Table of Contents

April 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

严格控制心率能提高β-阻滞药的功效吗?对非心手术随机试验的最新分析

孙鹏飞译 薛张纲校

Does Tight Heart Rate Control Improve Beta-Blocker Efficacy? An Updated Analysis of the Noncardiac Surgical Randomized Trials

W. Scott Beattie, Duminda N. Wijeysundera, Keyvan Karkouti, Stuart McCluskey, and Gordon Tait

Anesth Analg 2008 106: 1039-1048.

七氟烷引起离体心肌线粒体基质容积的特异性增加

黄施伟 译,马皓琳 李士通 校

Differential Increase of Mitochondrial Matrix Volume by Sevoflurane in Isolated Cardiac Mitochondria

Matthias L. Riess, Alexandre D. Costa, Richard Carlson, Jr, Keith D. Garlid, André Heinen, and David F. Stowe

Anesth Analg 2008 106: 1049-1055.

65岁以上病人髋关节成形术后贫血与生活质量关系

陶颖莹 陈杰

Postoperative Anemia and Quality of Life After Primary Hip Arthroplasty in Patients Over 65 Years Old

Niamh P. Conlon, Eilis P. Bale, G. Peter Herbison, and Maire McCarroll

Anesth Analg 2008 106: 1056-1061.

病例系列报道:输血时高钾所致的心跳骤停

刘沁译 薛张纲校

Cardiac Arrests Associated with Hyperkalemia During Red Blood Cell Transfusion: A Case Series

Hugh M. Smith, Stacy J. Farrow, SRNA, Joel D. Ackerman, James R. Stubbs, and Juraj Sprung

Anesth Analg 2008 106: 1062-1069.

猪稀释性凝血障碍模型的凝血特征及使用凝血酶原复合体浓缩物替代治疗的效果

邱郁薇 马皓琳 李士通

Characterization of the Coagulation Deficit in Porcine Dilutional Coagulopathy and Substitution with a Prothrombin Complex Concentrate

Gerhard Dickneite, Baerbel Doerr, and Franz Kaspereit

Anesth Analg 2008 106: 1070-1077.

出血性休克的猪用小容量高渗盐水/羟乙基淀粉复苏较4%明胶或6%羟乙基淀粉溶液复苏相比具有较轻的止血功能障碍和较少失血

赵燕星 陈杰

Less Impairment of Hemostasis and Reduced Blood Loss in Pigs After Resuscitation from Hemorrhagic Shock Using the Small-Volume Concept with Hypertonic Saline/Hydroxyethyl Starch as Compared to Administration of 4% Gelatin or 6% Hydroxyethyl Starch Solution

Thorsten Haas, Dietmar Fries, Carmen Holz, Petra Innerhofer, Werner Streif, Anton Klingler, Alexander Hanke, and Corinna Velik-Salchner

Anesth Analg 2008 106: 1078-1086.

抗纤溶疗法在先天性心脏病手术中的应用

秦敏菊译 薛张纲校

Antifibrinolytic Therapy in Surgery for Congenital Heart Disease (Review Article)

Michael P. Eaton

Anesth Analg 2008 106: 1087-1100.

PEDIATRIC ANESTHESIOLOGY:

丙泊酚靶控输注时双谱指数和丙泊酚血药浓度的关系:儿童和青年人对照研究

张莹译  马皓琳 李士通校

The Relationship Between Bispectral Index and Propofol During Target-Controlled Infusion Anesthesia: A Comparative Study Between Children and Young Adults

Agnes Rigouzzo, Laure Girault, Nicolas Louvet, Frederique Servin, Tom De-Smet, Veronique Piat, Robert Seeman, Isabelle Murat, and Isabelle Constant

Anesth Analg 2008 106: 1109-1116.

昂丹司琼咀嚼片对接受耳鼻喉手术的小儿在家出现呕吐的治疗效果

潘钱玲 陈杰

The Effects of Oral Ondansetron Disintegrating Tablets for Prevention of At-Home Emesis in Pediatric Patients After Ear-Nose-Throat Surgery

Peter J. Davis, Kathleen M. Fertal, Karen R. Boretsky, Gina M. Fedel, Michael D. Ingram, Susan K. Woelfel, Paul C. Hoffmann, Harshad Gurnaney, and Michael C. Young

Anesth Analg 2008 106: 1117-1121.

儿童麻醉中拔除喉罩与拔除气管导管时呼末七氟迷浓度比较

胡艳译  薛张刚校

A Comparison of the End-Tidal Sevoflurane Concentration for Removal of the Laryngeal Mask Airway and Laryngeal Tube in Anesthetized Children

Jeong-Rim Lee, Young-Sun Lee, Chong Sung Kim, Seong Deok Kim, and Hee-Soo Kim

Anesth Analg 2008 106: 1122-1125.

AMBULATORY ANESTHESIOLOGY:

择期整形手术前行手术当日妊娠试验实行一年的经验

胡湘    马皓琳 李士通 校)

One-Year Experience with Day-of-Surgery Pregnancy Testing Before Elective Orthopedic Procedures

Richard L. Kahn, Maureen A. Stanton, Sarani Tong-Ngork, Gregory A. Liguori, Chris R. Edmonds, and David S. Levine

Anesth Analg 2008 106: 1127-1131.

肥胖病人颈围增加对困难插管评估的重要性

王腾 陈杰

The Importance of Increased Neck Circumference to Intubation Difficulties in Obese Patients

Hélène Gonzalez, Vincent Minville, Khedija Delanoue, Michel Mazerolles, Dominique Concina, and Olivier Fourcade

Anesth Analg 2008 106: 1132-1136.

ANESTHETIC PHARMACOLOGY:

在受toll样受体2刺激的单核细胞中μ型阿片受体介导了吗啡导致的肿瘤坏死因子和白介素-6生成受抑

黄凝译  薛张纲校

The µ Opioid Receptor Mediates Morphine-Induced Tumor Necrosis Factor and Interleukin-6 Inhibition in Toll-Like Receptor 2-Stimulated Monocytes

Marie-Pierre Bonnet, Hélène Beloeil, Dan Benhamou, Jean-Xavier Mazoit, and Karim Asehnoune

Anesth Analg 2008 106: 1142-1149.

七氟醚介导的p38丝裂原活化的应激酶的活化与Jurkat T细胞的凋亡无关

吴进   马皓琳 李士通

Sevoflurane-Mediated Activation of p38-Mitogen-Activated Stresskinase is Independent of Apoptosis in Jurkat T-Cells

Martin Roesslein, Michael Frick, Volker Auwaerter, Matjaz Humar, Ulrich Goebel, Christian Schwer, Klaus K. Geiger, Heike L. Pahl, Benedikt H. J. Pannen, and Torsten Loop

Anesth Analg 2008 106: 1150-1160.

氟哌利多抑制HERG钾通道取决于通道门状态及S6残基F656

张燕 陈杰

Inhibition of the HERG Channel by Droperidol Depends on Channel Gating and Involves the S6 Residue F656

Tao Luo, Ailin Luo, Miu Liu, and Xianyi Liu

Anesth Analg 2008 106: 1161-1170.

通过BISNCT指数来比较在七氟醚麻醉中使用和不使用药效平顶效应的药效学模型

宣丽真译 薛张纲校

Comparative Pharmacodynamic Modeling Using Bispectral and Narcotrend-Index With and Without a Pharmacodynamic Plateau During Sevoflurane Anesthesia

Sascha Kreuer, Jörgen Bruhn, Elisabeth Walter, Reinhard Larsen, Christian C. Apfel, Ulrich Grundmann, Andreas Biedler, and Wolfram Wilhelm

Anesth Analg 2008 106: 1171-1181.

TECHNOLOGY, COMPUTING, AND SIMULATION:

脉搏变异指数是否能够指示出在脉搏描记图和动脉压波形中呼吸引起的变异?

唐亮   马皓琳 李士通   

Does the Pleth Variability Index Indicate the Respiratory-Induced Variation in the Plethysmogram and Arterial Pressure Waveforms?

Maxime Cannesson, Bertrand Delannoy, Antoine Morand, Pascal Rosamel, Yassin Attof, Olivier Bastien, and Jean-Jacques Lehot

Anesth Analg 2008 106: 1189-1194.

手术室内为了监测液体反应性的一种自动估算动脉脉压中呼吸变化的新颖运算方式的能力

慧译 马皓琳 李士通校

The Ability of a Novel Algorithm for Automatic Estimation of the Respiratory Variations in Arterial Pulse Pressure to Monitor Fluid Responsiveness in the Operating Room

Maxime Cannesson, Juliette Slieker, Olivier Desebbe, Christian Bauer, Pascal Chiari, Roland Hénaine, and Jean-Jacques Lehot

Anesth Analg 2008 106: 1195-1200.

心脏手术后通过实时监测脉压波动来指导液体治疗

胡潇 陈杰

Online Monitoring of Pulse Pressure Variation to Guide Fluid Therapy After Cardiac Surgery

Jose Otavio Auler, Jr., Filomena Galas, Ludhmila Hajjar, Luciana Santos, Thiago Carvalho, and Frédéric Michard

Anesth Analg 2008 106: 1201-1206.

关于通过麻醉-保护装置(AnaConDa)调整七氟醚用量的药代动力学模型预测效果:临床研究

施颖译 薛张纲校

The Predictive Performance of a Pharmacokinetic Model for Manually Adjusted Infusion of Liquid Sevofluorane for Use with the Anesthetic-Conserving Device (AnaConDa): A Clinical Study

Javier F. Belda, Marina Soro, Rafael Badenes, Andreas Meiser, María Luisa García, Gerardo Aguilar, and Francisco J. Martí

Anesth Analg 2008 106: 1207-1214.

SURGICAL ANESTHESIOLOGY:

地氟醚与氟烷相比可以对线粒体功能提供更多保护作用对抗大鼠前脑缺血再灌注损伤

姜旭晖   马皓琳 李士通

Desflurane Affords Greater Protection Than Halothane in the Function of Mitochondria Against Forebrain Ischemia Reperfusion Injury in Rats

Bing Zhang, Xia Wei, Xiaoguang Cui, Huacheng Zhou, Wengang Ding, and Wenzhi Li

Anesth Analg 2008 106: 1242-1249.

ANALGESIA:

静注单剂量地塞米松减轻全髋成形术后的运动性疼痛

陈伟 陈杰

Single-Dose Dexamethasone Reduces Dynamic Pain After Total Hip Arthroplasty

Kenneth J. Kardash, Frederic Sarrazin, Michael J. Tessler, and Ana M. Velly

Anesth Analg 2008 106: 1253-1257.

膝关节置换中使用塞来考昔<抗关节炎药,COX-2抑制剂>的前瞻性随机试验:改良的临床成果

刘婷洁译 薛张纲校

A Prospective Randomized Trial on the Role of Perioperative Celecoxib Administration for Total Knee Arthroplasty: Improving Clinical Outcomes

Scott S. Reuben, Asokumar Buvenandran, Brennan Katz, and Jeffrey S. Kroin

Anesth Analg 2008 106: 1258-1264.

慢性幻肢痛:降钙素、氯胺酮及其联合应用对痛阈和感觉阈的作用

潘方立 陈杰

Chronic Phantom Limb Pain: The Effects of Calcitonin, Ketamine, and Their Combination on Pain and Sensory Thresholds

Urs Eichenberger, Frank Neff, Gorazd Sveticic, Steinar Björgo, Steen Petersen-Felix, Lars Arendt-Nielsen, and Michele Curatolo

Anesth Analg 2008 106: 1265-1273.

血管内注射腰内侧支传导阻滞:前瞻性的评价1433注射

章一静译 薛张纲校

Intravascular Injection in Lumbar Medial Branch Block: A Prospective Evaluation of 1433 Injections

Chul Joong Lee, Yong Chul Kim, Jae Hyuck Shin, Francis Sahngun Nahm, Hyo Min Lee, Yun Suk Choi, Sang Chul Lee, Justin Sang Ko, Tae Hyeong Kim, Woo Seok Sim, Chung Su Kim, and Hyun Sung Cho

Anesth Analg 2008 106: 1274-1278.

腰骶椎移行病人腰骶神经根皮区变异

张曦 译,马皓琳 李士通

Dermatome Variation of Lumbosacral Nerve Roots in Patients with Transitional Lumbosacral Vertebrae

Yang Hyun Kim, Pyung Bok Lee, Chul Joong Lee, Sang Chul Lee, Yong Chul Kim, and Jin Huh

Anesth Analg 2008 106: 1279-1283.

在大鼠胸深层肌肉离断后背角小胶质细胞环氧合酶- 1和神经元环氧合酶-2上调

杜唯佳 陈杰

Upregulation of Dorsal Horn Microglial Cyclooxygenase-1 and Neuronal Cyclooxygenase-2 After Thoracic Deep Muscle Incisions in the Rat

Jeffrey S. Kroin, Mayumi Takatori, Jinyuan Li, Er-Yun Chen, Asokumar Buvanendran, and Kenneth J. Tuman

Anesth Analg 2008 106: 1288-1295.

对啮齿类神经痛模型给予咪达唑仑可逆转热痛觉过敏以及{gamma}-氨基丁酸转运体的丢失

夏俊明译 薛张纲校

Midazolam Administration Reverses Thermal Hyperalgesia and Prevents {gamma}-Aminobutyric Acid Transporter Loss in a Rodent Model of Neuropathic Pain

Andre Shih, Vjekoslav Miletic, Gordana Miletic, and Lesley J. Smith

Anesth Analg 2008 106: 1296-1302.

异氟醚单独应用或与芬太尼合用可抑制伤害性刺激诱导的大鼠腰段脊髓C-Fos基因表达

周雅春 马皓琳 李士通

Suppression of Noxious-Induced C-Fos Expression in the Rat Lumbar Spinal Cord by Isoflurane Alone or Combined with Fentanyl

Mathieu G. Sommers, Nha-Khanh Nguyen, Jan G. Veening, Kris C. Vissers, Merel Ritskes-Hoitinga, and Jan van Egmond

Anesth Analg 2008 106: 1303-1308.

米那普仑对脊神经结扎鼠的抗痛觉超敏和抗痛觉过敏作用

於章杰 陈杰

Antiallodynic and Antihyperalgesic Effect of Milnacipran in Mice with Spinal Nerve Ligation

Takahiro Suzuki, Kazuyoshi Ueta, Shinji Tamagaki, and Takashi Mashimo

Anesth Analg 2008 106: 1309-1315.

神经刺激仪探针置管用于全膝关节成形术后连续股神经阻滞的随机、对照、双盲试验

蒋宗明译 薛张纲校

Stimulating Catheters for Continuous Femoral Nerve Blockade After Total Knee Arthroplasty: A Randomized, Controlled, Double-Blinded Trial

Michael J. Barrington, David J. Olive, Craig A. McCutcheon, Christopher Scarff, Simone Said, Roman Kluger, Nicola Gillett, and Peter Choong

Anesth Analg 2008 106: 1316-1321.

静脉注射格拉司琼对布比卡因鞘内麻醉感觉和运动阻滞的影响

沈浩   马皓琳 李士通校

The Effects of Intravenous Granisetron on the Sensory and Motor Blockade Produced by Intrathecal Bupivacaine

Hany A. Mowafi, Samer A. Arab, Salah A. Ismail, and AbdulMohsin Al-Ghamdi

Anesth Analg 2008 106: 1322-1325.

 

 65岁以上病人髋关节成形术后贫血与生活质量关系

Postoperative Anemia and Quality of Life After Primary Hip Arthroplasty in Patients Over 65 Years Old

Niamh P. Conlon, FCARCSI*, Eilis P. Bale, RGN*, G. Peter Herbison, MSc{dagger}, and Maire McCarroll, FCARCSI*

From the *Department of Anesthesia, Cappagh National Orthopaedic Hospital, Finglas, Dublin, Ireland; and {dagger}Department of Preventive and Social Medicine, Dunedin School of Medicine, Dunedin, New Zealand.

Anesth Analg 2008 106: 1056-1061.

 

背景:目前尚不清楚贫血对老年病人髋关节成形术后生活质量有何影响。

方法:大于65岁初次行髋关节成形术的病人,进行为期三个月的术后随访,了解病人出院时的血色素水平与其在术后两月主观评估生活质量的相关性。采用SF-36量表和FACT-Anemia 问卷表在术前及术后两月评估患者生活质量。并计算术后第八天的血色素水平与SF-36量表和FACT-Anemia 问卷表结果(术前及术后两月)间的相关系数。

结果87位病人入组研究,其中79位病人采集到术后两月的数据。术后第八天血色素水平与SF-36量表数据变化间的相关性为0.49p<0.0005),与FACT-Anemia 问卷表数据变化间的相关性为0.46p=<0.0005)。该相关性不受年龄、是否存在重大心血管疾病或是否输血影响。

结论:大于65髋关节成形术的病人其术后两月的生活质量评分与该病人出院时血色素水平呈正相关。

(陶颖莹 陈杰 校)

BACKGROUND: It is uncertain whether anemia in elderly patients after primary hip arthroplasty has an effect on their quality of life.

METHODS: We conducted a prospective observational study over 3 mo to investigate the association between discharge hemoglobin levels and subjective experience of quality of life at 2 mo postoperatively in patients aged over 65 yr who were scheduled for primary hip arthroplasty. Quality of life was measured preoperatively and at 2 mo postoperatively using the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale. Pearson correlation coefficients between change in SF-36 and FACT-Anemia subscale scores (from preoperatively to 2 mo postoperatively) and hemoglobin on Day 8 were calculated.

RESULTS: Eighty-seven patients were included in the study. Data were available at 2 mo postoperatively from 79 of these patients. The correlation between Day 8 postoperative hemoglobin and change in SF-36 was 0.49 (P < 0.0005) and change in FACT-Anemia subscale score was 0.46 (P =< 0.0005). The correlation was not significantly changed after adjusting for advancing age, presence of significant cardiovascular disease, or whether the patient was transfused.

CONCLUSIONS: We found a positive correlation between hemoglobin levels on discharge and change in quality of life scores from preoperatively to 2 mo postoperatively in patients over 65 yr old after primary hip arthroplasty.


出血性休克的猪用小容量高渗盐水/羟乙基淀粉复苏较4%明胶或6%羟乙基淀粉溶液复苏相比具有较轻的止血功能障碍和较少失血

Less Impairment of Hemostasis and Reduced Blood Loss in Pigs After Resuscitation from Hemorrhagic Shock Using the Small-Volume Concept with Hypertonic Saline/Hydroxyethyl Starch as Compared to Administration of 4% Gelatin or 6% Hydroxyethyl Starch Solution

Thorsten Haas, MD*, Dietmar Fries, MD{dagger}, Carmen Holz, MD*, Petra Innerhofer, MD*, Werner Streif, MD{ddagger}, Anton Klingler, PhD§, Alexander Hanke, MD||, and Corinna Velik-Salchner, MD*

From the Departments of *Anaesthesiology and Critical Care Medicine, {dagger}General and Surgical Critical Care Medicine, {ddagger}Pediatrics, Innsbruck Medical University, §Department of General and Transplant Surgery, Division of Theoretical Surgery, Innsbruck Medical University, Innsbruck, Austria; and ||Department of Anaesthesiology and Intensive Care Medicine, University Clinics of Essen, Essen, Germany.

Anesth Analg 2008 106: 1078-1086.

 

背景:创伤病人用小容量高渗盐水/羟乙基淀粉200/0.62(HS-HES) 复苏较使用晶体液或胶体液更有效。上述四种液体均可导致剂量依赖性稀释性凝血功能紊乱,并对止血功能产生影响,但很少数据显示应用低容量复苏后对凝血功能影响。

方法:thrombelastometry (ROTEM®)研究了30头猪(体重35-45kg)失血60%[1484ml(1369-1624ml)],以4ml/kgHS-HES或以11的比例输注4%明胶或6%HES130/0.4来补充丢失的血容量。为了在有出血倾向时比较ROTEM各变量的变化(凝血时间,血栓形成时间,{alpha}角,血栓硬度,人纤维蛋白原聚合作用),行肝脏切开术并测定出血量。

结果:与输注4%明胶(4.5mm(3.0,5.8)]HES130/0.4 [3.5mm(2.3,4.0)]相比,输注HS-HES [11mm(10,11),p=0.0034]后人纤维蛋白原聚合中位数(25%75%)明显增高。输注HS-HES后肝切口平均失血量为725ml900375),输注4%明胶平均失血量为1625ml12751950),输注6%HES130/0.4(p=0.004)平均失血量为1600ml15001800)。各组血流动力学均稳定,但灌注压不同。

结论:出血性休克时用HS-HES200/0.62复苏比应用4%明胶或6%HES130/0.4复苏对血块形成的影响更小。

(赵燕星 陈杰 校)

BACKGROUND: Small-volume resuscitation using hypertonic saline/hydroxyethyl starch 200/0.62 (HS-HES) has been shown to be an effective alternative to the administration of crystalloids or colloids in trauma patients. All IV fluids cause dose-related dilutional coagulopathy and show intrinsic effects on the hemostatic system, but only few data refer to functional consequences after small-volume resuscitation.

METHODS: Using thrombelastometry (ROTEM®), we studied 30 pigs (weighing 35–45 kg) after withdrawal of 60% of blood volume [1484 mL (1369–1624 mL)] and receiving 4 mL/kg HS-HES for compensation of blood loss or 4% gelatin or 6% HES 130/0.4 in a 1:1 ratio to lost blood volume. To compare the ROTEM variables (coagulation time, clot formation time, {alpha}angle, clot firmness, and fibrinogen polymerization) with bleeding tendency, a hepatic incision was made and blood loss was measured.

RESULTS: Median (25th, 75th percentile) fibrinogen polymerization was significantly higher after HS-HES infusion [11 mm (10, 11), P = 0.0034] when compared with administration of 4% gelatin [4.5 mm (3.0, 5.8)] or HES 130/0.4 [3.5 mm (2.3, 4.0)]. Median blood loss after liver incision was 725 mL (900, 375) after HS-HES, 1625 mL (1275, 1950) after 4% gelatin, and 1600 mL (1500, 1800) after 6% HES 130/0.4 (P = 0.004). Hemodynamic stabilization was traceable in all groups but showed differences regarding filling pressures.

CONCLUSIONS: Resuscitation from hemorrhagic shock with HS-HES 200/0.62 results in less impairment of clot formation when compared with compensation of blood loss by administering 6% HES 130/0.4 or 4% gelatin.

 

昂丹司琼咀嚼片对接受耳鼻喉手术的小儿在家出现呕吐的治疗效果

The Effects of Oral Ondansetron Disintegrating Tablets for Prevention of At-Home Emesis in Pediatric Patients After Ear-Nose-Throat Surgery

Peter J. Davis, MD*{dagger}, Kathleen M. Fertal, RN, CCRC{dagger}, Karen R. Boretsky, MD*{dagger}, Gina M. Fedel, MD*{dagger}, Michael D. Ingram, MD*, Susan K. Woelfel, MD*{dagger}, Paul C. Hoffmann, RPh{ddagger}, Harshad Gurnaney, MD*{dagger}, and Michael C. Young, MS*{dagger}

From the *University of Pittsburgh School of Medicine, Departments of {dagger}Anesthesiology, and {ddagger}Pharmacy, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania.

Anesth Analg 2008 106: 1117-1121.

 

背景:扁桃体和增殖腺切除术后无论在医院或者在家都可能出现呕吐。作者评估了昂丹司琼咀嚼片(ODT)对接受了扁桃体摘除术包括或不包括增殖腺切除术或包括或不包括两侧鼓膜切开和置管术的小儿在家出现呕吐的疗效。

方法:所有的病人以氧化亚氮及氧气面罩吸入诱导,术中给予七氟醚。术中均给予吗啡,地塞米松及昂丹司琼。对于术后出现的疼痛以芬太尼或扑热息痛辅以可待因处理。在复苏室中给予止吐剂或在同一天手术室中15min内给予3次止吐剂或根据病人情况或病人要求处理。病人回家后随机服用五个剂量的ODT或者安慰剂。随访病人至术后3天,并记录在家呕吐次数。

结果:220名病人参加了研究,200名患者完成有效评估。服用ODT103名小儿中15名(14.5%)在家出现了呕吐,而服用安慰剂的97名小儿童中31名(32%)发生了呕吐(p=0.04)。进一步分析显示在院期间没有因恶心,呕吐而进行药物治疗的小儿在家服用ODT有疗效,而对在医院已接受抗呕吐治疗的小儿没有疗效。

结论:小儿扁桃体摘除术后前3天,在家服用昂丹司琼咀嚼片可以预防呕吐,但在院期间对恶心呕吐进行过预防性处理的小儿在家服用昂丹司琼咀嚼片可能无效。

(潘钱玲 陈杰 校)

BACKGROUND: Tonsillectomy and adenoidectomy are associated with a frequent incidence of vomiting, both in the hospital and at home. We evaluated the effects of oral ondansetron disintegrating tablets (ODT) on the incidence of at-home emesis in children undergoing tonsillectomy with and without adenoidectomy and with and without bilateral myringotomy and tube insertion.

METHODS: All patients underwent inhaled mask induction with nitrous oxide, oxygen, and sevoflurane. Morphine, dexamethasone, and ondansetron were administered to all patients intraoperatively. Postoperative pain was treated with fentanyl or acetaminophen with codeine. Rescue antiemetics in the postanesthesia care unit or same day surgery unit were administered for three emetic episodes within 15 min, or upon patient or parent request. Patients were randomized for at-home administration of five doses of either ondansetron ODT or a placebo. All patients were followed for the first 3 days after surgery. At-home emesis was the primary outcome variable.

RESULTS: Two hundred and twenty-one patients were entered into the study, yielding 200 evaluable subjects. At-home emesis occurred in 15 (14.5%) of the 103 children who received ODT, and 31 (32%) of the 97 children in the placebo group, P = 0.004. Subgroup analysis demonstrated efficacy in patients who did not require rescue medication for nausea and vomiting while in the hospital, but did not demonstrate efficacy for patients who required rescue medication.

CONCLUSIONS: At-home use of ODT may prevent emesis in children during the first 3 days after tonsillectomy in children. Patients who require rescue after prophylactic treatment for nausea and vomiting in the hospital may not respond to prophylactic ondansatron ODT at home.

 

肥胖病人颈围增加对困难插管评估的重要性

The Importance of Increased Neck Circumference to Intubation Difficulties in Obese Patients

Hélène Gonzalez, MD*, Vincent Minville, MD, MSc*{dagger}, Khedija Delanoue, MD*, Michel Mazerolles, MD*, Dominique Concina, MD*, and Olivier Fourcade, MD, PhD*

From the *Department of Anesthesiology and Intensive Care, GRCB 48, University Hospital of Toulouse, and {dagger}Physiology Laboratory, INSERM U 858, Toulouse University Hospital Rangueil, Toulouse, France.

Anesth Analg 2008 106: 1132-1136.

 

背景:作者用困难插管评分(IDS)法拟证明肥胖病人较瘦小病人插管更加困难。采用经典的评分方法并增加颈围一项。

方法:作者前瞻性比较了70名肥胖病人[体重指数(BMI)30kg/m2]61个较瘦病人(BMI<30kg/m2)困难插管的发生率。困难插管评分>5定义为困难插管,  ≤5为非困难插管。术前测量体重指数,颈围(在甲状软骨水平),张口度,颏胸距离和甲颏距离,及阻塞性睡眠呼吸暂停综合征病史和其他几项评分(Mallampati, Wilson, El Ganzouri)。在直接喉镜检查并评估,并记录IDS

结果:肥胖病人气管插管困难的机率较瘦的病人大(14.3%vs3%P0.03)。IDS>5的病人,甲颏距离、BMI、大颈围、较高Mallampati气道分级分数是预测潜在插管问题的关键。

结论:出现问题的插管与以下几项有关:甲颏距离、(新加入)颈围、BMIMallampati分级3级以上。颈围应该引入困难插管的评估。

(王腾 陈杰 校)

BACKGROUND: Using the intubation difficulty scale (IDS), we sought to confirm that obese patients are more difficult to intubate than lean patients. We assessed classical bedside tests and included neck circumference.

METHODS: We prospectively compared the incidence of difficult tracheal intubation in 70 obese [body mass index (BMI) ≥30 kg/m2] and 61 lean patients (BMI <30 kg/m2). The IDS scores, categorized as difficult intubation (IDS >5) or not (IDS ≤5), and the patient data, were compared between lean and obese patients. Preoperative measurements [BMI, neck circumference (at the level of the thyroid cartilage), width of mouth opening, sternomental distance, and thyromental distance], medical history of obstructive sleep apnea syndrome, and several scores (Mallampati, Wilson, El Ganzouri) were recorded. The view during direct laryngoscopy was graded, and the IDS was recorded. We then compared patients with IDS ≤5 and >5, concerning each item.

RESULTS: The results indicate that difficult tracheal intubation is more frequent in obese than in lean patients (14.3% vs 3%; P = 0.03). In the patients with IDS > 5, thyromental distance, BMI, large neck circumference, and higher Mallampati score were the only predictors of potential intubation problems.

CONCLUSION: We found that problematic intubation was associated with thyromental distance, increasing neck circumference, BMI, and a Mallampati score of ≥3. Neck circumference should be assessed preoperatively to predict difficult intubation.

 

氟哌利多抑制HERG钾通道取决于通道门状态及S6残基F656

Inhibition of the HERG Channel by Droperidol Depends on Channel Gating and Involves the S6 Residue F656

Tao Luo, MD, PhD*{dagger}, Ailin Luo, MD, PhD{dagger}, Miu Liu, MD*, and Xianyi Liu, MD*

From the Department of Anesthesiology, *Renmin Hospital of Wuhan University, and {dagger}Tongji Hospital of Huazhong University of Science and Technology, Wuhan, China.

Anesth Analg 2008 106: 1161-1170.

 

人类eag相关基因(HERG)编码快速激活的延迟整流钾通道(Ikr)的α亚基、Ikr电流主要参与心肌动作电位的复极过程。HERG发生突变或药物作用于Ikr都可诱发长QT综合征

背景:氟哌利多有中枢止吐作用,并广泛用于精神病学,麻醉学,急诊医学等领域。已有研究证明其与心电图QT间期延长有关,也可能与尖端扭转型室性心动过速和猝死有关。虽然QT间期延长与氟哌利多诱导增加心室动作电位时程是一致的,但其细胞机制并未阐明。快速激活延迟整流钾通道Ikr,是一个引起QT间期延长的药物作用的基本位点及人类eag相关基因(HERG)钾通道。为确定这些临床发现的潜在机理,作者研究了氟哌利多对人类HERG钾通道的作用。

方法:人类胚胎肾293细胞,异源表达野生型和突变型HERG钾通道,采用全细胞膜片钳技术( 22-24摄氏度)记录电流。

结果: HERG钾通道尾电流描记脉冲中,50毫伏时氟哌利多IC50 77.3 ± 9.6 nmmol(n = 8)。初期为快速阻断且其抑制作用在药物洗出后逆转。氟哌利多主要作用在开放和失活状态时HERG钾通道。在较快频率时较强稳态水平阻滞是功能依赖性。激活曲线向更负电位移动(P < 0.05, n = 8),且100 nM氟哌利多失活时程明显缩短(P < 0.05, n = 8)。但对HERG通道失活无相关影响。由氟哌利多导致HERG通道阻滞的强度在Phe-656(苯丙氨酸-656)突变到Thr(苏氨酸)或Ser-631(丝氨酸-631)突变到Ala(丙氨酸)时显著降低。但Phe-656突变到ThrF656M/S631A双突变时氟哌利多对通道阻滞的敏感性无影响。

结论:氟哌利多有效地抑制了转染的HERG钾通道,可能是QT间期延长的机制。开放和失活状态时通道阻断最为显著。在位置656的芳香环残基参与氟哌利多的结合位点,失活门可诱发构象变化,这种状态促进氟哌利多与通道的结合。

(张燕 陈杰 校)

BACKGROUND: Droperidol has a central antiemetic action and is widely used in the fields of psychiatry, anesthesia, and emergency medicine. It has been associated with prolongation of the QT interval of the electrocardiogram, and it may also be associated with torsades de pointes and sudden death. Although QT prolongation is consistent with droperidol-induced increases in cardiac ventricular action potential duration, the cellular mechanism for these observations has not been clearly studied. The rapidly activating delayed rectifier potassium channel, IKr, is a primary site of action of drugs causing QT prolongation and is encoded by the human-ether-a-go-go-related gene (HERG). To determine the mechanism underlying these clinical findings, we investigated the effect of droperidol on human HERG potassium channels.

METHODS: Wild type and mutant HERG channels were heterologously expressed in human embryonic kidney 293 cells, and the current was recorded by using whole cell patch clamp technique (22–24°C).

RESULTS: HERG tail currents following test pulses to 50 mV were inhibited by droperidol with an IC50 of 77.3 ± 9.6 nM (n = 8). The onset of block was fast and inhibition was completely reversible upon washout. Droperidol affected HERG channels mainly in their open and inactivated states. The effects were use-dependent with a stronger steady-state level of block at higher frequencies. The activation curve was slightly shifted towards more negative potentials (P < 0.05, n = 8) and the time course of inactivation was significantly decreased (P < 0.05, n = 8) by 100 nM droperidol. But there was no relevant effect on HERG channel deactivation. The potency for block of HERG channels by droperidol was significantly decreased with mutation of Phe-656 to Thr or mutation of Ser-631 to Ala, respectively. However, mutation of Phe-656 to Met or the double mutation F656M/S631A had no effect on channel sensitivity to block by droperidol.

CONCLUSIONS: Droperidolpotently inhibits transfected HERG channels and this is the probable mechanism for QT prolongation. Channel blockade shows greatest affinity for the open and inactivated state. Aromatic residue at position 656 may participate in droperidol binding, and inactivation gating can induce a conformational state that optimizes droperidol binding to the channel.

心脏手术后通过实时监测脉压波动来指导液体治疗

Online Monitoring of Pulse Pressure Variation to Guide Fluid Therapy After Cardiac Surgery

Jose Otavio Auler, Jr., MD, PhD*, Filomena Galas, MD, PhD*, Ludhmila Hajjar, MD*, Luciana Santos, MD*, Thiago Carvalho, MD*, and Frédéric Michard, MD, PhD{dagger}

From the *Department of Anesthesia and Critical Care, Heart Institute, INCOR, Hospital das Clinicas, University of Sao Paulo, SP, Brazil; and {dagger}Department of Anesthesia and Critical Care, Béclère Hospital-University Paris XI, Paris, France.

Anesth Analg 2008 106: 1201-1206.

 

背景:由机械通气引起的动脉压波动(△PP)已被认为是液体治疗反应的预测因子。直到现在,△PP需在脱机时(由一台计算机记录或一张纸打印出动脉压波形)计算 ,或由特定的心输出量监测仪测定,限制了这一参数的广泛使用。最近,一个新方法已被用于标准的床边监测并自动计算和实时监测△PP。这种方法是否能够可靠预测液体反应仍有待证实。

方法:作者对59名心脏手术术后行机械通气的病人进行了前瞻性的研究。研究的病人为液体治疗并发症低风险患者(肺动脉压<20mmHg,左室射血分数>40%)。所有的病人均行有创动脉监测和肺动脉置管。在液体输入前后(乳酸林格氏液以20ml/kg的输注速度超过20min)测定心脏充盈压和心排量,同时自动计算和持续监测△PP

结果39名患者(占总数66%,为液体治疗反应组)在液体输入后心排量增加了15%。在液体输入之前,液体治疗反应组和无反应组的右房压和肺动脉嵌压相当。相反,反应者组的△PP比无反应者组的△PP高(17%±3% 对应9%±2%P<0.001)。△PP12%作为停止治疗值时灵敏度为97%和特异性为95%

结论{Delta}PP自动实时监测作为标准床旁监护仪是可能的并能作为心脏术后预测液体治疗反应的可靠方法。将来仍需研究以确定是否这一技术能用于避免液体治疗高危患者的并发症。

(胡潇 陈杰 校)

BACKGROUND: The arterial pulse pressure variation induced by mechanical ventilation ({Delta}PP) has been shown to be a predictor of fluid responsiveness. Until now, {Delta}PP has had to be calculated offline (from a computer recording or a paper printing of the arterial pressure curve), or to be derived from specific cardiac output monitors, limiting the widespread use of this parameter. Recently, a method has been developed for the automatic calculation and real-time monitoring of {Delta}PP using standard bedside monitors. Whether this method is to predict reliable predictor of fluid responsiveness remains to be determined.

METHODS: We conducted a prospective clinical study in 59 mechanically ventilated patients in the postoperative period of cardiac surgery. Patients studied were considered at low risk for complications related to fluid administration (pulmonary artery occlusion pressure <20 mm Hg, left ventricular ejection fraction ≥40%). All patients were instrumented with an arterial line and a pulmonary artery catheter. Cardiac filling pressures and cardiac output were measured before and after intravascular fluid administration (20 mL/kg of lactated Ringer’s solution over 20 min), whereas {Delta}PP was automatically calculated and continuously monitored.

RESULTS: Fluid administration increased cardiac output by at least 15% in 39 patients (66% = responders). Before fluid administration, responders and nonresponders were comparable with regard to right atrial and pulmonary artery occlusion pressures. In contrast, {Delta}PP was significantly greater in responders than in nonresponders (17% ± 3% vs 9% ± 2%, P < 0.001). The {Delta}PP cut-off value of 12% allowed identification of responders with a sensitivity of 97% and a specificity of 95%.

CONCLUSION: Automatic real-time monitoring of {Delta}PP is possible using a standard bedside monitor and was found to be a reliable method to predict fluid responsiveness after cardiac surgery. Additional studies are needed to determine if this technique can be used to avoid the complications of fluid administration in high-risk patients.

 

 

静注单剂量地塞米松减轻全髋成形术后的运动性疼痛

Single-Dose Dexamethasone Reduces Dynamic Pain After Total Hip Arthroplasty

Kenneth J. Kardash, MD*, Frederic Sarrazin, BEng, MD*, Michael J. Tessler, MD*, and Ana M. Velly, DDS, PhD{dagger}{ddagger}

From the *Department of Anesthesia and {dagger}Center of Clinical Epidemiology and Community Studies, Sir Mortimer B Davis-Jewish General Hospital, McGill University, Montreal, Canada; and {ddagger}Department of Diagnostic and Biological Sciences, University of Minnesota, Minneapolis, Minnesota.

Anesth Analg 2008 106: 1253-1257.

 

背景:术前应用糖皮质激素可减轻术后恶心,同时可提高痛阈和减少阿片类的消耗。

方法:随机、双盲、对照研究连续50名在椎管内麻醉联合丙泊酚静脉镇静下接受择期单侧全髋成形术的患者。患者术前分别接受地塞米松40mg(静注)或生理盐水。术后48小时内给予静注吗啡、口服布洛芬400mg/6h和扑热息痛650mg/6h维持病人自控镇痛。在48小时内每4h记录一次静息状态下疼痛、副作用和累积的病人自控镇痛的吗啡用量。在24h记录运动性疼痛的评分。在48h测量每组25名患者的C反应蛋白水平。

结果:地塞米松组中术中应用丙泊酚镇静的剂量显著增加(234.6 ± 160.1 vs 138.8 ± 122.7 mg, P = 0.02)。运动性疼痛减轻(NRS 评分: 2.7, 95% CI: 2.2–3.1 vs 6.8, 6.4–7.2; P < 0.0001)。在任何时间内静息状态下疼痛和累积的吗啡用量均无显著差异。48h时地塞米松组C反应蛋白水平较对照组降低。对照组中有7名患者出现术后恶心,而地塞米松组只有一名患者。

结论:全髋成形术术前单剂量静注地塞米松40mg对术后有长时抑制炎症反应效应并减轻24h 运动性疼痛。

(陈伟 陈杰 校)

BACKGROUND: Preoperative glucocorticoids reduce postoperative nausea but may also improve analgesia and decrease opioid consumption.

METHODS: Fifty consecutive patients undergoing elective, unilateral, primary total hip arthroplasty under spinal anesthesia with propofol sedation received in a randomized, double-blind, placebo-controlled manner either 40 mg of dexamethasone or saline placebo IV before the start of surgery. IV patient-controlled analgesia morphine, ibuprofen 400 mg po q6 h and acetaminophen 650 mg po q6 h were given for 48 h. Pain (0–10 numeric rating scale, NRS) at rest, side effects, and total cumulative patient-controlled analgesia morphine consumption were recorded q4 h for 48 h. Dynamic pain NRS score was recorded at 24 h. C-reactive protein levels were measured in a subgroup of 25 patients at 48 h.

RESULTS: The intraoperative sedation requirement with propofol was significantly increased in the dexamethasone group (234.6 ± 160.1 vs 138.8 ± 122.7 mg, P = 0.02). Dynamic pain was greatly reduced in the dexamethasone group (NRS score: 2.7, 95% CI: 2.2–3.1 vs 6.8, 6.4–7.2; P < 0.0001). There was no significant effect on pain at rest or cumulative morphine consumption at any time. C-reactive protein levels at 48 h were markedly reduced by dexamethasone (52.4 mg/mL, 28.2–76.6 vs 194.2, 168.9–219.4; P < 0.0001). Seven patients in the control group, but only one in the dexamethasone group, were treated for nausea (P = 0.05).

CONCLUSIONS: A single, preoperative IV dose of dexamethasone 40 mg has a prolonged suppressive effect on the inflammatory response and decreases dynamic pain 24 h after total hip arthroplasty.

 

慢性幻肢痛:降钙素、氯胺酮及其联合应用对痛阈和感觉阈的作用

Chronic Phantom Limb Pain: The Effects of Calcitonin, Ketamine, and Their Combination on Pain and Sensory Thresholds

Urs Eichenberger, MD*, Frank Neff, MD{dagger}, Gorazd Sveticic, MD{dagger}, Steinar Björgo, MD*, Steen Petersen-Felix, MD, PhD{dagger}, Lars Arendt-Nielsen, PhD{ddagger}, and Michele Curatolo, MD, PhD*

From the *Division of Pain Therapy, Department of Anesthesiology, University Hospital of Bern, Inselspital, Switzerland; {dagger}Department of Anesthesiology, University Hospital of Bern, Inselspital, Switzerland; and {ddagger}Laboratory for Experimental Pain Research, Center for Sensory-Motor Interaction, Aalborg University, Denmark.

Anesth Analg 2008 106: 1265-1273.

 

背景:有研究显示降钙素对治疗急性幻肢痛有效,但对于慢性幻肢痛却鲜有研究。所有关于N-甲基-d-天冬氨酸拮抗剂的文献都模棱两可。作者检验了降钙素、氯胺酮及其联合应用治疗慢性患肢痛有效的假设。次级目标是通过大量的感觉测试来证明其机制。

方法20名受试者随机、双盲、交叉接受4种药物:降钙素200IE;氯胺酮0.4mg/kg(仅10 名受试者);降钙素200IE0.4mg/kg氯胺酮;安慰剂:0.9%生理盐水。注射前、注射期间,注射末和注射后48h进行幻肢痛程度的检测(视觉模拟量表)。在注射前和注射期间通过电、热和压力刺激检测痛阈。

结果:氯胺酮可以减轻幻肢痛而降钙素不能,两者联合应用与单独使用氯胺酮相比并不具有优越性。除了压力刺激外,截肢侧和对侧的痛阈没有差别。两者联合使用能明显降低电刺激引起的疼痛,但对热刺激和压力刺激没有显著影响。

结论:试验结果对降钙素在慢性幻肢痛应用提出质疑并强调了N-甲基-d-天冬氨酸拮抗剂的潜在价值。对感觉的评估提示外周机制可能不是幻肢痛的重要决定因素。氯胺酮而不是降钙素可影响幻肢痛的中枢致敏过程。

(潘方立 陈杰 校)

BACKGROUND: Calcitonin was effective in a study of acute phantom limb pain, but it was not studied in the chronic phase. The overall literature on N-methyl-d-aspartate antagonists is equivocal. We tested the hypothesis that calcitonin, ketamine, and their combination are effective in treating chronic phantom limb pain. Our secondary aim was to improve our understanding of the mechanisms of action of the investigated drugs using quantitative sensory testing.

METHODS: Twenty patients received, in a randomized, double-blind, crossover manner, 4 IV infusions of: 200 IE calcitonin; ketamine 0.4 mg/kg (only 10 patients); 200 IE of calcitonin combined with ketamine 0.4 mg/kg; placebo, 0.9% saline. Intensity of phantom pain (visual analog scale) was recorded before, during, at the end, and the 48 h after each infusion. Pain thresholds after electrical, thermal, and pressure stimulation were recorded before and during each infusion.

RESULTS: Ketamine, but not calcitonin, reduced phantom limb pain. The combination was not superior to ketamine alone. There was no difference in basal pain thresholds between the amputated and contralateral side except for pressure pain. Pain thresholds were unaffected by calcitonin. The analgesic effect of the combination of calcitonin and ketamine was associated with a significant increase in electrical thresholds, but with no change in pressure and heat thresholds.

CONCLUSIONS: Our results question the usefulness of calcitonin in chronic phantom limb pain and stress the potential interest of N-methyl-d-aspartate antagonists. Sensory assessments indicated that peripheral mechanisms are unlikely important determinants of phantom limb pain. Ketamine, but not calcitonin, affects central sensitization processes that are probably involved in the pathophysiology of phantom limb pain.

 

在大鼠胸深层肌肉离断后背角小胶质细胞环氧合酶- 1和神经元环氧合酶-2上调

Upregulation of Dorsal Horn Microglial Cyclooxygenase-1 and Neuronal Cyclooxygenase-2 After Thoracic Deep Muscle Incisions in the Rat

Jeffrey S. Kroin, PhD*, Mayumi Takatori, MD*, Jinyuan Li, MD, PhD*, Er-Yun Chen, MD{dagger}, Asokumar Buvanendran, MD*, and Kenneth J. Tuman, MD*

From the Departments of *Anesthesiology, and {dagger}Neurology, Rush Medical College, Chicago, Illinois.

Anesth Analg 2008 106: 1288-1295.

 

背景:大鼠足底皮下切口会产生痛觉过敏传导和大鼠腰椎脊髓内环氧合酶-2(COX-2)上调以及环氧合酶-1(COX-1)持续升高。在此试验中,作者假设胸部深切口会引起背角COX-1COX-2上调,这与疼痛相关的行为相吻合。并且特异性的细胞类型与COX表达增高有关。

方法:麻醉下大鼠左侧胸部皮肤切开,浅层和深层肌肉依次切断。记录喂养情况来评估疼痛相关行为。手术后4小时和24小时在脊髓中进行COX1COX-2免疫组化分析以及细胞类型标记。

结果:胸深层肌肉离断组与假切口对照组相比术后4小时喂养情况下降42%。术后4小时,同侧手术实验组相比同侧对照组,对侧手术实验组,双侧对照组,胸背角内COX-1COX-2的免疫活性都升高。腰段水平没有观察到手术引起的变化。术后24小时,喂养情况不再下降,任何脊髓节段都未出现手术引起的COX-1COX-2的活性改变。术后4小时,96%COX-1免疫活性细胞与小胶质细胞共同定位,98%COX-2免疫活性细胞与神经元共同定位。

结论:单侧胸部深切口会产生疼痛相关行为,同时,同侧胸背角小胶质细胞COX-1和神经元COX-2上调。

(杜唯佳 陈杰 校)

BACKGROUND: Plantar hindpaw incision produces hyperalgesia, transient upregulation of cyclooxygenase-2 (COX-2) and prolonged upregulation of cyclooxygenase-1 (COX-1) in rat lumbar spinal cord. Our hypothesis in this study was that a deep thoracic incision causes COX-1 and COX-2 upregulation in the dorsal horn coincident with pain-related behavior, and that specific cell types contribute to this increase in COX expression.

METHODS: A left lateral thoracic skin incision was made in anesthetized rats, and superficial and deep muscles were incised. Postoperative pain-related behavior was quantified by recording exploratory rearing. Four and 24 h postsurgery, COX-1 and COX-2 immunohistochemistry, with co-labeling for cell type, were performed on the spinal cord.

RESULTS: Deep thoracic muscle incision produced a 42% decrease in rearing compared to sham skin-incision controls at 4 h postsurgery (P = 0.001). There was an increase in both COX-1 and COX-2 immunoreactivity in the thoracic dorsal horn at 4 h postsurgery on the ipsilateral side of surgery animals compared to the ipsilateral side of control animals, contralateral side of surgery animals or contralateral side of control animals. No surgery-induced differences were seen at the lumbar level. At 24 h postsurgery, there was no longer a decrease in rearing, and no surgery-induced differences in COX-1 or COX-2 were seen at any level. At 4 h postsurgery, 96% of COX-1 immunoreactive cells co-localized with microglia and 98% of COX-2 immunoreactive cells co-localized with neurons.

CONCLUSIONS: A unilateral deep thoracic wound produces pain-related behavior and, at the same time, ipsilateral upregulation of microglial COX-1 and neuronal COX-2 in the thoracic dorsal horn.

 

米那普仑对脊神经结扎鼠的抗痛觉超敏和抗痛觉过敏作用

Antiallodynic and Antihyperalgesic Effect of Milnacipran in Mice with Spinal Nerve Ligation

Takahiro Suzuki, MD, PhD, Kazuyoshi Ueta, MD, PhD, Shinji Tamagaki, MD, and Takashi Mashimo, MD, PhD

From the Department of Anesthesiology, Osaka University Medical School, Osaka, Japan.

Anesth Analg 2008 106: 1309-1315.

背景:据报道抗抑郁药物-米那普仑有抗伤害刺激、抗痛觉超敏和抗痛觉过敏的作用。此项实验目的在于研究米那普仑应用于神经结扎诱导的神经性疼痛鼠模型,其抗痛觉超敏(过敏)的作用机制。

方法:牢固结扎C57BL6雄鼠的左侧第五腰神经。使用von Frey毛和辐射热分别测试结扎侧和健侧的对触觉刺激的撤回阈值和对热刺激的撤回潜伏期。

结果:以口服(7.5–120 mg/kg)、鞘内注射、脑室内注射或局部(210 ng–21 µg)的途径给予米那普仑。系统、鞘内和脑室内的给药增加了神经结扎鼠的撤回阈值和撤回潜伏期,而局部注射却无作用。在评估米那普仑镇痛效果的3天前,使用特异性的神经毒素、6-羟基多巴胺或5,7-二羟色胺来耗竭脊神经5-羟色胺能或去甲肾上腺素能神经元。在假手术组,这种对脊神经5-羟色胺能和去甲肾上腺素能的去神经方法减弱了米那普仑的镇痛作用。在试验组,米那普仑的镇痛作用能被阻断去甲肾上腺素能神经元的方法所减弱,而阻断5-羟色胺能神经元则无效。

结论:米那普仑应用于神经结扎引起的神经性疼痛模型,其抗痛觉超敏(过敏)作用主要由脊神经及其以上水平的活化的去甲肾上腺素能系统介导。

(於章杰 陈杰 校)

BACKGROUND: The antidepressant, milnacipran, has been reported to have antinociceptive, antiallodynic, and antihyperalgesic effects. In this study, we examined the mechanisms of the antiallodynic and antihyperalgesic effects of milnacipran in a model of neuropathic pain induced by spinal nerve ligation in mice.

METHODS: The fifth left lumbar nerve of male C57BL6 mice was tightly ligated. Withdrawal threshold to tactile stimulation and withdrawal latency to heat stimulation in the injured or contralateral paw was tested by using von Frey filaments and radiant heat, respectively.

RESULTS: Milnacipran was administered either orally (7.5–120 mg/kg), intrathecally, intracerebroventricularly, or locally (210 ng–21 µg). Both systemic, intrathecal and intracerebroventricular milnacipran increased withdrawal threshold and withdrawal latency in nerve-ligated mice whereas local injection had no effect. Depletion of spinal serotonergic or noradrenergic neurons was achieved by use of the specific neurotoxins, 6-hydroxydopamine or 5,7-dihydroxytryptamine, applied intrathecally 3 days before evaluation of the analgesic effect of milnacipran. Spinal serotonergic and noradrenergic denervation attenuated the effect of milnacipran in sham-operated mice. In nerve-ligated mice, however, the effect of milnacipran was lost after noradrenergic denervation but not after serotonergic denervation.

CONCLUSIONS: We concluded that the antiallodynic and antihyperalgesic effects of milnacipran on neuropathic pain induced by spinal nerve ligation are principally mediated through action at supraspinal and spinal sites via activation of the spinal noradrenergic system.

 

七氟烷引起离体心肌线粒体基质容积的特异性增加

Differential Increase of Mitochondrial Matrix Volume by Sevoflurane in Isolated Cardiac Mitochondria

Matthias L. Riess, MD, PhD*, Alexandre D. Costa, PhD{dagger}, Richard Carlson, Jr, BS*, Keith D. Garlid, MD, PhD{dagger}, André Heinen, MD*, and David F. Stowe, MD, PhD{ddagger}§||#

From the *Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin; {dagger}Department of Biology, Portland State University, Portland, Oregon; and Departments of {ddagger}Anesthesiology and §Physiology, Cardiovascular Research Center, Medical College of Wisconsin and ||VA Medical Center Research Service, and #Department of Biomedical Engineering, Marquette University, Milwaukee, Wisconsin.

Anesth Analg 2008; 106:1049-1055

背景:据报道,线粒体三磷酸腺苷敏感的钾(KATP)通道的开放触发和/或介导了吸入麻醉药的心肌保护作用。然而,吸入麻醉药对线粒体功能的影响尚未被认识透彻。预防缺血期间线粒体基质容积(MMV)的缩小可促进抗缺血再灌注损伤的心肌保护作用。我们探讨七氟烷是否增加MMV以及这种增加是否由mKATP通道的开放所介导。

方法:新鲜的豚鼠心肌线粒体经分离并稀释于含寡霉素和ATP的缓冲液中以抑制ATP的合成。在不用或使用mKATP通道阻断剂5-羟基癸酸盐(5-HD)的条件下,通过测定520nm波长处的吸光性来判定二氮嗪(一种公认的mKATP通道开放剂)和不同浓度的七氟烷引起的MMV的变化。

结果:与对照组相比,30300µM的七氟烷(约0.2-2.1vol%)增加MMV 30%50%,这与二氮嗪的作用相似。这些增加作用被5-HD所阻断。不过,更高浓度的七氟烷(1000 µM; 7.1 vol %)却对MMV无影响。

结论:临床相关浓度下,七氟烷通过mKATP通道的开放增加MMV。对线粒体完整性的保护可能促成了七氟烷抗缺血再灌注损伤的心肌保护作用。超临床麻醉药浓度下线粒体功能的损害可以用来解释所观察到的双相反应。这些结果加强了我们对吸入麻醉药作为心肌保护药物的细胞内机制的理解。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: Mitochondrial (m) adenosine triphosphate sensitive potassium (KATP) channel opening has been reported to trigger and/or mediate cardioprotection by volatile anesthetics. However, the effects of volatile anesthetics on mitochondrial function are not well understood. Prevention of mitochondrial matrix volume (MMV) contraction during ischemia may contribute to cardioprotection against ischemia/reperfusion injury. We investigated whether sevoflurane increases MMV and if this increase is mediated by mKATP channel opening.

METHODS: Mitochondria from fresh guinea pig hearts were isolated and diluted in buffer that included oligomycin and ATP to inhibit ATP synthesis. Changes in MMV by diazoxide, a known mKATP channel opener, and by different sevoflurane concentrations, were measured by light absorption at 520 nm in the absence or presence of the mKATP channel blocker, 5-hydroxydecanoate.

RESULTS: Compared with control, 30–300 µM sevoflurane (approximately 0.2–2.1 vol %) increased MMV by 30%–55%, which was similar to the effect of diazoxide. These increases were blocked by 5-hydroxydecanoate. Higher sevoflurane concentration (1000 µM; 7.1 vol %), however, had no effect on MMV.

CONCLUSIONS: In clinically relevant concentrations, sevoflurane increases MMV via mKATP channel opening. Preservation of mitochondrial integrity may contribute to the cardioprotective effects of sevoflurane against ischemia/reperfusion injury. Impaired mitochondrial function at supraclinical anesthetic concentrations may explain the observed biphasic response. These findings add to our understanding of the intracellular mechanisms of volatile anesthetics as cardioprotective drugs.



猪稀释性凝血障碍模型的凝血特征及使用凝血酶原复合体浓缩物替代治疗的效果

Characterization of the Coagulation Deficit in Porcine Dilutional Coagulopathy and Substitution with a Prothrombin Complex Concentrate

Gerhard Dickneite, PhD, Baerbel Doerr, and Franz Kaspereit

From the Department of Pharmacology and Toxicology, CSL Behring GmbH, Marburg, Germany.

Anesth Analg 2008; 106:1070-1077

背景:本研究使用猪的模型观察使用一个凝血酶原复合体浓缩物(PCC)(Beriplex P/N,包含凝血因子IIVIIIXX)是否能纠正凝血障碍以及动脉或静脉大量出血。

方法:猪麻醉诱导后制作稀释性凝血障碍的模型,分次放血(约全身血容量的65%),然后自体输注红细胞,并用羟乙基淀粉(Infukoll 6%1000mL进行容量扩充。试验猪随机分为三组:非处理组、安慰剂组和使用35 U/kg PCC进行处理组。动脉或静脉出血采用脾切除或骨损伤模型。在基础点、稀释后、给予处理后以及脾切除或骨损伤后不同时点取血进行血栓弹力酶图、血常规以及凝血试验。主要终点为损伤后到止血的时间。

结果:血液稀释导致凝血因子浓度下降到约35%,凝血酶原时间延长。血小板数量从约400,000/µL降低到约100,000/µL,而且血小板的凝聚和黏附均受损。PCC可有效替代缺乏的凝血酶原因子(IIVIIIXX),使延长的凝血酶原时间恢复正常。脾切除后,使用PCC可比稀释对照组显著缩短止血时间(中位数, 35 vs 82.5 min; P < 0.0001),血容量的丢失未明显减少(均值,275 vs 589 mL)。骨损伤后PCC还可显著缩短止血时程(中位数,27 vs 97 min P < 0.0011)和出血量(均值, 71 vs 589 mLP < 0.0017)。

结论:稀释性凝血障碍使凝血因子水平普遍下降和血小板功能受损。使用PCC替代治疗可有效纠正凝血紊乱,并显著改善动脉和静脉出血后止血。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: In this study, we used a porcine model to investigate whether impaired coagulation and severe arterial or venous bleeding could be normalized by substitution with a prothrombin complex concentrate (PCC), Beriplex P/N, containing coagulation factors II, VII, IX, and X.

METHODS: Dilutional coagulopathy was induced in anesthetized pigs by fractionated blood withdrawal (approximately 65% of total volume), followed by erythrocyte retransfusion and volume substitution with a total of 1000 mL of hydroxyethyl starch (Infukoll 6%). Animals were randomized to no treatment, treatment with placebo, or treatment with 35 U/kg PCC. Arterial (spleen incision) or venous (bone injury) bleeding was inflicted. Thromboelastometry, hematology, and coagulation tests were performed at baseline, after dilution, and after study treatments had been administered and injury inflicted. The primary end-point was postinjury time to hemostasis.

RESULTS: Hemodilution resulted in a decrease in coagulation factor concentrations to approximately 35% and prolonged prothrombin time. Platelet numbers decreased from approximately 400,000 to approximately 100,000/µL, and aggregation and adhesion were impaired. PCC effectively substituted the deficient prothrombin factors (II, VII, IX, and X) and normalized the prolonged prothrombin time. After spleen injury, PCC significantly reduced time to hemostasis versus dilutional control (median, 35 vs 82.5 min; P < 0.0001), and produced a nonsignificant trend towards reduction in blood loss (mean, 275 vs 589 mL). PCC also significantly reduced time to hemostasis (median, 27 vs 97 min; P < 0.0011) and blood loss (mean, 71 vs 589 mL; P < 0.0017) after bone injury.

CONCLUSIONS: Dilutional coagulopathy produced a generalized decrease in coagulation factors and impaired platelet function. Substitution with PCC effectively normalized coagulation and significantly improved hemostasis after venous and arterial bleeding.



丙泊酚靶控输注时双谱指数和丙泊酚血药浓度的关系:儿童和青年人对照研究

The Relationship Between Bispectral Index and Propofol During Target-Controlled Infusion Anesthesia: A Comparative Study Between Children and Young Adults

Agnes Rigouzzo, MD*, Laure Girault, MD*, Nicolas Louvet, MD*, Frederique Servin, MD, PhD{dagger}, Tom De-Smet{ddagger}, Veronique Piat, MD*, Robert Seeman, MD*, Isabelle Murat, MD, PhD*, and Isabelle Constant, MD, PhD*

From the *Service d'Anesthésie Pédiatrique, Hôpital Armand Trousseau, {dagger}Service d'Anesthésie, Hôpital Bichat, AP-HP, Paris, France; and {ddagger}Demed Engineering, Temse, Belgium.

Anesth Analg 2008; 106:1109-1116

背景:在这个前瞻性研究中,我们比较了儿童和青年人行丙泊酚靶控输注(TCI)时,脑电双谱指数(BIS)和丙泊酚血药浓度之间的关系。

方法:研究对象为45例青春期前儿童和45例青春期后成人,行丙泊酚TCI麻醉,儿童使用Kataria模式,成人使用Schnider模式。使用Rugloop软件持续记录所有来自于BISTCI系统的数据。研究中持续加用瑞芬太尼 (0.25 µg · kg–1 · min–1)。手术结束后所有患者的丙泊酚靶控血浆浓度(Ct)随机设为23456 µg/mL ,稳定12分钟。而且大多数患者另外靶控BIS50 ± 5,也维持12分钟。在每个12分钟的稳态期后,记录CtBIS ,并测定丙泊酚血浆浓度(Cm)。用Hill方程式和靶控BIS 50测定对应于一半最大效应(BIS50)的CtCm

结果:儿童与成人相似,BIS 值与对应的丙泊酚Ct Cm 有高度相关性,符合经典Emax剂量效应曲线。从剂量效应曲线导出的丙泊酚ECt50ECm50,儿童要高于成人:ECm50 4.0 (3.6–4.5) µg/mL3.3 (3.0–3.7) µg/mL〔均值(95%CI)〕( P < 0.001) 。当靶控BIS值为50时,临床上得到的儿童CtCm也高于成人(Cm504.3 ± 1.1 µg/mL3.4 ± 1.2 µg/mL(均值±标准差),P < 0.05)Ct普遍低估Cm,这个偏差儿童大于成人:2.6 ± 2.6 µg/mL1.7 ± 1.6 µg/mL (P = 0.05)

结论:在儿童和成人中,丙泊酚血药浓度和BIS都具有很好的相关性,儿童可能相对敏感性稍低。由于使用经典药代/药效模式对儿童丙泊酚的血浆浓度的预测很有限,那么使用一个脑部的药效反馈,例如BIS,可能在这个人群中比较有用。

(张莹译  马皓琳 李士通校)

BACKGROUND: In this prospective study, we compared the relationship between propofol concentrations and bispectral index (BIS) in children versus young adults anesthetized with target-controlled infusion (TCI) of propofol.

METHODS: Forty-five prepubertal subjects (children) and 45 postpubertal subjects (adults) were studied. All patients were anesthetized with TCI of propofol, based on the Kataria et al.'s model for children and on the Schnider et al.'s model for adults. All data from the BIS and the TCI system were continuously recorded using Rugloop software. Remifentanil was continuously administered throughout the study (0.25 µg · kg–1 · min–1). In all patients, after the end of surgery, a 12-min period with a stable target plasma concentration (Ct) of propofol, randomly assigned at 2, 3, 4, 5, and 6 µg/mL, was performed. In addition, in most of the patients, another 12-min period was performed during which the BIS was targeted at 50 ± 5. After each 12-min steady-state period, the Ct and BIS were noted and the plasma concentration of propofol was measured (Cm). The Ct and Cm corresponding to half maximal effect (BIS50) was determined by the Hill equation, and by targeting BIS at 50.

RESULTS: In children, as in adults, BIS values were highly correlated with the corresponding Ct or Cm of propofol following classical Emax dose–response curves. The ECt50 and the ECm50, derived from the dose–response curves, were higher in children than in adults: ECm50: 4.0 (3.6–4.5) µg/mL vs 3.3 (3.0–3.7) µg/mL [mean (95% CI)], P < 0.001; as well were the Ct and Cm clinically obtained when BIS was targeted at 50 (Cm50: 4.3 ± 1.1 µg/mL vs 3.4 ± 1.2 µg/mL, (mean ± sd) P < 0.05, children versus adults). Cm was generally under-estimated by the Ct, and the bias was higher in children than in adults: 2.6 ± 2.6 µg/mL vs 1.7 ± 1.6 µg/mL (P = 0.05).

CONCLUSIONS: The good relationship between propofol and BIS demonstrated in children as in adults suggested a slightly lower sensitivity to propofol in children. As the predictability of plasma propofol concentrations with the classical pharmacokinetic/pharmacodynamic models is limited in children, a cerebral pharmacodynamic feedback, such as BIS, may be useful in this population.



择期整形手术前行手术当日妊娠试验实行一年的经验

One-Year Experience with Day-of-Surgery Pregnancy Testing Before Elective Orthopedic Procedures

Richard L. Kahn, MD*{dagger}, Maureen A. Stanton, RN*, Sarani Tong-Ngork, BS*, Gregory A. Liguori, MD*{dagger}, Chris R. Edmonds, MD*{dagger}, and David S. Levine, MD*{dagger}

From the *Department of Anesthesiology, Hospital for Special Surgery, and {dagger}Weill Medical College of Cornell University, New York City, New York.

Anesth Analg 2008; 106:1127-1131

背景:在妊娠时,择期手术通常都被延期。一项在手术当日对所有育龄期妇女检测尿液中人绒毛膜促性腺素(hCG)的政策已在择期整形手术机构执行。以下是对实行一年来经验的回顾性报告和相关的费用。

方法:回顾从200512日至200612日的记录来测定行尿hCG试验和检测为阳性的病例数。费用计算包括提供的试纸和实验室检查的费用。

结果:在实行政策的第一年,2595位育龄妇女中的2588位进行了尿hCG检测。5位患者结果为阳性,手术被取消。在这五位中,3位事前未发现怀孕,一位未发现患者为无症状的宫外孕,一例为更年期假阳性。另外有3位妇女尿检为弱阳性,随后的血清hCG检测为阴性。这三位进行了手术。每次尿检的平均费用为$5.03,每个阳性结果为$3273

结论:手术当日常规检测育龄期妇女的尿hCG妊娠试验的政策可以有效地检测未发觉的妊娠。这导致所有种类的择期手术的延期。在检测的2588位妇女中,一位由于假阳性而延迟了手术。而每个真阳性检测花费的$3273应该与其所带来的利益相比较。

(胡湘    马皓琳 李士通 校)

BACKGROUND: Elective surgery is generally postponed in pregnancy. A policy of testing for urine human chorionic gonadotropin (hCG) in all women of childbearing age on the day of surgery was initiated at an elective orthopedic surgery facility. This is a retrospective report of our 1 yr experience and the associated costs.

METHODS: Records were reviewed from January 3, 2005, through January 2, 2006, to determine the number of urine hCG tests performed, and the disposition of all patients with a positive result. Costs were calculated using the charges for testing supplies and laboratory labor.

RESULTS: During the first year of policy implementation, 2588 of 2595 women of childbearing age underwent urine hCG testing. Five patients had a positive result, and surgery was cancelled. Of these five, three were previously unrecognized pregnancies, one an unrecognized asymptomatic ectopic pregnancy, and one a false-positive result in a perimenopausal woman. Three other women had a "weak positive" urine result, followed by a negative serum hCG. Surgery proceeded in all three. The calculated cost was $5.03 per urine test, and $3273 for each true positive result.

CONCLUSIONS: A policy of routinely performing urine hCG pregnancy tests in women of childbearing age on the day of surgery was effective in detecting unrecognized pregnancy. This resulted in a postponement of elective surgery in all cases. Of 2588 women tested, one had surgery postponed because of a false-positive result. The cost of $3273 per true positive test must be compared with the benefit.


七氟醚介导的p38丝裂原活化的应激酶的活化与Jurkat T细胞的凋亡无关

Sevoflurane-Mediated Activation of p38-Mitogen-Activated Stresskinase is Independent of Apoptosis in Jurkat T-Cells

Martin Roesslein, MD*, Michael Frick, MD§, Volker Auwaerter, PhD{dagger}, Matjaz Humar, PhD*, Ulrich Goebel, MD*, Christian Schwer, MD*, Klaus K. Geiger, MD*, Heike L. Pahl, PhD*, Benedikt H. J. Pannen, MD{ddagger}, and Torsten Loop, MD*

From the Departments of *Anesthesiology and Critical Care Medicine, {dagger}Forensic Medicine, University Hospital, Freiburg, Germany; {ddagger}Department of Anesthesiology and Critical Care Medicine, University Hospital, Duesseldorf; §Department of Medicine, University Hospital, Wuerzburg, Germany.

Anesth Analg 2008; 106:1150-1160

背景麻醉导致的炎症应激反应的调节可能与伤口感染或者肺炎等感染并发症的易感性增高有关。七氟醚是激活物蛋白-1(一种即时早期转录因子)的特殊抑制物,能诱导T细胞的凋亡。因为p38与凋亡的促进或抑制有关,因此我们研究七氟醚诱导的Jurkat T细胞凋亡是否由p38活化所介导。

方法:在体外把Jurkat T细胞暴露于不同浓度的七氟醚、异氟醚或地氟醚。用蛋白质斑迹法来测量丝裂原活化蛋白(MAP)激酶、上游区激酶、下游区转录激活因子-2 (ATF-2)以及细胞凋亡蛋白酶(半胱天冬酶-3 加工处理的磷酰化。在底物ATF-2免疫沉淀和磷酰化后用蛋白质斑迹法来测量p38激酶的活性。用绿色荧光蛋白-膜联蛋白V染色后用流式细胞计量术来测定细胞凋亡。

结果:地氟醚没有作用,而七氟醚和异氟醚可诱导p38的磷酰化,七氟醚可诱导p38激酶的活性。七氟醚对MAP激酶ERK JNK没有作用。七氟醚的暴露也可诱导凋亡信号调节激酶—1(ASK1)MAP激酶的激酶36(MKK3/MKK6)以及ATF-2的磷酰化。用一般的半胱天冬酶抑制物苄氧羰基缬--天冬氨酸-(O-Me)-氟甲基酮(Z-VAD.fmk)对细胞进行预处理不能阻止七氟醚诱导的p38的磷酰化。用特殊的p38抑制物SB202190 SB203580进行预处理不能阻止异氟醚和七氟醚介导的半胱天冬酶-3的加工处理和细胞凋亡。

结论:七氟醚是 Jurkat T细胞内凋亡信号调节激酶-1MKK3/MKK6p38MAP激酶串联反应的一种特异激活物。我们的数据表明七氟醚诱导的p38的活化不受半胱天冬酶活化的影响。而且,七氟醚诱导的细胞凋亡与p38 MAP激酶的活化无关。

(吴进   马皓琳 李士通 校)

BACKGROUND: Modulation of the inflammatory stress response by anesthesia may be responsible for an increased susceptibility to infectious complications, such as wound infection or pneumonia. Sevoflurane, a specific inhibitor of activator protein-1, an immediate early transcription factor, induces apoptosis in T-cells. Because p38 can be involved either in pro- or antiapoptotic processes, we examined whether the sevoflurane-induced apoptosis is mediated by p38 activation in Jurkat T-cells.

METHODS: Jurkat T-cells were exposed to different concentrations of sevoflurane, isoflurane, or desflurane in vitro. Phosphorylation of mitogen-activated protein (MAP) kinases, upstream kinases, downstream activating transcription factor 2 ATF-2, and caspase-3 processing were evaluated by Western blot. p38 kinase activity was evaluated after immunoprecipitation and phosphorylation of the substrate ATF-2 using Western blot. Apoptosis was assessed using flow cytometry after staining with green fluorescent protein-annexin V.

RESULTS: While desflurane had no effect, sevoflurane and isoflurane induced p38 phosphorylation with sevoflurane inducing p38 kinase activity. Sevoflurane did not affect the MAP kinases ERK and JNK. Sevoflurane exposure also induced phosphorylation of apoptosis signal-regulating kinase-1 (ASK1), MAP kinase kinases 3 and 6 (MKK3/MKK6), and ATF-2. Pretreatment of cells with the general caspase inhibitor Z-VAD.fmk did not prevent the sevoflurane-induced phosphorylation of p38. Isoflurane- and sevoflurane-mediated caspase-3 processing and apoptosis could not be abolished by pretreatment with the specific p38 inhibitors SB202190 and SB203580.

CONCLUSIONS: Sevoflurane is a specific activator of the apoptosis signal-regulating kinase-1-, MKK3/MKK6-p38 MAP kinase cascade in Jurkat T-cells. Our data suggest that sevoflurane-induced p38 activation is not affected by caspase activation. Furthermore, sevoflurane-induced apoptosis is not dependent on p38 MAP kinase activation.


脉搏变异指数是否能够指示出在脉搏描记图和动脉压波形中呼吸引起的变异?

Does the Pleth Variability Index Indicate the Respiratory-Induced Variation in the Plethysmogram and Arterial Pressure Waveforms?

Maxime Cannesson, MD, Bertrand Delannoy, MD, Antoine Morand, MD, Pascal Rosamel, MD, Yassin Attof, MD, Olivier Bastien, MD, PhD, and Jean-Jacques Lehot, MD, PhD

From the Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care, Louis Pradel Hospital and Claude Bernard Lyon 1 University, INSERM ERI 22, Lyon, France.

Anesth Analg 2008; 106:1189-1194

背景:呼吸的变异在脉搏氧饱和度仪的描记图中的波形振幅({Delta}POP)对前负荷的变化比较敏感,并且能够预测机械通气患者的液体反应性。但是它不能够简单地通过床边监护设备来计算出来。脉搏变异指数(PVI, Masimo公司, Irvine, CA)是能够自动计算{Delta}POP的一种新的演算法则。我们研究的目的是测试这种新仪器自动连续监测{Delta}POP的能力。

方法:25名患者在全麻诱导后进行研究。PVI自动连续地计算出在脉搏氧饱和度仪的描记图中的波形振幅(灌注指数)中的呼吸变异。先是头高脚低位再变为头低脚高位,记录下相关的数据(平均动脉压、中心静脉压、动脉脉压中的呼吸变异、{Delta}POP、和PVI)。

结果:PVI{Delta}POP之间的相关性非常显著(r = 0.92P < 0.05)。在75个数据中,有4256%)个数据的{Delta}POP>13%PVI的阈值是11.5%,能够区分{Delta}POP >13%{Delta}POP ≤13%。它的灵敏性是93%,特异性是97%PVI来预测{Delta}POP >13%的曲线下面积是0.990 ± 0.07

结论:这是第一个证实PVI能力的研究。PVI是通过脉搏氧饱和度仪的波形分析自动得出的指数,能够自动连续地监测{Delta}POP。这个新的指数对于非创伤性的液体反应性监测有临床应用的可能性。

(唐亮   马皓琳 李士通 校)      

BACKGROUND: Respiratory variations in the pulse oximeter plethysmographic waveform amplitude ({Delta}POP) are sensitive to changes in preload and can predict fluid responsiveness in mechanically ventilated patients. However, they cannot be easily calculated from a bedside monitor. Pleth variability index (PVI, Masimo Corp., Irvine, CA) is a new algorithm that automatically calculates {Delta}POP. The aim of our study was to test the ability of this new device to automatically and continuously monitor {Delta}POP.

METHODS: Twenty-five patients were studied after induction of general anesthesia. PVI automatically and continuously calculates the respiratory variations in the plethysmography waveform amplitude (perfusion index). Data (mean arterial blood pressure, central venous pressure, respiratory variations in arterial pulse pressure, {Delta}POP, and PVI) were recorded at baseline in anti-Trendelenburg position and, finally, in Trendelenburg position.

RESULTS: There was a significant relationship between PVI and {Delta}POP (r = 0.92; P < 0.05). Over the 75 measurements, 42 (56%) presented a {Delta}POP value >13%. A PVI threshold value of 11.5% was able to discriminate between {Delta}POP >13% and {Delta}POP ≤13% with a sensitivity of 93% and a specificity of 97%. Area under the curve for PVI to predict {Delta}POP >13% was 0.990 ± 0.07.

CONCLUSION: This study is the first to demonstrate the ability of PVI, an index automatically derived from the pulse oximeter waveform analysis, to automatically and continuously monitor {Delta}POP. This new index has potential clinical applications for noninvasive fluid responsiveness monitoring.



 

手术室内为了监测液体反应性的一种自动估算动脉脉压中呼吸变化的新颖运算方式的能力

The Ability of a Novel Algorithm for Automatic Estimation of the Respiratory Variations in Arterial Pulse Pressure to Monitor Fluid Responsiveness in the Operating Room
Maxime Cannesson, MD*, Juliette Slieker, MD*, Olivier Desebbe, MD*, Christian Bauer, MD*, Pascal Chiari, MD, PhD*, Roland Hénaine, MD†, and Jean-Jacques Lehot, MD*

From the Hospices Civils de Lyon, Departments of *Anesthesiology and Intensive Care, †Cardiac Surgery, Louis Pradel Hospital, Claude Bernard Lyon 1 university, Lyon, France.

Anesth Analg 2008 106: 1195-1200.

 

背景:动脉脉压中的呼吸变化([DELTA]PPman)是机械通气患者的液体反应性的精确预测因子。然而,它不能被持续监控。在本研究中,我们评估一种新颖的自动估算[DELTA]PP的运算方式([DELTA]PPauto)的临床效用。

方法:研究25例行冠脉旁路移植的患者。用基于自动检测运算方式、核心光滑处理、级系滤波器的方法持续显示[DELTA]PPauto。所有患者进行全麻、机械通气,还用肺动脉导管监测。在手术的8个阶段包括血管内容量扩充(500ml羟乙基淀粉)前和后同时记录[DELTA]PPman[DELTA]PPauto。容量扩充的反应者定义为心脏指数在容量扩充后上升15%以上的患者。

结果:200对收集的数据中[DELTA]PPman[DELTA]PPauto的一致性为0.7% ± 3.4% (平均偏倚 ± sd)17例患者对容量扩充有反应。允许鉴别容量扩充反应者的[DELTA]PPman阈值为12%,灵敏度88%,特异性100%。允许鉴别容量扩充反应者的[DELTA]PPauto阈值为10%,灵敏度82%,特异性88%

结论: [DELTA]PPauto[DELTA]PPman有高度相关性,是液体反应性的精确预测因子,并能持续监测[DELTA]PP。这种新颖的运算方式有潜在的临床应用可能。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: Respiratory variations in arterial pulse pressure ([DELTA]PPman) are accurate predictors of fluid responsiveness in mechanically ventilated patients. However, they cannot be continuously monitored. In our study, we assessed the clinical utility of a novel algorithm for automatic estimation of [DELTA]PP ([DELTA]PPauto).

METHODS: We studied 25 patients referred for coronary artery bypass grafting. [DELTA]PPauto was continuously displayed using a method based on automatic detection algorithms, kernel smoothing, and rank-order filters. All patients were under general anesthesia, mechanical ventilation, and were also monitored with a pulmonary artery catheter. [DELTA]PPman and [DELTA]PPauto were recorded simultaneously at eight steps during surgery including before and after intravascular volume expansion (500 mL hetastarch). Responders to volume expansion were defined as patients whose cardiac index increased by more than 15% after volume expansion.

RESULTS: Agreement between [DELTA]PPman and [DELTA]PPauto over the 200 pairs of collected data was 0.7% ± 3.4% (mean bias ± sd). Seventeen patients were responders to volume expansion. A threshold [DELTA]PPman value of 12% allowed discrimination of responders to volume expansion with a sensitivity of 88% and a specificity of 100%. A threshold [DELTA]PPauto value of 10% allowed discrimination of responders to volume expansion with a sensitivity of 82% and a specificity of 88%.

CONCLUSION: [DELTA]PPauto is strongly correlated to [DELTA]PPman is an accurate predictor of fluid responsiveness, and allows continuous monitoring of [DELTA]PP. This novel algorithm has potential clinical applications.

 

 

 

 

地氟醚与氟烷相比可以对线粒体功能提供更多保护作用对抗大鼠前脑缺血再灌注损伤

Desflurane Affords Greater Protection Than Halothane in the Function of Mitochondria Against Forebrain Ischemia Reperfusion Injury in Rats

Bing Zhang, MD, PhD, Xia Wei, MD, Xiaoguang Cui, MD, PhD, Huacheng Zhou, MD, PhD, Wengang Ding, MD, PhD, and Wenzhi Li, MD, PhD

From the Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, China.

Anesth Analg 2008; 106:1242-1249

背景:氟烷和地氟醚已经被证实可以减轻神经元损伤,但是它们对线粒体的影响还不清楚。我们研究了在大鼠脑部缺血后上述两者能否影响线粒体的作用。

方法:四十只成年雄性Wistar大鼠被随机分成四组(每组十只):对照组、1.5MAC氟烷组、1.0MAC地氟醚组和1.5MAC地氟醚组。在吸入1.5MAC氟烷或1.0MAC1.5MAC地氟醚40分钟后通过夹闭两侧颈总动脉和降低动脉血压造成前脑缺血。在分离得到脑线粒体后,用40–200 µM Ca2+通过分光光度计分析线粒体膜的通透性,附加若丹明123染料通过荧光分光光度计测得线粒体膜电位。线粒体呼吸链复合物的活性也通过分光光度计测得。

结果:这些结果显示在前脑缺血再灌注损伤后有明显的线粒体肿胀、附加Ca2+后膜电位丧失及呼吸链复合物I+IIIIV的活性受抑制。与1.5MAC氟烷组相比,1.01.5MAC地氟醚组分别减少线粒体肿胀23.9% (P < 0.001) 23.2% (P < 0.001),抑制膜电位损耗22.4% (P = 0.013) 20.4% (P = 0.027)1.0MAC地氟醚组和1.5MAC地氟醚组中呼吸链复合物I+IIIIV的活性与1.5MAC氟烷组相比得到较好的保护,分别达到34.6% (P = 0.027)38.7% (P = 0.011)53.9% (P = 0.009)55.8% (P = 0.007)

结论:在脑部缺血再灌注损伤后4小时的时候地氟醚与氟烷相比,抑制线粒体肿胀、增加膜电位和改善膜呼吸链复合物I+IIIIV活性,从而表现出了对线粒体功能更好的保护作用。

(姜旭晖   马皓琳 李士通 校)

BACKGROUND: Halothane and desflurane have been shown to attenuate neuronal injury; however, the effects of these anesthetics on mitochondria are unclear. We investigated whether halothane and desflurane affect the function of mitochondria after cerebral ischemia in rats.

METHODS: Forty male Wistar rats were randomly divided into four groups (n = 10 each): sham group; 1.5 minimal alveolar concentration (MAC) halothane group; 1.0 MAC desflurane; and 1.5 MAC desflurane group. Forebrain ischemia was induced after 40-min inhalation of 1.5 MAC halothane, 1.0 MAC or 1.5 MAC desflurane by clamping the bilateral common carotid arteries and decreasing arterial blood pressure. After isolation of the brain mitochondria, mitochondrial membrane permeability was assayed spectrophotometrically with 40–200 µM Ca2+, and mitochondrial membrane potentials were measured by a fluorospectrophotometer with the addition of rhodamine 123. The activities of mitochondrial respiratory chain complexes were also assayed spectrophotometrically.

RESULTS: The results showed obvious mitochondrial swelling, loss of membrane potential with the addition of Ca2+, and inhibition of the activities of complexes I + III and IV after forebrain ischemia reperfusion injury. Compared with the 1.5 MAC halothane group, 1.0 and 1.5 MAC desflurane reduced mitochondrial swelling by 23.9% (P < 0.001) and 23.2% (P < 0.001), whereas membrane potential dissipation was suppressed by 22.4% (P = 0.013) and 20.4% (P = 0.027). The activities of complexes I + III and IV were better preserved in 1.0 MAC and 1.5 MAC desflurane groups than in the 1.5 MAC halothane group by 34.6% (P = 0.027), 38.7% (P = 0.011), 53.9% (P = 0.009), and 55.8% (P = 0.007), respectively.

CONCLUSIONS: Desflurane shows better preservation of mitochondrial function at 4 h after cerebral ischemia reperfusion injury, indicated by inhibition of mitochondrial swelling, increase of membrane potential, and improvement of functions of mitochondria respiratory complexes I + III and IV when compared with halothane.


腰骶椎移行病人腰骶神经根皮区变异

Dermatome Variation of Lumbosacral Nerve Roots in Patients with Transitional Lumbosacral Vertebrae

Yang Hyun Kim, MD*, Pyung Bok Lee, MD*, Chul Joong Lee, MD{dagger}, Sang Chul Lee, MD{dagger}, Yong Chul Kim, MD{dagger}, and Jin Huh, MD{ddagger}

From the *Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seoul, {dagger}Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, and {ddagger}Department of Anesthesiology and Pain Medicine, Seoul Municipal Boramae Hospital, Seoul, Korea.

Anesth Analg 2008; 106:1279-1283

背景:移行椎的存在,会造成在脊神经阻滞的时候,难以辨别相应外叶神经根的腰水平。我们采用电刺激观察了存在腰骶的移行椎时肌肉神经支配模式和腰段神经根的感觉皮区改变的可能性。

方法:我们用Castellvi’s 标准来确定移行椎的存在。有移行椎伴腰骶神经根病的病人纳入研究。用电刺激进行选择性神经根阻滞。有腰化S1或者骶化L5的病人中S1L5神经根压迫造成的神经病学症状,分别和正常构型病人的L5或者S1神经根压迫比较。

结果32个病人有移行椎,其中12个有腰化S120个有骶化L5。腰化S1 (L6) 神经根造成的运动和感觉症状的分布和刺激正常构型中的S1神经根相似。在17个病人中,刺激骶化L4神经根引起的运动感觉症状分布和刺激正常构型中的L5神经根相似。

结论:我们的发现暗示,在L5骶化的病人,腰骶神经根的功能改变了。L4神经根提供了L5神经根通常的功能。

(张曦 译,马皓琳 李士通 校)

BACKGROUND: The presence of a transitional vertebra can create difficulty in identifying the lumbar level corresponding to an exiting nerve root at the time of a spinal nerve block. We investigated the possibility that the muscle innervation pattern and sensory dermatomes of the lumbar nerve roots are altered when a lumbosacral transitional vertebra is present using electrical stimulation.

METHODS: We determined the existence of transitional vertebrae using Castellvi’s criteria. Patients having transitional vertebrae with lumbosacral radiculopathy were recruited for the study. Selective nerve root blocks using electrical stimulation were performed. Neurologic symptoms caused by S1 or L5 nerve root compression in the patients with a lumbarized S1 or sacralized L5, respectively, were compared with those caused by either L5 or S1 nerve root compression in patients with a normal configuration.

RESULTS: Thirty-two patients had transitional vertebrae, of whom 12 had a lumbarized S1 and 20 had a sacralized L5. The distribution of motor and sensory symptoms caused by the lumbarized S1 (L6) nerve root stimulation was similar to that of the S1 nerve root stimulation in the normal configuration. In 17 patients, the distribution of motor and sensory symptoms caused by the sacralized L4 nerve root stimulation was similar to that of L5 nerve root stimulation in the normal configuration.

CONCLUSIONS: Our findings suggest that the function of the lumbosacral nerve roots is altered in patients with a sacralized L5, and that the L4 nerve root serves the usual function of the L5 nerve root.


静脉注射格拉司琼对布比卡因鞘内麻醉感觉和运动阻滞的影响

The Effects of Intravenous Granisetron on the Sensory and Motor Blockade Produced by Intrathecal Bupivacaine

Hany A. Mowafi, MBBch, MSc, MD, Samer A. Arab, MD, Salah A. Ismail, MBBch, MSc, MD, and AbdulMohsin Al-Ghamdi, MBBch, MD

From the Department of Anesthesia, Faculty of Medicine, King Faisal University, Saudi Arabia.

Anesth Analg 2008; 106:1322-1325

背景资料:我们假设,预先静脉注射格拉司琼能够通过5-HT3受体阻滞而影响脊麻的运动和感觉阻滞部分。

方法:四十个计划在脊麻下进行择期膝关节镜检查的病人随机分为两组,在进入手术室后分别静脉注射格拉司琼1mg(格拉司琼组)和生理盐水(对照组)。以0.5%高比重布比卡因2.5ml12.5mg)进行鞘内注射。记录感觉水平和运动阻滞的消退以及血流动力学变化。

结果:两组之间比较感觉阻滞的最高平面和达到最高感觉阻滞水平的时间没有显著性差异。与对照组相比,注射格拉司琼的患者感觉平面消退两个节段的时间明显缩短(69.8 ± 25.5 min vs 88.0 ± 27.8 min, P = 0.036),消退到T12的时间(105.5 ± 25.1 min vs 127.0 ± 30.5 min, P = 0.019)和消退到S1的时间(162.8 ± 41.1 min vs 189.8 ± 39.8 min, P = 0.041)也明显缩短。相反,在运动阻滞方面的任何研究时间两组之间没有显著差异。两组之间血流动力学方面也没有显著差异。

结论:我们认为静脉注射格拉司琼可以促进布比卡因蛛网膜下腔麻醉后感觉阻滞的更快恢复。

(沈浩   马皓琳 李士通校)

BACKGROUND: We hypothesized that pretreatment with IV granisetron would affect the sensory and motor components of spinal blockade through 5-HT3 receptor blockade.

METHODS: Forty unpremedicated patients scheduled for elective knee arthroscopy under spinal anesthesia were randomly allocated to receive either IV granisetron 1 mg (granisetron group) or saline (control group) on arrival to the operating room. Two and half milliliters (12.5 mg) of hyperbaric bupivacaine 0.5% was injected intrathecally. Regression of the sensory level and motor blockade, and the hemodynamic changes were evaluated.

RESULTS: There were no significant differences between the two groups in the maximum cephalad spread of sensory block or the time to maximum sensory level. Compared with the control group, patients who received granisetron had significantly faster sensory regression times by two segments (69.8 ± 25.5 min vs 88.0 ± 27.8 min, P = 0.036), to segment T12 (105.5 ± 25.1 min vs 127.0 ± 30.5 min, P = 0.019) and to segment S1 (162.8 ± 41.1 min vs 189.8 ± 39.8 min, P = 0.041), respectively. In contrast, motor block did not differ between the two groups at any study time. No significant differences were detected between the two study groups in the hemodynamic data.

CONCLUSION: We concluded that IV granisetron facilitated a faster recovery of sensory block after bupivacaine subarachnoid anesthesia.


异氟醚单独应用或与芬太尼合用可抑制伤害性刺激诱导的大鼠腰段脊髓C-Fos基因表达

Suppression of Noxious-Induced C-Fos Expression in the Rat Lumbar Spinal Cord by Isoflurane Alone or Combined with Fentanyl

Mathieu G. Sommers, DVM*, Nha-Khanh Nguyen, MSc{dagger}, Jan G. Veening, PhD{dagger}{ddagger}, Kris C. Vissers, MD, PhD, FIPP§, Merel Ritskes-Hoitinga, DVM, PhD, Dipl ECLAM*, and Jan van Egmond, PhD§

From the *Central Animal Laboratory, {dagger}Department of Anatomy, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; {ddagger}Department of Psychopharmacology, UIPS, Utrecht University, Utrecht, The Netherlands; and §Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Anesth Analg 2008; 106:1303-1308

背景:尽管在过去十年里对于麻醉中伤害感受过程的理解有了很大的进步,仍有很多患者在术后体验痛觉过敏和急性疼痛。伤害性刺激诱导的撤回反射(NIWR)模型是特别设计的,可有效地定量研究动物麻醉状态下对疼痛多形式刺激的反应。由于吸入麻醉药和阿片类药物的麻醉机制不同,本研究评估了异氟醚和芬太尼对腰段脊髓内c-fos基因表达的不同影响以测定全麻中伤害感受信息的传递。

方法:实验方案为包含4个组的随机区组设计:23/4最低肺泡气体浓度(MAC)异氟醚浅麻醉组(无刺激的/NIWR刺激的)和2NIWR刺激的手术麻醉组(11/2 MAC异氟醚麻醉和3/4 MAC异氟醚复合芬太尼400–600 µg · kg–1 · h–1麻醉 )。在对大鼠后爪进行2小时的周期性电刺激后定量测定脊髓背角中Fos免疫反应阳性的神经元数目。

结果:异氟醚对腰段c-fos基因表达的主要抑制效应表现于脊髓板层II浅层(P = 0.02),而芬太尼则在板层V处表现出最强的抑制效应(P = 0.05)

结论:本研究表明NIWR模型复合脊髓Fos免疫反应性测定作为评估吸入麻醉药和阿片类药物对全麻中伤害感受信息传递不同效应的模型是适当有效的。

(周雅春 马皓琳 李士通 校)

BACKGROUND: Although our understanding of nociceptive processing during anesthesia has increased greatly over the last decade, many patients still experience hyperalgesia and acute pain postoperatively. The noxious-induced withdrawal reflex (NIWR) model is specifically designed and validated to quantitatively study the reaction on painful, multimodal stimuli in animals under anesthetic conditions. Since the anesthetic mechanisms differ between inhaled anesthetics and opioids, we evaluated the differential effects of isoflurane and fentanyl on c-fos expression at the lumbar level as a measure of nociceptive information transfer during general anesthesia.

METHODS: The experimental setup consisted of a randomized block design with four experimental groups: two light 3/4minimum alveolar concentration (MAC) isoflurane anesthesia groups (unstimulated/NIWR-stimulated) and two NIWR-stimulated surgical anesthesia groups (11/2 MAC isoflurane anesthesia and 3/4MAC isoflurane anesthesia combined with fentanyl 400–600 µg · kg–1 · h–1). After 2 h of intermittent electrical stimulation of the hind paw of the rat, the number of Fos immunoreactive (Fos-IR) neurons in the dorsal horn was measured quantitatively.

RESULTS: The main suppressive effects on lumbar c-fos expression of isoflurane were observed in the superficial lamina II (P = 0.02), whereas fentanyl showed the strongest effects in lamina V (P = 0.05).

CONCLUSIONS: This study demonstrates that the NIWR model combined with spinal Fos-immunoreactivity is a suitable and useful model for evaluating the differential effects of inhaled anesthetics and opioids on nociceptive information transfer during general anesthesia.

 

严格控制心率能提高β-阻滞药的功效吗?对非心手术随机试验的最新分析

Does Tight Heart Rate Control Improve Beta-Blocker Efficacy? An Updated Analysis of the Noncardiac Surgical Randomized Trials

W. Scott Beattie, MD,PhD*, Duminda N. Wijeysundera, MD, Keyvan Karkouti, MD, MSc, Stuart McCluskey, MD, PhD*, and Gordon Tait, PhD*

From the Departments of *Anesthesia, and {dagger}Health Policy Management, and Evaluation/Clinical Epidemiology, Toronto General Hospital and University of Toronto, Toronto, Ontario.

.Anesth Analg 2008; 106:1039-1048

 

背景:最近一项评价围术期β-阻滞药效果的回归分析试验没能证明其能降低术后发病率和死亡率。严格的控制心率则有助于改进这种结果。回归分析没有考虑严格的控制心率对β-阻滞药效果的影响。

方法:运用已发布的调查方略,我们分析了所有非心手术后评价围术期β-阻滞药的随机试验。该调查从2176名患者中产生了10个实验。运用调查得来的数据分析心率控制和术后事件,主要是院中心梗的联系。计算比值比和95%可信区间,对心率控制结果和心梗作回归分析。

结果:这些研究的结果综合起来没有显示β-阻滞药有显著的心脏保护作用,而且研究和研究之间有很大差异性(OR = 0.76; 95% CI = 0.4–1.4; P = 0.38 heterogeneity: I2 = 34%).然而,基于最大心率的研究分组却显示这样的结果:最大心率低于100bpm的试验和心脏保护有关(OR = 0.23; 95% CI = 0.08–0.65; P = 0.005),而最大心率高于100bpm的试验和心脏保护无关(OR = 1.17; 95% CI = 0.79–1.80; P = 0.43),并且没有组内差异。对β-阻滞药影响下的心率和术后心梗比值比取对数作回归分析表明:β-阻滞药对最大心率,平均心率,心率变异性的效应和心梗的比值比成线性关联(r2 = 0.63; P < 0.001),即药物对心率效果越明显,术后心梗的发生越少。综观整个研究,β-阻滞药在降低术后心率方面有很大差异性。在一定程度上,这一差异性和药物类型有关,特别是美托洛尔以及和钙通道阻滞剂的混合使用。钙通道阻滞剂和包括美托洛尔在内的β-阻滞药一起使用能对心率产生更大控制。心率对β-阻滞药的反应大不一样。25%服用β-阻滞药的患者在心率大于100bpm时有临床事件发生,而15%的安慰剂对照患者也有心动过缓,如果服用的是β-阻滞药而非安慰剂这时就要降低药量了。最后,该分析发现围术期β-阻滞药的使用和心动过缓有关(OR = 3.49; 95% CI = 2.4–5.9),也和充血性心衰有关(OR = 1.68; 95% CI = 1.00–2.8).

结论:那些β-阻滞药对心率影响最有力的试验里术后心梗的发生也少,表明有效的心率控制对心脏保护的重要性。第二,分析表明β-阻滞药并非对所有病人都能降低心率,而可能会产生副作用。和其他药物合适的联合治疗对有效控制术后心率来说可能是必要的。

(孙鹏飞译 薛张纲校)

BACKGROUND: Recent meta-analyses assessing the efficacy of perioperative β-blockade trials have failed to show a reduction in postoperative morbidity and mortality. Tight control of heart rate (HR) has been suggested to improve these outcomes. Meta-analyses have not considered the influence of tight HR control on the efficacy of perioperative β-blockade.

METHODS: Using previously published search strategies, we identified all randomized trials evaluating perioperative β-blockers after noncardiac surgery. This search yielded 10 trials with 2176 patients. We used the data from these studies to correlate measures of HR control with major postoperative outcomes, primarily in-hospital myocardial infarction (MI). Odds ratio (OR) and 95% confidence intervals (CI) were calculated, and metaregression was performed correlating measures of HR control with MI.

RESULTS: The combined results of all studies did not show a significant cardioprotective effect of β-blockers, with considerable heterogeneity among the studies (OR = 0.76; 95% CI = 0.4–1.4; P = 0.38 heterogeneity: I2 = 34%). However, grouping the trials on the basis of maximal HR showed that trials where the estimated maximal HR was <100 bpm were associated with cardioprotection (OR = 0.23; 95% CI = 0.08–0.65; P = 0.005) whereas trials where the estimated maximal HR was >100 bpm did not demonstrate cardioprotection (OR = 1.17; 95% CI = 0.79–1.80; P = 0.43) with no heterogeneity. Moreover, metaregression of the HR response to β-blockade against the log OR of postoperative MI demonstrated a linear association between the effect of β-blockade on the mean, maximal, and variation in HR and the OR of an MI (r2 = 0.63; P < 0.001) where a larger effect of β-blockers on HR was associated with a decreased incidence of postoperative MI. Across all studies, β-blockade resulted in a reduction in postoperative HR (weighted mean difference: 8.6 bpm; 95% CI = –9.6 to –7.6; I2 = 85.3%) with considerable heterogeneity. This large heterogeneity in HR response to β-blockade was found to be related, in part, to the type of β-blocker, specifically, metoprolol, and the concomitant use of calcium channel blockers. Calcium channel blocker use and β-blockers other than metoprolol resulted in more effective control of HR. There was wide variability in the HR response to β-blockade. Twenty-five percent of patients receiving β-blockers had episodes when the HRs were more than 100 bpm, although 15% of placebo patients also had bradycardia, which would have required a dose reduction had they been administered β-blockers. Finally, this analysis found that perioperative β-blockade was associated with an increased incidence of bradycardia (OR = 3.49; 95% CI = 2.4–5.9) and congestive heart failure (OR = 1.68; 95% CI = 1.00–2.8).

CONCLUSIONS: The trials that achieve the most effective control of HR are associated with a reduced incidence of postoperative MI, suggesting that effective control of HR is important for achieving cardioprotection. Second, this analysis demonstrates that administration of β-blockers does not reliably decrease HRs in all patients, and may be associated with increased side effects. Judicious use of combination therapy with other drugs may be necessary to achieve effective postoperative control of HR.

 

病例系列报道:输血时高钾所致的心跳骤停

Cardiac Arrests Associated with Hyperkalemia During Red Blood Cell Transfusion: A Case Series

Hugh M. Smith, Stacy J. Farrow, SRNA, Joel D. Ackerman, James R. Stubbs, and Juraj Sprung

From the Departments of *Anesthesiology and {dagger}Transfusion Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota.

Anesth Analg 2008 106: 1062-1069.

 

背景:输血相关的高钾性心跳骤停是快速输注红细胞时的一个严重并发症。因此对于那些在快速输注红细胞时发生了高钾及心跳骤停的患者,我们就其特定的临床情境及相关结局进行了一系列的分析。

方法:我们回顾性的分析了Mayo临床麻醉数据库中在1988.11.1-2006.12.31期间,所有发生了术中输血相关的高钾性心跳骤停的患者。

结果:我们共找出了16名输血相关的高钾性心跳骤停患者,其中成人11名,儿童5名。大多数病人进行了以下三种手术:肿瘤手术,大血管手术及外伤手术。在心跳骤停时的血清钾浓度为7.2 ±1.4 mEq/L(范围为5.9-9.2 mEq/L),而心跳骤停前所输注的红细胞量的范围为1个单位(输予一2.7kg的新生儿)~54个单位。且几乎所有的患者在心跳骤停的同时都伴有酸中毒、高血糖、低血钙及低体温的发生。其中14位病人(87.5%)是通过中心静脉通路进行的红细胞输注,而使用商业性的快速输注装置(快速输注泵)者在11位成人中占8(72.7%),而其余所有的病人都是通过加压袋或注射泵来进行快速输注的。他们的平均复苏时间为32min(范围从2-127 min不等)。院内存活率为12.5%

结论:输血相关的高钾性心跳骤停的发病机理是多因素的,而输血后的血钾升高也常与低心输出量、酸中毒、高血糖、低血钙及低体温相并存。因此当在大量输注库存血及大出血的情况下,我们更需提高对潜在的高钾血症的警觉性并采取相应的预防措施。

(刘沁译 薛张纲校)

BACKGROUND: Transfusion-associated hyperkalemic cardiac arrest is a serious complication of rapid red blood cell (RBC) administration. We examined the clinical scenarios and outcomes of patients who developed hyperkalemia and cardiac arrest during rapid RBC transfusion.

METHODS: We retrospectively reviewed the Mayo Clinic Anesthesia Database between November 1, 1988, and December 31, 2006, for all patients who developed intraoperative transfusion-associated hyperkalemic cardiac arrest.

RESULTS: We identified 16 patients with transfusion-associated hyperkalemic cardiac arrest, 11 adult and 5 pediatric. The majority of patients underwent three types of surgery: cancer, major vascular, and trauma. The mean serum potassium concentration measured during cardiac arrest was 7.2 _ 1.4 mEq/L (range, 5.9 –9.2mEq/L). The number of RBC units administered before cardiac arrest ranged between 1 (in a 2.7 kg neonate) and 54. Nearly all patients were acidotic, hyperglycemic, hypocalcemic, and hypothermic at the time of arrest. Fourteen(87.5%) patients received RBC via central venous access. Commercial rapid infusion devices (pumps) were used in 8 of 11 (72.7%) of the adult patients, but RBC units were rapidly administered (pressure bags, syringe pumped) in all remaining patients. Mean resuscitation duration was 32 min (range, 2–127 min). The inhospital survival rate was 12.5%.

CONCLUSION: The pathogenesis of transfusion-associated hyperkalemic cardiac arrest is multifactorial and potassium increase from RBC administration is complicated by low cardiac output, acidosis, hyperglycemia, hypocalcemia, and hypothermia. Large transfusion of banked RBCs and conditions associated with massive hemorrhage should raise awareness of the potential for hyperkalemia and trigger preventative measures.

 

 

抗纤溶疗法在先天性心脏病手术中的应用

Antifibrinolytic Therapy in Surgery for Congenital Heart Disease

Eaton, Michael P. MD

From the Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York.

Anesth Analg 2008.106(4):1087-1100

 

摘要:丝氨酸蛋白酶抑制剂、抑肽酶,和赖氨酸类似物、[epsilon]氨基己酸,以及氨甲环酸,已经被证实在成人心血管手术中能起到减少出血,减少输血输液用量的作用。虽然在儿童患者中进行的心血管手术也明显有很高的出血风险及大量输血输液要求,但在这些患者中,这种抗纤溶疗法的风险与收益还没有被人完善地了解证实过。先天性心脏病的外科手术中使用抗纤溶疗法是有其合理的文献验证体系的,但是因为涉及的研究对象、步骤、方法、以及给药剂量有很大的不同,所以要对此做出一个定量的研究分析现在来讲还不现实。而对这些文献作定性的回顾性研究,可以发现刚刚提到的三类药物在先天性心脏病的外科治疗中都有减少出血,减少输血输液用量的作用,在人群中有很好的益处。在可知的数据中,还没有发现这三种药物的效益有何不同,除了抑肽酶可能有特有的抗炎作用,会对儿科病人有更有益的作用。现在,还没有足够证据能证实这三种药物的安全性,而似乎抑肽酶在儿科患者中引起过敏反应的可能性要低于成年患者。虽然这三种药物的药代动力学以及药效动力学已经被研究清楚,但它们的应用方法及使用剂量还是未达成共识,而且通常也不是按照药理学的试用剂量法则来决定用法用量。我们有必要对此作出更深入的研究,对这些药物的药代、药效动力学,以及安全性、可预测性了解更多,估测出对这些特殊患者群体的使用益处,最终能对这些药物的有效用法和用量得出一个共识。

(秦敏菊译 薛张纲校)

AbstractThe efficacy of the serine protease inhibitor, aprotinin, and the lysine analogs, [epsilon]-aminocaproic acid and tranexamic acid, in reducing bleeding and transfusion in adults undergoing cardiac surgery is well established. Although children undergoing cardiac surgery are clearly at high risk for bleeding and transfusion, the risks and benefits of this therapy for the pediatric population are less well understood. There is a reasonable body of literature examining antifibrinolytic therapy in congenital heart surgery, but the large variability in patients studied, procedures, methods, and dosing schemes makes a quantitative analysis of this literature impractical. A qualitative review of this literature reveals significant support for the efficacy of all three drugs for decreasing bleeding and transfusion in congenital heart surgery, likely with more benefit in certain populations. Limited data suggest that there is no difference in efficacy among the three drugs, although aprotinin may have unique antiinflammatory effects that are of benefit in pediatric patients. There is not enough evidence to draw any conclusions about the safety of these drugs in children, although it appears that the risk of anaphylaxis with aprotinin in children may be less than in adults. Dosing schemes used for these drugs have been variable and not always based on sound pharmacologic principles, despite available pharmacokinetic and pharmacodynamic data. Further research should be directed toward establishing safety, evaluating the relative efficacy of the two classes of drugs, proving benefit in specific patient groups, and better defining effective dosing schemes.

 

 

儿童麻醉中拔除喉罩与拔除气管导管时呼末七氟迷浓度比较

A Comparison of the End-Tidal Sevoflurane Concentration for Removal of the Laryngeal Mask Airway and Laryngeal Tube in Anesthetized Children

Jeong-Rim Lee, Young-Sun Lee, Chong Sung Kim, Seong Deok Kim, and Hee-Soo Kim

Department of Anesthesiology, Seoul National University College of Medicine, Seoul, Korea

Anesth Analg 2008 106: 1122-1125.

 

背景:在本次研究中我们将定量的比较能够避免儿童麻醉过程中拔除喉罩和气管导管时或拔除喉罩和气管导管后避免呛咳的七氟醚浓度。

方法:随机的选择40名年龄在8-12岁之间的儿童,随机的选择使用喉罩或气管导管。全麻诱导使用七氟醚,后插入喉罩或气管导管。麻醉维持依赖七氟醚和氧气。在手术结束时,可以得到一个预定的至少在10分钟内拔除喉罩或气管导管的呼末七氟醚浓度。用dixon 的自上而下的方法,将拔除喉罩及气管导管时七氟迷的浓度增大0.2%,确定能成功的避免呛咳,磨牙,有目的的体动,呼吸抑制,喉痉挛,去氧饱和。

结果50%儿童能成功拔除喉罩时的七氟醚呼末浓度为1.90%95%儿童能成功拔除的浓度为2.15%。对于气管导管,该浓度为1.83%2.0%。两组比较,50%的有效剂量没有显著的差别。

结论:95%的儿童(8-12岁)在麻醉过程中,肺泡最低麻醉浓度在0.860.8时可以顺利拔除喉罩及气管导管而不会有呛咳,体动及其他气道并发症的发生。相似的浓度应该分别被用于拔除儿童的喉罩及气管导管。

(胡艳译  薛张刚校)

BACKGROUND: In this study we quantified and compared the optimal sevoflurane concentration required to prevent coughing or moving during or after removal of the laryngeal mask airway (LMA) and the laryngeal tube (LT) in anesthetized children.

METHODS: Forty unpremedicated children, aged 8 mo to 12 yr, were randomly allocated to receive the LMA or LT. General anesthesia was induced via mask with sevoflurane and the LMA or LT was inserted. Anesthesia was maintained with sevoflurane and oxygen. At the end of surgery, a predetermined end-tidal sevoflurane concentration was maintained for at least 10 min and the LMA or LT was removed. Using Dixon's up-down method, the concentration for LMA and LT removal was determined by adjusting the dose by a 0.2% increment. Success was defined by the absence of coughing, teeth clenching, gross purposeful movement, breath holding, laryngospasm, and desaturation.

RESULTS: The end-tidal concentration of sevoflurane to achieve successful LMA removal in 50% of children was 1.90%, in 95% of children was 2.15%. For the LT, the concentrations were 1.83% and 2.00%. The 50% effective dose values did not differ significantly between groups.

CONCLUSIONS: LMA and LT removal in 95% of anesthetized children (aged 8 mo to 12 yr) can be safely accomplished without coughing, moving, or any other airway complications at 0.86 and 0.80 minimum alveolar anesthetic concentration, respectively, and a similar concentration should be used for removal of the LT or LMA in children.

 

在受toll样受体2刺激的单核细胞中μ型阿片受体介导了吗啡导致的肿瘤坏死因子和白介素-6生成受抑

The mu opioid receptor mediates morphine-induced tumor necrosis factor and interleukin-6 inhibition in toll-like receptor 2-stimulated monocytes

Bonnet MP, Beloeil H, Benhamou D, Mazoit JX, Asehnoune K.

Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.

Anesth Analg 2008 106: 1142-1149.

 

背景:吗啡具免疫调节作用,但其内在机制,尤其在toll样受体2TLR2)信号通路中的作用仅部分被了解。此研究中,在受TLR2刺激的人单核细胞生成肿瘤坏死因子(TNF),白介素-6IL6)和白介素-10IL10)方面,我们评估吗啡产生的作用,并识别此过程中所涉及的不同阿片受体以及淋巴细胞和单核细胞间的联系。

方法:通过密度梯度离心方法从新鲜血液中分离得到外周血单核细胞(PBMCs)。之后使用带抗CD14特异抗体高磁场细胞分选工具分离单核细胞。使用阿片受体拮抗剂预处理单核细胞和PBMCs后,将其于吗啡和金葡菌产生的肽聚糖(PGN,特异的TLR2激动剂)中培养。通过酶联免疫吸附试验测量上清液中TNFIL6IL10的量。

结果:促炎性反应因子:吗啡对受PGN刺激的单核细胞产生细胞因子有明显的剂量和浓度依赖性抑制。μ型阿片受体的激动可显著的调节吗啡导致的单核细胞生成TNFIL6受抑。在受PGN刺激的PBMCs,吗啡明显抑制TNF的生成,但对IL6生成抑制不明显。在吗啡导致的PBMCs生成TNF受抑过程中,并未涉及μ型阿片受体。抗炎性反应因子:无论是在单核细胞还是PBMCs IL-10都不是导致受PGN刺激的单核细胞生成TNFIL6受抑的因素。

结论:μ型阿片受体对受PGN刺激后的单核细胞生成TNFIL6有抑制作用,但对PBMCS无此作用。单核细胞与淋巴细胞间的直接联系改变了吗啡在仅有单核细胞存在时可观察到的抑制效果。IL10并非抑制TNFIL6生成的因素。欲描述吗啡的免疫抑制作用,TLR2μ型阿片受体在胞内通路水平的相互作用仍需进一步研究。

(黄凝译  薛张纲校)

BACKGROUND: Morphine possesses immunomodulatory effects but its intrinsic mechanisms, especially in the toll-like receptor 2 (TLR2) signaling pathway, are only partially understood. In this study, we evaluated the effects of morphine on tumor necrosis factor (TNF), interleukin-6 (IL-6), and interleukin-10 (IL-10) production in TLR2-stimulated human monocytes and identified the involvement of the different opioid receptors, and of the lymphocyte-to-monocyte contact.

METHODS: Peripheral blood mononuclear cells (PBMCs) were isolated from fresh blood by centrifugation on a density gradient. Monocytes were secondarily separated using a high-gradient magnetic cell sorting kit with specific anti-CD14 antibodies. Monocytes or PBMCs were pretreated with opioid receptors antagonists before being cultured with morphine and peptidoglycan (PGN) from Staphylococcus aureus (specific TLR2 agonist). The amount of TNF, IL-6, and IL-10 was measured in the supernatant enzyme-linked immunosorbent assay.

RESULTS: Proinflammatory cytokines: Morphine significantly inhibited the production of cytokines in a dose and concentration-dependent manner in PGN-stimulated monocytes. Mu opioid receptor activation specifically mediated this morphine-induced TNF and IL-6 inhibition in monocytes. Morphine significantly inhibited the TNF, but not the IL-6 production, in PGN-stimulated PBMCs. The mu opioid receptor was not involved in this morphine-induced TNF inhibition in PBMCs. Antiinflammatory cytokines: IL-10 was not a factor for the inhibition of TNF and IL-6 production after PGN stimulation in either monocytes or PBMCs cultures.

CONCLUSIONS: The mu opioid receptor mediates morphine-induced TNF and IL-6 inhibition in PGN-stimulated monocytes, but not in PBMCs. A direct monocyte-to-lymphocyte contact (PBMCs) alters the inhibitory effects of morphine observed on monocytes alone. IL-10 is not a factor for the inhibition of TNF or for IL-6 production. Interactions between TLR2 and mu opioid intracellular pathways remain to be studied to delineate these morphine immunosuppressive effects.

 

 

通过BISNCT指数来比较在七氟醚麻醉中使用和不使用药效平顶效应的药效学模型

Comparative Pharmacodynamic Modeling Using Bispectral and Narcotrend-Index With and Without a Pharmacodynamic Plateau During Sevoflurane Anesthesia

Kreuer, Sascha MD*; Bruhn, Jörgen MD†; Walter, Elisabeth MD*; Larsen, Reinhard MD*; Apfel, Christian C. MD‡; Grundmann, Ulrich MD*; Biedler, Andreas MD*; Wilhelm, Wolfram MD§

From the *Department of Anesthesiology and Intensive Care Medicine, University of Saarland, Homburg/Saar, Saarland, Germany; {dagger}Department of Anesthesiology, UMC St. Radboud, Nijmegen, The Netherlands; {ddagger}Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco; and §Department of Anesthesiology and Intensive Care Medicine, St. Marien-Hospital, Luenen, NRW, Germany.

Anesth Analg 2008 106: 1171-1181.

 

背景:我们比较了有和没有平顶曲线效应两种药效学模型,用双频指数(BIS, Aspect Medical Systems, Natick, MA, version XP)和Narcotrend指数(NCT, MonitorTechnik, Bad Bramstedt, Germany, version 4.0)来测量脑电活动以评价七氟醚的药效。此外,我们尝试分析平顶效应的起源。

方法:我们调查了26例被安排做根治性前列腺切除术的成年病人。在全麻诱导后至少45分钟,呼气末七氟醚浓度在1 vol% 4 vol%之间不等。为了评价浓度和脑电指数的关系,我们使用了两种不同的药效学模型来记录有和没有爆发性抑制时的BISNCT值:一种是基于单S型曲线的传统模型,另一种是基于双S型曲线的新型模型。模型的参数是由非线性混合效应模型VGloboMax, Hanover)的最小似然法估计的。两种模型的统计显著性由似然比检验。

结果:呼气末七氟醚浓度从1.04 ± 0.17 vol%4.43 ± 0.43 vol% ,新的双S型曲线的药动/药效学模型和传统的单S型曲线的Emax模型之间似然数的对数值分别是:BIS监测为396 (P < 0.001)NCT1121 (P < 0.001)。平顶定位于最大[delta]波和爆发抑制比增加之间改变时。

结论:含有插入平顶的双S型曲线药动学/药效学模型描述BISNCT指数反应的七氟醚的效应优于单S型曲线。

(宣丽真译 薛张纲校)

BACKGROUND: We compared two pharmacodynamic models, one with and one without a plateau effect. Bispectral indices (BIS, Aspect Medical Systems, Natick, MA, version XP) and Narcotrend (NCT, MonitorTechnik, Bad Bramstedt, Germany, version 4.0) were used as an electroencephalographic measure of sevoflurane drug effect. In addition, we tried to analyze the origin of the plateau.

METHODS: We investigated 26 adult patients scheduled for radical prostatectomy. At least 45 min after induction of general anesthesia, end-tidal sevoflurane concentrations were varied between 1 vol% and 4 vol%. To evaluate the relationship between concentrations and electroencephalographic indices, two different pharmacodynamic models were applied: a conventional model based on a single sigmoidal curve, and a novel model based on two sigmoidal curves for BIS and NCT values with and without burst suppression. The parameters of the models were estimated by NONMEM V (GloboMax, Hanover) by minimizing log likelihood. Statistical significance between the two models was calculated by the likelihood ratio test.

RESULTS: The end-tidal sevoflurane concentration ranged from 1.04 ± 0.17 vol% to 4.43 ± 0.43 vol%. The difference between the log likelihood values of the new pharmacokinetic/pharmacodynamic model with two connected sigmoidal curves and the classical Emax model with one sigmoidal curve is 396 (P < 0.001) for the BIS monitor and 1121 (P < 0.001) for the NCT. The plateau is positioned at the change between the maximum [delta] power and the increase of burst suppression ratio.

CONCLUSION: A pharmacokinetic/pharmacodynamic model consisting of two sigmoid curves with an intervening plateau describes the effect of sevoflurane on BIS and NCT indices better than a model with a single sigmoid curve.

 

关于通过麻醉-保护装置(AnaConDa)调整七氟醚用量的药代动力学模型预测效果:临床研究

The Predictive Performance of a Pharmacokinetic Model for Manually Adjusted Infusion of Liquid Sevofluorane for Use with the Anesthetic-Conserving Device (AnaConDa): A Clinical Study

Javier F. Belda, MD, PhD*, Marina Soro, MD, PhD{dagger}, Rafael Badenes, MD{dagger}, Andreas Meiser, MD, PhD{ddagger}, María Luisa García, MD{dagger}, Gerardo Aguilar, MD, PhD{dagger}, and Francisco J. Martí, MD, PhD{dagger}

From the *Department of Anesthesiology and Intensive Care, Hospital Clínico Universitario de Valencia, Valencia, Spain; {dagger}Department of Anesthesiology and Intensive Care, Hospital Clínico Universitario, Valencia, Spain; and {ddagger}Klinik fur Anaesthesiologie, St. Josef-Hospital, Klinikum der Ruhr-Universitat, Bochum, Germany

Anesth Analg 2008 106: 1207-1214.

 

背景:麻醉-保护装置(AnaConDa)可通过呼吸机用于重症监护室(ICU)的吸入性麻醉剂管理。在此,我们评价使用AnaConDa调整七氟醚用量的效果。

方法:我们研究了50例通过AnaConDa使用七氟醚的 ICU患者,他们被随机分为三组。 6小时内分别以呼末七氟醚浓度1 1%组 15例)和1.5 1.5 组, 15例)为目标调整输液计划,调节初始剂量,在10分钟内达到目标,然后减少至维持剂量,此后每小时调整一次,在呼吸回路中测定七氟醚的实际浓度,并与目标值进行比较。第三组(20例)则采用增加或减少靶浓度( ± 0.3 3小时的方法,评价七氟醚浓度的实际改变。通过计算性能误差率(PE)评价输液计划的可行性,通过计算精确度(median absolute PE, MDAPE)和偏移(median PE, MDPE)评价输液计划的有效性。

结果: 1 1.5 ,增加浓度0.3 及降低浓度0.3 %组的性能参数(平均值±标准差, )分别是: MDAPE 5.3 ± 5.5 2.6 ± 4.0 5.0 ± 5.6 5.5 ± 5.4 ; MDPE  –5.3 ± 5.5–2.3 ± 4.1–0.1 ± 7.10.2 ± 5.41 %和1.5 %组进行各类比较后无显著差异。

结论:通过使用AnaConDa调整七氟醚用量的ICU病人,可获得良好的6小时药代动力学模型预测效果。

(施颖译 薛张纲校)

BACKGROUND: The Anesthetic-Conserving Device (AnaConDa) can be used to administer inhaled anesthetics using an intensive care unit (ICU) ventilator. We evaluated the predictive performance of a simple manually adjusted pump infusion scheme, for infusion of liquid sevoflurane to the AnaConDa.

METHODS: We studied 50 ICU patients who received sevoflurane via the AnaConDa. They were randomly divided into three groups. A 6-h infusion of liquid anesthetic was adjusted according to the infusion scheme to a target end-tidal sevoflurane concentration of 1% (Group 1%, n = 15) and 1.5% (Group 1.5%, n = 15). The initial rate was adjusted to reach the target concentration in 10 min and then the infusion was reduced to the first hour maintenance rate and readjusted once each hour afterwards. The actual concentrations were measured in the breathing circuit and compared with the target values. In the third group (n = 20) we used the model to increase and decrease the target concentration (±0.3%) for 3 h and evaluated the actual change in concentration achieved. The ability of the infusion scheme to provide the target concentration was quantified by calculating the performance error (PE). Infusion scheme performance was evaluated in terms of accuracy (median absolute PE, MDAPE) and bias (median PE, MDPE).

RESULTS: Performance parameters (mean ± sd, %) were for 1%, 1.5%, increase of concentration by 0.3% and decrease of concentration by 0.3% groups, respectively: MDAPE 5.3 ± 5.5, 2.6 ± 4.0, 5.0 ± 5.6, 5.5 ± 5.4; MDPE –5.3 ± 5.5, –2.3 ± 4.1, –0.1 ± 7.1, 0.2 ± 5.4. No significant differences were found between means of all performance parameters when the 1% and 1.5% groups were compared.

CONCLUSIONS: There is an excellent 6-h predictive performance of a simplified pharmacokinetic model for manually adjusted infusion of liquid sevoflurane when using the AnaConDa to deliver sevoflurane to ICU patients.

 

膝关节置换中使用塞来考昔<抗关节炎药,COX-2抑制剂>的前瞻性随机试验:改良的临床成果

A prospective randomized trial on the role of perioperative celecoxib administration for total knee arthroplasty: improving clinical outcomes.

Reuben SS, Buvenandran A, Katz B, Kroin JS.

Department of Anesthesiology, Baystate Medical Center and the Tufts University School of Medicine, Springfield, MA 01199, USA.

Anesth Analg. 2008 106(4):1258-64,

 

背景:相当多的全膝置换术会产生术后疼痛问题,而如果疼痛未被减轻则会导致住院时间的延长、不能参加康复训练计划、较差的预后和巨大的医疗保健资源的浪费。此项研究假设是在全膝关节置换术中使用塞来考昔会改进镇痛效果以在术后获得更好的长短期临床疗效。

方法:我们对200名行全膝关节置换术的患者进行了随机选择,安慰剂对照双盲试验的前瞻性研究。所有患者均接受了一个相似的麻醉镇痛过程。术后患者均接受了硬膜外镇痛并被教授用数字等级〉或=3来记录疼痛程度。患者被随机的分配入两组中的其中一组:塞来考昔组和安慰剂组。塞来考昔组的患者在手术前7天每天两次口服塞来考昔100mg,手术当天术前1-2小时服用塞来考昔400mg,然后术后每12小时服用塞来考昔200mg直至第10天。对照组在相同的时间服用与之匹配的安慰剂胶囊。此项研究的主要目的是测定手术期间使用塞来考昔是否能减少术后阿片类物质的消耗,其次是确定使用塞来考昔是否能改善临床预后及是否能减少阿片类物质副作用。                                                     

结果:服用塞来考昔的试验组在术后40小时内比对照组所需使用的硬膜外镇痛药少:安慰剂组232.8+/-2.0ml,塞来考昔组209.1+/-1.8ml(P < 0.001)。在家中的术后4-10天塞来考昔组的患者每个时间测定点运动时的疼痛强度都有所缓解(F = 109.7, P < 0.001),而且在家中消耗欧克西克锭(一种麻醉性的生物碱,和可待因有关的,用作止育药和镇静药)也比对照组患者少(F = 417.8, P < 0.001)。在术后1-3天,两组患者进行伸展的主动运动有差别(F = 50.7, P < 0.001),塞来考昔组的患者在所有时间点上都具有更大的伸展度。与对照组比较,试验组的患者更早能将患膝屈曲至90(P < 0.001)。在之后12个月的随访中塞来考昔组患者(93.3 +/- 0.6)比对照组患者(86.4 +/- 0.9)获得更高的全膝关节置换术后社会能力得分(P < 0.001)。在术后短期内塞来考昔组患者不良反应事件(恶心、呕吐、瘙痒)发生较对照组少。

结论:手术期间使用塞来考昔能减少术后疼痛,阿片类物质使用及阿片类物质副作用,并能得到长期获益包括在全膝关节置换术后改善膝关节功能及更早有效达到膝关节伸展程度改善。                                                                         

(刘婷洁译 薛张纲校)

                                                                                                                                                                                                                                                                                                        BACKGROUND: Total knee arthroplasty (TKA) is associated with considerable postoperative pain, which, if unrelieved, may result in prolonged hospital stay, inability to participate in rehabilitation programs, poor outcomes, and greater use of healthcare resources. The hypothesis of this study is that perioperative administration of celecoxib wil l improve analgesic efficacy, with a resultant improvement in short- and long-term clinical outcomes after TKA.

METHODS: We studied 200 patients undergoing elective TKA in a prospective, randomized, double-blind, placebo-controlled fashion. All patients underwent a similar perioperative anesthetic/analgesic procedure. After completion of surgery, patients were started on an epidural infusion with patient-controlled epidural analgesia. Patients were instructed to keep their numerical rating score pain < or = 3. Patients were randomly assigned to one of two groups: celecoxib or placebo. The celecoxib group received celecoxib 100 mg orally twice a day 7 days before surgery. On the day of surgery, celecoxib 400 mg was administered 1-2 h before surgery and then 200 mg every 12 h for 10 postoperative days. The control group received matching placebo capsules at the same times. The primary objective of this study was to determine whether the perioperative use of celecoxib reduces the amount of postoperative opioid consumption. Secondary objectives were to determine whether celecoxib is associated with improved clinical outcomes and a reduction in opioid-related adverse effects.

RESULTS: The celecoxib group required less patient-controlled epidural analgesia over the 40-h postoperative period: placebo 232.8 +/- 2.0 mL, celecoxib 209.1 +/- 1.8 mL (P < 0.001). At home over days 4-10 after surgery, the celecoxib group had reduced pain intensity with movement (F = 109.7, P < 0.001) at all time points. The celecoxib group also consumed less oxycodone at home than placebo group (F = 417.8, P < 0.001). With active movement, range of motion (ROM) differed between the two groups over postoperative days 1-3 (F = 50.7, P < 0.001), with the celecoxib group having greater ROM at all time points. There was earlier achievement of 90 degrees knee flexion with celecoxib compared with placebo (P < 0.001). Celecoxib patients had a better overall Knee Society Score (93.3 +/- 0.6) than placebo patients (86.4 +/- 0.9) at 12-mo follow-up (P < 0.001). The incidence of side effects (nausea, vomiting, and pruritus) in the immediate postoperative period was less in the celecoxib group.

 CONCLUSIONS: Perioperative use of celecoxib reduces postoperative pain, opioid consumption, opioid-related adverse effects, and is associated with long-term benefits including improved knee function and less time to achieve effective knee ROM after TKA.

                                                                                                 

                                                                                                 

血管内注射腰内侧支传导阻滞:前瞻性的评价1433注射

Intravascular Injection in Lumbar Medial Branch Block: A Prospective Evaluation of 1433 Injections

Chul Joong Lee, Yong Chul Kim, Jae Hyuck Shin, Francis Sahngun Nahm, Hyo Min Lee, Yun Suk Choi, Sang Chul Lee, Justin Sang Ko, Tae Hyeong Kim, Woo Seok Sim, Chung Su Kim, and Hyun Sung Cho

 From the *Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and {dagger}Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Anesth Analg 2008 106: 1274-1278

 

背景腰内侧支传导阻滞 mbb 的结果和有效性在很大程度上依赖于技术的准确性。血管内摄取造成对阻滞的假阴性反应并出现各种并发症。在目前的研究中,我们前瞻性地评价了血管内注射发病率和相关因素,此外,我们评估效率普遍接受的安全管理措施,如间歇透视检查,以避免血管内注射。

方法 我们预期地审查了1433腰神经在七位医师执行的456名患者的MBBs。志向测试、斑点造影和在实时荧光镜的形象化之下的对比射入继续地进行了,无需改变位置针。 血液反燃和血管内的对比传播出现的发生在斑点幅射线照相的图象和在实时萤光透视法期间被检查了。 各种因素的研究,为血管内注射,包括医师的经验,病人的年龄,性别,针量具,阻滞脊髓水平。

结果:没有具体的因素被发现,影响发病的血管吸收,在座。总体发病率的内吸收为6.1 ,神经阻滞( 1433分之88 ,并有30人,这些预言preinjection心愿(敏感性= 34.1 )和52所当场照相(敏感性= 59.1

结论:心愿试验或无现货照相经常错过内摄取的反差,在腰椎内外。我们坚决主张用实时透视对比注射,以提高诊断和治疗中的应用价值,并避免可能出现的并发症。

章一静译 薛张纲校

BACKGROUND: The successful outcome and validity of lumbar medial branch block (MBB) are largely dependent on technique accuracy. Intravascular uptake of injectate causes a false-negative response to block and is associated with various possible complications. In the current study, we prospectively evaluated the incidence of, and the factors associated with, intravascular injection during block. In addition, we assessed the efficiencies of generally accepted safety measures, such as preinjection aspiration and intermittent fluoroscopy to avoid intravascular injections.

METHODS: We prospectively examined 1433 lumbar MBBs in 456 patients performed by seven physicians. Aspiration test, spot radiography, and contrast injection under real-time fluoroscopic visualization were performed sequentially without repositioning the needle. Incidences of blood flashback and the presence of intravascular contrast spread on spot radiographic images and during real-time fluoroscopy were checked. The factors studied for intravascular injection included physician experience, patient age and sex, needle gauge, and block spinal level.

RESULTS: No specific factors were found to affect the incidence of intravascular uptake during block. The overall incidence of intravascular uptake was 6.1% per nerve block (88/1433), and 30 of these were predicted by preinjection aspiration (sensitivity = 34.1%) and 52 by spot radiography (sensitivity = 59.1%).

CONCLUSIONS: The aspiration test with or without spot radiography frequently missed the intravascular uptake of contrast during lumbar MBBs. We strongly advocate the use of real-time fluoroscopy during contrast injection to increase diagnostic and therapeutic value and to avoid possible complications.

 

 

对啮齿类神经痛模型给予咪达唑仑可逆转热痛觉过敏以及{gamma}-氨基丁酸转运体的丢失

Midazolam Administration Reverses Thermal Hyperalgesia and Prevents {gamma}-Aminobutyric Acid Transporter Loss in a Rodent Model of Neuropathic Pain

Andre Shih, DVM*, Vjekoslav Miletic, PhD{dagger}, Gordana Miletic, PhD{dagger}, and Lesley J. Smith, DVM{ddagger} From the *Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida; {dagger}Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin; and {ddagger}Department of Surgical Sciences, School of Veterinary Medicine, University of Wisconsin, Madison, Wisconsin.

Anesth Analg 2008 106: 1296-1302.

 

背景:脊髓背角丢失抑制性GABA可导致神经痛。这里我们验证全身性的给予苯二氮卓类药物咪达唑仑是否可以减轻坐骨神经慢性挤压伤(CCI)引起的热痛觉过敏。

方法:分别在CCI之前以及之后的3天和7天用热刺激缩爪潜伏期试验来评价痛觉过敏。动物随机接受渗透性微泵输注咪达唑仑(2.0 mg · kg–1 · h–1),氟马西尼(0.004 mg · kg–1 · h–1),咪达唑仑复合氟马西,或生理盐水(0.01 mg · kg–1 · h–1)。四组经过模拟手术(无神经结扎)后的大鼠作为对照接受配对治疗。手术7天后使用蛋白质免疫印迹法评价腰段脊髓后角GABA转运体1GAT-1)的水平。

结果:生理盐水治疗组的大鼠在3天后出现热痛觉过敏现象,7天后更为显著。持续性输注咪达唑仑在此两天都对热痛觉过敏起到了有效的保护作用。氟马西尼同时投药拮抗了咪达唑仑的抗热痛觉过敏作用。单独输注氟马西尼对CCI大鼠的热痛觉过敏没有作用。接受模拟手术的大鼠术后分别接受盐水、咪达唑仑以及咪达唑仑复合氟马西尼治疗,都没有发生热痛觉过敏。意外的是,模拟手术的大鼠接受氟马西尼治疗后热刺激缩爪潜伏期显著缩短。GAT-1水平的改变与不同的治疗方法也有关系,咪达唑仑可防治CCI相关的GAT-1水平降低,氟马西尼拮抗咪达唑仑的作用。氟马西尼单独用药对GAT-1水平没有影响,但是在模拟手术组动物出现显著的受体水平降低。

结论:抑制性GABA在神经痛中起到重要作用。持续全身性给予苯二氮卓类药物咪达唑仑可有效减轻神经痛。

(夏俊明译 薛张纲校)

BACKGROUND: Loss of {gamma}-aminobutyric acid (GABA) inhibition in the spinal dorsal horn may contribute to neuropathic pain. Here we examined whether systemic administration of the benzodiazepine midazolam would alleviate thermal hyperalgesia due to chronic constriction injury (CCI) of the sciatic nerve.

METHODS: Hyperalgesia was evaluated with the thermal paw withdrawal latency test before, and 3 and 7 days after CCI. Animals randomly received, via osmotic minipump infusion, midazolam (2.0 mg · kg–1 · h–1), flumazenil (0.004 mg · kg–1 · h–1), midazolam plus flumazenil at the same doses, or saline (0.01 mg · kg–1 · h–1). Four groups of sham-operated rats (surgery without nerve ligation) received matched treatments. Levels of the GABA transporter 1 (GAT-1) in the lumbar spinal dorsal horn were estimated using western immunoblots 7 days after surgery.

RESULTS: Saline-treated CCI rats developed thermal hyperalgesia on Day 3 with a more pronounced effect on Day 7. Continuous midazolam infusion prevented thermal hyperalgesia on both days. The antihyperalgesic effect of midazolam was reversed by the coadministration of flumazenil. Infusion of flumazenil alone had no effect on the thermal hyperalgesia in CCI rats. Sham-operated rats treated with saline, midazolam, or midazolam plus flumazenil exhibited no thermal hyperalgesia. Unexpectedly, thermal paw withdrawal latency in sham animals treated with flumazenil alone was significantly decreased. Changes in GAT-1 levels paralleled the behavior. Midazolam prevented the CCI-associated decreases, and flumazenil reversed midazolam's effect. Flumazenil alone did not modify GAT-1 levels in CCI animals but in sham animals the transporter levels were significantly reduced.

CONCLUSIONS: GABA inhibition plays an important role in neuropathic pain. Continuous systemic benzodiazepine administration may prove effective in alleviating neuropathic pain.


神经刺激仪探针置管用于全膝关节成形术后连续股神经阻滞的随机、对照、双盲试验

Stimulating Catheters for Continuous Femoral Nerve Blockade After Total Knee Arthroplasty :A Randomized, Controlled, Double-Blinded Trial

Michael J. Barrington, David J. Olive, Craig A. McCutcheon, Christopher Scarff, Simone Said, Roman Kluger, Nicola Gillett, and Peter ChoongFrom the Departments of *Anaesthesia, {dagger}Physiotherapy, and {ddagger}Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Australia.

Anesth Analg 2008 106: 1316-1321.

 

背景:连续股神经阻滞(CFNB)常用于全膝关节成形术(TKA)术后镇痛. CFNB可以通过多种操作方法得以实施。神经刺激仪探针置管(SC)有在进针时确认导管放置于神经附近的好处。

方法:在该随机、对照、双盲试验中,我们比较了82例全身麻醉下TKA后病人采用SC和非刺激性导管(NSC)技术实施CFNB及其对镇痛效果的影响。接受CFNB的病人随机采用NSCSC置管技术。在通过股侧留置导管注射利多卡因1020分钟后及术后第1天(POD1)和第2天(POD2)评价感觉阻滞情况。期间采用标准的多模式镇痛策略,包括单次坐骨神经阻滞(术前)、静脉注射吗啡(病人自控镇痛)、使用塞来考昔和对乙酰氨基酚。研究变量包括:吗啡用量、病人疼痛评分和术后早期恢复指标。

结果:股神经分布区域感觉阻滞比例为(9095)%,且在所有测定时间组间无明显差异。在第一个24小时与SC组吗啡18 (2–51) mg (P = 0.69)相比,NSC组则需要 19.5 (1–67)mg1090%的中位数)。第一个24小时内,吗啡用量组间差异95%可信区间为(-8 5 mg。而静息状态下POD1POD2视觉模拟评分和主动与被动物理治疗时视觉模拟评分,以及术后早期恢复指标两组间均无差异。

结论:作为TKA后多模式镇痛的一部分,在本研究中盲探法留置导管管和SC法置管对建立和维持用于术后镇痛的CFNB同样可靠。

(蒋宗明译 薛张纲校)

BACKGROUND: Continuous femoral nerve blockade (CFNB) is often used for postoperative analgesia after total knee arthroplasty (TKA). CFNB can be instituted using a variety of techniques. Stimulating catheters (SC) have the advantage of confirming placement of the catheter close to the nerve during advancement.

METHODS: In this randomized, controlled, double-blind trial, we compared a SC with a nonstimulating catheter (NSC) technique for institution of CFNB and its effects on quality of analgesia after TKA performed under general anesthesia in 82 patients. Patients were randomized to have CFNB instituted using either a NSC or a SC technique. Sensory blockade was assessed 10 and 20 min after injection of lidocaine via femoral catheter and on postoperative days 1 (POD 1) and 2 (POD 2). A standardized multimodal analgesic technique, including a single injection sciatic block (preoperative), IV morphine (patient-controlled analgesia), celecoxib, and paracetamol, was administered to all patients. Outcome variables included morphine requirements, pain scores, and markers of early recovery.

RESULTS: The proportion of patients with sensory blockade in the femoral nerve distribution was between 90% and 95% at all measurement times with no difference between groups. In the first 24 h, the NSC group required 19.5 (1–67) [median (10th–90th centiles)] mg morphine compared with the SC Group 18 (2–51) mg (P = 0.69). At 24 h, the 95% confidence interval for difference in morphine consumption between groups was -8 to 5 mg. There was no difference between groups in visual analog scale scores at rest on POD 1 and POD 2, during active and passive physiotherapy; and in markers of early recovery after surgery.

CONCLUSIONS: In this study, blind catheter advancement was as reliable as a SC technique for establishing and maintaining CFNB for postoperative analgesia as a part of multimodal analgesia technique after TKA.