Table of Contents

November 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

凝血弹性度评价低温对凝血系统的影响

胡艳译   薛张刚校

A Thromboelastometric Evaluation of the Effects of Hypothermia on the Coagulation System

Malin Rundgren and Martin Engström

Anesth Analg 2008 107: 1465-1468.

心脏手术中止血环酸和抑肽酶:一项220例心脏手术病人的应用分析

丁俊云 译 陈杰 校

Tranexamic Acid and Aprotinin in Primary Cardiac Operations: An Analysis of 220 Cardiac Surgical Patients Treated with Tranexamic Acid or Aprotinin

Wulf Dietrich, Michael Spannagl, Johannes Boehm, Katharina Hauner, Siegmund Braun, Tibor Schuster, and Raimund Busley

Anesth Analg 2008 107: 1469-1478.

氨甲环酸减少成人脊柱融合术围术期失血量

江继宏 译  马皓琳 李士通 校

Tranexamic Acid Reduces Perioperative Blood Loss in Adult Patients Having Spinal Fusion Surgery

Jean Wong, Hossam El Beheiry, Yoga Raja Rampersaud, Stephen Lewis, Henry Ahn, Yoshani De Silva, Amir Abrishami, Naseer Baig, Robert J. McBroom, and Frances Chung

Anesth Analg 2008 107: 1479-1486.

关于常规心脏手术血液回收的一项随机对照研究

黄凝译  薛张纲校

A Randomized Controlled Trial of Cell Salvage in Routine Cardiac Surgery

Andrew A. Klein, Samer A. M. Nashef, Linda Sharples, Fiona Bottrill, Matthew Dyer, Johanna Armstrong, and Alain Vuylsteke

Anesth Analg 2008 107: 1487-1495.

合并低蛋白血症的老年心脏手术患者使用白蛋白对炎症反应,内皮细胞活化,以及长期肾功能是否有好处?

舒慧刚 译 陈杰 校

Is Albumin Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of Benefit with Regard to Inflammation, Endothelial Activation, and Long-Term Kidney Function?

Joachim Boldt, Ch Brosch, K. Röhm, A. Lehmann, A. Mengistu, and S. Suttner

Anesth Analg 2008 107: 1496-1503.

PEDIATRIC ANESTHESIOLOGY:

右美托咪定:治疗先天性心脏病手术围术期房性和交界性心动过速的新药:一项初步的研究

周雅春 译 马皓琳 李士通 校

Dexmedetomidine: A Novel Drug for the Treatment of Atrial and Junctional Tachyarrhythmias During the Perioperative Period for Congenital Cardiac Surgery: A Preliminary Study

Constantinos Chrysostomou, Lee Beerman, Dana Shiderly, Donald Berry, Victor O. Morell, and Ricardo Munoz

Anesth Analg 2008 107: 1514-1522.

儿童病人眼镜蛇式喉周气道与Unique喉罩前瞻性随机研究

蒋宗明译  薛张纲校

A Prospective, Randomized Comparison of Cobra Perilaryngeal Airway and Laryngeal Mask Airway Unique in Pediatric Patients

Peter Szmuk, Oscar Ghelber, Maria Matuszczak, Marry F. Rabb, Tiberiu Ezri, and Daniel I. Sessler

Anesth Analg 2008 107: 1523-1530.

用于儿童外周静脉置管的一种静脉通路指示装置:一项前瞻性、随机、对照试验
张磊 译 陈杰 校

A Vein Entry Indicator Device for Facilitating Peripheral Intravenous Cannulation in Children: A Prospective, Randomized, Controlled Trial

Eliahu Simhi, Ludmyla Kachko, Elhanan Bruckheimer, and Jacob Katz

Anesth Analg 2008 107: 1531-1535.

容积描记脉搏波幅对七氟醚麻醉的儿科病人静脉内注射含肾上腺素的硬膜外试验剂量是有效的指示剂

王宏 译 马皓琳 李士通校

Plethysmographic Pulse Wave Amplitude Is an Effective Indicator for Intravascular Injection of Epinephrine-Containing Epidural Test Dose in Sevoflurane-Anesthetized Pediatric Patients

Hany A. Mowafi, Samer A. Arab, Salah A. Ismail, Abdulmohsin A. Al-Ghamdi, and Roshdi R. Al-Metwalli

Anesth Analg 2008 107: 1536-1541.

AMBULATORY ANESTHESIOLOGY:

一篇关于阻塞性睡眠呼吸暂停综合症的系统综述及其对麻醉师的启示

刘沁译 薛张纲校

A Systemic Review of Obstructive Sleep Apnea and Its Implications for Anesthesiologists

Sharon A. Chung, Hongbo Yuan, and Frances Chung

Anesth Analg 2008 107: 1543-1563.

ANESTHETIC PHARMACOLOGY:

年龄对呼末七氟醚浓度和BIS指数动态关系的影响

叶乐 译 陈杰 校

The Influence of Age on the Dynamic Relationship Between End-Tidal Sevoflurane Concentrations and Bispectral Index

Luis I. Cortínez, Iñaki F. Trocóniz, Ricardo Fuentes, Pedro Gambús, Yung-Wei Hsu, Fernando Altermatt, and Hernán R. Muñoz

Anesth Analg 2008 107: 1566-1572.

儿童麻醉中的呼末七氟醚浓度、脑电双频指数及脑状态指数之间的动态关系

唐亮 译  马皓琳 李士通 校

The Dynamic Relationship Between End-Tidal Sevoflurane Concentrations, Bispectral Index, and Cerebral State Index in Children

Ricardo Fuentes, Luis I. Cortínez, Michel M. R. F. Struys, Alejandro Delfino, and Hernán Muñoz

Anesth Analg 2008 107: 1573-1578.

在非洲蟾蜍卵母细胞中芳香族挥发性麻醉药对钠离子电压门控通道的效应

刘婷洁译 薛张纲校

The Effects of Volatile Aromatic Anesthetics on Voltage-Gated Na+ Channels Expressed in Xenopus Oocytes

Takafumi Horishita, Edmond I. Eger, II, and R. Adron Harris

Anesth Analg 2008 107: 1579-1586.

全身低剂量布比卡因预防大鼠开胸术后异常性疼痛的发生

刘世文 译 陈杰 校

Low-Dose Systemic Bupivacaine Prevents the Development of Allodynia After Thoracotomy in Rats

Jin Woo Shin, Carlo Pancaro, Chi Fei Wang, and Peter Gerner

Anesth Analg 2008 107: 1587-1591.

利多卡因通过提高细胞周期蛋白依赖激酶抑制剂1A (p21)的表达从而抑制NIH-3T3细胞增殖

张莹译  马皓琳 李士通校

Lidocaine Inhibits NIH-3T3 Cell Multiplication by Increasing the Expression of Cyclin-Dependent Kinase Inhibitor 1A (p21)

Sukumar P. Desai, Koji Kojima, Charles A. Vacanti, and Shohta Kodama

Anesth Analg 2008 107: 1592-1597.

TECHNOLOGY, COMPUTING, AND SIMULATION:

AIMS设备使用的实用指南

秦敏菊译 薛张纲校

Anesthesia Information Management System Implementation: A Practical Guide (Special Article)

Stanley Muravchick, James E. Caldwell, Richard H. Epstein, Maria Galati, Warren J. Levy, Michael O'Reilly, Jeffrey S. Plagenhoef, Mohamed Rehman, David L. Reich, and Michael M. Vigoda

Anesth Analg 2008 107: 1598-1608.

一种新颖的神经肌肉阻滞咨询系统以改善神经肌肉阻滞:一个随机,对照,临床的实验

怀晓蓉 译 陈杰 校

Improved Neuromuscular Blockade Using a Novel Neuromuscular Blockade Advisory System: A Randomized, Controlled, Clinical Trial (Special Article)

Terence J. Gilhuly, Bernard A. MacLeod, Guy A. Dumont, Alex M. Bouzane, and Stephan K. W. Schwarz

Anesth Analg 2008 107: 1609-1617.

PATIENT SAFETY:

在用于电惊厥治疗的麻醉期间的体温变化:暗示麻醉学质量激励

姜旭晖译,马皓琳,李士通校

Body Temperature Change During Anesthesia for Electroconvulsive Therapy: Implications for Quality Incentives in Anesthesiology

Jerome H. Modell, Nikolaus Gravenstein, and Timothy E. Morey

Anesth Analg 2008 107: 1618-1620.

电阻聚合物与强热空气加温:志愿者的热能传递和核心温度复温速度的比较

施颖译 薛张纲校

Resistive Polymer Versus Forced-Air Warming: Comparable Heat Transfer and Core Rewarming Rates in Volunteers

Oliver Kimberger, Christine Held, Karin Stadelmann, Nikolaus Mayer, Corinne Hunkeler, Daniel I. Sessler, and Andrea Kurz

Anesth Analg 2008 107: 1621-1626.

CRITICAL CARE AND TRAUMA:

在严重脓毒症中早期使用高剂量抗凝血酶:来自KyberSept试验的单中心结果

朱紫瑜 译 陈杰 校

Early Administration of High-Dose Antithrombin in Severe Sepsis: Single Center Results from the KyberSept-Trial

Alain Eid, Christian J. Wiedermann, and Gary T. Kinasewitz

Anesth Analg 2008 107: 1633-1638.

ICU内的气管切开术:一项全国范围的调查

裘毅敏译,马皓琳 李士通校

Tracheostomy in the Intensive Care Unit: A Nationwide Survey

Stefan Kluge, Hans Jörg Baumann, Claudia Maier, Hans Klose, Andreas Meyer, Axel Nierhaus, and Georg Kreymann

Anesth Analg 2008 107: 1639-1643.

OBSTETRIC ANESTHESIOLOGY:

比较硬膜穿孔技术和标准硬膜外阻滞技术用于人工镇痛的随机试验

 孙鹏飞译 薛张纲校

A Randomized Trial of Dural Puncture Epidural Technique Compared with the Standard Epidural Technique for Labor Analgesia

Eric Cappiello, Nollag O'Rourke, Scott Segal, and Lawrence C. Tsen

Anesth Analg 2008 107: 1646-1651.

合并有Shone’s综合征的产妇行剖宫产时的麻醉管理

周姝婧 译 陈杰 校

The Anesthetic Management for Cesarean Delivery in a Patient with Shone's Syndrome (Case Report)

Kathleen Sachse and Medhat Hannallah

Anesth Analg 2008 107: 1652-1654.

ECONOMICS, EDUCATION, AND POLICY:

确定手术室内夜间所需值班急诊团队最佳规模的模拟模型

颜涛 译, 马皓琳 李士通 校

A Simulation Model for Determining the Optimal Size of Emergency Teams on Call in the Operating Room at Night

Jeroen M. van Oostrum, Mark Van Houdenhoven, Manon M. J. Vrielink, Jan Klein, Erwin W. Hans, Markus Klimek, Gerhard Wullink, Ewout W. Steyerberg, and Geert Kazemier

Anesth Analg 2008 107: 1655-1662.

NEUROSURGICAL ANESTHESIOLOGY AND NEUROSCIENCE:

加强氧气管理可改善清醒颈动脉手术患者脑供氧状况

夏俊明译 薛张纲校

Increased Oxygen Administration Improves Cerebral Oxygenation in Patients Undergoing Awake Carotid Surgery

Mark D. Stoneham, Omer Lodi, Thearina C. D. de Beer, and John W. Sear

Anesth Analg 2008 107: 1670-1675.

脑电双频谱指数在严重脑损伤合并难治性颅高压患者巴比妥酸昏迷中的应用

赵嫣红 译 陈杰 校

The Use of Bispectral Index to Monitor Barbiturate Coma in Severely Brain-Injured Patients with Refractory Intracranial Hypertension

Vincent Cottenceau, Laurent Petit, Françoise Masson, Dominique Guehl, Julien Asselineau, Jean-François Cochard, Catherine Pinaquy, Alain Leger, and François Sztark

Anesth Analg 2008 107: 1676-1682.

青少年脊柱侧弯手术中应用异丙酚-瑞芬太尼麻醉进行术中唤醒试验时混合听觉诱发电位指数和BIS的比较

朱 慧译 马皓琳 李士通校

A Comparison in Adolescents of Composite Auditory Evoked Potential Index and Bispectral Index During Propofol-Remifentanil Anesthesia for Scoliosis Surgery with Intraoperative Wake-Up Test

Heleen J. Blussé van Oud-Alblas, Jeroen W. B. Peters, Tom G. de Leeuw, Kris T. A. Vermeylen, Luuk W. L. de Klerk, Dick Tibboel, Jan Klein, and Frank Weber

Anesth Analg 2008 107: 1683-1688.

癫痫发作和全身麻醉药(综述)

宣丽真译 薛张纲校

The Howling Cortex: Seizures and General Anesthetic Drugs (Review Article)

Logan J. Voss, James W. Sleigh, John P. M. Barnard, and Heidi E. Kirsch

Anesth Analg 2008 107: 1689-1703.

GENERAL ARTICLES:

无创正压通气对加快病态肥胖病人预吸氧的效果:随机对照研究

潘钱玲 译 陈杰 校

Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study

Jean-Marc Delay, Mustapha Sebbane, Boris Jung, David Nocca, Daniel Verzilli, Yvan Pouzeratte, Moez El Kamel, Jean-Michel Fabre, Jean-Jacques Eledjam, and Samir Jaber

The Anesth Analg 2008 107: 1707-1713.

ANALGESIA:

七氟醚、地氟烷和异丙酚麻醉后的术后疼痛和镇痛药的需要量

黄丽娜 译 马皓琳 李士通 校

Postoperative Pain and Analgesic Requirements After Anesthesia with Sevoflurane, Desflurane or Propofol

Argyro Fassoulaki, Aikaterini Melemeni, Anteia Paraskeva, Ioanna Siafaka, and Constantine Sarantopoulos

Anesth Analg 2008 107: 1715-1719.

加巴喷丁抑制浅颈丛阻滞麻醉下甲状腺术后晚期疼痛

章一静译 薛张纲校

Gabapentin Attenuates Late but Not Early Postoperative Pain After Thyroidectomy with Superficial Cervical Plexus Block

Nicolas Brogly, Jean-Michel Wattier, Grégoire Andrieu, Daliana Peres, Emanuel Robin, Eric Kipnis, Laurent Arnalsteen, Béatrice Thielemans, Bruno Carnaille, François Pattou, Benoît Vallet, and Gilles Lebuffe

Anesth Analg 2008 107: 1720-1725.

在体内高或低皮质醇对人体单核细胞介导的炎症反应途径有双相影响

陈伟 译 陈杰 校

In Vivo Exposure to High or Low Cortisol Has Biphasic Effects on Inflammatory Response Pathways of Human Monocytes

Mark P. Yeager, Patricia A. Pioli, Kathleen Wardwell, Michael L. Beach, Peter Martel, Hong K. Lee, Athos J. Rassias, and Paul M. Guyre

Anesth Analg 2008 107: 1726-1734.

泰国的脊髓麻醉后心搏停止:40,271例麻醉的多中心前瞻性记录:

张曦 译,马皓琳 李士通 校

Cardiac Arrest After Spinal Anesthesia in Thailand: A Prospective Multicenter Registry of 40,271 Anesthetics

Somrat Charuluxananan, Somboon Thienthong, Mali Rungreungvanich, Thavat Chanchayanon, Thitima Chinachoti, Oranuch Kyokong, and Yodying Punjasawadwong

Anesth Analg 2008 107: 1735-1741.

对土耳其一家私人医院34109名行硬膜外阻止的妇产科病人的回顾性研究

陈珺珺译 薛张纲校

A Retrospective Review of 34,109 Epidural Anesthetics for Obstetric and Gynecologic Procedures at a Single Private Hospital in Turkey (Brief Report)

Kaan Katircioglu, Levent Hasegeli, H. Fehmi Ibrahimhakkioglu, Berkay Ulusoy, and Huseyin Damar

Anesth Analg 2008 107: 1742-1745.

3%氯普鲁卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌间沟臂丛神经阻滞中的比较:一项随机、前瞻、双盲对照试验:

王腾 译 陈杰 校

A Randomized, Prospective, Double-Blind Trial Comparing 3% Chloroprocaine Followed by 0.5% Bupivacaine to 2% Lidocaine Followed by 0.5% Bupivacaine for Interscalene Brachial Plexus Block

Soheila Jafari, Allison I. Kalstein, Habib M. Nasrullah, Mehrdad Hedayatnia, Joel M. Yarmush, and Joseph SchianodiCola

Anesth Analg 2008 107: 1746-1750.

用短针结合指压做眼球周单次注射麻醉

彭中美 译 马皓琳 李士通 校

Single Injection Peribulbar Anesthesia with a Short Needle Combined with Digital Compression (Brief Report)

Waleed Riad and Nauman Ahmed

Anesth Analg 2008 107: 1751-1753.

氨甲环酸减少成人脊柱融合术围术期失血量

Tranexamic Acid Reduces Perioperative Blood Loss in Adult Patients Having Spinal Fusion Surgery

Jean Wong, MD, FRCPC*, Hossam El Beheiry, MBBCh, PhD, FRCPC*, Yoga Raja Rampersaud, MD, FRCSC{dagger}, Stephen Lewis, MD, FRCSC{dagger}, Henry Ahn, MD, FRCSC{ddagger}, Yoshani De Silva, BSc*, Amir Abrishami, MD*, Naseer Baig, MD, FRCPC§, Robert J. McBroom, MD, FRCSC||, and Frances Chung, MD, FRCPC*

From the Departments of *Anesthesia, and {dagger}Orthopaedics, Toronto Western Hospital, University Health Network, Toronto, Ontario, {ddagger}Department of Orthopaedics, St. Michael's Hospital, Toronto, Ontario, Departments of §Anesthesia, and ||Orthopaedics, Trillium Hospital, Mississauga, Ontario, Canada.

Anesth Analg 2008; 107:1479-1486

背景:成年病人行脊柱重建手术往往伴随大量出血,以致常常需要输入异体血制品。本研究选取行择期后路胸/腰椎内固定脊柱融合术的成年病人,采用随机、前瞻、双盲、多中心的方法,探讨氨甲环酸(TXA)减少围手术期间失血及输血的效能。

方法:151名成年病人随机分为2组。TXA组:麻醉诱导后静脉推注10 mg/kg TXA,随后以1 mg/kg/hr TXA维持输注。安慰剂组:给予等容积安慰剂(生理盐水)。主要结果是手术中和手术后24 h内估计失血量及计算失血量。次要结果是异体输血的发生率和病人住院时间。

结果:4名病人皆因可识别的外科性出血被排除研究,因此147名病人纳入统计分析。与安慰剂组相比,TXA组病人总的估计失血量和计算失血量比安慰剂组分别降低大约25%和30% (1592 ± 1315 mL比2138 ± 1607 mL, P = 0.026; 3079 ± 2558比4363 ± 3030, P = 0.017)。两组中,输入的血制品量和住院时间没有差异。TXA、手术持续时间、椎骨融合的数目是影响围术期失血的独立因素。输注异体红细胞需考虑病人的ASA分级、手术持续时间及脊柱融合数目。

结论:对于择期行后路胸/腰椎内固定脊柱融合手术的成年病人,TXA明显减少围术期估计及计算的总失血量。

(江继宏 译  马皓琳 李士通 校)

BACKGROUND: Spinal reconstructive surgery in adults can be associated with significant blood loss, often requiring allogeneic blood transfusion. The objective of this randomized, prospective, double-blind, multicenter study was to evaluate the efficacy of tranexamic acid (TXA) in reducing perioperative blood loss and transfusion in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery.

METHODS: One hundred fifty-one adult patients were randomized to receive either a bolus of 10 mg/kg IV of TXA after induction followed by a maintenance infusion of 1 mg/kg/hr of TXA, or an equivalent volume of placebo (normal saline). The primary outcome was the total perioperative estimated and calculated blood loss intraoperatively and 24 h postoperatively. Secondary outcomes were incidence of allogeneic blood exposure, and duration of hospital stay.

RESULTS: Four patients were withdrawn for identifiable surgical bleeding, therefore 147 patients were included in the analysis. The total estimated and calculated perioperative blood loss was approximately 25% and 30% lower in patients given TXA versus placebo (1592 ± 1315 mL vs 2138 ± 1607 mL, P = 0.026; 3079 ± 2558 vs 4363 ± 3030, P = 0.017), respectively. There was no difference in the amounts of blood products transfused, and length of stay between the two groups. TXA, surgical duration, and number of vertebrae fused were independent factors related to perioperative blood loss. Predictors for the need for allogeneic red blood cell transfusion were ASA classification, surgical duration and number of levels fused.

CONCLUSIONS: TXA significantly reduced the estimated and calculated total amount of perioperative blood loss in adult patients having elective posterior thoracic/lumbar instrumented spinal fusion surgery.



右美托咪定:治疗先天性心脏病手术围术期房性和交界性心动过速的新药:一项初步的研究

Dexmedetomidine: A Novel Drug for the Treatment of Atrial and Junctional Tachyarrhythmias During the Perioperative Period for Congenital Cardiac Surgery: A Preliminary Study

Constantinos Chrysostomou, MD, Lee Beerman, MD, Dana Shiderly, BSN, RN, CCRN, Donald Berry, RPh, Victor O. Morell, MD, and Ricardo Munoz, MD

From the Department of Cardiology, Cardiac Intensive Care Unit, Children’s Hospital of Pittsburgh–University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Anesth Analg 2008; 107:1514-1522

研究背景:先天性心脏病手术围术期经常出现房性和交界性心动过速,且可使致病率和死亡率升高。上述节律失常虽然可被正常心脏良好耐受,但是在先天性心脏病患者中可引起严重的血流动力学不稳定,在心肺转流术后阶段尤为严重。由于目前可用的抗心律失常药物可能无效或耐受性差,故对这些心律失常的治疗颇为棘手。本研究检验了右美托咪定这一最初用于镇静的药物对于房性和交界性心动过速可能具有的疗效。尽管一些动物实验的数据显示该药可预防某种类型的室性心动过速,但尚无关于该药对房性和交界性心动过速治疗作用的研究。

研究目的:此为回顾性、非随机、非对照研究。研究包括了进入心脏病监护室的14名患者,右美托咪定用于镇静/镇痛和治疗交界性异位心动过速(JET)、房性异位性心动过速(AET)、折返型室上性心动过速(Re-SVT)、心房扑动(AF)或交界性加速性节律(JAR)。使用右美托咪定作为首选治疗药物或其他抗心律失常药物治疗失败后的补救措施。主要研究终点为(a) Re-SVT 在3分钟之内转为正常窦性心律(NSR),其他心律失常在2小时内转为正常窦性心律或 (b) 心率(HR)减慢使得血流动力学改善;JET ≤170 bpm, AET ≥20%, AF ≤150 bpm 且预防JAR进展为JET。

研究结果:患者平均年龄为2 ± 3月,平均体重为4 ± 1.5千克。大多数心律失常(79%)出现在术后。9名患者接受右美托咪定作为首选治疗药物,5名患者接受该药作为补救药物。10名患者(71%)接受1.1 ± 0.5 µg/kg初始负荷剂量。12名患者接受0.9 ± 0.3 µg · kg–1 · h–1 持续静脉输注。13名患者接受机械通气。4名患者(28%)出现不良反应。3名患者出现低血压但输注液体后好转,1名患者可能出现了短暂的完全性房室(AV)传导阻滞。14名患者中有9名患者接受了临时心房起搏(7名患者)或AV顺序起搏(2名患者)以改善AV同步性。13名患者(93%)达到了心律和/或HR得到控制的初步结果。在给予右美托咪定后67 ± 75 min之内JET心率从 197 ± 22 降至165 ± 17 bpm。这些患者中有5名患者在39 ± 31小时后转为NSR,有1名患者维持JAR。4名Re-SVT患者经治疗后此类心动过速均得以终止。3名患者转为NSR,一名患者转为JAR。一名AET(220–270 bpm)患者对右美托咪定反应良好,在35分钟内HR降至120 bpm 并且在85分钟内转为NSR。一名AF患者对该药没有反应。2名JAR患者均未进展为JET且HR从158 ± 11bpm降至129 ± 1 bpm。

结论:这一初步的观察性研究结果提示右美托咪定可能对于围术期房性和交界性心动过速的急性期具有潜在的治疗作用,可控制HR或使心律转为NSR。

(周雅春 译 马皓琳 李士通 校)

 

BACKGROUND: Atrial and junctional tachyarrhythmias occur frequently during the perioperative period for congenital cardiac surgery and can be a cause of increased morbidity and mortality. These rhythm disturbances that may be well tolerated in a normal heart can cause significant hemodynamic instability in patients with congenital heart defects, particularly during the postcardiopulmonary bypass period. Management of these arrhythmias presents more of a challenge, since currently available antiarrhythmic drugs can be ineffective and poorly tolerated. In this study, we examined the possible effect of dexmedetomidine, a primarily sedative drug, on atrial and junctional tachyarrhythmias. Though some animal data have shown that it can prevent certain types of ventricular tachycardia, its therapeutic role during these types of arrhythmias has not been studied.

METHODS: This was a retrospective, nonrandomized, noncontrolled study. Fourteen patients admitted to the cardiac intensive care unit and who received dexmedetomidine for both, sedation/analgesia and for junctional ectopic tachycardia (JET), atrial ectopic tachycardia (AET), reentry type supraventricular tachycardia (Re-SVT), atrial flutter (AF) or junctional accelerated rhythm (JAR) were included. Dexmedetomidine was used as a primary drug or as a rescue if other antiarrhythmics had been used. Our primary end-points were (a) conversion to normal sinus rhythm (NSR) within 3 min for Re-SVT, and 2 h for all other arrhythmias or (b) heart rate (HR) reduction to improve hemodynamics; JET ≤170 bpm, AET ≥20%, AF ≤150 bpm and for JAR prevention of progression to JET.

RESULTS: The mean age and weight were 2 ± 3 mo and 4 ± 1.5 kg, respectively. Most of the arrhythmias (79%) occurred during the postoperative period. Dexmedetomidine was used as a primary treatment in nine and as a rescue in five patients. Ten patients (71%) received an initial loading dose of 1.1 ± 0.5 µg/kg. A continuous infusion, 0.9 ± 0.3 µg · kg–1 · h–1 was administered in 12 patients. Thirteen patients’ lungs were mechanically ventilated. Adverse effects were seen in four patients (28%). Three had hypotension that responded to fluid administration and one had a possible brief complete atrioventricular (AV) block. Nine of the 14 patients were transiently paced with atrial (seven) or AV sequential (two) pacing to improve AV synchrony. The primary outcome with rhythm and/or HR control was achieved in 13 patients (93%). JET rate decreased from 197 ± 22 to 165 ± 17 bpm within 67 ± 75 min of dexmedetomidine administration. Five of these patients converted to NSR in 39 ± 31 h and one remained in JAR. All four patients with Re-SVT had resolution of their tachyarrhythmia. Three converted to NSR and one to JAR. One patient with AET (220–270 bpm) responded well with decreasing HR to 120 bpm within 35 min and to NSR in 85 min. One patient with AF failed to respond. In two patients with JAR, neither progressed to JET and HR decreased from 158 ± 11 to 129 ± 1 bpm.

CONCLUSION: This preliminary, observational report suggests that dexmedetomidine may have a potential therapeutic role in the acute phase of perioperative atrial and junctional tachyarrhythmias for either HR control or conversion to NSR.



容积描记脉搏波幅对七氟醚麻醉的儿科病人静脉内注射含肾上腺素的硬膜外试验剂量是有效的指示剂

Plethysmographic Pulse Wave Amplitude Is an Effective Indicator for Intravascular Injection of Epinephrine-Containing Epidural Test Dose in Sevoflurane-Anesthetized Pediatric Patients

Hany A. Mowafi, MBBch, MSc, MD, Samer A. Arab, MBBch, MD, Salah A. Ismail, MBBch, MSc, MD, Abdulmohsin A. Al-Ghamdi, MBBch, MD, and Roshdi R. Al-Metwalli, MBBch, MSc, MD

From the Department of Anesthesiology, Faculty of Medicine, King Faisal University, Saudi Arabia.

Anesth Analg 2008; 107:1536-1541

背景:体积描记脉搏波幅(PPWA)在成人可有效地检测静脉内注射硬膜外试验剂量,敏感性和特异性为100%。我们在七氟醚麻醉的儿科病人评价PPWA对静脉内注射模拟硬膜外试验剂量的检测功效。

方法:80个婴儿和儿童随机地分组,吸入含0.5 MAC或1 MAC和氧化亚氮的氧气,每组病人进一步随机地静脉注射含1:200,000肾上腺素 (0.5 µg/kg )的1%利多卡因0.1 mL/kg以模拟静脉内注射硬膜外试验剂量或注射生理盐水。注射后检测心率(HR),收缩压(SBP)和PPWA 5分钟,以HR增快超过10次/分钟、SBP升高超过15 mm Hg和PPWA减小超过10%定义为阳性实验反应。

结果:注射试验剂量后,0.5 MAC和1 MAC七氟醚组PPWA在79 ± 22和 80 ± 19 s平均最大降幅为69% ± 18% 和58% ± 14%。两个七氟醚组PPWA的敏感性、特异性、阳性预计值和阴性预计值都是100%,但是以HR和SBP作为检测标准时,0.5 MAC七氟醚组的敏感性分别是90%和95%,1 MAC七氟醚组都是85%。

结论:PPWA在儿科病人能有效地检测静脉内注射模拟的含肾上腺素的硬膜外试验剂量。

(王宏 译 马皓琳 李士通校)

BACKGROUND: Plethysmographic pulse wave amplitude (PPWA) was effective in detecting intravascular injection of epidural test dose with 100% sensitivity and specificity in adults. We evaluated the efficacy of PPWA in detecting intravascular injection of a simulated epidural test dose during sevoflurane anesthesia in pediatric patients.

METHODS: Eighty infants and children were randomized to receive either 0.5 minimal alveolar concentration (MAC) or 1 MAC sevoflurane and nitrous oxide in oxygen. Patients in each anesthesia group were further randomized to receive either 0.1 mL/kg of 1% lidocaine with 1:200,000 epinephrine (0.5 µg/kg of epinephrine) IV to simulate the intravascular injection of epidural test dose or saline. Heart rate (HR), systolic blood pressure (SBP), and PPWA were monitored for 5 min after injection. A positive test response was defined as HR increase ≥10 bpm, SBP increase ≥15 mm Hg, and PPWA decrease ≥10%.

RESULTS: Injecting the test dose resulted in an average maximum PPWA decrease by 69% ± 18% and 58% ± 14% at 79 ± 22 and 80 ± 19 s in the 0.5 MAC and 1 MAC sevoflurane groups, respectively. The sensitivity, specificity, positive predictive, and negative predictive values for PPWA were 100% in both sevoflurane groups, whereas by using HR and SBP criteria, the sensitivity was 90% and 95% respectively during 0.5 MAC sevoflurane anesthesia and 85% for both during 1 MAC sevoflurane anesthesia.

CONCLUSION: PPWA is effective for detection of an intravascular injection of a simulated epidural epinephrine-containing test dose in pediatric patients.



儿童麻醉中的呼末七氟醚浓度、脑电双频指数及脑状态指数之间的动态关系

The Dynamic Relationship Between End-Tidal Sevoflurane Concentrations, Bispectral Index, and Cerebral State Index in Children

Ricardo Fuentes, MD*, Luis I. Cortínez, MD*, Michel M. R. F. Struys, MD, PhD{dagger}{ddagger}, Alejandro Delfino, MD*, and Hernán Muñoz, MD, MSc*

From the *Departamento de Anestesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; {dagger}Department of Anesthesia, University Medical Center Groningen, Groningen, The Netherlands, and {ddagger}Department of Anesthesia, Ghent University, Ghent, Belgium.

Anesth Analg 2008; 107:1573-1578

背景:为了在儿童麻醉中使用脑电图监测仪来指导麻醉药的给予,就需要这些监测仪在这个人群中测得的麻醉药效应的足够特点。我们试图定量和比较用脑电双频指数(BIS)及脑状态指数(CSI)在儿童测得的七氟醚效应的动态变化。

方法:前瞻性研究15例择期行较小手术的健康儿童,年龄在3-15岁。在CSI和BIS同步记录过程中,七氟醚挥发器先设置为6%,持续5 min,然后降低。测定呼末浓度(CET)。对CET-七氟醚效应部位浓度平衡和药效学进行建模。比较两者之间的吻合度。数据为典型值(变异系数)。

结果:在研究的麻醉深度范围内,用效应部位平衡半衰期(t1/2 ke0)来表示的七氟醚效应的变化速度,CSI [2.0 (14) min]比BIS[1.2 (53) min]变化慢(P < 0.05)。在七氟醚给予 (E0) 之前BIS和CSI的估计基线效应,CSI为84 (39)而BIS为87 (7)(无显著意义)。七氟醚的催眠效应的敏感性用C50表示[最大效应(Emax)一半时稳态CET],CSI为2.1 (68) %而BSI为2.1 (16)%(无显著意义)。CSI为45(0)时的最大效应)高于BIS为27(39)时的最大效应27 (39) (P < 0.05)。人群预计误差BIS (–0.7 ± 26.9)优于CSI (–3.0 ± 178.6) (P < 0.05)。

结论:在儿童中,七氟醚的t1/2 ke0和药效动力学的定量和结果完全取决于测定其催眠作用所用的监测仪。在所研究的麻醉深度范围内,七氟醚效应的变化速度慢于CSI。为了在这些监测仪的监测下,适当地指导七氟醚在儿童中给药,这些差异必需要进行考虑。

(唐亮 译  马皓琳 李士通 校)      

BACKGROUND: To guide anesthetic administration with electroencephalogram monitors in children, an adequate characterization of the anesthetic effect measured by these monitors in this population is needed. We sought to quantify and compare the dynamic profile of sevoflurane’s effect measured with the cerebral state index (CSI) and the bispectral index (BIS) in children.

METHODS: Fifteen healthy children, aged 3–15 yr, scheduled to undergo minor surgery were prospectively studied. During the simultaneous recording of CSI and BIS, the sevoflurane vaporizer was set at 6 vol % for 5 min and then decreased. End-tidal concentrations (CET) were measured. The CET–sevoflurane effect–site concentration equilibration and pharmacodynamics were modeled. Goodness of fit between models was compared. Data are typical value (coefficient of variation).

RESULTS: Within the anesthetic depth range studied, the rate of change of sevoflurane’s effect expressed as the effect–site equilibration half-life (t1/2 ke0) was slower with the CSI [2.0 (14) min] than with BIS [1.2 (53) min] (P < 0.05). The estimated baseline effect of BIS and CSI before sevoflurane administration (E0) was 84 (39) for CSI and 87 (7) for BIS (NS). The sensitivity to sevoflurane hypnotic effect expressed in the C50 [steady-state CET eliciting half of the maximum response (Emax)] was 2.1 (68) % with CSI and 2.1 (16)% with BIS (NS). The Emax with CSI 45 (0) was higher than that with BIS 27 (39) (P < 0.05). The population prediction error was significantly better for BIS (–0.7 ± 26.9) than for CSI (–3.0 ± 178.6) (P < 0.05).

CONCLUSIONS: In children, the t1/2 ke0 of sevoflurane and the pharmacodynamics of sevoflurane were quantified and the results were entirely dependent on the monitor used to measure its hypnotic effect. Within the anesthetic depth range studied, the rate of change of sevoflurane’s effect was slower with the CSI. To adequately guide sevoflurane administration with these monitors in children, these differences should be considered.



利多卡因通过提高细胞周期蛋白依赖激酶抑制剂1A (p21)的表达从而抑制NIH-3T3细胞增殖

Lidocaine Inhibits NIH-3T3 Cell Multiplication by Increasing the Expression of Cyclin-Dependent Kinase Inhibitor 1A (p21)

Sukumar P. Desai, MD, Koji Kojima, MD, PhD, Charles A. Vacanti, MD, and Shohta Kodama, MD, PhD

From the Department of Anesthesiology, Perioperative and Pain Medicine, Laboratory for Tissue Engineering and Regenerative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

Anesth Analg 2008; 107:1592-1597

背景:我们发现了利多卡因抑制鼠类胚胎成纤维细胞系NIH-3T3生长的分子机制。局部麻醉药能在体外抑制细胞的生长。它们对伤口愈合的影响存在争议。我们研究了利多卡因在体外对鼠类成纤维细胞系NIH-3T3增殖的影响及其新机制。

方法:NIH-3T3细胞培养液中加入利多卡因[00.050.5125 mM]一起培养。接下来的几天内通过细胞计数测定细胞的增殖,测定溴脱氧尿苷的摄取、用多聚酶链反应阵列测定基因的表达,以及蛋白印迹分析来检验受影响蛋白的增高水平,以探讨利多卡因抑制细胞增殖的发生机制。

结果:利多卡因呈剂量依赖地抑制NIH-3T3细胞的增殖。0.050.5 mM利多卡因对细胞增殖没有影响,1 mM利多卡因有轻度影响,25 mM利多卡因严重抑制细胞的增殖(P = 0.006)。培养液中加入2 mM利多卡因后3.5天,2 mM利多卡因抑制溴脱氧尿苷的摄取(与对照组相比P = 0.02,与1 mM利多卡因相比P = 0.0495)。培养液中加入利多卡因1.5天后,利多卡因上调细胞周期蛋白-D1和细胞周期蛋白依赖激酶抑制剂1A [p21]的表达。培养液中加入利多卡因后2.5天,利多卡因使p21蛋白水平增加。

结论:脊麻、硬膜外麻醉或神经丛阻滞后在血浆中可见低浓度利多卡因,不会明显影响成纤维细胞的增殖。而更高浓度的利多卡因通过使细胞增殖强效抑制剂p21合成增加,从而在细胞生长周期S相抑制成纤维细胞的增殖。较高浓度可见于组织浸润后,可以明显抑制成纤维细胞的增殖,因而可能妨碍伤口的愈合。

(张莹译  马皓琳 李士通校)

BACKGROUND: We explored molecular mechanisms by which lidocaine inhibits growth in the murine embryonic fibroblast cell line NIH-3T3. Local anesthetics can adversely affect cell growth in vitro. Their effects on wound healing are controversial. We examined the effects and novel mechanisms by which lidocaine affects in vitro multiplication of the murine fibroblast cell line NIH-3T3.

METHODS: NIH-3T3 cells were grown in culture with lidocaine [0, 0.05, 0.5, 1, 2, and 5 mM]. Cell multiplication was assessed by determining cell counts on subsequent days, while mechanisms by which inhibition occurred were evaluated by bromodeoxyuridine uptake, gene expression using polymerase chain reaction array, and Western blot analysis to verify increased levels of affected proteins.

RESULTS: Lidocaine caused dose-dependent inhibition of multiplication of NIH-3T3 cells. Effects ranged from no inhibition [0.05 and 0.5 mM] and mild inhibition [1 mM], to severe inhibition [2 and 5 mM] [P = 0.006]. Lidocaine 2 mM inhibited bromodeoxyuridine uptake at day 3.5 [P = 0.02 versus control, and P = 0.0495 vs 1 mM lidocaine]. On day 1.5, lidocaine upregulated expression of cyclin-D1 and cyclin-dependent kinase inhibitor 1A [p21]. On day 2.5, lidocaine increased the levels of p21 protein.

CONCLUSIONS: Low concentrations of lidocaine, as would be seen in plasma after spinal, epidural, or plexus anesthesia, do not significantly affect multiplication of fibroblasts. Higher doses of lidocaine arrest cell multiplication at the S-phase of the growth cycle by upregulation of p21, an extremely potent inhibitor of cell multiplication. Higher concentrations, as would be seen after tissue infiltration, severely inhibit fibroblast multiplication and thus may impair wound healing.



在用于电惊厥治疗的麻醉期间的体温变化:暗示麻醉学质量激励

Body Temperature Change During Anesthesia for Electroconvulsive Therapy: Implications for Quality Incentives in Anesthesiology

Jerome H. Modell, MD, DSc (Hon.), Nikolaus Gravenstein, MD, and Timothy E. Morey, MD

From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida.

Anesth Analg 2008; 107:1618-1620

背景:美国麻醉学家学会已经对外宣布围手术期维持正常体温是麻醉学质量的体现。我们检验了是否可以在单一人群(接受电惊厥治疗(ECT)的病人)中达到这种麻醉质量激励。

方法:我们比较了麻醉前经红外测得的耳温和经过101种顺序的便于ECT的较短麻醉药后到达麻醉后复苏室(PACU)时的耳温。

结果:共有35例病人在麻醉前耳温测得<36°C,18例病人在麻醉后送到PACU时耳温<36°C。30种麻醉药使病人的体温在麻醉过程中降低,64种麻醉药使病人的体温在麻醉期间升高,7种不改变病人体温。所有的数据检查都表明病人麻醉前后的体温之间没有相关性。

讨论:我们得到了结论是当给予麻醉以便于ECT时,我们研究中的病人在麻醉期间的温度变化并不一致。如果送到PACU时病人的鼓室温度低于36°C,我们也不可以推测病人在麻醉过程中的体温管理是低于标准的。而且目前的体温测量方法也不足以确定病人在手术后是否低体温。由于避免低体温是一个有价值的目标,如果体温被用作为一种麻醉质量激励,麻醉科就必须保证体温监测设备可以准确测量术后体温。

(姜旭晖译,马皓琳,李士通校)

BACKGROUND: The American Society of Anesthesiologists has announced that perioperative normothermia is a "Quality Incentive in Anesthesiology." We examined whether we could meet this quality incentive in a simple population: patients undergoing anesthesia for electroconvulsive therapy (ECT).

METHODS: We compared infrared-measured ear temperature before anesthesia to temperature upon delivery of patients to the postanesthesia care unit (PACU) after 101 consecutive brief anesthetics to facilitate ECT.

RESULTS: For 35 procedures, the patients had an infrared ear thermometer temperature of <36°C before anesthesia was administered, and 18 had a temperature of <36°C after anesthesia when transferred to the PACU. For 30 anesthetics, the patients' temperature decreased during anesthesia, for 64 anesthetics it increased during anesthesia, and for 7 it did not change. Overall examination of the data demonstrated no correlation between preprocedure and postprocedure temperature.

DISCUSSION: We conclude that there was no consistent change in temperature during anesthesia between our study patients when anesthesia was administered to facilitate ECT. If patients' tympanic temperatures were below 36°C upon admission to the PACU, it would be incorrect to conclude that intraprocedural temperature management measures were substandard. Also, current methods of measuring temperature may be inadequate to ascertain if patients are hypothermic after surgery. As the avoidance of hypothermia is a meritorious goal, anesthesia departments need to ensure that their temperature monitoring equipment is adequate to ensure accurate measurement of postanesthetic temperature if this variable is to be used as a quality incentive.



ICU内的气管切开术:一项全国范围的调查

Tracheostomy in the Intensive Care Unit: A Nationwide Survey

Stefan Kluge, MD*, Hans Jörg Baumann, MD{dagger}, Claudia Maier, MD*, Hans Klose, MD{dagger}, Andreas Meyer, MD{dagger}, Axel Nierhaus, MD*, and Georg Kreymann, MD*

From the Departments of *Intensive Care; and {dagger}Pulmonary Medicine, University Medical Center, Hamburg-Eppendorf, Germany.

Anesth Analg 2008; 107:1639-1643

背景:近几年来气管切开术的指征、时机及技巧发生了改变。我们开展了一项调查以评估当前德国重症监护病房(ICUs)内气管切开术的实施。

方法:将问卷邮寄给513位德国ICU(包括小儿ICU)的医师负责人,。

结果:在513个ICU中,我们获得了455份反馈结果(89%)。在90%的ICU中,在机械通气的最初14天中实施气管切开术。86%的ICU常规实施经皮扩张气管切开术;改良的Ciaglia技术是最流行的经皮穿刺技术(69%)。绝大部分(98%)的经皮穿刺操作是在支气管镜控制下完成的。通常由一位外科医生(61%)在手术室内(72%)完成外科气管切开术,而经皮扩张气管切开术则是由一位重症护理医生(93%)在ICU (98%)患者的床边完成的。26%的ICU常规随访气管切开的病人,45%的ICU有关于气管切开的指征、时机及技术操作的指南。

结论:在德国,经皮扩张气管切开术是危重病人气管切开的一种选择。改良的Ciaglia技术是更好的经皮穿刺技术,几乎所有的内科医生都常规使用支气管镜引导。大多数气管切开术都在机械通气的第二周完成。

(裘毅敏译,马皓琳 李士通校)

BACKGROUND: The indication, timing and technique of tracheostomy have changed over the last several years. We performed a survey to assess the current practice of tracheostomy in German intensive care units (ICUs).

METHODS: A postal questionnaire was sent to the head physicians of 513 German ICUs, excluding pediatric ICUs.

RESULTS: We obtained responses from 455 of the 513 ICUs (89%). In 90% of the ICUs, tracheostomies were performed during the first 14 d of mechanical ventilation. Eighty-six percent of the ICUs routinely performed percutaneous dilatational tracheostomy; the modified Ciaglia technique was the most popular percutaneous technique (69%). The majority (98%) of the percutaneous procedures were performed under bronchoscopic control. Surgical tracheostomy is usually performed in the operating room (72%) by a surgeon (61%), whereas percutaneous dilatational tracheostomies are usually performed at the patient's bedside in the ICU (98%) by an intensivist (93%). Tracheostomized patients were followed up routinely in 26% of the ICUs, and in 45% of the ICUs there were guidelines regarding the indication, the timing and the technique of tracheostomy.

CONCLUSION: Percutaneous dilatational tracheostomy is the procedure of choice for tracheostomy in critically ill patients in Germany. The modified Ciaglia technique is the preferred percutaneous technique, and nearly all physicians routinely use bronchoscopic guidance. Most tracheostomies are done during the second week of mechanical ventilation.



确定手术室内夜间所需值班急诊团队最佳规模的模拟模型

A Simulation Model for Determining the Optimal Size of Emergency Teams on Call in the Operating Room at Night

Jeroen M. van Oostrum, MSc*, Mark Van Houdenhoven, PhD*{dagger}, Manon M. J. Vrielink, MSc*, Jan Klein, MD, PhD{dagger}, Erwin W. Hans, PhD{ddagger}, Markus Klimek, MD, DEAA{dagger}, Gerhard Wullink, PhD*{dagger}, Ewout W. Steyerberg, PhD§, and Geert Kazemier, MD, PhD*||

From the Departments of *Operating Rooms; {dagger}Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands; {ddagger}Department of Operational Methods for Production and Logistics, School of Business, Public Administration and Technology, University of Twente, The Netherlands; Departments of §Public Health; and ||Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.

Anesth Analg 2008; 107:1655-1662

背景:在夜间(如晚11:00至晨7:30)开展急诊手术的医院面临确定最佳手术室人员的问题。为减少急诊病人并发症的发生和促进病人的完全恢复,需要在预定的安全时间窗口内开始手术。我们开发了一种程序来确定最佳的夜间手术室团队构成,以使得人员开支最少而又能提供足够的资源使手术能在安全的时间范围内开始。

方法:应用离散事件模拟结合安全时限模型。允许安全地推迟急诊手术。采用Erasmus大学医学中心主手术室资料进行验证该模型。计算下列两种结果:超过安全时限的急诊手术和手术室及麻醉护士被从家中呼叫来的频率。我们使用下列Erasmus医学中心的输入资料来估计本模型中所有相关参数的分布:急诊病人到达的次数、外科手术时长、在麻醉后恢复室停留时间和转运次数。此外,由Erasmus医学中心的外科医生和手术室工作人员确定安全时限。

结果:与基准情况相比,将手术室内人员从9人减至5人导致延误处理病人的比例增加2.5%。当需要时被从家里呼叫到医院的手术室和麻醉护士有相当大的增加。

结论:采用安全时限有益于夜间手术室的管理。安全时限模型显著影响得到及时处置的急诊病人人数。我们的研究表明,通过对安全时限模型和计算机模拟方法的应用,手术室可以减少值班人员数量而不危害病人安全。

(颜涛 译, 马皓琳 李士通 校)

BACKGROUND: Hospitals that perform emergency surgery during the night (e.g., from 11:00 pm to 7:30 am) face decisions on optimal operating room (OR) staffing. Emergency patients need to be operated on within a predefined safety window to decrease morbidity and improve their chances of full recovery. We developed a process to determine the optimal OR team composition during the night, such that staffing costs are minimized, while providing adequate resources to start surgery within the safety interval.

METHODS: A discrete event simulation in combination with modeling of safety intervals was applied. Emergency surgery was allowed to be postponed safely. The model was tested using data from the main OR of Erasmus University Medical Center (Erasmus MC). Two outcome measures were calculated: violation of safety intervals and frequency with which OR and anesthesia nurses were called in from home. We used the following input data from Erasmus MC to estimate distributions of all relevant parameters in our model: arrival times of emergency patients, durations of surgical cases, length of stay in the postanesthesia care unit, and transportation times. In addition, surgeons and OR staff of Erasmus MC specified safety intervals.

RESULTS: Reducing in-house team members from 9 to 5 increased the fraction of patients treated too late by 2.5% as compared to the baseline scenario. Substantially more OR and anesthesia nurses were called in from home when needed.

CONCLUSION: The use of safety intervals benefits OR management during nights. Modeling of safety intervals substantially influences the number of emergency patients treated on time. Our case study showed that by modeling safety intervals and applying computer simulation, an OR can reduce its staff on call without jeopardizing patient safety.



青少年脊柱侧弯手术中应用异丙酚-瑞芬太尼麻醉进行术中唤醒试验时混合听觉诱发电位指数和BIS的比较

A Comparison in Adolescents of Composite Auditory Evoked Potential Index and Bispectral Index During Propofol-Remifentanil Anesthesia for Scoliosis Surgery with Intraoperative Wake-Up Test

Heleen J. Blussé van Oud-Alblas, MD*, Jeroen W. B. Peters, PhD*, Tom G. de Leeuw, MD*, Kris T. A. Vermeylen, MD*, Luuk W. L. de Klerk, MD, PhD{dagger}, Dick Tibboel, MD, PhD{ddagger}, Jan Klein, MD, PhD*, and Frank Weber, MD*

From the Departments of *Anesthesiology, {dagger}Orthopedics, and {ddagger}Pediatric Surgery, Erasmus Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands.

Anesth Analg 2008; 107:1683-1688

背景:脑电双频谱指数(BIS)和来源于脑电图和听觉诱发电位的混合A系ARX指数(cAAI),已被用来作为麻醉深度监测。在儿童和青少年脊柱侧弯手术应用异丙酚-瑞芬太尼麻醉的术中唤醒试验中,我们用密西根大学镇静评分比较两个指数在区别不同催眠状态方面的表现。同时评估术后显性回忆的情况。

方法:选取20名患者(10~20岁)。诱导时、唤醒试验和恢复时计算预期概率。在唤醒试验开始时、对指令能有目的的体动时和患者再麻醉后比较BIS和cAAI。在唤醒试验过程中,患者按指示记住一种颜色,随后进行显性回忆的调查。

结果:诱导时BIS和cAAI的预期概率是0.82 和 0.63 (P < 0.001),唤醒试验时为0.78和0.79 (P < 0.001),恢复时为0.74和0.78 (P < 0.001)。在唤醒试验过程中,BIS和cAAI均值在有目的的体动时有显著升高,再麻醉后显著降低。

结论:在诱导时,BIS表现比cAAI好。在统计学上尽管cAAI在唤醒试验和恢复时更好地鉴别意识清醒水平,但这些差异似乎并没有临床意义。两个指数在唤醒试验时均升高,指示更高的清醒水平。没有证明存在显性回忆。

(朱 慧译 马皓琳 李士通校)

BACKGROUND: The electroencephalogram-derived Bispectral Index (BIS), and the composite A-line ARX index (cAAI), derived from the electroencephalogram and auditory evoked potentials, have been promoted as anesthesia depth monitors. Using an intraoperative wake-up test, we compared the performance of both indices in distinguishing different hypnotic states, as evaluated by the University of Michigan Sedation Scale, in children and adolescents during propofol-remifentanil anesthesia for scoliosis surgery. Postoperative explicit recall was also evaluated.

METHODS: Twenty patients (aged 10–20 yr) were enrolled. Prediction probabilities were calculated for induction, wake-up test, and emergence. BIS and cAAI were compared at the start of the wake-up test, at purposeful movement to command, and after the patient was reanesthetized. During the wake-up test, patients were instructed to remember a color, and were then interviewed for explicit recall.

RESULTS: Prediction probabilities of BIS and cAAI for induction were 0.82 and 0.63 (P < 0.001), for the wake-up test, 0.78 and 0.79 (P < 0.001), and 0.74 and 0.78 for emergence (P < 0.001). During the wake-up test, a significant increase in mean BIS and cAAI (P < 0.05) was demonstrated at purposeful movement, followed by a significant decline after reintroduction of anesthesia.

CONCLUSIONS: During induction, BIS performed better than cAAI. Although cAAI was statistically a better discriminator for the level of consciousness during the wake-up test and emergence, these differences do not appear to be clinically meaningful. Both indices increased during the wake-up test, indicating a higher level of consciousness. No explicit recall was demonstrated.



七氟醚、地氟烷和异丙酚麻醉后的术后疼痛和镇痛药的需要量

Postoperative Pain and Analgesic Requirements After Anesthesia with Sevoflurane, Desflurane or Propofol

Argyro Fassoulaki, MD, PhD, DEAA*, Aikaterini Melemeni, MD, DESA*, Anteia Paraskeva, MD, DESA*, Ioanna Siafaka, MD*, and Constantine Sarantopoulos, MD, PhD, DEAA{dagger}

From the *Department of Anesthesiology, Aretaieio Hospital, Medical School, University of Athens; and {dagger}Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Anesth Analg 2008; 107:1715-1719

背景:全身麻醉药可能有会引起影响术后疼痛的感受伤害性作用。在评估术后疼痛的研究中,全身麻醉药对止痛药的需要量的影响还没有研究过,除了最近一个研究表明异丙酚麻醉较异氟醚麻醉,能提供更好的术后镇痛。

方法:在这个前瞻性、盲法、随机的研究中,我们记录了行(腹式)子宫切除术或子宫肌瘤切除术的病人术后2、4、8和24小时镇痛药的需要量(吗啡的mg数),和疼痛评分(VAS评分,单位mm),这些病人分别用七氟醚、地氟烷或异丙酚维持麻醉,并且维持脑电双频指数(BIS)值在35-45之间。进入麻醉后监护室后立即记录病人的疼痛评分。

结果:这三组间在术后2、4、8和24小时吗啡的累积消耗量并无差异(P = 0.50)。术后24小时之内,七氟醚组吗啡的消耗量为28 ± 13.8 mg,而地氟烷组和异丙酚组的消耗量分别为25 ± 11.7 mg和27 ± 16.1 mg。病人在转运至麻醉后恢复室即刻处于静息或咳嗽后、手术后2、4、8和24小时的VAS评分在三组间没有差异(静息时P 分别为0.40、0.39、0.50、0.47、0.06, 咳嗽后P分别为0.67、0.45、0.22、0.26、0.29)。

结论:七氟醚、地氟烷或异丙酚组吗啡的需要量和术后24小时的疼痛没有差异。

(黄丽娜 译 马皓琳 李士通 校)

BACKGROUND: General anesthetics may have nociceptive actions that affect postoperative pain. In studies evaluating postoperative pain, the effect of general anesthetics on analgesic requirements has not been considered except for one recent study suggesting that propofol anesthesia provides better analgesia after surgery than isoflurane.

METHODS: In this prospective, blind, randomized trial we recorded postoperative analgesic requirements (mg of morphine) and pain scores (visual analog scale in mm) 2, 4, 8, and 24 h postoperatively in patients undergoing abdominal hysterectomy or myomectomy under sevoflurane, desflurane or propofol anesthesia, titrated to maintain Bispectral Index values between 35 and 45. Pain scores were also recorded immediately after transfer to the postanesthesia care unit.

RESULTS: Cumulative morphine consumption did not differ among the three groups 2, 4, 8, or 24 h postoperatively (P = 0.50). The morphine consumed within 24 h postoperatively was 28 ± 13.8 mg in the sevoflurane group, 25 ± 11.7 mg in the desflurane group and 27 ± 16.1 mg in the propofol group. The visual analog scale values at rest or after cough immediately after patient transport to the postanesthesia care unit and 2, 4, 8, and 24 h after surgery did not differ among the three groups (P = 0.40, 0.39, 0.50, 0.47, 0.06 at rest and P = 0.67, 0.45, 0.22, 0.26, 0.29 after cough respectively).

CONCLUSION: Morphine consumption and pain 24 h postoperatively did not differ among the sevoflurane, desflurane, and propofol groups.



泰国的脊髓麻醉后心搏停止:40,271例麻醉的多中心前瞻性记录:

Cardiac Arrest After Spinal Anesthesia in Thailand: A Prospective Multicenter Registry of 40,271 Anesthetics

Somrat Charuluxananan, MD*, Somboon Thienthong, MD{dagger}, Mali Rungreungvanich, MD{ddagger}, Thavat Chanchayanon, MD§, Thitima Chinachoti, MD||, Oranuch Kyokong, MD*, and Yodying Punjasawadwong, MD

From the *Department of Anesthesiology, Faculty of Medicine, Chulalongkorn University, {dagger}Khon-Kaen University, {ddagger}Ramathibodi Hospital Mahidol University, §Prince of Songkla University, ||Siriraj Hospital Mahidol University, and ¶Chiang Mai University, Thailand.

Anesth Analg 2008; 107:1735-1741

背景和目的:作为泰国麻醉事故研究的部分,我们评估脊髓麻醉过程中,心搏停止的发生率和原因。

方法:在一个12月周期内(2003年3月1日到2004年2月28日), 一个前瞻性多中心研究,记录泰国20家医院(7所大学医院,5所三级医院,4所综合性医院,4所区医院)接受麻醉的病人。麻醉人员报告病人、外科和麻醉的相关因素和不良结果,包括脊髓麻醉过程中的心搏停止(时间过程定义为脊髓麻醉诱导到手术结束)。麻醉操作24 h内每当发生特别的不良事件时,记录不良事件的特殊表格。用单变量和多元分析来识别脊髓麻醉中与心搏停止有关的因素。P<0.05被认为有统计学意义。

结果:在记录的40,271例脊髓麻醉中,有11例心搏停止,相应的发生率是每10,000例中2.73 (95% CI: 1.12–4.34)。发生心搏停止的死亡率为90.9%。在这11个心搏停止的病人中,5个剖宫产,6个肢体手术,包括髋部手术。4个病人(36.3%),麻醉直接导致了心搏停止(高位交感神经阻滞、局麻药过量或缺乏心电监护),反之,其他心搏停止与特殊事件有关(假体粘合剂、大量出血、可疑肺栓塞和可疑心肌梗塞)。从多元分析,麻醉中心搏停止的危险是身材矮小(优势比0.944 [95% CI: 0.938–0.951], P < 0.001)、长时间手术(优势比1.003 [95% CI: 1.001–1.005], P = 0.002)及由外科医生进行的脊髓麻醉(优势比23.508 [95% CI: 6.112–90.415], P < 0.001)。

结论:脊髓麻醉中心搏停止是不常发生的,但是发生的死亡率很高。如果外科医生进行脊髓麻醉,这是心搏停止的一个显著性相关因素。增加麻醉医师人数、改善脊髓麻醉监护的指南及改善麻醉护士培训计划,可以减少心搏停止的发生率和/或改善病人的结局。

(张曦 译,马皓琳 李士通 校)

BACKGROUND AND OBJECTIVES: As part of the Thai Anesthesia Incidents Study of anesthetic adverse outcomes, we evaluated the incidence and factors related to cardiac arrest during spinal anesthesia.

METHODS: During a 12-mo period (March 1, 2003, to February 28, 2004), a prospective, multicenter registry of patients receiving anesthesia was initiated in 20 hospitals (7 university, 5 tertiary, 4 general, and 4 district hospitals) across Thailand. Anesthesia personnel reported patient-, surgery-, and anesthetic-related variables and adverse outcomes, including cardiac arrest during spinal anesthesia (defined as the time period from induction of spinal anesthesia until the end of operation). Adverse event specific forms were recorded within 24 h of an anesthetic procedure whenever a specific adverse event occurred. Univariate and multivariate analysis were used to identify factors related to cardiac arrest during spinal anesthesia. A P value <0.05 was considered significant.

RESULTS: In the registry of 40,271 cases of spinal anesthesia, there were 11 cardiac arrests, corresponding to an incidence of 2.73 (95% CI: 1.12–4.34) per 10,000 anesthetics. The mortality rate was 90.9% among patients who arrested. Among 11 patients who arrested, there were 5 cases of cesarean delivery and 6 cases of extremity surgery, including hip surgery. In 4 patients (36.3%), the anesthetic contributed directly to the arrest (high sympathetectomy, local anesthetic overdose, or lack of electrocardiography monitoring), whereas some arrests were associated with specific events (cementing of prosthesis, massive bleeding, suspected pulmonary embolism, and suspected myocardial infarction). From multivariate analysis, the risks of cardiac arrest during anesthesia were shorter stature (odds ratio 0.944 [95% CI: 0.938–0.951], P < 0.001), longer duration of surgery (odds ratio 1.003 [95% CI: 1.001–1.005], P = 0.002), and spinal anesthesia administered by the surgeon (odd ratio 23.508 [95% CI: 6.112–90.415], P < 0.001), respectively.

CONCLUSION: The incidence of cardiac arrest during spinal anesthesia was infrequent, but was associated with a high mortality rate. If the surgeon performed the spinal anesthetic, this was a significant factor associated with cardiac arrest. Increasing the number of anesthesiologists, improving monitoring guidelines for spinal anesthesia and improving the nurse-anesthetist training program may decrease the frequency of arrest and/or improve patient outcome.



用短针结合指压做眼球周单次注射麻醉

Single Injection Peribulbar Anesthesia with a Short Needle Combined with Digital Compression

Waleed Riad, AB, SB, MD, KSUF, and Nauman Ahmed, FCPS

From the Department of Anaesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia.

Anesth Analg 2008; 107:1751-1753

背景:我们比较用15毫米针和标准的25毫米针用于眼球周阻滞的效果。

方法:用15或25毫米长的针对150例病人行阻滞。在用15毫米针时,应用拇指和食指指压针头接口周围。注射麻醉药直到注意到眼睑发胀。增强不充分的阻滞。

结果:就局部麻醉药容量、补充给药和制动方面,在两组之间没有明显差异。

结论:用15毫米针眼球周阻滞加上指压的效果与25毫米针相当。

(彭中美 译 马皓琳 李士通 校)

BACKGROUND: We compare the efficacy of using a 15 mm to the standard 25 mm needle for performing peribulbar blockade.

METHODS: Blocks were performed on 150 patients using 15 or 25 mm needle length. Digital compression was applied by the thumb and index finger around the needle hub during injection with 15 mm needle. Anesthetic was injected until lid fullness was noted. Inadequate block was augmented.

RESULTS: No significant differences were noted between groups with respect to local anesthetic volume, supplementation, and akinesia.

CONCLUSION: Peribulbar blockade performed with a 15 mm needle with digital pressure is comparable to blockade using a 25 mm needle.

 

 

心脏手术中止血环酸和抑肽酶:一项220例心脏手术病人的应用分析

Tranexamic Acid and Aprotinin in Primary Cardiac Operations: An Analysis of 220 Cardiac Surgical Patients Treated with Tranexamic Acid or Aprotinin

Wulf Dietrich, MD, PhD*, Michael Spannagl, MD{dagger}, Johannes Boehm, MD{ddagger}, Katharina Hauner, MD{ddagger}, Siegmund Braun, MD§, Tibor Schuster, MS||, and Raimund Busley, MD

From the *Institute for Research in Cardiac Anesthesia; {dagger}Department of Hemostasiology, Ludwig Maximilian University, Munich; Departments of {ddagger}Cardiac Surgery and §Clinical Chemistry, German Heart Center Munich; ||Department of Medical Statistics and Epidemiology, Klinikum Rechts der Isar; and ¶Department of Anesthesiology, Behandlungszentrum Vogtareuth, Vogtareuth, Germany.

Anesth Analg 2008 107: 1469-1478.

 

背景:抗纤溶药物已广泛用于心脏手术中以减少出血。异体血输注,即使是在出血较少的心脏手术中使用率也非常高。本研究中作者对比了止血环酸和抑肽酶在减少心脏手术病人术中出血的效果。

方法:这一前瞻性、随机、双盲研究选择了220例冠脉搭桥术(CABG)或主动脉换瓣术(AVR)。患者随机接受止血环酸(约6g)或足剂量的抑肽酶(约5-6 x 106KU)。在严格的输注系统指导下进行输注,通过分子标记物来评估这两种药物在作用方式上的区别。主要观察项目为同种异体的红细胞输注率和手术后24小时血液丢失量。数据根据意向性分析原则通过方差分析和U检验来分析比较.

结果: 研究包括了220名患者(CABG: 134, AVR: 86),抑肽酶组中47%的患者住院期间输注了异体血,止血环酸组为61%(p=0.036),抑肽酶的使用使得异体血输注的危险性下降23%(RR 0.77, 95% CI 0.53–0.88)。虽然总的术后出血的组间无显著差异,但抑肽酶处理的冠脉搭桥病人中术后24小时内出血量减少 〔分别为500ml(350–750 mL) 、650 mL(475–875 mL ),中位数, 25th–75th百分位数; P = 0.039〕。抑肽酶组中输血率减少和术后第一天血红蛋白的浓度升高(11.3, 9.9–12.1 、 10.6, 9.9–11.6 mg/dL; P = 0.023)。在手术结束时纤溶酶激活通过D-二聚体比较(分别为抑肽酶组0.15, 0.11–0.17 mg/L ,止血环酸组为 0.18, 0.12–0.24 mg/L)。在抑肽酶组当肝素的需要量减少后,部分凝血酶激活时间延长到了术后4小时。19%的抑肽酶组病人和45%的止血环酸组病人在心肺分流术中至少追加了一次肝素,在止血环酸组术后和术后第一天肌钙蛋白T水平明显升高(P = 0.017)。两组病人在肾脏、心脏并发症的发生率或死亡率无显著差异。

结论:止血环酸组行冠脉搭桥术病人红细胞输注率略降低,主动脉换瓣膜病人没有差异。在止血环酸在冠脉搭桥术中出血量增加的影响有限,临床价值取决于特殊的病人和特定的机构。

(丁俊云 译 陈杰 校)

BACKGROUND: Antifibrinolytics are widely used in cardiac surgery to reduce bleeding. Allogeneic blood transfusion, even in primary cardiac operations with low blood loss, is still high. In the present study we evaluated the impact of tranexamic acid compared to aprotinin on the transfusion incidence in cardiac surgical patients with low risk of bleeding.

METHODS: This prospective, randomized, double-blind study included 220 patients undergoing primary coronary artery revascularization (coronary artery bypass grafting [CABG]) or aortic valve replacement (AVR). Randomized in blocks of 20, patients received either tranexamic acid (approximately 6 g) or full-dose aprotinin (approximately 5–6 x 106 Kallikrein Inhibiting Units). Transfusion was guided by a strict transfusion algorithm. Molecular markers of hemostasis were determined to assess differences in the mode of action of the two drugs. Primary end-points were the incidence of allogeneic red cell transfusion and 24-h postoperative blood loss. Data were analyzed according to the intention-to-treat principle and compared using the {chi}2 and Mann-Whitney U-test.

RESULTS: Two-hundred-twenty patients were enrolled (CABG: 134, AVR: 86). In the aprotinin Group 47% of patients received allogeneic blood during the hospital stay as compared to 61% in the tranexamic acid group (P = 0.036). Aprotinin conferred a 23% reduction in allogeneic transfusion risk (RR 0.77, 95% CI 0.53–0.88). Overall, no significant difference in postoperative bleeding was observed, although 24-h blood loss was reduced in aprotinin-treated CABG patients (500, 350–750 mL vs 650, 475–875 mL (median, 25th–75th percentile); P = 0.039). Despite the lower transfusion rate, the hemoglobin concentration on the first postoperative day was higher in the aprotinin group (11.3, 9.9–12.1 vs 10.6, 9.9–11.6 mg/dL; P = 0.023). The fibrinolytic activity at the end of operation determined by D-Dimer was comparable in both groups. (0.15, 0.11–0.17 mg/L [aprotinin] versus 0.18, 0.12–0.24 mg/L [tranexamic acid]). The activated partial thromboplastin time was prolonged up to 4 h postoperatively in the aprotinin group, while the heparin requirement was reduced: 19% of the patients in the aprotinin group and 45% in the tranexamic acid group received at least one additional bolus heparin during cardiopulmonary bypass (P < 0.001). Troponin T levels postoperatively and on postoperative day 1 were significantly higher in the tranexamic acid group (P = 0.017). No differences in renal, cardiac, or mortality outcomes were observed.

CONCLUSION: Considering the rate of transfusion of red blood cells, tranexamic acid was slightly inferior in patients undergoing CABG, but there was no difference in patients receiving AVR. Tranexamic acid seems to be less effective in operations with increased bleeding such as CABG. Clinical benefit depends on specific patient and institution characteristics (ClinicalTrials.gov NCT00396760).




合并低蛋白血症的老年心脏手术患者使用白蛋白对炎症反应,内皮细胞活化,以及长期肾功能是否有好处?

Is Albumin Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of Benefit with Regard to Inflammation, Endothelial Activation, and Long-Term Kidney Function?

Joachim Boldt, MD, Ch Brosch, MD, MD, K. Röhm, MD, A. Lehmann, MD, A. Mengistu, MD, and S. Suttner, MD

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Germany.

Anesth Analg 2008 107: 1496-1503.

 

背景:由于输注人血白蛋白对低白蛋白患者有益,因此,作者使用人血白蛋白纠正接受心脏手术的老年患者的低血容量的研究。

方法:在一项前瞻性随机的试验中,50名年龄>80岁,术前血清白蛋白浓度<3.5mg/dl的患者,在体外循环下接受心脏手术,25名给予5%的人血白蛋白,另外25名给予羟乙基淀粉。

开始输注量为500ml,然后持续输注至术后第二天的早晨,维持肺毛细血管压或者中心静脉压在12到14mmHg之间.

结果:在麻醉诱导后,术后5小时,术后第一天和术后第二天,分别检测炎症反应(白细胞介素-6,-10),内皮细胞活化(细胞间粘附分子-1),以及肾功能(包括谷胱甘肽转移酶-{alpha}和中性粒细胞明胶酶相关载脂蛋白)。随访至出院后约60天。给予2980±430mL人血白蛋白和3060±680mL羟乙基淀粉。给予人血白蛋白组血清白蛋白浓度显著增高(至4.5±0.3mg/dL)。给予人血白蛋白的患者与给予羟乙基淀粉的患者相比,血肌酐,肾小球滤过率,以及尿中谷胱甘肽转移酶和中性粒细胞明胶酶相关载脂蛋白的水平无差别。炎症反应在两组也很相似,而内皮细胞活化在羟乙基淀粉组里发生更少。没有患者发展为肾衰而需要肾脏替代疗法。

结论:年龄>80岁,低蛋白血症,接受心脏手术的患者使用人血白蛋白,和使用羟乙基淀粉相比,对于炎症反应、内皮细胞活化和肾功能并无优势。

(舒慧刚 译 陈杰 校)

BACKGROUND: Because patients with low albumin levels may benefit from human albumin (HA) administration, we studied correction of hypovolemia with HA in hypoalbuminic elderly cardiac surgery patients.

METHODS: In a prospective, randomized study, 50 patients aged >80 yr undergoing cardiac surgery using cardiopulmonary bypass with a preoperative serum albumin concentration of <3.5 mg/dL, received either 5% HA (n = 25) or hydroxyethyl starch (6% HES 130/0.4) (n = 25). Volume was added to the priming (500 mL) and given until the morning of the second postoperative day to keep pulmonary capillary wedge pressure or central venous pressure between 12 and 14 mm Hg.

RESULTS: Inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1), and kidney function (including glutathione transferase-{alpha} and neutrophil gelatinase-associated lipocalin) were measured after induction of anesthesia, 5 h after surgery, and the first and second postoperative day. A follow-up, approximately 60 days after discharge from the hospital, was done.

Two thousand nine hundred eighty ± 430 mL of HA and 3060 ± 680 mL of HES 130/0.4 were given. Serum albumin concentration was significantly increased by HA (to 4.5 ± 0.3 mg/dL). Serum creatinine, glomerular filtration rate, and urinary levels of {alpha}-glutathione transferase and neutrophil gelatinase-associated lipocalin were not different in the HA-compared to the HES-treated patients. The inflammatory response was similar in both groups, whereas endothelial activation was less in the HES group. None of the patients developed renal failure requiring renal replacement therapy.

CONCLUSION: Use of HA in hypoalbuminemic cardiac surgery patients aged >80 yr was without benefit with regard to inflammatory response, endothelial activation, and renal function compared to 6% HES 130/0.4.



用于儿童外周静脉置管的一种静脉通路指示装置:一项前瞻性、随机、对照试验
A Vein Entry Indicator Device for Facilitating Peripheral Intravenous Cannulation in Children: A Prospective, Randomized, Controlled Trial

Eliahu Simhi, MD*{dagger}, Ludmyla Kachko, MD*, Elhanan Bruckheimer, MD{ddagger}, and Jacob Katz, MD*

From the *Department of Anesthesia, Schneider Children’s Medical Center of Israel, Petah Tiqwa and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; {dagger}Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and {ddagger}Department of Pediatric Cardiology, Schneider Children’s Medical Center of Israel, Petah Tiqwa and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Anesth Analg 2008 107: 1531-1535.

 

背景:儿童由于静脉口径小和难于触及,血管通路的建立往往存在技术上的困难。本研究中,作者试图确定使用静脉通路指标装置( VEIDTM )是否有利于建立儿童外周静脉通路。

方法:在以色列的一个较大的三级医院行相同择期手术的202名健康儿童(ASA I-II 级),随机分配接受VEID协助或标准外周静脉插管。所有病例均使用22号套管行上肢静脉置管。主要结果检测指标为:尝试插管次数,第一次尝试的成功率,和插管时间。取这些数据的均数,使用方差分析和Pearson 2检验或Fisher’s精确检验进行组间比较;逐步logis回归被用来确定三个变量(年龄,静脉评估类别,使用静脉进入指标装置 )与第一次成功插管的显著相关性。P值〈=0.05被认为具有显著性。

结果:两组患者中的大部分第一次尝试插管即取得成功。VEID组中8 %,对照组中28 %的患者需要两次尝试,需要3次尝试的比例则分别为1 %和3 %( P < 0.01 ) 。通过静脉评估分类分析发现,对于容易置管的患者两组第一次置管成功率相似。然而,困难和中等类别,VEID组成功率为89.7 %,而对照组的成功率为23.3 %,( P < 0.01 )。

使用VEID组尝试次数较少与从寻求合适的静脉开始到插管成功的时间较短相关。( 9.1秒对比对照组的22.5秒)。

结论:静脉通路指示装置有利于健康儿童困难静脉置管,减少了尝试次数和穿刺时间。

(张磊 译 陈杰 校)

BACKGROUND: Vascular access is often technically difficult in children because of the small caliber and impalpability of the veins. In this study, we sought to determine if use of the Vein Entry Indicator Device (VEIDTM) in children facilitates peripheral venous access.

METHODS: Two-hundred-two healthy (ASA grade I and II) children scheduled for same-day surgery at a major tertiary hospital in Israel were randomly allocated to undergo VEID-assisted or standard peripheral venous cannulation. All cases involved the insertion of a 22-gauge cannula into an upper limb vein. Primary outcome measures were number of attempts to successful cannulation, rate of success at first attempt, and time required for insertion. The data were presented as mean (sd). Analyses of variance and Pearson {chi}2 test or Fisher’s exact test were used to compare the groups; forward stepwise logistic regression was used to identify the three variables (age, vein assessment category, use of the VEID) significantly associated with a successful first attempt. A P value of ≤0.05 was considered significant.

RESULTS: Successful cannulation was achieved at the first attempt in the majority of patients in both groups. Two attempts were needed in 8% of the VEID group and 28% of the control group, and 3 attempts were needed in 1% and 3%, respectively (P < 0.01). Analysis by vein assessment category yielded a similar rate of successful first-attempt cannulations in the two groups for easy veins. However, for the difficult and intermediate categories, the rate was 89.7% in the VEID group compared to 23.3% in the control group (P < 0.001). The fewer number of attempts in the study group was associated with a shorter time from the start of the search for an appropriate vein to successful cannulation (9.1 s versus 22.5 s in the control group).

CONCLUSIONS: The VEID facilitates the insertion of peripheral venous cannulas in healthy children with intermediate/difficult veins undergoing same-day surgery, reducing the number of attempts and the overall time required.


年龄对呼末七氟醚浓度和BIS指数动态关系的影响

The Influence of Age on the Dynamic Relationship Between End-Tidal Sevoflurane Concentrations and Bispectral Index

Luis I. Cortínez, MD*, Iñaki F. Trocóniz, PhD{dagger}, Ricardo Fuentes, MD*, Pedro Gambús, MD{ddagger}, Yung-Wei Hsu, MD§, Fernando Altermatt, MD*, and Hernán R. Muñoz, MD, MSc*

From the *Departamento de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile. Santiago, Chile; {dagger}Department of Pharmacy; School of Pharmacy; University of Navarra; Pamplona, Spain; {ddagger}Department of Anesthesiology, Hospital CLINIC, Universidad de Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain; and §Department of Anesthesiology, Mackay Memorial Hospital, Taiwan.

Anesth Analg 2008 107: 1566-1572.

 

背景:年龄是吸入麻醉药的药物代谢动力学的一个重要的因素。然而,年龄对七氟醚动态分布的影响尚未得到详细描述。作者进行此项研究来描绘年龄与其他相关变量对呼末七氟醚浓度(CET)和其用效能(用BIS指数来表示)的动态关系。

方法: 对50名,年龄3—71岁,行小手术的患者进行前瞻性研究。研究期间持续监测呼末七氟醚浓度(CET)和BIS。麻醉维持期间,待BIS值稳定于60–65间后,令吸入七氟醚浓度增加至5%维持5min,直至BIS <40后减低浓度。在此期间对呼末七氟醚浓度和其用效能(用BIS来表示)的动态关系的变化,利用种群药代学和药效学方法通过非线型混合效应模型V建立最大效能抑制模型。一个有预测性的检查方法被用于确认最终模型。

结果:七氟醚效应通过监测BIS值,由C50表示(稳态呼末半数有效浓度),伴随年龄增大而增加。由效应靶点的平衡半衰期( t1 / 2为ke0 )所表示的七氟醚效应的变化速度,在老年人中增加。预测分析证实这一模型是恰当的。

结论:年龄对呼末七氟醚浓度和用BIS表示的效应之间动态关系有显著的影响。

(叶乐 译 陈杰 校)

BACKGROUND: Age is an important determinant of the pharmacokinetic profile of inhaled anesthetics. The influence of age on the dynamic profile of sevoflurane’s effect has not been well described. We performed this study to characterize the influence of age and other covariates on the dynamic relationship between sevoflurane end-tidal concentration (CET) and its effect measured by bispectral index (BIS).

METHODS: Fifty patients, aged 3–71 yr, scheduled for minor surgery were prospectively studied. The BIS and sevoflurane CET were continuously measured during the study period. During maintenance of anesthesia and after stable BIS values of 60–65 were obtained, the inspired concentration of sevoflurane was increased to 5 vol % for 5 min or until BIS <40 and then decreased. The dynamic relationship between sevoflurane CET and its effect as measured by BIS during this transition period were modeled with an inhibitory Emax model using a population pharmacokinetic–pharmacodynamic approach with NONMEM V. A predictive check method was used to validate the final model.

RESULTS: The sensitivity to sevoflurane’s effect as measured by BIS expressed in the C50 [steady-state CET eliciting half of maximum response (Imax)] increased with age. The speed of change of sevoflurane’s effect, expressed as the effect–site equilibration half-life (t1/2 ke0), increased at older ages. The predictive check analysis confirmed the adequacy of the model.

CONCLUSIONS: Age significantly affects the dynamic relationship between sevoflurane CET and its effect measured with BIS.

全身低剂量布比卡因预防大鼠开胸术后异常性疼痛的发生

Low-Dose Systemic Bupivacaine Prevents the Development of Allodynia After Thoracotomy in Rats

Jin Woo Shin, MD, PhD{dagger}, Carlo Pancaro, MD*, Chi Fei Wang, PhD*, and Peter Gerner, MD*

From the *Pain Research Center, Department of Anesthesiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA; and {ddagger}Department of Anesthesiology and Pain Medicine, College of Medicine, University of Ulsan, Asan Medical Center, Seoul, South Korea.

Anesth Analg 2008 107: 1587-1591.

 
背景:最近,开胸手术后慢性疼痛的模型在大鼠上已被复制用来观察可能减少开胸手术后异常性疼痛发病率的药物作用。以往的研究表明,在大鼠模型鞘内注射或全身吗啡,可乐定,新斯的明,和加巴喷丁可减少开胸的术后疼痛,本研究目的是测试肋间和全身注射布比卡因是否能在慢性肋间神经痛动物模型上阻止疼痛的发生。
方法:雄性SD大鼠麻醉后,暴露右边第4和第5肋骨。开胸、关胸1小时,手术前后或手术前肋间注射或全身注射布比卡因1毫克( 0.2毫升0.5 % ),对照组关胸前不注射任何药物,手术后3周在大鼠切口周围预定区域测试机械痛。
结果:对照组 43 %的动物发生疼痛,手术前、手术后肋间注射、术前全身各自注射布比卡因的实验组疼痛的发生率只有6%12%12%
结论:以往的研究表明,阿片类药物,{alpha}2 -肾上腺素受体激动剂,新斯的明,和加巴喷丁可以防止关胸后疼痛的发生。目前的结果表明,手术前后肋间注射或者手术前全身给予布比卡因,能有效地防止机械痛。 

(刘世文 译 陈杰 校)

BACKGROUND: Chronic pain after thoracotomy has been recently reproduced in a rat model that allows investigation of the effect of drugs that might reduce the incidence of allodynia after thoracotomy. Previous studies suggest that intrathecal or systemic morphine, clonidine, neostigmine, and gabapentin reduce the incidence of allodynia in the rat postthoracotomy pain model. Our purpose was to test whether intercostal and systemic injection of bupivacaine prevented the development of allodynia in an animal model of chronic intercostal neuropathic pain.

METHODS: Male Sprague-Dawley rats were anesthetized and the right 4th and 5th ribs surgically exposed. The pleura were opened and the ribs were retracted for 1 h. Intercostal or systemic bupivacaine 1 mg (0.2 mL at 0.5%) was injected before and after surgery, or before surgery; a control group underwent rib retraction and did not receive any drug. Rats were tested for mechanical allodynia at a predetermined area around the incision site during the 3 wk after surgery.

RESULTS: Allodynia developed in 43% of the animals that did not receive bupivacaine (control group); in contrast, allodynia developed in only 6%, 12%, and 12% of those animals that received intercostal bupivacaine before surgery, after surgery, or systemically before surgery, respectively.

DISCUSSION: Previous studies suggest that allodynia after rib retraction can be prevented by opioids, {alpha}2-adrenergic agonists, neostigmine, and gabapentin. The current results suggest that bupivacaine is effective in preventing mechanical allodynia, whether given by intercostal injection before or after surgery, or systemically before surgery.

 



一种新颖的神经肌肉阻滞咨询系统以改善神经肌肉阻滞:一个随机,对照,临床的实验

Improved Neuromuscular Blockade Using a Novel Neuromuscular Blockade Advisory System: A Randomized, Controlled, Clinical Trial

Terence J. Gilhuly, MASc*{dagger}, Bernard A. MacLeod, MD, FRCPC*, Guy A. Dumont, PhD{dagger}, Alex M. Bouzane, MSc, MD*, and Stephan K. W. Schwarz, MD, PhD, FRCPC*{ddagger}

From the *Department of Anesthesiology, Pharmacology & Therapeutics, Hugill Anesthesia Research Centre, {dagger}Department of Electrical and Computer Engineering, and {ddagger}Department of Anesthesia, St. Paul's Hospital, The University of British Columbia, Vancouver, B.C., Canada.

Anesth Analg 2008 107: 1609-1617.

 

背景:传统单次给予神经肌肉阻滞剂常与术中控制受限,复苏延长以及麻醉后的阻滞作用的残余效应有关。为了克服这些限制,作者研发了一个新颖的自适应电脑控制程序--肌肉阻滞咨询系统(NMBAS)。NMBAS根据于一个六个序列的模型和病人肌电图描记,给予麻醉医生有关给药时间和剂量的建议。在此,检验了相对于标准管理NMBAS能够改善NMB的假说。

方法:作者设计了这项前瞻性、随机的、对照的、双盲的、平行对照的临床实验, 选择ASA I-III,应用罗库溴铵神经肌肉阻滞,麻醉时间≥1.5h,腹部手术的患者73例。这些患者随机分配到标准管理组或者NMBAS引导的罗库溴铵给药组。主要结果变量是手术中反映NMB不充分的发生率。次要结果变量包括在手术结束时逆转之前的四个成串刺激(TOF)比值,罗库溴铵的总剂量,逆转药物,麻醉剂和其它药物,术后副反应的发生率,以及NMBAS介绍的麻醉学上不配合的发生率。

结果:73个入组的患者中,每个组n=30的适合分析。统计的患者进行组间比较。与标准管理组相比较,NMBAS组中手术中与NMB不充分相关事件的总发生率显著降低(8/30vs19/30;p=0.004)。TOF比值的平均值在手术结束时尚未逆转前在NMBAS组更高(0.59[95%Cl,0.48-0.69]vs0.14[95%Cl,0.04-0.24];p<0.0001)。罗库溴铵总的给药剂量,逆转药物,以及其它药物,和术后副反应的发生率没有明显区别。

结论:与常规相比,NMBAS引导的管理与改善NBM质量和提高手术结束时TOF比值相关,可能降低NMB残余效应的风险和提高病人手术期间的安全性。

(怀晓蓉 译 陈杰 校)

BACKGROUND: Conventional incremental bolus administration of neuromuscular blocking (NMB) drugs is associated with limitations in intraoperative control, potential delays in recovery, and residual blockade in the postanesthetic period. To overcome such limitations, we developed a novel adaptive control computer program, the Neuromuscular Blockade Advisory System (NMBAS). The NMBAS advises the anesthesiologist on the timing and dose of NMB drugs based on a sixth-order Laguerre model and the history of the patient's electromyographic responses. Here, we tested the hypothesis that the use of the NMBAS improves NMB compared to standard care.

METHODS: We conducted a prospective, randomized, controlled, blinded, parallel-group, clinical trial with n = 73 patients (ASA physical status I-III) undergoing abdominal surgery under general anesthesia ≥1.5 h with NMB using rocuronium. Patients were allocated to standard care or NMBAS-guided rocuronium administration. The primary outcome variable was the incidence of intraoperative events reflecting inadequate NMB. Secondary outcome variables included train-of-four (TOF) ratios at the end of surgery before reversal, the total doses of rocuronium, reversal agents, anesthetics and other drugs, the incidence of postoperative adverse events, and the incidence of anesthesiologist noncompliance with NMBAS recommendations.

RESULTS: Of 73 enrolled patients, n = 30 per group were eligible for analysis. Patient demographics were comparable between the groups. The incidence in total intraoperative events associated with inadequate NMB was significantly lower in the NMBAS group compared to standard care (8/30 vs 19/30; P = 0.004). Mean TOF ratios at the end of surgery before reversal were higher in the NMBAS group (0.59 [95% CI, 0.48–0.69] vs 0.14 [95% CI, 0.04–0.24]; P < 0.0001). Total administered doses of rocuronium, reversal drugs, and other drugs, and the incidence of postoperative adverse events were not different.

CONCLUSIONS: Compared to standard practice, NMBAS-guided care was associated with improved NMB quality and higher TOF ratios at the end of surgery, potentially reducing the risk of residual NMB and improving perioperative patient safety.


在严重脓毒症中早期使用高剂量抗凝血酶:来自KyberSept试验的单中心结果

Early Administration of High-Dose Antithrombin in Severe Sepsis: Single Center Results from the KyberSept-Trial

Alain Eid, MD*, Christian J. Wiedermann, MD{dagger}, and Gary T. Kinasewitz, MD{ddagger}

From the *Division of Pulmonary and Critical Care, CO Springs Memorial Hospital, CO Springs, Colorado; {dagger}Division of Internal Medicine, Department of Medicine, Central Hospital of Bolzano, Bolzano, Italy; and {ddagger}Pulmonary and Critical Care Medicine, University of Oklahoma Health Science Center, Oklahoma.

Anesth Analg 2008 107: 1633-1638.

 

背景:在KyberSept试验的全部的结果中,对严重脓毒症中使用高剂量抗凝血酶的非治疗效应与主要结果——28天死亡率不一致的可能原因是由于异质性。控制的非治疗效应的KB试验结果与其主要成果,28天死亡率互相矛盾,可能是由于患者个体差异造成。目前还没有早期使用(微循环紊乱但还没有出现不可逆器官损害)抗凝血酶治疗严重脓毒症的相关作用的报道。

目标:作者报道KS试验中严重脓毒症患者出现新的器官衰竭早期在单中心的接受了治疗及由此产生的结果。

方法:所有参加者都来自美国某三级医院重症监护室。患者随机1:1分配(空白对照:n=41;抗凝血酶AT:n=40),在48小时内接受抗凝血酶治疗(30000IU静注,超过四天)或安慰剂治疗。

结果:组间原始变量基线稳定。80%的患者(n=65)在发生严重脓毒症的24小时内接受研究药物治疗;94%的患者(n=76)在48小时内接受研究药物。AT组的40名参与者中的9名(22.5%)在最初的7天内出现了新的器官功能障碍,而相较于39名空白对照组患者中的17名患者(43.6%),空白对照组的原始变量基线并无不同(P=0.058;2名患者最初就患有多器官功能障碍而被排除)。在28天时,40名接受AT治疗的患者中有16名(40%)死亡,而41名接受空白对照治疗的患者有22名(54%)死亡[明显减少,14%;优势比(95%可信区间),0.58(0.24-1.39)]。在接受AT治疗的患者中,出血的发生率明显增加(40名AT组患者中8名出现(20.0%),同时,空白对照组41名患者中有1名出现(2.4%);P<0.015)。

结论:由此分析的数据证实抗凝血酶治疗的患者出血的风险增加。当在严重脓毒症早期给予抗凝血酶,尽管统计学差异不明显,抗凝血酶治疗的器官衰竭和死亡率的绝对风险相应降低21%和14%,这显示抗凝血酶治疗对于有选择的脓毒症患者还是具有潜在益处的。此研究提示我们需要进一步进行抗凝血酶治疗脓毒症的研究,并侧重于减少患者个体差异性。

(朱紫瑜 译 陈杰 校)

BACKGROUND: The overall finding in the KyberSept trial of no treatment effect of high-dose antithrombin (AT) in severe sepsis was inconsistent for the primary outcome, 28-day mortality, possibly because of patient heterogeneity. No data have been reported on the effects of AT therapy administered early in severe sepsis when microcirculation is disturbed but irreversible organ damage has not yet developed.

OBJECTIVE: We report the post hoc results of the KyberSept trial in patients with severe sepsis treated at a single center early after new onset organ failure.

METHODS: All study participants from a United States tertiary care intensive care unit were analyzed. Patients had been randomized 1:1 (placebo: n = 41; AT: n = 40) to receive AT (30,000 IU IV over a period of four days) or placebo within 48 h.

RESULTS: Baseline variables were well balanced between groups. Eighty percent of patients (n = 65) received study drug within 24 h after onset of severe sepsis; 94% (n = 76) received study drug within 48 h. Nine of 40 participants in the AT group (22.5%) had new organ dysfunction during the first 7 days which was not present at baseline compared with 17 of 39 subjects (43.6%) in the placebo group (P = 0.058; two participants had dysfunction of all organs at baseline and were therefore excluded). At 28 days, 16 of 40 patients (40%) treated with AT died versus 22 of 41 (54%) with placebo [absolute reduction, 14%; odds ratio (95% confidence interval), 0.58 (0.24–1.39)]. In patients receiving AT, a significantly increased bleeding incidence was observed (any bleeding, 8 of 40 (20.0%) for AT group vs 1/41 (2.4%) for placebo group; P < 0.015).

CONCLUSIONS: Data from this post hoc analysis confirm an increased bleeding risk seen with AT treatment in these patients. When given early in severe sepsis, though statistically not significant, absolute risk reductions with AT of 21% and 14% for organ failure and mortality, respectively, indicate a potential for treatment benefit in selected sepsis patients. This observation may have implications for continuing sepsis trials with AT that focus on reduced patient heterogeneity.


合并有Shone’s综合征的产妇行剖宫产时的麻醉管理

The Anesthetic Management for Cesarean Delivery in a Patient with Shone's Syndrome

Kathleen Sachse, MD, and Medhat Hannallah, MD, FFARCS

From the Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC.

Anesth Analg 2008 107: 1652-1654.

 

Shone’s综合征是一种罕见的先天性心脏病,主要包含多达4种左心的梗阻性损伤。本文作者报道一位17岁合并有Shone’s综合征的产妇接受剖宫产术。该产妇合并有轻度二尖瓣狭窄和轻度左室流出道梗阻。作者尝试对其实施硬膜外腔阻滞麻醉,但患者出现了严重的低血压及与之相关的胎儿心动过缓,而需要立即在全麻下实施剖宫产术。文中还讨论了此类患者的围产期麻醉用药及管理要点。

(周姝婧 译 陈杰 校)

Shone's syndrome is a rare congenital cardiac condition that consists of up to four obstructive left-sided cardiac lesions. We report a 17-yr-old nullipara with Shone's syndrome who presented for cesarean delivery. She had mild mitral stenosis and mild left ventricular outflow tract obstruction. Epidural anesthesia was attempted, but the patient developed severe hypotension associated with fetal bradycardia necessitating immediate cesarean delivery under general anesthesia. The peripartum anesthetic and management considerations for these patients are discussed.

 

脑电双频谱指数在严重脑损伤合并难治性颅高压患者巴比妥酸昏迷中的应用

The Use of Bispectral Index to Monitor Barbiturate Coma in Severely Brain-Injured Patients with Refractory Intracranial Hypertension

Vincent Cottenceau, MD*, Laurent Petit, MD*, Françoise Masson, MD*, Dominique Guehl, MD, PhD{dagger}, Julien Asselineau, MS{ddagger}, Jean-François Cochard, MD*, Catherine Pinaquy, MD*, Alain Leger, MD*, and François Sztark, MD, PhD*

From the *Departments of Anesthesia and Intensive Care Unit, {dagger}Clinical Neurophysiology, and {ddagger}Clinical Epidemiology Unit, Centre Hospitalo-Universitaire de Bordeaux, Bordeaux, France; Université Victor Segalen Bordeaux 2, Bordeaux, France.

Anesth Analg 2008 107: 1676-1682.

 

背景:严重创伤性脑损伤(TBI)病人应用巴比妥药物治疗通常需要监测脑电图(EEG)爆发-抑制模式。而脑电双频谱指数(BIS)是来源于脑电图且考虑了皮层静息。作者试图探讨BIS的变化是否预示着特异性的爆发-抑制模式。

方法:对11位接受巴比妥治疗的创伤性脑损伤(TBI)病人进行前瞻性研究。每天记录一小时的脑电图。爆发/抑制比值(脑电图抑制率「SREEG」:60秒大脑皮层静息百分率)每5分钟在原脑电图上计算1分钟,并且与同步测得的BIS-XPTM相对比(脑电双频谱指数与抑制率「SRBIS」)。巴比妥昏迷的最适合脑电图水平定义为2-5次爆发/分钟。巴比妥昏迷的最合适BIS范围通过实验数据预测,在每一个实验中都将研究其精确度。

结果:测得的SREEG 与SRBIS一致性很高(组内相关系数0.94「95%可信区间:0.90-0.96」)。SREEG与BIS呈显著性相关。在一些实验中出现显著不一致。预测巴比妥昏迷的最佳BIS范围为6-15.

结论:在使用巴比妥药物治疗的创伤性脑损伤(TBI)病人中,SREEG 与BIS的相关性很高。当BIS指数小于6时,巴比妥类药物的输注速度将要减慢。当BIS指数大于15时,巴比妥类药物的输注速度将要加快。需要通过对脑电图相似信号的观察(正如BIS-XPTM所显示)定时检查脑电双频谱指数与脑电图抑制模式的对应关系

(赵嫣红 译 陈杰 校)

BACKGROUND: Barbiturate therapy in severely traumatic brain-injured (TBI) patients is usually monitored by an electroencephalogram (EEG) with burst-suppression pattern as a target. The Bispectral Index (BIS) is derived from EEG and considers cortical silence. We sought to determine whether a BIS range could predict a specific burst-suppression pattern.

METHODS: Eleven TBI patients treated with barbiturate were included prospectively. EEG was recorded daily for 1 h. Every 5 min, the number of bursts and the suppression ratio (suppression ratio from EEG [SREEG]: percentage of last 60 s in cortical silence) was calculated for 1 min on the raw EEG and compared to concomitant data from the BIS-XPTM (BIS and suppression ratio [SRBIS]). The optimal level of barbiturate coma was defined as 2–5 bursts/min in the EEG. A BIS range predictive of optimal level was determined from all data and its accuracy was studied for each examination.

RESULTS: Agreement between SREEG and SRBIS was high (interclass correlation coefficient 0.94 [95% confidence interval: 0.90–0.96]). There was a significant association between SREEG and BIS. Significant disagreements were observed in some examinations. The best accuracy to predict optimal pattern was obtained with a BIS range from 6 to 15.

CONCLUSION: The relationship between BIS and SREEG was high in TBI patients treated with barbiturates. The rate of barbiturate infusion might be decreased if BIS is <6 or increased if BIS is >15. Correspondence between BIS and suppression pattern should periodically be checked by observation of the EEG analogical signal (as displayed by BIS-XPTM).


无创正压通气对加快病态肥胖病人预吸氧的效果:随机对照研究

The Effectiveness of Noninvasive Positive Pressure Ventilation to Enhance Preoxygenation in Morbidly Obese Patients: A Randomized Controlled Study

Jean-Marc Delay, MD*, Mustapha Sebbane, MD*, Boris Jung, MD*, David Nocca, MD{dagger}, Daniel Verzilli, MD*, Yvan Pouzeratte, MD*, Moez El Kamel, MD*, Jean-Michel Fabre, MD, PhD{dagger}, Jean-Jacques Eledjam, MD, PhD*, and Samir Jaber, MD, PhD*

From the Departments of *Anesthesia and Critical Care B (DAR B), and {dagger}Digestive Surgery, Saint-Eloi University Hospital of Montpellier, Montpellier, France.

Anesth Analg 2008 107: 1707-1713.

 

背景:配合压力支持通气和呼气末正压通气的无创正压通气(NPPV)能有效地为插管时存在低氧的病人提供氧气。作者假设使用NPPV给氧要比自发通气(SV)进行预氧化能更快增加病态肥胖病人的呼气末氧浓度(ETO2)。

方法:28名病态肥胖患者参加了这一前瞻性地随机研究。使用SV或者NPPV(压力支持=8cmH2o,PEEP=6cmH2o)(NPPV组)给氧5 min。ETO2可以使用麻醉呼吸回路测量,也可表示为大气浓度的一小部分。主要终点是在给氧最后ETO2>95%的病人数量。次要终点包括达到最大ETO2的时间和给氧结束时的ETO2值。

结果:与SV组相比NPPV组中有更大比例的患者在5 min时ETO2达到95%(13/14 vs 7/14, P = 0.01)。在NPPV组ETO2达到最大值的时间明显少于SV组(185±46 vs 222±42 s,P=0.02)。在给氧结束时的平均ETO2值NPPV组比SV更大(96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001)。NPPV组可见中等程度的胃扩张。但两组均未见明显不良后果。

结论:在手术室对病态肥胖病人通过面罩进行NPPV给氧是安全、可行和有效的。对于这类人NPPV能提供更快速的给氧,达到更高的ETO2。

(潘钱玲 译 陈杰 校)

BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) with pressure support-ventilation and positive end-expiratory pressure are effective in providing oxygenation during intubation in hypoxemic patients. We hypothesized administration of oxygen (O2) using NPPV would more rapidly increase the end-tidal O2 concentration (ETo2) than preoxygenation using spontaneous ventilation (SV) in morbidly obese patients.

METHODS: Twenty-eight morbidly obese patients were enrolled in this prospective randomized study. Administration of O2 for 5 min was performed either with SV group or with NPPV (pressure support = 8 cm H2O, positive end-expiratory pressure = 6 cm H2O) (NPPV group). ETo2 was measured using the anesthesia breathing circuit, and is expressed as a fraction of atmospheric concentration. The primary end-point was the number of patients with an ETo2 >95% at the end of O2 administration. Secondary end-points included the time to reach the maximal ETo2 and the ETo2 at the conclusion of O2 administration.

RESULTS: A larger proportion of patients achieved a 95% ETo2 at 5 min with NPPV than SV (13/14 vs 7/14, P = 0.01). The time to reach the maximal ETo2 was significantly less in the NPPV than in the SV group (185 ± 46 vs 222 ± 42 s, P = 0.02). The mean ETo2 at the conclusion of O2 administration was larger in the NPPV group than the SV group (96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001). A modest, although significant, increase in gastric distension was observed in the NPPV group. No adverse effects were observed in either group.

CONCLUSION: Administration of O2 via a facemask with NPPV in the operating room is safe, feasible, and efficient in morbidly obese patients. In this population NPPV provides a more rapid O2 administration, achieving a higher ETo2.


在体内高或低皮质醇对人体单核细胞介导的炎症反应途径有双相影响
In Vivo
Exposure to High or Low Cortisol Has Biphasic Effects on Inflammatory Response Pathways of Human Monocytes

Mark P. Yeager, MD*, Patricia A. Pioli, PhD{dagger}, Kathleen Wardwell, BS{dagger}, Michael L. Beach, MD, PhD*, Peter Martel, MS{dagger}, Hong K. Lee, PhD{ddagger}, Athos J. Rassias, MD*, and Paul M. Guyre, PhD{dagger}

From the Departments of *Anesthesiology, {dagger}Physiology, and {ddagger}Pathology, Dartmouth Medical School, Hanover, New Hampshire and the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.

Anesth Analg 2008 107: 1726-1734.

 

背景:最近的研究表明,糖皮质激素对免疫反应有支持(刺激)和抑制性影响,这取决于糖皮质激素浓度。由于一些糖皮质激素对炎症的刺激,作者推测糖皮质激素在体内急性缺失将减少人单核细胞介导的炎症反应。

方法:分离健康志愿者参加在体治疗前和后的单核细胞; 1 )注射生理盐水, 2 )注射高剂量氢化可的松(8 µg·kg–1·min–1) ,其次是隔夜口服氢化可的松,以及3 )口服米非司酮(200 mg 在04:00和16:00 点)为阻止细胞内的糖皮质激素受体和注射依托咪酯(1.5 mg·kg–1·h–1 )12小时,以防止代偿性合成肾上腺皮质醇。连续测量血浆促肾上腺皮质激素,血浆和唾液皮质醇。测试单核细胞为: 1 )细胞因子反应, 2 )CD163 , CD119和CD54  的表达,3) mRNA水平的糖皮质激素反应炎症介质。所有数据测试均在离体有或没有脂多糖刺激单核细胞下进行。

结果:皮质醇和促肾上腺皮质激素的测量证明有效控制体内皮质醇。体内皮质醇增多和糖皮质激素的消耗对单核细胞mRNA水平4个重要的 糖皮质激素反应分子(糖皮质激素受体, CD163 ,白细胞介素-10 ,和细胞因子合成- 3抑制因子)有相互的影响。单核细胞因子反应和蛋白表达没有受到糖皮质激素缺失的影响。皮质醇增多增强了 CD163的表达 。
结论
:短期糖皮质激素缺失影响糖皮质激素反应分子的mRNA水平,但并不影响单核细胞蛋白的表达或细胞因子反应。

(陈伟 译 陈杰 校)

BACKGROUND: Recent studies demonstrate that glucocorticoids (GCs) have both supportive (stimulatory) and suppressive effects on immune responses, depending upon the GC concentration. Since some GC effects on inflammation are stimulatory, we hypothesized that acute in vivo GC depletion would decrease inflammatory responses of human monocytes.

METHODS: Monocytes were isolated from healthy volunteer participants before and after in vivo treatment with; 1) IV saline, 2) IV high dose hydrocortisone (8 µg·kg–1·min–1) followed by oral hydrocortisone overnight, and 3) oral RU486 (200 mg at 0400 and 1600 h) to block the intracellular GC receptor and IV etomidate (1.5 mg·kg–1·h–1) for 12 h to prevent compensatory adrenal cortisol synthesis. Plasma adrenocorticotropic hormone, plasma, and salivary cortisol were measured serially. Monocytes were tested for; 1) cytokine responses, 2) expression of CD163, CD119, and CD54, and 3) mRNA levels of GC-responsive inflammatory mediators. All measurements were made with and without in vitro stimulation of monocytes by lipopolysaccharide.

RESULTS: Cortisol and adrenocorticotropic hormone measurements demonstrated effective manipulation of in vivo cortisol. In vivo hypercortisolemia and in vivo GC depletion had reciprocal effects on monocyte mRNA levels of 4 important GC-responsive molecules: 1) GC receptor, CD163, interleukin-10, and suppressor of the cytokine synthesis-3. Monocyte cytokine responses and protein expression were not affected by GC depletion. CD163 expression was increased by hypercortisolemia.

CONCLUSIONS: Short-term GC depletion affects mRNA levels of GC-responsive molecules but does not affect monocyte protein expression or cytokine responses.

 

3%氯普鲁卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌间沟臂丛神经阻滞中的比较:一项随机、前瞻、双盲对照试验:

A Randomized, Prospective, Double-Blind Trial Comparing 3% Chloroprocaine Followed by 0.5% Bupivacaine to 2% Lidocaine Followed by 0.5% Bupivacaine for Interscalene Brachial Plexus Block

Soheila Jafari, MD, Allison I. Kalstein, DO, Habib M. Nasrullah, MD, Mehrdad Hedayatnia, MD, Joel M. Yarmush, MD, and Joseph SchianodiCola, MD

From the Department of Anesthesiology, New York Methodist Hospital, Brooklyn, New York.

Anesth Analg 2008 107: 1746-1750.

 

背景:2-氯普鲁卡因加布比卡因(C/B)后可用于区域麻醉,但由于其效果不是很显著,并没有能够得到广泛应用。在这项随机、前瞻、双盲对照试验中,作者比较了使用(C/B)和使用利多卡因加布比卡因(L/B)在肌间沟阻滞中的效用。

方法:30例准备在肌间沟臂丛神经阻滞下行肩膀关节手术的病人随机分成两组,每组15例。一组(C/B)使用3%氯普鲁卡因混合碳酸氢盐和肾上腺素,紧接着使用0.5%布比卡因和肾上腺素。另一组(L/B)使用2%利多卡因代替3%氯普鲁卡因。运动神经和感觉神经阻滞每15秒测试一次。主要评定的结束点是完全运动神经阻滞的出现。运用Time-to-event统计方法分析。

结果:一名L/B组的病人没有出现阻滞,不做分析。C/B组和L/B组出现运动神经阻滞的平均时间分别是90秒(15-575)和180(15-3720)秒(P=0.0325)。两组的感觉神经阻滞的平均时间分别是90(30-600)秒和12(30-3900)秒(P=0.0185)。统计显示,在5分钟内C/B组的15例病人中有13例有运动神经阻滞,L/B组14例病人中只有7例有运动神经阻滞。十分钟内,C/B组15名病人全部实现运动神经阻滞,L/B组只有10名。在L/B组中最长等待了60分钟来评估是不是完成了阻滞。

结论:研究表明:在肌间沟阻滞时,使用C/B药物比使用L/B能更快完成阻滞。

(王腾 译 陈杰 校)

BACKGROUND: The combination of 2-chloroprocaine and bupivacaine (C/B) for regional anesthesia has been described, but its use was largely abandoned due to equivocal results in efficacy. In this prospective, double-blind, randomized study, we compared the onset of an interscalene block using C/B versus a combination of lidocaine and bupivacaine (L/B).

METHODS: Thirty patients scheduled for shoulder arthroscopy under interscalene block were divided into two groups of 15 each. One group (C/B) received 3% 2-chloroprocaine combined with bicarbonate and epinephrine, immediately followed by 0.5% bupivacaine and epinephrine, whereas the other group (L/B) received 2% lidocaine instead of 3% 2-chloroprocaine. Motor and sensory block were assessed every 15 s. The primary end-point was the time of onset to complete motor block. Time-to-event (survival) statistical analysis tests were applied.

RESULTS: One L/B patient had a failed block, and was excluded. The median time to motor block for C/B and L/B was 90 (15–575) and 180 (15–3720) s, respectively (P = 0.0325), and to sensory block for C/B and L/B was 90 (30–600) and 210 (30–3900) s, respectively (P = 0.0185). Survival analysis showed that in 5 min, 13 of 15 patients from the C/B group but only 7 of 14 from the L/B group had a successful motor block. In 10 min, 15 of 15 patients from the C/B group but only 10 of 14 from the L/B group had a successful motor block. It took as long as 60 min to assess block success/failure for blocks in the L/B group.

CONCLUSIONS: This study demonstrates that a successful block was more rapid using C/B than L/B for interscalene blocks.

 

 

凝血弹性度评价低温对凝血系统的影响

A Thromboelastometric Evaluation of the Effects of Hypothermia on the Coagulation System

Malin Rundgren and Martin Engström

Department of Anaesthesia and Intensive Care, Halmstad Central Hospital, Halmstad, Sweden.

Anesth Analg 2008 107: 1465-1468.

 

背景:低温可分为意外和治疗性的。治疗性低温越来越多的被用于不同的情况,例如:心脏停搏后的神经保护等。低温会导致凝血系统的损害,但损害的程度很难评估。大部分的研究着眼于血浆而不是全血。我们用全血在一个宽范围的温度(25-40摄氏度)内研究低温对凝血系统的影响。

方法:从6个健康的志愿者采血,保存在柠檬酸盐试管中。在轮流用凝血弹性度评价凝血系统前,将样本放在25-40摄氏度的水中水浴30分钟。接触激活剂(鞣花酸)用于触发最初的凝血。测量凝血时间、血块形成时间、生理角及最大血块强度。所有的试验持续60分钟然后在与水浴温度相同的温度下进行测量。

结果:在研究的温度范围内,凝血功能的损害随温度的降低而加重。所有的测量值都呈阶梯式的下降,有显著差异(P<0.0001)。

结论:全血的检测分析提示低温进行性的损害凝血系统。

(胡艳译   薛张刚校)

BACKGROUND: Hypothermia may be accidental or therapeutic. Therapeutic hypothermia is increasingly used as treatment for various conditions, e.g., neuroprotection after cardiac arrest. Hypothermia leads to an impairment of the coagulation system, but the degree of impairment has been difficult to determine. Most studies have been performed on plasma instead of whole blood. We therefore evaluated whole blood investigating the effects of hypothermia on the coagulation system over a wide range of temperatures (25-40 degrees C).

METHODS: Blood was drawn from six healthy volunteers into citrated test tubes. Samples were then placed in water baths with temperatures ranging from 25 to 40 degrees C for 30 min before the coagulation system was studied using rotational thromboelastometry. A contact activator (Ellagic acid) was used for initiation of coagulation. Clotting time, clot formation time, alpha angle, and maximum clot strength were measured. All tests were run for 60 min and they were performed at the same temperature as the temperature in the water bath.

RESULTS: Coagulation was increasingly impaired with decreasing temperatures in the temperature range studied. All variables measured were significantly impaired in a stepwise pattern (P < 0.0001).

CONCLUSIONS: Evauation using a whole blood analysis shows that hypothermia progressively impairs the coagulation system.

 

 

关于常规心脏手术血液回收的一项随机对照研究

A Randomized Controlled Trial of Cell Salvage in Routine Cardiac Surgery

Andrew A. Klein, Samer A. M. Nashef, Linda Sharples, Fiona Bottrill, Matthew Dyer, Johanna Armstrong, and Alain Vuylsteke

Department of Anaesthesia, Papworth Hospital, Cambridge, CB23 3RE, UK.

Anesth Analg 2008 107: 1487-1495.

 

背景:之前的研究表明血液回收可能减少心脏手术的异体输血,但这些研究有局限性,包含了其他节约输血策略使用的不一致。我们设计了一项随机对照研究以确定对择期非复杂心脏手术行常规血液回收能否减少输血,以及在严格输血方案和常规使用抗纤维蛋白酶的设定下行常规血液回收的成本效益分析。

方法230名首次行冠脉搭桥术和/或心脏瓣膜手术的患者预先随机分为对照组和血液回收组。后一组通过细胞回收设备行术中和术后6小时内胸腔引流液的血液回收并行自体血回输。所有患者均使用氨甲环酸并按规定算法接受红细胞和凝血因子输注。

结果:两组间患者输异体血的比例没有差异(两组均为32%,相对危险因子1.0, P = 0.89)。以目前的血制品和细胞回收设备的价格,使用血液回收至少增加每个病人的花费103美元。当患者因出血再次行胸腔探查时予以排除(按方案计划),血液回收组患者输异体血单位量明显少于对照组(65vs100U,相对危险因子0.71, P = 0.04)。

结论:首次行常规心脏手术的患者在具有严格血液保存计划的医疗机构中,常规使用血液回收并不能减少患者输异体血的比例。然而,术后出血过多的患者却可通过血液回收明显减少输血的单位量。尽管使用血液回收能明显减少血制品的需要量,但会增加医疗机构的成本。

(黄凝译  薛张纲校)

BACKGROUND: Previous trials have indicated that cell salvage may reduce allogeneic blood transfusion during cardiac surgery, but these studies have limitations, including inconsistent use of other blood transfusion-sparing strategies. We designed a randomized controlled trial to determine whether routine cell salvage for elective uncomplicated cardiac surgery reduces blood transfusion and is cost effective in the setting of a rigorous transfusion protocol and routine administration of antifibrinolytics.

METHODS: Two-hundred-thirteen patients presenting for first-time coronary artery bypass grafting and/or cardiac valve surgery were prospectively randomized to control or cell salvage groups. The latter group had blood aspirate during surgery and mediastinal drainage the first 6 h after surgery processed in a cell saver device and autotransfused. All patients received tranexamic acid and were subjected to an algorithm for red blood cell and hemostatic blood factor transfusion.

RESULTS: There was no difference between the two groups in the proportion of patients exposed to allogeneic blood (32% in both groups, relative risk 1.0 P = 0.89). At current blood products and cell saver prices, the use of cell salvage increased the costs per patient by a minimum of $103. When patients who had mediastinal re-exploration for bleeding were excluded (as planned in the protocol), significantly fewer units of allogeneic red blood cells were transfused in the cell salvage compared with the control group (65 vs 100 U, relative risk 0.71 P = 0.04).

CONCLUSION: In patients undergoing routine first-time cardiac surgery in an institution with a rigorous blood conservation program, the routine use of cell salvage does not further reduce the proportion of patients exposed to allogeneic blood transfusion. However, patients who do not have excessive bleeding after surgery receive significantly fewer units of blood with cell salvage. Although the use of cell savage may reduce the demand for blood products during cardiac surgery, this comes at an increased cost to the institution.

 

 

儿童病人眼镜蛇式喉周气道与Unique喉罩前瞻性随机研究

A Prospective, Randomized Comparison of Cobra Peri laryngeal Airway and Laryngeal Mask Airway Unique in Pediatric Patients

Szmuk P,Ghelber O, Matuszczak M, Rabb, MF, Ezri T, Sessler D

 From the *Department of Anesthesiology, University of Texas Southwestern Medical School and Children’s Medical Center at Dallas, Texas; {dagger}Department of Anesthesiology, University of Texas Medical School at Houston, Texas; {ddagger}Department of Anesthesia, Wolfson Medical Center, Holon, Affiliated to Tel Aviv University, Israel; and §Department of Outcomes Research, The Cleveland Clinic, Ohio; ¶Member Outcomes Research Consortium.

Anesth Analg 2008 107: 1523-1530

 

背景:成人正压通气时眼镜蛇式喉周气道(CobraPLA)比Unique喉罩更能够提供有效的气道封闭压。因此,我们比较CobraPLA 和LMAU在婴儿和儿童使用情况。

方法:将200例儿科病人随机分成CobraPLA 和LMAU组。测定套囊充气压在40 60 cm H2O时气道密闭性,观察比较两组间病人舒适度、喉罩置入时间、装置的稳定性、通气效率、尝试插入次数,评价两组病人术后咽喉痛、发音障碍、喉痉挛、支气管痉挛和胃胀气的发生率。在CobraPLA头端和麻醉回路Y接口处测定呼出气CO2分压,对于出现重大事件组则再次细分为小和大CobraPLA亚组以及小和大LMA亚组;数据表示为均数±标准差,P < 0.05为差异有统计学意义。

结果:套囊充气达60 cm H2O时,大CobraPLA亚组气道密闭压(22 ± 7 cm H2O)明显高于小CobraPLA亚组(18 ± 5 cm H2O)和大LMA组(16 ± 5 cm H2O(P < 0.001)CobraPLALMA更稳定并且胃胀气较少,CobraPLA头端CO2分压比Y接口处高6.4 ± 6 mm Hg

结论CobraPLALMAU在大部分儿童麻醉中气道密闭效果相似,在某些病人前者优于后者。

(蒋宗明译  薛张纲校)

BACKGROUND: The Cobra Perilaryngeal Airway (PLA) provides better sealing pressure than the Laryngeal Mask Airway Unique (LMAU) during positive-pressure ventilation in adults. We compared the performance of the CobraPLA and LMAU in infants and children.

METHODS: Two-hundred pediatric patients were randomly assigned to a CobraPLA or an Laryngeal Mask Airway (LMA). We measured airway sealing at cuff inflation pressures of 40 and 60 cm H2O; ease and time of insertion; device stability; efficacy of ventilation; number of insertion attempts; incidence of postoperative sore throat, dysphonia, laryngospasm, bronchospasm, and gastric gas insufflation. Steady-state end-tidalCO2 was measured at the head of the CobraPLA and at the “Y-piece” piece of the anesthetic circuit. For the major outcomes, the airway groups were subdivided post hoc into small and large CobraPLA and small and large LMA subgroups. Results are presented as means ± sds; P < 0.05 was considered statistically significant.

RESULTS: Airway sealing pressure with the cuff inflated to 60 cm H2O in the large CobraPLA subgroup (22 ± 7 cm H2O) was significantly more than that of the small CobraPLA subgroup (18 ± 5 cm H2O) and large LMA subgroup (16 ± 5 cm H2O; P < 0.001). The CobraPLA was more stable than the LMA (same anatomic fit score before and after surgery) and produced less gastric insufflation. Head CobraPLA end-tidalCO2 values were 6.4 ± 6 mm Hg more than those of the Y piece of the circle circuit.

CONCLUSIONS: The CobraPLA airway performed as well as the LMAU during anesthesia in pediatric patients for a large range of outcomes and was superior for some.

 

 

一篇关于阻塞性睡眠呼吸暂停综合症的系统综述及其对麻醉师的启示

A Systemic Review of Obstructive Sleep Apnea and Its Implications for Anesthesiologists

Sharon A. Chung, Hongbo Yuan, and Frances Chung

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

Anesth Analg 2008 107: 1543-1563.

 

背景:阻塞性睡眠呼吸暂停综合症(OSA)在在人群中已占了极大的比例,但大多数患者却未曾得到及时的诊断。而认识到未获诊断的0SA患者其围手术期风险的增加,对麻醉师及外科医生来说却极为重要。故此,我们发表了一篇有关0SA患者围手术期处理的系统综述。

方法:这篇综述的文献范围是局限于外科专业的成年病人。主要的搜索词汇为围手术期护理睡眠呼吸暂停阻塞性睡眠呼吸暂停围手术期风险围手术期护理。我们搜索的是从196620073月在databases MedlineEmbaseBiological AbstractScience Citation IndexHealthstar上的英文文献。

结果:这篇文献支持了OSA患者其围手术期风险有所增高这一观点。美国麻醉医师协会指南主张在围手术期评估中都予行OSA筛查,而OSA的筛查方法也已在该综述中有所讨论。并且该篇综述还提出了一些用以减低OSA患者围手术期风险的对策。但是,除了美国麻醉医师协会共识的指南,我们也需要注意在该篇文献中却缺乏着循证医学支持的推荐措施。

结论:这篇综述对OSA患者的围手术期筛查方法及处理策略提出了一定建议。我们的最终目标是减低OSA患者的围手术期风险,而为实现此目标,我们还需要进一步行调查研究,以明确对这些未予诊断的OSA外科患者,其围手术期的筛查及处理策略是否可减低其不良事件的发生率。

(刘沁译 薛张纲校)

BACKGROUND: Obstructive sleep apnea (OSA) is present in a significant proportion of the population, but the majority of patients remain undiagnosed. It is crucial that anesthesiologists and surgeons recognize the increased perioperative risks associated with undiagnosed OSA. We present a systematic review of the literature on the perioperative management of surgical patients with OSA.

METHODS: The scope of this review is restricted to publications in all surgical specialties and in the adult patient population. The main search key words were: "perioperative care," "sleep apnea," "obstructive sleep apnea," "perioperative risk," and "perioperative care." The databases Medline, Embase, Biological Abstract, Science Citation Index, and Healthstar were searched for relevant English language articles from 1966 to March 2007.

RESULTS: The literature supports an increased perioperative risk in OSA patients. The American Society of Anesthesiologists guidelines support the routine screening for OSA during preoperative assessment, and methods of OSA screening are discussed in this review. This review suggests a number of perioperative management strategies to reduce surgical risk in patients with OSA. However, apart from the consensus-based American Society of Anesthesiologists guidelines, it is important to note that evidence-based recommendations are lacking in the literature.

CONCLUSIONS: This review suggests ways to screen for OSA in the preoperative setting and proposes perioperative management strategies. The ultimate goal is to reduce the perioperative risk of OSA patients but, to realize that goal, research will be needed to determine whether screening for OSA and/or adapting specific perioperative management approaches translates into a lessening of adverse events in surgical patients with undiagnosed OSA.

 

 

在非洲蟾蜍卵母细胞中芳香族挥发性麻醉药对钠离子电压门控通道的效应

The effects of volatile aromatic anesthetics on voltage-gated Na+ channels expressed in Xenopus oocytes.

Horishita T, Eger EI 2nd, Harris RA.

Waggoner Center for Alcohol and Addiction Research, The University of Texas at Austin, 1 University Station A4800, Austin, TX 78712, USA.

Anesth Analg 2008 107: 1579-1586

.

背景:许多吸入性麻醉药在临床使用浓度下会阻滞钠离子电压门控通道,这些麻醉药产生的结果与神经递质的释放有关,至少部分是使突触前钠通道的活性降低。挥发性芳香族麻醉剂能阻断N-甲基-D-门冬氨酸受体的功能,增加伽玛氨酪酸A受体功能,但这些效应很大程度上依靠芳香族化合物的化学效应。在最近的研究中我们测试不同的芳香族麻醉剂是否始终如一的阻断钠通道功能。

方法:我们使用非洲蟾蜍整个卵细胞,双极电压钳制术研究八种芳香族麻醉药对Na(v)1.2钠通道ß1亚基团的效应。

结果:在最高电流的一半的控制电压下所有芳香族麻醉药都阻断钠电流;均苯三酚(8% +/- 2%)、戊苯(13% +/- 2%)、戌苯(13% +/- 2%)的抑制是适度的比苯(37% +/- 2%)、氟苯(39% +/- 2%)1.2-二氟二苯(48% +/- 2%)1,4-二氟二苯(31 +/- 3%),和1,2,4三氟苯(33% +/- 1%)明显。这种交叉效应在NMDAr-氨基丁酸A受体上发现。平行,但更小些的阻滞在控制电位,接近最高电流(-90 mV) (V(H-90))时在钠电流上发现,戌苯在此电流上引起很小的增强作用(6% +/- 1%)。这些钠通道功能的改变与NMDA受体的阻断效应、化合物的脂溶性、及分子量、及阳离子相互作用相关联。

结论:不同芳香族化合物动力学效应在钠离子门控通道及他们不同的抑制作用。抑制范围产生于吸入麻醉药MAC值表明钠离子通道会被其中一些麻醉药物阻滞但有些不会。                                                                            

(刘婷洁译 薛张纲校)

BACKGROUND: Many inhaled anesthetics inhibit voltage-gated sodium channels at clinically relevant concentrations, and suppression of neurotransmitter release by these anesthetics results, at least partly, from decreased presynaptic sodium channel activity. Volatile aromatic anesthetics can inhibit N-methyl-D-aspartate (NMDA) receptor function and enhance gamma-amino butyric acid A receptor function, but these effects depend strongly on the chemical properties of the aromatic compounds. In the present study we tested whether diverse aromatic anesthetics consistently inhibit sodium channel function.

METHODS: We studied the effect of eight aromatic anesthetics on Na(v)1.2 sodium channels with beta(1) subunits, using whole-cell, two-electrode voltage-clamp techniques in Xenopus oocytes.

RESULTS: All aromatic anesthetics inhibited I(Na) (sodium currents) at a holding potential which produce half-maximal current (V(1/2)) (partial depolarization); inhibition was modest with 1,3,5-trifluorobenzene (8% +/- 2%), pentafluorobenzene (13% +/- 2%), and hexafluorobenzene (13% +/- 2%), but greater with benzene (37% +/- 2%), fluorobenzene (39% +/- 2%), 1,2-difluorobenzene (48% +/- 2%), 1,4-difluorobenzene (31 +/- 3%), and 1,2,4-trifluorobenzene (33% +/- 1%). Such dichotomous effects were noted by others for NMDA and gamma-aminobutyric acid A receptors. Parallel, but much smaller inhibition, was found for I(Na) at a holding potential which produced near maximal current(-90 mV) (V(H-90)), and hexafluorobenzene caused small  enhancement(6% +/- 1%) of this current. These changes in sodium channel function were correlated with effectiveness for inhibiting NMDA receptors, with lipid solubility of the compounds, with molecular volume, and with cation-pi interactions.

CONCLUSION: Aromatic compounds vary in their actions on the kinetics of sodium channel gating and this may underlie their variable inhibition. The range of inhibition produced by minimum alveolar anesthetic concentration concentrations of inhaled anesthetics indicates that sodium channel inhibition may underlie the action of some of these anesthetics, but not others.

 

 

AIMS设备使用的实用指南

Anesthesia Information Management System Implementation: A Practical Guide (Special Article)

Stanley Muravchick, James E. Caldwell, Richard H. Epstein, Maria Galati, Warren J. Levy, Michael O'Reilly, Jeffrey S. Plagenhoef, Mohamed Rehman, David L. Reich, and Michael M. Vigoda

From the *Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; {dagger}Department of Anesthesia and Perioperative Care, University of California, San Francisco, California; {ddagger}Department of Anesthesiology, Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania; §Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York; ||Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; ¶Department of Anesthesiology, Southeast Alabama Medical Center, Dothan, Alabama; #Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Pennsylvania; and **Department of Anesthesiology, University of Miami School of Medicine, Miami, Florida.

Anesth Analg 2008 107: 1598-1608.

 

麻醉情报管理系统(AIMS)显示并记录了围术期的生理数据和病人情况。虽然目前使用还较有限,但是它对增加患者安全性,改善临床有效率及诊断、改善收费管理和帐单管理、标准化管理、以及麻醉结果研究都有很多益处。AIMS的使用进程、恰当的警报选择、安装、使用较复杂,然而,每个环节的使用已经通过多次试验,这个文章总结了成功使用AIMS设备各个环节的基本要点,包括产品测评,信息技术需要的评估。

精确的记录是临床科学与循证医学的基础,麻醉医生也可以通过多次测量来作出临床决定。对于外科手术患者,由于常规的生理数据监护测量也已经很复杂,因此数字数据系统是自动记录数据必需的。虽然费用较贵,而且由于麻醉供给装置的调零复位会使报警失效,但是AIMS的优势仍然超过了它的缺点。事实上,麻醉患者安全基本指南(APSF)明确指出:APSF允许并支持围术期自动数据记录仪的使用,以及对这些数据的研究以改善患者安全。

AIMS的理念由简单的数据记录器发展而来,在20多年前首次被提出,最终发展为一个复杂的数字电子工作网络。与医学数据库、生理监护仪、输入装置的各个界面可用来收集,整理,显示,记录,检索围术期生理数据,以备后续研究。现代的AIMS有两个基本组成部分:自动化麻醉记录仪(AAR)和围术期数据库(PD),以针对各个患者的临床生理数据。一个综合的AIMS还要包括一个麻醉前评估装置和一个电子数据记录仓库(EDW),它能将各个患者的数据从PD设备上转出,生成并组织成为生理数据文件,提供给结果研究。

成功的AIMS安装使用需要基于计算机硬件、系统配置以及人员培训。关于AIMS的大致信息可以通过AIMS麻醉技术协同工作组以及美国麻醉医师学会(ASA)来获得。这篇综述回顾了不同体系对于使用AIMS的经验研究。

(秦敏菊译 薛张纲校)

Anesthesia Information Management Systems (AIMS) display and archive perioperative physiological data and patient information. Although currently in limited use, the potential benefits of an AIMS with regard to enhancement of patient safety, clinical effectiveness and quality improvement, charge capture and professional fee billing, regulatory compliance, and anesthesia outcomes research are great. The processes and precautions appropriate for AIMS selection, installation, and implementation are complex, however, and have been learned at each site by trial and error. This collaborative effort summarizes essential considerations for successful AIMS implementation, including product evaluation, assessment of information technology needs, resource availability, leadership roles, and training.

Accurate recorded data are the foundation of clinical science and evidence-based practice, and anesthesiologists base many clinical decisions upon repeated measurements. Given the complexity of even routine physiological monitoring, digital data systems are a compelling option for automatically acquiring and recording the information generated while caring for surgical patients. Despite concerns regarding cost and compromised vigilance due to reduced involvement by the anesthesia provider, the advantages of an anesthesia information management system (AIMS) appear to outweigh the drawbacks.1 In fact, the directors of the Anesthesia Patient Safety Foundation (APSF) have explicitly stated2 “the APSF endorses and advocates the use of automated record keeping in the perioperative period and the subsequent retrieval and analysis of the data to improve patient safety.” The AIMS concept has evolved from a simple record keeper, first proposed more than 2 decades ago,3,4 into a more complex digital electronic network (Fig. 1). Interfaces between medical databases, physiologic monitoring devices, and input devices are used to collect, organize, display, archive, and retrieve perioperative information for subsequent analysis. The two basic components of a modern AIMS are an automated anesthesia record (AAR) and a perioperative database (PD) for patient-specific clinical information. The most comprehensive AIMS also include a preanesthesia evaluation component and an electronic data warehouse (EDW) in which patient identifiers are removed from PD-derived information to generate and organize anonymous physiological data for outcomes research.。

Successful AIMS implementation requires many decisions regarding hardware and system configuration and the training and support of personnel. General information is available from the AIMS Consensus Working Group of the Society for Technology in Anesthesia5 and the American Society of Anesthesiologists. This review shares lessons learned during AIMS implementation at different institutions using a variety of AIMS products.

 

 

电阻聚合物与强热空气加温:志愿者的热能传递和核心温度复温速度的比较

Resistive Polymer Versus Forced-Air Warming: Comparable Heat Transfer and Core Rewarming Rates in Volunteers

Oliver Kimberger, MD*, Christine Held, MD*, Karin Stadelmann, MD*, Nikolaus Mayer, MD, Corinne Hunkeler, MD*, Daniel I. Sessler, MD, and Andrea Kurz, MD

From the *Department of Anesthesiology and Pain Therapy, University Hospital Bern, Switzerland; {dagger}Department of Anesthesiology, General Intensive Care and Pain Medicine, Medical University of Vienna, Austria; and {ddagger}Department of Outcomes Research, The Cleveland Clinic, Cleveland, Ohio.

Anesth Analg 2008 107: 1621-1626

 

背景:手术期亚低温增加多种严重并发症发生可能。确保围术期病人保持正常体温已列入常规,而强热空气加温是最常用的手段。在既往研究中,与强热空气相比,各种电阻加热系统已显示出不同的结果。最近,已成功开发基于聚合物的电阻病人变暖系统。我们在志愿者中进行强热空气加温系统与电阻聚合物系统功效的比较。

方法:共有八名健康志愿者参与本次研究,每人研究两天。应用10°C加强空气及4°C循环水床垫,将未经麻醉的志愿者冷却至核心温度(鼓膜)34 ° C。并使用度冷丁和丁螺环酮防止志愿者发抖。通过随机命令,使用下列其中一个变暖系统,将志愿者回暖(直至其核心温度达到36 ℃ ):(1)强热空气加温系统(Bair Hugger warming cover #300, blower #750, Arizant, Eden Prairie, MN);(2)电阻聚合物加温系统( HotDog全身毯子, HotDog标准控制器,Augustine Biomedical, Eden Prairie, MN) 。研究第二天使用候补系统。记录志愿者的代谢产热、皮肤热损失及核心温度。

结果:两种系统的代谢产热和皮肤热损失无明显差异。经过30分钟延迟,强热空气加温系统使志愿者核心温度增加了近线性的0.9895%信赖区间0.91-1.04/小时,而电阻聚合物系统则增加0.920.85-1.00/小时(P0.4)。

结论:在健康志愿者中,强热空气加温系统与电阻聚合物系统的热能传递和核心温度复温速度均相似。

(施颖译 薛张纲校)

BACKGROUND: Mild perioperative hypothermia increases the risk of several severe complications. Perioperative patient warming to preserve normothermia has thus become routine, with forced-air warming being used most often. In previous studies, various resistive warming systems have shown mixed results in comparison with forced-air. Recently, a polymer-based resistive patient warming system has been developed. We compared the efficacy of a standard forced-air warming system with the resistive polymer system in volunteers.

METHODS: Eight healthy volunteers participated, each on two separate study days. Unanesthetized volunteers were cooled to a core temperature (tympanic membrane) of 34°C by application of forced-air at 10°C and a circulating-water mattress at 4°C. Meperidine and buspirone were administered to prevent shivering. In a randomly designated order, volunteers were then rewarmed (until their core temperatures reached 36°C) with one of the following active warming systems: (1) forced-air warming (Bair Hugger warming cover #300, blower #750, Arizant, Eden Prairie, MN); or (2) polymer fiber resistive warming (HotDog whole body blanket, HotDog standard controller, Augustine Biomedical, Eden Prairie, MN). The alternate system was used on the second study day. Metabolic heat production, cutaneous heat loss, and core temperature were measured.

RESULTS: Metabolic heat production and cutaneous heat loss were similar with each system. After a 30-min delay, core temperature increased nearly linearly by 0.98 (95% confidence interval 0.91–1.04)°C/h with forced-air and by 0.92 (0.85–1.00)°C/h with resistive heating (P = 0.4).

CONCLUSIONS: Heating efficacy and core rewarming rates were similar with full-body forced-air and full-body resistive polymer heating in healthy volunteers.

 

 

比较硬膜穿孔技术和标准硬膜外阻滞技术用于人工镇痛的随机试验

A Randomized Trial of Dural Puncture Epidural Technique Compared with the Standard Epidural Technique for Labor Analgesia

Eric Cappiello, MD, Nollag O'Rourke, FFARCSI, Scott Segal, MD, and Lawrence C. Tsen, MD

From the Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts..

Anesth Analg 2008; 107:1646-1651

 

背景:该随机双盲前瞻性试验是为了检验在没有吸入麻醉的情况下硬膜外阻滞的药物给药之前即刻予以硬膜钻孔是否比标准的硬膜外阻滞有更好的人工镇痛效果。

方法80名宫颈扩张小于5cm的未育待产妇随机分组,接受标准硬膜外麻醉,一部分用25号细针在硬膜打孔,一部分没有。在硬膜外针和细针放置好以后,12ml 2.5 mg/mL的布比卡因打进硬膜外,病人自控输注的1.25 mg/mL布比卡因和2 µg/mL的芬太尼的混合液也开始工作。两组之间比较S1平面的出现和疼痛评分。

结果:人口学特征差别不大的组别之间,带有硬膜细孔的待产妇S!平面阻滞出现更多,在开始观察的20分钟后的疼痛评分更为明显和多见,单侧阻滞则少见。最高阻滞平面在两组没有差别。

结论:对待产妇来说,使用布比卡因和芬太尼硬膜外镇痛前即刻给与25号针硬膜钻孔加快硬膜外药物的播散,起效,双侧镇痛效果

( 孙鹏飞译 薛张纲校)

BACKGROUND: We designed this prospective, double-blind, randomized study to examine whether a dural puncture without intrathecal drug administration immediately before epidural drug administration would improve labor analgesia when compared to a traditional epidural technique without prior dural puncture.

METHODS: Eighty nulliparous parturients with cervical dilation less than 5 cm were randomly assigned to receive a standardized epidural technique, with or without a single dural puncture with a 25-gauge (G) Whitacre spinal needle. After successful placement of the needle(s) and the epidural catheter, 12 mL of bupivacaine 2.5 mg/mL was administered through the epidural catheter and a patient-controlled epidural infusion of bupivacaine 1.25 mg/mL + fentanyl 2 µg/mL was initiated. The presence of sacral analgesia (S1) and pain scores were compared between groups.

RESULTS: In demographically similar groups, parturients with prior dural puncture had more frequent blockade of the S1 dermatome (absolute risk difference [95% confidence interval] 22% [6–39]), more frequent visual analog scale scores <10/100 at 20 min (absolute risk difference 20% [1–38]), and reduced one-sided analgesia (absolute risk difference [95% CI] 17% [2–330]). The highest median sensory level (T10) was no different between groups.

CONCLUSIONS: Dural puncture with a 25-G spinal needle immediately before the initiation of epidural analgesia improves the sacral spread, onset, and bilateral pain relief produced by analgesic concentrations of bupivacaine with fentanyl in laboring nulliparous patients.

 

 

加强氧气管理可改善清醒颈动脉手术患者脑供氧状况

Increased Oxygen Administration Improves Cerebral Oxygenation in Patients Undergoing Awake Carotid Surgery

Mark D. Stoneham, MA, FRCA, Omer Lodi, FRCA, Thearina C. D. de Beer, DICM, FRCA, and John W. Sear, PhD, FFACRS

From the Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford, UK.

Anesth Analg 2008 107: 1670-1675.

 

背景:在神经阻滞麻醉下行颈动脉内膜剥脱术(CEA)中,有10% 15%的患者在血管钳闭后有脑缺氧的症状,表现为语音、用脑能力或者对侧肌力的改变。已有关于术中吸纯氧可避免此神经病学上的不足的报道。我们使用近红外脑血氧定量法来评估吸纯氧是否确实可以改善颈动脉钳闭时的脑氧饱和度(rSO2)。

方法16位清醒状态下行CEA术的患者参加了研究。在镇静和神经阻滞实施之前即安置双侧大脑rSO2传感器。患者通过文氏面罩呼吸28%浓度氧气。围手术期血压维持在高于患者平常血压的10%或以内。颈动脉钳闭后,予密闭麻醉面罩吸100%纯氧。随后取下面罩,患者吸室内空气。每次干涉行为后记录rSO2读数和动脉血气分析结果。

结果:分析了15位患者的数据。同侧rSO2值在颈动脉钳闭后下降7.4% ± 5% 。所有患者在吸100%纯氧后同侧rSO2值较吸28%氧气时上升6.9% ± 3.3% (range, 1%–12%) (paired t-test, P < 0.001)。血流动力学及Paco2值未有改变。

结论:在颈动脉钳闭时,吸纯氧相比吸28%氧气可以有效增加同侧rSO2值。病因学不明,但是可能与血氧含量上升或者增强脑血流相关。所以在行CEA术中吸纯氧可能有利于所有患者。

(夏俊明译 薛张纲校)

BACKGROUND: During regional anesthesia for carotid endarterectomy (CEA), 10% to 15% of patients develop signs of cerebral hypoxia after cross-clamping, manifested as changes in speech, cerebration or contralateral motor power. Reversal of such neurological deficits using administration of 100% O2 has been described. We used near-infrared cerebral oximetry to assess whether 100% O2 reliably improves regional cerebral oxygenation (rSO2) during carotid cross-clamping.

METHODS: Sixteen patients undergoing awake CEA were studied. Bilateral rSO2 optodes were applied before the initiation of sedation and the conduct of the regional blockade. Patients  received 28% oxygen by Venturi facemask. Perioperative blood pressure was maintained at or within 10% above the patient’s normal limits during carotid cross-clamping. After cross-clamping, 100% O2 was administered for 5 min by a close-fitting anesthetic facemask. The O2 mask was then removed and the patient breathed room air. The effects on rSO2 readings and arterial blood gases were observed after each intervention.

RESULTS: Data were analyzed for 15 patients. Ipsilateral rSO2 values decreased by 7.4% ± 5% after carotid cross-clamping. Administration of 100% O2 resulted in an increase in ipsilateral rSO2 in all patients of 6.9% ± 3.3% (range, 1%–12%) (paired t-test, P < 0.001) over the cross-clamped value while receiving 28% O2. Hemodynamic variables and arterial Paco2 values were unaltered.

CONCLUSION: With the carotid cross-clamped, ipsilateral rSO2 was reliably increased by the administration of 100% O2 compared with 28% O2. The etiology of this increase is unclear, but may relate to the associated increase in O2 content of the blood or to an improvement in cerebral blood flow. Thus administration of 100% O2 during carotid cross-clamping may be beneficial for all patients undergoing CEA.

                                                  

 

癫痫发作和全身麻醉药(综述)

The Howling Cortex: Seizures and General Anesthetic Drugs

Voss, Logan J. PhD*; Sleigh, James W. MD*; Barnard, John P. M. MBChB*; Kirsch, Heidi E. MD†

From the *Department of Anesthesia, Waikato Clinical School, University of Auckland, New Zealand; and {dagger}Department of Neurology, UCSF, California.

Anesth Analg 2008 107: 1689-1703.

 

全麻药导致的癫痫发作的真实影响方式尚不知道。麻醉诱导期间异常运动很常见,但可能并不预示真正的癫痫发作。相反,癫痫样的脑电活动通常被恩氟醚、依托咪酯、七氟醚诱导出,丙泊酚的程度较小,但是它很少引起全身的强直阵挛发作。甚至在“无抽搐性电休克治疗”中,麻醉药偶尔导致之前有癫痫病史的人的癫痫发作。这些癫痫发作最常见于麻醉诱导或苏醒期间,这时麻醉药的浓度相对较低。对于麻醉药相关的癫痫发生没有统一的机制。然而,越来越多的试验提出癫痫发作不是由太多兴奋引起,而是兴奋大规模已经进入振荡癫痫状态的神经元。增加的伽玛氨基丁酸能的抑制作用可使皮层致敏,只需要小量的兴奋就可导致癫痫发作。这被假设发生在1)在网状系统水平通过增加反射的倾向(比如:通过延长抑制滞后),2)通过对中间神经元的不同影响(抑制性抑制剂),或3)在突出水平通过改变氯离子反转电位(兴奋性GABA”)。在适用于神经药理学的基础上,预防麻醉药相关的癫痫发作包括1)避免使用七氟醚和依托咪酯,2)考虑用苯唑地西泮类的药物(α-亚基GABAA受体激动剂),或可减少钙离子进入神经细胞的药物,3)使用脑电图监测来发现早期皮层不稳定迹象和癫痫活动。癫痫发作可能虚假地提高麻醉深度的脑电指数。

(宣丽真译 薛张纲校)

The true incidence of seizures caused by general anesthetic drugs is unknown. Abnormal movements are common during induction of anesthesia, but they may not be indicative of true seizures. Conversely, epileptiform electrocortical activity is commonly induced by enflurane, etomidate, sevoflurane and, to a lesser extent, propofol, but it rarely progresses to generalized tonic-clonic seizures. Even “nonconvulsant” anesthetic drugs occasionally cause seizures in subjects with preexisting epilepsy. These seizures most commonly occur during induction or emergence from anesthesia, when the anesthetic drug concentration is relatively low. There is no unifying neural mechanism of anesthetic drug-related seizurogenesis. However, there is a growing body of experimental work suggesting that seizures are not caused simply by “too much excitation,” but rather by excitation applied to a mass of neurons which are primed to react to the excitation by going into an oscillatory seizure state. Increased [gamma]-amino-butyric acid (GABA)ergic inhibition can sensitize the cortex so that only a small amount of excitation is required to cause seizures. This has been postulated to occur 1) at the network level by increasing the propensity for reverberation (e.g., by prolongation of the “inhibitory lag”), or 2) via different effects on subpopulations of interneurons (“inhibiting-the-inhibitors”) or 3) at the synaptic level by changing the chloride reversal potential (“excitatory GABA”). On the basis of applied neuropharmacology, prevention of anesthetic-drug related seizures would include 1) avoiding sevoflurane and etomidate, 2) considering prophylaxis with adjunctive benzodiazepines ([alpha]-subunit GABAA agonists), or drugs that impair calcium entry into neurons, and 3) using electroencephalogram monitoring to detect early signs of cortical instability and epileptiform activity. Seizures may falsely elevate electroencephalogram indices of depth of anesthesia.

 

 

加巴喷丁抑制浅颈丛阻滞麻醉下甲状腺术后晚期疼痛

Gabapentin Attenuates Late but Not Early Postoperative Pain After Thyroidectomy with Superficial Cervical Plexus Block

Nicolas Brogly, MD*, Jean-Michel Wattier, MD*, Grégoire Andrieu, MD*, Daliana Peres, MD*, Emanuel Robin, MD, PhD*, Eric Kipnis, MD, PhD*, Laurent Arnalsteen, MD{dagger}, Béatrice Thielemans, DPharm{dagger}, Bruno Carnaille, MD, PhD{ddagger}, François Pattou, MD, PhD{ddagger}, Benoît Vallet, MD, PhD*, and Gilles Lebuffe, MD, PhD*

From the *Department of Anesthesiology and Intensive Care-Section of Pain, {dagger}Department of Pharmacology, {ddagger}Department of Endocrine and General Surgery, Claude Huriez University Hospital, rue Michel Polonovski, 59037 Lille cedex, France.

Anesth Analg 2008 107: 1720-1725.

 

背景:术前口服加巴喷丁已经显示出可以减少术后疼痛。然而,加巴喷丁对于区域阻滞麻醉的影响及其对慢性疼痛的影响目前还不清楚。在甲状腺手术病人,我们调查了术前口服加巴喷丁作为颈浅丛阻滞( SCPB)的辅助对早期和晚期( 6月)术后疼痛的作用。

方法 50例同意的患者随机分配接受术前2小时1200毫克的加巴喷丁( G组)或安慰剂( P组)术前焦虑数值从06,标准化后麻醉诱导后行SCPB,记录术中和术后和重症监护病房出ICU后回病房整个过程中镇痛药物的消费,在头24小时,疼痛程度,在休息时和吞咽时衡量尺度数值从010。如果静息时疼痛程度超过了4 / 10,病人接受1/ 6 h的四对乙酰氨基酚和/50毫克/ 6小时的四曲马多镇痛治疗。甲状腺手术前一天,和6个月后,病人被要求回答一个神经性疼痛的诊断问卷调查。

结果比较这两个群体的人口特征,术前焦虑,术中术后重症监护病房镇痛药物的消费。镇痛药的消耗量在手术后最初的24小时是相似的(G: 3 [0–5] doses/24 h; P: 3 [1–5] doses/24 h; P = NS),静息时(G 2,2 [0.2–3.7]; P 2 [0–6.3]; P = NS),和吞咽期间(G 2.8 [0.4–8.9]; P 3 [1.4–6.3]; P = NS])。八名患者安排一张诊断查询表计分超过3,这种延迟的神经痛据报道, 7名仅接受SCPB的有7名,而同时接受SCPB及术前辅助口服加巴喷丁的仅1名( P0.01 ) 。

结论术前口服加巴喷丁不立即减轻SCPB甲状腺术后疼痛 ,但对术后6个月的迟发神经痛有减缓作用。

章一静译 薛张纲校

BACKGROUND: Preoperative oral gabapentin has been shown to reduce postoperative pain. However, the effects of gabapentin as an adjunct to regional anesthesia is unclear and its effects on chronic pain remains unknown. In patients undergoing thyroidectomy, we investigated the effects on early and late (at 6 mo) postoperative pain of preoperative oral gabapentin as an adjunct to superficial cervical plexus block (SCPB).

METHOD: Fifty consecutive consenting patients were randomized to receive either 1200 mg of gabapentin (Group G) or placebo (Group P) 2 h preoperatively. Preoperative anxiety was assessed on a numeric scale from 0 to 6. A SCPB was performed after a standardized induction of anesthesia. The primary outcome, analgesic drug consumption, was assessed during the procedure and postoperatively in the postanesthesia care unit and after discharge to the ward. Over the first 24 h, pain levels at rest and during swallowing were measured on a numeric scale from 0 to 10. If the pain level was more than 4/10 at rest, patients received 1 g/6 h of IV paracetamol and/or 50 mg/6 h of IV tramadol as a rescue analgesic treatment in the interval. The day before operation and 6 mo after thyroidectomy, included patients were asked to answer a neuropathic pain diagnostic questionnaire.

RESULTS: Population characteristics, preoperative anxiety, intraoperative drug consumption, procedure duration, and postoperative care unit stay were comparable in both groups. Analgesic consumption during the first 24 postoperative hours was similar in both groups (G: 3 [0–5] doses/24 h; P: 3 [1–5] doses/24 h; P = NS), as well as pain at rest (G: 2,2 [0.2–3.7]; P: 2 [0–6.3]; P = NS), and during swallowing (G: 2.8 [0.4–8.9]; P: 3 [1.4–6.3]; P = NS]). Eight patients had a diagnostic questionnaire score more than 3, 6 mo after operation versus 2 in preoperative period (P = 0.04). Such delayed neuropathic pain complaints were reported in seven patients receiving SCPB alone and only in one patient receiving both SCPB and preoperative adjunctive oral gabapentin. (P = 0.01).

CONCLUSION: Oral preoperative administration of gabapentin did not modify immediate pain management in thyroidectomy patients receiving SCPB, but prevented delayed neuropathic pain at 6 mo.

 

 

对土耳其一家私人医院34109名行硬膜外阻止的妇产科病人的回顾性研究

A Retrospective Review of 34,109 Epidural Anesthetics for Obstetric and Gynecologic Procedures at a Single Private Hospital in Turkey

Kaan Katircioglu, MD*{dagger}, Levent Hasegeli, MD*, H. Fehmi Ibrahimhakkioglu, MD*, Berkay Ulusoy, MD*, and Huseyin Damar, MD*

From the Department of Anesthesiology and Reanimation, *Izmir Cinarli Obstetric and Gynecologic Hospital, and {dagger}Izmir Ataturk Training and Research Hospital, Izmir, Turkey.

Anesth Analg 2008 107: 1742-1745.

 

背景:在妇产科手术,我们对由有经验的麻醉医生经选择性硬膜外阻滞的安全性进行研究。

方法::我们随访了1993年至2006年产科所有与麻醉相关的信息(n = 35,628病例数)。主要研究了成功实行该麻醉的比例,主要并发症的发生率,死亡率。

结果:在妇产科麻醉中共有34109次实行硬膜外阻滞。在14年中实行硬膜外麻醉的比例从57%上升至96%。永久性的神经系统并发症、心脏停跳、母婴死亡率在这几年中均为0

结论:在土耳其一私人医院中,五名有经验的麻醉医生经合理的选择病人,硬膜外麻醉/镇痛是可靠和安全的麻醉方法。

(陈珺珺译 薛张纲校)

BACKGROUND: We examined the safety of the routineuse of epidural anesthesia by an experienced anesthetic team in a select group of obstetric and gynecologic patients.

METHODS: All anesthetic records and an obstetric department database from 1993 to 2006 were retrospectively reviewed (n = 35,628 cases). Success rate, major complication rates, and mortality rates were the major end-points of the study.

RESULTS: We performed 34,109 epidural blocks in obstetric and gynecologic anesthesia. The epidural rate increased from 57% to 96% over a 14-yr period. Permanent neurological sequel, cardiac arrest, or mortality and maternal mortality were not seen during this period.

CONCLUSIONS: Epidural anesthesia/analgesia, as performed in a private hospital in Turkey by five experienced anesthesiologists for a select group of patients, was a reliable and safe procedure.