Table of Contents

January 2008

CARDIOVASCULAR ANESTHESIOLOGY:

过调节豚鼠心肌蛋白激酶c线粒体ATP离子通道和一合酶增强乙醇的心肌缺血作用

陶颖莹 陈杰

Sevoflurane Enhances Ethanol-Induced Cardiac Preconditioning Through Modulation of Protein Kinase C, Mitochondrial KATP Channels, and Nitric Oxide Synthase, in Guinea Pig Hearts

Kazuhiro Kaneda, Masami Miyamae, Shingo Sugioka, Chika Okusa, Yoshitaka Inamura, Naochika Domae, Junichiro Kotani, and Vincent M. Figueredo

Anesth Analg 2008 106: 9-16.

异氟烷预处理在大鼠梗死后重中保持抗缺血再灌注损伤的保作用

黄施伟 译,马皓琳 李士通

Preconditioning by Isoflurane Retains Its Protection Against Ischemia-Reperfusion Injury in Postinfarct Remodeled Rat Hearts

Eliana Lucchinetti, Marina Jamnicki, Gregor Fischer, and Michael Zaugg

Anesth Analg 2008 106: 17-23.

大鼠心肺分流中使用全氟碳炎性所致不良后果有

吴威译,薛张纲校

Perfluorocarbon Administration During Cardiopulmonary Bypass in Rats: An Inflammatory Link to Adverse Outcome?

Fellery de Lange, Kenji Yoshitani, Alan D. Proia, G. Burkhard Mackensen, and Hilary P. Grocott

Anesth Analg 2008 106: 24-31.

间输入血小板和红细肝移植后存活率的影

杨卫红

The Impact of Intraoperative Transfusion of Platelets and Red Blood Cells on Survival After Liver Transplantation

Marieke T. de Boer, Michael C. Christensen, Mikael Asmussen, Christian S. van der Hilst, Herman G. D. Hendriks, Maarten J. H. Slooff, and Robert J. Porte

Anesth Analg 2008 106: 32-44.

经静脉心动图监测静脉空栓塞和管指下空吸出中,于心前多普食道超动图

彭中美   马皓琳 李士通 

Intracardiac Transvenous Echocardiography Is Superior to Both Precordial Doppler and Transesophageal Echocardiography Techniques for Detecting Venous Air Embolism and Catheter-Guided Air Aspiration

Simon T. Schäfer, Jochen Lindemann, Peter Brendt, Gernot Kaiser, and Jürgen Peters

Anesth Analg 2008 106: 45-54.

PEDIATRIC ANESTHESIOLOGY:

于小先天性缺陷疼痛价工具的用性的

陈恺铮译 薛张刚校

A Comparison of the Clinical Utility of Pain Assessment Tools for Children with Cognitive Impairment

Terri Voepel-Lewis, Shobha Malviya, Alan R. Tait, Sandra Merkel, Roxie Foster, Elliot J. Krane, and Peter J. Davis

Anesth Analg 2008 106: 72-78.

右旋美托啶对儿童心脏电生理的影

詹琼慧 陈杰

The Effects of Dexmedetomidine on Cardiac Electrophysiology in Children

Gregory B. Hammer, David R. Drover, Hong Cao, Ethan Jackson, Glyn D. Williams, Chandra Ramamoorthy, George F. Van Hare, Alisa Niksch, and Anne M. Dubin

Anesth Analg 2008 106: 79-83.

中高酸血症在科患者视频辅助下胸腔镜检查中的潜在治作用

邱郁薇 马皓琳 李士通

The Therapeutic Potential of Intraoperative Hypercapnia During Video-Assisted Thoracoscopy in Pediatric Patients

Ahmed M. Mukhtar, Gihan M. Obayah, Ashraf Elmasry, and Nabil M. Dessouky

Anesth Analg 2008 106: 84-88.

腹股/腹下阻:在非直下我把局麻打到里去了?

陈佳莉译 薛张纲校

Ilioinguinal/Iliohypogastric Blocks in Children: Where Do We Administer the Local Anesthetic Without Direct Visualization?

Marion Weintraud, Peter Marhofer, Adrian Bösenberg, Stephan Kapral, Harald Willschke, Michael Felfernig, and Stephan Kettner

Anesth Analg 2008 106: 89-93.

续锁骨下臂中改良的方法能更好地保障管位置

朱玫娟 陈杰

Continuous Infraclavicular Brachial Plexus Block: A Modified Technique to Better Secure Catheter Position in Infants and Children

Vrushali C. Ponde

Anesth Analg 2008 106: 94-96.

AMBULATORY ANESTHESIOLOGY:Back

在用地和芬太尼行麻醉的门诊矫形手中瑞芬太尼能否取代亚氮

唐亮   马皓琳 李士通

Can Remifentanil Replace Nitrous Oxide During Anesthesia for Ambulatory Orthopedic Surgery with Desflurane and Fentanyl?

Donald M. Mathews, Vijay Gaba, Bledi Zaku, and George G. Neuman

Anesth Analg 2008 106: 101-108.

前予米平可前焦吐(PONV

陈勇柱译  薛张刚校

Premedication with Mirtazapine Reduces Preoperative Anxiety and Postoperative Nausea and Vomiting

Chien-Chuan Chen, Chia-Shiang Lin, Yuan-Pi Ko, Yu-Chun Hung, Hsuan-Chih Lao, and Yung-Wei Hsu

Anesth Analg 2008 106: 109-113.

震波碎石期右旋美托啶与异痛作用的比试验

潘钱玲 陈杰

A Comparison of Sedation with Dexmedetomidine or Propofol During Shockwave Lithotripsy: A Randomized Controlled Trial

Kenan Kaygusuz, Gokhan Gokce, Sinan Gursoy, Semih Ayan, Caner Mimaroglu, and Yener Gultekin

Anesth Analg 2008 106: 114-119.

氯胺酮疗术后寒的效能

吴进   马皓琳 李士通

The Efficacy of Ketamine for the Treatment of Postoperative Shivering (Brief Report)

Emine Arzu Kose, Didem Dal, Seda Banu Akinci, Fatma Saricaoglu, and Ulku Aypar

Anesth Analg 2008 106: 120-122.

的病人比硫钠术后咽喉部病变发生率

陈珺珺译  薛张纲校

Propofol Causes Less Postoperative Pharyngeal Morbidity Than Thiopental After the Use of a Laryngeal Mask Airway (Brief Report)

Yuan-Yi Chia, Shih-Wei Lee, and Kan Liu

Anesth Analg 2008 106: 123-126.

ANESTHETIC PHARMACOLOGY:

氙气在人体中不影响氨基丁酸A型受体的

王腾 陈杰

Xenon Does Not Affect {gamma}-Aminobutyric Acid Type A Receptor Binding in Humans

Elina Salmi, Ruut M. Laitio, Sargo Aalto, Anu T. Maksimow, Jaakko W. Långsjö, Kaike K. Kaisti, Riku Aantaa, Vesa Oikonen, Liisa Metsähonkala, Kjell Någren, Esa R. Korpi, and Harry Scheinin

Anesth Analg 2008 106: 129-134.

饲养的大鼠在血流相似及有重大手术应麻醉葡萄糖和度以及心肌己糖激酶的影

颜涛 译,马皓琳 李士通

Anesthesia's Effects on Plasma Glucose and Insulin and Cardiac Hexokinase at Similar Hemodynamics and Without Major Surgical Stress in Fed Rats

Coert J. Zuurbier, Peter J. M. Keijzers, Anneke Koeman, Harry B. Van Wezel, and Markus W. Hollmann

Anesth Analg 2008 106: 135-142.

期硬膜外罗哌卡因CYP2D6活性的影

璇译 薛张纲校

The Effect of a Long–Term Epidural Infusion of Ropivacaine on CYP2D6 Activity

Jeroen Wink, Bernadette Th. Veering, Michel Kruit, Anton G. L. Burm, Gunilla A. I. Huledal, Gunilla Y. Ekström, Rudolf Stienstra, and Jack W. van Kleef Anesth

Analg 2008 106: 143-146.

TECHNOLOGY, COMPUTING, AND SIMULATION:

频谱熵是否可以反映丙泊酚与瑞芬太尼的合麻醉期管或切皮反?

王鹏 陈杰

Does Spectral Entropy Reflect the Response to Intubation or Incision During Propofol-Remifentanil Anesthesia?

Grégoire Weil, Sylvie Passot, Frédérique Servin, and Valérie Billard

Anesth Analg 2008 106: 152-159.

中持血糖监测的精确性

裘毅敏译,马皓琳 李士通校

The Accuracy of a Continuous Blood Glucose Monitor During Surgery

Koichi Yamashita, Takehiro Okabayashi, Takeshi Yokoyama, Tomoaki Yatabe, Hiromichi Maeda, Masanobu Manabe, and Kazuhiro Hanazaki

Anesth Analg 2008 106: 160-163.

腹腔铬细胞瘤手患者的即心律变异(HRV)及其浆儿酚胺水平的

秦佳译 薛张刚校

Real-Time Heart Rate Variability and Its Correlation with Plasma Catecholamines During Laparoscopic Adrenal Pheochromocytoma Surgery

Musa Sesay, Patrick Tauzin-Fin, Philippe Gosse, Philippe Ballanger, and Pierre Maurette

Anesth Analg 2008 106: 164-170.

CRITICAL CARE AND TRAUMA:

顺应性和死腔分示麻醉病人恢后最佳呼末正水平

於章杰 陈杰

Compliance and Dead Space Fraction Indicate an Optimal Level of Positive End-Expiratory Pressure After Recruitment in Anesthetized Patients

Stefan Maisch, Hajo Reissmann, Bernd Fuellekrug, Dieter Weismann, Thomas Rutkowski, Gerardo Tusman, and Stephan H. Bohm

Anesth Analg 2008 106: 175-181.

在人的尸体上比较两种紧甲膜切器械包

施杨译,薛张纲校

A Comparison of Two Emergency Cricothyroidotomy Kits in Human Cadavers (Brief Report)

Mehdi Benkhadra, François Lenfant, Wolfgang Nemetz, Friedrich Anderhuber, Georg Feigl, and Jean Fasel

Anesth Analg 2008 106: 182-185.

OBSTETRIC ANESTHESIOLOGY:

剖腹分娩后腹机平面(TAP)阻痛效:实验

张燕 陈杰

The Analgesic Efficacy of Transversus Abdominis Plane Block After Cesarean Delivery: A Randomized Controlled Trial

John G. McDonnell, Gerard Curley, John Carney, Aoife Benton, Joseph Costello, Chrisen H. Maharaj, and John G. Laffey

Anesth Analg 2008 106: 186-191.

NEUROSURGICAL ANESTHESIOLOGY:

丹曲林在新生小鼠脑组织-缺血损伤的作用

沈浩   马皓琳 李士通

The Effects of Dantrolene on Hypoxic-Ischemic Injury in the Neonatal Rat Brain

Mijeung Gwak, Pyonghwan Park, Kisoo Kim, Keunho Lim, Sungmoon Jeong, Chongwha Baek, and Jonghwan Lee

Anesth Analg 2008 106: 227-233.

项对血流速率通性波动产动态自身调节估:自身调节及平均流速指这两个模型的比

孙霞译,薛张纲校

An Assessment of Dynamic Autoregulation from Spontaneous Fluctuations of Cerebral Blood Flow Velocity: A Comparison of Two Models, Index of Autoregulation and Mean Flow Index

Marek Czosnyka, Piotr Smielewski, Andrea Lavinio, John D. Pickard, and Ronney Panerai

Anesth Analg 2008 106: 234-239.

颅内压监测在外脑损伤中的用(述)

印洁敏 陈杰

Monitoring Intracranial Pressure in Traumatic Brain Injury (Review Article)

Martin Smith

Anesth Analg 2008 106: 240-248.

GENERAL ARTICLES:Back

下半身加模仿正常硬膜外麻醉引起的寒战阈值的降低

黄丽娜    马皓琳 李士通

Lower-Body Warming Mimics the Normal Epidural-Induced Reduction in the Shivering Threshold

Anthony G. Doufas, Nobutada Morioka, Adel N. Maghoub, Edward Mascha, and Daniel I. Sessler

Anesth Analg 2008 106: 252-256.

Pentax-AWS电视:100患者的使用体

王光妍翻 薛张纲校

The Pentax-AWS Video-Laryngoscope: The First Experience in One Hundred Patients (Brief Report)

Takashi Asai, Yoshiro Enomoto, Keiko Shimizu, Koh Shingu, and Yasuhisa Okuda

Anesth Analg 2008 106: 257-259.

ANALGESIA:

丙泊麻醉的病人异氟麻醉的病人具有后疼痛

杜唯佳 陈杰

Anesthesia Matters: Patients Anesthetized with Propofol Have Less Postoperative Pain than Those Anesthetized with Isoflurane

Sean S. Cheng, Janet Yeh, and Pamela Flood

Anesth Analg 2008 106: 264-269.

用皮表面来区分骨折后的杂区域疼痛合症1型患者和骨折后有多患者

黄佳佳译,马皓琳,李士通校

Using Skin Surface Temperature to Differentiate Between Complex Regional Pain Syndrome Type 1 Patients After a Fracture and Control Patients with Various Complaints After a Fracture

Sjoerd P. Niehof, Annemerle Beerthuizen, Frank J. P. M. Huygen, and Freek J. Zijlstra

Anesth Analg 2008 106: 270-277.

腹腔术时哌罗哌卡因腹膜给药的分布和

王时来译 薛张纲校

Disposition and Clinical Outcome After Intraperitoneal Meperidine and Ropivacaine Administration During Laparoscopic Surgery

Michael J. Paech, Kenneth F. Ilett, L. Peter Hackett, Madhu Page-Sharp, and Richard W. Parsons

Anesth Analg 2008 106: 278-286.

脉自控痛(PCA时吗啡与氯胺酮合用是否单独使用吗啡?

宋翠侠 陈杰

Is the Combination of Morphine with Ketamine Better than Morphine Alone for Postoperative Intravenous Patient-Controlled Analgesia?

Gorazd Sveticic, Farzan Farzanegan, Patrick Zmoos, Sandra Zmoos, Urs Eichenberger, and Michele Curatolo

Anesth Analg 2008 106: 287-293.

一天次口服90mg尼美舒利不影胸外科大手吗啡的需求量

姜旭晖   马皓琳 李士通

Nimesulide 90 mg Orally Twice Daily Does Not Influence Postoperative Morphine Requirements After Major Chest Surgery

Donal F. Harney, Michelle Dooley, Brendan Harhen, Niall McGuiness, Gerard Cagney, Connail McCrory, Desmond J. Fitzgerald, and Noreen P. Dowd

Anesth Analg 2008 106: 294-300.

全膝成形后小罗哌卡因和芬太尼混合液中加入4mcg/ml上腺素行腰段硬膜外

张俪译 薛张纲校

Epinephrine 4 µg/mL Added to a Low-Dose Mixture of Ropivacaine and Fentanyl for Lumbar Epidural Analgesia After Total Knee Arthroplasty

Johannes G. Förster, Hilkka M. Lumme, Vilja J. Palkama, Per H. Rosenberg, and Mikko T. Pitkänen

Anesth Analg 2008 106: 301-304.

予半有效量的加巴后路腰椎融合吗啡使用量的影

胡潇 陈杰

The Median Effective Dose of Preemptive Gabapentin on Postoperative Morphine Consumption After Posterior Lumbar Spinal Fusion (Brief Report)

Alain C. Van Elstraete, Myriam Tirault, Thierry Lebrun, Ignace Sandefo, Jean-Christophe Bernard, Bruno Polin, Patrick Vally, and Jean-Xavier Mazoit

Anesth Analg 2008 106: 305-308.

腹式子切除吗啡和曲多病人自控痛效果的比较研

唐李隽   马皓琳 李士通

A Comparative Study of the Analgesic Effect of Patient-Controlled Morphine, Pethidine, and Tramadol for Postoperative Pain Management After Abdominal Hysterectomy (Brief Report)

Hakki Unlugenc, Mehmet Ali Vardar, and Sibel Tetiker

Anesth Analg 2008 106: 309-312.

在神性疼痛大鼠模型中的作用时间了的硬膜外腔罗哌卡因的痛效果

周时蓓译,薛张纲校

The Prolonged Analgesic Effect of Epidural Ropivacaine in a Rat Model of Neuropathic Pain

Chiyo Sato, Atsushi Sakai, Yumiko Ikeda, Hidenori Suzuki, and Atsuhiro Sakamoto

Anesth Analg 2008 106: 313-320.

利多卡因与布比卡因在临床疼痛模型中前列腺素E2释放环氧合酶基因表达和的疼痛影响的差异

潘方立 陈杰

The Differential Effects of Bupivacaine and Lidocaine on Prostaglandin E2 Release, Cyclooxygenase Gene Expression and Pain in a Clinical Pain Model

Sharon M. Gordon, Brian P. Chuang, Xiao Min Wang, May A. Hamza, Janet S. Rowan, Jaime S. Brahim, and Raymond A. Dionne

Anesth Analg 2008 106: 321-327.

节内给咯酸、吗啡罗哌卡因节内自控痛用于解肩后的疼痛:一项随

胡湘   马皓琳 李士通

Intraarticular Administration of Ketorolac, Morphine, and Ropivacaine Combined with Intraarticular Patient-Controlled Regional Analgesia for Pain Relief After Shoulder Surgery: A Randomized, Double-Blind Study

Kjell Axelsson, Anil Gupta, Eva Johanzon, Elisabeth Berg, Gustav Ekbäck, Narinder Rawal, Peter Enström, and Ulf Nordensson

Anesth Analg 2008 106: 328-333.

前加巴丁:罗哌卡因蛛膜下腔阻和血流的影

陈佳莉译 薛张纲校

Preoperative Gabapentin: The Effect on Ropivacaine Subarachnoid Block and Hemodynamics

Argyro Fassoulaki, Vassiliki Chatziara, Aikaterini Melemeni, Marianna Zotou, and Constantine Sarantopoulos

Anesth Analg 2008 106: 334-338.

人体腰椎脊神根套囊的超微结构

慧译 马皓琳 李士通校

The Ultrastructure of the Human Spinal Nerve Root Cuff in the Lumbar Spine

Miguel Angel Reina, María Concepción Villanueva, Fabiola Machés, Ana Carrera, Andrés López, and José Antonio De Andrés

Anesth Analg 2008 106: 339-344.

 

儿童髂腹股沟/髂腹下阻滞:在非直视下我们把局麻药打到哪里去了?

Ilioinguinal/Iliohypogastric Blocks in Children: Where Do We Administer the Local Anesthetic Without Direct Visualization?

Marion Weintraud, MD*, Peter Marhofer, MD*, Adrian Bösenberg, MBChB, FFA (SA){dagger}, Stephan Kapral, MD*, Harald Willschke, MD*, Michael Felfernig, MD{ddagger}, and Stephan Kettner, MD*

From the *Department of Anaesthesia and Intensive Care Medicine, Medical University of Vienna, 1090 Vienna, Austria; {dagger}Department of Anaesthesia, University Cape Town, Red Cross Children Hospital, Rondebosch, South Africa; and {ddagger}Department of Anaesthesia and Intensive Care, Royal Naval Hospital, Gibraltar, United Kingdom.

Anesth Analg 2008; 106:89-93

 

背景:外周神经阻滞的超声显像技术使我们能够直视目标神经周围的局麻药的分布。同样,超声显像可以在使用定位技术时观察局麻药的分布位置。我们做了一项研究来观察在定位技术下儿童髂腹下/髂腹股沟神经阻滞时局麻药的实际分布位置,试图以此来解释无效的神经阻滞。方法:全麻诱导后(1MAC氟烷和喉罩通气),对62个择期行腹股沟手术的儿童在标准解剖定位下做髂腹下/髂腹股沟神经阻滞。然后使用超声显像来观察局麻药的实际分布位置。麻醉医生在无超声指导下进行神经阻滞。如果局麻药在神经周围或者切皮后无临床体征则被认为是成功的。结果:其中14%的神经阻滞是成功的,我们观察到局麻药恰分布在神经周围。在其余的86%中,局麻药分布在解剖结构的附近(18%在髂肌,26%在腹横肌,29%在腹内斜肌,9%在腹外斜肌,2%在皮下,2%在腹膜),这些情况下45%的阻滞是失败的。结论:使用定位技术在儿童的髂腹下/髂腹股沟神经周围准确地打局麻很少成功。在多数病人中,局麻药不很精确地分布在解剖结构的附近使得阻滞效果不完善。

(陈佳莉译 薛张纲校) 

BACKGROUND: Ultrasonographic observation of peripheral nerve blocks enables direct visualization of the spread of local anesthetic around the targeted nerves. Similarly, ultrasonography may be used to determine the site of local anesthetic placement when landmark-based techniques are used. We performed a study to determine the actual location of local anesthetic when ilioinguinal/iliohypogastric nerve blocks are performed using landmark-based techniques in children in an attempt to explain a failed block.METHODS: After induction of general anesthesia (1 minimum alveolar anesthetic concentration halothane and laryngeal mask airway), 62 children scheduled for inguinal surgery received an ilioinguinal/iliohypogastric nerve block based on standard anatomical landmarks. Ultrasonography was then used to determine the actual location of local anesthetic placement. The anesthesiologist performing the block was blinded to the ultrasonographic investigation. Successful blocks were recorded either when the local anesthetic surrounded the nerves or were based on clinical signs after skin incision.RESULTS: In 14% of the blocks, the local anesthetic was administered correctly around the nerves resulting in successful blocks. In the remaining 86%, the local anesthetic was administered in adjacent anatomical structures (iliac muscle 18%, transverse abdominal muscle 26%, internal oblique abdominal muscle 29%, external oblique abdominal muscle 9%, subcutaneous 2%, and peritoneum 2%), and 45% of these blocks failed.CONCLUSION: Accurate placement of local anesthetic around the ilioinguinal/iliohypogastric nerves in children is seldom possible when landmark-based techniques are used. In the majority of patients, the local anesthetic was inaccurately placed in adjacent anatomical structures with unpredictable block results.

 

术前加巴喷丁:罗哌卡因蛛网膜下腔阻滞和血流动力学的影响

Preoperative Gabapentin: The Effect on Ropivacaine Subarachnoid Block and Hemodynamics

Argyro Fassoulaki, MD, PhD, DEAA*, Vassiliki Chatziara, MD{dagger}, Aikaterini Melemeni, MD, DESA*, Marianna Zotou, MD{dagger}, and Constantine Sarantopoulos, MD, PhD, DEAA{ddagger}

.From the *Department of Anesthesiology, Aretaieio Hospital, Medical School, {dagger}Department of Anesthesiology, St. Savas Hospital, Athens, Greece; and {ddagger}Department of Anesthesiology, Pharmacology and Toxicology, Medical College of Wisconsin, Wisconsin.

 Anesth Analg 2008; 106:334-338

 

背景:加巴喷丁是一种辅助镇痛药,可能可以增加蛛网膜下腔阻滞的平面。我们研究术前给予加巴喷丁对蛛网膜下腔阻滞的特征和血流动力学的影响。方法:随机选择70个用0.75%的罗哌卡因2.2 mL做腰麻行经尿道操作的病人,术前每6小时给他们400mg加巴喷丁或安慰剂,共计1200mg。每30分钟测量一次感觉和运动阻滞平面直到感觉阻滞平面低于L4。在相同的时间间隔,记录病人的血压和心率。结果:两组的感觉和运动阻滞平面没有区别。加巴喷丁组的32个患者中有26个蛛网膜下腔注药150分钟后感觉阻滞平面退到L4,而对照组33个患者中有25个。加巴喷丁组的收缩压降低了(P = 0.002 P = 0.03)。两组的舒张压没有区别,但是总体上,加巴喷丁组的心率比较快。结论:预先给予加巴喷丁对感觉阻滞平面的范围和运动阻滞平面的消退没有影响,但是却降低了用罗哌卡因进行腰麻的病人的收缩压。

(陈佳莉译 薛张纲校)

BACKGROUND: Gabapentin is an adjuvant analgesic and may enhance the spread of subarachnoid block. We investigated the effects of pretreatment with gabapentin on subarachnoid block characteristics and hemodynamics.METHODS: Seventy patients undergoing transurethral procedures under subarachnoid anesthesia with 2.2 mL of 0.75% ropivacaine were randomly assigned to receive preoperatively 400 mg of gabapentin 6 hourly, up to a total dose of 1200 mg, or placebo. Sensory and motor blocks were assessed every 30 min until regression of sensory block to L4. At the same time intervals, systolic and diastolic arterial blood pressures and heart rate were recorded.RESULTS: There were no differences between groups in the sensory block levels or degree of motor block. Sensory block 150 min after the subarachnoid injection had regressed to L4 in 26 of 32 patients in the gabapentin group and in 25 of the 33 patients in the control group. Systolic arterial blood pressure was decreased in the gabapentin group (P = 0.002 for the main effect of group, and P = 0.03 at 60 min between the groups). The diastolic arterial blood pressure did not differ between the groups, but overall, the heart rate was more rapid in the gabapentin group (P = 0.002, but only for baseline values between the groups, P = 0.036).CONCLUSION: Pretreatment with gabapentin had no effect on the spread of sensory block or the regression of motor block but was associated with lower systolic arterial blood pressure values in patients undergoing subarachnoid anesthesia with ropivacaine.

 

Pentax-AWS电视喉镜:100个患者的使用体验

The Pentax-AWS Video-Laryngoscope: The First Experience in One Hundred Patients

Takashi Asai, MD, PhD*, Yoshiro Enomoto, MD , Keiko Shimizu, MD , Koh Shingu, MD*, and Yasuhisa Okuda, MD

From the *Department of Anesthesiology, Kansai Medical University, Moriguchi City, Osaka, Japan; Department of Anes thesiology, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan.

Anesth Analg 2008; 106:257-259

 

我们学习了Pentax-AWS(东京,日本)100个患者使用的有效性,它是一个新的便携的,用电池的电视喉镜。 100个患者中的99个患者在第一次放置喉镜镜片的时候顺利完成操作并且见到了清晰的完整的声门。余下的未完成的患者是担心破坏已经松动的牙齿,所以放弃置镜片。98位患者顺利完成只置管。气管插管的平均时间为35s(范围,5-120s)

(王光妍翻 薛张纲校)

We studied the efficacy of the Pentax-AWS (Tokyo, Japan), a new portable, battery-operated video-laryngoscope, in 100 patients. It was possible to insert the blade of the Pentax-AWS and to see a full view of the glottis on the first attempt in 99 of 100 patients. In the remaining patient, insertion of the Pentax-AWS was abandoned because of a risk of damag ing teeth that were already loose. Tracheal intubation was successful in 98 patients. The median time taken for tracheal intubation was 35 s (range, 5–120 s).

 

 

对于插喉罩的病人异丙酚比硫喷妥钠术后咽喉部病变发生率较低

Propofol Causes Less Postoperative Pharyngeal Morbidity Than Thiopental After the Use of a Laryngeal Mask Airway

Yuan-Yi Chia, MD*{dagger}, Shih-Wei Lee, MD*, and Kan Liu, MD*

From the *Department of Anesthesiology, Kaohsiung Veterans General Hospital, and School of Medicine, National Yang-Ming University, and {dagger}Institution of Health Care Management, National Sun Yat-Sen University, Taiwan.

 

插喉罩的病人术后易出现咽喉痛。诱导药物的选择对于插喉罩之后咽喉痛的发生率是重要的。我们做了研究,将340名病人分为两组,分别给予2 mg/kg 异丙酚(P)5 mg/kg硫喷妥钠(T),比较插入喉罩喉后咽喉部病变的发生率。术中50%空氧混合12MAC七氟烷维持。术中自主或辅助自主呼吸。研究者通过盲法在术后21224小时对病人进行随访。在每个时间点询问病人是非题(是/否),包括有无咽喉痛、口疮、颚部溃疡、声嘶、发声困难和吞咽困难。术后2小时,T组咽喉痛、吞咽困难和术后恶心呕吐的发生率高于P组(咽喉痛24 vs 13%,吞咽困难15 vs 3%,恶心20 vs 11%,呕吐14 vs 6%,P< 0.05)。需要对症处理的咽喉痛和吞咽困难的人数分别是10人和8人(95%的置信区间是543)。我们得出了结论是,相比于硫喷妥钠,异丙酚用于诱导插喉罩,咽喉部疾病的早期发生率和术后恶心呕吐的发生率较低。

(陈珺珺译  薛张纲校)

The insertion of a laryngeal mask airway (LMA) may result in postoperative sore throat. The choice of induction drug on airway  morbidity after LMA insertion may be important. We performed this study to compare the incidence of postoperative pharyngeal morbidity after the insertion of a LMA in 340 patients administered either 2 mg/kg propofol (group P) or thiopental 5 mg/kg (group T) for induction of anesthesia. Patients were maintained at 1–2 minimum alveolar anesthetic concentration sevoflurane in 50% oxygen/air. Spontaneous or assisted spontaneous ventilation was maintained. An investigator blinded to group allocation visited patients at 2, 12, and 24 h postoperatively. Adverse responses were noted (yes/no) at each time point including sore throat, sore mouth, sore jaw, hoarseness, dysphonia, and dysphagia. At 2 h postoperatively, the incidence of sore throat, dysphagia, and postoperative nausea and vomiting in group T was higher than in group P (24% vs 13% for sore throat, 15% vs 3% for dysphagia, 20% vs 11% for nausea, 14% vs 6% for vomiting, P < 0.05). The number-needed-to-treat to prevent sore throat and dysphagia was 10 and 8, respectively (95% confidence intervals, 5–43). We concluded that, when propofol, rather than thiopental, is used for the induction of anesthesia, it results in a lower incidence of early pharyngeal morbidity and postoperative nausea and vomiting after the insertion of a LMA.

 

对于小儿先天性缺陷疼痛评价工具的临床实用性的评价

A Comparison of the Clinical Utility of Pain Assessment Tools for Children with Cognitive Impairment

Terri Voepel-Lewis, MSN, RN*, Shobha Malviya, MD*, Alan R. Tait, PhD*, Sandra Merkel, MS, RN*, Roxie Foster, PhD, RN{dagger}, Elliot J. Krane, MD{ddagger}, and Section Editor Peter J. Davis

From the *University of Michigan Health Systems, Department of Anesthesiology, Ann Arbor, Michigan; {dagger}University of Colorado Health Sciences Center, School of Nursing, Denver, Colorado; {ddagger}Stanford University Medical Center, Department of Anesthesiology, Stanford, California.

 Anesth Analg 2008; 106:72-78

 

背景:难以评价疼痛被认为是对于小儿先天性缺陷镇痛不充分的基本原因之一。若干行为观察疼痛工具对于这些患者有很好的心理学价值。然而,临床常规使用可能更大程度上依赖于他们的实用性.我们设计这个课题来评估三种最近发明的对于小儿先天缺陷疼痛评价工具的临床实用性和价值。

方法:来自三个临床中心的临床医生作为样本被要求观看早先试验中录制的15个先天性缺陷患儿术后三天的情况的录像。五名患儿曾参加r-FLACC组(校正脸,脚,行为,哭喊,可安慰性)。五名参加NCCPC-PV组(非交通性小儿术后疼痛检查表),五名参与NAPI组(护士评估疼痛强度)。在他们看来所有片断后,所有参与者完成CUAQ(临床实用性评估表)包括临床可行性,复杂性,兼容性和相对优势。结果:共有5名外科医生和15名护士参与该试验,对编码疼痛评分(如轻度,中等,非常)和原先观察者的r-FLACC评分有很好的认识(88%-98%完全同意; {kappa}0.71–0.96),CUAQ组在内部的可信性或一致性上具有很高的价值({alpha} = 0.84–0.93)。r-FLACC 和NAPI 评分都比NCCPC-PV.要高。r-FLACC组和NAPI组在复杂性上有相似的评分,但在兼容性,相对优势和总的有效性方面比NAPI评分稍高。总结:我们发现r-FLACC组和NAPI组在复杂性,兼容性,相对优势,和总的临床有效性方面都比NCCPC-PV组有优势,认为这些工具可能可以应用于临床工作。

(陈恺铮译 薛张刚校)

BACKGROUND: Difficulty assessing pain has been cited as one of the primary reasons for infrequent and inadequate assessment and analgesia for children with cognitive impairment (CI). Several behavioral observational pain tools have been shown to have good psychometric properties for pain assessment in this population; however, routine clinical use may depend largely on their pragmatic qualities. We designed this study to evaluate pragmatic attributes or clinical utility properties of three recently developed pain assessment tools for children with CI. METHODS: A sample of clinicians from three medical centers were asked to review 15 videotaped observations of children with CI, recorded during their first three postoperative days during participation in a previous study. Participants scored pain using the revised-Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (individualized for the child during the previous study) for five observations, the noncommunicative Non-Communicating Children’s Pain Checklist-Postoperative Version (NCCPC-PV) for five, and the Nursing Assessment of Pain Intensity (NAPI) for five observations. After their review of all segments, participants completed the Clinical Utility Attributes Questionnaire (CUAQ) ranking three attributes of clinical utility; complexity, compatibility, and relative advantage. RESULTS: Five physicians and 15 nurses comprised the sample. There was excellent agreement between the coded pain scores (i.e., mild, moderate, severe pain) assigned using all tools and r-FLACC scores assigned by original observers (88%–98% exact agreement; {kappa}0.71–0.96). The internal consistency or reliability of the CUAQ was supported by high {alpha}values for each of the subscales ({alpha} = 0.84–0.93). Subscale and total CUAQ scores were higher for the r-FLACC and NAPI compared with the NCCPC-PV. The r-FLACC had similar scores for complexity, but slightly higher scores for compatibility, relative advantage, and total utility compared with the NAPI.

CONCLUSIONS: We found that clinicians rated the complexity, compatibility, relative advantage, and overall clinical utility higher for the r-FLACC and NAPI compared with the NCCPC-PV, suggesting that these tools may be more readily adopted into clinical practice.

 

腹腔镜嗜铬细胞瘤手术患者的即时心律变异性(HRV)及其与血浆儿茶酚胺水平的关系

Real-Time Heart Rate Variability and Its Correlation with Plasma Catecholamines During Laparoscopic Adrenal Pheochromocytoma Surgery

Musa Sesay, MD*, Patrick Tauzin-Fin, MD*, Philippe Gosse, MD{dagger}, Philippe Ballanger, MD{ddagger}, and Pierre Maurette, MD

From the *Department of Anesthesiology, Centre Hospitalier Universitaire Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France; {dagger}Department of Cardiology, Centre Hospitalier Universitaire Sainte Andrée, Cours d’Albret, 33076 Bordeaux, France; and {ddagger}Department of Urology, Centre Hospitalier Universitaire Pellegrin, Place Amélie Raba Léon, 33076 Bordeaux, France.

Anesth Analg 2008; 106:164-170

 

背景:我们测量腹腔镜嗜铬细胞瘤手术患者的即时心律变异性及血浆儿茶酚胺水平,来评价心血管系统的短期调节机制。方法:我们招募了20例嗜铬细胞瘤患者(group p)和20例其他偶发瘤患者(group I).持续监测HRV、动脉收缩压和心律。低频和高频频谱分别意味着交感和副交感系统活性。低频与高频比值可代表自主神经系统的平衡性。测量术前、术中和术后的肾上腺素、去甲肾上腺素水平。对多组记录数值的平均值做直线回归分析,并找出个变量的相关系数。

结果:group I组并未观察到显著变化。group p中所有病人在腹膜充气和肿瘤切除时肾上腺素和去甲肾上腺素水平均升高。16个病人同时伴有收缩压、心率、低频和LF/HF比值的升高。3个病人的低频和LF/HF比值降低。第四个病人出现低血压和心动过速。15个病人高频增强,5个病人保持稳定。低频与去甲的相关性r = 0.68, P < 0.001,收缩压r = 0.66, P < 0.01,心率r = 0.62, P < 0.05

结论:该实验反映了嗜铬细胞瘤手术中低频HRV、血浆去甲肾上腺素水平、动脉压和心律的密切关系。

(秦佳译 薛张刚校)

BACKGROUND: We studied sympathovagal activity using real-time heart rate variability (HRV) and determined its relationship with plasma catecholamines to characterize short-term cardioregulatory mechanisms during laparoscopic adrenal pheochromocytoma surgery.

METHODS: We recruited 20 patients with pheochromocytoma (Group P) and 20 with incidentaloma (Group I). HRV, systolic blood pressure and heart rate were continuously monitored. The low frequency and high frequency spectra denoted, respectively, sympathetic and parasympathetic activity. The low frequency/high frequency (LF/HF) ratio represented sympathovagal balance. Blood samples for epinephrine and norepinephrine assays were collected before, during, and after surgery. After log transformation of the repeated measures, a linear regression model was applied on their mean values. The correlation coefficients among variables were calculated using the Spearman rank test.

RESULTS: No significant changes were observed in Group I. In Group P, epinephrine and norepinephrine increased in all patients during peritoneal insufflation and tumor resection. In 16 patients, systolic blood pressure, heart rate, low frequency, and LF/HF ratio increased concurrently. In four patients, low frequency and LF/HF ratio decreased. Three of these patients had normal systolic blood pressure and heart rate, and the fourth patient had hypotension and tachycardia. The high frequency component was enhanced in 15 patients and was stable in five. Low frequency was correlated with norepinephrine (r = 0.68, P < 0.001), systolic blood pressure (r = 0.66, P < 0.01), and heart rate (r = 0.62, P < 0.05).

CONCLUSION: This study demonstrated a strong correlation between low frequency HRV, plasma norepinephrine, arterial blood pressure, and heart rate during pheochromocytoma surgery.

 

在人的尸体上比较两种紧急环甲膜切开器械包

A Comparison of Two Emergency Cricothyroidotomy Kits in Human Cadavers

Mehdi Benkhadra, Francois Lenfant, Wolfgang Nemetz, Friedrich Anderhuber, Georg Feigl, and Jean Fasel

From the *Division of Anatomy, University of Geneva, Geneva, Switzerland; {dagger}Department of Anesthesiology and Critical Care, General Hospital, University Hospital Center, Dijon, France; {ddagger}Universitätsklinik für Anaesthesiologie und Intensivmedizin, Graz, Austria; and §Anatomisches Institut der Karl-Franzens-Universität, Graz, Austria.

Anesth Analg. 2008 Jan;106(1):182-185.

 

背景:为了避免插入气管导管时的损伤,我们比较了两中紧急环甲膜切开器械包,一种是基于塞尔丁格技术,另外一种是基于对喉后壁的机械探测,并考虑到插入导管的时间,成功率和并发症的发生率。方法:在纤维支气管镜监控下对40个用Thiel技术保护好的尸体上进行环甲膜切开。器械包随即分配使用:新技术或者塞尔丁格技术。在切开过程中,对成功率、喉损伤率进行比较。由纤维支气管镜发现的外伤性损害由解剖进行证实。结果:两组尸体在流行病学和解剖学上具有可比性。用新技术比用塞尔丁格技术快(平均54秒比上71秒,P=0.01)。失败率两者相当(4个比上1个,P=0.34)。塞尔丁格技术对支气管后壁损伤的并发症较少(0个对8个,P=0.003)。用塞尔丁格技术组中,只有4个尸体中发现了气管后壁的点状小损伤。结论:在这个模型中,除了插管时间缩短,新技术比塞尔丁格技术损伤更多,失败率也较高。

(施杨译,薛张纲校)

BACKGROUND: We compared two emergency cricothyroidotomy kits designed to avoid lesions during insertion, one based on the Seldinger technique (ST), the other based on the concept of a mechanical detection of the posterior wall of the larynx, with regard to insertion time, success rate, and complication rate. METHODS: Cricothyroidotomy was performed under fiberoptic control in 40 human cadavers embalmed according to Thiel's technique. The set chosen for use was randomized: new technique (NT) or ST. Duration of the procedure, success rates, and incidence of laryngeal injuries were compared. Traumatic lesions observed with the fiberoptic bronchoscope were anatomically confirmed after dissection. RESULTS: The two groups had comparable epidemiological and anatomical records. Cricothyroidotomy was performed faster with the NT than with the ST (median 54 vs 71 s, P = 0.01). Failure rates were comparable between groups (4 vs 1, P = 0.34), and there were fewer major complications in the posterior tracheal wall with the ST (0 vs 8, P = 0.003). In the ST group, only minor punctiform lesions of the posterior trachea wall were observed in four cases. CONCLUSIONS: In this model, despite a shorter insertion time, the NT produced more lesions and more failures than the ST.

 

腹腔镜手术时哌替啶和罗哌卡因腹膜内给药的分布和临床结果

Disposition and Clinical Outcome After Intraperitoneal Meperidine and Ropivacaine Administration During Laparoscopic Surgery

Michael J. Paech, Kenneth F. Ilett, L. Peter Hackett, Madhu Page-Sharp, and Richard W. Parsons

From the *Pharmacology and Anaesthesiology Unit, School of Medicine and Pharmacology, The University of Western Australia, Perth; and {dagger}Clinical Pharmacology and Toxicology Laboratory, PathWest Laboratory Medicine, Nedlands, Western Australia, Australia; {ddagger}Independent Biostatistician, Perth, Western Australia, Australia.

Anesth Analg 2008; 106:278-286

 

背景:很少有证据支持腹膜内注射哌替啶或局麻药用于术后镇痛是有效的。我们的研究目的是调查腹膜内给予哌替啶和罗哌卡因的镇痛效果并检测血浆浓度。无效假说是在腹腔镜手术后的前24小时各组间的疼痛变化趋势没有明显的区别。

方法:这是一个双盲的随机平行对照试验,共分为五组,由两个试验中心把250名接受腹腔镜手术的妇女随机分为腹膜内注射哌替啶50100mg组(M50组和M100组),罗哌卡因150mgR150组),哌替啶50mg和罗哌卡因150mgM50R150组),都在肌内注射盐水,或腹膜内注射盐水、肌内注射哌替啶50mgC组)。主要的结果是恢复期间的活动后疼痛情况,获得药代动力学模型。

结果:在术后监护病房或其后的时间,各组间的活动后疼痛评分均数没有显著性的差异(C2.2[2.8]M502.5[3.3]M1001.6[2.5]R1502.6[3.2]M50R1502.7[3.2],P=0.50)。各组在静息时的疼痛评分,静脉注射吗啡,恢复过程和病人的满意度上也没有显著性差异。腹腔内注射50mg哌替啶后的血浆浓度(中位数为5560µg/L)大约是同等剂量肌内注射时(中位数为113µg/L)的一半。结论:与常规的阿片类药物相比,腹腔内单独或联合注射哌替啶和罗哌卡因不能缓解腹腔镜术后的疼痛或减少阿片类药物的剂量。

(王时来译 薛张纲校)

BACKGROUND: Limited evidence supports the efficacy of intraperitoneal (IP) meperidine or local anesthetic for postoperative analgesia. Our study aims were to investigate analgesic efficacy and to quantify the plasma concentrations of meperidine and ropivacaine after IP administration. The null hypothesis was that there was no significant difference among groups for dynamic pain in the first 24 h after major abdominal laparoscopic surgery.

METHODS: This double-blind, five parallel group, placebo-controlled, two-center trial randomized 250 women having laparoscopic surgery to receive IP meperidine 50 or 100 mg (groups M50 and M100), ropivacaine 150 mg (group R150), meperidine 50 mg and ropivacaine 150 mg (group M50R150), all with intramuscular saline, or IP saline, with intramuscular meperidine 50 mg (group C). The primary outcome was pain during recovery. A pharmacokinetic profile of the drugs was obtained.

RESULTS: There were no significant differences among groups for mean (sd) dynamic pain scores in the postoperative care unit (2.2 [2.8], 2.5 [3.3], 1.6 [2.5], 2.6 [3.2], 2.7 [3.2] for groups C, M50, M100, R150, and M50R150, P = 0.50) or thereafter. There were no significant differences among groups for pain scores at rest, IV morphine use, recovery characteristics and patient satisfaction. After IP administration of meperidine 50 mg the plasma concentration (median average 55–60 µg/L) was approximately half that of an equivalent intramuscular dose (median average 113 µg/L).

CONCLUSIONS: Compared with systemic opioid, IP meperidine and ropivacaine, alone or in combination, did not produce better pain relief or opioid dose-sparing after laparoscopic surgery.

 

术前予米氮平可减少术前焦虑和术后恶心呕吐(PONV

Premedication with mirtazapine reduces preoperative anxiety and postoperative nausea and vomiting.

Chen CC, Lin CS, Ko YP, Hung YC, Lao HC, Hsu YW.

Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan.

Anesth Analg 2008 106: 109-113.

 

背景:米氮平是一种新的可阻断5-HT2 5-HT3受体的抗抑郁药。因此,米氮平可能有抗焦虑和PONV的效果。因而,我们将检验术前予米氮平可减少术前焦虑和PONV的假设。

方法:80位行择期妇科手术的至少具有两种PONV危险因素的女性患者被入选。麻醉诱导前予8 mg地塞米松,患者被随机分为M + D组(米氮平和地塞米松)和地塞米松组。术前1h30 mg米氮平或安慰剂。术前焦虑程度在给药前和1h后以视觉模拟评分法(VAS)来评估。全麻诱导用1%丙泊酚以200 mL/h的速度输注(直至意识丧失),然后以七氟醚空氧混合维持。用听觉诱发电位来检测麻醉深度。PONV的发生率,止吐药的应用,完全反应,术后Ramsay镇静分级评分及VAS疼痛评分将在术后1224h评估对比。

结果:M + D组的VAS焦虑评分在给予米氮平后降低。两组间丙泊酚的诱导剂量,术中七氟醚的浓度及恢复时间无差别。0-24 h PONV完全反应的发生率在M + D组降低(80% vs 50%, P < 0.01)

结论:术前予30 mg米氮平可降低中高危女性患者的术前焦虑程度和发生PONV的风险。

(陈勇柱译  薛张刚校)

BACKGROUND: Mirtazapine is a new antidepressant that blocks 5-HT2 and 5-HT3 receptors. With this receptor profile, it is possible that mirtazapine could provide both anxiolysis and efficacy for postoperative nausea and vomiting (PONV). We therefore tested the hypothesis that premedication with mirtazapine can reduce preoperative anxiety and PONV. METHODS: Eighty female patients with at least two PONV risk factors scheduled for gynecological surgery were enrolled. Dexamethasone 8 mg was given before induction of anesthesia and patients were randomly assigned to group M + D (mirtazapine plus dexamethasone) or group dexamethasone. An oral disintegrating mirtazapine 30 mg or placebo tablet was given 1 h before surgery. Preoperative anxiety level was assessed by a visual analog scale (VAS) before mirtazapine administration and 1 h thereafter. General anesthesia was induced with 1% propofol at the rate of 200 mL/h (until loss of consciousness) and was then maintained with sevoflurane in oxygen and air. An auditory evoked potentials index monitor was used to titrate sevoflurane. The incidence of PONV, the use of rescue antiemetic, complete response, postoperative Ramsay Sedation Scores, and VAS pain scores were assessed 1, 2, and 24 h after surgery and compared. RESULTS: The VAS anxiety scale was lower in group M + D after mirtazapine administration. There were no differences in the induction dose of propofol, the concentrations of sevoflurane during anesthesia, and recovery times between the two groups. The incidence of complete response to PONV over 0-24 h was lower in group M + D (80% vs 50%, P < 0.01). CONCLUSIONS: Premedication with mirtazapine 30 mg reduces the level of preoperative anxiety and the risk of PONV in moderate and high-risk female patients.

                                                         

在神经性疼痛大鼠模型中的作用时间延长了的硬膜外腔罗哌卡因的镇痛效果

The Prolonged Analgesic Effect of Epidural Ropivacaine in a Rat Model of Neuropathic Pain

Chiyo Sato, Atsushi Sakai, Yumiko Ikeda, Hidenori Suzuki, and Atsuhiro Sakamoto

Department of Pharmacology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.

Anesth Analg. 2008 Jan;106(1):313-20

 

背景:在临床实践中,治疗慢性疼痛时,硬膜外腔给予局部麻醉药的镇痛作用的持续时间有时会长于根据药物代谢动力学所推断的持续时间。为了研究这延长的作用时间的潜在机制,我们研究罗哌卡因(一种局部麻醉药)对于神经性疼痛大鼠模型的疼痛相关行为的作用。我们同时也分析神经生长因子(NGF)的表达。NGF和神经损伤后的伤害性回路的可塑性有关。方法:在坐骨神经慢性缩窄性损伤(CCI)所导致神经性疼痛的大鼠模型中,术后3天可以观察到热痛觉增敏和异常的机械性疼痛。CCI术后7-13天,经由硬膜外导管给与罗哌卡因或者生理盐水,每天一次。用酶免疫测定法测定L4背侧根神经结、皮肤、L4/5脊髓背侧和坐骨神经的NGF含量。结果:在开始罗哌卡因治疗后的4天,患CCI大鼠的同侧掌垫从热刺激物上缩回的时间点明显延长,同时热痛觉增敏也被很完全的缓解。同样的,经罗哌卡因治疗后,异常的机械性疼痛也得到部分程度的缓解。经罗哌卡因治疗后的CCI大鼠,NGF浓度在同侧L4背侧根神经结是增加的,不包括对侧的L4背侧根神经结。结论:对于CCI大鼠,在硬膜外腔重复给与罗哌卡因能发挥镇痛作用,可能是由于诱导伤害性回路的改变所致。

(周时蓓译,薛张纲校)

BACKGROUND: In clinical practice, the analgesic effects of epidurally administered local anesthetics on chronic pain sometimes outlast the duration of drug action expected from their pharmacokinetics. To investigate the underlying mechanisms of this prolonged effect, we examined the effects of ropivacaine, a local anesthetic, on pain-related behavior in a rat model of neuropathic pain. We also analyzed changes in the expression of nerve growth factor (NGF), which is involved in plasticity of the nociceptive circuit after nerve injury. METHODS: In a rat model of neuropathic pain produced by chronic constrictive injury (CCI) of the sciatic nerve, thermal hyperalgesia, and mechanical allodynia were observed from Day 3 after surgery. Ropivacaine or saline was administered through an epidural catheter once a day, every day, and from Days 7-13 after the CCI operation. NGF content was measured in the L4 dorsal root ganglion, the hindpaw skin, the L4/5 dorsal spinal cord, and the sciatic nerve, using enzyme immunoassay. RESULTS: The latency to withdrawal from thermal stimuli on the ipsilateral paw pads of CCI rats was significantly increased 4 days after the beginning of ropivacaine treatment, and thermal hyperalgesia was almost fully relieved. Similarly, mechanical allodynia was partially reduced after ropivacaine treatment. NGF content was increased in the L4 dorsal root ganglion on the ipsilateral, but not the contralateral, side, in CCI rats treated with ropivacaine. CONCLUSION: Repetitive administration of ropivacaine into the epidural space in CCI rats exerts an analgesic effect, possibly by inducing a plastic change in the nociceptive circuit.

 

长期硬膜外输注罗哌卡因对CYP2D6活性的影响

The effect of a long term epidural infusion of ropivacaine on CYP2D6 activity.

Wink J, Veering BT, Kruit M, Burm AG, Huledal GA, Ekström GY, Stienstra R, van Kleef JW.

Department of Anesthesiology, Leiden University Medical Centre, Leiden, The Netherlands.

Anesth Analg. 2008 106(1):143-6, table of contents.

 

背景:罗哌卡因及其产物哌啶甲酰胺(pipecoloxylidide)在离体状态下抑制人的肝微粒体酶CYP2D6,抑制常数K(i)分别为5microM1.4mg/L)和13microM3.6mg/L)。我们研究了硬膜外连续输注罗哌卡因(浓度2mg/mL,以14mL/h的速度输注50h)对CYP2D6活性的影响。方法:选取19名行髋或膝置换术的病人(41-85岁),均为CYP2D6酶的强代谢者。不允许使用已知抑制CYP2D6活性或被其代谢的药物、或者已知CYP1A2CYP3A4的强抑制剂/诱导剂。术前及硬膜外给药40h后,给予患者10mg异喹胍(CYP2D6活性标志物)。异喹胍的羟化代谢率(MR)由计算0-10h尿中排出的异喹胍/4-OH-异喹胍比值得出。结果:罗哌卡因输注前后MR的中位数(范围)分别为0.540.1-3.4)和1.790.3-6.7)。Hodges Lehman估计输注后MR/输注前MR2.295%可信区间为1.9-2.7P<0.001)。结论连续硬膜外输注罗哌卡因抑制强代谢者的CYP2D6酶活性,使异喹胍羟化代谢率升高两倍。然而,由于无一例患者被转化为功能性的弱代谢者(MR>12.6),这种影响对其他通过CYP2D6酶途径药物代谢的临床意义可能不大。

(罗 璇译 薛张纲校)

BACKGROUND: Ropivacaine and one of its metabolites, pipecoloxylidide, inhibit CYP2D6 in. human liver microsomes in vitro with K(i) values of 5 microM (1.4 mg/L) and 13 microM (3.6 mg/L), respectively. We investigated the effect of a 50 h continuous epidural infusion of ropivacaine 2 mg/mL at a rate of 14 mL/h on CYP2D6 activity. METHODS: Nineteen patients (41-85 yr) undergoing hip or knee replacement, all extensive metabolizers with respect to CYP2D6 activity, were included. Medications known to inhibit or be metabolized by CYP2D6, or known to be strong inhibitors/inducers of CYP1A2 or CYP3A4 were not allowed. Patients received 10 mg debrisoquine (a marker for CYP2D6 activity) before surgery and after 40 h epidural infusion. The metabolic ratio (MR) for debrisoquine hydroxylation was calculated as the amount of debrisoquine/amount of 4-OH-debrisoquine excreted in 0-10 h urine. RESULTS: The median (range) of MR before and after ropivacaine were 0.54 (0.1-3.4) and 1.79 (0.3-6.7), respectively. The Hodges Lehman estimate of the ratio MR after/MR before ropivacaine was 2.2 with a 95% confidence interval 1.9-2.7 (P < 0.001). CONCLUSION: A continuous epidural infusion of ropivacaine inhibits CYP2D6 activity in patients who are extensive metabolizers resulting in a twofold increase in the MR for debrisoquine hydroxylation. However, since none of the patients was converted into a functional poor metabolizer (MR >12.6), the effect on the metabolism of other drugs metabolized by CYP2D6 is unlikely to be of major clinical importance.

 

大鼠心肺分流术中使用全氟碳:与炎性所致不良后果有关?

Perfluorocarbon Administration During Cardiopulmonary Bypass in Rats: An Inflammatory Link to Adverse Outcome?

Fellery de Lange, Kenji Yoshitani, Alan D. Proia, MD, G. Burkhard Mackensen, Hilary P. Grocott

From the *Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; †Department of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; and ‡Department of Pathology, Duke University Medical Center, Durham, North Carolina.

(Anesth Analg 2008;106:24 –31)

 

背景:全氟碳(PFC)乳剂是一种人工氧载体,被证明可以减弱空气栓塞的效应。心肺分流术(CBP)中发生的脑血管空气栓塞可能导致心脏术后脑功能的不良结局。我们设计了这个试验来评估60%全氟碳乳剂(PTBCH)对大鼠心肺分流术后炎症的反应及神经认知功能结局的影响。

方法:经历60分钟心肺分流的28只大鼠被随机分成两个组:PTBCH心肺分流组接受3 mL/kgPTBCH加入静脉贮血器而对照心肺分流组接受3 mL/kg的生理盐水。在几个时间点测量细胞因子白细胞介素(IL)-1ßIL-6IL-10以及肿瘤坏死因子(TNF)-a。神经功能的测试原定在术后使用Morris水迷宫试验。组织学样本在一系列独立的试验中取得。

结果:生理学变量在两组间是可比较的,但与对照组相比,PTBCH心肺分流组需要更多新福林。在行心肺分流后的2小时及4小时,PTBCH组的细胞因子水平明显高于对照组(P 0.05)。因为在PTBCH组中无一样本存活,所以神经功能认知结局的评估无法进行。心肌组织学的分析显示在PTBCH分流组存在更多收缩带坏死的区域(P=0.034)

结论:在心肺分流中使用PTBCH与过度分泌细胞因子存在关联。这种增强的炎性反应及后继的低血压可能导致了大鼠接受PTBCH后死亡率的增加。观察到的此种心肌损伤的模式揭示了一种通用的血流灌注不足和儿茶酚胺过剩。

(吴威译,薛张纲校)

BACKGROUND: Perfluorocarbon (PFC) emulsions are artificial oxygen carriers that have been shown to attenuate the effects of air embolism. Cerebral air embolism, known to occur during cardiopulmonary bypass (CPB), may contribute to adverse cerebral outcomes after cardiac surgery. We designed this study to evaluate the effect of a 60% PFC emulsion (perfluoro-tert-butylcyclohexane; PTBCH) on the inflammatory response and neurocognitive outcome of rats after CPB.

METHODS: Twenty-eight Sprague Dawley rats subjected to 60 min of CPB were randomly divided into two groups: PTBCH CPB animals receiving 3 mL/kg of PTBCH into the venous reservoir and control CPB animals receiving 3 mL/kg of 0.9% saline. At several time points, the cytokines interleukin (IL)-1_, IL-6, IL-10, and tumor necrosis factor (TNF)-_ were measured. Neurocognitive testing was planned postoperatively using the Morris water maze. Histologic samples were obtained in a separate series of experiments.RESULTS: Physiologic variables were comparable between groups, but the PTBCHCPB animals required more phenylephrine compared with the controls. Cytokinelevels in the PTBCH CPB group were significantly higher than in the control groupat 2 and 4 h after CPB (P _ 0.05). Neurocognitive outcome could not be evaluatedas none of the animals in the PTBCH CPB group survived. Myocardial histologicalanalysis revealed increased areas of contraction band necrosis in the PTBCH CPBanimals (P _ 0.034).CONCLUSIONS: Administration of PTBCH during CPB was associated with an excessive release of cytokines. This enhanced inflammatory response with subsequent hypotension may have contributed to mortality in rats receiving PTBCH. The observed patterns of myocardial injury indicate global hypoperfusion and catecholamineexcess.

 

全膝成形术后小剂量罗哌卡因和芬太尼混合液中加入4mcg/ml的肾上腺素行腰段硬膜外镇痛

Epinephrine 4 mcg/mL Added to a Low-Dose Mixture of Ropivacaine and Fentanyl for Lumbar Epidural Analgesia After Total Knee Arthroplasty

Johannes G. Forster, Hilkka M. Lumme, Vilja J. Palkama, Per H. Rosenberg, and Mikko T. Pitkanen

Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Hospital, Haartmaninkatu 4, PO Box 340,00029 Helsinki, Finland;

Anesth Analg 2008;106:301–4

 

背景:研究已经发现在局麻药和阿片类药物的混合液中加入肾上腺素可以加强胸段硬膜外术后持续镇痛的效果,但是在腰段水平还没有证实。所以,我们研究了是否更高浓度的肾上腺素可以有加强腰段硬膜外的镇痛效果。方法:在行全膝置换的病人术后2天中给予腰段硬膜外镇痛,罗哌卡因1.8 mg/ml 以及芬太尼3mcg/ml,不加肾上腺素(组RFn=32)或者是加入肾上腺素4mcg/ml(组RFEn=31)。补救的镇痛药物包括硬膜外的研究混合液以及肠外给予羟考酮。结果:硬膜外药物的总量在RFE组中明显得较多。另外,该组中发生疼痛与不良反应与其他组没有明显区别。结论:作为多模式疼痛治疗的一部分,全膝成形术后,添加肾上腺素4mcg/ml(12-32mcg/h)对腰段硬膜外镇痛并无太大的加强作用。

(张俪译 薛张纲校)

BACKGROUND: Epinephrine 2mcgg/mL added to local anesthetic-opioid mixture has been found to improve postoperative continuous epidural analgesia at the thoracic (TEA) but not at lumbar (LEA) level. Therefore, we studied whether higher dose of epinephrine could improve LEA. METHODS: Patients received LEA comprising of ropivacaine 1.8 mg/mL and

fentanyl g/mL either without (group RF, 32) or with epinephrine g/mL (group RFE, 31)for 2 days after total knee arthroplasty. Rescue pain medication consisted of epidural top-ups (study mixture) and parenteral oxycodone. RESULTS: Total amounts of epidurally administered drugs were significantly higher in group RFE. Otherwise, the groups did not differ significantly regarding pain relief and side effects. CONCLUSIONS: As part of the multimodal pain treatment used, the epidural adjuvant epinephrine 4mcg/mL (12–32 mcg/h) did not improve LEA after total knee arthroplasty.

 

一项对于脑血流速率通过自发性波动产生动态自身调节的评估:对自身调节指数及平均流速指数这两个模型的比较

An Assessment of Dynamic Autoregulation from Spontaneous Fluctuations of Cerebral Blood Flow Velocity: A Comparison of Two Models, Index of Autoregulation and Mean Flow Index

Marek Czosnyka,  Piotr Smielewski, Andrea Lavinio, John D. Pickard, FMedSci Ronney Panerai

From the *Academic Neurosurgical Unit, Addenbrooke’s Hospital, Cambridge, UK; and Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.

(Anesth Analg 2008;106:234 –9)

 

背景:在临床实践中,各种方法包括:血流速度的自发性缓慢波动,动脉血压,脑灌注压等被用来评估脑血流自身调节。我们在一组头部外伤的病人中研究自身调节的动态指数以及时间相关指数(平均流速指数)之间的关联。

方法:被研究的50例头部外伤病人,平均年龄30岁,其中有镇静用药的,瘫痪的,机械通气的(轻度过度通气),采用连续监测动脉血压及颅内压。在头部受创后的3天,每天监测一次脑血流速度,选在不进行干预治疗(如吸痰)的时段。对记录得到的数据进行回顾性分析。为了描述自身调节的动态模型,将自身调节计算成一个系数,分为0级(没有自身调节)到9级(最强烈的自身调节)。平均流速指数被计算成一个血流速度在40个相邻的6秒中的平均数及脑灌注压的相关系数,然后在整个记录时段内进行平均计算。将每个病人在受伤后头3天记录到的自身调节指数及平均流速指数进行平均化。

结果:自身调节指数和平均流速指数显示了中等程度相关的线性关系,r0.62 P 0.0001。两项指数在结局不佳的病人中显示出预示预后及更坏的自身调节的一定关联。结论:自身调节指数及平均流速指数在头部外伤病人中契合的较好。自身调节影响头部外伤后的预后。

(孙霞译,薛张纲校)

                                                        BACKGROUND: Various methods of assessment of cerebral autoregulation, using

spontaneous slow fluctuations of blood flow velocity (FV), arterial blood pressure,

and cerebral perfusion pressure, have been used in clinical practice. We studied the association between the dynamic index of autoregulation (ARI) and time correlation index (mean flow index, Mx) in a group of patients after head injury.

METHODS: Fifty head-injured patients of an average age of 31 yr, sedated, paralyzed,and ventilated (mild hypocapnia) with continuous monitoring of arterial bloodpressure and intracranial pressure were studied. Cerebral blood FV was monitoreddaily for 3 days after injury during periods that were free from interventions (e.g.,suctioning).Digitally recorded data were analyzed retrospectively. ARI was calculated as a coefficient graded from 0 (absence of autoregulation) to 9 (strongest autoregulation),describing a dynamic model of autoregulation. Mx was calculated as the correlation coefficient between 40 consecutive 6-s averages of FV and cerebral

perfusion pressure and then averaged over the whole recording period. ARI and

Mx values, assessed during the first 3 days after injury, were averaged for each

patient.RESULTS: ARI and Mx showed moderately strong mutual linear relationship withcorrelation r__0.62; P _ 0.0001. Both indices correlated with outcome, indicating

worse autoregulation in patients achieving unfavorable outcome.

CONCLUSION: ARI and Mx agree relatively well in head-injured patients. Autoregulation affects outcome after head injury.

 

异氟烷预处理在大鼠梗死后重构心脏中保持抗缺血再灌注损伤的保护作用

Preconditioning by Isoflurane Retains Its Protection Against Ischemia-Reperfusion Injury in Postinfarct Remodeled Rat Hearts

Eliana Lucchinetti, PhD*, Marina Jamnicki, MD*, Gregor Fischer, DVM{dagger}, and Michael Zaugg, MD*

From the *Institute of Anesthesiology, University Hospital Zurich; and {dagger}Institute of Laboratory Animal Science, University of Zurich, Zurich, Switzerland.

Anesth Analg 2008; 106:17-23

背景:心脏梗死后的重构可能会影响保护信号系统。我们验证了异氟烷预处理在梗死后重构心脏中是否仍然保持保护作用。方法:通过结扎雄性Wistar大鼠冠脉的左前降支诱导心肌重构。6周后,病变的心脏被置于Langendorff装置上行40min缺血加上90min的再灌注。1.5MAC2.1vol%)的异氟烷预处理15min。使用1%氯化三苯四唑染色测定梗死面积并通过测定释放入灌流液中的乳酸脱氢酶(LDH)予以确证。一部分实验中,在给予异氟烷的同时分别加入蛋白激酶B和线粒体ATP依赖性钾通道的抑制剂LY29400210 µM)或5-羟基癸酸盐(100 µM)。记录心脏的功能。结果:冠脉永久结扎6周后,梗死大鼠的心脏重量/体重指数明显增加(5.41 ± 0.64 vs 3.60 ± 0.59 g/kg, P < 0.0001),确定心脏重构伴代偿性心肌肥厚。异氟烷预处理减少LDH释放且梗死面积从32% ± 6%缩小到2% ± 2% P < 0.0001)。异氟烷合用LY2940025-羟基癸酸盐完全取消了这种保护作用。功能评估也显示重构心脏中异氟烷预处理对缺血后心肌顿抑有明显保护作用,而两种阻断剂使用后均取消此作用。结论:在梗死后重构的大鼠心脏上,异氟烷预处理仍保持对缺血再灌注损伤的保护作用,其信号途径与先前报道的在健康大鼠心脏上的相似。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: Postinfarct remodeling in the heart may affect protective signaling. We tested whether isoflurane preconditioning retains its protection in postinfarct remodeled hearts.

METHODS: Myocardial remodeling was induced by ligation of the left anterior descending coronary artery in male Wistar rats. Six weeks later, diseased hearts were mounted on a Langendorff apparatus and exposed to 40 min of ischemia followed by 90 min of reperfusion. Isoflurane preconditioning was induced with 1.5 MAC (2.1 vol%) isoflurane for 15 min. Infarct size was determined using 1% triphenyltetrazolium chloride staining and corroborated with measurements of lactate dehydrogenase (LDH) release into the perfusate. In some experiments, the protein kinase B and mitochondrial ATP-dependent potassium channel inhibitors LY294002 (10 µM) or 5-hydroxydecanoate (100 µM), respectively, were concomitantly added with isoflurane. Cardiac function was recorded.

RESULTS: Six weeks after permanent coronary artery ligation, infarct rats exhibited a markedly increased heart weight/body weight index (5.41 ± 0.64 vs 3.60 ± 0.59 g/kg, P < 0.0001) confirming remodeling with compensatory hypertrophy. Isoflurane preconditioning decreased LDH release and reduced infarct size from 32% ± 6% to 2% ± 2% (P < 0.0001). Concomitant administration of LY294002 or 5-hydroxydecanoate with isoflurane completely abolished this protection. Functional assessment also showed significant protection from postischemic stunning by isoflurane preconditioning in remodeled hearts, which was lost in the presence of both blockers.

CONCLUSIONS: Myocardial preconditioning with isoflurane retains its protection against ischemia/reperfusion injury in postinfarct remodeled rat hearts via similar signaling pathways, as previously reported in healthy hearts.

 

经静脉心内超声心动图在监测静脉空气栓塞和导管指导下空气吸出中,优于心前区多普乐和经食道超声心动图技术

Intracardiac Transvenous Echocardiography Is Superior to Both Precordial Doppler and Transesophageal Echocardiography Techniques for Detecting Venous Air Embolism and Catheter-Guided Air Aspiration

Simon T. Schäfer, MD*, Jochen Lindemann*, Peter Brendt, MD*, Gernot Kaiser, MD*{dagger}, and Jürgen Peters, MD*

From the *Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen and Universitätsklinikum Essen; and {dagger}Klinik für Transplantations-und Allgemeinchirurgie, Universität Duisburg-Essen and Universitätsklinikum Essen, Essen, Deutschland, Germany.

Anesth Analg 2008; 106:45-54

背景:静脉空气栓塞(VAE)是坐位病人手术期间一种潜在的致命的并发症。因为用来发现持续性低容量VAE和定向吸气的方法很有限,我们试验了下列假设:经静脉心脏内超声心动图(ICE1)与经食道超声心动图(TEE)和心前区多普勒监测(PCD)技术相比,改善小量空气栓塞的发现,2)与在静态位用多孔中心静脉导管吸引相比,图象指导的多孔中心静脉导管操作改善了在中等和大量VAE时的空气恢复。方法和结果:成年猪(73 ± 4.6 kg, n = 7)术前给药,用异丙酚和芬太尼麻醉,气管内插管,机械通气,放置头高45度体位。第一,9个不同的小量空气栓塞(0.05–1 mL)随机通过耳静脉注射,以随机次序应用VAE发现方法。对于378个小量空气注射,与TEE (52.8%)PCD (46.8%)相比,ICE发现VAE有较高的敏感性(82.5%, P < 0.0001),而在TEEPCD之间无差异(P = 0.571)ICE对于与0.15 mL一样小的注射空气容量的发现率为90%,而PCDTEE对于0.25–0.30 mL的空气注射量的发现率仅50%,且空气容量需要达到0.4–1.0 mL,发现率才能达到100%。第二系列研究中,评估中等VAE(2, 5, 10 mL)的空气恢复;图象指导下吸气导管操作的心内空气恢复明显(34.1%17.2%, P < 0.0001)优于没有导管操作。第三系列研究中,注射大剂量空气(25, 50, and 100 mL),空气恢复在超声指导下吸气没有明显差异(41.3%31.8%, P = 0.11)

结论:与PCDTEE相比,通过ICE发现小量空气栓塞的敏感性高得多。而且,栓塞空气的恢复可通过图象指导下多孔中心静脉导管的操作来增强效果。需要临床研究来评估这一技术在坐位病人手术期间的应用。

(彭中美   马皓琳 李士通  校)

BACKGROUND: Venous air embolism (VAE) is a potentially fatal complication during surgical procedures with patients in the sitting position. Since methods for detection of persistent low-volume VAE and targeted air aspiration are limited, we tested the hypotheses that transvenous intracardiac echocardiography (ICE) 1) improves detection of small air emboli in comparison to transesophageal echocardiography (TEE) and precordial Doppler monitoring (PCD) techniques, and that 2) image-guided multiorifice central venous catheter manipulation improves air recovery in moderate and large VAE, when compared with aspiration with the multiorifice central venous catheter in a static position.

METHODS AND RESULTS: Adult swine (73 ± 4.6 kg, n = 7) were premedicated, anesthetized with propofol and fentanyl, endotracheally intubated, mechanically ventilated, and placed in a 45° head-up position. First, nine different small volumes of air emboli (0.05–1 mL) were randomly injected via an ear vein, and VAE detection methods were applied in random order. For 378 small volume air injections, ICE had a much higher sensitivity (82.5%, P < 0.0001) on the analysis of VAE detection than TEE (52.8%) or PCD (46.8%), with no difference (P = 0.571) between TEE and PCD. An injected air volume as small as 0.15 mL was detected by ICE in 90% of injections performed, whereas PCD and TEE detected only half of the boluses of 0.25–0.30 mL of air, and required boluses of 0.4–1.0 mL to achieve 100% detection. Air recovery was assessed in a second series of moderate VAE (2, 5, 10 mL); image-guided aspiration-catheter manipulation recovered significantly more (34.1% vs 17.2%, P < 0.0001) intracardiac air than without catheter manipulation. In a third series of injections of large air volumes (25, 50, and 100 mL), air recovery was not significantly different with ultrasound-guided aspiration (41.3% vs 31.8%, P = 0.11).

CONCLUSION: Small air emboli are detected by ICE with much greater sensitivity compared with both PCD and TEE techniques. Furthermore, recovery of embolized air is enhanced by image-guided manipulation of a multiorifice central venous catheter. Clinical studies are required to assess this technique during surgery with patients in the sitting position.


术中高碳酸血症在儿科患者视频辅助下胸腔镜检查中的潜在治疗作用

The Therapeutic Potential of Intraoperative Hypercapnia During Video-Assisted Thoracoscopy in Pediatric Patients

Ahmed M. Mukhtar, MD*, Gihan M. Obayah, MD*, Ashraf Elmasry, MD*, and Nabil M. Dessouky, MD{dagger}

From the Departments of *Anesthesia and Intensive Care, and {dagger}Pediatric Surgery, Cairo University, Cairo, Egypt.

Anesth Analg 2008; 106:84-88

背景:二氧化碳充气对行胸腔镜检查术患儿的心血管作用目前还没有报道,但一些临床试验却已证实了它对成年患者血流动力学的显著不良影响。本实验拟观察治疗性高碳酸血症对诱发的二氧化碳气胸的血流动力学影响的抵消作用。方法:本实验选取了12例行视频辅助胸腔镜下动脉导管闭合术的儿科患者。记录基线(T1)以及在二氧化碳注气后压力为2mmHgT2)、4mmHgT3)、6mmHgT4)、8 mmHgT5)、10mmHgT6)时的心肺参数的。结果:二氧化碳充气并未造成任何血流动力学不良影响。在整个研究中的心排血量以及中心静脉氧饱和度进行性增高。与基线相比,峰流速、心率矫正后的收缩流动时间、心率和中心静脉压在注气时明显升高,而收缩压和舒张压保持不变。动脉血二氧化碳分压从T1时点的40.7 ± 3 增加到T6时点的61 ± 1.6 mm Hg。动脉血氧分压也从T1时点的170.9±3.3 增加到T6时点的182 ± 2mmHg。动脉血PH值从T1时点7.31 ± 1.2 下降到 T6时点7.14 ± 4.6 。结论:在视频辅助胸腔镜下行动脉导管封堵术的患者,单肺通气时控制二氧化碳分压在50-70mmHg的高二氧化碳血症可增加心排血量、中心静脉氧分压和动脉血氧分压,同时不合并心肺不良影响。

(邱郁薇 马皓琳 李士通 校)

 

BACKGROUND: Although the cardiovascular effect of CO2 insufflation has not been reported in pediatric thoracoscopy, several clinical trials have demonstrated significant hemodynamic deterioration in adults. We investigated the concept of therapeutic hypercapnia for counteracting the hemodynamic effect of induced capnothorax.

METHODS: Twelve pediatric patients who underwent video-assisted thoracoscopic patent ductus arteriosus closure were enrolled in the study. Cardiorespiratory variables were determined during baseline T1 and after CO2 insufflation at pressures of 2 mm Hg T2, 4 mm Hg T3, 6 mm Hg T4, 8 mm Hg T5, and 10 mm Hg T6.

RESULTS: CO2 insufflation was not associated with any adverse hemodynamic effects. Cardiac output and central venous oxygen saturation increased progressively throughout the study protocol. Relative to baseline peak velocity, systolic flow time corrected for heart rate, heart rate, and central venous pressure increased significantly during insufflation, but systolic and diastolic blood pressure remained unchanged. Arterial CO2 increased from 40.7 ± 3 at T1 to 61 ± 1.6 at T6 mm Hg. Arterial oxygen tension increased from 170.9 ± 3.3 at T1 to 182 ± 2 at T6; arterial PH decreased from 7.31 ± 1.2 at T1 to 7.14 ± 4.6 at T6.

CONCLUSION: Hypercapnia targeting CO2 50–70 mm Hg was associated with increased cardiac output, central venous O2, and arterial O2 tension in patients undergoing video-assisted thoracoscopic patent ductus arteriosus closure using one-lung ventilation without any deleterious cardiopulmonary effects.


在用地氟醚和芬太尼进行麻醉的门诊矫形手术中瑞芬太尼能否取代氧化亚氮?

Can Remifentanil Replace Nitrous Oxide During Anesthesia for Ambulatory Orthopedic Surgery with Desflurane and Fentanyl?

Donald M. Mathews, MD, Vijay Gaba, MD, Bledi Zaku, BS, and George G. Neuman, MD

From the Department of Anesthesiology, St. Vincent Catholic Medical Centers, St. Vincent’s Manhattan, and New York Medical College, Valhalla, New York.

Anesth Analg 2008; 106:101-108

背景运用氧化亚氮(N2O)时常有些毒副作用。瑞芬太尼与N2O有一些相同的特点,包括降低MAC、镇痛效果以及撤药后临床效应迅速减退。我们比较了用地氟醚和芬太尼加用临床等效量的N2O或瑞芬太尼进行麻醉的门诊矫形手术后的结果。方法:70名进行门诊矫形手术的患者作为研究对象。35名患者予以66%浓度的N2O,而另外35名予以0.085µg · kg–1 · min–1瑞芬太尼的输注,两组患者都加以地氟醚使脑电双频指数(BIS)值滴定到50,并且输注芬太尼。主要测量结果是到被言语刺激唤醒的时间。次要的结果指标包括神经心理测试、到有定向力的时间、血流动力学值、疼痛和恶心的视觉模拟评分、出院时间和满意度评分。测定呼气末地氟醚浓度和芬太尼效应部位浓度的平均值。结果:瑞芬太尼组到被言语刺激唤醒的时间中位数(四分位距)为3.0 min (3.0–5.0 min)N2O组为4.6 min (3.0–8.1 min),两组之间无显著性差异。瑞芬太尼组到有定向力的时间中位数6.0 min (5.0–8.5 min),明显比N2O组的8.0 min (5.0–12.8 min)快。两组给予的地氟醚和芬太尼的量、神经心理测试以及其他的测量结果均无显著性差异。

结论:这个研究证明了在地氟醚/芬太尼麻醉中0.085 µg · kg–1 · min–1瑞芬太尼输注可以取代66%浓度的N2O而没有明显的临床结果的改变。

(唐亮   马皓琳 李士通 校)

BACKGROUND: The administration of nitrous oxide (N2O) may be associated with side effects and toxicities. Remifentanil shares characteristics with N2O, including MAC-reducing and antinociceptive effects and a rapid decrease in clinical effect when discontinued. We compared the outcome after ambulatory orthopedic surgery with desflurane and fentanyl supplemented with clinically equivalent doses of either N2O or remifentanil.

METHODS: Seventy patients undergoing ambulatory orthopedic surgery were studied. Thirty-five received 66% N2O and 35 received remifentanil 0.085 µg · kg–1 · min–1 in addition to desflurane, titrated to a bispectral index (BIS) value of 50, and a fentanyl infusion. The principle outcome measure was time to awakening to verbal stimulation. Secondary outcome measures included neuropsychological testing, time to orientation, hemodynamic values, pain and nausea visual analog scores, discharge times, and satisfaction scores. The average end-tidal desflurane concentration and fentanyl effect-site concentration were determined.

RESULTS: The median time (interquartile range) to awakening to verbal stimulation, 3.0 min (3.0–5.0 min) in the remifentanil group and 4.6 min (3.0–8.1 min) in the N2O group was not significantly different. Median time to orientation was significantly faster in the remifentanil group: 6.0 min (5.0–8.5 min) compared with 8.0 min (5.0–12.8 min) for the N2O group. There was no difference between groups in desflurane or fentanyl administration, neuropsychological testing, or any other outcome measure.

CONCLUSIONS: This study demonstrates that a remifentanil infusion of 0.085 µg · kg–1 · min–1 may be substituted for 66% N2O during desflurane/fentanyl anesthesia without any clinically significant change in outcome.

 

氯胺酮治疗术后寒战的效能

The Efficacy of Ketamine for the Treatment of Postoperative Shivering

Emine Arzu Kose, MD, Didem Dal, MD, Seda Banu Akinci, MD, Fatma Saricaoglu, MD, and Ulku Aypar, MD

From the Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey.

Anesth Analg 2008; 106:120-122

背景:关于氯胺酮在预防术后寒战方面应用的报道很少。因此,我们把两种剂量的氯胺酮在治疗术后寒战方面的效能与哌替定做了比较。方法:这是一个前瞻性的随机双盲研究,研究的对象是90ASA 评分I–II级的全麻后病人。寒战评分34级的病人分成3组,分别静脉注入哌替啶25mg、氯胺酮0.5mg/kg或氯胺酮0.75mg/kg。在设定的时间间隔里监测寒战和药物的副作用。结果:氯胺酮组治疗后的首个4分钟里的寒战分级比哌替啶组低。然而,在两个不同剂量的氯胺酮组中病人均出现眼球震颤并有飘走在空中的感觉。

结论氯胺酮0.5–0.75 mg/kg比哌替啶25mg在减少术后寒战方面起效更快,但副作用可能会限制其有用性。

(吴进   马皓琳 李士通 校)

BACKGROUND: There are few reports on the utility of ketamine for the prevention of postoperative shivering. We thus established the efficacy of two doses of ketamine compared with meperidine for the treatment of postoperative shivering.

METHODS: This is a prospective, randomized double-blind study involving 90 ASA I–II patients after general anesthesia. Patients with shivering grade 3–4 were allocated to receive either meperidine 25 mg, ketamine 0.5 mg/kg, or ketamine 0.75 mg/kg IV. Shivering and side effects were monitored at set time intervals.

RESULTS: Shivering grades for the first 4 min after treatment were lower in the ketamine groups; however, nystagmus and feeling like "walking in space" was experienced with both doses of ketamine.

CONCLUSION: Ketamine 0.5–0.75 mg/kg is more rapid than meperidine (25 mg) for the reduction of postoperative shivering, but the side effect profile may limit its usefulness.

 

饲养的大鼠在血流动力学相似及没有重大手术应激时麻醉对血浆葡萄糖和胰岛素浓度以及心肌己糖激酶的影响

Anesthesia's Effects on Plasma Glucose and Insulin and Cardiac Hexokinase at Similar Hemodynamics and Without Major Surgical Stress in Fed Rats

Coert J. Zuurbier, PhD, Peter J. M. Keijzers, MD, Anneke Koeman, Harry B. Van Wezel, PhD, MD, and Markus W. Hollmann, PhD, MD

From the Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Anesth Analg 2008; 106:135-142

背景:近来的证据表明己糖激酶线粒体联合体减弱细胞死亡,且血浆葡萄糖和胰岛素浓度能够影响临床转归。在本研究中,我们检验了在血流动力学相似且无重大手术应激状态下不同麻醉药自身如何影响这些糖代谢变量。方法:测定戊巴比妥(PENTO)、异氟烷(ISO)、七氟烷(SEVO)、氯胺酮-美托咪定-阿托品(KMA)和苏芬太尼-丙泊酚-吗啡(SPM)麻醉下人工饲养大鼠心肌细胞己糖激酶定位和血浆葡萄糖及胰岛素浓度,并将之与未麻醉大鼠(对照)的对应参数作对比。还检测了肌纤维膜和线粒体KATP通道和α2肾上腺能受体在ISO诱发的高糖血症中的作用。结果:不同麻醉药物下平均动脉压相似。与对照动物(5.6 ± 0.1 mM)相比,PENTO(5.3 ± 0.2 mM) SPM (5.1 ± 0.2 mM)对血糖浓度没有显著影响。其他所有麻醉药均导致高血糖症:7.4 ± 0.2 mM (SEVO), 9.9 ± 0.3 mM (ISO), and 14.8 ± 1.0 mM (KMA)。与对照(0.59 ± 0.22 ng/mL)相比,PENTO使胰岛素浓度升高(2.13 ± 0.13 ng/mL),但其他麻醉药不影响。使用5-羟基葵酸(5-hydroxydecanoate acid)抑制线粒体KATP通道或使用育亨宾抑制α2肾上腺能受体均不能防止ISO导致的高血糖。只有非选择性的KATP通道抑制剂格列本脲能预防ISO导致的高血糖。不同药物导致的胞浆HK相对总HK比例增加的顺序是:对照 (35.5% ± 2.1%), SEVO (35.5% ± 2.7%), ISO (36.6% ± 1.7%), PENTO (41.2% ± 2.0%; P = 0.082与对照相比), SPM (43.0% ± 1.8%;与对照相比P = 0.039), and KMA (46.6 ± 2.3%;与对照相比P = 0.002)。结论挥发性麻醉药和KMA导致的高血糖至少可以部分解释为抑制葡萄糖诱发的胰岛素释放。本数据表明ISO对胰岛素释放的抑制是由肌膜KATP通道激活介导的。使用PENTOSPM与高血糖无关,SPMKMA减低HK和线粒体结合所产生的抗凋亡作用。

(颜涛 译,马皓琳 李士通 校)

BACKGROUND: Recent evidence suggests that hexokinase mitochondria association attenuates cell death, and that plasma glucose and insulin concentrations can influence clinical outcome. In the present study, we examined how different anesthetics per se affect these variables of glucose metabolism, i.e., under similar hemodynamic conditions and in the absence of major surgical stress.

METHODS: In fed rats, the effects of pentobarbital (PENTO), isoflurane (ISO), sevoflurane (SEVO), ketamine-medetomidine-atropine (KMA), and sufentanil-propofol-morphine (SPM) on the cardiac cellular localization of hexokinase (HK) and levels of plasma glucose and insulin were determined and compared with values obtained in nonanesthetized animals (control). The role of mitochondrial and sarcolemmal KATP-channels and {alpha}2-adrenergic receptor in ISO-induced hyperglycemia was also evaluated.

RESULTS: Mean arterial blood pressure was similar among the different anesthetic strategies. PENTO (5.3 ± 0.2 mM) and SPM (5.1 ± 0.2 mM) had no significant effect on plasma glucose when compared with control (5.6 ± 0.1 mM). All other anesthetics induced hyperglycemia: 7.4 ± 0.2 mM (SEVO), 9.9 ± 0.3 mM (ISO), and 14.8 ± 1.0 mM (KMA). Insulin concentrations were increased with PENTO (2.13 ± 0.13 ng/mL) when compared with control (0.59 ± 0.22 ng/mL), but were unaffected by the other anesthetics. Inhibition of the mitochondrial KATP channel (5-hydroxydecanoate acid) or the {alpha}2-adrenergic receptor (yohimbine) did not prevent ISO-induced hyperglycemia. Only the nonspecific KATP channel inhibitor glibenclamide was able to prevent hyperglycemia by ISO. Cytoslic HK relative to total HK increased in the following sequence: control (35.5% ± 2.1%), SEVO (35.5% ± 2.7%), ISO (36.6% ± 1.7%), PENTO (41.2% ± 2.0%; P = 0.082 versus control), SPM (43.0% ± 1.8%; P = 0.039 versus control), and KMA (46.6 ± 2.3%; P = 0.002 versus control).

CONCLUSIONS: Volatile anesthetics and KMA induce hyperglycemia, which can be explained, at least partly, by impaired glucose-induced insulin release. The data indicate that the inhibition of insulin release by ISO is mediated by sarcolemmal KATP channel activation. The use of PENTO and SPM is not associated with hyperglycemia. SPM and KMA reduce the antiapoptotic association of HK with mitochondria.


 

术中持续血糖监测的精确性

The Accuracy of a Continuous Blood Glucose Monitor During Surgery

Koichi Yamashita, MD, PhD*, Takehiro Okabayashi, MD, PhD{dagger}, Takeshi Yokoyama, DDS, PhD*, Tomoaki Yatabe, MD*, Hiromichi Maeda, MD{dagger}, Masanobu Manabe, MD, PhD*, and Kazuhiro Hanazaki, MD, PhD{dagger}

From the *Department of Anesthesiology and Critical Care Medicine; and {dagger}First Department of Surgery, Kochi Medical School, Kochi, Japan.

Anesth Analg 2008; 106:160-163

背景资料:在术中很难获得一套严密的血糖控制方案,尤其当我们依赖于间断的血糖测试时。持续的血糖监测系统能有利于血糖的控制。在本研究中,我们将术中持续监测的血糖(STG-22TM, Nikkiso, 日本东京)与用传统实验室血糖测量仪(ABLTM 800FLEX (Radiometer Medical Aps, BrFormula nshFormula j, 丹麦)间断测得的血糖作比较,以判断术中持续血糖监测法的可靠性及精确性。材料及方法:该研究纳入了29个择期在全麻下行常规手术的患者。全麻诱导后,在前臂外周静脉置入20G静脉套管针,并与持续血糖监测仪连接。置入桡动脉穿刺套管针,并由麻醉医生从这里收集血糖监测的标本。设定抽血方案:在抽取实际样本血之前,先清除3 mL血液。样本血抽取后立即用ABLTM 800FLEX检测血糖。获得100个配对的血糖值,并使用Bland and Altman分析法进行对比。结果:偏倚及一致性效度的上、下限分别为–2.623–28。一致性效度上、下限的百分误差分别为21%18%。讨论及结论:持续监测获得的血糖值与同时间断监测获得的血糖值有21%的一致性。STG-22TM将有助于持续观察改变及减少血糖间断监测的频率,但仍不可排除使用可靠设备进行血糖监测的需求。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Protocols for tight control of blood glucose can be difficult to achieve in the surgical setting, especially when relying upon intermittent blood glucose testing. A continuous blood glucose monitoring system can facilitate blood glucose management. In the present study, we compared blood glucose measured continuously (STG-22TM, Nikkiso, Tokyo, Japan), during surgery with coincident measurements obtained intermittently using a conventional laboratory glucometer (ABLTM 800FLEX (Radiometer Medical Aps, BrFormula nshFormula j, Denmark). The goal of the study was to determine the reliability and accuracy of the continuous method during surgery.

MATERIAL AND METHODS: Twenty-nine patients scheduled for routine surgery with general anesthesia were enrolled in this study. After anesthetic induction, a 20G IV catheter was inserted in a peripheral forearm vein and connected to the continuous blood glucose monitor. A radial arterial catheter was also inserted from which samples for blood glucose estimation were obtained by an anesthesiologist, following an established protocol of discarding 3 mL of blood before the actual blood sampling. Blood glucose was measured by ABLTM 800FLEX immediately after sampling. One hundred points of paired blood glucose values were obtained, which were compared using Bland and Altman analysis.

RESULTS: Bias and upper and lower limits of agreement were –2.6, 23, and –28, respectively. The percentage error of the lower/upper limits of agreement was 21% and 18%, respectively.

DISCUSSION AND CONCLUSIONS: The blood glucose measurements obtained continuously agreed with the coincident intermittent measurements within 21%. The STG-22TM may still be useful for following changes continuously and reducing the frequency of intermittent measurement, but the need for testing samples with a reliable device is not eliminated.


丹曲林在新生小鼠脑组织中对低氧-缺血损伤的作用

The Effects of Dantrolene on Hypoxic-Ischemic Injury in the Neonatal Rat Brain

Mijeung Gwak, MD, PhD*, Pyonghwan Park, MD, PhD*, Kisoo Kim, MD, PhD||, Keunho Lim, MS{dagger}, Sungmoon Jeong, MD, PhD*, Chongwha Baek, MD, PhD{ddagger}, and Jonghwan Lee, PhD§

From the *Department of Anesthesiology and Pain Medicine, ||Department of Pediatrics, Asan Medical Center, College of Medicine, Ulsan University; {dagger}NMR Laboratory, Asan Institute for Life Sciences; {ddagger}Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University; and §Department of Anatomy, College of Veterinary Medicine, Konkuk University, Seoul, South Korea.

Anesth Analg 2008; 106:227-233

背景资料:低氧或缺血引起的脑组织损害的病理生理学已被归于很多机制和级联。其已涉及细胞内钙超载以及钙兴奋性毒素级联。有证据表明内质网钙平衡奈乱与神经细胞损伤的诱发有关。两种细胞内钙释放通道(包括ryanodyne受体和肌醇(145)-三磷酸受体)对于细胞内Ca2+信号肽必不可少。已有报道用来治疗恶性高热综合征的丹曲林可以通过ryanodyne受体抑制钙从内质网释放到细胞溶质中。我们设计了这个实验以观察丹曲林在新生大鼠脑中对缺氧-缺血性脑损伤的神经保护作用。方法:7天大的SD大鼠分为两组;对照组(n=69)和丹曲林组(n=60)。在缺氧-缺血性脑损伤(HII)前对照组用二甲亚砜进行脑室内注射,丹曲林组在二甲亚砜中添加丹曲林进行脑室内注射。通过在异氟醚麻醉下结扎颈总动脉,然后产生2.5小时的低氧状态(氧浓度维持在7-8%)来诱发HII。在HII后一天进行1H磁共振波谱分析。用这种无创伤方法来评价HII后的脑细胞的凋亡过程。HII14天用235-氯化三苯四唑染色来进行组织形态学分析和计算梗塞范围的百分比,从而用来评价丹曲林对HII的作用。另外24只大鼠在HII后一天进行末端脱氧核苷酰基转移酶介导性dUTP切口末端标记(TUNEL)染色。结果:丹曲林组右半球脑组织中脂类/肌酸比值在HII后一天显著降低于对照组(P<0.05)。两组之间N-乙酰天门冬氨酸/肌酸比值没有明显差异。总体形态学评分丹曲林组低于对照组(P<0.05),丹曲林组HII14235-氯化三苯四唑染色后的梗塞面积(%)显著小于对照组(P<0.05)。但是在24只大鼠的进一步工作显示TUNEL阳性细胞数目在两组间没有显著差别。

结论:我们的结果提示在HII前脑室内给予丹曲林在新生大鼠脑的HII模型中可以起到神经保护作用。

(沈浩   马皓琳 李士通 校)

BACKGROUND: The pathophysiology of brain damage from hypoxia or ischemia has been ascribed to various mechanisms and cascades. Intracellular calcium overload and a calcium excitotoxic cascade have been implicated. It has been suggested that disturbances of endoplasmic reticulum calcium homeostasis are involved in the induction of neuronal cell injury. Two types of intracellular Ca2+-release channels, involving the ryanodyne receptor and the inositol (1,4,5)-triphosphate receptor, are essential for Ca2+ signaling in cells. Dantrolene, which is used for the treatment of malignant hyperthermia syndrome, has been reported to inhibit Ca2+ release through ryanodyne receptors from the endoplasmic reticulum into the cytosol. We designed this study to investigate the neuroprotective effects of dantrolene on hypoxic-ischemic brain damage in the neonatal rat brain.

METHODS: Seven-day-old Sprague-Dawley rats were assigned into two groups; control group (n = 69) and dantrolene group (n = 60). Dimethyl sulfoxide was administered intracerebroventricularly in the control group, and dantrolene in dimethyl sulfoxide was similarly administered to the dantrolene group, before hypoxic-ischemic brain injury (HII). HII was induced by the ligation of the common carotid artery under isoflurane anesthesia, followed by exposure to about 2.5 h of hypoxia (oxygen concentration was maintained at 7%-8%). 1H magnetic resonance spectroscopy was performed 1 day after HII. This noninvasive method evaluated apoptotic processes in the brain after HII. Morphologic score analyses and the calculated percentage of infarct areas after 2,3,5-triphenyltetrazolium chloride staining 14 days after HII were also used to evaluate the effects of dantrolene on HII. Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) staining was performed 1 day after HII using 24 more rats.

RESULTS: The lipid/creatine ratios in the right hemispheres in the dantrolene group 1 day after HII were significantly lower than those of the control group (P < 0.05). There was no significant difference between the two groups in the N-acetylaspartate/creatine ratios. The gross morphologic scores were lower in the dantrolene group than in the control group (P < 0.05), and infarct area (%) after 2,3,5-triphenyltetrazolium chloride staining was less in the dantrolene group than in the control group (P < 0.05) 14 days after HII. Further work with 24 rats showed no significant difference, however, in the number of TUNEL positive cells on the two groups.

CONCLUSIONS: Our results show that dantrolene, administered intracerebroventricularly before HII, had a neuroprotective effect in HII model of the neonatal rat brain.


下半身加温模仿正常硬膜外麻醉引起的寒战阈值的降低

Lower-Body Warming Mimics the Normal Epidural-Induced Reduction in the Shivering Threshold

Anthony G. Doufas, MD, PhD*, Nobutada Morioka, MD{dagger}, Adel N. Maghoub, MD{dagger}, Edward Mascha, PhD{ddagger}§, and Daniel I. Sessler, MD§

From the *Department of Anesthesia, Stanford University School of Medicine; {dagger}Outcomes Research Group, Department of Anesthesia and Perioperative Care, University of California, San Francisco; {ddagger}Department of Quantitative Health Sciences, and §Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2008; 106:252-256

背景:轴索麻醉降低寒战阈值约0.6°C。这种作用可能会被下半身温度的明显(与实际相反的)升高所介导。相应地,下半身的加温会引起与硬膜外麻醉的突出作用相同的温度调节的抑制。我们验证了这一假说,即增加腿的皮肤温度到38°C可以模仿硬膜外麻醉过程中寒战阈值降低{approx}0.6°C

方法:体内变冷过程中的寒战阈值由9名女性志愿者在不同的2天内测得:一天是没有麻醉的对照天,一天是在T10-11硬膜外阻滞的情况下。在进行研究的每一天,下半身的皮肤温度保持接近38°C,而上半身的皮肤温度接近33°C。我们应用两个单侧检验方法评价了对照天和硬膜外阻滞天寒战阈值的相等性。

结果:在对照天和硬膜外阻滞天的阈值分别是35.8°C ± 0.5°C35.8°C ± 0.5°C,这两个值是相等的,因为差异的95%可信区间为0.0 (–0.4, 0.4),在我们事先说明的范围–0.6°C +0.6°C 内(P < 0.025,单侧等价检验)。

结论:下半身加温模仿正常硬膜外麻醉引起的寒战阈值下降。我们的结果支持了以轴索麻醉中明显增加下半身体温为基础的机制。

(黄丽娜    马皓琳 李士通 校)

BACKGROUND: Neuraxial anesthesia reduces the shivering threshold {approx}0.6°C. This effect might be mediated by an apparent (as opposed to actual) increase in lower body temperature. Accordingly, sufficient lower body warming should result in thermoregulatory inhibition comparable to that exerted by epidural anesthesia. We tested the hypothesis that increasing leg skin temperature to 38°C mimics the normal {approx}0.6°C reduction in the shivering threshold during epidural anesthesia.

METHODS: Shivering threshold during internal body cooling was determined in nine female volunteers on two separate days: one unanesthetized control day, and one day with a T10-11 epidural block. On each study day, lower body skin temperature was maintained near 38°C and upper body skin temperature near 33°C. We assessed equivalency of the shivering thresholds on the control and epidural days using the two one-sided tests method.

RESULTS: The thresholds on the control (35.8°C ± 0.5°C; mean ± sd) and epidural (35.8°C ± 0.5°C) days were shown to be equivalent because the 95% CI for the difference in means, 0.0 (–0.4, 0.4), was within our prespecified limits of –0.6°C to +0.6°C (P < 0.025 for both one-sided equivalency tests).

CONCLUSIONS: Lower body warming mimics the normal epidural-induced reduction in the shivering threshold. Our results support a mechanism based on increased apparent lower body skin temperature during neuraxial anesthesia.


用皮肤表面温度来区分骨折后的复杂区域疼痛综合症1型患者和骨折后有多种主诉的对照组患者

Using Skin Surface Temperature to Differentiate Between Complex Regional Pain Syndrome Type 1 Patients After a Fracture and Control Patients with Various Complaints After a Fracture

Sjoerd P. Niehof, BSc*, Annemerle Beerthuizen, MSc{dagger}{ddagger}, Frank J. P. M. Huygen, MD, PhD*, and Freek J. Zijlstra, PhD{ddagger}

From the Departments of *Pain Treatment, {dagger}Medical Psychology and Psychotherapy, and {ddagger}Anesthesiology, Erasmus MC, University Medical Center, CA Rotterdam, The Netherlands.

Anesth Analg 2008; 106:270-277

目的:在这项研究中,我们评估了通过用于温度记录数据的各种计算方法得到的皮肤表面温度记录来诊断急性骨折后复杂区域疼痛综合症1型(CRPS1)患者的有效性。方法:记录CRPS1患者及和CRPS1患者有/无和无相似主诉的对照组骨折患者去除石膏后手掌/脚掌和相应背面的体表温度,一共三组120位患者。用受试者操作特征分析来比较应用于温度记录数据的各种计算方法以得到诊断价值的指证。结果:三组之间体温数据和特征间无显著性差异。三组间最大的差异为CRPS1患者的血管舒缩征象。CRPS 1患者受伤的一侧一般比另一侧未受伤肢更暖和。受伤部位与未受伤肢之间的温度差异在CRPS1 患者中与两个对照组明显不同。发现CRPS1患者的两侧肢体间的温度差异最大。三组患者手掌/脚掌侧和背侧间温度记录值的差异均不明显。用来计算肢体间温度差异的各种计算方法之间的特异性及敏感性显著不同。最高的敏感性和特异性分别为71%64%,最高阳性预测值为35%,最高阴性预测值为84%,曲线下面积中等区间为60%-65%。结论:用静息状态下皮肤表面温度来区分急性CRPS 1骨折患者和有/无主诉的对照组骨折患者的有效性有限,只能用作辅助性诊断工具。

(黄佳佳译,马皓琳,李士通校)

OBJECTIVE: In this study, we assessed the validity of skin surface temperature recordings, based on various calculation methods applied to the thermographic data, to diagnose acute complex regional pain syndrome type 1 (CRPS1) fracture patients.

METHODS: Thermographic recordings of the palmar/plantar side and dorsal side of both hands or feet were made on CRPS1 patients and in control fracture patients with/without and without complaints similar to CRPS1 (total in the three subgroups = 120) just after removal of plaster. Various calculation methods applied to the thermographic data were compared using receiver operating characteristics analysis to obtain indicators of diagnostic value.

RESULTS: There were no significant differences in demographic data and characteristics among the three subgroups. The most pronounced differences among the subgroups were vasomotor signs in the CRPS1 patients. The involved side in CRPS1 patients was often warmer compared with the noninvolved extremity. The difference in temperature between the involved site and the noninvolved extremity in CRPS1 patients significantly differed from the difference in temperature between the contralateral extremities of the two control groups. The largest temperature difference between extremities was found in CRPS1 patients. The difference in temperature recordings comparing the palmar/plantar and dorsal recording was not significant in any group. The sensitivity and specificity varied considerably between the various calculation methods used to calculate temperature difference between extremities. The highest level of sensitivity was 71% and the highest specificity was 64%; the highest positive predictive value reached a value of 35% and the highest negative predictive 84%, with a moderate 0.60 ≥area under the curve ≤0.65.

CONCLUSION: The validity of skin surface temperature recordings under resting conditions to discriminate between acute CRPS1 fracture patients and control fracture patients with/without complaints is limited, and only useful as a supplementary diagnostic tool.


一天两次口服90mg尼美舒利并不影响胸外科大手术后吗啡的需求量

Nimesulide 90 mg Orally Twice Daily Does Not Influence Postoperative Morphine Requirements After Major Chest Surgery

Donal F. Harney*{dagger}, Michelle Dooley*, Brendan Harhen*, Niall McGuiness{ddagger}, Gerard Cagney*, Connail McCrory{dagger}, Desmond J. Fitzgerald*, and Noreen P. Dowd{dagger}

From the *Department of Clinical Pharmacology, Royal College of Surgeons, {dagger}Department of Anaesthesia, St. James’s Hospital, Dublin, Ireland; and {ddagger}Independent Data Management, Cork, Ireland.

Anesth Analg 2008; 106:294-300
 

背景:已经证实抑制环氧化酶2可以在很多外科手术中起到镇痛功效。我们假设围术期抑制环氧化酶2可以显著减少胸外科大手术术后吗啡的需求量,同时研究了这个潜在镇痛作用的效应部位。方法:这个单中心、双盲、随机化、安慰剂对照和平行组试验共有92例病人参加。年龄在1880岁之间、接受胸廓切开或正中胸骨切开的病人在围术期被随机给予标准的镇痛方式联合尼美舒利或者安慰剂。尼美舒利在手术前夜给予一次和术后5天每12小时给予一次口服。主要的功效变量为术后第一个48小时内吗啡消耗量和疼痛评分。次要的功效变量为尼美舒利在脑脊液中对环氧化酶活性的影响。结果:术后第一个48小时病人静息或活动时的疼痛评分和总吗啡消耗量在两组间没有统计学差异。两组间术后48小时吗啡总消耗量平均差异为尼美舒利组减少9.0 mg(95%可信区间为–28.910.9 mg) (P = 0.37)。术后两天脑脊液中6-keto-PGF1{alpha}浓度的校正均数(标准误)在安慰剂组比术前增加54.7 (25.7) pg/mL,而在尼美舒利组减少0.6 (18.2 pg/mL),这些变化没有统计学差异(P = 0.095)。结论:一天两次给予尼美舒利90mg结合标准的镇痛方法并不能影响胸外科较大手术后的疼痛评分、吗啡需求量和脑脊液中前列腺素的水平。

(姜旭晖   马皓琳 李士通 校)

BACKGROUND: Cyclooxygenase 2 inhibition has proven analgesic efficacy in a variety of surgical procedures. We postulated that perioperative cyclooxygenase 2 inhibition significantly reduces postoperative morphine requirements after major thoracic surgery and investigated the site of this potential analgesic effect.

METHODS: Ninety-two patients participated in this single-center, double-blind, randomized, placebo-controlled, parallel-group trial. Patients between the ages of 18 and 80 yr undergoing a thoracotomy or median sternotomy were randomized to receive either nimesulide or placebo in combination with a standard analgesic regimen perioperatively. Nimesulide was administered orally the evening before surgery and at 12-h intervals for 5 days postoperatively. The primary efficacy variables were morphine consumption and pain scores for the first 48 h postoperatively. The secondary efficacy variable was the effect of nimesulide on cyclooxygenase activity in cerebrospinal fluid (CSF).

RESULTS: Pain scores at rest or with movement, and total morphine consumption for the first 48 h postoperatively, were not statistically different between the groups. The mean difference in total morphine consumption up to 48 h postoperatively between the nimesulide and placebo group was a 9.0 mg reduction (95% CI: –28.9 to 10.9 mg) (P = 0.37). Adjusted mean (se) CSF 6-keto-PGF1{alpha} (6-keto-PGF1{alpha}) concentrations increased by 54.7 (25.7) pg/mL from preoperatively to Day + 2 postoperatively in the placebo group, whereas adjusted mean (se) CSF 6-keto-PGF1{alpha} concentration decreased by 0.6 pg/mL (18.2 pg/mL) in the nimesulide group. These changes were not statistically different between the groups (P = 0.095).

CONCLUSION: Nimesulide, at a dose of 90 mg twice daily in combination with a standard analgesic regimen, does not influence pain scores, morphine requirements, or CSF prostaglandin levels after major thoracic surgery.


腹式子宫切除术后吗啡、哌替啶和曲马多病人自控镇痛效果的比较研究

A Comparative Study of the Analgesic Effect of Patient-Controlled Morphine, Pethidine, and Tramadol for Postoperative Pain Management After Abdominal Hysterectomy

Hakki Unlugenc, MD*, Mehmet Ali Vardar, MD{dagger}, and Sibel Tetiker, MD*

From the Departments of *Anaesthesiology, and {dagger}Gynecology and Obstetric, Cukurova University Faculty of Medicine, Adana, Turkey.

Anesth Analg 2008; 106:309-312

我们设计了这个前瞻、随机、双盲研究,以比较吗啡、哌替啶和曲马多经静脉病人自控镇痛用于术后疼痛控制的镇痛效果和副作用。126ASA  III级、行腹式子宫切除术的患者,随机分为经静脉病人自控吗啡组(M)、哌替啶组 (P)和曲马多组(T)进行术后镇痛。24小时累计镇痛消耗量为吗啡25.7 ± 9.5 mg、哌替啶266 ± 90 mg和曲马多320 ± 10 mg。追加芬太尼的平均剂量T组显著高于M组和P(P < 0.05)。总之,吗啡、哌替啶和曲马多导致相等的疼痛评分和副作用,但曲马多组(T)需要较多的芬太尼补救镇痛剂量。

(唐李隽   马皓琳 李士通 校)

We designed this prospective, randomized, double-blind study to compare the analgesic effectiveness and side effects of IV patient-controlled morphine, pethidine, and tramadol for postoperative pain management. One-hundred-twenty-six ASA physical status I or II patients undergoing abdominal hysterectomy were randomly allocated to receive IV-patient controlled morphine (M), pethidine (P), or tramadol (T) for postoperative analgesia. The cumulative analgesic consumption over 24 h was 25.7 ± 9.5 mg for morphine, 266 ± 90 mg for pethidine, and 320 ± 10 mg for tramadol. The average supplementary fentanyl dose used was significantly higher in group T than in groups M and P (P < 0.05). In conclusion, morphine, pethidine, and tramadol resulted in equivalent pain scores and side effects, but tramadol group T required more rescue analgesic doses of fentanyl.


关节内给予酮咯酸、吗啡及罗哌卡因联合关节内自控区域镇痛用于缓解肩关节手术后的疼痛:一项随机双盲研究

Intraarticular Administration of Ketorolac, Morphine, and Ropivacaine Combined with Intraarticular Patient-Controlled Regional Analgesia for Pain Relief After Shoulder Surgery: A Randomized, Double-Blind Study

Kjell Axelsson, MD, PhD, Anil Gupta, MD, FRCA, PhD, Eva Johanzon, BSc, Elisabeth Berg, BSc, Gustav Ekbäck, MD, PhD, Narinder Rawal, MD, PhD, Peter Enström, MD, and Ulf Nordensson, MD

From the Division of Anesthesiology and Intensive Care and Division of Orthopedics, Department of Medicine, Örebro University Hospital, Örebro, Sweden.

Anesth Analg 2008; 106:328-333

背景:在这项研究中,我们评估了关节内区域镇痛对术后疼痛的效果及镇痛药需要量。方法:51位行肩关节手术(Bankart)的病人参与了此次双盲研究。在手术结束时,病人随机分成三组通过导管接受关节内给药:组1:罗哌卡因90mg(9ml)、吗啡4 mg(10ml) 和酮咯酸 30 mg (1 mL) ( 20 mL); 2 3: 盐水(20 mL) 另外, 1 3 接受1 mL 盐水静注而组 2接受酮咯酸30 mg (1 mL) 静注。手术后,组1在需要时经关节内导管给予0.5%罗哌卡因10mL减轻疼痛,而组23接受10mL盐水关节内注射。组3 为对照组。

结果:术后最初30120分钟里组1的静止和活动后疼痛分别较组23要轻。最初需要局麻药输注的时间在组1要较组23长(P<0.001)。术后最初24小时里吗啡的用量中位数组12要较组3小(P<0.001)。镇痛药消耗量在组1与组2之间没有显著性差异。满意度分数的中位数组1要高于组2p<0.05)和3(P<0.001) 结论:关节内联合应用罗哌卡因、吗啡和酮咯酸及后按需间断注射罗哌卡因与对照组相比较,提供较好的镇痛,减少吗啡使用量和提高病人的满意度。静脉注射酮咯酸较对照组吗啡用量减少及病人满意度更高。

(胡湘   马皓琳 李士通 校)

BACKGROUND: In this study we assessed the efficacy of intraarticular regional analgesia on postoperative pain and analgesic requirements.

METHODS: Fifty-one patients undergoing shoulder surgery (Bankart) were recruited into this double-blind study. At the end of the operation, patients were randomized to three groups to receive intraarticularly via a catheter: Group 1: ropivacaine 90 mg (9 mL), morphine 4 mg (10 mL), and ketorolac 30 mg (1 mL) (total volume 20 mL); Groups 2 and 3: saline (20 mL). In addition, Groups 1 and 3 received 1 mL saline IV while Group 2 received ketorolac 30 mg (1 mL) IV. Postoperatively, Group 1 received pain relief using 10 mL 0.5% ropivacaine on demand via the intraarticular catheter while Groups 2 and 3 received 10 mL of saline intraarticularly. Group 3 was the Control group.

RESULTS: Postoperative pain at rest and on movement were lower in Group 1 than in Groups 2 and 3 during the first 30 and 120 min, respectively. The time to first request for local anesthetic infusion was longer in Group 1 than in Groups 2 and 3 (P < 0.001). The median morphine consumption during the first 24 postoperative hours was less in Groups 1 and 2 than in Group 3 (P < 0.001). There was no significant difference in analgesic consumption between Group 1 and Group 2. The median satisfaction score was higher in Group 1 compared with Groups 2 (P < 0.05) and 3 (P < 0.001).

CONCLUSIONS: A combination of intraarticular ropivacaine, morphine, and ketorolac followed by intermittent injections of ropivacaine as needed provided better pain relief, less morphine consumption, and improved patient satisfaction compared with the control group. The group that received IV ketorolac consumed less morphine and was more satisfied with treatment than patients in the control group.


 

人体腰椎脊神经根套囊的超微结构

The Ultrastructure of the Human Spinal Nerve Root Cuff in the Lumbar Spine

Miguel Angel Reina, MD, PhD*, María Concepción Villanueva, MD{dagger}, Fabiola Machés, MD*, Ana Carrera, MD{ddagger}, Andrés López, MD*, and José Antonio De Andrés, MD, PhD§

From the *Department of Anesthesiology, Hospital Universitario Madrid Montepríncipe, Madrid, Spain; {dagger}Department of Pathology, Hospital General de Móstoles, Madrid, Spain; {ddagger}Department of Anatomy, Facultad de Medicina, Universidad de Barcelona, Spain; and §Department of Anesthesiology and Critical Care, Hospital General Universitario, Valencia, Spain.

Anesth Analg 2008; 106:339-344

背景:脊神经根套囊可能与选择性的神经根和硬膜外阻滞有关。方法:我们利用组织染色法、传染和扫描电子显微镜检查观察6名人类尸体的脊神经根套囊的超微结构,如细胞和纤维成分。结果:脊神经根套囊的形态学特征类似脊髓硬膜下间隙。细胞通过特殊连接聚集在致密层。细胞层的厚度为58微米;细胞平行于所属神经根方向排列。纤维成分主要由胶原纤维组成,存在于脊神经根套囊的外部,测得厚度为100150微米。大量脂肪细胞在同心层分隔硬膜层,从硬膜囊延伸到脊神经根神经节。然而,硬膜囊层中并没有找到脂肪细胞。结论:少量毛细管的存在及脂肪和轴突间较短的距离可能影响硬膜外注射物质进入神经根轴突的通路。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Spinal nerve root cuffs may be relevant in selective nerve root and epidural blockade.

METHODS: We examined the ultrastructural aspects of spinal nerve root cuffs, such as their cellular and fibrillar components, using special histological staining methods, transmission and scanning electron microscopy, from six human cadavers.

RESULTS: The morphology of the spinal nerve root cuff resembles that of the spinal subdural compartment. Cells gather together in compact layers due to specialized junctions. The thickness of its cellular layers is 5 to 8 microns; cells appear oriented parallel to the direction of their own nerve roots. The fibrillar component, made largely of collagen fibers, is found in the outer part of the spinal nerve root cuff and measures 100 to 150 microns. Numerous adipocytes separate dural laminas in concentric layers, extending from the dural sac to the spinal nerve root ganglia. However, adipocytes are not found within the thickness of the dural sac.

CONCLUSIONS: The presence of few capillaries and the short distance between fat and axons may affect the passage of epidurally injected substances towards nerve root axons.

 

七氟醚通过调节豚鼠心肌蛋白激酶c、线粒体ATP钾离子通道和一氧化氮合酶增强乙醇的心肌缺血预适应作用

Sevoflurane Enhances Ethanol-Induced Cardiac Preconditioning Through Modulation of Protein Kinase C, Mitochondrial KATP Channels, and Nitric Oxide Synthase in Guinea Pig Hearts

Kazuhiro Kaneda, DDS*, Masami Miyamae, MD, PhD{dagger}, Shingo Sugioka, DDS, PhD*, Chika Okusa, DDS*, Yoshitaka Inamura, DDS*, Naochika Domae, MD, PhD{dagger}, Junichiro Kotani, DDS, PhD*, and Vincent M. Figueredo, MD{ddagger}

From the Departments of *Anesthesiology, and {dagger}Internal Medicine, Osaka Dental University, Osaka, Japan; and {ddagger}Institute for Heart and Vascular Health, Albert Einstein Medical Center, Philadelphia, Pennsylvania.

Anesth Analg 2008 106: 9-16.

 

背景:使用吸入性麻醉药以及一般饮酒行为都会产生类似心肌缺血预处理效应而表现出心肌保护作用。本文作者研究了七氟醚是否能增强乙醇产生的心肌缺血预适应作用以及是否抑制心肌蛋白激酶c、线粒体ATP钾离子通道时会减弱其心肌保护作用。另研究了一般饮酒行为能否诱导内皮型一氧化氮合酶(eNOS)以及诱导型一氧化氮合酶(iNOS)的表达。法:对照组(CTL)豚鼠离体心肌先进行30min全心停灌后120min再灌处理。乙醇组(ETOH)的豚鼠先前六周内予以饮用水中加入2.5%乙醇处理再取心肌标本。ETOH组再用麻醉药物的预处理(七氟醚1MAC2%,10min)为 EtOH + SEVO组,乙醇未处理而用七氟醚处理为SEVO组。试验中使用白屈菜红碱、5-羟基癸酸分别抑制心肌蛋白激酶c、线粒体ATP钾离子通道。记录左心室发LVDP)、左心室舒张LVEDP)反映心肌收缩力恢复程度;TTC染色法检测心肌梗死面积,蛋白质印迹分析法检测内皮型一氧化氮合酶(eNOS)以及诱导型一氧化氮合酶(iNOS)表达量。

结果:心肌细胞进行缺血再灌注处理后与对照组相比EtOH + SEVO组、EtOH 组和SEVO组的左心室发展压(LVDP)均增高,而左心室舒张末压(LVEDP)均降低。EtOH 组和SEVO组的心肌梗死面积(分别为27%23%)与对照组(45%)相比显著减少(P<0.001 EtOH + SEVO组心肌梗死面积减少更显著(15%P<0.001)。白屈菜红碱、5-羟基癸酸在EtOH 组和SEVO组中均能减弱原本的心肌保护作用。EtOH 组中iNOS表达下降而eNOS表达增加。

结论:七氟醚能增强乙醇的心肌缺血预适应作用。而其机制可能与调节蛋白激酶c、线粒体ATP钾离子通道以及NOS表达量相关。

(陶颖莹 陈杰 校)

BACKGROUND: Volatile anesthetics and regular ethanol consumption induce cardioprotection mimicking ischemic preconditioning. We investigated whether sevoflurane enhances ethanol preconditioning and whether inhibition of protein kinase C (PKC) and mitochondrial KATP channels attenuated this enhanced cardioprotection. The effects of regular ethanol consumption on expression of inducible (iNOS) and endothelial (eNOS) nitric oxide synthase were determined.

METHODS: Isolated perfused guinea pig hearts underwent 30-min global ischemia and 120-min reperfusion (Control: CTL). The ethanol group (EtOH) received 2.5% ethanol in their drinking water for 6 wk. Anesthetic preconditioning was elicited by 10-min exposure to sevoflurane (1 minimum alveolar anesthetic concentration; 2%) in ethanol (EtOH + SEVO) or nonethanol (SEVO) hearts. PKC and mitochondrial KATP channels were inhibited with chelerythrine and 5-hydroxydecanoate pretreatment, respectively. Contractile recovery was assessed by monitoring of left ventricular developed and end-diastolic pressures. Infarct size was determined by triphenyltetrazolium chloride staining. Expression of iNOS and eNOS were determined by Western blot analysis.

RESULTS: After ischemia-reperfusion, hearts from the EtOH, sevoflurane (SEVO), and EtOH + SEVO groups had higher left ventricular developed pressure and lower left ventricular end-diastolic pressure compared with CTL. Infarct size was reduced in EtOH and SEVO hearts compared with CTL (27% and 23% vs 45%, respectively, P < 0.001). Sevoflurane further reduced infarct size in EtOH hearts (27% vs 15%, P < 0.001). Chelerythrine and 5-hydroxydecanoate abolished cardioprotection in both SEVO and EtOH cardioprotected hearts. iNOS expression was reduced and eNOS expression was increased in EtOH hearts.

CONCLUSIONS: Sevoflurane enhances cardiac preconditioning induced by regular EtOH consumption. This effect is mediated in part by modulation of PKC and mitochondrial KATP channels, and possibly by altered modulation of NOS expression.

 

手术期间输入血小板和红细胞对肝移植术后存活率的影响

The Impact of intraoperative Transfusion of Platelets and Red Blood Cells on Survival After Liver Transplantation

Marieke T. de Boer, MD*, Michael C. Christensen, Dr PH{dagger}, Mikael Asmussen, MSc{dagger}, Christian S. van der Hilst, MSc{ddagger}, Herman G. D. Hendriks, MD, PhD§, Maarten J. H. Slooff, MD, PhD*, and Robert J. Porte, MD, PhD*

 From the *Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; {dagger}Global Development, Novo Nordisk A/S, Bagsvaerd, Denmark; and {ddagger}Office for Medical Technology Assessment, §Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.

 Anesth Analg 2008 106: 32-44.

 

背景:手术期间红细胞输入与原位肝移植不良预后相关。虽然实验研究已经证明血小板与肝脏再灌注损伤有关,但是输注同种异体血小板对预后的影响尚未详细研究。本研究中,作者评估了不同血制品对原位肝移植预后的影响。方法:作者对1989年到2004年之间行第一次原位肝移植的433例病人预后相关的29个变量,包括血制品的输注等进行了研究。数据采用了单变量和多变量逐步Cox’s比例危害分析,并采用倾向数据调节分析来调整使用血制品中的偏差。结果:输注血制品的移植病人比例从19891996年的100%到19972004年的74%。在单变量和多变量分析中,移植的指征,输注血小板和红细胞对预测移植病人一年存活率密切相关。这些危险因素与公认的疾病指数,如终末肝病指数和Karnofsky评分无关。一年生存率的影响与血小板(P0.01)危害指数1.377/U、红细胞(P0.0011.057/U剂量相关的。血小板输注对存活率呈负性影响。结论:这项回顾性研究显示除了红细胞,血小板输注是原位肝移植存活率的独立影响因素。这些研究发现对于肝移植受体临床液体治疗来说非常重要。

(杨卫红 校)

BACKGROUND: Intraoperative transfusion of red blood cells (RBC) is associated with adverse outcome after orthotopic liver transplantation (OLT). Although experimental studies have shown that platelets contribute to reperfusion injury of the liver, the influence of allogeneic platelet transfusion on outcome has not been studied in detail. In this study, we evaluate the impact of various blood products on outcome after OLT.

METHODS: Twenty-nine variables, including blood product transfusions, were studied in relation to outcome in 433 adult patients undergoing a first OLT between 1989 and 2004. Data were analyzed using uni- and multivariate stepwise Cox’s proportional hazards analyses, as well as propensity score-adjusted analyses for platelet transfusion to control for selection bias in the use of blood products.

RESULTS: The proportion of patients receiving transfusion of any blood component decreased from 100% in the period 1989–1996 to 74% in the period 1997–2004. In uni- and multivariate analyses, the indication for transplantation, transfusion of platelets and RBC were highly dominant in predicting 1-yr patient survival. These risk factors were independent from well-accepted indices of disease, such as the Model for End-Stage Liver Disease score and Karnofsky score. The effect on 1-yr survival was dose-related with a hazard ratio of 1.377 per unit of platelets (P = 0.01) and 1.057 per unit of RBC (P = 0.001). The negative impact of platelet transfusion on survival was confirmed by propensity-adjusted analysis.

CONCLUSION: This retrospective study indicates that, in addition to RBC, platelet transfusions are an independent risk factor for survival after OLT. These findings have important implications for transfusion practice in liver transplant recipients.


右旋美托咪啶对儿童心脏电生理的影响

The Effects of Dexmedetomidine on Cardiac Electrophysiology in Children

Gregory B. Hammer, MD*{dagger}, David R. Drover, MD*, Hong Cao, MD*, Ethan Jackson, MD*, Glyn D. Williams, MB, ChB*, Chandra Ramamoorthy, MBBCHir*, George F. Van Hare, MD{dagger}, Alisa Niksch, MD{dagger}, and Anne M. Dubin, MD{dagger}

From the Departments of *Anesthesiology, and {dagger}Pediatrics, Lucile Packard Children’s Hospital and Stanford University School of Medicine, Stanford, California.

Anesth Analg 2008 106: 79-83.

 

背景:右旋美托咪啶是α2肾上腺素能受体激动剂,食品药物管理局已批准使用于成人短时间的镇静(<24小时)。但在儿童中的使用尚未批准。尽管如此,右旋美托咪啶用于婴儿和儿童的镇静及麻醉已逐渐增多。该药在血流动力学方面有一定的影响,包括心动过缓、高血压、低血压等。目前尚没有右旋美托咪啶对心脏传导系统方面影响的数据。因此,作者研究了右旋美托咪啶对儿童患者心脏传导的影响。方法125-17岁接受电生理研究并进行室上旁路消融术的儿童在使用右旋美托咪啶前和使用过程中测定了血流动力学和心脏电生理的有关参数。右旋美托咪啶的使用剂量为前10min1ug/kg静脉注射持续输注,10min后以0.7ug/kg/h维持。结果:使用右旋美托咪啶后动脉血压显著增加,心率显著减慢。窦房结功能明显受到影响,窦房结周期和恢复时间延长。房室结功能也受到抑制, Wenckeback环路和PR间期均延长。结论:在儿童患者中右旋美托咪啶显著抑制窦房结和房室结功能,并致血压增高和心率减慢。在电生理研究中不宜使用右旋美托咪啶,存在心动过缓和房室结阻滞等高危因素的患者,右旋美托咪啶可能引起副作用。

(詹琼慧 陈杰 校)

BACKGROUND: Dexmedetomidine (DEX) is an {alpha}2-adrenergic agonist that is approved by the Food and Drug Administration for short-term (<24 h) sedation in adults. It is not approved for use in children. Nevertheless, the use of DEX for sedation and anesthesia in infants and children appears to be increasing. There are some concerns regarding the hemodynamic effects of the drug, including bradycardia, hypertension, and hypotension. No data regarding the effects of DEX on the cardiac conduction system are available. We therefore aimed to characterize the effects of DEX on cardiac conduction in pediatric patients.

METHODS: Twelve children between the ages of 5 and 17 yr undergoing electrophysiology study and ablation of supraventricular accessory pathways had hemodynamic and cardiac electrophysiologic variables measured before and during administration of DEX (1 µg/kg IV over 10 min followed by a 10-min continuous infusion of 0.7 µg · kg–1 · h–1).

RESULTS: Heart rate decreased while arterial blood pressure increased significantly after DEX administration. Sinus node function was significantly affected, as evidenced by an increase in sinus cycle length and sinus node recovery time. Atrioventricular nodal function was also depressed, as evidenced by Wenckeback cycle length prolongation and prolongation of PR interval.

CONCLUSION: DEX significantly depressed sinus and atrioventricular nodal function in pediatric patients. Heart rate decreased and arterial blood pressure increased during administration of DEX. The use of DEX may not be desirable during electrophysiology study and may be associated with adverse effects in patients at risk for bradycardia or atrioventricular nodal block.

 

持续锁骨下臂丛神经阻滞:婴幼儿手术中改良的方法能更好地保障导管位置

Continuous Infraclavicular Brachial Plexus Block: A Modified Technique to Better Secure Catheter Position in Infants and Children

Vrushali C. Ponde, MD

From the Department of Anesthesiology, All India Institute of Physical Medicine and Rehabilitation, Mumbai, India.

Anesth Analg 2008 106: 94-96

.

介绍:臂丛神经阻滞时采用锁骨下方法可以达到合适的麻醉效果,并且就其本身来说更有利于持续输注时固定和管理导管。作者介绍了一种儿童手术中采用锁骨下法来进行持续注射的方法。方法:研究对象是25名年龄从8月到3岁,体重7-14公斤,接受择期前臂或者手部手术的儿童。采用附带有19G套管Touhy针的神经刺激仪进行锁骨下臂丛阻滞。进针点为锁骨中点的下1cm和外侧1cm。进针朝向喙突,保持针和皮肤成30°角。通过Touhy针放置20号硬膜外导管,深度为5-7cm。拔出Touhy针,保留导管。通过导管给予1ml/kg0.25%的布比卡因。在手术结束时开始以0.25mg/kg/h的速度持续给予0.125%布比卡因,直到术后第一天。术后第二天停止持续输注,改为每4-6小时间断给予单次注射。术后48h,拔除导管。结果:24名患者阻滞效果满意(占96%)。术后第一天,所有患者均未感觉明显疼痛(东安大略省儿童医院疼痛指数为4-6)。术后第二天,有两名儿童需要在足够剂量的局麻药外复合布洛芬糖丸。除了4名儿童,其余的导管都很容易被拔出。在这四名患者中,因为放置的导管有轻度成角,所以在拔出时需要给予1-2ml局麻药来克服阻力。未出现导管移动或者拔出时发生意外,出血或气胸。结论:在儿科患者中,改良的持续锁骨下臂丛神经阻滞有助于固定导管,并提供有效的术中和术后疼痛缓解。

(朱玫娟 陈杰 校)

INTRODUCTION: The infraclavicular approach to the brachial plexus provides suitable anesthesia and also lends itself well to stabilizing and securing a catheter for a continuous infusion.

We describe an approach for continuous infusions using an infraclavicular approach in children.

METHODS: Twenty-five patients aged 8 mo to 3 yr, weighing 7–14 kg, scheduled for forearm and hand surgeries were studied. The infraclavicular brachial plexus was located using a nerve stimulator attached to a sheathed 19-gauge Touhy needle. The needle was inserted through the skin at 1 cm below and 1 cm lateral to the midpoint of the clavicle. The needle was advanced and directed toward the coracoid process maintaining an angle of 30 degrees with the skin. A 20-gauge epidural catheter was passed to the 5–7 cm mark through the Touhy needle. The Touhy needle was removed and the catheter left in place.

Bupivacaine (1 mL/kg; 0.25%) was administered through the catheter. A continuous infusion of 0.25 mg/kg/h of bupivacaine (0.125%) was commenced near the end of surgery and continued on the first postoperative day. The continuous infusion was discontinued on the second postoperative day and intermittent boluses were administered every 4 to 6 h. In all patients the catheter was removed after 48 h.

RESULTS: Twenty-four patients (96%) had a successful block. On the first postoperative day all patients were pain free (Children’s Hospital Eastern Ontario Pain Scale score 4–6). On the second day, two children (8%) needed ibuprofen syrup along with a supplemental dose of local anesthesia.

The catheter was passed with ease in all but four children. However, in these four patients, slight needle angulation and a bolus of 1–2 mL local anesthetic solution was required to overcome the resistance. None of the patients had catheter dislodgements or accidental removal, hemorrhagic tap, or pneumothorax.

CONCLUSIONS: A modified technique for continuous infraclavicular brachial plexus block helps secure the catheter and provides effective intra- and postoperative pain relief in pediatric patients.

 

震波碎石期间右旋美托咪啶与异丙酚的镇痛作用的比较:随机对照试验

A Comparison of Sedation with Dexmedetomidine or Propofol During Shockwave Lithotripsy: A Randomized Controlled Trial

Kenan Kaygusuz, MD*, Gokhan Gokce, MD{dagger}, Sinan Gursoy, MD*, Semih Ayan, MD{dagger}, Caner Mimaroglu, MD*, and Yener Gultekin, MD{dagger}

From the Departments of *Anesthesiology and {dagger}Urology, Cumhuriyet University School of Medicine, Sivas, Turkey.

Anesth Analg 2008 106: 114-119.

 

背景:由于右旋美托咪啶具有镇静及镇痛两种作用,所以可能适用于疼痛时的清醒镇静。体外震波碎石(ESWL)有轻微疼痛需清醒镇静。因此作者在ESWL时比较右旋美托咪啶及异丙酚的作用。方法46名病人择期行ESWL,随机分成两组。分别接受右旋美托咪啶或异丙酚。右旋美托咪啶以6ug.kg-1.h-1注射10min,随后以0.2 ug.kg-1.h-1速率注射。异丙酚以 6ug.kg-1.h-1注射10min,接着以2.4ug.kg-1.h-1速率注射。所有的病人在接受ESWL10min静推1ug/kg的芬太尼。在接受ESWL1035min)时,每隔5min用视觉模拟量表进行疼痛程度的评估。镇静作用则用观察者警觉与镇静评分。在接受ESWL及之后的85min有规则的记录镇静评分及血液动力学变化与呼吸的变量。结果:40名患者接受评估。使用右旋美托咪啶后仅在2535min时视觉模拟量表值低于使用异丙酚的(P<0.05)。在镇静状态时,使用右旋美托咪啶的病人呼吸频率明显要比使用异丙酚的慢,但是SpO2较高(P<0.05,其它变量则相似(P>0.05)。结论:在ESWL时使用右旋美托咪啶及芬太尼的混合物用于镇静及镇痛是安全有效的方法。

(潘钱玲 陈杰 校)

BACKGROUND: Dexmedetomidine, because it has both sedative and analgesic properties, may be suitable for conscious sedation during painful procedures. Extracorporeal shockwave lithotripsy (ESWL) is a minimal to mildly painful procedure that requires conscious sedation. We thus evaluated the utility of dexmedetomidine compared with propofol during an ESWL procedure.

METHODS: Forty-six patients were randomly allocated into two groups to receive either dexmedetomidine or propofol for elective ESWL. Dexmedetomidine was infused at 6 µg · kg–1 · h–1 for 10 min followed by an infusion rate of 0.2 µg · kg–1 · h–1. Propofol was infused at 6 mg · kg–1 · h–1 for 10 min followed by an infusion of 2.4 mg · kg–1 · h–1. Fentanyl 1 µg/kg IV was given to all patients 10 min before ESWL. Pain intensity was evaluated with a visual analog scale at 5-min intervals during ESWL (10–35 min). Sedation was determined using the Observer's Assessment of Alertness/Sedation. The Observer's Assessment of Alertness/ Sedation scores and hemodynamic and respiratory variables were recorded regularly during ESWL (35 min) and up to 85 min after.

RESULTS: Forty patients were evaluated. Visual analog scale values with dexmedetomidine were significantly lower than those with propofol only at the 25–35 min assessments (P < 0.05). During sedation, the respiratory rate with dexmedetomidine was significantly slower but Spo2 was significantly higher than with propofol (P < 0.05). Other clinical variables were similar (P > 0.05).

CONCLUSION: A combination of dexmedetomidine with fentanyl can be used safely and effectively for sedation and analgesia during ESWL.

 

氙气在人体中不影响氨基丁酸A型受体的结合

Xenon Does Not Affect -Aminobutyric Acid Type A Receptor Binding in Humans

Elina Salmi, MD*{dagger}, Ruut M. Laitio, MD{ddagger}, Sargo Aalto, MSc*§, Anu T. Maksimow, MD*, Jaakko W. Långsjö, MD*{ddagger}, Kaike K. Kaisti, MD{ddagger}, Riku Aantaa, MD{ddagger}, Vesa Oikonen, MSc*, Liisa Metsähonkala, MD||, Kjell Någren, PhD*, Esa R. Korpi, MD¶, and Harry Scheinin, MD*#;

From the *Turku PET Centre and the #Departments of Pharmacology and Clinical Pharmacology, University of Turku, Turku, Finland; the §Department of Psychology, Åbo Akademi University, Turku, Finland; the {ddagger}Department of Anesthesiology and Intensive Care, Turku University Hospital, Turku, Finland, the {dagger}Department of Otorhinolaryngology – Head and Neck Surgery, Turku University Hospital, Turku, Finland; the ||Department of Child Neurology, Helsinki University Hospital, Helsinki, Finland and the ¶Institute of Biomedicine, Pharmacology, University of Helsinki, Helsinki, Finland.

Anesth Analg 2008 106: 129-134

.

背景:稀有气体氙气作为一种麻醉气体具有较好的血流动力学和神经保护的特性。动物和体外研究资料显示,氙气以抑制谷氨酸信号来发挥其麻醉作用的,但也有作用于GABA受体的报道。因此,氙气在人大脑中的麻醉作用机理仍需进一步研究。方法:以特异性的GABA受体苯二氮卓类结合位点11C配体氟马西尼和正电子体层扫描术(PET)研究8 名健康男性志愿者中氙气对GABA能的影响。每一个志愿者都经过两个动态的60minPET,研究清醒及一个MAC值下(约65%氙气)BIS值。用自动化的兴趣区域和CT显影基础分析法分析皮质和皮质下的灰质区。结果:在麻醉过程中,BIS23±7(平均值±标准差),心率和平均动脉压上均无显著变化。在大脑任何区域内氙气对11C—氟马西尼均无明显的影响。结论:氙气在人类大脑中不会影响11C—氟马西尼的作用。因此,氙气的麻醉效果不是由GABA受体体系介导的。

(王腾 陈杰 校)

BACKGROUND: The noble gas xenon acts as an anesthetic with favorable hemodynamic and neuroprotective properties. Based on animal and in vitro data, it is thought to exert its anesthetic effects by inhibiting glutamatergic signaling, but effects on {gamma}-aminobutyric acid type A (GABAA) receptors also have been reported. The mechanism of anesthetic action of xenon in the living human brain still remains to be determined.

METHODS: We used the specific GABAA receptor benzodiazepine-site ligand 11C-flumazenil and positron emission tomography to study the GABAergic effects of xenon in eight healthy male volunteers. Each subject underwent two dynamic 60-min positron emission tomography studies awake and during approximately one minimum alveolar concentration of xenon (65%). Bispectral index was recorded. Cortical and subcortical gray matter regions were analyzed using both automated regions-of-interest analysis and voxel-based analysis.

RESULTS: During anesthesia, the mean ± sd bispectral index was 23 ± 7, and there were no significant changes in heart rate or mean arterial blood pressure. Xenon did not significantly affect 11C-flumazenil binding in any brain region.

CONCLUSIONS: Xenon did not affect 11C-flumazenil binding in the living human brain, indicating that the anesthetic effect of xenon is not mediated via the GABAA receptor system.

 

频谱熵是否可以反映丙泊酚与瑞芬太尼的联合麻醉期间气管插管或切皮反应?

Does Spectral Entropy Reflect the Response to Intubation or Incision During Propofol-Remifentanil Anesthesia?

Grégoire Weil, MD*, Sylvie Passot, MD{dagger}, Frédérique Servin, MD{ddagger}, and Valérie Billard, MD*

From the *Département d'Anesthésie, Institut Gustave Roussy, Villejuif; {dagger}Département d'Anesthésie-Réanimation, Hôpital Bellevue, Saint-Etienne; and {ddagger}AP-HP, Service d'Anesthésie-Réanimation Chirurgicale, Hôpital Bichat, Paris, France.  

Anesth Analg 2008 106: 152-159.

 

背景:频谱熵是一种基于脑电图监测技术的一种扩大的包含着肌电频谱的频率带,预期有助于评估镇痛效能。虽然它与催眠状态的相关性已经被证明,但是在有害刺激和神经肌肉阻断时的情况下尚未研究。

方法:在这个前瞻性、开放、多中心的研究中,105名病人在接受丙泊酚输注后,靶控输注瑞芬太尼进行麻醉诱导,瑞芬太尼的靶浓度为28ng/ml。一半的病人接受神经肌肉阻滞剂。气管插管和切皮作为有害刺激的标准,记录运动和血流动力学的反应,比较刺激前后有无反应的病人之间频谱熵值。

结果:对刺激有或无血流动力学的反应病人间反应熵,状态熵或两者差均无显著差异。病人对气管插管有运动反应的病人比没有反应的病人有更高的反应熵,状态熵或两者差。这些结果可通过预测概率分析所证实,熵值只对运动反应具有意义的但较弱的预测价值。

结论:熵值能预测对伤害性刺激的运动反应而不能预测血流动力学的反应,这在肌肉麻痹病人的麻醉镇痛方面的评估中受到了限制。应当避免刺激前熵值较高(RE >55),以免发生运动反应。尽管有足够的催眠作用,当鸦片类用药不够时较低熵值不能防止运动反应。

(王鹏 陈杰 校)

BACKGROUND: Spectral entropy is an electroencephalogram-based monitoring technique with a frequency band enlarged to include the electromyogram spectrum, which is intended to help to assess analgesia. Although its correlation with hypnosis has been shown, its performance during a noxious stimulation and the influence of neuromuscular blockade have not been described.

METHODS: In this prospective, open, multicenter study, 105 patients received propofol then remifentanil target-controlled infusion for induction of anesthesia, with randomized remifentanil targets ranging from 2 to 8 ng/mL. Half of the patients received neuromuscular blockade. Intubation and incision were used as standard noxious stimulations, motor or hemodynamic responses were recorded, and spectral entropy values before and after stimulations were compared between responders and nonresponders.

RESULTS: No difference was found in response entropy (RE), state entropy (SE), or (RE – SE) between patients with or without hemodynamic response to stimulations. Patients with motor response to intubation had higher values of RE, SE, and (RE – SE) both before and after the intubation than patients with no response. These results were confirmed by a prediction probability analysis, showing a significant but weak predictive value of entropy for motor response only.

CONCLUSIONS: Entropy predicted a motor response to noxious stimulations but not a hemodynamic response, which limits its usefulness for assessing the analgesic component of anesthesia in paralyzed patients. High values (RE >55) before the stimulation should be avoided in order to decrease the risk of motor response, but lower values might not prevent this response when the opioid concentration is insufficient, despite an adequate hypnosis.

 

顺应性和死腔分数预示麻醉病人恢复后最佳呼气末正压水平

Compliance and Dead Space Fraction Indicate an Optimal Level of Positive End-Expiratory Pressure After Recruitment in Anesthetized Patients

Stefan Maisch, MD*, Hajo Reissmann, MD*, Bernd Fuellekrug, MD*, Dieter Weismann, PhD{dagger}, Thomas Rutkowski, MD*, Gerardo Tusman, MD{ddagger}, and Stephan H. Bohm, MD*

From the *Department of Anesthesiology, Universitaetsklinikum Hamburg-Eppendorf, Germany; {dagger}Drägerwerk AG, Lübeck, Germany; and {ddagger}Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina.

Anesth Analg 2008 106: 175-181

.

背景:最佳呼气末正压(PEEP)可定义为:可预防复张后再萎陷、避免过度扩张,在最小的死腔通气情况下达到理想的肺力学状态的PEEP。此项研究中,作者通过功能残气量(FRC)、顺应性、动脉氧分压(Pa02)和死腔分数来分析PEEP和复张的效应。方法: 20名行面颌手术、肺部情况正常的麻醉病人。在压力控制通气模式来使用阶梯式提高PEEP/吸气压力(0/10, 5/15, 10/20, 15/25cm H2O, 每个水平维持20分钟)后,进行肺复张动作(20/45 cm H2O,最长20分钟),接着逐渐减小压力(15/25, 10/20, 5/15, 0/10 cm H2O,每个水平维持20分钟)。在每个压力水平测量FRC、顺应性、Pa02和死腔分数。结果:比较同一PEEP水平时复张前后的数值时,所有变量都在10/20cm H2O水平有显著变化;顺应性在15/25cmH2O压力水平有显著升高。另外,FRC指标在5/15cm H2O15/25cm H2O水平之间有显著差异。结论:所有变量都显示了PEEP联合肺复张的正效应。最佳的PEEP10cm H2O,因为在此压力水平下能达到最高的顺应性和最低的死腔分数,反应了最大的肺泡扩张量。FRCPa02对肺泡过度扩张不敏感。

(於章杰 陈杰 校)

BACKGROUND: "Optimal" positive end-expiratory pressure (PEEP) can be defined as the PEEP that prevents recollapse after a recruitment maneuver, avoids over-distension, and, consequently, leads to optimal lung mechanics at minimal dead space ventilation. In this study, we analyzed the effects of PEEP and recruitment on functional residual capacity (FRC), compliance, arterial oxygen partial pressure (Pao2) and dead space fraction, and we determined the most suitable variables indicating optimal PEEP.

METHODS: We studied 20 anesthetized patients with healthy lungs undergoing faciomaxillary surgery. After a stepwise increase of PEEP/inspiratory pressures (0/10, 5/15, 10/20, 15/25 cm H2O, each level lasting for 20 min) using a pressure-controlled ventilation mode, a recruitment maneuver (at 20/45 cm H2O for a maximum of 20 min) was performed, followed by a stepwise pressure reduction (15/25, 10/20, 5/15, 0/10 cm H2O, with 20 min at each level). At each pressure level, FRC, compliance, Pao2, and dead space fraction were measured.

RESULTS: When comparing the values before and after recruitment at identical PEEP levels, all variables showed significant changes at 10/20 cm H2O; compliance was also significantly higher at the pressure step 15/25 cm H2O. In addition, FRC values showed significant differences at 5/15 cm H2O and 15/25 cm H2O.

CONCLUSIONS: All variables showed the positive effects of PEEP in conjunction with a recruitment maneuver. Optimal PEEP was 10 cm H2O because at this pressure level the highest compliance value in conjunction with the lowest dead space fraction indicated a maximum amount of effectively expanded alveoli. FRC and Pao2 were insensitive to alveolar over-distension.

 

剖腹产分娩后腹横机平面(TAP)阻滞的镇痛效应:随机对照实验

The Analgesic Efficacy of Transversus Abdominis Plane Block After Cesarean Delivery: A Randomized Controlled Trial

John G. McDonnell, MB, FCARCSI*, Gerard Curley, MB*{dagger}, John Carney, MB*{dagger}, Aoife Benton, MB{dagger}, Joseph Costello, MB, FCARCSI*, Chrisen H. Maharaj, MB, BSc, FCARCSI, DPM*{dagger}, and John G. Laffey, MD, MA, BSc, FCARCSI*{dagger}

From the *Department of Anaesthesia, Clinical Sciences Institute, Centre for Pain Research, National University of Ireland; and {dagger}Department of Anaesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland.

Anesth Analg 2008 106: 186-191.

 

背景: TAP阻滞为腹壁中线切开手术患者提供一种有效术后镇痛的方法。在一项随机、对照、双盲临床实验中,作者评估了这一方法用于Pfannensteil式剖腹产术后48小时镇痛效果。方法: 随机选择正在接受剖腹产分娩的50名妇女,随机接受TAP阻滞,分别使用罗哌卡因(n= 25)和安慰剂( n = 25 ,除了标准的术后病人自控吗啡镇痛和定期双氯芬酸以及对乙酰氨基酚镇痛。All patients were given a standard spinal anaesthetic, and at the end of surgery, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side.所有病人施与标准脊椎麻醉,并在术毕给与罗哌卡因(1.5mg/kg,一次最大剂量为150mg)或生理盐水来进行双侧TAP阻滞。在麻醉后恢复室及术后24612 24 3648h对患者进行盲法评估术后采用。结果: 同安慰剂组相比,罗哌卡因TAP阻滞后术后视觉模拟疼痛评分较低。术后48小时Mean (± SD) total morphine requirements in the first 48 postoperative hours were also reduced (66 Â± 26 versus 18 Â± 14 mg; p<0.001), and also the 12-hour interval morphine consumption up to 36 hours postoperatively.吗啡平均需求量减少( 66± 2618± 14mg; p < 0.001 ),同时,术后12小时到36小时期间吗啡消耗量减少。 接受TAP阻滞的患者The incidence of sedation was reduced in patients undergoing TAP blockade.镇静发生率也较低。There were no complications attributable to the TAP block.没有归因于TAP阻滞的并发症。结论: TAP阻滞TAP作为多重模式镇痛的组成部分,对择期剖腹产患者能提供较安慰剂具有更有效的术后48小时的镇痛。

(张燕 陈杰 校)

BACKGROUND: The transversus abdominis plane (TAP) block is an effective method of providing postoperative analgesia in patients undergoing midline abdominal wall incisions. We evaluated its analgesic efficacy over the first 48 postoperative hours after cesarean delivery performed through a Pfannensteil incision, in a randomized controlled, double-blind, clinical trial.

METHODS: Fifty women undergoing elective cesarean delivery were randomized to undergo TAP block with ropivacaine (n = 25) versus placebo (n = 25), in addition to standard postoperative analgesia comprising patient-controlled IV morphine analgesia and regular diclofenac and acetaminophen. All patients received a standard spinal anesthetic, and at the end of surgery, a bilateral TAP block was performed using 1.5 mg/kg ropivacaine (to a maximal dose of 150 mg) or saline on each side. Each patient was assessed postoperatively by a blinded investigator: in the postanesthesia care unit and at 2, 4, 6, 12, 24, 36, and 48 h postoperatively.

RESULTS: The TAP block with ropivacaine compared with placebo reduced postoperative visual analog scale pain scores. Mean (± sd) total morphine requirements in the first 48 postoperative hours were also reduced (66 ± 26 vs 18 ± 14 mg, P < 0.001), as was the 12-h interval morphine consumption up to 36 h postoperatively. The incidence of sedation was reduced in patients undergoing TAP blockade. There were no complications attributable to the TAP block.

CONCLUSIONS: The TAP block, as a component of a multimodal analgesic regimen, provided superior analgesia when compared with placebo block up to 48 postoperative hours after elective cesarean delivery.

 

颅内压监测在外伤性脑损伤中的应用(综述)

Monitoring Intracranial Pressure in Traumatic Brain Injury (Review Article)

Martin Smith, MBBS, FRCA

From the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, UK.

 Anesth Analg 2008 106: 240-248.

 

颅内压增高(ICP)是导致继发性脑损伤的一个重要因素,ICP监测已成为颅脑外伤监测的常规组成部分。ICP无法依据特殊的临床体征或CT表现确诊,因此需要正确测量。ICP监测有许多方式,目前临床实践中应用最广的是脑室内导管以及微传感器测压系统。ICP是一个与脑灌注压相关联的复变量,通过识别和分析ICP波形图还可以得到更多的病理学信息。另外还可以通过测得脑血管压力反应性和压力-容积代偿储备量的指数进一步增进ICP监测。不同颅脑外伤医疗中心对ICP的监测和治疗方式有很大差异。然而,大量临床证据支持ICP监测可帮助早期检出颅内肿块,指导介入治疗,评价预后,是颅脑外伤推荐使用处理原则。对于ICP监测和治疗在颅脑外伤后的价值还有待前瞻性的随机对照试验来确定。

(印洁敏 陈杰 校)

Increased intracranial pressure (ICP) is an important cause of secondary brain injury, and ICP monitoring has become an established component of brain monitoring after traumatic brain injury. ICP cannot be reliably estimated from any specific clinical feature or computed tomography finding and must actually be measured. Different methods of monitoring ICP have been described but intraventricular catheters and microtransducer systems are most widely used in clinical practice. ICP is a complex variable that links ICP and cerebral perfusion pressure and provides additional information from identification and analysis of pathologic ICP wave forms. ICP monitoring can also be augmented by measurement of indices describing cerebrovascular pressure reactivity and pressure-volume compensatory reserve. There is considerable variability in the use of ICP monitoring and treatment modalities among head injury centers. However, there is a large body of clinical evidence supporting the use of ICP monitoring to detect intracranial mass lesions early, guide therapeutic interventions, and assess prognosis, and it is recommended by consensus guidelines for head injury management. There remains a need for a prospective, randomized, controlled trial to identify the value of ICP monitoring and management after head injury.

 

丙泊酚麻醉的病人较异氟醚麻醉的病人具有较的术后疼痛

Anesthesia Matters: Patients Anesthetized with Propofol Have Less Postoperative Pain than Those Anesthetized with Isoflurane

Sean S. Cheng, MS, Janet Yeh, BS, and Pamela Flood, MD

From the Department of Anesthesiology, Columbia University, New York City, New York.

Anesth Analg 2008 106: 264-269

  

背景:临床前研究发现一些吸入麻醉药引起的疼痛高敏状态可能继发于烟碱样作用的受抑。先前的一项研究显示异氟醚麻醉的女性病人鼻吸入烟碱具有术后镇痛效应。为了研究烟碱是否能够逆转异氟醚的疼痛增敏作用,或是仅仅表现为镇痛效应,作者研究了烟碱女性患者在异氟醚或丙泊酚联合芬太尼的麻醉后术后疼痛的影响。方法:随机,前瞻性,双盲实验,作者选择了80名施行子宫手术的女性患者,分别用异氟醚和丙泊酚麻醉。每个小组实验对象都随机使用了3mg烟碱或者安慰剂。应用先前提供数字化模拟量表评估疼痛。结果:在人口统计学上组间无差异。丙泊酚麻醉的病人比异氟醚麻醉的病人术后第一天的疼痛和吗啡用量均减少(P < 0.01, P < 0.01).。实验组中,烟碱并无镇痛作用,也不能减少吗啡用量(P > 0.05)。结论:丙泊酚全身麻醉相比异氟醚全身麻醉可以减轻术后的疼痛,减少吗啡的用量。本试验中烟碱无镇痛作用。如果上述结果在其他人群中得到证实,减轻术后疼痛以及改善术后恶心呕吐的发生率可以作为丙泊酚麻醉的潜在优点。

杜唯佳 陈杰 校)

BACKGROUND: Preclinical studies have suggested that some volatile anesthetics induce a hyperalgesic state that may be secondary to nicotinic inhibition. A previous trial of treatment with nicotine nasal spray demonstrated postoperative analgesia in women anesthetized with isoflurane. To determine whether the effect of nicotine was reversing hyperalgesia induced by isoflurane, or simply acting as an analgesic, we studied the effect of nicotine on postoperative pain in women anesthetized with isoflurane or propofol, with fentanyl.

METHODS: In a randomized, prospective, double-blind trial, we assigned 80 women having open uterine surgery to be anesthetized with isoflurane or propofol. Within each anesthetic group, the subjects were further randomly assigned to receive nicotine 3 mg or placebo. Pain reported with a numerical analog scale was the primary outcome variable.

RESULTS: The patient demographics were similar. Women who were anesthetized with propofol reported less pain and used less morphine during the first day after surgery than women who were anesthetized with isoflurane (P < 0.01, P < 0.01). Nicotine treatment did not change pain report or morphine use in either anesthetic group (P > 0.05).

CONCLUSIONS: General anesthesia with propofol and is associated with less postoperative pain and morphine use than general anesthesia with isoflurane. Nicotine was not analgesic in this trial. If these results are repeated in other populations, reduced postoperative pain can be added to the previously described improvement in nausea and vomiting as a potential benefit of anesthesia with propofol.

 

术后静脉自控镇痛(PCA)时吗啡与氯胺酮合用是否优于单独使用吗啡?

Is the Combination of Morphine with Ketamine Better than Morphine Alone for Postoperative Intravenous Patient-Controlled Analgesia?

Gorazd Sveticic, MD, Farzan Farzanegan, MD, Patrick Zmoos, MD, Sandra Zmoos, CRNA, Urs Eichenberger, MD, and Michele Curatolo, MD

From the Department of Anesthesiology, Inselspital, Bern, Switzerland.

 Anesth Analg 2008 106: 287-293.

 

背景:吗啡合用氯胺酮行术后自控镇痛被先前的基础与临床研究所支持,但随后的阴性结果对其结果提出挑战。先前研究的重要的局限在于样本数较少,吗啡与氯胺酮合用并不理想,相关结果未得到充分分析。本研究中作者进行了大样本的研究来比较吗啡合用氯胺酮与单用吗啡行术后自控镇痛的差别。作者应用先前研究中确定的吗啡-氯胺酮优化的方法。方法:对352例择期较大矫形手术的病人行术后自控镇痛,随机双盲分两组,一组176人为M组,给予1.5mg吗啡,另一组176人(MK组)给予吗啡与氯胺酮各1.5mg。不满意的镇痛定义为镇痛不够完善或出现令人难以接受的副反应。除此之外,记录PCA药总量,PCA持续时间,直接的医疗费用,以及术后3-6月慢性疼痛的病例数。结果:M组不满意的镇痛发生率为33.0% MK组为36.9%p=0.05)。组间无显著差异。结论:对于较大矫形手术患者小剂量氯胺酮联合吗啡用于术后自控镇痛并非有益,不必常规应用。

(宋翠侠 陈杰 校)

BACKGROUND: The addition of ketamine to morphine for patient-controlled analgesia (PCA) is supported by previous basic and clinical research, but has been challenged by subsequent negative studies. Important limitations of previous studies are the low number of patients analyzed, the use of morphine-ketamine combinations that may not the optimal, and that not all the relevant outcomes have been analyzed. In this study, we compared the combination of morphine and ketamine with morphine alone for postoperative PCA in large patient groups. We used a morphine-ketamine combination identified by an optimization procedure in our previous study.

METHODS: After major elective orthopedic surgery, 352 patients received either PCA with morphine bolus 1.5 mg (Group M, n = 176) or a bolus of morphine plus ketamine 1.5 mg each (Group MK, n = 176) in a randomized, double-blind fashion. Unsatisfactory treatment was defined as the occurrence of either inadequate analgesia or unacceptable side effects. In addition, total consumption of PCA drugs, duration of PCA use, direct medical costs, and number of patients with chronic postoperative pain 3 and 6 mo after operation were recorded.

RESULTS: The incidence of unsatisfactory treatment was 33.0% in Group M and 36.9% in Group MK (P = 0.50). No significant differences were found between the groups with respect to secondary end points.

CONCLUSIONS: Small-dose ketamine combined with morphine for PCA provides no benefit to patients undergoing major orthopedic surgery and cannot be recommended for routine use.

 

预先给予半数有效剂量的加巴喷丁对后路腰椎融合术后吗啡使用量的影响

The Median Effective Dose of Preemptive Gabapentin on Postoperative Morphine Consumption After Posterior Lumbar Spinal Fusion (Brief Report)

Alain C. Van Elstraete, MD*, Myriam Tirault, MD*, Thierry Lebrun, MD*, Ignace Sandefo, MD*, Jean-Christophe Bernard, MD*, Bruno Polin, MD*, Patrick Vally, MD{dagger}, and Jean-Xavier Mazoit, MD, PhD{ddagger}§

From the Departments of *Anesthesiology, {dagger}Neurosurgery, Centre Médico-Chirurgical Saint Paul, Fort-de-France, Martinique, France; {ddagger}Univ Paris-Sud, Laboratoire d’Anesthésie, Faculté de Médecine, F-94276 Le Kremlin-Bicêtre, France; and §AP-HP, Departement d’Anesthesie-Réanimation, Hôpital de Bicêtre, F-94275 Le Kremlin-Bicêtre, France.

Anesth Analg 2008 106: 305-308.

 

背景:预给单剂量的加巴喷丁可以减少术后疼痛和术后镇痛药的消耗。然而,其理想剂量有待研究。方法:在这一前瞻性研究中,作者以序贯增减剂量确定半数有效剂量的方法术前预先给予67名择期行后路腰椎融合术患者加巴喷丁。研究药物的有效性通过术后第一个24小时的吗啡需要量来评估。结果:加巴喷丁镇痛半数有效剂量(中值和95%可信区间)为21.7mg/kg19.9-23.5mg/kg

结论:由于需要给予大剂量的加巴喷丁,所以需要进一步开展研究来评估其副作用。

(胡潇 陈杰 校)

BACKGROUND: A single dose of preemptive gabapentin reduces postoperative pain and postoperative analgesic consumption. However, the optimal dose of preemptive gabapentin remains to be evaluated.

METHODS: In this prospective study, we defined the median effective analgesic dose using an up-and-down sequential allocation technique of preemptive gabapentin in 67 patients undergoing elective posterior lumbar spinal fusion. The efficacy of the study drug was assessed by morphine consumption during the first 24 h postoperatively.

RESULTS: The median effective analgesic dose (median value and 95% confidence interval) of gabapentin was 21.7 mg/kg (19.9–23.5 mg/kg).

CONCLUSION: Given the large dose of gabapentin needed, further powered studies are warranted to assess side effects.

 

利多卡因与布比卡因在临床疼痛模型中前列腺素E2的释放,环氧合酶基因表达和的疼痛影响的差异

The Differential Effects of Bupivacaine and Lidocaine on Prostaglandin E2 Release, Cyclooxygenase Gene Expression and Pain in a Clinical Pain Model

Sharon M. Gordon, DDS, MPH, PhD*, Brian P. Chuang, DMD, MS{dagger}, Xiao Min Wang, MD, PhD{ddagger}, May A. Hamza, MD¶, Janet S. Rowan, RN§, Jaime S. Brahim, DDS, MS||, and Raymond A. Dionne, DDS, PhD{ddagger}

From the *University of Maryland, School of Dentistry, Baltimore, Maryland; {dagger}Practice of Endodontics, Boston, Massachusetts; {ddagger}National Institute of Nursing Research; §Department of Nursing, Clinical Research Center; ||National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland; and ¶Department of Pharmacology, Faculty of Medicine, Ain Shams University, Cairo Egypt.

Anesth Analg 2008; 106:321-327

 

背景除了阻滞手术区域所引起的伤害性信号的传入,长效的局部麻醉药可能直接调制炎症反应。在本研究中,笔者描述了布比卡因导致受试者术后疼痛加重的局部前列腺素E2(PGE2)释放和环氧合酶(COX)基因表达等促炎效应。方法:114名进行第三磨牙拔除术的受试者中术前随机用2%的利多卡因或布比卡因进行局部麻醉,并在术前90分钟及随后48小时内给与罗非考昔50mg或安慰剂。在术前和术后48小时进行口腔粘膜活检。在拔牙术后将微渗析探针置于手术区域,检测PGE2和血栓素B2(TXB2)结果在术后第一个4小时通过视觉模拟评分评估疼痛显示布比卡因/罗非昔考组较其它三组相比,疼痛显著减少。然而,布比卡因/安慰剂组与其他三组相比在术后24小时疼痛更明显,术后4小时 PGE2的水平更高。且与利多卡因/安慰剂组相比其在48小时的COX-2基因表达显著增高。血栓素水平在各组中没有显著差异,说明此效果归于COX-2而不是COX-1结论结果显示布比卡因在组织损伤后促进COX-2基因的表达,在局麻效果消失后出现更多前列腺素E2的释放和疼痛加剧。

(潘方立 陈杰 校)

BACKGROUND: In addition to blocking nociceptive input from surgical sites, long-acting local anesthetics might directly modulate inflammation. In the present study, we describe the proinflammatory effects of bupivacaine on local prostaglandin E2 (PGE2) production and cyclooxygenase (COX) gene expression that increases postoperative pain in human subjects.

METHODS: Subjects (n = 114) undergoing extraction of impacted third molars received either 2% lidocaine or 0.5% bupivacaine before surgery and either rofecoxib 50 mg or placebo orally 90 min before surgery and for the following 48 h. Oral mucosal biopsies were taken before surgery and 48 h after surgery. After extraction, a microdialysis probe was placed at the surgical site for PGE2 and thromboxane B2 (TXB2) measurements.

RESULTS: The bupivacaine/rofecoxib group reported significantly less pain, as assessed by a visual analog scale, compared with the other three treatment groups over the first 4 h. However, the bupivacaine/placebo group reported significantly more pain at 24 h and PGE2 levels during the first 4 h were significantly higher than the other three treatment groups. Moreover, bupivacaine significantly increased COX-2 gene expression at 48 h as compared with the lidocaine/placebo group. Thromboxane levels were not significantly affected by any of the treatments, indicating that the effects seen were attributable to inhibition of COX-2, but not COX-1.

CONCLUSIONS: These results suggest that bupivacaine stimulates COX-2 gene expression after tissue injury, which is associated with higher PGE2 production and pain after the local anesthetic effect dissipates.