Table of Contents

March 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

長時體外迴圈後抗凝血酶缺乏導致凝血酶活性增強

胡瀟 陳傑

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.

抗凝血酶對VIII因數缺乏血漿中重組啟動VII因數凝血效應的影響

孫鵬飛譯 薛張綱校

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.

纖維蛋白原在顱縫早閉手術中的應用

姜旭暉   馬皓琳 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.

聯合給予活化因數(NovoSeven®)和纖維蛋白原(Haemocomplettan® P)後能改善血塊形成

王鵬 陳傑

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.

限制性複溫和術後低溫在大鼠體外迴圈模型中對認知功能的作用

章一靜譯 薛張綱校

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.

 多功能襯墊式充氣加溫系統在近常溫的體外迴圈下心臟外科手術中的效果

邱郁薇 馬皓琳 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.

血管外科高危病人術前冠脈血運重建術:主題綜述

陶穎瑩 陳傑

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:

肺擴張和呼吸末正壓通氣在使用機械通氣的小兒麻醉中的效果

胡豔譯 薛張剛校

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.

適用於以麻醉為基礎的小兒慢性疼痛醫療方案的病兒群體的臨床特點

張瑩譯  馬皓琳 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.

用近紅外光譜法測定新生小豬選擇性順行腦灌注的血流指數

杜唯佳 陳傑

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:

前抑鬱症的一有效篩查工具:老年抑鬱症

黃凝譯  薛張綱校

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術的母親術前焦慮的比較

彭中美 馬皓琳 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.

閃光燈在減輕靜脈置管術疼痛的作用:一個前瞻性、隨機、安慰對照研究

王騰 陳傑

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:

關於異丙酚合用70%氙與合用70%笑氣時50%有效濃度(EC50)的比較

施穎譯 薛張綱校

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.

 大鼠的肝臟缺血再灌注損傷模型中七氟醚與異氟醚麻醉的肝能量代謝及其不同的保護效應

唐亮   馬皓琳 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.

不同化合物對野生型、突變型Aγ氨基丁酸和甘氨酸受體的麻醉樣作用

趙燕星 陳傑

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.

異丙酚對人類5-HT3A受體的分子作用:通過相似的酚類衍生物增強和抑制

宣麗真譯 薛張綱校

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.

高血糖減弱異氟烷在血管平滑肌細胞中誘導的ATP敏感的鉀通道啟動作用

黃施偉 馬皓琳 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.

人體外周血單核細胞產生痛敏肽/孤啡肽前體mRNA

鄭麗 陳傑

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:

用第二代動脈壓波形儀對心臟手術病人評估心輸出量的有效性

劉沁譯 薛張綱校

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.

志願者中光譜預測聽覺知曉

沈浩   馬皓琳 李士通

Spectral Entropy Predicts Auditory Recall in Volunteers

Daryn H. Moller and Ira J. Rampil

Anesth Analg 2008 106: 873-879.

異丙酚與fospropofol(一種新型異丙酚前體)的互動式網路仿真

陶穎瑩 陳傑

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:

食管部分切除術中胸段硬膜外應用布比卡因與靜脈內腎上腺素輸注對胃管引流的影響

劉婷潔譯 薛張綱校

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:

母體兒茶酚胺對妊娠子宮微血管內徑的影響

黃佳佳譯,馬皓琳 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:

決策支援增強了預防術後噁心和嘔吐指南的執行

張燕 陳傑

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:

可樂定輸注在志願者中對區域腦血流分佈的影響

秦敏菊譯 薛張綱校

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.

一過性腦缺血對加壓素誘導的兔腦血管收縮的影響

裘毅敏譯,馬皓琳 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氧-缺血損傷後氙氣/低溫神經保護措施:呼吸和鎮靜效應

潘方立 陳傑

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.

腸道準備引起的脫水不會導致老年人認知功能障礙

夏俊明譯  薛張綱校

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:

在接受異丙酚複合芬太尼麻醉的患者中神經肌肉阻滯水平對強直後運動誘發電位的幅度和經顱刺激的運動反應的影響

唐李雋 馬皓琳 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.

手法穩定氣管插管期間的頸椎移動:直接喉鏡法與GlideScope視頻喉鏡法的比較

印潔敏 陳傑

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:

發展中國家的麻醉和相關學科的現狀:一項尚比亞共和國的全國性調查

陳珺珺譯 薛張綱校

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:

塞來考昔圍手術期給藥與僅僅在術後給藥對接受大的整形外科手術病人術後影響的比較

吳進   馬皓琳 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.

一項前瞻性隨機雙盲研究測定胸段硬膜外給新斯的明對腹主動脈術後腸麻痹的影響

宋翠俠 陳傑

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:

嗎啡鞘內注射抑制爪炎症性水腫:一氧化氮(NO)和環磷鳥苷(cGMP)的作用

蔣宗明譯 薛張綱校

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.

鞘內注射環氧化酶-1抑制劑、環氧化酶-2抑制劑或非選擇性抑制劑對疼痛行為和脊髓Fos樣免疫反應的影響

顏濤 譯,馬皓琳 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.

一氧化氮合酶抑制劑和環氧合酶抑制劑在小鼠甲醛誘導疼痛中的相互作用:一項等輻射分析研究

潘錢玲 陳傑

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.

固定劑量的氟烷、異氟醚或異丙酚,並沒有優先抑制帶有上行投射的腰段脊髓背角神經元的實驗鼠的有害熱誘發反應

陳珺珺譯 薛張綱校

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:

患者自控持續斜角肌間溝阻滯能促進開放性肩部手術後的早期功能康復嗎?

慧譯 馬皓琳 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.

改良乳房根治術術後羅呱卡因連續傷口浸潤麻醉與單次椎旁神經阻滯的比較

陳偉 陳傑

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.

腰麻時預先擴容對腦脊液的性質和等比重的局麻藥的擴散的影響

陳珺珺譯 薛張綱校

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.

鼻部手術中左旋布比卡因局部浸潤的收縮血管和鎮痛作用

胡湘   馬皓琳 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,簡化鎖骨下臂叢阻滯的進路

陳珺珺譯 薛張綱校

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.

長時體外迴圈後抗凝血酶缺乏導致凝血酶活性增強

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:  體外迴圈期間,特別是深低溫停迴圈時抗凝血酶水平降低。低抗凝血酶水平可能導致促凝和抗凝因數間的不平衡導致系統性血栓形成。作者假設體外迴圈後病人血漿中加入促凝因數後低水平的抗凝血酶可能導致凝血酶產生增加。

方法:5例接受深低溫停迴圈心臟手術的病人在肝素化前和體外迴圈後抽取血液標本。抗凝血酶水平由產色反應來確定並由正常活性的百分比來表達。抗凝和促凝物質的平衡通過在病人血漿中加入正常人的血漿、抗凝血酶缺陷的血漿和提純的抗凝血酶來實現 ThrombinoscopeTM系統用於評估給或不給抗凝血酶時的凝血酶。

結果:在體外迴圈前後,抗凝血酶水平分別為82.0% (中位數71.0, 最大值109) 37.0% (中位數34.0, 最大值41.0)(P < 0.05)。當體外迴圈後的血漿加入正常抗凝血酶(105%)的捐獻者血漿後凝血酶56.6 nM (中位數42.1, 最大值61.0), 並保持在 61.1 nM (中位數54.9, 最大值64.5)。當加入抗凝血酶缺乏病人的血漿後,凝血酶(中位數,範圍)從56.6nM(中位數42.1, 最大值61.0)增至117 nM (中位數95.0, 最大值188) (P < 0.05)。當加入提純的抗凝血酶後,凝血酶減少到12.2 nM (中位數9.0, 最大值29.3) (P < 0.05)

結論:深低溫停迴圈患者體外迴圈後血漿抗凝血酶活性顯著下降。資料顯示在不給予抗凝血酶的情況下給予凝血因數可能導致過多的凝血酶生成,臨床上有潛在導致高凝狀態的可能。                                                                                                                           

(胡瀟 陳傑 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.


聯合給予活化因數(NovoSeven®)和纖維蛋白原(Haemocomplettan® P)後能改善血塊形成

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:重組活化因數(rFVIIa)常用於治療難治性心臟術後出血。然而,止血作用還取決於凝集因數,包括纖維蛋白原,在血管損傷部位形成穩定的血小板栓子。作者比較了單獨使用rFVIIa,纖維蛋白原以及聯合使用時的止血效果。

方法:採集 12例志願者和7例體外迴圈患者血液樣本。在體外,志願者的血漿加入肝素(0.1U/ml)或纖溶酶原(0.1ug/ml)以模擬凝血功能紊亂,然後加入rFVIIa1.5ug/ml)、纖維蛋白原(100mg/dl)或聯合給予rFVIIa及纖維蛋白原,以此來評價它們的促凝血功能。通過血栓彈力圖比較它們對凝血功能的影響。測定血栓的形成時間、第一個血栓形成時間以及血栓的最大硬度。凝血酶定量實驗用來測定添加纖維蛋白原和(或)rFVIIa後凝血酶的產生。

結果:在肝素化的志願者的血漿中,加入rFVIIa可以導致血凝塊形成時間從663秒縮短到435秒,但不影響血栓的最大硬度。纖維蛋白原可使血栓最大硬度從26.0mm增加到30.5mm,但它不影響血凝塊形成時間。在肝素化血漿樣本中聯合給予rFVIIa和纖維蛋白原,可以最大程度地將血凝塊形成時間縮短到359s(324–522s)以及將血栓最大硬度增加到29mm (27.8–31.0)。在給予組織型纖溶酶原的志願者的血漿中,纖溶現象比加入rFVIIa增加了45%。體外迴圈術後,在給予rFVIIa和纖維蛋白原後血凝塊形成時間和血栓最大硬度均改善了。凝血酶定量試驗說明了rFVIIa可以提高血栓形成的時間和凝血酶活化的速度,而纖維蛋白原沒有這些作用。

結論:給予rFVIIa後纖維蛋白形成時間和凝血酶產生均縮短,但只有另外給予纖維蛋白原後產生纖維蛋白凝塊強度增強。體外迴圈後全血通過聯合給與rFVIIa和纖維蛋白原而改善血凝塊形成。

(王鵬 陳傑 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.

 

血管外科高危病人術前冠脈血運重建術:主題綜述

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.

 

資料顯示進行血管外科手術的病人,其冠狀動脈相關的心臟併發症發生率呈現持續增高。

而術前進行冠狀動脈造影的病人如果顯示有接受冠脈血運重建術來改善術前及長期心臟功能的必要,則術前心臟功能評估對這些高危病人極為有益。然而目前的冠脈血運重建術與藥物治療在減少心臟併發症的效果上孰優孰劣仍存在爭議。本綜述根據最近發表的文獻總結並比較了選擇性血管手術的病人術前冠脈血運重建術治療與保守性藥物治療兩者效果。

(陶穎瑩 陳傑 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.

 

用近紅外光譜法測定新生小豬選擇性順行腦灌注的血流指數

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:複雜的先天性心臟病的嬰兒需在深低溫停迴圈(HCA)下手術。有人認為,選擇性腦灌注(SCP)可以提供足夠的腦血流而減輕缺血性腦損傷。作者採用近紅外光譜法監測腦灌注和組織氧合情況,研究不同SCP下血流速度,並且與HCA相比較。

方法21頭小豬在18°C行體外迴圈,然後行HCA或以2550mL · kg–1 · min–1SCP 90min,分別為HCV組、SCP25組和SCP50組。通過近紅外光譜法測定吲哚青綠血管造影劑的血流指數(BFI)以及組織氧合指數(TOI)。用經顱多普勒超聲測定平均腦血流速度(FVmean)

結果 SCP50組較HCV組(無血流)和SCP25組,其BFIFVmean都有顯著增高。SCP50組的TOI較基礎水平增高,並高於HCV組和SCP25組。SCP50的顱內壓較基礎水平沒有顯著升高。

結論:BFIFVmean都顯示了SCP50組的腦灌注較HCV組和SCP25組增高。SCP25組和SCP50組的TOIHCA組有明顯提高。SCP25mL · kg–1 · min–1時可能提供最合適的腦保護。

(杜唯佳 陳傑 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.

 

閃光燈在減輕靜脈置管術疼痛的作用:一個前瞻性、隨機、安慰對照研究

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:儘管操作中有有令人不適的疼痛經歷,靜脈置管術常在無鎮痛的情況下完成的。各種各樣的藥物和非藥物措施嘗試用於減輕靜脈置管帶來的疼痛。本文研究閃光燈減輕靜脈置管術疼痛的作用。

方法:前瞻性、隨機研究90名成年人(15—60歲),ASA分級在--級,不分性別,行擇期LC術患者。隨機分為三組,每組30人。第一組(對照組);第二組(分散注意組):不用閃光燈照相;第三組(閃光組):手背小靜脈不明顯的患者在靜脈置管術前用閃光燈給予拍照,然後迅速行靜脈穿刺置管,置入18號導管。

結果:每組均有2名患者因第一次置入未成功而在後期分析中刪除。閃光組靜脈置管時疼痛比較輕,疼痛率為50%14/28),而另兩組為100%28/28)(p0.01)。用視覺類比評分測定靜脈置管術疼痛程度(0—1000即沒有疼痛,100是最痛)。閃光組的靜脈置管疼痛減輕的程度比分散注意力組大(p0.01

結論:靜脈置管術前應用閃光燈是減輕置管疼痛的一種安全、有效、簡單易用的方法。

(王騰 陳傑 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.

 

不同化合物對野生型、突變型Aγ氨基丁酸和甘氨酸受體的麻醉樣作用

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.

 

介紹:沒有理論認為吸入麻醉藥的作用通過其揮發特性發揮其與生物學靶組織發生生物物理學相互作用而產生麻醉效應。證實突變導致吸入麻醉藥對各種受體作用減弱有助於證明具有麻醉作用的非揮發性麻醉藥所作用的受體。在以前的研究中,作者證實這些化合物 帶電荷或蒸氣壓特別低,而且這些化合物具有類似吸入麻醉藥的方式作用麻醉敏感受體。本研究通過比較它們對野生型Aγ氨基丁酸(GABAA或甘氨酸受體和突變受體的作用,驗證是否這些化合物或是其他帶電化合物,相同於揮發性麻醉藥的機制。突變受體是通過設計對吸入麻醉藥相對耐藥而確定。

方法:檢測β-羥基丁酸、氯化銨、二乙基鄰苯二甲酸酯和GABA對甘氨酸受體同價同效基因α1和突變基因α1S267I)的作用。檢測硫酸十二烷基頭孢匹胺和甘氨酸對α1β2γ2s和突變基因α1S270Iβ2γ2sGABA受體的作用。受體來源於非洲蟾蜍平滑肌細胞,用兩個電極電壓夾的方法。對於GABAA受體和甘氨酸受體,異氟醚和乙醇作為陽性對照,異丙酚作為陰性對照(如由突變導致無作用)。

結果:β-羥基丁酸、氯化銨、二乙基鄰苯二甲酸酯和GABA均增強甘氨酸受體功能。這種作用可被S267I突變體降低。硫酸十二烷基頭孢匹胺和甘氨酸增強GABAA受體功能,S270I突變體減弱這種作用。

結論:上述發現支持化合物調節GABA A或甘氨酸受體通過類似異氟醚和乙醇的作用機制的假說。比較藥物對麻醉敏感型野生受體與相對不敏感型突變受體的作用,可能幫助尋找有麻醉作用的化合物。

(趙燕星 陳傑 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.

 

人體外周血單核細胞產生痛敏肽/孤啡肽前體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  外周血單核細胞(PBMC)轉錄非典型的阿片樣物質痛敏肽/孤啡肽(N/OFQ)受體(NOPmRNA。筆者檢測了N/OFQ前體,促N/OFQ前體(pp N/OFQ)。

方法:取10名健康志願者PBMC,用聚合酶鏈反應(PCR)技術檢測pp N/OFQ

結果 凝膠PCR法中所有樣本中均檢出pp N/OFQ mRNA擴增子。這點通過定量即時PCR技術證實(mRNA 30.91+0.18)。

結論:這組資料提示PBMC轉錄pp N/OFQ,且表達NOP,意味NOP可能參與PBMC的自身調節。

(鄭麗 陳傑 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.

 

異丙酚與fospropofol(一種新型異丙酚前體)的互動式網路仿真

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.

 

根據近期發表的有關異丙酚及fospropofol(一種新型異丙酚前體)藥代及藥效學資料,本文作者建立了使用這兩種藥的互動式網路仿真。其中fospropofol是一種新型水溶性異丙酚前體藥物,其達到峰濃度的時間晚於異丙酚。而建立的模型能使麻醉醫師瞭解使用兩種藥物間的區別。另外該模型的附加優點在於保留了原試驗中不同試驗方案中不同病人間的差異。

(陶穎瑩 陳傑 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.

 

 決策支持增強了預防術後噁心和嘔吐指南的執行

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:預防術後噁心和嘔吐的指南實施廣泛,但由於沒有很好的執行,效果可能有限。 作者作者假設利用電子決策支援(簡稱DS)系統,能顯著改善指南的執行。

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:來自作者的地區教學醫院的選擇性手術患者的醫學資料常規收錄入術前門診麻醉資訊處理系統。 預防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.術後噁心和嘔吐指南確診為"高危"患者,作為預防術後噁心和嘔吐物件,根據是在場的至少有以下3個危險因數:女性,術後噁心和嘔吐史或暈動病,不吸煙體質,和預期術後使用阿片類藥物。 Using automated reminders, we studied the effect of DS on guidelines adherence using an off-on-off design.使用自動提醒方法,研究決策支援對指南執行的作用。 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.結果:200511月和20066月期間,對照組,決策支持組以及後決策支持組包括患者分別有 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.由於強制性資料錄入,術後噁心和嘔吐高危患者的比例由對照組28 ,上升到決策支持組32%和後決策支持組31%。 During the control period, 38% of all high-risk patients were prescribed PONV prophylaxis.對照組38%的高危患者開具了預防性術後噁心和嘔吐處方。 而決策支持組比例上升至73 ,後決策支持組下降至37

CONCLUSION: Electronic DS increases guidelines adherence for the prescription of PONV prophylaxis in high-risk PONV patients.結論:術後噁心和嘔吐的高危病人中,電子決策支援系統增強了預防術後噁心和嘔吐開具處方指南的執行。

(張燕 陳傑 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-缺血損傷後氙氣/低溫神經保護措施:呼吸和鎮靜效應

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:低溫(HT)能降低圍產期窒息引起的神經損傷,氙氣(XE)能增強此作用。筆者研究了缺氧-缺血(HI)損傷後不同濃度氙氣在正常體溫37NT)和低體溫32HT)的鎮靜作用及對呼吸的影響以確定能使7天齡的新生大鼠產生自主呼吸抑制的氙氣濃度。

方法:(I)三組對照組,分別為空白對照、禁食正常體溫對照組(NT)和禁食低溫對照組(HT)。(II)六組行HI損傷(結紮頸動脈後吸8%氧氣90min)。之後三組分別為正常體溫吸空氣、50%氙氣和70%氙氣(NTAir,NT50%Xe,NT70%Xe),另三組為低溫吸空氣、50%氙氣和70%氙氣(HTAir,HT50%Xe,HT70%Xe)。監測血氣、血糖和乳酸並記錄鎮靜狀態(自主運動和呼吸頻率)。

結果70只新生大鼠的血液生化資料全部獲得。(I)對照組在NTHT禁食9h後血氣、血糖和乳酸均正常。(IIHI損傷後,與對照組和NTAir組相比,在NTHT70%氙氣組PCO2pH較低,而HTAir組和HT50%Xe組僅有pH較低。HT70%XePCO2最高、pH最低,鎮靜效果最好。

結論:在HI損傷後,70%氙氣與吸空氣和對照組在NT HT都能產生鎮靜、呼吸抑制、CO2瀦留和pH下降。50%的氙氣則避免了這些影響。

(潘方立 陳傑 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.

 

手法穩定氣管插管期間的頸椎移動:直接喉鏡法與GlideScope視頻喉鏡法的比較

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:對於頸椎有潛在病損的患者,採用何種最佳氣管插管技術仍然具有爭議。作者運用連續螢光照相,進行了一項前瞻性研究,比較直接喉鏡法(DL)與GlideScope視頻喉鏡法(GVL)氣管插管時頸椎移動,期間由助手手法保持患者頭部的穩定。

方法:選擇20例沒有頸椎病變的患者。在全麻誘導使用神經肌肉阻滯後,隨機採用DLGVL行氣管插管。拍攝插管期間頸椎移動的螢光顯像照片,並將其分成四個階段:氣道操作前的基礎圖像,顯現聲門,氣管導管進入聲門,氣管插管。測定每位患者每個階段枕部至C5活動的峰值,計算平均值,利用兩因素方差分析比較每種方法產生的頸椎移動。對枕部至C1分別旋轉101520度的患者的比例,和聲門顯現的質量同樣做了研究。

結果:各個階段的頸椎平均移動度在DLGVL之間沒有顯著差異(P0.220.70)。兩種插管技術對頸椎產生的移動主要都是使頸椎前端伸展,且主要發生在顯露聲門時。在枕部至C1的伸展幅度大於101520度的這部分患者中插管基本沒有困難。GVL對聲門的顯露明顯優於DL

結論:在全身麻醉使用神經肌肉阻滯的情況下,手法保持頭部穩定,採用GVLDL進行氣管插管時前者更好地顯露聲門,但並不能減少對非病理性頸椎的移動度。

(印潔敏 陳傑 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.

 

一項前瞻性隨機雙盲研究測定胸段硬膜外給新斯的明對腹主動脈術後腸麻痹的影響

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:腸梗阻是腹主動脈術後胃腸道主要的併發症之一,可導致死亡率增加,住院時間延長和醫藥費的增加,在這項研究中作者評估了胸段硬膜外給與新斯的明對腹主動脈術後腸麻痹的作用。

方法 45名行腹主動脈手術的患者參與了這項研究,所有的患者接受一致的全麻與硬膜外麻醉。全麻誘導前在T7-T8椎間隙置入硬膜外導管,15min後給予0.5%布比卡因20ml。分別在手術結束以及術後8h經硬膜外導管給予單次劑量新斯的明(1ug/kg,生理鹽水稀釋成5ml1組),對照組(2組)同樣的途徑給5ml生理鹽水。術後入ICU病房,記錄腸鳴音次數以及每日排氣排便次數。

結果1組較2組,第一次腸鳴音和排氣時間明顯縮短(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)。兩組病人第一次排便時間相似(p>0.05)2組比1組病人噁心發生率高(p<0.05),兩組病人術後併發症發生率相似(p>0.05)

結論:胸段硬膜外給新斯的明促進腸鳴音恢復,縮短腹主動脈術後腸持麻痹續時間。

(宋翠俠 陳傑 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.

 

一氧化氮合酶抑制劑和環氧合酶抑制劑在小鼠甲醛誘導疼痛中的相互作用:一項等輻射分析研究

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:關於NOCOX在角叉菜膠誘導的炎症反應中對前列腺素生成的相互作用已經有報導。但是,關於iNO抑制因數和COX抑制因數在痛覺中相互作用的報導則很少。因此,本研究意在評價S-甲基異硫脲硫酸鹽(中度選擇性iNO抑制因數)與羅非考昔(選擇性COX-2抑制因數)和甲酚那酸(非選擇性抑制因數)在小鼠甲醛誘導痛中的相互作用。

方法:通過對小鼠甲醛誘導痛的後期表現,即在注射甲醛後小鼠舔其後爪所花費的時間來研究S-甲基異硫脲硫酸鹽、羅非考昔、甲酚那酸及將其混合使用時的劑量反應關係。這種相互作用通過將三種藥物同時給藥或將S-甲基異硫脲硫酸鹽與每一COX抑制因數混合給藥來評估。而其相互作用則通過等輻射法進行分析。

結果:單獨給藥時在甲醛誘導的後期可產生劑量依賴性抑制,其效價的強弱次序為羅非考昔>甲酚那酸>S-甲基異硫脲硫酸鹽。而對混合劑即S-甲基異硫脲硫酸鹽和羅非考昔,或甲酚那酸的等輻射分析則顯示有協同作用。對於相同的混合物實驗獲得的ED50要比理論上相加獲得的ED50明顯低,這驗證了iNOSNOCOX亞型的協同作用。

結論:研究發現NOSCOX抑制因數在小鼠甲醛誘導痛中有明顯的協同作用,為疼痛控制提供了一個可行的方法。

(潘錢玲 陳傑 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.


改良乳房根治術術後羅呱卡因連續傷口浸潤麻醉與單次椎旁神經阻滯的比較

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:連續浸潤麻醉與胸段椎旁神經阻滯用於乳房手術後的效能至今未作過對比研究。在這個研究中,作者評估乳房切除術後兩者的鎮痛作用和嗎啡鎮痛用量。

方法:48名接受腋窩切開改良乳房根治術患者隨機接受0.5%羅呱卡因20ml的術前胸段椎旁神經阻滯或0.5%羅呱卡因連續性浸潤麻醉,浸潤麻醉的輸注速度為2ml/h,方式是在術畢時放置兩根導管在手術部位的皮下,導管留置術後24小時。所有患者都接受全身麻醉。記錄術後24h嗎啡用量,疼痛評分和疼痛限制的肩關節活動,以及併發症的發生率,包括術後噁心嘔吐。

結果:兩組的嗎啡用量相近。兩者疼痛評分均較低。術後4h,胸段椎旁神經阻滯組在術後疼痛與疼痛限制性活動方面較輕,而在術後16h24h,連續性局部浸潤麻醉組優於胸段椎旁神經阻滯組。連續性局部浸潤麻醉組中術後噁心嘔吐的發生率相對頻繁。

結論:腋窩切開乳房切除術後,連續性傷口局部浸潤麻醉為較好的椎旁神經阻滯替換方法。

(陳偉 陳傑 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.

 

纖維蛋白原在顱縫早閉手術中的應用

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: 在顱縫早閉的修復過程中,由於大量失血和凝血因數的消耗及稀釋常導致的凝血異常,所以建議運用冷沉澱物、新鮮冰凍血漿和血小板進行治療。但是在大多數的歐洲國家冷沉澱物並不常備,新鮮冰凍血漿在糾正纖維蛋白原缺乏方面的有效性也很有限。我們報導了我們用人纖維蛋白原濃縮物(Hemocomplettan®)來改善兒童受損的纖維蛋白原聚合的經驗。

方法: 我們從進行大顱面手術的連續九例小兒的麻醉記錄單、用藥記錄、實驗室和血栓彈力圖(ROTEM®)資料庫,回顧性收集例行凝血試驗結果、ROTEM®、補液需要量、給予的人纖維蛋白原濃縮物和術後病程的數據。

結果: 九個小兒年齡為12822)個月,體重為9.5910kg,手術持續時間為6.44.57.2)小時,術中估計出血為估計血容量的80%49%92%),以上資料表示方法為中位數(25%75%百分位數)。由ROTEM®檢測到的纖維蛋白素原聚合作用受損是稀釋性凝血功能紊亂的主要根本問題。所有病例(如果需要)均通過反復給予人纖維蛋白原濃縮物(每次劑量30 mg/kg)而不輸注冰凍新鮮血漿和血小板達到了有效的止血,且無不良反應。所有小兒均在術後幾小時內順利脫離機械通氣,並儘快就能離開重症監護病房。

結論: 給予纖維蛋白原濃縮物可以有效改善小兒顱縫早閉手術中稀釋性凝血病的主要根本問題,即纖維蛋白素原的聚合和總體的凝血強度。

(薑旭暉   馬皓琳 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.


多功能襯墊式充氣加溫系統在近常溫的體外迴圈下心臟外科手術中的效果

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:一種新的襯墊式充氣加溫系統已可用於心臟外科手術。本試驗目的是驗證在近常溫體外迴圈手術中,標準體溫保護聯合襯墊式充氣加溫是否可以維持術中核心溫度,減少停機後體溫下降(體外迴圈停止後60min核心溫度下降最多)。

方法:常規、非急症心臟外科手術患者隨機分為兩組:常規體溫保護組(輸液加溫以及消極隔離,n=30)和常規保溫聯合使用積極的襯墊式充氣加溫系統(n=30 Arizant Healthcare Model 635, Eden Prairie, 明尼蘇達州)。圍術期用膀胱導管每15分鐘記錄核心體溫。比較兩組CPB前、CPB中及CPB後溫度差異。

結果:由於各種原因4例患者資料被剔除,剩餘常規處理組29例和充氣加溫組27例。兩組最初溫度相似,但充氣加溫組在體外迴圈開始時溫度高於常規處理組(36.3°C ± 0.6°C35.7°C ± 0.7°C, P = 0.002)。兩組體外迴圈中最低溫度(充氣組35.5°C ± 1.5°C比常規組35.3°C ± 1.3°C, P = 0.67)、體外迴圈結束時體溫(36.7°C ± 0.4°C36.6°C ± 0.4°C, P > 0.99)及出手術室即刻的體溫(36.5°C ± 0.4°C36.2°C ± 0.5°C, P = 0.36)均無差異。後下降兩組也無顯著差異(充氣加溫組0.03°C ± 0.54°C比常規組0.21°C ± 0.51°CP = 0.20)。

結論:在近常溫體溫管理中加入聯合襯墊式充氣加溫系統能夠顯著提高體外迴圈前的體溫,但對核心溫度無更多的臨床重要影響。

(邱鬱薇 馬皓琳 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.


適用於以麻醉為基礎的小兒慢性疼痛醫療方案的病兒群體的臨床特點

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:小兒慢性疼痛非常常見,且導致很多醫療費用,是個人和公眾都關注的健康問題。本研究的主要目的是為建立一個適用於以麻醉為基礎的小兒慢性疼痛治療方案的病兒的描述性臨床輪廓。我們打算將這個病人輪廓充當為需要評估的更正式人群的替代者。

方法:本研究使用定量觀察方法。獨立研究變數包括初步的疼痛相關診斷、疼痛症狀的持續時間、病人年齡、病人性別、保險狀態、完整的生物學家系單位、全日制學校出勤率、在家學習及抑鬱和/或焦慮共病。用以往研究證實很有效的一系列測量儀錶,從屬的研究變數包括病人自述的疼痛程度、病人自述或家長代述的健康相關的生活質量、不良家庭影響和父母滿意度。研究資料的收集發生於到慢性疼痛醫療診所初診時,但和醫護人員接觸前。

結果:研究物件(n = 100)大多是青少年女性,其慢性疼痛持續時間大於1年,疼痛常伴有臨床上明顯的焦慮和抑鬱。與國家和州立標準比較,生物學家系單位不完整 (P < 0.001)、不能參加全日制學校的學習 (P < 0.001)和需要家居教育(P < 0.001) 的百分比顯著不成比例。95%的本群患兒先前至少由一個其他亞專科治療過其慢性疼痛狀況。平均患兒自述或家長代述的健康相關生活質量評分(PedsQL總分)也明顯低於以前在風濕病患兒(P < 0.0001)、偏頭痛患兒(P < 0.0001)和癌症患兒 (P < 0.0001) 觀察到的PedsQL分值。

結論:患有慢性疼痛的病兒在接受麻醉為基礎的慢性疼痛治療計畫之前,大多接受過其他亞專科的治療,其健康相關的生活質量明顯較低。用常規方法估計慢性疼痛患兒健康相關的生活質量非常簡便,而且有實際意義。還需要將注意力集中于病兒應對機制的能力的連貫描述、有無使疼痛增強或減輕的父母行為,以及已經存在的父母疼痛和殘疾。

(張瑩譯  馬皓琳 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術的母親術前焦慮的比較

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

我們比較了孩子行門診手術的母親和自己行手術的女性病人的焦慮。我們發現母親與行腹部較大手術的病人有相似的焦慮,而與行較小手術的病人相比更為焦慮。母性焦慮的預測因素是孩子的年齡和母性的監護應對。

(彭中美 馬皓琳 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.



大鼠的肝臟缺血再灌注損傷模型中七氟醚與異氟醚麻醉的肝能量代謝及其不同的保護效應

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:我們研究了異氟醚和七氟醚對加溫的肝缺血再灌注(IR)模型中的細胞因數、肝組織的血流(HTBF)、貯能量及肝臟結構的影響。

方法:72Wistar鼠隨機分成3組:對照組,不進行吸入麻醉;七氟醚組,2%的七氟醚;異氟醚組,1.5%的異氟醚。在進行吸入麻醉30分鐘後,使這些大鼠肝缺血45分鐘及2小時和4小時的再灌注。在缺血期末、再灌注2小時、再灌注4小時分別處死一部分鼠。通過檢測天冬氨酸轉氨酶(AST)、丙氨酸轉氨酶(ALT)、HTBF、丙二醛、腫瘤壞死因數(TNF-{alpha}、白細胞介素(IL)-1β、能荷以及組織學檢查來評估肝臟損傷的程度。

結果:對照組和異氟醚組血清丙氨酸轉氨酶和天冬氨酸轉氨酶的水平相似,而七氟醚組在缺血後階段明顯降低(P < 0.01)。七氟醚組的HTBF顯著優於異氟醚組,而對照組較差。組織的丙二醛水平在再灌注2小時後七氟醚組明顯低於異氟醚組,而在對照組的缺血後階段達到最大值。在缺血後、再灌注2小時和4小時中,腫瘤壞死因數-{alpha}及白細胞介素-1β在七氟醚組最低,在對照組最高,但是沒有統計學意義(P > 0.05)。在七氟醚組,肝的三磷酸腺苷和能荷在所有測量時間點都明顯較高。在七氟醚及異氟醚組內,在缺血後階段的能荷比較低。七氟醚組的肝細胞損傷程度最小。

結論:在肝臟缺血前、缺血時、缺血後給予臨床上適當濃度的七氟醚都能很好的保護肝臟免於缺血再灌注損傷,而異氟醚對肝缺血再灌注損傷的效應不是很顯著。

(唐亮   馬皓琳 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.




高血糖減弱異氟烷在血管平滑肌細胞中誘導的ATP敏感的鉀通道啟動作用

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:異氟烷啟動血管ATP敏感鉀(KATP)通道,並可引起血管擴張。本研究中,我們探討高血糖是否改變異氟烷對血管KATP通道的啟動作用。

方法:血管平滑肌細胞分別在含正常葡萄糖(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)的培養基中孵育24h後,我們使用細胞粘附式的膜片鉗方法測試異氟烷對KATP通道活性的影響。主動脈中的過氧化物水平通過光澤精增強的化學發光技術進行測定。

結果:NG0.17 ± 0.02)和LG0.15 ± 0.02)相比,HG0.06 ± 0.01)孵育的動脈血管平滑肌細胞中異氟烷誘導的開放概率明顯減少(P < 0.05)。蛋白激酶CPKC)的抑制劑(鈣磷酸蛋白CPKC抑制劑20–28)預處理血管平滑肌細胞明顯減少HG對異氟烷誘導KATP通道活性的抑制作用。同時,PKC的啟動劑PMA可模擬HG的作用。HG孵育的動脈中過氧化物釋放明顯增加(18.3 ± 11.5相對光單位(RLU· s–1 · mg–1; NG比較P < 0.05)。用一種細胞滲透性過氧化物清除劑聚乙烯乙二醇-過氧化物歧化酶(250 U/mL)同時孵育,顯著減少HG誘導的過氧化物的增加,但無法減少HG對異氟烷誘導KATP通道活性的抑制作用。

結論:我們的實驗結果提示高血糖的代謝性應激可以削弱異氟烷誘導的血管KATP通道啟動作用(經過度啟動PKC介導)。在圍術期高血糖患者中,這可能妨礙其冠狀動脈對異氟烷的舒張反應從而導致缺血或缺氧。

(黃施偉 譯,馬皓琳 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.


志願者中光譜預測聽覺知曉

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

背景資料:從一個病人的角度看,術中記憶喪失是全麻的一個重要部分。在沒有特異性的方法來減少術中知曉的情況下,其發生率在普外科手術人群中約為0.2%,且可能在某些亞人群中會更高。我們嘗試檢驗了一種新的以光譜為基礎的臨床腦電圖監測儀預測知曉的有效性。

方法:我們用非盲交叉設計對16名志願者進行研究,來評價丙泊酚或七氟醚鎮靜過程中,光譜與行為指標之間的相關性。我們考慮到的指標包括單詞知曉和對於口頭指令的運動反應。同時我們測定了口頭指令對腦電圖的刺激性作用。用對數回歸、受試者操作特性以及預計概率來分析資料。

結果:狀態和反應與兩個反應指標均密切相關。在多種情況下這些參數的預計概率範圍在0.850.96之間。口頭指令運動反應以劑量和藥物依賴性方式增高

結論:在這群年輕健康的志願者中熵參數看來是預測知曉的可靠指標。這些研究結果認為將這些研究延伸到其他麻醉藥和手術病人是合理的。

(沈浩   馬皓琳 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.


母體兒茶酚胺對妊娠子宮微血管內徑的影響

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:伴隨著分娩鎮痛起效的母體兒茶酚胺改變包括腎上腺素(EPI)減少,但是去甲腎上腺素(NE)不變。因為在迴圈濃度中EPIβ腎上腺能作用為主,而NEα腎上腺能作用為主,因此我們推斷這樣的改變會引起子宮小動脈的收縮。

方法:18只臨產Sprague-Dawley大鼠中分離出來的子宮微血管(內徑73–120 µm),在保持近于正常氣壓的無流量狀態下用電鏡觀察。腔外給藥到表面灌流儲水池,並記錄血管穩態下的內徑。分別建立NENE中加入腎上腺素能拮抗劑呱唑嗪、EPI(類血栓素U46619預收縮血管20%30%後)及EPI中加入β腎上腺素能拮抗劑普萘洛爾和10–8 M EPI存在時給予NE的劑量效應曲線。洗出試驗模擬分娩鎮痛起效過程中母體兒茶酚胺的變化:同時加入10–8 MEPI 10–6.5 MNE (EC50)後只用NE洗,接著用β2腎上腺素能激動劑特布他林和NE。洗出規程在有普萘洛爾存在的情況下再重複一遍。

結果:NE引起劑量依賴性的血管收縮(P < 0.0001),可以被呱唑嗪阻斷(P < 0.0001)EPI加到經過U46619預收縮的微血管後,在低濃度時可以引起血管擴張,高濃度時引起血管收縮(P < 0.0001)。普萘洛爾可以逆轉這種單相的劑量依賴性血管收縮反應(P < 0.0001)。用10–8 M EPI預處理沒有經過預收縮的血管,可以顯著減弱NE引起的血管收縮作用(P < 0.0001)。在洗出試驗中,在NE持續存在的情況下,除出EPI可以引起血管收縮,且這種收縮作用可以被特布他林逆轉。普萘洛爾可以阻斷EPI和特布他林的作用。

結論:這些結果表明,EPI在產婦血漿中發現的濃度下可以擴張子宮阻力血管,並減弱由NE引起的血管收縮作用。這個觀察結果可能提示了人類孕婦分娩鎮痛起效時伴隨的子宮血流變化,因為有效的鎮痛伴隨著迴圈EPI水平的急性下降。

(黃佳佳譯,馬皓琳 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.



一過性腦缺血對加壓素誘導的兔腦血管收縮的影響

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:加壓素是一種心肺復蘇時選用的藥物,因為一些實驗研究已顯示,其在增加全身組織的灌注壓和改善腦灌注壓且不增加心肌氧耗方面優於腎上腺素。我們使用軟膜窗孔製品,觀察加壓素局部用於兔軟膜血管上時的作用及兔腦缺血後作用是否改變(n = 27)

方法:我們首先檢驗局部應用精氨酸加壓素(AVP) (10–11 M10–9 M10–7 M10–5 M,連續地)的作用。然後我們通過頸部驅血帶充氣加全身性低血壓,或單純全身性低血壓導致腦缺血5分鐘,並觀察腦缺血前後局部應用AVP(10–9 M10–7 M, 連續地)的作用。

結果(a)10–11 M AVP可擴張軟膜小動脈的直徑[7% ± 11% (P = 0.014 與基礎值比較)],但10–9 M10–7 M10–5 M AVP可收縮軟膜小動脈直徑[分別為7% ± 14%20% ± 14%16% ± 16% (P < 0.05)](b)低血壓前可收縮軟膜小動脈直徑(10–9 M AVP 收縮7% ± 10%, 10–7 M AVP收縮20% ± 15%),缺血前可收縮軟膜小動脈直徑(10–9 M AVP 收縮7% ± 11%10–7 M AVP 收縮21% ± 15% )。然而,缺血後5分鐘,由10–7 M AVP引起的血管收縮作用明顯下降,但不單是由於低血壓[低血壓對照組:10–9 M AVP 收縮7% ± 10%10–7 M AVP 收縮19% ± 14%;缺血組:10–9 M AVP 收縮5% ± 11%10–7 M AVP 收縮10% ± 13%(P = 0.35 與低血壓組對照)]

結論AVP的局部應用(這裏使用的最低濃度除外)可引起麻醉兔軟膜小動脈濃度依賴性血管收縮。在短暫(5分鐘)的腦缺血後,10–7 M AVP的血管收縮作用減少。

(裘毅敏譯,馬皓琳 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.



在接受異丙酚複合芬太尼麻醉的患者中神經肌肉阻滯水平對強直後運動誘發電位的幅度和經顱刺激的運動反應的影響

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:監測肌源性運動誘發電位(MEPs)過程中患者對經顱刺激的活動反應可能干擾手術。我們最近報導了一種可以增強肌源性MEPs幅度的新技術叫做“強直後MEPs(p-MEPs)”,該技術在經顱刺激前給予外周神經強直刺激。我們進行本研究來確定集中于患者運動的p-MEPs監測中神經肌肉阻滯的適當水平。

方法:15名異丙酚/芬太尼麻醉患者,記錄拇展肌對經顱電刺激反應的傳統MEPs (c-MEPs)p-MEPs。記錄p-MEPs時,在經顱刺激前6秒先給予脛後神經一個50mA強度、持續5秒的強直刺激。通過記錄對腕部正中神經超強電刺激的反應中的拇外展短肌複合肌肉動作電位(T1)的幅度來評估神經肌肉阻滯的水平。記錄T1為對照值的50%時的c-MEPp-MEP基線後,注射0.1 mg/kg維庫溴銨並記錄c-MEPsp-MEPs幅度。用範圍為14的運動評分評估患者運動(1=沒有運動,4=劇烈運動)。

結果:T1%T1c-MEPsp-MEPs的幅度及運動評分在給予維庫溴銨後平行改變。在維庫溴銨投藥前和投藥後1545分鐘p-MEPs的幅度比c-MEPs明顯高。當T1和%T1分別小於和等於1mV10%時,所有患者的運動評分為12,提示顯微鏡手術是能做得到的,而不會干擾手術操作。當T11 mV (0.8–1.2 mV)左右時,記錄c-MEPsp-MEPs的成功率分別是73% (11/15)100% (15/15)

結論:異丙酚/芬太尼麻醉下,T11mV時可以記錄p-MEP,這時患者對經顱刺激的運動反應不會干擾手術。這種技術可以用於不存在術前運動缺陷的患者,否則在手術操作中的患者運動不太可取。

(唐李雋 馬皓琳 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.


塞來考昔圍手術期給藥與僅僅在術後給藥對接受大的整形外科手術病人術後影響的比較

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

背景圍手術期應用環氧合酶(COX)-2抑制劑一直有著爭議。有一種假設是在大整形手術的術前或者術後應用塞來考昔並且在手術後連續應用三天能提高病人鎮痛效果以及改善臨床預後,我們設計這次隨機、雙盲、安慰劑對照實驗的目的就是為了證明這一假設。這次實驗的另外一個目的是為了弄清圍手術期應用塞來考昔是否比單單在術後應用更有優勢。

方法:120名接受大的整形外科手術(比如隆胸,腹壁成形術)的知情同意過的病人施行標準全身麻醉,被隨機分成了下面三組:1)對照組(n=40)術前和術後分別口服兩粒安慰劑,並且在術後三天口服安慰劑,一粒BID2)術後給藥組(n=40)術前口服兩粒安慰劑,術後口服兩粒塞來考昔(一粒200mg),術後三天口服塞來考昔,一粒200mg BID3)圍手術期給藥組n=40)術前3090分鐘口服兩粒塞來考昔(一粒200mg),術後口服兩粒安慰劑,術後三天口服塞來考昔,一粒200mg BID。術後每隔一定時間記錄下患者的疼痛評分、對鎮痛藥的需求以及不良反應。在手術後的第244872小時以及第七天隨訪評價患者的出院後疼痛、鎮痛需求、腸功能的恢復、日常活動的恢復、康復的質量以及病人對疼痛控制的滿意程度。

結果:與對照組相比,應用塞來考昔的兩組在術後首個三天在減少術後疼痛以及對阿片類鎮痛藥的需求上有著相似且明顯的效果(P < 0.01)。在應用塞來考昔的兩組中,病人腸功能和日常活動的恢復時間分別比對照組早1天和2天。另外,在應用塞來考昔的兩組中,病人對疼痛控制和康復質量的滿意度明顯比對照組提高(P < 0.05)

結論:手術當天以及術後三天口服塞來考昔400mg能有效改善大的整形外科手術病人術後的控制疼痛以及康復速度和質量。然而,圍手術期給藥與僅僅在術後給藥相比並沒有優勢。

(吳進   馬皓琳 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.



鞘內注射環氧化酶-1抑制劑、環氧化酶-2抑制劑或非選擇性抑制劑對疼痛行為和脊髓Fos樣免疫反應的影響

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:前列腺素由環氧化酶(COX)合成,被認為在傷害性感受在脊髓的傳遞中起重要作用。Fos的表達是脊髓神經元活化的指標。我們檢驗了鞘內注射選擇性和非選擇性COX抑制劑對脊髓C-Fos表達的影響。

方法:為檢驗COX-1COX-2在脊髓傷害性感受傳遞中的相對作用,我們檢測了選擇性COX-1抑制劑SC560、選擇性COX-2抑制劑塞來考昔和非選擇性COX抑制劑酮咯酸對福馬林誘發的行為和脊髓類c-Fos免疫反應(FLI)的影響。大鼠在後爪足底皮下注射福馬林(5%50μL)前分別鞘內注射上述藥物(306090µg)。對照組在注射福馬林前鞘內注射溶劑。

結果:給予塞來考昔或酮咯酸90µg的大鼠第一相縮爪行為減少,給予各劑量酮咯酸或90µg塞來考昔的大鼠第二相縮爪行為減少(P < 0.05)。給予塞來考昔或酮咯酸90µg的大鼠脊髓第I–II層區FLI明顯減少(P < 0.05)。相反,在脊髓第V–VI層區僅酮咯酸60µg90µg組出現FLI的大量減少(P < 0.05)。在脊髓第V–VI層區的FLI表達與第二相縮爪行為有顯著相關性((P < 0.05)

結論:COX-1COX-2的雙效抑制劑既抑制福馬林誘發的行為也抑制脊髓腰段各區FLI表達。FLI在脊髓第I–II層區的表達可能不是藥物產生抗-超敏反應能力的良好指標,而FLI在脊髓第V–VI層區的表達與第二相行為反應相關。

(顏濤 譯,馬皓琳 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.


患者自控持續斜角肌間溝阻滯能促進開放性肩部手術後的早期功能康復嗎?

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:肩部手術後早日活動在成功的功能康復中起重要作用。然而,術後疼痛常減少甚至妨礙有效的物理治療。我們研究了開放性肩部手術後由患者自控斜角肌間溝阻滯技術產生的鎮痛對早期功能康復的影響。

方法:87例患者隨機分成兩組:患者自控持續斜角肌間溝阻滯組(patient-controlled continuous interscalene block PCISB)和患者自控靜脈(阿片類)鎮痛組(patient-controlled analgesiaPCA)。術前行斜角肌間溝阻滯,另外鎮痛方案在麻醉後監護室中開始進行並持續72小時。術後第23天每天進行60min標準化物理治療。最大活動度被定義為在疼痛這個限制因素下所能達到的活動範圍。在術前1天和術後3天用能評估疼痛、日常生活活動、運動的力度和範圍的多模式評分系統(常數評分)來評價功能康復的效果。還通過術後72h和院內物理治療過程中的視覺類比評分來監測最大疼痛強度。

結果:斜角肌間溝阻滯的常數評分等級顯著提高。然而,兩組間可動性和力量亞評分無顯著差異。與PCA比較,6hP < 0.001)、24h P = 0.044)和72h P = 0.013)時的靜息疼痛評分以及術後48h時物理治療過程中的疼痛評分(P = 0.016) 證明PCISB更有效。

結論:與基於阿片類的PCA比較,PCISB改善鎮痛,但不促進肩關節早期功能恢復。

(朱 慧譯 馬皓琳 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.




鼻部手術中左旋布比卡因局部浸潤的收縮血管和鎮痛作用

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:在此項研究中,我們比較了切皮前給予行鼻部手術的病人2%利多卡因加腎上腺素(LA)和單純0.25%左旋布比卡因(LB)以術後鎮痛和收縮血管。  

方法:60例病人隨機分組,接受全麻下切皮前局部浸潤。LB組接受0.25%左旋布比卡因,LA組接受2%利多卡因加腎上腺素(增加容量注射)。記錄術中血流動力學變化、術前和術後血紅蛋白和紅細胞壓積值。記錄所有患者術後30分鐘及1281224小時的視覺類比標度(VAS)評分和最初24小時裏再予鎮痛治療的需要。

結果:在術後30分鐘和12812小時時,LB組的VAS評分低於LA組(分別為P < 0.0001P = 0.002P = 0.023P < 0.0001P = 0.011)。與LA組比較,LB組鎮痛藥的需要顯著降低(P=0.038)。LB組的術前和術後血紅蛋白和紅細胞壓積值有顯著差異性(P=0.0140.025)。LA組的術前和術後血紅蛋白和紅細胞壓積值有顯著差異性(P = 0.0310.024)

結論:我們認為,在鼻部手術中左旋布比卡因局部浸潤比利多卡因加腎上腺素的術後鎮痛作用顯著增加和持續時間更長。

(胡湘   馬皓琳 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.

 

抗凝血酶對VIII因數缺乏血漿中重組啟動VII因數凝血效應的影響

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(重組啟動VII因數)用於外傷和接受外科手術的病人時易有血栓形成的併發症,但在血友病人身上卻很少見。他們的出血體質和凝血酶形成減少有關,而rFVIIa可以促進凝血酶的形成。一般來說,從破損血管彌散出來的凝血酶很快被抗凝血酶(AT)滅活。評估AT水平對高凝後VIII因數缺乏的血漿中凝血酶形成的影響有助於更好的理解促凝因數如rFVIIa因數如何導致術後病人血栓形成。我們假設AT濃度的降低會增強VIII因數缺乏血漿中rFVIIa的促凝效應。

方法:利用血栓彈力圖和凝血酶化驗的方法做活體內比照研究VIII因數缺乏血漿和VIII因數/AT缺乏血漿中凝血酶的形成。評估加入的rFVIIa對這兩組效應的差別

結果:正如所料VIII因數缺乏的血漿中基於血栓彈力圖的血栓延遲形成的現象被rFVIIa所逆轉。當AT為正常值的20%-50%時,血栓形成加快,對rFVIIa的反應也得到強化。VIII因數缺乏的血漿中凝血酶形成和AT水平成負相關。補充的rFVIIa縮短凝血酶形成的延後時間,但對凝血酶形成的總量沒有影響。

結論:利用缺乏VIII因數的血漿作為凝血酶形成受抑模型,論證了活體內低AT水平增強rFVIIa的凝血效應。FVIII水平正常或升高的外傷和手術病人的AT減少被認為有潛在的血栓形成傾向。因此非血友病人接受FVIII治療期間監測AT水平有助於減少血栓形成的併發症。

(孫鵬飛譯 薛張綱校)

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.

 

限制性複溫和術後低溫在大鼠體外迴圈模型中對認知功能的作用

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:臨床研究未能證明低溫對預防體外迴圈( CPB )術後認知功能障礙( pocd )有顯著的好處 。有一種解釋為,也許是發生在CPB的結尾再加熱期間潛在地有害大腦極高熱,抵銷低體溫症的防護好處。在這項研究中,我們調查了CPB溫度的相對影響,再加熱戰略和在鼠CPB模型的手術後溫度

方法:四組雄性大鼠經手術準備,並受到90分鐘的體外迴圈。 A組為常溫( 37.5 )期間和之後體外迴圈。 B組進行了低溫( 32 ° C )的體外迴圈,在最後分流術時複溫至37.5 °C C組低溫( 32 °C )的體外迴圈,再是有限複溫至35 ℃之間。 D組有常溫體外迴圈與術後低溫( 35 ° C )誘導。依據術後3-9天在水迷宮中的表現比較各組的pocd。病理分析大腦( CA1區和CA3海馬區)也是一個依據。

結果:僅僅在( B組與A組)或體外迴圈後( D組與A組)低溫誘導對改善無明顯好處。低溫誘導在體外迴圈並持續到術後時期對POCD產生了一個顯著的改善,在水迷宮表現相對於其他所有溫度regimens C組與A組, P0.044 C組與B組, P0.011 C組與組發展, P值為0.012 在各小組中的組織病理學區別中未被展示。

結論 低體溫(32°C) CPB加上有限再加熱和長時期的手術後低體溫(35°C)減少大鼠CPB術後POCD的發生

(章一靜譯 薛張綱校)

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.

 

肺擴張和呼吸末正壓通氣在使用機械通氣的小兒麻醉中的效果

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:影像研究提示兒童全身麻醉時易引起肺膨脹不全。扶助呼吸及呼吸末正壓通氣有利於預防肺膨脹不全。然而兒童在全麻過程中的生理改變未得到闡明。

方法:在八個麻醉時使用機械通氣的兒童中(平均年齡:3.5歲;範圍2.3-6.5),我們測定平靜呼吸時的順應性(E(st))和氣流阻力(R(int)),及在使用恒定流量和吸氣末阻塞扶助呼吸時因組織的粘彈性所致的順應性及阻力(分別計為deltaEdeltaR),包括0呼吸末壓及5cmH2O呼吸末壓進行比較。

結果:當吸氣流量(V(I))恒定及終末零壓通氣時,吸氣末肺容量(總容量V(T))由8ML/kg增加致20ML/kg,導致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)。與使用呼吸末正壓通氣的結論相似。吸氣流量(V(I))8ML/kg增至26ML/kg及吸氣末肺容量(VT))恒定,終末零壓通氣時,E(st)1.09cmH2O/mL降到0.9cmH2O/mL, deltaR0.170.06P<0.01),但是R(int)deltaE沒有改變。呼吸末正壓通氣時順應性和阻力對吸氣流量和肺容量有相似的依賴性。

結論:在總容量增加(增至16mL/kg加呼吸末正壓通氣)時E(st)穩定下降提示當呼吸末正壓通氣時呼氣末舒張容量(功能殘氣量)顯著下降。終末零壓通氣和呼吸末正壓通氣時結論相似提示扶助呼吸和氧氣-氮氣通氣可以預防氣道閉塞。

(胡豔譯 薛張剛校)

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.

 

術前抑鬱症的一種有效篩查工具:老年抑鬱症評估簡表

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:抑鬱症是一種在外科術前患者中高發的心理疾患,對多數患者的術後轉歸產生嚴重影響。因此,獲得一種簡單快捷的抑鬱症篩查工具指導臨床治療和改善術後轉歸很有必要。

方法:本研究以非心外科手術外大型手術術前住院患者為研究物件,研究樣本人群中術前抑鬱症的患病率。同時,以老年抑鬱症評估簡表(GDS-SF)作為抑鬱症的評估工具,將結果按年齡、性別分組,驗證其與Beck抑鬱量表(BSI)評估結果的相關性,以評估該簡表作為篩查工具的可靠性。

結果:以BSI量表評估抑鬱症,在1043名術前候選者組成的樣本中,所獲抑鬱症患病率顯著高於健康社區人群患病率。抑鬱症女性發病較男性常見(P=0.02),老年人發病較中年和青少年少見(分別為P0.030.003)。此外,同一年齡組中,BDIGDS-SF的評估結果高度一致。

結論:上述資料再度證明術前人群抑鬱症篩查的必要性,並證實,作為醫生可選且可及的快速術前抑鬱症評估工具,GDS-SF量表的評估結果可靠。

(黃凝譯  薛張綱校)

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.

 

關於異丙酚合用70%氙與合用70%笑氣時50%有效濃度(EC50)的比較

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:氙在麻醉中有許多成功應用,例如疼痛控制及器官保護。然而它的MAC70%,因此無法單獨使用。在此,我們將異丙酚與氙合用達到50%95%有效麻醉時的用量與異丙酚合用笑氣時進行比較。

方法:我們將75名無術前應用70%氙及70%笑氣的女性患者隨機分成2組,每組的第一位患者在麻醉誘導時予以吸氧及4.5 µg/mL靶濃度的異丙酚。用Dixon的上下來回法決定下一位患者的異丙酚濃度。異丙酚起效後,給予患者面罩吸氧氣及70%氙或70%笑氣15分鐘。隨後觀察她們在切皮時及其後60秒內的反應,記錄為運動或不動。應用概率分析比較異丙酚在各組的50%有效濃度及95%有效濃度(EC50EC95)。

結果:異丙酚合用70%氙的EC501.5µg/mLEC952.3 µg/mL。異丙酚合用70%笑氣的EC50EC95分別為2.2 8.2 µg/mL。在相同有效濃度下,合用70%氙時異丙酚所需用量為合用70%笑氣時的32%72%。聽力覺醒在吸入氙時較吸入笑氣時更易發生。

結論:氙比笑氣更有效,但在切皮前後仍需合用少量催眠藥以對抗刺激作用。

(施穎譯 薛張綱校)

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.

 

異丙酚對人類5-HT3A受體的分子作用:通過相似的酚類衍生物增強和抑制

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受體是與術後噁心和嘔吐有關的興奮性配體門控離子通道,它們能夠被麻醉劑異丙酚抑制,相反,增強抑制性配體門控離子通道如r-氨基丁酸A型受體及甘氨酸受體的效應。為了研究這種完全相反的作用的分子機制,我們研究了異丙酚和其次級疏水衍生物2 -異丙基酚和苯酚對人體5-HT3A受體的作用。

方法:包含能夠穩定轉錄5-HT3A受體亞基的cDNA的人類胚胎腎293細胞作為膜片鉗(游離膜外面向外式膜片)。用快速溶解交換系統( 2毫秒)應用藥物 ,其濃度通過高效液相色譜法測定。

結果:當應用至平衡狀態(5 -羥色胺脈衝前60秒及脈衝期間),異丙酚能抑制人5-HT3A受體(IC50 = 18 ± 1.0 µM),令人驚異的是,在平衡時,次級疏水衍生物抑制 5-HT3A受體的效價與異丙酚相似(IC50 = 17 ± 3.2 µM),而苯酚的效價則很低 IC50 = 1.6 ± 0.2 mM)。在電流引出前改變給藥持續時間, 然後在藥物仍然存在時加入 5-HT,異丙酚的(平衡)效應有快慢兩個過程([tau]IN-1 = 35 ms[tau]IN-2 = 4.8 s);2 -異丙基酚為[tau]IN-1 = 64 ms[tau]IN-2 = 6.6 s;苯酚為[tau]IN-1 < 10 ms[tau]IN-2 = 20.4 s。當與5-HT一同短時間內給藥(開放式給藥),異丙酚明顯地抑制電流,加速5-HT誘導的脫敏作用 ,相反,2-異丙基酚和苯酚增強電流,減慢脫敏作用。慢脫敏作用也在5-HT的衍生物5-羥吲哚(1mM)上被觀察到,苯卻沒有。當5-HT濃度從30降到3µM時,苯酚、2 -異丙基酚、異丙酚的快速效應更顯著,而慢速效應則對5-HT不敏感。

結論:異丙酚被證實對5-HT3A受體至少有兩種相互獨立的作用,而在兩種相關的較小分子的酚類衍生物中所看到的增強作用則不能被檢測到。5-HT依賴和5-HT非依賴兩種相互作用因為這三種藥物而著稱。從其疏水性來看,異丙酚的效價比期望的低。潛在機制似乎涉及酚羥基,疏水相互作用並和空間結構限制。

(宣麗真譯 薛張綱校)

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.

 

用第二代動脈壓波形儀對心臟手術病人評估心輸出量的有效性

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:近來介紹過的一種能根據動脈波形來測定心輸出量而不需要行有創監測(FloTrac/VigileoTM)的儀器仍備受爭議。因此我們在心臟手術病人中設計了一個現況研究,通過與經肺動脈導管以間歇熱稀釋法測定心輸出量的比較,來評價這種經改良的檢測技術。

方法:40ASA分級為III級行冠脈搭橋(CPB)手術的病人被選入此項研究。經同步熱稀釋法及FloTrac/Vigileo儀分別在誘導後即刻(設時間為T1),行CPB之前(T2),行CPB之後(T3),關閉胸骨之後(T4),入ICU即刻(T5) ,及術後4h (T6)8h (T7)24h (T8) 測得心輸出量(CO),再由體表面積換算得心輸出指數(CI)。最後我們設定一個30%的差錯率來作為該新方法與標準的熱稀釋法間的評判標準。

 

結果:我們共分析了所得的282對測量資料。經熱稀釋法測得的CI其範圍從1.24.1 L /(min · m2) (平均2.5 ± 0.54 L /(min · m2))。偏倚和精確度(設精確度為偏倚的1.96個標準差)0.19 L /(min · m2) ± 0.60 L /(min · m2),顯示在整個圍手術期(T1–8) 用第二代動脈壓波形儀評估CI其總的差錯率為24.6%,而通過對單在手術期間(T1–4)ICU(T5–8)這兩個亞組的分析,又可得出其差錯率分別為28.3%20.7%

結論:在行冠脈搭橋手術的病人中,經改良的第二代半侵入式動脈波形儀在手術期間及手術後所測得的CI值,與以間歇熱稀釋法測定的CI值顯示了很好的一致性。

(劉沁譯 薛張綱校)

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.

 

食管部分切除術中胸段硬膜外應用布比卡因與靜脈內腎上腺素輸注對胃管引流的影響

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:胃管壞死是食管部分切除術後吻合口漏的一個主要原因。胃管末端吻合口處引流量的減少與吻合口漏有關。

方法:我們前瞻性的研究了術中胸段硬膜外應用布比卡因與之後腎上腺素的輸注對血流動力學及胃管引流量的影響。

結果:給予硬膜外藥物顯著地減少了胃管末端吻合口引流量(P<0.01),輸注腎上腺素後胃管引流量恢復到基線水平。

結論:胸段硬膜外布比卡因的給予會減少胃管末端吻合口處的引流量。

(劉婷潔譯 薛張綱校)

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.

                                                                       

可樂定輸注在志願者中對區域腦血流分佈的影響

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腎上腺素受體激動劑能通過它對藍斑的作用在大腦的意識功能部分保留時起到快速而可逆的鎮靜作用。我們這次觀察性研究的目的,就是想摹繪出哪些腦區的活動會被輸注可樂定而影響,從而更好的瞭解它的作用區域,特別是瞭解它與鎮靜作用之間的關係。

方法:此次研究由六個ASA 評分I~II級的右利手志願者參加。他們的腦電圖被持續監測。在得到一個由掃描H215O活動所標定的基線之後,可樂定開始以6 10 µg · kg–1 · h–1的速率輸注。於是就得到一個每8分鐘為一間隔的由11個相似掃描結果組成的序列。與此同時測量受試者的血漿可樂定濃度。最後使用統計學的參數圖形分析,找出標化的區域腦血流(rCBF),即該腦區活動的指示參數,與血漿中可樂定的濃度或腦電圖梭形波之間的線性關係。

結果:可樂定能引起臨床上的鎮靜作用以及腦電圖波形變化(即出現梭波),這種波形與非快動眼睡眠早期的波形相類似。統計學分析後,發現在丘腦區、前額葉、眶上回及頂葉聯合腦區大腦皮質、背扣帶回大腦皮質、楔前葉,可樂定濃度與區域腦血流(rCBF,即腦電圖出現梭形波)呈統計學意義的負線性相關關係。

結論:在可樂定誘發的鎮靜期間,我們觀察到的腦電圖變化以及某些腦區的區域腦血流減少,與非快動眼期睡眠中的腦電圖與區域腦血流變化相似。同時受抑制的腦區的腦電圖變化也與全麻期間以及植物人狀態下的腦電圖變化相似。這些發現都支持了這樣一個假設,即在這些非自然的意識狀態下,所發生的改變都是通過相同的作用網路發生的。

(秦敏菊譯 薛張綱校)

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.

 

腸道準備引起的脫水不會導致老年人認知功能障礙

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:術後認知功能障礙在接受非心臟手術的患者中有相當的發生幾率,而老年病人尤為易患。我們假定,脫水這一老年患者常見的圍手術期問題,可能引起認知功能障礙。我們利用無外科手術及麻醉干擾因素的病例來確定腸道準備引起的脫水是否會導致認知力改變。

方法:有38例處於術後認知功能障礙高發年齡段的患者參加我們的前瞻性研究。另有一個包括14位患者的對照組,接受腸鏡檢查,而不做任何腸道準備,按照年齡、教育程度和性別配對。

結果:接受腸道準備的患者出現總體重下降(1.5 kg [95% CI: 0.9–2.2]; P < 0.001),而接受腸鏡檢查的患者沒有體重改變。通過足部生物電阻抗法測量出的總體液量顯示,腸道準備組患者總體液量下降了2.6%,並且只有腸道準備組患者的紅細胞壓積上升(腸道準備前0.41 [0.40–0.43],腸道準備後0.43 [0.42–0.45]; P = 0.003)。在這種程度的脫水情況下,所有認知功能測驗結果與總體樣本平均值的差距小於一個標準差。重複測量的方差分析指出,在運動速度、執行功能、連線測驗和記憶力方面沒有顯著的組內差異,只有在學習能力方面有3秒的延遲。脫水狀態不影響學習(P = 0.42)、記憶力(P = 0.30)、運動速度(P = 0.36),以及執行功能測驗(P = 0.26)

結論:僅僅脫水並不至引起認知功能障礙。

(夏俊明譯  薛張綱校)

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.

 

 發展中國家的麻醉和相關學科的現狀:一項尚比亞共和國的全國性調查

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:全球的發展中國家有很多手術干預的治療。為了改善這些國家手術病人的狀況,有必要明確有關麻醉基本問題和病人的需求。通過這項調查,我們評估了尚比亞共和國的麻醉和相關學科(包括重症醫學、急診醫學和疼痛治療)的目前狀態。

方法:問卷被分發至尚比亞衛生部註冊過的87家醫院。問卷分為5個部分111個問題:包括綜合性醫院的資訊、麻醉、重症監護、急診醫學、和疼痛治療。

結果:八分之六的問卷被統計了(78%)。最常見的手術是婦產科和腹部手術。氯胺酮是最常用於全身麻醉的藥物(50%)。10%的病人實行氣管插管進行全麻。在大多數醫院(78%)沒有專業醫師進行麻醉。68個醫院中只有5家(7%)有重症監護室,總共也只有29張床。麻醉醫生幾乎不參與急診治療和疼痛治療。

結論:尚比亞共和國的醫學處於極度落後和資源貧乏狀態。

(陳珺珺譯 薛張綱校)

 

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.

 

嗎啡鞘內注射抑制爪炎症性水腫:一氧化氮(NO)和環磷鳥苷(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:在動物試驗中嗎啡能抑制炎症性水腫。但嗎啡發揮這種作用的機制和作用位點仍有爭議。因脊髓水平是炎症神經原性成分的調節部位,我們在角叉藻聚糖(CG)誘導引起的爪水腫動物中研究鞘內注射嗎啡的效應和脊髓NO/ cGMP通路的作用。

方法:男性Wistar大鼠接受鞘內注射嗎啡(20uL),間隔30分鐘後用150ug CG對動物爪進行刺激。採用爪體積增加(ml)測定水腫和髓過氧化物酶(MPO)分析間接評價中性粒細胞遷移。

結果:嗎啡(37, 75150 nmol)能抑制炎症性水腫,但對MPO的活性無影響。同時注射納絡酮(64 nmol)可以逆轉嗎啡的效應。在嗎啡注射前90分鐘使用皮質類固合成抑制劑醇氨魯米特(50mg/kg)不會改變其消水腫的作用。低劑量NO合成酶抑制劑L-精氨酸(1030 pmol之間)會加重水腫,而大劑量(3 30 nmol之間)則抑制爪水腫。使用鳥苷酸環化酶抑制劑1H-oxadiazolo[4,3-a]quinoxalin-1-oneODQ,21 42 nmol之間)水腫增加,磷酸二酯酶-5亞型抑制劑昔多芬(0.15 1.5 nmol之間)則可以抑制試驗動物的爪水腫。亞效應劑量L-精氨酸(3 pmol)ODQ(10 nmol)與嗎啡同時注射則會抑制後者的抗水腫作用。但是昔多芬(0.15 nmol)能使亞效應劑量的嗎啡發揮其正常效應(18 nmol)。再者ODQ也能抑制NO前體S-亞硝基-N –乙酰基青黴素的抗水腫作用。

 

結論:這些研究結果表明嗎啡能作用于脊髓水平的阿片受體從而產生抗水腫效應,並且NO/cGMP通路在此效應中可能是一重要的調節通路。

(蔣宗明譯 薛張綱校)

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.

 

固定劑量的氟烷、異氟醚或異丙酚,並沒有優先抑制帶有上行投射的腰段脊髓背角神經元的實驗鼠的有害熱誘發反應

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:揮發性麻醉藥是通過作用於脊髓產生感覺喪失和制動作用。根據這種理論,麻醉藥的作用位點是有限的。先前的證據表明,相比於局部脊髓中間神經元,帶有上行投射的脊髓背角神經元對全麻藥引起的抑制作用更易感。在我們的這項研究中,我們評估的揮發性麻醉藥和靜脈麻醉藥作用于脊髓腰段背角神經元,分別在有上行投射和沒有投射情況下的區別。

方法37只成年雄鼠的頸1椎板被切除,用於放置刺激電極;切除胸13/1椎板,用於記錄脊髓背腳細胞外的反應。分別給予兩種劑量的氟烷、異氟醚或異丙酚,評估對於熱刺激的神經反應。

結果:用氟烷和異氟醚麻醉,分別增加劑量,MAC0.8增加到1.2,相比於逆行刺激(AD)或沒有上行投射(nAD),含有上行投射的神經元並沒有明顯影響熱誘發反應。靜脈給予35mg/kg異丙酚後,AD神經元的熱反應分別降低了60% ± 18% (平均數±標準差) and 39% ± 14% 。同樣,在nAD神經元,分別給予35mg/kg異丙酚,熱反應下降至56% ± 14% and 50% ± 10%

結論:我們的研究表明,在相近的MAC情況下,相比于沒有上行投射的神經元,這些全麻藥並沒有優先抑制有上行投射的腰段脊髓背角神經元對熱刺激的反應。

(陳珺珺譯 薛張綱校)

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.

 

腰麻時預先擴容對腦脊液的性質和等比重的局麻藥的擴散的影響

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:在這項有兩部分組成的臨床研究中,我們調查了“預先擴容”對腦脊液(CSF)的物理性質和局麻藥在椎管內分佈的影響。

方法:首先,在臨床方面,對進行腰麻的68個病人被隨機的分為了兩組,一組預先給予10ml/kg乳酸林格氏液擴容,所有病人在腰段注射12mg  0.5%等比重的丁卡因。評估病人的動脈血壓、心率和阻滯平面。其次,在核磁共振影像研究中,招募了24名男性志願者。在輸注了10ml/kg的乳酸林格氏液後,測量了CSF的流動變化,以此檢測腰23水平CSF流量和容積的漂移。

結果:臨床研究中,兩組的動脈血壓、心率、阻滯平面的高峰並沒有明顯的差別,但是兩組到達阻滯高峰的達峰時間的中位數有差別(26.4 ± 15.7 vs 16.5 ± 9.2 min, P < 0.05),明顯長於對照組。在核磁共振影像中,擴容後CSF的回流明顯增加,但是每搏輸出量,絕對每搏輸出量,平均流量,搏距和向頭端方向的平均速率均下降。

結論:預先快速輸注晶體擴容可以影響腰段CSF流量,減少0.5%的等比重的丁卡因向頭端擴散,並且延遲到達阻滯峰值的達峰時間。

(陳珺珺譯 薛張綱校)

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,簡化鎖骨下臂叢阻滯的進路

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.

 

在這項觀察性研究中,我們使用了Doppler超聲用於垂直鎖骨下臂叢阻滯的操作。使用Doppler超聲的穿刺到鎖骨下動脈的影像的位置,記錄所用時間,並且傳統的穿刺方法相比較。100個病人中有89個病人,一次性就穿過中間索和後索。相比于傳統的穿刺,使用Doppler穿刺點明顯外側(P < 0.001),鎖骨下阻滯穿刺的成功速率也因此提高。

(陳珺珺譯 薛張綱校)

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.