Table of Contents

April 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

嚴格控制心率能提高β-阻滯藥的功效嗎?對非心手術隨機試驗的最新分析

孫鵬飛譯 薛張綱校

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.

七氟烷引起離體心肌線粒體基質容積的特異性增加

黃施偉 譯,馬皓琳 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歲以上病人髖關節成形術後貧血與生活品質關係

陶穎瑩 陳傑

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.

病例系列報導:輸血時高鉀所致的心跳驟停

劉沁譯 薛張綱校

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.

豬稀釋性凝血障礙模型的凝血特徵及使用凝血酶原複合體濃縮物替代治療的效果

邱郁薇 馬皓琳 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.

出血性休克的豬用小容量高滲鹽水/羥乙基澱粉復蘇較4%明膠或6%羥乙基澱粉溶液復蘇相比具有較輕的止血功能障礙和較少失血

趙燕星 陳傑

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.

抗纖溶療法在先天性心臟病手術中的應用

秦敏菊譯 薛張綱校

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

Michael P. Eaton

Anesth Analg 2008 106: 1087-1100.

PEDIATRIC ANESTHESIOLOGY:

丙泊酚靶控輸注時雙譜指數和丙泊酚血藥濃度的關係:兒童和青年人對照研究

張瑩譯  馬皓琳 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.

昂丹司瓊咀嚼片對接受耳鼻喉手術的小兒在家出現嘔吐的治療效果

潘錢玲 陳傑

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.

兒童麻醉中拔除喉罩與拔除氣管導管時呼末七氟迷濃度比較

胡豔譯  薛張剛校

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:

擇期整形手術前行手術當日妊娠試驗實行一年的經驗

胡湘    馬皓琳 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.

肥胖病人頸圍增加對困難插管評估的重要性

王騰 陳傑

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樣受體2刺激的單核細胞中μ型阿片受體介導了嗎啡導致的腫瘤壞死因數和白介素-6生成受抑

黃凝譯  薛張綱校

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.

七氟醚介導的p38絲裂原活化的應激酶的活化與Jurkat T細胞的凋亡無關

吳進   馬皓琳 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.

氟呱利多抑制HERG鉀通道取決於通道門狀態及S6殘基F656

張燕 陳傑

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.

通過BISNCT指數來比較在七氟醚麻醉中使用和不使用藥效平頂效應的藥效學模型

宣麗真譯 薛張綱校

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:

脈搏變異指數是否能夠指示出在脈搏描記圖和動脈壓波形中呼吸引起的變異?

唐亮   馬皓琳 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.

手術室內為了監測液體反應性的一種自動估算動脈脈壓中呼吸變化的新穎運算方式的能力

慧譯 馬皓琳 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.

心臟手術後通過即時監測脈壓波動來指導液體治療

胡瀟 陳傑

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.

關於通過麻醉-保護裝置(AnaConDa)調整七氟醚用量的藥代動力學模型預測效果:臨床研究

施穎譯 薛張綱校

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:

地氟醚與氟烷相比可以對線粒體功能提供更多保護作用對抗大鼠前腦缺血再灌注損傷

姜旭暉   馬皓琳 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:

靜注單劑量地塞米松減輕全髖成形術後的運動性疼痛

陳偉 陳傑

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.

膝關節置換中使用塞來考昔<抗關節炎藥,COX-2抑制劑>的前瞻性隨機試驗:改良的臨床成果

劉婷潔譯 薛張綱校

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:降鈣素、氯胺酮及其聯合應用對痛閾和感覺閾的作用

潘方立 陳傑

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.

血管內注射腰內側支傳導阻滯:前瞻性的評價1433注射

章一靜譯 薛張綱校

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經根皮區變異

張曦 譯,馬皓琳 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.

在大鼠胸深層肌肉離斷後背角小膠質細胞環氧合酶- 1和神經元環氧合酶-2上調

杜唯佳 陳傑

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.

對齧齒類神經痛模型給予咪達唑侖可逆轉熱痛覺過敏以及{gamma}-氨基丁酸轉運體的丟失

夏俊明譯 薛張綱校

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.

異氟醚單獨應用或與芬太尼合用可抑制傷害性刺激誘導的大鼠腰段脊髓C-Fos基因表達

周雅春 馬皓琳 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.

米那普侖對脊神經結紮鼠的抗痛覺超敏和抗痛覺過敏作用

於章傑 陳傑

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.

神經刺激儀探針置管用于全膝關節成形術後連續股神經阻滯的隨機、對照、雙盲試驗

蔣宗明譯 薛張綱校

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.

靜脈注射格拉司瓊對布比卡因鞘內麻醉感覺和運動阻滯的影響

沈浩   馬皓琳 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歲以上病人髖關節成形術後貧血與生活品質關係

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:目前尚不清楚貧血對老年病人髖關節成形術後生活品質有何影響。

方法:大於65歲初次行髖關節成形術的病人,進行為期三個月的術後隨訪,瞭解病人出院時的血色素水準與其在術後兩月主觀評估生活品質的相關性。採用SF-36量表和FACT-Anemia 問卷表在術前及術後兩月評估患者生活品質。並計算術後第八天的血色素水準與SF-36量表和FACT-Anemia 問卷表結果(術前及術後兩月)間的相關係數。

結果87位病人入組研究,其中79位病人採集到術後兩月的資料。術後第八天血色素水準與SF-36量表資料變化間的相關性為0.49p<0.0005),與FACT-Anemia 問卷表資料變化間的相關性為0.46p=<0.0005)。該相關性不受年齡、是否存在重大心血管疾病或是否輸血影響。

結論:大於65髖關節成形術的病人其術後兩月的生活品質評分與該病人出院時血色素水準呈正相關。

(陶穎瑩 陳傑 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.


出血性休克的豬用小容量高滲鹽水/羥乙基澱粉復蘇較4%明膠或6%羥乙基澱粉溶液復蘇相比具有較輕的止血功能障礙和較少失血

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:創傷病人用小容量高滲鹽水/羥乙基澱粉200/0.62(HS-HES) 復蘇較使用晶體液或膠體液更有效。上述四種液體均可導致劑量依賴性稀釋性凝血功能紊亂,並對止血功能產生影響,但很少資料顯示應用低容量復蘇後對凝血功能影響。

方法:thrombelastometry (ROTEM®)研究了30頭豬(體重35-45kg)失血60%[1484ml(1369-1624ml)],以4ml/kgHS-HES或以11的比例輸注4%明膠或6%HES130/0.4來補充丟失的血容量。為了在有出血傾向時比較ROTEM各變數的變化(凝血時間,血栓形成時間,{alpha}角,血栓硬度,人纖維蛋白原聚合作用),行肝臟切開術並測定出血量。

結果:與輸注4%明膠(4.5mm(3.0,5.8)]HES130/0.4 [3.5mm(2.3,4.0)]相比,輸注HS-HES [11mm(10,11),p=0.0034]後人纖維蛋白原聚合中位數(25%75%)明顯增高。輸注HS-HES後肝切口平均失血量為725ml900375),輸注4%明膠平均失血量為1625ml12751950),輸注6%HES130/0.4(p=0.004)平均失血量為1600ml15001800)。各組血流動力學均穩定,但灌注壓不同。

結論:出血性休克時用HS-HES200/0.62復蘇比應用4%明膠或6%HES130/0.4復蘇對血塊形成的影響更小。

(趙燕星 陳傑 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.

 

昂丹司瓊咀嚼片對接受耳鼻喉手術的小兒在家出現嘔吐的治療效果

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:扁桃體和增殖腺切除術後無論在醫院或者在家都可能出現嘔吐。作者評估了昂丹司瓊咀嚼片(ODT)對接受了扁桃體摘除術包括或不包括增殖腺切除術或包括或不包括兩側鼓膜切開和置管術的小兒在家出現嘔吐的療效。

方法:所有的病人以氧化亞氮及氧氣面罩吸入誘導,術中給予七氟醚。術中均給予嗎啡,地塞米松及昂丹司瓊。對於術後出現的疼痛以芬太尼或撲熱息痛輔以可待因處理。在復蘇室中給予止吐劑或在同一天手術室中15min內給予3次止吐劑或根據病人情況或病人要求處理。病人回家後隨機服用五個劑量的ODT或者安慰劑。隨訪病人至術後3天,並記錄在家嘔吐次數。

結果:220名病人參加了研究,200名患者完成有效評估。服用ODT103名小兒中15名(14.5%)在家出現了嘔吐,而服用安慰劑的97名小兒童中31名(32%)發生了嘔吐(p=0.04)。進一步分析顯示在院期間沒有因噁心,嘔吐而進行藥物治療的小兒在家服用ODT有療效,而對在醫院已接受抗嘔吐治療的小兒沒有療效。

結論:小兒扁桃體摘除術後前3天,在家服用昂丹司瓊咀嚼片可以預防嘔吐,但在院期間對噁心嘔吐進行過預防性處理的小兒在家服用昂丹司瓊咀嚼片可能無效。

(潘錢玲 陳傑 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.

 

肥胖病人頸圍增加對困難插管評估的重要性

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:作者用困難插管評分(IDS)法擬證明肥胖病人較瘦小病人插管更加困難。採用經典的評分方法並增加頸圍一項。

方法:作者前瞻性比較了70名肥胖病人[體重指數(BMI)30kg/m2]61個較瘦病人(BMI<30kg/m2)困難插管的發生率。困難插管評分>5定義為困難插管,  ≤5為非困難插管。術前測量體重指數,頸圍(在甲狀輭骨水準),張口度,頦胸距離和甲頦距離,及阻塞性睡眠呼吸暫停綜合征病史和其他幾項評分(Mallampati, Wilson, El Ganzouri)。在直接喉鏡檢查並評估,並記錄IDS

結果:肥胖病人氣管插管困難的機率較瘦的病人大(14.3%vs3%P0.03)。IDS>5的病人,甲頦距離、BMI、大頸圍、較高Mallampati氣道分級分數是預測潛在插管問題的關鍵。

結論:出現問題的插管與以下幾項有關:甲頦距離、(新加入)頸圍、BMIMallampati分級3級以上。頸圍應該引入困難插管的評估。

(王騰 陳傑 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.

 

氟呱利多抑制HERG鉀通道取決於通道門狀態及S6殘基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.

 

人類eag相關基因(HERG)編碼快速啟動的延遲整流鉀通道(Ikr)的α亞基、Ikr電流主要參與心肌動作電位的複極過程。HERG發生突變或藥物作用於Ikr都可誘發長QT綜合征

背景:氟呱利多有中樞止吐作用,並廣泛用於精神病學,麻醉學,急診醫學等領域。已有研究證明其與心電圖QT間期延長有關,也可能與尖端扭轉型室性心動過速和猝死有關。雖然QT間期延長與氟呱利多誘導增加心室動作電位時程是一致的,但其細胞機制並未闡明。快速啟動延遲整流鉀通道Ikr,是一個引起QT間期延長的藥物作用的基本位點及人類eag相關基因(HERG)鉀通道。為確定這些臨床發現的潛在機理,作者研究了氟呱利多對人類HERG鉀通道的作用。

方法:人類胚胎腎293細胞,異源表達野生型和突變型HERG鉀通道,採用全細胞膜片鉗技術( 22-24攝氏度)記錄電流。

結果: HERG鉀通道尾電流描記脈衝中,50毫伏時氟呱利多IC50 77.3 ± 9.6 nmmol(n = 8)。初期為快速阻斷且其抑制作用在藥物洗出後逆轉。氟呱利多主要作用在開放和失活狀態時HERG鉀通道。在較快頻率時較強穩態水準阻滯是功能依賴性。啟動曲線向更負電位元移動(P < 0.05, n = 8),且100 nM氟呱利多失活時程明顯縮短(P < 0.05, n = 8)。但對HERG通道失活無相關影響。由氟呱利多導致HERG通道阻滯的強度在Phe-656(苯丙氨酸-656)突變到Thr(蘇氨酸)或Ser-631(絲氨酸-631)突變到Ala(丙氨酸)時顯著降低。但Phe-656突變到ThrF656M/S631A雙突變時氟呱利多對通道阻滯的敏感性無影響。

結論:氟呱利多有效地抑制了轉染的HERG鉀通道,可能是QT間期延長的機制。開放和失活狀態時通道阻斷最為顯著。在位置656的芳香環殘基參與氟呱利多的結合位點,失活門可誘發構象變化,這種狀態促進氟呱利多與通道的結合。

(張燕 陳傑 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.

心臟手術後通過即時監測脈壓波動來指導液體治療

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:由機械通氣引起的動脈壓波動(△PP)已被認為是液體治療反應的預測因數。直到現在,△PP需在脫機時(由一台電腦記錄或一張紙列印出動脈壓波形)計算 ,或由特定的心輸出量監測儀測定,限制了這一參數的廣泛使用。最近,一個新方法已被用於標準的床邊監測並自動計算和即時監測△PP。這種方法是否能夠可靠預測液體反應仍有待證實。

方法:作者對59名心臟手術術後行機械通氣的病人進行了前瞻性的研究。研究的病人為液體治療併發症低風險患者(肺動脈壓<20mmHg,左室射血分數>40%)。所有的病人均行有創動脈監測和肺動脈置管。在液體輸入前後(乳酸林格氏液以20ml/kg的輸注速度超過20min)測定心臟充盈壓和心排量,同時自動計算和持續監測△PP

結果39名患者(占總數66%,為液體治療反應組)在液體輸入後心排量增加了15%。在液體輸入之前,液體治療反應組和無反應組的右房壓和肺動脈嵌壓相當。相反,反應者組的△PP比無反應者組的△PP高(17%±3% 對應9%±2%P<0.001)。△PP12%作為停止治療值時靈敏度為97%和特異性為95%

結論{Delta}PP自動即時監測作為標準床旁監護儀是可能的並能作為心臟術後預測液體治療反應的可靠方法。將來仍需研究以確定是否這一技術能用於避免液體治療高危患者的併發症。

(胡瀟 陳傑 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.

 

 

靜注單劑量地塞米松減輕全髖成形術後的運動性疼痛

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:術前應用糖皮質激素可減輕術後噁心,同時可提高痛閾和減少阿片類的消耗。

方法:隨機、雙盲、對照研究連續50名在椎管內麻醉聯合丙泊酚靜脈鎮靜下接受擇期單側全髖成形術的患者。患者術前分別接受地塞米松40mg(靜注)或生理鹽水。術後48小時內給予靜注嗎啡、口服布洛芬400mg/6h和撲熱息痛650mg/6h維持病人自控鎮痛。在48小時內每4h記錄一次靜息狀態下疼痛、副作用和累積的病人自控鎮痛的嗎啡用量。在24h記錄運動性疼痛的評分。在48h測量每組25名患者的C反應蛋白水準。

結果:地塞米松組中術中應用丙泊酚鎮靜的劑量顯著增加(234.6 ± 160.1 vs 138.8 ± 122.7 mg, P = 0.02)。運動性疼痛減輕(NRS 評分: 2.7, 95% CI: 2.2–3.1 vs 6.8, 6.4–7.2; P < 0.0001)。在任何時間內靜息狀態下疼痛和累積的嗎啡用量均無顯著差異。48h時地塞米松組C反應蛋白水準較對照組降低。對照組中有7名患者出現術後噁心,而地塞米松組只有一名患者。

結論:全髖成形術術前單劑量靜注地塞米松40mg對術後有長時抑制炎症反應效應並減輕24h 運動性疼痛。

(陳偉 陳傑 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:降鈣素、氯胺酮及其聯合應用對痛閾和感覺閾的作用

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:有研究顯示降鈣素對治療急性幻肢痛有效,但對於慢性幻肢痛卻鮮有研究。所有關於N-甲基-d-天冬氨酸拮抗劑的文獻都模棱兩可。作者檢驗了降鈣素、氯胺酮及其聯合應用治療慢性患肢痛有效的假設。次級目標是通過大量的感覺測試來證明其機制。

方法20名受試者隨機、雙盲、交叉接受4種藥物:降鈣素200IE;氯胺酮0.4mg/kg(僅10 名受試者);降鈣素200IE0.4mg/kg氯胺酮;安慰劑:0.9%生理鹽水。注射前、注射期間,注射末和注射後48h進行幻肢痛程度的檢測(視覺類比量表)。在注射前和注射期間通過電、熱和壓力刺激檢測痛閾。

結果:氯胺酮可以減輕幻肢痛而降鈣素不能,兩者聯合應用與單獨使用氯胺酮相比並不具有優越性。除了壓力刺激外,截肢側和對側的痛閾沒有差別。兩者聯合使用能明顯降低電刺激引起的疼痛,但對熱刺激和壓力刺激沒有顯著影響。

結論:試驗結果對降鈣素在慢性幻肢痛應用提出質疑並強調了N-甲基-d-天冬氨酸拮抗劑的潛在價值。對感覺的評估提示外周機制可能不是幻肢痛的重要決定因素。氯胺酮而不是降鈣素可影響幻肢痛的中樞致敏過程。

(潘方立 陳傑 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.

 

在大鼠胸深層肌肉離斷後背角小膠質細胞環氧合酶- 1和神經元環氧合酶-2上調

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:大鼠足底皮下切口會產生痛覺過敏傳導和大鼠腰椎脊髓內環氧合酶-2(COX-2)上調以及環氧合酶-1(COX-1)持續升高。在此試驗中,作者假設胸部深切口會引起背角COX-1COX-2上調,這與疼痛相關的行為相吻合。並且特異性的細胞類型與COX表達增高有關。

方法:麻醉下大鼠左側胸部皮膚切開,淺層和深層肌肉依次切斷。記錄餵養情況來評估疼痛相關行為。手術後4小時和24小時在脊髓中進行COX1COX-2免疫組化分析以及細胞類型標記。

結果:胸深層肌肉離斷組與假切口對照組相比術後4小時餵養情況下降42%。術後4小時,同側手術實驗組相比同側對照組,對側手術實驗組,雙側對照組,胸背角內COX-1COX-2的免疫活性都升高。腰段水準沒有觀察到手術引起的變化。術後24小時,餵養情況不再下降,任何脊髓節段都未出現手術引起的COX-1COX-2的活性改變。術後4小時,96%COX-1免疫活性細胞與小膠質細胞共同定位,98%COX-2免疫活性細胞與神經元共同定位。

結論:單側胸部深切口會產生疼痛相關行為,同時,同側胸背角小膠質細胞COX-1和神經元COX-2上調。

(杜唯佳 陳傑 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.

 

米那普侖對脊神經結紮鼠的抗痛覺超敏和抗痛覺過敏作用

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:據報導抗抑鬱藥物-米那普侖有抗傷害刺激、抗痛覺超敏和抗痛覺過敏的作用。此項實驗目的在於研究米那普侖應用於神經結紮誘導的神經性疼痛鼠模型,其抗痛覺超敏(過敏)的作用機制。

方法:牢固結紮C57BL6雄鼠的左側第五腰神經。使用von Frey毛和輻射熱分別測試結紮側和健側的對觸覺刺激的撤回閾值和對熱刺激的撤回潛伏期。

結果:以口服(7.5–120 mg/kg)、鞘內注射、腦室內注射或局部(210 ng–21 µg)的途徑給予米那普侖。系統、鞘內和腦室內的給藥增加了神經結紮鼠的撤回閾值和撤回潛伏期,而局部注射卻無作用。在評估米那普侖鎮痛效果的3天前,使用特異性的神經毒素、6-羥基多巴胺或5,7-二羥色胺來耗竭脊神經5-羥色胺能或去甲腎上腺素能神經元。在假手術組,這種對脊神經5-羥色胺能和去甲腎上腺素能的去神經方法減弱了米那普侖的鎮痛作用。在試驗組,米那普侖的鎮痛作用能被阻斷去甲腎上腺素能神經元的方法所減弱,而阻斷5-羥色胺能神經元則無效。

結論:米那普侖應用於神經結紮引起的神經性疼痛模型,其抗痛覺超敏(過敏)作用主要由脊神經及其以上水準的活化的去甲腎上腺素能系統介導。

(於章傑 陳傑 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.

 

七氟烷引起離體心肌線粒體基質容積的特異性增加

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:據報導,線粒體三磷酸腺苷敏感的鉀(KATP)通道的開放觸發和/或介導了吸入麻醉藥的心肌保護作用。然而,吸入麻醉藥對線粒體功能的影響尚未被認識透徹。預防缺血期間線粒體基質容積(MMV)的縮小可促進抗缺血再灌注損傷的心肌保護作用。我們探討七氟烷是否增加MMV以及這種增加是否由mKATP通道的開放所介導。

方法:新鮮的豚鼠心肌線粒體經分離並稀釋於含寡黴素和ATP的緩衝液中以抑制ATP的合成。在不用或使用mKATP通道阻斷劑5-羥基癸酸鹽(5-HD)的條件下,通過測定520nm波長處的吸光性來判定二氮嗪(一種公認的mKATP通道開放劑)和不同濃度的七氟烷引起的MMV的變化。

結果:與對照組相比,30300µM的七氟烷(約0.2-2.1vol%)增加MMV 30%50%,這與二氮嗪的作用相似。這些增加作用被5-HD所阻斷。不過,更高濃度的七氟烷(1000 µM; 7.1 vol %)卻對MMV無影響。

結論:臨床相關濃度下,七氟烷通過mKATP通道的開放增加MMV。對線粒體完整性的保護可能促成了七氟烷抗缺血再灌注損傷的心肌保護作用。超臨床麻醉藥濃度下線粒體功能的損害可以用來解釋所觀察到的雙相反應。這些結果加強了我們對吸入麻醉藥作為心肌保護藥物的細胞內機制的理解。

(黃施偉 譯,馬皓琳 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.



豬稀釋性凝血障礙模型的凝血特徵及使用凝血酶原複合體濃縮物替代治療的效果

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:本研究使用豬的模型觀察使用一個凝血酶原複合體濃縮物(PCC)(Beriplex P/N,包含凝血因數IIVIIIXX)是否能糾正凝血障礙以及動脈或靜脈大量出血。

方法:豬麻醉誘導後製作稀釋性凝血障礙的模型,分次放血(約全身血容量的65%),然後自體輸注紅細胞,並用羥乙基澱粉(Infukoll 6%1000mL進行容量擴充。試驗豬隨機分為三組:非處理組、安慰劑組和使用35 U/kg PCC進行處理組。動脈或靜脈出血採用脾切除或骨損傷模型。在基礎點、稀釋後、給予處理後以及脾切除或骨損傷後不同時點取血進行血栓彈力酶圖、血常規以及凝血試驗。主要終點為損傷後到止血的時間。

結果:血液稀釋導致凝血因數濃度下降到約35%,凝血酶原時間延長。血小板數量從約400,000/µL降低到約100,000/µL,而且血小板的凝聚和黏附均受損。PCC可有效替代缺乏的凝血酶原因子(IIVIIIXX),使延長的凝血酶原時間恢復正常。脾切除後,使用PCC可比稀釋對照組顯著縮短止血時間(中位數, 35 vs 82.5 min; P < 0.0001),血容量的丟失未明顯減少(均值,275 vs 589 mL)。骨損傷後PCC還可顯著縮短止血時程(中位數,27 vs 97 min P < 0.0011)和出血量(均值, 71 vs 589 mLP < 0.0017)。

結論:稀釋性凝血障礙使凝血因數水準普遍下降和血小板功能受損。使用PCC替代治療可有效糾正凝血紊亂,並顯著改善動脈和靜脈出血後止血。

(邱鬱薇 馬皓琳 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.



丙泊酚靶控輸注時雙譜指數和丙泊酚血藥濃度的關係:兒童和青年人對照研究

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:在這個前瞻性研究中,我們比較了兒童和青年人行丙泊酚靶控輸注(TCI)時,腦電雙譜指數(BIS)和丙泊酚血藥濃度之間的關係。

方法:研究物件為45例青春期前兒童和45例青春期後成人,行丙泊酚TCI麻醉,兒童使用Kataria模式,成人使用Schnider模式。使用Rugloop軟體持續記錄所有來自於BISTCI系統的資料。研究中持續加用瑞芬太尼 (0.25 µg · kg–1 · min–1)。手術結束後所有患者的丙泊酚靶控血漿濃度(Ct)隨機設為23456 µg/mL ,穩定12分鐘。而且大多數患者另外靶控BIS50 ± 5,也維持12分鐘。在每個12分鐘的穩態期後,記錄CtBIS ,並測定丙泊酚血漿濃度(Cm)。用Hill方程式和靶控BIS 50測定對應於一半最大效應(BIS50)的CtCm

結果:兒童與成人相似,BIS 值與對應的丙泊酚Ct Cm 有高度相關性,符合經典Emax劑量效應曲線。從劑量效應曲線導出的丙泊酚ECt50ECm50,兒童要高於成人:ECm50 4.0 (3.6–4.5) µg/mL3.3 (3.0–3.7) µg/mL〔均值(95%CI)〕( P < 0.001) 。當靶控BIS值為50時,臨床上得到的兒童CtCm也高於成人(Cm504.3 ± 1.1 µg/mL3.4 ± 1.2 µg/mL(均值±標準差),P < 0.05)Ct普遍低估Cm,這個偏差兒童大於成人:2.6 ± 2.6 µg/mL1.7 ± 1.6 µg/mL (P = 0.05)

結論:在兒童和成人中,丙泊酚血藥濃度和BIS都具有很好的相關性,兒童可能相對敏感性稍低。由於使用經典藥代/藥效模式對兒童丙泊酚的血漿濃度的預測很有限,那麼使用一個腦部的藥效回饋,例如BIS,可能在這個人群中比較有用。

(張瑩譯  馬皓琳 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.



擇期整形手術前行手術當日妊娠試驗實行一年的經驗

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:在妊娠時,擇期手術通常都被延期。一項在手術當日對所有育齡期婦女檢測尿液中人絨毛膜促性腺素(hCG)的政策已在擇期整形手術機構執行。以下是對實行一年來經驗的回顧性報告和相關的費用。

方法:回顧從200512日至200612日的記錄來測定行尿hCG試驗和檢測為陽性的病例數。費用計算包括提供的試紙和實驗室檢查的費用。

結果:在實行政策的第一年,2595位育齡婦女中的2588位進行了尿hCG檢測。5位元患者結果為陽性,手術被取消。在這五位中,3位事前未發現懷孕,一位未發現患者為無症狀的宮外孕,一例為更年期假陽性。另外有3位元婦女尿檢為弱陽性,隨後的血清hCG檢測為陰性。這三位進行了手術。每次尿檢的平均費用為$5.03,每個陽性結果為$3273

結論:手術當日常規檢測育齡期婦女的尿hCG妊娠試驗的政策可以有效地檢測未發覺的妊娠。這導致所有種類的擇期手術的延期。在檢測的2588位婦女中,一位元由於假陽性而延遲了手術。而每個真陽性檢測花費的$3273應該與其所帶來的利益相比較。

(胡湘    馬皓琳 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.


七氟醚介導的p38絲裂原活化的應激酶的活化與Jurkat T細胞的凋亡無關

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

背景麻醉導致的炎症應激反應的調節可能與傷口感染或者肺炎等感染併發症的易感性增高有關。七氟醚是啟動物蛋白-1(一種即時早期轉錄因數)的特殊抑制物,能誘導T細胞的凋亡。因為p38與凋亡的促進或抑制有關,因此我們研究七氟醚誘導的Jurkat T細胞凋亡是否由p38活化所介導。

方法:在體外把Jurkat T細胞暴露於不同濃度的七氟醚、異氟醚或地氟醚。用蛋白質斑跡法來測量絲裂原活化蛋白(MAP)激酶、上游區激酶、下游區轉錄啟動因數-2 (ATF-2)以及細胞凋亡蛋白酶(半胱天冬酶-3 加工處理的磷醯化。在底物ATF-2免疫沉澱和磷醯化後用蛋白質斑跡法來測量p38激酶的活性。用綠色螢光蛋白-膜聯蛋白V染色後用流式細胞計量術來測定細胞凋亡。

結果:地氟醚沒有作用,而七氟醚和異氟醚可誘導p38的磷醯化,七氟醚可誘導p38激酶的活性。七氟醚對MAP激酶ERK JNK沒有作用。七氟醚的暴露也可誘導凋亡信號調節激酶—1(ASK1)MAP激酶的激酶36(MKK3/MKK6)以及ATF-2的磷醯化。用一般的半胱天冬酶抑制物苄氧羰基纈--天冬氨酸-(O-Me)-氟甲基酮(Z-VAD.fmk)對細胞進行預處理不能阻止七氟醚誘導的p38的磷醯化。用特殊的p38抑制物SB202190 SB203580進行預處理不能阻止異氟醚和七氟醚介導的半胱天冬酶-3的加工處理和細胞凋亡。

結論:七氟醚是 Jurkat T細胞內凋亡信號調節激酶-1MKK3/MKK6p38MAP激酶串聯反應的一種特異啟動物。我們的資料表明七氟醚誘導的p38的活化不受半胱天冬酶活化的影響。而且,七氟醚誘導的細胞凋亡與p38 MAP激酶的活化無關。

(吳進   馬皓琳 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.


脈搏變異指數是否能夠指示出在脈搏描記圖和動脈壓波形中呼吸引起的變異?

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:呼吸的變異在脈搏氧飽和度儀的描記圖中的波形振幅({Delta}POP)對前負荷的變化比較敏感,並且能夠預測機械通氣患者的液體反應性。但是它不能夠簡單地通過床邊監護設備來計算出來。脈搏變異指數(PVI, Masimo公司, Irvine, CA)是能夠自動計算{Delta}POP的一種新的演算法則。我們研究的目的是測試這種新儀器自動連續監測{Delta}POP的能力。

方法:25名患者在全麻誘導後進行研究。PVI自動連續地計算出在脈搏氧飽和度儀的描記圖中的波形振幅(灌注指數)中的呼吸變異。先是頭高腳低位再變為頭低腳高位,記錄下相關的資料(平均動脈壓、中心靜脈壓、動脈脈壓中的呼吸變異、{Delta}POP、和PVI)。

結果:PVI{Delta}POP之間的相關性非常顯著(r = 0.92P < 0.05)。在75個數據中,有4256%)個數據的{Delta}POP>13%PVI的閾值是11.5%,能夠區分{Delta}POP >13%{Delta}POP ≤13%。它的靈敏性是93%,特異性是97%PVI來預測{Delta}POP >13%的曲線下面積是0.990 ± 0.07

結論:這是第一個證實PVI能力的研究。PVI是通過脈搏氧飽和度儀的波形分析自動得出的指數,能夠自動連續地監測{Delta}POP。這個新的指數對於非創傷性的液體反應性監測有臨床應用的可能性。

(唐亮   馬皓琳 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.



 

手術室內為了監測液體反應性的一種自動估算動脈脈壓中呼吸變化的新穎運算方式的能力

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:動脈脈壓中的呼吸變化([DELTA]PPman)是機械通氣患者的液體反應性的精確預測因數。然而,它不能被持續監控。在本研究中,我們評估一種新穎的自動估算[DELTA]PP的運算方式([DELTA]PPauto)的臨床效用。

方法:研究25例行冠脈旁路移植的患者。用基於自動檢測運算方式、核心光滑處理、級系濾波器的方法持續顯示[DELTA]PPauto。所有患者進行全麻、機械通氣,還用肺動脈導管監測。在手術的8個階段包括血管內容量擴充(500ml羥乙基澱粉)前和後同時記錄[DELTA]PPman[DELTA]PPauto。容量擴充的反應者定義為心臟指數在容量擴充後上升15%以上的患者。

結果:200對收集的資料中[DELTA]PPman[DELTA]PPauto的一致性為0.7% ± 3.4% (平均偏倚 ± sd)17例患者對容量擴充有反應。允許鑒別容量擴充反應者的[DELTA]PPman閾值為12%,靈敏度88%,特異性100%。允許鑒別容量擴充反應者的[DELTA]PPauto閾值為10%,靈敏度82%,特異性88%

結論: [DELTA]PPauto[DELTA]PPman有高度相關性,是液體反應性的精確預測因數,並能持續監測[DELTA]PP。這種新穎的運算方式有潛在的臨床應用可能。

(朱 慧譯 馬皓琳 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.

 

 

 

 

地氟醚與氟烷相比可以對線粒體功能提供更多保護作用對抗大鼠前腦缺血再灌注損傷

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:氟烷和地氟醚已經被證實可以減輕神經元損傷,但是它們對線粒體的影響還不清楚。我們研究了在大鼠腦部缺血後上述兩者能否影響線粒體的作用。

方法:四十只成年雄性Wistar大鼠被隨機分成四組(每組十隻):對照組、1.5MAC氟烷組、1.0MAC地氟醚組和1.5MAC地氟醚組。在吸入1.5MAC氟烷或1.0MAC1.5MAC地氟醚40分鐘後通過夾閉兩側頸總動脈和降低動脈血壓造成前腦缺血。在分離得到腦線粒體後,用40–200 µM Ca2+通過分光光度計分析線粒體膜的通透性,附加若丹明123染料通過螢光分光光度計測得線粒體膜電位。線粒體呼吸鏈複合物的活性也通過分光光度計測得。

結果:這些結果顯示在前腦缺血再灌注損傷後有明顯的線粒體腫脹、附加Ca2+後膜電位喪失及呼吸鏈複合物I+IIIIV的活性受抑制。與1.5MAC氟烷組相比,1.01.5MAC地氟醚組分別減少線粒體腫脹23.9% (P < 0.001) 23.2% (P < 0.001),抑制膜電位損耗22.4% (P = 0.013) 20.4% (P = 0.027)1.0MAC地氟醚組和1.5MAC地氟醚組中呼吸鏈複合物I+IIIIV的活性與1.5MAC氟烷組相比得到較好的保護,分別達到34.6% (P = 0.027)38.7% (P = 0.011)53.9% (P = 0.009)55.8% (P = 0.007)

結論:在腦部缺血再灌注損傷後4小時的時候地氟醚與氟烷相比,抑制線粒體腫脹、增加膜電位和改善膜呼吸鏈複合物I+IIIIV活性,從而表現出了對線粒體功能更好的保護作用。

(薑旭暉   馬皓琳 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經根皮區變異

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,會造成在脊神經阻滯的時候,難以辨別相應外葉神經根的腰水準。我們採用電刺激觀察了存在腰骶的移行椎時肌肉神經支配模式和腰段神經根的感覺皮區改變的可能性。

方法:我們用Castellvi’s 標準來確定移行椎的存在。有移行椎伴腰骶神經根病的病人納入研究。用電刺激進行選擇性神經根阻滯。有腰化S1或者骶化L5的病人中S1L5神經根壓迫造成的神經病學症狀,分別和正常構型病人的L5或者S1神經根壓迫比較。

結果32個病人有移行椎,其中12個有腰化S120個有骶化L5。腰化S1 (L6) 神經根造成的運動和感覺症狀的分佈和刺激正常構型中的S1神經根相似。在17個病人中,刺激骶化L4神經根引起的運動感覺症狀分佈和刺激正常構型中的L5神經根相似。

結論:我們的發現暗示,在L5骶化的病人,腰骶神經根的功能改變了。L4神經根提供了L5神經根通常的功能。

(張曦 譯,馬皓琳 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.


靜脈注射格拉司瓊對布比卡因鞘內麻醉感覺和運動阻滯的影響

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

背景資料:我們假設,預先靜脈注射格拉司瓊能夠通過5-HT3受體阻滯而影響脊麻的運動和感覺阻滯部分。

方法:四十個計畫在脊麻下進行擇期膝關節鏡檢查的病人隨機分為兩組,在進入手術室後分別靜脈注射格拉司瓊1mg(格拉司瓊組)和生理鹽水(對照組)。以0.5%高比重布比卡因2.5ml12.5mg)進行鞘內注射。記錄感覺水準和運動阻滯的消退以及血流動力學變化。

結果:兩組之間比較感覺阻滯的最高平面和達到最高感覺阻滯水準的時間沒有顯著性差異。與對照組相比,注射格拉司瓊的患者感覺平面消退兩個節段的時間明顯縮短(69.8 ± 25.5 min vs 88.0 ± 27.8 min, P = 0.036),消退到T12的時間(105.5 ± 25.1 min vs 127.0 ± 30.5 min, P = 0.019)和消退到S1的時間(162.8 ± 41.1 min vs 189.8 ± 39.8 min, P = 0.041)也明顯縮短。相反,在運動阻滯方面的任何研究時間兩組之間沒有顯著差異。兩組之間血流動力學方面也沒有顯著差異。

結論:我們認為靜脈注射格拉司瓊可以促進布比卡因蛛網膜下腔麻醉後感覺阻滯的更快恢復。

(沈浩   馬皓琳 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.


異氟醚單獨應用或與芬太尼合用可抑制傷害性刺激誘導的大鼠腰段脊髓C-Fos基因表達

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:儘管在過去十年裏對於麻醉中傷害感受過程的理解有了很大的進步,仍有很多患者在術後體驗痛覺過敏和急性疼痛。傷害性刺激誘導的撤回反射(NIWR)模型是特別設計的,可有效地定量研究動物麻醉狀態下對疼痛多形式刺激的反應。由於吸入麻醉藥和阿片類藥物的麻醉機制不同,本研究評估了異氟醚和芬太尼對腰段脊髓內c-fos基因表達的不同影響以測定全麻中傷害感受資訊的傳遞。

方法:實驗方案為包含4個組的隨機區組設計:23/4最低肺泡氣體濃度(MAC)異氟醚淺麻醉組(無刺激的/NIWR刺激的)和2NIWR刺激的手術麻醉組(11/2 MAC異氟醚麻醉和3/4 MAC異氟醚複合芬太尼400–600 µg · kg–1 · h–1麻醉 )。在對大鼠後爪進行2小時的週期性電刺激後定量測定脊髓背角中Fos免疫反應陽性的神經元數目。

結果:異氟醚對腰段c-fos基因表達的主要抑制效應表現於脊髓板層II淺層(P = 0.02),而芬太尼則在板層V處表現出最強的抑制效應(P = 0.05)

結論:本研究表明NIWR模型複合脊髓Fos免疫反應性測定作為評估吸入麻醉藥和阿片類藥物對全麻中傷害感受資訊傳遞不同效應的模型是適當有效的。

(周雅春 馬皓琳 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.

 

嚴格控制心率能提高β-阻滯藥的功效嗎?對非心手術隨機試驗的最新分析

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:最近一項評價圍術期β-阻滯藥效果的回歸分析試驗沒能證明其能降低術後發病率和死亡率。嚴格的控制心率則有助於改進這種結果。回歸分析沒有考慮嚴格的控制心率對β-阻滯藥效果的影響。

方法:運用已發佈的調查方略,我們分析了所有非心手術後評價圍術期β-阻滯藥的隨機試驗。該調查從2176名患者中產生了10個實驗。運用調查得來的資料分析心率控制和術後事件,主要是院中心梗的聯繫。計算比值比和95%可信區間,對心率控制結果和心梗作回歸分析。

結果:這些研究的結果綜合起來沒有顯示β-阻滯藥有顯著的心臟保護作用,而且研究和研究之間有很大差異性(OR = 0.76; 95% CI = 0.4–1.4; P = 0.38 heterogeneity: I2 = 34%).然而,基於最大心率的研究分組卻顯示這樣的結果:最大心率低於100bpm的試驗和心臟保護有關(OR = 0.23; 95% CI = 0.08–0.65; P = 0.005),而最大心率高於100bpm的試驗和心臟保護無關(OR = 1.17; 95% CI = 0.79–1.80; P = 0.43),並且沒有組內差異。對β-阻滯藥影響下的心率和術後心梗比值比取對數作回歸分析表明:β-阻滯藥對最大心率,平均心率,心率變異性的效應和心梗的比值比成線性關聯(r2 = 0.63; P < 0.001),即藥物對心率效果越明顯,術後心梗的發生越少。綜觀整個研究,β-阻滯藥在降低術後心率方面有很大差異性。在一定程度上,這一差異性和藥物類型有關,特別是美托洛爾以及和鈣通道阻滯劑的混合使用。鈣通道阻滯劑和包括美托洛爾在內的β-阻滯藥一起使用能對心率產生更大控制。心率對β-阻滯藥的反應大不一樣。25%服用β-阻滯藥的患者在心率大於100bpm時有臨床事件發生,而15%的安慰劑對照患者也有心動過緩,如果服用的是β-阻滯藥而非安慰劑這時就要降低藥量了。最後,該分析發現圍術期β-阻滯藥的使用和心動過緩有關(OR = 3.49; 95% CI = 2.4–5.9),也和充血性心衰有關(OR = 1.68; 95% CI = 1.00–2.8).

結論:那些β-阻滯藥對心率影響最有力的試驗裏術後心梗的發生也少,表明有效的心率控制對心臟保護的重要性。第二,分析表明β-阻滯藥並非對所有病人都能降低心率,而可能會產生副作用。和其他藥物合適的聯合治療對有效控制術後心率來說可能是必要的。

(孫鵬飛譯 薛張綱校)

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.

 

病例系列報導:輸血時高鉀所致的心跳驟停

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:輸血相關的高鉀性心跳驟停是快速輸注紅細胞時的一個嚴重併發症。因此對於那些在快速輸注紅細胞時發生了高鉀及心跳驟停的患者,我們就其特定的臨床情境及相關結局進行了一系列的分析。

方法:我們回顧性的分析了Mayo臨床麻醉資料庫中在1988.11.1-2006.12.31期間,所有發生了術中輸血相關的高鉀性心跳驟停的患者。

結果:我們共找出了16名輸血相關的高鉀性心跳驟停患者,其中成人11名,兒童5名。大多數病人進行了以下三種手術:腫瘤手術,大血管手術及外傷手術。在心跳驟停時的血清鉀濃度為7.2 ±1.4 mEq/L(範圍為5.9-9.2 mEq/L),而心跳驟停前所輸注的紅細胞量的範圍為1個單位(輸予一2.7kg的新生兒)~54個單位。且幾乎所有的患者在心跳驟停的同時都伴有酸中毒、高血糖、低血鈣及低體溫的發生。其中14位病人(87.5%)是通過中心靜脈通路進行的紅細胞輸注,而使用商業性的快速輸注裝置(快速輸注泵)者在11位成人中占8(72.7%),而其餘所有的病人都是通過加壓袋或注射泵來進行快速輸注的。他們的平均復蘇時間為32min(範圍從2-127 min不等)。院內存活率為12.5%

結論:輸血相關的高鉀性心跳驟停的發病機理是多因素的,而輸血後的血鉀升高也常與低心輸出量、酸中毒、高血糖、低血鈣及低體溫相並存。因此當在大量輸注庫存血及大出血的情況下,我們更需提高對潛在的高鉀血症的警覺性並採取相應的預防措施。

(劉沁譯 薛張綱校)

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.

 

 

抗纖溶療法在先天性心臟病手術中的應用

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:絲氨酸蛋白酶抑制劑、抑肽酶,和賴氨酸類似物、[epsilon]氨基己酸,以及氨甲環酸,已經被證實在成人心血管手術中能起到減少出血,減少輸血輸液用量的作用。雖然在兒童患者中進行的心血管手術也明顯有很高的出血風險及大量輸血輸液要求,但在這些患者中,這種抗纖溶療法的風險與收益還沒有被人完善地瞭解證實過。先天性心臟病的外科手術中使用抗纖溶療法是有其合理的文獻驗證體系的,但是因為涉及的研究物件、步驟、方法、以及給藥劑量有很大的不同,所以要對此做出一個定量的研究分析現在來講還不現實。而對這些文獻作定性的回顧性研究,可以發現剛剛提到的三類藥物在先天性心臟病的外科治療中都有減少出血,減少輸血輸液用量的作用,在人群中有很好的益處。在可知的資料中,還沒有發現這三種藥物的效益有何不同,除了抑肽酶可能有特有的抗炎作用,會對兒科病人有更有益的作用。現在,還沒有足夠證據能證實這三種藥物的安全性,而似乎抑肽酶在兒科患者中引起過敏反應的可能性要低於成年患者。雖然這三種藥物的藥代動力學以及藥效動力學已經被研究清楚,但它們的應用方法及使用劑量還是未達成共識,而且通常也不是按照藥理學的試用劑量法則來決定用法用量。我們有必要對此作出更深入的研究,對這些藥物的藥代、藥效動力學,以及安全性、可預測性瞭解更多,估測出對這些特殊患者群體的使用益處,最終能對這些藥物的有效用法和用量得出一個共識。

(秦敏菊譯 薛張綱校)

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.

 

 

兒童麻醉中拔除喉罩與拔除氣管導管時呼末七氟迷濃度比較

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:在本次研究中我們將定量的比較能夠避免兒童麻醉過程中拔除喉罩和氣管導管時或拔除喉罩和氣管導管後避免嗆咳的七氟醚濃度。

方法:隨機的選擇40名年齡在8-12歲之間的兒童,隨機的選擇使用喉罩或氣管導管。全麻誘導使用七氟醚,後插入喉罩或氣管導管。麻醉維持依賴七氟醚和氧氣。在手術結束時,可以得到一個預定的至少在10分鐘內拔除喉罩或氣管導管的呼末七氟醚濃度。用dixon 的自上而下的方法,將拔除喉罩及氣管導管時七氟迷的濃度增大0.2%,確定能成功的避免嗆咳,磨牙,有目的的體動,呼吸抑制,喉痙攣,去氧飽和。

結果50%兒童能成功拔除喉罩時的七氟醚呼末濃度為1.90%95%兒童能成功拔除的濃度為2.15%。對於氣管導管,該濃度為1.83%2.0%。兩組比較,50%的有效劑量沒有顯著的差別。

結論:95%的兒童(8-12歲)在麻醉過程中,肺泡最低麻醉濃度在0.860.8時可以順利拔除喉罩及氣管導管而不會有嗆咳,體動及其他氣道併發症的發生。相似的濃度應該分別被用於拔除兒童的喉罩及氣管導管。

(胡豔譯  薛張剛校)

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樣受體2刺激的單核細胞中μ型阿片受體介導了嗎啡導致的腫瘤壞死因數和白介素-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:嗎啡具免疫調節作用,但其內在機制,尤其在toll樣受體2TLR2)信號通路中的作用僅部分被瞭解。此研究中,在受TLR2刺激的人單核細胞生成腫瘤壞死因數(TNF),白介素-6IL6)和白介素-10IL10)方面,我們評估嗎啡產生的作用,並識別此過程中所涉及的不同阿片受體以及淋巴細胞和單核細胞間的聯繫。

方法:通過密度梯度離心方法從新鮮血液中分離得到外周血單核細胞(PBMCs)。之後使用帶抗CD14特異抗體高磁場細胞分選工具分離單核細胞。使用阿片受體拮抗劑預處理單核細胞和PBMCs後,將其于嗎啡和金葡菌產生的肽聚糖(PGN,特異的TLR2激動劑)中培養。通過酶聯免疫吸附試驗測量上清液中TNFIL6IL10的量。

結果:促炎性反應因數:嗎啡對受PGN刺激的單核細胞產生細胞因數有明顯的劑量和濃度依賴性抑制。μ型阿片受體的激動可顯著的調節嗎啡導致的單核細胞生成TNFIL6受抑。在受PGN刺激的PBMCs,嗎啡明顯抑制TNF的生成,但對IL6生成抑制不明顯。在嗎啡導致的PBMCs生成TNF受抑過程中,並未涉及μ型阿片受體。抗炎性反應因數:無論是在單核細胞還是PBMCs IL-10都不是導致受PGN刺激的單核細胞生成TNFIL6受抑的因素。

結論:μ型阿片受體對受PGN刺激後的單核細胞生成TNFIL6有抑制作用,但對PBMCS無此作用。單核細胞與淋巴細胞間的直接聯繫改變了嗎啡在僅有單核細胞存在時可觀察到的抑制效果。IL10並非抑制TNFIL6生成的因素。欲描述嗎啡的免疫抑制作用,TLR2μ型阿片受體在胞內通路水準的相互作用仍需進一步研究。

(黃凝譯  薛張綱校)

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.

 

 

通過BISNCT指數來比較在七氟醚麻醉中使用和不使用藥效平頂效應的藥效學模型

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:我們比較了有和沒有平頂曲線效應兩種藥效學模型,用雙頻指數(BIS, Aspect Medical Systems, Natick, MA, version XP)和Narcotrend指數(NCT, MonitorTechnik, Bad Bramstedt, Germany, version 4.0)來測量腦電活動以評價七氟醚的藥效。此外,我們嘗試分析平頂效應的起源。

方法:我們調查了26例被安排做根治性前列腺切除術的成年病人。在全麻誘導後至少45分鐘,呼氣末七氟醚濃度在1 vol% 4 vol%之間不等。為了評價濃度和腦電指數的關係,我們使用了兩種不同的藥效學模型來記錄有和沒有爆發性抑制時的BISNCT值:一種是基於單S型曲線的傳統模型,另一種是基於雙S型曲線的新型模型。模型的參數是由非線性混合效應模型VGloboMax, Hanover)的最小似然法估計的。兩種模型的統計顯著性由似然比檢驗。

結果:呼氣末七氟醚濃度從1.04 ± 0.17 vol%4.43 ± 0.43 vol% ,新的雙S型曲線的藥動/藥效學模型和傳統的單S型曲線的Emax模型之間似然數的對數值分別是:BIS監測為396 (P < 0.001)NCT1121 (P < 0.001)。平頂定位於最大[delta]波和爆發抑制比增加之間改變時。

結論:含有插入平頂的雙S型曲線藥動學/藥效學模型描述BISNCT指數反應的七氟醚的效應優於單S型曲線。

(宣麗真譯 薛張綱校)

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.

 

關於通過麻醉-保護裝置(AnaConDa)調整七氟醚用量的藥代動力學模型預測效果:臨床研究

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-保護裝置(AnaConDa)可通過呼吸機用於重症監護室(ICU)的吸入性麻醉劑管理。在此,我們評價使用AnaConDa調整七氟醚用量的效果。

方法:我們研究了50例通過AnaConDa使用七氟醚的 ICU患者,他們被隨機分為三組。 6小時內分別以呼末七氟醚濃度1 1%組 15例)和1.5 1.5 組, 15例)為目標調整輸液計畫,調節初始劑量,在10分鐘內達到目標,然後減少至維持劑量,此後每小時調整一次,在呼吸回路中測定七氟醚的實際濃度,並與目標值進行比較。第三組(20例)則採用增加或減少靶濃度( ± 0.3 3小時的方法,評價七氟醚濃度的實際改變。通過計算性能誤差率(PE)評價輸液計畫的可行性,通過計算精確度(median absolute PE, MDAPE)和偏移(median PE, MDPE)評價輸液計畫的有效性。

結果: 1 1.5 ,增加濃度0.3 及降低濃度0.3 %組的性能參數(平均值±標準差, )分別是: 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 %組進行各類比較後無顯著差異。

結論:通過使用AnaConDa調整七氟醚用量的ICU病人,可獲得良好的6小時藥代動力學模型預測效果。

(施穎譯 薛張綱校)

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.

 

膝關節置換中使用塞來考昔<抗關節炎藥,COX-2抑制劑>的前瞻性隨機試驗:改良的臨床成果

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:相當多的全膝置換術會產生術後疼痛問題,而如果疼痛未被減輕則會導致住院時間的延長、不能參加康復訓練計畫、較差的預後和巨大的醫療保健資源的浪費。此項研究假設是在全膝關節置換術中使用塞來考昔會改進鎮痛效果以在術後獲得更好的長短期臨床療效。

方法:我們對200名行全膝關節置換術的患者進行了隨機選擇,安慰劑對照雙盲試驗的前瞻性研究。所有患者均接受了一個相似的麻醉鎮痛過程。術後患者均接受了硬膜外鎮痛並被教授用數位等級〉或=3來記錄疼痛程度。患者被隨機的分配入兩組中的其中一組:塞來考昔組和安慰劑組。塞來考昔組的患者在手術前7天每天兩次口服塞來考昔100mg,手術當天術前1-2小時服用塞來考昔400mg,然後術後每12小時服用塞來考昔200mg直至第10天。對照組在相同的時間服用與之匹配的安慰劑膠囊。此項研究的主要目的是測定手術期間使用塞來考昔是否能減少術後阿片類物質的消耗,其次是確定使用塞來考昔是否能改善臨床預後及是否能減少阿片類物質副作用。                                                     

結果:服用塞來考昔的試驗組在術後40小時內比對照組所需使用的硬膜外鎮痛藥少:安慰劑組232.8+/-2.0ml,塞來考昔組209.1+/-1.8ml(P < 0.001)。在家中的術後4-10天塞來考昔組的患者每個時間測定點運動時的疼痛強度都有所緩解(F = 109.7, P < 0.001),而且在家中消耗歐克西克錠(一種麻醉性的生物鹼,和可待因有關的,用作止育藥和鎮靜藥)也比對照組患者少(F = 417.8, P < 0.001)。在術後1-3天,兩組患者進行伸展的主動運動有差別(F = 50.7, P < 0.001),塞來考昔組的患者在所有時間點上都具有更大的伸展度。與對照組比較,試驗組的患者更早能將患膝屈曲至90(P < 0.001)。在之後12個月的隨訪中塞來考昔組患者(93.3 +/- 0.6)比對照組患者(86.4 +/- 0.9)獲得更高的全膝關節置換術後社會能力得分(P < 0.001)。在術後短期內塞來考昔組患者不良反應事件(噁心、嘔吐、瘙癢)發生較對照組少。

結論:手術期間使用塞來考昔能減少術後疼痛,阿片類物質使用及阿片類物質副作用,並能得到長期獲益包括在全膝關節置換術後改善膝關節功能及更早有效達到膝關節伸展程度改善。                                                                         

(劉婷潔譯 薛張綱校)

                                                                                                                                                                                                                                                                                                        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.

                                                                                                 

                                                                                                 

血管內注射腰內側支傳導阻滯:前瞻性的評價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

 

背景腰內側支傳導阻滯 mbb 的結果和有效性在很大程度上依賴於技術的準確性。血管內攝取造成對阻滯的假陰性反應並出現各種併發症。在目前的研究中,我們前瞻性地評價了血管內注射發病率和相關因素,此外,我們評估效率普遍接受的安全管理措施,如間歇透視檢查,以避免血管內注射。

方法 我們預期地審查了1433腰神經在七位醫師執行的456名患者的MBBs。志向測試、斑點造影和在即時螢光鏡的形象化之下的對比射入繼續地進行了,無需改變位置針。 血液反燃和血管內的對比傳播出現的發生在斑點幅射線照相的圖像和在即時螢光透視法期間被檢查了。 各種因素的研究,為血管內注射,包括醫師的經驗,病人的年齡,性別,針量具,阻滯脊髓水準。

結果:沒有具體的因素被發現,影響發病的血管吸收,在座。總體發病率的內吸收為6.1 ,神經阻滯( 1433分之88 ,並有30人,這些預言preinjection心願(敏感性= 34.1 )和52所當場照相(敏感性= 59.1

結論:心願試驗或無現貨照相經常錯過內攝取的反差,在腰椎內外。我們堅決主張用即時透視對比注射,以提高診斷和治療中的應用價值,並避免可能出現的併發症。

章一靜譯 薛張綱校

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.

 

 

對齧齒類神經痛模型給予咪達唑侖可逆轉熱痛覺過敏以及{gamma}-氨基丁酸轉運體的丟失

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:脊髓背角丟失抑制性GABA可導致神經痛。這裏我們驗證全身性的給予苯二氮卓類藥物咪達唑侖是否可以減輕坐骨神經慢性擠壓傷(CCI)引起的熱痛覺過敏。

方法:分別在CCI之前以及之後的3天和7天用熱刺激縮爪潛伏期試驗來評價痛覺過敏。動物隨機接受滲透性微泵輸注咪達唑侖(2.0 mg · kg–1 · h–1),氟馬西尼(0.004 mg · kg–1 · h–1),咪達唑侖複合氟馬西,或生理鹽水(0.01 mg · kg–1 · h–1)。四組經過模擬手術(無神經結紮)後的大鼠作為對照接受配對治療。手術7天后使用蛋白質免疫印跡法評價腰段脊髓後角GABA轉運體1GAT-1)的水準。

結果:生理鹽水治療組的大鼠在3天后出現熱痛覺過敏現象,7天后更為顯著。持續性輸注咪達唑侖在此兩天都對熱痛覺過敏起到了有效的保護作用。氟馬西尼同時投藥拮抗了咪達唑侖的抗熱痛覺過敏作用。單獨輸注氟馬西尼對CCI大鼠的熱痛覺過敏沒有作用。接受模擬手術的大鼠術後分別接受鹽水、咪達唑侖以及咪達唑侖複合氟馬西尼治療,都沒有發生熱痛覺過敏。意外的是,模擬手術的大鼠接受氟馬西尼治療後熱刺激縮爪潛伏期顯著縮短。GAT-1水準的改變與不同的治療方法也有關係,咪達唑侖可防治CCI相關的GAT-1水準降低,氟馬西尼拮抗咪達唑侖的作用。氟馬西尼單獨用藥對GAT-1水準沒有影響,但是在模擬手術組動物出現顯著的受體水準降低。

結論:抑制性GABA在神經痛中起到重要作用。持續全身性給予苯二氮卓類藥物咪達唑侖可有效減輕神經痛。

(夏俊明譯 薛張綱校)

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.


神經刺激儀探針置管用于全膝關節成形術後連續股神經阻滯的隨機、對照、雙盲試驗

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:連續股神經阻滯(CFNB)常用于全膝關節成形術(TKA)術後鎮痛. CFNB可以通過多種操作方法得以實施。神經刺激儀探針置管(SC)有在進針時確認導管放置於神經附近的好處。

方法:在該隨機、對照、雙盲試驗中,我們比較了82例全身麻醉下TKA後病人採用SC和非刺激性導管(NSC)技術實施CFNB及其對鎮痛效果的影響。接受CFNB的病人隨機採用NSCSC置管技術。在通過股側留置導管注射利多卡因1020分鐘後及術後第1天(POD1)和第2天(POD2)評價感覺阻滯情況。期間採用標準的多模式鎮痛策略,包括單次坐骨神經阻滯(術前)、靜脈注射嗎啡(病人自控鎮痛)、使用塞來考昔和對乙醯氨基酚。研究變數包括:嗎啡用量、病人疼痛評分和術後早期恢復指標。

結果:股神經分佈區域感覺阻滯比例為(9095)%,且在所有測定時間組間無明顯差異。在第一個24小時與SC組嗎啡18 (2–51) mg (P = 0.69)相比,NSC組則需要 19.5 (1–67)mg1090%的中位數)。第一個24小時內,嗎啡用量組間差異95%可信區間為(-8 5 mg。而靜息狀態下POD1POD2視覺類比評分和主動與被動物理治療時視覺類比評分,以及術後早期恢復指標兩組間均無差異。

結論:作為TKA後多模式鎮痛的一部分,在本研究中盲探法留置導管管和SC法置管對建立和維持用於術後鎮痛的CFNB同樣可靠。

(蔣宗明譯 薛張綱校)

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.