Anesthesia & Analgesia

August 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:Back

Eckehard Stuth

Phenoxybenzamine Is Indicated in Treatment of Hypoplastic Left Heart Syndrome: Pro (Editorial)
Anesth Analg 2007 105: 307-309. [Full Text] [PDF]  

James A. DiNardo

Phenoxybenzamine Is Indicated in Treatment of Hypoplastic Left Heart Syndrome: Con (Editorial)
Anesth Analg 2007 105: 310-311. [Full Text] [PDF]  

Nina A. Guzzetta

Phenoxybenzamine in the Treatment of Hypoplastic Left Heart Syndrome: A Core Review (Editorial)
Anesth Analg 2007 105: 312-315. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Maintaining adequate systemic oxygen delivery after the Norwood procedure by balancing pulmonary and systemic blood flows is critical to improved early postoperative mortality. This review discusses the role of the {alpha}-adrenergic blocking drug, phenoxybenzamine, in helping to achieve this balance.

 

麻醉处理与麻醉后处理相结合单独麻醉预处理或麻醉后处理无优势

Anesthetic Preconditioning Combined with Postconditioning Offers No Additional Benefit Over Preconditioning or Postconditioning Alone (Editorial)

David I. Deyhimy, Neal W. Fleming, Ian G. Brodkin, and Hong Liu

Anesth Analg 2007 105: 316-324

Hiroyuki Kinoshita, Naoyuki Matsuda, Yoshiki Kimoto, Setsuko Tohyama, Keiko Hama, Katsutoshi Nakahata, and Yoshio Hatano

Sevoflurane, but Not Propofol, Prevents Rho Kinase-Dependent Contraction Induced by Sphingosylphosphorylcholine in the Porcine Coronary Artery (Editorial)
Anesth Analg 2007 105: 325-329. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Sphingosylphosphorylcholine induces coronary vasocontriction via activation of Rho kinase. Sevoflurane, but not propofol, inhibits this pathway, resulting in prevention of vasoconstriction.

Kevin J. Scholten, Vivek Kulkarni, and Jay B. Brodsky

Isolation of the Right Upper-Lobe with a Left-Sided Double-Lumen Tube After Left-Pneumonectomy (Case Report)
Anesth Analg 2007 105: 330-331. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Airway management of a patient undergoing right upper-lobe surgery after left pneumonectomy was accomplished using a left-sided endobronchial tube placed in the bronchus intermedius.

Martin M. Stechert and Jens P. Kellermeier

Aorto–Atrial Fistula: An Important Complication of Aortic Prosthetic Valve Endocarditis (Echo Rounds)
Anesth Analg 2007 105: 332-333. [Full Text] [PDF] [Video Loop]   

PEDIATRIC ANESTHESIOLOGY:Back

Kirsten C. Odegard, James A. DiNardo, Barry D. Kussman, Avinash Shukla, James Harrington, Al Casta, Francis X. McGowan, Jr, Paul R. Hickey, Emile A. Bacha, Ravi R. Thiagarajan, and Peter C. Laussen

The Frequency of Anesthesia-Related Cardiac Arrests in Patients with Congenital Heart Disease Undergoing Cardiac Surgery
Anesth Analg 2007 105: 335-343. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The frequency of anesthesia-related cardiac arrests is increased in patients with congenital heart disease undergoing cardiac surgery, but is not associated with an increase in mortality. Neonates and infants are at higher risk.

Sanjay M. Bhananker, Chandra Ramamoorthy, Jeremy M. Geiduschek, Karen L. Posner, Karen B. Domino, Charles M. Haberkern, John S. Campos, and Jeffrey P. Morray

Anesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest Registry
Anesth Analg 2007 105: 344-350. [Abstract] [Full Text] [PDF] [CME]  

IMPLICATIONS: The Pediatric Perioperative Cardiac Arrest (POCA) registry is a voluntary database that records the incidence of cardiac arrest in children undergoing anesthesia. We analyzed the incidence of cardiac arrest from the POCA Registry from the years 1998 through 2004.

Christine F. Lauro, Raphaela Goldbach-Mansky, Margaret Schmidt, and Zenaide M. N. Quezado

The Anesthetic Management of Children with Neonatal-Onset Multi-System Inflammatory Disease
Anesth Analg 2007 105: 351-357. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Neonatal-onset multi-system inflammatory disease (NOMID) is a rare autosomal dominantly inherited autoinflammatory disease characterized by seemingly unprovoked episodes of inflammation, recurrent fever, chronic aseptic meningitis, developmental delay, papilledema, and sensory organ involvement. An understanding of its clinical manifestations and respective implications are important for the anesthetic care of children with NOMID.

Alan R. Tait, Terri Voepel-Lewis, and Shobha Malviya

Presenting Research Information to Children: A Tale of Two Methods
Anesth Analg 2007 105: 358-364. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Many children have poor understanding of assent information for research. This study suggests that use of an informational form that considers the age and reading abilities of the child participant results in improved understanding and acceptance of the information.

Koichi Yuki, Kelly Chilson, Kirsten C. Odegard, and James A. DiNardo

Trendelenburg Position, Simulated Valsalva Maneuver, and Liver Compression Do Not Alter the Size of the Right Internal Jugular Vein in Patients with a Bidirectional Glenn Shunt
Anesth Analg 2007 105: 365-368. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: In patients with bidirectional Glenn shunts, the size of the right internal jugular vein is not affected by liver compression or the Trendelenberg position.

AMBULATORY ANESTHESIOLOGY:Back

Niamh P. Conlon, Richard P. Sullivan, Peter G. Herbison, Mathew Zacharias, and Donal J. Buggy

The Effect of Leaving Dentures in Place on Bag-Mask Ventilation at Induction of General Anesthesia
Anesth Analg 2007 105: 370-373. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The removal of dentures in edentate patients before their entering the operating room has been a well-honored tradition for decades. The authors demonstrate that bag-mask ventilation is easier and more successful if dentures are left in place.

ANESTHETIC PHARMACOLOGY:Back

Vivian M. Yuen, Michael G. Irwin, Theresa W. Hui, Man K. Yuen, and Libby H. Y. Lee

A Double-Blind, Crossover Assessment of the Sedative and Analgesic Effects of Intranasal Dexmedetomidine
Anesth Analg 2007 105: 374-380. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: This study evaluated the sedative, anxiolytic, analgesic, and hemodynamic effects of 1 and 1.5 {micro}g/kg dexmedetomidine administered intranasally in healthy volunteers. Both doses produced significant sedation. The intranasal route is effective, well tolerated, and convenient for the administration of dexmedetomidine.

Michael Cascio, Yilei Xing, Diane Gong, John Popovich, Edmond I. Eger, II, Saunak Sen, Gary Peltz, and James M. Sonner

Mouse Chromosome 7 Harbors a Quantitative Trait Locus for Isoflurane Minimum Alveolar Concentration
Anesth Analg 2007 105: 381-385. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The minimum alveolar concentration (MAC) of isoflurane is a quantitative trait because it varies continuously in a population. Using two mouse strains differing in isoflurane MAC, we identified a quantitative trait loci for isoflurane MAC on mouse chromosome 7. This chromosome contains genetic elements influencing the MAC of isoflurane.

Pavle S. Milutinovic, Liya Yang, Robert S. Cantor, Edmond I. Eger, II, and James M. Sonner

Anesthetic-Like Modulation of a {gamma}-Aminobutyric Acid Type A, Strychnine-Sensitive Glycine, and N-Methyl-d-Aspartate Receptors by Coreleased Neurotransmitters
Anesth Analg 2007 105: 386-392. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Neurotransmitters that are coreleased onto anesthetic-sensitive receptors may modulate the function of receptors for which they are not the native agonist via an anesthetic-like mechanism.

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

The Plasticizer Di(2-ethylhexyl) Phthalate Modulates {gamma}-Aminobutyric Acid Type A and Glycine Receptor Function (Technical Communication)
Anesth Analg 2007 105: 393-396. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The plasticizer di(2-ethylhexyl) phthalate modulates the function of both {gamma}-amino butyric acid type A and glycine receptors.

TECHNOLOGY, COMPUTING, AND SIMULATION:Back

S. Tejman-Yarden, A. Zlotnik, L. Weizman, J. Tabrikian, A. Cohen, N. Weksler, and G. M. Gurman

Acoustic Monitoring of Lung Sounds for the Detection of One-Lung Intubation
Anesth Analg 2007 105: 397-404. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: None of the monitors used today has proved effective for the early detection of one-lung intubation. In this study, one-lung ventilation sounds were collected from anesthetized patients during induction in order to investigate the efficacy of a new Auto-Regressive model of acoustic analysis for the detection of one-lung intubation.

Richard H. Epstein, Michael M. Vigoda, and David M. Feinstein

Anesthesia Information Management Systems: A Survey of Current Implementation Policies and Practices
Anesth Analg 2007 105: 405-411. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: A survey of 18 institutions using anesthesia information management systems revealed that, in many cases, system configurations may increase exposure to billing denial, Centers for Medicare and Medicaid Services noncompliance, security breeches, and medical legal defense difficulties. Configuration standards are needed to address these problems and to provide guidance for institutions using this technology.

PATIENT SAFETY:Back

Frank J. Overdyk, Rickey Carter, Ray R. Maddox, Jarred Callura, Amy E. Herrin, and Craig Henriquez

Continuous Oximetry/Capnometry Monitoring Reveals Frequent Desaturation and Bradypnea During Patient-Controlled Analgesia
Anesth Analg 2007 105: 412-418. [Abstract] [Full Text] [PDF] [CME]  

IMPLICATIONS: Continuous patient monitoring by pulse oximetry and capnometry during narcotic administration via patient-controlled analgesia suggests that the incidence of desaturation and bradypnea exceeds that documented by intermittent monitoring. Continuous monitoring may be important to prevent adverse events related to narcotic administration, but additional research is needed to reduce the rate of false positive alarms and to understand the true incidence of this problem.

ECONOMICS, EDUCATION, AND POLICY:Back

Franklin Dexter, Ann Willemsen-Dunlap, and John D. Lee

Operating Room Managerial Decision-Making on the Day of Surgery With and Without Computer Recommendations and Status Displays
Anesth Analg 2007 105: 419-429. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: For cultural and social reasons, anesthesia providers make decisions that increase personal clinical work load, even though such decisions may be economically unsound and increase patient and surgeon waiting times. Command displays showed promise in mitigating this tendency.

Franklin Dexter, John D. Lee, Angella J. Dow, and David A. Lubarsky

A Psychological Basis for Anesthesiologists’ Operating Room Managerial Decision-Making on the Day of Surgery
Anesth Analg 2007 105: 430-434. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Anesthesiologists made managerial decisions that increased the clinical work per unit time at each operating room (OR) to which they were assigned. Although sound for decisions involving individual ORs, this heuristic (i.e., simplified, rule-of-thumb approach) was then applied to decisions involving multiple ORs resulting in unnecessary overutilized OR time, unpredictable work hours, etc.

Maurizia Capuzzo, Giuseppe Gilli, Laura Paparella, Gaetano Gritti, Davide Gambi, Margherita Bianconi, Francesco Giunta, Cosimetta Buccoliero, and Raffaele Alvisi

Factors Predictive of Patient Satisfaction with Anesthesia
Anesth Analg 2007 105: 435-442. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Inpatient satisfaction can be improved by an organization in which there are surgical suite nurses dedicated only to anesthesia (e.g., in holding area, for regional blocks, and upon operating room entrance); a written anesthesia information leaflet is given during the preoperative visit, and there are two postoperative visits.

Edna Zohar, Yossi Noga, Ehud Davidson, Margalit Kantor, and Brian Fredman

Perioperative Patient Safety: Correct Patient, Correct Surgery, Correct Side—A Multifaceted, Cross-Organizational, Interventional Study
Anesth Analg 2007 105: 443-447. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: A hospital implemented a policy such that when a major error in patient readiness for anesthesia and surgery was found in the holding area, the patient was always returned to the parent department and the surgical procedure delayed. The result was a progressive reduction in the incidence of such errors.

CRITICAL CARE AND TRAUMA:Back

Piet A. H. Wyffels, Pieter-Jan Durnez, Johan Helderweirt, Willem M. A. Stockman, and Dirk De Kegel

Ventilation-Induced Plethysmographic Variations Predict Fluid Responsiveness in Ventilated Postoperative Cardiac Surgery Patients
Anesth Analg 2007 105: 448-452. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Pulse oximeter plethysmography wave forms can be used to predict fluid responsiveness. This observational study of fully sedated and ventilated patients after cardiac surgery shows that the change in plethysmographic wave forms induced by ventilation acts as a more accurate variable of fluid responsiveness than the more classic nondynamic variables such as central venous pressure and pulmonary artery occlusion pressure.

Stefan Lauer, Hendrik Freise, Lars G. Fischer, Kai Singbartl, Hugo V. Aken, Markus M. Lerch, and Andreas W. Sielenkämper

The Role of Thoracic Epidural Analgesia in Receptor-Dependent and Receptor-Independent Pulmonary Vasoconstriction in Experimental Pancreatitis
Anesth Analg 2007 105: 453-459. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Thoracic epidural analgesia partly restores pulmonary vasoreactivity in acute experimental pancreatitis.

OBSTETRIC ANESTHESIOLOGY:Back

Shmuel Evron, Vladimir Gladkov, Daniel I. Sessler, Vadim Khazin, Oscar Sadan, Mona Boaz, and Tiberiu Ezri

Predistention of the Epidural Space Before Catheter Insertion Reduces the Incidence of Intravascular Epidural Catheter Insertion
Anesth Analg 2007 105: 460-464. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Distention of the epidural space before epidural catheter placement was associated with fewer intravascular catheter insertions and fewer unblocked segments.

GENERAL ARTICLES:Back

Kathrine Holte, Billy B. Kristensen, Lotte Valentiner, Nicolai B. Foss, Henrik Husted, and Henrik Kehlet

Liberal Versus Restrictive Fluid Management in Knee Arthroplasty: A Randomized, Double-Blind Study
Anesth Analg 2007 105: 465-474. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Despite inducing hypercoagulability with liberal intravascular fluid administration, overall functional recovery was not dependent on the amount of fluid administered in knee arthroplasty surgery.

Richard A. Hanson, Mark H. Zornow, Michael J. Conlin, and Ansgar M. Brambrink

Laser Resection of the Prostate: Implications for Anesthesia (Medical Intelligence)
Anesth Analg 2007 105: 475-479. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Advances in endourology using laser technology have resulted in procedures for prostate reduction that are as effective as classic transurethral resection of the prostate (TURP) but that nearly eliminate the risk for TURP syndrome. More options for anesthetic management may now be available, including general anesthesia and the ability to perform these procedures on an outpatient basis.

ANALGESIA:Back

Hval Kjetil, Thagaard K. Sem, Schlichting Ellen, and Raeder Johan

The Prolonged Postoperative Analgesic Effect When Dexamethasone Is Added to a Nonsteroidal Antiinflammatory Drug (Rofecoxib) Before Breast Surgery
Anesth Analg 2007 105: 481-486. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Dexamethasone improves postoperative analgesia as a component of a multimodal regimen that includes rofecoxib, fentanyl, and bupivacaine.

Tong J. Gan and Ashraf S. Habib

Adenosine as a Non-Opioid Analgesic in the Perioperative Setting (Review Article)
Anesth Analg 2007 105: 487-494. [Abstract] [Full Text] [PDF]  

Steven P. Cohen, Sean M. Shockey, and Eugene J. Carragee

The Efficacy of Repeat Intradiscal Electrothermal Therapy (Brief Report)
Anesth Analg 2007 105: 495-498. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Although some patients may benefit from repeating the intradiscal electrothermal therapy procedure, pain reduction may be less pronounced and shorter-lived than after the initial procedure.

Shu-Ming Wang, R. Todd Constable, Fuyuze S. Tokoglu, Dana A. Weiss, David Freyle, and Zeev N. Kain

Acupuncture-Induced Blood Oxygenation Level-Dependent Signals in Awake and Anesthetized Volunteers: A Pilot Study
Anesth Analg 2007 105: 499-506. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Through the use of functional magnetic resonance imaging, we found that propofol-based general anesthesia suppresses acupuncture-induced blood oxygenation level-dependant signals in several areas of the brain.

Tetsuya Iijima, Tadahiko Ishiyama, Satoshi Kashimoto, Toshiaki Yamaguchi, Tomio Andoh, Kazumi Hanawa, Izumi Tanzawa, Keisi Kawata, Takehisa Hanawa, and Yoshimitsu Hiejima

A Comparison of Three Different Concentrations of Ropivacaine with Fentanyl for Patient-Controlled Epidural Analgesia
Anesth Analg 2007 105: 507-511. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: This study suggests that ropivacaine at 0.05% with 4 {micro}g/mL fentanyl is sufficient for preserving gastrointestinal motility, analgesia, and motor function for patients undergoing gynecologic lower abdominal surgery.

David Samson, Vincent Minville, Clément Chassery, Luc Nguyen, Antoine Pianezza, Olivier Fourcade, Anna Rabinowitz, and Kamran Samii

Eutectic Mixture of Local Anesthetic (EMLA®) Decreases Pain During Humeral Block Placement in Nonsedated Patients
Anesth Analg 2007 105: 512-515. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The patients who received EMLA(R) cream had less pain with needle puncture as well as throughout the performance of humeral block.

Olfa Kaabachi, Amine Zarghouni, Rami Ouezini, Ahmed Ben Abdelaziz, Olfa Chattaoui, and Hannu Kokki

Clonidine 1 µg/kg Is a Safe and Effective Adjuvant to Plain Bupivacaine in Spinal Anesthesia in Adolescents
Anesth Analg 2007 105: 516-519. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: In adolescents, clonidine 1 {micro}g/kg prolonged the duration of sensory block achieved with bupivacaine by 30 min and postoperative analgesia by 120 min without severe adverse events.

Ying Y. Lee, Warwick D. Ngan Kee, Hang K. Chang, Chi L. So, and Tony Gin

Spinal Ropivacaine for Lower Limb Surgery: A Dose–Response Study
Anesth Analg 2007 105: 520-523. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The ED50 and ED95 for spinal ropivacaine in lower limb surgery of 50 min duration or less were 7.6 and 11.4 mg, respectively. This provides a useful guide for clinicians to choose the optimal dose of spinal ropivacaine under different clinical situations.

Zohreh Tamanai-Shacoori, Valliollah Shacoori, Anne Jolivet-Gougeon, Jean-Marie Vo Van, Martine Repère, Pierre-Yves Donnio, and Martine Bonnaure-Mallet

The Antibacterial Activity of Tramadol Against Bacteria Associated with Infectious Complications After Local or Regional Anesthesia
Anesth Analg 2007 105: 524-527. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Tramadol has dose- and time-dependent bactericidal activity against Escherichia coli and Staphylococcus epidermidis as well as antibacterial activity against Staphylococcus aureus and Pseudomonas aeruginosa. The antibacterial properties of tramadol may be useful for reducing the risk of bacterial infection after local or regional anesthesia.

Antoine Pianezza, Marie-Luce Gilbert, Vincent Minville, Daren Filsinger, Quentin Gobert, Alain Guérot, Régis Fuzier, and Olivier Fourcade

A Modified Mid-Femoral Approach to the Sciatic Nerve Block: A Correlation Between Evoked Motor Response and Sensory Block (Brief Report)
Anesth Analg 2007 105: 528-530. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: Tibial evoked motor response predicts a better success rate than common peroneal response for the mid-femoral sciatic nerve block with a single injection.

Maryam Vosoughian, Ali Dabbagh, Samira Rajaei, and Hassan Maftuh

The Duration of Spinal Anesthesia with 5% Lidocaine in Chronic Opium Abusers Compared with Nonabusers (Brief Report)
Anesth Analg 2007 105: 531-533. [Abstract] [Full Text] [PDF]  

IMPLICATIONS: The duration of spinal blockade is decreased in patients who are chronic opium abusers compared with nonabusers.

麻醉预处理与麻醉后处理相结合较单独麻醉预处理或麻醉后处理无优势

Anesthetic Preconditioning Combined with Postconditioning Offers No Additional Benefit Over Preconditioning or Postconditioning Alone

David I. Deyhimy, MD*, Neal W. Fleming, MD, PhD*, Ian G. Brodkin, MD{dagger}, and Hong Liu, MD*

From the *Department of Anesthesiology and Pain Medicine, University of California, Davis, California; and {dagger}Department of Anesthesiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.

Anesth Analg 2007 105: 316-324.

 

背景:近来的研究表明麻醉预处理和麻醉后处理与心肌缺血预处理减少心肌梗死的面积程度相当。作者假定七氟醚的预处理和后处理相结合能更好地保护心肌。
方法Langendorff 灌注的大鼠心脏分成四组:对照组、预处理组、后处理组及预处理结合后处理组。在再灌注时,测量左心室功能(左室舒张压、左室舒张末期压及dp/dt)。再灌注末期,氯化2,3,5三苯基四唑染色法测定梗死灶面积。核磁共振法测量细胞内pH, Na+ Ca2+
结果:相对于对照组,治疗组的左心室舒张压、左室舒张末压、左室dp/dtmax dp/dtmin显著改善。心肌梗死面积在预处理组、后处理组、二者结合组分别为24%± 7%16%±8%22%±7%,而对照组为44%±8%,差异显著(P<0.05)。相对于对照组,实验组在再灌注末期胞内Na+Ca2+均显著减少,但实验组间无差别。
结论:七氟醚的后处理与预处理在全心缺血后保护心肌功能上一样有效。麻醉前与麻醉后处理相结合相对于单独麻醉预处理或麻醉后处理无优势。

(胡潇 陈杰 校)

BACKGROUND: Recent investigations demonstrate that anesthetic preconditioning and postconditioning reduce myocardial infarct size to a degree comparable to that achieved with ischemic preconditioning. We hypothesized that the combination of sevoflurane preconditioning and postconditioning would result in greater preservation of myocardium.

METHODS: Langendorff perfused rat hearts were divided into four groups: control, preconditioning, postconditioning, and preconditioning plus postconditioning. During reperfusion, left ventricular function (left ventricular developed pressure, left ventricular end diastolic pressure, and dp/dt) were measured. At the end of reperfusion, the infarct sizes were measured with 2,3,5 triphenyltetrazolium chloride staining. Nuclear magnetic resonance was used to measure intracellular pH, Na+, and Ca2+.

RESULTS: Left ventricular developed pressure, left ventricular end diastolic pressure, left ventricular dp/dtmax and dp/dtmin were significantly improved in the treatment groups when compared with those in the controls. Myocardial infarct size (24% ± 7%, 16% ± 8%, and 22% ± 7% in preconditioning, postconditioning, and pre-plus postconditioning groups versus 44% ± 8% in the control group, P < 0.05) and intracellular Na+ and Ca2+ were significantly decreased in all experimental groups at the end of reperfusion when compared with those in control. However, there were no differences between these variables in each treatment group.

CONCLUSION: Sevoflurane postconditioning is as effective as preconditioning in protecting myocardial function after global ischemia. The combination of sevoflurane preconditioning and postconditioning offered no additional benefit over either intervention alone.


儿童患者与麻醉相关的心跳骤停:来自于儿科围手术期心跳骤停的记录

Anesthesia-Related Cardiac Arrest in Children: Update from the Pediatric Perioperative Cardiac Arrest Registry

Sanjay M. Bhananker, MD, FRCA*, Chandra Ramamoorthy, MD{dagger}, Jeremy M. Geiduschek, MD*, Karen L. Posner, PhD*, Karen B. Domino, MD, MPH*, Charles M. Haberkern, MD, MPH*, John S. Campos, MA*, and Jeffrey P. Morray, MD{ddagger}

From the *Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington; {dagger}Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California; and {ddagger}Department of Anesthesiology, Phoenix Children's Hospital and Valley Anesthesiology Consultants, Phoenix, Arizona.

Anesth Analg 2007 105: 344-350.

背景:来自于儿科病人围手术期心跳骤停(POCA)的记录(1994–1997)表明与用药相关,常常源于氟烷对心血管的抑制作用。儿科麻醉的变化可能改变心跳骤停的原因。

方法:80个为儿童提供麻醉的北美研究机构志愿编入儿科围手术期心跳骤停的记录中。其中≤18岁发生心跳骤停儿童的每个标准数据形式均是匿名的。分析1998-2004年与心跳骤停有关的麻醉及其他相关因素。

结果:从19982004 年,193例(49%)心跳骤停者是与麻醉相关的,而药物相关者仅占18%,相比与1994-199737%有显著差异(p0.05〉。最常见因素是心血管方面,占总的 41%,其中失血引起的血容量减少以及输入库血引起的血钾过高是比较常见的因素。在呼吸因素(27%)中喉痉挛引起的气道阻塞最常见。器具相关因素中中心静脉导管置入引起的血管损伤是最常见的。麻醉监护不同阶段的心跳骤停因素也不相同(P < 0.01),心血管和呼吸因素引起的心跳骤停分别发生于外科手术期间及术后阶段。

结论:与氟烷引起的心血管抑制相关的心跳骤停的比例降低也许与儿童患者麻醉中氟烷的 使用减少有关,通过采取预防措施可能使各类心跳骤停发生率降低。

(宋翠侠 陈杰 校)

BACKGROUND: The initial findings from the Pediatric Perioperative Cardiac Arrest (POCA) Registry revealed that medication-related causes, often cardiovascular depression from halothane, were the most common. Changes in pediatric anesthesia practice may have altered the causes of cardiac arrest in anesthetized children.

METHODS: Nearly 80 North American institutions that provide anesthesia for children voluntarily enrolled in the Pediatric Perioperative Cardiac Arrest Registry. A standardized data form for each perioperative cardiac arrest in children ≤18 yr of age was submitted anonymously. We analyzed causes of anesthesia-related cardiac arrests and related factors in 1998–2004.

RESULTS: From 1998 to 2004, 193 arrests (49%) were related to anesthesia. Medication-related arrests accounted for 18% of all arrests, compared with 37% from 1994 to 1997 (P < 0.05). Cardiovascular causes of cardiac arrest were the most common (41% of all arrests), with hypovolemia from blood loss and hyperkalemia from transfusion of stored blood the most common identifiable cardiovascular causes. Among respiratory causes of arrest (27%), airway obstruction from laryngospasm was the most common cause. Vascular injury incurred during placement of central venous catheters was the most common equipment-related cause of arrest. The cause of arrest varied by phase of anesthesia care (P < 0.01). Cardiovascular and respiratory causes occurred most commonly in the surgical and postsurgical phases, respectively.

CONCLUSIONS: A reduction in the proportion of arrests related to cardiovascular depression due to halothane may be related to the declining use of halothane in pediatric anesthetic practice. The incidence of the most common remaining causes of arrest in each category may be reduced through preventive measures.

 

 

头低脚高位模拟瓦尔萨瓦动作,肝脏加压不能改变双向格林分流患者右颈内静脉的大小

Trendelenburg Position, Simulated Valsalva Maneuver, and Liver Compression Do Not Alter the Size of the Right Internal Jugular Vein in Patients with a Bidirectional Glenn Shunt

Koichi Yuki, MD*, Kelly Chilson, MD{dagger}, Kirsten C. Odegard, MD*, and James A. DiNardo, MD*

From the *Cardiac Anesthesia Service, Department of Anesthesiology, Perioperative and Pain Medicine, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts; {dagger}Department of Anesthesiology, Washington University, Saint Louis, Missouri; and {ddagger}Department of Anaesthesia, Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007 105: 365-368.

背景:超声越来越多地用于帮助儿童患者的右颈内静脉导管的置入。如果没有心脏疾病,变换体位及加强措施能增大右颈内静脉(RIJV)横断面积(CSA),并有助于导管置入。本文作者研究这些措施在儿童双向格林分流(BDG)的Fontan 手术时右颈内静脉横断面积的影响。

方法21名儿童行BDGFontan手术,通过超声面积法(sonosite)测定右颈内静脉(RIJV)横断面积(CSA)。联合使用两种体位〔仰卧位(S)和15度头低脚高位(T), 两种加强措施〔肝脏加压(L)和瓦尔萨瓦动作(V)〕。每个患者使用八种独立的措施(S,S+L,S+V,S+L+V,T,T+V,T+L,T+L+V)。重复测量的数据用单因素方差分析及配对T检验比较分析。

结果:右颈内静脉横断面积没有显著变化。

结论:改变体位和增强措施对于BDG Fontan手术患者右颈内静脉没有促进作用,因为这些措施不增加右颈内静脉横断面积。

(潘方立 陈杰 校)

BACKGROUND: Ultrasound is increasingly used to facilitate right internal jugular vein (RIJV) cannulation in children. In children without cardiac disease, position changes and enhancement maneuvers increase RIJV cross-sectional area (CSA) and further facilitate cannulation. We investigated the effect of these maneuvers on RIJV CSA in children with a bidirectional Glenn (BDG) shunt presenting for a Fontan procedure.

METHODS: The CSA (cm2) of the RIJV in 21 children with a BDG shunt presenting for a Fontan procedure was assessed by ultrasonic planimetry (SonoSite). Two positions, supine (S) and 15° Trendelenburg (T); and two enhancements maneuvers, manual liver compression (L) and a simulated Valsalva maneuver (V) were utilized in combination. Eight separate measurements (S, S + L, S + V, S + L + V, T, T + L, T + V, T + L + V) were made in each patient. Data were analyzed using one-way analysis of variance with repeated measures and with Tukey post hoc pairwise comparison analysis.

RESULTS: No significant change in the RIJV CSA or % change in CSA from baseline (S) was observed.

CONCLUSIONS: Position changes and enhancement maneuvers are unlikely to facilitate RIJV cannulation in BDG shunt patients presenting for Fontan procedure because these interventions do not increase RIJV CSA.


 

小鼠第七染色体上存在影响异氟醚最低肺泡浓度的数量性状遗传位点

Mouse Chromosome 7 Harbors a Quantitative Trait Locus for Isoflurane Minimum Alveolar Concentration

Michael Cascio, BS*, Yilei Xing, MD*, Diane Gong, PharmD{dagger}, John Popovich, BS*, Edmond I. Eger, II, MD*, Saunak Sen, PhD{ddagger}, Gary Peltz, MD, PhD§, and James M. Sonner, MD*

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA; {dagger}The Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin; {ddagger}Department of Biostatistics, University of California, San Francisco, CA; and §Department of Genetics and Genomics, Roche Palo Alto, Palo Alto, CA.

Anesth Analg 2007 105: 381-385.

 
背景:异氟醚的最低肺泡浓度具有数量特性,因为在不同的人群中是不同的。控制数量特性的基因组上的特定位点或基因的特定成分叫做量控位点。在这项研究中作者探寻小鼠中控制异氟醚肺泡最低浓度的量控位点。
方法:为完成这项研究,异氟醚的最低肺泡浓度不同的两种小鼠(C57BL/6JLP/J),通过两代的繁殖使得基因重新组合。这些小鼠的基因被标示特殊的标志。应用一种独立的计算方法来识别异氟醚的肺泡最低浓度量控位点的不同点。研究中,测量19种纯系小鼠的异氟醚最低肺泡浓度,并且通过科学的方法寻找基因上的变异的部位,并基于单个的核苷酸的多态性,研究纯系小鼠的异氟醚肺泡最低浓度的差异的相关性。
结论:两种基因分析的方法显示小鼠异氟醚肺泡最低浓度的量控位点存在于第七染色体。

(王鹏 陈杰 校)

BACKGROUND: The minimum alveolar concentration (MAC) of isoflurane is a quantitative trait because it varies continuously in a population. The location on the genome of genes or other genetic elements controlling quantiative traits is called quantitative trait loci (QTLs). In this study we sought to detect a quantitative trait locus underlying isoflurane MAC in mice.

METHODS: To accomplish this, two inbred mouse strains differing in isoflurane MAC, the C57BL/6J and LP/J mouse strains, were bred through two generations to produce genetic recombination. These animals were genotyped for microsatellite markers. We also applied an independent, computational method for identifying QTL-regulating differences in isoflurane MAC. In this approach, the isoflurane MAC was measured in a panel of 19 inbred strains, and computationally searched for genomic intervals where the pattern of genetic variation, based on single nucleotide polymorphisms, correlated with the differences in isoflurane MAC among inbred strains.

RESULTS AND CONCLUSIONS: Both methods of genetic analysis identified a QTL for isoflurane MAC that was located on the proximal part of mouse chromosome 7.


呼吸音声学监测在单肺插管定位中的应用

Acoustic Monitoring of Lung Sounds for the Detection of One-Lung Intubation

S. Tejman-Yarden, MD*, A. Zlotnik, MD{dagger}, L. Weizman, MSc{ddagger}, J. Tabrikian, PhD{ddagger}, A. Cohen, PhD{ddagger}, N. Weksler, MD{dagger}, and G. M. Gurman, MD{dagger}

From the Divisions of *Pediatrics; {dagger}Anesthesiology and Critical Care, Soroka Medical Center; and {ddagger}Electrical and Computer Engineering Department, Ben Gurion University of the Negev, Beer-Sheva, Israel.

Anesth Analg 2007 105: 397-404.

 

背景:传统的早期确定单肺插管(OLI)方法缺乏特异性且存在争议。在此项研究中,作者评估了OLI的新的声学监测系统。

方法:收集24个预定行常规外科手术对象的呼吸音。在麻醉诱导和气管插管定位时,使用4个压电传声器放置于背部行呼吸音采样。为了OLI,气管内导管置入气管并逐渐深入直到左侧胸壁呼吸音减弱、消失。再逐步退管直至双侧呼吸音对称。光导纤支镜确定最终的导管位置。声学分析通过多重输入多重输出(MIMO)系统,其中多元自回归模型测定进肺与出肺相关的声音并分级,通过广义似然比检验确定通气肺数目,而不需通过原始呼吸音数据重建。

结果:此项OLI检测运算有95.2%的灵敏度和4.8%的假阳性率。

结论:更高的灵敏度需要以更高的假阳性率为代价。

(於章杰 陈杰 校)

INTRODUCTION: Monitoring methods for the early diagnosis of one-lung intubation (OLI) are nonspecific and controversial. In this study, we evaluated a new acoustic monitoring system for the detection of OLI.

METHODS: Lung sounds were collected from 24 adult surgical patients scheduled for routine surgical procedures. Four piezoelectric microphones attached to the patients' backs were used to sample lung sounds during induction of anesthesia and endotracheal tube positioning. To achieve OLI, the endotracheal tube was inserted and advanced down the airway so that diminished or no breath sounds were heard on the left side of the chest. The tube was then withdrawn stepwise until equal breath sounds were heard. Fiberoptic bronchoscopy confirmed the tube's final position. Acoustic analyses were preformed by a new algorithm which assumes a Multiple Input Multiple Output system, in which a multidimensional Auto-Regressive model relates the input (lungs) and the output (recorded sounds) and a classifier, based on a Generalized Likelihood Ratio Test, indicates the number of ventilated lungs without reconstructing the original lung sounds from the recorded samples.

RESULTS: This algorithm achieved an OLI detection probability of 95.2% with a false alarm probability of 4.8%.

CONCLUSION: Higher detection values can be achieved at the price of a higher incidence of false alarms.


病人对麻醉满意度的预测因素

Factors Predictive of Patient Satisfaction with Anesthesia

Maurizia Capuzzo, MD*, Giuseppe Gilli{dagger}, Laura Paparella, MD{ddagger}, Gaetano Gritti, MD§, Davide Gambi, MD||, Margherita Bianconi, MD, Francesco Giunta, MD#, Cosimetta Buccoliero, MD*, and Raffaele Alvisi, MD*

From the *Department of Surgical, Anesthetic and Radiological Sciences, Section of Anesthesiology and Intensive Care, and {dagger}Department of Health Physics, University Hospital of Ferrara, Ferrara; {ddagger}Departments of Medical and Surgical Specialties, and §Medicine, Surgery, and Critical Care, Section of Anesthesiology and Intensive Care, University Hospital, Florence; ||Service of Anesthesia and Intensive care, Hospital Nuovo Ospedale S. Giovanni di Dio, Florence; ¶Department of Emergency, Section of Anesthesia and Intensive Care, University Hospital of Ferrara, Ferrara; #Department of Anesthesiology and Intensive Care, University Hospital of S. Chiara, Pisa, Italy.

Anesth Analg 2007 105: 435-442.

背景:在这个多因素的前瞻性研究中,作者通过对术后至少住院24小时的病人进行观察以发现影响病人对麻醉满意度的相关因素。

方法:研究在六个中心进行。病人年龄都在18岁以上,并且所接受的普外科手术种类范围很广,他们被要求回答10个有关对麻醉满意度的问题(总分,010)和一些相关问题来评估他们以往的健康状况(总分010)。麻醉科工作人员也被邀填写一份Maslach Burnout调查。

结果:结果收到了1290位病人的满意评估问卷(平均年龄在61±16岁,男性占54.4%)。总体平均满意度积分为8.795%可信区间:8.7-8.8),<9的有632人(49%),≥9的有658人(51%)。Maslach Burnout调查中有55位麻醉医师和68位护士递交了答卷。通过对总体平均满意度积分≥9的人群进行多变量回归分析,发现有五个因素起了重要的作用:1)接受过麻醉专业护理人员围手术期护理;2)术前给予麻醉宣传单;3)术后至少有两个麻醉医师访视;4)既往健康状况积分>8.55)年龄大于70岁。工作人员的劳累程度与病人的满意度无任何关联。

结论:住院病人的满意度可以通过以下几个方面得以改善:外科病房护理由麻醉专业的护理人员承担,术前给病人一份书面的麻醉信息宣传单以及术后加强访视。

(杜唯佳 陈杰 校)

BACKGROUND: In this multicenter prospective study, we identified factors associated with satisfaction with anesthesia in patients staying in hospital at least 24 h after surgery.

METHODS: The study was performed in six centers. Inpatients aged more than 18 yr, who underwent a wide range of common surgical procedures, were asked to answer a 10-item instrument to measure patient satisfaction with anesthesia (mean score range, 0–10) and some specific questions, and to rate their perceived health (score, 0–10). Anesthesia staff members were invited to self-compile a Maslach Burnout Inventory.

RESULTS: The satisfaction evaluation questionnaire was returned by 1290 patients (mean age, 61 ± 16 yr; males, 54.4%). The mean global satisfaction score was 8.7 (95% CI: 8.7–8.8), being <9 in 632 (49%) and ≥9 in 658 (51%) patients. The Maslach Burnout Inventory was returned by 55 anesthesiologists and 68 nurses. Multivariate regression identified five variables as significant predictors of a mean global satisfaction of ≥9: 1) having been treated in a service with perioperative nurses specifically dedicated only to anesthesia; 2) having been treated where anesthesia information leaflets were provided preoperatively; 3) having received more than two anesthesiologist visits after surgery; 4) having a perceived health score >8.5; and 5) being older that 70 yr. No relationship was found between staff burnout and patient satisfaction.

CONCLUSIONS: Inpatient satisfaction can be improved by an organization in which surgical suite nurses are dedicated only to anesthesia, a written anesthesia information leaflet is given during the preoperative visit and postoperative visits are enhanced.


胸段硬膜外镇痛在实验性胰腺炎中对受体依赖性及非受体依赖性肺血管收缩中的作用

The Role of Thoracic Epidural Analgesia in Receptor-Dependent and Receptor-Independent Pulmonary Vasoconstriction in Experimental Pancreatitis

Stefan Lauer, MD*, Hendrik Freise, MD*, Lars G. Fischer, MD*, Kai Singbartl, MD*, Hugo V. Aken, MD, FRCA, FANZCA*, Markus M. Lerch, MD{dagger}, and Andreas W. Sielenkämper, MD, MSc*

From the *Department of Anesthesiology and Intensive Care Medicine, University Hospital Muenster, Germany; and {dagger}Department of Gastroenterology, Endocrinology and Nutrition, Ernst-Moritz-Arndt Universität, Greifswald, Germany.

Anesth Analg 2007 105: 453-459.

 

背景:急性胰腺炎通常会导致肺部损伤、肺血管内皮细胞功能的损害以及肺血管收缩影响。如果暂不考虑胸段硬膜外腔镇痛(TEA)在严重疾病中可能带来的各种潜在危险,该技术在部分胰腺炎病人的镇痛方面是颇为重要的。尽管有证据显示硬膜外镇痛通过有效镇痛能改善肺功能,但连续硬膜外阻滞对肺血管内皮细胞的功能损害有何作用尚未清楚。

方法:在清醒的患胰腺炎大鼠在体模型上,进行TEA,同时监测血气、动脉血压、呼出气一氧化氮。随后在离体肺灌流模型中研究受体依赖性及非受体依赖性肺血管收缩。通过监测肺髓过氧物酶活性反映白细胞在肺部的聚集,通过监测干/湿比例反映肺水肿情况。

结果:急性胰腺炎期间会损害肺的氧合能力、代谢情况,以及引起乳酸酸中毒和呼出气一氧化氮水平升高,而这些情况在假手术组中显示可被TEA所改善 TEA能部分改善胰腺炎中发生的低血压。离体肺灌流模型中,与血管紧张素I I相关受体依赖性肺血管收缩功能在急性胰腺炎期间下降,反映出肺血管平滑肌细胞功能损害。低氧性肺血管收缩功能同样受到损害。而采用TEA能部分恢复肺血管对血管紧张素I I和低氧刺激的收缩反应。缓激肽诱导产生肺血管收缩,反映出肺内皮细胞功能损害、肺髓过氧物酶活性及肺水肿程度均不受TEA影响。

结论:研究证实了TEA改善胰腺炎相关的肺血管反应能力及气体交换能力的损害。

(陶颖莹 陈杰 校)

BACKGROUND: Acute pancreatitis commonly results in lung injury and deterioration of pulmonary endothelial function and vasoregulation. Despite a variety of potential risks with the use of thoracic epidural analgesia (TEA) in the critically ill, this technique is an important component of pain management in pancreatitis in selected cases. Although there is evidence that epidural analgesia improves lung function through effective pain relief, the influence of continuously applied epidural local anesthetics on pulmonary endothelial dysfunction is still unknown.

METHODS: In an in vivo model of TEA in awake rats with acute pancreatitis, we evaluated blood gas analysis, arterial blood pressure, and exhaled nitric oxide. This was followed by in vitro studies of receptor-dependent and receptor-independent pulmonary vasoconstriction using an isolated perfused lung model. Pulmonary myeloperoxidase activity, indicating leukocyte sequestration into the lungs and wet/dry ratio evaluating pulmonary edema, were also measured.

RESULTS: Deteriorated oxygenation, metabolic and lactate acidosis, as well as exhaled nitric oxide levels occurring during acute pancreatitis, were reduced by TEA to levels observed in sham-operated animals. TEA also partially ameliorated the hypotension occurring in pancreatitis. In isolated perfused lungs, receptor-dependent vasoconstriction due to angiotensin II was reduced during acute pancreatitis, indicating pulmonary vascular smooth muscle cell dysfunction. Hypoxic pulmonary vasoconstriction was likewise abolished. Treatment with TEA partly restored the vasoreactivity to angiotensin II and hypoxia. Bradykinin-induced vasoconstriction, indicating pulmonary endothelial dysfunction, myeloperoxidase activity and the degree of pulmonary edema, was not influenced by TEA.

CONCLUSIONS: Our study demonstrated that TEA improves pancreatitis-associated impairment of pulmonary vasoreactivity and gas exchange.

 

 

乳房手术前应用非类固醇类抗炎药(罗非考昔)中加入地塞米松会延长术后镇痛效应

The Prolonged Postoperative Analgesic Effect When Dexamethasone Is Added to a Nonsteroidal Antiinflammatory Drug (Rofecoxib) Before Breast Surgery

Hval Kjetil, MD*, Thagaard K. Sem, MD*, Schlichting Ellen, MD, PhD{dagger}, and Raeder Johan, MD, PhD*

From the Departments of *Anaesthesia and {dagger}Surgery, Ullevaal University Hospital; and University of Oslo, Faculty Division, Ullevaal University Hospital, Oslo, Norway.

Anesth Analg 2007 105: 481-486.

 

背景:糖皮质激素具有镇痛效应。在这个研究中,作者评价了地塞米松在包括长效非类固醇类抗炎药的多模式术后镇痛中的效果。

方法:一百名接受乳癌手术的病人作为研究对象。他们在异丙酚和瑞芬太尼麻醉前口服扑热息痛2g和罗非考昔50mg,这些病人以双盲、随机接受地塞米松16mg静脉注射或安慰剂。在手术结束前,两组病人都接受静脉注射芬太尼1ug/kg和伤口处局部浸润0.25%布比卡因2040ml.

结果:术后刚开始的4h内在疼痛评分或抢救药物治疗中两组间没有差别。安慰剂组病人,咳嗽或肩膀活动时的疼痛均分是3(以010分比例),而地塞米松组疼痛均分是1,没达到统计学意义(P0.06)。在术后2472h内,安慰剂组病人,咳嗽或肩膀活动时的疼痛均分是2,而地塞米松组是1,有统计学意义(P0.05)。在术后424h地塞米松组病人40%不痛,安慰剂组为24%,差异无统计学意义(P0.09)。在术后2472h内地塞米松组不痛的病人为46%,安慰剂组为28%(P0.06)。地塞米松组术后第一个晚上睡眠质量差的病人(68%)较对照组多(44%)(P0.05

结论:地塞米松16mg加到包括有非类固醇类抗炎药(罗非考昔)的多模式镇痛法中,延长(24h72h)术后镇痛效应。

(张燕 陈杰 校)

BACKGROUND: Glucocorticoids provide analgesia. In this study, we evaluated the effects of adding dexamethasone to a multimodal postoperative analgesic regimen, including a long-acting nonsteroidal antiinflammatory drug.

METHODS: One-hundred patients admitted for ambulatory breast cancer surgery were studied. They received paracetamol 2 g and rofecoxib 50 mg orally 1 h before start of general anesthesia with propofol and remifentanil. The patients were then randomized to receive, in a double-blind manner, either dexamethasone 16 mg IV or placebo. Both groups received fentanyl 1 µg/kg IV and 20–40 mL bupivacaine 2.5 mg/mL wound infiltration before the end of surgery.

RESULTS: There was no difference in pain scores or rescue medication between the groups during the first 4 h after surgery. After discharge, the median pain score during coughing or shoulder movement was 3 on a 0–10 scale in patients receiving placebo, and 1 in the patients receiving dexamethasone, which did not reach statistical significance (P = 0.06). From 24 to 72 h, the median pain with coughing or shoulder movement in patients receiving placebo was 2, and 1 in patients receiving dexamethasone, which did reach statistical significance (P < 0.05). Forty percent of patients receiving dexamethasone were pain free from 4 to 24 h, compared with 24% of patients receiving placebo, a difference that did not reach statistical significance (P = 0.09). Similarly, 46% of patients receiving dexamethasone were pain free from 24 to 72 h, compared with 28% of patients receiving placebo (P = 0.06). More patients had slept poorly on the first night in the dexamethasone group than in the control group, 68% vs 44%, (P < 0.05).

CONCLUSIONS: Dexamethasone 16 mg provides prolonged postoperative analgesia from 24 to 72 h after surgery when added to a multimodal regimen including nonsteroidal antiinflammatory drug (rofecoxib).

 

 

三种不同浓度的罗哌卡因联合芬太尼用于病人自控硬膜外镇痛的比较

A Comparison of Three Different Concentrations of Ropivacaine with Fentanyl for Patient-Controlled Epidural Analgesia

Tetsuya Iijima, MD*, Tadahiko Ishiyama, MD, PhD*, Satoshi Kashimoto, MD, PhD*, Toshiaki Yamaguchi, MD, PhD*, Tomio Andoh, MD, PhD*, Kazumi Hanawa, MSc{dagger}, Izumi Tanzawa, BSc{dagger}, Keisi Kawata, BSc{dagger}, Takehisa Hanawa, PhD{dagger}, and Yoshimitsu Hiejima, PhD{ddagger}

From the *Department of Anesthesiology, Faculty of Medicine, University of Yamanashi; {dagger}Department of Pharmacy, University of Yamanashi Hospital, Yamanashi, Japan; and {ddagger}School of Nursing, Faculty of Healthcare, Tokyo Healthcare University, Tokyo, Japan.

Anesth Analg 2007 105: 507-511.

背景:罗哌卡因联合芬太尼用于病人自控硬膜外镇痛以保存肠道功能,提供镇痛作用并保存活动能力的理想浓度仍不清楚。

方法:312名拟行妇科下腹部手术的女性患者随机分别接受005%0.075%.和0.1%罗哌卡因联合14ug/ml芬太尼,25ug/ml氟哌利多。病人自控硬膜外镇痛设定如下:初始 剂量5ml,夜间输注速度2ml/h,白天时间不予输注,一次快速输注量为2ml,锁定时间为10分钟,肠道功能评定首先通过排气和排便,疼痛评定通过主观视觉角度,肠蠕动功能评定通过Bromage评分。资料收集在同一天手术日,术后第一天的早上和晚上以及术后第二天的早上。

结果:在这三个组中胃肠道的动力没有什么不同,三个组的结果表明产生相同的镇痛效果和肠蠕动功能没有减弱。

结论:0.05%罗哌卡因能提供保存良好的胃肠道功能,优异的术后疼痛,且无运动阻滞。

(陈伟 陈杰 校)

BACKGROUND: The optimal concentration of ropivacaine in combination with fentanyl for patient-controlled epidural analgesia focusing on preservation of bowel function, analgesia, and motor function remains unclear.

METHODS: Three hundred-twelve women scheduled to undergo gynecologic lower abdominal surgery, were randomly allocated to receive ropivacaine 0.05, 0.075, or 0.1% in combination with fentanyl 4 µg/mL and droperidol 25 µg/mL. The settings of patient-controlled epidural analgesia were as follows: initial loading volume 5 mL, background infusion 2 mL/h during night-time, no background infusion during daytime, bolus volume 2 mL, and lockout interval 10 min. Bowel function was evaluated by the first passage of flatus and feces. Pain was assessed with a visual analog scale, and motor function was examined by modified Bromage scale. Data were collected in the evening on the day of surgery, in the morning and in the evening on the first postoperative day, and in the morning on the second postoperative day.

RESULTS: Gastrointestinal motility was not different among the three groups. All three solutions produced equivalent analgesia and no motor blockade.

CONCLUSION: We conclude that ropivacaine 0.05% is sufficient to preserve gastrointestinal motility, and provides excellent postoperative pain relief without motor blockade.


罗哌卡因脊麻在下肢手术中应用:剂量-效应的研究

Spinal Ropivacaine for Lower Limb Surgery: A Dose–Response Study

Ying Y. Lee, FFARCSI, MScPainM*{dagger}, Warwick D. Ngan Kee, MD*, Hang K. Chang, MBBS{dagger}, Chi L. So, MBBS{dagger}, and Tony Gin, MD*

From the *Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China; {dagger}Department of Anaesthesiology and Operating Theatre Services, Kwong Wah Hospital, Kowloon, Hong Kong SAR, China.

Anesth Analg 2007 105: 520-523.

 

背景:罗哌卡因脊麻在下肢手术中药物剂量与效应之间的关系尚未完全明确。

方法:作者前瞻性、随机、双盲研究60名拟在腰-硬联合麻醉下行下肢手术的患者。患者鞘内分别注射五种剂量的罗哌卡因(用生理盐水稀释至2.8ml):2471014mg。如果一个剂量可以在20分钟内使病人T12水平两侧的皮肤冷感觉阻断,且能够至少维持50分钟内不追加药物并确保手术的进行,这一剂量就认定为有效。

结果:设定的五个剂量的成功率分别是:0%,0%,42%,83%,100%。并由此衍算出罗派卡因的ED507.6mg95CI:6.28.7mg),ED9511.4mg95CI:9.718.3mg)。且随着剂量的增加向头测的感觉和运动的阻滞平面逐渐上升。

结论:罗哌卡因在50min左右的下肢外科手术中的ED50,ED95分别是7.6mg11.4mg。这一结果为我们在不同的临床情况下选择最佳罗哌卡因的麻醉剂量提供了的依据。

Abstract

BACKGROUND: The dose–response relationship for spinal ropivacaine in patients undergoing surgery of the lower extremity has not been fully determined.

METHODS: We performed a prospective, randomized, double-blind study of 60 patients scheduled for lower limb surgery under combined spinal–epidural anesthesia. Patients were assigned to receive 1 of 5 doses of intrathecal ropivacaine: 2, 4, 7, 10, or 14 mg diluted to 2.8 mL with normal saline. A dose was considered successful if a sensory block to cold was achieved bilaterally at the T12 dermatome within 20 min and surgery proceeded without supplementation for at least 50 min.

RESULTS: Anesthesia was successful in 0, 0, 42, 83, and 100% of the 2, 4, 7, 10, and 14 mg groups, respectively. The derived value for ED50 was 7.6 mg (95% CI: 6.2–8.7 mg) and for ED95 was 11.4 mg (95% CI: 9.7–18.3 mg). The cephalic level of sensory block and the degree of motor block increased with larger doses of ropivacaine.

CONCLUSION: The ED50 and ED95 for spinal ropivacaine in lower limb surgery of 50 min duration or less were 7.6 and 11.4 mg, respectively. This provides a useful guide for clinicians to choose the optimal dose of spinal ropivacaine under different clinical situations.

 

5%利多卡因进行腰麻的麻醉持续时间在长期滥用阿片类药物者用与非滥用者间的比较

The Duration of Spinal Anesthesia with 5% Lidocaine in Chronic Opium Abusers Compared with Nonabusers

Maryam Vosoughian, MD*, Ali Dabbagh, MD*, Samira Rajaei, MD{dagger}, and Hassan Maftuh, MD*

From the *Department of Anesthesiology, Faculty of Medicine, Shaheed Beheshti University; and {dagger}Department of Immunology, Faculty of Medicine, Tehran University, Tehran, Iran.

Anesth Analg 2007 105: 531-533.

 

背景:既往研究显示长期滥用阿片类药物者的痛阈较低。本研究作者试图证明长期滥用阿片类药物影响局麻药蛛网膜下腔阻滞时的麻醉持续时间。

 方法:在这项病例对照研究中,从大学附属医院的所有入院需要进行择期下腹部手术的病人中选出50名滥用阿片类药物者及50名非滥用阿片类药物者。所有的病人接受5%的高浓度不含防腐剂的利多卡因100mg及葡萄糖配成的混合药液进行蛛网膜下腔阻滞。

结果:滥用阿片类药物者的麻醉持续时间(60±7 min)比非滥用阿片类药物者(83±10min) 明显缩短(P0.0001)

 结论:阿片类药物滥用者蛛网膜下腔阻滞的麻醉持续时间缩短。

(潘钱玲 陈杰 校)

BACKGROUND: It has been demonstrated that chronic opium abusers have lower thresholds for pain. In this study we sought to determine whether chronic opium abuse has any effect on the duration of spinal block by local anesthetics.

METHODS: In a case-controlled study, 50 opium abusers and 50 nonabusers undergoing lower abdomen operations were selected from among the patients admitted to a university hospital for elective surgery. All patients received 100 mg hyperbaric preservative-free 5% lidocaine in dextrose, intrathecally.

RESULTS: The duration of anesthesia was much shorter in the opium abusers (60 ± 7 min) than in the nonabusers (83 ± 10 min) (P < 0.0001).

CONCLUSION: The study documents a shortened duration of spinal block in opium abusers.


酚卞明对左心发育不良综合征的治疗作用:一项核心综述

Phenoxybenzamine in the Treatment of Hypoplastic Left Heart Syndrome: A Core Review

Nina A. Guzzetta

From the Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia.

Anesth Analg 2007 105: 312-315.

 

对新生儿行Norwood心脏重建术后的围手术处理是相当复杂的。新生儿单个的心室储备及肺动脉和全身的循环对肺血流和全身的血流形成了细微的平衡。精细地调控肺和全身血管阻力对预防额外的肺血流对全身氧供的消耗十分必要。一项新兴的旨在改善早期死亡率的治疗策略是在手术过程中使用酚卞明,一种全身性血管扩张剂。最大限度的全身血管扩张被认为会减少心室的前负荷,并能通过改善术后全身血管阻力的波动来使得循环更为稳定。虽然这种策略在很多中心已经普及,但却没有经过仔细的审查。在接下来的综述里介绍了酚卞明药理的概述,Norwood术式的外科和生理过程和赞成使用或反对使用酚卞明的讨论。

(张 俪译 薛张纲校)

Perioperative management of neonates after the Norwood procedure is extremely complex. Limited reserve of the neonatal single ventricle and the parallel arrangement of the pulmonary and systemic circuits result in a tenuous balance between pulmonary and systemic blood flows. Precise manipulations of both pulmonary and systemic vascular resistance are necessary to prevent excessive pulmonary blood flow at the expense of systemic oxygen delivery. An emerging treatment strategy aimed at improving early mortality is the intraoperative administration of phenoxybenzamine, a profound systemic vasodilator. Maximum systemic vasodilation is thought to reduce afterload of the single ventricle and produce a more stable parallel circulation by ameliorating the postoperative fluctuations in systemic vascular resistance. Although this strategy has gained popularity at many centers, it is not without scrutiny. The following review provides an overview of the pharmacology of phenoxybenzamine, the surgical and physiologic implications of the Norwood procedure, and a discussion of the pros and cons of phenoxybenzamine administration.

 

 

先心患者行心脏手术发生与麻醉相关的心脏停搏的频率

The Frequency of Anesthesia-Related Cardiac Arrests in Patients with Congenital Heart Disease Undergoing Cardiac Surgery
Kirsten C. Odegard, MD*, James A. DiNardo, MD*, Barry D. Kussman, MBBCh, Avinash Shukla, MD*, James Harrington, MD*, Al Casta, MD*, Francis X. McGowan, Jr, MD*, Paul R. Hickey, MD*, Emile A. Bacha, MD, Ravi R. Thiagarajan, MBBS, and Peter C. Laussen, MBBS*

From the Departments of *Anesthesiology, Perioperative and Pain Medicine, {dagger}Cardiac Surgery, and {ddagger}Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007 105: 335-343.

 

背景:据报道,儿科麻醉中麻醉相关的心脏停搏频率为每10000例中有1.4-4.6例。ASA评分>III及年幼是危险因子。先心病人可能有更高的危险性。因此,在此项研究中,我们评估在一个大型儿科治疗中心欲行心脏手术的先心患者发生麻醉相关的心脏停搏的频率。

方法:根据建立的数据登记显示,从20001月到200512月,所有的心脏停搏都发生于心脏手术室。一次心脏停搏被定义为任何需要胸外或胸内按压的,不管有没有直接的电复律。被认为与麻醉相关的事件被分为很可能相关或可能相关。结果:在5213例麻醉中有40个病人发生了41次心脏停搏(平均年龄2.9个月;范围为2-23岁),总体发生率为0.79%78%发生于要求心肺旁路的开放过程,22%发生于不要求心肺旁路的闭和过程。11例心脏停搏被分类为与麻醉极相关(n=6)或可能相关(n=5),(每10000例麻醉中21.1例)但没有死亡的;30例被分类为操作相关。新生儿与麻醉相关的,或与操作相关的心脏停搏发生率最高。这与事件发生的年份及麻醉医师的经验无关。结论:行心脏手术的病人发生与麻醉相关的心脏停搏的频率有所增加,但与增加的死亡率并没有关系。新生儿和婴儿为高风险人群。仔细的术前准备和预防对保证及时有效的复苏非常重要。

(孙 霞译 薛张纲校)

BACKGROUND: The frequency of anesthesia-related cardiac arrests during pediatric anesthesia has been reported between 1.4 and 4.6 per 10,000 anesthetics. ASA physical status >III and younger age are risk factors. Patients with congenital cardiac disease may also be at increased risk. Therefore, in this study, we evaluated the frequency of cardiac arrest in patients with congenital heart disease undergoing cardiac surgery at a large pediatric tertiary referral center. METHODS: Using an established data registry, all cardiac arrests from January 2000 through December 2005 occurring in the cardiac operating rooms were reviewed. A cardiac arrest was defined as any event requiring external or internal chest compressions, with or without direct cardioversion. Events determined to be anesthesia-related were classified as likely related or possibly related. RESULTS: There were 41 cardiac arrests in 40 patients (median age, 2.9 mo; range, 2 days to 23 yr) during 5213 anesthetics over the time period, for an overall frequency of 0.79%; 78% were open procedures requiring cardiopulmonary bypass and 22% closed procedures not requiring cardiopulmonary bypass. Eleven cardiac arrests (26.8%) were classified as either likely (n = 6) or possibly related (n = 5) to anesthesia, (21.1 per 10,000 anesthetics) but with no mortality; 30 were categorized as procedure-related. The incidence of anesthesia-related and procedure-related cardiac arrests was highest in neonates (P < 0.001). There was no association with year of event or experience of the anesthesiologist. CONCLUSION: The frequency of anesthesia-related cardiac arrest in patients undergoing cardiac surgery is increased, but is not associated with an increase in mortality. Neonates and infants are at higher risk. Careful preparation and anticipation is important to ensure timely and effective resuscitation.

 

 

针对儿童的近期研究信息:关于两种方法的报告

Presenting Research Information to Children: A Tale of Two Methods

Alan R. Tait, PhD, Terri Voepel-Lewis, MSN, RN, and Shobha Malviya, MD

From the Department of Anesthesiology, University of Michigan Health System, Ann Arbor, Michigan.

Anesth Analg 2007 105: 358-364.

 

背景:儿童的研究信息常以一种难以理解的方式呈现。因此,我们设计了这个研究,用来检测关于儿童理解力的书面研究信息,提高了可读性和可行性后的效果。方法:190717岁的住院儿童参与了研究,他们有的接受手术治疗,有的接受药物治疗,并且随机的受到一份标准的研究资料或是一份提高了可读性和可行性的改良版。然后孩子们接受面试,确定他们对八个研究单元的理解,包括风险、权益、方案等,他们的反应由两名独立的鉴定人员记录。结果:被随机分配到改良版的孩子对资料的总体理解和对方案和权益的理解都明显优于另一组(P<0.05)。改良版对较幼小的孩子(710岁)对材料的理解的提高更为有效,包括改良的版式、年龄,阅读能力和孩子阅读资料的程度。对于两种版式,81.3%的孩子更倾向于改良版,因为它更易于接受和阅读。大字体和插图的应用也很受欢迎。结论:这一研究结果表明:为了更好的满足儿童不同年龄和阅读认知能力而对研究资料作出的改良可以提高他们对材料的理解力和接受力。

(王时来译 薛张纲校)

BACKGROUND: Research information for children is often presented in a manner that is difficult to understand. We designed this study, therefore, to examine the effect of improved readability and processability of written study information on childrens' understanding. METHODS: One-hundred-ninety children aged 7–17 yr who were hospitalized for a surgical procedure or medical treatment were randomized to receive study information using either a standard form or a modified form with improved readability and processability. Children were interviewed to determine their understanding of eight study elements, including the risks, benefits, protocol, etc., and their responses scored by two independent assessors. RESULTS: Children who were randomized to the modified form had significantly greater overall understanding of the information and greater understanding of the protocol and benefits (P < 0.05). The modified form was particularly effective in improving younger children's (7–10 yr) understanding of the material. Multivariate analysis identified several predictors of understanding, including the modified format, age, reading ability and the degree to which the child read the information. When shown both forms, 81.3% of children preferred the modified form stating that it was "friendlier" and "easier to read." The use of a larger font size and pictures were particularly popular. CONCLUSIONS: Results of this study suggest that modification of study information to better fit the ages and meet the reading and cognitive abilities of children results in their improved understanding and acceptance of the material.

 

 

鼻内用右旋美托咪啶镇静及镇痛作用的双盲交叉实验评估

A double-blind, crossover assessment of the sedative and analgesic effects of intranasal dexmedetomidine.

Vivian M. Yuen, Michael G. Irwin, Theresa W. Hui, Man K. Yuen, and Libby H. Y. Lee

From the Department of Anaesthesiology, Queen Mary Hospital, University of Hong Kong, Hong Kong.

Anesth Analg 2007 105: 374-380.

 

背景:α2受体激动剂右旋美托咪啶具有易唤醒的镇静作用以及无呼吸抑制的镇痛作用.这些特性可能使之成为很有用的麻醉术前用药,尽管外周给药并不可取.我们通过健康志愿者鼻内用右旋美托咪啶来评估其镇静,抗焦虑,镇痛和血流动力学作用.方法:实验采用了KOCH设计,双盲交叉对照的方法.实验共分成3组,A安慰剂组 B鼻内用右旋美托咪啶组(1毫克/公斤体重)C右旋美托咪啶组(1.5毫克/公斤体重).18个研究对象都参与到2个实验期.在进行了基础的各项改良评估如警觉/镇痛比度表,视觉直观疼痛比度表,脑电双频指数,视觉直观焦虑比度表,电子测痛仪测得的疼痛阈,收缩压和舒张压,心率以及呼吸频率,氧饱和度后给药.这些检测在每期研究中都重复进行.结果: 鼻内用右旋美托咪啶是可以耐受的.通过发现脑电双频指数,收缩压和舒张压,心率的下降,无论1mg/kg还是1.5mg/kg的右旋美托咪啶都比安慰剂组有更显著的镇静作用.给药后45分钟产生效果,其镇痛效果的峰值发生在90-150分钟后.A,B,C组收缩压最大下降值分别为6%,23%和21%.而对疼痛阈,氧饱和度以及呼吸频率却没有影响.由于在基础水平研究对象都没有焦虑,其抗焦虑作用不能被评估.结论: 右旋美托咪啶的鼻内用药途径是有效方便可行的.今后的研究将把重点放在无创途径用右旋美托咪啶对于各种临床情况的价值评估上,包括其用于诱导前的麻醉用药.

(施 杨译 薛张纲校)

BACKGROUND: The alpha2-receptor agonist, dexmedetomidine, provides sedation with facilitated arousal and analgesia with no respiratory depression. These properties render it potentially useful for anesthesia premedication, although parenteral administration is not practical in this setting. We designed this study to evaluate the sedative, anxiolytic, analgesic, and hemodynamic effects of dexmedetomidine administered intranasally in healthy volunteers. METHODS: Koch's design for crossover trials (three-treatment and two-period design) was adopted. The study was double-blind and there were three treatment groups: A (placebo), B (intranasal dexmedetomidine 1 microg/kg) and C (intranasal dexmedetomidine 1.5 microg/kg). Each of the 18 subjects participated in two study periods. The study drug was administered intranasally after baseline observations of modified Observer Assessment of Alertness/Sedation Scale, visual analog scale of sedation, bispectral index, visual analog scale of anxiety, pain pressure threshold measured by an electronic algometer, systolic blood pressure (SBP) and diastolic blood pressure, heart rate, respiratory rate, and oxygen saturation. These were repeated during the course of the study. RESULTS: Intranasal dexmedetomidine was well tolerated. Both 1 and 1.5 microg/kg doses equally produced significant sedation and decreases in bispectral index, SBP, diastolic blood pressure, and heart rate when compared with placebo (P < 0.05). The onset of sedation occurred at 45 min with a peak effect at 90-150 min. The maximum reduction in SBP was 6%, 23%, and 21% for Groups A, B, and C respectively. There was no effect on pain pressure threshold, oxygen saturation or respiratory rate. Anxiolysis could not be evaluated as no subjects were anxious at baseline. CONCLUSION: The intranasal route is effective, well tolerated, and convenient for the administration of dexmedetomidine. Future studies are required to evaluate the possible role of the noninvasive route of administration of dexmedetomidine in various clinical settings, including its role as premedication prior to induction of anesthesia.

 

 

增塑剂邻苯二甲酸二异辛酯调制A型γ-氨基丁酸和甘氨酸受体的功能

The Plasticizer Di(2-ethylhexyl) Phthalate Modulates {gamma}-Aminobutyric Acid Type A and Glycine Receptor Function

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

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

Anesth Analg 2007 105: 393-396.

 

介绍:由聚氯乙烯(PVC)组成的静脉(IV)液体袋含有邻苯二甲酸二异辛酯(DEHP),使PVC具有伸缩性。据报道,邻苯二甲酸酯能够抑制对吸入麻醉药敏感的神经元烟碱型乙酰胆碱受体。这增加了DEHP调制其它半胱氨酸环受体的功能,诸如A型γ-氨基丁酸(GABAA)和甘氨酸受体,这样,DEHP增塑的PVC干扰了这些受体的麻醉机制的电生理研究。方法:{alpha}1ß2 GABAA{alpha}1甘氨酸受体能在非洲爪蟾卵母细胞中表达并且通过双电极电压钳夹法研究测得。我们用激动剂诱导的电流测量含DEHP增塑的PVC的静脉容量袋以及DEHP饱和度的缓冲效应。结果:甘氨酸受体的激动剂诱导的电流被含DEHP增塑的PVC的静脉容量袋的缓冲增加了291.9% ± 84.5%,被DEHP饱和度的缓冲增加了70.8% ± 16.7%{alpha}1ß2 GABAA受体的激动剂诱导的电流被含DEHP增塑的PVC的静脉容量袋的缓冲减少了19.3% ± 3.2%,被DEHP饱和度的缓冲减少了31.7% ± 7.0%。结论:增塑剂DEHP同时调制了GABAA和甘氨酸受体的功能。如果DEHP增塑的PVC出现在实验装置中,DEHP污染会混杂这些受体麻醉机制的电生理研究的结果。

(陈佳莉译 薛张刚校)

INTRODUCTION: Intravenous (IV) fluid bags made of polyvinyl chloride (PVC) often contain the plasticizer di(2-ethylhexyl) phthalate (DEHP) to make the PVC flexible. Phthalate esters have been reported to inhibit neuronal nicotinic acetylcholine receptors, which are sensitive to many inhaled anesthetics. This raises the possibility that DEHP might modulate the function of other cys-loop receptors, such as {gamma}-amino butyric acid type A (GABAA) and glycine receptors, and that DEHP-plasticized PVC might interfere with electrophysiologic studies of anesthetic mechanisms on those receptors. METHODS: {alpha}1ß2 GABAA and {alpha}1 glycine receptors were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping. We then measured the effect of buffers from IV bags containing DEHP-plasticized PVC, and of buffers saturated with DEHP, on agonist-induced currents. RESULTS: Agonist-induced currents from glycine receptors were enhanced by buffers from IV bags containing DEHP-plasticized PVC by 291.9% ± 84.5% (mean ± se) and from saturated solutions of DEHP by 70.8% ± 16.7%. Agonist-induced currents from {alpha}1ß2 GABAA receptors were inhibited by buffers from IV bags containing DEHP-plasticized PVC by 19.3% ± 3.2% and by 31.7% ± 7.0% from buffers saturated with DEHP. CONCLUSIONS: The plasticizer DEHP modulates the function of both GABAA and glycine receptors. DEHP contamination can confound the results of electrophysiologic studies of anesthetic mechanisms on these receptors if DEHP-plasticized PVC is present in the experimental apparatus.

 

 

持续血氧和二氧化碳监测揭示病人自控镇痛患者中频发的低氧饱和度和呼吸缓慢

Continuous Oximetry/Capnometry Monitoring Reveals Frequent Desaturation and Bradypnea During Patient-Controlled Analgesia

Frank J. Overdyk, MSEE, MD, Diplomate ABA*, Rickey Carter, PhD{dagger}, Ray R. Maddox, PharmD{ddagger}, Jarred Callura, BS§, Amy E. Herrin, MS{dagger}, and Craig Henriquez, PhD§

From the Departments of *Anesthesia and Perioperative Medicine, and {dagger}Biostatistics, Bioinformatics and Epidemiology, Medical University of South Carolina, Charleston, South Carolina; {ddagger}Department of Clinical Pharmacy, Research, and Pulmonary Medicine, St. Joseph's/Candler Medical Center, Savannah, Georgia; and §Department of Biomedical Engineering, Duke University, Durham, North Carolina.

Anesth Analg 2007 105: 412-418.

 

背景:病人自控镇痛(PCA)最严重的并发症是呼吸抑制(RD)。在文献中呼吸抑制的发生率通过间歇采样脉搏氧饱和度(SPO2)和呼吸频率,其数值偏离正常域值得到。方法:术后病人给予吗啡和哌替啶PCA镇痛,我们在病房持续监测氧饱和度和二氧化碳图。护士在听到监护仪因为呼吸状态异常报警后进行干预。结果:总共分析了178名病人,分别有12%和41%出现过低氧饱和度(SPO2<90%)和呼吸缓慢(呼吸频率<10),持续时间达到3分钟或更长。有一个病人需要正压通气,没有病人需要盐酸纳洛酮拮抗。年龄大于65岁和病态肥胖的病人低氧饱和度的发生率比较高。年龄大于65岁的病人呼吸缓慢的发生率较高,相比之下病态肥胖的病人发生呼吸缓慢的相对比较少。结论:我们的研究中,应用相同的域值标准和相对较严格的持续时间标准,与呼吸抑制相关的呼吸缓慢的发生率比文献报道中高出1%到2%,我们通过低氧饱和度监测呼吸抑制的发生率与术前评估的结果是一致的。我们的结论是,因为呼吸抑制可以导致呼吸停止,因此持续呼吸监测对PCA病人的安全是合适的选择。我们需要较合适的报警设置,以减少因为呼吸抑制而触发的过频繁的报警。

(陈珺珺译 薛张纲校)

BACKGROUND: The most serious complication of patient-controlled analgesia (PCA) is respiratory depression (RD). The incidence of RD in the literature is derived from intermittent sampling of pulse oximetry (Spo2) and respiratory rate and defined as a deviation below an arbitrary threshold. METHODS: We monitored postsurgical patients in a hospital ward receiving morphine or meperidine PCA with continuous oximetry and capnography. Nurses responding to audible monitor bedside alarms documented respiratory status and interventions. RESULTS: A total of 178 patients were included in the analysis, 12% and 41% of whom had episodes of desaturation (Spo2 <90%) and bradypnea (respiratory rate <10) lasting 3 min or more. One patient required "rescue" with positive pressure ventilation, and none required naloxone. Patients over 65 years of age and the morbidly obese were at greater risk for desaturation. Patients over 65 years of age were also more likely to have bradypnea, whereas the morbidly obese and patients receiving continuous infusions were less likely to have bradypnea. CONCLUSIONS: Our incidence of RD by bradypnea is significantly higher than the 1%2% incidence in the literature, using the same threshold criteria but more stringent duration criteria, while our incidence of RD based on desaturation is consistent with previous estimates. We conclude that continuous respiratory monitoring is optimal for the safe administration of PCA, because any RD event can progress to respiratory arrest if undetected. Better alarm algorithms must be implemented to reduce the frequent alarms triggered by threshold criteria for RD.

 

 

用机械通气相关的脉搏波体积描计变异预测心脏手术后患者液体治疗反应性

Ventilation-induced plethysmographic variations predict fluid responsiveness in ventilated postoperative cardiac surgery patients.

Wyffels PA, Durnez PJ, Helderweirt J, Stockman WM, De Kegel D.

Department of Anaesthesiology, UZ Gasthuisberg, Leuven, Belgium.

Anesth Analg. 2007;105:448-452

 

背景:已经证明,相比中心静脉压(CVP)或肺动脉闭塞压(PAOP),机械通气相关的脉压变异(PPV)是一种更好的预测液体治疗后的心输出量变化的指标。测量指尖脉搏产生的体积描计波形与动脉血压的波形相似。方法:通过对32名行心脏手术病人的观察性研究,解答这种广泛使用的无创监测能否预测液体治疗反应性。输入500ml6%羟乙基淀粉后,分别使用PPVCVPPAOP、舒张期肺动脉压以及机械通气相关的脉搏波体积描计变异性(VPV)预测心输出量变化,并作一比较。结果:PPVVPV与心输出量变化有很好的相关性(P<0.05)。接收器进行特征性分析显示曲线下面积PPV0.937VPV0.892PPVVPV预测15%心输出量变化的适宜阈值都是变异率11.3%。结论:本研究表明,VPVPPV一样,是比CVPPAOP更可靠的预测液体治疗反应性的指标。

(罗 璇译 薛张纲校)

BACKGROUND: It has been shown that ventilation-induced pulse pressure variation (PPV) is a better variable than central venous pressure (CVP) or pulmonary artery occlusion pressure (PAOP) for predicting cardiac output changes after fluid administration. The plethysmographic wave form measured with a fingertip pulse is very similar to the arterial blood pressure curve. METHODS: We investigated whether this widely used, noninvasive instrument could predict fluid responsiveness by conducting an observational study in 32 patients who had undergone cardiac surgery. We compared PPV, CVP, PAOP, diastolic pulmonary artery pressure, and ventilation-induced plethysmographic variation (VPV) for predicting the cardiac output change after the administration of 500 mL 6% hydroxyethylstarch. RESULTS: We found a good correlation between cardiac output changes and both PPV and VPV (P < 0.05). Receiver operating characteristic analysis revealed an area under the curve of 0.937 for PPV and 0.892 for VPV. The optimal thresholds were a variation of 11.3% for both PPV and VPV in predicting a 15% increase in cardiac output. CONCLUSION: This study shows that VPV, like PPV, is a more reliable predictor of fluid responsiveness than CVP and PAOP.

 

 

激光前列腺切除术的麻醉

Laser Resection of the Prostate: Implications for Anesthesia 

Richard A. Hanson, MD*, Mark H. Zornow, MD*, Michael J. Conlin, MD{dagger}, and Ansgar M. Brambrink, MD, PhD*

From the Departments of *Anesthesiology and Peri-Operative Medicine, and {dagger}Surgery, Division of Urology, Oregon Health and Science University, Portland, Oregon.

Anesth Analg 2007 105: 475-479.

 

背景:钬激光:钇铝石榴石和钾钛磷使得经尿道前列腺切除术几乎不吸收任何冲洗液以及出血量减少到最低。经典的经尿道前列腺切除术的麻醉,我们经常是选择蛛网膜下腔阻滞,这样我们可以在监护过程中发现继发于冲洗液吸收引起的经尿道前列腺切术术综合征。新的激光技术允许医生和麻醉医生有更多的选择,选择最适合病人的麻醉方式。方法:在这项研究中,我们回顾了泌尿外科的文献,对近期的激光前列腺切除术的概况有所了解。同时我们部分屏蔽了这类文献,关于特殊患者的潜在影响和围手术期管理。结果:我们的研究提示,在经尿道激光术中麻醉医生可以安全的选择全麻,甚至是在移动的情况下。这包括有心血管疾病或者接受持续抗凝治疗的患者。结论:我们没有发现有特别的研究关于讨论接受激光手术的最佳麻醉方式的文章。因此,临床研究需要更好的去确定各种麻醉方式的风险和获益。

(王光妍译 薛张纲校)

BACKGROUND: Holmium:yttrium-aluminum-garnet and potassium-titanyl- phosphate lasers make it possible to perform transurethral prostate resection with almost no absorption of irrigant and minimal blood loss. Subarachnoid block is usually administered for classical transurethral resection of the prostate, so that the patient can be monitored for the onset of transurethral resection of the prostate syndrome secondary to irrigant absorption. New laser resection techniques may allow the patient and anesthesiologist to choose options most appropriate for the patients medical conditions and preference. METHODS: In this study, we review the urologic literature to provide an overview of current laser technology for prostate reduction surgery. We also screened this literature for evidence of potential effects on anesthesia care for special patient groups as well as for overall perioperative management.RESULTS: Our findings suggest that the anesthesiologist may now safely offer general anesthesia for endourologic laser surgery, even on an ambulatory basis. This includes patients with cardiovascular disease or receiving continuous anticoagulation therapy.CONCLUSION: We found no studies specifically aimed at evaluating best anesthetic practices for patients undergoing laser procedures. Therefore, clinical research is needed to better define the risks and benefits of the various anesthetic alternatives.

 

 

针刺对清醒和麻醉状态下志愿者的血氧水平依赖信号的影响:一项试验性研究

Acupuncture-induced blood oxygenation level-dependent signals in awake and anesthetized volunteers: a pilot study.

Wang SM, Constable RT, Tokoglu FS, Weiss DA, Freyle D, Kain ZN.

Center for Advancement of Perioperative Health, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA.

Anesth Analg 2007 105: 499-506.

 

背景:在全麻病人中应用针刺的临床效应,有许多矛盾的数据。我们假设:这些矛盾的数据由于麻醉中针刺对中枢神经系统活动的抑制的结果,而中枢神经系统活动可以通过MRI来显示。方法:通过交叉设计,在清醒和以异丙酚诱导的全麻两种试验条件下的志愿者接受标准化的胃部36针手法针刺。fMRI(功能磁共振成像)在两组试验期间被应用。配对t试验分析用来检验两组间的BOLD信号的区别。后续的分析验证六个相关的区域(丘脑、红核、脑岛、导水管周围灰质、反压舌脊脑回和下颞区)脑血流的变化结果:通过BOLD ,我们发现在包括中央后回反压舌脊脑回、左后脑岛、双前叶楔、丘脑、红核和黑质的大脑区域有明显区别(样本100P < 0.01)。修正了背景脑血流的后续的分析发现:BOLD信号在两组间的不同是直接由于区域脑血流的改变导致的。结论: 通以异丙酚诱导的全麻会减少对针刺刺激的神经生理反应。但仍需进一步研究来确定这些发现的临床意义。

(陈勇柱译 薛张纲校)

BACKGROUND: There are conflicting data regarding clinical efficacy of acupuncture applied while patients are under general anesthesia. We hypothesize that these conflicting data are a result of the inhibitory effect of anesthesia on acupuncture-induced central nervous system activity that can be demonstrated using magnetic resonance imaging. METHODS: Using a crossover study design, volunteers received standardized Stomach 36 manual acupuncture in two experimental conditions: while undergoing a propofol-based general anesthetic, and while awake. Functional magnetic resonance imaging was conducted during both experimental sessions. Paired-t-test analyses were performed to examine the differences in acupuncture-induced blood oxygenation level-dependent (BOLD) signals between awake and anesthesia conditions. A secondary analysis was performed to account for the changes in regional cerebral blood flow at six regions of interest (thalamus, red nucleus, insula, periaqueductal gray, retrosplenial cingular gyri, and the inferior temporal region). RESULTS: Using BOLD, we found significant differences between the two experimental sessions in brain areas, including postcentral gyri, retrosplenial cingular area, left posterior insula, bilateral precuneus, thalamus, red nuclei, and substantia nigra (cluster 100, P < 0.01). A secondary analysis correcting for background cerebral blood flow found that BOLD signal differences between experimental conditions were not directly caused by changes in regional blood flow. DISCUSSION: Propofol-based anesthesia reduces the neurophysiological response to acupuncture stimulation as measured by acupuncture-induced BOLD signals. Further work should be conducted to determine the clinical significance of these findings.

 

 

可乐定1 µg/kg对青少年使用单纯布比卡因脊髓麻醉是一个安全有效的佐剂

Clonidine 1 µg/kg Is a Safe and Effective Adjuvant to Plain Bupivacaine in Spinal Anesthesia in Adolescents

Olfa Kaabachi, Amine Zarghouni, Rami Ouezini, Ahmed Ben Abdelaziz, Olfa Chattaoui, and Hannu Kokki

Department of Anesthesiology and Intensive Care, Kassab Orthopedic Institute, Tunis, Tunisia.

Anesth Analg 2007 105: 516-519

 

背景:脊髓麻醉正在日益多地被用于青少年。然而,仅仅用布比卡因的麻醉对于既定手术也许时间太短了。在布比卡因中添加2µg /kg的可乐定可以延长麻醉时间,但是也许会导致低血压。在现在的研究中,我们调查青少年脊髓麻醉时鞘内使用1µg /kg的可乐定作为布比卡因的添加剂的安全性和有效性。方法:八十三位青少年,51位男性,年龄10-15岁,入选这项安慰剂对照的随机实验。患者给与脊髓麻醉,单纯用0.5%等比重的布比卡因0.2-0.4 mg/kg或者布比卡因加可乐定1µg /kg。感觉阻滞的持续时间是最主要的测量结果。结果:可乐定延长了感觉和运动阻滞的时间。2个皮区间的感觉复原时间在添加可乐定组是136 minsd,56),而在对照组是107 minsd,42)(95%置信区间:5-53 min, P = 0.02)。完全的运动阻滞的恢复在可乐定组是251 min(sd, 79),而对照组181 min (sd, 59) (95%置信区间: 39-103 min, P = 0.001)。首剂之后痛觉恢复的时间在可乐定组中要长,461 min (sd, 147),而对照组330 min (sd, 138) (95% 置信区间: 53-207 min, P = 0.01)。两组中低血压和心动过缓发生的频率是没有区别的。结论:在青少年中,1µg /kg的可乐定可以延长布比卡因所致的感觉阻滞的时间达30 min以及术后止痛时间延长120 min,并且没有严重的不良时间。

(周时蓓译 薛张纲校)

BACKGROUND: Spinal anesthesia is increasingly used in adolescents. However, the anesthesia provided by bupivacaine alone may be too short for the planned surgery. The addition of clonidine 2 microg/kg to bupivacaine provides a prolonged anesthetic action but may be associated with hypotension. In the present study, we investigated the efficacy and safety of intrathecal clonidine 1 mug/kg in adjunction to bupivacaine in spinal anesthesia in adolescents. METHODS: Eighty-three adolescents, 51 males, aged 10-15 yr, scheduled for orthopedic surgery were enrolled in this placebo-controlled, randomized study. Patients were given spinal anesthesia either with plain 0.5% isobaric bupivacaine 0.2-0.4 mg/kg or bupivacaine with clonidine 1 microg/kg. The duration of sensory block was the primary outcome measure. RESULTS: Clonidine prolonged the duration of both the sensory and motor block. The time to regression of sensory block by two dermatomes was 136 (mean) (sd, 56) min in the adolescents with clonidine versus 107 min (sd, 42) in the controls (95% CI for diff: 5-53 min, P = 0.02). The time to full recovery of motor block was 251 min (sd, 79) in the adolescents with clonidine versus 181 min (sd, 59) in the controls (95% CI: 39-103 min, P = 0.001). Time to the first dose of rescue analgesia was longer in the adolescents with clonidine, 461 min (sd, 147) versus 330 min (sd, 138) in the controls (95% CI: 53-207 min, P = 0.01). There was no difference in the frequency of hypotension or bradycardia between the groups. CONCLUSION: In adolescents, clonidine 1 microg/kg prolonged the duration of sensory block achieved with bupivacaine by 30 min and postoperative analgesia by 120 min without severe adverse events.

 

 

改良股正中入路坐骨神经阻滞法:诱发运动反应和感觉阻滞的关系(简要报告)

A Modified Mid-Femoral Approach to the Sciatic Nerve Block: A Correlation Between Evoked Motor Response and Sensory Block (Brief Report)

Antoine Pianezza, Marie-Luce Gilbert, Vincent Minville, Daren Filsinger, Quentin Gobert, Alain Guérot, Régis Fuzier, and Olivier Fourcade

Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Paul Sabatier, Toulouse, France.

Anesth Analg 2007 105: 528-530.

股正中入路外侧坐骨神经阻滞(LSMF)为单次注射阻滞所有坐骨神经分支提供了可靠、安全、有效的方法。然而,我们不知道当用单次注射技术实施LSMF时,坐骨神经的哪个分支(胫神经[T]或腓总神经[CP])能提供更好的成功率。在该前瞻研究中,我们比较了T运动反应和CP运动反应的成功率。方法:95名行踝关节或足部手术的病人入选。当第一次诱发TCP的运动反应时,注入0.475%的罗哌卡因30ml,最小强度为0.30.5mA。结果:72名病人分入T组,23名分入CP组。当坐骨神经感觉阻滞完全时认为成功。T反应和CP反应的成功率分别为90%(65)70%(16)( P < 0.05)。实施阻滞的时间(CP: 4.5 +/- 3 min T: 4.5 +/- 4 min; P = NS)及感觉和运动起效的时间组间无显著性差异。两组均未见并发症。结论:我们认为,在实施改良的LSMF阻滞时,T分支的诱发运动反应较CP反应具有更高的成功率。

(王丽珺译 薛张纲校)

BACKGROUND: The lateral sciatic mid-femoral block (LSMF), proved to be reliable, safe, and effective on both branches of the sciatic nerve with a single injection. However, we do not know which component of the sciatic nerve (the tibial [T] or the common peroneal [CP]) produces a better success rate when performing a LSMF with a single injection technique. In this prospective study we compared the success rate of the T motor response with the CP motor response. METHODS: Ninety-five patients undergoing ankle or foot surgery were enrolled. Thirty milliliters of 0.475% ropivacaine was injected at the first evoked motor response, either T or CP, with a minimal intensity between 0.3 and 0.5 mA. RESULTS: Seventy-two patients were included in group T and 23 in group CP. The block was considered a success when a complete sensory block of the sciatic nerve was obtained. The success rate was 90% (65) for the T response and 70% (16) for the CP response (P < 0.05).Time to perform the block (CP: 4.5 +/- 3 min vs T: 4.5 +/- 4 min; P = NS) as well as sensory and motor onset times were not significantly different between groups. No complications were observed in either group. CONCLUSION: We conclude that the evoked motor response of the T branch is associated with a higher success rate than a CP response using the modified LSMF block.

 

七氟烷(而非丙泊酚)可防止猪冠状动脉内由神经鞘氨醇磷酸胆碱引起的Rho激酶依赖性收缩

Sevoflurane, but Not Propofol, Prevents Rho Kinase-Dependent Contraction Induced by Sphingosylphosphorylcholine in the Porcine Coronary Artery

Hiroyuki Kinoshita, MD, PhD*, Naoyuki Matsuda, MD, PhD{dagger}, Yoshiki Kimoto, MD, PhD*, Setsuko Tohyama, MD{ddagger}, Keiko Hama, MD*, Katsutoshi Nakahata, MD, PhD*, and Yoshio Hatano, MD, PhD*

From the *Department of Anesthesiology, Wakayama Medical University, Wakayama, Japan; {dagger}Departments of Anesthesiology and Molecular Medical Pharmacology, Toyama University School of Medicine, Toyama, Japan; and {ddagger}Departments of Sports Medicine and Joint Reconstruction Surgery, Hokkaido University School of Medicine, Sapporo, Japan.

Anesth Analg 2007;105:325-329

 

背景:神经鞘氨醇磷酸胆碱可通过激活Rho激酶来引起冠脉痉挛。我们设计了目前的实验来检验麻醉药对猪冠状动脉内由神经鞘氨醇磷酸胆碱引起的Rho激酶激活的不同效应。

方法:不含内皮的猪冠状动脉环在含改良Krebs–Ringer碳酸氢盐溶液中的组织水浴中制得。分别在无或有七氟烷、丙泊酚或一种选择性Rho激酶抑制剂Y27632(应用神经鞘氨醇磷酸胆碱前15min时加入)的情况下,使用等长张力记录得到对神经鞘氨醇磷酸胆碱反应的浓度-反应曲线。Rho A由细胞内向质膜的易位和肌球蛋白轻链磷酸酶的肌球蛋白-定靶亚单位的磷酸化通过蛋白质印迹法来测定。

结果:神经鞘氨醇磷酸胆碱(10–710–5 M)引起猪冠状动脉的收缩,该效应可被选择性Rho激酶抑制剂Y276322 x 10–6 M)所取消。七氟烷(1.7%)减少神经鞘氨醇磷酸胆碱诱导的冠脉收缩,而较高浓度的七氟烷(3.4%)可取消其作用(P < 0.05)。相反,丙泊酚(3 x 10–6 M10–5 M)对由神经鞘氨醇磷酸胆碱引起的冠脉收缩没有影响。七氟烷,而非丙泊酚减少了细胞内Rho A向质膜的易位。七氟烷和Y27632(而非丙泊酚)相似地减少了肌球蛋白轻链磷酸酶的肌球蛋白-定靶亚单位的磷酸化(分别减少64.4%70.8%P < 0.05)。

结论:神经鞘氨醇磷酸胆碱通过激活Rho激酶而引起冠状动脉收缩。七氟烷(而非丙泊酚)抑制此途径,从而防止血管收缩。

 

BACKGROUND: Sphingosylphosphorylcholine may induce coronary vasospasm by the activation of Rho kinase. We designed the current study to examine the differential effects of anesthetics on Rho kinase activation induced by sphingosylphosphorylcholine in porcine coronary arteries.

METHODS: Rings of porcine coronary artery without endothelium were prepared in tissue bath containing modified Krebs–Ringer bicarbonate solution. Using isometric force recording, concentration–response curves in response to sphingosylphosphorylcholine were obtained in the absence or in the presence of sevoflurane, propofol, or a selective Rho kinase inhibitor Y27632, which was added 15 min before the application of sphingosylphosphorylcholine. Intracellular translocation of Rho A toward the plasma membrane and phosphorylation of the myosin-targeting subunit of myosin light chain phosphatase were also evaluated by Western blotting.

RESULTS: Sphingosylphosphorylcholine (10–7 to 10–5 M) produced contraction of the porcine coronary artery, which was abolished by a selective Rho kinase inhibitor Y27632 (2 x 10–6 M). Sevoflurane (1.7%) reduced sphingosylphosphorylcholine-induced coronary artery constriction, and the higher concentration (3.4%) abolished it (P < 0.05). In contrast, propofol (3 x 10–6 M and 10–5 M) had no effect on coronary artery constriction due to sphingosylphosphorylcholine. Sevoflurane, but not propofol, reduced intracellular translocation of Rho A toward the plasma membrane. Sevoflurane and Y27632, but not propofol, similarly decreased (64.4% or 70.8% reduction, respectively, P < 0.05) phosphorylation of the myosin-targeting subunit of myosin light chain phosphatase.

CONCLUSIONS: Sphingosylphosphorylcholine induces coronary vasocontriction via activation of Rho kinase. Sevoflurane, but not propofol, inhibits this pathway, resulting in prevention of vasoconstriction.

 

 

新生儿开始发病的多系统炎性疾病患儿的麻醉处理

The Anesthetic Management of Children with Neonatal-Onset Multi-System Inflammatory Disease

Christine F. Lauro, AB*, Raphaela Goldbach-Mansky, MD{dagger}, Margaret Schmidt, CRNA*, and Zenaide M. N. Quezado, MD*

From the *Department of Anesthesia and Surgical Services, National Institutes of Health Clinical Center; and {dagger}National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland.

Anesth Analg 2007;105:351-357

 

背景:新生儿开始发病的多系统炎性病(NOMID)是一种罕见的常染色体显性遗传性疾病,属于自身炎性疾病逐渐庞大的范畴,表现特征为荨麻疹、关节病和慢性无菌性脑膜炎,它合并有冷刺激诱发的自身炎性基因CIASI的突变,该基因是编码蛋白质和cryopyrin。由于对于该疾病的麻醉考虑知之甚少,我们寻求鉴别NOMID的主要特征和各自的麻醉和围术期含义的方法。

方法:我们在2003年到2006年研究了为做有创性诊断和治疗干预进行麻醉的NOMID儿童围麻醉期记录。另外,我们对该疾病的遗传学、临床、和生物化学异常进行了广泛的文献回顾。

结果: NOMID儿童17例(平均年龄8岁,范围9-11岁)为了诊断性和治疗性手术进行了麻醉。所有病人都累及神经系统,包括颅内压升高、慢性无菌性脑膜炎,和发育迟缓;7例有骨肥大,15例有眼部和14例有耳部NOMID的临床表现。尽管疾病是复杂的,但围术期过程是简单的,且没有观察到严重的不良反应。

结论:本研究第一次研究了NOMID(一种伴有关节炎、回归热、荨麻疹和慢性无菌性脑膜炎的自身炎性疾病)的麻醉含义。对于儿科麻醉医师而言,发热和无菌性脑膜炎的存在可能使对用于择期手术的麻醉药的管理较少令人满意,我们的发现提示没有活动性感染的证据时,即使有发热和慢性无菌性脑膜炎,全身和局域麻醉都可用于NOMID病人而无不良并发症。

(彭中美 马皓琳 李士通 校)

BACKGROUND: Neonatal-onset multi-system inflammatory disease (NOMID), a rare autosomal dominantly inherited disease, belongs to a growing spectrum of autoinflammatory diseases, is characterized by urticarial rash, arthropathy, and chronic aseptic meningitis, and is associated with mutations in the cold-induced autoinflammatory gene, CIAS1, the gene that encodes the protein, cryopyrin. As little is known about the anesthetic considerations of the disease, we sought to identify the main features and respective anesthetic and perioperative implications of NOMID.

METHODS: We examined perianesthetic records of children with NOMID who were anesthetized for invasive diagnostic and therapeutic interventions between 2003 and 2006. In addition, we conducted an extensive literature review of the genetic, clinical, and biochemical abnormalities of the disease.

RESULTS: Seventeen children with NOMID (median age 8 yr, range 9 mo to 11 yr) were anesthetized for diagnostic and therapeutic procedures. All patients had neurological involvement, including increased intracranial pressure, chronic aseptic meningitis, and developmental delay; 7 had bony overgrowth, 15 ocular, and 14 otological manifestations of NOMID. Despite the complexity of the disease, the perioperative course was uncomplicated, and no serious adverse events were observed.

CONCLUSIONS: This study is the first to investigate the anesthetic implications of NOMID, an autoinflammatory disease associated with arthropathy, recurrent fevers, urticarial rash, and chronic aseptic meningitis. While for the pediatric anesthesiologist, the presence of fever and aseptic meningitis might make the conduct of anesthetics for elective procedures less desirable, our findings suggest that without evidence of active infection, even in the presence of fever and chronic aseptic meningitis, general and regional anesthesia may be conducted in patients with NOMID without untoward complications.



全麻诱导气囊-面罩通气时适当保留假牙的影响

The Effect of Leaving Dentures in Place on Bag-Mask Ventilation at Induction of General Anesthesia

Niamh P. Conlon, FCARCSI*{dagger}, Richard P. Sullivan, MBChB*, Peter G. Herbison, MSc*, Mathew Zacharias, PhD*, and Donal J. Buggy, MD{dagger}{ddagger}

From the *Department of Anesthesia, Dunedin Hospital, Dunedin, New Zealand; {dagger}Department of Anesthesia, Mater Misericordiae University Hospital, Dublin, Ireland; and {ddagger}Outcomes Research Institute, Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2007;105:370-373

背景:手术麻醉前无牙病人去除假牙的最佳时间还不确定。

方法:我们进行了一个前瞻、随机、对照试验来评估全麻诱导气囊-面罩通气时,不去除假牙的影响。166个无牙的病人被随机分成两组。保留假牙组,麻醉诱导后气囊-面罩通气时保留假牙。去除假牙组,气囊-面罩通气前去除假牙。由麻醉医师评估气囊-面罩通气难度。

结果:成功的气囊-面罩通气的定义是3 L/min 新鲜气体流量及调节压力限制在20 cm H2O时,ETco2 上升到20 mmHg并回到基线。在保留假牙组,61/ 84 (73%)达到成功气囊-面罩通气。去除假牙组为40/81 (49%)(优势比0.3795% CI = 0.19–0.70P = 0.002)。

结论:我们推断,全麻诱导时如保留无牙病人的假牙在原处,气囊-面罩通气更容易。

(张曦 译,马皓琳 李士通 校)

BACKGROUND: The optimum timing for denture removal in edentulous patients before anesthesia and surgery is uncertain.

METHODS: We conducted a prospective, randomized, controlled trial to evaluate the effect of leaving dentures in during bag-mask ventilation at induction of general anesthesia. One hundred sixty-six edentulous patients were randomized to two groups. The Dentures-In group was bag-mask ventilated after induction of anesthesia with dentures left in place. The Dentures-Out group patients had their dentures removed before bag-mask ventilation. The degree of difficulty of bag-mask ventilation was assessed by the anesthesiologist.

RESULTS: Successful bag-mask ventilation, as defined by a increase in ETco2 to 20 mm Hg and back to baseline with 3 L/min fresh gas flow and the adjustable pressure limiting valve at 20 cm H2O, was achieved in 61 of 84 (73%) of the Dentures-In patients compared with 40 of 81 (49%) of the Dentures-Out patients (odds ratio 0.37, 95% CI = 0.19–0.70, P = 0.002).

CONCLUSION: We conclude that bag-mask ventilation is easier in edentulate patients when their dentures are left in situ during induction of general anesthesia.



共同释放的神经递质对A型γ氨基丁酸受体、士的宁敏感性甘氨酸受体和N-甲基-d-天冬氨酸受体的麻醉药样调节

Anesthetic-Like Modulation of a {gamma}-Aminobutyric Acid Type A, Strychnine-Sensitive Glycine, and N-Methyl-d-Aspartate Receptors by Coreleased Neurotransmitters

Pavle S. Milutinovic, MS*, Liya Yang, PhD{dagger}, Robert S. Cantor, PhD{ddagger}, Edmond I. Eger, II, MD{dagger}, and James M. Sonner, MD{dagger}

From the *University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco; {ddagger}Department of Chemistry, Dartmouth College, Hanover, New Hampshire.

Anesth Analg 2007;105:386-392

介绍:近来提出的一种麻醉机理预言共同释放的神经递质是非天然的激动剂,以类似麻醉药的方式对神经递质受体进行调节。

方法:我们通过将乙酰胆碱应用于NR1/NR2ANMDA受体、甘氨酸用于野生型{alpha}1ß2型和抗麻醉药的{alpha}1(S270I)ß2 GABA A型受体及将GABA应用于同源性{alpha}1野生型甘氨酸受体和抗麻醉药型{alpha}1 S267I甘氨酸受体来检验此预测。在爪蟾卵母细胞表达受体,并用双电极电压钳技术进行研究。

结果:我们发现,乙酰胆碱抑制NMDA受体功能,GABA增强甘氨酸受体功能,以及甘氨酸增强对GABA A型受体功能。作为具有麻醉药活性的化合物,GABA对抗麻醉药的S267I甘氨酸受体功能的增强作用远小于对野生型受体的作用。甘氨酸增强野生型GABA A型受体功能,但抑制抗麻醉药S270I GABA A型受体功能。

结论:这些结果表明,共同释放到对麻醉药敏感的受体的神经递质是非天然激动剂,能以类似麻醉药的机制调节这些受体的功能。这些发现支持最近的麻醉药作用理论。

(颜涛 译, 马皓琳 李士通 校)

INTRODUCTION: A mechanism of anesthesia has recently been proposed which predicts that coreleased neurotransmitters may modulate neurotransmitter receptors for which they are not the native agonist in a manner similar to anesthetics.

METHODS: We tested this prediction by applying acetylcholine to a NR1/NR2A N-methyl-d-aspartate receptor, glycine to a wild-type {alpha}1ß2 and anesthetic-resistant {alpha}1(S270I)ß2 {gamma}-amino-butyric acid (GABA) type A receptor, and GABA to a homomeric {alpha}1 wild type and anesthetic-resistant {alpha}1 S267I glycine receptor. Receptors were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping.

RESULTS: We found inhibition of N-methyl-d-aspartate receptor function by acetylcholine, enhancement of glycine receptor function by GABA, and enhancement of GABA type A receptor function by glycine. As expected of compounds with anesthetic activity, GABA showed far less potentiation (enhancement) of the function of the anesthetic-resistant S267I glycine receptor than that of the wild-type receptor. Glycine potentiated the function of wild-type GABA type A receptors but inhibited the function of the anesthetic-resistant S270I GABA type A receptor.

CONCLUSIONS: These results show that neurotransmitters that are coreleased onto anesthetic-sensitive receptors may modulate the function of receptors for which they are not the native agonist via an anesthetic-like mechanism. These findings lend support to a recent theory of anesthetic action.




麻醉信息管理系统:对当前实行政策和实践的一个调查报告

Anesthesia Information Management Systems: A Survey of Current Implementation Policies and Practices

Richard H. Epstein, MD*, Michael M. Vigoda, MD, MBA{dagger}, and David M. Feinstein{ddagger}

From the *Department of Anesthesiology, Jefferson Medical College, Philadelphia, Pennsylvania; {dagger}Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida; and {ddagger}Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007;105:405-411

背景资料:麻醉信息管理系统(AIMS)的使用逐年增加,但是麻醉专业机构并没有发表意见来指导配置及影响记账、安全性、医疗合法性以及依从性问题的政策决定。

方法:由美国麻醉技术协会委员会建立的一个45个问题构成的调查,发给18个独立机构的临床管理人员,这些机构中分别安装了六种不同的AIMS系统。这项调查的主要目的是建立一个当前政策和实践方面的基线。

结果:仅有超过2/3的人对于调查问题中25%的问题表示认同。报告的很多配置可能增加拒付、医疗保险和医疗补助的不配合、安全漏洞和医疗合法防御的困难。

结论:建议由麻醉专业组织如美国麻醉技术协会制定指导方针来协助AIMS的配置,可以帮助这些麻醉部门避免可能导致显著财务和法律风险的问题。

(沈浩 马皓琳 李士通 校)
BACKGROUND: Anesthesia information management systems (AIMS) implementation is increasing, but there are no published recommendations from anesthesia professional societies to guide configuration and policy decisions that affect billing, security, medical–legal, and compliance issues.

METHODS: A 45-question structured survey was developed by a committee of the Society for Technology in Anesthesia and was sent to the clinical administrator at 18 separate institutions, comprising six different installed AIMS systems. The primary goal of the survey was to establish a baseline of current policies and practices.

RESULTS: There was more than two-third agreement among respondents for only 25% of questions. A number of configurations reported may increase exposure to billing denial, Medicare and Medicaid noncompliance, security breeches, and medical–legal defense difficulties.

CONCLUSIONS: Developing guidelines by anesthesia professional organizations such as Society for Technology in Anesthesia to assist in the configuration of AIMS is recommended to help anesthesia departments avoid problems that may result in significant financial and legal risk.



围术期患者的安全性:正确的病人、正确的手术、正确的左右侧——一个多面性、跨组织、干预性研究

Perioperative Patient Safety: Correct Patient, Correct Surgery, Correct Side—A Multifaceted, Cross-Organizational, Interventional Study

Edna Zohar, MD, MHA*, Yossi Noga, BSc, MD, MHA*, Ehud Davidson, MD{dagger}, Margalit Kantor, RN, MA{dagger}, and Brian Fredman, MB, BCh*

From the *Departments of Anesthesiology, Critical Care and Pain Management; and {dagger}Hospital Administration, Meir Medical Center, Kfar Saba, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Anesth Analg 2007;105:443-447

背景:在围术期准备时,确保患者有一个安全的环境是很重要的。在这样的考虑下,在我们的手术室服务中用到了“患者安全第一”这样的一个哲学思想。

方法:在此项干预研究的第一期(2001-2002),我们定义和完成了此项干预的组织和教育方面。此后,进行执行期(20032005)。鉴于我们的0容忍政策,如果在手术室等待区发现患者对麻醉和手术的准备中有较大错误,患者将被送回到原先的科室(“失败”),手术将被延期直到较大错误被更正。

结果:共记录了15856位患者的数据。在3年的执行期,112位患者(0.17%)被送回原科室。与2003年相比较,2004年与2005年的大错误发生显著减少(P<0.002)(分别为1.04%0.59%0.49%)。此外,逐步逻辑回归表明由患者准备不足所引起的较大错误发生率呈时间相关性显著减少(优势比=1.4895% CI1.16-1.87)。另外,平均失败间隔时间分别为2003年的6.6天,2004年的11.2天和2005年的14.7天(P<0.03)。最后证实,随着时间过去,患者的准备工作显著改善提高(P < 0.0001),而全部患者的准备工作得分=100%

结论:教育和提高意识可以减少围术期错误。然而,即使是仔细设计适当的政策,仍然不能建立无错的环境。因此,必须在持续的基础上完成监护和系统分析。

(胡湘 马皓琳 李士通校)

BACKGROUND: It is important to ensure a patient-safe environment in the perioperative setting. With this in mind, a "patient-safety first" philosophy was adopted within our operating room service.

METHODS: During the first phase of the interventional study (2001–2002), we defined and executed the organizational and educational aspects of the intervention. Thereafter, the implementation phase (2003–2005) was performed. According to our zero tolerance policy, in the event that a major error in patient readiness for anesthesia and surgery was found in the operating room holding area, the patient would be returned to the parent department ("failure") and the surgical procedure delayed until the major error was corrected.

RESULTS: The data of 15,856 patients were recorded. During the 3-yr implementation period, 112 patients (0.71%) were returned to the department. A statistically significant (P < 0.002) reduction in major errors was recorded when comparing the year 2003 to the years 2004 and 2005 (1.04, 0.59, and 0.49% for the years 2003, 2004, and 2005, respectively). Furthermore, stepwise logistic regression demonstrated a time-dependant significant decrease in the incidence of a major error that resulted from inadequate patient preparation (odds ratio = 1.48, 95% CI: 1.16–1.87). In addition, the mean time between failures was 6.6, 11.2, and 14.7 days for the years 2003, 2004, and 2005, respectively (P < 0.03). Finally, a significant (P < 0.0001) improvement in patient preparation over time, as well as the overall probability that the patient preparation score = 100% (P < 0.001), were demonstrated.

CONCLUSIONS: Education and increased awareness can decrease perioperative errors. However, even with a carefully designed policy in place, an error-free environment was not achieved. Therefore, monitoring and system analysis should be performed on a continuing basis.



在置管前预先填充硬膜外间隙可以减少硬膜外导管置入血管的发生率

Predistention of the Epidural Space Before Catheter Insertion Reduces the Incidence of Intravascular Epidural Catheter Insertion

Shmuel Evron, MD*{dagger}, Vladimir Gladkov, MD*, Daniel I. Sessler, MD{ddagger}{dagger}, Vadim Khazin, MD*, Oscar Sadan, MD§, Mona Boaz, PhD¶, and Tiberiu Ezri, MD*{dagger}

From the *Department of Anesthesia, Edith Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Israel; {dagger}Outcomes Research Institute and Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky; {ddagger}Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio; §Departments of Obstetrics and Gynecology and ¶Epidemiology, Edith Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Israel.

Anesth Analg 2007;105:460-464

背景:在硬膜外麻醉或硬膜外镇痛过程中意外地将导管置入硬膜外静脉是一个常见的并发症。在一个试验性研究和一些以往的报道的基础上,我们验证了以下假设,在硬膜外置管前用盐水预先填充硬膜外间隙可以便于置管而且降低这个并发症的发生率。

方法:203名分娩妇女被随机分成两组,用阻力消失方法给予硬膜外穿刺,未填充组在硬膜外间隙注射2ml生理盐水,填充组则注射5ml生理盐水。填充组在置入硬膜外导管前注射器栓始终连接在导针上保持关闭。然后两组都通过硬膜外导管注射1.5%的利多卡因3ml作为试验剂量。

结果:填充组导管误置入血管的发生率更低(2%16%P=0.0001),且91%的填充组病人未发生任何未阻滞节段,未填充组67%P=0.0001)。两组的镇痛起效时间差异很小且没有重要的临床意义(5±2分钟比6±3分钟,P=0.0001)。两组镇痛质量(视觉评分和罗哌卡因消耗量)相似。

结论:硬膜外置管前在硬膜外间隙注射5ml生理盐水可以减少导管误置入静脉的发生率和未阻滞节段的数目。

(姜旭晖 马皓琳 李士通 校)

BACKGROUND: Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication.

METHODS: Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter.

RESULTS: There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 ± 2 min vs 6 ± 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups.

CONCLUSIONS: Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.




膝关节成形术中充足补液与限制补液的对比:一项随机双盲研究

Liberal Versus Restrictive Fluid Management in Knee Arthroplasty: A Randomized, Double-Blind Study

Kathrine Holte, MD*, Billy B. Kristensen, MD{dagger}, Lotte Valentiner, RN*, Nicolai B. Foss, MD{dagger}, Henrik Husted, MD{ddagger}, and Henrik Kehlet, MD, PhD§

From the Departments of *Surgical Gastroenterology, {dagger}Anesthesiology, and {ddagger}Orthopedic Surgery, Hvidovre University Hospital, Hvidovre, Denmark; and §Section for Surgical Pathophysiology, Rigshospitalet, Denmark.

Anesth Analg 2007;105:465-474

背景:描述围术期液体量与器官功能之间关系的数据很少。在这项研究中,我们研究了在膝关节成形术中两种血管内补液管理水平(“充足”比“限制”)对作为主要结果变量的生理学恢复的影响。

方法:在一个双盲研究中,将48ASA I–III 级,择期行快通道膝关节成形术的病人随机分入围术期血管内限制补液组和充足补液组。病人们均恒速输注乳酸林格液以及标准体积的胶体液。围术期管理的其他方面(包括麻醉、术前液体状况以及术后管理)均标准化。主要的结果变量包括肺功能(肺量测定法)、运动能力(“定时的起床和行走”测试)、凝血功能(血栓弹性描记®)、术后的低氧血症(夜间的脉搏血氧饱和度测定)、术后肠梗阻(排便)和病人的主观恢复程度(VAS评分)。住院期和并发症也记录在册。

结果:所有病人严格遵循液体应用指南。充足补液组的中位数为4250mL,变化范围在3150–5200 mL,而限制补液组分别为1740 mL1100–2165 mL。并且前者会导致术后6小时的肺功能改善、术后24–48 小时的显著的高凝性及降低呕吐的几率。其他评定的围术期生理恢复参数(术后低氧血症、运动能力或者是病人的主观恢复水平)没有总体差别。两组的住院天数也无差异(两组的中位数均为4天,无显著性差异)。

结论:相比限制补液而言,快通道膝关节成形术中的充足补液可能会引起显著的高凝,减少呕吐,但对其他恢复指数和住院天数却无差异。

(黄丽娜 李士通 马皓琳 校)

BACKGROUND: There are few data describing the relationship between amount of perioperative fluid and organ function. In this study we investigated the effects of two levels of intravascular fluid administration ("liberal" versus "restrictive") in knee arthroplasty on physiological recovery as the primary outcome variable.

METHODS: In a double-blind study, 48 ASA I–III patients undergoing fast-track elective knee arthroplasty were randomized to restrictive or liberal perioperative intravascular fluid administration. Patients received a fixed rate infusion of Ringer’s lactate solution with a standardized volume of colloid. All other aspects of perioperative management (including anesthesia, preoperative fluid status, and postoperative management) were standardized. Primary outcome variables included pulmonary function (spirometry), exercise capacity ("timed up and go" test), coagulation (Thrombelastograph®), postoperative hypoxemia (nocturnal pulse oximetry), postoperative ileus (defecation), and subjective patient recovery (visual analog scales). Hospital stay and complications were also noted.

RESULTS: Fluid guidelines were followed strictly in all patients. Liberal (median 4250 mL, range 3150–5200 mL) compared with restrictive (median 1740 mL, range 1100–2165 mL) intravascular fluid administration led to improved pulmonary function 6 h postoperatively, significant hypercoagulability 24–48 h postoperatively, and reduced incidence of vomiting. There were no overall differences in the other assessed perioperative physiological recovery variables (postoperative hypoxemia, exercise capacity or subjective patient recovery variables). No difference was found in hospital stay (median 4 days in both groups, not significant).

CONCLUSION: A liberal compared to a restrictive intravascular fluid regimen may lead to significant hypercoagulability and a reduction in vomiting, but without differences in other recovery variables or hospital stay after fast-track knee arthroplasty.



腺苷作为非阿片类镇痛剂在围术期的应用

Adenosine as a Non-Opioid Analgesic in the Perioperative Setting

Tong J. Gan, MB, FRCA, FFARCSI, and Ashraf S. Habib, MB, FRCA

From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2007;105:487-494

人体中普遍存在的代谢中间产物腺苷,几乎涉及细胞功能的每个方面,包括神经调节和传递。腺苷A1 A2 受体广泛分布于脑和脊髓,是疼痛治疗的新颖的非阿片类靶位。在临床试验(包括与安慰剂和雷米芬太尼输注比较的双盲研究)中已发现腺苷作为非麻醉性镇痛剂对麻醉患者的潜在作用。这些研究提示相比于安慰剂或雷米芬太尼,术中输注腺苷稳定中心血流动力学,减少手术中麻醉需求。此外,较低的疼痛评分和减少的阿片类消耗显示腺苷改善术后恢复。在目前腺苷产物已被批准使用的基础上,已很好地显示了腺苷的安全特性。与其运用有关的最常见不良事件包括面部潮红、胸部不适、呼吸困难、头痛、胃肠不适和头晕。这些反应通常短暂且耐受良好。需要进一步试验来保证研究腺苷作为非阿片类镇痛剂在围术期的完全的潜在作用。

(吴俭 马皓琳 李士通 校)

Adenosine, a ubiquitous metabolic intermediate in the body, is involved in nearly every aspect of cell function, including neuromodulation and neurotransmission. Adenosine A1 and A2 receptors are widely distributed in the brain and spinal cord, and are a novel, non-opiate target for pain management. The potential of adenosine as a non-narcotic analgesic in anesthetized patients has been explored in clinical trials, including double-blind studies versus placebo and remifentanil infusion. These studies suggest that, compared to placebo or remifentanil, an intraoperative adenosine infusion stabilizes core hemodynamics and reduces the requirement for anesthesia during surgery. Further, adenosine improves postoperative recovery, as indicated by lower pain scores and less opioid consumption. The safety profile of adenosine has been well characterized based on use of currently approved adenosine products. The most common adverse events associated with its use include flushing, chest discomfort, dyspnea, headache, gastrointestinal discomfort, and lightheadedness. These effects are generally well tolerated and transient. Further studies are warranted to investigate the full potential of adenosine as a non-opioid analgesic in the perioperative setting.



局麻药低熔混合物(EMLA®)减轻非镇静患者行肱骨径路神经阻滞时的疼痛

Eutectic Mixture of Local Anesthetic (EMLA®) Decreases Pain During Humeral Block Placement in Nonsedated Patients

David Samson, MD*, Vincent Minville, MD*, Clément Chassery, MD*, Luc Nguyen, MD*, Antoine Pianezza, MD*, Olivier Fourcade, MD, PhD*, Anna Rabinowitz, MS{dagger}, and Kamran Samii, MD*

From the *Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Paul Sabatier, Toulouse, France; and {dagger}Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Anesth Analg 2007;105:512-515

背景:我们评估了在实施神经阻滞前应用局麻药低熔混合物(EMLA®)凝胶的潜在效果。

方法:前瞻性地选取60例拟行肘部远端手术且能顺从肱骨中径路神经阻滞的患者,随机分为3组。E组:实施神经阻滞前60分钟局部应用EMLA乳剂,另外操作前5分钟静脉给予2ml生理盐水;P组:局部应用安慰剂乳剂,静脉给予2ml生理盐水;S组:局部应用安慰剂乳剂,静脉给予2ml生理盐水内含0.1 µg/kg舒芬太尼。用100-mm视觉疼痛评分(VAS)记录皮肤穿刺时的疼痛和整个操作过程中的总体疼痛(0分无疼痛,100分最疼痛)。

结果:E组与P组、S组比较疼痛较轻(5 ± 3 mm33 ± 20 mm30 ± 18 mm, P < 0.0001)P组在整个阻滞过程中的疼痛比E组更多(P = 0.01)

结论:用EMLA的患者在肱骨中径路神经阻滞的针穿刺和整个操作过程中疼痛较轻。

(朱慧 马皓琳 李士通 校)

BACKGROUND: We evaluated the potential role of an euctectic mixture of local anesthetic (EMLA®) cream application before performing midhumeral block.

METHODS: Sixty patients undergoing surgery distal to the elbow amenable to a humeral block were prospectively recruited for the study. The patients were randomly allocated to 1 of 3 groups: Group E: topical EMLA cream 60 min before block plus 2 mL IV normal saline 5 min before procedure; Group P: topical sham cream plus 2 mL IV normal saline, and Group S: topical sham cream plus 0.1 µg/kg of sufentanil in 2 mL solution IV. Pain experienced during skin puncture, and overall pain for the whole procedure were rated using a 100-mm visual analog scale (0: no pain to 100: worst pain).

RESULTS: Patients in Group E experienced less pain compared with those in Groups P and S (5 ± 3 mm vs 33 ± 20 mm and 30 ± 18 mm, respectively, P < 0.0001). The pain experienced throughout the complete humeral block was more substantial in Group P than in Group E (P = 0.01).

CONCLUSION: The patients who received EMLA cream had less pain with needle puncture as well as throughout the performance of humeral block.


曲马多对局部或区域麻醉后并发感染细菌的抗菌活力

The Antibacterial Activity of Tramadol Against Bacteria Associated with Infectious Complications After Local or Regional Anesthesia

Zohreh Tamanai-Shacoori, PhD*, Valliollah Shacoori, PhD{dagger}, Anne Jolivet-Gougeon, PhD*, Jean-Marie Vo Van, MD{ddagger}, Martine Repère, Pharm D{dagger}, Pierre-Yves Donnio, PhD*, and Martine Bonnaure-Mallet, PhD*

From the *Equipe de Microbiologie, UPRES-EA 1254, Université de Rennes I, France; {dagger}Laboratoire de Biochimie Médicale A; and {ddagger}Département d’Anesthésiologie, CHR de Rennes, France.

Anesth Analg 2007;105:524-527

背景资料:曲马多是可待因的合成模拟药,兼有阿片类药物及局麻药的特性。他一直被当作中枢性镇痛药使用,近来作为一个局麻药进行皮下及皮内注射。我们在没有任何局部麻醉药的情况下,观察曲马多针对可以引起局部或区域麻醉后感染并发症的大肠杆菌、金黄色葡萄球菌、表皮葡萄球菌及绿脓杆菌病原菌的体外抗菌活性。

方法:细菌培养18小时,稀释在无菌生理盐水,与曲马多6.2512.5 25 mg/mL一起在37°C的条件下孵化624小时。然后将混合物移植至血琼脂培养基上, 37°C孵化 24小时后记录菌落计数。

结果: 与对照组相比,曲马多对于大肠杆菌及表皮葡萄球菌有抗菌活性:在25 mg/mL 6 小时组或12.5 mg/mL 24小时组,曲马多能使大肠杆菌菌落计数下降约7 log10 (100% 杀灭)(P < 0.001)。曲马多 25 mg/mL 24小时组得到相似的结果,使绿脓杆菌菌株数下降近6 log10100%杀灭)(P < 0.001)。曲马多25 mg/mL 对于金黄色葡萄球菌及绿脓杆菌的抗菌效力较低,24小时后,使这些菌株的生长下降3log10 (P < 0.001)

结论:曲马多对于大肠杆菌及表皮葡萄球菌的杀菌活性具有时间及剂量依赖性。对于金黄色葡萄球菌及绿脓杆菌也同样具有抗菌活性。曲马多的抗菌特性可能对减少局部或区域麻醉后细菌感染的风险是有益的。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Tramadol is a synthetic analog of codeine with opioid and local anesthetic properties. It is used as a central-acting analgesic, and recently, in subcutaneous or intradermal injections, as a local anesthetic. We investigated in vitro the antibacterial activity of tramadol in the absence of any local anesthetics against Escherichia coli, Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa pathogens that can cause infectious complications after local or regional anesthesia.

METHODS: Bacterial cultures were grown for 18 h, diluted in sterile physiological saline, and incubated for 6 or 24 h at 37°C with 6.25, 12.5, or 25 mg/mL tramadol. The mixtures were then plated onto blood agar and colony counts were recorded after 24 h incubation at 37°C.

RESULTS: Tramadol had bactericidal activity against E. coli and S. epidermidis compared with controls: at 25 mg/mL for 6 h or at 12.5 mg/mL for 24 h, tramadol decreased by approximately 7 log10 (P < 0.001) the colony counts of E. coli (100% kill). Similar results were obtained with S. epidermidis, with approximately 6 log10 reduction (100% kill) when tramadol was used at 25 mg/mL for 24 h (P < 0.001). The antibacterial effect of 25 mg/mL tramadol was lower against S. aureus and P. aeruginosa, reducing the growth of these strains by approximately 3log10 after 24 h (P < 0.001).

CONCLUSIONS: Tramadol has dose- and time-dependent bactericidal activity against E. coli and S. epidermidis, as well as antibacterial activity against S. aureus and P. aeruginosa. The antibacterial properties of tramadol may be useful for reducing the risk of bacterial infection after local or regional anesthesia.