Anesthesia & Analgesia

October 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:

較大矯形手術期間輸注晶體或膠體液後止血功能變化:纖維蛋白原的作用

張燕 陳傑

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.

氯維地平快速有效控制心臟手術患者術前的高血壓:評價氨維地平在心臟手術-1術前抗高血壓作用的一項隨機、安慰劑對照的效能研究結果

裘毅敏譯,馬皓琳 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.

異氟醚啟動脂質雙分子層的人心臟線粒體三磷酸腺苷敏感的鉀離子通道的再生

吳威譯 薛張綱校

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彈性監測表明肝素和比伐盧定的凝血酶抑制方式不同

張美榮 陳傑

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.

近端等速表面積應該在評估二尖瓣返流中常規測定:核心綜述

沈浩    馬皓琳 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.

綜述:抑肽酶在心臟手術中作用機制研究及其進展

陳愷錚譯 薛張綱校

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監測儀和腦電圖用於異丙酚誘導鎮靜

王鵬 陳傑

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:

低濃度戊巴比妥增強大鼠海馬神經元興奮性

顏濤 譯,馬皓琳 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.

人外周單核細胞表達孤啡肽阿片受體,無μδκ阿片受體表達

陳勇柱譯 薛張綱校

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

異氟醚對在體大鼠海馬CA1區域雙脈衝效應具有雙向性

王騰 陳傑

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.

全身麻醉對用小波變換來評價的人體皮膚微循環的影響

馬皓琳   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.

使用異氟醚、氟烷及異丙酚後腹側脊髓索的抑制大於背側脊髓索

孫霞譯  薛張綱校

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.

異丙酚對過氧化氫刺激的人體臍靜脈內皮細胞具有減少凋亡並上調內皮一氧化氮合酶蛋白表達作用

於章傑 陳傑

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.

絲裂原活化蛋白激酶磷酸酶-1上調和細胞外信號調節激酶1/2磷酸化降解介導昔多芬對肺動脈平滑肌細胞的抗增殖作用

周雅春 馬皓琳 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:

顳動脈測溫器對比膀胱測溫器在術中及重症監護病房的監測

陳佳莉譯 薛張綱校        

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.

一項通過標準呼吸回路監測混合呼氣末CO2的簡單方法

潘方立 陳傑

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:

腦血流量及氧合的集成計算模型的研製與價值

潘錢玲 陳傑

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.

一項關於理論麻醉計畫中異丙酚濫用的調查

唐李雋   馬皓琳 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:

肺壓力-容積曲線得到的參數可以揭示實驗肺損傷後的復原情況,壓力-時間曲線沒有這個作用

陳珺珺譯 薛張綱校

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.

-靜腎臟替代療法對熱稀釋技術的影響

陳偉 陳傑 )

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.

一項關於通過Evac氣管導管吸引聲門下分泌物失敗的研究

邱郁薇 馬皓琳 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:

靜注右旋美托咪啶預防大鼠脊柱非損傷性缺血後鞘注嗎啡引起的脊髓腹側神經元變性

璿譯 薛張綱校

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.

關於腦組織氧合變化原因的模型

黃麗娜     馬皓琳  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:

脊麻剖宮產手術圍術期吸氧並不能避免或者減輕噁心嘔吐的發生

王光妍 薛張綱校

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:

喉鏡檢查期間二維解剖關係

宋翠俠 陳傑

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:

精索靜脈曲張手術術前應用加巴噴丁(抗焦慮藥)或者地塞米松,或者二者聯合運用:一項隨機對照試驗

周時蓓譯 薛張綱校

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.

阿片藥導致PACU中的鎮靜不能確保足夠鎮痛:病例對照研究

杜唯佳 陳傑

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.

硬膜外給予AMPA/紅藻氨酸鹽受體拮抗劑Tezampanel對大鼠的術後鎮痛作用

張瑩譯  馬皓琳 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.

左旋布比卡因複合(深叢和淺叢)頸叢與頸淺叢阻滯用於微創甲狀旁腺切除術的前瞻性隨機比較研究

慧譯 馬皓琳 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:一個奇特的用來定位硬膜外間隙的阻力消失注射器

張曦 譯,馬皓琳 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.

 

較大矯形手術期間輸注晶體或膠體液後止血功能變化:纖維蛋白原的作用

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:為了探討纖維蛋白聚合功能紊亂是否是稀釋性凝血功能障礙的主要問題以及是否可通過給予纖維蛋白原而逆轉,作者採用改良血栓彈性描記法進行了一項前瞻性研究。

方法: 66例矯形手術病人隨機接受改良明膠溶液,羥乙基澱粉130/0.4 ,或僅用乳酸林格液。用血栓彈性描記法分析,測定凝血因數濃度及凝血酶標記物。當血栓彈性描記法實測纖維蛋白聚合作用急劇降低時使用纖維蛋白原(30 mg/kg)。

結果:在接受羥乙基澱粉的病人(曲線下面積負基準( -5 [ -9-2 ] )中,{alpha}角,凝塊硬度和纖維蛋白原聚合(中位數[最小到最大] )明顯降低,其次是明膠溶液( -3 [ -8 0 ] ,最少的是乳酸林格液( -2 [ -41] (膠體與乳酸林格液相比,P< 0 .0001 。膠體組1 3名患者而非乳酸林格液組患者需要纖維蛋白原來維持凝塊堅固性邊界線。使用膠體使活化Ⅶ因數、Ⅷ因數、Ⅸ因數和von Willebrand因數的活性明顯下降。組間血栓彈性描記法測凝血時間,凝血酶分子標記物及其他凝血因數相當。

結論:在較大矯形手術中,纖維蛋白原/纖維蛋白聚合的紊亂是稀釋性凝血功能障礙的主要問題。凝血塊硬度降低由使用的液體類型決定,其中以羥乙基澱粉影響最為明顯。使用纖維蛋白原來增加纖維蛋白原的濃度可以逆轉容量療法、持續失血和血液替換治療中的不良反應。

(張燕 陳傑 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彈性監測表明肝素和比伐盧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:凝血試驗例如部分凝血活酶時間和活化凝血時間常用來監測肝素和凝血酶抑制劑比伐盧定的效果。當凝血酶的形成小於5%時,這些試驗僅反映血液凝固的起始相。在這個研究中,作者研究了肝素和比伐盧定引起的部分凝血活酶時間和活化凝血時間的延長是否可以反映凝血酶形成的抑制程度。

方法:用凝血酶形成測定法評估含肝素(0-5U/mL)或比伐盧定(0-30ug/mL)抗凝的貧血小板的血清的凝血酶形成。用凝血酶原片段1.2來測定凝血酶原的啟動情況。用Sonoclot和凝血彈性描記法來評估陶土啟動的含有肝素(1.52.5U/mL)或比伐盧定(12.525ug/mL)的全血樣本的血栓形成情況。

結果:根據凝血酶形成測定法的結果,隨著比伐盧定和肝素濃度的升高,凝血酶形成逐漸延遲,但僅肝素有劑量依賴性減少凝血酶的產生。肝素和比伐盧定延遲了凝血酶原片段1.2的產生,但是含比伐盧定的血樣和未抗凝血樣中凝血酶原片段1.2水準峰值沒有差別。在肝素化的血樣中,凝血酶原片段1.2水準明顯的低於對照組。在粘彈性測定中肝素和比伐盧定延遲了凝血,但只有肝素減少了血栓發生率。

結論:雖然肝素和比伐盧定的延長凝血試驗值相似,但在血栓形成動力學方面是不同的。

(張美榮 陳傑 )

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監測儀和腦電圖用於異丙酚誘導鎮靜

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)是一種監測鎮靜水準的單頻腦電圖,它是基於視覺腦電圖評分系統建立的, Loomis發明並由Kugler改良發展,可以作出區分鎮靜6個不同水準(A-F)差異的視覺專項分級圖(VEC),這六種圖像可以被繼續分為16種級別。作者設計本研究目的是比較單頻NCT自動分類的結果與5EEGVEC所得結果差異。

方法:12名男性志願者隨機用兩種不同的方法注射丙泊酚,交換用NCT監測和VEC監測。將NCT的評分結果與VEC比較。

結果:在丙泊酚注射期間14個樣本(占總數24個的58%)差異超過三個分級,NCT顯示的結果低於VEC的結果,占總數的25%24個樣本中9.37%)出現不一致的趨勢(至少5個單向差異,而且NCTVEC中均出現相反的趨勢結果)。此外,NCT監測有多個時段不能顯示趨勢,時間從幾秒鐘到10分鐘之間。

結論:正如NCT的規則系統獨有的並不被大眾接受, NCTVEC兩者差異的原因不易分析,解釋仍是推測的。

(王鵬 陳傑 )

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.


異氟醚對在體大鼠海馬CA1區域雙脈衝效應具有雙向性

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:作者在體研究具有完整的中間神經電路中異氟醚對海馬突觸傳遞和雙脈衝可塑性的影響。

方法:用長期植入電極的大鼠,刺激海馬CA1區的Schaffer collsterals,以測量興奮性突觸後電位EPSP群峰電位PSA)。大鼠吸入0.25-1.5MAC的異氟醚下機械通氣。對照組則不吸異氟醚。

結果:異氟醚能抑制EPSP的反應,增強突觸效能。而PSA只有在高濃度的異氟醚通氣條件下才會被抑制。也許是因為抑制了EPSP的反應,增強突觸效能,反射性的形成一個很好的平衡聯合體,低濃度的異氟醚(0.25-0.5MAC)增強(雙脈衝的增強作用)PPF,而高濃度的異氟醚(1.5MAC)延長雙脈衝的抑制作用。

結論:異氟醚對CA1區域突觸多個位點的影響作用:1)抑制EPSP,增 PPF顯示其抑制突觸前谷氨酸的傳導;2)在高濃度條件下延長PPF抑制PSA,顯示異氟醚對錐體神經元的抑制作用;3)對神經元之間的抑制作用表現在增強了突觸效應。抑制作用的程度因異氟醚濃度的不同而不同,而整體方向的突觸性質依賴於在體內抑制效應之間達到的一種平衡。

(王騰 陳傑 )

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.


異丙酚對過氧化氫刺激的人體臍靜脈內皮細胞具有減少凋亡並上調內皮一氧化氮合酶蛋白表達作用

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:血管內皮細胞在維持心血管穩態方面起重要作用。氧化應激在引起內皮細胞損傷和心血管疾病方面是一關鍵的致病因數。此次試驗評估了異丙酚對於氧化應激誘導的內皮細胞損傷的作用和是否涉及絲氨酸-蘇氨酸激酶Akt調節內皮一氧化氮合酶(eNOS)這一保護機制。

方法:使用人體臍靜脈內皮細胞作為試驗模型。使用過氧化氫(H2O2,100μM)作為氧化應激刺激物。分組包括1)對照;2)細胞僅經H2O2處理;3)細胞僅經異丙酚(50μM)處理;4)細胞經50μM異丙酚預處理30分鐘後給予H2O2。使用3-(45-二甲基噻唑-2-烴基)-25-聯苯四唑溴鹽測定法和台盼藍不相容試驗評估細胞成活力。使用煙酸己可堿33258染色法評估細胞凋亡。使用CaspACE比色分析系統評估Caspase-3活性。使用Western blot檢測Akt、磷酸AkteNOS表達。

結果:H2O2作用於人體臍靜脈內皮細胞上能減少細胞成活力,誘導凋亡和增加Caspase-3活性。異丙酚能顯著地保護細胞,減少H2O2誘導的細胞損傷、凋亡和減少H2O2誘導的Caspase-3活性增加。與對照組和僅H2O2刺激細胞組比較,異丙酚處理能顯著增加eNOS表達。但磷酸Akt473位點絲氨酸或308位點蘇氨酸)的表達組間無差異。

結論:50μM異丙酚通過抑制Caspase-3活性和不依賴Akt機制地增加eNOS表達,減少H2O2誘導的內皮細胞損傷和凋亡。

(於章傑 陳傑 )

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.


一項通過標準呼吸回路監測混合呼氣末CO2的簡單方法

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.

 

介紹:混合呼氣末CO2CO2排出量(V CO2)在麻醉過程中為非常規監測專案,因為其通過標準裝置難以測量。作者通過兩種實驗來檢驗呼吸機風箱內含有混合呼末CO2的假說。

方法:實驗中,肺模型裝有CO2氣源,從呼吸機風箱抽取樣本計算VCO2。這些資料與NICO裝置,一種市場上主流CO2監測儀檢測V CO2作比較。在臨床研究中,採集9名全麻受試者麻醉呼吸機中風箱中氣體,並與NICO裝置計算和比較。

結果:風箱法測定的VCO2與肺模型測量的VCO2精密度為26ml/min, 偏差為-24ml/min, CO2標定平均誤差為-12.0%。而臨床實驗中,風箱法測定的VCO2NICO法測定的VCO2偏差為-0.15ml/min,精密度為33.16ml/min

結論:在實驗室中從風箱測得的VCO2沒有NICO裝置精確,但可通過標準麻醉裝置測定。9名受試者中,以風箱中測定的VCO2NICO裝置測得值誤差為1.34%。考慮到兩者之間這樣小的百分誤,作者認為風箱法測量的VCO2能應用於臨床。

(潘方立 陳傑 )

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.

 

-靜腎臟替代療法對熱稀釋技術的影響

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:經肺熱稀釋技術已用於重危病人血流動力學監測。然而,其中許多患者接受腎臟替代治療(RRT)。因此,作者通過測量心臟指數(CI)、胸內血容量指數(ITBVI)及血管外肺水指數(EVLWI)來分析腎臟替代療法對其的影響。

方法:連續研究24名重危病人, 5F股動脈導管連在監護儀上,一個12F透析導管通過股靜脈連到下腔靜脈或上腔靜脈,患者連續接受肝素抗凝治療。記錄三次血流動力學監測指標,一次是通過中心靜脈注射鹽水時,一次是暫停靜脈腎臟替代治療時,另一次是腎臟替代療法重新連接後。室溫設定、液體狀況和血管活性藥物不變。

結果:經靜脈腎臟替代療法顯著影響心臟指數、胸內血容量指數,而對血管外肺水指數沒影響。在兩組經靜脈腎臟替代療法間沒有統計學意義的差異。

結論RRT對膿毒血症患者CI, ITBVI, and EVLWI有非臨床相關的影響並能維持心排血量,且透析導管尖端位置對測量沒有顯著的影響。

(陳偉 陳傑 )

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.


腦血流量及氧合的集成計算模型的研製與價值

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  許多研究小組已經設計了不同的腦血流量及氧合監測模型,每一種都有優缺點。作者描述了為研究和教學而設計的諾丁漢腦模型(NCS)的研製與價值。

方法:  生理假設轉換成微分方程式,將時間數位化。從已經發表的文獻上獲得的一組實驗支援這種模型試驗。如靜態及動態的自動調節反應;腦組織的氧合等。用已公佈NCS試驗方法去運行,並且將它的結果與已發表的資料相比較。

結果  NCS不論從品質或數量上都與已發表的資料相似。相關指數的值為(括弧中為發表的資料):自動調節指數為0.90.9);暫時充血反應率為1.31.3),二氧化碳反應為2.4%4.7%mmHg12-4.5);腦組織氧合反應22mmHg20-100)。

結論:  NCS是一種可以在將來用於研究及教學的值得信賴的測定腦血流量及氧合的模型。

(潘錢玲 陳傑 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.


喉鏡檢查期間二維解剖關係

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:直接喉鏡法視野只為一個麻醉者所見,這在教學時遇到難題:不能夠講清所看到喉鏡視野。影響喉鏡檢查的解剖因素多為內在因素,妨礙了意料之外的插管困難的原因分析。作者創立一種較完善的二維模型,在矢狀面展示頭頸部的解剖學關係。並評估這人體模型,測試各種條件變化時如何影響喉鏡檢查的視野。

方法:模型參數與文獻資料進行比較。使用Macintosh 3Miller 2 Macintosh 4鏡片暴露聲門,用下頜長度和門牙間張開度等評估暴露的情況。

結果:從已公佈數值的30節氣道長度和10度為一標準差。脊柱和下頜移動在正常活動範圍內。聲門暴露在張口度小於一個閾值時顯著降低。下頜短時需要較大的張口。張口窄于2.4cm時不能暴露聲門。Macintosh 4鏡片最易成功,能見聲門後部7mm

結論:此模型為年齡約為16歲男病人身高,比例和活動度。可用於解釋解剖學變化對喉鏡檢查的影響。將來還需進一步客觀評估來確定模型的用處,如教學以及作為工具研究困難喉鏡檢查的機制。

(宋翠俠 陳傑 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.


阿片藥導致PACU中的鎮靜不能確保足夠鎮痛:病例對照研究

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,靜滴嗎啡以控制急性疼痛可產生鎮靜作用。作者設計這個病例對照試驗來評估阿片類藥物用於PACU所產生的鎮靜與術後早期鎮痛之間的關係。

方法:PACU中,每隔5分鐘靜滴嗎啡2mg(體重60kg)或3mg(體重>60kg)來治療中度至重度疼痛。疼痛程度用總分為11分的口述評分(VRS)來評估,分值3表示中度至重度疼痛。鎮靜作用則以總分為6分的Rammsay法來評估,分值>3表示有明顯的鎮靜作用。26Rammsay鎮靜分數>3,VRS3的病人(鎮靜組)在離開PACU後參與了一項術後24小時的評估。評估患者PACU早期術後疼痛的回憶能力,術後當晚的睡眠品質,術後24小時的疼痛情況以及對於術後24小時疼痛管理的滿意程度。有兩個病人離開PACUVRS疼痛分值<3,但情況與Rammsay鎮靜分數>3,VRS3的病人相似,被列入對照組中。

結果:鎮靜組(Rammsay鎮靜分數>3,VRS3)病人在PACU中出現較多中度至重度的疼痛(對照組和鎮靜治療組重度/中度/無痛比例為:18/25%/75%58/16/26,P0.006),術後當晚的睡眠品質較差(對照組和鎮靜治療組睡眠品質好/中等/差的比例為:48%/42%/10%23/23/54%,P0.001),術後24小時的疼痛評分更高(對照組和鎮靜治療組重度/中度/無痛的比例為:6/44%/50%50/42/8,P值﹤0.0001)。此外,鎮靜組患者對於術後24小時疼痛管理的滿意程度較低(對照組和鎮靜治療組滿意/一般/不滿意的比例為:96/2%/2%50/30/20,P值﹤0.0001)。

結論:PACU應用阿片類藥物出現顯著的鎮靜作用,但並不能確保足夠的自我評定中的解痛。

(杜唯佳 陳傑 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.

 

異氟醚啟動脂質雙分子層的人心臟線粒體三磷酸腺苷敏感的鉀離子通道的再生

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:在異氟醚介導的人和動物心肌保護的預處理中,線粒體三磷酸腺苷敏感的鉀離子通道的啟動被認為是一個關鍵的步驟。最近的證據顯示活性氧簇在異氟醚介導的心肌保護作用中起到仲介作用。在此次研究中,我們調查異氟醚及活性氧簇對人心臟線粒體三磷酸腺苷敏感的鉀離子通道在脂質雙分子層的再生的直接作用。方法:在人左心室的外植塊中,線粒體內膜是孤立的,不適合作為心臟移植,並且在均勻的谷氨酸鉀溶液(150 mM)中融合進脂質雙分子層中。在暴露於異氟醚及過氧化氫的前後,ATP敏感的鉀離子電流都能被電極記錄到。結果:人線粒體ATP敏感的鉀離子通道可以通過對ATP及羥基癸酸甘油酯抑制後的敏感度來進行分類。異氟醚(0.8 mM)的加入增加了線粒體ATP敏感的鉀離子通道開放的可能性,不管ATP的抑制(0.5 mM)是否存在。異氟醚介導的鉀離子電流增加可被羥基癸酸甘油酯完全抑制。類似的,過氧化氫可以啟動先前被ATP抑制的線粒體ATP敏感鉀離子通道。結論:這些資料明確了在體外,異氟醚及活性氧簇直接啟動了人心臟線粒體ATP敏感鉀離子通道,並不像通常認為的那樣包含了細胞蛋白激酶的作用。線粒體ATP敏感鉀離子通道的啟動可能促成異氟醚在人心臟的心肌保護作用。

(吳威譯 薛張綱校)

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.

 

 

綜述:抑肽酶在心臟手術中作用機制研究及其進展

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

 

凝血反應和炎症瀑布反應在心肺體外迴圈後可引起多器官功能衰竭。基於這些觀察,在心臟手術中及術後採用穩定凝血過程和稀釋炎症反應的策略是很重要的。抑肽酶有止血作用。另外,抑肽酶在心臟手術和體外迴圈中可能有多種生物相關效應。例如,它抑制中性粒細胞和巨噬細胞的活化和分化、減少炎症細胞釋放、啟動炎症細胞分裂並減少氧化應激。由於這些已知的益處,認為在心臟及體外迴圈手術中應常規應用抑肽酶。在此篇綜述中,我們通過討論抑肽酶作用於心臟手術的經典和新的通路檢驗了這個有爭議的藥物

(陳愷錚譯 薛張綱校)

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.

 

 

人外周單核細胞表達孤啡肽阿片受體,無μδκ阿片受體表達

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:阿片受體在PBMC中的表達是有爭議的。這些受體目前被分為經典的MOP DOP KOP和非經典的NOP。方法:在這志願者實驗中,我們探查經典的和經典的阿片受體的表達,通過以下方法:1)放射性配體結合法;2)特異性抗體結合法 3)以PCR為基礎的實驗範式。結果:從健康志願者的外周單核細胞提取的膜,既不與阿片受體配基[3H]diprenorphine(一與經典阿片受體結合的非選擇性放射性配體)結合,也不與[3H]N/OFQ結合。每一放射性配體存在明顯的濃度依賴性結合去控制組織表達重組的MOP NOP.。此外,運用流體細胞測量儀式樣,既沒螢光納洛酮又沒兩類MOP 抗體結合到PBMC上,儘管有螢光納洛酮結合到重組的MOP上(作為正面對照)。運用經典的和經典的阿片受體的初級特異性,從10名志願者的PBMC中提取RNA,我們仍不能發現MOP, DOPKOP副本。相反,所有樣品都發現了NOP。結論:儘管我們運用了不同的實驗方法,但還是沒證明在健康志願者的PBMC中存在阿片受體蛋白。我們發現NOP mRNA,暗示在這些免疫細胞上有低密度的NOP表達。有可能是PBMC 自身產生的N/OFQ與免疫功能調控有關。       

(陳勇柱譯 薛張綱校)

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.

 

 

使用異氟醚、氟烷及異丙酚後腹側脊髓索的抑制大於背側脊髓索

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.

 

背景揮發性麻醉劑最初作用於脊髓來產生穩定性但其確切的作用部位仍未知。在0.81.2MAC,異氟醚對背側角的神經元不產生抑制,提示其還作用於另外的脊髓腹側部位,例如前運動中間神經元及運動神經元。我們假設異氟醚、氟烷及異丙酚對於傷害性反應在腹側角神經元能相當於背側角神經元產生更強的抑制作用。方法:用異氟醚及氟烷麻醉大鼠,觀察其背側(<1200 µm 深度)及腹側(>1200 µm)腰神經元對有害的機械刺激的反應,麻醉深度被決定為0.81.2MAC。在第三組中用0.8MAC的異氟醚及5 mg/kg 的異丙酚麻醉,同時記錄背側角及腹側角的反應。結果:異氟醚或氟烷濃度從0.8MAC上調到1.2MAC的過程中,背側角神經元的反應並沒有顯著的變化;異丙酚也同樣如此。另一方面,隨著異氟醚或氟烷濃度的提高,腹側角神經元的反應為從被抑制60%變為了被抑制45%。異丙酚更是深度抑制了腹側角神經元(>90%)。結論:這些資料顯示,在1MAC左右的範圍,異氟醚、氟烷及異丙酚對於有害的機械性刺激,脊髓背側角只有很少或沒有反應,而腹側角卻有抑制作用。這些麻醉藥在0.81.2MAC的範圍內在腹側角產生鎮靜作用。

(孫霞譯  薛張綱校)

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.

 

 

顳動脈測溫器對比膀胱測溫器在術中及重症監護病房的監測

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:中心體溫測量是術中病人監護的重要內容。通過對麻醉病人的有創操作獲得中心體溫相當方便。然而,這樣的測量方法對於清醒病人卻很困難。最近,介紹了一種新的無創中心體溫測量方法顳動脈測溫器(顳動脈掃描器TM TAT-5000),據報導它與有創的中心體溫測量結果比較結果是精確一致的。在這項研究中,我們探求這種新的測溫器是否可以替代有創的膀胱溫度測量法。方法:選定35個在行神經外科手術中的病人和35個在神經外科監護病房的病人,比較從顳動脈測溫器和膀胱測溫器測量得到的資料。每個病人可以得到4個資料。

結果:總共獲得280對測量資料。不同方法的平均偏倚為0.07°C±0.79°C;量表的一致性限度約為3倍的±0.5°C的先驗確定限度(–1.481.62)。用顳動脈測溫器診斷高溫(中心體溫>37.8°C)的靈敏度是0.72,特異度是0.89,陽性預測值是0.89,陰性預測值是0.94。其診斷低溫(中心體溫<35.5°C)的靈敏度是0.29,特異度是0.95,陽性預測值是0.31,陰性預測值是0.95。結論:這項研究的結果不支持顳動脈測溫器在術中監測中心體溫。顳動脈測溫器的測量結果尚不能完全替代膀胱測溫器測量的中心體溫。

(陳佳莉譯 薛張綱校)

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.

 

 

肺壓力-容積曲線得到的參數可以揭示實驗肺損傷後的復原情況,壓力-時間曲線沒有這個作用

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:在急性肺損傷中,避免過度通氣和肺複張可以預防呼吸機相關性肺損傷。從壓力-容積(PV)曲線或壓力-時間(Paw-t)上可以動態瞭解肺複張情況。方法:六隻通過灌洗造成急性肺損傷的實驗豬麻醉後,呼吸機設定為肺保護模式進行機械通氣。我們測定了滯後區域的標準複張措施的效果,並從PV曲線得到比例和從Pawt曲線上得到了壓力指數,通過多層CT得到充氣和非充氣的肺容積,比較兩者之間的相關性。結果:滯後區域和比例與充氣的肺容積相關(r = 0.886)。複張後可以造成充氣肺增加(+12%),而非充氣的肺減少(–18%) 。滯後區域與肺泡複張相關,表現為充氣肺增加(r = 0.886),非充氣肺減少(r = –0.829)。壓力指數始終>1,僅表示過度通氣。複張後指數並沒有改變,與其他肺容積無關。結論:從PV曲線得到的參數有助於瞭解肺的通氣和複張的情況。在目前肺保護的通氣模式設置下,從Pawt曲線得到的壓力指數對瞭解肺的複張情況沒有幫助。

(陳珺珺譯 薛張綱校)

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.

 

 

靜注右旋美托咪啶預防大鼠脊柱非損傷性缺血後鞘注嗎啡引起的脊髓腹側神經元變性

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:我們在最初的研究中證明了非損傷脊髓缺血後脊索應用嗎啡導致痙攣性截癱和選擇性脊髓腹側神經元變性。我們的目的是研究右旋美托咪啶對脊柱缺血後鞘注嗎啡引起腹側神經元變性的影響。方法:使用雄性Sprague-Dawley大鼠,在經歷一段時間非損傷性脊柱缺血(6分鐘)後的1小時和5小時,重複給予一個劑量的嗎啡鞘注(40μg×2)。實驗動物在給予第一個嗎啡鞘注劑量後分為以下4(n=8/)S組,靜注生理鹽水(ml/h)Dex0.1組,右旋美托咪啶(0.1μg/kg·h)Dex1組,右旋美托咪啶1μg/kg·h)Dex3組,右旋美托咪啶3μg/kg·h)。隨訪指標包括鎮靜深度,指示神經功能受損程度的運動缺陷指數,以及再灌注後72小時脊柱組織病理學檢查。結果:靜注右旋美托咪啶產生劑量依賴性的鎮靜深度。重複鞘注嗎啡導致截癱、神經功能損害和組織病理學改變。結論:以上資料表明,重複鞘注嗎啡會導致截癱和脊髓腹側神經元變性,但靜注鎮靜劑量的右旋美托咪啶可使其緩解。右旋美托咪啶可能對脊柱缺血後鞘注嗎啡大鼠的神經學預後有保護作用。

(羅 璿譯 薛張綱校)

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.

 

 

脊麻剖宮產手術圍術期吸氧並不能避免或者減輕噁心嘔吐的發生

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:全麻術後輔助吸氧可以減少術後噁心嘔吐的發生。我們設計這個研究來評價輔助吸氧治療對於接受脊麻的剖宮產婦女,減少噁心嘔吐的有效性。方法:我們設計了一個前瞻性的,隨機雙盲的研究,研究物件為接受標準脊麻以及術後鎮痛的剖宮產患者。在臍帶結紮後,患者被隨機接受70%或者21%的氧氣。將記錄從誘導到分娩,分娩到手術結束,以及在術後24小時這三個時間段患者噁心嘔吐的情況。我們將使用{chi}2核對總和t檢驗來分析這兩組的差異性。結果:從人口統計學和程式變數而言,這兩組試驗物件組成相似。從總體噁心嘔吐的發生率來看,這兩組沒有顯著的差異。吸氧氣組重度噁心的發生率在待產室、產後室以及術後分別為3%, 7%, 9%;在吸空氣組裏,相應的統計結果為3%, 9%, 7%。重度嘔吐在這三個時間段裏,兩組都是0%, 2%, 4%。這些差異都沒有統計學意義。結論:吸氧治療對於接受脊麻的剖宮產婦女,並不能減少或者減輕圍手術期及術後的噁心嘔吐。

(王光妍 薛張綱校)

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.

 

 

精索靜脈曲張手術術前應用加巴噴丁(抗焦慮藥)或者地塞米松,或者二者聯合運用:一項隨機對照試驗

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:我們研究在精索靜脈曲張術前1小時分別或者聯合給與患者加巴噴丁和地塞米松對於喉鏡暴露,氣管插管,術中血流動力學改變,阿片類藥物需求量,及術後疼痛的作用。方法:患者被隨機地,雙盲地分入四組實驗組:C組(對照組,n=20)使用安慰劑,G組(加巴噴丁組,n=20)給與800mg加巴噴丁,D組(地塞米松組,n=20)給與8mg地塞米松,GD組(加巴噴丁聯合地塞米松組)同時給與800mg加巴噴丁和8mg地塞米松,這些藥均在術前1小時靜脈注射。用異丙酚和雷米芬太尼完成標準麻醉誘導和維持。在誘導前和插管後記錄心率和動脈血壓。記錄術中雷米芬太尼使用量。記錄24小時血流動力學改變和視痛覺評分。並且同時記錄副反應。結果:GD組在插管後1, 3, 5, 10分鐘時的血流動力學紊亂,術後30分鐘及124612小時的痛覺評分,及術後噁心嘔吐率等方面要顯著低於G組和D(P < 0.05),同時遠遠的低於C(P < 0.001)。同時C組的所有這些評估要高於G組和D(P < 0.05)。結論:在精索靜脈曲張手術前1小時聯合給與加巴噴丁和地塞米松較之單獨給與其中任何一種藥能更好的減輕喉鏡暴露和氣管插管的反應,有助於術後止痛及預防術後噁心嘔吐。

(周時蓓譯 薛張綱校)

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.          

氯維地平快速有效控制心臟手術患者術前的高血壓:評價氨維地平在心臟手術-1術前抗高血壓作用的一項隨機、安慰劑對照的效能研究結果

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

背景資料:氯維地平是一種超短效的,第三代靜脈注射用的二氫吡啶類鈣通道拮抗劑,能快速可滴定地降低動脈壓,經血液及組織酯酶代謝能迅速終止藥物作用。作為一種動脈選擇性血管擴張劑,氯維地平能直接降低外周血管阻力,而不擴張靜脈毛細血管床。在這項隨機、雙盲、安慰劑對照的多中心研究中,我們評估了氯維地平治療術前高血壓的藥效及耐受性。

方法:我們將152位目前或近期患有高血壓的擇期心臟手術患者在術前隨機分成氯維地平組及安慰劑組。105位患者達到隨機化後的入選標準(動脈穿刺置管後的收縮壓[SBP] ≥160 mm Hg ),因為用藥後SBP較基礎值下降≥15%。患者輸注氯維地平(0.4–8.0 µg · kg–1 · min–1)20%脂肪乳(安慰劑)至少30分鐘。治療失敗的定義為:與基礎值相比,SBP下降未能≥15%或因其他原因終止用藥。

結果:氯維地平組有92.5%的治療成功率,失敗率(7.5%, 4/53)明顯低於對照組(82.7%, 43/52; P < 0.0001)。氯維地平組達到目標血壓(SBP降低≥15%的中位數時間為6.0 min95%可信區間6–8 min)。使用氯維地平期間心率與基礎值比較會有適度上升。各治療組的不良事件相似。

結論:氯維地平能快速有效地將擇期心臟手術患者的術前血壓降至目標血壓水準,且能較好地耐受。

(裘毅敏譯,馬皓琳 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.

 

 

 

近端等速表面積應該在評估二尖瓣返流中常規測定:核心綜述

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

近端等速表面積(PISA)測定法,又稱為“流量彙聚”法,可用於超聲心動圖來估計血流通過的二尖瓣口面積。它有廣泛的運用,但本綜述只集中於其在對二尖瓣返流的術中評價中的應用。在這項運用中,PISA可以定量的評價二尖瓣返流的嚴重程度,且有助於在手術室內臨床決策。在本綜述中,我討論了PISA方法後面的物理學原理以及用於計算有效二尖瓣返流口的面積、返流量和返流分數的各種數學公式。以圖解和視頻演示來呈現和說明逐步逼近法。最後,我將討論PISA測定法在手術室中的各種局限性和技術考慮因素。

(沈浩    馬皓琳 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.


 

低濃度戊巴比妥增強大鼠海馬神經元興奮性

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:儘管麻醉學家熟悉麻醉誘導和蘇醒期的興奮相,但是對該現象的細胞機制尚未完全瞭解。在約相當於手術麻醉所需藥物濃度1/10時,試驗物件對傷害性刺激反應增加。我們此前估計傷害反射閾值的下降最大出現在戊巴比妥濃度約為5 µM時。在此我們使用了大樹海馬腦片標本來檢驗5 µM戊巴比妥是否增加神經元的興奮性。

方法:在刺激Schaffer側支通路時對海馬CA1區神經元進行細胞內記錄。我們檢測了戊巴比妥對靜息細胞膜內在特性的影響和刺激-反應關係。我們評價了突觸信號強度(以興奮性突觸後電位斜率表示)和放電可能性之間的關係(E-S關係)。

結果:戊巴比妥增加海馬神經元的興奮性,顯示為在任何給定的突觸信號強度時放電可能性增高(P = 0.002),這種現象被稱為“E-S增強”。戊巴比妥使神經元輸入阻抗增加和動作電位閾值負值更大。在任何給定的刺激強度下,戊巴比妥不增加興奮性突觸後電位的斜率。

結論:5 µM濃度時,戊巴比妥通過增加突觸後神經元興奮性增加E-S耦聯。戊巴比妥誘發的細胞膜內在特性的改變可能使興奮性增加。

(顏濤 譯,馬皓琳 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.



全身麻醉對用小波變換來評價的人體皮膚微循環的影響

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:用小波變換進行的對鐳射多普勒血流儀信號的時間-頻率分析,顯示了與心臟(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)和很低的振動(0.0095–0.021)有關的5個特定頻率上的週期振動,這些可通過內皮依賴性的血管舒張劑乙醯膽鹼來調節。我們假設鐳射多普勒血流儀信號的小波變換可發現全麻引起的微循環的變化,諸如血管舒縮和交感神經活性。

方法:收入11例進行面頜部手術的患者。在用丙泊酚、芬太尼和咪達唑侖的全身麻醉前和全身麻醉過程中,用鐳射多普勒血流儀及乙醯膽鹼和硝普鈉離子透入法在前臂下部分測定皮膚微循環。用小波變換分析鐳射多普勒血流儀信號。

結果:光譜幅度在0.00950.021P < 0.01)、0.0210.052P < 0.001)和0.0520.15 Hz 頻程中(P < 0.01)顯著減小,在0.150.6 Hz頻程中顯著增大。全身麻醉對在0.00950.021 Hz頻程中相對幅度上的乙醯膽鹼與硝普鈉之間的差異無影響。

結論:全身麻醉降低與交感、肌源性活性相關的灌注信號的振動成份和內皮調節的成份。然而,離子透入法資料並未揭示對內皮的特殊作用。在0.150.6 Hz頻程中的增大與機械通氣的作用有關。

(馬皓琳   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.

 

 

 

絲裂原活化蛋白激酶磷酸酶-1上調和細胞外信號調節激酶1/2磷酸化降解介導昔多芬對肺動脈平滑肌細胞的抗增殖作用

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:肺動脈高壓是包括血管縮窄和肺血管系統閉塞性改變的一組疾病。磷酸二酯酶5型抑制劑如昔多芬可緩解野百合堿所致大鼠肺動脈高壓模型的肺血管重構,且可在體外實驗中抑制肺血管平滑肌細胞增殖。本實驗研究了昔多芬抑制血小板衍生生長因數(PDGF)誘導的豬肺動脈平滑肌細胞增殖的能力。

方法:採用MTT測定和螢光啟動細胞分選術評估肺動脈平滑肌細胞增殖和細胞週期分析。採用蛋白質印跡法測定絲裂原活化蛋白激酶磷酸酶-1MKP-1)的蛋白質表達和細胞外信號調節激酶(ERK1/2)的磷酸化水準。

結果:PDGF促進細胞增殖,增加處於S相細胞的百分比。這些效應可被昔多芬預處理劑量依賴性抑制。昔多芬(96 µM)也可使PDGF激發的ERK1/2磷酸化減少67%。昔多芬抑制ERK1/2的同時也快速誘導MKP-1表達。採用Rp-8-BrcGMPS25µM)抑制cGMP-依賴的激酶I {alpha}cGK I {alpha})可阻斷昔多芬誘導的MKP-1表達。昔多芬對於PDGF激發的ERK1/2磷酸化和PDGF誘導的修復性細胞增殖的抑制作用可被磷酸酶抑制劑釩酸鹽(12.5 µM)或Rp-8-BrcGMPS取消。

結論:本研究表明昔多芬可通過上調MKP-1表達並促進ERK1/2磷酸化降解來抑制肺動脈平滑肌細胞增殖。

(周雅春 馬皓琳 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.


 

一項關於理論麻醉計畫中異丙酚濫用的調查

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:雖然異丙酚不是一種傳統意義上的濫用藥物,但亞麻醉劑量存在濫用的可能。該調查用於評估理論麻醉計畫中異丙酚濫用的流行率及後果。

方法:對美國126個理論麻醉學訓練計畫發放電子郵件問卷。

結果:調查回復率為100%18%的部門報導了過去10年中至少有一次異丙酚濫用或轉換的事件。觀察到的異丙酚濫用事件發生率為10/10,000例麻醉/10年,比以往濫用異丙酚調查結果增高五倍(P = 0.005).。被報導的25例濫用異丙酚的個體中,7人死於濫用異丙酚(28%),其中6人是定居者。71%的計畫沒有象阿片類藥物那樣有明確的體系來控制或監管異丙酚。計畫中濫用時異丙酚管理的缺乏(如藥方記帳)和濫用的發生率具有相關性(P = 0.048)

結論:理論麻醉學中異丙酚濫用的現象在過去10年中似乎有所增加。很多死亡率發生在定居者。大多數計畫缺乏藥房記帳或異丙酚庫存的控制。如果所有報導因濫用異丙酚致死的計畫是沒有藥房記帳的中心,這就值得注意了。

(唐李雋   馬皓琳 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.

 

 

 

一項關於通過Evac氣管導管吸引聲門下分泌物失敗的研究

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:抽吸聲門下分泌物這種方法廣泛被用於預防呼吸機相關性肺炎。然而使用Hi-Lo® Evac型氣管導管 (Hi-Lo Evac; Mallinckrodt; Athlone, 愛爾蘭) (Evac ETT),吸引管常常發生異常,且隨後不能抽吸聲門下分泌物。本研究擬探討使用Evac ETT時吸引管功能失常的原因。

方法:我們研究了40例用Evac ETT插管的成年病人。在所有病例中觀察吸引管的功能失常,並通過可曲式支氣管鏡可視性觀察聲門下吸引口。

結果:40例病人中,19例病人吸引管吸引失敗(48%)。其中17例病人(43%)是由於聲門下吸引口被吸出的氣管粘膜堵塞所致。

結論:使用Evac ETT時,由於氣管粘膜脫出到聲門下吸引口從而不能有效吸淨聲門下分泌物。

(邱鬱薇 馬皓琳 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.


 

關於腦組織氧合變化原因的模型

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:臨床上表明腦灌注充分的標記可能是令人誤解的。體循環血壓、Paco2Pao2和腦水腫的各自的變化對腦血流量以及氧合作用的影響是相對比較明確的,而這些因素之間的相互作用的定量效應並不容易計算出來。我們的目的是應用一個計算模型研究這些因素的相互關係。

方法:應用一個關於腦血流的已被驗證過的定量計算模型,記錄體循環血壓(50–180 mm Hg)Paco2 (33–55 mm Hg [4.3–7.3 kPa])Sao2 (0.8–1.0)和腦水腫(毛細血管間距增加0%–10%)等因素的變化對大腦中動脈流速(MCAFV)、腦組織氧合(Pbo2)以及頸靜脈血氧飽和度(Sjo2) 的模擬影響。

結果:腦灌注充分的單獨指標(MCAFVSjo2Pbo2)與研究的參數中單一變化的臨床資料相一致:MCAFV Sjo2的自身調節的下限在平均動脈壓60 mm Hg左右。在我們的模型中,自身調節的上限在平均動脈壓170mm Hg左右,但是Sjo2Pbo2不及MCAFV顯著。從我們的模擬試驗來看,顯著的腦缺血不太可能與各個單獨的生理變化一同發生。然而,在該模型中,低血壓、缺氧以及水腫的綜合作用使缺血發生的可能性增大很多。水腫增加了Sjo2:Pbo2的梯度,證實了彌散限制性氧運輸可能會產生安慰性的假性Sjo2值。

結論:病理生理變化對腦氧合和灌注的影響已定量描述。兩個或者更多的生理紊亂的存在預示著明顯的腦缺血。腦水腫使Sjo2Pbo2之間的梯度增加。

(黃麗娜     馬皓琳  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.


 

硬膜外給予AMPA/紅藻氨酸鹽受體拮抗劑Tezampanel對大鼠的術後鎮痛作用

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:我們在大鼠術後疼痛模型中評價硬膜外給予一種非NMDA受體拮抗劑tezampanel的鎮痛效應。硬膜外給藥後,我們嘗試通過測試其對正常大鼠對熱刺激反應的影響來確定該藥是否影響傷害感受。還研究了硬膜外tezampanel對切開腳底的大鼠疼痛相關性行為的影響。

方法:麻醉大鼠,並在硬膜外置管。硬膜外置管一天后,測定熱退縮潛伏期的基礎值。通過測定硬膜外給予tezampanel或嗎啡對熱退縮潛伏期的影響來檢驗其鎮痛作用。並且檢查運動功能。與皮下藥物給予相比較。另一部分大鼠則在硬膜外置管後行腳底切開,以評價切開引起的疼痛行為。測定硬膜外給予tezampanel後,基於對von Frey絲的保護性退縮閾值和對熱刺激的退縮潛伏期的累積疼痛評分。同時測定硬膜外給予tezampanel對動脈血壓和心率的影響。

結果:硬膜外給予tezampanel或嗎啡均延長了對熱刺激的退縮潛伏期。只有皮下給予嗎啡可以影響熱退縮潛伏期。腳底切開後,硬膜外給予tezampanel降低保護性疼痛評分中位值,延長熱退縮潛伏期,並且提高機械刺激退縮閾值,提示其有鎮痛作用。動脈血壓和心率在硬膜外給藥後沒有變化。

結論:這些實驗顯示硬膜外給予tezampanel 可以產生對熱刺激的鎮痛作用,影響一部分大鼠的運動功能,且降低切皮引發的疼痛行為。給予最大劑量,也沒有明顯的全身鎮痛作用。

(張瑩譯  馬皓琳 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.

 

 

左旋布比卡因複合(深叢和淺叢)頸叢與頸淺叢阻滯用於微創甲狀旁腺切除術的前瞻性隨機比較研究

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:微創甲狀旁腺切除術(Minimally invasive parathyroidectomy, MIP)可在頸叢阻滯(cervical plexus block, CPB)下完成。據報導頸淺叢阻滯與複合深、淺叢阻滯效果相似,且更易操作,麻醉相關的併發症也較少。在這項研究中,我們比較頸淺叢阻滯和複合(深、淺叢)CPBMIP患者中應用的效果。

方法:42例單一腺瘤引起的原發性甲狀旁腺亢進患者,隨機分成兩組,分別用0.5%左旋布比卡因0.35 mL/kg施行頸淺叢阻滯(淺叢組,n = 20)或複合深叢和淺叢CPB(複合組,n = 22)。以完成手術需追加的芬太尼量為主要終點。

結果:兩組阻滯起效、術中疼痛評分和首次需要鎮痛藥的時間均無明顯差異。芬太尼的消耗量兩組相似,即淺叢組50 (0–200) µg,複合組50 (0–100) µg(P = 0.60)6例患者[淺叢組1(5%),複合組5(22.7%)]由於手術需要進行雙側頸部淋巴清掃而改為全身麻醉(P = 0.18)。因阻滯失敗而行全身麻醉的淺叢組有3例(15%),複合組有2例(9%(P = 0.99)。複合組中僅有1例阻滯後出現膈肌麻痹(P = 0.99)

結論:頸淺叢阻滯可替代複合深、淺叢阻滯進行MIP

(朱 慧譯 馬皓琳 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:一個奇特的用來定位硬膜外間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

介紹EpisureTM注射器是一個獨特的裝有彈簧的阻力消失(LOR)注射器,在Portex PulsatorTM LOR注射器裏有一個共軸的壓縮彈簧。這個彈簧在操作者用圖伊硬膜外穿刺針進針時,提供一個恒壓。

方法:我們用黃韌帶的人工模型、麻醉的豬和需要硬膜外鎮痛分娩的產婦評估此穿刺針。

結果:用安裝了彈簧的注射器的術者能阻止穿刺針的前進,因此與一個標準的LOR注射器相比較,針突出實驗室模型的背面較少。人類研究中令人滿意的分娩鎮痛和豬模型中的X光照片分析證實都放置在硬膜外腔。

結論:安裝彈簧的注射器可能是有用的LOR注射器,提供可靠客觀的證明在硬膜外腔。

(張曦 譯,馬皓琳 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.