Table of Contents

September 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

吸入低濃度七氟烷增強抗消化性潰瘍藥物替普瑞酮的遲發性心臟保護作用

王宏   馬皓琳 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.

氦誘導預處理的作用:氧化亞氮對兔子的直接作用

胡豔譯   薛張剛校

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細胞凋亡蛋白p53降低了氦在體心肌保護的閾值:線粒體通透性的作用

潘方立 陳傑

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.

衰老大鼠心臟異氟烷預處理和活性氧產生的弱化作用的研究

江繼宏   馬皓琳 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.

抑肽酶在嬰兒動脈轉接術中的功效

黃凝譯  薛張綱校

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:

硫噴妥鈉/七氟醚麻醉下小兒的正中神經軀體感覺誘發電位及酮基布洛芬和芬太尼的對其的附加作用

周姝婧 陳傑

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.

不同濃度丙泊酚對小兒心肌複極化分散的影響

張瑩譯  馬皓琳 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)指壓療法用於兒童麻醉

蔣宗明譯 薛張綱校

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:

氧化亞氮在婦科腔鏡手術術後噁心的劑量-反應關係的初步研究

於章傑 陳傑

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.

鞘內注射布比卡因和利多卡因的混合液的持續時間

張曦 譯,馬皓琳 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:

我們是否還需要一個新的例證來闡明吸入性麻醉藥產生麻醉效應的機制?

劉沁譯 薛張綱校

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.

關於對吸入麻醉藥反應的起源與演變的假說

趙嫣紅 陳傑

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

James M. Sonner

Anesth Analg 2008 107: 849-854.  

表面活性物質對受體功能的麻醉藥樣調變:對麻醉介面理論的一個檢驗

黃施偉 譯,馬皓琳 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.

大鼠蛛網膜下腔注射藜蘆定增加MAC值的研究

劉婷潔譯  薛張綱校

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.

腦脊髓液中鉀離子濃度的增加並不引起大鼠異氟醚MAC的增加

懷曉蓉 陳傑

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.

低臨床濃度異氟烷能預防小鼠脊髓由煙鹼誘發的去甲腎上腺素釋放

顏濤 譯,馬皓琳 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:

紅外測量人類呼吸中的二氧化碳:回顧從Tyndall到現在的“呼吸通過”裝置

唐亮   馬皓琳 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.

新生兒及小兒應用經食管脈搏血氧測定法的實驗性研究

秦敏菊譯 薛張綱校

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:

一項在體代謝試驗用於檢測人群中惡性高熱易感性:一項初步研究

葉樂 陳傑

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.

困難氣管插管的患者,可能需要轉介到睡眠診所

施穎譯 薛張綱校

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:

自適應輔助通氣時潮氣量的確定:一項多中心觀察研究

張磊 陳傑

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.

經皮擴張氣管切開術相關的適應性輔助通氣:一項臨床研究

吳進   馬皓琳 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.

不同氣管內吸引方法對FRC的影響

 孫鵬飛譯 薛張綱校

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:

擇期剖腹產鞘內注射可樂定對術後抗痛覺過敏和鎮痛作用的評估

朱紫瑜 陳傑

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.

產科病人中椎管內運用阿片類藥物後發生呼吸抑制

姜旭暉譯,馬皓琳,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:

神經外傷患者的腦灌注壓研究

夏俊明譯 薛張綱校
Cerebral Perfusion Pressure in Neurotrauma: A Review (Review Article)

Hayden White and Bala Venkatesh

Anesth Analg 2008 107: 979-988.

GENERAL ARTICLES:

頸部伸展時氣管拉長:氣管的哪一段伸長了?

陶穎瑩 陳傑

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.

鋼絲強化矽樹脂管與Parker管及聚氯乙烯管用于正常氣道患者全麻下經喉罩插管的比較

裘毅敏譯,馬皓琳、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:

透皮吸收煙鹼用於前列腺術後鎮痛

章一靜譯 薛張綱校

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.

經皮煙鹼貼劑作為術後疼痛處理:一項劑量範圍研究

丁俊雲 譯 陳傑 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.

經皮煙鹼貼劑不能改善術後疼痛治療

朱慧譯 馬皓琳 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.

血壓和壓力感受器敏感性對興奮性升級現象的影響

宣麗真譯 薛張綱校

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

Ok Yung Chung and Stephen Bruehl

Anesth Analg 2008 107: 1018-1025.

區域麻醉技術用於開胸手術術後鎮痛的隨機試驗――系統綜述

舒慧剛 陳傑

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.

持續輸注低劑量的氯胺酮改善頸椎手術後病人自控鎮痛的芬太尼的鎮痛效果

黃麗娜  馬皓琳 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.

在小鼠損傷的背根神經元中通過恢復鈣內流可以糾正胞膜的過度興奮狀態

陳珺珺譯 薛張綱校

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.

煙鹼受體激動劑在小鼠術後疼痛模型中的抗傷害作用

杜唯佳 陳傑

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.

砷化鎵鋁(830nm)低水準鐳射預照射血液可增強大鼠外周內源性阿片類物質鎮痛作用

周雅春 馬皓琳 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.

結紮小鼠脊神經後,神經妥樂平通過啟動下行疼痛抑制系統起到鎮痛作用

陳珺珺譯 薛張綱校

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:

超聲成像精確定位股外側神經

劉世文 陳傑

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.

比較超聲“雙泡征”引導的鎖骨下臂叢神經阻滯和神經刺激器引導的腋路臂叢神經阻滯

黃佳佳譯,馬皓琳 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.

多孔硬膜外導管和單孔導管的功能一致:在離體試驗中

陳珺珺譯 薛張綱校

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.

 

氦誘導預處理的作用:氧化亞氮對兔子的直接作用

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:氦誘導預處理通過啟動已存的信號來防止心肌梗,這一作用是否由內皮一氧化氮合酶產生的一氧化氮介導還是未知的。我們假設氦誘導對活體心肌的保護作用是由一氧化氮介導的進行試驗。

方法:我們將62只兔子進行血流動力學檢測,給與非選擇性一氧化氮合酶——N-硝基-L-精氨酸甲酯(L-NAME; 10 mg/kg)或者給與選擇性的一氧化氮合酶抑制劑——鹽酸氨基胍(AG; 300 mg/kg)或者給與神經選擇性一氧化氮合酶抑制劑——7-硝基吲唑(7-NI; 50 mg/kg)進行預處理,同時給與0.9%的生理鹽水(對照組)或者吸入70%氦和30%氧的混合氣5分鐘,再吸入空氧混合氣5分鐘,如此3個迴圈後,將冠狀動脈左前降支阻斷30分鐘,然後進行3小時的再灌注。所有兔子,無論是用沒用L-NAME均用DAF-2DA螢光探針及共聚焦鐳射顯微鏡檢查有無一氧化氮的產生。

結果:氦減少梗塞的心肌面積(24%+/-4%左室面積)(P<0.05),對照組為46%+/-4%L-NAME, AG, 7-NI單獨使用不能改變心肌梗塞得面積。L-NAME可以拮抗氦誘導的心肌保護。與對照組相比,氦可以提高DAF-2DA螢光(26 +/- 8 vs 15 +/- 5 U)。用L-NAME預處理後氦誘導的不能增強DAF-2DA螢光。

結論:結果提示氦的心肌保護作用是由活體內皮的一氧化氮合酶產生的一氧化氮介導的。

(胡豔譯   薛張剛校)

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.

 

 

抑肽酶在嬰兒動脈轉接術中的功效

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:此研究評價了在嬰兒動脈轉流手術中應用總劑量40,000血管舒緩素抑制單(KIU)/kg的抑肽酶對減少術後出血和血液製品需要量是否有效。

方法:採用前瞻性、雙盲、隨機化研究,選取50名因大動脈轉位行動脈轉接術的嬰兒。患兒隨機分入安慰劑組,25名患兒接受生理鹽水治療,另25名患兒麻醉誘導後接20,000KIU/kg抑肽酶,後再予20,000KIU/kg抑肽酶加入泵預沖液中。測量在重症監護病房最初24小時內經胸管引流的術後出血量和血液製品需要量(mL/kg/24 h)

結果:術後最初24小時出血量安慰劑組(49.7 ± 11.9 mL/kg/24 h)顯著高於(P < 0.0001)抑肽酶組(37.1 ± 3.5 mL/kg/24 h)。接受抑肽酶組新鮮冰凍血漿(mL/kg/24h)和濃縮血小板(mL/kg/24h)需要量明顯減少(P < 0.0001),但輸注血液製品患者的比例並未降低。抑肽酶組接受所有同種異體血液製品的總數[範圍 (中位數) = 2–4 (3)]少於安慰劑組[範圍(中位數) = 7–14 (10)]。抑肽酶組因過量出血再手術的比例亦顯著少於安慰劑組(16% vs 32%) (P = 0.01).

結論:本研究推斷抑肽酶能減少術後早期出血量及新鮮冰凍血漿和血小板輸注需要量(mL/kg/24 h)。能減少治療人群中遠期使用血液製品的總數和因過量出血再手術的比例。

(黃凝譯  薛張綱校)

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)指壓療法用於兒童麻醉

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:針灸及其相關技術被輔助用於圍術期麻醉處理。我們研究擬行內鏡手術兒童患者(印堂)指壓療法能否減輕術前焦慮和減少圍術期異丙酚的需求量。

方法:52例兒童患者隨機分為在印堂或其假想部位接受指壓療法治療干預。治療干預開始前所有兒童均採用雙頻指數(BIS)進行監測。評價基礎狀態和進入手術室前病人焦慮情況,通過靜脈使用異丙酚維持BIS值於40-60之間。

結果:研究結果顯示干預治療後,印堂針灸治療兒童焦慮程度降低而假想組則增加(-9% [-3 to -15] vs 2% [-6 to 7.4], P = 0.012)。相比,術前等待時兩組間BIS值差異無統計學意義。同時也發現兩組間圍術期異丙酚用量無明顯差別(214 ± 76 µg · kg-1 · min-1 vs 229 ± 95 µg · kg-1 · min-1, P = 0.52)

結論:內鏡手術兒童患者在印堂處採用指壓療法能減輕其術前焦慮程度;而對BIS值以及圍術期異丙酚需要量無影響。

(蔣宗明譯 薛張綱校)

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.

 

 

我們是否還需要一個新的例證來闡明吸入性麻醉藥產生麻醉效應的機制?

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:目前關於吸入性麻醉藥在面對有害刺激時產生麻醉效應的機制還是一個似是而非的論點。有許多發現,例如它的可加性,都說明了吸入性麻醉藥其產生麻醉效應是通過作用於一個普遍的位點。但是,二十多年的著重研究並沒有發現任何一個配體門控或是電壓門控的通道可以單獨介導產生麻醉效應。事實上,大多數假設的靶位僅提供了極小甚至的無效的介導作用。例如阿片類受體、5-羥色氨3受體、A型酪氨酸受體和谷氨酸受體。而鉀通道和鈣通道則表現出了與其麻醉機制的無關性,或是僅起到了較次要的作用。並且,目前也尚無任何配體門控或是電壓門控通道的協同作用能夠足以解釋這種介導機制。而另一些假定靶位(如鈉通道)還值得我們深入的研究,但吸入性麻醉藥其麻醉效應的產生是通過一個非特異途徑的可能性還仍然存在。

(劉沁譯 薛張綱校)

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.

 

 

大鼠蛛網膜下腔注射藜蘆定增加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:幾項研究的結果指出吸入麻醉藥抑制鈉通道蛋白轉運體的運作。我們假定蛛網膜下腔注射藜蘆定能增加鈉通道的活性和效應則會增加MAC值。

方法:我們測量大鼠在不同濃度藜蘆定注入蛛網膜下腔所引起的異氟烷MAC值的改變並與側腦室灌注所得的結果進行比較。

結果:與預期的一樣,蛛網膜下腔注射藜蘆定會增加MAC值。最大注射濃度(25 pgml)也在兩隻大鼠中表現出肢體神經元性損害,和MAC峰效應的降低。1.6 pgml的濃度產生MAC值最大增幅(21%)。腦室注入1.66.4 pgml的濃度不改變MAC值,給與大鼠25 pgml則大鼠死亡。

結論一個與吸入麻醉藥抑制鈉通道蛋白轉運體的運作有關的研究發現蛛網膜下腔給與藜蘆定會增加異氟烷MAC值。

(劉婷潔譯  薛張綱校)

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.

 

 

新生兒及小兒應用經食管脈搏血氧測定法的實驗性研究

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: 在這個實驗性研究中,我們探究了在嬰兒中把食管作為探測脈搏氧飽和度的新位點是否合適。

方法:一種新型的微型經食管脈搏血氧探測儀已經被研製成。本次研究了五個病例(一個兒童及四個新生兒)。

結果:所有病例的脈搏血氧飽和度值均可被測知。運用Bland and Altman曲線來分析經食管探測法以及傳統的趾端探測法的平均測定值,可以發現這兩種脈搏氧飽和度測定法的偏倚及界限分別是+0.3%+1.7%~1.0%

結論:這個研究提示,食管可以成為兒童及小兒檢測血氧飽和度的另一個位點。

(秦敏菊譯 薛張綱校)

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.

 

 

困難氣管插管的患者,可能需要轉介到睡眠診所

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:上呼吸道異常增加阻塞性睡眠呼吸暫停(OSA)和困難氣管插管的風險。兩者均造成顯著臨床問題,並增加圍手術期的發病率和死亡率。我們猜測,困難氣管插管的患者有較高的OSA患病率,而那些存在難以預料的困難插管患者,可能需要轉介到睡眠診所檢測多導睡眠圖( PSG

方法:CormackLehane法,根據直接喉鏡所見,挑選術前評估為四級的患者,在來自四家醫院的麻醉師顧問幫助下,將其中需要兩次及以上嘗試氣管插管方可成功者,列入研究範圍。收集患者呼吸暫停低通氣指數(AHI)資料及術後情況。AHI>5/小時者為ASO陽性。用t檢驗及2檢驗比較所得臨床和PSG資料。

結果:20個月中, 84例困難氣管插管患者被轉介到研究,其中33例患者同意參加。 66 33例中的22例)的患者患有OSAAHI> 5/小時)。在這22 OSA患者中, 10例(64%)為輕度OSAAHI 5-15),6例(18%)為中度OSAAHI > 15/小時),6例(18 %)為嚴重OSAAHI > 30/小時)。33例患者中,11例(33 %)被推薦進行持續氣道正壓通氣治療。OSA組與非OSA組間,在性別、頸部大小及睡眠品質方面有顯著差異,但在年齡及體重指數方面無明顯差異。

結論 根據PSG66 %接受睡眠監測的困難氣管插管患者被診斷為OSA。困難氣管插管是OSA的高危因素,應根據睡眠呼吸暫停的症狀和體征進行篩選。由此篩選出的患者,應考慮轉介到一個睡眠診所檢測PSG以確診。

(施穎譯 薛張綱校)

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.

 

 

不同氣管內吸引方法對FRC的影響

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:我們的目的是研究三種不同的氣管內吸引方法對FRC的影響。

方法:用交叉設計方法,20個心臟手術後的病人按照隨機順序接受了三種不同的氣管內吸引方法:壓力控制通氣下的密閉吸引,容量控制通氣下的密閉吸引,開放式吸引。在吸引之前和20分鐘之後分別測量FRC

結果和結論:不管用何種吸引方法,心臟手術後的病人接受吸引後FRC都降低。一些病人還有很顯著的FRC改變。常規的FRC測量可以完善呼吸系統檢測,從而有助於呼吸系統疾病的治療。

孫鵬飛譯 薛張綱校)

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.

 

 

神經外傷患者的腦灌注壓研究

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:目前已經認識到低腦血流量(及低腦灌注壓(CPP))與腦外傷的不良預後相關。但還不十分明確的是改變腦血流量或者CPP是否可以帶來臨床症狀的好轉。初步研究指出增加CPP可能有益,美國腦部創傷基金會在1996年的指南中公認了這一點,並且將目標值確立為70 mmHg。但是,由於缺少明確的益處以及併發症的增多使得此目標值降至60 mmHg。最近,由於有證據表明腦創傷後自我調節功能可能受損,一些研究者計畫對CPP進行個體化的管理。此外,隨著神經檢測技術的進步,臨床工作者可以更加精確地監控腦代謝及血流動力學。至今未止尚沒有強有力的證據來支持此項計畫。在此之前,當前的CPP管理方式仍將繼續沿用。

(夏俊明譯 薛張綱校)
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.


血壓和壓力感受器敏感性對興奮性升級現象的影響

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:對急性疼痛來說,提高的靜息血壓和自發性壓力感受器敏感性與痛覺減退有關。這些關聯在慢性疼痛明顯不同。我們研究了興奮性升級現象(中樞致敏的標誌)的程度是否同樣受血壓和壓力感受器敏感性的影響,以及這些關聯在慢性疼痛是否改變。

方法:對30名健康者和26名慢性背痛受試者的血壓和BRS(序列法)進行評估,然後完成一個標準化熱刺激記錄來評估興奮性升級現象。這項記錄在安慰劑組和α-2腎上腺素受體阻斷劑育亨賓組完成,來測試α-2腎上腺素受體機制的影響。

結果:1)在健康對照組,較高的收縮壓與較低的興奮性升級現象有關 P < 0.05 ),但是這在慢性疼痛者中相反( P < 0.05 );2 )在健康對照組,較高的BRS與較低的興奮性升級現象有關 P < 0.05 ),但是在慢性疼痛受試者中無關;3 )只有在慢性疼痛組較高的收縮壓是與較低的BRS有關的( P < 0.05 4 α-2腎上腺素受體阻斷劑對興奮性升級現象並沒有顯著著影響。

結論:這些結果表明,在健康個體升高的靜息血壓和自發性壓力感受器敏感性與痛覺減退有關,包括中樞致敏(由興奮性升級現象反應)減低和下行抑制增強。慢性疼痛的存在顯著改變了這些相互作用的性質。在重疊系統調節心血管系統和慢性疼痛患者的疼痛之間正常交互作用的逆轉可能使血壓和心率的健康緩衝作用變成不穩定的和最終較高的血壓和心血管發病率。

(宣麗真譯 薛張綱校)

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.

 

 

透皮吸收煙鹼用於前列腺術後鎮痛

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:以往的動物和人類研究表明,煙鹼可能有鎮痛作用。我們假設對於全麻下實施經恥骨後前列腺根治術(RRP)的患者,術前應用7mg煙鹼,會導致減少術後鎮痛的需求。

方法:不吸煙者經歷全麻下行RRP參加了這項前瞻性,雙盲,安慰劑對照研究。病人隨機分成兩組:在麻醉誘導前30-60分鐘,分別耳後透皮給予7毫克煙鹼或安慰劑。麻醉按常規。術後鎮痛是標準的應用嗎啡病人自控鎮痛並且每6小時給予痛力克15mg靜推。在蘇醒室、術後61224小時收集資料。

結果: 分析了90例患者: 44煙鹼組和46在安慰劑組。兩組病人在年齡,身高,體重, ASA的分級,手術長度,術中芬太尼的用量等方面沒有顯著差異。煙鹼組顯著降低24 h內嗎啡的用量(平均值±標準差): 33.3 ± 30.8mg,相比於44.7 ± 26.4mg P = 0.0059 ,時間x治療P0.0031 。但是,在咳嗽和休息時疼痛的報告沒有差異。此外,還有無顯著差異的團體在發生術後噁心嘔吐或需要救援antiemetics 。不過,相比於安慰劑組,在煙鹼組,最高的噁心口頭評定量表評分較高,(中位數, 25%至75=4 0-60 0-6 P0.0158 。術後24 h內血漿中煙鹼含量和術後嗎啡消費量呈負相關,在蘇醒室( P = 0.049 ,以及在術後61224小時均如此( P = 0.002)。

結論: 對於全麻下行RRP手術的患者,術前的應用7mg煙鹼可以顯著減少阿片類的消費量。儘管減少阿片類藥物的使用,但是使用透皮吸收的煙鹼並沒有降低疼痛評分或術後噁心嘔吐的發生。

(章一靜譯 薛張綱校)

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.

 

 

在小鼠損傷的背根神經元中通過恢復鈣內流可以糾正胞膜的過度興奮狀態

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:我們已經知道,在軸索顯微外科,減少神經元細胞膜Ca2+內流(ICa)可以增加神經元的興奮性。基於此,我們預見增加損傷神經元的ICa可以糾正其高興奮狀態

方法:增加或減少跨膜ICa可以改變細胞膜的生物物理特性和興奮性,我們使用細胞內記錄儀器,在結紮脊神經後,測定非解離的後根神經節的A型神經元的這一特性。

結果:當增加細胞外液Ca2+ 的水準可以促進 ICa,使超極化減少,觸發點抑制,在選擇性激動劑NS1619 and NS309激動Ca2+促發的K+ 流動時也可以出現。降低細胞外Ca2+的濃度產生相反的效應,與以往觀察到的未損傷神經元有相似的作用

結論:這些發現表明,軸索顯微外科術後機體感覺神經元的過度興奮和Ca2+內流減少有關,修復ICa的措施可以用來治療周圍神經病引起的疼痛。

(陳珺珺譯 薛張綱校)

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.


結紮小鼠脊神經後,神經妥樂平通過啟動下行疼痛抑制系統起到鎮痛作用

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:神經妥樂平是一種從接種牛痘病毒後而發炎的兔子皮膚中分離出來的非蛋白質提取物,在日本被廣泛用於治療諸如神經性疼痛等慢性疼痛病。儘管已經進行了一些針對神經妥樂平鎮痛機理的研究,然而,這個機理仍然沒被正確澄清。

方法:在使用戊巴比妥麻醉的情況下,將老鼠的左側第五腰神經用縫線結紮起來。機械鎮痛效果通過測試老鼠後爪在用von Frey細絲刺激後退縮闕值測定。在神經結紮後的28天進行行為測試。左側第五腰神經被結紮((L5-SNL)的小鼠用三種途徑給藥:靜脈、鞘內或腦室內使用神經妥樂平。我們測定了L5-SNL小鼠在使用神經妥樂平鎮痛後,去甲腎上腺素,5-羥色胺能和γ-氨基丁酸(GABA)拮抗劑的效應。在鞘內分別注射育亨賓({alpha}2腎上腺素能受體拮抗劑),酒石酸酮舍林(5-HT2A受體拮抗劑),MDL72,2225-HT3受體拮抗劑),甲基氯化荷包牡丹堿(γ-氨基丁酸受體拮抗劑)和CGP35,348γ-氨基丁酸受體拮抗劑)。

結果:靜脈注射神經妥樂平(50–100 NU/kg)能引起L5-SNL小鼠的抗痛覺超敏效應。而且,腦室注射神經妥樂平(400 mNU/),而非鞘內注射神經妥樂平能抑制痛覺超敏。神經妥樂平的抗痛覺超敏作用(100NU/Kg,靜脈內注射)可以被育亨賓鞘內注射(10 NU /鼠)、酮舍林(30 NU /鼠)、MDL72,222(30 NU /)、荷包牡丹堿(0.6 NU /)CGP35348 (30 NU /)所抑制。另一方面,鞘內注射m-CPBG5-HT3受體激動劑)的抗痛覺超敏作用通過鞘內注射荷包牡丹堿和CGP35348被逆轉,這表明5-HT3受體和脊椎抑制性中間神經元(γ-氨基丁酸能神經元)的相互作用。

結論:這些結果表明神經妥樂平的鎮痛作用是通過啟動疼痛下行抑制系統實現的,如去甲腎上腺素系統和5-羥色胺能系統,它們是從脊髓發出至脊髓背側角。此外,通過脊髓背側角5-HT3受體激動劑引起的抑制性γ-氨基丁酸能神經元的啟動也參與樂神經妥樂平的抗痛覺超敏作用。

(陳珺珺譯 薛張綱校)

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.


多孔硬膜外導管和單孔導管的功能一致:在離體試驗中

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.

 

在一項離體實驗中,我們通過可選擇孔數量的多孔導管決定流速。鹽水以1360mL/h通過Baxter Abbott公司及Alaris輸注泵經Portex  Braun 20號的多孔導管輸注。我們通過輸注和人工推注的方法,並記錄了開放導管的數目及持續輸注的壓力。單孔輸注速率<80mL/h,雙孔速率在100280mL/h,三孔速率>300mL/hBraun導管的壓力大於Portex導管壓力的40%。12名住院醫生使用3個孔的導管人工輸注。在臨床應用中,20號的多孔導管和單孔導管的功能相似,但是多孔導管可以用於增加負荷劑量。

(陳珺珺譯 薛張綱校)

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細胞凋亡蛋白p53降低了氦在體心肌保護的閾值:線粒體通透性的作用

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:促成活的信號激酶抑制糖原合成激酶3BGSK-3B)的活性並促進細胞凋亡蛋白p53的降解。氦氣通過啟動促成活激酶產生心肌保護的作用,但GSKp53是否介導這個過程尚未闡明。筆者假設抑制糖原合成激酶或細胞凋亡蛋白p53通過改變線粒體膜的通透性從而降低在體心肌保護的閾值

方法85只家兔行血流動力學監測,阻斷前降支(LAD30min並再灌注3h,在阻斷LAD前給與0.9%的生理鹽水(對照),或135次週期性吸入70%氦氣-30%氧氣(氧濃度0.30)的混合氣體5min再複吸30%氧的空氣氧氣複合氣體。其他的家兔在前降支阻斷前在給或不給mPTP的開啟藥物蒼木酐(5mg/kg)下給與GSK抑制劑SB216763(SB21:0.20.6mg/kg)p53抑制劑皮斐松-a(PIF;1.5 g/kg3.0g/kg),或 SB21(0.2mg/kg)PIF(1.5kg/mg)1個週期的氦氣。

結果:氦氣組心肌梗塞的面積(吸入氦氣135個週期後梗死面積分別為35±6[n=7],25±4[n=7],20±3%[n=6])較對照組(44±6%[n=7])小(P<0.05)。SB21(0.6 mg/kg [n=7])組和PIF(3.0[n=6])組心肌梗死減小,但小劑量組SB210.2mg/kg[n=6])PIF1.5mg/kg[n=7])未見減小。SB21(0.2mg/kg)PIF (1.5mg/kg)加吸入氦氣(1個週期,n=6)具有相當於吸入3個週期氦氣後減少梗塞面積的效應,且這一效應能被蒼木酐阻斷。

結論:抑制GSKp53通過mPTP機制降低了在體氦氣介導的心肌保護的閾值。

(潘方立 陳傑 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.

 

 

硫噴妥鈉/七氟醚麻醉下小兒的正中神經軀體感覺誘發電位及酮基布洛芬和芬太尼的對其的附加作用

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:軀體感覺誘發電位(SEP)通常用於術中判斷脊髓和腦功能。一般說來,揮發性麻醉藥對SEP很敏感,但對於七氟醚麻醉維持時對兒童SEP的影響目前知之甚少。在麻醉中經常使用的鎮痛藥和其他輔助用藥可能也會影響SEP。在這一前瞻性臨床研究中,作者用苯二氮卓類和巴比妥類藥物對273-8歲健康兒童實施靜脈麻醉誘導後,給予其七氟醚進行麻醉維持,以評估七氟醚對於正中神經SEP的影響。此外,作者同時評估了酮基布洛芬和芬太尼這兩種鎮痛藥對於SEP的影響。

方法:測定患兒正中神經的SEP後,靜脈給予麻醉前用藥咪達唑侖0.1mg/kg,根據不同分組(給予酮基布洛芬和芬太尼或不給)給予鎮痛藥,然後在麻醉維持過程中記錄3SEP值:吸入七氟醚15分鐘後呼氣末七氟醚的濃度達到2%時;吸入後25分鐘(給/不給予酮基布洛芬1mg/kg);吸入後35分鐘(給/不給予芬太尼1ug/kg)。

結果:與基礎測量值相比,N20潛伏期和中樞傳導時間在七氟醚維持麻醉中均有所延長(前者P=0.015,後者P=0.001)。鎮痛藥的使用對N20潛伏期和中樞傳導時間沒有影響。在5-8歲患兒中,平均N20-P25振幅有所下降(P=0.008)。此外,在年長兒中聯合應用酮基布洛芬和芬太尼後N20-P25振幅也有所下降(P=0.03)。但在年幼兒中未發現有下降的現象。

結論:在小兒,2%七氟醚可以通過與其他吸入麻醉藥相似的方式延長正中神經的SEP潛伏期。雖然吸入七氟醚時可以監測SEP,但應根據個體差異調整吸入劑量。聯合應用酮基布洛芬和芬太尼並不影響SEP潛伏期,但可降低年長兒皮質電位的振幅。

(周姝婧 陳傑 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.

 

 

氧化亞氮在婦科腔鏡手術術後噁心的劑量-反應關係的初步研究

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:氧化亞氮(N2O)是否增加婦科腔鏡手術術後噁心嘔吐(PONV)發生率仍有爭議。其發生率可能與麻醉氣體吸入的濃度有關。作者研究了氧化亞氮與術後噁心嘔吐的發生是否存在劑量相關效應。

方法:接受婦科腔鏡手術的患者隨機分為三組:吸入30%氧-空氣組(G0, n = 46)、吸入50% N2O-氧混合組(G50n = 46)、吸入70% N2O-氧混合組(G70, n = 45)。使用標準的全麻技術但並不給予預防噁心嘔吐藥物。控制術前已知的PONV危險因素。胃複安為解救藥物。評價術後二小時、二十四小時內的噁心、嘔吐、使用解救藥物的發生率及疼痛視覺評分(VAS)。

結果:各組的一般情況具有可比性,包括可能影響PONV的危險因素。PONV24小時發生率分別為:G033%15/46)、G5046%(21/46) G7062%(28/45)(P=0.018)。組間分析發現G0G70組之間有統計學差異(P=0.018),但其他組合之間卻無差異。在噁心發生率方面具有相似的差異:G0=26%,G50=35%,G70=56%,P=0.012;但在嘔吐發生率方面儘管有相似的趨勢,卻無統計學差異(G0=28%,G50=35%,G70=42%,P=0.377)。噁心的嚴重程度(用VAS 100mm評估)與N2O濃度之間呈正相關( G0=10.9,G50=12.7,G70=20.5,P=0.027)。同時分析24小時內最高的VAS評分。在解救藥物使用率、疼痛VAS評分和阿片類藥物使用量(術後二小時、二十四小時內)方面各組無差異。

結論N2O增加婦科腔鏡手術術後噁心發生率。這項初步實驗提示N2O可能以劑量相關的方式增加PONV的發生率。每組至少需要400個以上的樣本量方能揭示其組間的統計學差異性。作者不建議在婦科腔鏡手術中使用高濃度的N2O

(於章傑 陳傑 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.



關於對吸入麻醉藥反應的起源與演變的假說

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.

 

本文作者提出了有機體對吸入麻醉藥反應的進化論假說。作者推測,機體對吸入麻醉藥的反應是由於離子通道,這種對吸入麻醉藥的敏感性世代沿襲下來,由我們共同的祖先——單細胞生物裏的麻醉敏感性離子通道並遺傳下來(例如,單細胞生物還未產生神經系統對吸入麻醉藥的適應性反應,而其離子通道對吸入麻醉藥的反應要早於多細胞生物)。這種敏感性在多細胞生物裏被細化為神經突觸。

值得注意的是,作者推測,1)單細胞生物被選擇的有益特性是離子通道對環境中化合物的協同應答,而這會影響離子通道的構象平衡; 2)這種協同反應防止了正電荷進入細胞而產生有害後果,因此增加了生物體的適應性; 3)這些複合物(包括陰離子,陽離子,兩性離子和一些不帶電化合物)模擬了吸入麻醉藥在機體內的介面活性,並且通過改變連接離子通道的雙分子層結構來調節離子通道的功能。

假說包括了吸入麻醉藥已知特性。此外,這個假設也適合於那些非揮發性麻醉藥有類麻醉作用的物質對離子通道調節作用,包括那些在健康人與身患疾病人身上的調節離子通道功能的內源性複合物。後者包括代謝物在一些器官衰竭的終末階段以及一般的代謝疾病。這些預言部分已被研究並被證實。

(趙嫣紅 陳傑 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.


腦脊髓液中鉀離子濃度的增加並不引起大鼠異氟醚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:以往的研究顯示異氟醚的MAC與脊髓周圍腦脊液的鈉離子濃度相關。脊髓為吸入麻醉藥制動作用主要作用位點。如果這一相關性是由脊髓刺激提高所致,輸注高鉀液會有相似作用。相反,如果鉀離子此效應缺失可能解釋鉀離子通道並不介導吸入麻醉藥的制動作用,而鈉離子通道仍為介體。本文作者研究了改變鞘內鉀離子濃度對MAC的影響。

方法:大鼠鞘內置管,腰部鞘內給予貧鉀、富鉀液體,測定異氟醚應用前24h、使用中及24h後的MAC。另測定滲透壓對(輸注甘露醇)MAC的影響和鈉離子滲入脊髓情況。

結果:異氟醚的MAC在鞘內輸注鉀離子導致濃度升高後無顯著變化。在輸注KCl濃度超過12倍正常濃度後(29 mEq/L)大鼠自主活動時異氟醚濃度稍降低,有時為一個MAC,但平均MAC未超過對照MAC。在最大輸注濃度(58.1 mEq/L)時MAC明顯降低且隨後未恢復至正常(如此高濃度可產生損傷)。輸注低濃度鉀溶液時並不影響MAC。鞘內注射鈉離子可滲入脊髓。

結論:上述結果並不支援鉀通道媒介或調製MAC

(懷曉蓉 陳傑 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.


一項在體代謝試驗用於檢測人群中惡性高熱易感性:一項初步研究

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:離體收縮試驗以診斷惡性高熱(MH)需肌組織活檢,它可能給病人帶來嚴重的副作用。在研究過多篇不同的試驗計畫書後作者提出一個創傷相對較小的測試,通過肌注咖啡因和氟烷,測定局部的乳酸值,以區別高熱易感人群(MHS)和非易感人群(MHN)間差異。

方法:在8名先前已診斷為MHS的患者(其三個代表基因突變,GLY2434ARGTHR2206MET,ARG614CYS),和7MHN,以及7名對照組患者的股肌中埋入兩個可進行微型探針。在在平衡和乳酸水準基線記錄後,局部注射單次負荷劑量咖啡因(200uL80 Mm)和4%的氟烷200uL(容積百分比,大豆油懸浮液)。乳酸含量由分光光度法測定。資料採用中位數及四分位數間距表示。

結果:儘管各研究組的乳酸基線值在注射前是相似的,但在注射咖啡因後,局部乳酸值在MHS組(2.01.8-2.6 mM)顯著大於MHN(0.8(0.6-1.1)mM)和對照組(0.80.6-0.8mM。氟烷也引起MHS組【8.6 3.7-8.9 Mm】比MHN組【 0.90.5-1.1mM】和對照組【1.70.9-2.3mM】乳酸值高。但MHN組有一名患者和對照組兩名患者乳酸增加。另外,血流動力學和代謝參數在組間無差異。

結論:通過局部注射咖啡因和氟烷後檢測乳酸代謝,是一種創傷性和副作用較小的方法,以便檢測惡性高熱的易感人群。

(葉樂 陳傑 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.

 

自適應輔助通氣時潮氣量的確定:一項多中心觀察研究

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術病人自適應輔助通氣(ASV),並研究微處理器機械通氣模型下潮氣量的確定及影響因素。

方法:本研究為前瞻性、多中心、觀察研究,包括3個荷蘭ICU,時間長達5個多月。機械通氣資料在患者入ICU後穩定時收集。

結果:採集346位元心胸外科手術病人資料:262位病人使用ASV,而84位病人使用壓力控制/壓力支援通氣。使用ASV組的病人平均潮氣量為7.1 ±1.6ml/kg。換算成理想體重潮氣量為8.3 ±1.5ml/kg,在一些正確的預設體重病人中(例如:理想體重),潮氣量為8.1 ±1.4ml/kg。而在壓力控制或壓力支持通氣組病人理想體重的潮氣量為7.3 ±1.4ml/kg(與ASV相比P<0.001)。多變數計算回歸分析顯示ASV的潮氣量取決於兩個參數:呼吸頻率和預設體重。

結論ASV的潮氣量取決於兩個參數:呼吸頻率和預設體重。第一個因素在臨床上不是很重要,因為呼吸頻率是由電腦自動選擇。第二個因素在臨床上很重要,因為它是唯一的可以被醫生影響的因素。研究資料顯示了在使用ASV時設置正確體重的重要性。在相當數量使用ASV的病人中,理想體重的潮氣量>8ml/kg。今後尚需隨機臨床試驗比較ASV與其他通氣模式的差異。

(張磊 陳傑 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.

 

 

擇期剖腹產鞘內注射可樂定對術後抗痛覺過敏和鎮痛作用的評估

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:鞘內注射可樂定提高剖腹產術中麻醉和術後鎮痛。可樂定同時還具有抗痛覺過敏的特性。痛覺過敏歸因於術後疼痛並可能增加術後慢性疼痛的風險。在此研究中,作者評估了鞘內可樂定注射剖腹產術後抗痛覺過敏作用。

方法96名接受選擇性剖腹產術的產婦隨機分組,分別接受:鞘內布比卡因-舒芬太尼(BS組),布比卡因-舒芬太尼-可樂定75ugBSC組),或者布比卡因-可樂定150ugBC組)。首先評價的是切口周圍點狀機械性痛覺過敏的程度和發生率,通過對剖腹產術後24小時和48小時的von Frey毛髮刺激反應來評定。同時評估術後嗎啡需要量、疼痛評分和136月的後遺痛情況。

結果BC組在術後48小時切口周圍痛覺過敏的範圍明顯減少(中位數,25-75個百分點,分別為BC1.0(1.0-3.3)cm2BS9.5(5.0-14.0)cm2BSC5.02.5-12.3cm2(與BS組相比P=0.002)。BC組的術後48小時痛覺過敏發生率同樣較低,分別為BC16%BS41%BSC34%(與BS組相比P=0.03)。各組間的術後嗎啡量、疼痛評分、後遺痛的發生率和強度無差異。

結果:相比於鞘內使用布比卡因-舒芬太尼和鞘內使用可樂定75ug-布比卡因-舒芬太尼,鞘內使用150ug可樂定聯合布比卡因具有抗痛覺過敏的作用,顯著減少選擇性剖腹產後48小時切口周圍點狀機械性痛覺過敏的程度和發生率。

(朱紫瑜 陳傑 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.

 

 

頸部伸展時氣管拉長:氣管的哪一段伸長了?

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:作者試圖研究三種不同頸部位置時從上門齒至氣管隆突的氣道三部分各自長度改變。

方法20名擇期手術患者入組本實驗。將氣道分為三段:上門齒至聲帶(UI-VC)、聲帶至胸骨切跡(VC-SN)、胸骨切跡至氣管隆突(SN-CA)。患者予全麻誘導並行氣管插管,連接呼吸機行機械通氣。將支氣管鏡經氣管導管連接處置入氣管導管內插入直至其頂端觸及隆突並予以支氣管鏡上膠帶標記,隨後緩慢退出支氣管鏡並分別於胸骨切跡(透光法確認)聲帶及上門齒(支氣管鏡直視)時膠帶標記。分別測量病人頸部處屈位(相當於頭部墊10m枕頭)、自然位(相當於頭部墊5cm枕頭)、伸位(相當於頭部不墊枕頭)時四個標記間的三段距離以獲得氣管三段部分的各自長度,並對所獲得資料進行方差分析及配對t檢驗。

結果 UI-VC, VC-SN, SN-CA三段的長度分別為12.1 ± 1.495.37 ± 0.958.24 ± 1.16cm。當頸部從屈位至伸位變化中UI-VC VC-SN長度分別增加0.36 ±  0.68cmP=0.027)及1.74 ±  0.48cmP<0.001)。SN-CA段長度減少0.12± 0.70cmNS),而UI-CA的總長度增加1.99 ±0.7cmP<0.001)。在頸部位置處於屈位、自然位和伸位時SN-CA段分別占總長度的64%61%56%,但其長度無顯著變化。

結論:當頸部從屈位至伸位變化中,UI-CA的總長度增加1.99cm。氣道三段組成中以VC-SN段長度增加1.74cm為甚,UI-VC段只增加0.36cmSN-CA段長度無明顯改變。三種體位中SN-CA段平均占UI-CA總長度的60%。本實驗發現可以解釋為何插管病人頸部伸展時其原本固定的氣管導管會滑向深處。

(陶穎瑩 陳傑 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.

 

 

經皮煙鹼貼劑作為術後疼痛處理:一項劑量範圍研究

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: 動物試驗表明煙鹼具有術後鎮痛作用。人類應用經鼻煙鹼噴劑有不等的效果,可能是由於藥代動力學及不同情況病人如經常暴露於煙鹼的吸煙者存有變異性。在這項研究中,作者僅在非吸煙者中進行術前應用經皮煙鹼貼劑鎮痛效果的試驗。

方法:本研究對40名擬行普外科手術,術後要求行自控鎮痛且住院的患者進行一項隨機、雙盲、前瞻性、安慰劑-對照研究。術前應用劑量分別為051015mg的經皮煙鹼貼劑。主要的結果參數為是數位化評定量表(NRS)來判定術後一小時和術後五天疼痛評分。次要的結果參數是疼痛藥選用,對血流動力學的影響,噁心發生率和鎮靜作用等。

結果: 在術後一小時(P=0.003,平均NRS減少1.4,95% CI=0.3-2.6)和術後五天 (P=0.03,平均NRS減少1.0,95% CI=0.1-1.9)的疼痛評定中可以看出,與應用安慰劑處理的病人相比,應用了煙鹼的病人有更低疼痛評分。當煙鹼的用量超過5mg時,其有效性已經不再增加。在煙鹼組減少了疼痛藥的使用同時,增加了噁心的發生,減少了心動過速的發生和略微降低了收縮壓的傾向,但是這些作用均不顯著。

結論:在普外科手術,經皮使用煙鹼5-15mg,可以減低術後疼痛評分但是並不能減少麻醉性鎮痛藥的使用量,也不能降低阿片類鎮痛藥物相關的副作用。 

(丁俊雲 譯 陳傑 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.


區域麻醉技術用於開胸手術術後鎮痛的隨機試驗――系統綜述

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:開胸手術可導致嚴重的術後疼痛和肺功能的減弱,因此術後的區域鎮痛已被深入的研究。胸段的硬膜外鎮痛被普遍的認為是最好的方法,然而需要評估與其他技術的差異,指導臨床實踐,尋求需要進一步研究的領域。

方法:在這項隨機試驗的系統綜述中作者評估了胸部硬膜外、椎旁、鞘內注射、肋間和胸膜間等鎮痛技術在成人的開胸手術中的應用的相互比較,並與全身應用阿片類藥物鎮痛比較。並對術後疼痛,鎮痛藥的使用量,以及併發症作分析。

結果:持續的椎旁阻滯和硬膜外的局麻藥鎮痛同樣有效,並且能降低低血壓的發生率。與全身藥物鎮痛相比,椎旁阻滯能降低肺部併發症的發生率,而胸段硬膜外鎮痛則無此作用。胸段硬膜外鎮痛比鞘內注射和肋間技術優越,而它們都優於系統性藥物鎮痛;胸膜間的鎮痛則顯得不足。

結論:無論是胸段硬膜外鎮痛加阿片類藥物還是持續的椎旁阻滯都可以使用。如果不能用這些技術或者是存在禁忌,鞘內注射阿片類藥物或者肋間神經阻滯也可以,儘管持續鎮痛的時間略顯不足,需要輔助應用系統性藥物鎮痛。定量薈萃分析受到實驗設計的限制,且量本樣數也較少。還需進一步的研究以確定最適宜的硬膜外的藥物組合,嚴格評估椎旁持續輸注的風險和優點以及肋間技術與胸段硬膜外鎮痛的比較。

(舒慧剛 陳傑 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.



煙鹼受體激動劑在小鼠術後疼痛模型中的抗傷害作用

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, 中樞煙鹼受體的廣譜激動劑,具有術後鎮痛效應。許多亞型的特異性煙鹼受體激動劑在動物模型中具有抗傷害作用,但是對於實驗模型有高度的依賴性。本文作者研究了選擇性作用於{alpha}4β2 {alpha}7煙鹼受體激動劑對於小鼠術後疼痛模型的作用,探究哪一煙鹼受體亞型在今後臨床研究更具意義。

方法 小鼠在足切皮後,作者用一定劑量的配體選擇性作用於{alpha}4β2 {alpha}7煙鹼受體,給藥前後分別測定熱潛伏期和壓力閾值。在研究中,為了證明尼古丁可以降低疼痛輸入,一組小鼠用磷酸化的cAMP反應結合蛋白(CREB)在脊髓腰段進行了染色。

結果:在熱和壓力測試中,尼古丁和位變異煙鹼({alpha}4β2選擇性)可以作為一種非常有效的止痛藥。{alpha}7部分受體激動劑GTS-21可以顯著延長術後熱潛伏期,但是不改變壓力閾值。選擇性{alpha}7受體拮抗劑methyllicaconitine可以降低尼古丁延長熱潛伏期的效能,但是對壓力閾值沒有影響。細胞核用pCREB染色的脊髓背角淺層細胞的數量在術側成倍增加,使用尼古丁後呈劑量依賴性降低。

結論:研究表明尼古丁可以減少疼痛傳輸至脊髓背角淺層和深層。結果也同樣支持{alpha}4β2 {alpha}7煙鹼受體介導抗傷害作用。

(杜唯佳 陳傑 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.

 

 

超聲成像精確定位股外側神經

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:股外側皮神經(LFCN)麻醉在股前外側手術時很有用的,作者通過在屍體和志願者對比用超聲和解剖標誌來定位驗證超聲的準確性。

方法20具屍體,在超聲的引導下用一根針刺入股外側皮神經的靶點,注入綠色的染料,再在解剖標誌的定位下刺入第二根針,通過分離肌肉組織來確定股外側皮神經,染色評估針的位置,用神經刺激來驗證雙側股外側皮神經的位置,它們的位置通過超聲和解剖位置來比較。

結果:在超聲引導下刺入屍體的19根針,其中16根觸及到了股外側皮神經,針尖與神經的平行距離幾乎是0,利用解剖標誌定位的19根針中只有一根接觸到神經,其他針尖到神經的平均距離是18.0mm,在超聲引導下的20個志願者中,16例符合股外側皮神經的位置的,記錄器標誌到股外側皮神經的距離為0.0mm,在用解剖標誌定位的20例中,沒有一例觸及到股外側皮神經,記錄器標誌到股外側皮神經的距離為15.0mm

結論:通過超聲定位股外側皮神經在技術上可行並比解剖標誌定位法更準確。

(劉世文 陳傑 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.



 

吸入低濃度七氟烷增強抗消化性潰瘍藥物替普瑞酮的遲發性心臟保護作用

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:我們在兔子身上觀察七氟烷能否增強抗消化性胃潰瘍藥物替普瑞酮(GGA)誘發的遲發性心臟保護作用。

方法:S(+)-氯胺酮和塞拉嗪麻醉的兔子被分到七個試驗組:對照(僅有溶媒)組、GGA組、七氟烷組、GGA+七氟烷組、5-羥基葵酸鈉(5HD)組、GGA+5HD組和熱應激組。所有兔子冠狀動脈阻斷30分鐘後接受3小時的再灌注。冠狀動脈阻斷前24小時,兔子靜脈注射溶媒、GGA(10mg/kg)或熱應激(42°C15分鐘)預處理。心肌缺血前吸入七氟烷(0.5MAC)或靜脈注射5HD(5mg/kg)。測量各實驗組兔子心肌梗塞面積和頻臨缺血區面積以及熱休克蛋白(Hsp70水準。

結果:相對於溶媒,GGA顯著減少心肌梗塞面積與頻臨缺血區面積的比值(39 ± 10%59 ± 9%, P < 0.02)。七氟烷增強GGA誘發的心臟保護作用(23 ± 17%, P < 0.05GGA)5HD取消GGA的心臟保護作用(56 ± 15%, P < 0.01)。相對于對照組,GGA增加Hsp70的表達(0.69 ± 0.150.36 ± 0.05, P < 0.02)。聯合應用GGA和七氟烷與單獨應用GGAHsp70表達的影響沒有顯著性差異(0.69 ± 0.16, P > 0.98)

結論:GGA減少心肌梗塞面積似乎與增加Hsp70表達有關;七氟烷增強GGA誘發的心肌保護效應。

(王宏   馬皓琳 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.


衰老大鼠心臟異氟烷預處理和活性氧產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: 麻醉藥預處理的弱化作用在衰老心肌體外試驗中已得以廣泛研究,但還沒有相應的體內研究。為了擴展以前的研究和闡述年齡相關差異的可能機制,我們研究了在體衰老大鼠心臟中異氟烷預處理和活性氧(ROS)的產生情況。

方法:雄性Fisher大鼠,344只,按年齡分為青年組(3-5月)和老年組(20-24月),每組再分為預處理組和對照組,預處理組事先接受30min 1.0MAC異氟烷。四組大鼠均阻斷冠狀動脈30min,隨後再灌注2 h。無異氟烷處理時或在另外4組異氟烷處理前即刻給予螢光探針(二羥胡米胺1 mg)用於檢測超氧陰離子水準。分別用三苯基四唑染色和表面螢光顯微鏡觀察心肌梗死面積和超氧陰離子產生。

結果:與年輕對照(50.9% ± 1.9%)相比較,異氟烷減少了年輕大鼠心肌梗死面積(26.7% ± 3.0%P < 0.001),但與年老對照(46.5% ± 2.4%)相比較,異氟烷並不明顯影響年老大鼠心肌梗死面積(39.1% ± 0.9%P > 0.05)。與青年對照組(162.7 ± 25.5任意單位 [AU])相比,異氟烷增高了年輕大鼠的ROS水準(430.5 ± 95.9 AU;P < 0.01)。相反的是,異氟烷處理後老年大鼠ROS水準沒有明顯變化(316.4 ± 56.3 AU 異氟烷組比233.8 ± 59.2 AU 對照組)

結論:對於體內研究中的衰老心肌,異氟烷的心臟保護作用降低,異氟烷刺激產生的ROS水準降低。

(江繼宏   馬皓琳 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.


不同濃度丙泊酚對小兒心肌複極化分散的影響

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:心電圖顯示的QT間期延長可能是藥物誘發的,傳統上認為易導致扭轉性室速。扭轉性室速的一個較好預測指標是T波的最高峰和末尾之間的時間間隔(Tp-e)。以往的研究中,丙泊酚對校正性QT間期(QTc)的影響一直存在爭議,而且被複合用藥所混淆。近來有研究顯示,靶控輸注丙泊酚3µg/mLQTcTp-e沒有影響。而這個血漿濃度的丙泊酚在手術麻醉範圍中處於極低端。在這個隨機、雙盲的臨床研究中,我們研究了用於手術麻醉的臨床相關劑量範圍內,丙泊酚與QTcTp-e之間的劑量效應關係。

方法: 研究物件為60個健康的未術前用藥的兒童,年齡3–10歲。隨機給予靶控輸注3個不同濃度丙泊酚34.56µg/mL。術前記錄12 導聯心電圖,誘導後每5 分鐘記錄一次。由兩名不知分組情況和心電圖記錄時間的觀察者獨立地測定QTcTp-e。組內比較QTc Tp-e採用配對t檢驗。組間採用單因素方差分析。主要測量指標為組內和組間Tp-e變化大於25 ms

結果: 記錄到51 名兒童的心電圖。一般情況和ECG的基礎值之間沒有差異,此時的QTcTp-e均在正常範圍。三組誘導後,QTcTp-e 在組內和組間也沒有統計學差異。

結論: 臨床相關劑量的丙泊酚不影響健康兒童心肌複極化過程。這表明丙泊酚可以合理地用於心肌複極化不正常的兒童中。

(張瑩譯  馬皓琳 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.


鞘內注射布比卡因和利多卡因的混合液的持續時間

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:儘管布比卡因脊麻的持續時間可能過長而無法應用於門診手術,最近的動物資料顯示布比卡因脊麻中加入利多卡因可能減少布比卡因脊麻的持續時間。我們探究在人體中,鞘內布比卡因中加入利多卡因能否像動物研究一樣縮短布比卡因脊麻的持續時間。

方法:90個行經尿道膀胱腫瘤或者前列腺切除病人,被雙盲隨機分配成三組。鞘內注射高比重的0.5%布比卡因1.5毫升,加入0.6毫升以下溶液:鹽水(組In = 30,對照組),1%利多卡因(組IIn = 30)和2%利多卡因(組IIIn = 30)。測定最高感覺阻滯平面、達到最高感覺阻滯平面的時間、從最高感覺阻滯平面消退到兩個節段L1S2的時間、感覺阻滯最高時、消退到L1S2時的運動阻滯以及麻醉後監護室逗留時間(PACU時間)。

結果:所有三組,到達最高感覺阻滯平面的時間近似。組II從最高感覺阻滯平面消退到兩個節段L1S2的時間和PACU時間比組I顯著減少。組IIIL1S2消退時間及PACU時間顯著延長。

結論:我們推斷利多卡因(6 mg)加入到鞘內布比卡因(7.5 mg)能縮短布比卡因脊麻的持續時間,因此比單獨應用同樣劑量的布比卡因(7.5 mg)的脊麻恢復更快。

 (張曦 譯,馬皓琳 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.


表面活性物質對受體功能的麻醉藥樣調變:對麻醉介面理論的一個檢驗

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:吸入麻醉藥有介面活性,集中於如蛋白質/水或雙分子層/水等介面。我們通過將表面活性物質應用於{gamma}-氨基丁酸A型(GABAA)、甘氨酸以及N-甲基-D-天冬氨酸(NMDA)受體來驗證以下假設:介面活性是受體功能麻醉藥樣調變的一個充分條件。我們將麻醉藥樣調變定義為:對一些固有通道電流的增減作用與異氟烷和乙醇保持一致。我們還檢驗了以下假設:表面活性物質對那些因基因點突變導致對異氟烷和乙醇反應減弱的受體和正常受體的調變作用之間沒有區別。

方法:研究分別帶不同首基電荷(陰離子、陽離子、兩性離子以及不帶電荷)和不同尾長(8碳和12碳)的七種表面活性物質對同價同效基因的野生型{alpha}1和突變型{alpha}1 (S267I)甘氨酸受體、野生型{alpha}1β2{gamma}2s和突變型{alpha}1(S270I)β2{gamma}2sGABAA受體以及野生型NR1/NR2A和突變型NR1(F639A)/NR2A NMDA受體的作用。受體表達於非洲爪蟾的卵母細胞表面,採用雙電極電壓鉗進行研究。

結果:所有七種表面活性物質、異氟烷和乙醇均增強GABAA受體的功能。七種表面活性物質中的六種、異氟烷和乙醇增強甘氨酸受體的功能。七種表面活性物質中的六種、異氟烷和乙醇抑制NMDA受體的功能。至於突變型受體,七種表面活性物質中的五種增加了通過GABAA受體的電流,而七種表面活性物質中的六種增加了通過甘氨酸受體的電流。七種表面活性物質中的六種減少了通過NMDA受體的電流。與野生型受體相比,表面活性物質作為一組並不像異氟烷和乙醇那樣減弱了對突變型受體的調變作用。

結論:這些結果證實另一大類複合物(表面活性物質)以與吸入麻醉藥性質相似的方式對GABAA、甘氨酸和 NMDA受體的功能進行調變。我們不能否定關於介面活性是對這些受體麻醉藥樣調變作用的一個充分條件的假設。可減弱異氟烷和乙醇的調變作用的突變並不減弱表面活性物質的調變作用。

(黃施偉 譯,馬皓琳 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.


低臨床濃度異氟烷能預防小鼠脊髓由煙鹼誘發的去甲腎上腺素釋放

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:亞麻醉濃度的揮發性麻醉藥異氟烷抑制煙鹼型乙醯膽鹼受體。在人類和動物研究中,相似濃度的揮發性麻醉藥增加疼痛的敏感性。煙鹼的鎮痛作用被認為是與其增強去甲腎上腺素的釋放有關的。該研究欲為異氟烷改變煙鹼對去甲腎上腺素釋放的增強作用是其促進疼痛感受的潛在機制理論提供依據。           

方法:我們的研究採用小鼠腰段脊髓薄片模型。在有異氟烷或者沒有異氟烷存在的情況下使用煙鹼誘發去甲腎上腺素釋放。為了鑒別涉及的煙鹼受體類型,我們研究了受體和亞型特異性配體和缺乏煙鹼受體β2亞基基因表達的基因工程小鼠。測定了不同實驗條件下[3H]-去甲腎上腺素的釋放量。

結果:體內增強疼痛敏感性的異氟烷濃度(0.38%)能夠顯著且最大程度地抑制煙鹼對去甲腎上腺素釋放的增強作用。使用{alpha}7的選擇性興奮劑膽鹼能夠模擬對去甲腎上腺素釋放的增強作用,該作用在{alpha}7-煙鹼的選擇性抑制劑{alpha}-金環蛇毒素存在時受抑制。缺乏β2亞基動物中去甲腎上腺素釋放的增強作用與對照動物沒有差異。

結論:低臨床相關濃度的異氟烷抑制煙鹼對脊髓去甲腎上腺素釋放的增強作用。由於在脊髓去甲腎上腺素能傳導的總作用是抑制,故移除此機制可能是在這些濃度的異氟烷增強疼痛敏感性的原因。

(顏濤 譯,馬皓琳 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.


紅外測量人類呼吸中的二氧化碳:回顧從Tyndall到現在的“呼吸通過”裝置

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

測量患者呼吸過程中的二氧化碳或二氧化碳描記圖,是現代醫學發展中的基本技術進步之一。我會用從歷史記錄和與許多開發者的個人採訪中得到的資訊,來記述一下通過紅外測量呼吸中二氧化碳的主流二氧化碳描記圖的發展和商業化。

(唐亮   馬皓琳 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.


經皮擴張氣管切開術相關的適應性輔助通氣:一項臨床研究

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

我們測定了34ICU病人在內窺鏡引導下經皮擴張氣管切開術後,是否有必要對其適應性輔助通氣的分鐘通氣量進行調整。在這一過程中,分鐘通氣量沒有進行調整;僅最大壓力限制在必要時進行了相應的調整。氣管切開放置套管後,僅當Paco2相對基線值改變0.5 kPa時才調整經套管分鐘通氣量。74%的病人在使用內窺鏡時適應性輔助通氣不能維持分鐘通氣量,必須進行壓力限制的調整。少數病人(26%)的分鐘通氣量必須進行調整以達到相似的Paco2值。

(吳進   馬皓琳 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.


產科病人中椎管內運用阿片類藥物後發生呼吸抑制

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

椎管內阿片類藥物已經被證實可以顯著改善產程,明顯減輕剖宮產後疼痛。產婦通過硬膜外和蛛網膜下腔給予阿片類藥物後,在臨床上發生顯著呼吸抑制的危險性非常低。雖然危險性很低,但是呼吸抑制是一個嚴重的風險;產婦可能死亡或者遭受永久性的大腦損傷作為後遺症。本篇綜述主要討論了在自然分娩和剖宮產中給予嗎啡、硬膜外緩釋嗎啡和親脂阿片類藥物後發生呼吸抑制的機制、發生率、預防、監測方法以及處理方法。

(姜旭暉譯,馬皓琳,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.


鋼絲強化矽樹脂管與Parker管及聚氯乙烯管用于正常氣道患者全麻下經喉罩插管的比較

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)用於困難插管的處理。通常,插入鋼絲強化矽樹脂管用於氣管內插管。因為鋼絲強化矽樹脂管價格昂貴,因而值得考慮使用聚氯乙烯 (PVC) 管及後洞斜面Parker管取代之。我們比較了鋼絲強化矽樹脂管、PVC管及Parker管的盲插成功率,確定阻止經ILMA行氣管內插管的喉部結構。

方法:把63位成年患者隨機分成3組:組I (n = 20) 鋼絲強化矽樹脂管,組II (n = 21) Parker管,組III (n = 22) PVC管。我們對患者一般情況及臨床的連續性資料用方差分析和用於因果分析的Scheffé 檢驗進行比較。對頻率及百分比行卡方檢驗。

結果:組I (鋼絲強化矽樹脂管)的20位病人中有18位第一次插管即獲成功。明顯高於組II22位中有12位)(Parker管)或組III21位中有10位)(PVC tube)。在插管時將氣管導管行順時針或逆時針轉動並不能改變組I插管成功的例數,但能將組II的成功例數提高到22位中的19位,將組III的成功例數提高到21位中的12位。氣管插管處理後,組I90%)與組II86%)的插管成功率無顯著性差異(P = 0.72)。然而,組III的插管成功率(57%)明顯低於組I(P = 0.02)及組II(P = 0.03)。組II22位中的3位及組III21位中的9位患者盲插失敗,阻塞原因是由於會厭結節。

結論:使用經ILMA Parker管插管能提高氣管內插管的成功率,使之有可能取代鋼絲強化矽樹脂管。

(裘毅敏譯,馬皓琳、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.


經皮煙鹼貼劑不能改善術後疼痛治療

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:煙鹼 3mg鼻內劑量被報導有鎮痛作用。我們設計了安慰劑對照研究來檢驗這樣一個假設,即下腹部手術術後煙鹼經皮給藥(TDN3天能減輕術後疼痛,減少阿片類鎮痛藥用量並改善恢復的過程。

方法:97例行腹式全子宮切除的患者隨機分成2組:(1)對照組術前1h及術後2天裏使用假貼劑,(2) 煙鹼組麻醉誘導前1h及術後2天給予30TDN(含21mg尼古丁)。麻醉方法兩組一致,術後評估包括疼痛和鎮靜口頭等級量表、靜脈患者自控鎮痛嗎啡用量、恢復品質、腸道功能恢復、正常活動的恢復以及患者對疼痛治療的滿意度。術後1月和3月繼續評估後期恢復事件。

結果:平臥或坐起時術後患者自控鎮痛嗎啡用量和疼痛評分、術中芬太尼用量、口服鎮痛藥量,腸鳴音恢復以及腸胃氣兩組之間均無差異。儘管下床走動、住院時間和恢復品質評分並無差別,煙鹼組進食恢復時間有延遲。煙鹼組出院合格評分在48h72h高於對照組,但兩組恢復到可以工作的時間均為19天。

結論:圍術期高劑量TDN貼劑不能改善婦科盆腔術後鎮痛或減少鎮痛藥需求。儘管延遲進食恢復時間,更多煙鹼組患者術後48h72h可以出院。然而,日常生活活動恢復時間兩組相似。

(朱慧譯 馬皓琳 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.


持續輸注低劑量的氯胺酮改善頸椎手術後病人自控鎮痛的芬太尼的鎮痛效果

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:芬太尼聯合應用氯胺酮用於術後鎮痛的效果仍不明確。我們研究了氯胺酮對芬太尼用於病人自控鎮痛的輔助作用。

方法:頸椎和腰椎手術的病人分入3組:給予氯胺酮1 mg/kg負荷量後,分別在氯胺酮-1組和氯胺酮-2組持續給予氯胺酮42µg · kg–1 · h–1 83 µg · kg–1 · h–1,並設一對照組。術後病人自控鎮痛用芬太尼應用背景劑量注射。

結果:頸椎手術後氯胺酮-2組的疼痛評分和鎮痛需要明顯低於對照組。氯胺酮可以部分改善腰椎手術後芬太尼的鎮痛作用。

結論:小劑量的氯胺酮改善頸椎手術後芬太尼的鎮痛作用。

(黃麗娜  馬皓琳 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.


砷化鎵鋁(830nm)低水準鐳射預照射血液可增強大鼠外周內源性阿片類物質鎮痛作用

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:有報導表明低水準鐳射照射療法(LLLT)可減輕疼痛且無副作用。然而人們對LLLT的機制未作深入瞭解。最近的研究也表明含有阿片類物質的免疫細胞會移行至炎症區域並釋放β-內啡肽以抑制疼痛,這是外周內源性阿片類物質鎮痛的模式之一。本研究探討LLLT預照射血液是否可增強外周內源性阿片類物質的鎮痛作用。

研究方法:採用大鼠炎症模型評估LLLT預照射血液對外周內源性阿片類物質鎮痛作用的影響。此外,利用大鼠血細胞離體研究LLLT對阿片類物質生成的作用。通過逆轉錄聚合酶鏈反應測定β-內啡肽前體、阿黑皮素原和促腎上腺皮質激素釋放因數的表達。

研究結果:LLLT預照射對外周炎症組織具有鎮痛效應,且此種鎮痛效應可被納洛酮短時間拮抗。相應地,離體和在體研究均表明LLLT可使β-內啡肽前體mRNA表達增加。

結論:上述結果提示:除已報導的機制外,LLLT預照射血液還可通過通過增強大鼠外周內源性阿片類物質生成來產生鎮痛效應。

(周雅春 馬皓琳 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.


比較超聲“雙泡征”引導的鎖骨下臂叢神經阻滯和神經刺激器引導的腋路臂叢神經阻滯

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“雙泡征”行超聲引導下鎖骨下臂叢神經阻滯。就像以前描述的那樣,“雙泡征”中,上面的“泡泡”是指短軸橫斷面上的腋動脈重疊在下麵的泡泡上,下面的“泡泡”則由於注射局麻藥而產生。在這項研究中,我們比較了這種臂叢神經阻滯的新方法和傳統的三點神經刺激法腋路阻滯。

方法:70位病人隨機分為兩組,分別用超聲“雙泡征”進行的單次注射、超聲引導的鎖骨下臂叢神經阻滯和三點神經刺激腋路阻滯。

結果:兩種方法的成功率類似(89%91%)。然而,鎖骨下神經阻滯操作時間較短(3.90 ± 2.278.03 ± 3.92 min; P < 0.001),且穿刺引起的疼痛評分較低(0-10尺規上2.70 ± 2.024.17 ± 2.57; P = 0.01)

結論:和三點神經刺激法腋路阻滯相比,用雙泡征進行的超聲引導鎖骨下臂叢神經阻滯可以提供相似的阻滯效果、較短的操作時間和較低的操作疼痛評分。

(黃佳佳譯,馬皓琳 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.