Anesthesia & Analgesia

September 2007

 

CARDIOVASCULAR ANESTHESIA:

無麻醉作用的惰性氣體通過啟動促存活信號激酶和抑制線粒跨膜通道通透性途徑對心梗後心肌產生保護作用

陶穎瑩 陳傑

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.

減少圍手術期血栓併發症:肝素導致的血小板減少症(HIT)的新進展

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

陳勇柱譯 薛張綱校

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

Anesth Analg 2007 105: 570-582.

圍手術期心超檢查用於心室輔助設備植入

彭中美   馬皓琳 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.

心臟手術中偶然發現的卵圓孔未閉是否需要修補?

周懿之 陳傑

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:

異丙酚輸注濃度變化對麻醉小兒血漿cGMP濃度的影響

吳德華譯 薛張綱校

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.

一項兒童氣管內插管位置確定方法的對照試驗:頸部活動的安全性

胡湘     馬皓琳 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:

健康受試者吸入七氟醚後晚期預處理效果的分子學證據

潘方立 陳傑

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.

對羅呱卡因作用於離體豚鼠心臟標本產生的毒性作用使用左西孟旦的強心功能

孫霞譯 薛張綱校  

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七氟醚優先影響高階聯合區:一項志願者的功能性磁共振成像研究

朱慧 馬皓琳 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.

蘭替洛爾—超短效β1受體拮抗劑不改變豬異氟醚的最小肺泡有效濃度

丁震敏 陳傑

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.

大鼠脊髓內腦脊液中鈉離子濃度改變對異氟醚MAC的影響

王時來譯 薛張綱校

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.

在豬模型上使用右美托咪定行深度鎮靜並不影響游離微血管皮瓣的活性(以微透析和組織氧張力表示)

黃施偉 譯,馬皓琳 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.

酮體(β羥基丁酸和丙酮)的麻醉學特性

於章傑 陳傑

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:

用傳統的紅外線臨床氣體分析儀測量血液中的麻醉氣體

楊譯 薛張綱校

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.

七氟醚麻醉下神經肌肉阻滯和傷害性刺激對催眠監測的影響

黃麗娜   馬皓琳 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.

全身麻醉期間呼出一氧化碳的水準與吸入氧濃度的關係

詹瓊慧 陳傑

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.

動脈球囊阻塞控制骶骨手術術中出血

陳佳莉譯 薛張綱校

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:

抗纖維蛋白酶的水準與外科重症監護室發病率和死亡率的關係

唐李雋 馬皓琳 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.

羥乙基澱粉:分子量和取代級對血管內貯留的影響

楊衛紅 陳傑

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.

選擇性肺複張對於嚴重低血容量患者的血流動力學是否安全?一項在肺萎陷豬的動物模型關於低血容量的試驗性研究。

陳珺珺譯 薛張綱校

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.

隆凸可作為主動脈內球囊搏動定位的有用的影像學標誌

周雅春 馬皓琳 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:

毒扁豆堿逆轉成年小鼠由於中度缺氧引起的認知功能障礙

杜唯佳 陳傑

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

豬大腦皮層在顱內壓增高伴腦血流降低時的腦代謝

佳譯 薛張剛校

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:

足月肥胖孕婦胃對水排空的研究

邱郁薇 馬皓琳 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.

局麻藥和分娩方式:布比卡因、羅呱卡因及左旋布比卡因的比較

錢玲 陳傑 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.

東莨菪堿透皮給藥預防蛛網膜下腔用嗎啡導致的剖宮產術後噁心嘔吐

璿譯 薛張綱校

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:

補充供氧可以提高豬正常和吻合的結腸組織氧壓,但補充晶體液無影響

沈浩   馬皓琳 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.

成人肝移植期間在再灌注前、再灌注後早期、再灌注後晚期3個時期高鉀血症的預測

張燕 陳傑

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:

一項系統性回顧:患者回饋關於術後鎮痛作用的結果

王光妍譯 薛張綱校

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.

硬膜外腔注射自體靜脈血治療慢性頸部扭傷相關性疾患

裘毅敏譯,馬皓琳,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.

矯形外科中原發性痛覺過敏的演變全膝關節成形術前後定量感覺測試和臨床評價

王鵬 陳傑

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.

經腹全子宮切除術後使用帕瑞考西以增加鞘內注射嗎啡的鎮痛效果

周時蓓譯 薛張綱校

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 的坐骨神經阻滯:對大鼠無髓鞘神經纖維的 電子顯微鏡研究

張瑩   馬皓琳 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.

麻醉貓靜脈注射咪唑安定後的交感神經反射活性

杜唯佳 陳傑

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.

末梢神經性疼痛的病理生理:免疫細胞與分子

吳威譯 薛張綱校

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.

不管電刺激高於還是低於0.5mA超聲引導下的肌間溝置針都能產生成功的麻醉

姜旭暉譯  馬皓琳 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.

閉孔神經與股神經阻滯用於膝關節成形術後鎮痛的比較

陳偉 陳傑

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,鞘內注射羅呱卡因的藥代動力學和生物利用度

陳愷錚譯 薛張綱校

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.

持續正壓通氣呼吸可以增加頸胸段硬膜外注射利多卡因後的感覺阻滯頭向擴散

黃佳佳譯,馬皓琳 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.

經斜角肌臂叢阻滯:後外側臂叢阻滯的新方法

朱玫娟 陳傑

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.

 

圍手術期心超檢查用於心室輔助設備植入

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

心室輔助設備(VADs)是用於有嚴重心衰病人的機械性迴圈支援的設備。圍手術期經食道超聲心動圖是病的處理的主要組成,對於手術和麻醉決策極為重要。在本綜述中我們介紹了對於接受VAD病人綜合的超聲心電圖評估的原理和可得到的資料。除了標準檢查,設備特異性術前、術中和術後考慮因素對於心超評估是必須的。這些包括:(1VAD植入前心臟和大血管的檢查以排除明顯的主動脈反流、三尖瓣反流、二尖瓣狹窄、卵圓孔未閉或者可能引起左VAD植入後右向左分流的其他心臟異常,心內血栓、心室疤痕、肺動脈反流、肺動脈高壓、肺栓塞和升主動脈粥樣硬化疾病;並且評估右室功能;(2VAD植入後檢查設備及再評估心臟和大血管。設備檢查的目的是用二維和彩色持續的脈衝多普樂模式確認設備完整性和心臟沒有進氣、插管的位置和開放及設備瓣膜的能力。植入後心臟檢查的目的必須是排除主動脈反流或者無包被的右向左分流,並且評估右室功能、左室卸負荷和設備對全心功能的作用。各種VAD模型有不同的基礎和操作原則,需要特別的心超評估以有利於植入設備的特性的發揮。

(彭中美   馬皓琳 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.


 

一項兒童氣管內插管位置確定方法的對照試驗:頸部活動的安全性

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:由於頸部活動引起的氣管內導管的意外移位可以導致導管進入支氣管和意外的拔管。氣管內插管甚至可以在臨床上或者X線定位下已確定適當位置後移位。

方法:1072-8歲的兒童被隨機分為3組。第1組,氣管插管至主支氣管然後退出直到聽到雙肺相等的呼吸音,然後拔出2公分。在第2組,氣管插管的位置由在到達聲門水準的氣管導管上標記規定的記號來確定。第3組,由在胸骨上切跡觸摸氣管導管頂端來確定。在所有的分組中,由纖支鏡來測量從氣管導管頂端到隆突的距離。在頸部移動時的每一個位置評估氣管導管在氣管中的相對位置(隆突為0% ,聲帶為100%)。

結果:患者在中性位的氣管導管的相對位置在123組分別為21.4% ± 6.7%46.5% ± 13.0%43.4% ± 11.1%。在第1組,頸部彎曲後氣管導管的相對位置為9.5% ± 10.3%,且5位兒童發現導管進入支氣管(14.3%)。在其他兩組未發現拔管或者導管進入支氣管。

結論:聽診來定位氣管插管的位置較中段氣管要深,可能加大頸部彎曲後氣管導管進入支氣管的風險。

(胡湘     馬皓琳 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七氟醚優先影響高階聯合區:一項志願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)能客觀地估量麻醉的主觀效應。亞麻醉劑量的揮發性麻醉藥能影響記憶相關的區域(聯合區)。在這個研究中我們測定了0.25MAC七氟醚對健康志願者局部神經元效應,並區分第一皮層區和聯合區的效應。

方法:研究0.25MAC七氟醚對16ASA I級的志願者視覺、聽覺和運動啟動的影響。在使用fMRI3特斯拉Siemens磁發電機)的情況下,用脈衝動脈自旋標記物技術測定局部腦血流(regional cerebral blood flowrCBF) 。受試者吸入氧和0.25MAC七氟醚的混合氣體,並進行標準的ASA監測。完成視覺、聽覺和運動啟動任務。測定非啟動和啟動時清醒狀態下及吸入0.25MAC七氟醚時的rCBF。計算吸入0.25MAC七氟醚時基線狀態下與視覺、聽覺和運動啟動有關的11個興趣區中rCBF的變化(δCBF)。

結果:吸入0.25MAC七氟醚時在11個興趣區中rCBF與基線的變化沒有統計學意義。在啟動時一些區域的CBF有顯著升高。然而,只有在第一、第二視覺皮層(V1V2)、丘腦、海馬和輔助的運動區域,吸入0.25MAC七氟醚且啟動時rCBF的減少是有統計學意義的(P < 0.05)

結論:亞麻醉濃度的揮發性麻醉藥能影響記憶相關區域(聯合區)。在fMRI的幫助下,此研究表明0.25MAC七氟醚主要影響第一視覺皮層、相關聯合皮層和某些其他的高階聯合皮層。

(朱慧 馬皓琳 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.


 

在豬模型上使用右美托咪定行深度鎮靜並不影響游離微血管皮瓣的活性(以微透析和組織氧張力表示)

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:在面部和頸部整形大手術後往往有必要使用深度鎮靜來防止突然的自發移動對移植肌皮瓣造成機械性損傷。合適的定位可能有助於改善移植組織的氧合和灌注。我們假設右美托咪定,一種中樞性α2激動劑以及可能是理想的術後鎮靜藥物,可能導致失神經支配皮瓣的血管收縮,從而增加組織壞死的風險。

方法:12頭豬經麻醉後,兩塊對稱的肌皮瓣被提升至每側的上腹部。在其中一塊皮瓣上將交感神經纖維從動脈上剝離(失神經支配皮瓣),而另一塊則保持不動(神經支配皮瓣)。在模擬缺血和再灌注期後,動物被隨機接受丙泊酚(n = 6)或右美托咪定(n = 6) 術後深度鎮靜。用微透析和組織氧分壓來監測皮瓣組織的代謝。每30min對透析液中的葡萄糖、乳酸和丙酮酸濃度進行測定,共進行4h

結果:右美托咪定組的平均動脈壓更高(P = 0.036)。用乳酸-丙酮酸和乳酸-葡萄糖比值(中位數範圍乳酸-丙酮酸為14.3–24.5,而乳酸-葡萄糖為

0.3–0.6)及組織氧分壓測得的皮瓣組織的代謝在整個實驗過程中保持穩定,且組間無差別。

結論:我們的資料顯示:右美托咪定即使被用於深度鎮靜,也不會對失神經支配肌皮瓣的局部灌注或組織代謝產生有害的影響。

(黃施偉 譯,馬皓琳 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.


 

七氟醚麻醉下神經肌肉阻滯和傷害性刺激對催眠監測的影響

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:關於神經肌肉阻滯(NMB)對腦電雙頻指數(BIS)的影響,有相反的結果。我們研究了兩個NMB阻滯深度對BIS,腋生聽覺誘發電位指數(AAI)以及肌電圖(EMG,用針電極從額部和顳部緊靠近BIS感測器的肌肉處獲得)的影響。

方法:20名患者均應用七氟醚進行麻醉,吸入30min達到呼氣末濃度在1.2%(基線水準)。輸注羅庫溴銨分別達到4個成串刺激中第1個肌顫搐高度降低50%(部分阻滯)和95%(深度阻滯),次序是隨機選擇的。傷害性的強直性電刺激應用於以下4種情況下:1)在基線水準(對照),23)在每個程度的NMB時,4)在新斯的明拮抗後。在每一次傷害性刺激前後2min時,分別採集BISAAIEMG

結果:BISAAI的基礎值的中位數分別為 44 (39–50)15 (14–16)。在傷害性刺激前,NMB的兩個阻滯深度均不影響BISAAIEMG。相反,與部分NMB相比較,深度NMB會改變BISAAI對傷害性刺激的反應 (BIS P = 0.01, AAI P < 0.01)。而新斯的明拮抗後(BIS P < 0.01, AAI P = 0.01) ,與基線相比(BIS P = 0.08, AAI P = 0.02)。未發現EMG顯著性增高。

結論:在七氟醚麻醉下,NMB程度影響BISAAI對傷害性的強直性電刺激的反應,而在沒有傷害性刺激的情況下,NMB並不影響BISAAI

(黃麗娜   馬皓琳 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.


抗纖維蛋白酶的水準與外科重症監護室發病率和死亡率的關係

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:抗纖維蛋白酶(AT)水準已被建議作為重症監護室(ICU)中感染性休克患者預後的預測指標。我們研究了外科ICUAT水準的時程,並驗證了AT水準可能與部分外科ICU患者的發病率、死亡率增加有關的假設。

方法:連續選取327名預計入ICU治療超過48小時的患者,每日測定AT水準。結果:入ICU時,84.1% (n = 275)患者AT水準低於正常下限;入ICU48小時內明顯升高且到第7日內恢復正常的患者從未罹患膿毒血症(n = 208)。此種AT水準升高在膿毒症患者中延遲出現。重症膿毒血症患者(n = 55)AT水準始終低於其他患者。較ICU其他患者,低水準AT患者對血製品的需求增大、器官功能障礙的最大程度更嚴重。不管入ICU時的AT水準如何,患者在ICU停留時間相似。多變數分析顯示入ICUAT水準與死亡率的增加無相關性。

結論:不論是否發生膿毒血症,入ICUAT水準很低。雖然AT水準與器官功能障礙水準及膿毒血症的嚴重程度有關,但不是外科ICU患者預後較差的獨立相關因素。

(唐李雋 馬皓琳 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.



隆凸可作為主動脈內球囊搏動定位的有用的影像學標誌

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:一般認為主動脈結是用於主動脈內球囊搏動(IABP)尖端恰當定位的最有效影像學標誌。但是這並未經過正式研究驗證。在本研究中我們評估了主動脈結是否為IABP定位的可靠影像學標誌,且將其與另一潛在影像學標誌隆凸作比較。

研究方法:我們測量了100名患者三維電腦斷層血管造影術中自遠心端主動脈弓頂點(主動脈結)至左鎖骨下動脈(LSCA)之間的距離。在另150名患者用三維電腦斷層攝片測量LSCA起點水準至隆凸水準的距離。

研究結果:以主動脈結作為影像學標誌研究的人群中有16%的患者LSCA 至主動脈結的距離<0 cm或等於0 cmLSCA至隆凸距離的中位數為42mm(範圍3663mm)。在以隆凸作為影像學標誌研究的人群中,95.3%的患者LSCA起點在隆凸之上3555mm

結論:IABP放置於主動脈結處時,對於16%的患者而言IABP距離LSCA太近,而當IABP放置於隆凸上2cm處時,對於95.3%的患者而言,IABP尖端位置放置恰當(距LSCA起點處1.53.5cm)。相對於主動脈結而言,隆凸是定位IABP更可靠的影像學標誌。

(周雅春 馬皓琳 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.


 

足月肥胖孕婦胃對水排空的研究

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:麻醉誘導前2小時健康妊娠病人和非妊娠病人飲用適當清水對胃容量並無不良影響。本研究擬比較肥胖足月非產程婦女(妊娠前體重指數>35 kg/m2)飲用50mL300mL水後胃排空的情況。

方法:選取10例肥胖、足月妊娠志願者,在交叉研究設計中使用連續胃超聲檢查和對乙醯氨基酚的吸收率評價胃的排空情況。一夜禁食後,志願者口服1.5克對乙醯氨基酚和50mL300mL清水(隨機設計),之間間隔至少二天。使用胃超聲顯像技術連續評估胃竇橫斷面面積,計算胃排空的半衰期(T[1/2])。比較飲用50mL300mL後,對乙醯氨基酚血漿濃度-時間曲線下面積(AUC)、峰濃度(Cmax)到達峰濃度的時間(tmax)

結果:妊娠前平均體重指數為41 ± 9 kg/m2。飲用300mL清水與飲用50mL清水比較,胃排空T[1/2]無顯著性差異(23 ± 11 min vs 32 ± 15 min)。在6090120分鐘時的對乙醯氨基酚AUCCmaxtmax 均無明顯差異。

結論:肥胖非產程足月孕婦飲用300mL清水後胃排空的時間較50mL清水並無延長。攝入300mL水後60min時的胃竇容量與禁食一夜後的基礎值相似。

(邱鬱薇 馬皓琳 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.


補充供氧可以提高豬正常和吻合的結腸組織氧壓,但補充晶體液無影響

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

背景資料:低組織氧壓是導致結腸手術後傷口裂開和吻合口漏的重要原因。我們作結腸吻合手術的豬模型中檢驗了補充供氧和補充液體可否提高健康的和損傷的吻合口附近以及吻合口的結腸組織氧分壓。

方法:16頭瑞士長白豬用異氟醚0.8-1.0%麻醉並機械通氣。動物隨機分組,在結腸吻合手術中及其後測定的4個小時裏,低容量治療(低組,乳酸林格氏液3ml/kg/h連續輸注)或高容量治療(高組,乳酸林格氏液10ml/kg/h單次輸注,後以18ml/kg/h維持)。在手術後兩個半小時以30%濃度的氧氣進行機械通氣,每隔30min記錄一次組織氧壓。術後3小時以100%的氧濃度進行機械通氣60min。在最後的30min中記錄組織氧壓。分別在健康結腸壁、吻合口附近2cm以及吻合口用極譜描記克拉克型電極測定組織氧分壓。

結果:在每個組中,以100%濃度的氧氣進行機械通氣時的組織氧分壓都是用30%濃度氧氣進行機械通氣時的近2倍,並且用統計學意義。高容量還是低容量晶體液輸注對於結腸組織氧壓沒有影響。

結論:補充供氧可以提高健康的、吻合口附近和吻合口的結腸組織氧壓,但補充晶體液無影響。

(沈浩   馬皓琳 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.



硬膜外腔注射自體靜脈血治療慢性頸部扭傷相關性疾患

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

背景資料:慢性頸部扭傷相關性疾患(WAD)患者,儘管沒有客觀存在的神經功能缺損,仍主訴有諸如頭痛、眩暈及噁心的症狀。腦脊液滲漏(CSF)的患者也常會經歷這些症狀。最近有報導:放射性同位素(RI) 腦池造影術有助於診斷因CSF滲漏引起的顱內低壓。我們使用 RI腦池造影術研究了慢性WADCSF滲漏之間的關係,並評估了使用硬膜外腔注射自體靜脈血(EBP)對治療慢性WAD是否有效。

方法:我們研究了66位症狀超過3個月的慢性WAD患者。所有的患者均經RI腦池造影來測定CSF滲漏的存在。對於確診有CSF滲漏的患者,使用EBP治療。在EBP治療前、治療後1周及6個月的時候評估症狀。同時評估其工作狀態並隨訪RI腦池造影。

結果:66位元患者中,37位元顯示了存在CSF滲漏,其中36位患者接受了2.2 ± 0.7EBP治療。症狀平均持續33個月。與治療前相比,EBP治療後1周,存在症狀的患者的百分比明顯下降;頭痛:100%17%,記憶缺失:94%28%,眩暈:83%47%,視覺損傷:81%25%,噁心:78%42% (P < 0.01)。在6個月後的隨訪檢查中也觀察到這些療效(P < 0.01)。隨訪發現其工作狀態也有明顯改善。

結論:我們得出結論:對於某些慢性WAD患者,需考慮CSF滲漏的因素,而EBP治療對於慢性WAD是有效的。

(裘毅敏譯,馬皓琳,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 的坐骨神經阻滯:對大鼠無髓鞘神經纖維的 電子顯微鏡研究

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:神經周圍給予天然存在的vanilloids (辣椒素, resiniferatoxin [RTX]) 可以產生選擇性傷害性疼痛的阻滯作用。在神經周圍給予高濃度vanilloids的研究發現,它們可導致無髓鞘神經纖維退行性變。但是,使用電子顯微鏡研究vanilloid的局部毒性,結果則與此相反。在本研究中,我們擬確定RTX誘發的可逆性坐骨神經阻滯是否可以導致無髓鞘神經纖維退行性變。

方法:在大鼠實驗中,經皮在坐骨神經給予RTX。用測定大鼠對傷害性熱刺激的反應來監測RTX的作用。阻滯起效後48小時,取出坐骨神經。在三組動物中,RTX 0.0001% (0.1 µg)RTX 0.001% (1 µg)和對照組(RTX 溶劑, 0.1 mL),對無髓鞘神經纖維進行定量電子顯微鏡分析。

結果:RTX誘發的可逆性神經阻滯開始後48小時,坐骨神經的橫切面基本是正常的。一個很罕見的發現是無髓鞘神經軸突上有不規則的緊密膜狀沉積物。在兩種不同濃度RTX時的這種情況發生率均近1‰

結果:研究結果說明RTX可以提供選擇性長時效坐骨神經阻滯(最長2周),對無髓鞘神經纖維沒有明顯損害。

(張瑩   馬皓琳 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.



不管電刺激高於還是低於0.5mA超聲引導下的肌間溝置針都能產生成功的麻醉

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:我們定量檢測了超聲引導下置針用於肌間溝阻滯(ISB)後不同電流強度引起的反應。然後我們比較了高於或低於0.5mA的電刺激反應下不同的阻滯特徵。

方法:這次前瞻性觀測性的研究包括了61位擇期在ISB和全麻下行非住院肩關節手術的病人。術前一根絕緣的探針通過超聲引導放置在了肌間溝。在測定了能夠引起運動反應的最低電流量後,注射加入腎上腺素的30ml 0.5%的布比卡因。全麻誘導前測定在上軀幹分佈的運動和感覺阻滯範圍15min。術後記錄上軀幹阻滯成功率、麻醉後復蘇室中的疼痛評分、阻滯持續時間和術後整夜的止痛藥片消耗量。病人事先被分成A組(電流強度≤0.5 mA)和B組(電流強度>0.5 mA),比較兩組之間的結果。

結果:觀測的電流變化在0.14–1.7 mA,其中42%的病人電流≤0.5 mAA組)。所有的病人上軀幹運動感覺阻滯都很完全,在麻醉後復蘇室中不需要麻醉藥物。兩組的麻醉持續時間(17.8 ± 4.9 h,平均值±標準差)和在家中止痛藥需求量相當。兩組感覺阻滯起效時間相當,但B組在15min時的不完全運動阻滯發生率更高(B37%A12%P=0.03)。

結論:用神經刺激的超聲引導下ISB過程中,在電流大於或小於0.5mA觀察到的運動反應不影響上軀幹阻滯的成功率和持續時間。

(姜旭暉譯  馬皓琳 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.



持續正壓通氣呼吸可以增加頸胸段硬膜外注射利多卡因後的感覺阻滯頭向擴散

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:持續正壓通氣(CPAP)可以增加低胸段硬膜外注射利多卡因後的感覺阻滯尾向擴散。我們假設,CPAP會增加頸胸段硬膜外注射後阻滯頭向擴散。

方法:二十例硬膜外導管位於C6-7C7-T1間隙的病人,在環境壓力下呼吸(對照組)或用7.5cm水柱CPAP呼吸時給予一個硬膜外劑量的利多卡因。注射後,我們評估了感覺阻滯平面的擴散。並記錄注射前後肺量參數。

結果:資料以中位數(25%-75%範圍)值表示。感覺神經阻滯的平面對照組在C7 (C4–7) T4 (T4–6)CPAP組在C2 (C2–4)T4 (T2–5) (P = 0.003)。總的阻滯節段數在對照組和CPAP組分別為7.5 (6.8–9.8)10 (8–12) (P = 0.13)。從阻滯點頭向阻滯節段數在對照組和CPAP組分別為1(0.8–3.5)5 (3.5–7)(P = 0.006))。達到最高腦神經阻滯(上到C2)的病人數在對照組和CPAP組分別為一位和七位(P = 0.02)。兩組病人的肺量值均有較小的但顯著的下降,組間無差異。

結論:和環境壓力下呼吸相比,在頸胸段硬膜外利多卡因麻醉時提供CPAP可以增加感覺阻滯的頭向擴散。

(黃佳佳譯,馬皓琳 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.

 

減少圍手術期血栓併發症:肝素導致的血小板減少症(HIT)的新進展

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.

 

肝素被廣泛的用於圍手術的處理。肝素免疫導致的HIT是一嚴重的抗體介導的併發症,它在肝素治療5天以上病人中的發生率大約在0.5%-5%。在明顯的栓前障礙下,在發生的病人中HIT有發生血栓及加重後果的嚴重危險:大約38%-76%發生血栓,發生血栓的大約需要截肢,而大約20%-30%死於1個月內。HIT抗體存在短暫,一般3個月內消失。在抗體延時的病人中,肝素的再暴露可能是致命的。在圍手術的處理中,加強對HIT的及時辨別、診斷和治療是重要的。如果在肝素使用5-14天后血小板數量下降50%和或血栓發生,HIT當被考慮,在排除其他診斷的情況下。嚴重懷疑HIT的,即使在實驗室確診HIT之前,肝素即可停用,並應用腸外抗凝治療。實驗室檢驗結果可以幫助決定繼續非肝素化治療還是轉回使用肝素。在多數情況下,近期或當前有HIT的病人避免使用肝素是可行的。除了心血管手術。如果在HIT抗體未消失時手術不能延時,術中抗凝是可取的。

(陳勇柱譯 薛張綱校)

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.

                                                     

 

 

異丙酚輸注濃度變化對麻醉小兒血漿cGMP濃度的影響

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.

 

谷氨酸鹽-NO-cGMP通路是全身麻醉藥物的有效作用靶點。在健康成年志願者鎮靜期間血漿異丙酚濃度升高後伴隨血漿cGMP的降低。我們推測在麻醉的小兒中血漿異丙酚濃度升高能夠導致血漿cGMP濃度降低。方法:18例既往健康、年齡46.8+/19.6月、需要全身麻醉、下腹部手術患兒。吸入誘導後行氣管插管、間歇正壓通氣、骶部硬膜外麻醉。麻醉維持採用連續異丙酚輸注,按照先前的方案以達到預計血漿異丙酚濃度:分別在30min50imn70min達到631.5mg/ml。收集血漿標本,採用高效液相色譜法和免疫分析法測量異丙酚和cGMP濃度。結果:在每個預計血漿濃度點血漿cGMP濃度明顯改變分別為19.211.8-23.5),21.314.6-30.8),24.915.7-37.8nmol/L,相關係數為-0.62。結論:健康小兒中血漿異丙酚濃度增加可導致血漿cGMP濃度降低,血漿cGMP濃度可作為異丙酚麻醉深度的生化指標。

(吳德華譯 薛張綱校) 

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.

 

 

對羅呱卡因作用於離體豚鼠心臟標本產生的毒性作用使用左西孟旦的強心功能

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.

 

背景左西孟旦是一種作用於心衰的新型強心藥但其對於局麻藥導致的心肌抑制作用尚未知。因此,我們研究了左西孟旦對於羅呱卡因在離體豚鼠心臟標本產生的負性強心效應的作用。方法:使用傳統方法測量了豚鼠乳頭肌的動作電位和收縮力。心率、收縮壓、+dP/dtmax、冠脈血流及PRQRS間期被測量於離體恒壓灌流、非再迴圈豚鼠心臟標本。單獨或累積的左西孟旦及羅呱卡因濃度增加被單獨或聯合應用。結果:在離體乳頭肌,羅呱卡因導致濃度依賴的收縮力改變。使用10µM左西孟旦可以幾乎完全反轉使用10µM羅呱卡因產生的負性強心作用。左西孟旦產生的強心作用的敏感性不會被10µM的羅呱卡因所改變。動作電位只有在最高濃度的時候被影響。在豚鼠心臟,左西孟旦顯著的反轉了羅呱卡因產生的心率、收縮壓、冠脈血流及+dP/dtmax減少,使回復至基線值。結論:對於羅呱卡因產生的心肌抑制,左西孟旦是一種有效的強心藥,且其心肌敏感性、效能並不被局麻藥所影響。我們的結果提示左西孟旦的鈣增敏反應可有效的作用於局麻藥產生的心肌抑制。

 (孫霞譯 薛張綱校)                                                                             

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.

大鼠脊髓內腦脊液中鈉離子濃度改變對異氟醚MAC的影響

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:過去的研究表明氟烷的MAC值(50%的受試者對傷害性刺激無反映的吸入麻醉藥最低肺泡濃度)與中樞神經系統的鈉離子濃度直接相關。然而,這些研究改變了鈉離子的總濃度,但對脊髓和大腦的影響並沒有很好的區分。這裏存在明顯的區別,因為脊索是吸入麻醉藥產生制動作用的初級介導場所。相應的,在這個研究中,我們檢測了不同鞘內鈉離子濃度對比腦室內鈉離子濃度對MAC的影響。方法:我們通過大鼠身上的留置管或留置針在腰椎的蛛網膜下腔和腦室內注射無鈉溶液或重鈉溶液,並分別在注射前、注射中和注射後測量異氟醚的MAC值。結果:異氟醚的MAC值與鞘內注射的鈉離子濃度有關,而與腦室內注射的鈉離子濃度無關。結論:這一結果與通過鈉離子通道對MAC的介導或調節一致。這些包括電壓門控通道、配體門控通道和其他鈉離子敏感靶位。(例如:離子泵、轉運體、交換體)

(王時來譯 薛張綱校)

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).

 

 

用傳統的紅外線臨床氣體分析儀測量血液中的麻醉氣體

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:通常我們用氣相色譜分析的頂空平衡方法來測定血液中的吸入麻醉氣體分壓,但是由於技術、設備和後勤要求等原因在臨床工作中我們不常應用這種方法。為了使這種測量更可行,我們嘗試使用一種傳統的紅外線氣體分析儀:Datex-Ohmeda Capnomac。方法:在描述了這個儀器測量吸入麻醉氣體的濃度相對於一氧化二氮、二氧化碳和水蒸氣的線性關係後,血液被含有已知濃度七氟醚(0.5%5%)的氧氣和笑氣氧氣混合充滿,或者被同時含有異氟醚和地氟醚的氧氣充滿。結果:測得氧氣中七氟醚的濃度相對于張力儀測得的參考分壓值的偏差是-4.5(4.8%),這在40%氧氣混合60%笑氣中的變化不大。異氟醚和地氟醚相對於實際濃度的偏差分別為-3.9 (3.3%) -4.6 (3.8%)。結論:用臨床紅外線氣體分析儀的雙頂空平衡技術測量血液中吸入麻醉氣體分壓的精確度可以和之前我們研究所用的氣相色譜分析儀相媲美。

( 楊譯 薛張綱校)

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.

 

動脈球囊阻塞控制骶骨手術術中出血

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.

 

骶骨根治性手術會導致術中致命性的出血量。控制這種出血的安全有效的方法仍未發現。我們在這裏報導一種可充氣的膠質球囊的使用,它可以間斷地阻塞遠端腹主動脈,控制骶骨腫瘤切除術中失血量。球囊導管經過股動脈引導進入腹主動脈。通過測量雙足趾的血氧飽和度和超聲定位來指導並確定球囊在腹主動脈的腎動脈以下段。球囊每充氣60分鐘要放氣10分鐘。在5個進行骶骨腫瘤切除的病人中,使用球囊阻塞的病人估計出血量<300ml,手術時間<2小時。術後腎功能無明顯變化,盆腔器官和下肢功能完好。經皮動脈球囊阻塞可以提供安全有效的骶骨腫瘤切除術術中的失血量。

(陳佳莉譯 薛張綱校)

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.

 

 

選擇性肺複張對於嚴重低血容量患者的血流動力學是否安全?一項在肺萎陷豬的動物模型關於低血容量的試驗性研究。

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:我們先前已經顯示,在正常血容量的實驗豬,選擇性肺複張(S-LRM),即在帶囊氣管導管的頂端插入萎陷肺側的支氣管中,並經此吹入空氧混合氣,可以有效改善氧合和肺容量,並且鮮有血流動力血方面的副作用。在這項研究中,我們研究了迴圈尚可維持的低血容量條件下,S-LRM對於呼吸和迴圈的影響。方法:8只麻醉了的實驗豬給予通氣(Fio2 1.0),將帶囊的氣管導管插入右下肺葉支氣管中,肺葉選擇性灌洗以產生更好的肺葉萎陷。分別在正常血容量、靜脈放血20%、40%血容量時,給予實驗豬S-LRM。測定在S-LRM之前、當時、之後的血氣、呼吸系統順應性、血管壓力、心排量。結果:PaO2、靜脈混合血、呼吸系統順應性在S-LRM的三個容量水平均有顯著改善。在正常血容量和減少20%血容量時,S-LRM組的血流動力學沒有改變。在減少40%血容量時,S-LRM組心排量沒有改變,平均動脈壓輕度降低:S-LRM之前3分鐘時48 (37–52) mm Hg (平均, 2575百分位數), S-LRM 剛結束時40 (35–44) mm Hg (P = 0.0207), S-LRM之後3分鐘時47 (39–54) mm Hg 。結論:S-LRM可以有效改善氧合作用和呼吸系統順應性,對於迴圈只有很小的副作用,甚至在肺萎陷的動物模型出現嚴重低血容量時也是如此。

(陳珺珺譯 薛張綱校)

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.

 

 

豬大腦皮層在顱內壓增高伴腦血流降低時的腦代謝

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:顱內壓的增高伴隨著腦血流的減少,並會影響氧供和輸出。在這個研究裏,我們監測豬的大腦皮層在顱內壓增高時的能量依賴性代謝,並找出在什麼水準會產生傷害。方法:將32-40kg的馴養公豬麻醉,機械通氣,並將其隨機的分為實驗組(六隻)和對照組(五隻)。將一個微量測析探針放入大腦皮質測量細胞外液中乳酸、丙酮酸、谷氨酸、丙三純的濃度。每小時向腦室系統打入一定量的人工腦脊液以升高10mmhg的顱內壓,直到達到最高值50mmhg。結果:當顱內壓大於等於30mmhg、腦灌注壓力低於50mmhg時,可以檢測到乳酸、丙三醇的顯著上升。當顱內壓大於等於40mmhg、腦灌注壓低于40mmhg時,乳酸丙酮酸比值及谷氨酸值顯著上升,而糖的水準明顯下降。結論:資料可以證明,ICPCPP可能產生危害的臨界值分別為30mmhg40mmhg

(秦 佳譯 薛張剛校)

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.

                                                       

 

東莨菪堿透皮給藥預防蛛網膜下腔用嗎啡導致的剖宮產術後噁心嘔吐

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:蛛網膜下腔用嗎啡是剖宮產術後極佳的鎮痛方式,但導致明顯的噁心嘔吐。方法:比較術後最初24小時透皮給東莨菪堿、靜注昂丹思瓊和安慰劑的鎮吐效能。240名接受脊麻的剖宮產婦隨機分配,研究設計為雙盲,在斷臍時給東莨菪堿1.5mg、昂丹思瓊4mg或安慰劑。結果:研究顯示安慰劑組嘔吐發生率59.3%,東莨菪堿組降低至40%,昂丹思瓊組降低至41.8%。與安慰劑相比,東莨菪堿組在6-24小時嘔吐率下降最明顯。結論:東莨菪堿對接受蛛網膜下腔嗎啡鎮痛的剖宮產婦是有效的預防用藥。然而它的使用與口幹、視力模糊等副作用較高的發生率有關。

(羅 璿譯 薛張綱校)

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.

 

 

一項系統性回顧:患者回饋關於術後鎮痛作用的結果

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:術後患者回饋的鎮痛效果,包括生活品質、恢復品質、患者滿意度,到目前為止還沒有系統性的評測過。這些結果是根據患者的個人看法測評,並且被認為有效的最終臨床研究結果。我們進行了一項系統性的回顧調查來檢測患者術後回饋的鎮痛效果。方法:醫學檢索系統國立圖書館和Cochrane圖書館資料庫對近十年的資料進行檢索(19966月至20061月)。醫學文獻檢索系統同時搜索了一些結果,包括滿意度、生活品質、恢復品質。

結果:局部鎮痛技術與全身使用阿片類藥物相比,在統計學上鎮痛效果更好。部分由於重要的方法問題,資料不足以評估鎮痛的類型、鎮痛的程度以及副作用是否會影響生活品質、滿意度以及住院天數。結論:雖然有資料顯示改進術後鎮痛可以提高患者的回饋結果,但是住院患者中心的結果關於生活品質以及恢復品質有所改善的證據仍然不足。適當的減低疼痛評分實際上並不等同於臨床上有意義的疼痛改善。需要進一步的研究來驗證病人回饋方法的有效性,評估整個圍手術期患者回饋的鎮痛效果。

(王光妍譯 薛張綱校)

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.

 

 

經腹全子宮切除術後使用帕瑞考西以增加鞘內注射嗎啡的鎮痛效果

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:帕瑞考西的使用連同鞘內注射嗎啡和布比卡因可能可以增加鎮痛效果,減少嗎啡的阿片類物質相關的副反應。方法:在這項前瞻性,雙盲,隨機,安慰劑對照實驗中,經腹全子宮切除的患者在鞘內注射布比卡因和0.2mg嗎啡之前先靜脈注射生理鹽水或者40mg帕瑞考西。12小時後,重複給藥一次。觀察患者48小時。結果:鞘內注射布比卡因和嗎啡之外額外使用帕瑞考西可以顯著減少術後24小時累計的嗎啡消耗量,降低視覺痛覺評分,以及提升的患者滿意程度,並且不伴有明顯增加的副作用。結論:圍術期給與帕瑞考西可以增強鞘內注射嗎啡和布比卡因的術後鎮痛效果和改善患者舒適度。

(周時蓓譯 薛張綱校)

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.

                                                            

 

末梢神經性疼痛的病理生理:免疫細胞與分子

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:對於末梢神經系統的損傷通常導致慢性的神經性疼痛,表現為自發性疼痛和(或)對於疼痛或無害刺激的過度反應。這種疼痛的狀態使病人感到極其虛弱並且很難得到治療。儘管炎症性疼痛與神經性疼痛通常被認為是兩個分離的事件,有證據卻顯示出了與這種嚴格的二分法不同的結果。炎症是一種極具特徵性的現象,涉及到一系列不同的免疫細胞類型,如:肥大細胞、中性粒細胞、巨噬細胞及T淋巴細胞。另外,這些細胞也釋放許多導致疼痛的複合物。最近有證據顯示免疫細胞在末梢的神經性疼痛中起到一定的作用。在這篇綜述裏,我們鑒別各種不同的導致末梢神經性疼痛的免疫細胞以及在這種特殊狀況下起到關鍵作用的各種釋放因數。

(吳威譯 薛張綱校)

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,鞘內注射羅呱卡因的藥代動力學和生物利用度

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:羅呱卡因通過不同神經軸索阻滯用於硬膜外術後鎮痛.由於這些技術的廣泛使用和局麻藥在髓內分佈資料的相對貧乏,我們通過一個動物模型來評估羅呱卡因的髓內分佈,從而更多的研究羅呱卡因鞘內生物利用度的影響因素.方法:羊靜脈注射50mg羅呱卡因,一周後鞘內注射20mg羅呱卡因3h後硬膜外注射羅呱卡因100mg,通過同步微量滲析技術測量硬膜外和鞘內注射後硬膜外和鞘內的藥物濃度 。結果:吸收-時間曲線提示在鞘內和硬膜外注射後全身吸收有很大的變異性,但鞘內注射的吸收速度明顯快於硬膜外.在蛛網膜下腔,消除率比分佈率要高出近三倍.而在硬膜外腔隙,清除和分佈對於羅呱卡因的分佈作用有所不同,提示分佈過程的影響較大.硬膜外注射後鞘內的生物利用度為11.1% +/- 7.6%. 結論:通過動物模型,我們發現藥物在鞘內和硬膜外的分佈是不同的,硬膜外注射羅呱卡因的鞘內生物利用度是低的且存在較大的差異性.

(陳愷錚譯 薛張綱校)

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.

無麻醉作用的惰性氣體通過啟動促存活信號激酶和抑制線粒跨膜通道通透性途徑對心梗後心肌產生保護作用

 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:麻醉惰性氣體--氙氣具有心臟保護作用。作者假設其他沒有麻醉作用的惰性氣體[He、氖Ne、氬Ar]同樣具有心臟保護作用,並進一步假設所產生的心臟保護作用是通過啟動促存活信號激酶[包括三磷酸肌醇激酶、細胞外信號調節激酶和70-kDa核糖體蛋白s6激酶]以及抑制體內線粒體膜通道通透性[mPTP]的開放所介導。

方法:對98只家兔進行血流動力學監測,阻塞左前降支冠狀動脈30min後給予3小時的0.9%生理鹽水再灌注(對照組);在左前降支阻塞前給予370%HeNeAr 30%氧氣5分鐘並間斷給與70%氮氣-30%氧氣5分鐘,或長時間的左前降支阻塞及再灌注前給於三輪短暫的(5分鐘)缺血刺激並間斷給予5分鐘再灌注(缺血預適應組)。另外無論是否給予He預處理,選擇性給予每組家兔三磷酸肌醇激酶抑制劑(渥曼青黴素0.6mg/kg,細胞外信號調節激酶抑制劑  (PD098059 2mg/kg), 70-kDa核糖體蛋白s6激酶抑制劑(雷帕黴素0.25mg/kg, 或線粒體膜通道開放劑(蒼術苷5mg/kg)

結果:使用氦、氖、氬和缺血預適應組顯著降低了梗阻面積(用氯化三苯基四氮唑(TTC)確定心肌梗死範圍),左室面積(平均值±標準差)分別為23%±4%20%±3%22%±2%17%±3%;而對照組為45%±5%渥曼青黴素(wortmanninPI3K家族激酶特異抑制劑)、PD098059、雷帕黴素(Rapamycin) 蒼術苷(atractylosideMPT 孔道開放劑)均不影響梗死面積,但這些藥能抑制He所產生的心肌保護作用。

結論:沒有麻醉作用的惰性氣體可以通過啟動促存活信號激酶,以及抑制家兔體內線粒體膜通透性通道的開放等作用產生心肌保護的作用。

(陶穎瑩 陳傑 )

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.

 

心臟手術中偶然發現的卵圓孔未閉是否需要修補?

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. [

 

隨著術中經食道超聲心動圖應用增加,心臟手術中常發現卵圓孔未閉。由於術中診斷卵圓孔未閉對術後結局的影響尚未知曉,使心臟外科醫生陷入兩難的境地。改變手術方案修補卵圓孔未閉使患者面臨風險增加。而另一方面,不修補卵圓孔使患者面臨未知的即刻與長期不良結果。目前決定是否修補卵圓孔取決於臨床醫生個人偏好、術中術後低氧血症的可能性、以及任何與最初手術方案的偏差。多數臨床醫生同意如果手術有導致低氧血症的高危風險(例如安置左心室輔助裝置,心臟移植),則必須修補術中診斷出的卵圓孔未閉;心臟手術期間不進行心房切開和上下腔靜脈插管的操作可使卵圓孔未閉相關的圍術期和遠期併發症增加,因而建議應該關閉卵圓孔。經皮卵圓孔未閉修補技術為卵圓孔未閉未修補而術後低氧血症或其他併發症可能導致無法修補卵圓孔的案例提供有價值的替代方案。

(周懿之 陳傑 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.

 

健康受試者吸入七氟醚後晚期預處理效果的分子學證據

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:揮發性麻醉藥的預處理晚期作用涉及到對轉錄改變的應答。作者假設吸入七氟醚將改變人血液細胞的轉錄,並調整白細胞黏附分子的表達,這與晚期預處理時的發現一致。

方法:五名健康男性受試者持續吸入濃度0.5%-1.0%的七氟醚60min。分別在吸入前,吸入後15min60min及此後的6h24h48h採集靜脈血樣本,並立即用流式細胞儀進行細胞計數,提取mRNA並與Affymetrix U133 Plus 2.0 微點陣雜交。資料應用微點陣顯著性分析、基因位點濃縮分析和即時逆轉錄聚合酶連反應分析。L-選擇蛋白(CD62L,B2-整合蛋白(CD11b)的表達通過流式細胞儀計算粒細胞和單核細胞數來確定。

結果:吸入七氟醚能迅速地、顯著地改變白細胞的基因表達。包括對氧磷酸酶、12-脂肪氧化酶、熱休克蛋白40、趨化因數配體5、磷酸二酯酶5A的關鍵轉錄物在七氟醚作用下的調整可能涉及到晚期預處理或器官保護。七氟醚進一步降低涉及過氧化物酶體增值子受體共激動劑-1aPGC-1a)信號和脂肪酸氧化的轉錄。降低粒細胞L-選擇蛋白的表達伴隨著增加抑制炎症反應啟動能力,在吸入七氟醚24-48小時後表現出來。

結論:七氟醚在亞麻醉濃度能改變血細胞轉錄,減少促炎因數L-選擇蛋白的表達,符合人的“第二視窗保護作用

(潘方立 陳傑 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.

 

蘭替洛爾—超短效β1受體拮抗劑不改變豬異氟醚的最小肺泡有效濃度

 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:作者先前曾報導過超短效β1受體拮抗劑—蘭替洛爾不改變異氟醚的腦電效應。本文作者研究蘭替洛爾對能夠防止50%受試者對有害刺激產生體動反應的異氟醚的MAC的影響。

技術:十隻豬(29.0±3.4kg)施行異氟醚吸入麻醉。通過使用懸蹄夾技術記錄夾緊時的體動確定MAC。測定MAC後,開始輸注蘭替洛爾(第1分鐘0.125mg·kg-1·min-1,然後0.04 mg·kg-1·min-1)。經過20分鐘的穩定期,再次評估MAC(蘭替洛爾0.04 mg·kg-1·min-1)。然後蘭替洛爾的輸注速度從0.04 mg·kg-1·min-1提高到0.2mg·kg-1·min-1,經過20分鐘的穩定期,再次評估MAC0.2 mg·kg-1·min-1)。最後,停止輸注蘭替洛爾,經過20分鐘穩定期第四次評估MAC(基線2)。

結果:蘭替洛爾明顯減弱懸蹄夾刺激時的心率和平均動脈壓升高效應,但並不改變異氟醚的MAC

結論:蘭替洛爾不改變異氟醚的抗傷害效應。這個結果結合作者先前的工作,提示了蘭替洛爾不影響吸入麻醉藥的麻醉效能。

(丁震敏 陳傑)

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.

 

酮體(β羥基丁酸和丙酮)的麻醉學特性

 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:作者驗證如下假說――酮症酸中毒發生過程中的兩個蓄積代謝產物(β羥基丁酸和丙酮)具有類似麻醉藥物的作用方式改變離子通道,且在動物身上產生麻醉效果。

方法:在非洲蟾蜍卵母細胞上分別有α1β2γ2sA型γ-氨基丁酸(GABAA)、α1甘氨酸、NR1/NR2A N-甲基-D-天(門)冬氨酸和雙孔域TRESK通道的表達。作者使用雙電極電壓鉗技術進行研究,測量β羥基丁酸和丙酮對通道功能的效應。並在非洲蟾蜍的蝌蚪上測量兩者的麻醉效應。

結果:在引起人體酮症酸中毒的濃度範圍內,β羥基丁酸和丙酮都增強了甘氨酸受體功能。β羥基丁酸也在此濃度範圍內增強了GABAA 受體功能。兩者在蝌蚪上都產生了麻醉效應,EC50值分別為:β羥基丁酸151±11mM(均數±標準差)和丙酮264±2mM(均數±標準差)。丙酮在濃度大等於50mM時有增強GABAA受體作用,在濃度大等於100mM時可見其抑制TRESK通道功能的現象,在濃度大等於200mM時則可抑制NMDA受體功能。

結論:β羥基丁酸和丙酮都有麻醉效應。兩種酮體在產生臨床表現的酮症酸中毒濃度範圍內都增強了對甘氨酸受體的抑制作用。另外,β羥基丁酸也在此濃度範圍內增強了GABAA 受體功能。在亞麻醉效應濃度下,兩者可能產生伴隨酮症而表現的昏睡和意識減退。

(於章傑 陳傑 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.

 

全身麻醉期間呼出一氧化碳的水準與吸入氧濃度的關係

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:血紅素加氧酶降解亞鐵血紅素時會產生一氧化碳。許多應激因素會上調這種酶的活性並提高呼出氣一氧化碳的水準。最近,有報導顯示在麻醉和手術後的患者及危重症患者中呼出一氧化碳的水準是提高的,為了監測機械通氣期間的一氧化碳水準,闡明影響呼出氣一氧化碳水準的相關因素是十分重要的。人工通氣時吸入氧濃度是經常變化的。為了研究吸入氧濃度的變化對呼出一氧化碳水準的影響,作者監測了全身麻醉過程中呼出氣一氧化碳的水準。

方法:30名擇期手術的患者入選本研究,麻醉維持使用七氟醚和芬太尼,所有患者都進行氣管插管並行非複吸通氣。在呼吸回路的分岔口使用一氧化碳監測儀來監測呼出氣一氧化碳的水準,從而研究吸入氧濃度對呼出一氧化碳水準的影響,長時間吸入75%和35%氧時對呼出一氧化碳水準和動脈碳氧血紅蛋白濃度的影響。

結果:呼出氣一氧化碳的水準隨著氧濃度的改變而迅速改變。長時間吸入75%氧氣時在最初會增加呼出氣一氧化碳的水準,但繼之逐漸下降並伴有動脈碳氧血紅蛋白的減少。而長時間吸入35%氧氣時不會產生這些改變。

結論:在機械通氣期間監測呼出氣一氧化碳的水準時,考慮吸入氧濃度產生的影響是十分重要的。

(詹瓊慧 陳傑 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.

 

 羥乙基澱粉:分子量和取代級對血管內貯留的影響

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:羥乙基澱粉(HES) 的特性由其平均分子量(MW),濃度和取代級(DS)等決定。這一特性不斷地變化。

方法:HES與異硫氰酸螢光素結合形成FITC-HES之後,在一個輕度失血的模型中(失血量占血容量的10%)應用活體顯微鏡檢查小鼠的提睾肌A2V2血管,以此來評估三種6%HES濃度。在抽血建立輕度失血模型後,分別輸入三種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),然後利用活體顯微鏡檢查測定FITC-HES留率。

結果: V2血管輸注後120MinFITC-HES留率分別為: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在血管內留的時間長(HES-BHES-A相比,V2P=0.028 A2P0.038HES-CHES-A相比, V2P=0.022A2P0.037)。HES-BHES-C的血管消除率無明顯差異。

結論: HES-BHES-C在血管中留的時間相似。低DS和中度DS的中等分子量HESB和大分子量的HES在血管中留的時間相同。因此,應研究不同種類HES變化特徵以此優化HES輸注。

(楊衛紅 陳傑 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.

 

毒扁豆堿逆轉成年小鼠由於中度缺氧引起的認知功能障礙

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:齧齒類動物由於中度缺氧產生的相關認知功能改變可能與中樞膽鹼能神經傳導功能的減退有關。本文作者通過實驗來研究毒扁豆堿——一種乙醯膽鹼酯酶抑制劑,是否能夠改善低氧性缺氧後的活動記憶。

方法:90只體重在3035g,6-8周的Swiss Webster小鼠隨機分在三個低氧組,吸入氧濃度FiO20.10(組1:未經任何處理;組2:試驗最初腹腔內注射毒扁豆堿0.1mg/kg;組3:缺氧後腹腔內注射毒扁豆堿0.1mg/kg),或隨機分在兩個室內空氣組,一組在缺氧發作後未予任何處理,另一組給予毒扁豆堿。一次實物認知測試用來評估短期的記憶功能。測試中觀察小鼠探究新夥伴的傾向,試驗中,另一隻相似的小鼠也同樣參與其中。在15分鐘的嘗試試驗中,兩隻相同的小鼠被分別安置在箱子的兩處特定區域。嘗試試驗進行1小時後,其中一隻小鼠被一隻外形完全不同的小鼠所替代。兩隻試驗小鼠在整個試驗過程中表現由攝像機及相關電腦程式全程監視。資料結果進行方差分析,如需要的話,還可以繼續用NewmanKeuls測試進行事後比較。P<0.05有顯著性差異。

結果:試驗第一天,在FiO20.10的缺氧狀態下,未處理小鼠比起呼吸室內空氣的未處理小鼠,所花費的認識新夥伴的時間要短的多。而同樣在缺氧的環境中,事後給予毒扁豆堿的試驗小鼠,缺氧對其的影響與對照組相比沒有明顯差別。

結論:通過活動記憶評估發現,中度缺氧會損害到齧齒動物的行為表現。但是影響是短期的,因為在給予治療後,小鼠認知功能在7天后可以回復到正常水準。缺氧發作後給予毒扁豆堿可以預防認知功能的下降。中樞神經系統乙醯膽鹼水準的升高可能與缺氧小鼠給藥後行為改善有關。

(杜唯佳 陳傑 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.

 

局麻藥和分娩方式:布比卡因、羅呱卡因及左旋布比卡因的比較

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:硬膜外局麻藥對產婦分娩方式的影響研究並不多。在這項研究中,作者研究布比卡因、羅呱卡因及左旋布比卡因進行硬膜外分娩鎮痛中,分娩方式是否不同。

方法:要求無痛分娩的初產婦在宮口擴張<5cm時隨機接受布比卡因或羅呱卡因或左旋布比卡因進行硬膜外鎮痛。鎮痛方法:單次注射15ml 0.0625%的指定局麻藥複合芬太尼2ug/ml,隨後以10ml/h的速度輸注同種局麻藥維持鎮痛。主要觀察是手術分娩率(包括器械輔助的陰道分娩和剖宮產分娩)

結果:98名接受了布比卡因,90名接受了羅呱卡因,34名接受了左旋布比卡因(在其從美國市場淘汰之前)。結果所有組中手術分娩率方面沒有顯著的不同(布比卡因是46%,羅呱卡因是39%,左旋布比卡因是32%,p=0.35)。與羅呱卡因及布比卡因兩組相比,左旋布比卡因的運動阻滯更少(p<0.05)。三組中第一及第二產程的持續時間,產程中接受的每小時局麻藥的總量,及對新生兒的影響沒有顯著的區別.

結論:布比卡因,羅呱卡因及左旋布比卡因都適用於硬膜外分娩鎮痛,同時對分娩方式、產程的持續時間及對新生兒沒有顯著的影響。

(潘錢玲 陳傑 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.

 

成人肝移植期間在再灌注前、再灌注後早期、再灌注後晚期3個時期高鉀血症的預測

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:高鉀血症對接受原位肝移植的病人構成嚴重的危害,且不易預測。

方法:作者回顧性研究了1124例接受原位肝移植的成年病人。高鉀血症定義為血清[K] ≥5.5/L。在單變數分析中,共有47個受體,供體,手術不同期及實驗室指標用來做多變數初始分析。在原位肝移植3個時期(再灌注前,再灌注後早期,再灌注後晚期)高鉀血症的獨立預測是由多元對數回歸分析來決定的。

結果1124個病人中,在再灌注前,再灌注後早期,再灌注後晚期中分別有10.2%19.1%7.9%的病人發生高鉀血症。高基礎血K和輸血為獨立預測再灌注前高鉀血症。高基礎血K(或再灌注前高基礎血K)和心臟病死亡供體為獨立預測再灌注後早期高鉀血症。高基礎血K,熱缺血時間,供體較長的住院時間,術中尿量減少,靜脈轉流等為再灌注後晚期高鉀血症獨立預測因數。

結論:數個實驗室指標,手術不同時期和不同類別供體可作為不同時期高鉀血症的獨立預測因數。上述結果有助於為成人原位肝移植中有高鉀血症危險的病人更有針對性的超前治療。

(張燕 陳傑 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.


矯形外科中原發性痛覺過敏的演變全膝關節成形術前後定量感覺測試和臨床評價

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:定量感覺測試(QST)能發現微小的感覺缺失和疼痛,並額外提供了術後疼痛的病理生理學資訊。

方法: 20位擇期行膝關節成形術的病人,在術前、術後第1天和第4天以及術後第1月和第4個月進行定量感覺測試和臨床評估。臨床評估包括術前疼痛,膝關節手術操作引發的炎症以及術後在靜止休息時的疼痛和運動引起的疼痛(直觀類比標度評分),還包括嗎啡的累計使用量,雙側膝關節周徑和皮膚溫度。定量感覺測試包括溫度和機械壓力閾值和閾上刺激的靈敏度。並評估皮膚無害性的擦試而引起的異常性疼痛。同時在手術側和非手術側膝關節進行疼痛評估,並以手為參照對象。

結果:所有病人在手術前患側的膝關節都有長時間的劇烈疼痛和炎症。手術前的QST為進行手術的膝關節的炎症區域存在熱痛覺過敏提供了證據,但是在與非炎症區域的交界處不存在皮膚無害性接觸而引起的異常性疼痛。病人存在強烈的術後疼痛,大多數由於運動導致。原發性熱痛覺過敏表現在手術後的第一天和第四天,伴隨炎症區域無害性的接觸引起的異常性疼痛。手術後嗎啡的用量與術前的熱痛覺過敏相關聯。QST在第4個月恢復到基線,此時只有四位病人還存在運動導致的膝關節中度疼痛。

結論:熱痛覺過敏在所有QST症狀中與全膝關節成型術圍術期疼痛的密切相關,且可預測術後嗎啡的用量。

(王鵬 陳傑 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.

 

麻醉貓靜脈注射咪唑安定後的交感神經反射活性

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:雖有報導,在蛛網膜下腔應用咪唑安定所產生的抗傷害性反射機制是由脊髓的Ar-氨基丁酸(即苯二氮卓類受體複合物)所介導的,但是咪唑安定全身系統性的抗傷害反射機制仍然未知。本次試驗,分別對完整大腦和去大腦(中腦水準離斷)狀態的貓靜脈注射咪唑安定後,觀察對軀體交感神經AC反射的影響。

方法: 28只成年貓,用電刺激腓淺神經的傳出神經纖維A(有髓鞘)和傳出神經纖維C(脫髓鞘)來誘發心內交感神經的軀體交感AC反射。控制下的體-交感反射產生後,我們把貓隨機分成四組,分別靜脈注射如下劑量的咪唑安定:大腦完整的貓注射劑量分別為0.03mg/kg 0.1mg/kg0.5mg/kg;去大腦的貓注射劑量為0.1mg/kg.

結果:在完整大腦的貓中,軀體交感C反射在注射咪唑安定0.03mg/kg時明顯增強, 0.1-0.5 mg/kg時明顯減弱。在去大腦貓中,軀體交感C反射在劑量為0.1mg/kg時也是削弱的。

結論:靜脈使用咪唑安定對於軀體交感反射的效應與劑量相關。因此,咪唑安定有劑量依賴性的抗傷害反射效應。同時,咪唑安定產生的軀體交感C反射抑制效應,主要作用於中腦平面以下。

(杜唯佳 陳傑 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.

 

閉孔神經與股神經阻滯用於膝關節成形術後鎮痛的比較

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:股神經和閉孔神經阻滯在緩解膝關節成形術後疼痛方面都已被認為是有用的。本文作者比較兩者的效能。

方法:60名在脊麻下擇期行單側膝關節成形術的患者,在手術結束後接受隨機雙盲的股神經阻滯或閉孔神經阻滯或未作神經阻滯的臨床研究。神經阻滯用神經刺激儀定位,用藥為含有腎上腺素5ug/ml0.5%布比卡因20ml。病人自控鎮痛包括芬太尼、口服塞來考昔100mg 2/天)和每6小時口服撲熱息痛650mg,從到達恢復室就開始實行。記錄48小時休息和活動時疼痛情況、鎮痛劑使用量和鎮痛效果,以及膝關節屈曲的極限和住院天數作為療效成果。

結果:在任何結果變數中,閉孔神經阻滯組與病人自控鎮痛組沒有顯示顯著差異。扣除基礎疼痛評分,股神經阻滯組與病人自控鎮痛組相比在休息時所受疼痛較輕,在恢復室活動也經受較少疼痛。沒有一種阻滯作用對阿片類藥物的使用、功能恢復和單側療效有顯著影響。僅有一例股神經阻滯患者出現閉孔神經阻滯。

結論:股神經阻滯很少阻滯閉孔神經。在脊麻下行膝關節成形術後單次注射行股神經阻滯可改善術後多模式鎮痛效果,但這一作用只在手術日。單獨閉孔神經阻滯沒有益處。

(陳偉 陳傑 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.


經斜角肌臂叢阻滯:後外側臂叢阻滯的新方法

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.

 

有報導上段臂叢阻滯發生嚴重併發症。本文作者介紹一種從解剖學角度上較為有優勢的後外側臂叢阻滯法。隨機選擇27位擇期行上臂或肩部開放性手術的病人接受該新方法。神經阻滯成功率為85.2%。其中有2名病人要求術中額外靜脈予以舒芬太尼止痛,另外有2名病人局部阻滯不理想。使用該新途徑阻滯出現的副作用包括可逆性喉返神經阻滯(2名)可逆性Horner綜合症(1名)。仍需進一步研究來比較經斜角肌臂叢阻滯與其他徑路臂叢阻滯的優劣。

(朱玫娟 陳傑 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.