Table of Contents

February 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

氯胺酮和依托咪脂在离体的正常和缺血再灌注豚鼠心肌模型边缘丛的神经电生理效应

陈恺铮译 薛张纲校

The Electrophysiological Effects of Racemic Ketamine and Etomidate in an In Vitro Model of "Border Zone" Between Normal and Ischemic/Reperfused Guinea Pig Myocardium

Jean-Luc Hanouz, Yohann Repesse, Lan Zhu, Sandrine Lemoine, René Rouet, Laurent Sallé, Benoît Plaud, and Jean-Louis Gérard

Anesth Analg 2008 106: 365-370. te, decreased ischemia-induced action potential shortening and dispersion as well as reperfusion-induced ventricular arrhythmias.

丙泊酚和七氟醚在主动脉嵌夹后调节肾脏炎症反应和氧化应激反应的比较

潘方立 陈杰

The Comparative Abilities of Propofol and Sevoflurane to Modulate Inflammation and Oxidative Stress in the Kidney After Aortic Cross-Clamping Pilar Sánchez-Conde, José M. Rodríguez-López, Juan L. Nicolás, Francisco S. Lozano, Francisco J. García-Criado, Carlos Cascajo, Rogelio González-Sarmiento, and Clemente Muriel

Anesth Analg 2008 106: 371-378.

在胸外科手术中选择左双腔气管导管尺寸的实践模式

彭中美 马皓琳 李士通校

Practice Patterns in Choice of Left Double-Lumen Tube Size for Thoracic Surgery

David Amar, Dawn P. Desiderio, Paul M. Heerdt, Anne C. Kolker, Hao Zhang, and Howard T. Thaler

Anesth Analg 2008 106: 379-383.

通过蛋白酶A激活线粒体大电导钙激活钾通道介导地氟醚诱导的预处理

陈佳莉译 薛张纲校

Activation of Mitochondrial Large-Conductance Calcium-Activated K+ Channels via Protein Kinase A Mediates Desflurane-Induced Preconditioning

Andreas Redel, Markus Lange, Virginija Jazbutyte, Christopher Lotz, Thorsten M. Smul, Norbert Roewer, and Franz Kehl

Anesth Analg 2008 106: 384-391.

心脏手术期间的过敏性反应:临床意义

杜唯佳 陈杰

Anaphylaxis During Cardiac Surgery: Implications for Clinicians (Review Article)

Jerrold H. Levy and N. Franklin Adkinson, Jr

Anesth Analg 2008 106: 392-403.

PEDIATRIC ANESTHESIOLOGY:

比较婴儿体外循环中的肝素处理方案

裘毅敏译,马皓琳 李士通校

A Comparison of Heparin Management Strategies in Infants Undergoing Cardiopulmonary Bypass

Nina A. Guzzetta, Tanya Bajaj, Tom Fazlollah, Fania Szlam, Elizabeth Wilson, Anna Kaiser, Steven R. Tosone, and Bruce E. Miller

Anesth Analg 2008 106: 419-425.

小于两岁儿童的脑电双频指数与中潜伏期听觉诱发电位

陈勇柱译,薛张纲校

Bispectral Index and Middle Latency Auditory Evoked Potentials in Children Younger Than Two-Years-Old

Adelaida Lamas, Jesús López-Herce, Luis Sancho, Santiago Mencía, Ángel Carrillo, Maria José Santiago, and Vicente Martínez

Anesth Analg 2008 106: 426-432.

AMBULATORY ANESTHESIOLOGY:

使用异丙酚/瑞芬太尼与咪达唑仑/芬太尼用于结肠镜检查的病人自控镇静的随机、对照、双盲试验

张燕 陈杰

A Randomized, Controlled, Double-Blind Trial of Patient-Controlled Sedation with Propofol/Remifentanil Versus Midazolam/Fentanyl for Colonoscopy

Jeff E. Mandel, Jonathan W. Tanner, Gary R. Lichtenstein, David C. Metz, David A. Katzka, Gregory G. Ginsberg, and Michael L. Kochman

Anesth Analg 2008 106: 434-439.

催眠能缓解切除的乳腺活检患者的术前不良应激

唐亮   马皓琳 李士通

Hypnosis Decreases Presurgical Distress in Excisional Breast Biopsy Patients

Julie B. Schnur, Dana H. Bovbjerg, Daniel David, Kristin Tatrow, Alisan B. Goldfarb, Jeffrey H. Silverstein, Christina R. Weltz, and Guy H. Montgomery

Anesth Analg 2008 106: 440-444.

通过提高尸体模型食管的压力,比较七种不同声门上气道通气装置的密闭性

陈珺珺译  薛张纲校

A Comparison of Seal in Seven Supraglottic Airway Devices Using a Cadaver Model of Elevated Esophageal Pressure

Sven Bercker, Willi Schmidbauer, Thomas Volk, Gottfried Bogusch, Hans Peter Bubser, Mario Hensel, and Thoralf Kerner

Anesth Analg 2008 106: 445-448.

ANESTHETIC PHARMACOLOGY:

新型阿片类药物脱氧吗啡酮用于脊麻的药理特征

印洁敏 陈杰

Pharmacological Characterization of Noroxymorphone as a New Opioid for Spinal Analgesia

Kim K. Lemberg, Antti O. Siiskonen, Vesa K. Kontinen, Jari T. Yli-Kauhaluoma, and Eija A. Kalso

Anesth Analg 2008 106: 463-470.

瑞芬太尼-异丙酚使择期手术患者应答性丧失及对模拟疼痛刺激和喉镜检查反应丧失的响应面评价

吴进   马皓琳 李士通

An Evaluation of Remifentanil Propofol Response Surfaces for Loss of Responsiveness, Loss of Response to Surrogates of Painful Stimuli and Laryngoscopy in Patients Undergoing Elective Surgery

Ken B. Johnson, Noah D. Syroid, Dhanesh K. Gupta, Sandeep C. Manyam, Talmage D. Egan, Jeremy Huntington, Julia L. White, Diane Tyler, and Dwayne R. Westenskow

Anesth Analg 2008 106: 471-479.

吗啡通过蛋白激酶A依赖途径减轻微血管通透性升高

璇译 薛张纲校

Morphine Attenuates Microvascular Hyperpermeability via a Protein Kinase A-Dependent Pathway

Rudolph Puana, Russell K. McAllister, Felicia A. Hunter, Julie Warden, and Ed W. Childs

Anesth Analg 2008 106: 480-485.

等碳酸血症下呼吸增强加速七氟醚麻醉后的呼吸恢复

潘钱玲 陈杰

Accelerated Recovery from Sevoflurane Anesthesia with Isocapnic Hyperpnoea

Rita Katznelson, Leonid Minkovich, Zeev Friedman, Ludvik Fedorko, W. Scott Beattie, and Joseph A. Fisher

Anesth Analg 2008 106: 486-491.

早老素-1突变使神经元易受异氟醚毒性影响

张莹译  马皓琳 李士通校

A Presenilin-1 Mutation Renders Neurons Vulnerable to Isoflurane Toxicity

Ge Liang, Qiujun Wang, Yujuan Li, Baobin Kang, Maryellen F. Eckenhoff, Roderic G. Eckenhoff, and Huafeng Wei

Anesth Analg 2008 106: 492-500.

TECHNOLOGY, COMPUTING, AND SIMULATION:

新型便携式装置测量术前病人的代谢气体交换

吴威译,薛张纲校

Novel Portable Device Measures Preoperative Patient Metabolic Gas Exchange

Abraham Rosenbaum, Heike C. Howard, and Peter H. Breen

Anesth Analg 2008 106: 509-516.

PATIENT SAFETY:

连续硬膜外麻醉后严重皮肤炎症反应一例报告

王腾 陈杰

A Severe Inflammatory Cutaneous Reaction After Continuous Epidural Analgesia (Case Report)

Kareem Eltaki, Heba Abdulla, and Raymond S. Sinatra

Anesth Analg 2008 106: 517-519.

脑室内误给予依托米酯与罗库溴胺

胡湘     马皓琳 李士通

Unintentional Intracerebroventricular Administration of Etomidate and Rocuronium (Case Report)

Stephen Howell and Richard P. Driver, Jr

Anesth Analg 2008 106: 520-522.

CRITICAL CARE AND TRAUMA:

重症监护室获得性血行感染中白色念珠菌与非白色念珠菌感染的比较:危险因素和预后的不同

施杨译,薛张纲校

Candida Albicans Versus Non-Albicans Intensive Care Unit-Acquired Bloodstream Infections: Differences in Risk Factors and Outcome

George Dimopoulos, Fotinie Ntziora, George Rachiotis, Apostolos Armaganidis, and Matthew E. Falagas

Anesth Analg 2008 106: 523-529.

一种通过经食道超声心动图评价局部肺血流的新方法

王鹏 陈杰

A New Method to Estimate Regional Pulmonary Blood Flow Using Transesophageal Echocardiography

Yuichi Yatsu, Toshihito Tsubo, Hironori Ishihara, Hitomi Nakamura, and Kazuyoshi Hirota

Anesth Analg 2008 106: 530-534.

使胃充气最小化与胸腔按压最优化比较

沈浩   马皓琳 李士通

Minimizing Stomach Inflation Versus Optimizing Chest Compressions (Technical Communication)

Holger Herff, Peter Paal, Achim von Goedecke, Thomas Mitterlechner, Thomas Danninger, and Volker Wenzel

Anesth Analg 2008 106: 535-537.

OBSTETRIC ANESTHESIOLOGY:

识别腰椎间隙:触诊与超声比较

(吴威译,薛张纲校)

Identification of the Lumbar Interspinous Spaces: Palpation Versus Ultrasound (Brief Report)

Robert Whitty, Michael Moore, and Alison Macarthur

Anesth Analg 2008 106: 538-540.

ECONOMICS, EDUCATION, AND POLICY:

超声引导下基本操作技能的学习曲线及数学模型

陶颖莹 陈杰 )

Learning Curves and Mathematical Models for Interventional Ultrasound Basic Skills (Special Article)

Getúlio Rodrigues de Oliveira Filho, Pablo Escovedo Helayel, Diogo Brüggemann da Conceição, Ivo Sebastião Garzel, Patrícia Pavei, and Maurício Sperotto Ceccon

Anesth Analg 2008 106: 568-573.

NEUROSURGICAL ANESTHESIOLOGY:

过度通气能改善幕上开颅术的手术条件吗?一项多中心随机交叉试验

慧译 马皓琳 李士通校

Does Hyperventilation Improve Operating Condition During Supratentorial Craniotomy? A Multicenter Randomized Crossover Trial

Adrian W. Gelb, Rosemary A. Craen, G. S. Umamaheswara Rao, K. R. Madhusudan Reddy, Joseph Megyesi, Bibek Mohanty, Hari H. Dash, Kai C. Choi, and Mathew T. V. Chan

Anesth Analg 2008 106: 585-594.

GENERAL ARTICLES:

容量应激对猪局部血流量急性及持续性的影响

孙霞译  薛张纲校

The Immediate and Sustained Effects of Volume Challenge on Regional Blood Flows in Pigs

Syed Z. Ali, Hendrik Bracht, Vladimir Krejci, Mario Beck, Michael Stalder, Luzius Hiltebrand, Jukka Takala, Sebastian Brandt, and Stephan M. Jakob

Anesth Analg 2008 106: 595-600.

ANALGESIA:

针刺镇痛1:科学基础

於章杰 陈杰

Acupuncture Analgesia: I. The Scientific Basis (Review Article)

Shu-Ming Wang, Zeev N. Kain, and Paul White

Anesth Analg 2008 106: 602-610.

10. 针刺镇痛2 临床思考

於章杰 陈杰

Acupuncture Analgesia: II. Clinical Considerations (Review Article)

Shu-Ming Wang, Zeev N. Kain, and Paul F. White

Anesth Analg 2008 106: 611-621.

术后病人应用曲马多的有限效能:应用连续再评价方法研究ED80

黄丽娜    马皓琳 李士通

The Limited Efficacy of Tramadol in Postoperative Patients: A Study of ED80 Using the Continual Reassessment Method (Review Article)

Aude Thévenin, Hélène Beloeil, Antonia Blanie, Dan Benhamou, and Jean-Xavier Mazoit

Anesth Analg 2008 106: 622-627.

一项鞘内注射齐考诺肽对于严重慢性疼痛的安全性和耐受性的开放性长期研究的结果

王时来译 薛张纲校

Intrathecal Ziconotide for Severe Chronic Pain: Safety and Tolerability Results of an Open-Label, Long-Term Trial (Review Article)

Mark S. Wallace, Richard Rauck, Robert Fisher, Steven G. Charapata, David Ellis, Sanjeeva Dissanayake For the Ziconotide 98-022 Study Group

Anesth Analg 2008 106: 628-637.

对用X线透视引导行腰段硬膜外类固醇注射的碘化造影剂流型的前瞻性评价:侧旁层间硬膜外进路和经椎间孔硬膜外进路比较

黄佳佳译,马皓琳 李士通校

A Prospective Evaluation of Iodinated Contrast Flow Patterns with Fluoroscopically Guided Lumbar Epidural Steroid Injections: The Lateral Parasagittal Interlaminar Epidural Approach Versus the Transforaminal Epidural Approach (Review Article)

Kenneth D. Candido, Meda S. Raghavendra, Mariadas Chinthagada, Soraya Badiee, and Donald W. Trepashko

Anesth Analg 2008 106: 638-644.

PAIN MEDICINE:

阿片类药物导致的痛觉过敏和使用他克莫斯后的超快速脱毒

张俪译,薛张纲校

Opioid-Induced Hyperalgesia and Rapid Opioid Detoxification After Tacrolimus Administration (Case Report)

Antonio Siniscalchi, Emanuele Piraccini, Zuzana Miklosova, Stefania Taddei, Stefano Faenza, and Gerardo Martinelli

Anesth Analg 2008 106: 645-646.

I型复杂区域疼痛综合征的处理:经皮射频腰交感神经阻断术与苯酚腰交感神经松解术相比较的评估——初步研究

胡潇 陈杰

Management of Lower Limb Complex Regional Pain Syndrome Type 1: An Evaluation of Percutaneous Radiofrequency Thermal Lumbar Sympathectomy Versus Phenol Lumbar Sympathetic Neurolysis—A Pilot Study (Brief Report)

Prashanth S. Manjunath, T. S. Jayalakshmi, G. P. Dureja, and A. Toby Prevost

Anesth Analg 2008 106: 647-649.

PAIN MECHANISMS:

己酮可可碱对大鼠神经病模型中已存在的超敏反应的作用

周雅春 马皓琳 李士通

The Effect of Pentoxifylline on Existing Hypersensitivity in a Rat Model of Neuropathy (Brief Report)

Jian Liu, Weiyan Li, Juan Zhu, Jing Zhang, Xiaomei Feng, Ren Guan, and Jianguo Xu

Anesth Analg 2008 106: 650-653.

REGIONAL ANESTHESIA:

三维立体计算机X线断层摄影术用于困难的胸段硬膜外穿刺

周时蓓译 薛张纲校

Three-Dimensional Computed Tomography for Difficult Thoracic Epidural Needle Placement

Hiroaki Murata, Tetsuya Sakai, Shinichi Goto, and Koji Sumikawa

Anesth Analg 2008 106: 654-658.

运动对布比卡因臂丛神经阻滞时起效和进程的影响:一项肩关节镜手术病人的随机、前瞻性研究

陈伟 陈杰

The Effect of Motor Activity on the Onset and Progression of Brachial Plexus Block with Bupivacaine: A Randomized Prospective Study in Patients Undergoing Arthroscopic Shoulder Surgery

Kenneth E. Langen, Kenneth D. Candido, Michael King, Guido Marra, and Alon P. Winnie

Anesth Analg 2008 106: 659-663.

坐骨骶骨旁的注射能扩散到闭孔神经吗?:一个解剖学研究

张曦 译,马皓琳 李士通

Does Sciatic Parasacral Injection Spread to the Obturator Nerve? An Anatomic Study

Nathalie Valade, Jacques Ripart, Emmanuel Nouvellon, Philippe Cuvillon, Dominique Prat-Pradal, Jean-Yves Lefrant, and Jean-Emmanuel de La Coussaye Anesth

Analg 2008 106: 664-667.

识别腰椎间隙:触诊与超声比较

Identification of the Lumbar Interspinous Spaces:Palpation Versus Ultrasound

Robert Whitty, Michael Moore, Alison Macarthur

From the Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, Ontario Canada.

Anesth Analg 2008;106:538 –40.

 

背景:触诊识别腰椎间隙被证明是不够准确的。此次研究我们的目的是比较在腰椎区域超声成像与触诊的优劣。

方法:121名采用椎管麻醉的产妇中,我们比较了用超声成像定位的脊椎节段与麻醉师通过触诊定位的节段,并由麻醉师记录在病史上。

结果:67名病人(55%),麻醉师定位的脊椎节段穿刺点与超声评估的节段一致,39例病人(32%)其由超声定位的皮肤穿刺点节段比触诊所定至少高一个节段。无关系数0.0895%可信区间:0.020.14)。

结论:在腰椎节段定位上,超声成像与触诊契合度较差,而当两者存在差异时,超声定位的节段通常要比触诊所得高一些。

(吴威译,薛张纲校)

BACKGROUND: Palpation has been shown to be inaccurate at identifying lumbar

interspinous spaces. Our goal in this study was to compare ultrasound imaging of

the region to palpation.

METHODS: Using ultrasound in the postpartum period, we estimated the interspinouslevel used for obstetric neuraxial anesthesia in 121 women and compared thisestimation with the level estimated by palpation and documented in the chart bythe anesthesiologist.

RESULTS: In 67 of 121 (55%) patients, the vertebral level of the puncture markdocumented by the treating anesthesiologist was in agreement with vertebral levelas assessed using ultrasound, and in 39 (32%) women, the skin puncture level wasestimated by ultrasound to be at least one interspace higher. The unweightedkappa was 0.08 (95% confidence interval: 0.02, 0.14).

CONCLUSIONS: There was poor agreement between palpation and ultrasound estimationof the specific lumbar interspace, and when there was disagreement, the

ultrasound estimate was more often higher than the palpitation estimate.

 

 

小于两岁儿童的脑电双频指数与中潜伏期听觉诱发电位

Bispectral Index and Middle Latency Auditory Evoked Potentials in Children Younger Than Two-Years-Old

Adelaida Lamas, Jesu´ s Lo´pez-Herce, Luis Sancho,Santiago Mencı´a, Angel Carrillo,Maria Jose´ Santiago, Vicente Martı´nez

From the *Pediatric Intensive Care Unit, Hospital General Universitario

Gregorio Maran˜o´n, Madrid, Spain; and †Centro de Estudios

Sociosanitarios (CEES), Castilla-La Mancha University, Cuenca, Spain.

Anesth Analg 2008;106:426 –32.

 

背景:我们分析了在健康儿童清醒状态及不使用镇静药物的自然睡眠时脑电双频指数及中潜伏期听觉诱发电位的数值,并用改良的Ramsay评分分析它们的相关性。

方法:53位小于2岁的健康儿童参与研究。同时使用改良的Ramsay评分、脑电双频指数及中潜伏期听觉诱发电位评估儿童。每位病人参与一次研究,调查各方法间的相关度及协同度。三种方法的相关度使用Spearman Rank相关度测试来决定,而使用Cohen’s Kappa测试来评估它们的协同度。

结果:三种方法的相关度(r)中等偏上(P0.01):脑电双频指数与中潜伏期听觉诱发电位(r0.574),脑电双频指数与Ramsay评分(r=-0.504),中潜伏期听觉诱发电位与Ramsay评分(r=-0.624)。然而协同度κ却比较差:脑电双频指数与中潜伏期听觉诱发电位(κ0.392),脑电双频指数与Ramsay评分(κ0.270),中潜伏期听觉诱发电位与Ramsay评分(κ0.409)。在16个月儿童中,所有相关性均比较低。在入睡时(RS35),小于1月儿童的脑电双频指数值要高于6月以上儿童(在Bonferroni校正后的P值=0.028)。

结论:在不使用药物镇静的小于两岁儿童中,脑电双频指数、中潜伏期听觉诱发电位及Ramsay评分具有良好的相关性,但协同差。

(陈勇柱译,薛张纲校)

BACKGROUND: We analyzed the values of the bispectral index (BIS) and midlatencyauditory evoked potentials (MLAEP) and their correlation with the modified Ramsay score (RS) during wakefulness and natural sleep in healthy children without pharmacological sedation.

METHODS: Fifty-three healthy children younger than 2-yr-old were studied. Childrenwere evaluated simultaneously using the modified RS, the BIS, and MLAEPs. Eachpatient was studied only once. The correlation and agreement were studied. Thecorrelation among the three methods was determined using the Spearman RankCorrelation test and the agreement among the methods was assessed using by Cohen’s Kappa test.

RESULTS: There was a moderate-to-good correlation (r) among the three methods(P _ 0.01): BIS and MLAEP (r _ 0.574), BIS and RS (r _ _0.504), and MLAEP andRS (r__0.624). However, the level of agreement (_) was only poor to fair: BIS andMLAEP (_ _ 0.392), BIS and RS (_ _ 0.270), and MLAEP and RS (_ _ 0.409). Allthe correlations were lower in children between 1 and 6 mo-of-age. When thechildren were asleep (RS: 3–5), the BIS values were higher in children younger than1 mo-of-age than in children older than 6 mo-of-age (P after Bonferroni correction_ 0.028).

CONCLUSIONS: The BIS, MLAEP, and RS have a good correlation in children youngerthan 2 yr not receiving pharmacological sedation, though the level of agreement was poor.

 

 

新型便携式装置测量术前病人的代谢气体交换

Novel Portable Device Measures Preoperative Patient Metabolic Gas Exchange

Abraham Rosenbaum, Heike C. Howard, Peter H. Breen

From the Department of Anesthesiology, University of California, Irvine, California.

Anesth Analg 2008106:509 –16

 

背景:间接测热法测量气道二氧化碳的消除(Vco2),氧摄取(Vo2),以及呼吸商(Vco2/ Vo2),是一种评估机体代谢情况的无创方法。在麻醉中,间接测热法可以预示严重不良事件或急性代谢紊乱的发生。先前我们已经证明了一种新型间接测热法装置的准确性及精密度,它包含一种新型临床混合器、快反应温湿传感器以及一个流量计。但是由于不稳定的生命体征、呼吸频率及功能残气量,要在自主呼吸的情况下进行间接测热法是极具挑战性的。

方法:一项新型的专门设计用于自主呼吸时测量间接测热法的装置在代谢模拟肺的测试中被证明是有效的。在此后的研究中,此项装置被用来测量15位术前病人的Vco2Vo2

结果:在代谢模拟肺上测量所得的数据显示了极好的相关性及协同度:气道Vco2的平均百分误差是-4.7%±3.31%,气道Vo2的平均百分误差是-0.30%±5.25%。病人Vco2Vo2的平均值(分别是3.01±0.563.44±0.69mL/kg.min)与以前报道的数值契合。

结论:我们已经证明这种新型的便携式的混合流量装置(使用混合器及快反应湿度传感器)可以提供准确、方便的床旁测量Vco2Vo2。我们相信它在将来可以为术前评估及提供围手术期治疗的基础参考值作出贡献。

(吴威译,薛张纲校)

BACKGROUND: Indirect calorimetry (IC), the measurement of airway CO2 elimination (V˙ co2), V˙ o2 uptake (o2), and respiratory exchange ratio (RER _ V˙ co2/V˙ o2), is anoninvasive modality for the assessment of body metabolism. In anesthesia, IC cansignal critical events and onset of acute metabolic derangements. We havepreviously demonstrated the accuracy and precision of a new IC measurementsystem designed for mechanically ventilated patients, comprised of a new clinicalbymixer, fast response humidity and temperature sensor, and a flowmeter.

However, measurement of IC during spontaneous breathing is challenging because

of unstable tidal volume, frequency, and functional residual capacity (FRC). METHODS: A new device for IC measurements, designed specifically for spontaneous breathing, was validated against a metabolic lung simulator bench setup. In asecond study, the same device was used to conduct preoperative measurements of V˙co2 and V˙ o2 in 15 patients.

RESULTS: Our measurements showed excellent correlation and agreement with metabolic lung simulator values: The average (_sd) percent error for airwayV˙ co2was _4.7% _ 3.31%; the average (_sd) percent error for airway V˙ o2 was _0.30% _5.25%. Average values of V˙ co2 and V˙ o2 in the patient study (3.01 _ 0.56 and 3.44 _0.69 mL _ kg_1 _ min_1, respectively) were in agreement with previously reported values.

CONCLUSION: We have shown that the new, portable bymixer-flow device, using a by mixer and a fast response humidity sensor, provided accurate and convenient bedside measurement of V˙ co2 and V˙ o2. We believe that it can contribute in the future to preoperative assessment and baseline reference value for perioperative management.

 

 

三维立体计算机X线断层摄影术用于困难的胸段硬膜外穿刺

Three-Dimensional Computed Tomography for Difficult Thoracic Epidural Needle Placement
Hiroaki Murata, Tetsuya Sakai, Shinichi Goto, and Koji Sumikawa

Department of Anesthesiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki-City, Nagasaki 852-8501, Japan

Anesth Analg 2008 106: 654-658

 

背景:胸段硬膜外麻醉常常作为胸外科手术术后的镇痛方式。然而,重叠交错的棘突结构使得椎板间空间闭合,常常导致胸段硬膜外穿刺置针困难。随着多层螺旋CT的发展,胸部三维立体影像能够容易的获得,提供了也许有用的临床医学信息。因此,我们进行此项试验用以评估困难的胸段硬膜外穿刺置针和通过三维立体CT所获得的解剖学资料之间的关联。

方法:78位患者被纳入研究。每个患者,为了成功地完成硬膜外导管的放置所进行的皮肤穿刺的次数和完成操作所花的时间被记录下来。在最初尝试时硬膜外穿刺针成功的置入硬膜外腔的患者被确认为第一级成功者。其余的则被确认为第一级失败的患者。在三维立体CT上胸段椎板间空间闭塞的例数以及胸段棘上韧带和棘间韧带骨化的例数同样被评估。

结果:第一级成功者的比例为84.6%。胸段椎板间空间闭塞的例数在第一级失败的患者中远远多于那些成功的患者(P < 0.001)。胸段棘上韧带的骨化的例数在第一级失败的患者中较之在那些成功的患者中更常见(P=0.001)。硬膜外穿刺尝试的次数和操作所花费的时间与胸部椎板间空间闭塞的程度有明显的关联(P < 0.001)

结论:术前的三维立体CT成像可能对于困难的胸段硬膜外穿刺有预测的价值。

(周时蓓译 薛张纲校)

BACKGROUND: Thoracic epidural anesthesia is often used as a postoperative analgesic technique in thoracic surgery. However, the structure of the overlapping spinous processes, resulting in interlaminar space occlusion, often makes thoracic epidural needle placement difficult. With the development of multi-detector row spiral computed tomography (CT), three-dimensional (3D) thoracic images can be readily obtained, providing potentially useful clinical information .Therefore, we conducted this study to evaluate the correlation between difficult thoracic epidural needle placement and anatomical findings obtained by 3DCT image processing techniques.

METHODS: Seventy-eight patients were studied. The number of new skin puncture attempts required for successful catheter insertion into the epidural space and the time spent during the procedure were recorded for each patient. The patients were defined as a first-level success when the needle placement was successful at the spinal level initially attempted. The others were defined as a first-level failure. The number of occluded mid-thoracic interlaminar spaces and the existence of mid-thoracic supraspinous and interspinous ligament ossification on the 3DCT images were also evaluated.

 RESULTS: The percentage of first-level success was 84.6%. The number of occluded mid-thoracic interlaminar spaces was significantly greater in the first-level failure than in the first-level success (P < 0.001). The incidence of ossification of the mid-thoracic supraspinous ligament was significantly more frequent in first-level failure than in the first-level success (P = 0.001). The number of attempts and the time spent during the procedure significantly correlated to the number of occluded mid-thoracic interlaminar spaces (P < 0.001).

CONCLUSION: Preoperative 3DCT imaging may be useful in predicting difficult thoracic epidural needle placement.

 

吗啡通过蛋白激酶A依赖途径减轻微血管通透性升高

Morphine Attenuates Microvascular Hyperpermeability via a Protein Kinase A-Dependent Pathway.

Puana R, McAllister RK, Hunter FA, Warden J, Childs EW.

Department of Anesthesiology, Scott and White Clinic and Memorial Hospital, Scott, Sherwood and Brindley Foundation, Texas A&M Health Science Center College of Medicine, Temple, Texas 76508, USA.

Anesth Analg. 2008 106(2):480-5.

 

背景:本实验室最近发表的研究显示硫酸吗啡(MS)能减轻大鼠失血性休克后微血管通透性的升高。MS是内皮细胞表面的mu受体的配体。有几项研究表明内皮细胞表面mu受体活化后能激活腺苷酸环化酶。我们假设MS与内皮细胞表面mu受体结合后能通过激活腺苷酸环化酶增加环化单磷酸腺苷(cAMP)。cAMP经由蛋白激酶APKA)抑制Raf-1来抑制磷酸肌醇/丝裂原活化蛋白(MAP)激酶对血管通透性的增加。

方法:该研究的对象为5组经乌拉坦麻醉的Sprague-Dawley大鼠:第一组为对照组,第二组为不阻断受体的腺苷酸环化酶抑制剂SQ22536100 microg/kg),第三组为PKA抑制剂H8910 microg/kg),第四组为MS10 microg/kg)加PKA抑制剂,第五组为腺苷酸环化酶抑制剂加MS。用显微镜观察活体肠系膜毛细血管后微静脉,用鼠肺微血管内皮细胞单层衡量通透性。

结果:腺苷酸环化酶和PKA抑制剂组血管通透性升高。

结论:数据显示,当通过非受体抑制剂SQ22536抑制腺苷酸环化酶后,血管通透性升高。用MS处理后,这种血管通透性的升高被减轻。MS不能减轻用H89阻断PKA后的血管通透性升高,提示MSPKA的上游,依赖PKA起作用。

(罗 璇译 薛张纲校)

BACKGROUND: A recently published study from our laboratory demonstrated that morphine sulfate (MS) attenuates microvascular hyperpermeability after hemorrhagic shock in rats. MS binds to the mu receptors located on the surface of endothelial cells. Activation of the endothelial cell mu receptors has been shown by several investigators to stimulate adenylate cyclase. We hypothesize that MS binding to the mu receptor on endothelial cells increases cyclic adenosine monophosphate via adenylate cyclase activation. Cyclic adenosine monophosphate inhibits the phosphoinositide/MAP kinase hyperpermeability pathway via the protein kinase A (PKA)-dependent inhibition of Raf-1.

 METHODS: Studies were conducted in five groups of urethane-anesthetized Sprague-Dawley rats: Group 1--control group, Group 2--a non-receptor-blocking adenylate cyclase inhibitor: SQ22536, at 100 microg/kg (n = 5), Group 3--a PKA inhibitor: H89, at 10 microg/kg, Group 4--a morphine sulfate (10 microg/kg) and PKA inhibitor group, and Group 5--an adenylate cyclase inhibited and morphine (10 microg/kg) group. Intravital microscopy in mesenteric postcapillary venules and rat lung microvascular endothelial cell monolayers were used to measure permeability. RESULTS: Adenylate cyclase and PKA inhibition resulted in vascular hyperpermeability.

CONCLUSION: Our data demonstrated an increase in vascular hyperpermeability after inhibition of adenylate cyclase via SQ22536, a nonreceptor inhibitor. This increase in hyperpermeability was attenuated when treated with MS. Morphine did not attenuate hyperpermeability after blockage following PKA with H89 suggesting the action of MS is upstream of PKA and PKA dependent.

 

阿片类药物导致的痛觉过敏和使用他克莫斯后的超快速脱毒

Opioid-induced hyperalgesia and rapid opioid detoxification after tacrolimus administration.

Siniscalchi A, Piraccini E, Miklosova Z, Taddei S, Faenza S, Martinelli G

Department of Anesthesiology, S.Orsola-Malpighi Hospital, Bologna, Italy.

Anesth Analg. 2008 Feb;106(2):645-6

 

阿片类药物会导致中枢的敏感性和痛觉过敏,名为“阿片类导致的痛觉过敏”。我们的报告描述了一个接受小肠移植的患者出现了免疫抑制相关的神经病理性疼痛。她的疼痛治疗的三年过程中运用了各种不同的方法,包括静脉注射吗啡,但效果有限。她发展成为阿片类药物导致的痛觉过敏,然后在全身麻醉下运用全麻下行快速脱毒疗法而被成功治愈。脱毒治疗改善了她的生活质量,包括可以重新进行物理治疗。经过六个月的治疗后,她能够保持不使用阿片类药物。我们的经验说明在全麻下行快速脱毒治疗可能对阿片类药物导致的痛觉过敏是一种有效的方法,而且也有益于与传统的解毒方法做出比较。

(张俪译,薛张纲校)

Opioids can induce central sensitization and hyperalgesia, referred to as "opioid-induced hyperalgesia." Our report describes a patient who underwent intestinal transplant followed by immunosuppressant-related neuropathic pain. Her pain was treated with limited success over the course of 3 yr with different therapies, including i.v. morphine. She developed opioid-induced hyperalgesia, which was successfully treated with rapid detoxification under general anesthesia. Detoxification improved her quality of life, including the ability to resume physiotherapy. Six months after treatment, she remained opioid free. Our experience suggests that rapid detoxification under general anesthesia may be an effective treatment for opioid-induced hyperalgesia and merits comparison to traditional detoxification methods.

 

一项鞘内注射齐考诺肽对于严重慢性疼痛的安全性和耐受性的开放性长期研究的结果

Intrathecal Ziconotide for Severe Chronic Pain: Safety and Tolerability Results of an Open-Label, Long-Term Trial

Mark S. Wallace, MD*, Richard Rauck, MD{dagger}, Robert Fisher, MD{ddagger}, Steven G. Charapata, MD§, David Ellis, MD, PhD||, Sanjeeva Dissanayake, MBBS, MRCP¶ For the Ziconotide 98-022

Study Group From the *Center for Pain Medicine, University of California, San Diego, La Jolla, California; {dagger}Center for Clinical Research, Winston-Salem, North Carolina; {ddagger}RC Goodman Institute for Pain Management, Sparks Regional Medical Center, Fort Smith, Arkansas; §Pain Management Associates, Kansas City, Missouri; ||Elan Pharmaceuticals, Inc., San Diego, California; and ¶Elan Pharma, Ltd., Stevenage, UK.

Anesth Analg 2008 106: 628-637.

 

背景:齐考诺肽是一个非阿片类药物,用于接受鞘内注射治疗或者对于其他治疗不耐受或无效的病人的严重的慢性疼痛的治疗。

方法:644名伴有严重慢性疼痛的病人参加了这项开放性多中心研究。通过长期输注进行齐考诺肽的滴定。有效性的评估包括疼痛程度的VAS评分。安全性评估包括不良事件(AEs)、生命体征和常规的实验室指标。

结果:116名病人接受齐考诺肽的治疗不少于360天,总时间为350.9人年。齐考诺肽治疗时间的中位数是67.5天(可信区间是1.2-1215.5天),最后输注的平均剂量是8.4 µg/天(可信区间是0.048–240.0 µg/天)。VAS评分的中位数位于基线,第一个月直到第二个月最后可得到的观察记录分别是76mm(范围, 4–100 mm), 68 mm (范围, 0–100 mm), and 73 mm (范围, 0–100 mm)。大多数病人(99.7%)出现了一个以上的不良事件。多数是轻到重度的不良事件,58.6%的不良事件被认为与齐考诺肽无关。上报的较为常见的不良事件(≥25%的病人)包括恶心、头晕、头痛、混乱、疼痛、嗜睡和记忆损害。有临床意义的肌酸激酶水平增高(>3次超过正常值的上限)的发生率在基线的0.9%5.7%发生在第一个月, 3.4%发生在停药后。没有发生药物相关性的死亡、局部肉芽肿、永久性的后遗症发生。

结论:我们认为长期鞘内注射齐考诺肽对于患有严重慢性疼痛且难以控制的病人是一项治疗选择。

(王时来译 薛张纲校)

BACKGROUND: Ziconotide is a non-opioid drug indicated for management of severe chronic pain in patients for whom intrathecal (IT) therapy is warranted and who are intolerant of or refractory to other treatments.

 METHODS: Six-hundred and forty-four patients with severe chronic pain participated in this open-label, multicenter study. Ziconotide titration was followed by long-term infusion. Efficacy assessments included the Visual Analog Scale of Pain Intensity. Safety was assessed via adverse events (AEs), vital signs, and routine laboratory values.

RESULTS: One-hundred and nineteen patients received ziconotide for ≥360 days; total exposure was 350.9 patient years. Median duration of ziconotide therapy was 67.5 days (range, 1.2–1215.5 days); mean dose at last infusion was 8.4 µg/d (range, 0.048–240.0 µg/d). Median Visual Analog Scale of Pain Intensity scores at baseline, month 1, and the last available observation up to month 2 were 76 mm (range, 4–100 mm), 68 mm (range, 0–100 mm), and 73 mm (range, 0–100 mm), respectively. Most patients (99.7%) experienced ≥1 AE. Most AEs were of mild (43.5%) or moderate (42.3%) severity; 58.6% of AEs were considered unrelated to ziconotide. The most commonly reported AEs (≥25% of patients) included nausea, dizziness, headache, confusion, pain, somnolence, and memory impairment. Clinically significant abnormalities (>3 times the upper limit of normal) in creatine kinase levels were reported in 0.9% of patients at baseline, 5.7% at month 1, and 3.4% at ziconotide discontinuation. No drug-related deaths, IT granulomas, or permanent adverse sequelae occurred with ziconotide therapy.

CONCLUSION: We conclude that long-term IT ziconotide is an option for patients with severe, refractory chronic pain.

 

 

容量应激对猪局部血流量急性及持续性的影响

The Immediate and Sustained Effects of Volume Challenge on Regional Blood Flows in Pigs

Syed Z. Ali, MD*, Hendrik Bracht, MD, Vladimir Krejci, MD*, Mario Beck, Michael Stalder, Luzius Hiltebrand, MD*, Jukka Takala, MD, PhD, Sebastian Brandt, MD*, and Stephan M. Jakob, MD, PhD

From the Departments of *Anesthesiology and Intensive Care Medicine, University Hospital Bern, Inselspital, Bern, Switzerland.

Anesth Analg 2008 106: 595-600.

 

背景:由于伴随着血容量及血管紧张度的改变,术后对血容量状态的评估并不直接。低血容量及血流再分布可能会影响腹内脏器的灌注。我们打算研究血容量应激对不同的腹内及腹外血管床的影响。

方法:研究12头临床上血容量正常的猪至行大的腹部手术后6小时。容量应激包括快速输入6%羟乙基淀粉200ml。用全身(持续热稀释法)及局部(Doppler超声)方法持续测量颈动脉、肾动脉、腹主动脉、肝动脉、肠系膜上动脉及门静脉的血流量。急性及持续性的应激改变被比较于基础水平。

结果:容量应激导致心排量持续性增加22% ± 15%(P < 0.001)。肾动脉血流量增加10% ± 9%,颈动脉血流量增加22% ± 15%,肠系膜上动脉血流量增加26% ± 15%,门静脉血流量增加31% ± 20%(P < 0.001)。血流量在腹主动脉的增加(8% ± 13%)及肝动脉的增加(7% ± 19%)不明显。局部血流量的增加发生在早期并持续增加。平均动脉压及中心静脉压早期增加,随后降低(P < 0.001)

结论:临床上血流量正常的动物术后对于容量应激产生持续性的全血管床容量增加,虽然腹主动脉及肝动脉血流的增加不明显,没有统计学意义。对于是否改善术后器官灌注及更低的术后并发症则有待进一步的研究来评估。

(孙霞译  薛张纲校)

BACKGROUND: The postoperative assessment of volume status is not straightforward because of concomitant changes in intravascular volume and vascular tone. Hypovolemia and blood flow redistribution may compromise the perfusion of the intraabdominal organs. We investigated the effects of a volume challenge in different intra- and extraabdominal vascular beds.

METHODS: Twelve pigs were studied 6 h after major intraabdominal surgery under general anesthesia when clinically normovolemic. Volume challenges consisted of 200 mL rapidly infused 6% hydroxyethyl starch. Systemic (continuous thermodilution) and regional (ultrasound Doppler) flows in carotid, renal, celiac trunk, hepatic, and superior mesenteric arteries and the portal vein were continuously measured. The acute and sustained effects of the challenge were compared with baseline.

 RESULTS: Volume challenge produced a sustained increase of 22% ± 15% in cardiac output (P < 0.001). Blood flow increased by 10% ± 9% in the renal artery, by 22% ± 15% in the carotid artery, by 26% ± 15% in the superior mesenteric artery, and by 31% ± 20% in the portal vein (all P < 0.001). Blood flow increases in the celiac trunk (8% ± 13%) and the hepatic artery (7% ± 19%) were not significant. Increases in regional blood flow occurred early and were sustained. Mean arterial and central venous blood pressures increased early and decreased later (all P < 0.05). CONCLUSIONS: A volume challenge in clinically euvolemic postoperative animals was associated with a sustained increase in blood flow to all vascular beds, although the increase in the celiac trunk and the hepatic artery was very modest and did not reach statistical significance. Whether improved postoperative organ perfusion is accompanied by a lower complication rate should be evaluated in further studies.

 

重症监护室获得性血行感染中白色念珠菌与非白色念珠菌感染的比较:危险因素和预后的不同

Candida Albicans Versus Non-Albicans Intensive Care Unit-Acquired Bloodstream Infections: Differences in Risk Factors and Outcome

George Dimopoulos, Fotinie Ntziora, George Rachiotis, Apostolos Armaganidis, and Matthew E. Falagas

From the *Intensive Care Unit, Sotiria Hospital, Athens, Greece; {dagger}Alfa Institute of Biomedical Sciences (AIBS), Athens, Greece; {ddagger}Intensive Care Unit, Attikon University Hospital, Athens, Greece; §Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts; and ||Department of Medicine, Henry Dunant Hospital, Athens, Greece.

Anesth Analg 2008 106: 523-529.

 

目的:在此项研究中我们想要找出白色念珠菌感染和非白色念珠菌感染重症病人在危险因素和预后的不同。

方法:在希腊雅典的第三教学医院对进入重症监护病房后确诊为念珠菌血症的非免疫抑制或白血球减少症的病人进行前瞻性观察研究。

结果:在观察期间(20011月至200512月),1037个进入ICU的病患里有56例发生念珠菌血症,其中36例为人白色念珠菌感染,20例为非白色念珠菌种(8例为光滑念珠菌,6例为热带念珠菌,3例为近平滑念珠菌,1例为葡萄牙念珠菌,1例为克柔念珠菌,1例为都柏林念珠菌)。糖皮质激素的使用、中心静脉导管的放置和预存的念珠菌尿独立地与非白色念珠菌种感染相关(相对应的优势比分别为45.1,26.2,16.5,95%的可信区间分别为3.0-669.92.1-334.8,1.6-173.9)。治疗反应应答率在白色念珠菌和非白色念珠菌种间区别很明显(29/36[80.6%]9/20[45%],P=0.006),非白色念珠菌种感染的死亡率比白色念珠菌感染的高(18/20 [90%]19/36 [52.8%], P = 0.005)。多变量回归分析显示非白色念珠菌种感染的念珠菌血症和死亡独立相关(优势比为6.795%可信区间为1.2-37.7)。

结论:在非免疫抑制的重症病人中,由非白色念珠菌种引起的念珠菌血症常发生在使用医疗设备和接受激素治疗的病人中,它也和高死亡率相关。

(施杨译,薛张纲校)

OBJECTIVE: In this study we sought to identify differences in risk factors and outcome of critically ill patients with Candida albicans and non-albicans candidemia. METHODS: Nonimmunosuppressed, nonneutropenic patients with candidemia diagnosed after intensive care unit (ICU) admission were included in a prospective observational study in a medical-surgical ICU at a tertiary academic hospital in Athens, Greece.

RESULTS: During the study period (January 2001 to December 2005), 56 candidemia episodes in 1037 ICU admissions were included (5.4%). Of these patients, 36/56 (64.3%) had candidemia due to C. albicans and 20/56 (35.7%) due to non-albicans species (8/56 [14.3%] C. glabrata, 6/56 [10.7%] C. tropicalis, 3/56 [5.4%] C. parapsilosis, 1/56 [1.8%] C. lusitaniae, 1/56 [1.8%] C. krusei and 1/56 [1.8%] C. dubliniensis). Administration of glucocorticosteroids, central venous catheter placement, and preexisting candiduria were independently associated with candidemia due to C. non-albicans species (Odds ratio [OR]: 45.1, 95% confidence interval [CI]: 3.0-669.9; OR: 26.2, 95% CI: 2.1-334.8; and OR: 16.5, 95% CI: 1.6-173.9, respectively). The treatment response rate differed significantly between patients with C. albicans and patients with C. non-albicans bloodstream infections (29/36 [80.6%] vs 9/20 [45%], P = 0.006). Overall mortality was higher in patients with non-albicans species than C. albicans bloodstream infections (18/20 [90%] vs 19/36 [52.8%], P = 0.005). Multivariable logistic regression analysis revealed that candidemia due to non-albicans species was independently associated with death (OR: 6.7, 95% CI: 1.2-37.7).

CONCLUSIONS: In the subset of critically ill nonimmunosuppressed patients, candidemia caused by non-albicans species occurred more frequently in those with medical devices or receiving steroids. Candidemia due to non-albicans species was also associated with higher mortality.

 

氯胺酮和依托咪脂在离体的正常和缺血再灌注豚鼠心肌模型边缘丛的神经电生理效应

The Electrophysiological Effects of Racemic Ketamine and Etomidate in an In Vitro Model of "Border Zone" Between Normal and Ischemic/Reperfused Guinea Pig Myocardium

Jean-Luc Hanouz, MD, PhD*, Yohann Repesse, BSc{dagger}, Lan Zhu, MD{dagger}, Sandrine Lemoine, BSc{dagger}, René Rouet, PhD{dagger}, Laurent Sallé, PhD{dagger}, Benoît Plaud*, and Jean-Louis Gérard, MD, PhD*From the *Department of Anesthesiology, CHU Caen, France; and {dagger}Laboratory of Experimental Anesthesiology and Cellular Physiology, UPRES EA, CHU Caen, France.

Anesth Analg 2008; 106:365-370

背景:依托咪脂和氯胺酮被用于高危患者的麻醉诱导,然而它们对于动作电位变量和缺血再灌注引起的心律失常和传导阻滞的影响还不清楚.

方法:豚鼠右心室肌被放入5ml双室电泳使之分离成两条不渗透的胶带.一半暴露再普通的灌注液,另一半被暴露再低氧,高钾,酸中毒和缺糖的环境.持续监测两个条带的动作电位.自发的心律失常和传导阻滞被记录.依托咪脂(10–7, 10–6, and 10–5 M)和氯胺酮(10–6, 10–5, and 10–4 M)在试验中反复表面灌注,和对照组比较神经电生理效应.

结果:我们发现在控制条件下,依托咪脂和氯胺酮没有改变静息膜电位,最大上升率,动作电位或APD90.除氯胺酮(10–4 M)外其他更低浓度的氯胺酮以及任意浓度的依托咪脂都不能逆转缺血引起的APD90缩短和APD分散.依托咪脂和氯胺酮在缺血心肌不能改变传导阻滞的发生.与此相反,氯胺酮(10–6 M中有25%, 10–5 M中有13%10–4 M中有13% 对比对照组中90%, P < 0.05)较之依托咪脂(10–7 M中占38%, 10–6 M中占63%10–5 M中占63%90%的对照组较,NS)能减少再灌注引起的自发性心律失常.

结论:在豚鼠心肌,我们的数据显示氯胺酮在临床相关浓度减少缺血引起动作电位缩短和自发性再灌注引起心室心律失常.依托咪脂在再灌注引起的心律失常上的作用还有待于进一步的试验.

(陈恺铮译 薛张纲校)

BACKGROUND: Etomidate and ketamine are used during induction of anesthesia in high-risk patients. However, their effects on action potential (AP) variables and ischemia/reperfusion-induced arrhythmias and conduction blocks are unknown.

Methods: Guinea pig right ventricular muscle strips were mounted in a 5-mL double chamber bath with the strips separated into two zones by an impermeable latex membrane. One-half (normal zone) was exposed to normal perfusate while the other half (altered zone) was exposed to hypoxia, hyperkalemia, acidosis, and lack of glucose. AP variables were recorded continuously in the normal and altered zones. Spontaneous arrhythmias and conduction blocks were noted. Etomidate (10–7, 10–6, and 10–5 M) and ketamine (10–6, 10–5, and 10–4 M) were superfused into the bath throughout the experiment and the electrophysiologic effects compared with the control group.

RESULTS: We found that under control conditions, etomidate and ketamine did not modify resting membrane potential, maximal upstroke velocity, AP amplitude, or AP duration at 90% of repolarization (APD90). Ketamine (10–4 M), but not weaker concentrations and none of the concentration of etomidate, reversed the ischemia-induced shortening of APD90 and APD dispersion. Etomidate and ketamine did not modify the occurrence of conduction block during simulated ischemia. In contrast, ketamine (25% at 10–6 M, 13% at 10–5 M, and 13% at 10–4 M vs 90% in the control group, P < 0.05) but not etomidate (38% at 10–7 M, 63% at 10–6 M, and 63% at 10–5 M vs 90% in the control group, NS) decreased the incidence of reperfusion-induced spontaneous arrhythmias.

CONCLUSIONS: In guinea pig myocardium, our data suggest that ketamine, in clinically relevant concentrations, decreases ischemia-induced AP shortening and spontaneous reperfusion-induced ventricular arrhythmias. Further study is required to precisely determine the effect of etomidate on reperfusion-induced arrhythmias.

                                             

通过提高尸体模型食管的压力,比较七种不同声门上气道通气装置的密闭性

A Comparison of Seal in Seven Supraglottic Airway Devices Using a Cadaver Model of Elevated Esophageal Pressure

Sven Bercker, MD*, Willi Schmidbauer, MD{dagger}, Thomas Volk, MD{ddagger}, Gottfried Bogusch, PhD§, Hans Peter Bubser, MD{dagger}, Mario Hensel, MD{ddagger}, and Thoralf Kerner, MD{ddagger}

From the *Department of Anesthesiology and Intensive Care Medicine, Leipzig University Hospital, Germany; {dagger}Department of Anesthesiology and Intensive Care Medicine, Bundeswehrkrankenhaus, Berlin, Germany; {ddagger}Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, and §Center for Anatomy, Charité-Universitaetsmedizin, Berlin, Germany.

 Anesth Analg 2008 106: 445-448.

 

背景:声门上气道通气装置在临床麻醉和入院前的急诊医学中有越来越重要的意义,但是有关其引起误吸风险的数据很少。我们设计了这个研究,旨在比较七种不同声门上气道通气装置应用于尸体模型,在食管压力增高的情况下密闭情况。

方法:经典的喉罩,ProSealTM喉罩,插入喉管的FastrachTM喉罩,tubeTM喉罩, LTS IITM喉罩,CombitubeTM EasytubeTM 插入没有密闭的尸体食管中,食管与130cmH2O的水柱连接。缓慢地升高食管的压力,观察分别在什么情况下出现漏气。

结果Combitube, Easytube和插入喉管的FastrachTM喉罩能抵御超过120cmH2O的压力。ProSeal喉罩,喉管和LTS II喉管可以阻断食管7282cmH2O的压力。经典的喉罩在48cmH2O时漏气,气管导管只有很少的漏气。附加有食管引流管的装置可以防止肺的误吸。

结论:考虑到误吸的危险,对于有误吸危险的高危病人,可以使用有食管引流管通气装置。Combitube, Easytube, 和插入喉管的Fastrach喉罩在食管压力增高的情况下有很好的密闭能力。

(陈珺珺译  薛张纲校)

BACKGROUND: Supraglottic airway devices are increasingly important in clinical anesthesia and prehospital emergency medicine, but there are only few data to assess the risk for aspiration. We designed this study to compare the seal of seven supraglottic airway devices in a cadaver model of elevated esophageal pressure.

METHODS: The classic laryngeal mask airway, laryngeal mask airway ProSealTM, intubating laryngeal mask airway FastrachTM, laryngeal tubeTM, laryngeal tube LTS IITM, CombitubeTM, and EasytubeTM were inserted into unfixed human cadavers with an exposed esophagus that had been connected to a water column of 130 cm height. Slow and fast increases of esophageal pressure were performed and the water pressure at which leakage appeared was registered.

RESULTS: The Combitube, Easytube, and intubating laryngeal mask Fastrach withstood the water pressure up to more than 120 cm H2O. The laryngeal mask airway ProSeal, laryngeal tube, and laryngeal tube LTS II were able to block the esophagus until 72–82 cm H2O. The classic laryngeal mask airway showed leakage at 48 cm H2O, but only minor leakage was found in the trachea. Devices with an additional esophageal drain tube drained fluid sufficiently without pulmonary aspiration. CONCLUSIONS: Concerning the risk of aspiration, the use of devices with an additional esophageal drainage lumen might be superior for use in patients with an increased risk of aspiration. The Combitube, Easytube, and intubating laryngeal mask Fastrach showed the best capacity to withstand an increase of esophageal pressure.

 

 

通过蛋白酶A激活线粒体大电导钙激活钾通道介导地氟醚诱导的预处理

Activation of Mitochondrial Large-Conductance Calcium-Activated K+ Channels via Protein Kinase A Mediates Desflurane-Induced Preconditioning

Andreas Redel, MD, Markus Lange, MD, Virginija Jazbutyte, MSc, Christopher Lotz, MD, Thorsten M. Smul, MD, Norbert Roewer, MD, PhD, and Franz Kehl, MD, PhD, DEAA

 From the Department of Anesthesiology, University of Würzburg, Bayerische Julius-Maximilians-Universität, Würzburg, Germany.

Anesth Analg 2008 106: 384-391.

 

背景:ATP调节的钾通道参与到麻醉剂诱导的预处理(APC)中,但是APC中其他钾通道的作用却并不清楚。我们对APC由大电导钙激活钾(KCa)通道介导这一假定进行了检验。

方法:对用戊巴比妥钠麻醉的C57BL/6的雄性小鼠施以45分钟的冠状动脉阻塞和3小时的再灌注的实验。在阻塞冠状动脉前的30分钟,单独使用1.0MAC地氟醚15分钟,或与大电导KCa 通道激活剂NS16191 µg/g i.p.)、二甲基亚砜(10 µL/g i.p.) 、大电导KCa 通道阻断剂IBTX (0.05 µg/g i.p.)或者蛋白酶APKA)抑制剂H-89 (0.5 µg/g 脑室)结合使用1.0MAC地氟醚15分钟。用氯化三苯基四氮唑确定心肌梗塞的范围,并用伊文氏蓝确定危险区域。对离体心肌细胞用免疫细胞化学染色法测定心肌细胞中的大电导KCa 通道的线粒体和细胞膜位置。

结果:与控制组动物相比较,地氟醚大大减小了梗阻面积(7.4% ± 0.8% vs 51.3% ± 6.1%; P < 0.05)。通过NS1619(7.5% ± 1.8%; P < 0.05)激活大电导KCa通道模拟了地氟醚诱导的预处理,而通过IBTX (49.1% ± 7.5%)阻断大电导KCa通道则消除了地氟醚诱导的预处理。H-89阻断的PKA消除了地氟醚(45.1% ± 4.0%)诱导的预处理,但未消除NS1619(9.0% ± 2.4%, P < 0.05)诱导的预处理。免疫细胞化学染色显示大电导KCa通道位于心肌细胞的线粒体中,而非细胞膜中。

结论:这些数据表明,地氟醚诱导的APC部分由线粒体大电导KCa通道的激活所介导,并且地氟醚对这些通道的激活由PKA所介导。

(陈佳莉译 薛张纲校)

BACKGROUND: ATP-regulated K+ channels are involved in anesthetic-induced preconditioning (APC). The role of other K+ channels in APC is unclear. We tested the hypothesis that APC is mediated by large-conductance calcium-activated K+ channels (KCa).  

METHODS: Pentobarbital-anesthetized male C57BL/6 mice were subjected to 45 min of coronary artery occlusion and 3 h reperfusion. Thirty minutes before coronary artery occlusion, 1.0 MAC desflurane was administered for 15 min alone or in combination with the large-conductance KCa channel activator NS1619 (1 µg/g i.p.), its respective vehicle dimethylsulfoxide (10 µL/g i.p.), the large-conductance KCa channel blocker iberiotoxin (0.05 µg/g i.p.), or the protein kinase A (PKA) inhibitor H-89 (0.5 µg/g intraventricular). Infarct size was determined with triphenyltetrazolium chloride and area at risk with Evans blue. Mitochondrial and sarcolemmal localization of large-conductance KCa channels in cardiac myocytes was investigated with immunocytochemical staining of isolated cardiac myocytes.  RESULTS: Desflurane significantly reduced infarct size compared with control animals (7.4% ± 0.8% vs 51.3% ± 6.1%; P < 0.05). Activation of large-conductance KCa channels by NS1619 (7.5% ± 1.8%; P < 0.05) mimicked and blockade of large-conductance KCa channels by iberiotoxin (49.1% ± 7.5%) abrogated desflurane-induced preconditioning. PKA blockade by H-89 abolished desflurane-induced (45.1% ± 4.0%) but not NS1619-induced (9.0% ± 2.4%, P < 0.05) preconditioning. Immunocytochemical staining revealed that large-conductance KCa channels were localized in the mitochondria but not in the sarcolemma of cardiac myocytes.  

CONCLUSION: These data suggest that desflurane-induced APC is mediated in part by activation of mitochondrial large-conductance KCa channels, and that activation of these channels by desflurane is mediated by PKA.

在胸外科手术中选择左双腔气管导管尺寸的实践模式

Practice Patterns in Choice of Left Double-Lumen Tube Size for Thoracic Surgery

David Amar, MD, Dawn P. Desiderio, MD, Paul M. Heerdt, MD, PhD, Anne C. Kolker, MD, Hao Zhang, MD, and Howard T. Thaler, PhD

From the Departments of Anesthesiology and Critical Care Medicine and Epidemiology and Biostatistics, Memorial Sloan–Kettering Cancer Center and Weill Medical College of Cornell University, New York City, New York.

Anesth Analg 2008; 106:379-383

背景:一些麻醉医师选择相对于身体适当尺寸较小的左双腔气管导管(DLTs)(“小号”)用于肺分隔,以限制气道损伤的风险。关于DLT尺寸对于术中结果影响的资料很少。

方法:300例行需要肺分隔的胸外科手术的患者中,我们进行了一项前瞻性初步研究来评估不管性别和/或身高都用35 FR DLT(两个观察者的监护标准),与传统的插入尽可能大的DLT(两个其他观察者的监护标准)相比,术中低氧血症、肺分隔失败或需要DLT调整位置的发生率(非低劣)是否相似。用直接喉镜下放置好和侧卧位后,立即用纤支镜确认DLT的插入位置。

结果:不管性别和/或身高,术中暂时的低氧血症、不充分的肺分隔,或需要重新调整DLT位置的发生率在接受353739 FR DLT的患者之间没有区别。尽管35 FR DLT的使用率高,但2%的病人由于DLT无法进入左主支气管或肺分隔时支气管气囊不需要充气,而需要更小号。

结论:在这一初步研究的条件下,用比传统尺寸小的DLT在临床术中结果方面没有任何差异。

(彭中美 马皓琳 李士通校)

BACKGROUND: Some anesthesiologists choose smaller than body size-appropriate left sided double-lumen tubes (DLTs) ("down-size") for lung isolation in an attempt to limit the risk of airway trauma. There are few data on the effects of DLT size on intraoperative outcome measures.

METHODS: In 300 adults undergoing thoracic surgery requiring lung isolation, we conducted a prospective pilot study to evaluate whether the use of 35 FR DLT, regardless of gender and/or height (care standard of two investigators), was associated with a similar incidence of intraoperative hypoxemia, lung isolation failure, or need for DLT repositioning during surgery (noninferiority) than with the conventional goal of inserting the largest possible DLT (care standard of two other investigators). DLT insertion position was immediately confirmed with fiberoptic bronchoscopy after direct laryngoscopic placement and after lateral positioning.

RESULTS: The combined incidence of transient hypoxemia, inadequate lung isolation, or need for DLT repositioning during surgery did not differ among patients receiving 35, 37, or 39 FR DLT, regardless of gender or height. Despite the high frequency of 35 FR DLT use, 2% of patients required further down-sizing due to the inability to introduce the DLT into the left mainstem bronchus or when no inflation of the bronchial cuff was needed for lung isolation.

CONCLUSIONS: Under the conditions of this pilot study, the use of smaller than conventionally sized DLT was not associated with any differences in clinical intraoperative outcomes.

 

 

比较婴儿体外循环中的肝素处理方案

A Comparison of Heparin Management Strategies in Infants Undergoing Cardiopulmonary Bypass

Nina A. Guzzetta, MD*, Tanya Bajaj, CRC{dagger}, Tom Fazlollah, CRNA*, Fania Szlam, MMSc*, Elizabeth Wilson, MD*, Anna Kaiser, MD*, Steven R. Tosone, MD*, and Bruce E. Miller, MD*

From the *Department of Anesthesiology, Emory University School of Medicine, and {dagger}Cardiac Research Department, Children’s Healthcare of Atlanta at Egleston Atlanta, Georgia.

Anesth Analg 2008; 106:419-425

研究背景:近来对成年患者的研究已显示:在体外循环(CPB)的肝素使用中,与基于标准体重的肝素剂量相比较,基于肝素浓度的肝素抗凝方案明显降低了止血药的活性。儿科患者中与CPB相关的凝血问题是复杂的且受到很多变量的影响,CPB期间止血药作用的降低可能对患儿尤其有益。然而关于患儿CPB中肝素的水平及其与止血药作用的相关性方面的报道,目前仍缺乏。在本研究中,我们选择小于6个月的婴儿,比较了其基于患者特异性肝素浓度及基于标准体重的肝素处理方案。通过比较肝素浓度、止血药作用的生化指标水平及临床结果来评估两套方案的有效性。

方法:研究纳入了25例小于6个月择期行先天性心脏缺损修补术的婴儿。患儿随机接受400 U/kg肝素(对照组)或通过Hepcon止血处理系统加(Hepcon HMS; Medtronic,明尼阿波利斯, 明尼苏达州)计算所得的患者特异性肝素剂量(介入组)。在预定的间期比较两组的肝素浓度。CPB前后收集血样本以测得止血作用的生化指标,并记录临床观察结果。

结果:与对照组相比,介入组患儿获得的总的肝素剂量更大。两组之间给予初始肝素剂量后与CPB开始30分钟时的肝素浓度是相似的;然而,在复温开始时及CPB终止时,介入组较对照组有明显更高的肝素浓度。与对照组相比,介入组的患儿F1.2 产生更少,VIII因子消耗更少。但是临床上介入组的患儿CPB后需接受使用来自一个以上供体的血制品。

结论:对于小于6个月的婴儿,与基于标准体重的肝素处理方案相比,在CPB中使用基于肝素浓度的肝素处理方案能产生更高、更恒定的肝素浓度。而且,更高的肝素浓度与更大程度的抑制止血作用有关,正如临床上观察到的更少形成凝血酶及更少消耗VIII因子。本研究证实,在施行CPB的患儿中,使用基于患者特异性肝素浓度的肝素方案可减弱止血作用。然而,需要进一步研究以确定该方案是否有临床上有益的止血作用。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Recent investigations in adult patients have suggested that a heparin concentration-based anticoagulation protocol for heparin administration during cardiopulmonary bypass (CPB) significantly reduced hemostatic activation when compared with standard weight-based heparin doses. Reductions in hemostatic activation during CPB could be particularly beneficial in pediatric patients in whom CPB-related coagulation issues are complex and influenced by many variables. However, information regarding heparin levels during CPB and their correlation to hemostatic activation is lacking in children. In this investigation, we compared a patient-specific heparin concentration-based heparin management protocol with a standard weight-based protocol in infants <6-mo-of-age. The efficacy of these two protocols was assessed by comparisons of heparin concentration, levels of biochemical markers of hemostatic activation, and clinical outcome.

METHODS: Twenty-five infants <6-mo-old scheduled for primary, elective repair of a congenital heart defect were enrolled in this study. Patients were randomized to receive either 400 U/kg of heparin (control group) or a patient-specific heparin dose calculated by the Hepcon Hemostasis Management System Plus (Hepcon HMS; Medtronic, Minneapolis, MN; intervention group). Heparin concentrations were compared between the two groups at predetermined intervals. Blood samples for biochemical markers of hemostatic activation were collected before and after CPB, and measurements of clinical outcome were recorded.

RESULTS: Infants in the intervention group received a larger total heparin dose than infants in the control group. Heparin concentrations after the initial heparin dose and 30 min into CPB were similar between groups; however, at the start of rewarming and at the termination of CPB, infants in the intervention group had significantly higher heparin concentrations than infants in the control group. Infants in the intervention group also generated less F1.2 and consumed less factor VIII than infants in the control group. Clinically, however, infants in the intervention group received one more donor exposure from the administration of blood products post-CPB.

CONCLUSION: A heparin concentration-based heparin management protocol in infants <6-mo-old resulted in higher, more constant heparin concentrations during CPB than a standard weight-based protocol. Furthermore, higher heparin concentrations were associated with greater suppression of hemostatic activation, as measured by less generation of thrombin and less consumption of factor VIII. Our findings demonstrate that use of a patient-specific heparin concentration-based protocol for heparin administration during CPB in infants may attenuate hemostatic activation. However, further research is needed to determine if this protocol has clinically beneficial hemostatic effects.


催眠能缓解切除的乳腺活检患者的术前不良应激

Hypnosis Decreases Presurgical Distress in Excisional Breast Biopsy Patients

Julie B. Schnur, PhD*, Dana H. Bovbjerg, PhD*, Daniel David, PhD{dagger}, Kristin Tatrow, PhD{ddagger}, Alisan B. Goldfarb, MD§, Jeffrey H. Silverstein, MD§||¶, Christina R. Weltz, MD§, and Guy H. Montgomery, PhD*

From the *Department of Oncological Sciences, Mount Sinai School of Medicine, New York City, New York; {dagger}Department of Psychology, Babes-Bolyai University, Cluj-Napoca, Romania; {ddagger}Department of Rehabilitation Psychology, Good Shepherd Hospital, Allentown, Pennsylvania; and Departments of §Surgery, ||Anesthesiology, ¶Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, New York.

Anesth Analg 2008; 106:440-444

背景:切除性乳腺活检导致术前心理上的不良应激。这种不良应激是情绪沉重,可能会给术后副反应和麻醉的满意程度带来负面影响。我们研究一下简短的术前催眠谈话对于缓解切除性乳腺活检患者的术前不良应激的能力。

方法:90名要进行切除性乳腺活检患者随机分为两组,一组进行15分钟术前催眠谈话(n=49,平均年龄46.4(95% CI: 42.3–50.4)),另一组进行15分钟术前注意力对照谈话(n=41,平均年龄45.0(95% CI: 40.8–49.2))。催眠谈话涉及给予增加放松程度和缓解不良应激的暗示,注意力对照谈话是非指导性的移情倾听。用视觉模拟评分(VAS)和心境量表简短版(SV-POMS)测量术前不良应激。用方差分析和卡方检验分析数据。

结果:两组间的以下几方面没有差异:人口统计学(年龄、教育、种族、婚姻状况,所有的P>0.28);医学变量(术前诊断、既往切除活检、既往乳腺癌,所有的P>0.11);及手术当天评估的干预前不良应激(SV-POMSP > 0.74)。手术前,在干预后催眠组的患者在术前情绪失常VAS (16.5 vs 38.2, P < 0.0001, d = 0.85)、情绪低落VAS(6.6 vs 19.9, P < 0.02, d =0 .67)以及焦虑SV-POMS (10.0 vs 5.0, P < 0.0001, d = 0.85)的平均值都明显低于注意力对照组;另外催眠组放松程度VAS(75.7 vs 54.2, P < 0.001, d = –0.76)明显高于注意力对照组。

结论:这个研究结果显示术前简短的催眠干预是一个能控制等候诊断性乳腺癌手术的妇女术前不良应激的有效手段。

(唐亮   马皓琳 李士通 校)

BACKGROUND: Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients.

METHODS: Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3–50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8–49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and {chi}2 procedures.

RESULTS: Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P’s > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P’s > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = –0.76) than attention controls.

CONCLUSIONS: The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

 

 

瑞芬太尼-异丙酚使择期手术患者应答性丧失及对模拟疼痛刺激和喉镜检查反应丧失的响应面评价

An Evaluation of Remifentanil Propofol Response Surfaces for Loss of Responsiveness, Loss of Response to Surrogates of Painful Stimuli and Laryngoscopy in Patients Undergoing Elective Surgery

Ken B. Johnson, MD*, Noah D. Syroid, MS*, Dhanesh K. Gupta, MD{dagger}, Sandeep C. Manyam, PhD{ddagger}, Talmage D. Egan, MD*, Jeremy Huntington, BS*, Julia L. White, RN*, Diane Tyler, RN*, and Dwayne R. Westenskow, PhD*

From the *Departments of Anesthesiology and Biomedical Engineering, University of Utah, Salt Lake City, Utah; {dagger}Department of Anesthesiology, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois; and {ddagger}Department of Radiology, University of California, San Francisco, San Francisco, California.

Anesth Analg 2008; 106:471-479

引言:本研究中我们探讨了从志愿者中采集数据而建立起来的一组瑞芬太尼-异丙酚响应面相互作用模型将会怎样预测择期手术病人对事件的反应。我们的假设是这些模型将会预测病人群体应答性的丧失和恢复、对喉镜检查是否有反应以及术后对疼痛的反应。

方法:本研究包括21位病人。麻醉方法是静脉持续输注瑞芬太尼和异丙酚以及间断推注芬太尼。评价每个病人应答性的丧失和恢复、对喉镜检查的反应以及对术后疼痛的反应。把用模型预测的结果与观察到的反应进行比较。

结果:应答性丧失模型所预测的病人应答丧失比观察到的结果早2.4 ± 2.6 min。在喉镜检查时,喉镜检查模型预测病人有89%的可能性对检查无反应,而观察到的是81%的病人无反应。在苏醒期,应答性丧失模型所预测的应答性恢复比观察到的结果早0.6 ± 5.1 min。病人接受芬太尼来控制疼痛时对压力痛觉测定无反应的平均可能性是23% ± 35%

讨论:对一系列瑞芬太尼-异丙酚响应面相互作用模型的初次评价表明这些模型能预测到择期手术中病人对所选的相关事件的反应。然而在所预测的瑞芬太尼-异丙酚的效应室浓度迅速变化时显著的模型错误是显而易见的。

(吴进   马皓琳 李士通 校)

INTRODUCTION: In this study, we explored how a set of remifentanil-propofol response surface interaction models developed from data collected in volunteers would predict responses to events in patients undergoing elective surgery. Our hypotheses were that these models would predict a patient population’s loss and return of responsiveness and the presence or absence of a response to laryngoscopy and the response to pain after surgery.

METHODS: Twenty-one patients were enrolled. Anesthesia consisted of remifentanil and propofol infusions and fentanyl boluses. Loss and return of responsiveness, responses to laryngoscopy, and responses to postoperative pain were assessed in each patient. Model predictions were compared with observed responses.

RESULTS: The loss of responsiveness model predicted that patients would become unresponsive 2.4 ± 2.6 min earlier than observed. At the time of laryngoscopy, the laryngoscopy model predicted an 89% probability of no response to laryngoscopy and 81% did not respond. During emergence, the loss of responsiveness model predicted return of responsiveness 0.6 ± 5.1 min before responsiveness was observed. The mean probability of no response to pressure algometry was 23% ± 35% when patients required fentanyl for pain control.

DISCUSSION: This preliminary assessment of a series of remifentanil-propofol interaction models demonstrated that these models predicted responses to selected pertinent events during elective surgery. However, significant model error was evident during rapid changes in predicted effect-site propofol-remifentanil concentration pairs.



早老素-1突变使神经元易受异氟醚毒性影响

A Presenilin-1 Mutation Renders Neurons Vulnerable to Isoflurane Toxicity

Ge Liang, MD, Qiujun Wang, MD, Yujuan Li, MD, Baobin Kang, MD, Maryellen F. Eckenhoff, PhD, Roderic G. Eckenhoff, MD, and Huafeng Wei, MD, PhD

From the Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania.

Anesth Analg 2008; 106:492-500

背景:异氟醚是一种常用吸入麻醉药,可呈浓度和时间依赖地诱导大鼠神经元嗜铬细胞瘤神经分泌细胞(PC12)细胞发生凋亡,机制不明。我们假设是异氟醚通过激活肌醇1,4,5-三磷酸(IP3)受体来触发内质网(ER)钙离子异常释放,从而诱发细胞凋亡。一种家族性阿尔茨海默尔氏病患者伴有的早老素-1 (PS1)基因突变使IP3受体活性增加,因此可能使细胞易受异氟醚诱发的细胞毒性的影响。七氟醚和地氟醚对细胞内钙稳态的影响较小,所以我们预计其细胞毒性也较小。

方法:对用野生型带菌体(带菌体)或突变的PS1L286V)转染的PC12细胞给予1 MAC等效的异氟醚、七氟醚和地氟醚,共计12小时。测定线粒体氧化还原反应(MTT还原)和乳酸脱氢酶释放,以估计细胞的生存率。不同类型的细胞给予不同的吸入麻醉药后,测定胞质腔内钙离子浓度([Ca2+]c)和活性氧(ROS)产生的变化。我们还测定了IP3受体拮抗剂xestospongin C 对异氟醚诱发的L286V PC12细胞和大鼠原始皮质神经元的细胞毒性和内质网钙离子释放的影响。

结果:给予12小时1 MAC异氟醚引起L286V的细胞毒性,还导致L286V[Ca2+]c峰值快速且大量增高,但并不影响野生型或带菌体PC12细胞。Xestospongin C明显减轻异氟醚对L286V细胞和原始皮质神经元的细胞毒性,且抑制L286V细胞内质网钙离子的释放。异氟醚并不引发各种PC12细胞ROS产物的明显变化。与异氟醚不同,等效浓度七氟醚和地氟醚对L286V PC12细胞并不引起相似的细胞毒性或[Ca2+]c峰值升高。

结论:我们的研究结果显示L286V PS1突变通过钙从细胞内贮存释放以促进异氟醚诱发的[Ca2+]c,从而使细胞易受异氟醚神经毒性影响。ROS产物不涉及异氟醚引起的神经毒性。与异氟醚等效浓度的七氟醚和地氟醚不会引发L286V PC12细胞发生类似的[Ca2+]c升高和神经毒性。

(张莹译  马皓琳 李士通校)

BACKGROUND: Isoflurane, a commonly used inhaled anesthetic, induces apoptosis in rat pheochromocytoma neurosecretory cells (PC12) in a concentration- and time-dependent manner via an as yet unknown mechanism. We hypothesize that isoflurane induces apoptosis by causing abnormal calcium release from the endoplasmic reticulum (ER) via activation of inositol 1,4,5-trisphosphate (IP3) receptors. A presenilin-1 (PS1) mutation associated with familial Alzheimer’s disease was shown to increase the activity of IP3 receptors, and therefore may render cells vulnerable to isoflurane-induced cytotoxicity. Sevoflurane and desflurane have less ability to disrupt intracellular calcium homeostasis; and thus we predict they will cause less cytotoxicity.

METHODS: PC12 cells transfected with wild type, vector alone (Vector) or mutated PS1 (L286V) were treated with equivalent of 1 MAC of isoflurane, sevoflurane, and desflurane for 12 h. Mitochondria redox activity (MTT reduction) and lactate dehydrogenase release assays were performed to evaluate cell viability. Changes of calcium concentration in cytosolic space ([Ca2+]c) and production of reactive oxygen species (ROS) were determined after exposing different types of cells to various inhaled anesthetics. We also determined the effects of IP3 receptor antagonist xestospongin C on isoflurane-induced cytotoxicity and calcium release from the ER in L286V PC12 cells, and in rat primary cortical neurons.

RESULTS: Isoflurane at 1 MAC for 12 h induced cytotoxicity in L286V but not wild type or vector PC12 cells, and also caused greater and faster increase of peak [Ca2+]c in the L286V cells. Xestospongin C significantly attenuated isoflurane cytotoxicity in both L286V cells and primary cortical neurons and inhibited the calcium release from the ER in L286V cells. Isoflurane did not induce significant changes of ROS production in any type of PC12 cells. Sevoflurane and desflurane at equivalent exposure to isoflurane did not induce similar cytotoxicity or increase of peak [Ca2+]c in L286V PC12 cells.

CONCLUSION: Our results show that the L286V PS1 mutation augments the isoflurane-induced [Ca2+]c increase via calcium release from intracellular stores which, in turn, renders the cells vulnerable to isoflurane neurotoxicity. ROS production was not involved in isoflurane-induced neurotoxicity. Sevoflurane and desflurane, at equivalent exposure to isoflurane, did not induce a similar increase of [Ca2+]c or neurotoxicity in L286V PC12 cells.



脑室内误给予依托米酯与罗库溴胺

Unintentional Intracerebroventricular Administration of Etomidate and Rocuronium

Stephen Howell, MD, and Richard P. Driver, Jr, MD

From the Department of Anesthesiology, West Virginia University School of Medicine, 3618 Robert C. Byrd Health Science Center, West Virginia.

Anesth Analg 2008; 106:520-522

我们报导了在重症监护室中快速诱导用于气管内插管过程中通过脑室造瘘导管脑室内误给予依托米酯和罗库溴胺。发生了快速的意识丧失、呼吸暂停和声带外展,创造了极好的插管条件。病人在诱导和插管中始终保持血流动力学稳定。 护理人员的缺乏经验和制度的缺陷是导致用药错误的因素。我们将讨论管理、临床过程、易感因素和预防策略。

(胡湘     马皓琳 李士通 校)

We report the unintentional intracerebroventricular administration of etomidate and rocuronium through a ventriculostomy catheter in the intensive care unit during a rapid sequence induction for endotracheal intubation. Rapid loss of consciousness, apnea, and vocal cord abduction occurred, creating excellent intubating conditions. The patient remained hemodynamically stable throughout induction and intubation. Inexperience of nursing personnel and systems errors were factors contributing to the drug error. The management, clinical course, predisposing factors, and strategies for prevention will be discussed.


使胃充气最小化与胸腔按压最优化比较

Minimizing Stomach Inflation Versus Optimizing Chest Compressions

Holger Herff, MD, Peter Paal, MD, Achim von Goedecke, MD, MSc, Thomas Mitterlechner, MD, Thomas Danninger, BSc, and Volker Wenzel, MD, MSc

From the Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008; 106:535-537

在一个实验台模型中,我们在没有保护的气道评价了为了降低胃充气风险而开发出的有最大吸气流量限制的呼吸气囊-阀装置(Smart Bag® MO)。在模拟心肺复苏连续胸外按压过程中,只有潮气量充足吸气时间为0.5秒时才以设置为“关闭”状态的Smart Bag® MO或成人自动充气皮囊-阀装置通气。只要模拟心肺复苏中潮气量不足并将导致病人通气不足,即使通气窗为0.5秒,仍用设置为“开放”的Smart Bag® MO通气。

(沈浩   马皓琳 李士通 校)

In a bench model, we evaluated a bag-valve device (Smart Bag® MO) with limited maximum inspiratory gas flow developed to reduce the risk of stomach inflation in an unprotected airway. During simulated cardiopulmonary resuscitation with uninterrupted chest compressions, ventilation with the "disabled" Smart Bag® MO or an adult self-inflating bag-valve device provided only adequate tidal volumes if inspiratory time was 0.5 s. Ventilation with the "enabled" Smart Bag® MO, even in ventilation windows of 0.5 s, provided inadequate tidal volumes during simulated cardiopulmonary resuscitation and would result in hypoventilation in a patient.


过度通气能改善幕上开颅术的手术条件吗?一项多中心随机交叉试验

Does Hyperventilation Improve Operating Condition During Supratentorial Craniotomy? A Multicenter Randomized Crossover Trial

Adrian W. Gelb, MD, FRCPC*, Rosemary A. Craen, MBBS, FRCPC{dagger}, G. S. Umamaheswara Rao, MD{ddagger}, K. R. Madhusudan Reddy, MD§, Joseph Megyesi, MD, FRCSC||, Bibek Mohanty, MD, Hari H. Dash, MD, Kai C. Choi, PhD#, and Mathew T. V. Chan, FANZCA**

From the *Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, California; {dagger}Department of Anesthesia and Perioperative Medicine, University of Western Ontario, Canada; Departments of {ddagger}Anesthesia and §Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore, India; ||Department of Neurosurgery, University of Western Ontario, Canada; ¶Department of Neuroanesthesiology, All India Institute of Medical Sciences, Delhi, India; #Centre for Epidemiology and Biostatistics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region; and **Department of Anaesthesia and Intensive Care, CUHK Brain Tumor Center, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Special Administrative Region.

Anesth Analg 2008; 106:585-594

背景:过度通气已是神经外科麻醉中一个完整但缺乏有效验证的部分。我们进行一项两个阶段的交叉随机试验来评价开颅切除幕上大脑肿瘤患者在适度的低碳酸血症或正常二氧化碳血情况下外科医生估计的脑容量和测定的颅内压(ICP)。

方法:275例有幕上大脑肿瘤的成年患者随机分成两个治疗过程:过度通气(动脉二氧化碳分压Paco2 = 25 ± 2 mm Hg)后正常通气(Paco2 = 37 ± 2 mm Hg)或正常通气后过度通气。通气和呼气末CO2分压保持稳定20min。患者也随机分组接受异丙酚输注或异氟醚麻醉。每一研究阶段结束时,测定硬膜下颅内压,且要求不知道分组的神经外科医生用四点评分来评估脑容量。

结果:我们应用广义估计方程发现过度通气使脑容量增加的风险降低45% P = 0.004, 95% 可信区间为 22% 61%,所需处理例数为8。过度通气时的平均颅内压(±标准差)为12.3 ± 8.1 mm Hg,比正常通气时的16.2 ± 9.6 mm Hg低,P < 0.001。麻醉药的摄入不影响脑容量评估或颅内压。

结论:幕上大脑肿瘤患者术中过度通气能降低颅内压从而改善外科医生所评估的脑容量。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Hyperventilation has been an integral, but poorly validated part of neuroanesthetic practice. We conducted a two-period, crossover, randomized trial to evaluate surgeon-assessed brain bulk and measured intracranial pressure (ICP) in patients undergoing craniotomy for removal of supratentorial brain tumors during moderate hypocapnia or normocapnia.

METHODS: Two-hundred and seventy-five adult patients with supratentorial brain tumors were randomized to one of two treatment sequences: hyperventilation (arterial carbon dioxide tension, Paco2 = 25 ± 2 mm Hg) followed by normoventilation (Paco2 = 37 ± 2 mm Hg) or normoventilation followed by hyperventilation. Ventilation and end-tidal CO2 tension were kept constant for 20 min. Patients were also randomly assigned to receive a propofol infusion or isoflurane anesthesia. At the end of each study period, subdural ICP was measured and the neurosurgeon, blinded to the treatment group, was asked to rate the brain bulk using a four-point scale.

RESULTS: Using a generalized estimation equation model, we found that hyperventilation decreased the risk of increased brain bulk by 45%, P = 0.004, 95% confidence intervals 22% to 61%, and the number needed to treat was 8. The mean (±sd) ICP during hyperventilation, 12.3 ± 8.1 mm Hg, was lower than that during normoventilation, 16.2 ± 9.6 mm Hg, P < 0.001. Anesthetic regimen did not affect brain bulk assessment or ICP.

CONCLUSIONS: In patients with supratentorial brain tumors, intraoperative hyperventilation improves surgeon-assessed brain bulk which was associated with a decrease in ICP.



术后病人应用曲马多的有限效能:应用连续再评价方法研究ED80

The Limited Efficacy of Tramadol in Postoperative Patients: A Study of ED80 Using the Continual Reassessment Method

Aude Thévenin, MD, Hélène Beloeil, MD, PhD, Antonia Blanie, MD, Dan Benhamou, MD, and Jean-Xavier Mazoit, MD, PhD

From the AP-HP, Univ Paris-Sud, Hôpital Bicêtre, Département d'Anesthésie-Réanimation, France F-94275, Le Kremlin-Bicêtre, France.

Anesth Analg 2008; 106:622-627

背景:本研究的目的是重新评价曲马多用于术后镇痛的效能,并用连续再评定方法测定其ED80(即80%的病人疼痛充分缓解的临床剂量)。因为最初的24名患者的初步结果与文献是相矛盾的,我们进行了第二个试验来验证并证实我们的数据。

方法:本研究是双盲及前瞻性的。参加者通过3病例队列给予一个剂量的曲马多。每个组曲马多的剂量由前面病人的反应决定。开始之前选择了5个剂量,其阳性反应的机率分别是60 (0.4)100 (0.55)140 (0.7)190 (0.8)260 mg (0.9)。如果在T30时疼痛评分大于>=3/10,就认为曲马多是有效的。

结果:两个试验中,对80%病人有效的曲马多剂量是260mg。试验1和试验2 260mg剂量有效的机率分别是0.699 (95%可信区间是0.471–0.874)0.657 (95%可信区间是0.437–0.853)

结论:中等疼痛的手术后,曲马多不能作为单独用药。80%的病人缓解疼痛的剂量远远大于常用量100mg。连续再评价方法允许我们应用有限数目的病人来测定曲马多的ED80

(黄丽娜    马皓琳 李士通 校)

BACKGROUND: The aim of this study was to reevaluate the efficacy of tramadol for postoperative analgesia and to determine its ED80 (the clinical dose for which 80% of the patients had their pain adequately relieved) using the Continual Reassessment Method. Because the preliminary results of the first 24 patients were contradictory to the literature, we performed a second trial to verify and validate our data.

METHODS: The study was double-blind and prospective. Participants were allocated to a dose of tramadol by 3-patient cohorts, in order of inclusion. The dose of tramadol received in each cohort was determined by the reaction of all previous patients. Five doses were chosen before beginning, with a probability of a positive reaction associated with each: 60 (0.4), 100 (0.55), 140 (0.7), 190 (0.8), and 260 mg (0.9). Tramadol was considered effective if the numeric pain scale was >=3/10 at T30.

RESULTS: The effective dose in 80% of patients was 260 mg for both trials. The probability of success of the 260 mg dose was 0.699 (95% credibility interval, 0.471–0.874) and 0.657 (95% credibility interval, 0.437–0.853) for trial 1 and trial 2, respectively.

CONCLUSION: Tramadol used as a sole drug cannot be considered the drug of choice after moderately painful surgery. The doses needed to relieve pain in 80% of patients are much larger than the usual dose of 100 mg. The Continual Reassessment Method allowed us to determine the ED80 of tramadol with a limited number of patients.



对用X线透视引导行腰段硬膜外类固醇注射的碘化造影剂流型的前瞻性评价:侧旁层间硬膜外进路和经椎间孔硬膜外进路比较

A Prospective Evaluation of Iodinated Contrast Flow Patterns with Fluoroscopically Guided Lumbar Epidural Steroid Injections: The Lateral Parasagittal Interlaminar Epidural Approach Versus the Transforaminal Epidural Approach

Kenneth D. Candido, MD*, Meda S. Raghavendra, MD*, Mariadas Chinthagada, MD*, Soraya Badiee, DO*, and Donald W. Trepashko, MD{dagger}

From the *Department of Anesthesiology, Loyola University Medical Center, Maywood, Illinois; and {dagger}Department of Radiology, John Stroger Jr. Hospital of Cook County, Chicago, Illinois.

Anesth Analg 2008; 106:638-644

背景:腰段正中板间和经椎间孔(TF)硬膜外类固醇激素注射是用于继发于椎间盘退化病变的下背痛伴神经根病的治疗方法。因为疼痛的起源位于硬膜外间隙的前面,在硬膜外间隙中向腹侧弥散是抗炎药物布局的合理目标。在这个随机前瞻性观察性研究中,我们利用持续X线透视引导比较了用旁路板间(PIL)与经椎间孔进路造影剂在硬膜外间隙的流型。

方法:收入60位由椎间盘退化或突出引起下背痛和单侧神经根病的患者。受试者随机分为两组:TFPIL,每组30位。所有步骤均通过5ml造影剂持续X线透视引导。造影剂的扩散程度(主要测量结果)由干预者进行分级。扩散程度分为02分,0=没有向前扩散;1=向前扩散,水平和针刺一样;2=向前扩散≥1个节段。次要测量结果为2w1m3m6m时的镇痛水平。

结果:PIL100% 29/29)的患者和TF75%(21/28)的患者中观察到造影剂在硬膜外间隙向前扩散。平均扩散等级为PIL 1.93 (95% 可信区间〔CI, 1.83–2.0) TF 1.46 (95% CI, 1.17–1.46) (P = 0.003)。平均透视时间为PIL 28.96 s(95% CI, 23.9–34.1s) TF 46.25 s (95% CI, 36.27–56.23s) (P = 0.003)。两组间视觉模拟疼痛评分相类似。

结论:PIL途径放置造影剂到硬膜外间隙前面比TF途径更有优势,扩散程度高,且X线透视时间短。近年来TF途径引起的神经损伤逐渐受到关注,因此PIL途径可能更适合常规应用。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: Lumbar midline interlaminar and transforaminal (TF) epidural steroid injections are treatments for low back pain with radiculopathy secondary to degenerative disk disease. Since pain generators are located anteriorly in the epidural space, ventral epidural spread is the logical target for placement of antiinflammatory medications. In this randomized, prospective, observational study, we compared contrast flow patterns in the epidural space using the parasagittal interlaminar (PIL) and transforaminal approaches with continual fluoroscopic guidance.

METHODS: Sixty adult patients with low back pain and unilateral radiculopathy from herniated or degenerated discs were enrolled. Subjects were randomly assigned to one of two groups: TF or PIL (30 in each). All procedures were performed using continual fluoroscopic guidance and 5 mL of contrast. Contrast spread was rated (primary outcome measure) by the interventionalist. Spread was scored 0–2, with 0 = no anterior spread; 1 = anterior spread, same level as needle insertion; and 2 = anterior spread at ≥1 segmental level. The secondary outcome measure was analgesia at 2 wk, 1, 3, and 6 mo.

RESULTS: One hundred percent (29 of 29) patients in the PIL group and 75% (21 of 28) patients in the TF group demonstrated anterior epidural spread. The mean spread grade was 1.93 (95% confidence interval [CI], 1.83–2.0) in the PIL group and 1.46 (95% CI, 1.17–1.46) in the TF group (P = 0.003). Mean fluoroscopy time was 28.96 s (95% CI, 23.9–34.1 s) in the PIL group and 46.25 s (95% CI, 36.27–56.23 s) in the TF group (P = 0.003). Visual analog scale scores were equivalent between groups.

CONCLUSIONS: The PIL approach is superior to the TF approach for placing contrast into the anterior epidural space with reduction in fluoroscopy times and an improved spread grade. With increasing attention to neurological injury associated with TF, the PIL approach may be more suitable for routine use.



己酮可可碱对大鼠神经病模型中已存在的超敏反应的作用

The Effect of Pentoxifylline on Existing Hypersensitivity in a Rat Model of Neuropathy

Jian Liu, MD, Weiyan Li, MD, Juan Zhu, MD, Jing Zhang, MS, Xiaomei Feng, MD, Ren Guan, MD, and Jianguo Xu, MD

From the Department of Anaesthesiology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, People's Republic of China.

Anesth Analg 2008; 106:650-653

背景:我们以往采用大鼠L5脊神经横断模型已显示己酮可可碱可通过在脑额叶前部的抗炎作用预防痛觉过敏的产生。本研究检测己酮可可碱在创伤后应用的效能。

方法:本研究检测在L5脊神经横断后7天给予己酮可可碱对已存在的机械性异常痛、观察到的神经胶质激活和致炎细胞因子表达的作用。

结果:L5脊神经横断后给予己酮可可碱对于已存在的超敏反应、神经胶质激活和细胞因子表达没有作用。

结论:脊神经横断术后7天腹腔注射己酮可可碱无法缓解已存在的超敏反应,也不能减少神经胶质激活和细胞因子表达。

(周雅春 马皓琳 李士通 校)

BACKGROUND: Using a rat L5 spinal nerve transection model we previously showed that pentoxifylline prevents hyperalgesia through antiinflammation in the prefrontal brain. In this study, we examined efficacy when applied after injury.

METHODS: We examined the effect of pentoxifylline on existing mechanical allodynia, observing glial activation and proinflammatory cytokine expression in the lumbar spinal cord, when given 7 days after L5 spinal nerve transection.

RESULTS: There was no effect from pentoxifylline on existing hypersensitivity, glial activation, and cytokine expression when applied after L5 spinal nerve transection.

CONCLUSION: Pentoxifylline administered intraperitoneally on day 7 postsurgery failed to alleviate existing hypersensitivity, or reduce glial activation and cytokine expression.


坐骨骶骨旁的注射能扩散到闭孔神经吗?:一个解剖学研究

Does Sciatic Parasacral Injection Spread to the Obturator Nerve? An Anatomic Study

Nathalie Valade, MD{dagger}, Jacques Ripart, MD, PhD{dagger}, Emmanuel Nouvellon, MD, MSc{dagger}, Philippe Cuvillon, MD, MSc{dagger}, Dominique Prat-Pradal, MD, PhD*, Jean-Yves Lefrant, MD, PhD{dagger}, and Jean-Emmanuel de La Coussaye, MD, PhD{dagger}

From the *Laboratoire d'anatomie, faculté de médecine Montpellier-Nimes, Université Montpellier I, France; and {dagger}Division Anesthésie-Douleur-Urgence-Réanimation, Groupe Hospitalier Universitaire Caremeau, Nimes, France.

Anesth Analg 2008; 106:664-667

背景:骶骨旁坐骨神经阻滞能否提供一致的闭孔神经和会阴阻滞依然不确定。在这个解剖学工作中,我们评估了模拟骶骨旁注射有色乳剂的扩散情况,观察扩散到闭孔神经和骶神经根的情况。

方法:7个人尸体进行双侧骶骨旁注射,共14次。解剖分两步。第一步,后进路确定染料存在于梨状肌水平的坐骨神经来确定注射是成功的。第二步,骨盆内前面解剖评估染料在闭孔神经的骨盆部分周围和骶神经根(S1–3)上的存在情况。对所有神经进行相同评分,从0 (完全失败)3 (完全成功)。对所有神经 (坐骨、闭孔和骶神经根),评分为2 3表明注射成功。

结果:14个中的11个注射显示成功的骶骨旁注射。3个失败的注射排除在进一步分析之外。一个血管内注射,两个(同一尸体)注射在臀肌内的是太表浅了。11个成功的注射中,9 (82%)的评分证明乳剂扩散到闭孔神经和骶神经根。

结论:我们从这个解剖学研究中得到结论,成功的骶骨旁注射同样扩散到闭孔神经的骨盆部分和骶神经根。因此,骶骨旁阻滞应当理论上提供闭孔和会阴的阻滞,并且不需要另外进行闭孔神经阻滞。这个结果需要进一步临床研究的证实。

(张曦 译,马皓琳 李士通 校)

BACKGROUND: The ability of parasacral sciatic nerve block to provide consistent obturator nerve and perineal blockade remains undetermined. In this anatomic work, we assessed the spread of a colored latex mimicking a parasacral injection, and observed the spread to the obturator nerve and sacral nerve roots.

METHODS: Fourteen parasacral injections were performed bilaterally on seven human cadavers. Dissection was performed in two steps. First, the posterior approach confirmed the presence of dye on the sciatic nerve at the level of the piriformis muscle to define the success of the injection. Second, the anterior endopelvic dissection assessed the presence of dye around the pelvic portion of the obturator nerve and on the sacral roots (S1–3). The same score was used for all the nerves, from 0 (total failure) to 3 (total success). For all nerves (sciatic, obturator, sacral roots), a score of 2 or 3 was considered a successful injection.

RESULTS: Eleven of 14 injections were considered successful parasacral injections. The three failed injections were excluded from further analysis. One was intravascular and two (same cadaver) in the gluteal muscles were too superficial. Of the 11 successful injections, 9 (82%) were scored as providing the spread of latex to both the obturator nerve and to the sacral roots.

CONCLUSION: We conclude from this anatomical study that successful parasacral injection consistently spreads to the pelvic portion of the obturator nerve and to the sacral roots. Therefore, parasacral block should theoretically provide obturator and perineal blockade, and eliminate the need for systematic separate obturator nerve block. These results must be confirmed by further clinical studies.

丙泊酚和七氟醚在主动脉嵌夹后调节肾脏炎症反应和氧化应激反应的比较

The Comparative Abilities of Propofol and Sevoflurane to Modulate Inflammation and Oxidative Stress in the Kidney After Aortic Cross-Clamping

Pilar Sánchez-Conde, MD*, José M. Rodríguez-López, MD*, Juan L. Nicolás, MBBS{dagger}, Francisco S. Lozano, MD{ddagger}, Francisco J. García-Criado, MD{ddagger}, Carlos Cascajo, MD{ddagger}, Rogelio González-Sarmiento, MD§, and Clemente Muriel, MD*

From the *Department of Anesthesiology, University Hospital of Salamanca, Salamanca, Spain; {dagger}Department of Anesthesiology, Rodríguez-Chamorro Hospital, Zamora, Spain; Departments of {ddagger}Surgery, and §Medicine, University Hospital of Salamanca, Salamanca, Spain.

Anesth Analg 2008 106: 371-378.

 

背景:有报道显示丙泊酚对缺血-再灌注损伤具有一定的保护作用。在缺血-再灌注损伤中核转录因子kappaB(NF-KB)在炎症反应和氧化应激反应中起到关键作用。笔者比较了主动脉嵌夹后丙泊酚和七氟醚对肾脏NF-KB的表达和全身炎症反应的影响。

方法20只小猪分为4组:应用丙泊酚麻醉的假手术组(SP组,n=5),应用七氟醚的假手术组(SS组,n=5),丙泊酚麻醉手术组(CP组,n=5)和七氟醚麻醉手术组(CS组,n=5),后两组行主动脉-主动脉旁路下肾上主动脉嵌夹30min。麻醉为静注丙泊酚4mg.kg-1.h-1或吸入1.5%七氟醚。在手术开始时、开放主动脉后15分钟、术后244872小时和术后7天采集外周血标本和肾组织活检。检测血浆肌酐、髓过氧化酶、肿瘤坏死因子-{alpha},白介素1-β和肾脏超氧化阴离子及超氧化歧化酶。通过western-blotting检测肾组织NO合成酶及NF-KB

结果:与CS组相比,CP组的动物术后24-72小时髓过氧化酶、肿瘤坏死因子-{alpha}、白介素1-β和肾脏超氧化阴离子及超氧化歧化酶的浓度较低(P<0.05),术后24小时和48小时NF-KBNO合成酶的表达减少(P<0.05)

结论:与七氟醚相比,丙泊酚在嵌夹肾上主动脉期间可调节炎症因子并降低NF-KB的表达。

(潘方立 陈杰 校)

BACKGROUND: Propofol has been reported to provide protection against ischemia–reperfusion injury. Nuclear transcription factor kappa B (NF{kappa}B) plays a key role in oxidative stress and the inflammatory response during ischemia–reperfusion. We compared the effect of propofol with sevoflurane on kidney NF{kappa}B expression and systemic inflammatory responses induced by aortic clamping.

METHODS: Twenty piglets were divided into four groups: sham surgery group with propofol (group SP, n = 5); sham group with sevoflurane (group SS, n = 5); and suprarenal clamping for 30 min with aorta–aortic bypass under propofol (group CP, n = 5) or sevoflurane (group CS, n = 5) anesthesia. Propofol was administered at 4 mg · kg–1 · h–1 IV and sevoflurane given at 1.5% inspiratory concentration. Peripheral blood and kidney biopsies were taken before the start of surgery, 15 min after unclamping the aorta, 24, 48, 72 h, and 7 days after surgery. Plasma creatinine, myeloperoxidase, tumor necrosis factor-{alpha}, interleukin 1-β; and kidney superoxide anion and superoxidase dismutase were measured. The expression of inducible nitric oxide synthase and renal tissue NF{kappa}B was measured using Western blotting.

RESULTS: Compared with the CS group, animals in the CP group had lower concentrations of myeloperoxidase, tumor necrosis factor-{alpha}, interleukin 1β, superoxide anion, superoxidase dismutase (P < 0.05) from 24 to 72 h after surgery and diminished NF{kappa}B expression and inducible nitric oxide synthase activity (P < 0.05) at 48 and 72 h after surgery, respectively.

CONCLUSIONS: Compared with sevoflurane, propofol administration during suprarenal aortic clamping and unclamping led to modulation of markers of inflammation and decreased NF{kappa}B expression.

 

 

心脏手术期间的过敏性反应:临床意义

Anaphylaxis During Cardiac Surgery: Implications for Clinicians

Jerrold H. Levy, MD*, and N. Franklin Adkinson, Jr, MD{dagger}

From the *Emory University School of Medicine, Atlanta, Georgia; and {dagger}Johns Hopkins Asthma & Allergy Center, Division Allergy & Clinical Immunology, Baltimore, Maryland.

Anesth Analg 2008 106: 392-403.

 

外科手术中,患者常接受多种异体物质包括麻醉药,抗生素,血液制品,肝素,多肽(抑肽酶,橡胶制品,鱼精蛋白)和血管扩容剂等,这些都可能引起致命的过敏反应。急性心血管和肺功能不全是围术期过敏性反应的显著表现。心脏手术患者常在严密的监测下,当发生过敏性反应时可以早期发现,及时治疗。在治疗剂量之前给予小剂量药物,也称试验剂量,如发生过敏反应,临床医师就可以积极对症处理。对血流动力学不稳定的病人实施心肺分流术是一条救生之法,在一些难治性心血管功能障碍的病人当中可以考虑应用。血管舒张性休克的病人应该考虑使用精氨酸升压素。本综述中,主要针对最近一些有关于在手术室内发生的过敏性反应的实例以及处理方法作了探讨,特别是心脏手术患者。

(杜唯佳 陈杰 校)

During surgery, patients are exposed to multiple foreign substances including anesthetic drugs, antibiotics, blood products, heparin, polypeptides (aprotinin, latex, and protamine), and intravascular volume expanders, which have the potential to produce life-threatening allergic reactions termed "anaphylaxis." The hallmark of perioperative anaphylaxis is acute cardiovascular and pulmonary dysfunction. Patients undergoing cardiac surgery have extensive monitoring that permits rapid recognition and treatment when anaphylaxis occurs. Initial, smaller doses of drugs, often called test doses, administered before the therapeutic dose may produce anaphylaxis, and so clinicians need to be prepared to treat reactions if they occur. Institution of cardiopulmonary bypass for hemodynamically unstable patients can be a life-saving maneuver, and should be considered in patients with refractory cardiovascular dysfunction. Arginine vasopressin should also be considered for patients with vasodilatory shock. In this review, we focus on recent concepts in understanding the incidence and management approaches for patients at risk for anaphylaxis in the operating room setting, with an emphasis on cardiac surgical patients.

 

 

 

使用异丙酚/瑞芬太尼与咪达唑仑/芬太尼用于结肠镜检查的病人自控镇静的随机、对照、双盲试验

A Randomized, Controlled, Double-Blind Trial of Patient-Controlled Sedation with Propofol/Remifentanil Versus Midazolam/Fentanyl for Colonoscopy

Jeff E. Mandel, MD, MS*, Jonathan W. Tanner, MD, PhD*, Gary R. Lichtenstein, MD{dagger}, David C. Metz, MD{dagger}, David A. Katzka, MD{dagger}, Gregory G. Ginsberg, MD{dagger}, and Michael L. Kochman, MD{dagger}

From the Departments of *Anesthesiology and Critical Care, and {dagger}Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.

Anesth Analg 2008 106: 434-439.

 

背景: 使用异丙酚行病人自控镇静已用于具有狭窄治疗窗的中度镇静,但是以往的研究存在局限性。作者假设应用瑞米芬太尼联合异丙酚行病人自控镇静较芬太尼联合咪唑安定方便易行。

方法:50例接受结肠镜检查的病人随机分成咪达唑仑/芬太尼组(MF组)或异丙酚/瑞芬太尼组(PR),均行病人自控镇静。镇静和苏醒的时间间隔由患者,护士以及胃肠病医师评定,必要时由麻醉医师介入评估与处理。

结果PR组的病人镇静和苏醒快于MF(P<0.001)。在PR组,复苏时间短于手术操作时间。两组间病人、护士和肠胃病医师评定感觉一致。PR组的两名病人需要麻醉医师的介入,患者的动脉去氧饱和超过了安全限。

结论:在有适当的医疗护理中,异丙酚/瑞芬太尼行病人自控镇静优于咪达唑仑/芬太尼

(张燕 陈杰 校)

BACKGROUND: Patient-controlled sedation (PCS) with propofol has been advocated as a method for dealing with the narrow therapeutic window for moderate sedation, but previous studies have methodologic limitations. We hypothesized that, by using remifentanil in conjunction with propofol and using PCS in both arms of the study, we could demonstrate marked improvements in facility use compared with fentanyl plus midazolam.

METHODS: Fifty patients undergoing elective colonoscopy were randomized (with concealed allocation) to midazolam/fentanyl (group MF) or propofol/remifentanil (group PR) administered via PCS. Time intervals for sedation and recovery, perceptions by patient, nurse, and gastroenterologist, and need for anesthesiologist intervention were assessed.

RESULTS: Group PR patients were sedated and recovered significantly more rapidly than did group MF (P < 0.0001). In the group PR, recovery room time was actually shorter than procedure room time. Patient, nurse, and gastroenterologist perceptions were equivalent between the groups. Two patients in group PR required anesthesiologist intervention for arterial desaturation exceeding the primary safety end point.

CONCLUSIONS: PCS with propofol/remifentanil yields superior facility throughput compared with midazolam/fentanyl when used in an appropriate care setting.

 

 

 

新型阿片类药物脱氧吗啡酮用于脊麻的药理特征

Pharmacological Characterization of Noroxymorphone as a New Opioid for Spinal Analgesia

Kim K. Lemberg, DDS*{dagger}, Antti O. Siiskonen, MSc{ddagger}, Vesa K. Kontinen, MD, PhD*§, Jari T. Yli-Kauhaluoma, PhD{ddagger}, and Eija A. Kalso, MD, PhD*§

From the *Institute of Biomedicine, Pharmacology, {dagger}Department of Oral Radiology, Institute of Dentistry, {ddagger}Faculty of Pharmacy, Division of Pharmaceutical Chemistry, University of Helsinki, and §Department of Anaesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.

Anesth Analg 2008 106: 463-470.

 

背景:脱氧吗啡酮是羟考酮的主要代谢产物。羟考酮常用于急慢性疼痛的治疗,然而我们对于脱氧吗啡酮的镇痛作用却不了解。作者对大鼠进行了在体的药理学试验。

方法:用热和机械性伤害性模型研究大鼠脱氧吗啡酮的抗伤害特性。

结果:鞘内注射脱氧吗啡酮(15ug/10ul)可以产生较羟考酮200ug/10ul)和吗啡(15ug/10ul)更持久的镇痛作用。在鞘内注射药物前15分钟皮下给予钠络酮预处理,脱氧吗啡酮和吗啡的镇痛效果均显著降低,表明这是一种阿片受体介导的镇痛作用。在扁平烤盘、脚爪压力和摆尾试验中,分别皮下注射510,和25mg/kg脱氧吗啡酮没有效果。同样,在旋转试验中没有观察到研究所用的剂量对运动功能有所影响。在大鼠角叉胶炎症模型中,皮下注射脱氧吗啡酮25mg/kg,无抗痛觉过敏效果。

结论:鞘内注射脱氧吗啡酮时,它是一种有效的u阿片受体激动剂。全身作用效力的缺失也许表明脱氧吗啡酮穿透血脑屏障的能力较低,因为其计算出的logD值较低(log辛醇/水分配系数)。因此,在全身给予羟考酮镇痛时脱氧吗啡酮的作用可以忽略不计。由于其用于脊髓内的作用效果和长久的作用效力,脱氧吗啡酮是一种有用的脊髓阿片类药物,被滥用的可能性较低。但在临床应用前需要评估脊髓注射脱氧吗啡酮的安全性。

(印洁敏 陈杰 校)

BACKGROUND: Noroxymorphone is one of the major metabolites of oxycodone. Although oxycodone is commonly used in the treatment of acute and chronic pain, little is known about the antinociceptive effects of noroxymorphone. We present an in vivo pharmacological characterization of noroxymorphone in rats.

METHODS: The antinociceptive properties of noroxymorphone were studied with thermal and mechanical models of nociception in rats.

RESULTS: Intrathecal noroxymorphone (1 and 5 µg/10 µL) induced a significantly longer lasting antinociceptive effect compared with oxycodone (200 µg/10 µL) and morphine (1 and 5 µg/10 µL). Pretreatment with subcutaneous naloxone (1 mg/kg) 15 min before intrathecal drug administration significantly decreased the antinociceptive effect of both noroxymorphone and morphine, indicating an opioid receptor-mediated antinociceptive effect. In the hotplate, paw pressure, and tail flick tests, subcutaneous noroxymorphone was inactive in doses of 5, 10, and 25 mg/kg. Also, no effect on motor function was observed in the rotarod test with doses studied. No antihyperalgesic effect was observed in the carrageenan model for inflammation in rats with subcutaneous noroxymorphone 25 mg/kg.

CONCLUSIONS: The results of this study indicate that noroxymorphone is a potent µ-opioid receptor agonist when administered intrathecally. The lack of systemic efficacy may indicate reduced ability of noroxymorphone to penetrate the blood–brain barrier due to its low calculated logD value (log octanol/water partition coefficient). Thus, noroxymorphone should have a negligible role in analgesia after systemic administration of oxycodone. Because of its spinal efficacy and long duration of effect, noroxymorphone is an interesting opioid for spinal analgesia with a low potential for abuse. Its safety for spinal administration should be assessed before clinical use.


等碳酸血症下呼吸增强加速七氟醚麻醉后的呼吸恢复

Accelerated Recovery from Sevoflurane Anesthesia with Isocapnic Hyperpnoea

Rita Katznelson, MD*, Leonid Minkovich, MD, PhD*, Zeev Friedman, MD{dagger}, Ludvik Fedorko, MD, PhD, FRCPC*, W. Scott Beattie, MD, PhD, FRCPC*, and Joseph A. Fisher, MD, FRCP(C)*

From the *Department of Anesthesia, Toronto General Hospital, and {dagger}Mount Sinai Hospital, University Health Network, University of Toronto, Toronto, Ontario.

Anesth Analg 2008 106: 486-491.

 

背景:在动物及人类实验中发现等碳酸血症下呼吸增强(IH)可以减少异氟醚麻醉后的复苏时间。作者比较了术后等碳酸血症下呼吸增强(IH组)或常规方式(对照组)进行复苏后病人的恢复变量来研究IH对七氟醚麻醉病人的影响。

方法:选择30 ASAI-III级,行择期妇产科手术的病人。麻醉的诱导和维持以实验设计的标准,包括芬太尼,异丙酚,罗库溴铵及以空气/氧气为载体的七氟醚。在手术结束时病人随机分成对照组(C组)或是IH组。记录从停止七氟醚到呼吸恢复的时间。

结果:与C组相比,IH组拔管的时间更短(6.2±2.1vs12.3±3.8minp<0,01)。IH组出现自主呼吸(4.2±1.7vs6.5±3.8min, p=0.047),睁眼(5.5±1.4vs13.3±4.4minp<0.01),脑电双频指数值>753.9±1.1vs8.8±3.7minp<0.01),离开手术室时间(7.7±2.0vs15.3±3.4minp<0.01)以及离开PACU 67.2±19.3vs90.6±20.0minp<0.01)的时间均缩短。

结论IH可以减少七氟醚麻醉后的复苏时间,缩短病人在手术室及PACU的停留时间。

(潘钱玲 陈杰 校)

BACKGROUND: Isocapnic hyperpnoea (IH) reduces recovery time from isoflurane anesthesia in animals and humans. We studied the effect of IH on the emergence profile of sevoflurane-anesthetized patients by comparing postoperative recovery variables in patients administered IH (IH group) to those recovered in the customary fashion (control group).

METHODS: We enrolled 30 ASA I–III patients undergoing elective gynecological surgery. Induction and maintenance of anesthesia were standardized with a protocol consisting of fentanyl, propofol, rocuronium, and sevoflurane in air/O2. Patients were randomly assigned to control (C) or IH groups at the end of the surgery. We recorded time intervals from discontinuing sevoflurane to recovery milestones.

RESULTS: Time to tracheal extubation was much shorter in the IH group compared with group C (6.2 ± 2.1 vs 12.3 ± 3.8 min, respectively, P < 0.01). The IH group also had shorter times to initiation of spontaneous ventilation (4.2 ± 1.7 vs 6.5 ± 3.8 min, P = 0.047), eye opening (5.5 ± 1.4 vs 13.3 ± 4.4 min, P < 0.01), bispectral index value >75 (3.9 ± 1.1 vs 8.8 ± 3.7 min, P < 0.01), leaving operating room (7.7 ± 2.0 vs 15.3 ± 3.4 min, P < 0.01), and eligibility for postanesthetic care unit discharge (67.2 ± 19.3 vs 90.6 ± 20.0 min, P < 0.01).

CONCLUSION: IH accelerates recovery from sevoflurane anesthesia and shortens operating room and postanesthetic care unit stay.

 

连续硬膜外麻醉后严重皮肤炎症反应一例报告

A Severe Inflammatory Cutaneous Reaction After Continuous Epidural Analgesia

Kareem Eltaki, MD*, Heba Abdulla, MD{dagger}, and Raymond S. Sinatra, MD, PhD*

From the *Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut; {dagger}SUNY Downstate Medical Center, Department of Dermatology, Brooklyn, New York.

Anesth Analg 2008 106: 517-519.

 

一种罕见但又重要的硬膜外置管的风险因素是皮肤对消毒液、固定胶布或导管本身的反应。本文作者描述了一例经腹会阴切除术后应用连续硬膜外镇痛后严重皮肤炎症反应,强调做出正确诊断和及时就诊治疗的重要性。

(王腾 陈杰 校)

A very rare, but important, risk factor in placement of epidural catheters is skin reactions to the antiseptic solution, adhesive tape, or the catheter itself. We describe a case of a severe inflammatory cutaneous reaction after continuous epidural analgesia used after an abdominal perineal resection. We highlight the importance of making the proper diagnosis and initiating timely therapy.

 

 

一种通过经食道超声心动图评价局部肺血流的新方法

A New Method to Estimate Regional Pulmonary Blood Flow Using Transesophageal Echocardiography

Yuichi Yatsu, MD, Toshihito Tsubo, MD, Hironori Ishihara, MD, Hitomi Nakamura, MD, and Kazuyoshi Hirota, MD, FRCA

From the Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki, Aomori-ken, Japan.

Anesth Analg 2008 106: 530-534.

 

背景:作者报道了一种在实验性狗模型上通过经食道超声心动图评价膨胀不全时肺局部血流的方法。为了验证这种方法的可行性,作者研究了这种实验模型下检测局部肺血流变化的能力。

方法14只麻醉的进行机械通气的杂种狗随机分为异丙肾上腺素组(n=7)和多巴胺组(n=7)。通过左侧胸腔内注入每kg体重60ml生理盐水制成人为肺不张模型。通过脉冲多普勒计算速度时间积分(VTI)作为肺不张时血流指数。为了研究这种方法对血流变化的反应,全身给予异丙肾上腺素0.05µg · kg–1 · min–1(肺血管扩张剂)或多巴胺10µg · kg–1 · min–1(肺血管收缩剂 ,测VTI和肺内血流分流率(Qs/Qt)

结果:给予异丙肾上腺素的模型VTIQs/Qt明显上升。异丙肾上腺素组VTIQs/Qt变化百分率有明显的关联。多巴胺组,VTIQs/Qt无显著变化。

结论:经食道超声心动图可能在检测肺不张时的局部肺血流变化方面有用。

(王鹏 陈杰 校)

BACKGROUND: We report a novel method to estimate regional blood flow in the atelectatic lung using transesophageal echocardiography in an experimental dog model. To verify the efficacy of the method, we investigated the ability of this experimental model to detect changes in regional pulmonary blood flow.

METHODS: Fourteen anesthetized and ventilated mongrel dogs were randomized into an isoproterenol group (n = 7) or a dopamine group (n = 7). To produce an atelectatic lesion, 60 mL/kg of saline was infused into the left pleural space. The velocity time integral (VTI) derived from pulse Doppler was evaluated as an index of blood flow in the atelectatic lesion. To investigate the response of the method to changes in blood flow, the VTI and the shunt fraction (Qs/Qt) were measured during systemic administration of isoproterenol 0.05 µg · kg–1 · min–1 (as a pulmonary vasodilator) and dopamine 10 µg · kg–1 · min–1 (as a pulmonary vasoconstrictor).

RESULTS: Both VTI and Qs/Qt were increased significantly by isoproterenol administration. There was a significant correlation between the percentage changes of VTI and Qs/Qt with isoproterenol administration (r2 = 0.50, P < 0.001). Both VTI and Qs/Qt were unchanged during administration of dopamine.

CONCLUSIONS: Transesophageal echocardiography may be useful in detecting changes in regional pulmonary blood flow in an atelectatic lesion.

 

 

超声引导下基本操作技能的学习曲线及数学模型

Learning Curves and Mathematical Models for Interventional Ultrasound Basic Skills

Getúlio Rodrigues de Oliveira Filho, MD, PhD, Pablo Escovedo Helayel, MD, Diogo Brüggemann da Conceição, MD, Ivo Sebastião Garzel, MD, Patrícia Pavei, MD, and Maurício Sperotto Ceccon, MD

From the Department of Anesthesiology, Hospital Governador Celso Ramos, Nucleus for Teaching and Research in Medical Education, Florianópolis, SC, Brazil.

Anesth Analg 2008 106: 568-573.

背景:作者拟建立超声基本技能学习曲线及数学模型:针-超声射线校直和目标到达的优化

方法30名受试者参与本研究,每位受试者操作25例。试验中采用线性超声探头以及牛肌肉模型。每项操作试验分2个部分,第一部分中要求每位受试者针刺过程中超声光束与针的影像平行。第二部分中模型内纵向地插入一段肌腱,深达1-1.5cm,同时要求每位受试者将针一直插入并触及肌腱。对于操作结果使用累积法建立学习曲线,并对这两个部分的操作技能建立bush Mosteller数学模型。

结果:在实验的第一第二部分中分别只有30%10%的受试者达到熟练操作。通过bush Mosteller数学模型估计达到95%成功率的平均操作次数分别为37109

结论:掌握超声引导基本操作技能是需要一定的练习,而使用累积法显示麻醉医师掌握该技能的水平参差不齐。但必须注意的是本试验主要是在模型上进行,所以作者认为该结论并不一定适用于临床病人的神经阻滞操作。

( 陶颖莹 陈杰 )

BACKGROUND: We aimed to construct learning curves and mathematical learning models for ultrasound basic skills: optimizing needle-ultrasound beam alignment and reaching a target inside a phantom.

METHODS: Thirty subjects participated in the study. Each subject performed 25 trials. Linear ultrasound probes and a bovine muscular phantom were used. In Experiment 1, subjects tried to insert a needle parallel to the ultrasound beam with full imaging of the needle. For Experiment 2, a segment of tendon was inserted longitudinally into the phantom at a depth of 1 to 1.5 cm. Subjects tried to insert the needle until contacting the tendon. Learning curves were constructed using the cumulative sum (cusum) method. Bush and Mosteller’s mathematical learning models were constructed for each skill.

RESULTS: Only 30% and 11% of subjects attained proficiency in Experiments 1 and 2, respectively. The predicted average numbers of trials to achieve 95% success rates as estimated from Bush and Mosteller’s models were 37 and 109, respectively.

CONCLUSIONS: Learning interventional ultrasound basic skills may require a considerable number of trials. Cusum charts revealed that individuals acquire such abilities at variable rates. As skills were assessed in phantoms, our results do not apply to blocks given to real patients.

 

针刺镇痛1:科学基础

Acupuncture Analgesia: I. The Scientific Basis

Shu-Ming Wang, MD*, Zeev N. Kain, MD, MBA{dagger}{ddagger}, and Paul White, PhD, MD§

From the Departments of *Anesthesiology, {dagger}Pediatrics and {ddagger}Child and Adolescent Psychiatry, The Center for Advancement of Perioperative Health, Yale University School of Medicine, New Haven, Connecticut; and §Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas.

Anesth Analg 2008 106: 602-610.

 

在过去的3000年里,针刺技术在中国和其他亚洲国家被广泛应用。最近在美国,越来越多的医师和患者对此技术产生兴趣。尽管针刺诱导镇痛在美国很多疼痛管理程序中得到使用,但其作用机制未被阐明。很多研究提出针刺及相关技术可引发一系列反应:包括神经递质和内源性类阿片物质的释放,中枢神经系统c-fos基因的活化。中枢神经系统影像学技术的新近发展使科研人员能够更好地评价针刺诱导刺激后所发生的一系列事件。在此项综述中,作者调查了针刺镇痛在新近生理生化学和影像学方面的探索。

(於章杰 陈杰 校)

Acupuncture has been used in China and other Asian countries for the past 3000 yr. Recently, this technique has been gaining increased popularity among physicians and patients in the United States. Even though acupuncture-induced analgesia is being used in many pain management programs in the United States, the mechanism of action remains unclear. Studies suggest that acupuncture and related techniques trigger a sequence of events that include the release of neurotransmitters, endogenous opioid-like substances, and activation of c-fos within the central nervous system. Recent developments in central nervous system imaging techniques allow scientists to better evaluate the chain of events that occur after acupuncture-induced stimulation. In this review article we examine current biophysiological and imaging studies that explore the mechanisms of acupuncture analgesia.

 

10. 针刺镇痛2 临床思考

Acupuncture Analgesia: II. Clinical Considerations

Shu-Ming Wang, MD*, Zeev N. Kain, MD, MBA*{dagger}, and Paul F. White, PhD, MD, FANZCA{ddagger}

From the The Center for Advancement of Perioperative Health©, Departments of *Anesthesiology, and {dagger}Pediatrics, and Child and Adolescent Psychiatry, Yale University School of Medicine, New Haven, Connecticut; and {ddagger}Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Texas.

Anesth Analg 2008 106: 611-621.

 

背景:针刺及相关经皮神经调节疗法可用于治疗患者的急慢性疼痛。在此项综述中,作者细致审视了临床研究中针刺镇痛的相关研究。

方法:作者查阅Ovid和其出版的医学数据库,总结了关于使用针灸和其他针刺相关形式治疗疼痛的一些前瞻性、随机对照临床研究。但此项分析并不包括个别病例报道、病例系列分析和队列研究。

结果:对等审查文献表示:针灸和其他形式的针刺能有效地控制短期的腰背部、颈部和涉及膝盖的骨关节疼痛。然而,文献也同样表明:其短期的治疗效果并无长期效益。关于针刺对牙痛、肠镜相关疼痛和术中止痛的有效性数据并未收录。研究描述了在产程中应用针刺可能在早期有益,但这种效益并不贯穿整个产程。最后,关于针刺对术后疼痛的疗效由于涉及手术时间和患者的意识水平,并不包括在此项研究范围内。

结论:最近研究针刺及相关技术临床有效性的数据显示其收益是短效的。需要更多设计完善的临床对照试验来评估针刺对临床结局的影响,如当其应用于急慢性疼痛时对病人日常活动的恢复方面是否有益等。

(於章杰 陈杰 校)

BACKGROUND: Acupuncture and related percutaneous neuromodulation therapies can be used to treat patients with both acute and chronic pain. In this review, we critically examined peer-reviewed clinical studies evaluating the analgesic properties of acupuncture modalities.

METHODS: Using Ovid© and published medical databases, we examined prospective, randomized, sham-controlled clinical investigations involving the use of acupuncture and related forms of acustimulation for the management of pain. Case reports, case series, and cohort studies were not included in this analysis.

RESULTS: Peer-reviewed literature suggests that acupuncture and other forms of acustimulation are effective in the short-term management of low back pain, neck pain, and osteoarthritis involving the knee. However, the literature also suggests that short-term treatment with acupuncture does not result in long-term benefits. Data regarding the efficacy of acupuncture for dental pain, colonoscopy pain, and intraoperative analgesia are inconclusive. Studies describing the use of acupuncture during labor suggest that it may be useful during the early stages, but not throughout the entire course of labor. Finally, the effects of acupuncture on postoperative pain are inconclusive and are dependent on the timing of the intervention and the patient's level of consciousness.

CONCLUSIONS: Current data regarding the clinical efficacy of acupuncture and related techniques suggest that the benefits are short-lasting. There remains a need for well designed, sham-controlled clinical trials to evaluate the effect of these modalities on clinically relevant outcome measures such as resumption of daily normal activities when used in the management of acute and chronic pain syndromes.

 

I型复杂区域疼痛综合征的处理:经皮射频腰交感神经阻断术与苯酚腰交感神经松解术相比较的评估——初步研究

Management of Lower Limb Complex Regional Pain Syndrome Type 1: An Evaluation of Percutaneous Radiofrequency Thermal Lumbar Sympathectomy Versus Phenol Lumbar Sympathetic Neurolysis—A Pilot Study

Prashanth S. Manjunath, MD*, T. S. Jayalakshmi, MD{dagger}, G. P. Dureja, MD{dagger}, and A. Toby Prevost, PhD{ddagger}

From the *Department of Anesthesiology, University of Miami-Jackson Memorial Hospital, Miami; {dagger}Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi; and {ddagger}Centre for Applied Medical Statistics, Department of Public Health and Primary Care, University of Cambridge, Robinson Way, Cambridge.

Anesth Analg 2008 106: 647-649.

 

背景I型复杂区域疼痛综合征常难以处理。这项研究的目的是比较两种治疗方法:经皮射频腰交感神经阻断术和腰交感神经松解术的安全性和功效。

方法:20I型下肢复杂区域疼痛综合征患者随机接受经皮射频热能腰交感神经阻断术或7%苯酚时腰交感神经松解术。在疼痛缓解和发生副作用时停止实验。

结果:每组患者经治疗后疼痛值均有明显的下降,但各组间无明显差异。

结论:基于此项初步研究,射频腰交感神经阻断术具有苯酚腰交感神经松解术相当的疗效。但尚需更大规模的研究以证实这一发现。

(胡潇 陈杰 校)

BACKGROUND: Complex regional pain syndrome type 1 can be difficult to treat. The purpose of this study was to compare the safety and efficacy of two therapeutic options: percutaneous radiofrequency thermal lumbar sympathectomy and lumbar sympathetic neurolysis.

METHODS: We randomized 20 patients to receive percutaneous radiofrequency lumbar sympathectomy or lumbar sympathetic neurolysis with phenol 7% in lower limb complex regional pain syndrome type 1. The study end points were pain relief and side effects.

RESULTS: Within each group, there were statistically significant reductions from baseline in various pain scores after the procedure. However, there was no statistically significant difference in mean pain scores between the groups.

CONCLUSIONS: Based on this pilot study, radiofrequency lumbar sympathectomy may be comparable to phenol lumbar sympathectomy. A larger trial is required to confirm these findings.

 

运动对布比卡因臂丛神经阻滞时起效和进程的影响:一项肩关节镜手术病人的随机、前瞻性研究

The Effect of Motor Activity on the Onset and Progression of Brachial Plexus Block with Bupivacaine: A Randomized Prospective Study in Patients Undergoing Arthroscopic Shoulder Surgery

Kenneth E. Langen, MD*, Kenneth D. Candido, MD*, Michael King, MD*, Guido Marra, MD{dagger}, and Alon P. Winnie, MD{ddagger}

From the Departments of *Anesthesiology and {dagger}Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illnois. {ddagger}Department of Anesthesiology, Northwestern University Medical Center/Feinberg School of Medicine, Chicago, IL.

Anesth Analg 2008 106: 659-663.

 

背景:曾发现应用利多卡因行经锁骨上臂丛神经阻滞时手部肌肉连续运动可以缩短神经阻滞起效的潜伏期。在本研究中,作者研究了布比卡因肌间沟臂丛神经阻滞时手部肌肉重复收缩对麻醉起效速度的影响。

方法40名患者行肌间沟臂丛神经阻滞下择期行肩关节镜手术。在完成臂丛阻滞后,一组患者要求放松他们的手臂(即未活动组)。另一组要求完成5分钟的手部运动练习(活动组)。检测两侧手的握力和经皮电刺激的耐受性来评价运动和感觉阻滞的程度。

结果:运动组病人在阻滞完全后20min经皮电刺激的耐受性显著降低(P < 0.05)

结论:上述结果意味,尝试应用肌肉重复活动的频率依赖的传导阻滞作为布比卡因臂丛神经阻滞的辅助方法是没有价值的。

(陈伟 陈杰 校)

BACKGROUND: A decreased latency of onset of neural blockade has been noted when muscular exercise of the hand was performed after supraclavicular brachial plexus block using lidocaine. In this observational study, we examined the effect of repetitive muscle contraction of the hand on the speed of onset of interscalene brachial plexus block (ISB) using bupivacaine.

METHODS: Forty patients were enrolled, all of whom received an ISB as one component of their anesthetic management for elective arthroscopic shoulder surgery. Patients were asked either to rest their arms after the performance of the ISB (nonexercise group) or to perform a repetitive hand exercise for 5 min (exercise group). Bilateral hand grip strength and tolerance to transcutaneous electrical stimulation were used to quantify the degree of motor and sensory blockade.

RESULTS: Patients in the exercise group had a statistically significant lower tolerance to transcutaneous electrical stimulation 20 min after completion of the block (P < 0.05).

CONCLUSIONS: Our results imply that attempting to use a frequency-dependent conduction block with repetitive motor activity as a clinical adjuvant to brachial plexus block with bupivacaine is without merit.