Table of Contents

February 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

氯胺酮和依託咪脂在離體的正常和缺血再灌注豚鼠心肌模型邊緣叢的神經電生理效應

陳愷錚譯 薛張綱校

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動脈嵌夾後調節腎臟炎症反應和氧化應激反應的比較

潘方立 陳傑

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.

在胸外科手術中選擇左雙腔氣管導管尺寸的實踐模式

彭中美 馬皓琳 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.

通過蛋白酶A啟動線粒體大電導鈣啟動鉀通道介導地氟醚誘導的預處理

陳佳莉譯 薛張綱校

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.

心臟手術期間的過敏性反應:臨床意義

杜唯佳 陳傑

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:

比較嬰兒體外迴圈中的肝素處理方案

裘毅敏譯,馬皓琳 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.

小於兩歲兒童的腦電雙頻指數與中潛伏期聽覺誘發電位

陳勇柱譯,薛張綱校

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:

使用異丙酚/瑞芬太尼與咪達唑侖/芬太尼用於結腸鏡檢查的病人自控鎮靜的隨機、對照、雙盲試驗

張燕 陳傑

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.

催眠能緩解切除的乳腺活檢患者的術前不良應激

唐亮   馬皓琳 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.

通過提高屍體模型食管的壓力,比較七種不同聲門上氣道通氣裝置的密閉性

陳珺珺譯  薛張綱校

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:

新型阿片類藥物去氧嗎啡酮用於脊麻的藥理特徵

印潔敏 陳傑

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-異丙酚使擇期手術患者應答性喪失及對模擬疼痛刺激和喉鏡檢查反應喪失的回應面評價

吳進   馬皓琳 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.

嗎啡通過蛋白激酶A依賴途徑減輕微血管通透性升高

璿譯 薛張綱校

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強加速七氟醚麻醉後的呼吸恢復

潘錢玲 陳傑

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突變使神經元易受異氟醚毒性影響

張瑩譯  馬皓琳 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:

新型攜帶型裝置測量術前病人的代謝氣體交換

吳威譯,薛張綱校

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:

連續硬膜外麻醉後嚴重皮膚炎症反應一例報告

王騰 陳傑

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.

腦室內誤給予依託米酯與羅庫溴胺

胡湘     馬皓琳 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:

重症監護室獲得性血行感染中白色念珠菌與非白色念珠菌感染的比較:危險因素和預後的不同

施楊譯,薛張綱校

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.

一種通過經食道超聲心動圖評價局部肺血流的新方法

王鵬 陳傑

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.

使胃充氣最小化與胸腔按壓最優化比較

沈浩   馬皓琳 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:

識別腰椎間隙:觸診與超聲比較

(吳威譯,薛張綱校)

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:

超聲引導下基本操作技能的學習曲線及數學模型

陶穎瑩 陳傑 )

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:

過度通氣能改善幕上開顱術的手術條件嗎?一項多中心隨機交叉試驗

慧譯 馬皓琳 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:

容量應激對豬局部血流量急性及持續性的影響

孫霞譯  薛張綱校

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:

針刺鎮痛1:科學基礎

於章傑 陳傑

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

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

Anesth Analg 2008 106: 602-610.

10. 針刺鎮痛2 臨床思考

於章傑 陳傑

Acupuncture Analgesia: II. Clinical Considerations (Review Article)

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

Anesth Analg 2008 106: 611-621.

術後病人應用曲馬多的有限效能:應用連續再評價方法研究ED80

黃麗娜    馬皓琳 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.

一項鞘內注射齊考諾肽對於嚴重慢性疼痛的安全性和耐受性的開放性長期研究的結果

王時來譯 薛張綱校

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.

對用X線透視引導行腰段硬膜外類固醇注射的碘化造影劑流型的前瞻性評價:側旁層間硬膜外進路和經椎間孔硬膜外進路比較

黃佳佳譯,馬皓琳 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:

阿片類藥物導致的痛覺過敏和使用他克莫斯後的超快速脫毒

張儷譯,薛張綱校

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型複雜區域疼痛綜合征的處理:經皮射頻腰交感神經阻斷術與苯酚腰交感神經松解術相比較的評估——初步研究

胡瀟 陳傑

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:

己酮可哥堿對大鼠神經病模型中已存在的超敏反應的作用

周雅春 馬皓琳 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:

三維立體電腦X線斷層攝影術用於困難的胸段硬膜外穿刺

周時蓓譯 薛張綱校

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.

運動對布比卡因臂叢神經阻滯時起效和進程的影響:一項肩關節鏡手術病人的隨機、前瞻性研究

陳偉 陳傑

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擴散到閉孔神經嗎?:一個解剖學研究

張曦 譯,馬皓琳 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.

識別腰椎間隙:觸診與超聲比較

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:觸診識別腰椎間隙被證明是不夠準確的。此次研究我們的目的是比較在腰椎區域超聲成像與觸診的優劣。

方法:121名採用椎管麻醉的產婦中,我們比較了用超聲成像定位的脊椎節段與麻醉師通過觸診定位的節段,並由麻醉師記錄在病史上。

結果:67名病人(55%),麻醉師定位的脊椎節段穿刺點與超聲評估的節段一致,39例病人(32%)其由超聲定位的皮膚穿刺點節段比觸診所定至少高一個節段。無關係數0.0895%可信區間:0.020.14)。

結論:在腰椎節段定位上,超聲成像與觸診契合度較差,而當兩者存在差異時,超聲定位的節段通常要比觸診所得高一些。

(吳威譯,薛張綱校)

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.

 

 

小於兩歲兒童的腦電雙頻指數與中潛伏期聽覺誘發電位

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:我們分析了在健康兒童清醒狀態及不使用鎮靜藥物的自然睡眠時腦電雙頻指數及中潛伏期聽覺誘發電位的數值,並用改良的Ramsay評分分析它們的相關性。

方法:53位小於2歲的健康兒童參與研究。同時使用改良的Ramsay評分、腦電雙頻指數及中潛伏期聽覺誘發電位評估兒童。每位病人參與一次研究,調查各方法間的相關度及協同度。三種方法的相關度使用Spearman Rank相關度測試來決定,而使用Cohen’s Kappa測試來評估它們的協同度。

結果:三種方法的相關度(r)中等偏上(P0.01):腦電雙頻指數與中潛伏期聽覺誘發電位(r0.574),腦電雙頻指數與Ramsay評分(r=-0.504),中潛伏期聽覺誘發電位與Ramsay評分(r=-0.624)。然而協同度κ卻比較差:腦電雙頻指數與中潛伏期聽覺誘發電位(κ0.392),腦電雙頻指數與Ramsay評分(κ0.270),中潛伏期聽覺誘發電位與Ramsay評分(κ0.409)。在16個月兒童中,所有相關性均比較低。在入睡時(RS35),小於1月兒童的腦電雙頻指數值要高於6月以上兒童(在Bonferroni校正後的P值=0.028)。

結論:在不使用藥物鎮靜的小於兩歲兒童中,腦電雙頻指數、中潛伏期聽覺誘發電位及Ramsay評分具有良好的相關性,但協同差。

(陳勇柱譯,薛張綱校)

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.

 

 

新型攜帶型裝置測量術前病人的代謝氣體交換

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:間接測熱法測量氣道二氧化碳的消除(Vco2),氧攝取(Vo2),以及呼吸商(Vco2/ Vo2),是一種評估機體代謝情況的無創方法。在麻醉中,間接測熱法可以預示嚴重不良事件或急性代謝紊亂的發生。先前我們已經證明了一種新型間接測熱法裝置的準確性及精密度,它包含一種新型臨床混合器、快反應溫濕感測器以及一個流量計。但是由於不穩定的生命體征、呼吸頻率及功能殘氣量,要在自主呼吸的情況下進行間接測熱法是極具挑戰性的。

方法:一項新型的專門設計用於自主呼吸時測量間接測熱法的裝置在代謝類比肺的測試中被證明是有效的。在此後的研究中,此項裝置被用來測量15位元術前病人的Vco2Vo2

結果:在代謝類比肺上測量所得的資料顯示了極好的相關性及協同度:氣道Vco2的平均百分誤差是-4.7%±3.31%,氣道Vo2的平均百分誤差是-0.30%±5.25%。病人Vco2Vo2的平均值(分別是3.01±0.563.44±0.69mL/kg.min)與以前報導的數值契合。

結論:我們已經證明這種新型的攜帶型的混合流量裝置(使用混合器及快反應濕度感測器)可以提供準確、方便的床旁測量Vco2Vo2。我們相信它在將來可以為術前評估及提供圍手術期治療的基礎參考值作出貢獻。

(吳威譯,薛張綱校)

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.

 

 

三維立體電腦X線斷層攝影術用於困難的胸段硬膜外穿刺

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為胸外科手術術後的鎮痛方式。然而,重疊交錯的棘突結構使得椎板間空間閉合,常常導致胸段硬膜外穿刺置針困難。隨著多層螺旋CT的發展,胸部三維立體影像能夠容易的獲得,提供了也許有用的臨床醫學資訊。因此,我們進行此項試驗用以評估困難的胸段硬膜外穿刺置針和通過三維立體CT所獲得的解剖學資料之間的關聯。

方法:78位患者被納入研究。每個患者,為了成功地完成硬膜外導管的放置所進行的皮膚穿刺的次數和完成操作所花的時間被記錄下來。在最初嘗試時硬膜外穿刺針成功的置入硬膜外腔的患者被確認為第一級成功者。其餘的則被確認為第一級失敗的患者。在三維立體CT上胸段椎板間空間閉塞的例數以及胸段棘上韌帶和棘間韌帶骨化的例數同樣被評估。

結果:第一級成功者的比例為84.6%。胸段椎板間空間閉塞的例數在第一級失敗的患者中遠遠多於那些成功的患者(P < 0.001)。胸段棘上韌帶的骨化的例數在第一級失敗的患者中較之在那些成功的患者中更常見(P=0.001)。硬膜外穿刺嘗試的次數和操作所花費的時間與胸部椎板間空間閉塞的程度有明顯的關聯(P < 0.001)

結論:術前的三維立體CT成像可能對於困難的胸段硬膜外穿刺有預測的價值。

(周時蓓譯 薛張綱校)

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.

 

嗎啡通過蛋白激酶A依賴途徑減輕微血管通透性升高

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:本實驗室最近發表的研究顯示硫酸嗎啡(MS)能減輕大鼠失血性休克後微血管通透性的升高。MS是內皮細胞表面的mu受體的配體。有幾項研究表明內皮細胞表面mu受體活化後能啟動腺苷酸環化酶。我們假設MS與內皮細胞表面mu受體結合後能通過啟動腺苷酸環化酶增加環化單磷酸腺苷(cAMP)。cAMP經由蛋白激酶APKA)抑制Raf-1來抑制磷酸肌醇/絲裂原活化蛋白(MAP)激酶對血管通透性的增加。

方法:該研究的物件為5組經烏拉坦麻醉的Sprague-Dawley大鼠:第一組為對照組,第二組為不阻斷受體的腺苷酸環化酶抑制劑SQ22536100 microg/kg),第三組為PKA抑制劑H8910 microg/kg),第四組為MS10 microg/kg)加PKA抑制劑,第五組為腺苷酸環化酶抑制劑加MS。用顯微鏡觀察活體腸系膜毛細血管後微靜脈,用鼠肺微血管內皮細胞單層衡量通透性。

結果:腺苷酸環化酶和PKA抑制劑組血管通透性升高。

結論:資料顯示,當通過非受體抑制劑SQ22536抑制腺苷酸環化酶後,血管通透性升高。用MS處理後,這種血管通透性的升高被減輕。MS不能減輕用H89阻斷PKA後的血管通透性升高,提示MSPKA的上游,依賴PKA起作用。

(羅 璿譯 薛張綱校)

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.

 

阿片類藥物導致的痛覺過敏和使用他克莫斯後的超快速脫毒

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

 

阿片類藥物會導致中樞的敏感性和痛覺過敏,名為“阿片類導致的痛覺過敏”。我們的報告描述了一個接受小腸移植的患者出現了免疫抑制相關的神經病理性疼痛。她的疼痛治療的三年過程中運用了各種不同的方法,包括靜脈注射嗎啡,但效果有限。她發展成為阿片類藥物導致的痛覺過敏,然後在全身麻醉下運用全麻下行快速脫毒療法而被成功治癒。脫毒治療改善了她的生活質量,包括可以重新進行物理治療。經過六個月的治療後,她能夠保持不使用阿片類藥物。我們的經驗說明在全麻下行快速脫毒治療可能對阿片類藥物導致的痛覺過敏是一種有效的方法,而且也有益於與傳統的解毒方法做出比較。

(張儷譯,薛張綱校)

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.

 

一項鞘內注射齊考諾肽對於嚴重慢性疼痛的安全性和耐受性的開放性長期研究的結果

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:齊考諾肽是一個非阿片類藥物,用於接受鞘內注射治療或者對於其他治療不耐受或無效的病人的嚴重的慢性疼痛的治療。

方法:644名伴有嚴重慢性疼痛的病人參加了這項開放性多中心研究。通過長期輸注進行齊考諾肽的滴定。有效性的評估包括疼痛程度的VAS評分。安全性評估包括不良事件(AEs)、生命體征和常規的實驗室指標。

結果:116名病人接受齊考諾肽的治療不少於360天,總時間為350.9人年。齊考諾肽治療時間的中位數是67.5天(可信區間是1.2-1215.5天),最後輸注的平均劑量是8.4 µg/天(可信區間是0.048–240.0 µg/天)。VAS評分的中位數位於基線,第一個月直到第二個月最後可得到的觀察記錄分別是76mm(範圍, 4–100 mm), 68 mm (範圍, 0–100 mm), and 73 mm (範圍, 0–100 mm)。大多數病人(99.7%)出現了一個以上的不良事件。多數是輕到重度的不良事件,58.6%的不良事件被認為與齊考諾肽無關。上報的較為常見的不良事件(≥25%的病人)包括噁心、頭暈、頭痛、混亂、疼痛、嗜睡和記憶損害。有臨床意義的肌酸激酶水平增高(>3次超過正常值的上限)的發生率在基線的0.9%5.7%發生在第一個月, 3.4%發生在停藥後。沒有發生藥物相關性的死亡、局部肉芽腫、永久性的後遺症發生。

結論:我們認為長期鞘內注射齊考諾肽對於患有嚴重慢性疼痛且難以控制的病人是一項治療選擇。

(王時來譯 薛張綱校)

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.

 

 

容量應激對豬局部血流量急性及持續性的影響

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:由於伴隨著血容量及血管緊張度的改變,術後對血容量狀態的評估並不直接。低血容量及血流再分佈可能會影響腹內臟器的灌注。我們打算研究血容量應激對不同的腹內及腹外血管床的影響。

方法:研究12頭臨床上血容量正常的豬至行大的腹部手術後6小時。容量應激包括快速輸入6%羥乙基澱粉200ml。用全身(持續熱稀釋法)及局部(Doppler超聲)方法持續測量頸動脈、腎動脈、腹主動脈、肝動脈、腸系膜上動脈及門靜脈的血流量。急性及持續性的應激改變被比較于基礎水平。

結果:容量應激導致心排量持續性增加22% ± 15%(P < 0.001)。腎動脈血流量增加10% ± 9%,頸動脈血流量增加22% ± 15%,腸系膜上動脈血流量增加26% ± 15%,門靜脈血流量增加31% ± 20%(P < 0.001)。血流量在腹主動脈的增加(8% ± 13%)及肝動脈的增加(7% ± 19%)不明顯。局部血流量的增加發生在早期並持續增加。平均動脈壓及中心靜脈壓早期增加,隨後降低(P < 0.001)

結論:臨床上血流量正常的動物術後對於容量應激產生持續性的全血管床容量增加,雖然腹主動脈及肝動脈血流的增加不明顯,沒有統計學意義。對於是否改善術後器官灌注及更低的術後併發症則有待進一步的研究來評估。

(孫霞譯  薛張綱校)

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.

 

重症監護室獲得性血行感染中白色念珠菌與非白色念珠菌感染的比較:危險因素和預後的不同

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:在此項研究中我們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險因素和預後的不同。

方法:在希臘雅典的第三教學醫院對進入重症監護病房後確診為念珠菌血症的非免疫抑制或白血球減少症的病人進行前瞻性觀察研究。

結果:在觀察期間(20011月至200512月),1037個進入ICU的病患裏有56例發生念珠菌血症,其中36例為人白色念珠菌感染,20例為非白色念珠菌種(8例為光滑念珠菌,6例為熱帶念珠菌,3例為近平滑念珠菌,1例為葡萄牙念珠菌,1例為克柔念珠菌,1例為都柏林念珠菌)。糖皮質激素的使用、中心靜脈導管的放置和預存的念珠菌尿獨立地與非白色念珠菌種感染相關(相對應的優勢比分別為45.1,26.2,16.5,95%的可信區間分別為3.0-669.92.1-334.8,1.6-173.9)。治療反應應答率在白色念珠菌和非白色念珠菌種間區別很明顯(29/36[80.6%]9/20[45%],P=0.006),非白色念珠菌種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)。多變數回歸分析顯示非白色念珠菌種感染的念珠菌血症和死亡獨立相關(優勢比為6.795%可信區間為1.2-37.7)。

結論:在非免疫抑制的重症病人中,由非白色念珠菌種引起的念珠菌血症常發生在使用醫療設備和接受激素治療的病人中,它也和高死亡率相關。

(施楊譯,薛張綱校)

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.

 

氯胺酮和依託咪脂在離體的正常和缺血再灌注豚鼠心肌模型邊緣叢的神經電生理效應

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:依託咪脂和氯胺酮被用於高危患者的麻醉誘導,然而它們對於動作電位變數和缺血再灌注引起的心律失常和傳導阻滯的影響還不清楚.

方法:豚鼠右心室肌被放入5ml雙室電泳使之分離成兩條不滲透的膠帶.一半暴露再普通的灌注液,另一半被暴露再低氧,高鉀,酸中毒和缺糖的環境.持續監測兩個條帶的動作電位.自發的心律失常和傳導阻滯被記錄.依託咪脂(10–7, 10–6, and 10–5 M)和氯胺酮(10–6, 10–5, and 10–4 M)在試驗中反復表面灌注,和對照組比較神經電生理效應.

結果:我們發現在控制條件下,依託咪脂和氯胺酮沒有改變靜息膜電位,最大上升率,動作電位或APD90.除氯胺酮(10–4 M)外其他更低濃度的氯胺酮以及任意濃度的依託咪脂都不能逆轉缺血引起的APD90縮短和APD分散.依託咪脂和氯胺酮在缺血心肌不能改變傳導阻滯的發生.與此相反,氯胺酮(10–6 M中有25%, 10–5 M中有13%10–4 M中有13% 對比對照組中90%, P < 0.05)較之依託咪脂(10–7 M中占38%, 10–6 M中占63%10–5 M中占63%90%的對照組較,NS)能減少再灌注引起的自發性心律失常.

結論:在豚鼠心肌,我們的資料顯示氯胺酮在臨床相關濃度減少缺血引起動作電位縮短和自發性再灌注引起心室心律失常.依託咪脂在再灌注引起的心律失常上的作用還有待於進一步的試驗.

(陳愷錚譯 薛張綱校)

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.

                                             

通過提高屍體模型食管的壓力,比較七種不同聲門上氣道通氣裝置的密閉性

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:聲門上氣道通氣裝置在臨床麻醉和入院前的急診醫學中有越來越重要的意義,但是有關其引起誤吸風險的資料很少。我們設計了這個研究,旨在比較七種不同聲門上氣道通氣裝置應用於屍體模型,在食管壓力增高的情況下密閉情況。

方法:經典的喉罩,ProSealTM喉罩,插入喉管的FastrachTM喉罩,tubeTM喉罩, LTS IITM喉罩,CombitubeTM EasytubeTM 插入沒有密閉的屍體食管中,食管與130cmH2O的水柱連接。緩慢地升高食管的壓力,觀察分別在什麼情況下出現漏氣。

結果Combitube, Easytube和插入喉管的FastrachTM喉罩能抵禦超過120cmH2O的壓力。ProSeal喉罩,喉管和LTS II喉管可以阻斷食管7282cmH2O的壓力。經典的喉罩在48cmH2O時漏氣,氣管導管只有很少的漏氣。附加有食管引流管的裝置可以防止肺的誤吸。

結論:考慮到誤吸的危險,對於有誤吸危險的高危病人,可以使用有食管引流管通氣裝置。Combitube, Easytube, 和插入喉管的Fastrach喉罩在食管壓力增高的情況下有很好的密閉能力。

(陳珺珺譯  薛張綱校)

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.

 

 

通過蛋白酶A啟動線粒體大電導鈣啟動鉀通道介導地氟醚誘導的預處理

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調節的鉀通道參與到麻醉劑誘導的預處理(APC)中,但是APC中其他鉀通道的作用卻並不清楚。我們對APC由大電導鈣啟動鉀(KCa)通道介導這一假定進行了檢驗。

方法:對用戊巴比妥鈉麻醉的C57BL/6的雄性小鼠施以45分鐘的冠狀動脈阻塞和3小時的再灌注的實驗。在阻塞冠狀動脈前的30分鐘,單獨使用1.0MAC地氟醚15分鐘,或與大電導KCa 通道啟動劑NS16191 µg/g i.p.)、二甲基亞碸(10 µL/g i.p.) 、大電導KCa 通道阻斷劑IBTX (0.05 µg/g i.p.)或者蛋白酶APKA)抑制劑H-89 (0.5 µg/g 腦室)結合使用1.0MAC地氟醚15分鐘。用氯化三苯基四氮唑確定心肌梗塞的範圍,並用伊文氏藍確定危險區域。對離體心肌細胞用免疫細胞化學染色法測定心肌細胞中的大電導KCa 通道的線粒體和細胞膜位置。

結果:與控制組動物相比較,地氟醚大大減小了梗阻面積(7.4% ± 0.8% vs 51.3% ± 6.1%; P < 0.05)。通過NS1619(7.5% ± 1.8%; P < 0.05)啟動大電導KCa通道模擬了地氟醚誘導的預處理,而通過IBTX (49.1% ± 7.5%)阻斷大電導KCa通道則消除了地氟醚誘導的預處理。H-89阻斷的PKA消除了地氟醚(45.1% ± 4.0%)誘導的預處理,但未消除NS1619(9.0% ± 2.4%, P < 0.05)誘導的預處理。免疫細胞化學染色顯示大電導KCa通道位於心肌細胞的線粒體中,而非細胞膜中。

結論:這些資料表明,地氟醚誘導的APC部分由線粒體大電導KCa通道的啟動所介導,並且地氟醚對這些通道的啟動由PKA所介導。

(陳佳莉譯 薛張綱校)

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.

在胸外科手術中選擇左雙腔氣管導管尺寸的實踐模式

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:一些麻醉醫師選擇相對于身體適當尺寸較小的左雙腔氣管導管(DLTs)(“小號”)用於肺分隔,以限制氣道損傷的風險。關於DLT尺寸對於術中結果影響的資料很少。

方法:300例行需要肺分隔的胸外科手術的患者中,我們進行了一項前瞻性初步研究來評估不管性別和/或身高都用35 FR DLT(兩個觀察者的監護標準),與傳統的插入盡可能大的DLT(兩個其他觀察者的監護標準)相比,術中低氧血症、肺分隔失敗或需要DLT調整位置的發生率(非低劣)是否相似。用直接喉鏡下放置好和側臥位後,立即用纖支鏡確認DLT的插入位置。

結果:不管性別和/或身高,術中暫時的低氧血症、不充分的肺分隔,或需要重新調整DLT位置的發生率在接受353739 FR DLT的患者之間沒有區別。儘管35 FR DLT的使用率高,但2%的病人由於DLT無法進入左主支氣管或肺分隔時支氣管氣囊不需要充氣,而需要更小號。

結論:在這一初步研究的條件下,用比傳統尺寸小的DLT在臨床術中結果方面沒有任何差異。

(彭中美 馬皓琳 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.

 

 

比較嬰兒體外迴圈中的肝素處理方案

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:近來對成年患者的研究已顯示:在體外迴圈(CPB)的肝素使用中,與基於標準體重的肝素劑量相比較,基於肝素濃度的肝素抗凝方案明顯降低了止血藥的活性。兒科患者中與CPB相關的凝血問題是複雜的且受到很多變數的影響,CPB期間止血藥作用的降低可能對患兒尤其有益。然而關於患兒CPB中肝素的水平及其與止血藥作用的相關性方面的報導,目前仍缺乏。在本研究中,我們選擇小於6個月的嬰兒,比較了其基於患者特異性肝素濃度及基於標準體重的肝素處理方案。通過比較肝素濃度、止血藥作用的生化指標水平及臨床結果來評估兩套方案的有效性。

方法:研究納入了25例小於6個月擇期行先天性心臟缺損修補術的嬰兒。患兒隨機接受400 U/kg肝素(對照組)或通過Hepcon止血處理系統加(Hepcon HMS; Medtronic,明尼阿波利斯, 明尼蘇達州)計算所得的患者特異性肝素劑量(介入組)。在預定的間期比較兩組的肝素濃度。CPB前後收集血樣本以測得止血作用的生化指標,並記錄臨床觀察結果。

結果:與對照組相比,介入組患兒獲得的總的肝素劑量更大。兩組之間給予初始肝素劑量後與CPB開始30分鐘時的肝素濃度是相似的;然而,在複溫開始時及CPB終止時,介入組較對照組有明顯更高的肝素濃度。與對照組相比,介入組的患兒F1.2 產生更少,VIII因數消耗更少。但是臨床上介入組的患兒CPB後需接受使用來自一個以上供體的血製品。

結論:對於小於6個月的嬰兒,與基於標準體重的肝素處理方案相比,在CPB中使用基於肝素濃度的肝素處理方案能產生更高、更恒定的肝素濃度。而且,更高的肝素濃度與更大程度的抑制止血作用有關,正如臨床上觀察到的更少形成凝血酶及更少消耗VIII因數。本研究證實,在施行CPB的患兒中,使用基於患者特異性肝素濃度的肝素方案可減弱止血作用。然而,需要進一步研究以確定該方案是否有臨床上有益的止血作用。

(裘毅敏譯,馬皓琳 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.


催眠能緩解切除的乳腺活檢患者的術前不良應激

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:切除性乳腺活檢導致術前心理上的不良應激。這種不良應激是情緒沉重,可能會給術後副反應和麻醉的滿意程度帶來負面影響。我們研究一下簡短的術前催眠談話對於緩解切除性乳腺活檢患者的術前不良應激的能力。

方法:90名要進行切除性乳腺活檢患者隨機分為兩組,一組進行15分鐘術前催眠談話(n=49,平均年齡46.4(95% CI: 42.3–50.4)),另一組進行15分鐘術前注意力對照談話(n=41,平均年齡45.0(95% CI: 40.8–49.2))。催眠談話涉及給予增加放鬆程度和緩解不良應激的暗示,注意力對照談話是非指導性的移情傾聽。用視覺類比評分(VAS)和心境量表簡短版(SV-POMS)測量術前不良應激。用方差分析和卡方檢驗分析資料。

結果:兩組間的以下幾方面沒有差異:人口統計學(年齡、教育、種族、婚姻狀況,所有的P>0.28);醫學變數(術前診斷、既往切除活檢、既往乳腺癌,所有的P>0.11);及手術當天評估的干預前不良應激(SV-POMSP > 0.74)。手術前,在干預後催眠組的患者在術前情緒失常VAS (16.5 vs 38.2, P < 0.0001, d = 0.85)、情緒低落VAS(6.6 vs 19.9, P < 0.02, d =0 .67)以及焦慮SV-POMS (10.0 vs 5.0, P < 0.0001, d = 0.85)的平均值都明顯低於注意力對照組;另外催眠組放鬆程度VAS(75.7 vs 54.2, P < 0.001, d = –0.76)明顯高於注意力對照組。

結論:這個研究結果顯示術前簡短的催眠干預是一個能控制等候診斷性乳腺癌手術的婦女術前不良應激的有效手段。

(唐亮   馬皓琳 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-異丙酚使擇期手術患者應答性喪失及對模擬疼痛刺激和喉鏡檢查反應喪失的回應面評價

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:本研究中我們探討了從志願者中採集資料而建立起來的一組瑞芬太尼-異丙酚回應面相互作用模型將會怎樣預測擇期手術病人對事件的反應。我們的假設是這些模型將會預測病人群體應答性的喪失和恢復、對喉鏡檢查是否有反應以及術後對疼痛的反應。

方法:本研究包括21位病人。麻醉方法是靜脈持續輸注瑞芬太尼和異丙酚以及間斷推注芬太尼。評價每個病人應答性的喪失和恢復、對喉鏡檢查的反應以及對術後疼痛的反應。把用模型預測的結果與觀察到的反應進行比較。

結果:應答性喪失模型所預測的病人應答喪失比觀察到的結果早2.4 ± 2.6 min。在喉鏡檢查時,喉鏡檢查模型預測病人有89%的可能性對檢查無反應,而觀察到的是81%的病人無反應。在蘇醒期,應答性喪失模型所預測的應答性恢復比觀察到的結果早0.6 ± 5.1 min。病人接受芬太尼來控制疼痛時對壓力痛覺測定無反應的平均可能性是23% ± 35%

討論:對一系列瑞芬太尼-異丙酚回應面相互作用模型的初次評價表明這些模型能預測到擇期手術中病人對所選的相關事件的反應。然而在所預測的瑞芬太尼-異丙酚的效應室濃度迅速變化時顯著的模型錯誤是顯而易見的。

(吳進   馬皓琳 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突變使神經元易受異氟醚毒性影響

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:異氟醚是一種常用吸入麻醉藥,可呈濃度和時間依賴地誘導大鼠神經元嗜鉻細胞瘤神經分泌細胞(PC12)細胞發生凋亡,機制不明。我們假設是異氟醚通過啟動肌醇1,4,5-三磷酸(IP3)受體來觸發內質網(ER)鈣離子異常釋放,從而誘發細胞凋亡。一種家族性阿爾茨海默爾氏病患者伴有的早老素-1 (PS1)基因突變使IP3受體活性增加,因此可能使細胞易受異氟醚誘發的細胞毒性的影響。七氟醚和地氟醚對細胞內鈣穩態的影響較小,所以我們預計其細胞毒性也較小。

方法:對用野生型帶菌體(帶菌體)或突變的PS1L286V)轉染的PC12細胞給予1 MAC等效的異氟醚、七氟醚和地氟醚,共計12小時。測定線粒體氧化還原反應(MTT還原)和乳酸脫氫酶釋放,以估計細胞的生存率。不同類型的細胞給予不同的吸入麻醉藥後,測定胞質腔內鈣離子濃度([Ca2+]c)和活性氧(ROS)產生的變化。我們還測定了IP3受體拮抗劑xestospongin C 對異氟醚誘發的L286V PC12細胞和大鼠原始皮質神經元的細胞毒性和內質網鈣離子釋放的影響。

結果:給予12小時1 MAC異氟醚引起L286V的細胞毒性,還導致L286V[Ca2+]c峰值快速且大量增高,但並不影響野生型或帶菌體PC12細胞。Xestospongin C明顯減輕異氟醚對L286V細胞和原始皮質神經元的細胞毒性,且抑制L286V細胞內質網鈣離子的釋放。異氟醚並不引發各種PC12細胞ROS產物的明顯變化。與異氟醚不同,等效濃度七氟醚和地氟醚對L286V PC12細胞並不引起相似的細胞毒性或[Ca2+]c峰值升高。

結論:我們的研究結果顯示L286V PS1突變通過鈣從細胞內貯存釋放以促進異氟醚誘發的[Ca2+]c,從而使細胞易受異氟醚神經毒性影響。ROS產物不涉及異氟醚引起的神經毒性。與異氟醚等效濃度的七氟醚和地氟醚不會引發L286V PC12細胞發生類似的[Ca2+]c升高和神經毒性。

(張瑩譯  馬皓琳 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.



腦室內誤給予依託米酯與羅庫溴胺

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

我們報導了在重症監護室中快速誘導用於氣管內插管過程中通過腦室造瘺導管腦室內誤給予依託米酯和羅庫溴胺。發生了快速的意識喪失、呼吸暫停和聲帶外展,創造了極好的插管條件。病人在誘導和插管中始終保持血流動力學穩定。 護理人員的缺乏經驗和制度的缺陷是導致用藥錯誤的因素。我們將討論管理、臨床過程、易感因素和預防策略。

(胡湘     馬皓琳 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.


使胃充氣最小化與胸腔按壓最優化比較

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

在一個實驗台模型中,我們在沒有保護的氣道評價了為了降低胃充氣風險而開發出的有最大吸氣流量限制的呼吸氣囊-閥裝置(Smart Bag® MO)。在模擬心肺復蘇連續胸外按壓過程中,只有潮氣量充足吸氣時間為0.5秒時才以設置為“關閉”狀態的Smart Bag® MO或成人自動充氣皮囊-閥裝置通氣。只要模擬心肺復蘇中潮氣量不足並將導致病人通氣不足,即使通氣窗為0.5秒,仍用設置為“開放”的Smart Bag® MO通氣。

(沈浩   馬皓琳 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.


過度通氣能改善幕上開顱術的手術條件嗎?一項多中心隨機交叉試驗

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:過度通氣已是神經外科麻醉中一個完整但缺乏有效驗證的部分。我們進行一項兩個階段的交叉隨機試驗來評價開顱切除幕上大腦腫瘤患者在適度的低碳酸血症或正常二氧化碳血情況下外科醫生估計的腦容量和測定的顱內壓(ICP)。

方法:275例有幕上大腦腫瘤的成年患者隨機分成兩個治療過程:過度通氣(動脈二氧化碳分壓Paco2 = 25 ± 2 mm Hg)後正常通氣(Paco2 = 37 ± 2 mm Hg)或正常通氣後過度通氣。通氣和呼氣末CO2分壓保持穩定20min。患者也隨機分組接受異丙酚輸注或異氟醚麻醉。每一研究階段結束時,測定硬膜下顱內壓,且要求不知道分組的神經外科醫生用四點評分來評估腦容量。

結果:我們應用廣義估計方程發現過度通氣使腦容量增加的風險降低45% P = 0.004, 95% 可信區間為 22% 61%,所需處理例數為8。過度通氣時的平均顱內壓(±標準差)為12.3 ± 8.1 mm Hg,比正常通氣時的16.2 ± 9.6 mm Hg低,P < 0.001。麻醉藥的攝入不影響腦容量評估或顱內壓。

結論:幕上大腦腫瘤患者術中過度通氣能降低顱內壓從而改善外科醫生所評估的腦容量。

(朱 慧譯 馬皓琳 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.



術後病人應用曲馬多的有限效能:應用連續再評價方法研究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評價曲馬多用於術後鎮痛的效能,並用連續再評定方法測定其ED80(即80%的病人疼痛充分緩解的臨床劑量)。因為最初的24名患者的初步結果與文獻是相矛盾的,我們進行了第二個試驗來驗證並證實我們的資料。

方法:本研究是雙盲及前瞻性的。參加者通過3病例佇列給予一個劑量的曲馬多。每個組曲馬多的劑量由前面病人的反應決定。開始之前選擇了5個劑量,其陽性反應的機率分別是60 (0.4)100 (0.55)140 (0.7)190 (0.8)260 mg (0.9)。如果在T30時疼痛評分大於>=3/10,就認為曲馬多是有效的。

結果:兩個試驗中,對80%病人有效的曲馬多劑量是260mg。試驗1和試驗2 260mg劑量有效的機率分別是0.699 (95%可信區間是0.471–0.874)0.657 (95%可信區間是0.437–0.853)

結論:中等疼痛的手術後,曲馬多不能作為單獨用藥。80%的病人緩解疼痛的劑量遠遠大於常用量100mg。連續再評價方法允許我們應用有限數目的病人來測定曲馬多的ED80

(黃麗娜    馬皓琳 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.



對用X線透視引導行腰段硬膜外類固醇注射的碘化造影劑流型的前瞻性評價:側旁層間硬膜外進路和經椎間孔硬膜外進路比較

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:腰段正中板間和經椎間孔(TF)硬膜外類固醇激素注射是用於繼發於椎間盤退化病變的下背痛伴神經根病的治療方法。因為疼痛的起源位於硬膜外間隙的前面,在硬膜外間隙中向腹側彌散是抗炎藥物佈局的合理目標。在這個隨機前瞻性觀察性研究中,我們利用持續X線透視引導比較了用旁路板間(PIL)與經椎間孔進路造影劑在硬膜外間隙的流型。

方法:收入60位由椎間盤退化或突出引起下背痛和單側神經根病的患者。受試者隨機分為兩組:TFPIL,每組30位。所有步驟均通過5ml造影劑持續X線透視引導。造影劑的擴散程度(主要測量結果)由干預者進行分級。擴散程度分為02分,0=沒有向前擴散;1=向前擴散,水平和針刺一樣;2=向前擴散≥1個節段。次要測量結果為2w1m3m6m時的鎮痛水平。

結果:PIL100% 29/29)的患者和TF75%(21/28)的患者中觀察到造影劑在硬膜外間隙向前擴散。平均擴散等級為PIL 1.93 (95% 可信區間〔CI, 1.83–2.0) TF 1.46 (95% CI, 1.17–1.46) (P = 0.003)。平均透視時間為PIL 28.96 s(95% CI, 23.9–34.1s) TF 46.25 s (95% CI, 36.27–56.23s) (P = 0.003)。兩組間視覺類比疼痛評分相類似。

結論:PIL途徑放置造影劑到硬膜外間隙前面比TF途徑更有優勢,擴散程度高,且X線透視時間短。近年來TF途徑引起的神經損傷逐漸受到關注,因此PIL途徑可能更適合常規應用。

(黃佳佳譯,馬皓琳 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.



己酮可哥堿對大鼠神經病模型中已存在的超敏反應的作用

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:我們以往採用大鼠L5脊神經橫斷模型已顯示己酮可哥堿可通過在腦額葉前部的抗炎作用預防痛覺過敏的產生。本研究檢測己酮可哥堿在創傷後應用的效能。

方法:本研究檢測在L5脊神經橫斷後7天給予己酮可哥堿對已存在的機械性異常痛、觀察到的神經膠質啟動和致炎細胞因數表達的作用。

結果:L5脊神經橫斷後給予己酮可哥堿對於已存在的超敏反應、神經膠質啟動和細胞因數表達沒有作用。

結論:脊神經橫斷術後7天腹腔注射己酮可哥堿無法緩解已存在的超敏反應,也不能減少神經膠質啟動和細胞因數表達。

(周雅春 馬皓琳 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擴散到閉孔神經嗎?:一個解剖學研究

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:骶骨旁坐骨神經阻滯能否提供一致的閉孔神經和會陰阻滯依然不確定。在這個解剖學工作中,我們評估了模擬骶骨旁注射有色乳劑的擴散情況,觀察擴散到閉孔神經和骶神經根的情況。

方法:7個人屍體進行雙側骶骨旁注射,共14次。解剖分兩步。第一步,後進路確定染料存在於梨狀肌水平的坐骨神經來確定注射是成功的。第二步,骨盆內前面解剖評估染料在閉孔神經的骨盆部分周圍和骶神經根(S1–3)上的存在情況。對所有神經進行相同評分,從0 (完全失敗)3 (完全成功)。對所有神經 (坐骨、閉孔和骶神經根),評分為2 3表明注射成功。

結果:14個中的11個注射顯示成功的骶骨旁注射。3個失敗的注射排除在進一步分析之外。一個血管內注射,兩個(同一屍體)注射在臀肌內的是太表淺了。11個成功的注射中,9 (82%)的評分證明乳劑擴散到閉孔神經和骶神經根。

結論:我們從這個解剖學研究中得到結論,成功的骶骨旁注射同樣擴散到閉孔神經的骨盆部分和骶神經根。因此,骶骨旁阻滯應當理論上提供閉孔和會陰的阻滯,並且不需要另外進行閉孔神經阻滯。這個結果需要進一步臨床研究的證實。

(張曦 譯,馬皓琳 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動脈嵌夾後調節腎臟炎症反應和氧化應激反應的比較

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:有報導顯示丙泊酚對缺血-再灌注損傷具有一定的保護作用。在缺血-再灌注損傷中核轉錄因數kappaB(NF-KB)在炎症反應和氧化應激反應中起到關鍵作用。筆者比較了主動脈嵌夾後丙泊酚和七氟醚對腎臟NF-KB的表達和全身炎症反應的影響。

方法20只小豬分為4組:應用丙泊酚麻醉的假手術組(SP組,n=5),應用七氟醚的假手術組(SS組,n=5),丙泊酚麻醉手術組(CP組,n=5)和七氟醚麻醉手術組(CS組,n=5),後兩組行主動脈-主動脈旁路下腎上主動脈嵌夾30min。麻醉為靜注丙泊酚4mg.kg-1.h-1或吸入1.5%七氟醚。在手術開始時、開放主動脈後15分鐘、術後244872小時和術後7天採集外周血標本和腎組織活檢。檢測血漿肌酐、髓過氧化酶、腫瘤壞死因數-{alpha},白介素1-β和腎臟超氧化陰離子及超氧化歧化酶。通過western-blotting檢測腎組織NO合成酶及NF-KB

結果:與CS組相比,CP組的動物術後24-72小時髓過氧化酶、腫瘤壞死因數-{alpha}、白介素1-β和腎臟超氧化陰離子及超氧化歧化酶的濃度較低(P<0.05),術後24小時和48小時NF-KBNO合成酶的表達減少(P<0.05)

結論:與七氟醚相比,丙泊酚在嵌夾腎上主動脈期間可調節炎症因數並降低NF-KB的表達。

(潘方立 陳傑 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.

 

 

心臟手術期間的過敏性反應:臨床意義

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.

 

外科手術中,患者常接受多種異體物質包括麻醉藥,抗生素,血液製品,肝素,多肽(抑肽酶,橡膠製品,魚精蛋白)和血管擴容劑等,這些都可能引起致命的過敏反應。急性心血管和肺功能不全是圍術期過敏性反應的顯著表現。心臟手術患者常在嚴密的監測下,當發生過敏性反應時可以早期發現,及時治療。在治療劑量之前給予小劑量藥物,也稱試驗劑量,如發生過敏反應,臨床醫師就可以積極對症處理。對血流動力學不穩定的病人實施心肺分流術是一條救生之法,在一些難治性心血管功能障礙的病人當中可以考慮應用。血管舒張性休克的病人應該考慮使用精氨酸升壓素。本綜述中,主要針對最近一些有關於在手術室內發生的過敏性反應的實例以及處理方法作了探討,特別是心臟手術患者。

(杜唯佳 陳傑 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.

 

 

 

使用異丙酚/瑞芬太尼與咪達唑侖/芬太尼用於結腸鏡檢查的病人自控鎮靜的隨機、對照、雙盲試驗

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: 使用異丙酚行病人自控鎮靜已用於具有狹窄治療窗的中度鎮靜,但是以往的研究存在局限性。作者假設應用瑞米芬太尼聯合異丙酚行病人自控鎮靜較芬太尼聯合咪唑安定方便易行。

方法:50例接受結腸鏡檢查的病人隨機分成咪達唑侖/芬太尼組(MF組)或異丙酚/瑞芬太尼組(PR),均行病人自控鎮靜。鎮靜和蘇醒的時間間隔由患者,護士以及胃腸病醫師評定,必要時由麻醉醫師介入評估與處理。

結果PR組的病人鎮靜和蘇醒快於MF(P<0.001)。在PR組,復蘇時間短於手術操作時間。兩組間病人、護士和腸胃病醫師評定感覺一致。PR組的兩名病人需要麻醉醫師的介入,患者的動脈去氧飽和超過了安全限。

結論:在有適當的醫療護理中,異丙酚/瑞芬太尼行病人自控鎮靜優於咪達唑侖/芬太尼

(張燕 陳傑 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.

 

 

 

新型阿片類藥物去氧嗎啡酮用於脊麻的藥理特徵

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:去氧嗎啡酮是羥考酮的主要代謝產物。羥考酮常用於急慢性疼痛的治療,然而我們對於去氧嗎啡酮的鎮痛作用卻不瞭解。作者對大鼠進行了在體的藥理學試驗。

方法:用熱和機械性傷害性模型研究大鼠去氧嗎啡酮的抗傷害特性。

結果:鞘內注射去氧嗎啡酮(15ug/10ul)可以產生較羥考酮200ug/10ul)和嗎啡(15ug/10ul)更持久的鎮痛作用。在鞘內注射藥物前15分鐘皮下給予鈉絡酮預處理,去氧嗎啡酮和嗎啡的鎮痛效果均顯著降低,表明這是一種阿片受體介導的鎮痛作用。在扁平烤盤、腳爪壓力和擺尾試驗中,分別皮下注射510,和25mg/kg去氧嗎啡酮沒有效果。同樣,在旋轉試驗中沒有觀察到研究所用的劑量對運動功能有所影響。在大鼠角叉膠炎症模型中,皮下注射去氧嗎啡酮25mg/kg,無抗痛覺過敏效果。

結論:鞘內注射去氧嗎啡酮時,它是一種有效的u阿片受體激動劑。全身作用效力的缺失也許表明去氧嗎啡酮穿透血腦屏障的能力較低,因為其計算出的logD值較低(log辛醇/水分配係數)。因此,在全身給予羥考酮鎮痛時去氧嗎啡酮的作用可以忽略不計。由於其用於脊髓內的作用效果和長久的作用效力,去氧嗎啡酮是一種有用的脊髓阿片類藥物,被濫用的可能性較低。但在臨床應用前需要評估脊髓注射去氧嗎啡酮的安全性。

(印潔敏 陳傑 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強加速七氟醚麻醉後的呼吸恢復

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:在動物及人類實驗中發現等碳酸血症下呼吸增強(IH)可以減少異氟醚麻醉後的復蘇時間。作者比較了術後等碳酸血症下呼吸增強(IH組)或常規方式(對照組)進行復蘇後病人的恢復變數來研究IH對七氟醚麻醉病人的影響。

方法:選擇30 ASAI-III級,行擇期婦產科手術的病人。麻醉的誘導和維持以實驗設計的標準,包括芬太尼,異丙酚,羅庫溴銨及以空氣/氧氣為載體的七氟醚。在手術結束時病人隨機分成對照組(C組)或是IH組。記錄從停止七氟醚到呼吸恢復的時間。

結果:與C組相比,IH組拔管的時間更短(6.2±2.1vs12.3±3.8minp<0,01)。IH組出現自主呼吸(4.2±1.7vs6.5±3.8min, p=0.047),睜眼(5.5±1.4vs13.3±4.4minp<0.01),腦電雙頻指數值>753.9±1.1vs8.8±3.7minp<0.01),離開手術室時間(7.7±2.0vs15.3±3.4minp<0.01)以及離開PACU 67.2±19.3vs90.6±20.0minp<0.01)的時間均縮短。

結論IH可以減少七氟醚麻醉後的復蘇時間,縮短病人在手術室及PACU的停留時間。

(潘錢玲 陳傑 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.

 

連續硬膜外麻醉後嚴重皮膚炎症反應一例報告

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.

 

一種罕見但又重要的硬膜外置管的風險因素是皮膚對消毒液、固定膠布或導管本身的反應。本文作者描述了一例經腹會陰切除術後應用連續硬膜外鎮痛後嚴重皮膚炎症反應,強調做出正確診斷和及時就診治療的重要性。

(王騰 陳傑 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.

 

 

一種通過經食道超聲心動圖評價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:作者報導了一種在實驗性狗模型上通過經食道超聲心動圖評價膨脹不全時肺局部血流的方法。為了驗證這種方法的可行性,作者研究了這種實驗模型下檢測局部肺血流變化的能力。

方法14只麻醉的進行機械通氣的雜種狗隨機分為異丙腎上腺素組(n=7)和多巴胺組(n=7)。通過左側胸腔內注入每kg體重60ml生理鹽水製成人為肺不張模型。通過脈衝多普勒計算速度時間積分(VTI)作為肺不張時血流指數。為了研究這種方法對血流變化的反應,全身給予異丙腎上腺素0.05µg · kg–1 · min–1(肺血管擴張劑)或多巴胺10µg · kg–1 · min–1(肺血管收縮劑 ,測VTI和肺內血流分流率(Qs/Qt)

結果:給予異丙腎上腺素的模型VTIQs/Qt明顯上升。異丙腎上腺素組VTIQs/Qt變化百分率有明顯的關聯。多巴胺組,VTIQs/Qt無顯著變化。

結論:經食道超聲心動圖可能在檢測肺不張時的局部肺血流變化方面有用。

(王鵬 陳傑 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.

 

 

超聲引導下基本操作技能的學習曲線及數學模型

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:作者擬建立超聲基本技能學習曲線及數學模型:針-超聲射線校直和目標到達的優化

方法30名受試者參與本研究,每位受試者操作25例。試驗中採用線性超聲探頭以及牛肌肉模型。每項操作試驗分2個部分,第一部分中要求每位受試者針刺過程中超聲光束與針的影像平行。第二部分中模型內縱向地插入一段肌腱,深達1-1.5cm,同時要求每位受試者將針一直插入並觸及肌腱。對於操作結果使用累積法建立學習曲線,並對這兩個部分的操作技能建立bush Mosteller數學模型。

結果:在實驗的第一第二部分中分別只有30%10%的受試者達到熟練操作。通過bush Mosteller數學模型估計達到95%成功率的平均操作次數分別為37109

結論:掌握超聲引導基本操作技能是需要一定的練習,而使用累積法顯示麻醉醫師掌握該技能的水平參差不齊。但必須注意的是本試驗主要是在模型上進行,所以作者認為該結論並不一定適用于臨床病人的神經阻滯操作。

( 陶穎瑩 陳傑 )

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.

 

針刺鎮痛1:科學基礎

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.

 

在過去的3000年裏,針刺技術在中國和其他亞洲國家被廣泛應用。最近在美國,越來越多的醫師和患者對此技術產生興趣。儘管針刺誘導鎮痛在美國很多疼痛管理程式中得到使用,但其作用機制未被闡明。很多研究提出針刺及相關技術可引發一系列反應:包括神經遞質和內源性類阿片物質的釋放,中樞神經系統c-fos基因的活化。中樞神經系統影像學技術的新近發展使科研人員能夠更好地評價針刺誘導刺激後所發生的一系列事件。在此項綜述中,作者調查了針刺鎮痛在新近生理生化學和影像學方面的探索。

(於章傑 陳傑 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. 針刺鎮痛2 臨床思考

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:針刺及相關經皮神經調節療法可用于治療患者的急慢性疼痛。在此項綜述中,作者細緻審視了臨床研究中針刺鎮痛的相關研究。

方法:作者查閱Ovid和其出版的醫學資料庫,總結了關於使用針灸和其他針刺相關形式治療疼痛的一些前瞻性、隨機對照臨床研究。但此項分析並不包括個別病例報導、病例系列分析和佇列研究。

結果:對等審查文獻表示:針灸和其他形式的針刺能有效地控制短期的腰背部、頸部和涉及膝蓋的骨關節疼痛。然而,文獻也同樣表明:其短期的治療效果並無長期效益。關於針刺對牙痛、腸鏡相關疼痛和術中止痛的有效性資料並未收錄。研究描述了在產程中應用針刺可能在早期有益,但這種效益並不貫穿整個產程。最後,關於針刺對術後疼痛的療效由於涉及手術時間和患者的意識水平,並不包括在此項研究範圍內。

結論:最近研究針刺及相關技術臨床有效性的資料顯示其收益是短效的。需要更多設計完善的臨床對照試驗來評估針刺對臨床結局的影響,如當其應用於急慢性疼痛時對病人日常活動的恢復方面是否有益等。

(於章傑 陳傑 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型複雜區域疼痛綜合征的處理:經皮射頻腰交感神經阻斷術與苯酚腰交感神經松解術相比較的評估——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型複雜區域疼痛綜合征常難以處理。這項研究的目的是比較兩種治療方法:經皮射頻腰交感神經阻斷術和腰交感神經松解術的安全性和功效。

方法:20I型下肢複雜區域疼痛綜合征患者隨機接受經皮射頻熱能腰交感神經阻斷術或7%苯酚時腰交感神經松解術。在疼痛緩解和發生副作用時停止實驗。

結果:每組患者經治療後疼痛值均有明顯的下降,但各組間無明顯差異。

結論:基於此項初步研究,射頻腰交感神經阻斷術具有苯酚腰交感神經松解術相當的療效。但尚需更大規模的研究以證實這一發現。

(胡瀟 陳傑 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.

 

運動對布比卡因臂叢神經阻滯時起效和進程的影響:一項肩關節鏡手術病人的隨機、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:曾發現應用利多卡因行經鎖骨上臂叢神經阻滯時手部肌肉連續運動可以縮短神經阻滯起效的潛伏期。在本研究中,作者研究了布比卡因肌間溝臂叢神經阻滯時手部肌肉重複收縮對麻醉起效速度的影響。

方法40名患者行肌間溝臂叢神經阻滯下擇期行肩關節鏡手術。在完成臂叢阻滯後,一組患者要求放鬆他們的手臂(即未活動組)。另一組要求完成5分鐘的手部運動練習(活動組)。檢測兩側手的握力和經皮電刺激的耐受性來評價運動和感覺阻滯的程度。

結果:運動組病人在阻滯完全後20min經皮電刺激的耐受性顯著降低(P < 0.05)

結論:上述結果意味,嘗試應用肌肉重複活動的頻率依賴的傳導阻滯作為布比卡因臂叢神經阻滯的輔助方法是沒有價值的。

(陳偉 陳傑 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.