Table of Contents

October 2008

CARDIOVASCULAR ANESTHESIOLOGY:

圍術期氯維地平治療高血壓安全性評價實驗:心外科手術病人急性高血壓治療中,氯維地平與硝酸甘油,硝普鈉,尼卡地平的對照實驗

胡豔譯   薛張剛校

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.

脈壓與冠狀動脈搭橋術後不良預後的風險

印潔敏 陳傑

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-腎上腺素能受體興奮產生的正性鬆弛效應的維持

邱郁薇 馬皓琳 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.

依託咪酯對缺氧後再氧合和低氧預處理的離體人右房心肌沒有影響

黃凝譯  薛張綱校

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釋能改變冠心病病人的心肌功能

潘錢玲 陳傑

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:

術中小劑量氯胺酮不能預防兒科脊柱側彎手術後瑞芬太尼誘導的嗎啡需要量的增加

唐李雋    馬皓琳  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.

兒童七氟烷麻醉誘導時鼻內使用瑞芬太尼對插管條件和氣道反應的影響

蔣宗明譯 薛張綱校

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.

小於三歲的嬰幼兒骶管注射左旋布比卡因(2.5mg/kg)時的藥代動力學

王騰 陳傑

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:

恢復評分漢語翻譯質量的心理測試

朱慧   馬皓琳 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:

新型貝式閉合環路系統在使用BIS作為控制性變數的異丙酚麻醉中的精確性和臨床可行性

劉沁譯 薛張綱校

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後定向力完整

宋翠俠 陳傑

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、加巴噴丁和卡馬西平對嗎啡誘發兔子高碳酸血症的影響

王宏   馬皓琳 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.

船塢模型研究惰性氣體麻醉藥與非麻醉作用氣體與血清白蛋白不同結合位點

劉婷潔譯 薛張綱校

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.

三環類抗抑鬱藥對人的中性粒細胞吞噬功能和氧化突發的抑制作用

張燕 陳傑

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.

在已確定的重建突觸中研究利多卡因對膽鹼能神經傳遞的影響

姜旭暉譯,馬皓琳,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病人使用震動反應成像技術(VRI)用於評估不對稱肺臟疾病

秦敏菊譯 薛張綱校

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.

一種新型彎曲喉鏡片用於常規和困難氣管插管

陳偉 陳傑

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:

對於佩戴硬質頸托模擬插管困難的病人使用橡膠彈性探條引導置入ProSeal喉罩導氣管優於手指法和輔助裝置引導法

江繼宏   馬皓琳 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.

減肥術後體重減輕患者肺吸入的風險

施穎譯 薛張綱校

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:

非損傷肺行與不行呼氣末正壓機械通氣時肺部細胞因數的反應

王鵬 陳傑

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.

大鼠肺損傷性機械通氣時腎臟內內皮素-1的產生和腎臟血流的減少

吳進   馬皓琳 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.

丙泊酚通過降低再灌注肝氧自由基的釋放來減輕肺的動態順應性的降低和肺水的含量。

舒慧剛 陳傑

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.

聽覺誘發電位儀及畢氏腦波儀用於評價重症監護病人的鎮靜程度

孫鵬飛譯 薛張綱校

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:

隨機雙盲比較去氧腎上腺素和麻黃堿聯合輸注用於剖宮產腰麻中維持血壓:對胎兒酸堿情況和血流動力學控制的影響

黃佳佳譯,馬皓琳,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對於人離體妊娠子宮肌層收縮力抑制作用的對比

夏俊明譯 薛張綱校

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.

刺激內關穴(P6)預防椎管內麻醉下剖宮產手術噁心嘔吐的發生:隨機對照試驗的系統回顧

丁俊雲 陳傑

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.

術後嚴重疼痛的風險:臨床預測量表的修正與驗證

葉樂 陳傑

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:

右美托咪啶對開顱手術患者圍手術期血流動力學的影響

黃施偉 譯,馬皓琳 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.

為神經外科病人計畫早期蘇醒:一項使用小劑量麻醉劑的隨機前瞻性研究

宣麗真譯 薛張綱校

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.

貧血與腦預後: 問題很多,答案很少

劉世文 陳傑

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:

病人自控鎮痛時嗎啡與氫嗎啡酮的副作用

唐亮   馬皓琳 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.

經皮脈衝射頻可治療神經性疼痛模型中的機械性異常疼痛

張磊 陳傑

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-腎上腺素能受體興奮產生的正性鬆弛效應的維持

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:在糖尿病心肌病變,舒張功能障礙部分是由於肌漿網功能異常所致,而肌漿網功能異常既影響受磷蛋白,又會影響肌漿網對鈣離子的攝取(SERCA2a)。因此,正如以前證實的正性變力作用發生改變一樣,這一病理改變可能會使β-腎上腺素能受體興奮產生的正性鬆弛作用發生改變,β3-腎上腺素能受體的過度表達可能參與了這一作用。這項研究擬驗證在糖尿病心肌病變β-腎上腺素能受體正性鬆弛效應是否發生改變,而β3-腎上腺素能受體的過度表達是否參與了這一機制。

方法:這項研究觀察了靜脈注射鏈脲黴素4周(4W)和12周(12WWang)後處死的健康和糖尿病大鼠在體(多巴酚丁胺-超聲心動圖)以及離體(製備乳頭肌標本)的β-腎上腺素能反應。在離體大鼠,研究S-氰基吲哚洛爾(一種選擇性β3-腎上腺素能受體拮抗劑)或NG-硝基-1-精氨酸-甲基-酯(非選擇性一氧化氮合酶抑制劑)抑制β3-腎上腺素受體通路對異丙腎上腺素(非選擇性β-腎上腺素能受體激動劑)鬆弛效應的影響。採用蛋白質印跡方法量化β1-腎上腺素能受體 β3-腎上腺素能受體、受磷蛋白和SERCA2a的蛋白表達。資料採用基礎值的百分比均值±標準差表示。

結果:儘管受磷蛋白/SERCA2a蛋白比值增加,心肌舒張功能發生障礙,但與健康大鼠相比,在4W12W糖尿病大鼠在體(多巴酚丁胺)和離體(異丙腎上腺素)β-腎上腺素能受體興奮的正性鬆弛效應並未受到影響。與健康大鼠相比,4W12W糖尿病大鼠β3-腎上腺素能受體表達上調,而β1-腎上腺素能受體表達下調。S-氰基吲哚洛爾和NG-硝基-1-精氨酸-甲基-酯並沒有鬆弛效應。

結論:糖尿病心肌病中,β-腎上腺素能受體興奮的正性鬆弛效應並未發生改變,而β3-腎上腺素能受體的過度表達也並不影響這一過程。

(邱鬱薇 馬皓琳 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.



術中小劑量氯胺酮不能預防兒科脊柱側彎手術後瑞芬太尼誘導的嗎啡需要量的增加

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:在兒科脊柱側彎手術中,我們通常使用以瑞芬太尼為基礎的麻醉,以易於神經生理學檢測。由瑞芬太尼麻醉所導致的急性阿片類耐藥和/或痛覺過敏可能牽涉到N-甲基-右旋天冬氨酸系統的啟動。我們假設小劑量術中輸注N-甲基-右旋天冬氨酸拮抗劑氯胺酮能抑制耐藥性的發展,從而使接受瑞芬太尼麻醉行脊柱側彎手術的兒童術後嗎啡的用量減少。

方法:34名預定脊柱側彎手術的12-18歲青少年在異丙酚/瑞芬太尼麻醉過程中隨機地被指定為術中接受小劑量氯胺酮 (推注0.5 mg/kg 後連續輸注4 µg · kg–1 · min–1) 或相等量的鹽水。用病人自控鎮痛來評估術後72小時累積嗎啡消耗量。術後嗎啡消耗量、靜息和咳嗽時的疼痛指數和鎮靜指數由一名盲法研究者記錄:前4小時每小時一次,之後的20小時每4小時一次,然後每12小時一次至72小時。

結果:術後244872小時的累積嗎啡消耗量兩組無顯著性差異 (氯胺酮組:1.57 ± 0.563.05 ± 1.144.46 ± 1.53 mg/kg;鹽水組:1.60 ± 0.532.87 ± 1.054.11 ± 1.71 mg/kg)。疼痛或鎮靜指數也沒有差異。麻醉持續時間兩組相似。

結論:這些資料不支援術中小劑量氯胺酮應用來防止兒科脊柱側彎手術中瑞芬太尼誘導的急性阿片類耐藥和/或痛覺過敏的發展。

(唐李雋    馬皓琳  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.



恢復評分漢語翻譯質量的心理測試

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:評價恢復質量(QoR)評分的漢語翻譯用於評測術後和麻醉後患者健康狀況。

方法:漢語QoR評分是由一些語言專家用一系列的承上啟下翻譯而發展來。在懂英語的行各種手術的中國患者中比較QoR評分中國和英語版本的心理測量學表現。在交叉設計下,210名患者在術後次晨間隔1小時依照兩個序列之一隨機先後完成兩種QoR評分版本:先漢語版本然後英語版本,或者相反的順序。通過比較6-8小時後的評分及比較患者和當值護士所作的評分來計算試驗-再試驗和測試者之間的可靠性。

結果:患者對漢語版本QoR評分的反應和英語版本非常一致(加權κ統計數值,{kappa}w = 0.92)。兩種QoR評分都和患者滿意度評分相關(漢語版本, {rho}= 0.82; 英語版本, {rho}= 0.79),從而可確定其一致的有效性。QoR評分與女性負相關。在住院期間或手術較大時,在QoR評分和女性、住院持續時間和手術大小之間有顯著的負相關(判別式構想效度)。我們發現漢語版本QoR評分有很好的內在一致性(Cronbach’s {rho}= 0.91),觀察者之間({kappa}w = 0.77)和試驗可重複性({kappa}w = 0.83)。這些指標與原始英語版本中的都相似(Cronbach’s {rho}= 0.89,觀察者之間{kappa}w = 0.84,試驗可重複性 {kappa}w = 0.88)

結論:漢語版本的QoR評分在概念上、語義上和操作上都與英語版本相當。兩種評分標準對手術和麻醉後的QoR都提供了有效、可靠和敏感的評估。

(朱慧   馬皓琳 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、加巴噴丁和卡馬西平對嗎啡誘發兔子高碳酸血症的影響

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:在已經使用三環抗抑鬱藥、卡馬西平和加巴噴丁治療的患者中,嚴重加劇的慢性神經性疼痛常常需要嗎啡鎮痛。然而,聯合使用這些藥物是否加劇嗎啡對呼吸系統的抑制並不清楚,如果如此的話,是否這些效應是由於藥物代謝動力學或藥效學相互作用的結果。

方法:我們給兔子(每組n=6)連續4天下列藥物:皮下注射生理鹽水1ml(對照組);皮下注射阿米替林7mg/kg;口服卡馬西平100mg/kg;皮下注射加巴噴丁25mg/kg;以及三種藥物同時給予(聯合)。在給藥後第五天,嗎啡5mg/kg靜脈注射後檢測Paco2Pao2PH值。嗎啡注射後4小時裏連續監測血漿嗎啡、嗎啡3-葡糖苷酸和嗎啡6-葡糖苷酸濃度。

結果:阿米替林組在嗎啡注射前Paco2基線顯著高於對照組(P<0.05)。嗎啡注射後,阿米替林組和聯合用藥組在240min裏的所有時間點及加巴噴丁組10min30minPaco2顯著較高(P <0.05)。阿米替林組(58.4±1.6mmHgP < 0.005)和聯合用藥組 (57.4 ± 1.0 mm Hg, P < 0.02)Paco2峰值顯著高於對照組(50.2 ± 5.2 mm Hg)。同樣,阿米替林組和聯合用藥組0-240minPco2曲線下面積顯著高於對照組(P < 0.001)。各組間血漿嗎啡及嗎啡代謝產物沒有顯著差異。

結論:我們得到如下結論:阿米替林預處理通過藥效學過程加重嗎啡誘發的高碳酸血症。在此模型中,卡馬西平和加巴噴丁的作用不明顯。

(王宏   馬皓琳 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.



在已確定的重建突觸中研究利多卡因對膽鹼能神經傳遞的影響

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:利多卡因對膽鹼能突觸傳遞的突觸前影響還不是很清楚,因為對突觸前神經元的鑒別很困難,而且活體的中樞神經系統也很複雜。為了闡明利多卡因對膽鹼能突觸的影響,我們從椎實螺屬stagnalis的蝸牛離體重建了含兩種已被鑒定的內臟背4VD4)和左足e-1LPeD1)神經元的培養體細胞-體細胞化學突觸模型,來研究利多卡因如何影響膽鹼能突觸傳遞。

方法:我們記錄了VD4LPeD1神經元組成的化學突觸傳遞模型中神經元對乙酰膽鹼的反應和興奮性突觸後電位的增幅。在突觸前的VD4和突觸後的LPeD1神經元中的電壓鉗下製成用於測乙酰膽鹼的電流。

結果:利多卡因同時抑制了興奮性突觸後電位和突觸後神經元對乙酰膽鹼的反應。突觸前神經元中的興奮性突觸後電位呈電壓依賴性地減弱,而且利多卡因引起了興奮性突觸後電位幅度電壓依賴性失活曲線的超極化移位元。

結論:利多卡因通過突觸前神經元的膜電位去極化引起興奮性突觸後電位幅度的電壓依賴性失活,並抑制膽鹼能突觸傳遞。

(姜旭暉譯,馬皓琳,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.


對於佩戴硬質頸托模擬插管困難的病人使用橡膠彈性探條引導置入ProSeal喉罩導氣管優於手指法和輔助裝置引導法

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:我們在佩戴硬質頸托的模擬困難氣管插管的病人中比較了喉罩導氣管ProSealPLMA)的三種置入方法。

方法:19-68歲健康女性99, 麻醉後隨機採用手指法、輔助工具法或引導法置入PLMA。困難氣管插管採用佩戴硬質頸托模擬。PLMA置入前進行喉罩視野評級。手指法和輔助工具法置入喉按照廠家說明實施。引導法按以下步驟: 把引流管插入Eschmann氣管導管插管器內, 明視下把插管器插入食道, 順著插管器插入PLMA到位。置入失敗標準為: 1) 咽部放置失敗, 2) 位置不正, 3) 無效通氣。

結果:喉鏡視野評級中位數為3;置入平均距離為距門齒3.3cm。第一次試插時,引導法的成功率較高(引導法100%,手指法64%,輔助工具法61%; P < 0.0001),但三次試插後的成功率相似(引導法100%,手指法94%,輔助工具法91%)。各組間第一次試插時成功插入所需時間相似,但是三次試插後引導法所需時間較短(引導法31±8 s, 手指法49±28 s, 輔助工具法54±37 s; P < 0.02)

結論:對於用硬質頸托模擬的困難氣管插管病人,採用橡膠彈性探條引導法置入PLMA的成功率高於手指法和輔助工具法。

(江繼宏   馬皓琳 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.



大鼠肺損傷性機械通氣時腎臟內內皮素-1的產生和腎臟血流的減少

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

背景機械通氣可導致遠距離器官比如腎臟的損傷,其機制還不是很清楚。我們假設肺損傷性機械通氣所引發的全身炎症反應的上調最終導致了腎臟的功能障礙,這種全身炎症反應可以由血漿白介素-6(IL6)的水平反映,腎臟功能障礙由局部的內皮素-1(ET-1)和腎臟血管收縮介導。

方法:健康的雄性Wistar大鼠隨機分為兩組機械通氣(每組n=9),通氣4小時。其中一組採取肺保護性通氣,設置吸氣壓峰值為14cm H2O,呼氣末正壓值為5cm H2O;另一組採取肺損傷性通氣,設置吸氣壓峰值為20cm H2O,呼氣末正壓值為2cm H2O。隨機取9只大鼠作為非通氣的對照組。我們測定動靜脈血壓和心排血量(熱稀釋法),使用螢光微球體測定腎臟血流(RBF),計算出肌酐清除率、尿流以及鈉排泄分數。用蘇木精伊紅染色來評價肺的組織學損傷。用酶聯免疫吸附分析來測定腎臟內ET-1以及血漿中ET-1IL6的濃度。

結果:肺損傷性通氣後的肺損傷評分比肺保護性通氣後或者非通氣的肺損傷評分要高。與肺保護性通氣和對照組相比,肺損傷性通氣導致了腎臟內ET-1的顯著產生。同時,肺損傷性通氣組中的RBF與對照組和肺保護性通氣組相比分別有大約40%28%的減少(P < 0.05)。各組血漿中ET-1IL-6的水平沒有不同,而全身的血流動力學,比如心排血量也沒有差別。損傷性機械通氣對肌酐清除率、鈉排泄分數、尿排出量或者腎臟的組織學沒有影響。

結論:健康大鼠損傷性機械通氣4小時可導致其腎臟內ET-1的顯著產生和RBF的減少,這種變化獨立於IL-6。減少的RBF對腎臟的功能和組織學沒有可觀測到的影響。

(吳進   馬皓琳 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.



隨機雙盲比較去氧腎上腺素和麻黃堿聯合輸注用於剖宮產腰麻中維持血壓:對胎兒酸堿情況和血流動力學控制的影響

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:去氧腎上腺素和麻黃堿均可用于剖宮產腰麻中維持動脈血壓。一般來說,兩種藥物都是單獨應用,但是以前也曾有幾項研究描述過兩者合用的情況。然而,改變兩種血管升壓藥在混合物中的比例對效果的影響尚未有報導。

方法:125位擇期腰麻剖宮產婦隨機分成五組,通過靜脈持續輸注不同濃度比例的去氧腎上腺素和麻黃堿混合物。假設100ug去氧腎上腺素約相當於8mg麻黃堿,那麼五組混合物中就分別含有去氧腎上腺素等效劑量100%75%50%25%0%及麻黃堿0%25%50%75%100%。在切開子宮前調整輸注速度使收縮壓維持在接近基礎水平。比較血流動力學變化和臍帶血的血氣分析結果。

結果:隨著去氧腎上腺素的比例下降及麻黃堿比例增加,可以觀察到以下幾個明顯的趨勢:低血壓和噁心/嘔吐的發生率增加,收縮壓高於或低於基礎值的差異量中位數及收縮壓高於基礎值的偏倚增大,產婦心率增快,胎兒PH和堿剩餘下降,臍動脈血氧含量下降,臍靜脈血氧分壓增加。

結論:去氧腎上腺素和麻黃堿混合物持續靜脈輸注用於維持剖宮產腰麻過程中動脈血壓時,隨著去氧腎上腺素比例減少及麻黃堿比例增加,血流動力學可控性下降,胎兒的酸堿狀況也不甚理想。去氧腎上腺素和麻黃堿混合物持續靜脈輸注用於剖宮產腰麻避免低血壓,與單純去氧腎上腺素比較似乎沒有優勢。

(黃佳佳譯,馬皓琳,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.



右美托咪啶對開顱手術患者圍手術期血流動力學的影響

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:行顱內手術的患者在圍手術期常併發高血壓發作。{alpha}-2腎上腺能激動劑右美托咪啶(DEX)因其交感阻滯和鎮痛特性可改善手術關鍵時刻的血流動力學穩定,而在神經外科麻醉中得到廣泛使用。我們設計此研究來評估DEX對行顱內手術病人控制高血壓反應的有效性。

方法:擇期行開顱手術的患者被隨機分為接受七氟烷—阿片類或七氟烷—阿片類—DEX麻醉兩組。使用雙頻指數使兩組病人維持于相似的催眠水平(4050)。病人由不知分組情況的麻醉醫生管理,阿片類藥、七氟烷和血管活性藥物以常規方式調整以維持收縮壓(SBP)於90120mmHg、心率(HR5090bpm之間。持續記錄血流動力學參數並貯存在電腦內以備分析。麻醉技術控制SBPHR的有效性與目標範圍以外的曲線下面積(AUC)呈反比。對SBP-時間(AUCsbp mmHg*min/h)和HR—時間(bpm*min/h)曲線中高於和低於目標範圍的曲線下面積進行比較。用變異係數來評估血流動力學的穩定性。

結果:共有72例病人參加本次研究。其中14例的資料搜集有技術問題,故只有56例電腦內貯存資料被用於分析。DEX組中患者的高於目標範圍的AUCsbp明顯較低(p0.044)。SBPHR的變異係數在兩組間沒有差別。DEX組中需要降壓藥處理的病人比例明顯較小(12/28, 42%24/28, 86%, P = 0.0008)。手術中DEX組中需要的阿片類藥量較少,但七氟烷的用量無差別。在麻醉後監護室,DEX組病人高血壓的發作較少(1.25 ± 1.552.50 ± 2.00, P = 0.0114)且出監護室較早(91 ± 17 vs 130 ± 27 min, P < 0.0001)。術後阿片類藥和止吐藥的用量無差別。

結論:通過使用評估麻醉藥總體血流動力學穩定性的指標,我們判定術中輸注DEX對緩和圍術期SBP升高是有效的。DEX的使用不增加低血壓或心動過緩等常見副作用的發生率。

(黃施偉 譯,馬皓琳 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.




病人自控鎮痛時嗎啡與氫嗎啡酮的副作用

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:儘管保健醫療提供者們的“臨床知識”認為氫嗎啡酮可以改善疼痛的控制並且副作用小,但是嗎啡還是作為病人術後自控鎮痛的第一線藥物。在這個研究中,我們比較在產生相同藥物效應的藥物濃度時,嗎啡與氫化嗎啡的效能和副作用特性。藥物的效應通過疼痛評分和瞳孔縮小來確定。

方法:我們對50例普外科和婦產科手術患者進行前瞻性、隨機、雙盲的研究。受試者術後8小時裏隨機接受嗎啡(1 mg/mL)或者氫嗎啡酮(0.2 mg/mL)來進行自控鎮痛。主要的結果是噁心。次要的結果參數有瘙癢、嘔吐、鎮靜作用、疼痛報告、瞳孔縮小及患者滿意度。

結果:兩種藥物的副作用沒有差異。兩者的噁心(1 h: 44%52%, 8 h: 68% 64%)、嘔吐(1 h: 4%0%, 8 h: 0%4%)及瘙癢(1 h: 4%16%, 8 h: 40%40%)的發生率沒有差異。在處理副作用所需藥物用量和病人滿意度上沒有差異。

    嗎啡與氫嗎啡酮使用上的平均比率711小時後患者用了嗎啡10.9 ± 6.0 mg,氫嗎啡酮1.57 ± 1.0 mg8小時後嗎啡29.0 ± 18.0 mg,氫嗎啡酮3.9 ± 2.5 mg。術後1小時(7.9 ± 2.3 vs 7.1 ± 2.4)8小時(5.7 ± 2.8 vs 5.9 ± 2.7)病人活動時的疼痛評分,兩組之間沒有差異。靜息疼痛和瞳孔縮小方面,組間亦無差異。

結論:我們發現嗎啡與氫嗎啡酮間阿片類相關的副作用沒有顯著性差異。當患者自控使通過等同鎮痛和瞳孔縮小測定的藥效等同時,在疼痛控制的有效性及病人滿意度方面沒有差異。在選擇病人自控鎮痛的藥物是嗎啡還是氫嗎啡酮時,應該根據病人的病史,看看是否對哪種藥有特異的反應。

(唐亮   馬皓琳 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.

 

圍術期氯維地平治療高血壓安全性評價實驗:心外科手術病人急性高血壓治療中,氯維地平與硝酸甘油,硝普鈉,尼卡地平的對照實驗

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:心臟手術期間的急性高血壓很難處理,可能引起很多副作用。氯維地平是一種新型的超短效的二氫吡啶L型鈣離子通道拮抗劑類降血壓藥。圍術期氯維地平治療高血壓安全性評價實驗(ECLIPSE)是來比較氯維地平(CLV)和硝酸甘油(NTG),硝普鈉(SNP),尼卡地平(NIC)在治療心臟手術中急性高血壓時的安全性及有效性。

方法:我們分析三個前瞻性的隨機的標籤公開的平行對照研究的資料:在61個醫學中心心臟手術圍術期使用氯維地平和使用硝酸甘油或者硝普鈉或者術後使用尼卡地平的1964例患者中,1512例符合隨機化後滿足臨床需要急性治療的高血壓的標準。患者以11隨機分配到3個平行對照的治療組中。基本的指標是30天內死亡,心肌梗死,卒中或者腎功能不全的發生率。評價適當且精確的血壓控制被作為次要的指標。

結果:在心肌梗死,卒中,腎功能不全的危險性比較上,氯維地平與其他治療組無顯著差異。氯維地平,硝酸甘油,尼卡地平治療組在病死率上也無顯著差異。硝普鈉治療組的死亡率顯著增高(P=0.04)。氯維地平在保持血壓於預先設定的範圍內比硝酸甘油(P=0.0006)和硝普鈉(P=0.003)更有效;然而當血壓範圍縮窄時,與尼卡地平相比,氯維地平的血壓超過血壓界限的偏差小於尼卡地平。

結論:氯維地平在治療心臟手術急性高血壓患者時是安全、有效的。

(胡豔譯   薛張剛校)

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.

 

 

依託咪酯對缺氧後再氧合和低氧預處理的離體人右房心肌沒有影響

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:本試驗在體外研究了依託咪酯對缺氧後再氧合和低氧預處理的離體人右房心肌收縮功能恢復的影響。

方法:人右房心肌通過38名成人患者行心臟手術時獲得。記錄懸吊在充氧的蒂羅德溶液(34°C,刺激頻率1Hz)中心房肌小梁的等長收縮力(FoC)。所有組均在30分鐘的缺氧期後給予60分鐘再氧合(HR)。不同分組中,肌肉在HR期前和期間分別暴露於不同濃度的依託咪酯(10-7, 10-6, 10-5 M)10分鐘。在HR期前採用4分鐘缺氧後行7分鐘再氧合的方法行缺氧預處理。在缺氧預處理刺激前、中、後均暴露於10-5 M的依託咪酯。在HR結束後比較組間FoC恢復的情況(以基線值的百分率表示)

結果:與對照組相比(FoC: 52% ± 10%),依託咪酯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)不會改變HRFoC的恢復。使用10-5 M依託咪酯(FoC: 86% ± 7%; 與缺氧預處理組比較P = 0.74)亦不會改變缺氧預處理後FoC恢復的增加(87% ± 5%; 與對照組比較P < 0.001)

結論:依託咪酯不會改變暴露於HR後體外人心肌的FoC,而且不會改變缺氧預處理的保護效應。

(黃凝譯  薛張綱校)

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.

 

 

兒童七氟烷麻醉誘導時鼻內使用瑞芬太尼對插管條件和氣道反應的影響

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:靜脈通道建立之前,不使用肌肉鬆弛的條件下常常能夠完成兒童患者氣管插管。在該隨機對照研究中我們將比較鼻內使用瑞芬太尼(4ug/kg)或生理鹽水後對七氟烷誘導後2min3min對兒童氣管插管條件和氣道反應(咳嗽/肢體運動)的影響。

方法:選擇1-7歲兒童188例。8%七氟烷/氧化亞氮麻醉誘導後1min鼻內使用瑞芬太尼(4ug/kg)或生理鹽水。隨後七氟烷濃度降至5%,根據情況進行輔助或控制通氣;由一位不知分組與處理的麻醉醫師評價置入咽喉鏡和插管條件。鼻內使用瑞米芬太尼0123410min後從17例兒童採集血樣測定瑞米芬太尼濃度。

結果:使用負荷劑量瑞芬太尼後68.2%患者在2min內能達到較好插管條件,3min則為91.7%。與此相比,使用安慰劑組則分別為37%23%(P < 0.01)。在2, 3, 4, and 10 min時點瑞芬太尼平均血漿濃度分別為1.0 (0.60), 1.47 (0.52), 1.70 (0.46), and 1.16 (0.36) ng/mL。峰值濃度出現在3.47 min,未發現併發症。

結論:七氟烷麻醉誘導鼻內使用瑞芬太尼能在2-3min提供良好的插管條件。

(蔣宗明譯 薛張綱校)

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.

 

 

新型貝式閉合環路系統在使用BIS作為控制性變數的異丙酚麻醉中的精確性和臨床可行性

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:使用閉合環路系統來實現對麻醉給藥的控制是優化給藥方式的重要途徑。在這裏,我們將介紹一個新近研發的基於貝式環路的、將患者個體化、模型化的適應性控制方法,用以來控制臨床上在BIS指導下的異丙酚輸注,並且比較它在門診婦產科手術中,分別于麻醉師的直接觀察和BIS指導下滴定測得的異丙酚輸注的精確性及臨床可行性。

方法40ASA病人被隨機的分配到閉合環路組和手控組,所有的病人在誘導前均由靜脈給予1 mg咪唑達倫和0.5 mg的阿芬太尼。在閉合環路組,異丙酚的使用是根據先前提及的閉合環路系統來盡可能的使BIS值達到並維持在50。而在手控組,異丙酚的作用濃度是根據麻醉師的判斷而來使BIS值盡可能的達到並維持於50。同時,誘導時的特性參數、誘導的完成和在維持及蘇醒期間的平穩性也都將加以比較。而血流動力學和呼吸系統的平穩性指標也被計入了評價其臨床可行性的參數。

結果:用閉合環路系統滴定測得的異丙酚輸注時的BIS值與預設值極為接近。該閉合環路系統不僅可在臨床許可時間內完成對病人的誘導,還比手控組減少了藥物的過量使用,且自動控制組在蘇醒時間上更顯出了較大的優勢。但閉合環路組與手控組在臨床上的表現相近,這主要體現在相近的血流動力學和呼吸系統的平穩性,以及相當的運動頻率和質量評分。

結論:在使用BIS作為控制性參數的異丙酚輸注中,新型的貝式閉合環路系統在門診婦產科的麻醉中表現出了極大的精確性。這種控制系統不單具有臨床可行性,而且還可在進一步的臨床實踐中加以證實。

(劉沁譯 薛張綱校)

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.

 

 

船塢模型研究惰性氣體麻醉藥與非麻醉作用氣體與血清白蛋白不同結合位點

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:非麻醉作用氣體與麻醉藥在結構上相似,但在臨床上起相關聚合物不產生麻醉效應。氙、氪、氬是麻醉藥,而氖、氦是非麻醉作用氣體 。惰性氣體中麻醉藥與非麻醉作用氣體結構相似,它們的相互作用也單一。在分子麻醉學中,麻醉藥和非麻醉作用氣體的作用結合位點長久來一直是研究的一個問題所在。

方法:我們用人血清白蛋白來檢測惰性氣體麻醉藥和非麻醉作用氣體結合位點和能量,因為人血清白蛋白的結構我們已知曉且他和麻醉藥有一個結合位點。我們有電腦類比船屋來群找結合位點並計算小分子和 分子的結合能量。

結果:氙、氪、氬與人血清白蛋白與安氟醚結合位點結合,而氖、氦與氙有不同的結合位點。稀有氣體麻醉藥的結合依靠范德華能量,而非麻醉作用氣體結合依靠溶劑效應能量。優先結合位點是由能量決定的。范德華能量是麻醉藥必需的結合前提。

結論:此項結合能量組成的分析提供一個麻醉藥與非麻醉作用氣體有不同結合位點的原理。顯示麻醉藥與非麻醉作用氣體結合交互作用不同,可能解釋了麻醉藥與非麻醉作用氣體藥理作用的不同並且提供了一個麻醉藥物在原子水平上作用的解釋。

(劉婷潔譯 薛張綱校)

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病人使用震動反應成像技術(VRI)用於評估不對稱肺臟疾病

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:震動反應成像(Vibration response imaging VRI)是一種基於電腦處理的技術,它能用可視的動態二維圖像來反應呼吸過程中兩肺的震動情況。在病人體表放置36個感應器,收集並記錄其聲頻信號,傳輸到裝有數個篩檢程式的硬體板上,選出其中的特定頻率波段。濾波輸出的信號頻率以灰階編碼的二維圖像來表現。它由一系列的0.17s幀幅來組成。這些圖像以列表的形式表現了每個單肺在整個震動信號中所占的百分比。

方法:我們詳盡介紹了VRI技術,並研究了影像學顯示單肺有病變的ICU病人的VRI圖像。影像學顯示雙肺正常的ICU病人列為對照組。研究以對比兩肺的圖元計數加權來進行。運用這種方法,VRI圖像中的每個圖元根據其灰階都被指定一個值,圖元越暗,數值越高。

結果:影像血顯示雙肺正常的ICU病人,動態VRI圖像相似,兩肺所占的震動百分比具有可比性(分別為53%±12%47±12%)。而在影像學顯示雙肺不對稱疾病的ICU病人中,VRI圖像中患側與健側肺的震動百分比分別為27%±23%以及73%±23%p0.001〉。在不對稱肺疾病的患者中(影像學顯示一側肺有中重度疾病而另一側肺表現為正常或接近正常),患側肺在VRI圖像中通常表現為圖像較健側肺不規則、較小及顏色較淺(震動減少表現)。患側及健側肺的圖元計數加權分別為33%±21%67%±21%p0.003)。

結論VRI圖像技術可以提供一種無放射性的方法來識別及定位不對稱的肺實質疾病。

(秦敏菊譯 薛張綱校)

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.

 

 

減肥術後體重減輕患者肺吸入的風險

 

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:我們研究接受塑身手術,包括胃囊帶術及胃成形術的患者,評估其發生肺吸入的風險。

方法:我們對5年期間(2000-2005年)在盧昂大學醫院接受塑身手術的所有患者進行回顧性病例對照研究。分組方法:在接受塑身手術前,曾接受減肥手術(腹腔鏡可調胃囊帶術或Mason’s垂直胃成形術)的患者為既往減肥術組;其他患者均為對照組。資料包括所有麻醉管理記錄及醫院電腦資料庫中的資料,經分析後得出肺吸入的發病率。

結果:我們共完成198例塑身手術( 66例病例組和132個對照組)的資料統計。既往減肥術組的肺吸入發生率(4 : 6%)較對照組(0例)顯著升高(P < 0.006)。所有發生肺吸入的患者均接受過胃囊帶術。未接受積極預防措施的病人,需特別警惕對肺有影響的改變。

結論:胃囊帶術對體重減輕患者手術期間肺吸入的風險有重要影響。

(施穎譯 薛張綱校)

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.

 

 

聽覺誘發電位儀及畢氏腦波儀用於評價重症監護病人的鎮靜程度

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:據報導在ICU的沒有接受神經肌肉阻滯劑的鎮靜病人可由肌電圖來評估腦電雙頻指數(BIS)。我們研究ICU鎮靜病人使用肌松劑後聽覺誘發電位和BIS的變化。

方法:三十八個需使用肌肉鬆弛劑且持續以咪達唑侖及芬太尼止痛鎮靜達Ramsay鎮靜指標值5以上之重症加護病人納入研究。於肌肉鬆弛劑給予前三十分鐘及作用後三十分鐘每五分鐘紀錄畢氏腦波儀指數、訊號品質指數、聽覺誘發電位合成指數及肌肉電器活性一次。Student's 測試,Wilcoxon評分測試,Spearman測試的評分通過SPSS 10.0軟體統計出來。

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。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。還还还 發現給予肌肉鬆弛劑後畢氏腦波儀指數及聽覺誘發電位合成指數的降低與給予肌肉鬆弛劑前的指數及肌肉電器活性呈現明顯相關。

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。結論: 該研究表明,對ICU的鎮靜病人來說,BIS AAI在使用肌松劑後明顯降低,這種情況也適用於手術中接受麻醉的病人。

(孫鵬飛譯 薛張綱校)

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對於人離體妊娠子宮肌層收縮力抑制作用的對比

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鎮痛常用而有效的方法。然而,此方法的使用與使用輔助器生產率增高有關。證明該副作用機理的方法之一就是明確局部麻醉藥物對子宮肌收縮力的直接影響。我們對比了布比卡因和左旋布比卡因對於人足月子宮肌收縮幅度和頻率的作用。

方法:子宮樣本來源於足月、非臨產狀態、預定行下段剖宮產手術者。將子宮縱行肌束垂直固定,記錄收縮幅度(力量峰值)頻率的變化。施加1g(9.81 mN)的拉力後肌束開始自發性收縮。不使用任何促子宮收縮藥物。繼而使用布比卡因和左旋布比卡因持續作用於肌束,記錄下計量反應曲線。

結果:對比自體控制幅度,兩種藥物都降低子宮肌收縮幅度約1 x 10–4 M。伴隨著收縮幅度的降低,兩種藥物使子宮肌收縮頻率增加,達到有意義的收縮幅度為3 x 10–5 M

結論:要達到影響子宮收縮作用的血藥濃度要遠遠高於(33倍)現今臨床上使用的血藥濃度,使用低硬膜外藥物濃度並沒有顯著意義。

(夏俊明譯 薛張綱校)

 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.

 

 

為神經外科病人計畫早期蘇醒:一項使用小劑量麻醉劑的隨機前瞻性研究

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:為了早期檢測大腦的併發症,開顱術後迅速從麻醉中蘇醒是必要的。系統性高血壓是與快速蘇醒有關的主要缺點,可能誘發顱內血腫的形成。雖然各種藥物都被廣泛地評估過,關於使用麻醉劑緩解突發高血壓的資料仍很有限。我們假設在關顱時使用小劑量麻醉劑可以促進早期蘇醒時血流動力學變化。

方法:150例血壓正常的行小腦幕上腫瘤手術的成年病人使用標準異氟醚吸入麻醉,評估三種蘇醒方法。在關硬腦膜時,病人隨機得到:小劑量丙泊酚(3mg/kg/h),芬太尼(1.5 µg/kg/h),異氟醚(濃度0.2%),直到開始關皮膚。笑氣在貼完敷料後停止。

結果:丙泊酚組的平均蘇醒時間是6min,芬太尼組為4min,異氟醚組為5minp=0.08)。與拔管時和拔管後比較,拔管前更多病人出現高血壓(P = 0.009)。比較三組,全部使用芬太尼的病人在拔管前期較少使用艾司洛爾(P = 0.01)。術前腦顯像掃描示中線偏移顯著是蘇醒期高血壓的獨立危險因素。

結論:手術關閉時的疼痛可能是交感興奮的重要原因從而導致蘇醒期高血壓。對於使神經外科病人早期蘇醒,在關顱時使用小劑量芬太尼比丙泊酚和異氟醚更有利,同時是預防術後早期高血壓的最有效的方法。

(宣麗真譯 薛張綱校)

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.

 

脈壓與冠狀動脈搭橋術後不良預後的風險

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:在能夠走動、無需臥床的患者當中,脈壓(PP)增大已經被證實是發生血管意外的一個重要因素。然而脈壓與接受冠狀動脈旁路移植術(CABG)的患者發生急性圍手術期血管意外之間的聯繫還並不為人所熟知。

方法:作者對5436名接受心肺轉流CABG手術的患者進行了前瞻性的研究。其中,4801名患者符合最終的試驗選擇標準。採集其病史,術中及術後的生理和實驗室檢查,診斷學檢查,臨床徵象等綜合資料,採用多變數對數回歸對術前高血壓(收縮期,舒張期,脈壓)與心肌和腦缺血的預後及死亡率的關係進行評估;P<0.05則認為有顯著性。

結果: 917名患者(19.1%)發生致死性或非致死性的血管併發症,包括146名患者(3.0%)發生腦血管意外,715名患者(14.9%)發生心血管意外。147名患者住院期間死亡(3.1%)。所有術前測量的血壓變數中,脈壓與術後併發症風險的增加最為密切。脈壓增大10mmHg(大於閾值40mmHg),腦血管意外的發生率也增加(校正優勢率:1.1295CI[1.002-1.28];P=0.026)。脈壓>80mmHg的患者與脈壓80mmHg的患者相比,腦血管意外和/或死於神經病學併發症的發生率幾乎是後者的兩倍(5.5%對比2.8%P0.004)。脈壓大於80mmHg時與心臟併發症亦有關,充血性心力衰竭的發生率可增加52%,而因心臟原因引起的死亡率增加接近100%(分別為P0.0030.006)。

結論:在接受CABG手術的患者中,脈壓增大與其本身與腦和心臟的致死性和非致死性不良結果密切相關。這些發現突顯了術前脈壓與術後急性血管意外的風險間的聯繫。

(印潔敏 陳傑 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釋能改變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; {dagger}Department of Anesthesiology, University Hospital Chiangmai, Chiangmai, Thailand; {ddagger}Department of Anesthesiology, Brugmann University Hospital - Children University Hospital Reine Fabiola, Brussels, Belgium; and §Department of Anesthesiology, University of Amsterdam, and Division of Cardiothoracic and Vascular Anesthesiology, Academic Medical Center, Amsterdam, the Netherlands.

Anesth Analg 2008 107: 1145-1152.

 

背景:儘管冠狀動脈手術病人對中度血液稀釋有良好的耐受能力,但是在心肌氧需增加時並非如此。作者假設在這些病人在心率增快時血液稀釋可能導致心肌功能損害。

方法:40名冠狀動脈手術病人根據房室起搏率被隨機分為兩組【70bpmGroup 70)或90bpmGroup 90)】。當心率比較穩定時,在開始體外迴圈前進行血液稀釋。採集肺動脈導管、PiCCO導管和左室壓力導管壓力數據。在等容血液稀釋之前和之後穩態時進行測量。

結果:70組血液稀釋從40 ± 2 %至30 ± 1 %,90組從39 ± 4 %至30 ± 2 %導致全身血管阻力降低,舒張末期容積增加。70組與每博量的增加有關,而在90組則無關。90組血液稀釋後最大壓力變化率明顯降低(856 ± 93716 ± 80mmHg/s,P <0.01 ; 70組保持不變(血液稀釋之前為843 ± 86 mmHg/s, 血液稀釋之後為832 ±79 mmHg/s)。

結論:本研究條件下心率增快時中度血液稀釋與心肌功能受損有關。

(潘錢玲 陳傑 校)

BACKGROUND: Although moderate hemodilution is usually well tolerated in coronary artery surgery patients, this may not be the case when myocardial oxygen demand is increased. We hypothesized that, in these patients, hemodilution in the presence of an increased heart rate could be associated with an impairment of myocardial function.

METHODS: Forty coronary surgery patients were randomly assigned to two groups (n = 20), according to the rate of atrioventricular pacing [70 bpm (Group 70) or 90 bpm (Group 90)]. While paced at the fixed heart rate, hemodilution was performed before the start of cardiopulmonary bypass. Data were obtained from a pulmonary artery, a PiCCO catheter and a left ventricular pressure catheter. Measurements were obtained in steady-state conditions before and after isovolemic hemodilution.

RESULTS: Hemodilution from 40% ± 2% to 30% ± 1% in Group 70, and from 39% ± 4% to 30% ± 2% in Group 90 resulted in a decrease in systemic vascular resistance and an increase in end-diastolic volume in both groups. This was associated with an increase in stroke volume in Group 70 but not in Group 90. In this latter group, the maximal rate of pressure development decreased significantly after hemodilution [from 856 ± 93 to 716 ± 80 mm Hg/s (P < 0.01)], whereas it remained unchanged in Group 70 (843 ± 86 mm Hg/s before and 832 ± 79 mm Hg/s after hemodilution).

CONCLUSIONS: In the conditions of the present study, increased heart rate during moderate hemodilution was associated with a depression of myocardial function.

 

小於三歲的嬰幼兒骶管注射左旋布比卡因(2.5mg/kg)時的藥代動力學

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

Luis I. Cortínez, MD*, Ricardo Fuentes, MD*, Sandra Solari, MD{dagger}, Paola Ostermann, MD{ddagger}, Miguel Vega, MD{ddagger}, and Hernán R. Muñoz, MD, MSc*

From the *Departamento de Anestesiología y {dagger}Laboratorio Clínico, Facultad de Medicina, Pontificia Universidad Católica de Chile, and {ddagger}Servicio de Anestesiología, Hospital Josefina Martínez, Santiago, Chile.

Anesth Analg 2008 107: 1182-1184.

 

背景:嬰幼兒骶管中注射左旋布比卡因(2.5mg/kg)在許多醫院中經常採用。然而,這種應用方案下左旋布比卡因血液濃度尚無報導。本文報導了左旋布比卡因(2.5mg/kg)用於小於三歲嬰幼兒骶管注射後的藥代動力學的結果。

方法:這些孩子年齡從136個月在七氟醚麻醉下行腹部以下手術。骶管注射0.25%左旋布比卡因(2.5mg/kg)後,連續抽取靜脈血樣本檢測給藥三小時後布比卡因的血漿總濃度水平。測量左旋布比卡因的最大濃度Cmax和峰值時間Tmax中位數(範圍)分別是1.48 0.62-2.40 μg / mL37 10-60 min。個體Cmax最大值出現在一名一月齡嬰兒,時間是骶管阻滯後30min

結論:本研究中最大濃度的最高值幾乎接近于成人麻醉中毒劑量的閾值。儘管還沒有有關左旋布比卡因(2.5mg/kg)骶管注射的不良事件的報導,但必須引起注意,尤其是在小嬰兒中。

(王騰 陳傑 校)

BACKGROUND: Caudal administration of levobupivacaine (2.5 mg/kg) in children is used frequently in some hospitals. However, no reports of levobupivacaine concentrations have been published with this dosing scheme. We report the results of a study on the pharmacokinetics of levobupivacaine (2.5 mg/kg) after caudal administration in children younger than 3 yr.

METHODS: Ten children, aged 1–36 mo and scheduled for subumbilical surgery were studied under sevoflurane anesthesia. After caudal injection of 0.25% levobupivacaine (2.5 mg/kg), serial venous blood samples were taken for 3 h to measure total plasma concentration levels of levobupivacaine. Median (range) levobupivacaine Cmax and Tmax measured were 1.48 (0.62–2.40) µg/mL and 37 (10–60) min. The highest individual Cmax was observed in a 1-mo-old infant 30 min after caudal block.

CONCLUSIONS: The highest Cmax reached in this study was close to the toxic threshold of adult patients. Although no adverse events have been reported, care must be taken, especially in small infants, after caudal administration of levobupivacaine (2.5 mg/kg).

 

年老大鼠丙泊酚麻醉後定向力完整

Spatial Memory Is Intact in Aged Rats After Propofol Anesthesia

In Ho Lee, MD, PhD*, Deborah J. Culley, MD{dagger}, Mark G. Baxter, PhD{ddagger}, Zhongcong Xie, MD, PhD§, Rudolph E. Tanzi, PhD||, and Gregory Crosby, MD{dagger}

From the *Department of Anesthesiology, Korea University Guro Hospital, Seoul, Republic of Korea; {dagger}Department of Anesthesia, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts; {ddagger}Wellcome Trust Senior Research Fellow, Oxford University, Oxford, UK; §Department of Anesthesia, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts; and ||Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Genetics and Aging Research Unit, Charlestown, Massachusetts.

Anesth Analg 2008 107: 1211-1215.

 

背景:先前研究顯示年老大鼠笑氣鎮靜或丙泊酚—笑氣全麻後的定向力有持續受損。丙泊酚作用於不同受體且有恢復快的特性,推測丙泊酚對認知沒有持續作用。對此尚無仔細研究,因此作者設計本試驗檢測丙泊酚對定向力的長時作用。

方法18個月大的年老鼠隨機分組,試驗組100%氧氣-丙泊酚麻醉2hn=11),對照組吸100%氧氣(n=10)。丙泊酚通過外周靜脈導管持續泵入。維持大鼠自主呼吸和基礎體溫。平均動脈壓通過無創測壓獲取,丙泊酚停止之前測定靜脈血氣。2天恢復時間之後,通過12模式迷宮進行14天的定向記憶力評估,記錄錯誤總數、出現第一個錯誤之前正確選擇數、以及完成迷宮的時間並且使用ANOVA分析,P < 0.05認為具有統計學差異。

結果:丙泊酚平均輸注速率為0.6 ± 0.1mg/Kg/min,這個速率是成年鼠50%有效濃度。麻醉期間平均動脈壓為100 ± 2mmHg,靜脈血氣分析維持正常範圍。對照組與先前麻醉的大鼠在迷宮測量方面無任何差別,這意味著丙泊酚麻醉在成年鼠定向記憶不產生持續損害。

結論:本年老大鼠模型,丙泊酚麻醉相對於其他麻醉對大鼠定向力無持續損害。因此,當全身麻醉狀態對發展成麻醉後記憶受損既不是必然,也不足于形成,麻醉藥的選擇可能在老年後期認知功能結局中起一定作用。

(宋翠俠 陳傑 校)

BACKGROUND: We have previously demonstrated that aged rats have persistent impairment of spatial memory after sedation with nitrous oxide or general anesthesia with isoflurane-nitrous oxide. Propofol has different receptor mechanisms of action and a favorable short-term recovery profile, and it has been proposed that propofol is devoid of enduring effects on cognitive performance. No studies have investigated this question in aged subjects, however, so we designed an experiment to examine the long-term effects of propofol anesthesia on spatial working memory.

METHODS: Eighteen-mo-old rats were randomized to 2 h of 100% oxygen-propofol anesthesia (n = 11) or to a control group that breathed 100% oxygen (n = 10). Propofol was administered by continuous infusion via a tail vein catheter. Rats breathed spontaneously and rectal temperature was maintained. Mean arterial blood pressure was measured noninvasively and a venous blood gas was obtained just before discontinuation of propofol. After a 2-day recovery, spatial working memory was assessed for 14 days using a 12-arm radial maze. The number of total errors, number of correct choices to first error, and time to complete the maze was recorded and analyzed using a repeated measure analysis of variance (ANOVA), with P < 0.05 being considered statistically significant.

RESULTS: The average propofol infusion rate was 0.6 ± 0.1 mg · kg –1 · min–1, a rate corresponding to a 50% effective concentration dose in adult rats. Mean arterial blood pressure during anesthesia was 100 ± 2 mm Hg and venous blood gases remained in the normal range. There was no difference between the control and previously anesthetized rats on any measure of radial arm maze performance, indicating propofol anesthesia produces no lasting impairment in spatial working memory in aged rats.

CONCLUSIONS: In aged rats, propofol anesthesia is devoid of the persistent memory effects observed with other general anesthetics in this model. Thus, while it appears that the state of general anesthesia is neither necessary nor sufficient for development of postanesthetic memory impairment, the choice of anesthetics may play a role in late cognitive outcome in the aged.

 

三環類抗抑鬱藥對人的中性粒細胞吞噬功能和氧化突發的抑制作用

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

Annette Ploppa, MD*{dagger}, Donald M. Ayers, MD{dagger}, Tanja Johannes, MD*, Klaus E. Unertl, MD*, and Marcel E. Durieux, MD, PhD{dagger}

From the *Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany; and {dagger}Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.

Anesth Analg 2008 107: 1229-1235.

 

BACKGROUND: Tricyclic antidepressants are being investigated as long-acting analgesics for topical application in wounds or IV for postoperative pain relief. 景:三環類抗抑鬱藥作為長效鎮痛藥,應用於傷口局部或靜脈注射緩解術後疼痛正在研究中。 However, it remains unclear if tricyclic antidepressants affect the host defense and if reported toxic effects on neutrophils are of relevance in this setting.但三環類抗抑鬱藥是否影響宿主防禦反應和是否對中性粒細胞有害影響仍不清楚。 We therefore investigated the effects of amitriptyline, nortriptyline, and fluoxetine on human neutrophil phagocytosis, oxidative burst, and neutrophil toxicity in a human whole blood model.因此,作者研究了阿米替林、去甲替林氟西汀對人類全血細胞中嗜中性粒細胞吞噬功能、氧化應激和中性粒細胞的毒性作用。

METHODS: Heparinized blood samples from healthy volunteers were incubated with amitriptyline, nortriptyline, or fluoxetine (10(-6) to 10(-3) M) for 0, 1, or 3 h. 法:來自健康志願受試者的肝素化血液樣本加入濃度為10–6 10–3 M的阿米替林,去甲替林或氟西汀,培養0 1 ,或3小時。加入 Staphylococcus aureus in a bacteria:neutrophil ratio of 5:1 and dihydroethidium (for the determination of oxidative burst) were added.金黃色葡萄球菌(金黃色葡萄球菌:嗜中性粒細胞比例為5:1)和dihydroethidium 超氧化物陰離子螢光探針,用來測定氧化應激作用)。 Phagocytosis was stopped after 5, 10, 20, and 40 min.吞噬作用在5 10 2040分鐘後被截停。樣本通過流式細胞儀分析After lysis of red blood cells, samples were analyzed by flow cytometry.裂解後的紅細胞,。

RESULTS: In concentrations up to 10(-4) M, none of the compounds affected neutrophil phagocytosis and oxidative burst. 果:10–4M濃度下,藥物不影響中性粒細胞吞噬功能和氧化應激作用。 At 10(-3) M, all three compounds were highly toxic for neutrophils. 10–3M濃度下,三種藥物都對中性粒細胞具有高毒性。 Amitriptyline preserved morphological integrity, but completely suppressed neutrophil function.阿米替林對中性粒細胞形態無影響,但完全抑制其功能。 Nortriptyline and fluoxetine caused a marked disruption of neutrophils.甲替林與氟西汀對中性粒細胞產生明顯破壞作用。 抗抑鬱藥作用The effects of the investigated antidepressants were not time-dependent.無時間依賴性。

CONCLUSIONS: Phagocytosis and intracellular host defense are largely unaffected by antidepressants in concentrations of 10(-4) M and below. 論:抗抑鬱藥在濃度為10–4 M以下對細胞吞噬功能和細胞內宿主防禦反應基本無影響。 當抗抑鬱藥濃度在毫摩爾濃度時Our results confirm that antidepressants are highly toxic to neutrophils in millimolar concentrations.對中性粒細胞有強毒性。 因此,神經毒性及臨床副作用,而非中性粒細胞的功能受害作用,可能是在抗抑鬱藥作為鎮痛藥使用中的限制因素。The neurotoxic effects and clinical side effects, but not effects on neutrophil functions, therefore, are likely to be the limiting factors in using antidepressants as analgesics.神经毒性  及临床   ,,,,,

(張燕 陳傑 校)

BACKGROUND: Tricyclic antidepressants are being investigated as long-acting analgesics for topical application in wounds or IV for postoperative pain relief. However, it remains unclear if tricyclic antidepressants affect the host defense and if reported toxic effects on neutrophils are of relevance in this setting. We therefore investigated the effects of amitriptyline, nortriptyline, and fluoxetine on human neutrophil phagocytosis, oxidative burst, and neutrophil toxicity in a human whole blood model.

METHODS: Heparinized blood samples from healthy volunteers were incubated with amitriptyline, nortriptyline, or fluoxetine (10–6 to 10–3 M) for 0, 1, or 3 h. Staphylococcus aureus in a bacteria:neutrophil ratio of 5:1 and dihydroethidium (for the determination of oxidative burst) were added. Phagocytosis was stopped after 5, 10, 20, and 40 min. After lysis of red blood cells, samples were analyzed by flow cytometry.

RESULTS: In concentrations up to 10–4 M, none of the compounds affected neutrophil phagocytosis and oxidative burst. At 10–3 M, all three compounds were highly toxic for neutrophils. Amitriptyline preserved morphological integrity, but completely suppressed neutrophil function. Nortriptyline and fluoxetine caused a marked disruption of neutrophils. The effects of the investigated antidepressants were not time-dependent.

CONCLUSIONS: Phagocytosis and intracellular host defense are largely unaffected by antidepressants in concentrations of 10–4 M and below. Our results confirm that antidepressants are highly toxic to neutrophils in millimolar concentrations. The neurotoxic effects and clinical side effects, but not effects on neutrophil functions, therefore, are likely to be the limiting factors in using antidepressants as analgesics.

 

一種新型彎曲喉鏡片用於常規和困難氣管插管

A New Curved Laryngoscope Blade for Routine and Difficult Tracheal Intubation

Koji Nishikawa, MD, PhD*, Koki Yamada, MD, PhD*, and Atsuhiro Sakamoto, MD, PhD{dagger}

From the *Department of Anesthesiology, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan; and {dagger}Department of Anesthesiology, Nippon Medical School Hospital, Tokyo, Japan.

Anesth Analg 2008 107: 1248-1252.

 

作者基於一個新的扭轉peardrop現象的概念設計了一種新型彎曲喉鏡片,其在多種病人氣管插管術中比目前提供的Macintosh鏡片更便於充分暴露喉部。 新型設計有一雙尖端和S形壓舌片以便在溝回部位更有效施加壓力,提升會厭和改變施於舌的力的方向,以防在下頜下部位喉鏡壓迫舌頭導致舌頭後下位脫臼。一種X 型喉鏡技術已經用於指導新型彎曲鏡片的設計和比較新型彎曲鏡片和Macintosh鏡片應用於有或沒有困難氣道患者中的性能 研究結果證實在存在或不存在沒有預料的困難氣道的患者中,新型鏡片通過在下頜下部位適當方向壓迫舌根部和有效提升會厭為氣管插管術提供了充分的視野。在2- 13歲小兒患者中,新型彎曲喉鏡片還可以有效地推動U形會厭於喉部視野外以便於氣管插管。

(陳偉 陳傑 校)

We have designed a new curved laryngoscope blade based on a new concept of reversing the peardrop phenomenon to facilitate a view of the larynx sufficient for intubation in a greater variety of patients than the current Macintosh blade affords. The new design has a bifid tip and S-shaped spatula to exert more effective pressure in the vallecula area, elevate the epiglottis and change directions of the forces on the tongue to prevent posteroinferior displacement of the compressed tongue in the submandibular space during laryngoscopy. A radiograph laryngoscopy technique was used to guide the new blade curvature design and compare the performance of the new blade with the Macintosh blade in patients with or without a difficult airway. Our results confirm that the new blade provides a laryngeal view sufficient to accomplish intubation by compressing the root of the tongue in an anterocephalad direction in the submandibular space and elevating the epiglottis effectively in patients with or without unanticipated difficult airway. The new curved blade can also effectively move the U-shaped epiglottis out of the laryngeal view to facilitate intubation in pediatric patients aged 2 mo–13 yr.

 

非損傷肺行與不行呼氣末正壓機械通氣時肺部細胞因數的反應

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

Torsten Meier, MD*, Alexandra Lange*, Hilke Papenberg, MD*, Malte Ziemann, MD*, Christina Fentrop, PhD{dagger}, Ulrike Uhlig, PhD{dagger}, Peter Schmucker, MD*, Stefan Uhlig, PhD{dagger}, and Cordula Stamme, MD{ddagger}

From the *Department of Anesthesiology, University Medical Center Schleswig-Holstein, Campus Lübeck, Germany; {dagger}Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany; and {ddagger}Research Group Cellular Pneumology, Research Center Borstel, Germany.

Anesth Analg 2008 107: 1265-1275.

 

背景:在行機械通氣時呼氣末正壓(PEEP)可能會在健康的肺增加不同程度的應激。根據應激可通過細胞因數所反映的假設,作者通過對比在離體小鼠灌注肺模型(IPL)和健康病人來研究PEEP對支氣管肺泡和系統介質的影響。

方法:一、IPL給予呼氣末03610cm H2O壓力和吸氣末1025 cm H2O壓力通氣。測定靜脈白細胞介素-6和巨噬細胞炎症介質蛋白質-2。二、選擇行擇期耳鼻喉科手術的不吸煙患者,隨機分為不行PEEPPEEP 10 cm H20 兩組。監測支氣管肺泡灌洗出的介質、核因數кB,監測在肺泡的巨噬細胞中的啟動的核因數кB和循環系統中介質。對照組在行氣管插管後行支氣管肺泡灌洗。

結果:在IPL,增加呼氣末壓力介質濃度增加,在吸氣末壓力為10 cm H2O是介質濃度增加,但是在吸氣末壓力為25 cm H2O時介質濃度減少。在患者,支氣管肺泡中的白細胞介素-6,巨噬細胞炎症介質蛋白質-2,和粒細胞單核細胞集落刺激因數的增加與PEEP值無關。增加PEEP可以適度的增加白細胞介素-6和白細胞介素-8,但是不行呼氣末壓力則不增加。DNA核因數кB結合的活躍性在肺泡中的巨噬細胞和全身的介質水平沒有改變。

結論:細胞因數水平可反映機械應激,甚至低潮氣量通氣也可導致一定程度的應激。PEEP在高吸氣壓時有益,但即使在低吸氣壓時也可致中度應激。

(王鵬 陳傑 校)

BACKGROUND: Positive end-expiratory pressure (PEEP) during mechanical ventilation may impose different degrees of stress on healthy lungs. On the assumption that stress is reflected by cytokine production, we performed a translational study investigating the effect of PEEP on bronchoalveolar and systemic mediator levels in isolated perfused mouse lungs (IPL) and in patients with healthy lungs.

METHODS: (Part I) IPL were ventilated with end-expiratory pressures of 0, 3, 6, or 10 cm H2O and end-inspiratory pressure (EIP) levels of 10 or 25 cm H2O. Interleukin (IL)-6 and macrophage inflammatory protein-2 concentrations in the venous effluate were monitored. (Part II) Patients (nonsmokers) scheduled for elective otorhinolaryngology surgery (duration >90 min) were randomized to receive either ventilation with zero end-expiratory pressure or PEEP (10 cm H2O). Mediators in bronchoalveolar lavage, nuclear factor {kappa}B, (NF-{kappa}B)-activation in alveolar macrophages and circulating systemic mediators were monitored. Control patients underwent bronchoalveolar lavage after intubation.

RESULTS: In the IPL, mediator concentrations increased with increasing end-expiratory pressure at an EIP of 10 cm H2O, but decreased at 25 cm H2O EIP. In patients, bronchoalveolar IL-6, monocyte chemoattractant protein-1, and granulocyte monocyte-colony stimulating factor were increased by ventilation regardless of the PEEP level. IL-6 and IL-8 levels were moderately increased by PEEP but not zero end-expiratory pressure. Nuclear factor {kappa}B DNA binding activity in alveolar macrophages and systemic mediator levels did not change.

CONCLUSIONS: On the basis of the premise that cytokine levels may indicate mechanical stress, our findings indicate that even low tidal volume ventilation causes some stress. PEEP is beneficial at high inspiratory pressure, but imposes moderate stress at low inspiratory pressure.

 

丙泊酚通過降低再灌注肝氧自由基的釋放來減輕肺的動態順應性的降低和肺水的含量。

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, MD*, Chen-Jung Lin, MD*, Po-Huang Lee, MD, PhD{dagger}, Chau-Fong Chen, PhD{ddagger}, Yih-Loong Lai, PhD{ddagger}, Wei-Zen Sun, MD*, and Ya-Jung Cheng, MD, PhD*

From the Departments of *Anesthesiology, {dagger}Surgery, National Taiwan University Hospital, National Taiwan University; and {ddagger}Department of Physiology, College of Medicine, National Taiwan University, Taipei, Taiwan.

Anesth Analg 2008 107: 1284-1289.

 

背景:肝臟再灌注後由於活性氧自由基造成的間接的肺損傷是很常見的。麻醉劑的選擇能影響到氧化與抗氧化之間的平衡,而丙泊酚,一種常用的麻醉劑,具有抗氧化的作用。在這個實驗中,作者建立了一個模型來研究肺功能和肝臟缺血再灌注,目的是確定肝臟再灌注後的肺功能障礙和丙泊酚是否通過改變肝臟和肺產生的活性氧來影響這一功能。

方法:體重在160-250g之間的成年雄性大鼠,根據損傷的類型(對照和缺血再灌注)和使用不同的麻醉劑(戊巴比妥和丙泊酚)而隨機的分成四組。通過阻斷肝臟左內側葉的門靜脈和肝動脈來造成缺血再灌注的模型。所有的測量資料在缺血45分鐘,再灌注5小時後完成。肝臟缺血再灌注後的肺功能通過肺的動態順應性,肺循環阻力,通氣/血流比值和組織病理學來確定。肝細胞損傷通過穀丙轉氨酶所證實,測定下腔靜脈,頸內靜脈,頸動脈產生的活性氧,另測定肺和肝臟組織中脂質過氧化產物,硫代巴比妥酸反應物質和丙二醛。

結果:肝缺血再灌注導致遠隔肺損傷通過明顯的肺順應性的降低、阻力的增加及濕幹比顯示。活性氧的生成明顯增加,以下腔靜脈的樣本中最高。I/R+戊巴比妥組中肝臟中的硫代巴比妥酸和丙二醛,血清中的穀丙轉氨酶顯著增加。所有的這些改變在I/R+丙泊酚組明顯減少(P=0.05)。丙泊酚持續輸注,減少了肝臟再灌注後活性氧的產生,減少肝細胞的損傷,從而維護良好的肺功能。

結論:大鼠實驗證實了間接肺功能障礙和肝臟再灌注損傷、以及大量活性氧的產生和脂質過氧化反應等有關。丙泊酚持續輸注通過減少再灌注肝臟的氧化損傷來減輕間接的肺損傷。

(舒慧剛 陳傑 校)

BACKGROUND: Remote pulmonary injuries after hepatic reperfusion are frequently caused by reactive oxygen species (ROS)-induced damage. The choice of anesthetics may affect the balance between oxidants and antioxidants, and propofol, a commonly used anesthetic, has an antioxidant effect. In this study, we developed a model to study pulmonary function with hepatic ischemia/reperfusion (I/R) manipulation, with the aim of defining remote pulmonary dysfunction after hepatic reperfusion and determining if propofol affects this dysfunction by altering ROS production from the liver or lungs.

METHODS: Adult male rats weighing 160–250 g were randomly divided into four groups according to the type of surgery (sham or I/R) and the anesthetic administered (pentobarbital or propofol). To induce I/R, the portal vein and hepatic artery to the left and medial lobes of the liver were clamped. All of the measurements were done after 5 h of reperfusion, after 45 min of ischemia. Pulmonary function after hepatic I/R was determined by dynamic compliance, resistance and wet-to-dry ratio, and by histopathology. Hepato-cellular injuries were confirmed by alanine aminotransferase, whereas ROS production was measured from the inferior vena cava, jugular vein, and carotid artery. Products of lipid peroxidation, thiobarbiturate acid reactive substances and malondialdehyde, were measured in lung and hepatic tissues.

RESULTS: Remote lung injury after hepatic I/R was shown by a significant decrease of Cdyn, and increases in resistance and the wet-to-dry ratio. ROS production was significantly increased and was highest in samples from the inferior vena cava. Thiobarbiturate acid reactive substances and malondialdehyde in the liver and serum alanine aminotransferase were significantly increased only in the I/R+pentobarbital group. All of the changes were significantly attenuated in the I/R+ propofol group (P = 0.05). With propofol infusion, there was decreased ROS production from the reperfused liver, with less hepato-cellular injury, followed by well-maintained pulmonary function. CONCLUSION: Remote pulmonary dysfunction and reperfusion injury in the liver were demonstrated in our rat model, as well as massive ROS production and lipid peroxidation. Propofol infusion attenuated remote pulmonary injury by lessening oxidative injury from the reperfused liver.

 

刺激內關穴(P6)預防椎管內麻醉下剖宮產手術噁心嘔吐的發生:隨機對照試驗的系統回顧

P6 Stimulation for the Prevention of Nausea and Vomiting Associated with Cesarean Delivery Under Neuraxial Anesthesia: A Systematic Review of Randomized Controlled Trials

Terrence K. Allen, MBBS, FRCA, and Ashraf S. Habib, MBBCh, MSc, FRCA

From the Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.

Anesth Analg 2008 107: 1308-1312.

 

背景:關於刺激內關穴用於預防椎管內麻醉下剖宮產手術術中及術後的噁心嘔吐(IONVPONV)的發生已經有了一系列的調查報導。作者擬作一個系統回顧明確這一技術對預防術中及術後噁心嘔吐的發生的全面的功效。

方法:作者檢索了所有隨機對照試驗(1966-2007)的文獻,其中包括使用安慰劑後的椎管內麻醉下的剖宮產病人用各種不同方法刺激內關穴的情況,薈萃分析了主要結果為術中及術後噁心嘔吐的發生率及和需要應用止吐療法的情況。

結果:這一回顧調查包括了649名病人的六項研究。其中五項研究報告為術中的結果。在這些研究中,有兩項研究表明刺激內關穴明顯減少了術中噁心的發生,有一項研究表明刺激內關穴明顯減少了止吐措施的使用。但是, 沒有一項研究表明治療組和對照組在防治嘔吐方面存在差異。另四項研究包括術後的結果。在這些研究中, 有一項研究表明刺激內關穴明顯減少了術後噁心的發生,有兩項研究表明刺激內關穴明顯減少了術後嘔吐的發生,還有一項研究表明刺激內關穴明顯減少了術後止吐措施的使用。

結論:在一些研究表明刺激內關穴好處的同時,這一結果並非始終如一。這些試驗中存在的不協調不均一性的研究結果顯示尚不能確定刺激內關穴減少椎管內麻醉下剖宮產手術術中及術後噁心嘔吐的發生率這一結論。

(丁俊雲 陳傑 校)

BACKGROUND: A number of studies investigated the use of P6 stimulation for the prevention of intraoperative and postoperative nausea and vomiting (IONV and PONV) in women having cesarean delivery under neuraxial anesthesia. We performed a systematic review to determine the overall efficacy of these techniques in preventing IONV and PONV in this patient population.

METHODS: We performed a literature search of all randomized controlled trials (1966–2007) that compared different methods of P6 stimulation with placebo in women having cesarean delivery under neuraxial anesthesia. Data were extracted on the primary outcomes including the incidence of nausea, vomiting, and the need for rescue antiemetic therapy, both intraoperatively and postoperatively.

RESULTS: Six studies involving 649 patients were included in this review. Five studies reported on intraoperative outcomes. Of these, two studies reported a significant reduction in the incidence of intraoperative nausea with P6 stimulation, and one study reported a significant reduction in rescue antiemetic requirement. However, none of the studies reported any differences between the treatment and control groups with respect to vomiting. Four studies reported postoperative outcomes. Of these, one study reported a significant reduction in postoperative nausea, two studies reported a significant reduction in postoperative vomiting, and one study reported a significant reduction in the need for postoperative rescue antiemetic therapy.

CONCLUSIONS: While some studies showed a benefit of P6 stimulation, this finding was not consistent. The presence of heterogeneity and inconsistent results among the included trials prevents any definitive conclusions on the efficacy of P6 stimulation in reducing IONV and PONV associated with cesarean delivery performed under neuraxial anesthesia.

 

術後嚴重疼痛的風險:臨床預測量表的修正與驗證

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

Kristel J. M. Janssen*, Cor J. Kalkman{dagger}, Diederick E. Grobbee*, Gouke J. Bonsel{ddagger}, Karel G. M. Moons*{dagger}, and Yvonne Vergouwe*

From the *Julius Center for Health Sciences and Primary Care; {dagger}Department of Anesthesiology, Division of Perioperative Care and Emergency Medicine, University Medical Center Utrecht, The Netherlands; and {ddagger}Department of Public Health, Academic Medical Center, Amsterdam, The Netherlands.

Anesth Analg 2008 107: 1330-1339.

 

背景:最近發展了一項術前預測量表來預測外科住院病人術後第一小時內發生嚴重疼痛的風險。作者希望通過修正這一量表,能增強其在外科住院及門診病人(急診病人)中的實用性。另外,作者前瞻性研究用這一修正後的量表在隨後的其他醫院應用情況(外部驗證)。

方法:該項量表最早是通過1398名成年住院病人的資料制定的。作者採集了1997-1999年間同一醫學中心(Academic Medical Center Amsterdam, The Netherlands549名門診病人的資料,修正了這一量表。此外,作者在University Medical Center UtrechtThe Netherlands2004年做手術的1035名住院和門診病人,測試了這一修正後的量表,來驗證其有效性(外部驗證)。其有效性通過該量表的標定(實測頻率和預測風險一致),和分辨力(區分高危和低危病人的能力)來確立。

結果:為增強對門診病人的預測能力而對原始量表的修正,包括再歸類預測因數“手術類型”,及“手術性質”(是否急診),以及手術性質同其他預測因數間的互相影響。Utrecht醫院組的1/3病人發生嚴重術後疼痛(36%),而Amsterdam醫院組的發生率為62%。兩組間預測因數的分佈基本一致,儘管Utrecht醫院組的病人年齡相對較高,且更傾向於急診手術,而預期手術切口大小比Amsterdam醫院組小。這一修正後的預測量表顯示出很好的分辨力。且差異是有意義的(特徵曲線下面積為0.6595%可信區間為0.57-0.73)。

結論:這一早期制定的用於預測嚴重術後疼痛的量表經修正後,可以同時用於住院和門診病人。通過對許多年後再次在另一醫院接受手術的病人來驗證這一量表時,顯示該量表可以被推廣。作者認為對於新人群的預測,與其建立新的預測量表,不如對其做個簡單的調整來重校準。這同外部校準以及預測量表的更新是一個持續的、多階段的。

(葉樂 陳傑 校)

BACKGROUND: Recently, a prediction rule was developed to preoperatively predict the risk of severe pain in the first postoperative hour in surgical inpatients. We aimed to modify the rule to enhance its use in both surgical inpatients and outpatients (ambulatory patients). Subsequently, we prospectively tested the modified rule in patients who underwent surgery later in time and in another hospital (external validation).

METHODS: The rule was originally developed from the data of 1395 adult inpatients. We modified the rule with the data of 549 outpatients who underwent surgery between 1997 and 1999 in the same center (Academic Medical Center Amsterdam, The Netherlands). Furthermore, we tested the performance of the modified rule in 1035 in- and outpatients who underwent surgery in 2004, in the University Medical Center Utrecht, The Netherlands (external validation). Performance was quantified by the rule's calibration (agreement between observed frequencies and predicted risks) and discrimination (ability to distinguish between patients at high and low risk).

RESULTS: Modification of the original rule to enhance prediction in outpatients included reclassification of the predictor "type of surgery," addition of the predictor "surgical setting" (ambulatory surgery: yes/no) and addition of interaction terms between surgical setting and the other predictors. One-third of the patients in the Utrecht cohort reported severe postoperative pain (36%), compared to 62% of the patients in the Amsterdam cohort. The distribution of most predictors was similar in the two cohorts, although the patients in the Utrecht cohort were slightly older, more often underwent ambulatory surgery and had large expected incision sizes less often than patients in the Amsterdam cohort. The modified prediction rule showed good calibration, when an adjusted intercept was used for the lower incidence in the Utrecht cohort. The discrimination was reasonable (area under the Receiver Operating Characteristic curve 0.65 [95% confidence interval 0.57–0.73]).

CONCLUSIONS: A previously developed prediction rule to predict severe postoperative pain was modified to allow use in both inpatients and outpatients. By validating the rule in patients who underwent surgery several years later in another hospital, it was shown that the rule could be generalized in time and place. We demonstrated that, instead of deriving new prediction rules for new populations, a simple adjustment may be enough to recalibrate prediction rules for new populations. This is in line with the perception that external validation and updating of prediction rules is a continuing and multistage process.

 

貧血與腦預後: 問題很多,答案很少

Anemia and Cerebral Outcomes: Many Questions, Fewer Answers

Gregory M. T. Hare, MD, PhD*{dagger}, Albert K. Y. Tsui, BSc*{dagger}, Anya T. McLaren, MSc*{dagger}, Tenille E. Ragoonanan, BSc*{dagger}, Julie Yu*, and C. David Mazer, MD*{dagger}

From the *Department of Anesthesia, Cara Phelan Trauma Research Centre, Keenan Research Centre in the Li Ka Shing Knowledge Institute, University of Toronto, St. Michael’s Hospital, Toronto, Ontario; and {dagger}Department of Physiology, University of Toronto, Toronto, Ontario.

Anesth Analg 2008 107: 1356-1370.

 

一些臨床研究表明在圍手術期中急性貧血與大腦損傷有關,證據表明在接近輸血臨界閾(血紅蛋白, 7-8 g/dL)以及超過閾值的腦組織缺氧(血紅蛋白3-4 g/dL))可導致損傷。然而,缺氧和非缺氧貧血引起腦損傷的機制尚未明確。此外,在急性貧血中可以最大限度地減少腦損傷的保護機制沒有得到很好的界定。業已證明在不同的急性血液稀釋性貧血實驗模型中舒血管機制包括(NO可能有助於在貧血期間保持腦供氧的所有三個一氧化氮合酶( NOS )亞型(神經細胞,內皮細胞,及誘導型NOS )均上調;最近的實驗證據還顯示一個重要的轉錄因數,缺氧誘導因數(HIF) -1{alpha}  在臨床相關的血紅蛋白濃度(血紅蛋白6-7/升)的齧齒動物的大腦皮質中產生增加。這表明急性貧血會危及腦氧平衡,在缺氧條件下,HIF-1{alpha}降解受到抑制, 因此而積累,dimerize ,並轉移進入細胞核,促進轉錄的一些缺氧分子。許多這些分子,包括促紅細胞生成素,血管內皮生長因數,並誘導型NOS在腦貧血中也被證明是上調的。此外,HIF-1{alpha}轉錄可由非缺氧因素而增加,包括細胞因數和血管激素。此外,在沒有缺氧的組織一氧化氮合酶產生一氧化氮還可穩定HIF-1{alpha}。因此貧血期間,在常氧和缺氧的條件,HIF-1{alpha}可能是細胞反應的調控因數。實驗研究表明,HIF-1{alpha}是神經保護還是神經毒性取決於上調細胞的類型。本綜述作者描述這些細胞過程,以促進更清楚地瞭解性貧血引起的腦損傷和保護。貧血引起的損傷機制還包括腦栓塞,組織缺氧,炎症,活性氧的產生和興奮性中毒。潛在的腦保護機制包括一氧化氮合酶/一氧化氮依賴優化腦氧運送和細胞保護機制,包括HIF-1{alpha} ,促紅細胞生成素,和血管內皮生長因數。在總體平衡的這些啟動的細胞的機制可能會決定而不管在貧血期間上調導致細胞保護性或細胞損傷性的。更清楚地瞭解這些機制可以幫助我們有目的治療,儘量減少因圍手術期貧血所引起的腦損傷。

(劉世文 陳傑 校)

A number of clinical studies have associated acute anemia with cerebral injury in perioperative patients. Evidence of such injury has been observed near the currently accepted transfusion threshold (hemoglobin [Hb] concentration, 7–8 g/dL), and well above the threshold for cerebral tissue hypoxia (Hb 3–4 g/dL). However, hypoxic and nonhypoxic mechanisms of anemia-induced cerebral injury have not been clearly elucidated. In addition, protective mechanisms which may minimize cerebral injury during acute anemia have not been well defined. Vasodilatory mechanisms, including nitric oxide (NO), may help to maintain cerebral oxygen delivery during anemia as all three NO synthase (NOS) isoforms (neuronal, endothelial, and inducible NOS) have been shown to be up-regulated in different experimental models of acute hemodilutional anemia. Recent experimental evidence has also demonstrated an increase in an important transcription factor, hypoxia inducible factor (HIF)-1{alpha}, in the cerebral cortex of anemic rodents at clinically relevant Hb concentrations (Hb 6–7 g/dL). This suggests that cerebral oxygen homeostasis may be in jeopardy during acute anemia. Under hypoxic conditions, cytoplasmic HIF-1{alpha} degradation is inhibited, thereby allowing it to accumulate, dimerize, and translocate into the nucleus to promote transcription of a number of hypoxic molecules. Many of these molecules, including erythropoietin, vascular endothelial growth factor, and inducible NOS have also been shown to be up-regulated in the anemic brain. In addition, HIF-1{alpha} transcription can be increased by nonhypoxic mediators including cytokines and vascular hormones. Furthermore, NOS-derived NO may also stabilize HIF-1{alpha} in the absence of tissue hypoxia. Thus, during anemia, HIF-1{alpha} has the potential to regulate cerebral cellular responses under both hypoxic and normoxic conditions. Experimental studies have demonstrated that HIF-1{alpha} may have either neuroprotective or neurotoxic capacity depending on the cell type in which it is up-regulated. In the current review, we characterize these cellular processes to promote a clearer understanding of anemia-induced cerebral injury and protection. Potential mechanisms of anemia-induced injury include cerebral emboli, tissue hypoxia, inflammation, reactive oxygen species generation, and excitotoxicity. Potential mechanisms of cerebral protection include NOS/NO-dependent optimization of cerebral oxygen delivery and cytoprotective mechanisms including HIF-1{alpha}, erythropoietin, and vascular endothelial growth factor. The overall balance of these activated cellular mechanisms may dictate whether or not their up-regulation leads to cytoprotection or cellular injury during anemia. A clearer understanding of these mechanisms may help us target therapies that will minimize anemia-induced cerebral injury in perioperative patients.

 

經皮脈衝射頻可治療神經性疼痛模型中的機械性異常疼痛

Percutaneous Pulsed Radiofrequency Reduces Mechanical Allodynia in a Neuropathic Pain Model

Özgür Özsoylar, MD*, Didem Akçali, MD*, Pelin Çizmeci, MD*, Avni Babacan, MD*, Alex Cahana, MD, DAAPM, FIPP{dagger}, and Hayrunnisa Bolay, MD, PhD{ddagger}

From the *Department of Algology, Gazi University, Ankara, Turkey; {dagger}Department of Anesthesiology, Postoperative and Interventional Pain Program, Geneva University Hospital, Geneva, Switzerland; and {ddagger}Department of Neurology, Neuropsychiatry Center, Gazi University, Ankara, Turkey.

Anesth Analg 2008 107: 1406-1411.

 

背景:神經性疼痛是原發損傷或是外周或中樞神經系統機能障礙的結果,處理具有挑戰性。動物模型有助於瞭解神經性疼痛的機理和研究新的對策。在這項研究中,作者研究了經皮脈衝射頻――一種微創治療疼痛的方法在大鼠神經性病理性疼痛模型中機械性異常疼痛中的效應。

方法:神經性疼痛模型通過腰5-6脊神經結紮引起的外周神經疼痛而建立。在結紮術後的第14天,于大鼠左後爪的蹠肌側應用經皮脈衝射頻。機械性異常疼痛通過動態蹠肌觸覺監測儀(DPA)和von Frey filamentsVF)法在術後14天及PRF治療後1, 3, 5, 7, 10, 14 天測定。實驗分為6組:假手術+安慰劑脈衝射頻6min組;假手術+脈衝射頻6min組;神經性疼痛(NP+2min脈衝射頻;合併神經性疼痛+2min安慰性PRF;神經性疼痛+2min脈衝射頻; 神經性疼痛+6min脈衝射頻。

結果:與假手術組相比異常疼痛在所有有神經性疼痛的動物中都有所改善。DPAVF顯示與安慰劑脈衝射頻組相比經皮脈衝射頻組在射頻的1-14天中能改善異常疼痛。儘管從DPA(重量和退縮時間)方面6min脈衝射頻組無治療效應,但從VF方面看6min脈衝射頻組在第一周可以暫時的好轉,以後作用消失。

結論:經皮脈衝射頻在治療神經性疼痛模型上是一種有效的選擇,其潛在機制需然進一步研究。

(張磊 陳傑 校)

BACKGROUND: Neuropathic pain is a result of a primary lesion or dysfunction of the peripheral or central nervous system, and its treatment is challenging. Animal models have been helpful in understanding mechanisms of neuropathic pain and in developing new treatment strategies. In this study, we examined the effect of percutaneous pulsed radiofrequency (PRF), which is a minimally invasive pain treatment method, on mechanical allodynia in a neuropathic pain rat model.

METHODS: Neuropathic pain was achieved in a peripheral nerve pain model by performing L5–6 spinal nerve ligation. On the 14th postoperative day, percutaneous PRF was applied to the plantar side of the left rear paw. Animals were evaluated for mechanical allodynia with both dynamic plantar aesthesiometer (DPA) (weight and paw withdrawal time) and von Frey filaments (VF) on the 14th postoperative day and 1, 3, 5, 7, 10, and 14 days after PRF treatment. Experiments were conducted in six groups: Sham-operated + placebo PRF 6 min, sham-operated + PRF 6 min, neuropathic (NP) + 2 min placebo PRF, NP + 2 min PRF, NP + 6 min placebo PRF, and NP + 6 min PRF. RESULTS: Allodynia developed in all animals in the NP groups compared to sham-operated animals (P = 0.0001). DPA and VF showed that PRF application for 2 min significantly improved allodynia on 1–14th post-PRF day, compared to placebo PRF (P = 0.0001). Although DPA (both weight and paw withdrawal time) did not show any therapeutic effect from 6 min PRF application on 1–14th post-PRF days (P = 1.00), VF demonstrated transient improvement for the first week, which disappeared on later evaluations of the 6 min PRF group.

CONCLUSIONS: Percutaneous PRF is an effective treatment option in the NP pain model, and further studies are needed to clarify its underlying mechanisms of action.