Table of Contents

September 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

吸入低浓度七氟烷增强抗消化性溃疡药物替普瑞酮的迟发性心脏保护作用

王宏   马皓琳 李士通

Low-Dose Sevoflurane Inhalation Enhances Late Cardioprotection from the Anti-Ulcer Drug Geranylgeranylacetone

Hiroshi Kitahata, Junpei Nozaki, Shinji Kawahito, Takehito Tomino, and Shuzo Oshita

Anesth Analg 2008 107: 755-761.

氦诱导预处理的作用:氧化亚氮对兔子的直接作用

胡艳译   薛张刚校

The Mechanism of Helium-Induced Preconditioning: A Direct Role for Nitric Oxide in Rabbits

Paul S. Pagel, John G. Krolikowski, Phillip F. Pratt, Jr, Yon Hee Shim, Julien Amour, David C. Warltier, and Dorothee Weihrauch

Anesth Analg 2008 107: 762-768.

抑制糖原合成激酶或细胞凋亡蛋白p53降低了氦在体心肌保护的阈值:线粒体通透性的作用

潘方立 陈杰

Inhibition of Glycogen Synthase Kinase or the Apoptotic Protein p53 Lowers the Threshold of Helium Cardioprotection In Vivo: The Role of Mitochondrial Permeability Transition

Paul S. Pagel, John G. Krolikowski, Phillip F. Pratt, Jr, Yon Hee Shim, Julien Amour, David C. Warltier, and Dorothee Weihrauch

Anesth Analg 2008 107: 769-775.

衰老大鼠心脏异氟烷预处理和活性氧产生的弱化作用的研究

江继宏   马皓琳 李士通

Attenuation of Isoflurane-Induced Preconditioning and Reactive Oxygen Species Production in the Senescent Rat Heart

Long T. Nguyen, Mario J. Rebecchi, Leon C. Moore, Peter S. A. Glass, Peter R. Brink, and Lixin Liu

Anesth Analg 2008 107: 776-782.

抑肽酶在婴儿动脉转接术中的功效

黄凝译  薛张纲校

The Efficacy of Aprotinin in Arterial Switch Operations in Infants

Chinnamuthu Murugesan, Sanjay Kumar Banakal, Rajnish Garg, Shankaraiah Keshavamurthy, and Kanchi Muralidhar

Anesth Analg 2008 107: 783-787.

PEDIATRIC ANESTHESIOLOGY:

硫喷妥钠/七氟醚麻醉下小儿的正中神经躯体感觉诱发电位及酮基布洛芬和芬太尼的对其的附加作用

周姝婧 陈杰

Somatosensory Evoked Potentials by Median Nerve Stimulation in Children During Thiopental/Sevoflurane Anesthesia and the Additive Effects of Ketoprofen and Fentanyl

Susanna Westerén-Punnonen, Heidi Yppärilä-Wolters, Juhani Partanen, Kari Nieminen, Antti Hyvärinen, and Hannu Kokki

Anesth Analg 2008 107: 799-805.

不同浓度丙泊酚对小儿心肌复极化分散的影响

张莹译  马皓琳 李士通校

The Effect of Propofol Concentration on Dispersion of Myocardial Repolarization in Children

Helen V. Hume-Smith, Shubhayan Sanatani, Joanne Lim, Anthony Chau, and Simon D. Whyte

Anesth Analg 2008 107: 806-810.

(印堂)指压疗法用于儿童麻醉

蒋宗明译 薛张纲校

Extra-1 Acupressure for Children Undergoing Anesthesia

Shu-Ming Wang, Sandra Escalera, Eric C. Lin, Inna Maranets, and Zeev N. Kain

Anesth Analg 2008 107: 811-816.

AMBULATORY ANESTHESIOLOGY:

氧化亚氮在妇科腔镜手术术后恶心的剂量-反应关系的初步研究

於章杰 陈杰

The Dose–Response of Nitrous Oxide in Postoperative Nausea in Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study

Boris Mraovic, Tatjana Simurina, Zdenko Sonicki, Neven Skitarelic, and Tong J. Gan

Anesth Analg 2008 107: 818-823.

鞘内注射布比卡因和利多卡因的混合液的持续时间

张曦 译,马皓琳 李士通

The Duration of Intrathecal Bupivacaine Mixed with Lidocaine

Sung-Jin Lee, Sun-Joon Bai, Jong-Seok Lee, Won-Ok Kim, Yang-Sik Shin, and Ki-Young Lee

Anesth Analg 2008 107: 824-827.

ANESTHETIC PHARMACOLOGY:

我们是否还需要一个新的例证来阐明吸入性麻醉药产生麻醉效应的机制?

刘沁译 薛张纲校

Is a New Paradigm Needed to Explain How Inhaled Anesthetics Produce Immobility? (Review Article)

Edmond I. Eger, II, Douglas E. Raines, Steven L. Shafer, Hugh C. Hemmings, Jr, and James M. Sonner

Anesth Analg 2008 107: 832-848.

关于对吸入麻醉药反应的起源与演变的假说

赵嫣红 陈杰

A Hypothesis on the Origin and Evolution of the Response to Inhaled Anesthetics (Review Article)

James M. Sonner

Anesth Analg 2008 107: 849-854.  

表面活性物质对受体功能的麻醉药样调变:对麻醉界面理论的一个检验

黄施伟 译,马皓琳 李士通

Anesthetic-Like Modulation of Receptor Function by Surfactants: A Test of the Interfacial Theory of Anesthesia

Liya Yang and James M. Sonner

Anesth Analg 2008 107: 868-874.

大鼠蛛网膜下腔注射藜芦定增加MAC值的研究

刘婷洁译  薛张纲校

Intrathecal Veratridine Administration Increases Minimum Alveolar Concentration in Rats

Yi Zhang, Manohar Sharma, Edmond I. Eger, II, Michael J. Laster, Hugh C. Hemmings, Jr, and R. Adron Harris

Anesth Analg 2008 107: 875-878.

脑脊髓液中钾离子浓度的增加并不引起大鼠异氟醚MAC的增加

怀晓蓉 陈杰

Increases in Spinal Cerebrospinal Fluid Potassium Concentration Do Not Increase Isoflurane Minimum Alveolar Concentration in Rats

Dimitry Shnayderman, Michael J. Laster, Edmond I. Eger, II, Irene Oh, Yi Zhang, Steven L. Jinks, Joseph F. Antognini, and Douglas E. Raines

Anesth Analg 2008 107: 879-884.

低临床浓度异氟烷能预防小鼠脊髓由烟碱诱发的去甲肾上腺素释放

颜涛 译,马皓琳 李士通

Isoflurane Prevents Nicotine-Evoked Norepinephrine Release from the Mouse Spinal Cord at Low Clinical Concentrations

Thomas J. Rowley and Pamela Flood

Anesth Analg 2008 107: 885-889.

TECHNOLOGY, COMPUTING, AND SIMULATION:

红外测量人类呼吸中的二氧化碳:回顾从Tyndall到现在的“呼吸通过”装置

唐亮   马皓琳 李士通

Infrared Measurement of Carbon Dioxide in the Human Breath: "Breathe-Through" Devices from Tyndall to the Present Day (Special Article)

Michael B. Jaffe

Anesth Analg 2008 107: 890-904.

新生儿及小儿应用经食管脉搏血氧测定法的实验性研究

秦敏菊译 薛张纲校

A Pilot Study of Neonatal and Pediatric Esophageal Pulse Oximetry (Technical Communication)

Panayiotis A. Kyriacou, Deric P. Jones, Richard M. Langford, and Andy J. Petros

Anesth Analg 2008 107: 905-908.

PATIENT SAFETY:

一项在体代谢试验用于检测人群中恶性高热易感性:一项初步研究

叶乐 陈杰

An In-Vivo Metabolic Test for Detecting Malignant Hyperthermia Susceptibility in Humans: A Pilot Study

Frank Schuster, Thomas Metterlein, Sabrina Negele, Peter Kranke, Ralf M. Muellenbach, Ulrich Schwemmer, Norbert Roewer, and Martin Anetseder

Anesth Analg 2008 107: 909-914.

困难气管插管的患者,可能需要转介到睡眠诊所

施颖译 薛张纲校

Patients with Difficult Intubation May Need Referral to Sleep Clinics

Frances Chung, Balaji Yegneswaran, Francisco Herrera, Alex Shenderey, and Colin M. Shapiro

Anesth Analg 2008 107: 915-920.

CRITICAL CARE AND TRAUMA:

自适应辅助通气时潮气量的确定:一项多中心观察研究

张磊 陈杰

Determinants of Tidal Volumes with Adaptive Support Ventilation: A Multicenter Observational Study

Dave A. Dongelmans, Denise P. Veelo, Alexander Bindels, Jan M. Binnekade, Kees Koppenol, Matty Koopmans, Joke C. Korevaar, Michael A. Kuiper, and Marcus J. Schultz

Anesth Analg 2008 107: 932-937.

经皮扩张气管切开术相关的适应性辅助通气:一项临床研究

吴进   马皓琳 李士通

Adaptive Support Ventilation with Percutaneous Dilatational Tracheotomy: A Clinical Study (Brief Report)

Denise P. Veelo, Dave A. Dongelmans, Pauline Middelhoek, Johanna C. Korevaar, and Marcus J. Schultz

Anesth Analg 2008 107: 938-940.

不同气管内吸引方法对FRC的影响

 孙鹏飞译 薛张纲校

Functional Residual Capacity Changes After Different Endotracheal Suctioning Methods (Brief Report)

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

Anesth Analg 2008 107: 941-944.

OBSTETRIC ANESTHESIOLOGY:

择期剖腹产鞘内注射可乐定对术后抗痛觉过敏和镇痛作用的评估

朱紫瑜 陈杰

An Evaluation of the Postoperative Antihyperalgesic and Analgesic Effects of Intrathecal Clonidine Administered During Elective Cesarean Delivery

Patricia M. Lavand’homme, Fabienne Roelants, Hilde Waterloos, Valerie Collet, and Marc F. De Kock

Anesth Analg 2008 107: 948-955.

产科病人中椎管内运用阿片类药物后发生呼吸抑制

姜旭晖译,马皓琳,李士通校

Respiratory Depression After Neuraxial Opioids in the Obstetric Setting (Review Article)

Brendan Carvalho

Anesth Analg 2008 107: 956-961.

NEUROSURGICAL ANESTHESIOLOGY:

神经外伤患者的脑灌注压研究

夏俊明译 薛张纲校
Cerebral Perfusion Pressure in Neurotrauma: A Review
(Review Article)

Hayden White and Bala Venkatesh

Anesth Analg 2008 107: 979-988.

GENERAL ARTICLES:

颈部伸展时气管拉长:气管的哪一段伸长了?

陶颖莹 陈杰

Lengthening of the Trachea During Neck Extension: Which Part of the Trachea Is Stretched?

David T. Wong, Hao Weng, Eunice Lam, Hai-Bao Song, and Jin Liu

Anesth Analg 2008 107: 989-993.

钢丝强化硅树脂管与Parker管及聚氯乙烯管用于正常气道患者全麻下经喉罩插管的比较

裘毅敏译,马皓琳、李士通校

A Comparison of a Silicone Wire-Reinforced Tube with the Parker and Polyvinyl Chloride Tubes for Tracheal Intubation Through an Intubating Laryngeal Mask Airway in Patients with Normal Airways Undergoing General Anesthesia

Ghassan E. Kanazi, Mohammed El-Khatib, Viviane G. Nasr, Romeo Kaddoum, Achir Al-Alami, Anis S. Baraka, and Chakib M. Ayoub

Anesth Analg 2008 107: 994-997.

ANALGESIA:

透皮吸收烟碱用于前列腺术后镇痛

章一静译 薛张纲校

Transdermal Nicotine for Analgesia After Radical Retropubic Prostatectomy

Ashraf S. Habib, William D. White, Magdi A. El Gasim, Gamal Saleh, Thomas J. Polascik, Judd W. Moul, and Tong J. Gan

Anesth Analg 2008 107: 999-1004.

经皮烟碱贴剂作为术后疼痛处理:一项剂量范围研究

丁俊云 译 陈杰 校

Transdermal Nicotine Patch for Postoperative Pain Management: A Pilot Dose-Ranging Study

Daewha Hong, Jessamyn Conell-Price, Sean Cheng, and Pamela Flood

Anesth Analg 2008 107: 1005-1010.

经皮烟碱贴剂不能改善术后疼痛治疗

朱慧译 马皓琳 李士通校

Transdermal Nicotine Patch Failed to Improve Postoperative Pain Management

Alparslan Turan, Paul F. White, Onur Koyuncu, Beyhan Karamanliodlu, Gaye Kaya, and Christian C. Apfel

Anesth Analg 2008 107: 1011-1017.

血压和压力感受器敏感性对兴奋性升级现象的影响

宣丽真译 薛张纲校

The Impact of Blood Pressure and Baroreflex Sensitivity on Wind-Up

Ok Yung Chung and Stephen Bruehl

Anesth Analg 2008 107: 1018-1025.

区域麻醉技术用于开胸手术术后镇痛的随机试验――系统综述

舒慧刚 陈杰

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia

Girish P. Joshi, Francis Bonnet, Rajesh Shah, Roseanne C. Wilkinson, Frederic Camu, Barrie Fischer, Edmund A. M. Neugebauer, Narinder Rawal, Stephan A. Schug, Christian Simanski, and Henrik Kehlet

Anesth Analg 2008 107: 1026-1040.

持续输注低剂量的氯胺酮改善颈椎手术后病人自控镇痛的芬太尼的镇痛效果

黄丽娜  马皓琳 李士通

Continuous Low-Dose Ketamine Improves the Analgesic Effects of Fentanyl Patient-Controlled Analgesia After Cervical Spine Surgery (Brief Report)

Masanori Yamauchi, Makoto Asano, Masanori Watanabe, Soushi Iwasaki, Shingo Furuse, and Akiyoshi Namiki

Anesth Analg 2008 107: 1041-1044.

在小鼠损伤的背根神经元中通过恢复钙内流可以纠正胞膜的过度兴奋状态

陈珺珺译 薛张纲校

Restoration of Calcium Influx Corrects Membrane Hyperexcitability in Injured Rat Dorsal Root Ganglion Neurons

Quinn Hogan, Philipp Lirk, Mark Poroli, Marcel Rigaud, Andreas Fuchs, Patrick Fillip, Marko Ljubkovic, Geza Gemes, and Damir Sapunar

Anesth Analg 2008 107: 1045-1051.

烟碱受体激动剂在小鼠术后疼痛模型中的抗伤害作用

杜唯佳 陈杰

The Antinociceptive Response to Nicotinic Agonists in a Mouse Model of Postoperative Pain

Thomas J. Rowley, James Payappilly, Jeffery Lu, and Pamela Flood

Anesth Analg 2008 107: 1052-1057.

砷化镓铝(830nm)低水平激光预照射血液可增强大鼠外周内源性阿片类物质镇痛作用

周雅春 马皓琳 李士通

Pre-Irradiation of Blood by Gallium Aluminum Arsenide (830 nm) Low-Level Laser Enhances Peripheral Endogenous Opioid Analgesia in Rats

Satoshi Hagiwara, Hideo Iwasaka, Akira Hasegawa, and Takayuki Noguchi

Anesth Analg 2008 107: 1058-1063.

结扎小鼠脊神经后,神经妥乐平通过激活下行疼痛抑制系统起到镇痛作用

陈珺珺译 薛张纲校

The Antiallodynic Effect of Neurotropin® Is Mediated via Activation of Descending Pain Inhibitory Systems in Rats with Spinal Nerve Ligation

Ryohei Okazaki, Hiroyoshi Namba, Hiroyuki Yoshida, Hisashi Okai, Tomoshi Miura, and Minoru Kawamura

Anesth Analg 2008 107: 1064-1069.

REGIONAL ANESTHESIA:

超声成像精确定位股外侧神经

刘世文 陈杰

Ultrasound Imaging Accurately Identifies the Lateral Femoral Cutaneous Nerve

Irene Ng, Himat Vaghadia, Peter T. Choi, and Naeder Helmy

Anesth Analg 2008 107: 1070-1074.

比较超声“双泡征”引导的锁骨下臂丛神经阻滞和神经刺激器引导的腋路臂丛神经阻滞

黄佳佳译,马皓琳 李士通

A Comparison Between Ultrasound-Guided Infraclavicular Block Using the "Double Bubble" Sign and Neurostimulation-Guided Axillary Block (Brief Report)

De Q. H. Tran, Antonio Clemente, Don Q. Tran, and Roderick J. Finlayson

Anesth Analg 2008 107: 1075-1078.

多孔硬膜外导管和单孔导管的功能一致:在离体试验中

陈珺珺译 薛张纲校

Epidural Multiorifice Catheters Function as Single-Orifice Catheters: An In Vitro Study (Brief Report)

Allison J. Fegley, Jerrold Lerman, and Richard Wissler

Anesth Analg 2008 107: 1079-1081.

 

氦诱导预处理的作用:氧化亚氮对兔子的直接作用

The mechanism of helium-induced preconditioning: a direct role for nitric oxide in rabbits.

Paul S. Pagel, John G. Krolikowski, Phillip F. Pratt, Jr, Yon Hee Shim, Julien Amour, David C. Warltier, and Dorothee Weihrauch

Department of Anesthesiology, Medical College of Wisconsin, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 W. National Ave., Milwaukee, WI 53295, USA.

Anesth Analg 2008 107: 762-768.

 

背景:氦诱导预处理通过激活已存的信号来防止心肌梗,这一作用是否由内皮一氧化氮合酶产生的一氧化氮介导还是未知的。我们假设氦诱导对活体心肌的保护作用是由一氧化氮介导的进行试验。

方法:我们将62只兔子进行血流动力学检测,给与非选择性一氧化氮合酶——N-硝基-L-精氨酸甲酯(L-NAME; 10 mg/kg)或者给与选择性的一氧化氮合酶抑制剂——盐酸氨基胍(AG; 300 mg/kg)或者给与神经选择性一氧化氮合酶抑制剂——7-硝基吲唑(7-NI; 50 mg/kg)进行预处理,同时给与0.9%的生理盐水(对照组)或者吸入70%氦和30%氧的混合气5分钟,再吸入空氧混合气5分钟,如此3个循环后,将冠状动脉左前降支阻断30分钟,然后进行3小时的再灌注。所有兔子,无论是用没用L-NAME均用DAF-2DA荧光探针及共聚焦激光显微镜检查有无一氧化氮的产生。

结果:氦减少梗塞的心肌面积(24%+/-4%左室面积)(P<0.05),对照组为46%+/-4%L-NAME, AG, 7-NI单独使用不能改变心肌梗塞得面积。L-NAME可以拮抗氦诱导的心肌保护。与对照组相比,氦可以提高DAF-2DA荧光(26 +/- 8 vs 15 +/- 5 U)。用L-NAME预处理后氦诱导的不能增强DAF-2DA荧光。

结论:结果提示氦的心肌保护作用是由活体内皮的一氧化氮合酶产生的一氧化氮介导的。

(胡艳译   薛张刚校)

BACKGROUND: Helium produces preconditioning against myocardial infarction by activating prosurvival signaling, but whether nitric oxide (NO) generated by endothelial NO synthase plays a role in this phenomenon is unknown. We tested the hypothesis that NO mediates helium-induced cardioprotection in vivo.

METHODS: Rabbits (n = 62) instrumented for hemodynamic measurement were subjected to a 30-min left anterior descending coronary artery occlusion and 3 h reperfusion, and received 0.9% saline (control) or three cycles of 70% helium-30% oxygen administered for 5 min interspersed with 5 min of an air-oxygen mixture before left anterior descending coronary artery occlusion in the absence or presence of pretreatment with the nonselective NOS inhibitor N-nitro-l-arginine methyl ester (L-NAME; 10 mg/kg), the selective inducible NOS inhibitor aminoguanidine hydrochloride (AG; 300 mg/kg), or selective neuronal NOS inhibitor 7-nitroindazole (7-NI; 50 mg/kg). In additional rabbits, the fluorescent probe 4,5-diaminofluroscein diacetate (DAF-2DA) and confocal laser microscopy were used to detect NO production in the absence or presence of helium with or without L-NAME pretreatment.

RESULTS: Helium reduced (P < 0.05) infarct size (24% +/- 4% of the left ventricular area at risk; mean +/- sd) compared with control (46% +/- 3%). L-NAME, AG, and 7-NI did not alter myocardial infarct size when administered alone. L-NAME, but not 7-NI or AG, abolished helium-induced cardioprotection. Helium enhanced DAF-2DA fluorescence compared with control (26 +/- 8 vs 15 +/- 5 U, respectively). Pretreatment with L-NAME abolished these helium-induced increases in DAF-2DA fluorescence.

CONCLUSIONS: The results indicate that cardioprotection by helium is mediated by NO that is probably generated by endothelial NOS in vivo.

 

 

抑肽酶在婴儿动脉转接术中的功效

The Efficacy of Aprotinin in Arterial Switch Operations in Infants

Chinnamuthu Murugesan, MD, Sanjay Kumar Banakal, MD, Rajnish Garg, MD,Shankaraiah Keshavamurthy, MD, and Kanchi Muralidhar, MD

From the Department of Anesthesiology, Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India.

Anesth Analg 2008 107: 783-787.

 

背景:此研究评价了在婴儿动脉转流手术中应用总剂量40,000血管舒缓素抑制单(KIU)/kg的抑肽酶对减少术后出血和血液制品需要量是否有效。

方法:采用前瞻性、双盲、随机化研究,选取50名因大动脉转位行动脉转接术的婴儿。患儿随机分入安慰剂组,25名患儿接受生理盐水治疗,另25名患儿麻醉诱导后接20,000KIU/kg抑肽酶,后再予20,000KIU/kg抑肽酶加入泵预冲液中。测量在重症监护病房最初24小时内经胸管引流的术后出血量和血液制品需要量(mL/kg/24 h)

结果:术后最初24小时出血量安慰剂组(49.7 ± 11.9 mL/kg/24 h)显著高于(P < 0.0001)抑肽酶组(37.1 ± 3.5 mL/kg/24 h)。接受抑肽酶组新鲜冰冻血浆(mL/kg/24h)和浓缩血小板(mL/kg/24h)需要量明显减少(P < 0.0001),但输注血液制品患者的比例并未降低。抑肽酶组接受所有同种异体血液制品的总数[范围 (中位数) = 2–4 (3)]少于安慰剂组[范围(中位数) = 7–14 (10)]。抑肽酶组因过量出血再手术的比例亦显著少于安慰剂组(16% vs 32%) (P = 0.01).

结论:本研究推断抑肽酶能减少术后早期出血量及新鲜冰冻血浆和血小板输注需要量(mL/kg/24 h)。能减少治疗人群中远期使用血液制品的总数和因过量出血再手术的比例。

(黄凝译  薛张纲校)

BACKGROUND: In the present study we assessed whether aprotinin at a total dose (40,000 kallikrein inhibitor units (KIU)/kg) is effective in reducing postoperative blood loss and blood  product requirement after arterial switch operations in infants.

METHODS: A prospective, double-blind, randomized study, evaluated 50 infants who underwent arterial switch operations for transposition of great arteries. Patients were randomized into a placebo group, 25 patients who received normal saline and a treatment group, 25 patients who received 20,000 KIU/kg of aprotinin after induction of anesthesia, followed by 20,000 KIU/kg of aprotinin added to pump prime. Postoperative blood loss through the thoracic chest tubes and blood product requirements (mL/kg/24 h) were measured for the first 24 h in the intensive care unit.

RESULTS: Postoperative blood loss in the first 24 h was significantly (P < 0.0001) higher in the placebo group (49.7 ± 11.9 mL/kg/24 h) as compared to the aprotinin group (37.1 ± 3.5 mL/kg/24 h). Requirements for fresh frozen plasma (mL/kg/24h) and use of platelet concentrate transfusion (mL/kg/24 h) were significantly less in patients who received aprotinin (P < 0.0001), but did not reduce the proportion of patients transfused with blood products. The number of total donor exposures to all allogenic blood products was less in the aprotinin group [range (median) = 2–4 (3)] than the placebo group [range(median) = 7–14 (10)]. The re-exploration for excessive bleeding was significantly less with aprotinin group (16% vs 32%) (P = 0.01).

CONCLUSION: Our study concludes that aprotinin decreased the postoperative blood loss and requirement of transfusion of fresh frozen plasma and platelets (mL/kg/24 h) during the early postoperative period. Further, it reduced the number of donor exposures and re-exploration for excessive bleeding in the treatment population.

 

 

(印堂)指压疗法用于儿童麻醉

Extra-1 Acupressure for Children Undergoing Anesthesia

Shu-Ming Wang, Sandra Escalera, Eric C. Lin, Inna Maranets, and Zeev N. Kain

From the Departments of *Anesthesiology, {dagger}Pediatrics, and {ddagger}Child and Adolescent Psychiatry, Yale University School of Medicine, New Haven, Connecticut; and §Departments of Anesthesiology, Pediatrics, and Psychiatry and Human Behavior, University of California, Irvine, Irvine, California, and ¶Children’s Hospital of Orange County, Orange, California.

Anesth Analg 2008 107: 811-816.

 

背景:针灸及其相关技术被辅助用于围术期麻醉处理。我们研究拟行内镜手术儿童患者(印堂)指压疗法能否减轻术前焦虑和减少围术期异丙酚的需求量。

方法:52例儿童患者随机分为在印堂或其假想部位接受指压疗法治疗干预。治疗干预开始前所有儿童均采用双频指数(BIS)进行监测。评价基础状态和进入手术室前病人焦虑情况,通过静脉使用异丙酚维持BIS值于40-60之间。

结果:研究结果显示干预治疗后,印堂针灸治疗儿童焦虑程度降低而假想组则增加(-9% [-3 to -15] vs 2% [-6 to 7.4], P = 0.012)。相比,术前等待时两组间BIS值差异无统计学意义。同时也发现两组间围术期异丙酚用量无明显差别(214 ± 76 µg · kg-1 · min-1 vs 229 ± 95 µg · kg-1 · min-1, P = 0.52)

结论:内镜手术儿童患者在印堂处采用指压疗法能减轻其术前焦虑程度;而对BIS值以及围术期异丙酚需要量无影响。

(蒋宗明译 薛张纲校)

BACKGROUND: Acupuncture and related techniques have been used as adjuncts for perioperative anesthesia management. We examined whether acupressure in the Extra-1 (Yin-Tang) point would result in decreased preprocedural anxiety and reduced intraprocedural propofol requirements in a group of children undergoing endoscopic procedures.

METHODS: Fifty-two children were randomized to receive acupressure bead intervention either at the Extra-1 acupuncture point or at a sham point. A Bispectral Index (BIS) monitor was applied to all children before the onset of the intervention. Anxiety was assessed at baseline and before entrance to the operating room. Anesthetic techniques were standardized and maintained with IV propofol infusion titrated to keep BIS values of 40–60.

RESULTS: We found that after the intervention, children in the Extra-1 group experienced reduced anxiety whereas children in the sham group experienced increased anxiety (-9% [-3 to -15] vs 2% [-6 to 7.4], P = 0.012). In contrast, no significant changes in BIS values were observed in the preprocedural waiting period between groups (P = ns). We also found that total intraprocedural propofol requirements did not differ between the two study groups (214 ± 76 µg · kg-1 · min-1 vs 229 ± 95 µg · kg-1 · min-1, P = 0.52).

CONCLUSIONS: We conclude that acupressure bead intervention at Extra-1 acupoint reduces preprocedural anxiety in children undergoing endoscopic procedures. This intervention, however, has no impact on BIS values or intraprocedural propofol requirements.

 

 

我们是否还需要一个新的例证来阐明吸入性麻醉药产生麻醉效应的机制?

Is a New Paradigm Needed to Explain How Inhaled Anesthetics Produce Immobility?

Edmond I. Eger, II, Douglas E. Raines, Steven L. Shafer, Hugh C. Hemmings, Jr, and James M. Sonner

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; {dagger}Department of Anesthesia and Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; {ddagger}Department of Anesthesia, Columbia University, New York City, New York; and §Departments of Anesthesiology and Pharmacology, Weill Cornell Medical College, New York City, New York.

Anesth Analg 2008 107: 832-848.

 

摘要:目前关于吸入性麻醉药在面对有害刺激时产生麻醉效应的机制还是一个似是而非的论点。有许多发现,例如它的可加性,都说明了吸入性麻醉药其产生麻醉效应是通过作用于一个普遍的位点。但是,二十多年的着重研究并没有发现任何一个配体门控或是电压门控的通道可以单独介导产生麻醉效应。事实上,大多数假设的靶位仅提供了极小甚至的无效的介导作用。例如阿片类受体、5-羟色氨3受体、A型酪氨酸受体和谷氨酸受体。而钾通道和钙通道则表现出了与其麻醉机制的无关性,或是仅起到了较次要的作用。并且,目前也尚无任何配体门控或是电压门控通道的协同作用能够足以解释这种介导机制。而另一些假定靶位(如钠通道)还值得我们深入的研究,但吸入性麻醉药其麻醉效应的产生是通过一个非特异途径的可能性还仍然存在。

(刘沁译 薛张纲校)

A paradox arises from present information concerning the mechanism(s) by which inhaled anesthetics produce immobility in the face of noxious stimulation. Several findings, such as additivity, suggest a common site at which inhaled anesthetics act to produce immobility. However, two decades of focused investigation have not identified a ligand- or voltage-gated channel that alone is sufficient to mediate immobility. Indeed, most putative targets provide minimal or no mediation. For example, opioid, 5-HT3, -aminobutyric acid type A and glutamate receptors, and potassium and calcium channels appear to be irrelevant or play only minor roles. Furthermore, no combination of actions on ligand- or voltage-gated channels seems sufficient. A few plausible targets (e.g. sodium channels) merit further study, but there remains the possibility that immobilization results from a nonspecific mechanism.

 

 

大鼠蛛网膜下腔注射藜芦定增加MAC值的研究

Intrathecal veratridine administration increases minimum alveolar concentration in rats.

Zhang Y, Sharma M, Eger EI 2nd, Laster MJ, Hemmings HC Jr, Harris RA.

Department of Anesthesiology, Fuwai Hospital and Cardiovascular Institute, Beijing, China.

Anesth Analg 2008 107: 875-878.

 

背景:几项研究的结果指出吸入麻醉药抑制钠通道蛋白转运体的运作。我们假定蛛网膜下腔注射藜芦定能增加钠通道的活性和效应则会增加MAC值。

方法:我们测量大鼠在不同浓度藜芦定注入蛛网膜下腔所引起的异氟烷MAC值的改变并与侧脑室灌注所得的结果进行比较。

结果:与预期的一样,蛛网膜下腔注射藜芦定会增加MAC值。最大注射浓度(25 pgml)也在两只大鼠中表现出肢体神经元性损害,和MAC峰效应的降低。1.6 pgml的浓度产生MAC值最大增幅(21%)。脑室注入1.66.4 pgml的浓度不改变MAC值,给与大鼠25 pgml则大鼠死亡。

结论一个与吸入麻醉药抑制钠通道蛋白转运体的运作有关的研究发现蛛网膜下腔给与藜芦定会增加异氟烷MAC值。

(刘婷洁译  薛张纲校)

BACKGROUND: Results from several studies point to sodium channels as potential mediators of the immobility produced by inhaled anesthetics. We hypothesized that the intrathecal administration of veratridine, a drug that enhances the activity or effect of sodium channels, should increase MAC.

METHODS: We measured the change in isoflurane MAC caused by intrathecal infusion of various concentrations of veratridine into the lumbothoracic subarachnoid space of rats. We compared these result with those obtained from intracerebroventricular infusion.

RESULTS: As predicted, intrathecal infusion of veratridine increased MAC. The greatest infused concentration (25 microM) also produced neuronal injury in the hindlimbs of two rats and decreased the peak effect on MAC. A concentration of 1.6 microM produced the largest (21%) increase in MAC. Intraventricular infusion of 1.6 and 6.4 microM veratridine did not alter MAC. Rats given 25 microM died.

CONCLUSIONS: Intrathecal administration of veratradine increases MAC of isoflurane, a finding consistent with a role for sodium channels as potential mediators of the immobility produced by inhaled anesthetics.

 

 

新生儿及小儿应用经食管脉搏血氧测定法的实验性研究

A Pilot Study of Neonatal and Pediatric Esophageal Pulse Oximetry

Panayiotis A. Kyriacou, Deric P. Jones, Richard M. Langford, Andy J. Petros

From the *School of Engineering and Mathematical Sciences, City University, London, EC1V 0HB, UK; {dagger}St. Bartholomew's Hospital, Bart's and The London NHS Trust, London, EC1A 7BE, UK; and {ddagger}Paediatric and Neonatal Intensive Care Unit Great Ormond Street Hospital for Children Great Ormond Street London WC1N 3JH, UK.

Anesth Analg 2008 107: 905-908

 

背景: 在这个实验性研究中,我们探究了在婴儿中把食管作为探测脉搏氧饱和度的新位点是否合适。

方法:一种新型的微型经食管脉搏血氧探测仪已经被研制成。本次研究了五个病例(一个儿童及四个新生儿)。

结果:所有病例的脉搏血氧饱和度值均可被测知。运用Bland and Altman曲线来分析经食管探测法以及传统的趾端探测法的平均测定值,可以发现这两种脉搏氧饱和度测定法的偏倚及界限分别是+0.3%+1.7%~1.0%

结论:这个研究提示,食管可以成为儿童及小儿检测血氧饱和度的另一个位点。

(秦敏菊译 薛张纲校)

BACKGROUND: In this pilot study we explored the suitability of the esophagus as a new measuring site for blood oxygen saturation (Spo2) in neonates.

METHODS: A new miniaturized esophageal pulse oximeter has been developed. Five patients (one child and four neonates) were studied.

RESULTS: Spo2 values were obtained in the esophagus of all patients. A Bland and Altman plot of the difference between Spo2 values from the esophageal pulse oximeter and a commercial toe pulse oximeter against their mean showed that the bias and the limits of agreement between the two pulse oximeters were +0.3% and +1.7% to -1.0%, respectively.

CONCLUSIONS: This study suggests that the esophagus can be used as an alternative site for monitoring blood oxygen saturation in children and neonates.

 

 

困难气管插管的患者,可能需要转介到睡眠诊所

Patients with Difficult Intubation May Need Referral to Sleep Clinics

Frances Chung, FRCPC*, Balaji Yegneswaran, MBBS*, Francisco Herrera, MD*, Alex Shenderey, MD*, and Colin M. Shapiro, FRCPC

From the Departments of *Anesthesia, and {dagger}Psychiatry, University of Toronto, University Health Network, Toronto Western Hospital, Toronto, Ontario, Canada.

Anesth Analg 2008 107: 915-920.

 

目的:上呼吸道异常增加阻塞性睡眠呼吸暂停(OSA)和困难气管插管的风险。两者均造成显著临床问题,并增加围手术期的发病率和死亡率。我们猜测,困难气管插管的患者有较高的OSA患病率,而那些存在难以预料的困难插管患者,可能需要转介到睡眠诊所检测多导睡眠图( PSG

方法:CormackLehane法,根据直接喉镜所见,挑选术前评估为四级的患者,在来自四家医院的麻醉师顾问帮助下,将其中需要两次及以上尝试气管插管方可成功者,列入研究范围。收集患者呼吸暂停低通气指数(AHI)数据及术后情况。AHI>5/小时者为ASO阳性。用t检验及2检验比较所得临床和PSG数据。

结果:20个月中, 84例困难气管插管患者被转介到研究,其中33例患者同意参加。 66 33例中的22例)的患者患有OSAAHI> 5/小时)。在这22 OSA患者中, 10例(64%)为轻度OSAAHI 5-15),6例(18%)为中度OSAAHI > 15/小时),6例(18 %)为严重OSAAHI > 30/小时)。33例患者中,11例(33 %)被推荐进行持续气道正压通气治疗。OSA组与非OSA组间,在性别、颈部大小及睡眠质量方面有显著差异,但在年龄及体重指数方面无明显差异。

结论 根据PSG66 %接受睡眠监测的困难气管插管患者被诊断为OSA。困难气管插管是OSA的高危因素,应根据睡眠呼吸暂停的症状和体征进行筛选。由此筛选出的患者,应考虑转介到一个睡眠诊所检测PSG以确诊。

(施颖译 薛张纲校)

PURPOSE: Upper airway abnormalities carry the risk of obstructive sleep apnea (OSA) and difficult tracheal intubations. Both conditions contribute to significant clinical problems and have increased perioperative morbidity and mortality. We hypothesized that patients who presented with difficult intubation would have a very high prevalence of OSA and that those with unexpected difficult intubation may require referral to sleep clinics for polysomnography (PSG).

METHODS: Patients classified as a grade 4 Cormack and Lehane on direct laryngoscopic view, and who required more than two attempts for successful endotracheal intubation, were referred to the study by consultant anesthesiologists at four hospitals. Apnea-hypopnea index (AHI) data and postoperative events were collected. Patients with AHI >5/h were considered positive for OSA. Clinical and PSG variables were compared using t-tests and 2 test.

RESULTS: Over a 20-mo period, 84 patients with a difficult intubation were referred into the study. Thirty-three patients agreed to participate. Sixty-six percent (22 of 33) had OSA (AHI >5/h). Of the 22 OSA patients, 10 patients (64%) had mild OSA (AHI 5–15), 6 (18%) had moderate OSA (AHI >15/h), and 6 (18%) had severe OSA (AHI >30/h). Of the 33 patients, 11 patients (33%) were recommended for continuous positive airway pressure treatment. Between the OSA group and the non-OSA group, there were significant differences in gender, neck size, and the quality of sleep, but there were no significant differences in age and body mass index.

CONCLUSIONS: Sixty-six percent of patients with unexpected difficult intubation who consented to undergo a sleep study were diagnosed with OSA by PSG. Patients with difficult intubation are at high risk for OSA and should be screened for signs and symptoms of sleep apnea. Screening for OSA should be considered by referral to a sleep clinic for PSG.

 

 

不同气管内吸引方法对FRC的影响

Functional Residual Capacity Changes After Different Endotracheal Suctioning Methods

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

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

Anesth Analg 2008 107: 941-944.

 

背景:我们的目的是研究三种不同的气管内吸引方法对FRC的影响。

方法:用交叉设计方法,20个心脏手术后的病人按照随机顺序接受了三种不同的气管内吸引方法:压力控制通气下的密闭吸引,容量控制通气下的密闭吸引,开放式吸引。在吸引之前和20分钟之后分别测量FRC

结果和结论:不管用何种吸引方法,心脏手术后的病人接受吸引后FRC都降低。一些病人还有很显著的FRC改变。常规的FRC测量可以完善呼吸系统检测,从而有助于呼吸系统疾病的治疗。

孙鹏飞译 薛张纲校)

BACKGROUND: Our primary objective was to investigate the effects of three different endotracheal suctioning procedures on functional residual capacity (FRC).

METHODS: Using a crossover design, postoperative cardiac surgery patients (n = 20) received three different suctioning methods in randomized order: closed suctioning during pressure-controlled ventilation, closed suctioning during volume-controlled ventilation, and open suctioning. FRC was measured before and 20 min after the intervention.

RESULTS AND CONCLUSIONS: FRC is reduced in postcardiac surgery patients after suctioning, regardless of which method is used. Certain patients may have very pronounced changes of FRC. Routine FRC measurements could complement respiratory monitoring to optimize respiratory therapy.

 

 

神经外伤患者的脑灌注压研究

Cerebral Perfusion Pressure in Neurotrauma: A Review

Hayden White, MD*, and Bala Venkatesh, MD{dagger}

From the *Department of Critical Care, Logan Hospital, Griffiths University, Brisbane, Australia; and {dagger}Department of Intensive Care, Princess Alexandra and Wesley Hospitals, University of Queensland, Brisbane, Australia.

Anesth Analg 2008 107: 979-988.

 

摘要:目前已经认识到低脑血流量(及低脑灌注压(CPP))与脑外伤的不良预后相关。但还不十分明确的是改变脑血流量或者CPP是否可以带来临床症状的好转。初步研究指出增加CPP可能有益,美国脑部创伤基金会在1996年的指南中公认了这一点,并且将目标值确立为70 mmHg。但是,由于缺少明确的益处以及并发症的增多使得此目标值降至60 mmHg。最近,由于有证据表明脑创伤后自我调节功能可能受损,一些研究者计划对CPP进行个体化的管理。此外,随着神经检测技术的进步,临床工作者可以更加精确地监控脑代谢及血流动力学。至今未止尚没有强有力的证据来支持此项计划。在此之前,当前的CPP管理方式仍将继续沿用。

(夏俊明译 薛张纲校)
Abstract

It is now well recognized that low cerebral blood flow (and cerebral perfusion pressure (CPP)) is associated with poor outcome after traumatic brain injury. What is less clear is whether altering cerebral blood flow or CPP will lead to clinical improvement. Initial studies indicated that increasing CPP may be beneficial and the Brain Trauma Foundation acknowledged this by incorporating a target of 70 mm Hg in the 1996 guidelines. However, the lack of a demonstrable benefit and the increased complication rate associated with this approach led to a reduction in the CPP goal to 60 mm Hg. More recently, evidence that autoregulation may be disrupted after traumatic brain injury has led some authors to propose an individualized approach to CPP management. Furthermore, with the advent of advanced neuromonitoring techniques, clinicians are able to more closely monitor the effects of hemodynamic manipulations on cerebral metabolism. As yet, there is no strong outcome evidence to support this approach. Until then, the current debate over the optimal approach to CPP management is likely to continue.


血压和压力感受器敏感性对兴奋性升级现象的影响

The Impact of Blood Pressure and Baroreflex Sensitivity on Wind-Up

Chung, Ok Yung MD, MBA; Bruehl, Stephen PhD

From the Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

Anesth Analg 2008 107: 1018-1025.

 

背景:对急性疼痛来说,提高的静息血压和自发性压力感受器敏感性与痛觉减退有关。这些关联在慢性疼痛明显不同。我们研究了兴奋性升级现象(中枢致敏的标志)的程度是否同样受血压和压力感受器敏感性的影响,以及这些关联在慢性疼痛是否改变。

方法:对30名健康者和26名慢性背痛受试者的血压和BRS(序列法)进行评估,然后完成一个标准化热刺激记录来评估兴奋性升级现象。这项记录在安慰剂组和α-2肾上腺素受体阻断剂育亨宾组完成,来测试α-2肾上腺素受体机制的影响。

结果:1)在健康对照组,较高的收缩压与较低的兴奋性升级现象有关 P < 0.05 ),但是这在慢性疼痛者中相反( P < 0.05 );2 )在健康对照组,较高的BRS与较低的兴奋性升级现象有关 P < 0.05 ),但是在慢性疼痛受试者中无关;3 )只有在慢性疼痛组较高的收缩压是与较低的BRS有关的( P < 0.05 4 α-2肾上腺素受体阻断剂对兴奋性升级现象并没有显着著影响。

结论:这些结果表明,在健康个体升高的静息血压和自发性压力感受器敏感性与痛觉减退有关,包括中枢致敏(由兴奋性升级现象反应)减低和下行抑制增强。慢性疼痛的存在显着改变了这些相互作用的性质。在重叠系统调节心血管系统和慢性疼痛患者的疼痛之间正常交互作用的逆转可能使血压和心率的健康缓冲作用变成不稳定的和最终较高的血压和心血管发病率。

(宣丽真译 薛张纲校)

BACKGROUND: Elevated resting blood pressure (BP) and spontaneous baroreflex sensitivity (BRS) are associated with hypoalgesia to acute pain. These associations are significantly altered in chronic pain. We investigated whether degree of wind-up (marker for central sensitization) is similarly influenced by BP and BRS, and whether these associations are altered by chronic pain.

METHODS: BP and BRS (sequence method) were assessed in 30 healthy and 26 chronic back pain subjects who then completed a standardized thermal stimulation protocol to assess wind-up. This protocol was performed under placebo and [alpha]-2 adrenergic (ADRA2) blockade with yohimbine in counterbalanced order to test for the influence of ADRA2 mechanisms.

RESULTS: 1) In healthy controls, higher systolic BP was associated with lower wind-up (P < 0.05) but this was reversed in chronic pain subjects (P < 0.05); 2) higher BRS was associated with lower wind-up in healthy controls (P < 0.05) but not in the chronic pain group; 3) higher systolic BP was associated with lower BRS only in the chronic pain group (P < 0.05); and 4) ADRA2 receptor blockade did not significantly affect wind-up.

CONCLUSIONS: These findings suggest that hypoalgesia associated with elevated resting BP and BRS in healthy individuals involves both diminished central sensitization (reflected in wind-up) and enhanced descending inhibition. The presence of chronic pain significantly alters the nature of these interactions. The reversal of normal interactions between overlapping systems modulating cardiovascular systems and pain in chronic pain patients may shift the healthy buffering of BP and heart rate toward instability and eventual higher BP and cardiovascular morbidity.

 

 

透皮吸收烟碱用于前列腺术后镇痛

Transdermal Nicotine for Analgesia After Radical Retropubic Prostatectomy

Ashraf S. Habib, MBBCh, MSc, FRCA*, William D. White, MPH*, Magdi A. El Gasim, MD*, Gamal Saleh, MD*, Thomas J. Polascik, MD{dagger}, Judd W. Moul, MD{dagger}, and Tong J. Gan, MB, FRCA*

From the *Department of Anesthesiology, {dagger}Division of Urologic Surgery and Duke Prostate Center, Department of Surgery, Duke University Medical System, Durham, North Carolina.

Anesth Analg 2008 107: 999-1004

 

背景:以往的动物和人类研究表明,烟碱可能有镇痛作用。我们假设对于全麻下实施经耻骨后前列腺根治术(RRP)的患者,术前应用7mg烟碱,会导致减少术后镇痛的需求。

方法:不吸烟者经历全麻下行RRP参加了这项前瞻性,双盲,安慰剂对照研究。病人随机分成两组:在麻醉诱导前30-60分钟,分别耳后透皮给予7毫克烟碱或安慰剂。麻醉按常规。术后镇痛是标准的应用吗啡病人自控镇痛并且每6小时给予痛力克15mg静推。在苏醒室、术后61224小时收集数据。

结果: 分析了90例患者: 44烟碱组和46在安慰剂组。两组病人在年龄,身高,体重, ASA的分级,手术长度,术中芬太尼的用量等方面没有显著差异。烟碱组显着降低24 h内吗啡的用量(平均值±标准差): 33.3 ± 30.8mg,相比于44.7 ± 26.4mg P = 0.0059 ,时间x治疗P0.0031 。但是,在咳嗽和休息时疼痛的报告没有差异。此外,还有无显着差异的团体在发生术后恶心呕吐或需要救援antiemetics 。不过,相比于安慰剂组,在烟碱组,最高的恶心口头评定量表评分较高,(中位数, 25%至75=4 0-60 0-6 P0.0158 。术后24 h内血浆中烟碱含量和术后吗啡消费量呈负相关,在苏醒室( P = 0.049 ,以及在术后61224小时均如此( P = 0.002)。

结论: 对于全麻下行RRP手术的患者,术前的应用7mg烟碱可以显著减少阿片类的消费量。尽管减少阿片类药物的使用,但是使用透皮吸收的烟碱并没有降低疼痛评分或术后恶心呕吐的发生。

(章一静译 薛张纲校)

BACKGROUND: Previous animal and human studies suggested that nicotine might have an antinociceptive effect. We hypothesized that the preoperative application of a 7 mg nicotine patch would result in reduced postoperative analgesic requirements in patients undergoing radical retropubic prostatectomy (RRP) under general anesthesia.

METHODS: Nonsmokers undergoing RRP under general anesthesia were enrolled in this prospective, double-blind, placebo-controlled study. Patients were randomly assigned to receive a patch of 7 mg nicotine or placebo applied behind the ear 30–60 min before induction of anesthesia. The anesthetic technique was standardized. Postoperative analgesia was provided with a standardized morphine patient-controlled analgesia and 6 hourly ketorolac 15 mg IV. Data were collected in the postanesthesia care unit and at 6, 12, and 24 h after surgery.

RESULTS: Ninety patients were included in the analysis: 44 in the nicotine group and 46 in the placebo group. The groups did not differ significantly with respect to age, height, weight, ASA class, length of surgery, or amounts of intraoperative fentanyl received. The nicotine group showed significantly lower cumulative morphine consumption at 24 h (mean ± sd): 33.3 ± 30.8 mg vs 44.7 ± 26.4 mg (P = 0.0059, time x treatment P = 0.0031). However, the repeated measures tests found no difference in amount of pain reported on coughing or at rest, either as treatment effects or in interaction with time. In post hoc comparisons, there was no significant difference in amount of pain reported on coughing or at rest at any of the times assessed. There were also no significant differences between the groups in the incidence of postoperative nausea and vomiting or the need for rescue antiemetics. However, the maximum nausea verbal rating scale score was higher in the nicotine than in the placebo group (median, 25th to 75th percentiles = 4, 0–6 vs 0, 0–6, P = 0.0158). There was a significant negative correlation between the 24 h plasma nicotine levels and postoperative morphine consumption in the postanesthesia care unit (P = 0.049), as well as at 6, 12, and 24 h (P = 0.002).

CONCLUSION: The preoperative application of a 7 mg nicotine patch resulted in a significant reduction in opioid consumption in patients undergoing RRP under general anesthesia. Despite this reduction in opioid use, there was no reduction in pain scores or postoperative nausea and vomiting with the use of transdermal nicotine.

 

 

在小鼠损伤的背根神经元中通过恢复钙内流可以纠正胞膜的过度兴奋状态

Restoration of Calcium Influx Corrects Membrane Hyperexcitability in Injured Rat Dorsal Root Ganglion Neurons

Quinn Hogan, MD*{dagger}, Philipp Lirk, MD*{ddagger}, Mark Poroli, BS*, Marcel Rigaud, MD*§, Andreas Fuchs, MD*§, Patrick Fillip, MD*, Marko Ljubkovic, MD*||, Geza Gemes, MD*§, and Damir Sapunar, MD, PhD*||

From the *Department of Anesthesiology, Medical College of Wisconsin, {dagger}Milwaukee Veterans Administration Medical Center, Milwaukee, Wisconsin; {ddagger}Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria; §Department of Intensive Care and Anesthesiology, Medical University of Graz, Graz, Austria; and ||University of Split Medical School, Split, Croatia.

Anesth Analg 2008 107: 1045-1051.

背景:我们已经知道,在轴索显微外科,减少神经元细胞膜Ca2+内流(ICa)可以增加神经元的兴奋性。基于此,我们预见增加损伤神经元的ICa可以纠正其高兴奋状态

方法:增加或减少跨膜ICa可以改变细胞膜的生物物理特性和兴奋性,我们使用细胞内记录仪器,在结扎脊神经后,测定非解离的后根神经节的A型神经元的这一特性。

结果:当增加细胞外液Ca2+ 的水平可以促进 ICa,使超极化减少,触发点抑制,在选择性激动剂NS1619 and NS309激动Ca2+促发的K+ 流动时也可以出现。降低细胞外Ca2+的浓度产生相反的效应,与以往观察到的未损伤神经元有相似的作用

结论:这些发现表明,轴索显微外科术后机体感觉神经元的过度兴奋和Ca2+内流减少有关,修复ICa的措施可以用来治疗周围神经病引起的疼痛。

(陈珺珺译 薛张纲校)

BACKGROUND: We have previously shown that a decrease of inward Ca2+ flux (ICa) across the sensory neuron plasmalemma, such as happens after  axotomy, increases neuronal excitability. From this, we predicted that increasing ICa in injured neurons should correct their hyperexcitability.

METHODS: The influence of increased or decreased ICa upon membrane biophysical variables and excitability was determined during recording from A-type neurons in non dissociated dorsal root ganglia after spinal nerve ligation using an intracellular recording technique.

RESULTS: When the bath Ca2+ level was increased to promote ICa, the after-hyperpolarization was decreased and repetitive firing was suppressed, which also followed amplification of Ca2+-activated K+ current with selective agents NS1619 and NS309. A decreased external bath Ca2+ concentration had the opposite effects, similar to previous observations in uninjured neurons.

CONCLUSIONS: These findings indicate that at least a part of the hyperexcitability of somatic sensory neurons after axotomy is attributable to diminished inward Ca2+ flux, and that measures to restore ICa may potentially be therapeutic for painful peripheral neuropathy.


结扎小鼠脊神经后,神经妥乐平通过激活下行疼痛抑制系统起到镇痛作用

The Antiallodynic Effect of Neurotropin® Is Mediated via Activation of Descending Pain Inhibitory Systems in Rats with Spinal Nerve Ligation

Ryohei Okazaki, Hiroyoshi Namba, Hiroyuki Yoshida, Hisashi Okai, Tomoshi Miura, and Minoru Kawamura

From the Department of Development Research, Institute of Bio-active Science, Nippon Zoki Pharmaceutical Co., Ltd., 442-1, Kinashi, Kato, Hyogo, 673-1461, Japan.

Anesth Analg 2008 107: 1064-1069.

 

背景:神经妥乐平是一种从接种牛痘病毒后而发炎的兔子皮肤中分离出来的非蛋白质提取物,在日本被广泛用于治疗诸如神经性疼痛等慢性疼痛病。尽管已经进行了一些针对神经妥乐平镇痛机理的研究,然而,这个机理仍然没被正确澄清。

方法:在使用戊巴比妥麻醉的情况下,将老鼠的左侧第五腰神经用缝线结扎起来。机械镇痛效果通过测试老鼠后爪在用von Frey细丝刺激后退缩阙值测定。在神经结扎后的28天进行行为测试。左侧第五腰神经被结扎((L5-SNL)的小鼠用三种途径给药:静脉、鞘内或脑室内使用神经妥乐平。我们测定了L5-SNL小鼠在使用神经妥乐平镇痛后,去甲肾上腺素,5-羟色胺能和γ-氨基丁酸(GABA)拮抗剂的效应。在鞘内分别注射育亨宾({alpha}2肾上腺素能受体拮抗剂),酒石酸酮舍林(5-HT2A受体拮抗剂),MDL72,2225-HT3受体拮抗剂),甲基氯化荷包牡丹碱(γ-氨基丁酸受体拮抗剂)和CGP35,348γ-氨基丁酸受体拮抗剂)。

结果:静脉注射神经妥乐平(50–100 NU/kg)能引起L5-SNL小鼠的抗痛觉超敏效应。而且,脑室注射神经妥乐平(400 mNU/),而非鞘内注射神经妥乐平能抑制痛觉超敏。神经妥乐平的抗痛觉超敏作用(100NU/Kg,静脉内注射)可以被育亨宾鞘内注射(10 NU /鼠)、酮舍林(30 NU /鼠)、MDL72,222(30 NU /)、荷包牡丹碱(0.6 NU /)CGP35348 (30 NU /)所抑制。另一方面,鞘内注射m-CPBG5-HT3受体激动剂)的抗痛觉超敏作用通过鞘内注射荷包牡丹碱和CGP35348被逆转,这表明5-HT3受体和脊椎抑制性中间神经元(γ-氨基丁酸能神经元)的相互作用。

结论:这些结果表明神经妥乐平的镇痛作用是通过激活疼痛下行抑制系统实现的,如去甲肾上腺素系统和5-羟色胺能系统,它们是从脊髓发出至脊髓背侧角。此外,通过脊髓背侧角5-HT3受体激动剂引起的抑制性γ-氨基丁酸能神经元的激活也参与乐神经妥乐平的抗痛觉超敏作用。

(陈珺珺译 薛张纲校)

BACKGROUND: Neurotropin®, a nonprotein extract isolated from inflamed skin of rabbits inoculated with vaccinia virus, is widely used in Japan to treat chronic pain such as neuropathic pain. Although some studies have been conducted on the mechanism of the antiallodynic action of Neurotropin, this mechanism has yet to be adequately clarified.

METHODS: The left fifth lumbar nerve  of rats was tightly ligated   with silk sutures under pentobarbital anesthesia. Mechanical allodynia was confirmed by measuring the hindpaw  withdrawal  threshold in response to application of von Frey filaments. Behavioral tests were performed at 28 days after nerve ligation. Neurotropin was administered IV, intrathecally or intra cerebro ventricularly in L5 spinal nerve ligation (L5-SNL) rats. We examined the effects of noradrenergic, serotonergic and {gamma}-aminobutyric acid (GABA)ergic  antagonists on the antiallodynic action of Neurotropin in L5-SNL rats. Yohimbine hydrochloride (yohimbine) was used as an {alpha}2 adrenoceptor antagonist, ketanserin tartrate (ketanserin) as a 5-HT2A receptor antagonist, MDL72,222 as a 5-HT3 receptor antagonist, (-)-bicuculline methobromide (bicuculline) as a GABAA receptor antagonist, and CGP35,348 as a GABAB receptor antagonist, and intrathecally injected.

RESULTS: IV (50–100 NU/kg) doses of Neurotropin elicited an anti allodynic action in L5-SNL rats. Moreover, intracerebroventricular (400 mNU/rat), but not intrathecal, injection of Neurotropin inhibited allodynia. The antiallodynic action of Neurotropin (100 NU/kg, IV) was antagonized by intrathecal injections of yohimbine (10 nmol/rat), ketanserin (30 nmol/rat), MDL72,222(30 nmol/rat), bicuculline (0.6 nmol/rat) and CGP35348 (30 nmol/rat). On the other hand, the antiallodynic action of intrathecally injected m-CPBG (5-HT3 receptor agonist) was reversed by intrathecal injection of bicuculline and CGP35348, suggesting interaction of 5-HT3 receptors and spinal inhibitory (GABAergic) interneurons.

CONCLUSIONS: These results suggest that the antiallodynic effect of Neurotropin is mediated via activation of descending pain inhibitory systems, such as the noradrenergic and serotonergic systems, which project from supraspinal sites to the spinal dorsal horn. In addition, activation of inhibitory GABAergic interneurons via 5-HT3 receptors by serotonin released in the spinal dorsal horn may also be involved in the antiallodynic action of Neurotropin.


多孔硬膜外导管和单孔导管的功能一致:在离体试验中

Epidural Multiorifice Catheters Function as Single-Orifice Catheters: An In Vitro Study

Allison J. Fegley, MD*, Jerrold Lerman, MD, FRCPC, FANZCA*{dagger}, and Richard Wissler, MD, PhD*

From the *Strong Memorial Hospital, University of Rochester, Rochester, New York; and {dagger}Women and Children's Hospital of Buffalo, SUNY, Buffalo, New York.

Anesth Analg 2008 107: 1079-1081.

 

在一项离体实验中,我们通过可选择孔数量的多孔导管决定流速。盐水以1360mL/h通过Baxter Abbott公司及Alaris输注泵经Portex  Braun 20号的多孔导管输注。我们通过输注和人工推注的方法,并记录了开放导管的数目及持续输注的压力。单孔输注速率<80mL/h,双孔速率在100280mL/h,三孔速率>300mL/hBraun导管的压力大于Portex导管压力的40%。12名住院医生使用3个孔的导管人工输注。在临床应用中,20号的多孔导管和单孔导管的功能相似,但是多孔导管可以用于增加负荷剂量。

(陈珺珺译 薛张纲校)

In an in vitro study, we determined the flow rates required to use selective orifices of multi orifice catheters. Saline was infused at rates between 1 and 360 mL/h through Portex and  Braun 20-gauge multiorifice catheters using Baxter, Abbott Laboratories, and Alaris infusion pumps. The numbers of orifices used via  infusion and manual injection, and the pressure within the catheter during continuous infusion, were recorded. Infusion rates <80 mL/h used one orifice, between 100 and 280 mL/h used two orifices, and >300 mL/h used three orifices. Catheter pressures with Braun catheters were 40% greater than with Portex catheters. Manual injections by all 12 residents used all three orifices. Twenty-gauge multi orifice catheters function as single-orifice catheters at clinically relevant infusion rates, but function as multiorifice catheters during manual boluses.


 

 

 

抑制糖原合成激酶或细胞凋亡蛋白p53降低了氦在体心肌保护的阈值:线粒体通透性的作用

Inhibition of Glycogen Synthase Kinase or the Apoptotic Protein p53 Lowers the Threshold of Helium Cardioprotection In Vivo: The Role of Mitochondrial Permeability Transition

Paul S. Pagel, MD, PhD, John G. Krolikowski, BS, Phillip F. Pratt, Jr, PhD, Yon Hee Shim, MD, Julien Amour, MD, PhD, David C. Warltier, MD, PhD, and Dorothee Weihrauch, DVM, PhD

From the Anesthesia Service, the Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin.

Anesth Analg 2008 107: 769-775.

 

背景:促成活的信号激酶抑制糖原合成激酶3BGSK-3B)的活性并促进细胞凋亡蛋白p53的降解。氦气通过激活促成活激酶产生心肌保护的作用,但GSKp53是否介导这个过程尚未阐明。笔者假设抑制糖原合成激酶或细胞凋亡蛋白p53通过改变线粒体膜的通透性从而降低在体心肌保护的阈值

方法85只家兔行血流动力学监测,阻断前降支(LAD30min并再灌注3h,在阻断LAD前给与0.9%的生理盐水(对照),或135次周期性吸入70%氦气-30%氧气(氧浓度0.30)的混合气体5min再复吸30%氧的空气氧气复合气体。其他的家兔在前降支阻断前在给或不给mPTP的开启药物苍木酐(5mg/kg)下给与GSK抑制剂SB216763(SB21:0.20.6mg/kg)p53抑制剂皮斐松-a(PIF;1.5 g/kg3.0g/kg),或 SB21(0.2mg/kg)PIF(1.5kg/mg)1个周期的氦气。

结果:氦气组心肌梗塞的面积(吸入氦气135个周期后梗死面积分别为35±6[n=7],25±4[n=7],20±3%[n=6])较对照组(44±6%[n=7])小(P<0.05)。SB21(0.6 mg/kg [n=7])组和PIF(3.0[n=6])组心肌梗死减小,但小剂量组SB210.2mg/kg[n=6])PIF1.5mg/kg[n=7])未见减小。SB21(0.2mg/kg)PIF (1.5mg/kg)加吸入氦气(1个周期,n=6)具有相当于吸入3个周期氦气后减少梗塞面积的效应,且这一效应能被苍木酐阻断。

结论:抑制GSKp53通过mPTP机制降低了在体氦气介导的心肌保护的阈值。

(潘方立 陈杰 校)

BACKGROUND: Prosurvival signaling kinases inhibit glycogen synthase kinase-3β (GSK-3β) activity and stimulate apoptotic protein p53 degradation. Helium produces cardioprotection by activating prosurvival kinases, but whether GSK and p53 inhibition mediate this process is unknown. We tested the hypothesis that inhibition of GSK or p53 lowers the threshold of helium cardioprotection via a mitochondrial permeability transition pore (mPTP)-dependent mechanism.

METHODS: Rabbits (n = 85) instrumented for hemodynamic measurement and subjected to a 30 min left anterior descending coronary artery (LAD) occlusion and 3 h reperfusion received 0.9% saline (control), or 1, 3, or 5 cycles of 70% helium-30% oxygen administered for 5 min interspersed with 5 min of an air-oxygen mixture (fraction of inspired oxygen concentration = 0.30) before LAD occlusion. Other rabbits received the GSK inhibitor SB 216763 (SB21; 0.2 or 0.6 mg/kg), the p53 inhibitor pifithrin-{alpha} (PIF; 1.5 or 3.0 mg/kg), or SB21 (0.2 mg/kg) or PIF (1.5 mg/kg) plus helium (1 cycle) before LAD occlusion in the presence or absence of the mPTP opener atractyloside (5 mg/kg).

RESULTS: Helium reduced (P < 0.05) myocardial infarct size (35 ± 6 [n = 7], 25 ± 4 [n = 7], and 20 ± 3% [n = 6] of area at risk, 1, 3, and 5 cycles, respectively) compared with control (44 ± 6% [n = 7]). SB21 (0.6 [n = 7] but not 0.2 mg/kg [n = 6]) and PIF (3.0 [n = 6] but not 1.5 mg/kg [n = 7]) also reduced necrosis. SB21 (0.2 mg/kg) or 1.5 mg/kg PIF (1.5 mg/kg) plus helium (1 cycle; n = 6 per group) decreased infarct size to an equivalent degree as three cycles of helium alone, and this cardioprotection was blocked by atractyloside (n = 7 per group).

CONCLUSIONS: Inhibition of GSK or p53 lowers the threshold of helium-induced preconditioning via a mPTP-dependent mechanism in vivo.

 

 

硫喷妥钠/七氟醚麻醉下小儿的正中神经躯体感觉诱发电位及酮基布洛芬和芬太尼的对其的附加作用

Somatosensory Evoked Potentials by Median Nerve Stimulation in Children During Thiopental/Sevoflurane Anesthesia and the Additive Effects of Ketoprofen and Fentanyl

Susanna Westerén-Punnonen, MD*, Heidi Yppärilä-Wolters, PhD*{dagger}, Juhani Partanen, MD, PhD*{ddagger}, Kari Nieminen, MD§, Antti Hyvärinen, MD||, and Hannu Kokki, MD, PhD§

From the *Department of Clinical Neurophysiology, Kuopio University Hospital, Finland; {dagger}VTT Information Technology, Tampere, Finland; {ddagger}Department of Clinical Neurophysiology, Helsinki University Hospital, Jorvi Hospital, Espoo, Finland; §Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Finland; ||Department of Otorhinolaryngology, Kuopio University Hospital, Finland; ¶Department of Pharmacology and Toxicology, University of Kuopio.

Anesth Analg 2008 107: 799-805.

 

背景:躯体感觉诱发电位(SEP)通常用于术中判断脊髓和脑功能。一般说来,挥发性麻醉药对SEP很敏感,但对于七氟醚麻醉维持时对儿童SEP的影响目前知之甚少。在麻醉中经常使用的镇痛药和其它辅助用药可能也会影响SEP。在这一前瞻性临床研究中,作者用苯二氮卓类和巴比妥类药物对273-8岁健康儿童实施静脉麻醉诱导后,给予其七氟醚进行麻醉维持,以评估七氟醚对于正中神经SEP的影响。此外,作者同时评估了酮基布洛芬和芬太尼这两种镇痛药对于SEP的影响。

方法:测定患儿正中神经的SEP后,静脉给予麻醉前用药咪达唑仑0.1mg/kg,根据不同分组(给予酮基布洛芬和芬太尼或不给)给予镇痛药,然后在麻醉维持过程中记录3SEP值:①吸入七氟醚15分钟后呼气末七氟醚的浓度达到2%时;②吸入后25分钟(给/不给予酮基布洛芬1mg/kg);③吸入后35分钟(给/不给予芬太尼1ug/kg)。

结果:与基础测量值相比,N20潜伏期和中枢传导时间在七氟醚维持麻醉中均有所延长(前者P=0.015,后者P=0.001)。镇痛药的使用对N20潜伏期和中枢传导时间没有影响。在5-8岁患儿中,平均N20-P25振幅有所下降(P=0.008)。此外,在年长儿中联合应用酮基布洛芬和芬太尼后N20-P25振幅也有所下降(P=0.03)。但在年幼儿中未发现有下降的现象。

结论:在小儿,2%七氟醚可以通过与其它吸入麻醉药相似的方式延长正中神经的SEP潜伏期。虽然吸入七氟醚时可以监测SEP,但应根据个体差异调整吸入剂量。联合应用酮基布洛芬和芬太尼并不影响SEP潜伏期,但可降低年长儿皮质电位的振幅。

(周姝婧 陈杰 校)

BACKGROUND: Somatosensory evoked potentials (SEPs) are used to determine the spinal cord and brain function during surgical procedures. In general, SEPs are sensitive to volatile anesthetics, but little is known about the effects of anesthesia maintenance with sevoflurane on SEPs in children. Analgesics are often provided during anesthesia, and supplementary drugs may also affect the SEPs. In this prospective clinical trial of 27 healthy, 3- to 8-yr-old children, we evaluated the effects of sevoflurane anesthesia after IV induction with benzodiazepine and barbiturate on median nerve SEP. In addition, the effects of two analgesics (ketoprofen and fentanyl) on SEPs were evaluated.

METHODS: Median nerve SEPs were recorded before premedication with midazolam 0.1 mg/kg IV, and at three separate times during anesthesia maintenance with sevoflurane 2% end-tidal concentration in air/oxygen (after 15 min of sevoflurane inhalation), supplemented with/without ketoprofen 1 mg/kg (after 25 min) and fentanyl 1 µg/kg (after 35 min).

RESULTS: Compared with baseline measurements, an increase both in N20 latency (P = 0.015) and in central conduction time (P = 0.001) was noted during anesthesia maintenance with sevoflurane. The administration of analgesics did not have an influence on the N20 latency or central conduction time. In children 5 to 8 yr of age, the mean cortical N20-P25 amplitude was decreased (P = 0.008). In addition, in older children, the N20-P25 amplitude decreased after the co-administration of ketoprofen and fentanyl compared with the values measured before the analgesics (P = 0.03). These decreases were not seen in the younger children.

DISCUSSION: In children, anesthesia maintenance with 2% sevoflurane prolongs median SEP latencies in a manner that is similar to those reported for other volatile anesthetics. However, SEP monitoring can be done with sevoflurane inhalation, but the dosage should be adjusted due to interindividual variabilty. Co-administration of ketoprofen, and fentanyl did not affect the SEP latencies, but post hoc analysis suggested that older children had a decrease in cortical amplitudes.

 

 

氧化亚氮在妇科腔镜手术术后恶心的剂量-反应关系的初步研究

The Dose–Response of Nitrous Oxide in Postoperative Nausea in Patients Undergoing Gynecologic Laparoscopic Surgery: A Preliminary Study

Boris Mraovic, MD*, Tatjana Simurina, MD, MSc{dagger}, Zdenko Sonicki, MD, PhD{ddagger}, Neven Skitarelic, MD, PhD§, and Tong J. Gan, MD||

From the *Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania; {dagger}Department of Anesthesiology and ICU, General Hospital Zadar, Zadar, Croatia; {ddagger}Department of Medical Statistics, Epidemiology and Medical Informatics, School of Public Health "Andrija Stampar," Faculty of Medicine, University of Zagreb, Zagreb, Croatia; §ENT Department, General Hospital Zadar, Zadar, Croatia; and ||Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2008 107: 818-823.

 

背景:氧化亚氮(N2O)是否增加妇科腔镜手术术后恶心呕吐(PONV)发生率仍有争议。其发生率可能与麻醉气体吸入的浓度有关。作者研究了氧化亚氮与术后恶心呕吐的发生是否存在剂量相关效应。

方法:接受妇科腔镜手术的患者随机分为三组:吸入30%氧-空气组(G0, n = 46)、吸入50% N2O-氧混合组(G50n = 46)、吸入70% N2O-氧混合组(G70, n = 45)。使用标准的全麻技术但并不给予预防恶心呕吐药物。控制术前已知的PONV危险因素。胃复安为解救药物。评价术后二小时、二十四小时内的恶心、呕吐、使用解救药物的发生率及疼痛视觉评分(VAS)。

结果:各组的一般情况具有可比性,包括可能影响PONV的危险因素。PONV24小时发生率分别为:G033%15/46)、G5046%(21/46) G7062%(28/45)(P=0.018)。组间分析发现G0G70组之间有统计学差异(P=0.018),但其他组合之间却无差异。在恶心发生率方面具有相似的差异:G0=26%,G50=35%,G70=56%,P=0.012;但在呕吐发生率方面尽管有相似的趋势,却无统计学差异(G0=28%,G50=35%,G70=42%,P=0.377)。恶心的严重程度(用VAS 100mm评估)与N2O浓度之间呈正相关( G0=10.9,G50=12.7,G70=20.5,P=0.027)。同时分析24小时内最高的VAS评分。在解救药物使用率、疼痛VAS评分和阿片类药物使用量(术后二小时、二十四小时内)方面各组无差异。

结论N2O增加妇科腔镜手术术后恶心发生率。这项初步实验提示N2O可能以剂量相关的方式增加PONV的发生率。每组至少需要400个以上的样本量方能揭示其组间的统计学差异性。作者不建议在妇科腔镜手术中使用高浓度的N2O

(於章杰 陈杰 校)

BACKGROUND: Whether nitrous oxide (N2O) increases the incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery is still controversial, which may be due to the administration of different concentrations of inspired N2O. We investigated whether N2O results in a dose–response increase in PONV.

METHODS: Patients undergoing gynecologic laparoscopic surgery were randomized to receive 30% oxygen with air (G0, n = 46), 50% N2O with oxygen (G50, n = 46), or 70% N2O with oxygen (G70, n = 45). A standardized general anesthetic was used with no PONV prophylaxis. Known risk factors for PONV were controlled. Metoclopramide was used as a rescue antiemetic. The incidence of nausea, vomiting, use of rescue antiemetic, and pain visual analog scale (VAS) score was measured at 2 and 24 h postoperatively.

RESULTS: Patient demographics were comparable, and there were no differences among groups regarding factors that may influence PONV. The incidence of PONV at 24 h was 33% (15 of 46) in the G0 group, 46% (21 of 46) in the G50 group, and 62% (28 of 45) in the G70 group (P = 0.018). Subgroup analysis revealed a difference between G0 versus G70 groups (P = 0.018), but no significant difference between G0 versus G50 groups and G50 versus G70 groups. The incidence of nausea showed a similar difference (G0 = 26%, G50 = 35%, and G70 = 56%; P = 0.012), but the incidence of vomiting was not different among the groups although there was a trend (G0 = 28%, G50 = 35%, and G70 = 42%; P = 0.377). The severity of nausea (measured by VAS 100 mm) was significantly increased with increasing N2O concentration (G0 = 10.9, G50 = 12.7, and G70 = 20.5; P = 0.027). The highest VAS score during 24 h was used for the analysis. There was no difference in the use of a rescue antiemetic among groups. Pain VAS scores and opioids consumption were not different among groups (at 2 and 24 h after surgery).

CONCLUSIONS: N2O increases the incidence of postoperative nausea after gynecologic laparoscopic surgery. This preliminary finding indicates that N2O may increase PONV in a dose-dependent fashion. A study with a sample size of >400 patients in each group would be necessary to demonstrate a statistically significant difference among each of these three groups. We do not recommend using a high concentration of N2O in this clinical setting.



关于对吸入麻醉药反应的起源与演变的假说

A Hypothesis on the Origin and Evolution of the Response to Inhaled Anesthetics

James M. Sonner, MD

From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2008 107: 849-854.

 

本文作者提出了有机体对吸入麻醉药反应的进化论假说。作者推测,机体对吸入麻醉药的反应是由于离子通道,这种对吸入麻醉药的敏感性世代沿袭下来,由我们共同的祖先——单细胞生物里的麻醉敏感性离子通道并遗传下来(例如,单细胞生物还未产生神经系统对吸入麻醉药的适应性反应,而其离子通道对吸入麻醉药的反应要早于多细胞生物)。这种敏感性在多细胞生物里被细化为神经突触。

值得注意的是,作者推测,1)单细胞生物被选择的有益特性是离子通道对环境中化合物的协同应答,而这会影响离子通道的构象平衡; 2)这种协同反应防止了正电荷进入细胞而产生有害后果,因此增加了生物体的适应性; 3)这些复合物(包括阴离子,阳离子,两性离子和一些不带电化合物)模拟了吸入麻醉药在机体内的界面活性,并且通过改变连接离子通道的双分子层结构来调节离子通道的功能。

假说包括了吸入麻醉药已知特性。此外,这个假设也适合于那些非挥发性麻醉药有类麻醉作用的物质对离子通道调节作用,包括那些在健康人与身患疾病人身上的调节离子通道功能的内源性复合物。后者包括代谢物在一些器官衰竭的终末阶段以及一般的代谢疾病。这些预言部分已被研究并被证实。

(赵嫣红 陈杰 校)

In this article, I present an evolutionary explanation for why organisms respond to inhaled anesthetics. It is conjectured that organisms today respond to inhaled anesthetics owing to the sensitivity of ion channels to inhaled anesthetics, which in turn has arisen by common descent from ancestral, anesthetic-sensitive ion channels in one-celled organisms (i.e., that the response to anesthetics did not arise as an adaptation of the nervous system, but rather of ion channels that preceded the origin of multicellularity). This sensitivity may have been refined by continuing selection at synapses in multicellular organisms.

In particular, it is hypothesized that 1) the beneficial trait that was selected for in one-celled organisms was the coordinated response of ion channels to compounds that were present in the environment, which influenced the conformational equilibrium of ion channels; 2) this coordinated response prevented the deleterious consequences of entry of positive charges into the cell, thereby increasing the fitness of the organism; and 3) these compounds (which may have included organic anions, cations, and zwitterions as well as uncharged compounds) mimicked inhaled anesthetics in that they were interfacially active, and modulated ion channel function by altering bilayer properties coupled to channel function.

The proposed hypothesis is consistent with known properties of inhaled anesthetics. In addition, it leads to testable experimental predictions of nonvolatile compounds having anesthetic-like modulatory effects on ion channels and in animals, including endogenous compounds that may modulate ion channel function in health and disease. The latter included metabolites that are increased in some types of end-stage organ failure, and genetic metabolic diseases. Several of these predictions have been tested and proved to be correct.


脑脊髓液中钾离子浓度的增加并不引起大鼠异氟醚MAC的增加

Increases in Spinal Cerebrospinal Fluid Potassium Concentration Do Not Increase Isoflurane Minimum Alveolar Concentration in Rats

Dimitry Shnayderman, BS*, Michael J. Laster, DVM*, Edmond I. Eger, II, MD*, Irene Oh, BS*, Yi Zhang, MD*, Steven L. Jinks, PhD{dagger}, Joseph F. Antognini, MD{dagger}, and Douglas E. Raines, MD{ddagger}

From the *Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; {dagger}Department of Anesthesiology and Pain Medicine, University of California, Davis, California; and {ddagger}Department of Anesthesia and Critical Care, The Massachusetts General Hospital, Boston, Massachusetts.

Anesth Analg 2008 107: 879-884.

 

背景:以往的研究显示异氟醚的MAC与脊髓周围脑脊液的钠离子浓度相关。脊髓为吸入麻醉药制动作用主要作用位点。如果这一相关性是由脊髓刺激提高所致,输注高钾液会有相似作用。相反,如果钾离子此效应缺失可能解释钾离子通道并不介导吸入麻醉药的制动作用,而钠离子通道仍为介体。本文作者研究了改变鞘内钾离子浓度对MAC的影响。

方法:大鼠鞘内置管,腰部鞘内给予贫钾、富钾液体,测定异氟醚应用前24h、使用中及24h后的MAC。另测定渗透压对(输注甘露醇)MAC的影响和钠离子渗入脊髓情况。

结果:异氟醚的MAC在鞘内输注钾离子导致浓度升高后无显著变化。在输注KCl浓度超过12倍正常浓度后(29 mEq/L)大鼠自主活动时异氟醚浓度稍降低,有时为一个MAC,但平均MAC未超过对照MAC。在最大输注浓度(58.1 mEq/L)时MAC明显降低且随后未恢复至正常(如此高浓度可产生损伤)。输注低浓度钾溶液时并不影响MAC。鞘内注射钠离子可渗入脊髓。

结论:上述结果并不支持钾通道媒介或调制MAC

(怀晓蓉 陈杰 校)

BACKGROUND: Previous studies demonstrated that MAC for isoflurane directly correlates with the concentration of Na+ in cerebrospinal fluid surrounding the spinal cord, the primary site for mediation of the immobility produced by inhaled anesthetics. If this correlation resulted from increased irritability of the cord, then infusion of increased concentrations of potassium (K+) might be predicted to act similarly. However, an absence of effect of K+ might be interpreted to indicate that K+ channels do not mediate the immobility produced by inhaled anesthetics whereas Na+ channels remain as potential mediators. Accordingly, in the present study, we examined the effect of altering intrathecal concentrations of K+ on MAC.

METHODS: In rats prepared with chronic indwelling intrathecal catheters, we infused solutions deficient in K+ and with an excess of K+ into the lumbar space and measured MAC for isoflurane 24 h before, during, and 24 h after infusion. Rats similarly prepared were tested for the effect of altered osmolarity on MAC (accomplished by infusion of mannitol) and for the penetration of Na+ into the cord.

RESULTS: MAC of isoflurane never significantly increased with increasing concentrations of K+ infused intrathecally. At infused concentrations exceeding 12 times the normal concentration of KCl, i.e., 29 mEq/L, rats moved spontaneously at isoflurane concentrations just below, and sometimes at MAC, but the average MAC in these rats did not exceed their control MAC. At the largest infused concentration (58.1 mEq/L), MAC significantly decreased and did not subsequently return to normal (i.e., such large concentrations produced injury). Infusions of lower concentrations of K+ had no effect on MAC. Infusion of osmotically equivalent solutions of mannitol did not affect MAC. Na+ infused intrathecally measurably penetrated the spinal cord.

CONCLUSIONS: The results do not support a mediation or modulation of MAC by K+ channels.


一项在体代谢试验用于检测人群中恶性高热易感性:一项初步研究

An In-Vivo Metabolic Test for Detecting Malignant Hyperthermia Susceptibility in Humans: A Pilot Study

Frank Schuster, MD*, Thomas Metterlein, MD*, Sabrina Negele, MS*, Peter Kranke, MD*, Ralf M. Muellenbach, MD*, Ulrich Schwemmer, MD*, Norbert Roewer, MD*, and Martin Anetseder, MD{dagger}

From the *Department of Anesthesiology, University of Würzburg, Germany; {dagger}Department of Anesthesiology, Hospital Landshut-Achdorf, Germany.

Anesth Analg 2008 107: 909-914.

 

引言:离体收缩试验以诊断恶性高热(MH)需肌组织活检,它可能给病人带来严重的副作用。在研究过多篇不同的试验计划书后作者提出一个创伤相对较小的测试,通过肌注咖啡因和氟烷,测定局部的乳酸值,以区别高热易感人群(MHS)和非易感人群(MHN)间差异。

方法:在8名先前已诊断为MHS的患者(其三个代表基因突变,GLY2434ARGTHR2206MET,ARG614CYS),和7MHN,以及7名对照组患者的股肌中埋入两个可进行微型探针。在在平衡和乳酸水平基线记录后,局部注射单次负荷剂量咖啡因(200uL80 Mm)和4%的氟烷200uL(容积百分比,大豆油悬浮液)。乳酸含量由分光光度法测定。数据采用中位数及四分位数间距表示。

结果:尽管各研究组的乳酸基线值在注射前是相似的,但在注射咖啡因后,局部乳酸值在MHS组(2.01.8-2.6 mM)显著大于MHN(0.8(0.6-1.1)mM)和对照组(0.80.6-0.8mM。氟烷也引起MHS组【8.6 3.7-8.9 Mm】比MHN组【 0.90.5-1.1mM】和对照组【1.70.9-2.3mM】乳酸值高。但MHN组有一名患者和对照组两名患者乳酸增加。另外,血流动力学和代谢参数在组间无差异。

结论:通过局部注射咖啡因和氟烷后检测乳酸代谢,是一种创伤性和副作用较小的方法,以便检测恶性高热的易感人群。

(叶乐 陈杰 校)

INTRODUCTION: In vitro contracture testing to diagnose malignant hyperthermia (MH) susceptibility requires a muscle biopsy, which may be associated with severe side effects for the patient. After investigation of several different protocols, we present a less invasive metabolic test that involves IM injection of caffeine and halothane, and subsequent measurement of interstitial lactate to differentiate between MH susceptible (MHS) and MH non-susceptible (MHN) individuals.

METHODS: Two microdialysis probes with attached microtubing for trigger injection were inserted into the lateral vastus muscle of eight previously diagnosed MHS patients (representing three genetic variants Gly2434Arg, Thr2206Met, and Arg614Cys), seven MHN patients, and seven control individuals. After equilibration and lactate baseline recording, a single bolus of 200 µL caffeine 80 mM and a suspension of 200 µL halothane 4%V/V in soy bean oil (triggers) were injected locally. Lactate was measured spectrophotometrically. Data are presented as medians and interquartile ranges.

RESULTS: Although baseline lactate values were similar in the investigated groups before trigger injection, caffeine increased local lactate in MHS patients significantly more (2.0 [1.8–2.6] mM) than in MHN (0.8 [0.6–1.1] mM) or in control individuals (0.8 [0.6–0.8 mM]). Similarly, halothane lead to a significant lactate increase in MHS compared to MHN and control individuals (8.6 [3.7–8.9] mM vs 0.9 [0.5–1.1] mM and 1.7 [0.9–2.3] mM, respectively). However, a relevant increase of lactate was observed in one MHN and in two control individuals. Systemic hemodynamic and metabolic variables did not differ between the investigated groups.

DISCUSSION: Metabolic monitoring of IM lactate after local caffeine and halothane injection may allow less invasive testing to detect MH susceptibility, without systemic side effects.

 

自适应辅助通气时潮气量的确定:一项多中心观察研究

Determinants of Tidal Volumes with Adaptive Support Ventilation: A Multicenter Observational Study

Dave A. Dongelmans*, Denise P. Veelo*{dagger}, Alexander Bindels{ddagger}, Jan M. Binnekade*, Kees Koppenol{ddagger}, Matty Koopmans§, Joke C. Korevaar||, Michael A. Kuiper*§, and Marcus J. Schultz*¶#

From the *Department of Intensive Care Medicine, {dagger}Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; {ddagger}Department of Intensive Care Medicine, Catharina Hospital Eindhoven, Eindhoven, The Netherlands; §Department of Intensive Care Medicine, Medical Centre Leeuwarden, Leeuwarden, The Netherlands; ||Department of Clinical Epidemiology and Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; ¶HERMES Critical Care Group, Amsterdam, The Netherlands; and #Laboratory for Experimental Intensive Care and Anesthesiology (L.E.I.C.A), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

Anesth Analg 2008 107: 932-937. [

 

引言:本文作者研究了心胸外科手术病人自适应辅助通气(ASV),并研究微处理器机械通气模型下潮气量的确定及影响因素。

方法:本研究为前瞻性、多中心、观察研究,包括3个荷兰ICU,时间长达5个多月。机械通气数据在患者入ICU后稳定时收集。

结果:采集346位心胸外科手术病人数据:262位病人使用ASV,而84位病人使用压力控制/压力支持通气。使用ASV组的病人平均潮气量为7.1 ±1.6ml/kg。换算成理想体重潮气量为8.3 ±1.5ml/kg,在一些正确的预设体重病人中(例如:理想体重),潮气量为8.1 ±1.4ml/kg。而在压力控制或压力支持通气组病人理想体重的潮气量为7.3 ±1.4ml/kg(与ASV相比P<0.001)。多变量计算回归分析显示ASV的潮气量取决于两个参数:呼吸频率和预设体重。

结论ASV的潮气量取决于两个参数:呼吸频率和预设体重。第一个因素在临床上不是很重要,因为呼吸频率是由计算机自动选择。第二个因素在临床上很重要,因为它是唯一的可以被医生影响的因素。研究数据显示了在使用ASV时设置正确体重的重要性。在相当数量使用ASV的病人中,理想体重的潮气量>8ml/kg。今后尚需随机临床试验比较ASV与其他通气模式的差异。

(张磊 陈杰 校)

INTRODUCTION: In the present study, we investigated the behavior of adaptive support ventilation (ASV) in patients after cardiothoracic surgery. We determined tidal volumes (Vt) and factors that influence Vt with this mode of microprocessor-controlled mechanical ventilation (MV).

METHODS: This was a prospective, multicenter, observational study in three Dutch intensive care units over a 5-mo period. MV data were collected during steady-state after arrival in the intensive care unit.

RESULTS: Data were collected for 346 consecutive patients after cardiothoracic surgery: 262 patients weaned with ASV, and 84 patients weaned with pressure-controlled/pressure-support MV. With ASV the mean (± sd) Vt expressed per kilogram actual body weight was 7.1 ± 1.6 mL. Expressed per kilogram ideal body weight (IBW), Vt was 8.3 ± 1.5 mL. In patients with a correctly set body weight (SBW) (i.e., the IBW), Vt was 8.1 ± 1.4 mL/kg. With pressure-controlled/pressure-support-MV Vt was 7.3 ± 1.4 mL/kg IBW (P < 0.001 vs ASV). Multivariate logistic regression analysis showed Vt with ASV to be dependent on only two parameters: respiratory rate and the correctness of SBW.

CONCLUSIONS: Vt with ASV seems to be dependent on two parameters: respiratory rate and the correctness of SBW. The first factor is not clinically important because respiratory rate is automatically chosen by the microprocessor. The second factor is clinically important because it is the only factor that can be influenced by the operator. Our data show the importance of setting the correct weight with ASV. With ASV, Vt are >8 mL/kg IBW in a substantial number of patients. Randomized clinical trials should be performed to compare ASV with other ventilation modes.

 

 

择期剖腹产鞘内注射可乐定对术后抗痛觉过敏和镇痛作用的评估

An Evaluation of the Postoperative Antihyperalgesic and Analgesic Effects of Intrathecal Clonidine Administered During Elective Cesarean Delivery

Patricia M. Lavand’homme, MD, PhD, Fabienne Roelants, MD, Hilde Waterloos, RN, Valerie Collet, MSc, and Marc F. De Kock, MD, PhD

From the Department of Anesthesiology, St Luc Hospital Medical School, Université Catholique de Louvain, Brussels, Belgium.

Anesth Analg 2008 107: 948-955.

 

背景:鞘内注射可乐定提高剖腹产术中麻醉和术后镇痛。可乐定同时还具有抗痛觉过敏的特性。痛觉过敏归因于术后疼痛并可能增加术后慢性疼痛的风险。在此研究中,作者评估了鞘内可乐定注射剖腹产术后抗痛觉过敏作用。

方法96名接受选择性剖腹产术的产妇随机分组,分别接受:鞘内布比卡因-舒芬太尼(BS组),布比卡因-舒芬太尼-可乐定75ugBSC组),或者布比卡因-可乐定150ugBC组)。首先评价的是切口周围点状机械性痛觉过敏的程度和发生率,通过对剖腹产术后24小时和48小时的von Frey毛发刺激反应来评定。同时评估术后吗啡需要量、疼痛评分和136月的后遗痛情况。

结果BC组在术后48小时切口周围痛觉过敏的范围明显减少(中位数,25-75个百分点,分别为BC1.0(1.0-3.3)cm2BS9.5(5.0-14.0)cm2BSC5.02.5-12.3cm2(与BS组相比P=0.002)。BC组的术后48小时痛觉过敏发生率同样较低,分别为BC16%BS41%BSC34%(与BS组相比P=0.03)。各组间的术后吗啡量、疼痛评分、后遗痛的发生率和强度无差异。

结果:相比于鞘内使用布比卡因-舒芬太尼和鞘内使用可乐定75ug-布比卡因-舒芬太尼,鞘内使用150ug可乐定联合布比卡因具有抗痛觉过敏的作用,显著减少选择性剖腹产后48小时切口周围点状机械性痛觉过敏的程度和发生率。

(朱紫瑜 陈杰 校)

BACKGROUND: Intrathecal clonidine improves intraoperative anesthesia and postoperative analgesia after cesarean delivery. Clonidine also possesses antihyperalgesic properties. Hyperalgesia contributes to postoperative pain and may be associated with increased risk of chronic pain after surgery. In this study, we evaluated the postoperative antihyperalgesic effect of intrathecal clonidine after caesarean delivery.

METHODS: Ninety-six parturients undergoing elective cesarean delivery were randomly assigned to receive intrathecal bupivacaine-sufentanil (BS group), bupivacaine-sufentanil-clonidine 75 µg (BSC group), or bupivacaine-clonidine 150 µg (BC group). The primary outcome was the extent and the incidence of periincisional punctate mechanical hyperalgesia as assessed by response to application of a von Frey filament at 24 and 48 h after cesarean delivery. Postoperative morphine requirements and pain scores, as well as residual pain at 1, 3, and 6 mo, were also assessed.

RESULTS: The BC group had a significantly reduced area of periincisional hyperalgesia at 48 h (median, 25th–75th percentiles): 1.0 (1.0 – 3.3) cm2 vs 9.5 (5.0–14.0) cm2 in the BS group vs 5.0 (2.5–12.3) cm2 in the BSC group (P = 0.02 with the BS group). The incidence of hyperalgesia at 48 h was also lower in the BC group: 16% vs 41% in the BS group vs 34% in the BSC group (P = 0.03 with BS group). Postoperative morphine consumption, pain scores, and incidence and intensity of residual pain did not differ among groups.

CONCLUSIONS: Intrathecal clonidine 150 µg combined with bupivacaine had a postoperative antihyperalgesic effect expressed as a significant reduction in the extent and incidence of periincisional punctate mechanical hyperalgesia at 48 h after elective cesarean delivery compared with intrathecal bupivacaine-sufentanil and intrathecal clonidine 75 µg-bupivacaine-sufentanil.

 

 

颈部伸展时气管拉长:气管的哪一段伸长了?

Lengthening of the Trachea During Neck Extension: Which Part of the Trachea Is Stretched?

David T. Wong, MD*, Hao Weng, MD{dagger}, Eunice Lam{ddagger}, Hai-Bao Song, MD£, and Jin Liu, MD£

From the *Department of Anesthesiology, University of Toronto, Canada; {dagger}Department of Anesthesiology, Dongfeng General Hospital, Yunyang Medical College, No.10 Da-Ling-Lu street, Shiyan, Hubei, 442008, People’s Republic of China; and {ddagger}Student, Health Science Program, McMaster University, Hamilton, Canada; £Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China.

Anesth Analg 2008 107: 989-993.

 

背景:作者试图研究三种不同颈部位置时从上门齿至气管隆突的气道三部分各自长度改变。

方法20名择期手术患者入组本实验。将气道分为三段:上门齿至声带(UI-VC)、声带至胸骨切迹(VC-SN)、胸骨切迹至气管隆突(SN-CA)。患者予全麻诱导并行气管插管,连接呼吸机行机械通气。将支气管镜经气管导管连接处置入气管导管内插入直至其顶端触及隆突并予以支气管镜上胶带标记,随后缓慢退出支气管镜并分别于胸骨切迹(透光法确认)声带及上门齿(支气管镜直视)时胶带标记。分别测量病人颈部处屈位(相当于头部垫10m枕头)、自然位(相当于头部垫5cm枕头)、伸位(相当于头部不垫枕头)时四个标记间的三段距离以获得气管三段部分的各自长度,并对所获得数据进行方差分析及配对t检验。

结果 UI-VC, VC-SN, SN-CA三段的长度分别为12.1 ± 1.495.37 ± 0.958.24 ± 1.16cm。当颈部从屈位至伸位变化中UI-VC VC-SN长度分别增加0.36 ±  0.68cmP=0.027)及1.74 ±  0.48cmP<0.001)。SN-CA段长度减少0.12± 0.70cmNS),而UI-CA的总长度增加1.99 ±0.7cmP<0.001)。在颈部位置处于屈位、自然位和伸位时SN-CA段分别占总长度的64%61%56%,但其长度无显著变化。

结论:当颈部从屈位至伸位变化中,UI-CA的总长度增加1.99cm。气道三段组成中以VC-SN段长度增加1.74cm为甚,UI-VC段只增加0.36cmSN-CA段长度无明显改变。三种体位中SN-CA段平均占UI-CA总长度的60%。本实验发现可以解释为何插管病人颈部伸展时其原本固定的气管导管会滑向深处。

(陶颖莹 陈杰 校)

BACKGROUND: We sought to determine the distances of the three segments of the airway from upper incisors to carina in intubated patients in three different neck positions.

METHODS: Twenty patients undergoing elective surgery were studied. The airway was divided into three segments: upper incisor to vocal cords (UI-VC), vocal cords to sternal notch (VC-SN), and sternal notch to the carina (SN-CA). After general anesthesia and tracheal tube placement, the circuit was connected and the lungs ventilated. A bronchoscope was inserted through a ported elbow adapter until the tip just contacted carina. A marker tape was placed on the bronchoscope immediately above the adapter port. As the bronchoscope was withdrawn to the sternal notch (by transillumination), vocal cords and upper incisor (endoscopic visualization), three corresponding markers were placed along the bronchoscope. The three segments of the airway were obtained by measuring the distances between the four markers. Measurements were taken with the patient’s neck in flexion (10 cm pillow), neutral (5 cm pillow), and extension (no pillow) positions. Repeated measure analysis of variance and paired t-tests were used for analysis of the data.

RESULTS: The UI-VC, VC-SN, and SN-CA distances were 12.01 ± 1.49, 5.37 ± 0.95, 8.24 ± 1.16 cm. From neck flexion to extension, UI-VC and VC-SN increased by 0.36 ± 0.68 cm (P = 0.027) and 1.74 ± 0.48 cm (P < 0.001) respectively; SN-CA decreased by 0.12 ± 0.70 cm (NS). Overall, UI-CA increased by 1.99 ± 0.70 cm (P < 0.001). SN-CA represented 64%, 61%, 56% of the VC-CA distance with the neck in flexion, neutral, and extension respectively. SN-CA did not change significantly among the head positions (NS).

CONCLUSIONS: From neck flexion to extension, the UI-CA distance increased by 1.99 cm. The major contribution to this lengthening was an increase of the VC-SN distance by 1.74 cm; UI-VC increased by 0.36 cm whereas SN-CA did not change significantly. Averaging the three neck positions, SN-CA represented 60% of the VC-CA distance. Our findings may explain why tracheal tubes fixed at the mouth ascend in the trachea with neck extension.

 

 

经皮烟碱贴剂作为术后疼痛处理:一项剂量范围研究

Transdermal Nicotine Patch for Postoperative Pain Management: A Pilot Dose-Ranging Study

Daewha Hong, MS, Jessamyn Conell-Price, BA, Sean Cheng, MD, and Pamela Flood, MD

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

Anesth Analg 2008 107: 1005-1010.

 

背景: 动物试验表明烟碱具有术后镇痛作用。人类应用经鼻烟碱喷剂有不等的效果,可能是由于药代动力学及不同情况病人如经常暴露于烟碱的吸烟者存有变异性。在这项研究中,作者仅在非吸烟者中进行术前应用经皮烟碱贴剂镇痛效果的试验。

方法:本研究对40名拟行普外科手术,术后要求行自控镇痛且住院的患者进行一项随机、双盲、前瞻性、安慰剂-对照研究。术前应用剂量分别为051015mg的经皮烟碱贴剂。主要的结果参数为是数字化评定量表(NRS)来判定术后一小时和术后五天疼痛评分。次要的结果参数是疼痛药选用,对血流动力学的影响,恶心发生率和镇静作用等。

结果: 在术后一小时(P=0.003,平均NRS减少1.4,95% CI=0.3-2.6)和术后五天 (P=0.03,平均NRS减少1.0,95% CI=0.1-1.9)的疼痛评定中可以看出,与应用安慰剂处理的病人相比,应用了烟碱的病人有更低疼痛评分。当烟碱的用量超过5mg时,其有效性已经不再增加。在烟碱组减少了疼痛药的使用同时,增加了恶心的发生,减少了心动过速的发生和略微降低了收缩压的倾向,但是这些作用均不显著。

结论:在普外科手术,经皮使用烟碱5-15mg,可以减低术后疼痛评分但是并不能减少麻醉性镇痛药的使用量,也不能降低阿片类镇痛药物相关的副作用。 

(丁俊云 译 陈杰 校)

BACKGROUND: Nicotine has been shown to be antinociceptive in the postoperative period in animal studies. Human studies with nasal nicotine sprays have had mixed results, possibly due to variability in pharmacokinetics and potential patient variables such as exposure to nicotine in tobacco smokers. In this pilot study, we examined the analgesic effect of a transdermal nicotine patch applied before surgery in nonsmokers.

METHODS: We conducted a randomized, double-blind, prospective placebo-controlled trial of 40 subjects, undergoing general surgery that required postoperative patient-controlled analgesia and an overnight hospital admission. Immediately before surgery, a transdermal nicotine patch containing 0, 5, 10, or 15 mg was applied. The primary outcome variable was pain report using a numerical rating scale (NRS) in the first hour after surgery and over the next 5 days. Secondary outcomes were pain medication use, hemodynamic values, nausea, and sedation.

RESULTS: Patients treated with nicotine reported lower pain scores when compared with those treated with placebo during the first hour after surgery (P = 0.003, average NRS decrease = 1.4, 95% CI = 0.3–2.6) and for 5 days after surgery (P = 0.03, average NRS decrease = 1.0, 95% CI = 0.1–1.9). There was no increased benefit of nicotine with doses larger than 5 mg. There was a trend suggesting decreased pain medicine use, increased nausea, decreased tachycardia, and slightly decreased systolic blood pressure in the nicotine groups, but these values did not reach significance.

CONCLUSIONS: Transdermal nicotine, 5–15 mg, reduced postoperative pain scores but failed to decrease the need for opioid analgesics or opioid-related side effects after general surgical procedures.


区域麻醉技术用于开胸手术术后镇痛的随机试验――系统综述

A Systematic Review of Randomized Trials Evaluating Regional Techniques for Postthoracotomy Analgesia

Girish P. Joshi, MB, BS, MD,FFARCSI*, Francis Bonnet, MD, FRCA{dagger}, Rajesh Shah, FRCS (C/Th){ddagger}, Roseanne C. Wilkinson, PhD§, Frederic Camu, MD||, Barrie Fischer, FRCA, Edmund A. M. Neugebauer, PhD#, Narinder Rawal, MD**, Stephan A. Schug, MD (Cgn), FANZCA, FFP MANZCA{dagger}{dagger}, Christian Simanski, MD{ddagger}{ddagger}, and Henrik Kehlet, MD§§

From the *Department of Anesthesiology and Pain Management, University of TX Southwestern Medical Center, Dallas, Texas; {dagger}Hôpital Tenon Assistance Publique Hôpitaux de Paris and Université Pierre and Marie Curie, Paris, France; {ddagger}Wythenshawe Hospital, Manchester, UK; §Choice Pharma, Hitchin, UK; ||Department of Anesthesiology, Flemish Free University of Brussels Medical Center, Brussels, Belgium; ¶Department of Anaesthesia, Alexandra Hospital, Redditch, Worcestershire, UK; #Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany; **Department of Anaesthesiology and Intensive Care, Örebro Medical Center Hospital, Örebro, Sweden; {dagger}{dagger}School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia; {ddagger}{ddagger}Department of Trauma and Orthopaedic Surgery Cologne-Merheim, University of Witten/Herdecke, Cologne, Germany; and §§Section for Surgical Pathophysiology 4074, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark.

Anesth Analg 2008 107: 1026-1040.

 

背景:开胸手术可导致严重的术后疼痛和肺功能的减弱,因此术后的区域镇痛已被深入的研究。胸段的硬膜外镇痛被普遍的认为是最好的方法,然而需要评估与其他技术的差异,指导临床实践,寻求需要进一步研究的领域。

方法:在这项随机试验的系统综述中作者评估了胸部硬膜外、椎旁、鞘内注射、肋间和胸膜间等镇痛技术在成人的开胸手术中的应用的相互比较,并与全身应用阿片类药物镇痛比较。并对术后疼痛,镇痛药的使用量,以及并发症作分析。

结果:持续的椎旁阻滞和硬膜外的局麻药镇痛同样有效,并且能降低低血压的发生率。与全身药物镇痛相比,椎旁阻滞能降低肺部并发症的发生率,而胸段硬膜外镇痛则无此作用。胸段硬膜外镇痛比鞘内注射和肋间技术优越,而它们都优于系统性药物镇痛;胸膜间的镇痛则显得不足。

结论:无论是胸段硬膜外镇痛加阿片类药物还是持续的椎旁阻滞都可以使用。如果不能用这些技术或者是存在禁忌,鞘内注射阿片类药物或者肋间神经阻滞也可以,尽管持续镇痛的时间略显不足,需要辅助应用系统性药物镇痛。定量荟萃分析受到实验设计的限制,且量本样数也较少。还需进一步的研究以确定最适宜的硬膜外的药物组合,严格评估椎旁持续输注的风险和优点以及肋间技术与胸段硬膜外镇痛的比较。

(舒慧刚 陈杰 校)

BACKGROUND: Thoracotomy induces severe postoperative pain and impairment of pulmonary function, and therefore regional analgesia has been intensively studied in this procedure. Thoracic epidural analgesia is commonly considered the "gold standard" in this setting; however, evaluation of the evidence is needed to assess the comparative benefits of alternative techniques, guide clinical practice and identify areas requiring further research.

METHODS: In this systematic review of randomized trials we evaluated thoracic epidural, paravertebral, intrathecal, intercostal, and interpleural analgesic techniques, compared to each other and to systemic opioid analgesia, in adult thoracotomy. Postoperative pain, analgesic use, and complications were analyzed.

RESULTS: Continuous paravertebral block was as effective as thoracic epidural analgesia with local anesthetic (LA) but was associated with a reduced incidence of hypotension. Paravertebral block reduced the incidence of pulmonary complications compared with systemic analgesia, whereas thoracic epidural analgesia did not. Thoracic epidural analgesia was superior to intrathecal and intercostal techniques, although these were superior to systemic analgesia; interpleural analgesia was inadequate.

CONCLUSIONS: Either thoracic epidural analgesia with LA plus opioid or continuous paravertebral block with LA can be recommended. Where these techniques are not possible, or are contraindicated, intrathecal opioid or intercostal nerve block are recommended despite insufficient duration of analgesia, which requires the use of supplementary systemic analgesia. Quantitative meta-analyses were limited by heterogeneity in study design, and subject numbers were small. Further well designed studies are required to investigate the optimum components of the epidural solution and to rigorously evaluate the risks/benefits of continuous infusion paravertebral and intercostal techniques compared with thoracic epidural analgesia.



烟碱受体激动剂在小鼠术后疼痛模型中的抗伤害作用

The Antinociceptive Response to Nicotinic Agonists in a Mouse Model of Postoperative Pain

Thomas J. Rowley, MA, James Payappilly, Jeffery Lu, MD, and Pamela Flood, MD

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

Anesth Analg 2008 107: 1052-1057.

 

背景:尼古丁, 中枢烟碱受体的广谱激动剂,具有术后镇痛效应。许多亚型的特异性烟碱受体激动剂在动物模型中具有抗伤害作用,但是对于实验模型有高度的依赖性。本文作者研究了选择性作用于{alpha}4β2 {alpha}7烟碱受体激动剂对于小鼠术后疼痛模型的作用,探究哪一烟碱受体亚型在今后临床研究更具意义。

方法 小鼠在足切皮后,作者用一定剂量的配体选择性作用于{alpha}4β2 {alpha}7烟碱受体,给药前后分别测定热潜伏期和压力阈值。在研究中,为了证明尼古丁可以降低疼痛输入,一组小鼠用磷酸化的cAMP反应结合蛋白(CREB)在脊髓腰段进行了染色。

结果:在热和压力测试中,尼古丁和位变异烟碱({alpha}4β2选择性)可以作为一种非常有效的止痛药。{alpha}7部分受体激动剂GTS-21可以显著延长术后热潜伏期,但是不改变压力阈值。选择性{alpha}7受体拮抗剂methyllicaconitine可以降低尼古丁延长热潜伏期的效能,但是对压力阈值没有影响。细胞核用pCREB染色的脊髓背角浅层细胞的数量在术侧成倍增加,使用尼古丁后呈剂量依赖性降低。

结论:研究表明尼古丁可以减少疼痛传输至脊髓背角浅层和深层。结果也同样支持{alpha}4β2 {alpha}7烟碱受体介导抗伤害作用。

(杜唯佳 陈杰 校)

BACKGROUND: Nicotine, the prototypical broad spectrum agonist at central nicotinic receptors, has analgesic action after surgery. Various subtype-specific nicotinic agonists have antinociceptive effects in animal models, but the response is highly dependent on the model tested. In an effort to determine what nicotinic subtypes might be targeted in future clinical studies, we tested agonists selective for {alpha}4β2 and {alpha}7 containing nicotinic receptors in a mouse model of postoperative pain.

METHODS: After paw incision, mice were tested for heat latency and pressure threshold before and after treatment with a dose range of ligands selective for {alpha}4β2 and {alpha}7 containing nicotinic receptors. To demonstrate that nicotine reduced nociceptive input in this model, the lumbar spinal cords of a subgroup of these mice were stained for the phosphorylated form if CREB.

RESULTS: Nicotine and metanicotine ({alpha}4β2 selective) were fully effective as an analgesic in heat and pressure testing. The {alpha}7 partial agonist GTS-21 significantly increased the heat latency after surgery, but did not alter pressure threshold. The {alpha}7 selective antagonist methyllicaconitine decreased the efficacy of nicotine to increase heat latency but did not affect pressure threshold. The number of cells in the superficial dorsal horn with nuclei that stained for pCREB was double on the surgical side and the ratio was reduced by nicotine in a dose-dependent manner.

CONCLUSIONS: Our findings suggest that nicotine reduced nociceptive input to the superficial and deep dorsal horn. It also provides support for {alpha}4β2 and {alpha}7 nicotinic-mediated antinociceptive actions.

 

 

超声成像精确定位股外侧神经

Ultrasound Imaging Accurately Identifies the Lateral Femoral Cutaneous Nerve

Irene Ng, MBBS, FANZCA*, Himat Vaghadia, MBBS, FRCPC, FFARCS*, Peter T. Choi, MD, MSc (Epid), FRCPC{dagger}, and Naeder Helmy, MD{ddagger}

From the *Department of Anesthesia, the Vancouver Hospital, Vancouver, British Columbia, Canada; and {dagger}Department of Anesthesiology, Pharmacology and Therapeutics and the Vancouver Coastal Health Research Institute, The University of British Columbia, Vancouver, British Columbia, Canada; and {ddagger}Department of Orthopedic Surgery, The Vancouver Hospital, Vancouver, British Columbia, Canada.

Anesth Analg 2008 107: 1070-1074.

 

背景:股外侧皮神经(LFCN)麻醉在股前外侧手术时很有用的,作者通过在尸体和志愿者对比用超声和解剖标志来定位验证超声的准确性。

方法20具尸体,在超声的引导下用一根针刺入股外侧皮神经的靶点,注入绿色的染料,再在解剖标志的定位下刺入第二根针,通过分离肌肉组织来确定股外侧皮神经,染色评估针的位置,用神经刺激来验证双侧股外侧皮神经的位置,它们的位置通过超声和解剖位置来比较。

结果:在超声引导下刺入尸体的19根针,其中16根触及到了股外侧皮神经,针尖与神经的平行距离几乎是0,利用解剖标志定位的19根针中只有一根接触到神经,其它针尖到神经的平均距离是18.0mm,在超声引导下的20个志愿者中,16例符合股外侧皮神经的位置的,记录器标志到股外侧皮神经的距离为0.0mm,在用解剖标志定位的20例中,没有一例触及到股外侧皮神经,记录器标志到股外侧皮神经的距离为15.0mm

结论:通过超声定位股外侧皮神经在技术上可行并比解剖标志定位法更准确。

(刘世文 陈杰 校)

BACKGROUND: Anesthesia of the lateral femoral cutaneous nerve (LFCN) is useful in surgery involving the anterolateral thigh. We investigated the accuracy of ultrasound compared with anatomical landmarks in identifying the LFCN in human cadavers and volunteers.

METHODS: Twenty cadavers were examined. A needle was inserted targeting the LFCN with ultrasound guidance and green dye was injected. A second needle was inserted using anatomical landmarks. The LFCN was identified by dissection, and coloring of the LFCN and needle positions were evaluated. A volunteer study with 10 individuals was performed. Transdermal nerve stimulation was used to identify the LFCN bilaterally. Its position was compared with marked positions identified in advance using ultrasound and anatomical landmarks.

RESULTS: Sixteen of 19 needles inserted under ultrasound guidance in the cadavers were in contact with the LFCN. The median horizontal distance from the needle tip to the nerve was 0.0 mm (interquartile range [IQR], 0.0-0.0 mm). Only 1 of 19 needles inserted using anatomical landmarks was in contact with the LFCN. The median horizontal distance from the needle tip to the nerve was 18.0 mm (IQR, 11.0–23.0 mm). Sixteen of 20 marked positions made using ultrasound guidance corresponded to the identified LFCN in volunteers. The median horizontal distance from the pen-mark to the LFCN was 0.0 mm (IQR, 0.0-0.0 mm). None of the 20 marked positions made with anatomical landmarks corresponded to the LFCN. The median horizontal distance from the pen-mark to the LFCN was 15.0 mm (IQR, 10.8–20.0 mm).

CONCLUSIONS: Identification of the LFCN by ultrasound is technically feasible and more accurate than anatomical landmarks.



 

吸入低浓度七氟烷增强抗消化性溃疡药物替普瑞酮的迟发性心脏保护作用

Low-Dose Sevoflurane Inhalation Enhances Late Cardioprotection from the Anti-Ulcer Drug Geranylgeranylacetone

Hiroshi Kitahata, MD*, Junpei Nozaki, MD{dagger}, Shinji Kawahito, MD*, Takehito Tomino, BS*, and Shuzo Oshita, MD*

From the *Department of Anesthesiology, The University of Tokushima Graduate School, Institute of Health Biosciences, Tokushima, Japan; and {dagger}Department of Anesthesiology, Naruto Hospital, Tokushima.

Anesth Analg 2008; 107:755-761

背景:我们在兔子身上观察七氟烷能否增强抗消化性胃溃疡药物替普瑞酮(GGA)诱发的迟发性心脏保护作用。

方法:S(+)-氯胺酮和塞拉嗪麻醉的兔子被分到七个试验组:对照(仅有溶媒)组、GGA组、七氟烷组、GGA+七氟烷组、5-羟基葵酸钠(5HD)组、GGA+5HD组和热应激组。所有兔子冠状动脉阻断30分钟后接受3小时的再灌注。冠状动脉阻断前24小时,兔子静脉注射溶媒、GGA(10mg/kg)或热应激(42°C15分钟)预处理。心肌缺血前吸入七氟烷(0.5MAC)或静脉注射5HD(5mg/kg)。测量各实验组兔子心肌梗塞面积和频临缺血区面积以及热休克蛋白(Hsp70水平。

结果:相对于溶媒,GGA显著减少心肌梗塞面积与频临缺血区面积的比值(39 ± 10%59 ± 9%, P < 0.02)。七氟烷增强GGA诱发的心脏保护作用(23 ± 17%, P < 0.05GGA)5HD取消GGA的心脏保护作用(56 ± 15%, P < 0.01)。相对于对照组,GGA增加Hsp70的表达(0.69 ± 0.150.36 ± 0.05, P < 0.02)。联合应用GGA和七氟烷与单独应用GGAHsp70表达的影响没有显著性差异(0.69 ± 0.16, P > 0.98)

结论:GGA减少心肌梗塞面积似乎与增加Hsp70表达有关;七氟烷增强GGA诱发的心肌保护效应。

(王宏   马皓琳 李士通 校)

BACKGROUND: We investigated in rabbits whether sevoflurane enhances late cardioprotection induced by geranylgeranylacetone (GGA), a gastric antiulcer drug.

METHODS: S(+)-ketamine and xylazine-anesthetized rabbits were assigned to one of seven experimental groups: a control (vehicle only) group, a GGA group, a sevoflurane group, a GGA+sevoflurane group, a sodium 5-hydroxydecanoate (5HD) group, a GGA + 5HD group, and a heat stress group. All rabbits were subjected to 30 min of coronary artery occlusion followed by 3 h of reperfusion. Rabbits were pretreated with IV vehicle, GGA (10 mg/kg), or heat stress (42°C for 15 min) 24 h before coronary occlusion. Sevoflurane (0.5 minimum alveolar concentration) or 5HD (5 mg/kg) were administered before myocardial ischemia. Myocardial infarct size and the area at risk for ischemia were measured, and heat shock protein (Hsp) 70 levels in each experimental group were determined.

RESULTS: Compared with vehicle only, GGA significantly reduced the size of myocardial infarction in relation to the area at risk (39 ± 10% vs 59 ± 9%, P < 0.02). Sevoflurane enhanced the GGA-induced cardioprotection (23 ± 17%, P < 0.05 vs GGA). The cardioprotective effect of GGA was abolished by administration of 5HD (56 ± 15%, P < 0.01). GGA enhanced Hsp 70 expression compared with that in the control group (0.69 ± 0.15 vs 0.36 ± 0.05, P < 0.02). Administration of GGA with sevoflurane resulted in the same level of Hsp 70 expression as GGA (0.69 ± 0.16, P > 0.98).

CONCLUSIONS: GGA appears to reduce myocardial infarct size in association with increased Hsp 70 expression. Sevoflurane enhances the GGA-induced cardioprotective effect.


衰老大鼠心脏异氟烷预处理和活性氧产生的弱化作用的研究

Attenuation of Isoflurane-Induced Preconditioning and Reactive Oxygen Species Production in the Senescent Rat Heart

Long T. Nguyen, MD*, Mario J. Rebecchi, PhD*, Leon C. Moore, PhD{dagger}, Peter S. A. Glass, MB, ChB*, Peter R. Brink, PhD{dagger}, and Lixin Liu, MD, PhD*

From the Departments of *Anesthesiology, and {dagger}Physiology and Biophysics, Stony Brook University School of Medicine, Stony Brook, New York.

Anesth Analg 2008; 107:776-782

背景: 麻醉药预处理的弱化作用在衰老心肌体外试验中已得以广泛研究,但还没有相应的体内研究。为了扩展以前的研究和阐述年龄相关差异的可能机制,我们研究了在体衰老大鼠心脏中异氟烷预处理和活性氧(ROS)的产生情况。

方法:雄性Fisher大鼠,344只,按年龄分为青年组(3-5月)和老年组(20-24月),每组再分为预处理组和对照组,预处理组事先接受30min 1.0MAC异氟烷。四组大鼠均阻断冠状动脉30min,随后再灌注2 h。无异氟烷处理时或在另外4组异氟烷处理前即刻给予荧光探针(二羟胡米胺1 mg)用于检测超氧阴离子水平。分别用三苯基四唑染色和表面荧光显微镜观察心肌梗死面积和超氧阴离子产生。

结果:与年轻对照(50.9% ± 1.9%)相比较,异氟烷减少了年轻大鼠心肌梗死面积(26.7% ± 3.0%P < 0.001),但与年老对照(46.5% ± 2.4%)相比较,异氟烷并不明显影响年老大鼠心肌梗死面积(39.1% ± 0.9%P > 0.05)。与青年对照组(162.7 ± 25.5任意单位 [AU])相比,异氟烷增高了年轻大鼠的ROS水平(430.5 ± 95.9 AU;P < 0.01)。相反的是,异氟烷处理后老年大鼠ROS水平没有明显变化(316.4 ± 56.3 AU 异氟烷组比233.8 ± 59.2 AU 对照组)

结论:对于体内研究中的衰老心肌,异氟烷的心脏保护作用降低,异氟烷刺激产生的ROS水平降低。

(江继宏   马皓琳 李士通 校)

BACKGROUND: Although attenuation of anesthetic preconditioning in aged ex vivo heart models has been studied extensively, there are no comparable in vivo studies. To extend previous work and to address a possible mechanism underlying age-related differences, we investigated isoflurane-induced preconditioning and reactive oxygen species (ROS) production in the aged rat heart in vivo.

METHODS: Male Fisher 344 rats were assigned from their respective age groups (young, 3–5 mo; old, 20–24 mo) to either receive 30 min of 1.0 minimum alveolar concentration isoflurane or to a control group. Rats were subjected to coronary artery occlusion for 30 min followed by 2 h of reperfusion. A fluorescent probe for superoxide anion production (dihydroethidium, 1 mg) was administered in the absence of the isoflurane or just before isoflurane exposure in four additional groups. Myocardial infarct size and superoxide anion production were assessed using triphenyltetrazolium staining and epifluorescence microscopy, respectively.

RESULTS: Isoflurane decreased myocardial infarct size of young rats (26.7% ± 3.0%) compared with young controls (50.9% ± 1.9%; P < 0.001), whereas isoflurane did not significantly affect myocardial infarct size of old rats (39.1% ± 0.9%) compared with old controls (46.5% ± 2.4%; P > 0.05). Isoflurane increased ROS levels in young rats (430.5 ± 95.9 arbitrary units [AU]) compared with young controls (162.7 ± 25.5 AU; P < 0.01). In contrast, no significant changes in ROS levels were observed in old animals (316.4 ± 56.3 AU isoflurane versus 233.8 ± 59.2 AU control).

CONCLUSIONS: Reduction in the cardioprotective effects of isoflurane and attenuation of isoflurane-stimulated ROS production were observed in the senescent myocardium in vivo.


不同浓度丙泊酚对小儿心肌复极化分散的影响

The Effect of Propofol Concentration on Dispersion of Myocardial Repolarization in Children

Helen V. Hume-Smith, MBBS, BSc, FRCA*{dagger}, Shubhayan Sanatani, MD, BSc, FRCPC{ddagger}§, Joanne Lim, MASc*{dagger}, Anthony Chau, Bsc (Pharm), ACPR*{dagger}, and Simon D. Whyte, MBBS, FRCA*{dagger}

From the *Department of Pediatric Anesthesia, British Columbia Children’s Hospital and the {dagger}Department of Anesthesiology, Pharmacology and Therapeutics, {ddagger}Division of Pediatric Cardiology, British Columbia Children’s Hospital and the §Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.

Anesth Analg 2008; 107:806-810

背景:心电图显示的QT间期延长可能是药物诱发的,传统上认为易导致扭转性室速。扭转性室速的一个较好预测指标是T波的最高峰和末尾之间的时间间隔(Tp-e)。以往的研究中,丙泊酚对校正性QT间期(QTc)的影响一直存在争议,而且被复合用药所混淆。近来有研究显示,靶控输注丙泊酚3µg/mLQTcTp-e没有影响。而这个血浆浓度的丙泊酚在手术麻醉范围中处于极低端。在这个随机、双盲的临床研究中,我们研究了用于手术麻醉的临床相关剂量范围内,丙泊酚与QTcTp-e之间的剂量效应关系。

方法: 研究对象为60个健康的未术前用药的儿童,年龄3–10岁。随机给予靶控输注3个不同浓度丙泊酚34.56µg/mL。术前记录12 导联心电图,诱导后每5 分钟记录一次。由两名不知分组情况和心电图记录时间的观察者独立地测定QTcTp-e。组内比较QTc Tp-e采用配对t检验。组间采用单因素方差分析。主要测量指标为组内和组间Tp-e变化大于25 ms

结果: 记录到51 名儿童的心电图。一般情况和ECG的基础值之间没有差异,此时的QTcTp-e均在正常范围。三组诱导后,QTcTp-e 在组内和组间也没有统计学差异。

结论: 临床相关剂量的丙泊酚不影响健康儿童心肌复极化过程。这表明丙泊酚可以合理地用于心肌复极化不正常的儿童中。

(张莹译  马皓琳 李士通校)

BACKGROUND: QT interval prolongation on the electrocardiogram (ECG) may be drug-induced and is traditionally associated with torsades des pointes. A better predictor of torsades des pointes is the time interval between the peak and the end of the T-wave (Tp-e). Older studies of propofol’s effect on the corrected interval (QTc) are conflicting and confounded by polypharmacy. It was recently shown that target-controlled infusion of propofol at 3 µg/mL has no effect on QTc or Tp-e. This plasma concentration of propofol is at the extreme lower end of the range for surgical anesthesia. In this randomized, double-blind, clinical study, we investigated the dose–response relationship between propofol, QTc, and Tp-e in a range of doses clinically relevant for surgical anesthesia.

METHODS: Sixty healthy unpremedicated children, aged 3–10 yr, were recruited. Subjects were randomized to receive target-controlled infusions of propofol, to achieve 1 of 3 plasma concentrations: 3, 4.5, and 6 µg/mL. A preoperative 12 lead ECG was performed and repeated 5 min after induction. Two investigators, blinded to group allocation and to the timing of the ECG traces, independently measured QTc and Tp-e within and between each group. Paired t-tests were used to compare QTc and Tp-e within groups. One-way analysis of variance was used for intergroup analysis. The primary outcome measure was a change of >25 ms in Tp-e both within and between groups.

RESULTS: ECG recordings were obtained in 51 children. There were no demographic or ECG differences at baseline, at which time QTc and Tp-e values were within normal limits. There were no differences in QTc or Tp-e after induction within or between the three different groups.

DISCUSSION: Propofol has no effect on myocardial repolarization in healthy children at clinically relevant doses. This suggests that propofol would be a rational choice for children with a preexisting repolarization abnormality.


鞘内注射布比卡因和利多卡因的混合液的持续时间

The Duration of Intrathecal Bupivacaine Mixed with Lidocaine

Sung-Jin Lee, MD, PhD, Sun-Joon Bai, MD, PhD, Jong-Seok Lee, MD, Won-Ok Kim, MD, Yang-Sik Shin, MD, PhD, and Ki-Young Lee, MD, PhD

From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.

Anesth Analg 2008; 107:824-827

背景:尽管布比卡因脊麻的持续时间可能过长而无法应用于门诊手术,最近的动物数据显示布比卡因脊麻中加入利多卡因可能减少布比卡因脊麻的持续时间。我们探究在人体中,鞘内布比卡因中加入利多卡因能否像动物研究一样缩短布比卡因脊麻的持续时间。

方法:90个行经尿道膀胱肿瘤或者前列腺切除病人,被双盲随机分配成三组。鞘内注射高比重的0.5%布比卡因1.5毫升,加入0.6毫升以下溶液:盐水(组In = 30,对照组),1%利多卡因(组IIn = 30)和2%利多卡因(组IIIn = 30)。测定最高感觉阻滞平面、达到最高感觉阻滞平面的时间、从最高感觉阻滞平面消退到两个节段L1S2的时间、感觉阻滞最高时、消退到L1S2时的运动阻滞以及麻醉后监护室逗留时间(PACU时间)。

结果:所有三组,到达最高感觉阻滞平面的时间近似。组II从最高感觉阻滞平面消退到两个节段L1S2的时间和PACU时间比组I显著减少。组IIIL1S2消退时间及PACU时间显著延长。

结论:我们推断利多卡因(6 mg)加入到鞘内布比卡因(7.5 mg)能缩短布比卡因脊麻的持续时间,因此比单独应用同样剂量的布比卡因(7.5 mg)的脊麻恢复更快。

 (张曦 译,马皓琳 李士通 校)

BACKGROUND: Although spinal bupivacaine may have too long duration to be useful in the ambulatory setting, recent animal data suggest that lidocaine added to spinal bupivacaine may reduce the duration of bupivacaine spinal anesthesia. We explored whether lidocaine added to spinal bupivacaine could shorten the duration of bupivacaine spinal anesthesia in humans similarly to what has been reported in animals.

METHODS: Ninety patients presenting for transurethral resection of bladder tumor or prostate were assigned to one of three groups by double blind randomization to receive intrathecal 1.5 mL of hyperbaric 0.5% bupivacaine, plus 0.6 mL of one of three solutions: saline (Group I, n = 30, control), 1% lidocaine (Group II, n = 30), and 2% lidocaine (Group III, n = 30). Peak sensory block level, time to peak sensory block, times to two-segment, L1, and S2 regressions from peak sensory block, motor blocks at peak sensory block, L1, and S2 regressions, and postanesthesia care unit stay time (PACU time) were measured.

RESULTS: Times to peak sensory block were similar in all three groups. Times to two-segment, L1, and S2 regressions from peak sensory block, and PACU time were significantly reduced in Group II compared to Group I. Times to L1, S2 regressions, and PACU times in Group III were significantly prolonged.

CONCLUSIONS: We conclude that lidocaine (6 mg) mixed to spinal bupivacaine (7.5 mg) can shorten the duration of bupivacaine spinal anesthesia, therefore provide more rapid recovery from the spinal anesthesia compared to the same dose of bupivacaine (7.5 mg) alone.


表面活性物质对受体功能的麻醉药样调变:对麻醉界面理论的一个检验

Anesthetic-Like Modulation of Receptor Function by Surfactants: A Test of the Interfacial Theory of Anesthesia

Liya Yang, PhD, and James M. Sonner, MD

From the Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.

Anesth Analg 2008; 107:868-874

引言:吸入麻醉药有界面活性,集中于如蛋白质/水或双分子层/水等界面。我们通过将表面活性物质应用于{gamma}-氨基丁酸A型(GABAA)、甘氨酸以及N-甲基-D-天冬氨酸(NMDA)受体来验证以下假设:界面活性是受体功能麻醉药样调变的一个充分条件。我们将麻醉药样调变定义为:对一些固有通道电流的增减作用与异氟烷和乙醇保持一致。我们还检验了以下假设:表面活性物质对那些因基因点突变导致对异氟烷和乙醇反应减弱的受体和正常受体的调变作用之间没有区别。

方法:研究分别带不同首基电荷(阴离子、阳离子、两性离子以及不带电荷)和不同尾长(8碳和12碳)的七种表面活性物质对同价同效基因的野生型{alpha}1和突变型{alpha}1 (S267I)甘氨酸受体、野生型{alpha}1β2{gamma}2s和突变型{alpha}1(S270I)β2{gamma}2sGABAA受体以及野生型NR1/NR2A和突变型NR1(F639A)/NR2A NMDA受体的作用。受体表达于非洲爪蟾的卵母细胞表面,采用双电极电压钳进行研究。

结果:所有七种表面活性物质、异氟烷和乙醇均增强GABAA受体的功能。七种表面活性物质中的六种、异氟烷和乙醇增强甘氨酸受体的功能。七种表面活性物质中的六种、异氟烷和乙醇抑制NMDA受体的功能。至于突变型受体,七种表面活性物质中的五种增加了通过GABAA受体的电流,而七种表面活性物质中的六种增加了通过甘氨酸受体的电流。七种表面活性物质中的六种减少了通过NMDA受体的电流。与野生型受体相比,表面活性物质作为一组并不像异氟烷和乙醇那样减弱了对突变型受体的调变作用。

结论:这些结果证实另一大类复合物(表面活性物质)以与吸入麻醉药性质相似的方式对GABAA、甘氨酸和 NMDA受体的功能进行调变。我们不能否定关于界面活性是对这些受体麻醉药样调变作用的一个充分条件的假设。可减弱异氟烷和乙醇的调变作用的突变并不减弱表面活性物质的调变作用。

(黄施伟 译,马皓琳 李士通 校)

INTRODUCTION: Inhaled anesthetics are interfacially active, concentrating at interfaces such as the protein/water or bilayer/water interfaces. We tested the hypothesis that interfacial activity was a sufficient condition for anesthetic-like modulation of receptor function by applying surfactants to {gamma}-aminobutyric acid type A (GABAA), glycine, and N-methyl-d-aspartate (NMDA) receptors. We defined anesthetic-like modulation as an increase in currents through native channels that isoflurane and ethanol increased currents through, and a decrease in currents through channels that isoflurane and ethanol decreased currents through. We also tested the null hypothesis that there would be no difference in modulation of channel currents by surfactants in receptors with point mutations that diminished their response to isoflurane and ethanol compared to the native version of these receptors.

METHODS: The effect of seven surfactants with different head group charges (anionic, cationic, zwitterionic, and uncharged) and tail lengths (8 carbons and 12 carbons) on homomeric wild type {alpha}1 and mutant {alpha}1 (S267I) glycine receptors, wild type {alpha}1β2{gamma}2s and mutant {alpha}1(S270I)β2{gamma}2s GABAA receptors, and wild type NR1/NR2A and mutant NR1(F639A)/NR2A NMDA receptors was studied. Receptors were expressed in Xenopus laevis oocytes and studied using two-electrode voltage clamping.

RESULTS: All seven surfactants, isoflurane, and ethanol enhanced GABAA receptor function. Six of seven surfactants, isoflurane, and ethanol enhanced glycine receptor function. Six of seven surfactants, isoflurane, and ethanol inhibited NMDA receptor function. For the mutant receptors, five of seven surfactants increased currents through GABAA receptors, whereas six of seven surfactants increased currents through glycine receptors. Six of seven surfactants decreased currents through the NMDA receptor. In contrast to isoflurane and ethanol, surfactants as a group did not diminish modulation of mutant compared to wild type receptors.

CONCLUSION: These findings identify another large class of compounds (surfactants) that modulate the function of GABAA, glycine, and NMDA receptors in a manner that is qualitatively similar to inhaled anesthetics. We cannot reject the hypothesis that interfacial activity is a sufficient condition for anesthetic-like modulation of these receptors. Mutations that diminish the modulatory effect of isoflurane and ethanol did not diminish the modulatory effect of the surfactants.


低临床浓度异氟烷能预防小鼠脊髓由烟碱诱发的去甲肾上腺素释放

Isoflurane Prevents Nicotine-Evoked Norepinephrine Release from the Mouse Spinal Cord at Low Clinical Concentrations

Thomas J. Rowley, BS, and Pamela Flood, MD

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

Anesth Analg 2008; 107:885-889

背景:亚麻醉浓度的挥发性麻醉药异氟烷抑制烟碱型乙酰胆碱受体。在人类和动物研究中,相似浓度的挥发性麻醉药增加疼痛的敏感性。烟碱的镇痛作用被认为是与其增强去甲肾上腺素的释放有关的。该研究欲为异氟烷改变烟碱对去甲肾上腺素释放的增强作用是其促进疼痛感受的潜在机制理论提供依据。           

方法:我们的研究采用小鼠腰段脊髓薄片模型。在有异氟烷或者没有异氟烷存在的情况下使用烟碱诱发去甲肾上腺素释放。为了鉴别涉及的烟碱受体类型,我们研究了受体和亚型特异性配体和缺乏烟碱受体β2亚基基因表达的基因工程小鼠。测定了不同实验条件下[3H]-去甲肾上腺素的释放量。

结果:体内增强疼痛敏感性的异氟烷浓度(0.38%)能够显著且最大程度地抑制烟碱对去甲肾上腺素释放的增强作用。使用{alpha}7的选择性兴奋剂胆碱能够模拟对去甲肾上腺素释放的增强作用,该作用在{alpha}7-烟碱的选择性抑制剂{alpha}-金环蛇毒素存在时受抑制。缺乏β2亚基动物中去甲肾上腺素释放的增强作用与对照动物没有差异。

结论:低临床相关浓度的异氟烷抑制烟碱对脊髓去甲肾上腺素释放的增强作用。由于在脊髓去甲肾上腺素能传导的总作用是抑制,故移除此机制可能是在这些浓度的异氟烷增强疼痛敏感性的原因。

(颜涛 译,马皓琳 李士通 校)

BACKGROUND: Volatile anesthetics inhibit nicotinic acetylcholine receptors at subanesthetic concentrations. In both animal and human studies, similar concentrations of volatile anesthetics have been associated with increased sensitivity to pain. Nicotinic analgesia is thought to involve the enhanced release of norepinephrine. These studies are intended as a "proof of concept" that alteration of the nicotinic facilitation of norepinephrine release is a potential mechanism for isoflurane-induced pronociception.

METHODS: We conducted our study using a murine lumbar spinal cord slice model. We evoked norepinephrine release with nicotine in the presence and absence of isoflurane. To identify the type of nicotinic receptor involved, we studied the effect of receptor and subtype-specific ligands and genetically engineered mice, which lacked the gene expression for the nicotinic β2 subunit. The amount of [3H]-norepinephrine released was measured under the different conditions.

RESULTS: Nicotine-facilitated norepinephrine release was significantly and maximally inhibited by isoflurane at concentrations that enhance pain sensitivity in vivo (0.38%). Facilitation of norepinephrine release was mimicked by the {alpha}7 selective agonist choline and inhibited in the presence of {alpha}-bungarotoxin, an {alpha}7-nicotinic selective antagonist. Facilitation of norepinephrine release was not different in animals lacking β2 subunits compared with matched controls.

CONCLUSIONS: Nicotinic facilitation of norepinephrine release in the spinal cord is inhibited by isoflurane at low clinically relevant concentrations. Because the net effect of noradrenergic tone in the spinal cord is inhibitory, the removal of this mechanism might be responsible for the enhanced pain sensitivity seen at these concentrations of isoflurane.


红外测量人类呼吸中的二氧化碳:回顾从Tyndall到现在的“呼吸通过”装置

Infrared Measurement of Carbon Dioxide in the Human Breath: "Breathe-Through" Devices from Tyndall to the Present Day

Michael B. Jaffe, PhD

Anesth Analg 2008; 107:890-904

测量患者呼吸过程中的二氧化碳或二氧化碳描记图,是现代医学发展中的基本技术进步之一。我会用从历史记录和与许多开发者的个人采访中得到的信息,来记述一下通过红外测量呼吸中二氧化碳的主流二氧化碳描记图的发展和商业化。

(唐亮   马皓琳 李士通 校)

The ability to measure carbon dioxide (CO2) in the breath of a patient or capnometry, is one of the fundamental technological advances of modern medicine. I will chronicle the evolution and commercialization of mainstream capnometry based upon infrared measurement of CO2 in the breath using information from the historical record and personal interviews with many of the developers.


经皮扩张气管切开术相关的适应性辅助通气:一项临床研究

Adaptive Support Ventilation with Percutaneous Dilatational Tracheotomy: A Clinical Study

Denise P. Veelo, MD*{dagger}, Dave A. Dongelmans, MD*, Pauline Middelhoek, RN*, Johanna C. Korevaar, PhD{ddagger}, and Marcus J. Schultz, MD, PhD*§

From the Departments of *Intensive Care Medicine; {dagger}Anesthesiology; {ddagger}Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and §HERMES Critical Care Group, Amsterdam, The Netherlands.

Anesth Analg 2008; 107:938-940

我们测定了34ICU病人在内窥镜引导下经皮扩张气管切开术后,是否有必要对其适应性辅助通气的分钟通气量进行调整。在这一过程中,分钟通气量没有进行调整;仅最大压力限制在必要时进行了相应的调整。气管切开放置套管后,仅当Paco2相对基线值改变≥0.5 kPa时才调整经套管分钟通气量。74%的病人在使用内窥镜时适应性辅助通气不能维持分钟通气量,必须进行压力限制的调整。少数病人(26%)的分钟通气量必须进行调整以达到相似的Paco2值。

(吴进   马皓琳 李士通 校)

We determined the need for changes in minute ventilation with adaptive support ventilation after percutaneous dilatational tracheotomy under endoscopic guidance in 34 intensive care unit patients. During the procedure, minute ventilation was not changed; only maximum pressure limits were adjusted, if necessary. After insertion of the tracheotomy, cannula minute ventilation was adjusted only if Paco2-values changed ≥0.5 kPa from baseline. In 74% of patients, adaptive support ventilation was unable to maintain minute ventilation during the use of the endoscope, mandating pressure limitation adjustments. In a minority of patients (26%), minute ventilation had to be adjusted to achieve similar Paco2 values.


产科病人中椎管内运用阿片类药物后发生呼吸抑制

Respiratory Depression After Neuraxial Opioids in the Obstetric Setting

Brendan Carvalho, MBBCh, FRCA

From the Department of Anesthesia, Stanford University School of Medicine, Stanford, California.

Anesth Analg 2008; 107:956-961

椎管内阿片类药物已经被证实可以显著改善产程,明显减轻剖宫产后疼痛。产妇通过硬膜外和蛛网膜下腔给予阿片类药物后,在临床上发生显著呼吸抑制的危险性非常低。虽然危险性很低,但是呼吸抑制是一个严重的风险;产妇可能死亡或者遭受永久性的大脑损伤作为后遗症。本篇综述主要讨论了在自然分娩和剖宫产中给予吗啡、硬膜外缓释吗啡和亲脂阿片类药物后发生呼吸抑制的机制、发生率、预防、监测方法以及处理方法。

(姜旭晖译,马皓琳,李士通校)

Neuraxial opioids have contributed significantly to improved labor and postcesarean delivery analgesia. In the obstetric population, epidural and intrathecal opioids are associated with a very low risk of clinically significant respiratory depression. Although rare, respiratory depression is a serious risk; patients may die or suffer permanent brain damage as a consequence. This review discusses the mechanism and incidence, as well as the prevention, detection, and management of respiratory depression with morphine, extended-release epidural morphine, and lipophilic opioids in the labor and cesarean delivery setting.


钢丝强化硅树脂管与Parker管及聚氯乙烯管用于正常气道患者全麻下经喉罩插管的比较

A Comparison of a Silicone Wire-Reinforced Tube with the Parker and Polyvinyl Chloride Tubes for Tracheal Intubation Through an Intubating Laryngeal Mask Airway in Patients with Normal Airways Undergoing General Anesthesia

Ghassan E. Kanazi, MD, Mohammed El-Khatib, PhD, Viviane G. Nasr, MD, Romeo Kaddoum, MD, Achir Al-Alami, MD, Anis S. Baraka, MD, and Chakib M. Ayoub, MD, MBA

From the American University of Beirut-Medical Center, Department of Anesthesiology, Beirut, Lebanon.

Anesth Analg 2008; 107:994-997

研究背景:插管喉罩(ILMA)用于困难插管的处理。通常,插入钢丝强化硅树脂管用于气管内插管。因为钢丝强化硅树脂管价格昂贵,因而值得考虑使用聚氯乙烯 (PVC) 管及后洞斜面Parker管取代之。我们比较了钢丝强化硅树脂管、PVC管及Parker管的盲插成功率,确定阻止经ILMA行气管内插管的喉部结构。

方法:把63位成年患者随机分成3组:组I (n = 20) 钢丝强化硅树脂管,组II (n = 21) Parker管,组III (n = 22) PVC管。我们对患者一般情况及临床的连续性数据用方差分析和用于因果分析的Scheffé 检验进行比较。对频率及百分比行卡方检验。

结果:组I (钢丝强化硅树脂管)的20位病人中有18位第一次插管即获成功。明显高于组II22位中有12位)(Parker管)或组III21位中有10位)(PVC tube)。在插管时将气管导管行顺时针或逆时针转动并不能改变组I插管成功的例数,但能将组II的成功例数提高到22位中的19位,将组III的成功例数提高到21位中的12位。气管插管处理后,组I90%)与组II86%)的插管成功率无显著性差异(P = 0.72)。然而,组III的插管成功率(57%)明显低于组I(P = 0.02)及组II(P = 0.03)。组II22位中的3位及组III21位中的9位患者盲插失败,阻塞原因是由于会厌结节。

结论:使用经ILMA Parker管插管能提高气管内插管的成功率,使之有可能取代钢丝强化硅树脂管。

(裘毅敏译,马皓琳、李士通校)

BACKGROUND: The intubating laryngeal mask airway (ILMA) is used in the management of difficult intubation. Usually, a silicone wire-reinforced tube is inserted for tracheal intubation. Because the silicone wire-reinforced tube is expensive, alternatives, such as polyvinyl chloride (PVC) and posterior beveled Parker tubes, are worth considering. We compared the blind intubation success rates among the silicone wire-reinforced tube, the Parker tube, and the PVC tube, and identified laryngeal structures preventing tracheal intubations through the ILMA.

METHODS: Sixty-three adult patients were randomized into three groups: Group I (n = 20) silicone wire-reinforced tube, Group II (n = 21) Parker tube, and Group III (n = 22) PVC tube. Demographic and clinical continuous data were compared with the analysis of variance with the Scheffé test for post hoc analysis. Frequencies and percentages were compared with the {chi}2 test.

RESULTS: Tracheal intubation was successful from the first attempt in 18 of 20 patients in Group I (silicone wire-reinforced tube), which was significantly higher than the success rate in either Group II (12 of 22 patients) (Parker tube) or Group III (10 of 21 patients) (PVC tube). With clockwise or anticlockwise rotation of the tracheal tube, the number of successful intubations did not change in Group I, but it increased to 19 of 22 patients in Group II and to 12 of 21 patients in Group III. The rate of successful intubation between patients in Group I (90%) and Group II (86%) was not significantly different after manipulation of the tracheal tube (P = 0.72). However, the rate of successful tracheal intubations in patients of Group III (57%) was significantly lower in comparison to patients in both Group I (P = 0.02) and Group II (P = 0.03). In 3 of the 22 patients of Group II and in 9 of the 21 patients of Group III in whom blind intubation was not possible, the obstruction was due to the epiglottis tubercule.

CONCLUSIONS: Manipulation improved the success rate of intubation with the Parker tube through the ILMA rendering it a possible alternative to the silicone wire-reinforced tube.


经皮烟碱贴剂不能改善术后疼痛治疗

Transdermal Nicotine Patch Failed to Improve Postoperative Pain Management

Alparslan Turan, MD*{dagger}, Paul F. White, PhD, MD{ddagger}, Onur Koyuncu, MD§, Beyhan Karamanliodlu, MD*, Gaye Kaya, MD*, and Christian C. Apfel, MD, PhD||

From the *Department of Anesthesiology, Trakya University, Turkey, and {dagger}Department of Anesthesiology and Perioperative Medicine, and the Outcomes Research Institute, University of Louisville, Louisville, Kentucky; {ddagger}Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas; and Departments of §Anesthesiology, ||Anesthesiology and Perioperative Care, Perioperative Clinical Research Care, University of California at San Francisco, San Francisco, California.

Anesth Analg 2008; 107:1011-1017

背景:烟碱 3mg鼻内剂量被报道有镇痛作用。我们设计了安慰剂对照研究来检验这样一个假设,即下腹部手术术后烟碱经皮给药(TDN3天能减轻术后疼痛,减少阿片类镇痛药用量并改善恢复的过程。

方法:97例行腹式全子宫切除的患者随机分成2组:(1)对照组术前1h及术后2天里使用假贴剂,(2) 烟碱组麻醉诱导前1h及术后2天给予30TDN(含21mg尼古丁)。麻醉方法两组一致,术后评估包括疼痛和镇静口头等级量表、静脉患者自控镇痛吗啡用量、恢复质量、肠道功能恢复、正常活动的恢复以及患者对疼痛治疗的满意度。术后1月和3月继续评估后期恢复事件。

结果:平卧或坐起时术后患者自控镇痛吗啡用量和疼痛评分、术中芬太尼用量、口服镇痛药量,肠鸣音恢复以及肠胃气两组之间均无差异。尽管下床走动、住院时间和恢复质量评分并无差别,烟碱组进食恢复时间有延迟。烟碱组出院合格评分在48h72h高于对照组,但两组恢复到可以工作的时间均为19天。

结论:围术期高剂量TDN贴剂不能改善妇科盆腔术后镇痛或减少镇痛药需求。尽管延迟进食恢复时间,更多烟碱组患者术后48h72h可以出院。然而,日常生活活动恢复时间两组相似。

(朱慧译 马皓琳 李士通校)

BACKGROUND: A single 3 mg intranasal dose of nicotine has been reported to have analgesic properties. We designed placebo-controlled study to test the hypothesis that transdermal nicotine (TDN) administered over a 3-day period would decrease postoperative pain and opioid analgesic usage and improve the recovery process after lower abdominal surgery.

METHODS: Ninety-seven patients undergoing abdominal hysterectomy procedures were randomly assigned to one of two treatment groups: (1) control group received inert (sham) patches 1 h before and for 2 days after surgery, or the (2) nicotine group received TDN 30 (21 mg nicotine) patches 1 h before induction of anesthesia and for two additional days after surgery. The anesthetic technique was identical in both groups, and the postoperative assessments included verbal rating scales for pain and sedation, IV patient-controlled analgesia morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Follow-up evaluations were performed at 1 and 3 mo after the operation to assess late recovery events.

RESULTS: Postoperative patient-controlled analgesia morphine usage and pain scores while supine or sitting up, intraoperative fentanyl use, oral analgesic consumption, return of bowel sounds, and passage of flatus did not differ between the two groups. Although ambulation and hospitalization times, as well as quality of recovery scores, did not differ, resumption of oral intake was delayed in the nicotine group. Discharge eligibility scores were higher in the nicotine group at 48 and 72 h compared with the control group, but the time to return to work was 19 days in both treatment groups.

CONCLUSIONS: Perioperative administration of a high-dose TDN patch did not improve postoperative pain control or decrease the analgesic requirement after pelvic gynecological surgery. Despite delayed resumption of oral intake, more patients in the nicotine group were ready for discharge at 48 and 72 h after surgery. However, times to resuming activities of daily living were similar in both groups.


持续输注低剂量的氯胺酮改善颈椎手术后病人自控镇痛的芬太尼的镇痛效果

Continuous Low-Dose Ketamine Improves the Analgesic Effects of Fentanyl Patient-Controlled Analgesia After Cervical Spine Surgery

Masanori Yamauchi, MD, PhD*, Makoto Asano, MD, PhD{dagger}, Masanori Watanabe, MD*, Soushi Iwasaki, MD, PhD*, Shingo Furuse, MD*, and Akiyoshi Namiki, MD, PhD*

From the *Department of Anesthesiology, Sapporo Medical University School of Medicine, Sapporo, Japan; {dagger}Department of Anesthesia, Oji General Hospital, Tomakomai, Japan.

Anesth Analg 2008; 107:1041-1044

背景:芬太尼联合应用氯胺酮用于术后镇痛的效果仍不明确。我们研究了氯胺酮对芬太尼用于病人自控镇痛的辅助作用。

方法:颈椎和腰椎手术的病人分入3组:给予氯胺酮1 mg/kg负荷量后,分别在氯胺酮-1组和氯胺酮-2组持续给予氯胺酮42µg · kg–1 · h–1 83 µg · kg–1 · h–1,并设一对照组。术后病人自控镇痛用芬太尼应用背景剂量注射。

结果:颈椎手术后氯胺酮-2组的疼痛评分和镇痛需要明显低于对照组。氯胺酮可以部分改善腰椎手术后芬太尼的镇痛作用。

结论:小剂量的氯胺酮改善颈椎手术后芬太尼的镇痛作用。

(黄丽娜  马皓琳 李士通 校)

BACKGROUND: The effects of fentanyl with ketamine for postoperative pain are unknown. We investigated the adjuvant effects of ketamine for fentanyl patient-controlled analgesia.

METHODS: Cervical and lumbar spine surgery patients were divided into three groups: ketamine 1 mg/kg followed by 42 and 83 µg · kg–1 · h–1 in ketamine-1 and ketamine-2 group, respectively, and a control group. Postoperative patient-controlled analgesia fentanyl was administered with a background infusion.

RESULTS: Pain scores and analgesia requirement in the ketamine-2 group were significantly lower than those of the control group after cervical surgery. Ketamine partially improved the analgesic effects of fentanyl after lumbar surgery.

CONCLUSION: Small-dose ketamine improved the analgesic effects of fentanyl after cervical surgery.


砷化镓铝(830nm)低水平激光预照射血液可增强大鼠外周内源性阿片类物质镇痛作用

Pre-Irradiation of Blood by Gallium Aluminum Arsenide (830 nm) Low-Level Laser Enhances Peripheral Endogenous Opioid Analgesia in Rats

Satoshi Hagiwara, MD, PhD, Hideo Iwasaka, MD, PhD, Akira Hasegawa, MD, and Takayuki Noguchi, MD, PhD

From the Department of Brain and Nerve Science, Anesthesiology, Oita University Faculty of Medicine, Idaigaoka-Hasamamachi-Yufu City-Oita, Japan.

Anesth Analg 2008; 107:1058-1063

研究背景:有报道表明低水平激光照射疗法(LLLT)可减轻疼痛且无副作用。然而人们对LLLT的机制未作深入了解。最近的研究也表明含有阿片类物质的免疫细胞会移行至炎症区域并释放β-内啡肽以抑制疼痛,这是外周内源性阿片类物质镇痛的模式之一。本研究探讨LLLT预照射血液是否可增强外周内源性阿片类物质的镇痛作用。

研究方法:采用大鼠炎症模型评估LLLT预照射血液对外周内源性阿片类物质镇痛作用的影响。此外,利用大鼠血细胞离体研究LLLT对阿片类物质生成的作用。通过逆转录聚合酶链反应测定β-内啡肽前体、阿黑皮素原和促肾上腺皮质激素释放因子的表达。

研究结果:LLLT预照射对外周炎症组织具有镇痛效应,且此种镇痛效应可被纳洛酮短时间拮抗。相应地,离体和在体研究均表明LLLT可使β-内啡肽前体mRNA表达增加。

结论:上述结果提示:除已报道的机制外,LLLT预照射血液还可通过通过增强大鼠外周内源性阿片类物质生成来产生镇痛效应。

(周雅春 马皓琳 李士通 校)

BACKGROUND: Low-level laser therapy (LLLT) has been reported to relieve pain, free of side effects. However, the mechanisms underlying LLLT are not well understood. Recent studies have also demonstrated that opioid-containing immune cells migrate to inflamed sites and release β-endorphins to inhibit pain as a mode of peripheral endogenous opioid analgesia. We investigated whether pre-irradiation of blood by LLLT enhances peripheral endogenous opioid analgesia.

METHODS: The effect of LLLT pretreatment of blood on peripheral endogenous opioid analgesia was evaluated in a rat model of inflammation. Additionally, the effect of LLLT on opioid production was also investigated in vitro in rat blood cells. The expression of the β-endorphin precursors, proopiomelanocortin and corticotrophin releasing factor, were investigated by reverse transcription polymerase chain reaction.

RESULTS: LLLT pretreatment produced an analgesic effect in inflamed peripheral tissue, which was transiently antagonized by naloxone. Correspondingly, β-endorphin precursor mRNA expression increased with LLLT, both in vivo and in vitro.

CONCLUSION: These findings suggest that that LLLT pretreatment of blood induces analgesia in rats by enhancing peripheral endogenous opioid production, in addition to previously reported mechanisms.


比较超声“双泡征”引导的锁骨下臂丛神经阻滞和神经刺激器引导的腋路臂丛神经阻滞

A Comparison Between Ultrasound-Guided Infraclavicular Block Using the "Double Bubble" Sign and Neurostimulation-Guided Axillary Block

De Q. H. Tran, MD, FRCPC, Antonio Clemente, MD, Don Q. Tran, MD, and Roderick J. Finlayson, MD, FRCPC

From the Montreal General Hospital, Department of Anesthesia; McGill University, Montreal, Quebec, Canada.

Anesth Analg 2008; 107:1075-1078

背景:可以利用“双泡征”行超声引导下锁骨下臂丛神经阻滞。就像以前描述的那样,“双泡征”中,上面的“泡泡”是指短轴横断面上的腋动脉重叠在下面的泡泡上,下面的“泡泡”则由于注射局麻药而产生。在这项研究中,我们比较了这种臂丛神经阻滞的新方法和传统的三点神经刺激法腋路阻滞。

方法:70位病人随机分为两组,分别用超声“双泡征”进行的单次注射、超声引导的锁骨下臂丛神经阻滞和三点神经刺激腋路阻滞。

结果:两种方法的成功率类似(89%91%)。然而,锁骨下神经阻滞操作时间较短(3.90 ± 2.278.03 ± 3.92 min; P < 0.001),且穿刺引起的疼痛评分较低(0-10标尺上2.70 ± 2.024.17 ± 2.57; P = 0.01)

结论:和三点神经刺激法腋路阻滞相比,用双泡征进行的超声引导锁骨下臂丛神经阻滞可以提供相似的阻滞效果、较短的操作时间和较低的操作疼痛评分。

(黄佳佳译,马皓琳 李士通 校)

BACKGROUND: Ultrasound-guided infraclavicular block can be performed using the double bubble sign. Previously described, the double bubble sign consists superiorly of the axillary artery (in short axis) superimposed on an inferior bubble created by local anesthetic injection. In this study, we compared this new method of brachial plexus anesthesia to the traditional triple-nerve stimulation axillary block.

METHODS: Seventy patients were randomized to receive a single-injection, ultrasound-guided infraclavicular block using the double bubble sign or a triple-stimulation axillary block.

RESULTS: Both methods produced similar success rates (89%–91%). However, infraclavicular blocks were associated with a shorter performance time (3.90 ± 2.27 vs 8.03 ± 3.92 min; P < 0.001) and lower block-related pain scores (2.70 ± 2.02 vs 4.17 ± 2.57 on a 0–10 scale; P = 0.01).

CONCLUSION: Compared to triple-stimulation axillary block, ultrasound-guided infraclavicular block using the double bubble sign provided a similar efficacy, a shorter performance time and lower procedural pain scores.