Table of Contents

March 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

长时体外循后抗凝血酶缺乏致凝血酶活性增强

胡潇 陈杰

Antithrombin Deficiency Increases Thrombin Activity After Prolonged Cardiopulmonary Bypass

Roman Sniecinski, Fania Szlam, Edward P. Chen, Stephen O. Bader, Jerrold H. Levy, and Kenichi A. Tanaka

Anesth Analg 2008 106: 713-718.

抗凝血酶VIII因子缺乏血中重激活VII因子凝血效的影

孙鹏飞译 薛张纲校

Antithrombin Affects Hemostatic Response to Recombinant Activated Factor VII in Factor VIII Deficient Plasma

Fania Szlam, Taro Taketomi, Chelsea A. Sheppard, Christine L. Kempton, Jerrold H. Levy, and Kenichi A. Tanaka

Anesth Analg 2008 106: 719-724.

纤维蛋白原在颅缝中的

姜旭晖   马皓琳 李士通

Fibrinogen in Craniosynostosis Surgery

Thorsten Haas, Dietmar Fries, Corinna Velik-Salchner, Elgar Oswald, and Petra Innerhofer

Anesth Analg 2008 106: 725-731.

予活化因子(NovoSeven®)纤维蛋白原(Haemocomplettan® P)后能改善血形成

王鹏 陈杰

Improved Clot Formation by Combined Administration of Activated Factor VII (NovoSeven®) and Fibrinogen (Haemocomplettan® P)

Kenichi A. Tanaka, Taro Taketomi, Fania Szlam, Andreas Calatzis, and Jerrold H. Levy

Anesth Analg 2008 106: 732-738.

限制性复温后低在大鼠体外循模型中对认知功能的作用

章一静译 薛张纲校

The Effect of Limited Rewarming and Postoperative Hypothermia on Cognitive Function in a Rat Cardiopulmonary Bypass Model

Fellery de Lange, Wilbert L. Jones, George Burkhard Mackensen, and Hilary P. Grocott

Anesth Analg 2008 106: 739-745.

 多功能衬垫式充在近常的体外循下心外科手中的效果

邱郁薇 马皓琳 李士通

An Evaluation of a Full-Access Underbody Forced-Air Warming System During Near-Normothermic, On-pump Cardiac Surgery

Steven R. Insler, Mohamed H. Bakri, Fady Nageeb, Edward Mascha, Tomislav Mihaljevic, and Daniel I. Sessler

Anesth Analg 2008 106: 746-750.

血管外科高危病人前冠脉血重建:主题综

陶颖莹 陈杰

Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery: A Core Review (Review Article)

Miklos D. Kertai

Anesth Analg 2008 106: 751-758.

PEDIATRIC ANESTHESIOLOGY:

扩张和呼吸末正在使用机械通的小麻醉中的效果

胡艳译 薛张刚校

The Effect of Lung Expansion and Positive End-Expiratory Pressure on Respiratory Mechanics in Anesthetized Children

Athanasios G. Kaditis, Etsuro K. Motoyama, Walter Zin, Nobuhiro Maekawa, Isuta Nishio, Taiyo Imai, and Joseph Milic-Emili

Anesth Analg 2008 106: 775-785.

适用于以麻醉为基础的小儿慢性疼痛医疗方案的病儿群体的临床特点

张莹译  马皓琳 李士通校

A Clinical Profile of a Cohort of Patients Referred to an Anesthesiology-Based Pediatric Chronic Pain Medicine Program

Thomas R. Vetter

Anesth Analg 2008 106: 786-794.

用近外光定新生小猪选择灌注的血流指

杜唯佳 陈杰

Measurement of Blood Flow Index During Antegrade Selective Cerebral Perfusion with Near-Infrared Spectroscopy in Newborn Piglets

Patrick Meybohm, Grischa Hoffmann, Jochen Renner, Andreas Boening, Erol Cavus, Markus Steinfath, Jens Scholz, and Berthold Bein

Anesth Analg 2008 106: 795-803.

AMBULATORY ANESTHESIOLOGY:

前抑郁症的一有效筛查工具:老年抑郁症

黄凝译  薛张纲校

An Efficient Screening Tool for Preoperative Depression: The Geriatric Depression Scale-Short Form

Diana S. Bass, Deborah K. Attix, Barbara Phillips-Bute, and Terri G. Monk

Anesth Analg 2008 106: 805-809.

女性病人和孩子行手的母亲术前焦的比

彭中美 马皓琳 李士通

A Comparison of Preoperative Anxiety in Female Patients with Mothers of Children Undergoing Surgery (Brief Report)

Jill MacLaren and Zeev N. Kain

Anesth Analg 2008 106: 810-813.

光灯在轻静脉置管疼痛的作用:一前瞻性、机、安慰

王腾 陈杰

The Role of a Flash of Light for Attenuation of Venous Cannulation Pain: A Prospective, Randomized, Placebo-Controlled Study (Brief Report)

Anil Agarwal, Ghanshyam Yadav, Devendra Gupta, Manish Tandon, Prabhat Kumar Singh, and Uttam Singh

Anesth Analg 2008 106: 814-816.

ANESTHETIC PHARMACOLOGY:

合用70%氙与合用70%50%有效度(EC50)的比

施颖译 薛张纲校

The Effective Concentration 50 (EC50) for Propofol with 70% Xenon Versus 70% Nitrous Oxide

Ahmed R. Barakat, Markus N. Schreiber, Joachim Flaschar, Michael Georgieff, and Stefan Schraag

Anesth Analg 2008 106: 823-829.

 大鼠的肝缺血再灌注损伤模型中七醚与异氟醚麻醉的肝能量代及其不同的保

唐亮   马皓琳 李士通   

Hepatic Energy Metabolism and the Differential Protective Effects of Sevoflurane and Isoflurane Anesthesia in a Rat Hepatic Ischemia-Reperfusion Injury Model

Nurdan Bedirli, Ebru Ofluoglu, Mustafa Kerem, Gulten Utebey, Murat Alper, Demet Yilmazer, Abdulkadir Bedirli, Onur Ozlu, and Hatice Pasaoglu

Anesth Analg 2008 106: 830-837.

不同化合物野生型、突Aγ基丁酸和甘酸受体的麻醉作用

赵燕星 陈杰

The Anesthetic-Like Effects of Diverse Compounds on Wild-Type and Mutant {gamma}-Aminobutyric Acid Type A and Glycine Receptors

Liya Yang and James M. Sonner

Anesth Analg 2008 106: 838-845.

5-HT3A受体的分子作用:通相似的衍生物增强和抑制

宣丽真译 薛张纲校

Molecular Actions of Propofol on Human 5-HT3A Receptors: Enhancement as Well as Inhibition by Closely Related Phenol Derivatives

Martin Barann, Isabelle Linden, Stefan Witten, and Bernd W. Urban

Anesth Analg 2008 106: 846-857.

高血糖异氟在血管平滑肌胞中诱导ATP敏感的通道激活作用

黄施伟 马皓琳 李士通

Hyperglycemia Impairs Isoflurane-Induced Adenosine Triphosphate-Sensitive Potassium Channel Activation in Vascular Smooth Muscle Cells

Takashi Kawano, Katsuya Tanaka, Kazuaki Mawatari, Shuzo Oshita, Akira Takahashi, and Yutaka Nakaya

Anesth Analg 2008 106: 858-864.

人体外周血生痛敏/前体mRNA

郑丽 陈杰

Human Peripheral Blood Mononuclear Cells Produce Pre-Pro-Nociceptin/Orphanin FQ mRNA (Brief Report)

John P. Williams, Jonathan P. Thompson, David J. Rowbotham, and David G. Lambert

Anesth Analg 2008 106: 865-866.

TECHNOLOGY, COMPUTING, AND SIMULATION:

用第二代波形仪对病人估心出量的有效性

刘沁译 薛张纲校

Cardiac Output Derived from Arterial Pressure Waveform Analysis in Patients Undergoing Cardiac Surgery: Validity of a Second Generation Device

Jochen Mayer, Joachim Boldt, Michael W. Wolf, Johannes Lang, and Stefan Suttner

Anesth Analg 2008 106: 867-872.

志愿者中光预测

沈浩   马皓琳 李士通

Spectral Entropy Predicts Auditory Recall in Volunteers

Daryn H. Moller and Ira J. Rampil

Anesth Analg 2008 106: 873-879.

酚与fospropofol(一新型前体)的交互式仿

陶颖莹 陈杰

Interactive Web Simulation for Propofol and Fospropofol, a New Propofol Prodrug (Technical Communication)

Sinan Yavas, David Lizdas, Nikolaus Gravenstein, and Samsun Lampotang

Anesth Analg 2008 106: 880-883.

CRITICAL CARE AND TRAUMA:

食管部分切除术中胸段硬膜外应用布比卡因与静脉内肾上腺素输注对胃管引流的影响

刘婷洁译 薛张纲校

The Effect of Thoracic Epidural Bupivacaine and an Intravenous Adrenaline Infusion on Gastric Tube Blood Flow During Esophagectomy (Brief Report)

Omar Y. Al-Rawi, Stephen H. Pennefather, Richard D. Page, Ishani Dave, and Glen N. Russell

Anesth Analg 2008 106: 884-887.

OBSTETRIC ANESTHESIOLOGY:

母体酚胺妊娠子微血管内径的影

黄佳佳译,马皓琳 李士通校

The Effect of Maternal Catecholamines on the Caliber of Gravid Uterine Microvessels

Scott Segal and Steven Y. Wang

Anesth Analg 2008 106: 888-892.

ECONOMICS, EDUCATION, AND POLICY:

策支持增强了心和吐指南的

张燕 陈杰

Decision Support Increases Guideline Adherence for Prescribing Postoperative Nausea and Vomiting Prophylaxis

Fabian O. Kooij, Toni Klok, Markus W. Hollmann, and Jasper E. Kal

Anesth Analg 2008 106: 893-898.

NEUROSURGICAL ANESTHESIOLOGY:

注在志愿者中对区血流分布的影

秦敏菊译 薛张纲校

The Effect of Clonidine Infusion on Distribution of Regional Cerebral Blood Flow in Volunteers

Vincent Bonhomme, Pierre Maquet, Christophe Phillips, Alain Plenevaux, Pol Hans, Andre Luxen, Maurice Lamy, and Steven Laureys

Anesth Analg 2008 106: 899-909.

缺血诱导血管收的影

裘毅敏译,马皓琳 李士通校

The Effects of Transient Cerebral Ischemia on Vasopressin-Induced Vasoconstriction in Rabbit Cerebral Vessels

Masahiko Kumazawa, Hiroki Iida, Masayoshi Uchida, Mami Iida, Motoyasu Takenaka, Naokazu Fukuoka, Tomohiro Michino, and Shuji Dohi

Anesth Analg 2008 106: 910-915.

自主呼吸的新生大鼠缺-缺血损伤氙气/措施:呼吸和镇静

潘方立 陈杰

Xenon/Hypothermia Neuroprotection Regimes in Spontaneously Breathing Neonatal Rats After Hypoxic-Ischemic Insult: The Respiratory and Sedative Effects

John Dingley, Catherine Hobbs, James Ferguson, Janet Stone, and Marianne Thoresen

Anesth Analg 2008 106: 916-923.

道准引起的水不致老年人知功能障碍

夏俊明译  薛张纲校

Dehydration Induced by Bowel Preparation in Older Adults Does Not Result in Cognitive Dysfunction

Gareth L. Ackland, Jane Harrington, Paul Downie, James W. Holding, Deepak Singh-Ranger, Konstandina Griva, Michael G. Mythen, and Stanton P. Newman

Anesth Analg 2008 106: 924-929.

NEUROSURGICAL ANESTHESIA:

在接受酚复合芬太尼麻醉的患者中神肌肉阻水平强直后动诱发电位的幅度和经颅刺激的的影

唐李隽 马皓琳 李士通校

The Effects of the Neuromuscular Blockade Levels on Amplitudes of Posttetanic Motor-Evoked Potentials and Movement in Response to Transcranial Stimulation in Patients Receiving Propofol and Fentanyl Anesthesia

Yuri Yamamoto, Masahiko Kawaguchi, Hironobu Hayashi, Toshinori Horiuchi, Satoki Inoue, Hiroyuki Nakase, Toshisuke Sakaki, and Hitoshi Furuya

Anesth Analg 2008 106: 930-934.

手法管期椎移:直接喉GlideScope视频法的比

印洁敏 陈杰

Cervical Spine Motion During Tracheal Intubation with Manual In-Line Stabilization: Direct Laryngoscopy versus GlideScope® Videolaryngoscopy

Arnaud Robitaille, Stephan R. Williams, Marie-Hélène Tremblay, François Guilbert, Mélanie Thériault, and Pierre Drolet

Anesth Analg 2008 106: 935-941.

GENERAL ARTICLES:

展中家的麻醉和相关学科的现状:一项赞共和的全调查

陈珺珺译 薛张纲校

Anesthesia and Its Allied Disciplines in the Developing World: A Nationwide Survey of the Republic of Zambia

Stefan Jochberger, Feruza Ismailova, Wolfgang Lederer, Viktoria D. Mayr, Günter Luckner, Volker Wenzel, Hanno Ulmer, Walter R. Hasibeder, Martin W. Dünser For the "Helfen Berührt" Study Team

Anesth Analg 2008 106: 942-948.

PAIN MEDICINE:

考昔给药与仅仅给药对接受大的整形外科手病人后影的比

吴进   马皓琳 李士通

Perioperative Versus Postoperative Celecoxib on Patient Outcomes After Major Plastic Surgery Procedures

Tiffany Sun, Ozlem Sacan, Paul F. White, Jayne Coleman, Rod J. Rohrich, and Jeffrey M. Kenkel

Anesth Analg 2008 106: 950-958.

前瞻性定胸段硬膜外新斯的明腹主麻痹的影

宋翠侠 陈杰

A Prospective Randomized Double-Blind Study to Determine the Effect of Thoracic Epidural Neostigmine on Postoperative Ileus After Abdominal Aortic Surgery

Esra Caliskan, Ayda Turkoz, Mesut Sener, Nesrin Bozdogan, Oner Gulcan, and Riza Turkoz

Anesth Analg 2008 106: 959-964.

PAIN MECHANISMS:

吗啡注射抑制爪炎症性水:一NO)和鸟苷(cGMP)的作用

蒋宗明译 薛张纲校

Intrathecally Injected Morphine Inhibits Inflammatory Paw Edema: The Involvement of Nitric Oxide and Cyclic-Guanosine Monophosphate

Sara Comelli Brock and Carlos Rogério Tonussi

Anesth Analg 2008 106: 965-971.

注射环氧化酶-1抑制环氧化酶-2抑制或非选择性抑制剂对疼痛行和脊髓Fos免疫反的影

颜涛 译,马皓琳 李士通

The Effects of Intrathecal Cyclooxygenase-1, Cyclooxygenase-2, or Nonselective Inhibitors on Pain Behavior and Spinal Fos-Like Immunoreactivity

Il Ok Lee and Youngsun Seo

Anesth Analg 2008 106: 972-977.

合酶抑制环氧合酶抑制在小鼠甲醛诱导疼痛中的相互作用:一射分析

潘钱玲 陈杰

The Interaction Between Inhibitors of Nitric Oxide Synthase and Cyclooxygenase in Formalin-Induced Pain in Mice: An Isobolographic Study

Abdul-Shakoor Bhat, Surendra Kumar Tandan, Dinesh Kumar, Vamsi Krishna, and Vellanki Ravi Prakash

Anesth Analg 2008 106: 978-984.

固定量的异氟并没先抑制有上行投射的腰段脊髓背角神元的实验鼠的有害热诱发

陈珺珺译 薛张纲校

Immobilizing Doses of Halothane, Isoflurane or Propofol, Do Not Preferentially Depress Noxious Heat-Evoked Responses of Rat Lumbar Dorsal Horn Neurons with Ascending Projections

Linda S. Barter, Laurie O. Mark, Steven L. Jinks, Earl E. Carstens, and Joseph F. Antognini

Anesth Analg 2008 106: 985-990.

REGIONAL ANESTHESIA:

患者自控持斜角肌间沟能促进开放性肩部手后的早期功能康

慧译 马皓琳 李士通校

Does Patient-Controlled Continuous Interscalene Block Improve Early Functional Rehabilitation After Open Shoulder Surgery?

Klaus Hofmann-Kiefer, Tim Eiser, Daniel Chappell, Stephan Leuschner, Peter Conzen, and Dirk Schwender

Anesth Analg 2008 106: 991-996.

改良乳房根治术术罗哌卡因连续伤口浸麻醉次椎旁神的比

陈伟 陈杰

A Prospective Comparison of Continuous Wound Infiltration with Ropivacaine Versus Single-Injection Paravertebral Block After Modified Radical Mastectomy

Tatiana Sidiropoulou, Oreste Buonomo, Eleonora Fabbi, Maria Beatrice Silvi, Georgia Kostopanagiotou, Alessandro Fabrizio Sabato, and Mario Dauri

Anesth Analg 2008 106: 997-1001.

腰麻时预对脑脊液的性和等比重的局麻散的影

陈珺珺译 薛张纲校

The Effects of Prehydration on the Properties of Cerebrospinal Fluid and the Spread of Isobaric Spinal Anesthetic Drug

Byung Seop Shin, Justin Sang Ko, Mi Sook Gwak, Mikyung Yang, Chung Su Kim, Tae Soo Hahm, Sang Min Lee, Hyun Sung Cho, Sung Tae Kim, Ji Hye Kim, and Gaab Soo Kim

Anesth Analg 2008 106: 1002-1007.

鼻部手中左旋布比卡因局部浸的收血管和痛作用

胡湘   马皓琳 李士通

Vasoconstriction and Analgesic Efficacy of Locally Infiltrated Levobupivacaine for Nasal Surgery

Yavuz Demiraran, Ozcan Ozturk, Ender Guclu, Abdulkadir Iskender, Mehmet Hakan Ergin, and Abdurahman Tokmak

Anesth Analg 2008 106: 1008-1011.

用手提式Doppler骨下臂

陈珺珺译 薛张纲校

A Simplified Approach to Vertical Infraclavicular Brachial Plexus Blockade Using Hand-Held Doppler (Brief Report)

Steven Renes, Laura Clark, Mathieu Gielen, Huub Spoormans, Janneke Giele, and Anupama Wadhwa

Anesth Analg 2008 106: 1012-1014.

长时体外循环后抗凝血酶缺乏导致凝血酶活性增强

Antithrombin Deficiency Increases Thrombin Activity After Prolonged Cardiopulmonary Bypass

Roman Sniecinski, MD*, Fania Szlam, MMSc*, Edward P. Chen, MD{dagger}, Stephen O. Bader, MD*, Jerrold H. Levy, MD*, and Kenichi A. Tanaka, MD, MSc*

From the Departments of *Anesthesiology, and {dagger}Surgery (Cardiothoracic), Emory University School of Medicine, Atlanta, Georgia.

Anesth Analg 2008 106: 713-718.

 

背景:  体外循环期间,特别是深低温停循环时抗凝血酶水平降低。低抗凝血酶水平可能导致促凝和抗凝因子间的不平衡导致系统性血栓形成。作者假设体外循环后病人血浆中加入促凝因子后低水平的抗凝血酶可能导致凝血酶产生增加。

方法:5例接受深低温停循环心脏手术的病人在肝素化前和体外循环后抽取血液标本。抗凝血酶水平由产色反应来确定并由正常活性的百分比来表达。抗凝和促凝物质的平衡通过在病人血浆中加入正常人的血浆、抗凝血酶缺陷的血浆和提纯的抗凝血酶来实现 ThrombinoscopeTM系统用于评估给或不给抗凝血酶时的凝血酶。

结果:在体外循环前后,抗凝血酶水平分别为82.0% (中位数71.0, 最大值109) 37.0% (中位数34.0, 最大值41.0)(P < 0.05)。当体外循环后的血浆加入正常抗凝血酶(105%)的捐献者血浆后凝血酶56.6 nM (中位数42.1, 最大值61.0), 并保持在 61.1 nM (中位数54.9, 最大值64.5)。当加入抗凝血酶缺乏病人的血浆后,凝血酶(中位数,范围)从56.6nM(中位数42.1, 最大值61.0)增至117 nM (中位数95.0, 最大值188) (P < 0.05)。当加入提纯的抗凝血酶后,凝血酶减少到12.2 nM (中位数9.0, 最大值29.3) (P < 0.05)

结论:深低温停循环患者体外循环后血浆抗凝血酶活性显著下降。数据显示在不给予抗凝血酶的情况下给予凝血因子可能导致过多的凝血酶生成,临床上有潜在导致高凝状态的可能。                                                                                                                           

(胡潇 陈杰 校)

BACKGROUND: Antithrombin (AT) levels decrease during cardiopulmonary bypass (CPB), particularly when combined with deep hypothermic circulatory arrest (DHCA). Low AT levels might lead to imbalance of pro- and anticoagulant factors promoting systemic thrombotic events. We hypothesized that low levels of AT might lead to increased in vitro thrombin generation when procoagulant factors are added to the patient's plasma after CPB.

METHODS: Blood samples were obtained before heparinization and after separation from CPB from five patients undergoing cardiac surgery with DHCA. AT levels were determined by chromogenic assay and expressed as a percent of normal activity. The balance between procoagulant and anticoagulant elements was manipulated in the patients' plasma by adding normal donor plasma, AT-deficient plasma, or purified AT. The ThrombinoscopeTM system was used to evaluate thrombin generation with and without AT supplementation.

RESULTS: AT levels (median, range) were 82.0% (71.0, 109) and 37.0% (34.0, 41.0) of normal before and after separation from CPB, respectively (P < 0.05). Peak thrombin generation (median, range) was 56.6 nM (42.1, 61.0) in plasma after CPB, and it remained at 61.1 nM (54.9, 64.5) when a donor plasma with normal AT (105%) was added. When AT-deficient plasma was added to the patient's plasma, peak thrombin generation (median, range) was increased from 56.6 nM (42.0, 61.0) to 117 nM (95.0, 188) (P < 0.05 versus control). After the addition of purified AT, the peak thrombin generation was reduced to 12.2 nM (9.0, 29.3) (P < 0.05 versus control).

CONCLUSION: Plasma AT activity is severely decreased after CPB with DHCA. Our data suggest that the administration of coagulation factor components without AT repletion may lead to excessive thrombin generation, which clinically, may potentially lead to a hypercoagulable state.


联合给予活化因子(NovoSeven®)和纤维蛋白原(Haemocomplettan® P)后能改善血块形成

Improved Clot Formation by Combined Administration of Activated Factor VII (NovoSeven®) and Fibrinogen (Haemocomplettan® P)

Kenichi A. Tanaka, MD, MSc*, Taro Taketomi, MD*, Fania Szlam, MMSc*, Andreas Calatzis, MD{dagger}, and Jerrold H. Levy, MD*

From the *Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Emory University School of Medicine, Atlanta, Georgia; and {dagger}Haemostasis and Transfusion Medicine, Munich University Clinic, Munich, Germany.

Anesth Analg 2008 106: 732-738.

 

背景:重组活化因子(rFVIIa)常用于治疗难治性心脏术后出血。然而,止血作用还取决于凝集因子,包括纤维蛋白原,在血管损伤部位形成稳定的血小板栓子。作者比较了单独使用rFVIIa,纤维蛋白原以及联合使用时的止血效果。

方法:采集 12例志愿者和7例体外循环患者血液样本。在体外,志愿者的血浆加入肝素(0.1U/ml)或纤溶酶原(0.1ug/ml)以模拟凝血功能紊乱,然后加入rFVIIa1.5ug/ml)、纤维蛋白原(100mg/dl)或联合给予rFVIIa及纤维蛋白原,以此来评价它们的促凝血功能。通过血栓弹力图比较它们对凝血功能的影响。测定血栓的形成时间、第一个血栓形成时间以及血栓的最大硬度。凝血酶定量实验用来测定添加纤维蛋白原和(或)rFVIIa后凝血酶的产生。

结果:在肝素化的志愿者的血浆中,加入rFVIIa可以导致血凝块形成时间从663秒缩短到435秒,但不影响血栓的最大硬度。纤维蛋白原可使血栓最大硬度从26.0mm增加到30.5mm,但它不影响血凝块形成时间。在肝素化血浆样本中联合给予rFVIIa和纤维蛋白原,可以最大程度地将血凝块形成时间缩短到359s(324–522s)以及将血栓最大硬度增加到29mm (27.8–31.0)。在给予组织型纤溶酶原的志愿者的血浆中,纤溶现象比加入rFVIIa增加了45%。体外循环术后,在给予rFVIIa和纤维蛋白原后血凝块形成时间和血栓最大硬度均改善了。凝血酶定量试验说明了rFVIIa可以提高血栓形成的时间和凝血酶活化的速度,而纤维蛋白原没有这些作用。

结论:给予rFVIIa后纤维蛋白形成时间和凝血酶产生均缩短,但只有另外给予纤维蛋白原后产生纤维蛋白凝块强度增强。体外循环后全血通过联合给与rFVIIa和纤维蛋白原而改善血凝块形成。

(王鹏 陈杰 校)

BACKGROUND: Recombinant activated factor VII (rFVIIa) is increasingly used for treating refractory bleeding after cardiac surgery. However, hemostasis also depends on coagulation factors, including fibrinogen, which stabilizes platelet plugs at sites of vascular injury. We compared the hemostatic effects of rFVIIa, fibrinogen, or their combination.

METHODS: Blood samples were obtained from 12 volunteers and from 7 patients after cardiopulmonary bypass (CPB). The in vitro effects of rFVIIa (1.5 µg/mL), fibrinogen (100 mg/dL), and the combination were evaluated under simulated coagulopathy in volunteer plasma using heparin (0.1 U/mL) or tissue plasminogen activator (0.1 µg/mL). Hemostatic interventions were compared using thromboelastometry, which measures clotting time (CT, s), angle of thrombus formation, and maximal clot firmness (MCF, mm). The ThrombinoscopeTM was used to quantitate thrombin generation after addition of fibrinogen and/or rFVIIa.

RESULTS: In heparinized volunteer plasma, rFVIIa shortened CT (1st and 3rd quartiles) from 663 (522–736) to 435 (397–531) s, but it did not affect MCF. Fibrinogen increased MCF from 26.0 (24.4–26.7) to 30.5 (26.3–31.5) mm without affecting CT. The combination of rFVIIa and fibrinogen in heparinized samples was most effective in improving CT to 359 (324–522) s and MCF to 29 (27.8–31.0) mm. In tissue plasminogen activator-treated volunteer plasma, fibrinolysis increased by more than 45% by the addition of rFVIIa. After CPB, both CT and MCF were most improved with coadministration of rFVIIa and fibrinogen. Thrombinoscope evaluation demonstrated that rFVIIa decreased the lag time and increased peak thrombin generation, whereas fibrinogen had no effect.

CONCLUSION: The onset of fibrin formation and thrombin generation were shortened after rFVIIa addition, but fibrin clot strength was only increased after fibrinogen supplementation. In vitro clot formation was most improved by using both rFVIIa and fibrinogen in whole blood after CPB.

 

血管外科高危病人术前冠脉血运重建术:主题综述

Preoperative Coronary Revascularization in High-Risk Patients Undergoing Vascular Surgery: A Core Review

Miklos D. Kertai, MD, PhD*{dagger}

From the *Department of Cardiothoracic Anaesthesia, Semmelweis University, Budapest, Hungary; and {dagger}Department of Anesthesia, Harefield Hospital, London, UK.

Anesth Analg 2008 106: 751-758.

 

数据显示进行血管外科手术的病人,其冠状动脉相关的心脏并发症发生率呈现持续增高。

而术前进行冠状动脉造影的病人如果显示有接受冠脉血运重建术来改善术前及长期心脏功能的必要,则术前心脏功能评估对这些高危病人极为有益。然而目前的冠脉血运重建术与药物治疗在减少心脏并发症的效果上孰优孰劣仍存在争议。本综述根据最近发表的文献总结并比较了选择性血管手术的病人术前冠脉血运重建术治疗与保守性药物治疗两者效果。

(陶颖莹 陈杰 校)

Patients undergoing vascular surgery are at increased risk for cardiac complications related to the presence of underlying coronary artery disease. Preoperative cardiac evaluation may help to identify high-risk patients in whom coronary angiography may be planned with subsequent coronary revascularization for the purpose of improving perioperative and long-term cardiac outcomes. However, the indications and efficacy for type of revascularization for the reduction of cardiac complications compared to medical therapy has been controversial. My aim in this review is to summarize the role of preoperative revascularization compared to conservative medical therapy before elective vascular surgery using current evidence from published studies.

 

用近红外光谱法测定新生小猪选择性顺行脑灌注的血流指数

Measurement of Blood Flow Index During Antegrade Selective Cerebral Perfusion with Near-Infrared Spectroscopy in Newborn Piglets

Patrick Meybohm, MD*{dagger}, Grischa Hoffmann, MD{ddagger}, Jochen Renner, MD*{dagger}, Andreas Boening, MD{ddagger}, Erol Cavus, MD*, Markus Steinfath, MD*, Jens Scholz, MD*, and Berthold Bein, MD, DEAA*{dagger}

From the *Department of Anaesthesiology and Intensive Care Medicine, {dagger}Pediatric Anesthesia Research Unit, and {ddagger}Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany.

Anesth Analg 2008 106: 795-803.

 

背景:复杂的先天性心脏病的婴儿需在深低温停循环(HCA)下手术。有人认为,选择性脑灌注(SCP)可以提供足够的脑血流而减轻缺血性脑损伤。作者采用近红外光谱法监测脑灌注和组织氧合情况,研究不同SCP下血流速度,并且与HCA相比较。

方法21头小猪在18°C行体外循环,然后行HCA或以2550mL · kg–1 · min–1SCP 90min,分别为HCV组、SCP25组和SCP50组。通过近红外光谱法测定吲哚青绿血管造影剂的血流指数(BFI)以及组织氧合指数(TOI)。用经颅多普勒超声测定平均脑血流速度(FVmean)

结果 SCP50组较HCV组(无血流)和SCP25组,其BFIFVmean都有显著增高。SCP50组的TOI较基础水平增高,并高于HCV组和SCP25组。SCP50的颅内压较基础水平没有显著升高。

结论:BFIFVmean都显示了SCP50组的脑灌注较HCV组和SCP25组增高。SCP25组和SCP50组的TOIHCA组有明显提高。SCP25mL · kg–1 · min–1时可能提供最合适的脑保护。

(杜唯佳 陈杰 校)

BACKGROUND: Neonates with complex congenital heart defects have traditionally undergone surgery during deep hypothermic cardiac arrest (HCA). Selective cerebral perfusion (SCP) is thought to minimize ischemic brain injury by providing adequate cerebral blood flow. We investigated SCP with different flow rates compared with HCA with respect to cerebral perfusion and tissue oxygenation as assessed by near-infrared spectroscopy.

METHODS: Twenty-one piglets were placed on cardiopulmonary bypass at 18°C, then underwent either HCA or SCP at 25 or 50 mL · kg–1 · min–1 for 90 min. The blood flow index (BFI) derived by indocyanine green and tissue oxygen index (TOI) were determined by near-infrared spectroscopy. Mean cerebral blood flow velocity (FVmean) was recorded by transcranial Doppler ultrasound.

RESULTS: Both BFI and FVmean increased significantly (126 ± 27% of baseline; 19 ± 2 cm/s) in the SCP 50 group compared with HCA (no flow) and SCP 25 (65 ± 24%; 10 ± 1 cm/s), respectively. TOI increased in the SCP 50 group compared with baseline (74 ± 4% vs 65 ± 4%), and was higher compared with HCA (52 ± 2%) and SCP 25 (59 ± 2%). Intracranial pressure increased nonsignificantly compared with baseline in the SCP 50 group.

CONCLUSIONS: Both BFI and FVmean suggested increased cerebral perfusion in the SCP 50 group compared with the HCA and SCP 25 groups. TOI was significantly higher in both the SCP 25 and SCP 50 groups compared with HCA. SCP at 25 mL · kg–1 · min–1 may be most appropriate for cerebral protection.

 

闪光灯在减轻静脉置管术疼痛的作用:一个前瞻性、随机、安慰对照研究

The Role of a Flash of Light for Attenuation of Venous Cannulation Pain: A Prospective, Randomized, Placebo-Controlled Study

Anil Agarwal, MD*, Ghanshyam Yadav, MD*, Devendra Gupta, MD*, Manish Tandon, MD*, Prabhat Kumar Singh, MD*, and Uttam Singh, PhD{dagger}

From the Departments of *Anaesthesiology and {dagger}Biostatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Anesth Analg 2008 106: 814-816.

 

背景:尽管操作中有有令人不适的疼痛经历,静脉置管术常在无镇痛的情况下完成的。各种各样的药物和非药物措施尝试用于减轻静脉置管带来的疼痛。本文研究闪光灯减轻静脉置管术疼痛的作用。

方法:前瞻性、随机研究90名成年人(15—60岁),ASA分级在--级,不分性别,行择期LC术患者。随机分为三组,每组30人。第一组(对照组);第二组(分散注意组):不用闪光灯照相;第三组(闪光組):手背小静脉不明显的患者在静脉置管术前用闪光灯给予拍照,然后迅速行静脉穿刺置管,置入18号导管。

结果:每组均有2名患者因第一次置入未成功而在后期分析中删除。闪光组静脉置管时疼痛比较轻,疼痛率为50%14/28),而另两组为100%28/28)(p0.01)。用视觉模拟评分测定静脉置管术疼痛程度(0—1000即没有疼痛,100是最痛)。闪光组的静脉置管疼痛减轻的程度比分散注意力组大(p0.01

结论:静脉置管术前应用闪光灯是减轻置管疼痛的一种安全、有效、简单易用的方法。

(王腾 陈杰 校)

BACKGROUND: Venous cannulation is often performed without any analgesia, even though pain experienced during this procedure is at times very distressing. Various pharmacological and nonpharmacological measures have been tried with variable results to minimize venous cannulation pain. We designed the present study to evaluate the efficacy of a flash of light on attenuating venous cannulation pain.

METHODS: Ninety adults (15–60 yr), ASA physical status I and II, of either sex, undergoing elective laparoscopic cholecystectomy, were included in this prospective and randomized study. Patients were divided into three groups of 30 each. Group I (control); Group II (distraction): photographed without a flash of light; and Group III (flash): photographed with a flash of light just before venous cannulation of a vein on the dorsum of the nondominant hand. Immediately after the photograph, venous cannulation was performed using an 18-gauge cannula.

RESULTS: Two patients from each group could not be cannulated on their first attempt and were therefore dropped from subsequent analysis. The incidence of venous cannulation pain in the flash group was lower, i.e., 50% (14 of 28) when compared to 100% (28 of 28) observed in the other two study groups (P < 0.01). Severity of venous cannulation pain as assessed by the Visual Analog Scale scores (between 0 and 100; where 0 = no pain and 100 = worst imaginable pain) presented as median (interquartile range) were reduced in the flash [10(20)] and distraction [20(10)] groups compared with the control group [40(20)] (P < 0.01). The severity of venous cannulation pain was also reduced in the flash group compared with the distraction group (P < 0.01).

CONCLUSION: We conclude that a flash of light before venous cannulation is a safe, effective, and easy-to-use method for minimizing venous cannulation pain.

 

不同化合物对野生型、突变型Aγ氨基丁酸和甘氨酸受体的麻醉样作用

The Anesthetic-Like Effects of Diverse Compounds on Wild-Type and Mutant {gamma}-Aminobutyric Acid Type A and Glycine Receptors

Liya Yang, PhD, and James M. Sonner, MD

From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2008 106: 838-845.

 

介绍:没有理论认为吸入麻醉药的作用通过其挥发特性发挥其与生物学靶组织发生生物物理学相互作用而产生麻醉效应。证实突变导致吸入麻醉药对各种受体作用减弱有助于证明具有麻醉作用的非挥发性麻醉药所作用的受体。在以前的研究中,作者证实这些化合物 带电荷或蒸气压特别低,而且这些化合物具有类似吸入麻醉药的方式作用麻醉敏感受体。本研究通过比较它们对野生型Aγ氨基丁酸(GABAA或甘氨酸受体和突变受体的作用,验证是否这些化合物或是其他带电化合物,相同于挥发性麻醉药的机制。突变受体是通过设计对吸入麻醉药相对耐药而确定。

方法:检测β-羟基丁酸、氯化铵、二乙基邻苯二甲酸酯和GABA对甘氨酸受体同价同效基因α1和突变基因α1S267I)的作用。检测硫酸十二烷基头孢匹胺和甘氨酸对α1β2γ2s和突变基因α1S270Iβ2γ2sGABA受体的作用。受体来源于非洲蟾蜍平滑肌细胞,用两个电极电压夹的方法。对于GABAA受体和甘氨酸受体,异氟醚和乙醇作为阳性对照,异丙酚作为阴性对照(如由突变导致无作用)。

结果:β-羟基丁酸、氯化铵、二乙基邻苯二甲酸酯和GABA均增强甘氨酸受体功能。这种作用可被S267I突变体降低。硫酸十二烷基头孢匹胺和甘氨酸增强GABAA受体功能,S270I突变体减弱这种作用。

结论:上述发现支持化合物调节GABA A或甘氨酸受体通过类似异氟醚和乙醇的作用机制的假说。比较药物对麻醉敏感型野生受体与相对不敏感型突变受体的作用,可能帮助寻找有麻醉作用的化合物。

(赵燕星 陈杰 校)

INTRODUCTION: No theory of inhaled anesthetic action requires volatility of the anesthetic to accomplish the biophysical interaction of anesthetic with biological target. The identification of mutations that attenuate the effect of inhaled anesthetics on various receptors raises the possibility that nonvolatile compounds with anesthetic effects can be identified with the aid of these receptors. In previous studies, we identified compounds that were either charged or had an exceptionally low vapor pressure and which modulated anesthetic-sensitive receptors in a manner similar to inhaled anesthetics. We tested whether these, and another charged compound, shared a common mechanism with volatile anesthetics, by comparing their effect on wild-type {gamma}-aminobutyric acid type A (GABAA) or glycine receptors and mutant receptors that were engineered to be relatively resistant to inhaled anesthetics.

METHODS: The effect of β-hydroxybutyric acid, ammonium chloride, diethylhexyl phthalate, and GABA were tested on homomeric {alpha}1 and mutant {alpha}1 (S267I) glycine receptors. The effect of sodium dodecyl sulfate and glycine were tested on {alpha}1b2{gamma}2s and mutant {alpha}1(S270I)β2{gamma}2s GABAA receptors. Receptors were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping. For both GABAA and glycine receptors, isoflurane and ethanol were used as positive controls and propofol as a negative control (i.e., unaffected by the mutation).

RESULTS: β-hydroxybutyric acid, ammonium chloride, diethylhexyl phthalate, and GABA all enhanced glycine receptor function. This effect was reduced by the S267I mutations. Sodium dodecyl sulfate and glycine enhanced GABAA receptor function, and the S270I mutation attenuated this effect.

CONCLUSION: These findings support the hypothesis that the compounds studied modulate GABAA or glycine receptors by a mechanism similar to that of isoflurane and ethanol. Comparing the effect of drugs on anesthetic-sensitive wild-type receptors with relatively less sensitive mutant receptors may help identify compounds with anesthetic effects.

 

人体外周血单核细胞产生痛敏肽/孤啡肽前体mRNA

Human Peripheral Blood Mononuclear Cells Produce Pre-Pro-Nociceptin/Orphanin FQ mRNA

John P. Williams, FRCA*, Jonathan P. Thompson, MD, FRCA*, David J. Rowbotham, MD, FRCA{dagger}, and David G. Lambert, PhD*

From the Departments of *Cardiovascular Sciences (Pharmacology and Therapeutics Group), and {dagger}Health Sciences, Division of Anaesthesia, Critical Care and Pain Management, University of Leicester, Leicester Royal Infirmary, Leicester, UK.

Anesth Analg 2008 106: 865-866.

 

背景  外周血单核细胞(PBMC)转录非典型的阿片样物质痛敏肽/孤啡肽(N/OFQ)受体(NOPmRNA。笔者检测了N/OFQ前体,促N/OFQ前体(pp N/OFQ)。

方法:取10名健康志愿者PBMC,用聚合酶链反应(PCR)技术检测pp N/OFQ

结果 凝胶PCR法中所有样本中均检出pp N/OFQ mRNA扩增子。这点通过定量实时PCR技术证实(mRNA 30.91+0.18)。

结论:这组数据提示PBMC转录pp N/OFQ,且表达NOP,意味NOP可能参与PBMC的自身调节。

(郑丽 陈杰 校)

BACKGROUND: Peripheral blood mononuclear cells (PBMC) transcribe mRNA for the nonclassical opioid nociceptin/orphanin FQ (N/OFQ) receptor (NOP). We probed for the N/OFQ precursor, pre-pro-N/OFQ (ppN/OFQ).

METHODS: Using PBMC from 10 healthy volunteers we probed for ppN/OFQ using polymerase chain reaction (PCR) based experimental paradigms.

RESULTS: In gel-based PCR, we detected amplicons consistent with ppN/OFQ mRNA in all samples. This was confirmed in quantitative real-time PCR with cycle thresholds (representing quantity of mRNA) of 30.91 ± 0.18 (n = 10).

CONCLUSIONS: These data indicate that PBMCs transcribe ppN/OFQ which, coupled with NOP expression, suggest NOP may be involved in the autoregulation of PBMCs.

 

异丙酚与fospropofol(一种新型异丙酚前体)的交互式网络仿真

Interactive Web Simulation for Propofol and Fospropofol, a New Propofol Prodrug

Sinan Yavas, MD, David Lizdas, Nikolaus Gravenstein, MD, and Samsun Lampotang, PhD

From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.

Anesth Analg 2008 106: 880-883.

 

根据近期发表的有关异丙酚及fospropofol(一种新型异丙酚前体)药代及药效学数据,本文作者建立了使用这两种药的交互式网络仿真。其中fospropofol是一种新型水溶性异丙酚前体药物,其达到峰浓度的时间晚于异丙酚。而建立的模型能使麻醉医师了解使用两种药物间的区别。另外该模型的附加优点在于保留了原试验中不同试验方案中不同病人间的差异。

(陶颖莹 陈杰 校)

Using pharmacokinetic and pharmacodynamic data published in the scientific literature, we have developed interactive on-line simulations to model administration of propofol and fospropofol, a new water-soluble prodrug formulation of propofol. The prodrug formulation of fospropofol leads to a delayed onset to peak concentrations of propofol. A comparison simulation that overlays administration of fospropofol and propofol allows clinicians to understand the differences of administering fospropofol and traditional propofol. The simulations have the added advantage of allowing for differences among patients documented in test studies and the use of different models.

 

 决策支持增强了预防术后恶心和呕吐指南的执行

Decision Support Increases Guideline Adherence for Prescribing Postoperative Nausea and Vomiting Prophylaxis

Fabian O. Kooij, MD*{dagger}, Toni Klok, MD*, Markus W. Hollmann, MD, PhD, DEAA{dagger}, and Jasper E. Kal, MD, PhD*

From the *Department of Anesthesiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands and {dagger}Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands.

Anesth Analg 2008 106: 893-898.

 

背景:预防术后恶心和呕吐的指南实施广泛,但由于没有很好的执行,效果可能有限。 作者作者假设利用电子决策支持(简称DS)系统,能显著改善指南的执行。

METHODS: Medical information of all patients undergoing elective surgery in our regional teaching hospital is routinely entered in an anesthesia information management system at the preoperative screening clinic.方法:来自作者的地区教学医院的选择性手术患者的医学资料常规收录入术前门诊麻醉信息处理系统。 预防Our departmental PONV prevention guidelines identifies patients as "high-risk" and thus eligible for PONV prophylaxis based on the presence of at least three of the following risk factors: female gender, history of PONV or motion sickness, nonsmoker status, and anticipated use of postoperative opioids.术后恶心和呕吐指南确诊为"高危"患者,作为预防术后恶心和呕吐对象,根据是在场的至少有以下3个危险因子:女性,术后恶心和呕吐史或晕动病,不吸烟体质,和预期术后使用阿片类药物。 Using automated reminders, we studied the effect of DS on guidelines adherence using an off-on-off design.使用自动提醒方法,研究决策支持对指南执行的作用。 In these three study periods, we queried for all consecutive patients visiting the preoperative screening clinic who were eligible for PONV prophylaxis and studied how often it was prescribed correctly.

RESULTS: Between November 2005 and June 2006, 1340, 2715, and 1035 patients were included in the control, DS and post-DS periods, respectively.结果:200511月和20066月期间,对照组,决策支持组以及后决策支持组包括患者分别有 1340 27151035例。As a result of mandatory data entry of risk factors, the percentage of high-risk PONV patients increased from 28% in the control period to 32% and 31% in the DS and post-DS periods, respectively.由于强制性数据录入,术后恶心和呕吐高危患者的比例由对照组28 ,上升到决策支持组32%和后决策支持组31%。 During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis.对照组38%的高危患者开具了预防性术后恶心和呕吐处方。 而决策支持组比例上升至73 ,后决策支持组下降至37

CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.结论:术后恶心和呕吐的高危病人中,电子决策支持系统增强了预防术后恶心和呕吐开具处方指南的执行。

(张燕 陈杰 校)

BACKGROUND: Guidelines for postoperative nausea and vomiting (PONV) prevention are implemented widely but their effectiveness may be limited by poor adherence. We hypothesized that the use of an electronic decision support (DS) system would significantly improve guideline adherence.

METHODS: Medical information of all patients undergoing elective surgery in our regional teaching hospital is routinely entered in an anesthesia information management system at the preoperative screening clinic. Our departmental PONV prevention guidelines identifies patients as "high-risk" and thus eligible for PONV prophylaxis based on the presence of at least three of the following risk factors: female gender, history of PONV or motion sickness, nonsmoker status, and anticipated use of postoperative opioids. Using automated reminders, we studied the effect of DS on guidelines adherence using an off–on–off design. In these three study periods, we queried for all consecutive patients visiting the preoperative screening clinic who were eligible for PONV prophylaxis and studied how often it was prescribed correctly.

RESULTS: Between November 2005 and June 2006, 1340, 2715, and 1035 patients were included in the control, DS and post-DS periods, respectively. As a result of mandatory data entry of risk factors, the percentage of high-risk PONV patients increased from 28% in the control period to 32% and 31% in the DS and post-DS periods, respectively. During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis. This increased to 73% during the DS period and decreased to 37% in the post-DS period.

CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.

 

自主呼吸的新生大鼠缺氧-缺血损伤后氙气/低温神经保护措施:呼吸和镇静效应

Xenon/Hypothermia Neuroprotection Regimes in Spontaneously Breathing Neonatal Rats After Hypoxic-Ischemic Insult: The Respiratory and Sedative Effects

John Dingley, MD*{dagger}, Catherine Hobbs, PhD*, James Ferguson, BSc*, Janet Stone, PhD{ddagger}, and Marianne Thoresen, MD, PhD*

From the *Clinical Science at South Bristol, Child Health, University of Bristol, St. Michael's Hospital, Bristol, UK; {dagger}University of Wales Swansea, Singleton Park, Swansea, UK; and {ddagger}Department of Biochemistry, Children's Hospital, Bristol, UK.

Anesth Analg 2008 106: 916-923.

 

背景:低温(HT)能降低围产期窒息引起的神经损伤,氙气(XE)能增强此作用。笔者研究了缺氧-缺血(HI)损伤后不同浓度氙气在正常体温37NT)和低体温32HT)的镇静作用及对呼吸的影响以确定能使7天龄的新生大鼠产生自主呼吸抑制的氙气浓度。

方法:(I)三组对照组,分别为空白对照、禁食正常体温对照组(NT)和禁食低温对照组(HT)。(II)六组行HI损伤(结扎颈动脉后吸8%氧气90min)。之后三组分别为正常体温吸空气、50%氙气和70%氙气(NTAir,NT50%Xe,NT70%Xe),另三组为低温吸空气、50%氙气和70%氙气(HTAir,HT50%Xe,HT70%Xe)。监测血气、血糖和乳酸并记录镇静状态(自主运动和呼吸频率)。

结果70只新生大鼠的血液生化数据全部获得。(I)对照组在NTHT禁食9h后血气、血糖和乳酸均正常。(IIHI损伤后,与对照组和NTAir组相比,在NTHT70%氙气组PCO2pH较低,而HTAir组和HT50%Xe组仅有pH较低。HT70%XePCO2最高、pH最低,镇静效果最好。

结论:在HI损伤后,70%氙气与吸空气和对照组在NT HT都能产生镇静、呼吸抑制、CO2潴留和pH下降。50%的氙气则避免了这些影响。

(潘方立 陈杰 校)

BACKGROUND: Hypothermia (HT) reduces neuronal injury after perinatal asphyxia. The anesthetic gas xenon (XE) may enhance this effect. We investigated the sedative and respiratory effects of variable XE concentrations at 37°C normothermia (NT) or 32°C HT after a hypoxic-ischemic (HI) insult to determine the concentration at which XE was a respiratory depressant in spontaneously breathing 7-day-old rat pups.

METHODS: (I) In three control groups, the effects of fasting at NT and HT were investigated. (II) Six groups were subjected to a HI insult (left carotid ligation then 90 min breathing 8% oxygen); three then breathed Air, 50%Xe or 70%Xe for 5 h at NT (NTAir, NT50%Xe, NT70%Xe), while three breathed identical mixtures during HT (HTAir, HT50%Xe, or HT70%Xe), in addition to a control group. Blood gases, glucose, and lactate were measured. Sedation (spontaneous movement/respiratory rate) was recorded.

RESULTS: Blood chemistry data were successfully obtained from 70 pups. (I) Pups maintained normal blood gas, glucose, and lactate values after 9 h fasting at NT or HT. (II) After HI insult, in comparison with control and NTAir groups, 70%Xe at both NT and HT produced higher PCO2 and lower pH values while the HTAir and HT50%Xe groups only had lower pH values. The HT70%Xe combination produced the highest PCO2 and lowest pH values (56.8 mm Hg, 7.35, respectively) and the greatest sedative effect.

CONCLUSION: After HI insult, 70%Xe at both NT and HT induced sedation, respiratory depression, CO2 retention, and a decrease in pH relative to air and control groups. The effects were largely avoided with 50%Xe.

 

手法稳定气管插管期间的颈椎移动:直接喉镜法与GlideScope视频喉镜法的比较

Cervical Spine Motion During Tracheal Intubation with Manual In-Line Stabilization: Direct Laryngoscopy versus GlideScope® Videolaryngoscopy

Arnaud Robitaille, MD*, Stephan R. Williams, MD*, Marie-Hélène Tremblay, MD*, François Guilbert, MD, FRCPC{dagger}, Mélanie Thériault, MD{dagger}, and Pierre Drolet, MD, FRCPC{ddagger}

From the Departments of *Anesthesiology and {dagger}Radiology, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, and {ddagger}Department of Anesthesiology, Hôpital Maisonneuve-Rosemont, Montréal, Canada.

Anesth Analg 2008 106: 935-941.

 

背景:对于颈椎有潜在病损的患者,采用何种最佳气管插管技术仍然具有争议。作者运用连续荧光照相,进行了一项前瞻性研究,比较直接喉镜法(DL)与GlideScope视频喉镜法(GVL)气管插管时颈椎移动,期间由助手手法保持患者头部的稳定。

方法:选择20例没有颈椎病变的患者。在全麻诱导使用神经肌肉阻滞后,随机采用DLGVL行气管插管。拍摄插管期间颈椎移动的荧光显像照片,并将其分成四个阶段:气道操作前的基础图像,显现声门,气管导管进入声门,气管插管。测定每位患者每个阶段枕部至C5活动的峰值,计算平均值,利用两因素方差分析比较每种方法产生的颈椎移动。对枕部至C1分别旋转101520度的患者的比例,和声门显现的质量同样做了研究。

结果:各个阶段的颈椎平均移动度在DLGVL之间没有显著差异(P0.220.70)。两种插管技术对颈椎产生的移动主要都是使颈椎前端伸展,且主要发生在显露声门时。在枕部至C1的伸展幅度大于101520度的这部分患者中插管基本没有困难。GVL对声门的显露明显优于DL

结论:在全身麻醉使用神经肌肉阻滞的情况下,手法保持头部稳定,采用GVLDL进行气管插管时前者更好地显露声门,但并不能减少对非病理性颈椎的移动度。

(印洁敏 陈杰 校)

BACKGROUND: The optimal tracheal intubation technique for patients with potential cervical (C) spine injury remains controversial. Using continuous cinefluoroscopy, we conducted a prospective study comparing C-spine movement during intubation using direct laryngoscopy (DL) or GlideScope® videolaryngoscopy (GVL), with uninterrupted manual in-line stabilization of the head by an assistant.

METHODS: Twenty patients without C-spine pathology were studied. After induction of general anesthesia with neuromuscular blockade, both DL and GVL were performed on every patient in random order. Cinefluoroscopic images of C-spine movement during GVL and DL were acquired and divided into four stages: a baseline image before airway manipulation, glottic visualization, insertion of the endotracheal tube into the glottis, and tracheal intubation. Peak segmental motion from the occiput to C5 was measured offline for each patient and each stage, averages were calculated, and movements induced by each instrument were compared using a two-way ANOVA. Also studied were the proportion of patients with occiput-C1 rotation exceeding 10, 15, or 20 degrees, and the quality of glottic visualization.

RESULTS: No significant difference was found between DL and GVL regarding average segmental spine movement at any level (P values between 0.22 and 0.70). During both techniques, motion was mainly an extension concentrated in the rostral C-spine and occurred predominantly during glottic visualization. The proportion of patients with occiput-C1 extension of more than 10, 15, or 20 degrees was not significantly different. Glottic visualization was significantly better with GVL compared with DL.

CONCLUSION: During intubation under general anesthesia with neuromuscular blockade and manual in-line stabilization, the use of GVL produced better glottic visualization, but did not significantly decrease movement of the nonpathologic C-spine when compared with DL.

 

一项前瞻性随机双盲研究测定胸段硬膜外给新斯的明对腹主动脉术后肠麻痹的影响

A Prospective Randomized Double-Blind Study to Determine the Effect of Thoracic Epidural Neostigmine on Postoperative Ileus After Abdominal Aortic Surgery

Esra Caliskan, MD*, Ayda Turkoz, MD*, Mesut Sener, MD*, Nesrin Bozdogan, MD*, Oner Gulcan, MD{dagger}, and Riza Turkoz, MD{dagger}

From the Departments of *Anesthesiology and Reanimation, and {dagger}Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey.

Anesth Analg 2008 106: 959-964.

背景:肠梗阻是腹主动脉术后胃肠道主要的并发症之一,可导致死亡率增加,住院时间延长和医药费的增加,在这项研究中作者评估了胸段硬膜外给与新斯的明对腹主动脉术后肠麻痹的作用。

方法 45名行腹主动脉手术的患者参与了这项研究,所有的患者接受一致的全麻与硬膜外麻醉。全麻诱导前在T7-T8椎间隙置入硬膜外导管,15min后给予0.5%布比卡因20ml。分别在手术结束以及术后8h经硬膜外导管给予单次剂量新斯的明(1ug/kg,生理盐水稀释成5ml1组),对照组(2组)同样的途径给5ml生理盐水。术后入ICU病房,记录肠鸣音次数以及每日排气排便次数。

结果1组较2组,第一次肠鸣音和排气时间明显缩短(11.6 ± 11.2 h vs 22.6 ± 12.8 h 21.8 ± 15.6 h vs 36.6 ± 19.1 h , P < 0.05)。两组病人第一次排便时间相似(p>0.05)2组比1组病人恶心发生率高(p<0.05),两组病人术后并发症发生率相似(p>0.05)

结论:胸段硬膜外给新斯的明促进肠鸣音恢复,缩短腹主动脉术后肠持麻痹续时间。

(宋翠侠 陈杰 校)

BACKGROUND: Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery.

METHODS: We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7–T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 µg/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded.

RESULTS: Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 ± 11.2 h vs 22.6 ± 12.8 h and 21.8 ± 15.6 h vs 36.6 ± 19.1 h, respectively, P < 0.05). The times to first defecation were similar in both groups (P > 0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05).

CONCLUSIONS: Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

 

一氧化氮合酶抑制剂和环氧合酶抑制剂在小鼠甲醛诱导疼痛中的相互作用:一项等辐射分析研究

The Interaction Between Inhibitors of Nitric Oxide Synthase and Cyclooxygenase in Formalin-Induced Pain in Mice: An Isobolographic Study

Abdul-Shakoor Bhat, PhD, Surendra Kumar Tandan, PhD, Dinesh Kumar, PhD, Vamsi Krishna, PhD, and Vellanki Ravi Prakash, PhD

From the Division of Pharmacology and Toxicology, Indian Veterinary Research Institute, Izatnagar, Bareilly, Uttar Pradesh, India.

Anesth Analg 2008 106: 978-984.

 

背景:关于NOCOX在角叉菜胶诱导的炎症反应中对前列腺素生成的相互作用已经有报道。但是,关于iNO抑制因子和COX抑制因子在痛觉中相互作用的报道则很少。因此,本研究意在评价S-甲基异硫脲硫酸盐(中度选择性iNO抑制因子)与罗非考昔(选择性COX-2抑制因子)和甲酚那酸(非选择性抑制因子)在小鼠甲醛诱导痛中的相互作用。

方法:通过对小鼠甲醛诱导痛的后期表现,即在注射甲醛后小鼠舔其后爪所花费的时间来研究S-甲基异硫脲硫酸盐、罗非考昔、甲酚那酸及将其混合使用时的剂量反应关系。这种相互作用通过将三种药物同时给药或将S-甲基异硫脲硫酸盐与每一COX抑制因子混合给药来评估。而其相互作用则通过等辐射法进行分析。

结果:单独给药时在甲醛诱导的后期可产生剂量依赖性抑制,其效价的强弱次序为罗非考昔>甲酚那酸>S-甲基异硫脲硫酸盐。而对混合剂即S-甲基异硫脲硫酸盐和罗非考昔,或甲酚那酸的等辐射分析则显示有协同作用。对于相同的混合物实验获得的ED50要比理论上相加获得的ED50明显低,这验证了iNOSNOCOX亚型的协同作用。

结论:研究发现NOSCOX抑制因子在小鼠甲醛诱导痛中有明显的协同作用,为疼痛控制提供了一个可行的方法。

(潘钱玲 陈杰 校)

BACKGROUND: An interaction between nitric oxide (NO) and cyclooxygenases (COX) in the production of prostaglandins in carrageenan-induced inflammation has been established. However, limited information is available about the interaction between inducible NO synthase (iNOS) and COX inhibitors in pain perception. Therefore, in the present study we assessed the nature of the interaction between S-methylisothiourea (a moderately selective iNOS inhibitor) with rofecoxib (selective COX-2 inhibitor) and mefenamic acid (a nonselective COX inhibitor) in formalin- induced pain in mice.

METHODS: The dose-response relation of S-methylisothiourea, rofecoxib, mefenamic acid, and their combination was studied in the late phase of formalin-induced pain in mice over the time spent in licking the hindpaw after formalin injection. The interaction was evaluated by simultaneous administration of fixed proportions of S-methylisothiourea with each COX inhibitor and the nature of the interaction was determined by isobolographic analysis.

RESULTS: Each drug alone produced a dose-dependent suppression of the late stage of formalin-induced behaviors with rank order of potency being rofecoxib > mefenamic acid > S-methylisothiourea. Isobolographic analysis of the combination of S-methylisothiourea with rofecoxib or mefenamic acid revealed a synergistic interaction. The experimental ED50 of the combination was significantly lower than the theoretical additive ED50 of the corresponding drug combination that substantiated the synergistic interaction between iNOS or NO and COX isoforms.

CONCLUSIONS: Our results explicitly indicate the synergistic nature of the interaction between NOS and COX inhibitors in formalin-induced nociceptive behavior in mice, and provide an alternative approach for controlling pain.


改良乳房根治术术后罗哌卡因连续伤口浸润麻醉与单次椎旁神经阻滞的比较

A Prospective Comparison of Continuous Wound Infiltration with Ropivacaine Versus Single-Injection Paravertebral Block After Modified Radical Mastectomy

Tatiana Sidiropoulou, MD*, Oreste Buonomo, MD{dagger}, Eleonora Fabbi, MD{ddagger}, Maria Beatrice Silvi, MD{ddagger}, Georgia Kostopanagiotou, MD*, Alessandro Fabrizio Sabato, MD{ddagger}, and Mario Dauri, MD{ddagger}

From the *Second Department of Anesthesiology, University of Athens, Attikon Hospital, Athens, Greece; {dagger}Thoracic Surgery Division, Tor Vergata University, Rome, Italy; and {ddagger}Department of Anesthesiology and Intensive Care, Tor Vergata University, Rome, Italy.

Anesth Analg 2008 106: 997-1001.

背景:连续浸润麻醉与胸段椎旁神经阻滞用于乳房手术后的效能至今未作过对比研究。在这个研究中,作者评估乳房切除术后两者的镇痛作用和吗啡镇痛用量。

方法:48名接受腋窝切开改良乳房根治术患者随机接受0.5%罗哌卡因20ml的术前胸段椎旁神经阻滞或0.5%罗哌卡因连续性浸润麻醉,浸润麻醉的输注速度为2ml/h,方式是在术毕时放置两根导管在手术部位的皮下,导管留置术后24小时。所有患者都接受全身麻醉。记录术后24h吗啡用量,疼痛评分和疼痛限制的肩关节活动,以及并发症的发生率,包括术后恶心呕吐。

结果:两组的吗啡用量相近。两者疼痛评分均较低。术后4h,胸段椎旁神经阻滞组在术后疼痛与疼痛限制性活动方面较轻,而在术后16h24h,连续性局部浸润麻醉组优于胸段椎旁神经阻滞组。连续性局部浸润麻醉组中术后恶心呕吐的发生率相对频繁。

结论:腋窝切开乳房切除术后,连续性伤口局部浸润麻醉为较好的椎旁神经阻滞替换方法。

(陈伟 陈杰 校)

BACKGROUND: The efficacy of continuous wound infiltration with local anesthetic has not been compared with that of thoracic paravertebral block (PVB) after breast surgery. In this study, we evaluated the analgesic efficacy and morphine consumption of the two techniques after mastectomy.

METHODS: Forty-eight patients undergoing modified radical mastectomy with axillary dissection were randomly assigned to either a preoperative PVB with 20 mL of ropivacaine 0.5% (group PVB) or a continuous ropivacaine 0.5% infusion (CRI) at a 2 mL/h rate for each of two multilumen catheters placed subcutaneously at the end of the procedure (group CRI). The catheters were left in place for 24 h postoperatively. A standardized general anesthetic was administered to all patients. Postoperative morphine consumption, pain scores and painful restricted movement of the shoulder for 24 h postoperatively as well as incidence of adverse events, including postoperative nausea and vomiting, were recorded.

RESULTS: Morphine consumption was similar between groups (PVB: 42.6 ± 11 vs CRI: 38.7 ± 11 mg in 24 h, P = 0.225). Absolute pain scores were low in both groups. Four hours after surgery, group PVB showed a significant reduction in postoperative pain (PVB: 0 [0–10] vs CRI: 0 [0–30], P = 0.002) and reduced painful restricted movement (P = 0.004), whereas the CRI group had lower pain scores (PVB: 10 [0–30] vs CRI: 0 [0–20], P = 0.034) and painful restricted movement (P = 0.043) 16 and 24 h (PVB: 10 [0–30] vs CRI: 0 [0–30], P = 0.012) after surgery. Postoperative nausea and vomiting was significantly more frequent in the CRI group (P = 0.017).

CONCLUSIONS: Continuous wound infiltration of local anesthetics is an effective alternative to paravertebral analgesia after mastectomy with axillary dissection.

 

纤维蛋白原在颅缝早闭手术中的应用

Fibrinogen in Craniosynostosis Surgery

Thorsten Haas, MD*, Dietmar Fries, MD{dagger}, Corinna Velik-Salchner, MD*, Elgar Oswald, MD*, and Petra Innerhofer, MD*

From the Departments of *Anaesthesiology and Critical Care Medicine, and {dagger}General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008; 106:725-731

背景: 在颅缝早闭的修复过程中,由于大量失血和凝血因子的消耗及稀释常导致的凝血异常,所以建议运用冷沉淀物、新鲜冰冻血浆和血小板进行治疗。但是在大多数的欧洲国家冷沉淀物并不常备,新鲜冰冻血浆在纠正纤维蛋白原缺乏方面的有效性也很有限。我们报道了我们用人纤维蛋白原浓缩物(Hemocomplettan®)来改善儿童受损的纤维蛋白原聚合的经验。

方法: 我们从进行大颅面手术的连续九例小儿的麻醉记录单、用药记录、实验室和血栓弹力图(ROTEM®)数据库,回顾性收集例行凝血试验结果、ROTEM®、补液需要量、给予的人纤维蛋白原浓缩物和术后病程的数据。

结果: 九个小儿年龄为12822)个月,体重为9.5910kg,手术持续时间为6.44.57.2)小时,术中估计出血为估计血容量的80%49%92%),以上数据表示方法为中位数(25%75%百分位数)。由ROTEM®检测到的纤维蛋白素原聚合作用受损是稀释性凝血功能紊乱的主要根本问题。所有病例(如果需要)均通过反复给予人纤维蛋白原浓缩物(每次剂量30 mg/kg)而不输注冰冻新鲜血浆和血小板达到了有效的止血,且无不良反应。所有小儿均在术后几小时内顺利脱离机械通气,并尽快就能离开重症监护病房。

结论: 给予纤维蛋白原浓缩物可以有效改善小儿颅缝早闭手术中稀释性凝血病的主要根本问题,即纤维蛋白素原的聚合和总体的凝血强度。

(姜旭晖   马皓琳 李士通 校)

BACKGROUND: During craniosynostosis repair, massive blood loss, consumption and dilution of clotting factors often result in coagulopathy, for which cryoprecipitate, fresh frozen plasma (FFP), and platelets are recommended for treatment. However, cryoprecipitate is not available in most European countries, and the efficacy of FFP in correcting fibrinogen deficiency is limited. We report our experience with human fibrinogen concentrate (Hemocomplettan®) used to improve impaired fibrinogen polymerization in children.

METHODS: Results of routine coagulation tests, thrombelastometry (ROTEM®), transfusion requirements, administration of fibrinogen concentrate, and data on the postoperative course of nine consecutive children undergoing major craniofacial surgery were retrospectively collected from anesthesia protocols, medical charts, laboratory and ROTEM® databases.

RESULTS: The nine children aged 12 (8, 22) mo (median [25th, 75th percentile]), weighing 9.5 (9, 10) kg had a calculated blood loss of 80 (49, 92)% of calculated blood volume during the surgery lasting 6.4 (4.5, 7.2) h. Impaired fibrinogen polymerization detected by ROTEM® was the main problem underlying dilutional coagulopathy. In all cases, sufficient hemostasis was achieved without adverse effects by administering (if necessary), repeated doses of fibrinogen concentrates (each single dose 30 mg/kg) without FFP or platelet transfusions. All children were successfully weaned from mechanical ventilation within a few hours and were able to be discharged early from the Intensive Care Unit.

CONCLUSIONS: Administration of fibrinogen concentrate effectively improves fibrinogen polymerization and total clot strength, which were the main underlying problems of dilutional coagulopathy in children undergoing craniosynostosis surgery.


多功能衬垫式充气加温系统在近常温的体外循环下心脏外科手术中的效果

An Evaluation of a Full-Access Underbody Forced-Air Warming System During Near-Normothermic, On-pump Cardiac Surgery

Steven R. Insler, DO*{dagger}, Mohamed H. Bakri, MD, PhD{dagger}, Fady Nageeb, MD{ddagger}, Edward Mascha, PhD{dagger}§, Tomislav Mihaljevic, MD||, and Daniel I. Sessler, MD{dagger}

From the Departments of *Cardiothoracic Anesthesia, {dagger}Outcomes Research, §Quantitative Health Sciences, and ||Cardiovascular Surgery The Cleveland Clinic, Cleveland, Ohio; and {ddagger}Division of Anesthesia, Critical Care, and Comprehensive Pain Management, The Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2008; 106:746-750

背景:一种新的衬垫式充气加温系统已可用于心脏外科手术。本试验目的是验证在近常温体外循环手术中,标准体温保护联合衬垫式充气加温是否可以维持术中核心温度,减少停机后体温下降(体外循环停止后60min核心温度下降最多)。

方法:常规、非急症心脏外科手术患者随机分为两组:常规体温保护组(输液加温以及消极隔离,n=30)和常规保温联合使用积极的衬垫式充气加温系统(n=30 Arizant Healthcare Model 635, Eden Prairie, 明尼苏达州)。围术期用膀胱导管每15分钟记录核心体温。比较两组CPB前、CPB中及CPB后温度差异。

结果:由于各种原因4例患者数据被剔除,剩余常规处理组29例和充气加温组27例。两组最初温度相似,但充气加温组在体外循环开始时温度高于常规处理组(36.3°C ± 0.6°C35.7°C ± 0.7°C, P = 0.002)。两组体外循环中最低温度(充气组35.5°C ± 1.5°C比常规组35.3°C ± 1.3°C, P = 0.67)、体外循环结束时体温(36.7°C ± 0.4°C36.6°C ± 0.4°C, P > 0.99)及出手术室即刻的体温(36.5°C ± 0.4°C36.2°C ± 0.5°C, P = 0.36)均无差异。后下降两组也无显著差异(充气加温组0.03°C ± 0.54°C比常规组0.21°C ± 0.51°CP = 0.20)。

结论:在近常温体温管理中加入联合衬垫式充气加温系统能够显著提高体外循环前的体温,但对核心温度无更多的临床重要影响。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: A new underbody forced-air warming system is available for use during cardiac surgery. We tested the hypothesis combining underbody forced-air warming with standard thermal management would maintain intraoperative core temperature and reduce core temperature after-drop (largest decrease in core temperature in the 60 min after bypass) in patients undergoing near-normothermic cardiopulmonary bypass (CPB).

METHODS: Patients undergoing routine, nonemergent cardiac surgery were randomly assigned to routine thermal management (fluid warming and passive insulation, n = 30) or routine management supplemented by an active underbody forced-air system (n = 30; Arizant Healthcare Model 635, Eden Prairie, MN). Core body temperature was measured by bladder catheter at 15-min intervals during the perioperative period. Comparisons were made between groups for temperature before, during, and after CPB.

RESULTS: Data from four patients were excluded for cause, leaving 29 patients in the routine management group and 27 patients in the forced-air group. Initial temperatures were similar, but temperatures in the forced-air group were higher than in the routine group at the start of CPB (36.3°C ± 0.6°C vs 35.7°C ± 0.7°C, P = 0.002). There were no differences between groups in the lowest temperatures during CPB (forced air, 35.5°C ± 1.5°C vs routine, 35.3°C ± 1.3°C, P = 0.67); the end of CPB (36.7°C ± 0.4°C vs 36.6°C ± 0.4°C, P > 0.99); or the temperature at departure from the operating room (36.5°C ± 0.4°C vs 36.2°C ± 0.5°C, P = 0.36). After-drop was 0.03°C ± 0.54°C in patients randomized to underbody forced-air warming and 0.21°C ± 0.51°C in those assigned to routine management (P = 0.20).

CONCLUSIONS: Adding an underbody forced-air warming system to the near-normothermic thermal management protocol significantly increased pre-bypass temperature; however, it had no further clinically important effect on core temperature.


适用于以麻醉为基础的小儿慢性疼痛医疗方案的病儿群体的临床特点

A Clinical Profile of a Cohort of Patients Referred to an Anesthesiology-Based Pediatric Chronic Pain Medicine Program

Thomas R. Vetter, MD, MPH

From the Department of Anesthesia, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.

Anesth Analg 2008; 106:786-794

背景:小儿慢性疼痛非常常见,且导致很多医疗费用,是个人和公众都关注的健康问题。本研究的主要目的是为建立一个适用于以麻醉为基础的小儿慢性疼痛治疗方案的病儿的描述性临床轮廓。我们打算将这个病人轮廓充当为需要评估的更正式人群的替代者。

方法:本研究使用定量观察方法。独立研究变量包括初步的疼痛相关诊断、疼痛症状的持续时间、病人年龄、病人性别、保险状态、完整的生物学家系单位、全日制学校出勤率、在家学习及抑郁和/或焦虑共病。用以往研究证实很有效的一系列测量仪表,从属的研究变量包括病人自述的疼痛程度、病人自述或家长代述的健康相关的生活质量、不良家庭影响和父母满意度。研究资料的收集发生于到慢性疼痛医疗诊所初诊时,但和医护人员接触前。

结果:研究对象(n = 100)大多是青少年女性,其慢性疼痛持续时间大于1年,疼痛常伴有临床上明显的焦虑和抑郁。与国家和州立标准比较,生物学家系单位不完整 (P < 0.001)、不能参加全日制学校的学习 (P < 0.001)和需要家居教育(P < 0.001) 的百分比显著不成比例。95%的本群患儿先前至少由一个其他亚专科治疗过其慢性疼痛状况。平均患儿自述或家长代述的健康相关生活质量评分(PedsQL总分)也明显低于以前在风湿病患儿(P < 0.0001)、偏头痛患儿(P < 0.0001)和癌症患儿 (P < 0.0001) 观察到的PedsQL分值。

结论:患有慢性疼痛的病儿在接受麻醉为基础的慢性疼痛治疗计划之前,大多接受过其他亚专科的治疗,其健康相关的生活质量明显较低。用常规方法估计慢性疼痛患儿健康相关的生活质量非常简便,而且有实际意义。还需要将注意力集中于病儿应对机制的能力的连贯描述、有无使疼痛增强或减轻的父母行为,以及已经存在的父母疼痛和残疾。

(张莹译  马皓琳 李士通校)

BACKGROUND: Pediatric chronic pain is very common and results in significant health care costs. Pediatric chronic pain is both an individual and a public health concern. The primary objective of this study was to generate a descriptive clinical profile of the patients referred to an anesthesiology-based pediatric chronic pain medicine program. This patient profile was intended to serve as a surrogate for a more formal population needs assessment.

METHODS: A quantitative observational study design was applied. The independent study variables included the primary pain-related diagnosis, duration of pain symptoms, patient age, patient sex, insurance status, an intact biological family unit, fulltime school attendance, home schooling, and comorbid depression and/or anxiety. Using a series of previously well-validated measurement instruments, the dependent study variables included self-reported chronic pain intensity, self-reported and parent proxy-reported health-related quality of life, adverse family impact, and parental satisfaction. Study data collection occurred at the time of the first visit to the pediatric chronic pain medicine clinic but before interacting with any health care provider.

RESULTS: The enrolled patients (n = 100) were predominantly adolescent females, whose chronic pain had persisted for >1 yr and whose pain was frequently accompanied by clinically significant anxiety and depression. As compared with national and state norms, a significantly disproportionate percentage had a nonintact biological family unit (P < 0.001), was not attending school fulltime (P < 0.001), and was intentionally being home-schooled (P < 0.001). Ninety-five percent of the present cohort of patients had previously been under the care of at least one other subspecialist for their chronic pain condition. The mean initial patient self-reported and initial parent proxy-reported health-related quality of life scores (PedsQL Total Score) were also significantly lower than the PedsQL Total Score values previously observed in pediatric rheumatology patients (P < 0.0001), pediatric migraine patients (P < 0.0001), and pediatric cancer patients (P < 0.0001).

CONCLUSIONS: Pediatric chronic pain patients previously under the care of another subspecialist and subsequently referred to an anesthesiology-based pediatric chronic pain medicine program seemed to be experiencing significantly worse health-related quality of life. The routine assessment of chronic pain-related pediatric health-related quality of life seems feasible and worthwhile. Attention also needs to be focused on consistently addressing the strength of a patient's coping mechanisms, the presence of pain-promoting versus pain-reducing parental behaviors, and preexisting parental pain and disability.



女性病人和孩子行手术的母亲术前焦虑的比较

A Comparison of Preoperative Anxiety in Female Patients with Mothers of Children Undergoing Surgery

Jill MacLaren, PhD*{dagger}, and Zeev N. Kain, MD, MBA*{dagger}{ddagger}

From the *Center of the Advancement of Perioperative Health® and the {dagger}Departments of Anesthesiology, Pediatrics, and Child Psychiatry, Yale University School of Medicine, New Haven, Connecticut and the {ddagger}Depatment of Anesthesiology, University of California Irvine, Irvine, California.

Anesth Analg 2008; 106:810-813

我们比较了孩子行门诊手术的母亲和自己行手术的女性病人的焦虑。我们发现母亲与行腹部较大手术的病人有相似的焦虑,而与行较小手术的病人相比更为焦虑。母性焦虑的预测因素是孩子的年龄和母性的监护应对。

(彭中美 马皓琳 李士通 校)

We compared anxiety in mothers of children undergoing ambulatory surgery with female patients undergoing surgery themselves. We found that mothers were as anxious as patients undergoing major abdominal surgery and more anxious than patients undergoing minor surgery. Predictors of maternal anxiety were child age and maternal monitoring coping.



大鼠的肝脏缺血再灌注损伤模型中七氟醚与异氟醚麻醉的肝能量代谢及其不同的保护效应

Hepatic Energy Metabolism and the Differential Protective Effects of Sevoflurane and Isoflurane Anesthesia in a Rat Hepatic Ischemia-Reperfusion Injury Model

Nurdan Bedirli, MD*, Ebru Ofluoglu, PhD{dagger}, Mustafa Kerem, MD{ddagger}, Gulten Utebey, MD*, Murat Alper, MD§, Demet Yilmazer, MD§, Abdulkadir Bedirli, MD{ddagger}, Onur Ozlu, MD*, and Hatice Pasaoglu, MD{dagger}

From the *Department of Anesthesiology, Diskapi Training and Research Hospital; Departments of {dagger}Biochemistry and {ddagger}General Surgery, Gazi University Medical School; and §Department of Pathology, Diskapi Training and Research Hospital, Ankara, Turkey.

Anesth Analg 2008; 106:830-837

背景:我们研究了异氟醚和七氟醚对加温的肝缺血再灌注(IR)模型中的细胞因子、肝组织的血流(HTBF)、贮能量及肝脏结构的影响。

方法:72Wistar鼠随机分成3组:对照组,不进行吸入麻醉;七氟醚组,2%的七氟醚;异氟醚组,1.5%的异氟醚。在进行吸入麻醉30分钟后,使这些大鼠肝缺血45分钟及2小时和4小时的再灌注。在缺血期末、再灌注2小时、再灌注4小时分别处死一部分鼠。通过检测天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)、HTBF、丙二醛、肿瘤坏死因子(TNF-{alpha}、白细胞介素(IL)-1β、能荷以及组织学检查来评估肝脏损伤的程度。

结果:对照组和异氟醚组血清丙氨酸转氨酶和天冬氨酸转氨酶的水平相似,而七氟醚组在缺血后阶段明显降低(P < 0.01)。七氟醚组的HTBF显著优于异氟醚组,而对照组较差。组织的丙二醛水平在再灌注2小时后七氟醚组明显低于异氟醚组,而在对照组的缺血后阶段达到最大值。在缺血后、再灌注2小时和4小时中,肿瘤坏死因子-{alpha}及白细胞介素-1β在七氟醚组最低,在对照组最高,但是没有统计学意义(P > 0.05)。在七氟醚组,肝的三磷酸腺苷和能荷在所有测量时间点都明显较高。在七氟醚及异氟醚组内,在缺血后阶段的能荷比较低。七氟醚组的肝细胞损伤程度最小。

结论:在肝脏缺血前、缺血时、缺血后给予临床上适当浓度的七氟醚都能很好的保护肝脏免于缺血再灌注损伤,而异氟醚对肝缺血再灌注损伤的效应不是很显著。

(唐亮   马皓琳 李士通 校)      

BACKGROUND: We investigated the effects of isoflurane and sevoflurane in a warm liver ischemia-reperfusion (IR) model on cytokines, hepatic tissue blood flow (HTBF), energy content, and liver structure.

METHODS: Seventy-two Wistar rats were randomly assigned into 1 of 3 groups: Control group, no volatile anesthetics; sevoflurane group, 2% sevoflurane; isoflurane group, 1.5% isoflurane. Thirty minutes after the start of volatile anesthetics, rats were subjected to 45 min hepatic ischemia and 2 and 4 h of reperfusion. Rats were killed at the end of ischemia, 2 and 4 h of reperfusion. Aspartate aminotransferase and alanine aminotransferase, HTBF, malondialdehyde, tumor necrosis factor (TNF)-{alpha}, interleukin (IL)-1β, energy charge, and histologic examination were used to evaluate the extent of liver injury.

RESULTS: Serum alanine aminotransferase and aspartate aminotransferase levels were similar in control and isoflurane groups while there was a significant decrease in the sevoflurane group in the postischemic period (P < 0.01). HTBF was remarkably better in the sevoflurane group than in the isoflurane group and worse in the control group. Tissue malondialdehyde levels were significantly low in the sevoflurane group compared with the isoflurane group at 2 h of reperfusion (P < 0.05) and reached its maximum value in the postischemic period in the control group. After ischemia, 2 and 4 h of reperfusion, tumor necrosis factor-{alpha} and interleukin-1β values were lowest in the sevoflurane group and highest in the control group but it was not statistically significant (P > 0.05). In the sevoflurane group, hepatic adenosine triphosphate and energy charge were significantly high at all measurement times. At the postischemic period, energy charge was lower compared with the sevoflurane and isoflurane groups. The degree of hepatocyte injury was small in the sevoflurane group.

CONCLUSIONS: Clinically relevant concentrations of sevoflurane given before, during, and after hepatic ischemia protected the liver against IR injury, whereas the effects of isoflurane on hepatic IR injury were not notable.




高血糖减弱异氟烷在血管平滑肌细胞中诱导的ATP敏感的钾通道激活作用

Hyperglycemia Impairs Isoflurane-Induced Adenosine Triphosphate-Sensitive Potassium Channel Activation in Vascular Smooth Muscle Cells

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

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

Anesth Analg 2008; 106:858-864

背景:异氟烷激活血管ATP敏感钾(KATP)通道,并可引起血管扩张。本研究中,我们探讨高血糖是否改变异氟烷对血管KATP通道的激活作用。

方法:血管平滑肌细胞分别在含正常葡萄糖(NG, 5.5 mM右旋糖)l-葡萄糖(LG, 5.5 mM右旋糖加 17.5 mM 左旋糖)或高葡萄糖(HG, 23 mM右旋糖)的培养基中孵育24h后,我们使用细胞粘附式的膜片钳方法测试异氟烷对KATP通道活性的影响。主动脉中的过氧化物水平通过光泽精增强的化学发光技术进行测定。

结果:NG0.17 ± 0.02)和LG0.15 ± 0.02)相比,HG0.06 ± 0.01)孵育的动脉血管平滑肌细胞中异氟烷诱导的开放概率明显减少(P < 0.05)。蛋白激酶CPKC)的抑制剂(钙磷酸蛋白CPKC抑制剂20–28)预处理血管平滑肌细胞明显减少HG对异氟烷诱导KATP通道活性的抑制作用。同时,PKC的激活剂PMA可模拟HG的作用。HG孵育的动脉中过氧化物释放明显增加(18.3 ± 11.5相对光单位(RLU· s–1 · mg–1; NG比较P < 0.05)。用一种细胞渗透性过氧化物清除剂聚乙烯乙二醇-过氧化物歧化酶(250 U/mL)同时孵育,显著减少HG诱导的过氧化物的增加,但无法减少HG对异氟烷诱导KATP通道活性的抑制作用。

结论:我们的实验结果提示高血糖的代谢性应激可以削弱异氟烷诱导的血管KATP通道激活作用(经过度激活PKC介导)。在围术期高血糖患者中,这可能妨碍其冠状动脉对异氟烷的舒张反应从而导致缺血或缺氧。

(黄施伟 译,马皓琳 李士通 校) 

BACKGROUND: Isoflurane activates vascular adenosine triphosphate sensitive potassium (KATP) channels, and may induce vasodilation. In the present study, we investigated whether hyperglycemia modifies isoflurane activation of vascular KATP channel.

METHODS: We used a cell-attached patch-clamp configuration to test the effects of isoflurane on KATP channel activity in vascular smooth muscle cells (VSMCs) after incubation for 24 h in medium containing normal glucose (NG, 5.5 mM d-glucose), l-glucose (LG, 5.5 mM d-glucose plus 17.5 mM l-glucose), or high glucose (HG, 23 mM d-glucose). Superoxide levels in aortas were measured by the lucigenin-enhanced chemiluminescence technique.

RESULTS: Isoflurane-induced open probabilities were significantly reduced in VSMCs from arteries incubated in HG (0.06 ± 0.01) compared with NG (0.17 ± 0.02; P < 0.05) and LG (0.15 ± 0.02; P < 0.05). Pretreatment of VSMCs with protein kinase C (PKC) inhibitors, calphostin C and PKC inhibitor 20–28, greatly reduced HG inhibition of isoflurane-induced KATP channel activity. In addition, a PKC activator, PMA, mimicked the effects of HG. Superoxide release was significantly increased in arteries incubated in HG (18.3 ± 11.5 relative light units (RLU) · s–1 · mg–1; P < 0.05 versus NG). Coincubated with polyethylene glycol-superoxide dismutase (250 U/mL), a cell-permeable superoxide scavenger, greatly reduced the HG-induced increase of superoxide, but failed to reduce HG inhibition of isoflurane-induced KATP channel activity.

CONCLUSIONS: Our results suggest that the metabolic stress of hyperglycemia can impair isoflurane-induced vascular KATP channel activity mediated by excessive activation of PKC. This could impede the coronary vasodilation response to isoflurane, causing ischemia or hypoxia in patients with perioperative hyperglycemia.


志愿者中光谱预测听觉知晓

Spectral Entropy Predicts Auditory Recall in Volunteers

Daryn H. Moller, MD, and Ira J. Rampil, MS, MD

From the Departments of Anesthesiology and Neurological Surgery, University Hospital, Stony Brook, New York.

Anesth Analg 2008; 106:873-879

背景资料:从一个病人的角度看,术中记忆丧失是全麻的一个重要部分。在没有特异性的方法来减少术中知晓的情况下,其发生率在普外科手术人群中约为0.2%,且可能在某些亚人群中会更高。我们尝试检验了一种新的以光谱为基础的临床脑电图监测仪预测知晓的有效性。

方法:我们用非盲交叉设计对16名志愿者进行研究,来评价丙泊酚或七氟醚镇静过程中,光谱与行为指标之间的相关性。我们考虑到的指标包括单词知晓和对于口头指令的运动反应。同时我们测定了口头指令对脑电图的刺激性作用。用对数回归、受试者操作特性以及预计概率来分析数据。

结果:状态和反应与两个反应指标均密切相关。在多种情况下这些参数的预计概率范围在0.850.96之间。口头指令运动反应以剂量和药物依赖性方式增高

结论:在这群年轻健康的志愿者中熵参数看来是预测知晓的可靠指标。这些研究结果认为将这些研究延伸到其他麻醉药和手术病人是合理的。

(沈浩   马皓琳 李士通 校)

 

BACKGROUND: From a patient's perspective, intraoperative amnesia is an essential component of general anesthesia. Without specific strategies to reduce recall, its incidence is approximately 0.2% in the general surgical population and may be higher in certain subpopulations. We sought to test the validity for predicting recall of a new spectral entropy-based clinical electroencephalogram monitor.

METHODS: We studied 16 volunteers in an unblinded crossover design to assess the correlation of entropy values with behavioral end points during sedation with either propofol or sevoflurane. The end points we considered included word recall, and motor response to verbal command. We also examined the stimulatory effect of verbal commands on electroencephalogram entropy. Logistic regression, receiver operating characteristics, and prediction probability were used to analyze the data.

RESULTS: Both State Entropy and Response Entropy were closely correlated with both behavioral end points. The prediction probability of these parameters under a variety of conditions ranged from 0.85 to 0.96. Verbal command to move increased entropy in a dose and drug-dependent fashion.

CONCLUSIONS: Entropy parameters in this group of young, healthy volunteers appear to be reliable predictors of recall. These results justify extending these studies to additional anesthetics and to surgical patients.


母体儿茶酚胺对妊娠子宫微血管内径的影响

The Effect of Maternal Catecholamines on the Caliber of Gravid Uterine Microvessels

Scott Segal, MD, and Steven Y. Wang, MD, PhD

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008; 106:888-892

背景:伴随着分娩镇痛起效的母体儿茶酚胺改变包括肾上腺素(EPI)减少,但是去甲肾上腺素(NE)不变。因为在循环浓度中EPIβ肾上腺能作用为主,而NEα肾上腺能作用为主,因此我们推断这样的改变会引起子宫小动脉的收缩。

方法:18只临产Sprague-Dawley大鼠中分离出来的子宫微血管(内径73–120 µm),在保持近于正常气压的无流量状态下用电镜观察。腔外给药到表面灌流储水池,并记录血管稳态下的内径。分别建立NENE中加入肾上腺素能拮抗剂哌唑嗪、EPI(类血栓素U46619预收缩血管20%30%后)及EPI中加入β肾上腺素能拮抗剂普萘洛尔和10–8 M EPI存在时给予NE的剂量效应曲线。洗出试验模拟分娩镇痛起效过程中母体儿茶酚胺的变化:同时加入10–8 MEPI 10–6.5 MNE (EC50)后只用NE洗,接着用β2肾上腺素能激动剂特布他林和NE。洗出规程在有普萘洛尔存在的情况下再重复一遍。

结果:NE引起剂量依赖性的血管收缩(P < 0.0001),可以被哌唑嗪阻断(P < 0.0001)EPI加到经过U46619预收缩的微血管后,在低浓度时可以引起血管扩张,高浓度时引起血管收缩(P < 0.0001)。普萘洛尔可以逆转这种单相的剂量依赖性血管收缩反应(P < 0.0001)。用10–8 M EPI预处理没有经过预收缩的血管,可以显著减弱NE引起的血管收缩作用(P < 0.0001)。在洗出试验中,在NE持续存在的情况下,除出EPI可以引起血管收缩,且这种收缩作用可以被特布他林逆转。普萘洛尔可以阻断EPI和特布他林的作用。

结论:这些结果表明,EPI在产妇血浆中发现的浓度下可以扩张子宫阻力血管,并减弱由NE引起的血管收缩作用。这个观察结果可能提示了人类孕妇分娩镇痛起效时伴随的子宫血流变化,因为有效的镇痛伴随着循环EPI水平的急性下降。

(黄佳佳译,马皓琳 李士通校)

BACKGROUND: Changes in maternal catecholamines that accompany the onset of labor analgesia include a decrease in epinephrine (EPI) but no change in norepinephrine (NE). Because EPI exerts predominantly β-adrenergic, and NE predominantly {alpha}-adrenergic effects in circulating concentrations, we hypothesized that these changes could lead to uterine arteriole vasoconstriction.

METHODS: Uterine microvessels (73–120 µm internal diameter, n = 18) were harvested from near-term pregnant Sprague-Dawley rats, isolated and studied in a pressurized no-flow state with video microscopy. Drugs were applied extraluminally to the superfusion reservoir and the steady-state vessel diameter recorded. Dose-response curves were constructed for NE with and without the addition of the {alpha}-adrenergic antagonist prazosin, EPI (after 20%–30% preconstruction with the thromboxane analog U46619) with and without the addition of the β-adrenergic antagonist propranolol, and NE in the presence of 10–8 M EPI. Washout experiments modeled the changes in circulating maternal catecholamines observed during onset of analgesia: 10–8 M EPI and 10–6.5 M of NE (the EC50) were added simultaneously, then washed with NE only, and then with the β2-adrenergic agonist terbutaline and NE. The washout protocol was repeated in the presence of propranolol.

RESULTS: NE caused dose-dependent vasoconstriction (P < 0.0001), which was blocked by prazosin (P < 0.0001). EPI, added to U46619-preconstricted microvessels, caused vasodilation at lower concentrations and vasoconstriction at higher doses (P < 0.0001). Propranolol converted this response to monophasic dose-dependent vasoconstriction (P < 0.0001). Pretreatment of nonprecontracted vessels with EPI, 10–8 M, significantly attenuated NE-induced vasoconstriction (P < 0.0001). In washout experiments, removal of EPI with continued presence of NE resulted in vasoconstriction that was reversed by terbutaline. Propranolol blocked the effect of both EPI and terbutaline.

CONCLUSIONS: The results demonstrate that EPI, in concentrations found in the plasma of laboring women, vasodilates uterine resistance vessels and attenuates NE-induced vasoconstriction. This observation may have implications for changes in uterine blood flow that may accompany the onset of labor analgesia in human parturients, as effective analgesia is accompanied by an acute decrease in circulating EPI levels.



一过性脑缺血对加压素诱导的兔脑血管收缩的影响

The Effects of Transient Cerebral Ischemia on Vasopressin-Induced Vasoconstriction in Rabbit Cerebral Vessels

 

Masahiko Kumazawa, MD*, Hiroki Iida, MD*, Masayoshi Uchida, MD{dagger}, Mami Iida, MD{ddagger}, Motoyasu Takenaka, MD*, Naokazu Fukuoka, MD*, Tomohiro Michino, MD*, and Shuji Dohi, MD*

From the *Department of Anesthesiology and Pain Medicine, Gifu University Graduate School of Medicine, Gifu City, Gifu, Japan; {dagger}Department of Anesthesiology and Critical Medicine, Oregon Health and Science University, Portland, Oregon; and {ddagger}Department of Cardiology, Gifu University Graduate School of Medicine; Gifu City, Gifu, Japan.

Anesth Analg 2008; 106:910-915

背景:加压素是一种心肺复苏时选用的药物,因为一些实验研究已显示,其在增加全身组织的灌注压和改善脑灌注压且不增加心肌氧耗方面优于肾上腺素。我们使用软膜窗孔制品,观察加压素局部用于兔软膜血管上时的作用及兔脑缺血后作用是否改变(n = 27)

方法:我们首先检验局部应用精氨酸加压素(AVP) (10–11 M10–9 M10–7 M10–5 M,连续地)的作用。然后我们通过颈部驱血带充气加全身性低血压,或单纯全身性低血压导致脑缺血5分钟,并观察脑缺血前后局部应用AVP(10–9 M10–7 M, 连续地)的作用。

结果(a)10–11 M AVP可扩张软膜小动脉的直径[7% ± 11% (P = 0.014 与基础值比较)],但10–9 M10–7 M10–5 M AVP可收缩软膜小动脉直径[分别为7% ± 14%20% ± 14%16% ± 16% (P < 0.05)](b)低血压前可收缩软膜小动脉直径(10–9 M AVP 收缩7% ± 10%, 10–7 M AVP收缩20% ± 15%),缺血前可收缩软膜小动脉直径(10–9 M AVP 收缩7% ± 11%10–7 M AVP 收缩21% ± 15% )。然而,缺血后5分钟,由10–7 M AVP引起的血管收缩作用明显下降,但不单是由于低血压[低血压对照组:10–9 M AVP 收缩7% ± 10%10–7 M AVP 收缩19% ± 14%;缺血组:10–9 M AVP 收缩5% ± 11%10–7 M AVP 收缩10% ± 13%(P = 0.35 与低血压组对照)]

结论AVP的局部应用(这里使用的最低浓度除外)可引起麻醉兔软膜小动脉浓度依赖性血管收缩。在短暂(5分钟)的脑缺血后,10–7 M AVP的血管收缩作用减少。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: Vasopressin is a drug of choice for use during cardiopulmonary resuscitation because several experimental studies have shown that it is better than epinephrine at increasing systemic perfusion pressure and improving cerebral perfusion pressure without increasing myocardial oxygen consumption. We used a pial window preparation to determine the effects of vasopressin when applied topically to pial vessels and whether any effects were altered after cerebral ischemia in rabbits (n = 27).

METHODS: We first examined the effects of topical application of arginine-vasopressin (AVP) (10–11 M, 10–9 M, 10–7 M, and 10–5 M, sequentially). We then examined the effects of topical application of AVP (10–9 M and 10–7 M, sequentially) before and after a 5-min intervention consisting of cerebral ischemia produced by inflation of a neck tourniquet plus systemic hypotension or systemic hypotension alone.

RESULTS: Pial arteriolar diameters were (a) dilated by 10–11 M AVP [7% ± 11% (P = 0.014 versus baseline)], but constricted by 10–9 M, 10–7 M, and 10–5 M AVP [7% ± 14%, 20% ± 14%, and 16% ± 16% (each P < 0.05), respectively], and (b) constricted before hypotension (7% ± 10% at 10–9 M, 20% ± 15% at 10–7 M) or ischemia (7% ± 11% at 10–9 M, 21% ± 15% at 10–7 M). However, after the 5-min of ischemia, the decrease in diameter induced by 10–7 M AVP was significantly reduced but not by hypotension alone [hypotension control group: 7% ± 10% at 10–9 M, 19% ± 14% at 10–7 M; ischemia group: 5% ± 11% at 10–9 M, 10% ± 13% at 10–7 M (P = 0.35 versus hypotension control)].

CONCLUSIONS: Topical application of AVP (except at the lowest concentration used here) induced concentration-dependent vasoconstriction of pial arterioles in anesthetized rabbits. The vasoconstrictor effect of 10–7 M AVP was reduced after transient (5-min) cerebral ischemia.



在接受异丙酚复合芬太尼麻醉的患者中神经肌肉阻滞水平对强直后运动诱发电位的幅度和经颅刺激的运动反应的影响

The Effects of the Neuromuscular Blockade Levels on Amplitudes of Posttetanic Motor-Evoked Potentials and Movement in Response to Transcranial Stimulation in Patients Receiving Propofol and Fentanyl Anesthesia

Yuri Yamamoto, MD*, Masahiko Kawaguchi, MD*, Hironobu Hayashi, MD*, Toshinori Horiuchi, MD*, Satoki Inoue, MD*, Hiroyuki Nakase, MD{dagger}, Toshisuke Sakaki, MD{dagger}, and Hitoshi Furuya, MD*

From the Departments of *Anesthesiology and {dagger}Neurosurgery, Nara Medical University, Nara, Japan.

Anesth Analg 2008; 106:930-934

背景:监测肌源性运动诱发电位(MEPs)过程中患者对经颅刺激的活动反应可能干扰手术。我们最近报道了一种可以增强肌源性MEPs幅度的新技术叫做“强直后MEPs(p-MEPs)”,该技术在经颅刺激前给予外周神经强直刺激。我们进行本研究来确定集中于患者运动的p-MEPs监测中神经肌肉阻滞的适当水平。

方法:15名异丙酚/芬太尼麻醉患者,记录拇展肌对经颅电刺激反应的传统MEPs (c-MEPs)p-MEPs。记录p-MEPs时,在经颅刺激前6秒先给予胫后神经一个50mA强度、持续5秒的强直刺激。通过记录对腕部正中神经超强电刺激的反应中的拇外展短肌复合肌肉动作电位(T1)的幅度来评估神经肌肉阻滞的水平。记录T1为对照值的50%时的c-MEPp-MEP基线后,注射0.1 mg/kg维库溴铵并记录c-MEPsp-MEPs幅度。用范围为14的运动评分评估患者运动(1=没有运动,4=剧烈运动)。

结果:T1%T1c-MEPsp-MEPs的幅度及运动评分在给予维库溴铵后平行改变。在维库溴铵投药前和投药后1545分钟p-MEPs的幅度比c-MEPs明显高。当T1和%T1分别小于和等于1mV10%时,所有患者的运动评分为12,提示显微镜手术是能做得到的,而不会干扰手术操作。当T11 mV (0.8–1.2 mV)左右时,记录c-MEPsp-MEPs的成功率分别是73% (11/15)100% (15/15)

结论:异丙酚/芬太尼麻醉下,T11mV时可以记录p-MEP,这时患者对经颅刺激的运动反应不会干扰手术。这种技术可以用于不存在术前运动缺陷的患者,否则在手术操作中的患者运动不太可取。

(唐李隽 马皓琳 李士通校)

BACKGROUND: Patient movement in response to transcranial stimulation during monitoring of myogenic motor-evoked potentials (MEPs) may interfere with surgery. We recently reported a new technique to augment the amplitudes of myogenic MEPs, called "post-tetanic MEPs (p-MEPs)," in which tetanic stimulation of a peripheral nerve was applied prior to transcranial stimulation. We conducted the present study to determine an appropriate level of neuromuscular blockade during the monitoring of p-MEPs with a focus on patient movement.

METHODS: In 15 patients under propofol/fentanyl anesthesia, conventional MEPs (c-MEPs) and p-MEPs in response to transcranial electrical stimulation were recorded from the abductor hallucis muscle. For p-MEP recording, tetanic stimulation to the posterior tibial nerve at an intensity of 50 mA for 5 s was started 6 s prior to transcranial stimulation. The level of neuromuscular blockade was assessed by recording the amplitude of compound muscle action potentials (T1) from the abductor hallucis brevis muscle in response to supramaximal electrical stimulation of the median nerve at the wrist. After the baseline recordings of c-MEP and p-MEP at a T1 of 50% of control, 0.1 mg/kg of vecuronium was injected and the amplitudes of c-MEPs and p-MEPs were recorded. Patient movement was also assessed with the movement score ranging from 1 to 4 (1 = no movement, 4 = severe movement).

RESULTS: T1, %T1, the amplitudes of c-MEPs and p-MEPs, and the movement score changed in parallel after the administration of vecuronium. The amplitudes of p-MEPs before and 15–45 min after the administration of vecuronium were significantly higher than those of c-MEPs. When T1 and %T1 were less than and equal to 1 mV and 10%, respectively, the movement score was 1 or 2 in all patients, indicating that microscopic surgery was possible without the interruption of surgical procedures. When T1 was around 1 mV (0.8–1.2 mV), the success rates of recording of c-MEPs and p-MEPs were 73% (11 of 15) and 100% (15 of 15), respectively.

CONCLUSIONS: Under propofol/fentanyl anesthesia, p-MEP could be recorded at a T1 of 1 mV, in which patient movement in response to transcranial stimulation did not interfere with surgery. This technique may be used in patients without preoperative motor deficits, in which patient movement during surgical procedures is not preferable.


塞来考昔围手术期给药与仅仅在术后给药对接受大的整形外科手术病人术后影响的比较

Perioperative Versus Postoperative Celecoxib on Patient Outcomes After Major Plastic Surgery Procedures

 

Tiffany Sun, BS*{dagger}, Ozlem Sacan, MD*{dagger}, Paul F. White, PhD, MD, FANZCA*{dagger}, Jayne Coleman, MD*{dagger}, Rod J. Rohrich, MD, FACS*{dagger}, and Jeffrey M. Kenkel, MD, FACS*{dagger}

From the Departments of *Anesthesiology and Pain Management, and {dagger}Plastic Surgery; University of Texas Southwestern Medical Center at Dallas, Dallas, Texas.

Anesth Analg 2008; 106:950-958

背景围手术期应用环氧合酶(COX)-2抑制剂一直有着争议。有一种假设是在大整形手术的术前或者术后应用塞来考昔并且在手术后连续应用三天能提高病人镇痛效果以及改善临床预后,我们设计这次随机、双盲、安慰剂对照实验的目的就是为了证明这一假设。这次实验的另外一个目的是为了弄清围手术期应用塞来考昔是否比单单在术后应用更有优势。

方法:120名接受大的整形外科手术(比如隆胸,腹壁成形术)的知情同意过的病人施行标准全身麻醉,被随机分成了下面三组:1)对照组(n=40)术前和术后分别口服两粒安慰剂,并且在术后三天口服安慰剂,一粒BID2)术后给药组(n=40)术前口服两粒安慰剂,术后口服两粒塞来考昔(一粒200mg),术后三天口服塞来考昔,一粒200mg BID3)围手术期给药组n=40)术前3090分钟口服两粒塞来考昔(一粒200mg),术后口服两粒安慰剂,术后三天口服塞来考昔,一粒200mg BID。术后每隔一定时间记录下患者的疼痛评分、对镇痛药的需求以及不良反应。在手术后的第244872小时以及第七天随访评价患者的出院后疼痛、镇痛需求、肠功能的恢复、日常活动的恢复、康复的质量以及病人对疼痛控制的满意程度。

结果:与对照组相比,应用塞来考昔的两组在术后首个三天在减少术后疼痛以及对阿片类镇痛药的需求上有着相似且明显的效果(P < 0.01)。在应用塞来考昔的两组中,病人肠功能和日常活动的恢复时间分别比对照组早1天和2天。另外,在应用塞来考昔的两组中,病人对疼痛控制和康复质量的满意度明显比对照组提高(P < 0.05)

结论:手术当天以及术后三天口服塞来考昔400mg能有效改善大的整形外科手术病人术后的控制疼痛以及康复速度和质量。然而,围手术期给药与仅仅在术后给药相比并没有优势。

(吴进   马皓琳 李士通 校)

BACKGROUND: Controversy continues to surround the use of cyclooxygenase (COX)-2 inhibitors in the perioperative period. We designed this randomized, double-blind, placebo-controlled study to examine the hypothesis that administration of celecoxib preoperatively or postoperatively and for 3 days after major plastic surgery would improve pain control and clinically important patient outcomes. Another objective of the study was to determine whether perioperative administration of celecoxib offered any advantages over postoperative administration alone.

METHODS: One hundred and twenty healthy consenting patients undergoing major plastic surgery (e.g., breast augmentation, abdominoplasty procedures) using a standardized general anesthetic technique were randomized to one of three treatment groups: 1) control group (n = 40) received two placebos orally before and after surgery, as well as one placebo BID for 3 days after surgery; 2) postoperative group (n = 40) received two placebos before surgery and 2 celecoxib 200 mg po after surgery, followed by one celecoxib 200 mg po BID on postoperative day #1, #2 and #3; and 3) perioperative group (n = 40) received 2 celecoxib 200 mg po 30–90 min before surgery, and two placebos after surgery, followed by one celecoxib 200 mg po BID on postoperative day #1, #2, and #3. Pain scores, the need for rescue analgesics, and side effects were recorded at specific time intervals in the postoperative period. Follow-up evaluations were performed at 24, 48, 72 h, and 7 days after surgery to assess postdischarge pain, analgesic requirements, return of bowel function, resumption of normal daily activities, quality of recovery, as well as patient satisfaction with pain management.

RESULTS: Compared with the control group, the two celecoxib groups had similar significant reductions in postoperative pain and need for opioid analgesics during the first three postoperative days (P < 0.01). Patients recovered bowel function 1 day earlier and resumed normal activities 2 days earlier in the celecoxib groups. In addition, patient satisfaction with pain management and quality of recovery were significantly improved in the celecoxib (versus control) groups (P < 0.05).

CONCLUSION: Celecoxib (400 mg po) administered on the day of surgery and for 3 days postoperatively is effective in improving postoperative pain management, as well as the speed and quality of recovery after major plastic surgery. However, perioperative administration offers no advantages over simply giving the drug after surgery.



鞘内注射环氧化酶-1抑制剂、环氧化酶-2抑制剂或非选择性抑制剂对疼痛行为和脊髓Fos样免疫反应的影响

The Effects of Intrathecal Cyclooxygenase-1, Cyclooxygenase-2, or Nonselective Inhibitors on Pain Behavior and Spinal Fos-Like Immunoreactivity

Il Ok Lee, MD, PhD, and Youngsun Seo, MD, PhD

From the Departments of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.

Anesth Analg 2008; 106:972-977

背景:前列腺素由环氧化酶(COX)合成,被认为在伤害性感受在脊髓的传递中起重要作用。Fos的表达是脊髓神经元活化的指标。我们检验了鞘内注射选择性和非选择性COX抑制剂对脊髓C-Fos表达的影响。

方法:为检验COX-1COX-2在脊髓伤害性感受传递中的相对作用,我们检测了选择性COX-1抑制剂SC560、选择性COX-2抑制剂塞来考昔和非选择性COX抑制剂酮咯酸对福尔马林诱发的行为和脊髓类c-Fos免疫反应(FLI)的影响。大鼠在后爪足底皮下注射福尔马林(5%50μL)前分别鞘内注射上述药物(306090µg)。对照组在注射福尔马林前鞘内注射溶剂。

结果:给予塞来考昔或酮咯酸90µg的大鼠第一相缩爪行为减少,给予各剂量酮咯酸或90µg塞来考昔的大鼠第二相缩爪行为减少(P < 0.05)。给予塞来考昔或酮咯酸90µg的大鼠脊髓第I–II层区FLI明显减少(P < 0.05)。相反,在脊髓第V–VI层区仅酮咯酸60µg90µg组出现FLI的大量减少(P < 0.05)。在脊髓第V–VI层区的FLI表达与第二相缩爪行为有显著相关性((P < 0.05)

结论:COX-1COX-2的双效抑制剂既抑制福尔马林诱发的行为也抑制脊髓腰段各区FLI表达。FLI在脊髓第I–II层区的表达可能不是药物产生抗-超敏反应能力的良好指标,而FLI在脊髓第V–VI层区的表达与第二相行为反应相关。

(颜涛 译,马皓琳 李士通 校)

BACKGROUND: Prostaglandins are synthesized by cyclooxygenase (COX) and are thought to play an important role in nociceptive transmission in the spinal cord. Fos expression is an indicator of spinal neuron activation. We examined the role of intrathecal selective and nonspecific COX inhibitors on spinal C-Fos expression.

METHODS: To evaluate the relative contribution of COX-1 and COX-2 in nociceptive transmission in the spinal cord, we assessed the effects of the selective COX-1 inhibitor SC 560, the selective COX-2 inhibitor celecoxib, and the nonselective COX inhibitor ketorolac on formalin-evoked behavior and spinal c-Fos-like immunoreactivity (FLI). Rats received each of the drugs (30, 60, or 90 µg) intrathecally before the subcutaneous administration of formalin (5%, 50 µL) to the plantar surface of a hindpaw. The control group received vehicle intrathecally before the administration of formalin.

RESULTS: Phase 1 flinching behavior decreased in rats given celecoxib or ketorolac 90 µg. Phase 2 flinching behavior decreased in rats given all doses of ketorolac or celecoxib 90 µg (P < 0.05). The FLI was significantly reduced in rats given celecoxib or ketorolac 90 µg for laminae I–II (P < 0.05). By contrast, for laminae V–VI, only the ketorolac 60 or 90 µg treatment group demonstrated a larger decrease in FLI (P < 0.05). The FLI expression in laminae V–VI had a significant correlation with phase 2 flinching behavior (P < 0.05).

CONCLUSIONS: A dual inhibitor of COX-1 and COX-2 suppressed both responses of formalin-evoked behaviors and FLI expression of whole laminae in the lumbar spinal cord. FLI expression of laminae I–II alone may not be a good indicator of the ability to produce anti-hypersensitivity; however, the FLI of laminae V–VI correlates with phase 2 responses.


患者自控持续斜角肌间沟阻滞能促进开放性肩部手术后的早期功能康复吗?

Does Patient-Controlled Continuous Interscalene Block Improve Early Functional Rehabilitation After Open Shoulder Surgery?

Klaus Hofmann-Kiefer, MD*, Tim Eiser, MD*, Daniel Chappell, MD*, Stephan Leuschner, MD{ddagger}, Peter Conzen, MD*, and Dirk Schwender, MD{dagger}

From the *Clinic of Anesthesiology/Critical Care Medicine and Pain Therapy (M.A.B., P.C.), Ludwig-Maximilians-University, City of Munich, Germany; {dagger}Department of Anesthesia, Municipal Hospital Friedrichshafen, City of Friedrichshafen, Germany; and {ddagger}Department of Anesthesia, Municipal Hospital Luebeck, City of Luebeck, Germany.

Anesth Analg 2008; 106:991-996

背景:肩部手术后早日活动在成功的功能康复中起重要作用。然而,术后疼痛常减少甚至妨碍有效的物理治疗。我们研究了开放性肩部手术后由患者自控斜角肌间沟阻滞技术产生的镇痛对早期功能康复的影响。

方法:87例患者随机分成两组:患者自控持续斜角肌间沟阻滞组(patient-controlled continuous interscalene block PCISB)和患者自控静脉(阿片类)镇痛组(patient-controlled analgesiaPCA)。术前行斜角肌间沟阻滞,另外镇痛方案在麻醉后监护室中开始进行并持续72小时。术后第23天每天进行60min标准化物理治疗。最大活动度被定义为在疼痛这个限制因素下所能达到的活动范围。在术前1天和术后3天用能评估疼痛、日常生活活动、运动的力度和范围的多模式评分系统(常数评分)来评价功能康复的效果。还通过术后72h和院内物理治疗过程中的视觉模拟评分来监测最大疼痛强度。

结果:斜角肌间沟阻滞的常数评分等级显著提高。然而,两组间可动性和力量亚评分无显著差异。与PCA比较,6hP < 0.001)、24h P = 0.044)和72h P = 0.013)时的静息疼痛评分以及术后48h时物理治疗过程中的疼痛评分(P = 0.016) 证明PCISB更有效。

结论:与基于阿片类的PCA比较,PCISB改善镇痛,但不促进肩关节早期功能恢复。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Early mobilization after shoulder surgery plays a vital role in successful functional rehabilitation. However, postoperative pain often reduces, or even prevents, effective physiotherapy. We investigated the effect of analgesia via patient-controlled interscalene technique on early functional rehabilitation after open shoulder surgery.

METHODS: Eighty-seven patients were randomly assigned to one of two groups: patient-controlled continuous interscalene block (PCISB) and patient-controlled IV (opioid) analgesia (PCA). Interscalene block was performed preoperatively; otherwise analgesic protocols were started in the postanesthesia care unit and were continued for 72 h. Physiotherapy was performed for 60 min a day on day 2 and 3 after surgery according to a standardized protocol. Maximum mobility was defined as the range of motion that could be achieved with pain as the limiting factor. Efficiency of functional rehabilitation was evaluated 1 day before and 3 days after surgery with the help of a multimodal scoring system (Constant-Score) that evaluates pain, daily life activity, strength and range of motion. Maximum intensity of pain was also monitored via Visual Analog Scales for the first 72 h after surgery and during in-hospital physiotherapy.

RESULTS: Constant-Score rates were significantly improved by the interscalene block. However, no significant differences in mobility and strength sub-scores were observed between the groups. Compared with PCA, PCISB proved to be beneficial concerning pain at rest at 6 h (P < 0.001), 24 h (P = 0.044), and 72 h (P = 0.013) and for pain during physiotherapy at 48 h after surgery (P = 0.016).

CONCLUSION: Compared with opioid-based PCA, PCISB improved analgesia, but not function, during early rehabilitation of the shoulder joint.




鼻部手术中左旋布比卡因局部浸润的收缩血管和镇痛作用

Vasoconstriction and Analgesic Efficacy of Locally Infiltrated Levobupivacaine for Nasal Surgery

Yavuz Demiraran, MD*, Ozcan Ozturk, MD{dagger}, Ender Guclu, MD{dagger}, Abdulkadir Iskender, MD*, Mehmet Hakan Ergin, MD*, and Abdurahman Tokmak, MD{dagger}

From the Departments of *Anesthesiology, and {dagger}Otorhinolaryngology, University of Duzce, Duzce Faculty of Medicine, Duzce, Turkey.

Anesth Analg 2008; 106:1008-1011

背景:在此项研究中,我们比较了切皮前给予行鼻部手术的病人2%利多卡因加肾上腺素(LA)和单纯0.25%左旋布比卡因(LB)以术后镇痛和收缩血管。  

方法:60例病人随机分组,接受全麻下切皮前局部浸润。LB组接受0.25%左旋布比卡因,LA组接受2%利多卡因加肾上腺素(增加容量注射)。记录术中血流动力学变化、术前和术后血红蛋白和红细胞压积值。记录所有患者术后30分钟及1281224小时的视觉模拟标度(VAS)评分和最初24小时里再予镇痛治疗的需要。

结果:在术后30分钟和12812小时时,LB组的VAS评分低于LA组(分别为P < 0.0001P = 0.002P = 0.023P < 0.0001P = 0.011)。与LA组比较,LB组镇痛药的需要显著降低(P=0.038)。LB组的术前和术后血红蛋白和红细胞压积值有显著差异性(P=0.0140.025)。LA组的术前和术后血红蛋白和红细胞压积值有显著差异性(P = 0.0310.024)

结论:我们认为,在鼻部手术中左旋布比卡因局部浸润比利多卡因加肾上腺素的术后镇痛作用显著增加和持续时间更长。

(胡湘   马皓琳 李士通 校)

BACKGROUND: In this study, we compared the use of preincisional lidocaine 2% with epinephrine (LA) and levobupivacaine 0.25% plain (LB) for postoperative analgesia and vasoconstriction in patients undergoing nasal surgery.

METHODS: Sixty patients were randomly assigned to receive preincisional local infiltration under general anesthesia. Group LB received levobupivacaine 0.25%, and group LA received epinephrine plus lidocaine 2% (add volume injected). Intraoperative hemodynamic changes, pre- and postoperative hemoglobin and hematocrit values were recorded. Visual analog scale values 30 min and 1, 2, 8, 12, and 24 h postoperatively and the need for rescue analgesic treatment in the first 24 h of all patients was recorded.

RESULTS: At 30 min and 1, 2, 8, and 12 h postoperatively, visual analog scale values were lower in group LB than in group LA (P < 0.0001, P = 0.002, P = 0.023, P < 0.0001, and P = 0.011, respectively). The analgesic requirement was significantly lower in group LB when compared with that in group LA (P = 0.038). Group LB had significant differences between preoperative and postoperative hemoglobin and hematocrit values (P = 0.014 and 0.025). Group LA had significant differences between preoperative and postoperative hemoglobin and hematocrit values (P = 0.031 and 0.024).

CONCLUSIONS: We conclude that postoperative analgesia in nasal surgery with local infiltration of levobupivacaine was significantly more potent and longer lasting than that achieved by lidocaine plus epinephrine.

 

抗凝血酶对VIII因子缺乏血浆中重组激活VII因子凝血效应的影响

Antithrombin Affects Hemostatic Response to Recombinant Activated Factor VII in Factor VIII Deficient Plasma

Fania Szlam, MMSc*, Taro Taketomi, MD*, Chelsea A. Sheppard, MD{dagger}, Christine L. Kempton, MD{ddagger}, Jerrold H. Levy, MD*, and Kenichi A. Tanaka, MD, MSc* From the Departments of *Anesthesiology, {dagger}Pathology and {ddagger}Hematology/Oncology, Emory University School of Medicine, Atlanta, Georgia.

Anesth Analg 2008 106: 719-724.

 

背景rFVIIa(重组激活VII因子)用于外伤和接受外科手术的病人时易有血栓形成的并发症,但在血友病人身上却很少见。他们的出血体质和凝血酶形成减少有关,而rFVIIa可以促进凝血酶的形成。一般来说,从破损血管弥散出来的凝血酶很快被抗凝血酶(AT)灭活。评估AT水平对高凝后VIII因子缺乏的血浆中凝血酶形成的影响有助于更好的理解促凝因子如rFVIIa因子如何导致术后病人血栓形成。我们假设AT浓度的降低会增强VIII因子缺乏血浆中rFVIIa的促凝效应。

方法:利用血栓弹力图和凝血酶化验的方法做活体内比照研究VIII因子缺乏血浆和VIII因子/AT缺乏血浆中凝血酶的形成。评估加入的rFVIIa对这两组效应的差别

结果:正如所料VIII因子缺乏的血浆中基于血栓弹力图的血栓延迟形成的现象被rFVIIa所逆转。当AT为正常值的20%-50%时,血栓形成加快,对rFVIIa的反应也得到强化。VIII因子缺乏的血浆中凝血酶形成和AT水平成负相关。补充的rFVIIa缩短凝血酶形成的延后时间,但对凝血酶形成的总量没有影响。

结论:利用缺乏VIII因子的血浆作为凝血酶形成受抑模型,论证了活体内低AT水平增强rFVIIa的凝血效应。FVIII水平正常或升高的外伤和手术病人的AT减少被认为有潜在的血栓形成倾向。因此非血友病人接受FVIII治疗期间监测AT水平有助于减少血栓形成的并发症。

(孙鹏飞译 薛张纲校)

BACKGROUND: Thromboembolic complications can occur with recombinant activated factor VII (rFVIIa) treatment in trauma and surgical patients but they are infrequent in hemophiliacs. Bleeding diathesis in these conditions is often attributed to reduced thrombin generation, which may be improved with rFVIIa. Normally, thrombin that diffuses from local vascular injury sites is quickly inactivated by antithrombin (AT). Evaluating the influence of AT levels on thrombin generation in hypocoagulable FVIII-deficient plasma would be a simple approach to better understand how procoagulant stimuli, such as rFVIIa, might result in postoperative thrombotic complications. We hypothesize that reduced AT concentrations would increase the procoagulant effects of rFVIIa in FVIII-deficient plasma.

METHODS: Thrombin generation was evaluated in vitro in FVIII-deficient and AT/FVIII-deficient plasma using thrombelastography and a thrombin generation assay (ThrombinoscopeTM). The effect of added rFVIIa on these variables was evaluated.

RESULTS: Delayed thrombus formation based on thrombelastography in FVIII-deficient plasma was predictably reversed by rFVIIa. Improved thrombus formation and responses to rFVIIa were observed when AT levels were 20%–50% of normal. Thrombin generation in FVIII-deficient plasma increased in an inverse relationship to AT levels. Supplemental rFVIIa decreased the lag time of thrombin generation but not the amount of thrombin generated.

CONCLUSIONS: Using FVIII-deficient plasma as a model of reduced thrombin generation, we demonstrate that low AT levels enhance in vitro hemostatic responses to rFVIIa. Reduced AT levels in trauma and surgical patients with normal or increased FVIII levels may be considered potentially prothrombotic. Monitoring of AT levels during rFVIIa therapy may thus reduce thrombotic complications in nonhemophiliacs.

 

限制性复温和术后低温在大鼠体外循环模型中对认知功能的作用

The Effect of Limited Rewarming and Postoperative Hypothermia on Cognitive Function in a Rat Cardiopulmonary Bypass Model

Fellery de Lange, MD*, Wilbert L. Jones, MD*, George Burkhard Mackensen, MD, PhD*, and Hilary P. Grocott, MD, FRCPC*

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

Anesth Analg 2008 106: 739-745.

 

背景:临床研究未能证明低温对预防体外循环( CPB )术后认知功能障碍( pocd )有显着的好处 。有一种解释为,也许是发生在CPB的结尾再加热期间潜在地有害大脑极高热,抵销低体温症的防护好处。在这项研究中,我们调查了CPB温度的相对影响,再加热战略和在鼠CPB模型的手术后温度

方法:四组雄性大鼠经手术准备,并受到90分钟的体外循环。 A组为常温( 37.5 )期间和之后体外循环。 B组进行了低温( 32 ° C )的体外循环,在最后分流术时复温至37.5 °C C组低温( 32 °C )的体外循环,再是有限复温至35 ℃之间。 D组有常温体外循环与术后低温( 35 ° C )诱导。依据术后3-9天在水迷宫中的表现比较各组的pocd。病理分析大脑( CA1区和CA3海马区)也是一个依据。

结果:仅仅在( B组与A组)或体外循环后( D组与A组)低温诱导对改善无明显好处。低温诱导在体外循环并持续到术后时期对POCD产生了一个显着的改善,在水迷宫表现相对于其他所有温度regimens C组与A组, P0.044 C组与B组, P0.011 C组与组发展, P值为0.012 在各小组中的组织病理学区别中未被展示。

结论 低体温(32°C) CPB加上有限再加热和长时期的手术后低体温(35°C)减少大鼠CPB术后POCD的发生

(章一静译 薛张纲校)

BACKGROUND: Clinical studies have failed to demonstrate significant benefits of hypothermia for the prevention of postoperative cognitive dysfunction (POCD) after cardiopulmonary bypass (CPB). One explanation for this might be that potentially injurious cerebral hyperthermia occurs during rewarming at the end of CPB, off-setting the protective benefits of hypothermia. In this study, we investigated the relative influence of CPB temperature, rewarming strategies, and postoperative temperature in a rat CPB model.

METHODS: Four groups of male Sprague-Dawley rats were surgically prepared and subjected to 90 min of CPB. Group A was normothermic (37.5°C) during and after CPB. Group B underwent hypothermic (32°C) CPB, followed by rewarming to 37.5°C at the end of bypass. Group C had hypothermic (32°C) CPB, followed by limited rewarming to 35°C. Group D had normothermic CPB with hypothermia (35°C) induced only postoperatively. Groups were compared for POCD determined by the performance in the Morris water maze on postoperative days 3–9. Histologic analysis of the brains (CA1 and CA3 hippocampal regions) was also performed.

RESULTS: Hypothermia induced only during (group B versus group A) or after CPB (group D versus group A) conferred no significant POCD benefit. Hypothermia when induced during CPB and continued into the postoperative period resulted in a significant improvement in water maze performance versus all other temperature regimens (group C versus group A, P = 0.044; group C versus group B, P = 0.011; group C versus group D, P = 0.012). No histological differences among groups were demonstrated.

CONCLUSIONS: The combination of hypothermic (32°C) CPB coupled with limited rewarming and prolonged postoperative hypothermia (35°C) decreased POCD after CPB in rats.

 

肺扩张和呼吸末正压通气在使用机械通气的小儿麻醉中的效果

The effect of lung expansion and positive end-expiratory pressure on respiratory mechanics in anesthetized children

Athanasios G. Kaditis, MD*{dagger}, Etsuro K. Motoyama, MD*{ddagger}, Walter Zin, PhD§, Nobuhiro Maekawa, MD{ddagger}||, Isuta Nishio, MD{ddagger}, Taiyo Imai, MD*, and Joseph Milic-Emili, MD#

 From the *Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; {dagger}Department of Pediatrics, University of Thessaly School of Medicine, Larissa, Greece; {ddagger}Department of Anesthesiology University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; §Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; ||Department of Anesthesiology, Kobe University School of Medicine, Kobe, Japan; ¶Department of Anesthesiology, University of WA, Seattle, Washington; #Meakins-Christie Laboratories, Department of Physiology, McGill University Faculty of Medicine, Montreal, Quebec, Canada.

Anesth Analg 2008 106: 775-785

 

背景:影像研究提示儿童全身麻醉时易引起肺膨胀不全。扶助呼吸及呼吸末正压通气有利于预防肺膨胀不全。然而儿童在全麻过程中的生理改变未得到阐明。

方法:在八个麻醉时使用机械通气的儿童中(平均年龄:3.5岁;范围2.3-6.5),我们测定平静呼吸时的顺应性(E(st))和气流阻力(R(int)),及在使用恒定流量和吸气末阻塞扶助呼吸时因组织的粘弹性所致的顺应性及阻力(分别计为deltaEdeltaR),包括0呼吸末压及5cmH2O呼吸末压进行比较。

结果:当吸气流量(V(I))恒定及终末零压通气时,吸气末肺容量(总容量V(T))由8ML/kg增加致20ML/kg,导致E(st)1.06cmH2O/mL降到0.82cmH2O/mL, deltaE0.160.09R(int)0.13cmH2O/mL*s*kg0.11cmH2O/mL*s*kg,然而deltaR0.08增加至0.12P<0.05)。与使用呼吸末正压通气的结论相似。吸气流量(V(I))8ML/kg增至26ML/kg及吸气末肺容量(VT))恒定,终末零压通气时,E(st)1.09cmH2O/mL降到0.9cmH2O/mL, deltaR0.170.06P<0.01),但是R(int)deltaE没有改变。呼吸末正压通气时顺应性和阻力对吸气流量和肺容量有相似的依赖性。

结论:在总容量增加(增至16mL/kg加呼吸末正压通气)时E(st)稳定下降提示当呼吸末正压通气时呼气末舒张容量(功能残气量)显著下降。终末零压通气和呼吸末正压通气时结论相似提示扶助呼吸和氧气-氮气通气可以预防气道闭塞。

(胡艳译 薛张刚校)

BACKGROUND: Imaging studies have shown that general anesthesia in children results in atelectasis. Lung recruitment total lung capacity (TLC) maneuvers plus positive end-expiratory pressure (PEEP) are effective in preventing atelectasis. However, physiological changes in children during general anesthesia have not been elucidated.

METHODS: In eight anesthetized and mechanically ventilated children (median age: 3.5 years; range: 2.3-6.5), we measured static respiratory system elastance (E(st)), flow resistance (R(int)), and elastance and resistance components resulting from tissue viscoelasticity (deltaE and deltaR, respectively) using the constant inflow, end-inspiratory occlusion method preceded by TLC maneuvers, both with zero PEEP (ZEEP) and PEEP (5 cm H2O) for comparison.

RESULTS: With constant inspiratory flow V(I) and ZEEP, increases in end-inspiratory lung volume above relaxation volume (tidal volume, V(T)) from 8 to 20 mL x kg(-1) resulted in decreases in E(st) from 1.06 to 0.82 cm H2O x mL(-1) x kg, deltaE from 0.16 to 0.09, and R(int) from 0.13 to 0.11 cm H2O x mL(-1) x s x kg, whereas deltaR increased from 0.08 to 0.12 (P < 0.05). Similar relationships were found with PEEP. Increases in V(I) (8 to 26 mL x s(-1) x kg) with constant V(T) and ZEEP resulted in decreases in E(st) from 1.09 to 0.9 and deltaR from 0.17 to 0.06 (P < 0.01), whereas deltaE and R(int) did not change. There was a similar flow and volume dependence of elastance and resistance with PEEP.

CONCLUSIONS: The observed steady decreases in E(st) with increasing V(T) (up to 16 mL/kg with PEEP) indicate marked reductions in end-expiratory relaxation volume (functional residual capacity) even with PEEP. Similarity in results with ZEEP and PEEP suggests that TLC-maneuvers and O2-N2 ventilation prevented airway closure throughout the study.

 

术前抑郁症的一种有效筛查工具:老年抑郁症评估简表

An efficient screening tool for preoperative depression: the Geriatric Depression Scale-Short Form

. Diana S. Bass, BS*, Deborah K. Attix, PhD, ABPP/ABCN*, Barbara Phillips-Bute, PhD{dagger}, and Terri G. Monk, MD, ABA{dagger}{ddagger}

From the *Division of Neurology, Division of Medical Psychology, Duke University Medical Center, {dagger}Department of Anesthesiology, Duke University Medical Center, and {ddagger}Department of Anesthesiology, Durham Veterans Affairs Medical Center, Durham, North Carolina.

Anesth Analg 2008 106: 805-809.

 

背景:抑郁症是一种在外科术前患者中高发的心理疾患,对多数患者的术后转归产生严重影响。因此,获得一种简单快捷的抑郁症筛查工具指导临床治疗和改善术后转归很有必要。

方法:本研究以非心外科手术外大型手术术前住院患者为研究对象,研究样本人群中术前抑郁症的患病率。同时,以老年抑郁症评估简表(GDS-SF)作为抑郁症的评估工具,将结果按年龄、性别分组,验证其与Beck抑郁量表(BSI)评估结果的相关性,以评估该简表作为筛查工具的可靠性。

结果:以BSI量表评估抑郁症,在1043名术前候选者组成的样本中,所获抑郁症患病率显著高于健康社区人群患病率。抑郁症女性发病较男性常见(P=0.02),老年人发病较中年和青少年少见(分别为P0.030.003)。此外,同一年龄组中,BDIGDS-SF的评估结果高度一致。

结论:上述数据再度证明术前人群抑郁症筛查的必要性,并证实,作为医生可选且可及的快速术前抑郁症评估工具,GDS-SF量表的评估结果可靠。

(黄凝译  薛张纲校)

BACKGROUND: Depression is highly prevalent in patients before surgery, and it has been widely shown to have a serious impact on their postoperative outcomes. It would therefore be desirable for physicians to obtain a quick, simple screen to evaluate depression to consider treatment of symptomatology and potentially optimize postoperative outcomes.

METHODS: In this study, we investigated the prevalence of depression in a presurgical inpatient sample undergoing major, noncardiac surgery. In addition, we sought to establish the Geriatric Depression Scale-Short Form (GDS-SF) as a valid screening tool for depression by examining its relationship to the Beck Depression inventory (BDI) by age and gender.

RESULTS: In our sample of 1043 presurgical candidates, prevalence of depression as established by the BDI was significantly higher than rates consistently found in healthy community samples. Depression was more common in women than in men (P = 0.02), and depression rates were lower in elders relative to middle-aged and younger groups (P = 0.003 and 0.003, respectively). In addition, we found that there was a high correlation between the BDI and the GDS-SF within each of the age groups.

CONCLUSIONS: These data further support the need for depression screens in presurgical populations and establish the validity of the GDS-SF as a valid quick assessment alternative available to physicians.

 

关于异丙酚合用70%氙与合用70%笑气时50%有效浓度(EC50)的比较

The Effective Concentration 50 (EC50) for Propofol with 70% Xenon Versus 70% Nitrous Oxide

Ahmed R. Barakat, MD, FRCA*, Markus N. Schreiber, MD{dagger}, Joachim Flaschar, Dipl.-Ing. (FH){dagger}, Michael Georgieff, MD{dagger}, and Stefan Schraag, MD* From the *Department of Perioperative Medicine, Golden Jubilee National Hospital, Clydebank, UK; and {dagger}Department of Anesthesiology, University of Ulm, Germany.

Anesth Analg 2008 106: 823-829.

 

背景:氙在麻醉中有许多成功应用,例如疼痛控制及器官保护。然而它的MAC70%,因此无法单独使用。在此,我们将异丙酚与氙合用达到50%95%有效麻醉时的用量与异丙酚合用笑气时进行比较。

方法:我们将75名无术前应用70%氙及70%笑气的女性患者随机分成2组,每组的第一位患者在麻醉诱导时予以吸氧及4.5 µg/mL靶浓度的异丙酚。用Dixon的上下来回法决定下一位患者的异丙酚浓度。异丙酚起效后,给予患者面罩吸氧气及70%氙或70%笑气15分钟。随后观察她们在切皮时及其后60秒内的反应,记录为运动或不动。应用概率分析比较异丙酚在各组的50%有效浓度及95%有效浓度(EC50EC95)。

结果:异丙酚合用70%氙的EC501.5µg/mLEC952.3 µg/mL。异丙酚合用70%笑气的EC50EC95分别为2.2 8.2 µg/mL。在相同有效浓度下,合用70%氙时异丙酚所需用量为合用70%笑气时的32%72%。听力觉醒在吸入氙时较吸入笑气时更易发生。

结论:氙比笑气更有效,但在切皮前后仍需合用少量催眠药以对抗刺激作用。

(施颖译 薛张纲校)

BACKGROUND: Xenon anesthesia has many favorable properties, such as pain modulation and organ protection. However, due to its MAC of 70%, it cannot be used as a sole anesthetic. We estimated the amount of propofol required to supplement xenon to produce adequate anesthesia in 50% and 95% of patients in comparison with nitrous oxide.

METHODS: We randomized 75 premedicated female patients to receive either 70% xenon or 70% nitrous oxide in oxygen supplemented by propofol target-controlled infusion anesthesia starting with 4.5 µg/mL for the first patient in each group. Dixon's up and down method was used to determine the propofol concentration for subsequent patients. After induction of anesthesia with propofol, patients breathed 70% xenon or 70% nitrous oxide in oxygen via a facemask for 15 min. They were then observed for movement in response to skin incision for 60 s after the incision and assigned as movers or nonmovers. Probit analysis was used to estimate the effective concentration 50% and 95% (EC50 and EC95) for propofol in both groups.

RESULTS: The EC50 for propofol with 70% xenon was1.5µg/mL and the EC95 was 2.3 µg/mL. The EC50 and EC95 values for propofol with nitrous oxide were 2.2 and 8.2 µg/mL, respectively. This implies a reduction of propofol requirements between 32% (EC50) and 72% (EC95) by xenon compared with nitrous oxide. The suppression of auditory evoked potentials was more pronounced with xenon than with nitrous oxide.

CONCLUSION: Xenon seems to be clinically more potent than nitrous oxide, but still requires minimal supplement of a hypnotic anesthetic to suppress noxious stimulation during and after skin incision.

 

异丙酚对人类5-HT3A受体的分子作用:通过相似的酚类衍生物增强和抑制

Molecular Actions of Propofol on Human 5-HT3A Receptors: Enhancement as Well as Inhibition by Closely Related Phenol Derivatives

Martin Barann, PhD, Isabelle Linden, PhD, Stefan Witten, PhD, and Bernd W. Urban, PhD

From the Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany.

Anesth Analg 2008 106: 846-857.

 

背景:5-HT3受体是与术后恶心和呕吐有关的兴奋性配体门控离子通道,它们能够被麻醉剂异丙酚抑制,相反,增强抑制性配体门控离子通道如r-氨基丁酸A型受体及甘氨酸受体的效应。为了研究这种完全相反的作用的分子机制,我们研究了异丙酚和其次级疏水衍生物2 -异丙基酚和苯酚对人体5-HT3A受体的作用。

方法:包含能够稳定转录5-HT3A受体亚基的cDNA的人类胚胎肾293细胞作为膜片钳(游离膜外面向外式膜片)。用快速溶解交换系统( 2毫秒)应用药物 ,其浓度通过高效液相色谱法测定。

结果:当应用至平衡状态(5 -羟色胺脉冲前60秒及脉冲期间),异丙酚能抑制人5-HT3A受体(IC50 = 18 ± 1.0 µM),令人惊异的是,在平衡时,次级疏水衍生物抑制 5-HT3A受体的效价与异丙酚相似(IC50 = 17 ± 3.2 µM),而苯酚的效价则很低 IC50 = 1.6 ± 0.2 mM)。在电流引出前改变给药持续时间, 然后在药物仍然存在时加入 5-HT,异丙酚的(平衡)效应有快慢两个过程([tau]IN-1 = 35 ms[tau]IN-2 = 4.8 s);2 -异丙基酚为[tau]IN-1 = 64 ms[tau]IN-2 = 6.6 s;苯酚为[tau]IN-1 < 10 ms[tau]IN-2 = 20.4 s。当与5-HT一同短时间内给药(开放式给药),异丙酚明显地抑制电流,加速5-HT诱导的脱敏作用 ,相反,2-异丙基酚和苯酚增强电流,减慢脱敏作用。慢脱敏作用也在5-HT的衍生物5-羟吲哚(1mM)上被观察到,苯却没有。当5-HT浓度从30降到3µM时,苯酚、2 -异丙基酚、异丙酚的快速效应更显著,而慢速效应则对5-HT不敏感。

结论:异丙酚被证实对5-HT3A受体至少有两种相互独立的作用,而在两种相关的较小分子的酚类衍生物中所看到的增强作用则不能被检测到。5-HT依赖和5-HT非依赖两种相互作用因为这三种药物而著称。从其疏水性来看,异丙酚的效价比期望的低。潜在机制似乎涉及酚羟基,疏水相互作用并和空间结构限制。

(宣丽真译 薛张纲校)

BACKGROUND: 5-Hydroxytryptamine type 3 (5-HT3) receptors are excitatory ligand-gated ion channels which are involved in postoperative nausea and vomiting. They are depressed by the anesthetic propofol, which, in contrast, enhances the activity of inhibitory ligand-gated ion channels such as [gamma]-aminobutyric acid type A receptors and glycine receptors. To investigate the molecular mechanisms responsible for these contrasting actions, we examined the kinetics of the action of propofol and its lesser hydrophobic derivatives 2-isopropylphenol and phenol on human 5-HT3A receptors.

METHODS: Human embryonic kidney 293 cells containing stably transfected cDNA of the human 5-HT3A receptor subunit were patch clamped (excised outside-out patches). Drugs were applied with a fast solution exchange system (within 2 ms) and their concentrations were determined by high performance liquid chromatography.

 

RESULTS: When applied in equilibrium (60 s before and during the 5-HT pulse), propofol inhibited human 5-HT3A receptors (IC50 = 18 ± 1.0 µM). In equilibrium, the less hydrophobic 2-isopropylphenol was surprisingly a similarly potent inhibitor of human 5-HT3A receptors (IC50 = 17 ± 3.2 µM), whereas phenol was considerably less potent (IC50 = 1.6 ± 0.2 mM). Varying the duration of drug application before currents were elicited, and then applying 5-HT still in the presence of the drug revealed that fast and slow processes contributed to the (equilibrium) effects of propofol ([tau]IN-1 = 35 ms and [tau]IN-2 = 4.8 s), 2-isopropylphenol ([tau]IN-1 = 64 ms and [tau]IN-2 = 6.6 s), and phenol ([tau]IN-1 < 10 ms, [tau]IN-2 = 20.4 s). When applied transiently together with 5-HT (open channel application), propofol depressed currents and accelerated the 5-HT-induced desensitization significantly, whereas, in contrast, 2-isopropylphenol and phenol increased currents and slowed desensitization. Slowed desensitization was also observed for 5-hydroxyindole (1 mM), a 5-HT derivative, but not for benzene. The fast effects of phenol, 2-isopropylphenol, and propofol were more pronounced when the 5-HT concentration was decreased from 30 to 3 µM, whereas the slow effects were not sensitive to 5-HT.

CONCLUSIONS: At least two separate inhibitory actions on 5-HT3A receptors could be identified for propofol, whereas the enhancing action seen for the two related smaller phenol derivatives could no longer be detected. 5-HT-dependent and 5-HT-independent interactions could be distinguished for all three drugs. Propofol was less potent than expected from its hydrophobic properties. Underlying mechanisms appear to involve the phenolic hydroxyl group, hydrophobic interactions, and steric restrictions.

 

用第二代动脉压波形仪对心脏手术病人评估心输出量的有效性

Cardiac Output Derived from Arterial Pressure Waveform Analysis in Patients Undergoing Cardiac Surgery: Validity of a Second Generation Device

Jochen Mayer, MD, Joachim Boldt, MD, Michael W. Wolf, MD, Johannes Lang, MD, and Stefan Suttner, MD

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum Ludwigshafen, Germany.

Anesth Analg 2008 106: 867-872.

 

背景:近来介绍过的一种能根据动脉波形来测定心输出量而不需要行有创监测(FloTrac/VigileoTM)的仪器仍备受争议。因此我们在心脏手术病人中设计了一个现况研究,通过与经肺动脉导管以间歇热稀释法测定心输出量的比较,来评价这种经改良的检测技术。

方法:40ASA分级为III级行冠脉搭桥(CPB)手术的病人被选入此项研究。经同步热稀释法及FloTrac/Vigileo仪分别在诱导后即刻(设时间为T1),行CPB之前(T2),行CPB之后(T3),关闭胸骨之后(T4),入ICU即刻(T5) ,及术后4h (T6)8h (T7)24h (T8) 测得心输出量(CO),再由体表面积换算得心输出指数(CI)。最后我们设定一个≤30%的差错率来作为该新方法与标准的热稀释法间的评判标准。

 

结果:我们共分析了所得的282对测量数据。经热稀释法测得的CI其范围从1.24.1 L /(min · m2) (平均2.5 ± 0.54 L /(min · m2))。偏倚和精确度(设精确度为偏倚的1.96个标准差)0.19 L /(min · m2) ± 0.60 L /(min · m2),显示在整个围手术期(T1–8) 用第二代动脉压波形仪评估CI其总的差错率为24.6%,而通过对单在手术期间(T1–4)ICU(T5–8)这两个亚组的分析,又可得出其差错率分别为28.3%20.7%

结论:在行冠脉搭桥手术的病人中,经改良的第二代半侵入式动脉波形仪在手术期间及手术后所测得的CI值,与以间歇热稀释法测定的CI值显示了很好的一致性。

(刘沁译 薛张纲校)

BACKGROUND: The performance of a recently introduced, arterial waveform-based device for measuring cardiac output (CO) without the need of invasive calibration (FloTrac/VigileoTM) has been controversial. We designed the present study to assess the validity of an improved version of this monitoring technique compared with intermittent thermodilution CO measurement using a pulmonary artery catheter in patients undergoing cardiac surgery.

METHODS: Forty ASA III patients scheduled for elective coronary artery bypass grafting with cardiopulmonary bypass (CPB) were studied. Simultaneous CO measurements by bolus thermodilution and the FloTrac/Vigileo device were obtained after induction of anesthesia (T1), before CPB (T2), after CPB (T3), after sternal closure (T4), on arrival in the intensive care unit (T5), 4 h (T6), 8 h (T7), and 24 h after surgery (T8). CO was indexed to the body surface area (cardiac index, CI). A percentage error of 30% or less was established as the criterion for method interchangeability.

RESULTS: Two hundred and eighty-two data pairs were analyzed. Thermodilution CI ranged from 1.2 to 4.1 L · min–1 · m–2 (mean 2.5 ± 0.54 L · min–1 · m–2). Bias and precision (1.96 sd of the bias) were 0.19 L · min–1 · m–2 and ± 0.60 L · min–1 · m–2, resulting in an overall percentage error of 24.6%. Subgroup analysis revealed a percentage error of 28.3% for data pairs obtained intraoperatively (T1–4) and 20.7% in intensive care unit (T5–8).

CONCLUSION: CI values obtained by the improved, second generation semiinvasive arterial waveform device showed good intraoperative and postoperative agreement with intermittent pulmonary artery thermodilution CI measurements in patients undergoing coronary artery bypass graft surgery.

 

食管部分切除术中胸段硬膜外应用布比卡因与静脉内肾上腺素输注对胃管引流的影响

The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy.

Omar Y. Al-Rawi, FRCA*, Stephen H. Pennefather, MRCP, FRCA*, Richard D. Page, FRCS{dagger}, Ishani Dave, FRCA*, and Glen N. Russell, FRCA*

From the Departments of *Anaesthesia and {dagger}Thoracic Surgery, Cardiothoracic Centre, Liverpool, United Kingdom.

 

Anesth Analg 2008 106: 884-887.

 

背景:胃管坏死是食管部分切除术后吻合口漏的一个主要原因。胃管末端吻合口处引流量的减少与吻合口漏有关。

方法:我们前瞻性的研究了术中胸段硬膜外应用布比卡因与之后肾上腺素的输注对血流动力学及胃管引流量的影响。

结果:给予硬膜外药物显著地减少了胃管末端吻合口引流量(P<0.01),输注肾上腺素后胃管引流量恢复到基线水平。

结论:胸段硬膜外布比卡因的给予会减少胃管末端吻合口处的引流量。

(刘婷洁译 薛张纲校)

BACKGROUND: Gastric tube necrosis is a major cause of anastomotic leak after esophagectomy. A correlation has been shown between reduced flux at the anastomotic end of the gastric tube and anastomotic leaks.

METHODS: We prospectively studied the effect of intraoperative thoracic epidural bupivacaine and subsequent adrenaline infusion on hemodynamics and flux in the gastric tube.

RESULTS: Administering the epidural bolus significantly decreased flux at the anastomotic end of the gastric tube (P < 0.01). Gastric flux was returned to baseline by an adrenaline infusion.

CONCLUSIONS: The administration of a thoracic epidural bolus may decrease flux at the anastomotic end of the gastric tube.

                                                                       

可乐定输注在志愿者中对区域脑血流分布的影响

The Effect of Clonidine Infusion on Distribution of Regional Cerebral Blood Flow in Volunteers

Vincent Bonhomme, MD, MSc*, Pierre Maquet, MD, PhD{dagger}{ddagger}, Christophe Phillips, PhD{dagger}, Alain Plenevaux, PhD{dagger}, Pol Hans, MD*, Andre Luxen, PhD{dagger}, Maurice Lamy, MD*, and Steven Laureys, MD, PhD{dagger}{ddagger} From the *University Department of Anesthesia and Intensive Care Medicine, CHU de Liege and CHR de la Citadelle, and {dagger}Cyclotron Research Center, and {ddagger}Department of Neurology, University of Liege and CHU de Liege, Liege, Belgium

Anesth Analg 2008 106: 899-909.

 

背景:a-2肾上腺素受体激动剂能通过它对蓝斑的作用在大脑的意识功能部分保留时起到快速而可逆的镇静作用。我们这次观察性研究的目的,就是想摹绘出哪些脑区的活动会被输注可乐定而影响,从而更好的了解它的作用区域,特别是了解它与镇静作用之间的关系。

方法:此次研究由六个ASA 评分I~II级的右利手志愿者参加。他们的脑电图被持续监测。在得到一个由扫描H215O活动所标定的基线之后,可乐定开始以6 10 µg · kg–1 · h–1的速率输注。于是就得到一个每8分钟为一间隔的由11个相似扫描结果组成的序列。与此同时测量受试者的血浆可乐定浓度。最后使用统计学的参数图形分析,找出标化的区域脑血流(rCBF),即该脑区活动的指示参数,与血浆中可乐定的浓度或脑电图梭形波之间的线性关系。

结果:可乐定能引起临床上的镇静作用以及脑电图波形变化(即出现梭波),这种波形与非快动眼睡眠早期的波形相类似。统计学分析后,发现在丘脑区、前额叶、眶上回及顶叶联合脑区大脑皮质、背扣带回大脑皮质、楔前叶,可乐定浓度与区域脑血流(rCBF,即脑电图出现梭形波)呈统计学意义的负线性相关关系。

结论:在可乐定诱发的镇静期间,我们观察到的脑电图变化以及某些脑区的区域脑血流减少,与非快动眼期睡眠中的脑电图与区域脑血流变化相似。同时受抑制的脑区的脑电图变化也与全麻期间以及植物人状态下的脑电图变化相似。这些发现都支持了这样一个假设,即在这些非自然的意识状态下,所发生的改变都是通过相同的作用网络发生的。

(秦敏菊译 薛张纲校)

BACKGROUND: Through their action on the locus coeruleus, a2-adrenoceptor agonists induce rapidly reversible sedation while partially preserving cognitive brain functions. Our goal in this observational study was to map brain regions whose activity is modified by clonidine infusion so as to better understand its loci of action, especially in relation to sedation.

METHODS: Six ASA I–II right-handed volunteers were recruited. Electroencephalogram (EEG) was monitored continuously. After a baseline H215O activation scan, clonidine infusion was started at a rate ranging from 6 to 10 µg · kg–1 · h–1. A sequence of 11 similar scans was then performed at 8 min intervals. Plasma clonidine concentration was measured. Using statistical parametric mapping, we sought linear correlations between normalized regional cerebral blood flow (rCBF), an indicator of regional brain activity, and plasma clonidine concentration or spindle EEG activity.

RESULTS: Clonidine induced clinical sedation and EEG patterns (spindles) comparable to early stage nonrapid eye movement sleep. A significant negative linear correlation between clonidine concentration and rCBF or spindle activity was observed in the thalamus, prefrontal, orbital and parietal association cortex, posterior cingulate cortex, and precuneus.

CONCLUSIONS: The EEG patterns and decreases in rCBF of specific brain regions observed during clonidine-induced sedation are similar to those of early stage nonrapid eye movement sleep. Patterns of deactivated brain regions are also comparable to those observed during general anesthesia or vegetative state, reinforcing the hypothesis that alterations in the activity of a common network occur during these modified conscious states.

 

肠道准备引起的脱水不会导致老年人认知功能障碍

Dehydration Induced by Bowel Preparation in Older Adults Does Not Result in Cognitive Dysfunction

Gareth L. Ackland, PhD, FRCA*, Jane Harrington, PhD{dagger}, Paul Downie, FRCA*, James W. Holding, FRCA*, Deepak Singh-Ranger, MRCS{ddagger}, Konstandina Griva, PhD§, Michael G. Mythen, MD, FRCA||, and Stanton P. Newman, PhD

 

From the *University College Hospital, London, and Centre for Anaesthesia, University College London; {dagger}Centre for Behavioural and Social Sciences in Medicine, University College London; {ddagger}Department of Surgery, University College London; §Centre for Behavioural and Social Sciences in Medicine, University College London, and Department of Psychology, Thames Valley University, London; ||Institute of Child Health, University College London; and ¶Centre for Behavioural and Social Sciences in Medicine, University College London, UK.

.Anesth Analg 2008 106: 924-929.

 

背景:术后认知功能障碍在接受非心脏手术的患者中有相当的发生几率,而老年病人尤为易患。我们假定,脱水这一老年患者常见的围手术期问题,可能引起认知功能障碍。我们利用无外科手术及麻醉干扰因素的病例来确定肠道准备引起的脱水是否会导致认知力改变。

方法:有38例处于术后认知功能障碍高发年龄段的患者参加我们的前瞻性研究。另有一个包括14位患者的对照组,接受肠镜检查,而不做任何肠道准备,按照年龄、教育程度和性别配对。

结果:接受肠道准备的患者出现总体重下降(1.5 kg [95% CI: 0.9–2.2]; P < 0.001),而接受肠镜检查的患者没有体重改变。通过足部生物电阻抗法测量出的总体液量显示,肠道准备组患者总体液量下降了2.6%,并且只有肠道准备组患者的红细胞压积上升(肠道准备前0.41 [0.40–0.43],肠道准备后0.43 [0.42–0.45]; P = 0.003)。在这种程度的脱水情况下,所有认知功能测验结果与总体样本平均值的差距小于一个标准差。重复测量的方差分析指出,在运动速度、执行功能、连线测验和记忆力方面没有显著的组内差异,只有在学习能力方面有3秒的延迟。脱水状态不影响学习(P = 0.42)、记忆力(P = 0.30)、运动速度(P = 0.36),以及执行功能测验(P = 0.26)

结论:仅仅脱水并不至引起认知功能障碍。

(夏俊明译  薛张纲校)

BACKGROUND: Postoperative cognitive dysfunction occurs in a proportion of patients after noncardiac surgery. Older patients are particularly vulnerable. We hypothesized that dehydration, a common perioperative problem in the elderly, may provoke cognitive dysfunction. We used a clinical scenario free of surgical/anesthetic intervention to determine whether dehydration caused by bowel preparation results in cognitive changes.

METHODS: Thirty-eight patients of an age associated with a significant incidence of postoperative cognitive dysfunction were recruited in a prospective observational study. A further control group of 14 patients undergoing sigmoidoscopy, who did not receive any bowel preparation, were matched for age, education, and gender.

RESULTS: Loss of total body weight (1.5 kg [95% CI: 0.9–2.2]; P < 0.001) occurred in patients undergoing bowel preparation (2.0 [95% CI: 1.3–2.6] percent total body weight), whereas sigmoidoscopy patients’ weight did not change (0.17 kg [95% CI: –0.2–0.6 kg]; P = 0.26). Total body water, derived from foot bioimpedance, indicated dehydration in the bowel preparation group only (mean impedance change 36 [Omega] [95% CI; 25–46], P < 0.001) with a calculated decrease of 2.6% in total body water (95% CI: 1.1–4.8; P < 0.001). Hematocrit increased after bowel preparation only (prebowel prep 0.41 [0.40–0.43] versus postbowel prep 0.43 [0.42–0.45]; P = 0.003). Despite this degree of dehydration, all cognitive tests were within 1 sd of the population mean of normal values. Repeated measures analysis of variance did not reveal significant changes for within group comparisons over time for motor speed (P = 0.51), executive function (P = 0.57), Trail Making Tests and recall (P = 0.88), other than a 3 s slowing in learning ability (Rey Auditory Verbal Learning Test; P = 0.04). Hydration status did not affect learning (P = 0.42), recall (P = 0.30) motor speed (P = 0.36), or executive function tests (P = 0.26).

CONCLUSION: Dehydration alone does not result in cognitive dysfunction.

 

 发展中国家的麻醉和相关学科的现状:一项赞比亚共和国的全国性调查

Anesthesia and Its Allied Disciplines in the Developing World: A Nationwide Survey of the Republic of Zambia

Stefan Jochberger, MD*, Feruza Ismailova, MD{dagger}, Wolfgang Lederer, MD*, Viktoria D. Mayr, MD*, Günter Luckner, MD*, Volker Wenzel, MD*, Hanno Ulmer, PhD{ddagger}, Walter R. Hasibeder, MD§, Martin W. Dünser, MD|| For the "Helfen Berührt" Study Team

From the *Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria; {dagger}Department of Anesthesiology and Critical Care Medicine, University Teaching Hospital, Lusaka, Republic of Zambia; {ddagger}Institute of Medical Biostatistics, Innsbruck Medical University, Innsbruck, Austria; §Department of Anesthesiology and Critical Care, Krankenhaus der Barmherzigen Schwestern, Ried im Innkreis, Austria; and |Department of Intensive Care Medicine, Inselspital, Bern, Switzerland.

Anesth Analg 2008 106: 942-948.

 

背景:全球的发展中国家有很多手术干预的治疗。为了改善这些国家手术病人的状况,有必要明确有关麻醉基本问题和病人的需求。通过这项调查,我们评估了赞比亚共和国的麻醉和相关学科(包括重症医学、急诊医学和疼痛治疗)的目前状态。

方法:问卷被分发至赞比亚卫生部注册过的87家医院。问卷分为5个部分111个问题:包括综合性医院的信息、麻醉、重症监护、急诊医学、和疼痛治疗。

结果:八分之六的问卷被统计了(78%)。最常见的手术是妇产科和腹部手术。氯胺酮是最常用于全身麻醉的药物(50%)。10%的病人实行气管插管进行全麻。在大多数医院(78%)没有专业医师进行麻醉。68个医院中只有5家(7%)有重症监护室,总共也只有29张床。麻醉医生几乎不参与急诊治疗和疼痛治疗。

结论:赞比亚共和国的医学处于极度落后和资源贫乏状态。

(陈珺珺译 薛张纲校)

 

BACKGROUND: Many surgical interventions worldwide are performed in developing countries. To improve survival of acutely and critically ill patients in these countries, basic problems and demands of anesthesia care need to be identified. Using this survey, we evaluated the current status of anesthesia and its allied disciplines (intensive care medicine, emergency medicine, and pain therapy) in the Republic of Zambia.

METHODS: Questionnaires were sent to 87 hospitals registered at the Zambian Ministry of Health as performing minor or major surgery. The questionnaire consisted of 111 questions grouped into five sections: general hospital information, anesthesia, intensive care, emergency medicine, and pain therapy.

RESULTS: Sixty-eight questionnaires could be statistically  evaluated (78%). The most common operations were obstetric/gynecological and abdominal surgical procedures. Dissociative ketamine anesthesia was the technique most often used for general anesthesia (50%). Endotracheal intubation was performed in 10% of patients undergoing general anesthesia. In most hospitals (78%), anesthesia was administered by non physicians. Only 5 of 68 hospitals (7%) reported having an intensive care unit, with 29 beds to serve the entire country. Anesthesiologists play almost no role in emergency medicine and pain therapy.

CONCLUSIONS: Anesthesia in the Republic of Zambia is a highly under-developed and under-resourced medical specialty.

 

吗啡鞘内注射抑制爪炎症性水肿:一氧化氮(NO)和环磷鸟苷(cGMP)的作用

Intrathecally Injected Morphine Inhibits Inflammatory Paw Edema: The Involvement of Nitric Oxide and Cyclic-Guanosine Monophosphate

Sara Comelli Brock, MSc, and Carlos Rogério Tonussi, DSc

From the Departamento de Farmacologia, CCB, Universidade Federal de Santa Catarina, Brasil.

Anesth Analg 2008;106:965–71

 

背景:在动物试验中吗啡能抑制炎症性水肿。但吗啡发挥这种作用的机制和作用位点仍有争议。因脊髓水平是炎症神经原性成分的调节部位,我们在角叉藻聚糖(CG)诱导引起的爪水肿动物中研究鞘内注射吗啡的效应和脊髓NO/ cGMP通路的作用。

方法:男性Wistar大鼠接受鞘内注射吗啡(20uL),间隔30分钟后用150ug CG对动物爪进行刺激。采用爪体积增加(ml)测定水肿和髓过氧化物酶(MPO)分析间接评价中性粒细胞迁移。

结果:吗啡(37, 75150 nmol)能抑制炎症性水肿,但对MPO的活性无影响。同时注射纳络酮(64 nmol)可以逆转吗啡的效应。在吗啡注射前90分钟使用皮质类固合成抑制剂醇氨鲁米特(50mg/kg)不会改变其消水肿的作用。低剂量NO合成酶抑制剂L-精氨酸(1030 pmol之间)会加重水肿,而大剂量(3 30 nmol之间)则抑制爪水肿。使用鸟苷酸环化酶抑制剂1H-oxadiazolo[4,3-a]quinoxalin-1-oneODQ,21 42 nmol之间)水肿增加,磷酸二酯酶-5亚型抑制剂昔多芬(0.15 1.5 nmol之间)则可以抑制试验动物的爪水肿。亚效应剂量L-精氨酸(3 pmol)ODQ(10 nmol)与吗啡同时注射则会抑制后者的抗水肿作用。但是昔多芬(0.15 nmol)能使亚效应剂量的吗啡发挥其正常效应(18 nmol)。再者ODQ也能抑制NO前体S-亚硝基-N –乙酰基青霉素的抗水肿作用。

 

结论:这些研究结果表明吗啡能作用于脊髓水平的阿片受体从而产生抗水肿效应,并且NO/cGMP通路在此效应中可能是一重要的调节通路。

(蒋宗明译 薛张纲校)

BACKGROUND: Morphine can inhibit inflammatory edema in experimental animals.The mechanisms and sites by which opioids exert this effect are still under debate.Since the spinal level is a site for modulation of the neurogenic component of inflammation, we investigated the effect of intrathecal (IT) administration of morphine, and the involvement of spinal nitric oxide (NO)/cyclic-guanosine monophosphate-GMP pathway in carrageenan (CG)-induced paw edema.

METHODS: Male Wistar rats received IT injections of drugs (20 _L) 30 min before paw stimulation with CG (150 _g). Edema was measured as paw volume increase (mL), and neutrophil migration was evaluated indirectly by myeloperoxidase (MPO) assay.

RESULTS: Morphine (37, 75, and 150 nmol) inhibited inflammatory edema, but had no effect on MPO activity. Coinjection with naloxone (64 nmol) reversed the effect of morphine. The corticosteroid synthesis inhibitor, aminoglutethimide (50 mg/kg,v.o.), administered 90 min before morphine injection did not modify its antiedematogenic effect. Low doses of the NO synthase inhibitor, N_-nitro-l-arginine (L-NNA; 10 and 30 pmol) increased, while higher doses (3 and 30 nmol) inhibited edema. The guanylate cyclase inhibitor 1H-oxadiazolo[4,3-a]quinoxalin-1-one (ODQ; 21 and 42 nmol) increased, while the phosphodiesterase type 5 inhibitor sildenafil (0.15 and 1.5 nmol) inhibited paw edema. Coadministration of a subeffective dose of L-NNA (3 pmol) or ODQ (10 nmol) with morphine prevented its antiedematogenic effect, but sildenafil (0.15 nmol) rendered a subeffective dose of morphine effective (18 nmol). ODQ also prevented the antiedematogenic effect

of the NO donor S-nitroso-N-acethyl-penicilamine.

CONCLUSION: These results support the idea that morphine can act on opioid receptors at the spinal level to produce antiedematogenic, and that the NO/cGMP pathway seems to be an important mediator in this effect.

 

固定剂量的氟烷、异氟醚或异丙酚,并没有优先抑制带有上行投射的腰段脊髓背角神经元的实验鼠的有害热诱发反应

Immobilizing Doses of Halothane, Isoflurane or Propofol, Do Not Preferentially Depress Noxious Heat-Evoked Responses of Rat Lumbar Dorsal Horn Neurons with Ascending Projections

Linda S. Barter, MVSc, PhD*, Laurie O. Mark, BA{dagger}, Steven L. Jinks, PhD*, Earl E. Carstens, PhD{ddagger}, and Joseph F. Antognini, MD*{ddagger}

From the *Department of Anesthesiology and Pain Medicine, University of California, Davis, California; {dagger}School of Medicine, Indiana University, Indiana; and {ddagger}Section of Neurobiology, Physiology and Behavior, University of California, Davis, California.

Anesth Analg 2008 106: 985-990.

 

背景:挥发性麻醉药是通过作用于脊髓产生感觉丧失和制动作用。根据这种理论,麻醉药的作用位点是有限的。先前的证据表明,相比于局部脊髓中间神经元,带有上行投射的脊髓背角神经元对全麻药引起的抑制作用更易感。在我们的这项研究中,我们评估的挥发性麻醉药和静脉麻醉药作用于脊髓腰段背角神经元,分别在有上行投射和没有投射情况下的区别。

方法37只成年雄鼠的颈1椎板被切除,用于放置刺激电极;切除胸13/1椎板,用于记录脊髓背脚细胞外的反应。分别给予两种剂量的氟烷、异氟醚或异丙酚,评估对于热刺激的神经反应。

结果:用氟烷和异氟醚麻醉,分别增加剂量,MAC0.8增加到1.2,相比于逆行刺激(AD)或没有上行投射(nAD),含有上行投射的神经元并没有明显影响热诱发反应。静脉给予35mg/kg异丙酚后,AD神经元的热反应分别降低了60% ± 18% (平均数±标准差) and 39% ± 14% 。同样,在nAD神经元,分别给予35mg/kg异丙酚,热反应下降至56% ± 14% and 50% ± 10%

结论:我们的研究表明,在相近的MAC情况下,相比于没有上行投射的神经元,这些全麻药并没有优先抑制有上行投射的腰段脊髓背角神经元对热刺激的反应。

(陈珺珺译 薛张纲校)

BACKGROUND: The spinal cord is an important site where volatile anesthetics decrease sensation and produce immobility. Beyond this knowledge, our understanding of a site of anesthetic action is limited. Previous evidence suggests that dorsal horn neurons with ascending projections may be more susceptible to depression by general anesthetics than local spinal interneurons. In this study we evaluated the effects of volatile and injectable general anesthetics on lumbar dorsal horn neurons with and without ascending  rojections.

METHODS: Thirty-seven adult male rats underwent laminectomies at C1, for placement of a stimulating electrode, and T13/L1, for extracellular recording from the spinal cord dorsal horn. Neuronal responses to heat were evaluated under two doses of halothane, isoflurane, or propofol anesthesia.

RESULTS: Under both halothane and isoflurane anesthesia, increasing the dose from 0.8 to 1.2 minimum alveolar concentration (MAC) had no significant effect on heat-evoked responses in neurons that had ascending projections identified via antidromic stimulation (AD) or those without ascending projections (nAD). Heat responses in AD neurons 1 min after IV administration of 3 and 5 mg/kg of propofol were reduced to 60% ± 18% (mean ± se) and 39% ± 14% of control respectively. Similarly, in nAD neurons responses were reduced to 56% ± 14% and 50% ± 10% of control by 3 and 5 mg/kg propofol respectively.

CONCLUSIONS: Our findings suggest, at peri-MAC concentrations, these general anesthetics do not preferentially depress lumbar dorsal horn neurons with ascending projections compared to those with no identifiable ascending projections.

 

腰麻时预先扩容对脑脊液的性质和等比重的局麻药的扩散的影响

The Effects of Prehydration on the Properties of Cerebrospinal Fluid and the Spread of Isobaric Spinal Anesthetic Drug
Byung Seop Shin, MD*, Justin Sang Ko, MD*, Mi Sook Gwak, MD*, Mikyung Yang, MD*, Chung Su Kim, MD*, Tae Soo Hahm, MD*, Sang Min Lee, MD*, Hyun Sung Cho, MD*, Sung Tae Kim, MD{dagger}, Ji Hye Kim, MD{dagger}, and Gaab Soo Kim, MD*

From the Departments of *Anesthesiology and Pain Medicine, and {dagger}Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University College of Medicine, Seoul, Korea.

Anesth Analg 2008 106: 1002-1007.

 

背景:在这项有两部分组成的临床研究中,我们调查了“预先扩容”对脑脊液(CSF)的物理性质和局麻药在椎管内分布的影响。

方法:首先,在临床方面,对进行腰麻的68个病人被随机的分为了两组,一组预先给予10ml/kg乳酸林格氏液扩容,所有病人在腰段注射12mg  0.5%等比重的丁卡因。评估病人的动脉血压、心率和阻滞平面。其次,在核磁共振影像研究中,招募了24名男性志愿者。在输注了10ml/kg的乳酸林格氏液后,测量了CSF的流动变化,以此检测腰23水平CSF流量和容积的漂移。

结果:临床研究中,两组的动脉血压、心率、阻滞平面的高峰并没有明显的差别,但是两组到达阻滞高峰的达峰时间的中位数有差别(26.4 ± 15.7 vs 16.5 ± 9.2 min, P < 0.05),明显长于对照组。在核磁共振影像中,扩容后CSF的回流明显增加,但是每搏输出量,绝对每搏输出量,平均流量,搏距和向头端方向的平均速率均下降。

结论:预先快速输注晶体扩容可以影响腰段CSF流量,减少0.5%的等比重的丁卡因向头端扩散,并且延迟到达阻滞峰值的达峰时间。

(陈珺珺译 薛张纲校)

BACKGROUND: In a two-part clinical study, we investigated the effect of the administration of fluids "prehydration" on the physical properties of cerebrospinal fluid (CSF) and intrathecal  spread of local anesthetics.

METHODS: First, in the clinical spinal anesthesia study, 68 patients were allocated randomly into the prehydration or nonprehydration groups. One group was prehydrated with 10 mL/kg of lactated Ringer's solution, and spinal anesthesia was performed with 12 mg of 0.5% isobaric tetracaine in all patients at the lumbar level. The arterial blood pressure, heart rate, and sensory block level were assessed. Second, in a magnetic resonance image study, 24 male volunteers were enrolled. CSF motion variables were measured after infusion of 10 mL/kg of lactated Ringer's solution to examine the net flow and volume displacement of the CSF at the L2–3 disk level.

RESULTS: In the clinical study, there were no significant differences in arterial blood pressure, heart rate, and median peak sensory block level between the two groups, but the median time to reach peak sensory block level (26.4 ± 15.7 vs 16.5 ± 9.2 min, P < 0.05) was longer in group P. In  posthydration  magnetic resonance images, the CSF regurgitant fraction (caudal flow) was significantly increased after hydration, but the stroke volume, absolute stroke volume, mean flux, stroke distance, and mean velocity in the cranial direction were significantly decreased.

CONCLUSIONS: Rapid crystalloid prehydration can affect CSF flow in the lumbar region, reducing cephalic spread of 0.5% isobaric tetracaine and delaying the time to reach the peak sensory level.

 

用手提式Doppler,简化锁骨下臂丛阻滞的进路

A Simplified Approach to Vertical Infraclavicular Brachial Plexus Blockade Using Hand-Held Doppler (Brief Report)

Steven Renes, MD*, Laura Clark, MD{dagger}, Mathieu Gielen, MD, PhD*, Huub Spoormans, MD{ddagger}, Janneke Giele, MSc*, and Anupama Wadhwa, MD§

From the *Department of Anesthesiology, Radboud University Nijmegen Medical Center, The Netherlands; {dagger}Department of Anesthesiology and Perioperative Medicine, University of Louisville, Kentucky; {ddagger}Department of Anesthesiology, Bernhoven Hospital Oss, The Netherlands; and §Department of Anesthesiology and Perioperative Medicine, Outcomes Research Institute and University of Louisville, Kentucky.

Anesth Analg 2008 106: 1012-1014.

 

在这项观察性研究中,我们使用了Doppler超声用于垂直锁骨下臂丛阻滞的操作。使用Doppler超声的穿刺到锁骨下动脉的影像的位置,记录所用时间,并且传统的穿刺方法相比较。100个病人中有89个病人,一次性就穿过中间索和后索。相比于传统的穿刺,使用Doppler穿刺点明显外侧(P < 0.001),锁骨下阻滞穿刺的成功速率也因此提高。

(陈珺珺译 薛张纲校)

In this observational study, we used Doppler ultrasound during the performance of vertical infraclavicular brachial plexus blockade. The success rate at inserting the needle at the point where the sound of the subclavian artery via Doppler reached its maximum audibility was compared with that of the classical insertion point. In 89 of the 100 patients, the medial or posterior cord was found at first needle pass. Using the Doppler point for insertion resulted in a significantly more lateral entry point compared with the classical point (P < 0.001) and was associated with a high success rate of infraclavicular block.