Table of Contents
August 2008
CARDIOVASCULAR ANESTHESIOLOGY:
儿童心脏手术人群中抗肝素-血小板因子4抗体的形成的发病率和意义
朱紫瑜 译 陈杰 校
The Incidence and Implications of Anti-Heparin-Platelet Factor
4 Antibody Formation in a Pediatric Cardiac Surgical Population
Mary P. Mullen, David L. Wessel, Kristen C. Thomas, Kimberlee Gauvreau, Ellis J. Neufeld, Francis X. McGowan, Jr, and James A. DiNardo
Anesth Analg 2008 107:
371-378.
胡艳译 薛张刚校
The Influence of Aprotinin and Tranexamic Acid on Platelet
Function and Postoperative Blood Loss in Cardiac Surgery (Case Report)
Andinet M. Mengistu, Kerstin D. Röhm, Joachim Boldt, Jochen Mayer, Stefan W. Suttner, and Swen N. Piper
Anesth Analg 2008 107: 391-397.
PEDIATRIC ANESTHESIOLOGY:
潘钱玲 译 陈杰 校
Factors Predictive of Poor Behavioral Compliance During
Inhaled Induction in Children
Anna M. Varughese, Todd G. Nick, Joel Gunter, Yu Wang, and C. Dean Kurth
Anesth Analg 2008 107: 413-421.
黄凝译 薛张纲校
Pediatric Mastocytosis: Routine Anesthetic Management for a
Complex Disease
Melody C. Carter, Ashraf Uzzaman, Linda M. Scott, Dean D. Metcalfe, and Zenaide Quezado
Anesth Analg 2008 107: 422-427.
AMBULATORY ANESTHESIA:
预防性应用止吐药物对呕吐高危患者出院后恶心呕吐发生率及恢复期生活功能性质量的影响：一项前瞻、随机、双盲比较两种预防性止吐方案的试验研究
邱郁薇 译 马皓琳 李士通 校
Antiemetic Prophylaxis for Postdischarge Nausea and Vomiting
and Impact on Functional Quality of Living During Recovery in Patients with
High Emetic Risks: A Prospective, Randomized, Double-Blind Comparison of Two
Prophylactic Antiemetic Regimens
Peter H. Pan, Sherman C. Lee, and Lynne C. Harris
Anesth Analg 2008 107: 429-438.
评价3种不同剂量的帕洛诺司琼与安慰剂在术后72小时内防止术后恶心呕吐的有效性和安全性的随机双盲研究
唐亮 译 马皓琳 李士通 校
A Randomized, Double-Blind Study to Evaluate the Efficacy and
Safety of Three Different Doses of Palonosetron Versus Placebo in Preventing
Postoperative Nausea and Vomiting Over a 72-Hour Period
Anthony L. Kovac, Leopold Eberhart, Jan Kotarski, Giuseppina Clerici, Christian Apfel, and The Palonosetron 04-07 Study Group
Anesth Analg 2008 107: 439-444.
一项随机双盲研究：评估三种不同剂量的帕洛诺司琼与安慰剂对预防术后恶心呕吐的有效性与安全性
陶颖莹 译 陈杰 校
A Randomized, Double-Blind Study to Evaluate the Efficacy and
Safety of Three Different Doses of Palonosetron Versus Placebo for Preventing
Postoperative Nausea and Vomiting
Keith A. Candiotti, Anthony L. Kovac, Timothy I. Melson, Giuseppina Clerici, Tong Joo Gan, and The Palonosetron 04–06 Study Group
Anesth Analg 2008 107: 445-451.
蒋宗明译 薛张纲校
The Impact of Current Antiemetic Practices on Patient
Outcomes: A Prospective Study on High-Risk Patients
Paul F. White, Jerome F. O'Hara, Charles R. Roberson, Ronald H. Wender, Keith A. Candiotti, and The POST-OP Study Group
Anesth Analg 2008 107: 452-458.
吴进 译 马皓琳 李士通 校
The Relationship Between Patient Risk Factors and Early Versus
Late Postoperative Emetic Symptoms
Paul F. White, Ozlem Sacan, Nina Nuangchamnong, Tiffany Sun, and Matthew R. Eng
Anesth Analg 2008 107: 459-463.
ANESTHETIC PHARMACOLOGY:
周姝婧 译 陈杰 校
Palonosetron Exhibits Unique Molecular Interactions with the 5-HT3 Receptor
Camilo Rojas, Marigo Stathis, Ajit G. Thomas, Edward B. Massuda, Jesse Alt, Jie Zhang, Ed Rubenstein, Silvia Sebastiani, Sergio Cantoreggi, Solomon H. Snyder, and Barbara Slusher
Anesth Analg 2008 107: 469-478.
刘沁译 薛张纲校
Inhaled Anesthetics Do Not Combine to Produce Synergistic
Effects Regarding Minimum Alveolar Anesthetic Concentration in Rats
Edmond I. Eger, II, Michael Tang, Mark Liao, Michael J. Laster, Ken Solt, Pamela Flood, Andrew Jenkins, Douglas Raines, Jan F. Hendrickx, Steven L. Shafer, Tanifuji Yasumasa, and James M. Sonner
Anesth Analg 2008 107: 479-485.
黄施伟 译，马皓琳 李士通 校
General Anesthetics Have Additive Actions on Three Ligand Gated Ion Channels
Andrew Jenkins, Ingrid A. Lobo, Diane Gong, James R. Trudell, Ken Solt, R. Adron Harris, and Edmond I. Eger, II
Anesth Analg 2008 107: 486-493.
协同作用是普遍规律？关于产生催眠和肢体活动消失的麻醉药相互作用的综述
潘方立 译 陈杰 校
Is Synergy the Rule? A Review of Anesthetic Interactions
Producing Hypnosis and Immobility
Jan F. A. Hendrickx, Edmond I. Eger, II, James M. Sonner, and Steven L. Shafer
Anesth Analg 2008 107: 494-506.
刘婷洁译 薛张纲校
Additivity Versus Synergy: A Theoretical Analysis of
Implications for Anesthetic Mechanisms
Steven L. Shafer, Jan F. A. Hendrickx, Pamela Flood, James Sonner, and Edmond I. Eger, II
Anesth Analg 2008 107: 507-524.
黄丽娜 译 马皓琳 李士通 校
Synergy Between Pairs of Competitive Antagonists at Adult Human Muscle Acetylcholine Receptors
Man Liu and James P. Dilger
Anesth Analg 2008 107: 525-533.
异丙酚对肝L02细胞的保护作用，激活细胞外信号调节激酶通路减少因过氧化氢引起的细胞凋亡
怀晓蓉 译 陈杰
校
Propofol Protects Hepatic L02 Cells from Hydrogen
Peroxide-Induced Apoptosis via Activation of Extracellular Signal-Regulated
Kinases Pathway
Hao Wang, Zhanggang Xue, Qiong Wang, Xiaochen Feng, and Zonghou Shen
Anesth Analg 2008 107: 534-540.
TECHNOLOGY, COMPUTING, AND SIMULATION:
秦敏菊译 薛张纲校
The Performance of Six Pulse Oximeters in the Environment of
Neuronavigation
Alexander M. Mathes, Sascha Kreuer, Sven O. Schneider, Stephan Ziegeler, and Ulrich Grundmann
Anesth Analg 2008 107: 541-544.
姜旭晖译，马皓琳 李士通校
The Effects of Auditory Evoked Potential Click Sounds on
Bispectral Index and Entropy
Tomoki Nishiyama
Anesth Analg 2008 107: 545-548.
PATIENT SAFETY:
赵嫣红 译 陈杰 校
Coronary Artery Stents: Part I. Evolution of Percutaneous
Coronary Intervention (Review Article)
Lisa T. Newsome, Michael A. Kutcher, and Roger L. Royster
Anesth Analg 2008 107: 552-569.
施颖译 薛张纲校
Coronary Artery Stents: II. Perioperative Considerations and
Management (Review
Article)
Lisa T. Newsome, Robert S. Weller, J. C. Gerancher, Michael A. Kutcher, and Roger L. Royster
Anesth Analg 2008 107: 570-590.
唐李隽 译 马皓琳 李士通 校
Life After Death: The Aftermath of Perioperative Catastrophes
(Review Article)
Farnaz M. Gazoni, Marcel E. Durieux, and Lynda Wells
Anesth Analg 2008 107: 591-600.
CRITICAL CARE AND TRAUMA:
胸内血容指数可作为评估急性循环衰竭危重病人机体容量反应的一个指标：与中心静脉压的比较
叶乐 译 陈杰 校
The Intrathoracic Blood Volume Index as an Indicator of Fluid
Responsiveness in Critically Ill Patients with Acute Circulatory Failure: A
Comparison with Central Venous Pressure
Laurent Muller, Guillaume Louart, Christian Bengler, Pascale Fabbro-Peray, Julie Carr, Jacques Ripart, Jean-Emmanuel de La Coussaye, and Jean-Yves Lefrant
Anesth Analg 2008 107: 607-613.
孙鹏飞译 薛张纲校
Pulmonary Effects of Noninvasive Ventilation Combined with the
Recruitment Maneuver After Cardiac Surgery
Serdar Celebi, Özge Köner, Ferdi Menda, Oguz Omay, Ilhan Günay, Kaya Suzer, and Nahit Cakar
Anesth Analg 2008 107: 614-619.
OBSTETRIC ANESTHESIOLOGY:
黄佳佳译，马皓琳 李士通校
A Randomized Controlled Trial of Pudendal Nerve Block for Pain
Relief After Episiotomy
Younès Aissaoui, Rémi Bruyère, Hassan Mustapha, Dominique Bry, Noureddine Drissi Kamili, and Chantal Miller
Anesth Analg 2008 107: 625-629.
ECONOMICS, EDUCATION, AND POLICY:
随机药物抽检减少麻醉住院医师药物依赖发生率:来自一个研究方案的初步结果
丁俊云 译 陈杰 校
Random Drug Testing to Reduce the Incidence of Addiction in
Anesthesia Residents: Preliminary Results from One Program (Special Article)
Michael G. Fitzsimons, Keith H. Baker, Edward Lowenstein, and Warren M. Zapol
Anesth Analg 2008 107: 630-635.
NEUROSURGICAL ANESTHESIOLOGY:
夏俊明译 薛张纲校
A Study of Cognitive Dysfunction in Patients Having Carotid
Endarterectomy Performed with Regional Anesthesia
Eric J. Heyer, Mark I. Gold, E. Will Kirby, Joseph Zurica, Elizabeth Mitchell, Hadi J. Halazun, Lauren Teverbaugh, Robert R. Sciacca, Robert A. Solomon, Donald O. Quest, Thomas S. Maldonado, Thomas S. Riles, and E. Sander Connolly, Jr
Anesth Analg 2008 107: 636-642.
朱 慧译 马皓琳 李士通校
Intravenous Dexmedetomidine Decreases Lung Permeability
Induced by Intracranial Hypertension in Rats
Motoi Kumagai, Takashi Horiguchi, Toshiaki Nishikawa, Yoko Masaki, and Yoshitugu Tobe
Anesth Analg 2008 107: 643-647.
GENERAL ARTICLES:
杜唯佳 译 陈杰 校
Anesthetic Management of a Patient with 3-Methylcrotonyl-CoA
Carboxylase Deficiency (Case Report)
Karen A. Robbins and Elias N. León-ruiz
Anesth Analg 2008 107: 648-650.
ANALGESIA:
使用帕瑞考昔钠20mg一天两次的多日用药法能减轻全髋置换术后的疼痛
宣丽真译 薛张纲校
A Multiple-Day Regimen of Parecoxib Sodium 20 mg Twice Daily
Provides Pain Relief After Total Hip Arthroplasty
Eugene R. Viscusi, Joseph S. Gimbel, Andreas M. Halder, Michael Snabes, Mark T. Brown, and Kenneth M. Verburg
Anesth Analg 2008 107: 652-660.
彭中美 译 马皓琳 李士通 校
The Effect of Acupressure at the Extra 1 Point on Subjective
and Autonomic Responses to Needle Insertion
Young-Chang P. Arai, Takahiro Ushida, Tomoaki Osuga, Takako Matsubara, Kahori Oshima, Kana Kawaguchi, Chiaki Kuwabara, Sigeya Nakao, Atsushi Hara, Chihiro Furuta, Erina Aida, Shugyoku Ra, Yui Takagi, and Kyoko Watakabe
Anesth Analg 2008 107: 661-664.
乳癌术后病人自控椎旁镇痛的可行性：两种方法的前瞻性、随机双盲研究的比较
舒慧刚 译 陈杰 校
The Feasibility of Patient-Controlled Paravertebral Analgesia for Major Breast Cancer Surgery: A Prospective, Randomized, Double-Blind Comparison of Two Regimens (Brief Report)
Jennifer McElwain, Noelle M. Freir, Crina L. Burlacu, Denis C. Moriarty, Daniel I. Sessler, and Donal J. Buggy
Anesth Analg 2008 107:
665-668.
章一静译 薛张纲校
A Dose-Ranging
Study of Intraarticular Midazolam for Pain Relief After Knee Arthroscopy
(Brief Report)
Yatindra Kumar Batra, Rajesh Mahajan, Sushil Kumar, Subramanyam Rajeev, and Mandeep Singh Dhillon
Anesth Analg 2008 107: 669-672.
张莹译 马皓琳 李士通校
Modulators of Calcium Influx Regulate Membrane Excitability in Rat Dorsal Root Ganglion Neurons
Philipp Lirk, Mark Poroli, Marcel Rigaud, Andreas Fuchs, Patrick Fillip, Chun-Yuan Huang, Marko Ljubkovic, Damir Sapunar, and Quinn Hogan
Anesth Analg 2008 107: 673-685.
刘世文 译 陈杰 校
Prolonged Use of High-Dose Morphine Impairs Angiogenesis and
Mobilization of Endothelial Progenitor Cells in Mice
Chen-Fuh Lam, Pei-Jung Chang, Yu-Sheng Huang, Yen-Hui Sung, Chien-Chi Huang, Ming-Wei Lin, Yen-Chin Liu, and Yu-Chuan Tsai
Anesth Analg 2008 107: 686-692.
鞘内注射可乐定可以抑制小鼠脊髓背侧脚神经元的N－甲基－D－天门冬氨酸受体NR1磷酸化引起的神经性疼痛
陈珺珺译 薛张纲校
Intrathecal Clonidine Suppresses Phosphorylation of the
N-Methyl-D-Aspartate Receptor NR1 Subunit in Spinal Dorsal Horn Neurons of Rats
with Neuropathic Pain
Dae-Hyun Roh, Hyun-Woo Kim, Seo-Yeon Yoon, Hyoung-Sig Seo, Young-Bae Kwon, Ho-Jae Han, Alvin J. Beitz, and Jang-Hern Lee
Anesth Analg 2008 107: 693-700.
不同浓度及容量的局麻药行连续腘窝坐骨神经阻滞的效果：一项双中心、随机、对照研究
裘毅敏译，马皓琳、李士通校
The Effects of Varying Local Anesthetic Concentration and
Volume on Continuous Popliteal Sciatic Nerve Blocks: A Dual-Center, Randomized,
Controlled Study
Brian M. Ilfeld, Vanessa J. Loland, J. C. Gerancher, Anupama N. Wadhwa, Elizabeth M. Renehan, Daniel I. Sessler, Jonathan J. Shuster, Douglas W. Theriaque, Rosalita C. Maldonado, Edward R. Mariano For the PAINfRETM Investigators
Anesth Analg 2008 107: 701-707.
影响局麻药在硬膜外麻醉神经阻滞平面的因素及腰段和胸段硬膜外麻醉的比较
张磊 译 陈杰 校
Factors Affecting the Distribution of Neural Blockade by Local
Anesthetics in Epidural Anesthesia and a Comparison of Lumbar Versus Thoracic
Epidural Anesthesia (Review
Article)
W. Anton Visser, Ruben A. Lee, and Mathieu J. M. Gielen
Anesth Analg 2008 107: 708-721.
The influence of aprotinin and tranexamic acid on
platelet function and postoperative blood loss in cardiac surgery.
Andinet M. Mengistu, Kerstin D. Röhm, Joachim Boldt, Jochen
Mayer, Stefan W. Suttner, and Swen N. Piper
Department of Anesthesiology and Intensive Care Medicine,
Klinikum Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany.
a.mengistu@gmx.de
Anesth Analg 2008
107: 391-397.
背景：当前抗纤维蛋白溶解的药物，包括抑肽酶和氨甲环酸被用于心脏手术，通过对血小板不同的作用来减少术后的出血及输血需求。所以我们通过评估体外循环和心脏手术后的血小板功能来确定抑肽酶及氨甲环酸的作用。
方法：在一个随机的前瞻性研究中，对50位择期行体外循环心脏手术病人进行研究。25位接受高剂量的抑肽酶，25位接受高剂量的氨甲环酸。术前，体外循环后，术后3小时，24小时用改良的血栓弹性描记法和全血集合度测定来评价凝血及血小板功能。
结果：与术前相比，体外循环后两组的凝血的功能均受到损害(P < 0.01)。与改良的血栓弹性描记法的测定结果不同，体外循环后，使用氨甲环酸的病人的凝血酶受体介导的集合度有明显的下降(P
< 0.05)。与使用氨甲环酸组相比，使用抑肽酶的患者的胸管引流量明显减少（575 mL +/- 228 vs 1033 mL +/- 647, P
< 0.05)，术后的输血需求明显下降(P < 0.01)。
结论：使用全血集合度测定血小板功能显示抑肽酶和氨甲环酸能减少体外循环后最初24小时内的出血。
（胡艳译
薛张刚校）
BACKGROUND: Antifibrinolytic drugs including
aprotinin and tranexamic acid are currently used in cardiac surgery to reduce
postoperative bleeding and transfusion requirements, and may have different
effects on platelets. We therefore evaluated platelet function after
cardiopulmonary bypass (CPB) and cardiac surgery to determine the effect of
either aprotinin or tranexamic acid.
METHODS: In a prospective, randomized study, 50
patients scheduled for elective cardiac surgery with CPB were evaluated.
Patients received high-dose aprotinin (n = 25) or tranexamic acid (n = 25) as
antifibrinolytic drugs. Coagulation and platelet function were assessed
preoperatively, after CPB, 3 and 24 h after surgery using modified
thrombelastography and whole blood aggregometry.
RESULTS: Impaired coagulation after CPB occurred
in both groups compared with preoperative data (P < 0.01). In contrast to
modified thrombelastography, thrombin receptor-mediated aggregometry after CPB
was significantly decreased only in those patients receiving tranexamic acid
until the end of the study period in comparison to the aprotinin group (P <
0.05). Aprotinin-treated patients showed significantly less chest tube drainage
(575 mL +/- 228 vs 1033 mL +/- 647, P < 0.05) and need for postoperative
transfusion requirements (P < 0.01) compared with the tranexamic acid group.
CONCLUSIONS: Platelet function measured by whole
blood aggregometry is better preserved by aprotinin than tranexamic acid and
may be responsible for producing less bleeding within the first 24 h after CPB.
Pediatric mastocytosis: routine anesthetic management for
a complex disease.
Melody C. Carter, Ashraf Uzzaman, Linda M. Scott, Dean D.
Metcalfe, and Zenaide Quezado
Laboratory of Allergic Diseases, National Institute of
Allergy and Infectious Diseases, National Institutes of Health, 10 Center Dr.
MSC 1881, Bldg 10 Room 11C-213, Bethesda, MD 20892, USA.
Anesth Analg 2008
107: 422-427
背景:儿童肥大细胞增多症包括一系列临床变种,具有多器官系统内固有肥大细胞数目增多的特征。肥大细胞在介导过敏反应方面起作用，肥大细胞增多症患者易发生有或无刺激的过敏反应发作。
方法：调查自1993年至2006年为诊断或外科手术接受麻醉的儿童肥大细胞增多症患者的围麻醉期记录，同时进行有关儿童肥大细胞增多症麻醉经验的文献回顾。
结果：行麻醉时平均年龄为3.2岁(年龄6个月－20岁)的22名儿童肥大细胞增多症患者，29次为诊断或外科手术接受麻醉。此队列中包括该病所有变种。大多数患者有皮肤潮红，瘙痒，胃食管反流症和腹痛病史，一名患者有自发性过敏反应病史。不考虑该病的复杂性采用常规麻醉技术，整个围术期经过并不复杂，且无严重不良事件。
结论：回顾儿童肥大细胞增多症的主要特点和它所涉及的麻醉及围术期问题，并叙述此类儿科患者麻醉管理的实用方法。尽管很多麻醉中常规使用的药物据报道可引起肥大细胞脱颗粒，但并无依据证实与常规麻醉技术的差异是有必要的。然而为处理可能发生的不良事件，建议应了解此病所涉及的麻醉问题并仔细准备。
（黄凝译 薛张纲校）
BACKGROUND:
Pediatric mastocytosis consists of a spectrum of clinical variants
characterized by increased numbers of resident mast cells in various organ
systems. Mast cells are instrumental in mediating anaphylaxis and patients with
mastocytosis are at risk to develop provoked and unprovoked episodes of
anaphylaxis.
METHODS: We examined
perianesthetic records of patients with pediatric mastocytosis who were
anesthetized for diagnostic and surgical procedures from 1993 to 2006. In
addition, we conducted a literature review of the anesthetic experience in
pediatric mastocytosis.
RESULTS: Twenty-two
patients with pediatric mastocytosis, with a median age of 3.2 yr (range, 6
mo-20 yr) at the time of the procedure, were anesthetized for 29 diagnostic and
surgical procedures. All variants of the disease are represented in this
series. Most patients had a history of flushing, pruritus, gastro-esophageal reflux
diseases, and abdominal pain; one patient had a history of spontaneous
anaphylaxis. Routine anesthetic techniques were used and, despite the
complexity of the disease, the perioperative courses were uncomplicated and
without serious adverse events.
CONCLUSIONS: We
reviewed the main features of pediatric mastocytosis, its anesthetic and
perioperative implications, and describe a practical approach to the anesthetic
management of pediatric patients with the disease. Although many drugs used
routinely in anesthesia reportedly caused mast cell degranulation, deviations
from routine anesthesia techniques are not necessarily warranted. However, an
understanding of the anesthetic implications of the disease and meticulous
preparation to treat possible adverse events are advised.
The Impact of Current Antiemetic Practices on Patient
Outcomes: A Prospective Study on High-Risk Patients
Paul F. White, Jerome F. O'Hara, Charles
R. Roberson, Ronald H. Wender, Keith A. Candiotti, and The POST-OP Study Group
From the Department of Anesthesiology and Pain Management,
University of Texas Southwestern Medical Center at Dallas, Texas
Anesth Analg 2008
107: 452-458.
背景：该前瞻性、多中心、观察研究中将评价高危病人术后恶心呕吐（PONV）的发生率和持续时间，分析预防性和补救性止吐药物的使用，总结止吐药物使用指南对人群的有效性，其指南包括美国麻醉医师协会（ASA）和美国围麻醉期护理学会（ASPAN）指南。
方法：拟择期行腹腔镜手术或整形外科大手术的入选病人有下列两个或两个以上下列PONV危险因素：女性、PONV病史或运动晕动病、不吸烟。手术后第一个72h记录下列指标：止吐药物使用、呕吐事件发生、恶心严重性和因PONV对正常功能的干扰。止吐完全有效（CR）为无呕吐发生或无补救药物使用，止吐完全控制为CR和无中-重度恶心。分析受试者的ASA和ASPAN指南药物使用依从性对PONV发生率的影响。
结果：研究者中18％-40%病人有术后呕吐发生，其发生比例取决于使用止吐药物的数量。补救药物使用率为45%，其比例接近于先前报道的中-重度恶心发生率（47%）。因呕吐症状对生理功能干扰发生率为44%。使用3种及以上止吐药物产生的总体止吐效果优于使用少于1种预防性药物者。尽管受试者遵守ASA 和ASPAN使用指南，但CR率小于70%(ASA: 69%; ASPAN: 63%)。PONV完全控制率为10%低于3天研究期间CR率。
结论：对PONV高危因素病人，预防性使用3种或3种以上止吐药物对手术后病人72h内呕吐发生能产生积极结果。尽管遵从各个学会推荐的PONV使用指南，高危病人术后呕吐症状及其对病人正常活动干扰发生率仍大于30%。
（蒋宗明译 薛张纲校）
BACKGROUND: In this prospective, multicenter, observational study, we
evaluated the incidence and time course of postoperative nausea and vomiting
(PONV), assessed prophylactic and rescue antiemetic use in high-risk patients,
and determined population-based effectiveness of antiemetics, including the
impact of American Society of Anesthesiologists (ASA) and American Society of
Perianesthesia Nurses (ASPAN) guideline compliance.
METHODS: Eligible patients undergoing elective laparoscopic or
major plastic surgery possessed two or more of the following Apfel PONV risk
factors: female gender, history of PONV or motion sickness, and nonsmoking
status. Antiemetic use, emetic episodes, severity of nausea, and functional
interference due to PONV were documented during the first 72 h after surgery.
Complete response (CR) was defined as no emesis or rescue medication use, and
complete control was defined as CR and no moderate-severe nausea. The effect of
compliance (versus noncompliance) with ASA and ASPAN guidelines on PONV
outcomes was also analyzed.
RESULTS: The proportion of patients experiencing postoperative
emesis ranged from 18% to 40% depending on the number of antiemetics
administered. The rate of rescue medication (45%) was similar to the reported
incidences of moderate-to-severe nausea (47%) and functional interference due
to emetic symptoms (44%). The administration of three or more antiemetics
produced better patient outcomes overall compared to <1 prophylactic
antiemetic. CR rates were <70% despite adherence to current organizational
PONV management guidelines (ASA: 69%; ASPAN: 63%). The complete control rates
were 10% lower than CR rates over the 3 day study period.
CONCLUSIONS: Administration of three or more prophylactic
antiemetics had the most positive impact on emetic outcomes over 72 hrs in
patients at risk of developing PONV. Although compliance with organizational
PONV management guidelines improved patient outcomes, postoperative emetic
symptoms and interference with patient functioning still occurred in more than
30% of these high-risk patients.
Inhaled Anesthetics Do Not Combine to Produce
Synergistic Effects Regarding Minimum Alveolar Anesthetic Concentration in Rats
Edmond I. Eger, II, Michael Tang, Mark Liao, Michael J.
Laster, Ken Solt, Pamela Flood, Andrew Jenkins, Douglas Raines, Jan F.
Hendrickx, Steven L. Shafer, Tanifuji Yasumasa, and James M. Sonner
From the *Department of Anesthesia and Perioperative Care,
University of California, San Francisco, California; _files/image002.gif){kind=small}
Department
of Anesthesia and Critical Care, Massachusetts General Hospital, and _files/image004.gif){kind=small}
Department
of Anaesthesia, Harvard Medical School, Boston, Massachusetts; _files/image006.gif){kind=small}
Department
of Anesthesiology, Columbia University, New York City, New York; ||Department
of Anesthesiology, Emory University, Atlanta, Georgia; ¶Department of
Anesthesia, Stanford University, Stanford, California; **Department of
Biopharmaceutical Science, UCSF, San Francisco, California; and _files/image007.gif){kind=small}
_files/image008.gif){kind=small}
Department
of Anesthesiology, Jekei University School of Medicine, Tokyo, Japan.
Anesth Analg 2008
107: 479-485.
背景：我们假设有歧异效价[指一种对最低肺泡浓度(MAC）的作用小，而另一种作用大]的两种吸入性麻醉药对某一受体或通道可能有着协同作用。并且，这种可加性的偏差对我们关于麻醉药物是在多位点来发挥麻醉效应的观点也起到了支持作用。
方法：相应的，我们研究了11对有着歧异效价（一种对MAC的作用小，一种作用大）的麻醉药物作用于某特一受体或通道时其MAC的可加性。所谓的“歧异作用”，我们通常是指在MAC上，那种对体内某特一受体或通道作用强的麻醉药其激动或阻断效应至少是较弱的那种的两倍（而通常是更多）。这些受体或通道包括：TREK-1/TASK-3钾通道、A型_files/image010.gif){kind=small}
-氨基丁酸受体、甘氨酸受体、N-甲基右旋天冬氨酸受体和乙酰胆碱受体。我们还研究了苯环丙烷的可加性，因为N-甲基右旋天冬氨酸的阻断剂MK-801对于这些麻醉药物的MAC值也有歧异效应。此外，我们还研究了包括笑气在内的四组吸入性麻醉药的配对，因为有文献报道当笑气与异氟醚合用时有次相加性（拮抗作用）的产生。
结果：除了有次相加性的笑气和异氟醚间的组合之外，其他所有的配对都得到了一个根据可加性得出的其预计值10%以内的结果。
结论：有观点认为，当遭遇有害刺激时，吸入性麻醉药是通过作用于某单一位点来达到麻醉制动效果的，而我们的结果正也与这一观点相一致。
（刘沁译 薛张纲校）
BACKGROUND: We
hypothesized that pairs of inhaled anesthetics having divergent potencies [one
acting weakly at minimum alveolar anesthetic concentration (MAC); one acting
strongly at MAC] on specific receptors/channels might act synergistically, and
that such deviations from additivity would support the notion that anesthetics
act on multiple sites to produce anesthesia.
METHODS: Accordingly,
we studied the additivity of MAC for 11 anesthetic pairs divergently (one
weakly, one strongly) affecting a specific receptor/channel at MAC. By
"divergently," we usually meant that at MAC the more strongly acting
anesthetic enhanced or blocked the in vitro receptor or channel at least twice
(and usually more) as much as did the weakly acting anesthetic. The
receptors/channels included: TREK-1 and TASK-3 potassium channels; and _files/image011.gif){kind=small}
-aminobutyric
acid type A, glycine, N-methyl-d-aspartic acid, and acetylcholine receptors. We
also studied the additivity of cyclopropane-benzene because the
N-methyl-d-aspartic acid blocker MK-801 had divergent effects on the MACs of
these anesthetics. We also studied four pairs that included nitrous oxide
because nitrous oxide had been reported to produce infraadditivity (antagonism)
when combined with isoflurane.
RESULTS: All
combinations produced a result within 10% of that which would be predicted by
additivity except for the combination of isoflurane with nitrous oxide where
infraadditivity was found.
CONCLUSIONS: Such
results are consistent with the notion that inhaled anesthetics act on a single
site to produce immobility in the face of noxious stimulation.
Additivity Versus Synergy: A Theoretical Analysis of
Implications for Anesthetic Mechanisms
Steven L. Shafer, MD*_files/image012.gif){kind=small}
_files/image013.gif){kind=small}
,
Jan F. A. Hendrickx, MD, PhD_files/image014.gif){kind=small}
¶,
Pamela Flood, MD*, James Sonner, MD_files/image015.gif){kind=small}
,
and Edmond I. Eger, II, MD_files/image016.gif){kind=small}
From the
*Department of Anesthesiology, Columbia University, New York, New York; _files/image017.gif){kind=small}
Department
of Anesthesia, Stanford University, Stanford, California; _files/image018.gif){kind=small}
Departments
of Biopharmaceutical Sciences and _files/image019.gif){kind=small}
Anesthesia
and Perioperative Care, University of California at San Francisco, San
Francisco, California; and ¶Department of Anesthesiology and Critical Care
Medicine, OLV Hospital, Aalst, Belgium.
Anesth Analg 2008 107: 507-524.
背景：吸入性麻醉药假定作用于多种受体，在各方适度作用的叠加下产生固定的有害刺激。最近实验研究结果有了吸入性麻醉药相互影响的新发现。协同意味多方面的作用。这次尝试，我们探究相反的：在一方面有无叠加作用？
方法：用大量的聚集反应方法探索一对同一受体结合位置的竞争配体。构建一个电路来研究药物力量和不合理的浓度反映关系在有抑制物管理的连续电路中怎样被放大，在平行电路中被增强。集合的抑制物和增强电路进入信号处理单元来研究信号处理单位强制施加的影响所产生的附加交互作用。最后，协同，叠加，和占有部分受体之间的关系被探究来理解叠加后强制施加的影响。
结果：竞争性结合同一受体的药物与有相似效应的受体必须一一被添加。受体被抑制物固定在连续的电路中。在平行电路中被扩大，增加显著的药物力量与不合理的浓度反映关系。当集合的抑制物和增强的电路被安排进信号处理单元，相互作用会叠加或协同。关键在于药物浓度与影响效应和浓度与50%受体占有之间的关系，kd效应被低的浓度调节更可能被叠加。相似的，如果麻醉药效应出现在浓度在或超过50%受体被占有时，吸入性麻醉药在分离的地点作用不会显示叠加的交互作用。然而，如果麻醉药物效应出现在浓度非常低的受体被占有时，叠加作用会在其他麻醉作用受体上出现。
结论：药物在不同受体上的叠加作用只有在浓度依赖性药物浓度低于50%受体被占有时产生。
（刘婷洁译 薛张纲校）
BACKGROUND: Inhaled
anesthetics have been postulated to act at multiple receptors, with
modest action at each site summing to produce immobility to noxious
stimulation. Recent experimental results affirm prior findings that
inhaled anesthetics interact additively. Synergy implies multiple
sites of action by definition. In this essay, we explore the
converse: does additivity imply a single site of action?
METHODS: The
interaction of one versus two ligands competing for the same binding
site at a receptor was explored using the law of mass action.
Circuits were then constructed to investigate how the potency of
drugs and the steepness of the concentration versus response
relationship is amplified by the arrangement of suppressors into
serial circuits, and enhancers into parallel circuits. Assemblies of
suppressor and enhancer circuits into signal processing units were
then explored to investigate the constraints signal processing units
impose on additive interactions. Lastly, the relationship between
synergy, additivity, and fractional receptor occupancy was explored to
understand the constraints imposed by additivity.
RESULTS: Drugs that
compete for a single receptor, and that similarly affect the
receptor, must be additive in their effects. Receptors that bind
suppressors in serial circuits, or enhancers in parallel circuits,
increase the apparent potency of the drugs and the steepness of the
concentration versus response relationship. When assemblies of
suppressor and enhancer circuits are arranged into signal processing
units, the interactions may be additive or synergistic. The primary
determinant is the relationship between the concentration of drug
associated with the effect of interest and the concentration
associated with 50% receptor occupancy, kd.
Effects mediated by very low concentrations are more likely to be
additive. Similarly, inhaled anesthetics that act at separate sites
are unlikely to exhibit additive interactions if anesthetic drug
effect occurs at concentrations at or above 50% receptor occupancy.
However, if anesthetic drug effect occurs at very low levels of
receptor occupancy, then additivity is expected even among
anesthetics acting on different receptors.
CONCLUSIONS: Additivity
among drugs acting on different receptors is only likely if the
concentrations responsible for the drug effect of interest are well
below the concentration associated with 50% receptor occupancy.
The Performance of Six Pulse Oximeters in the Environment
of Neuronavigation
Alexander M. Mathes, Sascha Kreuer, Sven O. Schneider,
Stephan Ziegeler, Ulrich Grundmann From the Department of Anesthesiology,
Critical Care and Pain Medicine, Saarland University Hospital, Homburg (Saar),
Germany.
Anesth Analg
2008;107:541–4
背景：脉搏氧饱和度仪的使用已被公认是麻醉过程中的基本监护之一。然而，这种监护设备也很容易被多种外界干扰所影响。最近有看法指出，神经导航设备会影响脉搏氧饱和度仪的精确性。本次研究中，我们评估六种不同的脉搏氧饱和度仪在受到一种神经外科影像导航仪影响时的表现。另还将评估两种简单的屏蔽措施的效果。
方法：本研究入选二十个健康、成年、不抽烟的志愿者，在他们双手手指上夹上六种不同的脉搏氧饱和度仪，评估其心率、动脉氧饱和度、信号质量的基线。开启Brain
Lab Vector Vision 神经导航系统仪后，记录下其对信号质量、饱和度识别的影响。并使用两种不同的屏蔽方法：棉毯及铝箔，分别重复测定记录值。
结果：影像导航仪的启动对信号质量及饱和度识别检测带来了有统计学意义的干扰。而这种干扰可在一定程度上被两种屏蔽方法所逆转。六种不同品牌的脉搏氧饱和度仪的信号质量有统计学意义的差别（p<0.001）；氧饱和度识别也有统计学意义的差别（p<0.001）；对于屏蔽方法的反应性也有统计学意义的差别（p<0.001）。由铝箔屏蔽的测试中，所有受试的探头监测到的饱和度值几乎没有受到影响。
结论：神经导航仪的红外线脉冲会影响到脉搏氧饱和度仪的监测。而将探头用铝箔屏蔽能显著地消除这种干扰。
（秦敏菊译 薛张纲校）
BACKGROUND: Although
the use of pulse oximeters may be regarded a standard of care for monitoring
anesthesia procedures, these monitors may be susceptible to various kinds of
disturbances. Recently, it was suggested that neuronavigation equipment may
interfere with pulse oximeter accuracy. In this study, we evaluated the effect
of a neurosurgical image guidance system on the performance of six different
pulse oximeters. Two simple shielding methods were evaluated.
METHODS: Twenty
healthy, adult, nonsmoking volunteers were equipped with six different pulse
oximeters on both hands. Baseline values for heart rate, arterial oxygen saturation,
and signal quality were assessed. After activation of the Brain Lab
VectorVision Neuronavigation System, the effects on signal quality and saturation
recognition were evaluated. Measurements were repeated using two different
shielding techniques, a cotton blanket and aluminum sheets.
RESULTS: Activation
of the image guidance system resulted in a significant disturbance of signal
quality and saturation detection, which was partially reversible by both
shielding techniques. Significant differences were noted among the six brands
of pulse oximeters for signal quality (P 〈0.001) and saturation recognition (P 〈0.001),
and for the response to shielding methods (P〈0.001).Coverage of the probes with
aluminum foil resulted an in undisturbed saturation recognition in all subjects
with almost all monitors.
CONCLUSIONS: Infrared
pulse waves from neurosurgical navigation equipment may interfere with pulse
oximeter measurements. Shielding the probe with aluminum foil sufficiently
eliminated the infrared interference.
Coronary Artery Stents: II. Perioperative Considerations
and Management
Lisa T. Newsome, MD, DMD*, Robert S. Weller, MD*, J. C. Gerancher, MD*, Michael A. Kutcher, MD*, and Roger L. Royster, MD*
From the Departments of *Anesthesiology and _files/image020.gif){kind=small}
Cardiology
(Interventional Cardiology), Wake Forest University School of Medicine,
Winston-Salem, North Carolina.
Anesth Analg 2008;
107:570-590
装有冠状动脉支架的患者的围手术期管理，是临床医生所需面对的关系到患者生命安全的要点之一。无论是裸金属还是药物洗脱支架，围手术期支架血栓都是危及患者生命的严重并发症。非心脏手术似乎增加支架血栓、心肌梗死及死亡风险，特别是支架植入术后早期即接受手术的患者。术前停止双抗血小板治疗将进一步增加并发症发生可能。通常认为，除外出血风险显著大于继续的抗凝治疗，阿司匹林应在整个围手术期持续使用。我们建议局麻，因为术后是围手术期支架血栓发生可能最大的阶段。一旦发生支架血栓，24小时内患者应被送入心脏介入室，立即经皮冠状动脉介入治疗是治疗围手术期支架血栓的有效疗法。本文最后提出了围手术期裸金属及药物洗脱支架植入患者的不同处理建议。
(施颖译 薛张纲校)
The management of patients with coronary artery stents
during the perioperative period is one of the most important patient safety
issues clinicians confront. Perioperative stent thrombosis is a life-threatening
complication for patients with either bare-metal or drug-eluting stents.
Noncardiac surgery appears to increase the risk of stent thrombosis, myocardial
infarction, and death, particularly when patients undergo surgery early after
stent implantation. The incidence of complications is further increased when
dual-antiplatelet therapy is discontinued preoperatively. It is generally
agreed that aspirin must be continued throughout the perioperative period,
except in circumstances when the risk of bleeding significantly outweighs the
benefit of continued anticoagulation, such as procedures performed in a closed
space. We present considerations for regional anesthesia, as well as
postoperative recommendations as the occurrence of perioperative stent thrombosis
appears to be greatest during this period. Immediate percutaneous coronary
intervention is the definitive treatment for perioperative stent thrombosis,
and 24-h access to an interventional cardiology suite should be readily
available. Algorithms for perioperative management of patients with bare-metal
and drug-eluting stents are proposed.
Pulmonary Effects of Noninvasive Ventilation Combined
with the Recruitment Maneuver After Cardiac Surgery
Serdar Celebi, Özge Köner, Ferdi Menda, Oguz Omay, Ilhan
Günay, Kaya Suzer, and Nahit Cakar
From the *Department of Anesthesiology and Intensive Care,
Bakent University; Department of Anesthesiology and Intensive Care, Yeditepe
University Hospital; Department of Cardiovascular Surgery, Bakent University;
Department of Cardiovascular Surgery, Cardiology Institute, Istanbul
University; and ||Department of Anesthesiology and Intensive Care, Istanbul
University, Istanbul, Turkey.
Anesth Analg 2008;
107:614-619
背景：该研究的目标是评估开放性心脏手术后无创通气(NIV)结合或不结合肺复张疗法（RM）的肺效应。
方法 :100名冠脉旁路术后的病人被随机分为4组。1）术后机械通气结合持续膨肺的RM (RM
组, n = 25) 2）手术结束拔管后第一天里无创通气每6小时给与半小时的RM
(RM-NIV 组, n = 25) 3）拔管后NIV
(NIV 组, n = 25) 4）控制组，由不接受NIV和RM的病人组成(控制组,
n = 25)。各组间比较肺功能测试，氧指数，和胸片下的肺膨胀不全的情况。
结果：机械通气期间的RM和拔管后的RM比其他干涉提供了更高的脉氧饱和度。RM-NIV 和NIV组在研究最后的氧饱和度比控制组好。控制组术后肺膨胀不全评分(均数:
1)比 RM组高(1; P = 0.03), 比RM-NIV高
(0; P < 0.01)，比NIV组高
(0; P < 0.01)。NIV组在术后第二天的肺功能比其他组好，而术后第七天这一结果在各组之间差不多。
结论：NIV结合RM在机械通气期间和之后都提供更高的氧饱和度。NIV或结合RM的. NIV 比控制组提供更低的肺膨胀不全评分和更好的早期肺功能测试结果，而是否在机械通气期间，是否在加护病房和住院天数对此没有显著影响。心脏手术后采用NIV结合RM疗法有助于预防肺膨胀不全和低氧血症。
（孙鹏飞译 薛张纲校）
BACKGROUND: The aim of our study was to evaluate the pulmonary
effects of noninvasive ventilation (NIV) with or without recruitment
maneuver (RM) after open heart surgery.
METHODS: One-hundred patients undergoing coronary artery
bypass surgery were randomized into four groups after the operation:
1) RM with sustained inflation during mechanical ventilation postoperatively
(RM group, n = 25); 2) RM combined with NIV applied
for 1/2-h periods every 6 h in the first postoperative day after
tracheal extubation (RM-NIV group, n =
25); 3) NIV after tracheal extubation (NIV group, n = 25); and 4) a control group consisting
of patients receiving neither RM nor NIV (control group, n = 25). Pulmonary function tests, oxygenation index,
and atelectasis on chest radiograph were evaluated and compared among
the groups.
RESULTS: RM provided higher arterial oxygen levels during
mechanical ventilation and after tracheal extubation compared to
other interventions. Oxygenation was better in the RM-NIV and NIV
groups than in the control group (P = 0.02 and P = 0.008, respectively) at the end of the
study. The postoperative atelectasis score of the control group
(median: 1) was higher than those of the RM (1; P = 0.03), RM-NIV (0; P < 0.01) and NIV (0; P < 0.01) groups. Pulmonary function of
the NIV groups on postoperative day 2 was better than in the other
groups, whereas the tests were similar among the groups on
postoperative day 7.
CONCLUSIONS: NIV associated with RM provided better oxygenation
both during and after the mechanical ventilation period. NIV either
alone or in combination with RM provided lower atelectasis scores
and better early pulmonary function tests compared to the control
group, without a significant difference regarding the duration of
mechanical ventilation, intensive care unit stay, and the length of
hospitalization. NIV combined with RM is recommended after open
heart surgery to prevent postoperative atelectasis and hypoxemia.
A Study of Cognitive Dysfunction in Patients Having
Carotid Endarterectomy Performed with Regional Anesthesia
Eric J. Heyer, MD, PhD, Mark I. Gold, MD, E. Will Kirby, BA,
Joseph Zurica, BA, Elizabeth Mitchell, BA, Hadi J. Halazun, BA, Lauren
Teverbaugh, BA, Robert R. Sciacca, EngScD, Robert A. Solomon, MD, Donald O.
Quest, MD, Thomas S. Maldonado, MD, Thomas S. Riles, MD, and E. Sander
Connolly, Jr, MD
Anesth Analg 2008
107: 636-642.
背景：既往研究发现，与对照组相比，在全身麻醉下接受颈动脉内膜剥脱术（CEA）的患者中约25％在术后1天到一个月内发生认知功能障碍。在本次研究中，我们假定，与接受镇静治疗的对照组相比，在区域麻醉下接受CEA术的患者会在术后1天出现认知功能障碍。
方法：为验证假设，我们招收60名患者加入前瞻性研究。在区域麻醉下行CEA术的41位患者接受颈深丛及浅丛神经阻滞。对照组由19位在镇静治疗下接受冠状动脉造影术或支架术的患者组成。为解决重复进行认知水平测验而引起的“练习效果”问题，对照组是必不可少的。实验组患者来源于纽约医学研究中心，对照组患者来源于哥伦比亚长老会医学研究中心。所有患者的认知水平经由一系列既经证实有效的神经心理学测验评估。术后一天与术前相比的差异性表现由事件发生率和群组发生率来评价。
结果：术后一天，在区域麻醉下接受CEA术的患者中有24.4% 发生显著的认知功能障碍，此处的“显著”定义为比对照组的平均评分低两个标准差以上。
结论：在区域麻醉下接受CEA术的患者有发生术后认知功能障碍的可能，其几率与以往报导过的全麻下CEA术者没有明显差别。
（夏俊明译 薛张纲校）
METHODS: To test this hypothesis, we
enrolled 60 patients in a prospective study. CEA regional was
performed with superficial and deep cervical plexus blocks in 41
patients. The control group consisted of 19 patients having coronary
angiography or coronary artery stenting performed with sedation. A
control group is necessary to account for the "practice
effect" associated with repeated cognitive testing. The
patients from the CEA regional group were enrolled at New York
Medical Center and the control group at Columbia-Presbyterian
Medical Center. The cognitive performance of all patients was
evaluated using a previously validated battery of neuropsychometric
tests. Differences in performance, 1 day after compared with before
surgery, were evaluated by both event-rate and group-rate analyses.
BACKGROUND: In
previous studies, we found that approximately 25% of patients having
carotid endarterectomy with general anesthesia (CEA general) develop
cognitive dysfunction compared with a surgical control Group 1 day
and 1 mo after surgery. In this study, we tested the hypothesis that
patients having CEA with regional anesthesia (CEA regional) will
develop significant cognitive dysfunction 1 day after surgery
compared with a control group of patients receiving sedation 1 day
after surgery. We did not study persistence of dysfunction.
RESULTS: On
postoperative day 1, 24.4% of patients undergoing CEA regional had
significant cognitive dysfunction, where "significant" was
defined as a total deficit score _files/image022.gif){kind=small}
2
SD worse than the mean performance in the control group.
CONCLUSIONS: Patients
undergoing CEA regional had an incidence of cognitive dysfunction
which was not different than patients having CEA general as
previously published and compared with a contemporaneously enrolled
group.
使用帕瑞考昔钠20mg一天两次的多日用药法能减轻全髋置换术后的疼痛
A Multiple-Day Regimen of
Parecoxib Sodium 20 mg Twice Daily Provides Pain Relief After Total Hip
Arthroplasty
Viscusi, Eugene R. MD; Gimbel, Joseph S. MD; Halder, Andreas
M. MD, PhD; Snabes, Michael MD, PhD; Brown, Mark T. MD; Verburg, Kenneth M. PhD
Michael Snabes is currently at MCS Medical Consulting,
Winnetka, Illinois
From the *Department of Anesthesiology, Jefferson Medical
College, Thomas Jefferson University, Philadelphia, Pennsylvania; _files/image023.gif){kind=small}
Arizona
Research Center, Phoenix, Arizona; _files/image024.gif){kind=small}
Klinik
für Endoprothetik, Waldhausstrasse, Sommerfeld, Germany; _files/image025.gif){kind=small}
Pfizer
Global Research and Development, Skokie, Illinois; and ||Pfizer Global Research
and Development, New London, Connecticut.
Anesth Analg 2008
107: 652-660.
背景：这项多中心、多种剂量、随机、双盲、平行分组的研究比较了在全髋置换术后使用帕瑞考昔钠（帕瑞考昔）的两种给药方案对照安慰剂组的止痛效果和安全性。
方法：在第一试验日，490名患者在术后得到静脉注射帕瑞考昔40mg的起始负荷剂量，随后对490名患者中的484名再次使用帕瑞考昔20mg。第二试验日随机挑选479名患者进行双盲治疗：帕瑞考昔20mg
bid组（n=159），使用安慰剂后使用帕瑞考昔20mg qd组（n=159）和安慰剂组（n=161）。
结果：帕瑞考昔20mg bid治疗组的病人在第2到5天比安慰剂组病人显示明显低的24小时总疼痛强度（SPI-24）评分和改善的病人的药物治疗研究的全球评价（PGESM）等级（P<0.05）。帕瑞考昔20mg
qd治疗组的病人在第3、4天的SPI-24评分比安慰剂组显著的低（P<0.05），PGESM评级在第5天比安慰剂组改善。除了发热、呕吐和注意力不集中在安慰剂组中较其他帕瑞考昔治疗组更为常见（P<0.05），不良事件的发生率在所有治疗组中相似。
结论：帕瑞考昔20mg一天一次或两次的多日给药法在全髋置换术后是有效和普遍耐受的。
（宣丽真译
薛张纲校）
BACKGROUND:
This
multicenter, multiple-dose, randomized, double-blind, parallel-group study
compared the analgesic efficacy and safety of two dosing regimens of parecoxib
sodium (parecoxib) versus placebo after total hip arthroplasty.
METHODS: On study Day 1, 490 patients received a postoperative
initial loading dose of IV parecoxib 40 mg, followed by a re-dose of parecoxib
20 mg in 484 of 490 patients. Subsequently, 479 randomized patients received
double-blind treatment with parecoxib 20 mg bid (n = 159), parecoxib 20 mg qd (n = 159) followed by placebo, or placebo (n = 161) on Day 2.
RESULTS: Patients treated with parecoxib 20 mg bid reported
significantly lower summed pain intensity over 24 h (SPI-24) scores and
improved patients’ global evaluation of study medication (PGESM) ratings
compared with placebo-treated patients on Days 2 to 5 (P < 0.05). For patients treated with parecoxib 20 mg
qd, SPI-24 scores were significantly lower on Days 3 and 4 (P < 0.05), and PGESM ratings significantly improved on
Day 5 compared with placebo. The incidence of adverse events was similar in all
treatment groups with the exception of fever, vomiting and impaired
concentration, which were significantly more common in the placebo group
compared with one or other of the parecoxib treatment groups (P < 0.05).
CONCLUSION: Multiple-day administration of parecoxib 20 mg once or
twice daily is effective and generally well tolerated after total hip
arthroplasty.
A
Dose-Ranging Study of Intraarticular Midazolam for Pain Relief After Knee
Arthroscopy
Yatindra Kumar Batra, MD, MNAMS, FAMS*, Rajesh Mahajan, MD*, Sushil Kumar, MD*, Subramanyam Rajeev, MD, DNB*, and Mandeep Singh Dhillon, MS
From
the Departments of *Anaesthesia and Intensive Care and _files/image026.gif){kind=small}
Orthopaedic
Surgery, Postgraduate Institute of Medical Education and Research,
Chandigarh-160012, India.
Anesth Analg 2008 107: 669-672.
背景： 各种各样的镇痛药技术被用于在关节镜膝盖手术以后处理手术后痛苦。
关节腔内使用咪达唑仑的镇痛作用和中枢神经内使用咪达唑仑的镇痛作用相似。
方法： 对60名ASA
I或II级的接受关节镜检查的患者实行全身麻醉，并随机化接受关节腔内注射咪达唑仑50 µg/kg，75 µg/kg或者等渗盐。我们通过以下几个方面评估镇痛药的效果:直观镇痛评分、首次要求镇痛的时间、累计镇痛药的消耗。患者总共观察48
h。
结果：相比于等渗盐，早期关节腔内注射咪达唑仑可以明显降低直观镇痛评分。两药量都可以延长首次要求镇痛的时间(4.7 和4.6 vs 0.7 h)。使用两种剂量的药物对于累计镇痛药的消耗方面没有统计学的差异。
结论： 我们认为，在关节镜手术后，相比于安慰剂，关节腔内注射咪达唑仑可以减轻术后疼痛， 然而这种镇痛作用镇痛是相对短期的。
（章一静译 薛张纲校）
BACKGROUND: A variety of analgesic techniques have been
used to manage postoperative pain after arthroscopic knee surgery. Intraarticular
midazolam may have an analgesic effect similar to that seen when midazolam is
used in a centroneuraxial fashion.
METHODS: Sixty ASA status I or II patients undergoing knee
arthroscopy with general anesthesia were randomized to receive intraarticular
midazolam 50 µg/kg, 75 µg/kg, or isotonic saline. We assessed the efficacy of
the analgesic technique with visual analog scale pain scores, time until first request for analgesics,
and cumulative analgesic consumption. Patients were observed for 48 h.
RESULTS: The addition of intraarticular midazolam
significantly reduced visual analog pain scores in the early postoperative
period compared with saline. Both doses similarly prolonged duration until
first request for analgesic compared with saline (4.7 and 4.6 vs 0.7 h). There
was no statistically significant difference between the two doses of midazolam
or cumulative 48 h analgesic consumption.
CONCLUSIONS: We conclude that when intraarticular midazolam was
compared with placebo there was a reduction in pain after day-case arthroscopic
knee surgery; however, this pain relief was of relatively short duration
鞘内注射可乐定可以抑制小鼠脊髓背侧脚神经元的N－甲基－D－天门冬氨酸受体NR1磷酸化引起的神经性疼痛
Intrathecal Clonidine Suppresses Phosphorylation of the
N-Methyl-D-Aspartate Receptor NR1 Subunit in Spinal Dorsal Horn Neurons of Rats
with Neuropathic Pain
Dae-Hyun Roh, DVM, MS*, Hyun-Woo Kim, DVM, PhD_files/image027.gif){kind=small}
,
Seo-Yeon Yoon, DVM, PhD*, Hyoung-Sig Seo, DVM, MS*, Young-Bae
Kwon, DVM, PhD_files/image028.gif){kind=small}
,
Ho-Jae Han, DVM, PhD_files/image029.gif){kind=small}
,
Alvin J. Beitz, PhD||, and Jang-Hern Lee, DVM, PhD*
From the *Department of Veterinary Physiology, College of
Veterinary Medicine and BK21 Program for Veterinary Science, Seoul National
University, Seoul, South Korea; _files/image030.gif){kind=small}
Department
of Physiology, College of Medicine, Chungnam National University, Daejeon,
South Korea; _files/image031.gif){kind=small}
Department
of Pharmacology, Institute for Medical Science, Chonbuk National University
Medical School, Jeonju, South Korea; _files/image032.gif){kind=small}
Biotherapy
Human Resources Center, College of Veterinary Medicine, Chonnam National
University, Gwang-ju, South Korea; and ||Department of Veterinary and
Biomedical Sciences, College of Veterinary Medicine, University of Minnesota,
St Paul, MN.
Anesth Analg 2008
107: 693-700.
背景：鞘内注射α受体拮抗剂可乐定有镇痛的效果。尽管有一些关于可乐定相关的镇痛机制假设，但是作为主要抗伤害性刺激机制的N－甲基－D－天门冬氨酸(NMDA)受体，其与可乐定作用的关系尚没有很多研究。我们设计了这个试验来研究可乐定或者其他镇痛药物是否可以影响小鼠脊髓NMDA受体，从而缓解慢性缩窄性损伤(CCI)引起的神经病症状。
方法：单侧CCI的小鼠分别鞘内注射可乐定（1，5，20ug/小鼠），[d- 丙氨酸2, N甲基烟酰胺-苯丙氨酸4,
甘氨酸-ol5]-脑啡肽 (DAMGO, µ 阿片受体拮抗剂, 1 µg/小鼠)，加巴喷丁（抗惊厥药物，100 µg/小鼠）。注射之后，我们测定了小鼠对热或机械刺激的痛觉反应，并使用免疫组化评估脊髓磷酸化的NMDA受体亚单位1（pNR1）的表达。
结果：CCI手术后两周，小鼠表现出对热和机械刺激的异常痛觉敏感，脊髓背侧脚的pNR1神经元的表达也增加。鞘内注射可乐定(20
µg/小鼠)，DAMGO和加巴喷丁可以潜在降低机械或热刺激引起的痛觉反应。重要的是，鞘内注射可乐定，但是不注射DAMGO和加巴喷丁，在注射后30min可以剂量依赖性的降低CCI导致的脊髓背侧脚的pNR1的表达。另外，可乐定可以抑制CCI导致的脊髓背侧角NR1磷酸化，但是在注射可乐定之前10min，鞘内注射α－2受体拮抗剂咪唑克生(40 µg/小鼠)，可以完全逆转其对抗痛觉过敏的效果。
结论：我们的数据显示，鞘内注射可乐定的对抗痛觉过敏的作用与降低脊髓NMDA受体磷酸化有关，并提示可乐定的潜在的作用机制。
（陈珺珺译 薛张纲校）
BACKGROUND: Intrathecal
(IT) administration of the _files/image034.gif){kind=small}
-2
adrenoceptor agonist, clonidine, produces significant analgesic
effects. Although several mechanisms underlying clonidine-induced
analgesia have been proposed, the possible interaction with
N-methyl-D-aspartate (NMDA) receptors as a major antinociceptive
mechanism has not been addressed. We designed the present study to
determine whether clonidine or other analgesics can affect spinal
NMDA receptor activation in rats with chronic constriction injury
(CCI)-induced neuropathy.
METHODS: Rats
underwent unilateral CCI, and received IT clonidine (1, 5, 20
µg/rat), [d-Ala2, NMe-Phe4, Gly-ol5]-enkephalin (DAMGO, µ opioid
receptor agonist, 1 µg/rat), gabapentin (anticonvulsant, 100 µg/rat)
or vehicle 2 wks later. After drug injection, we measured the pain
response to thermal or mechanical stimuli and used
immunohistochemistry to evaluate spinal cord phosphorylated
NMDA-receptor subunit 1 (pNR1) expression.
RESULTS: Two weeks
after CCI surgery, rats displayed significant mechanical allodynia
and thermal hyperalgesia, and the spinal cord dorsal horn showed a
significant increase in the number of pNR1 immunoreactive neurons.
IT injection of clonidine (20 µg/rat), DAMGO and gabapentin potently
reduced mechanical allodynia and thermal hyperalgesia. Importantly,
IT clonidine, but not IT DAMGO or gabapentin, dose-dependently
reduced CCI-induced pNR1 expression in all lamina of the spinal cord
dorsal horn by 30 min after injection. In addition, IT injection of
the _files/image035.gif){kind=small}
-2
adrenoceptor antagonist, idazoxan (40 µg/rat) 10 min before
clonidine injection completely reversed clonidine’s anti hyperalgesic
and anti allodynic effects, as well as clonidine’s suppressive
effect on CCI-induced NR1 phosphorylation in the spinal cord dorsal
horn.
CONCLUSIONS: Our
data indicate that IT clonidine’s antihyperalgesic/antiallodynic effect
on neuropathic pain is associated with a significant reduction in
spinal NMDA receptor phosphorylation and suggests a potentially
novel mechanism of clonidine’s action.
儿童心脏手术人群中抗肝素-血小板因子4抗体的形成的发病率和意义
The Incidence and Implications of Anti-Heparin-Platelet
Factor 4 Antibody Formation in a Pediatric Cardiac Surgical Population
Mary P. Mullen, MD, PhD*_files/image036.gif){kind=small}
,
David L. Wessel, MD*_files/image037.gif){kind=small}
,
Kristen C. Thomas, MS, RN*, Kimberlee Gauvreau, ScD*_files/image038.gif){kind=small}
,
Ellis J. Neufeld, MD, PhD*_files/image039.gif){kind=small}
,
Francis X. McGowan, Jr, MD*_files/image040.gif){kind=small}
,
and James A. DiNardo, MD*_files/image041.gif){kind=small}
From the *Children's Hospital Boston and _files/image042.gif){kind=small}
Harvard
Medical School, _files/image043.gif){kind=small}
Harvard
School of Public Health, Boston, Massachusetts.
Anesth Analg 2008
107: 371-378.
背景：儿童心脏手术人群中血清抗肝素-血小板因子4抗体的发病率和意义仍未阐明。作者前瞻性研究以下两种群体中血清转化的发生率：首次施行心脏手术的新生儿以及有普通肝素使用史的再次心脏手术儿童。
方法：研究连续135名患者：新生儿组：60名新生儿，第一次心脏外科手术；再次手术组：75名，再次心脏手术者。分别对术前和术后5天及10天的血液样本进行酶联免疫吸附试验，从而确认是否有PF4免疫球蛋白G、A、M抗体。
结果：两组患者术前均未检测到抗肝素/抗肝素-血小板因子4抗体。在术后5天新生儿组1名患者（1.7%）检测到抗体；再次手术组12名患者（16%）检测到抗体；组间差异显著（P=0.006）。术后10天，新生儿组1名患者（1.7%）检测到抗体；再次手术组39名患者（52%）检测到抗体（P<0.001）。再次手术组的患者术后10天的血清与普通肝素使用史间有良好的相关性（P=0.003）。在任一新生儿组的患者中，未发现肝素诱导的血小板减少症（HIT）。再次手术组中一名患者（1.3%）发生了血清转化并发生了HIT，但没有发生血栓或者皮肤病损。
结论：HIT在儿童心脏手术患者中鲜有发生。在再次手术的儿童中，术后10天的抗肝素-血小板因子4抗体血清转化的发病率大约为50%，在成人心脏外科手术患者中有相似的发现。年龄和普通肝素使用史与此血清转化率有关。相反，新生儿初次手术组中血清转化率比较低。
（朱紫瑜 译 陈杰 校）
BACKGROUND: The
incidence and implications of anti-heparin-platelet factor 4 (PF4)
antibody seroconversion in the pediatric cardiac surgical population
remain largely unexplored. We sought to prospectively characterize
the incidence of seroconversion in two populations: neonates
undergoing primary cardiac surgery and children undergoing
reoperative cardiac surgery with a history of unfractionated heparin
(UFH) exposure.
METHODS: One hundred
and thirty-five consecutive patients were studied: Neonatal = 60
neonates, first time cardiac surgery. Reoperative (ReOp) = 75
children, reoperative cardiac surgery. Preoperative and
postoperative day (POD) 5 and 10 blood samples were used to
determine the presence of PF4 immunoglobulin (Ig)G, IgA, and IgM
antibodies with enzyme-linked immunosorbent assay.
RESULTS: No
anti-heparin/PF4 antibodies were detected preoperatively in either
group. On POD 5, antibodies were present in 1 of 60 (1.7%) Neonatal;
and in 12 of 75 (16%) ReOp; P = 0.006. On POD 10,
antibodies were present in 1 of 60 (1.7%) Neonatal; and in 39 of 75
(52%) ReOp; P < 0.001. Seroconversion
in ReOp patients on POD 10 was significantly associated (P = 0.03) with previous UFH exposures.
Heparin-induced thrombocytopenia (HIT) was not diagnosed in any
Neonatal patients. One ReOp patient (1.3%) seroconverted and
developed HIT without thrombosis or skin lesions.
CONCLUSIONS: HIT is
a rare occurrence in pediatric cardiac surgical patients. The
incidence of anti-heparin-PF4 antibody seroconversion in children
undergoing reoperation is approximately 50% at 10 days
postoperatively, a finding similar to that reported in adult cardiac
surgical patients. Both age and previous UFH exposure correlate with
this rate of seroconversion. In contrast, the rate of seroconversion
in neonates undergoing first time surgery is substantially lower.
Factors Predictive of Poor Behavioral Compliance During
Inhaled Induction in Children
Anna M. Varughese, MD, MPH*_files/image044.gif){kind=small}
,
Todd G. Nick, PhD_files/image045.gif){kind=small}
_files/image046.gif){kind=small}
,
Joel Gunter, MD*_files/image047.gif){kind=small}
,
Yu Wang, MS_files/image048.gif){kind=small}
,
and C. Dean Kurth, MD*_files/image049.gif){kind=small}
From the *Department of Anesthesiology; _files/image050.gif){kind=small}
Department
of Pediatrics, Cincinnati Children's Hospital Medical Center, University of
Cincinnati College of Medicine; and _files/image051.gif){kind=small}
Center
for Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical
Center, Cincinnati, Ohio.
Anesth Analg 2008
107: 413-421.
背景：术前确定小儿吸入麻醉诱导期间有情绪痛苦及不良行为依从有助于进行定向干预以减少痛苦，从而改善麻醉质量。本文作者探索了识别患者、操作、健康护理系统等因素预测诱导期间不良行为依从的方法。
方法：选择861名发育正常的1-13岁，ASAI-III级，进行吸入麻醉诱导的小儿。所有的麻醉诱导在诱导室中由父母陪伴下完成。行为习惯通过ICC评估，即一种观察量表，测定诱导期间对行为进行观察所获得的数值，ICC≥4认为行为顺从性差。行为依从性通过一个多变量定向逻辑回归模型取得，多变量模型特征由c统计法评估。
结果：21%小儿在麻醉诱导时出现不良行为依从。年龄小（<4y, p<0.001），术前准备时间短（p=0.004）, 术前焦虑（修订的耶鲁术前焦虑标准>40；p=0.016）等因素增加了不良行为依从可能性。先前的麻醉经历增加了学龄儿童的可能性（p=0.046）；这种影响在参加术前培训的孩子中有所改善（p=0.018）。这些因素在有不良行为依从与良好的行为依从（ICC=0）（c统计=0.75)的孩子间有差异。
结论：不良行为依从的预测因子有年龄，先前的麻醉经历，以及在术前门诊进行的术前培训，术前准备时间及焦虑程度等。包含这些因子的预测程序，有助于分辨能从行为或药理干预受益的孩子以及不需要干预的低风险的孩子。
（潘钱玲 译 陈杰 校）
BACKGROUND: Preoperative
identification of children at risk of emotional distress and poor
behavioral compliance during inhaled induction of anesthesia allows
targeted interventions to reduce distress, thereby enhancing the
quality of the anesthetic experience. We sought to identify patient,
procedural, and health care system factors predictive of poor
behavioral compliance during induction.
METHODS: We studied
861 developmentally appropriate children ages 1–13 yr, The American
Society of Anesthesiologists physical status I to III, presenting
for inhaled induction of anesthesia. All inductions were performed
in an induction room with parent(s) present. Behavioral compliance
was assessed using the Induction Compliance Checklist (ICC), an
observational scale consisting of 10 behaviors scored as the number
of behaviors observed during induction; ICC _files/image052.gif){kind=small}
4
was considered poor behavioral compliance. A multivariable ordinal logistic
regression model for behavioral compliance was generated and the
performance of the multivariable model was evaluated by the c
statistic.
RESULTS: Twenty-one
percent of children exhibited poor behavioral compliance on
induction. Factors increasing the odds of poor behavioral compliance
were younger age (<4 yr, P < 0.0001), shorter
preoperative preparation time (P =
0.004), and high anxiety levels in the preoperative clinic
(modified-Yale preoperative anxiety scale >40; P = 0.016). Previous anesthesia experience increased
the odds in school-age children (P
= 0.046); this effect was ameliorated in children attending the
preoperative tour (P =
0.018). The model using these factors demonstrated moderate
discrimination between children with poor compliance and those with
perfect compliance (ICC = 0) (c
statistic = 0.75).
CONCLUSIONS: Factors
predictive of poor behavioral compliance were age, previous
anesthesia, preoperative tour attendance, preoperative preparation
time and anxiety levels in the preoperative clinic. These factors,
bundled into a predictive algorithm, may help identify children who
could benefit from behavioral or pharmacological interventions and
avoid use of interventions to those at low risk.
一项随机双盲研究：评估三种不同剂量的帕洛诺司琼与安慰剂对预防术后恶心呕吐的有效性与安全性
A Randomized, Double-Blind Study to Evaluate the Efficacy
and Safety of Three Different Doses of Palonosetron Versus Placebo for
Preventing Postoperative Nausea and Vomiting
Keith A. Candiotti, MD*, Anthony L. Kovac, MD_files/image053.gif){kind=small}
,
Timothy I. Melson, MD_files/image054.gif){kind=small}
,
Giuseppina Clerici, MD_files/image055.gif){kind=small}
,
Tong Joo Gan, MB, FRCA||, and The Palonosetron 04–06 Study Group
From the *Departments of Anesthesiology, Perioperative
Medicine and Pain Management, University of Miami, Miami, Florida; _files/image056.gif){kind=small}
Department
of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas; _files/image057.gif){kind=small}
Helen
Keller Memorial Hospital, Sheffield, Alabama; _files/image058.gif){kind=small}
Research
and Development Department, Helsinn Healthcare SA, Lugano, Switzerland; and ||Department
of Anesthesiology, Duke University Medical Centre, Durham, North Carolina.
Anesth Analg 2008
107: 445-451.
背景：为了评估三种剂量的新型5-HT3受体阻滞剂---帕洛诺司琼的有效性及安全性，作者进行这一随机双盲研究，观察术后72小时的PONV(术后恶心呕吐)发病率及严重程度。
方法：作者对574名门诊腹部手术或腹腔镜下行妇科手术病人，根据其性别、有无PONV史、有无运动病、是否吸烟分层。有≥2项PONV危险因素的病人入组并在麻醉诱导前即刻随机静脉予以三种剂量（0.025mg、0.05mg、0.075mg）帕洛诺司琼中一种或安慰剂。随后观察帕洛诺司琼的主要疗效指标（co-primary efficacy end-points）包括术后0-24小时、24-72小时两个时段的完全缓解率（指无呕吐及不需补救药物，CR）。
结果：部分病人在第一个24小时出现与帕洛诺司琼剂量相关的CR。而在术后0-24小时这一时段安慰剂及帕洛诺司琼（0.075mg）的CR率分别为26%及43%（P=0.004），在术后24-72小时，安慰剂及帕洛诺司琼（0.075mg）的CR率分别为41%及49%（P=0.188）。与安慰剂相比帕洛诺司琼（0.075mg）可以显著降低严重恶心发生率（P=0.042）及减轻术后0-24小时内PONV对病人的影响（P=0.004）。
结论：帕洛诺司琼（0.075mg）能显著降低术后0-24小时内的CR率，减轻恶心程度，减少病人术后PONV的发生。
（陶颖莹 译 陈杰 校）
BACKGROUND: In this
randomized, double-blind study we assessed the efficacy and safety
of three different doses of the 5-HT3 receptor antagonist
palonosetron, compared with placebo, on the incidence and severity
of postoperative nausea and vomiting (PONV) for 72 h postsurgery.
METHODS: Five
hundred seventy-four patients undergoing either outpatient abdominal
or gynecological laparoscopic surgery were stratified according to
gender, history of PONV or motion sickness, and nonsmoking status.
Patients with _files/image059.gif){kind=small}
2
PONV risk factors were eligible and randomized to receive one of
three doses of IV palonosetron (0.025 mg, 0.050 mg, or 0.075 mg) or
placebo immediately prior to induction of anesthesia. Co-primary
efficacy end-points included complete response (CR: no emetic
episodes and no rescue medication) during the 0 to 24 h and 24 to 72
h postoperative time intervals.
RESULTS: A
dose-response trend in the proportion of patients with a CR was
observed with increasing doses of palonosetron in the first 24 hrs.
CR rates for placebo and palonosetron 0.075 mg were 26% and 43%,
respectively, for the 0 to 24 h postoperative interval (P
= 0.004), and 41% and 49%, respectively, for the 24 to 72 h interval
(P = 0.188). Compared with placebo,
palonosetron 0.075 mg was associated with a significant downward
shift toward less intense nausea (P = 0.042) and with significant reduction in
the impact of PONV on patient functioning (P = 0.004) during the 0 to 24 h interval.
CONCLUSIONS: A
single 0.075-mg IV dose of palonosetron significantly increased the
CR rate (no emetic episodes and no rescue medication) from 0 to 24
h, decreased nausea severity and patients experienced significantly
less interference in their postoperative function due to PONV.
帕诺斯琼在分子水平与5-羟色胺受体间独特的相互作用
Palonosetron Exhibits Unique Molecular Interactions with
the 5-HT3 Receptor
Camilo Rojas, PhD*, Marigo Stathis, MS*,
Ajit G. Thomas, MSE*, Edward B. Massuda, MS*, Jesse Alt,
BS*, Jie Zhang, PhD*, Ed Rubenstein, MD_files/image060.gif){kind=small}
,
Silvia Sebastiani, PhD_files/image061.gif){kind=small}
,
Sergio Cantoreggi, PhD_files/image062.gif){kind=small}
,
Solomon H. Snyder, MD||, and Barbara Slusher, PhD*
From the *Research and Translational Development, MGI PHARMA
INC, Baltimore, MD; _files/image063.gif){kind=small}
Medical
& Scientific Affairs, MGI PHARMA INC, Bloomington, Minnesota; _files/image064.gif){kind=small}
Medical
Marketing, HELSINN HEALTHCARE SA, Lugano, Switzerland; _files/image065.gif){kind=small}
Research
and Development, HELSINN HEALTHCARE SA, Lugano, Switzerland; and ||Department
of Neuroscience, Johns Hopkins Medical School, Baltimore, Maryland.
Anesth
Analg 2008 107:469-478
背景：在Ⅲ期临床试验中，与其它5-羟色胺受体拮抗剂相比，帕诺斯琼被证实能更有效地预防急性、迟发性，及其它由化疗所引发的恶心和呕吐。帕诺斯琼强大的临床效力可能部分源于它有更长的半衰期，及其与受体间更大的亲和力。然而，帕诺斯琼的这些特性并不足以解释它的药效。作者试图进一步阐明不同5-羟色胺受体间的差异，希望这有助于解释临床的观察结果。
方法：作者用3H-帕诺斯琼、3H-格拉琼斯和3H-奥坦西隆进行受体位点饱和结合试验，以获得相应的Scatchard分析和Hill系数。通过诊断性平衡结合试验和动力学解离试验，评价帕诺斯琼、格拉琼斯和奥坦西隆与5-羟色胺受体间的相互竞争和变构作用。最后，比较了三种拮抗剂对受体功能的长期效应，通过检测表达5-羟色胺受体的HEK293细胞内的钙内流实现的。
结果：通过Scatchard和Hill曲线分析结合等温线，作者发现单一双分子结合的格拉琼斯和奥坦西隆与帕诺斯琼之间存在协同效应。平衡诊断试验表明帕诺斯琼对3H配体有不同的结合效应，这说明帕诺斯琼是一种异构性拮抗剂，而格拉斯琼和奥坦西隆是竞争性拮抗剂。通过测定解离速率发现，帕诺斯琼是一种变构的效应物，它能够加快格拉斯琼和奥坦西隆与受体的解离速率。帕诺斯琼与5-羟色胺受体间不同的结合模式影响受体功能的发挥。在这些试验中，用每一种拮抗剂孵化细胞，然后使其无限稀释和解离2.5小时。可以观察到，在用格拉斯琼或奥坦西隆孵化的细胞中出现了与未暴露于5-羟色胺受体的对照组细胞中相似的钙离子内流；与其相反，在用帕诺斯琼孵化的细胞中观察到了强大的钙内流抑制效应。
结论：帕诺斯琼是一种异构性结合剂，当它与5-羟色胺受体结合时，产生协同效应。同时，帕诺斯琼触发的功能性效应的持续时间长于它与细胞表面受体的结合时间。它与受体的结合位点不同，及其导致的不同的受体功能可能与它独特的临床效益相关。作者认为，这是首次在分子水平探讨帕诺斯琼与5-羟色胺受体之间的相互作用，这也是它与其它5-羟色胺受体拮抗剂的截然不同之处。
（周姝婧 译 陈杰 校 ）
BACKGROUND: Palonosetron
is a 5-HT3-receptor antagonist (5-HT3-RA) that
has been shown to be superior to other 5-HT3-RAs in phase III
clinical trials for the prevention of acute, delayed, and overall
chemotherapy-induced nausea and vomiting. The improved clinical
efficacy of palonosetron may be due, in part, to its more potent
binding and longer half-life. However, these attributes alone are
not sufficient to explain the results with palonosetron. We sought
to elucidate additional differences among 5-HT3-RAs that
could help explain the observations in the clinic.
METHODS: Receptor
site saturation binding experiments were performed with [3H]
palonosetron, [3H] granisetron, and [3H] ondansetron
to obtain the corresponding Scatchard analyses and Hill
coefficients. Diagnostic equilibrium binding experiments and kinetic
dissociation experiments were conducted to examine competitive
versus potential allosteric interactions between ondansetron,
granisetron and palonosetron and the 5-HT3 receptor. Finally,
the long-term effect of the three antagonists on receptor function
as measured by Ca2+ influx in HEK 293 cells expressing the
5-HT3-receptor was compared.
RESULTS: Analyses of
binding isotherms using both Scatchard and Hill plots suggested
positive cooperativity for palonosetron and simple bimolecular
binding for both granisetron and ondansetron. Equilibrium diagnostic
tests discriminated differential effects of palonosetron on [3H]
ligand binding indicating that palonosetron was an allosteric
antagonist whereas granisetron and ondansetron were competitive
antagonists. Using dissociation rate strategies, palonosetron was
shown to be an allosteric modifier that accelerated the rate of
dissociation from the receptor of both granisetron and ondansetron.
Differences in the binding mode of palonosetron to the 5-HT3
receptor were shown to have an impact on receptor function. In these
experiments, cells were incubated with each antagonist, followed by
infinite dilutions and dissociation for 2.5 h; cells previously
incubated with either granisetron or ondansetron showed calcium-ion
influx similar to control cells that had not been exposed to a 5-HT3
receptor antagonist. In contrast, substantial inhibition of
calcium-ion influx was observed in cells that had been incubated
with palonosetron.
CONCLUSIONS: Palonosetron exhibited allosteric binding and positive cooperativity when binding to the 5-HT3 receptor. Palonosetron also triggered functional effects that persisted beyond its binding to the 5-HT3 receptor at the cell surface. Differences in binding and effects on receptor function may be relevant to the unique beneficial actions of palonosetron. To our knowledge, this is the first report showing palonosetron's interaction with the 5-HT3 receptor at the molecular level, clearly differentiating it from other 5-HT3-RAs.
协同作用是普遍规律？关于产生催眠和肢体活动消失的麻醉药相互作用的综述
Is Synergy the Rule? A Review of Anesthetic Interactions
Producing Hypnosis and Immobility
Jan F. A. Hendrickx, MD, PhD*, Edmond I. Eger,
II, MD_files/image066.gif){kind=small}
,
James M. Sonner, MD_files/image067.gif){kind=small}
,
and Steven L. Shafer, MD_files/image068.gif){kind=small}
From the *Department of Anesthesia, Stanford University
School of Medicine, Stanford, California; _files/image069.gif){kind=small}
Department
of Anesthesia and Perioperative Care, UCSF; and _files/image070.gif){kind=small}
Department
of Anesthesia, Stanford University School of Medicine, Stanford, CA, and
Department of Biopharmaceutical Science, University of CA at San Francisco, San
Francisco, California.
Anesth Analg 2008
107: 494-506.
背景：药物的相互作用可以揭示药物作用的机制：相加作用提示作用于同一位点，协同作用提示作用于不同位点。笔者应用这一推理回顾了已出版的最终会引起催眠和肢体活动消失的麻醉药物的相互作用。
方法：笔者搜索了Medline上所有的列有下列药物相互作用的原稿：丙泊酚、依托咪酯、美索比妥、硫苯妥钠、咪唑安定、地西泮、氯胺酮、右美托咪定，可乐定、吗啡、芬太尼、舒芬太尼、阿芬太尼、瑞芬太尼、氟哌利多、甲氧氯普胺、利多卡因、氟烷、恩氟醚、异氟醚、七氟醚、地氟醚、N2O和氙气，相互作用包括相加、协同、拮抗、等效。如果可能，数据将应用分数分析和响应面分析。
结果：在不同药物种类之间大多数相互作用是协同作用。氯胺酮是个例外，其主要相互作用是相加或拮抗作用。吸入麻醉药和静脉麻醉药之间主要为协同作用，但也有相加作用或在某些情况下可能是拮抗作用，如笑气和异氟醚。
结论：除了氯胺酮，静脉麻醉药通常作用于不同位点产生协同作用，吸入麻醉药通常和静脉麻醉药之间是协同作用，但吸入麻醉药之间不呈协同作用。
（潘方立 译 陈杰 校）
BACKGROUND: Drug
interactions may reveal mechanisms of drug action: additive
interactions suggest a common site of action, and synergistic
interactions suggest different sites of action. We applied this
reasoning in a review of published data on anesthetic drug
interactions for the end-points of hypnosis and immobility.
METHODS: We searched
Medline for all manuscripts listing propofol, etomidate,
methohexital, thiopental, midazolam, diazepam, ketamine, dexmedetomidine,
clonidine, morphine, fentanyl, sufentanil, alfentanil, remifentanil,
droperidol, metoclopramide, lidocaine, halothane, enflurane,
isoflurane, sevoflurane, desflurane, N2O, and Xe that
contained terms suggesting interaction: interaction, additive,
additivity, synergy, synergism, synergistic, antagonism, antagonistic,
isobologram, or isobolographic. When available, data were reanalyzed
using fraction analysis or response surface analysis.
RESULTS: Between
drug classes, most interactions were synergistic. The major
exception was ketamine, which typically interacted in either an
additive or infra-additive (antagonistic) manner. Inhaled
anesthetics typically showed synergy with IV anesthetics, but were
additive or, in the case of nitrous oxide and isoflurane, possibly
infra-additive, with each other.
CONCLUSIONS: Except
for ketamine, IV anesthetics acting at different sites usually
demonstrated synergy. Inhaled anesthetics usually demonstrated
synergy with IV anesthetics, but no pair of inhaled anesthetics
interacted synergistically.
异丙酚对肝L02细胞的保护作用，激活细胞外信号调节激酶通路减少因过氧化氢引起的细胞凋亡
Propofol Protects Hepatic L02 Cells from Hydrogen
Peroxide-Induced Apoptosis via Activation of Extracellular Signal-Regulated
Kinases Pathway
Hao Wang, MD, PhD*, Zhanggang Xue, MD*,
Qiong Wang, MS_files/image071.gif){kind=small}
,
Xiaochen Feng, MS_files/image072.gif){kind=small}
,
and Zonghou Shen, PhD_files/image073.gif){kind=small}
From the *Department of Anesthesiology, Zhongshan Hospital,
Fudan University, Shanghai, People’s Republic of China; and _files/image074.gif){kind=small}
Department
of Biochemistry and Molecular Biology, Shanghai Medical College, Fudan
University, Shanghai, People’s Republic of China.
Anesth Analg 2008
107: 534-540.
背景：在一些器官中异丙酚可以通过抑制缺血/再灌注所造成的损伤来保护细胞，但很少有关于它对肝上皮细胞作用的报告。作者研究了经异丙酚预处理的肝L02细胞在过氧化氢（H2O2）氧化应激情况下的效应，判断在这个过程中是否存在细胞外信号调节激酶（ERK）通路。
方法：预处理或未预处理过的人类肝L02细胞暴露在H2O2中，根据TUNEL测定、半胱天冬酶3、多形核白细胞ADP-核糖聚合酶（PARP）的分裂，来评估细胞凋亡的变化。ERK1/2的激活，丝裂原激活蛋白激酶//ERL激酶1/2(MEK1/2)由西方墨迹分析法量度。Bcl-2,Bcl-xL,Bad,和Bax的mRNA的表达用实时定量的逆转录酶聚合酶链反应来定量。
结果：异丙酚预处理可以减少由过氧化氢引起的肝内L02细胞凋亡、半胱天冬酶3和PARP分裂的总数。肝L02细胞单独用异丙酚（0.01-0.3mM）处理，ERK和MEK的剂量依存性激活的最小剂量，这种激活可以在0.5h内被检测到， 4h时到达下限<50%。特异抑制剂PD98059可完全抑制ERK的激活并加重细胞凋亡的程度。异丙酚处理可抑制凋亡基因Bad和Bax
mRNA表达，且这种反应可部分被PD98059逆转。
结论：这些研究结果表明，异丙酚对过氧化氢应激的肝L02细胞的具有保护作用，部分通过激活MEK-ERK通路，从而进一步抑制Bad和Bax的表达来实现的。
（怀晓蓉 译 陈杰 校）
BACKGROUND: Propofol
protects cells against ischemia/reperfusion injury in several
organs, but there are few reports of its effect on liver epithelial
cells. We investigated the effect of propofol preconditioning on
human hepatic L02 cells under hydrogen peroxide (H2O2)-induced
oxidative stress and attempted to determine whether the
extracellular signal-regulated kinases (ERK) pathway is involved in
this process.
METHODS: Preconditioned
or nonpreconditioned human hepatic L02 cells were exposed to H2O2
and the changes of apoptosis were evaluated by TUNEL assay,
Caspase-3 and poly ADP-ribose polymerase (PARP) cleavage. Activation
of ERK1/2 and mitogen-activated protein kinase//ERK Kinase 1/2
(MEK1/2) was measured by Western blot analysis. The mRNA expression
of Bcl-2, Bcl-xL,
Bad, and Bax was quantified by real-time quantitative reverse
transcriptase polymerase chain reaction.
RESULTS: Propofol
preconditioning reduced the population of apoptotic cells and
Caspase-3 and PARP cleavage induced by H2O2 inhepatic
L02 cells. L02 cells treated with propofol (0.01–0.3 mM) alone, led
to a dose-dependent activation of ERK and MEK, and such activation
was detected within 0.5 h and eventually declined to <50% at 4 h.
The addition of the specific inhibitor PD98059 completely abolished
the activation of ERK and aggravated the extent of apoptosis.
Moreover, propofol treatment repressed the mRNA expression of
proapoptotic genes Bad and Bax, and this repression could be partly reversed by PD98059.
CONCLUSIONS: These findings
demonstrate that propofol protects hepatic L02 cells from H2O2-induced
apoptosis, partly through activating the MEK-ERK pathway and further
suppressing Bad and Bax expression.
Coronary Artery Stents: Part I. Evolution of Percutaneous
Coronary Intervention
Lisa T. Newsome, MD, DMD*, Michael A. Kutcher, MD_files/image075.gif){kind=small}
,
and Roger L. Royster, MD*
From the Departments of *Anesthesiology, and _files/image076.gif){kind=small}
Cardiology
(Interventional Cardiology), Wake Forest University School of Medicine,
Winston-Salem, North Carolina.
Anesth Analg 2008
107: 552-569.
在过去的三十年，随着经皮腔内冠状动脉血管成形术和经皮腔内斑块旋切术，裸金属支架和药物洗脱支架的快速发展，心脏介入技术在冠状动脉性心脏病的治疗方面有了显著进展。裸金属支架（BMS）通过血管成形术维持血管腔的直径防止其塌陷。然而，裸金属支架会引起内膜增生从而产生支架内再狭窄，超过20％的病人需要再次行介入治疗，通过药物洗脱支架（DES）（包括西罗莫斯洗脱支架和紫杉醇洗脱支架）抑制血管内皮增生来防止再狭窄。然而，药物洗脱支架对血管内皮细胞生长的延迟在某种程度上会引起支架血栓形成。45％的病人死亡率与支架血栓形成相关。过早停用抗血栓治疗药物，尤其是氯吡格雷通常会引起支架血栓形成。60％的病人由于使用了未经批准使用的支架同样会增加了支架血栓形成的发生率。在裸金属支架和药物洗脱支架治疗中，氯吡格雷和阿司匹林都是预防支架血栓形成的基础性药物。关于两联抗血栓治疗的药物最佳持续使用时间仍有争议。食品药物管理局和美国心脏协会/美国大学的心脏学家和各个相关学科的学者对两联抗血栓治疗持续时间的建议为:使用药物洗脱支架的患者最佳治疗时间为一年，对使用裸金属支架的患者为六个月。所有使用冠脉支架治疗的患者必须终身服用阿司匹林药物。随着经皮腔内冠状动脉血管成形术作为冠状动脉硬化治疗手段的引入，经皮冠状动脉介入治疗经历了从单一的球囊扩张导管到复杂机械化的管腔内支架的戏剧化转变。这一系列的进展影响着围术期的用药。本文作者在第一部分回顾了经皮冠状动脉介入治疗的进展并进行关于经皮腔内冠状动脉血管成形术和冠脉支架术的讨论；在第二部分作者将对冠状动脉支架对非心脏病性外科手术术中问题和使用策略进行了讨论。
（赵嫣红 译 陈杰 校）
The subspecialty of interventional cardiology has made
significant progress in the management of coronary artery disease
over the past three decades with the development of percutaneous
coronary transluminal angioplasty, atherectomy, and bare-metal and
drug-eluting stents (DES). Bare-metal stents (BMS) maintain vessel
lumen diameter by acting as a scaffold and prevent collapse incurred
by angioplasty. However, these devices cause neointimal hyperplasia leading
to in-stent restenosis and requiring reintervention in more than 20%
of patients by 6 mo. DES (sirolimus and paclitaxel) prevent
restenosis by inhibiting neointimal hyperplasia. However, DESs also
delay endothelialization, causing the stents to remain thrombogenic
for an extended, yet unknown, period of time. Late stent thrombosis
is associated with a 45% mortality rate. Premature discontinuation
of antiplatelet therapy, particularly clopidogrel, is the strongest
predictor of stent thrombosis. Sixty percent of patients receive
stents for off-label (unapproved) indications, which also increases
the frequency of stent thrombosis. Clopidogrel and aspirin are the
cornerstone of therapy in the prevention of stent thrombosis in both
BMS and DES. Recommendations pertaining to the optimal duration of
dual-antiplatelet therapy have been debated. Both the Food and Drug
Administration and the American Heart Association/American College
of Cardiologists, in association with other major societies, have
made recommendations to extend the duration of dual-antiplatelet
therapy in patients with DES to 1 yr. The 6-wk duration of dual-antiplatelet
therapy in patients with BMS remains unchanged. All patients with
coronary stents must remain on life-long aspirin monotherapy. Since
the introduction of percutaneous transluminal coronary angioplasty
for the treatment of coronary atherosclerosis, the practice of
percutaneous coronary intervention has undergone a dramatic
transformation from simple balloon dilation catheters to
sophisticated mechanical endoprostheses. These advancements have
impacted the practice of perioperative medicine. In this series of
two articles, in Part I we will review the evolution of percutaneous
coronary intervention and discuss the issues associated with
percutaneous transluminal coronary angioplasty and coronary
stenting; in Part II we will discuss perioperative issues and
management strategies of coronary stents during noncardiac surgery.
胸内血容指数可作为评估急性循环衰竭危重病人机体容量反应的一个指标：与中心静脉压的比较
The Intrathoracic Blood Volume Index as an Indicator of
Fluid Responsiveness in Critically Ill Patients with Acute Circulatory Failure:
A Comparison with Central Venous Pressure
Laurent Muller, MD, MSc*_files/image077.gif){kind=small}
,
Guillaume Louart, MD*_files/image078.gif){kind=small}
,
Christian Bengler, MD*, Pascale Fabbro-Peray, MD_files/image079.gif){kind=small}
,
Julie Carr, MD*, Jacques Ripart, MD, PhD*_files/image080.gif){kind=small}
,
Jean-Emmanuel de La Coussaye, PhD, MD*_files/image081.gif){kind=small}
,
and Jean-Yves Lefrant, MD, PhD*_files/image082.gif){kind=small}
From the *Division Anesthésie Réanimation Douleur Urgences,
Groupe Hospitalo-Universitaire Caremeau, CHU Nîmes, Place du Professeur Robert
Debré, 30 029 Nîmes Cedex 9. Faculté de Médecine, Université Montpellier 1; _files/image083.gif){kind=small}
Equipe
d’Accueil 2992, Laboratoire de physiologie cardiovasculaire et d’anesthésie
expérimentale, Faculté de Médecine, Groupe Hospitalo-Universitaire Caremeau,
Place du Professeur Robert Debré, 30 029 Nîmes; and _files/image084.gif){kind=small}
Département
d’Information médicale, Groupe Hospitalo-Universitaire Caremeau, CHU Nîmes,
Place du Professeur Robert Debré, 30 029 Nîmes Cedex 9. Faculté de Médecine,
Université Montpellier 1.
Anesth Analg 2008 107: 607-613.
背景：胸内血容指数（ITBVI）和中心静脉压（CVP）常用于评估急性循环衰竭危重病人（收缩压小于90
mmHg或者需要血管升压药的病人）的液体容量，然而它们之间未曾比较。
方法：在这项前瞻性干预研究中，作者选择35名（其中男性21名）镇静下行机械辅助呼吸且监测心排血量（采用漂浮导管，温度稀释法）的急性循环衰竭病人。机体容量反应定义为休克指数（心输出量/心率/体表面积）升高大于15%。记录ITBVI和CVP变化特征曲线。
结果：51%患者在液体冲击试验后休克指数升高大于等于15%（为阳性反应）。基础血流动力学数据在阳性者与阴性者之间无差异。ITBVI的特征曲线下面积是0.64(95%CI：0.46-0.80)，而CVP是0.68（95％CI：0.46-0.80），两者无统计学差异（P＝0.73）。CVP和ITBVI的最佳甄别阈分别是9mmHg.（灵敏度＝61%，特异性＝82%）和928 mmHg（灵敏度＝78%，特异性＝53%）。
结论：ITBVI在评估急性循环衰竭危重病人的液体容量方面，与CVP有着相似的价值。
（叶乐 译 陈杰 校）
BACKGROUND: The
intrathoracic blood volume index (ITBVI) and central venous pressure
(CVP) are routinely used to predict fluid responsiveness in
critically ill patients with acute circulatory failure (systolic
blood pressure <90 mm Hg or vasopressor requirement). However,
they have never been compared.
METHODS: In this
prospective interventional study, we included 35 (21 men)
mechanically ventilated and sedated patients with acute
cardiovascular failure requiring cardiac output measurement (transpulmonary
thermodilution technique). Fluid responsiveness was defined as an
increase in stroke index (cardiac output/heart rate/body surface
area) _files/image085.gif){kind=small}
15%.
Receiver operating characteristic curves were generated for ITBVI
and CVP.
RESULTS: Fluid
challenge induced a stroke index increase _files/image086.gif){kind=small}
15%
in 18 (51%) patients (responders). At baseline, no studied hemodynamic
variables were different between responders and nonresponders. The
areas under the receiver operating characteristic curves were 0.64
[95% CI: 0.46–0.80] for ITBVI and 0.68 [95% CI: 0.50–0.83] for CVP,
without any statistical difference (P = 0.73). The
best cut-off values for CVP and ITBVI were 9 mm Hg (sensitivity =
61%; specificity = 82%) and 928 mL · m–2 (sensitivity =
78%; specificity = 53%).
CONCLUSION: ITBVI is
similar to CVP in its ability to predict fluid responsiveness in
critically ill patients with acute circulatory failure.
随机药物抽检减少麻醉住院医师药物依赖发生率:来自一个研究方案的初步结果
Random Drug Testing to Reduce the Incidence of
Addiction in Anesthesia Residents: Preliminary Results from One Program
Michael G. Fitzsimons, MD, Keith H. Baker, MD, PhD, Edward
Lowenstein, MD, and Warren M. Zapol, MD
From the Department of Anesthesia and Critical Care, Harvard
Medical School, Massachusetts General Hospital, Boston, Massachusetts.
Anesth Analg 2008
107: 630-635.
麻醉住院医师的药物滥用率约为1%-2%，几乎80%的研究方案中有一个或多个住院医师存在上述问题。教育和药物控制未能减少药物滥用的发生率。麻醉医生职业责任为患者提供良好用药.作者建立一个方案通过随机抽验麻醉科住院医师尿液来尝试减少药物滥用发生率。尽管有逻辑上和文化上问题，作者认为这方案易于施行。更大的多机构的研究是必须的以确定是否需制定随机尿检以减少麻醉住院医师的药物滥用发生率。
（丁俊云 译 陈杰 校）
Substance abuse occurs in approximately 1%–2% of anesthesia
residents and nearly 80% of programs have had one or more resident (s)
with such a problem. Education and control efforts have failed to
reduce the frequency of substance abuse. Anesthesia providers have a
professional obligation to be drug-free for the well being of their
patients. We have instituted a program of preplacement and random
urine testing of residents in anesthesiology in an attempt to
decrease the incidence of substance abuse. We demonstrate that such
a program is feasible, despite logistic and cultural obstacles.
Larger multi-institutional studies will be required to determine
whether instituting a program of random urine testing decreases the
incidence of substance abuse in anesthesiology residents.
Anesthetic Management of a Patient with
3-Methylcrotonyl-CoA Carboxylase Deficiency
Karen A. Robbins, MD, and Elias N. León-ruiz, MD
From the Department of Anesthesiology and Perioperative
Medicine, University Hospitals Case Medical Center, Cleveland, Ohio.
Anesth Analg 2008
107: 648-650.
有先天性代谢障碍的病人在围术期需特殊考虑。下文的病例报告中,作者成功处理了一例3-甲基巴豆酰辅酶A羧化酶缺乏症的病人，疾病导致继发性肉毒碱缺乏和β 氧化功能障碍。患者可能存在潜在的心肌病,在应激状态下有代谢失代偿、酸中毒、低血糖的危险。
（杜唯佳 译 陈杰 校）
Patients with inborn errors of metabolism require special
considerations in perioperative care. In the following case report,
we describe the successful management of a patient with 3-methylcrotonyl-CoA
carboxylase deficiency, a deficit that causes a secondary carnitine deficiency
and impaired β oxidation. Patients may have significant underlying
cardiomyopathy, and are at risk for metabolic decompensation,
acidosis, and hypoglycemia during periods of stress.
乳癌术后病人自控椎旁镇痛的可行性：两种方法的前瞻性、随机双盲研究的比较
The Feasibility of Patient-Controlled Paravertebral
Analgesia for Major Breast Cancer Surgery: A Prospective, Randomized,
Double-Blind Comparison of Two Regimens
Jennifer McElwain, FCARCSI*, Noelle M. Freir,
FCARCSI*, Crina L. Burlacu, FCARCSI*, Denis C. Moriarty,
FCARCSI*, Daniel I. Sessler, MD_files/image087.gif){kind=small}
,
and Donal J. Buggy, MD, MSc, DME, FRCPI, FCARCSI, FRCA*_files/image088.gif){kind=small}
From the *Department of Anaesthesia, Mater Misericordiae
University Hospital, Dublin, Ireland; _files/image089.gif){kind=small}
Department
of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; _files/image090.gif){kind=small}
National
Cancer Screening Service, Eccles Unit, Dublin, Ireland.
Anesth Analg 2008
107: 665-668.
背景：椎旁镇痛用于乳房术后是有效的。PCIA或者PCEA用于术后镇痛的效果已经被很好的证明。本研究目的是将椎旁镇痛应用到病人自控镇痛中，并且评估两种不同方法的效应和耐受性。
方法：参与此次随机双盲试验的是乳癌术后患者，随机分成两组进行两种不同方法的自控椎旁镇痛：19名病人接受0.2%的左旋布比卡因，持续剂量8ml/h，PCA剂量3ml，锁定时间15分（15分锁定组）；18名病人接受0.2%的左旋布比卡因，持续剂量4ml/h，PCA剂量8ml，锁定时间30分（30分锁定组）。主要预后指标一是动态疼痛评分（视觉疼痛评分量表），间隔4小时一次，进行36个小时。另一指标是静息疼痛评分，包括援救镇痛药物的需要量，左旋布比卡因的用量，需要量，PCA剂量和患者的满意度。
结果：静息和动态的疼痛评分分组进行比较。15分锁定组中有2名患者和30分锁定组有5名患者要援救镇痛药物（P=0.23）。两组病人接受的左旋布比卡因的量分别是15分锁定组400±95ml和30分锁定组330±130ml（P=0.012）。15分锁定组病人需要单次注射次数是75±16次，30分锁定组为69±14次（P=0.4）。然而，15分锁定组病人接受的PCA次数是39±22次，30分锁定组则只有24±16次（P=0.02）。收缩压，心率，呼吸频率，镇静评分，恶心，止吐药物的需要量和满意度两组是相似的。
结论：乳癌术后病人自控椎旁镇痛的两种方法都可以提供满意的镇痛效果并具有和很好耐受性。
（舒慧刚 译 陈杰 校）
BACKGROUND: Paravertebral
analgesia is useful for breast surgery. Patient controlled analgesia
by IV or epidural routes is well established for delivering
postoperative analgesia. Our objective was to apply patient control
to paravertebral analgesia and evaluate the efficacy and
tolerability of two distinct dosing regimens.
METHODS: Patients
undergoing major breast cancer surgery were recruited for this
prospective, double-blind, randomized trial of two
patient-controlled paravertebral analgesia regimens: 19 patients
received levobupivacaine 0.2% at 8 mL/h with 3-mL bolus and 15-min
lockout (15-min lockout group); 18 received levobupivacaine 0.2% at
4 mL/h with 8-mL bolus and 30-min lockout (30-min lockout group).
Our primary outcome was dynamic pain scores (visual analog scale) at
4-hourly intervals for 36 h. Secondary outcomes were resting pain
scores, rescue analgesia requirements, volume of levobupivacaine
administered, demands for levobupivacaine, levobupivacaine boluses
received, and patient satisfaction.
RESULTS: Resting and
dynamic pain scores were comparable in the groups. Two 15-min
lockout patients and five 30-min lockout patients required rescue
analgesia (P = 0.23). Patients received 400 ± 95 mL
and 330 ± 130 mL levobupivacaine in 15-min and 30-min lockout
groups, respectively (P = 0.012). The
15-min lockout group requested a bolus 75 ± 16 times; the 30-min
lockout group requested it 69 ± 14 times (P = 0.40). However, the 15-min lockout
group received 39 ± 22 boluses and the 30-min lockout group only 24
± 16 (P = 0.02).
Systolic pressure, heart rate, respiratory rate, sedation scores,
nausea, antiemetic requirement, and satisfaction scores were similar
in each group.
CONCLUSIONS: Patient-controlled
paravertebral analgesia for breast cancer surgery, with either
regimen, provided satisfactory analgesia and was well tolerated.
Prolonged Use of High-Dose Morphine Impairs Angiogenesis
and Mobilization of Endothelial Progenitor Cells in Mice
Chen-Fuh Lam, MD, PhD*, Pei-Jung Chang, MD*,
Yu-Sheng Huang, MD*, Yen-Hui Sung, MD*, Chien-Chi Huang,
BS*, Ming-Wei Lin, MS*_files/image091.gif){kind=small}
,
Yen-Chin Liu, MD, MS*, and Yu-Chuan Tsai, MD*
From the *Department of Anesthesiology; and _files/image092.gif){kind=small}
Institute
of Basic Medical Sciences, National Cheng Kung University College of Medicine
and Hospital, Tainan, Taiwan.
Anesth Analg 2008
107: 686-692.
背景：吗啡是一种治疗伤口疼痛最普通的处方药之一，本研究用一个带有受伤创口的小鼠做模型，观察大剂量吗啡对血管发生和内皮原细胞活动的影响。
方法：在小鼠身上制一切开伤口，用安慰剂或吗啡（20mg/kg, ip）治疗14天。通过测试用药前伤口的面积和用药后伤口面积的比例来比较伤口的愈合，通过鲁米若增强发光剂来检测伤口区超氧化物阴离子的浓度， 分离循环的单核细胞并计内皮原细胞数目（确定为CD34+/CD133+细胞），用Matrigel（基质胶）测定法测定在体和离体经过吗啡治疗后血管形成情况。
结果：吗啡组比对照组小鼠伤口愈合减慢，伤口周围的超氧化物离子高。吗啡减少伤口内皮原细胞的活动数目，基质胶测定法显示吗啡损害动物血管形成，用吗啡处理过的培养的内皮细胞显示动物血管发生受损及毛细血管形成减少。
结论：大剂量吗啡损害血管发生，增强系统氧化应激增强及内皮原细胞活动受损。本研究强调系统给予大剂量吗啡对血管发生存在潜在的有害作用。
（刘世文 译 陈杰 校）
BACKGROUND: Morphine
is one of the most commonly prescribed analgesics for treating wound
pain. Using a mouse model of excisional wound injury, we determined
the effects of high-dose morphine on angiogenesis and mobilization
of endothelial progenitor cells.
METHODS: An
excisional wound was created on mice treated with placebo or
morphine (20 mg/kg, i.p. injection for 14 days). Wound
healing was compared by measuring the final-to-initial wound area
ratio. Generation of superoxide anions in the wound was determined
by luminol-enhanced chemiluminescence. Circulating mononuclear cells
were isolated and measured for endothelial progenitor cell (defined
as CD34+/CD133+ cell) counts. In vivo
and in vitro measurements
of angiogenesis after morphine treatment were performed using the
Matrigel assay.
RESULTS: Mice
treated with morphine had reduced wound closure and higher wound
superoxide ions concentrations than control mice. Morphine reduced
the number of postwound circulating endothelial progenitor cells.
Matrigel assay showed impaired angiogenesis in animals and reduced
capillary tube formation in cultured endothelial cells treated with
morphine.
CONCLUSION: High-dose
morphine impaired angiogenesis, increased systemic oxidative stress,
and impaired mobilization of endothelial progenitor cells. This
study emphasizes the potential detrimental effect of high-dose
morphine on angiogenesis after systemic administration.
影响局麻药在硬膜外麻醉神经阻滞平面的因素及腰段和胸段硬膜外麻醉的比较
Factors Affecting the Distribution of Neural Blockade by
Local Anesthetics in Epidural Anesthesia and a Comparison of Lumbar Versus
Thoracic Epidural Anesthesia
W. Anton Visser, MD, PhD*, Ruben A. Lee, BE(Hons)_files/image093.gif){kind=small}
,
and Mathieu J. M. Gielen, MD, PhD_files/image094.gif){kind=small}
From the *Department of Anesthesiology, Intensive Care and
Pain Management, Amphia Hospital, Breda; _files/image095.gif){kind=small}
Department
of Biomechanical Engineering, Faculty of Mechanical, Maritime, and Materials
Engineering, Technical University of Delft, Delft; and _files/image096.gif){kind=small}
Department
of Anesthesiology, University Medical Center Nijmegen, Nijmegen, The
Netherlands.
Anesth Analg 2008
107: 708-721.
在不同的个体中，一定剂量的局麻药在硬膜外腔扩散的感觉阻滞是有个体差异的，影响因素仍有争论。基于最近关于硬膜外神经阻滞的研究结果，特别是胸段的硬膜外麻醉，作者发现局麻药的总容量似乎在决定感觉平面、交感神经、运动神经阻滞等发面起主要作用，硬膜外针或导管的位置决定阻滞神经的类型。年龄可能与感觉阻滞平面有一定的相关性，胸部的硬膜外神经阻滞比腰部更为明显。病人的特征及技术细节，如病人的体位、麻醉操作方式及注射速度，只能在感觉障碍分布方面起到很小的作用，或者说这些影响是不确定的。然而，很多病人因素和技术因素的结合可以帮助预测局麻药剂量的需求。基于这些研究结果，作者认为可以根据不同外科手术在镇痛和交感阻滞要求而优化硬膜外穿刺点。
（张磊 译 陈杰 校）
The spread of sensory blockade after epidural injection of a
specific dose of local anesthetic (LA) differs considerably among
individuals, and the factors affecting this distribution remain the
subject of debate. Based on the results of recent investigations
regarding the distribution of epidural neural blockade, specifically
for thoracic epidural anesthesia, we noted that the total mass of LA
appears to be the most important factor in determining the extent of
sensory, sympathetic, and motor neural blockade, whereas the site of
epidural needle/catheter placement governs the pattern of
distribution of blockade relative to the injection site. Age may be
positively correlated with the spread of sensory blockade, and the
evidence is somewhat stronger for thoracic than for lumbar epidural
anesthesia. Other patient characteristics and technical details,
such as patient position, and mode and speed of injection, exert
only a small effect on the distribution of sensory blockade, or
their effects are equivocal. However, combinations of several
patient and technical factors may aid in predicting LA dose
requirements. Based on these results, we have also formulated
suggested epidural insertion sites that may optimize both analgesia
and sympathicolysis for various surgical indications.
预防性应用止吐药物对呕吐高危患者出院后恶心呕吐发生率及恢复期生活功能性质量的影响：一项前瞻、随机、双盲比较两种预防性止吐方案的试验研究
Antiemetic Prophylaxis for Postdischarge Nausea and
Vomiting and Impact on Functional Quality of Living During Recovery in Patients
with High Emetic Risks: A Prospective, Randomized, Double-Blind Comparison of
Two Prophylactic Antiemetic Regimens
Peter H. Pan, MSEE, MD, Sherman C. Lee, MD, and Lynne C.
Harris, BSN
From the Department of Anesthesiology, Wake Forest
University School of Medicine, Winston-Salem, North Carolina.
Anesth Analg 2008;
107:429-438
背景：比较两种预防性应用止吐药物的方法预防出院后恶心呕吐的效果以及对患者恢复期生活质量的影响。
方法：64例行门诊妇科手术且存在呕吐高危风险的女性患者随机分为两组：试验组术中静脉注射地塞米松8
mg及恩丹司琼4 mg，随后在出院时及术后第1天、第二天早晨分次口服8 mg恩丹司琼片剂。对照组术中只静脉注射恩丹司琼4 mg。在麻醉后恢复室及出院后通过电话随访5天每日1次评价恶性呕吐症状以及疼痛的发生率及严重程度。用一项修订的呕吐功能性生活指数来评估对恢复期生活质量的影响。
结果：共有60例患者完成了这项实验，每组各30例。出院后，从麻醉后第8h到第120h期间恶心的发生率对照组和试验组分别为57%和20%，呕吐的发生率两组分别为20%和3%(P < 0.05)。33%的试验组患者及60%的对照组患者均报告有呕吐症状，对其生活质量产生了不良影响(P < 0.05)。
结论：与单次术中静脉注射恩丹司琼预防性应用相比，术中加地塞米松及术后每天一次恩丹司琼能显著降低出院后恶心呕吐的发生率，并减少对术后恢复期前5天生活质量的不良影响。
（邱郁薇 译 马皓琳 李士通 校）
BACKGROUND: We
compared two antiemetic prophylaxis regimens, their efficacy for
preventing postdischarge nausea and vomiting, and their impact on
quality of living, during recovery.
METHODS: Sixty-four
women undergoing outpatient gynecological surgery and at high risk
for emesis were randomized into one of two groups. The study group
received intraoperative IV dexamethasone 8 mg and ondansetron 4 mg,
followed with an 8 mg oral disintegrating ondansetron tablet, to be
taken on discharge and in the morning of postoperative days 1 and 2.
The control group received only the IV ondansetron 4 mg
intraoperatively. The incidence and severity of emetic symptoms and
pain were assessed while patients were in the recovery room and via
telephone and patient diary for 5 days after discharge. A modified
functional living index of emesis was used to assess the impact on
quality of living during recovery.
RESULTS: Sixty
patients, 30 in each group, completed the study. The incidences for
postdischarge nausea were 57% and 20%, and for postdischarge vomiting
20% and 3% in the control and study groups, respectively, for the
period between the 8th and 120th hours postanesthesia (P
< 0.05). Thirty-three percent of the study and 60% of the control
group reported that emetic symptoms negatively affected their
quality of living (P < 0.05).
CONCLUSIONS: When
compared with a single dose of intraoperative IV ondansetron
prophylaxis, our study regimen of additional intraoperative
dexamethasone and once a day ondansetron significantly reduced the
incidence of postdischarge nausea and vomiting and its negative
impact on quality of living during the first 5 days of recovery.
评价3种不同剂量的帕洛诺司琼与安慰剂在术后72小时内防止术后恶心呕吐的有效性和安全性的随机双盲研究
A Randomized, Double-Blind Study to Evaluate the Efficacy
and Safety of Three Different Doses of Palonosetron Versus Placebo in
Preventing Postoperative Nausea and Vomiting Over a 72-Hour Period
Anthony L. Kovac, MD*, Leopold Eberhart, MD_files/image097.gif){kind=small}
,
Jan Kotarski, MD_files/image098.gif){kind=small}
,
Giuseppina Clerici, MD_files/image099.gif){kind=small}
,
Christian Apfel, MD, PhD||, and The Palonosetron 04-07 Study Group
From the *Department of Anesthesiology, University of KS
Medical Center, KS City, Kansas; _files/image100.gif){kind=small}
Department
of Anesthesia and Intensive Care Medicine, Philipps-University of Marburg,
Marburg, Germany; _files/image101.gif){kind=small}
First
Department of Gynecological Surgery, University School of Medicine, Lublin,
Poland; _files/image102.gif){kind=small}
Research
and Development Department, Helsinn Healthcare SA, Lugano, Switzerland; and
||Perioperative Clinical Research Core, Department of Anesthesia and
Perioperative Care, University of CA San Francisco, San Francisco, CA.
Anesth Analg 2008;
107:439-444
背景：我们设计这个多中心、随机、双盲的研究来评估3种不同剂量的帕洛诺司琼与安慰剂对于术后72小时内术后恶心呕吐（PONV）的发生及严重程度影响的有效性和安全性。
方法：行择期妇科或者乳腺手术的女性患者，根据另外2个PONV风险因素（不吸烟状况和PONV和/或晕动病病史）分层。544名有以上有1个或2个风险因素的患者在麻醉诱导前即刻随机静脉注射一种剂量的帕洛诺司琼(0.025
mg、0.050 mg或0.075 mg)或安慰剂。术后0-24小时和24-72小时两时间段的主要有效性指标为完全有效（CR：没有呕吐并且没有使用缓解药物）。
结果：安慰剂和0.075 mg帕洛诺司琼的术后0-24小时CR率为36%和56% (P =
0.001)，24-72小时CR率为52%和70% (P = 0.002)，0-72小时CR率为36%和52% (P = 0.010)。0.075 mg帕洛诺司琼与安慰剂相比在0-24小时内(P
< 0.001)恶心程度较小（接近“轻度”或“无”），而且显著延迟了出现呕吐时间(P = 0.002)和治疗失败时间(P = 0.004)的中位数。尽管在统计学上0.025
mg和0.050 mg剂量的帕洛诺司琼CR率在0-24小时和24-72小时时间段内并不优于安慰剂，但是较低的剂量可以在0-24小时内缓解恶心的严重程度(P =
0.040和P = 0.004)。
结论：单次静脉注射0.075mg帕洛诺司琼能有效地缓解入院手术患者术后恶心的严重程度，并且推迟呕吐和治疗失败的时间；低剂量就不是那么有效。
（唐亮 译 马皓琳 李士通
校）
BACKGROUND: We
designed this multicenter, randomized, double-blind study to assess
the efficacy and safety of three doses of palonosetron, compared
with placebo, on the incidence and severity of postoperative nausea
and vomiting (PONV) in inpatients for 72 h after surgery.
METHODS: Female
patients undergoing either elective gynecological or breast surgery
were stratified according to two additional PONV risk factors:
nonsmoking status and history of PONV and/or motion sickness. Five
hundred forty-four patients with one or both of these risk factors
were randomized to receive one of the three doses of IV palonosetron
(0.025 mg, 0.050 mg, 0.075 mg) or placebo immediately before
induction of anesthesia. The primary efficacy end-point was complete
response (CR: no emesis and no use of rescue medications) evaluated
at the 0–24 and 24–72 h time intervals after surgery.
RESULTS: CR rates
for placebo and palonosetron 0.075 mg were 36% and 56% for 0–24 h (P
= 0.001), 52% and 70% for 24–72 h (P = 0.002) and 36% and 52% (P = 0.010) for the 0–72 h postoperative interval. Palonosetron
0.075 mg was associated with less intense nausea (e.g., toward
"mild" or "none") versus placebo during the 0–24
h (P < 0.001) time interval
and significantly delayed median time to emesis (P = 0.002) and treatment failure (P
= 0.004). Although CR rates for both the
0.025 mg and 0.050 mg palonosetron doses were not statistically superior
to placebo for the 0–24 h or 24–72 h periods, both lower doses
reduced nausea severity during the 0–24 h period (P = 0.040 and P = 0.004).
CONCLUSION: A single
0.075-mg IV dose of palonosetron effectively reduced the severity of
nausea and delayed the time to emesis and treatment failure in the
inpatient surgical setting; lower doses were not as effective.
The Relationship Between Patient Risk Factors and Early
Versus Late Postoperative Emetic Symptoms
Paul F. White, PhD, MD, FANZCA, Ozlem Sacan, MD, Nina
Nuangchamnong, MS, Tiffany Sun, MS, and Matthew R. Eng, MS
From the Department of Anesthesiology and Pain Management,
University of Texas Southwestern Medical Center at Dallas, Texas.
Anesth Analg 2008;
107:459-463
背景：术后恶心呕吐(PONV)仍然是择期手术术后常见的并发症，因此常常对具有发生PONV的已知危险因素的病人预防性应用止吐药物。我们设计这次前瞻性观察研究的目的就是来评价病人发生PONV的常见危险因素与其术后早期(0–24
h)以及晚期(24–72 h)发生呕吐症状的关联性。
方法：130名拟行择期腹腔镜手术(n = 88)或整形手术(n =
42)的病人根据Apfel风险评分系统算出其发生PONV的风险分数。Apfel风险评分系统给女性、不吸烟者、有PONV或晕动病史以及术后阿片类药物的使用四个危险因素各记一分。假定所有病人都将在术后接受阿片类镇痛药。所有病人预防性接受0、1、2或3种止吐药物。术后分别在0－6h，6－24h以及24－72h时段内评价恶心呕吐的发生情况以及需要止吐药物来补救治疗的情况。另外，用标准化的病人问卷来评价PONV对正常日常生活活动恢复的影响。
结果：在Apfel风险评分分别为2、3和4分的组中分别有87%、90%和95%病人预防性应用一种或更多种的止吐药。当危险因素为3个或者4个时，分别有56%和 75%的病人接受了_files/image103.gif){kind=small}
2种止吐药。在术后0－6h时段内，三个危险因素组和四个危险因素组分别有11%
和22%的病人发生呕吐，而两个危险因素组有6%的病人发生呕吐；在术后6–24 h时段内，呕吐的发生率分别为13%和27% (比0%)。然而，在术后24–72
h时段内，三组呕吐的发生率均低且组间没有差别(分别为9%、 5%和11%)。术后0–6 h 以及6–24
h时段内高危险因素组中中到重度恶心的发生率增高(分别为19%–28%比6% 和 20%–30%比9%)。然而，术后24–72
h时段内三个危险因素组和四个危险因素组恶心的发生率与两个危险因素组没有差别(5%和8%比6%)。四个危险因素组对补救止吐药的需要和呕吐症状对正常活动的干扰与两个和三个危险因素组相比明显提高。
结论：尽管常常预防性使用多种止吐药物，Apfel风险评分为3或4（与2相比）仍与术后首个24小时内较高的呕吐发生率相关。然而，后期(24–72
h)呕吐症状的发生率低且似乎与病人的Apfel风险评分没有关系。
（吴进 译 马皓琳 李士通 校）
BACKGROUND: Postoperative
nausea and vomiting (PONV) remain common complications after
elective surgery. Prophylactic antiemetic drugs are frequently
administered to patients with well known risk factors for developing
PONV. We designed this prospective observational study to assess the
relationship between common patient risk factors for developing PONV
and the occurrence of early (0–24 h) versus late (24–72 h) emetic
symptoms.
METHODS: One hundred
thirty patients undergoing elective laparoscopic (n =
88) or plastic (n = 42) surgery were
assigned a risk score for developing PONV based on the Apfel risk
scoring system, which assigns one point each for female gender,
nonsmoking status, history of PONV or motion sickness, and
postoperative opioid use. It was assumed that all patients would
receive an opioid analgesic in the postoperative period. The
patients received 0, 1, 2, or 3 antiemetic drugs for prophylaxis.
The occurrence of nausea, vomiting, and need for rescue antiemetics
was assessed at specific time intervals from 0 to 6, 6–24, and 24–72
h after surgery. In addition, the impact of PONV on recovery of
normal activities of daily living was assessed using a standardized patient
questionnaire.
RESULTS: One or more
prophylactic antiemetics were administered to 87%, 90%, and 95% of
the patients in the two, three, and four Apfel risk-factor groups,
respectively. In the presence of three or four risk factors, _files/image104.gif){kind=small}
2
antiemetics were administered to 56% and 75% of the patients,
respectively. Vomiting was reported in 11% and 22% of patients in
the three and four risk factor groups compared with 6% in the two
risk factor group at 0–6 h, and 13% and 27% (vs 0%) at 6–24 h,
respectively. However, in the 24–72 h postoperative period, the
incidences of emesis were low and did not differ in the three risk
groups (9%, 5%, and 11%, respectively). The occurrence of
moderate-to-severe nausea was increased in the higher risk groups at
0–6 h and 6–24 h (19%–28% vs 6% and 20%–30% vs 9%,
respectively). However, the incidences of nausea in the 24–72 h
period in the three and four risk factor groups were not different
from the two-risk factor group (5% and 8% vs 6%, respectively). The
need for rescue antiemetics and interference of emetic symptoms with
normal activities was greater in the four risk factor group compared
with the two and three risk factor groups.
CONCLUSION: Despite
the frequent use of multiple antiemetic drugs for prophylaxis, an
Apfel risk score of three or four (vs 2) was associated with a
higher incidence of emetic sequelae in the first 24 h after surgery.
However, the occurrence of late (24–72 h) emetic symptoms was low
and appeared to be unrelated to the patient's Apfel risk score.
General Anesthetics Have Additive Actions on Three Ligand
Gated Ion Channels
Andrew Jenkins, PhD*, Ingrid A. Lobo, PhD_files/image105.gif){kind=small}
,
Diane Gong, PharmD_files/image106.gif){kind=small}
,
James R. Trudell, PhD_files/image107.gif){kind=small}
,
Ken Solt, MD_files/image108.gif){kind=small}
,
R. Adron Harris, PhD_files/image109.gif){kind=small}
,
and Edmond I. Eger, II, MD||
From the *Department of Anesthesiology, Emory University,
Atlanta, Georgia; _files/image110.gif){kind=small}
Waggoner
Center for Alcohol and Addiction Research, Section of Neurobiology and
Institute for Cellular and Molecular Biology, The University of Texas at
Austin, Austin, Texas; _files/image111.gif){kind=small}
Department
of Anesthesiology, Stanford University, Stanford, California; _files/image112.gif){kind=small}
Department
of Anesthesia and Critical Care, Massachusetts General Hospital and Department
of Anesthesia, Harvard Medical School, Boston Massachusetts; and ||Department
of Anesthesia and Perioperative Care, University of CA, San Francisco,
California.
Anesth Analg 2008;
107:486-493
背景：本研究旨在确定成对的化合物包括全麻药，是否能够以一种协同的方式同时调制受体功能，以此来证明蛋白内存在多处麻醉药结合部位。
方法：通过使用标准的电生理方法，我们测定了包括苯、异氟烷（ISO）、氟烷（HAL）、氯仿、氟硝西泮、锌以及戊巴比妥至少一种药物以上复合对以下至少一种配体门控离子通道的作用：N－甲基-d-天冬氨酸受体、甘氨酸受体以及_files/image113.gif){kind=small}
-氨基丁酸A型受体。
结果：所有药物－药物－受体的结合都被发现呈相加而非协同性调制作用。ISO＋苯呈累加性地抑制N－甲基-d-天冬氨酸受体功能。ISO＋HAL和ISO＋锌一样，呈累加性地增强甘氨酸受体功能。ISO＋HAL和以下组合（HAL＋氯仿、戊巴比妥＋ISO、氟硝西泮＋ISO）一样，呈累加性地增强_files/image114.gif){kind=small}
-氨基丁酸A型受体功能。
结论：同时发生的全麻药对配体门控离子通道的变构调制作用完全是相加性的。而成对的全麻药协同性地产生全身麻醉作用，必然基于较单个受体更为复杂的系统。
（黄施伟 译，马皓琳 李士通 校）
BACKGROUND: The
purpose of this study was to determine whether pairs of compounds,
including general anesthetics, could simultaneously modulate
receptor function in a synergistic manner, thus demonstrating the
existence of multiple intraprotein anesthetic binding sites.
METHODS: Using
standard electrophysiologic methods, we measured the effects of at
least one combination of benzene, isoflurane (ISO), halothane (HAL),
chloroform, flunitrazepam, zinc, and pentobarbital on at least one
of the following ligand gated ion channels: N-methyl-d-aspartate
receptors, glycine receptors and _files/image115.gif){kind=small}
-aminobutyric
acid type A receptors.
RESULTS: All
drug-drug-receptor combinations were found to exhibit additive, not
synergistic modulation. ISO with benzene additively depressed N-methyl-d-aspartate
receptors function. ISO with HAL additively enhanced glycine
receptors function, as did ISO with zinc. ISO with HAL additively
enhanced _files/image116.gif){kind=small}
-aminobutyric
acid type A receptors function as did all of the following: HAL
with chloroform, pentobarbital with ISO, and flunitrazepam with ISO.
CONCLUSION: The
simultaneous allosteric modulation of ligand gated ion channels by
general anesthetics is entirely additive. Where pairs of general
anesthetic drugs interact synergistically to produce general
anesthesia, they must do so on systems more complex than a single
receptor.
Synergy Between Pairs of Competitive Antagonists at Adult
Human Muscle Acetylcholine Receptors
Man Liu, PhD, and James P. Dilger, PhD
From the Department of Anesthesiology, Stony Brook
University, Stony Brook, New York.
Anesth Analg 2008;
107:525-533
背景：临床上已经研究发现某些特定成对的烟碱乙酰胆碱受体(nAChR)竞争性拮抗剂的神经肌肉阻滞的协同作用。协同作用的机制还没有阐明。我们验证了这一假说，即协同作用源于拮抗剂在成人nAChR的两个配体结合位点的不同的选择性。
方法：我们在BOSC23细胞中表达了nAChR。在同时应用或无拮抗剂的情况下，我们在膜外面向外式膜片应用了乙酰胆碱，并且在室温下测量了可见电流。我们测定了(+)-筒箭毒碱、甲筒箭毒、哌库溴铵、维库溴铵、顺式阿曲库铵、罗库溴铵和阿曲库铵的IC90。对于两种拮抗剂的15种组合，我们测定了在第二种拮抗剂的IC70存在的情况下某种拮抗剂的IC90。我们绘制了90%抑制时的等效线图。对于单一的拮抗剂，我们测定了包括_files/image118.gif){kind=small}
和 _files/image120.gif){kind=small}
亚单元中的变异在内的受体抑制作用来确定位点选择性。
结果：两对拮抗剂，甲筒箭毒和顺式阿曲库铵以及顺式阿曲库铵和阿曲库铵呈相加作用。10种组合，包括(+)-筒箭毒碱和哌库溴铵以及哌库溴铵和维库溴铵，具有高度的协同性，以至于这种组合比期望的相加作用强2-3倍。3种组合比期望的相加作用强1.5-1.6倍。(+)-筒箭毒碱和甲筒箭毒的抑制作用仅对_files/image121.gif){kind=small}
亚单元的突变敏感。维库溴铵仅受_files/image122.gif){kind=small}
亚单元的突变的影响。其它拮抗剂的抑制作用可以被任一亚单元的突变所减低。
结论：很多拮抗剂的组合呈现出了对成人nAChR的协同作用。在结构上相似和不相似的拮抗剂观察到了协同作用。协同作用的程度并不总是与测定的突变位点特异性良好地相关。在某些，但不是全部的例子中，受体水平的协同作用与临床测定的协同作用相关。我们得出结论，肌肉松弛剂的协同作用的部分原因是与成人nAChR的直接相互作用。
（黄丽娜 译 马皓琳 李士通 校）
BACKGROUND: Synergistic
neuromuscular blocking effects have been observed clinically with
certain pairs of nicotinic acetylcholine receptor (nAChR)
competitive antagonists. The mechanism for synergy has not been
elucidated. We tested the hypothesis that synergy arises from a
differential selectivity of antagonists for the two ligand binding
sites on adult human nAChR.
METHODS: We
expressed nAChR in BOSC23 cells. We applied ACh with or without
antagonists to outside-out patches and measured macroscopic currents
at room temperature. We determined the IC90 for
(+)-tubocurarine, metocurine, pancuronium, vecuronium, cisatracurium,
rocuronium, and atracurium. For 15 combinations of two antagonists,
we determined the IC90 for one antagonist in the presence
of the IC70 of a second antagonist. We constructed isobolograms
for 90% inhibition. For single antagonists, we measured inhibition
of receptors containing mutations in the _files/image123.gif){kind=small}
-
and _files/image124.gif){kind=small}
-subunits
to determine site selectivity.
RESULTS: Two pairs
of antagonists, metocurine+cisatracurium and cisatracurium+
atracurium exhibited additive inhibition. Ten combinations,
including (+)-tubocurarine+ pancuronium and pancuronium+vecuronium,
were highly synergistic such that the combination was two to three
times more effective than expected for additivity. Three
combinations were 1.5–1.6 times more effective than expected for
additivity. Inhibition by (+)-tubocurarine and metocurine was
sensitive to mutations in the _files/image125.gif){kind=small}
-subunit
only. Vecuronium was affected by the _files/image126.gif){kind=small}
-subunit
mutation only. Inhibition by other antagonists was decreased by
mutations in either subunit.
CONCLUSIONS: Many
combinations of antagonists exhibited synergistic effects on adult
human nAChR. Synergy was observed with structurally similar and
dissimilar antagonists. The degree of synergy did not always
correlate well with site specificity assayed with mutants. In some,
but not all cases, the synergy at the receptor level correlated with
clinical determinations of synergy. We conclude that the synergistic
actions of muscle relaxants can be partially explained by direct
interactions with adult human nAChR.
The Effects of Auditory Evoked Potential Click Sounds on
Bispectral Index and Entropy
Tomoki Nishiyama, MD, PhD
From the Department of Anesthesiology, The University of
Tokyo, Tokyo, Japan.
Anesth Analg 2008;
107:545-548
背景：听觉诱发电位（AEP）的卡嗒声对脑电图指数和双频谱指数（BIS）会产生一定的影响，但是很多研究都测量了同时产生的指数却没有涉及这种影响。在本次研究中我监测了这种AEP的卡嗒声对BIS以及对熵监护仪测得的反应熵（RE）和状态熵（SE）的影响。
方法：四十位年龄在40—70岁之间择期在脊麻下行下肢手术的病人，用药为0.5%的布比卡因或丁卡因。病人镇静用1mg咪达唑仑，随后丙泊酚输注，开始速度1
mg · kg–1 · h–1。控制输注丙泊酚以使BIS或SE在80、60或40保持几分钟，然后给予65分贝的AEP卡嗒声60秒。卡嗒声停止后持续60
秒观察BIS、RE和SE的变化。
结果：在卡嗒声过程中BIS、RE和SE值显著增加。当BIS或SE值为60时这种增强作用持续时间最长。
结论：在脊麻时丙泊酚输注产生的不同程度的镇静过程中，AEP的卡嗒声可以一过性增强同时测定的BIS、RE和SE。因此，当AEP和这些监测指标同时应用于一个病人时，前者的卡嗒声对这些指标的影响必须要加以考虑。
（姜旭晖译，马皓琳 李士通校）
BACKGROUND: The
click sounds of auditory evoked potentials (AEP) might have some
effect on electroencephalogram indices and Bispectral Index (BIS)
but many studies, unconcerned about this effect, have measured both
indices simultaneously. In this study, I examined the effects, of
AEP click sounds on the BIS, and also on the response entropy (RE)
and state entropy (SE) of the entropy monitor.
METHODS: Forty
patients aged 40–70 yr and scheduled for surgery of lower
extremities under spinal anesthesia were anesthetized with 0.5%
bupivacaine or tetracaine. Patients were sedated with midazolam 1 mg
followed by propofol infusion started at 1 mg · kg–1 · h–1.
Propofol infusion was controlled to keep BIS or SE at 80, 60, or 40
for several minutes, and then click sounds (65 dB) of the AEP were
given for 60 s. The changes in BIS, RE, and SE were observed
continuously for 60 s after the click sounds had stopped.
RESULTS: BIS, SE,
and RE significantly increased during the click sounds. The longest
duration of increase was at BIS or SE 60.
CONCLUSION: AEP
monitor click sounds transiently increased the simultaneously
measured BIS, RE, and SE during different levels of sedation by
propofol infusion during spinal anesthesia. Therefore, the effects
of the click sounds should be considered when these monitors are
used simultaneously in the same patient.
Life After Death: The Aftermath of Perioperative
Catastrophes
Farnaz M. Gazoni, MD, Marcel E. Durieux, MD, PhD, and Lynda
Wells, MD
From the Department of Anesthesiology, University of
Virginia Health System, Charlottesville, Virginia.
Anesth Analg 2008;
107:591-600
大多数麻醉医师在其职业生涯中，会经历围术期患者死亡或较大的围术期灾祸。然而，麻醉训练没能使个人准备好处理此类应激事件的后果。多重调查显示：病人的死亡会对高达75%的有关卫生保健提供者产生较大的情绪影响，无论死亡是否为意料中或患者是否和医生熟识。心理上的复原通常需要数周或数月，并且，因缺乏情绪和专业支持而受阻碍。数据表明：大多数麻醉医生会青睐更正式的支持结构，包括从临床工作休息的选择权。即使围术期灾祸后专业功能的正式评估还未进行，英国和爱尔兰麻醉医师协会指定了推荐多级支持的指南，而在麻醉病人安全基础网站上的可用的“不利事件记录”提供了一系列步骤，以使患者损伤降到最低并在发生不良麻醉事件后鉴定其原因。在此类事件发生后未能妥善处理的负面后果同样对个人和卫生保健系统有重要意义。围术期灾祸对于提供者和卫生系统的短期和长期影响的更进一步研究是必要的。另外，如何处理围术期灾祸后果的教育和正式支持结构应当提供给各水平训练中的行医者。
（唐李隽 译
马皓琳 李士通 校）
Most anesthesiologists will experience the perioperative
death of a patient or a major perioperative catastrophe in the
course of their careers. Anesthesia training, however, does not
prepare individuals to handle the aftermath of such a stressful
event. Multiple surveys have shown that the death of a patient has
a major emotional impact on up to 75% of health care providers involved,
regardless of whether the death was expected or whether the patient
was well known to the practitioner. Psychological recovery often
takes weeks or months and is hampered by lack of emotional and
professional support. Data indicate that the majority of
anesthesiologists would prefer a more formal support structure,
including the option to take time off from clinical work. Although a
formal assessment of professional functioning after a perioperative
catastrophe has not been done, the Association of Anaesthetists of
Great Britain and Ireland instituted guidelines recommending support
at multiple levels, and the "Adverse Event Protocol"
available on the Anesthesia Patient Safety Foundation website
provides a suggested series of steps to minimize patient injury and
identify the cause of an adverse anesthesia event after it occurs.
The negative consequences of failure to cope well after these events
are significant to individuals and health care systems alike.
Further study into the short-term and long-term impact of
perioperative catastrophes on providers and health systems is
needed. Additionally, education on how to handle the aftermath of
perioperative catastrophes and formal support structures should be
provided to practitioners at all levels of training.
A Randomized Controlled Trial of Pudendal Nerve Block for
Pain Relief After Episiotomy
Younès Aissaoui, MD*_files/image127.gif){kind=small}
,
Rémi Bruyère, MD*, Hassan Mustapha, MD_files/image128.gif){kind=small}
,
Dominique Bry, MD*, Noureddine Drissi Kamili, MD, PhD_files/image129.gif){kind=small}
,
and Chantal Miller, MD*
From the *Département d’Anesthésiologie, Centre Hospitalier
d’Auxerre, France; _files/image130.gif){kind=small}
Département
d’Anesthésie Réanimation et Urgences, Hôpital Militaire d’Instruction des
Armées Mohammed V, Faculté de Médecine et de Pharmacie, Université Mohamed V
Souissi, Rabat, Morocco; and _files/image131.gif){kind=small}
Département
de Gynécologie Obstétrique. Centre
Hospitalier d’Auxerre. France.
Anesth Analg 2008;
107:625-629
背景：分娩过程中的会阴切开术或会阴撕裂引起产后期的显著疼痛。我们设计了这项随机双盲对照试验以研究神经刺激器引导下单侧会阴神经阻滞对会阴切开术后疼痛的缓解效果。
方法：40位阴道分娩过程中需要会阴正中旁切开的产妇随机分为两组：在会阴切开修补后用15mL的7.5mg/mL罗哌卡因（试验组）或生理盐水（对照组）行会阴神经阻滞。用会阴切开术后3、6、12、24和48
h时静息状态及活动（步行和坐）过程中的VAS评分来评价会阴切开的疼痛。难以忍受的疼痛（VAS>30 mm）则用每12h
700mg尼氟酸栓剂予以治疗。主要结果变量为会阴切开后48h内静息及活动时的疼痛评分。
结果：两组间人口统计学和产科特征方面均无差异。所有病人都成功完成了会阴神经刺激。试验组患者产后3、6、12、24和48
h时静息状态时的疼痛评分显著低于对照组(P
< 0.05)，在坐和步行时同样也获得了更好的镇痛效果。试验组和对照组分别有3位(15%)和17位(85%)病人需要额外镇痛治疗(P < 0.001)。
结论：此项研究显示用7.5mg/mL罗哌卡因行神经刺激器引导下的单侧会阴神经阻滞可以减弱会阴切开术后初始48h内的疼痛，并减少额外镇痛药的需要量。
（黄佳佳译，马皓琳 李士通校）
BACKGROUND: Pain
from episiotomy or perineal tears during childbirth is associated
with significant pain in the postpartum period. We performed this
randomized, double-blind, controlled trial to investigate the
efficacy of nerve stimulator-guided unilateral pudendal nerve block
for pain relief after episiotomy.
METHODS: Forty women
who gave birth vaginally with mediolateral episiotomy were
randomized to receive pudendal nerve block with 15 mL of either
ropivacaine 7.5 mg/mL (pudendal group) or normal saline (control
group) after repair of the episiotomy. Episiotomy pain was assessed
with a visual analog scale at rest at 3, 6, 12, 24, and 48 h
postepisiotomy and during activities (walking and sitting).
Breakthrough pain (visual analog scale >30 mm) was treated with
niflumic acid suppositories 700 mg every 12 h. The primary outcome
variables were pain scores at rest and during activities over 48 h
postpartum.
RESULTS: Demographic
and obstetric characteristics were not different between groups.
Successful pudendal nerve stimulation was achieved in all patients.
Patients in the pudendal group reported significantly lower pain
scores at rest than those in the control group at 3, 6, 12, 24, and
48 h after delivery (P < 0.05). They also reported
better analgesia while sitting and walking (P < 0.05). Additional analgesia was required by
three patients (15%) in the pudendal group versus 17 patients (85%)
in the placebo group (P <
0.001).
CONCLUSION: This
study demonstrates that nerve stimulator-guided unilateral pudendal
nerve block with ropivacaine 7.5 mg/mL is associated with decreased
pain and need for additional analgesics during the first 48 h
postepisiotomy.
Intravenous Dexmedetomidine Decreases Lung Permeability
Induced by Intracranial Hypertension in Rats
Motoi Kumagai, MD, Takashi Horiguchi, MD, Toshiaki
Nishikawa, MD, Yoko Masaki, PhD, and Yoshitugu Tobe, BA
From the Department of Anesthesia and Intensive Care, Akita
University School of Medicine, Akita, Japan.
Anesth Analg 2008;
107:643-647
背景：脑池内右美托咪定（DEX）减少颅内高压大鼠的心功能不全。然而，在颅内高压期间右美托咪定静脉给药对心功能和肺通透性方面的影响还未被评估过。我们假设右美托咪定静脉给药能减少大鼠颅内高压引起的血流动力学改变和肺通透性，并进行测试。
方法：氟烷麻醉并机械通气的大鼠分成4组。其中两组置入硬膜下带气囊的导管，充气60s以产生颅内高压。颅内高压前和后30min行动脉血气分析。平均动脉压、心率、颅内压持续监测30min。Dex组（n=8）静脉给右美托咪定首量80
µg/kg，继而6 µg · kg–1 · min–1(40 µg/mL)持续10 min，对照组（n=8）静脉给生理盐水首量2
mL/kg，继而0.15 mL · kg–1 · min–1持续 10 min。非颅内高压下施行手术，分为给右美托咪定（伪装-Dex组，n=5）和不给右美托咪定（伪装-对照,
n = 5）。所有组用伊文思蓝染色渗出技术测量肺通透性。处死前2h给予伊文思蓝染料20
mg/kg，并用双波长分光光度分析技术量化血浆和肺组织中的伊文思蓝。
结果：各组间基础动脉压、心率、Pao2 均无显著性差异。对照组中，颅内高压短暂地增加平均动脉压和心率，随即迅速下降进入平台期。在Dex组，平均动脉压短暂升高，然后迅速降至基线，然而颅内高压时心率并未变化。颅内高压后Dex组Pao2比对照组高[138
(127–169)比78 (59–124) mm Hg, 中位数 (范围), P < 0.01]。肺通透性指数Dex组比对照组低[430 (182–450)比570
(427–1170), P < 0.01]。但伪装-Dex组比伪装-对照组高[25
(24–35)比6 (4–7), P <
0.01]。
结论：预防性静脉给予右美托咪定能减少大鼠颅内高压引起的肺通透性和血流动力学变化。
（朱 慧译 马皓琳 李士通校）
BACKGROUND: Intracisternal
dexmedetomidine (Dex) attenuates cardiac dysfunction in rats with
intracranial hypertension (ICH). However, the effects of IV Dex on
cardiac function and lung permeability during ICH have not been
evaluated. We tested the hypothesis that IV Dex attenuates
hemodynamic changes and decreases lung permeability induced by ICH
in rats.
METHODS: Halothane-anesthetized
and mechanically ventilated rats were divided into four groups. In
two groups, a subdural balloon catheter was inflated for 60 s to
produce ICH. Arterial blood gas analysis was performed before and 30
min after ICH. Mean arterial blood pressure, heart rate (HR) and
intracranial pressure were monitored for 30 min. The Dex group (n
= 8) received IV Dex 80 µg/kg, followed by 6 µg · kg–1 ·
min–1 (40 µg/mL) for 10 min and the control group (n = 8) received IV saline 2 mL/kg, followed by at 0.15
mL · kg–1 · min–1 for 10 min. Surgery was
performed without ICH with Dex (Sham-Dex group, n = 5) and without Dex (Sham-control, n = 5). In all groups, pulmonary permeability
was measured using a modification of the Evans blue dye
extravasation technique. IV Evans blue dye 20 mg/kg was administered
2 h before being killed and Evans blue dye in plasma and lung tissue
was quantified by dual-wavelength spectrophotometric analysis.
RESULTS: There were
no significant differences in basal arterial blood pressure, HR, and
Pao2 among groups. In the control group, ICH resulted in
transient increases in mean arterial blood pressure and HR, followed
by a rapid decline and a plateau. In the Dex group, mean arterial
blood pressure showed a transient increase and subsequent, rapid
decrease to baseline, whereas HR did not change during ICH. Pao2
was higher in the Dex group than in the control group after ICH [138
(127–169) vs 78 (59–124) mm Hg, median (range), P <
0.01]. The pulmonary permeability index was lower in the Dex group
than the control group [430 (182–450) vs 570 (427–1170), P < 0.01]. It was however, higher in the
Sham-Dex group than the Sham-Control group [25 (24–35) vs 6 (4–7), P < 0.01].
CONCLUSIONS: Prophylactic
IV Dex decreases lung permeability as well as hemodynamic changes
induced by ICH in rats.
The Effect of Acupressure at the Extra 1 Point on
Subjective and Autonomic Responses to Needle Insertion
Young-Chang P. Arai, MD*, Takahiro Ushida, MD*,
Tomoaki Osuga, MD*, Takako Matsubara, PT*, Kahori Oshima_files/image132.gif){kind=small}
,
Kana Kawaguchi_files/image133.gif){kind=small}
,
Chiaki Kuwabara_files/image134.gif){kind=small}
,
Sigeya Nakao_files/image135.gif){kind=small}
,
Atsushi Hara_files/image136.gif){kind=small}
,
Chihiro Furuta_files/image137.gif){kind=small}
,
Erina Aida_files/image138.gif){kind=small}
,
Shugyoku Ra_files/image139.gif){kind=small}
,
Yui Takagi_files/image140.gif){kind=small}
,
and Kyoko Watakabe_files/image141.gif){kind=small}
From the *Multidisciplinary Pain Center, and _files/image142.gif){kind=small}
Society
for Chinese and Kampo Medicine, Aichi Medical University, Aichi, Japan.
Anesth Analg 2008;
107:661-664
背景：术前镇静药可以减少创伤性麻醉操作的不适感。一些研究者表示在针刺特别1点上的针压法有镇静效果。我们研究在特别1点上的针压法是否能减轻插针的疼痛。
方法：我们用口述等级量表（VRS）疼痛分数和心率变异性（HRV）研究针压特别1点和假点对插针的效果。22例健康女性志愿者随机分为2组：特别1点组接受针压法针压特别1点，假点组接受针压假点。心电图记录开始后，27号针插入前臂皮肤。随后，在针压法过程中另一个针头插入另一前臂皮肤。
结果：针压特别1点明显减轻VRS，但针压在假点能增加VRS。针压特别1点明显减轻HRV对针刺的低频率/高频率反应。
结论：与假点比较，针压特别1点明显减轻插针疼痛。针压特别1点明显减少插针引起HRV低频率/高频率反应，表明减少交感神经系统活性。
（彭中美 译 马皓琳 李士通 校）
BACKGROUND: Premedication
with sedatives can decrease the discomfort associated with invasive
anesthetic procedures. Some researchers have shown that acupressure
on the acupuncture extra 1 point is effective for sedation. We
investigated whether acupressure on the extra 1 point could
alleviate the pain of needle insertion.
METHODS: We
investigated the effect of acupressure at the extra 1 point or a
sham point on needle insertion using verbal rating scale (VRS) pain
scores and heart rate variability (HRV). Twenty-two healthy female
volunteers were randomly allocated to two groups: the extra 1 group
received acupressure at the extra 1 point, and the sham group received
acupressure at a sham point. After starting the electrocardiogram
record, a 27-gauge needle was inserted into the skin of a forearm.
Thereafter, another needle was inserted into the skin of the other
forearm during acupressure.
RESULTS: Acupressure
at the extra 1 point significantly reduced the VRS, but acupressure
at the sham increased the VRS. Acupressure at the extra 1
significantly reduced the low frequency/high frequency ratio of HRV
responding to needle insertion.
CONCLUSIONS: Acupressure
at the extra 1 point significantly reduced needle insertion pain
compared with acupressure at the sham point. Also, acupressure at
the extra 1 point significantly reduced the low frequency/high
frequency ratio of HRV responding to needle insertion, which implies
a reduction in sympathetic nervous system activity.
Modulators of Calcium Influx Regulate Membrane
Excitability in Rat Dorsal Root Ganglion Neurons
Philipp Lirk, MD*_files/image143.gif){kind=small}
,
Mark Poroli, BS*, Marcel Rigaud, MD*, Andreas Fuchs, MD*_files/image144.gif){kind=small}
,
Patrick Fillip, MD*, Chun-Yuan Huang, PhD*, Marko
Ljubkovic, MD*, Damir Sapunar, MD, PhD*_files/image145.gif){kind=small}
,
and Quinn Hogan, MD*||
From the *Department of Anesthesiology, Medical College of
Wisconsin, Milwaukee, Wisconsin; _files/image146.gif){kind=small}
Department
of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck,
Innsbruck, Austria; _files/image147.gif){kind=small}
Department
of Intensive Care and Anesthesiology, Medical University of Graz, Graz,
Austria; _files/image148.gif){kind=small}
University
of Split Medical School, Split, Croatia; and ||Department of Anesthesiology,
Milwaukee Veterans Administration Medical Center, Milwaukee, Wisconsin.
Anesth Analg 2008;
107:673-685
背景：神经元损伤导致的慢性神经性疼痛至今仍治疗困难，部分的原因是疼痛的细胞机制还不完全清楚。我们以往的研究显示，在啮齿类动物慢性神经性疼痛模型中，通过感觉神经元质膜的钙离子内流明显降低，但钙电流丧失对感觉神经功能的直接后果并未确定。因此我们研究了与钙内流消失相关的，神经损伤后神经膜性质变化，尤其是其兴奋性提高到哪种程度会导致慢性疼痛。
方法：从未受损伤的大鼠背根神经节上分离Ａ型神经元，用细胞内微电极进行测定。在测定兴奋性和生物物理学常数时，改变记录条件以抑制或增强钙内流。
结果：降低外部浴槽中钙离子的浓度或用浴槽镉阻断钙内流，都使后超极化的持续时间和面积减少，并伴有动作电位初始的电流阈值的降低和持续去极化期间的反复触发增多。相反地，提高细胞外液钙离子浓度可以增强细胞后超极化，抑制反复触发。神经元超极化时膜电位下降，是由阳离子非选择性H电流造成的，降低浴槽中钙离子的浓度、用镉阻断钙电流，或细胞内钙离子的螯合剂都会抑制这个电流。使用钙内流亚型的选择性阻滞剂的研究提示，N-、P/Q、L-和 R-型电流对细胞后超极化的产生均有影响，且阻断任何一种钙通道电流，均会降低动作电位的上升速度，延长动作电位时程，且（除了L型钙通道）降低引发动作电位的电流阈值。
结论：总之，我们的研究显示抑制内向钙电流会降低后超极化，减少超极化诱发的电压降低，提高感觉细胞元的兴奋性，重复这样的改变可能导致外周神经的损伤。这说明，损伤的感觉神经元中内向钙电流的降低会引发其功能障碍和过度兴奋，并可能导致神经性疼痛。
（张莹译 马皓琳 李士通校）
BACKGROUND: Chronic
neuropathic pain resulting from neuronal damage remains difficult to
treat, in part, because of incomplete understanding of underlying
cellular mechanisms. We have previously shown that inward Ca2+
flux (ICa) across the sensory neuron plasmalemma is
decreased in a rodent model of chronic neuropathic pain, but the
direct consequence of this loss of ICa on function of the
sensory neuron has not been defined. We therefore examined the
extent to which altered membrane properties after nerve injury,
especially increased excitability that may contribute to chronic
pain, are attributable to diminished Ca2+ entry.
METHODS: Intracellular
microelectrode measurements were obtained from A-type neurons of
dorsal root ganglia excised from uninjured rats. Recording
conditions were varied to suppress or promote ICa while
biophysical variables and excitability were determined.
RESULTS: Both
lowered external bath Ca2+ concentration and blockade of
ICa with bath cadmium diminished the duration and area of
the after-hyperpolarization (AHP), accompanied by decreased current
threshold for action potential (AP) initiation and increased repetitive
firing during sustained depolarization. Reciprocally, elevated bath
Ca2+ increased the AHP and suppressed repetitive firing.
Voltage sag during neuronal hyperpolarization, indicative of the
cation-nonselective H-current, diminished with decreased bath Ca2+,
cadmium application, or chelation of intracellular Ca2+.
Additional recordings with selective blockers of ICa subtypes showed
that N-, P/Q, L-, and R-type currents each contribute to generation
of the AHP and that blockade of any of these, and the T-type
current, slows the AP upstroke, prolongs the AP duration, and
(except for L-type current) decreases the current threshold for AP
initiation.
CONCLUSIONS: Taken
together, our findings show that suppression of ICa
decreases the AHP, reduces the hyperpolarization-induced voltage
sag, and increases excitability in sensory neurons, replicating
changes that follow peripheral nerve trauma. This suggests that the
loss of ICa previously demonstrated in injured sensory
neurons contributes to their dysfunction and hyperexcitability, and
may lead to neuropathic pain.
不同浓度及容量的局麻药行连续腘窝坐骨神经阻滞的效果：一项双中心、随机、对照研究
The Effects of Varying Local Anesthetic Concentration and
Volume on Continuous Popliteal Sciatic Nerve Blocks: A Dual-Center, Randomized,
Controlled Study
Brian M. Ilfeld, MD, MS*, Vanessa J. Loland, MD*,
J. C. Gerancher, MD_files/image149.gif){kind=small}
,
Anupama N. Wadhwa, MD_files/image150.gif){kind=small}
,
Elizabeth M. Renehan, MSc, MD_files/image151.gif){kind=small}
,
Daniel I. Sessler, MD||, Jonathan J. Shuster, PhD¶,
Douglas W. Theriaque, MS#, Rosalita C. Maldonado, BS*,
Edward R. Mariano, MD* For the PAINfRETM Investigators
From the *Department of Anesthesiology, University of
California San Diego, San Diego, California; _files/image152.gif){kind=small}
Department
of Anesthesiology, Wake Forest Medical Center; _files/image153.gif){kind=small}
Department
of Anesthesiology, University of Louisville, Louisville, Kentucky; _files/image154.gif){kind=small}
Department
of Anesthesiology, University of Ottawa, Ottawa, Ontario, Canada; ||Department
of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio; ¶Department of
Epidemiology and Health Policy Research, and #General Clinical Research Center,
University of Florida, Gainesville, Florida.
Anesth Analg 2008;
107:701-707
背景：对于影响持续周围神经阻滞作用的主要因素是局麻药浓度还是仅为总药量，尚未明了。因此我们检验了这样一个检验假设，即使用不同浓度及速率、但总剂量相等的罗哌卡因行连续腘窝坐骨神经阻滞产生的效果相似。
方法：选择行中度疼痛的脚踝或脚踝远端部位矫形手术的患者，术前均从后腘窝径路插入神经周围导管到坐骨神经附近。术后将患者随机分成两组：术后第二天神经周围输注罗哌卡因0.2%
(基础 8 mL/h，单次加量 4 mL)或 0.4% (基础4 mL/h, 单次加量2 mL)。因此，两组患者在每个小时内都接受了16 mg的罗哌卡因，通过病人自控的单次加量，每30分钟可能接受额外的8
mg。主要观察指标为从术后早晨开始的24小时内令人不快的肢体失去知觉的发生率。次要观察指标包括镇痛及病人满意度。
结果：与0.4%罗哌卡因组患者(n = 25)经历肢体无知觉0.6 (1.1) 〔均数（标准差）〕次比较，0.2%罗哌卡因组(n = 25)为1.8 (1.8)次，（估计的差异=1.2次，95%可信区间，0.3–2.0次；P = 0.009)。相反，镇痛及满意度各组相似。
结论：对于连续腘窝坐骨神经阻滞，局麻药的浓度及容量影响其阻滞特性。使用较大容量相对低浓度的罗哌卡因时，患者肢体失去知觉更常见。因此在行连续腘窝坐骨神经阻滞时，使用相对高浓度较低容量的罗哌卡因似乎更可取。
（裘毅敏译，马皓琳、李士通校）
BACKGROUND: It
remains unknown whether local anesthetic concentration, or simply
total drug dose, is the primary determinant of continuous peripheral
nerve block effects. We therefore tested the null hypothesis that
providing different concentrations and rates of ropivacaine, but at
equal total doses, produces comparable effects when used in a
continuous sciatic nerve block in the popliteal fossa.
METHODS: Preoperatively,
a perineural catheter was inserted adjacent to the sciatic nerve
using a posterior popliteal approach in patients undergoing
moderately painful orthopedic surgery at or distal to the ankle.
Postoperatively, patients were randomly assigned to receive a perineural
ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or
0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative
day. Therefore, both groups received 16 mg of ropivacaine each hour
with a possible addition of 8 mg every 30 min via a
patient-controlled bolus dose. The primary end point was the
incidence of an insensate limb, considered undesirable, during the
24-h period beginning the morning after surgery. Secondary end
points included analgesia and patient satisfaction.
RESULTS: Patients
given 0.2% ropivacaine (n = 25) experienced an
insensate limb with a mean (sd) of 1.8 (1.8) times, compared with
0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95%
confidence interval, 0.3–2.0 episodes; P = 0.009). In contrast, analgesia and
satisfaction were similar in each group.
CONCLUSIONS: For
continuous popliteal-sciatic nerve blocks, local anesthetic
concentration and volume influence block characteristics. Insensate
limbs were far more common with larger volumes of relatively dilute
ropivacaine. During continuous sciatic nerve block in the popliteal
fossa, a relatively concentrated solution in smaller volume thus
appears preferable.