Anesthesia & Analgesia

 

October 2006

Table of Content

CARDIOVASCULAR ANESTHESIA:

性別對單純主動脈瓣置換手術後住院病人的死亡率和發病率的影響

彭中美 馬皓琳 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.

可樂定可減弱心臟手術後T細胞亞群的早期促炎症反應

張美榮 陳傑

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.

太尼的心臟保護作用包括中心和外周阿片受體的藥理學證據

金琳 薛張綱校

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-阿片受體拮È善了長期儀器監測的心肌頓的恢復

黃施偉 譯,馬皓琳 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.

非諾多泮和多巴胺、硝普鈉在È主動脈夾閉中的比較研究

王震È 陳傑

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.

 組È因數通道制對由血栓彈圖所確定的凝血動學的影響

孫敏莉譯 薛張綱校

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.

缺血導致心肌非同步收縮模型的建立

黃佳佳譯,李士通 馬皓琳校

Modeling Ischemia-Induced Dyssynchronous Myocardial Contraction

David P. Strum and Michael R. Pinsky

Anesth Analg 2006 103: 846-853.

PEDIATRIC ANESTHESIA:

嬰È兒磁共振檢查中的鎮靜和麻醉:實施者藥理學È面的考慮

(印潔敏 陳傑 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.

小兒顱腦外傷行急診開顱減壓術期間低血壓的發生率和風險因素。

吳德華譯 薛張綱校

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:

硬膜外利多卡因導致大鼠量依賴性神經損傷

顏濤 譯, 馬皓琳 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.

異丙酚微È用於的麻醉È性

宋翠俠 陳傑

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:

支氣管內插管的模型優化探測

  路譯 薛張綱校

Model-Based Detection of Endobronchial Intubation

Rachana K. Visaria and Dwayne R. Westenskow

Anesth Analg 2006 103: 888-893.

自發腦電圖和誘發電位的同步監測用於預測全麻的不同臨狀態的判別能

唐李雋 馬皓琳 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.

異丙酚靜脈麻醉期間瑞太尼對中潛伏期聽覺誘發電位的影響

鄭麗 陳傑

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.

  項提供 醫師È異性回饋的麻醉資系統È善了預防性應用生素的時機

王麗珺譯 薛張綱校

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.

電腦評估負壓手術室的通風性能

邱郁薇 馬皓琳 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:

手術切皮前的操作分析: 1558例患者的觀察性研究

È慧 陳傑

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.

 兒科手術室中切皮前的工作分析:一項有關656次手術的獨立觀察研究

韓曉È譯 薛張綱校

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.

住院醫師È訓和手術室時間表的關係:1558例基於獨立觀測者的研究

姜旭暉譯,馬皓琳,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:

大學附屬醫院的圍術期肺誤吸的發生率和預後: 一項持續4È的回顧性分析

衛紅 陳傑

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.

 微量滲析法用於由肝破裂引起的出血性休克中腦代謝的評估

孫卓真譯 薛張綱校

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:

右旋美托咪啶不會提高清醒頸動脈內膜切除術病人的頸動脈內分流的發生率

胡È 馬皓琳 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.

胸骨多普勒法測心輸出量:剖宮產術應用標準的或持續腰硬聯合麻醉的比較

丁震敏 陳傑

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:

 甲狀腺手術插管困難:神話還是現實?

荻譯 薛張綱校

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.

關於新鮮冰凍血漿融化程式和凝血因數活性的時間過程:一項對照性實驗室研究

裘毅敏譯,馬皓琳 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.

意識和麻醉的科學整合

È瑜 陳傑

Integrating the Science of Consciousness and Anesthesia (Review Article)

George A. Mashour

Anesth Analg 2006 103: 975-982.

ANALGESIA:

鞘內注射嗎啡或太尼聯合病人自控鎮痛與單獨病人自控鎮痛在肝切除術後鎮痛效果的比較

陸文清譯 薛張綱校

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.

È房手術後恒定的一氧化氮產物的血漿濃度與術後早期疼痛慢性術後疼痛嚴重性的關係

黃麗娜 馬皓琳 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.

消炎靈漱口水和阿司È林漱口水在減弱術後咽喉痛È面的作用的評估:一個前瞻性,隨機,單盲的研究

李唯一 陳傑

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.

 在急性傷害性疼痛家兔模型中靜脈腺苷誘導傷害感受的È徵:與瑞太尼的對照研究

徐麗穎譯 薛張綱校

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.

急慢性疼痛病人人類µ阿片受體基因的能性A118G多態性的基因相關研究

張瑩 馬皓琳 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.

神經軸阻滯和全麻下行選擇性全髖置換(THR)的比較:一項Meta分析

周懿È 陳傑

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.

 通過硬膜外造影電腦體層攝影術對術後硬膜外鎮痛失敗的病例分析

王慧琳譯 薛張綱校

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.

太尼的心臟保護作用包括中心和外周阿片受體的藥理學證據

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:我們通過麻醉兔心肌缺血再灌注損傷模型觀察包括中心和外周阿片受體(OR)在內的太尼心臟保護作用(FENT)是否與交感過度興奮的藥理作用有關。È法:在35min冠狀動脈閉塞、120min再灌注後,向家兔腦室內注射L谷氨酸達到刺激中樞交感神經的作用。使用FENT治療(550 µg/kg,靜脈注射)前5min,向家兔腦室內注射È酸納洛酮或靜脈注射甲硫丁氨酸納洛酮(一種四元化合物,不能透過血腦屏障)。結果:只有FENT 50組心臟梗塞的面積縮小(由51% ± 2% 降至 24% ± 2%)。當外周OR阻滯時,這種保護作用消失(42% ± 4%),中樞OR阻滯時沒有影響(32% ± 3%)。使用FENT 50時,缺血期間心室合成物前體數量降低(由54 ± 3降至19 ± 7),而當中樞OR阻滯時,這種保護作用消失(40 ± 3), 外周OR阻滯時沒有影響(18 ± 7)。在灌注期間,使用FENT 50時心室合成物前體數量降低(由134 ± 50降至9 ± 5),當中樞和外周OR阻滯時,這種保護作用都減弱(分別為42 ± 420 ± 11)。使用FENT 50時,死亡率(50%)和室性心動過速的發生率(55%)都降為零。結論:太尼減少心肌缺血再灌注損傷的作用是通過外周ORs介導的,而阿片類藥物的心律失常作用是通過中樞OR介導的。

(金琳 薛張綱校)

 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.

 

 組È因數通道制對由血栓彈圖所確定的凝血動學的影響

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:組È因數通道制(TFPI)是40-kDa的內源性蛋白質,其可制組È因數(TF)結合活化因數X(FXa)啟動的凝結反應。TF/ FXa合成物隨後與TF/活化因數VII(FVIIa)合成物結合,最終制凝血酶生成。使用肝素引起內皮釋放TFPI濃度為正常值的六倍。血栓彈圖(TEG)經常用於監測圍術期的凝血狀態,假定TFPI既制共同的和TF凝血通路,TFPI可能潛在影響基於TEG讀數的診斷性解釋。因此,在這項研究中,我們通過TEG研究TFPI對凝血動的影響。È法:在體外,全血、因數VII缺È血漿,和正常血漿暴露不同的TFPI濃度後,其未性時,操作矽藻土啟動和TF-啟動TEG。結果:在全血,需附87.5 ng/mL TFPI(兩倍正常濃度)來延長血增殖,附175 ng/mL的濃度其血增殖和強度僅受輕微影響。因數VII缺È血漿實驗闡明在這些濃度TFPI-介導的凝血動制是È發於FXa制。矽藻土啟動顯著的弱TFPI-介導的對凝血動影響,然而TF啟動強TFPI-介導的延長凝血啟動和TFPI-介導的血增殖減少。結論:在包括肝素處理的情況中(例如,心肺轉流術),TEG凝血監測時,TFPI-介導的凝血制應該考慮。

(孫敏莉譯 薛張綱校)

 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.

 

 小兒顱腦外傷行急診開顱減壓術期間低血壓的發生率和風險因素

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 

 

我們回顧性研究了一家1級水準的小兒創傷中心一群13歲以下顱腦外傷(TBI)小兒行急診開顱減壓手術術中低血壓(IH)的發生率和危險因素。1994-2004期間,108例患兒行因TBI行急診開顱減壓術。總體,5652%)例患兒有IHIH獨立的危險因素為:每10ml估計失血量/kg體重(ARR 1.15 95%CI 1.08-1.22);顱腦CT中線移位每mmARR 1.04 95%CI 1.01-1.07);每10ml顱腦CT病灶È量(ARR 1.03 95%CI 1.01-1.05)和急診科就存在低血壓(5/5例急診科低血壓患兒有IH)。CT中線移位〉/= 4mm 預示IHARR 1.67 95% CI 1.06-2.63),失血量的獨立因素。IH在急性小兒TBI開顱減壓術中發生率高。急診科低血壓,失血量,CT病灶È積和CT中線移位預示IH。麻醉科醫生能通過術前CT中線移位〉/= 4mm 來評估手術期間的低血壓。

(吳德華譯 薛張綱校)

 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.

 

支氣管內插管的模型優化探測

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.

 

我們開發了一種新式的自動化的集總模型優化È法用來探測支氣管內插管(EBI)。該模型以常規監測的氣道壓和氣流作為輸入參數。在探測支氣管內插管時,這種È法的È徵是當支氣管內插管不到位時測試到胸壁僵硬(SCW)的發生。支氣管內插管採用10只麻È並且癱瘓的雜種狗進行,先行氣管內插管機械通氣,然後將導管插入右主支氣管。在胸壁周圍È壓氣以造成胸壁僵硬的結果。在口部連續測量並記錄氣道壓和氣流,並通過這些信號估計呼吸阻。模型參數進行重複識別直到呼吸阻和模型預測阻間的均ÈÈ誤差達到最小。對支氣管插管期間模型參數相對於基線的È進行分析。10例中的9例,在支氣管內插管期間可以肯定的是,該模型的依從性成分(C1)降低≥50%,而模型的性成分(R2)的È與基線相比≤10-fold。在40個胸壁僵硬案例中測試該標準,發現四個假陽性。在胸壁僵硬時,與基線相比有R1 R2明顯升高同時C2明顯降低。該項初步研究揭示了在支氣管內插管的無創適時探測中,它朝向È臨醫生進行決策邁出了有希望的一步。

(金  路譯 薛張綱校)

 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.

 

  項提供 醫師È異性回饋的麻醉資系統È善了預防性應用生素的時機

 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.

 

手術區的感染是引起術後發病率和死亡率增的常見原因,並且顯著增了治療費用。全國外科感染預防計畫(SIP)的一項內È就是確保預防性生素的時應用,這是降低術後感染的一個關鍵因素。我們麻醉科承擔了適時預防性應用生素的責任,此外,我們還採用了多種È法來提醒 麻醉 醫師應用預防性的生素。我們使用臨麻醉資系統為適時預防性應用生素提供實踐指南,並從資料庫生成報回饋給每個醫師,目的是為了能使病人在切口1小時內得到生素治療。這一È案實施前,69%的適應病人在切口60分鐘內接受了生素治療。這一È案開始1È後,穩步增到92%。醫師È異性回饋增了執行指南的依從性。麻醉資系統希望制定和監測新的實踐指南, 麻醉 醫師要確保非麻醉直接相關治療的適時應用,這在影響外科預後È面起著關鍵的作用。

(王麗珺譯 薛張綱校)

 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.

 

 兒科手術室中切皮前的工作分析:一項有關656次手術的獨立觀察研究

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.

 

我們設計了交叉組合調查來評估麻醉實施時間ART)和小兒經歷麻醉外科手術的外科準備時間(n=656)。資料由有經驗的且獨立的觀察者收集,數有È齡、ASA分級、麻醉器械和有創監測的位置。我們發現È均ART11.0 ± 9.7分鐘,È均外科準備時間是11.1 ± 10.0分鐘。ART的範圍從7 ± 7分到52 ± 18分。ART占整個手術時間的15%± 7%,它的異性很大,主要和整個手術時間長短有關。我們還發現ART有一個明顯的數,包括ASA分級和È齡。例如,È紀小的兒童要比È紀大的兒童ART長。主治麻醉醫生和住院麻醉醫生的房間覆蓋率對ART的影響不大。我們得出結論:小兒手術的ART是多的,最主要的相關因素有小兒的È齡和ASA分級。當安排外科手術時應考慮這些因素。

(韓曉È譯 薛張綱校)

 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.

 

 微量滲析法用於由肝破裂引起的出血性休克中腦代謝的評估

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

 

我們在難以控制的出血性休克的豬的模型中,評È使用精氨酸壓素(AVP)和高張的羥È基澱粉溶液(HHS)進行È量復蘇時的腦灌注壓腦內微量滲析法測得的腦代謝。16只被麻醉的豬首先造成其由於肝出血而形成的血流動學失代償狀態。然後分成兩組給與È量復蘇,一組為普通溶液組(n = 8),一組為AVP/HHS(n = 8)。給藥後30分鐘,使用人工壓迫控制出血,然後兩組給與同樣的晶體和膠體。觀察研究存活下來的豬一小時後得到以下結論。在血流動學失代償後,普通溶液復蘇組與AVP/HHS組相比腦灌注壓升小(mean +/- sem; 24 +/- 5 vs 45 +/- 7 mm Hg; P < 0.01);溶液復蘇後5分鐘È均腦內血管氧分壓與AVP/HHS組相比顯著下降(36 +/- 3 vs 64 +/- 4 torr P < 0.01)。同時兩組È間È比較了腦代謝的不同。結論是作為È量復蘇的初始手段,如考慮到腦內灌注腦供氧時AVP/HHS被證明優於普通溶液;但如考慮腦代謝存活動物的細胞二次損傷時與普通溶液無明顯差異。

(孫卓真譯 薛張綱校)

        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.

 

 甲狀腺手術插管困難:神話還是現實?

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.

 

甲狀腺手術被認為是困難氣道管理的一個危險因素。我們前瞻性研究了連續324位行甲狀腺手術的病人,È據插管困難尺規來調查困難插管的發生率以其他È的預測性因素。困難插管的總發生率為11.1% (95% CI: 7.6-14.5)。中位插管困難尺規為0(25th-75th 百分位數: 0; 2.7)。在三個預定義組中(回波描記無甲狀腺腫,臨可觸甲狀腺腫,不可觸的甲狀腺腫),困難插管分別發生在10% (95% CI: 4.8-17.4), 13% (95% CI: 6.5-18.4) 11% (95% CI: 4.7-16.8)的病人,組間無統計學差異。È的預測標準(可觸的腫,胸內的腫,氣道形,氣道壓迫或甲狀腺惡性腫瘤)與困難插管的發生率增高無關。經典的預測標準(張口度< 35mm Mallampati IIIIV,短頸,頸部活動度<80度,甲頦距< 65mm 和下頜骨退縮)在單數分析中是顯著可靠的困難插管風險因素。

(周 荻譯 薛張綱校)

 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.

 

 

鞘內注射嗎啡或太尼聯合病人自控鎮痛與單獨病人自控鎮痛在肝切除術後鎮痛效果的比較

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

 

持續硬膜外麻醉和鎮痛可以考慮用於肝切除手術,但是經常因為潛在的凝血能異常和可能發生硬膜外血腫而放棄使用。在這個前瞻、隨機、雙盲的研究中,我們比較兩組肝切除術後病人自控鎮痛的嗎啡用量:一組術前鞘內注射嗎啡(0.5mg)和太尼(15ug)(治療組);一組術前鞘內注射安慰(安慰組)。四十個肝切除(≥2個節段)的病人被挑選入組。主要監測指標是病人自控鎮痛的嗎啡用量。次要指標是評È休息和活動時的疼痛,評分用可視疼痛量表,包括評估鎮靜、噁心、騷癢和呼吸頻率。結果監測在髓麻醉後612182448小時。安慰組的病人每段時間嗎啡的用量ÈÈ是治療組的三倍(在48小時:124 +/- 30 vs 47 +/- 21 mg, P < 0.0001)。在治療組,前18小時的疼痛評分比較低。兩組不良反應的發生率沒有差異。所以,肝臟手術前鞘內注射嗎啡(0.5mg)和太尼(15ug)可以明顯減少術後嗎啡的用量而不增不良反應。

(陸文清譯 薛張綱校)

 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.

 

 在急性傷害性疼痛家兔模型中靜脈腺苷誘導傷害感受的È徵:與瑞太尼的對照研究

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強效靜脈鎮痛藥。靜脈應用腺苷的傷害感受效應還未被清晰闡明。我們在用家兔比較腺苷和瑞太尼的效應。È法:16只家兔,放置在懸帶允許適當的自由運動,靜脈應用腺苷(400 microg x kg(-1) x min(-1))或瑞太尼(0.4 microg x kg(-1) x min(-1)),持續240min。結果:通過評估對鉗夾前腳無反應的動物數量和出現逃避運動的電刺激閾,兩種藥物都可產生深度傷害感受。用瑞太尼,傷害感受效應迅速增強,60min達峰,隨後即使È續輸注仍開始減弱。停止輸注後,迅速減弱並且在30min內消失。靜脈應用腺苷的擴血管效應即刻產生且持續時間極短。腺苷的傷害感受效應增強緩慢,但在輸注期間逐漸增強,只在輸注結束時達峰。在輸注終止後360min內緩慢減弱。結論:瑞太尼起效迅速且作用時間短,很可能顯示了耐受性的發展,而腺苷的傷害感受效應起效緩慢且持續時間長,但血漿衰期極短,具有即刻開-關È性的擴血管效應。

(徐麗穎譯 薛張綱校)

 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.

 

 通過硬膜外造影電腦體層攝影術對術後硬膜外鎮痛失敗的病例分析

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.

 

此項前瞻性研究共包括125例患者,我們通過硬膜外造影電腦體層攝影術對大型È部外科手術術後硬膜外鎮痛失敗進行分析,比較兩組患者即硬膜外鎮痛成組和失敗組的硬膜外導管移出和液體漏出硬膜外腔的發生率。我們設想導管移出和液體漏出的發生率在鎮痛成組要低一些。我們在全麻前行胸段硬膜外導管放置。術中給藥為0.25%布比卡因,術後48小時採用0.125%布比卡因(10ml/h)嗎啡(0.25mg/h)持續硬膜外鎮痛。鎮痛失敗定義為:在靜息狀態下直觀類比標度疼痛評分大於30mm /48小時È內任何原因的硬膜外鎮痛中斷。當出現鎮痛失敗,且不是導管扭結或不良事件(n=11,我們就注射造影行CT掃描。鎮痛滿意的患者(即成組)È行CT掃描。鎮痛失敗的發生率為24.8%n31),失敗組行CT掃描(n=20)示有7位患者的硬膜外導管不在硬膜外腔,9位患者的導管位置正常,1位患者的導管位置偏於一側,3位患者的鎮痛液從硬膜外腔漏出。成組中,CT掃描(n=19)示11位患者的導管位置正常,5位患者導管偏于一側,3位患者鎮痛液有漏出。我們得出結論:硬膜外鎮痛失敗的主要原因是導管移出。CT掃描是較常用的發現液體漏出的È法,提示可能是早期導管移出。

(王慧琳譯 薛張綱校)

 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.

 

 

可樂定可減弱心臟手術後T細胞亞群的早期促炎症反應

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細胞對損傷的免疫反應起主導的作用。心臟手術後發生全身炎症反應綜合征的風險高並誘導促炎症反應細胞因數不È衡。可樂定通過減少交感神經活性而具有免疫調節作用,本研究對冠狀動脈旁路移植手術的病人的術後早期進行T淋巴細胞的能分析。40名心臟手術病人隨機分為兩組:可樂定組(可樂定1ug /kg/h n=20)和對照組(n=20)。從麻醉誘導後開始用藥直到手術後6小時。術前、入ICU、手術後6小時、12小時、手術後第一天和第二天的早晨分別取血測定Th1Th2細胞和細胞毒性淋巴細胞(Tc1Tc2細胞)。可樂定組,手術後6小時Th1/Th2Tc1/Tc2的比率較對照組顯著降低(p<0.05)。可樂定È了外周血T細胞亞型的比例增強促炎症反應,這一點可能有利於維持術後免疫È衡。

(張美榮 陳傑 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.

 

非諾多泮和多巴胺、硝普鈉在È主動脈夾閉中的比較研究

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

.

非諾多泮為選擇性多巴胺受體激動,可以迅速降低動脈壓,其作用時間和硝普鈉相似,但與硝普鈉不同,可以增腎血流量。作者比較了È主動脈夾閉手術中使用非諾多泮、多巴胺、硝普鈉的血流動學和腎血管效應。隨機選擇60名患者術前雙盲注射非諾多泮或多巴胺(2µg.kg.min-1)和硝普鈉。開È前,動脈夾閉即刻,松解後5min和術畢時分別記錄血流動學化。術中和術後測定尿量,血清肌酐和肌酐清除率。採用雙樣本等級檢驗比較組間持續數,Fisher’s 檢驗比較分離數。嚴重高血壓的發生率,最高收縮壓和使用高血壓藥物的情況各組間無差異。術中最多的血流動學化和所有腎能的指標沒有差異。因此非諾多泮和其他治療藥物相比在大血管手術包括動脈夾閉的過程中沒有顯著優勢。

(王震È 陳傑 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.

 

嬰È兒磁共振檢查中的鎮靜和麻醉:實施者藥理學È面的考慮

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.

 

既往多數有關兒童鎮靜的研究報僅就單一藥物研究,並且È齡範圍較大。臨實踐中,許多鎮靜和麻醉管理由護士和內科醫生完成。本研究則報了一系列藥物對嬰È兒鎮靜的有效性。258名需要行磁共振檢查的嬰兒中,由護士給予口服水合氯醛(n102)或靜注巴比妥(n67),其餘由內科醫生給予靜注丙酚(n68)。觀察表明水合氯醛組心肺制的發生率(2.9%)較巴比妥組(13.4%)和丙酚組(13.6%)低(P<0.05)。相對於口服水合氯醛的嬰兒(È均23.5±13.4分鐘;)使用丙酚的嬰兒可以更快的配合磁共振掃描(È均9.1±6.7分鐘, P<0.05)。巴比妥組出院時間最長(È均80.3±39.2分鐘),丙酚組的出院時間最短(È均53.9±30.1分鐘;P<0.05)。口服水合氯醛的嬰兒組在接受磁共振檢查中體動的發生率最高(22.5%),巴比妥組的發生率為12.2%,丙酚組僅為1.4%P<0.001)。

(印潔敏 陳傑 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).

 

異丙酚微È用於的麻醉È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.

用納米直徑的異丙酚微È替代異丙酚大豆È粗È作麻醉誘導可能存在多種處。作者用10mg/ml異丙酚微È(粒子直徑為24.5± 0.5nm)和異丙酚大豆È粗È對10只進行麻醉誘導,間隔7天隨機交叉麻醉。以捏夾足趾時腿不回縮和生命體征無化為麻醉終點。多個時間點取靜脈血樣本測定異丙酚血漿藥物濃度以紅細胞、白細胞計數和凝血指數。每只達到痛覺消失隨後順利復蘇且無明顯併發症。異丙酚微È和粗È麻醉下,下列指標無顯著差異:量(分別為10.3±1.29.7±1.6 mg/kgP=0.39),誘導時間(1.0±0.11.0±0.2minP=0.39),復蘇時間(17.4±4.618.2±3.8minP=0.70),心率(P=0.62),動脈壓(P=0.81),呼吸頻率(P=0.60),血像化、凝血酶原時間(P=0.89),部分凝血活酶時間(P=0.76),纖維蛋白濃度(P=0.52),血小板濃度(P=0.55),以血漿異丙酚濃度(P=0.20)。異丙酚微È和粗È並不會明顯È生命體征、血像、凝血化、以異丙酚血漿濃度。

(宋翠俠 陳傑 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.

 

異丙酚靜脈麻醉期間瑞太尼對中潛伏期聽覺誘發電位的影響

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.

 

作為全麻組成部分的阿片類藥是否能通過基於腦電圖的麻醉評估系統反映出來仍有爭議。為了驗證這一假設即瑞太尼定量地影響中潛伏期聽覺誘發電位,作者研究了擇期下肢遠端矯形外科手術的45位成È男性病人在異丙靜脈麻醉期間瑞太尼與中潛伏期聽覺誘發電位È間的相互關係。45個病人隨機分為三組。前兩組用TCI分別接受高靶控濃度的瑞太尼(8 ng mL–1)和低靶控濃度的瑞太尼(3ng mL–1)。第三個組用麻替代瑞太尼。通過TCI逐步增異丙酚濃度。記錄意識消失和喉罩置入時聽覺誘發電位指數(AEPex)和異丙酚濃度。然後異丙酚輸入È為AEPex數值為40的目標閉合回路TCI。結果發現單獨使用瑞太尼對聽覺誘發反應無顯著作用,相反濃度逐步增的瑞太尼導致意識消失的異丙酚濃度下降(P = 0.023)。作者推測瑞太尼濃度與AEPex呈負相關,對照組更為明顯(即單獨接受異丙酚組)。這些結果支持了先前的發現:在意識消失時瑞太尼和異丙酚的存在定量的相互作用,但瑞太尼對聽覺誘發電位直接作用仍是個問題。

(鄭麗 陳傑 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.

 

手術切皮前的操作分析: 1558例患者的觀察性研究

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.

在手術切皮前階段(即從患者躺手術臺到切皮的時間段)患者會產生強烈的張感和壓,它已被認為是影響整個手術的重要因素。作者進行了一項前瞻性的研究,在研究中讓受過訓練的觀察者來評估麻醉醫師、外科醫生和護士的工作狀況對於麻醉實施時間(anesthesia release timeART,È就是患者躺手術臺到外科醫生準備手術的時間段)和外科手術準備時間(surgical preparation timeSPT,È就是外科醫生準備手術到切皮的時間段)的影響以相關影響因素。選擇1558名擇期手術患者,麻醉實施時間(ART)È均為2216min,外科手術準備時間(SPT)È均為2213min,總的手術時間È均為207123min。作者發現麻醉實施時間(ART)和外科手術準備時間(SPT)都存在顯著差異,多因素回歸分析發現患者ASA分級、患者生理狀況、È齡、外科住院醫師的操作水準、無創監測手段、手術室內患者數量和前一個手術時長均與ART成正相關(P<0.05)。而麻醉操作者的性別、體重指數、同一手術室內麻醉操作者的人數並不是ART的影響因素(P>0.05)。24.5%的操作過程存在ARTSPT的延長(其中外科醫師È面占66.8%,麻醉È面占21.7%,後勤È面占11.5%)。所以,對於手術室內的時間安排,要求麻醉誘導時間的固定是不合適的,它會導致錯誤的管理期望。

(È慧 陳傑 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.

 

大學附屬醫院的圍術期肺誤吸的發生率和預後: 一項持續4È的回顧性分析

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.

在一大學附屬醫療中心,作者對非產科手術的成È病例,圍術期肺誤吸(PPA)的發生率和預後 進行了評估。這項持續4È的回顧性研究(2001.12004.12) 使用了診斷È善資料以醫院範圍內的醫療檔案記錄系統。PPA 是通過檢測到氣管支氣管È的非呼吸分泌物或新的肺部症狀和/或術後24小時內異常胸片等確診的。在99,441 麻醉病例中,14 例出現確診的PPA。其中7 (50%)與胃食管操作相關的。所有的病人有一個或數個PPA危險因素。10例全身麻醉病人了發生PPA 4例得到時的麻醉管理監測。在全麻病例中,5例病人在插管後即出現了誤吸,5例在更換氣管內插管時出現誤吸。所有的麻醉監測病例在手術操作期間均時發現了PPA。確診PPA 6例病人出現了肺部併發症,其中一例死亡。14例中有10(70%) PPA 是由不恰當的麻醉操作造成的。目前PPA的發生率是1/7103,患病率是1/16,573 ,死亡率是1/99441

(衛紅 陳傑

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.

 

胸骨多普勒法測心輸出量:剖宮產術應用標準的或持續腰硬聯合麻醉的比較

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:剖宮產術應用持續腰硬聯合麻醉(CSE)可能比標準CSE提供更好的心血管穩定性。作者利用胸骨多普勒法比較了兩種麻醉術的心血管穩定性。

È法:選擇性剖宮產術的健康女性(n = 40)隨機被分成兩組:持續(Seq)或標準(Std)CSE。在輸液前後腰硬聯合麻醉前後記錄一系列的心輸出量指數,包括每分鐘射程,每搏射程,每搏輸出量和校正的流速。患者使用的麻醉藥是高比重的布比卡因10 mg (Std)5 mg (Seq)聯合鞘內注射太尼15 µg。若前面這些藥物未能達到目標麻醉È面,硬膜外腔給予0.5%布比卡因(標準組20分鐘給予5ml,持續組在15分鐘內給予10ml後接著在25分鐘內給予5ml)。在鞘內注射後每隔5分鐘收集資料。出現低血壓者予麻黃素治療。統計分析使用反復È差分析、協È差分析t檢驗。P<0.05時表示有顯著意義.

結果:在鞘內注射後兩種麻醉È法的心輸出量, 包括每分鐘射程,每搏射程,每搏輸出量和校正的流速沒有明顯區別。整個測量期間,這些相同測量值的È均最低值沒有明顯的組間差異。

結論:擇期行剖宮產術的健康孕婦中,持續腰硬聯合麻醉與標準腰硬聯合麻醉相比,對心血管穩定性沒有更好的處。

(丁震敏 陳傑

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.


意識和麻醉的科學整合

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.

人類意識的本源和機制正成為21世紀科學和哲學領域最重要的問題È一。作為一門需認真研究的學科在整個20世紀的大部分時間內被忽視了,但現在它已獲得了合法的科學地位。對於意識的研究以對於全麻機制的研究開始匯攏起來。在該篇文章中,作者對意識研究作一介È,描述了意識的神經聯È,這可能是全身麻醉的作用目標,並且推薦了一種將意識和麻醉整合的途徑。

(È瑜 陳傑 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.

 

消炎靈漱口水和阿司È林漱口水在減弱術後咽喉痛È面的作用的評估:一個前瞻性,隨機,單盲的研究

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.

術後咽喉痛雖然是一個較小的併發症,術後有一定的發病率。作者比較阿司È林漱口水和消炎靈(一種經典的非甾體炎藥)漱口水對預防術後咽喉痛的效果。這個前瞻性、隨機、對照,單盲研究中包括6016-60歲的女性患者,在全麻下接受了È良È房切除術。隨機分為3組:組IC)服用礦泉水,組IIAS)阿司È林350mg片,組IIIBH10.15%的消炎靈漱口水5ml。以藥物都被稀釋成30ml的溶液,在麻醉誘導前5分鐘,用它來漱口30秒。在術後即時,2424小時評估術後咽喉痛的程度,以0-34個等級界定疼痛。阿司È林漱口水能降低術後4小時內的喉嚨痛的發病率而消炎靈漱口水能降低術後24小時內的喉嚨痛的發病率。組I術後喉嚨痛在術後即時和術後2小時顯得較為嚴重(p<0.05)。阿司È林和消炎靈漱口水都能顯著的降低術後喉嚨痛的發病率和嚴重性(p<0.05)。

(李唯一 陳傑 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).

 

神經軸阻滯和全麻下行選擇性全髖置換(THR)的比較:一項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:最近一項Meta分析顯示,相較於全身麻醉,使用神經軸阻滯可以減少不同種類手術後許多嚴重併發症的發生。但尚不明確這項來自多種類手術病人組的研究結果是否È適用於某些È定的手術病人。作者進行這項Meta分析是為了研究不同麻醉È式對選擇性全髖置換(THR)手術預後的影響。

È法:搜索Medline1996È-2005È8月)、MD Consult1966È-2005È9月)、BIOSIS1969È-2005È9月)和EMBASE1969È-2005È9月)的資料,分析其中包括隨機或ÈÈ隨機的神經軸(腰麻或硬膜外麻醉)阻滯和全麻下行選擇性全髖置換(THR)比較的資料。

結果:共十項獨立的實驗,包括330名全麻病人和348名神經軸阻滯病人。其中五項實驗得到的綜合結果顯示,神經軸阻滯能顯著降低可由影像學確診的深靜脈血栓或肺栓塞的發生。深靜脈血栓形成的相對比(OR)為0.27,其95%可信區間(CI)為0.170.42。發生肺栓塞的相對比(OR)為0.26,其95%可信區間(CI)為0.120.56。神經軸阻滯還能夠減少手術時間(7.1分鐘/每例,95CI2.311.9分鐘)和術中失血(275mL/每例,95CI180371mL)。另三項實驗顯示,與全麻相比,神經軸阻滯下進行THR的患者較少需要輸血(輸血病人為62/188=33%21/177=12%z檢驗結果P<0.001)。這項比較的相對比為0.26。然而,以研究結果的CI偏大,而且有結果顯示兩者沒有區別,È有結果顯示十分ÈÈ存在區別(95CI0.061.05)。

結論:在神經軸阻滯下進行選擇性全髖置換的病人似È較全麻下的病人預後好。

(周懿È 陳傑 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.

 

性別對單純主動脈瓣置換手術後住院病人的死亡率和發病率的影響

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

 

我們的回顧性研究的目的是為了檢查性別對單純主動脈瓣置換手術後住院病人的死亡率和發病率的影響。在1993È1月至2002È6月,2212例病人(女性782例,男性1430例)行主動脈瓣置換手術。用傾向È配來調整組間基礎È徵和圍手術期數的許多差異。未校準的資料女性組住院死亡率較高 27 [3.5%]女性比23 [1.6%] 男性; P = 0.005)。用傾向分數11È配的分析發現在各組間住院病人死亡率[OR (95%可信區間), 1.0 [0.4, 2.6]; P = 0.99]和總體發病率 (1.4 [0.7, 2.5]; P = 0.29) 沒有明顯差異。進一步分析,包括用傾向分數女性和男性分為五分相組和用傾向分數調整進行的對數回歸模型,發現女性心臟發病風險性升高[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)和其他發病率沒有統計學差異。這些結果提示行主動脈瓣置換手術的女性較男性的風險性增高不超過2.5倍。然而,女性性別可能使主動脈瓣置換手術後心臟發病風險升高。

(彭中美 馬皓琳 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-阿片受體拮È善了長期儀器監測的心肌頓的恢復

{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

 

我們驗證了關於選擇性{kappa}-阿片受體拮nor-binaltorphimine(nor-BNI)È善心肌頓的恢復的假設。十條被長期連接儀器用作測量心率,左心房、主動脈和左心室壓(LVP)、LVP的最大升速率(LV dP/dtmax)和最大下降速率(LV dP/dtmax)、冠狀動脈血流速和心肌壁增厚分數。使用螢光微球顆粒來測定局部心肌血流。高效液相法測定血漿兒茶酚胺水準,放免法測定血漿ß-內啡肽和強啡肽水準。左前降支動脈(LAD)周圍的阻斷可誘發可逆性的LAD缺血。在非同一天內動物以隨機交叉È式分別進行兩種實驗:(a10minLAD阻斷(對照實驗);(b)使用nor-BNI(2.5 mg/kg IV)24h後行第二次缺血(È預)。接受nor-BNI的在缺血前和整個再灌注期表現為心肌壁增厚分數、LV dP/dtmaxLV dP/dtmin 有增(與對照實驗相比,P < 0.05)。nor-BNI預處理後,強啡肽水準在誘發缺血後升至峰值15.1 ± 3.6pg/mL(與對照實驗相比,P < 0.05);而在缺血期和再灌注早期血漿ß-內啡肽水準的升高得到緩解。與對照實驗相比,nor-BNI使得總體的血流動學、局部心肌血流兒茶酚胺水準沒有È。總È,nor-BNIÈ善了長期儀器監測局部心肌缺血後心肌頓的恢復。

(黃施偉 譯,馬皓琳 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.

 

缺血導致心肌非同步收縮模型的建立

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

 

左室非同步收縮難以量化。我們以前參考局部振È和相位角用艾司洛爾引起的局部收縮能障礙建立過一個量化左室總體非同步收縮的模型。我們驗證了這樣一個假設,在類模型建立的我們的正弦波模型相位角分析局部非同步收縮È可以用於評估局部缺血時的非同步收縮。所以我們在10只麻醉好的開胸狗比較了冠脈內用艾司洛爾和相應局部缺血。在艾司洛爾引起心尖部收縮能障礙相應部位缺血È前、期間È後,分別測量局部總體左室È積(È積導管)、壓電晶體縮短程度以左室壓。我們定義局部收縮相位角({alpha})為局部最小È積和總體收縮末期È積È間的相對距離,以“度”為測量單位。我們還比較了最大心搏出量(SV)、觀察的有效心搏量(每次處理中局部SV占總體SV的部分)和計算的有效SV(所有局部SV×餘旋{alpha})。多巴酚丁胺灌注可增局部{alpha}相對於基礎值的均勻性。艾司洛爾和缺血均顯著延遲了心尖部的收縮,這從相對於基礎值來說顯著增大的{alpha}(12.4° ± 28.1°分別至 27.4° ± 30.4° 54.2° ± 32.6°) (均數 ± 標準差) 和減少的局部有效 SV (4.7 ± 2.5 mL分別至3.6 ± 2.2 mL 4 ± 2.5 mL,)中可以定量表現出來。我們的研究提示,冠脈內艾司洛爾和缺血對心肌能產生性質相似的機械影響,且利用正弦波模型評估局部有效心搏量是檢測和量化缺血引起的局部非同步收縮的敏感È法。相位角和局部振È分析可能成為確定和量化再同步化治療對心肌能的有作用的有效È法。

(黃佳佳譯,李士通 馬皓琳校)

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.

 

硬膜外利多卡因導致大鼠量依賴性神經損傷

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

 

儘管硬膜外單次注射利多卡因已經顯示ÈÈ不會導致神經毒性,但是局麻藥經常重複或者連續注射到硬膜外腔,且高量的局麻藥仍可能引起神經損傷。我們觀察了大量利多卡因連續輸注到大鼠硬膜外腔是否具有神經毒性以由此產生的能損害和組È學損傷是否具有量依賴性。在試驗1中,給13只大鼠硬膜外連續輸注(5 µL/min)È水或者2%利多卡因120 min。輸注後4天,給予2%利多卡因的大鼠甩尾潛伏期較給予È水者明顯延長,並且表現出更明顯的形態學È。在試驗2中,41只大鼠隨機分成5組,均以5 µL/min的速度於硬膜外分別注射生理È水120min5%利多卡因15min30min60min120min。給予5%利多卡因120min的大鼠產生明顯的甩尾潛伏期延長。各組動物爪壓閾值均無化。給予5%利多卡因3060120min的大鼠的神經損傷分數均明顯高於僅給予È水者。給予麻醉藥的持續時間不同造成的神經È損害È不同;輸注5%利多卡因120min動物神經損害明顯高於輸注15min30min者;輸注5%利多卡因60min動物神經損害明顯高於輸注15min者。結論是,這些結果提示在大鼠硬膜外連續輸注利多卡因導致量依賴性神經毒性作用。

(顏濤 譯, 馬皓琳 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.

 

自發腦電圖和誘發電位的同步監測用於預測全麻的不同臨狀態的判別能

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

 

自發或誘發的腦部電活動來多地被應用于全麻監測。以往研究觀察的數主要是自發腦電圖(EEG)、聲誘發電位(AEP)、體感誘發電位(SSEP)。但是,分別監測述指標可能丟失來自於同步收集的有用資。我們研究了從EEGAEPSSEP得到的同步資的組合,與從每個單獨的指標得到的資相比,是否對於區別麻醉狀態有更高的判別能。因此,我們評估了59個患者在四種全麻臨狀態下(清醒、淺麻醉、外科麻醉、深度外科麻醉)的30 EEG21 SSEP29 AEP數的化。用辨別分析來研究單個和聯合EEGAEPSSEP數預測述麻醉狀態的判別能。EEG數比AEPSSEP數有更高的判別能,正確分級病例分別有85%46%32%。用從聯合EEG + AEP EEG + AEP + SSEP得到的資,正確分級的頻率分別增至90%91%。由此可見,未來的麻醉監測應考慮不同電生理測量È法所得的同步聯合資,而非單個數或EEGAEPSSEP的組合。

(唐李雋 馬皓琳 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.

 

電腦評估負壓手術室的通風性能

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:需要負壓手術室來限制一些呼吸系統疾病在有嚴重急性呼吸窘迫綜合症、結核、禽流感或其他類似感染性疾病的病人間的傳播。在香港,我們將傳統的手術室轉換為了負壓手術室,並且付諸使用一È以。本文介È了它的通風設計,評估了與不同醫學燈具配置組合和將污染顆粒發射到室內空氣模式相關的氣流性能。È法:我們採用了電腦流體動學術進行資料分析。

結果:我們的分析顯示負壓手術室中的氣流性能是滿意的,與先前的正壓通氣設計具有可比性.氣流形式能夠有效地控制感染顆粒的擴散。我們的計算顯示氣流能È納病人釋放的有傳染性的顆粒從而足以保護外科手術組,反È亦然。

結論:電腦流體動學能夠用於評估負壓手術室的氣流性能,且類比有傳染性的顆粒從病人散佈的模型。

(邱鬱薇 馬皓琳 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.

 

住院醫師È訓和手術室時間表的關係:1558例基於獨立觀測者的研究

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

 

提高手術室效率的可能會影響到住院醫師的È訓。因此,我們設計了一個前瞻性的觀測性研究來測定È訓麻醉住院醫師所的從病人躺到手術臺到切皮的確切時間,以確定在圍誘導期間的麻醉È訓是否增了到切皮所需的時間。這個研究在三級學術醫療中心的住院手術室中進行。觀測了1558例病人,在其中75%的病人身進行了麻醉醫師È訓(每一例È訓所占的È均比例為46.4%)。當麻醉主治醫師同時在兩間手術室裏指導監護時È訓時間下降33%(p<0.001)。È訓時間所占比例隨ASA分級和外科監護的天數增而明顯增(p=0.001)。È訓使得皮前所需的時間È均增了4.5±3.2分鐘,但是這些延長的時間僅占到È均手術時間的3%(207 ± 132 min)。我們得出結論,È訓發生在手術室的大部分病例中,並且雖然È訓延長了到皮所需的時間,但是與完成手術所需的時間相比較該延長無顯著性。

(姜旭暉譯,馬皓琳,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.

 

右旋美托咪啶不會提高清醒頸動脈內膜切除術病人的頸動脈內分流的發生率

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

 

全身性給予右旋美托咪啶(DEX)減少腦血流量(CBF)是通過直接激動{alpha}-2受體使腦血管收縮和通過體內神經傳導的作用間接調節血管È滑肌。不伴有腦代謝率下降的CBF減少,已引起了我們對DEX可能限制那些已有腦迴圈損傷(如,頸動脈內膜切除)病人的腦組È充分氧合的關注。本研究中,123例在我們的機構中使用DEX作為初始鎮靜行清醒CEA術的連續系列中,我們確立了作為腦氧供不充分標誌的動脈內分流的發生率。在151位行CEA術的病人中前瞻性地記錄研究期間的資料。18位病人由於醫學或其他原因用咪唑安定與太尼(M/F)進行鎮靜。給那些被認為有術中中風風險的病人行預防性動脈內分流,這些病人與那些需要全麻的病人都被排除於最後的分析。DEX組中5位元病人(4.3%)需要行動脈內分流。在我們的機構中行清醒CEA術病人中分流的發生率為10% (歷史對照)。沒有病人發生中風或者其他嚴重的併發症。看來DEX用作行CEA術主要鎮靜藥不會提高頸動脈內分流的發生率。

(胡È 馬皓琳 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.

 

關於新鮮冰凍血漿融化程式和凝血因數活性的時間過程:一項對照性實驗室研究

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:在本項研究中,我們評估了2個市場可得的裝置的融化過程對於用於新鮮冰凍血漿(FFP)的凝血因數活性、血流穩態系統的制活化標誌的影響。在實驗過程中,FFP42°C的流動溫水中解凍。

È法:選擇20個健康獻血者的血漿取樣,分離,且分裝在3個血漿袋子裏。取樣後2小時內將血漿樣本袋放置在–30°C –40°C的溫度下冰凍,並儲存8周以。在取樣後(基線)、解凍即刻解凍後1246小時檢測每個血漿袋中的FVFVIIFVIII、纖維蛋白原、纖維蛋白單體 (FM)、右旋二聚體(DD){alpha}2-血纖維蛋白溶素({alpha}2-AP)蛋白 S (PS)的活性。

結果:解凍後的1-6h內,沒有發現不同解凍過程的凝血觀測指標活性的明顯差異。然而,解凍後即刻FVII的活性明顯降低(P < 0.01), FM 活性明顯增 (P = 0.001),但不依賴於解凍過程。

結論:所研究的血漿解凍過程顯示,在整個研究階段,被研究的凝血指標的活性穩定性均無明顯影響。FVII活性的降低FM臨明顯增高還需進一步研究。(裘毅敏譯,馬皓琳 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.

 

È房手術後恒定的一氧化氮產物的血漿濃度與術後早期疼痛慢性術後疼痛嚴重性的關係

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

 

在該研究中,我們比較了兩種鎮痛È法對圍手術期一氧化氮指數(NOx)以È房手術後慢性術後疼痛(CPSP)È後發展可能性的影響,並且試圖確定術後早期疼痛與NOxÈ發的CPSP的相互關係。29例連續的ASA 分級III級,施行È房手術並伴腋窩淋巴結清掃的病人,隨機分入兩組。S組(n = 15)的病人接受標準的術中術後鎮痛療法(硫酸嗎啡、雙氯酸、È酸右丙氧+對È醯氨基酚需要時服用)。N組病人(n = 14)接受持續椎旁阻滯(持續48小時)對È醯氨基酚和帕瑞考昔(接下來應用塞來考昔直到術後5)。定時記錄術後5天休息時肢活動時的疼痛的視覺類比評分比標度評分。術後10周進行電話訪問。應用McGill疼痛調查表評È疼痛的性質。術前、手術結束時、術後30 min24122448 h評估NoxS組的12名病人(占80%),N組無一例病人發生CPSP(P = 0.009)。與術後10周的疼痛等級評定指數1的病人(n = 18)相比,疼痛等級指數為0的病人(n = 11) 在術後30分鐘直至術後96小時的每個術後時間點時運動時的視覺類比評分均較小(P < 0.005)。休息時的評分在術後30分鐘分別為0.6 ± 1.530.2 ± 26.8P = 0.004,4小時時為2.3 ± 7.5 19.0 ± 25.8P = 0.013),8小時時為4.4 ± 10.2 21.4 ± 27.0 P = 0.03),12小時為0.7 ± 1.2 15.4 ± 27.0 P = 0.035)。N組術後48小時的NOx指數較S組高(40.6 ± 20.1 26.4 ± 13.5; P = 0.04)。

(黃麗娜 馬皓琳 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).

 

急慢性疼痛病人人類µ阿片受體基因的能性A118G多態性的基因相關研究

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

 

在這個前瞻觀察性研究中,我們在急性術後疼痛或慢性疼痛病人中,探討了人類µ阿片受體(MOR)基因中A118G單核苷多態性是否與不同個體間阿片類鎮痛藥需要量不同有關。我們在慢性非癌痛的受試者(n = 121例)和以前未用過阿片類的有急性術後疼痛的受試者(n = 101,作為對照組)中,測定了野生型A118MOR(主要)和異型G118MOR(次要)等位元基因的頻率。還分析了兩組病人A118GMOR基因型、阿片類藥物的需要量和疼痛數位評分È間的關係。與病人相比,有慢性疼痛的受試者次要等位元基因的頻率明顯低於急性術後疼痛組 (0.0790.158; 用卡È檢驗P = 0.009)A118GMOR多態性的存在與È均術後疼痛評分或術後即刻所用嗎啡量È間,沒有統計學的明顯相關性。在高四分位、用阿片類的慢性疼痛病人中,主要等位基因的純合攜帶者需要的阿片類量明顯較次要等位基因的攜帶者高。結果表明,雖然在急性術後疼痛中次要等位基因的存在並不影響阿片類鎮痛藥的應用,但是慢性疼痛病人中次要等位基因較少見,尤其是那些需要大量阿片類鎮痛藥的病人。

(張瑩 馬皓琳 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.