Anesthesia & Analgesia

July 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:

体外循环,溶血与硝普盐诱发的氰化物产物

丁震敏 陈杰

Cardiopulmonary Bypass, Hemolysis, and Nitroprusside-Induced Cyanide Production

Albert T. Cheung, Gonzalo E. Cruz-Shiavone, Qing C. Meng, Alberto Pochettino, John A. Augoustides, Joseph E. Bavaria, and E. Andrew Ochroch

Anesth Analg 2007 105: 29-33.

PEDIATRIC ANESTHESIOLOGY:

七氟醚和舒太尼婴儿麻醉中经食管超声和硬膜外麻醉的血流学效应

王时来译 薛张纲校

The Transesophageal Doppler and Hemodynamic Effects of Epidural Anesthesia in Infants Anesthetized with Sevoflurane and Sufentanil

Antoine Monsel, Amelie Salvat-Toussaint, Philippe Durand, Vincent Haas, Catherine Baujard, Philippe Rouleau, Souad El Aouadi, Dan Benhamou, and Karin Asehnoune

Anesth Analg 2007 105: 46-50.

连续监测态肺顺应性使检测婴儿儿童支气管内插管成为可能

邱郁薇 马皓琳 李士通

Continuous Monitoring of Dynamic Pulmonary Compliance Enables Detection of Endobronchial Intubation in Infants and Children

Aman Mahajan, Nir Hoftman, Angela Hsu, Robert Schroeder, and Samuel Wald

Anesth Analg 2007 105: 51-56.

瑞太尼减少小儿患者喉罩喉管置入所需的异丙酚EC50的一

顾新宇 陈杰

Remifentanil Halves the EC50 of Propofol for Successful Insertion of the Laryngeal Mask Airway and Laryngeal Tube in Pediatric Patients

Hye-Jin Park, Jeong-Rim Lee, Chong Sung Kim, Seong Deok Kim, and Hee-Soo Kim

Anesth Analg 2007 105: 57-61.

AMBULATORY ANESTHESIOLOGY:

日间手术术后恢复情况评价方法的系统回顾

陈勇柱译 薛张纲校

A Systematic Review of Postoperative Recovery Outcomes Measurements After Ambulatory Surgery

Francisco J. Herrera, Jean Wong, and Frances Chung

Anesth Analg 2007 105: 63-69.

ANESTHETIC PHARMACOLOGY:

吗啡在术后患者:代谢产物的药代学和药效学

唐李隽 李士通 马皓琳

Morphine in Postoperative Patients: Pharmacokinetics and Pharmacodynamics of Metabolites

Jean Xavier Mazoit, Karin Butscher, and Kamran Samii

Anesth Analg 2007 105: 70-78.

伴有高碳酸血症过度通气情况下七氟醚与地氟醚的快速苏醒

印洁敏 陈杰

Rapid Recovery from Sevoflurane and Desflurane with Hypercapnia and Hyperventilation

Derek J. Sakata, Nishant A. Gopalakrishnan, Joseph A. Orr, Julia L. White, and Dwayne R. Westenskow

Anesth Analg 2007 105: 79-82.

笑气短暂的减少老年鼠皮质蛋氨酸合酶但会造成持久的记忆缺陷

周时蓓 薛张纲校

Nitrous Oxide Decreases Cortical Methionine Synthase Transiently but Produces Lasting Memory Impairment in Aged Rats

Deborah J. Culley, Sumati V. Raghavan, Mostafa Waly, Mark G. Baxter, Rustam Yukhananov, Richard C. Deth, and Gregory Crosby

Anesth Analg 2007 105: 83-88.

蛋白激酶A在酒精诱导的大鼠急性神经行为改变中的作用

颜涛 马皓琳 李士通

The Role of Protein Kinase A in Acute Ethanol-Induced Neurobehavioral Actions in Rats

Chih-Chia Lai, Ting-In Kuo, and Hsun-Husn Lin

Anesth Analg 2007 105: 89-96.

异氟醚对血管紧张素II诱导的血管收缩制作用的机制与七氟醚不同

杨卫红 陈杰

The Mechanism Behind the Inhibitory Effect of Isoflurane on Angiotensin II-Induced Vascular Contraction Is Different from That of Sevoflurane

Ai Ishikawa, Koji Ogawa, Yasuyuki Tokinaga, Nobuhiko Uematsu, Kazuhiro Mizumoto, and Yoshio Hatano

Anesth Analg 2007 105: 97-102.

二氧化碳对大鼠的麻醉特性

施译 薛张纲校

Anesthetic Properties of Carbon Dioxide in the Rat

Robert J. Brosnan, Edmond I. Eger, II, Michael J. Laster, and James M. Sonner

Anesth Analg 2007 105: 103-106.

TECHNOLOGY, COMPUTING, AND SIMULATION:

出血时与应用升压药后脉搏周线衍生成的心排血量的可靠性

胡湘 马皓琳 李士通

The Reliability of Pulse Contour-Derived Cardiac Output During Hemorrhage and After Vasopressor Administration

Berthold Bein, Patrick Meybohm, Erol Cavus, Jochen Renner, Peter H. Tonner, Markus Steinfath, Jens Scholz, and Volker Doerges

Anesth Analg 2007 105: 107-113.

CRITICAL CARE AND TRAUMA:

生理盐水和高张生理盐水对于局部血流和氧输送的影响

李惟一 陈杰

The Effects of Normal and Hypertonic Saline on Regional Blood Flow and Oxygen Delivery

Li Wan, Rinaldo Bellomo, and Clive N. May

Anesth Analg 2007 105: 141-147.

由一种新的指示器和由传统的金属丝引导的经皮环甲膜穿刺术在人体模型的比较

陈佳莉译 薛张刚校

A Comparison of a New Indicator-Guided with a Conventional Wire-Guided Percutaneous Cricothyroidotomy Device in Mannequins

Nicole M. Assmann, David T. Wong, and Eduardo Morales

Anesth Analg 2007 105: 148-154.

长期机械通气下丙酚镇静家兔的器官毒性和死亡率

周雅春 马皓琳 李士通

Organ Toxicity and Mortality in Propofol-Sedated Rabbits Under Prolonged Mechanical Ventilation

Petros Ypsilantis, Maria Politou, Dimitrios Mikroulis, Michail Pitiakoudis, Maria Lambropoulou, Christina Tsigalou, Vasilios Didilis, Georgios Bougioukas, Nikolaos Papadopoulos, Constantinos Manolas, and Constantinos Simopoulos

Anesth Analg 2007 105: 155-166.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

瑞太尼对常人大脑血流量的影响:剂量和载脂蛋白E基因

郑丽 陈杰

Remifentanil-Induced Cerebral Blood Flow Effects in Normal Humans: Dose and ApoE Genotype

W. Andrew Kofke, Patricia A. Blissitt, Hengyi Rao, Jiongjiong Wang, Kathakali Addya, and John Detre

Anesth Analg 2007 105: 167-175.

OBSTETRIC ANESTHESIOLOGY:

硬膜外注射单剂量控吗啡(DepoDurTM)与传统吗啡用于剖宫产术后镇痛的比较

陈珺珺译 薛张纲校

Single-Dose, Extended-Release Epidural Morphine (DepoDurTM) Compared to Conventional Epidural Morphine for Post-Cesarean Pain

Brendan Carvalho, Laura M. Roland, Larry F. Chu, Vincent A. Campitelli, III, and Edward T. Riley

Anesth Analg 2007 105: 176-183.

GENERAL ARTICLES:

基于三维计算机断层摄影的经锁骨途径右锁骨下静脉穿刺新方法

沈浩 马皓琳 李士通

A Novel Supraclavicular Approach to the Right Subclavian Vein Based on Three-Dimensional Computed Tomography (Special Article)

Chul-Woo Jung, Jeong-Hwa Seo, Whal Lee, and Jae-Hyon Bahk

Anesth Analg 2007 105: 200-204.

ANALGESIA:

疼痛治疗:基本的人权

张美荣 陈杰

Pain Management: A Fundamental Human Right (Review Article)

Frank Brennan, Daniel B. Carr, and Michael Cousins

Anesth Analg 2007 105: 205-221.

评价塞来昔布(celecoxib)作为门前交叉韧带重建术多模式镇痛组成部分的镇痛效能

罗 璇译 薛张纲校

Evaluating the Analgesic Efficacy of Administering Celecoxib as a Component of Multimodal Analgesia for Outpatient Anterior Cruciate Ligament Reconstruction Surgery (Review Article)

Scott S. Reuben, Evan F. Ekman, and Derek Charron

Anesth Analg 2007 105: 222-227.

预防性给予多模式镇痛用药法对行前交叉韧带重建术的门病人的远期预后的影响

黄丽娜 李士通 马皓琳

The Effect of Initiating a Preventive Multimodal Analgesic Regimen on Long-Term Patient Outcomes for Outpatient Anterior Cruciate Ligament Reconstruction Surgery (Review Article)

Scott S. Reuben and Evan F. Ekman

Anesth Analg 2007 105: 228-232.

腰椎间盘切除术患者围术期口服羟考酮控剂型下术后吗啡需求量、疼痛评分以副作用

宋翠侠 陈杰

Postoperative Intravenous Morphine Consumption, Pain Scores, and Side Effects with Perioperative Oral Controlled-Release Oxycodone After Lumbar Discectomy (Review Article)

Stephan Blumenthal, Kan Min, Michael Marquardt, and Alain Borgeat

Anesth Analg 2007 105: 233-237.

肺叶切除术后肺能:一项随机双盲试验比较胸科手术后硬膜外罗哌卡因/舒太尼与静脉输注吗啡用于病人自控镇痛

王光妍 薛张纲校

Lung Function After Lobectomy: A Randomized, Double-Blinded Trial Comparing Thoracic Epidural Ropivacaine/Sufentanil and Intravenous Morphine for Patient-Controlled Analgesia (Review Article)

Christian Bauer, Jean-Gustave Hentz, Xavier Ducrocq, Meyer Nicolas, Monique Oswald-Mammosser, Annick Steib, and Jean-Pierre Dupeyron Anesth

Analg 2007 105: 238-244.

 

大鼠关腔内注射α2肾腺素受体激剂Fadolmidine对关疼痛的外周性制作用

张莹 马皓琳 李士通校

Peripheral Suppression of Arthritic Pain by Intraarticular Fadolmidine, an {alpha}2-Adrenoceptor Agonist, in the Rat

Osei B. Ansah and Antti Pertovaara

Anesth Analg 2007 105: 245-250.

硬膜外使用氟哌利多的止痒与镇吐效果:三种不同给药方式的比较

周懿之 陈杰

The Antipruritic and Antiemetic Effects of Epidural Droperidol: A Study of Three Methods of Administration

In Ho Lee and Il Ok Lee

Anesth Analg 2007 105: 251-255.

膝关术后镇痛:三种不同浓度的罗哌卡因对连续股神经阻滞的比较

张 俪译 薛张纲校

Postoperative Analgesia After Knee Surgery: A Comparison of Three Different Concentrations of Ropivacaine for Continuous Femoral Nerve Blockade

Gerhard Brodner, Hartmut Buerkle, Hugo Van Aken, Roushan Lambert, Marie-Luise Schweppe-Hartenauer, Carola Wempe, and Wiebke Gogarten Anesth

Analg 2007 105: 256-262.

骶骨旁坐骨神经阻滞:是否引出的运反应就预示着阻滞成呢?

黄佳佳译,马皓琳 李士通校

Parasacral Sciatic Nerve Block: Does the Elicited Motor Response Predict the Success Rate?

Bénédicte S. Hagon, Omar Itani, Jawad Hosseini Bidgoli, and Philippe J. Van der Linden

Anesth Analg 2007 105: 263-266.

舌咽神经阻滞对扁桃体切除术后疼痛的缓解作用:咽反射的制程度作为临指标的重要性

詹琼慧 陈杰

The Effects of Glossopharyngeal Nerve Block on Postoperative Pain Relief After Tonsillectomy: The Importance of the Extent of Obtunded Gag Reflex as a Clinical Indicator

Hee-Pyoung Park, Jung-won Hwang, Sang-Hyun Park, Young-Tae Jeon, Jae-Hyon Bahk, and Yong-Seok Oh

Anesth Analg 2007 105: 267-271.

 

七氟醚和舒太尼婴儿麻醉中经食管超声和硬膜外麻醉的血流学效应

The Transesophageal Doppler and Hemodynamic Effects of Epidural Anesthesia in Infants Anesthetized with Sevoflurane and Sufentanil

Antoine Monsel, MD*, Amelie Salvat-Toussaint, MD*, Philippe Durand, MD{dagger}, Vincent Haas, MD{dagger}, Catherine Baujard, MD*, Philippe Rouleau, MD*, Souad El Aouadi, MD*, Dan Benhamou, MD*, and Karin Asehnoune, MD, PhD*{dagger}

From the *Service d'Anesthésie-Réanimation et Unité Propre de Recherche de l'Enseignement Supérieur-Equipe d'Accueil (UPRES-EA 392); and {dagger}Service de Réanimation Pédiatrique, Centre Hospitalo-Universitaire de Bicêtre, Assistance Publique-Hôpitaux de Paris (AH-HP), Le Kremlin Bicêtre, France.

Anesth Analg 2007 105: 46-50.

 

背景:普遍观点认为儿科硬膜外麻醉可以提供儿童稳定的血流学。然而,与成人的相关资料比较而言,几乎没有关于婴儿硬膜外麻醉对心排量影响的资料。

方法:我们对14<10kg接受腹部手术的婴儿进行前瞻性研究,运用经食道超声检测心排量。用七氟醚进行常规麻醉维持,在用0.25%的布比卡因和1:200,000的肾腺素以0.75ml/kg的剂量进行腰椎连硬外麻醉的前后用经食道超声监测心排量。在开始硬膜外麻醉前,开始后5分钟,15分钟和20分钟分别监测心排量、脉压和心率。

结果:对于用七氟醚和舒太尼进行麻醉的患者,硬膜外可以引起每搏量增 29(P<0.0001)和心率降低13%(P<0.0001)。硬膜外麻醉还能分别引起收缩压、舒张压、平均脉压和全身血管阻下降11%18%15%25%。相反的,心排量保持不变。

结论:观察到的每搏量的增也许可以用硬膜外麻醉引起交感神经的阻滞导致后负荷的降低来解。这些结果证实硬膜外麻醉可以提供<10kg婴儿稳定的血流学,并且支持硬膜外麻醉在这一儿科人群中的应用。

(王时来译 薛张纲校)

BACKGROUND: It is thought that pediatric epidural anesthesia (EA) provides hemodynamic stability in children. However, when compared with information relating to adults, little is known about the hemodynamic effects of epidural EA on cardiac output (CO) in infants. METHODS: Using transesophageal Doppler to monitor CO, we prospectively studied 14 infants <10 kg who were scheduled for abdominal surgery. During sevoflurane general anesthesia, CO transesophageal Doppler monitoring was performed before and after lumbar EA with 0.75 mL/kg of 0.25% bupivacaine and 1:200,000 adrenaline. CO, arterial blood pressure, and heart rate were measured before and 5, 15, and 20 min after performance of EA. RESULTS: In patients anesthetized with sevoflurane and sufentanil, EA resulted in an increase in stroke volume by 29% (P < 0.0001) and a decrease in heart rate by 13% (P < 0.0001). EA also induced a significant decrease in systolic, diastolic, mean arterial blood pressure, and systemic vascular resistance by 11%, 18%, 15%, and 25%, respectively. Conversely, CO remained unchanged. CONCLUSIONS: The increase in stroke volume observed is probably explained by optimization of afterload because of the sympathetic blockade induced by EA. These results confirm that EA provides hemodynamic stability in infants weighing <10 kg and supports the use of EA in this pediatric population.

 

 

日间手术术后恢复情况评价方法的系统回顾

A systematic review of postoperative recovery outcomes measurements after ambulatory surgery.

Herrera FJ, Wong J, Chung F.

Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2007 105: 63-69

 

背景:日间手术的死亡率其发生是很罕见的,因此病人的生活质量(即出院后恢复正常的活能)应当是日间手术和麻醉后的考虑的最终原则之一。我们通过对日间手术恢复质量的评估方法的系统回顾,从而为相关的研究和质量评估提供有选择性的合适方法。方法:对MEDLINE EMBASECINAHLHAPI PsycINFOWeb of Science Search HistoryBiosys Previews SearchHealthStar, ASSIA中的文献系统性搜索,通过鉴别评价病人预后的方法来评价日间手术麻醉术后恢复况。评价指标应具有八项标准:适用性,可靠性,有效性,反应性,准确性,配合性,可受性,可行性。结果:有7篇符合标准的文章被选中。鉴别方法的质量是可变的。结论:40条恢复质量记录中仅有一个方法符合所有八项标准,然而这一方法不是特别针对日间手术和麻醉的。

(陈勇柱译 薛张纲校)

BACKGROUND: Mortality and morbidity in ambulatory surgery are rare, and thus the patient's quality of life (i.e., the ability to resume normal activities after discharge home) should be considered one of the principle end-points after ambulatory surgery and anesthesia. We conducted a systematic review of the instruments to measure the quality of recovery of ambulatory surgical patients in order to advise on the selection of appropriate measures for research and quality assurance. METHODS: A systematic literature search of MEDLINE, EMBASE, CINAHL, HAPI, PsycINFO, Web of Science Search History, Biosys Previews Search, HealthStar, and ASSIA was performed to identify patient-based outcome measures to assess postoperative recovery from ambulatory anesthesia. The instruments were assessed for eight criteria: appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility. RESULTS: Seven articles met the inclusion criteria set for the review. The quality of the identified instruments was variable. CONCLUSION: Only one instrument, 40-item Quality of recovery score, fulfilled all eight criteria, however this instrument was not specifically designed for ambulatory surgery and anesthesia.

 

 

笑气短暂的减少老年鼠皮质蛋氨酸合酶但会造成持久的记忆缺陷

Nitrous Oxide Decreases Cortical Methionine Synthase Transiently but Produces Lasting Memory Impairment in Aged Rats

Deborah J. Culley, Sumati V. Raghavan, Mostafa Waly, Mark G. Baxter, Rustam Yukhananov, Richard C. Deth, and Gregory Crosby

Department of Anesthesiology Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA.

Anesth Analg 2007 105: 83-88.

 

背景:笑气是一种常用的麻醉剂,能制蛋氨酸合酶的活性,而这种酶与甲基化作用,DNA的合成与修复有关。这种制作用触发无论是发育中还是成熟的大脑中负责空间记忆的区域的神经元泡的形成与退化,提高了笑气对于学习能有持久的影响的可能性。方法:为了测试这种可能性,我们随机的将18月龄的费希尔344大鼠分到2组(每组n=13),接受4小时70%笑气+30%氧气,70%氮气+30%氧气(对照组),并且用一个14天前曾经走过的12弯的放射的迷宫在吸入笑气后2天测试大鼠的记忆。此外,在结束暴露于笑气后的即刻和2天后,我们用标准的测定法测量在其他方面都受到相同对待的大鼠的肝和大脑皮质的蛋氨酸合酶的活性(每组每个时间点n=3)。结论:肝脏和皮质的蛋氨酸合酶在笑气麻醉期间是受到制的(6%23%分别在肝脏和大脑皮质较之对照组,P < 0.01)。肝脏的蛋氨酸合酶的活性在2天后仍然受到制,然而皮质的蛋氨酸合酶活性已经恢复。对照组和笑气组大鼠在错误率方面并没有差别。然而,曾经暴露于笑气的的大鼠用了更多的时间去走完迷宫,并且更早的做出第一次错误的选择(P < 0.05)。结论:用70%的笑气进行镇静明显的短暂的制老年大鼠大脑皮质蛋氨酸合酶的活性,但是引起持久的空间活记忆的损害。

(周时蓓 薛张纲校)

BACKGROUND: Nitrous oxide is a commonly used anesthetic that inhibits the activity of methionine synthase, an enzyme involved in methylation reactions and DNA synthesis and repair. This inhibition triggers vacuole formation and degeneration of neurons in areas of the developing and mature brain that are important for spatial memory, raising the possibility that nitrous oxide might have sustained effects on learning. METHODS: To test this possibility, we randomized 18-month-old Fischer 344 rats (n = 13 per group) to 4 h of 70% nitrous oxide + 30% oxygen or 70% nitrogen + 30% oxygen (control) and assessed memory using a 12-arm radial maze for 14 days beginning 2 days after nitrous oxide inhalation. In separate, identically treated groups of rats, we measured methionine synthase activity in the cortex and liver at the end of nitrous oxide exposure and 2 days later (n = 3 rats per group per time point) using a standard assay. RESULTS: Liver and cortical methionine synthase was inhibited during nitrous oxide inhalation (6% and 23% of control in liver and cortex, respectively; P < 0.01). Liver enzyme activity remained depressed 2 days later, whereas cortical enzyme activity recovered. There was no difference in error rate between control and nitrous oxide treated rats. However, those exposed to nitrous oxide took more time to complete the maze and made fewer correct choices before first error (P < 0.05). CONCLUSIONS: Sedation with 70% nitrous oxide profoundly, but transiently, reduces the activity of cortical methionine synthase but produces lasting impairment in spatial working memory in aged rats.

 

 

二氧化碳对大鼠的麻醉特性

Anesthetic Properties of Carbon Dioxide in the Rat

Robert J. Brosnan, Edmond I. Eger, II, Michael J. Laster, and James M. Sonner

From the *Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis; and {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2007 105: 103-106

 

背景:当二氧化碳分压超过95mmHg时二氧化碳可以降低氟烷的MAC.我们试图用大鼠来证实几个吸入麻醉剂的这种特性.方法:几组各8只小鼠用氟烷、异氟烷、地氟烷进行麻醉.每个麻醉剂都测定MAC值以随着吸入二氧化碳浓度升高的变化.第四组大鼠单独用二氧化碳进行麻醉并测定MAC.结果:吸入二氧化碳浓度的升对所有吸入麻醉剂的MAC值产生剂量依赖的线性下降关系.随着二氧化碳的消除,异氟烷、地氟烷的MAC值也回到原先的数值.由测得的数据倒推出当吸入麻醉剂的浓度为0%,二氧化碳的MAC值大约为50%一个大气压.单独吸入时,二氧化碳被证明是致命的.结论:和狗不同,大鼠的二氧化碳MAC值不会因氟烷、异氟烷、地氟烷激起阈值反应,大鼠二氧化碳的ED50也比道的狗大约高50%.

(施译 薛张纲校)

BACKGROUND: Carbon dioxide decreases halothane minimum alveolar concentrations (MAC) in dogs when Paco(2) exceeds 95 mm Hg. We sought to confirm these findings for several potent inhaled anesthetics in rats. METHODS: Groups of eight rats were anesthetized with halothane, isoflurane, or desflurane. MAC was determined for each anesthetic alone, and then with increasing concentrations of inspired CO(2). A fourth group was given CO(2) alone to determine the MAC of CO(2). RESULTS: Increasing inspired CO(2) concentrations produced a linear dose-dependent decrease in MAC of each potent inhaled anesthetic. With elimination of CO(2), the MAC of isoflurane and desflurane returned to the original MAC. As determined by extrapolating these data to 0% of the inhaled anesthetic, the MAC of CO(2) was approximately 50% of 1 atm. Given alone, CO(2) proved lethal. CONCLUSIONS: Unlike dogs, no threshold for the CO(2)-MAC response arose with halothane, isoflurane, or desflurane in rats. The ED(50) for CO(2) is also approximately 50% greater in rats than reported in dogs.

 

 

由一种新的指示器和由传统的金属丝引导的经皮环甲膜穿刺术在人体模型的比较

A Comparison of a New Indicator-Guided with a Conventional Wire-Guided Percutaneous Cricothyroidotomy Device in Mannequins

Nicole M. Assmann, MD, FRCA, David T. Wong, MD, and Eduardo Morales, MD

From the Department of Anesthesiology, Toronto Western Hospital, University of Toronto, Ontario, Canada.

Anesth Analg 2007 105: 148-154.

 

背景:经皮环甲膜穿刺术是在无法插管、无法通气的情况下的救生方法。在这项研究中,我们在人体模型比较了用一种新的指示器引导和用金属丝引导的环甲膜穿刺术的插入时间。方法:这项交叉试验研究比较了由指示器引导和由金属丝引导的环甲膜穿刺术的插入时间和成率。在一项视听培训课程后,64个麻醉医生每人分别用2种装置做5次环甲膜穿刺术。成的穿刺定义为将装置插入到正确的解剖位置。5次实验的两种装置的插入时间和成率用方差分析、成对t检验和{chi}2检验比较。结果:由指示器引导的装置比起由金属丝引导的装置插入时间快(32.6±14.9秒比42.3±12.5秒,P<0.001)而成率相似(95%比93.1%)。反复的尝试能够提高两种装置的使用术。其中用指示器引导的穿刺中有4次(1.3%)插在了气管腔的前面或后面,而用金属丝引导的却没有(P0.12)。参与者在临紧急环境下主观会更多地选择使用金属丝引导的穿刺装置而不是指示器引导的装置(59%比31%,P<0.001)。结论:在人体模型,指示器引导的环甲膜穿刺术比金属丝引导的时间要快,但是成率相似。更多的参与者在临紧急环境下主观地会选择使用金属丝引导的穿刺装置。

(陈佳莉译 薛张刚校)

BACKGROUND: Percutaneous cricothyroidotomy may be a life-saving procedure in cannot intubate–cannot ventilate situations. In this study we compared the insertion times of a new indicator-guided cricothyroidotomy device and a wire-guided device in mannequins. METHODS: This study was a crossover trial comparing the insertion times and success rates of an indicator-guided tube-over-needle device and a wire-guided cricothyroidotomy device in a mannequin. After an audiovisual training session, 64 anesthesiologists performed five cricothyroidotomies with each of the two devices. Successful insertion was defined as insertion of a device into the correct anatomic location. The insertion times and success rates between the two techniques for the five attempts were compared using repeated measures ANOVA, paired t-test, and {chi}2 analyses. RESULTS: Insertion times were faster (32.6 ± 14.9 s vs 42.3 ± 12.5 s, P < 0.001) while success rates were similar (95% vs 93.1%) with the indicator-guided device when compared with the wire-guided device. For both devices, performance improved with repeated attempts. Four insertion attempts (1.3%) were positioned anterior or posterior to the trachea lumen with the indicator-guided device compared to none with the wire-guided device (P = 0.12) Subjectively, more participants chose to use the wire-guided than the indicator-guided device (59% vs 31%, P < 0.001) in a clinical emergency situation.CONCLUSION: In a mannequin model, cricothyroidotomy insertion times were faster for the indicator-guided technique than for the wire-guided technique, but success rates were similar. Subjectively, more participants chose to use the wire-guided device in a clinical emergency situation.

 

 

硬膜外注射单剂量控吗啡(DepoDurTM)与传统吗啡用于剖宫产术后镇痛的比较

Single-Dose, Extended-Release Epidural Morphine (DepoDurTM) Compared to Conventional Epidural Morphine for Post-Cesarean Pain

Brendan Carvalho, MBBCh, FRCA, Laura M. Roland, MD, Larry F. Chu, MD, MS, Vincent A. Campitelli, III, MD, and Edward T. Riley, MD

From the Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2007 105: 176-183.

 

背景:单剂量硫酸吗啡制剂硬膜外注射在剖宫产术后镇痛效果良好,但是这种效果仅限于术后第一天。在最近的三相研究中,与传统的硬膜外吗啡制剂相比,控吗啡制剂(EREM)的效果更好,可以延长剖宫产术后镇痛的时间。然而这项研究计划并没有考虑到使用非甾体类炎药,术后使用不同镇痛药,并且呼吸制的监测和处理没有标准化。我们研究的目的是比较使用传统吗啡制剂和EREM用于剖宫产术后镇痛,术后镇痛药的用量,疼痛指数和副作用。方法:70名准备择期行剖宫产术的健康临产妇入了这项随机、双盲研究。产妇进行腰硬联合麻醉,在鞘内注射12mg布比卡因和10mcg太尼。在绷带绑完后,给予硬膜外给予单剂量吗啡4mgEREM 10mg。术后,所有的病人每6小时给予布洛口服。在疼痛时候口服羟考酮和静脉注射吗啡。术后48小时所有的病人监测氧饱和度和呼吸监测。

结果:单剂量给予EREM可以改善静息和活时的疼痛指数。相比于传统的硬膜外给予吗啡,EREM在术后48小时追的阿片类药物用量从17mg降至10mg。两种药物在副作用方面时相似的。结论:与传统硬膜外注射吗啡相比,剖宫产术后给予EREM可以提供更好和更长时间的镇痛效果,并且并没有明显增副作用。(陈珺珺译 薛张纲校)

BACKGROUND: A single-dose of neuraxial morphine sulfate provides good post-Cesarean analgesia; however, its efficacy is limited to the first postoperative day. In a recent phase III study, extended-release epidural morphine (EREM) formulation provided more effective, prolonged analgesia after Cesarean delivery, compared to conventional epidural morphine. However, the study protocol did not allow for the use of nonsteroidal antiinflammatory drugs, used various postoperative analgesics, and monitoring and treatment of respiratory depression were not standardized. Our aims in this study were to compare postoperative analgesic consumption, pain scores and side effects of EREM with conventional morphine for the management of post-Cesarean pain in a setting more reflective of current obstetric practice. METHODS: Seventy healthy parturients undergoing elective Cesarean delivery were enrolled in this randomized, double-blind study. Using a combined spinal epidural technique, patients received an intrathecal injection of bupivacaine 12 mg and fentanyl 10 mcg. After closure of the fascia, a single-dose of either conventional morphine 4 mg or EREM 10 mg was administered epidurally. Postoperatively, all patients received ibuprofen 600 mg orally every 6 h. Oral oxycodone and IV morphine were available for breakthrough pain. All patients received pulse oximetry and respiratory monitoring for 48 h post-Cesarean delivery. RESULTS: Single-dose EREM significantly improved pain scores at rest and during activity. The median (interquartile range) of supplemental opioid medication usage for 48 h post-Cesarean (in milligram-morphine equivalents) decreased from 17 (22) to 10 (17) mg with EREM compared to conventional epidural morphine (P = 0.037). Both drugs were well tolerated with no significant difference in adverse event profiles. CONCLUSION: EREM provides superior and prolonged post-Cesarean analgesia compared to conventional epidural morphine with no significant increases in adverse events.

 

 

评价塞来昔布(celecoxib)作为门前交叉韧带重建术多模式镇痛组成部分的镇痛效能

Evaluating the analgesic efficacy of administering celecoxib as a component of multimodal algesia for outpatient anterior cruciate ligament reconstruction surgery.

Reuben SS, Ekman EF, Charron D.

Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA.

Anesth Analg. 2007;105:222-7

 

背景:环氧化酶2制剂可能在矫形外科术后的多模式镇痛中起到重要作用。作者检验了塞来昔布作为门前交叉韧带(ACL)手术多模式镇痛治疗成分之一的镇痛效能。方法:200名连续的病人随机分为两组,分别在ACL术前1-2h接受1000mg对乙酰胺基酚400mg塞来昔布或安慰剂。所有病人都接受关内镇痛(布比卡因、可乐定和吗啡)术侧关外部降温措施。出院后,要求病人在术后最初的14天内,每6h服用对乙酰胺基酚1000mg,每12h服用塞来昔布200mg或安慰剂。如镇痛不够可用羟考酮5-10mg补救。结果:塞来昔布组的病人在恢复室感觉到的疼痛较少(P<0.01),术后阿片类镇痛用量少(P<0.001)。这些病人术后恶心呕吐的发生率低(P<0.05)且回家早(P<0.05)。在家中,塞来昔布组的病人无论在静息(P<0.05)或运(P<0.01)时均较低的疼痛评分,术后各时间点羟考酮的用量都较少。结论:围术期应用塞来昔布降低术后疼痛、阿片类药物用量、术后恶心呕吐恢复室停留时间。这些结果支持将塞来昔布作为ACL手术多模式镇痛的一个组成部分

(罗 璇译 薛张纲校)

BACKGROUND: Cyclooxygenase-2 inhibitors may play an important role in multimodal management of pain after orthopedic surgery. We examined the analgesic efficacy of administering celecoxib as a component of a multimodal analgesic regimen for outpatient anterior cruciate ligament (ACL) surgery. METHODS: Two-hundred consecutive patients were randomized to receive acetaminophen 1000 mg and either celecoxib 400 mg or placebo 1-2 h before ACL surgery. All patients received intraarticular analgesics (bupivacaine, clonidine, and morphine) and had an external cooling system applied to the operative knee. After discharge, patients were instructed to take acetaminophen 1000 mg every 6 h and either celecoxib 200 mg every 12 h or matching placebo for the first 14 days postoperatively. Oxycodone 5-10 mg was available for rescue analgesia. RESULTS: Patients in the celecoxib group were more likely to experience less pain in the recovery room (P < 0.01) and require less opioids (P < 0.001) for postoperative analgesia. These patients reported a lower incidence of postoperative nausea and vomiting (P < 0.05) and were discharged home earlier (P < 0.05). While at home, patients in the celecoxib group reported lower pain scores both at rest (P < 0.05) and with movement (P < 0.01), and used less oxycodone at all postoperative time intervals. CONCLUSIONS: The perioperative administration of celecoxib decreases postoperative pain, opioid use, postoperative nausea and vomiting, and recovery room length of stay. These results support the use of celecoxib as a component of a preventive multimodal analgesic technique for ACL surgery.

 

 

肺叶切除术后肺能:一项随机双盲试验比较胸科手术后硬膜外罗哌卡因/舒太尼与静脉输注吗啡用于病人自控镇痛

Double-Blinded Trial Comparing Thoracic Epidural Ropivacaine/Sufentanil and Intravenous Morphine for Patient-Controlled Analgesia

Christian Bauer, MD*, Jean-Gustave Hentz, MD{dagger}, Xavier Ducrocq, MD{ddagger}, Meyer Nicolas, MD, Monique Oswald-Mammosser, MD||, Annick Steib, MD, PhD{dagger}, and Jean-Pierre Dupeyron, MD, PhD{dagger}

From the *Department of Anesthesia and Intensive Care, Hopital Cardio-Vasculaire et Pneumologique Louis Pradel, Hospices Civils de Lyon, Lyon-Bron, France; {dagger}Anesthesiology Department, {ddagger}Thoracic Surgery Unit, Department of Public Health, Biostatistic and Methodology Unit, and Department of Respiratory, Cardiocirculatory, and Exercise Physiology, University Hospital Strasbourg, Strasbourg, France.

Anesth Analg 2007 105: 238-244.

 

背景:虽然目前认为胸科手术后胸段硬膜外镇痛(TEA)优于静脉输注吗啡,一些研究明确指出,TEA使用局麻药联合阿片类药物对于肺能有改善作用。方法:在这项前瞻性的、随机双盲研究中,我们对TEA使用 罗哌卡因/舒太尼(TEA组)和静脉输注吗啡(IV组)进行比较,它们会影响到68位患者的术后疼痛以肺能。疼痛的强度,FVC,FEV1,FEV1/FVC比值,用呼气流速,鼻吸气压作为呼吸肌强度的指标,从术后的第一天到第四天将对这些指标进行评估。结果:在静息以咳嗽时,TEA组的疼痛缓解程度更好( P < 0.001)TEA组的FVCFEV1的减退程度较IV组少(分别为P < 0.001 and P = 0.003)  。鼻吸气压,两组的FEV1/FVC比值和呼气流速减退程度相似。住院死亡率以术后肺部并发症,在两组中没有明显区别。结论:肺叶切除术后,TEA组提供了显著的肺能恢复,同时术后镇同也较全身使用吗啡好,虽然可能会发生一定程度的肋间肌运阻滞。

(王光妍 薛张纲校)

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid.METHODS: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day.RESULTS: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups.CONCLUSION: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

 

 

膝关术后镇痛:三种不同浓度的罗哌卡因对连续股神经阻滞的比较

Postoperative analgesia after knee surgery: a comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade.

Gerhard Brodner, Hartmut Buerkle, Hugo Van Aken, Roushan Lambert, Marie-Luise Schweppe-Hartenauer, Carola Wempe, and Wiebke Gogarten

Department of Anaesthesiology and Intensive Care and Pain Therapy, Fachklinik Hornheide, Münster, Germany.

Anesth Analg 2007 105: 256-262

 

背景:对于全膝置换术后最为有效的输注罗哌卡因的浓度目前尚没有明确的规定。我们近期设计了这样一个研究来比较罗哌卡因在三个不同的浓度(0.1,0.2.3%)来评价镇痛效果,通过对患者实行联合股神经和坐骨神经阻滞并采用连续输注调器来实现。第二个研究目的是评价其不良反应(如运阻滞),复原指数以罗哌卡因的血浆浓度。方法:122名患者在全麻复合区域股神经连续阻滞下行全膝置换术,区域阻滞的罗哌卡因浓度分别为0.1,0.20.3%。连续输注的的首剂为30ml0.5%罗哌卡因打入股神经阻滞导管,坐骨神经导管设定目标为态疼痛分数达40mm。疼痛和不良反应于气管导管拔除后1小时以术后的第一,第二,第三,第四和第五天评定。罗哌卡因的血浆浓度在开始后的244872小时测定,实验浓度为0.2%0.3%的罗哌卡因要在股神经阻滞结束后的24小时再测定一次。结果:0.1%浓度的罗哌卡因的镇痛效果不太有效。0.2%0.3%浓度的罗哌卡因的镇痛效果相当。0.2%0.3%浓度下最大输注速率分别为15.3913.77ml/h。在实验过程中两者在运阻滞,松弛或罗哌卡因的低于中毒剂量的血浆浓度几方面没有显著差异。结论:0.2%0.3%浓度的罗哌卡因在镇痛效果方面两者相仿。首剂的输注速率应该调在15ml/h从而可以获得有效的镇痛。

(张 俪译 薛张纲校)

BACKGROUND: The most effective ropivacaine concentration for femoral infusion after total knee arthroplasty is currently ill defined. We designed the present study to compare ropivacaine in three different concentrations (0.1, 0.2, and 0.3%) to evaluate analgesic quality, when administered as a continuous infusion with frequent infusion adjustments in patients receiving a combined femoral and sciatic nerve block. Secondary aims were to evaluate side effects such as motor blockade, rehabilitation indices, and ropivacaine plasma concentrations. METHODS: One hundred twenty-two patients undergoing total knee arthroplasty under combined general and regional anesthesia received femoral infusions of ropivacaine 0.1, 0.2, or 0.3%. Infusions were started after initial loading doses of 30 mL ropivacaine 0.5% into the femoral catheter and a sciatic catheter and were targeted to dynamic pain scores of 40 mm. Pain and side effects were assessed 1 h after tracheal extubation and on the first, second, third, fourth, and fifth postoperative days. Ropivacaine plasma concentrations were measured 24, 48, and 72 h after the start and 24 h after termination of femoral infusions in patients receiving ropivacaine 0.2% or 0.3%. RESULTS: Ropivacaine 0.1% provided ineffective analgesia. Ropivacaine 0.2% and 0.3% provided equivalent analgesia. Maximum infusion rates were 15.39 and 13.77 mL/h for ropivacaine 0.2% and 0.3%, respectively. There were no significant differences in motor blockade, mobilization, or ropivacaine plasma concentrations, which remained below toxic levels throughout the study period. CONCLUSION: Ropivacaine 0.2% and 0.3% were similar in terms of analgesic quality. Initial infusion rates should be adjusted to 15 mL/h to obtain effective analgesia.

 

体外循环,溶血与硝普盐诱发的氰化物产物

Cardiopulmonary Bypass, Hemolysis, and Nitroprusside-Induced Cyanide Production

Albert T. Cheung, MD, Gonzalo E. Cruz-Shiavone, BA, Qing C. Meng, PhD, Alberto Pochettino, MD, John A. Augoustides, MD, Joseph E. Bavaria, MD, and E. Andrew Ochroch, MD, MSCE

From the Departments of Anesthesiology, Surgery, and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania.

Anesth Analg 2007 105: 29-33.

 

背景:氰化物中毒是给予硝普钠后的一个并发症,心脏手术可能提高氰化物中毒的危险,因为体外循环(CPB)期间的溶血可能促使硝普钠放游离氰化物。

方法:作者收集25个心脏手术患者CPB期间的血样标本,该标本用于分析游离血红蛋白浓度与测定游离氰离子。

结果:整个CPB期间溶血导致血浆游离血红蛋白浓度提高平均速率0.27 mg·dL–1·min–1P0.001)。血浆标本中入硝普钠后产生的游离氰化物浓度与血浆游离血红蛋白浓度直接相关(P0.001)。

结论:CPB相关的溶血放的游离血红蛋白可促使硝普钠放游离氰化物。本离体试验提示心脏手术患者围术期给予硝普钠时,氰化物中毒危险提高。

(丁震敏 陈杰 校)

BACKGROUND: Cyanide toxicity is a complication of sodium nitroprusside administration. Cardiac surgery may increase the risk of cyanide toxicity, because hemolysis during cardiopulmonary bypass (CPB) may catalyze the release of free cyanide from sodium nitroprusside.

METHODS: We obtained serial blood specimens from 25 cardiac surgical patients during CPB. Plasma specimens were analyzed for free hemoglobin concentration and ability to generate free cyanide anion upon exposure to sodium nitroprusside.

RESULTS: Hemolysis based on plasma-free hemoglobin concentration increased over time during CPB at an average rate of 0.27 mg·dL–1·min–1 (P < 0.001). The concentration of free cyanide generated by the addition of sodium nitroprusside to the plasma samples was directly related to the plasma-free hemoglobin concentration (P < 0.001).

CONCLUSION: CPB-associated hemolysis and free hemoglobin release accelerated the immediate release of free cyanide from sodium nitroprusside. These in vitro findings suggest that cardiac surgical patients may be at increased risk of cyanide toxicity in response to the perioperative administration of sodium nitroprusside.

 

瑞太尼减少小儿患者喉罩喉管置入所需的异丙酚EC50的一

Remifentanil Halves the EC50 of Propofol for Successful Insertion of the Laryngeal Mask Airway and Laryngeal Tube in Pediatric Patients

Hye-Jin Park, MD*, Jeong-Rim Lee, MD{dagger}, Chong Sung Kim, MD{dagger}, Seong Deok Kim, MD{dagger}, and Hee-Soo Kim, MD{dagger}

From the *Department of Anesthesiology, College of Medicine, Eulji University, and {dagger}Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea.

Anesth Analg 2007 105: 57-61.

背景:异丙酚与瑞太尼是短小手术非肌松下插管可选用的药物。在本研究中,作者比较了使用和不使用瑞太尼时插入喉罩(LMA)或喉管(LT)所需的异丙酚浓度。

方法:选取手术时间<2h的小儿患者,并随机双盲分成4组:LMAP组: LMA置入使用异丙酚与盐水;LTP组: LT置入使用异丙酚和盐水;LMA-PR 组:LMA置入使用异丙酚和瑞太尼7.5 ng/mLLT-PR组: LT置入使用异丙酚和瑞太尼7.5 ng/mL。麻醉使用靶控输注异丙酚STELPUMP程序下瑞太尼。用于插入气道装置所需的异丙酚EC50使用Dixon's下调法决定。在每组连续的患者中,该患者接受的异丙酚浓度取决于前一个患者的反应,据此增大或减少0.2ug/ml

结果:使用瑞太尼患者,用于插入LMA的异丙酚EC502.57±0.22ug/ml,而插入LT2.59±0.20ug/ml,接受盐水患者相对应的值为5.45±0.21ug/ml5.58±0.23ug/mln.s.)。接受瑞太尼患者插喉罩条件良好的为64%9/14),插喉管的为79%11/14),接受盐水患者相对应的值分别为18%2/11)和404/10)。

结论:瑞太尼7.5ug/ml可减少用于气道插管所需的异丙酚浓度的一提高插管条件。而用于插喉罩和喉管所需的异丙酚浓度相似。

(顾新宇 陈杰 校)

BACKGROUND: Propofol and remifentanil are the drugs of choice for insertion of the supraglottic airway without muscle relaxants for short duration surgery. In this study, we compared propofol concentrations required for insertion of laryngeal mask way (LMA) or laryngeal tube (LT) with and without remifentanil.

METHODS: We included children scheduled for surgeries lasting <2 h, and assigned them to four groups in a randomized, double-blind manner: LMA with propofol + saline (LMA-P), LT with propofol + saline (LT-P), LMA with propofol + 7.5 ng/mL remifentanil (LMA-PR), LT with propofol +7.5 ng/mL remifentanil (LT-PR). Anesthesia was conducted by target-controlled infusion in determined target effect site concentration of propofol and remifentanil with the STELPUMP program. The EC50 of propofol for airway device placement was determined using Dixon's up-and-down method. The concentration of propofol for consecutive patients in each group was determined by the response of the previous patient, using increments or decrements of 0.2 µg/mL.

RESULTS: In patients receiving remifentanil, propofol EC50 for insertion of a LMA was 2.57 ± 0.22 µg/mL and that of LT was 2.59 ± 0.20 µg/mL (n.s.). In patients receiving saline, the corresponding values were 5.45 ± 0.21 µg/mL and 5.58 ± 0.23 µg/mL (n.s.). Conditions were excellent in 64% (9 of 14) and 79% (11 of 14) of patients receiving remifentanil, but in patients receiving saline, the values were 18% (2 of 11) for the LMA and 40.0% (4 of 10) for the LT.

CONCLUSIONS: Remifentanil 7.5 ng/mL reduced the propofol concentration required for airway insertion by half, and improved conditions for insertion. Propofol concentrations for insertion of the LMA and LT were similar.


伴有高碳酸血症过度通气情况下七氟醚与地氟醚的快速苏醒

Rapid Recovery from Sevoflurane and Desflurane with Hypercapnia and Hyperventilation

Derek J. Sakata, MD, Nishant A. Gopalakrishnan, PhD, Joseph A. Orr, PhD, Julia L. White, RN, BS, CCRC, and Dwayne R. Westenskow, PhD

From the Department of Anesthesiology, University of Utah, Salt Lake City, Utah.

Anesth Analg 2007 105: 79-82.

 

背景:在异氟醚麻醉中,因高碳酸血症而产生的过度通气可以令从关闭麻醉蒸发罐(1MAC)至病人睁眼的时间缩短67%

方法:在本次研究中作者测定在七氟醚与地氟醚麻醉中是否也可使苏醒时间相应地缩短。

结果:作者发现高碳酸血症产生的过度通气可以相应地使七氟醚与地氟醚的苏醒时间分别缩短52%64%(与正常通气量正常血二氧化碳浓度相比)。

结论:过度通气可以使肺内的麻醉气体迅速排出,因而重复呼吸引起的高碳酸血症能够显著缩短麻醉苏醒时间,并在不同溶解度的麻醉药中产生相应的缩短比例。

(印洁敏 陈杰 校)

BACKGROUND: Hypercapnia with hyperventilation shortens the time between turning off the vaporizer (1 MAC) and when patients open their eyes after isoflurane anesthesia by 62%.

METHODS: In the present study we tested whether a proportional shortening occurs with sevoflurane and desflurane.

RESULTS: Consistent with a proportional shortening, we found that hypercapnia with hyperventilation decreased recovery times by 52% for sevoflurane and 64% for desflurane (when compared with normal ventilation with normocapnia).

CONCLUSION: Concurrent hyperventilation to rapidly remove the anesthetic from the lungs and rebreathing to induce hypercapnia can significantly shorten recovery times and produce the same proportionate decrease for anesthetics that differ in solubility.

 

异氟醚对血管紧张素II诱导的血管收缩制作用的机制与七氟醚不同

The Mechanism Behind the Inhibitory Effect of Isoflurane on Angiotensin II-Induced Vascular Contraction Is Different from That of Sevoflurane

Ai Ishikawa, MD, Koji Ogawa, MD, Yasuyuki Tokinaga, MD, Nobuhiko Uematsu, MD, Kazuhiro Mizumoto, MD, and Yoshio Hatano, MD

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

Anesth Analg 2007 105: 97-102.

 

背景:血管紧张素IIAng II)诱导的血管收缩是通过Ca2介导的信号转导途径和Ca2致敏机制产生的。作者最近研究了七氟醚制血管紧张素II诱导的血管收缩,在鼠大脉平滑肌试验中,它主要是通过制蛋白激酶CPKC)磷酸化来调肌原纤维Ca2的致敏性,并无细胞内浓度Ca2明显的改变。本文研究异氟醚对于血管紧张素II诱导的血管收缩的制作用机制。

方法:通过等矩传感器,荧光计和免疫印迹法研究了异氟醚的血管收缩制作用,Ca2的增和Ang IIPKC磷酸化反应。

结果Ang II在鼠大脉平滑肌引出了短暂的收缩并伴随Ca2的增多和PKC的磷酸化。异氟醚(1.2%3.5%)浓度依赖性的制血管紧张素II诱导的鼠大脉平滑肌的血管收缩(在1.2%时P<0.05,在2.3%和3.5%时P<0.01n6)。受Ang II的影响,异氟醚同时也影响Ca2的增(在2.3%和3.5%时P<0.01n6),但在3.5%异氟醚下没有影响Ang II诱导的磷酸化(n=7)。

结论:以结果提示与七氟醚不同,异氟醚对于血管紧张素II诱导的血管收缩的制效果主要通过Ca2介导的信号转导途径的衰减。

(杨卫红 陈杰 校)

BACKGROUND: Angiotensin II (Ang II)-induced vascular contraction is mediated both by a Ca2+-mediated signaling pathway and a Ca2+ sensitization mechanism. We recently demonstrated that sevoflurane inhibits the contractile response to Ang II, mainly by inhibiting protein kinase C (PKC) phosphorylation that regulates myofilament Ca2+ sensitivity, without significant alteration of intracellular Ca2+ concentration ([Ca2+]i) in rat aortic smooth muscle. The current study was designed to determine the mechanisms by which isoflurane inhibits Ang II-induced contraction of rat aortic smooth muscle.

METHODS: The effects of isoflurane on vasoconstriction, increase in [Ca2+]i, and phosphorylation of PKC in response to Ang II (10–7 M) were investigated, using an isometric force transducer, a fluorometer, and Western blotting, respectively.

RESULTS: Ang II elicited a transient contraction of rat aortic smooth muscle that was associated with an increase in [Ca2+]i and PKC phosphorylation. Isoflurane (1.2%–3.5%) inhibited Ang II-induced contraction of rat aortic smooth muscle in a concentration-dependent manner (P < 0.05 at 1.2%, P < 0.01 at 2.3% and 3.5% isoflurane, n = 6). Isoflurane also inhibited elevation of [Ca2+]i in response to Ang II (P < 0.01 at 2.3% and 3.5% isoflurane, n = 6), but failed to affect Ang II-induced phosphorylation of PKC at concentrations up to 3.5% (n = 7).

CONCLUSION: These results suggest that, unlike sevoflurane, the inhibitory effect of isoflurane on Ang II-induced contraction is mainly mediated by attenuation of the Ca2+-mediated signaling pathway.


生理盐水和高张生理盐水对于局部血流和氧输送的影响

The Effects of Normal and Hypertonic Saline on Regional Blood Flow and Oxygen Delivery

Li Wan, MD*{dagger}{ddagger}, Rinaldo Bellomo, MD, FRACP, FJFICM*, and Clive N. May, PhD{dagger}

From the *Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia; {dagger}Department of Cardiovascular Physiology, Howard Florey Institute; and {ddagger}Department of Pharmacology, University of Melbourne, Parkville, Melbourne, Australia.

Anesth Analg 2007 105: 141-147.

 

背景:快速输注大量晶体液以期改善生命器官的灌注。然而,这样的措施对于哺乳物局部血流和氧气输送的影响还未被研究过。作者比较了生理盐水和高张生理盐水(浓度3%)对于正常物局部血流和氧气输送的影响。

方法:作者设计了一个随机,对照试验,实验对象为七只美利奴母。在的体内植入血流分析仪来观察主脉,冠脉,肾脉和肠系膜脉的血流况。物随机给于三种处理:对照观察,生理盐水(15mih内给于1L)或者3%的盐水(15min给于300ml),持续监测中心血流和脏器灌注210min

结果:两种液体在第一小时内都增了心率,心排量,中心静脉压、冠脉血流、肠系膜血流和周围电导(P<0.05)。在第二和第三个小时,都较对照组维持了更大的心排量,外周电导和肠系膜脉血流(P<0.05,但是差距减小。相反,肾血流未受影响,因为血液稀,肾脏的氧气输送在第一小时反而减小(p<0.05)。同时,两组尿量和肌酐清除率都增(p<0.05)。最后,试验发现,3%的盐水显著而短暂的增了血浆钠和晶体渗透压。

结论:正常浓度的盐水和高张盐水都有相似的系统和局部血流学影响。他们对肾血流均没有影响,在增尿量的同时降低了肾脏的氧气输送。

(李惟一 陈杰 校)

BACKGROUND: Boluses of crystalloids are frequently given to patients to optimize vital organ perfusion. However, their effect on regional blood flow and oxygen delivery in the normal mammalian circulation has not been studied. We compared the effects of normal or hypertonic (3%) saline or control on regional blood flow and oxygen delivery in normal animals.

METHODS: We conducted a randomized, controlled animal study in seven merino cross-ewes. We implanted chronic flow probes around aorta, coronary, renal, and mesenteric arteries. We randomized animals to three different interventions: observation (control), normal saline (1 L over 15 min), or 3% saline (300 mL over 15 min). We continuously measured central hemodynamics and organ blood flow for 210 min.

RESULTS: Both fluids increased heart rate, cardiac output, central venous pressure, peripheral conductance, coronary and mesenteric blood flow, and conductance in the first hour (P < 0.05). In the second and third hour, both maintained a greater cardiac output, total peripheral conductance, and mesenteric blood flow (P < 0.05) than control, but the difference decreased. In contrast, renal blood flow was unaffected and, because of hemodilution, renal oxygen delivery was decreased in the first hour (P < 0.05). Simultaneously, urine output and creatinine clearance increased (P < 0.05) in both groups. Finally, 3% saline significantly, but transiently, increased serum sodium and osmolarity.

CONCLUSIONS: Normal and hypertonic saline have similar systemic and regional hemodynamic effects. They also have no effect on renal blood flow and initially decrease renal oxygen delivery while increasing urine output.

 

瑞太尼对常人大脑血流量的影响:剂量和载脂蛋白E基因

Remifentanil-Induced Cerebral Blood Flow Effects in Normal Humans: Dose and ApoE Genotype

W. Andrew Kofke, MD, MBA, FCCM*{dagger}, Patricia A. Blissitt, RN, MSN, PhD{ddagger};, Hengyi Rao, PhD, Jiongjiong Wang, PhD||, Kathakali Addya, PhD, and John Detre, MD||#

From the Departments of *Anesthesiology and Critical Care, {dagger}Neurosurgery, Neurology, ||Radiology, and ¶Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; {ddagger}Neuroscience ICU, Duke University Medical Center, Durham, North Carolina; #The Center for Functional Neuroimaging, University of Pennsylvania, Philadelphia, Pennsylvania.

Anesth Analg 2007 105: 167-175.

背景:阿片类药物被认为与大脑边缘系统的活有关,且在物中可产生神经毒性。边缘系统激模式被认为与载脂蛋白EApoE)等位基因的分布情况相关。作者假设在外科手术过程中,小剂量的瑞太尼激边缘系统,且这一作用与用药剂量和ApoE基因有关。

方法27ASAI-II的志愿者接受四组剂量持续增大的瑞太尼输注:00.050.10.2µg · kg–1 · min–1,在输注期间吸100%纯氧。通过搏的脉自旋标记形成磁共振成像监测每组全脑血流量,在杏仁核,扣带回,海马,脑岛,丘脑区域。测定每个受试者ApoE 单核苷酸多态性。

结果:在没有校正Pco2的情况下,CBF出现显著的剂量依赖性增高现象,并且这一现象发生在全脑的各个区域。在通过校正Paco2使全脑CBF正常后,瑞太尼介导的CBF增作用在扣带回依然存在,但在海马和杏仁核出现CBF的下降。所有的Paco2校正作用在ApoE单核苷酸多态性存在的情况下被逆转了。

结论:镇静剂量的瑞太尼同时产生了多种边缘系统组织的激和制作用。扣带回皮质似乎对瑞太尼的激作用最为敏感,ApoE似乎与海马和杏仁核的激有关。

(郑丽 陈杰 校)

BACKGROUND: Opioids have been linked to limbic system activation and, in animals, to neurotoxicity. Limbic system nonpharmacologic activation patterns have been linked to the Apolipoprotein E (ApoE) allelic distribution. We tested the hypothesis that, in the absence of surgery, small doses of remifentanil produce limbic system activation in humans which varies with dose and ApoE genotype.

METHODS: Twenty-seven ASA I–II volunteers received a remifentanil (UltivaTM) infusion at four sequentially increasing doses: 0, 0.05, 0.1, and 0.2 µg · kg–1 · min–1 while receiving 100% oxygen. Cerebral blood flow (CBF) was measured at each dose globally and in the amygdala, cingulate, hippocampus, insula, and thalamus regions by pulsed arterial spin labeling magnetic resonance imaging. ApoE single nucleotide polymorphisms were determined in each subject.

RESULTS: Significant dose-related CBF increases, without correction for Paco2, were detected in all areas. After normalizing for global CBF to correct for Paco2 effects, the remifentanil-mediated increased CBF in the cingulate persisted, with decreased flow occurring in the hippocampus and amygdala. All these Paco2-corrected effects were reversed in the presence of the ApoE4 polymorphism.

CONCLUSION: Remifentanil at sedative doses produces both activating and depressing effects in various limbic system structures. The cingulate cortex seems to have the most susceptibility to remifentanil activation, and ApoE4 seems to produce relative activation of the hippocampus and amygdala.


疼痛治疗:基本的人权

Pain Management: A Fundamental Human Right

Frank Brennan, MBBS, DCH, Dip Obs, FRACP, FAChPM, FACLM, LLB*, Daniel B. Carr, MD, FABPM, FFPMANZCA (Hon){dagger}{ddagger}, and Michael Cousins, MBBS, MD, DSc, FANZA, FFPMANZCA, FAChPM (RACP)

From the *Department of Palliative Care, Calvary Hospital, Kogarah, NSW Australia; {dagger}Departments of Anesthesiology and Medicine, Tufts-New England Medical Center, Boston, Massachusetts; {ddagger}Javelin Pharmaceuticals, Inc., Cambridge, Massachusetts; Pain Management Research Institute, University of Sydney at Royal North Shore Hospital, St. Leonards, NSW Australia.

Anesth Analg 2007 105: 205-221.

 

本文调查了世界范围的医学的、伦理的和法律的态变化和所做的都归因于疼痛治疗作为一种人权这个概念。这个概念得到了2004国际疼痛研究协会欧洲联盟(IASP)、国际疼痛研究协会和世界卫生组织赞的“解痛地球日”的支持。作者调查了未减轻的疼痛的三个区域:急性疼痛、慢性非癌性疼痛和癌性疼痛,概括了未处理疼痛的不利的身体的和心理的影响和社会的、经济的代价。导致疼痛治疗不足的原因包括文化的、社会的、宗教的和政治的态度,也包括接受剧痛。注重病理生理学而不是生活质量的疾病生物医学模式增强了防意识:边缘化的疼痛治疗优先化。被申请改进的策略包括:定位疼痛治疗作为一个伦理问题,提升疼痛治疗作为一种合法的权利,提供立宪的保证和法令规定被忽视的法律、错误的法律和陋习,定义疼痛治疗作为一种基本的人权,分类疼痛治疗的失败是因为专业的不规范,指出操作的指导方向和规程应用的是专业的个体。世界卫生组织的作用是讨论疼痛治疗药物的有效性,特别是关于阿片类药物。作者认为:因为疼痛治疗是医学、伦理学和法律的内在的主题,我们正处在一个拐点,不合理的疼痛治疗被全世界的人看成是因为药品缺乏、不规范的操作和基本人权的丢失。

(张美荣 陈杰 校)

This article surveys worldwide medical, ethical, and legal trends and initiatives related to the concept of pain management as a human right. This concept recently gained momentum with the 2004 European Federation of International Association for the Study of Pain (IASP) Chapters-, International Association for the Study of Pain- and World Health Organization-sponsored "Global Day Against Pain," where it was adopted as a central theme. We survey the scope of the problem of unrelieved pain in three areas, acute pain, chronic noncancer pain, and cancer pain, and outline the adverse physical and psychological effects and social and economic costs of untreated pain. Reasons for deficiencies in pain management include cultural, societal, religious, and political attitudes, including acceptance of torture. The biomedical model of disease, focused on pathophysiology rather than quality of life, reinforces entrenched attitudes that marginalize pain management as a priority. Strategies currently applied for improvement include framing pain management as an ethical issue; promoting pain management as a legal right, providing constitutional guarantees and statutory regulations that span negligence law, criminal law, and elder abuse; defining pain management as a fundamental human right, categorizing failure to provide pain management as professional misconduct, and issuing guidelines and standards of practice by professional bodies. The role of the World Health Organization is discussed, particularly with respect to opioid availability for pain management. We conclude that, because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an "inflection point" in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.


腰椎间盘切除术患者围术期口服羟考酮控剂型下术后吗啡需求量、疼痛评分以副作用

Postoperative Intravenous Morphine Consumption, Pain Scores, and Side Effects with Perioperative Oral Controlled-Release Oxycodone After Lumbar Discectomy

Stephan Blumenthal, MD*, Kan Min, MD{dagger}, Michael Marquardt, MD*, and Alain Borgeat, MD*

From the Departments of *Anesthesiology; and {dagger}Orthopedic Surgery, Orthopedic University Clinic Zurich/Balgrist, Switzerland.

Anesth Analg 2007 105: 233-237.

 

背景:口服阿片制剂常用于术后镇痛。在这项研究中,作者评估了腰椎间盘切除术患者围术期口服羟考酮控剂以减少术后吗啡用量阿片制剂的副作用。

方法 40例择期手术病人,行1-2个段腰椎间盘切除术,进行前瞻性、随机、双盲、安慰剂对照试验。患者从手术前天晚到术后第二天早每12h口服羟考酮控剂20mg或安慰剂。所有患者术后接受吗啡自控镇痛,每6h均给予扑热息痛1g。分别在时间段T0-T24T24-T48评估术后吗啡用量。在术后第一个48h6h要行评估记录。术后每6h使用视觉评分量表评估镇痛效果,包括休息痛,咳嗽痛,运痛,同时评估恶心,呕吐,瘙痒,镇静和肠能情况。术后72h病人自评镇痛满意度。

结果:与安慰剂组相比口服羟考酮控剂组术后T0-T24(分别为52±29mg26±10mgT24-T4833±18mg13±8mg)时间段静脉吗啡用量明显减少。口服羟考酮组病人,第一个48h休息痛,咳嗽痛,运痛的评分明显降低,且在第一个24h术后恶心呕吐明显减少。羟考酮组的病人肠能恢复明显提前,且有较高的疼痛治疗满意度。

结论:与安慰剂组相比,腰椎间盘切除术患者,围术期口服羟考酮控剂可以减少术后吗啡用量,并提供较好的镇痛,且副作用较少。

(宋翠侠 陈杰 校)

BACKGROUND: Oral opioid formulations contribute to postoperative analgesia. In this study, we evaluated the perioperative application of oral controlled-release oxycodone to reduce postoperative IV morphine consumption and opioid side effects after lumbar discectomy.

METHODS: Forty patients scheduled for elective lumbar discectomy over 1 or 2 levels were included in this prospective, randomized, double-blind, placebo-controlled study. Every 12 h patients received either 20 mg oral controlled-release oxycodone or placebo, from the evening before surgery until the second postoperative morning. All patients received IV morphine via a morphine patient-controlled analgesia device for postoperative analgesia. Acetaminophen 1 g was administered to all patients every 6 h. Postoperative IV morphine consumption was assessed separately for T0T24 and T24T48. Postoperative assessments were conducted every 6 h for the first 48 h after surgery. Postoperative analgesia assessments included pain at rest, during coughing, and with motion, using a visual analog scale. Nausea, vomiting, pruritus, sedation, and bowel function were also assessed every 6 h. Patients rated their satisfaction with postoperative analgesia 72 h postoperatively.

RESULTS: Postoperative IV morphine consumption was significantly reduced during T0T24 (26 ± 10 mg vs 52 ± 29 mg) and T24T48 (13 ± 8 mg vs 33 ± 18 mg) in the controlled-release oxycodone group compared with that in the placebo group. Pain scores at rest, during coughing, and with motion were significantly lower during the first 48 postoperative hours in the controlled-release oxycodone group. Postoperative nausea and vomiting were significantly reduced during the first 24 h in the controlled-release oxycodone group. Lastly, the controlled-release oxycodone group also experienced significantly earlier recovery of bowel function and had higher patient satisfaction with pain therapy.

CONCLUSIONS: Perioperative oral controlled-release oxycodone reduces postoperative IV morphine consumption after lumbar discectomy while providing good analgesia with fewer side effects compared with placebo.

 

硬膜外使用氟哌利多的止痒与镇吐效果:三种不同给药方式的比较

The Antipruritic and Antiemetic Effects of Epidural Droperidol: A Study of Three Methods of Administration

In Ho Lee, MD*, and Il Ok Lee, MD{dagger}

From the *Department of Anesthesiology, Cheil General Hospital, and Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, Korea; and {dagger}Department of Anesthesiology, Korea University College of Medicine, Seoul, Korea.

Anesth Analg 2007 105: 251-255.

 

背景:本研究比较不同方式的硬膜外给予氟哌利多后,手术后恶心呕吐(PONV)的发生率。

方法:使用相同剂量的氟哌利多,观测三种不同给药方式(单次、连续以二者联合)对PONV的发生率和术后48小时由于连续硬膜外注射太尼诱发搔痒的影响。160ASA III级行结直肠癌切除术的病人,予硬膜外联合全身麻醉,并随机分为四组:(a)对照组(不给予氟哌利多),(b)单次注射组(给予氟哌利多2.5mg),(c)连续注射组(给予氟哌利多1.25mg/天),(d)联合组(给予氟哌利多单次1.25mg并连续0.625mg/天)。

结果:与对照组相比,所有给予氟哌利多组患者搔痒和PONV的发生明显减少(P<0.05)。硬膜外给予氟哌利多组间PONV的发生率和延迟发生率均相似。

结论:硬膜外给予氟哌利多能有效减少搔痒和术后恶心呕吐的发生,且与给药方式无关。

(周懿之 陈杰 校)

BACKGROUND: In this study, we compared rates of postoperative nausea and vomiting (PONV) and pruritus after using different protocols for administering epidural droperidol.

METHODS: Using the same dose of droperidol, we evaluated the effectiveness of three different methods of administration (single, continuous, and combined) on the frequency of PONV and pruritus induced by continuous infusion of epidural fentanyl for 48 h postoperatively. One hundred sixty ASA physical status I and II patients who underwent surgical resection for colorectal cancer under general anesthesia combined with epidural anesthesia were randomly allocated into four groups: (a) control group (no droperidol), (b) single injection group (droperidol 2.5 mg), (c) continuous group (droperidol 1.25 mg/day) and (d) combined single (droperidol 1.25 mg) and continuous (droperidol 0.625 mg/day) group.

RESULTS: Pruritus and PONV were significantly less frequent in all droperidol groups, when compared with the control group (P < 0.05). The incidence and the incidence over time of PONV were similar among all groups who received epidural droperidol.

CONCLUSION: Epidural droperidol is effective for reducing pruritus and PONV, regardless of the method of administration.

 

 

舌咽神经阻滞对扁桃体切除术后疼痛的缓解作用:咽反射的制程度作为临指标的重要性

The Effects of Glossopharyngeal Nerve Block on Postoperative Pain Relief After Tonsillectomy: The Importance of the Extent of Obtunded Gag Reflex as a Clinical Indicator

Hee-Pyoung Park, MD*, Jung-won Hwang, MD*, Sang-Hyun Park, MD*, Young-Tae Jeon, MD*, Jae-Hyon Bahk, MD{dagger}, and Yong-Seok Oh, MD*

From the *Department of Anesthesia and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Korea; and {dagger}Department of Anesthesia and Pain Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea.

Anesth Analg 2007 105: 267-271.

 

背景:作者评估了舌咽神经阻滞对成年患者扁桃体切除术后疼痛的缓解效果咽反射的制程度与术后疼痛缓解程度的相关性。

方法:75名进行扁桃体切除术的患者手术结束时接受了双侧舌咽神经阻滞,分为R组(0.75%罗哌卡因肾腺素)、B组(0.5%布比卡因肾腺素)、C组(未干预组)。

通过观察术后小时、8小时和24小时的咽喉部疼痛(100mm直观类比标度)和咽反射程度来评估舌咽神经阻滞的效果。

结果:R组和B组的疼痛评分吞咽反射明显少于C组(21±1723±1342±1628±2232±1962±14P<0.001)。舌咽神经的阻滞效果与咽反射的制程度显著相关(P<0.01)。

结论:舌咽神经是一种缓解扁桃体术后疼痛的有效方法。咽反射的制可以作为舌咽神经阻滞镇痛效果的临指标。

(詹琼慧 陈杰 校)

BACKGROUND: We evaluated the efficacy of glossopharyngeal nerve block (GNB) for the control of posttonsillectomy pain in adult patients, and correlated the extent of obtunded gag reflex as a clinical indicator of GNB with the extent of pain relief.

METHODS: Seventy-five patients undergoing tonsillectomy received bilateral GNB with 0.75% ropivacaine with epinephrine (Group R), 0.5% bupivacaine with epinephrine (Group B) at the end of the operation, or no intervention (Group C). To evaluate the effects of GNB, we assessed throat pain (100 mm visual analog scale) and severity of gag reflex response 0.5, 8, and 24 h after surgery.

RESULTS: In the immediate postoperative period, pain scores at rest and when swallowing in Groups R and B were significantly lower than those in Group C (21 ± 17 and 23 ± 13 vs 42 ± 16, 28 ± 22 and 32 ± 19 vs 62 ± 14, P < 0.001). The analgesic effect of GNB was strongly correlated with the extent of obtunded gag reflex (P < 0.01).

CONCLUSIONS: GNB is a useful method for the palliation of posttonsillectomy pain. An obtunded gag reflex response may be a clinical indicator for analgesia from GNB.

 

连续监测态肺顺应性使检测婴儿儿童支气管内插管成为可能

Continuous Monitoring of Dynamic Pulmonary Compliance Enables Detection of Endobronchial Intubation in Infants and Children

Aman Mahajan, MD, PhD, Nir Hoftman, MD, Angela Hsu, MD, Robert Schroeder, MD, and Samuel Wald, MD

From the Department of Anesthesiology, David Geffen School of Medicine at UCLA, Los Angeles, California.

Anesth Analg 2007;105:51-56

 

背景:听呼吸音常规用于确定气管插管的导管(ETT)置入气管。而在婴儿和儿童,这种方法却由于尽管插入支气管呼吸音仍然向双侧传导而受到限制。尽管有一些方法用于检测支气管内插管,但还没有哪一种方法简单而可靠。在本研究中,我们探讨采用持续监测流肺量测定法测得的肺顺应性气道压的改变是否能够可靠地检测儿科病人的支气管内插管。

方法:共有40例年龄1-6岁的病人。气管插管后,由两名观察者分别采用听呼吸音和肺量测定法(压容量环)监测导管位置的逐渐前移。在各放置点采用纤维支气管镜确定ETT的位置,同时记录肺顺应性、吸气峰压呼吸音的改变。

结果:支气管插管使测得的肺顺应性下降了45 ± 11%(均数± 标准差;P < 0.001,范围26%–66%),使气道压升高约26 ± 17% (均数± 标准差; P < 0.001,范围0–87)。与肺顺应性的改变相比,气道峰压的改变较小且变异度较大。听呼吸音法不能检测出7.5%病人的支气管内插管。

结论:监测肺顺应的改变是检测婴儿儿童支气管内插管的一个敏感而精确的指标。气道峰压的增高呼吸音的改变对于支气管内插管均是相对不敏感的指标。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: Auscultation of breath sounds is used routinely to confirm tracheal placement of endotracheal tubes (ETT). In infants and children, this method is limited by the conduction of breath sounds bilaterally, despite endobronchial intubation. Although several methods of detecting endobronchial intubation have been described, none is both simple and reliable. In this investigation, we determined whether changes in pulmonary compliance and airway pressures, measured using continuous side stream spirometry, can reliably detect endobronchial intubation in pediatric patients.

METHODS: Forty patients aged 1 month to 6 years were included. After endotracheal intubation the ETT was incrementally advanced as two observers monitored breath sounds and spirometry (Pressure-Volume Loops). Changes in pulmonary compliance, peak inspiratory pressure, or auscultation were reported, at which point ETT position was confirmed by fiberoptic bronchoscopy.

RESULTS: Endobronchial intubation decreased measured pulmonary compliance by 45 ± 11% (mean ± sd; P < 0.001, Range 26%–66%) and increased peak airway pressures by 26 ± 17% (mean ± sd; P < 0.001, Range 0–87). Changes in peak airway pressures were smaller and more variable when compared to changes in compliance. Breath-sound auscultation failed to detect endobronchial intubation in 7.5% of cases.

CONCLUSIONS: Pulmonary compliance changes are a sensitive and an accurate indicator of endobronchial intubation in infants and children. Both increased peak airway pressures and changes in breath sounds are less sensitive indicators of endobronchial intubation.

 

 

吗啡在术后患者:代谢产物的药代学和药效学

Morphine in Postoperative Patients: Pharmacokinetics and Pharmacodynamics of Metabolites

Jean Xavier Mazoit, MD, PhD, Karin Butscher, MD, and Kamran Samii, MD

From the Univ Paris-Sud, Laboratoire d’Anesthésie UPRES 3540, Faculté de Médecine, Le Kremlin Bicêtre, France F-94276; AP-HP, Département d’Anesthésie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France F-94275.

Anesth Analg 2007;105:70-78

 

背景:术后阶段中吗啡的需求存在很大变异性。我们进行了一项考虑到吗啡两个主要代谢产物有潜在作用的药代-药效学研究。

方法50名中至重度疼痛的患者术后先静脉滴定吗啡,随之肌注给药。每隔一小段时间测量吗啡、6-葡糖苷酸-吗啡(M-6-G) 3-葡糖苷酸-吗啡(M-3-G)的血药浓度和疼痛强度。用NONMEM软件进行药代学和药效学的拟合。

结果:药代学有良好的预见性。M-6-G M-3-G的清除率在肾衰患者中显著降低。因药效学的个体差异很大,其预见性较差。M-6-G的效价较吗啡高7.8倍,但单次静注吗啡后效应室浓度达到峰值的平均时间是M-6-G 4.25小时,吗啡0.33小时。M-3-G显示对M-6-G和吗啡的镇痛性质有轻微的制作用。单次静注吗啡后M-3-G效应室浓度达到峰值的时间是10小时。

结论M-6-G是较强的阿片类激剂,而M-3-G是较弱的阿片类拮剂。两者在肾衰患者的排泄均微乎其微。然而,吗啡的代谢很快,与之相比,其代谢产物通过血脑屏障的转运则看来是一个限速过程。由于M-3-G的弱镇痛作用在一些病人中可能发生在12天后,应该考虑换用其他分子。

(唐李隽 李士通 马皓琳 校)

BACKGROUND: There is great variability in the need for morphine in the postoperative period. We performed a pharmacokinetic–pharmacodynamic study considering the potential effect of the two main metabolites of morphine.

METHODS: Fifty patients with moderate to severe pain received morphine as an IV titration, followed by IM administration postoperatively. The plasma concentration of morphine, morphine-6-glucuronide (M-6-G), morphine-3-glucuronide (M-3-G), and pain intensity were measured at frequent intervals. Pharmacokinetic and pharmacodynamic fitting was performed with the software NONMEM.

RESULTS: The pharmacokinetics were largely predictable. M-6-G and M-3-G clearances were markedly decreased in patients with renal failure. The pharmacodynamics was less predictable, with an important interindividual variability. M-6-G was 7.8 times more potent than morphine, but the average time to peak concentration in the effect compartment after a bolus injection of morphine was 4.25 h for M-6-G, when compared to 0.33 h for morphine. M-3-G showed mild inhibition of the analgesic properties of morphine and of M-6-G. The time to M-3-G peak concentration in the effect compartment after a bolus injection of morphine was 10 h.

CONCLUSIONS: M-6-G is a potent opioid agonist and M-3-G a mild opioid antagonist. Both are poorly excreted in patients with renal failure. However, the metabolism of morphine was rapid when compared to the transfer of metabolites through the blood–brain barrier, which appears to be the limiting process. Because poor analgesia due to M-3-G’s effect may occur in some patients after 1 or 2 days, a switch to other molecules should be considered.

 

 

蛋白激酶A在酒精诱导的大鼠急性神经行为改变中的作用

The Role of Protein Kinase A in Acute Ethanol-Induced Neurobehavioral Actions in Rats

Chih-Chia Lai, PhD*{dagger}, Ting-In Kuo, MS{dagger}, and Hsun-Husn Lin, PhD{ddagger}

From the Departments of *Pharmacology and {ddagger}Physiology, {dagger}Institute of Pharmacology and Toxicology, Tzu Chi University, Hualien, Taiwan.

Anesth Analg 2007;105:89-96

 

背景:环腺苷酸依赖性蛋白激酶(PKA)信号通路参与基因敲除小鼠物模型中酒精诱导的镇静效应的调。本研究中,我们检测了PKA在酒精引起的SD大鼠行为改变中的作用。

方法:采用翻正反射消失(LORR)试验来研究腹膜腔内注射酒精的急性镇静效应。采用转轮试验(rotarod)来研究酒精引起的运损害。采用脑室内(ICV)注射N-甲基-d-天冬氨酸(NMDA)诱发搐来测定酒精对NMDA受体的影响。采用蛋白印迹分析来测定NR1蛋白水平和NR1亚基897磷酸丝氨酸。

结果:ICV注射H-9(一种非特异性蛋白激酶制剂)或KT5720(一种特异性PKA制剂)预处理呈剂量依赖性地减弱酒精导致的睡眠时间(LORR法)。采用福斯高林(腺苷环化酶激活剂)或白屈菜红碱(选择性PKC制剂)预处理对酒精导致的LORR没有影响。KT5720预处理也可减弱酒精导致的运能损害。酒精明显制NMDA导致的搐;预先脑室内注射KT5720可减弱酒精的这种制效应,但对我们测定的几个脑区内NMDA NR1亚基的897磷酸丝氨酸水平没有显著影响。

结论:我们的结果表明,PKA通路可能参与酒精导致的神经行为学改变,且NMDA受体可能涉酒精对PKA的调作用。

颜涛 马皓琳 李士通 校)

BACKGROUND: cAMP-dependent protein kinase (PKA) signaling pathways are involved in the regulation of ethanol-induced sedative effects in knockout mouse models. In the present study, we examined the role of PKA on the behavioral action caused by ethanol in Sprague Dawley rats.

METHODS: A loss of righting reflex (LORR) test was used to study the acute sedative effects of intraperitoneally injected ethanol. Rotarod performance was used to study the motor impairment caused by ethanol. Convulsions induced by intracerebroventricular (ICV) N-methyl-d-aspartate (NMDA) were used to evaluate ethanol’s effect on NMDA receptors. Western blot analysis was used to assay protein levels for NR1 and phosphoserine 897 on NR1 subnuits.

RESULTS: ICV pretreatment with H-9 (a nonspecific PK inhibitor) or KT 5720 (a specific PKA inhibitor) dose-dependently attenuated ethanol-induced sleeping time as assessed by LORR. ICV KT 5720 did not reduce ketamine or pentobarbital-induced sleeping time. Pretreatment with forskolin (an activator of adenylyl cyclase) or chelerythrine (a selective PKC inhibitor) had no effect on ethanol-induced LORR. Ethanol-induced motor impairment was also attenuated after pretreatment with KT 5720. Ethanol significantly inhibited NMDA-induced convulsions; the inhibitory effects of ethanol were reduced by prior ICV KT 5720, which had no significant effects on the levels of phosphoserine 897 on NMDA NR1 subunits in the several brain areas we examined.

CONCLUSIONS: Our results suggest that the PKA pathway may participate in ethanol-induced neurobehavioral changes and that NMDA receptors may be involved in the PKA regulation of ethanol’s actions.

 

 

出血时与应用升压药后脉搏周线衍生成的心排血量的可靠性

The Reliability of Pulse Contour-Derived Cardiac Output During Hemorrhage and After Vasopressor Administration

Berthold Bein, MD, Patrick Meybohm, MD, Erol Cavus, MD, Jochen Renner, MD, Peter H. Tonner, MD, Markus Steinfath, MD, Jens Scholz, MD, and Volker Doerges, MD

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

Anesth Analg 2007;105:107-113

 

背景:在危重的疾病中,可靠测量心排血量的方法是很重要的。脉搏周线衍生的心排血量(PCCO)在稳定的血流学中已经得到评价,但是其对血管紧张度的变化很敏感且在血流学改变的情况下并未得到验证。而且,PCCO要求用经肺热稀法COTPCO)来校准个体血管阻,要求重校准来维持正确测量的频率,尤其是在变化的条件下,尚未确定。我们在未控制出血和应用去甲肾腺素复苏的情况下对PCCO测量COTPCO和连续和单次肺脉CO(分别为CCOBCO)进行比较。

方法:13只猪被麻醉并接分别用BCOCCOTPCOPCCO监测心排血量的仪器。切开肝来完成未控制的出血。当平均脉压〈25mmHg,或心率进行性下降到〈峰值的20% ,即开始给予升压药治疗。在麻醉诱导后和开始治疗后15分钟完成TPCOBCO,重复获取PCCOCCO。用Bland-Altman分析来比较CO测量。

结果:平均脉压、心排血量和全身血管阻在出血后减少(分别为P < 0.001 and <0.01)。在出血后CCOPCCO(0.54 L/min; 1.46 L/min)之间一致性的偏移和极限增(–3.49; 6.12),在应用了去甲肾腺素后更恶化(–8.01; 9.9)。在重新校准后,偏移和极限一致回到–0.51 1.28

结论:PCCO在出血和应用升压药后需要频繁的重校准。

(胡湘 马皓琳 李士通 校)

BACKGROUND: Reliable measurement of cardiac output (CO) is important in the critically ill. Pulse contour-derived CO (PCCO) has been evaluated during stable hemodynamics, but is sensitive to changes in vascular tone and has not been validated under conditions of changing hemodynamics. Furthermore, PCCO requires calibration for the individual vascular impedance by transpulmonary thermodilution CO (TPCO), and the required frequency of recalibration to maintain accurate measurements, especially during changing conditions, has not been confirmed. We compared PCCO measurements of CO with TPCO and continuous and bolus pulmonary artery CO (CCO and BCO, respectively) during conditions of uncontrolled hemorrhage and resuscitation with norepinephrine.

METHODS: Thirteen pigs were anesthetized and instrumented for determination of CO by BCO and CCO, respectively, as well as bolus TPCO and PCCO. Uncontrolled hemorrhage was accomplished by liver incision. When mean arterial blood pressure was <25 mm Hg, or heart rate declined progressively to <20% of its peak value, vasopressor therapy was started. TPCO and BCO were performed after induction of anesthesia and 15 min after start of therapy, and PCCO and CCO were obtained repeatedly. CO measurements were compared using Bland-Altman analysis.

RESULTS: Mean arterial blood pressure, CO and systemic vascular resistance decreased after hemorrhage (P < 0.001 and <0.01, respectively). Bias and limits of agreement between CCO and PCCO (0.54 L/min; 1.46 L/min) increased after hemorrhage (–3.49; 6.12) and further deteriorated after norepinephrine administration (–8.01; 9.9). After recalibration, bias and limits of agreement returned to –0.51 and 1.28.

CONCLUSIONS: PCCO needs frequent recalibration during hemorrhage and after vasopressor administration.

 

长期机械通气下丙酚镇静家兔的器官毒性和死亡率

Organ Toxicity and Mortality in Propofol-Sedated Rabbits Under Prolonged Mechanical Ventilation

Petros Ypsilantis, DVM, PhD*#, Maria Politou, MD*#, Dimitrios Mikroulis, MD, PhD{dagger}, Michail Pitiakoudis, MD, PhD*, Maria Lambropoulou, MD, PhD{ddagger}, Christina Tsigalou, MD, Vasilios Didilis, MD, PhD{dagger}, Georgios Bougioukas, MD, PhD{dagger}, Nikolaos Papadopoulos, MD, PhD{ddagger}, Constantinos Manolas, MD, PhD||, and Constantinos Simopoulos, MD, PhD*

From the *Laboratory of Experimental Surgery and Surgical Research, {dagger}Cardiothoracic Surgery Clinic, {ddagger}Laboratory of Histology and Embryology, and ||First Clinic of Surgery, School of Medicine, Democritus University of Thrace, Alexandroupolis, Greece; and §Laboratory of Biochemistry, University General Hospital of Alexandroupolis, Alexandroupolis, Greece. #These authors contributed equally to this work.

Anesth Analg 2007;105:155-166

 

背景ICU病人长期大剂量应用丙酚可引起丙酚输注综合症。在本实验中我们研究了大剂量丙酚镇静下长期机械通气家兔的器官毒性和死亡率并测定丙酚脂质载体在其中的作用。

方法:18只健康雄性家兔行气管插管,镇静分别采用2%丙酚(P组)、七氟醚(S组)或七氟醚合并10%英脱利匹特(SI组)。镇静时间持续48小时或直至家兔死亡(P组)或为P组最长生存时间(S组和SI组)。丙酚初始输注速度为20 mg · kg–1 · h–1,七氟醚初始浓度为1.5%,根据需要调以保持一标准镇静水平。采系列血样标本行血生化分析,家兔尸体解剖时对心、肺、肝、胆、肾、膀胱股四头肌行组织学检查。

结果:P组死亡率为100%(生存时间,2638h),而S组和SI组死亡率为0。初始丙酚输注速度须增至65.7 ± 4.6 mg · kg–1 · h–1而七氟醚浓度须增至4%。P组和SI组血清肝能指标、血脂和肌酸激酶显著升高((P < 0.05),仅P组有乳酸盐水平升高,而所有组血淀粉酶均升高。组织学检查显示:P组家兔具有心肌炎、间质性肺炎肺水肿、肝炎、肝脂肪变性局灶肝坏死、胆管炎、胆坏死、急性肾小管坏死、膀胱皮细胞局灶缺失骨骼肌横纹肌溶解;S组家兔仅有轻度支气管炎肝肾初期炎症反应;SI组家兔具有轻度支气管炎、肝脂肪变性、肝炎胆、肾脏、膀胱初期炎症反应。

结论:对接受长期机械通气的家兔大剂量持续输注2%丙酚进行镇静可导致致命的多器官能衰竭综合症,类似于人类丙酚输注综合症。且记录到包括肺、肝胆膀胱损害的这个新发现。丙酚脂质载体在此综合征的表现中作用较小。研究证实七氟醚是长时间镇静的安全替代药品。

(周雅春 马皓琳 李士通 校)

BACKGROUND: Prolonged administration of propofol at large doses has been implicated in propofol infusion syndrome in intensive care unit patients. In this study we investigated organ toxicity and mortality of propofol sedation at large doses in prolonged mechanically ventilated rabbits and determined the role of propofol's lipid vehicle.

METHODS: Eighteen healthy male rabbits were endotracheally intubated and sedated with propofol 2% (Group P), sevoflurane (Group S) or sevoflurane while receiving Intralipid 10% (Group SI). Sedation lasted 48 h or until death (Group P) or the maximum surviving period of Group P (Groups S and SI). The initial propofol infusion rate (20 mg · kg–1 · h–1) or sevoflurane concentration (1.5%) was adjusted, if needed, to maintain a standard level of sedation. Blood biochemical analysis was performed in serial blood samples and histologic examination in the heart, lungs, liver, gallbladder, kidneys, urinary bladder, and quadriceps femoris muscle at autopsy.

RESULTS: The mortality rate was 100% (surviving period, 26–38 h) for Group P, whereas 0% for Groups S and SI. The initial propofol infusion rate had to be increased up to 65.7 ± 4.6 mg · kg–1 · h–1 and sevoflurane concentration up to 4%. Serum liver function indices, lipids and creatine kinase were significantly increased (P < 0.05) in Groups P and SI and lactate was increased only in Group P, whereas amylase was increased in all groups. In Group P, histologic examination revealed myocarditis, pulmonary edema with interstitial pneumonia, hepatitis, steatosis, and focal liver necrosis, cholangitis, gallbladder necrosis, acute tubular necrosis of the kidneys, focal loss of the urinary bladder epithelium, and rhabdomyolysis of skeletal muscles; in Group S, low-grade bronchitis and incipient inflammation of the liver and the kidneys; and in Group SI, low-grade bronchitis, liver steatosis and hepatitis, and incipient inflammation of the gallbladder, kidneys, and urinary bladder.

CONCLUSIONS: Continuous infusion of 2% propofol at large doses for the sedation of rabbits undergoing prolonged mechanical ventilation induced fatal multiorgan dysfunction syndrome similar to the propofol infusion syndrome seen in humans. Our novel findings including lung, liver, gallbladder, and urinary bladder injury were also noted. The role of propofol's lipid vehicle in the manifestation of the syndrome was minor. Sevoflurane proved to be a safe alternative medication for prolonged sedation.


基于三维计算机断层摄影的经锁骨途径右锁骨下静脉穿刺新方法

A Novel Supraclavicular Approach to the Right Subclavian Vein Based on Three-Dimensional Computed Tomography

Chul-Woo Jung, MD*, Jeong-Hwa Seo, MD*, Whal Lee, MD{dagger}, and Jae-Hyon Bahk, MD*

From the Departments of *Anesthesiology and Pain Medicine, and {dagger}Radiology, Seoul National University Hospital, Seoul, Korea.

Anesth Analg 2007;105:200-204

 

背景资料:我们用三维(3-D)计算机断层摄影术来开发了经锁骨途径到达锁骨下静脉的新方法,以最小化从穿刺点到静脉的距离。

方法:回顾性地调查了45个正常体格成年病人在计算机三维断层摄影术资料。假设胸锁乳突角为皮肤穿刺点,而在第一肋的锁骨下静脉为穿刺目标,在模拟三维影像测定最好的穿刺角度。从这些影像开发了一个三维视频来解穿刺途径。在初步的研究中,我们前瞻性地在60例需要中心静脉置管的正常体格成年病人中验证了此穿刺途径。并记录尝试次数、成率和并发症。

结果:最佳的穿刺角度是内斜10.6° ± 5.3°与穿刺点皮肤呈35.4° ± 12.5°。估计锁骨下静脉距离穿刺点的深度为13.7 ± 3.1 mm。在初步的研究中,用探寻针的第一次尝试成果率为87%,置管的总成率为100%,且无并发症。

结论:经锁骨穿刺到锁骨下静脉是中心静脉穿刺置管术的一个简单方法,这个初步研究提示了这种方法是相当安全的。在补充资料中以视频来生的解穿刺途径是可行的。

(沈浩 马皓琳 李士通 校)

BACKGROUND: We used three-dimensional (3-D) computed tomography to develop a novel supraclavicular approach to the subclavian vein that minimizes the distance from insertion site to the vein.

METHODS: Forty-five adult patients with normal body build were retrospectively included in the 3-D computed tomography investigation. Assuming that the clavisternomastoid angle was the skin entry point, and that the subclavian vein on the first rib was a target, the optimal angle of approach was measured on the simulated 3-D images. A 3-D video was developed from these images to explain the approach. In a pilot study, we prospectively tested this approach in 60 adult patients with normal body build requiring central venous catheterization. The number of attempts, success rate, and complications were noted.

RESULTS: The optimal angle of approach was 10.6° ± 5.3° medially and 35.4° ± 12.5° posteriorly from the skin entry point. The estimated depth of the subclavian vein was 13.7 ± 3.1 mm. During the pilot study, the first trial with a finder needle was successful in 87% of patients and the overall success rate of catheterizations was 100% without complications.

CONCLUSIONS: The proposed supraclavicular approach to the subclavian vein is a simple method of central venous catheterization. The pilot study suggests the method is reasonably safe. The video explaining the approach graphically is available in the supplementary material.

 

 

预防性给予多模式镇痛用药法对行前交叉韧带重建术的门病人的远期预后的影响

The Effect of Initiating a Preventive Multimodal Analgesic Regimen on Long-Term Patient Outcomes for Outpatient Anterior Cruciate Ligament Reconstruction Surgery

Scott S. Reuben, MD*{dagger}, and Evan F. Ekman, MD{ddagger}

From the *Department of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts; {dagger}Department of Anesthesiology and Pain Medicine, Tufts University School of Medicine, Boston, Massachusetts; and {ddagger}Southern Orthopaedic Sports Medicine, Parkridge Surgery Center, Columbia, South Carolina.

Anesth Analg 2007;105:228-232

 

背景:不能缓解的术后疼痛可能会损害复原,延缓康复,并导致不良结局。预防性的多模式镇痛术可能会改善术后的远期预后。

方法:我们对行前交叉韧带重建术的连续200名患者,于术前1-2小时给予扑热息痛1000mg并随机给予塞来考昔400mg或者安慰剂。所有的患者均给予关内镇痛药,并且在手术关应用外部冷却系统。出院后,病人遵医嘱在术后14天每6 小时服用扑热息痛1000mg,以每12 小时服用塞来考昔400mg或相对应的安慰剂。所有病人均登记入一个康复促进方案。术后6个月后,评价患者膝关活的等级,髌股的并发症的发生率,包括:膝关前部的疼痛、屈曲性挛缩、四头肌无和复合区域性疼痛综合征。

结果:对照组较塞来考昔组有更多的病人存在髌股并发症(P = 0.001),包括膝关前部的疼痛(14/96; 15%)(4/95; 1%)、复合区域性疼痛综合征(7/96; 7%)(1/95; 1%)、屈曲性挛缩(9/96; 9%)(2/95; 2%)以瘢痕组织需要再次关镜检查(8/96; 8%)(2/95; 2%)。塞来考昔组有更多的病人恢复到较高的膝关活等级(84%65%(P < 0.01),能够参到更大的活强度(P < 0.02),并且能恢复全部的体育活(P < 0.05)

结论:给予塞来考昔作为预防性多模式镇痛术的一个组成部分,对行前交叉韧带重建术的病人,会减少远期的髌股并发症的发生,且提高恢复到受伤前的运水平的可能性。

(黄丽娜 李士通 马皓琳 校)

 

BACKGROUND: Unrelieved postoperative pain may impair rehabilitation, delay recovery, and result in poor outcomes. Preventive multimodal analgesic techniques may improve long-term outcome after surgery.

METHODS: We randomized 200 consecutive patients to receive acetaminophen 1000 mg and either celecoxib 400 mg or placebo 1–2 h before anterior cruciate ligament surgery. All patients received intraarticular analgesics and had an external cooling system applied to the operative knee. After discharge patients were instructed to take acetaminophen 1000 mg every 6 h and either celecoxib 200 mg every 12 h or matching placebo for the first 14 days postoperatively. All patients were enrolled in an accelerated rehabilitation program. Six months postoperatively, the level of activity was assessed, as was the presence of patellofemoral complications including: anterior knee pain, flexion contracture, quadriceps weakness, and complex regional pain syndrome.

RESULTS: More patients in the control group developed patellofemoral complications compared to the celecoxib group (P = 0.001) including anterior knee pain (14/96; 15%) vs (4/95; 1%), complex regional pain syndrome (7/96; 7%) vs (1/95; 1%), flexion contractures (9/96; 9%) vs (2/95; 2%), and scar tissue requiring re-arthroscopy (8/96; 8%) vs (2/95; 2%) respectively. More patients in the celecoxib group returned to a higher activity level (84% vs 65%) (P < 0.01), were able to participate at a more intense level (P < 0.02), and return to full sports activity (P < 0.05).

CONCLUSIONS: The administration of celecoxib as a component of a preventive multimodal analgesic technique for anterior cruciate ligament reconstruction reduces long-term patellofemoral complications and increases the likelihood of returning to a preinjury level of activity.


大鼠关腔内注射α2肾腺素受体激剂Fadolmidine对关疼痛的外周性制作用

Peripheral Suppression of Arthritic Pain by Intraarticular Fadolmidine, an {alpha}2-Adrenoceptor Agonist, in the Rat

Osei B. Ansah, DVM, PhD, and Antti Pertovaara, MD, PhD

From the Biomedicum Helsinki, Institute of Biomedicine/Physiology, University of Helsinki, Helsinki, Finland.

Anesth Analg 2007;105:245-250

 

背景:以往的研究认为激外周α2和阿片类受体可以减少关疼痛。Fadolmidine是一种高选择性α2肾腺素能受体激剂,外周给药后只有极少部分进入中枢。我们在实验性单关炎中评估fadolmidine的外周伤害性作用特点以外周阿片类受体对其伤害作用的潜在影响。

方法:在大鼠膝关炎诱发单关炎后,我们测定了反复活膝关发出声音的频率。给大鼠发炎侧或对侧关腔内注射Fadolmidine和可乐定。用皮下(s.c.)注射α2肾腺素受体拮剂阿替美唑和关腔内注射一种不会穿透血脑屏障的阿片类受体拮剂蛋氨酸纳洛酮来试图逆转fadolmidine引起的作用。

结果:Fadolmidine呈剂量依赖地降低对发炎侧膝关活的发声反应,且患侧给药后的效应明显较对侧给药的效应强烈。可乐定同样剂量依赖地降低发声反应,但是患侧给药与对侧给药后的效应之间无明显差别。Fadolmidine诱发的伤害作用可以被皮下给予阿替美唑拮。而且发炎侧而不是对侧关腔给予蛋氨酸纳洛酮也可以拮fadolmidine的伤害作用,这个作用与fadolmidine是在发炎侧还是对侧关腔给药无关。

结论:大鼠关腔内给予fadolmidine可以明显制关炎导致的疼痛相关性行为,这可能是由于fadolmidine选择性激α2肾腺素受体和阿片类受体。

(张莹 马皓琳 李士通校)

BACKGROUND: Earlier results suggest that peripheral {alpha}2-adrenoceptors and opioid receptors may reduce arthritic pain. Fadolmidine is a highly selective {alpha}2-adrenoceptor agonist that has only limited central access after peripheral administration. We assessed the peripheral antinociceptive properties of fadolmidine and the potential contribution of peripheral opioid receptors to its antinociceptive effect in experimental monoarthritis.

METHODS: After induction of monoarthritis in the knee joints of rats, we determined the frequency of vocalization induced by repetitive movement of the knee joint. Fadolmidine and clonidine were administered intraarticularly ipsi- or contralateral to the inflamed joint. Reversal of the fadolmidine-induced effect was attempted with subcutaneous (s.c.) administration of atipamezole, an {alpha}2-adrenoceptor antagonist, and intraarticular administration of naloxone methiodide, an opioid receptor antagonist that does not penetrate the blood–brain barrier.

RESULTS: Fadolmidine produced a dose-dependent attenuation of the vocalization response to movement of the inflamed knee joint, and this effect was significantly stronger after ipsi- than contralateral drug administration. Clonidine also produced a dose-dependent attenuation of the vocalization response, but this effect was not significantly different after ipsi- versus contralateral drug administration. Fadolmidine-induced antinociception was reversed by s.c. administration of atipamezole. Furthermore, intraarticular administration of naloxone methiodide into the inflamed, but not the contralateral, joint reversed the antinociceptive effect of fadolmidine independent of whether fadolmidine was administered into the inflamed or contralateral joint.

CONCLUSIONS: In rats, intraarticular administration of fadolmidine provides a marked suppression of pain-related behavior in arthritis, due to a selective action on peripheral {alpha}2-adrenoceptors and opioid receptors.


骶骨旁坐骨神经阻滞:是否引出的运反应就预示着阻滞成呢?

Parasacral Sciatic Nerve Block: Does the Elicited Motor Response Predict the Success Rate?

Bénédicte S. Hagon, MD, Omar Itani, MD, Jawad Hosseini Bidgoli, MD, and Philippe J. Van der Linden, MD, PhD

From the Department of Anesthesiology CHU-Brugmann—Huderf, Brussels, Belgium.

Anesth Analg 2007;105:263-266

 

背景:在这项前瞻性、随机、双盲研究中,我们比较了胫神经和腓神经诱发的运反应引出对于骶骨旁进针法坐骨神经阻滞的有效性的预示程度。

方法:26ASA I–III 排定行择期下肢手术的病人接受骶骨旁坐骨神经阻滞,用神经刺激方法随机分别探测胫神经运反应(n = 14)和腓神经运反应(n = 12)。达到诱发的运反应后,含有肾腺素的10 mL 2% 利多卡因和10 mL 0.75% 罗哌卡因合液(肾腺素的实际终浓度为 1/160,000)通过针缓慢注射。由一位不知道诱发的运反应的麻醉医师在30分钟内每隔5分钟评估一次感觉和运阻滞。如果局麻药注射30分钟后阻滞仍未完全,就认为神经阻滞失败,添全身麻醉。

结果:两组间相比,完成阻滞的时间最小和最大的刺激均无差异。胫神经达到完全阻滞的成率要显著高于腓神经组(11/142/12P = 0.002)。

结论:在骶骨旁坐骨神经阻滞中,引出胫神经运反应比引出腓神经运反应预示着更高的神经阻滞成率。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: In this prospective, randomized, double-blind study, we compared the tibial and the peroneal evoked motor response with regard to efficacy of sciatic nerve block using the parasacral approach.

METHODS: Twenty-six ASA I–III patients scheduled for elective lower limb surgery were randomized to receive a parasacral sciatic block, using a nerve stimulator technique seeking either a tibial (n = 14) or peroneal (n = 12) motor response. After the evoked motor response was obtained, a solution of 10 mL 2% lidocaine with epinephrine and 10 mL 0.75% ropivacaine (actual final concentration of epinephrine, 1/160,000) was slowly injected through the needle. Sensory and motor blocks were assessed every 5 min for 30 min by an anesthesiologist blinded to the elicited motor response. If the block was not complete 30 min after injection of the local anesthetics, it was considered as failed, and general anesthesia was supplemented.

RESULTS: Time to perform the block and level of minimal and maximal stimulation were not different between groups. The success rate of complete block was significantly higher in the tibial compared to the peroneal group (11 of 14 vs 2 of 12; P = 0.002).

CONCLUSIONS: Eliciting a tibial motor response predicts a higher success rate than eliciting a peroneal motor response with parasacral sciatic nerve block.