Table of Contents

November 2008

 

CARDIOVASCULAR ANESTHESIOLOGY:

凝血彈性度評價低溫對凝血系統的影響

胡豔譯   薛張剛校

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

Malin Rundgren and Martin Engström

Anesth Analg 2008 107: 1465-1468.

心臟手術中止血環酸和抑肽酶:一項220例心臟手術病人的應用分析

丁俊雲 陳傑

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.

氨甲環酸減少成人脊柱融合術圍術期失血量

江繼宏   馬皓琳 李士通

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.

關於常規心臟手術血液回收的一項隨機對照研究

黃凝譯  薛張綱校

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.

合併低蛋白血症的老年心臟手術患者使用白蛋白對炎症反應,內皮細胞活化,以及長期腎功能是否有好處?

舒慧剛 陳傑

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:治療先天性心臟病手術圍術期房性和交界性心動過速的新藥:一項初步的研究

周雅春 馬皓琳 李士通

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.

兒童病人眼鏡蛇式喉周氣道與Unique喉罩前瞻性隨機研究

蔣宗明譯  薛張綱校

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.

用於兒童外周靜脈置管的一種靜脈通路指示裝置:一項前瞻性、隨機、對照試驗
張磊 陳傑

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.

容積描記脈搏波幅對七氟醚麻醉的兒科病人靜脈內注射含腎上腺素的硬膜外試驗劑量是有效的指示劑

王宏 馬皓琳 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:

一篇關於阻塞性睡眠呼吸暫停綜合症的系統綜述及其對麻醉師的啟示

劉沁譯 薛張綱校

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:

年齡對呼末七氟醚濃度和BIS指數動態關係的影響

葉樂 陳傑

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.

兒童麻醉中的呼末七氟醚濃度、腦電雙頻指數及腦狀態指數之間的動態關係

唐亮   馬皓琳 李士通   

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.

在非洲蟾蜍卵母細胞中芳香族揮發性麻醉藥對鈉離子電壓門控通道的效應

劉婷潔譯 薛張綱校

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.

全身低劑量布比卡因預防大鼠開胸術後異常性疼痛的發生

劉世文 陳傑

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.

利多卡因通過提高細胞週期蛋白依賴激酶抑制劑1A (p21)的表達從而抑制NIH-3T3細胞增殖

張瑩譯  馬皓琳 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設備使用的實用指南

秦敏菊譯 薛張綱校

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.

一種新穎的神經肌肉阻滯諮詢系統以改善神經肌肉阻滯:一個隨機,對照,臨床的實驗

懷曉蓉 譯 陳傑 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:

在用於電驚厥治療的麻醉期間的體溫變化:暗示麻醉學品質激勵

姜旭暉譯,馬皓琳,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.

電阻聚合物與強熱空氣加溫:志願者的熱能傳遞和核心溫度複溫速度的比較

施穎譯 薛張綱校

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:

在嚴重膿毒症中早期使用高劑量抗凝血酶:來自KyberSept試驗的單中心結果

朱紫瑜 譯 陳傑 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內的氣管切開術:一項全國範圍的調查

裘毅敏譯,馬皓琳 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:

比較硬膜穿孔技術和標準硬膜外阻滯技術用於人工鎮痛的隨機試驗

 孫鵬飛譯 薛張綱校

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.

合併有Shone’s綜合征的產婦行剖宮產時的麻醉管理

周姝婧 陳傑

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:

確定手術室內夜間所需值班急診團隊最佳規模的類比模型

顏濤 譯, 馬皓琳 李士通

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:

加強氧氣管理可改善清醒頸動脈手術患者腦供氧狀況

夏俊明譯 薛張綱校

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.

腦電雙頻譜指數在嚴重腦損傷合併難治性顱高壓患者巴比妥酸昏迷中的應用

趙嫣紅 陳傑 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.

青少年脊柱側彎手術中應用異丙酚-瑞芬太尼麻醉進行術中喚醒試驗時混合聽覺誘發電位指數和BIS的比較

慧譯 馬皓琳 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.

癲癇發作和全身麻醉藥(綜述)

宣麗真譯 薛張綱校

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:

無創正壓通氣對加快病態肥胖病人預吸氧的效果:隨機對照研究

潘錢玲 譯 陳傑 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、地氟烷和異丙酚麻醉後的術後疼痛和鎮痛藥的需要量

黃麗娜 馬皓琳 李士通

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.

加巴噴丁抑制淺頸叢阻滯麻醉下甲狀腺術後晚期疼痛

章一靜譯 薛張綱校

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.

在體內高或低皮質醇對人體單核細胞介導的炎症反應途徑有雙相影響

陳偉 陳傑

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.

泰國的脊髓麻醉後心搏停止:40,271例麻醉的多中心前瞻性記錄:

張曦 譯,馬皓琳 李士通

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.

對土耳其一家私人醫院34109名行硬膜外阻止的婦產科病人的回顧性研究

陳珺珺譯 薛張綱校

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%氯普魯卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌間溝臂叢神經阻滯中的比較:一項隨機、前瞻、雙盲對照試驗:

王騰 陳傑

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.

用短針結合指壓做眼球周單次注射麻醉

彭中美 馬皓琳 李士通

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.

氨甲環酸減少成人脊柱融合術圍術期失血量

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術往往伴隨大量出血,以致常常需要輸入異體血製品。本研究選取行擇期後路胸/腰椎內固定脊柱融合術的成年病人,採用隨機、前瞻、雙盲、多中心的方法,探討氨甲環酸(TXA)減少圍手術期間失血及輸血的效能。

方法:151名成年病人隨機分為2組。TXA組:麻醉誘導後靜脈推注10 mg/kg TXA,隨後以1 mg/kg/hr TXA維持輸注。安慰劑組:給予等容積安慰劑(生理鹽水)。主要結果是手術中和手術後24 h內估計失血量及計算失血量。次要結果是異體輸血的發生率和病人住院時間。

結果:4名病人皆因可識別的外科性出血被排除研究,因此147名病人納入統計分析。與安慰劑組相比,TXA組病人總的估計失血量和計算失血量比安慰劑組分別降低大約25%30% (1592 ± 1315 mL2138 ± 1607 mL, P = 0.026; 3079 ± 25584363 ± 3030, P = 0.017)。兩組中,輸入的血製品量和住院時間沒有差異。TXA、手術持續時間、椎骨融合的數目是影響圍術期失血的獨立因素。輸注異體紅細胞需考慮病人的ASA分級、手術持續時間及脊柱融合數目。

結論:對於擇期行後路胸/腰椎內固定脊柱融合手術的成年病人,TXA明顯減少圍術期估計及計算的總失血量。

(江繼宏   馬皓琳 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:治療先天性心臟病手術圍術期房性和交界性心動過速的新藥:一項初步的研究

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:先天性心臟病手術圍術期經常出現房性和交界性心動過速,且可使致病率和死亡率升高。上述節律失常雖然可被正常心臟良好耐受,但是在先天性心臟病患者中可引起嚴重的血流動力學不穩定,在心肺轉流術後階段尤為嚴重。由於目前可用的抗心律失常藥物可能無效或耐受性差,故對這些心律失常的治療頗為棘手。本研究檢驗了右美托咪定這一最初用於鎮靜的藥物對於房性和交界性心動過速可能具有的療效。儘管一些動物實驗的資料顯示該藥可預防某種類型的室性心動過速,但尚無關於該藥對房性和交界性心動過速治療作用的研究。

研究目的:此為回顧性、非隨機、非對照研究。研究包括了進入心臟病監護室的14名患者,右美托咪定用於鎮靜/鎮痛和治療交界性異位心動過速(JET)、房性異位性心動過速(AET)、折返型室上性心動過速(Re-SVT)、心房撲動(AF)或交界性加速性節律(JAR)。使用右美托咪定作為首選治療藥物或其他抗心律失常藥物治療失敗後的補救措施。主要研究終點為(a) Re-SVT 3分鐘之內轉為正常竇性心律(NSR),其他心律失常在2小時內轉為正常竇性心律或 (b) 心率(HR)減慢使得血流動力學改善;JET ≤170 bpm, AET ≥20%, AF ≤150 bpm 且預防JAR進展為JET

研究結果:患者平均年齡為2 ± 3月,平均體重為4 ± 1.5千克。大多數心律失常(79%)出現在術後。9名患者接受右美托咪定作為首選治療藥物,5名患者接受該藥作為補救藥物。10名患者(71%)接受1.1 ± 0.5 µg/kg初始負荷劑量。12名患者接受0.9 ± 0.3 µg · kg–1 · h–1 持續靜脈輸注。13名患者接受機械通氣。4名患者(28%)出現不良反應。3名患者出現低血壓但輸注液體後好轉,1名患者可能出現了短暫的完全性房室(AV)傳導阻滯。14名患者中有9名患者接受了臨時心房起搏(7名患者)或AV順序起搏(2名患者)以改善AV同步性。13名患者(93%)達到了心律和/HR得到控制的初步結果。在給予右美托咪定後67 ± 75 min之內JET心率從 197 ± 22 降至165 ± 17 bpm。這些患者中有5名患者在39 ± 31小時後轉為NSR,有1名患者維持JAR4Re-SVT患者經治療後此類心動過速均得以終止。3名患者轉為NSR,一名患者轉為JAR。一名AET220–270 bpm)患者對右美托咪定反應良好,在35分鐘內HR降至120 bpm 並且在85分鐘內轉為NSR。一名AF患者對該藥沒有反應。2JAR患者均未進展為JETHR158 ± 11bpm降至129 ± 1 bpm

結論:這一初步的觀察性研究結果提示右美托咪定可能對於圍術期房性和交界性心動過速的急性期具有潛在的治療作用,可控制HR或使心律轉為NSR

(周雅春 馬皓琳 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.



容積描記脈搏波幅對七氟醚麻醉的兒科病人靜脈內注射含腎上腺素的硬膜外試驗劑量是有效的指示劑

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:體積描記脈搏波幅(PPWA)在成人可有效地檢測靜脈內注射硬膜外試驗劑量,敏感性和特異性為100%。我們在七氟醚麻醉的兒科病人評價PPWA對靜脈內注射模擬硬膜外試驗劑量的檢測功效。

方法80個嬰兒和兒童隨機地分組,吸入含0.5 MAC1 MAC和氧化亞氮的氧氣,每組病人進一步隨機地靜脈注射含1:200,000腎上腺素 (0.5 µg/kg )1%利多卡因0.1 mL/kg以模擬靜脈內注射硬膜外試驗劑量或注射生理鹽水。注射後檢測心率(HR),收縮壓(SBP)PPWA 5分鐘,以HR增快超過10/分鐘、SBP升高超過15 mm HgPPWA減小超過10%定義為陽性實驗反應。

結果:注射試驗劑量後,0.5 MAC1 MAC七氟醚組PPWA79 ± 22 80 ± 19 s平均最大降幅為69% ± 18% 58% ± 14%。兩個七氟醚組PPWA的敏感性、特異性、陽性預計值和陰性預計值都是100%,但是以HRSBP作為檢測標準時,0.5 MAC七氟醚組的敏感性分別是90%95%1 MAC七氟醚組都是85%

結論PPWA在兒科病人能有效地檢測靜脈內注射模擬的含腎上腺素的硬膜外試驗劑量。

(王宏 馬皓琳 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.



兒童麻醉中的呼末七氟醚濃度、腦電雙頻指數及腦狀態指數之間的動態關係

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:為了在兒童麻醉中使用腦電圖監測儀來指導麻醉藥的給予,就需要這些監測儀在這個人群中測得的麻醉藥效應的足夠特點。我們試圖定量和比較用腦電雙頻指數(BIS)及腦狀態指數(CSI)在兒童測得的七氟醚效應的動態變化。

方法:前瞻性研究15例擇期行較小手術的健康兒童,年齡在3-15歲。在CSIBIS同步記錄過程中,七氟醚揮發器先設置為6%,持續5 min,然後降低。測定呼末濃度(CET)。對CET-七氟醚效應部位濃度平衡和藥效學進行建模。比較兩者之間的吻合度。資料為典型值(變異係數)。

結果:在研究的麻醉深度範圍內,用效應部位平衡半衰期(t1/2 ke0)來表示的七氟醚效應的變化速度,CSI [2.0 (14) min]BIS[1.2 (53) min]變化慢(P < 0.05)。在七氟醚給予 (E0) 之前BISCSI的估計基線效應,CSI84 (39)BIS87 (7)(無顯著意義)。七氟醚的催眠效應的敏感性用C50表示[最大效應(Emax)一半時穩態CET]CSI2.1 (68) %BSI2.1 (16)%(無顯著意義)。CSI450)時的最大效應)高於BIS2739)時的最大效應27 (39) (P < 0.05)。人群預計誤差BIS (–0.7 ± 26.9)優於CSI (–3.0 ± 178.6) (P < 0.05)

結論:在兒童中,七氟醚的t1/2 ke0和藥效動力學的定量和結果完全取決於測定其催眠作用所用的監測儀。在所研究的麻醉深度範圍內,七氟醚效應的變化速度慢於CSI。為了在這些監測儀的監測下,適當地指導七氟醚在兒童中給藥,這些差異必需要進行考慮。

(唐亮   馬皓琳 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.



利多卡因通過提高細胞週期蛋白依賴激酶抑制劑1A (p21)的表達從而抑制NIH-3T3細胞增殖

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:我們發現了利多卡因抑制鼠類胚胎成纖維細胞系NIH-3T3生長的分子機制。局部麻醉藥能在體外抑制細胞的生長。它們對傷口癒合的影響存在爭議。我們研究了利多卡因在體外對鼠類成纖維細胞系NIH-3T3增殖的影響及其新機制。

方法:NIH-3T3細胞培養液中加入利多卡因[00.050.5125 mM]一起培養。接下來的幾天內通過細胞計數測定細胞的增殖,測定溴去氧尿苷的攝取、用多聚酶鏈反應陣列測定基因的表達,以及蛋白印跡分析來檢驗受影響蛋白的增高水準,以探討利多卡因抑制細胞增殖的發生機制。

結果:利多卡因呈劑量依賴地抑制NIH-3T3細胞的增殖。0.050.5 mM利多卡因對細胞增殖沒有影響,1 mM利多卡因有輕度影響,25 mM利多卡因嚴重抑制細胞的增殖(P = 0.006)。培養液中加入2 mM利多卡因後3.5天,2 mM利多卡因抑制溴去氧尿苷的攝取(與對照組相比P = 0.02,與1 mM利多卡因相比P = 0.0495)。培養液中加入利多卡因1.5天后,利多卡因上調細胞週期蛋白-D1和細胞週期蛋白依賴激酶抑制劑1A [p21]的表達。培養液中加入利多卡因後2.5天,利多卡因使p21蛋白水準增加。

結論:脊麻、硬膜外麻醉或神經叢阻滯後在血漿中可見低濃度利多卡因,不會明顯影響成纖維細胞的增殖。而更高濃度的利多卡因通過使細胞增殖強效抑制劑p21合成增加,從而在細胞生長週期S相抑制成纖維細胞的增殖。較高濃度可見於組織浸潤後,可以明顯抑制成纖維細胞的增殖,因而可能妨礙傷口的癒合。

(張瑩譯  馬皓琳 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.



在用於電驚厥治療的麻醉期間的體溫變化:暗示麻醉學品質激勵

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:美國麻醉學家學會已經對外宣佈圍手術期維持正常體溫是麻醉學品質的體現。我們檢驗了是否可以在單一人群(接受電驚厥治療(ECT)的病人)中達到這種麻醉品質激勵。

方法:我們比較了麻醉前經紅外測得的耳溫和經過101種順序的便於ECT的較短麻醉藥後到達麻醉後復蘇室(PACU)時的耳溫。

結果:共有35例病人在麻醉前耳溫測得<36°C18例病人在麻醉後送到PACU時耳溫<36°C30種麻醉藥使病人的體溫在麻醉過程中降低,64種麻醉藥使病人的體溫在麻醉期間升高,7種不改變病人體溫。所有的資料檢查都表明病人麻醉前後的體溫之間沒有相關性。

討論:我們得到了結論是當給予麻醉以便於ECT時,我們研究中的病人在麻醉期間的溫度變化並不一致。如果送到PACU時病人的鼓室溫度低於36°C,我們也不可以推測病人在麻醉過程中的體溫管理是低於標準的。而且目前的體溫測量方法也不足以確定病人在手術後是否低體溫。由於避免低體溫是一個有價值的目標,如果體溫被用作為一種麻醉品質激勵,麻醉科就必須保證體溫監測設備可以準確測量術後體溫。

(姜旭暉譯,馬皓琳,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內的氣管切開術:一項全國範圍的調查

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:近幾年來氣管切開術的指征、時機及技巧發生了改變。我們開展了一項調查以評估當前德國重症監護病房(ICUs)內氣管切開術的實施。

方法:將問卷郵寄給513位德國ICU(包括小兒ICU)的醫師負責人,。

結果:在513ICU中,我們獲得了455份回饋結果(89%)。在90%ICU中,在機械通氣的最初14天中實施氣管切開術。86%ICU常規實施經皮擴張氣管切開術;改良的Ciaglia技術是最流行的經皮穿刺技術(69%)。絕大部分(98%)的經皮穿刺操作是在支氣管鏡控制下完成的。通常由一位外科醫生(61%)在手術室內(72%)完成外科氣管切開術,而經皮擴張氣管切開術則是由一位重症護理醫生(93%)ICU (98%)患者的床邊完成的。26%ICU常規隨訪氣管切開的病人,45%ICU有關於氣管切開的指征、時機及技術操作的指南。

結論:在德國,經皮擴張氣管切開術是危重病人氣管切開的一種選擇。改良的Ciaglia技術是更好的經皮穿刺技術,幾乎所有的內科醫生都常規使用支氣管鏡引導。大多數氣管切開術都在機械通氣的第二周完成。

(裘毅敏譯,馬皓琳 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.



確定手術室內夜間所需值班急診團隊最佳規模的類比模型

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:在夜間(如晚11:00至晨7:30)開展急診手術的醫院面臨確定最佳手術室人員的問題。為減少急診病人併發症的發生和促進病人的完全恢復,需要在預定的安全時間視窗內開始手術。我們開發了一種程式來確定最佳的夜間手術室團隊構成,以使得人員開支最少而又能提供足夠的資源使手術能在安全的時間範圍內開始。

方法:應用離散事件類比結合安全時限模型。允許安全地推遲急診手術。採用Erasmus大學醫學中心主手術室資料進行驗證該模型。計算下列兩種結果:超過安全時限的急診手術和手術室及麻醉護士被從家中呼叫來的頻率。我們使用下列Erasmus醫學中心的輸入資料來估計本模型中所有相關參數的分佈:急診病人到達的次數、外科手術時長、在麻醉後恢復室停留時間和轉運次數。此外,由Erasmus醫學中心的外科醫生和手術室工作人員確定安全時限。

結果:與基準情況相比,將手術室內人員從9人減至5人導致延誤處理病人的比例增加2.5%。當需要時被從家裏呼叫到醫院的手術室和麻醉護士有相當大的增加。

結論:採用安全時限有益於夜間手術室的管理。安全時限模型顯著影響得到及時處置的急診病人人數。我們的研究表明,通過對安全時限模型和電腦類比方法的應用,手術室可以減少值班人員數量而不危害病人安全。

(顏濤 譯, 馬皓琳 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.



青少年脊柱側彎手術中應用異丙酚-瑞芬太尼麻醉進行術中喚醒試驗時混合聽覺誘發電位指數和BIS的比較

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:腦電雙頻譜指數(BIS)和來源於腦電圖和聽覺誘發電位的混合AARX指數(cAAI),已被用來作為麻醉深度監測。在兒童和青少年脊柱側彎手術應用異丙酚-瑞芬太尼麻醉的術中喚醒試驗中,我們用密西根大學鎮靜評分比較兩個指數在區別不同催眠狀態方面的表現。同時評估術後顯性回憶的情況。

方法:選取20名患者(1020歲)。誘導時、喚醒試驗和恢復時計算預期概率。在喚醒試驗開始時、對指令能有目的的體動時和患者再麻醉後比較BIScAAI。在喚醒試驗過程中,患者按指示記住一種顏色,隨後進行顯性回憶的調查。

結果:誘導時BIScAAI的預期概率是0.82 0.63 (P < 0.001),喚醒試驗時為0.780.79 (P < 0.001),恢復時為0.740.78 (P < 0.001)。在喚醒試驗過程中,BIScAAI均值在有目的的體動時有顯著升高,再麻醉後顯著降低。

結論:在誘導時,BIS表現比cAAI好。在統計學上儘管cAAI在喚醒試驗和恢復時更好地鑒別意識清醒水準,但這些差異似乎並沒有臨床意義。兩個指數在喚醒試驗時均升高,指示更高的清醒水準。沒有證明存在顯性回憶。

(朱 慧譯 馬皓琳 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、地氟烷和異丙酚麻醉後的術後疼痛和鎮痛藥的需要量

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:全身麻醉藥可能有會引起影響術後疼痛的感受傷害性作用。在評估術後疼痛的研究中,全身麻醉藥對止痛藥的需要量的影響還沒有研究過,除了最近一個研究表明異丙酚麻醉較異氟醚麻醉,能提供更好的術後鎮痛。

方法:在這個前瞻性、盲法、隨機的研究中,我們記錄了行(腹式)子宮切除術或子宮肌瘤切除術的病人術後24824小時鎮痛藥的需要量(嗎啡的mg數),和疼痛評分(VAS評分,單位mm),這些病人分別用七氟醚、地氟烷或異丙酚維持麻醉,並且維持腦電雙頻指數(BIS)值在35-45之間。進入麻醉後監護室後立即記錄病人的疼痛評分。

結果:這三組間在術後24824小時嗎啡的累積消耗量並無差異(P = 0.50)。術後24小時之內,七氟醚組嗎啡的消耗量為28 ± 13.8 mg,而地氟烷組和異丙酚組的消耗量分別為25 ± 11.7 mg27 ± 16.1 mg。病人在轉運至麻醉後恢復室即刻處於靜息或咳嗽後、手術後24824小時的VAS評分在三組間沒有差異(靜息時P 分別為0.400.390.500.470.06 咳嗽後P分別為0.670.450.220.260.29)。

結論:七氟醚、地氟烷或異丙酚組嗎啡的需要量和術後24小時的疼痛沒有差異。

(黃麗娜 馬皓琳 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.



泰國的脊髓麻醉後心搏停止:40,271例麻醉的多中心前瞻性記錄:

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:作為泰國麻醉事故研究的部分,我們評估脊髓麻醉過程中,心搏停止的發生率和原因。

方法:在一個12月週期內(200331日到2004228) 一個前瞻性多中心研究,記錄泰國20家醫院(7所大學醫院,5所三級醫院,4所綜合性醫院,4所區醫院)接受麻醉的病人。麻醉人員報告病人、外科和麻醉的相關因素和不良結果,包括脊髓麻醉過程中的心搏停止(時間程序定義為脊髓麻醉誘導到手術結束)。麻醉操作24 h內每當發生特別的不良事件時,記錄不良事件的特殊表格。用單變數和多元分析來識別脊髓麻醉中與心搏停止有關的因素。P<0.05被認為有統計學意義。

結果:在記錄的40,271例脊髓麻醉中,有11例心搏停止,相應的發生率是每10,000例中2.73 (95% CI: 1.12–4.34)。發生心搏停止的死亡率為90.9%。在這11個心搏停止的病人中,5個剖宮產,6個肢體手術,包括髖部手術。4個病人(36.3%),麻醉直接導致了心搏停止(高位交感神經阻滯、局麻藥過量或缺乏心電監護),反之,其他心搏停止與特殊事件有關(假體粘合劑、大量出血、可疑肺栓塞和可疑心肌梗塞)。從多元分析,麻醉中心搏停止的危險是身材矮小(優勢比0.944 [95% CI: 0.938–0.951], P < 0.001)、長時間手術(優勢比1.003 [95% CI: 1.001–1.005], P = 0.002)及由外科醫生進行的脊髓麻醉(優勢比23.508 [95% CI: 6.112–90.415], P < 0.001)

結論:脊髓麻醉中心搏停止是不常發生的,但是發生的死亡率很高。如果外科醫生進行脊髓麻醉,這是心搏停止的一個顯著性相關因素。增加麻醉醫師人數、改善脊髓麻醉監護的指南及改善麻醉護士培訓計畫,可以減少心搏停止的發生率和/或改善病人的結局。

(張曦 譯,馬皓琳 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.



用短針結合指壓做眼球周單次注射麻醉

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:我們比較用15毫米針和標準的25毫米針用於眼球周阻滯的效果。

方法:用1525毫米長的針對150例病人行阻滯。在用15毫米針時,應用拇指和食指指壓針頭介面周圍。注射麻醉藥直到注意到眼瞼發脹。增強不充分的阻滯。

結果:就局部麻醉藥容量、補充給藥和制動方面,在兩組之間沒有明顯差異。

結論:用15毫米針眼球周阻滯加上指壓的效果與25毫米針相當。

(彭中美 馬皓琳 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.

 

 

心臟手術中止血環酸和抑肽酶:一項220例心臟手術病人的應用分析

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:抗纖溶藥物已廣泛用於心臟手術中以減少出血。異體血輸注,即使是在出血較少的心臟手術中使用率也非常高。本研究中作者對比了止血環酸和抑肽酶在減少心臟手術病人術中出血的效果。

方法:這一前瞻性、隨機、雙盲研究選擇了220例冠脈搭橋術(CABG)或主動脈換瓣術(AVR)。患者隨機接受止血環酸(約6g)或足劑量的抑肽酶(約5-6 x 106KU)。在嚴格的輸注系統指導下進行輸注,通過分子標記物來評估這兩種藥物在作用方式上的區別。主要觀察項目為同種異體的紅細胞輸注率和手術後24小時血液丟失量。資料根據意向性分析原則通過方差分析和U檢驗來分析比較.

結果: 研究包括了220名患者(CABG: 134, AVR: 86),抑肽酶組中47%的患者住院期間輸注了異體血,止血環酸組為61%p=0.036),抑肽酶的使用使得異體血輸注的危險性下降23%RR 0.77, 95% CI 0.53–0.88)。雖然總的術後出血的組間無顯著差異,但抑肽酶處理的冠脈搭橋病人中術後24小時內出血量減少 〔分別為500ml350–750 mL 650 mL475–875 mL ),中位數, 25th–75th百分位數; P = 0.039〕。抑肽酶組中輸血率減少和術後第一天血紅蛋白的濃度升高(11.3, 9.9–12.1 10.6, 9.9–11.6 mg/dL; P = 0.023)。在手術結束時纖溶酶啟動通過D-二聚體比較(分別為抑肽酶組0.15, 0.11–0.17 mg/L ,止血環酸組為 0.18, 0.12–0.24 mg/L)。在抑肽酶組當肝素的需要量減少後,部分凝血酶啟動時間延長到了術後4小時。19%的抑肽酶組病人和45%的止血環酸組病人在心肺分流術中至少追加了一次肝素,在止血環酸組術後和術後第一天肌鈣蛋白T水準明顯升高(P = 0.017)。兩組病人在腎臟、心臟併發症的發生率或死亡率無顯著差異。

結論:止血環酸組行冠脈搭橋術病人紅細胞輸注率略降低,主動脈換瓣膜病人沒有差異。在止血環酸在冠脈搭橋術中出血量增加的影響有限,臨床價值取決於特殊的病人和特定的機構。

(丁俊雲 陳傑 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).




合併低蛋白血症的老年心臟手術患者使用白蛋白對炎症反應,內皮細胞活化,以及長期腎功能是否有好處?

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:由於輸注人血白蛋白對低白蛋白患者有益,因此,作者使用人血白蛋白糾正接受心臟手術的老年患者的低血容量的研究。

方法:在一項前瞻性隨機的試驗中,50名年齡>80歲,術前血清白蛋白濃度<3.5mg/dl的患者,在體外迴圈下接受心臟手術,25名給予5%的人血白蛋白,另外25名給予羥乙基澱粉。

開始輸注量為500ml,然後持續輸注至術後第二天的早晨,維持肺毛細血管壓或者中心靜脈壓在1214mmHg之間.

結果:在麻醉誘導後,術後5小時,術後第一天和術後第二天,分別檢測炎症反應(白細胞介素-6-10),內皮細胞活化(細胞間粘附分子-1),以及腎功能(包括谷胱甘肽轉移酶-{alpha}和中性粒細胞明膠酶相關載脂蛋白)。隨訪至出院後約60天。給予2980±430mL人血白蛋白和3060±680mL羥乙基澱粉。給予人血白蛋白組血清白蛋白濃度顯著增高(至4.5±0.3mg/dL)。給予人血白蛋白的患者與給予羥乙基澱粉的患者相比,血肌酐,腎小球濾過率,以及尿中谷胱甘肽轉移酶和中性粒細胞明膠酶相關載脂蛋白的水準無差別。炎症反應在兩組也很相似,而內皮細胞活化在羥乙基澱粉組裏發生更少。沒有患者發展為腎衰而需要腎臟替代療法。

結論:年齡>80歲,低蛋白血症,接受心臟手術的患者使用人血白蛋白,和使用羥乙基澱粉相比,對於炎症反應、內皮細胞活化和腎功能並無優勢。

(舒慧剛 陳傑 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.



用於兒童外周靜脈置管的一種靜脈通路指示裝置:一項前瞻性、隨機、對照試驗
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:兒童由於靜脈口徑小和難於觸及,血管通路的建立往往存在技術上的困難。本研究中,作者試圖確定使用靜脈通路指標裝置( VEIDTM )是否有利於建立兒童外周靜脈通路。

方法:在以色列的一個較大的三級醫院行相同擇期手術的202名健康兒童(ASA III 級),隨機分配接受VEID協助或標準外周靜脈插管。所有病例均使用22號套管行上肢靜脈置管。主要結果檢測指標為:嘗試插管次數,第一次嘗試的成功率,和插管時間。取這些資料的均數,使用方差分析和Pearson 2檢驗或Fisher’s精確檢驗進行組間比較;逐步logis回歸被用來確定三個變數(年齡,靜脈評估類別,使用靜脈進入指標裝置 )與第一次成功插管的顯著相關性。P值〈=0.05被認為具有顯著性。

結果:兩組患者中的大部分第一次嘗試插管即取得成功。VEID組中8 %,對照組中28 %的患者需要兩次嘗試,需要3次嘗試的比例則分別為1 %和3 %( P < 0.01 。通過靜脈評估分類分析發現,對於容易置管的患者兩組第一次置管成功率相似。然而,困難和中等類別,VEID組成功率為89.7 %,而對照組的成功率為23.3 %,( P < 0.01 )。

使用VEID組嘗試次數較少與從尋求合適的靜脈開始到插管成功的時間較短相關。( 9.1秒對比對照組的22.5秒)。

結論:靜脈通路指示裝置有利於健康兒童困難靜脈置管,減少了嘗試次數和穿刺時間。

(張磊 陳傑 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.


年齡對呼末七氟醚濃度和BIS指數動態關係的影響

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:年齡是吸入麻醉藥的藥物代謝動力學的一個重要的因素。然而,年齡對七氟醚動態分佈的影響尚未得到詳細描述。作者進行此項研究來描繪年齡與其他相關變數對呼末七氟醚濃度(CET)和其用效能(用BIS指數來表示)的動態關係。

方法 50名,年齡3—71歲,行小手術的患者進行前瞻性研究。研究期間持續監測呼末七氟醚濃度(CET)BIS。麻醉維持期間,待BIS值穩定於60–65間後,令吸入七氟醚濃度增加至5%維持5min,直至BIS <40後減低濃度。在此期間對呼末七氟醚濃度和其用效能(用BIS來表示)的動態關係的變化,利用種群藥代學和藥效學方法通過非線型混合效應模型V建立最大效能抑制模型。一個有預測性的檢查方法被用於確認最終模型。

結果:七氟醚效應通過監測BIS值,由C50表示(穩態呼末半數有效濃度),伴隨年齡增大而增加。由效應靶點的平衡半衰期( t1 / 2ke0 )所表示的七氟醚效應的變化速度,在老年人中增加。預測分析證實這一模型是恰當的。

結論:年齡對呼末七氟醚濃度和用BIS表示的效應之間動態關係有顯著的影響。

(葉樂 陳傑 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.

全身低劑量布比卡因預防大鼠開胸術後異常性疼痛的發生

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,開胸手術後慢性疼痛的模型在大鼠上已被複製用來觀察可能減少開胸手術後異常性疼痛發病率的藥物作用。以往的研究表明,在大鼠模型鞘內注射或全身嗎啡,可樂定,新斯的明,和加巴噴丁可減少開胸的術後疼痛,本研究目的是測試肋間和全身注射布比卡因是否能在慢性肋間神經痛動物模型上阻止疼痛的發生。
方法:雄性SD大鼠麻醉後,暴露右邊第4和第5肋骨。開胸、關胸1小時,手術前後或手術前肋間注射或全身注射布比卡因1毫克( 0.2毫升0.5  ),對照組關胸前不注射任何藥物,手術後3周在大鼠切口周圍預定區域測試機械痛。
結果:對照組 43 %的動物發生疼痛,手術前、手術後肋間注射、術前全身各自注射布比卡因的實驗組疼痛的發生率只有6%12%12%
結論:以往的研究表明,阿片類藥物,{alpha}2 -腎上腺素受體激動劑,新斯的明,和加巴噴丁可以防止關胸後疼痛的發生。目前的結果表明,手術前後肋間注射或者手術前全身給予布比卡因,能有效地防止機械痛。 

(劉世文 陳傑 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.

 



一種新穎的神經肌肉阻滯諮詢系統以改善神經肌肉阻滯:一個隨機,對照,臨床的實驗

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:傳統單次給予神經肌肉阻滯劑常與術中控制受限,復蘇延長以及麻醉後的阻滯作用的殘餘效應有關。為了克服這些限制,作者研發了一個新穎的自適應電腦控制程式--肌肉阻滯諮詢系統(NMBAS)。NMBAS根據於一個六個序列的模型和病人肌電圖描記,給予麻醉醫生有關給藥時間和劑量的建議。在此,檢驗了相對於標準管理NMBAS能夠改善NMB的假說。

方法:作者設計了這項前瞻性、隨機的、對照的、雙盲的、平行對照的臨床實驗, 選擇ASA I-III,應用羅庫溴銨神經肌肉阻滯,麻醉時間≥1.5h,腹部手術的患者73例。這些患者隨機分配到標準管理組或者NMBAS引導的羅庫溴銨給藥組。主要結果變數是手術中反映NMB不充分的發生率。次要結果變數包括在手術結束時逆轉之前的四個成串刺激(TOF)比值,羅庫溴銨的總劑量,逆轉藥物,麻醉劑和其他藥物,術後副反應的發生率,以及NMBAS介紹的麻醉學上不配合的發生率。

結果73個入組的患者中,每個組n=30的適合分析。統計的患者進行組間比較。與標準管理組相比較,NMBAS組中手術中與NMB不充分相關事件的總發生率顯著降低(8/30vs19/30;p=0.004)。TOF比值的平均值在手術結束時尚未逆轉前在NMBAS組更高(0.59[95%Cl,0.48-0.69]vs0.14[95%Cl,0.04-0.24];p<0.0001)。羅庫溴銨總的給藥劑量,逆轉藥物,以及其他藥物,和術後副反應的發生率沒有明顯區別。

結論:與常規相比,NMBAS引導的管理與改善NBM品質和提高手術結束時TOF比值相關,可能降低NMB殘餘效應的風險和提高病人手術期間的安全性。

(懷曉蓉 譯 陳傑 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.


在嚴重膿毒症中早期使用高劑量抗凝血酶:來自KyberSept試驗的單中心結果

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試驗的全部的結果中,對嚴重膿毒症中使用高劑量抗凝血酶的非治療效應與主要結果——28天死亡率不一致的可能原因是由於異質性。控制的非治療效應的KB試驗結果與其主要成果,28天死亡率互相矛盾,可能是由於患者個體差異造成。目前還沒有早期使用(微循環紊亂但還沒有出現不可逆器官損害)抗凝血酶治療嚴重膿毒症的相關作用的報導。

目標:作者報導KS試驗中嚴重膿毒症患者出現新的器官衰竭早期在單中心的接受了治療及由此產生的結果。

方法:所有參加者都來自美國某三級醫院重症監護室。患者隨機11分配(空白對照:n=41;抗凝血酶ATn=40),在48小時內接受抗凝血酶治療(30000IU靜注,超過四天)或安慰劑治療。

結果:組間原始變數基線穩定。80%的患者(n=65)在發生嚴重膿毒症的24小時內接受研究藥物治療;94%的患者(n=76)在48小時內接受研究藥物。AT組的40名參與者中的9名(22.5%)在最初的7天內出現了新的器官功能障礙,而相較於39名空白對照組患者中的17名患者(43.6%),空白對照組的原始變數基線並無不同(P=0.0582名患者最初就患有多器官功能障礙而被排除)。在28天時,40名接受AT治療的患者中有16名(40%)死亡,而41名接受空白對照治療的患者有22名(54%)死亡[明顯減少,14%;優勢比(95%可信區間),0.580.24-1.39]。在接受AT治療的患者中,出血的發生率明顯增加(40AT組患者中8名出現(20.0%),同時,空白對照組41名患者中有1名出現(2.4%);P<0.015)。

結論:由此分析的資料證實抗凝血酶治療的患者出血的風險增加。當在嚴重膿毒症早期給予抗凝血酶,儘管統計學差異不明顯,抗凝血酶治療的器官衰竭和死亡率的絕對風險相應降低21%14%,這顯示抗凝血酶治療對於有選擇的膿毒症患者還是具有潛在益處的。此研究提示我們需要進一步進行抗凝血酶治療膿毒症的研究,並側重于減少患者個體差異性。

(朱紫瑜 譯 陳傑 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.


合併有Shone’s綜合征的產婦行剖宮產時的麻醉管理

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綜合征是一種罕見的先天性心臟病,主要包含多達4種左心的梗阻性損傷。本文作者報導一位元17歲合併有Shone’s綜合征的產婦接受剖宮產術。該產婦合併有輕度二尖瓣狹窄和輕度左室流出道梗阻。作者嘗試對其實施硬膜外腔阻滯麻醉,但患者出現了嚴重的低血壓及與之相關的胎兒心動過緩,而需要立即在全麻下實施剖宮產術。文中還討論了此類患者的圍產期麻醉用藥及管理要點。

(周姝婧 陳傑 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.

 

腦電雙頻譜指數在嚴重腦損傷合併難治性顱高壓患者巴比妥酸昏迷中的應用

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:嚴重創傷性腦損傷(TBI)病人應用巴比妥藥物治療通常需要監測腦電圖(EEG)爆發-抑制模式。而腦電雙頻譜指數(BIS)是來源於腦電圖且考慮了皮層靜息。作者試圖探討BIS的變化是否預示著特異性的爆發-抑制模式。

方法:11位接受巴比妥治療的創傷性腦損傷(TBI)病人進行前瞻性研究。每天記錄一小時的腦電圖。爆發/抑制比值(腦電圖抑制率「SREEG」:60秒大腦皮層靜息百分率)每5分鐘在原腦電圖上計算1分鐘,並且與同步測得的BIS-XPTM相對比(腦電雙頻譜指數與抑制率「SRBIS」)。巴比妥昏迷的最適合腦電圖水準定義為2-5次爆發/分鐘。巴比妥昏迷的最合適BIS範圍通過實驗資料預測,在每一個實驗中都將研究其精確度。

結果:測得的SREEG SRBIS一致性很高(組內相關係數0.9495%可信區間:0.90-0.96」)。SREEGBIS呈顯著性相關。在一些實驗中出現顯著不一致。預測巴比妥昏迷的最佳BIS範圍為6-15.

結論:在使用巴比妥藥物治療的創傷性腦損傷(TBI)病人中,SREEG BIS的相關性很高。當BIS指數小於6時,巴比妥類藥物的輸注速度將要減慢。當BIS指數大於15時,巴比妥類藥物的輸注速度將要加快。需要通過對腦電圖相似信號的觀察(正如BIS-XPTM所顯示)定時檢查腦電雙頻譜指數與腦電圖抑制模式的對應關係

(趙嫣紅 陳傑 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).


無創正壓通氣對加快病態肥胖病人預吸氧的效果:隨機對照研究

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:配合壓力支持通氣和呼氣末正壓通氣的無創正壓通氣(NPPV)能有效地為插管時存在低氧的病人提供氧氣。作者假設使用NPPV給氧要比自發通氣(SV)進行預氧化能更快增加病態肥胖病人的呼氣末氧濃度(ETO2)。

方法28名病態肥胖患者參加了這一前瞻性地隨機研究。使用SV或者NPPV(壓力支援=8cmH2o,PEEP=6cmH2o(NPPV)給氧5 minETO2可以使用麻醉呼吸回路測量,也可表示為大氣濃度的一小部分。主要終點是在給氧最後ETO2>95%的病人數量。次要終點包括達到最大ETO2的時間和給氧結束時的ETO2值。

結果:與SV組相比NPPV組中有更大比例的患者在5 minETO2達到95%(13/14 vs 7/14, P = 0.01)。在NPPVETO2達到最大值的時間明顯少於SV組(185±46 vs 222±42 sP=0.02)。在給氧結束時的平均ETO2NPPV組比SV更大(96.9 ± 1.3 vs 94.1 ± 2.0%, P < 0.001)NPPV組可見中等程度的胃擴張。但兩組均未見明顯不良後果。

結論:在手術室對病態肥胖病人通過面罩進行NPPV給氧是安全、可行和有效的。對於這類人NPPV能提供更快速的給氧,達到更高的ETO2

(潘錢玲 譯 陳傑 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.


在體內高或低皮質醇對人體單核細胞介導的炎症反應途徑有雙相影響
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,糖皮質激素對免疫反應有支持(刺激)和抑制性影響,這取決於糖皮質激素濃度。由於一些糖皮質激素對炎症的刺激,作者推測糖皮質激素在體內急性缺失將減少人單核細胞介導的炎症反應。

方法:分離健康志願者參加在體治療前和後的單核細胞; 1 )注射生理鹽水, 2 )注射高劑量氫化可的松(8 µg·kg–1·min–1 ,其次是隔夜口服氫化可的松,以及3 )口服米非司酮(200 mg 04001600 點)為阻止細胞內的糖皮質激素受體和注射依託咪酯(1.5 mg·kg–1·h–1 12小時,以防止代償性合成腎上腺皮質醇。連續測量血漿促腎上腺皮質激素,血漿和唾液皮質醇。測試單核細胞為: 1 )細胞因數反應, 2 CD163 CD119CD54  的表達,3 mRNA水準的糖皮質激素反應炎症介質。所有資料測試均在離體有或沒有脂多糖刺激單核細胞下進行。

結果:皮質醇和促腎上腺皮質激素的測量證明有效控制體內皮質醇。體內皮質醇增多和糖皮質激素的消耗對單核細胞mRNA水準4個重要的 糖皮質激素反應分子(糖皮質激素受體, CD163 ,白細胞介素-10 ,和細胞因數合成- 3抑制因數)有相互的影響。單核細胞因數反應和蛋白表達沒有受到糖皮質激素缺失的影響。皮質醇增多增強了 CD163的表達
結論:短期糖皮質激素缺失影響糖皮質激素反應分子的mRNA水準,但並不影響單核細胞蛋白的表達或細胞因數反應。

(陳偉 陳傑 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%氯普魯卡追加0.5%布比卡因和2%利多卡因追加0.5%布比卡因在肌間溝臂叢神經阻滯中的比較:一項隨機、前瞻、雙盲對照試驗:

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-氯普魯卡因加布比卡因(C/B)後可用於區域麻醉,但由於其效果不是很顯著,並沒有能夠得到廣泛應用。在這項隨機、前瞻、雙盲對照試驗中,作者比較了使用(C/B)和使用利多卡因加布比卡因(L/B)在肌間溝阻滯中的效用。

方法:30例準備在肌間溝臂叢神經阻滯下行肩膀關節手術的病人隨機分成兩組,每組15例。一組(C/B)使用3%氯普魯卡因混合碳酸氫鹽和腎上腺素,緊接著使用0.5%布比卡因和腎上腺素。另一組(L/B)使用2%利多卡因代替3%氯普魯卡因。運動神經和感覺神經阻滯每15秒測試一次。主要評定的結束點是完全運動神經阻滯的出現。運用Time-to-event統計方法分析。

結果:一名L/B組的病人沒有出現阻滯,不做分析。C/B組和L/B組出現運動神經阻滯的平均時間分別是90秒(15-575)和18015-3720)秒(P=0.0325)。兩組的感覺神經阻滯的平均時間分別是9030-600)秒和1230-3900)秒(P=0.0185)。統計顯示,在5分鐘內C/B組的15例病人中有13例有運動神經阻滯,L/B14例病人中只有7例有運動神經阻滯。十分鐘內,C/B15名病人全部實現運動神經阻滯,L/B組只有10名。在L/B組中最長等待了60分鐘來評估是不是完成了阻滯。

結論:研究表明:在肌間溝阻滯時,使用C/B藥物比使用L/B能更快完成阻滯。

(王騰 陳傑 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.

 

 

凝血彈性度評價低溫對凝血系統的影響

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:低溫可分為意外和治療性的。治療性低溫越來越多的被用於不同的情況,例如:心臟停搏後的神經保護等。低溫會導致凝血系統的損害,但損害的程度很難評估。大部分的研究著眼於血漿而不是全血。我們用全血在一個寬範圍的溫度(25-40攝氏度)內研究低溫對凝血系統的影響。

方法:從6個健康的志願者采血,保存在檸檬酸鹽試管中。在輪流用凝血彈性度評價凝血系統前,將樣本放在25-40攝氏度的水中水浴30分鐘。接觸啟動劑(鞣花酸)用於觸發最初的凝血。測量凝血時間、血塊形成時間、生理角及最大血塊強度。所有的試驗持續60分鐘然後在與水浴溫度相同的溫度下進行測量。

結果:在研究的溫度範圍內,凝血功能的損害隨溫度的降低而加重。所有的測量值都呈階梯式的下降,有顯著差異(P<0.0001)。

結論:全血的檢測分析提示低溫進行性的損害凝血系統。

(胡豔譯   薛張剛校)

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.

 

 

關於常規心臟手術血液回收的一項隨機對照研究

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減少心臟手術的異體輸血,但這些研究有局限性,包含了其他節約輸血策略使用的不一致。我們設計了一項隨機對照研究以確定對擇期非複雜心臟手術行常規血液回收能否減少輸血,以及在嚴格輸血方案和常規使用抗纖維蛋白酶的設定下行常規血液回收的成本效益分析。

方法230名首次行冠脈搭橋術和/或心臟瓣膜手術的患者預先隨機分為對照組和血液回收組。後一組通過細胞回收設備行術中和術後6小時內胸腔引流液的血液回收並行自體血回輸。所有患者均使用氨甲環酸並按規定演算法接受紅細胞和凝血因數輸注。

結果:兩組間患者輸異體血的比例沒有差異(兩組均為32%,相對危險因數1.0, P = 0.89)。以目前的血製品和細胞回收設備的價格,使用血液回收至少增加每個病人的花費103美元。當患者因出血再次行胸腔探查時予以排除(按方案計畫),血液回收組患者輸異體血單位量明顯少於對照組(65vs100U,相對危險因數0.71, P = 0.04)。

結論:首次行常規心臟手術的患者在具有嚴格血液保存計畫的醫療機構中,常規使用血液回收並不能減少患者輸異體血的比例。然而,術後出血過多的患者卻可通過血液回收明顯減少輸血的單位量。儘管使用血液回收能明顯減少血製品的需要量,但會增加醫療機構的成本。

(黃凝譯  薛張綱校)

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.

 

 

兒童病人眼鏡蛇式喉周氣道與Unique喉罩前瞻性隨機研究

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:成人正壓通氣時眼鏡蛇式喉周氣道(CobraPLA)比Unique喉罩更能夠提供有效的氣道封閉壓。因此,我們比較CobraPLA LMAU在嬰兒和兒童使用情況。

方法:將200例兒科病人隨機分成CobraPLA LMAU組。測定套囊充氣壓在40 60 cm H2O時氣道密閉性,觀察比較兩組間病人舒適度、喉罩置入時間、裝置的穩定性、通氣效率、嘗試插入次數,評價兩組病人術後咽喉痛、發音障礙、喉痙攣、支氣管痙攣和胃脹氣的發生率。在CobraPLA頭端和麻醉回路Y介面處測定呼出氣CO2分壓,對於出現重大事件組則再次細分為小和大CobraPLA亞組以及小和大LMA亞組;資料表示為均數±標準差,P < 0.05為差異有統計學意義。

結果:套囊充氣達60 cm H2O時,大CobraPLA亞組氣道密閉壓(22 ± 7 cm H2O)明顯高於小CobraPLA亞組(18 ± 5 cm H2O)和大LMA組(16 ± 5 cm H2O(P < 0.001)CobraPLALMA更穩定並且胃脹氣較少,CobraPLA頭端CO2分壓比Y介面處高6.4 ± 6 mm Hg

結論CobraPLALMAU在大部分兒童麻醉中氣道密閉效果相似,在某些病人前者優於後者。

(蔣宗明譯  薛張綱校)

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.

 

 

一篇關於阻塞性睡眠呼吸暫停綜合症的系統綜述及其對麻醉師的啟示

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:阻塞性睡眠呼吸暫停綜合症(OSA)在在人群中已占了極大的比例,但大多數患者卻未曾得到及時的診斷。而認識到未獲診斷的0SA患者其圍手術期風險的增加,對麻醉師及外科醫生來說卻極為重要。故此,我們發表了一篇有關0SA患者圍手術期處理的系統綜述。

方法:這篇綜述的文獻範圍是局限於外科專業的成年病人。主要的搜索辭彙為“圍手術期護理”、“睡眠呼吸暫停”、“阻塞性睡眠呼吸暫停”、“圍手術期風險”和“圍手術期護理”。我們搜索的是從196620073月在databases MedlineEmbaseBiological AbstractScience Citation IndexHealthstar上的英文文獻。

結果:這篇文獻支持了OSA患者其圍手術期風險有所增高這一觀點。美國麻醉醫師協會指南主張在圍手術期評估中都予行OSA篩查,而OSA的篩查方法也已在該綜述中有所討論。並且該篇綜述還提出了一些用以減低OSA患者圍手術期風險的對策。但是,除了美國麻醉醫師協會共識的指南,我們也需要注意在該篇文獻中卻缺乏著循證醫學支持的推薦措施。

結論:這篇綜述對OSA患者的圍手術期篩查方法及處理策略提出了一定建議。我們的最終目標是減低OSA患者的圍手術期風險,而為實現此目標,我們還需要進一步行調查研究,以明確對這些未予診斷的OSA外科患者,其圍手術期的篩查及處理策略是否可減低其不良事件的發生率。

(劉沁譯 薛張綱校)

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.

 

 

在非洲蟾蜍卵母細胞中芳香族揮發性麻醉藥對鈉離子電壓門控通道的效應

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:許多吸入性麻醉藥在臨床使用濃度下會阻滯鈉離子電壓門控通道,這些麻醉藥產生的結果與神經遞質的釋放有關,至少部分是使突觸前鈉通道的活性降低。揮發性芳香族麻醉劑能阻斷N-甲基-D-門冬氨酸受體的功能,增加伽瑪氨酪酸A受體功能,但這些效應很大程度上依靠芳香族化合物的化學效應。在最近的研究中我們測試不同的芳香族麻醉劑是否始終如一的阻斷鈉通道功能。

方法:我們使用非洲蟾蜍整個卵細胞,雙極電壓鉗制術研究八種芳香族麻醉藥對Na(v)1.2鈉通道ß1亞基團的效應。

結果:在最高電流的一半的控制電壓下所有芳香族麻醉藥都阻斷鈉電流;均苯三酚(8% +/- 2%)、戊苯(13% +/- 2%)、戌苯(13% +/- 2%)的抑制是適度的比苯(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%)明顯。這種交叉效應在NMDAr-氨基丁酸A受體上發現。平行,但更小些的阻滯在控制電位,接近最高電流(-90 mV) (V(H-90))時在鈉電流上發現,戌苯在此電流上引起很小的增強作用(6% +/- 1%)。這些鈉通道功能的改變與NMDA受體的阻斷效應、化合物的脂溶性、及分子量、及陽離子相互作用相關聯。

結論:不同芳香族化合物動力學效應在鈉離子門控通道及他們不同的抑制作用。抑制範圍產生於吸入麻醉藥MAC值表明鈉離子通道會被其中一些麻醉藥物阻滯但有些不會。                                                                            

(劉婷潔譯 薛張綱校)

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設備使用的實用指南

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.

 

麻醉情報管理系統(AIMS)顯示並記錄了圍術期的生理資料和病人情況。雖然目前使用還較有限,但是它對增加患者安全性,改善臨床有效率及診斷、改善收費管理和帳單管理、標準化管理、以及麻醉結果研究都有很多益處。AIMS的使用進程、恰當的警報選擇、安裝、使用較複雜,然而,每個環節的使用已經通過多次試驗,這個文章總結了成功使用AIMS設備各個環節的基本要點,包括產品測評,資訊技術需要的評估。

精確的記錄是臨床科學與循證醫學的基礎,麻醉醫生也可以通過多次測量來作出臨床決定。對於外科手術患者,由於常規的生理資料監護測量也已經很複雜,因此數位資料系統是自動記錄資料必需的。雖然費用較貴,而且由於麻醉供給裝置的調零重定會使報警失效,但是AIMS的優勢仍然超過了它的缺點。事實上,麻醉患者安全基本指南(APSF)明確指出:APSF允許並支援圍術期自動資料記錄儀的使用,以及對這些資料的研究以改善患者安全。

AIMS的理念由簡單的資料記錄器發展而來,在20多年前首次被提出,最終發展為一個複雜的數位電子工作網路。與醫學資料庫、生理監護儀、輸入裝置的各個介面可用來收集,整理,顯示,記錄,檢索圍術期生理資料,以備後續研究。現代的AIMS有兩個基本組成部分:自動化麻醉記錄儀(AAR)和圍術期資料庫(PD),以針對各個患者的臨床生理資料。一個綜合的AIMS還要包括一個麻醉前評估裝置和一個電子資料記錄倉庫(EDW),它能將各個患者的資料從PD設備上轉出,生成並組織成為生理資料檔案,提供給結果研究。

成功的AIMS安裝使用需要基於電腦硬體、系統配置以及人員培訓。關於AIMS的大致資訊可以通過AIMS麻醉技術協同工作組以及美國麻醉醫師學會(ASA)來獲得。這篇綜述回顧了不同體系對於使用AIMS的經驗研究。

(秦敏菊譯 薛張綱校)

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.

 

 

電阻聚合物與強熱空氣加溫:志願者的熱能傳遞和核心溫度複溫速度的比較

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:手術期亞低溫增加多種嚴重併發症發生可能。確保圍術期病人保持正常體溫已列入常規,而強熱空氣加溫是最常用的手段。在既往研究中,與強熱空氣相比,各種電阻加熱系統已顯示出不同的結果。最近,已成功開發基於聚合物的電阻病人變暖系統。我們在志願者中進行強熱空氣加溫系統與電阻聚合物系統功效的比較。

方法:共有八名健康志願者參與本次研究,每人研究兩天。應用10°C加強空氣及4°C迴圈水床墊,將未經麻醉的志願者冷卻至核心溫度(鼓膜)34 ° C。並使用度冷丁和丁螺環酮防止志願者發抖。通過隨機命令,使用下列其中一個變暖系統,將志願者回暖(直至其核心溫度達到36 ):(1)強熱空氣加溫系統(Bair Hugger warming cover #300, blower #750, Arizant, Eden Prairie, MN);(2)電阻聚合物加溫系統( HotDog全身毯子, HotDog標準控制器,Augustine Biomedical, Eden Prairie, MN 。研究第二天使用候補系統。記錄志願者的代謝產熱、皮膚熱損失及核心溫度。

結果:兩種系統的代謝產熱和皮膚熱損失無明顯差異。經過30分鐘延遲,強熱空氣加溫系統使志願者核心溫度增加了近線性的0.9895%信賴區間0.91-1.04/小時,而電阻聚合物系統則增加0.920.85-1.00/小時(P0.4)。

結論:在健康志願者中,強熱空氣加溫系統與電阻聚合物系統的熱能傳遞和核心溫度複溫速度均相似。

(施穎譯 薛張綱校)

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.

 

 

比較硬膜穿孔技術和標準硬膜外阻滯技術用於人工鎮痛的隨機試驗

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:該隨機雙盲前瞻性試驗是為了檢驗在沒有吸入麻醉的情況下硬膜外阻滯的藥物給藥之前即刻予以硬膜鑽孔是否比標準的硬膜外阻滯有更好的人工鎮痛效果。

方法80名宮頸擴張小於5cm的未育待產婦隨機分組,接受標準硬膜外麻醉,一部分用25號細針在硬膜打孔,一部分沒有。在硬膜外針和細針放置好以後,12ml 2.5 mg/mL的布比卡因打進硬膜外,病人自控輸注的1.25 mg/mL布比卡因和2 µg/mL的芬太尼的混合液也開始工作。兩組之間比較S1平面的出現和疼痛評分。

結果:人口學特徵差別不大的組別之間,帶有硬膜細孔的待產婦S!平面阻滯出現更多,在開始觀察的20分鐘後的疼痛評分更為明顯和多見,單側阻滯則少見。最高阻滯平面在兩組沒有差別。

結論:對待產婦來說,使用布比卡因和芬太尼硬膜外鎮痛前即刻給與25號針硬膜鑽孔加快硬膜外藥物的播散,起效,雙側鎮痛效果

孫鵬飛譯 薛張綱校)

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.

 

 

加強氧氣管理可改善清醒頸動脈手術患者腦供氧狀況

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:在神經阻滯麻醉下行頸動脈內膜剝脫術(CEA)中,有10% 15%的患者在血管鉗閉後有腦缺氧的症狀,表現為語音、用腦能力或者對側肌力的改變。已有關於術中吸純氧可避免此神經病學上的不足的報導。我們使用近紅外腦血氧定量法來評估吸純氧是否確實可以改善頸動脈鉗閉時的腦氧飽和度(rSO2)。

方法16位元清醒狀態下行CEA術的患者參加了研究。在鎮靜和神經阻滯實施之前即安置雙側大腦rSO2感測器。患者通過文氏面罩呼吸28%濃度氧氣。圍手術期血壓維持在高於患者平常血壓的10%或以內。頸動脈鉗閉後,予密閉麻醉面罩吸100%純氧。隨後取下面罩,患者吸室內空氣。每次干涉行為後記錄rSO2讀數和動脈血氣分析結果。

結果:分析了15位元患者的資料。同側rSO2值在頸動脈鉗閉後下降7.4% ± 5% 。所有患者在吸100%純氧後同側rSO2值較吸28%氧氣時上升6.9% ± 3.3% (range, 1%–12%) (paired t-test, P < 0.001)。血流動力學及Paco2值未有改變。

結論:在頸動脈鉗閉時,吸純氧相比吸28%氧氣可以有效增加同側rSO2值。病因學不明,但是可能與血氧含量上升或者增強腦血流相關。所以在行CEA術中吸純氧可能有利於所有患者。

(夏俊明譯 薛張綱校)

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.

                                                  

 

癲癇發作和全身麻醉藥(綜述)

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.

 

全麻藥導致的癲癇發作的真實影響方式尚不知道。麻醉誘導期間異常運動很常見,但可能並不預示真正的癲癇發作。相反,癲癇樣的腦電活動通常被恩氟醚、依託咪酯、七氟醚誘導出,丙泊酚的程度較小,但是它很少引起全身的強直陣攣發作。甚至在“無抽搐性電休克治療”中,麻醉藥偶爾導致之前有癲癇病史的人的癲癇發作。這些癲癇發作最常見於麻醉誘導或蘇醒期間,這時麻醉藥的濃度相對較低。對於麻醉藥相關的癲癇發生沒有統一的機制。然而,越來越多的試驗提出癲癇發作不是由太多興奮引起,而是興奮大規模已經進入振盪癲癇狀態的神經元。增加的伽瑪氨基丁酸能的抑制作用可使皮層致敏,只需要小量的興奮就可導致癲癇發作。這被假設發生在1)在網狀系統水準通過增加反射的傾向(比如:通過延長“抑制滯後”),2)通過對中間神經元的不同影響(“抑制性抑制劑”),或3)在突出水準通過改變氯離子反轉電位(“興奮性GABA”)。在適用於神經藥理學的基礎上,預防麻醉藥相關的癲癇發作包括1)避免使用七氟醚和依託咪酯,2)考慮用苯唑地西泮類的藥物(α-亞基GABAA受體激動劑),或可減少鈣離子進入神經細胞的藥物,3)使用腦電圖監測來發現早期皮層不穩定跡象和癲癇活動。癲癇發作可能虛假地提高麻醉深度的腦電指數。

(宣麗真譯 薛張綱校)

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.

 

 

加巴噴丁抑制淺頸叢阻滯麻醉下甲狀腺術後晚期疼痛

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:術前口服加巴噴丁已經顯示出可以減少術後疼痛。然而,加巴噴丁對於區域阻滯麻醉的影響及其對慢性疼痛的影響目前還不清楚。在甲狀腺手術病人,我們調查了術前口服加巴噴丁作為頸淺叢阻滯( SCPB)的輔助對早期和晚期( 6月)術後疼痛的作用。

方法 50例同意的患者隨機分配接受術前2小時1200毫克的加巴噴丁( G組)或安慰劑( P組)術前焦慮數值從06,標準化後麻醉誘導後行SCPB,記錄術中和術後和重症監護病房出ICU後回病房整個過程中鎮痛藥物的消費,在頭24小時,疼痛程度,在休息時和吞咽時衡量尺度數值從010。如果靜息時疼痛程度超過了4 / 10,病人接受1/ 6 h的四對乙醯氨基酚和/50毫克/ 6小時的四曲馬多鎮痛治療。甲狀腺手術前一天,和6個月後,病人被要求回答一個神經性疼痛的診斷問卷調查。

結果比較這兩個群體的人口特徵,術前焦慮,術中術後重症監護病房鎮痛藥物的消費。鎮痛藥的消耗量在手術後最初的24小時是相似的(G: 3 [0–5] doses/24 h; P: 3 [1–5] doses/24 h; P = NS),靜息時(G 2,2 [0.2–3.7]; P 2 [0–6.3]; P = NS),和吞咽期間(G 2.8 [0.4–8.9]; P 3 [1.4–6.3]; P = NS])。八名患者安排一張診斷查詢表計分超過3,這種延遲的神經痛據報導, 7名僅接受SCPB的有7名,而同時接受SCPB及術前輔助口服加巴噴丁的僅1名( P0.01

結論 術前口服加巴噴丁不立即減輕SCPB甲狀腺術後疼痛 ,但對術後6個月的遲發神經痛有減緩作用。

章一靜譯 薛張綱校

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.

 

 

對土耳其一家私人醫院34109名行硬膜外阻止的婦產科病人的回顧性研究

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:在婦產科手術,我們對由有經驗的麻醉醫生經選擇性硬膜外阻滯的安全性進行研究。

方法::我們隨訪了1993年至2006年產科所有與麻醉相關的資訊(n = 35,628病例數)。主要研究了成功實行該麻醉的比例,主要併發症的發生率,死亡率。

結果:在婦產科麻醉中共有34109次實行硬膜外阻滯。在14年中實行硬膜外麻醉的比例從57%上升至96%。永久性的神經系統併發症、心臟停跳、母嬰死亡率在這幾年中均為0

結論:在土耳其一私人醫院中,五名有經驗的麻醉醫生經合理的選擇病人,硬膜外麻醉/鎮痛是可靠和安全的麻醉方法。

(陳珺珺譯 薛張綱校)

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.