Anesthesia & Analgesia

May 2007

CARDIOVASCULAR ANESTHESIA:

性別差別對於老年病人冠脈手術後腦卒中風險的影響

裘毅敏譯,馬皓琳 李士通校

Gender Differences in Stroke Risk Among the Elderly After Coronary Artery Surgery

Tomoko Goto, Tomoko Baba, Asuka Ito, Kengo Maekawa, and Takaaki Koshiji

Anesth Analg 2007 104: 1016-1022.

擇期冠脈旁路移植術(CABG)病人術前存在認知障礙

印潔敏 陳傑

Preexisting Cognitive Impairment in Patients Scheduled for Elective Coronary Artery Bypass Graft Surgery

Brendan S. Silbert, David A. Scott, Lisbeth A. Evered, Matthew S. Lewis, and Paul T. Maruff

Anesth Analg 2007 104: 1023-1028.

胸科手術單肺通氣過程中壓控制通氣與容量控制通氣的比較

儷譯 薛張剛校

Pressure-Controlled Versus Volume-Controlled Ventilation During One-Lung Ventilation for Thoracic Surgery

M. Carmen Unzueta, J. Ignacio Casas, and M. Victoria Moral

Anesth Analg 2007 104: 1029-1033.

PEDIATRIC ANESTHESIA:

6-18個月嬰兒術後應用酮咯酸氨丁三醇:對嗎啡的應用、安全性評估和立體特異藥代動學的影響

張曦 譯,馬皓琳 李士通

Postoperative Ketorolac Tromethamine Use in Infants Aged 6–18 Months: The Effect on Morphine Usage, Safety Assessment, and Stereo-Specific Pharmacokinetics

Anne M. Lynn, Heidi Bradford, Eric D. Kantor, Kok-Yong Seng, David H. Salinger, James Chen, Richard G. Ellenbogen, Paolo Vicini, and Gail D. Anderson

Anesth Analg 2007 104: 1040-1051.

行扁桃體摘除術或增殖腺扁桃體摘除術的小兒患者使用地塞米松(0.0625-0.1mg/kg)預防嘔吐、減輕疼痛、縮短首次攝入液體的時間和聲音改的發生率沒有量遞增效應

顧新宇 陳傑

There Is No Dose-Escalation Response to Dexamethasone (0.0625–1.0 mg/kg) in Pediatric Tonsillectomy or Adenotonsillectomy Patients for Preventing Vomiting, Reducing Pain, Shortening Time to First Liquid Intake, or the Incidence of Voice Change

Michelle S. Kim, Charles J. Coté, Carmen Cristoloveanu, Andrew G. Roth, Polina Vornov, Melissa A. Jennings, John P. Maddalozzo, and Cristine Sullivan

Anesth Analg 2007 104: 1052-1058.

對預行動脈轉接術的新生兒應用血漿B型利鈉肽的時程價值

霞譯 薛張綱校

Time Course and Prognostic Value of Plasma B-type Natriuretic Peptide Concentration in Neonates Undergoing the Arterial Switch Operation

Maxime Cannesson, Clara Bionda, Bruno Gostoli, Olivier Raisky, Sylvie di Filippo, Dominique Bompard, Catherine Védrinne, Robert Rousson, Jean Ninet, Jean Neidecker, and Jean-Jacques Lehot

Anesth Analg 2007 104: 1059-1065.

新生兒缺氧-缺血後異氟醚延遲性預處理會減少成熟小鼠即時死亡率並改善紋狀體的能

黃麗娜 李士通 馬皓琳

Isoflurane-Delayed Preconditioning Reduces Immediate Mortality and Improves Striatal Function in Adult Mice After Neonatal Hypoxia–Ischemia

John J. McAuliffe, Bernadin Joseph, and Charles V. Vorhees

Anesth Analg 2007 104: 1066-1077.

AMBULATORY ANESTHESIA:

A Randomized, Double-Blind Comparison of the NK1 Antagonist, Aprepitant, Versus Ondansetron for the Prevention of Postoperative Nausea and Vomiting

宋翠俠 陳傑

A Randomized, Double-Blind Comparison of the NK1 Antagonist, Aprepitant, Versus Ondansetron for the Prevention of Postoperative Nausea and Vomiting

Tong J. Gan, Christian C. Apfel, Anthony Kovac, Beverly K. Philip, Neil Singla, Harold Minkowitz, Ashraf S. Habib, Jennifer Knighton, Alexandra D. Carides, Hong Zhang, Kevin J. Horgan, Judith K. Evans, Francasca C. Lawson, and The Aprepitant-PONV Study Group

Anesth Analg 2007 104: 1082-1089.

ANESTHETIC PHARMACOLOGY:

一些氟化雜環烷(Oxolanes)和雜環丁烷(Oxetanes)的麻醉藥特性

王時來譯 薛張綱校

Anesthetic Properties of Some Fluorinated Oxolanes and Oxetanes

Edmond I. Eger, II, David Lemal, Michael J. Laster, Mark Liao, Katarzyna Jankowska, Anilkumar Raghavanpillai, Anatoliy V. Popov, Yonghong Gan, and Yan Lou

Anesth Analg 2007 104: 1090-1097.

利多卡因、MK801MAC

Lidocaine, MK-801, and MAC              

Yi Zhang, Michael J. Laster, Edmond I. Eger, II, Manohar Sharma, and James M. Sonner

Anesth Analg 2007 104: 1098-1102.

太尼對卵白蛋白致敏的大鼠氣道的收縮效應的影響

鄭麗 陳傑

The Effects of Fentanyl on the Contractile Response of Ovalbumin-Sensitized Rat Trachea

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

Anesth Analg 2007 104: 1103-1108.

哮喘病人全身應用利多卡因對於氣道張和肺能的影響

施譯,薛張綱校

The Effects of Systemic Lidocaine on Airway Tone and Pulmonary Function in Asthmatic Subjects

Herng-Yu Sucie Chang, Alkis Togias, and Robert H. Brown

Anesth Analg 2007 104: 1109-1115.

左布比卡因與麥糖基-ß-環精聯合應用可以延長大鼠鞘內和坐骨神經阻滯的時間

張美榮 陳傑

Prolongation of Intrathecal and Sciatic Nerve Blocks Using a Complex of Levobupivacaine with Maltosyl-ß-Cyclodextrin in Rats

Ken Karashima, Masahiko Taniguchi, Tadashi Nakamura, Mayumi Takasaki, Kanako Matsuo, Mitsuru Irikura, and Tetsumi Irie

Anesth Analg 2007 104: 1121-1128.

鼠腦蛋白的七氟醚麻醉效應:一項蛋白質組的時間-過程分析

陳佳莉譯 薛張綱校

The Effects of Sevoflurane Anesthesia on Rat Brain Proteins: A Proteomic Time-Course Analysis

Armin Kalenka, Jochen Hinkelbein, Robert E. Feldmann, Jr, Wolfgang Kuschinsky, Klaus F. Waschke, and Martin H. Maurer

Anesth Analg 2007 104: 1129-1135.

全麻藥對大鼠小膠質細胞系中P2X7 P2Y受體的影響

顏濤 譯, 馬皓琳 李士通校

The Effects of General Anesthetics on P2X7 and P2Y Receptors in a Rat Microglial Cell Line

Mika Nakanishi, Takashi Mori, Kiyonobu Nishikawa, Makoto Sawada, Miyuki Kuno, and Akira Asada

Anesth Analg 2007 104: 1136-1144.

TECHNOLOGY, COMPUTING, AND SIMULATION:

雙頻指數(BIS)引導下的全身麻醉合併胸段硬膜外鎮痛可減少快通道結腸手術的恢復時間

衛紅 陳傑

Bispectral Index-Guided General Anesthesia in Combination with Thoracic Epidural Analgesia Reduces Recovery Time in Fast-Track Colon Surgery

Jochen Mayer, Joachim Boldt, Alexander Schellhaaß, Björn Hiller, and Stefan W. Suttner

Anesth Analg 2007 104: 1145-1149.

星狀神經節的經皮電刺激對創傷病人入院前得脈搏血氧測定信號品質得影響

陳珺珺譯 薛張綱校

The Influence of Stellate Ganglion Transcutaneous Electrical Nerve Stimulation on Signal Quality of Pulse Oximetry in Prehospital Trauma Care

Renate Barker, Thomas Lang, Helmut Hager, Barbara Steinlechner, Klaus Hoerauf, Michael Zimpfer, and Alexander Kober

Anesth Analg 2007 104: 1150-1153.

CRITICL CARE AND TRAUMA:

低溫對內毒素預處理的肺的作用

周雅春 馬皓琳 李士通

The Effects of Hypothermia on Endotoxin-Primed Lung

Jae-Yong Chin, Younsuck Koh, Mi Joung Kim, Han Seong Kim, Woo-Sung Kim, Dong-Soon Kim, Won-Dong Kim, and Chae-Man Lim

Anesth Analg 2007 104: 1171-1178.

NEUROSURGICAL ANESTHESIA:

σ受體激動通過保護bcl-2而具有離體神經保護作用

丁震敏 陳傑

Sigma Receptor Agonists Provide Neuroprotection In Vitro by Preserving bcl-2

Sufang Yang, Anish Bhardwaj, Jian Cheng, Nabil J. Alkayed, Patricia D. Hurn, and Jeffrey R. Kirsch

Anesth Analg 2007 104: 1179-1184.

OBSTETRIC ANESTHESIA:

腰椎橫向超聲可以為分娩硬膜外穿刺準確定位

姜旭暉譯,馬皓琳,李士通校

Ultrasound Using the Transverse Approach to the Lumbar Spine Provides Reliable Landmarks for Labor Epidurals

Cristian Arzola, Sharon Davies, Ayman Rofaeel, and Jose C. A. Carvalho

Anesth Analg 2007 104: 1188-1192.

GENERAL ARTICLES:

環狀軟骨施壓妨礙麻醉狀態下患者ProSeal喉罩的插入和通氣

詹慧 陳傑

Cricoid Pressure Impedes Insertion of, and Ventilation Through, the ProSeal Laryngeal Mask Airway in Anesthetized, Paralyzed Patients

Cheng W. Li, Fu S. Xue, Ya C. Xu, Yi Liu, Peng Mao, Kun P. Liu, Quan Y. Yang, Guo H. Zhang, and Hai T. Sun

Anesth Analg 2007 104: 1195-1198.

催眠 與外科 :過去,現在和將來

吳德華譯 薛張綱校

Hypnosis and Surgery: Past, Present, and Future (Review Article)

Albrecht H. K. Wobst

Anesth Analg 2007 104: 1199-1208.

PAIN MEDICINE:

外周神經應用辣椒素類似物可預防環紮大鼠坐骨神經造成的痛覺過敏

璿譯 薛張綱校

Perineural Resiniferatoxin Prevents the Development of Hyperalgesia Produced by Loose Ligation of the Sciatic Nerve in Rats

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

Anesth Analg 2007 104: 1210-1216.

腰段硬膜外類固醇注射用於治療腰椎間盤膨出患者的效果

唐李雋 馬皓琳 李士通

The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations

William E. Ackerman, III and Mahmood Ahmad

Anesth Analg 2007 104: 1217-1222.

慢性疼痛個體人的注意和工作記憶痕跡分散

李惟一 陳傑

Disruption of Attention and Working Memory Traces in Individuals with Chronic Pain

Bruce D. Dick and Saifudin Rashiq

Anesth Analg 2007 104: 1223-1229.

全膝關節置換術後硬膜外可樂定鎮痛的量效學研究

王光妍譯 薛張綱校

Epidural Clonidine for Postoperative Pain After Total Knee Arthroplasty: A Dose–Response Study

Yuan-Shiou Huang, Liu-Chi Lin, Billy K. Huh, Michael J. Sheen, Chun-Chang Yeh, Chih-Shung Wong, and Ching-Tang Wu

Anesth Analg 2007 104: 1230-1235.

PAIN MECHANISMS:

多方面截斷大鼠坐骨神經與股神經末稍後的神經性疼痛測量的症狀精確度:一項探查性行為分析

Refinement of Symptoms of Neuropathic Pain Measurements After Various Transections of the Nerve Endings of the Sciatic and Femoral Nerve in Rats: An Exploratory Behavioral Analysis

Marie P. Van Remoortere, Theo F. Meert, Kris C. Vissers, Hans Coppenolle, and Hugo Adriaensen

Anesth Analg 2007 104: 1236-1245.

雌激素通過改暫態型感受器電位-1能從從而放大宮頸擴張導致的疼痛

周懿之 陳傑

Estrogen Amplifies Pain Responses to Uterine Cervical Distension in Rats by Altering Transient Receptor Potential-1 Function

Tao Yan, Baogang Liu, Dongping Du, James C. Eisenach, and Chuanyao Tong

Anesth Analg 2007 104: 1246-1250.

右美沙去甲右美沙在小鼠表皮浸潤止痛中具有局部麻醉作用

陳勇柱譯 薛張綱校

Dextromethorphan or Dextrorphan Have a Local Anesthetic Effect on Infiltrative Cutaneous Analgesia in Rats

Yu-Wen Chen, Koung-Shing Chu, Ching-Nan Lin, Jann-Inn Tzeng, Chin-Chen Chu, Mao-Tsun Lin, and Jhi-Joung Wang

Anesth Analg 2007 104: 1251-1255.

阿密曲替林是人Kv1.1Kv7.2/7.3通道的強效阻滯

張瑩 馬皓琳 李士通校

Amitriptyline Is a Potent Blocker of Human Kv1.1 and Kv7.2/7.3 Channels

Mark A. Punke and Patrick Friederich

Anesth Analg 2007 104: 1256-1264.

REGIONAL ANESTHESIA:

超聲引導下的局部麻醉:最新的觀念與將來的趨勢

衛紅 陳傑

Ultrasound-Guided Regional Anesthesia: Current Concepts and Future Trends (Medical Intelligence)

Peter Marhofer and Vincent W. S. Chan

Anesth Analg 2007 104: 1265-1269.

超聲引導下股骨中段外側坐骨神經阻滯:一項隨機比較設計實驗

周時蓓譯 薛張綱校

Ultrasound Guidance for Lateral Midfemoral Sciatic Nerve Block: A Prospective, Comparative, Randomized Study (Medical Intelligence)

Vicente Domingo-Triadó, Salvador Selfa, Francisco Martínez, Dolores Sánchez-Contreras, Montserrat Reche, Jose Tecles, María T. Crespo, Jose M. Palanca, and Blanca Moro

Anesth Analg 2007 104: 1270-1274.

超聲介導下使用神經刺激法進行鎖骨下神經阻滯:一項前瞻性隨機試驗

邱郁薇 馬皓琳 李士通

Neurostimulation in Ultrasound-Guided Infraclavicular Block: A Prospective Randomized Trial (Medical Intelligence)

Emmanuel Dingemans, Stephan R. Williams, Geneviève Arcand, Philippe Chouinard, Patrick Harris, Monique Ruel, and François Girard

Anesth Analg 2007 104: 1275-1280.

運用超聲術和組織學檢查研究活體豬模型的神經內注射和電刺激

李惟一 陳傑

An Ultrasonographic and Histological Study of Intraneural Injection and Electrical Stimulation in Pigs (Brief Report)

Vincent W. S. Chan, Richard Brull, Colin J. L. McCartney, Daquan Xu, Sherif Abbas, and Patrick Shannon

Anesth Analg 2007 104: 1281-1284.

 

擇期冠脈旁路移植術(CABG)病人術前存在認知障礙

Preexisting Cognitive Impairment in Patients Scheduled for Elective Coronary Artery Bypass Graft Surgery

Brendan S. Silbert, MB, BS, FANZCA*, David A. Scott, MB, BS, PhD, FANZCA*, Lisbeth A. Evered, BSc*, Matthew S. Lewis, BApp Sci (Hons), PhD*{dagger}, and Paul T. Maruff, PhD{dagger}

From the *Department of Anaesthesia, Centre for Anaesthesia and Cognitive Function, St. Vincent's Hospital; and {dagger}School of Psychological Science, La Trobe University, Melbourne, Australia.

Anesth Analg 2007 104: 1023-1028.

 

背景:如果要對擇期CABG的病人是否會發生認知改做出有效的推論,術前對這些病人認知障礙的發病情況進行準確的評估是非常必要的。這樣的評估,需與一組並不患有心血管疾病的健康人進行比較。

方法:在一項回顧性觀察研究中,349名擬行擇期CABG的病人接受了神經心理測試。將其測試結果與沒有心血管疾病的170名健康對照者相比較,其中有較多的年齡和智商(IQ)匹配的女性。如果在總共7項測試中有兩項或更多的測試中,患者組的測試分值比對照組的分值減少超過2個標準差(sd),則認為存在認知障礙。

結果:擇期CABG病人的測試結果除了在有槽拼板測試和健康對照組的差異不明顯外,在其他的測試項中都明顯比對照組差。對兩組的測試結果分析發現患者組在言語學習測試中表現出的能減退最為嚴重。擬行擇期CABG病人中,有122名(35%)術前存在認知障礙。先前患有心肌梗塞,年齡和IQ是獨立預測認知障礙的指標。

結論:認知障礙普遍存在於將進行擇期CABG的病人中。在評估擇期CABG對認知能的影響時必須考慮到術前已經存在的認知障礙。

(印潔敏 陳傑 校)

BACKGROUND: An accurate assessment of the prevalence of cognitive impairment in patients scheduled for coronary artery bypass graft (CABG) surgery is necessary if valid assumptions regarding cognitive change are to be made. Such an assessment requires the use of a healthy control group free of cardiovascular disease.

METHODS: In a retrospective observational study, 349 patients scheduled for CABG surgery underwent neuropsychological testing. We compared the results with those from a group of 170 healthy controls without cardiovascular disease and containing more female patients who were matched for age and IQ score. Cognitive impairment was defined as test scores 2 sd less than the controls on two or more of the seven tests.

RESULTS: The CABG surgery patients performed significantly worse than the control group on all tests except the Grooved Pegboard test (nondominant). When analyzed by group, performance on the verbal learning test was the most impaired. Cognitive impairment was present in 122 (35%) of CABG surgery patients before their procedure. Prior myocardial infarction, age, and IQ were independent predictors of cognitive impairment.

CONCLUSIONS: Cognitive impairment is prevalent in patients presenting for CABG surgery. Impaired cognition before surgery must be considered when assessing the effects of CABG surgery on cognitive performance.

 

行扁桃體摘除術或增殖腺扁桃體摘除術的小兒患者使用地塞米松(0.0625-0.1mg/kg)預防嘔吐、減輕疼痛、縮短首次攝入液體的時間和聲音改的發生率沒有量遞增效應

There Is No Dose-Escalation Response to Dexamethasone (0.0625–1.0 mg/kg) in Pediatric Tonsillectomy or Adenotonsillectomy Patients for Preventing Vomiting, Reducing Pain, Shortening Time to First Liquid Intake, or the Incidence of Voice Change

Michelle S. Kim, MD*, Charles J. Coté, MD{dagger}, Carmen Cristoloveanu, MD{ddagger}, Andrew G. Roth, MD{ddagger}, Polina Vornov, MD{ddagger}, Melissa A. Jennings, RN*{ddagger}, John P. Maddalozzo, MD, and Cristine Sullivan, MBA, MS||

From the *Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; {dagger}Department of Anesthesia and Critical Care, Division of Pediatric Anesthesia, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; {ddagger}Department of Pediatric Anesthesia, Division of Clinical Otolaryngology, ||The Mary Ann and J. Milburn Smith Child Health Research Program, Feinberg School of Medicine, Northwestern University, Children's Memorial Hospital, Chicago, Illinois.

Anesth Analg 2007 104: 1052-1058.

 

背景:如果事先沒有給予預防措施,扁桃體摘除術易出現術後噁心、嘔吐(PONV)。先前已有研究證實某一量的地塞米松可降低PONV的發生率。但影響臨預後的地塞米松最有效量尚未確定。

方法125名患兒入選該隨機、雙盲、前瞻性的地塞米松量遞增研究,量分別為0.06250.1250.251mg/kg,最大量為24mg。用非參數方差分析方法分析治療組術後0-5h5-24h期間嘔吐的發生率Cox Proportional Likelihood Ratio Test用於比較治療組中首次嘔吐的時間和首次疼痛用藥時間。

結果:在整個研究中,5種量的地塞米松對嘔吐發生率無明顯區別。次要治療結果(止痛需求、首次攝取液體時間、聲音化)也無明顯區別。

結論:對於行扁桃體摘除術或增殖腺扁桃體摘除術為預防PONV或降低其他次要治療結果的發生率,給予最低量的地塞米松(0.0625mg/kg)與最高量(1.0mg/kg)一樣有效。這類患兒中,為預防PONV使用高量地塞米松是沒有必要的。

(顧新宇 陳傑 校)

BACKGROUND: Tonsillectomy is associated with postoperative nausea and vomiting (PONV) if no prophylaxis is administered. Previous studies have shown that a single dose of dexamethasone decreases the incidence of PONV. The most effective dose of dexamethasone to affect clinical outcome is yet to be defined.

METHODS: One-hundred-twenty-five children were enrolled in a double-blind, prospective, randomized, dose-escalating study of dexamethasone: 0.0625, 0.125, 0.25, 0.5, or 1 mg/kg, maximum dose 24 mg. Nonparametric ANOVA was used to analyze the incidence of vomiting by treatment group for 0 to ≤5 h, >5 to 24 h. The Cox Proportional Likelihood Ratio Test was used to compare the time of first vomit and time to first pain medication across treatment groups.

RESULTS: There was no difference in the incidence of vomiting for the five escalating doses of dexamethasone in the time period. There were no differences in secondary outcomes (analgesic requirements, time to first liquid, and change in voice) across treatment groups.

CONCLUSION: We conclude that the lowest dose of dexamethasone (0.0625 mg/kg) was as effective as the highest dose of dexamethasone (1.0 mg/kg) for preventing PONV or reducing the incidence of other secondary outcomes following tonsillectomy or adenotonsillectomy. There is no justification for the use of high-dose dexamethasone for the prevention of PONV in this cohort of children.

 

神經激肽1NK1)拮Aprepitant與昂丹司預防術後噁心嘔吐的一項隨機雙盲比較研究

A Randomized, Double-Blind Comparison of the NK1 Antagonist, Aprepitant, Versus Ondansetron for the Prevention of Postoperative Nausea and Vomiting

Tong J. Gan, MD*, Christian C. Apfel, MD, PhD{dagger}, Anthony Kovac, MD{ddagger}, Beverly K. Philip, MD, Neil Singla, MD, PhD||, Harold Minkowitz, MD, Ashraf S. Habib, MBBCh, MSc, FRCA*, Jennifer Knighton, MS#, Alexandra D. Carides, PhD#, Hong Zhang, PhD#, Kevin J. Horgan, MD#, Judith K. Evans, MD#, Francasca C. Lawson, MD#, and The Aprepitant-PONV Study Group**

From the *Department of Anesthesiology, Duke University Medical Centre, Durham, North Carolina; {dagger}Department of Anesthesiology and Perioperative Care, University of California, San Francisco, Medical Center at Mt. Zion, San Francisco, California; {ddagger}University of Kansas Medical Center, Kansas City, Kansas; Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts; ||Huntington Memorial Hospital, Clinical Management Services, Inc., Pasadena, California; ¶Memorial Hermann Memorial City Hospital, Houston, TX; and #Merck Research Laboratories, Blue Bell, Pennsylvania.

Anesth Analg 2007 104: 1082-1089.

 

背景:目前使用的止吐藥並不完全有效,NK1受體拮是一種新型的止吐藥,它對化療誘發的噁心嘔吐有確切效果。本研究首次評估NK1受體拮Aprepitant對術後噁心嘔吐的療效和耐受性。

方法在此項多中心、雙盲試驗中,805名患者術前隨機分別給予Aprepitant 40mg口服或, Aprepitant125mg口服,或昂丹司4mg靜注,行全麻下開腹手術。評估術後48h噁心、嘔吐的發生使用治療藥物。使用邏輯回歸方法比較。

結果:各組間主要治療終點(術後 0-24h沒有嘔吐並無需治療藥物)發生率沒有顯著差異,比例分別為Aprepitant 40mg45% Aprepitant 125 mg 組為43%,昂丹司4mg組為42%。無嘔吐率Aprepitant 40mg組(90%), Aprepitant125mg組(95%)(0-24h)較昂丹司4mg 組(74%)高(p<0.001)。但嘔吐治療藥物使用與否以噁心的控制並無顯著差異。0-48h期間Aprepitant兩種量下無嘔吐發生率也較高(p<0.001)。治療過程中副反應無顯著差異。

結論:在術後第一個24h 48hAprepitant比昂丹司預防嘔吐更有效。但嘔吐治療藥物噁心的控制並無顯著差異。

(宋翠俠 陳傑 校)

BACKGROUND: Antiemetics currently in use are not totally effective. Neurokinin-1 receptor antagonists are a new class of antiemetic that have shown promise for chemotherapy-induced nausea and vomiting. This is the first study evaluating the efficacy and tolerability of the neurokinin-1 receptor antagonist, aprepitant, for the prevention of postoperative nausea and vomiting.

METHODS: In this multicenter, double-blind trial, we randomly assigned 805 patients receiving general anesthesia for open abdominal surgery to a preoperative dose of aprepitant 40 mg orally, aprepitant 125 mg orally, or ondansetron 4 mg IV. Vomiting, nausea, and use of rescue therapy were assessed over 48 h after surgery. Treatments were compared using logistic regression.

RESULTS: Incidence rates for the primary end point (complete response [no vomiting and no use of rescue] over 0–24 h after surgery, tested for superiority of aprepitant) were not different across groups (45% with aprepitant 40 mg, 43% with aprepitant 125 mg, and 42% with ondansetron). The incidence of no vomiting (0–24 h) was higher with aprepitant 40 mg (90%) and aprepitant 125 mg (95%) versus ondansetron (74%) (P < 0.001 for both comparisons), although between-treatment use of rescue and nausea control was not different. Both aprepitant doses also had higher incidences of no vomiting over 0–48 h (P < 0.001). No statistically significant differences were seen among the side effect profiles of the treatments.

CONCLUSIONS: Aprepitant was superior to ondansetron for prevention of vomiting in the first 24 and 48 h, but no significant differences were observed between aprepitant and ondansetron for nausea control, use of rescue, or complete response.

 

太尼對卵白蛋白致敏的大鼠氣道的收縮效應的影響

The Effects of Fentanyl on the Contractile Response of Ovalbumin-Sensitized Rat Trachea

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

From the Department of Anesthesiology, Nagasaki University School of Medicine, Nagasaki 852-8501, Japan.

Anesth Analg 2007 104: 1103-1108.

 

背景:太尼是否會引起氣道高反應性至仍不明確。本文作者研究了太尼對卵白蛋白(OA)致敏的大鼠氣道的收縮效應的影響。

方法10ugOA與佐混合後通過腹腔內注射使大鼠致敏。15天后,將大鼠氣道切成3毫米寬的環形管道。測量OA導致氣道張度,並且研究應用納絡酮時太尼作用。第二步研究膽鹼能神經和血清素在收縮反應中的作用,通過河豚毒素和酮舍林研究太尼的作用。最後研究致敏大鼠機械通氣情況下,注射OA前後呼吸系統的阻。

結果:太尼量依賴性地弱OA導致的收縮效應,納絡酮可部分拮太尼這一作用。河豚毒素和酮舍林都可以弱OA引起的收縮效應。河豚毒素存在的情況下,太尼的作用並不會因此增強。而存在酮舍林時,OA導致的收縮效應幾乎都被太尼拮了。OA增高致敏大鼠呼吸系統阻,這一效應可被太尼弱。

結論:太尼通過阻斷氣道平滑肌膽鹼能神經弱了致敏大鼠氣道高反應性。

(鄭麗 陳傑 校)

BACKGROUND: It is not clear whether fentanyl affects a hyperresponsive airway. We examined the effects of fentanyl on the contractile response of ovalbumin (OA)-sensitized rat tracheas.

METHODS: Rats were sensitized with a single intraperitoneal injection of 10 µg of OA mixed with adjuvant. Fourteen days later, the trachea was cut into 3-mm-wide rings. The OA-induced tension was measured, and the effects of fentanyl were studied in the presence of naloxone. Second, the role of cholinergic nerves and serotonin in the contraction and the effects of fentanyl were examined using tetrodotoxin and ketanserin. Third, lungs of sensitized rats were ventilated, and respiratory system resistance was calculated before and after the administration of OA in the presence of fentanyl.

RESULTS: Fentanyl dose-dependently attenuated the OA-induced contraction, and naloxone partly reversed it. Both tetrodotoxin and ketanserin attenuated the contraction. Fentanyl had no further effect on the contraction in the presence of tetrodotoxin, whereas the contraction was nearly abolished by fentanyl in the presence of ketanserin. OA increased respiratory system resistance in sensitized rats, and this effect was attenuated by fentanyl.

CONCLUSIONS: Fentanyl attenuates the airway hyperresponsiveness of sensitized rat trachea through the inhibition of cholinergic nerves on the smooth muscle.

 

左布比卡因與麥糖基-ß-環精聯合應用可以延長大鼠鞘內和坐骨神經阻滯的時間

Prolongation of Intrathecal and Sciatic Nerve Blocks Using a Complex of Levobupivacaine with Maltosyl-ß-Cyclodextrin in Rats

Ken Karashima, MD*, Masahiko Taniguchi, MD, PhD*, Tadashi Nakamura, MD*, Mayumi Takasaki, MD, PhD*, Kanako Matsuo, MS{dagger}, Mitsuru Irikura, PhD{dagger}, and Tetsumi Irie, PhD{dagger}

From the *Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, Kiyotake, Miyazaki, Japan; and {dagger}Division of Clinical Chemistry and Informatics, Graduate School of Medical and Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan.

Anesth Analg 2007 104: 1121-1128.

背景:作者用環精為基礎的給藥系統包括左布比卡因聯合麥糖基-ß-環精(G2-ß-CD)應用於大鼠的神經和坐骨神經阻滯以研究是否延長局部麻醉作用的時間。

方法:大鼠隨機分為四組(每組六個),分別接受30µL1%左布比卡因聯合0(對照組),50, 100, 200 mM G2-ß-CD應用于腰麻。研究腰麻後肌張和尾部擺動的潛伏期。另外四組大鼠(每組六個)分別接受0.5% 1%左布比卡因聯合0100 mM G2-ß-CD行坐骨神經阻滯。研究給藥到坐骨神經阻滯期間本體感受,運動能和傷害感受的化。

結果:腰麻組,所有的大鼠在注射局麻藥後立即停止尾部擺動。1%左布比卡因聯合100 mM (80.0 ± 8.9 min) 200 mM (91.7 ± 7.0 min) G2-ß-CD的肌張恢復平均時間比對照組(38.3 ± 3.1 min)明顯延長,但是尾部擺動潛伏期沒有延長。坐骨神經阻滯組,所有的大鼠在左旋布比卡因注射後暫時不動。0.5%左旋布比卡因聯合 100 mM G2-ß-CD麻醉作用時間是單純應用0.5%左旋布比卡因的兩倍,1%左旋布比卡因聯合 100 mM G2-ß-CD麻醉作用時間是單純應用1%左旋布比卡因的1.4倍。

結論:左旋布比卡因聯合應用G2-ß-CD可以延長大鼠左旋布比卡因在腰麻和坐骨神經阻滯的麻醉作用時間

(張美榮 陳傑 校)

BACKGROUND: We used a cyclodextrin-based drug delivery system, consisting of levobupivacaine complexed with maltosyl-ß-cyclodextrin (G2-ß-CD), in spinal and sciatic nerve blocks in rats to investigate prolongation of the local anesthetic effect.

METHODS: Rats were assigned to four groups (n = 6 in each) and received intrathecally 30 µL of 1% levobupivacaine complexed with 0 (control), 50, 100, or 200 mM of G2-ß-CD. Muscle tone and tail flick latency were studied after intrathecal administration. Four more groups (n = 6) of rats received a sciatic nerve block with 0.5% or 1% levobupivacaine complexed with either 0 or 100 mM of G2-ß-CD. The time course of changes in proprioception, motor function, and nociception after circumferential subcutaneous administration to the sciatic nerve was examined.

RESULTS: With the intrathecal block, all rats stopped tail movement immediately after injection of the local anesthetic. The mean time to recovery of muscle tone with 1% levobupivacaine complexed with 100 mM (80.0 ± 8.9 min) and 200 mM (91.7 ± 7.0 min) of G2-ß-CD was significantly longer than that of the control group (38.3 ± 3.1 min), but tail flick latency was not prolonged. With the sciatic nerve block, all rats were temporarily immobilized after levobupivacaine injection. The anesthetic effects of 0.5% levobupivacaine with 100 mM of G2-ß-CD were twice as long as those for 0.5% levobupivacaine alone, and those of 1% levobupivacaine with 100 mM of G2-ß-CD were 1.4 times longer than those for 1% levobupivacaine alone.

CONCLUSIONS: The complex of levobupivacaine with G2-ß-CD prolonged the anesthetic effect of levobupivacaine in both intrathecal and sciatic nerve blocks in rats.


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雙頻指數(BIS)引導下的全身麻醉合併胸段硬膜外鎮痛可減少快通道結腸手術的恢復時間

Bispectral Index-Guided General Anesthesia in Combination with Thoracic Epidural Analgesia Reduces Recovery Time in Fast-Track Colon Surgery

Jochen Mayer, MD*, Joachim Boldt, MD, PhD*, Alexander Schellhaaß, MD*, Björn Hiller, MD{dagger}, and Stefan W. Suttner, MD*

From the *Department of Anesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen, Germany and {dagger}Department of General Surgery, Klinikum Ludwigshafen, Germany.

Anesth Analg 2007 104: 1145-1149.

 

背景: BIS引導下全身麻醉的恢復的因素已在不同人群中得以評估。使用BIS的處是不一致的。作者設計了此項研究,以評估BIS引導下的全身麻醉對要求快通道腸道手術的價值。

方法:44例接受開腹結腸切除術的病人隨機分成兩組:BIS-引導組(BIS , n = 22)或臨引導組(常規監護組, n = 22),均在放置硬膜外導管後靜脈注射丙酚。在術後監護室期間,對拔管時間,藥物費用,血流動學異常的發生率,術後當天下活動的能,以病人對整個麻醉過程的滿意度等方面進行評估。

結果:BIS-引導組,拔管時間明顯較早(7.6 vs. 15.4 min, P < 0.01) ,術後監護室的滯留時間明顯縮短 (51 vs. 85 min, P < 0.01)。所有的麻醉用藥費用減少了23% ,且需處理的低血壓發生率在BIS組也明顯較低。而下活動能,麻醉滿意度,併發症的發生率兩組間無明顯差異。

結論: BIS-引導組靜脈麻醉合併硬膜外鎮痛易於迅速恢復並減少快通道結腸手術病人的醫療支出。
(衛紅 陳傑 校)

BACKGROUND: The impact of bispectral index (BIS)-guided general anesthesia on recovery from general anesthesia has been evaluated in different patient populations. The benefit of using BIS has been inconsistent. We designed this study to examine the value of BIS-guided anesthesia in a fast-track setting where the goal is rapid recovery.

METHODS: Forty-four patients undergoing open colon resection were randomly assigned to receive either BIS-guided (BIS group, n = 22) or clinically guided (standard care group, n = 22) total IV anesthesia with propofol after placing a thoracic epidural catheter. Duration of postanesthesia care unit stay, time to tracheal extubation, direct drug cost, the incidence of hemodynamic abnormalities, ability of ambulation on the day of surgery, and patient satisfaction with anesthetic management were assessed.

RESULTS: In the BIS-guided group, tracheal extubation was achieved significantly earlier (7.6 vs. 15.4 min, P < 0.01) and the postanesthesia care unit stay was significantly shorter (51 vs. 85 min, P < 0.01). Total anesthetic drug cost was reduced by 23% and the incidence of hypotension requiring treatment was significantly lower in the BIS group. Early ambulation, patient satisfaction, and incidence of adverse events were not significantly different between the groups.

CONCLUSIONS: BIS-guided IV anesthesia in combination with thoracic epidural analgesia facilitates rapid recovery and reduces the overall cost of care in patients undergoing fast-track colon surgery.

 

σ受體激動通過保護bcl-2而具有離體神經保護作用

Sigma Receptor Agonists Provide Neuroprotection In Vitro by Preserving bcl-2

Sufang Yang, MD*, Anish Bhardwaj, MD{dagger}{ddagger}, Jian Cheng, PhD*, Nabil J. Alkayed, MD, PhD*, Patricia D. Hurn, PhD*, and Jeffrey R. Kirsch, MD*

From the Department of *Anesthesiology and Peri-operative Medicine, Oregon Health and Science University, Portland, Oregon; {dagger}Department of Neurology; and {ddagger}Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Anesth Analg 2007 104: 1179-1184.

背景:在幾種動物中,σ受體激動可減弱實驗性局部腦缺血後的腦損傷,作者檢測了經典σ1受體激動,4-苯丁基呱啶(PPBP)可通過某個機制包括細胞凋亡蛋白bcl-2保護神經的假說。

方法:將原始的皮質神經培物暴露在無氧-葡萄糖(OGD)或谷氨酸(100um)下2h。在創傷前15分鐘開始使用PPBP或創傷後15分鐘開始並持續24h。在另一組試驗中,培的神經在用PPBP治療前2h以量依賴模式使用σ1受體拮林卡唑。使用鈣黃綠素-AM和丙碘化物特異性的監測存活和死亡的細胞。bcl-2bax的表達通過定量即時聚合酶鏈逆轉錄和western blotting法測定,並通過TUNEL染色法檢測DNA損傷。

結果PPBP的提前治療可減輕OGD或谷氨酸(50100um)誘發的腦損傷,這個保護作用可被林卡唑逆轉(細胞死亡率:OGD48±2%OGD±PPBP 31±3%OGD±PPBP+林卡唑 46±2%)。PPBP治療提高bcl-2而不是baxMRNA水準。PPBP保護OGD損傷後的bcl-2蛋白作用可被林卡唑完全消除。最後,PPBP可降低OGD損傷後的TUNEL細胞數量,這提示少數細胞具有明顯的DNA損傷。

結論:這些資料顯示PPBP通過保護性基因如bcl-2產生保護作用而減少細胞死亡。

(丁震敏 陳傑 校)

BACKGROUND: Sigma ({sigma})-receptor agonists attenuate brain injury after experimental focal cerebral ischemia in several species. We tested the hypothesis that the potent, prototypical {sigma}1-receptor agonist, 4-phenyl-1-(4-phenylbutyl) piperidine (PPBP), protects neurons by a mechanism involving the antiapoptotic protein bcl-2.

METHODS: Primary cortical neuronal cultures were exposed to either 2 h of oxygen–glucose deprivation (OGD) or glutamate (100 µM). PPBP treatment was initiated either 15 min prior to the insult or at 15 min postinsult then continued for 24 h. In another set of experiments, cultured neurons were preincubated for 2 h prior to PPBP treatment with {sigma}1-receptor antagonist, rimcazole, in a dose-dependent manner. Alive and dead cells were detected with calcein-AM and propidium iodide respectively. Bcl-2 and bax expression were determined by quantitative real time reverse transcription polymerase chain reaction and western blotting, and DNA damage was detected by TUNEL staining.

RESULTS: PPBP pretreatment attenuated neuronal injury induced by OGD or glutamate (50 or 100 µM). This protection was reversed with rimcazole (cell death: OGD 48 ± 2%, OGD plus PPBP 31 ± 3%, OGD plus PPBP with rimcazole 46 ± 2%). PPBP treatment increased bcl-2 but not bax mRNA levels. PPBP's ability to preserve bcl-2 protein after OGD by PPBP was fully abolished by rimcazole. Lastly, PPBP reduced the number of TUNEL-positive cells after OGD, suggesting fewer cells with overt DNA damage.

CONCLUSIONS: These data demonstrate that PPBP reduces cell death in vitro by a mechanism involving receptor-dependent preservation of protective genes such as bcl-2

 

環狀軟骨施壓妨礙麻醉狀態下患者ProSeal喉罩的插入和通氣

Cricoid Pressure Impedes Insertion of, and Ventilation Through, the ProSeal Laryngeal Mask Airway in Anesthetized, Paralyzed Patients

Cheng W. Li, PhD, Fu S. Xue, MD, Ya C. Xu, MD, Yi Liu, MD, Peng Mao, MD, Kun P. Liu, MD, Quan Y. Yang, MD, Guo H. Zhang, PhD, and Hai T. Sun, MD

From the Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.

Anesth Analg 2007 104: 1195-1198.

背景:作者設計了一項前瞻性的對照研究,用以評估麻醉患者中環狀軟骨施壓是否影響喉罩(ProSeal LMA)的插入和通氣。

方法:麻醉誘導後,使用前端帶有環狀軟骨壓的指引工具幫喉罩(ProSeal LMA)盡可能深地插入氣道內,套壓設置為60cmH2O,記錄下通氣量和解剖位置,並記錄氣道封閉壓,然後釋放環狀軟骨壓,喉罩進一步插入氣道重新定位,並再次記錄述資料。

結果:在釋放環狀軟骨壓重新放置的喉罩位置後,肺通氣量、解剖位置和氣道封閉壓都顯著優於通過環狀軟骨壓所確定的喉罩位置(P<0.05)。無論有沒有環狀軟骨壓的存在,間歇正壓通氣的呼出潮氣量是相近的,但吸氣峰壓從帶有環狀軟骨壓時的28cmH2O降低至釋放環狀軟骨壓後的14cmH2OP<0.05)。

結論:使用環狀軟骨施壓妨礙喉罩插到合適的位置,插入喉罩時短暫的釋放環狀軟骨壓可以使得該裝置位於合適位置的前端。當糾正喉罩位置後,環狀軟骨施壓並不改潮氣量,但顯著增吸氣峰壓。

(詹慧 陳傑 校)

BACKGROUND: We designed this prospective self-controlled study to assess whether cricoid pressure hampers placement of and ventilation through the ProSeal laryngeal mask airway (ProSeal LMA) in anesthetized, paralyzed adult patients.

METHODS: After induction of anesthesia, the ProSeal LMA was inserted using the introducer tool with cricoid pressure advanced as far as possible, and the cuff pressure was set at 60 cm H2O. Ventilation adequacy and anatomic position were scored using measures previously described for ProSeal LMA assessment. Airway seal pressure was recorded. Cricoid pressure was then released, the ProSeal LMA further advanced and reseated, and the assessment repeated.

RESULTS: Lung ventilation scores, anatomic position scores, and airway seal pressure were significantly better after release of cricoid pressure and reseating of the ProSeal LMA than in the first position, where the ProSeal LMA was seated with cricoid pressure (P < 0.05). Expiratory tidal volume during intermittent positive pressure ventilation was similar with and without cricoid pressure, but peak inspiratory pressure decreased from 28 cm H2O with cricoid pressure to 14 cm H2O without cricoid pressure (P < 0.05).

CONCLUSIONS: Cricoid pressure applied before insertion hampered proper placement of the ProSeal LMA. Temporary cricoid pressure release during insertion allowed the device to be advanced to the proper position. After correct placement of the ProSeal LMA, application of cricoid pressure did not change tidal volume, but produced a significant increase in peak inspiratory pressure.

 

慢性疼痛個體人的注意和工作記憶痕跡分散

Disruption of Attention and Working Memory Traces in Individuals with Chronic Pain

Bruce D. Dick, PhD*{dagger}{ddagger}, and Saifudin Rashiq, MB, MSc, FRCPC*{ddagger}

From the Departments of *Anesthesiology and Pain Medicine and {dagger}Psychiatry, University of Alberta; and {ddagger}Multidisciplinary Pain Centre, University of Alberta Hospital, Edmonton, AB, Canada.

Anesth Analg 2007 104: 1223-1229.

 

背景:研究已經發現慢性疼痛能夠分散人的注意,而且這種對注意的影響足以導致顯著的能障礙、降低病患的生活品質。作者希望通過這個實驗來測定究竟慢性疼痛在多大程度影響人的注意和記憶。

方法:在患者接受鎮痛治療前後,分別對患者進行電腦化的工作記憶測定和神經心理學的注意測定。

結果:三分之二的慢性疼痛患者的注意評分都在臨損傷的範圍之內。這些結果是不受年齡,教育水準,睡眠品質和疼痛是否減輕等因素的影響。因為有報導藥物治療對評分有潛在的影響,所以藥物治療也被記錄在內。那些高度注意損傷的患者在工作性記憶測試中表現出有顯著的,更大程度的記憶困難。

結論:這些發現提示存在一種特的認知機制:記憶的維持是受慢性疼痛的影響。認知能不被短期的局部鎮痛所改善。

(李惟一 陳傑 校)

BACKGROUND: Research has found that chronic pain disrupts attention and that this disruption can lead to significant functional impairment and decreased quality of life. We conducted the present study to examine how attention and memory are disrupted by chronic pain.

METHODS: Computerized tests of working memory were given to participants with chronic pain along with a neuropsychological test of attention before and after procedures resulting in analgesia.

RESULTS: Two-thirds of participants with chronic pain had scores in the clinically impaired range on attentional tasks. These results were independent of age, education level, sleep disruption, and pain relief. Medication use was also recorded and is reported to account for potential effects of medication on task performance. Those participants with the highest level of impairment had significantly greater difficulties in maintaining a memory trace during a challenging test of working memory.

CONCLUSIONS: These findings point to a specific cognitive mechanism, the maintenance of the memory trace, that is affected by chronic pain during task performance. Cognitive function was not improved by short-term local analgesia.


雌激素通過改暫態型感受器電位-1能從從而放大宮頸擴張導致的疼痛

Estrogen Amplifies Pain Responses to Uterine Cervical Distension in Rats by Altering Transient Receptor Potential-1 Function

Tao Yan, MD, PhD, Baogang Liu, MD, PhD, Dongping Du, MD, PhD, James C. Eisenach, MD, and Chuanyao Tong, MD

From the Department of Anesthesiology and the Center for the Study of Pharmacologic Plasticity in the Presence of Pain, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2007 104: 1246-1250.

 

引言:已知雌激素能增敏疼痛刺激反應,但尚不清楚是否歸因於宮頸的急慢性疼痛。先前的研究顯示興奮暫態型感受器電位-1通道(TRPV1)可增敏內臟器官,而雌激素可增宮頸的TRPV1的表達。本研究測試了雌激素是否能增強大鼠宮頸擴張的反應以是否與TRPV1通道有關。

方法:選擇卵巢切除的大鼠,給予或不給予雌激素,麻醉後記錄不同等級的宮頸擴張時腹壁下神經和腹部肌肉對刺激的的反應。記錄給予TRPV1capsaizepine或該拮載體前後單個腹壁下神經纖維的衝動發放。

結果:給予雌激素治療的宮頸擴張的大鼠的腹部肌肉收縮反射的反應增強。予雌激素治療大鼠宮頸擴張時給予capsaizepine後,腹壁下神經的傳入反射減弱,而未給予雌激素替代的大鼠則沒有述反應。capsaizepine不能減少卵巢切除動物未接受雌激素替代的宮頸擴張的反應。

結論:以資料顯示TRPV1通道對雌激素缺失宮頸的普通牽拉感覺並不重要。相反,TRPV1的能對雌激素誘發的致敏作用有影響。這些資料提出以下可能:自宮頸的急慢性疼痛,比如產程或者癌症,可能被雌激素增強或被TRPV1的拮減弱。

(周懿之 陳傑 校)

INTRODUCTION: Estrogen sensitizes responses to painful stimuli, but its contribution to acute and chronic pain from the uterine cervix is unknown. Previous studies link the excitatory transient receptor potiential-1 channel (TRPV-1) to sensitization in viscera, and show that estrogen increases TRPV-1 expression in afferents from the uterine cervix. Here, we tested whether estrogen enhanced responses to uterine cervical distension in rats, and whether this involved TRPV-1 channels.

METHODS: Ovariectomized rats, with or without estrogen replacement, were anesthetized and hypogastric nerve and abdominal muscle contraction reflex responses to graded uterine cervical distension were recorded. Single unit hypogastric nerve fiber firing was measured before and after acute treatment with the TRPV-1 antagonist, capsaizepine, or vehicle.

RESULTS: Abdominal muscle contraction reflex responses to uterine cervical distension were enhanced in estrogen-treated rats. Hypogastric afferent responses to cervical distension were reduced by capsaizepine in estrogen-treated animals, but were unaffected in ovariectomized animals without estrogen replacement.

CONCLUSIONS: These data suggest that the TRPV-1 channel is unimportant for normal mechanosensation in the cervix in the absence of estrogen, since capsaizepine failed to reduce responses to uterine cervical distension in rats without estrogen replacement. In contrast, TRPV-1 function is important for estrogen-induced sensitization. These data raise the possibility that acute and chronic pain coming from the cervix, such as labor or cancer, may be enhanced by estrogen and might be reduced by antagonists of TRPV-1.


超聲引導下的局部麻醉:最新的觀念與將來的趨勢

Ultrasound-Guided Regional Anesthesia: Current Concepts and Future Trends

Peter Marhofer, MD*, and Vincent W. S. Chan, MD, FRCPC{dagger}

From the *Department of Anaesthesia and Intensive Care Medicine, Medical University Vienna, Vienna, Austria; and {dagger}Department of Anesthesia, University of Toronto, Toronto, Canada.

Anesth Analg 2007 104: 1265-1269.

 

有關超聲引導下的局部麻醉的領域目前發展十分迅速。初步的資料,儘管很有限,但也提示超聲可以提高阻滯成率,降低併發症。在這篇綜述中,作者將介紹超聲顯象的基本原理相關術支援方面的內容,著重闡述一些臨結果,討論超聲引導下的局部麻醉的局限性,思索其對未來臨麻醉的指導作用以該術的輔效。

(衛紅 陳傑 校)

The scope of ultrasound imaging guidance for regional anesthesia is growing rapidly. Preliminary data, although limited, suggest that ultrasound can improve block success rate and decrease complications. In this review, we describe the basic principles of ultrasound scanning and needling techniques for nerve blocks, highlight some of the data on clinical outcome, discuss specific limitations of ultrasound for regional anesthesia, and speculate on the future direction for physician training and competency assessment with this technology.

 

運用超聲術和組織學檢查研究活體豬模型的神經內注射和電刺激

An Ultrasonographic and Histological Study of Intraneural Injection and Electrical Stimulation in Pigs

Vincent W. S. Chan, MD*, Richard Brull, MD*, Colin J. L. McCartney, MB, ChB*, Daquan Xu, MB{dagger}, Sherif Abbas, MD{dagger}, and Patrick Shannon, MSc, MD{ddagger}

From the *Departments of Anesthesia, {ddagger}Pathology, University of Toronto; and {dagger}Department of Anesthesia, Toronto Western Hospital, Ontario, Canada.

Anesth Analg 2007 104: 1281-1284.

 

背景:本實驗作者評估了神經內刺激針最小刺激電流神經內注射的超聲像圖。

方法28頭活體豬的臂叢神經中插入2cm的探針,記錄引起肌肉收縮的最小刺激電流注入5ml染料後超聲像圖。

結果:肌肉收縮的最小刺激電流是0.43mA(範圍0.12-1.8mA)。在28例中24例觀察到神經的膨脹。此24例中,組織學檢查提示有神經外膜的穿透。沒有證據表明在任何神經束存在發育異常。

結論:超聲有於發現神經內注射,大於0.5mA的運動反應不能排除刺激針置入神經內。神經內注射和神經能不全的關係仍不明確。

(李惟一 陳傑 校)

BACKGROUND: In this study we evaluated the minimum stimulating current associated with intraneural needle placement and sonographic appearance of intraneural injection.

METHODS: We inserted a needle 2 cm inside 28 pig nerves (brachial plexus in vivo), recorded the minimum current to elicit a motor response, and injected dye (5 mL) under ultrasound (US) imaging.

RESULTS: The minimum current to elicit a motor response was 0.43 mA (range: 0.12–1.8 mA). Nerve expansion was visualized by US in 24 of 28 nerves. Histology revealed penetration of the epineurium in these same 24 nerves. There was no evidence of dysplasia within the fascicle of any nerve.

CONCLUSIONS: US may prove useful to detect intraneural injection, whereas a motor response above 0.5 mA may not exclude intraneural needle placement. The correlation between intraneural injection and neurological dysfunction remains unclear.


胸科手術單肺通氣過程中壓控制通氣與容量控制通氣的比較

Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for thoracic surgery

M. Carmen Unzueta, J. Ignacio Casas, and M. Victoria Moral

Department of Anesthesiology, Hospital de Sant Pau, Barcelona, Spain.

Anesth Analg 2007 104: 1029-1033.

 

背景:壓控制通氣(PCV)已經成為被推薦的一種方式運用於行胸外科手術單肺通氣(OLV)的病人來改善氧合。在這個實驗中,我們對比了單肺通氣中壓控制通氣模式與容量控制通氣(VCV)模式,觀察PCV是否能改善動脈血氧。方法:58個術前肺能良好的行胸外科手術的病人被隨機分為兩組。A組的病人單肺通氣時先行30分鐘的容量控制通氣,然後再行相同時間的壓控制通氣。B組的病人單肺通氣時先行30分鐘的壓控制通氣,再行相同時間的容量控制通氣。在每種通氣模式的最後測一個氣道壓以動脈血氣。結果:兩種模式下單肺通氣的動脈氧合沒有區別,容量控制模式(Pao2, 206.1 +/- 62.4 mm Hg),壓控制模式(Pao2, 202.1 +/- 56.4 mm Hg; P = 0.534)。氣道壓在壓控制模式比容量控制模式的要低(24.43 +/- 3.42 cm H2O vs. 34.16 +/- 5.21 cm H2O; P < 0.001)。結論:對於肺能情況良好的病人單肺通氣時使用壓控制模式與容量控制模式比較並沒有改善氧供,但是壓控制模式的確可以降低氣道壓。需要做進一步的研究針對患有嚴重的阻塞性或限制性通氣障礙

(張 儷譯 薛張剛校)

BACKGROUND: Pressure-controlled ventilation (PCV) has been suggested as a tool to improve oxygenation during one-lung ventilation (OLV) for patients undergoing thoracic surgery. In this study we investigated whether PCV results in improved arterial oxygenation compared with volume-controlled ventilation (VCV) during OLV. METHODS: Fifty-eight patients with good preoperative pulmonary function scheduled for thoracic surgery were prospectively randomized into two groups. Those in group A underwent OLV initially with VCV for 30 min followed by PCV for a similar period of time. Those in group B underwent OLV initially with PCV for 30 min followed by VCV for a similar duration. Airway pressures and arterial blood gases were obtained during OLV at the end of each ventilatory mode. RESULTS: There were no differences during OLV in arterial oxygenation between VCV (Pao2, 206.1 +/- 62.4 mm Hg) and PCV (Pao2, 202.1 +/- 56.4 mm Hg; P = 0.534). Peak airway pressure was lower with PCV than with VCV (24.43 +/- 3.42 cm H2O vs. 34.16 +/- 5.21 cm H2O; P < 0.001). CONCLUSIONS: The use of PCV during OLV does not lead to improved oxygenation during OLV compared with VCV for patients with good preoperative pulmonary function, but PCV did lead to lower peak airway pressures. Further study is needed for patients with severe obstructive or restrictive pulmonary disease

 

對預行動脈轉接術的新生兒應用血漿B型利鈉肽的時程價值

Time Course and Prognostic Value of Plasma B-type Natriuretic Peptide Concentration in Neonates Undergoing the Arterial Switch Operation

Maxime Cannesson, MD*, Clara Bionda, MD{dagger}, Bruno Gostoli, MD*, Olivier Raisky, MD, PhD{ddagger}, Sylvie di Filippo, MD, PhD, Dominique Bompard, MD*, Catherine Védrinne, MD, PhD*, Robert Rousson, MD, PhD{dagger}, Jean Ninet, MD{ddagger}, Jean Neidecker, MD*, and Jean-Jacques Lehot, MD, PhD*

From the Departments of *Anesthesiology and Intensive Care, {dagger}Biochemistry, {ddagger}Cardiac Surgery, and Pediatric Cardiology, Hospices Civils de Lyon, Louis Pradel Hospital and Claude Bernard Lyon 1 University, Lyon, France.

Address correspondence and reprint requests to Maxime Cannesson, Service d'Anesthésie Réanimation, Hôpital Cardiologique Louis Pradel, 200 avenue du Doyen Lépine, 69500 Bron, France.

Anesth Analg 2007 104: 1059-1065.

 

背景:血漿B型利鈉肽(BNP)可以預防成人心臟外科的術後併發症。我們的目標是調查預行動脈轉接手術(ASO)以使大動脈轉位(TGA)的新生兒的BNP動學程式價值。方法:在30個新生兒中,分別於ASO術前、術後立即、術後6122448小時測量BNP濃度。以手術72小時後病人需要機械通氣或存在低心排量綜合征來確定為有複雜的術後進展。通過研究術後BNP的濃度來預測是否有複雜性進展。結果:氣管插管時間、縮血管藥維持時間、ICU停留時間分別為6848121)小時、7869141)小時9676149)小時。有複雜術後進展的病人術後6小時12小時BNP濃度高於單純進展者〔分別為459 (210–897) vs 137 (67–248) ng/L 547 (193–868) vs 185 (79–354) ng/LP < 0.05〕,並且前者的氣管插管時間、縮血管藥維持時間、ICU停留時間長於後者〔分別為96 (70–190) vs 50 (48–66)小時, 100 (83–190) vs 70 (59–72) 小時, 120 (90–240) vs 84 (72–96) 小時, P < 0.05〕。術後6小時BNP濃度大於160 ng/L作為預測複雜性預後的指標的有93%的敏感度67%的特異度。結論:BNP濃度可以預測行ASO的新生兒的不良預後。這個指標有潛在的臨價值。

(孫 霞譯 薛張綱校)

BACKGROUND: Plasma B-type natriuretic peptide (BNP) can predict postoperative complications after cardiac surgery in adults. Our aim was to investigate BNP kinetics and prognostic value in neonates undergoing the arterial switch operation (ASO) for transposition of the great arteries (TGA). METHODS: We measured BNP concentrations in 30 neonates before, immediately after, and 6, 12, 24, and 48 h after ASO for TGA. Complicated postoperative evolution was defined as patients requiring mechanical ventilation or presenting low cardiac output syndrome for more than 72 h. We studied the ability of postoperative BNP concentrations to predict complicated evolution. RESULTS: Intubation duration, inotropic support duration, and intensive care unit stay were 68 (48–121) h, 78 (69–141) h, and 96 (76–149) h respectively. Patients with complicated evolution had higher 6 and 12-h BNP concentrations than patients with simple evolution (459 (210–897) vs 137 (67–248) ng/L and 547 (193–868) vs 185 (79–354) ng/L respectively; P < 0.05) and had longer intubation, inotropic support, and intensive care unit stay (96 (70–190) vs 50 (48–66) h, 100 (83–190) vs 70 (59–72) h, and 120 (90–240) vs 84 (72–96) h, P < 0.05). A 6-h BNP concentration >160 ng/L was able to predict complicated evolution with a sensitivity of 93% and a specificity of 67%. CONCLUSION: In neonates, BNP concentrations can predict adverse outcome in the postoperative period after ASO for TGA. This marker has potential clinical applications.

 

一些氟化雜環烷(Oxolanes)和雜環丁烷(Oxetanes)的麻醉藥特性

Anesthetic Properties of Some Fluorinated Oxolanes and Oxetanes

Edmond I. Eger, II, MD*, David Lemal, PhD{dagger}, Michael J. Laster, DVM*, Mark Liao, BS*, Katarzyna Jankowska, DVM*, Anilkumar Raghavanpillai, PhD{dagger}, Anatoliy V. Popov, PhD{dagger}, Yonghong Gan, PhD{dagger}, and Yan Lou, MS{dagger}

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California 94143-0464; and {dagger}Department of Chemistry, Dartmouth College, Hanover, New Hampshire 03755-3564.

.Anesth Analg 2007 104: 1090-1097.

 

背景:新的高效吸入麻醉藥的研究進展緩慢,一大原因是現有的兩個出色的藥物,地氟醚和七氟醚。儘管如此,無論地氟醚還是七氟醚都不是最完美的麻醉藥,地氟醚會刺激心肺系統,而七氟醚(儘管迅速)蘇醒較緩慢。七氟醚同時會導致搐和術後興奮。方法和結果:在近期的報導中,我們闡述了31環單氟化醚的理化和麻醉特性。儘管製造了集中新的麻醉藥,但是沒有一個比七氟醚更好。剩餘的醚要麼不穩定,要麼會產生明顯的中樞系統刺激,包括搐。結論:我們發現這些環醚類並沒有顯示出優於地氟醚或七氟醚的地方。

(王時來譯 薛張綱校)

BACKGROUND: The search for new potent inhaled anesthetics has slowed, in large part because of the excellence of the two most recent additions, desflurane and sevoflurane. Nonetheless, neither desflurane nor sevoflurane are ideal anesthetics, desflurane causing cardiorespiratory stimulation, and sevoflurane having a slower (albeit rapid) recovery from anesthesia. Sevoflurane also can produce convulsions and postoperative agitation. METHODS AND RESULTS: In the present report, we describe the physical and anesthetic properties of 31 cyclic ethers halogenated solely with fluorine. Although several produced anesthesia, none had solubilities that would make them better than sevoflurane. The remaining ethers were unstable or produced obvious central nervous system irritation, including convulsions. CONCLUSIONS: We find that none of these cyclic ethers appear to provide advantages over desflurane or sevoflurane.

 

哮喘病人全身應用利多卡因對於氣道張和肺能的影響

The Effects of Systemic Lidocaine on Airway Tone and Pulmonary Function in Asthmatic Subjects

Herng-Yu Sucie Chang, Alkis Togias, and Robert H. Brown

Department of Environmental Health Sciences, The Johns Hopkins University, Baltimore, Maryland 21205, USA

Anesth Analg 2007 104: 1109-1115

 

背景:為了防止哮喘病人反應性的支氣管收縮,局麻藥常常通過氣霧吸入或靜脈途徑作為麻醉輔用藥.利多卡因可弱氣道對引起張增的神經刺激的反應,但是關於利多卡因對基礎氣道張效果的資料卻很少.因此我們就要來測試一下在哮喘病人中,利多卡因對基礎氣道張的效應.方法:CT來分析15個患有哮喘的自願者分別在基礎條件和在輸注利多卡因情況下的小、中、大氣道(直徑分別為2-5,5-8,8mm).同時分析肺泡腔的直徑、肺泡壁厚度和肺能在應用利多卡因前後的化.結果:利多卡因引起1秒肺能測試中用潮氣量的明顯下降(7±2%,P=0.06),與基礎狀態相比,輸注利多卡因也可引起肺泡腔直徑少許但明顯的縮小(-3±-0.5%,P<0.001).並且,第一秒用潮氣量的化和肺泡腔大小的化呈明顯的相關性(r2=0.47,P=0.01).結論:利多卡因能弱氣道對通過感覺神經通路引起支氣管痙攣的藥物的反應,但它並不減小基礎狀態下的氣道張.相反,即使是通過靜脈注射利多卡因,也可明顯地增氣道張,引起氣道狹窄.因此,當用利多卡因來預防由插管導致的支氣管痙攣時,也應該時時通過聽診來檢測氣道狀況.

(施譯,薛張綱校)

BACKGROUND: To prevent reflex-induced bronchoconstriction in patients with asthma, local anesthetics are commonly administered by aerosol or IV as adjunct medication. Lidocaine attenuates responsiveness to a neurally active stimulus that increases tone, but there is scant information about the effect of lidocaine on baseline airway tone. Therefore we examined the effects of IV lidocaine on baseline airway tone in asthmatic subjects. METHODS: Small, medium, and large airways (2-5, 5-8, >8 mm diameter) were analyzed by computed tomography in 15 asthmatic volunteers under baseline conditions and during infusion of lidocaine. Changes in luminal airway diameter and wall thickness from baseline to during lidocaine infusion, and the change in pulmonary function induced by lidocaine, were analyzed. RESULTS: Lidocaine caused a significant decrease in the forced expiratory volume in 1 s pulmonary function measure (7 +/- 2%, P = 0.006). There was also a small but significant decrease in the airway luminal diameter at total lung capacity during lidocaine infusion compared to baseline (-3 +/- 0.5%, P < 0.001). Moreover, there was a significant correlation between the change in forced expiratory volume in 1 s and the change in airway luminal diameter at total lung capacity (r2 = 0.47, P = 0.01). CONCLUSION: Lidocaine, which reduces airway responsiveness to drugs that cause bronchospasm through sensory nerve activation, did not reduce baseline airway tone. Instead, even when administered IV, lidocaine significantly increased airway tone and caused airway narrowing. Therefore, while the administration of lidocaine can prevent intubation-induced bronchospasm, the airways should be constantly monitored by auscultation even during IV lidocaine administration.

 

鼠腦蛋白的七氟醚麻醉效應:一項蛋白質組的時間-過程分析

The Effects of Sevoflurane Anesthesia on Rat Brain Proteins: A Proteomic Time-Course Analysis

Armin Kalenka, MD*, Jochen Hinkelbein, MD*, Robert E. Feldmann, Jr, PhD{dagger}, Wolfgang Kuschinsky, MD{dagger}, Klaus F. Waschke, MD*, and Martin H. Maurer, MD{dagger}

Department of Anesthesiology and Critical Care Medicine, University of Heidelberg, Theodor Kutzer Ufer 1-3, 68167 Mannheim, Germany.

Anesth Analg 2007 104: 1129-1135

 

背景:新近的研究顯示了老鼠在地氟醚麻醉後總計三天的腦蛋白表達的化。在本項研究中,我們觀察到了七氟醚麻醉後長達28天的蛋白質組水準的持續性化的存在。方法:我們讓老鼠處於含2.4%七氟醚的空氣中3小時,讓其自發吸入七氟醚使其麻醉。這些老鼠(每組6個)分別在麻醉後立即、72小時或28天被處死。我們取出死亡老鼠的大腦,並用二維凝膠電子分析儀和聚集光譜測定法繪製全部蛋白表達譜。資料通過方差分析進行統計分析(P<0.01),得出表達因數的一系列雙重改。結果:我們發現麻醉後即刻有11個蛋白質點調節有差別。在麻醉後72小時有17個蛋白質表達有差別。在麻醉後28天只有一個蛋白質點調節有差別。這些調節有差別的蛋白的難以理解的靶向可歸因於突觸間隙泡處理和細胞-細胞傳遞。結論:七氟醚誘導相關的蛋白質表達譜在 1MAC麻醉後即刻和72小時後有改。麻醉後28天,除了一個蛋白質外的所有蛋白質均回到豐度的基線水準。

(陳佳莉譯 薛張綱校)

BACKGROUND: Recent studies showed changes in cerebral protein expression up to 3 days after desflurane anesthesia in rats. In the present study, we investigated the existence of persisting changes on the proteome level after sevoflurane anesthesia that persisted for as long as 28 days after anesthesia. METHODS: Rats were anesthetized by spontaneous inhalation of 2.4% sevoflurane in air for 3 h. Animals (n = 6 for each group) were killed either directly, 72 h, or 28 days after anesthesia. Brains were removed and subjected to global protein expression profiling based on two-dimensional gel electrophoresis and mass spectrometry. Expression factors were compared to results from untreated conscious animals at each time point. Data were statistically analyzed by ANOVA (P < 0.01) and a cut of more than two-fold change in the expression factor. RESULTS: We found 11 protein spots differentially regulated directly after anesthesia. Seventeen proteins were differentially expressed 72 h after the anesthesia. Only one spot was differentially regulated 28 days after anesthesia. The plausible targets of these differentially regulated proteins can be attributed to synaptic vesicle handling and cell–cell communication. CONCLUSIONS: Sevoflurane induced relevant changes in protein expression profiles directly and 72 h after an anesthesia with 1 MAC. Twenty-eight days after the anesthesia, all proteins except one had returned to baseline levels of abundance.

 

星狀神經節的經皮電刺激對創傷病人入院前得脈搏血氧測定信號品質得影響

The Influence of Stellate Ganglion Transcutaneous Electrical Nerve Stimulation on Signal Quality of Pulse Oximetry in Prehospital Trauma Care

Renate Barker, MD, Thomas Lang, MD, Helmut Hager, MD, Barbara Steinlechner, MD, Klaus Hoerauf, MD, Michael Zimpfer, MD, and Alexander Kober, MD

From the Department of Anesthesia and General Intensive Care, Medical University of Vienna, Vienna, Austria.

Anesth Analg 2007 104: 1150-1153.

 

背景:準確的外周動脈血氧飽和度監測是住院前急診的重要工具。這種監測要求有適當的體積描記的搏動。信號的品質會因為外周環境的低溫造成血管收縮而降低。阻斷星狀神經節可以改善外周血管的灌注,可以通過直接輸液或經皮神經電刺激(TENS)實現。我們評估了星狀神經節經皮神經電刺激是否可以減少血管收縮,從而改善外周脈搏血氧定量測定的信號監測品質。方法:我們研究了53名因輕微創傷而送往醫院的病人。我們記錄了病人的生命體症,包括送往醫院前和之後中心和皮膚溫度。脈搏氧飽和度感受器夾在病人兩隻手的第二個手指。一側的星狀神經節的TENS在開始送往醫院途中進行。脈搏血氧定量監測會因為信號過低而報警,並且雙側分開記錄。 結果:相比於另一測,進行TENS一側的手的報警顯著減少(TENS側平均報警次數是 3.1 [1–15],相比於另一側的8.8 [1–28] P < 0.05)。失控持續時間也縮短(進行TENS一側持續時間平均為77 [16–239] s ,相比於另一側的333 [78–1002] s) 結論:資料顯示通過TENS阻斷星狀神經節可以改善入院前病人的外周脈搏血氧測定的品質。

(陳珺珺譯 薛張綱校)

BACKGROUND: Accurate monitoring of the peripheral arterial oxygen saturation has become an important tool in the prehospital emergency medicine. This monitoring requires an adequate plethysmographic pulsation. Signal quality is diminished by cold ambient temperature due to vasoconstriction. Blockade of the stellate ganglion can improve peripheral vascular perfusion and can be achieved by direct injection or transcutaneous electrical nerve stimulation (TENS) stimulation. We evaluated whether TENS on the stellate ganglion would reduce vasoconstriction and thereby improve signal detection quality of peripheral pulse oximetry. METHODS: In our study, 53 patients with minor trauma who required transport to the hospital were enrolled. We recorded vital signs, including core and skin temperature before and after transport to the hospital. Pulse oximetry sensors were attached to the patient’s second finger on both hands. TENS of the stellate ganglion was started on one side after the beginning of the transport. Pulse oximeter alerts, due to poor signal detection, were recorded for each side separately. RESULTS: On the hand treated with TENS we detected a significant reduction of alerts compared to the other side (mean alerts TENS 3.1 [1–15] versus control side 8.8 [1–28] P < 0.05). The duration of dropouts was shorter as well (mean duration TENS 77 [16–239] s versus control side 333 [78–1002] s). CONCLUSION: The data indicate that blockade of the stellate ganglion with TENS improves signal quality of pulse oximeters in the prehospital setting.

 

催眠 與外科 :過去,現在和將來

Hypnosis and surgery: past, present, and future

Wobst AH

Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610-0254, USA.

Anesth analg, 2007 may; 104(5):1199-208

 

催眠曾經被認為是一種主觀狀態的感應,通過暗示可以引出知覺或記憶的改。自從18世紀第一次公眾證實了由Mesmer實驗的“動物吸引(animal magne- tism)”現象,這種利用心理學工具已經極大地吸引著醫學界和公眾的眼球。運用催眠來改疼痛的感覺和記憶可以追溯到幾世紀以前。然而完全理解這種心理暗示其與麻醉學中藥理學的對比卻鮮有進展。目前,由於催眠似乎能夠輔和可能強有知覺的鎮靜,因此引起了很大的興趣。當代臨研究者聲稱聯合鎮痛與催眠運用於小的外科手術較傳統的藥理麻醉更有優,患者和外科醫生之間更有親切感。疼痛通路的基本研究涉到疼痛屈曲反射和正電子發射x線斷層掃描,它們可以產生與催眠相關聯的生理學反應的客觀資料。本文,我們回顧了這種古老的治療性工具——暗示的量——的歷史、基礎和臨研究以現代實踐運用。

(吳德華譯 薛張綱校)

Hypnosis has been defined as the induction of a subjective state in which alterations of perception or memory can be elicited by suggestion. Ever since the first public demonstrations of "animal magnetism" by Mesmer in the 18th century, the use of this psychological tool has fascinated the medical community and public alike. The application of hypnosis to alter pain perception and memory dates back centuries. Yet little progress has been made to fully comprehend or appreciate its potential compared to the pharmacologic advances in anesthesiology. Recently, hypnosis has aroused interest, as hypnosis seems to complement and possibly enhance conscious sedation. Contemporary clinical investigators claim that the combination of analgesia and hypnosis is superior to conventional pharmacologic anesthesia for minor surgical cases, with patients and surgeons responding favorably. Simultaneously, basic research of pain pathways involving the nociceptive flexion reflex and positron emission tomography has yielded objective data regarding the physiologic correlates of hypnosis. In this article I review the history, basic scientific and clinical studies, and modern practical considerations of one of the oldest therapeutical tools: the power of suggestion.

 

外周神經應用辣椒素類似物可預防環紮大鼠坐骨神經造成的痛覺過敏

Perineural resiniferatoxin prevents the development of hyperalgesia produced by loose ligation of the sciatic nerve in rat

Kissin I, Freitas CF, Bradley EL Jr.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.

Anesth Analg. 2007 104(5):1210-6

 

背景:辣椒素受體(TRPV1)存在于外周神經纖維中;受辣椒素刺激,介導降鈣素基因相關肽其他神經肽的釋放,參與神經炎症反應。另一方面,神經損傷後釋放多種炎症介質,也能啟動或致敏TRPV1受體。這些發現提示阻斷TRPV1受體有預防神經病的保護作用。本研究檢測了一個假說,即外周神經應用辣椒素類似物(RTX)能阻止大鼠坐骨神經環紮鬆帶造成的痛覺過敏的進展。方法:在雄性Sprague-Dawley大鼠坐骨神經處,經皮注射單次量的RTX0.0005%,0.1ml)或對照,3h後行手術,環繞注藥神經放置四條鬆帶。評估對傷害性熱刺激的反應(縮爪潛伏期、爪時間)、對反復von Frey filaments刺激的反應後爪姿勢的改(展趾,蹠屈,外旋)。結果:術前外周神經應用RTX可完全防止環紮導致的縮爪潛伏期縮短、爪時間的增和對von Frey filaments刺激的縮爪頻率增。RTX還表現出對後爪姿勢不足進展的預防作用,但不完全,例如,術後7天,爪姿勢積分(0-6RTX組為1.69+/-0.92而對照組為4.06+/-1.68P<0.005)。在已發生神經病的背景下應用RTX作用有限,熱痛覺減退持續時間相對較短。結論:外周神經應用RTX能阻止坐骨神經環紮鬆帶所致神經病的進展。有望通過外周用藥經TRPV1受體途徑預防外周神經術後的神經性疼痛。

(羅 璿譯 薛張綱校)

BACKGROUND: The vanilloid receptors (TRPV1) are found in peripheral nerve fibers; their stimulation by capsaicin leads to release of calcitonin gene-related peptide and other neuropeptides participating in neuroinflammation. On the other hand, various inflammatory mediators, released after nerve damage, can activate or sensitize the TRPV1 receptors. These findings together suggest a protective effect of TRPV1 receptor blockade in neuropathy. In the present study, we tested the hypothesis that perineural resiniferatoxin (RTX) can prevent the development of hyperalgesia caused by placing loosely constrictive ligatures around the sciatic nerve. METHODS: Male Sprague-Dawley rats received a single percutaneous injection of RTX (0.0005%, 0.1 mL) or vehicle at the sciatic nerve, and underwent surgery 3 h later to place four loose ligatures around the nerve on the side of drug administration. Responses to noxious heat (withdrawal latency, paw-lift duration), repetitive stimulation with von Frey filaments, and changes in hindpaw posture (toe spread, ventroflexion, and foot exorotation) were assessed. RESULTS: Perineural RTX administered before surgery completely prevented ligation-induced reduction in withdrawal latency, increase in paw lift duration and increase in withdrawal frequency to von Frey filaments. The preventive effect of RTX on the development of deficits in hindpaw posture was pronounced but not complete, e.g., on day 7 after surgery, the cumulative paw-posture score (0-6) was 1.69 +/- 0.92 with RTX and 4.06 +/- 1.68 with vehicle (P < 0.005). The effect of RTX used against the background of already developed neuropathy was limited to thermal hypoalgesia lasting for a relatively short period. CONCLUSION: Perineural RTX prevents the development of neuropathy caused by placing loosely constrictive ligatures on the sciatic nerve. Perioperative use of drugs acting via the TRPV1 receptors may hold the promise for preventing neuropathic pain after surgery on peripheral nerves.

 

全膝關節置換術後硬膜外可樂定鎮痛的量效學研究

Epidural Clonidine for Postoperative Pain After Total Knee Arthroplasty: A Dose–Response Study

Yuan-Shiou Huang, MD*, Liu-Chi Lin, MD{dagger}, Billy K. Huh, MD, PhD{ddagger}, Michael J. Sheen, MD*, Chun-Chang Yeh, MD*, Chih-Shung Wong, MD, PhD*, and Ching-Tang Wu, MD*

From the Departments of *Anesthesiology, {dagger}Orthopaedics, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, Republic of China; and {ddagger}Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2007;104:1230-1235

 

背景:聯合可樂定,局麻藥和阿片類藥物可以改善膝關節置換術後硬膜外鎮痛效果.在這項研究中,我們想要測定可以提供最佳鎮痛效果以最小副作用的硬膜外可樂定量.方法:八十個接受全膝關節置換術的病人, ASA 評分在I–III,被隨機分成四組,每組20個人.每一個病人都接受相同的硬膜外麻醉操作.手術後, C0, C1, C2, C4組接受PCEA,使用可樂定(各組的可樂定濃度分別為0,1.0, 2.0,4.0ug/ml)0.1的嗎啡入0.2%的羅呱卡因.鎮痛效果的評估包括了兩個方面,PCEA消耗的容量,疼痛範圍視覺模型所測定的術後第1,2,4,12, 24, 48, 72個小在靜息以活動時的疼痛程度.術後記錄72小時內的收縮壓,心率,鎮靜,感覺和運動阻斷情況.結果:C0,C1,C2,C4組得PCEA用量分別為71.8 ± 19.5 mL, 49.6 ± 12.3 mL, 48.1 ± 9.3 mL, and 39.4 ± 9.0 mL.使用可樂定組的患者術後疼痛發生明顯減少(P = 0.002).C4,四位病人的感覺阻滯時間延長,一位病人同時出現深度鎮靜以感覺運動阻滯時間延長.在鎮痛費,沒有顯著的統計學差異(P = 0.78),而且發現C1C2組病人之間疼痛程度有顯著差異(P=0.06).結論:與嗎啡和羅呱卡因配伍硬膜外術後鎮痛,可樂定鎮痛最佳濃度為1.0 µg/mL

(王光妍譯 薛張綱校)

BACKGROUND: Combinations of epidural clonidine, local anesthetics, and opioids have improved postoperative analgesia after total knee arthroplasty. In this study we sought to determine the optimal epidural bolus dose of clonidine, which provides the best analgesia and fewest side effects.METHODS: Eighty ASA I–III patients, who underwent total knee arthroplasty were randomly assigned to one of four groups of 20 patients each. Identical epidural anesthesia procedures were used for all groups. After surgery, groups C0, C1, C2, and C4 received patient-controlled epidural analgesia (PCEA) with clonidine (0, 1.0, 2.0, or 4.0 µg/mL, respectively) and morphine (0.1 mg/mL) in 0.2% ropivacaine. The analgesia effect was estimated by PCEA consumption volume and visual analog pain scale at rest and with movement at 1, 2, 4, 12, 24, 48, and 72 h after surgery. Systolic blood pressure, heart rate, sedation, and sensory and motor blockade were also recorded for 72 h after surgery.RESULTS: The PCEA consumption volume for groups C0, C1, C2, and C4 were 71.8 ± 19.5 mL, 49.6 ± 12.3 mL, 48.1 ± 9.3 mL, and 39.4 ± 9.0 mL, respectively. The clonidine groups experienced less postoperative pain (P = 0.002). In the C4 group, four patients had prolonged sensory blockade and one patient had both severe sedation and prolonged sensory motor blockade. No significant statistical difference in analgesic consumption (P = 0.78) and pain intensity (P = 0.66) between groups C1 and C2 were noted. CONCLUSIONS: The optimal amount of epidural clonidine in a solution of morphine and ropivacaine.

 

右美沙去甲右美沙在小鼠表皮浸潤止痛中具有局部麻醉作用

Dextromethorphan or dextrorphan have a local anesthetic effect on infiltrative cutaneous analgesia in rats.

Chen YW, Chu KS, Lin CN, Tzeng JI, Chu CC, Lin MT, Wang JJ.

Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan.

Anesth Analg 2007 104: 1251-1255.

 

背景:右美沙阻斷了局部麻醉的靶位元點鈉通道。在研究當中我們評價右美沙是否具有局部麻醉作用。方法:我們將右美沙其活性代謝產物去甲右美沙和利多卡因分別注射小鼠的皮下,觀察它們的表皮麻醉情況。藥物之間的相互作用和生理安全指數(LD50s/ED50s)也被評價。結果: 右美沙去甲右美沙在皮下注射後具有局部麻醉作用。它們的效是右美沙〉去甲右美沙〉利多卡因(組間P < 0.01)。右美沙或去甲右美沙合用利多卡因將產生效應。右美沙和去甲右美沙在生理安全指數分別比利多卡因高2.4- 1.9-倍。結論:右美沙和去甲右美沙比利多卡因在局部麻醉局用更高的效能,但具有更高的生理安全指數。右美沙或去甲右美沙和利多卡因的聯合注射將產生效應。

(陳勇柱譯 薛張綱校)

BACKGROUND: Dextromethorphan blocks sodium channels, the site of action of local anesthetics. In this study we evaluated whether dextromethorphan has a local anesthetic effect. METHODS: We administered dextromethorphan and its active metabolite--dextrorphan, and lidocaine subcutaneously to rats and tested them for cutaneous anesthesia. Drug-drug interactions and systemic safety indices (LD50s/ED50s) were also evaluated. RESULTS: Dextromethorphan and dextrorphan had a local anesthetic effect after cutaneous infiltration. The ranking of potencies was dextromethorphan > dextrorphan > lidocaine (P < 0.01 for each comparison). A combination of dextromethorphan or dextrorphan with lidocaine produced an additive effect. Dextromethorphan and dextrorphan had 2.4- and 1.9-fold higher system safety indices than did lidocaine. CONCLUSION: Dextromethorphan and dextrorphan were more potent local anesthetics than lidocaine, but with higher systemic safety indices. Coadministration of dextromethorphan or dextrorphan with lidocaine produced an additive effect.

 

超聲引導下股骨中段外側坐骨神經阻滯:一項隨機比較設計實驗

Ultrasound Guidance for Lateral Midfemoral Sciatic Nerve Block: A Prospective, Comparative, Randomized Study (Medical Intelligence)
Vicente Domingo-Triadó, Salvador Selfa, Francisco Martínez, Dolores Sánchez-Contreras, Montserrat Reche, Jose Tecles, María T. Crespo, Jose M. Palanca, and Blanca Moro

Department of Anesthesiology, Hospital Lluis Alcanyis, Xativa, Valencia, Spain

Anesth Analg 2007 104: 1270-1274.

 

在股骨中段水準阻滯坐骨神經時經常會使用神經刺激術。我們調查研究在股骨中段外側水準定位阻滯坐骨神經時使用超聲與神經刺激相結合的方式較之僅僅使用神經刺激術的效能。61位行擇期足部和踝關節手術的患者參與了這項隨機設計實驗。在做股骨中段水準外側坐骨神經阻滯時,30位患者是在超聲引導術下完成的(US組),而另外31位是在沒有超聲引導術下完成的(ES組)。在使用神經刺激器時一旦獲得令人滿意的體動反應,就給與35ml0.5%的囉呱卡因。實驗所需要記錄的幾條重要資料是:試圖獲得一個令人滿意的體動反應的次數,第一次嘗試就能成地定位神經的比例,有良好的效果和足夠的持續時間的感覺運動的阻滯,以麻醉區域的分佈。第一次嘗試就能成地定位坐骨神經在US組中毫無疑問地比ES組中更經常的發生(76.6% 41.9%; P < 0.001)。感覺阻滯的效果對充氣止血帶的忍受能在US組中也更好(P < 0.01)。我們得出如下結論,超聲結合神經刺激方法提高了感覺阻滯的效果對於充氣止血帶的忍受能,減少了在股骨中段水平行坐骨神經阻滯時的嘗試次數。

(周時蓓譯 薛張綱校)

Block of the sciatic nerve at the midfemoral level is usually performed using nerve stimulation techniques. We investigated the efficacy of ultrasound, combined with nerve stimulation, to locate and block the sciatic nerve at the lateral midfemoral level compared to nerve stimulation alone. Sixty-one patients scheduled for foot and ankle surgery were enrolled in this prospective, randomized study. Thirty patients underwent a lateral block of the sciatic nerve at the midfemoral level guided by ultrasound (group US) and 31 patients received the block without ultrasound (group ES). Once an adequate motor response was obtained using nerve stimulation, 35 mL of ropivacaine 0.5% was administered. The main end-points of the study were: number of attempts to obtain an adequate motor response, success rate of nerve location at the first attempt, quality and duration of both sensory and motor blocks, and anesthetic distribution. The success of sciatic nerve location at the first attempt was significantly more frequent in the US group than in the ES group (76.6% versus 41.9%; P < 0.001). The quality of the sensory block and the tolerance to the pneumatic tourniquet were also significantly better in the US group (P < 0.01). We conclude that ultrasound combined with nerve stimulation improved the quality of the sensory block and the tolerance to the pneumatic tourniquet, reducing the number of attempts to perform sciatic nerve block at the midfemoral level.

 

性別差別對於老年病人冠脈手術後腦卒中風險的影響

Gender Differences in Stroke Risk Among the Elderly After Coronary Artery Surgery

 

Tomoko Goto, MD*, Tomoko Baba, MD*, Asuka Ito, MD*, Kengo Maekawa, MD*, and Takaaki Koshiji, MD{dagger}

From the Departments of *Anesthesiology and {dagger}Cardiovascular Surgery, Kumamoto Chuo Hospital, Kumamoto, Japan.

Anesth Analg 2007;104:1016-1022

背景:已有研究顯示:女性比男性更容易發生冠脈搭橋術(CABG)後的腦卒中,但性別差別對於全身動脈粥樣硬化的影響尚未得到充分研究。我們研究了老年(年齡60) CABG術後的患者,因頸顱頸動脈升主動脈粥樣硬化其他危險因素導致的腦卒中的發生率中的性別差別。

方法:前瞻性收集720位行CABG術患者 (31.8%女性) 的數據。所有的患者在術前接受腦的磁共振影像血流影像學檢查來評估已有的腦梗塞、頸動脈狹窄顱內動脈狹窄。術中進行主動脈周超聲檢查以評估升主動脈的動脈粥樣硬化。對所有的患者在術前術後第七天用Hasegawa癡呆量表監測認知狀態。

結果:與男性相比,女性年齡更大,有更多的高血壓顱內動脈狹窄發生。而男性在高脂血症、外周血管疾病、腹主動脈瘤、吸煙史、重度冠脈狹窄重度升主動脈粥樣硬化方面的發生率明顯增高。與女性相比,儘管男性在先兆腦梗或術前認知缺損的發生率沒有差異,但男性患者圍術期腦卒中的發生率最低限度地高於女性(3.9%1.3%, P = 0.066)。先兆腦梗、升主動脈粥樣硬化、已有的認知缺損外周血管疾病是圍術期腦卒中的單數預測因素。逐步邏輯回歸分析證實,先兆腦梗主動脈粥樣硬化是圍術期腦卒中明顯的獨立的預測因素。

結論:這些資料顯示:男性腦卒中的危險因素較女性更多,包括重度冠脈狹窄、重度主動脈粥樣硬化外周血管疾病。男女在先兆腦梗術前認知缺損的發生率相似。

(裘毅敏譯,馬皓琳 李士通校)

 

BACKGROUND: Previous studies have shown that women are at higher risk than men for stroke after coronary artery bypass graft (CABG) surgery, but gender differences in systemic atherosclerosis have not been studied adequately. We investigated gender differences in the incidence of craniocervical and ascending aortic atherosclerosis and other risk factors for stroke in elderly patients (age 60 yr) undergoing CABG surgery.

METHODS: Data were prospectively collected on 720 patients (31.8% women) undergoing CABG surgery. All patients underwent preoperative brain magnetic resonance imaging and angiography to assess for prior cerebral infarctions, carotid artery stenosis, and intracranial arterial stenosis. Epiaortic ultrasound was performed at the time of surgery to assess for atherosclerosis of the ascending aorta. Cognitive status was measured using the Hasegawa-dementia score in all patients before surgery and on the seventh postoperative day.

RESULTS: Women were older and had more hypertension and intracranial arterial stenosis than did men. Men had significantly higher rates of hyperlipidemia, peripheral vascular disease, abdominal aortic aneurysm, smoking history, severe carotid artery stenosis, and severe aortic atherosclerosis than did women. Although there were no differences in prior cerebral infarction or preoperative cognitive impairment, the rate of perioperative stroke was marginally higher in men than in women (3.9% vs 1.3%, P = 0.066). Univariate predictors of perioperative stroke were prior cerebral infarctions, ascending aortic atherosclerosis, preexisting cognitive impairment, and peripheral vascular disease. Stepwise logistic regression analysis demonstrated that significant independent predictors of perioperative stroke were prior cerebral infarctions and aortic atherosclerosis.

CONCLUSIONS: These data suggest that men are more likely than women to have risk factors for stroke, including severe carotid artery stenosis, severe aortic atherosclerosis, and peripheral vascular disease. The rates of prior cerebral infarction and preoperative cognitive impairment were similar between genders.


6-18個月嬰兒術後應用酮咯酸氨丁三醇:對嗎啡的應用、安全性評估和立體特異藥代動學的影響

Postoperative Ketorolac Tromethamine Use in Infants Aged 6–18 Months: The Effect on Morphine Usage, Safety Assessment, and Stereo-Specific Pharmacokinetics

 

Anne M. Lynn, MD*, Heidi Bradford, BA*, Eric D. Kantor, BA{dagger}, Kok-Yong Seng, MS{ddagger}, David H. Salinger, PhD{ddagger}, James Chen, MD*, Richard G. Ellenbogen, MD, Paolo Vicini, PhD{ddagger}, and Gail D. Anderson, PhD{dagger}

From the Departments of *Anesthesia and Pain Management and Neurosurgery, Children's Hospital and Regional Medical Center, University of Washington School of Medicine; {dagger}Department of Pharmacy, University of Washington School of Pharmacy; {ddagger}Department of Bioengineering, University of Washington College of Engineering and the School of Medicine, Seattle, Washington.

Anesth Analg 2007;104:1040-1051

背景:非甾體炎藥已經在治療兒童的術後疼痛方面很有用。當前美國唯一可用的胃腸外非甾體炎藥是有環氧酶-1和環氧酶-2作用的酮咯酸氨丁三醇。酮咯酸的嬰兒藥代動學資料稀少,使量確定困難。給予的酮咯酸是一個外消旋混合物,S(-)異構體產生鎮痛效應。此研究中,我們描述一群25個嬰兒和剛會走路的孩子,接受單量靜脈注射外消旋酮咯酸的群體藥代動學,並評估病人異對酮咯酸分佈的潛在影響。

方法:在此雙盲,安慰對照試驗中,研究37個嬰兒和剛會走路的孩子(年齡6-18個月)術後酮咯酸藥代動學、安全性和鎮痛效果。術後第一天,嬰兒隨機接受十分鐘的靜脈注射安慰、0.5或者1 mg/kg酮咯酸。給藥後12小時收集血樣。資料分析採用非房室的和房室的(非線性混和效應模型)方法。以逐步方式分析包括體重、年齡和手術過程在內的病人數來確定其對酮咯酸藥代動學的潛在影響。

結果:二室模型最好地描述了資料。包含的數不顯著減少非線性混和效應模型目標函數值和嵌套模型的藥代動學參數的主體間可性。估算的R(+)異構體的中央室分佈體積的平均值和標準誤差為1200 ± 163 mL (個體間差異的異係數, 13.6%),周圍室的分佈體積為828 ± 108 mL (13.0%),從中央室的清除率7.52 ± 0.7 mL/min (9.3%),推斷清除衰期238 ± 48 minS(–)異構體的相應值分別為2320 ± 34 (14.6%)224 ± 193 mL (86.2%)45.3 ± 5.5 mL/min (12.1%)50 ± 42 min。應用群體藥代動學參數進行的量類比顯示S(–) 酮咯酸沒有蓄積,但是R(+)酮咯酸平穩增。安全性評估顯示對腎能或肝能測試、外科引流或者連續血氧含量在安慰和酮咯酸組之間沒有副作用。累積應用嗎啡顯示病人間的異很大,組間沒有不同。

結論:嬰兒和剛會走路的兒童(年齡6-18個月)中酮咯酸立體異構體特異性清除率顯示鎮痛的S(-)異構體消除快速。對外科引流、測量的血氧飽和度、腎或者肝能測試未見副作用。每4或者6小時模擬單量應用0.5或者1 mg/kg,不會導致鎮痛的異構體S(–) 酮咯酸畜積,但是導致R(+)酮咯酸的增。大於6個月的嬰兒可能需要縮短量間隔。

(張曦 譯,馬皓琳 李士通 校)

 

BACKGROUND: Nonsteroidal antiinflammatory drugs have been useful for treating postoperative pain in children. The only parenteral nonsteroidal antiinflammatory drug currently available in the United States is ketorolac tromethamine with cyclooxygenase-1 and cyclooxygenase-2 effects. Information on the pharmacokinetics of ketorolac in infants is sparse, making dosing difficult. Ketorolac is administered as a racemic mixture with the S(–) isomer responsible for the analgesic effect. In this study, we describe the population pharmacokinetics of ketorolac in a group of 25 infants and toddlers who received a single IV administration of racemic ketorolac and evaluate the potential influence of patient covariates on ketorolac disposition.

METHODS: In this double-blind, placebo-controlled study, ketorolac pharmacokinetic, safety, and analgesic effects were studied in 37 infants and toddlers (aged 6–18 mo) postoperatively. On postoperative day 1, infants were randomized to receive placebo, 0.5, or 1 mg/kg ketorolac as a 10-min IV infusion. Blood samples were collected up to 12-h after dosing. The data were analyzed using noncompartmental and compartmental (nonlinear mixed-effects model) means. The patient covariates, including body weight, age, and surgical procedure, were analyzed in a stepwise fashion to identify their potential influence on ketorolac pharmacokinetics.

RESULTS: The data were best described by a two-compartmental model. Inclusion of covariates did not significantly decrease the nonlinear mixed-effects model objective function values and between-subject variability in the pharmacokinetic parameters of nested models. The mean and standard error of the estimates of the R(+) isomer were central volume of distribution 1200 ± 163 mL (coefficient of variation of interindividual variability, 13.6%), peripheral volume of distribution 828 ± 108 mL (13.0%), clearance from the central compartment 7.52 ± 0.7 mL/min (9.3%), and extrapolated elimination half-life 238 ± 48 min. Those of the S(–) isomer were 2320 ± 34 (14.6%), 224 ± 193 mL (86.2%), 45.3 ± 5.5 mL/min (12.1%), and 50 ± 42 min respectively. Dosing simulations, using population pharmacokinetic parameters, showed no accumulation of S(–) ketorolac but steady increases in R(+) ketorolac. Safety assessment showed no adverse effects on renal or hepatic function tests, surgical drain output, or continuous oximetry between placebo and ketorolac groups. Cumulative morphine administration showed large interpatient variability and was not different between groups.

CONCLUSION: The stereo-isomer-specific clearance of ketorolac in infants and toddlers (aged 6–18 mo) shows rapid elimination of the analgesic S(–) isomer. No adverse effects on surgical drain output, oximetry measured saturations, renal or hepatic function tests were seen. Simulation of single dosing at 0.5 or 1 mg/kg every 4 or 6 h does not lead to accumulation of S(–) ketorolac, the analgesic isomer, but does result in increases in R(+) ketorolac. Shorter dose intervals may be needed in infants older than 6 mo.


新生兒缺氧-缺血後異氟醚延遲性預處理會減少成熟小鼠即時死亡率並改善紋狀體的能

Isoflurane-Delayed Preconditioning Reduces Immediate Mortality and Improves Striatal Function in Adult Mice After Neonatal Hypoxia–Ischemia

 

John J. McAuliffe, MD, MBA, FAAP*, Bernadin Joseph, BS*, and Charles V. Vorhees, PhD{dagger}

From the *Department of Anesthesia, Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio; and {dagger}Department of Pediatrics, Division of Neurology, Cincinnati Children's Research Foundation and University of Cincinnati, Cincinnati, Ohio.

Anesth Analg 2007;104:1066-1077

背景:已經發現缺氧-缺血前暴露於缺氧和異氟醚有於新生大鼠的神經保護。我們研究了異氟醚、缺氧或者是室內空氣的延緩性預處理對生後10天經歷了65min缺氧-缺血的小鼠運動和認知能的長期效應。

方法:9天大的C57x129T2 F1小鼠接受1.8%的異氟醚、缺氧(氮氣中的氧氣10%)或者假物(室內空氣)預處理。第二天,在65min的缺氧或者是室內空氣的處理後,對小鼠實行永久的右頸總動脈結紮術或者假結紮。在70天時,應用一組Morris水迷宮測驗檢查其學習。通過其對去水嗎啡注射的反應評價紋狀體的能。對成熟鼠腦(P120)的紋狀體背海馬的切片進行組織學分析。

結果:在新生鼠嚴重的缺氧-缺血前24hr進行異氟醚預處理可以使斷奶前的死亡率從20%減少至0%P < 0.04),並且改善成熟小鼠的紋狀體能,其是通過去水嗎啡注射後的沿軌道運行的能評價的(P < 0.028),但在空間有關的記憶水迷宮測試中的表現並無改善。缺氧預處理相對於假的預處理組,可以提高對隱藏迷宮的學習,但並沒有更難去降低迷宮測驗的空間記憶。它對斷奶前的死亡率去水嗎啡的反應並無顯著影響。組織學分析顯示海馬區在未行預處理組和異氟醚預處理組有相等的損害。

結論:異氟醚和缺氧對新生小鼠的延緩性預處理範例中,有選擇性的能性神經保護作用。

(黃麗娜 李士通 馬皓琳 校)

 

BACKGROUND: Exposure to hypoxia and isoflurane (Iso) before hypoxia–ischemia has been found to be neuroprotective in neonatal rats. We investigated the long-term effects of delayed preconditioning with Iso, hypoxia, or room air on motor and cognitive function in mice that had 65 min of hypoxia–ischemia on postnatal day 10.

METHODS: Nine-day-old C57x129T2 F1 mice received either 1.8% Iso, hypoxic (10% O2 in N2), or sham (room air) preconditioning. The following day, the mice were subjected to permanent right common carotid ligation or sham ligation followed by 65 min of hypoxia, or room air. At 70 days of age, learning was tested using a series of Morris water maze tests. Striatal function was assessed by response to apomorphine injection. Histological analysis was performed on adult brain (P120) sections of striatum and dorsal hippocampus.

RESULTS: Iso preconditioning 24 h before severe neonatal hypoxia–ischemia reduced preweaning mortality from 20% to 0% (P < 0.04) and improved striatal function in adult mice, as assessed by circling after apomorphine injection (P < 0.028), but no improvements in performance were noted in the spatial-reference memory water maze tests. Hypoxic preconditioning improved learning relative to the sham-preconditioned group on the hidden maze, but not the more difficult reduced maze test of spatial memory. It had no significant effect on preweaning mortality and apomorphine response. Histologic analysis showed the hippocampus of non-preconditioned and Iso-preconditioned animals to be equally injured.

CONCLUSION: Iso and hypoxia confer selective functional neuroprotection in a delayed preconditioning paradigm in neonatal mice.


利多卡因、MK801MAC       

Lidocaine, MK-801, and MAC

 

Yi Zhang, MD{dagger}, Michael J. Laster, DVM*, Edmond I. Eger, II, MD*, Manohar Sharma, PhD*, and James M. Sonner, MD*

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, and from the {dagger}Department of Anesthesiology, Fuwai Hospital and Cardiovascular Institute, Beijing, China.

Anesth Analg 2007;104:1098-1102

背景:以前的研究發現,局麻藥/鈉離子通道阻滯利多卡因大量使用可以產生和NMDA受體拮地佐環平(癲癇藥 MK801)一樣的降低吸入藥物MAC的作用。已有研究提示吸入麻醉藥阻斷鈉離子通道就是損害通過NMDA受體的傳遞的一個可能原因。我們假設縱然利多卡因和MK801 在不同位點影響NMDA神經傳遞,但是其對MAC的淨效應是相同的。

方法:我們測定不同的利多卡因輸注對於大鼠環丙烷、氟烷、異氟醚和鄰二氟苯MAC的影響。同時我們也測定了利多卡因複合MK801注射對於大鼠異氟醚和鄰二氟苯的MAC的影響。

結果:我們的資料和預測相反。A、我們發現利多卡因沒有封頂效應,在一些單獨運用利多卡因的實驗中結果幾乎是恒定的;B、注射利多卡因並不能降低鄰二氟苯MAC,卻能降低其他吸入麻醉藥的MACC、與鄰二氟苯相比,添MK801能同樣地影響利多卡因輸注所產生的異氟醚和鄰二氟苯MAC的降低作用。

結論:利多卡因並不能通過減少神經末梢中谷氨酸的釋放來原發性地降低MAC

 

BACKGROUND: Previous studies have found that the local anesthetic/sodium channel blocker lidocaine decreased MAC by maximum amounts approximately equal to the decreases produced by dizocilpine (MK-801), a N-methyl-d-aspartate (NMDA) receptor antagonist. Blockade of sodium channels by inhaled anesthetics has been suggested as a possible cause for impairment of transmission through NMDA receptors. We postulated that the net effect of lidocaine and MK-801 on MAC would be the same, albeit by affecting NMDA neurotransmission at different points.

METHODS: We measured the effect of various lidocaine infusions on the MAC of cyclopropane, halothane, isoflurane, and o-difluorobenzene in rats. We also measured the effect of concurrent lidocaine-MK-801 infusion on the MAC of isoflurane and o-difluorobenzene.

RESULTS: Our data contradicted our predictions. (a) We found no limit to the effect of lidocaine infusion, in some cases finding that lidocaine, alone, produced immobility; (b) lidocaine infusion did not decrease the MAC of o-difluorobenzene differently from the MAC of other inhaled anesthetics; and (c) the addition of MK-801 equally affected the decrease in MAC produced by lidocaine infusion for isoflurane versus o-difluorobenzene.

CONCLUSION: Lidocaine does not primarily decrease MAC by decreasing the release of glutamate from nerve terminals.


全麻藥對大鼠小膠質細胞系中P2X7 P2Y受體的影響

The Effects of General Anesthetics on P2X7 and P2Y Receptors in a Rat Microglial Cell Line

 

Mika Nakanishi, MD*, Takashi Mori, MD, PhD*, Kiyonobu Nishikawa, MD, PhD*, Makoto Sawada, PhD{dagger}, Miyuki Kuno, MD, PhD{ddagger}, and Akira Asada, MD, PhD*

From the *Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka City University, Osaka, Japan; {dagger}Department of Brain Science, Research Institute of Environmental Medicine, Nagoya University, Nagoya, Aichi, Japan; and {ddagger}Department of Physiology, Graduate School of Medicine, Osaka City University, Osaka, Japan.

Anesth Analg 2007;104:1136-1144

背景:小膠質細胞在腦對缺氧和創傷的炎症反應中起重要的調節作用。小膠質細胞表達的離子向型P2X受體和代謝向型P2Y受體(P2YRs)能被來自受損的腦細胞或星形膠質細胞產生的細胞外三磷酸腺苷(ATP)所啟動,且參與由腦損傷誘發的信號通路。儘管一些吸入和靜脈麻醉藥能通過神經元機制產生神經保護效應,對全麻藥在病理狀態下如何調節小膠質細胞的反應仍屬未知。我們檢驗了不同的全麻藥在大鼠小膠質細胞系對嘌呤能反應的影響。

方法:在全細胞構型下通過U管系統給予ATP獲得持續啟動電流。在研究中多次給予ATPATP產生的非脫敏感電流呈現P2X7 受體特徵。用Ca2+敏感的螢光染色(fura-2)測定P2YRs介導的細胞內鈣離子移動。

結果:高至最小肺泡濃度3倍的吸入麻醉藥(七氟烷、異氟烷和氟烷)對P2X7 受體介導電流無影響。靜脈麻醉藥(氯胺酮、丙酚和硫噴妥鈉)可逆性強P2X7 受體介導電流。P2X7 受體啟動強度與辛醇/緩衝液分配係數無關。低濃度硫噴妥輕微制P2X7 受體介導電流,表明其對P2X7 受體具有雙向性作用。研究中所試驗的全身麻醉藥對P2Y受體介導的細胞內Ca2+移動均無影響。

結論:我們的結果表明,在病理狀態下,靜脈麻醉藥(尤其是硫噴妥鈉和丙酚)能通過P2X7 受體調節小膠質細胞的能。

(顏濤 譯, 馬皓琳 李士通校)

 

BACKGROUND: Microglial cells play important roles in coordinating the inflammatory brain responses to hypoxia and trauma. Ionotropic P2X receptors and metabotropic P2Y receptors (P2YRs) expressed in microglia can be activated by extracellular adenosine triphosphate (ATP) derived from damaged cells or astrocytes, and participate in the signaling pathways evoked in brain insult. Although several inhaled and IV anesthetics produce neuroprotective effects through neuronal mechanisms, little is known about how general anesthetics modulate microglial responses in the pathological state. We examined the effects of various general anesthetics on purinergic responses in a rat microglial cell line.

METHODS: Currents were consistently activated by applications of ATP via a U-tube system under the whole-cell configuration. ATP-induced nondesensitizing currents observed after several applications of ATP exhibited characteristics of P2X7 receptors. The P2YRs-mediated mobilization of intracellular Ca2+ was measured using a Ca2+-sensitive fluorescent dye (fura-2).

RESULTS: Inhaled anesthetics (sevoflurane, isoflurane, and halothane) at doses three times as high as minimum alveolar concentrations had no effect on the P2X7Rs-mediated currents. IV anesthetics (ketamine, propofol, and thiopental) enhanced the P2X7Rs-mediated currents reversibly. The potencies for activation of P2X7Rs were not correlated with the octanol/buffer partition coefficients. Thiopental, at low concentrations, slightly inhibited the P2X7Rs-mediated currents, suggesting its dual actions on P2X7Rs. The P2YRs-mediated mobilization of intracellular Ca2+ was not affected by any of the general anesthetics tested.

CONCLUSIONS: Our results suggest that IV anesthetics, particularly thiopental and propofol, may modulate microglial functions through P2X7Rs in pathological conditions.


低溫對內毒素預處理的肺的作用

The Effects of Hypothermia on Endotoxin-Primed Lung

 

Jae-Yong Chin, MD*, Younsuck Koh, MD, FCCM*, Mi Joung Kim, MS*, Han Seong Kim, MD{dagger}, Woo-Sung Kim, MD*, Dong-Soon Kim, MD*, Won-Dong Kim, MD*, and Chae-Man Lim, MD*

From the *Division of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea; and {dagger}Department of Pathology, Ilsan Paik Hospital, Inje University College of Medicine, Koyang-Si, Korea.

Anesth Analg 2007;104:1171-1178

研究背景:低溫可能對內毒素誘導的急性肺損傷有保護作用。大多數研究在發生中性粒細胞炎症反應之前給予低溫,並無臨相關性。本研究旨在探討在中性粒細胞炎症反應啟動後給予低溫是否能減輕內毒素誘導的急性肺損傷。

研究方法:第一個實驗中,大鼠分為以下4組:1)生理鹽水組,大鼠氣管內滴入生理鹽水/1小時後處死;2LPS預處理組,大鼠氣管內灌注脂多糖(LPS/1小時後處死;3LPSNT組,大鼠氣管內灌注LPS/6小時後處死,所有過程均在正常體溫下(NT)(37 ± 0.5°C)完成;4LPS-HT組,大鼠氣管內灌注LPS/6小時後處死,在灌注LPS1小時將大鼠體溫降至32 ± 0.5°C,維持低體溫5小時。取肺灌洗液行生化檢測。第二個實驗附26只大鼠,完全按照述實驗方法分為生理鹽水組(n=2)、LPS-NT組(n12)和LPSHT組(n12),取新鮮肺泡中性粒細胞池進行氧化爆發評估。

研究結果 LPSNT組肺的中性粒細胞計數、蛋白質水準、乳酸脫氫酶活性肺髓過氧化物酶活性均高於LPS預處理組。LPSHT組支氣管肺泡灌洗液中性粒細胞計數、蛋白質水準、乳酸脫氫酶活性顯微鏡下肺泡中性粒細胞浸潤計數均低於LPSHT組。LPSHT組中性粒細胞受刺激後過氧化氫產量低於LPSNT組。

結論:即使在中性粒細胞炎症反應啟動之後給予低溫仍可有效減輕內毒素誘導的急性肺損傷。

(周雅春 馬皓琳 李士通 校)

 

BACKGROUND: Hypothermia may be effective for endotoxin-induced acute lung injury. In most studies, hypothermia was induced before the development of neutrophilic inflammation, which would be clinically irrelevant. We investigated whether hypothermia induced after the onset of such neutrophilic inflammation reduces acute lung injury.

METHODS: In the first experiment, rats were allocated to one of four groups: intratracheal saline instillation/killed at 1 h (saline), intratracheal lipopolysaccharide (LPS) instillation/killed at 1 h (LPS-primed), intratracheal LPS instillation/killed at 6 h (LPS-NT), all under normothermia (NT) (37 ± 0.5°C) throughout study, and intratracheal LPS instillation/killed at 6 h with hypothermia (HT) (32 ± 0.5°C) for the last 5 h of study (LPS-HT). Lungs were lavaged for biochemical measurements. In the second experiment in 26 additional rats, we followed exactly the same protocol as described above for the saline group (n = 2), LPS-NT (n = 12), and LPS-HT (n = 12), and obtained a fresh pool of alveolar neutrophils to assess oxidative burst.

RESULTS: Compared with the LPS-primed group, the neutrophil count, protein level, and lactate dehydrogenase activity in the bronchoalveolar lavage fluid, and myeloperoxidase activity of the lung were all higher in the LPS-NT group. Compared with this LPS-NT group, the neutrophil count, protein level, and lactate dehydrogenase activity in the bronchoalveolar lavage fluid, and microscopic scores for alveolar neutrophilic infiltration were all lower in the LPS-HT group. The stimulated production of hydrogen peroxide in neutrophils was lower in the LPS-HT group than in the LPS-NT group.

CONCLUSION: Hypothermia, applied even after the onset of neutrophilic inflammation, was effective in reducing endotoxin-induced acute lung injury.


腰椎橫向超聲可以為分娩硬膜外穿刺準確定位

Ultrasound Using the Transverse Approach to the Lumbar Spine Provides Reliable Landmarks for Labor Epidurals

 

Cristian Arzola, MD, Sharon Davies, MD, Ayman Rofaeel, MD, and Jose C. A. Carvalho, MD, PhD

From the Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, Ontario, Canada.

Anesth Analg 2007;104:1188-1192

背景:在最近的研究中柱超聲成像已經在硬膜外腔間隙的定位中得到應用。在本研究中我們評估了橫向超聲單屏顯像的方法在分娩硬膜外定位中的精度和准度。

方法:我們選入了61位要求進行分娩硬膜外的病人,我們通過超聲成像(橫向切面,25MHz彎曲排列的探針)來識別正中線、椎間隙和從皮膚到硬膜外間隙的距離(超聲深度單位用UD表示)。在硬膜外穿刺過程中我們記錄下穿刺點的成率,並測定硬膜外間隙到最近的標記過的圖針的一距離(針的深度用ND表示)。我們通過一致性相關係數和95%一致限的Bland–Altman分析計算了UDND的相關性。

結果:孕婦的平均年齡是33±4.6歲,體重指數是29.7±4.8UD4.66±0.68cm, ND4.65±0.72cm。穿刺點的成率是91.8%73.8%病人不需重新進針。UDND之間的一致性相關係數是0.88195%可信區間是0.820–0.94295%一致限是–0.666 to 0.687 cm

結論:我們發現超聲決定穿刺點有很高水準的成率,UDND之間有很好的一致性。這提示了我們提出的橫向超聲單屏顯像的方法對分娩硬膜外進針是可靠的指導。

(姜旭暉譯,馬皓琳,李士通校)

 

BACKGROUND: Ultrasound imaging of the spine has recently been proposed to facilitate identification of the epidural space. In this study, we assessed the accuracy and precision of the transverse approach, using a "single-screen" method, to facilitate labor epidurals.

METHODS: We enrolled 61 patients requesting labor epidurals. Ultrasound imaging (transverse approach, 2–5 MHz curved array probe) identified the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth/UD). During the epidural puncture, we recorded the success of the insertion point, and measured the distance to the epidural space to the nearest half-centimeter of the marked Tuohy needle (needle depth/ND). We calculated the agreement between UD and ND by the concordance correlation coefficient and Bland–Altman analysis with 95% limits of agreement.

RESULTS: The average maternal age was 33 ± 4.6 yr, body mass index 29.7 ± 4.8, UD 4.66 ± 0.68 cm, and ND 4.65 ± 0.72 cm. The success of the insertion point was 91.8%, with no need to redirect the needle in 73.8% of the patients. The concordance correlation coefficient between UD and ND was 0.881 (95% CI 0.820–0.942). The 95% limits of agreement were –0.666 to 0.687 cm.

CONCLUSIONS: We found a good level of success in the ultrasound-determined insertion point, and very good agreement between UD and ND. This suggests that our proposed ultrasound single-screen method, using the transverse approach, can be a reliable guide to facilitate labor epidural insertion.


腰段硬膜外類固醇注射用於治療腰椎間盤膨出患者的效果

The Efficacy of Lumbar Epidural Steroid Injections in Patients with Lumbar Disc Herniations

 

William E. Ackerman, III, MD*, and Mahmood Ahmad, MD{dagger}

From the *Pain Medicine Consultants P.A., Little Rock, Arkansas 72223 and {dagger}United Pain Care Inc., Sherwood, Arkansas 72120.

Anesth Analg 2007;104:1217-1222

引言:腰段硬膜外類固醇注射可通過三種途徑實現:經尾骨(C)、椎板間 (IL) 或經閉孔神經 (TF)。此次研究旨在確定述術用於治療腰椎間盤膨出所致神經根痛的效果。

方法90名年齡1860歲,患有L5-S1椎間盤膨出伴神經根痛的患者,被隨機分成三組,接受每2週一次至各組最大量的硬膜外類固醇注射療法。評估疼痛緩解、無、活動度水準。

結果:疼痛緩解在TF注射組最為顯著。從研究開始至第24周,疼痛緩解程度如下:C組:完全疼痛緩解1/30,部分疼痛緩解16/30,未緩解 13/30 IL組:完全疼痛緩解3/30,部分疼痛緩解15/30,未緩解12/30 TF組:完全疼痛緩解9/30,部分疼痛緩解 16/30,未緩解5/30

結論TF經路的硬膜外類固醇給藥比CIL經路更有效。我們認為這個觀察結果的原因可能為用TF法時,類固醇進入腹側硬膜外腔的概率較高。

(唐李雋 馬皓琳 李士通 校)

 

INTRODUCTION: Lumbar epidural steroid injection can be accomplished by one of three methods: caudal (C), interlaminar (IL), or transforaminal (TF). In this study we sought to determine the efficacy of these techniques for the management of radicular pain associated with lumbar disk herniations.

METHODS: Ninety patients aged 18–60 years with L5-S1 disk herniations and radicular pain were randomly assigned to one of these groups to have epidural steroid injection therapy every 2 wk for a maximum of three injections. Pain relief, disability, and activity levels were assessed.

RESULTS: Pain relief was significantly more effective with TF injections. At 24 wk from the initiation of this study, pain relief was as follows: C: complete pain relief: 1/30, partial pain relief: 16/30, and no relief: 13/30; IL: complete pain relief: 3/30, partial pain relief: 15/30, and no relief: 12/30; and TF: complete pain relief: 9/30, partial pain relief: 16/30, and no relief: 5/30.

CONCLUSIONS: The TF route of epidural steroid placement is more effective than the C or IL routes. We attribute this observation to a higher incidence of steroid placement in the ventral epidural space when the TF method is used.


多方面截斷大鼠坐骨神經與股神經末稍後的神經性疼痛測量的症狀精確度:一項探查性行為分析

Refinement of Symptoms of Neuropathic Pain Measurements After Various Transections of the Nerve Endings of the Sciatic and Femoral Nerve in Rats: An Exploratory Behavioral Analysis

 

Marie P. Van Remoortere, MD*, Theo F. Meert, PhD, PhD{dagger}, Kris C. Vissers, MD, PhD, FIPP{ddagger}, Hans Coppenolle, PhD, and Hugo Adriaensen, MD, PhD*

From the *Department of Anesthesiology, University hospital of Antwerp, Edegem, Belgium; {dagger}CNS, Pain and Alzheimer Discovery, Johnson & Johnson Pharmaceutical Research & Development, Beerse, Belgium; {ddagger}Department of Anesthesiology and Palliative Care, UMC St. Radboud, Nijmegen, The Netherlands; and Department of Biometrics & Clinical Informatics, Johnson & Johnson Pharmaceuticals Research & Development, Beerse, Belgium.

Anesth Analg 2007;104:1236-1245

背景:很多動物模型被用來研究神經性疼痛的基礎病理生理學機制。絕大多數的這些模型依賴於結紮所選擇的神經使動物肢體部分去神經。在此項研究中,我們通過分別單獨或聯合橫切隱神經、脛神經、腓神經完成分佈在大鼠後爪蹠側的三個周圍神經的破壞。

方法:在為期12周的階段裏用感覺試驗來評定大鼠後爪光滑皮膚三個不同解剖學區域(內側、中部、外側)的神經疼痛症狀的發展。機械性痛覺過敏(針刺), 異常性冷疼痛(丙酮)和異常後爪姿勢持續表現在脛神經和脛神經聯合隱神經橫斷的大鼠中。

結果:脛神經和腓腸神經的橫斷導致異常性冷疼痛和中等強度的機械性痛覺過敏。脛神經或隱神經,或兩者的同時橫切沒有導致特別的神經性疼痛行為和適當刺激後累的後爪異常的姿勢。

結論:交錯的神經分佈支配可以使結紮神經來研究外周神經病的解釋複雜。

 

BACKGROUND: Many animal models can be used to study the underlying pathophysiological mechanisms of neuropathic pain. Most of these models rely on a partial denervation of the limb of the animal by ligating a selected nerve. In this study, we performed nerve lesions on three peripheral nerves supplying the plantar side of the rat hindpaw by differentially transecting the saphenous, the tibial, and the sural nerves alone or in paired combinations.

METHODS: The development of neuropathic pain symptoms at three different anatomical areas (medial, central, and lateral) of the glabrous skin of the hindpaw was evaluated by sensory testing over a 12-wk period. Mechanical hyperalgesia (pinprick), cold allodynia (acetone), and abnormalities of hindpaw posture were continuously present in animals with tibial and tibial and saphenous nerve transection.

RESULTS: Transection of the tibial and sural nerves induced cold allodynia and moderate mechanical hyperalgesia. Transection of the sural, the saphenous, or both nerves simultaneously induced no signs of specific neuropathic pain behavior and no abnormalities in posture of the affected hindpaw were noted after adequate stimulation.

CONCLUSIONS: The overlapping innervation of nerve distribution can complicate the interpretation of nerve ligation studies of peripheral neuropathies.


阿密曲替林是人Kv1.1Kv7.2/7.3通道的強效阻滯

Amitriptyline Is a Potent Blocker of Human Kv1.1 and Kv7.2/7.3 Channels

 

Mark A. Punke, MD, and Patrick Friederich, MD

From the Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Anesth Analg 2007;104:1256-1264

背景:Kv1.1Kv7.2/7.3通道控制神經細胞的興奮性。因為神經細胞的過度興奮是神經性疼痛、癲癇和焦慮的一個體征,所以這些通道可能是阿密曲替林通過改神經細胞興奮性來產生藥理學和毒理學作用的重要分子靶向。阿密曲替林這些作用的分子機制目前尚未完全闡明,因此我們研究的目的是闡明阿密曲替林與人Kv1.1Kv7.2/7.3通道、Kv7.2/7.3通道開放瑞替濱相互作用的特徵。

方法:Kv1.1Kv7.2/7.3通道表達在人胚胎腎細胞和中國倉鼠卵母巢細胞,使用膜片鉗術研究阿密曲替林和瑞替濱的作用。

結果:阿密曲替林呈可逆和濃度依賴地制Kv1.1Kv7.2/7.3通道。IC50值分別為22±3µM(n=33)10±1µM (n=40)Kv7.2/7.3通道的去活內向電流也受到制,IC50值為4.2±0.6 µM(n=32)。阿密曲替林可逆地制Kv7.2/7.3通道使靜息膜電位去極化。瑞替濱逆轉阿密曲替林對Kv7.2/7.3通道電流的制作用,以膜電位去極化作用。

結論:因為阿密曲替林僅在產生毒理學的相關血藥濃度制Kv1.1Kv7.2/7.3 通道,因此我們的研究表明了這些通道在阿密曲替林的神經興奮性不良反應中起的作用。由於阿密曲替林的制作用可以被瑞替濱逆轉,在治療神經性疼痛時,將阿密曲替林和瑞替濱複合給藥可以有額外的處。

(張瑩 馬皓琳 李士通校)

 

BACKGROUND: Kv1.1 and Kv7.2/7.3 channels control excitability of neuronal cells. As hyperexcitability is a sign of neuropathic pain, epilepsy, and anxiety disorders, these channels may be important molecular targets of amitriptyline that cause pharmacological as well as toxicological effects by altering neuronal excitability. Since the molecular mechanisms underlying these effects of amitriptyline have not been fully elucidated, we aimed to characterize the interaction of amitriptyline with human Kv1.1 and Kv7.2/7.3 channels. We also intended to establish the interaction of amitriptyline with the Kv7.2/7.3 channel opener, retigabine.

METHODS: Kv1.1 and Kv7.2/7.3 channels were expressed in human embryonic kidney cells and in Chinese hamster ovary cells. The effects of amitriptyline and retigabine were studied with the patch-clamp technique.

RESULTS: Amitriptyline inhibited Kv1.1 and Kv7.2/7.3 channels in a concentration-dependent and reversible manner. The IC50-value was 22 ± 3 µM (n = 33) and 10 ± 1 µM (n = 40), respectively. Deactivating inward currents of Kv7.2/7.3 channels were inhibited with an IC50-value of 4.2 ± 0.6 µM (n = 32). Inhibition of Kv7.2/7.3 channels by amitriptyline reversibly depolarized the resting membrane potential. Retigabine reversed both the inhibitory action of amitriptyline on Kv7.2/7.3 channels as well as the depolarization of the membrane potential.

CONCLUSIONS: Since amitriptyline inhibited Kv1.1 and Kv7.2/7.3 channels only at toxicologically relevant plasma concentrations, our results suggest a role for these channels in the neuroexcitatory side effects of amitriptyline. As the inhibitory effects of amitriptyline were reversed by retigabine, a combination of amitriptyline and retigabine could be of additional benefit in the therapy of neuropathic pain.


超聲介導下使用神經刺激法進行鎖骨下神經阻滯:一項前瞻性隨機試驗

Neurostimulation in Ultrasound-Guided Infraclavicular Block: A Prospective Randomized Trial

 

Emmanuel Dingemans, MD*, Stephan R. Williams, MD, PhD*, Geneviève Arcand, MD, FRCPC*, Philippe Chouinard, MD, FRCPC*, Patrick Harris, MD, FRCSC{dagger}, Monique Ruel, RN*, and François Girard, MD, FRCPC*

From the Department of *Anesthesiology and {dagger}Surgery, Centre Hospitalier de l’Université de Montréal, Hôpital Notre-Dame, Canada

Anesth Analg 2007;104:1275-1280

超聲介導下(USG)進行鎖骨下神經阻滯可以對進針和局麻藥的分佈提供即時顯像。USG阻滯時,局麻藥擴散的顯像是否能取代神經刺激作為局麻藥注射的終點,還從來沒有正式評價過。因此,在這項前瞻性隨機研究中,我們選取了72例計畫行手或前臂手術的患者,比較USG行鎖骨下神經阻滯時,單獨應用USGU組)和USG聯合神經刺激(S組)神經阻滯術完成的速度和阻滯效果。在U組,局麻藥放置在U型分佈的後面,在腋動脈的各個側面盡可能少的注射(29例患者注射了1次,6例患者注射了2次,3例患者注射了3次)。在S組,當用0.30.6mA之間的刺激電流獲得遠端運動反應後,單次注射1.5%利多卡因、0.125%的布比卡因和腎腺素1:200 000(最後濃度)共 0.5 mL/kgU組操作時間明顯短於S(分別為3.1 ± 1.6 分鐘和5.2 ± 4.7分鐘, P = 0.006)S37%的病人局麻藥主要擴散在腋動脈前面,63%的病人局麻藥主要擴散在後面。注射後30分鐘,U86%的病人肌皮神經、正中神經、尺神經、橈神經達到完全性感覺阻滯,而在S組僅有57%的病人達到(P = 0.007)。U組病人單次注射和多次注射兩種情況下完全阻滯的成率相同,均為86%。阻滯需要追的發生率,U組為8%S組為26%P = 0.049)。S組中一例病人由於20分鐘後肢體遠端不能得到刺激而失敗退出。我們得出結論,當將局麻藥擴散顯像用作注射的終點時,USG鎖骨下神經阻滯使操作快,而且產生了較高的成率。局麻藥在腋動脈後外側的擴散預示阻滯成,減少了直接神經顯像的需要。

(邱鬱薇 馬皓琳 李士通 校)

 

Ultrasound guidance (USG) for infraclavicular blocks provides real time visualization of the advancing needle and local anesthetic distribution. Whether visualization of local anesthetic spread can supplant neurostimulation as the end point for local anesthetic injection during USG block has never been formally evaluated. Therefore, for this prospective randomized study, we recruited 72 patients scheduled for hand or forearm surgery and compared the speed of execution and quality of USG infraclavicular block with either USG alone (Group U) or USG combined with neurostimulation (Group S). In Group U, local anesthetic was deposited in a U-shaped distribution posterior and to each side of the axillary artery using as few injections as possible (1, 2, and 3 injections in 29, 6, and 3 patients, respectively). In Group S, a single injection was made after obtaining a distal motor response with a stimulating current between 0.3 and 0.6 mA. The anesthetic solution consisted of 0.5 mL/kg of lidocaine 1.5%, bupivacaine 0.125%, and epinephrine 1:200 000 (final concentrations). Procedure times were significantly shorter in Group U compared with Group S (3.1 ± 1.6 min and 5.2 ± 4.7 min, respectively; P = 0.006). In Group S, anesthetic spread was mainly anterior to the axillary artery in 37% of patients and mainly posterior in 63% of patients. Thirty minutes after the injection, 86% of patients in Group U had complete sensory block in the musculocutaneous, median, radial, and ulnar nerve territories compared with 57% in Group S (P = 0.007). Patients blocked in Group U with a single injection had the same rate of complete block (86%) as those blocked with more than one injection (86%). Block supplementation rates were 8% in Group U versus 26% in Group S (P = 0.049). Block failure occurred in one patient in Group S because of an inability to obtain a distal stimulation after 20 min. We conclude that USG infraclavicular block is more rapidly performed and yields a higher success rate when visualization of local anesthetic spread is used as the end point for injection. Posterolateral spread of local anesthetic around the axillary artery predicts successful block, circumventing the need for direct nerve visualization.