Anesthesia & Analgesia

June 2007

CARDIOVASCULAR ANESTHESIA:

大血管手術後停用或繼續用他汀類藥物對心臟能的影響

張儷譯 薛張綱校

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.

嗎啡和太尼對選擇性冠狀動脈旁路移植術心肺轉流時炎症反應的影響

張美榮 陳傑

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.

能性纖溶酶原啟動物制的多態性可能影響心臟手術後凝血能亂

邱郁薇 馬皓琳 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:

托下頜側臥位對阻塞性睡眠呼吸暫停綜合征兒童麻醉中的心率異性的影響

霞譯 薛張綱校

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.

小兒輸尿管移植術病人單次骶管注入可樂定、嗎啡或氫化嗎啡酮聯合羅呱卡因的比較

宋翠俠 陳傑

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.

在高水準吸入氧濃度的麻醉兒童中,呼吸末正壓對能性殘氣量和通氣均勻性損傷的影響

彭中美 馬皓琳 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:

格拉司與昂丹司用於預防性應用昂丹司無效的術後患者的處理的初步研究

王時來譯 薛張綱校

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.

單次量鎂對日間手術後輔鎮痛作用的評估:隨機對照研究

鄭麗 陳傑

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.

麻醉醫生在快通道手術中的角色:從多模式鎮痛到圍手術期的醫療護理

黃麗娜 馬皓琳 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:

異丙酚對瑞太尼輸注後引起痛覺過敏的調節

薛張綱校

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.

異氟醚、氟烷和巴比妥對小鼠雜性耳聾的影響

印潔敏 陳傑

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.

較大的肝臟手術後嗎啡的代謝

張曦 譯,馬皓琳 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.

利魯唑一種谷氨酸釋放制誘導小鼠對傷害性刺激反應的翻正反射消失、傷害和制動

陳佳莉譯 薛張綱校

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.

對有害刺激的反應小鼠大腦{gamma}-氨基丁酸酸性水準的增導致翻正反射消失但非不動

衛紅 陳傑

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.

氨具有麻醉藥特性

吳儉 譯,馬皓琳 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.

局麻藥利多卡因和普魯卡因對爪蟾卵表達的甘氨酸和γ-氨基丁酸受體的作用

陳珺珺譯 薛張綱校

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.

靜脈麻醉藥大腦濃度檢測方法(藥代/藥效分析法和品質守衡法)的比較

李惟一 陳傑

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:產品有不同嗎?

朱慧 馬皓琳 李士通

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

Max T. Baker

Anesth Analg 2007 104: 1447-1451

地氟醚性肝炎與原和自身原特異性IgG4體相關

吳德華譯 薛張綱校

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:

使用麻醉資管理系統時麻醉記錄完整性的研究

李惟一 陳傑

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.

麻醉資管理系統中入交互性可視提醒對按時應用預防性生素的影響

黃佳佳譯,馬皓琳,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:

 

一例發生於糖尿病人的嚴重低血糖——與使用艾考精腹膜透析液有關

璿譯 薛張綱校

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.

給予正常高限鎂後減輕快速輸注晶體液導致的凝血化

周懿之 陳傑

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:

對有運動障礙進行深部腦刺激電極植入術的患者使用雙頻指數監測不能改善麻醉表現

裘毅敏 譯,馬皓琳 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.

右旋美托咪啶對兔肌運動誘發電位作用

王光妍譯 薛張綱校

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.

全身麻醉對腦磁波描記術成檢出間斷癲癇樣活動的影響的回顧性分析

周懿之 陳傑

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.

頸動脈內丙酚注射後大腦電靜止是轉換時間的一個函數

馬皓琳 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在鼠和狗的蛛網膜下和硬膜外中傷害效應的評價

陳勇柱譯 薛張綱校

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.

小獵鞘內注射CGX-1160的藥代動學研究的資料分析

顧新宇 陳傑

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.

在整形外科手術中帕瑞考昔的給藥時機對鎮痛效果的影響

姜旭暉譯 馬皓琳 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.

脂質體包裹的囉呱卡因用於口唇粘膜的局部麻醉

周時蓓譯 薛張綱校

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.

鎂作為輔用藥用於術後止痛:隨機試驗的系統綜述

丁震敏 陳傑

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.

多峰止痛用於預防異丙酚引起的注射痛:聯合應用瑞太尼和利多卡因預處理與單用瑞太尼或利多卡因的比較

唐李雋 馬皓琳 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

外科病人圍術期應用巴噴丁/普巴林是否有?有關安全性有效性的系統綜述

王麗珺譯 薛張綱校

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傷害效應是部分通過大麻素CB1 CB2受體介導的

黃施偉 馬皓琳 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

鼠試驗性神經病與焦慮和鬱引起的延遲性行為改有關

琳譯 薛張綱校

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:

連續外周神經阻滯在整形外科手術病人中的併發症不良反應

胡湘 馬皓琳 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.

頸部屈伸運動對高位胸段硬膜外腔造影分佈的影響

孫敏莉譯 薛張綱較

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.

術前胰島素患者在使用硬膜外麻醉和鎮痛後可減少術後胰島素的發生率

詹慧 陳傑

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.

肛周椎管內阻滯與鞍部椎管內阻滯的前瞻性隨機雙盲的比較研究

顧新宇 陳傑

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.

 

大血管手術後停用或繼續用他汀類藥物對心臟能的影響

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:他汀類藥物可以減少非手術人群的心臟發病率,對於手術病人也有處。我們隨訪了那些接受大血管手術後繼續使用他汀類藥物的病人,檢查心臟能,並與那些術後停止使用他汀類藥物的病人作對照。方法:前瞻性地收集接受腎下性腹主動脈瘤手術的病人圍手術期心臟發病率與他汀類藥物的關係。在20011月至200312月期間,還沒有關於圍手術期繼續使用他汀類藥物的相關指南(停用他汀類藥物組,n491)。從20041月開始,指南提出手術後應該盡可能早地使用他汀類藥物(非停用他汀類藥物組,n178)。心肌壞死的發生(定義為心肌肌鈣蛋白I的增超過第99個百分點或者是多於0.2ng/ml)。組內分析(prospensity評分)和組外分析(Lee評分)都做了風險校正。結果:由於手術緣故的停止服藥延遲的時間長度在停藥組和非停藥組中分別為4天和1天(p<0.001),用prospensity評分對組內術前可能接受過治療的進行校正,長期服用他汀類藥物以術後早期沒有繼續服用他汀類藥物的組(即非停藥組和停藥組)預測患者心肌壞死的比值比(OR值)分別為0.382.1(相對危險性的減少值為5.495%的可信區間:1.225.3p<0.001)。用Lee評分校正後的比值比在非停藥組中為0.38,在停藥組中為2.1(相對危險性的減少值為5.595%的可信區間:1.226.0p<0.001)。術後停用他汀類藥物(>4天)是術後發生心肌壞死的一項獨立的預測指標(OR 2.995%的可信區間:1.6-5.5)。結論:接受大血管手術後停用他汀類藥物會增術後心臟的危險性,建議大血管手術後儘早地繼續使用他汀類藥物治療。

(張儷譯 薛張綱校)

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.

 

托下頜側臥位對阻塞性睡眠呼吸暫停綜合征兒童麻醉中的心率異性的影響

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:氣道阻塞發生于OSAS兒童的麻醉中。吸氣對閉塞的氣道導致交感神經活性增。對心率異性(HRV)的分析提供了關於自主神經系統的資。HRV低頻/高頻比例被認為是交感、副交感平衡的指標。方法:我們研究了20OSAS兒童(3-9歲)全麻、頸正中位仰臥、側臥位托下頜對HRV的影響。HRV被記錄於麻醉誘導前誘導後,病人吸入5%的七氟醚並處於頸正中位托下頜於仰臥位或側臥位。結果:取頸正中位全麻的病人增氣道梗阻。托下頜側臥位改善了病人的喘鳴音評分。低頻/高頻比例心率在誘導後增且取頸正中位的病人達到最高值。該值在仰臥位側臥位托下頜的病人中顯著下降。麻醉誘導後HRV短期下降,在取正中位病人中達最低值。該值在仰臥側臥位托下頜的病人中增。結論:吸入麻醉、托下頜側臥位導致的HRV改與OSAS兒童喘鳴音評分的改相符。

(孫 霞譯 薛張綱校)

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.

 

 

格拉司與昂丹司用於預防性應用昂丹司無效的術後患者的處理的初步研究

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:隨著術後噁心嘔吐(PONV)發生風險的增,常給予患者預防量的選擇性5-羥色胺-35HT3)受體拮。對於化療病人,已經證實當一個5HT3拮治療無效時,另一個不同的5HT3拮可以緩解症狀。我們假設可以通過一項對PONV的交叉初步研究明確5HT3的處。在手術結束時,給予250名接受了全麻的女性患者4mg預防性的昂丹司,並在術後4小時進行隨訪。方法:88名女性發生了PONV,然後隨機地給予重複量的4mg昂丹司(n30),1mg格拉司(n30),或者0.1mg格拉司(n28),然後隨訪24小時。結果:接受重複量昂丹司的患者有效率為57%,接受0.11mg格拉司的患者有效率分別為60%和68%。這一差異並沒有統計學意義(P0.773)。結論:不同於化療誘發噁心嘔吐的患者,交叉量的格拉司對預防性應用昂丹司無效的手術患者並沒有明顯的效果。

(王時來譯 薛張綱校)

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.

 

 

異丙酚對瑞太尼輸注後引起痛覺過敏的調節

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:實驗與臨研究表明大多數的阿片類藥物可增強痛覺敏感性.麻醉過程中,阿片類藥物通常和靜脈或吸入麻醉藥一同使用.我們利用疼痛人體實驗模型研究低於催眠量的異丙酚是否具有對由瑞太尼輸注後引起的痛覺過敏和止痛作用.方法:15個健康的支援者入了這個隨機、雙盲、安慰對照的交叉配對實驗.高電流密度的經皮電刺激(41.7 +/- 14.3 mA)可誘發急性疼痛並產生一個穩定的痛覺過敏區域.同時或分別給予實驗者異丙酚(1.5mg/kg)和瑞太尼(0.05mg/kg/min)的靶控輸注,對痛覺的強度和痛覺過敏的區域進行輸注前、輸注中和輸注30分鐘後的評估.結果:在輸注中, 異丙酚明顯比對照組減輕電刺激引起的疼痛(72% +/- 21%),低於催眠量的異丙酚不會引起任何痛覺過敏效應.同時輸注瑞太尼有協同止痛效果(0.025mg/kg/min0.05mg/kg/min的瑞太尼分別比對照組減輕疼痛62% +/- 26%58% +/- 25%),但是撤藥後,疼痛和痛覺過敏要比對照組增.結論:結果反應了異丙酚和瑞太尼在臨對人體的相互作用. 那就是異丙酚可延遲或弱瑞太尼輸注後引起的止痛作用.儘管如此,疼痛效應並沒有完全被異丙酚所對,這就解釋了在以瑞太尼為主的麻醉實施後對鎮痛藥需求的增.

( 薛張綱校)

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.

 

 

利魯唑一種谷氨酸釋放制誘導小鼠對傷害性刺激反應的翻正反射消失、傷害和制動

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:全身麻醉狀態由行為的和感知覺的成分構成,包括遺忘、無意識、無痛覺和制動。在體外,谷氨酸能興奮性神經元在細胞和微電路水準是麻醉藥作用的重要靶向。利魯唑(2-氨基-6-[三糖甲氧]苯噻唑)是一種神經保護藥,在中樞神經系統制神經末梢的谷氨酸釋放。這裏,我們檢驗了體內利魯唑能選擇性阻滯谷氨酸能神經遞質,由此產生全身麻醉狀態。方法:對成年ddY雄鼠腹膜內給予利魯唑。使用三個終點來評估全麻狀態:1)翻正反射消失(LORR,作為無意識的測量標準),2)對傷害性刺激反應的運動消失(作為制動的測量標準),3)疼痛反應消失(作為無痛覺的測量標準)。結果:利魯唑腹膜內給藥誘發量依賴性翻正反射消失的50%有效量為27.423.332.295%可信區間)mg/kg。行為表現和微分析研究揭示了利魯唑誘導的損害和翻正反射消失的時間-過程改與鼠腦中谷氨酸降低水準一致。這表明,利魯唑誘導的翻正反射消失(無意識),至少一部分,是由於它降低了腦內谷氨酸濃度。利魯唑不僅量依賴性地產生翻正反射消失,還產生對痛覺刺激反應的運動消失(制動),以疼痛反應消失(無痛覺),其50%有效量分別為43.037.149.9mg/kg10.07.4-13.5mg/kg。這三個量-反應曲線是平行的,表明利魯唑的行為效應是通過一個共同的作用位點介導的。結論:這些發現表明利魯唑誘導的翻正反射消失、制動和傷害與它制中樞神經系統谷氨酸能神經遞質的能有關。

(陳佳莉譯 薛張綱校)

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.

 

 

局麻藥利多卡因和普魯卡因對爪蟾卵表達的甘氨酸和γ-氨基丁酸受體的作用

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:電壓依賴性鈉通道是局麻藥作用的基本位點。儘管全身給予低量的局麻藥可以產生鎮痛效果,但是這種效果的分子靶點尚不清楚,與之相關的制性神經遞質受體的研究不充分。方法:我們應用雙極電壓鉗位元系統檢測了利多卡因和普魯卡因(0.1 µM 3 10 mM)對非洲爪蟾卵表達的人突體α1甘氨酸和α1β2γ2Sγ-GABAA和ρ1 GABAC受體的作用。我們還評估了局麻藥在兩種突甘氨酸受體α1(S267C) and α1 (S267Q)的作用,以此來瞭解局麻藥和甘氨酸受體的相互作用。結果:在低濃度的情況下,利多卡因和普魯卡因可以增強甘氨酸受體的能,但在高濃度的情況下,都可以制甘氨酸受體的能。利多卡因(10µM)可以使甘氨酸濃度效應曲線顯著左移,這表明增了其與甘氨酸的親和。這種增強作用在突體受體中也可以觀察到。利多卡因和普魯卡因在高濃度的情況下可以制GABA A受體的作用,但是利多卡因和普魯卡因對GABA C受體的能沒有影響。結論:在低濃度的情況下,利多卡因和普魯卡因可以增強甘氨酸受體的能,但在高濃度的情況下,可以制甘氨酸和GABA A受體的能。局麻藥所致的增強甘氨酸受體能可能與全麻藥的機制不同。這些發現可能可以解釋局麻藥的一些藥理作用,如傷害性刺激和致驚厥。

(陳珺珺譯 薛張綱校)

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.

地氟醚性肝炎與原和自身原特異性IgG4體相關

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例病例報導在地氟醚麻醉後出現藥物誘發性肝損害。然而,這些報導中沒有檢測患者血清中的自身體,而既往的氟烷或異氟醚誘導的肝損害則檢測過患者血清中的自身體。方法和結果:我們第一次檢測了一例地氟醚誘導的肝損害患者血清中的細胞色素P450 2E1 IgG4自身體、58kDa內質網蛋白和三氟乙醯氯化原特異性IgG4體。結論:結果顯示過敏性和自身免疫性機制地氟醚誘導的肝損害發揮了重要作用。

(吳德華譯 薛張綱校)

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.

 

一例發生於糖尿病人的嚴重低血糖——與使用艾考精腹膜透析液有關

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)作為腹膜透析液,通常用於伴有糖尿病的腎衰病人,它可能誤導旁血糖儀高估血糖水準。未能認清這一高血糖假像會導致嚴重不良後果。由於未甄別的對血糖的高估,一名合併腎衰使用艾考精進行腹膜透析的糖尿病人發生嚴重低血糖,本文對此作了報導。

(羅 璿譯 薛張綱校)

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.

 

 

右旋美托咪啶對兔肌運動誘發電位作用

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來被用於患者圍手術期管理時的用藥,包括用於圍手術期間的輔用藥。右旋美托咪啶在肌運動誘發電位的作用還不確定。我們設計這項研究來探索右旋美托咪啶在兔子肌運動誘發電位中的作用。方法:這項研究使用的是新西蘭的白兔。首先,要確定右旋美托咪啶作為輔藥用於兔子麻醉的合適量,分別測定在52550100ug/kg /h濃度下眼瞼和四肢的撤回反射以對捏耳和夾尾的反映來評價麻醉程度。接下來,在10只使用氯胺酮和太尼麻醉的兔子,對兔子的比目魚肌肉進行單個刺激和五個成串刺激,記錄在分別使用了5, 25, and 50 µg/kg/h的右旋美托咪啶前,中,後的肌運動誘發電位。結果:在使用到50ug/kg/h的右旋美托咪啶時,超過50%的動物眼瞼反射,肢體反射,以對捏耳的反映被制。但是夾尾反射沒有減弱。右旋美托咪啶制肌運動誘發電位呈量依賴關係,但是當出現多個刺激,在50 µg/kg/h的量時,肌運動誘發電位可以在全部的動物中被檢測到。結論:氯胺酮和太尼麻醉下給予量的右旋美托咪啶,使用多個刺激測定兔子肌運動誘發電位是可行的。

(王光妍譯 薛張綱校)

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在鼠和狗的蛛網膜下和硬膜外中傷害效應的評價

 

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是一種新型的激動機制並未完全明確的螺毒素。為了評價傷害性活動,我們分別單次在鼠蛛網膜下 (0.03, 0.1, 0.3, 3 nmol)或硬膜外 (10, 30, 89 nmol)輸注Contulakin-G。蛛網膜下腔中硬膜外Contulakin-G明顯地降低皮下注射福馬林反應得Phase II,同時降低Phase I足爪縮回時間至一個很低的程度。蛛網膜下和硬膜外中藥物的ED50s分別是0.07 nmol45 nmol,其比值是647。在狗中,蛛網膜下Contulakin-G(50-500 nmoL)導致30分時間點熱至皮膚刺痛延時呈量依賴性增,同樣情況下嗎啡(150450 nmol)。硬膜外嗎啡(7507500 nmol),而不是硬膜外1000 nmol Contulakin-G,同樣明顯地降低購的皮膚刺痛。在接受Contulakin-G的鼠或狗中為觀察到運動能的化。在狗中,未觀察到明顯的量依賴性的生理化,如運動能,心率,動脈壓或體溫。Contulakin-G是一種極性的傷害藥物,在鼠或狗的蛛網膜下輸注未觀察到不良反應,可提供替代性阿片類髓鎮痛。

(陳勇柱譯 薛張綱校)

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.

 

 

脂質體包裹的囉呱卡因用於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:局部麻醉用於消除針頭插入粘膜所引起的疼痛將會成為牙科學顯著的進步。方法:在這項雙盲互換實驗中,我們評估脂質體包裹的囉呱卡因用於局部麻醉的效能。30名健康志願者接受60mg局部麻醉藥:分別是脂質體包裹的1%囉呱卡因,未經包裹的1%囉呱卡因,2.5%利多卡因和2.5%丙胺卡因混合液(EMLA),以20%苯佐卡因明膠,用於右側尖牙相對的頰粘膜皺襞,維持2分鐘。隨後插入30-G的針頭,疼痛程度用一種視覺類比資料標度(VAS)來評價。用一個小試驗來衡量局部麻醉持續的時間。用電動牙髓測試器來測試牙髓的反應。結果:脂質體包裹的囉呱卡因,囉呱卡因,EMLA,以苯佐卡因組對應的VAS數值的中數和四分位數間距分別是:0.8 (0.4-1.5), 1.6 (0.8-2.6), 1.1 (0.3-2.7), 2.2 (0.9-2.9)。脂質體包裹的囉呱卡因組相較於苯佐卡因組在VAS顯示了更低的中數(P = 0.0205)。脂質體包裹的囉呱卡因,囉呱卡因,EMLA,以苯佐卡因的軟組織麻醉持續時間的中數和四分位數間距分別是:11 (7-14), 6.5 (4-11), 14 (11-16), 7 (6-9)分鐘。EMLA和脂質體包裹的囉呱卡因能很好的減輕疼痛,並且較之其他局部麻醉藥有更長的軟組織麻醉持續時間(P = 0.0001)。結論:脂質體包裹的1%囉呱卡因明膠與EMLA在減少針頭插入粘膜所引起的疼痛方面以軟組織麻醉的持續時間方面是不相下的。沒有一種局部麻醉藥對於減少髓內麻醉是有效的。

(周時蓓譯 薛張綱校)

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.

 

 

外科病人圍術期應用巴噴丁/普巴林是否有?有關安全性有效性的系統綜述

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:巴噴丁和普巴林具有異常性疼痛和痛覺過敏的特性,可用於治療神經性疼痛。這些特性對於術後急性疼痛同樣有效。該研究對照試驗評價了巴噴丁對術後疼痛的鎮痛效果、副反應和臨價值。方法:對Medline, PubMedCochrane Central Register of Controlled Trials (CENTRAL)資料庫系統搜索22篇關於圍術期應用巴噴丁治療術後疼痛的隨機對照試驗。結果:巴噴丁組解除疼痛的作用優於對照組。術前12h單次應用巴噴丁3001200mg,第一個24h表現出少量阿片作用的有20%-62%。由於單次量巴噴丁的協同作用,術後第一個24小時阿片類藥物的減少量相當於嗎啡30 +/- 4 mg(平均值+/-95%可信區間)。Mata分析表明巴噴丁減少24h阿片類藥物用量的作用與巴噴丁的量無明顯相關。巴噴丁減少了阿片相關的副反應,如噁心、嘔吐和尿瀦留(需要治療的人數分別為2567)。巴噴丁最常見的副反應是鎮靜和頭暈(需要治療的人數分別為3512)。結論:巴噴丁有效地降低了術後疼痛、阿片用量和阿片相關的副反應。尚無法得出應用巴噴丁的最佳量和持續時間。圍術期應用巴噴丁的長期處仍需進一步研究。

(王麗珺譯 薛張綱校)

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.

 

 

鼠試驗性神經病與焦慮和鬱引起的延遲性行為改有關

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礙,特別是焦慮和鬱。雖然已有疼痛與鬱相互關係的臨研究,但疼痛是否引起鬱或鬱是否重疼痛還不清楚。為研究疼痛和情感障礙的相互關係,我們使用經典的行為試驗,測量了神經結紮鼠焦慮和鬱相關行為。方法:在結紮了左側單側第五腰神經之後,我們使用von Frey和輻射熱試驗測量疼痛的行為。在不限定範圍內、黑暗狀態、迷宮和強迫游泳試驗中,測量活動水準、焦慮相關行為與鬱相關行為。結果:在結紮神經後數日內可以觀察到感覺超敏反應。在結紮神經後27日內並未觀察到焦慮與鬱相關行為。然而結紮神經後1530日可以觀察到明顯焦慮與鬱相關行為,活動度並未減少。結論:神經損傷能夠引起鼠情感異常,但出現的時間明顯晚於感覺超敏時間。

(金 琳譯 薛張綱校)

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.

 

 

頸部屈伸運動對高位胸段硬膜外腔造影分佈的影響

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:為了胸段硬膜外鎮痛(thoracic epidural analgesiaTEA)的安全性和有效性,控制TEA的平面和明確影響它擴散的因素是重要的。在本項研究中,我們觀察頸部屈伸運動時注射入高位胸段硬膜外腔造影分佈情況。 方法:硬膜外導管放置硬膜外腔,其頂端在T1–2椎體間水準。患者隨機分為3組(伸、屈和中立組),當頸部伸、屈,或中立位置時注射5ml造影。造影擴散的範圍通過側位硬膜外造影術來計數椎體單位(vertebral body unitsVBUs)從而確定。結果:42個患者平均分配到3組。在伸、屈和中立組,放射照相下造影向頭端擴散(中位數)是1.05.51.5VBUs,在屈位較其他兩組擴散範圍更廣(p<0.001)。伸、屈和中立組放射照相下造影向尾部擴散分別為10.010.0,和7.0VBUs,各組之間沒有顯著不同(p = 0.145)。結論:在高位胸段硬膜外腔,造影向頭端的擴散受到限制。然而,頸屈增了頭端擴散。這些結果提示當TEA是高位時,硬膜外導管的頂端應該位於這一阻滯水準的部,頸屈可以引起不必要的頸段阻滯。

(孫敏莉譯 薛張綱較)

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.

 

嗎啡和太尼對選擇性冠狀動脈旁路移植術心肺轉流時炎症反應的影響

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:實驗資料表明嗎啡具有獨特的炎藥性質。作者假設,與太尼相比,平衡麻醉術中入嗎啡可以減弱心肺轉流(CPB)手術期間的炎症反應。

方法30名擇期冠狀動脈旁路移植術病人隨機雙盲分組,分別接受嗎啡(40mg)和太尼(1000ug)作為標準的阿片類藥物複合異氟醚麻醉的一部分。手術前後監測炎症反應標記物血清白介素-6IL-6)、白介素-8IL-8)和中性粒細胞表面黏附因數的表達(CD11aCD11bCD11cCD18)。ICU中監測體溫,並計算術後高熱(體溫>38.0°C)的發生率。

結果CPB後所有病人IL-6IL-8濃度均增。在CPB3h24h,嗎啡組血清IL-6水準的增低於太尼組(P < 0.05)。CPB15min3h兩組中性粒細胞表面黏附因數的表達均減少。嗎啡組CD11bCD18的表達顯著減少 (P < 0.05)。,太尼組術後過高熱的發生率(73%)比嗎啡組(0%)更高(P < 0.05)。

結論:與太尼相比,給予嗎啡作為平衡的麻醉術的一部分制了CPB下心臟手術的多種炎症反應(IL-6, CD 11b, CD 18,術後過高熱)。

(張美榮 陳傑 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.


小兒輸尿管移植術病人單次骶管注入可樂定、嗎啡或氫化嗎啡酮聯合羅呱卡因的比較

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:骶管阻滯是小兒術後鎮痛的常見方法。在安全和有效性方面,骶管使用阿片類藥物有較麻煩的副作用。骶管應用可樂定的鎮痛作用較好。作者比較了一組60例小兒輸尿管移植術骶管使用可樂定或氫化嗎啡酮或嗎啡鎮痛的副作用與恢復的差別。

方法:將6月到6歲的的小兒患者隨機雙盲分組,並單次給予骶管可樂定2mcg/kg,氫化嗎啡酮10mcg/kg,或50mcg/kg嗎啡複合含有腎腺素的0.2%羅呱卡因(1.0ml/kg)。七氟醚-空氣/氧氣麻醉後,所有患兒均接受護士管制的嗎啡鎮痛. 評估第一個24h靜脈使用嗎啡後術後疼痛強度和副反應,並記錄口服量以出院情況.

結果:與骶管使用氫化嗎啡酮或嗎啡比起來,使用可樂定可以引起較少的術後噁心嘔吐(p=0.01)與瘙癢(p=0.007)。骶管使用嗎啡比可樂定鎮痛更持久(p=0.02)。而疼痛評分、嗎啡應用總量、第一次口服量或出院時間均沒有什麼差別,也沒有發現術後呼吸制、過度鎮靜、低血壓與心動過緩。

結論:儘管骶管使用嗎啡可獲得更持久的鎮痛,但是骶管使用可樂定聯用護士管制的鎮痛也許可提供顯著的鎮痛和較少的副作用。基於述結果,小兒輸尿管移植術後骶管注射可樂定也許優於阿片類藥。

(宋翠俠 陳傑 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.

 

單次量鎂對日間手術後輔鎮痛作用的評估:隨機對照研究

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:先前的研究顯示鎂可能是術後鎮痛的一種有效輔。

方法:選擇門診腹股溝疝修補術或曲張靜脈手術的病人,採用全身麻醉,並在麻醉誘導後靜脈隨機給予硫酸鎂4mg或生理鹽水。所有的病人在術前經直腸給予雙氯酸100mg,並對疝氣修補的病人行髂腹下神經阻滯。在復蘇室記錄疼痛程度,鎮痛藥品消耗,以傷害性反應,並在術後三天採取問卷調查。

結果:隨機選擇200名患者,101名使用鎂,99名使用安慰。在注射研究藥物之前以即刻兩組的血流動學改沒有差異。兩組患者術後124h靜息和運動時的疼痛強度,以非阿片類和阿片類鎮痛藥物的累積用量相似。術後噁心嘔吐,頭暈,頭痛,昏厥的發生率也沒有差異。鎂組術後顫的發生率顯著降低(分別為4%13.1%P=0.0232)。84名安慰病人和82名鎂病人回饋了完整的問卷調查表。無論是腹股溝疝修補組還是曲張靜脈剝脫組,術後前三天兩組結果無明顯差異,。

結論:腹股溝疝修補或曲張靜脈手術的病人在全麻下輔其他鎮痛佐,如治療前靜脈注射4g硫酸鎂並不影響術後疼痛程度和鎮痛藥的消耗。

(鄭麗 陳傑 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.

 

異氟醚、氟烷和巴比妥對小鼠雜性耳聾的影響

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:在耳部手術中使用乳突鑽頭可能會引起雜性耳聾(NIHL)。作者研究了吸入麻醉藥或巴比妥是否能夠對小鼠的雜性耳聾起到保護作用。

方法:小鼠分為非麻醉對照組和麻醉組,麻醉組又分為給予氟烷、異氟醚和巴比妥的不同亞組,分別暴露於寬譜帶的白雜中連續3日,每日3小時。在暴露前,暴露後1日,12,和3周,1個月分別測定腦幹聽覺反應評估小鼠的聽水準。在暴露的1周後,柯替氏器行螢光的異硫氰酸鹽共軛毒傘素和TUNEL試染色。

結果:對照組暴露於雜刺激後的小鼠聽閾值升到了77.5±8.0分貝(dB)的聽級(HL)。而在給予巴比妥,異氟醚,和氟烷的各麻醉組中,小鼠的聽閾值分別升至62.5±6.3dB HL45.5±9.8dB HL,和39.3±6.2dB HL,麻醉組較對照組小鼠的聽受到了保護(P<0.05)。給予巴比妥的小鼠聽下降較給予吸入麻醉藥的小鼠嚴重(P<0.05)。對照組小鼠纖毛細胞的存活率下降,巴比妥組的小鼠略有下降,吸入麻醉藥組的小鼠中則大部分未受到影響。

結論:氟烷、異氟醚和巴比妥對小鼠的雜性耳聾(NIHL)和毛細胞的破壞均具有保護作用,吸入麻醉藥更為有效。

(印潔敏 陳傑 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.

 

對有害刺激的反應小鼠大腦{gamma}-氨基丁酸酸性水準的增導致翻正反射消失但非不動

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:全身麻醉狀態分行為和知覺兩部分,包括健忘, 意識喪失和不動性. {gamma}-氨基丁酸制神經傳導是全身麻醉作用在離體細胞水準的重要靶位點。但是在體試驗中增的氨基丁酸神經傳導在全身麻醉狀態的基本組分中的能性關聯還不是很明確。巴枯林是{gamma}-氨基丁酸轉氨酶制,它制釋放的{gamma}-氨基丁酸的降解,並且增在中樞神經系統的內源性{gamma}-氨基丁酸。在此,作者檢測{gamma}-氨基丁酸增的的能來產生全身麻醉的狀態。

方法: 所有的藥物均全身性地應用于成年雄性ddY小鼠。為了評估全身麻醉的組分,使用了兩個終末點。一個是翻正反射的缺失 (LORR; 作為意識喪失的度量標準);另一個是對鉗尾刺激反應的活動缺失(作為不動性的度量標準)

結果: 巴枯林誘導的 LORR 呈量依賴模式,50%的有效量為100 mg/kg (75–134; 95% 可信區間)。行為和微量滲析的研究顯示內源性{gamma}-氨基丁酸誘導的 LORR出現了濃度依賴的模式。但是,即使是大量的巴枯林 (285–400 mg/kg) 不產生對鉗尾刺激反應的活動缺失。相反,吸入所有試驗濃度的揮發性麻醉藥均出現翻正反射和鉗尾刺激反應消失,這結果支持吸入麻醉藥作用在多個細胞靶位點的觀點。

結論:這些結果證實LORR與增的{gamma}-氨基丁酸神經傳導有關。但有害刺激對不動性無影響。由此提示, LORR 和不動性是由不同的神經通路介導的,或者是在中樞神經系統的不同區域。

衛紅 陳傑 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.


靜脈麻醉藥大腦濃度檢測方法(藥代/藥效分析法和品質守衡法)的比較

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:現在有兩種公認的計算靜脈麻醉藥物在腦組織中濃度的方法:1.通過測定動脈血藥濃度和觀察腦電圖改,使用藥代/藥效模型來估計靜脈麻醉藥物在腦組織中濃度。2.採樣動脈和頸靜脈的血藥濃度和測定腦血流來直接測量腦組織中藥物代謝的狀況。(總體守恆法)這兩種方法尚未相互比較過。因為精確測定藥物從動脈到其腦中效應部位的時間是建立靜脈麻醉藥物效應/濃度關係的關鍵,作者在綿身用這兩種方法來測定異丙酚,美索比托和氯胺酮在腦組織中的濃度。

方法:7只,先在每只身安置動脈和失狀竇導管,腦皮層電圖和失狀竇超聲血流分析儀,然後隨機給予小量的異丙酚,美索比托和氯胺酮進行短時間麻醉,同時採取多個血樣標本和腦電圖化來評估藥效。

結果:使用藥代/藥效分析法得出的t1/2Keo:氯胺酮為2.0±0.4min,異丙酚為2.7±1.1min,而美索比托的t1/2Keo0.3±0.1min明顯較前兩者縮短。藥代/藥效分析法和總體守恆分析法在藥物到達峰值的時間無明顯差異。

結論:用兩種方法來測定藥物從動脈到其腦中效應部位的時間並無明顯差異,美索比托進入腦組織的時間大大快於異丙酚和氯胺酮。

(李惟一 陳傑 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.


使用麻醉資管理系統時麻醉記錄完整性的研究

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記錄的麻醉資料存在準確性和完整性方面的不足,麻醉記錄的品質尚有改進之處。

方法:作者收集了其醫療機構一月中所有的電子麻醉記錄,瞭解以下六個專案的記錄完整性。:1.過敏原2.靜脈通路3.心電節律4.面罩通氣的難易度5.咽喉鏡的暴露情況6.氣管導管的插入深度

結果:在2838份記錄中,必填的過敏原項目中有64%空缺。插管病人中,59%插管深度項空缺(918份中空缺了538份)。86%的記錄,心電節律的診斷至少空缺了一次。面罩通氣的難易可以通過觸摸屏能表中輸入, 781份只填了664份。咽喉鏡的暴露情況也可以在觸摸屏中輸入,但883份中只填了811份。只有84%的記錄中提了靜脈通路。

結論:作者發現臨麻醉電子記錄也是不完整的。難以依賴空項標記和記錄保存系統來完成不完整資料的輸入。結論提示用戶輸入資料時需要一種程式來提示用戶疏忽和不完整的項目,來更好的完善臨資料。

(李惟一 陳傑 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.

 

給予正常高限鎂後減輕快速輸注晶體液導致的凝血化

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:快速輸注晶體液會增強凝血能,不考慮對電解質、pH值和血漿滲透壓濃度的影響,所造成的結果包括深靜脈血栓形成和其他血凝的形成。其中血漿鎂離子濃度的改可能對凝血狀態的平衡有重要影響。本在體實驗研究了當血漿鎂離子濃度保持不或局部升高,凝血能對快速血液稀釋的反應。

方法:參與研究的25名健康志願者,隨機分為三組,給予生理鹽水、Balsol(含鎂離子1.5g/L)、以添鎂離子的Balsol(含鎂離子3.0g/L)。研究者不知曉受試者接受何種液體。採集基礎血樣檢測紅細胞比容、血漿鎂離子濃度以血栓彈性描記圖(TEG),30分鐘內輸入14mL/kg(占血容量20%)的液體,隨後採集第二次血樣。所有結果均與其本身的基礎值比較,使用方差分析檢驗其顯著性。

結果:三組受試者有相似程度的紅細胞比容下降,生理鹽水組有明顯的鎂離子減少(從0.81±0.070.74±0.07,大約下降8.6%,P<0.003),Balsol組沒有化,而添鎂離子的Balsol組則有明顯增(從從0.84±0.070.99±0.07,大約升高17.9%,P<0.001)。稀釋後TEG結果顯示添鎂離子的Balsol組沒有明顯改。而其他兩組血形成則有明顯統計學意義的增(反應時間到凝固開始和凝血時間縮短,αangle增)。

結論:快速血液稀釋誘發凝血可能與鎂離子濃度下降有部分關係,其作用在鎂離子濃度保持正常限時可減弱。因此,晶體復蘇液需維持約3mmol/L的較高鎂離子濃度。

(周懿之 陳傑 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.


全身麻醉對腦磁波描記術成檢出間斷癲癇樣活動的影響的回顧性分析

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:腦磁波描記術(MEG)的研究要求患者靜止平臥較長時間。但對於罹患癲癇的兒童和不合作成人,為保證研究的高品質往往需要患者處於全身麻醉或鎮靜狀態。由於全麻藥物有驚厥和預防驚厥的特性,該研究調查使用麻醉藥物是否會減少發作間期癲癇樣活動的成檢出率。

方法:41名癲癇患者(女性10人,男性31人;年齡148歲),於麻醉狀態下進行MEG測試。為確定麻醉對癲癇樣活動的作用,將麻醉組患者與另一些未接受麻醉癲癇患者的記錄比較,其中還包括一組不需麻醉就可獲得腦電記錄的兒童亞組。

結果:41名患者中38名給予異丙酚,2名給予依託咪酯,1名給予七氟醚。其中29名患者(71%)的MEG結果中發現有間斷癲癇樣活動。研究MEG中間隙癲癇樣活動的比例時發現無麻醉組有63%的病人發生癲癇。年齡小於18歲的兒童中,有28人(74%)有間隙癲癇樣活動,而無麻醉組則有80%。

結論:MEG研究中,麻醉程度達到患者無意識和體動時,對MEG記錄下的間隙癲癇樣活動波形並無明顯影響。

(周懿之 陳傑 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.

 

小獵鞘內注射CGX-1160的藥代動學研究的資料分析

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:從螺毒素提取出來的合成肽能在動物中產生重要的止痛作用。其肽結構決定需鞘內注射才能發揮效應,因此作者研究小獵兔鞘內注射CGX-1160負荷量和連續給藥後的藥代動學。

方法:在負荷量研究中,8只動物在異氟醚麻醉下接受的量範圍在16.71000nmol。腦液樣藥物測定一直到24h。在連續輸注研究中,3只動物分別接受輸注速度為1040160ug/h,並且每個速率維持24h。腦液樣測定藥物存在於輸注期和清除期後72h的藥物累積釋放。兩研究資料用NONMEN模型分析。

結果:藥物濃度呈雙指數化:快速率常數相較於慢速率常數更是量級化的指標。單次用藥結果顯示:由於本研究使用大量輸注範圍,慢速率常數呈量非線性依賴。

結論:臨藥理學結果處理的資料,為CGX-1160達到治療效果的鞘內濃度而選擇合理的濃度提供了根據。

(顧新宇 陳傑 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.

 

鎂作為輔用藥用於術後止痛:隨機試驗的系統綜述

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:各隨機試驗關於鎂是否是術後止痛的一種有效輔有不同結論。

方法:作者對圍手術期間比較鎂和安慰作用的研究進行了一個綜合性搜索(電子資料庫,文獻目錄,包括所有語言,直至20064月)。關於術後疼痛強度和止痛要求的資從各試驗中收集並比較。副作用二歧資料用經典的Meta分析法分析。

結果:共有14個隨機試驗(共778個患者,其中404個服用鎂)測試了鎂左旋葡萄糖,葡萄糖酸鹽還是硫酸鹽。服用鎂的患者,術後疼痛強度有4個試驗(29%)顯著降低,7個試驗(50%)與對照組無明顯區別,1個試驗(7%)升高,2個試驗(14%)未報導疼痛強度。服用鎂的患者,8個試驗(57%)中術後止痛要求顯著降低,5個試驗(36%)與安慰無明顯區別,1個試驗(7%)升高。服用鎂患者較少發生術後寒顫(相關危險係數0.3895%可信區間0.17-0.88,需治療數14)。有7個試驗報導了血清鎂離子水準。其中6個試驗中服用鎂的患者血清鎂離子水準升高,服用安慰的患者血清鎂離子水準降低。

結論:這些試驗未能提供可信證據以證實圍術期鎂用藥對術後疼痛強度止痛要求有有的影響。但圍術期應用鎂可預防術後低血鎂症,從而降低術後寒顫的發生率。故如何應用鎂達到術後止痛要求值得進一步研究,因為鎂是相對無害且不貴,並從生物學基礎來看具有潛在的傷害作用。

(丁震敏 陳傑 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.


術前胰島素患者在使用硬膜外麻醉和鎮痛後可減少術後胰島素的發生率

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:胰島素是內分泌系統對手術的特徵性應激反應。目前尚不知道術前胰島素現象是否影響到術後的內分泌狀態。作者試圖尋求接受擇期髖關節和膝關節成形術患者的術前胰島素的特徵,並評估圍術期硬膜外鎮痛對術前有或沒有胰島素患者的術後改善程度。

方法:60名進行髖關節或膝關節置換手術的患者用內穩態評估模型(HOMA)分為胰島素和非胰島素兩組,HOMA為禁食狀態下胰島素含量(μU/mL×血糖值(mmol/L/22.5。每組患者隨機分成兩個亞組,一亞組接受術中硬膜外阻滯和術後硬膜外鎮痛(即硬膜外組),另一亞組接受全身麻醉和術後自控性鎮痛(即對照組)。鎮痛效果的評估使用VAS法,一直評估到術後48小時,手術結束時術後48小時分別計算HOMA值以判斷術後胰島素狀態。

結果:對於術前存在胰島素的患者,在使用硬膜外麻醉和鎮痛後,顯著影響術後HOMA評分(P<0.001)。而術前不存在胰島素狀態的患者無論是硬膜外組還是對照組,其術後胰島素現象均相似(P>0.05)。手術結束後術後第一天第二天的VAS評分在不同組間沒有差別。

結論:與術中全身麻醉術後自控鎮痛相比,術中硬膜外麻醉術後硬膜外鎮痛可以減少手術後即刻和手術後48小時的胰島素現象,但僅限於術前已存在胰島素現象的患者。

(詹慧 陳傑 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.

 

肛周椎管內阻滯與鞍部椎管內阻滯的前瞻性隨機雙盲的比較研究

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:在這個前瞻性,隨機雙盲研究中,作者評估了極低量的布比卡因對於安全進行短小的肛周手術是否足夠。

方法80例患者隨機分成兩組,接受高比重布比卡因,量分別為1.5mgn=40),6.0mgn=40)。

結果:低量組麻醉效果滿意,且比高量組阻滯範圍更局限(平均S4,P<0.01)。離活動更早(98分鐘vs147分鐘,P<0.01),出院時間更早(126分鐘VS249分鐘,P<0.01.

結論1.5mg布比卡因麻可成用於短小肛周手術。

(顧新宇 陳傑 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.

 

能性纖溶酶原啟動物制的多態性可能影響心臟手術後凝血能亂

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:心臟手術後可能發生細胞因數介導的炎症反應以凝血能障礙。這項研究中我們觀察了心臟手術後纖溶酶原啟動物制-1PAI-1)基因表達的短時模式以它與PAI 基因型的關係,並獲取了與圍手術期發病率有關的初步資料。

方法:在82例擇期行心臟手術的病人,心肺轉流術(CPB)後1h6h24h取血中單核細胞測量PAI-1 mRNA的相對改。分析DNA測定4G/5G PAI-1多態基因型的攜帶。

結果:CPB後所有病人PAI-1 基因表達下降。5G等位基因的純合子載體中PAI-1基因表達下降更為明顯。5G等位基因的純合子載體基因也更有可能接受凝血血製品的輸注。PAI-1基因表達的改與CPB的持續時間無關。

結論:CPB後,PAI-1 的基因表達隨時間延長而下降。我們發現心臟手術後,PAI-1基因型、PAI-1的基因表達與凝血製品的輸注之間有聯繫。

(邱鬱薇 馬皓琳 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.

 

 

在高水準吸入氧濃度的麻醉兒童中,呼吸末正壓對能性殘氣量和通氣均勻性損傷的影響

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:吸入氧濃度(Fio2)高在應用後短期導致再吸收性肺不張。然而,在麻醉的兒童,不同水準Fio2和它們與呼吸末正壓(PEEP)之間的相互作用對能性殘氣量(FRC)和換氣分佈的影響尚未知曉。我們假設與用0.3Fio2相比,用1.0 Fio2導致FRC和換氣均勻性下降,而與PEEP 3-cm H2O相比,PEEP 6-cm H2O可預防這種下降作用。

方法:46例沒有心肺疾病的兒童(3-6歲)隨機分別在整個研究階段接受PEEP 6-cm H2OPEEP 6組)或PEEP 3-cm H2OPEEP 3組)。給予Fio2 (0.31.0) 的次序也隨機化。氣管插管後進行確定的補充方法,5分鐘後第一次測定。然後在第二個Fio2水準,重複這一過程。由一不知情的觀察者計算FRC和肺清除指數(LCI)。

結果:在PEEP6組,FRC(平均值±標準差)在兩個Fio2水準是相似的(0.3: 25.6 ± 2.9 mL/kg1.0: 25.6 ± 2.8 mL/kg, P = 0.189),但FRCPEEP3組是降低的(0.3: 24.9 ± 3.81.0: 21.7 ± 4.1, P < 0.0001)。而且,持續PEEP6-cm H2O時,LCI在兩個Fio2水準是相似的(0.3: 6.45 ± 0.4 vs 6.43 ± 0.4, P = 0.668) LCIPEEP3組中Fio2較高時是增高的 (0.3: 6.5 ± 0.51.0: 7.7 ± 1.2, P < 0.0001)

結論:在應用很低的PEEP 3–cm H2O期間,與Fio2 0.3時相比,在Fio2 1.0FRC和換氣分佈明顯降低。而這降低可通過應用PEEP 6-cm H2O來對,表明不管氧濃度多少,低水準PEEP足以維持FRC和換氣分佈。

(彭中美 馬皓琳 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.

 

 

麻醉醫生在快通道手術中的角色:從多模式鎮痛到圍手術期的醫療護理

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:改善圍手術期的效率提高工作量已經在現代麻醉實踐中日重要。快通道手術作為一種多學科的手段,通過小手術(如:門診病人)或大手術(住院病人)後促進病人恢復來改善圍手術期的效率。在這篇論文中,我們著重研究麻醉醫生在快通道手術中更大的作用。

方法:2005年的秋季,一個多學科的臨研究者團相聚在McGill大學討論指導改善手術後恢復過程的當麻醉和外科實踐。這次會議的參者的一個分組,被佈置了任務來回顧關於這個主題的回顧性文獻,因為其與麻醉醫生作為圍手術期間內科醫生的作用有關。

結果:麻醉醫生作為圍手術期的內科醫生,通過對術前用藥、麻醉用藥以術、將副作用(如:疼痛、噁心、嘔吐、眩暈)降至最低的預防性藥物應用以用以維持手術期間術後重要器官系統能的輔藥物給予的決定,在快通道手術中起著關鍵性的作用。

結論:麻醉醫生作為關鍵的圍手術期內科醫生,其決定對手術團改善成的快通道手術程式是至關重要的。

(黃麗娜 馬皓琳 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.

 

 

較大的肝臟手術後嗎啡的代謝

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:嗎啡代謝受損會導致鎮靜和呼吸制的增。

方法:此研究中,我們將進行肝切除術病人(n = 15)與進行結腸切除術的對照組(n = 15)比較,研究嗎啡的藥代動學。嗎啡通過病人自控鎮痛靜脈給予。術後兩天,每天2-3次測定嗎啡、嗎啡-6-葡糖苷酸和嗎啡-3-葡糖苷酸的血漿濃度。每天評估疼痛強度評分三次,每三小時評估一次呼吸次數和鎮靜評分。

結果:嗎啡的需要量在肝切除組1.1 (0.8–2.5 [中位數,四分位數間距]) mg/h和結腸切除組1.5 (1.1–1.7) mg/h [P = 0.84])沒有統計學差異。疼痛強度評分也沒有統計學差異(P > 0.3)。肝切除術組的嗎啡血漿濃度比對照組高(P < 0.01),反映嗎啡代謝率較低。嗎啡的血漿濃度和肝切除的體積有關(P < 0.02)。但是,嗎啡-6-葡糖苷酸和嗎啡-3-葡糖苷酸的血漿濃度組間沒有差異 (分別為P = 0.62P = 0.48)。肝切除後,鎮靜發生率較高(P = 0.02),但是呼吸制沒有增(P = 0.48)

結論:此研究表明肝切除手術病人比結腸切除手術病人,嗎啡血漿濃度高。肝切除手術病人鎮靜評分高。因此建議在此病人組應用嗎啡時要慎重。

(張曦 譯,馬皓琳 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.

 

 

氨具有麻醉藥特性

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:近期有種麻醉理論預測某些內源性化合物竟然具有麻醉特性。該理論提出了在可在疾病中大量增的代謝物也能產生麻醉作用的可能性。由於在病理生理濃度,氨可逆性地損傷記憶、意識和對傷害刺激的反應,在某種意義與麻醉相似。我們研究了氨是否具有麻醉特性。

方法:研究了氨對{alpha}1ß2 {alpha}1ß2{gamma}2s {gamma}-氨基丁酸A型受體、{alpha}1甘氨酸受體和 NR1/NR2A N-甲基-d-天冬氨酸受體以雙孔域鉀通道TRESK的影響。在非洲爪蟾卵母細胞表達述通道,並通過雙電極電壓鉗進行研究。通過測定靜脈輸注氯化產生的異氟烷最小肺泡濃度減少程度來評價氨對大鼠的制動作用。測量橄欖油-水分配係數以確定游離氨(NH3)是否遵守Meyer-Overton關係。

結果:氨確實使TRESK通道和甘氨基受體調。未發現對{alpha}1ß2 {alpha}1ß2{gamma}2 s {gamma}-氨基丁酸A型受體或NR1/NR2A N-甲基-d-天門冬氨酸受體起作用。氨可逆性減少異氟烷的需要量,通過計算得出使大鼠制動的EC501.6 ± 0.1 mM氯化。NH3Ostwald橄欖油-水分配係數為0.018。在pH 7.4麻醉的EC50時,在大量橄欖油中氨濃度是0.42 µM,比觀察到的遵守Meyer-Overton關係的麻醉減少近五個數量級。

結論:這些發現支持氨具有麻醉特性的假說。不能通過大量油中濃度預測氨作用強度。

(吳儉 譯,馬皓琳 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:產品有不同嗎?

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

七氟醚目前在美國可以從兩家公司得到:Ultane® (Abbott Laboratories, Inc.)和一般的產品七氟醚吸入麻醉藥(Baxter Healthcare Corp.)。這些產品經食品和藥品監督管理局在治療評定為等效,但它們之間是有一些不同的。Ultane是一步處理製作的,而一般的七氟醚是用三步處理生產出來的。Ultane含水>300 ppm而一般的七氟醚含水130 ppmUltane用塑膠聚乙烯萘聚合體瓶包裝,而一般的七氟醚用漆線紋的鋁瓶包裝。討論了製造過程、雜質、路易士酸性反應導致的七氟醚降解以非玻璃的容器對七氟醚的適合性。

(朱慧 馬皓琳 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.

 

 

麻醉資管理系統中入交互性可視提醒對按時應用預防性生素的影響

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:為減少手術部位感染的發生率,術前生素需在切皮前60min內給予。這項研究的目的在於驗證我們的麻醉資管理系統中入帶有與生素給予有關資的交互性可視電子提醒資是否可以增預防性生素應用的依從性。

方法:我們對於20046月至200512月期間門診手術和日間手術中一種常用預防性生素的使用麻醉電子記錄情況進行了回顧性研究。此間期包括了完成新型提醒信號的20052月之前和之後的病例。依從性定義為生素在手術開始時間前60 min內給予,非依從性病例分為使用過早和使用過晚兩類。

結果:使用提醒信號系統之前和之後分別有49879478個病例的依從性從82.4% 增到 89.1% (P < 0.01)。在麻醉科主治醫生有住院醫生或麻醉護士輔 (之前82.9%比之後89.1%, P < 0.01) 麻醉科主治醫生單獨工作時(之前80.1%比之後89.3%, P < 0.01)都有發現這種增。依從性的提高同時伴隨著生素使用過晚概率的下降(之前15.2%比之後8.1%, P < 0.01),但是生素使用過早的發生率無顯著化(即,切皮前60min以給予)(之前2.4%比之後2.8%, P < 0.01)

結論:在麻醉資管理系統中有關給予術前生素的交互性可視電子提醒信號的安裝使用,可以持續性地提高對於外科預防性給予生素定時指導方針的依從性。

(黃佳佳譯,馬皓琳,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.


對有運動障礙進行深部腦刺激電極植入術的患者使用雙頻指數監測不能改善麻醉表現

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

背景資料:深部腦刺激(DBS)已成為運動障礙的治療希望。在電極植入術中,患者需反復地從麻醉中蘇醒過來以便於神經學測試。我們研究了雙頻指數(BIS TM)監測對於接受“睡-醒-睡”麻醉的患者而言,是否對觀察其覺醒時間、異丙酚的消耗心肺的穩定性(即,心率、動脈壓呼氣末二氧化碳)有所幫。

方法:我們研究了21位預定行DBS電極植入術的患者。其中10位患者在BIS指導下控制異丙酚麻醉深度(BIS組),另11位無BIS指導(非BIS組)。在BIS組,睡眠階段控制BIS評分在40–60,而在非BIS組,在觀察者的警覺/鎮靜分析量表的值定為1(=對觸覺刺激無反應[無意識])。在鑽孔釘住立體定位環的部位,用2的利多卡因浸潤用於鎮痛,不使用阿片類藥物。在清醒的病人需要神經學測試的階段,中斷使用異丙酚。

結果:我們發現兩組患者在覺醒時間、異丙酚用量心肺穩定性方面無差異。而BIS組明顯必須給予更多的異丙酚推注(30 ± 11.6 17 ± 4.6)以維持BIS評分在目標範圍內(P < 0.05)

結論:對於運動障礙患者的DBS植入術,使用BIS監測對麻醉處理無改善。

(裘毅敏 譯,馬皓琳 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.

 

 

頸動脈內丙酚注射後大腦電靜止是轉換時間的一個函數

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:我們假設在短暫的大腦低灌注期間,推注高脂溶性麻醉丙酚後大腦電(腦電圖,EEG靜止的持續時間直接與推注到轉換到大腦迴圈所的時間有關。

方法:將24只新西蘭白大白兔隨機分入兩個丙酚用量組:0.50.8 mL組。在每一組中,12只動物接受了1%丙酚的兩次頸動脈內注射:在正常生理條件下做第一次注射,在雙側頸動脈閉塞和IV推注腺苷和艾司洛爾產生的大腦低灌注期間第二次注射。我們測定了兩個大腦迴圈條件下大腦電靜止的持續時間和丙酚乳的轉換時間。通過植入的顱窗用電視顯微鏡檢查來測定轉換時間。

結果:大腦低灌注延長了低推注(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)容量的轉換時間。大腦低灌注期間大腦電靜止的持續時間是低(大腦電靜止s = 152 + 2.3 x 轉換時間, n = 12, r = 0.73, P = 0.007)和高(大腦電靜止s = 186 + 3.2 x 轉換時間, n = 12, r = 0.68, P = 0.02)推注容量和轉換時間的函數。

結論:這些結果提示高脂溶性藥物的轉換時間的處理深深地增強了作用部位的傳遞。

(馬皓琳 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.


在整形外科手術中帕瑞考昔的給藥時機對鎮痛效果的影響

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:帕瑞考昔是一種選擇性的環氧化酶—2制,在術前給藥可以減少術後疼痛且不增出血。

方法:我們將62例預定行全髖關節成形手術的病人,隨機分組分別進行以下的IV給藥方案:1)對照組:在誘導時、關閉傷口時和誘導後12小時給予安慰,2)前組:在誘導時和誘導後12小時各給予40mg帕瑞考昔,關閉傷口時給予安慰,3)後組:在誘導時給予安慰,在關閉傷口和誘導後12小時各給予帕瑞考昔40mg。在24小時裏每隔四小時用視覺類比尺規來評價靜止時和活動時的疼痛評分。每隔四小時記錄一次治療副反應。計算術後五天裏的紅細胞減少量。

結果:和對照組相比,前組和後組的術後疼痛得分要低。三組的術後出血量相似。前組和後組之間無顯著差異,也沒有提示切皮前給予帕瑞考昔產生超前鎮痛效能的任何趨勢。和對照組相比,前組和後組在麻醉後復蘇室的嗎啡用量較對照組少(14.2 ± 2.015.7 ± 2.020.4 ± 2.3 mg),雖然該趨勢只有在前組具有顯著性(P < 0.05)。前組和後組中第一次的疼痛得分較對照組低(56.1 ± 7.564.2 ± 7.078.3 ± 5),但也只有在前組具有顯著性(P = 0.001)。前組和後組第一次需要止痛的時間都較對照組晚(38 ± 928.2 ± 6.618 ± 6 min),但也只在前組和對照組有具有顯著性(P = 0.05)。前組(26 ± 12 mg)和後組(25 ± 13 mg)24小時的嗎啡消耗量相似,都顯著少於對照組(47 ± 27 mg, P < 0.001)

結論:在髖關節成形手術之前給予帕瑞考昔沒有起到超前鎮痛的作用。切皮前給藥有改善手術結束後即刻的鎮痛的趨勢,這和所預計的非甾體類炎藥的作用時程相一致。在圍術期間隔12小時給予兩次帕瑞考昔,可以改善術後24小時內的鎮痛效果並且不增出血量。

(姜旭暉譯 馬皓琳 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.

 

 

多峰止痛用於預防異丙酚引起的注射痛:聯合應用瑞太尼和利多卡因預處理與單用瑞太尼或利多卡因的比較

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:眾所周知,注射異丙酚時會導致疼痛。預先與利多卡因混合或用瑞太尼預處理可減輕注射痛。一種多峰(止痛)途徑可能會進一步減輕異丙酚的注射痛。

方法:在對156名患者的隨機、前瞻性、雙盲研究中,我們比較了三組中異丙酚注射痛的發生率和嚴重性。利多卡因組(n = 54)2%利多卡因和異丙酚預先混合(40mg利多卡因入180mg異丙酚中);瑞太尼組(n = 50)30秒內預先靜脈注射瑞太尼2 µg · kg–1 ;複合組(n = 52):聯合應用利多卡因和瑞太尼。

結果:異丙酚誘導時疼痛的總發生率在複合組(9.6%)較瑞太尼組(36%)和利多卡因組(35%)明顯減少(P = 0.003)。中、重度疼痛的發生率也有很大差異:複合組(0%)、瑞太尼組(18%)、利多卡因組(12.9%)(P < 0.02)。三組在麻醉後監護病房中的記憶痛在統計學亦有類似的顯著性差異。

結論:兩種不同鎮痛模式(瑞太尼和利多卡因)的聯合用藥,可完全遏制異丙酚注射所致的中、重度疼痛,且與兩藥單用相比,能顯著減少輕度疼痛的發生率。

(唐李雋 馬皓琳 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傷害效應是部分通過大麻素CB1 CB2受體介導的

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門冬醯胺酶,此酶負責anandamide(一種內源性大麻素)的代謝。為了研究丙酚的潛在的傷害效應,我們在大鼠的後爪內注射不同量(0.0050.050.55500µg)的麻醉藥來測定ED50值。為了進一步研究丙酚產生其傷害效應的機制,我們使用了特異性的大麻素受體拮:AM251CB1受體)和AM630CB2受體),並且測定了皮爪組織中脂肪酸醯胺/內源性大麻素(anandamide2-生四烯酸甘油和棕櫚醯乙醇醯胺)的濃度。

方法:對分成6個不同組的65Wistar大鼠進行福馬林試驗:1)對照組(10%的IntralipidTM);2)丙酚組(ED50量);3AM2514AM251+丙酚;5AM6306AM630+丙酚。在2.5%福馬林注射入後爪前15min將藥物注入同一後爪背側的皮下。用高效液相色譜/質譜分析測定脂肪酸醯胺/內源性大麻素水準。

結果:丙酚在福馬林試驗的前期和後期產生量依賴性的傷害效應,在後期的ED500.08 ± 0.061 µg。此效應被AM251AM630所拮。由於在對側爪內給予更高量的丙酚並未產生傷害效應,故此作用為局部介導。最後,爪內只有棕櫚醯乙醇醯胺的濃度明顯升高。

結論:在一項炎症痛的試驗中,局部注射丙酚呈量依賴性地減輕疼痛反應。這種傷害效應是部分通過CB1 CB2受體介導的。
(黃施偉 馬皓琳 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.

 

 

連續外周神經阻滯在整形外科手術病人中的併發症不良反應

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:來流行的連續外周神經阻滯(CPNBs)保證了更深入的對其不良反應併發症的研究。

方法:在整形外科病人全麻或者麻前用標準導管插入術術前完成前路坐骨神經、股神經和肌間溝臂叢的Cons。前瞻性評估與CPNBs有關的併發症與不良反應。

結果:我們分析了20022004年間849位連續病人(平均年齡65 ± 13 yr)中的1398CPNBs221位病人接受肌間溝,628位病人接受了股神經,549位病人接受了坐骨神經CPNBs。對所有後來的病人,我們都實施了股神經和坐骨神經聯合CPNBs。在所有的病例中,9例在插入部位發生局部炎症反應(0.6%),三例局部感染 (膿皰)(0.2%,所有的股神經CPNBs)。在一個接受股神經阻滯的病人,腹膜後血腫導致了對股神經的壓傷。肌電圖證實股四頭肌完全的去神經。沒有其他較大的神經併發症被記錄。有一例肌間溝CPNB相關的高鐵血紅蛋白血症。接受了股神經和坐骨神經CPNBs的病人中大約6%的發生血管刺破。一例病人報導發生導管斷裂。

結論:我們的結果增了CPNBs產生大的併發症是罕見的證據。然而, CPNBs 相關的小的不良反應可能更常見。

(胡湘 馬皓琳 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.