Anesthesia & Analgesia

June 2007

CARDIOVASCULAR ANESTHESIA:

大血管手术后停用或继续用他汀类药物õ心脏能的影响

张俪译 薛张纲校

The Impact of Postoperative Discontinuation or Continuation of Chronic Statin Therapy on Cardiac Outcome After Major Vascular Surgery

Yannick Le Manach, Gilles Godet, Pierre Coriat, Claire Martinon, Michèle Bertrand, Marie-Hélène Fléron, and Bruno Riou

Anesth Analg 2007 104: 1326-1333.

吗啡和太尼õ选择性冠脉旁路移植术心肺转流时炎症反应的影响

张美荣 陈杰

The Effects of Morphine and Fentanyl on the Inflammatory Response to Cardiopulmonary Bypass in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery

Glenn S. Murphy, Joseph W. Szokol, Jesse H. Marymont, Michael J. Avram, and Jeffery S. Vender

Anesth Analg 2007 104: 1334-1342.

能性纤溶酶原激活物制剂的多态性可能影响心脏手术后凝血能õ

邱郁薇 马皓琳 李士通

Coagulopathy After Cardiac Surgery May Be Influenced by a Functional Plasminogen Activator Inhibitor Polymorphism

Edel Duggan, Michael J. O’Dwyer, Emma Caraher, Dara Diviney, Eilis McGovern, Dermot Kelleher, Ross McManus, and Thomas Ryan

Anesth Analg 2007 104: 1343-1347.

PEDIATRIC ANESTHESIA:

托下颌侧卧位õ阻塞性睡眠呼吸暂停综合征儿童麻醉中的心率变异性的影响

霞译 薛张纲校

The Effects of Jaw Thrust and the Lateral Position on Heart Rate Variability in Anesthetized Children with Obstructive Sleep Apnea Syndrome

Young-Chang P. Arai, Meiho Nakayama, Naoko Kato, Yoshiko Wakao, Hiroshi Ito, and Toru Komatsu

Anesth Analg 2007 104: 1352-1355.

小儿输尿管移植术病人单次骶管注入可õ定、吗啡或氢化吗啡酮联合罗哌卡因的比较

宋翠侠 陈杰

A Comparison of Single-Dose Caudal Clonidine, Morphine, or Hydromorphone Combined with Ropivacaine in Pediatric Patients Undergoing Ureteral Reimplantation

Thomas R. Vetter, Daniel Carvallo, Jodie L. Johnson, Michael S. Mazurek, and Robert G. Presson, Jr

Anesth Analg 2007 104: 1356-1363.

在高水õ吸入氧浓度的麻醉儿童中,呼吸末正压õ能性残气量和通气均匀性损伤的影响

彭中美 马皓琳 李士通

The Impact of Positive End-Expiratory Pressure on Functional Residual Capacity and Ventilation Homogeneity Impairment in Anesthetized Children Exposed to High Levels of Inspired Oxygen

Britta S. von Ungern-Sternberg, Adrian Regli, Andreas Schibler, Jürg Hammer, Franz J. Frei, and Thomas O. Erb

Anesth Analg 2007 104: 1364-1368.

AMBULATORY ANESTHESIA:

格拉司琼与昂õ司琼用于预防性应用昂õ司琼无效的术后患者的处理的初步研究

王时来译 薛张纲校

Granisetron Versus Ondansetron Treatment for Breakthrough Postoperative Nausea and Vomiting After Prophylactic Ondansetron Failure: A Pilot Study

Keith A. Candiotti, Fani Nhuch, Aimee Kamat, Krisnaprasad Deepika, Kristopher L. Arheart, David J. Birnbach, and David A. Lubarsky

Anesth Analg 2007 104: 1370-1373.

单次剂量镁剂õ日间手术后辅镇痛作用的评估:随机õ照研究

郑丽 陈杰

An Evaluation of a Single Dose of Magnesium to Supplement Analgesia After Ambulatory Surgery: Randomized Controlled Trial

Martin R. Tramèr and Chris J. Glynn

Anesth Analg 2007 104: 1374-1379.

麻醉医生在快通道手术中的角色:从多模式镇痛到围手术期的医疗理

黄丽娜 马皓琳 李士通

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care (Special Article

Paul F. White, Henrik Kehlet, Joseph M. Neal, Thomas Schricker, Daniel B. Carr, Franco Carli, and the Fast-Track Surgery Study Group

Anesth Analg 2007 104: 1380-1396.

ANESTHETIC PHARMACOLOGY:

异丙酚õ瑞太尼输注后引起痛觉过敏的调

杨译 薛张纲校

Modulation of Remifentanil-Induced Postinfusion Hyperalgesia by Propofol

Boris Singler, Andreas Tröster, Neil Manering, Jürgen Schüttler, and Wolfgang Koppert

Anesth Analg 2007 104: 1397-1403.

异氟醚、氟烷和巴比妥õ小鼠噪声性耳聋的影响

印洁敏 陈杰

The Effect of Isoflurane, Halothane and Pentobarbital on Noise-Induced Hearing Loss in Mice

Jong Woo Chung, Joong Ho Ahn, Jong Yang Kim, Hyun Jung Lee, Hun Hee Kang, Yoon Kyung Lee, Joung Uk Kim, and Seung-Woo Koo

Anesth Analg 2007 104: 1404-1408.

较大的肝脏手术后吗啡的代谢

张曦 译,马皓琳 李士通

Morphine Metabolism After Major Liver Surgery

Åsa Rudin, Johan F. Lundberg, Margareta Hammarlund-Udenaes, Per Flisberg, and Mads U. Werner

Anesth Analg 2007 104: 1409-1414.

利鲁唑一种谷氨酸放制剂诱导小鼠õ伤害性刺激反应的翻正反射消失、伤害和制

陈佳莉译 薛张纲校

Riluzole, a Glutamate Release Inhibitor, Induces Loss of Righting Reflex, Antinociception, and Immobility in Response to Noxious Stimulation in Mice

Masahiro Irifune, Nobuhito Kikuchi, Takuya Saida, Tohru Takarada, Yoshitaka Shimizu, Chie Endo, Katsuya Morita, Toshihiro Dohi, Tomoaki Sato, and Michio Kawahara

Anesth Analg 2007 104: 1415-1421.

õ有害刺激的反应小鼠大脑{gamma}-氨基丁酸酸性水õ的增导致翻正反射消失但非不

杨卫红 陈杰

Increased {gamma}-Aminobutyric Acid Levels in Mouse Brain Induce Loss of Righting Reflex, but Not Immobility, in Response to Noxious Stimulatio

Sohtaro Katayama, Masahiro Irifune, Nobuhito Kikuchi, Tohru Takarada, Yoshitaka Shimizu, Chie Endo, Takashi Takata, Toshihiro Dohi, Tomoaki Sato, and Michio Kawahara

Anesth Analg 2007 104: 1422-1429.

氨具有麻醉药õ性

吴俭 译,马皓琳 李士通

Ammonia Has Anesthetic Properties

Robert J. Brosnan, Liya Yang, Pavle S. Milutinovic, Jing Zhao, Michael J. Laster, Edmond I. Eger, II, and James M. Sonner

Anesth Analg 2007 104: 1430-1433.

局麻药利多卡因和普鲁卡因õ爪蟾卵表达的甘氨酸和γ-氨基丁酸受体的作用

陈珺珺译 薛张纲校

The Effects of the Local Anesthetics Lidocaine and Procaine on Glycine and {gamma}-Aminobutyric Acid Receptors Expressed in Xenopus Oocyte

Koji Hara and Takeyoshi Sata

Anesth Analg 2007 104: 1434-1439.

静脉麻醉药大脑浓度检测õ法(药代/药效分析法和质量守衡法)的比较

李惟一 陈杰

A Comparison of Pharmacokinetic/Pharmacodynamic versus Mass-Balance Measurement of Brain Concentrations of Intravenous Anesthetics in Sheep

Logan J. Voss, Guy Ludbrook, Cliff Grant, Richard Upton, and James W. Sleigh

Anesth Analg 2007 104: 1440-1446.

七氟醚:产品有不同吗?

朱慧 马皓琳 李士通

Sevoflurane: Are There Differences in Products? (Medical Intelligence)

Max T. Baker

Anesth Analg 2007 104: 1447-1451

地氟醚性肝炎与原和自身原õ异性IgG4体相关

吴德华译 薛张纲校

Desflurane Hepatitis Associated with Hapten and Autoantigen-Specific IgG4 Antibodies (Case Report)

James S. Anderson, Noel R. Rose, Jackie L. Martin, Edmond I. Eger, and Dolores B. Njoku

Anesth Analg 2007 104: 1452-1453.

TECHNOLOGY, COMPUTING, AND SIMULATION:

使用麻醉信息管理系统时麻醉记录完整性的研究

李惟一 陈杰

An Observational Study of Anesthesia Record Completeness Using an Anesthesia Information Management System

William D. Driscoll, Mary Ann Columbia, and Robert A. Peterfreund

Anesth Analg 2007 104: 1454-1461.

麻醉信息管理系统中入交互性可视提醒õ按时应用预防性生素的影响

黄佳佳译,马皓琳,李士通校

The Effect of an Interactive Visual Reminder in an Anesthesia Information Management System on Timeliness of Prophylactic Antibiotic Administration

David B. Wax, Yaakov Beilin, Matthew Levin, Neil Chadha, Marina Krol, and David L. Reich

Anesth Analg 2007 104: 1462-1466.

 

CRITICAL CARE AND TRAUMA:

 

一例发生于糖尿病人的严重低血糖——与使用艾考精õ膜透析液有关

璇译 薛张纲校

Significant Hypoglycemia Secondary to Icodextrin Peritoneal Dialysate in a Diabetic Patient (Case Report)

Henry R. Kroll and Thomas R. Maher

Anesth Analg 2007 104: 1473-1474.

给予正常高限镁剂后减轻快速输注晶体液导致的凝血变化

周懿õ 陈杰

The Coagulation Changes Induced by Rapid In Vivo Crystalloid Infusion Are Attenuated When Magnesium Is Kept at the Upper Limit of Norma

Thomas G. Ruttmann, Luis F. Montoya-Pelaez, and Michael F. M. James

Anesth Analg 2007 104: 1475-1480.

NEUROSURGICAL ANESTHESIA:

õ有运障碍进行深部脑刺激电极植入术的患者使用双频指数监测不能õ善麻醉表现

裘毅敏 译,马皓琳 李士通

Bispectral Index Monitoring Does Not Improve Anesthesia Performance in Patients with Movement Disorders Undergoing Deep Brain Stimulating Electrode Implantation

Uwe Schulz, Didier Keh, Christoph Barner, Udo Kaisers, and Willehad Boemke

Anesth Analg 2007 104: 1481-1487.

右旋美托咪啶õ兔肌运诱发电位作用

王光妍译 薛张纲校

The Effects of Dexmedetomidine on Myogenic Motor Evoked Potentials in Rabbits

Yuri Yamamoto, Masahiko Kawaguchi, Meiko Kakimoto, Satoki Inoue, and Hitoshi Furuya

Anesth Analg 2007 104: 1488-1492.

全身麻醉õ脑磁波描记术成检出间断癫痫样活的影响的回顾性分析

周懿õ 陈杰

A Retrospective Analysis of the Effect of General Anesthetics on the Successful Detection of Interictal Epileptiform Activity in Magnetoencephalography

Guruswamy Balakrishnan, Kavita M. Grover, Karen Mason, Brien Smith, Gregory L. Barkley, Norman Tepley, and Susan M. Bowyer

Anesth Analg 2007 104: 1493-1497.

颈脉内丙酚注射后大脑电静止是转换时间的一个函数

马皓琳 李士通

Electrocerebral Silence After Intracarotid Propofol Injection Is a Function of Transit Time

Mei Wang and Shailendra Joshi

Anesth Analg 2007 104: 1498-1503.

PAIN MEDICINE:

Contulakin-G在鼠和狗的蛛网膜下和硬膜外中伤害效应的评价

陈勇柱译 薛张纲校

An Assessment of the Antinociceptive Efficacy of Intrathecal and Epidural Contulakin-G in Rats and Dogs

Jeffrey W. Allen, Katrin Hofer, Damon McCumber, John D. Wagstaff, Richard T. Layer, R. Tyler McCabe, and Tony L. Yaksh

Anesth Analg 2007 104: 1505-1513.

小猎鞘内注射CGX-1160的药代学研究的数据分析

顾新宇 陈杰

The Pharmacokinetics of the Conopeptide Contulakin-G (CGX-1160) After Intrathecal Administration: An Analysis of Data from Studies in Beagles

Steven E. Kern, Jeff Allen, John Wagstaff, Steven L. Shafer, and Tony Yaksh

Anesth Analg 2007 104: 1514-1520.

在整形外科手术中帕瑞考昔的给药时机õ镇痛效果的影响

姜旭晖译 马皓琳 李士通校

The Influence of Timing of Administration on the Analgesic Efficacy of Parecoxib in Orthopedic Surgery

Valéria Martinez, Anissa Belbachir, Aithem Jaber, Kamel Cherif, Adel Jamal, Yves Ozier, Daniel I. Sessler, Marcel Chauvin, and Dominique Fletcher

Anesth Analg 2007 104: 1521-1527.

脂质体包õ的啰哌卡因用于口唇粘膜的局部麻醉

周时蓓译 薛张纲校

Liposome-Encapsulated Ropivacaine for Topical Anesthesia of Human Oral Mucosa

Michelle Franz-Montan, André L. R. Silva, Karina Cogo, Cristiane de C. Bergamaschi, Maria C. Volpato, José Ranali, Eneida de Paula, and Francisco C. Groppo

Anesth Analg 2007 104: 1528-1531.

镁剂作为辅用药用于术后止痛:随机试验的系统综述

丁震敏 陈杰

Magnesium as an Adjuvant to Postoperative Analgesia: A Systematic Review of Randomized Trials

Christopher Lysakowski, Lionel Dumont, Christoph Czarnetzki, and Martin R. Tramèr

Anesth Analg 2007 104: 1532-1539.

多峰止痛用于预防异丙酚引起的注射痛:联合应用瑞太尼和利多卡因预处理与单用瑞太尼或利多卡因的比较

唐李隽 马皓琳 李士通

Multimodal Analgesia to Prevent Propofol-Induced Pain: Pretreatment with Remifentanil and Lidocaine Versus Remifentanil or Lidocaine Alone

Marie T. Aouad, Sahar M. Siddik-Sayyid, Achir A. Al-Alami, and Anis S. Baraka

Anesth Analg 2007 104: 1540-1544

外科病人围术期应用巴喷丁/普巴林是否有?有关安全性有效性的系统综述

王丽珺译 薛张纲校

Do Surgical Patients Benefit from Perioperative Gabapentin/Pregabalin? A Systematic Review of Efficacy and Safety

Elina M. Tiippana, Katri Hamunen, Vesa K. Kontinen, and Eija Kalso

Anesth Analg 2007 104: 1545-1556.

PAIN MECHANISMS:

大鼠局部注射丙酚的伤害效应是部分通过大麻素CB1 CB2受体介导的

黄施伟 马皓琳 李士通

The Antinociceptive Effects of Local Injections of Propofol in Rats Are Mediated in Part by Cannabinoid CB1 and CB2 Receptors

Josée Guindon, Jesse LoVerme, Daniele Piomelli, and Pierre Beaulieu

Anesth Analg 2007 104: 1563-1569

鼠试验性神经病变与焦虑和郁引起的延迟性行为õ变有关

琳译 薛张纲校

Experimental Neuropathy in Mice Is Associated with Delayed Behavioral Changes Related to Anxiety and Depression

Takahiro Suzuki, Mitsuyuki Amata, Gaku Sakaue, Shinya Nishimura, Takaya Inoue, Masahiko Shibata, and Takashi Mashimo

Anesth Analg 2007 104: 1570-1577.

REGIONAL ANESTHESIA:

连续外周神经阻滞在整形外科手术病人中的õ发症不良反应

胡õ 马皓琳 李士通

Complications and Adverse Effects Associated with Continuous Peripheral Nerve Blocks in Orthopedic Patient

Martin Wiegel, Udo Gottschaldt, Ria Hennebach, Thilo Hirschberg, and Andreas Reske

Anesth Analg 2007 104: 1578-1582.

颈部屈伸运õ高位胸段硬膜外腔造影剂分布的影响

孙敏莉译 薛张纲较

The Influence of Neck Flexion and Extension on the Distribution of Contrast Medium in the High Thoracic Epidural Space

Chul Joong Lee, Yunseok Jeon, Young Jin Lim, Jae Hyon Bahk, Yong Chul Kim, Sang Chul Lee, and Chong Sung Kim

Anesth Analg 2007 104: 1583-1586.

术前胰岛素患者在使用硬膜外麻醉和镇痛后可减少术后胰岛素的发生率

õ琼慧 陈杰

Epidural Anesthesia and Analgesia Decrease the Postoperative Incidence of Insulin Resistance in Preoperative Insulin-Resistant Subjects Only

Francesco Donatelli, Angelo Vavassori, Simona Bonfanti, Piervirgilio Parrella, Luca Lorini, Roberto Fumagalli, and Franco Carli

Anesth Analg 2007 104: 1587-1593.

肛周椎管内阻滞与鞍部椎管内阻滞的前瞻性随机双盲的比较研究

顾新宇 陈杰

Spinal Perianal Block: A Prospective, Randomized, Double-Blind Comparison with Spinal Saddle Block (Brief Report)

Medhat R. Wassef, Emil I. Michaels, Jeffrey M. Rangel, and Arkadiy T. Tsyrlin

Anesth Analg 2007 104: 1594-1596.

 

血管手术后停用或继续用他汀类药物õ心脏能的影响

The Impact of Postoperative Discontinuation or Continuation of Chronic Statin Therapy on Cardiac Outcome After Major Vascular Surgery

Yannick Le Manach, Gilles Godet, Pierre Coriat, Claire Martinon, Michèle Bertrand, Marie-Hélène Fléron, and Bruno Riou

Department of Anesthesiology and Critical Care, Centre Hospitalier Universitaire Pitie-Salpetriere, Assistance-Publique Hopitaux de Paris, Universite Pierre et Marie Curie-Paris 6, Paris, France.

Anesth Analg 2007 104: 1326-1333.

 

背景:他汀类药物可以减少非手术人群的心脏发病率,õ于手术病人õ有处。我们随访了那些接受大血管手术后继续使用他汀类药物的病人,检查心脏能,õ与那些术后停止使用他汀类药物的病人作õ照。õ法:前瞻性地收集接受肾下性õ主脉瘤手术的病人围手术期心脏发病率与他汀类药物的关系。在2001õ1月至2003õ12月期间,还没有关于围手术期继续使用他汀类药物的相关指南(停用他汀类药物组,n491)。从2004õ1月开始,指南提出手术后应该尽可能早地使用他汀类药物(非停用他汀类药物组,n178)。心肌坏死的发生(定õ为心肌肌钙蛋白I的增超过第99个百分õ或者是多于0.2ng/ml)。组内分析(prospensity评分)和组外分析(Lee评分)都做了风险校正。结果:由于手术缘故的停止服药延迟的时间长度在停药组和非停药组中分别为4天和1天(p<0.001),用prospensity评分õ组内术前可能接受过治疗的进行校正,长期服用他汀类药物以术后早期没有继续服用他汀类药物的组(即非停药组和停药组)预测患者心肌坏死的比值比(OR值)分别为0.382.1(相õ危险性的减少值为5.495%的可信区间:1.225.3p<0.001)。用Lee评分校正后的比值比在非停药组中为0.38,在停药组中为2.1(相õ危险性的减少值为5.595%的可信区间:1.226.0p<0.001)。术后停用他汀类药物(>4天)是术后发生心肌坏死的一õ独立的预测指标(OR 2.995%的可信区间:1.6-5.5)。结论:接受大血管手术后停用他汀类药物会增术后心脏的危险性,建议大血管手术后尽早地继续使用他汀类药物治疗。

(张俪译 薛张纲校)

BACKGROUND: Statins reduce cardiac morbidity in nonsurgical populations, and may benefit surgical patients. We sought to examine cardiac outcome in patients who continued, compared with those who discontinued, statin therapy after major vascular surgery. METHODS: Prospectively collected data were examined for an association between statin therapy and perioperative cardiac morbidity in patients undergoing infrarenal aortic surgery. Between January 2001 and December 2003, there were no guidelines for perioperative continuation of statins (discontinuation group, n = 491). From January 2004, guidelines were instituted whereby statin therapy was continued starting as soon as possible after surgery (continuation group, n = 178). The occurrence of cardiac myonecrosis (defined as an increase of cardiac troponin I more than the 99th percentile or 0.2 ng/mL) was analyzed. Intra-cohort (propensity score) and extra-cohort (Lee score) adjustments of the risk were performed. RESULTS: The median delay between surgery and resumption of statin therapy was 4 days and 1 day in the discontinuation and continuation groups (P < 0.001), respectively. Using propensity score matching for likelihood of preoperative treatment, the odds ratio associated with chronic statin treatment to predict myonecrosis for patients with versus without early postoperative statin resumption (continuation versus discontinuation groups) was 0.38 and 2.1 (relative risk reduction of 5.4; 95% confidence interval: 1.2-25.3, P < 0.001), respectively. The odds ratio after adjustment for the Lee score was 0.38 in the continuation group and 2.1 in the discontinuation group (relative reduction of 5.5; 95% confidence interval: 1.2-26.0, P < 0.001). Postoperative statin withdrawal (>4 days) was an independent predictor of postoperative myonecrosis (OR 2.9, 95% confidence interval 1.6-5.5). CONCLUSIONS: Discontinuation of statin therapy after major vascular surgery is associated with an increased postoperative cardiac risk, suggesting that statin therapy should be resumed early after major vascular surgery.

 

托下颌侧卧位õ阻塞性睡眠呼吸暂停综合征儿童麻醉中的心率变异性的影响

The Effects of Jaw Thrust and the Lateral Position on Heart Rate Variability in Anesthetized Children with Obstructive Sleep Apnea Syndrome

Young-Chang P. Arai, MD*, Meiho Nakayama, MD{dagger}, Naoko Kato, DDS{ddagger}, Yoshiko Wakao, MD{ddagger}, Hiroshi Ito, MD{ddagger}, and Toru Komatsu, MD{ddagger}

From the *Multidisciplinary Pain Centre; and Departments of {dagger}Otolaryngology and {ddagger}Anaesthesiology, Aichi Medical University, School of Medicine, Nagakutecho, Aichigun, Aichi, Japan.

Address correspondence and reprint requests to: Young-Chang P. Arai, MD, Multidisciplinary Pain Centre, Aichi Medical University, School of Medicine, 21 Karimata, Nagakutecho, Aichigun, Aichi, 480-1195, Japan.

Anesth Analg 2007 104: 1352-1355.

 

背景:气道阻塞发生于OSAS儿童的麻醉中。吸气õ闭塞的气道导致交感神经活性增。õ心率变异性(HRV)的分析提供了关于自主神经系统的信息。HRV低频/高频比例被认为是交感、副交感õ衡的指标。õ法:我们研究了20OSAS儿童(3-9岁)全麻、颈正中位仰卧、侧卧位托下颌õHRV的影响。HRV被记录于麻醉诱导前诱导后,病人吸入5%的七氟醚õ处于颈正中位托下颌于仰卧位或侧卧位。结果:取颈正中位全麻的病人增气道梗阻。托下颌侧卧位õ善了病人的喘鸣音评分。低频/高频比例心率在诱导后增且取颈正中位的病人达到最高值。该值在仰卧位侧卧位托下颌的病人中显著下降。麻醉诱导后HRV短期下降,在取正中位病人中达最低值。该值在仰卧侧卧位托下颌的病人中增。结论:吸入麻醉、托下颌侧卧位导致的HRVõ变与OSAS儿童喘鸣音评分的õ变相符。

(孙 霞译 薛张纲校)

BACKGROUND: Airway obstruction occurs in anesthetized children with obstructive sleep apnea syndrome (OSAS). The inspiratory attempts against the occluded airway lead to an increased sympathetic activity. Heart rate variability (HRV) analysis provides information about the autonomic nervous system. The low-frequency component/high-frequency component ratio of HRV is considered to be an index of sympatho-parasympathetic balance. METHODS: We investigated the effects of general anesthesia, the neutral neck position, and jaw thrust in the supine and lateral positions on HRV in 20 children (aged 3–9 yr), with OSAS. HRV was recorded before and after anesthesia induction, at the neutral neck position and with jaw thrust maneuver in the supine and lateral positions with the patients breathing 5% sevoflurane. RESULTS: General anesthesia with the patient in the neutral neck position increased airway obstruction. The patients’ stridor scores improved with the airway maneuver of jaw thrust and lateral position. The low-frequency component/high-frequency component ratio and heart rate increased at the postinduction measurement and reached the highest value with the patient in the neutral neck position. The values significantly decreased with the jaw thrust maneuver and with the patient in the supine and lateral positions. Ultra-short-term entropy of HRV decreased after anesthetic induction and reached the lowest value with the patient in the neutral neck position. The values increased during jaw thrust and with patients in the supine and lateral positions. CONCLUSIONS: Changes of HRV induced by inhaled anesthesia, jaw thrust, and lateral positioning procedures corresponded to changes in the stridor score of children with OSAS.

 

 

格拉司琼与昂õ司琼用于预防性应用昂õ司琼无效的术后患者的处理的初步研究

Granisetron Versus Ondansetron Treatment for Breakthrough Postoperative Nausea and Vomiting After Prophylactic Ondansetron Failure: A Pilot Study

Keith A. Candiotti, MD, Fani Nhuch, MD, Aimee Kamat, MD, Krisnaprasad Deepika, MD, Kristopher L. Arheart, EdD, David J. Birnbach, MD, MPH, and David A. Lubarsky, MD, MBA.

Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, Florida 33101, USA.

Anesth Analg 2007 104: 1370-1373.

 

引言:随着术后恶心呕吐(PONV)发生风险的增,常给予患者预防剂量的选择性5-羟色胺-35HT3)受体拮剂。õ于化疗病人,已经证实当一个5HT3拮剂治疗无效时,另一个不同的5HT3拮剂可以缓解症。我们假设可以通过一õõPONV的交叉初步研究明确5HT3的处。在手术结束时,给予250名接受了全麻的女性患者4mg预防性的昂õ司琼,õ在术后4小时进行随访。õ法:88名女性发生了PONV,然后随机地给予重复剂量的4mg昂õ司琼(n30),1mg格拉司琼(n30),或者0.1mg格拉司琼(n28),然后随访24小时。结果:接受重复剂量昂õ司琼的患者有效率为57%,接受0.11mg格拉司琼的患者有效率分别为60%和68%。这一差异õ没有统计学意õ(P0.773)。结论:不同于化疗诱发恶心呕吐的患者,交叉剂量的格拉司琼õ预防性应用昂õ司琼无效的手术患者õ没有明显的效果。

(王时来译 薛张纲校)

INTRODUCTION: Patients with an increased risk of postoperative nausea and vomiting (PONV) are frequently given prophylactic doses of a selective 5-hydroxytryptamine-3 antagonist (5HT3). In chemotherapy patients, it has been demonstrated that after unsuccessful treatment with one 5HT3 administering a different 5HT3 alleviated symptoms. We hypothesized that we could define a benefit of a 5HT3, cross-over in a pilot study of PONV. Two-hundred-fifty female patients received prophylactic ondansetron 4 mg at the end of a surgical procedure requiring general anesthesia and were then followed postoperatively for 4 h. METHODS: Eighty-eight women developed PONV and were randomly assigned to receive a repeat dose of ondansetron 4 mg (n = 30), granisetron 1 mg (n = 30), or granisetron 0.1 mg (n = 28) and then followed for 24 h. RESULTS: Patients receiving the repeat dose of ondansetron showed a complete response of 57%. Those receiving 1 or 0.1 mg doses of granisetron had rates of 60% and 68%, respectively. This difference was not statistically significant (P = 0.773). CONCLUSION: Unlike patients with chemotherapy-induced nausea and vomiting, perioperative patients who failed ondansetron prophylaxis did not have a significant response to cross-over dosing with granisetron.

 

 

异丙酚õ瑞太尼输注后引起痛觉过敏的调

Modulation of remifentanil-induced postinfusion hyperalgesia by propofol.

Boris Singler, Andreas Tröster, Neil Manering, Jürgen Schüttler, and Wolfgang Koppert

Department of Anesthesiology, University Hospital Erlangen, Erlangen, Germany.

Anesth Analg 2007 104: 1397-1403.

 

背景:实验与临研究表明大多数的阿片类药物可增强痛觉敏感性.麻醉过程中,阿片类药物通常和静脉或吸入麻醉药一同使用.我们利用疼痛人体实验模型研究低于催眠剂量的异丙酚是否具有õ由瑞太尼输注后引起的痛觉过敏和止痛作用.õ法:15个健康的支援者入了这个随机、双盲、安慰剂õ照的交叉配õ实验.高电流密度的经皮电刺激(41.7 +/- 14.3 mA)可诱发急性疼痛õ产生一个稳定的痛觉过敏区域.同时或分别给予实验者异丙酚(1.5mg/kg)和瑞太尼(0.05mg/kg/min)的靶控输注,õ痛觉的强度和痛觉过敏的区域进行输注前、输注中和输注30分钟后的评估.结果:在输注中, 异丙酚明显比õ照组减轻电刺激引起的疼痛(72% +/- 21%),低于催眠剂量的异丙酚不会引起任何痛觉过敏效应.同时输注瑞太尼有协同止痛效果(0.025mg/kg/min0.05mg/kg/min的瑞太尼分别比õ照组减轻疼痛62% +/- 26%58% +/- 25%),但是撤药后,疼痛和痛觉过敏要比õ照组增.结论:结果反应了异丙酚和瑞太尼在临õ人体的相互作用. 那就是异丙酚可延迟或弱瑞太尼输注后引起的止痛作用.尽管如此,疼痛效应õ没有完全被异丙酚所õ,这就解了在以瑞太尼为主的麻醉实施后õ镇痛药需求的增.

( 杨译 薛张纲校)

BACKGROUND: Experimental and clinical studies suggest that brief opioid exposure can enhance pain sensitivity. During anesthesia, however, opioids are commonly administered in combination with either IV or inhaled hypnotic drugs. In this investigation we sought to determine the analgesic and antihyperalgesic properties of propofol in subhypnotic concentrations on remifentanil-induced postinfusion hypersensitivity in an experimental human pain model. METHODS: Fifteen healthy volunteers were included in this randomized, double-blind, and placebo-controlled study in a cross-over design. Transcutaneous electrical stimulation at high current densities (41.7 +/- 14.3 mA) induced spontaneous acute pain (numerical rating scale = 6 of 10) and stable areas of hyperalgesia. Pain intensities and areas of hyperalgesia were assessed before, during and after a 30 min target-controlled infusion of propofol (1.5 microg/mL) and remifentanil (0.05 microg x kg(-1) x min(-1)), either alone or in combination (propofol 1.5 microg/mL with remifentanil 0.025 or 0.05 microg x kg(-1) x min(-1)). RESULTS: During infusion, propofol significantly reduced the electrically evoked pain to 72% +/- 21% of control. Subhypnotic concentrations of propofol did not lead to any hyperalgesic effects. Coadministration of remifentanil led to synergistic analgesic effects (to 62% +/- 26% and 58% +/- 25% of control, for 0.025 or 0.05 microg x kg(-1) x min(-1), respectively), but upon withdrawal, pain and hyperalgesia increased above control level. CONCLUSIONS: The results suggest clinically relevant interactions of propofol and remifentanil in humans, since propofol led to a delay and a weakening of remifentanil-induced postinfusion anti-analgesia in humans. Nevertheless, pronociceptive effects were not completely antagonized by propofol, which may account for the increased demand for analgesics after remifentanil-based anesthesia in clinical practice.

 

 

利鲁唑一种谷氨酸放制剂诱导小鼠õ伤害性刺激反应的翻正反射消失、伤害和制

Riluzole, a Glutamate Release Inhibitor, Induces Loss of Righting Reflex, Antinociception, and Immobility in Response to Noxious Stimulation in Mice

Masahiro Irifune,Nobuhito Kikuchi,Takuya Saida,Tohru Takarada,Yoshitaka Shimizu, Chie Endo,Katsuya Morita,Toshihiro Dohi,Tomoaki Sato,and Michio Kawahara

Address correspondence and reprint requests to Masahiro Irifune, DDS, PhD, Department of Dental Anesthesiology, Division of Clinical Medical Science, Programs for Applied Biomedicine, Graduate School of Biomedical Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan

Anesth Analg 2007 104: 1415-1421.

 

背景:全身麻醉态由行为的和感知觉的成分构成,包括遗忘、无意识、无痛觉和制。在体外,谷氨酸能兴奋性神经元在细胞和微电路水õ是麻醉药作用的重要靶向。利鲁唑(2-氨基-6-[三糖甲氧]苯噻唑)是一种神经保药,在中枢神经系统制神经末梢的谷氨酸放。这里,我们检验了体内利鲁唑能选择性阻滞谷氨酸能神经递质,由此产生全身麻醉态。õ法:õ成õddY雄鼠õ膜内给予利鲁唑。使用三个终õ来评估全麻态:1)翻正反射消失(LORR,作为无意识的测量标准),2)õ伤害性刺激反应的运消失(作为制的测量标准),3)疼痛反应消失(作为无痛觉的测量标准)。结果:利鲁唑õ膜内给药诱发剂量依赖性翻正反射消失的50%有效剂量为27.423.332.295%可信区间)mg/kg。行为表现和微分析研究揭示了利鲁唑诱导的损害和翻正反射消失的时间-过程õ变与鼠脑中谷氨酸降低水õ一致。这表明,利鲁唑诱导的翻正反射消失(无意识),至少一部分,是由于它降低了脑内谷氨酸浓度。利鲁唑不仅剂量依赖性地产生翻正反射消失,还产生õ痛觉刺激反应的运消失(制),以疼痛反应消失(无痛觉),其50%有效剂量分别为43.037.149.9mg/kg10.07.4-13.5mg/kg。这三个剂量-反应曲线是õ行的,表明利鲁唑的行为效应是通过一个共同的作用位õ介导的。结论:这些发现表明利鲁唑诱导的翻正反射消失、制和伤害与它制中枢神经系统谷氨酸能神经递质的能有关。

(陈佳莉译 薛张纲校)

BACKGROUND: The general anesthetic state comprises behavioral and perceptual components, including amnesia, unconsciousness, analgesia, and immobility. In vitro, glutamatergic excitatory neurons are important targets for anesthetic action at the cellular and microcircuits levels.Riluzole(2-amino-6-[trifluoromethoxy]benzoth- iazole) is a neuroprotective drug that inhibits glutamate release from nerve terminals in the central nervous system. Here, we examined in vivo the ability of riluzole to produce components of the general anesthetic state through a selective blockade of glutamatergic neurotransmission.METHODS: Riluzole was administered intraperitoneally in adult male ddY mice. To assess the general anesthetic components, three end-points were used: 1) loss of righting reflex(LORR; as a measure of unconsciousness), 2) loss of movement in response to noxious stimulation (as a measure of immobility), and 3) loss of nociceptive response (as a measure of analgesia). RESULTS: The intraperitoneal administration of riluzole induced LORR in a dose-dependent fashion with a 50% effective dose value of 27.4 (23.3–32.2; 95% confidence limits) mg/kg. The behavioral and microdialysis studies revealed that time-course changes in impairment and LORR induced by riluzole corresponded with decreased glutamate levels in the mouse brain. This suggests that riluzole-induced LORR (unconsciousness) could result, at least in part, from its ability to decrease brain glutamate concentrations. Riluzole dose-dependently produced not only LORR, but also loss of movement in response to painful stimulation (immobility), and loss of nociceptive response (analgesia) with 50% effective dose values of 43.0 (37.1–49.9), and 10.0 (7.4–13.5) mg/kg, respectively. These three dose–response curves were parallel, suggesting that the behavioral effects of riluzole may be mediated through a common site of action.CONCLUSIONS: These findings suggest that riluzole-induced LORR, immobility, and antinociception appear to be associated with its ability to inhibit glutamatergic neurotransmission in the central nervous system.

 

 

局麻药利多卡因和普鲁卡因õ爪蟾卵表达的甘氨酸和γ-氨基丁酸受体的作用

The Effects of the Local Anesthetics Lidocaine and Procaine on Glycine and -Aminobutyric Acid Receptors Expressed in Xenopus Oocytes
Koji Hara, MD, PhD, and Takeyoshi Sata, MD, PhD

From the Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan.

Address correspondence and reprint requests to Koji Hara, MD, PhD, Department of Anesthesiology, University of Occupational and Environmental Health, School of Medicine, 1-1, Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan.

Anesth Analg 2007 104: 1434-1439.

 

背景:电压依赖性钠通道是局麻药作用的基本位õ。尽管全身给予低剂量的局麻药可以产生镇痛效果,但是这种效果的分子靶õ尚不清楚,与õ相关的制性神经递质受体的研究不充分。õ法:我们应用双极电压钳位系统检测了利多卡因和普鲁卡因(0.1 µM 3 10 mM)õ非洲爪蟾卵表达的人突变体α1甘氨酸和α1β2γ2Sγ-GABAA和ρ1 GABAC受体的作用。我们还评估了局麻药在两种突变甘氨酸受体α1(S267C) and α1 (S267Q)的作用,以此来了解局麻药和甘氨酸受体的相互作用。结果:在低浓度的情况下,利多卡因和普鲁卡因可以增强甘氨酸受体的能,但在高浓度的情况下,都可以制甘氨酸受体的能。利多卡因(10µM)可以使甘氨酸浓度效应曲线显著左移,这表明增了其与甘氨酸的亲和。这种增强作用在突变体受体中õ可以观察到。利多卡因和普鲁卡因在高浓度的情况下可以制GABA A受体的作用,但是利多卡因和普鲁卡因õGABA C受体的能没有影响。结论:在低浓度的情况下,利多卡因和普鲁卡因可以增强甘氨酸受体的能,但在高浓度的情况下,可以制甘氨酸和GABA A受体的能。局麻药所致的增强甘氨酸受体能可能与全麻药的机制不同。这些发现可能可以解局麻药的一些药理作用,如伤害性刺激和致厥。

(陈珺珺译 薛张纲校)

BACKGROUND: The voltage-dependent sodium channel is the primary site of action for local anesthetics (LAs). Although systemically administered low-dose LAs have been shown to exert antihyperalgesic effects, the molecular targets responsible for these effects are not fully known and their functional effects on inhibitory neurotransmitter receptors associated with antinociception have not been sufficiently studied. METHODS: We examined the effects of lidocaine and procaine (0.1 µM to 3 or 10 mM) on recombinant human α1 glycine, α1β2γ2Sγ-aminobutyric acid type A (GABAA), andρ1 GABAC receptors expressed in Xenopus laevis oocytes, using a two-electrode voltage-clamp system. We also evaluated the effects of LAs on two mutant glycine receptors, α1 (S267C) andα1 (S267Q), in an effort to clarify the interaction between LAs and glycine receptors. RESULTS: Low concentrations of both lidocaine and procaine enhanced glycine receptor function, whereas high concentrations of lidocaine and procaine inhibited glycine receptor function. Lidocaine (10 µM) produced a significant leftward shift in the glycine concentration-response curve, indicating an increase in the apparent affinity for glycine. This enhancement was not altered in the mutant receptors. Both lidocaine and procaine at high concentrations inhibited GABAA receptor currents, whereas neither lidocaine nor procaine affected GABAC receptor function. CONCLUSIONS: Lidocaine and procaine enhanced glycine receptor function at low concentrations and inhibited the functions of glycine and GABAA receptors at high concentrations. The mechanism of the LA-induced enhancement of glycine receptor function probably differs from that of general anesthetics. These findings may explain the pharmacological effects of LAs, such as antinociception and convulsion.

地氟醚性肝炎与原和自身原õ异性IgG4体相关

Desflurane hepatitis associated with hapten and autoantigen-specific IgG4 antibodies.

Anderson JS, Rose NR, Martin JL, Eger EI, Njoku DB.

Anesthesia Consultants Associated, El Paso, Texas, USA.

Anesth Analg. 2007 104(6):1452-3.

 

背景:有3例病例道在地氟醚麻醉后出现药物诱发性肝损害。然而,这些道中没有检测患者血清中的自身体,而既往的氟烷或异氟醚诱导的肝损害则检测过患者血清中的自身体。õ法和结果:我们第一次检测了一例地氟醚诱导的肝损害患者血清中的细胞色素P450 2E1 IgG4自身体、58kDa内质网蛋白和三氟õ酰氯化原õ异性IgG4体。结论:结果显示过敏性和自身免疫性机制地氟醚诱导的肝损害发挥了重要作用。

(吴德华译 薛张纲校)

BACKGROUND: Three cases of drug-induced liver injury (DILI) have been reported after desflurane anesthesia. However, no previous reports have detected serum autoantibodies such as that reported with DILI from halothane or isoflurane. METHODS AND RESULTS: We describe the first documentation of cytochrome P450 2E1 IgG4 autoantibodies, as well as 58 kDa endoplasmic reticulum protein and trifluoroacetyl chloride hapten-specific IgG4 antibodies, in a patient who developed DILI after desflurane anesthesia. CONCLUSIONS: These findings suggest that allergic and autoimmune mechanisms have critical roles in the development of desflurane DILI.

 

一例发生于糖尿病人的严重低血糖——与使用艾考精õ膜透析液有关

Significant Hypoglycemia Secondary to Icodextrin Peritoneal Dialysate in a Diabetic Patient

Henry RK, Thomas RM

Department of Anesthesiology, Henry Ford Hospital, Detroit, Michigan.

Anesth Analg 2007 104:1473-1474

 

艾考精(Icodextrin)作为õ膜透析液,通常用于伴有糖尿病的肾衰病人,它可能误导旁血糖仪高估血糖水õ。未能认清这一高血糖假象会导致严重不良后果。由于未甄别的õ血糖的高估,一名合õ肾衰使用艾考精进行õ膜透析的糖尿病人发生严重低血糖,本文õ此作了道。

(罗 璇译 薛张纲校)

Icodextrin, a peritoneal dialysate commonly used in the renal failure patient with diabetes, may lead to an overestimation of blood glucose levels as determined by bedside glucometers. This spurious hyperglycemia can lead to significant morbidity if unrecognized. We describe a case of severe hypoglycemia caused by an unappreciated overestimation of blood glucose in a diabetic patient with concomitant chronic renal failure requiring peritoneal dialysis with icodextrin.

 

 

右旋美托咪啶õ兔肌运诱发电位作用

The Effects of Dexmedetomidine on Myogenic Motor Evoked Potentials in Rabbits

Yuri Yamamoto, MD, Masahiko Kawaguchi, MD, Meiko Kakimoto, MD, Satoki Inoue, MD, and Hitoshi Furuya, MD

From the Department of Anesthesiology, Nara Medical University, Nara, Japan.

Address correspondence and reprint requests to Masahiko Kawaguchi, MD, Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8522, Japan.

Anesth Analg 2007;104:1488-1492

背景: 右旋美托咪啶一直以来被用于患者围手术期管理时的用药,包括用于围手术期间的辅用药。右旋美托咪啶在肌运诱发电位的作用还不确定。我们设计这õ研究来探索右旋美托咪啶在兔子肌运诱发电位中的作用。õ法:这õ研究使用的是新西兰的白兔。首先,要确定右旋美托咪啶作为辅药用于兔子麻醉的合适剂量,分别测定在52550100ug/kg /h浓度下眼睑和四肢的撤回反射以õ捏耳和õ尾的反映来评价麻醉程度。接下来,在10只使用氯胺酮和太尼麻醉的兔子,õ兔子的比目鱼肌肉进行单个刺激和五个成串刺激,记录在分别使用了5, 25, and 50 µg/kg/h的右旋美托咪啶前,中,后的肌运诱发电位。结果:在使用到50ug/kg/h的右旋美托咪啶时,超过50%的物眼睑反射,肢体反射,以õ捏耳的反映被制。但是õ尾反射没有减弱。右旋美托咪啶制肌运诱发电位呈剂量依赖关系,但是当出现多个刺激,在50 µg/kg/h的剂量时,肌运诱发电位可以在全部的物中被检测到。结论:氯胺酮和太尼麻醉下给予剂量的右旋美托咪啶,使用多个刺激测定兔子肌运诱发电位是可行的。

(王光妍译 薛张纲校)

BACKGROUND: Dexmedetomidine is used in the perioperative management of patients, including as an intraoperative adjuvant. The effects of dexmedetomidine on myogenic motor evoked potentials (MEPs) remain undetermined. We conducted the present study to investigate the effects of dexmedetomidine on myogenic MEPs in rabbits. METHODS: New Zealand white rabbits were used for the studies. First, to determine appropriate doses of dexmedetomidine as an adjunct for anesthesia in rabbits, the level of anesthesia was evaluated by testing the palpebral and limb withdrawal reflexes, and the reactions to ear pinching and tail clamp at 5, 25, 50, 100 µg/kg/h. Second, in 10 rabbits under ketamine and fentanyl anesthesia, myogenic MEPs in response to single pulse and a train-of-five pulses were recorded from the soleus muscle before, during, and after the administration of dexmedetomidine at 5, 25, and 50 µg/kg/hRESULTS: At 50 µg/kg/h of dexmedetomidine, palpebral reflex, limb reflex, and reaction to ear pinching were inhibited in >50% of animals, but the reaction to tail clamp was not reduced. Dexmedetomidine suppressed myogenic MEPs in a dose-dependent manner, but when multipulses were used for stimulation, could be recorded in all animals at 50 µg/kg/h. CONCLUSIONS: As long as multipulse is used for stimulation, the recording of myogenic MEPs is feasible in rabbits under ketamine and fentanyl anesthesia during the administration of dexmedetomidine at doses that are an adjunct to anesthesia.

 

Contulakin-G在鼠和狗的蛛网膜下和硬膜外中伤害效应的评价

 

An assessment of the antinociceptive efficacy of intrathecal and epidural Contulakin-G in rats and dogs

 

Allen JW, Hofer K, McCumber D, Wagstaff JD, Layer RT, McCabe RT, Yaksh TL

Department of Anesthesiology Research, University of California, San Diego, La Jolla, California 92093-0818, USA

Anesth Analg 2007 104: 1505-1513

 

Contulakin-G是一种新型的激机制õ未完全明确的螺毒素。为了评价伤害性活,我们分别单次在鼠蛛网膜下 (0.03, 0.1, 0.3, 3 nmol)或硬膜外 (10, 30, 89 nmol)输注Contulakin-G。蛛网膜下腔中硬膜外Contulakin-G明显地降低皮下注射福尔马林反应得Phase II,同时降低Phase I足爪缩回时间至一个很低的程度。蛛网膜下和硬膜外中药物的ED50s分别是0.07 nmol45 nmol,其比值是647。在狗中,蛛网膜下Contulakin-G(50-500 nmoL)导致30分时间õ热至皮肤刺痛延时呈剂量依赖性增,同样情况下吗啡(150450 nmol)。硬膜外吗啡(7507500 nmol),而不是硬膜外1000 nmol Contulakin-G,同样明显地降低购的皮肤刺痛。在接受Contulakin-G的鼠或狗中为观察到运能的变化。在狗中,未观察到明显的剂量依赖性的生理变化,如运能,心率,脉压或体温。Contulakin-G是一种极性的伤害药物,在鼠或狗的蛛网膜下输注未观察到不良反应,可提供替代性阿片类髓镇痛。

(陈勇柱译 薛张纲校)

Contulakin-G is a novel conopeptide with an incompletely defined mechanism of action. To assess nociceptive activity we delivered Contulakin-G as a bolus intrathecally (0.03, 0.1, 0.3, 3 nmol) or epidurally (10, 30, 89 nmol) in rats. Intrathecal Contulakin G significantly decreased Phase II and, to a lesser degree, Phase I paw flinching produced by intradermal formalin. Intrathecal and epidural doses of ED50s were 0.07 nmol and 45 nmol, respectively, giving an epidural/intrathecal ED50 ratio = 647). In dogs, intrathecal Contulakin-G (50-500 nmoL) produced a dose-dependent increase in the thermally evoked skin twitch latency by 30 min after administration, as did morphine (150 and 450 nmol). Epidural morphine (750 and 7500 nmol), but not epidural 1000 nmol Contulakin-G, also significantly decreased skin twitch in dogs. No changes in motor function were seen in any rats or dogs receiving these doses of Contulakin-G. In dogs, no physiologically significant dose-dependent changes in motor function, heart rate, arterial blood pressure, or body temperature were found. Contulakin-G is a potent antinociceptive drug when delivered intrathecally with no observable negative side effects in rats or dogs and may provide an alternative to opioid spinal analgesics.

 

 

脂质体包õ的啰哌卡因用于口唇粘膜的局部麻醉

Liposome-Encapsulated Ropivacaine for Topical Anesthesia of Human Oral Mucosa

 

Michelle Franz-Montan, André L. R. Silva, Karina Cogo, Cristiane de C. Bergamaschi, Maria C. Volpato, José Ranali, Eneida de Paula, and Francisco C. Groppo

Department of Physiological Sciences, Dentistry School of Piracicaba, Piracicaba, SP, Brazil

Anesth Analg 2007 104: 1528-1531

 

背景:局部麻醉用于消除针头插入粘膜所引起的疼痛将会成为牙科学显著的进步。õ法:在这õ双盲互换实验中,我们评估脂质体包õ的啰哌卡因用于局部麻醉的效能。30名健康志愿者接受60mg局部麻醉药:分别是脂质体包õ的1%啰哌卡因,未经包õ的1%啰哌卡因,2.5%利多卡因和2.5%丙胺卡因混合液(EMLA),以20%苯佐卡因明胶,用于右侧尖牙相õ的粘膜皱襞,维持2分钟。随后插入30-G的针头,疼痛程度用一种视觉模拟数据标度(VAS)来评价。用一个小试验来衡量局部麻醉持续的时间。用电牙髓测试器来测试牙髓的反应。结果:脂质体包õ的啰哌卡因,啰哌卡因,EMLA,以苯佐卡因组õ应的VAS数值的中数和四分位数间距分别是:0.8 (0.4-1.5), 1.6 (0.8-2.6), 1.1 (0.3-2.7), 2.2 (0.9-2.9)。脂质体包õ的啰哌卡因组相较于苯佐卡因组在VAS显示了更低的中数(P = 0.0205)。脂质体包õ的啰哌卡因,啰哌卡因,EMLA,以苯佐卡因的软组织麻醉持续时间的中数和四分位数间距分别是:11 (7-14), 6.5 (4-11), 14 (11-16), 7 (6-9)分钟。EMLA和脂质体包õ的啰哌卡因能很好的减轻疼痛,õ且较õ其他局部麻醉药有更长的软组织麻醉持续时间(P = 0.0001)。结论:脂质体包õ的1%啰哌卡因明胶与EMLA在减少针头插入粘膜所引起的疼痛õ面以软组织麻醉的持续时间õ面是不相下的。没有一种局部麻醉药õ于减少髓内麻醉是有效的。

(周时蓓译 薛张纲校)

BACKGROUND: The elimination of pain caused by needle insertion for local anesthesia would be a significant advance in dentistry. METHODS: In this blinded cross-over study we evaluated the efficacy of liposome-encapsulated ropivacaine for topical anesthesia. Thirty healthy volunteers received 60 mg topical anesthetics: Liposome-encapsulated 1% ropivacaine, 1% plain ropivacaine, 2.5% lidocaine and 2.5% prilocaine mixture (EMLA), and 20% benzocaine gel, in the buccal fold of the upper-right canine for 2 min in different sessions. After insertion of 30-G needles, pain was rated on a visual analog scale (VAS). A pinprick test was used to measure the duration of topical anesthesia. The pulpar response was assessed by an electric pulp tester. RESULTS: VAS median and interquartile range (in cm) were 0.8 (0.4-1.5), 1.6 (0.8-2.6), 1.1 (0.3-2.7), 2.2 (0.9-2.9) for liposome-encapsulated ropivacaine, ropivacaine, EMLA, and benzocaine groups, respectively. The liposome-encapsulated ropivacaine group showed lower VAS mean values when compared with the benzocaine group (P = 0.0205). The median values and interquartile range for the duration of soft tissue anesthesia were 11 (7-14), 6.5 (4-11), 14 (11-16), and 7 (6-9) min for liposome-encapsulated ropivacaine, ropivacaine, EMLA, and benzocaine groups, respectively. EMLA and liposome-encapsulated ropivacaine were just as efficient for reducing pain, and showed longer soft tissue anesthesia when compared to the other local anesthetics (P = 0.0001). CONCLUSION: Liposomal-encapsulated 1% ropivacaine gel was equivalent to EMLA for reducing pain during needle insertion and for the duration of soft tissue anesthesia. None of the topical anesthetics was effective for inducing pulpal anesthesia.

 

 

外科病人围术期应用巴喷丁/普巴林是否有?有关安全性有效性的系统综述

Do Surgical Patients Benefit from Perioperative Gabapentin/Pregabalin? A Systematic Review of Efficacy and Safety

 

Elina M. Tiippana, Katri Hamunen, Vesa K. Kontinen, and Eija Kalso

Pain Clinic, Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.

Anesth Analg. Volume: 104, Issue: 6, Date: 2007 05 21, Pages: 1545-56,tableofcontents

 

背景:巴喷丁和普巴林具有异常性疼痛和痛觉过敏的õ性,可用于治疗神经性疼痛。这些õ性õ于术后急性疼痛同样有效。该研究õ照试验评价了巴喷丁õ术后疼痛的镇痛效果、副反应和临价值。õ法:õMedline, PubMedCochrane Central Register of Controlled Trials (CENTRAL)数据库系统搜索22篇关于围术期应用巴喷丁治疗术后疼痛的随机õ照试验。结果:巴喷丁组解除疼痛的作用优于õ照组。术前12h单次应用巴喷丁3001200mg,第一个24h表现出少量阿片作用的有20%-62%。由于单次剂量巴喷丁的协同作用,术后第一个24小时阿片类药物的减少量相当于吗啡30 +/- 4 mg(õ均值+/-95%可信区间)。Mata分析表明巴喷丁减少24h阿片类药物用量的作用与巴喷丁的剂量无明显相关。巴喷丁减少了阿片相关的副反应,如恶心、呕吐和尿潴留(需要治疗的人数分别为2567)。巴喷丁最常见的副反应是镇静和头晕(需要治疗的人数分别为3512)。结论:巴喷丁有效地降低了术后疼痛、阿片用量和阿片相关的副反应。尚无法得出应用巴喷丁的最佳剂量和持续时间。围术期应用巴喷丁的长期处仍需进一步研究。

(王丽珺译 薛张纲校)

BACKGROUND: Gabapentin and pregabalin have antiallodynic and antihyperalgesic properties useful for treating neuropathic pain. These properties may also be beneficial in acute postoperative pain. In this study we evaluated randomized, controlled trials examining the analgesic efficacy, adverse effects, and clinical value of gabapentinoids in postoperative pain. METHODS: A systematic search of Medline, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases yielded 22 randomized, controlled trials on perioperative administration of gabapentinoids for postoperative pain relief. RESULTS: Pain relief was better in the gabapentin groups compared with the control groups. The opioid-sparing effect during the first 24 h after a single dose of gabapentin 300-1200 mg, administered 1-2 h preoperatively, ranged from 20% to 62%. The combined effect of a single dose of gabapentin was a reduction of opioid consumption equivalent to 30 +/- 4 mg of morphine (mean +/- 95% CI) during the first 24 h after surgery. Metaregression analysis suggested that the gabapentin-induced reduction in the 24-h opioid consumption was not significantly dependent on the gabapentin dose. Gabapentin reduced opioid-related adverse effects, such as nausea, vomiting, and urinary retention (number-needed-to-treat 25, 6, and 7, respectively). The most common adverse effects of the gabapentinoids were sedation and dizziness (number-needed-to-harm 35 and 12, respectively). CONCLUSIONS: Gabapentinoids effectively reduce postoperative pain, opioid consumption, and opioid-related adverse effects after surgery. Conclusions about the optimal dose and duration of the treatment cannot be made because of the heterogeneity of the trials. Studies are needed to determine the long-term benefits, if any, of perioperative gabapentinoids.

 

 

鼠试验性神经病变与焦虑和郁引起的延迟性行为õ变有关

Experimental Neuropathy in Mice Is Associated with Delayed Behavioral Changes Related to Anxiety and Depression

 

Takahiro Suzuki, Mitsuyuki Amata, Gaku Sakaue, Shinya Nishimura, Takaya Inoue, Masahiko Shibata, and Takashi Mashimo

Address correspondence and reprint requests to Takahiro Suzuki, Department of Anesthesiology, Osaka University Medical School, 2–2 Yamadaoka, Suita, Osaka 565-0871, Japan.

Anesth Analg 2007 104: 1570-1577.

 

背景:慢性疼痛的患者通常伴有情感障碍,õ别是焦虑和郁。虽然已有疼痛与郁相互关系的临研究,但疼痛是否引起郁或郁是否重疼痛还不清楚。为研究疼痛和情感障碍的相互关系,我们使用经典的行为试验,测量了神经结扎鼠焦虑和郁相关行为。õ法:在结扎了左侧单侧第五腰神经õ后,我们使用von Frey和辐射热试验测量疼痛的行为。在不限定范围内、黑暗态、迷宫和强迫游泳试验中,测量活水õ、焦虑相关行为与郁相关行为。结果:在结扎神经后数日内可以观察到感觉超敏反应。在结扎神经后27日内õ未观察到焦虑与郁相关行为。然而结扎神经后1530日可以观察到明显焦虑与郁相关行为,活度õ未减少。结论:神经损伤能够引起鼠情感异常,但出现的时间明显晚于感觉超敏时间。

(金 琳译 薛张纲校)

BACKGROUND: Patients with chronic pain frequently suffer affective disorders, particularly anxiety and depression. Although clinical research on the relationship between pain and depressive symptoms has been done, it is not clear whether pain causes depression or depression exaggerates pain. To investigate the relation between pain and affect, we measured anxiety and depression-related behaviors in mice after spinal nerve ligation using classical behavioral tests. METHODS: After unilateral ligation of the left fifth lumbar nerve, we measured pain behaviors using von Frey and radiant heat tests. Activity level, anxiety-related behaviors, and depression-related behaviors were tested with open field, light-dark exploration, elevated plus-maze, and forced swim tests. RESULTS: Sensory hypersensitivity was observed within a few days after ligation. Anxiety and depression-related behaviors were not seen 2 and 7 days after ligation. However, 15 and 30 days after ligation we found clear evidence of anxiety and depression-related behaviors, without loss of mobility. CONCLUSIONS: Nerve injury can trigger affective disturbances in mice that appear much later than sensory hypersensitivity.

 

 

颈部屈伸运õ高位胸段硬膜外腔造影剂分布的影响

The Influence of Neck Flexion and Extension on the Distribution of Contrast Medium in the High Thoracic Epidural Space

 

Chul Joong Lee, MD, PhD*, Yunseok Jeon, MD, PhD{dagger}, Young Jin Lim, MD, PhD{dagger}, Jae Hyon Bahk, MD, PhD{dagger}, Yong Chul Kim, MD, PhD{dagger}, Sang Chul Lee, MD, PhD{dagger}, and Chong Sung Kim, MD, PhD{dagger}

Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Seoul, Korea.

Anesth Analg 2007 104: 1583-1586

 

背景:为了胸段硬膜外镇痛(thoracic epidural analgesiaTEA)的安全性和有效性,控制TEA的õ面和明确影响它扩散的因素是重要的。在本õ研究中,我们观察颈部屈伸运时注射入高位胸段硬膜外腔造影剂分布情况。 õ法:硬膜外导管放置硬膜外腔,其顶端在T1–2椎体间水õ。患者随机分为3组(伸、屈和中立组),当颈部伸、屈,或中立位置时注射5ml造影剂。造影剂扩散的范围通过侧位硬膜外造影术来计数椎体单位(vertebral body unitsVBUs)从而确定。结果:42个患者õ均分配到3组。在伸、屈和中立组,放射照相下造影剂向头端扩散(中位数)是1.05.51.5VBUs,在屈位较其他两组扩散范围更õ(p<0.001)。伸、屈和中立组放射照相下造影剂向尾部扩散分别为10.010.0,和7.0VBUs,各组õ间没有显著不同(p = 0.145)。结论:在高位胸段硬膜外腔,造影剂向头端的扩散受到限制。然而,颈屈增了头端扩散。这些结果提示当TEA是高位时,硬膜外导管的顶端应该位于这一阻滞水õ的部,颈屈可以引起不必要的颈段阻滞。

(孙敏莉译 薛张纲较)

BACKGROUND: For safe and effective thoracic epidural analgesia (TEA), it is important to control the level of TEA and to identify factors that influence its spread. In this study, we observed the distribution of contrast injected into the high thoracic epidural space during neck flexion and extension. METHODS: An epidural catheter was inserted into the epidural space until its tip was located at the T1–2 intervertebral level. Patients were randomly allocated to three groups (extension, flexion, and neutral groups), and were injected with 5 mL of contrast when the neck was extended, flexed, or in the neutral position. Extent of contrast spread was determined by counting the number of vertebral body units (VBUs) through lateral epidurography. RESULTS: Forty-two patients were equally allocated to the three groups. Radiographic spreads in the cephalad direction (median) was 1.0, 5.5, and 1.5 VBUs in the extension, flexion, and neutral groups, and spread was greater in the flexion than in the other two groups (P < 0.001). Median radiographic caudal spread was 10.0, 10.0, and 7.0 VBUs in the extension, flexion, and neutral groups, respectively, which was not significantly different among groups (P = 0.145). CONCLUSIONS: Cranial spread of contrast in the high thoracic epidural space is limited. However, neck flexion increases cranial spread. These results suggest that when TEA is high, the tip of the epidural catheter should be located at the upper part of the level to be blocked and that neck flexion may cause an unwanted cervical block.

 

吗啡和太尼õ选择性冠脉旁路移植术心肺转流时炎症反应的影响

The Effects of Morphine and Fentanyl on the Inflammatory Response to Cardiopulmonary Bypass in Patients Undergoing Elective Coronary Artery Bypass Graft Surgery

Glenn S. Murphy, MD, Joseph W. Szokol, MD, Jesse H. Marymont, MD, Michael J. Avram, PhD, and Jeffery S. Vender, MD

From the Department of Anesthesiology, Evanston Northwestern Healthcare, Northwestern University Feinberg School of Medicine, Illinois.

Anesth Analg 2007 104: 1334-1342.

 

背景:实验数据表明吗啡具有独õ的炎药性质。作者假设,与太尼相比,õ衡麻醉术中入吗啡可以减弱心肺转流(CPB)手术期间的炎症反应。

õ法30名择期冠脉旁路移植术病人随机双盲分组,分别接受吗啡(40mg)和太尼(1000ug)作为标准的阿片类药物复合异氟醚麻醉的一部分。手术前后监测炎症反应标记物血清白介素-6IL-6)、白介素-8IL-8)和中性粒细胞表面黏附因子的表达(CD11aCD11bCD11cCD18)。ICU中监测体温,õ计算术后高热(体温>38.0°C)的发生率。

结果CPB后所有病人IL-6IL-8浓度均增。在CPB3h24h,吗啡组血清IL-6水õ的增低于太尼组(P < 0.05)。CPB15min3h两组中性粒细胞表面黏附因子的表达均减少。吗啡组CD11bCD18的表达显著减少 (P < 0.05)。,太尼组术后过高热的发生率(73%)比吗啡组(0%)更高(P < 0.05)。

结论:与太尼相比,给予吗啡作为õ衡的麻醉术的一部分制了CPB下心脏手术的多种炎症反应(IL-6, CD 11b, CD 18,术后过高热)。

(张美荣 陈杰 校)

BACKGROUND: Experimental data suggest that morphine has unique antiinflammatory properties. We hypothesized that morphine, when compared with fentanyl, would attenuate the perioperative inflammatory response to cardiopulmonary bypass (CPB) when administered as part of a balanced anesthetic technique.

METHODS: Thirty patients undergoing elective coronary artery bypass graft surgery were randomized to receive, in a double-blind manner, either morphine (40 mg) or fentanyl (1000 µg) as part of a standardized opioid-isoflurane anesthetic. Serum concentrations of interleukin (IL)-6 and IL-8 and expression of neutrophil surface adhesion molecules (CD 11a, CD 11b, CD 11c, and CD 18) were measured perioperatively as indicators of the inflammatory response to surgery. Core temperatures were monitored in the intensive care unit to determine the incidence of postoperative hyperthermia (temperature >38.0°C).

RESULTS: IL-6 and IL-8 concentrations increased in all patients after CPB. The increase in serum IL-6 levels was significantly attenuated in the morphine group compared to the fentanyl group at 3 and 24 h post-CPB (P < 0.05). Reductions in expression of neutrophil adhesion molecules were observed in both groups 15 min and 3 h post-CPB; however, a significantly larger reduction in CD 11b and CD 18 expression was noted in patients receiving morphine (P < 0.05). The incidence of postoperative hyperthermia was more frequent in the fentanyl group (73%) compared to the morphine group (0%, P < 0.05).

CONCLUSIONS: Compared with fentanyl, the administration of morphine as part of balanced anesthetic technique suppressed several components the inflammatory response (IL-6, CD 11b, CD 18, postoperative hyperthermia) to cardiac surgery and CPB.


小儿输尿管移植术病人单次骶管注入可õ定、吗啡或氢化吗啡酮联合罗哌卡因的比较

A Comparison of Single-Dose Caudal Clonidine, Morphine, or Hydromorphone Combined with Ropivacaine in Pediatric Patients Undergoing Ureteral Reimplantation

Thomas R. Vetter, MD, Daniel Carvallo, MD, Jodie L. Johnson, MD, Michael S. Mazurek, MD, and Robert G. Presson, Jr, MD

From the Department of Anesthesia, Indiana University School of Medicine, Indianapolis, Indiana.

Anesth Analg 2007 104: 1356-1363.

 

背景:骶管阻滞是小儿术后镇痛的常见õ法。在安全和有效性õ面,骶管使用阿片类药物有较麻烦的副作用。骶管应用可õ定的镇痛作用较好。作者比较了一组60例小儿输尿管移植术骶管使用可õ定或氢化吗啡酮或吗啡镇痛的副作用与恢复的差别。

õ法:将6月到6岁的的小儿患者随机双盲分组,õ单次给予骶管可õ定2mcg/kg,氢化吗啡酮10mcg/kg,或50mcg/kg吗啡复合含有肾腺素的0.2%罗哌卡因(1.0ml/kg)。七氟醚-空气/氧气麻醉后,所有患儿均接受士管制的吗啡镇痛. 评估第一个24h静脉使用吗啡后术后疼痛强度和副反应,õ记录口服量以出院情况.

结果:与骶管使用氢化吗啡酮或吗啡比起来,使用可õ定可以引起较少的术后恶心呕吐(p=0.01)与瘙痒(p=0.007)。骶管使用吗啡比可õ定镇痛更持õ(p=0.02)。而疼痛评分、吗啡应用总量、第一次口服量或出院时间均没有什õ差别,õ没有发现术后呼吸制、过度镇静、低血压与心过缓。

结论:尽管骶管使用吗啡可获得更持õ的镇痛,但是骶管使用可õ定联用士管制的镇痛õ许可提供显著的镇痛和较少的副作用。基于述结果,小儿输尿管移植术后骶管注射可õ定õ许优于阿片类药。

(宋翠侠 陈杰 校)

BACKGROUND: Caudal blockade is a common technique for pediatric postoperative analgesia. While safe and effective, caudal opioids are associated with troublesome side effects. Caudal clonidine may offer significant analgesic benefits. We prospectively compared the analgesic, side effect, and rehabilitation profiles of caudal clonidine, hydromorphone, or morphine in a group of 60 pediatric patients undergoing ureteral reimplantation.

METHODS: Patients aged 6 mo to 6 yr were evenly and randomly enrolled in a double-blind manner. Patients received a single caudal dose of 2 mcg/kg of clonidine, 10 mcg/kg of hydromorphone, or 50 mcg/kg of morphine, combined with 1.0 mL/kg of 0.2% ropivacaine with epinephrine. After sevoflurane in oxygen/air anesthesia, all subjects received proxy nurse-controlled analgesia with morphine. Postoperative pain intensity, use of IV morphine, and side effects were assessed during the first 24 h. Oral intake and discharge home were recorded.

RESULTS: Caudal clonidine resulted in less postoperative nausea and vomiting (P = 0.01) and pruritus (P = 0.007) than did caudal hydromorphone or caudal morphine. Caudal morphine produced more sustained initial analgesia than did caudal clonidine (P = 0.02). No difference was observed in pain scores, total morphine use, time to first oral intake or discharge home. No postoperative respiratory depression, excessive sedation, hypotension, or bradycardia was identified.

CONCLUSIONS: Although caudal morphine may result in more sustained initial analgesia, caudal clonidine combined with nurse-controlled analgesia appears to provide comparable analgesia with fewer side effects. Based on these results, the use of caudal clonidine may be superior to caudal opioids after pediatric ureteral reimplantation.

 

单次剂量镁剂õ日间手术后辅镇痛作用的评估:随机õ照研究

An Evaluation of a Single Dose of Magnesium to Supplement Analgesia After Ambulatory Surgery: Randomized Controlled Trial

Martin R. Tramèr, MD, DPhil*, and Chris J. Glynn, FRCA, MSc{dagger}

From the *Division of Anesthesiology, Department Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland; and {dagger}Pain Relief Unit, Nuffield Department of Anesthetics, The Churchill, Oxford, UK.

Anesth Analg 2007 104: 1374-1379.

 

背景:先前的研究显示镁剂可能是术后镇痛的一种有效辅剂。

õ法:选择门õ股沟疝修补术或曲张静脉手术的病人,采用全身麻醉,õ在麻醉诱导后静脉随机给予硫酸镁4mg或生理盐水。所有的病人在术前经直肠给予双氯酸100mg,õõ疝气修补的病人行髂õ下神经阻滞。在复苏室记录疼痛程度,镇痛药品消耗,以伤害性反应,õ在术后三天采取问卷调查。

结果:随机选择200名患者,101名使用镁剂,99名使用安慰剂。在注射研究药物õ前以即刻两组的血流学õ变没有差异。两组患者术后124h静息和运时的疼痛强度,以非阿片类和阿片类镇痛药物的累积用量相似。术后恶心呕吐,头晕,头痛,昏厥的发生率õ没有差异。镁剂组术后颤的发生率显著降低(分别为4%13.1%P=0.0232)。84名安慰剂病人和82名镁剂病人回馈了完整的问卷调查表。无论是õ股沟疝修补组还是曲张静脉剥脱组,术后前三天两组结果无明显差异,。

结论:õ股沟疝修补或曲张静脉手术的病人在全麻下辅其它镇痛佐剂,如治疗前静脉注射4g硫酸镁õ不影响术后疼痛程度和镇痛药的消耗。

(郑丽 陈杰 校)

BACKGROUND: Previous studies have suggested that magnesium may be a useful adjuvant to postoperative analgesia.

METHODS: We randomized adults undergoing ambulatory ilioinguinal hernia repair or varicose vein operation under general anesthesia (propofol, fentanyl, isoflurane-N2O) to receive magnesium sulfate 4 g IV or physiological saline after induction. All patients preoperatively received diclofenac 100 mg rectally and those undergoing hernia repair had a postoperative ilioinguinal-iliohypogastric nerve block done. Pain, analgesic consumption, and adverse effects were recorded in the recovery room and, using a questionnaire, up to 3 days postoperatively.

RESULTS: We randomized 200 patients (101 magnesium, 99 placebo). There were no differences in hemodynamic variables before and immediately after study drug injection. Pain intensity at rest and on movement after 1, 2, and 4 h, time to first rescue analgesic, and cumulative numbers of non-opioid and opioid analgesics were similar among groups. There was no difference in the incidence of postoperative nausea and vomiting, dizziness, headache, or fainting. The incidence of postoperative shivering was significantly lower in the magnesium group (4% vs 13.1%, P = 0.0232). Adequately completed questionnaires were returned by 84 placebo and 82 magnesium patients. There was no difference between groups for any of the analyzed outcomes during the first three postoperative days, neither for patients undergoing inguinal hernia repair nor for those undergoing varicose vein stripping.

CONCLUSIONS: In patients undergoing ambulatory ilioinguinal hernia repair or varicose vein operations under general anesthesia supplemented with other analgesic adjuvants, pretreatment with IV magnesium sulfate 4 g has no impact on postoperative pain and analgesic consumption.

 

异氟醚、氟烷和巴比妥õ小鼠噪声性耳聋的影响

The Effect of Isoflurane, Halothane and Pentobarbital on Noise-Induced Hearing Loss in Mice

Jong Woo Chung, MD*, Joong Ho Ahn, MD*, Jong Yang Kim, MD*, Hyun Jung Lee, MS{dagger}, Hun Hee Kang, MS{dagger}, Yoon Kyung Lee, MD{ddagger}, Joung Uk Kim, MD{ddagger}, and Seung-Woo Koo, MD{ddagger}

From the Department of *Otolaryngology and {ddagger}Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea; and {dagger}Asan Institute for Life Science, Seoul, Korea.

Anesth Analg 2007 104: 1404-1408.

 

背景:在耳部手术中使用õ突钻头可能会引起噪声性耳聋(NIHL)。作者研究了吸入麻醉药或巴比妥是否能够õ小鼠的噪声性耳聋起到保作用。

õ法:小鼠分为非麻醉õ照组和麻醉组,麻醉组又分为给予氟烷、异氟醚和巴比妥的不同亚组,分别暴露于宽谱带的白噪声中连续3日,每日3小时。在暴露前,暴露后1日,12,和3周,1个月分别测定脑õ听觉反应评估小鼠的听水õ。在暴露的1周后,柯替氏器行荧光的异硫氰酸盐共轭毒伞素和TUNEL试剂染色。

结果:õ照组暴露于噪声刺激后的小鼠听阈值升到了77.5±8.0分贝(dB)的听级(HL)。而在给予巴比妥,异氟醚,和氟烷的各麻醉组中,小鼠的听阈值分别升至62.5±6.3dB HL45.5±9.8dB HL,和39.3±6.2dB HL,麻醉组较õ照组小鼠的听受到了保(P<0.05)。给予巴比妥的小鼠听下降较给予吸入麻醉药的小鼠严重(P<0.05)。õ照组小鼠纤毛细胞的存活率下降,巴比妥组的小鼠略有下降,吸入麻醉药组的小鼠中则大部分未受到影响。

结论:氟烷、异氟醚和巴比妥õ小鼠的噪声性耳聋(NIHL)和毛细胞的破坏均具有保作用,吸入麻醉药更为有效。

(印洁敏 陈杰 校)

BACKGROUND: Ear surgery using mastoid drills can lead to noise-induced hearing loss (NIHL). We investigated whether inhaled anesthetics or pentobarbital could have protective effects on NIHL in mice.

METHODS: Mice were exposed to broad band white noise for 3 h per day for 3 consecutive days, with or without anesthesia, using halothane, isoflurane, or pentobarbital. The hearing level of each mouse was analyzed before exposure, and 1 day, 1, 2, and 3 Wk, and 1 mo after noise exposure by measuring auditory brainstem response thresholds. At 1 Wk after noise exposure, the organ of Corti was stained with a fluorescent isothiocyanate-conjugated phalloidin probe and a TUNEL kit.

RESULTS: In the unanesthetized control group, the hearing threshold increased to 77.5 ± 8.0 dB hearing level (HL) after noise stimulation. In the pentobarbital, isoflurane, and halothane groups, hearing threshold increased to 62.5 ± 6.3 dB HL, 45.5 ± 9.8 dB HL, and 39.3 ± 6.2 dB HL, respectively, with all anesthetized groups of mice showing significantly preserved hearing compared with the control group (P < 0.05). But, in mice anesthetized with pentobarbital, hearing loss was more severe than in those treated with the inhaled anesthetics (P < 0.05). Hair cell survival was reduced in unanesthetized control mice and somewhat reduced in pentobarbital-treated mice, but largely unaffected in mice treated with inhaled anesthetics.

CONCLUSIONS: These findings indicate that, while halothane, isoflurane and pentobarbital could protect mice against NIHL and hair cell damage, inhaled anesthetics were more effective.

 

õ有害刺激的反应小鼠大脑{gamma}-氨基丁酸酸性水õ的增导致翻正反射消失但非不

Increased {gamma}-Aminobutyric Acid Levels in Mouse Brain Induce Loss of Righting Reflex, but Not Immobility, in Response to Noxious Stimulation

Sohtaro Katayama, DDS, PhD*, Masahiro Irifune, DDS, PhD*, Nobuhito Kikuchi, DDS, PhD*, Tohru Takarada, DDS, PhD*, Yoshitaka Shimizu, DDS*, Chie Endo, DDS*, Takashi Takata, DDS, PhD{dagger}, Toshihiro Dohi, PhD{ddagger}, Tomoaki Sato, DDS, PhD, and Michio Kawahara, MD, PhD*

From the *Department of Dental Anesthesiology, Division of Clinical Medical Science, Programs for Applied Biomedicine, {dagger}Department of Oral Maxillofacial Pathobiology, Division of Frontier Medical Science, and {ddagger}Department of Dental Pharmacology, Division of Integrated Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan; and Department of Applied Pharmacology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan.

Anesth Analg 2007 104: 1422-1429.

 

背景:全身麻醉态分行为和知觉两部分,包括健忘, 意识丧失和不性. {gamma}-氨基丁酸制神经传导是全身麻醉作用在离体细胞水õ的重要靶位õ。但是在体试验中增的氨基丁酸神经传导在全身麻醉态的基本组分中的能性关联还不是很明确。巴枯林是{gamma}-氨基丁酸转氨酶制剂,它制放的{gamma}-氨基丁酸的降解,õ且增在中枢神经系统的内源性{gamma}-氨基丁酸。在此,作者检测{gamma}-氨基丁酸增的的能来产生全身麻醉的态。

õ法: 所有的药物均全身性地应用于成õ雄性ddY小鼠。为了评估全身麻醉的组分,使用了两个终末õ。一个是翻正反射的缺失 (LORR; 作为意识丧失的度量标准);另一个是õ钳尾刺激反应的活缺失(作为不性的度量标准)

结果: 巴枯林诱导的 LORR 呈剂量依赖模式,50%的有效剂量为100 mg/kg (75–134; 95% 可信区间)。行为和微量渗析的研究显示内源性{gamma}-氨基丁酸诱导的 LORR出现了浓度依赖的模式。但是,即使是大剂量的巴枯林 (285–400 mg/kg) 不产生õ钳尾刺激反应的活缺失。相反,吸入所有试验浓度的挥发性麻醉药均出现翻正反射和钳尾刺激反应消失,这结果支持吸入麻醉药作用在多个细胞靶位õ的观õ。

结论:这些结果证实LORR与增的{gamma}-氨基丁酸神经传导有关。但有害刺激õ不性无影响。由此提示, LORR 和不性是由不同的神经通路介导的,或者是在中枢神经系统的不同区域。

杨卫红 陈杰 校)

BACKGROUND: The general anesthetic state comprises behavioral and perceptual components, including amnesia, unconsciousness, and immobility. {gamma}-Aminobutyric acidergic (GABAergic) inhibitory neurotransmission is an important target for anesthetic action at the in vitro cellular level. In vivo, however, the functional relevance of enhancing GABAergic neurotransmission in mediating essential components of the general anesthetic state is unknown. Gabaculine is a GABA-transaminase inhibitor that inhibits degradation of released GABA, and consequently increases endogenous GABA in the central nervous system. Here, we examined, behaviorally, the ability of increased GABA levels to produce components of the general anesthetic state.

METHODS: All drugs were administered systemically in adult male ddY mice. To assess the general anesthetic components, two end-points were used. One was loss of righting reflex (LORR; as a measure of unconsciousness); the other was loss of movement in response to tail-clamp stimulation (as a measure of immobility).

RESULTS: Gabaculine induced LORR in a dose-dependent fashion with a 50% effective dose of 100 (75–134; 95% confidence limits) mg/kg. The behavioral and microdialysis studies revealed that the endogenous GABA-induced LORR occurred in a brain concentration-dependent manner. However, even larger doses of gabaculine (285–400 mg/kg) produced no loss of tail-clamp response. In contrast, all the tested volatile anesthetics concentration-dependently abolished both righting and tail-clamp response, supporting the evidence that volatile anesthetics act on a variety of molecular targets.

CONCLUSIONS: These findings indicate that LORR is associated with enhanced GABAergic neurotransmission, but that immobility in response to noxious stimulation is not, suggesting that LORR and immobility are mediated through different neuronal pathways and/or regions in the central nervous system.


静脉麻醉药大脑浓度检测õ法(药代/药效分析法和质量守衡法)的比较

A Comparison of Pharmacokinetic/Pharmacodynamic versus Mass-Balance Measurement of Brain Concentrations of Intravenous Anesthetics in Sheep

Logan J. Voss, PhD*, Guy Ludbrook, MD, PhD, FANZCA*, Cliff Grant, MMedSc*, Richard Upton, PhD*, and James W. Sleigh, MD, MBChB, FANZCA{dagger}

From the *Department of Anaesthesia and Intensive Care, University of Adelaide and Royal Adelaide Hospital, North Terrace, Adelaide University, Adelaide, South Australia, Australia; {dagger}Department of Anaesthesiology, Waikato Clinical School, University of Auckland, Hamilton, New Zealand.

Anesth Analg 2007 104: 1440-1446.

 

背景:现在有两种公认的计算静脉麻醉药物在脑组织中浓度的õ法:1.通过测定脉血药浓度和观察脑电图õ变,使用药代/药效模型来估计静脉麻醉药物在脑组织中浓度。2.采样脉和颈静脉的血药浓度和测定脑血流来直接测量脑组织中药物代谢的况。(总体守恒法)这两种õ法尚未相互比较过。因为精确测定药物从脉到其脑中效应部位的时间是建立静脉麻醉药物效应/浓度关系的关键,作者在绵身用这两种õ法来测定异丙酚,美索比托和氯胺酮在脑组织中的浓度。

õ法:7只,先在每只身安置脉和失窦导管,脑皮层电图和失窦超声血流分析仪,然后随机给予小剂量的异丙酚,美索比托和氯胺酮进行短时间麻醉,同时采取多个血样标本和脑电图变化来评估药效。

结果:使用药代/药效分析法得出的t1/2Keo:氯胺酮为2.0±0.4min,异丙酚为2.7±1.1min,而美索比托的t1/2Keo0.3±0.1min明显较前两者缩短。药代/药效分析法和总体守恒分析法在药物到达峰值的时间无明显差异。

结论:用两种õ法来测定药物从脉到其脑中效应部位的时间õ无明显差异,美索比托进入脑组织的时间大大快于异丙酚和氯胺酮。

(李惟一 陈杰 校)

BACKGROUND: There are two recognized methods of estimating the brain concentrations of IV anesthetic drugs: (i) use of pharmacokinetic/pharmacodynamic (PK/PD) modeling of drug effect, from arterial concentrations and electroencephalogram changes, and (ii) direct measurement of the uptake of drug in the brain, by simultaneously measuring arterial and jugular concentrations and cerebral blood flow (mass-balance method). These two methods have not been directly compared. Because an accurate estimate of the time taken for transfer of anesthetic drug from arterial blood to its effect-compartment in the brain is critical for accurate effect-compartment dosing in IV anesthesia, we compared the PK/PD and mass-balance methods for propofol, methohexital, and ketamine in a sheep model.

METHODS: After instrumentation with arterial and sagittal-sinus cannulae, electrocorticogram, and sagittal sinus Doppler flow measurement seven adult sheep were given a random sequence of short anesthetic infusions with methohexital, ketamine, and propofol. Multiple blood samples were taken for measurement of the time course of the drug concentrations, and the electrocorticogram processed (approximate entropy, for propofol and methohexital and percentage high frequency time, for ketamine) to numerically quantify drug effect.

RESULTS: Using the PK/PD method the t1/2Keo was 2.0 ± 0.4 min for ketamine, 2.7 ± 1.1 min for propofol, and was significantly shorter (0.3 ± 0.1 min) for methohexital. PK/PD and the mass-balance methods did not differ in the times to peak effect.

CONCLUSIONS: Both methods of calculating the delay in transfer of drug from arterial blood to brain give similar values. Methohexital crosses into the brain much faster than either propofol or ketamine.


使用麻醉信息管理系统时麻醉记录完整性的研究

An Observational Study of Anesthesia Record Completeness Using an Anesthesia Information Management System

William D. Driscoll, MA, Mary Ann Columbia, RN, and Robert A. Peterfreund, MD, PhD

From the Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts.

Anesth Analg 2007 104: 1454-1461.

 

背景:以往的研究表明手工记录的麻醉资料存在准确性和完整性õ面的不足,麻醉记录的质量尚有õ进õ处。

õ法:作者收集了其医疗机构一月中所有的电子麻醉记录,了解以下六个õ目的记录完整性。:1.过敏原2.静脉通路3.心电律4.面罩通气的难易度5.咽喉镜的暴露情况6.气管导管的插入深度

结果:在2838份记录中,必填的过敏原õ目中有64%空缺。插管病人中,59%插管深度õ空缺(918份中空缺了538份)。86%的记录,心电律的断至少空缺了一次。面罩通气的难易可以通过触摸屏菜单中输入, 781份只填了664份。咽喉镜的暴露情况õ可以在触摸屏中输入,但883份中只填了811份。只有84%的记录中提了静脉通路。

结论:作者发现临麻醉电子记录õ是不完整的。难以依赖空õ标记和记录保存系统来完成不完整数据的输入。结论提示用户输入数据时需要一种程序来提示用户疏忽和不完整的õ目,来更好的完善临资料。

(李惟一 陈杰 校)

BACKGROUND: Studies of the accuracy and completeness of handwritten anesthesia records demonstrate deficiencies in documentation, suggesting that the quality of anesthesia records can be improved.

METHODS: We reviewed all electronic anesthesia records generated during a 1-month period at our institution to ascertain completion rates for six clinical documentation elements: allergies, IV access, electrocardiogram rhythm, ease of mask ventilation, laryngoscopic grade of view, and insertion depth of the endotracheal tube.

RESULTS: Of 2838 records, 64% had the necessary free text remark in the allergy element. The free text required to complete endotracheal tube depth documentation appeared in 538 of 918 cases in which the patient was tracheally intubated (59%). Free text documentation of the electrocardiogram rhythm diagnosis appeared at least once in 86% of records. Documentation of mask ventilation characteristics was entered by touch screen from a pick list and was expected in 781 records but appeared in 664 records (85%). Laryngoscopic grade of view documentation was also selected by touch screen and expected in 883 records but present in 811 cases (92%). Any notation of IV access appeared in 84% of records.

CONCLUSIONS: We found that electronic clinical anesthesia documentation was often incomplete. Dependence on free text remarks and the record keeping system’s inability to automatically present entries in logical sequences consistent with workflow were associated with incomplete data entry. Our results suggest that the user interface for data entry, and the logic that an electronic system uses for preventing omissions and inconsistencies, merit further study and development in order to facilitate clinically useful documentation.

 

给予正常高限镁剂后减轻快速输注晶体液导致的凝血变化

The Coagulation Changes Induced by Rapid In Vivo Crystalloid Infusion Are Attenuated When Magnesium Is Kept at the Upper Limit of Normal

Thomas G. Ruttmann, MBChB, MMed, PhD, FCA*, Luis F. Montoya-Pelaez, MBChB, FCA*, and Michael F. M. James, MBChB, PhD, FRCA, FCA*

From the Department of Anaesthesiology, University of Cape Town Medical School, Cape Town, Republic of South Africa.

Anesth Analg 2007 104: 1475-1480.

 

背景:快速输注晶体液会增强凝血能,不考虑õ电解质、pH值和血浆渗透压浓度的影响,所造成的结果包括深静脉血栓形成和其他血凝块的形成。其中血浆镁离子浓度的õ变可能õ凝血态的õ衡有重要影响。本在体实验研究了当血浆镁离子浓度保持不变或局部升高,凝血能õ快速血液稀的反应。

õ法:参与研究的25名健康志愿者,随机分为三组,给予生理盐水、Balsol(含镁离子1.5g/L)、以添镁离子的Balsol(含镁离子3.0g/L)。研究者不知晓受试者接受何种液体。采集基础血样检测红细胞比õ、血浆镁离子浓度以血栓õ性描记图(TEG),30分钟内输入14mL/kg(占血õ量20%)的液体,随后采集第二次血样。所有结果均与其本身的基础值比较,使用õ差分析检验其显著性。

结果:三组受试者有相似程度的红细胞比õ下降,生理盐水组有明显的镁离子减少(从0.81±0.070.74±0.07,大约下降8.6%,P<0.003),Balsol组没有变化,而添镁离子的Balsol组则有明显增(从从0.84±0.070.99±0.07,大约升高17.9%,P<0.001)。稀后TEG结果显示添镁离子的Balsol组没有明显õ变。而其他两组血块形成则有明显统计学意õ的增(反应时间到凝固开始和凝血时间缩短,αangle增)。

结论:快速血液稀诱发凝血可能与镁离子浓度下降有部分关系,其作用在镁离子浓度保持正常限时可减弱。因此,晶体复苏液需维持约3mmol/L的较高镁离子浓度。

(周懿õ 陈杰 校)

BACKGROUND: Rapid crystalloid infusion enhances coagulation, regardless of electrolytes, pH or osmolality, an effect thought to be related to deep vein thrombosis and other clot formations. Altered serum magnesium may play a role in the balance of coagulation. In this in vivo study we investigated the coagulation response to rapid hemodilution when serum magnesium is maintained or partially increased.

METHODS: Twenty-five healthy volunteers were investigated on three occasions, randomly receiving normal saline, Balsol (magnesium 1.5 g/L), and Balsol plus additional magnesium (magnesium 3.0 g/L). Investigators were blinded to the solution’s identity. Baseline blood samples were taken measuring hematocrit, serum magnesium, and thrombelastography (TEG), whereafter 14 mL/kg (20% blood volume) was infused over 30 min, followed by a second blood sample. All results were compared to their own baseline values using ANOVA with LSD post hoc significance testing.

RESULTS: All groups had a similar postdilutional hematocrit decrease, with significant magnesium reduction in the saline group (0.81 ± 0.07 to 0.74 ± 0.07 (approximately –8.6%) (P < 0.003)), no change in the Balsol group and significant increase in the Balsol + magnesium group (0.84 ± 0.07 to 0.99 ± 0.06 (approximately 17.9%) (P < 0.001)). Postdilutional TEG results reflected no significant change from control in the Balsol + magnesium group. Both of the other two groups had statistically significant increased clot formation (reaction time to onset of clotting and clotting time shortened; {alpha}-angle increased).

CONCLUSIONS: Rapid hemodilution-induced coagulation may be partially due to decreased magnesium, and the effect is attenuated by maintaining magnesium at the upper limit of normal. Crystalloid resuscitation fluids should possibly contain higher magnesium levels, around 3 mmol/L.


全身麻醉õ脑磁波描记术成检出间断癫痫样活的影响的回顾性分析

A Retrospective Analysis of the Effect of General Anesthetics on the Successful Detection of Interictal Epileptiform Activity in Magnetoencephalography

Guruswamy Balakrishnan, MD*, Kavita M. Grover, MD{dagger}, Karen Mason, BS T{dagger}, Brien Smith, MD{dagger}{ddagger}, Gregory L. Barkley, MD{dagger}{ddagger}, Norman Tepley, PhD{dagger}, and Susan M. Bowyer, PhD{dagger}{ddagger}

From the Departments of *Anesthesiology, and {dagger}Neurology, Henry Ford Medical Group, Detroit, Michigan; {ddagger}Department of Neurology, Wayne State University, Detroit, Michigan; and §Department of Physics, Oakland University, Rochester, Michigan.

Anesth Analg 2007 104: 1493-1497.

 

背景:脑磁波描记术(MEG)的研究要求患者静止õ卧较长时间。但õ于õ患癫痫的儿童和不合作成人,为保证研究的高质量往往需要患者处于全身麻醉或镇静态。由于全麻药物有厥和预防厥的õ性,该研究调查使用麻醉药物是否会减少发作间期癫痫样活的成检出率。

õ法:41名癫痫患者(女性10人,男性31人;õ龄148岁),于麻醉态下进行MEG测试。为确定麻醉õ癫痫样活的作用,将麻醉组患者与另一些未接受麻醉癫痫患者的记录比较,其中还包括一组不需麻醉就可获得脑电记录的儿童亚组。

结果:41名患者中38名给予异丙酚,2名给予依托咪酯,1名给予七氟醚。其中29名患者(71%)的MEG结果中发现有间断癫痫样活。研究MEG中间隙癫痫样活的比例时发现无麻醉组有63%的病人发生癫痫。õ龄小于18岁的儿童中,有28人(74%)有间隙癫痫样活,而无麻醉组则有80%。

结论:MEG研究中,麻醉程度达到患者无意识和体时,õMEG记录下的间隙癫痫样活波形õ无明显影响。

(周懿õ 陈杰 校)

BACKGROUND: A magnetoencephalography (MEG) study requires the patient to lie still for a prolonged period of time. In children and uncooperative adults with epilepsy, general anesthesia or sedation may be required to insure a good quality study. As general anesthetics have anticonvulsant and proconvulsant properties, we investigated whether the use of anesthesia reduced the successful detection of interictal epilepsy activity.

METHODS: MEG testing was performed on 41 epilepsy patients (10 women, 31 men; 1–48 yr) while anesthetized. To determine the impact of anesthesia on the identification of epileptiform activity, the anesthesia group of patients was compared with all other patients with epilepsy who were recorded in our laboratory without anesthesia, as well as with a subgroup of children with epilepsy who were able to be recorded without the need for anesthesia.

RESULTS: Propofol was used in 38 patients, etomidate in two, and one received sevoflurane. Twenty-nine (71%) were found to have interictal epileptiform activity in their MEG results. The percentage of MEG studies with a positive yield for interictal epileptiform activity is comparable with the percentage (63%) found in the patients with epilepsy undergoing MEG without anesthesia. In the 38 children younger than 18 yr, 28 (74%) had interictal epileptiform activity compared with 80% done without anesthesia.

CONCLUSION: We conclude that levels of anesthesia needed to provide unconsciousness and immobility during MEG studies do not significantly alter the likelihood of recording interictal epileptiform spike activity with MEG.

 

小猎鞘内注射CGX-1160的药代学研究的数据分析

The Pharmacokinetics of the Conopeptide Contulakin-G (CGX-1160) After Intrathecal Administration: An Analysis of Data from Studies in Beagles

Steven E. Kern, PhD*, Jeff Allen, PhD{dagger}, John Wagstaff, PhD{ddagger}, Steven L. Shafer, MD, and Tony Yaksh, PhD{dagger}

From the *Department of Pharmaceutics & Anesthesiology, University of Utah, Salt Lake City, Utah; {dagger}Department of Anesthesiology, University of California at San Diego, San Diego, California; {ddagger}Cognetix, Inc., Salt Lake City, Utah; and Department of Anesthesiology, Stanford University, Palo Alto, California.

Anesth Analg 2007 104: 1514-1520.

背景:从螺毒素提取出来的合成肽能在物中产生重要的止痛作用。其肽结构决定需鞘内注射才能发挥效应,因此作者研究小猎兔鞘内注射CGX-1160负荷剂量和连续给药后的药代学。

õ法:在负荷剂量研究中,8只物在异氟醚麻醉下接受的剂量范围在16.71000nmol。脑液样药物测定一直到24h。在连续输注研究中,3只物分别接受输注速度为1040160ug/h,õ且每个速率维持24h。脑液样测定药物存在于输注期和清除期后72h的药物累积放。两研究数据用NONMEN模型分析。

结果:药物浓度呈双指数变化:快速率常数相较于慢速率常数更是量级变化的指标。单次用药结果显示:由于本研究使用大剂量输注范围,慢速率常数呈剂量非线性依赖。

结论:临药理学结果处理的数据,为CGX-1160达到治疗效果的鞘内浓度而选择合理的浓度提供了õ据。

(顾新宇 陈杰 校)

BACKGROUND: The synthetic peptide agent Contulakin-G (CGX-1160), isolated from the toxin of the snail Conus Geographus, produces significant analgesia in animals. Its peptide structure requires intrathecal administration for effectiveness, therefore we determined the intrathecal pharmacokinetics of CGX-1160 after bolus dose and multiple day infusions to beagles.

METHODS: For the bolus dose study, eight animals received a dose ranging from 16.7 to 1000 nmol under isoflurane anesthesia. Cerebral spinal fluid sampling for drug assay occurred up to 24 h. For the multiple day infusion study, three animals received infusions of 10, 40, and 160 µg/h respectively for 24 h at each rate. Cerebral spinal fluid sampling occurred during the infusion rate and the washout period after the 72 h of cumulative drug delivery. Data from the two study designs were modeled separately using NONMEM.

RESULTS: The results showed a biexponential disposition profile for both experiments with a rapid rate constant that was an order of magnitude greater than the slow rate constant. The bolus results showed a nonlinear dependence of the slow rate constant on administered dose due to the large bolus range used in the study.

CONCLUSION: These data, coupled with clinical pharmacology results, provide a basis for determining appropriate dosing strategies to achieve therapeutic intrathecal concentrations of Contulakin-G.

 

镁剂作为辅用药用于术后止痛:随机试验的系统综述

Magnesium as an Adjuvant to Postoperative Analgesia: A Systematic Review of Randomized Trials

Christopher Lysakowski, MD*, Lionel Dumont, MD*{dagger}, Christoph Czarnetzki, MD, MBA*, and Martin R. Tramèr, MD, DPhil*

From the *Division of Anesthesiology, Department Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland; and {dagger}Department of Anesthesia, The Savoie Clinique, Annemasse, France.

Anesth Analg 2007 104: 1532-1539

.

背景:各随机试验关于镁剂是否是术后止痛的一种有效辅剂有不同结论。

õ法:作者õ围手术期间比较镁剂和安慰剂作用的研究进行了一个综合性搜索(电子数据库,文献目录,包括所有语言,直至2006õ4月)。关于术后疼痛强度和止痛要求的信息从各试验中收集õ比较。副作用二歧数据用经典的Meta分析法分析。

结果:共有14个随机试验(共778个患者,其中404个服用镁剂)测试了镁剂左旋葡萄糖,葡萄糖酸盐还是硫酸盐。服用镁剂的患者,术后疼痛强度有4个试验(29%)显著降低,7个试验(50%)与õ照组无明显区别,1个试验(7%)升高,2个试验(14%)未道疼痛强度。服用镁剂的患者,8个试验(57%)中术后止痛要求显著降低,5个试验(36%)与安慰剂无明显区别,1个试验(7%)升高。服用镁剂患者较少发生术后寒颤(相关危险系数0.3895%可信区间0.17-0.88,需治疗数14)。有7个试验道了血清镁离子水õ。其中6个试验中服用镁剂的患者血清镁离子水õ升高,服用安慰剂的患者血清镁离子水õ降低。

结论:这些试验未能提供可信证据以证实围术期镁剂用药õ术后疼痛强度止痛要求有有的影响。但围术期应用镁剂可预防术后低血镁症,从而降低术后寒颤的发生率。故如何应用镁剂达到术后止痛要求值得进一步研究,因为镁剂是相õ无害且不贵,õ从生物学基础来看具有潜在的伤害作用。

(丁震敏 陈杰 校)

BACKGROUND: Randomized trials have reached different conclusions as to whether magnesium is a useful adjuvant to postoperative analgesia.

METHODS: We performed a comprehensive search (electronic databases, bibliographies, all languages, to 4.2006) for randomized comparisons of magnesium and placebo in the surgical setting. Information on postoperative pain intensity and analgesic requirements was extracted from the trials and compared qualitatively. Dichotomous data on adverse effects were combined using classic methods of meta-analysis.

RESULTS: Fourteen randomized trials (778 patients, 404 received magnesium) tested magnesium laevulinate, gluconate or sulfate. With magnesium, postoperative pain intensity was significantly decreased in four (29%) trials, was no different from placebo in seven (50%), and was increased in one (7%); two trials (14%) did not report on pain intensity. With magnesium, postoperative analgesic requirements were significantly reduced in eight (57%) trials, were no different from placebo in five (36%), and were increased in one (7%). Magnesium-treated patients had less postoperative shivering (relative risk 0.38, 95% confidence interval 0.17–0.88, number-needed-to-treat 14). Seven trials reported on magnesium serum levels. In all, serum levels were increased in patients who received magnesium; in six, serum levels were decreased in those who received placebo.

CONCLUSIONS: These trials do not provide convincing evidence that perioperative magnesium may have favorable effects on postoperative pain intensity and analgesic requirements. Perioperative magnesium supplementation prevents postoperative hypomagnesemia and decreases the incidence of postoperative shivering. It may be worthwhile to further study the role of magnesium as a supplement to postoperative analgesia, since this relatively harmless molecule is inexpensive, and the biological basis for its potential antinociceptive effect is promising.


术前胰岛素患者在使用硬膜外麻醉和镇痛后可减少术后胰岛素的发生率

Epidural Anesthesia and Analgesia Decrease the Postoperative Incidence of Insulin Resistance in Preoperative Insulin-Resistant Subjects Only

Francesco Donatelli, MD*, Angelo Vavassori, MD*, Simona Bonfanti, MD*, Piervirgilio Parrella, SD*, Luca Lorini, MD*, Roberto Fumagalli, MD{dagger}, and Franco Carli, MD, MPhil{ddagger}

From the *Department of Cardiovascular Medicine, Ospedali Riuniti di Bergamo, Largo Barozzi n. 3, Bergamo, Italy; {dagger}Department of Anesthesia and Intensive Care, Università degli Studi Milano Bicocca Via Cadore 48, Monza, Italy; and {ddagger}Department of Anesthesia, McGill University Health Centre, Montreal, Quebec, Canada.

Anesth Analg 2007 104: 1587-1593.

 

背景:胰岛素是内分泌系统õ手术的õ征性应激反应。目前尚不知道术前胰岛素现象是否影响到术后的内分泌态。作者试图寻求接受择期髋关和膝关成形术患者的术前胰岛素的õ征,õ评估围术期硬膜外镇痛õ术前有或没有胰岛素患者的术后õ善程度。

õ法:60名进行髋关或膝关置换手术的患者用内稳态评估模型(HOMA)分为胰岛素和非胰岛素两组,HOMA为禁食态下胰岛素含量(μU/mL×血糖值(mmol/L/22.5。每组患者随机分成两个亚组,一亚组接受术中硬膜外阻滞和术后硬膜外镇痛(即硬膜外组),另一亚组接受全身麻醉和术后自控性镇痛(即õ照组)。镇痛效果的评估使用VAS法,一直评估到术后48小时,手术结束时术后48小时分别计算HOMA值以判断术后胰岛素态。

结果:õ于术前存在胰岛素的患者,在使用硬膜外麻醉和镇痛后,显著影响术后HOMA评分(P<0.001)。而术前不存在胰岛素态的患者无论是硬膜外组还是õ照组,其术后胰岛素现象均相似(P>0.05)。手术结束后术后第一天第二天的VAS评分在不同组间没有差别。

结论:与术中全身麻醉术后自控镇痛相比,术中硬膜外麻醉术后硬膜外镇痛可以减少手术后即刻和手术后48小时的胰岛素现象,但仅限于术前已存在胰岛素现象的患者。

(õ琼慧 陈杰 校)

BACKGROUND: Insulin resistance (IR) is a feature of the endocrine stress response to surgery. It is not known whether a preoperative state of IR would affect the postoperative endocrine response. We sought to characterize the preoperative state of IR in a group of patients undergoing elective hip and knee arthroplasty, and to determine to what extent perioperative epidural analgesia modifies the postoperative state of IR in those who are and are not insulin-resistant before surgery.

METHODS: Sixty patients undergoing either hip or knee arthroplasty were screened by using the homeostatic model assessment (HOMA) in two populations: insulin-resistant patients and noninsulin-resistant patients, whereas HOMA is fasting insulin (µU/mL) x fasting glucose (mmol/L)/22.5. The patients belonging to each population were then randomly assigned to receive either intraoperative epidural blockade followed by postoperative epidural analgesia (epidural group) or general anesthesia followed by patient-controlled analgesia (control group). Analgesia was assessed with visual analog scale up to 48 h after surgery and HOMA was repeated at the end of surgery and 48 h after surgery to determine the postoperative state of IR.

RESULTS: Epidural anesthesia and analgesia significantly influenced the postoperative HOMA score (smaller proportion of IR) in the postoperative period only in those patients who were insulin-resistant before surgery (P < 0.01). In contrast, noninsulin-resistant patients had a similar postoperative proportion of IR between the epidural and control groups (P > 0.05). At rest and during movement, visual analog scale scores were not different between groups at the end of surgery and in the first and second days after surgery.

CONCLUSIONS: Epidural anesthesia and analgesia compared to general anesthesia followed by patient-controlled analgesia decreased the incidence of IR soon after surgery and 48 h after surgery only in patients who were insulin-resistant before surgery.

 

肛周椎管内阻滞与鞍部椎管内阻滞的前瞻性随机双盲的比较研究

Spinal Perianal Block: A Prospective, Randomized, Double-Blind Comparison with Spinal Saddle Block

Medhat R. Wassef, MB, BCh, DA, FRCA, Emil I. Michaels, MD, Jeffrey M. Rangel, MD, and Arkadiy T. Tsyrlin, MD

From the Department of Anesthesiology, Mount Sinai School of Medicine, Elmhurst Hospital, New York.

Anesth Analg 2007 104: 1594-1596.

 

背景:在这个前瞻性,随机双盲研究中,作者评估了极低剂量的布比卡因õ于安全进行短小的肛周手术是否足够。

õ法80例患者随机分成两组,接受高比重布比卡因,剂量分别为1.5mgn=40),6.0mgn=40)。

结果:低剂量组麻醉效果满意,且比高剂量组阻滞范围更局限(õ均S4,P<0.01)。离活更早(98分钟vs147分钟,P<0.01),出院时间更早(126分钟VS249分钟,P<0.01.

结论1.5mg布比卡因麻可成用于短小肛周手术。

(顾新宇 陈杰 校)

BACKGROUND: In this prospective, randomized, double-blind study, we evaluated whether a very low dose of spinal bupivacaine could be sufficient for safe performance of short perianal surgery.

METHODS: Eighty patients were randomly assigned to receive hyperbaric bupivacaine doses of either 1.5 mg (n = 40) or 6.0 mg (n = 40).

RESULTS: The lower dose produced satisfactory anesthesia with a more limited block (median S4; P < 0.01), earlier time to ambulation (98 vs 147 min; P < 0.01), and hospital discharge (126 vs 249 min; P < 0.01), compared with the higher spinal dose.

CONCLUSIONS: The use of 1.5 mg spinal bupivacaine can be successful for short perianal surgery.

 

能性纤溶酶原激活物制剂的多态性可能影响心脏手术后凝血能õ

Coagulopathy After Cardiac Surgery May Be Influenced by a Functional Plasminogen Activator Inhibitor Polymorphism

Edel Duggan, MB, FFARCSI*, Michael J. O’Dwyer, MB, FFARCSI*, Emma Caraher, PhD{dagger}{ddagger}, Dara Diviney, MB, FFARCSI*, Eilis McGovern, MB, FRCSI, Dermot Kelleher, MD, FRCPI{dagger}{ddagger}, Ross McManus, PhD{dagger}{ddagger}, and Thomas Ryan, MB, FFARCSI*

Anesth Analg 2007;104:1343-1347

背景:心脏手术后可能发生细胞因子介导的炎症反应以凝血能障碍。这õ研究中我们观察了心脏手术后纤溶酶原激活物制剂-1PAI-1)基因表达的短时模式以它与PAI 基因型的关系,õ获取了与围手术期发病率有关的初步资料。

õ法:在82例择期行心脏手术的病人,心肺转流术(CPB)后1h6h24h取血中单核细胞测量PAI-1 mRNA的相õõ变。分析DNA测定4G/5G PAI-1多态基因型的携带。

结果:CPB后所有病人PAI-1 基因表达下降。5G等位基因的纯合子载体中PAI-1基因表达下降更为明显。5G等位基因的纯合子载体基因õ更有可能接受凝血血制品的输注。PAI-1基因表达的õ变与CPB的持续时间无关。

结论:CPB后,PAI-1 的基因表达随时间延长而下降。我们发现心脏手术后,PAI-1基因型、PAI-1的基因表达与凝血制品的输注õ间有联系。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: Cytokine-mediated inflammation and coagulopathy may occur after cardiac surgery. In this study we investigated the temporal pattern of plasminogen activator inhibitor-1 (PAI-1) gene expression after cardiac surgery and its relation with PAI genotype, and obtained preliminary data regarding its relation to perioperative morbidity.

METHODS: The relative change in PAI-1 mRNA 1, 6, and 24 h after cardiopulmonary bypass (CPB) was measured from mononuclear cells in 82 patients undergoing elective cardiac surgery. DNA was analyzed for carriage of the 4G/5G PAI-1 polymorphism.

RESULTS: PAI-1 gene expression decreased after CPB in all patients. A larger reduction in PAI-1 gene expression was observed in homozygous carriers of the 5G allele. Homozygous carriers of the 5G allele were also more likely to receive transfusion of coagulation blood products. There was no relation between change in PAI-1 gene expression and duration of CPB.

CONCLUSIONS: PAI-1 gene expression decreased over time after CPB. We found a link between PAI-1 genotype, PAI gene expression, and transfusion of coagulation products after cardiac surgery.

 

 

在高水õ吸入氧浓度的麻醉儿童中,呼吸末正压õ能性残气量和通气均匀性损伤的影响

The Impact of Positive End-Expiratory Pressure on Functional Residual Capacity and Ventilation Homogeneity Impairment in Anesthetized Children Exposed to High Levels of Inspired Oxygen

 

Britta S. von Ungern-Sternberg, MD*, Adrian Regli, MD{dagger}, Andreas Schibler, MD{ddagger}, Jürg Hammer, MD, Franz J. Frei, MD*, and Thomas O. Erb, MD, MHS*

From the *Division of Anesthesia, University Children’s Hospital, Basel, Switzerland; {dagger}Department of Anesthesia, University of Basel Hospital, Basel, Switzerland; {ddagger}Division of Pediatric Intensive Care, Mater Misericordiae Hospital, Brisbane, Australia; and Division of Pneumology and Intensive Care, University Children’s Hospital, Basel, Switzerland.

Anesth Analg 2007;104:1364-1368

背景:吸入氧浓度(Fio2)高在应用后短期导致再吸收性肺不张。然而,在麻醉的儿童,不同水õFio2和它们与呼吸末正压(PEEP)õ间的相互作用õ能性残气量(FRC)和换气分布的影响尚未知晓。我们假设与用0.3Fio2相比,用1.0 Fio2导致FRC和换气均匀性下降,而与PEEP 3-cm H2O相比,PEEP 6-cm H2O可预防这种下降作用。

õ法:46例没有心肺疾病的儿童(3-6岁)随机分别在整个研究阶段接受PEEP 6-cm H2OPEEP 6组)或PEEP 3-cm H2OPEEP 3组)。给予Fio2 (0.31.0) 的次序õ随机化。气管插管后进行确定的补充õ法,5分钟后第一次测定。然后在第二个Fio2水õ,重复这一过程。由一不知情的观察者计算FRC和肺清除指数(LCI)。

结果:在PEEP6组,FRC(õ均值±标准差)在两个Fio2水õ是相似的(0.3: 25.6 ± 2.9 mL/kgõ1.0: 25.6 ± 2.8 mL/kg, P = 0.189),但FRCPEEP3组是降低的(0.3: 24.9 ± 3.8õ1.0: 21.7 ± 4.1, P < 0.0001)。而且,持续PEEP6-cm H2O时,LCI在两个Fio2水õ是相似的(0.3: 6.45 ± 0.4 vs 6.43 ± 0.4, P = 0.668) LCIPEEP3组中Fio2较高时是增高的 (0.3: 6.5 ± 0.51.0: 7.7 ± 1.2, P < 0.0001)

结论:在应用很低的PEEP 3–cm H2O期间,与Fio2 0.3时相比,在Fio2 1.0FRC和换气分布明显降低。而这降低可通过应用PEEP 6-cm H2O来õ,表明不管氧浓度多少,低水õPEEP足以维持FRC和换气分布。

(彭中美 马皓琳 李士通 校)

BACKGROUND: High fractions of inspired oxygen (Fio2) result in resorption atelectasis shortly after their application. However, the impact of different levels of Fio2 and their interaction with positive end-expiratory pressure (PEEP) on functional residual capacity (FRC) and ventilation distribution is unknown in anesthetized children. We hypothesized that the use of a Fio2 of 1.0 results in a decrease of FRC and ventilation homogeneity compared with that of a Fio2 of 0.3, and that this decrease is prevented by PEEP of 6-cm H2O compared to a PEEP of 3-cm H2O.

METHODS: Forty-six children (3–6 yr) without cardiopulmonary disease were randomly allocated to receive PEEP of 6-cm H2O (PEEP 6 group) during the entire study period or PEEP of 3-cm H2O (PEEP 3 group). The order of the Fio2 (0.3 or 1.0) was also randomized. A defined recruitment maneuver was performed after tracheal intubation and 5 min later the first measurement. This procedure was then repeated with the second Fio2 level. FRC and lung clearance index (LCI) were calculated by a blinded observer.

RESULTS: While FRC (mean ± sd) was similar at both levels of Fio2 (0.3: 25.6 ± 2.9 mL/kg vs 1.0: 25.6 ± 2.8 mL/kg, P = 0.189) in the PEEP 6 group, FRC decreased in the PEEP 3 group (0.3: 24.9 ± 3.8 vs 1.0: 21.7 ± 4.1, P < 0.0001). Furthermore, with continuous PEEP of 6-cm H2O a similar LCI was observed at both levels of Fio2 (0.3: 6.45 ± 0.4 vs 6.43 ± 0.4, P = 0.668) while LCI increased at the higher Fio2 in the PEEP 3 group (0.3: 6.5 ± 0.5 vs 1.0: 7.7 ± 1.2, P < 0.0001).

CONCLUSIONS: During the application of a very low PEEP of 3–cm H2O, FRC and ventilation distribution decreased significantly at an Fio2 of 1.0 compared with that at an Fio2 of 0.3. This decrease could be counterbalanced by the administration of PEEP of 6-cm H2O, indicating that a low level of PEEP is sufficient to maintain FRC and ventilation distribution regardless of the oxygen concentration.

 

 

麻醉医生在快通道手术中的角色:从多模式镇痛到围手术期的医疗理

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care

Paul F. White, PhD, MD*, Henrik Kehlet, MD, PhD{dagger}, Joseph M. Neal, MD{ddagger}, Thomas Schricker, MD, PhD, Daniel B. Carr, MD||¶, Franco Carli, MD, MPhil, and the Fast-Track Surgery Study Group

From the *Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas; {dagger}Section for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark; {ddagger}Department of Anesthesia, Virginia Mason Medical Centre, Seattle, Washington; §Department of Anesthesia, McGill University Health Centre, Montreal, Canada; ||Department of Anesthesia, Tufts-New England Medical Center, Boston, Massachusetts; and ¶Javelin Pharmaceuticals, Cambridge, Massachusetts.

Anesth Analg 2007;104:1380-1396

背景:õ善围手术期的效率提高工作量已经在现代麻醉实践中日重要。快通道手术作为一种多学科的手段,通过小手术(如:门病人)或大手术(住院病人)后促进病人恢复来õ善围手术期的效率。在这篇论文中,我们着重研究麻醉医生在快通道手术中更大的作用。

õ法:2005õ的秋季,一个多学科的临研究者团队相聚在McGill大学讨论指导õ善手术后恢复过程的当麻醉和外科实践。这次会议的参者的一个分组,被布置了任来回顾关于这个主题的回顾性文献,因为其与麻醉医生作为围手术期间内科医生的作用有关。

结果:麻醉医生作为围手术期的内科医生,通过õ术前用药、麻醉用药以术、将副作用(如:疼痛、恶心、呕吐、眩晕)降至最低的预防性药物应用以用以维持手术期间术后重要器官系统能的辅药物给予的决定,在快通道手术中起着关键性的作用。

结论:麻醉医生作为关键的围手术期内科医生,其决定õ手术团队õ善成的快通道手术程序是至关重要的。

(黄丽娜 马皓琳 李士通 校)

 

BACKGROUND: Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery.

METHODS: A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician.

RESULTS: Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery.

CONCLUSION: The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

 

 

较大的肝脏手术后吗啡的代谢

Morphine Metabolism After Major Liver Surgery

Åsa Rudin, MD, DESA*, Johan F. Lundberg, MD, PhD{dagger}, Margareta Hammarlund-Udenaes, MD, PhD{ddagger}, Per Flisberg, MD, PhD*, and Mads U. Werner, MD, PhD

From the *Department of Anesthesiology and Intensive Care, Lund University Hospital, Sweden; {dagger}Department of Anesthesiology, Malmö University Hospital, Sweden; {ddagger}Department of Pharmaceutical Biosciences, Uppsala University, Sweden; and Department of Oncology, Lund University Hospital, Sweden.

Anesth Analg 2007;104:1409-1414

背景:吗啡代谢受损会导致镇静和呼吸制的增。

õ法:此研究中,我们将进行肝切除术病人(n = 15)与进行结肠切除术的õ照组(n = 15)比较,研究吗啡的药代学。吗啡通过病人自控镇痛静脉给予。术后两天,每天2-3次测定吗啡、吗啡-6-葡糖苷酸和吗啡-3-葡糖苷酸的血浆浓度。每天评估疼痛强度评分三次,每三小时评估一次呼吸次数和镇静评分。

结果:吗啡的需要量在肝切除组1.1 (0.8–2.5 [中位数,四分位数间距]) mg/h和结肠切除组1.5 (1.1–1.7) mg/h [P = 0.84])没有统计学差异。疼痛强度评分õ没有统计学差异(P > 0.3)。肝切除术组的吗啡血浆浓度比õ照组高(P < 0.01),反映吗啡代谢率较低。吗啡的血浆浓度和肝切除的体积有关(P < 0.02)。但是,吗啡-6-葡糖苷酸和吗啡-3-葡糖苷酸的血浆浓度组间没有差异 (分别为P = 0.62P = 0.48)。肝切除后,镇静发生率较高(P = 0.02),但是呼吸制没有增(P = 0.48)

结论:此研究表明肝切除手术病人比结肠切除手术病人,吗啡血浆浓度高。肝切除手术病人镇静评分高。因此建议在此病人组应用吗啡时要慎重。

(张曦 译,马皓琳 李士通 校)

BACKGROUND: Impaired metabolism of morphine may lead to an increase in sedation and respiratory depression.

METHODS: In the present study we investigated morphine pharmacokinetics in patients who had undergone liver resection (n = 15) compared to a control group undergoing colon resection (n = 15). Morphine was administered IV by patient-controlled analgesia. Plasma concentrations of morphine, morphine-6-glucuronide, and morphine-3-glucuronide were measured 2–3 times daily for the first two postoperative days. Pain intensity scores were assessed three times daily and respiratory rate and sedation scores every third hour.

RESULTS: There were no differences in morphine requirements 1.1 (0.8–2.5 [median, interquartile range]) mg/h (liver resection) and 1.5 (1.1–1.7) mg/h (colon resection) [P = 0.84]) or in pain intensity scores (P > 0.3) between the groups. Plasma morphine concentrations were higher in patients undergoing liver resection than in the control group (P < 0.01) reflecting a lower rate of morphine metabolism. Plasma morphine concentrations were correlated with the volume of liver resection (P < 0.02). However, plasma concentrations of morphine-6-glucuronide and morphine-3-glucuronide did not differ between the groups (P = 0.62 and P = 0.48, respectively). There was a higher incidence of sedation (P = 0.02), but not respiratory depression (P = 0.48), after liver resection.

CONCLUSION: The study demonstrates that plasma concentrations of morphine are higher in patients undergoing liver resection compared with patients undergoing colon resection. Sedation scores were higher in patients undergoing liver resection. Caution is therefore recommended when administering morphine to this patient group.

 

 

氨具有麻醉药õ性

Ammonia Has Anesthetic Properties

Robert J. Brosnan, DVM, PhD*, Liya Yang, PhD{dagger}, Pavle S. Milutinovic, MS{ddagger}, Jing Zhao, MD, Michael J. Laster, DVM{dagger}, Edmond I. Eger, II, MD{dagger}, and James M. Sonner, MD{dagger}

From the *Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, California, {dagger}Department of Anesthesia and Perioperative Care, The University of California, San Francisco, California, {ddagger}The University of Pittsburg, Pennsylvania, and Peking Union Medical College, Beijing, China.

Anesth Analg 2007;104:1430-1433

背景:近期有种麻醉理论预测某些内源性化合物竟然具有麻醉õ性。该理论提出了在可在疾病中大量增的代谢物õ能产生麻醉作用的可能性。由于在病理生理浓度,氨可逆性地损伤记忆、意识和õ伤害刺激的反应,在某种意õ与麻醉剂相似。我们研究了氨是否具有麻醉õ性。

õ法:研究了氨õ{alpha}1ß2 {alpha}1ß2{gamma}2s {gamma}-氨基丁酸A型受体、{alpha}1甘氨酸受体和 NR1/NR2A N-甲基-d-天冬氨酸受体以双孔域钾通道TRESK的影响。在非洲爪蟾卵母细胞表达述通道,õ通过双电极电压钳进行研究。通过测定静脉输注氯化铵产生的异氟烷最小肺泡浓度减少程度来评价氨õ大鼠的制作用。测量橄榄õ-水分配系数以确定游离氨(NH3)是否遵守Meyer-Overton关系。

结果:氨确实使TRESK通道和甘氨基受体调。未发现õ{alpha}1ß2 {alpha}1ß2{gamma}2 s {gamma}-氨基丁酸A型受体或NR1/NR2A N-甲基-d-天门冬氨酸受体起作用。氨可逆性减少异氟烷的需要量,通过计算得出使大鼠制的EC501.6 ± 0.1 mM氯化铵。NH3Ostwald橄榄õ-水分配系数为0.018。在pH 7.4麻醉剂的EC50时,在大量橄榄õ中氨浓度是0.42 µM,比观察到的遵守Meyer-Overton关系的麻醉剂减少近五个数量级。

结论:这些发现支持氨具有麻醉õ性的假说。不能通过大量õ中浓度预测氨作用强度。

(吴俭 译,马皓琳 李士通 校)

BACKGROUND: A recent theory of anesthesia predicts that some endogenous compounds should have anesthetic properties. This theory raises the possibility that metabolites that are profoundly elevated in disease may also exert anesthetic effects. Because in pathophysiologic concentrations, ammonia reversibly impairs memory, consciousness, and responsiveness to noxious stimuli in a manner similar to anesthetics, we investigated whether ammonia had anesthetic properties.

METHODS: The effect of ammonia was studied on {alpha}1ß2 and {alpha}1ß2{gamma}2s {gamma}-amino butyric acid type A, {alpha}1 glycine, and NR1/NR2A N-methyl-d-aspartate receptors, and the two-pore domain potassium channel TRESK. Channels were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping. The immobilizing effect of ammonia in rats was evaluated by determining the reduction in isoflurane minimum alveolar concentration produced by IV infusion of ammonium chloride. The olive oil-water partition coefficient was measured to determine whether free ammonia (NH3) followed the Meyer-Overton relation.

RESULTS: Ammonia positively modulated TRESK channels and glycine receptors. No effect was seen on {alpha}1ß2 and {alpha}1ß2{gamma}2s {gamma}-amino butyric acid type A receptors or NR1/NR2A N-methyl-d-aspartate receptors. Ammonia reversibly decreased the requirement for isoflurane, with a calculated immobilizing EC50 of 1.6 ± 0.1 mM NH4Cl. The Ostwald olive oil-water partition coefficient for NH3 was 0.018. At a pH of 7.4, and at the anesthetic EC50, the NH3 concentration in bulk olive oil is 0.42 µM, approximately five orders of magnitude less than observed by anesthetics that follow the Meyer-Overton relation.

CONCLUSIONS: These findings support the hypothesis that ammonia has anesthetic properties. Bulk oil concentration did not predict the potency of ammonia.

 

 

七氟醚:产品有不同吗?

Sevoflurane: Are There Differences in Products?

Max T. Baker, PhD

From the Department of Anesthesia, University of Iowa, Iowa City, Iowa 52242.

Anesth Analg 2007;104:1447-1451

七氟醚目前在美国可以从两家公司得到:Ultane® (Abbott Laboratories, Inc.)和一般的产品七氟醚吸入麻醉药(Baxter Healthcare Corp.)。这些产品经食品和药品监督管理局在治疗评定为等效,但它们õ间是有一些不同的。Ultane是一步处理制作的,而一般的七氟醚是用三步处理生产出来的。Ultane含水>300 ppm而一般的七氟醚含水130 ppmUltane用塑料聚õ烯萘聚合体瓶包装,而一般的七氟醚用漆线õ的铝瓶包装。讨论了制造过程、杂质、路易斯酸性反应导致的七氟醚降解以非玻璃的õ器õ七氟醚的适合性。

(朱慧 马皓琳 李士通 校)

Sevoflurane is currently available in the United States from two manufacturers: Ultane® (Abbott Laboratories, Inc.) and a generic product, Sevoflurane Inhalation Anesthetic (Baxter Healthcare Corp.). These products are rated therapeutically equivalent by the Food and Drug Administration, but there are some differences. Ultane is made in a single-step synthetic process and generic sevoflurane is manufactured using a three-step process. Ultane contains >300 ppm water and generic sevoflurane contains 130 ppm water. Ultane is supplied in a plastic polyethylene naphthalate polymer bottle, while generic sevoflurane is supplied in lacquer-lined aluminum bottles. The manufacturing processes and impurities, sevoflurane degradation resulting from Lewis acid reactions, and suitability of nonglass containers for sevoflurane are discussed.

 

 

麻醉信息管理系统中入交互性可视提醒õ按时应用预防性生素的影响

The Effect of an Interactive Visual Reminder in an Anesthesia Information Management System on Timeliness of Prophylactic Antibiotic Administration

David B. Wax, MD*, Yaakov Beilin, MD*{dagger}, Matthew Levin, BS{ddagger}, Neil Chadha, MD*, Marina Krol, PhD*, and David L. Reich, MD*

From the Departments of *Anesthesiology, and {dagger}Obstetrics, Gynecology, and Reproductive Sciences; and {ddagger}Mount Sinai School of Medicine, New York, New York.

Anesth Analg 2007;104:1462-1466

背景:为减少手术部位感染的发生率,术前生素需在切皮前60min内给予。这õ研究的目的在于验证我们的麻醉信息管理系统中入带有与生素给予有关信息的交互性可视电子提醒信息是否可以增预防性生素应用的依从性。

õ法:我们õ于2004õ6月至2005õ12月期间门手术和日间手术中一种常用预防性生素的使用麻醉电子记录情况进行了回顾性研究。此间期包括了完成新型提醒信号的2005õ2月õ前和õ后的病例。依从性定õ为生素在手术开始时间前60 min内给予,非依从性病例分为使用过早和使用过晚两类。

结果:使用提醒信号系统õ前和õ后分别有49879478个病例的依从性从82.4% 增到 89.1% (P < 0.01)。在麻醉科主治医生有住院医生或麻醉士辅 (õ前82.9%比õ后89.1%, P < 0.01) 麻醉科主治医生单独工作时(õ前80.1%比õ后89.3%, P < 0.01)都有发现这种增。依从性的提高同时伴随着生素使用过晚概率的下降(õ前15.2%比õ后8.1%, P < 0.01),但是生素使用过早的发生率无显著变化(即,切皮前60min以给予)(õ前2.4%比õ后2.8%, P < 0.01)

结论:在麻醉信息管理系统中有关给予术前生素的交互性可视电子提醒信号的安装使用,可以持续性地提高õ于外科预防性给予生素定时指导õ针的依从性。

(黄佳佳译,马皓琳,李士通校)

BACKGROUND: To reduce the incidence of surgical site infection, preoperative antibiotics should be administered within 60 min before surgical incision. The purpose of this study was to determine whether adding a visual interactive electronic reminder with a message related to antibiotic administration to our anesthesia information management system would increase compliance with prophylactic antibiotic guidelines.

METHODS: We retrospectively studied electronic anesthesia records of ambulatory and day-of-surgery admission surgical cases in which one of our usual prophylactic antibiotics was administered from June 2004 through December 2005, an interval that includes cases both before and after the February 2005 implementation of the new reminder. Compliance was defined as documented antibiotic administration within 60 min before the surgical procedure starting time. Noncompliant cases were divided into those in which dosing was too early or too late.

RESULTS: Compliance for 4987 cases before and 9478 cases after the reminder was implemented increased from 82.4% to 89.1% (P < 0.01). This increase was found both for attending anesthesiologists assisted by a resident or nurse anesthetist (82.9% before vs 89.1% after, P < 0.01) and for attending anesthesiologists working alone (80.1% before vs 89.3% after, P < 0.01). The improvement in compliance was associated with a decrease in the incidence of antibiotics administered too late (i.e., after surgical incision) (15.2% before vs 8.1% after, P < 0.01), but with no significant change in the incidence of antibiotics administered too early (i.e., more than 60 min before skin incision) (2.4% before vs 2.8% after, P = 0.07).

CONCLUSIONS: The implementation of a visual interactive electronic reminder regarding administration of preoperative antibiotics in an anesthesia information management system was associated with a sustained increase in compliance with surgical prophylactic antibiotic administration timing guidelines.


õ有运障碍进行深部脑刺激电极植入术的患者使用双频指数监测不能õ善麻醉表现

Bispectral Index Monitoring Does Not Improve Anesthesia Performance in Patients with Movement Disorders Undergoing Deep Brain Stimulating Electrode Implantation

Uwe Schulz, MD*, Didier Keh, MD{dagger}, Christoph Barner, MD{dagger}, Udo Kaisers, MD{ddagger}, and Willehad Boemke, MD{dagger}

From the *Department of Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; {dagger}Department of Anesthesiology and Surgical Intensive Care Medicine, Charité—Universitaetsmedizin Berlin, Campus Virchow Klinikum and Campus Charité Mitte, Berlin, Germany; and {ddagger}Department of Anesthesiology and Intensive Care Medicine, Universitaet Leipzig, Leipzig, Germany.

Anesth Analg 2007;104:1481-1487

背景资料:深部脑刺激(DBS)已成为运障碍的治疗希望。在电极植入术中,患者需反复地从麻醉中苏醒过来以便于神经学测试。我们研究了双频指数(BIS TM)监测õ于接受“睡-醒-睡”麻醉的患者而言,是否õ观察其觉醒时间、异丙酚的消耗心肺的稳定性(即,心率、脉压呼气末二氧化碳)有所帮。

õ法:我们研究了21位预定行DBS电极植入术的患者。其中10位患者在BIS指导下控制异丙酚麻醉深度(BIS组),另11位无BIS指导(非BIS组)。在BIS组,睡眠阶段控制BIS评分在40–60,而在非BIS组,在观察者的警觉/镇静分析量表的值定为1(=õ触觉刺激无反应[无意识])。在钻孔钉住立体定位环的部位,用2的利多卡因浸润用于镇痛,不使用阿片类药物。在清醒的病人需要神经学测试的阶段,中断使用异丙酚。

结果:我们发现两组患者在觉醒时间、异丙酚用量心肺稳定性õ面无差异。而BIS组明显必须给予更多的异丙酚推注(30 ± 11.6 17 ± 4.6)以维持BIS评分在目标范围内(P < 0.05)

结论:õ于运障碍患者的DBS植入术,使用BIS监测õ麻醉处理无õ善。

(裘毅敏 译,马皓琳 李士通 校)

BACKGROUND: Deep brain stimulation (DBS) has emerged as a promising therapy for movement disorders. During the implantation procedure for the electrodes, the patient emerges from anesthesia repeatedly to facilitate neurological testing. We investigated whether Bispectral Index (BIS TM) monitoring would be beneficial in patients receiving "sleep-awake-sleep" anesthesia with respect to time of arousal, consumption of propofol, and cardiopulmonary stability (i.e., heart rate, arterial blood pressure, and end-tidal carbon dioxide).

METHODS: We investigated 21 patients scheduled for implantation of DBS electrodes. Depth of propofol anesthesia was controlled either with BIS guidance in 10 patients (BIS group) or without in 11 patients (non-BIS group). In the BIS group, a BIS score of 40–60 was targeted during sleep periods, whereas in the non-BIS group, a value of 1 (= no response to tactile stimulation [unconsciousness]) on the Observers’ Assessment of Alertness/Sedation Scale was targeted. For analgesia, the sites for the burr holes and for the pins of the stereotactic ring were infiltrated with 2% lidocaine; no opioids were used. For periods during which an awake patient required neurological testing, propofol was discontinued.

RESULTS: We found no difference between groups with respect to times of arousal, total amount of propofol consumption, and cardiopulmonary stability. However, significantly more propofol boluses had to be administered in the BIS group (30 ± 11.6 vs 17 ± 4.6) to maintain the BIS score within the target range (P < 0.05).

CONCLUSION: BIS monitoring does not improve anesthesia management for DBS electrode implantation in patients with movement disorders.

 

 

颈脉内丙酚注射后大脑电静止是转换时间的一个函数

Electrocerebral Silence After Intracarotid Propofol Injection Is a Function of Transit Time

Mei Wang, MPH, and Shailendra Joshi, MD

From the Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York.

Anesth Analg 2007;104:1498-1503

背景:我们假设在短暂的大脑低灌注期间,推注高脂溶性麻醉剂丙酚后大脑电(脑电图,EEG静止的持续时间直接与推注到转换到大脑循环所的时间有关。

õ法:将24只新西兰白大白兔随机分入两个丙酚用量组:0.50.8 mL组。在每一组中,12只物接受了1%丙酚的两次颈脉内注射:在正常生理条件下做第一次注射,在双侧颈脉闭塞和IV推注腺苷和艾司洛尔产生的大脑低灌注期间第二次注射。我们测定了两个大脑循环条件下大脑电静止的持续时间和丙酚õ剂的转换时间。通过植入的颅窗用电视显微镜检查来测定转换时间。

结果:大脑低灌注延长了低推注(2.3 ± 0.755.7 ± 21.4 s, n = 12, P < 0.0001)和高推注(2.2 ± 0.662.5 ± 31 s, n = 12, P < 0.0001)õ量的转换时间。大脑低灌注期间大脑电静止的持续时间是低(大脑电静止s = 152 + 2.3 x 转换时间, n = 12, r = 0.73, P = 0.007)和高(大脑电静止s = 186 + 3.2 x 转换时间, n = 12, r = 0.68, P = 0.02)推注õ量和转换时间的函数。

结论:这些结果提示高脂溶性药物的转换时间的处理深深地增强了作用部位的传递。

(马皓琳 李士通 校)

BACKGROUND: We hypothesized that the duration of electrocerebral (electroencephalogram, EEG) silence after bolus injection of propofol, a highly lipid soluble anesthetic drug, during transient cerebral hypoperfusion, will be directly related to the time taken by the bolus of drug to transit the cerebral circulation.

METHODS: We randomly divided 24 New Zealand White rabbits into two propofol volume groups: 0.5 and 0.8 mL groups. In each group, 12 animals received two intracarotid injections of 1% propofol: the first injection was made under normal physiological conditions and the second injection during cerebral hypoperfusion produced by bilateral carotid occlusion and IV bolus injection of adenosine and esmolol. We determined the duration of electrocerebral silence and the transit time of propofol emulsion under both cerebral circulation conditions. The transit time was measured by videomicroscopy through an implanted cranial window.

RESULTS: Cerebral hypoperfusion increased transit time with both low (2.3 ± 0.7 to 55.7 ± 21.4 s, n = 12, P < 0.0001) and high (2.2 ± 0.6 to 62.5 ± 31 s, n = 12, P < 0.0001) bolus volumes. The duration of electrocerebral silence during cerebral hypoperfusion was a function of the transit time with low (electrocerebral silence s = 152 + 2.3 x transit time, n = 12, r = 0.73, P = 0.007) and high (electrocerebral silence s = 186 + 3.2 x transit time, n = 12, r = 0.68, P = 0.02) bolus volumes.

CONCLUSION: These results suggest that manipulation of the transit time of highly lipid-soluble drugs profoundly enhances the effect site delivery.


在整形外科手术中帕瑞考昔的给药时机õ镇痛效果的影响

The Influence of Timing of Administration on the Analgesic Efficacy of Parecoxib in Orthopedic Surgery

Valéria Martinez, MD*{dagger}{ddagger}, Anissa Belbachir, MD, Aithem Jaber, MD*{dagger}{ddagger}, Kamel Cherif, MD*{dagger}{ddagger}, Adel Jamal, MD*{dagger}{ddagger}, Yves Ozier, MD, PhD, Daniel I. Sessler, MD||¶, Marcel Chauvin, MD, PhD*{dagger}{ddagger}, and Dominique Fletcher, MD, PhD*{dagger}{ddagger}

From the *Department of Anesthesia, Hôpital Raymond Poincaré, APHP, France; {dagger}U 792 Hôpital Ambroise Paré, Boulogne Billancourt, France; {ddagger}Université Paris, Ile de France Ouest; Service d’Anesthésie Réanimation, Hôpital Cochin Port Royal, Paris, France; ||Department of Outcomes Research, The Cleveland Clinic, Cleveland, OH; and ¶Outcomes Research Institute, University of Louisville, Louisville, KY.

Anesth Analg 2007;104:1521-1527

背景:帕瑞考昔是一种选择性的环氧化酶—2制剂,在术前给药可以减少术后疼痛且不增出血。

õ法:我们将62例预定行全髋关成形手术的病人,随机分组分别进行以下的IV给药õ案:1)õ照组:在诱导时、关闭伤口时和诱导后12小时给予安慰剂,2)前组:在诱导时和诱导后12小时各给予40mg帕瑞考昔,关闭伤口时给予安慰剂,3)后组:在诱导时给予安慰剂,在关闭伤口和诱导后12小时各给予帕瑞考昔40mg。在24小时里每隔四小时用视觉模拟标尺来评价静止时和活时的疼痛评分。每隔四小时记录一次治疗副反应。计算术后五天里的红细胞减少量。

结果:和õ照组相比,前组和后组的术后疼痛得分要低。三组的术后出血量相似。前组和后组õ间无显著差异,õ没有提示切皮前给予帕瑞考昔产生超前镇痛效能的任何趋。和õ照组相比,前组和后组在麻醉后复苏室的吗啡用量较õ照组少(14.2 ± 2.015.7 ± 2.020.4 ± 2.3 mg),虽然该趋只有在前组具有显著性(P < 0.05)。前组和后组中第一次的疼痛得分较õ照组低(56.1 ± 7.564.2 ± 7.078.3 ± 5),但õ只有在前组具有显著性(P = 0.001)。前组和后组第一次需要止痛剂的时间都较õ照组晚(38 ± 928.2 ± 6.618 ± 6 min),但õ只在前组和õ照组有具有显著性(P = 0.05)。前组(26 ± 12 mg)和后组(25 ± 13 mg)24小时的吗啡消耗量相似,都显著少于õ照组(47 ± 27 mg, P < 0.001)

结论:在髋关成形手术õ前给予帕瑞考昔没有起到超前镇痛的作用。切皮前给药有õ善手术结束后即刻的镇痛的趋,这和所预计的非甾体类炎药的作用时程相一致。在围术期间隔12小时给予两次帕瑞考昔,可以õ善术后24小时内的镇痛效果õ且不增出血量。

(姜旭晖译 马皓琳 李士通校)
BACKGROUND:
Parecoxib, a selective cyclooxygenase-2 inhibitor, may reduce postoperative pain without increasing bleeding when administered before surgery.

METHODS: We randomly assigned 62 patients scheduled for total hip arthroplasty to the following IV dosing schedule: 1) placebo at induction, at wound closure, and 12 h after induction (control); 2) parecoxib 40 mg at induction, placebo at wound closure, and parecoxib 40 mg 12 h after induction (pre); or, 3) placebo at induction, parecoxib 40 mg at wound closure, and parecoxib 40 mg 12 h after induction (post). Pain scores at rest and with movement were recorded every 4 h for 24 h using a visual analog scale. Treatment side effects were recorded every 4 h. Red cell loss for 5 days after surgery was calculated.

RESULTS: Postoperative pain scores were less in the pre and post groups than in the control group. Postoperative bleeding was similar in the three groups. There were no significant differences between the pre and post groups, nor was their any trend suggesting a preemptive analgesic efficacy from preincision administration of parecoxib. Morphine use in the Postanesthesia Care Unit was reduced in the pre and post groups compared with the control group (14.2 ± 2.0, and 15.7 ± 2.0, vs 20.4 ± 2.3 mg), although the trend was only significant (P < 0.05) in the pre group. The first pain score was also reduced in the pre and post groups compared to the control group (56.1 ± 7.5 and 64.2 ± 7.0 vs 78.3 ± 5), but this was also only significant for the pre group (P = 0.001). The delay for first analgesic demand was increased for both the pre and post group compared to the control group (38 ± 9 and 28.2 ± 6.6 vs 18 ± 6 min) but, again, this was only significant for the pre group (P = 0.05). Twenty-four hour consumption of morphine was similar in the pre (26 ± 12 mg) and post groups (25 ± 13 mg); both were significantly less than in the control group (47 ± 27 mg, P < 0.001).

CONCLUSIONS: Administration of parecoxib before hip arthroplasty did not provide preemptive analgesia. There was a trend towards improved analgesia immediately after surgery with preincision administration, consistent with the expected time course of nonsteroidal antiinflammatory drug’s effect. Perioperative parecoxib administration, consisting of two injections spaced 12 h apart, improved postoperative analgesia over the first 24 h without increasing bleeding.

 

 

多峰止痛用于预防异丙酚引起的注射痛:联合应用瑞太尼和利多卡因预处理与单用瑞太尼或利多卡因的比较

Multimodal Analgesia to Prevent Propofol-Induced Pain: Pretreatment with Remifentanil and Lidocaine Versus Remifentanil or Lidocaine Alone

Marie T. Aouad, MD, Sahar M. Siddik-Sayyid, MD, FRCA, Achir A. Al-Alami, MD, and Anis S. Baraka, MD, FRCA

From the Department of Anesthesiology, American University of Beirut Medical Center, Beirut, Lebanon.

Anesth Analg 2007;104:1540-1544

背景:众所周知,注射异丙酚时会导致疼痛。预先与利多卡因混合或用瑞太尼预处理可减轻注射痛。一种多峰(止痛)途径可能会进一步减轻异丙酚的注射痛。

õ法:在õ156名患者的随机、前瞻性、双盲研究中,我们比较了三组中异丙酚注射痛的发生率和严重性。利多卡因组(n = 54)2%利多卡因和异丙酚预先混合(40mg利多卡因入180mg异丙酚中);瑞太尼组(n = 50)30秒内预先静脉注射瑞太尼2 µg · kg–1 ;复合组(n = 52):联合应用利多卡因和瑞太尼。

结果:异丙酚诱导时疼痛的总发生率在复合组(9.6%)较瑞太尼组(36%)和利多卡因组(35%)明显减少(P = 0.003)。中、重度疼痛的发生率õ有很大差异:复合组(0%)、瑞太尼组(18%)、利多卡因组(12.9%)(P < 0.02)。三组在麻醉后监病房中的记忆痛在统计学亦有类似的显著性差异。

结论:两种不同镇痛模式(瑞太尼和利多卡因)的联合用药,可完全遏制异丙酚注射所致的中、重度疼痛,且与两药单用相比,能显著减少轻度疼痛的发生率。

(唐李隽 马皓琳 李士通 校)

BACKGROUND: Propofol is well-known for its pain on injection. Premixture with lidocaine or pretreatment with remifentanil reduces injection pain. A multimodal approach might offer additional mitigation of propofol injection pain.

METHODS: In a randomized, prospective, double-blind study of 156 patients, we compared the incidence and severity of propofol pain among three groups. Patients in the lidocaine group (n = 54) received 2% lidocaine premixed with propofol (40 mg lidocaine in 180 mg propofol). Patients in the remifentanil group (n = 50), received pretreatment with remifentanil 2 µg · kg–1 IV over 30 s. Patients in the combination group (n = 52) received both lidocaine and remifentanil.

RESULTS: A significant decrease in the overall incidence of propofol pain at induction was achieved in the combination group (9.6%) compared with that in the remifentanil group (36%) and the lidocaine group (35%) (P = 0.003). The incidence of severe and moderate pain was also significantly different in the combination group (0%), compared with that in the remifentanil (18%) and lidocaine groups (12.9%) (P < 0.02). Similar, statistically significant differences among the three groups were achieved concerning recalled pain in the postanesthesia care unit.

CONCLUSIONS: The combination of two different analgesic modalities, remifentanil and lidocaine completely abolishes moderate and severe pain associated with propofol injection, and significantly reduces the incidence of mild pain when compared with each drug used alone.


大鼠局部注射丙酚的伤害效应是部分通过大麻素CB1 CB2受体介导的

The Antinociceptive Effects of Local Injections of Propofol in Rats Are Mediated in Part by Cannabinoid CB1 and CB2 Receptors

Josée Guindon, DVM, PhD*, Jesse LoVerme, PhD{dagger}, Daniele Piomelli, PhD{ddagger}, and Pierre Beaulieu, MD, PhD, FRCA*

From the *Department of Pharmacology, Faculty of Medicine, Université de Montréal–CHUM, Montréal, Québec, Canada; Departments of {dagger}Psychiatry and {ddagger}Pharmacology, University of California, Irvine, California; and Department of Anesthesiology, Faculty of Medicine, Université de Montréal–CHUM, Montréal, Québec, Canada.

Anesth Analg 2007;104:1563-1569

背景:丙酚可以制脂肪酸天门冬酰胺酶,此酶负责anandamide(一种内源性大麻素)的代谢。为了研究丙酚的潜在的伤害效应,我们在大鼠的后爪内注射不同剂量(0.0050.050.55500µg)的麻醉药来测定ED50值。为了进一步研究丙酚产生其伤害效应的机制,我们使用了õ异性的大麻素受体拮剂:AM251CB1受体)和AM630CB2受体),õ且测定了皮爪组织中脂肪酸酰胺/内源性大麻素(anandamide2-生四烯酸甘õ和棕榈酰õ醇酰胺)的浓度。

õ法:õ分成6个不同组的65Wistar大鼠进行福尔马林试验:1)õ照组(10%的IntralipidTM);2)丙酚组(ED50剂量);3AM2514AM251+丙酚;5AM6306AM630+丙酚。在2.5%福尔马林注射入后爪前15min将药物注入同一后爪背侧的皮下。用高效液相色谱/质谱分析测定脂肪酸酰胺/内源性大麻素水õ。

结果:丙酚在福尔马林试验的前期和后期产生剂量依赖性的伤害效应,在后期的ED500.08 ± 0.061 µg。此效应被AM251AM630所拮。由于在õ侧爪内给予更高剂量的丙酚õ未产生伤害效应,故此作用为局部介导。最后,爪内只有棕榈酰õ醇酰胺的浓度明显升高。

结论:在一õ炎症痛的试验中,局部注射丙酚呈剂量依赖性地减轻疼痛反应。这种伤害效应是部分通过CB1 CB2受体介导的。
(黄施伟 马皓琳 李士通 校)

BACKGROUND: Propofol can inhibit fatty acid amidohydrolase, the enzyme responsible for the metabolism of anandamide (an endocannabinoid). To study the potential antinociceptive effect of propofol, we administered different doses (0.005, 0.05, 0.5, 5, and 500 µg) of the anesthetic in the hind paw of animals to determine an ED50. To further investigate the mechanisms by which propofol produced its antinociceptive effect, we used specific antagonists for the cannabinoid CB1 (AM251) and CB2 (AM630) receptors and measured fatty-acid amide/endocannabinoid (anandamide, 2-arachidonylglycerol, and palmitoylethanolamide) concentrations in skin paw tissues.

METHODS: Formalin tests were performed on 65 Wistar rats allocated to six different groups: 1) control (IntralipidTM 10%); 2) propofol (ED50 dose); 3) AM251; 4) AM251 + propofol; 5) AM630; 6) AM630 + propofol. Drugs were injected subcutaneously in the dorsal surface of the hind paw (50 µL) 15 min before 2.5% formalin injection into the same paw. Fatty-acid amide/endocannabinoid levels were measured by high performance liquid chromatography/mass spectrometry analysis.

RESULTS: Propofol produced a dose-dependent antinociceptive effect for the early and late phases of the formalin test with an ED50 of 0.08 ± 0.061 µg for the latter phase. This effect was antagonized by AM251 and AM630. It was locally mediated, since a higher dose of propofol given in the contralateral paw was not antinociceptive. Finally, only paw concentrations of palmitoylethanolamide were significantly increased.

CONCLUSION: In a test of inflammatory pain, locally injected propofol decreased pain behavior in a dose-dependent manner. This antinociceptive effect was mediated, in part, by CB1 and CB2 receptors.

 

 

连续外周神经阻滞在整形外科手术病人中的õ发症不良反应

Complications and Adverse Effects Associated with Continuous Peripheral Nerve Blocks in Orthopedic Patients

Martin Wiegel, MD, Udo Gottschaldt, MD, Ria Hennebach, MD, Thilo Hirschberg, MD, and Andreas Reske, MD

From the Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany.

Anesth Analg 2007;104:1578-1582

背景:来流行的连续外周神经阻滞(CPNBs)保证了更深入的õ其不良反应õ发症的研究。

õ法:在整形外科病人全麻或者麻前用标准导管插入术术前完成前路坐骨神经、股神经和肌间沟臂丛的Cons。前瞻性评估与CPNBs有关的õ发症与不良反应。

结果:我们分析了20022004õ间849位连续病人(õ均õ龄65 ± 13 yr)中的1398CPNBs221位病人接受肌间沟,628位病人接受了股神经,549位病人接受了坐骨神经CPNBs。õ所有后来的病人,我们都实施了股神经和坐骨神经联合CPNBs。在所有的病例中,9例在插入部位发生局部炎症反应(0.6%),三例局部感染 (脓疱)(0.2%,所有的股神经CPNBs)。在一个接受股神经阻滞的病人,õ膜后血肿导致了õ股神经的压伤。肌电图证实股四头肌完全的去神经。没有其他较大的神经õ发症被记录。有一例肌间沟CPNB相关的高铁血红蛋白血症。接受了股神经和坐骨神经CPNBs的病人中大约6%的发生血管刺破。一例病人导发生导管断裂。

结论:我们的结果增了CPNBs产生大的õ发症是罕见的证据。然而, CPNBs 相关的小的不良反应可能更常见。

(胡õ 马皓琳 李士通 校)

BACKGROUND: The increasing popularity of continuous peripheral nerve blocks (CPNBs) warrants further study of their adverse effects and complications.

METHODS: Anterior sciatic, femoral, and interscalene brachial plexus CPNBs were performed preoperatively using standardized catheter techniques in orthopedic patients prior to general or spinal anesthesia. Complications and adverse effects related to CPNBs were prospectively evaluated.

RESULTS: We analyzed 1398 CPNBs in 849 consecutive patients (mean age 65 ± 13 yr) between 2002 and 2004. Two-hundred-twenty-one patients received interscalene, 628 patients femoral, and 549 sciatic CPNBs, respectively. In all the latter patients, we performed both femoral and sciatic CPNBs. Overall, there were 9 cases of local inflammation at the insertion site (0.6%), and 3 local infections (pustule) (0.2%, all femoral CPNBs). In one patient undergoing a femoral technique, a retroperitoneal hematoma led to compression injury of the femoral nerve. Complete denervation of the quadriceps femoris muscle was confirmed by electroneuromyography. No other major neurological complications were noted. There was one case of methemoglobinemia associated with an interscalene CPNB. Vascular puncture occurred in approximately 6% of patients undergoing femoral and sciatic CPNBs. Catheter rupture was noted in one patient.

CONCLUSIONS: Our results add to the evidence that major complications from CPNBs are rare. However, minor adverse effects associated with CPNBs may be more common.