Anesthesia & Analgesia

October 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:

较大矫形手术期间输注晶体或胶体液后止血功能变化:纤维蛋白原的作用

张燕 陈杰

Hemostatic Changes After Crystalloid or Colloid Fluid Administration During Major Orthopedic Surgery: The Role of Fibrinogen Administration

Markus Mittermayr, Werner Streif, Thorsten Haas, Dietmar Fries, Corinna Velik-Salchner, Anton Klingler, Elgar Oswald, Christian Bach, Mirjam Schnapka-Koepf, and Petra Innerhofer

Anesth Analg 2007 105: 905-917.

氯维地平快速有效控制心脏手术患者术前的高血压:评价氨维地平在心脏手术-1术前抗高血压作用的一项随机、安慰剂对照的效能研究结果

裘毅敏译,马皓琳 李士通

Clevidipine Effectively and Rapidly Controls Blood Pressure Preoperatively in Cardiac Surgery Patients: The Results of the Randomized, Placebo-Controlled Efficacy Study of Clevidipine Assessing Its Preoperative Antihypertensive Effect in Cardiac Surgery-1

Jerrold H. Levy, Miguel Y. Mancao, Richard Gitter, Dean J. Kereiakes, Alina M. Grigore, Solomon Aronson, and Mark F. Newman

Anesth Analg 2007 105: 918-925.

异氟醚激活脂质双分子层的人心脏线粒体三磷酸腺苷敏感的钾离子通道的再生

吴威译 薛张纲校

Isoflurane Activates Human Cardiac Mitochondrial Adenosine Triphosphate-Sensitive K+ Channels Reconstituted in Lipid Bilayers

Ming T. Jiang, Yuri Nakae, Marko Ljubkovic, Wai-Meng Kwok, David F. Stowe, and Zeljko J. Bosnjak

Anesth Analg 2007 105: 926-932.

凝血酶形成分析和凝血粘弹性监测表明肝素和比伐卢定的凝血酶抑制方式不同

张美荣 陈杰

Thrombin Generation Assay and Viscoelastic Coagulation Monitors Demonstrate Differences in the Mode of Thrombin Inhibition Between Unfractionated Heparin and Bivalirudin

Kenichi A. Tanaka, Fania Szlam, He Ying Sun, Taro Taketomi, and Jerrold H. Levy

Anesth Analg 2007 105: 933-939.

近端等速表面积应该在评估二尖瓣返流中常规测定:核心综述

沈浩    马皓琳 李士通 校)

Proximal Isovelocity Surface Area Should Be Routinely Measured in Evaluating Mitral Regurgitation: A Core Review

A. Stephane Lambert

Anesth Analg 2007 105: 940-943.

综述:抑肽酶在心脏手术中作用机制研究及其进展

陈恺铮译 薛张纲校

Aprotinin in Cardiac Surgery: A Review of Conventional and Novel Mechanisms of Action (Review Article)

Matthew D. McEvoy, Scott T. Reeves, J. G. Reves, and Francis G. Spinale

Anesth Analg 2007 105: 949-962.

AMBULATORY ANESTHESIOLOGY:

NarcotrendTM监测仪和脑电图用于异丙酚誘导镇静

王鹏 陈杰

The NarcotrendTM Monitor and the Electroencephalogram in Propofol-Induced Sedation

Alfred W. Doenicke, Johann Kugler, Eberhard Kochs, Jeus Rau, Haraed Mückter, Rainer Hoernecke, Peter Conzen, Harry Bromber, and Gerhard Schneider

Anesth Analg 2007 105: 982-992.

ANESTHETIC PHARMACOLOGY:

低浓度戊巴比妥增强大鼠海马神经元兴奋性

颜涛 译,马皓琳 李士通

Low Concentrations of Pentobarbital Enhance Excitability of Rat Hippocampal Neurons

David P. Archer and Sheldon H. Roth

Anesth Analg 2007 105: 993-997.

人外周单核细胞表达孤啡肽阿片受体,无μδκ阿片受体表达

陈勇柱译 薛张纲校

Human Peripheral Blood Mononuclear Cells Express Nociceptin/Orphanin FQ, but Not µ, {delta}, or {kappa}Opioid Receptors

John P. Williams, Jonathan P. Thompson, John McDonald, Timothy A. Barnes, Tom Cote, David J. Rowbotham, and David G. Lambert

Anesth Analg 2007 105: 998-1005

异氟醚对在体大鼠海马CA1区域双脉冲效应具有双向性

王腾 陈杰

Isoflurane Bidirectionally Modulates the Paired-Pulse Responses in the Rat Hippocampal CA1 Field In Vivo

Kaori Tachibana, Koichi Takita, Toshikazu Hashimoto, Machiko Matsumoto, Mitsuhiro Yoshioka, and Yuji Morimoto

Anesth Analg 2007 105: 1006-1011.

全身麻醉对用小波变换来评价的人体皮肤微循环的影响

马皓琳   李士通

The Effects of General Anesthesia on Human Skin Microcirculation Evaluated by Wavelet Transform

Svein Aslak Landsverk, Per Kvandal, Alan Bernjak, Aneta Stefanovska, and Knut A. Kirkeboen

Anesth Analg 2007 105: 1012-1019.

使用异氟醚、氟烷及异丙酚后腹侧脊髓索的抑制大于背侧脊髓索

孙霞译  薛张纲校

Neurons in the Ventral Spinal Cord Are More Depressed by Isoflurane, Halothane, and Propofol Than Are Neurons in the Dorsal Spinal Cord

JongBun Kim, Aubrey Yao, Richard Atherley, Earl Carstens, Steven L. Jinks, and Joseph F. Antognini

Anesth Analg 2007 105: 1020-1026.

异丙酚对过氧化氢刺激的人体脐静脉内皮细胞具有减少凋亡并上调内皮一氧化氮合酶蛋白表达作用

於章杰 陈杰

Propofol Reduces Apoptosis and Up-Regulates Endothelial Nitric Oxide Synthase Protein Expression in Hydrogen Peroxide-Stimulated Human Umbilical Vein Endothelial Cells

Baohua Wang, Tao Luo, David Chen, and David M. Ansley

Anesth Analg 2007 105: 1027-1033.

丝裂原活化蛋白激酶磷酸酶-1上调和细胞外信号调节激酶1/2磷酸化降解介导昔多芬对肺动脉平滑肌细胞的抗增殖作用

周雅春 马皓琳 李士通

The Antiproliferative Effect of Sildenafil on Pulmonary Artery Smooth Muscle Cells Is Mediated via Upregulation of Mitogen-Activated Protein Kinase Phosphatase-1 and Degradation of Extracellular Signal-Regulated Kinase 1/2 Phosphorylation

Bingbing Li, Lingchao Yang, Jianying Shen, Chunshen Wang, and Zhen Jiang

Anesth Analg 2007 105: 1034-1041.

TECHNOLOGY, COMPUTING, AND SIMULATION:

颞动脉测温器对比膀胱测温器在术中及重症监护病房的监测

陈佳莉译 薛张纲校        

Temporal Artery Versus Bladder Thermometry During Perioperative and Intensive Care Unit Monitoring

Oliver Kimberger, Delphine Cohen, Udo Illievich, and Rainer Lenhardt

Anesth Analg 2007 105: 1042-1047.

一项通过标准呼吸回路监测混合呼气末CO2的简单方法

潘方立 陈杰

A Simple Method to Determine Mixed Exhaled CO2 Using a Standard Circle Breathing Circuit

John J. Badal, Robert G. Loeb, and Dax K. Trujillo

Anesth Analg 2007 105: 1048-1052.

ECONOMICS, EDUCATION, AND POLICY:

脑血流量及氧合的集成计算模型的研制与价值

潘钱玲 陈杰

Development of a Scheduled Drug Diversion Surveillance System Based on an Analysis of Atypical Drug Transactions

Richard H. Epstein, David M. Gratch, and Zvi Grunwald

Anesth Analg 2007 105: 1053-1060.

一项关于理论麻醉计划中异丙酚滥用的调查

唐李隽   马皓琳 李士通

A Survey of Propofol Abuse in Academic Anesthesia Programs

Paul E. Wischmeyer, Bradley R. Johnson, Joel E. Wilson, Colleen Dingmann, Heidi M. Bachman, Evan Roller, Zung Vu Tran, and Thomas K. Henthorn

Anesth Analg 2007 105: 1066-1071.

CRITICAL CARE AND TRAUMA:

肺压力-容积曲线得到的参数可以揭示实验肺损伤后的复原情况,压力-时间曲线没有这个作用

陈珺珺译 薛张纲校

Parameters Derived from the Pulmonary Pressure–Volume Curve, but Not the Pressure–Time Curve, Indicate Recruitment in Experimental Lung Injury

Dietrich Henzler, Nadine Hochhausen, Rolf Dembinski, Sandra Orfao, Rolf Rossaint, and Ralf Kuhlen

Anesth Analg 2007 105: 1072-1078.

-静肾脏替代疗法对热稀释技术的影响

陈伟 陈杰 )

The Influence of Venovenous Renal Replacement Therapy on Measurements by the Transpulmonary Thermodilution Technique

Samir G. Sakka, Tino Hanusch, Oliver Thuemer, and Karl Wegscheider

Anesth Analg 2007 105: 1079-1082.

一项关于通过Evac气管导管吸引声门下分泌物失败的研究

邱郁薇 马皓琳 李士通

Investigating the Failure to Aspirate Subglottic Secretions with the Evac Endotracheal Tube (Brief Report)

Christos K. Dragoumanis, George I. Vretzakis, Vassilios E. Papaioannou, Vassilios N. Didilis, Theodsia D. Vogiatzaki, and Ioannis A. Pneumatikos

Anesth Analg 2007 105: 1083-1085.

NEUROSURGICAL ANESTHESIOLOGY:

静注右旋美托咪啶预防大鼠脊柱非损伤性缺血后鞘注吗啡引起的脊髓腹侧神经元变性

璇译 薛张纲校

Intravenous Infusion of Dexmedetomidine Can Prevent the Degeneration of Spinal Ventral Neurons Induced by Intrathecal Morphine After a Noninjurious Interval of Spinal Cord Ischemia in Rats

Manabu Kakinohana, Masakatsu Oshiro, Satoko Saikawa, Seiya Nakamura, Tatsuya Higa, Kenneth J. Davison, Martin Marsala, and Kazuhiro Sugahara

Anesth Analg 2007 105: 1086-1093.

关于脑组织氧合变化原因的模型

黄丽娜     马皓琳  李士通 

Modeling the Causes of Variation in Brain Tissue Oxygenation

Iain K. Moppett and Jonathan G. Hardman

Anesth Analg 2007 105: 1104-1112.

OBSTETRIC ANESTHESIOLOGY:

脊麻剖宫产手术围术期吸氧并不能避免或者减轻恶心呕吐的发生

王光妍 薛张纲校

Intraoperative Oxygen Administration Does Not Reduce the Incidence or Severity of Nausea or Vomiting Associated with Neuraxial Anesthesia for Cesarean Delivery

Thomas W. Phillips, Jr, David M. Broussard, William D. Sumrall, III, and Stuart R. Hart

Anesth Analg 2007 105: 1113-1117.

GENERAL ARTICLES:

喉镜检查期间二维解剖关系

宋翠侠 陈杰

A Two-Dimensional Model of Anatomic Relationships During Laryngoscopy

Shea D. Aiken, Nathan Delson, Terence M. Davidson, and Randolph H. Hastings

Anesth Analg 2007 105: 1118-1126.

ANALGESIA:

精索静脉曲张手术术前应用加巴喷丁(抗焦虑药)或者地塞米松,或者二者联合运用:一项随机对照试验

周时蓓译 薛张纲校

The Preoperative Use of Gabapentin, Dexamethasone, and Their Combination in Varicocele Surgery: A Randomized Controlled Trial

Serhat Koç, Dilek Memis, and Necdet Sut

Anesth Analg 2007 105: 1137-1142.

阿片药导致PACU中的镇静不能确保足够镇痛:病例对照研究

杜唯佳 陈杰

Opioid-Induced Sedation in the Postanesthesia Care Unit Does Not Insure Adequate Pain Relief: A Case-Control Study

Claude Lentschener, Patrice Tostivint, Paul F. White, Marc E. Gentili, and Yves Ozier

Anesth Analg 2007 105: 1143-1147.

硬膜外给予AMPA/红藻氨酸盐受体拮抗剂Tezampanel对大鼠的术后镇痛作用

张莹译  马皓琳 李士通校

Epidural Tezampanel, an AMPA/Kainate Receptor Antagonist, Produces Postoperative Analgesia in Rats

Hee Cheol Jin, Amber J. Keller, Jong Kwon Jung, Alberto Subieta, and Timothy J. Brennan

Anesth Analg 2007 105: 1152-1159.

左旋布比卡因复合(深丛和浅丛)颈丛与颈浅丛阻滞用于微创甲状旁腺切除术的前瞻性随机比较研究

慧译 马皓琳 李士通校

A Prospective, Randomized Comparison Between Combined (Deep and Superficial) and Superficial Cervical Plexus Block with Levobupivacaine for Minimally Invasive Parathyroidectomy

Tatjana Stopar Pintaric, Marko Hocevar, Simona Jereb, Andrea Casati, and Vesna Novak Jankovic

Anesth Analg 2007 105: 1160-1163.

EpisureTM注射器:一个奇特的用来定位硬膜外间隙的阻力消失注射器

张曦 译,马皓琳 李士通

The EpisureTM Syringe: A Novel Loss of Resistance Syringe for Locating the Epidural Space (Brief Report)

Edward T. Riley and Brendan Carvalho

Anesth Analg 2007 105: 1164-1166.

 

较大矫形手术期间输注晶体或胶体液后止血功能变化:纤维蛋白原的作用

Hemostatic Changes After Crystalloid or Colloid Fluid Administration During Major Orthopedic Surgery: The Role of Fibrinogen Administration

Markus Mittermayr, MD*, Werner Streif, MD{dagger}, Thorsten Haas, MD*, Dietmar Fries, MD*, Corinna Velik-Salchner, MD*, Anton Klingler, PhD{ddagger}, Elgar Oswald, MD*, Christian Bach, MD§, Mirjam Schnapka-Koepf, MD||, and Petra Innerhofer, MD*

From the Departments of *Anesthesiology and Critical Care Medicine; {dagger}Pediatrics; {ddagger}Division of Theoretical Surgery; §Department of Orthopaedic Surgery; and ||Central Laboratory, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2007 105: 905-917

 

背景:为了探讨纤维蛋白聚合功能紊乱是否是稀释性凝血功能障碍的主要问题以及是否可通过给予纤维蛋白原而逆转,作者采用改良血栓弹性描记法进行了一项前瞻性研究。

方法: 66例矫形手术病人随机接受改良明胶溶液,羟乙基淀粉130/0.4 ,或仅用乳酸林格液。用血栓弹性描记法分析,测定凝血因子浓度及凝血酶标记物。当血栓弹性描记法实测纤维蛋白聚合作用急剧降低时使用纤维蛋白原(30 mg/kg)。

结果:在接受羟乙基淀粉的病人(曲线下面积负基准( -5 [ -9-2 ] )中,{alpha}角,凝块硬度和纤维蛋白原聚合(中位数[最小到最大] )明显降低,其次是明胶溶液( -3 [ -8 0 ] ,最少的是乳酸林格液( -2 [ -41] (胶体与乳酸林格液相比,P< 0 .0001 。胶体组1 3名患者而非乳酸林格液组患者需要纤维蛋白原来维持凝块坚固性边界线。使用胶体使活化Ⅶ因子、Ⅷ因子、Ⅸ因子和von Willebrand因子的活性明显下降。组间血栓弹性描记法测凝血时间,凝血酶分子标记物及其他凝血因子相当。

结论:在较大矫形手术中,纤维蛋白原/纤维蛋白聚合的紊乱是稀释性凝血功能障碍的主要问题。凝血块硬度降低由使用的液体类型决定,其中以羟乙基淀粉影响最为明显。使用纤维蛋白原来增加纤维蛋白原的浓度可以逆转容量疗法、持续失血和血液替换治疗中的不良反应。

(张燕 陈杰 校)

BACKGROUND: To explore whether disturbed fibrin polymerization is the main problem underlying dilutional coagulopathy and can be reversed by fibrinogen administration, we conducted a prospective study using modified thrombelastography (ROTEM®).

METHODS: Sixty-six orthopedic patients randomly received modified gelatin solution, hydroxyethyl starch 130/0.4, or exclusively Ringer lactate solution. ROTEM® analysis was performed, concentrations of coagulation factors and markers of thrombin generation were measured. Fibrinogen concentrate (Hemocomplettan®) was administered (30 mg/kg) when thrombelastographically measured fibrinogen polymerization was critically decreased.

RESULTS: The {alpha}angle, clot firmness, and fibrinogen polymerization (median [min to max]) significantly decreased in the patients receiving hydroxyethyl starch (area under the curve minus baseline (–5 [–9 to –2]), followed by gelatin solution (–3 [–8 to 0]), with the least reductions seen for Ringer lactate solution (–2 [– 4 to 1]) (colloids versus Ringer lactate P < 0.0001). Thirteen patients in the colloid groups but none in the Ringer lactate group needed fibrinogen concentrate to maintain borderline clot firmness. Activity of FVII, FVIII, FIX, and von Willebrand ristocetin activity decreased significantly with colloids. Thrombelastographically measured coagulation time, molecular markers of thrombin generation, and activity of all other coagulation factors were comparable in all groups.

CONCLUSION: Disturbance of fibrinogen/fibrin polymerization is the primary problem triggering dilutional coagulopathy during major orthopedic surgery. The magnitude of clot firmness reduction is determined by the type of fluid used, with hydroxyethyl starch showing the most pronounced effects. These undesirable effects of intravascular volume therapy can be reversed by increasing fibrinogen concentration by administering fibrinogen concentrate, even during continuing blood loss and intravascular volume replacement.


凝血酶形成分析和凝血粘弹性监测表明肝素和比伐卢定的凝血酶抑制方式不同

Thrombin Generation Assay and Viscoelastic Coagulation Monitors Demonstrate Differences in the Mode of Thrombin Inhibition Between Unfractionated Heparin and Bivalirudin

Kenichi A. Tanaka, MD, MSc, Fania Szlam, MMSc, He Ying Sun, PhD, Taro Taketomi, MD, and Jerrold H. Levy, MD

From the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.

Anesth Analg 2007 105: 933-939.

 

背景:凝血试验例如部分凝血活酶时间和活化凝血时间常用来监测肝素和凝血酶抑制剂比伐卢定的效果。当凝血酶的形成小于5%时,这些试验仅反映血液凝固的起始相。在这个研究中,作者研究了肝素和比伐卢定引起的部分凝血活酶时间和活化凝血时间的延长是否可以反映凝血酶形成的抑制程度。

方法:用凝血酶形成测定法评估含肝素(0-5U/mL)或比伐卢定(0-30ug/mL)抗凝的贫血小板的血清的凝血酶形成。用凝血酶原片段1.2来测定凝血酶原的激活情况。用Sonoclot和凝血弹性描记法来评估陶土激活的含有肝素(1.52.5U/mL)或比伐卢定(12.525ug/mL)的全血样本的血栓形成情况。

结果:根据凝血酶形成测定法的结果,随着比伐卢定和肝素浓度的升高,凝血酶形成逐渐延迟,但仅肝素有剂量依赖性减少凝血酶的产生。肝素和比伐卢定延迟了凝血酶原片段1.2的产生,但是含比伐卢定的血样和未抗凝血样中凝血酶原片段1.2水平峰值没有差别。在肝素化的血样中,凝血酶原片段1.2水平明显的低于对照组。在粘弹性测定中肝素和比伐卢定延迟了凝血,但只有肝素减少了血栓发生率。

结论:虽然肝素和比伐卢定的延长凝血试验值相似,但在血栓形成动力学方面是不同的。

(张美荣 陈杰 )

BACKGROUND: Coagulation tests, such as activated partial thromboplastin time and activated clotting time, are used to monitor the effects of unfractionated heparin and the direct thrombin inhibitor, bivalirudin. These tests reflect only the initial phase of blood clotting, when <5% of thrombin has been formed. In this study, we sought to determine if similar increases in activated partial thromboplastin time or activated clotting time due to heparin or bivalirudin would reflect the same degree of inhibition of thrombin formation.

METHODS: Thrombin formation was evaluated in platelet-poor plasma activated in the presence of heparin (0–5 U/mL) or bivalirudin (0–30 µg/mL) using a thrombin generation assay (ThrombinoscopeTM). Prothrombin activation was measured by prothrombin fragment 1.2 (F1.2) formation. Thrombus formation was further evaluated in kaolin-activated whole blood samples containing heparin (1.5 or 2.5 U/mL) or bivalirudin (12.5 or 25 µg/mL) using SonoclotTM and thromboelastography.

RESULTS: Based on the Thrombinoscope results, increasing concentrations of bivalirudin and heparin progressively delayed the onset of thrombin formation, but only heparin dose-dependently decreased the amount of thrombin generated. Heparin and bivalirudin delayed the onset of F1.2 formation, but there was no difference in peak F1.2 levels between bivalirudin and non-anticoagulated samples (206 ± 28.2 vs 182 ± 23.9 nmol/L, P = 0.09). In heparinized samples, F1.2 levels were significantly lower (75.7 ± 29.8 nmol/L, P < 0.05) than controls. Heparin and bivalirudin prolonged the onset of clotting on viscoelastic monitors, but only heparin decreased the rate of thrombus formation.

CONCLUSION: Thrombus formation kinetics differs between heparin and bivalirudin despite similar prolongation of clotting test values.


NarcotrendTM监测仪和脑电图用于异丙酚誘导镇静

The NarcotrendTM Monitor and the Electroencephalogram in Propofol-Induced Sedation

Alfred W. Doenicke*, Johann Kugler{dagger}, Eberhard Kochs{ddagger}, Jeus Rau§, Haraed Mückter||, Rainer Hoernecke*, Peter Conzen*, Harry Bromber, and Gerhard Schneider#

From the Institutes of *Anesthesiology, {dagger}Neurology and Psychiatry, Ludwig Maximilians University; {ddagger}Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany; §Department of Anesthesia and Critical Care, Johanniter Hospital, Stendal, Germany; ||Walther Straub Institute, Ludwig Maximilians University, Munich, Germany; ¶Department of Anesthesia and Critical Care, Martin Luther University, Halle, Germany; and #Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.

Anesth Analg 2007 105: 982-992.

 

背景:NarcotrendTM NCT)是一种监测镇静水平的单频脑电图,它是基于视觉脑电图评分系统建立的, Loomis发明并由Kugler改良发展,可以作出区分镇静6个不同水平(A-F)差异的视觉专项分级图(VEC),这六种图像可以被继续分为16种级别。作者设计本研究目的是比较单频NCT自动分类的结果与5EEGVEC所得结果差异。

方法:12名男性志愿者随机用两种不同的方法注射丙泊酚,交换用NCT监测和VEC监测。将NCT的评分结果与VEC比较。

结果:在丙泊酚注射期间14个样本(占总数24个的58%)差异超过三个分级,NCT显示的结果低于VEC的结果,占总数的25%24个样本中9.37%)出现不一致的趋势(至少5个单向差异,而且NCTVEC中均出现相反的趋势结果)。此外,NCT监测有多个时段不能显示趋势,时间从几秒钟到10分钟之间。

结论:正如NCT的规则系统独有的并不被大众接受, NCTVEC两者差异的原因不易分析,解释仍是推测的。

(王鹏 陈杰 )

BACKGROUND: The NarcotrendTM (NCT) is a one-channel electroencephalogram (EEG) monitor of the level of sedation. It is based on a visual EEG scoring system, which was developed by Loomis and modified by Kugler, to yield a visual expert classification (VEC) scheme for differentiation of six levels of sedation (A–F), which are subdivided into 16 substages. We designed the present study to test whether results of the automated classification of one-channel NCT input reflect those from VEC of five-channel EEG.

METHODS: Twelve healthy male volunteers received propofol using two different infusion regimens in a randomized, crossover design with concomitant NCT monitoring and VEC. Scoring results of NCT were compared with those of VEC.

RESULTS: During the infusion period, score differences of more than three substages were observed in 14 of 24 (= 58%) propofol administrations (4%–7% of total data). Often, the NCT indicated lighter sedation than VEC, which revealed more {delta}activity from nonfrontal leads. During recovery, NCT reported deeper sedation than VEC in 6 of 24 (= 25%) propofol administrations. Discordant trends (periods of at least five subsequent epochs with monotonic, but opposite trends for both NCT and VEC) were noted in 9 of 24 propofol administrations (37%). Furthermore, NCT had several periods when no staging information was displayed, varying from a few seconds to 10 min.

CONCLUSIONS: As the algorithm of NCT is proprietary and not accessible to the public, reasons for the observed differences between NCT and VEC cannot be analyzed and explanations must remain speculative.


异氟醚对在体大鼠海马CA1区域双脉冲效应具有双向性

Isoflurane Bidirectionally Modulates the Paired-Pulse Responses in the Rat Hippocampal CA1 Field In Vivo

Kaori Tachibana, MD, PhD*, Koichi Takita, MD, PhD*, Toshikazu Hashimoto, MD, PhD*, Machiko Matsumoto, PhD{dagger}, Mitsuhiro Yoshioka, MD, PhD{dagger}, and Yuji Morimoto, MD, PhD*

From the Departments of *Anesthesiology and Critical Care Medicine and {dagger}Neuropharmacology, Hokkaido University Graduate School of Medicine, Sapporo, Japan.

Anesth Analg 2007 105: 1006-1011

 

背景:作者在体研究具有完整的中间神经电路中异氟醚对海马突触传递和双脉冲可塑性的影响。

方法:用长期植入电极的大鼠,刺激海马CA1区的Schaffer collsterals,以测量兴奋性突触后电位EPSP群峰电位PSA)。大鼠吸入0.25-1.5MAC的异氟醚下机械通气。对照组则不吸异氟醚。

结果:异氟醚能抑制EPSP的反应,增强突触效能。而PSA只有在高浓度的异氟醚通气条件下才会被抑制。也许是因为抑制了EPSP的反应,增强突触效能,反射性的形成一个很好的平衡联合体,低浓度的异氟醚(0.25-0.5MAC)增强(双脉冲的增强作用)PPF,而高浓度的异氟醚(1.5MAC)延长双脉冲的抑制作用。

结论:异氟醚对CA1区域突触多个位点的影响作用:1)抑制EPSP,增 PPF显示其抑制突触前谷氨酸的传导;2)在高浓度条件下延长PPF抑制PSA,显示异氟醚对锥体神经元的抑制作用;3)对神经元之间的抑制作用表现在增强了突触效应。抑制作用的程度因异氟醚浓度的不同而不同,而整体方向的突触性质依赖于在体内抑制效应之间达到的一种平衡。

(王腾 陈杰 )

BACKGROUND: We studied the effects of isoflurane on hippocampal synaptic transmission and paired-pulse plasticity, under in vivo intact interneuron circuitry.

METHODS: Using rats chronically implanted with electrodes, excitatory postsynaptic potential (EPSP) and population spike amplitude (PSA) were measured in the hippocampal CA1 field by stimulating Schaffer collaterals. The lungs of the rats were mechanically ventilated with 0.25–1.5 minimum alveolar anesthetic concentration (MAC) isoflurane. A control value was obtained in the absence of isoflurane.

RESULTS: Isoflurane depressed EPSP responses and enhanced synaptic efficacy. PSA was not depressed except under high concentrations, presumably reflecting a well-balanced combination with the decreased EPSP and enhanced synaptic efficacy. Low concentrations of isoflurane (0.25 and 0.5 MAC) increased paired-pulse facilitation (PPF), whereas a high concentration of isoflurane (1.5 MAC) prolonged the paired-pulse depression.

CONCLUSIONS: Isoflurane appeared to affect multiple sites of CA1 synapses: 1) the depression of presynaptic glutamatergic transmission as shown by depressed EPSP and increased PPF; 2) the depression of pyramidal neurons as shown by prolonged PPF and depressed PSA under high concentration; and 3) the depression of interneurons as shown by the greater synaptic efficacy. The degree of each of these inhibitory effects seemed to vary at different concentrations, and the overall direction of the synaptic properties may depend on the balances between these inhibitory effects in vivo.


异丙酚对过氧化氢刺激的人体脐静脉内皮细胞具有减少凋亡并上调内皮一氧化氮合酶蛋白表达作用

Propofol Reduces Apoptosis and Up-Regulates Endothelial Nitric Oxide Synthase Protein Expression in Hydrogen Peroxide-Stimulated Human Umbilical Vein Endothelial Cells

Baohua Wang, MD, PhD*, Tao Luo, MD*, David Chen, PhD{dagger}, and David M. Ansley, MD, FRCPC*

From the Departments of *Anesthesiology, Pharmacology and Therapeutics, and {dagger}Chemistry, University of British Columbia, Vancouver, British Columbia, Canada.

Anesth Analg 2007 105: 1027-1033

.

背景:血管内皮细胞在维持心血管稳态方面起重要作用。氧化应激在引起内皮细胞损伤和心血管疾病方面是一关键的致病因子。此次试验评估了异丙酚对于氧化应激诱导的内皮细胞损伤的作用和是否涉及丝氨酸-苏氨酸激酶Akt调节内皮一氧化氮合酶(eNOS)这一保护机制。

方法:使用人体脐静脉内皮细胞作为试验模型。使用过氧化氢(H2O2,100μM)作为氧化应激刺激物。分组包括1)对照;2)细胞仅经H2O2处理;3)细胞仅经异丙酚(50μM)处理;4)细胞经50μM异丙酚预处理30分钟后给予H2O2。使用3-(45-二甲基噻唑-2-烃基)-25-联苯四唑溴盐测定法和台盼蓝不相容试验评估细胞成活力。使用烟酸己可碱33258染色法评估细胞凋亡。使用CaspACE比色分析系统评估Caspase-3活性。使用Western blot检测Akt、磷酸AkteNOS表达。

结果:H2O2作用于人体脐静脉内皮细胞上能减少细胞成活力,诱导凋亡和增加Caspase-3活性。异丙酚能显著地保护细胞,减少H2O2诱导的细胞损伤、凋亡和减少H2O2诱导的Caspase-3活性增加。与对照组和仅H2O2刺激细胞组比较,异丙酚处理能显著增加eNOS表达。但磷酸Akt473位点丝氨酸或308位点苏氨酸)的表达组间无差异。

结论:50μM异丙酚通过抑制Caspase-3活性和不依赖Akt机制地增加eNOS表达,减少H2O2诱导的内皮细胞损伤和凋亡。

(於章杰 陈杰 )

BACKGROUND: Vascular endothelial cells play an important role in maintaining cardiovascular homeostasis. Oxidative stress is a critical pathogenic factor in endothelial cell damage and the development of cardiovascular diseases. In this study we evaluated the effects of propofol on oxidative stress-induced endothelial cell insults and the role of serine–threonine kinase Akt modulation of endothelial nitric oxide synthase (eNOS) as a mechanism of protection.

METHODS: Human umbilical vein endothelial cells were used as the experimental model. Hydrogen peroxide (H2O2, 100 µM) was used as the stimulus of oxidative stress. Study groups included 1) control; 2) cells incubated with H2O2 alone; 3) cells incubated with propofol (50 µM) alone; or 4) cells pretreated with propofol 50 µM for 30 min then co-incubated with H2O2. Cell viability was assessed using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay and Trypan blue dye exclusion test. Cell apoptosis was evaluated by Hoechst 33258 staining. Caspase-3 activity was determined by the colorimetric CaspACETM Assay System. Expressions of Akt, phospho-Akt, and eNOS were detected by Western blotting.

RESULTS: H2O2 decreased cell viability, induced apoptosis, and increased caspase-3 activity in human umbilical vein endothelial cells. Propofol significantly protected cells from H2O2-induced cell damage, apoptosis and decreased H2O2-induced increase in caspase-3 activity. Propofol treatment significantly increased eNOS expression compared to control and H2O2-stimulated cells. There was no significant difference in phospho-Akt (Ser 473 or Thr 308) expression among the groups.

CONCLUSIONS: Propofol 50 µM can reduce H2O2-induced damage and apoptosis in endothelial cells, by suppressing caspase-3 activity and by increasing eNOS expression via an Akt-independent mechanism.


一项通过标准呼吸回路监测混合呼气末CO2的简单方法

A Simple Method to Determine Mixed Exhaled CO2 Using a Standard Circle Breathing Circuit

John J. Badal, MD, Robert G. Loeb, MD, FACS, and Dax K. Trujillo, MD

From the Department of Anesthesiology, University of Arizona, Tucson, Arizona.

Anesth Analg 2007 105: 1048-1052.

 

介绍:混合呼气末CO2CO2排出量(V CO2)在麻醉过程中为非常规监测项目,因为其通过标准装置难以测量。作者通过两种实验来检验呼吸机风箱内含有混合呼末CO2的假说。

方法:实验中,肺模型装有CO2气源,从呼吸机风箱抽取样本计算VCO2。这些数据与NICO装置,一种市场上主流CO2监测仪检测V CO2作比较。在临床研究中,采集9名全麻受试者麻醉呼吸机中风箱中气体,并与NICO装置计算和比较。

结果:风箱法测定的VCO2与肺模型测量的VCO2精密度为26ml/min, 偏差为-24ml/min, CO2标定平均误差为-12.0%。而临床实验中,风箱法测定的VCO2NICO法测定的VCO2偏差为-0.15ml/min,精密度为33.16ml/min

结论:在实验室中从风箱测得的VCO2没有NICO装置精确,但可通过标准麻醉装置测定。9名受试者中,以风箱中测定的VCO2NICO装置测得值误差为1.34%。考虑到两者之间这样小的百分误,作者认为风箱法测量的VCO2能应用于临床。

(潘方立 陈杰 )

INTRODUCTION: Mixed exhaled CO2 and CO2 excretion (VCO2) are not routinely monitored during anesthesia because they are difficult to measure using standard equipment. We conducted two experiments to test the hypothesis that the ventilator bellows contains mixed exhaled CO2.

METHODS: In the laboratory experiment, a lung model was assembled with a CO2 source. The gasses were sampled from the bellows and VCO2 was calculated. These values were compared to VCO2 measured by the NICO monitor (Novametrix Medical Systems), a commercially available mainstream capnometer. In the clinical experiment, gasses were sampled from the ventilator bellows in nine subjects under general anesthesia. VCO2 was calculated and compared to values obtained from the NICO monitor.

RESULTS: VCO2 measured from the bellows connected to the lung model resulted in an overall precision of 26 mL/min, bias of –24 mL/min, and average error of –12.0% compared to set CO2 flow. In the clinical trial, calculated VCO2 sampled from the bellows compared to measured VCO2 from the NICO monitor had a bias of –0.15 mL/min, and precision of 33.16 mL/min.

CONCLUSION: VCO2 calculated from the bellows was not as accurate as NICO VCO2 in the laboratory; however, it can be done using standard anesthesia equipment. Furthermore, in nine anesthetized subjects, the bellows method of VCO2 determination had an overall percent error of 1.34% from NICO VCO2. Given this small percent error between the bellows method and the NICO monitor, we believe that the bellows method of VCO2 determination is suitable for clinical practice.

 

-静肾脏替代疗法对热稀释技术的影响

The Influence of Venovenous Renal Replacement Therapy on Measurements by the Transpulmonary Thermodilution Technique

Samir G. Sakka, MD, PhD*, Tino Hanusch, cand. med.{dagger}, Oliver Thuemer, MD{dagger}, and Karl Wegscheider, PhD{ddagger}

From the *Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke Medical Center Cologne-Merheim, Germany; {dagger}Department of Anesthesiology and Intensive Care Medicine, Friedrich-Schiller-University, Jena, Germany; and {ddagger}Institute for Biometry, University of Hamburg, Germany.

Anesth Analg 2007 105: 1079-1082.

 

背景:经肺热稀释技术已用于重危病人血流动力学监测。然而,其中许多患者接受肾脏替代治疗(RRT)。因此,作者通过测量心脏指数(CI)、胸内血容量指数(ITBVI)及血管外肺水指数(EVLWI)来分析肾脏替代疗法对其的影响。

方法:连续研究24名重危病人, 5F股动脉导管连在监护仪上,一个12F透析导管通过股静脉连到下腔静脉或上腔静脉,患者连续接受肝素抗凝治疗。记录三次血流动力学监测指标,一次是通过中心静脉注射盐水时,一次是暂停静脉肾脏替代治疗时,另一次是肾脏替代疗法重新连接后。室温设定、液体状况和血管活性药物不变。

结果:经静脉肾脏替代疗法显著影响心脏指数、胸内血容量指数,而对血管外肺水指数没影响。在两组经静脉肾脏替代疗法间没有统计学意义的差异。

结论RRT对脓毒血症患者CI, ITBVI, and EVLWI有非临床相关的影响并能维持心排血量,且透析导管尖端位置对测量没有显著的影响。

(陈伟 陈杰 )

BACKGROUND: Use of the transpulmonary thermodilution technique has been suggested for extended hemodynamic monitoring in critically ill patients. However, many of these patients also require renal replacement therapy (RRT). Therefore, we analyzed the influence of venovenous RRT on measurement of cardiac index (CI), intrathoracic blood volume index (ITBVI), and extravascular lung water index (EVLWI).

METHODS: We studied 24 consecutive critically ill patients (15 males, 9 females; age 39–81, mean 62 yr) who had received a clinically indicated 5F femoral arterial catheter (PV2015L20, Pulsion Medical Systems, Germany), which was connected to a monitor (PiCCOplus, Pulsion Medical Systems, Germany). A 12F dialysis catheter (Trilyse Expert, Vygon) was either advanced from the vena femoralis into the vena cava inferior (n = 12) or placed into the superior vena cava (n = 12). Patients continuously received heparin for anticoagulation. Hemodynamic measurements were performed in triplicate by central venous injection of saline (15 mL, <8°C) during RRT, during a brief interruption in RRT (by disconnection, without retransfusion), and immediately after reconnection. Ventilator settings, fluid status, and vasoactive drugs remained unchanged.

RESULTS: RRT was associated with significant changes in CI (mean change, –0.1 L/min/m2, P = 0.003) and ITBVI (mean change, –18 mL/m2, P = 0.02), whereas EVLWI was unaffected (mean change, +0.1 mL/kg, P = 0.42). The influence of RRT on CI, ITBVI, and EVLWI was not statistically different in both subgroups.

CONCLUSIONS: RRT had no clinically relevant effect on measurement of CI, ITBVI, and EVLWI in patients with sepsis and maintained cardiac output. Furthermore, the dialysis catheter tip position had no significantly different influence under these conditions.


脑血流量及氧合的集成计算模型的研制与价值

Development and Validation of an Integrated Computational Model of Cerebral Blood Flow and Oxygenation

Iain K. Moppett, DM, FRCA, and Jonathan G. Hardman, DM, FRCA

From the Division of Anaesthesia and Intensive Care, Queen’s Medical Centre Campus, Nottingham University Hospitals, Nottingham, UK.

Anesth Analg 2007 105: 1094-1103.

 

背景  许多研究小组已经设计了不同的脑血流量及氧合监测模型,每一种都有优缺点。作者描述了为研究和教学而设计的诺丁汉脑模型(NCS)的研制与价值。

方法:  生理假设转换成微分方程式,将时间数字化。从已经发表的文献上获得的一组实验支持这种模型试验。如静态及动态的自动调节反应;脑组织的氧合等。用已公布NCS试验方法去运行,并且将它的结果与已发表的数据相比较。

结果  NCS不论从质量或数量上都与已发表的数据相似。相关指数的值为(括号中为发表的数据):自动调节指数为0.90.9);暂时充血反应率为1.31.3),二氧化碳反应为2.4%4.7%mmHg12-4.5);脑组织氧合反应22mmHg20-100)。

结论:  NCS是一种可以在将来用于研究及教学的值得信赖的测定脑血流量及氧合的模型。

(潘钱玲 陈杰 校)

BACKGROUND: Various groups have constructed simulations and models of cerebral blood flow and oxygenation, each with its strengths and weaknesses. We describe the development and validation of a novel computational model, the Nottingham cerebral simulator (NCS), designed for experimental and teaching use.

METHODS: Physiological hypotheses were converted into differential equations; these are solved numerically with respect to time. A battery of tests was derived from published literature against which to test the simulation: static and dynamic autoregulation responses; carbon dioxide reactivity; brain tissue oxygenation. The NCS was programmed to simulate the methodologies of published experiments and the results of the simulation and the published data were compared.

RESULTS: The NCS results are qualitatively and quantitatively similar to published data. The values for regulatory indices were (published values in parentheses): index of autoregulation 0.9 (0.9); transient hyperemic response ratio 1.3 (1.3), carbon dioxide reactivity 2.4%–4.7% mm Hg–1 (2–4.5); brain tissue oxygen tension 22 mm Hg (20–100).

CONCLUSIONS: The NCS is a credible model of cerebral blood flow and oxygenation, which warrants further use as an experimental and teaching tool.


喉镜检查期间二维解剖关系

A Two-Dimensional Model of Anatomic Relationships During Laryngoscopy

Shea D. Aiken, MD*, Nathan Delson, PhD{dagger}, Terence M. Davidson, MD{ddagger}§, and Randolph H. Hastings, MD, PhD||¶

From the *School of Medicine, Departments of {dagger}Mechanical and Aerospace Engineering, {ddagger}Head and Neck Surgery, and ||Anesthesiology, University of California, San Diego, California; §Otolaryngology Services, and ¶Department of Anesthesiology, VA San Diego Healthcare System, San Diego, California.

Anesth Analg 2007 105: 1118-1126.

 

背景:直接喉镜法视野只为一个麻醉者所见,这在教学时遇到难题:不能够讲清所看到喉镜视野。影响喉镜检查的解剖因素多为内在因素,妨碍了意料之外的插管困难的原因分析。作者创立一种较完善的二维模型,在矢状面展示头颈部的解剖学关系。并评估这人体模型,测试各种条件变化时如何影响喉镜检查的视野。

方法:模型参数与文献资料进行比较。使用Macintosh 3Miller 2 Macintosh 4镜片暴露声门,用下颌长度和门牙间张开度等评估暴露的情况。

结果:从已公布数值的30节气道长度和10度为一标准差。脊柱和下颌移动在正常活动范围内。声门暴露在张口度小于一个阈值时显著降低。下颌短时需要较大的张口。张口窄于2.4cm时不能暴露声门。Macintosh 4镜片最易成功,能见声门后部7mm

结论:此模型为年龄约为16岁男病人身高,比例和活动度。可用于解释解剖学变化对喉镜检查的影响。将来还需进一步客观评估来确定模型的用处,如教学以及作为工具研究困难喉镜检查的机制。

(宋翠侠 陈杰 校)

BACKGROUND: The view obtained during direct laryngoscopy is only seen by a single anesthesiologist. The inability of instructors to observe the view poses problems for teaching the technique. The anatomic interactions affecting laryngoscopy are largely internal, hampering efforts to understand why some patients are unexpectedly difficult to intubate. In response, we have constructed a full scale, adjustable, two-dimensional model showing the head and neck in the sagittal plane. In this article, we validate the mannequin and test how various conditions or changes in equipment affect the laryngoscopic view.

METHODS: Model parameters were compared with literature values. Glottic exposure was evaluated over a range of jaw lengths and interincisor gaps for Macintosh 3, Miller 2, and Macintosh 4 blades.

RESULTS: Thirty segmental airway distances and 10 angles were within 1 standard deviation from published values. Spine and jaw mobilities approximated normal range of motion. Glottic exposure decreased steeply for mouth openings below a threshold. A larger mouth opening was required to obtain a view when the mandible was short. None of the blades exposed the glottis when mouth opening was narrow, 2.4 cm. The Macintosh 4 blade was closest to success, within 7 mm of viewing the posterior cords.

leak point;liminal value;threshold;threshold value

CONCLUSIONS: The model reflects an average 16-yr-old male patient in size, proportion, and mobility. It can be used to explicate how anatomic relationships affect laryngoscopy. An objective assessment is necessary to determine the model’s utility for teaching and as a tool for researching the mechanisms responsible for laryngoscopic difficulty.


阿片药导致PACU中的镇静不能确保足够镇痛:病例对照研究

Opioid-Induced Sedation in the Postanesthesia Care Unit Does Not Insure Adequate Pain Relief: A Case-Control Study

Claude Lentschener, MD*, Patrice Tostivint*, Paul F. White, PhD{dagger}, Marc E. Gentili, PhD{ddagger}, and Yves Ozier, MD, PhD*

From the *Department of Anesthesia and Critical Care, Université Paris-Descartes, Faculté de Médecine, Assistance Publique–Hôpitaux de Paris, Hôpital Cochin, Paris Cedex, France; {dagger}Department of Anesthesiology and Pain Management, University of Texas, Southwestern Medical Center at Dallas, Dallas, Texas; and {ddagger}Department of Anesthesiology, CHP Saint-Grégoire, Saint-Grégoire, France.

Anesth Analg 2007 105: 1143-1147.

 

背景PACU中,静滴吗啡以控制急性疼痛可产生镇静作用。作者设计这个病例对照试验来评估阿片类药物用于PACU所产生的镇静与术后早期镇痛之间的关系。

方法:PACU中,每隔5分钟静滴吗啡2mg(体重≤60kg)或3mg(体重>60kg)来治疗中度至重度疼痛。疼痛程度用总分为11分的口述评分(VRS)来评估,分值≥3表示中度至重度疼痛。镇静作用则以总分为6分的Rammsay法来评估,分值>3表示有明显的镇静作用。26Rammsay镇静分数>3,VRS3的病人(镇静组)在离开PACU后参与了一项术后24小时的评估。评估患者PACU早期术后疼痛的回忆能力,术后当晚的睡眠质量,术后24小时的疼痛情况以及对于术后24小时疼痛管理的满意程度。有两个病人离开PACUVRS疼痛分值<3,但情况与Rammsay镇静分数>3,VRS3的病人相似,被列入对照组中。

结果:镇静组(Rammsay镇静分数>3,VRS3)病人在PACU中出现较多中度至重度的疼痛(对照组和镇静治疗组重度/中度/无痛比例为:18/25%/75%58/16/26,P0.006),术后当晚的睡眠质量较差(对照组和镇静治疗组睡眠质量好/中等/差的比例为:48%/42%/10%23/23/54%,P0.001),术后24小时的疼痛评分更高(对照组和镇静治疗组重度/中度/无痛的比例为:6/44%/50%50/42/8,P值﹤0.0001)。此外,镇静组患者对于术后24小时疼痛管理的满意程度较低(对照组和镇静治疗组满意/一般/不满意的比例为:96/2%/2%50/30/20,P值﹤0.0001)。

结论:PACU应用阿片类药物出现显著的镇静作用,但并不能确保足够的自我评定中的解痛。

(杜唯佳 陈杰 校)

BACKGROUND: Sedation can occur during intravenous titration of morphine for acute pain control in the postanesthesia care unit (PACU). We designed this case-control study to evaluate the relationship between opioid-induced sedation in the PACU and adequacy of early postoperative analgesia.

METHODS: Intravenous morphine was titrated in 2 mg (body weight ≤60 kg) or 3 mg (body weight >60 kg) boluses every 5 min to treat moderate-to-severe pain in the PACU. Pain was assessed using a 11-point verbal rating scale (VRS) with scores ≥3 representing moderate-to-severe pain. The 6-point Ramsay score was used to assess the level of sedation with scores >3 representing clinically significant sedation. Twenty-six patients, with a Ramsay sedation score >3 and a pain VRS ≥3 at discharge from the PACU, were evaluated 24 h after surgery to assess (a) the recall of early postoperative pain in the PACU, (b) quality of sleep on the first night after surgery, (c) pain on the 24th postoperative hour, and (d) satisfaction with pain management at 24 h after surgery. Two patients discharged from the PACU with VRS pain scores <3 were matched to each of the patients with pain scores ≥3 and Ramsay score >3, as part of a 52 patient control group.

RESULTS: Patients with Ramsay scores >3 and pain scores ≥3 more frequently reported moderate-to-severe pain in the PACU (severe/moderate/no pain: 18%/25%/57% vs 58%/16%/26%, P = 0006, for the control and the sedated group, respectively), poorer quality of sleep the night after surgery (well/moderate/bad: 48%/42%/10% vs 23%/23%/54%, P = 0.001, for the control and the sedated group, respectively), and higher pain scores at the 24th hour after surgery (severe/moderate/no pain: 6%/44%/50% vs 50%/42%/8%, P < 0.0001, for the control and the sedated group, respectively). In addition, their overall satisfaction with pain control during the first 24 postoperative hours was lower (satisfied/moderately satisfied/not satisfied: 96%/2%/2% vs 50%/30%/20%, P < 0.0001, for the control and the sedated group, respectively).

CONCLUSION: Clinically significant opioid-induced sedation in the PACU does not insure adequate self-reported pain relief.

 

异氟醚激活脂质双分子层的人心脏线粒体三磷酸腺苷敏感的钾离子通道的再生

Isoflurane Activates Human Cardiac Mitochondrial Adenosine Triphosphate-Sensitive K_ Channels Reconstituted in Lipid Bilayers

Ming T. Jiang, MBYuri NakakaeMarko LjubkovicWai-Meng Kwok,

David F. Stowe, MD,  Zeljko J. Bosnj

Address correspondence and reprint requests to Ming Tao Jiang,MB, PhD,    Department of Anesthesiology, Medical College of Wisconsin,

Anesth Analg 2007;105:926 –32

 

背景:在异氟醚介导的人和动物心肌保护的预处理中,线粒体三磷酸腺苷敏感的钾离子通道的激活被认为是一个关键的步骤。最近的证据显示活性氧簇在异氟醚介导的心肌保护作用中起到中介作用。在此次研究中,我们调查异氟醚及活性氧簇对人心脏线粒体三磷酸腺苷敏感的钾离子通道在脂质双分子层的再生的直接作用。方法:在人左心室的外植块中,线粒体内膜是孤立的,不适合作为心脏移植,并且在均匀的谷氨酸钾溶液(150 mM)中融合进脂质双分子层中。在暴露于异氟醚及过氧化氢的前后,ATP敏感的钾离子电流都能被电极记录到。结果:人线粒体ATP敏感的钾离子通道可以通过对ATP及羟基癸酸甘油酯抑制后的敏感度来进行分类。异氟醚(0.8 mM)的加入增加了线粒体ATP敏感的钾离子通道开放的可能性,不管ATP的抑制(0.5 mM)是否存在。异氟醚介导的钾离子电流增加可被羟基癸酸甘油酯完全抑制。类似的,过氧化氢可以激活先前被ATP抑制的线粒体ATP敏感钾离子通道。结论:这些数据明确了在体外,异氟醚及活性氧簇直接激活了人心脏线粒体ATP敏感钾离子通道,并不像通常认为的那样包含了细胞蛋白激酶的作用。线粒体ATP敏感钾离子通道的激活可能促成异氟醚在人心脏的心肌保护作用。

(吴威译 薛张纲校)

BACKGROUND: Activation of the mitochondrial adenosine triphosphate (ATP)-

sensitive K_ channel (mitoKATP) has been proposed as a critical step in myocardial

protection by isoflurane-induced preconditioning in humans and animals. Recent

evidence suggests that reactive oxygen species (ROS) may mediate isofluranemediated

myocardial protection. In this study, we examined the direct effect of isoflurane and ROS on human cardiac mitoKATP channels reconstituted into the lipid bilayers.

METHODS: Inner mitochondrial membranes were isolated from explanted human left

ventricles not suitable for heart transplantation and fused into lipid bilayers in

symmetrical potassium glutamate solution (150 mM). ATP-sensitive K_ currents

were recorded before and after exposure to isoflurane and H2O2 under voltage

clamp.RESULTS: The human mitoKATP was identified by its sensitivity to inhibition by ATP and 5-hydroxydecanoate. Addition of isoflurane (0.8 mM) increased the open

probability of the mitoKATP channels, either in the presence or absence of ATP

inhibition (0.5 mM). The isoflurane-mediated increase in K_ currents was completely

inhibited by 5-hydroxydecanoate. Similarly, H2O2 (200 _M) was able to activate the mitoKATP previously inhibited by ATP. CONCLUSIONS: These data confirm that isoflurane, as well as ROS, directly activates reconstituted human cardiac mitoKATP channel in vitro, without apparent involvement of cytosolic protein kinases, as commonly proposed. Activation of the mitoKATP channel may contribute to the myocardial protective effect of isoflurane in the human heart.

 

 

综述:抑肽酶在心脏手术中作用机制研究及其进展

Aprotinin in Cardiac Surgery: A Review of Conventional and Novel Mechanisms of Action

Matthew D. McEvoy, MD*, Scott T. Reeves, MD*, J. G. Reves, MD*, and Francis G. Spinale, MD, PhD{dagger}

Department of Anesthesiology and Perioperative Medicine, 165 Ashley Ave., CH 525, Charleston, SC 29425.

Anesth Analg 2007; 105:949-962

 

凝血反应和炎症瀑布反应在心肺体外循环后可引起多器官功能衰竭。基于这些观察,在心脏手术中及术后采用稳定凝血过程和稀释炎症反应的策略是很重要的。抑肽酶有止血作用。另外,抑肽酶在心脏手术和体外循环中可能有多种生物相关效应。例如,它抑制中性粒细胞和巨噬细胞的活化和分化、减少炎症细胞释放、激活炎症细胞分裂并减少氧化应激。由于这些已知的益处,认为在心脏及体外循环手术中应常规应用抑肽酶。在此篇综述中,我们通过讨论抑肽酶作用于心脏手术的经典和新的通路检验了这个有争议的药物

(陈恺铮译 薛张纲校)

Induction of the coagulation and inflammatory cascades can cause multiorgan dysfunction after cardiopulmonary bypass (CPB). In light of these observations, strategies that can stabilize the coagulation process as well as attenuate the inflammatory response during and after cardiac surgery are important. Aprotinin has effects on hemostasis. In addition, aprotinin may exert multiple biologically relevant effects in the context of cardiac surgery and CPB. For example, it decreases neutrophil and macrophage activation and chemotaxis, attenuates release and activation of proinflammatory cytokines, and reduces oxidative stress. Despite these perceived benefits, the routine use of aprotinin in cardiac surgery with CPB has been called into question. In this review, we examined this controversial drug by discussing the classical and novel pathways in which aprotinin may be operative in the context of cardiac surgery.

 

 

人外周单核细胞表达孤啡肽阿片受体,无μδκ阿片受体表达

Human peripheral blood mononuclear cells express nociceptin/orphanin FQ, but not mu, delta, or kappa opioid receptors.

Williams JP, Thompson JP, McDonald J, Barnes TA, Cote T, Rowbotham DJ, Lambert DG.

Department of Cardiovascular Sciences, Pharmacology and Therapeutics Group, Division of Anaesthesia, Critical Care and Pain Management, University of Leicester, Leicester Royal Infirmary, Leicester, United Kingdom.

Anesth Analg 2007 105: 998-1005.

 

背景:阿片受体在PBMC中的表达是有争议的。这些受体目前被分为经典的MOP DOP KOP和非经典的NOP。方法:在这志愿者实验中,我们探查经典的和经典的阿片受体的表达,通过以下方法:1)放射性配体结合法;2)特异性抗体结合法 3)以PCR为基础的实验范式。结果:从健康志愿者的外周单核细胞提取的膜,既不与阿片受体配基[3H]diprenorphine(一与经典阿片受体结合的非选择性放射性配体)结合,也不与[3H]N/OFQ结合。每一放射性配体存在明显的浓度依赖性结合去控制组织表达重组的MOP NOP.。此外,运用流体细胞测量仪式样,既没荧光纳洛酮又没两类MOP 抗体结合到PBMC上,尽管有荧光纳洛酮结合到重组的MOP上(作为正面对照)。运用经典的和经典的阿片受体的初级特异性,从10名志愿者的PBMC中提取RNA,我们仍不能发现MOP, DOPKOP副本。相反,所有样品都发现了NOP。结论:尽管我们运用了不同的实验方法,但还是没证明在健康志愿者的PBMC中存在阿片受体蛋白。我们发现NOP mRNA,暗示在这些免疫细胞上有低密度的NOP表达。有可能是PBMC 自身产生的N/OFQ与免疫功能调控有关。       

(陈勇柱译 薛张纲校)

BACKGROUND: Expression of opioid receptors on peripheral blood mononuclear cells (PBMC) is controversial. These receptors are currently classified as classical (MOP/mu/mu, DOP/delta/delta and KOP/kappa/kappa) and nonclassical NOP (nociceptin/orphanin FQ; N/OFQ). METHODS: In this volunteer study we probed for the expression of both classical and nonclassical opioid receptors using 1) radioligand binding, 2) specific antibody binding, and 3) polymerase chain reaction-based experimental paradigms. RESULTS: Membranes prepared from PBMC from healthy volunteers did not bind either [3H]diprenorphine (a nonselective radioligand for classical opioid receptors) or [3H]N/OFQ. There was significant concentration-dependent binding of each radioligand to control tissues expressing recombinant MOP and NOP. In addition, using fluorescence-activated cell sorting paradigms, there was no binding of fluorescent naloxone or either of two MOP antibodies to whole PBMC, though fluorescent naloxone did bind to recombinant MOP (as a positive control). Using primers specific for classical and nonclassical opioid receptors, and RNA extracted from the PBMC of 10 healthy volunteers, we were also unable to detect MOP, DOP, and KOP transcripts. In contrast, NOP was detected in all samples. CONCLUSIONS: Despite using several complementary experimental strategies, we failed to demonstrate protein for classical or nonclassical opioid receptors on PBMC from healthy volunteers. We detected NOP mRNA, suggesting low-density NOP expression on these immunocytes. It is possible that N/OFQ, produced by the PBMC itself, may be involved in the control of immune function.

 

 

使用异氟醚、氟烷及异丙酚后腹侧脊髓索的抑制大于背侧脊髓索

Neurons in the Ventral Spinal Cord Are More Depressed by Isoflurane, Halothane, and Propofol Than Are Neurons in the Dorsal Spinal Cord

JongBun Kim, MD, PhD*, Aubrey Yao, MD*, Richard Atherley, BS*, Earl Carstens, PhD, Steven L. Jinks, PhD*, and Joseph F. Antognini, MD* 

From the *Department of Anesthesiology and Pain Medicine, University of California, Davis, California; Department of Anesthesia and Pain Medicine, Catholic University of Korea, Seoul, Korea; and Section of Neurobiology, Physiology and Behavior, University of California, Davis, California. 

Anesth Analg 2007 105: 1020-1026.

 

背景挥发性麻醉剂最初作用于脊髓来产生稳定性但其确切的作用部位仍未知。在0.81.2MAC,异氟醚对背侧角的神经元不产生抑制,提示其还作用于另外的脊髓腹侧部位,例如前运动中间神经元及运动神经元。我们假设异氟醚、氟烷及异丙酚对于伤害性反应在腹侧角神经元能相当于背侧角神经元产生更强的抑制作用。方法:用异氟醚及氟烷麻醉大鼠,观察其背侧(<1200 µm 深度)及腹侧(>1200 µm)腰神经元对有害的机械刺激的反应,麻醉深度被决定为0.81.2MAC。在第三组中用0.8MAC的异氟醚及5 mg/kg 的异丙酚麻醉,同时记录背侧角及腹侧角的反应。结果:异氟醚或氟烷浓度从0.8MAC上调到1.2MAC的过程中,背侧角神经元的反应并没有显著的变化;异丙酚也同样如此。另一方面,随着异氟醚或氟烷浓度的提高,腹侧角神经元的反应为从被抑制60%变为了被抑制45%。异丙酚更是深度抑制了腹侧角神经元(>90%)。结论:这些数据显示,在1MAC左右的范围,异氟醚、氟烷及异丙酚对于有害的机械性刺激,脊髓背侧角只有很少或没有反应,而腹侧角却有抑制作用。这些麻醉药在0.81.2MAC的范围内在腹侧角产生镇静作用。

(孙霞译  薛张纲校)

BACKGROUND: Volatile anesthetics act primarily in the spinalcord to produce immobility but their exact site of action isunclear. Between 0.8 and 1.2 minimum alveolar anesthetic concentration(MAC), isoflurane does not depress neurons in the dorsal horn,suggesting that it acts at a more ventral site within the spinalcord such as in premotor interneurons and motoneurons. We hypothesizedthat isoflurane, halothane, and propofol would exert a greaterdepressant effect on nociceptive responses of ventral horn neuronswhen compared with dorsal horn neurons. METHODS: Rats were anesthetized with isoflurane or halothaneand responses of dorsal (<1200 µm deep) and ventral(>1200 µm) lumbar neurons to noxious mechanical stimulationof the hindpaw were determined at 0.8 and 1.2 MAC. In a thirdgroup anesthetized with isoflurane at 0.8 MAC, we administered5 mg/kg propofol while recording responses from dorsal hornor ventral horn neurons. RESULTS: Dorsal horn neuronal responses were not significantlyaffected when either isoflurane or halothane was increased from0.8 to 1.2 MAC; propofol also had no significant effect. Onthe other hand, with increased isoflurane or halothane concentration,responses of ventral horn neurons were depressed by 60% and45%, respectively. Propofol profoundly depressed (>90%) ventralhorn neurons. CONCLUSIONS: These data suggest that, in the peri-MAC range,isoflurane, halothane, and propofol have little or no effecton neuronal responses to noxious mechanical stimulation in thespinal dorsal horn but depress such responses in the ventralhorn. Immobility produced in the 0.8–1.2 MAC range bythese anesthetics appears to result from a depressant actionin the ventral horn.

 

 

颞动脉测温器对比膀胱测温器在术中及重症监护病房的监测

Temporal Artery Versus Bladder Thermometry During Perioperative and Intensive Care Unit Monitoring

Oliver Kimberger, MD , Delphine Cohen, MSc, Udo Illievich, MD, and Rainer Lenhardt, MD

Department of Anesthesiology, Medical University Vienna, Vienna 1090, Austria.  

Anesth Analg 2007 105: 1042-1047

 

背景:中心体温测量是术中病人监护的重要内容。通过对麻醉病人的有创操作获得中心体温相当方便。然而,这样的测量方法对于清醒病人却很困难。最近,介绍了一种新的无创中心体温测量方法颞动脉测温器(颞动脉扫描仪TM TAT-5000),据报导它与有创的中心体温测量结果比较结果是精确一致的。在这项研究中,我们探求这种新的测温器是否可以替代有创的膀胱温度测量法。方法:选定35个在行神经外科手术中的病人和35个在神经外科监护病房的病人,比较从颞动脉测温器和膀胱测温器测量得到的数据。每个病人可以得到4个数据。

结果:总共获得280对测量数据。不同方法的平均偏倚为0.07°C±0.79°C;量表的一致性限度约为3倍的±0.5°C的先验确定限度(–1.481.62)。用颞动脉测温器诊断高温(中心体温>37.8°C)的灵敏度是0.72,特异度是0.89,阳性预测值是0.89,阴性预测值是0.94。其诊断低温(中心体温<35.5°C)的灵敏度是0.29,特异度是0.95,阳性预测值是0.31,阴性预测值是0.95。结论:这项研究的结果不支持颞动脉测温器在术中监测中心体温。颞动脉测温器的测量结果尚不能完全替代膀胱测温器测量的中心体温。

(陈佳莉译 薛张纲校)

BACKGROUND: Core temperature measurements are an important component of perioperative patient monitoring. It is fairly easy to obtain core temperature measurements invasively in anesthetized patients. However, such measurements are more difficult to obtain noninvasively in awake patients. Recently, a new version of a temporal artery thermometer for noninvasive core temperature measurements (TemporalScannerTM TAT-5000) was introduced with accuracy and precision advertised as being comparable to invasive core temperature measurements. In this study, we sought to determine if this new thermometer is an acceptable substitute for invasive bladder temperature measurement. METHODS: In 35 patients undergoing neurosurgical interventions and 35 patients in the neurosurgical intensive care unit, measurements from the temporal artery thermometer were compared with those from a bladder thermometer. Four measurements were obtained from each patient. RESULTS: Overall 280 measurement pairs were obtained. The mean bias between the methods was 0.07°C ± 0.79°C; the limits of agreement were {approx}3 times greater than the a priori defined limit of ±0.5°C (–1.48 to 1.62). The sensitivity for detecting fever (core temperature >37.8°C) using the temporal artery thermometer was 0.72, and the specificity was 0.97. The positive predictive value for fever was 0.89; the negative predictive value was 0.94. The sensitivity for detecting hypothermia (core temperature <35.5°C) was 0.29, and the specificity was 0.95. The positive predictive value for hypothermia was 0.31, and the negative predictive value was 0.95.

CONCLUSIONS: The results of this study do not support the use of temporal artery thermometry for perioperative core temperature monitoring; the temporal artery thermometer does not provide information that is an adequate substitute for core temperature measurement by a bladder thermometer.

 

 

肺压力-容积曲线得到的参数可以揭示实验肺损伤后的复原情况,压力-时间曲线没有这个作用

Parameters Derived from the Pulmonary Pressure–Volume Curve, but Not the Pressure–Time Curve, Indicate Recruitment in Experimental Lung Injury

Dietrich Henzler, MD, PhD*, Nadine Hochhausen, MD*, Rolf Dembinski, MD, PhD{dagger}, Sandra Orfao, MSc{ddagger}, Rolf Rossaint, MD*, and Ralf Kuhlen, MD§

From the Departments of *Anesthesiology and {dagger}Surgical Intensive Care Unit, University Hospital, RWTH Aachen; {ddagger}Applied Mathematics II, RWTH Aachen, Aachen, Germany; and §Surgical Intensive Care Unit, Klinikum Berlin Buch, Berlin, Germany.

Anesth Analg 2007 105: 1072-1078.

 

背景:在急性肺损伤中,避免过度通气和肺复张可以预防呼吸机相关性肺损伤。从压力-容积(PV)曲线或压力-时间(Paw-t)上可以动态了解肺复张情况。方法:六只通过灌洗造成急性肺损伤的实验猪麻醉后,呼吸机设定为肺保护模式进行机械通气。我们测定了滞后区域的标准复张措施的效果,并从PV曲线得到比例和从Pawt曲线上得到了压力指数,通过多层CT得到充气和非充气的肺容积,比较两者之间的相关性。结果:滞后区域和比例与充气的肺容积相关(r = 0.886)。复张后可以造成充气肺增加(+12%),而非充气的肺减少(–18%) 。滞后区域与肺泡复张相关,表现为充气肺增加(r = 0.886),非充气肺减少(r = –0.829)。压力指数始终>1,仅表示过度通气。复张后指数并没有改变,与其他肺容积无关。结论:从PV曲线得到的参数有助于了解肺的通气和复张的情况。在目前肺保护的通气模式设置下,从Pawt曲线得到的压力指数对了解肺的复张情况没有帮助。

(陈珺珺译 薛张纲校)

BACKGROUND: In acute lung injury, ventilation avoiding tidal hyperinflation and tidal recruitment has been proposed to prevent ventilator-associated lung injury. Information about dynamic recruitment may be obtained from the characteristics of pressure–volume (PV) curves or the profile of pressure–time (Paw-t) curves. METHODS: Six anesthetized pigs with lung lavage-induced acute lung injury were ventilated with lung-protective settings. We measured the effects of a standard recruitment maneuver on hysteresis area and ratio obtained from the PV curve and on the stress index obtained from the Paw-t curve and correlated this with aerated and nonaerated lung volumes as measured by multislice computed tomography. RESULTS: Hysteresis area and ratio correlated with aerated lung volume (r = 0.886). The recruitment maneuver resulted in an increase in aerated (+12%) and a decrease (–18%) in nonaerated lung. Hysteresis area correlated with alveolar recruitment, represented by an increase in aerated lung (r = 0.886) and a decrease in nonaerated lung (r = –0.829) during tidal ventilation. The stress index was always >1 and indicated tidal hyperinflation only. Values did not change after the recruitment maneuver and did not correlate with any other lung volume. CONCLUSIONS: Parameters derived from the PV curve may help in characterizing the lung aeration of the lung and in indicating recruitment. In the presence of lung-protective ventilator settings, the stress index derived from the Paw-t curve was not able to indicate recruitment.

 

 

静注右旋美托咪啶预防大鼠脊柱非损伤性缺血后鞘注吗啡引起的脊髓腹侧神经元变性

Intravenous infusion of dexmedetomidine can prevent the degeneration of spinal ventral neurons induced by intrathecal morphine after a noninjurious interval of spinal cord ischemia in rats.

Kakinohana M, Oshiro M, Saikawa S, Nakamura S, Higa T, Davison KJ, Marsala M, Sugahara K.

Department of Anesthesiology, Faculty of Medicine, University of the Ryukyus, Okinawa, Japan.

Anesth Analg. 2007 105(4):1086-93

 

背景:我们在最初的研究中证明了非损伤脊髓缺血后脊索应用吗啡导致痉挛性截瘫和选择性脊髓腹侧神经元变性。我们的目的是研究右旋美托咪啶对脊柱缺血后鞘注吗啡引起腹侧神经元变性的影响。方法:使用雄性Sprague-Dawley大鼠,在经历一段时间非损伤性脊柱缺血(6分钟)后的1小时和5小时,重复给予一个剂量的吗啡鞘注(40μg×2)。实验动物在给予第一个吗啡鞘注剂量后分为以下4(n=8/)S组,静注生理盐水(ml/h)Dex0.1组,右旋美托咪啶(0.1μg/kg·h)Dex1组,右旋美托咪啶1μg/kg·h)Dex3组,右旋美托咪啶3μg/kg·h)。随访指标包括镇静深度,指示神经功能受损程度的运动缺陷指数,以及再灌注后72小时脊柱组织病理学检查。结果:静注右旋美托咪啶产生剂量依赖性的镇静深度。重复鞘注吗啡导致截瘫、神经功能损害和组织病理学改变。结论:以上数据表明,重复鞘注吗啡会导致截瘫和脊髓腹侧神经元变性,但静注镇静剂量的右旋美托咪啶可使其缓解。右旋美托咪啶可能对脊柱缺血后鞘注吗啡大鼠的神经学预后有保护作用。

(罗 璇译 薛张纲校)

BACKGROUND: In recent studies, we demonstrated that neuraxial morphine after noninjurious spinal cord ischemia in the rat could induce spastic paraplegia and degeneration of selective spinal ventral neurons. Our objective was to investigate the impact of dexmedetomidine infusion on the degeneration of spinal ventral neurons induced by intrathecal (IT) morphine after spinal cord ischemia. METHODS: Male Sprague-Dawley rats were given repetitive doses of IT morphine (40 microg x 2) at 1 and 5 h after a noninjurious interval (6 min) of spinal cord ischemia. The animals were assigned to one of the following four groups after the first IT injection (n = 8/group): Group S, IV infusion of saline (mL/h); Group Dex 0.1, dexmedetomidine (0.1 microg . kg(-1) x h(-1)); Group Dex 1, dexmedetomidine (1 microg x kg(-1) x h(-1)); Group Dex 3, dexmedetomidine (3 microg x kg(-1) x h(-1)). Follow-up evaluation included a sedation scale, the Motor Deficit Index to determine neurological dysfunction and histopathology of the spinal cord at 72 h of reperfusion. RESULTS: IV dexmedetomidine produced a dose-dependent increase in the sedation index. Repetitive IT morphine injection induced paraplegia and degeneration of the spinal ventral neurons. IV dexmedetomidine at a sedative dose in comparison with saline significantly attenuated neurological dysfunction and histopathological consequences. CONCLUSION: These data show that repetitive administration of IT morphine can induce paraplegia with degeneration of spinal ventral neurons, which can be attenuated by IV dexmedetomidine at a sedative dose. The use of dexmedetomidine may provide beneficial effects on neurological outcome after IT morphine after spinal cord ischemia in rats.

 

 

脊麻剖宫产手术围术期吸氧并不能避免或者减轻恶心呕吐的发生

Intraoperative Oxygen Administration Does Not Reduce the Incidence or Severity of Nausea or Vomiting Associated with Neuraxial Anesthesia for Cesarean Delivery

Thomas W. Phillips, Jr, MD, David M. Broussard, MD, William D. Sumrall, III, MD, and Stuart R. Hart, MD

From the Department of Anesthesiology, Ochsner Medical Center, New Orleans, Louisiana.

Anesth Analg 2007 105: 1113-1117.

 

背景:全麻术后辅助吸氧可以减少术后恶心呕吐的发生。我们设计这个研究来评价辅助吸氧治疗对于接受脊麻的剖宫产妇女,减少恶心呕吐的有效性。方法:我们设计了一个前瞻性的,随机双盲的研究,研究对象为接受标准脊麻以及术后镇痛的剖宫产患者。在脐带结扎后,患者被随机接受70%或者21%的氧气。将记录从诱导到分娩,分娩到手术结束,以及在术后24小时这三个时间段患者恶心呕吐的情况。我们将使用{chi}2检验和t检验来分析这两组的差异性。结果:从人口统计学和程序变量而言,这两组试验对象组成相似。从总体恶心呕吐的发生率来看,这两组没有显著的差异。吸氧气组重度恶心的发生率在待产室、产后室以及术后分别为3%, 7%, 9%;在吸空气组里,相应的统计结果为3%, 9%, 7%。重度呕吐在这三个时间段里,两组都是0%, 2%, 4%。这些差异都没有统计学意义。结论:吸氧治疗对于接受脊麻的剖宫产妇女,并不能减少或者减轻围手术期及术后的恶心呕吐。

(王光妍 薛张纲校)

BACKGROUND: Supplemental oxygen may reduce postoperative nausea and vomiting after general anesthesia. We designed this study to evaluate the efficacy of supplemental oxygen administration for reducing nausea and vomiting in women having neuraxial anesthesia for cesarean delivery.METHODS: We conducted a prospective, randomized, double-blind study of women having standardized neuraxial anesthesia and postoperative analgesia for cesarean delivery. After umbilical cord clamp, women were randomized to receive either 70% or 21% oxygen for surgery. Nausea and vomiting were recorded at three time intervals: induction until delivery, delivery until the end of surgery, and at 24 postoperative hours. {chi}2 and Students t-tests were used to determine significant differences.RESULTS: The study groups were similar with respect to demographic and procedural variables. There was no significant difference between groups in the overall incidences of nausea and vomiting. The incidence of severe nausea (rated by mothers) in the oxygen group predelivery, postdelivery, and postoperatively was 3%, 7%, and 9%, respectively, and in the medical air group was 3%, 9%, and 7%, respectively. Severe vomiting (>2 episodes) in both the oxygen and medical air groups were 0%, 2%, and 4% at the corresponding time intervals. These differences were not statistically significant.CONCLUSION: Administration of supplemental oxygen during cesarean delivery with neuraxial anesthesia does not decrease the incidence or severity of intraoperative or postoperative nausea or vomiting.

 

 

精索静脉曲张手术术前应用加巴喷丁(抗焦虑药)或者地塞米松,或者二者联合运用:一项随机对照试验

The Preoperative Use of Gabapentin, Dexamethasone, and Their Combination in Varicocele Surgery: A Randomized Controlled Trial
Serhat Koç, Dilek Memis, and Necdet Sut

Department of Anaesthesiology and Reanimation, Medical Faculty, Trakya University, Edirne, Turkey.

Anesth Analg 2007 105: 1137-1142.

                                           

背景:我们研究在精索静脉曲张术前1小时分别或者联合给与患者加巴喷丁和地塞米松对于喉镜暴露,气管插管,术中血流动力学改变,阿片类药物需求量,及术后疼痛的作用。方法:患者被随机地,双盲地分入四组实验组:C组(对照组,n=20)使用安慰剂,G组(加巴喷丁组,n=20)给与800mg加巴喷丁,D组(地塞米松组,n=20)给与8mg地塞米松,GD组(加巴喷丁联合地塞米松组)同时给与800mg加巴喷丁和8mg地塞米松,这些药均在术前1小时静脉注射。用异丙酚和雷米芬太尼完成标准麻醉诱导和维持。在诱导前和插管后记录心率和动脉血压。记录术中雷米芬太尼使用量。记录24小时血流动力学改变和视痛觉评分。并且同时记录副反应。结果:GD组在插管后1, 3, 5, 10分钟时的血流动力学紊乱,术后30分钟及124612小时的痛觉评分,及术后恶心呕吐率等方面要显著低于G组和D(P < 0.05),同时远远的低于C(P < 0.001)。同时C组的所有这些评估要高于G组和D(P < 0.05)。结论:在精索静脉曲张手术前1小时联合给与加巴喷丁和地塞米松较之单独给与其中任何一种药能更好的减轻喉镜暴露和气管插管的反应,有助于术后止痛及预防术后恶心呕吐。

(周时蓓译 薛张纲校)

BACKGROUND: We investigated the effects of gabapentin and dexamethasone given together or separately 1 h before the start of surgery on laryngoscopy, tracheal intubation, intraoperative hemodynamics, opioid consumption, and postoperative pain in patients undergoing varicocele operations. METHODS: Patients were randomly divided into four double-blind groups: group C (control, n = 20) received placebo, group G (gabapentin, n = 20) received 800 mg gabapentin, group D (dexamethasone, n = 20) received 8 mg dexamethasone, group GD (gabapentin plus dexamethasone) received both 800 mg gabapentin and 8 mg dexamethasone IV 1 h before the start of surgery. Standard induction and maintenance of anesthesia were accomplished and continued by propofol and remifentanil infusion. Heart rate and arterial blood pressure were recorded before induction and after intubation. Intraoperative total remifentanil consumption was recorded. Hemodynamic variables and visual analog scale were recorded for 24 h. Side effects were noted. RESULTS: Hemodynamics at 1, 3, 5, and 10 min after tracheal intubation, total remifentanil consumption during surgery, postoperative visual analog scale scores at 30 min, 1, 2, 4, 6, and 12 h, and postoperative nausea and vomiting were found to be significantly lower in group GD than in group G and group D (P < 0.05 for both), and substantially lower when compared with group C (P < 0.001). All values in group C were also higher than in groups G and D (P < 0.05). CONCLUSION: Gabapentin and dexamethasone administered together an hour before varicocele surgery results in less laryngeal and tracheal intubation response, improves postoperative analgesia, and prevents postoperative nausea and vomiting better than individual administration of each drug.          

氯维地平快速有效控制心脏手术患者术前的高血压:评价氨维地平在心脏手术-1术前抗高血压作用的一项随机、安慰剂对照的效能研究结果

Clevidipine Effectively and Rapidly Controls Blood Pressure Preoperatively in Cardiac Surgery Patients: The Results of the Randomized, Placebo-Controlled Efficacy Study of Clevidipine Assessing Its Preoperative Antihypertensive Effect in Cardiac Surgery-1

Jerrold H. Levy, MD*, Miguel Y. Mancao, MD{dagger}, Richard Gitter, MD{ddagger}, Dean J. Kereiakes, MD, FACC§||, Alina M. Grigore, MD, Solomon Aronson, MD, FACC, FCCP, FAHA#, and Mark F. Newman, MD#

From the *Cardiothoracic Anesthesiology and Critical Care, Emory University Hospital, Atlanta, Georgia; {dagger}Sacred Heart Health System, Pensacola, Florida; {ddagger}Birmingham Baptist Medical Center Montclair, Birmingham, Alabama; §Lindner Research Center and ||Christ Hospital Heart and Vascular Center, The Linder Research Center, Cincinnati, Ohio; ¶Mayo Clinic Hospital, Department of Anesthesiology, Phoenix, Arizona; and #Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2007; 105:918-925

背景资料:氯维地平是一种超短效的,第三代静脉注射用的二氢吡啶类钙通道拮抗剂,能快速可滴定地降低动脉压,经血液及组织酯酶代谢能迅速终止药物作用。作为一种动脉选择性血管扩张剂,氯维地平能直接降低外周血管阻力,而不扩张静脉毛细血管床。在这项随机、双盲、安慰剂对照的多中心研究中,我们评估了氯维地平治疗术前高血压的药效及耐受性。

方法:我们将152位目前或近期患有高血压的择期心脏手术患者在术前随机分成氯维地平组及安慰剂组。105位患者达到随机化后的入选标准(动脉穿刺置管后的收缩压[SBP] ≥160 mm Hg ),因为用药后SBP较基础值下降≥15%。患者输注氯维地平(0.4–8.0 µg · kg–1 · min–1)20%脂肪乳(安慰剂)至少30分钟。治疗失败的定义为:与基础值相比,SBP下降未能≥15%或因其他原因终止用药。

结果:氯维地平组有92.5%的治疗成功率,失败率(7.5%, 4/53)明显低于对照组(82.7%, 43/52; P < 0.0001)。氯维地平组达到目标血压(SBP降低≥15%的中位数时间为6.0 min95%可信区间6–8 min)。使用氯维地平期间心率与基础值比较会有适度上升。各治疗组的不良事件相似。

结论:氯维地平能快速有效地将择期心脏手术患者的术前血压降至目标血压水平,且能较好地耐受。

(裘毅敏译,马皓琳 李士通 校)

BACKGROUND: Clevidipine is an ultrashort-acting, third-generation IV dihydropyridine calcium channel blocker that exerts rapid and titratable arterial blood pressure reduction, with fast termination of effect due to metabolism by blood and tissue esterases. As an arterial-selective vasodilator, clevidipine reduces peripheral vascular resistance directly, without dilating the venous capacitance bed. In this randomized, double-blind, placebo-controlled multicenter trial we evaluated the efficacy and tolerability of clevidipine in treating preoperative hypertension.

METHODS: One-hundred-fifty-two patients scheduled for cardiac surgery with current or recent hypertension were randomized to receive clevidipine or placebo preoperatively. One-hundred-five patients met postrandomization entrance criteria (systolic blood pressure [SBP] ≥160 mm Hg after inserting an arterial catheter) for reduction by ≥15% from baseline in SBP. The patients thus received infusions of clevidipine (0.4–8.0 µg · kg–1 · min–1) or 20% lipid emulsion (placebo) for at least 30 min. Treatment failure was defined as failure to reduce SBP by ≥15% from baseline or discontinuance of drug for any reason.

RESULTS: Patients treated with clevidipine demonstrated a 92.5% rate of treatment success and a significantly lower rate of treatment failure (7.5%, 4 of 53) than patients receiving placebo (82.7%, 43 of 52; P < 0.0001). Clevidipine achieved target blood pressures (SBP reduced by ≥15%) at a median of 6.0 min (95% confidence interval 6–8 min). A modest increase in heart rate from baseline occurred during clevidipine administration. Adverse events for each treatment group were similar.

CONCLUSIONS: Clevidipine was effective in rapidly decreasing blood pressure preoperatively to targeted blood pressure levels and was well tolerated in patients scheduled for cardiac surgery.

 

 

 

近端等速表面积应该在评估二尖瓣返流中常规测定:核心综述

Proximal Isovelocity Surface Area Should Be Routinely Measured in Evaluating Mitral Regurgitation: A Core Review

A. Stephane Lambert, MD, FRCPC

From the Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.

Anesth Analg 2007; 105:940-943

近端等速表面积(PISA)测定法,又称为“流量汇聚”法,可用于超声心动图来估计血流通过的二尖瓣口面积。它有广泛的运用,但本综述只集中于其在对二尖瓣返流的术中评价中的应用。在这项运用中,PISA可以定量的评价二尖瓣返流的严重程度,且有助于在手术室内临床决策。在本综述中,我讨论了PISA方法后面的物理学原理以及用于计算有效二尖瓣返流口的面积、返流量和返流分数的各种数学公式。以图解和视频演示来呈现和说明逐步逼近法。最后,我将讨论PISA测定法在手术室中的各种局限性和技术考虑因素。

(沈浩    马皓琳 李士通 校)

The proximal isovelocity surface area (PISA) measurement, also known as the "flow convergence" method, can be used in echocardiography to estimate the area of an orifice through which blood flows. It has many applications, but this review focuses only on its use in the intraoperative evaluation of mitral regurgitation. In that setting, PISA provides a quantitative assessment of the severity of mitral regurgitation and it is useful in clinical decision-making in the operating room. In this review, I discuss the physical principles behind the PISA method, along with the various mathematical formulas used to calculate the effective mitral regurgitant orifice area, the regurgitant volume, and the regurgitant fraction. A step-by-step approach is presented and illustrated with graphic and video demonstrations. Finally, I will discuss the various limitations and technical considerations of PISA measurement in the operating room.


 

低浓度戊巴比妥增强大鼠海马神经元兴奋性

Low Concentrations of Pentobarbital Enhance Excitability of Rat Hippocampal Neurons

David P. Archer, MD*, and Sheldon H. Roth, PhD*{dagger}

From the Departments of *Anesthesia and {dagger}Pharmacology and Therapeutics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.

Anesth Analg 2007; 105:993-997

背景:尽管麻醉学家熟悉麻醉诱导和苏醒期的兴奋相,但是对该现象的细胞机制尚未完全了解。在约相当于手术麻醉所需药物浓度1/10时,试验对象对伤害性刺激反应增加。我们此前估计伤害反射阈值的下降最大出现在戊巴比妥浓度约为5 µM时。在此我们使用了大树海马脑片标本来检验5 µM戊巴比妥是否增加神经元的兴奋性。

方法:在刺激Schaffer侧支通路时对海马CA1区神经元进行细胞内记录。我们检测了戊巴比妥对静息细胞膜内在特性的影响和刺激-反应关系。我们评价了突触信号强度(以兴奋性突触后电位斜率表示)和放电可能性之间的关系(E-S关系)。

结果:戊巴比妥增加海马神经元的兴奋性,显示为在任何给定的突触信号强度时放电可能性增高(P = 0.002),这种现象被称为“E-S增强”。戊巴比妥使神经元输入阻抗增加和动作电位阈值负值更大。在任何给定的刺激强度下,戊巴比妥不增加兴奋性突触后电位的斜率。

结论:5 µM浓度时,戊巴比妥通过增加突触后神经元兴奋性增加E-S耦联。戊巴比妥诱发的细胞膜内在特性的改变可能使兴奋性增加。

(颜涛 译,马皓琳 李士通 校)

BACKGROUND: Although the excitation phase observed during anesthetic induction and emergence is familiar to anesthesiologists, the cellular mechanisms of this phenomenon are not well understood. At anesthetic concentrations approximately one-tenth those required for surgical anesthesia, subjects demonstrate increased responsiveness to noxious stimulation. We previously estimated that the decrease in nociceptive reflex threshold is maximal at pentobarbital concentrations of approximately 5 µM. Here we used the rat hippocampal slice preparation to examine whether 5 µM pentobarbital increases the excitability of neurons.

METHODS: Intracellular recordings were obtained from CA1 neurons during stimulation of the Schaffer collateral pathway. We examined the effect of pentobarbital on resting intrinsic membrane properties and stimulus-response relationships. Excitability was evaluated with the relationship between the synaptic signal strength, as indicated by the excitatory postsynaptic potential slope, and the probability of spiking (E-S relationship).

RESULTS: Pentobarbital increased the excitability of hippocampal neurons, as shown by an increased probability of spiking at any given synaptic signal strength (P = 0.002), an effect known as "E-S potentiation." Pentobarbital was associated with an increase in the input resistance of the neuron and a shift of the action potential threshold towards more negative values. Pentobarbital did not increase the excitatory postsynaptic potential slope at any given stimulus strength.

CONCLUSIONS: At a 5 µM concentration, pentobarbital increased E-S coupling by enhancing the excitability of the postsynaptic neurons. Pentobarbital induced changes in intrinsic membrane properties that may contribute to increased excitability.



全身麻醉对用小波变换来评价的人体皮肤微循环的影响

The Effects of General Anesthesia on Human Skin Microcirculation Evaluated by Wavelet Transform

Svein Aslak Landsverk, MD*, Per Kvandal, MD{dagger}, Alan Bernjak, BSc{ddagger}, Aneta Stefanovska, PhD{ddagger}§, and Knut A. Kirkeboen, MD, PhD*||

From the Departments of *Anesthesiology, {dagger}Intensive Care Medicine, Ulleval University Hospital, Oslo, Norway; {ddagger}Faculty of Electrical Engineering, University of Ljubljana, Ljubljana, Slovenia; §Department of Physics, Lancaster University, Lancaster, UK; and ||Institute for Experimental Medical Research, Ulleval University Hospital, Oslo, Norway.

Anesth Analg 2007; 105:1012-1019

背景:用小波变换进行的对激光多普勒血流仪信号的时间-频率分析,显示了与心脏(0.6–2 Hz)、呼吸(0.15–0.6 Hz)、血管壁中肌源性活性((0.052–0.15 Hz)、交感活性(0.021–0.052 Hz)和很低的振动(0.0095–0.021)有关的5个特定频率上的周期振动,这些可通过内皮依赖性的血管舒张剂乙酰胆碱来调节。我们假设激光多普勒血流仪信号的小波变换可发现全麻引起的微循环的变化,诸如血管舒缩和交感神经活性。

方法:收入11例进行面颌部手术的患者。在用丙泊酚、芬太尼和咪达唑仑的全身麻醉前和全身麻醉过程中,用激光多普勒血流仪及乙酰胆碱和硝普钠离子透入法在前臂下部分测定皮肤微循环。用小波变换分析激光多普勒血流仪信号。

结果:光谱幅度在0.00950.021P < 0.01)、0.0210.052P < 0.001)和0.0520.15 Hz 频程中(P < 0.01)显著减小,在0.150.6 Hz频程中显著增大。全身麻醉对在0.00950.021 Hz频程中相对幅度上的乙酰胆碱与硝普钠之间的差异无影响。

结论:全身麻醉降低与交感、肌源性活性相关的灌注信号的振动成份和内皮调节的成份。然而,离子透入法数据并未揭示对内皮的特殊作用。在0.150.6 Hz频程中的增大与机械通气的作用有关。

(马皓琳   李士通 校)

BACKGROUND: Time-frequency analysis of the laser Doppler flowmetry signal, using wavelet transform, shows periodic oscillations at five characteristic frequencies related to the heart (0.6–2 Hz), respiration (0.15–0.6 Hz), myogenic activity in the vessel wall (0.052–0.15 Hz), sympathetic activity (0.021–0.052 Hz), and very slow oscillations (0.0095–0.021), which can be modulated by the endothelium-dependent vasodilator acetylcholine. We hypothesized that wavelet transform of laser Doppler flowmetry signals could detect changes in the microcirculation induced by general anesthesia, such as alterations in vasomotion and sympathetic activity.

METHODS: Eleven patients undergoing faciomaxillary surgery were included. Skin microcirculation was measured on the lower forearm with laser Doppler flowmetry and iontophoresis with acetylcholine and sodium nitroprusside before and during general anesthesia with propofol, fentanyl, and midazolam. The laser Doppler flowmetry signals were analyzed using wavelet transform.

RESULTS: There were significant reductions in spectral amplitudes in the 0.0095–0.021 (P < 0.01), the 0.021–0.052 (P < 0.001), and the 0.052–0.15 Hz frequency interval (P < 0.01) and a significant increase in the 0.15–0.6 Hz frequency interval. General anesthesia had no effect on the difference between acetylcholine and sodium nitroprusside on relative amplitudes in the 0.0095–0.021 Hz frequency interval (P < 0.001).

CONCLUSION: General anesthesia reduces the oscillatory components of the perfusion signal related to sympathetic, myogenic activity and the component modulated by the endothelium. However, the iontophoretic data did not reveal a specific effect on the endothelium. The increase in the 0.15–0.6 Hz interval is related to the effect of mechanical ventilation.

 

 

 

丝裂原活化蛋白激酶磷酸酶-1上调和细胞外信号调节激酶1/2磷酸化降解介导昔多芬对肺动脉平滑肌细胞的抗增殖作用

The Antiproliferative Effect of Sildenafil on Pulmonary Artery Smooth Muscle Cells Is Mediated via Upregulation of Mitogen-Activated Protein Kinase Phosphatase-1 and Degradation of Extracellular Signal-Regulated Kinase 1/2 Phosphorylation

Bingbing Li, MD, PhD*, Lingchao Yang, MD{dagger}, Jianying Shen, MD, PhD{ddagger}, Chunshen Wang, MD§, and Zhen Jiang, MD*

From the *Department of Anesthesiology, Zhongshan Hospital affiliated Fudan University; {dagger}Department of Cardiology, School of Medicine, Xinhua Hospital affiliated Shanghai Jiaotong University; {ddagger}Departments of Cardiology; and §Cardiac Surgery, Zhongshan Hospital affiliated Fudan University, Shanghai, China.

Anesth Analg 2007; 105:1034-1041

背景:肺动脉高压是包括血管缩窄和肺血管系统闭塞性改变的一组疾病。磷酸二酯酶5型抑制剂如昔多芬可缓解野百合碱所致大鼠肺动脉高压模型的肺血管重构,且可在体外实验中抑制肺血管平滑肌细胞增殖。本实验研究了昔多芬抑制血小板衍生生长因子(PDGF)诱导的猪肺动脉平滑肌细胞增殖的能力。

方法:采用MTT测定和荧光激活细胞分选术评估肺动脉平滑肌细胞增殖和细胞周期分析。采用蛋白质印迹法测定丝裂原活化蛋白激酶磷酸酶-1MKP-1)的蛋白质表达和细胞外信号调节激酶(ERK1/2)的磷酸化水平。

结果:PDGF促进细胞增殖,增加处于S相细胞的百分比。这些效应可被昔多芬预处理剂量依赖性抑制。昔多芬(96 µM)也可使PDGF激发的ERK1/2磷酸化减少67%。昔多芬抑制ERK1/2的同时也快速诱导MKP-1表达。采用Rp-8-BrcGMPS25µM)抑制cGMP-依赖的激酶I {alpha}cGK I {alpha})可阻断昔多芬诱导的MKP-1表达。昔多芬对于PDGF激发的ERK1/2磷酸化和PDGF诱导的修复性细胞增殖的抑制作用可被磷酸酶抑制剂钒酸盐(12.5 µM)或Rp-8-BrcGMPS取消。

结论:本研究表明昔多芬可通过上调MKP-1表达并促进ERK1/2磷酸化降解来抑制肺动脉平滑肌细胞增殖。

(周雅春 马皓琳 李士通 校)

BACKGROUND: Pulmonary hypertension is a group of diseases comprising vascular constriction and by obstructive changes of the pulmonary vasculature. Phosphodiesterase type 5 inhibitors, e.g., sildenafil, can alleviate vascular remodeling in the monocrotaline pulmonary hypertension model in rats, and inhibit the proliferation of pulmonary vascular smooth muscle cells in vitro. We examined the ability of sildenafil to inhibit platelet-derived growth factor (PDGF)-induced proliferation of porcine pulmonary artery smooth muscle cells.

METHODS: Pulmonary artery smooth muscle cell proliferation and cell cycle analysis were assessed by MTT assay and fluorescence-activated cell sorting. Western blotting was used to examine protein expression of mitogen-activated protein kinase phosphatase-1 (MKP-1) and phosphorylation level of extracellular signal-regulated kinase (ERK1/2).

RESULTS: PDGF increased cell proliferation and the percentage of cells in S phase. These effects were inhibited by pretreatment with sildenafil in a dose-dependent manner. Sildenafil (96 µM) also caused a 67% decrease in PDGF-stimulated ERK1/2 phosphorylation. Sildenafil inhibition of ERK1/2 was accompanied by a rapid induction of MKP-1. Inhibition of the cGMP-dependent kinase I {alpha}(cGK I {alpha}) using Rp-8-BrcGMPS (25 µM) blocked sildenafil-induced MKP-1 expression. Either vanadate (12.5 µM), a phosphatase inhibitor, or Rp-8-BrcGMPS abolished the inhibitory effect of sildenafil on PDGF-stimulated phosphorylation of ERK1/2 and restored PDGF-induced cell proliferation.

CONCLUSION: This study indicates that sildenafil upregulates MKP-1 expression and promotes degradation of phosphorylation of ERK1/2, which suppresses the proliferation of pulmonary artery smooth muscle cells.


 

一项关于理论麻醉计划中异丙酚滥用的调查

A Survey of Propofol Abuse in Academic Anesthesia Programs

 

Paul E. Wischmeyer, MD*, Bradley R. Johnson, BS{dagger}, Joel E. Wilson, MD*, Colleen Dingmann, RN, PhD*, Heidi M. Bachman, BS*, Evan Roller, BS{dagger}, Zung Vu Tran, PhD{ddagger}, and Thomas K. Henthorn, MD*

From the *Department of Anesthesiology, University of Colorado, Denver, Colorado; {dagger}Department of Chemistry, Valparaiso University, Valparaiso, Indiana; and {ddagger}Department of Biostatistics, University of Colorado, Denver, Colorado.

Anesth Analg 2007; 105:1066-1071

背景:虽然异丙酚不是一种传统意义上的滥用药物,但亚麻醉剂量存在滥用的可能。该调查用于评估理论麻醉计划中异丙酚滥用的流行率及后果。

方法:对美国126个理论麻醉学训练计划发放电子邮件问卷。

结果:调查回复率为100%18%的部门报道了过去10年中至少有一次异丙酚滥用或转换的事件。观察到的异丙酚滥用事件发生率为10/10,000例麻醉/10年,比以往滥用异丙酚调查结果增高五倍(P = 0.005).。被报道的25例滥用异丙酚的个体中,7人死于滥用异丙酚(28%),其中6人是定居者。71%的计划没有象阿片类药物那样有明确的体系来控制或监管异丙酚。计划中滥用时异丙酚管理的缺乏(如药方记帐)和滥用的发生率具有相关性(P = 0.048)

结论:理论麻醉学中异丙酚滥用的现象在过去10年中似乎有所增加。很多死亡率发生在定居者。大多数计划缺乏药房记帐或异丙酚库存的控制。如果所有报道因滥用异丙酚致死的计划是没有药房记帐的中心,这就值得注意了。

(唐李隽   马皓琳 李士通 校)

BACKGROUND: Although propofol has not traditionally been considered a drug of abuse, subanesthetic doses may have an abuse potential. We used this survey to assess prevalence and outcome of propofol abuse in academic anesthesiology programs.

METHODS: E-mail surveys were sent to the 126 academic anesthesiology training programs in the United States.

RESULTS: The survey response rate was 100%. One or more incidents of propofol abuse or diversion in the past 10 yr were reported by 18% of departments. The observed incidence of propofol abuse was 10 per 10,000 anesthesia providers per decade, a fivefold increase from previous surveys of propofol abuse (P = 0.005). Of the 25 reported individuals abusing propofol, 7 died as a result of the propofol abuse (28%), 6 of whom were residents. There was no established system to control or monitor propofol as is done with opioids at 71% of programs. There was an association between lack of control of propofol (e.g., pharmacy accounting) at the time of abuse and incidence of abuse at the program (P = 0.048).

CONCLUSIONS: Propofol abuse in academic anesthesiology likely has increased over the last 10 yr. Much of the mortality is in residents. Most programs have no pharmacy accounting or control of propofol stocks. This may be of concern, given that all programs reporting deaths from propofol abuse were centers in which there was no pharmacy accounting for the drug.

 

 

 

一项关于通过Evac气管导管吸引声门下分泌物失败的研究

Investigating the Failure to Aspirate Subglottic Secretions with the Evac Endotracheal Tube

Christos K. Dragoumanis, MD, PhD*, George I. Vretzakis, MD, PhD{dagger}, Vassilios E. Papaioannou, MD, PhD*, Vassilios N. Didilis, MD, PhD{ddagger}, Theodsia D. Vogiatzaki, MD, PhD§, and Ioannis A. Pneumatikos, MD, PhD*

From the *Department of Intensive Care, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece; {dagger}Department of Anesthesiology, University of Thessaly Medical School, Larissa, Greece; and Departments of {ddagger}Cardiothoracic Surgery, §Anesthesiology, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.

Anesth Analg 2007; 105:1083-1085

背景:抽吸声门下分泌物这种方法广泛被用于预防呼吸机相关性肺炎。然而使用Hi-Lo® Evac型气管导管 (Hi-Lo Evac; Mallinckrodt; Athlone, 爱尔兰) (Evac ETT),吸引管常常发生异常,且随后不能抽吸声门下分泌物。本研究拟探讨使用Evac ETT时吸引管功能失常的原因。

方法:我们研究了40例用Evac ETT插管的成年病人。在所有病例中观察吸引管的功能失常,并通过可曲式支气管镜可视性观察声门下吸引口。

结果:40例病人中,19例病人吸引管吸引失败(48%)。其中17例病人(43%)是由于声门下吸引口被吸出的气管粘膜堵塞所致。

结论:使用Evac ETT时,由于气管粘膜脱出到声门下吸引口从而不能有效吸净声门下分泌物。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: Aspiration of subglottic secretions is a widely used intervention for prevention of ventilator-associated pneumonia. However, using the Hi-Lo® Evac endotracheal tube (Hi-Lo Evac; Mallinckrodt; Athlone, Ireland) (Evac ETT), dysfunction of the suction lumen and subsequent failure to aspirate the subglottic secretions are common. Our objective in this study was to determine the causes of suction lumen dysfunction experienced with the Evac ETT.

METHODS: We studied 40 adult patients intubated with the Evac ETT. In all cases for which dysfunction of the suction lumen was observed, the subglottic suction port was examined visually using a flexible bronchoscope.

RESULTS: Dysfunction of the suction lumen occurred in 19 of 40 patients (48%). In 17 of these (43%), it was attributed to blockage of the subglottic suction port by suctioned tracheal mucosa.

CONCLUSION: Evacuation of subglottic secretions using the Evac ETT is often ineffective due to prolapse of tracheal mucosa into the subglottic suction port.


 

关于脑组织氧合变化原因的模型

Modeling the Causes of Variation in Brain Tissue Oxygenation

Iain K. Moppett, DM, FRCA, and Jonathan G. Hardman, DM, FRCA

From the Division of Anaesthesia and Intensive Care, Queen’s Medical Centre Campus, Nottingham University Hospitals, Nottingham, UK.

Anesth Analg 2007; 105:1104-1112

背景:临床上表明脑灌注充分的标记可能是令人误解的。体循环血压、Paco2Pao2和脑水肿的各自的变化对脑血流量以及氧合作用的影响是相对比较明确的,而这些因素之间的相互作用的定量效应并不容易计算出来。我们的目的是应用一个计算模型研究这些因素的相互关系。

方法:应用一个关于脑血流的已被验证过的定量计算模型,记录体循环血压(50–180 mm Hg)Paco2 (33–55 mm Hg [4.3–7.3 kPa])Sao2 (0.8–1.0)和脑水肿(毛细血管间距增加0%–10%)等因素的变化对大脑中动脉流速(MCAFV)、脑组织氧合(Pbo2)以及颈静脉血氧饱和度(Sjo2) 的模拟影响。

结果:脑灌注充分的单独指标(MCAFVSjo2Pbo2)与研究的参数中单一变化的临床数据相一致:MCAFV Sjo2的自身调节的下限在平均动脉压60 mm Hg左右。在我们的模型中,自身调节的上限在平均动脉压170mm Hg左右,但是Sjo2Pbo2不及MCAFV显著。从我们的模拟试验来看,显著的脑缺血不太可能与各个单独的生理变化一同发生。然而,在该模型中,低血压、缺氧以及水肿的综合作用使缺血发生的可能性增大很多。水肿增加了Sjo2:Pbo2的梯度,证实了弥散限制性氧运输可能会产生安慰性的假性Sjo2值。

结论:病理生理变化对脑氧合和灌注的影响已定量描述。两个或者更多的生理紊乱的存在预示着明显的脑缺血。脑水肿使Sjo2Pbo2之间的梯度增加。

(黄丽娜     马皓琳  李士通  校)

BACKGROUND: Clinical markers of the adequacy of cerebral perfusion may be misleading. The effects of isolated changes in systemic blood pressure, Paco2, Pao2, and cerebral edema on cerebral blood flow and oxygenation are relatively well known, but the quantitative effects of interactions between these factors are not easily calculated. We aimed to investigate the relationship between these factors using a computational model.

METHODS: Using a validated, quantitative, computational model of cerebral blood flow, the simulated effects of changes in systemic blood pressure (50–180 mm Hg), Paco2 (33–55 mm Hg [4.3–7.3 kPa]), Sao2 (0.8–1.0), and cerebral edema (0%–10% increase in intercapillary distance) on middle cerebral artery flow velocity (MCAFV), brain tissue oxygenation (Pbo2), and jugular venous oxygen saturation (Sjo2) were recorded.

RESULTS: Individual markers of adequacy of cerebral perfusion (MCAFV, Sjo2, and Pbo2) behave in accordance with clinical data with single changes in the parameters studied: the lower limit of autoregulation for MCAFV and Sjo2 lies around 60 mm Hg mean arterial blood pressure. In our model, the upper limit of autoregulation lies around 170 mm Hg, but is much less distinct for Sjo2 and Pbo2 than for MCAFV. Significant cerebral ischemia appears unlikely to occur with isolated physiological changes according to our simulation. However, the combination of hypotension, hypoxia, and edema makes ischemia much more likely in this model. Edema increases the Sjo2:Pbo2 gradient, confirming that diffusion-limited oxygen delivery may make Sjo2 values falsely reassuring.

CONCLUSION: The simulated effects of pathophysiological changes on cerebral oxygenation and perfusion have been quantitatively described. Significant cerebral ischemia is predicted in the presence of two or more physiological derangements. Cerebral edema is associated with an increased gradient between Sjo2 and Pbo2.


 

硬膜外给予AMPA/红藻氨酸盐受体拮抗剂Tezampanel对大鼠的术后镇痛作用

Epidural Tezampanel, an AMPA/Kainate Receptor Antagonist, Produces Postoperative Analgesia in Rats

Hee Cheol Jin, MD, PhD, Amber J. Keller, MD, Jong Kwon Jung, MD, Alberto Subieta, BS, and Timothy J. Brennan, MD, PhD

From the Department of Anesthesia, University of Iowa College of Medicine, Iowa City, Iowa.

Anesth Analg 2007; 105:1152-1159

背景:我们在大鼠术后疼痛模型中评价硬膜外给予一种非NMDA受体拮抗剂tezampanel的镇痛效应。硬膜外给药后,我们尝试通过测试其对正常大鼠对热刺激反应的影响来确定该药是否影响伤害感受。还研究了硬膜外tezampanel对切开脚底的大鼠疼痛相关性行为的影响。

方法:麻醉大鼠,并在硬膜外置管。硬膜外置管一天后,测定热退缩潜伏期的基础值。通过测定硬膜外给予tezampanel或吗啡对热退缩潜伏期的影响来检验其镇痛作用。并且检查运动功能。与皮下药物给予相比较。另一部分大鼠则在硬膜外置管后行脚底切开,以评价切开引起的疼痛行为。测定硬膜外给予tezampanel后,基于对von Frey丝的保护性退缩阈值和对热刺激的退缩潜伏期的累积疼痛评分。同时测定硬膜外给予tezampanel对动脉血压和心率的影响。

结果:硬膜外给予tezampanel或吗啡均延长了对热刺激的退缩潜伏期。只有皮下给予吗啡可以影响热退缩潜伏期。脚底切开后,硬膜外给予tezampanel降低保护性疼痛评分中位值,延长热退缩潜伏期,并且提高机械刺激退缩阈值,提示其有镇痛作用。动脉血压和心率在硬膜外给药后没有变化。

结论:这些实验显示硬膜外给予tezampanel 可以产生对热刺激的镇痛作用,影响一部分大鼠的运动功能,且降低切皮引发的疼痛行为。给予最大剂量,也没有明显的全身镇痛作用。

(张莹译  马皓琳 李士通校)

BACKGROUND: We evaluated the epidural administration of tezampanel, a non-N-methyl-d-aspartate receptor antagonist, in a rat model for postoperative pain. We sought to determine if this drug affects nociception when administered epidurally by testing its effects on responses to heat in normal rats. The effects of epidural tezampanel on pain-related behaviors in rats that underwent plantar incision were also studied.

METHODS: Rats were anesthetized and epidural catheters were placed. One day after epidural catheterization, the baseline heat withdrawal latency was measured. Epidural tezampanel or morphine was tested for analgesia by examining their effects against heat withdrawal latency. Motor function was also tested. Comparisons to subcutaneous drug administration were made. Other rats underwent plantar incision after epidural catheterization to assess pain behavior caused by incision. The effects of epidural tezampanel on the cumulative pain scoring, based on guarding, the withdrawal threshold to von Frey filament application, and the withdrawal latency to heat, were measured. The effects of epidural tezampanel on arterial blood pressure and heart rate were also tested.

RESULTS: Both epidural morphine and epidural tezampanel increased withdrawal latency to heat. Only subcutaneous morphine affected heat withdrawal latency. After plantar incision, epidural tezampanel decreased the median guarding pain score, increased the heat withdrawal latency and increased the mechanical withdrawal threshold indicating analgesic effects. Arterial blood pressure and heart rate did not change after epidural drug administration.

CONCLUSION: These experiments demonstrate that epidural administration of tezampanel produces analgesia to heat, motor side effects in some rats, and reduces pain behaviors caused by incision. No systemic analgesia was apparent using the largest dose.

 

 

左旋布比卡因复合(深丛和浅丛)颈丛与颈浅丛阻滞用于微创甲状旁腺切除术的前瞻性随机比较研究

A Prospective, Randomized Comparison Between Combined (Deep and Superficial) and Superficial Cervical Plexus Block with Levobupivacaine for Minimally Invasive Parathyroidectomy

Tatjana Stopar Pintaric, MD, MSc*, Marko Hocevar, MD, PhD{dagger}, Simona Jereb, MD{ddagger}, Andrea Casati, MD§, and Vesna Novak Jankovic, MD, PhD||

From the Departments of *Anaesthesiology, {dagger}Surgery, {ddagger}Radiology, Institute of Oncology, Ljubljana, Slovenia; §Department of Anaesthesiology, University of Parma, Parma, Italy; and ||Department of Anaesthesiology and Intensive Therapy, Clinical Center Ljubljana, Ljubljana, Slovenia.

Anesth Analg 2007; 105:1160-1163

背景:微创甲状旁腺切除术(Minimally invasive parathyroidectomy, MIP)可在颈丛阻滞(cervical plexus block, CPB)下完成。据报道颈浅丛阻滞与复合深、浅丛阻滞效果相似,且更易操作,麻醉相关的并发症也较少。在这项研究中,我们比较颈浅丛阻滞和复合(深、浅丛)CPBMIP患者中应用的效果。

方法:42例单一腺瘤引起的原发性甲状旁腺亢进患者,随机分成两组,分别用0.5%左旋布比卡因0.35 mL/kg施行颈浅丛阻滞(浅丛组,n = 20)或复合深丛和浅丛CPB(复合组,n = 22)。以完成手术需追加的芬太尼量为主要终点。

结果:两组阻滞起效、术中疼痛评分和首次需要镇痛药的时间均无明显差异。芬太尼的消耗量两组相似,即浅丛组50 (0–200) µg,复合组50 (0–100) µg(P = 0.60)6例患者[浅丛组1(5%),复合组5(22.7%)]由于手术需要进行双侧颈部淋巴清扫而改为全身麻醉(P = 0.18)。因阻滞失败而行全身麻醉的浅丛组有3例(15%),复合组有2例(9%(P = 0.99)。复合组中仅有1例阻滞后出现膈肌麻痹(P = 0.99)

结论:颈浅丛阻滞可替代复合深、浅丛阻滞进行MIP

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Minimally invasive parathyroidectomy (MIP) can be performed under cervical plexus block (CPB). Superficial CPB has been reported to be easier to perform with similar efficacy and less anesthesia-related complications than combined deep and superficial CPB. In this study, we compared the efficacy of superficial and combined (deep and superficial) CPB in patients undergoing MIP.

METHODS: Forty-two patients with primary hyperparathyroidism due to a solitary adenoma were randomized to receive either a superficial (group superficial, n = 20) or a combined deep and superficial CPB (group combined, n = 22) using 0.35 mL/kg of 0.5% levobupivacaine. The primary end-point was the amount of supplemental fentanyl required to complete surgery.

RESULTS: There were no differences in onset of block, pain scores during surgery, or time to first analgesic request between groups. Fentanyl consumption was similar in both groups, i.e., 50 (0–200) µg in group superficial and 50 (0–100) µg in group combined (P = 0.60). Six patients [1 in group superficial (5%) and 5 in group combined (22.7%)] were converted to general anesthesia for surgically required bilateral neck dissection (P = 0.18). General anesthesia for block failure was reported in three superficial (15%) and two combined group patients (9%) (P = 0.99). In group combined, only one patient (4.5%) showed diaphragmatic paresis after the block (P = 0.99).

CONCLUSION: Superficial CPB is an alternative to combined block for MIP.

 

 

 

EpisureTM注射器:一个奇特的用来定位硬膜外间隙的阻力消失注射器

The EpisureTM Syringe: A Novel Loss of Resistance Syringe for Locating the Epidural Space

Edward T. Riley, MD, and Brendan Carvalho, MBBCh, FRCA

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

Anesth Analg 2007; 105:1164-1166

介绍EpisureTM注射器是一个独特的装有弹簧的阻力消失(LOR)注射器,在Portex PulsatorTM LOR注射器里有一个共轴的压缩弹簧。这个弹簧在操作者用图伊硬膜外穿刺针进针时,提供一个恒压。

方法:我们用黄韧带的人工模型、麻醉的猪和需要硬膜外镇痛分娩的产妇评估此穿刺针。

结果:用安装了弹簧的注射器的术者能阻止穿刺针的前进,因此与一个标准的LOR注射器相比较,针突出实验室模型的背面较少。人类研究中令人满意的分娩镇痛和猪模型中的X光照片分析证实都放置在硬膜外腔。

结论:安装弹簧的注射器可能是有用的LOR注射器,提供可靠客观的证明在硬膜外腔。

(张曦 译,马皓琳 李士通 校)

INTRODUCTION: The Episure syringeTM is a unique spring-loaded loss-of-resistance (LOR) syringe with a coaxial compression spring within a Portex PulsatorTM LOR syringe. This syringe supplies a constant pressure while the operator is advancing the Tuohy needle.

METHODS: We evaluated the syringe using an artificial model of the ligamentum flavum, an anesthetized pig, and women who desired epidural analgesia for labor.

RESULTS: The operator, using the spring-loaded syringe, was able to stop the forward movement of the needle, so that compared with a standard LOR syringe less of the needle protruded out the back of the laboratory model. Satisfactory labor analgesia in the human study and radiograph analyses in the porcine model confirmed epidural placement in all attempts.

CONCLUSION: The spring-loaded syringe is a potentially useful LOR syringe that provides a reliable, objective end-point for identification of the epidural space.