Anesthesia & Analgesia

December 2007

 

CARDIOVASCULAR ANESTHESIOLOGY:

活性氧介導七氟醚和地氟醚誘導預處理在人離體右心房心肌保護作用

陳愷錚譯 薛張剛校

Reactive Oxygen Species Mediate Sevoflurane- and Desflurane-Induced Preconditioning in Isolated Human Right Atria In Vitro

Jean-Luc Hanouz, Lan Zhu, Sandrine Lemoine, Charline Durand, Olivier Lepage, Massimo Massetti, André Khayat, Benoît Plaud, and Jean-Louis Gérard

Anesth Analg 2007 105: 1534-1539.

磺達肝素在下肢較大整形手術(留置或未留置軸索或深部周圍神經導管)術後長期應用預防血栓形成的安全性及有效性研究:EXPERT研究

邱郁薇 馬皓琳 李士通

The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study

François J. Singelyn, Cees C.P.M. Verheyen, Franco Piovella, Hugo K. Van Aken, Nadia Rosencher for the EXPERT Study Investigators

Anesth Analg 2007 105: 1540-1547.

心率變異性在術後不良心臟事件的危險分層中的作用

杜唯佳 陳傑

The Role of Heart Rate Variability in Risk Stratification for Adverse Postoperative Cardiac Events (Review Article)

Timo Laitio, Jouko Jalonen, Tom Kuusela, and Harry Scheinin

Anesth Analg 2007 105: 1548-1560.

PEDIATRIC ANESTHESIOLOGY:

氯胺酮不增加肺動脈高壓兒童在自主呼吸行七氟醚麻醉時的肺血管阻力

陳佳麗譯,薛張綱校

Ketamine Does Not Increase Pulmonary Vascular Resistance in Children with Pulmonary Hypertension Undergoing Sevoflurane Anesthesia and Spontaneous Ventilation

Glyn D. Williams, Bridget M. Philip, Larry F. Chu, M. Gail Boltz, Komal Kamra, Heidi Terwey, Gregory B. Hammer, Stanton B. Perry, Jeffrey A. Feinstein, and Chandra Ramamoorthy

Anesth Analg 2007 105: 1578-1584.

小兒門診手術中用喉罩導氣管編程壓力支援通氣

彭中美 馬皓琳 李士通

Programming Pressure Support Ventilation in Pediatric Patients in Ambulatory Surgery with a Laryngeal Mask Airway

Javier Garcia-Fernandez, Gerardo Tusman, Fernando Suarez-Sipmann, Julio Llorens, Marina Soro, and Javier F. Belda

Anesth Analg 2007 105: 1585-1591.

一項關於POVOC評分預測兒童術後嘔吐的前瞻性評估

於章傑 陳傑

A Prospective Evaluation of the POVOC Score for the Prediction of Postoperative Vomiting in Childre

Peter Kranke, Leopold H. Eberhart, Hakki Toker, Norbert Roewer, Hinnerk Wulf, and Peter Kiefer

Anesth Analg 2007 105: 1592-1597.

新式含氧飽和度探頭中心靜脈導管用於小兒心臟手術的試驗和臨床性評價

陳勇柱譯 薛張剛校

An Experimental and Clinical Evaluation of a Novel Central Venous Catheter with Integrated Oximetry for Pediatric Patients Undergoing Cardiac Surgery

Oliver J. Liakopoulos, Jonathan K. Ho, Aaron Yezbick, Elizabeth Sanchez, Clayton Naddell, Gerald D. Buckberg, Ryan Crowley, and Aman Mahajan

Anesth Analg 2007 105: 1598-1604.

全麻患兒神經刺激的電流強度與周圍神經阻滯成功率之間的關係

裘毅敏譯,馬皓琳 李士通校

The Relationship Between Current Intensity for Nerve Stimulation and Success of Peripheral Nerve Blocks Performed in Pediatric Patients Under General Anesthesia

Harshad Gurnaney, Arjunan Ganesh, and Giovanni Cucchiaro

Anesth Analg 2007 105: 1605-1609.

健康兒童白陶土啟動凝血彈性描記法的參考值

陳偉 陳傑

Reference Values for Kaolin-Activated Thromboelastography in Healthy Children

Kah-Lok Chan, Robyn G. Summerhayes, Vera Ignjatovic, Stephen B. Horton, and Paul T. Monagle

Anesth Analg 2007 105: 1610-1613.

AMBULATORY ANESTHESIOLOGY:

門診麻醉學會處理術後噁心嘔吐指南

璿譯 薛張綱校

Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting (Special Article)

Tong J. Gan, Tricia A. Meyer, Christian C. Apfel, Frances Chung, Peter J. Davis, Ashraf S. Habib, Vallire D. Hooper, Anthony L. Kovac, Peter Kranke, Paul Myles, Beverly K. Philip, Gregory Samsa, Daniel I. Sessler, James Temo, Martin R. Tramèr, Craig Vander Kolk, and Mehernoor Watcha

Anesth Analg 2007 105: 1615-1628.

ANESTHETIC PHARMACOLOGY:

評估基於貝葉斯的閉環系統用於丙泊酚輸注的理想模型權重,應用雙頻指數作為對照變數:一個模擬研究

張曦 譯,馬皓琳 李士通

Estimation of Optimal Modeling Weights for a Bayesian-Based Closed-Loop System for Propofol Administration Using the Bispectral Index as a Controlled Variable: A Simulation Study

Tom De Smet, Michel M. R. F. Struys, Scott Greenwald, Eric P. Mortier, and Steven L. Shafer

Anesth Analg 2007 105: 1629-1638.

豬失血性休克對異氟醚的最小肺泡麻醉濃度的影響

張燕 陳傑

The Influence of Hemorrhagic Shock on the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model

Tadayoshi Kurita, Kotaro Takata, Masahiro Uraoka, Koji Morita, Yoshimitsu Sanjo, Takasumi Katoh, and Shigehito Sato

Anesth Analg 2007 105: 1639-1643.

依託咪酯的麻醉效應:種族特異性的與{alpha}2-腎上腺素能受體的相互作用

陳珺珺譯 薛張綱校

The Anesthetic Effects of Etomidate: Species-Specific Interaction with {alpha}2-Adrenoceptors

Andrea Paris, Lutz Hein, Marc Brede, Philipp-Alexander Brand, Jens Scholz, and Peter H. Tonner

Anesth Analg 2007 105: 1644-1649.

術後疼痛模型中的繼發性痛覺過敏取決於脊髓鈣-鈣調蛋白依賴的蛋白激酶IIα的啟動

周雅春 馬皓琳 李士通

Secondary Hyperalgesia in the Postoperative Pain Model Is Dependent on Spinal Calcium/Calmodulin-Dependent Protein Kinase II{alpha} Activation

Toni L. Jones, Adam C. Lustig, and Linda S. Sorkin

Anesth Analg 2007 105: 1650-1656.

p38絲裂原啟動蛋白激酶(p38MAP激酶)抑制劑可以保護離體試驗中利多卡因誘導的神經軸突損傷,而半胱氨酸蛋白酶活性抑制劑無此作用

陶穎瑩 陳傑

In Vitro, Lidocaine-Induced Axonal Injury Is Prevented by Peripheral Inhibition of the p38 Mitogen-Activated Protein Kinase, but Not by Inhibiting Caspase Activity

Philipp Lirk, Ingrid Haller, Hans Peter Colvin, Silke Frauscher, Lukas Kirchmair, Peter Gerner, and Lars Klimaschewski

Anesth Analg 2007 105: 1657-1664.

骶骨背側角神經元的痛覺域值的時間空間決定因素與異氟醚誘導的制動性的關係

佳譯,薛張剛校

Temporal and Spatial Determinants of Sacral Dorsal Horn Neuronal Windup in Relation to Isoflurane-Induced Immobility

Robert C. Dutton, Jason M. Cuellar, Edmond I. Eger, II, Joseph F. Antognini, and Earl Carstens

Anesth Analg 2007 105: 1665-1674.

超臨床劑量的異氟烷濃度能輕微增加甲烷而非甲苯對水的親和力

唐李雋   馬皓琳 李士通

Concentrations of Isoflurane Exceeding Those Used Clinically Slightly Increase the Affinity of Methane, but Not Toluene, for Water

Charles W. Buffington, Michael J. Laster, Katarzyna Jankowska, and Edmond I. Eger, II

Anesth Analg 2007 105: 1675-1680.

TECHNOLOGY, COMPUTING, AND SIMULATION:

在志願者身上新的迴圈水裝置比強風裝置加熱更快#New_Circulating_Water_Devices_Warm

潘錢玲 陳傑

New Circulating-Water Devices Warm More Quickly than Forced-Air in Volunteers

Anupama Wadhwa, Ryu Komatsu, Mukadder Orhan-Sungur, Pamela Barnes, JangHyeok In, Daniel I. Sessler, and Rainer Lenhardt

Anesth Analg 2007 105: 1681-1687.

耳機式紅外線鼓膜測溫儀用於術中監測核心體溫的有效性

施楊譯,薛張綱校

The Usefulness of an Earphone-Type Infrared Tympanic Thermometer for Intraoperative Core Temperature Monitoring

Tomohiro Kiya, Michiaki Yamakage, Tomo Hayase, Jun-Ichi Satoh, and Akiyoshi Namiki

Anesth Analg 2007 105: 1688-1692.

CRITICAL CARE AND TRAUMA:

細胞外PH值對血管加壓素所引起的血管平滑肌細胞上ATP敏感性K通道阻滯作用的影響

潘方立 陳傑

The Effects of Extracellular pH on Vasopressin Inhibition of ATP-Sensitive K+ Channels in Vascular Smooth Muscle Cells

Takashi Kawano, Katsuya Tanaka, Hossein Nazari, Shuzo Oshita, Akira Takahashi, and Yutaka Nakaya

Anesth Analg 2007 105: 1714-1719.

NEUROSURGICAL ANESTHESIA:

腦室內給予右旋美托咪啶對清醒大鼠心血管及交感功能的影響

孫霞譯 薛張綱校

The Effects of Centrally Administered Dexmedetomidine on Cardiovascular and Sympathetic Function in Conscious Rats

Tetsuro Shirasaka, De-Lai Qiu, Hiroshi Kannan, and Mayumi Takasaki

Anesth Analg 2007 105: 1722-1728.

嗎啡增強自發性癲癇發作的機制

沈浩      馬皓琳 李士通

Mechanisms of Morphine Enhancement of Spontaneous Seizure Activity

Ehsan Saboory, Miron Derchansky, Mohammed Ismaili, Shokrollah S. Jahromi, Richard Brull, Peter L. Carlen, and Hossam El Beheiry

Anesth Analg 2007 105: 1729-1735.

OBSTETRIC ANESTHESIOLOGY:

模擬陰道分娩後失血量準確評估

 

王騰 陳傑

The Accuracy of Blood Loss Estimation After Simulated Vaginal Delivery (Brief Report)

Paloma Toledo, Robert J. McCarthy, Bradley J. Hewlett, Paul C. Fitzgerald, and Cynthia A. Wong

Anesth Analg 2007 105: 1736-1740.

GENERAL ARTICLES:

一項麻醉科的全球臨床研究的文獻統計分析

王光妍譯  薛張綱校

A Bibliometric Analysis of Global Clinical Research by Anesthesia Departments

Madhav Swaminathan, Barbara G. Phillips-Bute, and Katherine P. Grichnik

Anesth Analg 2007 105: 1741-1746.

ANALGESIA:

診斷性鞘內注射預測手術結果的能力

姜旭暉     馬皓琳  李士通

The Ability of Diagnostic Spinal Injections to Predict Surgical Outcomes (Medical Intelligence)

Steven P. Cohen and Robert W. Hurley

Anesth Analg 2007 105: 1756-1775.

阿片類藥物和沉浸式虛擬現實分散注意力的鎮痛作用:來自主觀性和功能性腦顯像評估的證據

黃佳佳   馬皓琳 李士通

The Analgesic Effects of Opioids and Immersive Virtual Reality Distraction: Evidence from Subjective and Functional Brain Imaging Assessments (Medical Intelligence)

Hunter G. Hoffman, Todd L. Richards, Trevor Van Oostrom, Barbara A. Coda, Mark P. Jensen, David K. Blough, and Sam R. Sharar

Anesth Analg 2007 105: 1776-1783.

腦部PET對術後疼痛是否使用硬膜外鎮痛的鑒別

王鵬 陳傑

The Use of Brain Positron Emission Tomography to Identify Sites of Postoperative Pain Processing With and Without Epidural Analgesia (Brief Report)

Asokumar Buvanendran, Amjad Ali, Travis R. Stoub, Richard A. Berger, and Jeffrey S. Kroin

Anesth Analg 2007 105: 1784-1786.

種族和社會經濟因素對患者接受圍術期硬膜外鎮痛的影響

王時來譯 薛張綱校

The Influence of Race and Socioeconomic Factors on Patient Acceptance of Perioperative Epidural Analgesia (Brief Report)

Edward Andrew Ochroch, Andrea B. Troxel, Jonathan K. Frogel, and John T. Farrar

Anesth Analg 2007 105: 1787-1792.

與環氧化酶-2選擇性抑制劑和非選擇性抗炎藥物有關的心血管血栓栓塞的副作用

慧譯 馬皓琳 李士通校

Cardiovascular Thromboembolic Adverse Effects Associated with Cyclooxygenase-2 Selective Inhibitors and Nonselective Antiinflammatory Drugs (Brief Report)

Girish P. Joshi, Ralph Gertler, and Ruth Fricker

Anesth Analg 2007 105: 1793-1804.

普巴加林的藥理學及在疼痛治療中的作用

周懿之 陳傑

Pregabalin: Its Pharmacology and Use in Pain Management (Review Article)

Noor M. Gajraj

Anesth Analg 2007 105: 1805-1815.

針刺毀損小鼠末梢神經建立局部疼痛症候群的模型

張儷譯  薛張綱校

Needlestick Distal Nerve Injury in Rats Models Symptoms of Complex Regional Pain Syndrome

Sandra M. Siegel, Jeung W. Lee, and Anne Louise Oaklander

Anesth Analg 2007 105: 1820-1829.

抑制環腺苷酸通路可以緩解神經性疼痛且減輕大鼠坐骨神經部分結紮後脊髓相應部位環腺苷酸磷酸化

張瑩譯  馬皓琳 李士通校

Inhibition of the Cyclic Adenosine Monophosphate Pathway Attenuates Neuropathic Pain and Reduces Phosphorylation of Cyclic Adenosine Monophosphate Response Element-Binding in the Spinal Cord After Partial Sciatic Nerve Ligation in Rats

Jiin-Tarng Liou, Fu-Chao Liu, Shi-Tai Hsin, Ching-Yue Yang, and Ping-Wing Lui

Anesth Analg 2007 105: 1830-1837.

p38 細胞分裂素活化蛋白激酶對大鼠慢性縮窄性損傷導致脊髓炎性細胞因數腫瘤壞死因數α合成的影響。

張豔 陳傑

The Influence of p38 Mitogen-Activated Protein Kinase Inhibitor on Synthesis of Inflammatory Cytokine Tumor Necrosis Factor Alpha in Spinal Cord of Rats with Chronic Constriction Injury

Li Xu, Yuguang Huang, Xuerong Yu, Jianying Yue, Nan Yang, and Pingping Zuo

Anesth Analg 2007 105: 1838-1844.

胸段脊柱周圍阻斷下行乳腺癌手術:一項隨機、雙盲試驗

周時蓓譯,薛張綱校

Thoracic Paravertebral Block for Breast Cancer Surgery: A Randomized Double-Blind Study (Case Report)

Jytte F. Moller, Lone Nikolajsen, Svein Aage Rodt, Hanne Ronning, and Palle S. Carlsson

Anesth Analg 2007 105: 1848-1851.

關於股骨創傷後臨床症狀出現前股神經阻滯緩解疼痛的一項隨機對照試驗

黃麗娜    馬皓琳  李士通 

A Randomized Controlled Trial of Femoral Nerve Blockade Administered Preclinically for Pain Relief in Femoral Trauma (Brief Report)

Arno Schiferer, Carmen Gore, Laszlo Gorove, Thomas Lang, Barbara Steinlechner, Michael Zimpfer, and Alexander Kober

Anesth Analg 2007 105: 1852-1854.

旁正中法:一項較好的老年患者中初次連續脊麻進路方法

胡湘   馬皓琳 李士通

The Paramedian Technique: A Superior Initial Approach to Continuous Spinal Anesthesia in the Elderly (Brief Report)

Anna Rabinowitz, Benoît Bourdet, Vincent Minville, Clément Chassery, Antoine Pianezza, Aline Colombani, Bernard Eychenne, Kamran Samii, and Olivier Fourcade

Anesth Analg 2007 105: 1855-1857.

壓電式振動針和導管增強超聲引導周圍神經阻滯

朱玫娟 陳傑

Piezoelectric Vibrating Needle and Catheter for Enhancing Ultrasound-Guided Peripheral Nerve Blocks (Technical Communication)

Stephen M. Klein, Matthew P. Fronheiser, John Reach, Karen C. Nielsen, and Stephen W. Smith

Anesth Analg 2007 105: 1858-1860.

 

心率變異性在術後不良心臟事件的危險分層中的作用

The Role of Heart Rate Variability in Risk Stratification for Adverse Postoperative Cardiac Events

Timo Laitio, MD*, Jouko Jalonen, MD*, Tom Kuusela, PhD{dagger}, and Harry Scheinin, MD{ddagger}

From the *Department of Anesthesiology and Intensive Care, Turku University Hospital; {dagger}Department of Physics; and {ddagger}Turku PET Centre and Department of Pharmacology and Clinical Pharmacology, University of Turku, Turku, Finland.

Anesth Analg 2007 105: 1548-1560.

越來越多的證據表明自主神經功能的損害和心臟猝死之間有密切的關係。心率變異性(HRV)的測定廣泛用於評估自主神經功能的變化。對於心臟病患者的許多研究均顯示心率變異性的下降和壓力反射功能異常較以前公認的臨床指標(比如左室射血分數)在心臟猝死的預測中更有意義。三分之一的術後併發症和半數以上的死亡是由於心臟併發症引起的。許多危險性指標對患者圍術期短期內的危險分層很有幫助,但對長期預後的危險分層作用不大。目前還沒有關於術後危險評估的類似臨床方法。最近有少數研究顯示術前心率變異性降低是術後遠期死亡的獨立預測因素。今後,宜開展更多針對手術病人的研究,來確立術前壓力反射功能異常或者和心率變異性異常一起對術後短期或者遠期的預後的價值。

(杜唯佳 陳傑 校)

There is growing evidence of a strong association between the compromised autonomic nervous system and sudden cardiac death. Heart rate variability (HRV) measures are widely used to measure alterations in the autonomic nervous system. Several studies with cardiac patients show that decreased HRV as well as baroreceptor dysfunction are more powerful predictors for sudden cardiac death than established clinical predictors such as left ventricular ejection fraction. One-third of all postoperative complications and more than half of the deaths are due to cardiac complications. Several risk indices are useful for immediate perioperative short-term, but not for long-term outcome risk stratification of an individual patient. Currently, there are no clinically assimilated methods for long-term postoperative risk assessment. Recently, few studies have shown that preoperatively decreased HRV can independently predict postoperative long-term mortality. Further studies with surgical patients are needed to establish a possible predictive value of preoperative baroreceptor dysfunction, alone and combined with HRV, for short- and long-term postoperative outcome.

一項關於POVOC評分預測兒童術後嘔吐的前瞻性評估

A Prospective Evaluation of the POVOC Score for the Prediction of Postoperative Vomiting in Children

Peter Kranke, MD, PhD, MBA*, Leopold H. Eberhart, MD, PhD{dagger}, Hakki Toker, MD{ddagger}, Norbert Roewer, MD, PhD*, Hinnerk Wulf, MD, PhD{dagger}, and Peter Kiefer, MD, PhD{ddagger}

From the *Department of Anaesthesiology, University Hospitals of Würzburg, Würzburg, Germany; {dagger}Department of Anaesthesiology and Critical Care, University Hospitals of Marburg and Giessen GmbH, Campus Marburg, Germany; and {ddagger}Department of Anaesthesiology, Evangelischen Krankenhauses Oberhausen, Germany.

Anesth Analg 2007 105: 1592-1597.Abstract

背景:POVOC是最近發表的一項預測兒童術後嘔吐(PV)的評分標準,但還未客觀驗證。

 

方法:作者以使用標準麻醉技術但不預先使用止吐藥的方式,研究673位元施行各種外科手術(但排除斜視手術,因其為POVOC評分的危險因素之一)的016歲病人。在術後階段關於是否發生術後嘔吐,對患者行篩選。再將這些發生率與POVOC評分所得出的預計危險度相比較。評估POVOC評分時,充分考慮到其易於使用、描述和校正的特點。

 

結果:95%病人收集到預測術後嘔吐危險度的完整資料。結果顯示當風險因素為0123時的PV發生率分別為3.4%11.6%8.2%42.3%。並得出一條斜率為0.78、截距為2.37的回歸線。其特徵曲線下面積為0.7295%可信區間為0.68-0.76)。

 

結論:即使有些危險因素未能提供, POVOC評分能比較準確地評估兒科病人,且其結果並不遜于成人。

(於章傑 陳傑 校)

BACKGROUND: A score to predict postoperative vomiting (PV) in children (POVOC score) has recently been published but has not yet undergone an external validation.

METHODS: We studied 673 patients (age 0–16 yr) undergoing a variety of surgical procedures (but excluding strabismus surgery, one of the risk factors according to the POVOC score) using standardized anesthesia techniques without administering antiemetics. The patients were prospectively screened for PV in the postoperative period and these incidences were compared with the predicted risk for PV according to the POVOC score. The POVOC score was evaluated with respect to its ease of use, discrimination, and calibration.

RESULTS: Complete data to predict the risk for PV could be obtained in 95% of patients. The actual observed incidences of PV were 3.4, 11.6, 28.2, and 42.3% for the presence of 0, 1, 2, or 3 risk factors, resulting in a regression line with a slope of 0.78 and an offset of 2.37. The area under the receiver operating characteristic curve was 0.72 (95% CI: 0.68–0.76).

CONCLUSIONS: Using the POVOC score, PV in pediatric patients can be predicted with sufficient accuracy comparable to the results in adult patients, even if one of the risk factors is not applicable.

 健康兒童白陶土啟動凝血彈性描記法的參考值

Reference Values for Kaolin-Activated Thromboelastography in Healthy Children

Kah-Lok Chan*{dagger}, Robyn G. Summerhayes, BSc (Hons)*{dagger}{ddagger}, Vera Ignjatovic, PhD*{dagger}{ddagger}, Stephen B. Horton, PhD, FACBS§||, and Paul T. Monagle, MD, FRACP, FRCPA, FCCP*{dagger}

From the *Department of Clinical Hematology, Royal Children’s Hospital; {dagger}Department of Pathology, The University of Melbourne; {ddagger}Murdoch Children’s Research Institute; §Cardiac Surgical Unit, Royal Children’s Hospital; and ||Department of Pediatrics, The University of Melbourne, Melbourne, Australia.

Anesth Analg 2007 105: 1610-1613.

背景:兒童的凝血系統隨年齡的變化而改變,也不同于成人的凝血系統。因此,需確定特定年齡的凝血變數參考值。凝血彈性描記法( TEG)是凝血試驗一部分,可以提供良好的評估和處理大劑量不間斷使用肝素的體外轉流術的心臟手術後的凝血紊亂。本研究作者擬確定健康兒童白陶土啟動的凝血彈性描記法的參考值,以便為兒童凝血彈性描記法的結果有個準確的詮釋。

方法:研究100名擇期手術的健康兒童和25個健康成人志願者的白陶土啟動凝血彈性描記法試驗結果。記錄以下凝血彈性描記法變數:反應時間,凝固時間,角度,最大變幅,達到最大變幅後30分鐘的溶解百分率和凝固指數。不同年齡組之間的差異通過方差分析來評定。

結果:研究提供了一個月小兒至16歲兒童之間各特定年齡的參考值。在成人和兒童之間所有測定值無顯著差異。

結論:凝血彈性描記法的結果需考慮到年齡的特定性,以及分析儀和啟動劑的特殊性,以便根據測定結果提供了恰當的詮釋。本研究提供的參考值對於需要監測實際凝血狀態的急症者是有意義的。

(陳偉 陳傑 校)

BACKGROUND: The hemostatic system of children changes with age and differs significantly from the hemostatic system of adults. Age-specific reference values are therefore required for most hemostatic variables. Thromboelastography (TEG®) is a point-of-care coagulation test that may provide superior evaluation and management of coagulopathies after cardiac surgery, when large-dose unfractionated heparin is administered for cardiopulmonary bypass. In this study, we established reference values for kaolin-activated TEG in healthy children, to facilitate accurate interpretation of pediatric TEG results.

METHODS: Kaolin-activated TEG was performed on 100 healthy children undergoing elective day surgery and 25 healthy adult volunteers. The following TEG variables were recorded: reaction time, coagulation time, {alpha}angle, maximum amplitude, percentage lysis 30 min after maximum amplitude was reached, and the coagulation index. Differences between age-groups were evaluated using analysis of variance.

RESULTS: Age-specific reference values for kaolin-activated TEG in healthy children between 1 mo and 16 yr of age are presented. No significant differences between children and adults were observed.

CONCLUSIONS: TEG results, from a particular clinical setting, must be compared to age-specific, as well as analyzer- and activator-specific, reference values to allow for correct interpretation of the results. Reference values provided here will be of use in acute clinical situations where a practical monitor of hemostasis is required.

 豬失血性休克對異氟醚的最小肺泡麻醉濃度的影響

The Influence of Hemorrhagic Shock on the Minimum Alveolar Anesthetic Concentration of Isoflurane in a Swine Model

Tadayoshi Kurita, MD, Kotaro Takata, MD, Masahiro Uraoka, MD, Koji Morita, PhD, Yoshimitsu Sanjo, PhD, Takasumi Katoh, MD, and Shigehito Sato, MD

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

Anesth Analg 2007 105: 1639-1643.

背景: 雖然失血性休克降低吸入麻醉的最小肺泡濃度,但是很少影響腦電圖。失血性休克也可誘發內啡呔的釋放,它是一種天然合成的阿片類物質。作者研究這種阿片類物質的釋放是否可解釋MAC的降低。

 

方法: 選取11頭豬,使用露爪鉗夾技術測定各階段異氟醚的MAC,分別為出血前;出血預計血容量30%(出血21ml/kg,時間大於30分鐘);液體復蘇後(使用相當於血液丟失量的羥乙基澱粉);及給予0.1mg/kgu受體拮抗劑納洛酮後。

 

結果:失血性休克使異氟醚的MAC2.05%±0.28%降到1.50%±0.51%(P=0.0007)。液體復蘇不能逆轉下降的MAC1.59%±0.53%,但是給予納洛酮後MAC恢復到基礎水平(1.96%±0.26%)。MAC值的降低取決於休克的嚴重度,但是伴隨著液體復蘇和給予納洛酮引起的血流動力學改變和代謝變化並不能解釋MAC的變化     

 

結論:與以往的報導一致,失血性休克降低MAC。給予納洛酮後能逆轉MAC的影響。失血性休克期間啟動內源性阿片系統從而來降低MAC。這種啟動不能改變腦電圖。上述結果與以往發現的失血性休克很少改變腦電圖結論相一致。

(張燕 陳傑 校)

BACKGROUND: Although hemorrhagic shock decreases the minimum alveolar concentration (MAC) of inhaled anesthetics, it minimally alters the electroencephalographic (EEG) effect. Hemorrhagic shock also induces the release of endorphins, which are naturally occurring opioids. We tested whether the release of such opioids might explain the decrease in MAC.

METHODS: Using the dew claw-clamp technique in 11 swine, we determined the isoflurane MAC before hemorrhage, after removal of 30% of the estimated blood volume (21 mL/kg of blood over 30 min), after fluid resuscitation using a volume of hydroxyethylstarch equivalent to the blood withdrawn, and after IV administration of 0.1 mg/kg of the µ-opioid antagonist naloxone.

RESULTS: Hemorrhagic shock decreased the isoflurane MAC from 2.05% ± 0.28% to 1.50% ± 0.51% (P = 0.0007). Fluid resuscitation did not reverse MAC (1.59% ± 0.53%), but additional administration of naloxone restored it to control levels (1.96% ± 0.26%). The MAC values decreased depending on the severity of the shock, but the alterations in hemodynamic variables and metabolic changes accompanying fluid resuscitation or naloxone administration did not explain the changes in MAC.

CONCLUSIONS: Consistent with previous reports, we found that hemorrhagic shock decreases MAC. In addition, we found that naloxone administration reversed the effect on MAC, and we propose that activation of the endogenous opioid system accounts for the decrease in MAC during hemorrhagic shock. Such an activation would not be expected to materially alter the EEG, an expectation consistent with our previous finding that hemorrhagic shock minimally alters the EEG.

 

 

 p38絲裂原啟動蛋白激酶(p38MAP激酶)抑制劑可以保護離體試驗中利多卡因誘導的神經軸突損傷,而半胱氨酸蛋白酶活性抑制劑無此作用

In Vitro, Lidocaine-Induced Axonal Injury Is Prevented by Peripheral Inhibition of the p38 Mitogen-Activated Protein Kinase, but Not by Inhibiting Caspase Activity

Philipp Lirk, MD, MSc*, Ingrid Haller, MD*, Hans Peter Colvin*, Silke Frauscher, MD{dagger}, Lukas Kirchmair, MD*, Peter Gerner, MD{ddagger}, and Lars Klimaschewski, MD{dagger}

From the *Department of Anesthesiology and Critical Care Medicine, and {dagger}Division of Neuroanatomy, Innsbruck Medical University, Austria; and {ddagger}Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2007 105: 1657-1664.

背景:所有的局麻藥都在一定程度上存在神經毒性,目前已在分離培養的神經細胞(包括軸突和神經元胞體)進行了局麻藥的毒性研究。然而由於臨床操作中外周神經阻滯主要是局麻藥作用於軸突的過程,故此類方法或許未能準確地反映體內外周神經處於阻滯時的狀態。

 

方法:作者研究了在房室分割感覺神經元培養模型(包括神經元胞體組成的中央室和軸突組成的外周室)中利多卡因的神經毒性表現。在試驗中觀察神經元胞體或軸突在使用利多卡因配合或不配合神經保護劑,並評估神經元的存活性及軸突在培養皿上的生長。

                                        

結果:在外周室模型中使用利多卡因可以導致軸突數量降低59%±9%,而不影響神經元胞體的存活。對軸突培養中加入利多卡因,再對軸突加入p38絲裂原啟動蛋白激酶抑制劑--SB203580,觀察到軸突細胞的損傷情況減輕(軸突生長暈的最大距離只降低至93%±9%),而對神經元胞體加入SB203580時軸突生長的最大距離降低至48%±6%。而 改用半胱氨酸蛋白酶活性抑制劑z-vad-fmk時並未顯示相應的保護作用

 

結論:無論是p38MAP激酶的抑制劑或半胱氨酸蛋白酶活性抑制劑,均能增加分離培養的神經元在局麻藥作用時的生存活性。p38MAP激酶抑制劑可以預防利多卡因造成的神經細胞的軸突變性,而半胱氨酸蛋白酶活性抑制劑卻無此作用。作者認為在分離培養的神經元上局麻藥所造成的神經毒性的過程,可能與臨床中單純軸突上使用局麻藥產生的現象不同。

(陶穎瑩 陳傑 校)

BACKGROUND: All local anesthetics (LAs) are, to some extent, neurotoxic. Toxicity studies have been performed in dissociated neuron cultures, immersing both axon and soma in LA. This approach, however, does not accurately reflect the in vivo situation for peripheral nerve blockade, where LA is applied to the axon alone.

METHODS: We investigated lidocaine neurotoxicity in compartmental sensory neuron cultures, which are composed of one central compartment containing neuronal cell bodies and a peripheral compartment containing their axons, allowing for selective incubation. We applied lidocaine ± neuroprotective drugs to neuronal somata or axons, and assessed neuron survival and axonal outgrowth.

RESULTS: Lidocaine applied to the peripheral compartment led to a decreased number of axons (to 59% ± 9%), without affecting survival of cell bodies. During axonal incubation with lidocaine, the p38 mitogen-activated protein kinase inhibitor SB203580 (10 µM) attenuated axonal injury when applied to the axon (insignificant reduction of maximal axonal distance to 93% ± 9%), but not when applied to the cell body (deterioration of maximal axonal length to 48% ± 6%). Axonal co-incubation of lidocaine with the caspase inhibitor z-vad-fmk (20 µM) was not protective.

CONCLUSIONS: Whereas inhibition of either p38 mitogen-activated protein kinase or caspase activity promote neuronal survival after LA treatment of dissociated neuronal cultures, axonal degeneration induced by lidocain (40 mM) is prevented by p38 MAP kinase but not by caspase inhibition. We conclude that processes leading to LA-induced neurotoxicity in dissociated neuronal culture may be different from those observed after purely axonal application.

 

 在志願者身上新的迴圈水裝置比強風裝置加熱更快

New Circulating-Water Devices Warm More Quickly than Forced-Air in Volunteers

Anupama Wadhwa, MD*, Ryu Komatsu, MD{dagger}, Mukadder Orhan-Sungur, MD{dagger}, Pamela Barnes, MD{ddagger}, JangHyeok In, MD{dagger}, Daniel I. Sessler, MD§, and Rainer Lenhardt, MD*||

From the *Outcomes Research Institute, University of Louisville, Louisville, Kentucky; {dagger}Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, Kentucky; {ddagger}Department of Anesthesiology, University of Chicago, Chicago, Illinois; §Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; and ||Neurosciences Intensive Care Unit, University of Louisville, Louisville, Kentucky.

Anesth Analg 2007 105: 1681-1687.

背景:新的迴圈水系統比強風能提供更多的熱量,主要是由於水的熱容量比干熱空氣大,其次是由於它能像使身體前面熱起來一樣使身體後面也熱起來。目前已有幾種加熱系統,但其中三個主要的系統已經進行過直接的比較了。因此作者在志願者身上進行與上腹部或胸腔手術相似操作時進行兩種迴圈水系統和一種強風系統的比較。

方法:7個健康的志願者分別參加3天的研究。受試者每天在麻醉後開始降低體溫,使其中心體溫降低到34℃左右,並持續4560分鐘。然後用三種加熱系統中的一種對其進行複溫直到遠端食管中心溫度接近36℃或者麻醉持續8小時。這三種加熱系統分別是:1)能量轉換墊(兩個分開的軀幹墊及兩個整體墊;型號為Kimberly Clark,Roswell,GA);2)迴圈水系統(型號為以色列產的用於心臟手術的Allon MTRE 3365);3)下肢的強風加熱系統(型號為Bair Hugger#525,750blowerEden Prairie,MN.資料取平均數±標準差;P0.05表示有統計學意義。

結果:用Kimberly Clark系統加熱後中心體溫從34℃升至36℃速率為1.2℃±0.2/h,用Allon 系統為0.9℃±0.2/h,用Bair Hugger0.6℃±0.1/hP0.002)。

結論Kimberly Clark系統的加熱速率比Allon系統快25%,比Bair Hugger系統快兩倍。兩種迴圈水系統使低體溫的志願者複溫所需的時間顯著短於強風系統。

(潘錢玲 陳傑 校)

BACKGROUND: Newer circulating-water systems supply more heat than forced-air, mainly because the heat capacity of water is much greater than for that of dry warm air and, in part, because they provide posterior as well as anterior heating. Several heating systems are available, but three major ones have yet to be compared directly. We therefore compared two circulating-water systems with a forced-air system during simulation of upper abdominal or chest surgery in volunteers.

METHODS: Seven healthy volunteers participated on three separate study days. Each day, they were anesthetized and cooled to a core temperature near 34°C, which was maintained for 45–60 min. They were then rewarmed with one of three warming systems until distal esophageal core temperature reached 36°C or anesthesia had lasted 8 h. The warming systems were 1) energy transfer pads (two split torso pads and two universal pads; Kimberly Clark, Roswell, GA); 2) circulating-water garment (Allon MTRE 3365 for cardiac surgery, Akiva, Israel); and 3) lower body forced-air warming (Bair Hugger #525, #750 blower, Eden Prairie, MN). Data are presented as mean ± sd; P < 0.05 was statistically significant.

RESULTS: The rate of increase of core temperature from 34°C to 36°C was 1.2°C ± 0.2°C/h with the Kimberly Clark system, 0.9°C ± 0.2°C/h with the Allon system, and 0.6°C ± 0.1°C/h with the Bair Hugger (P = 0.002).

CONCLUSIONS: The warming rate with the Kimberly Clark system was 25% faster than with the Allon system and twice as fast as with the Bair Hugger. Both circulating-water systems thus warmed hypothermic volunteers in significantly less time than the forced-air system.

 細胞外PH值對血管加壓素所引起的血管平滑肌細胞上ATP敏感性K通道阻滯作用的影響

The Effects of Extracellular pH on Vasopressin Inhibition of ATP-Sensitive K+ Channels in Vascular Smooth Muscle Cells

Takashi Kawano, MD*, Katsuya Tanaka, MD*, Hossein Nazari, PhD{dagger}, Shuzo Oshita, MD*, Akira Takahashi, MD{dagger}, and Yutaka Nakaya, MD{dagger}

From the Departments of *Anesthesiology and {dagger}Nutrition and Metabolism, Institute of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan.

Anesth Analg 2007 105: 1714-1719.

背景:精氨酸血管加壓素(AVP)可以阻滯ATP敏感的K通道(KATP)並有助於恢復由於血管舒張引起的休克病人的血管張力。在目前的研究中,筆者觀察了酸化細胞外環境是否改變AVP對血管平滑肌KATP的阻滯作用。

方法:筆者應用細胞膜片鉗技術研究細胞外PH值(PH0)對大鼠主動脈平滑肌細胞上AVP-KATP通道的作用。

結果:浸浴在AVP溶液中能顯著阻滯細胞外環境酸化(PH0=7.0)引起的KATP通道的活動,具有濃度依賴性,IC5016.8pM。且在中度(PH0=7.0)和重度(PH0=6.5)細胞外酸性環境時,浸浴在AVP中能阻滯吡那地爾引起的KATP通道活動,IC50分別為266.721.4pM,但是在中性(PH0=7.4)和鹼性(PH0=9.0)環境下不能阻滯。細胞外環境酸化增強AVP KATP通道的阻滯作用可以在預先使用OPC21268,一種 V1受體阻滯劑後而被消除,但不能被V2受體阻滯劑OPC31260消除。在預先使用了蛋白激酶C阻滯劑卡弗他丁CAVP引起的阻滯作用被抑制。

結論:作者的實驗結果顯示AVP可以阻滯在酸化的細胞外環境中血管平滑肌細胞上KATP通道的活性,並且其阻滯效果受細胞外環境酸化程度的影響,通過V1受體蛋白激酶C細胞信號途徑。這種在酸性環境下有效的對血管平滑肌細胞上KATP通道的阻滯作用使其成為治療血管源性休克的合適的方法。

(潘方立 陳傑 校)

BACKGROUND: Arginine vasopressin (AVP) inhibits ATP-sensitive potassium (KATP) channels and may help to restore vascular tone in patients with vasodilatory shock. In the present study, we investigated whether extracellular acidification modifies the inhibition of vascular KATP channels by AVP.

METHODS: We used a cell-attached patch-clamp configuration to investigate the effects of extracellular pH (pHo) on AVP-KATP channel interaction in rat aortic smooth muscle cells.

RESULTS: Bath application of AVP significantly inhibited extracellular acidification (pHo = 6.5)-induced KATP channel activity in a concentration-dependent manner, with an half-maximal inhibitory concentration (IC50) value of 16.8 pM. Furthermore, bath application of AVP significantly inhibited pinacidil-induced KATP channel activity at mild (pHo = 7.0) and severe (pHo = 6.5) extracellular acidification, with IC50 values of 266.7 and 21.4 pM, respectively, but failed to significantly inhibit at normal pH (pHo = 7.4) or under alkalosis (pHo = 9.0). Augmentation of AVP inhibition of vascular KATP channels during extracellular acidification was eliminated by pretreatment with OPC-21268, a specific blocker of the V1 receptor, but not by a V2 blocker, OPC-31260. AVP-induced inhibition was also suppressed by pretreatment with a protein kinase C inhibitor, calphostin C.

CONCLUSIONS: Our results suggest that AVP inhibits extracellular acidification-induced vascular KATP channel activity, and that the inhibitory effects of AVP on vascular KATP channels are enhanced by extracellular acidification via the V1 receptor-protein kinase C cell-signaling pathway. The potent inhibition of vascular KATP channels by AVP under acidic conditions may make it suitable for management of vasodilatory shock.

 模擬陰道分娩後失血量準確評估

The Accuracy of Blood Loss Estimation After Simulated Vaginal Delivery

Paloma Toledo, MD, Robert J. McCarthy, PharmD, Bradley J. Hewlett, BS, Paul C. Fitzgerald, RN, MS, and Cynthia A. Wong, MD

From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Anesth Analg 2007 105: 1736-1740.

背景:用肉眼觀察估計血液損失量往往比實際失血量低。在這個研究中,作者設法確定用標有刻度的被墊測量模擬陰道分娩中失血量的估測效果。

方法:受試者被隨機分組,用標有刻度和未標刻度的被墊測量陰道分娩過程中的失血量,而失血量又被分為3005001000,和2000ml四組,然後相互比較。

結果:用視覺直估未標有刻度被墊上的失血量數值低於實際失血量,估測的差距隨失血量增大而增大(從300ml2000ml,錯誤率由16%增大到41%),而用標有刻度的被墊估測錯誤率均小於15%

結論:標有刻度陰道分娩被墊可以改善失血量估測的準確度。

(王騰 陳傑 校)

BACKGROUND: Visual blood loss estimation often underestimates blood loss. In this study we sought to determine the effect of calibrated drape markings on blood loss estimation in a simulated vaginal delivery.

METHODS: Subjects were randomized to estimate simulated blood loss (300, 500, 1000, and 2000 mL) in calibrated or noncalibrated vaginal delivery drapes and then crossover.

RESULTS: Visual blood loss estimation with noncalibrated drapes underestimated blood loss, with worsening accuracy at larger volumes (16% error at 300 mL to 41% at 2000 mL). The calibrated drape error was <15% at all volumes.

CONCLUSIONS: Calibrated vaginal delivery drapes improve blood loss estimation.

 

 

腦部PET對術後疼痛是否使用硬膜外鎮痛的鑒別

The Use of Brain Positron Emission Tomography to Identify Sites of Postoperative Pain Processing With and Without Epidural Analgesia

Asokumar Buvanendran, MD*, Amjad Ali, MD{dagger}, Travis R. Stoub, PhD{ddagger}, Richard A. Berger, MD§, and Jeffrey S. Kroin, PhD*

From the Departments of *Anesthesiology, {dagger}Radiology, {ddagger}Neurology, and §Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois.

Anesth Analg 2007 105: 1784-1786.

為了減輕術後疼痛而使用不同鎮痛方法時腦部的變化尚未闡明。作者在一名69歲的婦女行全膝置換術術後兩天內,分別在她處於中等程度的術後疼痛和在硬膜外鎮痛下完全緩解疼痛的情況下,利用PET(正電子發射型電腦斷層顯像)進行了頭部掃描。利用術後第一天(沒有進行硬膜外鎮痛而處於中等疼痛)PET掃描得到的資料減去術後第二天(硬膜外完全鎮痛)PET掃描的資料確定疼痛引起的活動的大腦區域。術後疼痛伴隨著對側初級自身感覺大腦皮層活動性的增強。術後活動性增強的大腦區域還有對側的顱頂部的大腦皮層,兩側的丘腦後結節和下丘腦的背內側核,對側的殼核,對側的上部顳側腦回,同側的梭狀回,同側的後葉和對側的小腦前葉。這些研究證明了可利用PET評估術後急性疼痛的中樞變化。

(王鵬 陳傑 校)

It is not known how different analgesic regimes affect the brain when reducing postoperative pain. We performed positron emission tomography (PET) scans on a 69-yr-old woman in the presence of moderate postoperative pain and then with epidural analgesia producing complete analgesia, during the first 2 days after total knee arthroplasty. Day 2 postsurgery PET scan data (no pain with epidural analgesia) were subtracted from Day 1 postsurgery PET scan data (time of moderate pain without epidural analgesia) to determine the brain regions activated. Postsurgical pain was associated with increased activity in the contralateral primary somatosensory cortex. Other brain regions showing increased postsurgical activity were the contralateral parietal cortex, bilateral pulvinar and ipsilateral medial dorsal nucleus of the thalamus, contralateral putamen, contralateral superior temporal gyrus, ipsilateral fusiform gyrus, ipsilateral posterior lobe, and contralateral anterior cerebellar lobe. This study demonstrates the feasibility of evaluating the central processing of acute postoperative pain using PET.

 

普巴加林的藥理學及在疼痛治療中的作用

Pregabalin: Its Pharmacology and Use in Pain Management

Noor M. Gajraj, MD, FRCA, DABPM

From the Texas Anodyne Research Institute and Sherman Pain Care, Texas.

Anesth Analg 2007 105: 1805-1815.

普加巴林是一種新型合成物,是神經遞質{gamma}-氨基丁酸的衍生物。它是{alpha}2-{delta} ({alpha}2-{delta})配合物,具有鎮痛、抗驚厥、抗焦慮和睡眠調節作用。普巴加林與鈣離子通道的{alpha}2-{delta}亞基牢固結合,可導致數種神經遞質的釋放減少,包括谷氨酸、去甲腎上腺素、5-羥色胺、多巴胺和P-物質。本綜述討論普加巴林的藥理特性,以及在疼痛治療中療效。本綜述將重點討論在2005年作者前一綜述後普加巴林藥理學的進展。

(周懿之 陳傑 校)

Pregabalin is a new synthetic molecule and a structural derivative of the inhibitory neurotransmitter {gamma}-aminobutyric acid. It is an {alpha}2-{delta} ({alpha}2-{delta}) ligand that has analgesic, anticonvulsant, anxiolytic, and sleep-modulating activities. Pregabalin binds potently to the {alpha}2-{delta} subunit of calcium channels, resulting in a reduction in the release of several neurotransmitters, including glutamate, noradrenaline, serotonin, dopamine, and substance P. In this review, I will discuss the pharmacology of pregabalin and available efficacy studies in pain management. This review will focus on the advances in pregabalin pharmacology since my previous review in 2005.

 

p38 細胞分裂素活化蛋白激酶對大鼠慢性縮窄性損傷導致脊髓炎性細胞因數腫瘤壞死因數α合成的影響。

 

11.The Influence of p38 Mitogen-Activated Protein Kinase Inhibitor on Synthesis of Inflammatory Cytokine Tumor Necrosis Factor Alpha in Spinal Cord of Rats with Chronic Constriction Injury

Li Xu, MD*, Yuguang Huang, MD*, Xuerong Yu, MD*, Jianying Yue, MD{dagger}, Nan Yang, PhD{ddagger}, and Pingping Zuo, PhD{ddagger}

Anesth Analg 2007 105: 1838-1844.

背景:腫瘤壞死因數αTNF-α)可觸發p38細胞分裂素活化蛋白激酶(MAPK)的啟動。磷酸化p38pp38)可誘導TNF-α的上調。在此次試驗中,作者驗證如下假設:對坐骨神經造成慢性縮窄性損傷(CCI)刺激脊髓釋放TNF-α以及產生異常性疼痛是通過p38 MAPK途徑。

方法:Sprague–Dawley大鼠分成5組:1)對照組,2)假手術組,3)未治療的CCI,4)生理鹽水治療組,5)p38 MAPK抑制劑SB203580治療組。治療組,在CCI前一天、後一天和後七天向鞘內給予生理鹽水或SB2035802μg,一天兩次)。在手術後不同時間處死大鼠並通過]Western blot分析(蛋白印跡分析)或免疫組化來驗證脊髓中p38 MAPK的活化和TNFα水平。在手術後3714天通過von Frey hairs法測定機械性異常痛。

結果:與時間相匹配,pp38 M APK CCI手術後3714天顯著增高(P<0.05),末梢神經損傷誘導機械性異常痛和脊髓中TNF-α的濃度增加(P<0.05)。用SB203580前處理或早處理能抑制p38 MAPK的活化,減少TNF-α合成物,以及減弱機械性異常性疼痛。

結論:P38 MAPK 活化是TNF-α合成物達到高峰以及在末梢神經損傷後的機械性異常痛的信號級聯放大中的一步。

(張豔 陳傑 校)

BACKGROUND: Tumor necrosis factor {alpha}(TNF-{alpha}) could trigger p38 mitogen-activated protein kinase (MAPK) activation. Conversely phosphorylated p38 (p-p38) could induce the upregulation of TNF-{alpha}. In this study, we examined the hypothesis that chronic constrictive injury (CCI) of the sciatic nerve could promote spinal cord release of TNF-{alpha} and produce allodynia via the p38 MAPK pathway.

METHODS: Sprague–Dawley rats were divided into five groups: 1) naïve control rats, 2) sham surgery rats, 3) CCI surgery rats without treatment, 4) CCI surgery rats with saline (0.9%) treatment, and 5) CCI surgery rats with the p38 MAPK inhibitor SB203580 treatment. In treatment groups, saline or SB203580 (2 µg, twice a day) was given intrathecally starting 1 day before or 1 day or 7 days after CCI. All rats were killed at different times after surgery to examine p38 MAPK activity and TNF-{alpha} levels in the spinal cord by Western blot analysis or immunohistochemistry. Mechanical allodynia was tested by a series of von Frey hairs 3, 7, and 14 days after surgery.

RESULTS: p-p38 MAPK was significantly increased at 3, 7, and 14 days after CCI surgery compared with time-matched shams (P < 0.05). Peripheral nerve injury induced mechanical allodynia and enhanced spinal concentrations of TNF-{alpha} (P < 0.05). Pretreatment or early treatment with SB203580 inhibited p38 MAPK activity, resulting in reduction of TNF-{alpha} synthesis and attenuation of mechanical allodynia (P < 0.05).

CONCLUSION: p38 MAPK activation is one aspect of the signaling cascade that culminates in TNF-{alpha} synthesis and contributes to mechanical allodynia after peripheral nerve injury.

 

 壓電式振動針和導管增強超聲引導周圍神經阻滯

 

Piezoelectric Vibrating Needle and Catheter for Enhancing Ultrasound-Guided Peripheral Nerve Blocks

Stephen M. Klein, MD*, Matthew P. Fronheiser, BS{dagger}, John Reach, MD{ddagger}, Karen C. Nielsen, MD*, and Stephen W. Smith, PhD{dagger}

Anesth Analg 2007; 105:1858-1860

超聲顯影已被用於單次周圍神經阻滯和連續置管。目前此技術的一個局限性在於不能確定針尖或導管頂端的位置。作者設計了一種新的針和導管,使其遠端可以被彩色血流Doppler超聲顯影。定制一根18G100mm長的絕緣Tuohy針,一根20G50mm聚酰胺導管(頂端開口)和一根Teflon包裹的鋼導芯(B. Braun, Bethlehem, PA),在其適當位置粘附兩個壓電式傳動裝置。當結合一個功能發生器(FG502,Tektronix, Richardson, TX)和一個100W的聲波放大器(R3000,KLH, Sun ValleyCA)時,這個裝置可以產生1-8KHz的震動。模擬進行一次側路膕窩神經阻滯,針和導管刺入用防腐劑保存屍體的大腿。啟動時,在短軸上使用二維彩色Doppler超聲模式和12MHz L38探頭(MicroMaxx, Sonosite, Bothell, WA)進行超聲掃描,可以看到針和導管的頂端均被彩色顯影。震動技術可能是進行超聲引導區域麻醉的一項有效輔助方法。需要更多的研究來評估其的有效性和在活體組織的安全性。

(朱玫娟 陳傑 校)

Ultrasound imaging has been used for performing single-injection peripheral nerve blocks and continuous catheters. One limitation with current technology is the inability to confirm the location of the needle or catheter tip. We describe a new needle and catheter design that permits distal tip visualization using color flow Doppler. An 18-gauge 100-mm insulated Tuohy needle and a 20-gauge 50-mm polyamide catheter (open tip) with a Teflon-coated steel stylet (B. Braun, Bethlehem, PA) were customized by adhering in place two piezoelectric actuators. These created 1–8 kHz vibrations when coupled to a function generator (FG502, Tektronix, Richardson, TX) and a 100 W audio amplifier (R3000, KLH, Sun Valley, CA). Mimicking a lateral popliteal fossa block, the needle and catheter were inserted into the leg of an unembalmed cadaver. When activated, the tip of each was highlighted in color when scanned in the short axis using the color Doppler mode of a two-dimensional ultrasound and a 12 MHz L38 probe (MicroMaxx, Sonosite, Bothell, WA). Vibration technology may be a useful adjunct while performing ultrasound-guided regional anesthesia. Further study evaluating its usefulness and safety in live tissue is warranted.

氯胺酮不增加肺動脈高壓兒童在自主呼吸行七氟醚麻醉時的肺血管阻力

Ketamine Does Not Increase Pulmonary Vascular Resistance in Children with Pulmonary Hypertension Undergoing Sevoflurane Anesthesia and Spontaneous Ventilation

Glyn D. Williams, Bridget M. Philip, Larry F. Chu, MD, M. Gail Boltz,  Komal Kamra, Heidi Terwey, Gregory B. Hammer,  Stanton B. Perry,  Jeffrey A. Feinstein, Chandra Ramamoorthy

From the *Department of Anesthesia, Stanford School of Medicine, and {dagger}Department of Pediatrics, Division of Pediatric Cardiology, Stanford School of Medicine, Stanford University, Stanford, California.

Anesth Analg 2007;105:1578 –84

 

背景:在肺血管阻力增高的兒童中使用氯胺酮是存在爭議的。在此次前瞻性、空開標籤的研究中,我們評估了肺動脈高壓兒童(平均肺動脈壓力>25mmHg)的血流動力學對於氯胺酮的反應。

方法:參予研究的是年齡在3個月至18歲,預約了在全麻下行心導管檢查的肺動脈高壓患兒。病人通過面罩自主呼吸含1.0MAC七氟醚的空氣進行麻醉。在心導管測量完基礎值後,七氟醚下調至0.5MAC,並注入氯胺酮(2 mg/kg IV over 5 min),隨之以維持劑量(10ug/kg/min)。在氯胺酮負荷劑量輸注完成後的51015分鐘分別重複心導管測量,並將不同時間的資料進行比較(ANOVAP0.05)。

結果:研究包含了15例病人(年齡在108147個月),其中包括:原發性肺動脈高壓(5例),先天性心臟病(9例),膈疝(1例)。肺血管阻力指數在基礎值的中位數是11.3Wood單位。33%的病人有高於系統平均值的肺動脈壓力。心率(9994/分,P0.016)及PaO295104mmHgP0.07)在氯胺酮給藥後發生改變(基礎值,氯胺酮給藥後15分鐘值,P值)。在平均全身動脈壓、平均肺動脈壓、全身或肺血管阻力指數、心排指數、動脈pHPaO2間無明顯差異。

結論:在七氟醚的共同作用下,氯胺酮並不增加自主呼吸的肺動脈高壓兒童的肺血管阻力。

(陳佳麗譯,薛張綱校)

BACKGROUND: The use of ketamine in children with increased pulmonary vascular

resistance is controversial. In this prospective, open label study, we evaluated thehemodynamic responses to ketamine in children with pulmonary hypertension(mean pulmonary artery pressure _25 mm Hg).

METHODS: Children aged 3 mo to 18 yr with pulmonary hypertension, who were

scheduled for cardiac catheterization with general anesthesia, were studied.

Patients were anesthetized with sevoflurane (1 minimum alveolar anesthetic

concentration [MAC]) in air while breathing spontaneously via a facemask. Afterbaseline catheterization measurements, sevoflurane was reduced (0.5 MAC) andketamine (2 mg/kg IV over 5 min) was administered, followed by a ketamineinfusion (10 _g _ kg_1 _ min_1). Catheterization measurements were repeated at 5,10, and 15 min after completion of ketamine load. Data at various time points werecompared (ANOVA, P _ 0.05).RESULTS: Fifteen patients (age 147, 108 mo; median, interquartile range) were studied.Diagnoses included idiopathic pulmonary arterial hypertension (5), congenital heartdisease (9), and diaphragmatic hernia (1). At baseline, median (interquartile range)baseline pulmonary vascular resistance index was 11.3 (8.2) Wood units; 33% ofpatients had suprasystemic mean pulmonary artery pressures. Heart rate (99, 94 bpm;P _ 0.016) and Pao2 (95, 104 mm Hg; P _ 007) changed after ketamine administration(baseline, 15 min after ketamine; P value). There were no significant differences in mean systemic arterial blood pressure, mean pulmonary artery pressure, systemic orpulmonary vascular resistance index, cardiac index, arterial pH, or Paco2.CONCLUSIONS: In the presence of sevoflurane, ketamine did not increase pulmonaryvascular resistance in spontaneously breathing children with severe pulmonary hypertension.

 

活性氧介導七氟醚和地氟醚誘導預處理在人離體右心房心肌保護作用

Reactive Oxygen Species Mediate Sevoflurane- and Desflurane-Induced Preconditioning in Isolated Human Right Atria In Vitro

Jean-Luc Hanouz, MD, PhD*, Lan Zhu, MD{dagger}, Sandrine Lemoine, BSc{dagger}, Charline Durand, BSc{dagger}, Olivier Lepage, MD{ddagger}, Massimo Massetti, MD, PhD{ddagger}, André Khayat, MD{ddagger}, Benoît Plaud, MD, PhD*, and Jean-Louis Gérard, MD, PhD*

From the *Department of Anesthesiology; {dagger}Laboratory of Experimental Anesthesiology and Cellular Physiology; and {ddagger}Department of Cardiac and Thoracic Surgery, CHU Caen, France.

Anesth Analg 2007; 105:1534-1539

 

背景:活性氧介導七氟醚和地氟醚誘導預處理在人離體右心房心肌保護作用。方法:我們記錄右心房小梁在充氧短桿菌素溶液中的等長收縮(34°C,刺激頻率1HZ)。在所有組中,都是一個30分鐘的缺氧期和60分鐘再充氧。在缺氧再充氧前10分鐘,肌肉暴露在2%七氟醚或6%地氟醚中5分鐘。在單獨組中,2%七氟醚+氮-甘氨酸或6%地氟醚+氮-甘氨酸中都加入0.1mM-甘氨酸MPG(一種活性氧清除劑)。0.1mM-甘氨酸單獨作用的效果也被測試,比較組與組間60分鐘再氧合後復蘇的力量。(平均數± 標準差)結果:2%七氟醚(85% ± 4%)或6%地氟醚(86% ± 7%)預處理與對照組相(56% ± 12%)比增加心肌細胞收縮力(P<0.001),這種作用在加入MPG後消失(七氟醚56% ± 12%,地氟醚48% ± 13%)。MPG單獨使用組與對照組沒有差別(57% ± 7%53% ± 11%)總結:在離體試驗中,七氟醚合地氟醚預處理人心肌細胞,使心肌細胞對缺氧的產生耐受是通過活性氧機制。

(陳愷錚譯 薛張剛校)

BACKGROUND: We examined the role of reactive oxygen species (ROS) in sevoflurane- and desflurane-induced preconditioning on isolated human right atrial myocardium.METHODS: We recorded isometric contraction of human right atrial trabeculae suspended in an oxygenated Tyrode’s solution (34°C, stimulation frequency 1 Hz). In all groups, a 30-min hypoxic period was followed by 60 min of reoxygenation. Ten minutes before hypoxia reoxygenation, muscles were exposed to 5 min of sevoflurane 2% or desflurane 6%. In separate groups, the sevoflurane 2% (Sevo + N-(2-mercaptopropionyl)-glycine [MPG]) or desflurane 6% (Des + MPG) was administered in the presence of 0.1 mM MPG, a ROS scavenger. The effect of 0.1 mM MPG alone was tested. Recovery of force after a 60-min reoxygenation period was compared between groups (mean ± sd). RESULTS: Preconditioning with sevoflurane 2% (85% ± 4% of baseline) or desflurane 6% (86% ± 7% of baseline) enhanced the recovery of the force of myocardial contraction after 60 min reoxygenation compared with the control group (53% ± 11% of baseline, P < 0.001). This effect was abolished in the presence of MPG (56% ± 12% of baseline for Sevo + MPG, 48% ± 13% of baseline for Des + MPG). The effect of MPG alone on the recovery of force was not different from the control group (57% ± 7% of baseline versus 53% ± 11%; P = NS).CONCLUSIONS: In vitro, sevoflurane and desflurane preconditioned human myocardium against hypoxia through a ROS-dependent mechanism.

 

耳機式紅外線鼓膜測溫儀用於術中監測核心體溫的有效性

The Usefulness of an Earphone-Type Infrared Tympanic Thermometer for Intraoperative Core Temperature Monitoring

Tomohiro Kiya, Michiaki Yamakage, Tomo Hayase, Jun-Ichi Satoh, and Akiyoshi

Namiki

From the Department of Anesthesiology, Sapporo Medical University, School of Medicine, Sapporo, Hokkaido, Japan.

Anesth Analg. 2007 Dec;105(6):1688-92,

 

背景:在這個研究中,我們想要確認新型的耳機式紅外線鼓膜測溫儀(IRT)在術中監測核心體溫的有效性。方法:兩組病人在不同的手術條件下進行研究。第一組包括18名在全麻下擇期手術的成年病人(ASA評級III),麻醉誘導前,耳機式IRT被放置在左耳道或右耳道,麻醉中監測鼓膜溫度和直腸以及食道溫度。第二組包括擇期行體外迴圈下的心外科手術病人18名(ASA評級IIIII)。和第一組一樣,在降溫和複溫過程中用IRT監測鼓膜溫度,同時行直腸和食道溫度監測。結果:實驗組一:用IRT測得的平均體溫(±2個標準差)比食道溫度高了0.08℃(±0.34℃),比直腸溫度高了0.11℃(±0.55℃)。實驗組二:在體外迴圈的降溫和複溫過程中用IRT測得的平均體溫(±2個標準差)比食道溫度高了0.72℃(±2.2℃)。結論:在術中用耳機式IRT在臨床中用於連續檢測核心體溫是可靠的。

(施楊譯,薛張綱校)

BACKGROUND: In this study we sought to determine the usefulness of a novel earphone-type infrared tympanic thermometer (IRT) for core temperature monitoring during surgery. METHODS: Two groups of patients were studied under different surgical conditions. The first group consisted of 18 adult patients (ASA I or II) who had been scheduled for elective surgery under general anesthesia. Before induction of general anesthesia, an earphone-type IRT was inserted into either the left or right ear canal. Tympanic temperature was monitored and recorded along with both rectal and esophageal temperatures during anesthesia. The second group consisted of eight adult patients (ASA II or III) who had been scheduled for cardiac surgery with cardiopulmonary bypass. Similar to the first group, tympanic temperature was measured by the earphone-type IRT and recorded along with the rectal and esophageal temperatures during cooling and rewarming phases of cardiopulmonary bypass. RESULTS: Study 1-The average temperature (+/-2 sd) measured with the IRT was +0.08 degrees C (+/-0.34 degrees C) above the esophageal temperature, and that with the rectal temperature was +0.11 degrees C (+/-0.55 degrees C) above the esophageal temperature. Study 2-The average temperature (+/-2 sd) measured with the IRT was +0.72 degrees C (+/-2.2 degrees C) above the esophageal temperature during cooling and warming phases during cardiac surgery with cardiopulmonary bypass. CONCLUSIONS: The earphone-type IRT might be used in a clinical setting for reliable and continuous core temperature monitoring during an operation.

 

種族和社會經濟因素對患者接受圍術期硬膜外鎮痛的影響

The Influence of Race and Socioeconomic Factors on Patient Acceptance of Perioperative Epidural Analgesia

Edward Andrew Ochroch, MD, MSCE*, Andrea B. Troxel, ScD{dagger}, Jonathan K. Frogel, MD{ddagger}, and John T. Farrar, MD, PhD§

From the *Department of Anesthesiology and Critical Care, University of Pennsylvania Health System; {dagger}Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; {ddagger}Henry Ford Hospital, Detroit, Michigan; and §Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Pennsylvania.

Anesth Analg 2007 105:1787-1792.

 

背景:儘管證據顯示對患者有利,但是少數民族和社會經濟狀況較低的患者可能較非少數民族和社會經濟狀況較高的患者更為抵觸硬膜外鎮痛。

方法:一個專家小組基於2000年美國人口普查進行了電話調查記錄。在超過四個時間節點上對賓西法尼亞大學附屬醫院的所有手術病人至少聯繫兩次。

結果:致電3739名患者,與其中1265名患者取得了聯繫並有1193人接受了調查,72人拒絕參與。762人(64%)表示如果麻醉師推薦的話會接受的硬膜外操作,425人(36%)表示拒絕。如果麻醉師和外科醫生都推薦硬膜外的話接受者會增加到932人(78.5%)。拒絕圍術期硬膜外鎮痛的單變數預測因素是美籍非裔。接受的單變數預測因素是有全職或兼職工作者,總家庭收入>$50,001/每年,大學畢業學歷,曾接受硬膜外治療和瞭解硬膜外知識。當把種族、總家庭收入、職業和教育背景混合於同一多變數對數回歸模型時,美籍非裔是一個預計拒絕的因素,(優勢比為0.58P < 0.006,可信區間為0.41–0.81)並且是唯一的拒絕或接受硬膜外鎮痛的預計因素。

結論:圍術期是否接受硬膜外鎮痛主要受種族和社會經濟狀況的影響。當麻醉師盡力改善患者預後和舒適度的時候必需考慮到這一潛在的障礙。

(王時來譯 薛張綱校)

BACKGROUND: Ethnic minorities and patients of lower socioeconomic status may be more averse to the acceptance of epidural analgesia than nonminority counterparts and those of higher socioeconomic status, despite evidence for substantial benefit to the patient. METHODS: A scripted telephone survey was developed from the 2000 United States Census by a panel of experts. Contact was attempted at least twice for all patients listed for surgery at the Hospital of the University of Pennsylvania over a 4-mo period. RESULTS: Three thousand seven hundred thirty-nine patients were called and 1265 subjects were successfully contacted and 1193 consented, whereas 72 refused to participate. Seven hundred sixty-two subjects (64%) would accept an epidural if recommended by an anesthesiologist and 425 (36%) would refuse. If the epidural was recommended by both the anesthesiologist and surgeon acceptance increased to 932 (78.5%). The univariate predictor of refusal of perioperative epidural analgesia was African American race. Univariate predictors of acceptance include full- or part-time employment, total household income >$50,001/yr, college graduate, prior epidural treatment, and knowledge of what an epidural is. When the potential confounders of race, total household income, employment, and education were included in a multivariate logistic regression model, African American race predicted refusal (odds ratio [OR], 0.58; P < 0.006; confidence interval [CI], 0.41–0.81) and was the only factor that predicted refusal or acceptance of epidural analgesia. CONCLUSIONS: Acceptance of perioperative epidural analgesia is strongly affected by race and socioeconomic status. Anesthesiologists need to recognize this potential barrier when trying to maximize patient comfort and outcome.

 

新式含氧飽和度探頭中心靜脈導管用於小兒心臟手術的試驗和臨床性評價

An experimental and clinical evaluation of a novel central venous catheter with integrated oximetry for pediatric patients undergoing cardiac surgery.

Liakopoulos OJ, Ho JK, Yezbick A, Sanchez E, Naddell C, Buckberg GD, Crowley R, Mahajan A.

Department of Cardiothoracic Surgery, David Geffen School of Medicine, University of California, Los Angeles, California 90095, USA.

Anesth Analg 2007 105: 1598-1604.

 

背景:中心靜脈氧飽和度(ScvO2)精確反映心臟迴圈功能,但在小兒患者並不總是可行的。通過試驗和臨床性方法,我們運用一種新式含纖維光學氧飽和度探頭的中心靜脈導管監測圍手術期必需的ScvO2及檢測在小兒心臟手術中的可行性。

方法:在5只已麻醉的豬上,血流動力學(心臟指數[CI],心率,平均動脈壓[MAP],平均肺動脈壓[MPAP],中心靜脈壓[CVP]),纖維光學ScvO2 (ScvO2-cath)和血氣氧飽和度(ScvO2-blood)將在穩定基礎狀態、前負荷減少(腔靜脈阻斷)和多巴胺輸注(5 mcg x kg(-1) x min(-1))狀態下監測。在15名小兒心臟手術患者(中位年齡8.4月,體重8.0 kg)中 ,含氧飽和度探頭中心靜脈導管經皮放置,ScvO2-cath和血流動力學在術中及術後24 h的時間點將被檢測。氧飽和度和血流動力學資料將被檢驗相關性(Pr)Bland-Altman分析。結果:無導管相關的併發症。ScvO2-cathScvO2-blood的檢測結果具有顯著(P < 0.001)相關性:試驗組(Pr = 0.96),臨床組(Pr = 0.94)。在兩方案中的所有時間點的相似偏倚和精確度被檢驗(試驗組偏倚: +0.03% +/- 4.11%;臨床組偏倚: -0.03% +/- 4.41%)ScvO2-cathCI (Pr = 0.87), MAP (Pr = 0.59), MPAP (Pr = 0.44) CVP (Pr = 0.38)的相關性(P < 0.001)好與MAP (Pr = 0.61), MPAP (Pr = 0.38), CVP (Pr = 0.35) heart rate (Pr = 0.25)。結論:在小兒心臟手術中新式含氧飽和度探頭中心靜脈導管提供了精確持續的ScvO2檢測管理。ScvO2纖維光學氧飽和度與CI的變化的相關性比常規血流動力學變化更好。

(陳勇柱譯 薛張剛校)

BACKGROUND: Central venous oxygen saturation (ScvO2) accurately reflects cardiocirculatory function, but is not always feasible in pediatric patients. Using an experimental and clinical approach, we determined the accuracy of a novel pediatric central venous catheter with integrated fiberoptic oximetry, correlated ScvO2 to periprocedural vital variables, and tested its feasibility in pediatric cardiac surgery patients. METHODS: In five anesthetized pigs, hemodynamics (cardiac index [CI], heart rate; mean arterial blood [MAP]; mean pulmonary artery [MPAP], central venous pressure [CVP]), fiberoptic ScvO2 (ScvO2-cath), and blood gas oximetry (ScvO2-blood) were measured during stable baseline conditions, preload reduction (caval occlusion), and dopamine infusion (5 mcg x kg(-1) x min(-1)). In 16 pediatric patients undergoing cardiac surgery (median age 8.4 mo; weight 8.0 kg), central venous oximetry catheters were placed percutaneously, and ScvO2-cath and hemodynamics recorded at several time-points during and until 24 h after surgery. Oximetry and hemodynamic data were compared by correlation (Pr) and the Bland-Altman analysis. RESULTS: There were no catheter-related complications. ScvO2-cath and ScvO2-blood measurements correlated significantly (P < 0.001) in both the experimental (Pr = 0.96) and clinical protocol (Pr = 0.94). A similar bias and precision over all time-points was detected in both protocols (Exp-bias: +0.03% +/- 4.11%; Clinical-bias: -0.03% +/- 4.41%). ScvO2-cath correlated (P < 0.001) with CI (Pr = 0.87), MAP (Pr = 0.59), MPAP (Pr = 0.44), and CVP (Pr = 0.38) and estimated CI better than MAP (Pr = 0.61), MPAP (Pr = 0.38), CVP (Pr = 0.35), or heart rate (Pr = 0.25). CONCLUSION: Integrated central venous oximetry catheters provide accurate continuous ScvO2 monitoring in pediatric patients undergoing cardiac surgery. ScvO2 fiberoptic oximetry correlates better with changes in CI as compared to routine hemodynamic variables.

                                                         

骶骨背側角神經元的痛覺域值的時間空間決定因素與異氟醚誘導的制動性的關係

Temporal and Spatial Determinants of Sacral Dorsal Horn Neuronal Windup in Relation to Isoflurane-Induced Immobility

Robert C. Dutton, MD*, Jason M. Cuellar, PhD, Edmond I. Eger, II, MD*, Joseph F. Antognini, MD, and Earl Carstens, PhD

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco; {dagger}Department of Anesthesia, Stanford University School of Medicine; {ddagger}Department of Anesthesiology and Pain Medicine; and §Section of Neurobiology, Physiology and Behavior, University of California, Davis, California.

Anesth Analg 2007 105: 1665-1674.

 

背景:痛覺域值是骶骨背側神經元對C-纖維重複性刺激的累加性疼痛反應。我們調查域值的強度和頻率依賴性,及異氟醚的NMDA受體阻滯作用,來決定異氟醚對其他麻醉藥物在痛覺抑制上有無協同作用。方法:我們對20組老鼠的骶骨背側神經元給於不同頻率(0.3-10hz)不同強度(0.8-5刺激閾)的電刺激,此時肺泡氣的異氟醚濃度為0.7-1.3。累計反應(曲線下面積),起始反應,和絕對閾值(曲線下面積減去二十次的起始反應),並計算閾值的斜率。結論:增加刺激強度和頻率可以逐漸增加曲線下面積,制動性也與肺泡氣的濃度需要量有關。增加異氟醚的肺泡氣濃度可以顯著抑制低強度和低頻率刺激的痛覺域值,但對高強度高頻率的刺激並無明顯作用。NMDA受體阻滯劑MK801可明顯降低痛覺域值1Hz.結論:骶骨背角神經元的疼痛閾值在低刺激強度和頻率下增加了異氟醚的需要量,可能與NMDA受體依賴性機制有關。 在高刺激頻率和強度下,異氟醚則需要聯用大量其他麻醉藥來達到制動性。

(秦 佳譯,薛張剛校)

BACKGROUND: Windup is a progressive increase in response of dorsal horn neurons to repetitive C-fiber stimulation that may underlie temporal summation of pain. We investigated the frequency- and intensity-dependency of windup, and the effects of isoflurane and N-methyl-d-aspartate (NMDA) receptor blockade, to determine if they parallel the influence of temporal and spatial summation of noxious stimuli on anesthetic requirements. METHODS: We recorded responses of rat sacral dorsal horn neurons to 20-s trains of electrical tail stimulation at different frequencies (0.3–10 Hz) and intensities (0.8–5 x stimulus threshold) during delivery of 0.7 to 1.3 minimum alveolar anesthetic concentration isoflurane. Summed responses (area under the curve [AUC] windup), initial response, absolute windup (AUC minus 20 times the initial response), and slope of windup were quantified. RESULTS: Increases in stimulus intensity and frequency progressively increased AUC windup (P < 0.01 for both) and correlated with isoflurane concentrations required for immobility (R2 = 0.98 and 0.97, respectively). Increasing the isoflurane concentration significantly suppressed each measure of windup elicited by low-intensity and low-frequency, but not high-intensity and high-frequency stimulus trains. The initial response magnitude significantly correlated with slope of windup across stimulus intensities and isoflurane concentrations. The NMDA receptor antagonist MK801 significantly reduced windup (to 53%; P < 0.05) at 1 Hz. CONCLUSION: Windup of dorsal horn neurons at low stimulus intensities and frequencies increases isoflurane requirements for immobility via a NMDA receptor-dependent mechanism. At high stimulus intensities and frequencies, windup was resistant to isoflurane consistent with larger anesthetic requirements for immobility.

 

依託咪酯的麻醉效應:種族特異性的與{alpha}2-腎上腺素能受體的相互作用

The Anesthetic Effects of Etomidate: Species-Specific Interaction with {alpha}2-Adrenoceptors

Andrea Paris, MD*, Lutz Hein, MD{dagger}, Marc Brede, MD{ddagger}, Philipp-Alexander Brand, MD*, Jens Scholz, MD*, and Peter H. Tonner, MD*

From the *Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Kiel; {dagger}Institute of Experimental and Clinical Pharmacology and Toxicology, University of Freiburg, Freiburg im Breisgau; and {ddagger}Department of Anaesthesia and Critical Care, University of Wuerzburg Hospitals, Wuerzburg, Germany.

Anesth Analg 2007 105: 1644-1649.

 

背景:在靜脈麻醉藥中,依託咪酯在結構和臨床上和{alpha}2腎上腺素能受體激動劑如右旋美托咪啶相似。我們研究依託咪酯的鎮靜效應是否由{alpha}2腎上腺素能受體介導。方法:在非洲爪蛙蝌蚪,使用和不使用{alpha}2腎上腺素能受體拮抗劑阿替咪唑,判定依託咪酯的麻醉效能(1–20 µM)。正向反射消失確定了感覺缺失。通過非線性對數回歸曲線,獲得資料,計算半數最大有效濃度和曲線的斜率。此外,在野生型(WT)小鼠上和攜帶{alpha}2A腎上腺素能受體缺失基因({alpha}2A-KO)的小鼠,依託咪酯的鎮靜、催眠作用(8 mg/kg IP)通過旋轉試驗研究。統計了平均數±標準差。結果:麻醉的蝌蚪的數量隨著依託咪酯濃度增加而增加。阿替美唑明顯增加了依託咪酯半數最大有效濃度,從(4.5±0.2 µM;斜率:2.6±0.3) 變為8.4±0.4 µM (斜率:2.3 ±0.3)。依託咪酯在所有的小鼠中都表現出時間依賴的鎮靜效應,通過旋轉試驗評估。在WT小鼠中,依託咪酯的鎮靜效應沒有因為阿替美唑(2 mg/kg)的使用降低。同樣的是,與WT小鼠相比,({alpha}2A-KO)的小鼠身上依託咪酯的鎮靜作用也沒有降低。結論:依託咪酯的鎮靜效應表現為種族特異性的與a2腎上腺素能受體相互作用。儘管在非洲爪蛙蝌蚪身上,依託咪酯的鎮靜效應因為阿替美唑降低,但在小鼠中表現為依託咪酯的鎮靜效應非{alpha}2腎上腺素能受體介導的

(陳珺珺譯 薛張綱校)

BACKGROUND: The IV anesthetic, etomidate, has structural and clinical similarities to specific {alpha}2-adrenoceptor agonists such as dexmedetomidine. We investigated whether the sedative effects of etomidate may be mediated by {alpha}2-adrenoceptors. METHODS: The anesthetic potency of etomidate (1–20 µM) was determined in Xenopus laevis tadpoles in the absence and presence of the specific {alpha}2-adrenoceptor antagonist atipamezole (10 µM). Anesthesia was defined as loss of righting reflex. Nonlinear logistic regression curves were fitted to the data and half-maximal effective concentrations and the slopes of the curves were calculated. Additionally, sedative/ hypnotic effects of etomidate (8 mg/kg IP) were studied by rotarod test in wild-type (WT) mice and mice carrying targeted deletions of the {alpha}2A-adrenoceptor gene ({alpha}2A-KO). Data are presented as mean ± sem. RESULTS: The fraction of anesthetized tadpoles increased with increasing concentrations of etomidate. Atipamezole significantly increased the half-maximal effective concentration of etomidate (4.5 ± 0.2 µM; slope: 2.6 ± 0.3) to 8.4 ± 0.4 µM (slope: 2.3 ± 0.3). Etomidate resulted in time-dependent sedative effects in all mice, as assessed by rotarod performance. In WT mice, the sedative effects of etomidate were not decreased by atipamezole (2 mg/kg). Consistently, etomidate-induced sedation was not reduced in {alpha}2A-KO animals compared with WT mice. CONCLUSIONS: The sedative effects of etomidate exhibit a species-specific interaction with {alpha}2-adrenoceptors. Although the decrease in potency of etomidate by atipamezole may be caused by an interaction with {alpha}2-adrenoceptors in X. laevis tadpoles, results in mice indicate that the hypnotic effect of etomidate does not require {alpha}2-adrenoceptors.

 

門診麻醉學會處理術後噁心嘔吐指南

Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting.

Gan TJ, Meyer TA, Apfel CC, Chung F, Davis PJ, Habib AS, Hooper VD, Kovac AL, Kranke P, Myles P, Philip BK, Samsa G, Sessler DI, Temo J, Tramèr MR, Vander Kolk C, Watcha M; Society for Ambulatory Anesthesia.

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.

Anesth Analg. 2007 105(6):1615-28, table of contents.

 

該指南是在門診麻醉協會發起下,由一個跨學科的國際性小組編纂而成,小組的成員都關注術後噁心嘔吐(PONV)且為這方面的專家。這個小組批判性地評價了當前有關PONV的醫學文獻,為處理PONV高危的成人和兒童提供了一套有證據支援的方案。概況說來,該指南鑒別出成人和兒童發生PONV的高危因素;推薦了減少PONV基線發生率的措施;評定出預防PONV最有效的單一和聯合治療方法;推薦了PONV發生時的處理程式;提供了管理PONV高危個體的運算法則。

(羅 璿譯 薛張綱校)

The present guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in postoperative nausea and vomiting (PONV) under the auspices of The Society of Ambulatory Anesthesia. The panel critically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. In brief, these guidelines identify risk factors for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic monotherapy and combination therapy regimens for PONV prophylaxis; recommend approaches for treatment of PONV when it occurs; and provide an algorithm for the management of individuals at increased risk for PONV.

 

針刺毀損小鼠末梢神經建立局部疼痛症候群的模型

Needlestick distal nerve injury in rats models symptoms of complex regional pain syndrome.

Sandra M. Siegel, Jeung W. Lee, and Anne L. Oaklander

Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.

Anesth Analg 2007 105: 1820-1829.

 

背景:局部疼痛症候群由慢性肢體疼痛和有時候看起來似乎微不足道的由外傷引起的家族性自主神經異常組成。一些病理學方面的研究已經證實了局部疼痛症候群患者中發現有較小的末梢神經損傷,但在回顧性研究當中卻不能建立因果關係。因此,我們預想末梢神經損傷是否可以引起局部疼痛症候群類似於動物畸形。我們利用針刺,是人類局部疼痛症候群的一個原因,來評價損害的效果。方法:分別用30號,22號,和18號的針刺穿雄性的SD小鼠的左側脛神經。非手術和佯裝手術的老鼠作為對照。測量後爪的功能,浮腫和姿態。結果:手術後的七天,測量同側後爪收縮的最大極限,S-W單纖維絲減少>=51%的在佯裝手術治療的組中為0%,在18號穿刺針組中為67%,在22號針刺組中為88%,30號針刺組中為89%。57%的所有針刺老鼠都有對側後爪“鏡像”表現。這種保護機制的普遍性和嚴重性顯示了其對傷害的獨立性。對腳底寒冷和針刺刺激引起的疼痛反應並不普遍而且只有同側的疼痛反應,因為後爪出現了神經性水腫。同側後爪姿態出現強直在18號針刺組中為42

(張儷譯  薛張綱校)

BACKGROUND: Complex Regional Pain Syndrome (CRPS)-I consists of chronic limb pain and dysautonomia triggered by traumas that sometime seem too trivial to be causative. Several pathological studies have identified minor distal nerve injuries (DNIs) in CRPS-I patients, but retrospective studies cannot establish causality. Therefore, we, prospectively investigated whether DNIs are sufficient to cause CRPS-like abnormalities in animals. We used needlestick, a cause of human CRPS, to evaluate lesion-size effects. METHODS: Left tibial nerves of male Sprague–Dawley rats were transfixed once by 30G, 22G, or 18G needles. Unoperated and sham-operated rats provided controls. Hindpaw sensory function, edema, and posture were measured. RESULTS: At Day-7 postoperatively, thresholds for ipsilateral-hindpaw withdrawal from Semmes–Weinstein monofilaments were reduced by ≥51% in 0% of sham-operated controls; 67% of rats that received 18G-DNI, 88% that received 22G-DNI, and 89% that received 30G-DNI. Fifty-seven percent of all DNI rats had contralateral hindpaw "mirror" changes. The prevalence and severity of allodynia appeared independent of lesion size. Hyperalgesic responses to cold and pinprick applied to the plantar hindpaw were less common and were ipsilesional only, as was neurogenic hindpaw edema. Ipsilesional-only, tonic, dystonic-like hindpaw postures were evident in 42% of 18G-DNI, 6% of 22G-DNI, and no 30G-DNI or sham-operated control rats. The prevalence of postural abnormalities correlated with needle diameter (P = 0.001). Counting protein gene product 9.5-immunolabeled axons in skin biopsies from rats’ ipsilesional hindpaws demonstrated mean reductions of 0% after 30G-needlestick, 15% after 22G-needlestick, and 26% after 18G-needlestick, which closely reproduces the 29% mean epidermal neurite losses of CRPS-I patients. CONCLUSIONS: Needlestick DNI models several clinical and pathological features of human CRPS and provides direct prospective evidence that even minor DNI can cause CRPS-like abnormalities in rats.

 

一項麻醉科的全球臨床研究的文獻統計分析

A Bibliometric Analysis of Global Clinical Research by Anesthesia Departments

Madhav Swaminathan, MD, FASE, FAHA, Barbara G. Phillips-Bute, PhD, and Katherine P. Grichnik, MD, FASE

From the Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth. Analg. 2007 105: 1741-1746.

 

背景:為數不多的研究調查過麻醉基礎的研究員從事研究的多樣性。我們用MedlineOvid資料庫檢測了屬於麻醉科的全球臨床研究。我們同時也研究了經濟發展對學術發展的影響。方法:我們使用Medline檢索了20002005的英文出版物。僅檢測臨床研究,其中學術聯盟包括與麻醉相關的辭彙(比如麻醉學,麻醉等)。同時從公開可及的資料中獲取人口數量和粗略國家收入資料。雜誌的影響因素從雜誌引用報告中獲取。結果:總共檢索出了6736篇文章包括64個國家的551種雜誌。全部文章中的85%被發表在了46種雜誌上。隨即對照實驗構成了468570%)的出版物。土耳其的隨機對照實驗占的百分比是最高的為88%。美國佔有最大的比例(總量的20%)以及平均出版刊物的影響因素(3.0)。結論:屬於研究者的臨床研究是多樣的,其超越了傳統領域的麻醉和重症監護。美國創造了最多的臨床研究,但是按照每個人口算卻是歐洲國家更高。

(王光妍譯  薛張綱校)

BACKGROUND: Few studies have investigated the diversity in research conducted by anesthesia-based researchers. We examined global clinical research attributed to anesthesia departments using Medline® and Ovid® databases. We also investigated the impact of economic development on national academic productivity.METHODS: We conducted a Medline search for English-language publications from 2000 to 2005. The search included only clinical research in which institutional affiliation included words relating to anesthesia (e.g., anesthesiology, anesthesia, etc.). Population and gross national income data were obtained from publicly available databases. Impact factors for journals were obtained from Journal Citation Reports (Thomson Scientific).RESULTS: There were 6736 publications from 64 countries in 551 journals. About 85% of all publications were represented by 46 journals. Randomized controlled trials constituted 4685 (70%) of publications. Turkey had the highest percentage of randomized controlled trials (88%). The United States led the field in quantity (20% of total) and mean impact factor (3.0) of publications. Finland had the highest productivity when adjusted for population (36 publications per million population). Publications from the United States declined from 23% in 2000 to 17% in 2005.CONCLUSIONS: Clinical research attributable to investigators in our specialty is diverse, and extends beyond the traditional field of anesthesia and intensive care. The United States produces the most clinical research, but per capita output is higher in European nations.

 

 

胸段脊柱周圍阻斷下行乳腺癌手術:一項隨機、雙盲試驗

Thoracic paravertebral block for breast cancer surgery: a randomized double-blind study.

Jytte F. Moller, Lone Nikolajsen, Svein Aage Rodt, Hanne Ronning, and Palle S. Carlsson

Department of Anesthesiology, Aarhus University Hospital, Denmark

Anesth Analg 2007 105:1848-51

 

背景:在這項隨機、雙盲試驗中,我們測驗在使用異丙酚和喉罩進行全身麻醉前完成多極胸段脊柱周圍阻斷是否能增強書後陣痛作用。方法:88名患者隨機在脊柱旁注射0.5%羅呱卡因(30ml)或者等量的等張生理鹽水。9名患者被排除出去,剩下79名患者進行評估。(羅呱卡因,n = 38;安慰劑,n = 41)。不同的效果體現在病人在蘇醒室內使用患者自控陣痛需求的芬太尼的總量,以及術後當天至術後第二天固定的間隔時間內用數值來評價疼痛指數。結果:羅呱卡因組較之安慰劑組,患者在蘇醒室內消耗的芬太尼總量的中位數小。(0微克[範圍:0-250微克]vs100微克[範圍:0-800微克]P = 0.001)。同樣的,在蘇醒室內,羅呱卡因組較之安慰劑組較少的病人疼痛指數〉=313 vs 31P < 0.0001)。在離開蘇醒時候,無論是疼痛平分還是陣痛藥的消耗量都沒有統計學上的差異。結論:多級脊柱周圍阻斷能為乳腺手術提供良好的陣痛效果,但是持續的時間要比之前的報告短暫。                                                         

(周時蓓譯,薛張綱校)

BACKGROUND: We examined in this randomized, double-blind study whether a multilevel paravertebral block performed before general anesthesia with propofol and a laryngeal mask enhances postoperative analgesia after breast cancer surgery. METHODS: Eighty-eight patients were randomized to receive paravertebral injections with either ropivacaine 0.5% (30 mL) or an equivalent amount of isotonic saline. Nine patients were excluded after randomization, thus 79 patients remained for evaluation (ropivacaine, n = 38; placebo, n = 41). Variables of efficacy were the amount of fentanyl delivered by the patient-controlled analgesia device in the postanesthesia care unit (PACU), postoperative pain measured on a numeric rating scale at regular intervals from the day of surgery and until the second postoperative day. RESULTS: The median consumption of fentanyl in the PACU was less in the ropivacaine group compared with the placebo group (0 microg [range: 0-250 microg] versus 100 microg [range: 0-800 microg], P = 0.001). Also, fewer patients in the ropivacaine group reported pain > or =3 on the numbers rating scale in the PACU (13 vs 31, P < 0.0001). No statistical difference in pain scores or consumption of analgesics could be demonstrated after discharge from the PACU. CONCLUSIONS: A multilevel paravertebral block provides good analgesia for breast surgery, but the duration of analgesia is briefer than described in previous studies.

 

腦室內給予右旋美托咪啶對清醒大鼠心血管及交感功能的影響

The Effects of Centrally Administered Dexmedetomidine on Cardiovascular and Sympathetic Function in Conscious Rats

Tetsuro Shirasaka, MD, PhD*, De-Lai Qiu, MD, PhD, Hiroshi Kannan, MD, PhD,and Mayumi Takasaki, MD, PhD*

 From the Departments of *Anesthesiology and Intensive Care and {dagger}Integrative Physiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.

Anesth Analg 2007; 105:1722-1728

背景:2受體在大腦中有表達,包括與自主神經系統控制有所牽涉的下丘腦.全身性給予DEX對心血管的作用是已經明確的,然而腦室內給予DEX對清醒動物心血管功能的影響仍然所知甚少.在這項研究中,我們研究腦室內給予DEX對清醒的,不受限制的大鼠心血管反應及交感神經活性的影響及其機制.方法:分別腦內給予58例清醒大鼠0.5, 12 µg/kgDEX ,測量MAP,HR及血漿兒茶酚胺濃度.大鼠被同時給予阿托品(n = 8), 心得安(n = 8), 或六甲雙銨(n = 8), 以評估DEX引起的迷走或交感傳出神經活性的影響.一些大鼠行頸動脈竇及減壓神經去神經以排除壓力感受器反射的影響.結果:腦室內給予DEX有劑量依賴性MAP,HR及血漿去甲腎上腺素濃度降低.大劑量DEX降低血漿腎上腺素濃度.DEXMAP影響的幅度被六甲雙銨及心得安所減少.HR影響的幅度被阿托品及心得安所減少.用六甲雙銨預處理的大鼠比未作處理的大鼠對於DEX引起的MAPHR減小的幅度要小.行頸動脈竇及減壓神經去神經預處理的大鼠比未行預處理的大鼠對於DEX引起的MAPHR減小的幅度要大.結論:結果表明腦室內給予DEX通過交感抑制降低MAP,通過交感抑制和迷走刺激降低HR.

(孫霞譯 薛張綱校)

BACKGROUND: The 2-receptor is expressed in the brain, includingthe hypothalamus, where it is implicated in autonomic nervoussystem control. The effects of systemic administration of dexmedetomidine(DEX) on cardiovascular responses are well known; however, littleis known about the effects of central administration of DEXon cardiovascular responses in conscious animals. In this study,we explored the effects and the mechanism of intracerebroventricularly(icv) administered DEX on cardiovascular responses and sympatheticnerve activity in conscious, unrestrained rats. METHODS: We administered DEX (0.5, 1, and 2 µg/kg) icvand measured the mean arterial blood pressure (MAP), heart rate(HR), and plasma catecholamine in conscious rats (n = 58). Ratswere also administered atropine (n = 8), propranolol (n = 8),or hexamethonium (n = 8) to assess the influence of vagal orsympathetic efferent activity in the DEX-induced responses.Some of the rats underwent carotid sinus and aortic nerve denervationto exclude the effect of the baroreceptor reflex. RESULTS: Intracerebroventricular administration of DEX dose-dependentlydecreased MAP, HR, and plasma norepinephrine. Large dose ofDEX decreased plasma epinephrine. The amplitude of MAP reductioninduced by DEX was reduced by hexamethonium or propranolol.The amplitude of HR reduction was reduced by atropine or propranolol.The amplitude of MAP and HR reduction induced by DEX were smallerin hexamethonium-pretreatment rats than in intact ones. Theamplitude of MAP and HR reduction induced by DEX were largerin sinus and aortic nerve denervation rats than in intact ones. CONCLUSIONS: These results indicate that icv administrationof DEX decreases MAP by sympathetic inhibition and decreasesHR by sympathetic inhibition and vagal stimulation.

 

磺達肝素在下肢較大整形手術(留置或未留置軸索或深部周圍神經導管)術後長期應用預防血栓形成的安全性及有效性研究:EXPERT研究

The Safety and Efficacy of Extended Thromboprophylaxis With Fondaparinux After Major Orthopedic Surgery of the Lower Limb With or Without a Neuraxial or Deep Peripheral Nerve Catheter: The EXPERT Study

François J. Singelyn, MD, PhD*, Cees C.P.M. Verheyen, MD{dagger}, Franco Piovella, MD{ddagger}, Hugo K. Van Aken, MD§, Nadia Rosencher, MD|| for the EXPERT Study Investigators

From the *Department of Anesthesiology, Clinical Center, Soyaux, France; {dagger}Department of Orthopaedic Surgery and Traumatology, Isala Clinics, Zwolle, The Netherlands; {ddagger}Thromboembolic Disease Unit, IRCCS Policlinico San Matteo, Pavia, Italy; §Department of Anaesthesiology and Intensive Care, University Hospital Münster, Germany; and ||Paris 5 University Anesthesiology, Cochin Hospital AP-HP, Paris, France.

Anesth Analg 2007; 105:1540-1547

背景:沒有人對下肢大關節成形術患者長期使用磺達肝素治療的利弊比值進行過評估。磺達肝素與持續軸索或深部周圍神經阻滯同時應用的試驗資料也幾乎沒有。我們在較大整形手術患者中進行了一項前瞻性干預試驗,主要設計停藥48小時以允許拔出軸索或深部周圍神經導管時評估磺達肝素的功效。同時評估磺達肝素長時間應用治療用於預防靜脈血栓栓塞的安全性及有效性。方法:患者術後3-5周每日一次皮下注射2.5 mg磺達肝素。在留置軸索或深部周圍神經導管的患者,磺達肝素最後一次注射後36h拔出導管。導管拔出後12h重新給予下一次劑量的磺達肝素。主要試驗終點為術後4-6周出現有症狀的靜脈血栓栓塞以及大出血。結果:5704例患者參與了這項研究。置入軸索或深部周圍神經留置導管的患者分別為1553 例(27%)和78 例(1.4%)。靜脈血栓栓塞發生率為1.0%(54/5387)。留置導管者與未留置導管者靜脈血栓栓塞發生率無顯著性差異(1.1%0.8%)(優勢比95%可信區間的上限為1.49,低於預先設置的非劣效邊界值1.75)。大出血的發生率為0.8%(42/5382)。沒有1例患者發生軸索或神經周圍血腫。結論:每日一次皮下注射2.5 mg 磺達肝素3-5周可以安全有效預防較大整形手術後的靜脈血栓栓塞。暫時的停用磺達肝素48h以利於安全拔出軸索或深部周圍神經導管不會降低預防血栓的效果。

(邱鬱薇 馬皓琳 李士通 校)

BACKGROUND: The benefit-risk ratio of extended fondaparinux therapy has not been assessed in patients undergoing major lower limb joint arthroplasty. Few data on the concomitant use of fondaparinux and continuous neuraxial or deep peripheral nerve blockade are available. We performed a prospective intervention study in patients undergoing major orthopedic surgery primarily designed to assess the efficacy of fondaparinux when drug administration was withheld for 48 h to permit removal of a neuraxial or deep peripheral nerve catheter. The safety and efficacy of extended fondaparinux therapy for the prevention of venous thromboembolism were also evaluated. METHODS: Patients received a daily subcutaneous injection of 2.5 mg fondaparinux for 3 to 5 wk postoperatively. In patients with a neuraxial or deep peripheral nerve catheter, the catheter was removed 36 h after the last fondaparinux dose. The next fondaparinux dose was administered 12 h after catheter removal. The primary end points were symptomatic venous thromboembolism and major bleeding up to 4–6 wk after surgery. RESULTS: We recruited 5704 patients. A neuraxial or deep peripheral nerve catheter was inserted in 1553 (27%) patients and 78 (1.4%) patients, respectively. The rate of venous thromboembolism was 1.0% (54 of 5387). There was no difference between patients without (1.1%) or with (0.8%) a catheter (the upper limit of the 95% confidence interval of the odds ratio, 1.49, being below the predetermined noninferiority margin of 1.75). The incidence of major bleeding was 0.8% (42 of 5382). No neuraxial or perineural hematoma was reported. CONCLUSIONS: Once-daily subcutaneous injection of 2.5 mg fondaparinux given for 3 to 5 wk was effective and safe for prevention of venous thromboembolism after major orthopedic surgery. Temporary discontinuation of fondaparinux for 48 h permitted safe removal of a neuraxial or deep peripheral nerve catheter without decreasing thromboprophylatic efficacy.


小兒門診手術中用喉罩導氣管編程壓力支援通氣

Programming Pressure Support Ventilation in Pediatric Patients in Ambulatory Surgery with a Laryngeal Mask Airway

Javier Garcia-Fernandez, MD, PhD*, Gerardo Tusman, MD{dagger}, Fernando Suarez-Sipmann, MD{ddagger}, Julio Llorens, MD, PhD§, Marina Soro, MD, PhD§, and Javier F. Belda, MD, PhD§

From the *Pediatric Anesthesiology and Postsurgical Critical Care Department, La Paz Universitary Hospital, Madrid, Spain; {dagger}Anesthesiology Department, La Comunidad Hospital, Mar de Plata, Argentina; {ddagger}Intensive Care Department, Fundación Jiménez Díaz-Capio, Madrid, Spain; §Anesthesiology Department, Clinical Universitary Hospital, University of Valencia, Valencia, Spain.

Anesth Analg 2007; 105:1585-1591

 

背景:用壓力支援通氣技術(PSV)的麻醉工作站是可取的,但很少的文獻報導如何在小兒全麻中用喉罩導氣管(LMA)編程流量觸發的PSV。方法:我們研究了60ASA III級、2個月-14歲、安排在用LMA行全麻和局域麻醉聯合下行門診手術的病人。病人根據他們的體重分組:A≤10 kgB11–20 kg,和C>20 kg。所有的都用下列設置行PSV通氣:呼氣末正壓4 cm H2O,沒有誘發自主觸發的最小流量觸發,和最小水平的壓力支持使潮氣量達到10 mL/kg

結果:我們研究中最常用的流量觸發為0.4 L/min,範圍0.2 - 0.6 L/min。我們發現在流量觸發設置與病人年齡、體重、順應性、氣道阻力和呼吸頻率之間沒有相關性。在壓力支持水平(A = 15 cm H2O, B = 10 cm H2O C = 9 cm H2O)與年齡(P < 0.001)、體重(P < 0.001)、動態順應性(P < 0.001)和氣道阻力(P < 0.001)之間有很好的相關性。結論:在門診小兒麻醉中,用ProsealTM LMA行壓力支持通氣可簡單地用研究的常用臨床非創傷性變數編程。然而,需要更多研究來評估可能需要用於其他臨床情況(呼吸病理學、氣管內導管或者其他手術類型)或者其他麻醉工作站的壓力支持通氣的水平。

(彭中美 馬皓琳 李士通 校)

BACKGROUND: Anesthesia workstations with pressure support ventilation (PSV) are available, but there are few studies published on how to program flow-triggered PSV using a laryngeal mask airway (LMA) under general anesthesia in pediatric patients. METHODS: We studied 60 ASA I and II patients, from 2 mo to 14 yr, scheduled for ambulatory surgery under combined general and regional anesthesia with a LMA. Patients were classified according to their body weight as follows: Group A ≤10 kg, Group B 11–20 kg, and Group C >20 kg. All were ventilated in PSV using the following settings: positive end-expiratory pressure of 4 cm H2O, the minimum flow-trigger without provoking auto-triggering, and the minimum level of pressure support to obtain 10 mL/kg of tidal volume. RESULTS: The flow-trigger most frequently used in our study was 0.4 L/min, ranging from 0.2 to 0.6 L/min. We found no correlation between the flow-trigger setting and the patient’s age, weight, compliance, resistance, or respiratory rate. There was a good correlation between the level of pressure support (Group A = 15 cm H2O, Group B = 10 cm H2O and Group C = 9 cm H2O) and age (P < 0.001), weight (P < 0.001), dynamic compliance (P < 0.001), and airway resistances (P < 0.001). CONCLUSIONS: PSV with a ProsealTM LMA in outpatient pediatric anesthesia can be programmed simply using the common clinical noninvasive variables studied. However, more studies are needed to estimate the level of pressure support that may be required in other clinical situations (respiratory pathology, endotracheal tubes, or other types of surgeries) or with other anesthesia workstations.


全麻患兒神經刺激的電流強度與周圍神經阻滯成功率之間的關係

The Relationship Between Current Intensity for Nerve Stimulation and Success of Peripheral Nerve Blocks Performed in Pediatric Patients Under General Anesthesia

Harshad Gurnaney, MBBS, Arjunan Ganesh, MBBS, and Giovanni Cucchiaro, MD

From the Department of Anesthesia and Critical Care Medicine, The Children’s Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Anesth Analg 2007; 105:1605-1609

背景:我們評估了全麻患兒用來獲得運動反應的最低電流安培數與周圍神經阻滯(PNB)的成功率及神經學併發症發生率之間的關係。方法:我們回顧了200210月至20067月費城兒童醫院的局域麻醉資料庫,並且包括了所有全麻下在周圍神經刺激儀輔助下施行單次注射法PNB的患兒數據。分析的資料包括:年齡、性別、阻滯類型、刺激閾、感覺與運動阻滯的存在及神經併發症。結果:在研究期間有660位患兒接受了PNB。患兒的平均年齡13.8歲(範圍=2-18歲)。所有的阻滯均在0.2 1 mA(中位數=0.5 mA,四分位距: 0.45–0.55 mA)的電流下實施。總的成功率為96%。使用刺激閾≤0.5 >0.5 mA實施的阻滯成功率無差別 (96.3% 相對 95.9%; P = 0.793)。成功率與性別、實施的阻滯類型或使用的電流強度之間無相關性。有兩位接受坐骨神經阻滯的患兒,其大拇趾及足背的神經阻滯延長,持續72小時。我們的患兒未發現有長期的後遺症。結論:本研究中,使用低刺激閾值(≤0.5 mA)及高刺激閾值(>0.5 mA)刺激所得到的PNB成功率是相似的。因此,可能沒有必要使用針頭操作來得到一個低刺激閾值(≤0.5 mA),因為這樣可能會增加神經內注射的危險性。

(裘毅敏譯,馬皓琳 李士通校)

BACKGROUND: We evaluated the relationship between the lowest current amperage used to obtain a motor response, the success rate and the incidence of neurological complications with peripheral nerve blocks (PNB) in pediatric patients under general anesthesia. METHODS: We reviewed the regional anesthesia database at The Children’s Hospital of Philadelphia and included all pediatric patients who received a single-injection PNB under general anesthesia with the aid of a peripheral nerve stimulator between October 2002 and July 2006. Data analyzed included age, sex, type of block, stimulation threshold, presence of sensory and motor blockade, and neurological complications. RESULTS: Six-hundred sixty patients received a PNB during the study period. The average age of the patients was 13.8 yr (range = 2–18 yr). All the blocks were performed using a current ranging between 0.2 and 1 (median = 0.5 mA, interquartile range: 0.45–0.55 mA). The overall success rate was 96%. There was no difference in success rate between blocks performed using a stimulation threshold of ≤0.5 or >0.5 mA (96.3% vs 95.9%; P = 0.793). There was no correlation between the success rate and sex, type of block performed or intensity of current used. Two patients reported prolonged nerve blockade of the great toe and dorsum of the foot after a sciatic nerve block, which lasted for 72 h. No long-term sequelae were noted in our patients. CONCLUSION: In this study, a similar PNB success rate was observed with both a low (≤0.5 mA) and a high stimulation threshold (>0.5 mA). Therefore, it may not be necessary to perform needle manipulations to achieve a low stimulation threshold (≤0.5 mA), as this may increase the risk of intraneural injection.


評估基於貝葉斯的閉環系統用於丙泊酚輸注的理想模型權重,應用雙頻指數作為對照變數:一個模擬研究

Estimation of Optimal Modeling Weights for a Bayesian-Based Closed-Loop System for Propofol Administration Using the Bispectral Index as a Controlled Variable: A Simulation Study

Tom De Smet, MSc*, Michel M. R. F. Struys, MD, PhD{dagger}{ddagger}, Scott Greenwald, PhD§, Eric P. Mortier, MD, DSc{dagger}, and Steven L. Shafer, PhD||¶

From *Demed Engineering, Temse, Belgium; {dagger}Department of Anesthesia, Ghent University Hospital, Gent, Belgium; {ddagger}Heymans Institute of Pharmacology, Ghent University, Gent, Belgium; §Aspect Medical Systems, Inc., Newton, Massachusetts; ||Stanford University School of Medicine, Stanford, California; and ¶University of California at San Francisco, San Francisco, California.

Anesth Analg 2007; 105:1629-1638

背景:將貝葉斯方法應用於基於模型的閉環系統,要求整合標準反應模型和病人特有的反應模型。這個過程利用特殊的模型權重,被稱作貝葉斯變數,此變數決定此特有的模型怎樣偏離標準模型。在這個研究中,我們應用類比來選擇產生理想控制器的貝葉斯變數,用於丙泊酚輸注的貝葉斯閉環系統的,應用雙頻指數(BIS)作為對照變數。方法:測定模型過程的有關貝葉斯變數是經過鑒定的。每組這樣的貝葉斯變數表示一個潛在的控制器。終成理想控制的組,由模擬人群計算後來評估。我們選擇了625個候選組。與我們之前的閉環研究相似,我們應用類比草案來評估控制器的表現。我們的人群包括了用來自於以前工作的人群特性產生的416個虛擬病人。應用與外科案例相似的BIS偏離軌道。結果:我們能應用貝葉斯優化來發展、描繪和優化用於病人個體化模型基礎的閉環控制器的參數設定。在BIS目標為305070時,選擇優化組產生的控制器表現的絕對預測誤差中位數分別為12.9 ± 2.877.59 ± 0.745.76 ± 1.03

結論:我們相信這個系統能被安全地引入麻醉醫師直接觀察下的用於麻醉誘導和維持的臨床試驗中。

(張曦 譯,馬皓琳 李士通 校)

BACKGROUND: Implementing Bayesian methods in a model-based closed-loop system requires the integration of a standard response model with a patient-specific response model. This process makes use of specific modeling weights, called Bayesian variances, which determine how the specific model can deviate from the standard model. In this study we applied simulations to select the Bayesian variances yielding the optimal controller for a Bayesian-based closed-loop system for propofol administration using the Bispectral Index (BIS) as a controlled variable. METHODS: The relevant Bayesian variances determining the modeling process were identified. Each set of such Bayesian variances represents a potential controller. The set, which will result in optimal control, was estimated using calculations on a simulated population. We selected 625 candidate sets. Similar to our previous closed-loop performance study, we applied a simulation protocol to evaluate controller performance. Our population consisted of 416 virtual patients, generated using population characteristics from previous work. A BIS offset trajectory similar to a surgical case was used. RESULTS: We were able to develop, describe, and optimize the parameter setting for a patient-individualized model-based closed-loop controller using Bayesian optimization. Selection of the optimal set yields a controller performing with the following median absolute prediction errors at BIS targets 30, 50, and 70: 12.9 ± 2.87, 7.59 ± 0.74, and 5.76 ± 1.03 respectively. CONCLUSIONS: We believe this system can be introduced safely into clinical testing for both induction and maintenance of anesthesia under direct observation of an anesthesiologist.


術後疼痛模型中的繼發性痛覺過敏取決於脊髓鈣-鈣調蛋白依賴的蛋白激酶IIα的啟動

Secondary Hyperalgesia in the Postoperative Pain Model Is Dependent on Spinal Calcium/Calmodulin-Dependent Protein Kinase II{alpha} Activation

Toni L. Jones, PhD, Adam C. Lustig, BS, and Linda S. Sorkin, PhD

From the Department of Anesthesiology, University of California San Diego, La Jolla, California.

Anesth Analg 2007; 105:1650-1656

背景:鞘內給予非N-甲基-d-天冬氨酸(NMDA)受體拮抗劑可阻斷足底切皮後原發性()和繼發性()機械痛覺過敏和自發痛,而鞘內給予NMDA受體拮抗劑並無此作用。熱刺激後痛覺過敏也由非NMDA受體而不是NMDA受體介導。儘管以前對熱刺激模型的疼痛行為學研究表明蛋白激酶明確參與其下游脊髓非NMDA受體啟動,但是蛋白激酶信號傳導機制尚未在術後疼痛模型中得到驗證。在本實驗中我們研究了脊髓鈣-鈣調蛋白依賴的蛋白激酶IIαCaMKIIα)是否介導了足底切皮後/痛覺過敏及自發痛行為。方法:在插入鞘內導管的大鼠後爪行一1cm切口,在隨後的2天內測試大鼠對鄰近切口或距切口1cm處機械刺激的反應。一些大鼠接受鞘內預處理CaMKIIα抑制劑(1434104 nmol KN-93)或賦形劑(無菌生理鹽水中的5%二甲基亞碸)。其餘組單獨接受鞘內注射34nmol104nmol KN-93並接受後爪承重測試。切皮或假處理後1h取出腰段脊髓用Western免疫印跡法測定CaMKIIαα-氨基-3-羥基-5-甲基異噁唑-4-丙酸GLUR1-831磷酸化程度。結果:切皮增加脊髓CaMKIIα GLUR1-831磷酸化程度。儘管預處理鞘內注射KN-93的所有劑量均可減輕痛覺過敏的發展,但是僅鞘內注射34nmol KN-93對於痛覺過敏有效。鞘內注射KN-93不影響非激發性疼痛。結論:脊髓CaMKIIα啟動和α-氨基-3-羥基-5-甲基異噁唑-4-丙酸受體(AMPA)功能增強參與了切皮激發痛覺過敏模型中脊髓致敏機制。

(周雅春 馬皓琳 李士通 校)

 

BACKGROUND: Spinally administered non-N-methyl-d-aspartate (NMDA), but not NMDA, receptor antagonists block primary (1°) and secondary (2°) mechanical hyperalgesia and spontaneous pain after plantar incision. Hyperalgesia after thermal stimulation is also mediated by non-NMDA, but not NMDA, receptors. Although previous pain behavior studies in the thermal stimulus model demonstrated distinct protein kinase involvement downstream from spinal non-NMDA receptor activation, protein kinase signaling mechanisms have not been examined in the postoperative pain model. In the present study, we investigated whether spinal calcium/calmodulin-dependent protein kinase II{alpha} (CaMKII{alpha}) mediates 1° and/or 2° hyperalgesia and spontaneous pain behavior after plantar incision. METHODS: Catheterized rats received a 1 cm incision in the hindpaw and were tested over 2 days for responses to mechanical stimulation adjacent to or 1 cm away from the incision site. Some rats received intrathecal (IT) pretreatment with a CaMKII{alpha} inhibitor (14, 34, or 104 nmol KN-93) or vehicle (5% dimethyl sulfoxide in sterile saline). Separate groups received IT 34 nmol or 104 nmol KN-93 and were tested for hindpaw weight bearing. Lumbar spinal cords were extracted 1 h after incision or sham treatment to measure phosphorylated CaMKII{alpha} and {alpha}-amino-3-hydroxy-5-methylisoxazole-4-proprionic acid GLUR1-831 in Western immunoblots. RESULTS: Incision increased spinal CaMKII{alpha} and GLUR1-831 phosphorylation. Although pretreatment with all doses of IT KN-93 reduced the development of 2° hyperalgesia, only 34 nmol KN-93 appeared to have an effect on 1° hyperalgesia. IT KN-93 did not affect nonevoked pain. CONCLUSION: Spinal sensitization underlying incision-evoked hyperalgesia involves spinal CaMKII{alpha} activation and enhanced spinal {alpha}-amino-3-hydroxy-5-methylisoxazole-4-proprionic acid receptor (AMPA) function.


超臨床劑量的異氟烷濃度能輕微增加甲烷而非甲苯對水的親和力

Concentrations of Isoflurane Exceeding Those Used Clinically Slightly Increase the Affinity of Methane, but Not Toluene, for Water

Charles W. Buffington, MD*, Michael J. Laster, DVM{dagger}, Katarzyna Jankowska, DVM{dagger}, and Edmond I. Eger, II, MD{dagger}

From the *Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania; and {dagger}Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California.

Anesth Analg 2007; 105:1675-1680

背景:吸入麻醉劑可影響在脂膜和周圍水相交界處的蛋白質。其基礎的溶液化學性質不明。由於非極性蛋白成份的疏水性對構相有重要影響,我們驗證了以下假設:異氟烷影響兩種非極性化合物甲烷和甲苯在鹽水中的可溶性。方法:我們在37°C無異氟烷和約存在1%5%15%異氟烷時,用連續稀釋技術測定甲烷和甲苯的鹽水/氣分配係數(PCs)。我們還測量了用以前研究中用的麻醉藥環丙烷或氯乙烷使苯飽和對苯蒸汽壓的影響,以證實它們和苯的平衡使苯在水中溶解度降低。結果:臨床相關的異氟烷濃度(1%5%)對甲烷和甲苯的鹽水/PC沒有影響,但15%–20%異氟烷增加甲烷的PC (P < 0.05)而對甲苯沒有作用。用環丙烷或氯乙烷使苯飽和降低苯蒸汽壓力,其降低程度與苯中溶解的麻醉藥量成比例。

結論:異氟烷在遠遠大於臨床相關濃度時有輕微的疏水作用,而這種作用無法解釋麻醉劑如何作用。那個發現環丙烷和氯乙烷降低苯在水中溶解度的既往研究,可能在這些麻醉劑干擾了苯和水的相互作用的結論方面有誤。應該改為這些麻醉劑只是降低了苯的蒸汽壓力,這樣做是遵循了拉烏爾定律。

(唐李雋   馬皓琳 李士通 校)

BACKGROUND: Inhaled anesthetics may affect proteins at the interface between membrane lipids and the surrounding aqueous phase. The underlying solution chemistry is not known. Because the hydrophobicity of nonpolar protein components importantly influences their conformation, we tested the hypothesis that isoflurane affects the solubility of two nonpolar compounds, methane and toluene, in saline.

METHODS: Using a serial dilution technique, we determined the saline:gas partition coefficients (PCs) of methane and toluene at 37°C in the absence of isoflurane and in the presence of approximately 1%, 5%, and 15% isoflurane. We also measured the effect on the vapor pressure of benzene produced by saturating benzene with either cyclopropane or chloroethane, anesthetics used in a previous study to demonstrate that their equilibration with benzene decreased the solubility of benzene in water. RESULTS: Clinically relevant concentrations of isoflurane (1% and 5%) did not affect the saline:gas PC of methane and toluene, but 15%–20% isoflurane increased the PC of methane (P < 0.05) but not toluene. Saturating benzene with cyclopropane or chloroethane, decreased the vapor pressure of benzene in proportion to the amount of anesthetic dissolved in the benzene. CONCLUSION: Isoflurane has a weak antihydrophobic effect at concentrations far above the clinically relevant range, and this effect is unlikely to explain how anesthetics act. A previous study, which found that cyclopropane and chloroethane decreased the solubility of benzene in water, probably erred in its conclusion that these anesthetics interfered with the interaction of benzene and water. Instead, the anesthetics simply decreased the vapor pressure of benzene, doing so in accordance with Raoult's Law.


嗎啡增強自發性癲癇發作的機制

Mechanisms of Morphine Enhancement of Spontaneous Seizure Activity

Ehsan Saboory, PhD*, Miron Derchansky, PhD*{dagger}, Mohammed Ismaili, PhD*, Shokrollah S. Jahromi, PhD*, Richard Brull, MD, FRCPC{ddagger}, Peter L. Carlen, MD, FRCPC*{dagger}§, and Hossam El Beheiry, MBBCh, PhD, FRCPC*{ddagger}

From the *Toronto Western Research Institute, Departments of {dagger}Physiology, {ddagger}Anesthesia and Pain Management, and §Medicine (Neurology), University of Toronto, University Health Network, Toronto, Ontario, Canada.

Anesth Analg 2007; 105:1729-1735

背景:大劑量阿片類藥物治療可以使癲癇突然發生;然而這種危險副作用產生的機制尚不清楚。我們的研究目的在於揭示大劑量嗎啡的神經興奮活性是否通過選擇性刺激阿片受體來介導。方法:完整分離小鼠海馬組織並孵育在低鎂人工腦脊液中,誘發CA1神經元產生自發性癲癇樣事件。結果:運用嗎啡對記錄的自發性癲癇樣事件有雙相作用。低濃度嗎啡(10µM)降低癲癇的電活動。而大劑量嗎啡(30µM100µM)會增強癲癇放電並且呈現明顯的劑量依賴性。非選擇性阿片類受體拮抗藥納絡酮阻斷嗎啡的致驚厥作用。選擇性µ受體和{kappa}受體激動劑和拮抗劑可以分別增加或抑制自發性癲癇活性。相反,{delta}受體配體藥物沒有作用。

結論:嗎啡產生的致癲癇作用是通過選擇性啟動µ{kappa}阿片受體介導,而與{delta}阿片受體系統的啟動無關。嗎啡神經興奮性的劑量依賴性機制強調了臨床謹慎調節和個體化嗎啡劑量。

(沈浩      馬皓琳 李士通 校)

BACKGROUND: High-dose opioid therapy can precipitate seizures; however, the mechanism of such a dangerous adverse effect remains poorly understood. The aim of our study was to determine whether the neuroexcitatory activity of high-dose morphine is mediated by selective stimulation of opioid receptors. METHODS: Mice hippocampi were resected intact and bathed in low magnesium artificial cerebrospinal fluid to induce spontaneous seizure-like events recorded from CA1 neurons. RESULTS: Application of morphine had a biphasic effect on the recorded spontaneous seizure-like events. In a low concentration (10 µM), morphine depressed electrographic seizure activity. Higher morphine concentrations (30 and 100 µM) enhanced seizure activity in an apparent dose-dependent manner. Naloxone, a nonselective opiate antagonist blocked the proconvulsant action of morphine. Selective µ and {kappa}opiate receptor agonists and antagonists enhanced and suppressed the spontaneous seizure activity, respectively. On the contrary, {delta}opioid receptor ligands did not have an effect. CONCLUSIONS: The proseizure effect of morphine is mediated through selective stimulation of µ and {kappa}opiate receptors but not the activation of the {delta}receptor system. The observed dose-dependent mechanism of morphine neuroexcitation underscores careful adjustment and individualized opioid dosing in the clinical setting.



診斷性鞘內注射預測手術結果的能力

The Ability of Diagnostic Spinal Injections to Predict Surgical Outcomes

Steven P. Cohen, MD*{dagger}, and Robert W. Hurley, MD, PhD*

From the *Pain Management Division, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; and {dagger}Department of Surgery, Walter Reed Army Medical Center, Washington, DC.

Anesth Analg 2007; 105:1756-1775

背景:自從80多年前第一次描述診斷性鞘內注射以來,關於其用來預測手術結果的應用一直是廣受爭議的物件。因為在這個論題上既沒有標準化的指導方針也沒有實質性的綜述,其應用結果仍不一致。方法:在這次綜述中包括的診斷過程為腰段和頸段椎間盤造影、腰段椎間關節阻滯、腰段和頸段選擇性神經根阻滯和骶髂關節內注射。我們通過MEDLINEOVID搜索引擎、書籍、書籍章節、參考文獻和會議錄來獲取資料。結果:由於所有阻滯方法均缺乏隨機、對照性研究,得出的結論具有一定的局限性。通過現有的資料,能揭示腰段椎間盤造影改善融合手術結果的證據很有限,且沒有證據證實其可以影響椎間盤置換的效果。雖然範圍很有限,但是目前的文獻支持頸段椎間盤造影可以預測手術結果。有強有力的證據提示腰段選擇性神經根阻滯可以改善對有症狀的神經根的識別,中等程度的證據提示腰段和頸段神經根阻滯都可以改善手術結果。支援椎間關節病手術的資料很少,而且應用篩選性阻滯也不可能預測結果。支持用於退行性、非創傷性損傷的骶髂關節融合的資料同樣也很少。因為用來診斷疼痛性骶髂關節的最可靠方法是小劑量診斷性注射,一個可能合理的結論是篩選性阻滯改善手術結果。但是這一結論沒有間接的證據支持。結論:隨機性研究的缺乏、方法學上的缺陷以及在注射變數、手術方法和結果測定方面的差異限制了對診斷性阻滯影響手術結果的評價能力。需要進行更多的研究來優化注射技術,並確定即便要,哪一種診斷性篩選阻滯方法可以改善手術結果。

(薑旭暉     馬皓琳  李士通 校)

BACKGROUND: Since their first description more than 80 yr ago, the use of diagnostic spinal injections to predict surgical outcomes has been the subject of intense controversy. Because there are no standardized guidelines or substantive reviews on this topic, their use has remained inconsistent. METHODS: Diagnostic procedures included in this review were lumbar and cervical discography, lumbar facet blocks, lumbar and cervical selective nerve root blocks, and sacroiliac (SI) joint injections. We garnered materials via MEDLINE and OVID search engines, books and book chapters, bibliographic references, and conference proceedings. RESULTS: The lack of randomized, comparative studies for all blocks limited the conclusions that could be drawn. For the data that do exist, there is limited evidence that lumbar discography improves fusion outcomes, and no evidence that it influences disk replacement results. Although limited in scope, the current literature supports the notion that cervical discography improves surgical outcomes. There is strong evidence that lumbar selective nerve root blocks improve the identification of a symptomatic nerve root(s), and moderate evidence that both lumbar and cervical nerve root blocks improve surgical outcomes. The data supporting surgery for facet arthropathy are weak, and the use of screening blocks does not appear to improve outcomes. The data supporting SI joint fusion for degenerative, nontraumatic injuries are similarly weak. Because the most reliable method to diagnose a painful SI joint is with low volume, diagnostic injections, one might reasonably conclude that screening blocks improve surgical outcomes. However, this conclusion is not supported by indirect evidence. CONCLUSIONS: The ability to evaluate the effect of diagnostic blocks on surgical outcomes is limited by a lack of randomized studies, methodological flaws, and wide-ranging discrepancies with regard to injection variables, surgical technique, and outcome measures. More research is needed to optimize injection techniques and determine which, if any, diagnostic screening blocks can improve surgical outcomes.


阿片類藥物和沉浸式虛擬現實分散注意力的鎮痛作用:來自主觀性和功能性腦顯像評估的證據

The Analgesic Effects of Opioids and Immersive Virtual Reality Distraction: Evidence from Subjective and Functional Brain Imaging Assessments

Hunter G. Hoffman, PhD*{dagger}, Todd L. Richards, PhD{dagger}, Trevor Van Oostrom, MD{ddagger}, Barbara A. Coda, MD§, Mark P. Jensen, PhD||, David K. Blough, PhD¶, and Sam R. Sharar, MD{ddagger}

From the Department of *Mechanical Engineering, {dagger}Radiology, and {ddagger}Anesthesiology, University of Washington, Seattle, Washington; §McKenzie Anesthesia Group, Springfield, Oregon; and Department of ||Rehabilitation Medicine and ¶Pharmacy, University of Washington, Seattle, Washington.

Anesth Analg 2007; 105:1776-1783

背景:沉浸式虛擬現實(VR)是一種通過分散注意力達到鎮痛作用的新方法,然而,它和阿片類藥物聯合應用對疼痛相關大腦活動的影響尚不得而知。我們利用主觀疼痛分級和功能性磁共振顯像來衡量接受阿片類藥物和/VR分散注意力治療的受試者的疼痛和疼痛相關腦活動。方法:九位元健康受試者接受溫度痛覺刺激並在一受試者內部設計中接受四種干預條件:(a) 對照(無鎮痛),(b)給予阿片類藥物(氫嗎啡酮血漿靶濃度4 ng/mL (c) 沉浸式VR分散注意力,和(d)聯合阿片類藥物+VR 觀察結果包括主觀疼痛分級(標記圖形量表0-10分)和五個特定疼痛相關部位腦活動的血氧水平依賴性評價。結果:阿片類藥物單獨使用可顯著降低受試者的疼痛不適感分級(P < 0.05),並顯著減少腦島(P < 0.05)和丘腦(P < 0.05)的疼痛相關腦活動。VR 單獨使用可以顯著減少頂級疼痛(P < 0.01)和疼痛不適感(P < 0.01),並顯著減少腦島(P < 0.05)、丘腦(P < 0.05)SS2(P < 0.05)的疼痛相關腦活動。阿片類藥物和VR 聯合應用比單獨應用阿片類藥物在所有主觀疼痛測量值上都更為有效地減少疼痛報告(P < 0.01)。疼痛相關的腦血氧水平依賴性腦活動模式和主觀疼痛報告是相一致的。結論:這些主觀的疼痛報告和客觀的功能性磁共振顯像結果提示單獨阿片類藥物和單獨VR的鎮痛效能具有會聚作用的證據。另外,疼痛相關腦活動也支持,當VR作為阿片類藥物的輔助鎮痛方法時,具有顯著的主觀鎮痛作用。這些結果為臨床上多模式鎮痛機制(如聯合藥物和非藥物)的應用提供了初步資料。

(黃佳佳   馬皓琳 李士通 校)

BACKGROUND: Immersive virtual reality (VR) is a novel form of distraction analgesia, yet its effects on pain-related brain activity when used adjunctively with opioid analgesics are unknown. We used subjective pain ratings and functional magnetic resonance imaging to measure pain and pain-related brain activity in subjects receiving opioid and/or VR distraction. METHODS: Healthy subjects (n = 9) received thermal pain stimulation and were exposed to four intervention conditions in a within-subjects design: (a) control (no analgesia), (b) opioid administration [hydromorphone (4 ng/mL target plasma level)], (c) immersive VR distraction, and (d) combined opioid + VR. Outcomes included subjective pain reports (0–10 labeled graphic rating scales) and blood oxygen level-dependent assessments of brain activity in five specific, pain-related regions of interest. RESULTS: Opioid alone significantly reduced subjective pain unpleasantness ratings (P < 0.05) and significantly reduced pain-related brain activity in the insula (P < 0.05) and thalmus (P < 0.05). VR alone significantly reduced both worst pain (P < 0.01) and pain unpleasantness (P < 0.01) and significantly reduced pain-related brain activity in the insula (P < 0.05), thalmus (P < 0.05), and SS2 (P < 0.05). Combined opioid + VR reduced pain reports more effectively than did opioid alone on all subjective pain measures (P < 0.01). Patterns of pain-related blood oxygen level-dependent activity were consistent with subjective analgesic reports. CONCLUSIONS: These subjective pain reports and objective functional magnetic resonance imaging results demonstrate converging evidence for the analgesic efficacy of opioid administration alone and VR distraction alone. Furthermore, patterns of pain-related brain activity support the significant subjective analgesic effects of VR distraction when used as an adjunct to opioid analgesia. These results provide preliminary data to support the clinical use of multimodal (e.g., combined pharmacologic and nonpharmacologic) analgesic techniques.



與環氧化酶-2選擇性抑制劑和非選擇性抗炎藥物有關的心血管血栓栓塞的副作用

Cardiovascular Thromboembolic Adverse Effects Associated with Cyclooxygenase-2 Selective Inhibitors and Nonselective Antiinflammatory Drugs

Girish P. Joshi, MBBS, MD, FFARCSI*, Ralph Gertler, MD{dagger}, and Ruth Fricker, MD{ddagger}

From the *Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; {dagger}Institute of Anesthesiology and Intensive Care, German Heart Centre of the State of Bavaria and the Technical University Munich; and {ddagger}Pfizer GmbH, Karlsruhe, Germany.

Anesth Analg 2007; 105:1793-1804

背景:非甾類抗炎藥(nonsteroidal antiinflammatory drugsNSAIDs,包括非選擇性〔NS-NSAIDs和環氧化酶-2cyclooxygenase-2COX-2〕選擇性抑制劑)儘管有眾多優點,但其引起心血管(cardiovascularCV)血栓栓塞副作用的增多限制了它們的應用。方法:在這個描述性綜述中,我們精密地調查了評估長期和短期應用COX-2選擇性抑制劑和NS-NSAIDs引起的心血管副作用的隨機、有效和安慰劑對照的研究、觀察性試驗和mata分析。同時提出這些心血管副作用的潛在機制。結果:儘管評估心血管風險的研究有局限性,但COX-2選擇性抑制劑和NS-NSAIDs的心血管風險仍都增加,尤其在高危患者中。因此,美國食品藥物管理局已給予一個相似的“裝箱”警告來突出與這些藥物應用相關的心血管事件增加的潛在性。然而,COX-2選擇性抑制劑之間的心血管風險不同(例如羅非昔布比塞來昔布的心血管風險高),同樣NS-NSAIDs藥物之間的心血管風險也不同(如雙氯芬酸比萘普生的心血管風險高)。結論:在長期、前瞻性、隨機、充足的對相關患者人群的臨床研究完成以前,與NSAIDs應用有關,尤其對高危患者的心血管風險將可能仍是有爭論的。然而,在沒有心血管風險的患者中短期應用(如圍術期)的益處可能大於其潛在的心血管副作用。最後,應謹慎地進行風險/利益評估,且COX-2選擇性抑制劑和NS-NSAIDs在有心血管風險因素的患者中應用都應慎重。

(朱 慧譯 馬皓琳 李士通校)

BACKGROUND: Concerns of increased cardiovascular (CV) thromboembolic adverse effects from nonsteroidal antiinflammatory drugs (NSAIDs, both nonselective [NS]-NSAIDs and cyclooxygenase [COX]-2 selective inhibitors) have prevented their use despite numerous benefits. METHODS: In this descriptive review, we critically examine the randomized, active- and placebo-controlled studies, observational trials, and meta-analyses evaluating the CV adverse effects associated with long-term and short-term use of COX-2 selective inhibitors and NS-NSAIDs. The potential mechanisms for these CV effects are also presented. RESULTS: Although the studies evaluating the CV risks have limitations, there appears to be an increased CV risk with both COX-2 selective inhibitors and NS-NSAIDs, particularly in high-risk patients. Therefore, the United States Food and Drug Administration has given a similar "boxed" warning highlighting the potential for increased risk of CV events associated with their use. Nevertheless, there are differences in the CV risks between COX-2 selective inhibitors (e.g., higher CV risk with rofecoxib than celecoxib) as well as differences in the CV risks between individual NS-NSAIDs (e.g., higher CV risks with diclofenac than naproxen). CONCLUSIONS: Until long-term, prospective, randomized, adequately powered, clinical studies in relevant patient populations have been completed, the CV risks associated with the use of NSAIDs, especially in high-risk patients, will likely continue to be controversial. Nevertheless, the benefits of their short-term (e.g., perioperative) use in patients without CV risks probably outweigh their potential CV adverse effects. Finally, careful risk/benefit assessment should be undertaken and both COX-2 selective inhibitors and NS-NSAIDs should be used with caution in patients with CV risk factors.



抑制環腺苷酸通路可以緩解神經性疼痛且減輕大鼠坐骨神經部分結紮後脊髓相應部位環腺苷酸磷酸化

Inhibition of the Cyclic Adenosine Monophosphate Pathway Attenuates Neuropathic Pain and Reduces Phosphorylation of Cyclic Adenosine Monophosphate Response Element-Binding in the Spinal Cord After Partial Sciatic Nerve Ligation in Rats

Jiin-Tarng Liou, MD*{dagger}, Fu-Chao Liu, MD*{dagger}, Shi-Tai Hsin, MD*, Ching-Yue Yang, MD*, and Ping-Wing Lui, MD, PhD{ddagger}

From the *Department of Anesthesiology, Chang Gung Memorial Hospital; {dagger}Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan; and {ddagger}Suao and Yuanshan Veterans Hospital, Yilan, National Yang-Ming University, Taipei, Taiwan.

Anesth Analg 2007; 105:1830-1837

背景:近來的研究表明,環腺苷酸(cAMP)轉導在感受傷害性處理中有一定作用。脊髓中cAMP的啟動通過蛋白激酶AcAMP反應結合蛋白 (CREB)的啟動從而誘導基因轉錄。鞘內注射蛋白激酶A抑制劑可以逆轉機械性感覺過敏,而注射CREB反義引物可以減弱大鼠坐骨神經部分結紮引發的觸覺異常性疼痛。在這個研究中,我們的目的是在慢性神經性疼痛模型中觀察脊髓cAMP轉導對傷害性感受處理的作用。方法: 雄性SD大鼠鞘內置管1周後,行坐骨神經部分結紮。結紮後2小時、3714天,評價大鼠後爪對機械和熱刺激的傷害感受。觀察鞘內注射腺苷酸環化酶抑制劑 SQ22536 0.7 µmol對傷害感受的影響。並且測定脊髓背角CREB表達和免疫反應以及CREB磷酸化蛋白 (CREB-IR pCREB-IR)含量的變化。. 結果: 坐骨神經部分結紮後兩周,大鼠脊髓背角 CREB-IR pCREB-IR蛋白的表達增高。在最早3天裏,pCREB-IR的增高部分可被 cAMP通路阻滯所逆轉。 機械和熱刺激的退縮反應閾值平行增高。結論: 這些結果顯示大鼠坐骨神經部分結紮引起的觸覺異常疼痛和熱感覺過敏,pCREB的增高可能有一定作用。如果對於有慢性神經性疼痛的病人可以達到早期干預,調製 cAMP 通路就可能有臨床相關性。

(張瑩譯  馬皓琳 李士通校)

BACKGROUND: Recent reports have identified a role for cyclic adenosine monophosphate (cAMP) transduction in nociceptive processing. Spinal activation of the cAMP induced gene transcription through the activation of protein kinase A and cAMP response element-binding protein (CREB). Intrathecal injection of protein kinase A inhibitor reversed the mechanical hyperalgesia, whereas injection of CREB antisense attenuated tactile allodynia caused by partial sciatic nerve ligation (PSNL) in rats. In the present study, we aimed to assess the effects of spinal cAMP transduction on the nociceptive processing in a chronic neuropathic pain model.

METHODS: PSNL was performed in male Sprague-Dawley rats 1 wk after intrathecal catheterization. Nociception to mechanical and thermal stimuli was assessed at the hindpaw 2 h, 3, 7, and 14 days after PSNL. The effects of adenylate cyclase inhibitor, SQ22536 (0.7 µmol, intrathecal) on these nociceptions were evaluated. Changes in the expression and immunoreactivity of CREB and its phosphorylated proteins (CREB-IR and pCREB-IR) in the dorsal horn of the spinal cord were also measured. RESULTS: The expression of CREB-IR and pCREB-IR proteins was shown to increase for 2 wk after PSNL. The increase in pCREB was partially reversed by the blockade of the cAMP pathway in the early 3 days, with a parallel increase in mechanical and thermal withdrawal thresholds. CONCLUSION: These results revealed the possible contribution of an increase in pCREB to the PSNL-induced tactile allodynia and thermal hyperalgesia. Modulation of the cAMP pathway may be clinically relevant if early intervention can be achieved in patients with chronic neuropathic pain.



關於股骨創傷後臨床症狀出現前股神經阻滯緩解疼痛的一項隨機對照試驗

A Randomized Controlled Trial of Femoral Nerve Blockade Administered Preclinically for Pain Relief in Femoral Trauma

Arno Schiferer, MD, DEAA*, Carmen Gore, MD{dagger}, Laszlo Gorove, MD{ddagger}, Thomas Lang, MD*, Barbara Steinlechner, MD*, Michael Zimpfer, MD, MBA§, and Alexander Kober, MD||

From the *Department of Anesthesiology and General Intensive Care, Medical University of Vienna, Austria; {dagger}Department of Anesthesiology, University Hospital of Bucharest, Rumania; {ddagger}Hungarian National Emergency and Ambulance Service, Budapest, Hungary; §Department of Anesthesiology and General Intensive Care, Medical University of Vienna, Austria; and ||Vienna Red Cross, Van Swieten and the Research Institute of the Vienna Red Cross, Vienna, Austria.

Anesth Analg 2007; 105:1852-1854

背景:股骨創傷後在意外發生地點以及搬運過程中的鎮痛通常會被延誤或者鎮痛不充分。在該項前瞻性的隨機對照試驗中,我們評價了臨床症狀出現前應用股神經阻滯緩解疼痛與焦慮,並與用安乃近靜脈鎮痛進行比較。方法:有疼痛的股骨創傷(例如骨折或嚴重的挫傷)的病人,隨機分入兩組,一組為在意外發生地點行股神經阻滯(n = 31),一組為靜脈給予安乃近鎮痛(n = 31)。應用視覺類比評分(VAS)評價疼痛程度與焦慮程度。分別採集基線水平、搬運過程中以及到達醫院時的變數值。結果:應用股神經阻滯的病人,疼痛分值下降一半,VAS評分由意外發生地的 86 ± 6 mm下降到搬運過程中的41 ± 15 mm。同時焦慮程度也下降一半,VAS評分由84 ± 11 mm 下降到 39 ± 14 mm。心率下降20 ± 5 bpm。在安乃近組,疼痛、焦慮以及心率沒有下降(P < 0.001)。股神經阻滯組的治療時間長7.4 ± 3.5 min。結論:臨床症狀出現前進行股神經阻滯可以有效地緩解股骨創傷後的疼痛、焦慮,降低心率。區域阻滯可以成為訓練有素的醫生進行醫院外鎮痛的一項選擇。

(黃麗娜    馬皓琳  李士通  校)

BACKGROUND: Analgesia at the location of the accident and on transport for femoral trauma is often delayed or insufficient. In this prospective, randomized, controlled study, we evaluated the preclinical use of femoral nerve blockade for reducing pain and anxiety compared with IV analgesia using metamizol. METHODS: Patients with painful femoral trauma, such as fracture or severe contusion, were randomized to receive at the site of the accident a femoral nerve blockade (n = 31) or IV analgesia with metamizol (n = 31). A visual analog scale (VAS) was used to assess pain and anxiety. Variables were assessed at baseline, during transport and upon arrival at the hospital. RESULTS: In patients receiving the femoral nerve blockade, pain values decreased by half from VAS 86 ± 6 mm at the site of the accident to VAS 41 ± 15 mm during transport. Anxiety decreased by half from VAS 84 ± 11 mm to VAS 39 ± 14 mm. Heart rate decreased by 20 ± 5 bpm. In the metamizol group, pain, anxiety, and heart rate did not decrease (P < 0.001). Time of treatment was 7.4 ± 3.5 min longer in the femoral nerve blockade group. CONCLUSION: Preclinically administered femoral nerve blockade effectively decreases pain, anxiety, and heart rate after femoral trauma. Regional blockade is an option for out-of-hospital analgesia administered by a trained physician.



旁正中法:一項較好的老年患者中初次連續脊麻進路方法

The Paramedian Technique: A Superior Initial Approach to Continuous Spinal Anesthesia in the Elderly

Anna Rabinowitz, MS*{dagger}, Benoît Bourdet, MD*, Vincent Minville, MD*, Clément Chassery, MD*, Antoine Pianezza, MD*, Aline Colombani, MD*, Bernard Eychenne, MD*, Kamran Samii, MD*, and Olivier Fourcade, MD, PhD*

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

Anesth Analg 2007; 105:1855-1857

背景:老年患者的脊麻經常會涉及到顯著的技術困難。因此,我們對經典的正中法進路和旁正中法行連續脊麻(CSA)進行了比較。 方法:我們前瞻性地研究了40位年齡〉75歲的髖骨折行開放性手術復位的病人。他們隨機被分為2組:M組:正中法,PM組:旁正中法。病人側臥位,於L4-5進針行連續脊麻。由穿刺針中流出腦脊液表示腰穿成功。萬一初次失敗,由同一位操作者來重複同種進針法。如果兩次嘗試都不成功,則由同一位操作者來行另一解剖學進路進針。如果都失敗了,那麼由麻醉醫師同事進行最後一次嘗試。萬一失敗或阻滯不全,則病人接受全麻。 結果:PM組的初次嘗試成功率為85%17)而M組為45%9)(P=0.02)。所有的導管都成功置入。沒有病人需要全麻。在M組有6位病人針穿破血管而PM組為0P=0.03),但是都沒有臨床後遺症。沒有其他的顯著臨床併發症發生。 結論:總而言之,在老年病人行連續脊麻的首次嘗試後,旁正中進針法較正中法成功率高。

(胡湘   馬皓琳 李士通 校)

BACKGROUND: Spinal anesthesia in elderly patients is frequently associated with significant technical difficulties. Thus, we compared the classical midline approach to the paramedian approach to perform continuous spinal anesthesia (CSA). METHODS: We prospectively studied 40 patients aged >75 yr who underwent open surgical repair of a hip fracture. These patients were randomly allocated to one of two groups: Group M: midline approach, and Group PM: paramedian approach. Patients were positioned in the lateral decubitus to receive CSA at L4-5 level. CSA was considered successful if cerebrospinal fluid was obtained through the needle. In case of initial failure in either approach, the same approach was repeated by the same operator. If two attempts were unsuccessful, the other anatomical approach was used by the same operator. If both approaches failed, a staff anesthesiologist performed a final attempt. In case of failure or insufficient block, the patient received general anesthesia. RESULTS: The success rate after the first attempt was 85% (17) for Group PM and 45% (9) for Group M (P = 0.02). All catheters were successfully introduced. No patient required general anesthesia. Vascular puncture after needle puncture was observed in six patients in Group M versus 0 in Group PM (P = 0.03), but none were of clinical consequence. No other clinically significant complications were observed.

CONCLUSION: In summary, after the initial attempt, the paramedian approach is associated with an increased success rate, compared with the midline approach, during the performance of CSA in elderly patients.