Table of Contents

January 2008

CARDIOVASCULAR ANESTHESIOLOGY:

七氟醚通過調節豚鼠心肌蛋白激酶c、線粒體ATP鉀離子通道和一氧化氮合酶增強乙醇的心肌缺血預適應作用

陶穎瑩 陳傑

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.

異氟烷預處理在大鼠梗死後重構心臟中保持抗缺血再灌注損傷的保護作用

黃施偉 譯,馬皓琳 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.

大鼠心肺分流術中使用全氟碳:與炎性所致不良後果有關?

吳威譯,薛張綱校

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.

手術期間輸入血小板和紅細胞對肝移植術後存活率的影響

楊衛紅

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.

經靜脈心內超聲心動圖在監測靜脈空氣栓塞和導管指導下空氣吸出中,優於心前區多普樂和經食道超聲心動圖技術

彭中美   馬皓琳 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:

對於小兒先天性缺陷疼痛評價工具的臨床實用性的評價

陳愷錚譯 薛張剛校

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.

右旋美托咪啶對兒童心臟電生理的影響

詹瓊慧 陳傑

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.

術中高碳酸血症在兒科患者視頻輔助下胸腔鏡檢查中的潛在治療作用

邱郁薇 馬皓琳 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.

兒童髂腹股溝/髂腹下阻滯:在非直視下我們把局麻藥打到哪里去了?

陳佳莉譯 薛張綱校

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.

持續鎖骨下臂叢神經阻滯:嬰幼兒手術中改良的方法能更好地保障導管位置

朱玫娟 陳傑

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

在用地氟醚和芬太尼進行麻醉的門診矯形手術中瑞芬太尼能否取代氧化亞氮?

唐亮   馬皓琳 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.

術前予米氮平可減少術前焦慮和術後噁心嘔吐(PONV

陳勇柱譯  薛張剛校

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.

震波碎石期間右旋美托咪啶與異丙酚的鎮痛作用的比較:隨機對照試驗

潘錢玲 陳傑

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.

氯胺酮治療術後寒戰的效能

吳進   馬皓琳 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.

對於插喉罩的病人異丙酚比硫噴妥鈉術後咽喉部病變發生率較低

陳珺珺譯  薛張綱校

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:

氙氣在人體中不影響氨基丁酸A型受體的結合

王騰 陳傑

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.

飼養的大鼠在血流動力學相似及沒有重大手術應激時麻醉對血漿葡萄糖和胰島素濃度以及心肌己糖激酶的影響

顏濤 譯,馬皓琳 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.

長期硬膜外輸注羅呱卡因對CYP2D6活性的影響

璿譯 薛張綱校

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:

頻譜熵是否可以反映丙泊酚與瑞芬太尼的聯合麻醉期間氣管插管或切皮反應?

王鵬 陳傑

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.

術中持續血糖監測的精確性

裘毅敏譯,馬皓琳 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.

腹腔鏡嗜鉻細胞瘤手術患者的即時心律變異性(HRV)及其與血漿兒茶酚胺水平的關係

秦佳譯 薛張剛校

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:

順應性和死腔分數預示麻醉病人恢復後最佳呼氣末正壓水平

於章傑 陳傑

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.

在人的屍體上比較兩種緊急環甲膜切開器械包

施楊譯,薛張綱校

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:

剖腹產分娩後腹橫機平面(TAP)阻滯的鎮痛效應:隨機對照實驗

張燕 陳傑

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:

丹曲林在新生小鼠腦組織中對低氧-缺血損傷的作用

沈浩   馬皓琳 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.

一項對於腦血流速率通過自發性波動產生動態自身調節的評估:對自身調節指數及平均流速指數這兩個模型的比較

孫霞譯,薛張綱校

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.

顱內壓監測在外傷性腦損傷中的應用(綜述)

印潔敏 陳傑

Monitoring Intracranial Pressure in Traumatic Brain Injury (Review Article)

Martin Smith

Anesth Analg 2008 106: 240-248.

GENERAL ARTICLES:Back

下半身加溫模仿正常硬膜外麻醉引起的寒戰閾值的降低

黃麗娜    馬皓琳 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電視喉鏡:100個患者的使用體驗

王光妍翻 薛張綱校

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:

丙泊酚麻醉的病人較異氟醚麻醉的病人具有較的術後疼痛

杜唯佳 陳傑

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.

用皮膚表面溫度來區分骨折後的複雜區域疼痛綜合症1型患者和骨折後有多種主訴的對照組患者

黃佳佳譯,馬皓琳,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.

腹腔術時呱羅呱卡因腹膜給藥的分佈和

王時來譯 薛張綱校

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.

術後靜脈自控鎮痛(PCA)時嗎啡與氯胺酮合用是否優於單獨使用嗎啡?

宋翠俠 陳傑

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.

一天兩次口服90mg尼美舒利並不影響胸外科大手術後嗎啡的需求量

姜旭暉   馬皓琳 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.

全膝成形術後小劑量羅呱卡因和芬太尼混合液中加入4mcg/ml的腎上腺素行腰段硬膜外鎮痛

張儷譯 薛張綱校

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.

預先給予半數有效劑量的加巴噴丁對後路腰椎融合術後嗎啡使用量的影響

胡瀟 陳傑

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.

腹式子宮切除術後嗎啡、呱替啶和曲馬多病人自控鎮痛效果的比較研究

唐李雋   馬皓琳 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.

在神經性疼痛大鼠模型中的作用時間延長了的硬膜外腔羅呱卡因的鎮痛效果

周時蓓譯,薛張綱校

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.

利多卡因與布比卡因在臨床疼痛模型中前列腺素E2的釋放,環氧合酶基因表達和的疼痛影響的差異

潘方立 陳傑

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.

關節內給予酮咯酸、嗎啡及羅呱卡因聯合關節內自控區域鎮痛用於緩解肩關節手術後的疼痛:一項隨機雙盲研究

胡湘   馬皓琳 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.

術前加巴噴丁:羅呱卡因蛛網膜下腔阻滯和血流動力學的影響

陳佳莉譯 薛張綱校

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.

人體腰椎脊神經根套囊的超微結構

慧譯 馬皓琳 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.

 

兒童髂腹股溝/髂腹下阻滯:在非直視下我們把局麻藥打到哪里去了?

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:外周神經阻滯的超聲顯像技術使我們能夠直視目標神經周圍的局麻藥的分佈。同樣,超聲顯像可以在使用定位技術時觀察局麻藥的分佈位置。我們做了一項研究來觀察在定位技術下兒童髂腹下/髂腹股溝神經阻滯時局麻藥的實際分佈位置,試圖以此來解釋無效的神經阻滯。方法:全麻誘導後(1MAC氟烷和喉罩通氣),對62個擇期行腹股溝手術的兒童在標準解剖定位下做髂腹下/髂腹股溝神經阻滯。然後使用超聲顯像來觀察局麻藥的實際分佈位置。麻醉醫生在無超聲指導下進行神經阻滯。如果局麻藥在神經周圍或者切皮後無臨床體征則被認為是成功的。結果:其中14%的神經阻滯是成功的,我們觀察到局麻藥恰分佈在神經周圍。在其餘的86%中,局麻藥分佈在解剖結構的附近(18%在髂肌,26%在腹橫肌,29%在腹內斜肌,9%在腹外斜肌,2%在皮下,2%在腹膜),這些情況下45%的阻滯是失敗的。結論:使用定位技術在兒童的髂腹下/髂腹股溝神經周圍準確地打局麻很少成功。在多數病人中,局麻藥不很精確地分佈在解剖結構的附近使得阻滯效果不完善。

(陳佳莉譯 薛張綱校) 

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.

 

術前加巴噴丁:羅呱卡因蛛網膜下腔阻滯和血流動力學的影響

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:加巴噴丁是一種輔助鎮痛藥,可能可以增加蛛網膜下腔阻滯的平面。我們研究術前給予加巴噴丁對蛛網膜下腔阻滯的特徵和血流動力學的影響。方法:隨機選擇70個用0.75%的羅呱卡因2.2 mL做腰麻行經尿道操作的病人,術前每6小時給他們400mg加巴噴丁或安慰劑,共計1200mg。每30分鐘測量一次感覺和運動阻滯平面直到感覺阻滯平面低於L4。在相同的時間間隔,記錄病人的血壓和心率。結果:兩組的感覺和運動阻滯平面沒有區別。加巴噴丁組的32個患者中有26個蛛網膜下腔注藥150分鐘後感覺阻滯平面退到L4,而對照組33個患者中有25個。加巴噴丁組的收縮壓降低了(P = 0.002 P = 0.03)。兩組的舒張壓沒有區別,但是總體上,加巴噴丁組的心率比較快。結論:預先給予加巴噴丁對感覺阻滯平面的範圍和運動阻滯平面的消退沒有影響,但是卻降低了用羅呱卡因進行腰麻的病人的收縮壓。

(陳佳莉譯 薛張綱校)

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電視喉鏡:100個患者的使用體驗

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

 

我們學習了Pentax-AWS(東京,日本)100個患者使用的有效性,它是一個新的便攜的,用電池的電視喉鏡。 100個患者中的99個患者在第一次放置喉鏡鏡片的時候順利完成操作並且見到了清晰的完整的聲門。餘下的未完成的患者是擔心破壞已經鬆動的牙齒,所以放棄置鏡片。98位患者順利完成只置管。氣管插管的平均時間為35s(範圍,5-120s)

(王光妍翻 薛張綱校)

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).

 

 

對於插喉罩的病人異丙酚比硫噴妥鈉術後咽喉部病變發生率較低

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.

 

插喉罩的病人術後易出現咽喉痛。誘導藥物的選擇對於插喉罩之後咽喉痛的發生率是重要的。我們做了研究,將340名病人分為兩組,分別給予2 mg/kg 異丙酚(P)5 mg/kg硫噴妥鈉(T),比較插入喉罩喉後咽喉部病變的發生率。術中50%空氧混合12MAC七氟烷維持。術中自主或輔助自主呼吸。研究者通過盲法在術後21224小時對病人進行隨訪。在每個時間點詢問病人是非題(是/否),包括有無咽喉痛、口瘡、顎部潰瘍、聲嘶、發聲困難和吞咽困難。術後2小時,T組咽喉痛、吞咽困難和術後噁心嘔吐的發生率高於P組(咽喉痛24 vs 13%,吞咽困難15 vs 3%,噁心20 vs 11%,嘔吐14 vs 6%,P< 0.05)。需要對症處理的咽喉痛和吞咽困難的人數分別是10人和8人(95%的置信區間是543)。我們得出了結論是,相比於硫噴妥鈉,異丙酚用於誘導插喉罩,咽喉部疾病的早期發生率和術後噁心嘔吐的發生率較低。

(陳珺珺譯  薛張綱校)

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.

 

對於小兒先天性缺陷疼痛評價工具的臨床實用性的評價

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:難以評價疼痛被認為是對於小兒先天性缺陷鎮痛不充分的基本原因之一。若干行為觀察疼痛工具對於這些患者有很好的心理學價值。然而,臨床常規使用可能更大程度上依賴於他們的實用性.我們設計這個課題來評估三種最近發明的對於小兒先天缺陷疼痛評價工具的臨床實用性和價值。

方法:來自三個臨床中心的臨床醫生作為樣本被要求觀看早先試驗中錄製的15個先天性缺陷患兒術後三天的情況的錄影。五名患兒曾參加rFLACC組(校正臉,腳,行為,哭喊,可安慰性)。五名參加NCCPCPV組(非交通性小兒術後疼痛檢查表),五名參與NAPI組(護士評估疼痛強度)。在他們看來所有片斷後,所有參與者完成CUAQ(臨床實用性評估表)包括臨床可行性,複雜性,相容性和相對優勢。結果:共有5名外科醫生和15名護士參與該試驗,對編碼疼痛評分(如輕度,中等,非常)和原先觀察者的rFLACC評分有很好的認識(88%-98%完全同意; {kappa}0.71–0.96),CUAQ組在內部的可信性或一致性上具有很高的價值({alpha} = 0.84–0.93)。r-FLACC NAPI 評分都比NCCPC-PV.要高。r-FLACC組和NAPI組在複雜性上有相似的評分,但在相容性,相對優勢和總的有效性方面比NAPI評分稍高。總結:我們發現r-FLACC組和NAPI組在複雜性,相容性,相對優勢,和總的臨床有效性方面都比NCCPC-PV組有優勢,認為這些工具可能可以應用於臨床工作。

(陳愷錚譯 薛張剛校)

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.

 

腹腔鏡嗜鉻細胞瘤手術患者的即時心律變異性(HRV)及其與血漿兒茶酚胺水平的關係

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:我們測量腹腔鏡嗜鉻細胞瘤手術患者的即時心律變異性及血漿兒茶酚胺水平,來評價心血管系統的短期調節機制。方法:我們招募了20例嗜鉻細胞瘤患者(group p)和20例其他偶發瘤患者(group I).持續監測HRV、動脈收縮壓和心律。低頻和高頻頻譜分別意味著交感和副交感系統活性。低頻與高頻比值可代表自主神經系統的平衡性。測量術前、術中和術後的腎上腺素、去甲腎上腺素水平。對多組記錄數值的平均值做直線回歸分析,並找出個變數的相關係數。

結果:group I組並未觀察到顯著變化。group p中所有病人在腹膜充氣和腫瘤切除時腎上腺素和去甲腎上腺素水平均升高。16個病人同時伴有收縮壓、心率、低頻和LF/HF比值的升高。3個病人的低頻和LF/HF比值降低。第四個病人出現低血壓和心動過速。15個病人高頻增強,5個病人保持穩定。低頻與去甲的相關性r = 0.68, P < 0.001,收縮壓r = 0.66, P < 0.01,心率r = 0.62, P < 0.05

結論:該實驗反映了嗜鉻細胞瘤手術中低頻HRV、血漿去甲腎上腺素水平、動脈壓和心律的密切關係。

(秦佳譯 薛張剛校)

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.

 

在人的屍體上比較兩種緊急環甲膜切開器械包

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:為了避免插入氣管導管時的損傷,我們比較了兩中緊急環甲膜切開器械包,一種是基於塞爾丁格技術,另外一種是基於對喉後壁的機械探測,並考慮到插入導管的時間,成功率和併發症的發生率。方法:在纖維支氣管鏡監控下對40個用Thiel技術保護好的屍體上進行環甲膜切開。器械包隨即分配使用:新技術或者塞爾丁格技術。在切開過程中,對成功率、喉損傷率進行比較。由纖維支氣管鏡發現的外傷性損害由解剖進行證實。結果:兩組屍體在流行病學和解剖學上具有可比性。用新技術比用塞爾丁格技術快(平均54秒比上71秒,P=0.01)。失敗率兩者相當(4個比上1個,P=0.34)。塞爾丁格技術對支氣管後壁損傷的併發症較少(0個對8個,P=0.003)。用塞爾丁格技術組中,只有4個屍體中發現了氣管後壁的點狀小損傷。結論:在這個模型中,除了插管時間縮短,新技術比塞爾丁格技術損傷更多,失敗率也較高。

(施楊譯,薛張綱校)

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.

 

腹腔鏡手術時呱替啶和羅呱卡因腹膜內給藥的分佈和臨床結果

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:很少有證據支持腹膜內注射呱替啶或局麻藥用於術後鎮痛是有效的。我們的研究目的是調查腹膜內給予呱替啶和羅呱卡因的鎮痛效果並檢測血漿濃度。無效假說是在腹腔鏡手術後的前24小時各組間的疼痛變化趨勢沒有明顯的區別。

方法:這是一個雙盲的隨機平行對照試驗,共分為五組,由兩個試驗中心把250名接受腹腔鏡手術的婦女隨機分為腹膜內注射呱替啶50100mg組(M50組和M100組),羅呱卡因150mgR150組),呱替啶50mg和羅呱卡因150mgM50R150組),都在肌內注射鹽水,或腹膜內注射鹽水、肌內注射呱替啶50mgC組)。主要的結果是恢復期間的活動後疼痛情況,獲得藥代動力學模型。

結果:在術後監護病房或其後的時間,各組間的活動後疼痛評分均數沒有顯著性的差異(C2.2[2.8]M502.5[3.3]M1001.6[2.5]R1502.6[3.2]M50R1502.7[3.2],P=0.50)。各組在靜息時的疼痛評分,靜脈注射嗎啡,恢復過程和病人的滿意度上也沒有顯著性差異。腹腔內注射50mg呱替啶後的血漿濃度(中位數為5560µg/L)大約是同等劑量肌內注射時(中位數為113µg/L)的一半。結論:與常規的阿片類藥物相比,腹腔內單獨或聯合注射呱替啶和羅呱卡因不能緩解腹腔鏡術後的疼痛或減少阿片類藥物的劑量。

(王時來譯 薛張綱校)

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.

 

術前予米氮平可減少術前焦慮和術後噁心嘔吐(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:米氮平是一種新的可阻斷5-HT2 5-HT3受體的抗抑鬱藥。因此,米氮平可能有抗焦慮和PONV的效果。因而,我們將檢驗術前予米氮平可減少術前焦慮和PONV的假設。

方法:80位行擇期婦科手術的至少具有兩種PONV危險因素的女性患者被入選。麻醉誘導前予8 mg地塞米松,患者被隨機分為M + D組(米氮平和地塞米松)和地塞米松組。術前1h30 mg米氮平或安慰劑。術前焦慮程度在給藥前和1h後以視覺類比評分法(VAS)來評估。全麻誘導用1%丙泊酚以200 mL/h的速度輸注(直至意識喪失),然後以七氟醚空氧混合維持。用聽覺誘發電位來檢測麻醉深度。PONV的發生率,止吐藥的應用,完全反應,術後Ramsay鎮靜分級評分及VAS疼痛評分將在術後1224h評估對比。

結果:M + D組的VAS焦慮評分在給予米氮平後降低。兩組間丙泊酚的誘導劑量,術中七氟醚的濃度及恢復時間無差別。0-24 h PONV完全反應的發生率在M + D組降低(80% vs 50%, P < 0.01)

結論:術前予30 mg米氮平可降低中高危女性患者的術前焦慮程度和發生PONV的風險。

(陳勇柱譯  薛張剛校)

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.

                                                         

在神經性疼痛大鼠模型中的作用時間延長了的硬膜外腔羅呱卡因的鎮痛效果

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:在臨床實踐中,治療慢性疼痛時,硬膜外腔給予局部麻醉藥的鎮痛作用的持續時間有時會長於根據藥物代謝動力學所推斷的持續時間。為了研究這延長的作用時間的潛在機制,我們研究羅呱卡因(一種局部麻醉藥)對於神經性疼痛大鼠模型的疼痛相關行為的作用。我們同時也分析神經生長因數(NGF)的表達。NGF和神經損傷後的傷害性回路的可塑性有關。方法:在坐骨神經慢性縮窄性損傷(CCI)所導致神經性疼痛的大鼠模型中,術後3天可以觀察到熱痛覺增敏和異常的機械性疼痛。CCI術後7-13天,經由硬膜外導管給與羅呱卡因或者生理鹽水,每天一次。用酶免疫測定法測定L4背側根神經結、皮膚、L4/5脊髓背側和坐骨神經的NGF含量。結果:在開始羅呱卡因治療後的4天,患CCI大鼠的同側掌墊從熱刺激物上縮回的時間點明顯延長,同時熱痛覺增敏也被很完全的緩解。同樣的,經羅呱卡因治療後,異常的機械性疼痛也得到部分程度的緩解。經羅呱卡因治療後的CCI大鼠,NGF濃度在同側L4背側根神經結是增加的,不包括對側的L4背側根神經結。結論:對於CCI大鼠,在硬膜外腔重複給與羅呱卡因能發揮鎮痛作用,可能是由於誘導傷害性回路的改變所致。

(周時蓓譯,薛張綱校)

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.

 

長期硬膜外輸注羅呱卡因對CYP2D6活性的影響

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:羅呱卡因及其產物呱啶甲酰胺(pipecoloxylidide)在離體狀態下抑制人的肝微粒體酶CYP2D6,抑制常數K(i)分別為5microM1.4mg/L)和13microM3.6mg/L)。我們研究了硬膜外連續輸注羅呱卡因(濃度2mg/mL,以14mL/h的速度輸注50h)對CYP2D6活性的影響。方法:選取19名行髖或膝置換術的病人(41-85歲),均為CYP2D6酶的強代謝者。不允許使用已知抑制CYP2D6活性或被其代謝的藥物、或者已知CYP1A2CYP3A4的強抑制劑/誘導劑。術前及硬膜外給藥40h後,給予患者10mg異喹胍(CYP2D6活性標誌物)。異喹胍的羥化代謝率(MR)由計算0-10h尿中排出的異喹胍/4-OH-異喹胍比值得出。結果:羅呱卡因輸注前後MR的中位數(範圍)分別為0.540.1-3.4)和1.790.3-6.7)。Hodges Lehman估計輸注後MR/輸注前MR2.295%可信區間為1.9-2.7P<0.001)。結論連續硬膜外輸注羅呱卡因抑制強代謝者的CYP2D6酶活性,使異喹胍羥化代謝率升高兩倍。然而,由於無一例患者被轉化為功能性的弱代謝者(MR>12.6),這種影響對其他通過CYP2D6酶途徑藥物代謝的臨床意義可能不大。

(羅 璿譯 薛張綱校)

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.

 

大鼠心肺分流術中使用全氟碳:與炎性所致不良後果有關?

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)乳劑是一種人工氧載體,被證明可以減弱空氣栓塞的效應。心肺分流術(CPB)中發生的腦血管空氣栓塞可能導致心臟術後腦功能的不良結局。我們設計了這個試驗來評估60%全氟碳乳劑(PTBCH)對大鼠心肺分流術後炎症的反應及神經認知功能結局的影響。

方法:經歷60分鐘心肺分流的28只大鼠被隨機分成兩個組:PTBCH心肺分流組接受3 mL/kgPTBCH加入靜脈貯血器而對照心肺分流組接受3 mL/kg的生理鹽水。在幾個時間點測量細胞因數白細胞介素(IL)-1ßIL-6IL-10以及腫瘤壞死因數(TNF)-a。神經功能的測試原定在術後使用Morris水迷宮試驗。組織學樣本在一系列獨立的試驗中取得。

結果:生理學變數在兩組間是可比較的,但與對照組相比,PTBCH心肺分流組需要更多新福林。在行心肺分流後的2小時及4小時,PTBCH組的細胞因數水平明顯高於對照組(P 0.05)。因為在PTBCH組中無一樣本存活,所以神經功能認知結局的評估無法進行。心肌組織學的分析顯示在PTBCH分流組存在更多收縮帶壞死的區域(P=0.034)

結論:在心肺分流中使用PTBCH與過度分泌細胞因數存在關聯。這種增強的炎性反應及後繼的低血壓可能導致了大鼠接受PTBCH後死亡率的增加。觀察到的此種心肌損傷的模式揭示了一種通用的血流灌注不足和兒茶酚胺過剩。

(吳威譯,薛張綱校)

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.

 

全膝成形術後小劑量羅呱卡因和芬太尼混合液中加入4mcg/ml的腎上腺素行腰段硬膜外鎮痛

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:研究已經發現在局麻藥和阿片類藥物的混合液中加入腎上腺素可以加強胸段硬膜外術後持續鎮痛的效果,但是在腰段水平還沒有證實。所以,我們研究了是否更高濃度的腎上腺素可以有加強腰段硬膜外的鎮痛效果。方法:在行全膝置換的病人術後2天中給予腰段硬膜外鎮痛,羅呱卡因1.8 mg/ml 以及芬太尼3mcg/ml,不加腎上腺素(組RFn=32)或者是加入腎上腺素4mcg/ml(組RFEn=31)。補救的鎮痛藥物包括硬膜外的研究混合液以及腸外給予羥考酮。結果:硬膜外藥物的總量在RFE組中明顯得較多。另外,該組中發生疼痛與不良反應與其他組沒有明顯區別。結論:作為多模式疼痛治療的一部分,全膝成形術後,添加腎上腺素4mcg/ml(12-32mcg/h)對腰段硬膜外鎮痛並無太大的加強作用。

(張儷譯 薛張綱校)

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.

 

一項對於腦血流速率通過自發性波動產生動態自身調節的評估:對自身調節指數及平均流速指數這兩個模型的比較

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:在臨床實踐中,各種方法包括:血流速度的自發性緩慢波動,動脈血壓,腦灌注壓等被用來評估腦血流自身調節。我們在一組頭部外傷的病人中研究自身調節的動態指數以及時間相關指數(平均流速指數)之間的關聯。

方法:被研究的50例頭部外傷病人,平均年齡30歲,其中有鎮靜用藥的,癱瘓的,機械通氣的(輕度過度通氣),採用連續監測動脈血壓及顱內壓。在頭部受創後的3天,每天監測一次腦血流速度,選在不進行干預治療(如吸痰)的時段。對記錄得到的資料進行回顧性分析。為了描述自身調節的動態模型,將自身調節計算成一個係數,分為0級(沒有自身調節)到9級(最強烈的自身調節)。平均流速指數被計算成一個血流速度在40個相鄰的6秒中的平均數及腦灌注壓的相關係數,然後在整個記錄時段內進行平均計算。將每個病人在受傷後頭3天記錄到的自身調節指數及平均流速指數進行平均化。

結果:自身調節指數和平均流速指數顯示了中等程度相關的線性關係,r0.62 P 0.0001。兩項指數在結局不佳的病人中顯示出預示預後及更壞的自身調節的一定關聯。結論:自身調節指數及平均流速指數在頭部外傷病人中契合的較好。自身調節影響頭部外傷後的預後。

(孫霞譯,薛張綱校)

                                                        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.

 

異氟烷預處理在大鼠梗死後重構心臟中保持抗缺血再灌注損傷的保護作用

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:心臟梗死後的重構可能會影響保護信號系統。我們驗證了異氟烷預處理在梗死後重構心臟中是否仍然保持保護作用。方法:通過結紮雄性Wistar大鼠冠脈的左前降支誘導心肌重構。6周後,病變的心臟被置於Langendorff裝置上行40min缺血加上90min的再灌注。1.5MAC2.1vol%)的異氟烷預處理15min。使用1%氯化三苯四唑染色測定梗死面積並通過測定釋放入灌流液中的乳酸脫氫酶(LDH)予以確證。一部分實驗中,在給予異氟烷的同時分別加入蛋白激酶B和線粒體ATP依賴性鉀通道的抑制劑LY29400210 µM)或5-羥基癸酸鹽(100 µM)。記錄心臟的功能。結果:冠脈永久結紮6周後,梗死大鼠的心臟重量/體重指數明顯增加(5.41 ± 0.64 vs 3.60 ± 0.59 g/kg, P < 0.0001),確定心臟重構伴代償性心肌肥厚。異氟烷預處理減少LDH釋放且梗死面積從32% ± 6%縮小到2% ± 2% P < 0.0001)。異氟烷合用LY2940025-羥基癸酸鹽完全取消了這種保護作用。功能評估也顯示重構心臟中異氟烷預處理對缺血後心肌頓抑有明顯保護作用,而兩種阻斷劑使用後均取消此作用。結論:在梗死後重構的大鼠心臟上,異氟烷預處理仍保持對缺血再灌注損傷的保護作用,其信號途徑與先前報導的在健康大鼠心臟上的相似。

(黃施偉 譯,馬皓琳 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.

 

經靜脈心內超聲心動圖在監測靜脈空氣栓塞和導管指導下空氣吸出中,優於心前區多普樂和經食道超聲心動圖技術

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:靜脈空氣栓塞(VAE)是坐位病人手術期間一種潛在的致命的併發症。因為用來發現持續性低容量VAE和定向吸氣的方法很有限,我們試驗了下列假設:經靜脈心臟內超聲心動圖(ICE1)與經食道超聲心動圖(TEE)和心前區多普勒監測(PCD)技術相比,改善小量空氣栓塞的發現,2)與在靜態位元用多孔中心靜脈導管吸引相比,圖像指導的多孔中心靜脈導管操作改善了在中等和大量VAE時的空氣恢復。方法和結果:成年豬(73 ± 4.6 kg, n = 7)術前給藥,用異丙酚和芬太尼麻醉,氣管內插管,機械通氣,放置頭高45度體位。第一,9個不同的小量空氣栓塞(0.05–1 mL)隨機通過耳靜脈注射,以隨機次序應用VAE發現方法。對於378個小量空氣注射,與TEE (52.8%)PCD (46.8%)相比,ICE發現VAE有較高的敏感性(82.5%, P < 0.0001),而在TEEPCD之間無差異(P = 0.571)ICE對於與0.15 mL一樣小的注射空氣容量的發現率為90%,而PCDTEE對於0.25–0.30 mL的空氣注射量的發現率僅50%,且空氣容量需要達到0.4–1.0 mL,發現率才能達到100%。第二系列研究中,評估中等VAE(2, 5, 10 mL)的空氣恢復;圖像指導下吸氣導管操作的心內空氣恢復明顯(34.1%17.2%, P < 0.0001)優於沒有導管操作。第三系列研究中,注射大劑量空氣(25, 50, and 100 mL),空氣恢復在超聲指導下吸氣沒有明顯差異(41.3%31.8%, P = 0.11)

結論:與PCDTEE相比,通過ICE發現小量空氣栓塞的敏感性高得多。而且,栓塞空氣的恢復可通過圖像指導下多孔中心靜脈導管的操作來增強效果。需要臨床研究來評估這一技術在坐位病人手術期間的應用。

(彭中美   馬皓琳 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.


術中高碳酸血症在兒科患者視頻輔助下胸腔鏡檢查中的潛在治療作用

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:二氧化碳充氣對行胸腔鏡檢查術患兒的心血管作用目前還沒有報導,但一些臨床試驗卻已證實了它對成年患者血流動力學的顯著不良影響。本實驗擬觀察治療性高碳酸血症對誘發的二氧化碳氣胸的血流動力學影響的抵消作用。方法:本實驗選取了12例行視頻輔助胸腔鏡下動脈導管閉合術的兒科患者。記錄基線(T1)以及在二氧化碳注氣後壓力為2mmHgT2)、4mmHgT3)、6mmHgT4)、8 mmHgT5)、10mmHgT6)時的心肺參數的。結果:二氧化碳充氣並未造成任何血流動力學不良影響。在整個研究中的心排血量以及中心靜脈氧飽和度進行性增高。與基線相比,峰流速、心率矯正後的收縮流動時間、心率和中心靜脈壓在注氣時明顯升高,而收縮壓和舒張壓保持不變。動脈血二氧化碳分壓從T1時點的40.7 ± 3 增加到T6時點的61 ± 1.6 mm Hg。動脈血氧分壓也從T1時點的170.9±3.3 增加到T6時點的182 ± 2mmHg。動脈血PH值從T1時點7.31 ± 1.2 下降到 T6時點7.14 ± 4.6 。結論:在視頻輔助胸腔鏡下行動脈導管封堵術的患者,單肺通氣時控制二氧化碳分壓在50-70mmHg的高二氧化碳血症可增加心排血量、中心靜脈氧分壓和動脈血氧分壓,同時不合併心肺不良影響。

(邱鬱薇 馬皓琳 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進行麻醉的門診矯形手術中瑞芬太尼能否取代氧化亞氮?

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

背景運用氧化亞氮(N2O)時常有些毒副作用。瑞芬太尼與N2O有一些相同的特點,包括降低MAC、鎮痛效果以及撤藥後臨床效應迅速減退。我們比較了用地氟醚和芬太尼加用臨床等效量的N2O或瑞芬太尼進行麻醉的門診矯形手術後的結果。方法:70名進行門診矯形手術的患者作為研究物件。35名患者予以66%濃度的N2O,而另外35名予以0.085µg · kg–1 · min–1瑞芬太尼的輸注,兩組患者都加以地氟醚使腦電雙頻指數(BIS)值滴定到50,並且輸注芬太尼。主要測量結果是到被言語刺激喚醒的時間。次要的結果指標包括神經心理測試、到有定向力的時間、血流動力學值、疼痛和噁心的視覺類比評分、出院時間和滿意度評分。測定呼氣末地氟醚濃度和芬太尼效應部位濃度的平均值。結果:瑞芬太尼組到被言語刺激喚醒的時間中位數(四分位距)為3.0 min (3.0–5.0 min)N2O組為4.6 min (3.0–8.1 min),兩組之間無顯著性差異。瑞芬太尼組到有定向力的時間中位數6.0 min (5.0–8.5 min),明顯比N2O組的8.0 min (5.0–12.8 min)快。兩組給予的地氟醚和芬太尼的量、神經心理測試以及其他的測量結果均無顯著性差異。

結論:這個研究證明了在地氟醚/芬太尼麻醉中0.085 µg · kg–1 · min–1瑞芬太尼輸注可以取代66%濃度的N2O而沒有明顯的臨床結果的改變。

(唐亮   馬皓琳 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.

 

氯胺酮治療術後寒戰的效能

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:關於氯胺酮在預防術後寒戰方面應用的報導很少。因此,我們把兩種劑量的氯胺酮在治療術後寒戰方面的效能與呱替定做了比較。方法:這是一個前瞻性的隨機雙盲研究,研究的物件是90ASA 評分I–II級的全麻後病人。寒戰評分34級的病人分成3組,分別靜脈注入呱替啶25mg、氯胺酮0.5mg/kg或氯胺酮0.75mg/kg。在設定的時間間隔裏監測寒戰和藥物的副作用。結果:氯胺酮組治療後的首個4分鐘裏的寒戰分級比呱替啶組低。然而,在兩個不同劑量的氯胺酮組中病人均出現眼球震顫並有飄走在空中的感覺。

結論氯胺酮0.5–0.75 mg/kg比呱替啶25mg在減少術後寒戰方面起效更快,但副作用可能會限制其有用性。

(吳進   馬皓琳 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.

 

飼養的大鼠在血流動力學相似及沒有重大手術應激時麻醉對血漿葡萄糖和胰島素濃度以及心肌己糖激酶的影響

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:近來的證據表明己糖激酶線粒體聯合體減弱細胞死亡,且血漿葡萄糖和胰島素濃度能夠影響臨床轉歸。在本研究中,我們檢驗了在血流動力學相似且無重大手術應激狀態下不同麻醉藥自身如何影響這些糖代謝變數。方法:測定戊巴比妥(PENTO)、異氟烷(ISO)、七氟烷(SEVO)、氯胺酮-美托咪定-阿托品(KMA)和蘇芬太尼-丙泊酚-嗎啡(SPM)麻醉下人工飼養大鼠心肌細胞己糖激酶定位和血漿葡萄糖及胰島素濃度,並將之與未麻醉大鼠(對照)的對應參數作對比。還檢測了肌纖維膜和線粒體KATP通道和α2腎上腺能受體在ISO誘發的高糖血症中的作用。結果:不同麻醉藥物下平均動脈壓相似。與對照動物(5.6 ± 0.1 mM)相比,PENTO(5.3 ± 0.2 mM) SPM (5.1 ± 0.2 mM)對血糖濃度沒有顯著影響。其他所有麻醉藥均導致高血糖症:7.4 ± 0.2 mM (SEVO), 9.9 ± 0.3 mM (ISO), and 14.8 ± 1.0 mM (KMA)。與對照(0.59 ± 0.22 ng/mL)相比,PENTO使胰島素濃度升高(2.13 ± 0.13 ng/mL),但其他麻醉藥不影響。使用5-羥基葵酸(5-hydroxydecanoate acid)抑制線粒體KATP通道或使用育亨賓抑制α2腎上腺能受體均不能防止ISO導致的高血糖。只有非選擇性的KATP通道抑制劑格列本脲能預防ISO導致的高血糖。不同藥物導致的胞漿HK相對總HK比例增加的順序是:對照 (35.5% ± 2.1%), SEVO (35.5% ± 2.7%), ISO (36.6% ± 1.7%), PENTO (41.2% ± 2.0%; P = 0.082與對照相比), SPM (43.0% ± 1.8%;與對照相比P = 0.039), and KMA (46.6 ± 2.3%;與對照相比P = 0.002)。結論揮發性麻醉藥和KMA導致的高血糖至少可以部分解釋為抑制葡萄糖誘發的胰島素釋放。本資料表明ISO對胰島素釋放的抑制是由肌膜KATP通道啟動介導的。使用PENTOSPM與高血糖無關,SPMKMA減低HK和線粒體結合所產生的抗凋亡作用。

(顏濤 譯,馬皓琳 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.


 

術中持續血糖監測的精確性

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

背景資料:在術中很難獲得一套嚴密的血糖控制方案,尤其當我們依賴於間斷的血糖測試時。持續的血糖監測系統能有利於血糖的控制。在本研究中,我們將術中持續監測的血糖(STG-22TM, Nikkiso, 日本東京)與用傳統實驗室血糖測量儀(ABLTM 800FLEX (Radiometer Medical Aps, BrFormula nshFormula j, 丹麥)間斷測得的血糖作比較,以判斷術中持續血糖監測法的可靠性及精確性。材料及方法:該研究納入了29個擇期在全麻下行常規手術的患者。全麻誘導後,在前臂外周靜脈置入20G靜脈套管針,並與持續血糖監測儀連接。置入橈動脈穿刺套管針,並由麻醉醫生從這裏收集血糖監測的標本。設定抽血方案:在抽取實際樣本血之前,先清除3 mL血液。樣本血抽取後立即用ABLTM 800FLEX檢測血糖。獲得100個配對的血糖值,並使用Bland and Altman分析法進行對比。結果:偏倚及一致性效度的上、下限分別為–2.623–28。一致性效度上、下限的百分誤差分別為21%18%。討論及結論:持續監測獲得的血糖值與同時間斷監測獲得的血糖值有21%的一致性。STG-22TM將有助於持續觀察改變及減少血糖間斷監測的頻率,但仍不可排除使用可靠設備進行血糖監測的需求。

(裘毅敏譯,馬皓琳 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.


丹曲林在新生小鼠腦組織中對低氧-缺血損傷的作用

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

背景資料:低氧或缺血引起的腦組織損害的病理生理學已被歸於很多機制和級聯。其已涉及細胞內鈣超載以及鈣興奮性毒素級聯。有證據表明內質網鈣平衡奈亂與神經細胞損傷的誘發有關。兩種細胞內鈣釋放通道(包括ryanodyne受體和肌醇(145)-三磷酸受體)對於細胞內Ca2+信號肽必不可少。已有報導用來治療惡性高熱綜合征的丹曲林可以通過ryanodyne受體抑制鈣從內質網釋放到細胞溶質中。我們設計了這個實驗以觀察丹曲林在新生大鼠腦中對缺氧-缺血性腦損傷的神經保護作用。方法:7天大的SD大鼠分為兩組;對照組(n=69)和丹曲林組(n=60)。在缺氧-缺血性腦損傷(HII)前對照組用二甲亞碸進行腦室內注射,丹曲林組在二甲亞碸中添加丹曲林進行腦室內注射。通過在異氟醚麻醉下結紮頸總動脈,然後產生2.5小時的低氧狀態(氧濃度維持在7-8%)來誘發HII。在HII後一天進行1H磁共振波譜分析。用這種無創傷方法來評價HII後的腦細胞的凋亡過程。HII14天用235-氯化三苯四唑染色來進行組織形態學分析和計算梗塞範圍的百分比,從而用來評價丹曲林對HII的作用。另外24只大鼠在HII後一天進行末端去氧核苷酰基轉移酶介導性dUTP切口末端標記(TUNEL)染色。結果:丹曲林組右半球腦組織中脂類/肌酸比值在HII後一天顯著降低於對照組(P<0.05)。兩組之間N-乙酰天門冬氨酸/肌酸比值沒有明顯差異。總體形態學評分丹曲林組低於對照組(P<0.05),丹曲林組HII14235-氯化三苯四唑染色後的梗塞面積(%)顯著小於對照組(P<0.05)。但是在24只大鼠的進一步工作顯示TUNEL陽性細胞數目在兩組間沒有顯著差別。

結論:我們的結果提示在HII前腦室內給予丹曲林在新生大鼠腦的HII模型中可以起到神經保護作用。

(沈浩   馬皓琳 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.


下半身加溫模仿正常硬膜外麻醉引起的寒戰閾值的降低

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:軸索麻醉降低寒戰閾值約0.6°C。這種作用可能會被下半身溫度的明顯(與實際相反的)升高所介導。相應地,下半身的加溫會引起與硬膜外麻醉的突出作用相同的溫度調節的抑制。我們驗證了這一假說,即增加腿的皮膚溫度到38°C可以模仿硬膜外麻醉過程中寒戰閾值降低{approx}0.6°C

方法:體內變冷過程中的寒戰閾值由9名女性志願者在不同的2天內測得:一天是沒有麻醉的對照天,一天是在T10-11硬膜外阻滯的情況下。在進行研究的每一天,下半身的皮膚溫度保持接近38°C,而上半身的皮膚溫度接近33°C。我們應用兩個單側檢驗方法評價了對照天和硬膜外阻滯天寒戰閾值的相等性。

結果:在對照天和硬膜外阻滯天的閾值分別是35.8°C ± 0.5°C35.8°C ± 0.5°C,這兩個值是相等的,因為差異的95%可信區間為0.0 (–0.4, 0.4),在我們事先說明的範圍–0.6°C +0.6°C 內(P < 0.025,單側等價檢驗)。

結論:下半身加溫模仿正常硬膜外麻醉引起的寒戰閾值下降。我們的結果支援了以軸索麻醉中明顯增加下半身體溫為基礎的機制。

(黃麗娜    馬皓琳 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.


用皮膚表面溫度來區分骨折後的複雜區域疼痛綜合症1型患者和骨折後有多種主訴的對照組患者

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:在這項研究中,我們評估了通過用於溫度記錄資料的各種計算方法得到的皮膚表面溫度記錄來診斷急性骨折後複雜區域疼痛綜合症1型(CRPS1)患者的有效性。方法:記錄CRPS1患者及和CRPS1患者有/無和無相似主訴的對照組骨折患者去除石膏後手掌/腳掌和相應背面的體表溫度,一共三組120位患者。用受試者操作特徵分析來比較應用於溫度記錄資料的各種計算方法以得到診斷價值的指證。結果:三組之間體溫資料和特徵間無顯著性差異。三組間最大的差異為CRPS1患者的血管舒縮徵象。CRPS 1患者受傷的一側一般比另一側未受傷肢更暖和。受傷部位與未受傷肢之間的溫度差異在CRPS1 患者中與兩個對照組明顯不同。發現CRPS1患者的兩側肢體間的溫度差異最大。三組患者手掌/腳掌側和背側間溫度記錄值的差異均不明顯。用來計算肢體間溫度差異的各種計算方法之間的特異性及敏感性顯著不同。最高的敏感性和特異性分別為71%64%,最高陽性預測值為35%,最高陰性預測值為84%,曲線下面積中等區間為60%-65%。結論:用靜息狀態下皮膚表面溫度來區分急性CRPS 1骨折患者和有/無主訴的對照組骨折患者的有效性有限,只能用作輔助性診斷工具。

(黃佳佳譯,馬皓琳,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.


一天兩次口服90mg尼美舒利並不影響胸外科大手術後嗎啡的需求量

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:已經證實抑制環氧化酶2可以在很多外科手術中起到鎮痛功效。我們假設圍術期抑制環氧化酶2可以顯著減少胸外科大手術術後嗎啡的需求量,同時研究了這個潛在鎮痛作用的效應部位。方法:這個單中心、雙盲、隨機化、安慰劑對照和平行組試驗共有92例病人參加。年齡在1880歲之間、接受胸廓切開或正中胸骨切開的病人在圍術期被隨機給予標準的鎮痛方式聯合尼美舒利或者安慰劑。尼美舒利在手術前夜給予一次和術後5天每12小時給予一次口服。主要的功效變數為術後第一個48小時內嗎啡消耗量和疼痛評分。次要的功效變數為尼美舒利在腦脊液中對環氧化酶活性的影響。結果:術後第一個48小時病人靜息或活動時的疼痛評分和總嗎啡消耗量在兩組間沒有統計學差異。兩組間術後48小時嗎啡總消耗量平均差異為尼美舒利組減少9.0 mg(95%可信區間為–28.910.9 mg) (P = 0.37)。術後兩天腦脊液中6-keto-PGF1{alpha}濃度的校正均數(標準誤)在安慰劑組比術前增加54.7 (25.7) pg/mL,而在尼美舒利組減少0.6 (18.2 pg/mL),這些變化沒有統計學差異(P = 0.095)。結論:一天兩次給予尼美舒利90mg結合標準的鎮痛方法並不能影響胸外科較大手術後的疼痛評分、嗎啡需求量和腦脊液中前列腺素的水平。

(薑旭暉   馬皓琳 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.


腹式子宮切除術後嗎啡、呱替啶和曲馬多病人自控鎮痛效果的比較研究

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

我們設計了這個前瞻、隨機、雙盲研究,以比較嗎啡、呱替啶和曲馬多經靜脈病人自控鎮痛用於術後疼痛控制的鎮痛效果和副作用。126ASA  III級、行腹式子宮切除術的患者,隨機分為經靜脈病人自控嗎啡組(M)、呱替啶組 (P)和曲馬多組(T)進行術後鎮痛。24小時累計鎮痛消耗量為嗎啡25.7 ± 9.5 mg、呱替啶266 ± 90 mg和曲馬多320 ± 10 mg。追加芬太尼的平均劑量T組顯著高於M組和P(P < 0.05)。總之,嗎啡、呱替啶和曲馬多導致相等的疼痛評分和副作用,但曲馬多組(T)需要較多的芬太尼補救鎮痛劑量。

(唐李雋   馬皓琳 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.


關節內給予酮咯酸、嗎啡及羅呱卡因聯合關節內自控區域鎮痛用於緩解肩關節手術後的疼痛:一項隨機雙盲研究

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:在這項研究中,我們評估了關節內區域鎮痛對術後疼痛的效果及鎮痛藥需要量。方法:51位行肩關節手術(Bankart)的病人參與了此次雙盲研究。在手術結束時,病人隨機分成三組通過導管接受關節內給藥:組1:羅呱卡因90mg(9ml)、嗎啡4 mg(10ml) 和酮咯酸 30 mg (1 mL) ( 20 mL); 2 3: 鹽水(20 mL) 另外, 1 3 接受1 mL 鹽水靜注而組 2接受酮咯酸30 mg (1 mL) 靜注。手術後,組1在需要時經關節內導管給予0.5%羅呱卡因10mL減輕疼痛,而組23接受10mL鹽水關節內注射。組3 為對照組。

結果:術後最初30120分鐘裏組1的靜止和活動後疼痛分別較組23要輕。最初需要局麻藥輸注的時間在組1要較組23長(P<0.001)。術後最初24小時裏嗎啡的用量中位數組12要較組3小(P<0.001)。鎮痛藥消耗量在組1與組2之間沒有顯著性差異。滿意度分數的中位數組1要高於組2p<0.05)和3(P<0.001) 結論:關節內聯合應用羅呱卡因、嗎啡和酮咯酸及後按需間斷注射羅呱卡因與對照組相比較,提供較好的鎮痛,減少嗎啡使用量和提高病人的滿意度。靜脈注射酮咯酸較對照組嗎啡用量減少及病人滿意度更高。

(胡湘   馬皓琳 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.


 

人體腰椎脊神經根套囊的超微結構

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:脊神經根套囊可能與選擇性的神經根和硬膜外阻滯有關。方法:我們利用組織染色法、傳染和掃描電子顯微鏡檢查觀察6名人類屍體的脊神經根套囊的超微結構,如細胞和纖維成分。結果:脊神經根套囊的形態學特徵類似脊髓硬膜下間隙。細胞通過特殊連接聚集在緻密層。細胞層的厚度為58微米;細胞平行於所屬神經根方向排列。纖維成分主要由膠原纖維組成,存在於脊神經根套囊的外部,測得厚度為100150微米。大量脂肪細胞在同心層分隔硬膜層,從硬膜囊延伸到脊神經根神經節。然而,硬膜囊層中並沒有找到脂肪細胞。結論:少量毛細管的存在及脂肪和軸突間較短的距離可能影響硬膜外注射物質進入神經根軸突的通路。

(朱 慧譯 馬皓琳 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.

 

七氟醚通過調節豚鼠心肌蛋白激酶c、線粒體ATP鉀離子通道和一氧化氮合酶增強乙醇的心肌缺血預適應作用

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:使用吸入性麻醉藥以及一般飲酒行為都會產生類似心肌缺血預處理效應而表現出心肌保護作用。本文作者研究了七氟醚是否能增強乙醇產生的心肌缺血預適應作用以及是否抑制心肌蛋白激酶c、線粒體ATP鉀離子通道時會減弱其心肌保護作用。另研究了一般飲酒行為能否誘導內皮型一氧化氮合酶(eNOS)以及誘導型一氧化氮合酶(iNOS)的表達。法:對照組(CTL)豚鼠離體心肌先進行30min全心停灌後120min再灌處理。乙醇組(ETOH)的豚鼠先前六周內予以飲用水中加入2.5%乙醇處理再取心肌標本。ETOH組再用麻醉藥物的預處理(七氟醚1MAC2%,10min)為 EtOH + SEVO組,乙醇未處理而用七氟醚處理為SEVO組。試驗中使用白屈菜紅堿、5-羥基癸酸分別抑制心肌蛋白激酶c、線粒體ATP鉀離子通道。記錄左心室發展壓(LVDP)、左心室舒張末壓(LVEDP)反映心肌收縮力恢復程度;TTC染色法檢測心肌梗死面積,蛋白質印跡分析法檢測內皮型一氧化氮合酶(eNOS)以及誘導型一氧化氮合酶(iNOS)表達量。

結果:心肌細胞進行缺血再灌注處理後與對照組相比EtOH + SEVO組、EtOH 組和SEVO組的左心室發展壓(LVDP)均增高,而左心室舒張末壓(LVEDP)均降低。EtOH 組和SEVO組的心肌梗死面積(分別為27%23%)與對照組(45%)相比顯著減少(P<0.001 EtOH + SEVO組心肌梗死面積減少更顯著(15%P<0.001)。白屈菜紅堿、5-羥基癸酸在EtOH 組和SEVO組中均能減弱原本的心肌保護作用。EtOH 組中iNOS表達下降而eNOS表達增加。

結論:七氟醚能增強乙醇的心肌缺血預適應作用。而其機制可能與調節蛋白激酶c、線粒體ATP鉀離子通道以及NOS表達量相關。

(陶穎瑩 陳傑 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.

 

手術期間輸入血小板和紅細胞對肝移植術後存活率的影響

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:手術期間紅細胞輸入與原位肝移植不良預後相關。雖然實驗研究已經證明血小板與肝臟再灌注損傷有關,但是輸注同種異體血小板對預後的影響尚未詳細研究。本研究中,作者評估了不同血製品對原位肝移植預後的影響。方法:作者對1989年到2004年之間行第一次原位肝移植的433例病人預後相關的29個變數,包括血製品的輸注等進行了研究。資料採用了單變數和多變數逐步Cox’s比例危害分析,並採用傾向資料調節分析來調整使用血製品中的偏差。結果:輸注血製品的移植病人比例從19891996年的100%到19972004年的74%。在單變數和多變數分析中,移植的指征,輸注血小板和紅細胞對預測移植病人一年存活率密切相關。這些危險因素與公認的疾病指數,如終末肝病指數和Karnofsky評分無關。一年生存率的影響與血小板(P0.01)危害指數1.377/U、紅細胞(P0.0011.057/U劑量相關的。血小板輸注對存活率呈負性影響。結論:這項回顧性研究顯示除了紅細胞,血小板輸注是原位肝移植存活率的獨立影響因素。這些研究發現對於肝移植受體臨床液體治療來說非常重要。

(楊衛紅 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.


右旋美托咪啶對兒童心臟電生理的影響

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腎上腺素能受體激動劑,食品藥物管理局已批准使用于成人短時間的鎮靜(<24小時)。但在兒童中的使用尚未批准。儘管如此,右旋美托咪啶用於嬰兒和兒童的鎮靜及麻醉已逐漸增多。該藥在血流動力學方面有一定的影響,包括心動過緩、高血壓、低血壓等。目前尚沒有右旋美托咪啶對心臟傳導系統方面影響的資料。因此,作者研究了右旋美托咪啶對兒童患者心臟傳導的影響。方法125-17歲接受電生理研究並進行室上旁路消融術的兒童在使用右旋美托咪啶前和使用過程中測定了血流動力學和心臟電生理的有關參數。右旋美托咪啶的使用劑量為前10min1ug/kg靜脈注射持續輸注,10min後以0.7ug/kg/h維持。結果:使用右旋美托咪啶後動脈血壓顯著增加,心率顯著減慢。竇房結功能明顯受到影響,竇房結週期和恢復時間延長。房室結功能也受到抑制, Wenckeback環路和PR間期均延長。結論:在兒童患者中右旋美托咪啶顯著抑制竇房結和房室結功能,並致血壓增高和心率減慢。在電生理研究中不宜使用右旋美托咪啶,存在心動過緩和房室結阻滯等高危因素的患者,右旋美托咪啶可能引起副作用。

(詹瓊慧 陳傑 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.

 

持續鎖骨下臂叢神經阻滯:嬰幼兒手術中改良的方法能更好地保障導管位置

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

.

介紹:臂叢神經阻滯時採用鎖骨下方法可以達到合適的麻醉效果,並且就其本身來說更有利於持續輸注時固定和管理導管。作者介紹了一種兒童手術中採用鎖骨下法來進行持續注射的方法。方法:研究物件是25名年齡從8月到3歲,體重7-14公斤,接受擇期前臂或者手部手術的兒童。採用附帶有19G套管Touhy針的神經刺激儀進行鎖骨下臂叢阻滯。進針點為鎖骨中點的下1cm和外側1cm。進針朝向喙突,保持針和皮膚成30°角。通過Touhy針放置20號硬膜外導管,深度為5-7cm。拔出Touhy針,保留導管。通過導管給予1ml/kg0.25%的布比卡因。在手術結束時開始以0.25mg/kg/h的速度持續給予0.125%布比卡因,直到術後第一天。術後第二天停止持續輸注,改為每4-6小時間斷給予單次注射。術後48h,拔除導管。結果:24名患者阻滯效果滿意(占96%)。術後第一天,所有患者均未感覺明顯疼痛(東安大略省兒童醫院疼痛指數為4-6)。術後第二天,有兩名兒童需要在足夠劑量的局麻藥外複合布洛芬糖丸。除了4名兒童,其餘的導管都很容易被拔出。在這四名患者中,因為放置的導管有輕度成角,所以在拔出時需要給予1-2ml局麻藥來克服阻力。未出現導管移動或者拔出時發生意外,出血或氣胸。結論:在兒科患者中,改良的持續鎖骨下臂叢神經阻滯有助於固定導管,並提供有效的術中和術後疼痛緩解。

(朱玫娟 陳傑 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.

 

震波碎石期間右旋美托咪啶與異丙酚的鎮痛作用的比較:隨機對照試驗

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:由於右旋美托咪啶具有鎮靜及鎮痛兩種作用,所以可能適用于疼痛時的清醒鎮靜。體外震波碎石(ESWL)有輕微疼痛需清醒鎮靜。因此作者在ESWL時比較右旋美托咪啶及異丙酚的作用。方法46名病人擇期行ESWL,隨機分成兩組。分別接受右旋美托咪啶或異丙酚。右旋美托咪啶以6ug.kg-1.h-1注射10min,隨後以0.2 ug.kg-1.h-1速率注射。異丙酚以 6ug.kg-1.h-1注射10min,接著以2.4ug.kg-1.h-1速率注射。所有的病人在接受ESWL10min靜推1ug/kg的芬太尼。在接受ESWL1035min)時,每隔5min用視覺類比量表進行疼痛程度的評估。鎮靜作用則用觀察者警覺與鎮靜評分。在接受ESWL及之後的85min有規則的記錄鎮靜評分及血液動力學變化與呼吸的變數。結果:40名患者接受評估。使用右旋美托咪啶後僅在2535min時視覺類比量表值低於使用異丙酚的(P<0.05)。在鎮靜狀態時,使用右旋美托咪啶的病人呼吸頻率明顯要比使用異丙酚的慢,但是SpO2較高(P<0.05,其他變數則相似(P>0.05)。結論:在ESWL時使用右旋美托咪啶及芬太尼的混合物用於鎮靜及鎮痛是安全有效的方法。

(潘錢玲 陳傑 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.

 

氙氣在人體中不影響氨基丁酸A型受體的結合

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

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背景:稀有氣體氙氣作為一種麻醉氣體具有較好的血流動力學和神經保護的特性。動物和體外研究資料顯示,氙氣以抑制谷氨酸信號來發揮其麻醉作用的,但也有作用於GABA受體的報導。因此,氙氣在人大腦中的麻醉作用機理仍需進一步研究。方法:以特異性的GABA受體苯二氮卓類結合位點11C配體氟馬西尼和正電子體層掃描術(PET)研究8 名健康男性志願者中氙氣對GABA能的影響。每一個志願者都經過兩個動態的60minPET,研究清醒及一個MAC值下(約65%氙氣)BIS值。用自動化的興趣區域和CT顯影基礎分析法分析皮質和皮質下的灰質區。結果:在麻醉過程中,BIS23±7(平均值±標準差),心率和平均動脈壓上均無顯著變化。在大腦任何區域內氙氣對11C—氟馬西尼均無明顯的影響。結論:氙氣在人類大腦中不會影響11C—氟馬西尼的作用。因此,氙氣的麻醉效果不是由GABA受體體系介導的。

(王騰 陳傑 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.

 

頻譜熵是否可以反映丙泊酚與瑞芬太尼的聯合麻醉期間氣管插管或切皮反應?

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:頻譜熵是一種基於腦電圖監測技術的一種擴大的包含著肌電頻譜的頻率帶,預期有助於評估鎮痛效能。雖然它與催眠狀態的相關性已經被證明,但是在有害刺激和神經肌肉阻斷時的情況下尚未研究。

方法:在這個前瞻性、開放、多中心的研究中,105名病人在接受丙泊酚輸注後,靶控輸注瑞芬太尼進行麻醉誘導,瑞芬太尼的靶濃度為28ng/ml。一半的病人接受神經肌肉阻滯劑。氣管插管和切皮作為有害刺激的標準,記錄運動和血流動力學的反應,比較刺激前後有無反應的病人之間頻譜熵值。

結果:對刺激有或無血流動力學的反應病人間反應熵,狀態熵或兩者差均無顯著差異。病人對氣管插管有運動反應的病人比沒有反應的病人有更高的反應熵,狀態熵或兩者差。這些結果可通過預測概率分析所證實,熵值只對運動反應具有意義的但較弱的預測價值。

結論:熵值能預測對傷害性刺激的運動反應而不能預測血流動力學的反應,這在肌肉麻痹病人的麻醉鎮痛方面的評估中受到了限制。應當避免刺激前熵值較高(RE >55),以免發生運動反應。儘管有足夠的催眠作用,當鴉片類用藥不夠時較低熵值不能防止運動反應。

(王鵬 陳傑 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.

 

順應性和死腔分數預示麻醉病人恢復後最佳呼氣末正壓水平

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

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背景:最佳呼氣末正壓(PEEP)可定義為:可預防複張後再萎陷、避免過度擴張,在最小的死腔通氣情況下達到理想的肺力學狀態的PEEP。此項研究中,作者通過功能殘氣量(FRC)、順應性、動脈氧分壓(Pa02)和死腔分數來分析PEEP和複張的效應。方法: 20名行面頜手術、肺部情況正常的麻醉病人。在壓力控制通氣模式來使用階梯式提高PEEP/吸氣壓力(0/10, 5/15, 10/20, 15/25cm H2O, 每個水平維持20分鐘)後,進行肺複張動作(20/45 cm H2O,最長20分鐘),接著逐漸減小壓力(15/25, 10/20, 5/15, 0/10 cm H2O,每個水平維持20分鐘)。在每個壓力水平測量FRC、順應性、Pa02和死腔分數。結果:比較同一PEEP水平時複張前後的數值時,所有變數都在10/20cm H2O水平有顯著變化;順應性在15/25cmH2O壓力水平有顯著升高。另外,FRC指標在5/15cm H2O15/25cm H2O水平之間有顯著差異。結論:所有變數都顯示了PEEP聯合肺複張的正效應。最佳的PEEP10cm H2O,因為在此壓力水平下能達到最高的順應性和最低的死腔分數,反應了最大的肺泡擴張量。FRCPa02對肺泡過度擴張不敏感。

(於章傑 陳傑 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.

 

剖腹產分娩後腹橫機平面(TAP)阻滯的鎮痛效應:隨機對照實驗

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阻滯為腹壁中線切開手術患者提供一種有效術後鎮痛的方法。在一項隨機、對照、雙盲臨床實驗中,作者評估了這一方法用於Pfannensteil式剖腹產術後48小時鎮痛效果。方法: 隨機選擇正在接受剖腹產分娩的50名婦女,隨機接受TAP阻滯,分別使用羅呱卡因(n= 25)和安慰劑( n = 25 ,除了標準的術後病人自控嗎啡鎮痛和定期雙氯芬酸以及對乙酰氨基酚鎮痛。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.所有病人施與標準脊椎麻醉,並在術畢給與羅呱卡因(1.5mg/kg,一次最大劑量為150mg)或生理鹽水來進行雙側TAP阻滯。在麻醉後恢復室及術後24612 24 3648h對患者進行盲法評估術後採用。結果: 同安慰劑組相比,羅呱卡因TAP阻滯後術後視覺類比疼痛評分較低。術後48小時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.嗎啡平均需求量減少( 66± 2618± 14mg; p < 0.001 ),同時,術後12小時到36小時期間嗎啡消耗量減少。 接受TAP阻滯的患者The incidence of sedation was reduced in patients undergoing TAP blockade.鎮靜發生率也較低。There were no complications attributable to the TAP block.沒有歸因於TAP阻滯的併發症。結論: TAP阻滯TAP作為多重模式鎮痛的組成部分,對擇期剖腹產患者能提供較安慰劑具有更有效的術後48小時的鎮痛。

(張燕 陳傑 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.

 

顱內壓監測在外傷性腦損傷中的應用(綜述)

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.

 

顱內壓增高(ICP)是導致繼發性腦損傷的一個重要因素,ICP監測已成為顱腦外傷監測的常規組成部分。ICP無法依據特殊的臨床體征或CT表現確診,因此需要正確測量。ICP監測有許多方式,目前臨床實踐中應用最廣的是腦室內導管以及微感測器測壓系統。ICP是一個與腦灌注壓相關聯的複變數,通過識別和分析ICP波形圖還可以得到更多的病理學資訊。另外還可以通過測得腦血管壓力反應性和壓力-容積代償儲備量的指數進一步增進ICP監測。不同顱腦外傷醫療中心對ICP的監測和治療方式有很大差異。然而,大量臨床證據支持ICP監測可幫助早期檢出顱內腫塊,指導介入治療,評價預後,是顱腦外傷推薦使用處理原則。對於ICP監測和治療在顱腦外傷後的價值還有待前瞻性的隨機對照試驗來確定。

(印潔敏 陳傑 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.

 

丙泊酚麻醉的病人較異氟醚麻醉的病人具有較的術後疼痛

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:臨床前研究發現一些吸入麻醉藥引起的疼痛高敏狀態可能繼發於煙鹼樣作用的受抑。先前的一項研究顯示異氟醚麻醉的女性病人鼻吸入煙鹼具有術後鎮痛效應。為了研究煙鹼是否能夠逆轉異氟醚的疼痛增敏作用,或是僅僅表現為鎮痛效應,作者研究了煙鹼女性患者在異氟醚或丙泊酚聯合芬太尼的麻醉後術後疼痛的影響。方法:隨機,前瞻性,雙盲實驗,作者選擇了80名施行子宮手術的女性患者,分別用異氟醚和丙泊酚麻醉。每個小組實驗物件都隨機使用了3mg煙鹼或者安慰劑。應用先前提供數位化類比量表評估疼痛。結果:在人口統計學上組間無差異。丙泊酚麻醉的病人比異氟醚麻醉的病人術後第一天的疼痛和嗎啡用量均減少(P < 0.01, P < 0.01).。實驗組中,煙鹼並無鎮痛作用,也不能減少嗎啡用量(P > 0.05)。結論:丙泊酚全身麻醉相比異氟醚全身麻醉可以減輕術後的疼痛,減少嗎啡的用量。本試驗中煙鹼無鎮痛作用。如果上述結果在其他人群中得到證實,減輕術後疼痛以及改善術後噁心嘔吐的發生率可以作為丙泊酚麻醉的潛在優點。

杜唯佳 陳傑 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.

 

術後靜脈自控鎮痛(PCA)時嗎啡與氯胺酮合用是否優於單獨使用嗎啡?

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:嗎啡合用氯胺酮行術後自控鎮痛被先前的基礎與臨床研究所支持,但隨後的陰性結果對其結果提出挑戰。先前研究的重要的局限在於樣本數較少,嗎啡與氯胺酮合用並不理想,相關結果未得到充分分析。本研究中作者進行了大樣本的研究來比較嗎啡合用氯胺酮與單用嗎啡行術後自控鎮痛的差別。作者應用先前研究中確定的嗎啡-氯胺酮優化的方法。方法:對352例擇期較大矯形手術的病人行術後自控鎮痛,隨機雙盲分兩組,一組176人為M組,給予1.5mg嗎啡,另一組176人(MK組)給予嗎啡與氯胺酮各1.5mg。不滿意的鎮痛定義為鎮痛不夠完善或出現令人難以接受的副反應。除此之外,記錄PCA藥總量,PCA持續時間,直接的醫療費用,以及術後3-6月慢性疼痛的病例數。結果:M組不滿意的鎮痛發生率為33.0% MK組為36.9%p=0.05)。組間無顯著差異。結論:對於較大矯形手術患者小劑量氯胺酮聯合嗎啡用於術後自控鎮痛並非有益,不必常規應用。

(宋翠俠 陳傑 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.

 

預先給予半數有效劑量的加巴噴丁對後路腰椎融合術後嗎啡使用量的影響

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:預給單劑量的加巴噴丁可以減少術後疼痛和術後鎮痛藥的消耗。然而,其理想劑量有待研究。方法:在這一前瞻性研究中,作者以序貫增減劑量確定半數有效劑量的方法術前預先給予67名擇期行後路腰椎融合術患者加巴噴丁。研究藥物的有效性通過術後第一個24小時的嗎啡需要量來評估。結果:加巴噴丁鎮痛半數有效劑量(中值和95%可信區間)為21.7mg/kg19.9-23.5mg/kg

結論:由於需要給予大劑量的加巴噴丁,所以需要進一步開展研究來評估其副作用。

(胡瀟 陳傑 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.

 

利多卡因與布比卡因在臨床疼痛模型中前列腺素E2的釋放,環氧合酶基因表達和的疼痛影響的差異

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

 

背景除了阻滯手術區域所引起的傷害性信號的傳入,長效的局部麻醉藥可能直接調製炎症反應。在本研究中,筆者描述了布比卡因導致受試者術後疼痛加重的局部前列腺素E2(PGE2)釋放和環氧合酶(COX)基因表達等促炎效應。方法:114名進行第三磨牙拔除術的受試者中術前隨機用2%的利多卡因或布比卡因進行局部麻醉,並在術前90分鐘及隨後48小時內給與羅非考昔50mg或安慰劑。在術前和術後48小時進行口腔粘膜活檢。在拔牙術後將微滲析探針置於手術區域,檢測PGE2和血栓素B2(TXB2)結果在術後第一個4小時通過視覺類比評分評估疼痛顯示布比卡因/羅非昔考組較其他三組相比,疼痛顯著減少。然而,布比卡因/安慰劑組與其他三組相比在術後24小時疼痛更明顯,術後4小時 PGE2的水平更高。且與利多卡因/安慰劑組相比其在48小時的COX-2基因表達顯著增高。血栓素水平在各組中沒有顯著差異,說明此效果歸於COX-2而不是COX-1結論結果顯示布比卡因在組織損傷後促進COX-2基因的表達,在局麻效果消失後出現更多前列腺素E2的釋放和疼痛加劇。

(潘方立 陳傑 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.