Anesthesia & Analgesia

September 2007

 

CARDIOVASCULAR ANESTHESIA:

无麻醉作用的惰性气体通过激活促存活信号激酶和抑制线粒跨膜通道通透性途径对心梗后心肌产生保护作用

陶颖莹 陈杰

Noble Gases Without Anesthetic Properties Protect Myocardium Against Infarction by Activating Prosurvival Signaling Kinases and Inhibiting Mitochondrial Permeability Transition In Vivo

Paul S. Pagel, John G. Krolikowski, Yon Hee Shim, Suneetha Venkatapuram, Judy R. Kersten, Dorothee Weihrauch, David C. Warltier, and Phillip F. Pratt, Jr

Anesth Analg 2007 105: 562-569.

减少围手术期血栓并发症:肝素导致的血小板减少症(HIT)的新进展

Reducing Thrombotic Complications in the Perioperative Setting: An Update on Heparin-Induced Thrombocytopenia (Review Article)

陈勇柱译 薛张纲校

Jerrold H. Levy, Kenichi A. Tanaka, and Marcie J. Hursting

Anesth Analg 2007 105: 570-582.

围手术期心超检查用于心室辅助设备植入

彭中美   马皓琳 李士通

Perioperative Echocardiographic Examination for Ventricular Assist Device Implantation (Review Article)

Siriluk Chumnanvej, Malissa J. Wood, Thomas E. MacGillivray, and Marcos F. Vidal Melo

Anesth Analg 2007 105: 583-601.

心脏手术中偶然发现的卵圆孔未闭是否需要修补?

周懿之 陈杰

The Incidental Finding of a Patent Foramen Ovale During Cardiac Surgery: Should It Always Be Repaired? A Core Review (Review Article)

Mikhail R. Sukernik and Elliott Bennett-Guerrero

Anesth Analg 2007 105: 602-610.

PEDIATRIC ANESTHESIOLOGY:

异丙酚输注浓度变化对麻醉小儿血浆cGMP浓度的影响

吴德华译 薛张纲校

The Effect of Varying Continuous Propofol Infusions on Plasma Cyclic Guanosine 3',5'-Monophosphate Concentrations in Anesthetized Children

Thomas Engelhardt, Man K. Chan, Alan J. McCheyne, Cengiz Karsli, Igor Luginbuehl, and Bruno Bissonnette

Anesth Analg 2007 105: 616-619.

一项儿童气管内插管位置确定方法的对照试验:颈部活动的安全性

胡湘     马皓琳 李士通

A Comparative Study of Endotracheal Tube Positioning Methods in Children: Safety from Neck Movement

Seung-Yeon Yoo, Jin-Hee Kim, Sung-Hee Han, and Ah-Young Oh

Anesth Analg 2007 105: 620-625

ANESTHETIC PHARMACOLOGY:

健康受试者吸入七氟醚后晚期预处理效果的分子学证据

潘方立 陈杰

Molecular Evidence of Late Preconditioning After Sevoflurane Inhalation in Healthy Volunteers

Eliana Lucchinetti, José Aguirre, Jianhua Feng, Min Zhu, Marc Suter, Donat R. Spahn, Luc Härter, and Michael Zaugg

Anesth Analg 2007 105: 629-640.

对罗哌卡因作用于离体豚鼠心脏标本产生的毒性作用使用左西孟旦的强心功能

孙霞译 薛张纲校  

The Effects of Levosimendan on Myocardial Function in Ropivacaine Toxicity in Isolated Guinea Pig Heart Preparations

Sebastian N. Stehr, Torsten Christ, Berit Rasche, Stefan Rasche, Erich Wettwer, Andreas Deussen, Ursula Ravens, Thea Koch, and Matthias Hübler

Anesth Analg 2007 105: 641-647.

0.25MAC七氟醚优先影响高阶联合区:一项志愿者的功能性磁共振成像研究

朱慧 马皓琳 李士通

Sevoflurane 0.25 MAC Preferentially Affects Higher Order Association Areas: A Functional Magnetic Resonance Imaging Study in Volunteers

Ramachandran Ramani, Maolin Qiu, and Robert Todd Constable

Anesth Analg 2007 105: 648-655.

兰替洛尔—超短效β1受体拮抗剂不改变猪异氟醚的最小肺泡有效浓度

丁震敏 陈杰

Landiolol, an Ultra–Short-Acting ß1-Adrenoceptor Antagonist, Does Not Alter the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model

Tadayoshi Kurita, Kotaro Takata, Masahiro Uraoka, Koji Morita, and Shigehito Sato

Anesth Analg 2007 105: 656-660.

大鼠脊髓内脑脊液中钠离子浓度改变对异氟醚MAC的影响

王时来译 薛张纲校

Alterations in Spinal, but Not Cerebral, Cerebrospinal Fluid Na+ Concentrations Affect the Isoflurane Minimum Alveolar Concentration in Rats

Michael J. Laster, Yi Zhang, Edmond I. Eger, II, Dimitry Shnayderman, and James M. Sonner

Anesth Analg 2007 105: 661-665.

在猪模型上使用右美托咪定行深度镇静并不影响游离微血管皮瓣的活性(以微透析和组织氧张力表示)

黄施伟 译,马皓琳 李士通

Deep Sedation with Dexmedetomidine in a Porcine Model Does Not Compromise the Viability of Free Microvascular Flap as Depicted by Microdialysis and Tissue Oxygen Tension

Silvia Nunes, Leena Berg, L.-P Raittinen, Heikki Ahonen, Jussi Laranne, Leena Lindgren, Iikka Parviainen, Esko Ruokonen, and Jyrki Tenhunen

Anesth Analg 2007 105: 666-672.

酮体(β羟基丁酸和丙酮)的麻醉学特性

於章杰 陈杰

Anesthetic Properties of the Ketone Bodies ß-Hydroxybutyric Acid and Acetone

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

Anesth Analg 2007 105: 673-679.

TECHNOLOGY, COMPUTING, AND SIMULATION:

用传统的红外线临床气体分析仪测量血液中的麻醉气体

杨译 薛张纲校

Measurement of Anesthetics in Blood Using a Conventional Infrared Clinical Gas Analyzer

Philip J. Peyton, Michael Chong, Christopher Stuart-Andrews, Gavin J. B. Robinson, Robert Pierce, and Bruce R. Thompson

Anesth Analg 2007 105: 680-687.

七氟醚麻醉下神经肌肉阻滞和伤害性刺激对催眠监测的影响

黄丽娜   马皓琳 李士通

The Effect of Neuromuscular Block and Noxious Stimulation on Hypnosis Monitoring During Sevoflurane Anesthesia

Andreas Ekman, Erik Stålberg, Eva Sundman, Lars I. Eriksson, Lars Brudin, and Rolf Sandin

Anesth Analg 2007 105: 688-695.

全身麻醉期间呼出一氧化碳的水平与吸入氧浓度的关系

詹琼慧 陈杰

Exhaled Carbon Monoxide Levels Change in Relation to Inspired Oxygen Fraction During General Anesthesia

Takehiko Adachi, Kiichi Hirota, Tomoko Hara, Yukiko Sasaki, and Yasufumi Hara

Anesth Analg 2007 105: 696-699.

动脉球囊阻塞控制骶骨手术术中出血

陈佳莉译 薛张纲校

Control of Blood Loss During Sacral Surgery by Aortic Balloon Occlusion (Technical Communication)

Lan Zhang, Quan Gong, Hong Xiao, Chongqi Tu, and Jin Liu

Anesth Analg 2007 105: 700-703.

CRITICAL CARE AND TRAUMA:

抗纤维蛋白酶的水平与外科重症监护室发病率和死亡率的关系

唐李隽 马皓琳 李士通

Antithrombin Levels, Morbidity, and Mortality in a Surgical Intensive Care Unit

Yasser Sakr, Konrad Reinhart, Stefan Hagel, Michael Kientopf, and Frank Brunkhorst

Anesth Analg 2007 105: 715-723.

羟乙基淀粉:分子量和取代级对血管内贮留的影响

杨卫红 陈杰

Hydroxyethyl Starch: The Effect of Molecular Weight and Degree of Substitution on Intravascular Retention In Vivo

Takashi Hitosugi, Toshiyuki Saito, Sono Suzuki, Ieko Kubota, Emi Shoda, Toru Shimizu, and Yoshiyuki Oi

Anesth Analg 2007 105: 724-728.

选择性肺复张对于严重低血容量患者的血流动力学是否安全?一项在肺萎陷猪的动物模型关于低血容量的试验性研究。

陈珺珺译 薛张纲校

Are Selective Lung Recruitment Maneuvers Hemodynamically Safe in Severe Hypovolemia? An Experimental Study in Hypovolemic Pigs with Lobar Collapse

Lars Kjærsgaard Hansen, Jacob Koefoed-Nielsen, Jonas Nielsen, and Anders Larsson

Anesth Analg 2007 105: 729-734.

隆凸可作为主动脉内球囊搏动定位的有用的影像学标志

周雅春 马皓琳 李士通

The Carina as a Useful Radiographic Landmark for Positioning the Intraaortic Balloon Pump

Jin-Tae Kim, Jeong-Rim Lee, Jae-Kwang Kim, Seung Zhoo Yoon, Yunseok Jeon, Jae-Hyon Bahk, Ki-Bong Kim, Chong-Sung Kim, Young-Jin Lim, Hee-Soo Kim, and Seong-Deok Kim

Anesth Analg 2007 105: 735-738.

NEUROSURGICAL ANESTHESIOLOGY:

毒扁豆碱逆转成年小鼠由于中度缺氧引起的认知功能障碍

杜唯佳 陈杰

Physostigmine Reverses Cognitive Dysfunction Caused by Moderate Hypoxia in Adult Mice

Alex Bekker, Michael Haile, Kevin Gingrich, Leslie Wenning, Alex Gorny, David Quartermain, and Thomas Blanck

Anesth Analg 2007 105: 739-743

猪大脑皮层在颅内压增高伴脑血流降低时的脑代谢

佳译 薛张刚校

Brain Metabolism During a Decrease in Cerebral Perfusion Pressure Caused by an Elevated Intracranial Pressure in the Porcine Neocortex

Norbert Zoremba, Joerg Schnoor, Michael Berens, Ralf Kuhlen, and Rolf Rossaint

Anesth Analg 2007 105: 744-750.

OBSTETRIC ANESTHESIOLOGY:

足月肥胖孕妇胃对水排空的研究

邱郁薇 马皓琳 李士通

Gastric Emptying of Water in Obese Pregnant Women at Term

Cynthia A. Wong, Robert J. McCarthy, Paul C. Fitzgerald, Kiril Raikoff, and Michael J. Avram

Anesth Analg 2007 105: 751-755.

局麻药和分娩方式:布比卡因、罗哌卡因及左旋布比卡因的比较

钱玲 陈杰 校)

Local Anesthetics and Mode of Delivery: Bupivacaine Versus Ropivacaine Versus Levobupivacaine

Yaakov Beilin, Nicole R. Guinn, Howard H. Bernstein, Jeff Zahn, Sabera Hossain, and Carol A. Bodian

Anesth Analg 2007 105: 756-763.

东莨菪碱透皮给药预防蛛网膜下腔用吗啡导致的剖宫产术后恶心呕吐

璇译 薛张纲校

Transdermal Scopolamine for Prevention of Intrathecal Morphine-Induced Nausea and Vomiting After Cesarean Delivery

Miriam J. P. Harnett, Nollag O’Rourke, Mary Walsh, Jean Marie Carabuena, and Scott Segal

Anesth Analg 2007 105: 764-769.

GENERAL ARTICLES:

补充供氧可以提高猪正常和吻合的结肠组织氧压,但补充晶体液无影响

沈浩   马皓琳 李士通

Supplemental Oxygen, but Not Supplemental Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and Anastomotic Colon in Pigs

Oliver Kimberger, Edith Fleischmann, Sebastian Brandt, André Kugener, Barbara Kabon, Luzius Hiltebrand, Vladimir Krejci, and Andrea Kurz

Anesth Analg 2007 105: 773-779.

成人肝移植期间在再灌注前、再灌注后早期、再灌注后晚期3个时期高钾血症的预测

张燕 陈杰

Predictors of Hyperkalemia in the Prereperfusion, Early Postreperfusion, and Late Postreperfusion Periods During Adult Liver Transplantation

Victor W. Xia, Rafik M. Ghobrial, Bin Du, Tabitha Chen, Ke-Qin Hu, Jonathan R. Hiatt, Ronald W. Busuttil, and Randolph H. Steadman

Anesth Analg 2007 105: 780-785.

ANALGESIA:

一项系统性回顾:患者回馈关于术后镇痛作用的结果

王光妍译 薛张纲校

The Effect of Analgesic Technique on Postoperative Patient-Reported Outcomes Including Analgesia: A Systematic Review

Spencer S. Liu and Christopher L. Wu

Anesth Analg 2007 105: 789-808.

硬膜外腔注射自体静脉血治疗慢性颈部扭伤相关性疾患

裘毅敏译,马皓琳,李士通校

Epidural Blood Patch Therapy for Chronic Whiplash-Associated Disorder

Shinichi Ishikawa, Masataka Yokoyama, Satoshi Mizobuchi, Hidenori Hashimoto, Eiji Moriyama, and Kiyoshi Morita

Anesth Analg 2007 105: 809-814.

矫形外科中原发性痛觉过敏的演变全膝关节成形术前后定量感觉测试和临床评价

王鹏 陈杰

The Evolution of Primary Hyperalgesia in Orthopedic Surgery: Quantitative Sensory Testing and Clinical Evaluation Before and After Total Knee Arthroplasty

Valéria Martinez, Dominique Fletcher, Didier Bouhassira, Daniel I. Sessler, and Marcel Chauvin
Anesth Analg 2007 105: 815-821.

经腹全子宫切除术后使用帕瑞考西以增加鞘内注射吗啡的镇痛效果

周时蓓译 薛张纲校

Improving the Analgesic Efficacy of Intrathecal Morphine with Parecoxib After Total Abdominal Hysterectomy (Brief Report)

Supranee Niruthisard, Thewarug Werawataganon, Pavena Bunburaphong, Montson Ussawanophakiat, Chuthayuth Wongsakornchaikul, and Kusonsi Toleb

Anesth Analg 2007 105: 822-824.

Resiniferatoxin 的坐骨神经阻滞:对大鼠无髓鞘神经纤维的 电子显微镜研究

张莹   马皓琳 李士通

Sciatic Nerve Block with Resiniferatoxin: An Electron Microscopic Study of Unmyelinated Fibers in the Rat

Igor Kissin, Cristina F. Freitas, Howard L. Mulhern, and Umberto DeGirolami

Anesth Analg 2007 105: 825-831.

麻醉猫静脉注射咪唑安定后的交感神经反射活性

杜唯佳 陈杰

Reflex Sympathetic Activity After Intravenous Administration of Midazolam in Anesthetized Cats

Ryoji Iida, Ken-ichi Iwasaki, Jitsu Kato, Shigeru Saeki, and Setsuro Ogawa

Anesth Analg 2007 105: 832-837.

末梢神经性疼痛的病理生理:免疫细胞与分子

吴威译 薛张纲校

Pathophysiology of Peripheral Neuropathic Pain: Immune Cells and Molecules (Review Article)

Michael A. Thacker, Anna K. Clark, Fabien Marchand, and Stephen B. McMahon

Anesth Analg 2007 105: 838-847.

不管电刺激高于还是低于0.5mA超声引导下的肌间沟置针都能产生成功的麻醉

姜旭晖译  马皓琳 李士通校

Ultrasound-Guided Interscalene Needle Placement Produces Successful Anesthesia Regardless of Motor Stimulation Above or Below 0.5 mA

Sanjay K. Sinha, Jonathan H. Abrams, and Robert S. Weller

Anesth Analg 2007 105: 848-852.

闭孔神经与股神经阻滞用于膝关节成形术后镇痛的比较

陈伟 陈杰

Obturator Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty

Ken Kardash, Don Hickey, Michael J. Tessler, Stacey Payne, David Zukor, and Ana Miriam Velly

Anesth Analg 2007 105: 853-858.

硬膜外,鞘内注射罗哌卡因的药代动力学和生物利用度

陈恺铮译 薛张纲校

Epidural, Intrathecal Pharmacokinetics, and Intrathecal Bioavailability of Ropivacaine

François-Xavier Rose, Jean-Pierre Estebe, Maja Ratajczak, Eric Wodey, François Chevanne, Gilles Dollo, David Bec, Jean-Marc Malinovsky, Claude Ecoffey, and Pascal Le Corre Anesth

Analg 2007 105: 859-867.

持续正压通气呼吸可以增加颈胸段硬膜外注射利多卡因后的感觉阻滞头向扩散

黄佳佳译,马皓琳 李士通

Continuous Positive Airway Pressure Breathing Increases Cranial Spread of Sensory Blockade After Cervicothoracic Epidural Injection of Lidocaine

W. Anton Visser, Maarten J. P. G. van Eerd, Robert van Seventer, Mathieu J. M. Gielen, Janneke L. P. Giele, and Gert J. Scheffer

Anesth Analg 2007 105: 868-871.

经斜角肌臂丛阻滞:后外侧臂丛阻滞的新方法

朱玫娟 陈杰

Transscalene Brachial Plexus Block: A New Posterolateral Approach for Brachial Plexus Block (Brief Report)

Hoang C. Nguyen, Erwin Fath, Sebastian Wirtz, and Tareg Bey

Anesth Analg 2007 105: 872-875.

 

围手术期心超检查用于心室辅助设备植入

Perioperative Echocardiographic Examination for Ventricular Assist Device Implantation

Siriluk Chumnanvej, MD*, Malissa J. Wood, MD{dagger}, Thomas E. MacGillivray, MD{ddagger}, and Marcos F. Vidal Melo, MD, PhD*

From the *Department of Anesthesia and Critical Care; {dagger}Division of Cardiology, Department of Medicine; and {ddagger}Cardiac Surgical Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007;105:583-601

心室辅助设备(VADs)是用于有严重心衰病人的机械性循环支持的设备。围手术期经食道超声心动图是病的处理的主要组成,对于手术和麻醉决策极为重要。在本综述中我们介绍了对于接受VAD病人综合的超声心电图评估的原理和可得到的数据。除了标准检查,设备特异性术前、术中和术后考虑因素对于心超评估是必须的。这些包括:(1VAD植入前心脏和大血管的检查以排除明显的主动脉反流、三尖瓣反流、二尖瓣狭窄、卵圆孔未闭或者可能引起左VAD植入后右向左分流的其他心脏异常,心内血栓、心室疤痕、肺动脉反流、肺动脉高压、肺栓塞和升主动脉粥样硬化疾病;并且评估右室功能;(2VAD植入后检查设备及再评估心脏和大血管。设备检查的目的是用二维和彩色持续的脉冲多普乐模式确认设备完整性和心脏没有进气、插管的位置和开放及设备瓣膜的能力。植入后心脏检查的目的必须是排除主动脉反流或者无包被的右向左分流,并且评估右室功能、左室卸负荷和设备对全心功能的作用。各种VAD模型有不同的基础和操作原则,需要特别的心超评估以有利于植入设备的特性的发挥。

(彭中美   马皓琳 李士通 校)

Ventricular assist devices (VADs) are systems for mechanical circulatory support of the patient with severe heart failure. Perioperative transesophageal echocardiography is a major component of patient management, and important for surgical and anesthetic decision making. In this review we present the rationale and available data for a comprehensive echocardiographic assessment of patients receiving a VAD. In addition to the standard examination, device-specific pre-, intra-, and postoperative considerations are essential to the echocardiographic evaluation. These include: (a) the pre-VAD insertion examination of the heart and large vessels to exclude significant aortic regurgitation, tricuspid regurgitation, mitral stenosis, patent foramen ovale, or other cardiac abnormality that could lead to right-to-left shunt after left VAD placement, intracardiac thrombi, ventricular scars, pulmonic regurgitation, pulmonary hypertension, pulmonary embolism, and atherosclerotic disease in the ascending aorta; and to assess right ventricular function; and (b) the post-VAD insertion examination of the device and reassessment of the heart and large vessels. The examination of the device aims to confirm completeness of device and heart deairing, cannulas alignment and patency, and competency of device valves using two-dimensional, and color, continuous and pulsed wave Doppler modalities. The goal for the heart examination after implantation should be to exclude aortic regurgitation, or an uncovered right-to-left shunt; and to assess right ventricular function, left ventricular unloading, and the effect of device settings on global heart function. The variety of VAD models with different basic and operation principles requires specific echocardiographic assessment targeted to the characteristics of the implanted device.


 

一项儿童气管内插管位置确定方法的对照试验:颈部活动的安全性

A Comparative Study of Endotracheal Tube Positioning Methods in Children: Safety from Neck Movement

Seung-Yeon Yoo, MD*, Jin-Hee Kim, MD, PhD*{dagger}, Sung-Hee Han, MD, PhD*{dagger}, and Ah-Young Oh, MD, PhD{dagger}

From the *Department of Anesthesiology, Seoul National University Medical College, Seoul, Korea, {dagger}Department of Anesthesiology, Seoul National University Bundang Hospital, Seongnam City, Kyeonggi-do, Korea.

Anesth Analg 2007;105:620-625

背景:由于颈部活动引起的气管内导管的意外移位可以导致导管进入支气管和意外的拔管。气管内插管甚至可以在临床上或者X线定位下已确定适当位置后移位。

方法:1072-8岁的儿童被随机分为3组。第1组,气管插管至主支气管然后退出直到听到双肺相等的呼吸音,然后拔出2公分。在第2组,气管插管的位置由在到达声门水平的气管导管上标记规定的记号来确定。第3组,由在胸骨上切迹触摸气管导管顶端来确定。在所有的分组中,由纤支镜来测量从气管导管顶端到隆突的距离。在颈部移动时的每一个位置评估气管导管在气管中的相对位置(隆突为0% ,声带为100%)。

结果:患者在中性位的气管导管的相对位置在123组分别为21.4% ± 6.7%46.5% ± 13.0%43.4% ± 11.1%。在第1组,颈部弯曲后气管导管的相对位置为9.5% ± 10.3%,且5位儿童发现导管进入支气管(14.3%)。在其他两组未发现拔管或者导管进入支气管。

结论:听诊来定位气管插管的位置较中段气管要深,可能加大颈部弯曲后气管导管进入支气管的风险。

(胡湘     马皓琳 李士通 校)

BACKGROUND: The unexpected displacement of the endotracheal tube (ETT) as a result of neck movements can cause endobronchial intubation and accidental extubation. The ETT is subject to movement even after its proper placement has been confirmed either clinically or radiographically.

METHODS: One-hundred-seven children (2–8 yr) were divided randomly into three groups. In Group I, the ETT was entered into the main bronchus and withdrawn until equal sounds in both lung were heard, and then withdrawn 2 cm. In Group II, the ETT position was determined by placing the prescribed marks on the ETT at the level of the vocal cords, and in Group III, by palpating the ETT tip at the suprasternal notch. In all groups, the distance between the ETT tip and the carina was measured using a fiberoptic bronchoscope. The relative ETT tip position along the trachea (carina; 0%, vocal cords; 100%) was assessed in each position during neck movement.

RESULTS: The relative position of the ETT with the patient in the neutral position in Groups I, II, and III was 21.4% ± 6.7%, 46.5% ± 13.0%, and 43.4% ± 11.1%, respectively. In Group I, the relative ETT position after flexion was 9.5% ± 10.3%, and endobronchial intubation was observed in five children (14.3%). There was no extubation or endobronchial intubation in the other two groups.

CONCLUSIONS: Positioning the ETT by auscultation places the ETT more deeply than the midtrachea, which can increase the risk of endobronchial intubation during neck flexion.


 

0.25MAC七氟醚优先影响高阶联合区:一项志愿者的功能性磁共振成像研究

Sevoflurane 0.25 MAC Preferentially Affects Higher Order Association Areas: A Functional Magnetic Resonance Imaging Study in Volunteers

Ramachandran Ramani, MD*, Maolin Qiu, PhD{dagger}, and Robert Todd Constable, PhD{dagger}

From the *Department of Anesthesia; and {dagger}Magnetic Resonance Research Center, Yale University School of Medicine, New Haven, Connecticut.

Anesth Analg 2007;105:648-655

背景:功能性磁共振成像(Functional magnetic resonance imagingfMRI)能客观地估量麻醉的主观效应。亚麻醉剂量的挥发性麻醉药能影响记忆相关的区域(联合区)。在这个研究中我们测定了0.25MAC七氟醚对健康志愿者局部神经元效应,并区分第一皮层区和联合区的效应。

方法:研究0.25MAC七氟醚对16ASA I级的志愿者视觉、听觉和运动激活的影响。在使用fMRI3特斯拉Siemens磁发电机)的情况下,用脉冲动脉自旋标记物技术测定局部脑血流(regional cerebral blood flowrCBF) 。受试者吸入氧和0.25MAC七氟醚的混合气体,并进行标准的ASA监测。完成视觉、听觉和运动激活任务。测定非激活和激活时清醒状态下及吸入0.25MAC七氟醚时的rCBF。计算吸入0.25MAC七氟醚时基线状态下与视觉、听觉和运动激活有关的11个兴趣区中rCBF的变化(δCBF)。

结果:吸入0.25MAC七氟醚时在11个兴趣区中rCBF与基线的变化没有统计学意义。在激活时一些区域的CBF有显著升高。然而,只有在第一、第二视觉皮层(V1V2)、丘脑、海马和辅助的运动区域,吸入0.25MAC七氟醚且激活时rCBF的减少是有统计学意义的(P < 0.05)

结论:亚麻醉浓度的挥发性麻醉药能影响记忆相关区域(联合区)。在fMRI的帮助下,此研究表明0.25MAC七氟醚主要影响第一视觉皮层、相关联合皮层和某些其他的高阶联合皮层。

(朱慧 马皓琳 李士通 校)

BACKGROUND: Functional magnetic resonance imaging (fMRI) can objectively measure the subjective effects of anesthesia. Memory-related regions (association areas) are affected by subanesthetic doses of volatile anesthetics. In this study we measured the regional neuronal effects of 0.25 MAC sevoflurane in healthy volunteers and differentiated the effect between primary cortical regions and association areas.

METHODS: The effect of 0.25 MAC sevoflurane on visual, auditory, and motor activation was studied in 16 ASA I volunteers. With fMRI (3 Tesla Siemens magnetom), regional cerebral blood flow (rCBF) was measured by the pulsed arterial spin labeling technique. Subjects inhaled a mixture of O2 and 0.25 MAC sevoflurane and standard ASA monitoring was performed. Visual, auditory, and motor activation tasks were used. rCBF was measured in the awake state and during inhalation of 0.25 MAC sevoflurane, without and with activation. The change in rCBF ({delta}CBF) with 0.25 MAC Sevoflurane during baseline state and with activation was calculated in 11 regions of interest related to visual, auditory, and motor activation tasks.

RESULTS: The change from baseline rCBF with 0.25 MAC sevoflurane was not statistically significant in the 11 regions of interest. With activation there was a significant increase in CBF in several regions. However, only in the primary and secondary visual cortices (V1, V2), thalamus, hippocampus, and supplementary motor area was the decrease in activation with 0.25 MAC sevoflurane statistically significant (P < 0.05).

CONCLUSION: Memory-related regions (association areas) are affected by subanesthetic concentrations of volatile anesthetics. Using fMRI, this study showed that 0.25 MAC sevoflurane predominantly affects the primary visual cortex, the related association cortex, and certain other higher order association cortices.


 

在猪模型上使用右美托咪定行深度镇静并不影响游离微血管皮瓣的活性(以微透析和组织氧张力表示)

Deep Sedation with Dexmedetomidine in a Porcine Model Does Not Compromise the Viability of Free Microvascular Flap as Depicted by Microdialysis and Tissue Oxygen Tension

Silvia Nunes, MD, PhD*, Leena Berg, MD, PhD{dagger}, L.-P Raittinen{ddagger}, Heikki Ahonen, RN§, Jussi Laranne, MD, PhD{ddagger}, Leena Lindgren, MD, PhD||, Iikka Parviainen, MD, PhD§, Esko Ruokonen, MD, PhD§, and Jyrki Tenhunen, MD, PhD*

From the Critical Care Medicine Research Group, *Department of Intensive Care, Tampere University Hospital, Tampere, Finland; {dagger}Department of Surgery, Kuopio University Hospital, Kuopio, Finland; {ddagger}Department of Otorhinolaryngology, Tampere University Hospital, Tampere, Finland; §Department of Intensive Care, Kuopio University Hospital, Kuopio, Finland; and ||Department of Anesthesiology, Tampere University Hospital, Tampere, Finland.

Anesth Analg 2007;105:666-672

背景:在面部和颈部整形大手术后往往有必要使用深度镇静来防止突然的自发移动对移植肌皮瓣造成机械性损伤。合适的定位可能有助于改善移植组织的氧合和灌注。我们假设右美托咪定,一种中枢性α2激动剂以及可能是理想的术后镇静药物,可能导致失神经支配皮瓣的血管收缩,从而增加组织坏死的风险。

方法:12头猪经麻醉后,两块对称的肌皮瓣被提升至每侧的上腹部。在其中一块皮瓣上将交感神经纤维从动脉上剥离(失神经支配皮瓣),而另一块则保持不动(神经支配皮瓣)。在模拟缺血和再灌注期后,动物被随机接受丙泊酚(n = 6)或右美托咪定(n = 6) 术后深度镇静。用微透析和组织氧分压来监测皮瓣组织的代谢。每30min对透析液中的葡萄糖、乳酸和丙酮酸浓度进行测定,共进行4h

结果:右美托咪定组的平均动脉压更高(P = 0.036)。用乳酸-丙酮酸和乳酸-葡萄糖比值(中位数范围乳酸-丙酮酸为14.3–24.5,而乳酸-葡萄糖为

0.3–0.6)及组织氧分压测得的皮瓣组织的代谢在整个实验过程中保持稳定,且组间无差别。

结论:我们的资料显示:右美托咪定即使被用于深度镇静,也不会对失神经支配肌皮瓣的局部灌注或组织代谢产生有害的影响。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: Deep sedation is often necessary after major reconstructive plastic surgery in the face and neck regions to prevent sudden spontaneous movements capable of inflicting mechanical injury to the transplanted musculocutaneous flap(s). An adequate positioning may help to optimize oxygenation and perfusion of the transplanted tissues. We hypothesized that dexmedetomidine, a central {alpha}2-agonist and otherwise potentially ideal postoperative sedative drug, may induce vasoconstriction in denervated flaps, and thus increase the risk of tissue deterioration.

METHODS: Two symmetrical myocutaneous flaps were raised on each side of the upper abdomen in 12 anesthetized pigs. The sympathetic nerve fibers were stripped from the arteries in one of the flaps (denervated flap), while nerve fibers were kept untouched in the other (innervated flap). After simulation of ischemia and reperfusion periods, the animals were randomized to deep postoperative sedation with either propofol (n = 6) or dexmedetomidine (n = 6). Flap tissue metabolism was monitored by microdialysis and tissue-oxygen partial pressure. Glucose, lactate, and pyruvate concentrations were analyzed from the dialysate every 30 min for 4 h.

RESULTS: Mean arterial blood pressure was higher in the dexmedetomidine group (P = 0.036). Flap tissue metabolism remained stable throughout the experiment as measured by lactate–pyruvate and lactate–glucose ratios (median ranges 14.3–24.5 for lactate–pyruvate and 0.3–0.6 for lactate–glucose) and by tissue-oxygen partial pressure, and no differences were found between groups.

CONCLUSIONS: Our data suggest that dexmedetomidine, even if used for deep sedation, does not have deleterious effects on local perfusion or tissue metabolism in denervated musculocutaneous flaps.


 

七氟醚麻醉下神经肌肉阻滞和伤害性刺激对催眠监测的影响

The Effect of Neuromuscular Block and Noxious Stimulation on Hypnosis Monitoring During Sevoflurane Anesthesia

Andreas Ekman, MD, DEAA*, Erik Stålberg, MD, PhD{dagger}, Eva Sundman, MD, PhD*, Lars I. Eriksson, MD, PhD*, Lars Brudin, MD, PhD{ddagger}, and Rolf Sandin, MD, PhD*

From the *Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institute, Stockholm; {dagger}Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala; and {ddagger}Department of Medicine and Care, Linköping University, Linköping, Sweden.

Anesth Analg 2007;105:688-695

背景:关于神经肌肉阻滞(NMB)对脑电双频指数(BIS)的影响,有相反的结果。我们研究了两个NMB阻滞深度对BIS,腋生听觉诱发电位指数(AAI)以及肌电图(EMG,用针电极从额部和颞部紧靠近BIS传感器的肌肉处获得)的影响。

方法:20名患者均应用七氟醚进行麻醉,吸入30min达到呼气末浓度在1.2%(基线水平)。输注罗库溴铵分别达到4个成串刺激中第1个肌颤搐高度降低50%(部分阻滞)和95%(深度阻滞),次序是随机选择的。伤害性的强直性电刺激应用于以下4种情况下:1)在基线水平(对照),23)在每个程度的NMB时,4)在新斯的明拮抗后。在每一次伤害性刺激前后2min时,分别采集BISAAIEMG

结果:BISAAI的基础值的中位数分别为 44 (39–50)15 (14–16)。在伤害性刺激前,NMB的两个阻滞深度均不影响BISAAIEMG。相反,与部分NMB相比较,深度NMB会改变BISAAI对伤害性刺激的反应 (BIS P = 0.01, AAI P < 0.01)。而新斯的明拮抗后(BIS P < 0.01, AAI P = 0.01) ,与基线相比(BIS P = 0.08, AAI P = 0.02)。未发现EMG显著性增高。

结论:在七氟醚麻醉下,NMB程度影响BISAAI对伤害性的强直性电刺激的反应,而在没有伤害性刺激的情况下,NMB并不影响BISAAI

(黄丽娜   马皓琳 李士通 校)

BACKGROUND: There are conflicting results on the influence of neuromuscular block (NMB) on the bispectral index (BIS). We investigated the influence of two degrees of NMB on BIS, Alaris auditory-evoked potential index (AAI), and the electromyogram (EMG) obtained with needle electrodes from the frontal and temporal muscles, immediately adjacent to the BIS-sensor.

METHODS: Twenty patients were anesthetized with sevoflurane, titrated for 30 min to an end-tidal concentration of 1.2% (baseline). Rocuronium was infused to 50% (partial) and 95% (profound) depression of the first twitch in a train-of-four response, the order being randomly chosen. Noxious tetanic electrical stimulation was applied at four occasions: 1) at baseline (control measurement), 2 and 3) at each degree of NMB, and 4) after neostigmine reversal. BIS, AAI, and EMG were obtained 2 min before and 2 min after each noxious stimulation.

RESULTS: Median BIS and AAI at baseline were 44 (39–50) and 15 (14–16), respectively. The two degrees of NMB did not affect BIS, AAI, and EMG before noxious stimulation. In contrast, profound NMB altered the BIS and AAI responses to noxious stimulation when compared with partial NMB, (BIS P = 0.01, AAI P < 0.01), after neostigmine reversal (BIS P < 0.01, AAI P = 0.01) and compared with baseline (BIS P = 0.08, AAI P = 0.02). No significant increase in EMG was found.

CONCLUSION: BIS and AAI responses to noxious tetanic electrical stimulation are affected by the degree of NMB during sevoflurane anesthesia whereas NMB does not affect BIS or AAI in the absence of noxious stimulation.


抗纤维蛋白酶的水平与外科重症监护室发病率和死亡率的关系

Antithrombin Levels, Morbidity, and Mortality in a Surgical Intensive Care Unit

Yasser Sakr, MB BCh*, Konrad Reinhart, MD*, Stefan Hagel, MD*, Michael Kientopf, MD{dagger}, and Frank Brunkhorst, MD*

From the *Department of Anesthesiology and Intensive Care, and {dagger}Institute of Clinical Chemistry and Laboratory Medicine, Friedrich-Schiller-University Hospital, Jena, Germany.

Anesth Analg 2007;105:715-723

背景:抗纤维蛋白酶(AT)水平已被建议作为重症监护室(ICU)中感染性休克患者预后的预测指标。我们研究了外科ICUAT水平的时程,并验证了AT水平可能与部分外科ICU患者的发病率、死亡率增加有关的假设。

方法:连续选取327名预计入ICU治疗超过48小时的患者,每日测定AT水平。结果:入ICU时,84.1% (n = 275)患者AT水平低于正常下限;入ICU48小时内明显升高且到第7日内恢复正常的患者从未罹患脓毒血症(n = 208)。此种AT水平升高在脓毒症患者中延迟出现。重症脓毒血症患者(n = 55)AT水平始终低于其他患者。较ICU其他患者,低水平AT患者对血制品的需求增大、器官功能障碍的最大程度更严重。不管入ICU时的AT水平如何,患者在ICU停留时间相似。多变量分析显示入ICUAT水平与死亡率的增加无相关性。

结论:不论是否发生脓毒血症,入ICUAT水平很低。虽然AT水平与器官功能障碍水平及脓毒血症的严重程度有关,但不是外科ICU患者预后较差的独立相关因素。

(唐李隽 马皓琳 李士通 校)

BACKGROUND: Antithrombin (AT) levels have been suggested as being predictive of outcome in intensive care unit (ICU) patients with septic shock. We investigated the time course of AT levels in a surgical ICU and tested the hypothesis that AT levels may be associated with morbidity and increased mortality rates in a cohort of surgical ICU patients.

METHODS: Three-hundred-twenty-seven consecutive patients admitted to the ICU with an estimated length of stay more than 48 h were included. AT levels were measured daily.

RESULTS: On admission to the ICU, AT levels were below the lower limit of normal in 84.1% (n = 275) of patients and increased significantly by 48 h after admission to reach normal values by the 7th ICU day in patients who never had sepsis (n = 208). This increase in AT levels was delayed in patients with sepsis. Patients with severe sepsis (n = 55) had consistently lower AT levels compared with other patients. Patients with lower AT levels were more likely to need blood products and had a greater maximum degree of organ dysfunction in the ICU than did other patients. The ICU length of stay was similar, regardless of the AT level on admission. Admission AT levels were not associated with increased ICU mortality in a multivariable analysis.

CONCLUSIONS: AT levels are low on admission to the ICU, regardless of the presence of sepsis. Although associated with the degree of organ dysfunction and the severity of sepsis, AT levels were not independently associated with worse outcome in this group of surgical ICU patients.



隆凸可作为主动脉内球囊搏动定位的有用的影像学标志

The Carina as a Useful Radiographic Landmark for Positioning the Intraaortic Balloon Pump

Jin-Tae Kim, MD, PhD*, Jeong-Rim Lee, MD*, Jae-Kwang Kim, MD*, Seung Zhoo Yoon, MD, PhD*, Yunseok Jeon, MD, PhD*, Jae-Hyon Bahk, MD, PhD*, Ki-Bong Kim, MD, PhD{dagger}, Chong-Sung Kim, MD, PhD*, Young-Jin Lim, MD, PhD*, Hee-Soo Kim, MD, PhD*, and Seong-Deok Kim, MD, PhD*

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

Anesth Analg 2007;105:735-738

研究背景:一般认为主动脉结是用于主动脉内球囊搏动(IABP)尖端恰当定位的最有效影像学标志。但是这并未经过正式研究验证。在本研究中我们评估了主动脉结是否为IABP定位的可靠影像学标志,且将其与另一潜在影像学标志隆凸作比较。

研究方法:我们测量了100名患者三维计算机断层血管造影术中自远心端主动脉弓顶点(主动脉结)至左锁骨下动脉(LSCA)之间的距离。在另150名患者用三维计算机断层摄片测量LSCA起点水平至隆凸水平的距离。

研究结果:以主动脉结作为影像学标志研究的人群中有16%的患者LSCA 至主动脉结的距离<0 cm或等于0 cmLSCA至隆凸距离的中位数为42mm(范围3663mm)。在以隆凸作为影像学标志研究的人群中,95.3%的患者LSCA起点在隆凸之上3555mm

结论:IABP放置于主动脉结处时,对于16%的患者而言IABP距离LSCA太近,而当IABP放置于隆凸上2cm处时,对于95.3%的患者而言,IABP尖端位置放置恰当(距LSCA起点处1.53.5cm)。相对于主动脉结而言,隆凸是定位IABP更可靠的影像学标志。

(周雅春 马皓琳 李士通 校)

BACKGROUND: The aortic knob is thought to be the most useful radiographic landmark for the proper positioning of the intraaortic balloon pump (IABP) tip. However, this has not been studied formally. In this study we assessed whether the aortic knob is a reliable landmark for positioning the IABP and compared it with another potential landmark, the carina.

METHODS: We measured the distance from the top of the distal aortic arch (aortic knob) to the left subclavian artery (LSCA) on three-dimensional computed tomography angiography in 100 patients. The distance from the level of the LSCA origin to the level of the carina was also measured using three-dimensional computed tomography in 150 additional patients.

RESULTS: In 16% of the aortic knob study population, the LSCA to aortic knob distance was <0 cm or 0 cm. The median distance from the LSCA to the carina was 42 mm (range: 30–63 mm). In the carina study population, the origin of the LSCA was 35–55 mm above the carina in 95.3% of patients.

CONCLUSION: In 16% of patients, the IABP was too close to the LSCA origin when it was placed at the aortic knob, whereas positioning the IABP at 2 cm above the carina provided an adequate position for the IABP tip (1.5–3.5 cm distal to the origin of the LSCA) in 95.3% of patients. The carina may be a more reliable landmark for positioning the IABP than the aortic knob.


 

足月肥胖孕妇胃对水排空的研究

Gastric Emptying of Water in Obese Pregnant Women at Term

Cynthia A. Wong, MD, Robert J. McCarthy, PharmD, Paul C. Fitzgerald, RN, MS, Kiril Raikoff, MS, and Michael J. Avram, PhD

From the Department of Anesthesiology and Mary Beth Donnelley Clinical Pharmacology Core Facility, Northwestern University, Feinberg School of Medicine, Chicago, Illinois.

Anesth Analg 2007;105:751-755

背景:麻醉诱导前2小时健康妊娠病人和非妊娠病人饮用适当清水对胃容量并无不良影响。本研究拟比较肥胖足月非产程妇女(妊娠前体重指数>35 kg/m2)饮用50mL300mL水后胃排空的情况。

方法:选取10例肥胖、足月妊娠志愿者,在交叉研究设计中使用连续胃超声检查和对乙酰氨基酚的吸收率评价胃的排空情况。一夜禁食后,志愿者口服1.5克对乙酰氨基酚和50mL300mL清水(随机设计),之间间隔至少二天。使用胃超声显像技术连续评估胃窦横断面面积,计算胃排空的半衰期(T[1/2])。比较饮用50mL300mL后,对乙酰氨基酚血浆浓度-时间曲线下面积(AUC)、峰浓度(Cmax)到达峰浓度的时间(tmax)

结果:妊娠前平均体重指数为41 ± 9 kg/m2。饮用300mL清水与饮用50mL清水比较,胃排空T[1/2]无显著性差异(23 ± 11 min vs 32 ± 15 min)。在6090120分钟时的对乙酰氨基酚AUCCmaxtmax 均无明显差异。

结论:肥胖非产程足月孕妇饮用300mL清水后胃排空的时间较50mL清水并无延长。摄入300mL水后60min时的胃窦容量与禁食一夜后的基础值相似。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: Healthy nonpregnant and pregnant patients may ingest clear liquids until 2 h before induction of anesthesia without adversely affecting gastric volume. In this study, we compared gastric emptying in obese, term, nonlaboring pregnant women (prepregnancy body mass index >35 kg/m2) after the ingestion of 50 and 300 mL of water.

METHODS: Gastric emptying was assessed in 10 obese, term pregnant volunteers using both serial gastric ultrasound examinations and acetaminophen absorption in a crossover study design. After an overnight fast, volunteers ingested 1.5 g acetaminophen and 50 or 300 mL water (randomly assigned) on two occasions separated by at least 2 days. Serial gastric antrum cross-sectional areas were determined using gastric ultrasound imaging and the half-time to gastric emptying (T[1/2]) was calculated. Areas under the plasma acetaminophen concentration versus time curve (AUC), peak concentrations (Cmax), and time to peak concentration (tmax) for 50 mL and 300 mL ingestions were compared.

RESULTS: Mean prepregnancy body mass index was 41 ± 9 kg/m2. Gastric emptying T[1/2] was not different after ingestion of 300 mL water compared with 50 mL (23 ± 11 min vs 32 ± 15 min). There were no differences between acetaminophen AUCs at 60, 90, or 120 min, Cmax or tmax after ingestion of 300 mL compared with 50 mL of water.

CONCLUSIONS: Gastric emptying in obese, nonlaboring term pregnant women is not delayed after ingestion of 300 mL compared with 50 mL of water. Gastric antral volume after ingestion of 300 mL of water is similar to the baseline fasting level at 60 min.


补充供氧可以提高猪正常和吻合的结肠组织氧压,但补充晶体液无影响

Supplemental Oxygen, but Not Supplemental Crystalloid Fluid, Increases Tissue Oxygen Tension in Healthy and Anastomotic Colon in Pigs

Oliver Kimberger, MD*, Edith Fleischmann, MD{dagger}, Sebastian Brandt, MD*, André Kugener, MD{ddagger}, Barbara Kabon, MD{dagger}, Luzius Hiltebrand, MD*, Vladimir Krejci, MD*, and Andrea Kurz, MD*§

From the *Department of Anesthesiology, University of Bern, Switzerland; {dagger}Department of Anesthesia and General Intensive Care, Division of Cardiothoracic and Vascular Anesthesia and Intensive Care, and {ddagger}Department of Anesthesia and General Intensive Care, Medical University Vienna, Austria; and §Outcomes Research Institute, University of Louisville, Louisville, Kentucky.

Anesth Analg 2007;105:773-779

背景资料:低组织氧压是导致结肠手术后伤口裂开和吻合口漏的重要原因。我们作结肠吻合手术的猪模型中检验了补充供氧和补充液体可否提高健康的和损伤的吻合口附近以及吻合口的结肠组织氧分压。

方法:16头瑞士长白猪用异氟醚0.8-1.0%麻醉并机械通气。动物随机分组,在结肠吻合手术中及其后测定的4个小时里,低容量治疗(低组,乳酸林格氏液3ml/kg/h连续输注)或高容量治疗(高组,乳酸林格氏液10ml/kg/h单次输注,后以18ml/kg/h维持)。在手术后两个半小时以30%浓度的氧气进行机械通气,每隔30min记录一次组织氧压。术后3小时以100%的氧浓度进行机械通气60min。在最后的30min中记录组织氧压。分别在健康结肠壁、吻合口附近2cm以及吻合口用极谱描记克拉克型电极测定组织氧分压。

结果:在每个组中,以100%浓度的氧气进行机械通气时的组织氧分压都是用30%浓度氧气进行机械通气时的近2倍,并且用统计学意义。高容量还是低容量晶体液输注对于结肠组织氧压没有影响。

结论:补充供氧可以提高健康的、吻合口附近和吻合口的结肠组织氧压,但补充晶体液无影响。

(沈浩   马皓琳 李士通 校)

BACKGROUND: Low tissue oxygen tension is an important factor leading to the development of wound dehiscence and anastomotic leakage after colon surgery. We tested whether supplemental fluid and supplemental oxygen can increase tissue oxygen tension in healthy and injured, perianastomotic, and anastomotic colon in an acutely instrumented pig model of anastomosis surgery.

METHODS: Sixteen Swiss Landrace pigs were anesthetized (isoflurane 0.8%–1%) and their lungs ventilated. The animals were randomly assigned to low fluid treatment ("low" group, 3 mL · kg–1 · h–1 lactated Ringer’s solution) or high fluid treatment ("high" group, 10 mL/kg bolus, 18 mL · kg–1 · h–1 lactated Ringer’s solution) during colon anastomosis surgery and a subsequent measurement period (4 h). Two-and-half hours after surgery, tissue oxygen tension was recorded for 30 min during ventilation with 30% oxygen. Three hours after surgery, the animals’ lungs were ventilated with 100% oxygen for 60 min. Tissue oxygen tension was recorded in the last 30 min. Tissue oxygen tension was measured with polarographic Clark-type electrodes, positioned in healthy colonic wall, close (2 cm) to the anastomosis, and in the anastomosis.

RESULTS: In every group, tissue oxygen tension during ventilation with 100% oxygen was approximately twice as high as during ventilation with 30% oxygen, a statistically significant result. High or low volume crystalloid fluid treatment had no effect on colon tissue oxygen tension.

CONCLUSIONS: Supplemental oxygen, but not supplemental crystalloid fluid, increased tissue oxygen tension in healthy, perianastomotic, and anastomotic colon tissue.



硬膜外腔注射自体静脉血治疗慢性颈部扭伤相关性疾患

Epidural Blood Patch Therapy for Chronic Whiplash-Associated Disorder

Shinichi Ishikawa, MD*{dagger}, Masataka Yokoyama, MD{dagger}, Satoshi Mizobuchi, MD{dagger}, Hidenori Hashimoto, MD*, Eiji Moriyama, MD{ddagger}, and Kiyoshi Morita, MD{dagger}

From the *Department of Anesthesiology, Fukuyama Kohnan Hospital, Kohnan-cho, Fukuyama City, Hiroshima, Japan; {dagger}Department of Anesthesiology and Resuscitology, Okayama University Medical School, Shikata-cho, Okayama City, Okayama, Japan; {ddagger}Department of Neurosurgery, National Hospital Organization Fukuyama Medical Center, Okinogami-cho, Fukuyama City, Hiroshima, Japan.

Anesth Analg 2007;105:809-814

背景资料:慢性颈部扭伤相关性疾患(WAD)患者,尽管没有客观存在的神经功能缺损,仍主诉有诸如头痛、眩晕及恶心的症状。脑脊液渗漏(CSF)的患者也常会经历这些症状。最近有报道:放射性同位素(RI) 脑池造影术有助于诊断因CSF渗漏引起的颅内低压。我们使用 RI脑池造影术研究了慢性WADCSF渗漏之间的关系,并评估了使用硬膜外腔注射自体静脉血(EBP)对治疗慢性WAD是否有效。

方法:我们研究了66位症状超过3个月的慢性WAD患者。所有的患者均经RI脑池造影来测定CSF渗漏的存在。对于确诊有CSF渗漏的患者,使用EBP治疗。在EBP治疗前、治疗后1周及6个月的时候评估症状。同时评估其工作状态并随访RI脑池造影。

结果:66位患者中,37位显示了存在CSF渗漏,其中36位患者接受了2.2 ± 0.7EBP治疗。症状平均持续33个月。与治疗前相比,EBP治疗后1周,存在症状的患者的百分比明显下降;头痛:100%17%,记忆缺失:94%28%,眩晕:83%47%,视觉损伤:81%25%,恶心:78%42% (P < 0.01)。在6个月后的随访检查中也观察到这些疗效(P < 0.01)。随访发现其工作状态也有明显改善。

结论:我们得出结论:对于某些慢性WAD患者,需考虑CSF渗漏的因素,而EBP治疗对于慢性WAD是有效的。

(裘毅敏译,马皓琳,李士通校)

BACKGROUND: Despite the absence of objective neurological deficits, patients with chronic whiplash-associated disorder (WAD) complain of symptoms such as headache, dizziness, and nausea. These symptoms are also often experienced by patients with cerebrospinal fluid (CSF) leak. It was recently reported that radioisotope (RI) cisternography is useful in the diagnosis of intracranial hypotension due to CSF leak. We investigated the relation between chronic WAD and CSF leak by RI cisternography and evaluated whether epidural blood patch (EBP) administration is effective in the treatment of chronic WAD.

METHODS: We studied 66 patients with chronic WAD with symptoms lasting longer than 3 mo. All patients underwent RI cisternography to determine the presence of CSF leak. In patients in whom CSF leak was identified, EBP was administered. Symptoms were assessed before, 1 wk after, and 6 mo after EBP. Work status was also assessed and follow-up RI cisternography was performed.

RESULTS: Of the 66 patients, 37 showed CSF leak, and 36 of these patients received EBP 2.2 ± 0.7 times. The mean duration of symptoms was 33 mo. One week after EBP, the percentage of patients with symptoms was decreased significantly compared with that before EBP; headache: 100% vs 17%, respectively, memory loss: 94% vs 28%, dizziness: 83% vs 47%, visual impairment: 81% vs 25%, nausea: 78% vs 42% (P < 0.01). These effects were also observed at the 6 month follow-up examination (P < 0.01). Work status was also significantly improved at follow-up.

CONCLUSIONS: We conclude that CSF leak should be considered in some cases of chronic WAD and that EBP is an effective therapy for chronic WAD.



Resiniferatoxin 的坐骨神经阻滞:对大鼠无髓鞘神经纤维的 电子显微镜研究

Sciatic Nerve Block with Resiniferatoxin: An Electron Microscopic Study of Unmyelinated Fibers in the RatIgor Kissin, MD, PhD*, Cristina F. Freitas, BA*, Howard L. Mulhern, BS{dagger}, and Umberto DeGirolami, MD{dagger}

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, and {dagger}Department of Pathology, Children’s Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007;105:825-831

背景:神经周围给予天然存在的vanilloids (辣椒素, resiniferatoxin [RTX]) 可以产生选择性伤害性疼痛的阻滞作用。在神经周围给予高浓度vanilloids的研究发现,它们可导致无髓鞘神经纤维退行性变。但是,使用电子显微镜研究vanilloid的局部毒性,结果则与此相反。在本研究中,我们拟确定RTX诱发的可逆性坐骨神经阻滞是否可以导致无髓鞘神经纤维退行性变。

方法:在大鼠实验中,经皮在坐骨神经给予RTX。用测定大鼠对伤害性热刺激的反应来监测RTX的作用。阻滞起效后48小时,取出坐骨神经。在三组动物中,RTX 0.0001% (0.1 µg)RTX 0.001% (1 µg)和对照组(RTX 溶剂, 0.1 mL),对无髓鞘神经纤维进行定量电子显微镜分析。

结果:RTX诱发的可逆性神经阻滞开始后48小时,坐骨神经的横切面基本是正常的。一个很罕见的发现是无髓鞘神经轴突上有不规则的紧密膜状沉积物。在两种不同浓度RTX时的这种情况发生率均近1‰

结果:研究结果说明RTX可以提供选择性长时效坐骨神经阻滞(最长2周),对无髓鞘神经纤维没有明显损害。

(张莹   马皓琳 李士通 校)

BACKGROUND: Perineural administration of the naturally occurring vanilloids (capsaicin, resiniferatoxin [RTX]) produces selective nociceptive blockade. Studies using perineural vanilloids in high concentrations suggest that they can cause a degeneration of unmyelinated fibers. However, electron microscopic studies of local vanilloid toxicity produced conflicting outcomes. In the present study, we sought to determine whether RTX-induced reversible sciatic nerve block results in the degenerative changes of unmyelinated fibers.

METHODS: In rat experiments, RTX was administered percutaneously at the sciatic nerve. The effect of RTX was monitored by measuring the rat’s response to noxious heat. The sciatic nerves were removed 48 h after the blockade initiation. Quantitative electron microscopic evaluation of the unmyelinated fibers was performed in three groups of animals: RTX 0.0001% (0.1 µg), RTX 0.001% (1 µg), and control (RTX vehicle, 0.1 mL).

RESULTS: Cross-sections of the sciatic nerve 48 h after the initiation of RTX-induced reversible nerve blockade appeared essentially normal. One rarely observed finding was the irregularly compacted membranous deposits in the unmyelinated axons. The frequency of this finding was approximately one per thousand fibers with both concentrations of RTX.

CONCLUSIONS: The results of the study suggest that a selective and long-lasting sciatic nerve block (up to 2 wk) can be provided by RTX without any significant damage to the unmyelinated nerve fibers.



不管电刺激高于还是低于0.5mA超声引导下的肌间沟置针都能产生成功的麻醉

Ultrasound-Guided Interscalene Needle Placement Produces Successful Anesthesia Regardless of Motor Stimulation Above or Below 0.5 mA

Sanjay K. Sinha, MBBS*, Jonathan H. Abrams, MD*, and Robert S. Weller, MD{dagger}

From the *Department of Anesthesiology, Saint Francis Hospital and Medical Center, Hartford, Connecticut; and {dagger}Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Anesth Analg 2007;105:848-852

背景:我们定量检测了超声引导下置针用于肌间沟阻滞(ISB)后不同电流强度引起的反应。然后我们比较了高于或低于0.5mA的电刺激反应下不同的阻滞特征。

方法:这次前瞻性观测性的研究包括了61位择期在ISB和全麻下行非住院肩关节手术的病人。术前一根绝缘的探针通过超声引导放置在了肌间沟。在测定了能够引起运动反应的最低电流量后,注射加入肾上腺素的30ml 0.5%的布比卡因。全麻诱导前测定在上躯干分布的运动和感觉阻滞范围15min。术后记录上躯干阻滞成功率、麻醉后复苏室中的疼痛评分、阻滞持续时间和术后整夜的止痛药片消耗量。病人事先被分成A组(电流强度≤0.5 mA)和B组(电流强度>0.5 mA),比较两组之间的结果。

结果:观测的电流变化在0.14–1.7 mA,其中42%的病人电流≤0.5 mAA组)。所有的病人上躯干运动感觉阻滞都很完全,在麻醉后复苏室中不需要麻醉药物。两组的麻醉持续时间(17.8 ± 4.9 h,平均值±标准差)和在家中止痛药需求量相当。两组感觉阻滞起效时间相当,但B组在15min时的不完全运动阻滞发生率更高(B37%A12%P=0.03)。

结论:用神经刺激的超声引导下ISB过程中,在电流大于或小于0.5mA观察到的运动反应不影响上躯干阻滞的成功率和持续时间。

(姜旭晖译  马皓琳 李士通校)

BACKGROUND: We quantified the motor response after ultrasound (U-S)-guided needle placement for interscalene block (ISB). We then compared block characteristics based on motor response above or below 0.5 mA.

METHODS: Sixty-one patients scheduled for ambulatory shoulder surgery under ISB and general anesthesia were included in this prospective, observational study. Preoperatively, an insulated needle was positioned by U-S in the interscalene groove. The lowest current producing motor response was determined, and 30 mL 0.5% bupivacaine with epinephrine was injected. Motor and sensory block were tested in the upper trunk distribution for 15 min until general anesthesia was induced. Postoperatively, the success of upper trunk block, pain score in the postanesthesia care unit and block duration, and analgesic tablet consumption overnight were recorded. Patients were divided a priori into Group A (current ≤0.5 mA) and Group B (current >0.5 mA), and results were compared between groups.

RESULTS: The observed current range was 0.14–1.7 mA, with current ≤0.5 mA in 42% of patients (Group A). All patients had complete sensorimotor upper trunk block and none required narcotics in the postanesthesia care unit. Block duration (both groups: 17.8 ± 4.9 h, mean ± sd) and home analgesic use were equivalent. Sensory block onset was equivalent between groups, but incomplete motor block at 15 min was more likely in Group B: 37% vs 12% in Group A (P = 0.03).

CONCLUSION: During U-S-guided ISB using nerve stimulation, the observed motor response below or above 0.5 mA had no impact on success or duration of upper trunk block.



持续正压通气呼吸可以增加颈胸段硬膜外注射利多卡因后的感觉阻滞头向扩散

Continuous Positive Airway Pressure Breathing Increases Cranial Spread of Sensory Blockade After Cervicothoracic Epidural Injection of Lidocaine

W. Anton Visser, MD*, Maarten J. P. G. van Eerd, MD*, Robert van Seventer, MD*, Mathieu J. M. Gielen, MD, PhD{dagger}, Janneke L. P. Giele, MSc{dagger}, and Gert J. Scheffer, MD, PhD{dagger}

From the *Department of Anesthesiology, Intensive Care and Pain Management, Amphia Hospital, Breda, The Netherlands; and {dagger}Department of Anesthesiology, University Medical Center Nijmegen, Nijmegen, The Netherlands.

Anesth Analg 2007;105:868-871

背景:持续正压通气(CPAP)可以增加低胸段硬膜外注射利多卡因后的感觉阻滞尾向扩散。我们假设,CPAP会增加颈胸段硬膜外注射后阻滞头向扩散。

方法:二十例硬膜外导管位于C6-7C7-T1间隙的病人,在环境压力下呼吸(对照组)或用7.5cm水柱CPAP呼吸时给予一个硬膜外剂量的利多卡因。注射后,我们评估了感觉阻滞平面的扩散。并记录注射前后肺量参数。

结果:数据以中位数(25%-75%范围)值表示。感觉神经阻滞的平面对照组在C7 (C4–7) T4 (T4–6)CPAP组在C2 (C2–4)T4 (T2–5) (P = 0.003)。总的阻滞节段数在对照组和CPAP组分别为7.5 (6.8–9.8)10 (8–12) (P = 0.13)。从阻滞点头向阻滞节段数在对照组和CPAP组分别为1(0.8–3.5)5 (3.5–7)(P = 0.006))。达到最高脑神经阻滞(上到C2)的病人数在对照组和CPAP组分别为一位和七位(P = 0.02)。两组病人的肺量值均有较小的但显著的下降,组间无差异。

结论:和环境压力下呼吸相比,在颈胸段硬膜外利多卡因麻醉时提供CPAP可以增加感觉阻滞的头向扩散。

(黄佳佳译,马皓琳 李士通 校)

BACKGROUND: Continuous positive airway pressure (CPAP) increases the caudad spread of sensory blockade after low-thoracic epidural injection of lidocaine. We hypothesized that CPAP would increase cephalad spread of blockade after cervicothoracic epidural injection.

METHODS: Twenty patients with an epidural catheter at the C6–7 or C7–T1 interspace received an epidural dose of lidocaine while breathing at ambient pressure (control group), or while breathing with 7.5 cm H2O CPAP. After injection, we evaluated the spread of sensory blockade. Spirometry variables before and after epidural injection were also measured.

RESULTS: Data are presented as median (interquartile range) values. Sensory block ranged from C7 (C4–7) to T4 (T4–6) in the control group and from C2 (C2–4) to T4 (T2–5) in the CPAP group (P = 0.003 for the cranial border). The total number of segments blocked was 7.5 (6.8–9.8) in the control group and 10 (8–12) in the CPAP group (P = 0.13). The number of segments blocked cranial to the injection site was one (0.8–3.5) in the control group and five (3.5–7) in the CPAP group (P = 0.006). The number of patients with a maximal cranial block (up to C2) was one in the control group and seven in the CPAP group (P = 0.02). In both groups, there was a small but significant decrease from baseline in spirometry values, with no differences between groups.

CONCLUSION: Applying CPAP during cervicothoracic epidural injection of lidocaine resulted in a more cranial extension of sensory blockade when compared with breathing at ambient pressure.

 

减少围手术期血栓并发症:肝素导致的血小板减少症(HIT)的新进展

Reducing thrombotic complications in the perioperative setting: an update on heparin-induced thrombocytopenia.

Levy JH, Tanaka KA, Hursting MJ.

Emory University School of Medicine, Atlanta, Georgia 30322, USA.

Anesth Analg 2007 105: 570-582.

 

肝素被广泛的用于围手术的处理。肝素免疫导致的HIT是一严重的抗体介导的并发症,它在肝素治疗5天以上病人中的发生率大约在0.5%-5%。在明显的栓前障碍下,在发生的病人中HIT有发生血栓及加重后果的严重危险:大约38%-76%发生血栓,发生血栓的大约需要截肢,而大约20%-30%死于1个月内。HIT抗体存在短暂,一般3个月内消失。在抗体延时的病人中,肝素的再暴露可能是致命的。在围手术的处理中,加强对HIT的及时辨别、诊断和治疗是重要的。如果在肝素使用5-14天后血小板数量下降50%和或血栓发生,HIT当被考虑,在排除其他诊断的情况下。严重怀疑HIT的,即使在实验室确诊HIT之前,肝素即可停用,并应用肠外抗凝治疗。实验室检验结果可以帮助决定继续非肝素化治疗还是转回使用肝素。在多数情况下,近期或当前有HIT的病人避免使用肝素是可行的。除了心血管手术。如果在HIT抗体未消失时手术不能延时,术中抗凝是可取的。

(陈勇柱译 薛张纲校)

Heparins are widely used in the perioperative setting. Immune heparin-induced thrombocytopenia (HIT) is a serious, antibody-mediated complication of heparin therapy that occurs in approximately 0.5%-5% of patients treated with heparin for at least 5 days. An extremely prothrombotic disorder, HIT confers significant risks of thrombosis and devastating consequences on affected patients: approximately 38%-76% develop thrombosis, approximately 10% with thrombosis require limb amputation, and approximately 20%-30% die within a month. HIT antibodies are transient and typically disappear within 3 mo. In patients with lingering antibodies, however, re-exposure to heparin can be catastrophic. In the perioperative setting, heightened awareness is important for the prompt recognition, diagnosis, and treatment of HIT. HIT should be considered if the platelet count decreases 50% and/or thrombosis occurs 5-14 days after starting heparin, with other diagnoses excluded. On strong clinical suspicion of HIT, heparin should be discontinued and a parenteral alternative anticoagulant initiated, even before laboratory confirmation of HIT is obtained. Subsequent laboratory test results may help with the decision to continue with nonheparin therapy or switch back to heparin. Heparin avoidance in patients with current or previous HIT is feasible in most clinical situations, except perhaps in cardiovascular surgery. If the surgery cannot be delayed until HIT antibodies have disappeared, intraoperative alternative anticoagulation is recommended.

                                                     

 

 

异丙酚输注浓度变化对麻醉小儿血浆cGMP浓度的影响

The effect of varying continuous propofol infusions on plasma cyclic guanosine 3',5'-monophosphate concentrations in anesthetized children.

Engelhardt T, Chan MK, McCheyne AJ, Karsli C, Luginbuehl I, Bissonnette B.

Department of Anaesthesia and Laboratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2007 105: 616-619.

 

谷氨酸盐-NO-cGMP通路是全身麻醉药物的有效作用靶点。在健康成年志愿者镇静期间血浆异丙酚浓度升高后伴随血浆cGMP的降低。我们推测在麻醉的小儿中血浆异丙酚浓度升高能够导致血浆cGMP浓度降低。方法:18例既往健康、年龄46.8+/19.6月、需要全身麻醉、下腹部手术患儿。吸入诱导后行气管插管、间歇正压通气、骶部硬膜外麻醉。麻醉维持采用连续异丙酚输注,按照先前的方案以达到预计血浆异丙酚浓度:分别在30min50imn70min达到631.5mg/ml。收集血浆标本,采用高效液相色谱法和免疫分析法测量异丙酚和cGMP浓度。结果:在每个预计血浆浓度点血浆cGMP浓度明显改变分别为19.211.8-23.5),21.314.6-30.8),24.915.7-37.8nmol/L,相关系数为-0.62。结论:健康小儿中血浆异丙酚浓度增加可导致血浆cGMP浓度降低,血浆cGMP浓度可作为异丙酚麻醉深度的生化指标。

(吴德华译 薛张纲校) 

BACKGROUND: The glutamate-nitric oxide-cyclic guanosine 3',5'-monophosphate (cGMP) pathway is potentially an effective target for general anesthetics. Plasma cGMP concentrations are reduced after an increase in predicted plasma propofol concentrations during sedation in healthy adult volunteers. We hypothesized that an increase in measured plasma propofol concentration leads to a reduction in plasma cGMP in anesthetized children. METHODS: Eighteen healthy children aged 46.8 (+/-19.6) mo, requiring general anesthesia for lower body surgical procedures were enrolled. After inhaled induction, tracheal intubation and initiation of intermittent positive pressure ventilation, caudal epidural analgesia was performed. Anesthesia was maintained using a continuous propofol infusion adapted from a previously published regimen to achieve predicted propofol plasma concentration of 6, 3, and 1.5 microg/mL after 30, 50, and 70 min, respectively. Samples for propofol and cGMP plasma concentrations were collected and analyzed using high-performance liquid chromatography and an enzyme immunoassay system. RESULTS: The plasma cGMP concentrations varied significantly (median [range]) 19.2 [11.8-23.5], 21.3 [14.6-30.8], and 24.9 [15.7-37.8] nmol/L among each predicted plasma propofol concentration, . The correlation coefficient (r) was -0.62. CONCLUSIONS: This study demonstrates that an increase in plasma propofol concentration leads to a decrease in plasma cGMP in healthy children, and could serve as a biochemical marker for depth of propofol anesthesia in children.

 

 

对罗哌卡因作用于离体豚鼠心脏标本产生的毒性作用使用左西孟旦的强心功能

The Effects of Levosimendan on Myocardial Function in Ropivacaine Toxicity in Isolated Guinea Pig Heart Preparations

Sebastian N. Stehr, MD*, Torsten Christ, MD, Berit Rasche, MD*, Stefan Rasche, MD*, Erich Wettwer, PhD, Andreas Deussen, MD, Ursula Ravens, MD, Thea Koch, MD*, and Matthias Hübler, MD*

From the Departments of *Anesthesiology and Intensive Care Medicine, Pharmacology and Toxicology, and Institute of Physiology, Medical Faculty Carl Gustav Carus, Dresden, Germany.

Anesth Analg 2007 105: 641-647.

 

背景左西孟旦是一种作用于心衰的新型强心药但其对于局麻药导致的心肌抑制作用尚未知。因此,我们研究了左西孟旦对于罗哌卡因在离体豚鼠心脏标本产生的负性强心效应的作用。方法:使用传统方法测量了豚鼠乳头肌的动作电位和收缩力。心率、收缩压、+dP/dtmax、冠脉血流及PRQRS间期被测量于离体恒压灌流、非再循环豚鼠心脏标本。单独或累积的左西孟旦及罗哌卡因浓度增加被单独或联合应用。结果:在离体乳头肌,罗哌卡因导致浓度依赖的收缩力改变。使用10µM左西孟旦可以几乎完全反转使用10µM罗哌卡因产生的负性强心作用。左西孟旦产生的强心作用的敏感性不会被10µM的罗哌卡因所改变。动作电位只有在最高浓度的时候被影响。在豚鼠心脏,左西孟旦显著的反转了罗哌卡因产生的心率、收缩压、冠脉血流及+dP/dtmax减少,使回复至基线值。结论:对于罗哌卡因产生的心肌抑制,左西孟旦是一种有效的强心药,且其心肌敏感性、效能并不被局麻药所影响。我们的结果提示左西孟旦的钙增敏反应可有效的作用于局麻药产生的心肌抑制。

 (孙霞译 薛张纲校)                                                                             

BACKGROUND: Levosimendan is a novel drug used for inotropic support in heart failure, but its efficacy in local anesthetic-induced myocardial depression is not known. Therefore, we investigated the effects of levosimendan on the negative inotropic response to ropivacaine in isolated heart preparations of guinea pigs. METHODS: Action potentials and force of contraction were studied with conventional techniques in guinea-pig papillary muscles. Heart rate, systolic pressure, the first derivative of left ventricular pressure (+dP/dtmax), coronary flow, and PR and QRS intervals were measured in isolated constant-pressure perfused, nonrecirculating Langendorff heart preparations. Single or cumulatively increasing concentrations of levosimendan and ropivacaine were used either alone or in combination. RESULTS: In isolated papillary muscle, ropivacaine reduced force of contraction in a concentration-dependent manner. Exposure to 10 µM levosimendan in the presence of 10 µM ropivacaine almost completely reversed the negative inotropic response. Sensitivity to the positive inotropic effect of levosimendan was not altered by 10 µM ropivacaine (–logEC50 [M] = 7.03 without versus 6.9 with ropivacaine, respectively). Action potential parameters were influenced only at the highest concentration. In the Langendorff heart, levosimendan significantly reversed the ropivacaine-induced reduction in heart rate, systolic pressure, coronary flow, and +dP/dtmax to baseline values. CONCLUSION: Levosimendan is an effective inotropic drug in ropivacaine-induced myocardial depression and levosimendan myocardial sensitivity, and efficacy was not affected by the local anesthetic. Our results suggest that the calcium-sensitizing action of levosimendan is effective in local anesthetic-induced cardiac depression.

大鼠脊髓内脑脊液中钠离子浓度改变对异氟醚MAC的影响

Alterations in Spinal, but Not Cerebral, Cerebrospinal Fluid Na+ Concentrations Affect the Isoflurane Minimum Alveolar Concentration in Rats

Michael J. Laster, DVM*, Yi Zhang, MD{dagger}, Edmond I. Eger, II, MD*, Dimitry Shnayderman, BS*, and James M. Sonner, MD*

Anesth Analg 2007 105: 661-665.

 

背景:过去的研究表明氟烷的MAC值(50%的受试者对伤害性刺激无反映的吸入麻醉药最低肺泡浓度)与中枢神经系统的钠离子浓度直接相关。然而,这些研究改变了钠离子的总浓度,但对脊髓和大脑的影响并没有很好的区分。这里存在明显的区别,因为脊索是吸入麻醉药产生制动作用的初级介导场所。相应的,在这个研究中,我们检测了不同鞘内钠离子浓度对比脑室内钠离子浓度对MAC的影响。方法:我们通过大鼠身上的留置管或留置针在腰椎的蛛网膜下腔和脑室内注射无钠溶液或重钠溶液,并分别在注射前、注射中和注射后测量异氟醚的MAC值。结果:异氟醚的MAC值与鞘内注射的钠离子浓度有关,而与脑室内注射的钠离子浓度无关。结论:这一结果与通过钠离子通道对MAC的介导或调节一致。这些包括电压门控通道、配体门控通道和其他钠离子敏感靶位。(例如:离子泵、转运体、交换体)

(王时来译 薛张纲校)

BACKGROUND: Previous studies demonstrated that MAC (the minimum alveolar concentration of an inhaled anesthetic that produces immobility in 50% of subjects exposed to noxious stimulation) for halothane directly correlates with the central nervous system concentration of Na+. However, those studies globally altered Na+ concentrations, and thus did not distinguish effects on the spinal cord from cerebral effects. This is an important distinction because the cord appears to be the primary site for mediation of the immobility produced by inhaled anesthetics. Accordingly, in the present study, we examined the effect of altering intrathecal versus intracerebroventricular concentrations of Na+ on MAC. METHODS: In rats prepared with chronic indwelling catheters or stylets, we infused solutions deficient in Na+ and with an excess of Na+ into the lumbar subarachnoid and intracerebroventricular spaces and measured MAC for isoflurane before, during, and after infusion. RESULTS: MAC of isoflurane correlated directly with concentrations of Na+ infused intrathecally but did not correlate with concentrations infused intracerebroventricularly. CONCLUSION: The results are consistent with a mediation or modulation of MAC by Na+ channels. These might include voltage-gated or ligand-gated channels or other Na-sensitive targets (e.g., pumps, transporters, exchangers).

 

 

用传统的红外线临床气体分析仪测量血液中的麻醉气体

Measurement of Anesthetics in Blood Using a Conventional Infrared Clinical Gas Analyzer

Philip J. Peyton, Michael Chong, Christopher Stuart-Andrews, Gavin J. B. Robinson, Robert Pierce, and Bruce R. Thompson

Anesth Analg 2007 105: 680-687.

 

背景:通常我们用气相色谱分析的顶空平衡方法来测定血液中的吸入麻醉气体分压,但是由于技术、设备和后勤要求等原因在临床工作中我们不常应用这种方法。为了使这种测量更可行,我们尝试使用一种传统的红外线气体分析仪:Datex-Ohmeda Capnomac。方法:在描述了这个仪器测量吸入麻醉气体的浓度相对于一氧化二氮、二氧化碳和水蒸气的线性关系后,血液被含有已知浓度七氟醚(0.5%5%)的氧气和笑气氧气混合充满,或者被同时含有异氟醚和地氟醚的氧气充满。结果:测得氧气中七氟醚的浓度相对于张力仪测得的参考分压值的偏差是-4.5(4.8%),这在40%氧气混合60%笑气中的变化不大。异氟醚和地氟醚相对于实际浓度的偏差分别为-3.9 (3.3%) -4.6 (3.8%)。结论:用临床红外线气体分析仪的双顶空平衡技术测量血液中吸入麻醉气体分压的精确度可以和之前我们研究所用的气相色谱分析仪相媲美。

( 杨译 薛张纲校)

BACKGROUND: Measurement of the partial pressure of volatile anesthetics in blood is usually done using a "headspace equilibration" method with gas chromatography. However, it is not often performed in clinical studies because of the technical, equipment, and logistic requirements. To improve the accessibility of this measurement, we tested the use of a common infrared clinical gas analyzer, the Datex-Ohmeda Capnomac, for this purpose. METHODS: After characterization of the linearity of the device in measuring the volatile anesthetic concentration in the presence of nitrous oxide, carbon dioxide, and water vapor, blood was tonometered with known concentrations of sevoflurane (actual value between 0.5% and 5.0%) in oxygen and oxygen/nitrous oxide mixtures, as well as mixtures of isoflurane and desflurane in oxygen. RESULTS: Mean bias (standard deviation) overall for sevoflurane in oxygen relative to the tonometered reference partial pressure was -4.5 (4.8%) of the actual concentration. This was not altered significantly by measurement in 40% oxygen/60% nitrous oxide. For isoflurane and desflurane it was -3.9 (3.3%) and -4.6 (3.8%), respectively, of the actual concentration. CONCLUSIONS: The accuracy and precision of measurement of volatile anesthetic gas partial pressures in blood by a double headspace equilibration technique, using a clinical infrared gas analyzer, were comparable to that achieved by previous studies using gas chromatography.

 

动脉球囊阻塞控制骶骨手术术中出血

Control of Blood Loss During Sacral Surgery by Aortic Balloon Occlusion

Lan Zhang,*Quan Gong, Hong Xiao,Chongqi Tu,and Jin Liu,

Address correspondence to Quan Gong, MM, Department of Orthopedics, West China Hospital, Sichuan University, No. 37, Guo-xue-xiang, Chengdu, Sichuan 610041, People's Republic of China.  

Anesth Analg 2007 105: 700-703.

 

骶骨根治性手术会导致术中致命性的出血量。控制这种出血的安全有效的方法仍未发现。我们在这里报导一种可充气的胶质球囊的使用,它可以间断地阻塞远端腹主动脉,控制骶骨肿瘤切除术中失血量。球囊导管经过股动脉引导进入腹主动脉。通过测量双足趾的血氧饱和度和超声定位来指导并确定球囊在腹主动脉的肾动脉以下段。球囊每充气60分钟要放气10分钟。在5个进行骶骨肿瘤切除的病人中,使用球囊阻塞的病人估计出血量<300ml,手术时间<2小时。术后肾功能无明显变化,盆腔器官和下肢功能完好。经皮动脉球囊阻塞可以提供安全有效的骶骨肿瘤切除术术中的失血量。

(陈佳莉译 薛张纲校)

Radical sacral surgery can be associated with life-threatening blood loss. Effective and safe methods for controlling this blood loss remain elusive. We here report the use of an inflatable sizing balloon to intermittently occlude the distal abdominal aorta and control blood loss during sacral tumor resections. The balloon catheter was introduced into the abdominal aorta via the femoral artery. Pulse oxygen saturation signals from bilateral toes and ultrasonography were used to guide and confirm the location of the balloon in the abdominal aorta and distal to the renal arteries. The balloon was deflated for 10 min after each 60 min occlusion period. In five patients undergoing sacral tumor resection, the estimated blood loss when using balloon occlusion was <300 mL, and surgical duration was <2 h. No significant change in kidney, pelvic organ, and lower extremity function was found after the surgeries. Percutaneous aortic balloon occlusion can provide safe and effective control of blood loss during sacrococcygeal tumor resection.

 

 

选择性肺复张对于严重低血容量患者的血流动力学是否安全?一项在肺萎陷猪的动物模型关于低血容量的试验性研究。

Are Selective Lung Recruitment Maneuvers Hemodynamically Safe in Severe Hypovolemia? An Experimental Study in Hypovolemic Pigs with Lobar Collapse

Lars Kjærsgaard Hansen, MD*, Jacob Koefoed-Nielsen, MD*{dagger}, Jonas Nielsen, MD, PhD{ddagger}, and Anders Larsson, MD, PhD*{dagger}

From the *Department of Anesthesia and Intensive Care, Center for Cardiovascular Research, Aalborg Hospital, Århus University Hospitals, Aalborg; {dagger}Clinical Institute, Århus University, Århus; and {ddagger}Department of Anaesthesia and Intensive Care, Copenhagen University Hospital Gentofte, Hellerup, Denmark.

Anesth Analg 2007 105: 729-734.

 

背景:我们先前已经显示,在正常血容量的实验猪,选择性肺复张(S-LRM),即在带囊气管导管的顶端插入萎陷肺侧的支气管中,并经此吹入空氧混合气,可以有效改善氧合和肺容量,并且鲜有血流动力血方面的副作用。在这项研究中,我们研究了循环尚可维持的低血容量条件下,S-LRM对于呼吸和循环的影响。方法:8只麻醉了的实验猪给予通气(Fio2 1.0),将带囊的气管导管插入右下肺叶支气管中,肺叶选择性灌洗以产生更好的肺叶萎陷。分别在正常血容量、静脉放血20%、40%血容量时,给予实验猪S-LRM。测定在S-LRM之前、当时、之后的血气、呼吸系统顺应性、血管压力、心排量。结果:PaO2、静脉混合血、呼吸系统顺应性在S-LRM的三个容量水平均有显著改善。在正常血容量和减少20%血容量时,S-LRM组的血流动力学没有改变。在减少40%血容量时,S-LRM组心排量没有改变,平均动脉压轻度降低:S-LRM之前3分钟时48 (37–52) mm Hg (平均, 2575百分位数), S-LRM 刚结束时40 (35–44) mm Hg (P = 0.0207), S-LRM之后3分钟时47 (39–54) mm Hg 。结论:S-LRM可以有效改善氧合作用和呼吸系统顺应性,对于循环只有很小的副作用,甚至在肺萎陷的动物模型出现严重低血容量时也是如此。

(陈珺珺译 薛张纲校)

BACKGROUND: We have previously shown, in normovolemic pigs, that a selective lung recruitment maneuver (S-LRM), i.e., insufflation of air-oxygen via a balloon catheter with its tip located in the bronchus of a collapsed lung lobe, effectively improves oxygenation and lung volume without affecting hemodynamics negatively. In this study, we examined the respiratory and circulatory effects of S-LRM during hypovolemia with compromised circulation. METHODS: In eight ventilated (fraction of inspired oxygen, Fio2 1.0) and anesthetized pigs a balloon catheter was inserted in the bronchus of the right lower lung lobe. The lobe was selectively lavaged to create a dense lobar collapse. The pigs were then subjected to S-LRM (40 cm H2O airway pressure for 30 s) at normovolemia, after venesection of 20% and 40% of the blood volume, respectively. Blood gases, compliance of the respiratory system (Crs), vascular pressures, and cardiac output were registered before, during, and after the S-LRM. RESULTS: Pao2, venous admixture, and Crs improved significantly with S-LRM at all three volume levels. No change in hemodynamics with S-LRM occurred in normovolemia and 20% hypovolemia. For 40% hypovolemia, cardiac output was unchanged by S-LRM, whereas minor decreases in mean arterial blood pressure were seen: 48 (37–52) mm Hg (median, 25th and 75th percentiles) 3 min before S-LRM, 40 (35–44) mm Hg at the end of S-LRM (P = 0.0207), and 47 (39–54) mm Hg 3 min after S-LRM.

CONCLUSION: A S-LRM effectively improved oxygenation and Crs and had only minor circulatory side effects, even in severe hypovolemia in this animal model of lobar collapse.

 

 

猪大脑皮层在颅内压增高伴脑血流降低时的脑代谢

Brain Metabolism During a Decrease in Cerebral Perfusion Pressure Caused by an Elevated Intracranial Pressure in the Porcine Neocortex

Norbert Zoremba, MD*, Joerg Schnoor, MD*, Michael Berens, MD*, Ralf Kuhlen, MD, PhD{dagger}, and Rolf Rossaint, MD, PhD*

From the Departments of *Anesthesiology and {dagger}Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany.

Anesth Analg 2007 105: 744-750

 

背景:颅内压的增高伴随着脑血流的减少,并会影响氧供和输出。在这个研究里,我们监测猪的大脑皮层在颅内压增高时的能量依赖性代谢,并找出在什么水平会产生伤害。方法:将32-40kg的驯养公猪麻醉,机械通气,并将其随机的分为实验组(六只)和对照组(五只)。将一个微量测析探针放入大脑皮质测量细胞外液中乳酸、丙酮酸、谷氨酸、丙三纯的浓度。每小时向脑室系统打入一定量的人工脑脊液以升高10mmhg的颅内压,直到达到最高值50mmhg。结果:当颅内压大于等于30mmhg、脑灌注压力低于50mmhg时,可以检测到乳酸、丙三醇的显著上升。当颅内压大于等于40mmhg、脑灌注压低于40mmhg时,乳酸丙酮酸比值及谷氨酸值显著上升,而糖的水平明显下降。结论:数据可以证明,ICPCPP可能产生危害的临界值分别为30mmhg40mmhg

(秦 佳译 薛张刚校)

BACKGROUND: Cranial hypertension coincides with a reduction in cerebral blood flow as well as in oxygen delivery and influences outcome. In this study, we monitored changes in energy-related metabolites in the porcine cortex during an increase of intracranial pressure (ICP) and to determine the level at which damage occurs.

METHODS: Male domestic pigs (32–40 kg) were anesthetized, mechanically ventilated, and randomly assigned to either the experimental (n = 6) or control groups (n = 5). A microdialysis probe (CMA 70) was inserted into the cortex to measure extracellular dialysate concentrations of lactate, pyruvate, glucose, glutamate, and glycerol. Every hour an increase of 10 mm Hg in ICP was preformed in the experimental group by infusion of artificial cerebrospinal fluid into the ventricular system of the brain until a maximum ICP of 50 mm Hg was reached. RESULTS: We demonstrated a significant increase of lactate and glycerol compared with control at ICP values ≥30 mm Hg and cerebral perfusion pressure (CPP) below 50 mm Hg. The increase of ICP to ≥40 mm Hg in conjunction with a reduction in CPP below 40 mm Hg led to a significant increase in the lactate/pyruvate-ratio and glutamate, as well as a decrease of glucose in relation to control. CONCLUSIONS: Our data strongly suggest that, during a defined ICP increase, lower CPP values may be tolerable until severe damage occurs. Borderline ICP and CPP values of 30 and 40 mm Hg, respectively, could be advised.

                                                       

 

东莨菪碱透皮给药预防蛛网膜下腔用吗啡导致的剖宫产术后恶心呕吐

Transdermal scopolamine for prevention of intrathecal morphine-induced nausea and vomiting after cesarean delivery.

Harnett MJ, O'Rourke N, Walsh M, Carabuena JM, Segal S.

Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.

Anesth Analg. 2007 105(3):764-9

 

背景:蛛网膜下腔用吗啡是剖宫产术后极佳的镇痛方式,但导致明显的恶心呕吐。方法:比较术后最初24小时透皮给东莨菪碱、静注昂丹思琼和安慰剂的镇吐效能。240名接受脊麻的剖宫产妇随机分配,研究设计为双盲,在断脐时给东莨菪碱1.5mg、昂丹思琼4mg或安慰剂。结果:研究显示安慰剂组呕吐发生率59.3%,东莨菪碱组降低至40%,昂丹思琼组降低至41.8%。与安慰剂相比,东莨菪碱组在6-24小时呕吐率下降最明显。结论:东莨菪碱对接受蛛网膜下腔吗啡镇痛的剖宫产妇是有效的预防用药。然而它的使用与口干、视力模糊等副作用较高的发生率有关。

(罗 璇译 薛张纲校)

BACKGROUND: Intrathecal morphine for cesarean delivery provides excellent postoperative analgesia but is associated with significant nausea and vomiting. METHODS: We compared the antiemetic efficacy of transdermal scopolamine, IV ondansetron, and placebo during the first 24 h postoperatively. Two-hundred forty women undergoing cesarean delivery under spinal anesthesia were randomly allocated, in a double-blind study design, to receive transdermal scopolamine 1.5 mg, ondansetron 4 mg, or placebo at the time of cord clamping. RESULTS: Our study showed that the overall rates for all emesis were 59.3% in the placebo group and were reduced to 40% in the scopolamine group and 41.8% in the ondansetron group. The greatest reduction in emesis in the scopolamine group when compared with placebo was in the 6-24 h time period. CONCLUSION: Scopolamine is an effective medication for prophylactic use in parturients receiving intrathecal morphine while undergoing cesarean delivery. Its use, however, was associated with a higher incidence of side effects such as dry mouth and blurry vision.

 

 

一项系统性回顾:患者回馈关于术后镇痛作用的结果

The Effect of Analgesic Technique on Postoperative Patient-Reported Outcomes Including Analgesia: A Systematic Review

Spencer S. Liu, MD*, and Christopher L. Wu, MD{dagger}

From the *Department of Anesthesiology, The Hospital of Special Surgery, and the Cornell Weill Medical Center, New York, New York; and {dagger}Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University, Baltimore, Maryland.

Address correspondence to Christopher Wu, MD, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Carnegie 280, 600 North Wolfe St., Baltimore, MD 21287.

Anesth Analg 2007 105: 859-867.

 

背景:术后患者回馈的镇痛效果,包括生活质量、恢复质量、患者满意度,到目前为止还没有系统性的评测过。这些结果是根据患者的个人看法测评,并且被认为有效的最终临床研究结果。我们进行了一项系统性的回顾调查来检测患者术后回馈的镇痛效果。方法:医学检索系统国立图书馆和Cochrane图书馆数据库对近十年的资料进行检索(19966月至20061月)。医学文献检索系统同时搜索了一些结果,包括满意度、生活质量、恢复质量。

结果:局部镇痛技术与全身使用阿片类药物相比,在统计学上镇痛效果更好。部分由于重要的方法问题,数据不足以评估镇痛的类型、镇痛的程度以及副作用是否会影响生活质量、满意度以及住院天数。结论:虽然有数据显示改进术后镇痛可以提高患者的回馈结果,但是住院患者中心的结果关于生活质量以及恢复质量有所改善的证据仍然不足。适当的减低疼痛评分实际上并不等同于临床上有意义的疼痛改善。需要进一步的研究来验证病人回馈方法的有效性,评估整个围手术期患者回馈的镇痛效果。

(王光妍译 薛张纲校)

BACKGROUND: The effect of postoperative analgesia on patient-reported outcomes, such as quality of life, quality of recovery, and patient satisfaction, has not been systematically examined. These outcomes are assessed from the patient's perspective and are recognized as valid and important end-points in clinical medicine and research. We performed a systematic review to examine the effect of postoperative analgesia on patient-reported outcomes.METHODS: The National Library of Medicine's Medline and the Cochrane Library databases were searched for the past decade (Jan, 1996 to Jun 1, 2006). Additional Medline searches for specific outcomes (i.e., satisfaction, quality of life, and quality of recovery) were also conducted

RESULTS: Regional analgesic techniques provide statistically superior analgesia compared with systemic opioids. There are insufficient data to determine if the type of analgesic technique, degree of analgesia, and presence of side effects may influence quality of life, quality of recovery, satisfaction, and length of stay, due in part to some significant methodologic issues.CONCLUSIONS: Although there are data suggesting that improved postoperative analgesia leads to better patient outcomes, there is insufficient evidence to support subsequent improvements inpatient-centered outcomes such as quality of life and quality of recovery. Modest reductions in pain scores do not necessarily equate to clinically meaningful improved pain relief for the patient. Further studies are needed to develop validated patient-reported instruments and to assess the effect of analgesic techniques on patient-reported outcomes in the perioperative period.

 

 

经腹全子宫切除术后使用帕瑞考西以增加鞘内注射吗啡的镇痛效果

Improving the Analgesic Efficacy of Intrathecal Morphine with Parecoxib After Total Abdominal Hysterectomy (Brief Report)

Supranee Niruthisard, Thewarug Werawataganon, Pavena Bunburaphong, Montson Ussawanophakiat, Chuthayuth Wongsakornchaikul, and Kusonsi Toleb

Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Anesth Analg 2007 105: 822-824.

 

背景:帕瑞考西的使用连同鞘内注射吗啡和布比卡因可能可以增加镇痛效果,减少吗啡的阿片类物质相关的副反应。方法:在这项前瞻性,双盲,随机,安慰剂对照实验中,经腹全子宫切除的患者在鞘内注射布比卡因和0.2mg吗啡之前先静脉注射生理盐水或者40mg帕瑞考西。12小时后,重复给药一次。观察患者48小时。结果:鞘内注射布比卡因和吗啡之外额外使用帕瑞考西可以显著减少术后24小时累计的吗啡消耗量,降低视觉痛觉评分,以及提升的患者满意程度,并且不伴有明显增加的副作用。结论:围术期给与帕瑞考西可以增强鞘内注射吗啡和布比卡因的术后镇痛效果和改善患者舒适度。

(周时蓓译 薛张纲校)

BACKGROUND: The addition of parecoxib to intrathecal morphine and bupivacaine may improve analgesia and reduce morphine's opioid-related side effects. METHODS: In this prospective, double-blind, randomized, placebo-controlled trial, total abdominal hysterectomy patients received either IV normal saline or parecoxib 40 mg before receiving intrathecal bupivacaine and morphine 0.2 mg. Twelve hours later, this administration was repeated. Patients were observed for 48 h. RESULTS: The addition of parecoxib to intrathecal morphine and bupivacaine significantly reduced cumulative morphine consumption, Visual Analog Pain scores, and increased patient satisfaction for 24 h postoperatively without an obvious decrease of adverse side effects. CONCLUSION: Perioperative parecoxib enhanced the postoperative analgesia of intrathecal morphine and bupivacaine and improved patient satisfaction.

                                                            

 

末梢神经性疼痛的病理生理:免疫细胞与分子

Pathophysiology of Peripheral Neuropathic Pain: Immune Cells and Molecules

Michael A. Thacker,  Anna K. Clark,  Fabien Marchand,  Stephen B. McMahon.

Address correspondence and reprint requests to S.B. McMahon, Kings College London, Neurorestoration group,  Wolfson Centre for Age Related Diseases,  Wolfson Wing, Hodgkin Building, Guys Campus, London, SE1 1UL, UK. Anesth Analg 2007; 105 : 838–47

 

背景:对于末梢神经系统的损伤通常导致慢性的神经性疼痛,表现为自发性疼痛和(或)对于疼痛或无害刺激的过度反应。这种疼痛的状态使病人感到极其虚弱并且很难得到治疗。尽管炎症性疼痛与神经性疼痛通常被认为是两个分离的事件,有证据却显示出了与这种严格的二分法不同的结果。炎症是一种极具特征性的现象,涉及到一系列不同的免疫细胞类型,如:肥大细胞、中性粒细胞、巨噬细胞及T淋巴细胞。另外,这些细胞也释放许多导致疼痛的复合物。最近有证据显示免疫细胞在末梢的神经性疼痛中起到一定的作用。在这篇综述里,我们鉴别各种不同的导致末梢神经性疼痛的免疫细胞以及在这种特殊状况下起到关键作用的各种释放因子。

(吴威译 薛张纲校)

BACKGROUD: Damage to the peripheral nervous system often leads to chronic neuropathic pain characterized by spontaneous pain and an exaggerated response to painful and/or innocuous stimuli. This pain condition is extremely debilitating and usually difficult to treat. Although inflammatory and neuropathic pain syndromes are often considered distinct entities, emerging evidence belies this strict dichotomy. Inflammation is a well-characterized phenomenon, which involves a cascade of different immune cell types, such as mast cells, neutrophils, macrophages, and T lymphocytes. In addition, these cells release numerous compounds that contribute to pain. Recent evidence suggests that immune cells play a role in neuropathic pain in the periphery. In this review we identify the different immune cell types that contribute to neuropathic pain in the periphery and release factors that are crucial in this particular condition.

 

硬膜外,鞘内注射罗哌卡因的药代动力学和生物利用度

Epidural, intrathecal pharmacokinetics, and intrathecal bioavailability of ropivacaine.

François-Xavier Rose, Jean-Pierre Estebe, Maja Ratajczak, Eric Wodey, François Chevanne, Gilles Dollo, David Bec, Jean-Marc Malinovsky, Claude Ecoffey, and Pascal Le Corre

Anesth Analg. 2007 Sep;105(3):859-67

 

背景:罗哌卡因通过不同神经轴索阻滞用于硬膜外术后镇痛.由于这些技术的广泛使用和局麻药在髓内分布数据的相对贫乏,我们通过一个动物模型来评估罗哌卡因的髓内分布,从而更多的研究罗哌卡因鞘内生物利用度的影响因素.方法:羊静脉注射50mg罗哌卡因,一周后鞘内注射20mg罗哌卡因3h后硬膜外注射罗哌卡因100mg,通过同步微量渗析技术测量硬膜外和鞘内注射后硬膜外和鞘内的药物浓度 。结果:吸收-时间曲线提示在鞘内和硬膜外注射后全身吸收有很大的变异性,但鞘内注射的吸收速度明显快于硬膜外.在蛛网膜下腔,消除率比分布率要高出近三倍.而在硬膜外腔隙,清除和分布对于罗哌卡因的分布作用有所不同,提示分布过程的影响较大.硬膜外注射后鞘内的生物利用度为11.1% +/- 7.6%. 结论:通过动物模型,我们发现药物在鞘内和硬膜外的分布是不同的,硬膜外注射罗哌卡因的鞘内生物利用度是低的且存在较大的差异性.

(陈恺铮译 薛张纲校)

BACKGROUND: Ropivacaine is used by the epidural route for postoperative pain management with various neuraxial techniques. Given the widespread use of these techniques and the relative paucity of data on spinal disposition of local anesthetics, we evaluated through an experimental animal model, the spinal disposition of ropivacaine, allowing further studies of factors influencing their intrathecal bioavailability.

METHODS: Sheep received an IV bolus dose of ropivacaine (50 mg), and 1 wk after, an intrathecal dose of ropivacaine (20 mg) followed 3 h later by epidural ropivacaine (100 mg). A simultaneous microdialysis technique was used to measure epidural and intrathecal drug concentrations after both epidural and intrathecal administrations.RESULTS: Absorption-time plots showed a large variability in the systemic absorption after both intrathecal and epidural administration, with an apparent faster systemic absorption after intrathecal administration. In the intrathecal space, the elimination clearance was around three-times higher than the distribution clearance. In the epidural space, the relative contribution of elimination and distribution to ropivacaine disposition was different, indicating a more pronounced influence of the distribution process. The intrathecal bioavailability after epidural administration was 11.1% +/- 7.6%. CONCLUSIONS:
Using an animal model, we showed that drug dispositions in the intrathecal and epidural compartments are different, and that the intrathecal bioavailability of ropivacaine after epidural administration is low, and highly variable.

无麻醉作用的惰性气体通过激活促存活信号激酶和抑制线粒跨膜通道通透性途径对心梗后心肌产生保护作用

 Noble Gases Without Anesthetic Properties Protect Myocardium Against Infarction by Activating Prosurvival Signaling Kinases and Inhibiting Mitochondrial Permeability Transition In Vivo
Paul S. Pagel, MD, PhD*{dagger}, John G. Krolikowski, BS*, Yon Hee Shim, MD*, Suneetha Venkatapuram, MD{ddagger}, Judy R. Kersten, MD*§, Dorothee Weihrauch, DVM, PhD*, David C. Warltier, MD, PhD*{dagger}{ddagger}§, and Phillip F. Pratt, Jr, PhD*§

From the *Department of Anesthesiology, The Medical College of Wisconsin and the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin; {dagger}Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin; and Departments of {ddagger}Medicine (Division of Cardiovascular Diseases) and §Pharmacology and Toxicology, The Medical College of Wisconsin and the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin.

Anesth Analg 2007 105: 562-569.

 

背景:麻醉惰性气体--氙气具有心脏保护作用。作者假设其他没有麻醉作用的惰性气体[He、氖Ne、氩Ar]同样具有心脏保护作用,并进一步假设所产生的心脏保护作用是通过激活促存活信号激酶[包括三磷酸肌醇激酶、细胞外信号调节激酶和70-kDa核糖体蛋白s6激酶]以及抑制体内线粒体膜通道通透性[mPTP]的开放所介导。

方法:对98只家兔进行血流动力学监测,阻塞左前降支冠状动脉30min后给予3小时的0.9%生理盐水再灌注(对照组);在左前降支阻塞前给予370%HeNeAr 30%氧气5分钟并间断给与70%氮气-30%氧气5分钟,或长时间的左前降支阻塞及再灌注前给于三轮短暂的(5分钟)缺血刺激并间断给予5分钟再灌注(缺血预适应组)。另外无论是否给予He预处理,选择性给予每组家兔三磷酸肌醇激酶抑制剂(渥曼青霉素0.6mg/kg,细胞外信号调节激酶抑制剂  (PD098059 2mg/kg), 70-kDa核糖体蛋白s6激酶抑制剂(雷帕霉素0.25mg/kg, 或线粒体膜通道开放剂(苍术苷5mg/kg)

结果:使用氦、氖、氩和缺血预适应组显著降低了梗阻面积(用氯化三苯基四氮唑(TTC)确定心肌梗死范围),左室面积(平均值±标准差)分别为23%±4%20%±3%22%±2%17%±3%;而对照组为45%±5%渥曼青霉素(wortmanninPI3K家族激酶特异抑制剂)、PD098059、雷帕霉素(Rapamycin) 苍术苷(atractylosideMPT 孔道开放剂)均不影响梗死面积,但这些药能抑制He所产生的心肌保护作用。

结论:没有麻醉作用的惰性气体可以通过激活促存活信号激酶,以及抑制家兔体内线粒体膜通透性通道的开放等作用产生心肌保护的作用。

(陶颖莹 陈杰 )

BACKGROUND: The anesthetic noble gas, xenon, produces cardioprotection. We hypothesized that other noble gases without anesthetic properties [helium (He), neon (Ne), argon (Ar)] also produce cardioprotection, and further hypothesized that this beneficial effect is mediated by activation of prosurvival signaling kinases [including phosphatidylinositol-3-kinase, extracellular signal-regulated kinase, and 70-kDa ribosomal protein s6 kinase] and inhibition of mitochondrial permeability transition pore (mPTP) opening in vivo.

METHODS: Rabbits (n = 98) instrumented for hemodynamic measurement and subjected to a 30-min left anterior descending coronary artery (LAD) occlusion and 3 h reperfusion received 0.9% saline (control), three cycles of 70% He-, Ne-, or Ar-30% O2 administered for 5 min interspersed with 5 min of 70% N2–30% O2 before LAD occlusion, or three cycles of brief (5 min) ischemia interspersed with 5 min reperfusion before prolonged LAD occlusion and reperfusion (ischemic preconditioning). Additional groups of rabbits received selective inhibitors of phosphatidylinositol-3-kinase (wortmannin; 0.6 mg/kg), extracellular signal-regulated kinase (PD 098059; 2 mg/kg), or 70-kDa ribosomal protein s6 kinase (rapamycin; 0.25 mg/kg) or mPTP opener atractyloside (5 mg/kg) in the absence or presence of He pretreatment.

RESULTS: He, Ne, Ar, and ischemic preconditioning significantly (P < 0.05) reduced myocardial infarct size [23% ± 4%, 20% ± 3%, 22% ± 2%, 17% ± 3% of the left ventricular area at risk (mean ± sd); triphenyltetrazolium chloride staining] versus control (45% ± 5%). Wortmannin, PD 098059, rapamycin, and atractyloside alone did not affect infarct size, but these drugs abolished He-induced cardioprotection.

CONCLUSIONS: The results indicate that noble gases without anesthetic properties produce cardioprotection by activating prosurvival signaling kinases and inhibiting mPTP opening in rabbits.

 

心脏手术中偶然发现的卵圆孔未闭是否需要修补?

The Incidental Finding of a Patent Foramen Ovale During Cardiac Surgery: Should It Always Be Repaired? A Core Review 

Mikhail R. Sukernik, MD, PhD*, and Elliott Bennett-Guerrero, MD{dagger}

From the *Department of Anesthesiology, Pennsylvania State University College of Medicine, Hershey, Pennsylvania; and {dagger}Duke Clinical Research Institute, Durham, North Carolina.

Anesth Analg 2007 105: 602-610. [

 

随着术中经食道超声心动图应用增加,心脏手术中常发现卵圆孔未闭。由于术中诊断卵圆孔未闭对术后结局的影响尚未知晓,使心脏外科医生陷入两难的境地。改变手术方案修补卵圆孔未闭使患者面临风险增加。而另一方面,不修补卵圆孔使患者面临未知的即刻与长期不良结果。目前决定是否修补卵圆孔取决于临床医生个人偏好、术中术后低氧血症的可能性、以及任何与最初手术方案的偏差。多数临床医生同意如果手术有导致低氧血症的高危风险(例如安置左心室辅助装置,心脏移植),则必须修补术中诊断出的卵圆孔未闭;心脏手术期间不进行心房切开和上下腔静脉插管的操作可使卵圆孔未闭相关的围术期和远期并发症增加,因而建议应该关闭卵圆孔。经皮卵圆孔未闭修补技术为卵圆孔未闭未修补而术后低氧血症或其它并发症可能导致无法修补卵圆孔的案例提供有价值的替代方案。

(周懿之 陈杰 校)

With the increased use of intraoperative transesophageal echocardiography, patent foramen ovale (PFO) has become a common finding during heart surgery. This finding presents a difficult dilemma for cardiac surgeons, since the impact of intraoperatively diagnosed PFOs on postoperative outcome is unknown. Changes in the surgical plan required for closure of a PFO subject the patient to the possibility of additional risk. On the other hand, a decision to not close a PFO exposes the patient to unclear immediate and long-term consequences. Deciding whether or not to close a PFO currently depends on the clinicians’ personal preferences, the probability of intraoperative and postoperative hypoxemia, and any anticipated deviation from the initial surgical plan. Most clinicians agree that an intraoperatively diagnosed PFO must be closed when surgery leads to a high risk of hypoxemia (e.g., left ventricular assist devices placement, heart transplantation); should be closed in most cases when minimal deviation from the initial surgical plan is needed for PFO closure (e.g., mitral valve or tricuspid valve surgeries); and probably, should be closed during heart surgeries performed without atriotomy and bicaval cannulation when the risk of perioperative or remote PFO-related complications is increased. The recent development of percutaneous methods of PFO closure provides a valuable backup for those cases when PFO is not closed and postoperative hypoxemia or other complications may be attributable to the uncorrected PFO.

 

健康受试者吸入七氟醚后晚期预处理效果的分子学证据

Molecular Evidence of Late Preconditioning After Sevoflurane Inhalation in Healthy Volunteers

Eliana Lucchinetti, PhD*, José Aguirre, MD*, Jianhua Feng, MD, PhD*, Min Zhu, PhD*, Marc Suter, MD*, Donat R. Spahn, MD*, Luc Härter, PhD{dagger}, and Michael Zaugg, MD*

From the *Institute of Anesthesiology; and {dagger}Department of Trauma Surgery, University Hospital Zurich, Switzerland.

Anesth Analg 2007 105: 629-640.

 

背景:挥发性麻醉药的预处理晚期作用涉及到对转录改变的应答。作者假设吸入七氟醚将改变人血液细胞的转录,并调整白细胞黏附分子的表达,这与晚期预处理时的发现一致。

方法:五名健康男性受试者持续吸入浓度0.5%-1.0%的七氟醚60min。分别在吸入前,吸入后15min60min及此后的6h24h48h采集静脉血样本,并立即用流式细胞仪进行细胞计数,提取mRNA并与Affymetrix U133 Plus 2.0 微点阵杂交。数据应用微点阵显著性分析、基因位点浓缩分析和实时逆转录聚合酶连反应分析。L-选择蛋白(CD62L,B2-整合蛋白(CD11b)的表达通过流式细胞仪计算粒细胞和单核细胞数来确定。

结果:吸入七氟醚能迅速地、显著地改变白细胞的基因表达。包括对氧磷酸酶、12-脂肪氧化酶、热休克蛋白40、趋化因子配体5、磷酸二酯酶5A的关键转录物在七氟醚作用下的调整可能涉及到晚期预处理或器官保护。七氟醚进一步降低涉及过氧化物酶体增值子受体共激动剂-1aPGC-1a)信号和脂肪酸氧化的转录。降低粒细胞L-选择蛋白的表达伴随着增加抑制炎症反应激活能力,在吸入七氟醚24-48小时后表现出来。

结论:七氟醚在亚麻醉浓度能改变血细胞转录,减少促炎因子L-选择蛋白的表达,符合人的“第二窗口保护作用

(潘方立 陈杰 校)

BACKGROUND: Late preconditioning by volatile anesthetics evolves in response to transcriptional changes. We hypothesized that sevoflurane inhalation would modify the transcriptome in human blood and modulate the expression of adhesion molecules in white blood cells consistent with the occurrence of a late preconditioning phase.

METHODS: Five healthy male subjects inhaled sevoflurane at an end-tidal concentration of 0.5%–1.0% for 60 min. Venous blood samples were collected at baseline, after 15 and 60 min of inhalation, and 6, 24, 48, and 72 h thereafter and immediately processed for flow cytometry and mRNA extraction and hybridization to Affymetrix U133 Plus 2.0 microarrays. Data were analyzed using Significance Analysis of Microarray and Gene Set Enrichment Analysis and confirmed by real-time reverse transcription polymerase chain reaction. L-selectin (CD62L) and ß2-integrin (CD11b) expression was determined on granulocytes and monocytes using flow cytometry.

RESULTS: Sevoflurane inhalation rapidly and markedly altered gene expression in white blood cells. Key transcripts potentially involved in late preconditioning or organ protection including paraoxonase, 12-lipoxygenase, heat shock protein 40, chemokine ligand 5, and phosphodiesterase 5A were regulated in response to sevoflurane. Sevoflurane further decreased transcripts involved in peroxisome proliferator-activated receptor {gamma}coactivator-1{alpha} (PGC-1{alpha}) signaling and fatty acid oxidation. Reduced L-selectin (CD62L) expression on granulocytes accompanied with increased resistance to inflammatory activation was present at 24 to 48 h after sevoflurane exposure.

CONCLUSIONS: Sevoflurane at subanesthetic concentrations modifies blood transcriptome and decreases the expression of the proinflammatory L-selectin (CD62L), consistent with a "second window of protection" in humans.

 

兰替洛尔—超短效β1受体拮抗剂不改变猪异氟醚的最小肺泡有效浓度

 Landiolol, an Ultra–Short-Acting ß1-Adrenoceptor Antagonist, Does Not Alter the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model

Tadayoshi Kurita, MD, Kotaro Takata, MD, Masahiro Uraoka, MD, Koji Morita, PhD, and Shigehito Sato, MD

From the Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Handayama, Hamamatsu, Japan.

Anesth Analg 2007 105: 656-660.

.

背景:作者先前曾报道过超短效β1受体拮抗剂—兰替洛尔不改变异氟醚的脑电效应。本文作者研究兰替洛尔对能够防止50%受试者对有害刺激产生体动反应的异氟醚的MAC的影响。

技术:十只猪(29.0±3.4kg)施行异氟醚吸入麻醉。通过使用悬蹄夹技术记录夹紧时的体动确定MAC。测定MAC后,开始输注兰替洛尔(第1分钟0.125mg·kg-1·min-1,然后0.04 mg·kg-1·min-1)。经过20分钟的稳定期,再次评估MAC(兰替洛尔0.04 mg·kg-1·min-1)。然后兰替洛尔的输注速度从0.04 mg·kg-1·min-1提高到0.2mg·kg-1·min-1,经过20分钟的稳定期,再次评估MAC0.2 mg·kg-1·min-1)。最后,停止输注兰替洛尔,经过20分钟稳定期第四次评估MAC(基线2)。

结果:兰替洛尔明显减弱悬蹄夹刺激时的心率和平均动脉压升高效应,但并不改变异氟醚的MAC

结论:兰替洛尔不改变异氟醚的抗伤害效应。这个结果结合作者先前的工作,提示了兰替洛尔不影响吸入麻醉药的麻醉效能。

(丁震敏 陈杰)

BACKGROUND: We previously reported that landiolol, an ultra–short-acting ß1-adrenoceptor antagonist, does not alter the electroencephalographic effect of isoflurane. Here, we investigated the influence of landiolol on the minimum alveolar anesthetic concentration (MAC) of isoflurane required to prevent movement in response to a noxious stimulus in 50% of subjects.

METHODS: Ten swine (29.0 ± 3.4 kg) were anesthetized by inhalation of isoflurane. MAC was determined using the dewclaw clamp technique, in which movement in response to clamping is recorded. After determination of MAC in the baseline period, an infusion of landiolol (0.125 mg · kg–1 · min–1 for 1 min, then 0.04 mg · kg–1 · min–1) was started. After a 20-min stabilization period, MAC was again assessed (0.04 mg · kg–1 · min–1 landiolol). The infusion of landiolol was then increased from 0.04 to 0.2 mg · kg–1 · min–1, and after a 20-min stabilization period, MAC was again assessed (0.2 mg · kg–1 · min–1 landiolol). Finally, the infusion of landiolol was stopped, and after a 20-min stabilization period, MAC was assessed for a fourth time (Baseline 2).

RESULTS: Landiolol clearly attenuated the increases in heart rate and mean arterial blood pressure that occurred in response to the dewclaw clamp, but did not alter the MAC of isoflurane.

CONCLUSIONS: Landiolol does not alter the antinociceptive effect of isoflurane. This result, combined with that from our previous work, also suggests that landiolol does not influence the anesthetic potency of inhaled anesthetics.

 

酮体(β羟基丁酸和丙酮)的麻醉学特性

 Anesthetic Properties of the Ketone Bodies ß-Hydroxybutyric Acid and Acetone

Liya Yang, PhD*, Jing Zhao, MD*, Pavle S. Milutinovic, MS, Robert J. Brosnan, DVM, PhD§, Edmond I. Eger, II, MD*, and James M. Sonner, MD*

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

.Anesth Analg 2007 105: 673-679.

 

背景:作者验证如下假说――酮症酸中毒发生过程中的两个蓄积代谢产物(β羟基丁酸和丙酮)具有类似麻醉药物的作用方式改变离子通道,且在动物身上产生麻醉效果。

方法:在非洲蟾蜍卵母细胞上分别有α1β2γ2sA型γ-氨基丁酸(GABAA)、α1甘氨酸、NR1/NR2A N-甲基-D-天(门)冬氨酸和双孔域TRESK通道的表达。作者使用双电极电压钳技术进行研究,测量β羟基丁酸和丙酮对通道功能的效应。并在非洲蟾蜍的蝌蚪上测量两者的麻醉效应。

结果:在引起人体酮症酸中毒的浓度范围内,β羟基丁酸和丙酮都增强了甘氨酸受体功能。β羟基丁酸也在此浓度范围内增强了GABAA 受体功能。两者在蝌蚪上都产生了麻醉效应,EC50值分别为:β羟基丁酸151±11mM(均数±标准差)和丙酮264±2mM(均数±标准差)。丙酮在浓度大等于50mM时有增强GABAA受体作用,在浓度大等于100mM时可见其抑制TRESK通道功能的现象,在浓度大等于200mM时则可抑制NMDA受体功能。

结论:β羟基丁酸和丙酮都有麻醉效应。两种酮体在产生临床表现的酮症酸中毒浓度范围内都增强了对甘氨酸受体的抑制作用。另外,β羟基丁酸也在此浓度范围内增强了GABAA 受体功能。在亚麻醉效应浓度下,两者可能产生伴随酮症而表现的昏睡和意识减退。

(於章杰 陈杰 校)

BACKGROUND: We tested the hypothesis that two metabolites that are elevated in ketosis (ß-hydroxybutyric acid, and acetone) modulate ion channels in a manner similar to anesthetics and produce anesthesia in animals.

METHODS: {alpha}1ß2{gamma}2s{gamma}-aminobutyric acid type A (GABAA), {alpha}1 glycine, NR1/NR2A N-methyl-d-aspartate, and two pore domain TRESK channels were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping. The effect of ß hydroxybutyric acid and acetone on channel function was measured. The anesthetic effects of these drugs were measured in X. laevis tadpoles.

RESULTS: Both ß hydroxybutyric acid and acetone enhanced glycine receptor function in the concentration range that is obtained in ketoacidosis in humans. Beta hydroxybutyric acid also enhanced GABAA receptor function at these concentrations. Both acetone and ß-hydroxybutyric acid anesthetized tadpoles, with an EC50 for acetone of 264 ± 2 mM (mean ± se) and for ß-hydroxybutyric acid of 151 ± 11 mM at pH 7.0. Acetone enhanced GABAA receptors at concentrations of 50 mM and above. Inhibition of TRESK channel function was seen with 100 mM acetone or larger concentration. N-methyl-D-aspartate receptor function was inhibited at concentrations of acetone of 200 mM and larger.

CONCLUSIONS: Beta hydroxybutyric acid and acetone are anesthetics. Both ketone bodies enhance inhibitory glycine receptors at concentrations observed clinically in ketoacidosis. In addition, ß-hydroxybutyric acid enhances GABAA receptor function at these concentrations. Subanesthetic concentrations of these drugs may contribute to the lethargy and impairment of consciousness seen in ketoacidosis.

 

全身麻醉期间呼出一氧化碳的水平与吸入氧浓度的关系

Exhaled Carbon Monoxide Levels Change in Relation to Inspired Oxygen Fraction During General Anesthesia

Takehiko Adachi, MD, PhD*, Kiichi Hirota, MD, PhD*{dagger}, Tomoko Hara, MD*, Yukiko Sasaki, MD, PhD*, and Yasufumi Hara, MD*

From the *Department of Anesthesiology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute; and {dagger}Department of Anesthesia, Kyoto University Hospital, Osaka, Japan.

.Anesth Analg 2007 105: 696-699.

 

背景:血红素加氧酶降解亚铁血红素时会产生一氧化碳。许多应激因素会上调这种酶的活性并提高呼出气一氧化碳的水平。最近,有报道显示在麻醉和手术后的患者及危重症患者中呼出一氧化碳的水平是提高的,为了监测机械通气期间的一氧化碳水平,阐明影响呼出气一氧化碳水平的相关因素是十分重要的。人工通气时吸入氧浓度是经常变化的。为了研究吸入氧浓度的变化对呼出一氧化碳水平的影响,作者监测了全身麻醉过程中呼出气一氧化碳的水平。

方法:30名择期手术的患者入选本研究,麻醉维持使用七氟醚和芬太尼,所有患者都进行气管插管并行非复吸通气。在呼吸回路的分岔口使用一氧化碳监测仪来监测呼出气一氧化碳的水平,从而研究吸入氧浓度对呼出一氧化碳水平的影响,长时间吸入75%和35%氧时对呼出一氧化碳水平和动脉碳氧血红蛋白浓度的影响。

结果:呼出气一氧化碳的水平随着氧浓度的改变而迅速改变。长时间吸入75%氧气时在最初会增加呼出气一氧化碳的水平,但继之逐渐下降并伴有动脉碳氧血红蛋白的减少。而长时间吸入35%氧气时不会产生这些改变。

结论:在机械通气期间监测呼出气一氧化碳的水平时,考虑吸入氧浓度产生的影响是十分重要的。

(詹琼慧 陈杰 校)

BACKGROUND: Heme oxygenase produces carbon monoxide (CO) during the breakdown of heme molecules. A variety of stressors upregulate this enzymatic activity and can increase exhaled CO levels. Recently, exhaled CO levels have been reported to increase in critically ill patients and after anesthesia and surgery. To use this measurement during mechanical ventilation, it is important to clarify the effects of factors which interfere with exhaled CO levels. The fraction of inspired oxygen (Fio2) is often changed during artificial ventilation. To investigate the effect of changes of Fio2 on exhaled CO, we measured exhaled CO levels during general anesthesia.

METHODS: Thirty patients who underwent elective operations were enrolled in this study. Anesthesia was maintained with sevoflurane and fentanyl. All patients were tracheally intubated and ventilated with a non-rebreathing ventilator. Exhaled CO levels were measured in gas sampled from the expired limb of the respiration circuit using a CO monitor. The effects of sequential changes of Fio2 on exhaled CO levels, and the effects of long-term inhalation of Fio2 0.75 and Fio2 0.35 on exhaled CO levels and arterial carboxyhemoglobin concentrations were investigated.

RESULTS: Exhaled CO levels changed rapidly in response to changes of Fio2. Long-term inhalation of Fio2 0.75 initially increased and then gradually decreased exhaled CO to basal levels, concomitant with a decrease of arterial carboxyhemoglobin. Long-term inhalation of Fio2 0.35 did not elicit any significant change in the observed variables.

CONCLUSION: When monitoring exhaled CO levels during mechanical ventilation, it is important to consider the effects of Fio2.

 

 羟乙基淀粉:分子量和取代级对血管内贮留的影响

Hydroxyethyl Starch: The Effect of Molecular Weight and Degree of Substitution on Intravascular Retention In Vivo

Takashi Hitosugi, DDS*, Toshiyuki Saito, MD, PhD*{dagger}, Sono Suzuki, DDS*, Ieko Kubota, DDS*, Emi Shoda, DDS*, Toru Shimizu, MD, PhD{ddagger}, and Yoshiyuki Oi, MD, PhD*

From the *Department of Anesthesiology, Nihon University Graduate School of Dentistry; {dagger}Department of Anatomy, Tokyo Medical University, Tokyo, Japan; and {ddagger}Department of Bioengineering, University of California, San Diego, La Jolla, California.

.Anesth Analg 2007 105: 724-728.

 

背景:羟乙基淀粉(HES) 的特性由其平均分子量(MW),浓度和取代级(DS)等决定。这一特性不断地变化。

方法:HES与异硫氰酸荧光素结合形成FITC-HES之后,在一个轻度失血的模型中(失血量占血容量的10%)应用活体显微镜检查小鼠的提睾肌A2V2血管,以此来评估三种6%HES浓度。在抽血建立轻度失血模型后,分别输入三种FITC-HES:HES-A(MW150-200kDa,DS0.6-0.68),HES-B(MW175-225kDa,DS0.45-0.55),HES-C(MW550-850kDa,DS0.7-0.8),然后利用活体显微镜检查测定FITC-HES留率。

结果: V2血管输注后120MinFITC-HES留率分别为:HES-A27%±6.6%;HES-B:65%±9.1%;HES-C:89%±8.7% ; A2血管HES-A27%±6.6%;HES-B73%±10.2%;HES-C89%±8.7%HES-BHES-CHES-A在血管内留的时间长(HES-BHES-A相比,V2P=0.028 A2P0.038HES-CHES-A相比, V2P=0.022A2P0.037)。HES-BHES-C的血管消除率无明显差异。

结论: HES-BHES-C在血管中留的时间相似。低DS和中度DS的中等分子量HESB和大分子量的HES在血管中留的时间相同。因此,应研究不同种类HES变化特征以此优化HES输注。

(杨卫红 陈杰 校)

BACKGROUND: Hydroxyethyl starch (HES) solution is characterized by its mean molecular weight (MW), concentration, and degree of substitution (DS). This character varies worldwide.

METHODS: After binding fluorescein-isothiocyanate (FITC-HES), we evaluated the retention rate of three types of 6% HES in the A2 and V2 blood vessels of rat cremaster muscles using intravital microscopy in a mild hemorrhage model (10% of total blood volume). After blood withdrawal, we infused three types of FITC-HES: HES-A (MW 150–200 kDa, DS 0.6–0.68), HES-B (MW 175–225 kDa, DS 0.45–0.55), or HES-C (MW 550–850 kDa, DS 0.7–0.8) before determining the FITC-HES retention rate in the intravital microscope.

RESULTS: For V2, the FITC-HES retention rates 120 min after the start of the infusion were 27% ± 7.2% of baseline values (HES-A), 65% ± 9.1% (HES-B), and 86% ± 9.6% (HES-C); for A2 they were 27% ± 6.6%, 73% ± 10.2%, and 89% ± 8.7%, respectively. HES-B and HES-C were retained in the vessels longer than HES-A (P = 0.028 for V2, P = 0.038 for A2 between HES-B and HES-A; P = 0.022 for V2, P = 0.037 for A2 between HES-C and HES-A). There was no difference in the rate of disappearance from the vessels between HES-B and HES-C.

CONCLUSIONS: HES-B and HES-C are equally retained in the blood vessels. Middle-sized HES-B with low DS and middle substitution pattern stayed in the blood vessels as long as the large-sized HES. HES solutions of varying characters should be examined to optimize HES infusion.

 

毒扁豆碱逆转成年小鼠由于中度缺氧引起的认知功能障碍

Physostigmine Reverses Cognitive Dysfunction Caused by Moderate Hypoxia in Adult Mice

Alex Bekker, MD, PhD, Michael Haile, MD, Kevin Gingrich, MD, Leslie Wenning, BA, Alex Gorny, MD, David Quartermain, PhD, and Thomas Blanck, MD, PhD

From the Department of Anesthesiology, New York University Medical Center, New York, New York.

Anesth Analg 2007 105: 739-743. Abstract

 

背景:啮齿类动物由于中度缺氧产生的相关认知功能改变可能与中枢胆碱能神经传导功能的减退有关。本文作者通过实验来研究毒扁豆碱——一种乙酰胆碱酯酶抑制剂,是否能够改善低氧性缺氧后的活动记忆。

方法:90只体重在3035g,6-8周的Swiss Webster小鼠随机分在三个低氧组,吸入氧浓度FiO20.10(组1:未经任何处理;组2:试验最初腹腔内注射毒扁豆碱0.1mg/kg;组3:缺氧后腹腔内注射毒扁豆碱0.1mg/kg),或随机分在两个室内空气组,一组在缺氧发作后未予任何处理,另一组给予毒扁豆碱。一次实物认知测试用来评估短期的记忆功能。测试中观察小鼠探究新伙伴的倾向,试验中,另一只相似的小鼠也同样参与其中。在15分钟的尝试试验中,两只相同的小鼠被分别安置在箱子的两处特定区域。尝试试验进行1小时后,其中一只小鼠被一只外形完全不同的小鼠所替代。两只试验小鼠在整个试验过程中表现由摄像机及相关电脑程序全程监视。数据结果进行方差分析,如需要的话,还可以继续用NewmanKeuls测试进行事后比较。P<0.05有显著性差异。

结果:试验第一天,在FiO20.10的缺氧状态下,未处理小鼠比起呼吸室内空气的未处理小鼠,所花费的认识新伙伴的时间要短的多。而同样在缺氧的环境中,事后给予毒扁豆碱的试验小鼠,缺氧对其的影响与对照组相比没有明显差别。

结论:通过活动记忆评估发现,中度缺氧会损害到啮齿动物的行为表现。但是影响是短期的,因为在给予治疗后,小鼠认知功能在7天后可以回复到正常水平。缺氧发作后给予毒扁豆碱可以预防认知功能的下降。中枢神经系统乙酰胆碱水平的升高可能与缺氧小鼠给药后行为改善有关。

(杜唯佳 陈杰 校)

BACKGROUND: Cognitive changes associated with moderate hypoxia in rodents may result from the diminished functioning of central cholinergic neurotransmission. We designed this study to examine whether treatment with physostigmine (PHY), an acetylcholinesterase inhibitor, could improve the impairment of working memory after hypoxic hypoxia.

METHODS: We randomized 90 Swiss Webster, 30–35 g mice (6–8 wks) to three hypoxia groups at fraction of inspired oxygen, FiO2 = 0.10 (1. no treatment; 2. PHY 0.1 mg/kg intraperitoneally administered immediately before; or 3. after hypoxia), or to two room air groups (given either no treatment or PHY after an insult). An object recognition test was used to assess short-term memory function. The object recognition test exploits the tendency of mice to prefer exploring novel objects in an environment when a familiar object is also present. During the 15 min training trial, two identical objects were placed in two defined sites of the box. During the test trial performed 1 h later, one of the objects was replaced by a new object with a different shape. The time spent exploring the two objects was automatically recorded by a video camera and associated software. The performance was analyzed with ANOVA, followed by post hoc comparisons using the Newman– Keuls test when appropriate. P values <0.05 were considered significant.

RESULTS: Untreated mice subjected to hypoxia at Fio2 = 0.1 spent significantly less time exploring a novel object on testing day 1 than did untreated mice breathing room air. Performance of the mice subjected to hypoxia, who received physostigmine after, but not before, the insult did not differ from the control group.

CONCLUSION: Moderate hypoxia impairs rodents' performance in a working memory task. It appears that changes are transient, because the cognitive functioning of the mice returned to the baseline level 7 days after treatment. Postinsult administration of PHY prevented deterioration of cognitive function. An increased level of acetylcholine in the central nervous system may be responsible for the improved performance of the hypoxia-treated mice.

 

局麻药和分娩方式:布比卡因、罗哌卡因及左旋布比卡因的比较

Local Anesthetics and Mode of Delivery: Bupivacaine Versus Ropivacaine Versus Levobupivacaine

Yaakov Beilin, MD*{dagger}, Nicole R. Guinn, BS*, Howard H. Bernstein, MD*{dagger}, Jeff Zahn, MD*, Sabera Hossain, MS{ddagger}, and Carol A. Bodian, DrPH{ddagger}

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

.Anesth Analg 2007 105: 756-763.

 

背景:硬膜外局麻药对产妇分娩方式的影响研究并不多。在这项研究中,作者研究布比卡因、罗哌卡因及左旋布比卡因进行硬膜外分娩镇痛中,分娩方式是否不同。

方法:要求无痛分娩的初产妇在宫口扩张<5cm时随机接受布比卡因或罗哌卡因或左旋布比卡因进行硬膜外镇痛。镇痛方法:单次注射15ml 0.0625%的指定局麻药复合芬太尼2ug/ml,随后以10ml/h的速度输注同种局麻药维持镇痛。主要观察是手术分娩率(包括器械辅助的阴道分娩和剖宫产分娩)

结果:98名接受了布比卡因,90名接受了罗哌卡因,34名接受了左旋布比卡因(在其从美国市场淘汰之前)。结果所有组中手术分娩率方面没有显著的不同(布比卡因是46%,罗哌卡因是39%,左旋布比卡因是32%,p=0.35)。与罗哌卡因及布比卡因两组相比,左旋布比卡因的运动阻滞更少(p<0.05)。三组中第一及第二产程的持续时间,产程中接受的每小时局麻药的总量,及对新生儿的影响没有显著的区别.

结论:布比卡因,罗哌卡因及左旋布比卡因都适用于硬膜外分娩镇痛,同时对分娩方式、产程的持续时间及对新生儿没有显著的影响。

(潘钱玲 陈杰 校)

BACKGROUND: The influence of the labor epidural local anesthetic (LA) on mode of delivery has not been adequately studied. In this study, we sought to determine if there is a difference in mode of delivery among parturients who receive epidural bupivacaine, ropivacaine, or levobupivacaine.

METHODS: Nulliparous women at term requesting labor analgesia with a cervical dilation <5 cm were randomized to receive epidural bupivacaine, ropivacaine, or levobupivacaine. Analgesia was initiated with a bolus of 15 mL of 0.0625% of the assigned LA with fentanyl 2 µg/mL. Analgesia was maintained with an infusion of the same solution at 10 mL/h. The primary endpoint was the operative delivery rate (instrumental assisted vaginal delivery plus cesarean delivery).

RESULTS: Ninety-eight women received bupivacaine, 90 ropivacaine, and 34 levobupivacaine (before it was removed from the US market). There was no significant difference in the operative delivery rate (bupivacaine = 46%, ropivacaine = 39%, and levobupivacaine = 32%, P = 0.35) among groups. There was less motor block in the levobupivacaine group when compared with the ropivacaine and bupivacaine groups, P < 0.05. There was no significant difference in the duration of the first or second stage of labor, the total dose of LA received per hour of labor, or neonatal outcome among groups.

CONCLUSIONS: Bupivacaine, ropivacaine, and levobupivacaine all confer adequate labor epidural analgesia, with no significant influence on mode of delivery, duration of labor, or neonatal outcome.

 

成人肝移植期间在再灌注前、再灌注后早期、再灌注后晚期3个时期高钾血症的预测

Predictors of Hyperkalemia in the Prereperfusion, Early Postreperfusion, and Late Postreperfusion Periods During Adult Liver Transplantation

Victor W. Xia, MD*, Rafik M. Ghobrial, MD{dagger}, Bin Du, MD*§, Tabitha Chen, BS*, Ke-Qin Hu, MD{ddagger}, Jonathan R. Hiatt, MD{dagger}, Ronald W. Busuttil, MD, PhD{dagger}, and Randolph H. Steadman, MD*

From the Departments of *Anesthesiology and {dagger}Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California; {ddagger}Division of Gastroenterology, University of California, Irvine Medical Center, Orange, California; and §Department of Anesthesiology, 2nd Affiliated Hospital, Kunming Medical College, Kunming, China.

.Anesth Analg 2007 105: 780-785.

 

背景:高钾血症对接受原位肝移植的病人构成严重的危害,且不易预测。

方法:作者回顾性研究了1124例接受原位肝移植的成年病人。高钾血症定义为血清[K] ≥5.5/L。在单变量分析中,共有47个受体,供体,手术不同期及实验室指标用来做多变量初始分析。在原位肝移植3个时期(再灌注前,再灌注后早期,再灌注后晚期)高钾血症的独立预测是由多元对数回归分析来决定的。

结果1124个病人中,在再灌注前,再灌注后早期,再灌注后晚期中分别有10.2%19.1%7.9%的病人发生高钾血症。高基础血K和输血为独立预测再灌注前高钾血症。高基础血K(或再灌注前高基础血K)和心脏病死亡供体为独立预测再灌注后早期高钾血症。高基础血K,热缺血时间,供体较长的住院时间,术中尿量减少,静脉转流等为再灌注后晚期高钾血症独立预测因子。

结论:数个实验室指标,手术不同时期和不同类别供体可作为不同时期高钾血症的独立预测因子。上述结果有助于为成人原位肝移植中有高钾血症危险的病人更有针对性的超前治疗。

(张燕 陈杰 校)

BACKGROUND: Hyperkalemia poses serious hazards to patients undergoing orthotopic liver transplantation (OLT), and its predictors have not been thoroughly examined.

METHODS: We retrospectively studied 1124 consecutive adult patients who underwent OLT. Hyperkalemia was defined as serum K+ ≥5.5 mmol/L. A total of 47 recipient, donor, intraoperative, and laboratory variables were initially analyzed in univariate analyses. Independent predictors of hyperkalemia in three periods of OLT (prereperfusion, early postreperfusion, and late postreperfusion) were determined in multivariate logistic regression analyses.

RESULTS: Of 1124 patients, 10.2%, 19.1%, and 7.9% had hyperkalemia in the prereperfusion, early postreperfusion, and late postreperfusion periods, respectively. Higher baseline K+ and red blood cell transfusion were independent predictors of prereperfusion hyperkalemia. Higher baseline K+ (or prereperfusion K+) and donation after cardiac death donor were independent predictors of early postreperfusion hyperkalemia. Higher baseline K+, longer warm ischemia time, longer donor hospital stay, lower intraoperative urine output, and the use of venovenous bypass were independent predictors of late postreperfusion hyperkalemia.

CONCLUSIONS: Several laboratory, intraoperative, and donor variables were identified as independent predictors of hyperkalemia in the different periods. Such information may be used for more targeted preemptive interventions in patients who are at risk of developing hyperkalemia during adult OLT.


矫形外科中原发性痛觉过敏的演变全膝关节成形术前后定量感觉测试和临床评价

The Evolution of Primary Hyperalgesia in Orthopedic Surgery: Quantitative Sensory Testing and Clinical Evaluation Before and After Total Knee Arthroplasty

Valéria Martinez, MD*{dagger}, Dominique Fletcher, MD, PhD*{dagger}, Didier Bouhassira, MD, PhD{dagger}, Daniel I. Sessler, MD{ddagger}, and Marcel Chauvin, MD*{dagger}

From the *Department of Anesthesia, Assistance Publique Hôpitaux de Paris, Hôpital Raymond Poincaré, Garches; {dagger}INSERM, U-792, Hôpital Ambroise Paré, Centre d’Evaluation et de Traitement de la Douleur, Université Versailles Saint-Quentin, Versailles, France; and {ddagger}Department of Outcomes Research, The Cleveland Clinic, University of Louisville, Louisville, Kentucky.

.Anesth Analg 2007 105: 815-821.

 

背景:定量感觉测试(QST)能发现微小的感觉缺失和疼痛,并额外提供了术后疼痛的病理生理学信息。

方法: 20位择期行膝关节成形术的病人,在术前、术后第1天和第4天以及术后第1月和第4个月进行定量感觉测试和临床评估。临床评估包括术前疼痛,膝关节手术操作引发的炎症以及术后在静止休息时的疼痛和运动引起的疼痛(直观类比标度评分),还包括吗啡的累计使用量,双侧膝关节周径和皮肤温度。定量感觉测试包括温度和机械压力阈值和阈上刺激的灵敏度。并评估皮肤无害性的擦试而引起的异常性疼痛。同时在手术侧和非手术侧膝关节进行疼痛评估,并以手为参照对象。

结果:所有病人在手术前患侧的膝关节都有长时间的剧烈疼痛和炎症。手术前的QST为进行手术的膝关节的炎症区域存在热痛觉过敏提供了证据,但是在与非炎症区域的交界处不存在皮肤无害性接触而引起的异常性疼痛。病人存在强烈的术后疼痛,大多数由于运动导致。原发性热痛觉过敏表现在手术后的第一天和第四天,伴随炎症区域无害性的接触引起的异常性疼痛。手术后吗啡的用量与术前的热痛觉过敏相关联。QST在第4个月恢复到基线,此时只有四位病人还存在运动导致的膝关节中度疼痛。

结论:热痛觉过敏在所有QST症状中与全膝关节成型术围术期疼痛的密切相关,且可预测术后吗啡的用量。

(王鹏 陈杰 校)

 BACKGROUND: Quantitative sensory testing (QST) allows precise characterization of sensory deficits and painful symptoms and may offer additional information on the pathophysiology of postoperative pain.

METHODS: We evaluated 20 patients scheduled for total knee arthroplasty clinically and with QST before surgery, at 1 and 4 days after surgery, and at 1 and 4 mo after surgery. The clinical evaluation included preoperative pain and inflammation of the operative knee, postoperative assessment of pain at rest and during movement (   Visual Analog Scale score), cumulative morphine consumption, and circumference and temperature of both knees. QST included thermal and mechanical (pressure) pain threshold measurements and assessment of responses to suprathreshold stimuli. Brush-evoked allodynia was also evaluated. Measurements were taken on the operative knee, contralateral knee, and on the hand as a control site.

RESULTS: All patients had prolonged and severe pain before surgery and inflammation of the operative knee. Preoperative QST provided evidence of heat hyperalgesia in the inflammatory area on the operative knee, but absence of punctate or brush-evoked allodynia in the adjacent noninflamed area. Patients had intense postoperative pain, mostly induced by movement. Primary heat hyperalgesia was present on the operative knee on the first and fourth day after surgery, and was associated with punctate mechanical allodynia in the inflammatory area, but not in the adjacent noninflamed area. Postoperative morphine consumption was correlated with preoperative heat hyperalgesia (r = 0.63; P = 0.01). QST returned to baseline at the 4-mo evaluation. Only four patients had moderate knee pain induced by movement at that time.

CONCLUSION: Heat hyperalgesia was the predominant QST symptom associated with perioperative pain after total knee arthroplasty, and was predictive of postoperative morphine consumption.

 

麻醉猫静脉注射咪唑安定后的交感神经反射活性

Reflex Sympathetic Activity After Intravenous Administration of Midazolam in Anesthetized Cats

Ryoji Iida, MD, PhD*, Ken-ichi Iwasaki, MD, PhD{dagger}, Jitsu Kato, MD, PhD*, Shigeru Saeki, MD, PhD*, and Setsuro Ogawa, MD, PhD*

From the Departments of *Anesthesiology and {dagger}Hygiene and Space Medicine, Nihon University School of Medicine, Tokyo, Japan.

Anesth Analg 2007 105: 832-837.

 

背景:虽有报道,在蛛网膜下腔应用咪唑安定所产生的抗伤害性反射机制是由脊髓的Ar-氨基丁酸(即苯二氮卓类受体复合物)所介导的,但是咪唑安定全身系统性的抗伤害反射机制仍然未知。本次试验,分别对完整大脑和去大脑(中脑水平离断)状态的猫静脉注射咪唑安定后,观察对躯体交感神经AC反射的影响。

方法: 28只成年猫,用电刺激腓浅神经的传出神经纤维A(有髓鞘)和传出神经纤维C(脱髓鞘)来诱发心内交感神经的躯体交感AC反射。控制下的体-交感反射产生后,我们把猫随机分成四组,分别静脉注射如下剂量的咪唑安定:大脑完整的猫注射剂量分别为0.03mg/kg 0.1mg/kg0.5mg/kg;去大脑的猫注射剂量为0.1mg/kg.

结果:在完整大脑的猫中,躯体交感C反射在注射咪唑安定0.03mg/kg时明显增强, 0.1-0.5 mg/kg时明显减弱。在去大脑猫中,躯体交感C反射在剂量为0.1mg/kg时也是削弱的。

结论:静脉使用咪唑安定对于躯体交感反射的效应与剂量相关。因此,咪唑安定有剂量依赖性的抗伤害反射效应。同时,咪唑安定产生的躯体交感C反射抑制效应,主要作用于中脑平面以下。

(杜唯佳 陈杰 校)

BACKGROUND: Although intrathecal midazolam has been reported to produce antinociceptive effects mediated by {gamma}-aminobutyric acid type A-benzodiazepine receptor complexes in the spinal cord, the effects of systemic midazolam on nociception remain unclear. We performed this study to examine the effects of IV-administered midazolam on somatosympathetic A{delta} and C reflex discharges in brain-intact cats and decerebrate cats (with transection at midbrain level).

METHODS: Somatosympathetic A{delta}and C reflexes were elicited in the inferior cardiac sympathetic nerve by electrical stimulation of myelinated (A{delta}) and unmyelinated (C) afferent fibers of the superficial peroneal nerve in 28 mature cats. After control somatosympathetic reflex responses were obtained, midazolam was administered IV to four groups of randomly allocated cats as follows: brain-intact cats at a dose of 0.03 mg/kg, brain-intact cats at a dose of 0.1 mg/kg, brain-intact cats at a dose of 0.5 mg/kg, and decerebrate cats at a dose of 0.1 mg/kg.

RESULTS: C reflex discharges were significantly augmented at the dose of 0.03 mg/kg and significantly depressed at the dose of 0.1 and 0.5 mg/kg in brain-intact cats. C reflex discharges were also significantly depressed at the dose of 0.1 mg/kg in decerebrate cats.

CONCLUSIONS: We have demonstrated that IV midazolam produces dose-related effects on somatosympathetic reflex discharges. The clinical implication of these findings is that the effect of midazolam on nociception depends on its dosage. It also appears that the infra-midbrain region plays a major role in mediating the depressive effects of midazolam on somatosympathetic C reflex discharges.

 

闭孔神经与股神经阻滞用于膝关节成形术后镇痛的比较

Obturator Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty

Ken Kardash, MD*, Don Hickey, MD*, Michael J. Tessler, MD*, Stacey Payne, BScN{dagger}, David Zukor, MD{ddagger}, and Ana Miriam Velly, DDS, PhD§

From the Departments of *Anesthesia, {dagger}Nursing, and {ddagger}Orthopedic Surgery, Jewish General Hospital, McGill University, Montreal, Canada; and §Department of Diagnostic and Behavioral Sciences, University of Minnesota, Minneapolis, Minnesota.

Anesth Analg 2007 105: 853-858.

 

背景:股神经和闭孔神经阻滞在缓解膝关节成形术后疼痛方面都已被认为是有用的。本文作者比较两者的效能。

方法:60名在脊麻下择期行单侧膝关节成形术的患者,在手术结束后接受随机双盲的股神经阻滞或闭孔神经阻滞或未作神经阻滞的临床研究。神经阻滞用神经刺激仪定位,用药为含有肾上腺素5ug/ml0.5%布比卡因20ml。病人自控镇痛包括芬太尼、口服塞来考昔100mg 2/天)和每6小时口服扑热息痛650mg,从到达恢复室就开始实行。记录48小时休息和活动时疼痛情况、镇痛剂使用量和镇痛效果,以及膝关节屈曲的极限和住院天数作为疗效成果。

结果:在任何结果变量中,闭孔神经阻滞组与病人自控镇痛组没有显示显著差异。扣除基础疼痛评分,股神经阻滞组与病人自控镇痛组相比在休息时所受疼痛较轻,在恢复室活动也经受较少疼痛。没有一种阻滞作用对阿片类药物的使用、功能恢复和单侧疗效有显著影响。仅有一例股神经阻滞患者出现闭孔神经阻滞。

结论:股神经阻滞很少阻滞闭孔神经。在脊麻下行膝关节成形术后单次注射行股神经阻滞可改善术后多模式镇痛效果,但这一作用只在手术日。单独闭孔神经阻滞没有益处。

(陈伟 陈杰 校)

BACKGROUND: Both femoral and obturator nerve blocks have been suggested to be useful in relieving pain after total knee arthroplasty (TKA). We sought to compare their efficacy.

METHODS: Sixty patients undergoing elective unilateral TKA under spinal anesthesia received in a randomized, double-blind manner a femoral, obturator, or sham nerve block at the end of surgery. Blocks were performed using nerve stimulation and 20 mL bupivacaine 0.5% containing epinephrine 5 µg/mL. Patient-controlled IV analgesia with fentanyl, celecoxib 100 mg PO bid, and acetaminophen 650 mg PO every 6 h were started on arrival in the recovery room. Pain (0–10 numeric rating scale, NRS) at rest and with movement, analgesic use, and side effects were recorded for 48 h. Maximum knee flexion and total days in hospital were recorded as functional outcomes.

RESULTS: There were no significant differences in the obturator block group and the control group in any outcome variable. With baseline pain scores subtracted, femoral block resulted in less pain at rest compared with control (NRS difference from baseline 2.1 ± 0.4 sem vs 3.4 ± 0.4, respectively; P = 0.02) and less pain with movement (NRS difference 2.6 ± 0.6, 4.3 ± 0.6, P = 0.05) at recovery room discharge. Neither block had a significant effect on opioid use, functional outcome, or side effects. Only one (5%) patient with femoral block developed obturator motor block.

CONCLUSION: Femoral nerve blocks rarely block the obturator nerve. Single-injection femoral nerve block improved multimodal analgesia after spinal anesthesia for TKA, but this effect did not persist beyond the day of surgery. Obturator nerve block alone was of no benefit.


经斜角肌臂丛阻滞:后外侧臂丛阻滞的新方法

Transscalene Brachial Plexus Block: A New Posterolateral Approach for Brachial Plexus Block

Hoang C. Nguyen, MD*, Erwin Fath, MD*, Sebastian Wirtz, MD*, and Tareg Bey, MD{dagger}

From the *Department of Anesthesiology and Intensive Care Medicine, Asklepios Klinik Barmbek, Hamburg, Germany; and {dagger}Department of Emergency Medicine, University of California Irvine Medical Center, Orange, California.

.Anesth Analg 2007 105: 872-875.

 

有报道上段臂丛阻滞发生严重并发症。本文作者介绍一种从解剖学角度上较为有优势的后外侧臂丛阻滞法。随机选择27位择期行上臂或肩部开放性手术的病人接受该新方法。神经阻滞成功率为85.2%。其中有2名病人要求术中额外静脉予以舒芬太尼止痛,另外有2名病人局部阻滞不理想。使用该新途径阻滞出现的副作用包括可逆性喉返神经阻滞(2名)可逆性Horner综合症(1名)。仍需进一步研究来比较经斜角肌臂丛阻滞与其它径路臂丛阻滞的优劣。

(朱玫娟 陈杰 校)

Depending on the approach to the upper brachial plexus, severe complications have been reported. We describe a novel posterolateral approach for brachial plexus block which, from an anatomical and theoretical point of view, seems to offer advantages. Twenty-seven patients were scheduled to undergo elective major surgery of the upper arm or shoulder using this new transscalene brachial plexus block. The success rate was 85.2% for surgery. Two patients required additional analgesia with IV sufentanil. In two others, regional anesthesia was inadequate. The side effects of this technique included reversible recurrent laryngeal nerve blockade in two patients and a reversible Horner syndrome in one patient. Further studies are needed to compare the transscalene brachial plexus block with other approaches to the brachial plexus.