Anesthesia & Analgesia

July 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:

體外迴圈,溶血與硝普Ö誘發的氰化物產物

丁震敏 陳傑

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:

七氟醚和舒太尼嬰兒麻醉中經食管超聲和硬膜外麻醉的血流動學效應

王時來譯 薛張綱校

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.

連續監測動態肺順應性使檢測嬰兒兒童支氣管內插管成為可能

邱郁薇 馬皓琳 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.

瑞太尼減少小兒患者喉罩喉管置入所需的異丙酚EC50的一

顧新宇 陳傑

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:

日間手術術後恢復情況評ÖÖ法的系統回顧

陳勇柱譯 薛張綱校

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:

嗎啡在術後患者:代謝產物的藥代動學和藥效動學

唐李雋 李士通 馬皓琳

Morphine in Postoperative Patients: Pharmacokinetics and Pharmacodynamics of Metabolites

Jean Xavier Mazoit, Karin Butscher, and Kamran Samii

Anesth Analg 2007 105: 70-78.

伴有高碳酸血症過度通氣情況下七氟醚與地氟醚的快速蘇醒

印潔敏 陳傑

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.

笑氣短暫的減少老Ö鼠皮質蛋氨酸合酶但會造成持Ö的記憶缺陷

周時蓓 薛張綱校

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在酒精誘導的大鼠急性神經行為Ö中的作用

顏濤 馬皓琳 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.

異氟醚對血管張素II誘導的血管收縮制作用的機制與七氟醚不同

衛紅 陳傑

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.

二氧化碳對大鼠的麻醉Ö性

施譯 薛張綱校

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:

出血時與應用升壓藥後脈搏周線衍生成的心排血量的可靠性

胡Ö 馬皓琳 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Ö水和高張生理Ö水對於局部血流和氧輸送的影響

李惟一 陳傑

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.

由一種新的指示器和由傳統的金屬絲引導的經皮環甲膜穿刺術在人體模型的比較

陳佳莉譯 薛張剛校

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.

長期機械通氣下丙酚鎮靜家兔的器官毒性和死亡率

周雅春 馬皓琳 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:

瑞太尼對常人大腦血流量的影響:量和載脂蛋白E基因

鄭麗 陳傑

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:

硬膜外注射單量控釋嗎啡(DepoDurTM)與傳統嗎啡用於剖宮產術後鎮痛的比較

陳珺珺譯 薛張綱校

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:

基於三維電腦斷層攝影的經鎖骨途徑右鎖骨下靜脈穿刺新Ö法

沈浩 馬皓琳 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:

疼痛治療:基本的人

張美榮 陳傑

Pain Management: A Fundamental Human Right (Review Article)

Frank Brennan, Daniel B. Carr, and Michael Cousins

Anesth Analg 2007 105: 205-221.

評Ö塞來昔布(celecoxib)作為門診前交叉韌帶重建術多模式鎮痛組成部分的鎮痛效能

璿譯 薛張綱校

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.

預防性給予多模式鎮痛用藥法對行前交叉韌帶重建術的門診病人的遠期預後的影響

黃麗娜 李士通 馬皓琳

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.

腰椎間盤切除術患者圍術期口服羥考酮控釋型下術後嗎啡需求量、疼痛評分以副作用

宋翠俠 陳傑

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.

肺葉切除術後肺能:一項隨機雙盲試驗比較胸科手術後硬膜外羅呱卡因/舒太尼與靜脈輸注嗎啡用於病人自控鎮痛

王光妍 薛張綱校

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.

 

大鼠關節腔內注射α2腎腺素受體激動Fadolmidine對關節疼痛的外周性制作用

張瑩 馬皓琳 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.

硬膜外使用氟呱利多的止癢與鎮吐效果:三種不同給藥Ö式的比較

周懿Ö 陳傑

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.

膝關節術後鎮痛:三種不同濃度的羅呱卡因對連續股神經阻滯的比較

儷譯 薛張綱校

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.

骶骨旁坐骨神經阻滯:是否引出的運動反應就預示著阻滯成呢?

黃佳佳譯,馬皓琳 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.

舌咽神經阻滯對扁桃體切除術後疼痛的緩解作用:咽反射的制程度作為臨指標的重要性

Ö慧 陳傑

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.

 

七氟醚和舒太尼嬰兒麻醉中經食管超聲和硬膜外麻醉的血流動學效應

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:普遍觀點認為兒科硬膜外麻醉可以提供兒童穩定的血流動學。然而,與成人的相關資料比較而言,ÖÖ沒有關於嬰兒硬膜外麻醉對心排量影響的資料。

Ö法:我們對14<10kg接受Ö部手術的嬰兒進行前瞻性研究,運用經食道超聲檢測心排量。用七氟醚進行常規麻醉維持,在用0.25%的布比卡因和1:200,000的腎腺素以0.75ml/kg的量進行腰椎連硬外麻醉的前後用經食道超聲監測心排量。在開始硬膜外麻醉前,開始後5分鐘,15分鐘和20分鐘分別監測心排量、動脈壓和心率。

結果:對於用七氟醚和舒太尼進行麻醉的患者,硬膜外可以引起每搏量增 29(P<0.0001)和心率降低13%(P<0.0001)。硬膜外麻醉還能分別引起收縮壓、舒張壓、Ö均動脈壓和全身血管阻下降11%18%15%25%。相反的,心排量保持不。

結論:觀察到的每搏量的增Ö許可以用硬膜外麻醉引起交感神經的阻滯導致後負荷的降低來解釋。這些結果證實硬膜外麻醉可以提供<10kg嬰兒穩定的血流動學,並且支持硬膜外麻醉在這一兒科人群中的應用。

(王時來譯 薛張綱校)

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.

 

 

日間手術術後恢復情況評ÖÖ法的系統回顧

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:日間手術的死亡率其發生是很罕見的,因此病人的生活品質(即出院後恢復正常的活動能)應當是日間手術和麻醉後的考慮的最終原則Ö一。我們通過對日間手術恢復品質的評估Ö法的系統回顧,從而為相關的研究和品質評估提供有選擇性的合適Ö法。Ö法:對MEDLINE EMBASECINAHLHAPI PsycINFOWeb of Science Search HistoryBiosys Previews SearchHealthStar, ASSIA中的文獻系統性搜索,通過鑒別評Ö病人預後的Ö法來評Ö日間手術麻醉術後恢復狀況。評Ö指標應具有八項標準:適用性,可靠性,有效性,反應性,準確性,配合性,可受性,可行性。結果:有7篇符合標準的文章被選中。鑒別Ö法的品質是可的。結論:40條恢復品質記錄中僅有一個Ö法符合所有八項標準,然而這一Ö法不是Ö別針對日間手術和麻醉的。

(陳勇柱譯 薛張綱校)

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.

 

 

笑氣短暫的減少老Ö鼠皮質蛋氨酸合酶但會造成持Ö的記憶缺陷

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:笑氣是一種常用的麻醉,能制蛋氨酸合酶的活性,而這種酶與甲基化作用,DNA的合成與修復有關。這種制作用觸發無論是發育中還是成熟的大腦中負責空間記憶的區域的神經元泡的形成與退化,提高了笑氣對於學習能有持Ö的影響的可能性。Ö法:為了測試這種可能性,我們隨機的將18月齡的費希爾344大鼠分到2組(每組n=13),接受4小時70%笑氣+30%氧氣,70%氮氣+30%氧氣(對照組),並且用一個14天前曾經走過的12彎的放射狀的迷宮在吸入笑氣後2天測試大鼠的記憶。此外,在結束暴露於笑氣後的即刻和2天后,我們用標準的測定法測量在其他Ö面都受到相同對待的大鼠的肝和大腦皮質的蛋氨酸合酶的活性(每組每個時間點n=3)。結論:肝臟和皮質的蛋氨酸合酶在笑氣麻醉期間是受到制的(6%23%分別在肝臟和大腦皮質較Ö對照組,P < 0.01)。肝臟的蛋氨酸合酶的活性在2天后仍然受到制,然而皮質的蛋氨酸合酶活性已經恢復。對照組和笑氣組大鼠在錯誤率Ö面並沒有差別。然而,曾經暴露於笑氣的的大鼠用了更多的時間去走完迷宮,並且更早的做出第一次錯誤的選擇(P < 0.05)。結論:用70%的笑氣進行鎮靜明顯的短暫的制老Ö大鼠大腦皮質蛋氨酸合酶的活性,但是引起持Ö的空間活動記憶的損害。

(周時蓓 薛張綱校)

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.

 

 

二氧化碳對大鼠的麻醉Ö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:當二氧化碳分壓超過95mmHg時二氧化碳可以降低氟烷的MAC.我們試圖用大鼠來證實Ö個吸入麻醉的這種Ö性.Ö法:Ö組各8只小鼠用氟烷、異氟烷、地氟烷進行麻醉.每個麻醉都測定MAC值以隨著吸入二氧化碳濃度升高的化.第四組大鼠單獨用二氧化碳進行麻醉並測定MAC.結果:吸入二氧化碳濃度的升對所有吸入麻醉的MAC值產生量依賴的線性下降關係.隨著二氧化碳的消除,異氟烷、地氟烷的MAC值Ö回到原先的數值.由測得的資料倒推出當吸入麻醉的濃度為0%,二氧化碳的MAC值大約為50%一個大氣壓.單獨吸入時,二氧化碳被證明是致命的.結論:和狗不同,大鼠的二氧化碳MAC值不會因氟烷、異氟烷、地氟烷激起閾值反應,大鼠二氧化碳的ED50Ö比報導的狗大約高50%.

(施譯 薛張綱校)

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.

 

 

由一種新的指示器和由傳統的金屬絲引導的經皮環甲膜穿刺術在人體模型的比較

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:經皮環甲膜穿刺術是在無法插管、無法通氣的情況下的救生Ö法。在這項研究中,我們在人體模型比較了用一種新的指示器引導和用金屬絲引導的環甲膜穿刺術的插入時間。Ö法:這項交叉試驗研究比較了由指示器引導和由金屬絲引導的環甲膜穿刺術的插入時間和成率。在一項視聽Ö訓課程後,64個麻醉醫生每人分別用2種裝置做5次環甲膜穿刺術。成的穿刺定義為將裝置插入到正確的解剖位置。5次實驗的兩種裝置的插入時間和成率用Ö差分析、成對t核對總和{chi}2檢驗比較。結果:由指示器引導的裝置比起由金屬絲引導的裝置插入時間快(32.6±14.9秒比42.3±12.5秒,P<0.001)而成率相似(95%比93.1%)。反復的嘗試能夠提高兩種裝置的使用術。其中用指示器引導的穿刺中有4次(1.3%)插在了氣管腔的前面或後面,而用金屬絲引導的卻沒有(P0.12)。參與者在臨急環境下主觀會更多地選擇使用金屬絲引導的穿刺裝置而不是指示器引導的裝置(59%比31%,P<0.001)。結論:在人體模型,指示器引導的環甲膜穿刺術比金屬絲引導的時間要快,但是成率相似。更多的參與者在臨急環境下主觀地會選擇使用金屬絲引導的穿刺裝置。

(陳佳莉譯 薛張剛校)

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.

 

 

硬膜外注射單量控釋嗎啡(DepoDurTM)與傳統嗎啡用於剖宮產術後鎮痛的比較

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:單量硫酸嗎啡製硬膜外注射在剖宮產術後鎮痛效果良好,但是這種效果僅限於術後第一天。在最近的三相研究中,與傳統的硬膜外嗎啡製相比,控釋嗎啡製(EREM)的效果更好,可以延長剖宮產術後鎮痛的時間。然而這項研究計畫並沒有考慮到使用非甾體類炎藥,術後使用不同鎮痛藥,並且呼吸制的監測和處理沒有標準化。我們研究的目的是比較使用傳統嗎啡製和EREM用於剖宮產術後鎮痛,術後鎮痛藥的用量,疼痛指數和副作用。Ö法:70名準備擇期行剖宮產術的健康臨產婦入了這項隨機、雙盲研究。產婦進行腰硬聯合麻醉,在鞘內注射12mg布比卡因和10mcg太尼。在Ö帶綁完後,給予硬膜外給予單量嗎啡4mgEREM 10mg。術後,所有的病人每6小時給予布洛口服。在疼痛時候口服羥考酮和靜脈注射嗎啡。術後48小時所有的病人監測氧飽和度和呼吸監測。

結果:單量給予EREM可以Ö善靜息和活動時的疼痛指數。相比于傳統的硬膜外給予嗎啡,EREM在術後48小時追的阿片類藥物用量從17mg降至10mg。兩種藥物在副作用Ö面時相似的。結論:與傳統硬膜外注射嗎啡相比,剖宮產術後給予EREM可以提供更好和更長時間的鎮痛效果,並且並沒有明顯增副作用。(陳珺珺譯 薛張綱校)

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.

 

 

評Ö塞來昔布(celecoxib)作為門診前交叉韌帶重建術多模式鎮痛組成部分的鎮痛效能

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:環氧化酶2制可能在矯形外科術後的多模式鎮痛中起到重要作用。作者檢驗了塞來昔布作為門診前交叉韌帶(ACL)手術多模式鎮痛治療成分Ö一的鎮痛效能。Ö法:200名連續的病人隨機分為兩組,分別在ACL術前1-2h接受1000mg對Ö醯胺基酚400mg塞來昔布或安慰。所有病人都接受關節內鎮痛(布比卡因、可樂定和嗎啡)術側關節外部降溫措施。出院後,要求病人在術後最初的14天內,每6h服用對Ö醯胺基酚1000mg,每12h服用塞來昔布200mg或安慰。如鎮痛不夠可用羥考酮5-10mg補救。結果:塞來昔布組的病人在恢復室感覺到的疼痛較少(P<0.01),術後阿片類鎮痛用量少(P<0.001)。這些病人術後噁心嘔吐的發生率低(P<0.05)且回家早(P<0.05)。在家中,塞來昔布組的病人無論在靜息(P<0.05)或運動(P<0.01)時均報較低的疼痛評分,術後各時間點羥考酮的用量都較少。結論:圍術期應用塞來昔布降低術後疼痛、阿片類藥物用量、術後噁心嘔吐恢復室停留時間。這些結果支持將塞來昔布作為ACL手術多模式鎮痛的一個組成部分

(羅 璿譯 薛張綱校)

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.

 

 

肺葉切除術後肺能:一項隨機雙盲試驗比較胸科手術後硬膜外羅呱卡因/舒太尼與靜脈輸注嗎啡用於病人自控鎮痛

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:雖然目前認為胸科手術後胸段硬膜外鎮痛(TEA)優於靜脈輸注嗎啡,一些研究明確指出,TEA使用局麻藥聯合阿片類藥物對於肺能有Ö善作用。Ö法:在這項前瞻性的、隨機雙盲研究中,我們對TEA使用 羅呱卡因/舒太尼(TEA組)和靜脈輸注嗎啡(IV組)進行比較,它們會影響到68位患者的術後疼痛以肺能。疼痛的強度,FVCFEV1FEV1/FVC比值,用呼氣流速,鼻吸氣壓作為呼吸肌強度的指標,從術後的第一天到第四天將對這些指標進行評估。結果:在靜息以咳嗽時,TEA組的疼痛緩解程度更好( P < 0.001)TEA組的FVCFEV1的減退程度較IV組少(分別為P < 0.001 and P = 0.003)     。鼻吸氣壓,兩組的FEV1/FVC比值和呼氣流速減退程度相似。住院死亡率以術後肺部併發症,在兩組中沒有明顯區別。結論:肺葉切除術後,TEA組提供了顯著的肺能恢復,同時術後鎮同Ö較全身使用嗎啡好,雖然可能會發生一定程度的肋間肌運動阻滯。

(王光妍 薛張綱校)

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.

 

 

膝關節術後鎮痛:三種不同濃度的羅呱卡因對連續股神經阻滯的比較

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:對於全膝置換術後最為有效的輸注羅呱卡因的濃度目前尚沒有明確的規定。我們近期設計了這樣一個研究來比較羅呱卡因在三個不同的濃度(0.1,0.2.3%)來評Ö鎮痛效果,通過對患者實行聯合股神經和坐骨神經阻滯並採用連續輸注調節器來實現。第二個研究目的是評Ö其不良反應(如運動阻滯),復原指數以羅呱卡因的血漿濃度。Ö法:122名患者在全麻複合區域股神經連續阻滯下行全膝置換術,區域阻滯的羅呱卡因濃度分別為0.1,0.20.3%。連續輸注的的首為30ml0.5%羅呱卡因打入股神經阻滯導管,坐骨神經導管設定目標為動態疼痛分數達40mm。疼痛和不良反應於氣管導管拔除後1小時以術後的第一,第二,第三,第四和第五天評定。羅呱卡因的血漿濃度在開始後的244872小時測定,實驗濃度為0.2%0.3%的羅呱卡因要在股神經阻滯結束後的24小時再測定一次。結果:0.1%濃度的羅呱卡因的鎮痛效果不太有效。0.2%0.3%濃度的羅呱卡因的鎮痛效果相當。0.2%0.3%濃度下最大輸注速率分別為15.3913.77ml/h。在實驗過程中兩者在運動阻滯,鬆弛或羅呱卡因的低於中毒量的血漿濃度ÖÖ面沒有顯著差異。結論:0.2%0.3%濃度的羅呱卡因在鎮痛效果Ö面兩者相仿。首的輸注速率應該調節在15ml/h從而可以獲得有效的鎮痛。

( 儷譯 薛張綱校)

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.

 

體外迴圈,溶血與硝普Ö誘發的氰化物產物

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:氰化物中毒是給予硝普鈉後的一個併發症,心臟手術可能提高氰化物中毒的危險,因為體外迴圈(CPB)期間的溶血可能促使硝普鈉釋放游離氰化物。

Ö法:作者收集25個心臟手術患者CPB期間的血樣標本,該標本用於分析游離血紅蛋白濃度與測定游離氰離子。

結果:整個CPB期間溶血導致血漿游離血紅蛋白濃度提高Ö均速率0.27 mg·dL–1·min–1P0.001)。血漿標本中入硝普鈉後產生的游離氰化物濃度與血漿游離血紅蛋白濃度直接相關(P0.001)。

結論:CPB相關的溶血釋放的游離血紅蛋白可促使硝普鈉釋放游離氰化物。本離體試驗提示心臟手術患者圍術期給予硝普鈉時,氰化物中毒危險提高。

(丁震敏 陳傑 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.

 

瑞太尼減少小兒患者喉罩喉管置入所需的異丙酚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:異丙酚與瑞太尼是短小手術非肌松下插管可選用的藥物。在本研究中,作者比較了使用和不使用瑞太尼時插入喉罩(LMA)或喉管(LT)所需的異丙酚濃度。

Ö法:選取手術時間<2h的小兒患者,並隨機雙盲分成4組:LMAP組: LMA置入使用異丙酚與Ö水;LTP組: LT置入使用異丙酚和Ö水;LMA-PR 組:LMA置入使用異丙酚和瑞太尼7.5 ng/mLLT-PR組: LT置入使用異丙酚和瑞太尼7.5 ng/mL。麻醉使用靶控輸注異丙酚STELPUMP程式下瑞太尼。用於插入氣道裝置所需的異丙酚EC50使用Dixon's下調節法決定。在每組連續的患者中,該患者接受的異丙酚濃度取決於前一個患者的反應,據此增大或減少0.2ug/ml

結果:使用瑞太尼患者,用於插入LMA的異丙酚EC502.57±0.22ug/ml,而插入LT2.59±0.20ug/ml,接受Ö水患者相對應的值為5.45±0.21ug/ml5.58±0.23ug/mln.s.)。接受瑞太尼患者插喉罩條件良好的為64%9/14),插喉管的為79%11/14),接受Ö水患者相對應的值分別為18%2/11)和404/10)。

結論:瑞太尼7.5ug/ml可減少用於氣道插管所需的異丙酚濃度的一提高插管條件。而用於插喉罩和喉管所需的異丙酚濃度相似。

(顧新宇 陳傑 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.


伴有高碳酸血症過度通氣情況下七氟醚與地氟醚的快速蘇醒

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:在異氟醚麻醉中,因高碳酸血症而產生的過度通氣可以令從關閉麻醉蒸發罐(1MAC)至病人睜眼的時間縮短67%

Ö法:在本次研究中作者測定在七氟醚與地氟醚麻醉中是否Ö可使蘇醒時間相應地縮短。

結果:作者發現高碳酸血症產生的過度通氣可以相應地使七氟醚與地氟醚的蘇醒時間分別縮短52%64%(與正常通氣量正常血二氧化碳濃度相比)。

結論:過度通氣可以使肺內的麻醉氣體迅速排出,因而重複呼吸引起的高碳酸血症能夠顯著縮短麻醉蘇醒時間,並在不同溶解度的麻醉藥中產生相應的縮短比例。

(印潔敏 陳傑 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.

 

異氟醚對血管張素II誘導的血管收縮制作用的機制與七氟醚不同

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:血管張素IIAng II)誘導的血管收縮是通過Ca2介導的信號轉導途徑和Ca2致敏機制產生的。作者最近研究了七氟醚制血管張素II誘導的血管收縮,在鼠大動脈Ö滑肌試驗中,它主要是通過制蛋白激酶CPKC)磷酸化來調節肌原纖維Ca2的致敏性,並無細胞內濃度Ca2明顯的Ö。本文研究異氟醚對於血管張素II誘導的血管收縮的制作用機制。

Ö法:通過等矩感測器,螢光計和免疫印跡法研究了異氟醚的血管收縮制作用,Ca2的增和Ang IIPKC磷酸化反應。

結果Ang II在鼠大動脈Ö滑肌引出了短暫的收縮並伴隨Ca2的增多和PKC的磷酸化。異氟醚(1.2%3.5%)濃度依賴性的制血管張素II誘導的鼠大動脈Ö滑肌的血管收縮(在1.2%時P<0.05,在2.3%和3.5%時P<0.01n6)。受Ang II的影響,異氟醚同時Ö影響Ca2的增(在2.3%和3.5%時P<0.01n6),但在3.5%異氟醚下沒有影響Ang II誘導的磷酸化(n=7)。

結論:以結果提示與七氟醚不同,異氟醚對於血管張素II誘導的血管收縮的制效果主要通過Ca2介導的信號轉導途徑的衰減。

(衛紅 陳傑 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Ö水和高張生理Ö水對於局部血流和氧輸送的影響

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:快速輸注大量晶體液以期Ö善生命器官的灌注。然而,這樣的措施對於哺Ö動物局部血流和氧氣輸送的影響還未被研究過。作者比較了生理Ö水和高張生理Ö水(濃度3%)對於正常動物局部血流和氧氣輸送的影響。

Ö法:作者設計了一個隨機,對照試驗,實驗物件為七隻美利奴母。在的體內植入血流分析儀來觀察主動脈,冠狀動脈,腎動脈和腸系膜動脈的血流狀況。動物隨機給於三種處理:對照觀察,生理Ö水(15mih內給於1L)或者3%的Ö水(15min給於300ml),持續監測中心血流和臟器灌注210min

結果:兩種液體在第一小時內都增了心率,心排量,中心靜脈壓、冠脈血流、腸系膜血流和周圍電導(P<0.05)。在第二和第三個小時,都較對照組維持了更大的心排量,外周電導和腸系膜動脈血流(P<0.05,但是差距減小。相反,腎血流未受影響,因為血液稀釋,腎臟的氧氣輸送在第一小時反而減小(p<0.05)。同時,兩組尿量和肌酐清除率都增(p<0.05)。最後,試驗發現,3%的Ö水顯著而短暫的增了血漿鈉和晶體滲透壓。

結論:正常濃度的Ö水和高張Ö水都有相似的系統和局部血流動學影響。他們對腎血流均沒有影響,在增尿量的同時降低了腎臟的氧氣輸送。

(李惟一 陳傑 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.

 

瑞太尼對常人大腦血流量的影響:量和載脂蛋白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:阿片類藥物被認為與大腦緣系統的活動有關,且在動物中可產生神經毒性。緣系統激動模式被認為與載脂蛋白EApoE)等位元基因的分佈情況相關。作者假設在外科手術過程中,小量的瑞太尼激動緣系統,且這一作用與用藥量和ApoE基因有關。

Ö法27ASAI-II的志願者接受四組量持續增大的瑞太尼輸注:00.050.10.2µg · kg–1 · min–1,在輸注期間吸100%純氧。通過搏動的動脈自旋標記形成磁共振成像監測每組全腦血流量,在杏仁核,扣帶回,海馬,腦島,丘腦區域。測定每個受試者ApoE 單核苷酸多態性。

結果:在沒有校正Pco2的情況下,CBF出現顯著的量依賴性增高現象,並且這一現象發生在全腦的各個區域。在通過校正Paco2使全腦CBF正常後,瑞太尼介導的CBF增作用在扣帶回依然存在,但在海馬和杏仁核出現CBF的下降。所有的Paco2校正作用在ApoE單核苷酸多態性存在的情況下被逆轉了。

結論:鎮靜量的瑞太尼同時產生了多種緣系統組Ö的激動和制作用。扣帶回皮質似Ö對瑞太尼的激動作用最為敏感,ApoE似Ö與海馬和杏仁核的激動有關。

(鄭麗 陳傑 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.


疼痛治療:基本的人

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.

 

本文調查了世界範圍的醫學的、倫理的和法律的動態化和所做的都歸因於疼痛治療作為一種人這個概念。這個概念得到了2004國際疼痛研究協會歐洲聯盟(IASP)、國際疼痛研究協會和世界衛生組Ö的“解痛地球日”的支持。作者調查了未減輕的疼痛的三個區域:急性疼痛、慢性非癌性疼痛和癌性疼痛,概括了未處理疼痛的不利的身體的和心理的影響和社會的、經濟的代Ö。導致疼痛治療不足的原因包括文化的、社會的、宗教的和政治的態度,Ö包括接受痛。注重病理生理學而不是生活品質的疾病生物醫學模式增強了防護意識:緣化的疼痛治療優先化。被申請Ö進的策略包括:定位疼痛治療作為一個倫理問題,提升疼痛治療作為一種合法的利,提供立憲的保證和法令規定被忽視的法律、錯誤的法律和陋習,定義疼痛治療作為一種基本的人,分類疼痛治療的失敗是因為專業的不規範,指出操作的指導Ö向和規程應用的是專業的個體。世界衛生組Ö的作用是討論疼痛治療藥物的有效性,Ö別是關於阿片類藥物。作者認為:因為疼痛治療是醫學、倫理學和法律的內在的主題,我們正處在一個拐點,不合理的疼痛治療被全世界的人看成是因為藥品缺Ö、不規範的操作和基本人的丟失。

(張美榮 陳傑 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.


腰椎間盤切除術患者圍術期口服羥考酮控釋型下術後嗎啡需求量、疼痛評分以副作用

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:口服阿片製常用於術後鎮痛。在這項研究中,作者評估了腰椎間盤切除術患者圍術期口服羥考酮控釋以減少術後嗎啡用量阿片製的副作用。

Ö法 40例擇期手術病人,行1-2個節段腰椎間盤切除術,進行前瞻性、隨機、雙盲、安慰對照試驗。患者從手術前天晚到術後第二天早每12h口服羥考酮控釋20mg或安慰。所有患者術後接受嗎啡自控鎮痛,每6h均給予撲熱息痛1g。分別在時間段T0-T24T24-T48評估術後嗎啡用量。在術後第一個48h6h要行評估記錄。術後每6h使用視覺評分量表評估鎮痛效果,包括休息痛,咳嗽痛,運動痛,同時評估噁心,嘔吐,瘙癢,鎮靜和腸能情況。術後72h病人自評鎮痛滿意度。

結果:與安慰組相比口服羥考酮控釋組術後T0-T24(分別為52±29mg26±10mgT24-T4833±18mg13±8mg)時間段靜脈嗎啡用量明顯減少。口服羥考酮組病人,第一個48h休息痛,咳嗽痛,運動痛的評分明顯降低,且在第一個24h術後噁心嘔吐明顯減少。羥考酮組的病人腸能恢復明顯提前,且有較高的疼痛治療滿意度。

結論:與安慰組相比,腰椎間盤切除術患者,圍術期口服羥考酮控釋可以減少術後嗎啡用量,並提供較好的鎮痛,且副作用較少。

(宋翠俠 陳傑 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.

 

硬膜外使用氟呱利多的止癢與鎮吐效果:三種不同給藥Ö式的比較

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:本研究比較不同Ö式的硬膜外給予氟呱利多後,手術後噁心嘔吐(PONV)的發生率。

Ö法:使用相同量的氟呱利多,觀測三種不同給藥Ö式(單次、連續以二者聯合)對PONV的發生率和術後48小時由於連續硬膜外注射太尼誘發搔癢的影響。160ASA III級行結直腸癌切除術的病人,予硬膜外聯合全身麻醉,並隨機分為四組:(a)對照組(不給予氟呱利多),(b)單次注射組(給予氟呱利多2.5mg),(c)連續注射組(給予氟呱利多1.25mg/天),(d)聯合組(給予氟呱利多單次1.25mg並連續0.625mg/天)。

結果:與對照組相比,所有給予氟呱利多組患者搔癢和PONV的發生明顯減少(P<0.05)。硬膜外給予氟呱利多組間PONV的發生率和延遲發生率均相似。

結論:硬膜外給予氟呱利多能有效減少搔癢和術後噁心嘔吐的發生,且與給藥Ö式無關。

(周懿Ö 陳傑 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.

 

 

舌咽神經阻滯對扁桃體切除術後疼痛的緩解作用:咽反射的制程度作為臨指標的重要性

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:作者評估了舌咽神經阻滯對成Ö患者扁桃體切除術後疼痛的緩解效果咽反射的制程度與術後疼痛緩解程度的相關性。

Ö法:75名進行扁桃體切除術的患者手術結束時接受了雙側舌咽神經阻滯,分為R組(0.75%羅呱卡因腎腺素)、B組(0.5%布比卡因腎腺素)、C組(未Ö預組)。

通過觀察術後小時、8小時和24小時的咽喉部疼痛(100mm直觀類比標度)和咽反射程度來評估舌咽神經阻滯的效果。

結果:R組和B組的疼痛評分吞咽反射明顯少於C組(21±1723±1342±1628±2232±1962±14P<0.001)。舌咽神經的阻滯效果與咽反射的制程度顯著相關(P<0.01)。

結論:舌咽神經是一種緩解扁桃體術後疼痛的有效Ö法。咽反射的制可以作為舌咽神經阻滯鎮痛效果的臨指標。

(Ö慧 陳傑 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.

 

連續監測動態肺順應性使檢測嬰兒兒童支氣管內插管成為可能

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:聽診呼吸音常規用於確定氣管插管的導管(ETT)置入氣管。而在嬰兒和兒童,這種Ö法卻由於儘管插入支氣管呼吸音仍然向雙側傳導而受到限制。儘管有一些Ö法用於檢測支氣管內插管,但還沒有哪一種Ö法簡單而可靠。在本研究中,我們探討採用持續監測流肺量測定法測得的肺順應性氣道壓的Ö是否能夠可靠地檢測兒科病人的支氣管內插管。

Ö法:共有40例Ö齡1-6歲的病人。氣管插管後,由兩名觀察者分別採用聽診呼吸音和肺量測定法(壓Ö量環)監測導管位置的逐漸前移。在各放置點採用纖維支氣管鏡確定ETT的位置,同時記錄肺順應性、吸氣峰壓呼吸音的Ö。

結果:支氣管插管使測得的肺順應性下降了45 ± 11%(均數± 標準差;P < 0.001,範圍26%–66%),使氣道壓升高約26 ± 17% (均數± 標準差; P < 0.001,範圍0–87)。與肺順應性的Ö相比,氣道峰壓的Ö較小且異度較大。聽診呼吸音法不能檢測出7.5%病人的支氣管內插管。

結論:監測肺順應的Ö是檢測嬰兒兒童支氣管內插管的一個敏感而精確的指標。氣道峰壓的增高呼吸音的Ö對於支氣管內插管均是相對不敏感的指標。

(邱鬱薇 馬皓琳 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.

 

 

嗎啡在術後患者:代謝產物的藥代動學和藥效動學

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:術後階段中嗎啡的需求存在很大異性。我們進行了一項考慮到嗎啡兩個主要代謝產物有潛在作用的藥代-藥效動學研究。

Ö法50名中至重度疼痛的患者術後先靜脈滴定嗎啡,隨Ö肌注給藥。每隔一小段時間測量嗎啡、6-葡糖苷酸-嗎啡(M-6-G) 3-葡糖苷酸-嗎啡(M-3-G)的血藥濃度和疼痛強度。用NONMEM軟體進行藥代動學和藥效動學的擬合。

結果:藥代動學有良好的預見性。M-6-G M-3-G的清除率在腎衰患者中顯著降低。因藥效動學的個體差異很大,其預見性較差。M-6-G的效Ö較嗎啡高7.8倍,但單次靜注嗎啡後效應室濃度達到峰值的Ö均時間是M-6-G 4.25小時,嗎啡0.33小時。M-3-G顯示對M-6-G和嗎啡的鎮痛性質有輕微的制作用。單次靜注嗎啡後M-3-G效應室濃度達到峰值的時間是10小時。

結論M-6-G是較強的阿片類激動,而M-3-G是較弱的阿片類拮。兩者在腎衰患者的排泄均微Ö其微。然而,嗎啡的代謝很快,與Ö相比,其代謝產物通過血腦屏障的轉運則看來是一個限速過程。由於M-3-G的弱鎮痛作用在一些病人中可能發生在12天后,應該考慮換用其他分子。

(唐李雋 李士通 馬皓琳 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在酒精誘導的大鼠急性神經行為Ö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:環腺苷酸依賴性蛋白激酶(PKA)信號通路參與基因敲除小鼠動物模型中酒精誘導的鎮靜效應的調節。本研究中,我們檢測了PKA在酒精引起的SD大鼠行為Ö中的作用。

Ö法:採用翻正反射消失(LORR)試驗來研究Ö膜腔內注射酒精的急性鎮靜效應。採用轉輪試驗(rotarod)來研究酒精引起的運動損害。採用腦室內(ICV)注射N-甲基-d-天冬氨酸(NMDA)誘發搐來測定酒精對NMDA受體的影響。採用蛋白印跡分析來測定NR1蛋白水準和NR1亞基897磷酸絲氨酸。

結果:ICV注射H-9(一種非Ö異性蛋白激酶制)或KT5720(一種Ö異性PKA制)預處理呈量依賴性地減弱酒精導致的睡眠時間(LORR法)。採用福斯高林(腺苷環化酶啟動)或白屈菜紅堿(選擇性PKC)預處理對酒精導致的LORR沒有影響。KT5720預處理Ö可減弱酒精導致的運動能損害。酒精明顯制NMDA導致的搐;預先腦室內注射KT5720可減弱酒精的這種制效應,但對我們測定的Ö個腦區內NMDA NR1亞基的897磷酸絲氨酸水準沒有顯著影響。

結論:我們的結果表明,PKA通路可能參與酒精導致的神經行為學Ö,且NMDA受體可能涉酒精對PKA的調節作用。

顏濤 馬皓琳 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.

 

 

出血時與應用升壓藥後脈搏周線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,可靠測量心排血量的Ö法是很重要的。脈搏周線衍生的心排血量(PCCO)在穩定的血流動學中已經得到評Ö,但是其對血管張度的化很敏感且在血流動學Ö的情況下並未得到驗證。而且,PCCO要求用經肺熱稀釋法COTPCO)來校準個體血管阻,要求重校準來維持正確測量的頻率,尤其是在化的條件下,尚未確定。我們在未控制出血和應用去甲腎腺素復蘇的情況下對PCCO測量COTPCO和連續和單次肺動脈CO(分別為CCOBCO)進行比較。

Ö法:13只豬被麻醉並接分別用BCOCCOTPCOPCCO監測心排血量的儀器。切開肝來完成未控制的出血。當Ö均動脈壓〈25mmHg,或心率進行性下降到〈峰值的20% ,即開始給予升壓藥治療。在麻醉誘導後和開始治療後15分鐘完成TPCOBCO,重複獲取PCCOCCO。用Bland-Altman分析來比較CO測量。

結果:Ö均動脈壓、心排血量和全身血管阻在出血後減少(分別為P < 0.001 and <0.01)。在出血後CCOPCCO(0.54 L/min; 1.46 L/min)Ö間一致性的偏移和極限增(–3.49; 6.12),在應用了去甲腎腺素後更惡化(–8.01; 9.9)。在重新校準後,偏移和極限一致回到–0.51 1.28

結論:PCCO在出血和應用升壓藥後需要頻Ö的重校準。

(胡Ö 馬皓琳 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.

 

長期機械通氣下丙酚鎮靜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病人長期大量應用丙酚可引起丙酚輸注綜合症。在本實驗中我們研究了大量丙酚鎮靜下長期機械通氣家兔的器官毒性和死亡率並測定丙酚脂質載體在其中的作用。

Ö法:18只健康雄性家兔行氣管插管,鎮靜分別採用2%丙酚(P組)、七氟醚(S組)或七氟醚合併10%英脫利ÖÖ(SI組)。鎮靜時間持續48小時或直至家兔死亡(P組)或為P組最長生存時間(S組和SI組)。丙酚初始輸注速度為20 mg · kg–1 · h–1,七氟醚初始濃度為1.5%,Ö據需要調節以保持一標準鎮靜水準。采系列血樣標本行血生化分析,家兔屍體解剖時對心、肺、肝、膽、腎、膀胱股四頭肌行組Ö學檢查。

結果:P組死亡率為100%(生存時間,2638h),而S組和SI組死亡率為0。初始丙酚輸注速度須增至65.7 ± 4.6 mg · kg–1 · h–1而七氟醚濃度須增至4%。P組和SI組血清肝能指標、血脂和肌酸激酶顯著升高((P < 0.05),僅P組有Ö酸Ö水Ö升高,而所有組血澱粉酶均升高。組Ö學檢查顯示:P組家兔具有心肌炎、間質性肺炎肺水腫、肝炎、肝脂肪性局灶肝壞死、膽管炎、膽壞死、急性腎小管壞死、膀胱皮細胞局灶缺失骨骼肌橫紋肌溶解;S組家兔僅有輕度支氣管炎肝腎初期炎症反應;SI組家兔具有輕度支氣管炎、肝脂肪性、肝炎膽、腎臟、膀胱初期炎症反應。

結論:對接受長期機械通氣的家兔大量持續輸注2%丙酚進行鎮靜可導致致命的多器官能衰竭綜合症,類似於人類丙酚輸注綜合症。且記錄到包括肺、肝膽膀胱損害的這個新發現。丙酚脂質載體在此綜合征的表現中作用較小。研究證實七氟醚是長時間鎮靜的安全替代藥品。

(周雅春 馬皓琳 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.


基於三維電腦斷層攝影的經鎖骨途徑右鎖骨下靜脈穿刺新Ö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

 

背景資料:我們用三維(3-D)電腦斷層攝影術來開發了經鎖骨途徑到達鎖骨下靜脈的新Ö法,以最小化從穿刺點到靜脈的距離。

Ö法:回顧性地調查了45個正常體格成Ö病人在電腦三維斷層攝影術資料。假設胸鎖Ö突角為皮膚穿刺點,而在第一肋的鎖骨下靜脈為穿刺目標,在類比三維影像測定最好的穿刺角度。從這些影像開發了一個三維視頻來解釋穿刺途徑。在初步的研究中,我們前瞻性地在60例需要中心靜脈置管的正常體格成Ö病人中驗證了此穿刺途徑。並記錄嘗試次數、成率和併發症。

結果:最佳的穿刺角度是內斜10.6° ± 5.3°與穿刺點皮膚呈35.4° ± 12.5°。估計鎖骨下靜脈距離穿刺點的深度為13.7 ± 3.1 mm。在初步的研究中,用探尋針的第一次嘗試成果率為87%,置管的總成率為100%,且無併發症。

結論:經鎖骨穿刺到鎖骨下靜脈是中心靜脈穿刺置管術的一個簡單Ö法,這個初步研究提示了這種Ö法是相當安全的。在補充資料中以視頻來生動的解釋穿刺途徑是可行的。

(沈浩 馬皓琳 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.

 

 

預防性給予多模式鎮痛用藥法對行前交叉韌帶重建術的門診病人的遠期預後的影響

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:不能緩解的術後疼痛可能會損害復原,延緩康復,並導致不良結局。預防性的多模式鎮痛術可能會Ö善術後的遠期預後。

Ö法:我們對行前交叉韌帶重建術的連續200名患者,于術前1-2小時給予撲熱息痛1000mg並隨機給予塞來考昔400mg或者安慰。所有的患者均給予關節內鎮痛藥,並且在手術關節應用外部冷卻系統。出院後,病人遵醫囑在術後14天每6 小時服用撲熱息痛1000mg,以每12 小時服用塞來考昔400mg或相對應的安慰。所有病人均登記入一個康復促進Ö案。術後6個月後,評Ö患者膝關節活動的等級,髕股的併發症的發生率,包括:膝關節前部的疼痛、屈曲性攣縮、四頭肌無和複合區域性疼痛綜合征。

結果:對照組較塞來考昔組有更多的病人存在髕股併發症(P = 0.001),包括膝關節前部的疼痛(14/96; 15%)(4/95; 1%)、複合區域性疼痛綜合征(7/96; 7%)(1/95; 1%)、屈曲性攣縮(9/96; 9%)(2/95; 2%)以瘢痕組Ö需要再次關節鏡檢查(8/96; 8%)(2/95; 2%)。塞來考昔組有更多的病人恢復到較高的膝關節活動等級(84%65%(P < 0.01),能夠參到更大的活動強度(P < 0.02),並且能恢復全部的體育活動(P < 0.05)

結論:給予塞來考昔作為預防性多模式鎮痛術的一個組成部分,對行前交叉韌帶重建術的病人,會減少遠期的髕股併發症的發生,且提高恢復到受傷前的運動水準的可能性。

(黃麗娜 李士通 馬皓琳 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.


大鼠關節腔內注射α2腎腺素受體激動Fadolmidine對關節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:以往的研究認為激動外周α2和阿片類受體可以減少關節疼痛。Fadolmidine是一種高選擇性α2腎腺素能受體激動,外周給藥後只有極少部分進入中樞。我們在實驗性單關節炎中評估fadolmidine的外周傷害性作用Ö點以外周阿片類受體對其傷害作用的潛在影響。

Ö法:在大鼠膝關節炎誘發單關節炎後,我們測定了反復活動膝關節發出聲音的頻率。給大鼠發炎側或對側關節腔內注射Fadolmidine和可樂定。用皮下(s.c.)注射α2腎腺素受體拮阿替美唑和關節腔內注射一種不會穿透血腦屏障的阿片類受體拮蛋氨酸納洛酮來試圖逆轉fadolmidine引起的作用。

結果:Fadolmidine呈量依賴地降低對發炎側膝關節活動的發聲反應,且患側給藥後的效應明顯較對側給藥的效應強烈。可樂定同樣量依賴地降低發聲反應,但是患側給藥與對側給藥後的效應Ö間無明顯差別。Fadolmidine誘發的傷害作用可以被皮下給予阿替美唑拮。而且發炎側而不是對側關節腔給予蛋氨酸納洛酮Ö可以拮fadolmidine的傷害作用,這個作用與fadolmidine是在發炎側還是對側關節腔給藥無關。

結論:大鼠關節腔內給予fadolmidine可以明顯制關節炎導致的疼痛相關性行為,這可能是由於fadolmidine選擇性激動α2腎腺素受體和阿片類受體。

(張瑩 馬皓琳 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.


骶骨旁坐骨神經阻滯:是否引出的運動反應就預示著阻滯成呢?

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:在這項前瞻性、隨機、雙盲研究中,我們比較了脛神經和腓神經誘發的運動反應引出對於骶骨旁進針法坐骨神經阻滯的有效性的預示程度。

Ö法:26ASA I–III 排定行擇期下肢手術的病人接受骶骨旁坐骨神經阻滯,用神經刺激Ö法隨機分別探測脛神經運動反應(n = 14)和腓神經運動反應(n = 12)。達到誘發的運動反應後,含有腎腺素的10 mL 2% 利多卡因和10 mL 0.75% 羅呱卡因合液(腎腺素的實際終濃度為 1/160,000)通過針緩慢注射。由一位不知道誘發的運動反應的麻醉醫師在30分鐘內每隔5分鐘評估一次感覺和運動阻滯。如果局麻藥注射30分鐘後阻滯仍未完全,就認為神經阻滯失敗,添全身麻醉。

結果:兩組間相比,完成阻滯的時間最小和最大的刺激均無差異。脛神經達到完全阻滯的成率要顯著高於腓神經組(11/142/12P = 0.002)。

結論:在骶骨旁坐骨神經阻滯中,引出脛神經運動反應比引出腓神經運動反應預示著更高的神經阻滯成率。

(黃佳佳譯,馬皓琳 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.