Table of Contents

October 2008

CARDIOVASCULAR ANESTHESIOLOGY:

围术期氯维地平治疗高血压安全性评价实验:心外科手术病人急性高血压治疗中,氯维地平与硝酸甘油,硝普钠,尼卡地平的对照实验

胡艳译   薛张刚校

The ECLIPSE Trials: Comparative Studies of Clevidipine to Nitroglycerin, Sodium Nitroprusside, and Nicardipine for Acute Hypertension Treatment in Cardiac Surgery Patients

Solomon Aronson, Cornelius M. Dyke, Kevin A. Stierer, Jerrold H. Levy, Albert T. Cheung, Philip D. Lumb, Dean J. Kereiakes, and Mark F. Newman

Anesth Analg 2008 107: 1110-1121.

脉压与冠状动脉搭桥术后不良预后的风险

印洁敏 陈杰

Pulse Pressure and Risk of Adverse Outcome in Coronary Bypass Surgery

Manuel L. Fontes, Solomon Aronson, Joseph P. Mathew, Yinghui Miao, Benjamin Drenger, Paul G. Barash, Dennis T. Mangano, For the Multicenter Study of Perioperative Ischemia (McSPI) Research Group, and the Ischemia Research and Education Foundation (IREF) Investigators

Anesth Analg 2008 107: 1122-1129.

糖尿病心肌病中β-肾上腺素能受体兴奋产生的正性松弛效应的维持

邱郁薇 马皓琳 李士通

Preservation of the Positive Lusitropic Effect of β-Adrenoceptors Stimulation in Diabetic Cardiomyopathy

Julien Amour, Xavier Loyer, Pierre Michelet, Aurélie Birenbaum, Bruno Riou, and Christophe Heymes

Anesth Analg 2008 107: 1130-1138.

依托咪酯对缺氧后再氧合和低氧预处理的离体人右房心肌没有影响

黄凝译  薛张纲校

Etomidate Has No Effect on Hypoxia Reoxygenation and Hypoxic Preconditioning in Isolated Human Right Atrial Myocardium

Jean-Luc Hanouz, Sandrine Lemoine, Lan Zhu, Olivier Lepage, Gerard Babatasi, Massimo Massetti, André Khayat, Benoit Plaud, and Jean-Louis Gérard

Anesth Analg 2008 107: 1139-1144.

中度急性等容血液稀释能改变冠心病病人的心肌功能

潘钱玲 陈杰

Moderate Acute Isovolemic Hemodilution Alters Myocardial Function in Patients with Coronary Artery Disease

Stefanie Cromheecke, Suraphong Lorsomradee, Philippe J. Van der Linden, and Stefan G. De Hert

Anesth Analg 2008 107: 1145-1152.

PEDIATRIC ANESTHESIOLOGY:

术中小剂量氯胺酮不能预防儿科脊柱侧弯手术后瑞芬太尼诱导的吗啡需要量的增加

唐李隽    马皓琳  李士通 

Intraoperative Low-Dose Ketamine Does Not Prevent a Remifentanil-Induced Increase in Morphine Requirement After Pediatric Scoliosis Surgery

Thomas Engelhardt, Christian Zaarour, Basem Naser, Carolyne Pehora, Joost de Ruiter, Andrew Howard, and Mark W. Crawford

Anesth Analg 2008 107: 1170-1175.

儿童七氟烷麻醉诱导时鼻内使用瑞芬太尼对插管条件和气道反应的影响

蒋宗明译 薛张纲校

The Effect of Intranasal Administration of Remifentanil on Intubating Conditions and Airway Response After Sevoflurane Induction of Anesthesia in Children

Susan T. Verghese, Raafat S. Hannallah, Marjorie Brennan, Jessica L. Yarvitz, Kelly A. Hummer, Kantilal M. Patel, Jainping He, and Robert McCarter

Anesth Analg 2008 107: 1176-1181.

小于三岁的婴幼儿骶管注射左旋布比卡因(2.5mg/kg)时的药代动力学

王腾 陈杰

Pharmacokinetics of Levobupivacaine (2.5 mg/kg) After Caudal Administration in Children Younger Than 3 Years (Brief Report)

Luis I. Cortínez, Ricardo Fuentes, Sandra Solari, Paola Ostermann, Miguel Vega, and Hernán R. Muñoz

Anesth Analg 2008 107: 1182-1184.

AMBULATORY ANESTHESIOLOGY:

恢复评分汉语翻译质量的心理测试

朱慧   马皓琳 李士通

Psychometric Testing of the Chinese Quality of Recovery Score

Matthew T. V. Chan, Charlotte C. K. Lo, Candy K. W. Lok, Tak Wing Chan, Kai C. Choi, and Tony Gin

Anesth Analg 2008 107: 1189-1195.

ANESTHETIC PHARMACOLOGY:

新型贝式闭合环路系统在使用BIS作为控制性变量的异丙酚麻醉中的精确性和临床可行性

刘沁译 薛张纲校

The Accuracy and Clinical Feasibility of a New Bayesian-Based Closed-Loop Control System for Propofol Administration Using the Bispectral Index as a Controlled Variable

Tom De Smet, Michel M. R. F. Struys, Martine M. Neckebroek, Kristof Van den Hauwe, Sjoert Bonte, and Eric P. Mortier

Anesth Analg 2008 107: 1200-1210.

年老大鼠丙泊酚麻醉后定向力完整

宋翠侠 陈杰

Spatial Memory Is Intact in Aged Rats After Propofol Anesthesia

In Ho Lee, Deborah J. Culley, Mark G. Baxter, Zhongcong Xie, Rudolph E. Tanzi, and Gregory Crosby

Anesth Analg 2008 107: 1211-1215.

阿米替林、加巴喷丁和卡马西平对吗啡诱发兔子高碳酸血症的影响

王宏   马皓琳 李士通

The Effect of Amitriptyline, Gabapentin, and Carbamazepine on Morphine-Induced Hypercarbia in Rabbits

Eran Kozer, Zina Levichek, Noriko Hoshino, Bhushan Kapur, John Leombruno, Nobuko Taguchi, Facundo Garcia-Bournissen, Gideon Koren, and Shinya Ito

Anesth Analg 2008 107: 1216-1222.

船坞模型研究惰性气体麻醉药与非麻醉作用气体与血清白蛋白不同结合位点

刘婷洁译 薛张纲校

Noble Gas Binding to Human Serum Albumin Using Docking Simulation: Nonimmobilizers and Anesthetics Bind to Different Sites

Tomoyoshi Seto, Hideto Isogai, Masayuki Ozaki, and Shuichi Nosaka

Anesth Analg 2008 107: 1223-1228.

三环类抗抑郁药对人的中性粒细胞吞噬功能和氧化突发的抑制作用

张燕 陈杰

The Inhibition of Human Neutrophil Phagocytosis and Oxidative Burst by Tricyclic Antidepressants

Annette Ploppa, Donald M. Ayers, Tanja Johannes, Klaus E. Unertl, and Marcel E. Durieux

Anesth Analg 2008 107: 1229-1235.

在已确定的重建突触中研究利多卡因对胆碱能神经传递的影响

姜旭晖译,马皓琳,李士通校

The Effect of Lidocaine on Cholinergic Neurotransmission in an Identified Reconstructed Synapse

Shin Onizuka, Toshiharu Kasaba, and Mayumi Takasaki

Anesth Analg 2008 107: 1236-1242.

TECHNOLOGY, COMPUTING, AND SIMULATION:

ICU病人使用震动反应成像技术(VRI)用于评估不对称肺脏疾病

秦敏菊译 薛张纲校

Assessment of Asymmetric Lung Disease in Intensive Care Unit Patients Using Vibration Response Imaging (Technical Communication)

Smith Jean, Ismail Cinel, Christina Tay, Joseph E. Parrillo, and R. Phillip Dellinger

Anesth Analg 2008 107: 1243-1247.

一种新型弯曲喉镜片用于常规和困难气管插管

陈伟 陈杰

A New Curved Laryngoscope Blade for Routine and Difficult Tracheal Intubation (Technical Communication)
Koji Nishikawa, Koki Yamada, and Atsuhiro Sakamoto

Anesth Analg 2008 107: 1248-1252.

PATIENT SAFETY:

对于佩戴硬质颈托模拟插管困难的病人使用橡胶弹性探条引导置入ProSeal喉罩导气管优于手指法和辅助装置引导法

江继宏   马皓琳 李士通

Gum Elastic Bougie-Guided Insertion of the ProSeal Laryngeal Mask Airway Is Superior to the Digital and Introducer Tool Techniques in Patients with Simulated Difficult Laryngoscopy Using a Rigid Neck Collar

Stephan Eschertzhuber, Joseph Brimacombe, Matthias Hohlrieder, Karl-Heinz Stadlbauer, and Christian Keller

Anesth Analg 2008 107: 1253-1256.

减肥术后体重减轻患者肺吸入的风险

施颖译 薛张纲校

The Risk of Pulmonary Aspiration in Patients After Weight Loss Due to Bariatric Surgery (Brief Report)

Jerome Jean, Vincent Compère, Veronique Fourdrinier, Caroline Marguerite, Isabelle Auquit-Auckbur, Pierre Yves Milliez, and Bertrand Dureuil

Anesth Analg 2008 107: 1257-1259.

CRITICAL CARE AND TRAUMA:

非损伤肺行与不行呼气末正压机械通气时肺部细胞因子的反应

王鹏 陈杰

Pulmonary Cytokine Responses During Mechanical Ventilation of Noninjured Lungs With and Without End-Expiratory Pressure

Torsten Meier, Alexandra Lange, Hilke Papenberg, Malte Ziemann, Christina Fentrop, Ulrike Uhlig, Peter Schmucker, Stefan Uhlig, and Cordula Stamme

Anesth Analg 2008 107: 1265-1275.

大鼠肺损伤性机械通气时肾脏内内皮素-1的产生和肾脏血流的减少

吴进   马皓琳 李士通

Production of Endothelin-1 and Reduced Blood Flow in the Rat Kidney During Lung-Injurious Mechanical Ventilation

Jan Willem Kuiper, Amanda M. G. Versteilen, Hans W. M. Niessen, Rosanna R. Vaschetto, Pieter Sipkema, Cobi J. Heijnen, A. B. Johan Groeneveld, and Frans B. Plötz

Anesth Analg 2008 107: 1276-1283.

丙泊酚通过降低再灌注肝氧自由基的释放来减轻肺的动态顺应性的降低和肺水的含量。

舒慧刚 陈杰

Propofol Attenuates the Decrease of Dynamic Compliance and Water Content in the Lung by Decreasing Oxidative Radicals Released from the Reperfused Liver

Kuang-Cheng Chan, Chen-Jung Lin, Po-Huang Lee, Chau-Fong Chen, Yih-Loong Lai, Wei-Zen Sun, and Ya-Jung Cheng

Anesth Analg 2008 107: 1284-1289.

听觉诱发电位仪及毕氏脑波仪用于评价重症监护病人的镇静程度

孙鹏飞译 薛张纲校

Composite Auditory Evoked Potential Index Versus Bispectral Index to Estimate the Level of Sedation in Paralyzed Critically Ill Patients: A Prospective Observational Study

Chueng-He Lu, Kee-Ming Man, Hsin-Yi Ou-Yang, Shun-Ming Chan, Shung-Tai Ho, Chih-Shung Wong, and Wen-Jinn Liaw

Anesth Analg 2008 107: 1290-1294.

OBSTETRIC ANESTHESIOLOGY:

随机双盲比较去氧肾上腺素和麻黄碱联合输注用于剖宫产腰麻中维持血压:对胎儿酸碱情况和血流动力学控制的影响

黄佳佳译,马皓琳,李士通校

A Randomized Double-Blinded Comparison of Phenylephrine and Ephedrine Infusion Combinations to Maintain Blood Pressure During Spinal Anesthesia for Cesarean Delivery: The Effects on Fetal Acid-Base Status and Hemodynamic Control

Warwick D. Ngan Kee, Anna Lee, Kim S. Khaw, Floria F. Ng, Manoj K. Karmakar, and Tony Gin

Anesth Analg 2008 107: 1295-1302.

布比卡因和左旋布比卡因对于人离体妊娠子宫肌层收缩力抑制作用的对比

夏俊明译 薛张纲校

A Comparison of the Inhibitory Effects of Bupivacaine and Levobupivacaine on Isolated Human Pregnant Myometrium Contractility

Rebecca A. Fanning, Deirdre P. Campion, Colm B. Collins, Simon Keely, Liam P. Briggs, John J. O'Connor, and Michael F. Carey

Anesth Analg 2008 107: 1303-1307.

刺激内关穴(P6)预防椎管内麻醉下剖宫产手术恶心呕吐的发生:随机对照试验的系统回顾

丁俊云 陈杰

P6 Stimulation for the Prevention of Nausea and Vomiting Associated with Cesarean Delivery Under Neuraxial Anesthesia: A Systematic Review of Randomized Controlled Trials (Review Article)
Terrence K. Allen and Ashraf S. Habib

Anesth Analg 2008 107: 1308-1312.

术后严重疼痛的风险:临床预测量表的修正与验证

叶乐 陈杰

The Risk of Severe Postoperative Pain: Modification and Validation of a Clinical Prediction Rule

Kristel J. M. Janssen, Cor J. Kalkman, Diederick E. Grobbee, Gouke J. Bonsel, Karel G. M. Moons, and Yvonne Vergouwe

Anesth Analg 2008 107: 1330-1339.

NEUROSURGICAL ANESTHESIOLOGY:

右美托咪啶对开颅手术患者围手术期血流动力学的影响

黄施伟 译,马皓琳 李士通

The Effect of Dexmedetomidine on Perioperative Hemodynamics in Patients Undergoing Craniotomy

Alex Bekker, Mary Sturaitis, Marc Bloom, Mario Moric, John Golfinos, Erik Parker, Ramesh Babu, and Abishabeck Pitti

Anesth Analg 2008 107: 1340-1347.

为神经外科病人计划早期苏醒:一项使用小剂量麻醉剂的随机前瞻性研究

宣丽真译 薛张纲校

Planning for Early Emergence in Neurosurgical Patients: A Randomized Prospective Trial of Low-Dose Anesthetics

Hemant Bhagat, Hari H. Dash, Parmod K. Bithal, Rajendra S. Chouhan, and Mihir P. Pandia

Anesth Analg 2008 107: 1348-1355.

贫血与脑预后: 问题很多,答案很少

刘世文 陈杰

Anemia and Cerebral Outcomes: Many Questions, Fewer Answers (Review Article)

Gregory M. T. Hare, Albert K. Y. Tsui, Anya T. McLaren, Tenille E. Ragoonanan, Julie Yu, and C. David Mazer

Anesth Analg 2008 107: 1356-1370.

ANALGESIA:

病人自控镇痛时吗啡与氢吗啡酮的副作用

唐亮   马皓琳 李士通   

The Side Effects of Morphine and Hydromorphone Patient-Controlled Analgesia (Brief Report)

Daewha Hong, Pamela Flood, and Geraldine Diaz

Anesth Analg 2008 107: 1384-1389.

经皮脉冲射频可治疗神经性疼痛模型中的机械性异常疼痛

张磊 陈杰

Percutaneous Pulsed Radiofrequency Reduces Mechanical Allodynia in a Neuropathic Pain Model

Özgür Özsoylar, Didem Akçali, Pelin Çizmeci, Avni Babacan, Alex Cahana, and Hayrunnisa Bolay

Anesth Analg 2008 107: 1406-1411.

 

糖尿病心肌病中β-肾上腺素能受体兴奋产生的正性松弛效应的维持

Preservation of the Positive Lusitropic Effect of β-Adrenoceptors Stimulation in Diabetic Cardiomyopathy

Julien Amour, MD, PhD*, Xavier Loyer, PhD{dagger}, Pierre Michelet, MD, PhD{ddagger}, Aurélie Birenbaum, MD*, Bruno Riou, MD, PhD§, and Christophe Heymes, PhD{dagger}

From the *UMPC Univ Paris 06, EA 3975, Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire (CHU) Pitié-Salpêtrière, Paris, France; {dagger}INSERM U689, CHU Lariboisière, Université Denis Diderot - Paris 7, Paris, France; {ddagger}Service de Réanimation Chirurgicale, Hôpital Sainte-Maguerite, Université de la Méditerranée, Marseille, France; and §UMPC Univ Paris 06, EA 3975, Service d'Accueil des Urgences, Centre Hospitalier Universitaire (CHU) Pitié-Salpêtrière, Paris, France.

Anesth Analg 2008; 107:1130-1138

背景:在糖尿病心肌病变,舒张功能障碍部分是由于肌浆网功能异常所致,而肌浆网功能异常既影响受磷蛋白,又会影响肌浆网对钙离子的摄取(SERCA2a)。因此,正如以前证实的正性变力作用发生改变一样,这一病理改变可能会使β-肾上腺素能受体兴奋产生的正性松弛作用发生改变,β3-肾上腺素能受体的过度表达可能参与了这一作用。这项研究拟验证在糖尿病心肌病变β-肾上腺素能受体正性松弛效应是否发生改变,而β3-肾上腺素能受体的过度表达是否参与了这一机制。

方法:这项研究观察了静脉注射链脲霉素4周(4W)和12周(12WWang)后处死的健康和糖尿病大鼠在体(多巴酚丁胺-超声心动图)以及离体(制备乳头肌标本)的β-肾上腺素能反应。在离体大鼠,研究S-氰基吲哚洛尔(一种选择性β3-肾上腺素能受体拮抗剂)或NG-硝基-1-精氨酸-甲基-酯(非选择性一氧化氮合酶抑制剂)抑制β3-肾上腺素受体通路对异丙肾上腺素(非选择性β-肾上腺素能受体激动剂)松弛效应的影响。采用蛋白质印迹方法量化β1-肾上腺素能受体 β3-肾上腺素能受体、受磷蛋白和SERCA2a的蛋白表达。数据采用基础值的百分比均值±标准差表示。

结果:尽管受磷蛋白/SERCA2a蛋白比值增加,心肌舒张功能发生障碍,但与健康大鼠相比,在4W12W糖尿病大鼠在体(多巴酚丁胺)和离体(异丙肾上腺素)β-肾上腺素能受体兴奋的正性松弛效应并未受到影响。与健康大鼠相比,4W12W糖尿病大鼠β3-肾上腺素能受体表达上调,而β1-肾上腺素能受体表达下调。S-氰基吲哚洛尔和NG-硝基-1-精氨酸-甲基-酯并没有松弛效应。

结论:糖尿病心肌病中,β-肾上腺素能受体兴奋的正性松弛效应并未发生改变,而β3-肾上腺素能受体的过度表达也并不影响这一过程。

(邱郁薇 马皓琳 李士通 校)

BACKGROUND: In diabetic cardiomyopathy, diastolic dysfunction results in part from sarcoplasmic reticulum abnormalities affecting both phospholamban and sarcoplasmic reticulum Ca2+ uptake (SERCA2a). Consequently, the positive lusitropic effect of β-adrenoceptors stimulation could be altered, and β3-adrenoceptor over-expression may play a role, as previously demonstrated with an altered positive inotropic effect. In this study, we tested the hypothesis that the β-adrenergic positive lusitropic effect is altered in diabetic cardiomyopathy, and that β3-adrenoceptor over-expression is involved.

METHODS: β-adrenergic responses were investigated in vivo (dobutamine-echocardiography) and in vitro (papillary muscle preparation) in healthy and diabetic rats killed 4 (4W) and 12 (12W) wk after IV streptozotocin injection. The effect of β3-adrenoceptor pathway inhibition by S-cyanopindolol (selective β3-adrenoceptor antagonist) or by NG-nitro-l-arginine-methyl-ester (nonselective nitric oxide synthase inhibitor) on the lusitropic response to isoproterenol (nonselective β-adrenoceptors agonist) was studied in vitro. Western blots were performed to quantify the protein expressions of β1- and β3-adrenoceptors, phospholamban, and SERCA2a. Data are presented as mean percentages of baseline ± sd.

RESULTS: Despite the increased phospholamban/SERCA2a protein ratio and documented diastolic dysfunction, the positive lusitropic effect of β-adrenoceptors stimulation was preserved in vivo (dobutamine) and in vitro (isoproterenol) in 4W and 12W diabetic, compared with healthy, rats. The β3-adrenoceptor was up-regulated whereas β1-adrenoceptor was down-regulated in 4W and 12W diabetic, compared with healthy, rats. Nevertheless, S-cyanopindolol or NG-nitro-l-arginine-methyl-ester had no lusitropic effect.

CONCLUSIONS: The positive lusitropic effect of β-adrenoceptor stimulation was preserved in diabetic cardiomyopathy. β3-adrenoceptor over-expression does not seem to affect this process.



术中小剂量氯胺酮不能预防儿科脊柱侧弯手术后瑞芬太尼诱导的吗啡需要量的增加

Intraoperative Low-Dose Ketamine Does Not Prevent a Remifentanil-Induced Increase in Morphine Requirement After Pediatric Scoliosis Surgery

Thomas Engelhardt, MD, PhD, FRCA*, Christian Zaarour, MD*, Basem Naser, MBBS, FRCPC*, Carolyne Pehora, RN, MN*, Joost de Ruiter, MBBCh, FRCPC*, Andrew Howard, MD, FRCSC*, and Mark W. Crawford, MBBS, FRCPC*

From the *Department of Anesthesia, and the {dagger}Division of Orthopedic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Anesth Analg 2008; 107:1170-1175

背景:在儿科脊柱侧弯手术中,我们通常使用以瑞芬太尼为基础的麻醉,以易于神经生理学检测。由瑞芬太尼麻醉所导致的急性阿片类耐药和/或痛觉过敏可能牵涉到N-甲基-右旋天冬氨酸系统的激活。我们假设小剂量术中输注N-甲基-右旋天冬氨酸拮抗剂氯胺酮能抑制耐药性的发展,从而使接受瑞芬太尼麻醉行脊柱侧弯手术的儿童术后吗啡的用量减少。

方法:34名预定脊柱侧弯手术的12-18岁青少年在异丙酚/瑞芬太尼麻醉过程中随机地被指定为术中接受小剂量氯胺酮 (推注0.5 mg/kg 后连续输注4 µg · kg–1 · min–1) 或相等量的盐水。用病人自控镇痛来评估术后72小时累积吗啡消耗量。术后吗啡消耗量、静息和咳嗽时的疼痛指数和镇静指数由一名盲法研究者记录:前4小时每小时一次,之后的20小时每4小时一次,然后每12小时一次至72小时。

结果:术后244872小时的累积吗啡消耗量两组无显著性差异 (氯胺酮组:1.57 ± 0.563.05 ± 1.144.46 ± 1.53 mg/kg;盐水组:1.60 ± 0.532.87 ± 1.054.11 ± 1.71 mg/kg)。疼痛或镇静指数也没有差异。麻醉持续时间两组相似。

结论:这些数据不支持术中小剂量氯胺酮应用来防止儿科脊柱侧弯手术中瑞芬太尼诱导的急性阿片类耐药和/或痛觉过敏的发展。

(唐李隽    马皓琳  李士通  校)

BACKGROUND: Remifentanil-based anesthesia is commonly used to facilitate neurophysiologic monitoring during pediatric scoliosis surgery. Acute opioid tolerance and/or hyperalgesia resulting from remifentanil-based anesthesia may involve activation of N-methyl-d-aspartate systems. We hypothesized that low-dose intraoperative infusion of the N-methyl-d-aspartate antagonist ketamine would suppress the development of tolerance and thereby decrease postoperative morphine consumption in children receiving remifentanil-based anesthesia for scoliosis surgery.

METHODS: Thirty-four adolescents aged 12–18 yr scheduled for scoliosis surgery were randomly assigned to receive intraoperative low-dose ketamine (bolus dose of 0.5 mg/kg followed by continuous infusion of 4 µg · kg–1 · min–1) or an equal volume of saline during propofol/remifentanil anesthesia. Cumulative morphine consumption was assessed using a patient-controlled analgesia device for 72 h after surgery. Postoperative morphine consumption, pain scores at rest and during cough, and sedation scores were recorded by a blinded investigator every hour for the first 4 h, every 4 hours for 20 h, and then every 12 hours for 72 h.

RESULTS: Cumulative morphine consumption at 24, 48, and 72 h after surgery did not differ significantly between groups (ketamine group: 1.57 ± 0.56, 3.05 ± 1.14, and 4.46 ± 1.53 mg/kg; saline group: 1.60 ± 0.53, 2.87 ± 1.05, and 4.11 ± 1.71 mg/kg, respectively). No differences in pain or sedation scores were found. The duration of anesthesia was similar in the two groups.

CONCLUSIONS: These data do not support the use of intraoperative low-dose ketamine to prevent the development of remifentanil-induced acute opioid tolerance and/or hyperalgesia during pediatric scoliosis surgery.



恢复评分汉语翻译质量的心理测试

Psychometric Testing of the Chinese Quality of Recovery Score

Matthew T. V. Chan, MBBS, FANZCA*, Charlotte C. K. Lo, MBChB, BMedSc, FANZCA*, Candy K. W. Lok, MPH, MSc*, Tak Wing Chan, DPhil(Oxon){dagger}, Kai C. Choi, PhD{ddagger}, and Tony Gin, MD, FRCA, FANZCA*

From the *Department of Anaesthesia and Intensive Care, and {dagger}Centre for Epidemiology and Biostatistics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong; and {ddagger}Department of Scoiology, The University of Oxford, Oxford, UK.

Anesth Analg 2008; 107:1189-1195

背景:评价恢复质量(QoR)评分的汉语翻译用于评测术后和麻醉后患者健康状况。

方法:汉语QoR评分是由一些语言专家用一系列的承上启下翻译而发展来。在懂英语的行各种手术的中国患者中比较QoR评分中国和英语版本的心理测量学表现。在交叉设计下,210名患者在术后次晨间隔1小时依照两个序列之一随机先后完成两种QoR评分版本:先汉语版本然后英语版本,或者相反的顺序。通过比较6-8小时后的评分及比较患者和当值护士所作的评分来计算试验-再试验和测试者之间的可靠性。

结果:患者对汉语版本QoR评分的反应和英语版本非常一致(加权κ统计数值,{kappa}w = 0.92)。两种QoR评分都和患者满意度评分相关(汉语版本, {rho}= 0.82; 英语版本, {rho}= 0.79),从而可确定其一致的有效性。QoR评分与女性负相关。在住院期间或手术较大时,在QoR评分和女性、住院持续时间和手术大小之间有显著的负相关(判别式构想效度)。我们发现汉语版本QoR评分有很好的内在一致性(Cronbach’s {rho}= 0.91),观察者之间({kappa}w = 0.77)和试验可重复性({kappa}w = 0.83)。这些指标与原始英语版本中的都相似(Cronbach’s {rho}= 0.89,观察者之间{kappa}w = 0.84,试验可重复性 {kappa}w = 0.88)

结论:汉语版本的QoR评分在概念上、语义上和操作上都与英语版本相当。两种评分标准对手术和麻醉后的QoR都提供了有效、可靠和敏感的评估。

(朱慧   马皓琳 李士通 校)

BACKGROUND: We evaluated a Chinese translation of the quality of recovery (QoR) score for measuring health status in patients after surgery and anesthesia.

METHODS: The Chinese QoR score was developed by a panel of linguistic experts using a series of forward and backward translations. We then compared the psychometric performance of the Chinese QoR score with the original English version in bilingual Chinese patients undergoing a variety of surgeries. Using a crossover design, 210 patients were randomly assigned to complete both versions of the QoR score, 1 h apart, in the morning after surgery according to one of the two sequences: Chinese followed by the English QoR score or the reverse order. Test-retest and interrater reliabilities were calculated by comparing scores administered 6–8 h later and those completed by the patients and duty nurses, respectively.

RESULTS: Patient responses to the Chinese QoR score agreed well with the English version (weighted kappa statistic, {kappa}w = 0.92). Both QoR scores correlated with patient satisfaction scores (Chinese version, {rho}= 0.82; English version, {rho}= 0.79) confirming convergent validity. There was also significant negative correlation between the QoR scores and female gender, duration of hospital stay, or magnitude of surgery (discriminant construct validity). We found the Chinese QoR score has good internal consistency (Cronbach’s {rho}= 0.91), interobserver ({kappa}w = 0.77), and test-retest reliability ({kappa}w = 0.83). These values were similar to those of the original English version (Cronbach’s {rho}= 0.89, interobserver {kappa}w = 0.84, test-retest reliability {kappa}w = 0.88).

CONCLUSION: The Chinese QoR score is conceptually, semantically, and operationally equivalent to the English version. Both scales provide valid, reliable, and responsive assessment of the QoR after surgery and anesthesia.



阿米替林、加巴喷丁和卡马西平对吗啡诱发兔子高碳酸血症的影响

The Effect of Amitriptyline, Gabapentin, and Carbamazepine on Morphine-Induced Hypercarbia in Rabbits

Eran Kozer, MD*, Zina Levichek, MD*, Noriko Hoshino, MD*, Bhushan Kapur, PhD*{dagger}, John Leombruno, BScPharm{ddagger}, Nobuko Taguchi, MD*, Facundo Garcia-Bournissen, MD*, Gideon Koren, MD*, and Shinya Ito, MD*

From the *Division of Clinical Pharmacology and Toxicology, the Hospital for Sick Children; {dagger}Department of Clinical Pathology, Sunnybrook Health Sciences Centre; and {ddagger}Department of Pharmacy, the Hospital for Sick Children, Toronto, Ontario, Canada.

Anesth Analg 2008; 107:1216-1222

背景:在已经使用三环抗抑郁药、卡马西平和加巴喷丁治疗的患者中,严重加剧的慢性神经性疼痛常常需要吗啡镇痛。然而,联合使用这些药物是否加剧吗啡对呼吸系统的抑制并不清楚,如果如此的话,是否这些效应是由于药物代谢动力学或药效学相互作用的结果。

方法:我们给兔子(每组n=6)连续4天下列药物:皮下注射生理盐水1ml(对照组);皮下注射阿米替林7mg/kg;口服卡马西平100mg/kg;皮下注射加巴喷丁25mg/kg;以及三种药物同时给予(联合)。在给药后第五天,吗啡5mg/kg静脉注射后检测Paco2Pao2PH值。吗啡注射后4小时里连续监测血浆吗啡、吗啡3-葡糖苷酸和吗啡6-葡糖苷酸浓度。

结果:阿米替林组在吗啡注射前Paco2基线显著高于对照组(P<0.05)。吗啡注射后,阿米替林组和联合用药组在240min里的所有时间点及加巴喷丁组10min30minPaco2显著较高(P <0.05)。阿米替林组(58.4±1.6mmHgP < 0.005)和联合用药组 (57.4 ± 1.0 mm Hg, P < 0.02)Paco2峰值显著高于对照组(50.2 ± 5.2 mm Hg)。同样,阿米替林组和联合用药组0-240minPco2曲线下面积显著高于对照组(P < 0.001)。各组间血浆吗啡及吗啡代谢产物没有显著差异。

结论:我们得到如下结论:阿米替林预处理通过药效学过程加重吗啡诱发的高碳酸血症。在此模型中,卡马西平和加巴喷丁的作用不明显。

(王宏   马皓琳 李士通 校)

BACKGROUND: Severe exacerbation of chronic neuropathic pain often requires morphine in patients already treated with drugs such as tricyclic antidepressants, carbamazepine and gabapentin. However, it is unclear if a combination of these drugs intensifies the effects of morphine on the respiratory system and, if so, whether these effects are due to pharmacokinetic or pharmacodynamic interaction.

METHODS: We gave rabbits (n = 6 per group) the following drugs daily for 4 days: subcutaneous normal saline 1 mL (control); amitriptyline subcutaneously 7 mg/kg; carbamazepine orally 100 mg/kg; gabapentin subcutaneously 25 mg/kg; and all three drugs concurrently (combination). On the fifth day, morphine 5 mg/kg was given IV, and Paco2, Pao2 and pH were measured. Morphine, morphine 3-glucoronide and morphine 6-glucoronide concentrations were measured in the plasma over the 4 h period after morphine injection.

RESULTS: Compared with controls, premorphine baseline Paco2 was significantly higher (P < 0.05) in the amitriptyline group. Postmorphine Paco2 was significantly higher in the amitriptyline and combination groups at all time points over the 240 min, and in the gabapentin group at 10 and 30 min after morphine injection (P < 0.05). Peak Paco2 was significantly higher in the amitriptyline group (58.4 ± 1.6 mm Hg; mean SD, P < 0.005) and in the combination group (57.4 ± 1.0 mm Hg, P < 0.02) than in the control group (50.2 ± 5.2 mm Hg). Similarly, the area under the curve of Paco2 from zero to 240 min was significantly higher in the amitriptyline and combination groups than in the control (P < 0.001). There were no significant differences among the groups in plasma concentrations of morphine and its metabolites.

CONCLUSIONS: We conclude that pretreatment with amitriptyline increases morphine- induced hypercarbia through pharmacodynamic processes. The effects of carbamazepine or gabapentin were not obvious in this model.



在已确定的重建突触中研究利多卡因对胆碱能神经传递的影响

The Effect of Lidocaine on Cholinergic Neurotransmission in an Identified Reconstructed Synapse

Shin Onizuka, MD, Toshiharu Kasaba, MDC, and Mayumi Takasaki, MD

From the Department of Anesthesiology, Miyazaki Medical College, University of Miyazaki, Kiyotake-Cho, Miyazaki, Japan.

Anesth Analg 2008; 107:1236-1242

背景:利多卡因对胆碱能突触传递的突触前影响还不是很清楚,因为对突触前神经元的鉴别很困难,而且活体的中枢神经系统也很复杂。为了阐明利多卡因对胆碱能突触的影响,我们从椎实螺属stagnalis的蜗牛离体重建了含两种已被鉴定的内脏背4VD4)和左足e-1LPeD1)神经元的培养体细胞-体细胞化学突触模型,来研究利多卡因如何影响胆碱能突触传递。

方法:我们记录了VD4LPeD1神经元组成的化学突触传递模型中神经元对乙酰胆碱的反应和兴奋性突触后电位的增幅。在突触前的VD4和突触后的LPeD1神经元中的电压钳下制成用于测乙酰胆碱的电流。

结果:利多卡因同时抑制了兴奋性突触后电位和突触后神经元对乙酰胆碱的反应。突触前神经元中的兴奋性突触后电位呈电压依赖性地减弱,而且利多卡因引起了兴奋性突触后电位幅度电压依赖性失活曲线的超极化移位。

结论:利多卡因通过突触前神经元的膜电位去极化引起兴奋性突触后电位幅度的电压依赖性失活,并抑制胆碱能突触传递。

(姜旭晖译,马皓琳,李士通校)

BACKGROUND: The presynaptic effect of lidocaine on cholinergic synaptic transmission is unclear because of the difficulty in identifying presynaptic neurons and the complexity of the central nervous system in vivo. To clarify the effect of lidocaine on cholinergic synapse, we reconstructed a cultured soma–soma chemical synapse model consisting of two identified visceral dorsal 4 (VD4) and left pedal e-1 (LPeD1) neurons from the snail, Lymnaea stagnalis, in vitro, and used it to determine how lidocaine affects cholinergic synaptic transmission.

METHODS: The response to acetylcholine and excitatory postsynaptic potential (EPSP) amplitude was recorded in the reconstructed chemical synaptic transmission model composed of VD4 and LPeD1 neurons. The currents for acetylcholine measurements were made under voltage-clamp in the presynaptic VD4 and postsynaptic LPeD1 neurons.

RESULTS: Lidocaine inhibited both EPSP and the response for acetylcholine of the postsynaptic neuron. EPSP amplitude was reduced in a voltage-dependent manner in the presynaptic neuron, and lidocaine induced a hyperpolarization shift of the voltage-dependent inactivation curves of EPSP amplitude.

CONCLUSIONS: Lidocaine inhibits cholinergic synaptic transmission with a voltage-dependent inactivation of EPSP amplitude through the membrane potential depolarization of presynaptic neurons.


对于佩戴硬质颈托模拟插管困难的病人使用橡胶弹性探条引导置入ProSeal喉罩导气管优于手指法和辅助装置引导法

Gum Elastic Bougie-Guided Insertion of the ProSeal Laryngeal Mask Airway Is Superior to the Digital and Introducer Tool Techniques in Patients with Simulated Difficult Laryngoscopy Using a Rigid Neck Collar

Stephan Eschertzhuber, MD*, Joseph Brimacombe, MD{dagger}, Matthias Hohlrieder, MD*, Karl-Heinz Stadlbauer, MD*, and Christian Keller, MD, MSc*{ddagger}

From the *Department of Anaesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria; {dagger}Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns, Australia; and {ddagger}Department of Anaesthesia, SchulthessKlinik, Lengghalde 2, Zürich, Switzerland.

Anesth Analg 2008; 107:1253-1256

背景:我们在佩戴硬质颈托的模拟困难气管插管的病人中比较了喉罩导气管ProSealPLMA)的三种置入方法。

方法:19-68岁健康女性99, 麻醉后随机采用手指法、辅助工具法或引导法置入PLMA。困难气管插管采用佩戴硬质颈托模拟。PLMA置入前进行喉罩视野评级。手指法和辅助工具法置入喉按照厂家说明实施。引导法按以下步骤: 把引流管插入Eschmann气管导管插管器内, 明视下把插管器插入食道, 顺着插管器插入PLMA到位。置入失败标准为: 1) 咽部放置失败, 2) 位置不正, 3) 无效通气。

结果:喉镜视野评级中位数为3;置入平均距离为距门齿3.3cm。第一次试插时,引导法的成功率较高(引导法100%,手指法64%,辅助工具法61%; P < 0.0001),但三次试插后的成功率相似(引导法100%,手指法94%,辅助工具法91%)。各组间第一次试插时成功插入所需时间相似,但是三次试插后引导法所需时间较短(引导法31±8 s, 手指法49±28 s, 辅助工具法54±37 s; P < 0.02)

结论:对于用硬质颈托模拟的困难气管插管病人,采用橡胶弹性探条引导法置入PLMA的成功率高于手指法和辅助工具法。

(江继宏   马皓琳 李士通 校)

BACKGROUND: We compared three techniques for insertion of the laryngeal mask airway ProSealTM (PLMA) in patients with simulated difficult laryngoscopy using a rigid neck collar.

METHODS: Ninety-nine anesthetized healthy female patients aged 19–68 yr were randomly allocated for PLMA insertion using the digital, introducer tool (IT) or guided techniques. Difficult laryngoscopy was simulated using a rigid neck collar. The laryngoscopic view was graded before PLMA insertion. The digital and IT techniques were performed according to the manufacturer’s instructions. The guided technique involved priming the drain tube with an Eschmann tracheal tube introducer, placing the introducer in the esophagus under direct vision and railroading the PLMA into position. Failed insertion was defined by any of the following criteria: 1) failed pharyngeal placement, 2) malposition, and 3) ineffective ventilation.

RESULTS: The median laryngoscopic view was 3 and the mean interincisor distance was 3.3 cm. Insertion was more frequently successful with the guided technique at the first attempt (guided 100%, digital 64%, IT 61%; P < 0.0001), but success after three attempts was similar (guided 100%, digital 94%, IT 91%). The time taken for successful placement was similar among groups at the first attempt, but was shorter for the guided technique after three attempts (guided 31 ± 8 s, digital 49 ± 28 s, IT 54 ± 37 s; P < 0.02).

CONCLUSION: The guided insertion technique is more frequently successful than the digital or IT techniques in patients with simulated difficult laryngoscopy using a rigid neck collar.



大鼠肺损伤性机械通气时肾脏内内皮素-1的产生和肾脏血流的减少

Production of Endothelin-1 and Reduced Blood Flow in the Rat Kidney During Lung-Injurious Mechanical Ventilation

Jan Willem Kuiper, MD*, Amanda M. G. Versteilen, MSc{dagger}, Hans W. M. Niessen, MD, PhD{ddagger}§, Rosanna R. Vaschetto, MD*, Pieter Sipkema, PhD{dagger}§, Cobi J. Heijnen, PhD||, A. B. Johan Groeneveld, MD, PhD, FCCP, FCCM||¶, and Frans B. Plötz, MD, PhD*§

From the Departments of *Pediatric Intensive Care, {dagger}Physiology, {ddagger}Pathology, and the §Institute for Cardiovascular Research (ICaR-VU), VU Medical Center, Amsterdam, The Netherlands; ||Lab for Psychoneuroimmunology, University Medical Center Utrecht, Utrecht, The Netherlands; and ¶Department of Intensive Care, VU Medical Center, Amsterdam, The Netherlands.

Anesth Analg 2008; 107:1276-1283

背景机械通气可导致远距离器官比如肾脏的损伤,其机制还不是很清楚。我们假设肺损伤性机械通气所引发的全身炎症反应的上调最终导致了肾脏的功能障碍,这种全身炎症反应可以由血浆白介素-6(IL6)的水平反映,肾脏功能障碍由局部的内皮素-1(ET-1)和肾脏血管收缩介导。

方法:健康的雄性Wistar大鼠随机分为两组机械通气(每组n=9),通气4小时。其中一组采取肺保护性通气,设置吸气压峰值为14cm H2O,呼气末正压值为5cm H2O;另一组采取肺损伤性通气,设置吸气压峰值为20cm H2O,呼气末正压值为2cm H2O。随机取9只大鼠作为非通气的对照组。我们测定动静脉血压和心排血量(热稀释法),使用荧光微球体测定肾脏血流(RBF),计算出肌酐清除率、尿流以及钠排泄分数。用苏木精伊红染色来评价肺的组织学损伤。用酶联免疫吸附分析来测定肾脏内ET-1以及血浆中ET-1IL6的浓度。

结果:肺损伤性通气后的肺损伤评分比肺保护性通气后或者非通气的肺损伤评分要高。与肺保护性通气和对照组相比,肺损伤性通气导致了肾脏内ET-1的显著产生。同时,肺损伤性通气组中的RBF与对照组和肺保护性通气组相比分别有大约40%28%的减少(P < 0.05)。各组血浆中ET-1IL-6的水平没有不同,而全身的血流动力学,比如心排血量也没有差别。损伤性机械通气对肌酐清除率、钠排泄分数、尿排出量或者肾脏的组织学没有影响。

结论:健康大鼠损伤性机械通气4小时可导致其肾脏内ET-1的显著产生和RBF的减少,这种变化独立于IL-6。减少的RBF对肾脏的功能和组织学没有可观测到的影响。

(吴进   马皓琳 李士通 校)

INTRODUCTION: The mechanisms by which mechanical ventilation (MV) can injure remote organs, such as the kidney, remain poorly understood. We hypothesized that upregulation of systemic inflammation, as reflected by plasma interleukin-6 (IL-6) levels, in response to a lung-injurious ventilatory strategy, ultimately results in kidney dysfunction mediated by local endothelin-1 (ET-1) production and renal vasoconstriction.

METHODS: Healthy, male Wistar rats were randomized to 1 of 2 MV settings (n = 9 per group) and ventilated for 4 h. One group had a lung-protective setting using peak inspiratory pressure of 14 cm H2O and a positive end-expiratory pressure of 5 cm H2O; the other had a lung-injurious strategy using a peak inspiratory pressure of 20 cm H2O and positive end-expiratory pressure of 2 cm H2O. Nine randomly assigned rats served as nonventilated controls. We measured venous and arterial blood pressure and cardiac output (thermodilution method), renal blood flow (RBF) using fluorescent microspheres, and calculated creatinine clearance, urine flow, and fractional sodium excretion. Histological lung damage was assessed using hematoxylin-eosin staining. Renal ET-1 and plasma ET-1 and IL-6 concentrations were measured using enzyme-linked immunosorbent assays.

RESULTS: Lung injury scores were higher after lung-injurious MV than after lung-protective ventilation or in sham controls. Lung-injurious MV resulted in significant production of renal ET-1 compared with the lung-protective and control groups. Simultaneously, RBF in the lung-injurious MV group was approximately 40% lower (P < 0.05) than in the control group and 28% lower (P < 0.05) than in the lung-protective group. Plasma ET-1 and IL-6 levels did not differ among the groups and systemic hemodynamics, such as cardiac output, were comparable. There was no effect on creatinine clearance, fractional sodium excretion, urine output, or kidney histology.

CONCLUSIONS: Lung-injurious MV for 4 h in healthy rats results in significant production of renal ET-1 and in decreased RBF, independent of IL-6. Decreased RBF has no observable effect on kidney function or histology.



随机双盲比较去氧肾上腺素和麻黄碱联合输注用于剖宫产腰麻中维持血压:对胎儿酸碱情况和血流动力学控制的影响

A Randomized Double-Blinded Comparison of Phenylephrine and Ephedrine Infusion Combinations to Maintain Blood Pressure During Spinal Anesthesia for Cesarean Delivery: The Effects on Fetal Acid-Base Status and Hemodynamic Control

Warwick D. Ngan Kee, MBChB, MD, FANZCA, Anna Lee, MPH, PhD, Kim S. Khaw, MBBS, FRCA, Floria F. Ng, RN, BASc, Manoj K. Karmakar, MBBS, FRCA, and Tony Gin, MBChB, MD, FRCA, FANZCA

From the Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.

Anesth Analg 2008; 107:1295-1302

背景:去氧肾上腺素和麻黄碱均可用于剖宫产腰麻中维持动脉血压。一般来说,两种药物都是单独应用,但是以前也曾有几项研究描述过两者合用的情况。然而,改变两种血管升压药在混合物中的比例对效果的影响尚未有报道。

方法:125位择期腰麻剖宫产妇随机分成五组,通过静脉持续输注不同浓度比例的去氧肾上腺素和麻黄碱混合物。假设100ug去氧肾上腺素约相当于8mg麻黄碱,那么五组混合物中就分别含有去氧肾上腺素等效剂量100%75%50%25%0%及麻黄碱0%25%50%75%100%。在切开子宫前调整输注速度使收缩压维持在接近基础水平。比较血流动力学变化和脐带血的血气分析结果。

结果:随着去氧肾上腺素的比例下降及麻黄碱比例增加,可以观察到以下几个明显的趋势:低血压和恶心/呕吐的发生率增加,收缩压高于或低于基础值的差异量中位数及收缩压高于基础值的偏倚增大,产妇心率增快,胎儿PH和碱剩余下降,脐动脉血氧含量下降,脐静脉血氧分压增加。

结论:去氧肾上腺素和麻黄碱混合物持续静脉输注用于维持剖宫产腰麻过程中动脉血压时,随着去氧肾上腺素比例减少及麻黄碱比例增加,血流动力学可控性下降,胎儿的酸碱状况也不甚理想。去氧肾上腺素和麻黄碱混合物持续静脉输注用于剖宫产腰麻避免低血压,与单纯去氧肾上腺素比较似乎没有优势。

(黄佳佳译,马皓琳,李士通校)

BACKGROUND: Phenylephrine and ephedrine are both used to maintain arterial blood pressure during spinal anesthesia for cesarean delivery. Usually, either drug is given alone but several previous studies have described combining the drugs. However, the effect of varying the proportion of vasopressors in such combinations has not been reported.

METHODS: One-hundred-twenty-five parturients having spinal anesthesia for elective cesarean delivery were randomized to receive an IV infusion of phenylephrine and ephedrine combined in one of five different concentration ratios. Assuming phenylephrine 100 µg to be approximately equipotent to ephedrine 8 mg, the groups contained the proportional potency equivalent of 100%, 75%, 50%, 25% or 0% of phenylephrine and 0%, 25%, 50%, 75% or 100%, respectively, of ephedrine. The infusions were adjusted to maintain systolic blood pressure (SBP) near baseline until uterine incision. Hemodynamic changes and umbilical cord blood gases were compared.

RESULTS: As the proportion of phenylephrine decreased and proportion of ephedrine increased among the groups, the following significant trends were detected: the incidences of hypotension and nausea/vomiting increased, the median magnitude of deviations of SBP above or below baseline and the bias for SBP to be above baseline increased, maternal heart rate was faster, fetal pH and base excess decreased, umbilical arterial oxygen content decreased and umbilical venous Po2 increased.

CONCLUSIONS: When varying combinations of phenylephrine and ephedrine were given by infusion to maintain arterial blood pressure during spinal anesthesia for cesarean delivery, as the proportion of phenylephrine decreased and the proportion of ephedrine increased, hemodynamic control was reduced and fetal acid-base status was less favorable. Combinations of phenylephrine and ephedrine appear to have no advantage compared with phenylephrine alone when administered by infusion for the prevention of hypotension associated with spinal anesthesia for cesarean delivery.



右美托咪啶对开颅手术患者围手术期血流动力学的影响

The Effect of Dexmedetomidine on Perioperative Hemodynamics in Patients Undergoing Craniotomy

Alex Bekker, MD, PhD*, Mary Sturaitis, MD{dagger}, Marc Bloom, MD, PhD*, Mario Moric, MS{dagger}, John Golfinos, MD{ddagger}, Erik Parker, MD{ddagger}, Ramesh Babu, MD{ddagger}, and Abishabeck Pitti, MD*

From the *Department of Anesthesiology, New York University Medical Center, New York, New York; {dagger}Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois; and {ddagger}Department of Neurosurgery, New York University Medical Center, New York, New York.

Anesth Analg 2008; 107:1340-1347

背景:行颅内手术的患者在围手术期常并发高血压发作。{alpha}-2肾上腺能激动剂右美托咪啶(DEX)因其交感阻滞和镇痛特性可改善手术关键时刻的血流动力学稳定,而在神经外科麻醉中得到广泛使用。我们设计此研究来评估DEX对行颅内手术病人控制高血压反应的有效性。

方法:择期行开颅手术的患者被随机分为接受七氟烷—阿片类或七氟烷—阿片类—DEX麻醉两组。使用双频指数使两组病人维持于相似的催眠水平(4050)。病人由不知分组情况的麻醉医生管理,阿片类药、七氟烷和血管活性药物以常规方式调整以维持收缩压(SBP)于90120mmHg、心率(HR5090bpm之间。持续记录血流动力学参数并贮存在计算机内以备分析。麻醉技术控制SBPHR的有效性与目标范围以外的曲线下面积(AUC)呈反比。对SBP-时间(AUCsbp mmHg*min/h)和HR—时间(bpm*min/h)曲线中高于和低于目标范围的曲线下面积进行比较。用变异系数来评估血流动力学的稳定性。

结果:共有72例病人参加本次研究。其中14例的资料搜集有技术问题,故只有56例计算机内贮存资料被用于分析。DEX组中患者的高于目标范围的AUCsbp明显较低(p0.044)。SBPHR的变异系数在两组间没有差别。DEX组中需要降压药处理的病人比例明显较小(12/28, 42%24/28, 86%, P = 0.0008)。手术中DEX组中需要的阿片类药量较少,但七氟烷的用量无差别。在麻醉后监护室,DEX组病人高血压的发作较少(1.25 ± 1.552.50 ± 2.00, P = 0.0114)且出监护室较早(91 ± 17 vs 130 ± 27 min, P < 0.0001)。术后阿片类药和止吐药的用量无差别。

结论:通过使用评估麻醉药总体血流动力学稳定性的指标,我们判定术中输注DEX对缓和围术期SBP升高是有效的。DEX的使用不增加低血压或心动过缓等常见副作用的发生率。

(黄施伟 译,马皓琳 李士通 校)

BACKGROUND: The perioperative course of patients undergoing intracranial surgery is frequently complicated by hypertensive episodes. Dexmedetomidine (DEX), an {alpha}-2 adrenoreceptor agonist, is gaining popularity in neuroanesthesia, because its sympatholytic and antinociceptive properties may improve hemodynamic stability at critical moments of surgery. We designed this study to assess the efficacy of DEX in controlling hypertensive responses in patients undergoing intracranial surgery.

METHODS: Patients scheduled for elective craniotomy were randomly assigned to receive either sevoflurane–opioid or sevoflurane–opioid–DEX anesthesia. Bispectral index was used to maintain a similar level of hypnosis in both groups (40–50). Opioids, sevoflurane, and vasoactive medications were titrated in a routine manner, at the discretion of the blinded anesthesiologist managing the case, to maintain systolic blood pressure (SBP) targeted within 90–130 mm Hg and heart rate (HR) between 50 and 90 bpm. Hemodynamic variables were continuously recorded and stored on a computer for analysis. Efficacy of the anesthetic technique in controlling SBP or HR is inversely proportional to the area under the curve (AUC) outside the targeted range. Areas under the curves above and below targeted ranges for SBP-time (AUCsbp mm Hg * min/h) and HR-time (bpm * min/h) were compared. Coefficient of variation was used to assess hemodynamic stability.

RESULTS: Seventy-two patients were recruited for the study. Computerized records of 56 patients only were analyzed because of technical problems with data collection in 14 cases. AUCsbp for above the targeted range was significantly lower for patients in the DEX group (P = 0.044). The coefficient of variation for SBP or HR did not differ between groups. A significantly smaller proportion of patients in the DEX group required treatment with antihypertensive medications (12 of 28, 42% vs 24 of 28, 86%, P = 0.0008). The DEX group required fewer opioids in the intraoperative period, but there were no differences in the use of sevoflurane. In the postanesthesia care unit, patients in the DEX group had fewer hypertensive episodes (1.25 ± 1.55 vs 2.50 ± 2.00, P = 0.0114) and were discharged earlier (91 ± 17 vs 130 ± 27 min, P < 0.0001). There were no differences in the requirement for postoperative opioids or antiemetics.

CONCLUSIONS: By using indices, which assess a global hemodynamic stability of the anesthetic, we determined that intraoperative DEX infusion was effective for blunting the increases in SBP perioperatively. The use of DEX did not increase the incidence of hypotension or bradycardia, common side effects of the drug.




病人自控镇痛时吗啡与氢吗啡酮的副作用

The Side Effects of Morphine and Hydromorphone Patient-Controlled Analgesia

Daewha Hong, MS, Pamela Flood, MD, and Geraldine Diaz, MD

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

Anesth Analg 2008; 107:1384-1389

背景:尽管保健医疗提供者们的“临床知识”认为氢吗啡酮可以改善疼痛的控制并且副作用小,但是吗啡还是作为病人术后自控镇痛的第一线药物。在这个研究中,我们比较在产生相同药物效应的药物浓度时,吗啡与氢化吗啡的效能和副作用特性。药物的效应通过疼痛评分和瞳孔缩小来确定。

方法:我们对50例普外科和妇产科手术患者进行前瞻性、随机、双盲的研究。受试者术后8小时里随机接受吗啡(1 mg/mL)或者氢吗啡酮(0.2 mg/mL)来进行自控镇痛。主要的结果是恶心。次要的结果参数有瘙痒、呕吐、镇静作用、疼痛报告、瞳孔缩小及患者满意度。

结果:两种药物的副作用没有差异。两者的恶心(1 h: 44%52%, 8 h: 68% 64%)、呕吐(1 h: 4%0%, 8 h: 0%4%)及瘙痒(1 h: 4%16%, 8 h: 40%40%)的发生率没有差异。在处理副作用所需药物用量和病人满意度上没有差异。

    吗啡与氢吗啡酮使用上的平均比率711小时后患者用了吗啡10.9 ± 6.0 mg,氢吗啡酮1.57 ± 1.0 mg8小时后吗啡29.0 ± 18.0 mg,氢吗啡酮3.9 ± 2.5 mg。术后1小时(7.9 ± 2.3 vs 7.1 ± 2.4)8小时(5.7 ± 2.8 vs 5.9 ± 2.7)病人活动时的疼痛评分,两组之间没有差异。静息疼痛和瞳孔缩小方面,组间亦无差异。

结论:我们发现吗啡与氢吗啡酮间阿片类相关的副作用没有显著性差异。当患者自控使通过等同镇痛和瞳孔缩小测定的药效等同时,在疼痛控制的有效性及病人满意度方面没有差异。在选择病人自控镇痛的药物是吗啡还是氢吗啡酮时,应该根据病人的病史,看看是否对哪种药有特异的反应。

(唐亮   马皓琳 李士通 校)      

BACKGROUND: Despite "clinical lore" among health care providers that treatment with hydromorphone results in improved pain control and fewer adverse side effects, morphine continues to be the first-line medication for postoperative patient-controlled analgesia (PCA). In this study, we compared the efficacy and side-effect profiles of morphine and hydromorphone at concentrations producing equivalent drug effect measured by pain score and miosis.

METHODS: We conducted a prospective, randomized, double-blind trial of 50 general and gynecological surgery patients. Subjects were randomly assigned to receive either morphine (1 mg/mL) or hydromorphone (0.2 mg/mL) via PCA after surgery and were followed for a period of 8 h. The primary outcome was nausea. Secondary outcome variables were pruritus, vomiting, sedation, pain report, pupillary miosis, and patient satisfaction.

RESULTS: The side effect profile was not different between drugs. The incidence of nausea did not differ between morphine and hydromorphone-treated patients (1 h: 44% vs 52%, 8 h: 68% vs 64%), vomiting (1 h: 4% vs 0%, 8 h: 0% vs 4%), or pruritus (1 h: 4% vs 16%, 8 h: 40% vs 40%). There was no difference in the amount of medication required to treat side effects or patient satisfaction.

The average ratio of morphine to hydromorphone use was about 7:1. The patients used 10.9 ± 6.0 mg morphine versus 1.57 ± 1.0 mg hydromorphone after 1 h and 29.0 ± 18.0 mg morphine versus 3.9 ± 2.5 mg hydromorphone after 8 h. There was no difference between the morphine and hydromorphone groups with respect to postoperative pain scores with movement at 1 h (7.9 ± 2.3 vs 7.1 ± 2.4) or 8 h (5.7 ± 2.8 vs 5.9 ± 2.7). There was also no difference in pain at rest or miosis between groups.

CONCLUSIONS: We found no systematic difference between morphine and hydromorphone in opioid-related side effects. Neither was there any difference in efficacy of pain control or patient satisfaction when patients self-titrated to equal drug effect as measured by equianalgesia and pupillary miosis. The choice between morphine and hydromorphone for use in PCA should be guided by patient history, as there may be idiosyncratic reactions to either drug.

 

围术期氯维地平治疗高血压安全性评价实验:心外科手术病人急性高血压治疗中,氯维地平与硝酸甘油,硝普钠,尼卡地平的对照实验

The ECLIPSE trials: comparative studies of clevidipine to nitroglycerin, sodium nitroprusside, and nicardipine for acute hypertension treatment in cardiac surgery patients.

Solomon Aronson, MD, FACC, FCCP, FAHA, FASE*, Cornelius M. Dyke, MD{dagger}, Kevin A. Stierer, MD{ddagger}, Jerrold H. Levy, MD§, Albert T. Cheung, MD||, Philip D. Lumb, MB, BS, FCCM, Dean J. Kereiakes, MD#, and Mark F. Newman, MD*.

From the *Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; {dagger}Gaston Memorial Hospital, Gastonia, North Carolina; {ddagger}The Heart Institute at St. Joseph Medical Center, Towson, Maryland; §Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia; ||Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania; ¶Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, California; and #The Christ Hospital Heart and Vascular Center/The Lindner Research Center, Cincinnati, Ohio.

Anesth Analg. 2008 107(4):1110-21

 

背景:心脏手术期间的急性高血压很难处理,可能引起很多副作用。氯维地平是一种新型的超短效的二氢吡啶L型钙离子通道拮抗剂类降血压药。围术期氯维地平治疗高血压安全性评价实验(ECLIPSE)是来比较氯维地平(CLV)和硝酸甘油(NTG),硝普钠(SNP),尼卡地平(NIC)在治疗心脏手术中急性高血压时的安全性及有效性。

方法:我们分析三个前瞻性的随机的标签公开的平行对照研究的数据:在61个医学中心心脏手术围术期使用氯维地平和使用硝酸甘油或者硝普钠或者术后使用尼卡地平的1964例患者中,1512例符合随机化后满足临床需要急性治疗的高血压的标准。患者以11随机分配到3个平行对照的治疗组中。基本的指标是30天内死亡,心肌梗死,卒中或者肾功能不全的发生率。评价适当且精确的血压控制被作为次要的指标。

结果:在心肌梗死,卒中,肾功能不全的危险性比较上,氯维地平与其他治疗组无显著差异。氯维地平,硝酸甘油,尼卡地平治疗组在病死率上也无显著差异。硝普钠治疗组的死亡率显著增高(P=0.04)。氯维地平在保持血压于预先设定的范围内比硝酸甘油(P=0.0006)和硝普钠(P=0.003)更有效;然而当血压范围缩窄时,与尼卡地平相比,氯维地平的血压超过血压界限的偏差小于尼卡地平。

结论:氯维地平在治疗心脏手术急性高血压患者时是安全、有效的。

(胡艳译   薛张刚校)

BACKGROUND: Acute hypertension during cardiac surgery can be difficult to manage and may adversely affect patient outcomes. Clevidipine is a novel, rapidly acting dihydropyridine L-type calcium channel blocker with an ultrashort half-life that decreases arterial blood pressure (BP). The Evaluation of CLevidipine In the Perioperative Treatment of Hypertension Assessing Safety Events trial (ECLIPSE) was performed to compare the safety and efficacy of clevidipine (CLV) with nitroglycerin (NTG), sodium nitroprusside (SNP), and nicardipine (NIC) in the treatment of perioperative acute hypertension in patients undergoing cardiac surgery.

 METHODS: We analyzed data from three prospective, randomized, open-label, parallel comparison studies of CLV to NTG or SNP perioperatively, or NIC postoperatively in patients undergoing cardiac surgery at 61 medical centers. Of the 1964 patients enrolled, 1512 met postrandomization inclusion criteria of requiring acute treatment of hypertension based on clinical criteria. The patients were randomized 1:1 for each of the three parallel comparator treatment groups. The primary outcome was the incidence of death, myocardial infarction, stroke or renal dysfunction at 30 days. Adequacy and precision of BP control was evaluated and is reported as a secondary outcome.

RESULTS: There was no difference in the incidence of myocardial infarction, stroke or renal dysfunction for CLV-treated patients compared with the other treatment groups. There was no difference in mortality rates between the CLV, NTG or NIC groups. Mortality was significantly higher, though, for SNP-treated patients compared with CLV-treated patients (P=0.04). CLV was more effective compared with NTG (P=0.0006) or SNP (P=0.003) in maintaining BP within the prespecified BP range. CLV was equivalent to NIC in keeping patients within a prespecified BP range; however, when BP range was narrowed, CLV was associated with fewer BP excursions beyond these BP limits compared with NIC.

CONCLUSIONS: CLV is a safe and effective treatment for acute hypertension in patients undergoing cardiac surgery.

 

 

依托咪酯对缺氧后再氧合和低氧预处理的离体人右房心肌没有影响

Etomidate Has No Effect on Hypoxia Reoxygenation and Hypoxic Preconditioning in Isolated Human Right Atrial Myocardium.

Jean-Luc Hanouz, MD, PhD*, Sandrine Lemoine, PhD{dagger}, Lan Zhu, MD{dagger}, Olivier Lepage, MD{ddagger}, Gerard Babatasi, MD, PhD{ddagger}, Massimo Massetti, MD, PhD{ddagger}, André Khayat, MD{ddagger}, Benoit Plaud, MD, PhD*, and Jean-Louis Gérard, MD, PhD*

From the *Department of Anesthesiology, {dagger}Laboratory of Experimental Anesthesiology and Cellular Physiology, {ddagger}Department of Cardiac and Thoracic Surgery, CHU Caen, Caen Cedex, France

Anesth Analg 2008 107: 1139-1144.

 

背景:本试验在体外研究了依托咪酯对缺氧后再氧合和低氧预处理的离体人右房心肌收缩功能恢复的影响。

方法:人右房心肌通过38名成人患者行心脏手术时获得。记录悬吊在充氧的蒂罗德溶液(34°C,刺激频率1Hz)中心房肌小梁的等长收缩力(FoC)。所有组均在30分钟的缺氧期后给予60分钟再氧合(HR)。不同分组中,肌肉在HR期前和期间分别暴露于不同浓度的依托咪酯(10-7, 10-6, 10-5 M)10分钟。在HR期前采用4分钟缺氧后行7分钟再氧合的方法行缺氧预处理。在缺氧预处理刺激前、中、后均暴露于10-5 M的依托咪酯。在HR结束后比较组间FoC恢复的情况(以基线值的百分率表示)

结果:与对照组相比(FoC: 52% ± 10%),依托咪酯10-7 M(FoC: 57% ± 9%; P = 0.24)10-6 M(FoC: 61% ± 11%; P = 0.10), 10-5 M(FoC: 54% ± 9%; P = 0.29)不会改变HRFoC的恢复。使用10-5 M依托咪酯(FoC: 86% ± 7%; 与缺氧预处理组比较P = 0.74)亦不会改变缺氧预处理后FoC恢复的增加(87% ± 5%; 与对照组比较P < 0.001)

结论:依托咪酯不会改变暴露于HR后体外人心肌的FoC,而且不会改变缺氧预处理的保护效应。

(黄凝译  薛张纲校)

BACKGROUND: We examined the effects of etomidate on recovery of contractile function after hypoxia reoxygenation and hypoxic preconditioning in vitro using isolated human myocardium.

METHODS: Human right atrial myocardium were obtained at the time of cardiac surgery from 38 adults patients. We recorded isometric force of contraction (FoC) of atrial trabeculae suspended in an oxygenated Tyrode's solution (34°C, stimulation frequency 1 Hz). In all groups, a 30-min hypoxic period was followed by 60 min of reoxygenation (HR). In separate groups, muscles were exposed to etomidate (10-7, 10-6, 10-5 M) 10 min before and throughout the HR periods. Hypoxic preconditioning was induced by 4-min hypoxia followed by 7-min reoxygenation applied before HR periods. Etomidate 10-5 M was administered before, throughout, and after the hypoxic preconditioning stimulus. Recovery of FoC (expressed as % of baseline value) at the end of HR was compared among groups.

RESULTS: Compared with the control group (FoC: 52% ± 10%), etomidate 10-7 M (FoC: 57% ± 9%; P = 0.24), 10-6 M (FoC: 61% ± 11%; P = 0.10), and 10-5 M (FoC: 54% ± 9%; P = 0.29) did not modify the recovery of FoC after HR. Hypoxic preconditioning-induced increase in the recovery of FoC (87% ± 5%; P < 0.001 vs control group) was not modified in the presence of etomidate 10-5 M (FoC: 86% ± 7%; P = 0.74 vs hypoxic preconditioning group).

CONCLUSIONS: Etomidate did not modify the in vitro FoC of human myocardium exposed to HR. Furthermore, etomidate did not modify the protective effect of hypoxic preconditioning.

 

 

儿童七氟烷麻醉诱导时鼻内使用瑞芬太尼对插管条件和气道反应的影响

The Effect of Intranasal Administration of Remifentanil on Intubating Conditions and Airway Response After Sevoflurane Induction of Anesthesia in Children
Susan T. Verghese, MD*{dagger}, Raafat S. Hannallah, MD*{dagger}, Marjorie Brennan, MD*{dagger}, Jessica L. Yarvitz, BSN{dagger}, Kelly A. Hummer, RN{dagger}, Kantilal M. Patel, PhD*, Jainping He, MS{ddagger}, and Robert McCarter, ScD*{ddagger}

From the *George Washington University Medical Center, Washington, District of Columbia; {dagger}Children’s National Medical Center, Washington, District of Columbia; and {ddagger}Children’s Research Institute, Washington, District of Columbia.

Anesth Analg 2008 107: 1176-1181

 

背景:静脉通道建立之前,不使用肌肉松弛的条件下常常能够完成儿童患者气管插管。在该随机对照研究中我们将比较鼻内使用瑞芬太尼(4ug/kg)或生理盐水后对七氟烷诱导后2min3min对儿童气管插管条件和气道反应(咳嗽/肢体运动)的影响。

方法:选择1-7岁儿童188例。8%七氟烷/氧化亚氮麻醉诱导后1min鼻内使用瑞芬太尼(4ug/kg)或生理盐水。随后七氟烷浓度降至5%,根据情况进行辅助或控制通气;由一位不知分组与处理的麻醉医师评价置入咽喉镜和插管条件。鼻内使用瑞米芬太尼0123410min后从17例儿童采集血样测定瑞米芬太尼浓度。

结果:使用负荷剂量瑞芬太尼后68.2%患者在2min内能达到较好插管条件,3min则为91.7%。与此相比,使用安慰剂组则分别为37%23%(P < 0.01)。在2, 3, 4, and 10 min时点瑞芬太尼平均血浆浓度分别为1.0 (0.60), 1.47 (0.52), 1.70 (0.46), and 1.16 (0.36) ng/mL。峰值浓度出现在3.47 min,未发现并发症。

结论:七氟烷麻醉诱导鼻内使用瑞芬太尼能在2-3min提供良好的插管条件。

(蒋宗明译 薛张纲校)

BACKGROUND: Intubation without the use of muscle relaxants in children is frequently done before IV access is secured. In this randomized controlled trial, we compared intubating conditions and airway response to intubation (coughing and/or movement) after sevoflurane induction in children at 2 and 3 min after the administration of intranasal remifentanil (4 mcg/kg) or saline.

METHODS: One hundred eighty-eight children, 1–7-yr old, were studied. Nasal remifentanil (4 mcg/kg) or saline was administered 1 min after an 8% sevoflurane N2O induction. The sevoflurane concentration was then reduced to 5% in oxygen, and ventilation assisted/controlled. An anesthesiologist blinded to treatment assignment used a validated score to evaluate the conditions for laryngoscopy and response to intubation. Blood samples for determination of remifentanil blood concentrations were collected from 17 children at baseline, 2, 3, 4, and 10 min after nasal administration of remifentanil.

RESULTS: Good or excellent intubating conditions were achieved at 2 min (after the remifentanil bolus) in 68.2% and at 3 min in 91.7% of the children who received intranasal remifentanil versus 37% and 23% in children who received placebo (P < 0.01). The mean remifentanil plasma concentrations (±sd) at 2, 3, 4, and 10 min were 1.0 (0.60), 1.47 (0.52), 1.70 (0.46), and 1.16 (0.36) ng/mL, respectively. Peak plasma concentration was observed at 3.47 min. There were no complications associated with the use of nasal remifentanil.

CONCLUSIONS: Nasal administration of remifentanil produces good-to-excellent intubating conditions in 2–3 min after sevoflurane induction of anesthesia.

 

 

新型贝式闭合环路系统在使用BIS作为控制性变量的异丙酚麻醉中的精确性和临床可行性

The Accuracy and Clinical Feasibility of a New Bayesian-Based Closed-Loop Control System for Propofol Administration Using the Bispectral Index as a Controlled Variable

Tom De Smet, MSc*, Michel M. R. F. Struys, MD, PhD{ddagger}§, Martine M. Neckebroek, MD{dagger}, Kristof Van den Hauwe, MD{dagger}, Sjoert Bonte, BSc{dagger}, and Eric P. Mortier, MD, DSc{dagger}

From the *Demed Engineering, Temse, Belgium; {dagger}Department of Anesthesia, Ghent University Hospital, Ghent; {dagger}Departments of Anesthesia, Ghent University, Ghent, Belgium and §Department of Anesthesia, University Medical Center, Groningen, the Netherlands

Anesth Analg 2008 107: 1200-1210.

 

背景:使用闭合环路系统来实现对麻醉给药的控制是优化给药方式的重要途径。在这里,我们将介绍一个新近研发的基于贝式环路的、将患者个体化、模型化的适应性控制方法,用以来控制临床上在BIS指导下的异丙酚输注,并且比较它在门诊妇产科手术中,分别于麻醉师的直接观察和BIS指导下滴定测得的异丙酚输注的精确性及临床可行性。

方法40ASA病人被随机的分配到闭合环路组和手控组,所有的病人在诱导前均由静脉给予1 mg咪唑达伦和0.5 mg的阿芬太尼。在闭合环路组,异丙酚的使用是根据先前提及的闭合环路系统来尽可能的使BIS值达到并维持在50。而在手控组,异丙酚的作用浓度是根据麻醉师的判断而来使BIS值尽可能的达到并维持于50。同时,诱导时的特性参数、诱导的完成和在维持及苏醒期间的平稳性也都将加以比较。而血流动力学和呼吸系统的平稳性指标也被计入了评价其临床可行性的参数。

结果:用闭合环路系统滴定测得的异丙酚输注时的BIS值与预设值极为接近。该闭合环路系统不仅可在临床许可时间内完成对病人的诱导,还比手控组减少了药物的过量使用,且自动控制组在苏醒时间上更显出了较大的优势。但闭合环路组与手控组在临床上的表现相近,这主要体现在相近的血流动力学和呼吸系统的平稳性,以及相当的运动频率和质量评分。

结论:在使用BIS作为控制性参数的异丙酚输注中,新型的贝式闭合环路系统在门诊妇产科的麻醉中表现出了极大的精确性。这种控制系统不单具有临床可行性,而且还可在进一步的临床实践中加以证实。

(刘沁译 薛张纲校)

BACKGROUND: Closed-loop control of the hypnotic component of anesthesia has been proposed in an attempt to optimize drug delivery. Here, we introduce a newly developed Bayesian-based, patient-individualized, model-based, adaptive control method for bispectral index (BIS) guided propofol infusion into clinical practice and compare its accuracy and clinical feasibility under direct observation of an anesthesiologist versus BIS guided, effect compartment controlled propofol administration titrated by the anesthesiologist during ambulatory gynecological procedures.

METHODS: Forty ASA patients were randomly allocated to the closed-loop or manual control group. All patients received midazolam 1 mg IV and alfentanil 0.5 mg IV before induction. In the closed-loop control group, propofol was administered using the previously described closed-loop control system to reach and maintain a target BIS of 50. In the manual control group, the propofol effect-site concentration was adapted at the discretion of the anesthesiologist to reach and maintain a BIS as close as possible to 50. Induction characteristics, performance, and robustness during maintenance and recovery times were compared. Hemodynamic and respiratory stability were calculated as clinical feasibility parameters.

RESULTS: The closed-loop control system titrated propofol administration accurately resulting in BIS values close to the set point. The closed-loop control system was able to induce the patients within clinically accepted time limits and with less overshoot than the manual control group. Automated control resulted in beneficial recovery times. Our closed-loop control group showed similar acceptable clinical performance specified by similar hemodynamic, respiratory stability, comparable movement rates, and quality scores than the manual control group.

CONCLUSIONS: The Bayesian-based closed-loop control system for propofol administration using the BIS as a controlled variable performed accurate during anesthesia for ambulatory gynecological procedures. This control system is clinical feasibility and can be further validated in clinical practice.

 

 

船坞模型研究惰性气体麻醉药与非麻醉作用气体与血清白蛋白不同结合位点

Noble gas binding to human serum albumin using docking simulation: nonimmobilizers and anesthetics bind to different sites.

Tomoyoshi Seto, MD, PhD*{dagger}, Hideto Isogai, PhD{dagger}, Masayuki Ozaki, MD*, and Shuichi Nosaka, MD*

From the *Department of Anesthesiology, Shiga University of Medical Science, Otsu, Japan; and {dagger}Department of Applied Chemistry, Ritsumeikan University, Kusatsu, Japan.

Anesth Analg 2008 107: 1223-1228.

 

背景:非麻醉作用气体与麻醉药在结构上相似,但在临床上起相关聚合物不产生麻醉效应。氙、氪、氩是麻醉药,而氖、氦是非麻醉作用气体 。惰性气体中麻醉药与非麻醉作用气体结构相似,它们的相互作用也单一。在分子麻醉学中,麻醉药和非麻醉作用气体的作用结合位点长久来一直是研究的一个问题所在。

方法:我们用人血清白蛋白来检测惰性气体麻醉药和非麻醉作用气体结合位点和能量,因为人血清白蛋白的结构我们已知晓且他和麻醉药有一个结合位点。我们有计算机模拟船屋来群找结合位点并计算小分子和 分子的结合能量。

结果:氙、氪、氩与人血清白蛋白与安氟醚结合位点结合,而氖、氦与氙有不同的结合位点。稀有气体麻醉药的结合依靠范德华能量,而非麻醉作用气体结合依靠溶剂效应能量。优先结合位点是由能量决定的。范德华能量是麻醉药必需的结合前提。

结论:此项结合能量组成的分析提供一个麻醉药与非麻醉作用气体有不同结合位点的原理。显示麻醉药与非麻醉作用气体结合交互作用不同,可能解释了麻醉药与非麻醉作用气体药理作用的不同并且提供了一个麻醉药物在原子水平上作用的解释。

(刘婷洁译 薛张纲校)

BACKGROUND: Nonimmobilizers are structurally similar to anesthetics, but do not produce

anesthesia at clinically relevant concentrations. Xenon, krypton, and argon are anesthetics, whereas neon and helium are nonimmobilizers. The structures of noble gases with anesthetics or nonimmobilizers are similar and their interactions are simple. Whether the binding site of anesthetics differs from that of nonimmobilizers has long been a question in molecular anesthesiology.

METHODS: We investigated the binding sites and energies of anesthetic and nonimmobilizer noble gases in human serum albumin (HSA) because the 3D structure of HSA is well known and it has an anesthetic binding site. The computational docking simulation we used searches for binding sites and calculates the binding energy for small molecules and a template molecule.

RESULTS: Xenon, krypton, and argon were found to bind to the enflurane binding site of HSA, whereas neon and helium were found to bind to sites different from the xenon binding site. Rare gas anesthetic binding was dominated by van der Waals energy, while nonimmobilizer binding was dominated by solvent-effect energy. Binding site preference was determined by the ratios of local binding energy (van der Waals energy) and nonspecific binding energy (solvent-effect energy) to the total binding energy. van der Waals energy dominance is necessary for anesthetic binding.

CONCLUSIONS: This analysis of binding energy components provides a rationale for the binding site difference of anesthetics and nonimmobilizers, reveals the differences between the binding interactions of anesthetics and nonimmobilizers, may explain pharmacological differences between anesthetics and nonimmobilizers, and provide an understanding of anesthetic action at the atomic level.

 

 

ICU病人使用震动反应成像技术(VRI)用于评估不对称肺脏疾病

Assessment of Asymmetric Lung Disease in Intensive Care Unit Patients Using Vibration Response Imaging

Smith Jean, PhD, Ismail Cinel, MD, PhD, Christina Tay, MD, Joseph E. Parrillo, MD, and R. Phillip Dellinger, MD

From the Department of Medicine, Robert Wood Johnson School of Medicine, University of Medicine and Dentistry of New Jersey, Cooper University Hospital, Camden, New Jersey.

Anesth Analg 2008 107: 1243-1247

 

背景:震动反应成像(Vibration response imaging VRI)是一种基于计算机处理的技术,它能用可视的动态二维图像来反应呼吸过程中两肺的震动情况。在病人体表放置36个感应器,收集并记录其声频信号,传输到装有数个过滤器的硬件板上,选出其中的特定频率波段。滤波输出的信号频率以灰阶编码的二维图像来表现。它由一系列的0.17s帧幅来组成。这些图像以列表的形式表现了每个单肺在整个震动信号中所占的百分比。

方法:我们详尽介绍了VRI技术,并研究了影像学显示单肺有病变的ICU病人的VRI图像。影像学显示双肺正常的ICU病人列为对照组。研究以对比两肺的像素计数加权来进行。运用这种方法,VRI图像中的每个像素根据其灰阶都被指定一个值,像素越暗,数值越高。

结果:影像血显示双肺正常的ICU病人,动态VRI图像相似,两肺所占的震动百分比具有可比性(分别为53%±12%47±12%)。而在影像学显示双肺不对称疾病的ICU病人中,VRI图像中患侧与健侧肺的震动百分比分别为27%±23%以及73%±23%p0.001〉。在不对称肺疾病的患者中(影像学显示一侧肺有中重度疾病而另一侧肺表现为正常或接近正常),患侧肺在VRI图像中通常表现为图像较健侧肺不规则、较小及颜色较浅(震动减少表现)。患侧及健侧肺的像素计数加权分别为33%±21%67%±21%p0.003)。

结论VRI图像技术可以提供一种无放射性的方法来识别及定位不对称的肺实质疾病。

(秦敏菊译 薛张纲校)

BACKGROUND: Vibration response imaging (VRI) is a computer-based technology that creates a visual dynamic two-dimensional image of distribution of vibration within the lung during the respiratory process. The acoustic signals, recorded from 36 posteriorly positioned surface skin sensors, are transferred to a hardware board where several stages of filtering are applied to select a specific frequency band. The filtered output signal frequencies are presented as a gray-scale coded dynamic image, consisting of a series of 0.17 s frames, and as a table featuring the percentage contribution of each lung to the total vibration signal.

METHODS: We describe the VRI technology in detail and examine images obtained from consecutive intensive care unit (ICU) patients with one diseased lung on chest radiograph. ICU patients with normal chest radiographs are presented as controls. Analysis of the image was performed by comparing the weighted pixel count analysis from both lungs. In this method, the pixels in the image were assigned values based on their grayscale color with the darker pixels assigned higher values.

RESULTS: In patients with normal chest radiographs, the right and left lungs developed similarly in dynamic VRI images, and the percent lung vibrations from both sides were comparable (53% ± 12% and 47% ± 12%, respectively). In ICU patients with asymmetric lung disease, however, the percent lung vibrations from the diseased and nondiseased lungs were 27% ± 23% and 73% ±23%, respectively (P 0.001). In patients with asymmetric lung disease (one lung has moderate to severe disease and the other appears normal or close to normal as per chest radiograph), the diseased lung usually appeared in VRI as irregular, smaller, and lighter in color (reduced vibration signal) when compared to the nonaffected lung. The weighted pixel count from diseased and nondiseased lungs were 33% ±21% and 67% ±21%, respectively (P 0.003).

CONCLUSION: The VRI technology may provide a radiation-free method for identifying and tracking of asymmetric lung parenchymal processes.

 

 

减肥术后体重减轻患者肺吸入的风险

 

The Risk of Pulmonary Aspiration in Patients After Weight Loss Due to Bariatric Surgery

Jerome Jean, MD*, Vincent Compère, MD*, Veronique Fourdrinier, MD*, Caroline Marguerite, MD*, Isabelle Auquit-Auckbur, MD, Pierre Yves Milliez, MD, and Bertrand Dureuil, MD*

From the Departments of *Anesthetics and Intensive Care, {dagger}Plastic Surgery, Rouen University Hospital, University of Rouen, France.

Anesth Analg 2008 107: 1257-1259.

 

背景:我们研究接受塑身手术,包括胃囊带术及胃成形术的患者,评估其发生肺吸入的风险。

方法:我们对5年期间(2000-2005年)在鲁昂大学医院接受塑身手术的所有患者进行回顾性病例对照研究。分组方法:在接受塑身手术前,曾接受减肥手术(腹腔镜可调胃囊带术或Mason’s垂直胃成形术)的患者为既往减肥术组;其他患者均为对照组。数据包括所有麻醉管理记录及医院计算机数据库中的资料,经分析后得出肺吸入的发病率。

结果:我们共完成198例塑身手术( 66例病例组和132个对照组)的资料统计。既往减肥术组的肺吸入发生率(4 : 6%)较对照组(0例)显著升高(P < 0.006)。所有发生肺吸入的患者均接受过胃囊带术。未接受积极预防措施的病人,需特别警惕对肺有影响的改变。

结论:胃囊带术对体重减轻患者手术期间肺吸入的风险有重要影响。

(施颖译 薛张纲校)

BACKGROUND: We conducted a study including patients with gastric banding or gastroplasty who previously underwent plastic or functional surgery to assess the risk of pulmonary aspiration.

METHODS: A retrospective case–control study was performed including all patients undergoing a plastic or functional surgery over a 5-yr period (2000–2005) at Rouen University Hospital. Two groups were defined: the postbariatric group included patients who previously had bariatric surgery (laparoscopic adjustable gastric banding or Mason’s vertical gastroplasty) before undergoing the plastic surgery; all other patients were assigned to the control group. Data included all anesthetic management and were recorded in the hospital computer database. The incidence of pulmonary aspiration was the outcome variable.

RESULTS: One hundred ninety-eight plastic and functional operations (66 cases and 132 controls) were performed. Pulmonary aspiration was significantly (P < 0.006) higher in the postbariatric group (4 patients: 6%) than in the nonbariatric group (0 patient). For this complication, all patients had previously undergone gastric banding. One patient who did not receive prokinetic prophylaxis required intensive care for severe pulmonary alteration.

CONCLUSION: The risk of perioperative pulmonary aspiration in a patient after weight loss due to gastric banding was considered significant.

 

 

听觉诱发电位仪及毕氏脑波仪用于评价重症监护病人的镇静程度

Composite Auditory Evoked Potential Index Versus Bispectral Index to Estimate the Level of Sedation in Paralyzed Critically Ill Patients: A Prospective Observational Study.

Lu, Chueng-He MD *; Man, Kee-Ming MD +; Ou-Yang, Hsin-Yi RN, MS ++; Chan, Shun-Ming MD *; Ho, Shung-Tai MD *; Wong, Chih-Shung MD, PhD *; Liaw, Wen-Jinn MD, PhD *

From the Departments of *Anesthesiology, and +Nursing, Tri-Service General Hospital, National Defense Medical Center; and ++Department of Anesthesiology, Tungs' Taichung MetroHarbor Hospital, Taiwan.

Anesth Analg. 2008.107(4):1290-1294

 

背景:据报道在ICU的没有接受神经肌肉阻滞剂的镇静病人可由肌电图来评估脑电双频指数(BIS)。我们研究ICU镇静病人使用肌松剂后听觉诱发电位和BIS的变化。

方法:三十八个需使用肌肉松弛剂且持续以咪达唑仑及芬太尼止痛镇静达Ramsay镇静指标值5以上之重症加护病人纳入研究。于肌肉松弛剂给予前三十分钟及作用后三十分钟每五分钟纪录毕氏脑波仪指数、讯号品质指数、听觉诱发电位合成指数及肌肉电器活性一次。Student's 测试,Wilcoxon评分测试,Spearman测试的评分通过SPSS 10.0软件统计出来。

結果: 肌肉鬆弛劑作用後,畢氏腦波儀指數、肌肉電器活性、聽覺誘發電位合成指數及肌肉電器活性皆明顯降低。结果:肌肉松弛剂作用后,毕氏脑波仪指数、肌肉电器活性、听觉诱发电位合成指数及肌肉电器活性皆明显降低。还还还 发现给予肌肉松弛剂后毕氏脑波仪指数及听觉诱发电位合成指数的降低与给予肌肉松弛剂前的指数及肌肉电器活性呈现明显相关。

結論: 臨床評估重症病人的鎮靜程度以單一畢氏腦波儀或聽覺誘發電位儀為唯一指標可能造成病人過度鎮靜狀況。结论: 该研究表明,对ICU的镇静病人来说,BIS AAI在使用肌松剂后明显降低,这种情况也适用于手术中接受麻醉的病人。

(孙鹏飞译 薛张纲校)

BACKGROUND: Electromyographic activity (EMG) has been reported to elevate the Bispectral Index (BIS) in patients not receiving neuromuscular blockade while under sedation in the intensive care unit (ICU). We investigated the change of the composite A-line autoregressive index (AAI) and BIS after administration of muscle relaxants in sedated surgical ICU patients.
METHODS
: We prospectively investigated 38 patients who required administration of a muscle relaxant while continuously sedated with midazolam hydrochloride and fentanyl citrate to achieve a Ramsay Sedation Scale value equal to 5. BIS, EMG activity of BIS (EMG-BIS), signal quality index of BIS, AAI, EMG activity of AAI (EMG-AAI), and acceleromyography at the adductor pollicis muscle were recorded simultaneously every 5 min for 30 min before and after neuromuscular blockade. Student's t-test, the Wilcoxon's signed ranks test, and the Spearman test were calculated using the standard statistics software SPSS 10.0 (SPSS Inc., Chicago, IL).
RESULTS
: After administration of a muscle relaxant, BIS (58.61 +/- 7.45 vs 44.68 +/- 6.65, P < 0.001), EMG-BIS (37.33 +/- 7.15 vs 27.24 +/- 1.51, P < 0.001), AAI (34.11 +/- 10.96 vs 15.97 +/- 6.69, P < 0.001), and EMG-AAI (59.58 +/- 9.57 vs 1.00 +/- 0.00, P < 0.001) decreased significantly. Significant correlations between BIS and EMG-BIS (rs = 0.75, P < 0.001) and AAI and EMG-AAI (rs = 0.87, P < 0.001) were also found during the baseline period.
CONCLUSIONS
: This study demonstrated that, in sedated ICU patients, BIS and AAI markedly decreased after administration of myorelaxant, and the decreased BIS and AAI values after neuromuscular blockade were correlated to those usually seen in the state of surgical anesthesia, respectively.

 

 

布比卡因和左旋布比卡因对于人离体妊娠子宫肌层收缩力抑制作用的对比

A Comparison of the Inhibitory Effects of Bupivacaine and Levobupivacaine on Isolated Human Pregnant Myometrium Contractility

Rebecca A. Fanning, FCARCSI*, Deirdre P. Campion, PhD{dagger}, Colm B. Collins, PhD{dagger}, Simon Keely, PhD{dagger}, Liam P. Briggs, FFARCSI*, John J. O'Connor, PhD{ddagger}, and Michael F. Carey, MD*

 From the *Department of Perioperative Medicine, Coombe Women and Infants University Hospital, {dagger}University College Dublin School of Agriculture, Food Science and Vetenary Medicine, and {ddagger}Conway Institute of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland

Anesth Analg 2008 107: 1303-1307.

 

背景:硬膜外使用布比卡因或左旋布比卡因是分娩镇痛常用而有效的方法。然而,此方法的使用与使用辅助器生产率增高有关。证明该副作用机理的方法之一就是明确局部麻醉药物对子宫肌收缩力的直接影响。我们对比了布比卡因和左旋布比卡因对于人足月子宫肌收缩幅度和频率的作用。

方法:子宫样本来源于足月、非临产状态、预定行下段剖宫产手术者。将子宫纵行肌束垂直固定,记录收缩幅度(力量峰值)频率的变化。施加1g(9.81 mN)的拉力后肌束开始自发性收缩。不使用任何促子宫收缩药物。继而使用布比卡因和左旋布比卡因持续作用于肌束,记录下计量反应曲线。

结果:对比自体控制幅度,两种药物都降低子宫肌收缩幅度约1 x 10–4 M。伴随着收缩幅度的降低,两种药物使子宫肌收缩频率增加,达到有意义的收缩幅度为3 x 10–5 M

结论:要达到影响子宫收缩作用的血药浓度要远远高于(33倍)现今临床上使用的血药浓度,使用低硬膜外药物浓度并没有显著意义。

(夏俊明译 薛张纲校)

 BACKGROUND: Epidural analgesia with levobupivacaine and bupivacaine is a common and effective method of labor pain relief. However, its use is associated with an increased instrumental delivery rate. One of the mechanisms postulated to account for this unwanted effect is the direct effect of local anesthetics on myometrial contractility. We determined the effects of bupivacaine and levobupivacaine on the amplitude and frequency of contractions of human term myometrium.

METHODS: Uterine specimens were obtained from nonlaboring parturients scheduled for elective lower-segment cesarean delivery at term. Longitudinal muscle strips were prepared and mounted vertically in tissue chambers, and changes in the amplitude (peak force) and the frequency of contractions were recorded. Spontaneous contractions commenced after a period of application of 1 g (9.81 mN) of tension to the myometrial strips. No uterotonic drugs were used. The muscle strips were then exposed to cumulative concentrations of bupivacaine and levobupivacaine and dose–response curves were generated.

RESULTS: Both bupivacaine and levobupivacaine decreased the amplitude of contractions in human myometrium in a concentration-dependent manner, reaching significance at 1 x 10–4 M for both bupivacaine and levobupivacaine compared with the internal control amplitude. With both drugs, the decrease in amplitude was accompanied by an increase in the frequency of contractions reaching significance at 3 x 10–5 M for both bupivacaine and levobupivacaine compared with the internal control frequency.

CONCLUSIONS: The concentrations required for the effects on amplitude are much higher (33 fold) than the clinically relevant plasma concentrations of these drugs after epidural administration, and are unlikely to be significant in the setting of low-dose epidural analgesia in labor.

 

 

为神经外科病人计划早期苏醒:一项使用小剂量麻醉剂的随机前瞻性研究

Planning for Early Emergence in Neurosurgical Patients: A Randomized Prospective Trial of Low-Dose Anesthetics

Hemant Bhagat, MD, DM, Hari H. Dash, MD, Parmod K. Bithal, MD, Rajendra S. Chouhan, MD, and Mihir P. Pandia, MD

From the Department of Neuroanesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, India.

Anesth Analg 2008 107: 1348-1355.

 

背景:为了早期检测大脑的并发症,开颅术后迅速从麻醉中苏醒是必要的。系统性高血压是与快速苏醒有关的主要缺点,可能诱发颅内血肿的形成。虽然各种药物都被广泛地评估过,关于使用麻醉剂缓解突发高血压的数据仍很有限。我们假设在关颅时使用小剂量麻醉剂可以促进早期苏醒时血流动力学变化。

方法:150例血压正常的行小脑幕上肿瘤手术的成年病人使用标准异氟醚吸入麻醉,评估三种苏醒方法。在关硬脑膜时,病人随机得到:小剂量丙泊酚(3mg/kg/h),芬太尼(1.5 µg/kg/h),异氟醚(浓度0.2%),直到开始关皮肤。笑气在贴完敷料后停止。

结果:丙泊酚组的平均苏醒时间是6min,芬太尼组为4min,异氟醚组为5minp=0.08)。与拔管时和拔管后比较,拔管前更多病人出现高血压(P = 0.009)。比较三组,全部使用芬太尼的病人在拔管前期较少使用艾司洛尔(P = 0.01)。术前脑显像扫描示中线偏移显著是苏醒期高血压的独立危险因素。

结论:手术关闭时的疼痛可能是交感兴奋的重要原因从而导致苏醒期高血压。对于使神经外科病人早期苏醒,在关颅时使用小剂量芬太尼比丙泊酚和异氟醚更有利,同时是预防术后早期高血压的最有效的方法。

(宣丽真译 薛张纲校)

BACKGROUND: For early detection of a cerebral complication, rapid awakening from anesthesia is essential after craniotomy. Systemic hypertension is a major drawback associated with fast tracking, which may predispose to formation of intracranial hematoma. Although various drugs have been widely evaluated, there are limited data with regards to use of anesthetics to blunt emergence hypertension. We hypothesized that use of low-dose anesthetics during craniotomy closure facilitates early emergence with a decrease in hemodynamic consequences.

METHODS: Three emergent techniques were evaluated in 150 normotensive adult patients operated for supratentorial tumors under standard isoflurane anesthesia. At the time of dural closure, the patients were randomized to receive low-dose propofol (3 mg · kg1 · h1), fentanyl (1.5 µg · kg1 · h1) or isoflurane (end-tidal concentration of 0.2%) until the beginning of skin closure. Nitrous oxide was discontinued after head dressing.

RESULTS: Median time to emergence was 6 min with propofol, 4 min with fentanyl, and 5 min with isoflurane (P = 0.008). More patients had hypertension in the pre-extubation compared with extubation or postextubation phase (P = 0.009). Comparing the three groups, fewer patients required esmolol with fentanyl use overall, and in the pre-extubation phase (P = 0.01). Significant midline shift in the preoperative cerebral imaging scans was found to be an independent risk factor for emergence hypertension.

CONCLUSIONS: Pain during surgical closure may be an important cause of sympathetic stimulation leading to emergence hypertension. The use of low-doses of fentanyl during craniotomy closure is more advantageous than propofol or isoflurane for early emergence in neurosurgical patients and is the most effective technique for preventing early postoperative hypertension.

 

脉压与冠状动脉搭桥术后不良预后的风险

Pulse Pressure and Risk of Adverse Outcome in Coronary Bypass Surgery

Manuel L. Fontes, MD*{dagger}, Solomon Aronson, MD, FACC, FCCP, FAHA, FASE*{ddagger}, Joseph P. Mathew, MD*{ddagger}, Yinghui Miao, MD, MPH§, Benjamin Drenger, MD*||, Paul G. Barash, MD, Dennis T. Mangano, PhD, MD*§ For the Multicenter Study of Perioperative Ischemia (McSPI) Research Group, the Ischemia Research and Education Foundation (IREF) Investigators

From the *Multicenter Study of Perioperative Ischemia (McSPI) Research Group, {dagger}the Weill Medical College of Cornell University, {ddagger}Duke University Medical Center, §Ischemia Research and Education Foundation, ||Hadassah University Hospital, and ¶Yale University School of Medicine.

Anesth Analg 2008 107: 1122-1129.

 

背景:在能够走动、无需卧床的患者当中,脉压(PP)增大已经被证实是发生血管意外的一个重要因素。然而脉压与接受冠状动脉旁路移植术(CABG)的患者发生急性围手术期血管意外之间的联系还并不为人所熟知。

方法:作者对5436名接受心肺转流CABG手术的患者进行了前瞻性的研究。其中,4801名患者符合最终的试验选择标准。采集其病史,术中及术后的生理和实验室检查,诊断学检查,临床征象等综合数据,采用多变量对数回归对术前高血压(收缩期,舒张期,脉压)与心肌和脑缺血的预后及死亡率的关系进行评估;P<0.05则认为有显著性。

结果: 917名患者(19.1%)发生致死性或非致死性的血管并发症,包括146名患者(3.0%)发生脑血管意外,715名患者(14.9%)发生心血管意外。147名患者住院期间死亡(3.1%)。所有术前测量的血压变量中,脉压与术后并发症风险的增加最为密切。脉压增大10mmHg(大于阈值40mmHg),脑血管意外的发生率也增加(校正优势率:1.1295CI[1.002-1.28];P=0.026)。脉压>80mmHg的患者与脉压≤80mmHg的患者相比,脑血管意外和/或死于神经病学并发症的发生率几乎是后者的两倍(5.5%对比2.8%P0.004)。脉压大于80mmHg时与心脏并发症亦有关,充血性心力衰竭的发生率可增加52%,而因心脏原因引起的死亡率增加接近100%(分别为P0.0030.006)。

结论:在接受CABG手术的患者中,脉压增大与其本身与脑和心脏的致死性和非致死性不良结果密切相关。这些发现突显了术前脉压与术后急性血管意外的风险间的联系。

(印洁敏 陈杰 校)

BACKGROUND: Among ambulatory patients, an increase in pulse pressure (PP) is a well-established determinant of vascular risk. The relationship of PP and acute perioperative vascular outcome among patients having coronary artery bypass graft (CABG) surgery is less well known.

METHODS: We conducted a prospective observational study involving 5436 patients having elective CABG surgery requiring cardiopulmonary bypass. Of these, 4801 met final inclusion criteria. Comprehensive data were captured for medical history, intraoperative and postoperative physiologic and laboratory measures, diagnostic testing, and clinical events. The relationship between preoperative hypertension (systolic, diastolic, PP) and ischemic cardiac and cerebral outcomes and death was assessed using multivariable logistic regression; P < 0.05 was considered significant.

RESULTS: Nine hundred and seventeen patients (19.1%) had fatal and nonfatal vascular complications, including 146 patients (3.0%) with cerebral and 715 patients (14.9%) with cardiac events. In-hospital mortality occurred in 147 patients (3.1%). Among all blood pressure variables measured preoperatively, PP was most strongly associated with an increased risk of postoperative complications. PP increments of 10 mm Hg (above a threshold of 40 mm Hg) were associated with an increased risk of cerebral events (adjusted odds ratio: 1.12; 95% CI [1.002–1.28]; P = 0.026). The incidence of a cerebral event and/or death from neurologic complications nearly doubled for patients with PP >80 mm Hg versus ≤80 mm Hg (5.5% vs 2.8%; P = 0.004). PP more than 80 mm Hg was also found to be associated with cardiac complications, increasing the incidence of congestive heart failure by 52%, and death from cardiac cause by nearly 100% (P = 0.003 and 0.006, respectively).

CONCLUSION: An increase in PP was independently and significantly associated with greater fatal and nonfatal adverse cerebral and cardiac outcomes in patients having CABG surgery. These findings highlight the associated risks of preoperative PP on acute postoperative vascular outcomes.

 

中度急性等容血液稀释能改变冠心病病人的心肌功能

Moderate Acute Isovolemic Hemodilution Alters Myocardial Function in Patients with Coronary Artery Disease

Stefanie Cromheecke, MD*, Suraphong Lorsomradee, MD{dagger}, Philippe J. Van der Linden, MD, PhD{ddagger}, and Stefan G. De Hert, MD, PhD§

From the *Department of Anesthesiology, ZNA Middelheim Antwerp, Belgium;