgery involving cross-clamping of the aorta.

 

婴幼儿磁共振检查中的镇静和麻醉:实施者药理学方面的考虑

Sedation and Anesthesia Protocols Used for Magnetic Resonance Imaging Studies in Infants: Provider and Pharmacologic Considerations

Priti G. Dalal, MD, FRCA, David Murray, MD, Thomas Cox, MD, John McAllister, MD, and Rebecca Snider, RN

From the Department of Anesthesiology, St. Louis Children’s Hospital, Washington University School of Medicine, St. Louis, Missouri.

Anesth Analg 2006 103: 863-868.

 

既往多数有关儿童镇静的研究仅就单一药物研究,并且年龄范围较大。临实践中,许多镇静和麻醉管理由士和内科医生完成。本研究则了一系列药物对婴幼儿镇静的有效性。258名需要行磁共振检查的婴儿中,由士给予口服水合氯醛(n102)或静注巴比妥(n67),其余由内科医生给予静注丙酚(n68)。观察表明水合氯醛组心肺制的发生率(2.9%)较巴比妥组(13.4%)和丙酚组(13.6%)低(P<0.05)。相对于口服水合氯醛的婴儿(平均23.5±13.4分钟;)使用丙酚的婴儿可以更快的配合磁共振扫描(平均9.1±6.7分钟, P<0.05)。巴比妥组出院时间最长(平均80.3±39.2分钟),丙酚组的出院时间最短(平均53.9±30.1分钟;P<0.05)。口服水合氯醛的婴儿组在接受磁共振检查中体的发生率最高(22.5%),巴比妥组的发生率为12.2%,丙酚组仅为1.4%P<0.001)。

(印洁敏 陈杰 校)

Most studies report the efficacy of only a single drug to achieve sedation in a broad age range of children. In clinical practice, a variety of sedative and anesthetic regimes are monitored by nurses and physicians. In this study we report the efficacy of a tiered approach to monitoring and sedation in infants. Two-hundred-fifty-eight infants who required magnetic resonance imaging (MRI) studies received either oral chloral hydrate (n = 102) or bolus doses of IV pentobarbital (n = 67) monitored by nurses or IV propofol infusion (n = 68) titrated by physicians. Fewer cardiorespiratory events were observed in the chloral hydrate group (2.9%) compared to pentobarbital (13.4%) and propofol groups (13.6%); P < 0.05, propofol versus chloral hydrate. Infants who received propofol were ready to begin MRI scanning earlier (mean 9.1 ± 6.7 min) than infants who received oral chloral hydrate (mean 23.5 ± 13.4 min; P < 0.05). The time to discharge was longest in the pentobarbital (mean 80.3 ± 39.2 min) and shortest in the propofol group (mean 53.9 ± 30.1 min; P < 0.05). Infants in the chloral hydrate group moved more frequently (22.5%) during MRI scanning (with four sedation failures of 102) compared to 12.2% in the pentobarbital group and 1.4% in the propofol group (P < 0.001).

 

异丙酚微乳剂用于的麻醉特性

Anesthetic Properties of a Propofol Microemulsion in Dogs

Timothy E. Morey, MD*, Jerome H. Modell, MD, DSc (Hon)*{dagger}, Dushyant Shekhawat, BS{ddagger}, Dinesh O. Shah, PhD*{dagger}{ddagger}, Brian Klatt, BS, George P. Thomas, MSc, PhD, Frank A. Kero, BS*||, Matthew M. Booth, PhD*, and Donn M. Dennis, MD, FAHA*¶#

From the Departments of *Anesthesiology, {ddagger}Chemical Engineering, ||Chemistry, ¶Pharmacology and Experimental Therapeutics, and #Psychiatry, University of Florida, Gainesville, Florida; {dagger}NanoMedex, Inc., Alachua, Florida; and Calvert Laboratories, Inc., Olyphant, Pennsylvania.

Anesth Analg 2006 103: 882-887.

用纳米直径的异丙酚微乳剂替代异丙酚大豆油粗乳剂作麻醉诱导可能存在多种处。作者用10mg/ml异丙酚微乳剂(粒子直径为24.5± 0.5nm)和异丙酚大豆油粗乳剂对10只进行麻醉诱导,间隔7天随机交叉麻醉。以捏夹足趾时腿不回缩和生命体征无变化为麻醉终点。多个时间点取静脉血样本测定异丙酚血浆药物浓度以红细胞、白细胞计数和凝血指数。每只达到痛觉消失随后顺利复苏且无明显并发症。异丙酚微乳剂和粗乳剂麻醉下,下列指标无显著差异:剂量(分别为10.3±1.29.7±1.6 mg/kgP=0.39),诱导时间(1.0±0.11.0±0.2minP=0.39),复苏时间(17.4±4.618.2±3.8minP=0.70),心率(P=0.62),脉压(P=0.81),呼吸频率(P=0.60),血像变化、凝血酶原时间(P=0.89),部分凝血活酶时间(P=0.76),纤维蛋白浓度(P=0.52),血小板浓度(P=0.55),以血浆异丙酚浓度(P=0.20)。异丙酚微乳剂和粗乳剂并不会明显改变生命体征、血像、凝血变化、以异丙酚血浆浓度。

(宋翠侠 陈杰 校)

Microemulsions of propofol with nanometer droplet diameter are alternatives to soybean macroemulsions for inducing anesthesia, and may have important advantages. We used a propofol (10 mg/mL) microemulsion (particle diameter 24.5 ± 0.5 nm) and a commercial macroemulsion to induce anesthesia in dogs (n = 10) using a randomized, crossover design separated by a 7-day rest interval. The end points were loss of leg withdrawal after a toe pinch and changes in vital signs. Venous blood samples were acquired at multiple times to measure plasma propofol concentrations and indices of erythrocytes, leukocytes, and coagulation. All dogs were rendered insensitive to pain followed by successful recovery without noticeable complications. Comparing indices between microemulsion and macroemulsion formulations, no differences were noted with respect to dose (10.3 ± 1.2 and 9.7 ± 1.6 mg/kg, respectively, P = 0.39), time to induction (1.0 ± 0.1 and 1.0 ± 0.2 min, P = 0.39), time to recovery (17.4 ± 4.6 and 18.2 ± 3.8 min, P = 0.70), heart rate (P = 0.62), arterial blood pressure (P = 0.81), respiratory rate (P = 0.60), hemogram variables, prothrombin time (P = 0.89), activated partial thromboplastin time (P = 0.76), fibrinogen concentration (P = 0.52), platelet concentration (P = 0.55), or plasma propofol concentrations (P = 0.20). Induction with a propofol microemulsion or macroemulsion did not significantly vary with respect to vital signs, the hemogram, clotting variables, and plasma propofol concentrations.

 

异丙酚静脉麻醉期间瑞太尼对中潜伏期听觉诱发电位的影响

The Contribution of Remifentanil to Middle Latency Auditory Evoked Potentials During Induction of Propofol Anesthesia

Stefan Schraag, MD, PhD*, Joachim Flaschar, Dipl-Ing (FH){dagger}, Manuela Schleyer, MD{dagger}, Michael Georgieff, MD, PhD{dagger}, and Gavin N.C. Kenny, MD, BSc(Hons), FRCA, FANZCA{ddagger}

From the *Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, UK; {dagger}Department of Anesthesiology, University of Ulm, Germany; and {ddagger}Department of Anesthesia, Glasgow Royal Infirmary, Glasgow, UK.

Anesth Analg 2006 103: 902-907.

 

作为全麻组成部分的阿片类药是否能通过基于脑电图的麻醉评估系统反映出来仍有争议。为了验证这一假设即瑞太尼定量地影响中潜伏期听觉诱发电位,作者研究了择期下肢远端矫形外科手术的45位成年男性病人在异丙静脉麻醉期间瑞太尼与中潜伏期听觉诱发电位之间的相互关系。45个病人随机分为三组。前两组用TCI分别接受高靶控浓度的瑞太尼(8 ng mL–1)和低靶控浓度的瑞太尼(3ng mL–1)。第三个组用麻替代瑞太尼。通过TCI逐步增异丙酚浓度。记录意识消失和喉罩置入时听觉诱发电位指数(AEPex)和异丙酚浓度。然后异丙酚输入改为AEPex数值为40的目标闭合回路TCI。结果发现单独使用瑞太尼对听觉诱发反应无显著作用,相反浓度逐步增的瑞太尼导致意识消失的异丙酚浓度下降(P = 0.023)。作者推测瑞太尼浓度与AEPex呈负相关,对照组更为明显(即单独接受异丙酚组)。这些结果支持了先前的发现:在意识消失时瑞太尼和异丙酚的存在定量的相互作用,但瑞太尼对听觉诱发电位直接作用仍是个问题。

(郑丽 陈杰 校)

There is a debate regarding whether opioids, as a component of general anesthesia, are adequately reflected in the assessment of anesthesia based on derivatives of the electroencephalogram. To test the hypothesis of a possible quantitative contribution of remifentanil on middle latency auditory evoked potentials, we studied its interaction with propofol anesthesia in 45 unpremedicated male patients undergoing elective lower limb orthopedic surgery. They were allocated randomly to three groups. The first two groups received remifentanil either with a high (8 ng mL–1) or a low (3 ng mL–1 target concentration using target-controlled infusion (TCI). The third group received spinal anesthesia instead of remifentanil. Anesthesia was induced by a stepwise increase in propofol concentration using TCI. The auditory evoked potential index (AEPex) and calculated propofol effect site concentrations were determined at loss of consciousness and the reaction to laryngeal mask airway insertion was noted. The propofol infusion was then converted to a closed-loop TCI using an AEPex value of 40 as the target. We found no significant contribution of remifentanil alone on the auditory evoked response, whereas increasing concentrations of remifentanil led to a significant decrease of the calculated propofol effect site concentrations (P = 0.023) necessary for unconsciousness. Prediction probability for AEPex was inversely related to the remifentanil concentration and was best for the control group, which received propofol alone. These results support previous findings of a quantitative interaction between remifentanil and propofol for loss of consciousness but question the specific contribution of remifentanil to auditory evoked potentials.

 

手术切皮前的操作分析: 1558例患者的观察性研究

Task Analysis of the Preincision Surgical Period: An Independent Observer-Based Study of 1558 Cases

Alejandro Escobar, MD*, Elizabeth A. Davis, RDCS*, Jan Ehrenwerth, MD*, Gail A. Watrous, RN*, Gene S. Fisch, PhD{dagger}, Zeev N. Kain, MD, MBA*, and Paul G. Barash, MD*

From the *Department of Anesthesiology, {dagger}General Clinical Research Center, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut.

Anesth Analg 2006 103: 922-927.

在手术切皮前阶段(即从患者躺手术台到切皮的时间段)患者会产生强烈的紧张感和压,它已被认为是影响整个手术的重要因素。作者进行了一项前瞻性的研究,在研究中让受过训练的观察者来评估麻醉医师、外科医生和士的工作况对于麻醉实施时间(anesthesia release timeART,也就是患者躺手术台到外科医生准备手术的时间段)和外科手术准备时间(surgical preparation timeSPT,也就是外科医生准备手术到切皮的时间段)的影响以相关影响因素。选择1558名择期手术患者,麻醉实施时间(ART)平均为2216min,外科手术准备时间(SPT)平均为2213min,总的手术时间平均为207123min。作者发现麻醉实施时间(ART)和外科手术准备时间(SPT)都存在显著差异,多因素回归分析发现患者ASA分级、患者生理况、年龄、外科住院医师的操作水平、无创监测手段、手术室内患者数量和前一个手术时长均与ART成正相关(P<0.05)。而麻醉操作者的性别、体重指数、同一手术室内麻醉操作者的人数并不是ART的影响因素(P>0.05)。24.5%的操作过程存在ARTSPT的延长(其中外科医师方面占66.8%,麻醉方面占21.7%,后勤方面占11.5%)。所以,对于手术室内的时间安排,要求麻醉诱导时间的固定是不合适的,它会导致错误的管理期望。

(詹琼慧 陈杰 校)

Intense production pressure has focused on the preincision period (from patient-on-table to incision) as an important component of overall operating room efficiency. We conducted a prospective study in which trained independent observers measured the performance of anesthesiologists, surgeons, and nursing staff to determine anesthesia release time (ART, patient-on-table until release for surgical preparation) and surgical preparation time (SPT, start surgical preparation to incision) and the factors, including delays, that affect their duration. We enrolled 1558 patients undergoing elective surgery in a tertiary medical center. The mean ART was 21 ± 16 min. Mean SPT was 22 ± 13 min, and mean case length was 207 ± 123 min. Significant variation was seen in both ART (range, 1–115 min) and SPT (range, 1–130 min). Multivariate regression analysis revealed ASA physical status, age, level of resident training, invasive monitoring, case length, and case number in the room were all positive predictors of ART duration (P < 0.05). In contrast, gender, body mass index, number of anesthesia personnel concurrently in the room, and number of rooms covered per anesthesia attending were not predictors for ART (P > 0.05). Delays affected both ART and SPT and were encountered in 24.5% of all procedures (surgery 66.8%, anesthesiology 21.7%, and logistical 11.5%). For operating room scheduling purposes, we conclude that assigning a constant fixed duration for anesthetic induction is inappropriate and will result in creating erroneous administrative expectations.

 

大学附属医院的围术期肺误吸的发生率和预后: 一项持续4年的回顾性分析

The Incidence and Outcome of Perioperative Pulmonary Aspiration in a University Hospital: A 4-Year Retrospective Analysis

Tetsuro Sakai, MD, PhD, Raymond M. Planinsic, MD, Joseph J. Quinlan, MD, Linda J. Handley, MHA, Tae-Yop Kim, MD, and Ibetsam A. Hilmi, MB CHB, FRCA

From the Department of Anesthesiology, UPMC Presbyterian/Montefiore Hospital, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.

Anesth Analg 2006 103: 941-947.

在一大学附属医疗中心,作者对非产科手术的成年病例,围术期肺误吸(PPA)的发生率和预后 进行了评估。这项持续4年的回顾性研究(2001.12004.12) 使用了断改善数据以医院范围内的医疗档案记录系统。PPA 是通过检测到气管支气管树的非呼吸分泌物或新的肺部症和/或术后24小时内异常胸片等确的。在99,441 麻醉病例中,14 例出现确的PPA。其中7 (50%)与胃食管操作相关的。所有的病人有一个或数个PPA危险因素。10例全身麻醉病人了发生PPA 4例得到时的麻醉管理监测。在全麻病例中,5例病人在插管后即出现了误吸,5例在更换气管内插管时出现误吸。所有的麻醉监测病例在手术操作期间均时发现了PPA。确PPA 6例病人出现了肺部并发症,其中一例死亡。14例中有10(70%) PPA 是由不恰当的麻醉操作造成的。目前PPA的发生率是1/7103,患病率是1/16,573 ,死亡率是1/99441

(杨卫红 陈杰

We evaluated the current incidence and outcome of perioperative pulmonary aspiration (PPA) in the nonobstetric adult population at a tertiary university medical center. A 4-yr retrospective analysis (January 2001–December 2004) was conducted using both quality improvement data and the hospital-wide medical archive recording system. PPA was defined as either detection of nonrespiratory secretions from the tracheobronchial tree or development of new pulmonary symptoms and/or new abnormalities in chest radiographs within 24 hr postoperatively. Of 99,441 anesthetics, 14 cases had confirmed PPA. Seven of them (50%) occurred in connection with gastroesophageal procedures. All patients had one or more predisposing risk factors for PPA. PPA occurred under general anesthesia in 10 patients and under monitored anesthesia care in 4 patients. In general anesthesia cases, the aspiration was recognized immediately after induction in 5 patients and occurred during changing of the endotracheal tubes in 5. The PPA was detected during the surgical procedures in all the monitored anesthesia care cases. Six patients with confirmed PPA developed pulmonary complications, of which, one died. Ten of 14 (70%) cases of PPA were the result of improper anesthesia technique. The current incidence of PPA is 1 of 7103, with morbidity 1 of 16,573 and mortality 1 of 99,441.

 

胸骨多普勒法测心输出量:剖宫产术应用标准的或持续腰硬联合麻醉的比较

Suprasternal Doppler Estimation of Cardiac Output: Standard Versus Sequential Combined Spinal Epidural Anesthesia for Cesarean Delivery

Johanna K. Bray, FRCA*, Roshan Fernando, FRCA*, Nisa P. Patel, FRCA*, and Malachy O. Columb, FRCA{dagger}

From the *Department of Anesthetics, Royal Free Hospital, London, and {dagger}South Manchester University Hospital, Wythenshawe, United Kingdom.

Anesth Analg 2006 103: 959-964.

背景:剖宫产术应用持续腰硬联合麻醉(CSE)可能比标准CSE提供更好的心血管稳定性。作者利用胸骨多普勒法比较了两种麻醉术的心血管稳定性。

方法:选择性剖宫产术的健康女性(n = 40)随机被分成两组:持续(Seq)或标准(Std)CSE。在输液前后腰硬联合麻醉前后记录一系列的心输出量指数,包括每分钟射程,每搏射程,每搏输出量和校正的流速。患者使用的麻醉药是高比重的布比卡因10 mg (Std)5 mg (Seq)联合鞘内注射太尼15 µg。若前面这些药物未能达到目标麻醉平面,硬膜外腔给予0.5%布比卡因(标准组20分钟给予5ml,持续组在15分钟内给予10ml后接着在25分钟内给予5ml)。在鞘内注射后每隔5分钟收集数据。出现低血压者予麻黄素治疗。统计分析使用反复方差分析、协方差分析t检验。P<0.05时表示有显著意义.

结果:在鞘内注射后两种麻醉方法的心输出量, 包括每分钟射程,每搏射程,每搏输出量和校正的流速没有明显区别。整个测量期间,这些相同测量值的平均最低值没有明显的组间差异。

结论:择期行剖宫产术的健康孕妇中,持续腰硬联合麻醉与标准腰硬联合麻醉相比,对心血管稳定性没有更好的处。

(丁震敏 陈杰

BACKGROUND: Sequential (Seq) combined spinal epidural (CSE) may provide better cardiovascular stability than standard (Std) CSE for cesarean delivery. We compared the cardiovascular stability of both techniques using suprasternal Doppler.

METHODS: Healthy women (n = 40) scheduled for elective cesarean delivery were randomized into two groups; Std or Seq CSE. Serial measures of cardiac output indices, including minute distance, stroke distance, stroke volume, peak velocity, and corrected flow time, were recorded before and after intravascular fluid administration and after CSE. Women received either hyperbaric bupivacaine 10 mg (Std) or 5 mg (Seq) with intrathecal fentanyl 15 µg. An epidural top-up with bupivacaine 0.5% w/v (5 mL at 20 min in the Std group and 10 mL at 15 min followed by 5 mL at 25 min in the Seq group) was given if predefined sensory targets were not met. Data were collected every 5 min after intrathecal injection. Hypotension was treated with ephedrine. Statistical analyses included repeated measures analysis of variance, analysis of covariance and Student’s t-test. P < 0.05 denoted significance.

RESULTS: Results showed no difference in cardiac output, minute distance, stroke distance, stroke volume, peak velocity, or corrected flow time between groups over the first 20 min after spinal injection. For whole measurement periods, mean lowest values for these same measures showed no group differences.

CONCLUSION: We therefore found no benefit in terms of cardiovascular stability of Seq to Std CSE for elective cesarean delivery in the healthy pregnant population.


意识和麻醉的科学整合

Integrating the Science of Consciousness and Anesthesia

George A. Mashour, MD, PhD

From the Department of Anesthesia and Critical Care, Massachusetts General Hospital, Department of Anaesthesia, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2006 103: 975-982.

人类意识的本源和机制正成为21世纪科学和哲学领域最重要的问题之一。作为一门需认真研究的学科在整个20世纪的大部分时间内被忽视了,但现在它已获得了合法的科学地位。对于意识的研究以对于全麻机制的研究开始汇拢起来。在该篇文章中,作者对意识研究作一介绍,描述了意识的神经联系,这可能是全身麻醉的作用目标,并且推荐了一种将意识和麻醉整合的途径。

(曹瑜 陈杰 校)

The nature and mechanism of human consciousness is emerging as one of the most important scientific and philosophical questions of the 21st century. Disregarded as a subject of serious inquiry throughout most of the 20th century, it has now regained legitimacy as a scientific endeavor. The investigation of consciousness and the mechanisms of general anesthesia have begun to converge. In the present article I provide an introduction to the study of consciousness, describe the neural correlates of consciousness that may be targets of general anesthetics, and suggest an integrated approach to the science of consciousness and anesthesia.

 

消炎灵漱口水和阿司匹林漱口水在减弱术后咽喉痛方面的作用的评估:一个前瞻性,随机,单盲的研究

An Evaluation of the Efficacy of Aspirin and Benzydamine Hydrochloride Gargle for Attenuating Postoperative Sore Throat: A Prospective, Randomized, Single-Blind Study

Anil Agarwal, MD, S. S. Nath, MD, Debolina Goswami, MD, Devendra Gupta, MD, Sanjay Dhiraaj, MD, and Prabhat K. Singh, MD

From the Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Anesth Analg 2006 103: 1001-1003.

术后咽喉痛虽然是一个较小的并发症,术后有一定的发病率。作者比较阿司匹林漱口水和消炎灵(一种经典的非甾体炎药)漱口水对预防术后咽喉痛的效果。这个前瞻性、随机、对照,单盲研究中包括6016-60岁的女性患者,在全麻下接受了改良乳房切除术。随机分为3组:组IC)服用矿泉水,组IIAS)阿司匹林350mg片剂,组IIIBH10.15%的消炎灵漱口水5ml。以药物都被稀成30ml的溶液,在麻醉诱导前5分钟,用它来漱口30秒。在术后即时,2424小时评估术后咽喉痛的程度,以0-34个等级界定疼痛。阿司匹林漱口水能降低术后4小时内的喉咙痛的发病率而消炎灵漱口水能降低术后24小时内的喉咙痛的发病率。组I术后喉咙痛在术后即时和术后2小时显得较为严重(p<0.05)。阿司匹林和消炎灵漱口水都能显著的降低术后喉咙痛的发病率和严重性(p<0.05)。

(李唯一 陈杰 校)

Postoperative sore throat (POST), although a minor complication, remains a source of postoperative morbidity. We compared the efficacy of dispersible aspirin gargle to benzydamine hydrochloride (a topical nonsteroidal anti inflammatory drug) gargles for prevention of POST. We enrolled 60 consecutive female patients, 16–60 yr of age, ASA physical status I or II, undergoing elective modified radical mastectomy under general anesthesia in this prospective, randomized, placebo-controlled, single-blind study. Patients were randomly divided into 3 groups of 20 subjects each: Group 1 (C) mineral water; Group 2 (AS) tab aspirin 350 mg; and Group 3 (BH) 15 mL of benzydamine hydrochloride (0.15%). All the medications were made into 30 mL of solution. Patients were asked to gargle this mixture for 30 s, 5 min before induction of anesthesia. Grading of POST was done at 0, 2, 4, and 24 h postoperatively on a 4-point scale (0–3). Aspirin gargles reduced the incidence of POST for 4 h whereas benzydamine hydrochloride gargles reduced POST for 24 h. POST was more severe in the control group at 0 and 2 h (P < 0.05). Aspirin and benzydamine hydrochloride gargles significantly reduced the incidence and severity of POST (P < 0.05).

 

神经轴阻滞和全麻下行选择性全髋置换(THR)的比较:一项Meta分析

A Comparison of Neuraxial Block Versus General Anesthesia for Elective Total Hip Replacement: A Meta-Analysis

William J. Mauermann, MD, Ashley M. Shilling, MD, and Zhiyi Zuo, MD, PhD

From the Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia.

Anesth Analg 2006 103: 1018-1025.

 

背景:最近一项Meta分析显示,相较于全身麻醉,使用神经轴阻滞可以减少不同种类手术后许多严重并发症的发生。但尚不明确这项来自多种类手术病人组的研究结果是否也适用于某些特定的手术病人。作者进行这项Meta分析是为了研究不同麻醉方式对选择性全髋置换(THR)手术预后的影响。

方法:搜索Medline1996年-20058月)、MD Consult1966年-20059月)、BIOSIS1969年-20059月)和EMBASE1969年-20059月)的资料,分析其中包括随机或几乎随机的神经轴(腰麻或硬膜外麻醉)阻滞和全麻下行选择性全髋置换(THR)比较的数据。

结果:共十项独立的实验,包括330名全麻病人和348名神经轴阻滞病人。其中五项实验得到的综合结果显示,神经轴阻滞能显著降低可由影像学确的深静脉血栓或肺栓塞的发生。深静脉血栓形成的相对比(OR)为0.27,其95%可信区间(CI)为0.170.42。发生肺栓塞的相对比(OR)为0.26,其95%可信区间(CI)为0.120.56。神经轴阻滞还能够减少手术时间(7.1分钟/每例,95CI2.311.9分钟)和术中失血(275mL/每例,95CI180371mL)。另三项实验显示,与全麻相比,神经轴阻滞下进行THR的患者较少需要输血(输血病人为62/188=33%21/177=12%z检验结果P<0.001)。这项比较的相对比为0.26。然而,以研究结果的CI偏大,而且有结果显示两者没有区别,也有结果显示十分之九存在区别(95CI0.061.05)。

结论:在神经轴阻滞下进行选择性全髋置换的病人似乎较全麻下的病人预后好。

(周懿之 陈杰 校)

BACKGROUND: A recent meta-analysis showed that compared with general anesthesia (GA), neuraxial block reduced many serious complications in patients undergoing various types of surgeries. It is not known whether this finding from studying heterogeneous patient groups is applicable to a particular surgical patient population. We performed the present meta-analysis to determine whether anesthesia choice affected the outcome after elective total hip replacement (THR).

METHODS: Medline (1966 to August 2005), MD Consult (1966 to August 2005), BIOSIS (1969 to August 2005), and EMBASE (1969 to August 2005) databases were searched. Randomized and quasirandomized studies comparing GA and neuraxial (spinal or epidural) block for elective THR were included in this analysis.

RESULTS: Ten independent trials, involving 330 patients under GA and 348 patients under neuraxial block, were identified and analyzed. Pooled results from five trials showed that neuraxial block significantly decreased the incidence of radiographically diagnosed deep venous thrombosis or pulmonary embolism. The odds ratio (OR) for deep venous thrombosis was 0.27 with 95% confidence interval (CI) 0.17–0.42. The OR for pulmonary embolism was 0.26 with 95% CI 0.12–0.56. Neuraxial block also decreased the operative time by 7.1 min/case (95% CI 2.3–11.9 min) and intraoperative blood loss by 275 mL/case (95% CI 180–371 mL). Data from three trials showed that patients under neuraxial block for THR were less likely to require blood transfusion than were patients under GA (21/177 = 12% vs 62/188 = 33% of patients transfused, P < 0.001 by z-test). The OR for this comparison was 0.26. However, the CIs were wide and compatible with both no effect and a nine-tenths reduction (95% CI 0.06–1.05).

CONCLUSIONS: Patients undergoing elective THR under neuraxial anesthesia seem to have better outcomes than those under GA.

 

性别对单纯主脉瓣置换手术后住院病人的死亡率和发病率的影响

The Impact of Gender on In-Hospital Mortality and Morbidity After Isolated Aortic Valve Replacement

Andra Ibrahim Duncan, MD*, Jia Lin, MD, PhD*, Colleen G. Koch, MD, MS*, A. Marc Gillinov, MD{dagger}, Meng Xu, MS{ddagger}, and Norman J. Starr, MD*

From the Departments of *Cardiothoracic Anesthesia, {dagger}Cardiothoracic Surgery, and {ddagger}Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio.

Anesth Analg 2006;103:800-808

 

我们的回顾性研究的目的是为了检查性别对单纯主脉瓣置换手术后住院病人的死亡率和发病率的影响。在19931月至20026月,2212例病人(女性782例,男性1430例)行主脉瓣置换手术。用倾向匹配来调整组间基础特征和围手术期变量的许多差异。未校准的数据女性组住院死亡率较高 27 [3.5%]女性比23 [1.6%] 男性; P = 0.005)。用倾向分数11匹配的分析发现在各组间住院病人死亡率[OR (95%可信区间), 1.0 [0.4, 2.6]; P = 0.99]和总体发病率 (1.4 [0.7, 2.5]; P = 0.29) 没有明显差异。进一步分析,包括用倾向分数女性和男性分为五分相组和用倾向分数调整进行的对数回归模型,发现女性心脏发病风险性升高[OR (95% CI), 3.4 [1.1, 10.8]; P = 0.038], 但死亡率 (0.9 [0.3, 2.5]; P = 0.88)和其它发病率没有统计学差异。这些结果提示行主脉瓣置换手术的女性较男性的风险性增高不超过2.5倍。然而,女性性别可能使主脉瓣置换手术后心脏发病风险升高。

(彭中美 马皓琳 李士通 校)

The objective of our retrospective investigation was to examine the influence of gender on in-hospital mortality and morbidity after isolated aortic valve replacement (AVR). Between January 1993 and June 2002, 2212 patients (782 females, 1430 males) underwent AVR. Propensity matching was used to adjust for numerous differences in baseline characteristics and perioperative variables between groups. Unadjusted in-hospital mortality was higher in females (27 [3.5%] females versus 23 [1.6%] males; P = 0.005). An analysis using 1:1 matching by propensity score did not find a significant difference in in-hospital mortality [OR (95% confidence intervals), 1.0 [0.4, 2.6]; P = 0.99) or overall morbidity (1.4 [0.7, 2.5]; P = 0.29) between groups. Further analyses, including classification of women and men into quintile groups by propensity scores and logistic regression models with propensity score adjustment, found that females were at increased risk for cardiac morbidity [OR (95% CI), 3.4 [1.1, 10.8]; P = 0.038), but not mortality (0.9 [0.3, 2.5]; P = 0.88) nor other morbidities. These results suggest that there is no greater than a 2.5-fold increase in risk for females compared with males undergoing AVR. Female gender, however, may impart increased risk for cardiac morbidity after AVR.

 

κ-阿片受体拮改善了长期仪器监测的心肌顿的恢复

{kappa}-Opioid Receptor Antagonism Improves Recovery from Myocardial Stunning in Chronically Instrumented Dogs

Maike A. Grosse Hartlage, MD*, Marc M. Theisen, MD*, Nelson P. Monteiro de Oliveira*, Hugo Van Aken, MD, FRCA, FRANZCA*, Manfred Fobker, MD{dagger}, and Thomas P. Weber, MD*

From the *Department of Anaesthesiology and Intensive Care; and {dagger}Institute of Clinical Chemistry and Laboratory Medicine, University Hospital Münster, Münster, Germany.

Anesth Analg 2006;103:822-832

 

我们验证了关于选择性{kappa}-阿片受体拮剂nor-binaltorphimine(nor-BNI)改善心肌顿的恢复的假设。十条被长期连接仪器用作测量心率,左心房、主脉和左心室压(LVP)、LVP的最大升速率(LV dP/dtmax)和最大下降速率(LV dP/dtmax)、冠脉血流速和心肌壁增厚分数。使用荧光微球颗粒来测定局部心肌血流。高效液相法测定血浆儿茶酚胺水平,放免法测定血浆ß-内啡肽和强啡肽水平。左前降支脉(LAD)周围的阻断可诱发可逆性的LAD缺血。在非同一天内物以随机交叉方式分别进行两种实验:(a10minLAD阻断(对照实验);(b)使用nor-BNI(2.5 mg/kg IV)24h后行第二次缺血(干预)。接受nor-BNI的在缺血前和整个再灌注期表现为心肌壁增厚分数、LV dP/dtmaxLV dP/dtmin 有增(与对照实验相比,P < 0.05)。nor-BNI预处理后,强啡肽水平在诱发缺血后升至峰值15.1 ± 3.6pg/mL(与对照实验相比,P < 0.05);而在缺血期和再灌注早期血浆ß-内啡肽水平的升高得到缓解。与对照实验相比,nor-BNI使得总体的血流学、局部心肌血流儿茶酚胺水平没有改变。总之,nor-BNI改善了长期仪器监测局部心肌缺血后心肌顿的恢复。

(黄施伟 译,马皓琳 李士通 校)

We tested the hypothesis that the selective {kappa}-opioid receptor antagonist nor-binaltorphimine (nor-BNI) improves recovery from myocardial stunning. Ten dogs were chronically instrumented for measurement of heart rate, left atrial, aortic and left ventricular pressure (LVP), and the maximum rate of LVP increase (LV dP/dtmax) and decrease (LV dP/dtmax), coronary blood flow velocity and myocardial wall-thickening fraction. Regional myocardial blood flow was determined with fluorescent microspheres. Catecholamine plasma levels were measured by high-performance liquid chromatography, and ß-endorphin and dynorphin plasma levels by radioimmunoassay. An occluder around the left anterior descending artery (LAD) allowed induction of a reversible LAD-ischemia. Animals underwent two experiments in a randomized crossover fashion on separate days: (a) 10 min LAD-occlusion (control experiment), (b) second ischemic episode 24 h after nor-BNI (2.5 mg/kg IV) (intervention). Dogs receiving nor-BNI showed an increase in wall-thickening fraction, LV dP/dtmax and LV dP/dtmin before ischemia and during the whole reperfusion (P < 0.05 versus control experiment). After nor-BNI pretreatment, dynorphin levels increased after induction of ischemia to a peak level of 15.1 ± 3.6 pg/mL (P < 0.05 versus control experiment). The increase in plasma ß-endorphin during ischemia and early reperfusion was attenuated after nor-BNI. Compared with the control experiment, nor-BNI left global hemodynamics, regional myocardial blood flow, and catecholamine levels unchanged. In conclusion, nor-BNI improves recovery from myocardial stunning after regional myocardial ischemia in chronically instrumented dogs.

 

缺血导致心肌非同步收缩模型的建立

Modeling Ischemia-Induced Dyssynchronous Myocardial Contraction

David P. Strum, MD, and Michael R. Pinsky, MD, CM

From the Cardiopulmonary Research Laboratory, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Anesth Analg 2006;103:846-853

 

左室非同步收缩难以量化。我们以前参考局部振幅和相位角用艾司洛尔引起的局部收缩能障碍建立过一个量化左室总体非同步收缩的模型。我们验证了这样一个假设,在类模型建立的我们的正弦波模型相位角分析局部非同步收缩也可以用于评估局部缺血时的非同步收缩。所以我们在10只麻醉好的开胸狗比较了冠脉内用艾司洛尔和相应局部缺血。在艾司洛尔引起心尖部收缩能障碍相应部位缺血之前、期间之后,分别测量局部总体左室容积(容积导管)、压电晶体缩短程度以左室压。我们定义局部收缩相位角({alpha})为局部最小容积和总体收缩末期容积之间的相对距离,以“度”为测量单位。我们还比较了最大心搏出量(SV)、观察的有效心搏量(每次处理中局部SV占总体SV的部分)和计算的有效SV(所有局部SV×余旋{alpha})。多巴酚丁胺灌注可增局部{alpha}相对于基础值的均匀性。艾司洛尔和缺血均显著延迟了心尖部的收缩,这从相对于基础值来说显著增大的{alpha}(12.4° ± 28.1°分别至 27.4° ± 30.4° 54.2° ± 32.6°) (均数 ± 标准差) 和减少的局部有效 SV (4.7 ± 2.5 mL分别至3.6 ± 2.2 mL 4 ± 2.5 mL,)中可以定量表现出来。我们的研究提示,冠脉内艾司洛尔和缺血对心肌能产生性质相似的机械影响,且利用正弦波模型评估局部有效心搏量是检测和量化缺血引起的局部非同步收缩的敏感方法。相位角和局部振幅分析可能成为确定和量化再同步化治疗对心肌能的有作用的有效方法。

(黄佳佳译,李士通 马皓琳校)

Left ventricular (LV) contraction dyssynchrony is not easily quantified. We previously described a model for quantifying LV dyssynchrony that referenced regional amplitude and phase angles to global LV systole using esmolol-induced regional dyskinesis. We tested the hypothesis that our sine wave model and phase angle analysis of regional dyssynchrony in a canine model could also assess dyssynchrony of contraction during regional ischemia. Hence we compared intracoronary esmolol and matched regional ischemia in 10 anesthetized open-chest dogs. Regional and total LV volumes (conductance catheter), piezoelectric crystal shortening, and LV pressures were measured before, during, and after esmolol-induced apical dyskinesis and matched regional ischemia. We defined regional phase angle of contraction ({alpha}) as the relative distance, measured in degrees, that regional minimal volume differed from global end-systole. We also compared maximal stroke volume (SV), observed effective SV (that portion of regional SV contributing to total SV for each treatment), and calculated effective SV (total regional SV x cosine {alpha}). Dobutamine infusion increased homogeneity of regional {alpha}relative to baseline. Both esmolol and ischemia significantly delayed (P < 0.05) apical contraction as quantified by increased {alpha}(12.4° ± 28.1° to 27.4° ± 30.4° and 54.2° ± 32.6°, respectively) (mean ± sd) and decreased regional effective SV (4.7 ± 2.5 mL to 3.6 ± 2.2 mL and 4 ± 2.5 mL, respectively) relative to baseline. Our study indicates that intracoronary esmolol and ischemia induced qualitatively similar mechanical effects on myocardial function and that a sine wave model to estimate regional effective SV is a sensitive method to detect and quantify regional dyssynchrony induced by ischemia. Potentially, phase angle and regional amplitude analyses may prove to be effective measures to identify and quantify the beneficial effects of resynchronization therapies on myocardial function.

 

硬膜外利多卡因导致大鼠剂量依赖性神经损伤

Epidural Lidocaine Induces Dose-Dependent Neurologic Injury in Rats

Tomoko Muguruma, MD, Shinichi Sakura, MD, and Yoji Saito, MD

From the Department of Anesthesiology, Shimane University School of Medicine, Izumo City, Japan.

Anesth Analg 2006;103:876-881

 

尽管硬膜外单次注射利多卡因已经显示几乎不会导致神经毒性,但是局麻药经常重复或者连续注射到硬膜外腔,且高剂量的局麻药仍可能引起神经损伤。我们观察了大剂量利多卡因连续输注到大鼠硬膜外腔是否具有神经毒性以由此产生的能损害和组织学损伤是否具有剂量依赖性。在试验1中,给13只大鼠硬膜外连续输注(5 µL/min)盐水或者2%利多卡因120 min。输注后4天,给予2%利多卡因的大鼠甩尾潜伏期较给予盐水者明显延长,并且表现出更明显的形态学改变。在试验2中,41只大鼠随机分成5组,均以5 µL/min的速度于硬膜外分别注射生理盐水120min5%利多卡因15min30min60min120min。给予5%利多卡因120min的大鼠产生明显的甩尾潜伏期延长。各组物爪压阈值均无变化。给予5%利多卡因3060120min的大鼠的神经损伤分数均明显高于仅给予盐水者。给予麻醉药的持续时间不同造成的神经根损害也不同;输注5%利多卡因120min物神经损害明显高于输注15min30min者;输注5%利多卡因60min物神经损害明显高于输注15min者。结论是,这些结果提示在大鼠硬膜外连续输注利多卡因导致剂量依赖性神经毒性作用。

(颜涛 译, 马皓琳 李士通 校)

Although epidural lidocaine administered as a bolus has been shown to cause little neurotoxicity, local anesthetics are often administered repetitively or continuously into the epidural space, and in high doses may induce neurologic injury. We investigated whether epidural lidocaine is neurotoxic when a large dose is continuously administered in rats, and whether the functional impairment and histologic damage is dose dependent. In Experiment 1, 13 rats received a 120-min epidural infusion (at 5 µL/min) of saline or 2% lidocaine. Four days after infusion, rats given 2% lidocaine developed significantly more prolonged tail-flick latencies and showed more apparent morphologic damage than those given saline. In Experiment 2, 41 rats were randomly divided into 5 groups to receive an epidural infusion of saline for 120 min or 5% lidocaine for 15, 30, 60, or 120 min at a rate of 5 µL/min. Rats given 5% lidocaine for 120 min developed a significant increase in tail-flick latency. Paw pressure thresholds did not change in any group. Nerve injury scores for rats given 5% lidocaine for 30, 60, and 120 min were significantly higher than those for rats given saline. Significant difference in damage in nerve roots was also observed among rats given the anesthetic for different durations of time; nerve injury scores with 120-min infusion were higher than with 15- and 30-min infusions, and injury with 60-min infusion was greater than with 15-min infusion. In conclusion, these results suggest that epidural lidocaine causes dose-dependent neurotoxicity after continuous infusion in rats.

 

自发脑电图和诱发电位的同步监测用于预测全麻的不同临态的判别能

The Discriminant Power of Simultaneous Monitoring of Spontaneous Electroencephalogram and Evoked Potentials as a Predictor of Different Clinical States of General Anesthesia

Christian Jeleazcov, MD*, Gerhard Schneider, MD{dagger}, Michael Daunderer, MD{ddagger}, Bertram Scheller, MD, Jürgen Schüttler, MD*, and Helmut Schwilden, MD, PhD*

From the *Department of Anesthesiology, Universität Erlangen-Nürnberg, Erlangen; {dagger}Department of Anesthesiology, Technische Universität München; {ddagger}Department of Anesthesiology, Universität München, Munich; and Department of Anesthesiology, Universität Frankfurt am Main, Frankfurt am Main, Germany.

Anesth Analg 2006;103:894-901

 

自发或诱发的脑部电活来多地被应用于全麻监测。以往研究观察的变量主要是自发脑电图(EEG)、声诱发电位(AEP)、体感诱发电位(SSEP)。但是,分别监测述指标可能丢失来自于同步收集的有用信息。我们研究了从EEGAEPSSEP得到的同步信息的组合,与从每个单独的指标得到的信息相比,是否对于区别麻醉态有更高的判别能。因此,我们评估了59个患者在四种全麻临态下(清醒、浅麻醉、外科麻醉、深度外科麻醉)的30 EEG21 SSEP29 AEP变量的变化。用辨别分析来研究单个和联合EEGAEPSSEP变量预测述麻醉态的判别能。EEG变量比AEPSSEP变量有更高的判别能,正确分级病例分别有85%46%32%。用从联合EEG + AEP EEG + AEP + SSEP得到的信息,正确分级的频率分别增至90%91%。由此可见,未来的麻醉监测应考虑不同电生理测量方法所得的同步联合信息,而非单个变量或EEGAEPSSEP的组合。

(唐李隽 马皓琳 李士通 校)

Spontaneous or evoked electrical brain activity is increasingly used to monitor general anesthesia. Previous studies investigated the variables from spontaneous electroencephalogram (EEG), acoustic (AEP), or somatosensory evoked potentials (SSEP). But, by monitoring them separately, the available information from simultaneous gathering could be missed. We investigated whether the combination of simultaneous information from EEG, AEP, and SSEP shows a more discriminant power to differentiate between anesthesia states than from information derived from each measurement alone. Therefore, we assessed changes of 30 EEG, 21 SSEP, and 29 AEP variables recorded from 59 patients during four clinical states of general anesthesia: "awake," "light anesthesia," "surgical anesthesia," and "deep surgical anesthesia." The single and combined discriminant powers of EEG, AEP, and SSEP variables as predictors of these states were investigated by discriminant analysis. EEG variables showed a higher discriminant power than AEP or SSEP variables: 85%, 46%, and 32% correctly classified cases, respectively. The frequency of correctly classified cases increased to 90% and 91% with information from EEG + AEP and EEG + AEP + SSEP, respectively. Thus, future anesthesia monitoring should consider combined information simultaneously distributed on different electrophysiological measurements, rather than single variables or their combination from EEG or AEP or SSEP.

 

计算机评估负压手术室的通风性能

A Computer Evaluation of Ventilation Performance in a Negative-Pressure Operating Theater

Tin-tai Chow, PhD*, Anne Kwan, FANZCA{dagger}, Zhang Lin, PhD*, and Wei Bai, MSc*

From the *Division of Building Science and Technology, City University of Hong Kong; and {dagger}Department of Anaesthesiology, United Christian Hospital, Hong Kong Special Administrative Region, China.

Anesth Analg 2006;103:913-918

 

背景:需要负压手术室来限制一些呼吸系统疾病在有严重急性呼吸窘迫综合症、结核、禽流感或其他类似感染性疾病的病人间的传播。在香港,我们将传统的手术室转换为了负压手术室,并且付诸使用一年以。本文介绍了它的通风设计,评估了与不同医学灯具配置组合和将污染颗粒发射到室内空气模式相关的气流性能。方法:我们采用了计算机流体学术进行数据分析。

结果:我们的分析显示负压手术室中的气流性能是满意的,与先前的正压通气设计具有可比性.气流形式能够有效地控制感染颗粒的扩散。我们的计算显示气流能容纳病人放的有传染性的颗粒从而足以保外科手术组,反之亦然。

结论:计算机流体学能够用于评估负压手术室的气流性能,且模拟有传染性的颗粒从病人散布的模型。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: A negative-pressure operating theater is required to limit the spread of respiratory diseases in patients with severe acute respiratory syndrome, tuberculosis, avian influenza, or similar infectious diseases. In Hong Kong, we converted a conventional operating theater into a negative-pressure operating theater that has been in service for more than a year. In this article, we introduce its ventilation design and evaluate the airflow performance in relation to different combinations of medical lamp configurations and modes of launching infectious particles into the room air.

METHODS: We used a computational fluid dynamics technique for the numerical analysis.

RESULTS: Our analyses showed that the airflow performance in the negative-pressure operating theater was satisfactory and comparable to the original positive-pressure design. The airflow pattern effectively controlled the dispersion of infectious particles. Our calculations demonstrated that the airflow contained the dispersion of infectious particles released from the patient sufficiently to protect the surgical team, and vice versa.

CONCLUSIONS: Computational fluid dynamics can be used to assess airflow in a negative-pressure operating room and model the dispersion of infectious particles from the patient.

 

住院医师培训和手术室时间表的关系:1558例基于独立观测者的研究

Resident Teaching Versus the Operating Room Schedule: An Independent Observer-Based Study of 1558 Cases

Elizabeth A. Davis, RDCS*, Alejandro Escobar, MD*, Jan Ehrenwerth, MD*, Gail A. Watrous, RN*, Gene S. Fisch, PhD{dagger}, Zeev N. Kain, MD, MBA*, and Paul G. Barash, MD*

From the *Department of Anesthesiology, {dagger}General Clinical Research Center, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut.

Anesth Analg 2006;103:932-937

 

提高手术室效率的可能会影响到住院医师的培训。因此,我们设计了一个前瞻性的观测性研究来测定培训麻醉住院医师所的从病人躺到手术台到切皮的确切时间,以确定在围诱导期间的麻醉培训是否增了到切皮所需的时间。这个研究在三级学术医疗中心的住院手术室中进行。观测了1558例病人,在其中75%的病人身进行了麻醉医师培训(每一例培训所占的平均比例为46.4%)。当麻醉主治医师同时在两间手术室里指导监时培训时间下降33%(p<0.001)。培训时间所占比例随ASA分级和外科监的天数增而明显增(p=0.001)。培训使得划皮前所需的时间平均增了4.5±3.2分钟,但是这些延长的时间仅占到平均手术时间的3%(207 ± 132 min)。我们得出结论,培训发生在手术室的大部分病例中,并且虽然培训延长了到划皮所需的时间,但是与完成手术所需的时间相比较该延长无显著性。

(姜旭晖译,马皓琳,李士通校)

Efforts to improve operating room efficiency may threaten clinician training. Therefore, we designed a prospective, observational study to determine the actual time spent teaching anesthesiology residents during the interval from patient-on-table to skin incision and to determine whether anesthesia teaching in the peri-induction period increases the time to surgical incision. This study was conducted in an inpatient operating room suite of a tertiary academic medical center. Of 1558 cases examined, 75% had an element of teaching (mean percent teaching per case = 46.4). A 33% decrease in teaching occurs when the attending anesthesiologist concurrently directed care in 2 rooms (P < 0.001). The percent teaching significantly increased as a function of ASA physical status classification and time of day of surgical case (P = 0.001). Teaching accounted for a mean increase of time to incision of 4.5 ± 3.2 min, but represented only 3% of the mean surgical case length (207 ± 132 min). We conclude that teaching occurs in the majority of cases in the operating room and although it contributes to increased time to incision, this increase is insignificant compared with the time required to complete the surgical procedure.

 

右旋美托咪啶不会提高清醒颈脉内膜切除术病人的颈脉内分流的发生率

Dexmedetomidine Does Not Increase the Incidence of Intracarotid Shunting in Patients Undergoing Awake Carotid Endarterectomy

Alex Bekker, MD, PhD*, Mark Gold, MD*, Raza Ahmed, MD*, Jung Kim, MD*, Caron Rockman, MD{dagger}, Glenn Jacobovitz, MD{dagger}, Thomas Riles, MD{dagger}, and Gene Fisch, PhD{ddagger}

From the Departments of *Anesthesiology and {dagger}Surgery, New York University Medical Center, New York, New York; and {ddagger}Department of Applied Sciences, Yeshiva University, New York, New York.

Anesth Analg 2006;103:955-958

 

全身性给予右旋美托咪啶(DEX)减少脑血流量(CBF)是通过直接激{alpha}-2受体使脑血管收缩和通过体内神经传导的作用间接调血管平滑肌。不伴有脑代谢率下降的CBF减少,已引起了我们对DEX可能限制那些已有脑循环损伤(如,颈脉内膜切除)病人的脑组织充分氧合的关注。本研究中,123例在我们的机构中使用DEX作为初始镇静剂行清醒CEA术的连续系列中,我们确立了作为脑氧供不充分标志的脉内分流的发生率。在151位行CEA术的病人中前瞻性地记录研究期间的数据。18位病人由于医学或其他原因用咪唑安定与太尼(M/F)进行镇静。给那些被认为有术中中风风险的病人行预防性脉内分流,这些病人与那些需要全麻的病人都被排除于最后的分析。DEX组中5位病人(4.3%)需要行脉内分流。在我们的机构中行清醒CEA术病人中分流的发生率为10% (历史对照)。没有病人发生中风或者其他严重的并发症。看来DEX用作行CEA术主要镇静药不会提高颈脉内分流的发生率。

(胡湘 马皓琳 李士通 校)

Systemic administration of dexmedetomidine (DEX) decreases cerebral bloodflow (CBF) via direct {alpha}-2-mediated constriction of cerebral blood vessels and indirectly via its effect on the intrinsic neural pathway modulating vascular smooth muscle. Reduction in CBF without a concomitant decrease in cerebral metabolic rate has raised concerns that DEX may limit adequate cerebral oxygenation of brain tissue in patients with already compromised cerebral circulation (e.g., carotid endarterectomy [CEA]). In this study, we established the incidence of intraarterial shunting used as a sign of inadequate oxygen delivery in a consecutive series of 123 awake CEA performed in our institution using DEX as a primary sedative. Data were prospectively recorded in 151 patients who underwent CEA during the study period. Eighteen patients were sedated with midazolam and fentanyl (M/F) for medical or logistical reasons. Patients thought to be at risk of an intraoperative stroke were treated with a prophylactic intraarterial shunt. These patients, as well as those who required general anesthesia, were excluded from the final analysis. Five patients (4.3%) in the DEX group required intraarterial shunts. The incidence of shunting in patient undergoing awake CEA in our institution is 10% (historical control). No patients developed a stroke or other serious complications. It appears that the use of DEX as a primary sedative drug for CEA does not increase the incidence of intraarterial shunts.

 

关于新鲜冰冻血浆融化程序和凝血因子活性的时间过程:一项对照性实验室研究

Thawing Procedures and the Time Course of Clotting Factor Activity in Fresh-Frozen Plasma: A Controlled Laboratory Investigation

Christian von Heymann, MD*, Axel Pruss, MD{dagger}, Michael Sander, MD*, Anne Finkeldey, cand. med.{ddagger}, Sabine Ziemer, MD{ddagger}, Ulrich Kalus, MD{dagger}, Holger Kiesewetter, MD{dagger}, Abdulgabar Salama, MD{dagger}, and Claudia Spies, MD*

From the *Department of Anesthesiology and Intensive Care Medicine, {dagger}Institute for Transfusion Medicine, {ddagger}Institute for Laboratory Medicine and Pathological Biochemistry, Charité-University Hospital Berlin, Charité Campus Mitte, Berlin.

Anesth Analg 2006;103:969-974

 

背景:在本项研究中,我们评估了2个市场可得的装置的融化过程对于用于新鲜冰冻血浆(FFP)的凝血因子活性、血流稳态系统的制活化标志的影响。在实验过程中,FFP42°C的流温水中解冻。

方法:选择20个健康献血者的血浆取样,分离,且分装在3个血浆袋子里。取样后2小时内将血浆样本袋放置在–30°C –40°C的温度下冰冻,并储存8周以。在取样后(基线)、解冻即刻解冻后1246小时检测每个血浆袋中的FVFVIIFVIII、纤维蛋白原、纤维蛋白单体 (FM)、右旋二聚体(DD){alpha}2-血纤维蛋白溶素({alpha}2-AP)蛋白 S (PS)的活性。

结果:解冻后的1-6h内,没有发现不同解冻过程的凝血观测指标活性的明显差异。然而,解冻后即刻FVII的活性明显降低(P < 0.01), FM 活性明显增 (P = 0.001),但不依赖于解冻过程。

结论:所研究的血浆解冻过程显示,在整个研究阶段,被研究的凝血指标的活性稳定性均无明显影响。FVII活性的降低FM临明显增高还需进一步研究。(裘毅敏译,马皓琳 李士通校)

BACKGROUND: In this study, we evaluated the effects of the thawing process of 2 commercially available devices on the activity of clotting factors, inhibitors and activation markers of the hemostatic system in fresh-frozen plasma (FFP). In an experimental procedure, FFP was thawed under running warm water at 42°C.

METHODS: Plasma of 20 healthy donors was sampled, separated, and distributed in 3 plasma bags. Within 2 h after sampling plasma bags was frozen at a temperature of –30°C to –40°C and stored for at least 8 wk. After sampling (baseline) as well as immediately and 1, 2, 4, and 6 h after thawing, the activity of FV, FVII, FVIII, fibrinogen, fibrin monomers (FM), d-dimers (DD), {alpha}2-antiplasmin ({alpha}2-AP), and protein S (PS) was determined from each plasma bag.

RESULTS: From 1 h to 6 h after thawing, no significant differences in the activity of the investigated coagulation markers dependent on the thawing procedure were found. However, immediately after thawing and independent of the thawing procedure, the activity of FVII was significantly decreased (P < 0.01), whereas FM were significantly increased (P = 0.001).

CONCLUSION: The thawing procedures studied exhibited no significant influence on activity and stability of the investigated markers of coagulation over the study period. The decreased activity of FVII and the clinical significance of the increase in FM require further research.

 

乳房手术后恒定的一氧化氮产物的血浆浓度与术后早期疼痛慢性术后疼痛严重性的关系

The Associations Between Severity of Early Postoperative Pain, Chronic Postsurgical Pain and Plasma Concentration of Stable Nitric Oxide Products After Breast Surgery

Gabriella Iohom, FCARCSI*, Hamza Abdalla, MRCP*, James O'Brien, FCARCSI*, Szilvia Szarvas, MD, DEEA*, Vivienne Larney, FCARCSI*, Elisabeth Buckley, FCARCSI*, Mark Butler, MSc{dagger}, and George Declan Shorten, PhD*

*Department of Anaesthesia and Intensive Care Medicine, {dagger}Department of Clinical Biochemistry, Cork University Hospital, Cork, Ireland.

Anesth Analg 2006;103:995-1000

 

在该研究中,我们比较了两种镇痛方法对围手术期一氧化氮指数(NOx)以乳房手术后慢性术后疼痛(CPSP)继后发展可能性的影响,并且试图确定术后早期疼痛与NOx继发的CPSP的相互关系。29例连续的ASA 分级III级,施行乳房手术并伴腋窝淋巴结清扫的病人,随机分入两组。S组(n = 15)的病人接受标准的术中术后镇痛疗法(硫酸吗啡、双氯酸、盐酸右丙氧+对乙酰氨基酚需要时服用)。N组病人(n = 14)接受持续椎旁阻滞(持续48小时)对乙酰氨基酚和帕瑞考昔(接下来应用塞来考昔直到术后5)。定时记录术后5天休息时肢活时的疼痛的视觉模拟评分比标度评分。术后10周进行电话访问。应用McGill疼痛调查表评价疼痛的性质。术前、手术结束时、术后30 min24122448 h评估NoxS组的12名病人(占80%),N组无一例病人发生CPSP(P = 0.009)。与术后10周的疼痛等级评定指数1的病人(n = 18)相比,疼痛等级指数为0的病人(n = 11) 在术后30分钟直至术后96小时的每个术后时间点时运时的视觉模拟评分均较小(P < 0.005)。休息时的评分在术后30分钟分别为0.6 ± 1.530.2 ± 26.8P = 0.004,4小时时为2.3 ± 7.5 19.0 ± 25.8P = 0.013),8小时时为4.4 ± 10.2 21.4 ± 27.0 P = 0.03),12小时为0.7 ± 1.2 15.4 ± 27.0 P = 0.035)。N组术后48小时的NOx指数较S组高(40.6 ± 20.1 26.4 ± 13.5; P = 0.04)。

(黄丽娜 马皓琳 李士通 校)

In this study, we compared the effects of two analgesic regimens on perioperative nitric oxide index (NOx) and the likelihood of subsequent development of chronic postsurgical pain (CPSP) after breast surgery and sought to determine the association among early postoperative pain, NOx, and the likelihood of subsequent development of CPSP. Twenty-nine consecutive ASA I or II patients undergoing breast surgery with axillary clearance were randomly allocated to one of two groups. Patients in group S (n = 15) received a standard intraoperative and postoperative analgesic regimen (morphine sulfate, diclofenac, dextropropoxyphene hydrochloride + acetaminophen prn). Patients in group N (n = 14) received a continuous paravertebral block (for 48 h) and acetaminophen and parecoxib (followed by celecoxib up to 5 days). Visual analog scale pain scores at rest and on arm movement were recorded regularly until the fifth postoperative day. A telephone interview was conducted 10 wk postoperatively. The McGill Pain Questionnaire was used to characterize pain. NOx was estimated preoperatively, at the end of surgery, 30 min and 2, 4, 12, 24, 48 h postoperatively. Twelve (80%) patients in group S and no patient in group N developed CPSP (P = 0.009). Compared with patients with a pain rating index 1 (n = 18) 10 wk postoperatively, patients with a pain rating index = 0 (n = 11) had lesser visual analog scale pain scores on movement at each postoperative time point from 30 min until 96 h postoperatively (P < 0.005) and at rest 30 min (0.6 ± 1.5 versus 30.2 ± 26.8; P = 0.004), 4 h (2.3 ± 7.5 versus 19.0 ± 25.8; P = 0.013), 8 h (4.4 ± 10.2 versus 21.4 ± 27.0; P = 0.03) and 12 h (0.7 ± 1.2 versus 15.4 ± 27.0; P = 0.035) postoperatively. NOx values were greater in group N compared with group S 48 h postoperatively (40.6 ± 20.1 versus 26.4 ± 13.5; P = 0.04).

 

急慢性疼痛病人人类µ阿片受体基因的能性A118G多态性的基因相关研究

A Genetic Association Study of the Functional A118G Polymorphism of the Human µ-Opioid Receptor Gene in Patients with Acute and Chronic Pain

Piotr K. Janicki, MD, PhD, Gregg Schuler, MSci, David Francis, MSII, Angela Bohr, MSII, Vitaly Gordin, MD, Tomasz Jarzembowski, MD, Victor Ruiz-Velasco, PhD, and Berend Mets, MB, ChB, PhD, FRCA, FFA (SA)

From the Department of Anesthesiology, Pennsylvania State College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania.

Anesth Analg 2006;103:1011-1017

 

在这个前瞻观察性研究中,我们在急性术后疼痛或慢性疼痛病人中,探讨了人类µ阿片受体(MOR)基因中A118G单核苷多态性是否与不同个体间阿片类镇痛药需要量不同有关。我们在慢性非癌痛的受试者(n = 121例)和以前未用过阿片类的有急性术后疼痛的受试者(n = 101,作为对照组)中,测定了野生型A118MOR(主要)和变异型G118MOR(次要)等位基因的频率。还分析了两组病人A118GMOR基因型、阿片类药物的需要量和疼痛数字评分之间的关系。与病人相比,有慢性疼痛的受试者次要等位基因的频率明显低于急性术后疼痛组 (0.0790.158; 用卡方检验P = 0.009)A118GMOR多态性的存在与平均术后疼痛评分或术后即刻所用吗啡剂量之间,没有统计学的明显相关性。在高四分位、用阿片类的慢性疼痛病人中,主要等位基因的纯合携带者需要的阿片类剂量明显较次要等位基因的携带者高。结果表明,虽然在急性术后疼痛中次要等位基因的存在并不影响阿片类镇痛药的应用,但是慢性疼痛病人中次要等位基因较少见,尤其是那些需要大剂量阿片类镇痛药的病人。

(张莹 马皓琳 李士通校)

In this prospective, observational study we explored whether A118G single nucleotide polymorphism in the human µ-opioid receptor (MOR) gene could explain the inter-individual differences in opioid analgesic requirements in patients with acute postoperative pain and chronic pain. The frequency of the wild-type A118 MOR (major) and variant G118 MOR (minor) alleles in the subjects with chronic, noncancer pain (n = 121) and opioid-naïve subjects with acute postoperative pain (n = 101), serving as the control group, were examined. The relationships among the A118G MOR genotype, opioid requirements, and the numerical pain score were analyzed in both groups. The frequency of the minor allele was significantly lower in the subjects with chronic pain when compared with the group with acute postoperative pain (0.079 versus 0.158; P = 0.009 by {chi}2 test). No statistically significant association was observed between the presence of A118G MOR polymorphism and the average postoperative pain score or the doses of morphine used in the immediate postoperative period. In the high-quartile, opioid utilization, chronic pain patients, the homozygotic carriers of the major allele required significantly higher opioid dose than did the carriers of the minor allele. The results indicate that although the presence of the minor allele does not appear to affect opioid analgesic use in acute postoperative pain, the minor allele is less common in chronic pain patients, especially in those requiring higher doses of opioid analgesics.