Table of Contents

May 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

乳化异氟醚对兔子缺血再灌注损伤后的心脏保护

胡艳译  薛张刚校

Emulsified Isoflurane Produces Cardiac Protection After Ischemia-Reperfusion Injury in Rabbits

Yan Rao, Yan-lin Wang, Wen-sheng Zhang, and Jin Liu

Anesth Analg 2008 106: 1353-1359.

浓缩纤维蛋白原、ⅩⅢ因子和新鲜冷冻血浆对离体血液稀释(60%)导致血凝形成障碍的影响

胡潇 陈杰

The In Vitro Effects of Fibrinogen Concentrate, Factor XIII and Fresh Frozen Plasma on Impaired Clot Formation After 60% Dilution

Thorsten Haas, Dietmar Fries, Corinna Velik-Salchner, Christian Reif, Anton Klingler, and Petra Innerhofer

Anesth Analg 2008 106: 1360-1365.

凝血功能监测:新技术以及粘弹性重点照护检验凝血设备的临床应用

邱郁薇 马皓琳 李士通

Coagulation Monitoring: Current Techniques and Clinical Use of Viscoelastic Point-of-Care Coagulation Devices (Review Article)

Michael T. Ganter and Christoph K. Hofer

Anesth Analg 2008 106: 1366-1375

PEDIATRIC ANESTHESIOLOGY:

新式麻醉通气机能否在容积控制通气时准确输送小潮气量?

黄凝译  薛张纲校

Do New Anesthesia Ventilators Deliver Small Tidal Volumes Accurately During Volume-Controlled Ventilation?

Patricia R. Bachiller, Joseph M. McDonough, and Jeffrey M. Feldman

Anesth Analg 2008 106: 1392-1400.

AMBULATORY ANESTHESIOLOGY:

氟哌啶醇联合地塞米松对腹腔镜辅助下阴式子宫切除术后恶心呕吐的预防作用

潘方立 陈杰

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy

Chin-Chen Chu, Ja-Ping Shieh, Jann-Inn Tzeng, Jen-Yin Chen, Yi Lee, Shung-Tai Ho, and Jhi-Joung Wang

Anesth Analg 2008 106: 1402-1406.

氟哌啶醇与枢复宁用于术后恶心呕吐(短讯)

蒋宗明译 薛张纲校

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)

Carl E. Rosow, Kenneth L. Haspel, Sarah E. Smith, Loreta Grecu, and Edward A. Bittner

Anesth Analg 2008 106: 1407-1409.

氟哌啶醇伍用昂丹司琼与单用昂丹司琼对术后恶心呕吐预防作用的比较

陶颖莹 陈杰

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)
Loreta Grecu, Edward A. Bittner, Jay Kher, Sarah E. Smith, and Carl E. Rosow

Anesth Analg 2008 106: 1410-1413.

门诊手术病人监测麻醉后与快通道不可行相关的危险因素

吴进   马皓琳 李士通

Risk Factors Associated with Fast-Track Ineligibility After Monitored Anesthesia Care in Ambulatory Surgery Patients

Rebecca S. Twersky, Svetlana Sapozhnikova, and Ben Toure

Anesth Analg 2008 106: 1421-1426.

ANESTHETIC PHARMACOLOGY:

全麻对局麻药的中枢神经系统和心血管系统毒性的影响

唐亮   马皓琳 李士通

The Effects of General Anesthesia on the Central Nervous and Cardiovascular System Toxicity of Local Anesthetics

Susan E. Copeland, Leigh A. Ladd, Xiao-Qing Gu, and Laurence E. Mather

Anesth Analg 2008 106: 1429-1439.

局麻药的中毒剂量在全麻中对其全身及局部药代动力学的影响

刘沁译 薛张纲校

The Effects of General Anesthesia on Whole Body and Regional Pharmacokinetics of Local Anesthetics at Toxic Doses

Susan E. Copeland, Leigh A. Ladd, Xiao-Qing Gu, and Laurence E. Mather

Anesth Analg 2008 106: 1440-1449.

普萘洛尔增加清醒大鼠利多卡因诱导的惊厥阈值:对大脑的直接影响    

杜唯佳 陈杰

Propranolol Increases the Threshold for Lidocaine-Induced Convulsions in Awake Rats: A Direct Effect on the Brain

Taketo Nakamura, Yutaka Oda, Ryota Takahashi, Katsuaki Tanaka, Ichiro Hase, and Akira Asada

Anesth Analg 2008 106: 1450-1455.

体外抑制有丝分裂原活化蛋白激酶通路对布比卡因和罗哌卡因诱发的神经毒性有保护作用

颜涛 译, 马皓琳 李士通

In Vitro, Inhibition of Mitogen-Activated Protein Kinase Pathways Protects Against Bupivacaine- and Ropivacaine-Induced Neurotoxicity

Philipp Lirk, Ingrid Haller, Hans Peter Colvin, Leopold Lang, Bettina Tomaselli, Lars Klimaschewski, and Peter Gerner

Anesth Analg 2008 106: 1456-1464.

通过Lymnaea神经元观察利多卡因通过Na+-H+交换增加细胞内钠浓度的研究

刘婷洁译 薛张钢校

Lidocaine Increases Intracellular Sodium Concentration Through a Na+-H+ Exchanger in an Identified Lymnaea Neuron

Shin Onizuka, Toshiharu Kasaba, Ryuji Tamura, and Mayumi Takasaki

Anesth Analg 2008 106: 1465-1472.

地氟醚预处理通过靶向作用于TNF-α近端信号而抑制NF-κB的活化

潘钱玲 陈杰

Desflurane Preconditioning Inhibits Endothelial Nuclear Factor-{kappa}-B Activation by Targeting the Proximal End of Tumor Necrosis Factor-{alpha} Signaling

Yuan Li, Xiaonan Zhang, Biao Zhu, and Zhanggang Xue

Anesth Analg 2008 106: 1473-1479.

TECHNOLOGY, COMPUTING, AND SIMULATION:

肝移植病人的心输出量监测:肺动脉导管和未校准动脉压波形分析比较

彭中美 马皓琳 李士通

Cardiac Output Measurement in Patients Undergoing Liver Transplantation: Pulmonary Artery Catheter Versus Uncalibrated Arterial Pressure Waveform Analysis

Biais Matthieu, Nouette-Gaulain Karine, Cottenceau Vincent, Vallet Alain, Cochard Jean François, Revel Philippe, and Sztark François

Anesth Analg 2008 106: 1480-1486.

不同吸入氧分数的单增量变化对使用氧气洗出技术测定机械通气病人的功能潮气量的影响

秦敏菊译 薛张纲校

The Impact of Different Step Changes of Inspiratory Fraction of Oxygen on Functional Residual Capacity Measurements Using the Oxygen Washout Technique in Ventilated Patients (Technical Communication)

Hermann Heinze, Beate Sedemund-Adib, Matthias Heringlake, Ulrich W. Gosch, Hartmut Gehring, and Wolfgang Eichler

Anesth Analg 2008 106: 1491-1494.

PATIENT SAFETY:

直接喉镜法中显示不佳和上唇咬诊评分增高是GlideScope®视频喉镜困难气管插管的预测因子

张燕 陈杰

Poor Visualization During Direct Laryngoscopy and High Upper Lip Bite Test Score Are Predictors of Difficult Intubation with the GlideScope® Videolaryngoscope

Marie-Hélène Tremblay, Stephan Williams, Arnaud Robitaille, and Pierre Drolet

Anesth Analg 2008 106: 1495-1500.

静脉注射布比卡因造成心跳骤停的猪模型中复合使用肾上腺素和加压素与脂肪乳剂比较

沈浩   马皓琳 李士通

A Comparison of the Combination of Epinephrine and Vasopressin with Lipid Emulsion in a Porcine Model of Asphyxial Cardiac Arrest After Intravenous Injection of Bupivacaine

Viktoria D. Mayr, Lukas Mitterschiffthaler, Andreas Neurauter, Christian Gritsch, Volker Wenzel, Tilko Müller, Günter Luckner, Karl H. Lindner, and Hans-Ulrich Strohmenger

Anesth Analg 2008 106: 1566-1571.

OBSTETRIC ANESTHESIOLOGY:

关于产痛评估的动态模型的建立与验证

施颖译 薛张纲校

The Development and Validation of a Dynamic Model to Account for the Progress of Labor in the Assessment of Pain

Jessamyn Conell-Price, Jennifer B. Evans, Daewha Hong, Steven Shafer, and Pamela Flood

Anesth Analg 2008 106: 1509-1515.

NEUROSURGICAL ANESTHESIOLOGY:

咪达唑仑对大鼠脑局部糖代谢具有时间依赖性的影响

陈伟 陈杰

The Time-Dependent Effects of Midazolam on Regional Cerebral Glucose Metabolism in Rats

Ulderico Freo, Mauro Dam, and Carlo Ori

Anesth Analg 2008 106: 1516-1523.

GENERAL ARTICLES:

麻醉学活跃的研究领域:麻醉学文献的同引分析

慧译 马皓琳 李士通校

Active Research Fields in Anesthesia: A Document Co-Citation Analysis of the Anesthetic Literature

Milan P. Jankovic, Mark Kaufmann, and Christoph H. Kindler

Anesth Analg 2008 106: 1524-1533.

ANALGESIA:

麻醉后监护室中严重疼痛的有关因素

孙鹏飞译 薛张纲校

Predictive Factors of Severe Postoperative Pain in the Postanesthesia Care Unit

Frédéric Aubrun, Nathalie Valade, Pierre Coriat, and Bruno Riou

Anesth Analg 2008 106: 1535-1541.

用超声判断颈部硬膜外阻滞穿刺针的深度

王腾 陈杰

Sonographic Estimation of Needle Depth for Cervical Epidural Blocks

Soo Hwan Kim, Kang Hun Lee, Kyung Bong Yoon, Woo Young Park, and Duck-Mi Yoon

Anesth Analg 2008 106: 1542-1547.

关节内注射硫酸镁和/或布比卡因用于膝关节镜手术后的镇痛

黄丽娜 马皓琳 李士通

Intraarticular Injection of Magnesium Sulphate and/or Bupivacaine for Postoperative Analgesia After Arthroscopic Knee Surgery

Noha M. Elsharnouby, Hala E. Eid, Nahla F. Abou Elezz, and Ashraf N. Moharram

Anesth Analg 2008 106: 1548-1552.

REGIONAL ANESTHESIA:

一项关于超声及神经刺激联合定位腘窝-坐骨神经阻滞的前瞻性随机对照研究

夏俊明译 薛张纲校

Combined Ultrasound and Neurostimulation Guidance for Popliteal Sciatic Nerve Block: A Prospective, Randomized Comparison with Neurostimulation Alone

Eric Dufour, Patrick Quennesson, Anne Laure Van Robais, Françoise Ledon, Pierre-Antoine Laloë, Ngai Liu, and Marc Fischler

Anesth Analg 2008 106: 1553-1558.

BRIEF REPORTS:

全膝关节成形术后周围神经应用左旋布比卡因和罗哌卡因的镇痛效果:一个前瞻性的、随机双盲研究

王鹏 陈杰 校)

Postoperative Analgesic Efficacy of Peripheral Levobupivacaine and Ropivacaine: A Prospective, Randomized Double-Blind Trial in Patients After Total Knee Arthroplasty (Brief Report)

Florian Heid, Nicole Müller, Tim Piepho, Maren Bäres, Markus Giesa, Philipp Drees, Andreas Rümelin, and Christian Werner

Anesth Analg 2008 106: 1559-1561.

比较全身复合硬膜外麻醉(0.375%罗哌卡因)和单纯全麻用于上腹部手术

黄佳佳译,马皓琳,李士通校

Combined General/Epidural Anesthesia (Ropivacaine 0.375%) Versus General Anesthesia for Upper Abdominal Surgery (Brief Report)

Yuhong Li, Shengmei Zhu, and Meijuan Yan

Anesth Analg 2008 106: 1562-1565.

凝血功能监测:新技术以及粘弹性重点照护检验凝血设备的临床应用

Coagulation Monitoring: Current Techniques and Clinical Use of Viscoelastic Point-of-Care Coagulation Devices

Michael T. Ganter, MD*, and Christoph K. Hofer, MD{dagger}

From the *Department of Anesthesia and Perioperative Care University of CA San Francisco, San Francisco California; and {dagger}Institute of Anesthesiology and Intensive Care Medicine, Triemli City Hospital Zurich, Switzerland.

Anesth Analg 2008; 106:1366-1375

围术期监测凝血功能对麻醉或手术中更好的理解出血原因、指导止血治疗及预测出血的危险因素非常重要,可以。评价全血粘弹性的重点照护检验(POC)凝血监测设备,即血栓弹力描记图、旋转式血栓弹力测定法以及Sonoclot® 分析,在围术期能够克服常规凝血检验的一些局限性。这些技术的优点在于可以在床旁评估整个凝血的过程,包括从纤维蛋白形成开始一直到血块凝缩和纤维蛋白溶解,而且得到结果只有很短的延迟。而且这些技术可以评估患者全血的凝血状态,包括血浆凝血系统与血小板及红细胞的相互作用,从而提供关于血小板功能的有效的额外信息。弹性POC凝血设备越来越多的应用于临床实践中,尤其在心脏手术及肝脏手术中应用更为广泛。这些技术还可以在很多临床情况中提供有效信息,如大出血、评估低凝和高凝状态、指导促凝或抗凝治疗及诊断手术出血。当粘弹性检验结果正常时,应该考虑出血的外科原因。总之,粘弹性POC凝血检测设备可以帮助临床医生明确出血原因及指导促凝和抗凝治疗。为确保最佳的准确性和性能,需要标准化的血液取样及处理的操作、严格的质量控制以及培训过的操作人员。

(邱郁薇 马皓琳 李士通 校)

Perioperative monitoring of blood coagulation is critical to better understand causes of hemorrhage, to guide hemostatic therapies, and to predict the risk of bleeding during the consecutive anesthetic or surgical procedures. Point-of-care (POC) coagulation monitoring devices assessing the viscoelastic properties of whole blood, i.e., thrombelastography, rotation thrombelastometry, and Sonoclot® analysis, may overcome several limitations of routine coagulation tests in the perioperative setting. The advantage of these techniques is that they have the potential to measure the clotting process, starting with fibrin formation and continue through to clot retraction and fibrinolysis at the bedside, with minimal delays. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Viscoelastic POC coagulation devices are increasingly being used in clinical practice, especially in the management of patients undergoing cardiac and liver surgery. Furthermore, they provide useful information in a large variety of clinical scenarios, e.g., massive hemorrhage, assessment of hypo- and hypercoagulable states, guiding pro- and anticoagulant therapies, and in diagnosing of a surgical bleeding. A surgical etiology of bleeding has to be considered when viscoelastic test results are normal. In summary, viscoelastic POC coagulation devices may help identify the cause of bleeding and guide pro- and anticoagulant therapies. To ensure optimal accuracy and performance, standardized procedures for blood sampling and handling, strict quality controls and trained personnel are required.


门诊手术病人监测麻醉后与快通道不可行相关的危险因素

Risk Factors Associated with Fast-Track Ineligibility After Monitored Anesthesia Care in Ambulatory Surgery Patients

Rebecca S. Twersky, MD, MPH, Svetlana Sapozhnikova, BA, and Ben Toure, MD

From the Department of Anesthesiology, SUNY Downstate Medical Center, Brooklyn, New York City, New York.

Anesth Analg 2008; 106:1421-1426

背景门诊手术麻醉后快通道被认为是在不损害病人安全和满意度的同时提高效率和最大化利用资源的一种途径。报道成功快通道的研究把重点主要放在麻醉技术上而不是与不成功的快通道相关的特定的病人因素、手术操作或者过程变量上。为了能够执行改善快通道的程序、随着时间测量变化以及鉴别出与病人监测麻醉后不能成功地到快通道相关的变量,我们完成了这个回顾性研究。

方法:指定了一个基于改良的Aldrete评分的用于所有接受监测麻醉的病人的快通道方案。它包括书面的方针变化和第一个月内医护部门会议上的每周一次的回顾以及随后的6个月干预期内的每月反馈。收集的3个月基线和连续6个月干预期的资料包括快通道状态、外科服务和操作、手术者和麻醉者、年龄、性别、ASA评分、在手术室里的总的时间以及总的手术后时间(手术结束到实际出院)。

结果:3个月基线期内完成了332例病例,在6个月干预期内完成了641例病例。快通道成功率从23% 提高到了56% P < 0.001)。多变量回归分析得出的快通道不可行的独立危险因素有病人年龄<60岁(与老年相比)、ASA评分III级(与I级相比)、普通外科(与整形外科和眼科相比)、实施后的月份以及总的术后时间。在快通道组总的术后时间明显缩短了64分钟(P < 0.001)。

结论:快通道的成功率能通过教育和病人的反馈得到提高和维持。我们鉴别出了与快通道不可行明显相关的危险因素。如果在前瞻性的研究中发现这些因素与快通道不可行有关,那么它们将促进用于快通道的多学科病人和程序特定的指南的制订。

(吴进   马皓琳 李士通 校)

BACKGROUND: Fast-tracking after ambulatory anesthesia has been advocated as a pathway to improve efficiency and maximize resources without compromising patient safety and satisfaction. Studies reporting successful fast-tracking focus primarily on anesthesia techniques and not on specific patient factors, surgical procedure, or process variables associated with unsuccessful fast-tracking. We performed this retrospective study to implement a process for improving fast-tracking, measure change over time, and identify variables associated with patients unable to fast-track successfully after monitored anesthesia care.

METHODS: A fast-track protocol for all patients receiving monitored anesthesia care based on the Modified Aldrete Score was instituted. It consisted of written policy changes and weekly review at physician and nursing department meetings for the first month, followed by monthly feedback during a 6-mo intervention period. Data collected for a 3-mo baseline and the consecutive 6-mo intervention period included fast-track status, surgical service and procedure, surgeon and anesthesiology provider, age, gender, ASA status, total time in operating room, and total postoperative time (end of surgery to actual discharge).

RESULTS: Three hundred and thirty-two cases were completed during the 3-mo baseline period, and 641 cases were completed during the 6-mo intervention period. Fast-track success rate improved from 23% to 56%, P < 0.001. Independent risk factors for fast-track ineligibility identified by multivariate regression analysis were significant for patients <60 yr-old, ASA III versus I, general surgery versus orthopedics and ophthalmology, month after implementation, and total postoperative time. Total postoperative time was significantly shorter by 64 min in the fast-track group, P < 0.001.

CONCLUSION: Fast-track success rate can be improved and sustained over time by education and personnel feedback. We identified risk factors that were significantly associated with fast-track ineligibility. If those factors are found to be associated with fast-track ineligibility in a prospective investigation, they should enable development of multidisciplinary patient and procedure-specific guidelines for fast-tracking.


全麻对局麻药的中枢神经系统和心血管系统毒性的影响

The Effects of General Anesthesia on the Central Nervous and Cardiovascular System Toxicity of Local Anesthetics

Susan E. Copeland, MVetClinStud, Leigh A. Ladd, PhD, Xiao-Qing Gu, BSc, and Laurence E. Mather, PhD

From the Department of Anaesthesia and Pain Management, University of Sydney at Royal North Shore Hospital, NSW 2065, Australia.

Anesth Analg 2008; 106:1429-1439

背景:局麻药的毒性常常是在急性制备的麻醉实验动物中进行研究的。我们测定了氟烷/ O2麻醉对6个酰胺类局麻药静脉注射后产生的心血管和中枢神经系统(CNS)毒性效应的影响。

方法:用以前作为试验工具的母羊(约45-50kg, n = 18),测定了清醒和麻醉时分别在不同的场所,对静脉输注布比卡因(100 mg)、左布比卡因(125 mg)、罗哌卡因(150 mg)、利多卡因(350 mg)、甲哌卡因(350 mg)、丙胺卡因(350 mg)和盐水(对照)3分钟的行为、心血管和药物代谢动力学方面的反应。

结果:局麻药在清醒的羊中会导致惊厥,但是在全麻的羊中没有明显的CNS效应。在清醒的羊中,最初表现为负性收缩力和轻微心动过缓但动脉血压不发生改变,接着在突然发作CNS兴奋性中毒时表现为正性收缩力、心动过速和高血压,伴随QRS波群增宽。清醒的羊中输注布比卡因、左布比卡因和罗哌卡因时致命的心律失常的发生率分别为3/112/123/13;输注丙胺卡因时1/9发生电机械分离(接着多形性室性心动过速出现)导致死亡。在麻醉的羊中,全麻预先存在的心血管抑制在注射局麻药后更加恶化了,增加的QRS宽度更延长了;同时血中局麻药的浓度翻倍了。然而,所有的麻醉羊都存活了。

结论:全麻产生了生理性的干扰,加强了局麻药的心脏抑制作用,改变了局麻药的中毒剂量的药代动力学。然而,局麻药导致心血管毒性引起的死亡只发生在清醒的动物中。

(唐亮   马皓琳 李士通 校)

BACKGROUND: Local anesthetic toxicity is often studied experimentally in acutely prepared, anesthetized laboratory animals. We determined the influence of halothane/O2 anesthesia on cardiovascular and central nervous system (CNS) toxic responses to six amide-type local anesthetics administered IV.

METHODS: Behavioral, cardiovascular, and pharmacokinetic responses were determined in previously instrumented ewes (approximately 45–50 kg, n = 18), on separate occasions when conscious and anesthetized, to bupivacaine (100 mg), levobupivacaine (125 mg), ropivacaine (150 mg), lidocaine (350 mg), mepivacaine (350 mg), prilocaine (350 mg), and saline (control) infused IV over 3 min.

RESULTS: The local anesthetics caused convulsions in conscious sheep, but no overt CNS effects in anesthetized sheep. Negative inotropy and slight bradycardia without changes in arterial blood pressure occurred initially in conscious sheep, followed by positive inotropy, tachycardia, and hypertension at the abrupt onset of CNS excitotoxicity, along with widening of QRS complexes. Fatal cardiac arrhythmias occurred in, respectively, 3 of 11, 2 of 12, and 2 of 13 conscious sheep infused with bupivacaine, levobupivacaine, and ropivacaine; in 1 of 9 with prilocaine, electromechanical dissociation (followed by polymorphic ventricular tachycardia) caused death. In anesthetized sheep, cardiovascular depression, preexisting from the general anesthesia, was exacerbated by all local anesthetics, and increased QRS width was prolonged; concurrent blood local anesthetic concentrations were doubled. Nevertheless, all anesthetized animals survived.

CONCLUSIONS: General anesthesia produced physiological perturbations, exacerbated local anesthetic-induced cardiovascular depression, and changed the pharmacokinetics of toxic doses of local anesthetics. However, cardiovascular fatalities from local anesthetics occurred only in conscious animals.


体外抑制有丝分裂原活化蛋白激酶通路对布比卡因和罗哌卡因诱发的神经毒性有保护作用

In Vitro, Inhibition of Mitogen-Activated Protein Kinase Pathways Protects Against Bupivacaine- and Ropivacaine-Induced Neurotoxicity

Philipp Lirk, MD, MSc*, Ingrid Haller, MD*, Hans Peter Colvin*, Leopold Lang{dagger}, Bettina Tomaselli, PhD{ddagger}, Lars Klimaschewski, MD{dagger}, and Peter Gerner, MD*§

From the *Department of Anesthesiology and Critical Care, {dagger}Division of Neuroanatomy, and {ddagger}Biocenter/Division of Neurobiochemistry, Medical University of Innsbruck, Austria; and §Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008; 106:1456-1464

背景:动物模型表明,特异性激活p38有丝分裂原活化蛋白激酶(MAPK)可能是利多卡因导致神经毒性的一个关键步骤,但是对另外两种应用非常广泛的局麻药布比卡因和罗哌卡因还未研究过。我们对如下假设进行了检验:(A)这些药物的神经毒性小于其原型药利多卡因,(B)它们对背根神经节神经元特定亚群具有选择性毒性作用,(C)诱导p38 MAPK或相关酶如c-jun末端N-激酶(JNK)和细胞外信号调节激酶(ERK)的激活。

方法:我们将原代培养的感觉神经元在相当于阻断钠电流剂量的利多卡因、布比卡因和罗哌卡因中孵育。然后,试图找出布比卡因和罗哌卡因毒性对神经元亚群的潜在的选择性。神经元亚群由免疫组织化学染色和细胞大小来确定。随后,采用酶联免疫吸附法检验p38 MAPKJNKERK在其中的关联性。最后,通过选择性抑制p38 MAPKJNKERK的活性确定MAPK通路在布比卡因和罗哌卡因诱导的神经毒性中的关联性。

结果:我们发现在体外实验中布比卡因和罗哌卡因的神经毒性效能相似,为剂量依赖性,但是对本研究涉及的神经元亚群没有选择性。布比卡因和罗哌卡因的神经毒性至少部分是MAPKs介导的。特别的是,我们证实了p38 MAPKJNK途径在布比卡因神经毒性中的关联性,还描述了p38 MAPK途径涉及罗哌卡因神经毒性的特征。

结论:在等效剂量下,利多卡因在体外的神经毒性与布比卡因和罗哌卡因并没有显著差别。而且布比卡因和罗哌卡因对背根神经节神经元特定亚群产生的神经毒性并无不同。它们的神经毒性作用是通过激活特定MAPKs产生的;在体外,使用特异性药理学方法抑制这些激酶活性能够减弱毒性作用。

(颜涛 译, 马皓琳 李士通 校)

BACKGROUND: Animal models show us that specific activation of the p38 mitogen-activated protein kinase (MAPK) may be a pivotal step in lidocaine neurotoxicity, but this has not been investigated in the case of two very widely used local anesthetics, bupivacaine and ropivacaine. We investigated the hypotheses that these drugs (A) are less neurotoxic than the prototype local anesthetic, lidocaine (B) are selectively toxic for subcategories of dorsal root ganglion neurons and (C) induce activation of either p38 MAPK or related enzymes, such as the c-jun terminal N-kinase (JNK) and extracellular signal-regulated kinase (ERK).

METHODS: We incubated primary sensory neuron cultures with doses of lidocaine, bupivacaine, and ropivacaine equipotent at blocking sodium currents. Next, we sought to determine potential selectivity of bupivacaine and ropivacaine toxicity on neuron categories defined by immunohistochemical staining, or size. Subsequently, the involvement of p38 MAPK, JNK, and ERK was tested using enzyme-linked immunosorbent assays. Finally, the relevance of MAPK pathways in bupivacaine- and ropivacaine-induced neurotoxicity was determined by selectively inhibiting activity of p38 MAPK, JNK, and ERK.

RESULTS: We found that the neurotoxic potency of bupivacaine and ropivacaine is dose-dependent and similar in vitro, but is not selective for any of the investigated subgroups of neurons. Neurotoxicity of bupivacaine and ropivacaine was mediated, at least in part, by MAPKs. Specifically, we demonstrated the relevance of both p38 MAPK and JNK pathways for the neurotoxicity of bupivacaine and characterized the involvement of the p38 MAPK pathway in the neurotoxicity of ropivacaine.

CONCLUSIONS: Given equipotent doses, the neurotoxic potential of lidocaine does not appear to be significantly different from that of bupivacaine and ropivacaine in vitro. Moreover, bupivacaine and ropivacaine do not exert their neurotoxicity differently on specific subsets of dorsal root ganglion neurons. Their neurotoxic effects are brought about through the activation of specific MAPKs; the specific pharmacologic inhibition of these kinases attenuates toxicity in vitro.


肝移植病人的心输出量监测:肺动脉导管和未校准动脉压波形分析比较

Cardiac Output Measurement in Patients Undergoing Liver Transplantation: Pulmonary Artery Catheter Versus Uncalibrated Arterial Pressure Waveform Analysis

Biais Matthieu, MD, Nouette-Gaulain Karine, MD, PhD, Cottenceau Vincent, MD, Vallet Alain, MD, Cochard Jean François, MD, Revel Philippe, MD, and Sztark François, MD, PhD

From the Service d'Anesthésie Réanimation I, Hôpital Pellegrin, Centre Hospitalo-Universitaire de Bordeaux, Place Amélie Raba-Léon, Bordeaux Cedex, France.

Anesth Analg 2008; 106:1480-1486

背景:心输出量(CO)和创伤性血流动力学监测在肝移植中较为有用。尽管有潜在的并发症,肺动脉导管(PAC)仍常用于这些病人。近年来,开始采用一种较小创伤的设备 (Vigileo®/FloTracTM),用动脉压波形分析来估计CO,而不用体外校准。在这一研究中,我们比较了肝移植病人用自动热稀释PAC,瞬时CO stat模式(ICOSM) 得到的CO,和用这一新设备动脉压波形分析(APCO)得到的CO

方法20例行肝移植病人,在镇静和机械通气状态下同时检测APCO ICOSM。检测点如下:PAC插入后(T1–3)、门静脉夹闭(T4–6)、无肝期(T7–9)、移植肝再灌注后(T10–15)和在ICU里的术后期(T15–20)

结果:我们登记了20例病人,获得400个检测值。没有资料剔除。ICOSM APCO的偏差是0.8 L/min,一致性的95%极限是 –1.83.5 L/min. 百分误差是 43% ICOSM APCO的偏差与全身血管阻力有相关性[r2 = 0.55, P < 0.0001, y = 15.8–2.2 ln(x)] ,亚组分析发现偏差和百分误差在低全身血管阻力的病人 (Child-Pugh B C级的病人)中有升高。在不同手术阶段没有差异。

结论:我们的结果提示在行肝移植的病人中Vigileo/FloTrac CO监测资料与自动热稀释方法得到的数据不一致,特别是全身血管阻力低的Child-Pugh BC级病人。

(彭中美 马皓琳 李士通 校)

BACKGROUND: Cardiac output (CO) and invasive hemodynamic measurements are useful during liver transplantation. The pulmonary artery catheter (PAC) is commonly used for these patients, despite the potential complications. Recently, a less invasive device (Vigileo®/FloTracTM) became available, which estimates CO using arterial pressure waveform analysis without external calibration. In this study, we compared CO obtained with a PAC using automatic thermodilution, instantaneous CO stat-mode (ICOSM), and CO obtained with the new device, arterial pressure waveform analysis (APCO) in patients undergoing liver transplantation.

METHODS: Twenty sets of simultaneous measurements of APCO and ICOSM were determined in sedated and mechanically ventilated patients undergoing liver transplantation. Time points were as follows: after PAC insertion (T1–3), after portal clamping (T4–6), during anhepathy (T7–9), after graft reperfusion (T10–15), and in the postoperative period in the intensive care unit (T15–20).

RESULTS: We enrolled 20 patients and 400 measurements were obtained. No data were rejected. Bias between ICOSM and APCO was 0.8 L/min, 95% limits of agreement were –1.8 to 3.5 L/min. The percentage error was 43%. Bias between ICOSM and APCO was correlated with systemic vascular resistance [r2 = 0.55, P < 0.0001, y = 15.8–2.2 ln(x)] and subgroup analysis revealed an increase in the bias and in the percentage error in patients with low systemic vascular resistance (Child-Pugh grade B and C patients). There was no difference between the different surgical periods.

CONCLUSIONS: Our results suggest that Vigileo/FloTrac CO monitoring data do not agree well with those of automatic thermodilution in patients undergoing liver transplantation, especially in Child-Pugh grade B and C patients with low systemic vascular resistance.



静脉注射布比卡因造成心跳骤停的猪模型中复合使用肾上腺素和加压素与脂肪乳剂比较

A Comparison of the Combination of Epinephrine and Vasopressin with Lipid Emulsion in a Porcine Model of Asphyxial Cardiac Arrest After Intravenous Injection of Bupivacaine

Viktoria D. Mayr, MD*, Lukas Mitterschiffthaler, BS*, Andreas Neurauter, MEng*, Christian Gritsch, MRer.nat.*, Volker Wenzel, MD*, Tilko Müller, MD{dagger}, Günter Luckner, MD*, Karl H. Lindner, MD*, and Hans-Ulrich Strohmenger, MD*

From the Departments of *Anesthesiology and Critical Care Medicine, and {dagger}Urology, Innsbruck Medical University, Innsbruck, Austria.

Anesth Analg 2008; 106:1566-1571

背景资料:在猪动物模型上,我们比较了复合使用肾上腺素和加压素与脂肪乳剂对于布比卡因造成的心跳骤停后生存率的影响。

方法:在静脉注射了0.5%布比卡因5mg/kg后,通气停止2± 0.5min(均值±标准差)直到产生心跳骤停。在未处理的心跳骤停一分钟后开始心肺复苏。在心肺复苏两分钟后,十个动物每隔5分钟给予一次肾上腺素复合加压素或4ml/kg20%脂肪乳剂。每次给药后三分钟给予最多3次电击(446 J/kg),以后的电击均采用6 J/kg。实验中自始至终采血以测定布比卡因的血浆浓度。

结果:在加压素组,所有的五头猪都存活,而脂肪乳剂组没有一头猪自发循环恢复(P<0.01)。两组间血浆总布比卡因浓度没有显著性差异。

结论:在这个布比卡因导致的心跳骤停的模型中,加压素复合肾上腺素的升压药与脂肪乳剂比较,在心肺复苏中能产生更加高的冠状动脉灌注压并提高生存率。

 (沈浩   马皓琳 李士通 )

BACKGROUND: In a porcine model, we compared the effect of the combination of vasopressin/epinephrine with that of a lipid emulsion on survival after bupivacaine- induced cardiac arrest.

METHODS: After administration of 5 mg/kg of a 0.5% bupivacaine solution IV, ventilation was interrupted for 2 ± 0.5 (mean ± sd) min until asystole occurred. Cardiopulmonary resuscitation (CPR) was initiated after 1 min of untreated cardiac arrest. After 2 min of CPR, 10 animals received, every 5 min, either vasopressin combined with epinephrine or 4 mL/kg of a 20% lipid emulsion. Three minutes after each drug administration, up to three countershocks (4, 4, and 6 J/kg) were administered; all subsequent shocks with 6 J/kg. Blood for determination of the plasma bupivacaine concentration was drawn throughout the experiment.

RESULTS: In the vasopressor group, all five pigs survived, whereas none of five pigs in the lipid group had restoration of spontaneous circulation (P < 0.01). There was no significant difference between groups in the plasma concentration of total bupivacaine.

CONCLUSION: In this model of a bupivacaine-induced cardiac arrest, the vasopressor combination of vasopressin and epinephrine compared with lipid emulsion resulted in higher coronary perfusion pressure during CPR and survival rates.



麻醉学活跃的研究领域:麻醉学文献的同引分析

Active Research Fields in Anesthesia: A Document Co-Citation Analysis of the Anesthetic Literature

Milan P. Jankovic, MD, Mark Kaufmann, MD, and Christoph H. Kindler, MD

Department of Anesthesia, University Hospital Basel, Basel, Switzerland.

Anesth Analg 2008; 106:1524-1533

背景:科学的发展导致了信息流的增加以及不同研究领域间知识的连接以指数级增长。本研究中,我们使用文献计量学方法来获得一个形成麻醉学这个活跃的科学研究领域结构的概念网络。

方法:从《Web of Science®》(科学信息研究所)选取2003年《Institute for Scientific Information Journal Citation Reports®》(科学信息研究所期刊引用报告)所列的23本杂志中主题标题为“麻醉学”的所有原始文献(n = 3275)包括它们的参考文献(n = 79,972)。挑选出高频被引参考文献(≥5)后,创建成对的同引参考文献并将其用单键和变量水平聚类方法分组为均一结构的文件簇。另外,对每个文件簇,我们把与其相应的2003年纸类出版物区分开来,每个至少同引了簇核心的两个文献。然后用两个已建立起来的簇和相应前沿论文中的文件标题检查来命名活跃的麻醉学研究领域。这些研究领域根据该簇核心中近期文献的比例(直接引用率指数)分类并进一步分析。

结果:确定了46个当前麻醉学研究领域。名为“食管引流型喉罩通气道”的研究领域直接索引率指数最高(100%),而“神经性疼痛的实验模型”及“挥发性麻醉药引起的心肌保护作用”同引的实力水平最高(第9极)。最大的簇核心“术后恶心呕吐”包括12篇相似的论文。《Anesthesia & Analgesia 杂志发表了大多数的前沿论文,而《Anesthesiology》杂志发表了大多数的在前沿论文中作为参考文献引用的基础型文章。

结论:通过同引分析,我们识别出了高频引用文献的明显相似的聚类表现在46个当前活跃的麻醉研究领域,并确定了其间的多重知识网络。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: The expansion of science has resulted in an increased information flow and in an exponentially growing number of connections between knowledge in different research fields. In this study, we used methods of scientometric analysis to obtain a conceptual network that forms the structure of active scientific research fields in anesthesia.

METHODS: We extracted from the Web of Science® (Institute for Scientific Information) all original articles (n = 3275) including their references (n = 79,972) that appeared in 2003 in all 23 journals listed in the Institute for Scientific Information Journal Citation Reports® under the subject heading "Anesthesiology." After identification of highly cited references (≥5), pairs of co-cited references were created and grouped into uniformly structured clusters of documents using a single linkage and variable level clustering method. In addition, for each such cluster of documents, we identified corresponding front papers published in 2003, each of which co-cited at least two documents of the cluster core. Active anesthetic research fields were then named by examining the titles of the documents in both the established clusters and in their corresponding front papers. These research fields were sorted according to the proportion of recent documents in their cluster core (immediacy index) and were further analyzed.

RESULTS: Forty-six current anesthetic research fields were identified. The research field named "ProSeal laryngeal mask airway" showed the highest immediacy index (100%) whereas the research fields "Experimental models of neuropathic pain" and "Volatile anesthetic-induced cardioprotection" exhibited the highest level of co-citation strength (level 9). The research field with the largest cluster core, containing 12 homogeneous papers, was "Postoperative nausea and vomiting." The journal Anesthesia & Analgesia published most front papers while Anesthesiology published most of the fundamental documents used as references in the front papers.

CONCLUSIONS: Using co-citation analysis, we identified distinct homogenous clusters of highly cited documents representing 46 active current anesthetic research fields and determined multiple nets of knowledge among them.



关节内注射硫酸镁和/或布比卡因用于膝关节镜手术后的镇痛

Intraarticular Injection of Magnesium Sulphate and/or Bupivacaine for Postoperative Analgesia After Arthroscopic Knee Surgery

Noha M. Elsharnouby*, Hala E. Eid*, Nahla F. Abou Elezz{dagger}, and Ashraf N. Moharram{ddagger}

From the Departments of *Anesthesiology and Intensive Care, {dagger}Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain-shams University, and {ddagger}Department of Orthopedic and Traumatology, Faculty of Medicine, Cairo University, Cairo, Egypt.

Anesth Analg 2008; 106:1548-1552

背景:关节内注射布比卡因经常被用于预防膝关节镜手术后的疼痛。关节内注射镁,一种N-甲基天冬氨酸受体阻滞剂,将在产生术后镇痛或者增强关节内布比卡因的镇痛效果方面引起人们特别的兴趣。我们设计了该项研究以确定关节内硫酸镁或布比卡因是否会降低VAS评分,并会减少镇痛药的需要量,以及二者联合是否会较单独应用一种药物,更大地减少VAS评分,随后减少镇痛药的需要量。

方法:108名行关节镜下半月板切除术的病人随机盲分入四组。盐水安慰剂组(S)病人注射20mL等渗盐水,镁组(M组)注射20ml加入了1g硫酸镁的等渗盐水。布比卡因组(B组)注射0.25%布比卡因20mL,而镁和布比卡因组注射含0.25%布比卡因和1g硫酸镁的混合液20mL。通过手术后124681224小时的VAS评分来评价术后镇痛。休息和运动时病人的疼痛评分均进行评定。

结果:与其他组相比较,MB组的休息和运动时VAS评分显著较低,首次需要术后镇痛药的时间显著延迟,总的镇痛药的需求量也显著较少。

结论:与单独应用布比卡因、镁,或盐水安慰剂相比,镁复合布比卡因关节内给药会减少术后疼痛。

(黄丽娜 马皓琳 李士通 校)

BACKGROUND: Intraarticular bupivacaine is often used for prevention of pain after arthroscopic knee surgery. Intraarticular magnesium, a N-methyl-d-aspartate receptor blocker, would be of particular interest in either producing postoperative analgesia or enhancing the analgesic effect of intraarticular bupivacaine. We designed this study to determine whether intraarticular magnesium sulfate or bupivacaine results in a decrease in visual analog scale (VAS) score followed by a decrease in analgesic requirement and whether their combination would provide more reduction in VAS, and subsequently less analgesic requirement, than either drug alone.

METHODS: One-hundred and eight patients undergoing arthroscopic meniscectomy were randomized blindly into one of four parallel groups. The saline placebo group (group S) received 20 mL of isotonic saline, and the magnesium group (group M) received 20 mL of isotonic saline containing 1 g magnesium sulfate. The bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, whereas the magnesium with bupivacaine group (group MB) received bupivacaine 0.25% and 1 g of magnesium sulfate in 20 mL. The postoperative analgesia was assessed using VAS recorded after surgery at 1, 2, 4, 6, 8, 12, and 24 h. Patients were evaluated at rest and with movement.

RESULTS: Group MB had a significantly reduced VAS both at rest and on movement, a significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic requirement than other groups.

CONCLUSION: Magnesium combined with bupivacaine produces a reduction in postoperative pain when given intraarticularly in comparison to either bupivacaine or magnesium alone, or to saline placebo.



比较全身复合硬膜外麻醉(0.375%罗哌卡因)和单纯全麻用于上腹部手术

Combined General/Epidural Anesthesia (Ropivacaine 0.375%) Versus General Anesthesia for Upper Abdominal Surgery

Yuhong Li, MD, PhD, Shengmei Zhu, MD, PhD, and Meijuan Yan, MS

From the Department of anesthesiology, First Affiliated Hospital, School of Medicine, Zhejiang University, China.

Anesth Analg 2008; 106:1562-1565

背景:我们研究了0.375%罗哌卡因用于硬膜外复合全身麻醉下行肾切手术时对应激反应和麻醉药用量的影响。

方法:32ASAI-II级,因肾脏肿瘤行长约2h肾切手术的成年患者随机分成两组:硬膜外(生理盐水)/全身麻醉组(C组)和硬膜外(0.375%罗哌卡因)/全身麻醉组(R组)。靶控输注舒芬太尼和异丙酚行麻醉诱导,滴定到BIS达到4050。靶控输注维库溴铵行气管插管。插管后,用异丙酚输注维持麻醉,滴定到BIS值保持在4050。根据动脉血压和心率水平调整舒芬太尼的靶浓度。分别在气管插管前即刻、插管后2min、切皮后即刻、腹腔探查开始后即刻、手术开始后1h及拔管后即刻抽取血样以测量血中肾上腺素、血糖和皮质醇水平。

结果:与R组相比较,C组在手术开始后1h及拔管后即刻糖和皮质醇的血浆浓度相对变化较大。两组血中肾上腺素的水平相类似。术中用于麻醉诱导和维持所需的异丙酚用量没有显著差异,但是麻醉维持中舒芬太尼的用量在R组显著减少(P < 0.05)

结论:硬膜外0.375%罗哌卡因用于肾切手术麻醉维持可抑制围术期应激激素反应并且减少舒芬太尼的用量。

(黄佳佳译,马皓琳,李士通校)

BACKGROUND: We designed this study to investigate the effect of 0.375% ropivacaine on stress hormone responses and anesthetic requirements in combined epidural/ general anesthesia for nephrectomy.

METHODS: Thirty-two adults, ASA physical status I–II, undergoing nephrectomy lasting about 2 h for renal carcinoma were randomly assigned to one of two groups: epidural (saline)/general anesthesia (group C) and epidural (0.375% ropivacaine)/ general (group R) anesthesia. Induction of anesthesia was performed with target-controlled infusion sufentanil and propofol titrated to achieve bispectral index score (define) between 40 and 50. Endotracheal intubation was facilitated by the target-controlled infusion administration of vecuronium. After intubation, anesthesia was maintained with propofol infusion titrated to maintain bispectral index between 40 and 50. The target concentration of sufentanil was titrated according to arterial blood pressure and heart rate. Plasma samples were taken immediately before, 2 min after tracheal intubation, immediately after incision, immediately after the initiation of celiac exploration, 1 h after operation, and immediately after tracheal extubation for measurements of epinephrine, glucose, and cortisol in both groups.

RESULTS: The relative changes of plasma concentrations of glucoses and cortisol were higher at 1 h after operation and immediately after extubation in group C when compared with group R. The plasma concentrations of epinephrine in both groups were similar. The requirements of propofol for induction and maintenance of anesthesia were not statistically different in the groups, but the requirement of sufentanil during maintenance was significant reduced in group R (P < 0.05).

CONCLUSIONS: Epidural ropivacaine 0.375% suppressed stress hormone responses and sufentanil requirements perioperatively during maintenance of anesthesia for nephrectomy.

 

.浓缩纤维蛋白原、ⅩⅢ因子和新鲜冷冻血浆对离体血液稀释(60%)导致血凝形成障碍的影响

The In Vitro Effects of Fibrinogen Concentrate, Factor XIII and Fresh Frozen Plasma on Impaired Clot Formation After 60% Dilution

Thorsten Haas, MD*, Dietmar Fries, MD{dagger}, Corinna Velik-Salchner, MD*, Christian Reif{ddagger}, Anton Klingler, MD, PhD§, and Petra Innerhofer, MD*

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

Anesth Analg 2008 106: 1360-1365.

 

背景:先前的研究表明提高纤维蛋白原浓度能改善稀释性血凝块形成。作者进行了一项离体研究来探讨应用纤维蛋白原、因子ⅩⅢ(FⅩⅢ)及联合应用是否改善血凝块形成,以及在应用纤维蛋白原或新鲜冷冻血浆后是否产生不同的效应。

方法:采集六名健康捐献者血液并用乳酸林格氏溶液稀释60%。稀释的等量血液样本分别加入两种不同剂量的纤维蛋白原浓聚物,FⅩⅢ浓聚物,或联合应用,或两种不同剂量的新鲜冷冻血浆。使用血栓弹力测定仪(ROTEM)测定血液样本在基础状态(未稀释)、血液稀释后和补充凝血物质后凝血指标。变化由变异系数表示,比较单纯应用纤维蛋白原浓聚物或联合应用FⅩⅢ的效应及应用新鲜冷冻血浆后的效应。

结果:血液稀释60%后,所有ROTEM参数和凝血试验指标均出现显著变化。单纯使用FⅩⅢ后无显著影响,联合使用纤维蛋白原后凝血时间、α角和纤维蛋白原和纤维蛋白聚合作用得到改善并强于单用纤维蛋白原组。在应用新鲜冷冻血浆替代纤维蛋白原后,所有ROTEM变异系数的中值在正常范围,出现剂量依赖性变化(EXTEM MCF FFP 小剂量 [38 (35, 40.3) mm)],凝血时间缩短到近基础值。

结论:血液稀释后在加入纤维蛋白原可恢复所有的ROTEM参数。这种效应在联合应用FⅩⅢ后增强,其作用强于新鲜冷冻血浆。

(胡潇 陈杰 校)

BACKGROUND: Previous investigations have shown that increasing fibrinogen concentration improves dilution-dependent impairment of clot formation. We conducted an in vitro study to explore whether substitution with fibrin-stabilizing factor XIII (FXIII) combined with fibrinogen promotes further improvement of clot formation, and whether fibrinogen administration as concentrate or fresh frozen plasma (FFP) results in comparable effects.

METHODS: Blood from six healthy donors was diluted by 60% using lactated Ringer’s solution. Aliquots of diluted blood samples were incubated with two different doses of fibrinogen concentrate, FXIII concentrate, the combination of both, or with two different doses of FFP. Using thrombelastometry (ROTEM®) blood samples were analyzed at baseline (undiluted), after dilution and after supplementation. Variables were analyzed for changes from baseline, and effects of fibrinogen concentrate alone or combined with FXIII were compared with effects observed with corresponding FFP doses.

RESULTS: After 60% in vitro dilution of blood all ROTEM parameters and global coagulation tests changed significantly. Among the substitutes tested FXIII alone had no effect, the combination with fibrinogen improved coagulation time, {alpha}angle and fibrinogen/fibrin polymerization significantly more than did small-dose fibrinogen alone. After substituting fibrinogen, median values of all ROTEM variables were within the normal range, thereby showing dose dependency but also significant differences (P = 0.027) from corresponding FFP doses (EXTEM MCF FFP small dose [38 (35, 40.3) mm)], which enabled only coagulation time to be shortened to baseline levels.

CONCLUSIONS: Supplementation of fibrinogen restored all ROTEM parameters after dilution. This effect was partially enhanced by adding FXIII and was significantly stronger than for FFP substitution.

 

氟哌啶醇联合地塞米松对腹腔镜辅助下阴式子宫切除术后恶心呕吐的预防作用

The Prophylactic Effect of Haloperidol Plus Dexamethasone on Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopically Assisted Vaginal Hysterectomy

Chin-Chen Chu, MD*{dagger}, Ja-Ping Shieh, MD, MS*, Jann-Inn Tzeng, MD, MS*, Jen-Yin Chen, MD, MS*, Yi Lee, MD{ddagger}, Shung-Tai Ho, MD, MS{dagger}, and Jhi-Joung Wang, MD, PhD*

From the *Department of Anesthesiology, Chi-Mei Medical Center, Tainan; {dagger}Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei; and {ddagger}Department of Anesthesiology, Buddhist Tzu-Chi Medical Center, Tzu-Chi University School of Medicine, Hualien, Taiwan.

Anesth Analg 2008 106: 1402-1406.

 

背景:氟哌啶醇,一种常用镇静剂,已发现具有较强的镇吐作用而用于术后恶心呕吐的防治,但联合应用氟哌啶醇和地塞米松对术后恶心呕吐的治疗作用尚未评估。笔者通过与单纯给与氟哌啶醇、安慰剂或氟哌利多比较评估联合应用氟哌啶醇和地塞米松对腹腔镜辅助下阴式子宫切除术后恶心呕吐的预防作用。

方法:400名成年行腹腔镜辅助下阴式子宫切除术的女性患者(n=80,分为四组)入选此随机、双盲、安慰剂、正性对照的研究。在麻醉诱导后15min分别给与生理盐水(S组)、氟哌利多1.25mg(D)、氟哌啶醇2mg( H)、地塞米松5mg( Dx)或氟哌啶醇2mg+地塞米松5mg( H+Dx)。记录术后恶心呕吐和药物相关的副作用。

结果:术后恶心呕吐的发生率分别为D36%H37%Dx38%H+Dx19%,均显著低于S65%P<0.05),H+Dx组发生率最低(19%P<0.05)。5组中QT间期延长、术后疼痛的程度、镇静深度及锥体外系症状等副作用没有显著差异。

结论:同时给与氟哌啶醇2mg和地塞米松5mg较应用安慰剂及单一药物患者术后恶心呕吐的发生率低,且不增加副作用的发生。

(潘方立 陈杰 校)

 BACKGROUND: Haloperidol, a major tranquilizer, has been found to have a potent antiemetic effect on postoperative nausea and vomiting (PONV), but the prophylactic effect of haloperidol plus dexamethasone on PONV has not been evaluated. We evaluated the prophylactic effect of haloperidol plus dexamethasone to either given alone, placebo or droperidol on PONV in patients undergoing a laparoscopic-assisted vaginal hysterectomy.

METHODS: Four hundred adult women (n = 80 in each of five groups) scheduled for a laparoscopic-assisted vaginal hysterectomy were enrolled in a randomized, double-blind, placebo, and positive-control study. Fifteen minutes after the induction of anesthesia, patients received an IV injection of either saline (group S), droperidol 1.25 mg (group D), haloperidol 2 mg (group H), dexamethasone 5 mg (group Dx), or haloperidol 2 mg plus dexamethasone 5 mg (group H + Dx) to prevent PONV. The occurrence of PONV and medication-related side effects were recorded.

RESULTS: The incidences of PONV (0–24 h) in the D (36%), H (37%), Dx (38%), and H + Dx (19%) groups were significantly lower than in the S group (65%; P < 0.05 for each comparison). The H + Dx group had the lowest incidence of PONV (19%; P < 0.05 for each comparison) of the five study groups. No differences were found between the D, H, and Dx groups. Also, no differences were found among the five groups in the side effects of QT prolongation, intensity of postoperative pain, level of sedation, and occurrence of extra-pyramidal symptoms.

CONCLUSION: Prophylactic haloperidol 2 mg plus dexamethasone 5 mg produced a greater reduction in the incidence of PONV than did either drug used alone, placebo or droperidol without increasing perioperative adverse outcomes.


氟哌啶醇
伍用昂丹司琼与单用昂丹司琼对术后恶心呕吐预防作用的比较

Haloperidol Plus Ondansetron Versus Ondansetron Alone for Prophylaxis of Postoperative Nausea and Vomiting

Loreta Grecu, MD*, Edward A. Bittner, MD, PhD*, Jay Kher, MD{dagger}, Sarah E. Smith, BS{ddagger}, and Carl E. Rosow, MD, PhD*

From the *Department of Anesthesia and Critical Care, Massachusetts General Hospital; {dagger}Tufts New England Medical Center; and {ddagger}Boston University School of Medicine, Boston, Massachusetts.

.Anesth Analg 2008 106: 1410-1413.

 

介绍:氟哌啶醇1mg与昂丹司琼4mg对术后恶心呕吐的预防作用及安全性是相同的。本研究比较了两药伍用与单用昂丹司琼的区别。

方法:本研究为随机、双盲研究,共有268位成年全麻病人入组并随机分为氟哌啶醇1mg与昂丹司琼4mg伍用组、生理盐水1mg与昂丹司琼4mg伍用组。同时收集患者进入PACU480min内的有效性及安全性的相关数据。

结果:氟哌啶醇与昂丹司琼伍用组的完整回应更多(76.2%vs59.2%, 更少恶心、复苏反应,但复苏时间延长。而两组间的镇静、术后住院时间、QTc延长均无差异。研究中患者未出现肌力改变、静坐不能或严重心律失常。

结论:氟哌啶醇与昂丹司琼伍用较单用昂丹司琼对术后恶心呕吐的预防作用更为显著,作用时间也更长,而并发症未出现增多趋势。

(陶颖莹 陈杰 校)

INTRODUCTION: Haloperidol 1 mg and ondansetron 4 mg are equally safe and effective for postoperative nausea and vomiting prophylaxis. We compared the combination to ondansetron alone in a mixed surgical population.

METHODS: Two-hundred and sixty-eight adults undergoing general anesthesia received 4 mg ondansetron plus 1 mg haloperidol or saline in this randomized, double-blind protocol. Efficacy and safety data were obtained until 480 min after postanesthesia care unit entry.

RESULTS: The combination had more complete responders (76.2% vs 59.2%), less nausea, less rescue, and longer time to rescue. Sedation, time to postanesthesia care unit discharge, and QTc prolongation were not different. No subject had dystonia, akathisia, or serious dysrhythmias.

CONCLUSIONS: Postoperative nausea and vomiting prophylaxis with both drugs is significantly more effective and longer lasting than ondansetron alone. There is no detectable increase in side effects

 

普萘洛尔增加清醒大鼠利多卡因诱导的惊厥阈值:对大脑的直接影响

Propranolol Increases the Threshold for Lidocaine-Induced Convulsions in Awake Rats: A Direct Effect on the Brain

Taketo Nakamura, MD, Yutaka Oda, MD, PhD, Ryota Takahashi, MD, PhD, Katsuaki Tanaka, MD, PhD, Ichiro Hase, MD, PhD, and Akira Asada, MD, PhD

From the Department of Anesthesiology, Osaka City University Graduate School of Medicine, Osaka, Japan.

Anesth Analg 2008 106: 1450-1455.

 

背景:普奈洛尔是一种临床上常用的β受体阻滞剂局麻药用于控制疼痛, 普奈洛尔用来治疗高血压和心动过速然而,很少有实验来研究普奈洛尔在局麻中的毒性作用作者研究了在清醒自主呼吸的大鼠中,普萘洛尔对于利多卡因诱发惊厥的影响

方法:雄性SD大鼠随机分为6(每组8) 大鼠预先在脑室内注射生理盐水(脑室对照组:CV-C), 10 30 µg/kg普奈洛尔(小剂量组:CV-S,大剂量组:CV-L),或者静脉注射生理盐水(静脉对照组:IV-C), 1 3 mg/kg普奈洛尔(小剂量组: IV -S,大剂量组: IV -L) 3min后静脉给与利多卡因(4mg/kg/min)直到发生强直阵挛性抽搐。

结果:引起抽搐的利多卡因剂量在CV-L组较CV-C组高(30.6 ± 5.1 vs 23.5 ± 2.2 mg/kg,, P = 0.008) 在发生抽搐时,CV-L组血浆总利多卡因浓度以及未结合蛋白的利多卡因浓度,大脑中利多卡因的浓度较CV-C组高(36.1 ± 4.8 vs 26.0 ± 3.8 µg/mL, 22.5 ± 3.5 vs 13.7 ± 2.6 µg/mL, 82.7 ± 7.1 vs 57.3 ± 5.7 µg/g, P < 0.001)IV -L组的惊厥剂量,血浆总利多卡因浓度以及未结合蛋白的利多卡因浓度,大脑中利多卡因的浓度较IV -S组及CV-L组高。IV -L静脉给予利多卡因前血浆普奈洛尔的浓度相比CV-L组增高60(554.7 ± 104.6 9.3 ± 6.7 ng/mL)

结论:普奈洛尔通过直接作用于大脑而增加利多卡因诱导惊厥的阈值。

(杜唯佳 陈杰 校)

BACKGROUND: Propranolol is a β-adrenoceptor antagonist used clinically. Local anesthetics are used for controlling pain, whereas propranolol is concomitantly given to treat hypertension and tachycardia. However, there are few studies examining the effects of propranolol on the toxicity of local anesthetics. We investigated the effect of propranolol on lidocaine-induced convulsions in awake, spontaneously breathing rats.

METHODS: Male Sprague-Dawley rats were randomly divided into six groups (n = 8, each group). Rats were pretreated with intracerebroventricular saline (cerebroventricle- control: CV-C group), 10 or 30 µg/kg of (S)-(–)-propranolol (propranolol) (cerebroventricle-small dose: CV-S and cerebroventricle-large dose: CV-L groups, respectively) or IV saline (IV-control: IV-C group), 1 or 3 mg/kg of propranolol (IV-small dose: IV-S and IV-large dose: IV-L groups, respectively). Three minutes later, lidocaine was administered IV at 4 mg · kg–1 · min–1 until tonic-clonic convulsions occurred.

RESULTS: The convulsive dose of lidocaine in the CV-L group was significantly larger than that in the CV-C group (30.6 ± 5.1 vs 23.5 ± 2.2 mg/kg, respectively, P = 0.008). Plasma concentrations of total and protein-unbound lidocaine, concentrations of lidocaine in the brain at the onset of convulsions were also significantly higher in the CV-L group than those in the CV-C group (36.1 ± 4.8 vs 26.0 ± 3.8 µg/mL, 22.5 ± 3.5 vs 13.7 ± 2.6 µg/mL, 82.7 ± 7.1 vs 57.3 ± 5.7 µg/g, P < 0.001 for all). The convulsive dose, plasma concentrations of total and protein-unbound lidocaine, and brain lidocaine in the IV-L group were also significantly larger than those in IV-C group and comparable with those in the CV-L group. The plasma concentration of propranolol before starting an infusion of lidocaine in the IV-L group was approximately 60-fold higher than that in the CV-L group (554.7 ± 104.6 and 9.3 ± 6.7 ng/mL, respectively).

CONCLUSIONS: Propranolol increased the threshold for lidocaine-induced convulsions by directly acting on the brain.


地氟醚预处理通过靶向作用于TNF-α近端信号而抑制NF-κB的活化

Desflurane Preconditioning Inhibits Endothelial Nuclear Factor-{kappa}-B Activation by Targeting the Proximal End of Tumor Necrosis Factor-{alpha} Signaling

Yuan Li, MD*, Xiaonan Zhang, MSc{dagger}, Biao Zhu, MD*, and Zhanggang Xue, MD*

From the *Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China; and {dagger}Shanghai Public Health Clinical Center, Fudan University, Shanghai, China.

.Anesth Analg 2008 106: 1473-1479.

 

背景:  挥发性麻醉药可干扰缺血再灌注损伤中起关键作用的炎症因子及粘附分子的表达。有报道显示这一过程可抑制NF-κB,但其详细分子机制并未阐明

方法:  用地氟醚预处理(1MACECV304(人脐静脉内皮细胞)30min,冲洗15min后,缺氧30min,再氧合60min,最后以TNF-α(10μg/ml)刺激ECV304。未进行预处理以及/或者未刺激的对照组也包括入实验。通过蛋白质印迹法检测IκB-α,磷酸IκB-α,磷酸IκB-α激酶(IKKα)/IKKβ以及磷酸-p38。核NF-κBp65亚基通过亚细胞分级及蛋白质印迹法测量。TNF-R1在细胞表面的表达量用流式细胞计量术来测量。受体相关的信号转导因子如TRAF-2IKKα则以TNF-R1的抗体和之后的蛋白质印迹法通过免疫沉淀法来测量。

结果:  预处理可抑制IκB-α的磷酸化,降解及p65的核定位。地氟醚也可影响p38的磷酸化,而p38的磷酸化在适度的炎症反应中有一定作用。IKKα/IKKβ的磷酸化可被预处理抑制,然而细胞表面大量的TNF-R1不受影响。TRAF-2IKKα与TNF-R1的联系也被地氟醚所破坏。

结论:  研究结果显示地氟醚在NF-κB途经上的分子靶点在IKK的活化以前,细胞膜表面大量的TNF-R1不受麻醉剂预处理的影响。研究显示地氟醚预处理靶向作用于TNF-α近端信号。

潘钱玲 陈杰 校)

BACKGROUND: Volatile anesthetics interfere with inflammatory cytokine production and expression of adhesion molecules which are critical for ischemia reperfusion induced injury. Nuclear factor (NF)-{kappa}B has been reported to be suppressed in this process, but the detailed molecular mechanism is still unclear.

METHODS: In this study, ECV304 (a human umbilical vein endothelial cell line) was preconditioned with 30 min desflurane (1 minimal alveolar concentration), after 15 min washout, 30 min anoxia, and 60 min reoxygenation was performed. ECV304 was finally stimulated with tumor necrosis factor (TNF)-{alpha} (10 ng/mL). Control groups, which were not preconditioned and/or not stimulated, were also included in the protocol. I{kappa}B-{alpha}, phospho-I{kappa}B-{alpha}, phospho-I{kappa}B kinase (IKK{alpha})/IKKβ, and phopho-p38 were detected by Western blotting. The nuclear NF-{kappa}B p65 subunit was measured by subcellular fractionation and Western blotting. The surface expression of TNF-R1 was measured by flow cytometry. Receptor-associated signaling adaptors, e.g., TNF receptor-associated factor 2 (TRAF2) and IKK-{alpha}, were evaluated by immunoprecipitation by TNF-R1 antibody and subsequent Western blotting.

RESULTS: Desflurane preconditioning inhibits I{kappa}B-{alpha} phosphorylation, degradation, and p65 nuclear localization. Desflurane also affects p38 phosphorylation, which is needed for optimal inflammatory response. The phosphorylation of IKK{alpha}/IKKβ was suppressed by preconditioning while the surface abundance of TNF-R1 was not affected. The association of TRAF2 and IKK-{alpha} with TNF-R1 was compromised by desflurane.

CONCLUSIONS: Our results suggest that the molecular target of desflurane in the NF-{kappa}B pathway is upstream of IKK activation. The abundance of TNF-R1 on the cell membrane is not affected by anesthetic preconditioning. We suggest that desflurane preconditioning targets the proximal end of TNF-{alpha} signaling.


 

直接喉镜法中显示不佳和上唇咬诊评分增高是GlideScope®视频喉镜困难气管插管的预测因子

Poor Visualization During Direct Laryngoscopy and High Upper Lip Bite Test Score Are Predictors of Difficult Intubation with the GlideScope® Videolaryngoscope

Marie-Hélène Tremblay, MD, Stephan Williams, MD, PhD, Arnaud Robitaille, MD, FRCPC, and Pierre Drolet, MD, FRCPC

From the Department of Anesthesiology, CHUM, Hôpital Notre-Dame, University of Montréal, Montréal, Canada.

.Anesth Analg 2008 106: 1495-1500.


背景:在声门可视性方面,GlideScope®视频喉镜等于或优于直接喉镜,但GlideScope®困难插管的预测特征尚未评定。本前瞻性研究主要评定病人困难GlideScope®插管的特征。

方法:记录400名进行气管插管麻醉患者的术前人口学及形态学特征。诱导后,在所有病人中应用直接喉镜评估CormackLehane声门可视性,然后行GlideScope®插管。记录插管次数及所需时间。用单变量和多变量分析法鉴定与困难GlideScope®插管相关的特点。

结果:342例患者1次插管成功,48例患者2次插管成功,9例患者3次插管成功,1名病人插管失败。平均插管时间为21±14s. 单变量分析后发现以下特点与插管时间较长和/或多次尝试有关:高龄、男性、打鼾史、高Mallampati气道等级、张口度小、甲颏距离短、颈围大、上唇咬诊评分高及在直接喉镜中高的CormackLehane等级。然而,在logistic比例风险多元回归模型中分析这些变量发现只有直接喉镜CormackLehane等级高、上唇咬诊评分高及甲颏距离短与插管时间长或多次尝试显著相关。

结论:尽管成功率高,在直接喉镜CormackLehane等级高、上唇咬诊评分高或甲颏距离短的病人中使用GlideScope®插管可能更具挑战性。

(张燕 陈杰 校)

BACKGROUND: The GlideScope® videolaryngoscope allows equal or superior glottic visualization compared with direct laryngoscopy, but predictive features for difficult GlideScope intubation have not been identified. We undertook this prospective study to identify patient characteristics associated with difficult GlideScope intubation.

METHODS: Demographic and morphometric factors were recorded preoperatively for 400 patients undergoing anesthesia with endotracheal intubation. After induction, direct laryngoscopy was performed in all patients to assess the Cormack and Lehane grade of glottic visualization followed by GlideScope intubation. The number of attempts and time needed for intubation were recorded. Univariate and multivariate analyses were performed to identify the characteristics associated with difficult GlideScope intubation.

RESULTS: Intubation required 1, 2, and 3 attempts in 342, 48, and 9 participants, respectively, with one failure. Mean time for intubation was 21 ± 14 s. After univariate analysis, the following characteristics were significantly correlated (P < 0.05) with longer time to intubate and/or multiple attempts: older age, male sex, history of snoring, high Mallampati class, small mouth opening, short sternothyroid and manubriomental distances, large neck circumference, high upper lip bite test score, and high Cormack and Lehane grade during direct laryngoscopy. However, after introducing these variables in nominal logistic and proportional hazard multiple regression models, only high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, and short sternothyroid distance were significantly associated with multiple attempts or lengthier intubations.

CONCLUSION: Despite a high success rate, intubation with the GlideScope is likely to be more challenging in patients with high Cormack and Lehane grade during direct laryngoscopy, high upper lip bite test score, or short sternothyroid distance.

 

咪达唑仑对大鼠脑局部糖代谢具有时间依赖性的影响

The Time-Dependent Effects of Midazolam on Regional Cerebral Glucose Metabolism in Rats

Ulderico Freo, MD*, Mauro Dam, MD{dagger}, and Carlo Ori, MD*

From the *Department of Pharmacology and Anesthesiology, University of Padova, Padova, Italy; and {dagger}Istituto di Cura San Camillo, Ospedale/IRCCS, Venezia – Lido, Italy.

Anesth Analg 2008 106: 1516-1523.

 

背景:咪达唑仑有催眠和镇静作用,这可能是由不同的神经元结构介导的。作者研究催眠剂量的咪达唑仑对意识行为和脑代谢模式的影响。
方法:疼痛反射的丧失及自主运动降低被用作衡量咪达唑仑催眠和镇静效果的指数,脑局部糖代谢率( rCMRglc )作为咪唑唑仑的神经元影响指数。在静脉注射盐水或咪达唑仑(5 mg/kg23060120180min后测定T-344大鼠62个脑区的自主运动活性(用监测仪测定)及rCMRglc(用2 -脱氧葡萄糖(14C )放射性定量测定法)。

结果:咪达唑仑注射后,大鼠在2min内麻醉,30分钟清醒,但自主运动活性严重受损,此后逐渐恢复。麻醉可引起rCMRglc的普遍降低( 59个脑区受影响,平均降低38 %) 。意识恢复与rCMRglc在视觉,听觉,自体感觉皮质和蓝斑的正常化相关联( 47个脑区受影响,减少31 %) 。活动度的恢复与rCMRglc在额部、边缘区域、和丘脑的缓慢正常化相类似(在 60120180分钟,分别有31个、17个及4个区域受影响, 导致26%20%15%的控制值跌幅)
结论:咪达唑仑的催眠作用可能是大脑觉醒和感官功能的抑制引起的,其镇静作用可能由皮层下功能和边缘区域抑制所致。

(陈伟 陈杰 校)

BACKGROUND: Midazolam has hypnotic and sedative activities, which may be mediated by different neuronal structures. We investigated the time course effect of a hypnotic dose of midazolam on conscious motor behavior and on patterns of brain metabolism.

METHODS: Loss of nociceptive reflexes and impairment of spontaneous locomotor activity were used as indices for the hypnotic and sedative effects of midazolam, and the regional cerebral metabolic rates for glucose (rCMRglc) were used as indices of neuronal effects of midazolam. Locomotor activity was measured with a monitor and rCMRglc were measured with the quantitative autoradiographic [14C]2-deoxyglucose procedure in 62 brain regions of Fischer-344 rats at 2, 30, 60, 120, and 180 min after IV administration of saline or midazolam 5 mg/kg.

RESULTS: After midazolam administration, rats were anesthetized at 2 min, awake but severely impaired at 30 min and slowly recovering motor activity thereafter. Anesthesia was associated with widespread rCMRglc decreases (59 areas affected, 38% mean decrease). Recovery of consciousness was associated with normalizing rCMRglc in visual, auditory, and somatosensory cortices and in the locus coeruleus (47 regions affected, 31% decrease). Recovery of motor activity was paralleled by slow rCMRglc normalization in the frontal motor, limbic, and thalamic regions (at 60, 120, and 180 min 31, 17, 4 areas affected, 26, 20, and 15% decreases from control values).

CONCLUSIONS: Whereas the hypnotic effects of midazolam may result from inhibition of brain structures involved in arousal and sensory processing, its sedative effects may result from inhibition of subcortical motor and limbic regions.


用超声判断颈部硬膜外阻滞穿刺针的深度

Sonographic Estimation of Needle Depth for Cervical Epidural Blocks

Soo Hwan Kim, MD*, Kang Hun Lee, MD*, Kyung Bong Yoon, MD, PhD*{dagger}, Woo Young Park, MD*, and Duck-Mi Yoon, MD, PhD*{dagger}

From the Departments of *Anesthesiology and Pain Medicine, and {dagger}Anesthesia and Pain Research Institute, Yonsei University Health System, Seoul, Korea.

Anesth Analg 2008 106: 1542-1547.

 

背景:在颈部硬膜外腔内注射类固醇类药物可以治疗面部,颈部和上肢的急慢性疼痛综合征。超声是神经阻滞时有价值的工具,在穿刺前可提供有用的组织信息。本研究目的是通过比较超声显影下皮肤到硬脊膜之间的距离与实际皮肤到硬脊膜的距离来评估超声的准确度和精确度。

方法:从疼痛门诊选取50例需颈部硬膜外阻滞治疗的患者。选取颈6/7区域的冠状面和矢状面超声影像。在矢状面超声束引导下将硬膜外穿刺针置入,并比较各个超声面上皮肤到硬脊膜之间的距离与实际皮肤到硬脊膜的距离。另外,检测超声的可见度、穿刺次数及并发症。

结果:冠状面及矢状面测量的间距与实际穿刺针的深度之间的相关系数分别为0.92720.926848个病人顺利的完成了颈部硬膜外阻滞(96%)。两个病人硬膜被穿破(2%)。没有发生与硬膜外阻滞相关的血性穿刺液流出,阻滞后并发症及血流动力学的不稳定。

结论:超声能为颈段硬膜外阻滞提供皮肤到硬膜的精确穿刺距离。在穿刺前明确皮肤至硬膜外距离及椎管的解剖结构能够帮助我们在硬膜外穿刺时更安全的定位。

(王腾 陈杰 校)

                                                                    

BACKGROUND: Cervical epidural steroid injections are often used to treat acute and chronic pain syndromes involving the face, neck, and upper extremities. Ultrasound has evolved as a valuable tool for performing neuraxial blocks, providing useful prepuncture information on the structure. Our goal was to evaluate the accuracy and precision of ultrasound by comparing skin to dura distance from ultrasound with the actual skin to epidural depth.

METHODS: We enrolled 50 patients undergoing cervical epidural blocks at the pain clinic. Ultrasound images with transverse and longitudinal median views of the C6/7 area were taken. The epidural needle was inserted, reproducing the direction of the ultrasound beam on the longitudinal median view. Measured distances from skin to dura on each ultrasound view were compared with the actual needle depth. Additionally, we examined ultrasound visibility, the number of puncture attempts, and any complications related to the procedure.

RESULTS: Concordance correlation coefficients between the measured distances on ultrasound and actual needle depth were 0.9272 and 0.9268 on transverse and longitudinal median view, respectively. The cervical epidural block was successfully performed on 48 patients (96%). There were two incidents (4%) of dural puncture. No bloody taps, postprocedure complications, or hemodynamic instability related to cervical epidural blocks occurred.

CONCLUSIONS: Ultrasound provides very accurate information on the skin to dura distance for epidural blocks in the cervical spine. Knowledge of skin to dura distance and a preview of spinal anatomy before puncture can more safely identify the epidural space.

 

全膝关节成形术后周围神经应用左旋布比卡因和罗哌卡因的镇痛效果:一个前瞻性的、随机双盲研究

Postoperative Analgesic Efficacy of Peripheral Levobupivacaine and Ropivacaine: A Prospective, Randomized Double-Blind Trial in Patients After Total Knee Arthroplasty

Florian Heid, MD*, Nicole Müller*, Tim Piepho, MD*, Maren Bäres, MD*, Markus Giesa, MD{dagger}, Philipp Drees, MD{dagger}, Andreas Rümelin, MD, PhD*, and Christian Werner, MD, PhD*

From the Departments of *Anesthesiology, and {dagger}Orthopaedic Surgery, Johannes Gutenberg-University Mainz, Germany.

Anesth Analg 2008 106: 1559-1561.

 

背景:先前的一些研究显示最新的局麻药左旋布比卡因与罗哌卡因可用于术中及术后连续周围神经阻滞。

方法:作者比较了全膝置换术患者应用0.125%的左旋布比卡因或0.2%的罗哌卡因行术后自控股神经镇痛效果。该实验为一双盲、随机、前瞻性研究,60例患者随机接受股神经周围输注左旋布比卡因或罗哌卡因。通过分析术后72h局麻药的消耗,疼痛评分,运动阻滞及阿片类药物的需求量来评价效果。

结果:疼痛评分,运动阻滞范围及阿片类药物需求量均较低,组间无差异。罗哌卡因消耗量较布比卡因高67%(单位为mg)。

结论:0.125%的左旋布比卡因和0.2%的罗哌卡因在全膝置换术后有相似的止痛效果,但左旋布比卡因强于罗哌卡因。

(王鹏 陈杰 校)

BACKGROUND: Several previous trials have characterized the intra- and postoperative effects of the recently introduced local anesthetics, levobupivacaine and ropivacaine, for a variety of continuous peripheral nerve blocks.

METHODS: We compared the analgesic efficacy of levobupivacaine 0.125% versus ropivacaine 0.2% via patient-controlled femoral nerve analgesia after total knee arthroplasty. In a double-blind, randomized, prospective design, 60 patients received femoral infusion with either substance. We analyzed postoperative local anesthetic consumption, pain scores, motor block, and opioid requirements over 72 h.

RESULTS: Pain scores, motor block incidence, and opioid requirements were low and not different between the groups. Ropivacaine consumption in milligrams was 67% higher than that of levobupivacaine.

CONCLUSIONS: Both levobupivacaine 0.125% and ropivacaine 0.2% provide similar analgesia after total knee arthroplasty with the latter being less potent.

 

乳化异氟醚对兔子缺血再灌注损伤后的心脏保护

Emulsified Isoflurane Produces Cardiac Protection After Ischemia-Reperfusion Injury in Rabbits

Yan Rao, Yan-lin Wang, Wen-sheng Zhang, and Jin Liu

Department of Anesthesiology, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei, China.

Anesth Analg 2008 106: 1353-1359.

 

背景:在本次研究中我们将比较乳化异氟醚和吸入异氟醚对心脏的保护作用。

方法:32只兔子被暂时结扎冠状动脉左前降支造成30分钟的心肌缺血,接着进行3小时的再灌注。在冠状动脉左前降支被阻断之前,兔子被随机分为四组(八只为一组):C组,没有缺血预处理治疗;IS组,吸入1.1%异氟醚;EI组,以8%的乳化异氟醚持续输入,终末浓度为0.64%IN组,30%甘油持续输入30分钟。所有治疗在缺血前30分钟进行,用异氟醚的用15分钟洗出。3小时再灌注后测量心肌梗塞面积,乳酸脱氢酶,肌酸激酶的改变及线粒体超微结构的评估。

结果:IS EI组的3小时再灌注后的心梗面积比C组和IN组小(分别为20% +/- 8%, 18% +/- 8%, 39% +/- 6%, and 34% +/- 9%, P < 0.01)IS组和EI组,C组和IN组之间的心梗面积没有差别。3小时再灌注后IS(456 +/- 58 U/L and 1725 +/- 230 U/L)EI(456 +/- 58 U/L and 1725 +/- 230 U/L)的血浆乳酸脱氢酶和肌酸激酶低于C组(676 +/- 82 U/L and 2373 +/- 529 U/L; P < 0.01)ISEI组和C组在线粒体超微结构的改变上没有显著差异。

结论:结果提示我们,在兔子的缺血再灌注损伤后,静脉输注乳化异氟醚和吸入异氟醚产生的心肌保护作用没有显著差异。

(胡艳译  薛张刚校)

BACKGROUND: In this study, we examined the cardioprotective effects of parental emulsified isoflurane compared with inhaled isoflurane.

METHODS: Thirty-two rabbits were subjected to 30 min of myocardial ischemia induced by temporary ligation of the left anterior descending coronary artery followed by 3 h of reperfusion. Before left anterior descending coronary artery occlusion, the rabbits were randomly allocated into one of four groups (eight for each group): group C, no ischemia preconditioning treatment; group IS, inhaled isoflurane 1.1% end-tidal; group EI, a continuous infusion of 8% emulsified isoflurane to an end-tidal concentration of 0.64%; and group IN, a continuous infusion of 30% Intralipid started 30 min. Treatments were started 30 min before ischemia followed by a 15 min washout period for isoflurane groups. Myocardial infarct volume, lactate dehydrogenase, and creatine kinase levels were measured and changes in mitochondrial ultrastructure assessed after 3 h myocardial reperfusion.

RESULTS: Myocardial infarct size 3 h after reperfusion was lower in groups IS and EI compared with groups C and IN (20% +/- 8%, 18% +/- 8%, 39% +/- 6%, and 34% +/- 9%, respectively, P < 0.01). There were no differences in myocardial infarct size between groups IS and EI or between groups C and IN. Plasma lactate dehydrogenase and creatine kinase levels were lower in group IS (456 +/- 58 U/L and 1725 +/- 230 U/L) and group EI (456 +/- 58 U/L and 1725 +/- 230 U/L) 3 h after myocardial reperfusion compared with groups C (676 +/- 82 U/L and 2373 +/- 529 U/L; P < 0.01). Mitochondrial ultrastructure changes were less pronounced in groups IS and EI compared with group C.

 CONCLUSIONS: Our results indicate that, in rabbits, i.v. emulsified isoflurane provides similar myocardial protection against ischemia-reperfusion injury as inhaled isoflurane.

 

 

新式麻醉通气机能否在容积控制通气时准确输送小潮气量?

Do new anesthesia ventilators deliver small tidal volumes accurately during volume-controlled ventilation?

Bachiller PR, McDonough JM, Feldman JM.

Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA.

Anesth Analg 2008 106: 1392-1400.

 

背景:婴儿和新生儿机械通气时,潮气量的小变化可导致通气不足过度,气压伤,容量伤。部分是由于传统麻醉通气机在容量控制通气(VCV)模式时,呼吸回路顺应性和新鲜气流会影响输送的潮气量。尽管PCV时输送的潮气量并不确定,采用循环呼吸系统的压力控制通气(PCV)模式已成为最小化机械通气对小患者伤害的一种普遍方式。新一代麻醉通气机通过调整新鲜气流和呼吸环路的顺应性解决了VCV的问题。此项研究中,我们评估了新式麻醉通气机输送小潮气量的准确性。

方法:评估在不同呼吸回路顺应性(完全扩展和收缩的回路)和肺顺应性的情况下,采用VCV模式预设潮气量分别为100ml200ml500ml,四台麻醉通气机向气道输送容量的准确性。使用一种机械测试肺(成人和儿童)模拟容积从0.00250.03L/cmH2O肺的顺应性,使用带刻度屏的呼吸速率计和定制软件测定压力。我们测试了Smartvent 7900, Avance, and Aisys麻醉通气机系统(GE Healthcare, Madison, WI)Apollo 麻醉通气机 (Draeger Medical, Telford, PA)Smartvent 7900Avance通气机使用吸入流量传感器控制输送容量,而AisysApollo通气机使用补偿回路顺应性方式。

结果:我们发现使用顺应性补偿的麻醉通气机(AisysApollo)在正常情况和低肺顺应性时,使用VCV模式能准确的向测试肺气道输送大和小潮气量(达预设潮气量的95.5%-106.2%)。然而,无顺应性补偿的麻醉通气机在使用VCV模式输送预设潮气量的准确性较差,特别是在低潮气量和低肺顺应性时(达预设潮气量的45.6%-100.3%)。

结论:正常情况和低肺顺应性时,新一代对呼吸环路顺应性和新鲜气流有补偿机制的麻醉通气机采用容量控制通气模式能准确的向气道输送小潮气量。准确的VCV由于在肺顺应性改变时能确保容量,可能将成为PCV的一种有效替代手段,并使手术室内新策略如小容量/肺保护通气成为可能。

(黄凝译  薛张纲校)

BACKGROUND: During mechanical ventilation of infants and neonates, small changes in tidal volume may lead to hypo- or hyperventilation, barotrauma, or volutrauma. Partly because breathing circuit compliance and fresh gas flow affect tidal volume delivery by traditional anesthesia ventilators in volume-controlled ventilation (VCV) mode, pressure-controlled ventilation (PCV) using a circle breathing system has become a common approach to minimizing the risk of mechanical ventilation for small patients, although delivered tidal volume is not assured during PCV. A new generation of anesthesia machine ventilators addresses the problems of VCV by adjusting for fresh gas flow and for the compliance of the breathing circuit. In this study, we evaluated the accuracy of new anesthesia ventilators to deliver small tidal volumes.

METHODS: Four anesthesia ventilator systems were evaluated to determine the accuracy of volume delivery to the airway during VCV at tidal volume settings of 100, 200, and 500 mL under different conditions of breathing circuit compliance (fully extended and fully contracted circuits) and lung compliance. A mechanical test lung (adult and infant) was used to simulate lung compliances ranging from 0.0025 to 0.03 L/cm H(2)O. Volumes and pressures were measured using a calibrated screen pneumotachograph and custom software. We tested the Smartvent 7900, Avance, and Aisys anesthesia ventilator systems (GE Healthcare, Madison, WI) and the Apollo anesthesia ventilator (Draeger Medical, Telford, PA). The Smartvent 7900 and Avance ventilators use inspiratory flow sensors to control the volume delivered, whereas the Aisys and Apollo ventilators compensate for the compliance of the circuit.

RESULTS: We found that the anesthesia ventilators that use compliance compensation (Aisys and Apollo) accurately delivered both large and small tidal volumes to the airway of the test lung under conditions of normal and low lung compliance during VCV (ranging from 95.5% to 106.2% of the set tidal volume). However, the anesthesia ventilators without compliance compensation were less accurate in delivering the set tidal volume during VCV, particularly at lower volumes and lower lung compliances (ranging from 45.6% to 100.3% of the set tidal volume).

CONCLUSIONS: Newer generation anesthesia machine ventilators that compensate for breathing circuit compliance and for fresh gas flow are able to deliver small tidal volumes accurately to the airway under conditions of normal and low lung compliance during volume-controlled ventilation. Accurate VCV may be a useful alternative to PCV, as volume is guaranteed when lung compliance changes, and new strategies such as small volume/lung protective ventilation become possible in the operating room.

 

 

氟哌啶醇与枢复宁用于术后恶心呕吐(短讯)

Haloperidol Versus Ondansetron for Prophylaxis of Postoperative Nausea and Vomiting (Brief Report)
Carl E. Rosow, Kenneth L. Haspel, Sarah E. Smith, Loreta Grecu, and Edward A. Bittner

From the *Department of Anesthesia and Critical Care, Massachusetts General Hospital; {dagger}Department of Anesthesiology, Yale University School of Medicine; and {ddagger}Boston University School of Medicine, Boston, Massachusetts.

Anesth Analg 2008 106: 1407-1409

 

背景:氟哌啶醇对于术后恶心呕吐预防有效,但同5-HT3 受体拮抗剂比较的资料极少。

方法:全麻时244例成人病例随机分为接受静脉氟哌啶醇(1 mg)和枢复宁(4 mg)。采用三盲法评价每组病人的恶心、呕吐、需要采取补救措施、镇静、锥体外系反应、QTc间期以及出麻醉后恢复室时间。

结果:在药物有效性和毒性方面组间无差异性。有效率氟哌啶醇和枢复宁分别为78.2% 76.8%;术后QTc间期延长的发生率分别为28.9%22.1%(无统计学差异)。

结论:在所有外科病人中,用氟哌啶醇(1 mg)预防术后恶心呕吐的有效性和毒性与使用枢复宁(4 mg)无明显差别。

(蒋宗明译 薛张纲校)

BACKGROUND: Haloperidol is effective for postoperative nausea and vomiting prophylaxis, but there are almost no data comparing it to 5-HT3 antagonists.

METHODS: Two hundred forty-four adults were randomized to receive IV haloperidol 1 mg or ondansetron 4 mg, during general anesthesia. Nausea, vomiting, need for rescue, sedation, extrapyramidal effects, QTc intervals, and time to postanesthesia care unit discharge were evaluated with a third-party blind design.

RESULTS: There was no intergroup difference in any measure of efficacy or toxicity. Haloperidol and ondansetron subjects (78.2% and 76.8%) had complete response. Postoperatively, prolonged QTc occurred in 28.9% and 22.1% (N.S.).

CONCLUSIONS: In a mixed surgical population, the efficacy and toxicity of postoperative nausea and vomiting prophylaxis with haloperidol 1 mg was not significantly different from ondansetron 4 mg.

 

 

局麻药的中毒剂量在全麻中对其全身及局部药代动力学的影响

The effects of general anesthesia on whole body and regional pharmacokinetics of local anesthetics at toxic doses

Copeland Susan E, Ladd Leigh A, Gu, Xiao-Qing, Mather Laurence E.

Department of Anaesthesia and Pain Management, University of Sydney at Royal North Shore Hospital, Sydney NSW 2065, Australia.

Anesth Analg  2008 106(5):1440-9

 

背景:局麻药的毒性效应在对麻醉动物的实验中已经有了广泛研究,但临床上所发生的毒性效应却大都出现在清醒病人的身上。在此项研究中,我们将六种局麻药以近似的最大推荐剂量静注,并研究全麻对其药代动力学的影响。

方法:我们将长期以来用作动物模型的母羊(体重约45-50 kgn18),分别在清醒及氟烷麻醉状态下在大于3分钟的时间内缓慢静注布比卡因100mg、左旋布比卡因125mg、罗哌卡因150mg、利多卡因350mg、甲哌卡因350mg、或丙胺卡因350mg(剂量均以其盐酸盐计)。然后以非旋光/旋光性高效液相色谱法对动脉、心脏和大脑静脉进行连续的血药浓度监测,我们以非房室法对全身整体性的药代动力学进行分析,再以质量平衡的方法分析心脏和大脑局部的药代动力学。而以体外平衡透析的方法来分析这些局麻药分别在有或没有氟烷麻醉状态下的血浆结合率。

结果:局麻药的血药浓度在全麻状态下增加到了两倍,这是因为全麻减少了局麻药的全身分布及清除(分别减少到清醒状态下其数值的33%52%)。心脏和大脑的摄药量在全麻状态下也有所增加,导致其在这两个区域的清除以相应减慢。右旋布比卡因的清除率大于左旋布比卡因,右旋丙胺卡因的清除率大于左旋丙胺卡因,但甲哌卡因的清除却不受光学异构的影响。而氟烷并不影响局麻药的血浆结合率。

结论:全麻状态很明显的改变了各种局麻药的全身和局部药代动力学效应、以及其全身效应。因此,在局麻药的毒性研究中全麻状态是一个极其重要却又常被忽视的因素之一。

(刘沁译 薛张纲校)

BACKGROUND: Local anesthetic toxicity is often studied experimentally in anesthetized subjects, but clinical toxicity usually occurs in conscious patients. In this study, we determined the influence of general anesthesia on the pharmacokinetics of six local anesthetics administered i.v. at approximately the highest recommended doses.

METHODS: Chronically instrumented ewes (approximately 45-50 kg, n = 18) were infused over 3 min with (base doses as HCl salts) bupivacaine (100 mg), levobupivacaine (125 mg), ropivacaine (150 mg), lidocaine (350 mg), mepivacaine (350 mg), or prilocaine (350 mg), on separate occasions when conscious and halothane anesthetized. Serial arterial, heart, and brain venous blood drug concentrations were measured by achiral/chiral high-performance liquid chromatography, as relevant. Whole body pharmacokinetics were assessed by noncompartmental analysis; heart and brain pharmacokinetics were assessed by mass balance. Drug blood binding, in the absence and presence of halothane, was assessed by equilibrium dialysis in vitro.

RESULTS: Blood local anesthetic concentrations were doubled with anesthesia because of decreased whole body distribution and clearance (respectively, to 33% and 52% of values when conscious). Heart and brain net drug uptake were greater under anesthesia, reflecting slower efflux from both regions. Clearances of R-bupivacaine > S-bupivacaine and R-prilocaine > S-prilocaine, but, mepivacaine clearance was not enantioselective. Halothane did not influence blood binding of the local anesthetics.

CONCLUSIONS: General anesthesia significantly changed whole body and regional pharmacokinetics of each local anesthetic as well as the systemic effects. General anesthesia is thus an important but frequently overlooked factor in studies of local anesthetic toxicity.

 

 

通过Lymnaea神经元观察利多卡因通过Na+-H+交换增加细胞内钠浓度的研究

Lidocaine increases intracellular sodium concentration through a Na+-H+ exchanger in an identified Lymnaea neuron.

Onizuka S, Kasaba T, Tamura R, Takasaki M.

Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Miyazaki, Kiyotake-Cho, Miyazaki 889-1692, Japan.

Anesth Analg 2008 106: 1473-1479.

 

背景:细胞内钠离子浓度与神经元活性有关。对细胞内钠离子来说,钠氢交换起重要作用,而它又受细胞内PH值的影响。然而,利多卡因对细胞内PH及钠氢交换的影响并不明确。我们用椎实螺属神经元来测定利多卡因如何影响细胞内PH值、钠氢交换及细胞内钠离子浓度。

方法:细胞内钠浓度可由sodium-binding苯并呋喃间苯二甲酸反映,而细胞内PH值由2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein反映,它们被用来测定细胞内钠浓度及PH。细胞内钠离子的测定包括正常钠离子,钠盐中的钠离子,修正过细胞外PH后细胞内钠离子及钠氢交换拮抗剂的预处理下测定的游离钠离子。此外,细胞内钠离子与PH同时被记录。从0.1-10mm,利多卡因、马比佛卡因、布比卡因,普鲁卡因及QX-314被分别评价。

结果:利多卡因、马比佛卡因、普鲁卡因使细胞内钠离子浓度增加成剂量依赖性。对比下QX-314每次加剂量并不都改变钠离子细胞内浓度。利多卡因在钠盐及钠氢交换拮抗剂的预处理下不能增加细胞内钠离子浓度,利多卡因、马比佛卡因、普鲁卡因在基础水平上引起了明显的细胞内PH值的下降。相比下QX-314不引起细胞内PH值改变。这些结果证明利多卡因通过蛋白捕获使细胞呈酸性,激活钠氢交换而增加细胞内钠离子浓度。细胞内钠浓度增加及PH改变导致细胞毒性。

结论:利多卡因通过蛋白捕获激活钠氢交换而增加细胞内钠离子浓度。

(刘婷洁译 薛张钢校)

BACKGROUND: The intracellular sodium concentration ([Na(+)]in) is related to neuron excitability. For [Na(+)]in, a Na(+)-H(+) exchanger plays an important role, which is affected by intracellular pH ([pH]in). However, the effect of lidocaine on [pH]in and a Na(+)-H(+) exchanger is unclear. We used neuron from Lymnaea stagnalis to determine how lidocaine affects [pH]in, Na(+)-H(+) exchanger, and [Na(+)]in.

METHODS: Intracellular sodium 4imaging by sodium-binding benzofuran isophthalate and intracellular pH imaging by 2',7'-bis(2-carboxyethyl)-5(6)-carboxyfluorescein were used to measure [Na(+)]in and [pH]in. Measurements for [Na(+)]in were made in normal, Na(+) free saline, with modified extracellular pH, and a Na(+)-H(+) exchanger antagonist [(5-N-ethyl-N-isopropyl amiloride, N-methylisopropylamiloride, and 5-(N,N-hexamethylene)-amiloride) pretreatment trials. Furthermore, [Na(+)]in and [pH]in were recorded simultaneously. From 0.1 to 10 mM, lidocaine, mepivacaine, bupivacaine, prilocaine, and QX-314 were evaluated.

RESULTS: Lidocaine, mepivacaine, and prilocaine increased the [Na(+)]in in a dose-dependent manner. In contrast, QX-314 did not change the [Na(+)]in at each dose. In the Na(+) free saline or in the presence of each Na(+)-H(+) exchanger antagonist, lidocaine failed to increase [Na(+)]in. Lidocaine, mepivacaine, and prilocaine induced a significant decrease in [pH]in below baseline with an increase in [Na(+)]in. In contrast, QX-314 did not change the [pH]in. These results demonstrated that lidocaine increases [Na(+)]in through Na(+)-H(+) exchanger activated by intracellular acidification, which is induced by the proton trapping of lidocaine. This [Na(+)]in increase and [pH]in change induces cell toxicity.

CONCLUSION: Lidocaine increases the [Na(+)] through a Na(+)-H(+) exchanger by proton trapping.

 

 

不同吸入氧分数的单增量变化对使用氧气洗出技术测定机械通气病人的功能潮气量的影响

The Impact of Different Step Changes of Inspiratory Fraction of Oxygen on Functional Residual Capacity Measurements Using the Oxygen Washout Technique in Ventilated Patients

Heinze, Hermann MD; Sedemund-Adib, Beate MD; Heringlake, Matthias MD; Gosch, Ulrich W. MD; Gehring, Hartmut MD; Eichler, Wolfgang MD

From the Department of Anaesthesiology, University of Luebeck, Luebeck, Germany.

Anesth Analg 2008 106: 1491-1494

 

背景:功能残气量(FRC)的测定能指导我们调整通气治疗方法。使用氧气洗出技术,能够在床旁测定自主呼吸病人的功能残气量。但是,对于监测来说至关重要的高度可重复性,却没有在机械通气的病人中表现出来。较大的吸入氧分数单增量变化(⊿FiO2)会影响高吸入氧分数的机械通气患者的临床应用。我们要研究的是这种FRC测量方法的可重复性,以及不同的⊿FiO2对于这种可重复性的影响。

方法:LUFU系统(Draeger MedicalLuebeck ,德国)使用氧气洗出来估测FRC,即快速⊿FiO2过程中的多次呼吸氮洗出技术的一个参数。在20个心血管外科的术后患者中,使用⊿FiO20.10.20.6,来重复测定这些患者的FRC

结果:重复测定对于FRC的测出并无不同,同样使用的⊿FiO20.10.2或者0.6也对结果没有影响(⊿0.1: 2.62 L±0.58, 2.62 L ±0.59, P =0.995; 0.2: 2.70 L±0.59, 2.66 L ±0.56, P =0.258; 0.6: 2.61 L ±0.58, 2.59 L ±0.58, P =0.639)。它们各自的变异系数分别为6.6%5.6%6.6%

结论:机械化通气的病人可以用氧气洗出技术来测定FRC,具有临床上能接受的可重复性。

并且使用的⊿FiO20.10.2或者0.6,对于这种可重复性的影响并没有统计学意义。

(秦敏菊译 薛张纲校)

BACKGROUND: Functional residual capacity (FRC) measurements may help to guide respiratory therapy. Using the oxygen washout technique, FRC can be assessed at bedside during spontaneous breathing. High repeatability, crucial for monitoring, has not been shown in ventilated patients. A large step change of inspiratory fraction of oxygen (Fio2) (⊿Fio2) may impede the clinical use in patients ventilated with high Fio2. We investigated the repeatability of FRC measurements and the impact of different Fio2 on this repeatability.

METHODS: The LUFU system (Draeger Medical, Luebeck, Germany) estimates FRC by oxygen washout, a variant of multiple-breath-nitrogen-washout during a fast Fio2. In 20 postoperative cardiac surgery patients, FRC was measured in duplicate using Fio2 of 0.1, 0.2, and 0.6.

RESULTS: There were no differences between repeated measurements of FRC, neither using a Fio2 of 0.1, 0.2 nor 0.6(0.1: 2.62 L ± 0.58, 2.62 L ± 0.59, P = 0.995; 0.2: 2.70 L ± 0.59, 2.66 L ± 0.56, P = 0.258; 0.6: 2.61 L ± 0.58, 2.59 L ± 0.58, P = 0,639). Coefficients of variation were 6.6%, 5.6%, and 6.6%, respectively.

CONCLUSIONS: FRC can be measured in ventilated patients using the oxygen washout technique with a clinically acceptable repeatability. Repeatability is not significantly influenced whether using a Fio2 of 0.1, 0.2, or 0.6.

 

 

关于产痛评估的动态模型的建立与验证

The Development and Validation of a Dynamic Model to Account for the Progress of Labor in the Assessment of Pain

Jessamyn Conell-Price, BA, Jennifer B. Evans, Daewha Hong, MS, Steven Shafer, MD, and Pamela Flood, MD

From the Department of Anesthesiology, Columbia University, New York City, New York.

Anesth Analg 2008 106: 1509-1515.

 

背景:产痛常被描述为女性生命中最严重的疼痛,且充满变数。虽然与产痛相关的已知因素有许多,但仍难以估计这些因素对个体的影响,因为分娩是一个动态的过程,所产生的疼痛亦不断改变。以往的研究往往使用平均疼痛评分,本研究的目的是建立和验证一个模型,分析整个分娩过程中影响疼痛的因素。

方法:我们回溯建库,连续选取200610月至20071月在纽约长老会医院分娩的200名初产妇进行研究。评定量表包括:宫缩痛(0-10级)、宫颈扩张度及镇痛前催产素的使用。用S形方程的非线性效应建模描述疼痛与宫颈扩张之间的关系。91例初产妇的数据用于建模,95例初产妇的数据用于验证(所有初产妇疼痛评分均大于零)。使用由此产生的模型分析催产素应用对疼痛的影响。

结果:由训练集得出的模型对验证集有预测价值(P<0.001)。疼痛预测分数为实际测量分数的平均值。将催产素作为协变进行分析,结果表明:48%应用催产素的妇女,在分娩开始时承受更多的痛苦,但与未应用催产素的妇女相比,疼痛的增长率及最大强度并无增加,并且拥有更缓慢的早期产程及更迅速的后期产程。

结论:我们建立并验证了用于描述产痛的动态模型。该模型适用于统计分析影响因素的协方差,并可用于比较各影响因素对产痛及其变化的影响。

(施颖译 薛张纲校)

BACKGROUND: Labor pain is often described as the worst pain in a woman's life, but the experience is highly variable. Although many factors have been linked to labor pain, it has been difficult to assess the individual effects of these factors because labor is a dynamic process and pain intensity changes over the course of labor. Previous studies have used average pain scores. The aim of this study was to develop and validate a model that would allow for the statistical analysis of factors that affect pain throughout labor.

METHODS: We conducted this study with a retrospective database drawn from the medical records of 200 consecutive nulliparous parturients who delivered at New York Presbyterian Hospital between October 2006 and January 2007. Numerical rating scale scores for pain with contractions (0–10 scale), cervical dilation, and oxytocin use before analgesia request were recorded. Nonlinear effects modeling with a sigmoid equation was used to describe the relationship between reported pain and cervical dilation. The modeling technique was developed with data from 91 parturients and validated with an independent set of 95 parturients (all parturients with pain scores more than zero). The resulting model was used to analyze the effect of a sample covariate, oxytocin administration, on reported pain in the entire data set.

RESULTS: The model derived from our training set was predictive of the data from our validation set (P < 0.001). Predicted pain scores were on average two numerical rating scale points above or below measured pain scores. Analyzing oxytocin as a covariant showed that women treated with oxytocin reported 48% more pain at the start of labor but did not have a significantly more rapid increase in pain or higher maximal pain when compared with women not treated with oxytocin. Women treated with oxytocin had slower early labor and more rapid late labor.

CONCLUSION: We have developed and validated a model for describing pain over the course of labor. Our model is suited to the statistical analysis of covariance and could potentially be used to compare the effects of covariants on labor pain and the rate of change of pain.

 

 

麻醉后监护室中严重疼痛的有关因素

Predictive Factors of Severe Postoperative Pain in the Postanesthesia Care Unit

Frédéric Aubrun, MD, PhD*, Nathalie Valade, MD*, Pierre Coriat, MD*, and Bruno Riou, MD, PhD

From the Departments of *Anesthesiology and Pain Medicine, and {dagger}Anesthesia and Pain Research Institute, Yonsei University Health System, Seoul, Korea.

Anesth Analg 2008 106: 1535-1541.

 

背景:麻醉后监护室中广泛使用静滴吗啡(IMT )来控制疼痛。术后疼痛和吗啡用量的差异性有很多因素构成。我们把IMT >0.15 mg/kgIMT失败看作严重的术后疼痛,来分析与之有关的术前和术中因素。

方法:评估有关疼痛,治疗的术前信息和术中事件,以及他们在术后疼痛中扮演的角色。IMT以后病人分为两组:严重疼痛(SP)组和非严重疼痛组。数据用均数±标准差来表示。

结果:该研究包括342名病人:200(58%)在非严重疼痛组,142(42%)在严重疼痛组。运用单变量分析的方法,两组在用药和手术史方面没有显著差别,而SP组的术前治疗更多(P < 0.05)SP组的手术和麻醉时间更长(P < 0.001) IMT之前和之后的舒芬太尼以及类似物用量更高。运用多变量分析的方法,术中阿片类药物大量使用(舒芬太尼量>0.6 µg/kg(比值比= 2.68, P < 0.001) ,术中采用全麻(比值比 = 3.96, P = 0.03),术前麻醉药物的使用(比值比 = 1.91, P < 0.01)都是和严重术后疼痛有关的独立因素。

结论:术中舒芬太尼的大量使用,全麻和术前使用过麻醉药物治疗明显和严重术后疼痛有关。

(孙鹏飞译 薛张纲校)

BACKGROUND: IV morphine titration (IMT) is widely used in the postanesthesia care unit to achieve pain relief. Numerous factors contribute to variability in postoperative pain or morphine consumption. We analyzed prospectively the pre- and intraoperative predictive factors of severe postoperative pain defined as a dose of IMT >0.15 mg/kg or a failure of IMT.

METHODS: We assessed the role of preoperative information about pain, medical treatments, and intraoperative events and their role on postoperative pain. After IMT, patients were divided into two groups: severe pain (SP) and nonsevere pain. Data are expressed as mean ± sd.

RESULTS: Three hundred forty-two patients were included in the study: 200 (58%) in the nonsevere pain group and 142 (42%) in the SP group. Using a univariate analysis, there was no significant difference between groups related to medical or surgical history except for more frequent preoperative treatments in the SP group (P < 0.05). Duration of the surgical procedure and anesthesia were longer in the SP group (P < 0.001). The dose of sufentanil and visual analog scale scores before and at the end of IMT were higher in the SP group (P < 0.001). Using a multivariate analysis, a high dose of intraoperative opioid (sufentanil dose >0.6 µg/kg) (Odds ratio = 2.68, P < 0.001), a general anesthetic procedure (Odd ratio = 3.96, P = 0.03), and the use of preoperative analgesic drugs (Odds ratio = 1.91, P < 0.01) were independent factors associated with severe postoperative pain.

CONCLUSION: A higher intraoperative dose of sufentanil, general anesthesia, and preoperative treatment with analgesics were significantly associated with severe postoperative pain.                                              

 

 

一项关于超声及神经刺激联合定位腘窝-坐骨神经阻滞的前瞻性随机对照研究

Combined Ultrasound and Neurostimulation Guidance for Popliteal Sciatic Nerve Block: A Prospective, Randomized Comparison with Neurostimulation Alone

Eric Dufour, Patrick Quennesson, Anne Laure Van Robais, Françoise Ledon, Pierre-Antoine Laloë, Ngai Liu, and Marc Fischler

From the *Department of Anesthesiology, Hôpital Foch, Suresnes, France; Departments of {dagger}Anesthesiology, and {ddagger}Surgery, Clinique La Montagne, Courbevoie, France.

Anesth Analg 2008 106: 1553-1558.

 

背景:作为定位周围神经的有效工具,超声定位使得神经阻滞的实施更为容易。但是其在腘窝-坐骨神经阻滞中的效果尚未得到肯定。

方法:在这项随机单盲前瞻性研究中,我们对比了解剖结构联合神经刺激定位(NS组,n30)与超声引导下神经刺激定位(US-NS组,n30)实施腘窝-坐骨神经阻滞所需要的时间(以主要终点为准)。每例阻滞都是由一位操作者单独完成的。正确的针位由最小刺激电流</=0.5 mA来确定,或者,在US-NS组是由针柄引起神经活动来确定,即使此时最小刺激电流>0.5 mA。在US-NS组,分别于胫神经和腓总神经处给予10ml 0.5%左布比卡因,并且为了提高麻醉效果,没有调整进针位置。所有操作都有影像记录,并且要求在7分钟内完成。成功的阻滞定义为:30分钟后,神经分布区域内冷感觉完全消失,足背及足跖屈曲消失。

结果NS组的5个病人,US-NS组的3个病人退出了研究。两组的阻滞需要时间没有显著差异。US-NS组的穿刺针通过次数只有在探测第一根神经时较低(1 [1-2] vs 2 [1-6]; P < 0.01)US-NS组的30分钟成功率明显较高(65% vs 16%; P < 0.001)

结论:超声及神经刺激联合定位并不减少阻滞所需时间,但是提高了腘窝-坐骨神经阻滞的30分钟成功率。

(夏俊明译 薛张纲校)

BACKGROUND: Ultrasound imaging, an effective tool to localize peripheral nerves, may facilitate block performance. However, its usefulness during popliteal sciatic nerve block has not been assessed.

METHODS: In this prospective, randomized, patient-blinded study, we compared the block time (as the primary end-point) of a popliteal sciatic nerve block with double-injection performed using anatomical landmarks and neurostimulation (NS group; n = 30) versus combined ultrasound and neurostimulation guidance (US-NS group; n = 30). Each block procedure was performed by a single operator. Correct needle placement was defined by a minimal stimulating current ≤0.5 mA, or, in the US-NS group, by mobilization of the nerve by the needle shaft even if the minimal stimulating current >0.5 mA. Ten milliliter levobupivacaine 0.5% was administered separately on the tibial and common peroneal nerves without needle adjustment to improve the spread of anesthetic in the US-NS group. All procedures were video-recorded, and a maximum of 7 min was allowed to perform the block. Successful block was defined as complete loss of cold sensation in the sciatic distribution and an inability to perform a plantar and dorsal flexion of the foot at 30 min.

RESULTS: Five patients in the NS group and three in US-NS group were excluded from the study for prolonged procedure. Block time was not significantly different between groups. The number of needle passes was lower only for the detection of the first nerve in the US-NS group (1 [1–2] vs 2 [1–6]; P < 0.01). A greater success rate was observed at 30 min in the US-NS group (65% vs 16%; P < 0.001).

CONCLUSIONS: Combined ultrasound and neurostimulation guidance does not decrease block time but increases the success rate of popliteal sciatic nerve block observed at 30 min.